STD UPDATE 2017 FSACOFP CONVENTION

Transcription

1 STD UPDATE 2017 FSACOFP CONVENTION L. Michael Waters, Jr, DO Adjunct Clinical Assistant Professor of Family Medicine LECOM-Bradenton Clinical Assistant Professor of Family Medicine PCOM- Georgia

2 DISCLOSURES & ACKNOWLEDGEMENTS No conflicts of interest or financial disclosures Thank-you for your help: Todd Leibowitz, DO, PGY-1 (Family Practice Residency) Barrett Attarha OMS IV, PCOM-GA

3 STD LIST AND DESCRIPTIONS Gonorrhea: N. gonorrhoeae; could be asymptomatic or burning urination and discharge, can lead to PID Chlamydia: C. trachomatis; burning on urination and discharge, can lead to PID Herpes: HSV I and HSV II; skin lesions and blisters mimicking razor stubble/ingrown hair Trichomoniasis: Trichomonas vaginalis; green, foul smelly discharge to asymptomatic Pubic Lice: Pthirus pubis; genital itching and visible nits Syphilis: Treponema pallidum: rash, ulcers, cardiac, neurological HPV: Human Papilloma virus (multiple numbers), skin lesions to cancer HIV: multiple different HIV viruses; fatigue, and multitude of other symptoms including immune suppression Hepatitis: Hepatitis B and Hepatitis C; asymptomatic or fatigue and signs of liver failure Chancroid: H. ducreyi; painful genital ulcer and inguinal lymph node

4 STD RISK FACTORS IT DOESN T MATTER MARRIED OR SINGLE Unprotected sex Any kind of sex, oral, anal, vaginal Multiple partners Alcohol and Illicit Drug Use Increased risk of poor choices for unprotected sex and multiple partners MSM, bisexual, men Specifically increased risk of Syphilis and HIV Bacterial vaginosis Increased risk of getting or giving HIV Increased risk of getting Chlamydia and Gonorrhea

5 PURITY PLEDGES From a public health perspective are encouraged as a delayed age of initial intercourse decreases STD rates and pregnancy rates in the population Have shown in several studies that they don t prevent all sexual activity Anal and oral sex is still performed in some cases = Technical Virginity Important that parents are aware to continue to communicate with children after Pledge is signed

6 CHLAMYDIA SCREENING WOMEN Sexually active women under 25 years of age Sexually active women aged 25 years and older if at increased risk Retest approximately 3 months after treatment PREGNANT WOMEN All pregnant women under 25 years of age Pregnant women, aged 25 and older if at increased risk Retest during the 3rd trimester for women under 25 years of age or at risk Pregnant women with chlamydial infection should have a test-of-cure 3-4 weeks after treatment and be retested within 3 months

7 CHLAMYDIA SCREENING MEN MSM *Consider screening young men in high prevalence clinical settings or in populations with high burden of infection (e.g. MSM) At least annually for sexually active MSM at sites of contact (urethra, rectum) regardless of condom use Every 3 to 6 months if at increased risk

8 CHLAMYDIA DIAGNOSIS AND TREATMENT Diagnosed by first catch urine, or by urethral swab (men), or endocervical and vaginal swab (female) Treated with 1 g oral Azithromycin x 1 Typically given empirically with 250mg IM Ceftriaxone Other treatment options include: Doxycyline 100mg po BID for 7 days Erythromycin base 500mg four times daily po for 7 days Levaquin 500mg po daily for 7 days Need to treat sex partners within past 60 days

9 HIV SCREENING HIV Women For sexually active individuals, screen at first HIV evaluation, and at least annually thereafter More frequent screening for might be appropriate depending on individual risk behaviors and the local epidemiology Consent is needed to be obtained in most situations Done for free if donating blood All women aged years (opt-out) All women who seek evaluation and treatment for STDs Pregnant Women Men MSM All pregnant women should be screened at first prenatal visit (opt -out) Retest in the third trimester if at high risk All men aged (opt-out) All men who seek evaluation and treatment for STDs At least annually for sexually active MSM if HIV status is unknown or negative and the patient himself or his sex partner(s) have had more than one sex partner since most recent HIV test

