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Sexually Transmitted Infections and 2010 CDC STD Treatment Guidelines April 11, 2012 HIV/STD/TB/Hepatitis Symposium Bismarck ND David McNamara, M.D. Infectious.

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Presentation on theme: "Sexually Transmitted Infections and 2010 CDC STD Treatment Guidelines April 11, 2012 HIV/STD/TB/Hepatitis Symposium Bismarck ND David McNamara, M.D. Infectious."— Presentation transcript:

1 Sexually Transmitted Infections and 2010 CDC STD Treatment Guidelines April 11, 2012 HIV/STD/TB/Hepatitis Symposium Bismarck ND David McNamara, M.D. Infectious Disease Division Gundersen Lutheran La Crosse WI

2 Disclosures No commercial disclosures No commercial disclosures Dakota AIDS Education & Training Center Dakota AIDS Education & Training Center

3 Learning Objective At the end of the presentation, participants should be familiar with basics of: At the end of the presentation, participants should be familiar with basics of: Common Sexually Transmitted Infections Common Sexually Transmitted Infections 2010 CDC STD Treatment Guidelines 2010 CDC STD Treatment Guidelines Common presentations of HIV Common presentations of HIV HIV Screening HIV Screening

4 What is Your Professional Discipline? 1. Nurse 2. Physician 3. Public Health (RN, Epidemiologist) 4. Allied Health 5. Laboratory 6. Social Worker 7. Other

5 Overview Sexually Transmitted Infections Sexually Transmitted Infections Case # 1 Case # 1 Case # 2 Case # 2 Case # 3 Case # 3 Case # 4 Case # 4 Summary Summary

6 Sexually Transmitted Infections Common Common Wide variety of pathogens can be transmitted sexually Wide variety of pathogens can be transmitted sexually Often transmit more efficiently male→female than female→male Often transmit more efficiently male→female than female→male Sequelae Sequelae Direct effect of pathogen on body Direct effect of pathogen on body Infertility, ectopic pregnancy, cancer, transmission to fetus Infertility, ectopic pregnancy, cancer, transmission to fetus

7 Some (not all) Pathogens Transmitted Sexually T. pallidum (Syphilis) Neisseria gonorrhoeae Chlamydia trachomatis Ureaplasma urealyticum Mycoplasma genitalium Haemophilus ducreyi (Chancroid) Chlamydia trachomatis L1, L2, L3 (Lymphogranuloma venereum) Klebsiella granulomatis (Granuloma Inguinale) Trichomonas vaginalis Scabies, Pediculosis pubis HSV, Herpes Simplex Virus HSV, Herpes Simplex Virus HIV HIV HBV, HDV HBV, HDV CMV, EBV CMV, EBV Human Papilloma Virus (HPV) Human Papilloma Virus (HPV) HHV-8, Kaposi’s Sarcoma Herpes Virus (KSHV) HHV-8, Kaposi’s Sarcoma Herpes Virus (KSHV)

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10 Overview Sexually Transmitted Infections Sexually Transmitted Infections Case # 1 Case # 1 Case # 2 Case # 2 Case # 3 Case # 3 Case # 4 Case # 4 Summary Summary

11 Case #1 19 year-old female student presents for routine care Sexually active with male partner Feels well, no GU symptoms Cervical swab Routine pap smear Chlamydia/Gonorrhea Nucleic Acid Amplicification Test (NAAT) Chlamydia NAAT returns positive

12 How should she be treated? 1. Ceftriaxone 250 mg IM x 1 dose 2. Azithromycin or doxycycline for patient 3. Azithromycin or doxycycline for both patient and her partner 4. Cipro 500 mg PO BID x 7 days 5. Confirm NAAT with culture prior to treatment

13 Chlamydia Chlamydia trachomatis Chlamydia trachomatis Most common bacterial STI Most common bacterial STI Often asymptomatic Often asymptomatic Can give urethritis in men Can give urethritis in men Common cause of infertility Common cause of infertility Scarring of fallopian tube (Pelvic Inflammatory Disease) Scarring of fallopian tube (Pelvic Inflammatory Disease) 10-15% of women with untreated Chlamydia develop PID 10-15% of women with untreated Chlamydia develop PID Women often re-infected if partner not treated Women often re-infected if partner not treated Treat with azithromycin or doxycycline Treat with azithromycin or doxycycline Sexually active women need yearly Chlamydia/gonorrhea testing Sexually active women need yearly Chlamydia/gonorrhea testing

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15 Observed Single dose treatment advantage Observed Single dose treatment advantage treatment completed treatment completed No sexual intercourse for 7 days after treatment completed No sexual intercourse for 7 days after treatment completed Test of cure not recommended Test of cure not recommended 3 month re-testing recommended to screen for re-infection 3 month re-testing recommended to screen for re-infection

