Rebellion 21: Clap Back – Gonorrhea and Chlamydia Updates via Jenny Beck-Esmay, MD

Infection rates for gonorrhea and chlamydia have been on the rise in the United States for many years.  In addition, N. gonorrhoeae has the ability to rapidly acquire resistance to antibiotics.  In 2020, the CDC released updated guidelines for the treatment of these common sexually transmitted infections.  In this 14-minute presentation from Rebellion in EM 2021, Dr. Jenny Beck-Esmay, MD reviews the new guidelines and their supporting evidence as well as best practices for the testing of STDs in the emergency department.

Jenny Beck-Esmay, MD
Assistant Residency Director
Assistant Professor
Department of Emergency Medicine
Mount Sinai Morningside – Mount Sinai West
Twitter: @jbeckesmay

Objectives:

1. Review updated antibiotic treatment guidelines for gonorrhea and chlamydia
2. Describe the best practices for gonorrhea and chlamydia testing

Outline:

1. Review epidemiology and increasing rates of GC/Chlamydia in US
2. Review best practices for GC/Chlamydia testing in male and female ED patients
   1. Centers for Disease Control and Prevention. Recommendations for the Laboratory-Based Detection of Chlamydia Trachomatis and Neisseria Gonorrhoeae 2014. MMWR 2014. PMID: 24622331
3. Review new CDC treatment recommendations for GC/Chlamydia
   1. New dosing
   2. When is expedited partner therapy appropriate
   3. What are the best discharge instructions
   4. >

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
• 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: 1^st 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 1^st 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
• 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)

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