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Updates in STD Management

Updates in STD Management. Jessica Lee Howell, MD Swedish First Hill Family Medicine Residency Infectious Diseases in Primary Care CME Conference May 9, 2014. Objective Questions. How are we doing as a nation in screening and managing STDs? Who is at risk for STDs in our community?

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Updates in STD Management

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  1. Updates in STD Management Jessica Lee Howell, MD Swedish First Hill Family Medicine Residency Infectious Diseases in Primary Care CME Conference May 9, 2014

  2. Objective Questions • How are we doing as a nation in screening and managing STDs? • Who is at risk for STDs in our community? • What are the screening recommendations? • What resistance issues are concerning? • What are the current treatment guidelines? • What are some special cases we may encounter?

  3. STDs: National Report Card • Chlamydia >1.4 million cases in 2012 •  largest number of cases ever reported to CDC for any condition •  # of cases in women unchanged • Gonorrhea 335,000 cases in 2012 •  74% decline from 1975-1997 •  rates steadily increasing since 2009

  4. STDs: National Report Card • Syphilis 16,000 cases in 2012 •  Congenital syphilis cases decreasing •  Cases among men, especially MSM rising • HIV 50,000 new cases in 2012 •  1 in 6 unaware of their infection •  2/3 new infections among MSM

  5. HPV Vaccination

  6. STDs: Health Disparity

  7. STDs: Syphilis

  8. STDs: WA/King County

  9. Screening Recommendations High Risk = H/o STDs, new or multiple sexual partners, inconsistent condom use, exchanging sex for money or drugs

  10. Screening Recommendations

  11. STD Treatment • Of course, there’s an app! App: STD Tx Guide

  12. Gonorrheal Resistance

  13. Gonorrhea: Antibiotic History

  14. Gonorrhea: Treatment Update • Treat with CTX + Azithromycin or Doxycycline • If signs of treatment failure on CTX, TOC by culture and report to KC PH: (206) 744-2275 • If alternate therapy, TOC by culture after 1 week at infected anatomic site -> CTX 250mg IM + Azithro 2g PO if positive. • King County: If culture unavailable, refer to KC PH for testing or NAAT ok

  15. Gonorrhea: New Therapy Options 1. Injectable gentamicin + PO Azithromycin 2. PO Gemifloxacin + PO Azithromycin • Phase IV clinical trial by CDC/NIH • 400 participants • 100% cure rate for pharyngeal/rectal GC. • 100%, 99.5% cure rate for genital GC • High reported GI side effects

  16. Expedited Partner Therapy • Make every effort to get partners from previous 60 days evaluated and treated • King County: no TOC for Cefixime + Azithromycin (except pharyngeal) • King County: No EPT for MSM • Pharmacies providing free EPT • http://www.kingcounty.gov/healthservices/health/communicable/std/providers/pharmacies.aspx

  17. Chlamydial Resistance • Few case studies • In vitro studies tetracycline, Sulfa resistance • More to come…

  18. Syphilis Resistance • Penicillin G: bacteriocidal, no known resistance (would require multistep mutation) • Macrolides: bacteriostatic • Erythromycin: 1950s • Clindamycin: 1960s • Azithromycin: 1990 • Tetracycline: no known resistance

  19. Quick Case #1: • 32-year old woman • History of CT, treated 2008. Partner treated. • CC: “I got it again” • No symptoms of PID

  20. Quick Case #1: • NAAT negative • Wet mount negative for trichomonas, BV, yeast • What do you do?

  21. Nongonoccal Cervicitis/Urethritis • Most common pathogens: • Chlamydia • HSV • BV • Trichomonas • Candida • Mycoplasma genitalium& hominis • Ureaplasmaurealyticum & parvum • Irritants

  22. Nongonoccal Cervicitis/Urethritis • CDC recommended therapy • Azithromycin 1g PO OR • Doxycycline 100mg PO BID x 7 days • Refer to gynecology if no improvement

  23. Quick Case #2: • 43 year old man • Recent travel to Mexico • Sexual preference: “married” • Returns with painless penile lesion • What do you do?

  24. Primary Syphilis • Ddx: HSV, HIV, Chancroid, non-STD lesion If MSM, other high-risk, clinical primary syphilis or concern for follow-up, treat presumptively.

  25. Primary Syphilis

  26. King County STD Resources • KC Public Health STD Clinic: • http://www.kingcounty.gov/healthservices/health/communicable/hiv/resources/STDclinic.aspx • KC Reporting Forms: • http://www.kingcounty.gov/healthservices/health/communicable/providers/reporting.aspx • Pharmacy List for Free EPT: • http://www.kingcounty.gov/healthservices/health/communicable/std/providers/pharmacies.aspx • KC Lab: 206-418-5400

  27. Questions? Much thanks to Drs. Maureen Brown and Carroll Haymon for their advice and guidance.

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