New Directions in STI Clinical Management Highlights of the 2010 Treatment Guidelines – Dr. Hsu

New Directions in STI Clinical Management  Highlights of the 2010 Treatment Guidelines – Dr. Hsu

So I’m delighted all of you
are in the room today ready with clickers in
hand to participate in this very interactive
workshop on New Directions in STI Clinical Management, Highlights from the 2010 CDC
STD Treatment Guidelines. So if you’re willing
to go with me on this ride today though I
should probably introduce myself because although I know
some of you in the audience, I’m not sure all of you know
exactly who I am or what I do. So my roots are I’m
actually a pediatrician and a pediatric infectious
disease specialist and I do still practice at
Boston University Medical Center on Thursday afternoons
doing same day sicks with adolescents actually. That’s my primary focus at
this point in my career. The other thing is I
do still, I don’t think about STDs all the time and
I still am a Pedi ID doc over at BU Medical Center
so some of you will see me, my name on charts there
related to that as well. But the one major
portion of my life now is that I have a position at
the Massachusetts Department of Public Health where
I’m the Medical Director for the Division
of STD Prevention and that actually comes
with it the ownership of one of eight wonderful,
clinical training grants that focus particularly on post
graduate medical education. And years ago when Susan
Gray and I were but residents and fellows together we dreamed
of doing things like this but we would have
to do it on pennies. And now here we are, fast
forward 5, 10 years later and we can actually do these
things as joint operations, partly off of CDC funding for
making sure that clinicians stay up to date in the area of
STD diagnosis, management, and treatment, and
sexual health as well. So we cover the New
England region, and if any of you are eager
to learn more, today is but a teaser of what
you could learn. You could spend a lot
more time, valuable time in a vaginitis workshop
relearning how to do wet mounts. Oh yeah. [laughter] So before
we begin, today’s goals are to gain some insight
into hot topics in the STD clinical management
world, highlight areas of the 2010 STD treatment
guidelines that should be read for, carefully for final
recommendations and we’re going to do this interactively. So here’s a fun thing for those
of you who are not so much in the know about how these
guidelines come about. Well of course they come
about from a committee right? And a committee, once
somebody told me– it must be like a Ben
Franklin quote or something– all stomachs, no heads, that
ultimately it’s very hard to decide things on committee. And that sometimes
undoubtedly explains some of the more schizophrenic
messages and pieces of the document if you’re ever
wondering why one place seems to say something and the other
place says something else, well, experts don’t always agree. However, the treatment
guidelines development process does wind up being evidence
based on some principle outcomes of STD therapy that are not
always the outcomes you and I as clinicians practicing
in clinic focus on. They do focus on
microbiological eradication. They do focus on making sure
the patient feels better from the signs and
symptoms point of view. They do focus on prevention of
sequelae, but they also focus on prevention of transmission. There is a very clear
public health message that comes across. These are the CDC STD treatment
guidelines and I’m going to highlight some of the reasons that that might be really
interesting for us as clinicians to understand why it’s
so different and why in some settings, you know,
kind of be aware of the fact that we are over
prescribing antibiotics in some ways contrary to
what we do with our messages with our kids who have
viruses and we don’t want to overprescribe antibiotics. These are sometimes
somewhat different messages. Okay, one of the
interesting things about the recommended
treatment regimens are that they’re distinctly
preferred over alternative regimens. This may not have been
so clear before 2010 but at this point the CDC’s
sort of saying, listen, you better have a really
good reason to pick something on that alternative list like
a terrible allergy directly to the drug on the
recommended list because the recommended
drugs are actually on the recommended list because
percentage points maybe not always statistically
significant may be better at microbiologic eradication or something else made
it slightly better based on evidence, based on research, and therefore it hit
the recommended list, not the alternative list. Here’s a fun little detail. They’re alphabetized unless
there is priority of choice. So the fact that Ceftriaxone is
higher on the list than Cefixime for gonococcal treatment is a
subtle thing telling clinicians, if you read the finer
print in the first 10 pages of the 120 page document which
I’m sure you do all the time, it says actually they’re
alphabetized unless there is a priority of choice and Ceftriaxone is
actually really recommended over and above Cefixime. Huh. A not so fun
thing to admit, you know how long it
takes to get these things out the door of the CDC? They were reviewed
in April of 2009. They didn’t get published
until 2010, December 17th. And it is because Tom Frieden,
literally the guy at the head of CDC, has to sign off on it. A bunch of agencies have to
sign off on this thing, okay? And the MMWRQ is
probably as long as a loop around the equator
at this point. So it is a very inefficient
process which tells you almost
immediately as soon as the darn thing is published
it’s already probably slightly out of date, but you
do with what you can. CDC is getting savvier about
getting the word out not only through this network of STD
HIV prevention training centers of which there are eight
clinical ones across the land, but they have all sorts of
magical things on their website like pocket guides and
teaching slides and charts and there’s an app for that. There is now an eBook on the
CDC STD treatment guidelines. I downloaded it to my iPad which
I only got a few weeks ago. You know what the thing
is just like a recycling of like the paper version. I don’t know that it’s
any better but it’s kind of fun you can get
it on your iPad. Prevention and screening issues. There are some new
messages in 2010. The 2010 new messages
are, first of all, there’s a whole new section,
it’s at the bottom of the slide, screening and correctional
facilities. Never before data
from epidemiology in correctional facilities about how many percentage
points higher is the prevalence of trichomonas, is the
prevalence of chlamydia, is the prevalence of gonorrhea. How jails wind up being, and
correctional facilities wind up being nexuses of
communication of STI’s and potential transmission
back to the community. And cutting down on jail
transmission arguably with a captive population
might cut down on community translation. So for those of you who might
work with DYS or children in custody or even adolescents
and young adults post captivity, etcetera, these are
some of the things that you might think about. There’s a whole new section. In terms of the older sections, in pregnant women asymptomatic
BV or trich screening or HSV-2 serologic screening
still not recommended. Adolescents, they expanded the
explanation of benefits arguably for an adolescent,
savvy audience, the stuff that they talk about in the CDC STD treatment
guidelines is probably too basic to be honest. It’s much better to go to a talk such as Martha Perry’s
talk that’s coming up. For men who have sex with
men, it has become very clear that the nucleic acid
amplification tests, and I’ll tell you how to
get these, for the rectum and the pharynx are
recommended for screening. And for women who have sex
with women, this offering of the HPV vaccine, this
idea that BV is common but screening is still
not recommended are some of the newer messages within the
