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Sexually Transmitted Disease Treatment Guidelines

Sexually Transmitted Disease Treatment Guidelines. John Kulig, MD, MPH Lead Medical Specialist Job Corps Health and Wellness Webinar May 11 th & 12 th , 2011. Learning Objectives. Participants will be able to: List Job Corps PRH requirements for STD screening

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Sexually Transmitted Disease Treatment Guidelines

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  1. Sexually Transmitted Disease Treatment Guidelines John Kulig, MD, MPH Lead Medical Specialist Job Corps Health and Wellness Webinar May 11th & 12th, 2011

  2. Learning Objectives Participants will be able to: • List Job Corps PRH requirements for STD screening • Implement current CDC treatment recommendations for STDs on center • Describe appropriate follow-up and contact notification following treatment of STDs

  3. Evolution in Terminology • Venereal Disease (VD) • Sexually Transmitted Disease (STD) • Sexually Transmitted Infection (STI) • Sexually Acquired Infection (SAI)

  4. http://www.cdc.gov/std/treatment/2010/default.htm

  5. PRH requirements for STD testing upon entry Females • HIV antibody • Chlamydia: endocervical or urine • Gonorrhea: endocervical or urine Optional • Syphilis serology Males • HIV antibody • Urine dipstick • Chlamydia: urine • Gonorrhea: urine if leukocyte esterase + Optional • Syphilis serology

  6. Urine dipstick testing on center

  7. Job Corps nationally contracted laboratory:Center for Disease Detection, San Antonio, Texas

  8. Chlamydia — Prevalence among 16- to 24-year-old women entering the National Job Training Program by state of residence: United States and outlying areas, 2008 *Less than 100 women residing in these states/areas and entering the National Job Training Program were screened for chlamydia in 2008. SOURCE: National Job Training Program, Department of Labor (in collaboration with the Center for Disease Detection, San Antonio, Texas).

  9. Chlamydia — Prevalence among 16- to 24-year-old men entering the National Job Training Program by state of residence: United States and outlying areas, 2008 *Less than 100 men residing in these states/areas and entering the National Job Training Program were screened for chlamydia in 2008. SOURCE: National Job Training Program, Department of Labor (in collaboration with the Center for Disease Detection, San Antonio, Texas).

  10. Mucoid discharge with Chlamydia Purulent discharge with gonorrhea

  11. Treatment recommendations for Chlamydia urogenital infection • azithromycin 1 g orally in a single dose OR • doxycycline 100 mg orally twice a day for 7 days

  12. Clinical efficacy of azithromycin for Chlamydial infections in pregnancy • doxycycline, ofloxacin, and levofloxacin are contraindicated in pregnant women • clinical experience and published studies suggest that azithromycin is safe and effective • repeat testing to document eradication (preferably by NAAT) three weeks after completion of therapy is recommended for all pregnant women to ensure therapeutic cure

  13. Gonorrhea — Prevalence among 16- to 24-year-old women entering the National Job Training Program by state of residence: United States and outlying areas, 2008 *Less than 100 women residing in these states/areas and entering the National Job Training Program were screened for gonorrhea by the national contract laboratory in 2008. Note: Many training centers test female students for gonorrhea using local laboratories; these results are not available to CDC. For this map, gonorrhea test results for students at centers submitting specimens to the national contract laboratory were included if the number of gonorrhea tests submitted was greater than 90% of the number of chlamydia tests submitted. SOURCE: National Job Training Program, Department of Labor (in collaboration with the Center for Disease Detection, San Antonio, Texas).

  14. Gonorrhea — Prevalence among 16- to 24-year-old men entering the National Job Training Program by state of residence: United States and outlying areas, 2008 *Less than 100 men residing in these states/areas and entering the National Job Training Program were screened for gonorrhea by the national contract laboratory in 2008. Note: Many training centers test male students for gonorrhea using local laboratories; these results are not available to CDC. For this map, gonorrhea test results for students at centers submitting specimens to the national contract laboratory were included if the number of gonorrhea tests submitted was greater than 90% of the number of chlamydia tests submitted. SOURCE: National Job Training Program, Department of Labor (in collaboration with the Center for Disease Detection, San Antonio, Texas).

  15. Increasing prevalence of antimicrobial-resistant Neisseriagonorrhoeae • quinolones, as of April 2007, are no longer recommended in the United States for the treatment of gonorrhea and associated conditions, such as PID • only one class of antimicrobials, the cephalosporins, is recommended and available for the treatment of gonorrhea in the United States

  16. Treatment of uncomplicated Neisseriagonorrhoeaeinfection Cervix, urethra, rectum: • ceftriaxone 250 mg IM in a single dose OR, IF NOT AN OPTION • cefixime 400 mg orally in a single dose Pharynx: • ceftriaxone 250 mg IM in a single dose PLUS • azithromycin 1g orally in a single dose OR • doxycycline 100 mg orally twice a day for 7 days

  17. Primary syphilis

  18. Secondary syphilis

  19. Treatment recommendations for primary and secondary syphilis • benzathine penicillin G 2.4 million units IM in a single dose NO YES

  20. HSV HSV HSV Ectopic sebaceous glands

  21. Treatment recommendations for primary genital herpes infection • acyclovir 400 mg orally three times a day for 7–10 days • OR • acyclovir 200 mg orally five times a day for 7–10 days • OR • famciclovir 250 mg orally three times a day for 7–10 days • OR • valacyclovir 1 g orally twice a day for 7–10 days

