Khalil G. Ghanem, MD, PhD
Associate Professor of Medicine
Division of Infectious Diseases
Johns Hopkins University
School ...
clinicaloptions.com
24th Annual CCO HIV and Hepatitis C Symposium
About These Slides
 Users are encouraged to use these s...
clinicaloptions.com
24th Annual CCO HIV and Hepatitis C Symposium
Aberg JA, et al. Clin Infect Dis. 2014;58:e1-e34.
clinicaloptions.com
24th Annual CCO HIV and Hepatitis C Symposium
Objectives
 At the end of this presentation, participan...
clinicaloptions.com
24th Annual CCO HIV and Hepatitis C Symposium
Probability of Asymptomatic STDs
Holmes KK, et al. Sex T...
clinicaloptions.com
24th Annual CCO HIV and Hepatitis C Symposium
Risk Assessment: History and Physical
Examination
 Scre...
Screening
Chlamydia, Gonorrhea, Trichomoniasis,
Syphilis, and Herpes
clinicaloptions.com
24th Annual CCO HIV and Hepatitis C Symposium
Best Specimen Type to Screen for Genital
Gonorrhea and C...
clinicaloptions.com
24th Annual CCO HIV and Hepatitis C Symposium
Why Screen for Extragenital Gonorrhea
and Chlamydia Infe...
clinicaloptions.com
24th Annual CCO HIV and Hepatitis C Symposium
Extragenital GC and CT Diagnostics
 Sensitivity of cult...
clinicaloptions.com
24th Annual CCO HIV and Hepatitis C Symposium
GC and CT Screening Recommendations
Aberg JA, et al. Cli...
clinicaloptions.com
24th Annual CCO HIV and Hepatitis C Symposium
Screening for Trichomoniasis
 Indications for HIV+ wome...
clinicaloptions.com
24th Annual CCO HIV and Hepatitis C Symposium
Retesting to Detect Repeat Infections
 Reinfection with...
clinicaloptions.com
24th Annual CCO HIV and Hepatitis C Symposium
Screening for Syphilis: Serological Tests
1. Peeling RW,...
clinicaloptions.com
24th Annual CCO HIV and Hepatitis C Symposium
Screening for Syphilis: Serological
Algorithms
Tradition...
clinicaloptions.com
24th Annual CCO HIV and Hepatitis C Symposium
Screening for Syphilis: Interpretation of
Reverse Sequen...
clinicaloptions.com
24th Annual CCO HIV and Hepatitis C Symposium
Screening for Syphilis: Epidemiology
Syphilis and HIV
 ...
clinicaloptions.com
24th Annual CCO HIV and Hepatitis C Symposium
Screening for Syphilis: Cost and Efficacy
 Every 3-mo s...
clinicaloptions.com
24th Annual CCO HIV and Hepatitis C Symposium
Syphilis and HIV: Recommendations
 Routine serologic sc...
clinicaloptions.com
24th Annual CCO HIV and Hepatitis C Symposium
Screening for Herpes Simplex Viruses
 Routine screening...
clinicaloptions.com
24th Annual CCO HIV and Hepatitis C Symposium
 Use glycoprotein G-based type-specific assays (gG1 and...
Management
Gonorrhea Therapy and
Human Papillomavirus Prevention
clinicaloptions.com
24th Annual CCO HIV and Hepatitis C Symposium
Gonorrhea Drug Resistance Timeline
Unemo M, et al. Ann N...
clinicaloptions.com
24th Annual CCO HIV and Hepatitis C Symposium
Mechanisms of Resistance to
Cephalosporins
 Combined ef...
clinicaloptions.com
24th Annual CCO HIV and Hepatitis C Symposium
GC Cephalosporin Susceptibility: United
States and the W...
clinicaloptions.com
24th Annual CCO HIV and Hepatitis C Symposium
GC Macrolide Resistance
 133 GISP isolates with reduced...
clinicaloptions.com
24th Annual CCO HIV and Hepatitis C Symposium
Updated CDC GC Treatment
Recommendations
 Firstline
– C...
clinicaloptions.com
24th Annual CCO HIV and Hepatitis C Symposium
Treatment Failure With Alternate Regimens
 Culture rele...
clinicaloptions.com
24th Annual CCO HIV and Hepatitis C Symposium
What About Patients With Penicillin or
Cephalosporin All...
clinicaloptions.com
24th Annual CCO HIV and Hepatitis C Symposium
Future Antimicrobial Options
 Recent randomized trial o...
clinicaloptions.com
24th Annual CCO HIV and Hepatitis C Symposium
HPV: Anal Pap and HPV Vaccination
 Anal Pap screening r...