2010 STD treatment guidelines which tells you right now that the CDC STD treatment
guidelines are not all about treatment. There’s a whole section on
prevention and screening, there’s a whole section under each disease once you’ve
diagnosed the patient with it, some counseling messages
specific to that disease, counseling messages specific to partner management
related to that disease. How many days out you
need to go to think back about the patient’s
previous partnerships to know who should be treated with
expedited partner therapy. All sorts of details like that
are actually in this document because they are very concerned
about the public health aspects and prevention of disease. Okay without further
adieu, let’s dive into one of the biggest changes within the 2010 STD
treatment guidelines. We have a 20 year old guy,
presents with complaints of burning with urination and
urethral discharge for one day. Three female sex partners
during the last year, didn’t use condoms with
any of these partners. Previously HIV and STD negative, but last checkup
was over a year ago. Upon exam, this is not a
not straightforward case, this is pretty straightforward,
pus at the urethral meatus. No epididymitis, no inguinal
adenopathy, no systemic systems. How are you going to treat him? Vote now. [ Pause ] Low dose Ceftriaxone IM,
higher dose Ceftriaxone IM, Ceftriaxone combined
with Azithromycin or straightforward
Azithromycin at 1 gram po. How would you want to treat him? Would you want to
give him more drug as a shot or as an oral drug? All right, most of you
are shooting from the hip and you’re doing to give
him dual therapy probably with the idea in mind that this
is urethritis and you don’t know yet what the cause of his
urethritis is so you’re going to cover broadly,
broadly right at the point where he has, he needs care. He’s already symptomatic. You want to interrupt the
chain of transmission, Ceftriaxone IM 250 and
Azithromycin 1 gram and you would be correct. I’m going to change
the story a little bit. What if he weren’t
so symptomatic and you did this
as a screen, okay? And it came back
just as gonorrhea. Unusual. It’s unusual. Only 10% of male urethral cases
that we know of with the type of circulating strains of neisseria gonorrhea these
days are they asymptomatic enough at the urethra that the
guy is walking around with it, could transmit it still, only
10% of them are asymptomatic. 90% of them do really
cause that pus, okay? But if you knew that
he only had gonorrhea and you had eliminated chlamydia from the equation could you
be a little bit more narrow with your drug use here? Or could you choose a whole
another drug that’s an oral option like Ciprofloxacin
or Cefixime or Cefpodoxime? And this is not a question of
what the recommendation is, this is a question of
what you do in practice. What do you actually
do in practice? So what’s your answer? All right, let’s see
what the audience votes. Okay so most people are still
giving 250 of Ceftriaxone and it, a few people are also
giving Ceftriaxone 125 still, but virtually no one is actually
usually using a quinolone or using Cefixime 400 milligram, that tablet formulation is
actually back out on the market as of April of 2008, or
Cefpodoxime 400 milligrams po. Okay, there wasn’t really
a right answer to that one, but let me tell you what the
recommendations are okay? Because that one was just
what’s your practice? The recommendation is now
officially go with Ceftriaxone if you have Ceftriaxone or if Ceftriaxone’s really
unavailable then you can go with Cefixime, but
you need to co treat with Azithromycin 1 gram po or Doxycycline 100 milligrams
po bid for seven days regardless of whether or not you’ve
eliminated chlamydia or not. And the reason is because of
the concerns that I’m going to delineate on the
next few slides related to evolving gonococcal
resistance. This is going to happen and
this is likely going to happen in the next decade of our life. Let’s go back to the fact though that the gonorrhea treatment
guidelines also actually highlight one very
particular fact. If you’re pretty sure that
the infection is solely at the urogenital
site, yeah you can go with Ceftriaxone or Cefixime. But you know what, if you
have a sneaking suspicion or very high suspicion that
the pharynx might be involved, and there it’s the
flipside, gonorrhea hanging out in the tonsillar
crypts, hmm, probably asymptomatic
90% of the time. Only 10% of the time do you get that glaring exudative
pharyngitis that you might even see
just like group A strep. Okay? Definitely asymptomatic
carriers running around. You really need to treat those
patients with the possibility of oropharyngal infection
with Ceftriaxone 250. Cefixime not enough drug
to get really deeply into the tonsillar
crypts to be running around in the serum long enough. The efficacy points really
do drop for that site. Okay, and here are some
of the data that have yet to be published still. Chris Hall is still
working on the manuscript but they presented it
at a series of meetings and what I’ve done here on this
slide is summarized a bunch of things and these
slides will be available after the talk just
not beforehand because then it ruins the
fun of the quiz questions. So efficacy data for agents
with activity against GC, let me walk you through it. Ceftriaxone 125, Cefixime
400, Cefpodoxime 200 versus 400 were actually
tested in trials and cefuroxime 1 gram po. Now granted these
trials are not very big. I mean you just don’t, in
some places in the nation, particularly New England
we don’t have a lot of gonococcal disease, and
thank goodness for that, but they looked at the site, is
just the urogenital or rectal. Ph includes pharyngeal okay? And what you see is for
every drug at every dose, pharyngeal infection is probably
consistently the cure rate is lower for every drug, okay? Except for maybe arguably,
well it’s still efficacious 94% of the time for Ceftriaxone
at 125 and they haven’t even completed
all the studies for 250 but we hope it would
be better for that. Okay and that, the same
holds true for Cefpodoxime and other drugs, but other time
you talk about the pharynx, it’s just harder to
get rid of the bug from that particular area
with the same dose of drug. So the concept here is that the
CDC has promulgated a series of recommendations that
dual therapy may hinder the development any microbial
resistance. The thing we were
doing all along for our presumptive urethritis
cases actually might have been driving the fact that we have yet to see extreme
gonococcal resistance against third generation
parenteral cephalosporins like Ceftriaxone which
if you think about, at the 250 milligram
dose is a lot smaller than what you could
even give for a rule out sepsis case, right? So 250 milligrams, arguably we
could still go up from there and we may see that in
the coming years actually. Dual oral therapy may
be more efficacious for pharyngeal GC treatment but
the data are yet to come in, so the CDC was unwilling in
this very evidence based series of guidelines to say
anything about the combination of Cefixime and Azithromycin
orally. And what we do know
to be the case is that we have very
limited options in cephalosporin
allergic patients. But this really has to be your
cephalosporin allergic patient, not your peni-allergic patient, but your cephalosporin allergic
patient because the rates of cross reactivity between
third generation cephalosporins and penicillin are
less than 1 in 20. Less than 1 in 20 and
probably even less than that. And there are details within
the STD treatment guidelines to tell you that
you as clinicians, when you use a parenteral third
generation cephalosporin are practicing in recommended
guidelines. Now that having been said, if you’re in a private practice
setting and you have some risk of anaphylaxis, nobody really
wants to own that burden. But you have options. But let it definitely be
said that the CDC has laid it out very clearly that this