10 HIV DIAGNOSIS AND TREATMENT Rapid testing followed by confirmation RNA testing Western blot confirmation Medications started based upon CD4 count HAART therapy (combination therapy) Antibiotic co-treatment for prevention of opportunistic illnesses Azithromycin 1200mg weekly Bactrim DS 160mg TMP po daily

11 GONORRHEA SCREENING Women Sexually active women under 25 years of age Sexually active women age 25 and older and if at increased risk If positive = Retest 3 months after treatment Pregnant Women All pregnant women under 25 years of age and older women if at increased risk Retest 3 months after treatment

12 GONORRHEA SCREENING Men who have sex with men (MSM) HIV + At least annually for sexually active MSM at sites of contact (urethra, rectum, pharynx) regardless of condom use Every 3 to 6 months if at increased risk For sexually active individuals, screen at first HIV evaluation, and at least annually thereafter More frequent screening for might be appropriate depending on individual risk behaviors and the local epidemiology

13 GONORRHEA DIAGNOSIS AND TREATMENT Diagnosed by endocervical and vaginal swabs (women); urethral swabs (men); and urine (men and women) Resistance has been shown for just monotherapy, so CDC recommends combination therapy (Ceftriaxone and Azithromycin) In 2007 flouroquinolone resistance resulted in stopping those drugs for gonorrhea Typically treated before culture returns so dual therapy is easier If ceftriaxone unavailable or pt hates shots, substitute with Cefixime 400mg po x1 For most gonorrhea infections recommended to take Ceftriaxone 250mg and Azithromycin 1g x1 Disseminated gonococcal infections and conjunctivitis are recommended Ceftriaxone 1g and Azithromycin 1g x1. Pediatric and neonatal cases are weight based dosing for the ceftriaxone.

14 TRICHOMONAS SCREENING Women *Consider for women receiving care in high-prevalence settings (e.g., STD clinics and correctional facilities) and for women at high risk for infection (e.g., women with multiple sex partners, exchanging sex for payment, illicit drug use, and a history of STD) 17 Persons with HIV: Recommended for sexually active women at entry of care and annually thereafter

15 TRICHOMONIASIS DIAGNOSIS AND TREATMENT Diagnosed with vaginal and urethral swabs, or urine culture Treat with metronidazole or tinidazole Tinidazole 2g PO x 1 (with food) Metronidazole 2g PO/IV x1 or 500mg BID for 7 days (IV/PO) Do not drink alcohol within 24 hours of either of these medications No sexual activity for 7-10 days after treatment is concluded Treat all partners, can easily reacquire If not successfully treated, this infection can last for years

16 SYPHILIS SCREENING Pregnant Women All pregnant women at the first prenatal visit Retest early in the third trimester and at delivery if at high risk MSM Men who have Sex with men HIV + At least annually for sexually active MSM Every 3 to 6 months if at increased risk For sexually active individuals, screen at first HIV evaluation, and at least annually thereafter More frequent screening might be appropriate depending on individual risk behaviors and the local epidemiology

17 SYPHILIS DIAGNOSIS AND TREATMENT Need two tests to confirm: either RPR or VDRL and a FTA-ABS (a treponeal test) Typically a one time injection Most treatments are 2.4million units IM of Benzathine Penicillin G Late latent syphilis is with 7.2 million units (given over 3 weeks with 2.4 million units given weekly Limited data on non-penicillin treatment, but some treatments ok if not pregnant Doxycyline 100mg po BID for 28 days Tetracycline 500mg po four times daily for 28 days Doxycyline preferred due to less GI effects and fewer dosages per day Pregnant patients with PCN allergy need to be desensitized and treated with PCN Need to treat all sexual partners within the past 90 days

