National Clinical Training Center for Family Planning



Title: Management of Chlamydia and Gonorrhea Cases Among Rising STI RatesSpeaker: Dr. Hilary RenoDuration: 00:30:07NCTCFP (00:00):Welcome to this virtual coffee break sponsored by the National Clinical Training Center for Family Planning. The National Clinical Training Center for Family Planning is one of the training centers funded through the Office of Population Affairs to provide programming to enhance the knowledge of family planning staff.NCTCFP (00:17):Our guest presenter today is Dr. Hilary Reno, assistant professor in the Division of Infectious Disease at the Washington University School of Medicine in St. Louis, Missouri. Dr. Reno's clinical practice and research focuses on sexually transmitted infections and HIV, especially those around access to quality care and new diagnostics and therapeutics. Additionally, Dr. Reno is a medical consultant with the CDC, Medical Director of the St. Louis County Sexual Health Clinic, and Director of the St. Louis STI Regional Response Coalition.NCTCFP (00:53):In this presentation, entitled Management of Chlamydia and Gonorrhea Cases Among Rising STI Rates, Dr. Reno will discuss current trends in chlamydia and gonorrhea rates as well as recommendations for screening, testing, and treatment in clinical settings.NCTCFP (01:12):Before we begin, we must go over disclosures. Successful Completion: contact hours will be prorated according to documented attendance. To receive contact hours, participants must complete and submit the online evaluation request for credit form. CNE and certificates of completion will be emailed approximately four weeks after the completion of the evaluation request for credit form.NCTCFP (01:39):Commercial Support and Sponsorship: there is no commercial support for this training.NCTCFP (01:46):Non Endorsement of Products: the University of Missouri-Kansas City School of Nursing and Health Studies and the ANCC do not approve or endorse any commercial products associated with this activity.NCTCFP (02:01):Conflict of Interest: in accordance with continuing education guidelines, the speakers and planning committee members have disclosed commercial interests or financial relationships with companies whose products or services may be discussed during this program.NCTCFP (02:17):Our speaker: Dr. Hilary Reno has nothing to disclose.NCTCFP (02:22):The Planning Committee: Katherine Atcheson, Angela Bolen, and Sharon Colbert have nothing to disclose. Jacki Witt serves on the advisory panel for Afaxys, which has been resolved.NCTCFP (02:34):Acknowledgement of Funding: this presentation was supported by grant number 5-FPTPA006029-02-00 from the United States Department of Health and Human Services (HHS), Office of the Assistant Secretary of Health (OASH), Office of Population Affairs (OPA). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HHS, OASH, or OPA.NCTCFP (03:10):Accreditation Statement. Continuing Nursing Education: the University of Missouri-Kansas City School of Nursing and Health Studies is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.NCTCFP (03:26):This webinar offers 0.5 contact hours for nurses.NCTCFP (03:31):Now onto our speaker, Dr. Hilary Reno.Dr. Hilary Reno (03:37):Great, thank you. Today we'll be covering a few topics, mainly focused on gonorrhea and chlamydia infections. We'll first cover the trends in our SG rates in this country and then talk a little more focused on gonorrhea and chlamydia and persistent and recurrent non gonococcal urethritis as well as the treatment recommendations for that. We'll also discuss when extragenital testing is indicated, as well as describe the process for self collected STD testing and some advantages to this method of testing and clinical study.Dr. Hilary Reno (04:14):As many people have probably heard through news reports and CDC reports, STDs in the United States have increased markedly. We have seen increases in gonorrhea and chlamydia, as well as syphilis and genital syphilis. From 2017 to 2018 the total cases of chlamydia have increased almost 3% and gonorrhea has increased 5%. We see even greater increases in syphilis and congenital syphilis, but our webinar today shall focus on gonorrhea and chlamydia. These are very common infections. In fact, the chlamydia cases for 2018 totaled over 1.7 million, which is the highest number of cases of a reportable disease ever recorded in the United States.Dr. Hilary Reno (04:59):When we look at these rates at a little more detail, we see that both women and men have experienced increases in chlamydia. This graph shows the rates of reported chlamydia from 2000 to 2018, and you can see that the total overall has increased. We've seen increases in women and men. You'll notice that the rate of slope of increase for both lines are about the same.Dr. Hilary