16 How should her sexual partner be managed? Timely treatment of sexual partner important to reduce risk of re-infecting index patient, others Timely treatment of sexual partner important to reduce risk of re-infecting index patient, others Instruct patient to refer most recent sexual partner, and any other partners within 60 days of Chlamydia diagnosis, for testing and treatment Instruct patient to refer most recent sexual partner, and any other partners within 60 days of Chlamydia diagnosis, for testing and treatment If sexual partner(s) unlikely to present for treatment, consider Expedited Partner Therapy If sexual partner(s) unlikely to present for treatment, consider Expedited Partner Therapy Patient must inform partner, provide written material to seek evaluation for symptoms of complications (testicular pain, pelvic pain) Patient must inform partner, provide written material to seek evaluation for symptoms of complications (testicular pain, pelvic pain) Patient-delivered prescription or antibiotic for partner(s) Patient-delivered prescription or antibiotic for partner(s) Not for Men who have sex with Men (MSM) Not for Men who have sex with Men (MSM) Very high HIV risk, partners need testing/treatment Very high HIV risk, partners need testing/treatment

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19 Overview Sexually Transmitted Infections Sexually Transmitted Infections Case # 1 Chlamydia Case # 1 Chlamydia Case # 2 Case # 2 Case # 3 Case # 3 Case # 4 Case # 4 Summary Summary

20 Case #2 28 year old man presents with painful, burning urination x 1 week Yellow urethral discharge x 3 days “I’ve never had this before!” Reports 3 female sexual partners in last several months Intermittent condom use, only when partner is new

21 Urethral swab taken Gram stain Gram Negative Diplococci Public Health Image Library

22 Likely etiology of urethritis? 1. Chlamydia 2. Herpes Simplex Virus 3. Gonorrhea 4. E. coli UTI/ epididymitis 5. Syphilis

23 How should this be treated? 1. Ceftriaxone 250 mg IM x 1 2. Ceftriaxone 250 mg IM + Azithromycin 1g PO x 1 3. Doxycycline 100 mg PO BID x 7 days 4. Ciprofloxacin 500 mg PO BID x 7 days 5. Cefixime 400 mg PO x 1

24 Gonorrhea Neisseria gonorrhoeae Neisseria gonorrhoeae 700,000 cases/year in U.S. 700,000 cases/year in U.S. Men: urethral discharge, urethritis Men: urethral discharge, urethritis Women: asymptomatic, dysuria, vaginal discharge, PID Women: asymptomatic, dysuria, vaginal discharge, PID Diagnosis: Diagnosis: Gram Stain Gram Stain Culture: Thayer-Martin media or chocolate agar Culture: Thayer-Martin media or chocolate agar NAAT on urine, urethral swab, cervical swab NAAT on urine, urethral swab, cervical swab Will transmit to infant during birth Will transmit to infant during birth

25 Provide treatment for Chlamydia together with Gonorrhea Provide treatment for Chlamydia together with Gonorrhea Common co-infections Common co-infections Cipro/Levofloxacin resistent Gonorrhea now common Cipro/Levofloxacin resistent Gonorrhea now common Resistance to Cephalosporins rare but expected to increase Resistance to Cephalosporins rare but expected to increase Routine test of cure not recommended (only if symptoms) Routine test of cure not recommended (only if symptoms) Rescreen at 3 months to detect re-infection Rescreen at 3 months to detect re-infection

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28 Overview Sexually Transmitted Infections Sexually Transmitted Infections Case # 1 Chlamydia Case # 1 Chlamydia Case # 2 Gonorrhea Case # 2 Gonorrhea Case # 3 Case # 3 Case # 4 Case # 4 Case # 5 Case # 5 Summary Summary

29 Case # 3 32 year old man presents with ulcer on penis Does not hurt, present for 1 week Married, wife doesn’t have any symptoms Travels frequently for business several sexual encounters per year with other men 2 years ago Treated for gonorrhea HIV test negative at that time Uses condoms “most of the time”

30 Public Health Image Library

31 Most likely etiology of penile ulcer? 1. Herpes Simplex Virus 2. Syphilis 3. Gonorrhea 4. Chlamydia 5. Lymphogranuloma Venereum (LGV)

32 Syphilis Treponema pallidum Treponema pallidum 36,000 cases/year in U.S. 36,000 cases/year in U.S. 2/3 in MSM 2/3 in MSM A systemic disease A systemic disease Primary: painless genital ulcer (chancre) Primary: painless genital ulcer (chancre) Secondary: rash Secondary: rash Latent Latent asymptomatic at first asymptomatic at first neurologic, bone, heart disease in years neurologic, bone, heart disease in years Pregnancy: transmission to infant Pregnancy: transmission to infant Diagnosis: RPR or VDRL blood test Diagnosis: RPR or VDRL blood test All patients with Syphilis need HIV testing! All patients with Syphilis need HIV testing! All partners need evaluation, usually presumptive treatment All partners need evaluation, usually presumptive treatment