18 HERPES - SCREENING Per USPSTF Women No longer recommended for asymptomatic adults and adolescents (even if pregnant), Grade D Moderate certainty from USPSTF that asymptomatic screening provides more harm than good. Type-specific HSV serologic testing should be considered for women presenting for an STD evaluation (especially for women with multiple sex partners) Pregnant Women Men MSM *Evidence does not support routine HSV-2 serologic screening among asymptomatic pregnant women. However, type -specific serologic tests might be useful for identifying pregnant women at risk for HSV infection and guiding counseling regarding the risk for acquiring genital herpes during pregnancy *Type-specific HSV serologic testing should be considered for men presenting for an STD evaluation (especially for men with multiple sex partners) *Type-specific serologic tests can be considered if infection status is unknown in MSM with previously undiagnosed genital tract infection Persons with HIV *Type-specific HSV serologic testing should be considered for persons presenting for an STD evaluation (especially for those persons with multiple sex partners), persons with HIV infection, and MSM at increased risk for HIV acquisition

19 HERPES DIAGNOSIS AND TREATMENT Through labs PCR is preferred at this time Culture can be obtained as well Can treat either daily as a prophylactically or to treat each outbreak Acyclovir 1 st episode: 400mg PO tid x 7-10 days, if severe, 5-10mg/kg IV q8h x 10 days Recurrence: 400mg PO tid x 5 days Suppression: 400mg PD bid Valacyclovir 1 st episode: 1000mg PO bid x 7-10 days Recurrence: 500mg PO bid x 3 days Suppression: 1000mg PO daily

20 HPV SCREENING Women Women years of age every 3 years with cytology Women years of age every 3 years with cytology, or every 5 years with a combination of cytology and HPV testing Pregnant Women Pregnant women should be screened at same intervals as non-pregnant women Persons with HIV Women should be screened within 1 year of sexual activity or initial HIV diagnosis using conventional or liquid-based cytology; testing should be repeated 6 months later

21 HPV PREVENTION AND TREATMENT Vaccines for females 3 injections given at 1-2 months and 6 months after Prevents cervical, vaginal, oropharyngeal, anal, and vulvar cancer Cervarix protects against 16, & 18 Gardasil protects against 6, 11, 16, & 18 Coming out with a Gardasil 9 Now only 2 doses recommended if younger than 15 Vaccine for males 3 injections given at 1-2 months and 6 months after Prevents penile, oropharyngeal, and anal cancer Gardasil protects against 6, 11, 16, & 18 Coming out with a Gardasil 9 Now only 2 doses recommended if younger than 15

22 HEPATITIS B SCREENING Women If Increased risk population Pregnant Women Men MSM Test for HBsAg at first prenatal visit of each pregnancy regardless of prior testing; retest at delivery if at high risk If increased risk population All MSM should be tested for HBsAg Persons with HIV Test for HBsAg and anti-hbc and/or anti-hbs

23 HEPATITIS C SCREENING Women Women born between Other women If risk factors are present Pregnant Women Pregnant women born between Other pregnant women if risk factors are present MEN Men born between Other men If risk factors are present MSM MSM born between Other MSM if risk factors are present Annual HCV testing in MSM with HIV infection HIV Serologic testing at initial evaluation Annual HCV testing in MSM with HIV infection

24 HEPATITIS B & C INFORMATION Diagnosed by blood test Recommended to get Hep B vaccine Not required to refer, but if you don t feel comfortable, send to GI Multiple drug therapies have been FDA approved to treat 7 antiviral or interferon therapies for Hep B 17 antiviral or interferon therapies for Hep C If these fail, liver transplant might be in order

25 PUBIC LICE mm size Pthirus pubis Diagnosed by visualization of nits and itching Can be treated with any lice topical Wash area first Towel dry Apply and leave as listed Remove nits Repeat if needed

