Sexually Transmitted Infections
Sexually Transmitted Infections
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Professor of Medicine
Emory University School of Medicine
Atlanta, Georgia
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Dr Workowski has received research support from
Gilead Sciences, Inc. (Updated 02/28/19)
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After attending this presentation, learners will be able to:
▪
Describe the current epidemiology of syphilis, gonorrhea,
chlamydia
▪
Describe current screening and diagnostic
recommendations
▪
Identify current treatment recommendations in the era of
emerging antimicrobial resistance
Limitations of case report data
•
Not all STDs are nationally notifiable
•
Most STDs are asymptomatic, only those diagnosed can be reported
•
Trends are influenced by screening coverage and reporting practices
STIs are on the rise
Proportion of P&S Syphilis Cases that Reported Meth or
Heroin Use or Sex with a PWID, 2012–2016
Kidd, MMWR 2019; Feb 15
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Initial care visit
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Syphilis serology, NAAT (gonorrhea, chlamydia)
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MSM (site of exposure)
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Hepatitis A,B, C
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Women
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Trichomonas testing (NAAT)
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Cervical pap test (HIV OI guidelines)
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Frequent screening dependent on risk (3-6 mo)
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New sex partner, partner with concurrent partners or more than
one partner, or partner with an STI
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High risk behavior
•
Partner services, prevention counseling
2015 Treatment Guidelines, HIVMA 2014
Syphilis serologic screening algorithms
Traditional
Reverse sequence
Active infection, F+, miss early
Early primary,
requires RPR (active),
false +
MMWR 60(5);2011
RPR Sensitivity
Primary 62-78%
Secondary 97-100%
EL 82-100%
Tertiary 47-64%
NS (VDRL) 49-87%
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All persons with syphilis should be evaluated for neurologic
symptoms/signs
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CSF examination recommended:
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Neurologic or ophthalmic symptoms/signs
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Auditory disease, cranial nerve dysfunction, meningitis, stroke, altered mental
status, loss of vibration sense, iritis, uveitis
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Evidence of tertiary disease
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aortitis, gumma
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Serologic treatment failure
•
CNS invasion in early syphilis is
common
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CSF abnormalities of unclear significance in the absence of signs/symptoms
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Neurosyphilis = CSF tests + reactive RPR + signs/symptoms
2015 CDC Treatment Guidelines
Syphilis
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Benz Pcn 2.4 mu IM x 1 early syphilis
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Role of enhanced therapy
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IM+oral
(Rolfs 1997)
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Observational > 500 HIV+ - no
difference in serologic outcomes
at 12 months 1 vs 3
(Ganesan 2014,
Yang 2014)
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RCT Benz pcn 1 vs 3 early syphilis
(NCT 03637660)
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PCN alternatives (early, latent, NS)
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Doxycycline, ceftriaxone
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Optimal dose/duration
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Prevention -doxycycline prophylaxis
Bolan, STD; Molina, Lancet 2018
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MSM and women -+rectal
chlamydia NAAT
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PCR based genotyping
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Protocolitis +/- perianal ulcers
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Presumptive tx (doxy 100 mg bid
