STD Diagnosis and Treatment Ina Park, MD, MS STD Control Branch, California Department of Public Health California STD/HIV Prevention Training Center Stephanie 23 year-old female presents for contraception, Pap, and desires IUD placement No complaints; LMP 3 weeks prior New male partner within past month -- they initially used condoms, but stopped using them about 4 weeks ago STD Screening for Women Sexually Active adolescents & up to age 25 Chlamydia and gonorrhea screening (USPSTF grade B recommendation) Others STDs and HIV based on risk Women > 25 years of age STD/HIV testing based on risk Pregnant women Chlamydia Gonorrhea (<25 years of age or risk) HIV Syphilis serology HepB sag Hep C (if high risk) STD Atlas, 1997 Physical Exam Cervix with discharge from os CDC 2010 STD Tx Guidelines www.cdc.gov/std/treatment 1
Cervicitis Diagnosis Diagnostic criteria: Pus from the cervix covers a Q-tip (Q-tip test) OR Cervical friability (easily bleeds when touched) Test for GC and CT Evaluate for PID, BV and trichomonas; consider HSV Cervicitis Treatment Treat for chlamydia: Age 25 or younger STD risk: new/multiple partners, partner with other partners, unprotected sex Follow-up unlikely Treat for gonorrhea: High prevalence (>5%) Treat BV if present CDC 2010 STD Tx Guidelines www.cdc.gov/std/treatment CDC 2010 STD Tx Guidelines www.cdc.gov/std/treatment Chlamydia Treatment Adolescents and Adults Stephanie Recommended regimens (non-pregnant): Azithromycin 1 g orally in a single dose Doxycycline 100 mg orally twice daily for 7 days Recommended regimens (pregnant*): Azithromycin 1 g orally in a single dose Amoxicillin 500 mg orally TID x 7 days * Test of cure at 3-4 weeks only in pregnancy No evidence of BV or trich, no findings on pelvic exam Lab tests for GC and CT ordered Prescription for azithromycin 1 gram given 2
Stephanie Physical Exam 4 days later, she returns to clinic with RLQ abdominal pain Her prescription was never filled b/c I felt fine and I was busy Lab tests are still pending She has a low grade fever and increased vaginal discharge, External genitalia and glands normal Thin yellow vaginal discharge Cervix is friable with mucopurulent discharge from the os Bimanual exam reveals mild cervical motion tenderness, questionable uterine tenderness PID Diagnosis Minimum Clinical Criteria: Lower abdominal/pelvic pain and one or more of the following: o Uterine tenderness OR o Adnexal tenderness OR o Cervical motion tenderness Pelvic Inflammatory Disease (PID) Ascending infection starting from cervix Can involve the endometrium, fallopian tubes, and pelvic peritoneum Cervical infection may or may not be present at the time of diagnosis Severe PID (4%) Outpatient PID (36%) Subacute PID (60%) CDC 2010 STD Tx Guidelines www.cdc.gov/std/treatment 3
Pelvic Inflammatory Disease Adhesions-Tubal blockage STD Atlas, 1997 www.advancedfertility.com/hsg.htm PID: Oral Treatment Regimens Oral/IM regimens: Ceftriaxone 250 mg IM (or other parenteral 3rd generation cephalosporin) x 1 or Cefoxitin 2 g IM with probenecid 1 g orally once PLUS Doxycycline 100 mg orally twice daily for 14 days WITH OR WITHOUT Metronidazole 500 mg orally twice daily for 14 days PID: Indications for Hospitalization Surgical emergency cannot be excluded Tubo-ovarian abscess Pregnancy Severe illness (nausea, vomiting, high fever) Unable to follow or tolerate outpatient regimen Failure to respond to outpatient therapy CDC 2010 STD Tx Guidelines www.cdc.gov/std/treatment CDC 2010 STD Tx Guidelines www.cdc.gov/std/treatment 4
PID: Patient Follow-Up Outpatient: re-examine within 72 hours to ensure improvement in symptoms; if not better, place on intravenous therapy Repeat CT/GC testing at 3 months All sex partners within past 60 days need treatment Stephanie No indications for hospitalization Treatment: ceftriaxone + doxy Scheduled f/u in 3 days At the f/u visit, she reported compliance with treatment regimen; symptoms much improved Test results: CT neg, GC neg, HIV neg She reschedules an appt for an IUD and takes a script for a vaginal ring in the meantime Jeremy What STD screening would you offer this patient? 24 Y/O bisexual male presents to clinic for STD check up. No symptoms Reports giving and receiving unprotected oral sex with 4 new male partners during trip to New Orleans ~1 week ago. 1 female partner who does not know that he occasionally has sexual contact with men. A. Syphilis screening B. Urine NAAT for GC/CT C. Pharyngeal NAAT for GC D. Rectal NAAT for GC/CT E. All of the above 2% 6% 1% 2% 88% S y p h i l i s s c r e e n i n g U r i n e N A A T f o r G C / C T P h a r y n g e a l N A A T f o r G C R e c t a l N A A T f o r G C / C T A l l o f t h e a b o v e 5