33 Primary and secondary syphilis Primary and secondary syphilis Benzathine PCN G 2.4 Million Units IM x 1 dose Benzathine PCN G 2.4 Million Units IM x 1 dose Latent Syphilis Latent Syphilis Early: Benzathine PCN G 2.4 Million Units IM x 1 dose Early: Benzathine PCN G 2.4 Million Units IM x 1 dose Late, or unknown duration: Benzathine PCN G 2.4 Million Units IM x q week x 3 doses Late, or unknown duration: Benzathine PCN G 2.4 Million Units IM x q week x 3 doses Tertiary: cardiac, Gumma (need to rule out Neurosyphilis) Tertiary: cardiac, Gumma (need to rule out Neurosyphilis) Benzathine PCN G 2.4 Million Units IM x q week x 3 doses Benzathine PCN G 2.4 Million Units IM x q week x 3 doses Neurosyphilis Neurosyphilis Penicillin G 24 million units/day (continuous IV infusion) x days Penicillin G 24 million units/day (continuous IV infusion) x days

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35 Overview Sexually Transmitted Infections Sexually Transmitted Infections Case # 1 Chlamydia Case # 1 Chlamydia Case # 2 Gonorrhea Case # 2 Gonorrhea Case # 3 Syphilis Case # 3 Syphilis Case # 4 Case # 4 Case # 5 Case # 5 Summary Summary

36 CC: Sore Throat 20 year-old woman presents to University Student Health Service 20 year-old woman presents to University Student Health Service sore throat sore throat “achy all over” for past 5 days “achy all over” for past 5 days joints ache, fevers, “I feel rotten” joints ache, fevers, “I feel rotten” missed classes for 3 days missed classes for 3 days “exhausted” “exhausted”

37 PMH: PMH: otherwise well otherwise well Meds: Meds: oral contraceptives oral contraceptives Social History Social History grew up in rural ND grew up in rural ND sophomore business major sophomore business major occasional alcohol use occasional alcohol use no tobacco no tobacco new boyfriend for 3 months new boyfriend for 3 months

38 Exam VS: Temp 100.3° F VS: Temp 100.3° F Awake, alert, looks tired and ill Awake, alert, looks tired and ill Oropharynx red; tonsils swollen Oropharynx red; tonsils swollen Small, swollen mobile cervical lymph nodes Small, swollen mobile cervical lymph nodes Lungs: clear Lungs: clear Cor: RRR with normal s1s2 no murmurs Cor: RRR with normal s1s2 no murmurs Abdomen soft, nontender, no HSM Abdomen soft, nontender, no HSM Joints: no effusions or synovitis Joints: no effusions or synovitis Skin: rash on chest, back Skin: rash on chest, back

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41 Labs Labs WBC 2.3 N45 L5 M28 B9 E4 WBC 2.3 N45 L5 M28 B9 E4 Hb 12.8 g/dL Hb 12.8 g/dL platelets 112,000 platelets 112,000 Group A Strep PCR: negative Group A Strep PCR: negative Assessment? Assessment? Febrile illness with pharyngitis, leukopenia and rash Febrile illness with pharyngitis, leukopenia and rash Differential diagnosis? Differential diagnosis?

42 Likely Diagnosis? 1. Mononucleosis 2. Epstein-Barr Virus Infection 3. Streptococcal Pharyngitis 4. Acute HIV infection 5. Severe Cold

43 Further testing? Further testing? Monospot: negative Monospot: negative CMV Antibody CMV Antibody IgG positive, IgM negative IgG positive, IgM negative Testing for HIV infection? Testing for HIV infection? HIV Antibody Screen: negative HIV Antibody Screen: negative HIV Viral Load: 770,000 copies/mL HIV Viral Load: 770,000 copies/mL

44 Diagnosis: Acute HIV Infection Illness associated with initial HIV infection Illness associated with initial HIV infection Fever, body aches, sore throat, swollen lymph nodes common Fever, body aches, sore throat, swollen lymph nodes common Rash in 50% Rash in 50% Uncommonly recognized Uncommonly recognized Important to make diagnosis: Important to make diagnosis: reduce HIV transmission to others reduce HIV transmission to others sexual partners, infants sexual partners, infants treat HIV before advanced AIDS develops treat HIV before advanced AIDS develops

45 Is there HIV in North Dakota? Is there HIV in North Dakota? ND a low incidence state, but… ND a low incidence state, but…

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51 North Dakota Since 1984 Since 1984 ~ 10 new cases/year ~ 10 new cases/year Total 505 Total AIDS 316 AIDS 189 HIV (non AIDS) 189 HIV (non AIDS) 227 live in ND 227 live in ND

