Gonorrhea and the Fading Treatment Frontier: Sexually Transmitted Infections Community Update


MOLLY MITCHELL: Good afternoon
and welcome to the Public Health Practice Grand
Rounds for April, 2010. My name is Molly Mitchell,
and I am the coordinator of the Mid-Atlantic Public
Health Training Center and on behalf of
the Training Center and the Maryland Department
of Health and Mental Hygiene and the Region Three STD
HIV Prevention Training Center, I’d like to keep you to our
presentation today of Gonorrhea and the Fading Treatment
Frontier, Sexually Transmitted Infections Community Update. But before we begin
today’s presentation, I’d like to invite you
to visit our website site to view our
available online and face to face trainings. In addition to the trainings
that we have online, including our archived grand
rounds and our public health nursing training,
we also have face to face trainings coming up,
including our core competency training series with Dr.
Carolyn Fowler, which includes a community assessment
and formative evaluation training on April 28 and May
7 and using social marketing principles to influence
decision-makers on May 14. And I’d also like to remind you
that next month’s Public Health Practice Grand Rounds will be
on public health and urban rats with Dr. Gregory Glass. And for those of you who want
to watch in today’s presentation online, we invite you
to email questions at anytime for our presenter
to our email address at MAPHTC that stands for mid-Atlantic
Public Health Training Center, at JHSOH dot EDU. And if you are watching
this webcast in a group, we ask that you please let
us know that by filling out our sign-in sheet,
so that we have a better idea of the count of
people who are watching online. And with that, I’m going
to hand the podium over to Barbara Conrad, who is
the chief of the Center for Sexually
Transmitted Infection Prevention at the Maryland
Department of Health and Mental Hygiene. Thank you. BARBARA CONRAD: Good
afternoon, and welcome again. As you may be aware, April is
National STD Awareness Month. This year’s tagline is, get
yourself talking, get tested, and as you’ll hear today,
really good third part is, get treated. While we initially
worked with Dr. Rompalo to plan this seminar,
we thought we were going to have a closer
cozier scope to things. We knew we wanted something
for STD Awareness Month. And we originally intended
this to be part of our Maryland State Gonorrhea Plan focused on
public and private health care providers in Maryland’s
highest risk counties. But through our partnership with
the mid-Atlantic Public Health Training Center and the Region
Three STDs HIV Prevention Training Center, we
realize we can now reach a much broader audience. We look forward to making
this an annual offering. I would like now to introduce
today’s speaker, Dr. Anne Rompalo. Dr. Rompalo is a Professor of
Medicine at the Johns Hopkins University School of Medicine,
Division of Infectious Diseases and in the Department of
Obstetrics and Gynecology. She holds a joint appointment
at the JHU Bloomberg School of Public Health in
the Division of Epidemiology and the Division of
Population, Family, and Reproductive Health. We are also very
fortunate to have her serve as our
medical consultant to the Maryland Department
of Health and Mental Hygiene, Infectious Disease,
and Environmental Health Administration’s Center for
Sexually Transmitted Infection Prevention, the co-sponsor
of today’s webcast. And she serves on the CDC STD
Treatment Guidelines Advisory Committee. So welcome, Dr. Rompalo. [APPLAUSE] DR. ANNE MARIE
ROMPALO: Thank you. Thank you, everyone. So, good afternoon to everyone
here and everyone on the web. We’re going to
attack this problem and try to go through some of
the issues that we face now and currently. Before I dive into
the lecture, I need to go through some
continuing education announcements that the
CDC is providing CMEs. And the CDC, our
planners, and myself, we have no financial interests
or other relationships with the manufacturers,
et cetera. This presentation will
not include any discussion of unlabelled use of
products and there is no commercial support
for this activity. And you can read these
slides as we go through. Please do. We’re offering a 1.0
AMA category 1 credits. I think we have
CNEs also available, which is listed here. And these are our
course objectives. What I’m going to discuss is
the current morbidity trends for gonorrhea, specifically
in Federal Region III, with particular emphasis
on the State of Maryland and discuss the
current treatment recommendations for gonorrhea
and describe finally the clinical
considerations for making a clinical diagnosis
of this disease and how to actually
get to that diagnosis through available testing. And I want to thank our School
of Medicine first year students for sharing their
slides with me. Actually I stole these slides. They are listed here. The students had to do a
presentation on this, which was brilliant under the
direction of Dr. Khalil Ghanem and I wanted to thank them for
sharing their slides with me. All right, if you
had been on the web or actually in Britain, The
Independent and BBC News, gonorrhea just recently
got the headlines. It’s obviously gonorrhea
is getting harder to treat. And this came out in a
conference where a Dr. Cathy Ison explained that choosing
an effective antibiotic can be a challenge because the
organism that causes gonorrhea is very versatile and develops
resistance to antibiotics very quickly. And you can see
the BBC News said, “warning of gonorrhea drug
risk” and The Independent “fears gonorrhea is
becoming treatable.” So we’re going to talk
about these issues because they certainly
are important. The current morbidity in
our region is as followed. Region three is made
up of five states and the District of Columbia. And you can see I
have listed here from taking these numbers
down from the CDC website, there’s a lot of
gonorrhea in our region, even though the rates
are coming down. For example, in Pennsylvania,
if I can do this, there were 11,434
specific absolute number of cases about a decade ago. We are down to 10,000 cases now. And Maryland is doing quite
well, down from 10,000 or 11,000 or so
cases down to 6,500. Nonetheless we’re
not down to zero. And the problem is that
our treatment options are running thin. So we do have these issues. There are lot of cases
and they’re current. This is how Maryland
STI rates fall out. And they are higher than
some of the US averages. For example, in
specifically for gonorrhea, we ranked number 19 in 2007