Reno (05:23):When we look at gonorrhea, we see a slightly different pattern in that though total rates increase, they really started to turn upwards in 2013, 2014. The rate of increase for men has been greater than the rate of increase we've seen in women.Dr. Hilary Reno (05:39):There's many reasons for this. It should be noted that gonorrhea especially has increased in men who have sex with men and that might account for the increased slope of rates that we see in men. This could be a combination of a number of things including increased access to testing.Dr. Hilary Reno (05:56):We also have had some messaging from the CDC around how important it is, especially for high priority populations like youth, men who have sex with men, and women who are planning to be pregnant or could be pregnant, to seek out care for sexually transmitted infections. As our rates increase it's especially important that patients be aware that they could be at risk for sexually transmitted infection. Messaging encourages them to talk about their concerns about their sexual health, as well as to seek testing and discuss treatment options. This is especially important for pregnant women who are at risk for complications from gonorrhea and chlamydia infections, as well as, of course, congenital syphilis.Dr. Hilary Reno (06:41):This is largely a case based discussion. Let's start with our first case. A 20 year old woman with vaginal discharge is presenting for care. She notes that she has had vaginal discharge without abdominal pain for about a week and she reports that she has two sexual partners, both men. She reports vaginal sex, receptive oral sex, and uses condoms often. She's not on any other birth control. Physical exam is normal aside from some clear discharge from her cervical os.Dr. Hilary Reno (07:12):What sort of testing we really going to focus on here for this patient? Of course, she needs evaluation for her vaginal discharge and as a young woman we're going to be concerned about sexually transmitted infections. Appropriate testing for gonorrhea and chlamydia with nucleic acid amplification testing is indicated and available testing for vaginitis, for example, looking for clue cells on a wet mount, perhaps also doing a KOH, looking for yeast forms, as well as doing pH to help with a differential diagnosis is important here.Dr. Hilary Reno (07:44):For any person who is receiving testing for STDs we should consider what I refer to as package testing. That's the term I use to refer to the concept that if someone is at risk for gonorrhea and chlamydia, they should also receive testing for syphilis and HIV. For this patient we would recommend gonorrhea and chlamydia testing, evaluation for vaginitis, as well as HIV and syphilis testing.Dr. Hilary Reno (08:12):For her test results we find that her RPR for syphilis is non-reactive, her HIV test is negative, and that her gonorrhea and chlamydia net test from a vaginal sample indicated that she had chlamydia trachomatis infection.Dr. Hilary Reno (08:29):Let's talk about chlamydia and its presentations. These are pictures of first for normal cervix, which is located up above, and then an abnormal cervix, seen below. On pelvic exam and visualization of the cervix, when a patient has chlamydia findings can include clear discharge, even a pus like appearance of discharge from the cervical os, as well as friability and redness of the cervical surface. In men, chlamydia traditionally presents with a clear mucoid like discharge as seen in the picture with sub-label #3.Dr. Hilary Reno (09:08):We all understand, of course, that not everyone with chlamydia presents in the same way and so we must remember that up to 70% of patients can have an infection and have no symptoms. Many of them may not have clinical findings of chlamydia infection either.Dr. Hilary Reno (09:28):If we think back to our patient, how are we best going to manage her chlamydia infection? The recommended treatment from the CDC treatment guidelines from 2015, which are being updated and an update is expected this year in 2020, currently recommend azithromycin, 1 gram, as a single dose for treatment for chlamydia or doxycycline, 100 milligrams twice a day, for seven days. The alternative regimens are listed, including erythromycin four times a day, which is very difficult to take, and in addition can be quite nauseous. Levaquin or ofloxacin is listed.Dr. Hilary Reno (10:06):Let's talk about case two, in which we have a very similarly presenting patient with vaginal discharge, but also notes receptive anal sex with her partners, sometimes without condoms, and is complaining of rectal discharge. Similarly she would be tested, but at this time we would also consider how to address her rectal discharge. What we really want to focus on here is that the patient would still receive an endocervical