1. Denver Prevention Training Center Denver Public Health Department Pieces of the Puzzle Conference Great Falls November 21, 2013

2. www.denverptc.org

3. www.astda.org

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6.  New section in STD journal since January, 2013  Highlights manuscripts at the interface between research and practice  Collaborative effort between the journal and STD Prevention Online o Open access o Blogs and podcasts with authors  November issue features three articles: o EPT in federally qualified health facilities o Adolescent’s attitudes toward EPT o Express visits in Baltimore 6

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9. 9 www.STIvienna2013.com

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12. The 5-Minute STI Clinical Case Study

13.  30 year-old gay man complaining of a faint, non- itching rash for >4 weeks  Took left-over amoxicillin for sore throat about 1 month ago – however, pt. does not have a prior history of penicillin allergy  No neurological symptoms or other physical complaints

14.  Sexual and STI History o 2 partners in past 6 months: One steady partner One occasional partner (about 3 months ago) o Protected receptive and insertive anal sex with steady partner only o Unprotected oral sex with steady and occasional partners o No history of genital/rectal sores o Rectal gonorrhea and chlamydia > 1 year ago o History of primary syphilis – treated 4 years ago with 2.4 MU LAB o Most recent RPR: NR (14 months ago; this clinic o HIV: negative (14 months ago; this clinic)

15.  Faint erythematous macular rash trunk and extremities  Soles of feet involved, but palms of hands are not  No excoriations or scratch marks noted  No penile or anal lesions observed  Neurological exam: normal

21. What laboratory test would be the least useful in this case? a) Qualitative (stat) RPR b) Quantitative RPR c) Treponemal test (TPPA or FTA-abs) d) HIV rapid test e) HIV viral load

22.  Qualitative RPR reactive: ++++  HIV Rapid Test: Positive

23. Based on our knowledge so far, what is the most likely diagnosis? a) Acute HIV Infection b) Drug rash c) Secondary syphilis d) Scabies

24. You decide to treat the patient for secondary syphilis – what do the CDC treatment guidelines recommend: a) LAB 2.4 MU i.m. now and refer to HIV care b) LAB 2.4 MU i.m. now and once a week for 2 subsequent weeks + refer to HIV care c) Patient should undergo LP before treatment is initiated d) Refer to HIV care as treatment will depend on HIV viral load and CD4 count

25. Regarding the patient’s follow up – which is a CDC recommendation? a) Patient should return for follow-up at 1 and 2 weeks for additional treatment b) Serological follow-up should be more frequent than in HIV negative patients c) Follow-up should include a neurological work-up and LP to exclude neurosyphilis

27. Penicillin, Tetracycline, and Ciprofloxacin Resistance Among Neisseria gonorrhoeae Isolates, Gonococcal Isolate Surveillance Project (GISP), 2011 NOTE: PenR = penicillinase producing Neisseria gonorrhoeae and chromosomally mediated penicillin- resistant N. gonorrhoeae; TetR = chromosomally and plasmid mediated tetracycline-resistant N. gonorrhoeae; and QRNG = quinolone-resistant N. gonorrhoeae. 2011-Fig 34. SR

28. Distribution of Minimum Inhibitory Concentrations (MICs) of Cefixime Among Neisseria gonorrhoeae Isolates, Gonococcal Isolate Surveillance Project (GISP), 2009–2011 NOTE: Isolates were not tested for cefixime susceptibility in 2007 and 2008 2011-Fig 31. SR

29. WestMidwest Northeast/Sout hTotal No.% # TestedNo.% # TestedNo.% # TestedNo.% # Tested 2000001,91030.21,56570.41,986100.25,461 2001402,06610.21,56170.41,845120.25,472 200200.22,16310.11,27380.41,93190.25,367 2003102,55800.11,62830.12,36640.16,552 2004202,540201,67320.12,10960.16,322 200550.22,55100.11,409102,23960.16,199 200640.22,489001,420102,18050.16,089 2007 2008 2009371.91,92470.51,398102,308450.85,630 2010683.32,07260.51,14630.12,475771.45,693 20113.20.60.3 1 Gonorrhea Isolates with Cefixime MICS >0.25μg/mL MMWR 2011;60:873-877 and MMWR 2012;61:590-594

