Sexually Transmitted Infections in the ER. Sahand Ensafi, CCPA University Health Network

Transcription

1 Sexually Transmitted Infections in the ER Sahand Ensafi, CCPA University Health Network

2 WARNING This presentation will contain numerous grotesque images of genitalia. Viewer discretion is advised.

3 No disclosures

4 Overview Many pitfalls in the recognition, diagnosis and management of STI s in the ED Following this talk you should feel more comfortable with: Identification of common STIs in the ED Confirming the diagnosis using the appropriate modalities Management of said infections using most recent guidelines/recommendations

5 Case 1 25 y.o sexually active female seen in fast track Dyspareunia x 1 week Vaginal discharge x 2 days Treated for Gonorrhea 2mo ago 1 New Partner Normal Vitals

6 Diagnosis A. Urine NAAT for G&C B. Pelvic Exam with Urine NAAT for G&C C. Pelvic Exam with Cervical NAAT for G&C D. Pelvic Exam with Cervical swabs for culture

7 Chlamydia

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9 Gonorrhea

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11 Clinical Features Often G&C will coexist, Gonorrhea more likely to become symptomatic Vaginal discharge sometimes described as mucopurulent when coinfection present but difficult to differentiate clinically Reactive arthritis Septic arthritis Women Asymptomatic cervicitis Vaginal discharge, bleeding, dysuria, lower abdo discomfort Men Urethritis, epididymitis, proctitis, urethral discharge

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13 Diagnosis

14 Recommended Diagnostic Modality 2013 Public Health Ontario Guidelines

15 Specimen Collection Ideally, patients should not void x 2h Urethral Swabs Painful, next urination may be painful, Increase H2O consumption post swab, thin dry swab (can moisten with water) inserted 3-4cm in male Urine Sample First Void - ~10-20cc into container Cervical Swab Remove overlying vaginal secretions/exudate Insert sterile swab 1-2cm into endocervical canal, rotate 180 and withdraw

16 Chlamydia is not an issue Management Always playing catch up with Gonorrhea 1935 Sulfonamides Res Penicillin Res over ~ two decades 1945 Tetracycline Patients with PCN allergy High level resistance Spectinomycin Res. 1967, high levels s Quinolones Res. 1990, high levels s Macrolides Azithro better than Eryhtro Res. late 90 s Cephalosporins Res to cefixime 8% in Toronto 2013

17 Second Line: Cefixime Azithro 1g Ceftriaxone mixed with 0.9mL of 1% xylo without epi!

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19 The Future Patients with uncomplicated gonorrhea received either gentamicin 240mg IM + Azithro 2g PO or gemifloxacin 320mg PO + Azithro 2g PO Microbio cure in 100% of 202 gent/azithro combo & 99.5% of 199 of gemi/azithro combo Ceftriaxone resistant strains have been reported in Japan, Spain and France

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21 Patient Education

22 Case 2 32 y.o female received during handover RUQ Pain T-38 BP-120/80 HR-88 WBC-12 B-hcg negative All other labs unremarkable Awaiting U/S Instructions: Refer to surgery if cholecystitis D/C home if U/S Normal

23 Case 2 - Continued Ultrasound: No gallstones Thickened fluid filled fallopian tubes Next Step: A. D/C patient home with f/u GP and repeat ultrasound as out-patient B. Refer to General Surgery C. Other?

24 Next Step Re-examine the patient! Was there a pelvic exam? CMT/adnexal tenderness Swabs sent Endocervical Swab - +Chlamydia

25 Fitz-Hugh Curtis Syndrome Perihepatitis

26 Diagnosis Public Health Agency of Canada

27 Making the Diagnosis DO NOT MISS this diagnosis 10-15% of women of reproductive age 2/3 go unrecognized Landmark Scandinavian Cohort Study (Westrom et al.) Patients >= 1 episode of PID 1/10 ectopic on 1 st pregnancy after episode 1/5 infertility 1/4 recurrence 1/4 chronic pelvic pain

28 PID Treatment Pregnancy PCN Allergy Toronto Public Health Guidelines 2014

29 Case 3 A 60 year old male presents to the ER with a 2 day history of a painless lesion at the base of the penis. He would like a course of antivirals as he believes that it is a herpes flare.

30 Something doesn t add up

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32 Epidemiology

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34 The Great Imitator Primary Chancre ~2 to 4 weeks post exposure (9 to 90 days) Papule Ulceration Painless, smooth slightly raised edge, well defined, clean base

35 The Great Imitator Secondary 5-8 wks post resolution of primary Total body, macular rash trunk palms/soles Constitutional Symptoms Generalized adenopathy Discrete, Non-tender Latent/Tertiary to follow

36 Confirmation Darkfield Microscopy of scrapings/fluid from primary/secondary lesions Sensitivity ~ 80% Serologic testing has become standard for secondary/latent/tertiary Not as reliable in primary VDRL, RPR vs MHA-TP, FTA-ABS Non-treponemal tests may not be reactive in early primary infection Ensure patient has follow-up, consider adjunct treponemal tests False positive for screen is possible Viruses, Drugs/substance abuse, Rheumatic fever, Lupus/Leprosy

37 Management Pregnancy PCN Allergy Follow - Up

38 Syphilis Patient Education

39 Summary G&C Urine NAAT sufficient in men and asymptomatic women Think CULTURE if patient has treatment failure, recurrent episodes, female with symptoms, marital complications Azithro + Ceftriaxone..Gemifloxacin/Gentamicin may be an alternative Ceftriaxone dilution with 0.9mL of xylo/lido for comfort PID Do not miss! High index of suspicion with high rate of complications RUQ pain NYD think of FHC!! R/a out patients in 48-72h Ceftriaxone + Doxy x 2 weeks Syphillis Making a comeback Difficult to diagnose, easy to treat VDRL may take 2 weeks post chancre to become positive Pen G to become syphilis free

40 If you retained nothing

41 Death is the cure for all disease -Thomas Browne

42 References Ratnam, Sam. "The Laboratory Diagnosis of Syphilis." The Canadian Journal of Microbiology (2005): US National Library of Medicine. Web. Report on Sexually Transmitted Infection in Canada: Rep. Public Health Agency of Canada, Feb Web. Sept "Sexual Health and Sexually Transmitted Infections Prevention and Control Protocol, 2013 (Revised)Sexual Health and Sexually Transmitted Infections Prevention and Control Protocol, 2013 (Revised)." (n.d.): n. pag. Ontario Ministry of Health and Long Term Care Web. 1 Oct Marx, John A., Robert S. Hockberger, Ron M. Walls, and Michelle H. Biros. "Chapter 98: Sexually Transmitted Diseases." Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia: Elsevier Saunders, Print. Tintinalli, Judith E., and J. Stephan. Stapczynski. "Chapter 144: Sexually Transmitted Diseases." Tintinalli's Emergency Medicine: A Comprehensive Study Guide. New York: McGraw-Hill, Print. Canadian Guidelines on Sexually Transmitted Infections. Public Health Agency of Canada, Web. 1 Oct