at least is a recommendation to back you up that the
parenteral was really the way to go. The other parenteral medications that maybe would work would
be a drug like spectinomycin and it’s a little scary
but that drug isn’t even on the market anymore
in the United States. And forget about
desensitization, CDC was crazy when they recommended that. It just isn’t very efficient to
recommend it for a lot of people who are more and more
gonorrhea’s actually being diagnosed in the
private setting. Azithromycin remains in
your back pocket but it’s in the tiny details of
the gonococcal section, it requires two grams to actually effectively
treat gonorrhea and we do have two MMWR’s of
course from the western part of the nation California and
Hawaii usually being the first to see the signals in
gonococcal resistance, okay? And they definitely have
already seen signals of high grade Azithromycin
resistance. And treatment failures
have already been seen even to two grams, which, as you all
know, have you given two grams to your patients before in
an effort to treat them? They tend to throw
it up more too. It’s not very well tolerated. So let me give you a little
bit of history as a reminder and the key point here is we
just don’t want to relive this. So this is what we have done
in the past with gonorrhea. Well in the 30’s it was actually
even sensitive to things that weren’t even arguably
things that were antibiotics but were more like
potassium, permanganate, silver salts, mercurochrome. In the 40’s we finally
got to penicillin. In the 44 35% treatment failure
with sulfonamides which started in the 30’s, so only
a decade later. And 72, the penicillin
regimen increased to 4.8 million units per,
plus Probenecid but that was because it was in
response to the fact that a few decades before, although penicillin therapy
had started it was started at a lower dose and the lower
dose was no longer working. By the 70’s, 80’s–
80’s we’re talking about tetracycline
resistance being reported. By the late 80’s
penicillin’s taken off the books and 2000’s concern regarding
rising quinolone problems which we don’t tend to use
as much in pediatric medicine because still almost no
quinolones are available for use in under 18 at least
on the FDA books. So if you want to be
official about it, we’re not really supposed to be
using it with those patients. And where are we now? In the last two decades already
there have been many reports from Japan and Hong Kong–
so it always starts in Asia– and there have been many
reports of resistance to second generation
cephalosporins then third generation oral cephalosporins
and now an isolate from Japan that was reported
earlier this summer that was resistant
to Ceftriaxone. So we know that it’s probably
within the next decade that we’re going to see
something that’s resistant to everything that’s currently
licensed on the market. So what’s happening now is CDC’s
sponsoring a series of trials on dual therapy going back
to older drugs in combination with the newer ones like
Gentamicin as an IM shot. I can’t even imagine how
painful that must be, combined with things
like Ceftriaxone and we will see the
data soon enough. So if you’re ever
faced with a case that you think might be failing
treatment in front of you, you might be the first one, hopefully you won’t be the
first one in New England to find this– it would be rare. It was probably going to be,
first signal’s going to be in California or
Hawaii, but if you do, call your local department
of public health. Try to get a culture. Hmm, not that easy
to do necessarily. Try to get susceptibility
testing done and report to CDC for additional help really
more than anything else. Immediate, real-time help. You can use gonococcal NAAT by
the way, probably within one to two weeks for diagnosis from a nucleic acid
amplification test. The kind of DNA test that most
of us are using to diagnose or screen for gonorrhea at
this point in our careers, like the APTIMA TMA or the
Becton Dickinson Gen-Probe. All of those are nucleic
acid amplification tests. So ala CSI, you could use these
as rapidly as one to two weeks, by the way we think,
one to two weeks after. Clearance of gonorrhea
is faster than clearance of chlamydia DNA okay? So you heard it here, the
study has yet to be published but the CDC’s already
espousing this notion, okay? So you could use those
for test of cure. They’re not recommending it yet,
only if you have a suspicion. And I don’t know if we’re
going to be going back to this, but I sure do wonder
if the resources and the thought behind
do I have a lab that I could send a gonococcal
culture to if I wanted to should I actually ask the
lab could they receive something sent in a culturette tube, would
that work to grow gonorrhea? Those are reasonable
questions to ask your lab if you’re ever faced with this
question of is it resistant to something that you just gave. Okay, so before we go
onto the next case, questions about gonococcal
treatment because that was
really quite a change in the 2010 treatment guidelines that you really should be doing
dual therapy for everybody for a lot of good reasons. I’ll tell you there’s
some controversy about it. There’s some experts in
the field who did not feel that that had enough
evidence to support. So not everyone’s doing it
and certainly departments of public health I don’t believe
are calling clinicians just to remind them not to do that
if they only use 250 milligrams of Ceftriaxone for just
a straight GC case. No questions? Okay we’re going to
move on to screening. All right 16 year old runaway
female brought in by DSS for medical clearance
prior to foster care. She is asymptomatic but
she reports oral, vaginal, and anal sex with multiple males
in exchange for a place to stay. So you’re going to offer
the following gonorrhea and chlamydia screening. A urine NAAT, a urine NAAT plus
a rectal pharyngeal culture for GC and chlamydia. Or a urine NAAT plus
rectal pharyngeal NAAT, that DNA test or that RNA test. Genital swab NAAT, any
part, just a genital swab. A general genital swab plus
rectal pharyngeal NAAT, or you’re going to look up the 2010 treatment
guidelines for guidance. I gave you an out. Vote now. [ Pause ] Okay, let’s see what people say. You’re going to use nucleic
acid amplification testing and it looks like the
majority of the room wants to do just a general
genital swab. Wow the word is getting out. Excellent. Excellent. But there’s still some people who are doing a smattering
of other things. You know what, doing any
screening whatsoever trumps not doing any screening,
so that is all good. All good. Okay, despite the fact
that all of you who know this and use this know that
that’s the cleaning swab, not the actual sample swab. This is a bad picture, sorry. Haven’t had a chance
to revise that. Chlamydia and gonorrhea NAAT
testing is still not FDA cleared for rectal and pharyngeal
specimens, but now it is the preferred
testing method over culture because it is several percentage
points better in terms of sensitivity and specificity
while it used to be measured against culture, it’s not
a very good gold standard if it doesn’t detect
as many infections. So specificity’s
actually very good now with the newest generation
assays that amplify chlamydia and gonorrhea DNA and RNA. So CDC was unable to argue
labs, the FDA into approving it or getting any of the commercial
manufacturers to do the studies for extragenital sites
so they went another way. They twisted the arms of some
major national laboratories as well as the fact that
they twisted the arms of all the public
health laboratories that they already
had connections with and they ran validation panels, and many public health
laboratories across the nation will
do samples for you, or nationally every clinician in their back pocket
can force their lab to send their sample
to Quest or LabCorp. I own no stock. I have no commercial
disclosures. Those are the two major
national ones that we know about and the list is growing
