9/28/2015. Sexually Transmitted Infections. STDs in Minnesota: Number of Cases Reported in 2013*

Transcription

1 Sexually Transmitted Infections SANE-A TRAINING 2015 Barbara Kern-Pieh RN MS CNM SANE-A SANE-P STDs in Minnesota: Number of Cases Reported in 2013* Total of 23,133 STD cases reported to MDH in 2013: 18,724 Chlamydia cases 3,872 Gonorrhea cases 537 Syphilis cases (all stages) 0 Chancroid cases *Minnesota STD Surveillance System STDs in Minnesota: Annual Review STDs in Minnesota Rate per 100,000 by Year of Diagnosis, * P&S = Primary and Secondary 1

2 CDC Recommendations In cases of sexual assault, all patients are offered prophylactic medication to prevent gonorrhea and chlamydia infection given the high rates of infection after assault Trichomoniasis and Bacterial Vaginosis can be diagnosed or excluded in the ED if microscopy is available; otherwise empiric treatment should be administered Routine baseline testing for STIs is not recommended in cases of sexual assault CDC Recommended Prophylaxis For Gonorrhea : Ceftriaxone 250 mg IM in a single dose Cefixime 400 mg orally in a single dose For Trichomonas: Metronidazole 2 g orally in a single dose For Chlamydia: Azithromycin 1 g orally in a single dose Doxycycline 100 mg orally twice a day for 7 days 2

3 Chlamydia Trachomatis (CT) Transmission rate: 4 17% following Sexual Assault Increase prevalence young women vs. mature women Incubation period: 1-3 weeks Symptoms: Men - 25% asymptomatic NGU discharge or dysuria Women % asymptomatic vaginal discharge, dysuria, abdominal pain Complications: Epididymitis, Prostatitis, Bartholinitis Proctitis, Reiter s syndrome, Endometritis, Perihepatitis Salpingitis, Infertility, Perinatal conjunctivitis, Koala Bears** pneumonia Chlamydia Trachomatis (CT) Chlamydia Statistics Chlamydia has continued to increase over the past decade There has been a 64% increase from 2004 to 2014 The rates of Chlamydia went up in both males and females in 2014 Females continue to have higher rates of chlamydia than males in age groups 39 and under. Chlamydia disproportionately impacts youth year olds make up only 14% of the population, but account for 66% of all chlamydia cases reported The Black/African American population has rates that are 9 times higher than that of whites 3

4 Chlamydia Infections by Residence at Diagnosis Minnesota, 2014 Total Number of Cases = 19,897 Suburban = Seven-county metro area including Anoka, Carver, Dakota, Hennepin (excluding Minneapolis), Ramsey (excluding St. Paul), Scott, and Washington counties. Greater MN = All other Minnesota counties outside the seven-county metro area. Diagnostic tests for Chlamydia and Gonorrhea NOT Recommended for Acute Sexual Assault EXAM DNA amplification best choice if diagnosis is needed PCR/LCR Increase sensitivity for Chlamydia NAAT Nucleic Acid Amplification Test Urine specimens particularly men Future role for diagnosing extra-genital sites Culture-Sensitivity 72-95% for gonorrhea Gram stain 90% sensitivity for gonorrhea in men with urethritis 60% Sensitivity for gonorrhea in women with cervicitis DNA probe/eia -Similar sensitivity to culture Chlamydia Treatment Guidelines Preferred Recommended Regimens Azithromycin 1 g orally in a single dose Doxycycline 100 mg orally twice a day for 7 days Alternative Regimens Erythromycin base 500 mg orally four times a day for 7 days Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days Ofloxacin 300 mg orally twice a day for 7 days Levofloxacin 500 mg orally for 7 days 4

5 Side Effects of Azithromycin Gastrointestinal Mild diarrhea, vomiting, constipation Stomach pain Dizziness Fatigue Mild headache Anxiety Insomnia Vaginal itching or discharge Mild rash or itching Ringing in ears, problems with hearing Decreased sense of taste or smell Trichomonas Frothy yellow- green discharge Strawberry petechiae Foul odor Wet Prep or NAAT to confirm Treat with acute SA exam Differential Diagnosis of Vaginal Infections 5

