2017/18: Annual Critical Review Complete - what's changed?

The latest critical review (2017/2018) of the Australasian STI Management Guidelines for primary care is now complete. 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 the latest review focused on STI and syndrome management. The major changes proposed are to Mycoplasma genitalium, cervicitis, urethritis, PID and anorectal syndromes.

Please read the rationale for the changes here .

Please remember these guidelines are for a PRIMARY CARE audience.

Mycoplasma genitalium

Diagnosis

Diagnosis in males
Test	Site/Specimen	Consideration
NAAT*	FPU	n/a

Diagnosis in females
Test	Site/Specimen	Consideration
NAAT	Endocervical swab
NAAT	vaginal swab (clinician or self-collected)
NAAT	FPU	Not as sensitive as vaginal swab

*NAAT – Nucleic Acid Amplification Test – some also detect macrolide resistance which will guide choice of therapy

FPU – First pass urine

Specimen collection

Clinician collected | Self-collection

Investigations

· Throat swabs are not recommended as pharyngeal infection is uncommon.

· NAAT testing for Mycoplasma genitalium is available in reference laboratories and in some private laboratories. Some tests can detect macrolide resistance mutations which can guide choice of therapy.

Special considerations:

Screening asymptomatic people for M. genitalium is not recommended. Only test those with symptoms and their contacts.

Management

Treating a macrolide-susceptible M. genitalium infection with azithromycin will result in treatment failure and macrolide resistance in about 10% of infections.

Macrolide resistance is likely to be present in at least half of infections in Australian cities, based on studies from the eastern states. At one centre resistance was present in 50% of infections in heterosexuals and 80% in MSM. Resistance to fluoroquinolones is present in 10 – 15% of infections.

Doxycycline is ineffective in two-thirds of infections but will lower bacterial load in most cases, increasing the likelihood of cure with a subsequent antibiotic.

Pre-treating M. genitalium infections with doxycycline 100mg bd for one week and then treating susceptible infections with azithromycin and macrolide-resistant infections with a fluoroquinolone eradicated >90% of infections.(4)

Without access to resistance testing, it is reasonable to assume macrolide resistance in infections persisting after failure of azithromycin and in MSM.(3)

Principal Treatment Options
Situation	Recommended	Alternative
M. genitalium infection known or suspected to be macrolide-susceptible	Doxycycline 100mg bd for 7 days followed by Azithromycin 1g stat then 500mg daily for three days (total 2.5g)*	Doxycycline 100mg bd for 7 days followed by Azithromycin 1g single dose*
M. genitalium infection known or suspected to be macrolide-resistant	Doxycycline 100mg bd for 7 days followed by Moxifloxacin 400mg daily for 7 days
Pelvic inflammatory disease due to M.genitalium	Moxifloxacin 400mg daily for 14 days**

*It is not known to what extent the improved outcomes resulting from the use of doxycycline followed by 2.5g azithromycin are due to this dose of azithromycin, rather than simply the pre-treatment with doxycycline. The higher dose of azithromycin requires a private prescription.

**M. genitalium results are often received about a week after PID treatment has begun. After a good response to treatment it may be reasonable to shorten the course of moxifloxacin to ten days, due to the cost and potential toxicity of this drug, however this has not been studied.

Moxifloxacin requires a private prescription, cannot be used in pregnancy, and is expensive and is associated with diarrhoea, occasional tendinopathy and rare neurological and cardiac events.

Other immediate management

ü Advise no condomless sex until tested for cure (14 days after completion of treatment).

ü Advise no sex with untested previous sexual partners.

ü Provide patient with factsheet

ü M. genitalium is not a notifiable condition.

Special treatment situations

Special considerations

If moxifloxacin fails or cannot be used, seek specialist advice.

Contact tracing

· In heterosexuals the risk of PID and reproductive complications suggests a greater need to trace, test and treat infected contacts. The time period for contact tracing is unknown.

· Asymptomatic infection and macrolide resistance are more common in MSM and there is only limited evidence that this is harmful. As moxifloxacin will probably be required for treatment, contact tracing may be best confined to continuing partners of a symptomatic person.

See Australasian Contract Tracing Manual – Mycoplasma genitalium for more information.

Follow up

Test of Cure (TOC)

TOC by NAAT should be done at least 2 weeks after treatment is completed ie 4 weeks after commencing therapy.

Ano-rectal syndromes

Specimen collection

These should always be clinician collected as the patient should be examined. Ideally this should be done via proctoscope. If patients are reluctant to undergo anorectal examination the importance and benefits of physical examination should be explained with respect to achieving an accurate diagnosis and appropriate management plan.

Special considerations

·     Ano-rectal chlamydia that presents with proctitis should raise the suspicion of LGV, which requires a longer course of treatment

· STIs are a neglected cause of proctitis. All patients with proctitis should be assessed for risk of STIs and tested if indicated.