30.  “CDC no longer recommends cefixime at any dose as a first-line regimen for treatment of gonococcal infections.”  “If Cefixime is used as an alternative agent, then the patient should return in 1 week for a test-of-cure at the site of infection.” MMWR 2012;61:590-594

31.  Recommended regimen o Ceftriaxone 250 mg in a single i.m. dose PLUS o Azithromycin 1 g orally in a single dose or o Doxycycline 100 mg orally twice a day for 7 days MMWR 2012;61:590-594

32.  Alternative regimen (if ceftriaxone is not available) o Cefixime 400 mg in a single dose PLUS o Azithromycin 1 g orally in a single dose or o Doxycycline 100 mg orally twice a day for 7 days  Alternative regimen (severe cephalosporin allergy) o Azithromycin 2 g in a single oral dose PLUS with both of the above:  Test-of-cure in 1 week o NAAT o Culture ( preferred if failure is suspected) MMWR 2012;61:590-594

33.  401 patients with uncomplicated urogenital GC  Randomized to either of two regimens: o Gentamicin (GENT) 240 mg I.M. + Azithromycin 2 g orally o Gemifloxacin (GEMI) 320 mg + Azithromycin 2 g both orally  Microbiological cure: o 100% of GENT/AZI o 99.5% of GEMI/AZI  Pharyngeal infections: o 10/10 (GENT/AZI) cured o 15/15 (GEMI/AZI) cured  Rectal Infections: o 1/1 (GENT/AZI) o 5/5 (GEMI/AZI) Kirkcaldy RD. Centers for Disease Control and Prevention 2013 STI & World Congress Abstract S.08 33

36.  First isolated in 1980 from 2 men with non-gonococcal urethritis  Growing evidence as a causal organism in o Urethritis o Cervicitis o Pelvic inflammatory disease  Testing not widely available  Susceptibility to antimicrobials differs from C. trachomatis and N. gonorrhoeae o Not particularly susceptible to standard doxycycline and azithromycin treatment

37. Cause of Nongonococcal Urethritis Seattle, 2007 - 2011 N = 606 Manhart et al. Clin Infect Dis 2013;56:934

38. Treatment Results C. trachomatis8690 M. genitalium4030 U. urealyticum7570 Clinical Cure8076 Azithromycin Doxycycline % % Manhart et al. Clin Infect Dis 2013;56:934

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40. 40 Cramer et al, Sex Transm Dis 2013;40:658

41. 41 Cramer et al, Sex Transm Dis 2013;40:658

42. 42 Cramer et al, Sex Transm Dis 2013;40:658

44.  Partners with only Internet contact info: 645/4,255 (15.1%) syphilis index cases 691/3,607 (19.1%) HIV index cases  Successfully contacted via Internet o 47.1% of partners of syphilis index cases o 46.6% of partners of HIV index cases  Successful partner outcomes: o 42.2% of partners of syphilis index cases: +7.2% o 17.1% of partners of HIV index cases: +7.9% Bernstein et al. San Francisco Department of Health 2013 STI & AIDS World Congress Abstract 008.1 44

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47. Rietmeijer et al. Sex Transm Dis 2011;38:359 47

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49.  Collaborative effort between Rotterdam and Amsterdam health departments  Index patients receive code from clinician or disease intervention specialist (DIS)  Patients go online with code  Site creates form that is sent to contact  Contacts present to clinic with form Gotz et al. Rotterdam Municipal Health Department 2013 STI & AIDS World Congress 2013: Abstract 008.2 49

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51.  Evaluation period: March – July, 2012 o 1,184 patients received SAT code o 580 notifications sent 82% by SMS 16% by email 86% non-anonymous o 160 (14%) partners notified through SAT o 56% of partners accessed SAT site o 20% visited STI clinic STI positivity lower (28%) in SAT contacts (N=116) compared to contacts (45%) through traditional contact cards (N=152) 51

52. Any Questions?

54. Contact: kees@rietmeijer.us 54