Download Answers to those burning questions - 8/2/2012

8/2/2012
Answers to those burning
questions Ann Avery MD
Infectious Diseases Physician-MetroHealth Medical Center
Assistant Professor- Case Western Reserve University SOM
Medical Director -Cleveland Department of Public Health
Basic concepts
Transmission dynamics of STDs
STDs occur at the intersection of the other
epidemics –esp drugs and poverty
Condoms work when used consistently
Prevention education and behavior change
is challenging (to both the provider and
the patient)
When there’s one, look for others
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HIV and STDs
Synergy between STDs and HIV
ALL clients seeking STD screening should
be offered HIV testing at the same time.
All patients between 13 and 64
recommended to have HIV test at least
once. ( CDC Oct 2006)
Risk of an STD
Is dependent on:
• Personal behaviors
• Background Community
prevalence
• Transmission dynamics of a
given STD
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Estimates of Risk and
Duration
risk of
Duration
acquistion of
infectivity
Gonorrhea
0.6
10-50
days
Chlamydia
0.3
6 mos.
Disease
HSV-2
0.6
lifelong
Chancroid
0.8
20 days
HIV-1
0.05
lifelong
The Five Ps:
Partners
Practices
Past History of STDs
Protection from STDs
Prevention of Pregnancy
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Urethritis and mucopurulent
cervicitis
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Causative organisms for Urethritis
and cervicitis
N. gonorrhea
Chlamydia
trachomatis
Trichomonas
Mycoplasma
genitalium
Herpes simplex
virus
Adenovirus
Gram negative
Anaerobes
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Diagnostic tests
Gram stain
Microscopy of the vaginal/ cervical
fluid
Nucleic acid amplification
Culture
DNA probes
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Complications of Untreated genital
infections
result of spread of pathogen, inflammatory
response and subsequent healing (scarring)
Pelvic inflammatory disease / epididymitis
• Infertility
• Chronic pelvic pain
• Ectopic pregnancy
prostatitis
urethral stricture
Disseminated gonorrhea/ reactive arthritis post
Chlamydia (Reiter’s syndrome)
• Joint involvement, ocular, and skin
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Does this cervix have
Chlamydia?
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CDC 2004 surveillance report
Chlamydia rates per 100,000,
Cleveland
Group
2004-05
Overall
1,029
Black female teens 15-19y
10,341
(1 in 10)
Black male teens 15-19y
3,414
(1 in 29)
Black females 20-24y
7,985
(1 in 12)
Black males 20-24y
4,486
(1 in 22)
CDPH Dept of Biostatistics
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Why screen and treat an
asymptomatic infection?
Subtle symptoms
Long duration of infectivity
Prevent Complications
• PID
Chronic Pelvic Pain
Infertility
Ectopic Pregnancy
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25% of women with gonorrhea or Chlamydia have
endometritis histologically
PID
Organisms
• Gonorrhea, Chlamydia, anaerobes
Treatment
• Ceftriaxone 250 mg IM + Doxycycline
100 mg po BID x 14 +/- metronidazole
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Normal female genitalia
How does the diagnosis of
Chlamydia affect future fertility?
Evaluated time to pregnancy and rates of ectopic
pregnancy in relation to CT diagnosis among ALL
women
31% CT + and 29.5% CT- became pregnant
Time to birth comparable
No effect on fertility or ectopic pregnancy
noted retrospectively among clients
diagnosed with CT
Andersen et al. Sex Trans Dis June 2005. 32 (6)377-381
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Recurrent Chlamydia infections in
young women
Prospectively recruited women diagnosed with
CT to return for f/u eval at 1 and 4 months ( all
treated)
Among women negative at first f/u --7.1%
positivity at 4 mo f/u
Re-screening in 3-4 months recommended for
all patients with infection.
Whittington et al. Sex Trans Dis Feb 2001. 28(2)117-123
Gonorrhea rates by ethnicity
CDC 2007 GISP report
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Gonorrhea screening
Screening in areas of with at least
1% prevalence
• high incidence tend to concentrated in
urban areas.
NAATs screening
Cultures
Probes
Gonorrhea
Can also live in oral pharynx
• Usually without symptoms
• Easily passed through oral sex to cause
urethritis
Can live in rectal environment
• may cause proctitis or no symptoms
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Pharyngeal Gonorrhea
Pharyngeal Gonorrhea
Symptoms:
• >90% of infections are asymptomatic
• Sore throat, when symptoms present
• Lymphadenopathy may be present
• Most infections will self-resolve
Diagnosis: GC culture or NAATs
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Screening for Rectal and
Pharyngeal CT and GC in
MSM
CDC recommends screening of atrisk men who have sex with men
(MSM) at least annually for urethral
and rectal GC and CT, and for
pharyngeal GC.
