1. Unit 6: Specialised Techniques: Anti-Microbial Resistance Monitoring and Assessment of STI Syndrome Aetiologies #4-6-1

2. Warm Up Questions: Instructions v Take five minutes now to try the Unit 6 warm up questions in your manual. v Please do not compare answers with other participants. v Your answers will not be collected or graded. v We will review your answers at the end of the unit. #4-6-2

3. What You Will Learn v By the end of this unit you should be able to: © discuss the objectives of anti-microbial resistance monitoring in N. gonorrhoeae and H. ducreyi © discuss why assessment of syndrome aetiologies is a core component of a comprehensive STI surveillance system © describe the two main STI syndromes and their microbiological causes © discuss how data from assessments of syndrome aetiologies are used to revise syndromic treatment guidelines #4-6-3

4. Monitoring of Anti-Microbial Resistance of STI Pathogens v Resistance is the alteration of a pathogen, making it non-responsive to a particular drug. v Monitoring helps identify which groups are at higher risk of infection with resistant strains and helps to detect newly emerging resistance. v Appropriate treatment can then be planned. #4-6-4

5. Laboratory Requirements v Surveys are usually organised by the national AIDS/STI control programme. v Choose sites with well-trained staff and laboratory expertise. v Lab should be able to: © culture organism © perform serologic confirmatory tests © perform MIC agar dilution testing v If no national lab support is available, isolates can be sent to another country for testing. #4-6-5

6. Planning the Testing v Sample size depends on: © expected prevalence of disease in population © whether sample will be used to monitor trends over time v Possible types of sampling are: © random © systematic © consecutive #4-6-6

7. Frequency of Assessment v At least once a year v Best to sample on an ongoing basis v Resistance can thus be detected early on v For example, test 20 isolates per month at each sentinel site #4-6-7

8. Data Analysis and Interpretation v Microbiologists familiar with test sensitivity and specificity should interpret results. v If a change is noted, determine if it is due to: © real shifts in resistance patterns © problems in the laboratory v If shifts are noted, do the following to explore the problem or resistance pattern: © expand sample © increase number of sites #4-6-8

9. What Should be Done with Resistance Data v Resistance should be reported immediately to a WHO Collaborating Centre. v Resistance data should be used to update treatment guidelines and revise the country list of essential drugs. #4-6-9

10. Figure 6.1. Frequency of Tetracycline-Resistant N. Gonorrhoeae, 1988-1993 #4-6-10 Source: Van Dyck et al., Sex Transm Dis 1997

11. Figure 6.2. Frequency of Penicillinase-Producing N. Gonorrhoeae, 1988-1993 #4-6-11 Source: Van Dyck et al., Sex Transm Dis 1997

12. Disseminating Results v Distribute results on resistance (similar to Figures 6.1 and 6.2) at least annually. v This assists interpretation of test results for patients whose previous therapies failed. v Information in report should include: © gender of patients © clinic setting where patients were tested © changes in sentinel sites over time #4-6-12

13. Assessing STI Syndrome Aetiologies v Involves determining which micro-organisms cause urethral discharge and genital ulcer disease v Especially important where syndromic case reporting takes place v Should be conducted by the national AIDS/STI control programme every 2-3 years #4-6-13

14. Objectives of Assessing STI Syndrome Aetiologies v Provide data for guiding STI syndromic management v Assist in interpretation of syndromic case reports and assessment of disease burden due to specific pathogens v Design or modify guidelines for treating urethral discharge and genital ulcers #4-6-14

15. Laboratory Requirements v Microbiologist experienced in STI diagnostic tests should develop national laboratory protocols. v Range of diagnostic tests is broad. v Choice depends on local availability of laboratory resources. v See Table 6.1 in your manual for laboratory tests for specific STI syndromes. #4-6-15

16. Where to Conduct the Assessments v Ideally, aetiology assessment should be conducted in: © Different types of populations © Populations with high and low disease rates © Different locations v If your country has limited resources, conduct the assessment in a single specialised STI clinic: © With well-trained staff that can perform Gram stains and microscopy © With the ability to perform syphilis serologic testing #4-6-16

