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STI Update: Best Practices for
Protecting Women's Reproductive
Health
October 27, 2011
STI Update:
Best Practices for Protecting
Women’s Reproductive Health
Heidi M. Bauer, MD MPH
STD Control Branch, California Department of Public Health
California STD/HIV Prevention Training Center
October 27, 2011
Family PACT Webcast
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STI Update: Best Practices for
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October 27, 2011
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STI Update:
Best Practices for Protecting
Women’s Reproductive Health
Heidi M. Bauer, MD MPH
STD Control Branch, California Department of Public Health
California STD/HIV Prevention Training Center
October 27, 2011
Family PACT Webcast
6
2
STI Update: Best Practices for
Protecting Women's Reproductive
Health
October 27, 2011
Overview






Prevention and Screening
Chlamydia & Gonorrhea
Cervicitis, Urethritis & Pelvic Inflammatory
Disease
Vaginitis: Trichomoniasis & Bacterial Vaginosis
Viral STIs: Genital Warts & Herpes
Syphilis
7
Risk Assessment: Women


NEW question 
◦ "Is it possible that any of your sex partners in
the past 12 months had sex with someone
else while they were still in a sexual
relationship with you?"
Douching may increase risk of BV, some STIs,
and HIV
CDC 2010 STD Treatment Guidelines
www.cdc.gov/std/treatment
8
STD Screening for Women
Sexually Active adolescents & up to age 25
Routine chlamydia and gonorrhea screening
Others STIs and HIV based on risk
Women over 25 years of age
STI/HIV testing based on risk
Pregnant women
Chlamydia
Gonorrhea (<25 years of age or risk)
HIV
Syphilis serology
HepB sAg*
Hep C (if high risk)*
*Not a Family PACT benefit
CDC 2010 STD Tx Guidelines www.cdc.gov/std/treatment
9
3
STI Update: Best Practices for
Protecting Women's Reproductive
Health
October 27, 2011
Estimated Chlamydia Screening Coverage (HEDIS),
Females 16–25, U.S.A. and California, 1999–2009
California
National
Source:
National Committee on Quality Assurance; California DHCS Division of Medi-Cal Managed Care;
Kaiser Permanente Northern CA; California DPH Office of Family Planning; CDPH STD Control Branch
10
Rev. 4/2009
10
Pregnancy Test Only (PTO) and Emergency
Contraception (EC) visits are Missed
Opportunities for CT/GC Screening
Among FP clients ≤25 who
were not tested for CT:
37% other
visit types
63% PTO or
EC visits
*Only half of PTO clients were
screened.
Howard H et al. “Over 20 Study”, 9 clinics from 3 agencies, 2003-2005.
Region IX IPP meeting, January 2010
11
Percent CT +
Chlamydia Rates for Females <26
Screening vs. PTO Clients
20
18
16
14
12
10
8
6
4
2
0
Exam
PTO
15%
12%
9%
7%
8%
4%
IPP FP
CA FP
NC FP
Infertility Prevention Project Title X clinics (CA, AZ, NE, PA, SC, VA), 1997-2005
