Jenny Beck-Esmay, MD
Assistant Residency Director
Assistant Professor
Department of Emergency Medicine
Mount Sinai Morningside – Mount Sinai West
Twitter: @jbeckesmay
Objectives:
- Review updated antibiotic treatment guidelines for gonorrhea and chlamydia
- Describe the best practices for gonorrhea and chlamydia testing
Outline:
- Review epidemiology and increasing rates of GC/Chlamydia in US
- Review best practices for GC/Chlamydia testing in male and female ED patients
- Centers for Disease Control and Prevention. Recommendations for the Laboratory-Based Detection of Chlamydia Trachomatis and Neisseria Gonorrhoeae 2014. MMWR 2014. PMID: 24622331
- Review new CDC treatment recommendations for GC/Chlamydia
- New dosing
- When is expedited partner therapy appropriate
- What are the best discharge instructions
- https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm
- https://www.cdc.gov/std/tg2015/chlamydia.htm
- https://www.cdc.gov/std/tg2015/gonorrhea.htm
Gonorrhea and Chlamydia Updates
- Despite improvement in treatment, infections are on the rise
- Between 2015 – 2019
- Chlamydia infections increased by 19%
- Gonorrhea infections increased by 56%
- With increase in cases, we have also seen an increase in resistance
- Between 2013 – 2018
- Gonorrhea infections with reduced susceptibility to azithromycin has increased from 0.6% to 4.6% (This is a 7-fold increase in just a few years)
- In 2019, >50% of gonorrhea infections in the US were resistant to one antibiotic
- Between 2015 – 2019
- Previous empiric treatment that was recommended (Prior to Dec 2020):
- Ceftriaxone 250mg IM x1 + Azithromycin 1g PO x1
- However due to rising resistance this is no longer recommended
- NEW, empiric treatment recommended (Since Dec 2020):
- Ceftriaxone 500mg IM x1 + Doxycycline 100mg PO BID x7d
- Special Circumstances:
- Pregnant Women: Ceftriaxone 500mg IM x1 + Azithromycin 1g PO x1
- Obesity (>150kg): Ceftriaxone 1000mg IM x1 + Doxycycline 100mg PO BID x7d
- Discharge Instructions:
- Abstain from sexual intercourse until completion of entire antibiotic course + resolution of symptoms + partner completing treatment (Expedited Partner Therapy)
- Expedited Partner Therapy: Cefixime 800mg PO x1 + Doxycycline 100mg PO BID x7d (This does not cover for PID or TOA)
- Patients should be offered testing for HIV and Syphilis
- Since 2015, incidence of HIV has remained fairly stable
- Since 2015, incidence of Syphilis has increased by 74%
- Testing:
- Male: 1st catch urine sample (Not a clean catch urine – midstream) as good as urethral swab
- Female:
- Vaginal swab as sensitive as cervical swab (Can be collected by the patient themselves)
- Urine: Needs to be 1st catch urine (Not a clean catch urine – midstream); Not as sensitive as vaginal or cervical swab
- Recurrent Symptoms/Visits + Negative Testing for Gonorrhea/Chlamydia:
- Recurrent empiric dosing of antibiotics is most likely making resistance to treatment worse
- Male: Think about Trichomonas vaginalis and/or Mycoplasma genitalium
- Female:
- Think about Trichomonas vaginalis, Mycoplasma genitalium, abnormal vaginal flora, irritants, and/or dysplasia
- Disparities
- In 2019:
- Over half of all reported STIs were in adolescents and young adults (ages 15 to 24 years)
- Just over 30% of reported STIs (gonorrhea, chlamydia, & syphilis) were in non-Hispanic, black patients even though they make up about 12.5% of the US population
- Men who have sex with men are also disproportionally impacted by STIs
- This is most likely due to lack of access to high quality sexual health care and not sexual habits alone
- In 2019:
- Take Home Messages:
- STIs are on the rise
- Antibiotic resistance is also on the rise
- New empiric treatment regimen: Ceftriaxone 500mg IM x1 + Doxycycline 100mg PO BID x7d (Remember that pregnancy and obesity (>150kg) have different recommendations)
Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)
The post Rebellion 21: Clap Back – Gonorrhea and Chlamydia Updates via Jenny Beck-Esmay, MD appeared first on REBEL EM - Emergency Medicine Blog.