Gonorrhea and Chlamydia David H. Martin, MD LSU Health Sciences Center Section of Infectious Diseases

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  • Gonorrhea and ChlamydiaDavid H. Martin, MDLSU Health Sciences CenterSection of Infectious Diseases

  • DisclosureI have no financial interests or other relationship with manufacturers of commercial products, suppliers of commercial services, or commercial supporters. My presentation will not include any discussion of the unlabeled use of a product or a product under investigational use.

  • An STD About to Happen!

  • Cell Monolayer Infected with Chlamydia and Stained with Chlamydia Specific Fluorescent Antibodies Cell cytoplasma counter stained redChlamydial inclusions stained apple green

  • Electron Micrograph of a Chlamydia Infected EndocervixChlamydial inclusionMicroabscessColumnar epithelial cells

  • Gonococcal Urethritis

  • Gram Negative Intracellular Diplococci (GNID)

  • Nongonococcal Urethritis

  • Inflammation Without GNID

  • Etiology of Nongonococcal Urethritis - 2002Chlamydia trachomatis20-40%Ureaplasma urealyticum20-40% ?Mycoplasma genitalium20-25%Trichomonas vaginalis1-5%Herpes simplex virus
  • EpidydimitisDischargeScrotal erythema

  • Gonococcal Endocervicitis

  • Chlamydial Endocervicitis

  • Etiology of PID

    1. N. gonorrhoeae20-40%2. C. trachomatis20%3. Mixed aerobes and anaerobes including Mycooplama hominis + N. gonorrhoeae40-60%

  • Diagnosis of PIDHistoryLower abdominal pain of less than 15 days durationConstant painOnset within 7 days of menstruationFever and/or chillsSexual history

  • Diagnosis of PIDSignsBilateral adnexal tendernessCervical motion painAdnexal massEndocervical dischargeIUD

  • Maternal Chlamydial Infection65% of infants are infected30 50%of infants develop conjunctivitis5%of infants develop pneumonia

  • Proportion of Chlamydial and Gonococcal Infections that are Asymptomatic

    WomenMenC. trachomatis80-90%70-80%N. gonorrhoeae50-70%20-30%

  • Epidemiology

  • U.S. Gonorrhea Rates: 19702000

  • Chlamydia Trends in positivity among 15-44 year old women tested in family planning clinics, 19882000

  • Diagnosis

  • Gram Negative Intracellular Diplococci (GNID)

  • One Step Methylene Blue Stain

  • Performance of Culture for N. gonorrhoeae and C. trachomatis*Assuming no mistakes are made in specimen labeling and laboratory procedures.

    Sensitivity

    Specificity

    N. gonorrhoeae

    80-90%

    100%*

    C. trachomatis

    60-85%

    100%*

  • Cell Monolayer Infected with Chlamydia and Stained with Chlamydia Specific Fluorescent Antibodies Cell cytoplasma counter stained redChlamydial inclusions stained apple green

  • Performance of the Pace 2 Gonococcal DNA Hybridization Assay in Women

    SensitivitySpecificityRange of 10 studies85-100%96-99%Mean92.1%98.3%

  • A Systematic Review of NAAT Sensitivity Using Urine, Cervical and Urethral Specimens for Chlamydial InfectionsPCR-polymerase chain reaction. TMA-transcription mediated amplification. SDA-strand displacement amplification.Cook RL, et al. Annals Int Med. 2005; 142: 914

    Assay TypeWomenMenUrineCervixUrineUrethraPCR83%86%84%88%TMA92%99%88%96%SDA80%99%93%92%

  • Performance of an Amplification Test for the Detection of N. gonorrhoeae in Endocervical, Male Urethra and Urine Specimens*True positive defined as positive endocervical or urethral culture or LCR and alternative gene target positive by LCRKoumans EH, et al. Clin Infect Dis 1998;27:1171.

    Sensitivity*

    Specificity

    Endocervical

    97%

    99.7%

    Male urethra

    99%

    99.9%

    Female urine

    96%

    100%

    Male urine

    98%

    100%

  • Potential Urine Based Screening OpportunitiesJuvenile detention/jailsEmergency departmentsHigh schoolsGeneral medicine clinics, especially teen clinicsDrug rehabilitation programsHomeless clinicsMilitary induction centers

  • Vaginal Swab Study Specimen Collection Illustration

  • Sensitivity of Different Specimens by Three Different AssaysFCU first catch urine, Cx endocervix, S-vag self-collected vaginal swab, C-vag - Clinician collected vaginal swab. Schachter J, et al. STD 32;2005:725

    AssayFCUCxS-vagC-vagTMA72%89%93%90%PCR84%91%91%93%LCR98%96%98%100%Combined81%91%93%93%

  • Testing Preference Survey Among 1090 Women Following a Pelvic Examination and a SOVs Protocol90% found self collection of vaginal swabs very easy and another 7% found it somewhat easy.76% preferred a SOVs over a pelvic examination. 60% preferred it over a urine specimen.94% said they would be tested for STIs more often is SOVs were available.Chernesky MA, et al. Sex Transm Dis 32; 2005:729

  • Penicillin and Tetracycline Resistance Among U.S. Gonococcal Isolates- 2000

  • 2006 CDC STD Treatment GuidelinesUncomplicated Gonococcal InfectionsRecommended RegimensCefixime 400 mg orally in a single doseorCeftriaxone 125 mg IM in a single doseorCiprofloxacin 500 mg orally in a single doseorLevofloxacin 250 mg orally in a single dosePLUS (If chlamydia not ruled out)Doxycycline 100 mg orally 2 times a day for 7 days or Azithromycin 1 gm orally

  • Percent of U.S. N. gonorrhoeae Isolates With Decreased Susceptibility or Resistance to Ciprofloxacin, 19902000

  • 2006 CDC STD Treatment GuidelinesUncomplicated Gonococcal InfectionsAlternative RegimensSpectinomycin 2 g IM single doseOther single dose IM Cephalosporins (cefotaxime 500 mg, cefoxitin 2 g + probenecid, etc.)Other single dose Quinolones (enoxacin 400 mg, lomefloxacin 400 mg, norfloxacin 800 mg)

  • 2006 CDC STD Treatment GuidelinesChlamydial Infections

    Recommended Regimens

    Azithromycin 1 gram, orally, single dose

    Doxycycline 100 mg orally 2 times a day for 7 days

  • 2006 CDC STD Treatment GuidelinesNongonococcal Urethritis (NGU)Recommended RegimensAzithromycin 1 gram, orally, single doseDoxycycline 100 mg orally 2 times a day for 7 days

  • 2006 CDC STD Treatment GuidelinesPersistent or Recurrent NGU

    Metronidazole 2 grams, orally, single doseORTinidazole 2 grams, orally, single dosPLUSAzithromycin 1 gram, orally, single dose (if not used previously)

  • 2006 CDC STD Treatment GuidelinesChlamydial Infection During PregnancyRecommended RegimensAzithromycin 1 gram, orally, single doseOR Amoxicillin 500 mg orally 3 times daily for 7 days

  • 2006 CDC STD Treatment GuidelinesMild PIDRecommended Regimen BCeftriaxone 250 mg IM oncePLUSDoxycycline 100 mg orally 2 times a day for 14 daysWITH OR WITHOUTMetronidazole 500 orally 2 times daily for 14 days

  • Just a little sunshine

  • Just a little rain

  • Just a little pleasure

  • AND THEN.

  • Just a little PAIN!!

    ******Male GU tract

    ***************************************************