longer every day that have run a validation
panel to sub, clear this testing for use for clinical
results okay? So other tests are being
verified by other laboratories and the concept we’re
moving toward and the MMWR that I hope is stuck in
queue will be published in the next few months
will be that the idea is that the self collected vaginal
swab may in fact be more, slightly more sensitive than any
other female sample, even urine, even the clinician
collected endocervical swab. The self collected vaginal
swab might be better. Any speculation onto why? Any guesses? They’ve run studies and they’re
always consistently a few, a couple percentage
points better. Yeah?>>It’s just a couple of percentage points
better though right?>>Yeah just a few. So any screening beats
no screening, absolutely. And urine as a very
convenient specimen, relatively less invasive
specimen, still a very good
specimen to get. Always in the 90’s percent. Those of us in the field have
been speculating that women in the bathrooms collecting
their own samples are spending great quality time with their
vaginas twirling the swab like it always was
supposed to be twirled. If you read the package
inserts on all of these, you as the clinician are
supposed to have contact time with that area for
a good 10 seconds, 15 seconds when you go to do it. But all of us as
clinicians have been trained from clinician babyhood to
make the patient comfortable, to minimize the time in
stirrups, to do all of this. And I think we carry
with that the idea that just touching
it is good enough. Probably not. Look at the package inserts. Definitely look at
the number of seconds that the manufacturer says
that it should be in contact with the tissues to
do this correctly. Okay so that’s coming. Self collected vaginal swab. You heard it here
first, maybe not. But, and also the idea
that you can get rectal and pharyngeal screening for
your high risk patients, okay? And I mentioned some
of these here. I want to point out one other
thing related to repeat testing and repeat screening for
high risk individuals who have already demonstrated
their high riskiness by the fact that they’ve carried
the infection before, they are by definition in
a sexual network that had that particular disease. So they are very high
risk for reacquisition within the next three month
time horizon particularly for gonorrhea and chlamydia so there is a standing
recommendation from the CDC to repeat screening
three months later. It’s not test of cure,
it’s repeat screening. And by then, the dead
DNA should be gone, okay? So that repeat nucleic
acid amplification test for Chlamydia is certainly
going to work at three months, definitely for gonorrhea. Is that clear? Getting a lot of nods. Yes? Susan Gray.>>So I’m just thinking
about some of my at-risk, high-risk patients
having oral sex.>>Um hum.>>Do you think that I should
do an oral swab once a year for them?>>I kind of picked the
DSS case as most high risk because she was doing
commercial sex work. What it amounted to is
commercial sex work. The guidelines are
actually not clearly saying that all adolescents
need to be screened in the oropharyngeal region. Why? Probably the most common
organism floating around there out of chlamydia and gonorrhea,
which is it going to be? It’s going to be chlamydia. Everybody who has ever done
studies on the oropharynx, even with the newer
generation of chlamydia testing, the newest generation of
chlamydia testing can’t find it, doesn’t, don’t find it more than one percentage
point of the time, okay? And moreover, it
doesn’t hang out there as long as gonorrhea does. Gonorrhea kind of
finds its happy home in the tonsillar crypts. Chlamydia doesn’t seem
to do that, doesn’t seem to be as transmissible. So current guidelines even from the CDC say very
clearly don’t screen anybody for chlamydia but you can
screen the high risk individuals for gonorrhea and gonorrhea
of course prevalence points, way fewer prevalence points
compared to chlamydia. So in many populations
it’s not worthwhile, it’s not considered
worthwhile to routinely screen for gonorrhea in the oropharynx. Okay. Let’s talk about
women and the rectum related to gonorrhea and chlamydia. Do they have to report
a history of anal sex or will it be sufficient
to do a genital swab, like a vaginal swab? Will you capture the majority
of transmissible infections for gonorrhea and chlamydia? For women it’s argued
yes, you will. For men who have sex with men, it’s clear the answer
is no you don’t. Very clear. You’ll miss over half of
the transmissible infections if you don’t swab the
anus on the report of recipient anal sex, okay? But for women I think
it’s definitely clear that one genital swab, probably
the vaginal swab will be reasonable and the best screen, although CDC’s not
saying don’t use urine. They’re just saying
the best screen. Doesn’t take options
off the table, it just gives you more
confusing, confusing options. Yes, Atsuko [assumed spelling]
was next and then I’ll go to–>>Katie.>>Katie. Yes, whose
name I just blanked on. Okay.>>If someone, so working in
the ER there have been patients who come in and said I
just had unprotected- you know the BU student who drank too much last night
just had unprotected sex yesterday wants to be screened
for everything today, is, if they were exposed to GC
or chlamydia will that show on the screening test
just 24 hours later?>>Not necessarily. We think it’ll show relatively
quickly, and sometimes if you have enough
contact time and whatever– well it’ll show in two
different ways Atsuko. It’s possible that they’re
carrying their partner’s material still and it’s
not actually true infection in that case. Regardless, that individual has
just essentially described a higher risk situation for
acquisition and transmission of STIs and arguably what you
should do in that situation is that person deserves
screening anyway. That person deserves
screening even if it was only a
prevalent infection from previous to that day. So you can’t be sure. You get them when you can. We are a very convenience
oriented service, those of us who are in
adolescent medicine. So I would argue, go
right ahead and do it, but explain to the patient
that that may not be reflective of the day before, that
if they really want to capture the day before,
even if this test is negative, coming in approximately
a week to two weeks after the event is a
really good time to come in. And of course all STI’s are
not created equal right? So maybe chlamydia and gonorrhea
you can detect within one or two weeks with these
super sensitive NAAT tests, but what about HIV? What’s the window
period swallowed down to? What about syphilis
which is much lower risk, much lower prevalence except in
young men who have sex with men. And what about trichomonas? It would take a little
longer to develop symptoms, certainly within the week or so. Maybe hard to detect if
you’re not symptomatic. We don’t usually
screen for it still. Okay.>>[I’m] doing a [inaudible]
team rotation during residency and being told that for cases of
possible abuse that you wanted to get a culture
as a gold standard. Is that still true even
though these tests seem to be better than culture?>>Um hum. Um hum. Great question. There are actually
sections of the guidelines that address sexual assault and
the usage of all different types of laboratory tests, STD tests in particular for
sexual assault. That is based, here
what’s governing what we do as clinicians is at least
in part what is acceptable within a court of
law to be, huh, something that a case cannot
be challenged on, okay? So in many courts of law
they’re finally moving forward and what they’re doing in child
protection is they’re wanting to confirm that one positive with another positive
that’s a different test. So it’s simply a different
amplified portion of the genome to make doubly certain that whatever chlamydia
trachomatis they found was actually chlamydia trachomatis
of the sexual variance that are screened for in the