and remain there in 2008. Remember the 2008 statistics
are the most recent statistics available, even
though it’s 2010 now. We still rank high in other
STIs not to be forgotten. But we’re focusing on GC today. These are the rates in our
state for gonorrhea in the city. And you can see that although
the rates have been coming down nicely, they still remain high. And most of this is being
driven, I would say, from Baltimore City. But nonetheless I’ll show you
how this falls out in a second according to zip code
maps of our state. This is the age
distribution in Maryland for chlamydia and gonorrhea. And quite frankly throughout
the United States, gonorrhea and chlamydia
is a disease of the young. You can see much higher
rates for chlamydia. And gonorrhea, which is shown
in the striped line here, whereas gonorrhea is also high
in the 15 to 24-year-old group. Now, when you look at
the state of Maryland and any state in
our jurisdiction or wherever you’re
listening from, can do this. You can go to the CDC
website and get information on your state’s statistics. The incidence rate
by jurisdiction is shown here, with the
highest rates colored in for Baltimore City being
in the very deep, deep red. But you can see there’s other
areas, other hotspots, Prince George’s County, Dorchester,
Wicomico, Somerset also have relatively
high gonorrhea rates. If you even break
this down further, you’ll see that
it’s not completely distributed throughout
each county, but in specific sectors. So the bottom line is when
you’re listening to this and trying to decide what
to do with gonorrhea, you really have to
have an idea on what’s going on in your community
and in your catchment area, to say that oh
well, you know, if I live in a specific
region of Baltimore, my gonorrhea rates
may not be that high. However, other
regions are high too. So I think you as
a clinician have to know what’s going on in
and around your community. So let’s talk a bit
about the disease. Here’s the basics. Gonorrhea is shown here inside
a polymorpha nuclear cell is a gram negative diplococci. It colonizes and infects
the mucous membrane. It’s an anaerobic bacteria. It’s non-modal. It doesn’t form spores. And it’s the number two cause
of bacterial STDs in the United States. The symptoms here
and the presentation are shown in the
male and the female. In males it causes a urethritis. This is shown as a purulent
pussy urethral discharge, but you know it
doesn’t have to be. this dramatic or pussy. It can be a
mucopurulent discharge. It could also cause epididymitis
and rectal infections. And although not listed here,
also pharyngeal infections. Any place you have contact
with an infected individual, you can get it anyplace sex
happens, it can happen too. This is a endocervical
discharge here and a service situs in a woman. She may also have urethral
infections, rectal infections, throat infections, or pelvic
inflammatory disease, which is almost an ascension
of the bacteria that infect the cervix
up into the womb, into the genital tract
Falloopian tubes, et cetera, causing
pelvic inflammation. Why is gonorrhea
so serious then? Well, because I mean not only
on a personal level which I just showed you certainly
those infections are serious but in a
public health spin preventative methods
actually have failed to halt the disease spread. The numbers are going down, but
the disease is still spreading and it’s persistent. And now to add
insult to injury, we have emerging
anti-microbial resistance. And that renders our ability to
treat increasingly complicated. So what do we do? As far as the
treatment, I’m going to talk a little
bit about this now. I’m going to highlight the rise
of antibiotic resistant strains historically, geographically,
and genetically, and try to discuss what we have
now in the current treatment guidelines, and maybe
hint about how they’re going to change when
they come out hopefully in August of 2010. I’m going to try to appreciate
better ways to manage antibiotic resistance. So here’s a very
complicated slide from the Annals of
Internal Medicine, which I will break down. But if you’re
interested, there’s a really nice review by Kim
Markowski and Associates in the Annals in
2008, which goes through the historical
perspective of resistance. So let me try to break this down
in a more manageable fashion. The history of
resistance actually came when we first started
to treat gonorrhea. Treatment in the
pre-antibiotic era was with mercury
and silver nitrate. And sometimes these were even
delivered intra-urethrally to kill the bacteria,
also damaging the urethra as a consequence. Sulfanilamide was
introduced in 1936. And you know, as soon
as you introduce this, resistance starts to occur. You can see right around the
1945 or so resistance started to be accumulating
into the ’50s. Penicillin was
introduced in 1945. It was a brilliant drug. But as we began to use
it, the gonorrhea also became familiar with it
and it took more and more penicillin, in other
words, much higher doses to kill the gonorrhea
that was there. This is a little
history of resistance as far as gonorrhea
in World War II. And a poster says
she may look clean, BUT pick-ups, “good time? Girls, prostitutes, spread
syphilis and gonorrhea. You can’t beat the
Axis if you get VD. Now, OK, there’s
a lot of gonorrhea that, I don’t know if you
can actually look at someone and say whether they
have gonorrhea or not. That’s the whole point. I mean this is a nice poster,
and I understand where they were going with this. But the bottom line is,
you can’t look at somebody and know whether they
have an STI or STD or not. You can superimpose
anybody’s face here and it could be the same
message, never mind, girl, boy, doesn’t matter. So, although this was a
nice poster and a nice push in the World War II era,
there is no poster child for any STIs right now. Anybody can have it. So in 1976, gonorrhea
got wise to penicillin. And we had a penicillinase
producing Neisseria gonorrhea in other words, it completely
annhilated the penicillin drug by deactivating it. So what we ended up trying
was a different antibiotic, which was tetracycline. And we started to use
tetracyclines and nicely. And then in 1985,
gonorrhea became resistant to tetracyclines. So by 1989, we could no
longer use penicillin at all. And the CDC said no
penicillin cannot be used in their treatment
guidelines of 1989. Now, So we then
developed cephalosporins and you may know them as
ceftriaxone, cefixime. There a lot of cephalosporins
that actually we can and continue to use. But along with
cephalosporins, we also started to use quinolones. And that’s not