Howard H et al. “Over 20 Study”, 9 clinics from 3 agencies, 2003-2005. N=4288
Geisler WM et al. Am J Ob Gyn. 2008:198:502. GC: 3%+ in women 16-25. N=1465
Chlamydia Screening Project Personal communication, A. Costello, Southern Nevada Health District ,
Title X Family Planning Program, Las Vegas NV, 2006
12
4
STI Update: Best Practices for
Protecting Women's Reproductive
Health
October 27, 2011
Reducing missed opportunities for
CT/GC screening:
Staff training on guidelines
Check lists and chart prompts
Standing orders for EC & PTO visits
Waiting room posters
Trigger question on intake, history,
& exam forms for all visit types
Express visits for STI testing
Signs on restroom doors
13
Chlamydia
14
Chlamydia, Gonorrhea, and Primary & Secondary Syphilis
California Rates, 1990–2010
Chlamydia
Rate per 100,000 population
400
400.0
(N=155,300)
300
200
Gonorrhea
100
P&S Syphilis
0
1990 '91
STD Control Branch
'92
'93
'94
'95
'96
'97
'98
'99 2000 '01
'02
'03
'04
'05
'06
'07
'08
69.1
(N=26,840)
5.3
(N=2,059)
'09 2010
Year
Rev. 7/2011
15
5
STI Update: Best Practices for
Protecting Women's Reproductive
Health
October 27, 2011
Chlamydia, Rates by Gender, California,
1990–2010
600
Rate per 100,000 population
500
Female
400
300
200
Male
100
0
1990 '91
'92
'93
'94
'95
'96
'97
'98
'99 2000 '01
'02
'03
'04
'05
'06
'07
'08
'09 2010
Year
STD Control Branch
Rev. 7/2011
16
Chlamydia, Rates by Gender and Age Group (in years)
California, 2010
Male
Rate per 100,000
3,000
2,000
1,000
Female
0
0
1,000
2,000
3,000
10-14
15-19
20-24
25-29
30-34
35-44
45+
Total
STD Control Branch
Note:
Age was “Not Specified” for 0.3% of female cases and 0.3% of male cases for the given year.
Since this disease is often asymptomatic, reported cases may reflect chlamydial infections
identified through screening programs offered primarily to women.
Rev. 7/2011
17
Chlamydia among Females Ages 15-24, Rates by
County, California, 2010
STD Control Branch
Rev. 7/2011
18
6
STI Update: Best Practices for
Protecting Women's Reproductive
Health
October 27, 2011
Chlamydia Prevalence Monitoring, Percent Positive for Females by
Age Group (in years) and Health Care Setting, California, 2010
25
23.7
15–19
20–24
25+
Percent Positive
20
15
10
8.3
6
5
4.5
3.8
STD Control Branch
Managed
Care
Organization
(2009 data)
8.1
6
5.6
1.9
0
13.7
13.2
6.5
5.4
5.3
4.6
2.3
Family
Planning
Clinics
College Sites
Teen Clinics School-Based
Sites*
Juvenile
Detention*
STD Clinics
* These two venues target adolescents primarily.
Source: California Department of Public Health, STD Control Branch; Los Angeles Infertility Prevention
Project; and San Francisco Infertility Prevention Project
Rev. 7/2011
19
Chlamydia Treatment
Adolescents and Adults
Recommended regimens (non-pregnant):
 Azithromycin 1 g orally in a single dose
