Sexually Transmitted Diseases

Transcription

1 Sexually Transmitted Diseases Ina Park, MD, MS California Prevention Training Center University of California San Francisco Dept of Family and Community Medicine

2 Disclosures/Disclaimers No disclosures Will discuss off-label use of nucleic acid amplification tests for rectal/pharyngeal GC/CT testing All responses will reflect 2015 CDC Guidelines and/or USPSTF recommendations

3 For Bacterial STDS, Winter is here Chlamydia Gonorrhea Syphilis Congenital syphilis 5% 19% 18% 28%

4 628 cases of congenital syphilis 28% increase from prior year

5 Case 1: I want to be tested for everything 20 yr old female with no significant PMH presents for STD testing Has had 2 male partners and 1 female partner in the past 3 months Has given and received oral sex and also had vaginal sex, denies anal sex Denies illicit drug use Not having any vaginal symptoms, feels well

6 What screening tests are indicated for her 1) GC/CT 2) GC/CT, syphilis 3) GC/CT, HIV 4) GC/CT, syphilis, HIV and herpes 5) GC/CT, syphilis, HIV, herpes, HepB sag

7 STD Screening for Women Sexually Active adolescents & adults <25 years old Routine chlamydia and gonorrhea screening* Other STDs based on risk HIV (at least 1 time between ages 13-64) Women 25 years of age and older STD testing based on risk HIV (at least 1 time between ages 13-64) Pregnant women Chlamydia Gonorrhea (<25 years of age or risk) HIV Syphilis serology HepB sag Hep C (if high risk) CDC, 2015 STD Tx Guidelines, and USPSTF

8 Herpes Serology: Recommendations (CDC & USPSTF) Type-specific HSV-2 serology tests may be useful Patients with recurrent/atypical symptoms w/ negative HSV-2 cx/pcr Someone given a clinical diagnosis without lab confirmation Patients whose partner(s) have genital HSV NOT USEFUL (Grade D, do not offer) Routine screening of asymptomatic patients Routine screening during pregnancy. CDC 2015 STD Treatment Guidelines USPSTF 2016 Final Recommendation Statement

9 Rationale for HSV Serology Grade D recommendation 10 studies including n=6537 patients Cutoff for positive serology >1.1 (value recommended by the manufacturer) Sensitivity of 99% (95% CI, 97%-100%) and Specificity 81% (95% CI, 68%-90%) Translation: If you test 100,000 people (assuming 16% seroprevalence) 15,840 True positive results 15,960 False positive results Predictive value is 50% (probability of a positive test reflecting true positive) Feltner, JAMA, Dec 2016

10 What if the patient was a male who had sex with males and females?

11 STD Screening for MSM* At LEAST annually: HIV Syphilis Urine GC and CT (NAAT) Rectal GC and CT (receptive anal sex) Pharyngeal GC (receptive oral sex) Hep C if IDU or other risk factor Anal Cancer in HIV+ MSM: Annual digital rectal exam may be useful, some centers perform anal Pap and HRA More frequent (3-6 months) if patient or their sex partners have multiple partners, uses methamphetamine, or sexual performance enhancing drugs CDC 2015 STD Treatment Guidelines

12 STDs predict future HIV Risk among MSM Rectal GC or CT Primary or Secondary Syphilis No rectal STD or syphilis infection 1 in 15 MSM were diagnosed with HIV within 1 year.* 1 in 18 MSM were diagnosed with HIV within 1 year.** 1 in 53 MSM were diagnosed with HIV within 1 year.* *STD Clinic Patients, New York City. Pathela, CID 2013:57; **Matched STD/HIV Surveillance Data, New York City. Pathela, CID 2015:61

13 Case 2: It burns 20 yr old female presents with dysuria, frequency x 3 days She denies F/C, N/V, abdominal pain, or vaginal discharge Exam unremarkable, no CVAT Udip of midstream urine large LE, negative nitrite

14 What would be appropriate treatment and/or workup for this patient? 1) Ciprofloxacin 500 mg BID x 3 days 2) Ciprofloxacin 500 mg BID x 3 days and test urine for CT 3) Ciprofloxacin 500 mg BID x 3 days and azithromycin 1 g

15 Chlamydia and acute urethral syndrome Think CT in a young sexually active woman with dysuria, leukocytes in the urine, negative nitrite If urine culture results presented, then culture will likely be negative.