or vaginal test for chlamydia, but also a rectal swab for chlamydia as well.Dr. Hilary Reno (10:39):What is the role of extragenital testing in patients? We know that for men who have sex with men, if extragenital testing is not performed, up to 80% of STDs can be missed. Extragenital, gonorrhea, and chlamydia net tests are recommended for all sexually active men who have sex with men, at least on an annual basis.Dr. Hilary Reno (11:01):This is a report from last year at an STD clinic in which they wanted to demonstrate how helpful or not helpful extragenital testing could be in men who have sex with women and women who have sex with men, i.e., heterosexual couples. If you look at first Figure C, which shows rectal gonorrhea detection and focus on women who have sex with men, WSM, that column shows in the dark bars where gonorrhea was isolated only from a rectal net test, and then the light gray indicates those patients for which gonorrhea was found in the rectum and the vaginal site testing. For women who have sex with men, about 15 to 20% of women who report rectal sex and are being tested, might potentially have rectal gonorrhea without having endocervical positive tests for gonorrhea.Dr. Hilary Reno (11:55):We can think about our patient who presented with vaginal and rectal discharge and determine that based on her symptoms, she should have been tested at both the vaginal and the extragenital erectile site. The question is, is this something we would recommend for all patients that participate in receptive anal sex, especially when we're talking about men who have sex with women. Men who have sex with women would not report receptive anal sex, but they might report a receptive oral sex. If you look at Figure A, you will see pharyngeal gonorrhea rates in men who have sex with women in that first bar. 40 cases out of 120 were found in men that were positive only at the pharynx site and not also at the urethral site, which could indicate that we'd be missing some infections in men if we did not do testing at the pharynx if they reported performing oral sex on their partner.Dr. Hilary Reno (12:48):Currently, guidelines do not recommend extragenital screening in heterosexual populations, but they do recommend extragenital screening in women who have sex with men and men who have sex with women for whom have symptomatic extragenital complaints. Again, for men who have sex with men, they are recommended to have extragenital screening done as reported by patient sexual behaviors.Dr. Hilary Reno (13:13):Remember that extragenital testing is essential for men who have sex with men at least annually as well as for certain women who have sex with men, including those who are symptomatic. Again, we do not currently recommend screening, though I think that what we will notice over the coming years as evidence increases is that for certain women who have sex with men who report receptive anal sex, eventually we may recommend screening there.Dr. Hilary Reno (13:39):Back to our patient who has been tested positive at the endocervical and rectal sites for chlamydia. How are we most appropriately going to manage her? Here's some options including azithromycin, 1 gram single dose, ceftriaxone and azithromycin, an erythromycin regimen, a seven day doxycycline regimen, or a 21 day doxycycline regimen.Dr. Hilary Reno (14:03):What does the evidence tell us? This is really getting at what is the best way to manage rectal chlamydia. Based on a study that gathered all the evidence from numerous other studies is that we have some indication that doxycycline performs better than azithromycin does for rectal chlamydia. If you look at the column for doxycycline and the percentage of patients in those studies that were positive at follow up, you'll see that the numbers, 0% positive at follow up, 1%, up to 10%, are lower than those reported for azithromycin in these same studies where the positivity rate at followup testing ranged from 6 to 44%. It is these findings that tell us that perhaps doxycycline is going to be preferred for rectal chlamydia management, though we do not currently have the report from a randomized controlled trial, but anticipate that as those trials are underway.Dr. Hilary Reno (14:57):Let's move on to gonorrhea. Gonorrhea traditionally presents with much more mucopurulent discharge like seen in these pictures. For the figure labeled Plate 1 you can see copious purulent discharge coming from the urethral meatus as well as the figure labeled Number 1, purulent discharge. The picture off to the upper right of the cervix shows mucopurulent discharge from the os well as a red, angry cervix that will more than likely bleed when the swab is applied, what we call friable. Then the Gram stain down below shows us intracellular Gram negative diplococci within the white cells. Those small