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Preventing and managing sexually transmitted diseases in hiv infected patients.2014

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  • HPV, human papillomavirus; STD, sexually transmitted disease.
  • STD, sexually transmitted disease; Trich, trichomoniasis.
  • ETOH, alcohol; STD, sexually transmitted disease.
  • NAATs, nucleic acid amplification tests.
  • CT, chlamydia; GC, gonorrhea; MSM, men who have sex with men.
  • CDC, Centers for Disease Control and Prevention; CT, chlamydia; FDA, US Food and Drug Administration; GC, gonorrhea; NAATs, nucleic acid amplification tests.
  • CT, chlamydia; GC, gonorrhea; MSM, men who have sex with men; STD, sexually transmitted disease.
  • FDA, US Food and Drug Administration; NAATs, nucleic acid amplification tests.
  • CT, chlamydia; GC, gonorrhea.
  • EIA, enzyme immunoassay; FTA-Abs, fluorescent treponemal antibody absorption; IgM, immunoglobulin M; POC, point of care; RPR, rapid plasma reagin; TPHA, treponema pallidum hemaglutination assay; TPI, treponema pallidum immobilization assay; TPPA, treponema pallidum passive particle agglutination assay; TRUST, toluidine red unheated serum test; VDRL, venereal disease research laboratory; WB, Western blot.
  • CIA, chemiluminescence immunoassay; EIA, enzyme immunoassay; RPR, rapid plasma reagin; VDRL, venereal disease research laboratory.
  • CDC, Centers for Disease Control and Prevention; CIA, chemiluminescence immunoassay; FTA, fluorescent treponemal antibody; RPR, rapid plasma reagin; STD, sexually transmitted disease.
  • MSM, men who have sex with men.
  • MSM, men who have sex with men.
  • HSV, herpes simplex virus; MSM, men who have sex with men; PCR, polymerase chain reaction; STD, sexually transmitted disease.
  • Eqv, equivalent; HSV, herpes simplex virus; Ig, immunoglobulin.
  • MIC, minimal inhibitory concentrations.
  • CLSI, clinical and laboratory standards institute; GC, gonorrhea; MIC, minimal inhibitory concentrations; MSM, men who have sex with men.
  • GC, gonorrhea; GISP, gonococcal isolate surveillance project; MIC, minimal inhibitory concentrations.
  • BID, twice daily; CDC, Centers for Disease Control and Prevention; GC, gonorrhea; IM, intramuscular; PO, orally.
  • PID, pelvic inflammatory disease; PO, orally.
  • ACIP, advisory committee on immunization practices; HPV, human papillomavirus; MSM, men who have sex with men.
  • Preventing and managing sexually transmitted diseases in hiv infected patients.2014

    1. 1. Khalil G. Ghanem, MD, PhD Associate Professor of Medicine Division of Infectious Diseases Johns Hopkins University School of Medicine Baltimore, Maryland Preventing and Managing Sexually Transmitted Diseases in HIV-Infected Patients Supported by educational grants from multiple commercial supporters.
    2. 2. clinicaloptions.com 24th Annual CCO HIV and Hepatitis C Symposium About These Slides  Users are encouraged to use these slides in their own noncommercial presentations, but we ask that content and attribution not be changed. Users are asked to honor this intent  These slides may not be published or posted online without permission from Clinical Care Options (email permissions@clinicaloptions.com) Disclaimer The materials published on the Clinical Care Options Web site reflect the views of the authors of the CCO material, not those of Clinical Care Options, LLC, the CME providers, or the companies providing educational grants. The materials may discuss uses and dosages for therapeutic products that have not been approved by the United States Food and Drug Administration. A qualified healthcare professional should be consulted before using any therapeutic product discussed. Readers should verify all information and data before treating patients or using any therapies described in these materials.