nucleic acid amplification tests and there wasn’t
cross reactivity to, god forbid, something
else, okay? For gonorrhea, the cross
reactivity dependent on the test can happen. So if you amplify it in
two different platforms, some courts of law
will now accept that. But it matters very much
what your local practice is and consulting with
[inaudible] over and Children’s and my colleagues like Bob
Sege and his team over at BMC, probably worthwhile to
see whether or not courts of law are starting to accept
it in Massachusetts, okay? Culture still remains
a gold standard because of the specificity
related to it. If you grow it out on a plate and you know darn sure
it’s neisseria gonorrhea, not neisseria meningitidis,
not neisseria sicca, lactimica or anything other, yeah. So that’s what you’re running
into here and I would talk to the colleague
specific in that area. But it’s definitely shifting. That’s the good news. It’s definitely shifting. There are, Carolyn
Black published a paper about the specificity in those
child sexual abuse settings. It’s a good recent paper,
only about two years old. Okay– [ Pause ] We’re going to move on to
what amounts to EPT right? So, not really a
question about EPT yet. I’m curious to know
you in the audience, before today what was the most
common method you would use to treat partners of
chlamydia infected patients? Would you encourage the
patient to bring their partners in with them when they
return for treatment? Would you, and you
can only pick one, sorry there’s no
way to pick both. Give the patient
extra medication to give to their partners? Give the patient a prescription
for their partners regardless of what you knew about
the legal landscape? Counsel the patient about the
need to self refer partners? Call the health department
because it’s their job. None of the above because
it’s definitely a health department job? [ Pause ] So let’s see what
the audience thinks. What had you been doing?>>There’s also the postcards.>>The postcards. Or going onto a website,
the website that’s like–>>[Inaudible]>>Yes.>> I think. It’s out by San Francisco. I should’ve put that up there. Ah well, okay. Well it looks like about half
of the population in here, about half of 20
people are saying that they usually counsel the
patient to, about the need to self refer their
partners for treatment. Great. At least you’re
doing that right? Because sometimes
we’re only human. I mean unless you’re an
automated robot you probably don’t do the exact same thing
every time you have a chlamydia patient in front of you. Hopefully the majority
of us the majority of the time are remembering that the index patient will get
reinfected unless we get their partners in for treatment
somehow. So regardless of how you
do it, this is great. Thinking about it is the key. It is the most common reported
STI in the United States and I think those
of us in the field of public health are perpetually
shocked by the volume of cases we’ve now
been discovering that are completely asymptomatic and we don’t actually
know the meaning of that. We don’t know how many of those
asymptomatic women are truly progressing on to PID if
we don’t capture okay? That is one of the great
unknowns surprisingly. But we’re still going to do it. In the absence of newer
evidence, we need to screen, and when we find it, we
need to treat as clinicians, not as public health people. That’s a different concept. The number of cases in
Massachusetts alone mushroomed, doubled in 10 years, and this
is definitely a testimony to more clinicians getting savvy
to testing and screening as well as better generation assays
that detect it better. And patients with chlamydia
infection are at increased risk for reinfection if their sex
partners are not also treated. So what is this idea of EPT,
expedited partner therapy? Well it makes sense
that for that patient, if you give them more
drug for their partners, or you give them a script
for drug for their partners or you tell them that they
go to a specific pharmacy for their partners as
happened in Washington State– they do it pharmacy
dispensed stuff– it’s going to be at least
as good for reinfection, decreasing your risk of
reinfection as usual care which could’ve been
telling the patient to tell their partners
about stuff. But CDC actually
sponsored a study on this and they proved it. It’s sort of like, you know,
hopping out of a plane, do you really need the parachute
to make sure that you survive? Well, yes. Nobody’s going to do a
study thankfully of that. CDC’s not sponsoring
a study on that, don’t go away with
thinking that. But they did sponsor
studies on EPT and the EPT trials
were really interesting because basically the
proportion reinfected– so the higher the bar is on this
graph, the worse you’re off, okay– was dropped, better, for expedited partner
therapy however you did it, best for gonorrhea. It wasn’t statistically
significant although it was point estimate-wise
different for chlamydia and for the combination it was
driven by gonococcal disease. So what have we done
in Massachusetts? We’ve done chlamydia disease. I’ll explain, don’t worry. But here’s this website that
I was talking about, okay? This is the Don’t worry about copying it. A you can get it, B
you can Google it. CDC EPT. It’s much
faster to get to it, okay? And this is a screen capture
of, it couldn’t be more than a week ago they just
updated this, and the date that they updated it is
at the bottom of the page. Most of the nation has gone
green and this is entirely because CDC pushed EPT out as
a legislative initiative state by state by state, okay? New England’s all green. Ah, but saying New
England’s green doesn’t mean that you can do the same
thing in Rhode Island that you should be
doing in Massachusetts or you should be doing
in New Hampshire. You have to read
the dizzying details and under each state they
summarize what happens with the details. And in Massachusetts we
elect to do chlamydia alone. Okay, EPT’s supported by
the CDC and permissible in at least 30 states. That was 37 at last count. Standard treatment for Chlamydia
infection is one oral dose of one gram, EPT shown to be
safe and effective and at least as good as usual care. Most states with long-standing
EPT programs also have had no reports of adverse events. California, been doing
this on the west coast for over five years, close to
a decade, no adverse events. They had a hotline,
hotline never got used. So here’s our clinical
advisory in Massachusetts that Connecticut just
borrowed by the way also, and we borrowed New York State’s because we were not the
first off the block here. And in August of 2011 we
put it on our DPH website, my own systems website. It’s not always that easy to
Google my own State Department of Health website, so if any of you have any trouble
finding this thing, here it is. It’s the clinical
provider notification. It went through a number of
clinical provider emails, listservs, but we’re not very
great about getting in touch with docs and nurses who
are actually prescribers. And connected to that very same
document is the partner patient information brochure
that should be going out. And this is what we’d like
to happen in Massachusetts and most states that have
implemented EPT have requested that the provider who does
it give a patient a very specific brochure. We didn’t say you had to
give the one that we have on DPH website by the way. You have to give it
or its equivalent. It’s in a Q & A format. It’s been vetted
six ways to Sunday for like a sixth
grade reading level and there’s definitely
encouragement to follow up with clinicians, not to bypass clinical care
completely, those partners. Because really that’s
still the gold standard. And no state in the nation
says oh you providers you have to do EPT. No no, it’s always couched as if your patient’s partners
are not likely to come in for care or your patient’s
getting repeatedly infected, EPT would be a consideration
and a recommendation from a Department