16 Chlamydia Treatment Adolescents and Adults Recommended regimens (non-pregnant): Azithromycin 1 g orally in a single dose Doxycycline 100 mg orally twice daily for 7 days Recommended regimens (pregnant*): Azithromycin 1 g orally in a single dose * Test of cure at 3-4 weeks only in pregnancy

17 Case 2: Vaginal swab is preferred specimen type for women Nucleic acid amplification tests (NAATs) recommended for detection of genital tract infections in men and women with and without symptoms - highly sensitive and specific compared to culture - less dependent on specimen collection/handling Optimal specimen types are: First catch urine for men, swabs for rectal/pharyngeal STDs in MSM Self collected vaginal swabs from women

18 Case 3: A 25 year old sexually active MSW presented 1 week ago with mild dysuria, no discharge, and Udip LE positive (small) Test him for GC/CT Treated for urethritis with azithromycin 1g

19 Case 3 continued 7 days later, his laboratory results come back, urine GC positive, CT negative Now what? 1) Treat him with ceftriaxone 250 mg IM 2) Treat him with ceftriaxone 250 mg IM plus doxycycline 100 mg BID x 7d 3) Treat him with ceftriaxone 250 IM and azithromycin 1g

20 Gonorrhea Dual Therapy Uncomplicated Genital, Rectal, or Pharyngeal Infections Ceftriaxone 250 mg IM in a single dose PLUS* Azithromycin 1 g orally Regardless of CT test result CDC 2015 STD Treatment Guidelines

21 What does dual therapy mean? Ceftriaxone and azithromycin administered on the same day Preferrably simultaneously and under direct observation

22 Gonorrhea Treatment Alternatives Anogenital Infections ALTERNATIVE CEPHALOSPORINS: Cefixime 400 mg orally once PLUS Dual treatment with azithromycin 1 g (preferred) or doxycycline 100 mg BID x 7 days, regardless of CT IN CASE OF SEVERE ALLERGY: Gentamicin Azithromycin 240 mg 2 IM g orally + azithromycin once 2g PO (Caution: OR GI intolerance, emerging resistance) Gemifloxacin 320 mg orally + azithromycin 2g PO

23 Any downside to the new regimens? Nausea was common 27% for gentamicin + AZ, 37% for gemifloxacin + AZ 3% and 7% in each group vomited <1hr after administration

24 Antibiotic-Resistant Gonorrhea

25 % of Isolates with Elevated Ceftriaxone MICs ( μg/ml) and Elevated Cefixime MICs ( 0.25 μg/ml), Gonococcal Isolate Surveillance Project (GISP), US: 0.8% EU: 4.5% China: 21% * Isolates not tested for cefixime susceptibility in 2007 and 2008.

26 Ceftriaxone-Resistant Gonorrhea Has Reached North America Emerging Infectious Diseases, Vol 24 (2), February 2018

27 Suspected GC Treatment Failure TEST WITH CULTURE AND NAAT: If GC culture not available, call your local health department REPEAT TREATMENT: Gemifloxacin 320 mg + AZ 2g OR Gentamicin 240 mg IM + AZ 2g If reinfection suspected, repeat treatment with CTX AZ 1g REPORT: To your local health department within 24 hours TEST AND TREAT PARTNERS: Treat all partners in last 60 days with same regimen TEST OF CURE (TOC): TOC 7-14 days with culture (preferred) and NAAT

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29 Partner Treatment

30 Case 4: Ron, I have news for you You diagnose Dr Goldschmidt with chlamydia, and ask him to come in for azithromycin DOT. He has had 6 partners in the past 2 months. What does CDC recommend as the most effective way to ensure his partners are treated? 1) Have him bring partners with him when is treated. 2) Tell him to encourage his partners to see a provider 3) Give medication or a prescription to his partner(s) without actually evaluating them in person 4) More than one of the above

