STIs in Primary Care Dr Eleanor Draeger 19 th January 2016
Poli=cs! 2012! Health and Social Care act! Sexual Health commissioning moved to local authority! 2015! 200 million cuts to public health! 40% reduc=on in local authority spending! 2017! University Hospital Bristol awarded contract for integrated sexual health in Bristol, North Somerset and South Glos
Number of STI diagnoses among women: England, 2006 2015 50,000 45,000 40,000 Herpes: anogenital herpes Gonorrhoea Warts: anogenital warts (first episode) Syphilis: primary, secondary & early latent Number of diagnoses 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Year Data from routine GUM service returns Chlamydia data excluded due to high numbers (see slide 14) Data type: service data 12 Public Health England: 2015 STI Slide Set
Number of STI diagnoses among men: England, 2006 2015 50,000 45,000 40,000 Herpes: anogenital herpes Gonorrhoea Warts: anogenital warts (first episode) Syphilis: primary, secondary & early latent Number of diagnoses 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Year Data from routine GUM service returns Chlamydia data excluded due to high numbers (see slide 13) Data type: service data 11 Public Health England: 2015 STI Slide Set
Total number of chlamydia diagnoses among women: England, 2006 2015 140,000 120,000 GUM services Community services Number of diagnoses 100,000 80,000 60,000 40,000 20,000 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Year Data from routine GUM service returns & chlamydia data from community services Chlamydia data from 2012 onwards are not comparable to data from previous years (please see Notes slide for more details) Data type: service data 14 Public Health England: 2015 STI Slide Set
Total number of chlamydia diagnoses among men: England, 2006 2015 100,000 90,000 80,000 GUM services Community services Number of diagnoses 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Year Data from routine GUM service returns & chlamydia data from community services Chlamydia data from 2012 onwards are not comparable to data from previous years (please see Notes slide for more details) Data type: service data 13 Public Health England: 2015 STI Slide Set
Ways STIs can present! Discharge vaginal, rectal or urethral! Itching! Pain dysuria, abdominal, rectal, dyspareunia! Lumps! Ulcers / rashes! Asymptoma=c
Vaginal Discharge Infec=ous! Gonorrhoea! Chlamydia! Trichomonas! Bacterial Vaginosis! Thrush Non- infec=ous! Physiological! Inflammatory! Foreign Body! Fistulae! Trauma
Thrush or BV?! THRUSH! BV! Thick, white discharge! O^en itchy! Superficial dyspareunia! External dysuria! Thin, watery discharge! Not itchy! Offensive smell! Abdominal pain
Thrush! Candida albicans (80-92%) Ø Ø Normal commensal organism in vagina Infec=on when Corynebacterium suppressed! Approx 75 % of have Candida at least once in life=me
Thrush Treatment! Topical! Clotrimazole pessary nocte! Clotrimazole cream top bd! Oral! Fluconazole 150mg once (contraindicated in pregnancy)! Rule out diabetes/hiv/immunosuppression if it recurs! Refer to GUM if 4 episodes in a year
Bacterial Vaginosis (BV)! Commonest cause of abnormal vaginal discharge! Overgrowth of commensal bacteria! Gardnerella vaginalis! Mycoplasma hominis! Associated with:! Non- white ethnicity; IUD; Douching; Use of sex toys! Anal sex prior to Vaginal sex
Is BV an STI?! YES! NO! Lower mean age of first having sex! New or mul=ple partners! Not using condoms! Associated with Chlamydia and GC! Similar rates in sexually and non- sexually ac=ve teens! Trea=ng partners doesn t reduce recurrence! Spontaneous onset and remission
BV treatment Treatment Metronidazole 400mg po bd 5/7 Metronidazole 2g po stat Metronidazole PV gel 0.75% daily 5/7 Clindamycin PV cream 2% daily 7/7 Cure rate at 1 month 78-88% 72-73% 71-79% 61-94%
What tests should I do?! Chlamydia / Gonorrhoea! TV NAAT (if available)! HVS! HIV/STS
Urethral Discharge! Ideally all men with urethral discharge should have microscopy! Blind treatment should be done only if no microscopy available! MC&S recommended as well as NAATs