 Doxycycline 100 mg orally twice daily for 7 days
Recommended regimens (pregnant*):
Azithromycin 1 g orally in a single dose
Amoxicillin 500 mg orally TID x 7 days
* Test of cure at 3-4 weeks only in pregnancy
CDC 2010 STD Treatment Guidelines
www.cdc.gov/std/treatment
20
Gonorrhea
21
7
STI Update: Best Practices for
Protecting Women's Reproductive
Health
October 27, 2011
Gonorrhea, Rates by Gender, California, 1990–2010
Rate per 100,000 population
250
200
150
Male
100
Female
50
0
1990 '91
'92
'93
'94
'95
'96
'97
'98
'99 2000 '01
'02
'03
'04
'05
'06
'07
'08
'09 2010
Year
STD Control Branch
Rev. 7/2011
22
Gonorrhea, Rates by Gender and Age
Group (in years), California, 2010
Male
300
Rate per 100,000
200
100
Female
0
0
100
200
300
10-14
15-19
20-24
25-29
30-34
35-44
45+
Total
STD Control Branch
Note:
Gender “Not Specified” accounted for less than 0.5% of all cases.
Rev. 7/2011
23
Gonorrhea, Rates by County, California, 2010
STD Control Branch
Rev. 7/2011
24
8
STI Update: Best Practices for
Protecting Women's Reproductive
Health
October 27, 2011
Gonorrhea, Female Rates by Race/Ethnicity and
Age Group (in years), California, 2010
26 times white rate
Rate per 100,000
1,500
1,200
STD Control Branch
900
600
Black
300
0
Hispanic
White
10 - 14
15 - 19
20 - 24
25 - 29 30 - 34
Age Group
35 - 44
45+
Rev. 7/2011
25
Neisseria Gonorrhoeae Isolates with Alert Values or
Decreased Susceptibility, CA GISP Data, 1990-2011*
12%
10%
Azithromycin
Cefpodoxime
Cefixime & Cefpodoxime
8%
Cefixime
Percent of Isolates
Ceftriaxone
6%
4%
2%
0%
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Year
* 2011 data for January-June only
Note: Cefpodoxime and cefixime alerts have MICs ≥ 0.25 µg/mL. Ceftriaxone alerts have MICs ≥ 0.125/mL.
Azithromycin alerts have MICs ≥ 2.0/mL.
STD Control Branch
STD Clinic Sites: Orange, San Diego, San Francisco, Long Beach (ended participation in 2007), Los
Angeles (added in 2003)
26
3 Changes to Gonorrhea Treatment
in 2010
1. Ceftriaxone IM preferred over oral
cephalosporins
2. Ceftriaxone dose increased to 250 mg
3. Dual treatment for chlamydia regardless of
test result
CDC 2010 STD Treatment Guidelines
www.cdc.gov/std/treatment
27
9
STI Update: Best Practices for
Protecting Women's Reproductive
Health
October 27, 2011
Gonorrhea Treatment
Uncomplicated Genital/Rectal Infections
Ceftriaxone 250 mg IM
in a single dose
PLUS*
OR, if not an option:
Cefixime 400 mg orally
in a single dose
Azithromycin
1 g orally
or
Doxycycline
100 mg BID x
7 days
* Regardless of CT test result
CDC 2010 STD Treatment Guidelines
www.cdc.gov/std/treatment
28
Gonorrhea Treatment Alternatives
Anogenital Infections
ALTERNATIVE CEPHALOSPORINS:
 Single dose IM cephalosporin regimens or
 Cefpodoxime 400 mg orally once or
 Cefuroxime axetil 1 g orally once*