6 Trichomonas Treatment Guidelines Preferred Recommended Regimens Metronidazole 2 g orally in a single dose *Monitor Alcohol use or delay ingestion Alternative Regimen Metronidazole 500 mg twice a day for 7 days Common Side Effects of Metronidazole Dizziness Headache Diarrhea Nausea Stomach pain Loss of appetite Constipation Changes in taste Dry mouth Human Papilloma Virus Prevalence 16-30% sexually active young adults with evidence HPV DNA Incubation period 4-6 weeks Transmission Genital contact (viral shed + break in skin) Symptoms New bumps or growth on genitalia (Genital Warts) May occur in non-genital areas Abnormal PAP smear/changes on the cervix Complications Carcinoma of the cervix vagina, vulva, anus, penis Perinatal Laryngeal papillomas 6

7 External Genital Warts Not Treated at Acute SANE exam Refer to clinic for recommend follow up Patient applied Podofilox 0.5% Solution or Gel, twice a day for 3 consecutive days per week Imiquimod 5% cream at bedtime three times a week Provider administered Cryotherapy every 1-2 weeks Podophyllin resin 10% - 25% Trchloracetic acid or bichlorocetic acid 80% -90% Intralesional interferon, Laser surgery Therapy for the warts does not cure 7

8 Transmission Gonorrhea (GC) 6 12 % estimated risk of transmission during SA Mode of transmission Vaginal, anal, or oral sex Pregnant woman - baby during childbirth Incubation 2 to 5 days may not develop for up to 30 days Infections in the genitals, rectum, and throat Women - no symptoms until complications have occurred PID can result in tubal scarring that can lead to infertility or ectopic pregnancy Men may have no symptoms A burning sensation when urinating A white, yellow, or green discharge from the penis Painful or swollen testicles (less common) Gonorrhea 8

9 Gonorrhea Gonorrhea Statistics Gonorrhea has continued to increase over the past decade There has been a 5% increase from 2013 to 2014 The rates of gonorrhea went up in males and down females in 2014 Females continue to have higher rates of gonorrhea than males in age groups 24 and under Gonorrhea disproportionately impacts youth The year olds make up only 14% of the population, but account for 51% of all gonorrhea cases reported There continues be even larger racial disparities in gonorrhea compared to chlamydia The Black/African American population has rates that are 18 times higher than that of whites. Gonorrhea Infections by Residence at Diagnosis Minnesota, 2014 Total Number of Cases = 4,073 Suburban = Seven-county metro area including Anoka, Carver, Dakota, Hennepin (excluding Minneapolis), Ramsey (excluding St. Paul), Scott, and Washington counties. Greater MN = All other Minnesota counties outside the seven-county metro area. 9

10 Uncomplicated Gonococcal Infections of the Cervix, Urethra, and Rectum Preferred Recommended Regimens Preexisting GC will also be treated by prophylaxis Ceftriaxone 250 mg IM in a single dose for Prophylaxis Recommended Regimens following diagnosis Ceftriaxone 125mg IM in a single dose Cefixime 400 mg orally in a single dose Ciprofloxacin 500 mg orally in a single dose Ofloxacin 400 mg orally in a single dose Levofloxacin 250 mg orally in a single dose PLUS IF CHLAMYDIAL INFECTION IS NOT RULED OUT Azithromycin 1 g PO in a single dose Doxycycline 100 mg orally BID for 7 days Side effects of Ceftriaxone Common side effects of Ceftriaxone Rash Diarrhea Nausea Vomiting Upset stomach Blood clots Dizziness Headache Pain or swelling in the tongue Lump where the medicine was injected Sweating Vaginal itching or discharge. Quinolone Resistant NG Minnesota statistics show that resistant strains of gonorrhea have dropped in recent years among men who have sex with men, but are on the increase in heterosexual contacts. This supports the CDC recommendation that we use Ceftriaxone as first choice for GC prophylaxis, with ciprofloxacin or cefixime as alternate choices. 10