MMWR, July 9, 2009
STIs in MSM
Screened men attending
STD clinic and gay men’s
health clinic with rectal,
pharyngeal and urethral
swabs
53% of Chlamydia
infections not in
urethra
64% of gonococcal
infections were not in
urethra
Kent et al. CID 2005;41:67-74
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It’s Everywhere!
Kent et al. CID 2005;41:67-74
Asymptomatic infection in Men
86%
asymptomatic
rectal infections
42%
asymptomatic
urethral
infections
Kent et al. CID 2005;41:67-74
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Screening for Rectal and
Pharyngeal CT and GC
The rectum and pharynx are the most
common sites of GC and CT infection
among MSM.
Infections are usually asymptomatic and
typically occur without concomitant
urethral infection
Only a minority of MSM at risk for STDs
are screened for GC and CT at the
recommended frequency.
- treatment same as for urethral infections
CDC Recommendations
Yearly screening for rectal GC and CT for
MSM who had receptive anal intercourse
during the preceding year
Yearly screening for pharyngeal GC for
MSM who have had receptive oral
intercourse during the preceding year.
Screening is recommended regardless of
history of condom use during exposure.
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CDC Recommendations
Also screen:
• at three to sex month intervals for
MSM who have multiple or
anonymous partners
• MSM who have sex in conjunction
with illicit drug use, use
methamphetamine or whose sex
partners have participate in those
activities.
NAAT Testing
Nucleic acid amplification testing (NAAT) is
generally more sensitive than culture for the
detection of both GC and CT.
NAAT tests have not been cleared by the FDA for
the diagnosis of extra-genital CT or GC.
Under U.S. law, labs may offer NAAT testing for
diagnosis of extra-genital CT or GC after internal
validation of the method by verification study.
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NAAT Testing
CDC encourages labs to do their
own studies to establish
performance and initiate testing.
For more information about the
process:
•Carol Farshy [email protected]
NAAT Testing
A list of labs that have
completed the studies to
establish performance is
available on the American Public
Health Laboratories’ website:
www.aphl.org/aphlprograms/infectious.std
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FIGURE 2. Percentage of gonorrhea isolates with cefixime MICs ≥0.25 µg/mL and
ceftriaxone MICs ≥0.125 µg/mL, by sex of sex partner --- Gonococcal Isolate
Surveillance Project, United States, 2000--2010
MMWR July 8, 2011 / 60(26);873-877
Gonorrhea treatment
Ceftriaxone 250 mg
or
Cefixime 400 mg po – (not for MSM)
Plus treatment for Chlamydia
Azithromycin 1 gm po once
or
Doxycycline 100mg po BID x 7 days
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Partner Management
Maintain abstinence for 7 days while
completing treatment regimen and until
all partners are treated
All sexual contacts within past 60 days
should be evaluated and treated
Expedited Partner Therapy (e.g. Field
delivered Therapy, Patient Delivered
Partner Therapy) should be offered if legal
NGU
Case screnario 33 y/o heterosexual male presents to
clinic with dysuria- NGU by gram
stain. Treated with doxy 100 BID.
Returns in 2 wks and states no relief
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NGU
Mycoplasma genitalium getting
some attention
Occurs about 10% of NGU but
much higher in pts with “persistent
NGU” as relatively resistant to
Doxycycline
Pearl- responds best to
Azithromycin or Moxifloxacin but
not Cipro or Levo
NGU persistent
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Trichomonas
Diagnostic options
• Wet mount
• Culture
• Pcr/ naat
Treatment issues
Trichomonas
Single dose Metronidazole is NOT recommended
for Bacterial vaginosis due to lower efficacy.
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Challenge question
Allergy to Metronidazole?
Epidemiological Synergy
Co-infection with HIV prolongs the
infectiousness on STDs
STDs facilitate HIV transmission
by increasing genital HIV-RNA/DNA
levels
STDs facilitate HIV acquisition by
disrupting epithelial barriers and
attracting inflammatory cells
GUD increases risk of HIV 8 fold
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Urine-Based Tests
Nucleic Acid Amplification
Tests (NAATs) for gonorrhea
and chlamydia
Highly accurate
Non-invasive collection
• High patient acceptability
• Appropriate for screening
asymptomatic persons
Allows screening in nontraditional settings
• Community settings
• Correctional settings
• Schools
Urethritis/ cervicitis,
proctitis
Gonorrhea
Chlamydia
Trichomonas
Mycoplasma,
Herpes Simplex Virus
adenovirus
Vaginitis
Trichomonas
Bacterial vaginosis
Candida
Syphilis
Herpes Simplex Virus
Chancroid (h. ducrei)
HPV
syphilis
Genital ulcers
Genital warts
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Contact info:
Ann Avery MD
[email protected]
216 778 7828 office
216 207 1141 pager
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