    3. 3. clinicaloptions.com 24th Annual CCO HIV and Hepatitis C Symposium Aberg JA, et al. Clin Infect Dis. 2014;58:e1-e34.
    4. 4. clinicaloptions.com 24th Annual CCO HIV and Hepatitis C Symposium Objectives  At the end of this presentation, participants should be able to: – Recognize critical components of the history and physical examination of HIV-infected patients that impact STD screening and management – Describe recommended approaches to screen for syphilis, gonorrhea, chlamydia, trichomoniasis, and herpes – Identify appropriate antimicrobial treatment regimens for gonorrhea – Formulate an approach to preventing HPV infections among HIV-infected persons
    5. 5. clinicaloptions.com 24th Annual CCO HIV and Hepatitis C Symposium Probability of Asymptomatic STDs Holmes KK, et al. Sex Transm Dis. 4th ed. New York City: McGraw-Hill. 2008. 100 80 60 40 20 0 Urethra/Cervix Rectum Pharynx Urethra/Cervix Rectum Pharynx Urethra/Vagina Any Gonorrhea Chlamydia Trich Herpes Men Women
    6. 6. clinicaloptions.com 24th Annual CCO HIV and Hepatitis C Symposium Risk Assessment: History and Physical Examination  Screening for all STDs is risk based, so accurate information is critical – Obtain a sexual history in an open, nonjudgmental manner • Do you have oral sex? Do you use a condom when you have oral sex? vs The last time you put your mouth on your partner’s penis, did you use a condom? Do you use a condom most times you do that?  A sexual history should include: – Current and past sexual practices (number of partners, gender of partners, all exposure sites, condom and contraceptive use, past STD history, etc) – Use of drugs (ETOH, poppers, methamphetamines, etc) with sex – Risks and status of partners  A physical examination should include: – Pelvic examination in women – Anogenital examination in both men and women – Careful skin/mucus membrane examination Aberg JA, et al. Clin Infect Dis. 2014;58:e1-e34.
    7. 7. Screening Chlamydia, Gonorrhea, Trichomoniasis, Syphilis, and Herpes
    8. 8. clinicaloptions.com 24th Annual CCO HIV and Hepatitis C Symposium Best Specimen Type to Screen for Genital Gonorrhea and Chlamydia  Women – A vaginal swab for NAATs testing is preferred – Endocervical swabs and urine are acceptable alternate specimen types for NAATs testing – Endocervical swabs are the only acceptable specimen type for gonorrhea cultures  Men – First-catch urine for NAATs testing is preferred – Urethral swabs are acceptable alternate specimen types for NAATs testing – Urethral swabs are the only acceptable specimen type for gonorrhea cultures MMWR Recomm Rep. 2010;59:1-116.
    9. 9. clinicaloptions.com 24th Annual CCO HIV and Hepatitis C Symposium Why Screen for Extragenital Gonorrhea and Chlamydia Infections?  Most cases of pharyngeal and rectal GC and CT are asymptomatic  Up to 65% of cases of GC[1,2] and 50% of cases of CT[2] among MSM may be missed if genital-only testing were performed  In women, 10% of CT and 31% of GC infections would have been missed if extragenital testing were not done[3]  Rectal and pharyngeal infections are of public health significance[4] 1. Gunn RA, et al. Sex Transm Dis. 2008;35:845-848. 2. Kent CK, et al. Clin Infect Dis. 2005;41:67-74. 3. Peters RP, et al. Sex Transm Dis. 2011;38:783-787. 4. Bernstein KT, et al. Clin Infect Dis. 2009;49:1793-1797.
    10. 10. clinicaloptions.com 24th Annual CCO HIV and Hepatitis C Symposium Extragenital GC and CT Diagnostics  Sensitivity of culture < 50% to detect rectal and pharyngeal GC vs > 90% sensitivity for NAATs (this can vary by NAAT type)[1]  The CDC recommends that NAATs be used to detect these extragenital infections[2]  Although none of the NAATs are FDA cleared to use with extragenital specimens, most large laboratories have established performance specifications to satisfy compliance to Clinical Laboratory Improvement Amendments 1. Ota KV, et al. Sex Transm Infect. 2009;85:182-186. 2. MMWR Recomm Rep. 2010;59:1-116.