listed on the slide. But if you go back
to the Annals slide, you’ll see that quinolones
started to be used probably around the 1980s,
fluoroquinolones, such as ciprofloxacin
and cetofloxacin. And what started to
happen of course, was the gonorrhea started
to become resistant to that. The first cephalosporin
resistant strain actually was identified
in Japan in 1998. And the 2000 cephalosporin
resistant strains of gonorrhea started popping up
throughout Asia. Let me go to the
next slide here. If history serves, this is
Pennan Barry, who actually was a student here at Hopkins,
and Jeffrey Klausner who works in the San Francisco
Health Department, wrote an article that
said, if history serves as a pattern for
future events then we can expect wide dissemination
of cephalosporin resistance among gonorrhea
isolates in the future. So how did this work
itself out geographically? Well, in the 1980s,
quinolone resistance appeared in Southeast Asia. Then what we had, 1984, an
isolate popped up in Australia. 1991, you can’t see
the Hawaii there. But we detected quinolone
resistant Neisseria gonorrhea in Hawaii and the quinolones
were could no longer be used there for
treatment of gonorrhea. Sure enough, it started to
pop up in the West Coast. Reports came also out
of India in the 90s and in Rwanda resistance
was documented. So in the 2000s, the CDC said,
we can no longer recommend the use of quinolones,
ofloxacin, and ciprofloxacin, for the therapy of gonorrhea,
because the resistance patterns and the percentages
of resistance were too high throughout
the United States. Started in California, it spread
throughout the West Coast. It spread among men who had
sex with men, MSM populations. And then it has been documented
throughout the states. How are we tracking this? This is busy, I understand. But what this is is a window
into what we have in place. It’s called the Gonococcal
Isolate Surveillance Project or GISP. And there’s clinics in
regional laboratories are located throughout
the United States. And what happens, how do we
keep our finger on the pulse of resistance, is that– and you can see Baltimore
and Maryland STD clinics are members of these. And you can see there’s
labs that are peppered throughout the United States. What happens is, isolates are
collected from the first 25 men who come into
the clinics who have urethral discharge and
approximately 28 states. And what they do is
they send these isolates to regional laboratories. Our regional laboratory
is in Atlanta. And they test it to penicillin,
tetracycline, spectinomycin, superfloxacin,
they’re all listed here, all the cephalosporins,
and azithromycin. And they do it by old
time agar dilution. Figure out the minimum
inhibitory concentration. And they use the
National Committee for Clinical
Laboratory Standards to decide if this gonorrhea
isolate is resistant or not. It is a great system
to keep your finger on the pulse of resistance. And there is a similar
system that’s been set up in Europe and in Great Britain. It’s called GRASP. But we try to keep
on top of resistance through some a
mechanism like this. The Maryland State Lab is one
of the few state labs that still those cultures by the way. And they do track
resistance monitoring, which is good for us. Now, the genetics of resistance
are shown in this slide. It’s Genes to Society
is the name of one of our courses for
the medical students. And this surely is
a representation of how gene is actually changing
and genetics influence society. The treatment that we
used is listed here with penicillin
and tetracyclines. And we had gene
mutations in the gonocci that allowed the gonocci to slip
away from penicillin therapy. It is totally resistant. And they’re all listed here. There’s Eflux pumps
and pen A mutations, et cetera, and plasmids. We have tetracycline plasmas. And they’re listed here as well
floraquinolones, macrolids, and even cephalosporin. So we know where in the
gonocci the genes are mutating and the plasmas
are being formed. So this is a constant
battle between us coming up with better drugs
against gonorrhea who wants to foil them. So, what are the
concerns about treatment? There’s a lot of things
that come into treatment. And you know, let’s start
with patient non-adherence. If you choose say, a medication
that’s not point of care delivered. In other words, you don’t
watch the person swallow the medication, but
they have to take it twice a day or over
five or so days. You worry about adherence. Are they taking
all the medicines? This is common and we deal
with this all the time. There’s also the inadequacy
of screening high risk populations. High risk populations, women who
have sex for drugs or exchange for drugs for money, men
who have sex with men who have anonymous partners, or
for that matter anyone who has anonymous partners or
is entering into a high risk social or sexual network. So are we in the public health
arena actually finding them? Are we screening them? Do we have services
that will afford them to come in in a
non-threatening clinic or situation? That’s an issue. What if I’m allergic to
penicillins and cephalosporins? What do you have
left to give me? We have to grapple with that. Right now we’re dealing
with inadequate access to susceptibility tests, which
I’ll talk about in a second, the use of the new and sexy
nucleic acid amplification tests or NAAT tests are
brilliant in finding the disease. But they won’t tell us
anything at this point about whether the
disease, the gonococci are actually sensitive to
our choices of antibiotics. And then of course, we have
lack of drugs being developed. And there is no
incentives for industry to move forward on that. And then finally,
we want to know, are we really getting
all the disease if we have inadequate
surveillance. And all these things feed into
the limited treatment options and increased number
of resistant gonococci. So in the public health
arena and in the clinics, we have choices
that we have to make and they’re not always easy. So the CDC recommends
right now that we pick for uncomplicated
gonococcal infections of the cervix, of the urethra,
or of the rectum, we choose ceftriaxone, 125
milligrams, which is given IM, intramuscularly
in a single dose, or cefixime, which
is a 400 milligram oral tablet given
in a single dose or you can give
it by suspension. The alternative is
spectinomycin, which we can not get in the United States. Now, you also have
the type of infection complicates the
medication you’re going to pull off the shelf. Because pharyngeal
gonorrhea, and as you all know oral sex
is sex, OK, and you can get a gonococcal