little dots that kind of sit next to each other, that's a diplococcus. That is gonorrhea within the white cells. If Gram stain of the discharge is performed, this is what would appear for gonorrhea.Dr. Hilary Reno (15:51):Gonorrhea is managed with ceftriaxone, 250 milligrams IM, plus 1 gram of azithromycin. Currently, by treatment guidelines, both of these treatments are recommended because we are trying to ensure that gonorrhea that could be resistant to ceftriaxone or azithromycin does not emerge. This is called double coverage. By giving both antibiotics, we're ensuring that the organism is killed by this regimen. This is the recommended treatment for gonorrhea at all sites, cervix, the urethra, the rectum, and the pharynx.Dr. Hilary Reno (16:23):It's especially important for pharyngeal infections to treat with ceftriaxone and azithromycin at this time. It is important to note that the oropharynx is a little special. It is difficult for cephalosporins that are in oral form to penetrate the oral pharynx at levels high enough to kill gonorrhea.Dr. Hilary Reno (16:42):I would like to note that this is the treatment recommendations based on the 2015 CDC STD Treatment Guidelines. The 2020 guidelines may alter this and so it's very important that we all look for those guideline in their new form and review them closely when they are released.Dr. Hilary Reno (17:01):What do you do for the patient that has a severe penicillin or cephalosporin allergy? First of all, make sure the allergy is real. For many cases it is a reported allergy or an intolerance and not a true allergy. If the patient is truly allergic, the best regimen to treat a patient with is gentamicin, 240 milligrams IM and 2 grams of azithromycin in a onetime dose. The regimen involving gemifloxacin is not available in the United States.Dr. Hilary Reno (17:28):Also note that anyone who does not receive ceftriaxone and azithromycin for treatment of pharyngeal gonorrhea should have a test of cure. We have seen treatment failures with the gentamicin regimen and so a NAAT test should be performed in two weeks.Dr. Hilary Reno (17:43):As I've already hinted, there's a lot of resistant gonorrhea around, so we're very concerned about its further emergence. It's something that will probably need to be addressed as we continue with our evolution of our treatment guidelines. It's important to note that there are still antibiotics available to treat gonorrhea and that the United States has not seen ceftriaxone resistant strains yet, but we may see a time in which culturing gonorrhea and having the ability to look at its sensitivities will be very important in its management.Dr. Hilary Reno (18:15):It's important for all of us if we suspect treatment failure to know how to order a gonorrhea culture and make sure that we can get those sensitivities if we need it. I will have some resources at the end of this talk that will help you accomplish that.Dr. Hilary Reno (18:31):What about patients that are treated but still have persistent discharge or dysuria, especially for men? Let's briefly touch on persistent and recurrent nongonococcal urethritis. This can usually be caused by mycoplasma genitalium or trichomonas vaginalis.Dr. Hilary Reno (18:48):Just a few quick words about trichomonas. We had a wonderful randomized controlled trial that came out in late 2018 that showed us that there are fewer failures with a seven day course of metronidazole to treat trichomonas as opposed to the previously recommended 2 gram dose, a one time dose of metronidazole. Metronidazole, 500 milligrams twice a day for seven days, had fewer treatment failures. About 11% of patients treated with that seven day regimen had a positive trichomonas NAAT test to cure versus 19% who received that 2 gram one time dose. Patients did very well on it and were compliant with the medication.Dr. Hilary Reno (19:31):Let's talk about mycoplasma genitalium. It's an emerging infection. We know it can be implemented as a cause of both urethritis in men and mucopurulent cervicitis and PID in women. The exact role that it plays clinically has still not been well described. We do now have an FDA cleared test for mycoplasma genitalium and so some people are testing for this. But again, our lack of knowledge about its true clinical implications have not led us to recommend screening for mycoplasma genitalium at this time.Dr. Hilary Reno (20:06):Let's cover how to manage persistent or recurrent nongonococcal urethritis. For patients who have been evaluated and treated with azithromycin, 1 gram, the treatment recommendations currently indicate repeating that dose but also considering other infections, including trichomonas and mycoplasma genitalia. For men who have sex with women, recommendations are to also consider coverage for trichomonas with metronidazole in a 2 gram, one time