STD Section Services for Providers and Gonorrhea Update

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1 STD Section Services for Providers and Gonorrhea Update Susan Philip, MD MPH Director, STD Prevention and Control Services San Francisco Department of Public Health Assistant Clinical Professor of Medicine Division of Infectious Diseases University of California, San Francisco

2 Outline What Services Does SFDPH STD Prevention and Control Offer to Providers? What can you do to assist STD prevention efforts Gonorrhea treatment update

3 For Full Treatment Guidelines: CDC STD Treatment Guidelines December 17, 2010 Revised August 9, 2012

4 What Can STD Prevention and Control Do for You?

5

6 City Clinic Sole municipal STD clinic for City and County of SF ~19,000 patient visits in % male, 35% MSM Clinical training and research site Clinician Consultations:

7 Monthly STD Report via and

8 What can You as a Provider do to help STD Prevention and Control Decrease STD morbidity in SF?

9 Clinicians Role as Key STD/HIV Prevention Partners Screen appropriately for STDs, including: Chlamydia and Gonorrhea using Nucleic Acid Amplification Tests (NAAT) annually in women <26 Chlamydia and Gonorrhea screening using NAATs at the pharynx and rectum in MSM, syphilis RPR or VDRL, and HIV testing every 3-6 months Treat STDs according to CDC and SFDPH Treatment Guidelines Report STDs to SFDPH STD, including gender of sex partners and treatment Encourage patients with STDs and HIV to work with SFDPH staff

10 Timely CMRs allow us to: ensure treatment and offer assistance if needed Report accurate STD epidemiology for SF Determine prevention needs in our communities

11 Syphilis Patient Interviews and Partner Services Offered to all patients with a new early syphilis diagnosis Voluntary, culturally appropriate services Helps us understand where prevention efforts are needed Allows us to offer preventive treatment to partners of patients with syphilis Please encourage your patients to work with our staff we have to work in partnership in order to decrease rates in SF.

12 LINCS (Linkage, Integration, Navigation and Comprehensive Services) LINCS seeks to provide and coordinate comprehensive Linkage to Care, Partner Services, and Navigation services to people who test positive for HIV in SFDPH and Community testing sites. For more information, please pick up a LINCS flyer near registration

13 Gonorrhea

14

15 History of Antibiotics for GC Sulfa 50K units Penicillin PPNG 4800K units Tetracycline 3rd Gen Ceph Cipro Spectinomycin Courtesy P. Barry MD MPH

16 Penicillinase-Producing N. Gonorrhoeae (1970s s) Spread of Ciprofloxacin Resistance (1990s s)

17 The Gonococcal Isolate Surveillance Project (GISP) US sentinel surveillance Monitors trends in NG antibiotic susceptibility STD clinic sites Urethral NG isolates obtained from first 25 men per site each month Susceptibility testing by 4 5 regional labs Confirmatory testing by CDC Minimum inhibitory concentrations (MICs) by agar dilution

18 GISP in SF City Clinic a CDC GISP site since 1987 Urethral cultures only from first 25 symptomatic men each month sent to CDC Limitations: STD Clinic population, urethral cultures only Previously extensive delays in returning results We have been working with the SFDPH Public Health Laboratory and Dr. Pandori to do some enhanced work with these specimens

19 NEJM 2012

20 Clinicians Role as Key STD/HIV Prevention Partners Screen appropriately for STDs, including: Chlamydia and Gonorrhea using Nucleic Acid Amplification Tests (NAAT) annually in women <26 Chlamydia and Gonorrhea screening using NAATs at the pharynx and rectum in MSM, syphilis RPR or VDRL, and HIV testing every 3-6 months Treat STDs according to CDC and SFDPH Treatment Guidelines Report STDs to SFDPH STD, including gender of sex partners and treatment Encourage patients with STDs and HIV to work with SFDPH staff

21 Proportion of asymptomatic rectal and urethral chlamydial and gonococcal infection among MSM San Francisco, 2003 Rectal Infections 14% 16% 86% 84% Urethral Infections Chlamydia n=316 42% Gonorrhea n=264 10% Asymptomatic Symptomatic 58% 90% Kent, CK et al, Clin Infect Dis July 2005 Chlamydia n=315 Gonorrhea n=364

22 Urogenital and Extragenital NAAT Testing, MSM, San Francisco, % 14.3% 80% 60% 91.4% Identified infections 40% 85.7% Missed infections 20% 0% Urethral screening only 8.6% Rectal and pharyngeal screening only

23 Clinicians Role as Key STD/HIV Prevention Partners Screen appropriately for STDs, including: Chlamydia and Gonorrhea using Nucleic Acid Amplification Tests (NAAT) annually in women <26 Chlamydia and Gonorrhea screening using NAATs at the pharynx and rectum in MSM, syphilis RPR or VDRL, and HIV testing every 3-6 months Treat STDs according to CDC and SFDPH Treatment Guidelines Report STDs to SFDPH STD, including gender of sex partners and treatment Encourage patients with STDs and HIV to work with SFDPH staff

