STI - Obstetric Rounds

Transcript

1. Sexually Transmitted Infections Obstetric Grand Rounds Brady Bouchard (FMR1) January 17, 2014
2. Don't have sex, because you will get pregnant and die. “ ” — Mean Girls
4. The Bugs Prevalence Trend Demographic Chlamydia Most common: 65,000 cases in 2006 ↑ Women (15-24) Men (20-29) Gonorrhea Common: 10,808 cases ↑↑ (94% inc. 1997-2004) Men (⅔rds). MSM, Young men/ women HPV Very common (70% of adults) Not reportable Young men/women (F=M) Genital Herpes Very common (~20% of adults) ↑ (20% inc. 2000-2004) Young men/women (F>M) Hepatitis B Varies (low- moderate) = MSP, IVDU, vertical transmission
5. The Bugs Prevalence Trend Demographic Syphilis Previously rare: 1,493 cases ↑↑ (Dramatic regional outbreaks) MSM, Sex workers, Endemic regions Chancroid Rare = Endemic regions Lymphogranuloma venereum Rare Recent outbreaks MSM, Endemic regions HIV Rare (2,529 cases reported 2004) ↑ (20% inc. 2000-2004) MSM, IVDU, Women (15-19) Granuloma inguinale (Donovanosis) Very rare (100 cases per year/US) = Endemic regions
6. Rate (per 100,000 population) of positive HIV test reports (all ages) by province/territory – Canada: 2012
7. Risk Factors • Young (15-24) • Unmarried • Consideration of local prevalence • New partner(s) in last 60 days • Multiple partners (>2 in last year) • History of prior STI / partner with known STI • IVDU • Time in prison / youth detention • Contact with sex workers • Homelessness • Sexual assault victims
8. Brief Screening Ideally for all non-sexual health-related visits:! ! • Are you sexually active? • Do you have symptoms that may make you think you have an STI? • What are you doing to avoid pregnancy? • What are you doing to avoid STIs? • Concerns of sexual or relationship violence? • Are you or your partner IVDU?
9. Targeted History Non-judgemental, simple/understandable language, and a reminder of confidentiality.! ! • Personal risk assessment: new partner, MSP, condom use, Hep A/B vacc., types of sexual exposures, IVDU, abuse/violence • Genital symptoms: discharge, dysuria, abdominal pain, testicular pain, rashes, lesions → inc. risk of HIV • Systemic symptoms: fever, weight loss, lymphadenopathy • Patient knowledge: understanding of STIs, risks, risk mitigation • Last pap / menstrual period: opportunistic screening!
10. Targeted History STI Risk Assessment Questionnaire:! http://bit.ly/1lOFb5E
11. Physical Exam • Systemic signs of STI: weight loss, fever, inguinal lymphadenopathy • Inspect mucocutaneous regions and orifices! • Male: Palpate scrotum, epididymis • Female: External vaginal exam, speculum exam, obtain samples if indicated
12. Screening Guidelines Targeted testing based on:! At risk population Local prevalence Specific patient request ! “The Usual”: Chlamydia, Gonorrhea, Syphilis & HIV! ! for all sexually active patients under 25! as well as! those at risk
13. Screening Guidelines Beware the “already tested” syndrome:! • false sense of security from multiple negative results • laissez-faire attitude to barrier protection once “cleared” of STIs
14. Testing • Urine NAAT preferred (most sens/spec) for Chlamydia and Gonorrhea! • Test of cure not usually required (high treatment success rates) • CSF/vesicle fluid/ulcer swab NAAT preferred for HSV (~100% sens/spec), but not widely available • Serological Treponemal ELISA preferred for Syphilis, highly sensitive but not specific. If positive test result, lab will confirm with Treponemal-specific test (TP-PA, MHA-TP, FTA- ABS)
15. Testing • HIV testing is done by serological ELISA. May test positive 3 weeks after infection, but may take up to 6 months (repeat HIV testing in high-risk patients)
 NAAT/PCR is used in infants born to HIV- infected mothers. • HPV testing can be done on liquid cytology Pap smear samples (not yet in Sask.). HPV testing not widely available in Canada • Hep B testing is done by serological ELISA.
