STD’s general approach and what’s new?

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

2. Topics • History – how good is it? • History – some hints • The man with urethral symptoms • The woman with cervicitis/pelvic pain • Chlamydia + gonorrhea • Hepatitis B virus (HBV) • Hepatitis A virus (HAV) • Management of a sexual post-exposure situation • Questions

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

4. History – some “hints” • Don’t just say the word “sex” and assume that everyone is talking about the same thing • many patients don’t consider oral sex as “sex” • many patients don’t consider a massage with masturbation as “sex” • Don’t just ask about “prostitutes”; the world is changing • many patients don’t consider someone a prostitute if they don’t pay “cash” • many “sex workers” perform sex for drugs, food, a hotel room, etc. • many sex workers in other countries perform sex for something as “simple” as an alcoholic drink or lunch • 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” • Oral sex • Almost every STD is efficiently transmitted via oral sex, except HIV • Syphilis is rampant in Montreal saunas among MSM (as is HIV, other STD’s, and unprotected sex) • Don’t let YOUR embarrassment of sexuality affect your history-taking • Ask about protected vs. unprotected sex (including oral) • Ask about extra-marital or other partners • Ask about relevant sexual practices (i.e. anal complaints? Ask about unprotected anal or anal-oral sex)

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

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

8. The woman with cervical discharge/friability or pelvic pain • Separate women into “instrumented” and “non-instrumented” infections • Non-instrumented: usually STD (gonorrhea/chlamydia) • Instrumented: may be associated with STD, but could also be 2o to instrumentation alone • Therapy is same • Polymicrobial coverage INCLUDING gonorrhea and chlamydia • 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? • JGH used as sentinel lab for changes in susceptibility of gonorrhea • i.e. JGH first one in Quebec to detect FQ-resistant gonorrhea • In case of allergies and drug reactions, need to know alternative possible therapies • e.g. pen-, tetra-, fq-resistant gonorrhea. Treatment??? • How about a patient with severe beta-lactam allergy: Treatment????

11. Chlamydia: therapy • Male or non-pregnant female: • doxy/tetra or erythro or levoflox x 7 days • azithromycin 1.0 gm x 1 dose • Pregnancy: • erythro x 7 days • amoxicillin x 7 days • azithromycin 1.0 gm x 1 dose

12. Gonorrhea: therapy • Male or non-pregnant female: • Cefixime (SupraxTM) 400 mg x 1 dose • Ceftriaxone 125 mg IM x 1 dose • NOT IN THE ARM !!!! Buttock ONLY! • Dilute with xylocaine 1% (without epi) • Beta-lactam allergic: • Cipro 500 mg PO x 1 dose • Watch out for failures!!! Approx. 10%+ now resistant to FQ’s • Azithro 2.0 gm x 1 dose (GI sx +++++) • Spectinomycin

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

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

15. Hepatitis B • Almost everyone born in Quebec (Canada, too) after 1980 received HBV vaccine in grade 4; considered to be protected • Individuals born < 1980 did NOT receive HBV vaccine, unless specifically obtained at travel clinic, STD clinic, etc. • 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 • HAV vaccine only “routine” in the past 1-2 years, for children • Individuals did NOT receive HAV vaccine, unless specifically obtained at travel clinic, STD clinic, etc. • 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 • Diagnosis of syphilis • JGH uses a specific EIA screen (false-positives uncommon) • If negative, no further testing • If positive, titer with RPR (to follow Rx) AND confirmatory tests with TP-PA and LIA (both done at provincial lab/LSPQ)

18. Syphilis • Therapy of syphilis: • 10 and 20: Bicillin 2.4 x 106 U IM (buttock) x 1 dose • Late latent: Bicillin 2.4 x 106 U IM (buttock) x 3 doses • HIV+: Optimal Rx not known; usually “over-treat” with Bicillin 2.4 x 106 U IM (buttock) x 3 doses • Bicillin NOT licensed in Canada; only available by SAP; arranged with MDH at JGH

19. 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) Management of a sexual post-exposure situation * optional Plus: follow-up serology for HIV and syphilis

20. Questions?