PLUS
Dual treatment with azithromycin 1 g or doxycycline
100 mg BID x 7 days, regardless of CT test result
IN CASE OF ALLERGY:
 Azithromycin 2 g orally once
(Caution: GI intolerance, emerging resistance)
*Not a Family PACT benefit
29
Gonorrhea Treatment
Oropharyngeal Infections
Ceftriaxone 250 mg
IM in a single dose
IN CASE OF ALLERGY:
 Azithromycin 2 g orally once
PLUS
Azithromycin
1 g orally
or
Doxycycline
100 mg BID x
7 days
CDC 2010 STD Treatment Guidelines
www.cdc.gov/std/treatment
30
10
STI Update: Best Practices for
Protecting Women's Reproductive
Health
October 27, 2011
Treatment Efficacy for Pharyngeal
Gonorrhea
DRUG AND DOSE
Cefriaxone 125 mg IM
EFFICACY
94%
LIMITS / Ns
L95%CI = 85.6%
Ceftriaxone 250 mg IM
99%
L95%CI = 94.0%
Cefpodoxime 400 mg PO
70%,
26/37 patients
Cefixime 400 mg PO
89%,
8/9 patients
Cefixime + azithro 1 g PO
100%,
36/36 patients
Azithromycin 2 g PO
95%,
L95%CI = 76.2%
20/21 patients
L. Newman, CDC STD Treatment Consultation Meeting 04/09
31
What to do if you suspect a cephalosporinrelated treatment failure:
CULTURE: If GC culture not available on-site, call CA STD Control
Branch for resources 510 620 3400
REPEAT TREATMENT: Ceftriaxone 500 mg IM PLUS
Azithromycin 2 g orally in a single dose
REPORT: To your local health department within 24 hours; call
STD Control Branch if consult desired
TREAT PARTNERS: All partners in last 60 days should be
treated with CTX 500 mg + AZ 2g
TEST OF CURE (TOC): Patient returns in 1 week for TOC with
culture (if culture not avail, with NAAT)
*if reinfection suspected, repeat tx with CTX 250 + AZ 1g
See www.std.ca.gov for most current information
32
Preventing Repeat Infection:
CT/GC Partner Treatment and
Client Retesting
33
11
STI Update: Best Practices for
Protecting Women's Reproductive
Health
October 27, 2011
Created by:
California Department of Public Health
(CDPH) Sexually Transmitted Disease
(STD) Control Branch, San Francisco
Department of Public Health STD
34
CT/GC Partner Management Options:
Patient referral
• Ask patient to notify partner and ensure treatment
• Suggest patient bring partner to clinic for
concurrent treatment (“BYOP”)
• Internet-based anonymous notification
Expedited partner treatment (EPT)
• Patient-delivered partner treatment (PDPT)*
• Health department field-delivered treatment
• Pharmacy-based
Provider or clinic-based referral
Health department referral
*PDPT covered only if the partner is an enrolled Family PACT client
35
The Effectiveness of Expedited Partner
Treatment on Re-Infection Rates
20%
GONORRHEA
CHLAMYDIA
P=.02
P=.17
15%
10%
5%
0%
13%
11%
11%
3%
Usual Care
EPT
Usual Care
EPT
Golden M, et al. N Engl J Med 2005 Feb 17;352(7):676-85.
36
12
STI Update: Best Practices for
Protecting Women's Reproductive
Health
October 27, 2011
CT Partner Management Strategies
Used in California FP Clinics
Bring Your Own
Partner “BYOP”
Patient-Delivered
Partner Treatment
(PDPT)
Patient Referral
14%
20%
54%
12%
None/Unknown
Yu Y-Y, et al. STD. Oct 2011.
37
Percent of Partners Treated by Management
Strategy, California FP Clinics, 2005-2006
Yu Y-Y, et al. STD. Oct 2011.
38
CT/GC Partner Management Strategies
Gaps:
▪
Not eliciting all partners
▪
Patient referral
What works:
 Individualized partner treatment
options
 Asking client to being partner to clinic
(“BYOP”)
 Patient-delivered partner treatment
(PDPT)
39
13
STI Update: Best Practices for
Protecting Women's Reproductive
Health
October 27, 2011
CT Rates Higher for Repeat Testing Compared with
Screening, California FP clinics, 2008/2009
Percent positive
Baseline
Repeat Infection
18
16
14
12
10
8
6
4
2
0
15-19
20-25
26-30
31-35
>35
Age Group
Source: Family PACT and Quest Diagnostics data
Prepared by: CDPH STD Control Branch
40
Why is retesting for CT/GC important
for women’s health?
Repeat CT
6
infection leads to
5
higher risk of
4
Relative Risk

