HOT OFF THE PRESS! R.

Transcription

1 STI Update 2016: New CDC Treatment Guidelines Focus on the Female HOT OFF THE PRESS! R. Mimi Secor, DNP, FNP-BC, FAANP Onset, Massachusetts

2 Mimi Secor, DNP, FNP-BC, FAANP Nurse Practitioner for 40 years Just Us Women, North Attleboro, Massachusetts 2013 MCNP Lifetime Achievement Award (Mass NP Assoc) DNP 2015, from Rocky Mountain University, Provo, Utah Nov 2016, 5 th Place in FIRST bodybuilding Show Passion: Helping NPs become Healthy, Happy and Fit Coauthor of 2014 Advanced Health Assessment of Women: Skills and Procedures. Springer, AJN Book of the Year! Coauthor, The GYN Exam for NPs in a Nutshell Visiting Scholar, Boston College Fellow, American Academy of Nurse Practitioners Owned a private practice for 12 years in Massachusetts ( ) Worked in Alaska for 7 years ( ) Secor 2017 Copyright 2

3 STI Update: Objectives Upon completion of this session attendees will be able to describe: 1. Discuss epidemiology of STIs in US 15 mins 2. Explain diagnostic work- up for STIs 15 mins 3. Management: focusing on the female: Herpes, CT/GC, PID, Cervicitis, HIV, Sexual Assault: 30 mins Secor 2017 Copyright 3

4 Disclosure: Mimi Secor, DNP, FNP-BC, NCMP, FAANP Speaker: Hologic Shionogi Secor 2017 Copyright 4

5 Secor 2017 Copyright 5

6 New CDC STI Treatment Guidelines: June, 2015 MMWR. (June 5, 2015). Sexually Transmitted Diseases Treatment Guidelines, Volume 64 (3). Secor 2017 Copyright 6

7 2013 Prevalence: 110 Million STDs in US Incidence: 20 Million New Infections a Year Human Papillomavirus 20 Million Chlamydia 3 Million Hepatitis B 1.25 Million HIV/AIDS 1.2 Million: 16% Unaware! References: 1 Satterwhite CL, et al. Sexually transmitted infections among U.S. women and men: Prevalence and incidence estimates, Sex Transm Dis 2013; 40(3): pp Owusu- Edusei K, et al. The estimated direct medical cost of selected sexually transmitted infections in the United States, Sex Transm Dis 2013; 40(3): pp Secor 2017 Copyright Genital Herpes 50 Million+ 7

8 A Little Coitus Never Hoitus Teens hooking up Friends with benefits Secor 2017 Copyright 8

9 2010 National STI Survey Often Asymptomatic, Underdiagnosed! 20 million new STIs yearly in US 50% in young years old 25% of ALL teens have 1 > STI 50% of Black teens have > 1 STI Secor 2017 Copyright 9

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11 STI Statistics- National Survey 20 Million NEW STIs yearly = Syndemic STIs increasing: synergy risk, increasing in older adults Chlamydia: > females Gonorrhea: > Men having Sex with Men (MSM) Trichomoniasis: > teens 22/100, older women 11% Herpes: highest prevalence HPV: highest incidence: 40% Americans! Syphilis: 15% incr. since 2003, 69% increase in women HIV: > in MSM (Screen all adults) Hepatitis C: increasing esp. in older adults (Screen all adults born between ) Secor 2017 Copyright 11

12 NEW: HIV Testing 2015 Universal Screening per CDC, 1.2 million Screen ALL adolescents, AND appropriate adults Except if prevalence exceedingly low Screening is cost effective even in low risk pops 50,000 newly diagnosed yearly: 16% Unaware!!! 250,000 undiagnosed with HIV in US Undiagnosed transmit >20,000 infections per year 25% newly HIV+ report NO high risk behaviors >50% diagnosed late, benefiting less from Rx Qaseem et al. Ann Intern Med 2009 Jan 20; epub ahead of print, Secor 2017 Copyright 12

13 Pregnancy: STI Screening NEW 2015 HIV: 1 st, 3 rd trimester Chlamydia: Ages < 25 years GC: If high risk esp. if < 25 years Syphilis: Hepatitis A, B, C (per risk): BV, Trich: Consider screening HSV Type 2: If high risk or symptomatic (not proactive) Secor 2017 Copyright 13

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16 Primary Genital Herpes in Women Handsfield HH. Color Atlas and Synopsis of Sexually Transmitted Diseases Secor 2017 Copyright 16