26 CHANCROID INFO, DIAGNOSIS, AND TREATMENT Painful ulcers Can be with HIV or HSV Confirmed with PCR (not FDA approved) or special culture medium Treated with: Azithromycin 1g orally in a single dosage Ceftriaxone 250mg IM in a single dosage Ciprofloxacin 500mg orally bid for 3 days Erythromycin base 500mg orally tid for 7 days

27 NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) Chancroid (Revised 9/96) Chlamydia (Revised 6/09) Gonorrhea (Effective 1/14) Syphilis (Effective 1/14), multiple kinds, including Congenital Syphilis (Effective 1/15)

28 STD COMPLICATIONS Cancer: from HPV = Cervical (virtually all), anal (95%), oropharyngeal (70%), vaginal (65%), vulvar (50%), penile (35%) HPV 16 is most likely cause PID: per the CDC, most women infected with gonorrhea and chlamydia have no symptoms Infertility: caused by PID and other infections can harm the uterus and fallopian tubes Neonatal problems: fetal infections/transmission of illness, fetal demise, microcephaly and other birth defects Divorce / Breakups: these can be stressful and expensive

29 REFERENCES Those who have a new sex partner, more than one sex partner, a sex partner with concurrent partners, or a sex partner who has a sex ually transmitted infection. Screening for Chlamydia and Gonorrhea: U.S. Preventive Services Task Force Recommendation Statement. Annals of inter nal medicine. Sep Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, e.g., those with a new sex partner, more than one sex partner, a sex partner with concurrent partners, or a sex partner who h as a sexually transmitted infection. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, Adolescent clinics, correctional facilities, and STD clinics. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, More frequent STD screening (i.e., for syphilis, gonorrhea, and chlamydia) at 3 6-month intervals is indicated for MSM, including those with HIV infection if risk behaviors persist or if they or their sexual partners have multiple partners. Centers for Disease Control and Prevention. Sex ually Transmitted Diseases Treatment Guidelines, Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, Those who have a new sex partner, more than one sex partner, a sex partner with concurrent partners, or a sex partner who has an STI. Additional risk factors for gonorrhea include inconsistent condom use among persons who are not in mutually monogamous relationships; previous or coexist ing sexually transmitted infections; and exchanging sex for money or drugs. Clinicians should consider the communities they serve and may opt to consult local pub lic health authorities for guidance on identifying groups that are at increased risk. Screening for Chlamydia and Gonorrhea: U.S. Preventive Services Task Force Recom mendation Statement. Annals of internal medicine. Sep Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015.

30 REFERENCES US Preventive Services Task Force. Screening for syphilis infection in pregnancy: reaffirmation recommendation statement. Ann als of internal medicine. 5/19/ ;150(10): American Academy of Pediatrics, American College of Obstetricians and Gynecologists, and March of Dimes Birth Defects Foundat ion. Guidelines for Perinatal Care. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2007 Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, CDC, Health Resources and Services Administration, National Institutes of Health, HIV Medicine Association of the Infectious Diseases Society of America, HIV Prevention in Clinical Care Working Group. Recommendations for incorporating human immunodeficiency virus (HIV) prevention in to the medical care of persons living with HIV. Clin Infect Dis. Jan ;38(1): Aberg JA, Gallant JE, Ghanem KG et al. Primary Care Guidelines for the Management of Persons Infected With HIV: 2013 Update by the HIV Medicine Association of the Infectious Diseases Society of America. CID. Jan ;58: e1-e34. Centers for Disease Control and Prevention, Health Resources and Services Administration, National Institutes of Health, Amer ican Academy of HIV Medicine, Association of Nurses in AIDS Care, International Association of Providers of AIDS Care, the National Minority AIDS Council, and Urban Coalition for HIV/AIDS Prevention Services. Recommendations for HIV Prevention with Adults and Adolescents with HIV in the United States, December 11, Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, CDC. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health -care settings. MMWR. 9/22/ ;55(No. RR-14):1-17. Going most of the way, technical virginity among American adolescents, Uecker et al