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Update on the Treatment of STI: The Silent Epidemic

Update on the Treatment of STI: The Silent Epidemic. David E. Soper, MD Department of Obstetrics and Gynecology Medical University of South Carolina Charleston, South Carolina. Objectives. After attending this presentation the practitioner will be able to :

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Update on the Treatment of STI: The Silent Epidemic

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  1. Update on the Treatment of STI:The Silent Epidemic David E. Soper, MD Department of Obstetrics and GynecologyMedical University of South CarolinaCharleston, South Carolina

  2. Objectives After attending this presentation the practitioner will be able to: • Diagnose and treat chlamydia infection • Treat gonococcal infection • Understand reverse screening for syphilis • Manage mild to moderate PID with IUD in situ • Diagnose genital herpes infection

  3. STI Chlamydia Gonorrhea Syphilis Herpes HPV Hepatitis B Trichomoniasis Bacterial vaginosis Number of Cases per Year 2.86 million 820,000 55,400 776,000 14.1 million 19,000 1.1 million Not available The Silent EpidemicEstimated Annual Rates USA

  4. Sexual Behaviors • 15 million new STIs each year • 25% in teenagers • 900,000 adolescents become pregnant • Adolescent statistics • 47% of high school students had ever had coitus • 15% had >4 lifetime sex partners • 40% did not use a condom with last sex contact

  5. Cervicitis • Two major diagnostic signs • Purulent or mucopurulent endocervical exudate • Sustained endocervical bleeding easily induced by gentle passage of a cotton swab through cervical os

  6. CervicitisEtiology • If pathogen detected, most likely: • Chlamydia trachomatis • Neisseria gonorrhoeae • Can also accompany trichomoniasis and herpes • Most cases = no organism isolated • Other possibilities • BV, Mycoplasma genitalium, frequent douching

  7. Cervicitis Diagnosis • NAAT for chlamydia and gonorrhea • Vaginal, cervical or urine samples • Self collected vaginal swabs most sensitive • CT = 97%[95-98] vs 95% [85-91]

  8. CervicitisTreatment • Recommended regimen • Treat for chlamydia • Azithromycin 1 g orally in a single dose Or • Doxycycline 100 mg orally twice a day for 7 days • Concurrent therapy for GC of prevalence >5% • < 25 years of age • Treat BV and/or trichomonas if detected

  9. CervicitisRecurrent or Persistent • Reinfection? • Consider M. genitalium • Moxifloxicin 400 mg orally once daily for 7 days • Retest CT or GC positive in 3 to 6 months • High rate of reinfection

  10. ChlamydiaScreening Guidelines • Sexually active adolescents • Screen annually, even if asymptomatic • More frequent (q 3-6 mos) if positive • Women aged 20-25 • Annual screening also recommended • Older women with risk factors • New sex partner • Multiple sex partners

  11. Chlamydia ScreeningNew Risk Factors • Screening for older women with risk factors • Sex partner with concurrent sex partners • Resumed sexual activity • Widowed • Divorced • Separated • Bacterial vaginosis

  12. Chlamydia ScreeningOptimal Urogenital Specimen • Vaginal swabs from women • Can be self collected • First catch urine for men • NAATs not FDA cleared for oral or rectal site • Improved sensitivity and specificity over culture • Self collected swabs comparable

  13. Chlamydia Recommended regimens • Azithromycin 1 gram orally single dose OR • Doxycycline 100 mg orally bid for 7 days • Treat partner • NO SEX for 7 days

  14. Chlamydia Alternative regimens • Erythromycin base 500 mg orally qid x 7 days OR • Erythromycin ethylsuccinate 800 mg qid x 7 days OR • Levofloxacin 500 mg orally for 7 days (substituted for ofloxacin 300 mg bid for 7 days) TEST OF CURE >3 weeks after therapy

  15. Uncomplicated Gonococcal Infections of Cervix, Urethra, Rectum DUAL THERAPY !! • Ceftriaxone 250mg in a single IM dose PLUS • Azithromycin 1 gram orally in a single dose

  16. Gonococcal InfectionAlternative Regimens • Cefexime 400 mg in a single oral dose PLUS • Azithromycin 1 gram orally in a single dose • Or doxycycline 100mg orally twice a day for 7 days • High level of tetracycline resistance in GISP • Azithromycin preferrable PLUS • Test of cure in one week

  17. Gonococcal InfectionPenicillin/Cephalosporin Allergy • Azithromycin 2 grams in a single oral dose PLUS • Test-of-cure in one week • Allergy should be severe and an immediate hypersensitivity reaction

  18. Mycoplasma genitalium • Emerging pathogen • Persistent or recurrent urethritis in men • Suggestive as an etiology of cervicitis • Can cause PID • ? Link to preterm birth • Linked to acquisition of HIV

  19. Mycoplasma genitaliumTreatment • Azithromycin 1 gram orally in a single dose • Superior to multidose doxycycline • Multidose azithromycin • 1 gram followed in one week with another 1gram ? Best • Moxifloxicin 400mg daily for 7 days • 91% efficacy • 14 day course 100% • Other quinolones (levo- or ciprofloxacin) ineffective

  20. Pelvic Inflammatory DiseaseMild to Moderate • Outpatient • Ceftriaxone 250mg IM • Doxycycline 100 mg bid for 14 days • With or without metronidazole • Doesn’t cover M. genitalium • If no clinical response rule out abscess then - • Consider Moxifloxin 400mg daily for 14 days