17 Genital Herpes Simplex Virus: Key Points Most transmission is asymptomatic = 70% Atypical symptoms are MOST common HSV increases HIV risk!!!! HSV 1 = ~ 50% of Primary genital infections Secor 2017 Copyright 17

18 Genital Herpes Simplex Virus: Key Points Culture lesions with PCR (higher sensitivity) Serology IgG Type 1, 2, (IgM is NOT type specific) Offer episodal and/or suppressive therapy Highly stigmatized so Counseling is KEY Education Condoms help Secor 2017 Copyright 18

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20 Chlamydia: Prevalence New - NHANES Research % among persons aged years in the U.S. 4.7% among sexually active females aged yrs 13.5% among non-hispanic blacks CDC recommends Annual Screening For all Sexually Active Females < 25 years old For all Pregnant women, recheck 3 rd trimester if Rxed CDC. (2014, Sep 26). Prevalence of Chlamydia trachomatis Genital Infection Among Persons Aged Years - United States, MMWR Weekly, 63(38), Secor 2017 Copyright 20

21 Chlamydia: Another Hidden STI 1 million reported BUT estimates > 2.8 million! MOST common reportable disease in U.S. MOST Asymptomatic, MOST Undiagnosed 50% of males, 75% of females, 42% screened 10-40% untreated infections may result in PID Chronic pelvic pain, Ectopic pregnancy, Infertility CDC. (2014). MMWR, 63(38), Secor 2017 Copyright 21

22 Chlamydia Screening Yearly CDC Guidelines: All < 25 years old NEW: Vaginal (preferred), Cervical or Urine testing Pt self-collected is acceptable NEW PCR Testing; One collection, multiple detections If available NEW Anyone regardless of age: If risk factors If new partner, esp. if under < 25 (ASK) Or multiple sex partners Include other STIs; GC, HIV, Hep B, C, RPR, HSV? Secor 2017 Copyright 22

23 2015 Chlamydia Treatment: Recommended Regimens- Equal Efficacy Azithromycin 1 gram PO single dose (97% cure) (Pregnancy) or Doxycycline 100 mg PO BID for 7 day (100% cure) or Amoxicillin 500 mg PO TID for 7 days (Pregnancy) Alternatives (see CDC guidelines) Secor 2017 Copyright 23

24 Chlamydia Follow-up: New Research 2014 High reinfection rates support retesting recommendations!!! Aghaizu A et al., Sex Transm Infect 2014 Nov 90:524 Secor 2017 Copyright 24

25 Chlamydia Treatment: NEW 2015 Follow-up Retesting 3-12 months after treatment recommended < 3 weeks NOT recommended (False + risk) Follow-up 3-4 weeks if: Pregnant (Test of cure, or by 3 rd trimester) Compliance unclear Symptoms persist Reinfection suspected Secor 2017 Copyright 25

26 Chlamydia Infection: NEW 2015 Test for Other STIs!!! GC Syphilis HIV Other tests as indicated: HSV, Hepatitis B, C Secor 2017 Copyright 26

27 Chlamydia: Treatment of Sexual Partners Presumptive treatment All partners in past 60 days Expedited partner therapy: State specific NEW: Patient-delivered partner therapy increased EPT use and had a modest effect on gonorrhea and chlamydia incidence. NEW: Schuchat A., N Engl J Med 2015 Feb 19; 372:775 Secor 2017 Copyright 27

28 Expedited Partner Therapy, Legal Status: Prohibited 2016: KY, FL, OH, WV Secor 2017 Copyright 28

29 Chlamydia: Sexual Abstinence Sexual abstinence and/or condoms 7 days after completion of medication Secor 2017 Copyright 29

30 Chlamydia is NOT a flower Secor 2017 Copyright 30

31 GONORRHEA: Uncommon in Heterosexual Women Secor 2017 Copyright 31

32 Uncomplicated Gonococcal Infections of Cervix, Urethra, Rectum, Pharynx* Ceftriaxone (Rocephin) 250 mg IM single dose Or (alternative) Cefixime (Suprax) 400 mg oral single dose tablet or liquid (Less effective for oropharyngeal GC) PLUS Azithromycin 1 gm orally single dose (Duel purpose) NO: Fluoroquinolones NO Longer Recommended Secor 2017 Copyright 32

