4/6/17 UNPRECEDENTED HIGH. Shelagh Larson, RNC, WHNP, NCMP

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1 Shelagh Larson, RNC, WHNP, NCMP UNPRECEDENTED HIGH Total combined cases of chlamydia, gonorrhea, and syphilis reported in 2015 reached the highest number ever, according to the annualmore than 1.5 million chlamydia cases reported (1,526,658), nearly 400,000 cases of gonorrhea (395,216), and nearly 24,000 cases of primary and secondary (P&S) syphilis (23,872) Many cases of chlamydia, gonorrhea, and syphilis continue t o go undiagnosed and unreported, and data on several additional STDs such as human papillomavirus, herpes simplex virus, and trichomoniasis are not routinely reported to CDC. estimates that nearly 20 million new STDs occur every year in this country, half among young people aged 15 24, and account for almost $16 billion in health care costs. WHY: more than half of state and local STD programs have experienced budget cuts, resulting in more than 20 health department STD clinic closures in one year alone. Fewer clinics mean reduced access to STD testing and treatment for those who need these services. 1

2 Patients aged between 15 and 24 years accounted for 2/3 of the more than 1.5 million cases of chlamydia and half of the nearly 400,000 cases of gonorrhea. Men who have sex wit h men accounted for t he majorit y of new gonorrhea and primary and secondary syphilis cases, and may face a higher risk ofantibiotic resistant gonorrhea. The rate of syphilis diagnosis among women rose more than 27% since 2014, and there was a 6% increase in congenital syphilis to 487 cases 2015, 1,526,658 cases were reported; 479cases/100,000 population. ^ 5.9% from availability of urine test increased rate in US Men ^ 10.5% compared to ^ women 3.8% from Still women report 2x reported cases than men a total of 1,526,658 chlamydial to a rate of cases per 100,000 population infect ions During , rates increased in 37 st at es and the District of Columbia. 2

3 AZITHROMYCIN 1 G PO IN A SINGLE DOSE Doxycycline 100 mg BID x7 days Alternative Regimens Erythromycin base 500 mg PO QID x 7 days Erythromycin ethylsuccinate 800 mg PO QID x 7 days Levofloxacin 500 mg po daily x 7 days Ofloxacin 300 mg po BID x 7 days Pregnancy Amoxicillin 500 mg PO TID for 7 days Erythromycin base 500 mg PO QID x 7 days or 250 mg orally QID x 14 days Erythromycin ethylsuccinate 800 mg PO QID x 7 days or 400 mg PO QID xfor 14 days 3

4 Recommended Regimens Azithromycin 1 g orally in a single dose Alternative Regimens Amoxicillin 500 mg orally three times a day for 7 days Erythromycin base 500 mg orally four times a day for 7 days Erythromycin base 250 mg orally four times a day for 14 days Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days Erythromycin ethylsuccinate 400 mg orally four times a day for 14 days 4

5 2009 historical low: 98.1cases/100, : 395,216 cases reported (^123.9 cases/100,000) to 12.8% increase overall increase 18.3% men, 6.8% in women More than 800,000 gonorrhea infections are estimated to occur in this country each year, but fewer than half are diagnosed With increased resistance to the fluoroquinolones and declining susceptibility to cefixime, dual therapy with ceftriaxone and azithromycin is now the only CDC recommended treatment for gonorrhea Ant ibiot ic resist anc e is t hreat ening t he effec t iveness of gonorrhea t reat ment in t he Unit ed States health officials have identified a cluster of gonorrhea infections that shows both decreased susceptibility to ceftriaxone and very high-level resist ance t o azithromycin gonorrhea has developed resistance to nearly every drug ever used to treat it, including sulfonamides, penicillin, tetracycline, and fluoroquinolones recent CDC data indicate that resistance to azithromycin is emerging. azithromycin combined with ceftriaxone is still an effective treatment option for gonorrhea 5

