Tag Archives: STIs

Check out the new warning from the CDC regarding the rise of antibiotic-resistant gonorrhea.

‘Untreatable’ Gonorrhea Looms, CDC Warns

By Crystal  Phend, Senior Staff Writer, MedPage TodayPublished: February 08, 2012

Gonorrhea is putting up increasing resistance to the last antibiotic class highly effective against it, the CDC has again warned.

The prevalence of gonorrhea resistant to the cephalosporin cefixime (Suprax) was just 0.1% in 2006 but had jumped 17-fold to 1.7% as of mid-2011, Gail A. Bolan, MD, director of sexually transmitted disease prevention at the CDC in Atlanta, and colleagues reported.

That rate is up from 1.4% in 2010, as the CDC reported last year when it first warned about cephalosporin resistance.

The CDC has typically changed gonorrhea treatment recommendations once the prevalence of resistance tops 5% in its surveillance of infections, but there aren’t any agents left to switch to, Bolan’s group wrote in a perspective article in the New England Journal of Medicine.

“It is time to sound the alarm,” they wrote. “There is much to do and the threat of untreatable gonorrhea is emerging rapidly.”

Because of resistance to other classes, the CDC currently recommends only third-generation cephalosporins for gonorrhea treatment. This class of drugs remains highly effective against most gonorrhea strains U.S. clinicians are likely to see, and should still be used, the group noted.

The most effective strategy for gonorrhea at genital and other sites, they said, is a 250 mg intramuscular dose of ceftriaxone (Rocephin) plus 1 g of the oral macrolide antibiotic azithromycin (Zithromax, Zmax), which fights gonorrhea bacteria through a different molecular target and also covers other copathogens.

Clinicians had gotten away from dual treatment with the advent of more sensitive tests for chlamydia, which often accompanies gonorrhea, Bolan noted.

“Now we feel we need to go back to dual therapy,” she said in an interview with MedPage Today.

She drew an analogy to combination therapy for tuberculosis, which has both extensively drug-resistant varieties (XDR) as well as a “totally” drug-resistant form of tuberculosis reported last month by researchers in India.

For gonorrhea, the tetracycline antibiotic doxycycline “seems less preferable,” the group added, “since gonococcal strains with decreased susceptibility to cefixime currently exhibit tetracycline resistance as well.”

Oral cefixime should be used only if ceftriaxone can’t be, they recommended. If neither will work because a patient is allergic to cephalosporins, 2 g of azithromycin is the only alternative.

Action to expand this armamentarium is necessary, Bolan’s group argued.

“Investing in rebuilding our defenses against gonococcal infections now, with involvement of the health care, public health, and research communities, is paramount if we are to control the spread and reduce the consequences of cephalosporin-resistant strains,” they wrote.

Neisseria gonorrhoeae has a track record of resistance:

  • To sulfanilamide in the 1940s
  • To penicillins and tetracyclines in the 1980s
  • To fluoroquinolones by 2007

The patterns of resistance across the country and demographic groups for cephalosporins mirrors those seen when resistance to fluoroquinolones emerged, Bolan and colleagues noted.

The biggest increases in cephalosporin resistance were in the western United States (from 0.2% in 2006 to 3.6% in 2011) and among men who have sex with men (from 0.2% to 4.7%).

Clinicians should be vigilant for cases in which cephalosporin treatment has failed, retesting patients who show persistent or recurrent symptoms soon after treatment and reporting cases to local or state health departments.

The high-risk groups should get retesting regardless of apparent treatment success, the researchers recommended.

“Clinicians caring for men who have sex with men, especially on the West Coast or in Hawaii, should consider performing a test of cure with a culture or a nucleic acid–amplification test one week after treatment, particularly if cefixime is administered,” they wrote.

Bolan reported having no conflicts of interest to disclose.

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Filed under General Women's Health, Nurse Practitioner Professional Issues, Sexually Transmitted Infections, Vaginal Health, Vulvovaginitis

Are You Following the “Not so New” 2010 CDC STI Treatment Guidelines?

 
by R. Mimi Secor, MS, M.Ed, FNP-BC, FAANP – January 16, 2012   Bookmark and Share


The New CDC STD Treatment Guidelines were released in December 2010 and provide the most current, evidence-based recommendations for screening, diagnosis and treatment of Sexually Transmitted Infections.
 