of Public Health. Voluntary, not required. That’s that point there. And in Massachusetts we
delineated three options we recommend, but we didn’t take
other things off the table. It could be up to the
clinician’s imagination. You can write a written
prescription or we have a pharmacy board of
regulation carve-out that says that if you write EPT in the
top line of a paper script, you don’t have to write
a name and you don’t have to write a date of birth. Every other script, every other
prescribed medication needs to have the two identifiers and
even sometimes address I think in the Board of Registration
in Pharmacy saying that the prescription
has to have it. EPT for chlamydia, carved out. If your electronic medical
record system doesn’t permit this, what very clever community
health centers have just started doing is creating
EPT the dummy patient which is really interesting. We’ll see if this works. We’re going to try to replicate
it in a couple of places and see if this actually works because
then the patient still has to give it to the partner
and the partner has to carry it to the pharmacy. And then at the pharmacy
they still need a name and somebody to pay for it. So somebody still has to admit to be non-anonymized
at that point. And there’s one other way
you could do the written prescription or direct
dispensation of the medication a few extra
doses for all the partners as long as it always trots
along with those brochures. I think there’s a safety factor when you make somebody
take a script saying EPT in the top line although
there are more barriers for the partner to get the drug, at least then the pharmacist
can also offer counseling. And the way pharmacies are
rolling out in Massachusetts is in theory that’s
yet another point where they can give this partner
delivered patient information or they can give this
information, this clinical, same frequently asked
questions thing. Okay any questions about that? Ah, maybe I should
answer the question about why just chlamydia. Do you want to know how this
thing passed in Massachusetts? It passed as a budget rider on
a budget that had to be passed. For six years it never got
out of conference committee and then finally Al DeMaria
the state epidemiologist works with Kevin Cranston who’s now
the Director of the Bureau of Infectious Diseases and
we work with the legislators and they basically tacked it
on to the August 2010 budget. It wasn’t totally
under the radar screen. Planned Parenthood
was fully pulling in grassroots support for this. A lot of legislators got
called on EPT for chlamydia. But somewhere between
the Senate and the House, it lost the language that Al and
I had written in there related to the fact that we wanted to make expedited partner
therapy really for more than just sexually
transmissible diseases, but for diseases
dangerous to public health, like neisseria meningitidis
or pertussis. I mean how many of you as pediatricians have ever
prescribed sight unseen tons of extra doses of Azithromycin
for a family of an index case that actually has pertussis? That in theory is
not explicitly legal within the state
that you did it in. It’s unlikely to be
explicitly legal. But we do it anyway. We do it in our patient’s
best interests. We do it in our family’s
best interests. So we have to be careful. You should be aware
of what you’re doing. But I’m just saying, we tried. If we can prove that it works
for chlamydia, that it’s safe for a few years, I
think we’ll be able to broaden the legislation
and then bring it down to the regulatory level because regulations are
easier to change than laws. Regulations can be
easier to change and we’ll change it
later on down the line.>>So [inaudible]–>>Yeah?>>that patient information
packet probably says something about if you have known
allergies to this medication or have any questions about
your allergies, call us or something like that?>>Absolutely. Do not take in very
big, bold faced letters. Absolutely. It’s definitely one of the
things that was framed, and again we can’t
take the credit for it. 37, 36 states went ahead of
us on this endeavor, okay? So we borrowed a lot from
a lot of other states. We learned a lot from other
states and how they implemented. Okay any other questions
about EPT? Okay I think we still have some
more time to talk a little bit about herpes, what do you think? All right, so let’s
switch gears. Case history, 18 year old
college student comes to you with the results of her
Herpes Select Focus ELISA. HSV-1 specific antibody
not detected. HSV-2 specific antibody, detected with an
index value of 2. The lab report states that
anything above 1.1 is positive. She has never had
any genital symptoms. She wants to know what to
tell her husband who as far as she knows does
not have herpes. He has been her only
lifetime sex partner. She has had no other
history of STD. What is the next question
you would want from her? What would you, what additional
information would be helpful? Would it be helpful to
know her race ethnicity? Which lab she had
the test done in? Whether she is telling
the truth about her number of previous partners,
or all of the above?>>Wait I’m confused about why
did she have that test done?>>Ah, it’s an inherited thing. She may have gone in
as a worried patient, asked for STD screening and in
whatever facility she was in, she was also offered
a herpes screening. Or she maybe heard about the
Scarlet Letter disease herpes and she got screened for herpes. But you’re absolutely right,
it’s not recommended to screen for herpes in an
asymptomatic individual because what then do you
do with that information? Great question. And that is exactly the point, but you have inherited
this case. So what would be the next
thing that you’re stuck with? What would you want
to know about her? Give me a sense. All right, let’s
see what a little under 20 people would’ve done. Yes, that would be nice. The truth of the situation. It’s always nice
to have the truth. If to be the window
or the fly on the wall in that patient’s bedroom. Well, maybe not. Okay, her race ethnicity’s
actually really important. We do not live, where
STI’s are concerned, it’s not a color blind world, at
least not to STI’s so I’ll get into that in a second. And here are the data to support
some of the concepts here. And several of you in the room
have seen me display this slide before but I’ll walk
you through it again because I think the
data are so valuable. It’s from Fuji Xu’s article
in JAMA that was published in 2006 based on Enhain’s
[assumed spelling] data Arguably a good population prevalence
sampling in the United States of America, National Health and
Nutrition Examination Survey. And what we’re doing is we’re
looking at lifetime number of sexual partners increasing
across the X axis here and on the Y axis is
the proportion of people with herpes 2 positivity
in the bloodstream. Seropositivity, okay? So for every set of
strata of lifetime number of sexual partners, what you
see is that men versus women, the men have less
seropositivity than the women, but for every strata
within the age groups, you see that non-white
patients have higher rates of seropositivity even at the
same number of reported levels of sexual partnerships
previous to that, speaking a lot to sexual networks, to sexual
partnerships, to dyads, to relationships, to
who you hang out with and who you have sex with I
think, and your risk therefore for acquisition and transmission
having nothing to do with actual individual behavior. Something to think about. All right, herpes prevalence in
terms of age group over time. Just a reminder, no matter which
years you look at with Enhain’s, in general, patient population
by the time in the United States of America you reach the ripe
old age of your fifties, you, the majority of the time
80% of you are going to be Herpes seropositive
for Herpes serotest 1. The one that we used to call the
above the belt herpes, Herpes 1. Okay? Not always above the belt
but usually above the belt, 60% of the time still. Herpes 2, it’s a quarter
