Professor Jonathan Ross

Transcription

1 SECOND JOINT CONFERENCE OF BHIVA AND BASHH 2010 Professor Jonathan Ross Whittall Street Clinic, Birmingham COMPETING INTEREST OF FINANCIAL VALUE > 1,000: Speaker Name Statement Professor Ross has received personal payments for consultancy and / or lecturing from Gilead Sciences, Roche Products, Bayer, Bristol-Myers Squibb, GSK, Pfizer and MSD. Hospitality or sponsorship to support Prof Jonathan Ros attendance at medical meetings has been reeived from Roche Products, Boehringer Ingelheim, Gilead Sciences, Bristtol-Myers Squibb, GSK, Abbott and MSD. Date 13 April April 2010, Manchester Central Convention Complex Testing for STIs: what s new? Jonathan Ross

2 where are we now? STI testing at BHIVA/BASHH 2010 Conference Abstracts use of gonococcal NAAT compared to culture for rectal and pharyngeal infections point of care tests asymptomatic screening in GU clinics current practice

3 where are we now? STI testing at BHIVA/BASHH 2010 national audit of STI screening Chlamydia urine or urethral NAAT in asymptomatic men 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Anglia Merseyside North Thames North West Northern Northern Ireland Oxford Scotland South Thames South West Trent W Midlands Wales Wessex Yorkshire BASHH national Audit 2009

4 Gonorrhoea NAAT in asymptomatic patients %age men - urethra menurine MSM - urethra MSM - urine women - cervix women - urine women - vaginal BASHH national Audit 2009 Gonorrhoea clinic policy for testing in men 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% urethral culture urine NAAT Anglia Merseyside North Thames North West Northern Northern Ireland Oxford Scotland South Thames South West Trent W Midlands Wales Wessex Yorkshire BASHH national Audit 2009

5 Using NAAT for rectal/pharyngeal specimens receptive anal intercourse gonorrhoea asymptomatic MSM - 16% women - 4% BASHH national Audit 2009 Using NAAT for rectal/pharyngeal specimens receptive anal intercourse gonorrhoea asymptomatic MSM - 16% women - 4% fellatio gonorrhoea asymptomatic MSM - 11% women - 1% BASHH national Audit 2009

6 where are we now? STI testing at BHIVA/BASHH 2010 national audit of STI screening should Neisseria gonorrhoeae NAAT tests replace culture?

7 where are we now? STI testing at BHIVA/BASHH 2010 national audit of STI screening should Neisseria gonorrhoeae NAAT tests replace culture? sensitivity Neisseria gonorrhoeae NAAT sensitivity J Clin Micro 2006:39:1751

8 Neisseria gonorrhoeae NAAT sensitivity BHIVA/BASHH 2010 gonorrhoea cases in Leeds (oral abstract 34) 18% of cases detected only on NAAT (TMA) gonorrhoea cases in London (oral abstract 43) 15% of cases detected only on NAAT (TMA) gonorrhoea cases in Manchester (poster abstract 182) 26% of cases detected only on NAAT (TMA) J Clin Micro 2006:39:1751, BHIVA/BASHH Ann Int Med 2005:142:914

9 where are we now? STI testing at BHIVA/BASHH 2010 national audit of STI screening should Neisseria gonorrhoeae NAAT tests replace culture? sensitivity specificity Rates of diagnoses of gonorrhoea: Males Females Rates per 100,000 population England Wales Scotland Northern Ireland Routine GUM clinic returns

10 gonorrhoea rate 1% GC NAAT specificity 95% positive predictive value = 33% gonorrhoea rate 1% gonorrhoea rate 33% GC NAAT specificity 95% GC NAAT specificity 90% positive predictive value = 33% positive predictive value = 90%

11 where are we now? STI testing at BHIVA/BASHH 2010 national audit of STI screening should Neisseria gonorrhoeae NAAT tests replace culture? sensitivity specificity antibiotic resistance Decreased susceptibility ( 0.25mg/l) of gonorrhoea to cefixime: Percentage of GRASP isolates MSM Heterosexual Males Females Data from the Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP)

12 Microarrays multiple oligonucleotides acting as DNA probes identify specific DNA or RNA sequences STI microarray design ~10 genes per pathogen genus/species-specific genes avoid variable sequences or mobile elements check for possible cross-homology with commensal Multiplex PCR for each gene target T m matched primer combinations >100 plex! oligonucleotide reporters per PCR product on array 60 mers on Agilent 8 x 15K array format