As both the incidence and prevalence of STIs in the US and Worldwide continue to burgeon, the proportion of patients that are appropriately screened is significantly lower than recommended in these recently published guidelines.  This is especially a problem among the highest risk populations of young adults 25 years old and younger. It is estimated that only 40- 60% of young adults are appropriately screened for chlamydia.
 
Yet, rates of chlamydia, gonorrhea, trichomoniasis, genital herpes, HPV, HIV and syphilis are all increasing particularly among adolescents, young adults and high risk populations.  Often asymptomatic (over half of women with chlamydia or bacterial vaginosis) and unaware they harbor various STIs, many go undetected and untreated.  This contributes to further transmission of STIs and may also increase the risk of developing associated complications and sequelae such as PID, chronic pelvic pain, infertility and preterm labor. 
 
When patients ask to be screened for all STIs what tests do you order?   When do you test patients for genital herpes? Are you retesting your patients with confirmed gonorrhea 1 week post treatment as recommended?  BUT are you still treating patients with BV in pregnancy with vaginal antibiotics even though the “new” guidelines warn against vaginal treatment?
 
The New CDC STD Treatment Guidelines were released in December 2010 and continue to provide the most current, evidence-based recommendations for screening, diagnosis and treatment of Sexually Transmitted Infections. To provide the highest quality STI care, clinicians need to familiarize themselves with these “not so new” guidelines.
 
As both the incidence and prevalence of STIs in the US and Worldwide continues to increase rapidly, the proportion of patients that are appropriately screened is significantly lower than recommended.  This is especially a problem among the highest risk populations of young adults 25 years old and younger.
 
In fact, it is estimated that only 40- 60% of young adults are appropriately screened for chlamydia. With 1 million cases of chlamydia reported each year, it’s estimated there are another 2 million infections undiagnosed each year. Undiagnosed chlamydia can lead to PID, chronic pelvic pain and infertility.
 
Yet, rates of chlamydia, gonorrhea, trichomoniasis, genital herpes, HPV, HIV and syphilis are all increasing particularly among adolescents, young adults, and high risk populations including aging baby boomers.
 
 According to a new report, rates of trichomoniasis in women 40 and over range from 8 to 13%.  This is a disturbingly high rate especially since most clinicians are unaware of this and do not routinely screen older women for trichomoniasis.
 
 Often asymptomatic (over half of women with chlamydia or bacterial vaginosis) and unaware they harbor various STIs, many go undetected and untreated.  This contributes to further transmission of STIs and may also increase the risk of developing associated complications and sequelae such as PID, chronic pelvic pain, infertility and preterm labor. 
 
There is an urgent need for more comprehensive STI screening particularly targeting high risk populations, adolescents, young adults, and individuals of any age who are “at risk” by history including the growing older population.
 
Opportunistic screening is a new trend in the US (widely implemented in Canada and the UK) that involves screening for STIs at the same time patients are seen for other health problems.  With convenient and accurate PCR urine testing for chlamydia and gonorrhea, office based-outpatient HIV testing, and new vaginal pH screening tests now available, opportunistic screening is an effective screening strategy that’s quick, easy and affordable.  
 
Vaginal microscopy is moderately accurate (approximately 60% for average proficiency) for diagnosing vaginal infections including some STIs such as trichomoniasis.  However, accuracy depends largely on the skill of the clinician, and it’s fairly complex and time consuming. 
 
Therefore many clinicians rely on their clinical judgment “eyeballing” discharge and treating based on symptoms and empiric diagnosis.  This approach is inaccurate and not recommended by the CDC.  Relying on Pap smear reports suggesting vaginitis or STIs is also not recommended due to low sensitivity and specificity.
 
Use of vaginal pH testing is another diagnostic option for vaginitis and vaginitis related STI screening (e.g. checking for trichomoniasis).  Traditionally, vaginal pH testing involves the use of Nitrazine pH paper (on a roll) requiring multiple steps to conduct the test including use of a color and numerical scale to determine if the test is normal or abnormal.  Considered too cumbersome and time consuming for many busy clinicians, vaginal pH testing is not widely utilized.
 