x 21 d)
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Painful perianal ulcers or mucosal
ulcers presumptive therapy for
HSV
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Short course therapy 7-14 d GUM
clinic in UK (Simon, STD 2018)
Disseminated Gonococcal Infection (DGI)
Estimated to account for 0.5-3% of gonococcal infections
Risk factors: female, menses, pregnancy, terminal complement
deficiency
Clinical presentation
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Monoarticular arthritis
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Skin lesions (petechial or pustular) + tenosynovitis + polyarthralgia
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Perihepatitis, endocarditis, meningitis
Mucosal site infection often asymptomatic (NAAT)
Antimicrobial susceptibility (AST) testing (culture)
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United States
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Ceftriaxone 250 mg IM in a single dose
PLUS
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Azithromycin 1 g orally in a single dose
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United Kingdom
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Ceftriaxone 1 gram IM in a single dose
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Europe (European CDC)
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Ceftriaxone 500 mg IM in single dose
PLUS
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Azithromycin 2 gm orally in a single
dose
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Japan
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Ceftriaxone 1 gm IV/IM in a single
dose
Optimize therapeutic regimen
PK/PD (site of penetration)
Concentration dependent vs
independent
Bacterial burden
Mutational frequency to resistance
Novel agents (Zoliflodacin, Gepotidacin)
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Treatment Failures
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Most treatment failures due to
reinfection
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If treatment failure suspect, obtain
culture/susceptibility test + ensure
partner treatment
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Taylor-Robinson & Jensen, Clin Microbiol Rev 2011; Lis et al., CID 2015 – updated; Napierala Mavedzenge & Weiss, AIDS 2009
HPV Vaccine
Nanovalent HPV Vaccine
Types 6, 11, 16, 18
, 31, 33, 45, 52, 58
FDA approved to prevent warts, cervical, vulvar, vaginal and anal cancer
2 doses for males/females aged 9-14
3 doses for males/females aged 15-26
Immunocompromised patients need 3 doses, regardless of age of initiation
Cervical Intraepithelial Neoplasia Grades 2 and 3 — Prevalence per 1000 Person-
Years Among Female Enrollees in Private Health Plans Aged 15–39 Years, by Age
Group and Year, 2007–2014
Flagg EW, Am J Public Health 2016; 106(12):2211–2218.
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www.cdc.gov/std/tg2015
Current epidemiology, screening, and treatment recommendations for syphilis, gonorrhea, and chlamydia. Learn about rising STI trends, testing during HIV care, and syphilis serologic screening algorithms. Gain insights into evaluating CNS involvement.
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Presentation Transcript
Sexually Transmitted Infections Kimberly A. Workowski, MD Professor of Medicine Emory University School of Medicine Atlanta, Georgia
Learning Objectives After attending this presentation, learners will be able to: Describe the current epidemiology of syphilis, gonorrhea, chlamydia Describe current screening and diagnostic recommendations Identify current treatment recommendations in the era of emerging antimicrobial resistance Slide 3 of 60
STIs are on the rise Limitations of case report data Not all STDs are nationally notifiable Most STDs are asymptomatic, only those diagnosed can be reported Trends are influenced by screening coverage and reporting practices Slide 4 of 60
Proportion of P&S Syphilis Cases that Reported Meth or Heroin Use or Sex with a PWID, 2012 2016 25% Women 20% Proportion of Cases MSW 15% 10% MSM 5% 0% Year Kidd, MMWR 2019; Feb 15 Slide 5 of 60
STI Testing during HIV care STI Testing during HIV care Initial care visit Syphilis serology, NAAT (gonorrhea, chlamydia) MSM (site of exposure) Hepatitis A,B, C Women Trichomonas testing (NAAT) Cervical pap test (HIV OI guidelines) Frequent screening dependent on risk (3-6 mo) New sex partner, partner with concurrent partners or more than one partner, or partner with an STI High risk behavior Partner services, prevention counseling 2015 Treatment Guidelines, HIVMA 2014 Slide 6 of 60