    11. 11. clinicaloptions.com 24th Annual CCO HIV and Hepatitis C Symposium GC and CT Screening Recommendations Aberg JA, et al. Clin Infect Dis. 2014;58:e1-e34. Interval Site-Specific Screening Chlamydia Annually for All women aged ≤ 25 yrs All sexually active MSM High-risk women* aged > 25 yrs Every 3-6 mos for MSM With multiple or anonymous partners Use illicit drugs or who have partners who do Anorectal: On the basis of report of receptive anal intercourse Pharyngeal: Not recommended due to low prevalence Gonorrhea Annually for All sexually active MSM Every 3-6 mos for MSM With multiple or anonymous partners Use illicit drugs or who have partners who do Targeted screening High-risk women* Anorectal: On the basis of report of receptive anal intercourse Pharyngeal: If patient reports receptive oral sex *Includes women with previous CT/GC infection, other STDs, new or multiple sex partners, inconsistent condom use; those who engage in commercial sex work and drug use; certain demographic groups; those living in communities with a high prevalence of disease.
    12. 12. clinicaloptions.com 24th Annual CCO HIV and Hepatitis C Symposium Screening for Trichomoniasis  Indications for HIV+ women[1]  At entry into care  Subsequent screening performed at least annually based on: – Reported prevalence of trichomonas vaginalis – Effect of treatment at reducing vaginal HIV shedding – Potential complications of upper genital–tract infections among women who are left untreated – Partners (among black women)[2]  Diagnostics[2,3]  Wet mount: sensitivity ~ 51% to 65% (time dependent)  Culture: sensitivity 75% to 95%  Rapid antigen test: sensitivity 82% to 95%  NAAT assay*: sensitivity 100% – No FDA-approved NAATs for men; some laboratories have verified the performance characteristics of NAATs through a validation process for male urine specimens or penile meatal swabs 1. MMWR Recomm Rep. 2010;59 ;1-116. 2. Sutton M, et al. Clin Infect Dis. 2007;45:1319-1326. 3. APHL. Issues in Brief: Laboratory Detection of Trichomonas. August 2013. www.aphl.org. *FDA approved in 2011 for use with urine, endocervical, and vaginal swabs and Thin Prep Pap.
    13. 13. clinicaloptions.com 24th Annual CCO HIV and Hepatitis C Symposium Retesting to Detect Repeat Infections  Reinfection with GC, CT, and trichomoniasis is common in both men and women[1,2]  All persons treated for GC, CT, and all women treated for trichomoniasis should be retested in 3 mos because of high reinfection rates regardless of whether their partner(s) was/were treated[3] 1. Fung M, et al. Sex Transm Inf. 2007;83:304-309. 2. Hosenfeld CB, et al. Sex Transm Dis. 2009;36:478-489. 3. MMWR Recomm Rep. 2010;59:1-116.
    14. 14. clinicaloptions.com 24th Annual CCO HIV and Hepatitis C Symposium Screening for Syphilis: Serological Tests 1. Peeling RW, et al. Bull World Health Org. 2004;82:439-446. 2. CDC. Reverse sequence syphilis screening. Common Patterns of Serological Reactivity in Syphilis Patients[1] Serological Tests For Syphilis[1,2] Nontreponemal Tests Treponemal Tests Complement fixation tests  Wasserman reaction Flocculation tests  RPR  VDRL  TRUST  TPI  FTA-Abs  TPHA  TPPA  EIA  WB and pseudoblots  Automated chemi- luminescence platforms  Chromatographic POC tests  Microsphere immunoassay FTA-Abs TPHA VDRL/RPR IgM Untreated Treated 100 80 60 40 20 2 4 6 8 10 12 2 10 20Time of Reaction Wks Yrs Time Postinfection Primary Secondary Latent (asymptomatic) TertiaryClinical Stages of Syphilis Primary lesion Secondary lesion PatientsWhoTestPositive(%)
    15. 15. clinicaloptions.com 24th Annual CCO HIV and Hepatitis C Symposium Screening for Syphilis: Serological Algorithms Traditional Algorithm Reverse Sequence Algorithm − + CDC. Reverse sequence syphilis screening. RPR/VDRL No further testing Treponemal test No further testing RPR/VDRL No further testing Confirmatory treponemal test Treponemal immunoassay (EIA/CIA) + − − +
    16. 16. clinicaloptions.com 24th Annual CCO HIV and Hepatitis C Symposium Screening for Syphilis: Interpretation of Reverse Sequence Algorithm Slide courtesy of Barbara Detrick, JHH.
