Upgrade in Sexually Transmitted Diseases, 2011

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Redesign in Sexually Transmitted Maladies, 2011. William Wong, MD Chicago Bureau of General Wellbeing City of Chicago. Staff Divulgence. Business, Monetary, or Authoritative Clashes of Interest: None Off-mark or FDA non-endorsed utilization of medications: None .

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Refresh in Sexually Transmitted Diseases, 2011 William Wong, MD Chicago Department of Public Health City of Chicago

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Faculty Disclosure Commercial, Financial, or Organizational Conflicts of Interest: None Off-mark or FDA non-endorsed utilization of medications: None

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Learning Objectives 1. Depict the effect of HIV and STIs in Chicago and the United States. 2. Talk about patterns in antimicrobial resistance in gonorrhea and different STDs 3. Recognize suggested treatment regimens for uncomplicated gonococcal diseases of the cervix, urethra, and rectum Describe flow HIV and STI screening proposals for youths and grown-ups.

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Local Trends in Sexually Transmitted Infections Reported Gonorrhea and Chlamydia – Chicago, 2002-2009 Number of Reported Cases Number of Reported Cases

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P&S Syphilis, by Sex and Sexual Behavior - Chicago, 1998-2006 n=295 n=418 n=297 n=267 n=353 n=317 n=292 n=282 n=338

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Local Trends in HIV/AIDS

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2010 Sexually Transmitted Diseases Treatment Guidelines William Wong, MD Chicago Department of Public Health City of Chicago

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Overview of Complications of Sexually Transmitted Diseases >19 million STDs in the United States every year, most asymptomatic Infertility Ectopic Pregnancy Chronic Pelvic Pain Upper Tract Infection Systemic Infection Low Fetal Birthweight Congenital Infection STDs Cervical and Anogenital Cancer HIV Transmission Health mind cost: $16.4 billion (2009) * Potentially Fatal

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Populations at Greatest Risk for STDs Youth Nearly half of STDs happen in 15-25 year old Racial and ethnic minorities STDs among most noteworthy of all racial/ethnic incongruities African Americans: 71% GC, 48% CT, 52% syphilis Over most recent 5 years, syphilis cases expanded over 150% among African American Men who have intercourse with Men (MSM) Account for 62% of syphilis cases in 2009 High rates of co-contamination with HIV

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STD Prevention: Clinician's Role Pre-introduction inoculation Provide/allude for hazard decrease directing Assess hazard and test appropriately Diagnosing and treating Referring accomplices Reporting STD/HIV cases as per state and neighborhood laws Keep STD/HIV reports classified

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December 17, 2010 Sexually Transmitted Diseases Treatment Guidelines, 2010 Division of STD Prevention National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Website: www.cdc.gov/sexually transmitted disease/treatment/2010 or call 1-800-CDC-INFO

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2010 STD Treatment Guidelines Methods Evidence-based orderly audit Enlistment of Subject Matter Experts Consultants meeting to assess and rate confirm Guidelines meeting in April 2009 Identify basic research crevices in learning 2010 Guidelines distributed and dispersed

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Clinical Prevention Guidance Five noteworthy procedures Education and advising of people at-hazard towards conduct change Identification of asymptomatically tainted people, people far-fetched to look for administrations Effective finding and treatment of contaminated people Evaluation, treatment, advising of sex accomplices of tainted people Pre-presentation immunization of people at-hazard

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Screening with NAATs Screen for STDS at anatomic destinations NAATs perform superior to culture (rectum and pharynx) Commercial labs have approved NAATS Most contaminations asymptomatic Preferred examples Self-gathered vaginal swabs in females Urine example in guys

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Special Populations: Men who engage in sexual relations with Men Recommended Annual Screening Tests HIV serology , if pessimistic or not tried in a year ago Syphilis serology Chlamydia and Gonorrhea : urethral, rectal, pharyngeal tests depending of webpage of introduction More successive screening (i.e.3-6 month interims) for MSM with different or unknown accomplices, unlawful medication utilize, methamphetamines, or accomplices with high-chance practices HBsAg testing to recognize momentum disease Hepatitis A & B immunizations, in nonimmune Hepatitis C (HCV ) screening HCV serology at beginning visit HCV RNA with unexplained alanine aminotransferase (ALT) rise Routine HCV testing with high-chance sexual conduct or ulcerative STDs

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Clinical Prevention Guidance High-power behavioral directing for all sexually dynamic teenagers and grown-ups at expanded danger of disease (USPSTF) The Five P's: Partners, Prevention of Pregnancy, Protection from STDs, and Past History of STDs Pre-introduction immunization Hepatitis An infection (HAV), hepatitis B infection (HBV), human papillomavirus (HPV) (bivalent/quadrivalent) Condoms Female nitrile condoms Microbicides www.microbicide.org Pre-presentation prophylaxis for HIV/STD Male circumcision Reduced procurement of HPV/genital HSV

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Urethritis Bacterial STDs: GC (5-20%), CT (15-40%) Nongonococcal urethritis (NGU) Mycoplasma genitalium 5-25% Ureaplasa 0-20%; information conflicting, biovars fluctuate Trichomonas vaginalis 5-20% (age, topography) HSV 15-30%; urethritis in essential disease Adenovirus, enteric life forms, Candida, anaerobes