31 Partner Management Recs Clinical evaluation first-line option (but traditional referral has low rates of partner treatment) Concurrent patient-partner therapy may be effective for patients with one partner Offer Expedited Partner Therapy routinely to heterosexual pts with CT/GC if partner cannot be promptly treated (multiple RCTs showing efficacy) Dual therapy (cefixime 400 mg + azithromycin 1 g) is crucial if this is offered

32 Legal Status of Expedited Partner Therapy in U.S. (7/2017) Centers for Disease Control and Prevention. Legal Status of Expedited Partner Therapy. July

33 Repeat Infections Or the STD

34 Repeat Infection is Common and Dangerous 15% of women with CT are reinfected in 3-6 months Repeat CT infection leads to higher risk of complications: PID, ectopic pregnancy, infertility Relative Risk Pelvic Inflammatory Disease Ectopic Pregnancy Most infections are asymptomatic 0 1st Infection 2nd Infection 3rd Infection Hillis SD, et al. (1997). Am J Obstet Gynecol 176(1 Pt 1):

35 Rescreen for STDs and HIV Women who test positive for CT/GC, or trichomonas should be rescreened three months following treatment. Men who test positive for chlamydia or gonorrhea should be rescreened at three months after adequate therapy. All patients with a bacterial STDs or trichomonas should be tested for HIV

36 Case 5: I ve had a lot of HPV 23 year old female with history of genital warts at age 16 (resolved after treatment with liquid nitrogen), and an ASCUS pap/ HR HPV+, returning for repeat cytology today

37 HPV 101 Over 170 types of HPV classified Updated incidence/prevalence estimates (CDC): 14 million new infections per year 79 million people infected in the US devilliers, 2013, Virology Satterwhite, 2013, STD

38 . HPV Vaccines Bivalent vaccine (type 16/18) withdrawn from US market Quadrivalent vaccine now phased out. Nonavalent HPV Vaccine Types 6, 11, 16, 18, 31, 33, 45, 52, 58 Prevents warts, cervical cancer, anal cancer FDA-approved for females and males 9-26

39 Case 5, continued: What vaccination should she be prescribed against HPV? 1) Nonavalent vaccine (2 dose series, 0, 6 mos) 2) Nonavalent vaccine (3 dose series, 0, 2, 6 mos) 3) Either of the above is acceptable 4) She should not get HPV vaccine

40 * Irrespective of history of abnormal Pap, HPV, genital warts MMWR, May ; 59(20): , MMWR, December ; 60(50); MMWR, March 27, 2015; 64(11); MMWR, December 16, 2016 / 65(49); vHPV Vaccine Recommendations Population Recommendation Gender Age # of doses Females (9-14 yrs old) Males (9-14 yrs old) Schedule 2 0, 6-12 months , 2, 6 months 2 0, 6-12 months , 2, 6 months (permissive) 3 0, 2, 6 months MSM,HIV+ Males , 2, 6 months

41 Case 6: Young man with a rash 30 yr old man who has sex with men (MSM) with a 4 day history of low grade fever, lymphadenopathy Last sexual encounter was 30 days ago He took a rapid home HIV test OTC which was negative Skin: macular-papular rash on trunk (chest/back) No rash on palms or soles GU exam unremarkable other than LAD

42 Syphilis: current epidemiology Syphilis rates among MSM will soon be similar to those in the early 1980s Peterman, 2015, Expert Rev Anti Infect Ther

43 The USPSTF recommends screening for syphilis infection in persons who are at increased risk for infection Who is at increased risk? USPSTF, Syphilis Infection in Nonpregnant Adults and Adolescents: Screening. November 2016.