    17. 17. clinicaloptions.com 24th Annual CCO HIV and Hepatitis C Symposium Screening for Syphilis: Epidemiology Syphilis and HIV  The estimated proportion of primary and secondary syphilis cases attributable to MSM increased from 7% in 2000 to 75% in 2012[1]  In Maryland, 60% of primary and secondary cases of syphilis were among HIV+ MSM, and 30% of MSM diagnosed with early syphilis from 2010-2011 had been diagnosed with syphilis in the preceding 4 yrs[2,3] 1. www.cdc.gov. STD surveillance. 2012. 2. Data courtesy of Ravikiran Muvva, BCHD. 3. MMWR. 2013; 62:649-650. 25 20 15 10 5 0 16:1 8:1 4:1 2:1 1:1 100 80 60 40 20 0 Rate (per 100,000 Population) Rate Ratio (log scale) 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 61.3 38.7 41.6 58.4 41.9 58.1 39.9 60.1 2009 2010 2011 2012 PrimaryandSecondary CasesinMen(%) Male Female Total Male-to-female ratio Yr HIV Negative/Unknown HIV Positve Yr
    18. 18. clinicaloptions.com 24th Annual CCO HIV and Hepatitis C Symposium Screening for Syphilis: Cost and Efficacy  Every 3-mo screening among highly active MSM is very high- yield and cost-efficient. Contact tracing is high-yield but costly. Screening in jails also appeared to be cost-efficient[1,2]  Mathematical models suggest that changes in behaviors and condom use, particularly short-term ones (even long-term ones if they are modest), would not affect syphilis rates, and that frequent screening among very high-risk individuals is probably what would have the most impact[3]  Approximately 30% of high-risk MSM were not rescreened in the 6 mos following therapy for syphilis[4] 1. Gray RT, et al. Sex Transm Dis. 2010;37:298-305. 2. Lewis FM, et al. J Public Health Manag Pract. 2011;17:513-521. 3. Gray RT, et al. Sex Transm Dis. 2011;38:1151-1158. 4. Marcus JL, et al. Sex Transm Dis. 2011;38:24-29.
    19. 19. clinicaloptions.com 24th Annual CCO HIV and Hepatitis C Symposium Syphilis and HIV: Recommendations  Routine serologic screening for syphilis is recommended AT LEAST annually for sexually active HIV-infected persons, with more frequent screening (every 3-6 mos) in those with multiple partners, a history of unprotected intercourse, a history of sex in conjunction with illicit drug use, methamphetamine use, or sexual partners who participate in such activities Aberg JA, et al. Clin Infect Dis. 2014;58:e1-e34.
    20. 20. clinicaloptions.com 24th Annual CCO HIV and Hepatitis C Symposium Screening for Herpes Simplex Viruses  Routine screening for HSV is not recommended. Counseling infected persons and their sex partners may help reduce the risk of HSV sexual and perinatal transmission[1]  Type-specific HSV serologic assays may be performed in the following patients[2] : – Patients with recurrent genital symptoms or atypical symptoms in whom HSV cultures/PCR have been negative – Patients who have been given a clinical diagnosis of genital herpes without laboratory confirmation – Patients who have a partner with genital herpes – Consider screening persons presenting for an STD evaluation, persons HIV+, and MSM 1. Aberg JA, et al. Clin Infect Dis. 2014;58:e1-e3. 2. MMWR Recomm Rep. 2010;59:1-116.