  21. PID and the IUD • “Evidence is insufficient to recommend the removal of IUDs in women diagnosed with PID.” • Risk primarily restricted to the first 3 weeks after insertion • Consider removal only if patient fails to respond to conventional therapy

  22. Genital Ulcer DiseaseDiagnosis • Serologic test for syphilis • Diagnostic evaluation for herpes • H. ducreyi • Syndromic diagnosis • Ulcer plus suppurative adenopathy • Consider HIV testing

  23. Primary and Secondary Syphilis—Rates by Region, United States, 2003–2012 2012-Fig 32. SR Pg 33

  24. Primary and Secondary Syphilis—Rates by Age Among Women Aged 15–44 Years, United States, 2003–2012 2012-Fig 36. SR, Pg 35

  25. Congenital Syphilis—Reported Cases Among Infants by Year of Birth and Rates of Primary and Secondary Syphilis Among Women, United States, 2003—2012 * CS=congenital syphilis; P&S=primary and secondary syphilis. 2012-Fig 43. SR, Pg 39

  26. Syphilis Screening • Non-treponemal testing • Quantitative • VDRL • RPR • Treponemal testing • TP-PA • FTA-abs • EIA

  27. Syphilis SerologyReverse Screening • Start with treponemal test • EIA • Confirm with quantitative, non-treponemal test • RPR

  28. Syphilis SerologyReverse Screening • Why? • Automated (high throughput) • Low cost in high volume settings • Less lab occupational hazard (pipetting) • Objective results • No false negatives due to prozone reaction

  29. Treatment of Syphilis Primary, secondary, Benzathine penicillin and early latent 2.4 mu IM Latent Benzathine penicillin 2.4 mu IM, wkly x 3

  30. SyphilisAlternative Therapies • Limited data to support alternatives to penicillin • Clinical and serologic follow-up mandatory • Ceftriaxone 1-2 gm IM/IV qd x 10-14d • Doxycycline 100 mg bid x 14d • Azithromycin 2 gm once • Emerging macrolide resistance (NEJM,2004)

  31. Herpes Simplex Virus Type 2—Seroprevalence Among Non-Hispanic Whites and Non-Hispanic Blacks by Age Group, National Health and Nutrition Examination Survey, 1976–1980, 1988–1994, 1999–2004, 2005–2008 *Age-adjusted by using the 2000 U.S. Census civilian, non-institutionalized population aged 14-49 years as the standard. NOTE: Error bars indicate 95% confidence intervals. 2012-Fig 49. SR, Pg 46

  32. Genital HerpesDiagnosis • Viral culture • Positive in 80-90% of primary disease • Positive in only 30-50% of recurrent disease • Dependent on stage of lesion • Antigen detection tests • Don’t discriminate between HSV 1 and 2 • PCR • Now established for lesions

  33. HSV Serology • Assays that do not distinguish HSV-1 from HSV-2 remain commercially available • Whole virus lysates of HSV-1 and 2 • Only valuable if seronegative • Type-specific assays • Glycoprotein G2 for HSV-2 • Glycoprotein G1 for HSV-1 • Time frame to conversion 2 weeks to 3 months

  34. HSV Serology • Populations in which testing may be beneficial • Persons seeking STD evaluation • Persons with partners with genital HSV • Patients with atypical lesions or symptoms • Pregnant women • HIV seropositive persons • Persons at risk for HIV

  35. Genital HerpesModern Diagnostic Approach • Clinical diagnosis • PPV = 81% • Sensitivity = 39% • HSV type-specific PCR • When lesions are present • Culture commonly false negative • Type specific HSV antibodies

  36. Genital HerpesTreatment for First Episode • Acyclovir 400 mg tid x 7-10 days OR • Acyclovir 200 mg 5 times daily x 7-10 OR • Famciclovir 250 mg tid x 7-10 days OR • Valacyclovir 1 g orally bid x 7-10 days

  37. Genital HerpesEpisodic Therapy • Acyclovir • 400 mg tid for 5 days • 800 mg bid for 5 days • 800 mg tid for 2 days • Valacyclovir • 500 mg bid for 3 days • 1 gram daily for 5 days

  38. Genital HerpesEpisodic Therapy • Famciclovir • 125 mg bid for 5 days • 1 gram bid for 1 day • 500 mg then 250 mg bid for 2 days

  39. Genital HerpesSuppressive Therapy • Acyclovir 400 mg bid • Famciclovir 250 mg bid • Valacyclovir 500 mg daily* • Valacyclovir 1 gram daily

  40. Covariate Analyses of Factors Influencing the Transmission of Genital Herpes Covariate Acquisition of Symptomatic HSV-2 infection Hazard Ratio (95% CI) P Value Valacyclovir (vs. placebo) 0.25 (0.08-0.75) 0.01 Susceptible partner female 3.30 (1.31-8.28) 0.01 Susceptible partner HSV-1-negative 1.64 (0.64-4.17) 0.30 Less frequent condom use at 1.70 (0.95-3.05) 0.08 time of acquisition More frequent sexual contacts 1.83 (0.97-3.43) 0.06 during study Duration of HSV-2 infection in 2.89 (1.12-7.49) 0.03 source <2 yr (vs. >2 yr) Duration of relationship 3.18 (0.89-11.33) 0.08 <2.5 yr (vs. >2.5 yr)

  41. What have you learned? • Vaginal swabs for chlamydia testing • DUAL THERAPY for gonococcal infection !! • Mycoplasma genitalium is coming • Ok to leave the IUD in while Rx for PID • Reverse screening for syphilis • PCR testing for skin lesions suspicious for HSV

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