dose or tinidazole. Note that this is the 2 gram, one time dose because although we have a randomized controlled trial that has indicated women have a higher rate with a seven day dose, we do not have that indication for men yet. The 2 gram dose that they do not have infection with trichomonas is likely still sufficient.Dr. Hilary Reno (20:58):For men who have sex with men, because as we must consider mycoplasma genitalium possible etiology for recurrent NGU, treatment would then be indicated with moxifloxacin, 400 milligrams a day for seven to 10 days.Dr. Hilary Reno (21:14):Now that we've covered some basics, let's review some different, more innovative ways of increasing testing for patients. I first want to talk about self-collected testing. Self-collected testing is when patients collect their own NAAT samples. We know these perform very well. There have been multiple studies that have shown that gonorrhea and chlamydia detection when patients are collecting their own NAAT swabs is at least equal to provider administered testing. Patients also like them. Surveys show high patient satisfaction with this and they found that self-administered tests are easy and comfortable. Clinicians like them too. There was at least one study that looked at clinician attitudes towards self-collected testing and they liked them as well.Dr. Hilary Reno (21:57):Why would we offer self-collected testing? First of all, they can meet the need for testing in a place where it may not occur. For example, at the St. Louis County Health Department we went through a time period when one of our nurse practitioners was on leave and we were strapped to meet patient need for testing. Self-collected testing offered us the ability to have patients perform their own tests and increase the ability of us to offer testing for patients. Another reason to offer them is because patients like them and they perform well.Dr. Hilary Reno (22:27):One way that self-collected testing could fit into a clinic is represented here. There's many other ways, but this is just one way. The patient may present for screening, perhaps they don't have symptoms, so they're giving testing kits and instructions. They go to the bathroom, collect their samples. For a woman, this may be a self-collected vaginal sample. For a man, this could be a urine sample. For a man who has sex with men, it could be all including a urine sample, a rectal sample, and a pharyngeal sample. They then are given good instructions on how to assemble the test, putting the tube in the right direction, snapping it off, and turning the cap on tightly. They drop the test samples off at the lab. They receive exit instructions and then eventually they received their results and if they need to return for treatment they're able to do that.Dr. Hilary Reno (23:14):This is how self-collected testing can be integrated into what we call an express visit. You'll notice there's not a clinician step along the way. That is something that has done in a lot of STD clinics and has been done with great success. It can increase patient volume, decrease clinician time, and make testing more available for patients. It's important that if a clinic or a clinic system is interested in starting self-collected testing that they approach it from a systematic, thoughtful process.Dr. Hilary Reno (23:44):Some steps that need to be considered for rollout include staff instruction time, so that staff understands why this is being implemented. The development and use of patient instruction and education sheets. Make sure that restaurants are available for patient use. Many clinics also need to develop test kits that can be assembled and given to the patient for them to go collect their samples. Designating a spot for sample drop off is important. Then also making a plan for managing follow up calls so that patients get their test results and get treatment when needed is also very important.Dr. Hilary Reno (24:19):Here are some examples of materials that have already been developed for self-collection. You can see these are from the STD Prevention Training Center at the University of Washington in Seattle. These are available free from their website. They're available as 8x11 sheets as well as poster size for posting.Dr. Hilary Reno (24:38):The first thing you will see is how to self-collect a throat swab. The second one is how to self-collect a rectal swab. The instructions are very clear and anticipate problems that patients may have as they're doing it. You see the use of a lot of visualizations. The patients, especially after they've done it once, they're able to replicate this easily.Dr. Hilary Reno (25:00):What are some of the limitations of self-collected testing? I'm sure we can think about them. For example, patients are generally not seeing clinicians, so if they have an asymptomatic