pharyngitis, which I haven’t spent too
much time discussing, but it does not tend
to be symptomatic. It’s not like you
have a strep throat. You can carry gonorrhea in
the throat asymptomatically quite efficiently and pass
it on to someone else. With that site of infection,
you have to choose ceftriaxone because the other modes, the
other, I’m sorry, antibiotics, may not be as
effective in killing, having high enough killing
rates to be easily used. There is no alternative regimen. Spectinomycin doesn’t
have a high enough kill rate for pharyngeal
gonorrhea even if we had it. And for disseminated
infection, we go ceftriaxone,
one gram IM or IV every 24 hours until
we have resolution. And we can chase that
with oral regimens. However as I said, spectinomycin
is not currently available in the United States. And we only were able to start
reusing cefixime in April of 2008. When I say that there’s limited
choices, I’m not kidding. So how do we make– I mean, what feeds into
the choice of antibiotics? Well, it’s who, who to
screen, who to test, where to do the test? And that’s going to determine
what’s used to treat. As I said, treatment is specific
to different sites, cervical, pharyngeal, rectal, I mean,
I just discussed that. And you have to– it’s almost like don’t
assume, if I come in, that I don’t have
gonorrhea of the throat. If I say that, I don’t have sex. You need to ask me the question,
well, what do you mean by sex and have you been exposed and
is there any reason for me to maybe do a culture of
your throat for gonorrhea? Testing different sites, assume
that you talk to your patients about those. So as a clinician, you
know every opportunity to see a patient is
also an opportunity to train them, to talk to
them about what sex is, how you get disease,
and hopefully do a little bit of behavioral
intervention in the meantime. And then you had to pick a
test and that’s not so easy. Now, it is and it isn’t. Diagnostic methods that
are available for gonorrhea are cultures. Cultures are brilliant. They don’t cost very much. They’re suitable for any
of the exposed sites. And you can do anti-microbial
susceptibility testing on a culture. The anatomic sites to
test is in the response to the complaints or clinical
findings and exposure history. See, I can come in
with a discharge, but you have to ask me other– to test also what sites
have been exposed. So you have to engage in
that conversation in persons at significant risk. So in men, urethra in all
men, pharynx and rectum, depending on symptoms
and exposure history, cultures great. Women, cervix should be
tested, pharynx, rectum, depending on symptoms
and exposure history. The vagina may be tested
if you don’t have a cervix. Bartholin’s and
Skene’s glands may be cultured if there’s exudate. And I didn’t show
pictures of that. But if someone comes in
with a Bartholin abscess, certainly you can
culture that discharge that you will see for
gonorrhea and chlamydia. Now, what we’ve
been using however, are the new non-culture tests. And the one that’s
used most frequently is the amplified test, nucleic
acid amplification tests, which are listed here. It could be polymerase
chain reaction tests, which are PCR manufacturers
are listed, transcription mediated
amplification tests, which are called TMA. There is strand
displacement, et cetera. And the advantages
of these tests are that they’re
highly sensitive. The FDA has cleared these
tests, any of these NAATs, for endocervical and anal swabs
from women, urethral swabs from men or even a urine
specimen, a first catch urine specimen from boys or
girls, men or women. So a urine specimen is even
adequate to do these tests and some are listed here. Also, the Aptima
combo two is cleared by the FDA for self-administered
or for administered vaginal swabs. So if a girl says, I don’t
want to get up on the stirrups, I don’t want the examination,
you can do a vegetable swab and send it. It’s that good. Some tests, you
can use one sample, one swab for both
gonorrhea and chlamydia. However, there is a glitch. The FDA has not cleared
these tests overall for oropharyngeal for pharynx
for oral or rectal specimens. Though if your
laboratory has gone through the process of
validating these tests against cultures, it’s fine. But not all laboratories
have actually done that. So again, not only do you have
to be aware of what gonorrhea is doing in your
community, you have to know what the laboratories
in your community where you’re sending the tests,
what they can do for you. There is a concern
about cross-reactivity with some tests, with
other gonorrhea species, particularly in the
oropharyngeal site, and that’s one of the reasons
why it’s not completely FDA cleared. But remember, sensitivity
is as good, if not better than culture. Now there are some non-amplified
tests, which can be used. And they’re listed here. They’re not as sensitive as
nucleic acid amplification test from all sites, no
matter what site. So the test of choice is NAATs. Thus cephalosporins
right now are the only anti-microbial agent
that the CDC and actually probably WHO are recommending
for gonococcal infections. What if I have an allergy
to cephalosporins? That’s an issue. A person with the
penicillin allergy is three times more likely to be
allergic to another medication. And they’re listed here. Dermatologic rashes, et cetera,
is like 1% to almost 3%, fever, eosinophilia as a
result to the penicillin can be as high as 8%. But mind you, look
anaphylaxis is low. You have to ask the
questions however. If I’m a patient that says
to you, when I got penicillin I was intubated, and
had a tracheostomy. That’s a real anaphylactic
reaction and must respect that. However, if I said that
when I received ampicillin when I was six months old
my mother said I had a rash, that may not be a true reaction. So I mean you have to ask
questions and weigh it before you make a decision that
this person is truly allergic. Cephalosporin allergies,
this is what you can use in special populations. Persons who can’t tolerate
cephalosporins or quinolones, CDCs should be treated
with spectinomycin. And now mind you, we don’t
have spectinomycin available currently but this still stays
in the treatment guidelines. And you have to remember that
if you’re going to treat them with spectinomycin, it
will have no activity or not good activity
below I think it’s 75% killing rate for
oropharyngeal gonorrhea. Really, test for allergy
to cephalosporins. It’s currently unavailable,
but some people do desensitize with
starting with very small– allergists, with very small
levels and diluted doses and then ratcheting up the dose. An alternative drug is two
