2016: Annual Critical Review Complete - what's changed?

Posted in Updates

The latest annual critical review of the Guidelines was complete in April 2016. The Editorial Committee conduct this annual review to ensure the Guidelines are aligned with the latest research and best practice developments.

Whilst the critical review is conducted annually, the Guidelines are a living document, for which we welcome your feedback on an ongoing basis.

What’s changed? This year’s review focused on changes to recommendations regarding STI and Syndrome management. The following is a list of noteworthy updates (per guideline, in alphabetical order).

Ano-rectal syndromes:
• For rectal coinfection with gonorrhoea and chlamydia, treatment should be given for both infections i.e.: Ceftriaxone 500mg IMI, stat in 2mL 1% lignocaine PLUS Azithromycin 1g PO, stat PLUS Doxycycline 100mg PO, BD 21 days – 21 days Doxycycline also covers treatment of untested LGV.

Bacterial vaginosis:
• The principle treatment option for Metronidazole 400mg PO, BD with food now 7 days.

• Treatment with Doxycycline 100mg BD PO 7 days is equivalent to Azithromycin 1g PO and covers emerging evidence of undiagnosed rectal CT in women and MSM). Failure of Azithromycin to treat these sites is possibly contributing to persisting infection.
• Contact tracing: consider the use of patient delivered partner therapy (PDPT), where appropriate. PDPT is currently legal in VIC and NT.

• Special treatment situations: for less severe crusted scabies, use: Ivermectin 200mcg/kg PO, on days 1, and second dose between day 8-14 (additional dose maybe required for moderate –severe scabies, seek specialist advice).
• For persistent infection: Ivermectin 200mcg/kg PO, on days 1 and 8-14, not before 4 weeks after failure of both topical Permethrin and Benzyl Benzoate.

• Possible causes: in sexually active men of ANY age, Chlamydia trachomatis and Neisseria gonorrhoeae remain the most likely cause. In men who practise insertive anal sex, and men who have had recent instrumentation, enteric pathogens (for example, Escherichia coli and Proteus spp) become increasingly likely.

• Special treatment situation: rectal coinfection with chlamydia, includes recommendations to treat each infection separately using Doxycycline 100mg PO, BD: 7 days if asymptomatic, but 21 days if symptomatic.

Hepatitis B:
• In diagnosis: on the request form, specify 3 tests (HBsAg, Anti-HBs & Anti-HBc) or include “? Chronic hepatitis B”.
• All patients with cirrhosis require treatment with long-term oral antiviral treatment which is available from specialist services and suitably trained GPs.

Hepatitis C (Updates in line with updates to DAA availability on the PBS, as of 1 March 2016):
• All hepatitis C (HCV) antibody positive/ and hepatitis C RNA positive patients should be offered HCV treatment in consultation with an authorised HCV treatment provider.
• For further details see http://www.ashm.org.au/HCV/management-hepc.

• All people with HIV should start ART as soon as possible after diagnosis.
• For diagnosis: point of care testing is now available.
• Contact tracing: Pre-exposure prophylaxis (PrEP) is an important new prevention option and can provide highly effective biomedical HIV prevention in HIV-negative individuals. See the National PrEP Guidelines.

Mycoplasma genitalium:
• Several commercial assays are likely to become available in 2016/2017.
• Azithromycin 1g PO is effective in up to 60% of infected individuals and only those with persisting symptoms should have further treatment.
• MG is developing resistance to single dose macrolide treatments used for Chlamydia trachomatis, complicating the choice of first line treatment of urethritis for some men.

PID – Pelvic Inflammatory Disease:
• The majority of cases have no identified cause.
• All women of reproductive age with new onset abdominal pain should have urine pregnancy test and, if positive, urgent pelvic ultrasound; testing for STIs as indicated in diagnosis; and, urinalysis for UTI.
• Pelvic ultrasound is useful to detect alternative causes of pain, if the diagnosis is uncertain.
• Clinician collected specimens is recommended although self-collection is acceptable if examination declined.
• Begin treatment immediately, and consider admission in case of suspicion (or definitive diagnosis) of a pelvic abscess.

• Testing is currently available through private pathology companies.

Urethritis – male:
• Possible cause: Mycoplasma genitalium is developing resistance to single dose treatments used for Chlamydia trachomatis, complicating the choice of first line treatment of urethritis for some men. CT at non-genital sites may not be treated adequately with single dose treatments.