Syphilis serologic screening algorithms Traditional Reverse sequence EIA or CIA RPR Sensitivity Primary 62-78% Secondary 97-100% EL 82-100% Tertiary 47-64% NS (VDRL) 49-87% Quantitati ve RPR EIA/CIA+ EIA/CIA- RPR+ RPR- Early primary, requires RPR (active), false + Quantitative RPR TP-PA or other trep. test RPR+ TP-PA+ RPR- TP-PA- Syphilis Syphilis Syphilis unlikely (past or present) (past or present) TP-PA Active infection, F+, miss early TP-PA+ TP-PA- Syphilis Syphilis unlikely (past or present) MMWR 60(5);2011 Slide 7 of 60
Evaluation of CNS Involvement All persons with syphilis should be evaluated for neurologic symptoms/signs CSF examination recommended: Neurologic or ophthalmic symptoms/signs Auditory disease, cranial nerve dysfunction, meningitis, stroke, altered mental status, loss of vibration sense, iritis, uveitis Evidence of tertiary disease aortitis, gumma Serologic treatment failure CNS invasion in early syphilis is common CSF abnormalities of unclear significance in the absence of signs/symptoms Neurosyphilis = CSF tests + reactive RPR + signs/symptoms 2015 CDC Treatment Guidelines Slide 8 of 60
Syphilis Benz Pcn 2.4 mu IM x 1 early syphilis Role of enhanced therapy IM+oral (Rolfs 1997) Observational > 500 HIV+ - no difference in serologic outcomes at 12 months 1 vs 3 (Ganesan 2014, Yang 2014) RCT Benz pcn 1 vs 3 early syphilis (NCT 03637660) PCN alternatives (early, latent, NS) Doxycycline, ceftriaxone Optimal dose/duration Prevention -doxycycline prophylaxis Bolan, STD; Molina, Lancet 2018 Slide 9 of 60
LGV LGV Proctitis Proctitis MSM and women -+rectal chlamydia NAAT PCR based genotyping Protocolitis +/- perianal ulcers Presumptive tx (doxy 100 mg bid x 21 d) Painful perianal ulcers or mucosal ulcers presumptive therapy for HSV Short course therapy 7-14 d GUM clinic in UK (Simon, STD 2018) Slide 10 of 60
Disseminated Gonococcal Infection (DGI) Estimated to account for 0.5-3% of gonococcal infections Risk factors: female, menses, pregnancy, terminal complement deficiency Clinical presentation Monoarticular arthritis Skin lesions (petechial or pustular) + tenosynovitis + polyarthralgia Perihepatitis, endocarditis, meningitis Mucosal site infection often asymptomatic (NAAT) Antimicrobial susceptibility (AST) testing (culture) Slide 11 of 60
Gonorrhea Gonorrhea Optimize therapeutic regimen PK/PD (site of penetration) Concentration dependent vs independent Bacterial burden Mutational frequency to resistance Novel agents (Zoliflodacin, Gepotidacin) Treatment Failures Most treatment failures due to reinfection If treatment failure suspect, obtain culture/susceptibility test + ensure partner treatment United States Ceftriaxone 250 mg IM in a single dose PLUS Azithromycin 1 g orally in a single dose United Kingdom Ceftriaxone 1 gram IM in a single dose Europe (European CDC) Ceftriaxone 500 mg IM in single dose PLUS Azithromycin 2 gm orally in a single dose Japan Ceftriaxone 1 gm IV/IM in a single dose Slide 12 of 60
M. M. g genitalium enitalium Meta Meta- -Analyses Analyses Syndrome Summary risk estimate Studies accounting for CT (subset) NGU 5.5 (4.3 7.0) - Female Urethritis 2.2 (1.6 2.9) 2.1 (1.5 2.9) Cervicitis 1.6 (1.4 2.0) 1.9 (1.4 2.8) PID / Endometritis 1.9 (1.3 3.5) 2.0 (0.95 4.0) Preterm Delivery 1.9 (1.2 2.9) 2.3 (1.1 5.0) Spontaneous Abortion 1.8 (1.1 3.0) 2.3 (1.0 4.9) Infertility 3.0 (1.3 6.7) 3.7 (1.7 8.1) HIV 2.0 (1.4 2.8) - Taylor-Robinson & Jensen, Clin Microbiol Rev 2011; Lis et al., CID 2015 updated; Napierala Mavedzenge & Weiss, AIDS 2009 Slide 13 of 60
HPV Vaccine Nanovalent HPV Vaccine Types 6, 11, 16, 18, 31, 33, 45, 52, 58 FDA approved to prevent warts, cervical, vulvar, vaginal and anal cancer 2 doses for males/females aged 9-14 3 doses for males/females aged 15-26 Immunocompromised patients need 3 doses, regardless of age of initiation Slide 14 of 60
Cervical Intraepithelial Neoplasia Grades 2 and 3 Prevalence per 1000 Person- Years Among Female Enrollees in Private Health Plans Aged 15 39 Years, by Age Group and Year, 2007 2014 Flagg EW, Am J Public Health 2016; 106(12):2211 2218. Slide 15 of 60
STI Screening and Management STI Screening and Management www.cdc.gov/std/tg2015 Slide 16 of 60
