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

2. 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

3. 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

4. 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.

5. 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

6. “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”

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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.”

20. 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!

21. 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)

22. 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.

23. 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

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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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!

31. 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)

32. 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 

33. 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!

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

35. Gonorrhea
SLIDE SHOW

36. Gonococcal urethritis

37. Gonococcal cervicitis

38. Gonorrhea - gram stain of urethral discharge

39. Bartholin’s abscess

40. Bartholin’s abscess

41. Gonococcal ophthalmia

42. Disseminated gonorrhea - skin lesion

43. Disseminated gonorrhea - skin lesion

44. Syphilis
SLIDE SHOW

45. Syphilis - Treponema pallidum

46. Syphilis - Treponema pallidum on darkfield

47. Primary syphilis-chancre

48. Primary syphilis - chancre

49. Primary syphilis - chancre

50. Primary syphilis - chancre of anus

51. Primary syphilis - chancre

52. Secondary syphilis - papulosquamous rash

53. Secondary syphilis - papulo-pustular rash

54. Secondary syphilis

55. Secondary syphilis

56. Secondary syphilis

57. Secondary syphilis - alopecia

58. Late syphilis - serpiginous gummata of forearm

59. Late syphilis - ulcerating gumma

60. Cardiovascular syphilis - narrowing of coronary ostia in aortus

61. Neurosyphilis - spirochetes in neural tissue

62. Congenital syphilis - mucous patches

63. Congenital syphilis - - Hutchinson’s teeth

64. Congenital syphilis - perforation of palate

65. Lice and Scabies

66. Female Crab Louse

67. Lice in pubic area

68. Scabies mite

69. Scabies

70. Scabies

71. Scabies causing eczema-like hand condition