Clinical Cases from the STD Clinical Consultation Network

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1 Clinical Cases from the STD Clinical Consultation Network Christine Johnston STD TCG April 24, 2017 Last Updated: uwptc.org

2 STD Clinical Consultation Network (STDCCN) Developed by Denver PTC Launched in June 2015 Provides STD clinical consultation services within 1-3 business days, depending on urgency, to healthcare providers nationally Your consultation request is linked to your regional PTC s expert faculty We are just a click away!

3 Case 1: Timing of ceftriaxone/azithromycin administration QUESTION: The gonorrhea treatment of ceftriaxone and azithromycin is meant to be given simultaneously. If patients are treated with azithromycin prior to receiving a positive gonorrhea test result, do you recommend retreating with azithromycin plus ceftriaxone vs administering ceftriaxone alone?

4 Case 1: Timing of ceftriaxone/azithromycin administration 1. Treat with azithromycin/ceftriaxone if >7 days since azithromycin was administered 2. Treat with ceftriaxone alone regardless of timing of azithromycin dosing 3. Treat with ceftriaxone alone if <=5 days since azithromycin was administered 4. Treat with both drugs regardless of timing of azithromycin dosing

5 Case 1: CTX/Azithromycin timing Gray areas: Question and answers for the 2015 CDC Guidelines - The half-life of azithromycin is long (68 hours). - It is probably safe to administer ceftriaxone within five days of the azithromycin dose. The half-life of ceftriaxone is short (6 9 hours). - Patients should be retreated with both drugs if they fail to take azithromycin when they receive the ceftriaxone injection.

6 Case 2: Vaginal seeding Pt who might end up with a C/S for breech, she is interested in vaginal seeding. She is HSV-2 positive and taking prophylaxis as prescribed (acyclovir 400 mg PO TID). Do you think vaginal seeding is a good idea for her if she is GBS negative?

7 Case 2: Vaginal seeding Association between C-sections and increased risk for obesity, asthma, allergies and immune deficiencies Babies born via C-section are colonized with skin microbiome, rather than vaginal microbiome Study: 4 patients underwent microbial restoration procedure Incubate gauze in vaginal secretions for 60 minutes Within 2 minutes of birth, put gauze in mouth of infant, then swab entire face and skin Partially restored colonization with vaginal microbiome (compared with 7 infants who underwent vaginal birth and 7 who underwent C-section Increasing popularity of this practice among patients, despite unknown risks or benefits Dominguez-Bello et al, Nat Med 2016

8 Case 2: Do you recommend vaginal seeding? 1. Yes 2. No

9 Case 2: Vaginal seeding: Answer There are no data regarding risks of HSV transmission with vaginal seeding in women with a history of genital herpes. There have been cases of transmission of neonatal herpes among women receiving suppressive therapy, suggesting that breakthrough shedding can occur. Lack of data regarding benefit of vaginal seeding and the risks for possible HSV transmission. Given that potential harm outweighs unknown benefit, would strongly advise against vaginal seeding. Pinninti J Pedatrics 2012

10 Case 3: Dosing of azithromycin QUESTION: A 22 year old female with a positive vaginal chlamydia test was treated with a Z-pack as an oversight: 500 mg azithromycin day 1, 250 mg per day days 2-5. Would this schedule achieve adequate concentration of med? Does she need treatment with azithromycin 1 gm?

11 Case 3: Dosing of azithromycin 1. Redose with azithromycin 1 gm PO x 1 2. Do not redose. Her treatment was adequate with z-pack. ANSWER: Redose with Azithromycin 1 gm PO x 1. Although it is PROBABLY adequate, re-treat in cases where patients received Z-packs

12 Case 4: Boric acid toxicity QUESTION: A 25 yo woman with recurrent BV was treated with metronidazole, now using intravaginal boric acid capsules (600 mg) for 21 days to eradicate BV. When is it safe to resume/receive receptive oral sex? ANSWER: 24 hours after the last administration

13 Case 4: Boric acid toxicity Per Washington Poison Center: - The amount of boric acid in a Type O gelatin capsule is about 600 mg (0.6 g) which is a very low dose The average ingested dose which caused any symptoms at all in humans was 3.2 grams, but it was also highly variable with individual values ranging from 0.1 to 55.5 g). - Even if someone were to ingest the entire capsule, the concern would be for mild mucosal irritation or GI irritation. Treatment: rinse out the mouth only. - Still would always counsel people to wait ~24 hours if possible before engaging in oral sex.

14 Case 5: Treatment of PID and GC QUESTION: A 25 year old woman received outpatient treatment for PID with cefoxitin 2 gm IV x 1 and doxycycline 100 gm PO BID x 10 days. Test results later returned positive for GC and CT. Should the patient return to receive ceftriaxone +/- azithromycin to treat GC? ANSWER: TOC in 2 weeks

15 Case 5: PID and GC CDC outpatient PID regimens: Ceftriaxone 250 mg IM* OR-cefoxitin 2 gm IM + probenecid 1 gm PO WITH Doxycycline 100 mg PO BID x 14 days WITH/WITHOUT Metronidazole 500 mg BID x 14 days *or other third generation parenteral cephalosporin 2015 CDC STD Guidelines

16 Case 5: PID and GC TOC in 2 weeks, including culture/sensis. If the TOC is positive for gonorrhea, we would then recommend retreatment with ceftriaxone 250mg IM and azithromycin 1g PO. Cefoxitin is considered an effective, single-dose injectable to treat gonorrhea when given with probenecid 1g PO. However, she did not receive the recommended first-line or alternative therapy (no probenecid given). If probenecid given, rescreen in 3 months.

17 Case 6: Rising syphilis titers 46 yo MSM with well controlled HIV infection on ART (VL undetectable, CD4 >500) with previously treated syphilis with negative RPR 2 years ago. - Three months ago had positive RPR with 1:32 dilution. - Asymptomatic. - Received benzathine PCN 2.4 million units q week x3. - He has had 3 anonymous sex partners in the interim, does not use condoms. Now has RPR at 1: Careful neuro ROS/exam is negative - Should he be retested in 3 months, retested now, retreated?

18 Case 6: Rising syphilis titers 1. Retreat. He is probably reinfected. 2. Perform an LP. He may have CNS invasion from previous infection. 3. Retest in 1-3 months. The increasing titer is delayed response to previously treated infection.

19 Case 6: Answer Possibilities: - Patient has been reinfected, and has early syphilis - He had CNS invasion which was not cleared with benzathine penicillin.

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