ERIN MAHONY, CNM, ARNP SPRING 2011 BACTERIAL STI UPDATE ERIN MAHONY, CNM, ARNP SPRING 2011

GENERAL CONSIDERATIONS CHLAMYDIA & GONORRHEA UNTREATED CT/GC INCREASE A WOMAN’S RISK OF: PID, ECTOPIC PREGNANCY, TUBAL INFERTILITY, CHRONIC PELVIC PAIN ~8% INCREASED RISK OF INFERTILITY ESP. WITH GC ~5% OR LESS RISK OF INFERTILITY WITH CT DEPENDS ON THE NUMBER OF EPISODES OF PID

WA STATE DOH SCREENING GUIDELINES FOR WOMEN MUCOPURULENT CERVICITIS OR PID SEX PARTNER DIAGNOSED WITH CT/GC AGE <25 & SEXUALLY ACTIVE AGE > 25 WITH EITHER: INCONSISTENT CONDOM USE >1 SEXUAL PARTNER IN LAST 3 MO. PREGNANT WOMEN PLANNING IUD INSERTION HX OF CT OR GC IN LAST 2 YRS

RACIAL & GENDER DISPARITIES MALE TO FEMALE TRANSMISSION MORE EFFICIENT FEMALES MORE LIKELY ASYMPTOMATIC MORE DIFFICULT DIAGNOSIS IN WOMEN GREATER AND MORE SIGNIFICANT LONG-TERM COMPLICATIONS IN WOMEN SIGNIFICANTLY GREATER INCIDENCE IN AF. AMERICAN & NATIVE AM.

CONTROL OF CT & GC: WHERE DO WE STAND & WHAT CAN WE DO? CURRENT STATUS OF GC & CT INFECTION RATES ARE INCREASING NEW APPROACHES NEEDED WHAT CAN WE DO BETTER? IMPROVE AND EXPAND SCREENING IMPROVE PARTNER TREATMENT ENCOURAGE RESCREENING

“COMMON” CLINICAL PRESENTATION ASYMPTOMATIC INCREASED OR ABN VAGINAL D/C DYSURIA IN BOTH MEN & WOMEN URETHRAL D/C IN MEN DYSPARUNIA SCROTAL PAIN OR SWELLING ADVISED BY SEXUAL PARTNER TO “GET CHECKED”

TESTING BE AWARE OF SENSITIVITY OF TEST YOUR FACILITY IS USING. ACKNOWLEDGE FALSE POS. AND NEG POSITIVE PREDICTIVE VALUE IS PRIMARILY A FUNCTION OF PREVALENCE & SPECIFICITY OFFER BOTH SWAB AND URINE TEST INCREASED SENSITIVITY AND SPECIFICITY WITH URINE TEST MORE FALSE POS. WITH GC THAN CT

TREATMENT CHLAMYDIA/ MPC (MUCOPURULENT CERVICITIS IN WOMEN) NGU (NON-GONOCOCCAL URETHRITIS IN MEN) Azithromycin 1 gm single dose or Doxycycline 100 mg bid x 7d

Chlamydia trachomatis Alternative regimens Erythromycin base 500 mg qid for 7 days or Erythromycin ethylsuccinate 800 mg qid for 7 days Ofloxacin 300 mg twice daily for 7 days Levofloxacin 500 mg for 7 days

Chlamydia trachomatis Treatment in Pregnancy Recommended regimens Erythromycin base 500 mg qid for 7 days or Amoxicillin 500 mg three times daily for 7 days Alternative regimens Erythromycin base 250 mg qid for 14 days Erythromycin ethylsuccinate 800 mg qid for 14 days Erythromycin ethylsuccinate 400 mg qid for 14 days Azithromycin 1 gm in a single dose

Neisseria gonorrhoeae Cervix, Urethra, Rectum Cefixime 400 mg po (single dose) or Ceftriaxone 125 IM (old rec) New Rec Ceftriaxone 250 mg IM (single dose) Ciprofloxacin 500 mg po (single dose) Ofloxacin 400 mg/Levofloxacin 250 mg (no longer recommended) PLUS Chlamydial therapy if infection not ruled out

Neisseria gonorrhoeae Cervix, Urethra, Rectum Alternative regimens Spectinomycin 2 grams IM in a single dose or Single dose cephalosporin (cefotaxime 500 mg) PLUS Chlamydial therapy if infection not ruled out