complications:
PID, ectopic
pregnancy,
Ectopic
Pregnancy
3
2
1
infertility

Pelvic
Inflammatory
Disease
Most infections
0
1st
2nd
3rd
Infection Infection Infection
are asymptomatic
Hillis SD, et al. (1997). Am J Obstet Gynecol 176(1 Pt 1): 103-7.
41
Retesting Recommendations:




Retest all women and men with CT or GC 3
months after treatment
If client returns earlier than 3 months, consider
retest
If client does not return for retesting at 3
months, retest when possible
Test of cure is not recommended, except in
pregnancy, compliance is in question, or
symptoms persist
CDC 2010 STD Tx Guidelines, www.cdc.gov/std/treatment
42
14
STI Update: Best Practices for
Protecting Women's Reproductive
Health
October 27, 2011
Retesting Rates in California FP
Clinics, 2007



Only ~1/3 of women
treated for CT are
retested within 6
months of treatment
Surprisingly, another
~1/3 returned to
clinic but were not
retested
These are missed
opportunities!
Returned
and
Retested
Did not
Return
Returned
but NOT
Retested
Chow J. Region IX Infertility Prevention Project Data (2007)
43
Strategies for Improving
Retesting
 Counseling
at treatment visit
materials
 Protocols and chart prompts
 Express retesting visits
 Advance appointments
 Reminder systems: telephone, postcards,
text message, email
 Home-based testing
 Written
Downer SR et al Aust Health Rev 2006;30:389;
Leong KC et al. Fam Pract 2006; 23:699.
44
CT/GC Management in a Nutshell:
1
Screen
2 Treat
3 Treat
4 Screen
(Clients)
(Partners)
(3 months)
45
15
STI Update: Best Practices for
Protecting Women's Reproductive
Health
October 27, 2011
What’s New at the State?
46
InTOUCH: Texting and Home Testing to
Improve Retesting
www.intouch4health.org
47
“I Know” Campaign and Online Testing
*
www.dontthinkknow.org
*Not a Family PACT benefit
48
16
STI Update: Best Practices for
Protecting Women's Reproductive
Health
October 27, 2011
“Partner Packs” PDPT
Program




Azithromycin
distribution program
started in 2007
54 California Title X
agencies participating
>35,000 doses
distributed
Increased routine use
of PDPT
Barandas A, California Family Health Council, 2010
Jotblad S et al. CDPH, in preparation
49
Coming soon…



Free condoms: www.teensource.org
Expanded clinic access sites
GC “hot spots”
50
Cervicitis: Dx & Tx
Diagnosis:
 Evaluate for PID, BV and trich
 Consider HSV
 Test for GC and CT
Treat for chlamydia:
• Age 25 or younger
• STI risk: new/multiple partners, partner
with other partners, unprotected sex
• Follow-up unlikely
Treat for gonorrhea if high prevalence (>5%)
Treat BV if present
51
17
STI Update: Best Practices for
Protecting Women's Reproductive
Health
October 27, 2011
Mycoplasma genitalium



Sexually transmitted pathogen
Associated with acute and persistent
non-gonococcal urethritis (NGU) in
men, endometritis in women
Insufficient evidence for infertility,
ectopic pregnancy, adverse birth
outcomes
• Diagnostic test in development
• Azithro superior to doxy for M. genitalium
urethritis: 82% vs 39%
• Moxifloxacin effective for persistent NGU
caused by M. genitalium
52
Urethritis
Common Infectious Causes

Bacterial STIs:
◦ GC 5-20%
◦ CT 15-40%

Non-gonococcal urethritis (NGU)
◦
◦
◦
◦
◦
Mycoplasma genitalium 5-25%
Ureaplasma 0-20%; data inconsistent
Trichomonas vaginalis 5-20%
HSV 15-30%
Adenovirus, enterics, Candida, anaerobes
53
Urethritis Diagnosis
Exam findings:
o Purulent discharge
Stat laboratory:
o Gram stain exudate:  5 WBC/HPF
or intracellular GNDC
o Positive LE on urine dip
o  10 WBCs/HPF on first void urine
Laboratory tests:
o GC and CT testing
o Screen for syphilis, offer HIV
CDC 2010 STD Treatment Guidelines
www.cdc.gov/std/treatment
54
18
STI Update: Best Practices for
Protecting Women's Reproductive
Health
October 27, 2011
Urethritis Treatment
Initial episode, uncomplicated:
 Treat for both GC and CT unless GC ruled
out
 Azithromycin efficacy better for M.
genitalium
Persistent infection:
 If noncompliance or re-infection, repeat
treatment with standard therapy
 Consider trichomonas, doxy-resistant
ureaplasma, prostatitis, non-infectious
etiologies
CDC 2010 STD Treatment Guidelines
www.cdc.gov/std/treatment
55
Persistent NGU Treatment
Recommended regimens:
Metronidazole 2 g orally in a single dose
OR
Tinidazole 2 g orally in a single dose
PLUS
Azithromycin 1 g orally in a single dose
(if not used for initial episode)
Moxifloxacin 400 mg PO x 7d effective for NGU
treatment failures due to M. genitalium*
*Not a Family PACT benefit
CDC 2010 STD Treatment Guidelines
www.cdc.gov/std/treatment
56
Pelvic Inflammatory
Disease (PID)