17. Sample Size v Depends on: © Specific aetiology © Expected prevalence of pathogens v Minimum sample size of 50 or 100 specimens from consecutive patients will provide adequate information for useful analysis. #4-6-17

18. Data Analysis v Analyse results for each disease separately. v Frequency of various STIs and risk behaviours can then be analysed by: © Gender © Age group © Geographic area © Marital status © Other relevant characteristics #4-6-18

19. In Summary v Anti-microbial resistance monitoring helps detect emerging resistance and develop treatment guidelines. v Assessing syndrome aetiologies provides information on the relative contributions of different pathogens to the main STI syndromes. v This guides STI syndromic treatment and assists in the interpretation of syndromic case reports. #4-6-19

20. Warm Up Review v Take a few minutes now to look back at your answers to the warm up questions at the beginning of the unit. v Make any changes you want to. v We will discuss the questions and answers in a few minutes. #4-6-20

21. Answers to Warm Up Questions, Cont. 1. For countries where syndromic STI case reporting is used, syndrome aetiologies should be reassessed every ________ years. a. one to two b. two to three c. three to four #4-6-21

22. Answers to Warm Up Questions, Cont. 1. For countries where syndromic STI case reporting is used, syndrome aetiologies should be reassessed every ________ years. a. one to two b. two to three c. three to four #4-6-22

23. Answers to Warm Up Questions, Cont. 2. True or false? Monitoring anti-microbial resistance of N. gonorrhoeae may help to detect newly emerging resistance. #4-6-23

24. Answers to Warm Up Questions, Cont. 2. True or false? Monitoring anti-microbial resistance of N. gonorrhoeae may help to detect newly emerging resistance. True #4-6-24

25. Answers to Warm Up Questions, Cont. 3.Choose an item below that is not one of the main purposes of assessing syndrome aetiologies. a.provide data for guiding STI syndromic management b.assess effectiveness of HIV prevention programmes c.assist in the interpretation of syndromic case reports and the assessment of disease burden caused by specific pathogens d.evaluate syndromic management algorithms for urethral discharge and genital ulcers #4-6-25

26. Answers to Warm Up Questions, Cont. 3.Choose an item below that is not one of the main purposes of assessing syndrome aetiologies. a.provide data for guiding STI syndromic management b.assess effectiveness of HIV prevention programmes c.assist in the interpretation of syndromic case reports and the assessment of disease burden caused by specific pathogens d.evaluate syndromic management algorithms for urethral discharge and genital ulcers #4-6-26

27. Answers to Warm Up Questions, Cont. 4. List two possible uses of data obtained from monitoring anti-microbial resistance of STI pathogens. #4-6-27

28. Answers to Warm Up Questions, Cont. 4. List two possible uses of data obtained from monitoring anti-microbial resistance of STI pathogens. Obtain the data necessary for developing and revising treatment guidelines; detect newly emerging resistance #4-6-28

29. Answers to Warm Up Questions, Cont. 5. Which of the following sampling strategies is the most difficult to use when conducting anti- microbial resistance monitoring? a. random b. systematic c. consecutive #4-6-29

30. Answers to Warm Up Questions, Cont. 5. Which of the following sampling strategies is the most difficult to use when conducting anti- microbial resistance monitoring? a. random b. systematic c. consecutive #4-6-30

31. Small Group Discussion: Instructions v Get into small groups to discuss these questions. v Choose a speaker for your group who will report back to the class. #4-6-31

32. Small Group Reports v Select one member from your group to present your answers. v Discuss with the rest of the class. #4-6-32

33. Case Study: Instructions v Try this case study individually. v We’ll discuss the answers in class. #4-6-33

34. Case Study Review v Follow along as we go over the case study in class. v Discuss your answers with the rest of the class. #4-6-34

35. Questions, Process Check v Do you have any questions on the information we just covered? v Are you happy with how we worked on Unit 6? v Do you want to try something different that will help the group? #4-6-35