Neisseria gonorrhoeae Pharynx Ceftriaxone 250 IM in a single dose or Ciprofloxacin 500 mg in a single dose PLUS Chlamydial therapy if infection not ruled out

Neisseria gonorrhoeae Treatment in Pregnancy Cephalosporin regimen Women who can’t tolerate cephalosporin regimen may receive 2 g spectinomycin IM No quinolone or tetracycline regimen Erythromycin or amoxicillin for presumptive or diagnosed chlamydial infection

Neisseria gonorrhoeae Antimicrobial Resistance Geographic variation in resistance to penicillin and tetracycline No significant resistance to ceftriaxone Fluoroquinolone resistance in SE Asia, Pacific, Hawaii, California Surveillance is crucial for guiding therapy recommendations

STD UPDATE PER MATT GOLDEN, MD, MPH – MEDICAL DIRECTOR, PHSKC STD CLINIC 6% (may be higher now) RESISTANCE TO QUINOLONES FOR GC TX – DON’T USE. TX WITH AZITHROMYCIN 1 GM WILL TREAT 90% OF GC CASES

PDPT RECOMMENDATIONS (PATIENT DELIVERED PARTNER THERAPY) PDPT REDUCES RE-INFECTION RATES! A GOOD FAITH EFFORT TO ASSURE PARTNER TX IS THE DIAGNOSING CLINICIAN’S RESPONSIBILITY IF UNABLE/UNWILLING – DOH WILL ASSUME RESPONSIBILITY NO NATIONAL GUIDELINES FOR PDPT PDPT IS LEGAL IN WA AND OR MEDICATION SHOULD BE DISPENSED WITH INFORMATION ABOUT DRUG ALLERGIES/SE’S

LEGAL STATUS OF PDPT IN WA STATE When Chlamydia & gonorrhea are identified in a pt. The adequate treatment and prevention of recurrence in the patient often depends on the treatment of the partner or partners who may not be available or agreeable to direct examination. The Medical Commission recognizes that it is a common practice for health care practitioners to provide antibiotics for the partner(s) without prior examination. While this is not the ideal in terms of the diagnosis and control or Chlamydia and gonorrhea, the Medical Commission recognizes that this is often the only reasonable way to access and treat the partner(s) and impact the personal and public health risks of continued, or additional, Chlamydia and gonorrheal infections. The Medical Commission urges practitioners to use all reasonable efforts to assure that appropriate information and advice is made available to the absent treated third party. MEDICAL QUALITY ASSURANCE COMMISSION POLICY STATEMENT – NOV. 2003

PDPT RECOMMENDATIONS WA STATE DOH 2004 “The provider should inform the patient that it would be best to have all partners exposed during the previous 60 days to come into a clinic for examination, testing and treatment. However, if treatment is not otherwise assured, the patient should be provided antibiotics for their partner(s). These medications must include appropriate written information for the treated third party.” CDC 2005 “CDC has concluded that expedited partner therapy is a useful option to facilitate partner management.”

Recurrent Gonorrhea & Chlamydia Infection in absence of PDPT CT: 12.6% of men 13.3 % of women GC: 9.4% of men 11.7 % of women This is why we must be vigilant about treating sexual partners!

King County DOH provided partner meds In King Co. the DOH provides packets for treatment of sexual partners. Includes medication, information, condoms Provide required written information for the SP (med. side effects, allergies, tx without exam, f/u) Meds for CT, GC or both List of certain pharmacies which have partner meds if clinic does not provide Currently available services outside of King Co. (Snohomish county)

Rescreening for CT & CG Whenever possible, women should be re-screened for CT 3-5 mo after original tx Test of cure is not indicated except in pregnant women or if using alternative treatment recommendation d/t pt allergy or other CI. Rescreening can be done on a urine specimen While limited data are available, existing data support re-screening in men for GC in addition to CT Do NOT re-test sooner than 3 wks. after treatment. Will get false positive.

