Selected STDs. Chlamydia trachomatis. Updates on Women s Health Issues

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1 Updates on Women s Health Issues Kevin A. Ault, MD Department of Obstetrics and Gynecology University of Kansas Medical Center 1 Selected STDs Relevant biology Epidemiology Clinical diseases 2015 New guidelines download the app! Special points Chlamydia trachomatis Most closely related to gram negative bacteria Unique biphasic life cycle Diseases: urethritis, cervicitis and PID Long term sequeale fallopian tube damage, infertility and ectopic pregnancy The silent epidemic Courtesy of David Soper, MD 1

2 2014-Fig 1. SR, Pg Fig 3. SR, Pg 9 HSG showing bilateral hydrosalpinges Image courtesy of Brad Van Voorhis, MD University of Iowa Chlamydia Rates of Reported Cases by Sex, United States, NOTE: As of January 2000, all 50 states and the District of Columbia have regulations that require the reporting of chlamydia cases. Chlamydia Rates of Reported Cases by State, United States and Outlying Areas, 2014 NOTE: The total rate of reported cases of chlamydia for the United States and outlying areas (Guam, Puerto Rico, and Virgin Islands) was per 100,000 population. 2

3 2014-Fig H. SR Pg 62 Chlamydia Rates of Reported Cases Among Women Years of Age by State, United States and Outlying Areas, 2014 NOTE: Rates for Guam and the Virgin Islands were calculated by using the 2010 population estimates. Chlamydia special points Screening women < = 25 yo Nucleic acid amplification testing available urine testing may be useful in many settings 2010 guidelines recommend retesting of positives, continued in 2015 Partner delivered therapy? 2015 CDC Recommendations for the treatment of Chlamydia Recommended therapies Azithromycin 1 g PO single dose Doxycycline 100 mg po BID for 7 days Alternative Erythromycin 500 mg po QID for 7 days Ofloxacin 300 mg po BID for 7 days Levofloxacin 500 mg po q d for 7 days Source: CDC 3

4 Prevention of Chlamydia associated sequelae Rekart et al 13, data for British Columbia Source CDC/MMWR 2009, also 2012 STD Prevention Conference 4

5 2014-Fig 12. SR, Pg Fig I. SR Pg 62. Gram Stain of Urethral Discharge Showing Gonorrhea Gonorrhea Rates of Reported Cases by Year, United States, Gonorrhea Rates of Reported Cases Among Women Aged Years of Age by State, United States and Outlying Areas, 2014 NOTE: Rates for Guam and the Virgin Islands were calculated by using the 2010 population estimates. 5

6 2012-Fig 24. SR, Pg 25 Percentage of Neisseria gonorrhoeae Isolates with Elevated Ceftriaxone Minimum Inhibitory Concentrations (MICs) ( μg/ml), Gonococcal Isolate Surveillance Project (GISP), Rising resistance in gonococci Superbug GC recently described Resistance to cephalosporins is mediated via the penicillin binding protein 2 multiple genotypes Initially in eastern Asia, but 3 % cephalosporin resistance in recent EU abstract (2012) and 7 % in a Canadian series (2013) Potential strategies surveillance, screening and rescreening, looking for treatment failures See Hess et al 12, Bolan et al 12 and Allen et al CDC Guidelines for the treatment of Gonorrhea Ceftriaxone 250 mg in a single intramuscular dose PLUS Azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice daily for 7 days 6

7 Gonorrhea Screening Screen at risk women including pregnant women if risk factors are present Risk factors might include age < 25, history of prior STD, new/multiple partners, inconsistent condom use, commercial sex worker, drug use Prevalence varies widely See Newman et al 07 Human papilloma virus Small DNA viruses, approximately 8 kb > 100 types with 20 infecting the genital tract In humans, HPV 16/18 associated with cancer and HPV 6/11 associated with genital warts Several other HPV types specifically associated with cervical cancer CLINICAL PRESENTATION OF GENITAL WARTS Courtesy CDC 7

8 2014-Fig 50. SR Pg 46 Genital Warts Initial Visits to Physicians Offices, United States, NOTE: The relative standard errors for genital warts estimates of more than 100,000 range from 18% to 23%. SOURCE: National Disease and Therapeutic Index, IMS Health, Integrated Promotional Services. IMS Health Report, The 2014 data were not obtained in time to include them in this report. Treatment for Genital Warts 2015 CDC Guidelines Patient applied Podofilox or Imiquimod or Sinecatechins Provider applied Podophyillin, cryotherapy or trichloroacetic acid Genital Wart Diagnosis by Age Australia Source: Ali et al 2013 (women only) 24 8

9 Estimated HPV Related Cancers USA 2015 Men N = 15, 346 Women N = 23, 875 From Pahud and Ault 15 Summary of current HPV vaccination recommendations ACIP recommends routine vaccination of females aged years with 3 doses of HPV vaccine. The vaccination series can be started as young as age 9 years. Vaccination also is recommended for females aged Beginning in 2011, routine vaccinations of adolescent males beginning at age See or MMWR 26 HPV related Cancers Prevent by 9 Valent Vaccine USA 2015 Women Men From Pahud and Ault 15 9

10 Screening Guidelines for the Prevention and Early Detection of Cervical Cancer 28 Resolution of Abnormal Cytology in Adolescents Source Moscicki et al 04 n = Weighted prevalence of low-risk and high-risk human papillomavirus (HPV) among female respondents years of age, by age group. Hariri S et al. J Infect Dis. 2011;204: Published by Oxford University Press on behalf of the Infectious Diseases Society of America

11 2014-Fig 53. SR Pg 48 STD s The Big Picture Source CDC 2013 update Genital herpes Due to HSV II in a majority of cases, however genital HSV I increasing Member of the herpesvirus family Family characterized by latency and reactivation Genital Herpes Initial Visits to Physicians Offices, United States, NOTE: The relative standard errors for genital herpes estimates of more than 100,000 range from 19% to 23%. SOURCE: National Disease and Therapeutic Index, IMS Health, Integrated Promotional Services. IMS Health Report, The 2014 data were not obtained in time to include them in this report. 11

12 HSV 2 and The tip of the iceberg 9.2% Recognized infection Iceberg represents all those with HSV-2 antibody 90.8% Unrecognized and asymptomatic infection Trauma of Contracting Genital Herpes I m going to read you a list of items that people may or may not consider traumatic. For each one I read, please tell me how traumatic it would be for you personally: very traumatic, somewhat traumatic, not very traumatic, or not traumatic at all? AIDS infected 96% Having genital herpes 68% Breaking up with a significant other 54% Getting fired from your job Failing a course in school 28% 51% % Saying Very Traumatic. Genital herpes clinical presentation Multiple painful ulcers Usually 3-5 mm in size Most common cause of genital ulcer disease in the USA Laboratory test - culture 12

13 Clinical Presentations - HSV 2015 CDC Recommendations for the treatment of first episode genital herpes Recommended therapies Acyclovir 400 mg po three times a day Acyclovir 200 mg po five times a day Famciclovir 250 mg three times a day Valacyclovir 1 g twice a day All treatment for 7-10 days. Other strategies include episodic and suppressive therapy. Source: CDC Conclusions HSV and HPV are highly prevalent HPV vaccine recommendations updated GC resistance is rising Many STDs are without symptoms, and this plays a role in transmission and screening strategies 13