STD Screening for MSM HIV Syphilis Urethral GC and CT Rectal GC and CT (if anal sex) Pharyngeal GC (if oral sex) Hepatitis B (HBsAg) Hepatitis C (if high risk) HSV-2 serology (consider) Anal Pap (consider for HIV+) * At least annually, more frequent (3-6 months) if at high risk (multiple/anonymous partners, drug use, high risk partners) * CDC 2010 STD Tx Guidelines www.cdc.gov/std/treatment Proportion of MSM* Attending STD Clinics with Primary and Secondary Syphilis, Gonorrhea or Chlamydia by HIV Status, STD Surveillance Network (SSuN), 2011 *MSM=men who have sex with men. Excludes all persons for whom there was no laboratory documentation or self-report of HIV status. GC urethral and CT urethral include results from both urethral and urine specimens. 2011-Fig Y. SR Proportion of CT/GC MISSED if screening only performed at urethral site (urine), San Francisco, 2008-2009 n=3398 patient visits 3 friends with HSV Helen Sylvia Victoria Chlamydia Gonorrhea Among asymptomatic MSM Marcus et al, STD Oct 2011; 38: 922-4 6
Clinical Progression of Herpes Lesions Helen was diagnosed with her first outbreak of genital HSV-2. She had multiple large bilateral vulvar ulcers which are at the early healing stage after 3 days Is it too late for me to start treatment for herpes? Early Redness/ Swelling Thin-Walled Fluid- Filled Vesicles and Pustules Early Healing of Vesicles, Erosions, or Ulcers Crusting Scabbing Healed Skin Genital Herpes Treatment 1st Clinical Recurrent Genital Herpes: Episode: Episodic Suppressive (mg for 7-10 days) (mg days) (mg, daily) Acyclovir 400 TID 400 TID x 5 d 400 BID 250 5x/day 800 BID x 5 d 800 TID x 2 d Famciclovir 250 TID 125 BID x 5 d 250 BID* 1000 BID x 1 d 500 mg PO x 1, then 250mg BID x 2 days Valacyclovir 1000 BID 500 BID x 3 d 500 QD 1000 QD x 5 d 1000 QD * Somewhat less effective for suppression of shedding CDC 2010 STD Treatment Guidelines www.cdc.gov/std/treatment Helen s back I already ran out of the prescription, help! She starts valacyclovir and has taken it for 7 days but she s still not completely healed There is no evidence of cellulitis 7
Primary Genital Herpes Incubation period ~ 4 days (2-14 day range) Systemic symptoms in up to 80% Fever, headache, malaise, myalgia Local symptoms pain, itching, dysuria, discharge, inguinal adenopathy Multiple painful lesions develop bilaterally New lesions may appear for up to 10 days, with mean duration of lesions 18 days. Treatment should continue if healing is incomplete after the first course of antivirals ALL first episodes of HSV should be treated Should I go on suppressive therapy? Sylvia was diagnosed with HSV-2 last year. She isn t sexually active right now (has sex with men) and has had 3 outbreaks in the past year, which she treated with episodic acyclovir. Episodic vs Suppressive Therapy Episodic therapy Decreases healing time by 2 days Decreases pain by 1 day Decreases viral shedding by 2 days Suppressive therapy Decreases frequency of recurrences by 70-80% Decreases severity of recurrences Decreases subclinical viral shedding Decreases transmission Management of Patients Consider daily suppressive therapy for: Are bothered by their outbreaks, regardless of their relationship status Are sexually active with an uninfected partner* Are newly diagnosed and concerned about transmitting genital herpes to their partner* Consider episodic therapy for patients who: Are not sexually active and not concerned about their outbreaks Are sexually active with a partner who also has genital herpes * Studied in immunocompetent heterosexual adults 8
A. Nearly 100% B. 75-80% C. About 50% D. Only 25% E. Not sure How effective is suppressive therapy at reducing HSV-2 transmission? N e a r l y 1 0 0 % 2% 7 5-8 0 % 53% A b o u t 5 0 % 37% O n l y 2 5 % 5% N o t s u r e 3% Transmission of HSV-2 to Susceptible Partners is Reduced with Once-Daily Suppression 1484 heterosexual couples randomized to 500 mg of valacyclovir vs placebo once daily for 8 months Monthly serum samples collected from susceptible partners Valacyclovir group showed decreased transmission lower frequency of shedding fewer copies of HSV-2 DNA when shedding occurred Percent Transmission 4 3.5 3 2.5 2 1.5 1 0.5 0 1.9% Valacyclovir Group (N=743) 3.6% Control Group (N=741) Corey et al, NEJM 2004; 350(1):11-20. Intermittent Suppression Treatment scenarios Reduce risk of episode on special occasions: wedding, vacation, final exam Reduce transmission risk: pregnancy, new sexual relationship To evaluate herpes symptoms or differentiate herpes symptoms from other symptoms Use suppressive therapy dosage indicated for each antiviral agent Treatment must be initiated ~ 5 days in advance of desired event Victoria was diagnosed with HSV-2 2 years ago and had 6 outbreaks her first year. She has been outbreak free on suppressive acyclovir therapy which she has taken continuously for a year. How long can I stay on supression? 9
