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North Dakota STD Update Webinar – August 23, 2012

North Dakota STD Update Webinar – August 23, 2012. Kees Rietmeijer, MD, PhD Medical Director, Denver STD/HIV Prevention Training Center. A Man with a Faint Rash. The 5-Minute STI Clinical Case Study. Case History. 30 year-old gay man complaining of a faint, non-itching rash for >4 weeks

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North Dakota STD Update Webinar – August 23, 2012

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  1. North Dakota STD UpdateWebinar – August 23, 2012 Kees Rietmeijer, MD, PhD Medical Director, Denver STD/HIV Prevention Training Center

  2. A Man with a Faint Rash The 5-Minute STI Clinical Case Study

  3. Case History • 30 year-old gay man complaining of a faint, non-itching rash for >4 weeks • Took left-over amoxicillin for sore throat about 1 month ago – however, pt. does not have a prior history of penicillin allergy • No neurological symptoms or other physical complaints

  4. Case History -Continued • Sexual and STI History • 2 partners in past 6 months: • One steady partner • One occasional partner (about 3 months ago) • Protected receptive and insertive anal sex with steady partner only • Unprotected oral sex with steady and occasional partners • No history of genital/rectal sores • Rectal gonorrhea and chlamydia > 1 year ago • History of primary syphilis – treated 4 years ago with 2.4 MU LAB • Most recent RPR: NR (14 months ago; this clinic • HIV: negative (14 months ago; this clinic)

  5. Physical Exam • Faint erythematous macular rash trunk and extremities • Soles of feet involved, but palms of hands are not • No excoriations or scratch marks noted • No penile or anal lesions observed • Neurological exam: normal

  6. Question 1 What laboratory test would be the least useful in this case? • Qualitative (stat) RPR • Quantitative RPR • Treponemal test (TPPA or FTA-abs) • HIV rapid test • HIV viral load

  7. Stat Lab Results • Qualitative RPR reactive: ++++ • HIV Rapid Test: Positive

  8. Question 2 Based on our knowledge so far, what is the most likely diagnosis? • Acute HIV Infection • Drug rash • Secondary syphilis • Scabies

  9. Question 3 You decide to treat the patient for secondary syphilis – what do the CDC treatment guidelines recommend: • LAB 2.4 MU i.m. now and refer to HIV care • LAB 2.4 MU i.m. now and once a week for 2 subsequent weeks + refer to HIV care • Patient should undergo LP before treatment is initiated • Refer to HIV care as treatment will depend on HIV viral load and CD4 count

  10. Question 4 Regarding the patient’s follow up – which is a CDC recommendation? • Patient should return for follow-up at 1 and 2 weeks for additional treatment • Serological follow-up should be more frequent than in HIV negative patients • Follow-up should include a neurological work-up and LP to exclude neurosyphilis

  11. Gonorrhea The Continuing Saga

  12. Ceftriaxone 250 mg IM in a single dose OR, IF NOT AN OPTION Cefixime 400 mg orally in a single dose or 400 mg by suspension (200 mg/5ml) PLUS Azithromycin 1g orally in a single dose Or Doxycycline 100 mg twice a day for 7 days Uncomplicated Gonococcal Infections of the Cervix, Urethra, and Rectum CDC 2010 STD Treatment Guidelines

  13. Recommended RegimensCeftriaxone 250 mg IM in a single dose PLUS Azithromycin 1g orally in a single dose Or Doxycycline 100 mg twice a day for 7 days Uncomplicated Gonococcal Infections of the Pharynx CDC 2010 STD Treatment Guidelines

  14. Alternative regimens for uncomplicated gonorrhea Cefpodoxime 400 mg – poor cure rates for pharyngeal infections Cefuroxime 1 g orally – poor cure rates for pharyngeal infections Spectinomycin: no longer available in U.S. Azithromycin 2 g orally – concerns about macrolide resistance Alternative Regimens CDC 2010 STD Treatment Guidelines