6 Screen all sexually active women younger than 25 years, as well as older women with risk factors such as new or multiple sex partners, or a sex partner who has a sexually transmitted infection. Screen sexually act ive MSM at anat omic sit es of possible exposure at least annually. Evaluate and treat all patients sex partners from the previous 60 days Obtain cultures to test for decreased susceptibility from any patients with suspected or documented gonorrhea treatment failures Report any suspected treatment failure to local or state public health officials within 24 hours, helping to ensure that any potential resistance is recognized early Primary and secondary cases (P&S) ^ every year since : cases reported 19% increase from 2014 In 2015, men accounted for over 90% of all cases of P&S syphilis, 81.7% were MSM (CDC) data show a 15 percent increase in the number of syphilis infections from 2013 to 2014 alone. Two new studies presented at the 2016 STD Prevention Conference suggest that syphilis is taking a particularly severe toll on gay, bisexual, and other men who have sex with men (MSM), especially in the South. 6

7 Until normal quantit ies of penicillin G benzathine are available, CDC suggests the following: Refrain from the use of Pen G for treatment of other infectious diseases (e.g., streptococcal pharyngitis) where other effective antimicrobials are available. Adhere t o t he rec ommended dosing regimen of 2.4 million unit s of penic illin G benzathine IM for the treatment of primary, secondary and early latent syphilis (i.e., early syphilis) practitioners have inadvertently prescribed combination benzathine-procaine penicillin (Bicillin C-R) instead of the standard benzathine penicillin product (Bicillin L-A) Primary & Secondary Adult s IM in a single dose Early Latent Syphilis Adult s IM in a single dose For Infants/Children Benzathine penicil lin G 50,000 units/kg IM, up to the adult dose of 2.4 million units in a single dose Late Latent Syphilis Adult s administered as 3 doses of 2.4 million unit s IM each at 1-week int ervals 7.2 million units total For infants/children Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million units, administered as 3 doses at 1- week intervals 7

8 The risk for penicillin cross-reactivity between most second-generation (cefoxitin) and all third generation cephalosporins(cefixime and ceftriaxone) is negligible cefoxitin, cefixime, and ceft riaxone do not have an R group side chain similar t o penicillin G. is the most common sexually transmitted infection in the United States 40 distinct types can infect the genital tract; 5about 90% of infections are asymptomatic and resolve spontaneously within two year types 16 and 18 account for approximately 70% of cervical cancers worldwide, Types 6 and 11 are responsible for approximately 90% of genital warts. A quadrivalent HPV vaccine that protects against infection by HPV types 6, 11, 16 and 18 has been licensed in the United States for use in females since June 2006,and in males since October In October 2009, a bivalent HPV vaccine that protects against infection by HPV types 16 and 18 was licensed for use in females. In December 2014, a 9-valent vaccine that protects against infection by the HPV types included in the quadrivalent vaccine (6,11,16,18), as well as five additional cancer causing types (HPV types 31, 33, 45, 52, and 58), 8

9 For females all three vaccines have been recommended for those aged 11 or 12 years, and through age 26 those who have not been vaccinated previously Vac c inat ion is also rec ommended through age 26 years for immunoc ompromised persons (including those infected with HIV) who have not been vaccinated previously. For males the quad- and 9-valent vaccines recommended for those aged 11 or 12 years, and through age 21 in those who have not been vaccinated previously. Vac c inat ion of gay, bisexual, and other men who have sex with men (collectively referred to as MSM) through age 26 is also recommended; ot her males aged years may be vaccinated. YES. If you get them!!! In 2015, a national survey found that 63% of girls aged years had received at least 1 dose of the HPV vaccine, and 42% had received all 3 doses in the series. Vac c ine upt ake is lower among boys; 50% aged years received at least 1 dose, but only 28% received all 3 doses. 16 9

10 WET Mount: specimens should be examined within 10 minutes to observe motile parasites, which are diagnostic. Wet mount is an inexpensive diagnostic test; however, sensitivity is estimated at 51-65%, and varies based on the ind ivid ual p erforming the test and how p romp tly the slid e is interpreted Neither conventional nor liquid-based (Pap) smears are suitable for routine screening or diagnosis of T. vaginalis, because sensitivity is poor Nucleic acid amplification tests (NAATs) Trichomonas Vaginalis Qx Amplified DNA Assay are the most sensitive tests available for detection launched in Europe in 2012, but is not FDA-cleared in the United States at this time. CDC. Sexually transmitted disease surveillance Acc essed Oct. 19, CDC. (Sept ) STD Prevention Conference. Retrieved from d-preventionconference.html. CDC (Oct, 2016). Other sexually transmitted diseases. Retrieved from: 10