    21. 21. clinicaloptions.com 24th Annual CCO HIV and Hepatitis C Symposium  Use glycoprotein G-based type-specific assays (gG1 and gG2) – If gG2 is positive, patient has genital herpes – If gG1 is positive, patient either has oral herpes or genital herpes – Do NOT use crude antigen-based serological assays – Do NOT use IgM serological assays  REMEMBER: – Antibodies may be negative in early primary infection – The specificity of these tests is high but not perfect. As such, if the pretest probability of having herpes is low, a positive test result has a high likelihood of being a false positive Screening Tests for Herpes Simplex Virus Wald A, et al. Clin Infect Dis. 2002;35:S173-S182.
    22. 22. Management Gonorrhea Therapy and Human Papillomavirus Prevention
    23. 23. clinicaloptions.com 24th Annual CCO HIV and Hepatitis C Symposium Gonorrhea Drug Resistance Timeline Unemo M, et al. Ann N Y Acad Sci. 2011;1230:E19-E28. Protargol 1897 Protargol no longer recommended 1938 Sulphonamide resistance wide spread 1944-45 1936 Sulphonamides 1943 Penicillin Erythromycin 1952 Spectinomycin 1961 1962 Tetracycline 1958 Penicillin and streptomycin clinical resistance first reported 1949 Streptomycin and chloramphenicol 1977 Erythromycin resistance wide spread β-lactamase plasmids first reported (high-level penicillin resistance) 1976 Ceftriaxone 1980 Cefixime 1983 1983 Azithromycin 1987 Spectinomycin resistance reported to rapidly emerge when widely used 1989 Penicillin no longer recommended 1985 Tetracycline high-level resistance reported Tetracycline no longer recommended 1986 1993 Fluoroquinolones, cefixime and ceftriaxone recommended Ceftriaxone recommended (ciprofloxacin alternative) 1989 Chromosomal penicillin resistance elucidated 1985 Fluoroquinolone resistance first reported in USA (Hawaii) – already a problem in Asia 1991 Cefixime out of production 2002 Fluoroquinolones no longer recommended 2007 Cefixime clinical failure verified beyond Japan (in Europe) 2007 2021? Untreatable gonorrhea? 2011 First high-level ceftriaxone resistant strain fully characterized Super Bug Status!! 2001 Cefixime decreased susceptibility in Hawaii, USA 2007 Azithromycin no longer recommended 2008 Cefixime available again 1999 Azithromycin resistance first reported
    24. 24. clinicaloptions.com 24th Annual CCO HIV and Hepatitis C Symposium Mechanisms of Resistance to Cephalosporins  Combined effects of several chromosomal mutations: – PenA (PBP2) – Results in 100× increased MIC to cefixime – Results in 20× increased MIC to ceftriaxone – Acquired via horizontal transfer from oral commensal bacteria (N sicca, N perflava, N cinerea, and/or N flavescens) – MtrR (MTRCDE-encoded pump repressor) – MtrR mutations result in overexpression of an efflux pump – PenB (PorB1b) – Decrease the influx of the antibiotic into the periplasm Bolan GA, et al. N Engl J Med. 2012;366:485-487.
    25. 25. clinicaloptions.com 24th Annual CCO HIV and Hepatitis C Symposium GC Cephalosporin Susceptibility: United States and the World  Although the MIC breakpoints for resistance to cephalosporin have not been defined, the CLSI defines susceptibility to cefixime and ceftriaxone as MICs of 0.25 μg/mL or below and 0.125 μg/mL or below, respectively[1] 1. Bolan GA, et al. N Engl J Med. 2012;366:485-487. 2. Unemo M, et al. Euro Surveill. 2010;15:19721. 3. Unemo M, et al. Euro Surveill. 2011;16:19792. 4. Unemo M, et al. Antimicrob Agents Chemother. 2012;56:1273-1280. [2] [3] [4] 5 4 3 2 1 0 2005 2006 2009 2010 2011 MSM West Midwest Northeast and South Men who report having sex exclusively with women IsolatesWithElevated MICsofCefixime(%) Percentage of Isolates in Which MICs of Cefixime Were ≥ 0.25 µg/mL, 2005-2011[1]
    26. 26. clinicaloptions.com 24th Annual CCO HIV and Hepatitis C Symposium GC Macrolide Resistance  133 GISP isolates with reduced susceptibility to azithromycin (at MIC ≥ 2 μg/mL) have been reported in the United States since 2005, including 7 (0.5% of GISP isolates) in 2012[1,2]  The first strain with high-level resistance to azithromycin (MIC ≥ 512 μg/mL) identified in the United States was detected in Hawaii in 2011, and several additional strains have now been detected in Hawaii and California[2] 1. MMWR Recomm Rep. 2010;59:1-116. 2. Katz AR, et al. Clin Infect Dis. 2012;54:841-843.