  22. Treatment recommendations for recurrent genital herpes infection • Acyclovir 400 mg orally three times a day for 5 days • OR • Acyclovir 800 mg orally twice a day for 5 days • OR • Acyclovir 800 mg orally three times a day for 2 days • OR • Famciclovir 125 mg orally twice daily for 5 days • OR • Famciclovir 1000 mg orally twice daily for 1 day • OR • Famciclovir 500 mg once, followed by 250 mg twice daily for 2 days OR • Valacyclovir 500 mg orally twice a day for 3 days • OR • Valacyclovir 1 g orally once a day for 5 days

  23. Treatment recommendations for genital herpes prophylaxis • acyclovir 400 mg orally twice a day • OR • famciclovir 250 mg orally twice a day • OR • valacyclovir 500 mg orally once a day* • OR • valacyclovir 1 g orally once a day • * valacyclovir 500 mg once a day might be less effective than other valacyclovir or acyclovir dosing regimens in patients who have very frequent recurrences (i.e. ≥10 episodes per year).

  24. Trichomonads Clue cell Saline wet mount examination of vaginal discharge

  25. Treatment recommendations for trichomonas infection • metronidazole 2 g orally in a single dose OR • tinidazole 2 g orally in a single dose Caution: Avoid alcohol consumption during treatment and for 24 hours after completion of metronidazole or 72 hours after tinidazole.

  26. Diagnostic criteria for bacterial vaginosis 3 of the following 4 symptoms or signs: • homogeneous, thin, white discharge that smoothly coats the vaginal walls • presence of clue cells on microscopic examination • pH of vaginal fluid > 4.5 • a fishy odor of vaginal discharge before or after addition of 10% KOH (i.e., the whiff test)

  27. Treatment recommendations for bacterial vaginosis • metronidazole 500 mg orally twice a day for 7 days (caution – alcohol) OR • metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days OR • clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days (caution oil-based)

  28. Genital warts

  29. Treatment recommendations for external genital warts Patient-Applied: • podofilox 0.5% solution or gel OR • imiquimod 5% cream OR • sinecatechins 15% ointment

  30. Treatment recommendations for external genital warts Provider–Administered: • Cryotherapy with liquid nitrogen or cryoprobe. Repeat applications every 1–2 weeks. OR • Podophyllin resin 10%–25% in a compound tincture of benzoin OR • Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80%–90% OR • Surgical removal

  31. Oral treatment recommendations for pelvic inflammatory disease • ceftriaxone 250 mg IM in a single dose PLUS • doxycycline 100 mg orally twice a day for 14 days WITH or WITHOUT • metronidazole 500 mg orally twice a day for 14 days

  32. Empiric treatment recommendations for acute epididymitis • ceftriaxone 250 mg IM in a single dose PLUS • doxycycline 100 mg orally twice a day for 10 days

  33. Sexual transmission of hepatitis • hepatitis A via fecal-oral transmission – vaccine preventable • hepatitis B via unprotected sex and injection drug use – vaccine preventable • hepatitis C via injection drug use and unprotected sex (10%) – not vaccine preventable

  34. Diagnostic evaluation after sexual assault • NAATs for C. trachomatis and N. gonorrhoeae. These tests are preferred for the diagnostic evaluation of sexual assault victims, regardless of the sites of penetration or attempted penetration. • Wet mount and culture or point-of-care testing of a vaginal-swab specimen for T. vaginalisinfection. The wet mount also should be examined for evidence of bacterial vaginosis and candidiasis, especially if vaginal discharge, malodor, or itching is evident. • A serum sample for immediate evaluation for HIV infection, hepatitis B, and syphilis.

  35. Prophylaxis after sexual assault • ceftriaxone 250 mg IM in a single dose OR • cefixime 400 mg orally in a single dose PLUS • metronidazole 2 g orally in a single dose PLUS • azithromycin 1 g orally in a single dose OR • doxycycline 100 mg orally twice a day for 7 days

  36. Postexposure HIV prophylaxis assessment after sexual assault • Assistance with PEP-related decisions can be obtained by calling the National Clinician’s Post-Exposure Prophylaxis Hotline (PEP Line) (telephone: 888-448-4911)

  37. STD prevention approaches • Education and counseling of persons at risk on ways to avoid STDs through changes in sexual behaviors and use of recommended prevention services • Identification of asymptomatically infected persons and of symptomatic persons unlikely to seek diagnostic and treatment services • Effective diagnosis, treatment, and counseling of infected persons • Evaluation, treatment, and counseling of sex partners of persons who are infected with an STD • Pre-exposure vaccination of persons at risk for vaccine-preventable STDs

  38. STD prevention counseling: The Five Ps • Partners – gender and number • Prevention of pregnancy • Protection from STDs • Practices – vaginal, oral, anal sex – condom use – injection drug use – sex for money or sex for drugs • Past history of STDs – patient and partner(s)

  39. Notification and follow-up • Patient • Partner(s) • Health Department – state and/or local • Test-of-cure vs test for reinfection • NAAT may remain positive for 3-4 weeks after treatment

  40. Expedited Partner Therapy (EPT) • Expedited Partner Therapy (EPT) is the clinical practice of treating the sex partners of patients diagnosed with Chlamydia or gonorrhea by providing prescriptions or medications to the patient to take to his/her partner without the health care provider first examining the partner.

  41. Expedited Partner Therapy (EPT) • http://www.cdc.gov/std/ept/ • http://www.cdc.gov/std/ept/legal/EPTLegalMatrix11-02-2010.pdf • permissible in 27 states • potentially allowable in 15 states/DC/PR • prohibited in 8 states: Arkansas, Florida, Kentucky, Michigan, Ohio, Oklahoma, South Carolina, West Virginia

  42. Questions?

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