·     If syphilis is suspected, consider testing with anal swab for treponemal PCR and syphilis serology. Due to the window period, syphilis serology may not detect primary syphilis that presents with proctitis.

·     If the patient is a known contact of M. genitalium, or if no other infectious cause for proctitis is found, consider testing for M. genitalium by ano-rectal swab for NAAT

·     Rectal infections are commonly accompanied by concomitant infection at other anatomical sites.

If the patient is a man who has sex with men (MSM), consider additional testing.

Syndromic Treatment of nonspecific proctitis

· doxycycline 100mg PO bd for 21 days,

· PLUS ceftriaxone 500mg in 2mL of 1% lignocaine, IMI stat

· PLUS Valaciclovir 500mg PO, BD for 5 - 10 days.

Treatment advice

·    If specific STI test are negative, corresponding treatment for the pathogen can be ceased.

·     Testing for LGV may not be available in some locations, or turnaround time for results may be lengthy. Single doses of azithromycin are unreliable for treating LGV.

·     Limited evidence comparing other antiviral agents (aciclovir) with valaciclovir indicate that they are therapeutically equivalent for treating herpes. The ability for the patient to adhere to the recommended dosing frequency should be considered when selecting the appropriate treatment. Initial episodes of herpes may require a longer duration of treatment.

· If all tests are negative, all medications are ceased and yet symptoms persists then seek specialist advice

PID – Pelvic Inflammatory Disease

Management

Azithromycin has been removed as a treatment recommendation for mild to moderate infections (see table below).

Principal Treatment Options
Infection	Recommended
Mild – moderate Outpatient treatment	Ceftriaxone 500mg in 2mL of 1% lignocaine IMI, or 500 mg IV, stat PLUS Metronidazole 400mg PO, BD for 14 days PLUS Doxycycline 100mg PO, BD for 14 days

* If M.genitalium confirmed 2 weeks of Moxifloxacin 400mg daily for 14 days

Urethritis – male

Management

Principal treatment options
Infection	Recommended	Alternative regimens
NGU likely	Doxycycline 100mg PO, BD for 7 days	Azithromycin 1g PO, stat
Gonorrhoea likely	Ceftriaxone 500mg in 2mL of 1% lignocaine IMI, stat PLUS Azithromycin 1g PO, stat	Ceftriaxone 500mg in 2mL of 1% lignocaine IMI, stat PLUS Doxycycline 100mg PO, BD for 7 days
Mycoplasma genitalium	After completing doxycycline, use either azithromycin or moxifloxacin. See Mycoplasma genitalium {link}	Seek specialist advice

NGU – Non-gonococcal urethritis

Treatment advice

o   Ceftriaxone is the most effective treatment for gonorrhoea but azithromycin is usually added to reduce the chance of resistance emerging.

o   Azithromycin is effective for chlamydia but will fail and select resistance in at least 10% of M. genitalium, therefore doxycycline is preferred for NGU.

o   When NGU is considered likely but you would also prefer to treat a potential case of gonorrhoea, it is reasonable to add doxycycline instead of azithromycin to ceftriaxone.

If symptoms do not resolve, seek specialist advice for management of persistent NGU, including M. genitalium (often resistant), herpes simplex virus (HSV) and adenovirus.

Cervicitis

Management

In the absence of a definitive causative organism, in a woman with increased risk of STI treat syndromically.

Principal treatment options
Situation	Recommended	Alternative
Unknown organism	Doxycycline 100mgPO. BD for 7 days	Azithromycin 1g PO stat

Ano-genital lumps

LGV removed from guideline

Epididymitis

Treatment

Ceftriaxone 500mg in 2mL of 1% lignocaine IMI, stat

PLUS EITHER

Doxycycline 100mg PO, starting the next day, BD for 14 days

OR

Azithromycin 1g PO, stat and repeated 1 week later

Chlamydia

Management

Doxycycline 100mg PO, BD 7 days

OR

Azithromycin 1g PO, stat

(Rather than Azithromycin listed as an alternative)

Herpes

Management

Principal Treatment Options
Situation	Recommended	Alternative
Initial episode	Valaciclovir 500mg PO, BD for 5 -10 days	Aciclovir 400mg PO, TDS for 5 -10 days

Trichomonas

Management-

Diagnosis in females
Test	Site/Specimen	Consideration
NAAT	High vaginal swab or FPU	High vaginal swab should ideally be clinician collected during pelvic examination but can be self-collected if client declines examination.
Other	High vaginal swab (wet prep)	TV can be found on a high vaginal swab (wet prep) by the laboratory if TV is requested. However this test has poor sensitivity compared to NAAT testing.

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

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.

Chlamydia

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.

Ectoparasites

• 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.

Epididymo-orchitis

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.

Gonorrhoea

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.

HIV

• 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.

Trichomoniasis

• 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.

Tuesday, 10 April 2018