    27. 27. clinicaloptions.com 24th Annual CCO HIV and Hepatitis C Symposium Updated CDC GC Treatment Recommendations  Firstline – Ceftriaxone 250 mg IM x 1 + azithromycin 1 g PO × 1 or doxycycline 100 mg PO BID × 7 days – Azithromycin is preferred over doxycycline, but both are acceptable – Use dual therapy even if C trachomatis is ruled out  Alternate – Cefixime 400 mg PO x 1 + azithromycin 1 g PO × 1 or doxycycline 100 mg PO BID × 7 days – Azithromycin 2 g PO × 1 (single therapy, single dose) – Azithromycin 2 g PO × 1 is the only regimen currently available to treat a patient who has an allergy to cephalosporins CDC. Morb Mortal Wkly Rep. 2012;61:590-594.
    28. 28. clinicaloptions.com 24th Annual CCO HIV and Hepatitis C Symposium Treatment Failure With Alternate Regimens  Culture relevant clinical sites and perform antimicrobial susceptibility testing using disk diffusion, E-test, or agar dilution  Treat with intramuscular ceftriaxone 250 mg + azithromycin 2 g orally as a single dose  Evaluate sex partners from the preceding 60 days with culture from all exposed sites and treat with above enhanced regimen  The laboratory should retain the isolate for possible further testing CDC. Morb Mortal Wkly Rep. 2012;61:590-594.
    29. 29. clinicaloptions.com 24th Annual CCO HIV and Hepatitis C Symposium What About Patients With Penicillin or Cephalosporin Allergies?  The cross-reactivity between penicillins and cephalosporins has been found to be low (< 2.5%) – The risk is highest with first-generation cephalosporins – The risk of penicillin cross-reactivity between most second- generation and all third- and fourth-generation cephalosporins is negligible  If severe allergy to penicillin or cephalosporins, treat with azithromycin 2 g PO × 1  Oral PID treatment in that setting is more complicated Park MA, et al. Int Arch Allergy Immunol. 2010;153:268-273. Novalbos A, et al. Clin Exp Allergy. 2001;31:438-443.
    30. 30. clinicaloptions.com 24th Annual CCO HIV and Hepatitis C Symposium Future Antimicrobial Options  Recent randomized trial of: – Injectable gentamicin (5 mg/kg) + oral azithromycin (2 g) – 100% effectiveness – Oral gemifloxacin (320 mg) + oral azithromycin (2 g) – 99.5% effectiveness  Many trial participants reported adverse effects from the drugs, mostly gastrointestinal issues Kirkcaldy RD. Sex Transm Infect. 2013;89:A14-A15.
    31. 31. clinicaloptions.com 24th Annual CCO HIV and Hepatitis C Symposium HPV: Anal Pap and HPV Vaccination  Anal Pap screening recommendations  Recommended groups – MSM – Women with history of receptive anal intercourse or abnormal cervical Pap test results – All HIV+ persons with genital warts (weak recommendation, moderate quality evidence)[1]  If anal cytologic screening (anal Pap smears) is performed and abnormal: – High-resolution anoscopy should be performed with biopsy of abnormal areas – Appropriate therapy based on biopsy results[1]  HPV vaccination recommendations  ACIP recommends vaccination for all HIV-infected males (quadrivalent vaccine only) and females in a 3-dose series at 11 or 12 yrs of age and for those 13-26 yrs of age if not previously vaccinated[1] – Efficacy data in HIV+ patients lacking – 1 small trial in HIV+ boys and girls found the vaccine safe and immunogenic as did a study in HIV-infected men[2,3] 1. Aberg JA, et al. Clin Infect Dis. 2014;58:e1-e34. 2. Levin MJ, et al. J Acquir Immune Defic Syndr. 2010;55:197-204. 3. Wilkin T, et al. J Infect Dis. 2010;202:1246-1253.

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