13 Organisms on the STI Pan-pathogen Microarray Treponema pallidum (1) Neisseria gonorrheae (1) Chlamydia trachomatis (2) Mycoplasma genitalium (1) Trichomonas vaginalis (1) Candida albicans (1) Gardnerella vaginalis (1) Haemophilus ducreyi (1) Ureaplasma urealyticum (1) Escherichia coli (5) Neisseria meningitidis (2) Lactobacillus species (2) Staphylococcus aureus (9) Streptococcus agalactiae (3) Streptococcus pyogenes (11) Herpes Simplex Virus type 1 (1) Herpes Simplex Virus type 2 (1) Cytomegalovirus (2) Human Papillomavirus type 6 (1) Human Papillomavirus type 11 (1) Human Papillomavirus type 16 (1) Human Papillomavirus type 18 (1) Human Adenovirus (2) (number of publicly available genomes at time of array design) Gene sequencing sequence all or part of the gonococcal genome identify existing mutations characterise new mutations limited by technology and cost

14 Predicting antibiotic sensitivity with NG - MAST Sex Trans Infect 2010;86:51-5 where are we now? STI testing at BHIVA/BASHH 2010 national audit of STI screening should Neisseria gonorrhoeae NAAT tests replace culture? sensitivity specificity antibiotic resistance rectal and pharyngeal specimens

15 BHIVA/BASHH 2010 Rectal and pharyngeal gonorrhoea detection by NAAT and culture 8% 7% 6% 5% 4% 3% 2% 1% 0% rectum pharynx 70% 60% 50% 40% 30% 20% 10% 0% rectum pharynx NAAT culture oral abstracts 35/43 London MSM screening poster abstract 180 Bristol selected MSM Sexually Transmitted Diseases 2008;35: , BHIVA BASHH 2010 Poster 192

16 where are we now? STI testing at BHIVA/BASHH 2010 national audit of STI screening should Neisseria gonorrhoeae NAAT tests replace culture? sensitivity specificity antibiotic resistance rectal and pharyngeal specimens contamination Before recommendations After recommendations Female toilet 1 inner door handle negative negative Female toilet 2 inner door handle negative negative Female toilet 2 toilet handle negative negative Male toilet inner door handle Gonorrhoea positive Chlamydia and gonorrhoea Female room examination trolley negative negative Laboratory computer 1 keyboard negative negative Laboratory computer 2 keyboard negative negative Specimen hatch (where samples are left by patients for staff to collect) Chlamydia positive Trolley used instead Female toilet 1 toilet handle Male toilet specimen trolley Female toilet 1- specimen trolley Chlamydia positive negative negative Chlamydia and gonorrhoea Chlamydia and gonorrhoea positive Chlamydia and gonorrhoea positive BHIVA/BASHH Oral Abstract 42

17 Before recommendations After recommendations Female toilet 1 inner door handle negative negative Female toilet 2 inner door handle negative negative Female toilet 2 toilet handle negative negative Male toilet inner door handle Gonorrhoea positive Chlamydia and gonorrhoea Female room examination trolley negative negative Laboratory computer 1 keyboard negative negative Laboratory computer 2 keyboard negative negative Specimen hatch (where samples are left by patients for staff to collect) Chlamydia positive Trolley used instead Female toilet 1 toilet handle Male toilet specimen trolley Female toilet 1- specimen trolley Chlamydia positive negative negative Chlamydia and gonorrhoea Chlamydia and gonorrhoea positive Chlamydia and gonorrhoea positive BHIVA/BASHH Oral Abstract 42 Sex Trans Infect 2008;84:107-10

18 Contamination Sex Trans Infect 2008;84: Contamination laboratory approach cleaning of surfaces and equipment with hypochlorite rinsing with distilled water regular processing of environmental swabs separate sample preparation and analysis rooms

19 NAATs are now the preferred tests for gonorrhoea from all sites positive NAATs require repeat testing against a different target to avoid false positive results positive NAATs require culture to monitor antibiotic resistance urine NAATs are less sensitive than vulvo-vaginal specimens in women contamination of clinic surfaces has the potential to cause false positive results where are we now? STI testing at BHIVA/BASHH 2010 national audit of STI screening can Neisseria gonorrhoeae NAAT tests replace culture? testing for Trichomonas vaginalis

20 T. vaginalis diagnoses at UK STI clinics chlamydia gonorrhoea trichomonas No. of cases Year Male Female T. vaginalis diagnoses in USA Emerg Inf Dis 2001;7:927-32