rash, that may not be noticed. Patients may also have symptoms that they haven't visualized and don't recognize as an issue. Discharge, lumps, bumps, sores, those sorts of things, those won't be discovered through self-collected testing like this if it is paired with not seeing a clinician. This is why it's important for the clinical systems who are considering this approach to think through it and figure out what would work best for them and the self-collected testing would fill a need for them.Dr. Hilary Reno (25:39):What do you do once a patient has a positive test? What is important as far as follow up? Let's cover some basics. Of course, it's important to administer their treatment and make sure the patients are able to come back for their treatment or are able to receive the prescription that's called in for them. It's also a great time to provide some prevention counseling as well as to refer them for other services. If a patient, for example, has syphilis, they are indicated to be considered for PrEP. Making sure that there is a way to link patients to PrEP care is important. If they have herpes, they may need continuing long term care and management. For the management of syphilis, they may need to be informed on how to return for additional injections of Bicillin as indicated by the syphilis stage.Dr. Hilary Reno (26:23):It's also very important to let all patients with gonorrhea and chlamydia understand that they should be retested in three months. That follow up testing is not done very often. One study at Quest showed that only 27% of patients who had gonorrhea and chlamydia were retested in a six month period. But of those retested, 17% percent had an infection, so this is definitely higher yield. Of course, for pregnant women, they're often and should be retested for weeks after an STD is diagnosed.Dr. Hilary Reno (26:54):One final thing I want to talk about is the intersection of these increasing STD rates that we see as well as how they're interacting with other public health challenges at this time, including substance use disorder, hepatitis C, and HIV. Our public health system may focus sometimes only on one of these things, but we need to understand that they're interacting and all of our public health systems need to become quite adept at communicating across departments and divisions because often we are seeing these things go hand in hand.Dr. Hilary Reno (27:28):For example, we recently looked at reported intravenous drug use in patients with early syphilis in Missouri over time, from 2012 to 2018. We did it by region because we were very interested in understanding what is happening outside of our major urban areas like St. Louis and Kansas City. You can see St. Louis is in red, Kansas City is in orange. You can see over time that there has been a slight increase in intravenous drug use reported in patients with early syphilis. But you really see marked increases in our small metropolitan areas and our rural areas of Missouri, they're in blue and green.Dr. Hilary Reno (28:04):Again, we need to understand that many of these public health threats are interacting together. How can we tackle them at the same time? Is there a way for us to use innovative testing methods like express testing and packaged testing to improve diagnosis and reduce our rates of STDs?Dr. Hilary Reno (28:21):I'd like to acknowledge a few people. First, Dr. Brad Stoner, who is the director of the St. Louis HIV STD Prevention Training Center. Some of my research colleagues at the Institute for Public Health at Wash U. Here's some good resources for you including the CDC STD Treatment Guide. 2015 is available for Apple and Android as an app. It is free from the CDC and it will be updated when the 2020 guidelines are released. There is also a toolbox by Denver Health that's available on Apple. It includes a newsfeed on anything STD related as well as some important other bits of information.Dr. Hilary Reno (29:03):Then I'd lastly like to leave you with some information from the National Network of Prevention Training Centers. First of all, that NNPTCs provide clinical training but also a web based consultation network. You'll see that there, it’s . Medical professionals are able to go online, register quickly, ask a question, and then your regional prevention training center will respond within a certain timeframe that you can designate, usually within one to five business days. Hopefully that'll give you some resources so you can prove your care in sexual health and STD prevention testing and treatment.NCTCFP (29:46):Thank you so much, Dr. Reno, and thank you to our watchers for joining us today. We hope you'll join us for the next virtual coffee break from the National Clinical Training center for Family Planning. ................
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