Chlamydia! Caused by Chlamydia Trachoma1s! Most common bacterial STI in UK! 5-10% of men and women under 24 infected! 186,000 cases in 2011 in UK! Transmimed via! Oral, anal and vaginal sex! Genital contact! Ver=cal transmission
Chlamydia presenta=on! WOMEN! Endocervix! 70-80% asymptoma=c! Can cause discharge and abdominal pain! Rectal! Almost all asymptoma=c! Pharyngeal! Can cause symptoms, but mostly asymptoma=c! MEN! Urethral! 50% asymptoma=c! If symptoma=c: Dysuria; Discharge; Tes=cular pain! Rectal! Almost all asymptoma=c! If symptoma=c, suspect LGV
Chlamydia Treatment! Azithromycin 1g stat! Doxycycline 100mg bd for 7 days! In pregnancy! Azithromycin (unlicensed, but safe) 1g stat! Could use Erythromycin
Gonorrhoea! Caused by Neisseria Gonorrhoeae! 2 nd most common bacterial STI in UK! Transmimed via! Oral, anal and vaginal sex! Sharing sex toys! Genital contact! Ver=cal transmission (at delivery)
Number of gonorrhoea diagnoses by sexual risk: England, 2011 2015 25,000 Heterosexual men MSM Heterosexual women WSW 20,000 Number of diagnoses 15,000 10,000 5,000 0 2011 2012 2013 2014 2015 Year Data from routine GUM service returns Data type: service data 21 Public Health England: 2015 STI Slide Set
Gonorrhoea - Presenta=on! MEN! Urethral! Discharge (>80%)! Dysuria (>50%)! Asymptoma=c (<10%)! Rectal! Anal discharge (12%)! Pain/discomfort (7%)! Pharyngeal! Usually asymptoma=c (>90%)! WOMEN! Endocervical! Discharge (up to 50%)! Lower abdominal pain (25%)! Asymptoma=c (>50%)! Urethral! Dysuria (12%) but no frequency! Rectal! Almost all asymptoma=c! Pharyngeal! Usually asymptoma=c (>90%)
Ophthalmia Neonatorum! Typically shows within 1 st 5 days of life! Can be complicated by corneal ulcera=on and blindness if untreated! Don t forget to test the parents
Gonorrhoea Treatment! Ce^riaxone 500mg (2 vials of 250mg) IM PLUS! Azithromycin 1g PO! Before treatment of GC! send MC&S (charcoal) swab! Even if pa=ent asymptoma=c and/or contact BASHH UK na=onal guideline for the management of gonorrhoea 2011
Alterna=ve Treatment! Pt refuses injec=on! Cefixime 400mg PLUS Azithromycin 1g! Severe penicillin allergy! Azithromycin 2g po stat OR! Spec=nomycin 2g im stat
What tests to do - WOMEN * Asymptoma=c * Vulvo- vaginal NAAT * Asymptoma=c GC contact * NAAT and MC&S from all relevant sites * Symptoma=c GC contact or high risk * NAAT and MC&S from all relevant sites * Microscopy if possible Where did the penis go?
What tests to do - MEN * Asymptoma=c * Urine NAAT (+ throat and rectal if MSM) * Asymptoma=c GC contact * NAAT and MC&S from all relevant sites * Symptoma=c GC contact or high risk (MSM) * NAAT and MC&S from all relevant sites * Microscopy if possible Where did the penis go?
Do I have to do a speculum?
Data from Leeds! Comparison of VVS and endocervical swabs to detect chlamydia! 3973 women in an urban sexual health centre! All pa=ents took a VVS before rou=ne examina=on! Clinicians took endocervical swab during examina=on Schoeman et al; Assessment of best single sample for finding chlamydia in women with and without samples: a diagnostic test study: BMJ. 2012 Dec 12;345:e8013. doi: 10.1136/bmj.e8013.
Leeds Results! Overall 10.3% were infected with Chlamydia! Sensi=vi=es: Symptoma,c Asymptoma,c Vulvo- Vaginal Swab Endocervical swab 97% 97% 88% 89%
Drug Resistant Gonorrhoea! Ciprofloxacin resistance! 10-40% in 2011! Cefixime resistance! 2-15% in 2011! Azithromycin resistance! 0.5% in 2011! Spec=nomycin! 0% in 2011 Source: GRASP programme, HPA hmp://www.hpa.org.uk/webc/hpawebfile/hpaweb_c/1317137225276
2011
2015
Terminology is everything! MSM men who have sex with men! Not all MSM iden=fy as gay! Ques=ons to ask:! When did you last have sex?! Was that with a man or a woman or both?! Pa=ents are only embarrassed if you are
MSM Sexual Health! 2-5% of the male popula=on is es=mated to be MSM! In 2013 >80% of all syphilis diagnoses in men were in MSM >60% of GC diagnoses in men were in MSM
Take- home messages! Symptoma=c men should be offered microscopy! Swab and culture ALL relevant sites! Don t forget TOC and partner no=fica=on
Take home messages! Many simple STIs can be diagnosed and treated in primary care! MSM should be directed to GUM! Don t forget partner notification! If in doubt, examine the patient
Questions?