Long-term suppressive therapy Continuous suppresive therapy appears safe Safety data for up to 6 years with continuous acyclovir, 1 year for valacyclovir and famciclovir Check-in once a year to discuss the need to continue. No laboratory monitoring is necessary in a healthy person I feel like I will never date again Fife KH et al. JID 1994 Online dating for patients with herpes We re all pregnant Positivesingles.com Hdate.com Hsvsingles.com Mpwh.com Herpespassions.com Lovewithherpes.com Herpeslove.net STDsoulmates.com Helen Sylvia Victoria 10
ACOG Recommendations Offer antivirals for primary outbreak* oral or IV if severe outbreak Offer suppressive therapy women 36 weeks with active recurrent genital HSV (level B) C-section for women with active symptoms or prodromal symptoms at delivery Offer suppressive therapy to reduce transmission in discordant couples + *ACOG practice bulletin No.82, June 2007 +ACOG practice bulletin No 57, Nov 2004 Brenda 19 year old woman who has sex with both women and men Asymptomatic, no prior STDs STD screening done on intake No known drug allergies GC positive CT negative What regimen would you use to treat Gonorrhea? 1. Cefixime 400 mg PO plus azithromycin 1 gm PO 2. Ceftriaxone 250 mg IM 3. Azithromycin 2 gm PO 4. Ceftriaxone 250 mg IM plus azithromycin 1 gm PO 5. E. Ceftriaxone 125 mg IM plus azithromycin 1gm PO C e f i x i m e 4 0 0 m g P O p l u s... 5% C e f t r i a x o n e 2 5 0 m g I M 15% A z i t h r o m y c i n 2 g m P O 4% E. C e f t r i a x o n e 1 2 5 m g I... C e f t r i a x o n e 2 5 0 m g I M p l.. 71% 5% 11
Dual Antibiotic Therapy for Gonorrhea (Urogenital, rectal, pharyngeal) Ceftriaxone 250 mg IM in a single dose * Regardless of CT test result PLUS* Azithromycin 1 g orally (preferred) or Doxycycline 100 mg BID x 7 days* CDC 2010 STD Treatment Guidelines www.cdc.gov/std/treatment Gonorrhea Treatment Alternatives Anogenital Infections ALTERNATIVE CEPHALOSPORINS: Cefixime 400 mg orally once PLUS Dual treatment with azithromycin 1 g (preferred) or doxycycline 100 mg BID x 7 days, regardless of CT IN CASE OF SEVERE ALLERGY: Gentamicin Azithromycin 240 mg 2 IM g + orally azithromycin once 2g PO (Caution: OR GI intolerance, emerging resistance) Gemifloxacin 320 mg orally + azithromycin 2g PO 12
EVA 18yo female presents for college PE Vaginal swab NAAT tests positive for chlamydia. She receives appropriate treatment with Azithromycin 1 gm. Chlamydia Treatment Adolescents and Adults Recommended regimens (non-pregnant): Azithromycin 1 g orally in a single dose Doxycycline 100 mg orally twice daily for 7 days Recommended regimens (pregnant*): Azithromycin 1 g orally in a single dose Amoxicillin 500 mg orally TID x 7 days * Test of cure at 3-4 weeks only in pregnancy When should she return for followup after chlamydia treatment? Repeat Infection is Dangerous A. A. One week for test of cure B. B. Three weeks for test of cure C. C. Three months for retesting D. D. One year for annual exam 2% A. O n e w e e k f o r t e s t o f c u r e B. T h r e e w e e k s f o r t e s t o f... C. T h r e e m o n t h s f o r r e t e s... 74% 18% 6% D. O n e y e a r f o r a n n u a l... Repeat CT infection leads to higher risk of complications: PID, ectopic pregnancy, infertility Most infections are asymptomatic Relative Risk 6 5 4 3 2 1 0 1st Infection 2nd Infection 3rd Infection Pelvic Inflammatory Disease Ectopic Pregnancy Hillis SD, et al. (1997). Am J Obstet Gynecol 176(1 Pt 1): 103-7. 13
Current Retesting Recommendations All individuals (male and female) with CT or GC should be retested ~ 3 months after initial treatment Retesting should occur whenever patient returns to clinic anytime within 1-12 months post treatment Test of cure at 3 weeks for CT is only recommended routinely for pregnant women CDC 2010 STD Tx Guidelines, www.cdc.gov/std/treatment Want to know more about STDs? There s an app for that. CDC Treatment Guidelines App for Apple and Android Available now, FREE! ( STD Tx ) Download the app now Need advice from an STD expert? Contact us! Clinician Warmline 510-620-3400 stdcb@cdph.ca.gov 14
Thank you!! Contact information ina.park@cdph.ca.gov 15