33 GC: Uncomplicated Oropharyngeal If alternative treatment given: Follow-up test of cure: 2 weeks Secor 2017 Copyright 33

34 GC: NEW 2015 Allergy to Penicillin, Cephalosporins Oral Gemifloxacin 320 mg PLUS Oral Azithromycin 2 g OR Single dose of intramuscular Gentamicin 240 mg PLUS Oral Azithromycin 2 g Secor 2017 Copyright 34

35 Uncomplicated GC: New Treatment Options- Similar Cure Rates N = 600 men (mostly) Gentamicin 240 mg IM plus azithromycin 2 g PO Gemifloxacin 320 mg PO plus azithromycin 2 g PO Side effects: GI significant!!!! Nausea in 28% to 37% of patients Diarrhea in 18% to 23%. Kirkcaldy RD et al. The efficacy and safety of gentamicin plus azithromycin and gemifloxacin plus azithromycin as treatment of uncomplicated gonorrhea. Clin Infect Dis 2014 Oct 15; 59:1083. ( Secor 2017 Copyright 35

36 GC: Treatment Failures Report within 24 hours Local or state health department STD program CDC (tel ) Secor 2017 Copyright 36

37 Cervicitis: NEW Condition 2015 CDC STI Guidelines Symptoms: Often asymptomatic Abnormal vaginal discharge, Intermenstrual bleeding Exam: Mucopus, > 10 WBCs per HPF (predictive) Friability of cervix, sustained endocervical bleeding easily induced by gentle passage of a cotton swab through the cervical os Secor 2017 Copyright 37

38 Rule out: C. Trachomatis N. gonorrhea Trichomoniasis Cervicitis: Diagnosis NEW 2015 Genital herpes (especially primary HSV-2) No organism isolated (> 30 years old) M. genitalium, BV or frequent douching (limited data) Cancer (Pap, HPV testing, consider Colposcopy Secor 2017 Copyright 38

39 Cervicitis: NEW 2015 CDC Treatment Guidelines Presumptive Rx if < 25 years Azithromycin 1 g orally in a single dose OR Doxycycline 100 mg orally twice a day for 7 days Follow-up: Recommended! Secor 2017 Copyright 39

40 Secor 2017 Copyright Slide courtesy of David Soper, MD, Medical University of South Carolina 40

41 PID: Diagnosing per CDC Maintain a low threshold for diagnosis! Due to difficulty of diagnosis & potential for damage even from mild PID Often unrecognized & untreated!!! Mild or nonspecific symptoms DUB, dyspareunia, vaginitis esp. BV Menorrhagia Secor 2017 Copyright 41

42 Pelvic Inflammatory Disease (PID) Diagnostic Criteria Minimum Criteria Abdominal pain and/or tenderness Cervical motion tenderness, +/- mucopus Adnexal tenderness Additional Criteria (1 should be present) - Fever >38C - Wet Mount: WBCs >10 per hpf (predictive) - Pelvic mass on exam - ESR > 15 mm hr + endocervical N. gonorrhea or C. trachomatis Secor 2017 Copyright 42

43 Positive Chandelier test? 43 Secor 2017 Copyright

44 NEW 2015 Update: Outpatient - PID Treatment: IM, Oral Ceftriaxone 250 mg IM in a single dose* PLUS Doxycycline 100 mg orally BID x 14 days WITH (Preferred per CDC) or Without Metronidazole 500 mg PO bid for 14 days Esp. if BV as frequently assoc. with PID CDC, 2015, www/cdc.gov/stds Secor 2017 Copyright 44

45 PID: Criteria for Hospitalization No clinical response, at 72 hours F/u Unable to follow-up Can not exclude surgical emergency Pregnancy Tubo-ovarian abscess Severe nausea, vomiting or high fever Secor 2017 Copyright 45

46 HIV Prevention Recommendations: Post-exposure Prophylaxis (PEP) Offer as soon as possible, within 72 hours: - to anyone who has sustained a mucosal or parenteral exposure to HIV USPHS preferred PEP regimen should be used: - tenofovir/emtricitabine (Truvada ) 1 tablet daily with raltegravir (Isentress ) twice daily for 28 days - If source person s test is negative for HIV, PEP can be stopped before 28 days. Rescreen for HIV: 3 months after completing PEP Kuhar, DT, et al. Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis.Infection Control and Hospital Epidemiology. 2013;34(9): Marrazzo JM, del Rio C, Holtgrave DR, et al. HIV prevention in clinical care settings: 2014 recommendations of the International Antiviral Society USA Secor 2017 Panel. Copyright JAMA. 2014;312(4):