11 Herpes Simplex Transmission Close contact with a person who is shedding virus Incubation period 6-14 days after sexual contact Symptoms Pain, itching, genital sores, dysuria, vaginal or urethral discharge, tender inguinal adenopathy Sero-prevalence 4-40% (US) antibodies to HSV 2 Latency 90% recur in the first year Sacral nerve root ganglion Subclinical viral shedding up to 6% of time women Perinatal transmission Herpes Simplex Dew drops on a rose petal 11

12 Genital Herpes First Clinical Episode STD Treatment Guidelines Treatment for Herpes includes: 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 Therapy can decrease rate of reactivation but there is no cure Primary Herpes from this SA will not be visible at SANE exam Patient teaching about what to look for if develops Recurrent Herpes can be triggered by stress of sexual assault Advise patient that episodic treatment may be necessary Hepatitis B If immunized has preventative effect Treatment will depend upon source status (HBsAg Positive vs HBsAg Negative) Post exposure prophylaxis *without HBIG Repeat with 2 doses at 1 and 4-6 months HIV 12

13 HIV STOP Neucleoside and Neucleoside Reverse Transcriptase Inhibitors Truvada (tenofovir+emtricitabine) * CDC post SA Combivir (zidovudine +Lamivudine) Protease Inhibitors Kaletra (Lopinavir +Ritonavir) Entry Inhibitors Maraviroc enfurirtide Integrase Inhibitors Raltegravir (Isentress)*CDC post SA HIV Risk Factors Assailant factors Risk behaviors MSM, IV drugs Viral load Geographic risks prison, African, Haiti Fluid left on victim (saliva, blood, semen) Victim factors Intact membranes vs. skin or mucosal lacerations Vaginal inflammation (BV, cervicitis, other STI) Immune status What type of body fluids exposed to Insertion into anus or vagina 13

14 Estimated Risk of HIV transmission following different types of exposures Type of exposure Needle sharing to an infected source Receptive anal intercourse with infected source Receptive Vaginal intercourse with an infected source Insertive anal intercourse with infected source Insertive Vaginal intercourse with an infected source Estimated Risk 0.67% (1 in 150) % (1in 200 to 6 in 200) % (1 in1000 to 2 in 1000) 0.06% (1 in 1500) 0.05 % (1 in 2000) Oral Sex with ejaculation with an infected source Conflicting data, risk is considered low. HIV npep Recommend when risk is high * ( blood or body fluids of donor to non-intact membrane of victim) HIV PEP for 28 day course Baseline HIV, CBC, diff, platelets, CMP recommended at baseline Don t delay initiation, recommend F/U with Infectious Disease next clinic day Advise compliance with Rx Follow with Infectious Disease clinic if initiated for remaining doses (Truvada) Tenofovir 300 mg PO daily + Emtricitabine 200 mg PO daily Plus Raltegravir (Isentress) 400 mg PO twice daily or Dolutegravir 50 mg PO daily 14

15 Treponema Pallidum (Syphilis) Incubation period days Symptoms Primary Painless papule Painless ulcer (chancre) Inguinal lymphadenopathy Symptoms Secondary Disseminated rash Complications Congenital syphilis - Central nervous Latent syphilis - Cardiovascular Transmission Contact with infectious, moist lesion(s), Most commonly during oral, anal or vaginal sex 30-50% risk of infection per exposure to early (primary or secondary) syphilis Less common through casual skin to skin contact Cannot be spread by use of toilet seats, swimming pools, hot tubs, shared clothing or eating utensils. Syphilis Statistics Rates of all stages of syphilis increased fro 2103 to 2014 There has been a 5% increase from 2013 to 2014 Males have higher rates of primary and secondary syphilis than females in all age groups year old males have the highest rate at 27.7 per 100, year old females have the highest rate at 3.2 per 100,000 The rates of primary and secondary syphilis are 7 times higher in the Black/African American population than that of the White population Black/African American population are 23.8 per 100,000 White population are 3.6 per 100,000 15