of the American population by the time they reach their
third decade has become Herpes 2 positive and only a
tenth of those people, even less than a tenth of those
people ever show symptomotology from it. But they’re shedding
it and transmitting it and there are disease
outbreaks related to transmission from this. So there are arguments
back in the field. So what’s your advice? You’ve inherited this patient. You would never have
done sero testing anyway because you knew the guidelines
were not to do serotesting in an asymptomatic 18 year old, but you’ve just gotten
this result anyway. And so are you going to
interpret it for her? You’re stuck holding the bag. False positive? She has Herpes 2 and just never
had a symptomatic outbreak? She’s probably sero
converting having acquired it from her current partner? Or actually you’re not sure. You can vote you’re not sure. How are you going
to counsel her? It’s a tough case. All right, great. Let’s take a look. All right, many of
you are convinced at this point she has Herpes 2 and just never had a
symptomatic outbreak and some of you are thinking not sure. About a quarter of you are
thinking she’s seroconverting. Great thought given how
low the actual number was. I don’t remember if it
was 2 and the cutoff for positivity was 1 or 1.1. Okay, so let me go
back to this graph. Let’s say that we agree for the
sake of argument she’s white and she’s only had
one partnership. Her odds of carrying
Herpes 2 at the age of 18 are probably no
greater, as a woman, at the age of 18 probably
no greater than 10% and arguably considerably
lower given that she’s had only one sexual
partnership in her life. Okay? So when you calculate
the positive predictive value of this particular test, over half the time this
test is going to fail. It’s wrong. You have to actually do
the numbers and go back to the way we calculate
statistics for sensitivity, specificity given the prevalence of the population
serotest positivity. But over half the time
in this particular case with a white woman who has had
only one sexual partnership in theory it’s actually, odds
are it’s a false positive. Very interesting numbers. You have to run the
numbers to believe it. Yes?>>What if your strong suspicion
was that she’d had more than one sexual partner, she
wasn’t telling you the truth?>>Even then, until you reach
serotest prevalence on the order of greater than 5%, many times
tests don’t perform nearly as well as we as clinicians
want them to perform. You really have to run the
numbers given that test, and given a guess which we have. We have good guesses
with Enhain’s data. You could take the
population’s sero prevalence and give it a good guess
and calculate the true, positive predicted value
of that positive test. But is it arguably, you know
that classic two by two diagram? Test positive, test positive, disease positive,
disease negative? Which box is she falling in? That’s what you’re thinking
of here and we as clinicians, we want to believe
in these lab tests. We order them. We wouldn’t do them on our patients unless we
thought we had some belief, but it turns out that unless
you reach higher percentage prevalence, it’s
very likely that some of these tests are not very good for true positive
predicted value. And we’re talking about tests
that are actually very good. The HerpeSelect in particular, 90’s percent sensitivity
and specificity. Over 95%. And that’s what I’m
calculating positive predicted value off of. This type of sensitivity
and specificity. Over 95%. Still, run it on your
100,000 patients and you’ll see that over half the time for this
particular patient it’s actually the wrong answer. Okay, if your patient is
really wanting to know, there is one more thing. The western blot– similar to the western blot the
way the HIV tests are run, there is a Western
Blot assay now out that’s commercially
available– I shouldn’t say commercially. It’s Rhoda Ashley’s lab out in
the University of Washington and you can actually have
patients who can pay, pay for this Western Blot
for confirmation or denial of whether or not this single
test is actually the true test or the true answer. But I’m going to give
you one more hint, okay? Although the package insert
states that an index value of 1.1 should be
interpreted as positive, several experts use
a cutoff of 3.5. And the positive predicted
value is as low as 38% in college students with very
low HSV-2 seroprevalence. If the seroprevalence
was only about 3%, the positive predicted
value was 38% meaning, 62% of the time the
test was wrong. That’s seriously
food for thought. I think about it all the time
in relation to other tests that we do as well and how
much test ordering we do. So the issue here is really
Herpes serologies have a lot of limitation. They don’t tell you how long the
patient is infected, if they had or will have symptoms
ever in their lifetime, how likely a person is
to shed asymptomatically, and more recent studies
show that those people who are serotest
positive, serotest positive, never had an outbreak, never
had a genital outbreak. Clearly shedding. That’s the latest study
from over the summer that got published out
of those Herpes experts. Anna Wald is one of them,
Larry Corey’s another. They are clearly shedding even
if they’ve never had it before. That’s why there’s so much
transmission and that’s why 25% of the population is
likely positive indicating that they’ve mounted some
sort of immune defense. It’s merely a marker of exposure
not a marker of disease. False positives we’ve
talked about, and false negatives can
also occur with these tests because it takes so long
for antibodies to develop. Remember again, antibodies
take six weeks, sometimes maybe as short as four weeks to develop following a
primary infection with Herpes and this we always knew. So the testing issues are
legion, but what’s coming down the pike is something
even more confusing, the fact that there will
be a genital ulcer PCR. There is one, it’s just
that most of us don’t know where to find it right now. Becton Dickinson does
have a genital ulcer PCR– did I get that right? Yeah. Becton Dickinson’s
assay is amplifying for herpes DNA specifically as a
nucleic acid amplification test, but the test is now licensed–
the news came out this summer– for genital ulcer disease. Active genital ulcer disease,
not licensed for shedders, okay? Or asymptomatic individuals. Just a reminder, other
tests that might be useful and these are other tests
people think about IGM, IGM doesn’t really work
very well for Herpes. It turns out that people will
remount an IGM defense even if it’s upon reactivation
disease. So IGM doesn’t tell you
about recency of disease, the way we learned in medical
school or nursing school that IGM was usually the first
marker, only got mounted once in a disease lifetime. No no no, it’s much more
complicated than that. IGM can actually be mounted
upon reactivation of infection. So the IGM specific assays
are not specific first of all, nor should they be
used for this purpose. Okay, so when could you
use serology though? Patients presenting for an
STD evaluation especially if multiple partners, HIV
infected, and MSM at risk for HIV because HSV and HIV
tied associated transmission acquisition issues,
different issue, okay? But it’s not recommended
for routine, prenatal, or universal screening. And the arguments for HSV-2
serology screening though are that the experts in the field who are really pushing this idea
are that you could self identify and potentially cut
down on transmission. You could self identify,
cut down on transmission, and they may be motivated
to protect partners from what amounts to a lot
of asymptomatic disease much of the time but can be very
stigmatizing and harmful in those individuals who do actually have genital
ulcer disease from herpes. Okay and those are the arguments
against– unproven benefit, effect on sexual risk
behaviors not perfectly known, potential significant