grams of azithromycin orally. You can do this. It is available if they have
true allergy to cephalospirins and penicillins. You got to make sure
however, that they clear, and that they don’t throw up the
2 grams of azithromycin, which can be very, very nauseating. The best option
is to desensitize. Contraindication,
even if isolates are not resistant obviously. Pregnant women should not
be treated with quinolones or tetracyclines. And that’s an issue. OK. Now all is not perfect
with azithromycin. There has been decreased
susceptibility to azithromycin and we must keep this in mind. Again, the most current GISP
Surveillance Project has reported some
resistance and we need to watch that and keep a
lot of focus on this problem because again there are
no medications coming down the pike. So solutions to be
implemented or reinforced is on a national and
international level, but also right here is to
increase surveillance and try to collaborate, this is with
an international partners, because you saw
geography, if you see something going on
in Japan or in Asia, it will come quickly to us. Evaluate the factors associated
with resistance if we can and maintain the capacity
to monitor resistance. You can’t throw out cultures and
susceptibility tests quite yet. Unless we have some new
sexy way to find the gene that’s associated with
resistance and come up with it on the Nucleic Acid
Amplification Test we cannot throw these old time
cultures out so quickly. We need to invest in research
in centers for drug discovery and collaborations with
pharmaceutical industries is part and parcel of
attacking this gonococci. And implement adequate
screening programs for high risk population. Now look, high risk
population is sexually active women less than 25. I mean, that’s
sexually active women. So annual screening for
men who have sex with men. If you are in an HIV clinic and
say you know, my men, my MSM, they’re not having any
sex, everything’s great. Don’t assume that. Ask, how’s your sex life? Did you meet a new partner? Regardless of signs
or symptoms, screen. Should be driven by risk
behaviors not necessarily symptoms. Screen every three
to four months after a confirmed infection. People who have
gonorrhea or chlamydia tend to get it
again, whether it’s because they haven’t gotten
their partner treated or because they don’t
reconnect with their partner, but reconnect with someone
in this sexual network where there’s a high
prevalence of gonorrhea. These people need
to be retested. And then obviously,
treat sexual partners, any sexual partner that can be
identified in the past 60 days. Comments regarding
treat sexual partners. Well, let’s talk about
this for a second. Classic partner services
can indeed play a role here. In other words,
telling the person about the complications
of gonorrhea and asking them to
refer their partner in. In some jurisdictions
actually they still do contact tracing
for gonorrhea. Pittsburgh, Pennsylvania did
an intensive gonorrhea project over a decade ago. And they showed that classic
partner identification and treatment methods
did make a difference. In other words, you’re the
disease intervention specialist at the Health Department. You talked to me and
say, Ann, tell me the names of your partners. If you can’t talk to them,
I will in an anonymous fashion and get these people in. The problem is that we cannot
always sustain these activities because we don’t
have enough funding. So, what we try to do is come
up with a better mousetrap to get partners treated. Counseling the person to tell
their partners is one way. In some states we’re doing
expedited partner therapy. It’s not blessed in the
State of Maryland yet. But if I have
gonorrhea you give me medication to deliver
to my partner. The effect of that is
that I tend not to have as many recurrent infections. So that’s an option. And you can go to
the CDC.gov website look up expedited
partner therapy and see if your state actually
is one of the states where it’s allowed. So overall, this means that
as health care providers we have the option of counseling
people about what they can do and always to refer
their partners in. But you may, as a
health care provider, be contacted by
your local health department for more additional
information on the patient to make sure that their
partners have been treated. So don’t be surprised if someone
from the health department actually contacts you. And they might do this
for gonorrhea and HIV too. It’s all part of
the partner services that we have available
in state and local health departments to try to
contain these diseases. What this means for
your clinical practice, besides using the right drug. Again, this is the get yourself
tested, get yourself talking, get yourself testing
month for clinicians. Remember to be assertive
in your practice and get the discussion going. And don’t assume
that your client is going to raise the issue. Because they may be like my
mother, God rest her soul. They tested me for everything
when I asked her what they did. So you have to make sure
that you start the discussion with your patients. Test multiple sites if that
patient has multiple sites exposed. And then pick the correct
therapy, which we talked about. And always encourage
that patient to get their partners in however
means that you have available. Work with your local
health department. If they are able to
do partner services, then certainly
get them involved. Refer them cases directly. Because we always count
on our laboratories to do the reporting for us. But sometimes you
have to be proactive. And again, I’m going to
say this also for syphilis. Remember gonorrhea
is local, meaning that if you’re
seeing an increase in your patient population,
you should tell the health department so that
they can get word out. Because actually,
you may be seeing an increase in the whole area. And it’s nice to
know, since we’re in the public health arena,
to try to get to that quickly. If you work in an emergency
or urgent care center, anyone that’s listening from out there,
test and treat is a good idea. Yes, test but treat, because
you may not see them again. And try to do follow up with
the local health department to bolster that
care and make sure that the partners
are getting treated, if you can’t contact that
person who was positive. So again, we go back to
limited treatment options and increased numbers
of resisting gonococci. But hopefully we can
attack these one by one. And we talked a little
bit on how to do that. There’s no combination
therapies approved yet. And these are some of