  15. Gonorrhea Isolates with Cefixime MICS >0.25μg/mL MMWR 2011;60:873-877 and MMWR 2012;61:590-594

  16. MMWR 2012;61:590-594

  17. CDC Recommendations for Gonorrhea Treatment - February 2012 • Treat with most effective regimen • Ceftriaxone 250 mg + Azithromycin 1 g • Closely monitor treatment failure • Persistent symptoms: • Test by culture • Submit isolate for resistance testing • MSM: • Consider test of cure after 1 week (by culture or NAAT) especially if treated with cefixime • Report suspected treatment failure Dear Colleague Letter, Dr. Gail Bolan, February 12, 2012

  18. MMWR August 10, 212 • “CDC no longer recommends cefixime at any dose as a first-line regimen for treatment of gonococcal infections.” • “If Cefixime is used as an alternative agent, then the patient should return in 1 week for a test-of-cure at the site of infection.”

  19. MMWR August 10, 2012 • Recommended regimen • Ceftriaxone 250 mg in a single i.m. dose PLUS • Azithromycin 1 g orally in a single dose or • Doxycycline 100 mg orally twice a day for 7 days

  20. MMWR August 10, 2012 • Alternative regimen (if ceftriaxone is not available) • Cefixime 400 mg in a single dose PLUS • Azithromycin 1 g orally in a single dose or • Doxycycline 100 mg orally twice a day for 7 days • Alternative regimen (severe cephalosporin allergy) • Azithromycin 2 g in a single oral dose PLUS with both of the above: • Test-of-cure in 1 week • NAAT • Culture ( preferred if failure is suspected)

  21. Expedited Partner Therapy

  22. Expedited Partner Therapy • Approach whereby partners are treated without an intervening clinical assessment • Patients delivering medications to partners • Patients delivering prescriptions to partners • Field treatment by DIS or outreach workers (with or without testing)

  23. EPT Studies • Schillinger et al. Sex Transm Dis 2003;30:49-56 • 20% reduction in CT re-infection of 20% among women (P = 0.102) • Golden et al. New Engl J Med 2005;352:676-85 • 73% reduction in GC re-infection among men and women (P < 0.01) • 17% reduction in CT re-infection (P = 0.17) • Kissinger et al. Clin Infect Dis 2005; 41:623-9 • 46% reduction in GC and/or CT infection among men with urethritis (P<0.001)

  24. EPT and the STD Treatment Guidelines • “….patient delivered therapy (i.e., via medications or prescriptions) can prevent re-infection of index case and has been associated with a higher likelihood of partner notification, compared with unassisted patient referral of partners” • EPT recommendations are limited to GC and CT contacts only • EPT is not recommended for MSM CDC 2010 STD Treatment Guidelines

  25. EPT Medications • Contact to gonorrhea • Cefixime 400 mg PO x 1 • Azithromycin 1 g PO x 1 • Contact to chlamydia • Azithromycin 1 g PO x 1

  26. Partner Pack Chlamydia

  27. Legal Status of EPT

  28. EPT Acceptance DMHC 2006 - 2009 Mickiewicz et al. Sex Transm Dis 2012; In Press

  29. In the context of decreasing cefixime susceptibility, is it still safe to provide EPT for gonorrhea?

  30. What is the Future for EPT for Gonorrhea? • No recommendations have been made thus far (August 2012 MMWR does not address EPT) • While cefixime susceptibility appears to be decreasing, frank resistance has not (yet) been reported in the U.S. • There are important differences in cefixime susceptibility by region and by sexual preference • Probably safe to continue EPT for gonorrhea among heterosexuals while monitoring susceptibility and resistance regionally • Convey message to patients with gonorrhea that the best option for their partners is to see a health care provider

  31. Gonorrhea The Continuing Saga is….. …well…. Continuing…… Stay Tuned!!!

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