costs, increased demand on the healthcare system,
unnecessary C-sections. If a woman is labeled
herpes positive, what does that mean the
next time that she goes to, the first time that she
ever goes to deliver? I want to highlight
one new treatment issue from the 2010 Treatment
Guidelines and that is the addition of Famciclovir 500
milligrams po times one, then 250 milligrams
bid for two days as a new regimen
for recurrent HSV. Nothing else changed in
the treatment for HSV. Does this arguably
affect any of us who do adolescent
and young adult care? Yes. If young adult,
Famciclovir is licensed for use in those 18 or older. 18 or older, okay? So it’s another short course on
the long list of short courses that you could use to
treat recurrent infection. And the short courses are so
short at this point that some of them are even only one
day’s worth of therapy. So I’m not sure why
you would choose to do this one particularly
given that recurrent therapy
Famciclovir, that’s that new one, or 1
gram PO BID for one day. You could use that. Acyclovir remains the
pedi one of choice. Valacyclovir is actually
licensed for use for genital Herpes in those
who are of pubertal age and up. Interesting FDA approval. And the first clinical episode
treatment, okay this is all in the STD Treatment Guidelines
which you can download easily, hasn’t changed at all. Tends to be a little
bit longer treatment or until clinical resolution. Seven to 10 days or until
clinical resolution. Don’t forget, this is
not new news in 2010 but in 2006 they
amplified the news about daily suppressive
herpes therapy for people who have recurrent
genital ulcers. Those, the few people
in the population who do have recurrent, consistently recurrent
infections, there are a number of safe regimens known up
to at least a year for use. And should discuss
the need annually to continue therapy
with patients. Now I’m just going to do one
last moment on herpes here and pause to laugh at the
CDC STD Treatment Guidelines which I did mention to you earlier also give
clinicians a whole host of counseling messages that they
might do with their patients in the 15 minutes that they
have with them in the office. Um hum. Okay so you are supposed
to discuss the natural history, the first episode, encourage
partner notification, abstain from sex when lesions
or prodrome are present, condoms reduce the
risk of transmission, transmission can occur when
asymptomatic and the risk of neonatal infection
which is new in the 2010 guidelines should
be discussed with men and women. And you should counsel pregnant
women not known to be infected with either HSV-1 or 2 to
avoid genital exposure. Asymptomatic persons, what do
you do with their diagnosis? This is what you can do. HSV-2, it goes on and on. And I got to tell you that I
had a long conversation with one of the great nurse practitioners
that I happen to work with, Alison Marshall, she works over at the South Boston
Community Health Center and set up their adolescent
practice I think over there with a whole bunch
of other people, and she pulled this
really great study. A study from 2004 showed
that patients were satisfied with their care if they had
at least 15 minutes face time with their practitioner
so you don’t need to spend hours counseling
them on every point that the CDC suggests
that you counsel on, but the key is probably bringing
them back for that follow up visit to clarify a
few key points and say to the patient, so
what did you hear? The day that I gave you
your herpes diagnosis, what did you really hear out of
the things I tried to tell you? What is your impression? What are your questions
now in follow-up? Because much of the initial
information we try to give them, we dose them up with, we inoculate them,
they’re not hearing. 48 hours after the visit, gone. And her suggestion, she came up
with this really nice pneumonic. The four 2’s just for the
initial visit– four t’s. Transmission. Treatment. Maybe mentioning it to
your partner, maybe not. And you as the clinician
really being a therapist with your patient to really
understand what does this disease mean for
this patient, okay? That could be different
for every patient. Okay. Yes? Go.>>Well what about
with adolescents where they might be kind of changing their sexual
partners maybe more often than other age groups? Do you offer the daily
suppressive therapy in hopes of kind of decreasing at
least transmission even if they’re not having
frequent genital outbreaks?>>No. The short
answer is probably no. I do do it based on the people who are having frequent
outbreaks. I maybe don’t personally wait
for six, I wait until I see them on a track because patients who
present one way tend to present that way over and over and
I will have a conversation with my patients about when
to start suppressive therapy if it’s the right
choice for them. It’s not mandated. But definitely it’s that
back and forth relationship with the patient that will
clue you in to whether to not it’s worthwhile. I basically at this point sit
atop the knowledge that a lot of herpes transmission happens, but that’s why we have
immune systems also. It’s not entirely the
clinician’s burden to stop every herpes
transmission event. Okay, I think in the
interest of time, is it 2:40? Are we going to have to stop? It is this 2:40. Okay, let me see what
possible messages, I think we can skip
the trich one. I think most of you know
what to do with that. The only comment I would’ve
had was just the fact that if you think you
have treatment failure, 3 to 5% of the time trich can
be resistant to Metronidazole and there’s a phone number in
the STD Treatment Guidelines that you can call
down in Georgia. They will send you media. They want your protozoan
parasites, okay? They want to study those
protozoan parasites. So if you think you have a
resistant trich, goodness, call the DPH or call the
number in the Atlanta number and you’ll get the
parasite lab at the CDC. It’s not the STD lab– eventually you’ll
get a hold of them. You’ll get some media
and you’ll be able to send it down for testing. In the meantime, the treatment
guidelines do tell you about how to handle your patient with,
that may have been resistant to that 2 grams of trichomonas or may have just
had reacquisition or reinfection, okay? Either way, what’s
your next step? Do you treat with twice
a day Metronidazole? That’s what I just
did with a patient. That’s one of the options. Do you move to Tindamax, Tinidazole which
is quite expensive? Hard to get, prior
approval required. Could justify it. You have options. They’re all listed in the
STD Treatment Guidelines. So let me leave you
on that note. Some resources that
you can have here. There are STD resources at the
Department of Public Health. All Departments of
Public Health. There are treatment guidelines. That having been said, I
still want to drive all of you in this room more
and more to the web because the web is
the living document. So as gonorrhea resistance
raises higher on our screen, as changes come, the CDC
is staying quite accurate on updating the website even
if they’re not very good at publishing MMWR’s
very rapidly. They are very good at updating
treatment recommendations right on that website, and the
website is actually very easy to navigate for treatment
guidelines related to STDs. And the last resource
is my own organization. We are one of those eight
clinically funded organizations to do the National Network of
Prevention Training Centers to keep clinicians up to date. So if you have colleagues
in other parts of the nation that haven’t heard about us
yet, come to one of our courses. You’ll be sold, I swear to you. You’ll be sold. And they’re all around the
nation and they’re also in web form, so go to our
website too for much more than you would ever want to know
about HPV, syphilis, chlamydia, herpes, HIV, gonorrhea. I’ll stick around for questions. [Applause] Thanks so
much for your attention.

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