Transcript 2006 CDC STD Treatment Guidelines “What’s New”

Sexually Transmitted Diseases
Treatment Guidelines, 2006
MMWR
August 4, 2006
Volume 55
No. RR-11
Gonococcal Isolate Surveillance Project (GISP) — Percent
of Neisseria gonorrhoeae isolates with resistance or
intermediate resistance to ciprofloxacin, 1990–2004
Percent
10.0
Resistance
8.0
Intermediate resistance
6.0
4.0
2.0
0.0
1990
91
92
93
94
95
96
97
98
99
2000
01
02
Note: Resistant isolates have ciprofloxacin MICs ≥ 1 µg/ml. Isolates with
intermediate resistance have ciprofloxacin MICs of 0.125 - 0.5 µg/ml.
Susceptibility to ciprofloxacin was first measured in GISP in 1990.
03
04
Gonococcal Isolate Surveillance Project (GISP) — Percent
of Neisseria gonorrhoeae isolates with resistance to
ciprofloxacin by sexual behavior,
2001–2004
Percent Ciprofloxacin Resistant
25
Heterosexual
Men who have sex with men (MSM)
20
15
10
5
0
2001
2002
2003
2004
Gonorrhea
• Do not use quinolones (cipro, oflox, levo)
http://www.cdc.gov/std/gisp
2006 NC STD Treatment Guidelines
Uncomplicated Gonorrhea
Cefpodoxime 400 mg PO x 1
or
Ceftriaxone 125mg IM
Alternatives: Gentimicin 240 mg IM ( not for oral pharyngeal)- do test of cure
Quinolones: Do test of cure
Ciprofloxacin 500mg PO
or
Ofloxacin 400mg PO
or
Levofloxacin 250mg PO
Azithromycin 2.0 g PO ( expensive, nausea and vomiting)
Add co-treatment for Ct if not treating with Azithromycin
Plus, Azithromycin 1g PO or Doxycycline 100mg po BID x 7d
2006 CDC STD Treatment Guidelines
Uncomplicated Gonorrhea
Alternatives:
• Spectinomycin 2g IM
Oral Alternatives:
• Cefpodoxime (Vantin®) 400mg PO single
dose OR
• Cefuroxime (Ceftin®) 500mg PO single
dose
Percent of GC Re-infection in Males by Study
7.0
Golden 2005
14.8
Kissinger 2005
22.0
Peterman 2005
5.0
Sparks 2003
46.0
McKee 2000
0.0
Gunn 2004
5.1
Mehta 2003
0.0
10.0
20.0
30.0
40.0
50.0
60.0
% Re-infection
Fung et al. National STD Prevention Conference. 2006
70.0
80.0
90.0
100.0
Urethritis Management
• 2006 CDC STD Guidelines:
If Chlamydia or Gonorrhea positive,
some experts suggest repeat
Chlamydia or Gonorrhea Testing in
About 3 Months
Expedited Partner Therapy (EPT)
•Chlamydia Azithromycin 1 g x 1
•Gonorrhea Single dose FQ or cephalosporin
•Condoms
•Educational pamphlets
RCTs of EPT for Chlamydia and/or
GC
Ref
Patients
EPT
1
1787 women
Azithro vs STD
referral for CT
1- and 3-mo 12% vs 15%
post-therapy P = 0.1
2
646 men
2105 women
Azithro/Cefixime
vs STD referral for
CT or GC
10-18 wks
11% vs 13% CT
post-therapy P = 0.17
Azithro/Cefixime
vs STD referral for
CT or GC
2-8 wks
23% vs 43% CT/GC
post-therapy P<0.001
3
977 men
1.
2.
3.
NAAT Test
% Positive
3% vs 11% GC
P = 0.01
Schillinger et al. Sex Transm Dis. 2003 Jan;30(1):49-56.
Golden et al. N Engl J Med. 2005 Feb 17;352(7):676-85.
Kissinger et al. Clin Infect Dis. 2005 Sep 1;41(5):623-9.
Other Considerations for EPT
• Cost-effectiveness of EPT
– Sparse data
– Influenced by cost of antibiotics, clinical settings, type of
provider, resources available, etc.
– Modeling studies suggest EPT had cost-savings
compared to standard partner referral
• Legality
– Golden et al. (Sex Transm Dis 2005;32) survey of
directors of medical practice and pharmacy boards in
2003; of 47 states with usable data, EPT not legal or not
known to be legal in 43.
• Other considerations
– PID in female partners, drug allergies, missed
education/STD screening opportunities
SUMMARY
EPT for CT and GC
• EPT efficacy not convincingly demonstrated for
CT, but studies suggest a modest benefit could
occur
• EPT trials had limitations
• EPT is at least as effective as partner referral
and more partners will get treated
• EPT has some barriers that should be further
addressed
2006 STD Guidelines - EPT
• EPT should be considered an option
(not routine) for partner management of
heterosexual male or female patients
(not MSM) with chlamydia or gonorrhea
(not Trichomoniasis)
2006 CDC STD Treatment
Guidelines
•
•
•
•
•
Prevention Methods
The ABC’s of prevention using clientcentered counseling
Pre-exposure vaccination
Nonoxynol-9 (spermicides, condoms) not
effective, not recommended
Emergency contraception section added
Post-exposure prophylaxis for HIV