SYPHILIS Increase in syphilis in MSM in every major city in the world! Significant decrease in all STD’s during the early 80’s with HIV awareness Remained low(er) until ~’99 when rise began Startling increase seen in ’05, ’06 especially in syphilis in MSM Also increasing in the heterosexual pop. Geographic differences. Southern states greater incidence Af. Am > Cauc. Have high index of suspicion

Testing RPR, VDRL – screening, non-specific FTA, TPPA – specific treponemal tests for confirmation

PHSKC STD/HIV Screening Guidelines for MSM Sex with other men in past 12 mo. HIV serology, if HIV neg or not prev. tested Serology test for syphilis Pharyngeal GC culture Receptive anal sex in past 12 mo Rectal GC culture Rectal CT culture Repeat testing in 2-6 mo if: Crystal meth Bacterial STD Unprotected anal sex with partner of unknown or discordant HIV status

Syphilis Primary, Secondary, Early Latent Recommended regimen Benzathine Penicillin G, 2.4 million units IM Penicillin Allergy* Doxycycline 100 mg twice daily x 14 days or Ceftriaxone 1 gm IM/IV daily x 8-10 days (limited studies) or Azithromycin 2 gm single oral dose (preliminary data) *Use in HIV-infection has not been studied

Primary/Secondary Syphilis Response to Treatment No definitive criteria for cure or failure are established Re-examine clinically and serologically at 6 and 12 months Consider treatment failure if signs/symptoms persist or sustained 4x increase in nontreponemal test Treatment failure: HIV test, CSF analysis; administer benzathine pcn weekly x 3 wks Additional therapy not warranted in instances when titers don’t decline despite nl CSF and repeat therapy

Syphilis Latent Syphilis Recommended regimen Benzathine penicillin G 2.4 million units IM at one week intervals x 3 doses Penicillin allergy* Doxycycline 100 mg orally twice daily or Tetracycline 500 mg orally four times daily Duration of therapy 28 days; close clinical and serologic follow-up; data to support alternatives to pcn are limited

Syphilis Management of Sex Partners At risk- 3 mo + sx for primary, 6 mo + sx for secondary, one yr for early latent Exposure to primary, secondary, or early latent within 90 days, tx presumptively Exposure to primary, secondary, or early latent > 90 days, tx presumptively if serology not available Exposure to latent syphilis who have high nontreponemal titers > 1:32, consider presumptive tx for early syphilis

STD PREVENTION Condoms effective in decreasing but not eliminating infection. Overall ~80% effective in preventing STD’s Studies vary, but none show NO effectiveness! Evidence of regression and clearance of HPV with consistent condom use!

Summary – Condom Efficacy HIV - decreased by 80-95% CT, GC - decreased by ~ 50% HSV II - decreased by 30-70% Vag. Inf. (BV, VVC) - modest decrease Syphilis - decreased by ~25% HPV - decreased by 80% (study in progress)

Abstinence & Sex Education Few experimentally evaluated interventions Programs that promote abstinence and consistent contraceptive use can delay first sex While some educational interventions appear to be efficacious, effect sizes tends to be small and the impact is not sustained. By 1 yr post intervention, the effect seems to be gone 

So….What’s New in STD’s? QRNG is on the rise – particularly among MSM - Higher dose of Ceftriaxone IM new recommendation. - Presumptive treatment for CT in pts with pos GC, despite negative screen. PDPT proven to reduce recurrence rate of GC/CT Rescreening for GC & CT should be routine STD epidemic in MSM continues Condoms are highly effective – but not perfect Abstinence is efficacious but temporary!

HSV – 2 . Chronic suppressive Rx prevents transmission HPV vaccine very effective. Two options available (Gardasil and Cervarix)

Gonorrhea SLIDE SHOW

Gonococcal urethritis

Gonococcal cervicitis

Gonorrhea - gram stain of urethral discharge

Bartholin’s abscess

Bartholin’s abscess

Gonococcal ophthalmia

Disseminated gonorrhea - skin lesion

Disseminated gonorrhea - skin lesion

Syphilis SLIDE SHOW

Syphilis - Treponema pallidum

Syphilis - Treponema pallidum on darkfield

Primary syphilis-chancre

Primary syphilis - chancre

Primary syphilis - chancre

Primary syphilis - chancre of anus

Primary syphilis - chancre

Secondary syphilis - papulosquamous rash

Secondary syphilis - papulo-pustular rash

Secondary syphilis

Secondary syphilis

Secondary syphilis

Secondary syphilis - alopecia

Late syphilis - serpiginous gummata of forearm

Late syphilis - ulcerating gumma

Cardiovascular syphilis - narrowing of coronary ostia in aortus

Neurosyphilis - spirochetes in neural tissue

Congenital syphilis - mucous patches

Congenital syphilis - - Hutchinson’s teeth

Congenital syphilis - perforation of palate

Lice and Scabies

Female Crab Louse

Lice in pubic area

Scabies mite

Scabies

Scabies

Scabies causing eczema-like hand condition