the research questions and clinical trials that are
being considered by the Centers for Disease Control and the
STD clinical trials group. And that’s testing
azithromycin with gemifloxacin, and which is a new type of
cephalosporin quinolone. It may hold promise. In the absence of new
drug discoveries maybe we are going to have to
do combination therapies from all drugs, for
example like gentamycin, to sort of hold the fort
until we can come up with a new medicine. So we’re thinking about this,
but it’s not quite there yet. The Center of Disease Control. I’m not saying that this is
written in stone because I haven’t seen the
treatment guidelines, but they are discussing
on increasing the dose of ceftriaxone
from 125 to 250 milligrams in a single IM delivered dose. The World Health Organization
is already doing that. And I do believe that the
CDC will probably follow suit in their August, hopefully
August 2010 treatment guidelines. If you’re interested,
we’re going to stop. I know a little bit
early but that’s always OK for a lunch lecture. The references are listed here. If you need to have any
information more so. And for continuing
education credits, they are available
from the CDC at listed here www2a.cc.govTCEOnline. It’s listed here. You have to complete the online
evaluation with the course numbers that are listed here. Details to follow
and here they are. I’m going to leave this up. I should go to the next slide. OK. OK. Email questions to
[email protected] And we are open for questions
from the audience or the web. So, let’s go. [APPLAUSE] Yes. AUDIENCE: It seems like there’s
awareness of this issue. Everyone I talk to, even in the
medical profession, are like have never heard this before. I mean, they’re not looking
at STD prevention themselves, it seems like not
a lot of people realize that this is an issue. And I’m just kind of
wondering, why not or how can we get this information
out so maybe people will be a little more cautious
with their sexual practices when they realize
that there’s something out there that they might not
be able to treat eventually? DR. ANNE MARIE ROMPALO:
Should I repeat the question, or are we good? Guys in the back? Do I have to repeat the
question for the online group? No? Oh, I will. Why so people not
aware of this and how can we get the
message out that gonorrhea is becoming resistant and
for your own sexual health you might want to take better
precautions from getting it. You know, that’s
a great question. It’s been in the
academic press, obviously you can see for the past 10
or so years, AND it just hit the press in Britain. I think the CDC will be– I mean, it has, in their website
consistently updated this. And again, it’s for
a lot of clinicians. But I think you walk
a fine line between, as you know from the
School of Public Health, between educating the public
and then causing hysteria. And I think the CDC is trying
to walk that line nicely. We’re not to the
point, I don’t think, that we need to be
hysterical about this. But we need to be cautious
and understand the reasons why this is happening. And with any delivery
of antibiotics, we have to think,
what are we using? Why are we using it? Are we misusing it? And is it appropriate? And you know that’s
just a public health cry in general for resistance. Yes. Dr. Gray. AUDIENCE: Why do you think so
much drug resistance comes out of Southeast Asia, whether
it be with STRIs or malaria? DR. ANNE MARIE
ROMPALO: The question was what do I hypothesize this
is one of the reasons where a lot of the resistance
starts and comes out of Southeast Asia. One of the hypothesis
is that it’s very easy to get
medication over the counter or from a pharmacist
if you walk in and say, oh, I have X, Y, and
Z, and medications are given. And that was one
of the hypothesis as to why quinolones
became resistant at a rapid rate, its over use
and misuse of medications. And I think that
probably drove it. Then some of the history
about how it came across was from tourism
then to the islands. But we have airplanes now that
take resistance everywhere. So I think it was a
misuse of antibiotics or the easy availability. AUDIENCE: Can I ask a follow up? DR. ANNE MARIE ROMPALO: Yes. AUDIENCE: What efforts are
being made to improve drug availability in Southeast Asia? Because even malaria, a
certain resistance is emerging. It’s all coming
from the same place. AUDIENCE: And if you
know, please chime in. But I don’t know of
any programs that are addressing this currently. I think it’s going to
take a serious effort that may be spearheaded by
WHO to address this. But yes, we should. I mean, we’re a global
community and we need to address this
for a lot of diseases. Yes. OK. MOLLY MITCHELL: Three
from the web world. DR. ANNE MARIE ROMPALO: From
the web world we have questions. Let’s go. Do you recommend routine STD
screening among MSM population, screening for both pharyngeal
and genitourinary gonorrhea? Now, OK. Yes. I recommend screening
based on risk behavior. For example, if I’m an MSM, a
man who has sex with other men and I’m mutually monogamous with
my partner, that’s one thing and I don’t need screening. It doesn’t matter if I’m
MSM or not quite frankly. I could be heterosexual,
bisexual, whatever. If I am in a mutually monogamous
relationship, well then, you know, and I truly believe
that and so does my partner, OK. Do you have to screen? No. But if I come in and say,
you know, you say to me, Annem how’s your sex life? And I say, well,
I met someone new. Perhaps you should screen me. A new partner puts you at risk
for gonorrhea and chlamydia. And you need to talk
to me about that. Now screening is different
than a diagnostic test. A diagnostic test, I’m coming
in with signs or symptoms. You’re going after those
signs and symptoms. But screening is
according to risk. If I say that I’ve met– I have one partner, one partner. However, I meant a couple
of people on the internet and had sex with
them on Friday night. That’s risk. So anonymous partner, that’s
risk, and I should be screened. So yes, I do recommend
screening according to risk. Why can’t spectinomycin be
obtained in the United States? I don’t know. It has to do I guess with cost
and whether drug companies want to actually
manufacture it or not. Margin, cost, profit margin. Is suprax being used,
tested, to treat gonorrhea? I believe suprax what’s
the other word for suprax? AUDIENCE: Cefixime. Cefixime. And yes, it is. Suprax is cefixime. And it is recommended as an
oral alternative to ceftriaxone. Tri-x So if you have
it, it’s brilliant. You can give it to your