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53 Human Immunodeficiency Virus Infects CD4+ T-lymphocytes Infects CD4+ T-lymphocytes immune system control of infection and cancer immune system control of infection and cancer Initial infection often has a febrile, viral syndrome Initial infection often has a febrile, viral syndrome Retrovirus Retrovirus integrates into host cell DNA, chronic infection integrates into host cell DNA, chronic infection Usually asymptomatic afterwards Usually asymptomatic afterwards Gradual, progressive failure of T-cell arm of immune system Gradual, progressive failure of T-cell arm of immune system Death often in 8-12 years if undiagnosed/ untreated Death often in 8-12 years if undiagnosed/ untreated

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56 CDC 2006 HIV Testing Guidelines Major departure from prior guidelines Major departure from prior guidelines Test all persons years old at least once, regardless of risk factors Test all persons years old at least once, regardless of risk factors Make HIV testing routine, similar to cholesterol or blood pressure screening Make HIV testing routine, similar to cholesterol or blood pressure screening “Opt-out” testing: “Opt-out” testing: Inform patient of HIV testing Inform patient of HIV testing Verbal assent ok; written consent not required Verbal assent ok; written consent not required Patient can “opt out” if desired Patient can “opt out” if desired

57 HIV Testing Healthcare provider orders “HIV 1/2 Antibody” blood test Healthcare provider orders “HIV 1/2 Antibody” blood test Lab runs a 2 part test: Lab runs a 2 part test: Initial screen: HIV Antibody ELISA Initial screen: HIV Antibody ELISA very sensitive, not as specific very sensitive, not as specific some false positives occur some false positives occur if ELISA positive, lab runs if ELISA positive, lab runs HIV Antibody Western Blot test HIV Antibody Western Blot test very specific very specific

58 Prenatal HIV Testing All pregnant women need an HIV blood test All pregnant women need an HIV blood test Reason? Reason? Prevent mother-to-child transmission (MTCT) of HIV Prevent mother-to-child transmission (MTCT) of HIV Untreated HIV+ mother: 20-30% risk of transmission of HIV to infant Untreated HIV+ mother: 20-30% risk of transmission of HIV to infant Treated HIV+ mother: <2-5% MTCT Treated HIV+ mother: <2-5% MTCT

59 Case #4 Lessons Learned Heterosexual contact most common route of HIV infection in women Heterosexual contact most common route of HIV infection in women HIV Antibody test will not detect HIV infection until 3-5 weeks after infection HIV Antibody test will not detect HIV infection until 3-5 weeks after infection Consider Acute Retroviral Syndrome in differential diagnosis of acute febrile illness, Consider Acute Retroviral Syndrome in differential diagnosis of acute febrile illness, especially if rash, sore throat, leukopenia or thrombocytopenia especially if rash, sore throat, leukopenia or thrombocytopenia Lab testing: Lab testing: HIV Antibody (takes 3-5 weeks for + Ab) HIV Antibody (takes 3-5 weeks for + Ab) HIV Viral Load (HIV RNA PCR) HIV Viral Load (HIV RNA PCR)

60 Overview Sexually Transmitted Infections Sexually Transmitted Infections Case # 1 Chlamydia Case # 1 Chlamydia Case # 2 Gonorrhea Case # 2 Gonorrhea Case # 3 Syphilis Case # 3 Syphilis Case # 4 HIV Case # 4 HIV Summary Summary

61 Why does this matter in ND?

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64 HIV, STIs have been less common here than in many parts of the country HIV, STIs have been less common here than in many parts of the country Potential for missed, delayed diagnoses Potential for missed, delayed diagnoses North Dakota developing rapidly North Dakota developing rapidly More connected than we used to be More connected than we used to be Incidence of HIV, STIs likely to rise Incidence of HIV, STIs likely to rise Timely recognition of HIV increasingly important Timely recognition of HIV increasingly important

65 Summary Recognize, treat common STIs Recognize, treat common STIs Recognize signs of HIV infection and make diagnosis Recognize signs of HIV infection and make diagnosis Screen for HIV infection in order to: Screen for HIV infection in order to: Avoid transmission to others Avoid transmission to others Prevent advanced AIDS Prevent advanced AIDS Prevent transmission to infants Prevent transmission to infants

66 Acknowledgements Acknowledgements Anne Grande, Education Coordinator Dakota AIDS Education & Training Center Anne Grande, Education Coordinator Dakota AIDS Education & Training Center Christopher Wegner, HIV Prevention Capacity Building Coordinator, American Red Cross Christopher Wegner, HIV Prevention Capacity Building Coordinator, American Red Cross Further resources: Further resources: cdc.gov cdc.gov North Dakota Department of Health, North Dakota Department of Health,

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