1. STD’s general approach and what’s new? Mark Miller, MD, FRCPC J.G.H. McGill University Montreal, Canada

2. Topics zHistory – how good is it? zHistory – some hints zThe man with urethral symptoms zThe woman with cervicitis/pelvic pain zChlamydia + gonorrhea zHepatitis B virus (HBV) zHepatitis A virus (HAV) zManagement of a sexual post-exposure situation zQuestions

3. History – how good is it? z Sexual history is notoriously unreliable z Positive predictive value of “unprotected” exposure is good z Negative predictive value is HORRIBLE!

4. History – some “hints” z Don’t just say the word “sex” and assume that everyone is talking about the same thing u many patients don’t consider oral sex as “sex” u many patients don’t consider a massage with masturbation as “sex” zDon’t just ask about “prostitutes”; the world is changing u many patients don’t consider someone a prostitute if they don’t pay “cash” u many “sex workers” perform sex for drugs, food, a hotel room, etc. u many sex workers in other countries perform sex for something as “simple” as an alcoholic drink or lunch u sex workers often roam the beaches and resorts, looking for “susceptible” tourists, to have sex in exchange for meals, drinks, etc.

5. History – some “hints” z Oral sex u Almost every STD is efficiently transmitted via oral sex, except HIV z Syphilis is rampant in Montreal saunas among MSM (as is HIV, other STD’s, and unprotected sex) z Don’t let YOUR embarrassment of sexuality affect your history-taking u Ask about protected vs. unprotected sex (including oral) u Ask about extra-marital or other partners u Ask about relevant sexual practices (i.e. anal complaints? Ask about unprotected anal or anal-oral sex)

6. The man with urethral symptoms z Men with urethral discomfort and/or urethral discharge almost always have an STD u usually chlamydia u less often gonorrhea (“kleenex sign”) z Other causes u UTI (urethral discomfort; never have a discharge!) u Adenovirus (along with URTI) u Herpes simplex!!!!!!!!! u Rarely: Trichomonas, bacterial

7. The man with urethral symptoms and lymph nodes / swelling z Men with urethral discomfort, discharge WITH lymphadenitis and/or swelling u Usually Herpes simplex u Also possible: Group A strep urethritis/”penile edema” syndrome u Gonorrhea and Chlamydia rarely give adenitis

8. The woman with cervical discharge/friability or pelvic pain z Separate women into “instrumented” and “non- instrumented” infections u Non-instrumented: usually STD (gonorrhea/chlamydia) u Instrumented: may be associated with STD, but could also be 2 o to instrumentation alone z Therapy is same u Polymicrobial coverage INCLUDING gonorrhea and chlamydia u Pick any regime, as long as it covers both categories !!

9. Gonorrhea / Chlamydia - diagnosis Diagnosis of gonorrhea / chlamydia: - PCR (use appropriate swab & transport tube) - if gonorrhea positive, don’t forget you will not get a susceptibility result! - therefore, for highly-suspected gonorrhea, perform a CULTURE at same time (regular swab)

10. Gonorrhea: why do a culture? z JGH used as sentinel lab for changes in susceptibility of gonorrhea u i.e. JGH first one in Quebec to detect FQ-resistant gonorrhea z In case of allergies and drug reactions, need to know alternative possible therapies u e.g. pen-, tetra-, fq-resistant gonorrhea. Treatment??? u How about a patient with severe beta-lactam allergy: Treatment????

11. Chlamydia: therapy zMale or non-pregnant female: udoxy/tetra or erythro or levoflox x 7 days uazithromycin 1.0 gm x 1 dose zPregnancy: uerythro x 7 days uamoxicillin x 7 days uazithromycin 1.0 gm x 1 dose

12. Gonorrhea: therapy zMale or non-pregnant female: u Cefixime (Suprax TM ) 400 mg x 1 dose u Ceftriaxone 125 mg IM x 1 dose T NOT IN THE ARM !!!! Buttock ONLY! T Dilute with xylocaine 1% (without epi) zBeta-lactam allergic: uCipro 500 mg PO x 1 dose uWatch out for failures!!! Approx. 10%+ now resistant to FQ’s uAzithro 2.0 gm x 1 dose (GI sx +++++) uSpectinomycin

13. Use the “free” pharmacy codes: 2K (therapy) 2L (prophylaxis/contact)

14. Chlamydia: what’s new? z New strain in Europe, with genetic mutation z Not detected by some PCR-based tests z Test used @ JGH: BD Probe-Tec does detect new chlamydia variant

15. Hepatitis B z Almost everyone born in Quebec (Canada, too) after 1980 received HBV vaccine in grade 4; considered to be protected z Individuals born < 1980 did NOT receive HBV vaccine, unless specifically obtained at travel clinic, STD clinic, etc. z HBV vaccine is free of charge (paid by public health) for all individuals with STD; given routinely in ID clinic; arranged in MDH

16. Hepatitis A z HAV vaccine only “routine” in the past 1-2 years, for children z Individuals did NOT receive HAV vaccine, unless specifically obtained at travel clinic, STD clinic, etc. z HAV vaccine is free of charge (paid by public health) for all MSM (gay, bi); given routinely in ID clinic; arranged in MDH

17. Syphilis z Diagnosis of syphilis u JGH uses a specific EIA screen (false-positives uncommon) u If negative, no further testing u If positive, titer with RPR (to follow Rx) AND confirmatory tests with TP-PA and LIA (both done at provincial lab/LSPQ)

18. Syphilis z Therapy of syphilis: u 1 0 and 2 0 : Bicillin 2.4 x 10 6 U IM (buttock) x 1 dose u Late latent: Bicillin 2.4 x 10 6 U IM (buttock) x 3 doses u HIV+: Optimal Rx not known; usually “over-treat” with Bicillin 2.4 x 10 6 U IM (buttock) x 3 doses z Bicillin NOT licensed in Canada; only available by SAP; arranged with MDH at JGH

19. Management of a sexual post- exposure situation Infection Chlamydia Gonorrhoea Trichomonas* Syphilis Hepatitis B HIV Management azithro 1.0 gm x 1 dose ceftriaxone 125 mg x 1 [ mtz 2.0 gm x 1 dose ]* ?nothing (“covered” by ctrx) HBIG + HBV vaccine (if susceptible) 3-drug Rx for 4-6 weeks (Tfv/Etrc/Ataz = Truvada/Reyataz) * optional Plus: follow-up serology for HIV and syphilis

20. Questions?