patient, they swallow it. You watch them swallow it. And always co-treat
for chlamydia with either doxycycline,
100 milligrams twice daily for a week or
azithromycin, one gram orally. But always co-treat. And quite frankly, because
they travel together. Gonorrhea and chlymadia
are good buddies and they travel together. But quite frankly,
it’s probably giving us a leg up on deterring resistance
of the gonorrhea further. Yes, another question. Thank you, internet people. When can NAATs testing
accurately retest a patient after treatment? Dr. Gatos, one of our
specialists is in the audience and she’s holding
up three fingers. Are you saying three days? AUDIENCE: Three weeks. DR. ANNE MARIE
ROMPALO: Three weeks. Yeah. OK. Remember, Nucleic Acid
Amplification Tests are picking up pieces
of the DNA or RNA, that unique bug
that you’re testing. So for gonorrhea, it would be
the gonococcal polymerase chain reaction picking up
pieces of its DNA. It’s not a test of
cure in classic sense, because you’re not
doing a culture. Culture would be, yes,
I’m culture positive, the organism grows,
and you treat me. And then I test to see
if the organism is dead. NAATs will pick
up dead organisms. So you have to give
the body a chance to clear the dead organisms. So that’s designated
three weeks. OK. All right. Another question. Do you recommend test
of cure for persons with positive
pharyngeal culture who are treated with other
drugs than IM ceftriaxone? No. Well, this is for
example cefixime plus one gram of azithromycin
or 2 grams of azithromycin. Test of cure has
not been recommended with the cephalosporine
ceftriaxone or cefixime, in general because the
cure rate is so high. It’s like 97% to 99%,
pharyngeal, cervical, urethral, rectal sites, it’s very good. However azithromycin
ranks in maybe 90% to 95%. You don’t have to
do a test of cure, but if you’re concerned
about it, a test of cure would be nice with culture. So, not with the cephalosporins. I’d consider it with
the azithromycin. Again, it will depend on whether
your patient shows up or not. But the percentage I
think is 93% cure rate with azithromycin, 2
grams for gonorrhea. I’d test the throat though. OK. Could you comment on
health disparities for African Americans
for gonorrhea and how to approach
that as a public health department or provider? There is health
disparity in many, if not all sexually transmitted
infections, gonorrhea, chlamydia is an equal
opportunity offender across the board
with syphilis also. What do we have to
do I think, is we have to make African Americans
in our communities aware, de-stigmatize screening,
and try to get people to engage in coming
in and getting screened and treated. It’s not an easy. It’s not an easy task. With syphilis, I’ll
go to syphilis. With the Syphilis
Elimination Project, which started in 1996
actually, concerted efforts by local health and
national health departments were to get the communities
involved in education, particularly the African
American communities in education about the
disease and where it is and how to get treated. And that really with
community based outreach, that really helped decline
the disparity rates between African Americans
and other races. However, we have to
continue to do that. So it’s not something
that is once and done. We have to educate and
continue the support. Another question, is there any
chance of vaccine development for gonorrhea? I’m laughing because there
are some researchers who are in here that that really
would love to find a vaccine. There is a fervent wish and a
lot of research to that effect. But we’re not there yet. Many people are
pursuing a vaccine, but we haven’t
cracked that code. So are we good? AUDIENCE: Have one
more off the line. DR. ANNE MARIE ROMPALO: Yes. AUDIENCE: For states that are
considering expedited partner therapy, given the
rise in resistance to gonorrhea,
would you recommend that they do chlamydia and
gonorrhea cluster packs and prescriptions or
the chlamydia only. Because really,
you can’t track– DR. ANNE MARIE ROMPALO:
Expedited partner therapy I believe they
give therapy for– AUDIENCE: The question? DR. ANNE MARIE ROMPALO:
Oh, I’m so sorry. The question was,
would I recommend states that are doing expedited
partner therapy to co-treat for gonorrhea and chlamydia? AUDIENCE: Would you
recommend co-treating if a state’s going down the path
towards considering legalizing expedited partner
therapy and they’re trying to consider whether to
do chlamydia only treatment or chlamydia and
gonorrhea treatment? AUDIENCE: Or identify cases. DR. ANNE MARIE ROMPALO:
Or identify cases. Repeat the question. If a state– AUDIENCE: [INAUDIBLE]. DR. ANNE MARIE ROMPALO: If a
state is going down the path to decide what therapies
to use, should they treat for gonorrhea
and chlamydia regardless of the pathogen? Is that what you’re saying? So if I come in with
chlamydia, shall I be treated for
gonorrhea and chlamydia? DR. ANNE MARIE
ROMPALO: I think what– DR. ANNE MARIE
ROMPALO: I am, I– AUDIENCE: It’s, are we so
worried about gonorrhea resistance that EPT should
not be available for them? DR. ANNE MARIE ROMPALO:
OK, so in other ways, are we so concerned about
the resistance of gonorrhea that EPT should not be
available for gonorrhea? AUDIENCE: And should
you only be giving doses to an infected patient to give
to a partner that would only treat chlamydia as
opposed both GC and– DR. ANNE MARIE ROMPALO: No. ,
OK I think that to answer that question, I think it would be
more dangerous to only give azithromycin if someone,
and you missed gonorrhea. In other words, expedited
partnered therapy should I, if– let’s put it in perspective. If I come to see you and I have
had a gonorrhea and chlamydia test already, and
I’m in front of you with chlamydia
only, not gonorrhea, you may choose to give
me expedited partner therapy for chlamydia only. Now, whether that’s
going to have any effect on the
population, I don’t know. However, if I come in front
of you and I have a discharge, and you decide that you’re
going to treat me for gonorrhea and chlamydia and you’re
going to do expedited partner therapy, well then perhaps
you need to do both. Now, we have an expert
here for expedited, EPT, who is going to speak
to that right now. AUDIENCE: So the CDC guidelines
are that you need a documented diagnosis. So the idea presu– if you
treat someone presumptively. I see you today. You’re dripping. I’m going to treat
you today but I’m not going to wait for the results. You can’t give them
[INAUDIBLE] in that case. DR. ANNE MARIE ROMPALO:
OK, so right now, the CDC recommends EPT only when
you have a documented diagnosis of a pathogen.