Some association with M. genitalium
◦ Insufficient data to support testing/treatment
for MG
No change in criteria for diagnosis or
hospitalization
Minimum Clinical Criteria:
o Uterine tenderness OR
o Adnexal tenderness OR
o Cervical motion tenderness
57
19
STI Update: Best Practices for
Protecting Women's Reproductive
Health
October 27, 2011
PID Treatment Issues





Emergence of QRNG
◦ Quinolones not recommended
◦ If parenteral treatment not feasible and GC prevalence
and individual risk low, FQs may be considered
Limited data: Ceftriaxone 250 mg IM + azithro 1g PO q
wk x 2
No oral cephalosporins are recommended
When to use metronidazole:
◦ Oral regimens only
◦ Assess for BV and if present, use metronidazole
◦ If no wet mount available, use metronidazole
Insufficient evidence to warrant removal of IUD
CDC 2010 STD Treatment Guidelines
www.cdc.gov/std/treatment
58
PID: Oral Treatment Regimens
Oral regimens:
 Ceftriaxone 250 mg IM (or other parenteral 3rd
generation cephalosporin) x 1 or
 Cefoxitin 2 g IM with probenecid 1 g orally once
PLUS
 Doxycycline 100 mg orally twice daily for 14 days
WITH OR WITHOUT
 Metronidazole 500 mg orally twice daily for 14 days
CDC 2010 STD Treatment Guidelines
www.cdc.gov/std/treatment
59
PID: Parenteral Regimens*
*Not a Family PACT benefit
Parenteral regimen A:
Continued for 24 hours after clinical improvement,
 Cefoxitin 2 g IV q6h or Cefotetan 2 g IV q12h plus
 Doxycycline 100 mg IV or PO q12h
 Then Doxycycline 100 mg PO BID for total of 14 d
Parenteral regimen B:
 Clindamycin 900 mg IV q8h plus
 Gentamicin loading dose (2 mg/kg) IV or IM followed
by maintenance dose (1.5 mg/kg q8h)
 Then Doxycycline 100 mg PO BID or
Clindamycin 450 mg PO QID for total of 14 d
CDC 2010 STD Treatment Guidelines
www.cdc.gov/std/treatment
60
20
STI Update: Best Practices for
Protecting Women's Reproductive
Health
October 27, 2011
Trichomoniasis





Diagnostic testing:
◦ Aptima TV (NAAT) recently approved
◦ POC tests (Affirm VP III, OSOM Trich Rapid Test*)
◦ Trich on Pap may need confirmation, liquid cytology
more specific
Consider selective screening
Consider retesting women 3 months after treatment
Antimicrobial resistance significant (5-10%)
Treat all recent sex partners; consider EPT
*Not a Family PACT benefit
CDC 2010 STD Treatment Guidelines
www.cdc.gov/std/treatment
61
Trichomonas Screening?


Screening rationale is based on:
 High prevalence (STD clinics and other
settings)
 Selected high risk patients
 Association with adverse health outcomes
 Availability of NAAT (GenProbe Aptima ASR)
Controversies about screening:
 No evidence that screening and treatment
improves health outcomes
 Expense
62
Trichomoniasis Testing and Screening
Recommendations



Test women with vaginal discharge
Screening recommended for HIV+ women
Consider screening in those at high risk
for infection:
◦
◦
◦
◦