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Mycoplasma genitalium (MG) Associated with intense or steady NGU No part in male barrenness Conflicting/deficient confirmation in commitments to cervicitis, PID, fruitlessness, ectopic pregnancy, unfriendly birth results Azithromycin better than doxycycline for MG urethritis Moxifloxicin for relentless NGU

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NGU Treatment Current medication regimens satisfactory: Azithromycin 1 gm or Doxycycline 100 mg BID x 7 days Cost contemplations and absence of general wellbeing sway information for MG lacking to downgrade doxycycline to option operator Recurrence Reexposure from untreated accomplices T. vaginalis, M. genitalium, U. ureaplasma may represent a few disappointments

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Cervicitis CT/GC NAATs on vaginal, cervical, pee prescribed No new antimicrobial treatment trials Research required on the etiology of constant cervicitis including the potential part of Mycoplasma genitalium

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Chlamydia Primary concentration of screening endeavors to distinguish and anticipate difficulties in ladies Annual screening of all sexually dynamic ladies matured ≤25 years is suggested Selective male screening (pre-adult facilities, redresses, national employment preparing program, <30 yo, STD centers, military) Retest ladies/men 3 mo post-treatment CT testing in third trimester (reinfection)

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Gonorrhea Screen sexually dynamic ladies at expanded hazard (USPSTF) <25 years Previous GC or different STDs Commercial sex work No screening in men or ladies at okay of contamination (USPSTF) Retest ladies/men 3 months after treatment New or numerous accomplices Inconsistent condom utilize Drug utilize

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Advent of Antimicrobial Resistance in N. gonorrhoeae in the United States 1936 Sulfanilamide presented 1940's Penicillin and Tetracycline presented 1945 1/3 of GC sulfanilamide-safe; penicillin (50,000 units) gets to be treatment of decision 1972 Recommended helpful penicillin measurement achieves 4.8 million units 1985 Widespread antibiotic medication resistance, so antibiotic medication relinquished 1987 Penicillin surrendered 1993 Fluoroquinolones (FQ) suggested 2000 Fluoroquinolone-safe GC (QRNG) recognized; FQ not prescribed to treat GC obtained in Hawaii, Pacific Islands, or Asia 2002 FQs not prescribed for GC in MSM in U.S. 2007 QRNG across the board all through U.S.; FQs no longer prescribed for GC treatment Credit: Adapted from S. Wang, CDC

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Gonorrhea Treatment Efficacy Oropharyngeal Ceftriaxone 125 mg = 94.1% 250 mg = 98.9% Oral cephalosporins have constrained use because of poor tissue infiltration Azithromycin 2 gm = 95% Anogenital Ceftriaxone 125 mg = 98.9% 250 mg = 99.2% Geographic conveyance in vitro diminished vulnerability, ceftriaxone disappointments, upgraded pharyngeal viability, steady direction at all anatomic destinations

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Neisseria gonorrhoeae Cervix, Urethra, Rectum Recommended Ceftriaxone 250 mg IM single measurement (favored) PLUS Azithromycin 1 gm or Doxycycline 100 mg BID x 7 days OR, IF NOT AN OPTION Cefixime 400 mg single dosage PLUS Azithromycin 1 gm or Doxycycline 100 mg BID x 7 days

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Neisseria gonorrhoeae Cervix, Urethra, Rectum Alternate Regimens Cefpodoxime 400 mg orally in single dosage or Cefuroxime axetil 1 gm orally in single measurements or Azithromycin 2 g (penicillin hypersensitivity)

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Neisseria gonorrhoeae Pharynx Recommended Ceftriaxone 250 mg IM in a solitary measurements PLUS Azithromycin 1 gm or Doxycycline 100 mg BID x 7 days Alternatives Azithromycin 2 gm (penicillin sensitivity)

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Cephalosporin GC Treatment Failures Suspected treatment disappointment (oral and injectable) Treatment disappointment or in vitro resistance Infectious malady interview Culture and weakness Treat with Ceftriaxone 250 mg IM x 1 dosage Ensure accomplice treatment Report to CDC through state or neighborhood general wellbeing

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Genital, Perianal, Anal Ulcers History/physical examination frequently wrong Majority because of HSV or syphilis Chancroid is less regular Consider non-irresistible eitology (yeast, aphthi, settled medication emission, psoriasis) Serological test for syphilis required Diagnostic assessment for HSV (culture, PCR) Treat for analysis no doubt in view of clinical and epidemiological information If syphilis is suspected, regard observationally as beginning tests might be negative in essential syphilis Biopsy if dubious

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Syphilis Definitive finding for early syphilis Darkfield microscopy, PCR No monetarily accessible Treponema pallidum location tests Nontreponemal/treponemal serological testing (e.g. RPR and FTA) Reverse serologic screening developing (Syph EIA and RPR) Management standards for HIV+ comparative Frequent clinical/serological observing Neurosyphilis can happen at any stage

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Evaluation of CNS Involvement Neurologic, visual, sound-related signs/manifestations = assess with lumbar