New, improved vaginal pH tests are now available affording a simple and quick way to screen patients during both routine and problem gynecologic visits.
 
The new VS-SENSE diagnostic vaginal swab test facilitates diagnosis of bacterial vaginosis (BV) and trichomoniasis by identifying changes in the acidity parameters of the vaginal secretions. The VS-SENSE swab is coated with an innovative proprietary polymer which contains a colorimetric pH indicator, Nitrazine yellow.  When the polymer in the swab, which is yellow before use, contacts vaginal fluid and reaches a specific threshold, the user observes a blue or green color change on the swab.  When the tip of the swab stains blue or green the VS-SENSE test is positive indicating an elevated vaginal pH level (>4.7 +.3/-.2) which is associated with bacterial vaginosis, trichomoniasis and atrophic vaginitis (low estrogen).  If after 10 seconds the swab tip does not change color, but remains yellow, the VS-SENSE test is negative, indicating that vaginal acidity is normal and the risk of having an infection associated with elevated vaginal pH level in unlikely.
 
The VS-SENSE technology is based on combining the measurement of the vaginal pH with buffer capacity (the concentration of protein within the discharge) which together raises the overall accuracy of the test to over 90%.
 
This new vaginal pH test, VS-SENSE, provides a quick, easy, accurate approach for screening and diagnosis of vaginitis and is especially well suited for busy primary care and women’s health practices. For more information about this pH test go to; www.cs-commonsense.com or check my website www.mimisecor.com
 
For more information on courses/presentations, management of vaginal infections and STIs, and to download a PDF copy of the 2010 CDC STI Treatment Guidelines, visit,  www.mimisecor.com or go to, www.cdc.gov/stds.org

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STIs in the Aging Population: “What? I thought only my teenager could get that!”

In most current clinical practices, the goal is to educate young men and women about sexually transmitted infections. However, studies increasingly show that it is not only teens and young adults that need to watch the notches on their lipstick cases. In fact, an estimated 50% of STIs occur in the “lower risk” population of men and women over 25 years of age. A recent 2010 national survey reported 1 in 6 Americans has genital herpes and 1 in 3 women over the age of thirty is infected.

According to data from the UK Health Protection Agency, women ages 45 years and older are being diagnosed with increased rates of various STIs. Between the years 2002-2006, incidence rates of chlamydia increased by 25%, gonorrhea by 22%, syphilis by 100%, herpes by 8% and genital warts by 9%. In addition, 10% of all HIV infections (There are approx. 50,000 new cases of HIV per year in the US) were diagnosed in adults 50 years of age and older. Of the approximately 50,000 new cases of HIV infection per year in the US, notably 25% of newly diagnosed patients reported no high risk behaviors.

In a recent large US study of 7,593 women, Gaydos and colleagues reported that trichomoniasis was harbored in many women in their 40s and 50s with the highest rate of 13% in women over 45 years old. Prevalence rates in women ages 18-39 was approximately 8%, and in women ages 45-49 was a surprisingly high rate of 13.4 percent.

Why are older patients transmitting and acquiring sexual infections? One possible factor is related to clinicians. In a recent study, 68% of women older than 65 were never questioned by their primary care clinician about their sexuality. Only 10% of women reported the clinician had brought up the subject, and 22% raised the subject only because of concerns related to the history obtained from the patient.

Is this because of clinician embarrassment? Often, a patient is older than the clinician, or of the opposite sex. Though it should not be a factor during a medical visit, age and comfort with the patient are potential impeding factors when discussing sexual information. The same holds true for clinicians recently graduated from college. They are examining patients that are their parents and grandparents ages, and these young clinicians may not acknowledge/or accept the normal sexuality of this patient population and generation.

There are other contributing factors explaining why sexually transmitted infections are on the rise in the older population. Condom use is at an all-time low in women over 45 years of age. Often by this age or shortly after, menopause has begun and many women, in response no longer worrying about pregnancy risk, often no longer feel they need to use condoms. In fact, only 11% of older women reported regular condom use, with 41% never using condoms, and 38% using them only half of the time.