new or multiple partners
history of STIs
exchange sex for payment
use injection drugs
Consider retest in 3 months
NAATs preferred test for males
CDC 2010 STD Treatment Guidelines
www.cdc.gov/std/treatment
63
21
STI Update: Best Practices for
Protecting Women's Reproductive
Health
October 27, 2011
Prevalence of T. vaginalis by Race/Ethnicity,
U.S. Women aged 14-49, NHANES 2001-2004
13.3%
14
12
10
8
6
4
3.1%
1.3%
2
1.8%
0
Overall
White
Hispanic
Black
Sutton M et al. Clin Infect Dis 2007; 15 (10):1319-26
64
Trichomoniasis Treatment
Recommended regimen:
 Metronidazole 2 g PO x 1
 Tinidazole 2 g po x 1
Consider treating HIV-infected women:
 Metronidazole 500 mg PO BID x 7d
Alternative regimen:
 Metronidazole 500 mg PO BID x 7d
Recommended regimen in pregnancy:
Metronidazole 2 g PO x 1
Note: Vaginal therapy is ineffective
Tinidazole is a Category C drug in pregnancy
CDC 2010 STD Treatment Guidelines
www.cdc.gov/std/treatment
65
Trichomoniasis Treatment Failure
First treatment failure, re-treat with:
 Metronidazole 500 mg PO BID x 7 days
If repeat failure, treat with:
 Metronidazole 2 g PO x 5 days
 Tinidazole 2 g PO x 5 days
Susceptibility testing: send isolate to CDC
CDC 2010 STD Treatment Guidelines
www.cdc.gov/std/treatment
66
22
STI Update: Best Practices for
Protecting Women's Reproductive
Health
October 27, 2011
Bacterial Vaginosis (BV)




Additional alternative treatment regimens
Insufficient evidence to support screening high
risk pregnant women; against screening in low
risk (USPSTF)
Pre-procedural screening/treatment not
recommended
Prevention: use condoms, avoid douching
67
BV Treatment
Recommended regimens:
Metronidazole 500 mg PO BID x 7 d
Metronidazole gel 0.75% 5 g per vagina QD/BID x 5 d
Clindamycin cream 2% 5 g per vagina QHS x 7 d
Alternative regimens:
Tinidazole 2 g PO QD x 2 days
Tinidazole 1 g PO QD x 5 days
Clindamycin 300 mg PO BID x 7 d
Clindamycin ovules 100 mg per vagina QHS x 3 d
Recurrences:
Metronidazole gel 2x weekly x 4-6 weeks
Oral nitroimidazole followed by intravaginal boric acid
and suppressive metronidazole gel*
*Not a Family PACT benefit
CDC 2010 STD Treatment Guidelines
www.cdc.gov/std/treatment
68
New Genital Wart
Treatment



Sinecatechins (Veregen) a green tea
extract ointment (strengths 15% and
10%) approved for treatment of genital
warts*
Cost $287 for 15 grams
Not recommended in pregnancy, HIV,
HSV
*Not a Family PACT benefit
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October 27, 2011
Efficacy of Sinecatechins


Randomized double-blind placebo controlled trial
of N=502 patients with 2-30 warts each
Applied ointment three times a day for 16 weeks or
until clearance of all warts
100%
Complete Clearance
Partial Clearance
80%
60%
40%
20%
0%
78%
57%
52%
34%
Sinecatechin
Placebo
Sinecatechin
Placebo
Tatti S et al, Obstet Gynecol. 2008 Jun;111(6):1371-9
70
Genital Herpes

Testing:
◦ Culture, PCR for lesions
◦ Type-specific serology
◦ IgM testing not useful

Added for episodic treatment:

Suppressive therapy: prevents outbreaks and
transmission
Stronger recommendation for antiviral treatment in
late pregnancy
Famciclovir 500 mg PO x 1, then 250 mg BID x 2 d*

*Not a Family PACT benefit
71
Herpes Serology*: Recommendations



Type-specific HSV-2 serology tests may be useful:
◦ Recurrent/atypical symptoms with negative culture
◦ Clinical diagnosis without lab confirmation
◦ Patients with a partner with genital HSV
Some experts recommend serology tests:
◦ Patients who request testing or as part of
“comprehensive STI evaluation”
◦ Patients with multiple partners, HIV-infected, MSM at
high HIV risk
Universal screening NOT recommended
*Not a Family PACT benefit
CDC 2010 STD Treatment Guidelines
www.cdc.gov/std/treatment
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STI Update: Best Practices for
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Health
October 27, 2011
Genital Herpes Treatment Issues