44 Who is at increased risk for syphilis? Men who have sex with men (MSM) HIV+ men HIV+ women History of incarceration History of commercial sex work Certain racial ethnic groups (Hispanic, Black, Pacific Islander, Alaska Native) Syphilis Infection in Nonpregnant Adults and Adolescents: Screening. USPSTF, November 2016.

45 Secondary Syphilis Exposure Primary Syphilis Secondary Syphilis Usually occurs 3-6 weeks after primary chancre Rash (75-90%) Palm/Soles (60%) Generalized lymphadenopathy (70-90%) Constitutional symptoms (50-80%) Mucous patches (5-30%) Condyloma lata (5-25%) Patchy alopecia (10-15%) Symptoms of neurosyphilis (1-2%)

46 Rashes of Secondary Syphilis SFCC- split papule Macular Palmar Dr. Joseph Engelman, San Francisco City Clinic Papular STD Atlas, 1997

47 Syphilis Treatment Primary, Secondary & Early Latent: Benzathine penicillin G 2.4 million units IM in a single dose Late Latent and Unknown Duration: Benzathine Penicillin G 7.2 million units total, given as 3 doses of 2.4 million units each at 1 week intervals Neurosyphilis: Aqueous Crystalline Penicillin G million units IV daily administered as 3-4 million IV q 4 hr for d In pregnancy, benzathine penicillin is the only recommended therapy. No alternatives

48 Case 7: Man with a Drip A 23 yo male presents for evaluation of a urethral discharge without dysuria He has been seen in STD clinic 15 times between 5/22/12 and 9/2/14 Sometimes visible discharge on exam, sometimes not On 9 occasions a urethral Gram stain performed 5 times <5PMN/ hpf 4 times >5PMN/ hpf GC documented 5/23/13, otherwise, tested for GC and CT at each of the 15 visits and always negative Most recently treated with 1gm Azithromycin orally once; partner received treatment; GC and CT neg

49 Today he presents with thick, white discharge now what? Source: Diepgen TL, Yihune G et al. Dermatology Online Atlas

50 What is your next step? 1) Give up 2) Give him longer course of azithromycin 3) Get a urine culture 4) Try a different antibiotic 5) Get a consult from ID 6) More than 1 of the above

51 Sexually Transmitted Diseases, 4 th Edition, Holmes et al CDC 2015 STD Treatment Guidelines Urethritis Common Infectious Causes Bacterial STDs: GC 5-20% CT 15-40% Mycoplasma genitalium 15-25% Other etiologies: Trichomonas vaginalis 5-20% (regional differences) HSV Ureaplasma 0-20%; data inconsistent Adenovirus, enterics, Candida, anaerobes

52 CDC 2015 STD Treatment Guidelines Appropriate Management of Persistent Urethritis Document urethritis Rule out noncompliance Rule out untreated partner/re-infection Consider M. genitalium- particularly if initially treated with doxycycline Consider T. vaginalis* in men who have sex with women trichomonas culture * MSM low probability of T. Vaginalis

53 CDC 2015 STD Treatment Guidelines Persistent NGU Treatment If azithromycin NOT given for 1 st episode: Azithromycin 1 g orally in a single dose PLUS Metronidazole 2 g orally in a single dose OR Tinidazole 2 g orally in a single dose If azithromycin given for 1 st episode: Moxifloxacin 400 mg orally qd x 7d PLUS Metronidazole 2 g orally in a single dose OR Tinidazole 2 g orally in a single dose Urology referral if symptoms persist

54 Epilogue Patient takes moxifloxacin 400 mg po x 7 days. Symptoms finally resolve. Take home point: Think about M. genitalium in cases of urethritis treatment failure.

55 Want to know more about STDs? There s an app for that. CDC Treatment Guidelines App for Apple and Android Available now, FREE! (Search STD TX on app store)

56 STD Clinical Consultation Network (STDCCN) Provides STD clinical consultation services to healthcare providers nationwide (1-5 days depending on urgency) Your consultation request is linked to a CDC-funded STD Prevention Training Center s expert faculty We are just a click away!

57 Thank you!! Contact information

58 Any burning questions?