24

25 Current Recommended Gonorrhea Treatment Ceftriaxone 250mg IM x 1 Azithromycin 1g PO x 1 OR Doxycycline 100mg PO bid x 7 days This is Dual treatment for GC add the azithromycin or doxycycline regardless of CT result CDC 2010 STD Treatment Guidelines, GC tx revised August 2012

26 Alternative Gonorrhea Treatment for Uncomplicated Urogenital GC Cefixime 400mg PO x 1 OR Azithromycin 1g PO x 1 OR Doxycycline 100mg PO bid x 7 days Azithromycin 2g PO x 1 (if cephalosporin allergic) Test of Cure with NAAT now recommended (7 days) if using an alternative regimen CDC 2010 STD Treatment Guidelines, GC tx revised August 2012

27 Gonorrhea Dual treatment may hinder development of antibiotic resistance No longer different recommended treatment regimens for urethral and rectal infections vs. pharyngeal Only ceftriaxone + (azithro or doxy) recommended for pharyngeal infection Treatment with azithromycin (or doxycycline) is dual treatment for N. gonorrhoeae. Do this even with a negative C. trachomatis NAAT result!

28 Gonorrhea Treatment FAQs

29

30 What about my Patient s partners? In CA, providers can legally provide treatment to partners of patients with gonorrhea (and chlamydia) without a face to face visit. Partners should be highly encouraged to present for ceftriaxone 250mg IM + azithromycin 1g PO If absolutely certain that will not or cannot, can prescribe cefixime 400mg PO x 1 AND azithromycin 1g PO x 1 (to be taken together).

31 Patient Delivered Partner Therapy for Chlamydia (Azithromycin 1 gm) PLEASE READ THIS VERY CAREFULLY Why do I need to take this medicine? Your sex partner has recently been treated for Chlamydia. Chlamydia is a curable infection you can get from having sex with a person who already has it. Many people with Chlamydia do not know they have it because they feel okay and do not have any symptoms. However, if you do not take medicine to cure it, you can get very sick. You could have Chlamydia. It is important that you get treated. We want to be sure that you get the medicine you need as soon as possible. The best way to take care of yourself is to see your doctor or come to City Clinic for a check-up and medicine. If you are not able to go to your doctor or City Clinic within 1 week, you should take the medicine enclosed. Is the medicine safe? The medicine is very safe. However, you should talk to your doctor or come to City Clinic if you have any of the problems listed below. DO NOT take the medicine if: You are female and having lower belly pain, pain with sex, vomiting or fever You are male and having pain or swelling in the testicle (balls) or fever You ever had a bad reaction, rash or allergy to Azithromycin (Zithromax), Erythromycin, or Clarithromycin (Biaxin) You have a serious long-term illness such as kidney, heart or liver disease You are taking prescribed medicine, especially for heart disease or serious mental illness How do I take the medicine? You will receive 2 pink 500mg Azithromycin pills. Take both pills at the same time with a full glass of water. This medicine may cause an upset stomach, diarrhea, nausea, or vomiting. This should not last long. If these symptoms persist or you develop a rash or fever, contact your doctor or City Clinic. Do not share or give this medicine to anyone else. Do not have sex for the next 7 days because it takes 7 days for the medicine to cure Chlamydia. If you have unprotected sex during the 7 days after taking the medicine, you could still pass the infection to your sex partners. We recommend re-testing in 3 months to make sure that you have not been re-infected. What can I do if I still have questions? If you have any questions about the medicine, please call (415) during clinic hours. All calls are confidential. You can also come into City Clinic for a low cost or free visit including: exam, testing and medicine. For more information and directions, visit our website. City Clinic Monday 8 am 4pm th Street Tuesday 1 pm 6 pm San Francisco, CA Wednesday 8 am 4 pm (415) Thursday 1 pm 4 pm Friday 8 am 4 pm F:\PROTOCOLS\Partner Delivered Therapy\PDTCT(A)_ENG.doc Revised 10/19/2006 Patient Delivered Partner Therapy Fact Sheets available org Click on For Providers

32 Clinicians Role as Key STD/HIV Prevention Partners Screen appropriately for STDs, including: Chlamydia and Gonorrhea using Nucleic Acid Amplification Tests (NAAT) annually in women <26 Chlamydia and Gonorrhea screening using NAATs at the pharynx and rectum in MSM, syphilis RPR or VDRL, and HIV testing every 3-6 months Treat STDs according to CDC and SFDPH Treatment Guidelines Report STDs to SFDPH STD, including gender of sex partners and treatment Encourage patients with STDs and HIV to work with SFDPH staff

33 What if I Suspect Gonorrhea Treatment failure? Is this re-exposure? many patients have ongoing sex, and not all partners get treated Call us (SFDPH STD) to discuss: Dr. Cohen , Dr. Philip , Clinician line during clinic hours Have patient return for repeat NAAT testing from all sites (urine, rectum, pharynx) and consider culture specimen discuss with SF STD and we can coordinate with lab Remind patients of the importance of talking with our staff in suspected cases of treatment failure

34 Thank You! Link to the 2010 Guidelines & updated provider materials available at:

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