So in other words, you can’t do syndromic EPT. AUDIENCE: So for
example, in Baltimore, we don’t culture a
man for chlamydia. We don’t do [INAUDIBLE]. So every man is just
diagnosed with AGU, so they are not
allowed to do EPT. DR. ANNE MARIE ROMPALO: Do
you want me to repeat that? No OK. DR. ANNE MARIE ROMPALO: Yes. Dr. Gray, you had a question. DR. GRAY: I’m going to
lay my neck on the block. DR. ANNE MARIE ROMPALO: Uh, oh. Dr. Gray is preparing to lay
his neck on the block for those of you that are online. OK, go ahead. DR. GRAY: We have been
routinely using zithro and cipro non-pregnant and
zithro and cefixime if a woman is pregnant as
treatment for either gonorrhea or chlamydia in Uganda. DR. ANNE MARIE ROMPALO: OK. This is the Uganda
[NON-ENGLISH] study. And they have been
treating women with gonorrhea
with ciprofloxacin and azithromycin Two
grams or one gram? DR. GRAY: We’re up to two now. DR. ANNE MARIE
ROMPALO: Two grams. And then pregnant
women with cifixime and two grams of azithromycin. Now is he in trouble? Well, I tell you,
there is evidence of ciprofloxacin
resistance coming out, hopefully it will
be published soon, from a study done in
Macarere STD clinics by Dr.– oh I’m blocking his name. It will be coming out soon. And there is a high enough
percentage ciprofloxacin resistance in that population
to merit, not using it. Obviously, it
would be nice to do some testing on the specimens
that you get to confirm that. But in general, this is
one of the few studies, and hopefully we’ll
get it published soon, from Uganda that documents
that the WHO old guidelines are no longer applicable. So something to keep in mind. Should we be covering patients
who test positive for chlamydia for gonorrhea as well,
even if they test negative? No. I can answer that simply. The CDC does not
recommend we do that. If you have test
results in front of you, you need to treat according
to the test that’s positive. Otherwise, we’re
going to be again, misusing the gonococcal therapy. What about their partners? I think we just
answered that hopefully with the EPT discussion, that
we treat to the test result. All right. Why are partners in
past 60 days treated and not those six months? Well, because we are
trying to do the best shot at incubation periods. Quite frankly, with gonorrhea,
the incubation period is relatively fast in men. So the incubation
period for a man who has run into someone who
has gonorrhea on Friday night, and is inoculated
with gonorrhea, they would incubate
perhaps for 24 to 48 hours and come in with a discharge
theoretically on Monday morning. We do 60 days because
we’re not always certain how long it takes for
a woman to incubate gonorrhea or chlamydia for that matter. So 60 days is a cushion
whereby we think most transmissions will occur. And that’s why we
do that six months. Actually a study has been
done on how long men, yes, men can remain culture
positive for gonorrhea and be asymptomatic. And actually what
happens, this was done way before internal review
boards were established. This was in the 1960s. And what happens is men who have
been inoculated and infected with gonorrhea and
are asymptomatic, if you follow them
and don’t treat them, they will either become
symptomatic or self cure within about a 60 day period. So that’s also data that
back up this recommendation. There’s another
question buried here. How do you test for
gonorrhea in the throat? Culture. You do a pharyngeal
culture very much like a strep throat
culture, where you go back to the pharynx. And it’s on special media. Thayer-Martin media which is
modified antibiotic media, chocolate auger that’s
cooked and exploded but it has antibiotics in it to
kill the bacteria that grow naturally in the throat
and allow the gonorrhea to present itself. So culture is the way to go. Although, if you have
actually confirmed the use of NAATs testing in your
laboratory compared to culture, you can use that. And the CDC is now
working on recommendations on how to do that, and perhaps
even get that out in press so that labs will know how to do
this and get that ball rolling. Can you comment on
geographic risk? Many with relatively
low risk behaviors are at risk due to prevalence
in their community. That’s absolutely true. Baltimore communities,
I pick on us. I mean, we have a lot of
gonorrhea and chlamydia in certain, in
actually in almost all of our neighborhoods. So if you go out and have
maybe two or three partners, at the age of, I don’t
know, I’ll make this up, 21, you can be at higher risk then
if you go to East Elbow, South Dakota and have two or
three or four or five partners at age 21. Because the geographic
prevalence in that area is not that high. However, if I’m from
East Elbow, South Dakota and I go to Las Vegas
and have three or four anonymous partners,
you know, what happens in Las Vegas doesn’t
always stay in Las Vegas, even though the commercials say
that you can bring that back. So it’s a combination
of geographic risk. But it’s also a combination
of personal risk. And you have to weigh
and screen appropriately. OK. Any other questions? AUDIENCE: Two
chlamydia questions. DR. ANNE MARIE
ROMPALO: OK there’s two called media questions and
then I think we’ll wrap it up and you can all have lunch. Here we go. AUDIENCE: Put the slide up
that shows them how to get– DR. ANNE MARIE ROMPALO: OK. Do you think the
chlamydia rates are high due to patient returning
too soon for a test of cure? No. I do not think that that’s true. I think chlamydia rates
are high because there’s a high prevalence of chlamydia
within the young people community. And I believe that
what happens is, you may meet Prince
or Princess Charming and they’ll be you’re always
and only for about six months, and then you go back
into the infected pool. So I think that that’s one
of the reasons why it’s high. We just have high
chlamydia rates. Has chlamydia has
shown any tendency toward drug resistance? That’s an excellent question. There have been, there have
been some reports out of Sweden, correct, Mary in the back? No. There have been some reports
out of the Sweden area, where there have been some
excelling resistant I believe chlamydia or azithromycin
resistant chlamydia. But it’s not ready
for prime time. It’s not anything that we
need to be worried about. Although in the literature, you
may find one or two reports. But it’s not an issue
as I speak today. I would like to thank
you all for listening. I need to go back to
this continuing education credit from the CDC. To receive credit, complete
the online evaluation and post-test using course
number EC1700 or WD1700. And the origination
date is obviously today with expiration is going
to be up on the web. And you can still
get your CME credits up and including
to May the 21st. OK. Thank you so much. We’re signing off from the
School of Public Health and thank you for listening. [APPLAUSE]

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