SHIP 2007 STD UPDATE Alicia Nelson, RN, MSN, MEd, FNP DSHS STD Nurse Consultant alicia.nelsondshs.state.tx 512.533.30

1. SHIP2007STD UPDATEAlicia Nelson, RN, MSN, MEd, FNPDSHS STD Nurse Consultantalicia.nelson@dshs.state.tx.us512.533.3078

2. STD Medication Update Gonorrhea Chlamydia Syphilis

3. Which of these conditions have become harder to treat because of antibiotic resistance? a. Tuberculosis b. Staph infections c. Meningitis d. Gonorrhea e. All of the above 

4. In the United States, gonorrhea is the second most frequently reported notifiable disease, with 339,593 cases documented in 2005. In April 2007, CDC determined that Fluoroquinolones (which were a convenient single-dose oral therapy) are no longer recommended as treatment for GC

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9. So how did this happen?

10. QRNG fluoroquinolone resistance Nisseria gonorrhoeae A key factor in the development of antibiotic resistance is the ability of infectious organisms to adapt quickly to new environmental conditions..

11. Bacteria are single-celled organisms that, compared with higher life forms, have small numbers of genes

12. Bacteria can evolve rapidly Therefore, even a single random genetic mutation can greatly affect their ability to cause disease. And because most microbes reproduce by dividing every few hours, bacteria can evolve rapidly. A mutation that helps a microbe survive exposure to an antibiotic will quickly become dominant throughout the microbial population. Plus, Microbes also often acquire genes from each other, including genes that confer resistance.

13. How do we find resistance?

14. GISP

15. GISP The Gonococcal Isolate Surveillance Project (GISP) began in 1986 to monitor trends in antimicrobial susceptibilities of strains of N. gonorrhoeae in the US in order to establish a basis for the selection of treatments.

16. GISP GISP is a collaborative project between: selected STD clinics regional US laboratories CDC

17. GISP In GISP, N. gonorrhoeae specimens are collected from the first 25 men with urethral gonorrhea attending STD clinics each month in approximately 28 cities in the United States Texas GISP site - Dallas

18. At regional laboratories, the susceptibilities of these isolates to penicillin, tetracycline, spectinomycin, ciprofloxacin, ceftriaxone, cefixime, and azithromycin are determined by agar dilution.

19. QRNGfluoroquinolone resistance Nisseria gonorrhoeae Since 2001, GISP has observed QRNG increases among isolates from MSM, and more recently, from heterosexual males

20. QRNGfluoroquinolone resistance Nisseria gonorrhoeae Preliminary data from January--June 2006 indicate that QRNG prevalence increased to 38.3% among MSM and 6.7% among heterosexual males During January--June 2006, QRNG was identified in 25 out of 26 GISP sites, and increases in the prevalence of QRNG were observed among isolates from heterosexual males and MSM in most regions of the country

21. GISP Data from CDC's Gonococcal Isolate Surveillance Project (GISP) in 26 US cities showed that in the first half of 2006, 6.7% of gonorrhea cases in heterosexual men were fluoroquinolone-resistant Neisseria gonorrhoeae (QRNG) This is an 11-fold increase from 0.6% in 2001, and well above 5%, the recognized threshold for changing treatment recommendations.

23. Findings from GISP, which is conducted in publicly funded clinics and includes only male urethral isolates, might not be representative of the entire U.S. population infected with gonorrhea.

24. Fluoroquinolones for GC Fluoroquinolones ciprofloxacin (Cipro) ofloxacin (Floxin) levofloxacin (Levaquin)

25. Recommended RegimensUncomplicated Gonococcal Infections of the Cervix, Urethra, and Rectum Ceftriaxone 125 mg IM in single dose Or Cefixime 400 mg orally in a single dose (The tablet formulation of Cefixime is currently unavailable in the US.)

26. Alternative Regimensfor uncomplicated GC infections of the Cervix, Urethra, and Rectum Spectinomycin 2 g in a single IM dose Or Single-dose cephalosporin regimen

27. Alternative Single-dose cephalosporin regimensfor GC infections of the Cervix, Urethra, and Rectum Ceftizoxime 500 mg IM Cefoxitin 2 g IM Cefotaxime 500 mg IM Some evidence indicates that these are effective: Cefpodoxime 400 mg orally (Vantin) Cefuroxime axetil 1 g orally (Ceftin)

28. cefpodoxime (Vantin) DSHS Pharmacy stocks cefpodoxime in packets of two 200 mg tablets = cefpodoxime 400 mg PO STD sites in Texas will need to update their standing orders and treatment protocols to reflect these changes  Sites with directly observed therapy (DOT) and/or expedited partner therapy (EPT) protocols should use cefpodoxime instead of ciprofloxacin

29. Pharmacy Inventory Control System (PICS)   Ciprofloxacin (Cipro) will be discontinued as a medication for gonorrhea on July 1.   STD sites should estimate the number of gonorrhea treatments they need and prepare to adjust their ceftriaxone orders now.  Please submit orders for ceftriaxone and cefpodoxime as “urgently needed” through the Pharmacy Inventory Control System (PICS). 

30. Pharmacy Inventory Control System (PICS) DSHS Pharmacy is anticipating an increased need for ceftriaxone.  In order to help the Pharmacy determine new order amounts, Texas STD sites should record ceftriaxone usage in PICS for the next few months.

31. REMEMBER The only treatment available now for Uncomplicated GC infection of the Pharynx: Ceftriaxone 125 mg IM in a single dose

32. For STD-related questions relating to the revised treatment protocols, please contact Alicia Nelson, R.N., at 512-533-3078 or alicia.nelson@dshs.state.tx.us.  For Pharmacy-related questions, please contact Bo Shifflet, R.Ph., at 512-458-7500 or PICSHelpdesk@dshs.state.tx.us.

33. http://www.cdc.gov/std/Gonorrhea/

34. Chlamydia Medications Recommended Regimens Azithromycin 1 gram orally single dose Doxycycline 100 mg orally BID x 7 DSHS Pharmacy prepackaged envelope of azithromycin 250 mg x 4 (single dose pack)

35. Syphilis Medication Bicillin now in full supply Becton-Dickinson LurLock syringe system with the eclipse safety covered needle.