16 Primary & Secondary Syphilis Infections by Residence at Diagnosis Minnesota, 2014 Total Number of Cases = 257 Suburban = Seven-county metro area including Anoka, Carver, Dakota, Hennepin (excluding Minneapolis), Ramsey (excluding St. Paul), Scott, and Washington counties. Greater MN = All other Minnesota counties outside the seven-county metro area. Characteristics of Early Syphilis Cases Among MSM Gay and bisexual men account for 76% of cases among men. 79% of cases among MSM are White, but a disproportionate number of cases (11%) are African American. 56% in the City of Minneapolis and 26% live in the suburbs 50% of cases are also infected with HIV. MSM=Men who have sex with men Early Syphilis includes primary, secondary, and early latent stages of syphilis. Syphilis 16

17 Syphilis Syphilis & HIV Syphilis is a marker for HIV risk Atypical presentation of disease sometimes occurs Multiple ulcers, overlapping stages Higher non-treponemal titers Syphilis facilitates HIV transmission Increased the number of receptor cells Increases HIV viral load in genital lesions, semen or both Syphilis Diagnosis Clinical Suspicion High Risk Population HIV Positive Annual Physical / STD Screen Pregnant 17

18 Early Syphilis Treatment Benzathine PCN G 2.4 million units IM once PCN-allergic: Non-Pregnant Doxycycline 100 mg po BID x 14 days Pregnant: Desensitize Benzathine PCN G 2.4 millions units IM once Alternative Therapies Tetracycline 500 mg po QID x 14 days Ceftriaxone 1 gm IM/IV QD x 8-10 days Bacterial Vaginosis Bacterial Vaginosis Vaginal Bacteriosis NOT STI Can Increase Risk of HIV transmission 18

19 Differential Diagnosis of Vaginal Infections Bacterial Vaginosis 19

20 Bacterial Vaginosis Recommended Regimens Metronidazole 500 mg orally twice a day for 7 days Metronidazole gel 0.75%, one full applicator (5g) intravaginally, once a day for 5 days Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days Alternative Regimens Metronidazole 2 g orally in a single dose Clindamycin 300mg orally twice a day for 7 days Clindamycin ovules 100g intravaginally once at bedtime for 3 days Bacterial Vaginosis - Pregnancy Recommended Regimens Metronidazole 250 mg po tid for 7 days Or Metronidazole 500 mg po bid for 7 days Or Clindamycin 300 mg po bid for 7 days Monallial Vaginitis, Candida Vaginitis, Yeast Infection White curdy discharge Inflammation of vulva and vagina PURITIS!!! No odor Some increase risk with antibiotic Rx Minimized by use of one time dosing treatment 20

21 Differential Diagnosis of Vaginal Infections Candida Vaginitis Clotrimazole 100mg 2 tablets qd vaginally for 3 days Clotrimazole 500mg tablet once vaginally Fluconazole 150mg orally once Alternatives: OTC Clotrimazole cream Butaconazole cream Miconazole cream or suppository Nystatin suppository Terconazole ointment, cream or suppository PID - Pelvic Inflammatory Disease Lower Genital Tract Infection Mucopurulent Cervical Discharge Pain Abdominal Tenderness Fever WBC Laboratory findings RISK OF INFERTILITY INCREASE RISK OF HIV TRANSMISSION 21

22 Other STI Considerations Proctitis Pediculosis pubis Scabies Tetanus - if immunity not up to date if injury warrants re-imunization Hepatitis C no immunization Timely evaluation and blood testing at F/U visits 22

23 Pediatric Considerations Gonorrhea + considered diagnostic of sexual assault Syphilis + considered diagnostic of sexual assault HIV + considered diagnostic of sexual assault Chlamydia + considered diagnostic of sexual assault trichomonas Highly suspicious for sexual assault Genital HPV HPV warts suspicious for sexual assault Bacterial vaginosis Inconclusive 23