21 epidemiology of T. vaginalis limitations of microscopy/culture IJSA 2003;14:28-29

22 Screening for T. vaginalis in asymptomatic women 70% National average 27% National average 11% 60% 50% 40% 30% 20% 10% 0% microscopy culture Anglia Merseyside North Thames North West Northern Northern Ireland Oxford Scotland South Thames South West Trent W Midlands Wales Wessex Yorkshire BASHH national Audit 2009 Should we screen for T. vaginalis in STI clinics? recognised association with: adverse pregnancy outcomes transmission of HIV not currently recommended unless symptomatic

23 epidemiology of T. vaginalis inadequacy of microscopy/culture NAAT testing transcription mediated amplification Trichomonas - Diagnostic test performance Women sensitivity specificity Men sensitivity specificity ATV Aptima Combo TV transcription mediated amplification Schwebke ISSTDR 2009

24 Should we screen for T. vaginalis in STI clinics? practical issues not yet licensed expected July 2010 not a multiplex test Tigris platform specific Should we screen for T. vaginalis in STI clinics? practical issues not yet licensed expected July 2010 confirmation of positive results not a multiplex test Tigris cost platform specific who to test true prevalence BHIVA BASHH 2010 Poster 244

25 T. vaginalis testing is currently sub-optimal a licensed NAAT will soon be available need to review who to test: symptomatic women male partners of women with T. vaginalis men with (persistent) urethritis? asymptomatic screening where are we now? STI testing at BHIVA/BASHH 2010 national audit of STI screening can Neisseria gonorrhoeae NAAT tests replace culture? testing for Trichomonas vaginalis using multiplex PCR for genital ulcer disease

26 where are we now? STI testing at BHIVA/BASHH 2010 national audit of STI screening can Neisseria gonorrhoeae NAAT tests replace culture? testing for Trichomonas vaginalis using multiplex PCR for genital ulcer disease advantages of genital ulcer PCR Advantages of genital ulcer PCR clinical diagnosis of ulcers inaccurate

27 Sex Transm Dis 1994;70:7-11 Advantages of genital ulcer PCR clinical diagnosis of ulcers inaccurate alternative laboratory tests less sensitive herpes culture

28 Detection of HSV in serologically positive patients presenting with genital lesions 60% 50% %age positive 40% 30% 20% 10% PCR culture 0% cervix vulva perianal (women) penile perianal (men) JID 2003;188; BASHH and IUSTI Europe guidelines recommend PCR as the diagnostic test of choice for herpes

29 Advantages of genital ulcer PCR clinical diagnosis of ulcers inaccurate alternative tests less sensitive herpes H. ducreyi Advantages of genital ulcer PCR clinical diagnosis of ulcers inaccurate alternative tests less sensitive herpes H. ducreyi syphilis

30 J Clin Microbiol 2010;48: Manchester STI clinic 512 patients with genital ulcers over 12 months tested with multiplex PCR herpes 215 (42%) 2 syphilis 29 (6%) serology negative 2 (0.4%) BHIVA/BASHH Oral Abstract 23

31 Advantages of genital ulcer PCR clinical diagnosis of ulcers inaccurate alternative tests less sensitive herpes H. ducreyi syphilis Treponema pallidum sensitivity testing ribosomal mutation (23S rrna gene - A2058G) azithromycin resistant Antimicrobial Agents Chemotherapy 2007;51:

32 Advantages of genital ulcer PCR clinical diagnosis of ulcers inaccurate alternative tests less sensitive herpes H. ducreyi syphilis Treponema pallidum sensitivity testing ribosomal mutation (23S rrna gene - A2058G) syphilis infection at unusual sites panuveitis, retinitis, testes, bone, gastritis, congenital syphilis, placenta, CSF where are we now? STI testing at BHIVA/BASHH 2010 national audit of STI screening can Neisseria gonorrhoeae NAAT tests replace culture? testing for Trichomonas vaginalis using multiplex PCR for genital ulcer disease advantages of genital ulcer PCR limitations of genital ulcer PCR

33 Limitations of genital ulcer PCR currently 4 primer targets: 47kDa gene for syphilis glycoprotein D for herpes haemolytic cytotoxin from H. ducreyi internal control Limitations of genital ulcer PCR currently 4 primer targets: 47kDa gene for syphilis glycoprotein D for herpes haemolytic cytotoxin from H. ducreyi internal control cost availability

34 genital ulcer multiplex PCR is: available accurate sensitive extends diagnostic spectrum but expensive

35 Testing for STIs: what s new? Jonathan Ross