17. Treatment • Treatment for bacterial STIs is free across Canada! • Orange book reference for treatment regimens, and/or Canadian Guidelines on STIs • Ideal treatment regimens:
 Single dose, oral
18. Treating Common STIs • Chlamydia:! • Doxycycline 100mg PO BID for 7 days, or
 Azithromycin 1g PO single dose, or in pregnancy,
 Amoxicillin 500 mg PO TID for 7 days! • Retest in 6 months (high rate of recurrence)! • Gonorrhea:! • Cefixime 800mg PO single dose, and
 Azithromycin 1g PO single dose
 (includes empiric therapy for Chlamydia)
19. Treating Common STIs • Trichomoniasis:! • Metronidazole 2g PO single dose
 (also works for BV)
20. Treating Common STIs • HSV:! • First episode:
 Valacyclovir 1000mg PO BID for 10 days
 Recurrent lesions:
 Valacyclovir 500mg PO BID for 3 days
 Suppressive (episodes 6 times / year):
 Valacyclovir 500mg PO daily
 (example only, other antivirals work too.)
21. WHO Guidelines for the management of sexually transmitted infections:! Vaginal Discharge
23. Reporting Requirements • Reportable (Notifiable) Diseases must be reported to local Public Health Officer • Can be by the lab (done automatically for positive test results), or yourself as the physician! • Partner notification is also strongly encouraged: typically either by the infected patient or (with permission) by the physician (without naming the index case!)! • If the infected patient is not amenable to partner notification, explore reasons and/or report to public health.
24. Notifiable Diseases • Chlamydia • Gonorrhea • Genital Herpes • Hepatitis B • Syphilis • Chancroid • Lymphogranuloma venereum (LGV) • HIV • Granuloma inguinale
25. Counselling • Safe sex and STI prevention counselling should accompany all sexual health visits, with a stronger emphasis in particular populations: • Adolescents initiating sexual activities for the first time (preferably beforehand) • At-risk populations (sex workers, etc.)
26. Prevention • Abstinence • Delaying sexual activity until entering a long term monogamous relationship • Barrier methods (male/female condom) • Regular STI screening
27. Referring Onward Saskatchewan Sexual Health Clinics available in North Battleford, Meadow Lake, Prince Albert, Saskatoon and Regina.
28. References Canadian Guidelines on Sexually Transmitted Infections: http://www.phac- aspc.gc.ca/std-mts/sti-its/ ! Saskatchewan Communicable Disease Control Manual: http:// www.health.gov.sk.ca/cdc-section5 ! Saskatchewan Sexual Health - STI Information: http://www.health.gov.sk.ca/ sti-information ! At a Glance - HIV and AIDS in Canada: Surveillance Report to December 31st, 2012: http://www.phac-aspc.gc.ca/aids-sida/publication/survreport/ 2012/dec/index-eng.php ! HIV InSite UCSF: http://hivinsite.ucsf.edu/insite?page=basics-01-01 ! WHO Guidelines for the management of sexually transmitted infections: http://www.who.int/hiv/pub/sti/pub6/en/
29. Questions How do you clinically differentiate Trich from BV?! • In Trich, vaginal pH is usually >4.5, and whiff test / KOH test is negative. Causative agents of urethritis:! • N. gonorrhoaeae, C. trachomatis, Trichomonas vaginalis, HSV, Mycoplasma genitalium, Ureaplasma urealyticum
30. Questions Three infections commonly associated with vaginal discharge in adult women:! • Bacterial vaginosis, Candidiasis, Trichomoniasis Strawberry cervix is characteristic of:! • Trichomoniasis These STIs can increase the susceptibility and/ or transmissibility of HIV:! • Chlamydia, Gonorrhea, Trichmoniasis, HSV, Syphilis, Chancroid
31. Strawberry Cervix