All patients with initial genital HSV should receive
treatment
Episodic therapy for recurrent HSV:
◦ Added Famciclovir 500 mg PO x 1, then 250mg BID for 2
days



Famciclovir is less effective for suppressive
therapy than acyclovir and valacyclovir
Suppressive HSV therapy does not reduce the risk
of HIV in HSV-2 infected individuals
Antiviral therapy recommended late in pregnancy
in women with symptomatic HSV to reduce Csections
CDC 2010 STD Treatment Guidelines
www.cdc.gov/std/treatment
73
Syphilis




Screening: MSM, HIV+, pregnancy
Diagnosis: Reverse serology screening
challenges
Treatment: no extra dose of BIC for primary,
secondary, and early latent syphilis in HIV-infected
patients
CSF evaluation: only for neuro symptoms, tertiary
syphilis, or serology treatment failure
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Primary & Secondary Syphilis, Cases by Gender
California, 1996–2010
P&S Syphilis Rates, 1940-2010, California
2,250
Number of Cases
1,750
1,500
Rate per 100,000
2,000
ALL MALE
75
50
25
0
1940
1950
1960
1970
1980
1990
2000
2010
Year
MEN WHO
HAVE SEX
WITH MEN
1,250
1,000
750
500
250
FEMALE
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
STD Control Branch
Year
Rev. 7/2011
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STI Update: Best Practices for
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October 27, 2011
Primary & Secondary Syphilis, Rates by County
California, 2010
STD Control Branch
Rev. 7/2011
76
Syphilis Reverse Serology Screening
Treponemal tests
Non-treponemal tests
(i.e., EIA, CLIA)
reflex to
• SPECIFIC TO TP
• QUALITATIVE
• REACTIVITY PERSISTS
OVER LIFETIME
(i.e. RPR, VDRL)
• NOT SPECIFIC TO TP
• QUANTITATIVE
• REACTIVITY DECLINES
WITH TIME
CHALLENGES:
• Cannot distinguish between active/old disease
(treated/untreated)
• Confusion re: management of patients with
discrepant serology
77
Reverse Serology Testing Algorithm
Treponemal Test
(EIA/CLIA)
+
-
No infection,
Early infection or
False Negative
Quantitative Non‐trep Test (RPR, VDRL)
-
+
2nd Trep Test (TP‐PA)
Probable false positive EIA
If high risk: repeat trep EIA (and RPR if EIA still+)
INFECTION: old vs. new
+
INFECTION: old vs. late/early untreated
Assess for hx of treated syphilis, sx/signs
If treated, no further action
If untreated, consider rx for latent syphilis If low risk, consider repeat trep EIA in 1 month (and RPR if EIA still +)
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STI Update: Best Practices for
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October 27, 2011
Syphilis Treatment
Primary, Secondary & Early Latent:
Benzathine penicillin G 2.4 million units IM in a single
dose
Late Latent and Unknown Duration:
Benzathine Penicillin G 7.2 million units total, given as
3 doses of 2.4 million units each at 1 week intervals
Neurosyphilis:
Aqueous Crystalline Penicillin G 18-24 million units IV
daily administered as 3-4 million IV q 4 hr for 10 -14 d
No enhanced efficacy of additional doses of BPG,
amoxicillin or other antibiotics even if HIV infected
CDC 2010 STD Treatment Guidelines
www.cdc.gov/std/treatment
79
Online STD Resources
CDC Treatment Guidelines
www.cdc.gov/std/treatment
California STD/HIV Prevention Training Center
www.stdhivtraining.org
California Department of Public Health
STD Control Branch
www.std.ca.gov
80
Planned Parenthood Regina in Saskatchewan, Canada
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STI Update: Best Practices for
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October 27, 2011
QUESTIONS?
82
Evaluation and Other Forms
At the conclusion of session complete:
1. Evaluation Form
2. Sign-in Sheet
3. Continuing Education Forms (if
applicable)
o Post-Test
o CE Application
Forms can be downloaded at the end of this session
by file transfer.
Those without web access can get forms by calling
1-877- FAMPACT
Thank You!
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