Perhaps the most debilitating STI is HIV. In women, it can exacerbate the already stressful menopausal transition worsening menopausal symptoms. HIV may also contribute to an earlier onset of menopause. To make matters worse, women with HIV tend to have a lower bone mineral density, and more significant abnormal cardiovascular markers than HIV negative menopausal women.

Current Pap smear guidelines now recommend cervical cancer screening with Pap smears begin at age 21 (not 3 years after sexual debut), then every two years until age 30, then every 2 to 3 years until ages 65 to 70 years of age. If a woman has had three consecutive abnormal pap smears in the past 10 years she may stop screening between the ages of 65 and 70. Women who are HPV positive or have a history of abnormal Pap and /or hpv results should continue regular Pap smear/HPV screening, and need to also be reminded of risks for cervical, vulvar, oral and perianal carcinomas. Of note, all women and men should be educated about the HPV related risks for various associated HPV related cancers and conditions (such as genital warts caused by low risk subtypes of HPV).

Although the subject of sex with older patients still tends to be taboo, a sort of civilian version of “don’t ask, don’t tell”, it is critically important to inform all patients of HPV related health problems they may be at risk of either acquiring or transmitting and how to prevent such infections through consistent use of condoms and/or abstinence. As health care providers and clinicians, we must discuss sexual activity with our patients regardless of their age and/or our/their reluctance. Our lives depend on all clinicians adopting a more open and honest approach to sexuality, STI prevention, screening, testing and treatment especially with their “older” patients.

Vaginal pH testing is a quick and easy diagnostic screening tool for vaginitis and vaginitis related STI screening. Traditionally, vaginal pH testing involves the use of Nitrazine pH paper (on a roll) requiring multiple steps to conduct the test including use of a color and numerical scale to determine if the test is normal or abnormal. Considered too cumbersome and time consuming for many busy clinicians, vaginal pH testing is not widely utilized.

New, improved vaginal pH tests are now available affording a simple and quick way to screen patients during both routine and problem gynecologic visits.

The new VS-SENSE diagnostic vaginal swab test facilitates diagnosis of bacterial vaginosis (BV), trichomoniasis and atrophic vaginitis by identifying changes in the acidity parameters of the vaginal secretions. The VS-SENSE swab is coated with an innovative proprietary polymer which contains a colorimetric pH indicator, Nitrazine yellow. When the polymer in the swab, which is yellow before use, contacts vaginal fluid and reaches a specific threshold, the user observes a blue or green color change on the swab. When the tip of the swab stains blue or green the VS-SENSE test is positive indicating an elevated vaginal pH level (>4.7 +.3/-.2) which is associated with both bacterial vaginosis, trichomoniasis or atrophic vaginitis. If after 10 seconds the swab tip does not change color, but remains yellow, the VS-SENSE test is negative, indicating that vaginal acidity is normal and the risk of having an infection associated with elevated vaginal pH level in unlikely.

The VS-SENSE technology is based on combining the measurement of the vaginal pH with buffer capacity (the concentration of protein within the discharge) which together raises the overall accuracy of the test to over 90%.

This new vaginal pH test, VS-SENSE, provides a quick, easy, accurate approach for screening and diagnosis of vaginitis and is especially well suited for busy primary care and women’s health practices.

For more information on testing for vaginal infections and STIs, and to download a PDF copy of the New 2010 CDC STI Treatment Guidelines, visit, http://www.mimisecor.com or go to, http://www.cdc.gov/stds.org

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Filed under Diagnostic Testing, General Women's Health, Human Papillomavirus, Nurse Practitioner Professional Issues, Sexually Transmitted Infections, Uncategorized, Vaginal Health, Vulvovaginitis

Check out my blog about STIs in Older Adults

Check out my blog about STIs in older adults
http://bit.ly/tNzJBw

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Filed under Diagnostic Testing, General Women's Health, Human Papillomavirus, Sexually Transmitted Infections, Uncategorized, Vaginal Health, Vulvovaginitis