47 HIV Prevention Recommendations: Pre-exposure Prophylaxis (PrEP) Men Who Have Sex with Men HIV-positive sexual partner Recent bacterial STI High number of sex partners History of inconsistent or no condom use Commercial sex work Heterosexual Women and Men HIV-positive sexual partner Recent bacterial STI High number of sex partners History of inconsistent or no condom use Commercial sex work In high-prevalence area or network Injection Drug Users HIV-positive injecting partner Sharing injection equipment US Public Health Service. Pre-exposure prophylaxis for the prevention of HIV infection in the United States Marrazzo JM, del Rio C, Holtgrave DR, et al. HIV prevention in clinical care settings: 2014 recommendations of the International Antiviral Society USA Panel. JAMA. 2014;312(4): Secor 2017 Copyright 47

48 HIV Prevention Recommendations: Pre-exposure Prophylaxis (PrEP) Clinical evaluation Documented negative HIV test result before prescribing PrEP No signs/symptoms of acute HIV infection Normal renal function; no contraindicated medications Documented hepatitis B virus serologies and vaccination status Daily oral doses of TDF/FTC (Truvada), 90-day supply Follow-up visits at least every 3 months: HIV test, medication adherence counseling, behavioral risk reduction support, side effect assessment, STI symptom assessment At 3 months and every 6 months thereafter, assess renal function Every 6 months, test for bacterial STIs US Public Health Service. Pre-exposure prophylaxis for the prevention of HIV infection in the United States Marrazzo JM, del Rio C, Holtgrave DR, et al. HIV prevention in clinical care settings: 2014 recommendations of the International Antiviral Society USA Panel. JAMA. 2014;312(4): Secor 2017 Copyright 48

49 HIV Prevention Recommendations: Clinician Support Clinician Consultation Center (CCC) University of California, San Francisco PrEPline, (1-855 HIV-PREP) PEPline ( ) Secor 2017 Copyright 49

50 Sexual Assault- Post Treatment: NEW EC, Hep B, HPV Vaccination*, HIV PEP** Ceftriaxone 250 mg IM in a single dose PLUS Metronidazole or Tinidazole 2 g orally in a single dose PLUS Azithromycin 1 g orally in a single dose CONSIDER (NOT per CDC) Valacyclovir 1 gm orally qid x5 D (within hours) F/u: 1 wk, 6 wks (RPR) (HIV), 3 mo (RPR, HIV), 6 mo (HIV) *Males ages 9-21, MAY be offered to age 26; Females ages 9-26 ** Per risk, see CDC p 107, Rx: Zidovudine x 28 days (80% reduction) Secor 2017 Copyright 50

51 STI Update: Summary Upon completion of this session attendees will be able to describe: 1. Discuss epidemiology of STIs in US 15 mins 2. Explain diagnostic work- up for STIs 15 mins 3. Management: focusing on the female: Herpes, CT/GC, PID, Cervicitis, HIV, Sexual Assault: 30 mins Secor 2017 Copyright 51

52 Summary and Thank you Mimi Secor, DNP, FNP-BC, FAANP www. MimiSecor.com Facebook Coach Kat and Dr Mimi Facebook page Text Mimi to

53 Bibliography New Cervical Cancer Screening Guidelines CDC STI Treatment Guidelines, Vol 64 (3), June 5, Vaginal Microscopy Video ides Secor 2017 Copyright 53

54 Bib and Resources Fantasia, Secor The GYN Exam for NPs. Springer pub. Carcio & Secor Advanced Health Assessment of Women (3 nd ed). Springer publishing, NY. Contraception Journal with ARHP membership, ARHP.org Journal Watch Women s Health Hatcher et al Contraceptive Technology Update (20 nd edition), Ardent Press Secor 2017 Copyright 54

55 Bibliography ml#clinicalslides Centers for Disease Control and Prevention (CDC). (2009). Sexually transmitted disease surveillance, Atlanta: U.S. Department of Health and Human Services; Jan ( Centers for Disease Control and Prevention (CDC). (2009). Trends in reportable sexually transmitted diseases in the United States, 2007: National surveillance data for chlamydia, gonorrhea, and syphilis. Atlanta: U.S. Department of Health and Human Services; Jan ( Secor 2017 Copyright 55