natural treatment for the disease gonorrhea disease

hello i'm linda desantis with thecalifornia prevention training center and i'm here today with dr. ina park. welcome ina. thanks linda, and it's great to be here. ina's the medical director ofthe california ptc and an associate professor in the department of familyand community medicine at uc san francisco school of medicine recentlydr. park was one of the contributing authors to the 2015 cdc std treatmentguidelines which will be discussing here today. it's very exciting. thanks linda, and you know, since 2010have been so many changes both in populations, in the bugs, as well as inthe treatments so i'm really excited to

launch into my sort of top-10 changesfor both you and the providers out there watching. so we're going to talk firstabout how stds are on the rise here in the us and then we're going to talkabout screening of certain populations at risk for stds then we're going tolaunch into gonorrhea therapy and that's sort of one of the most importantchanges in the guidelines for this go round. and then we're going to talk about a new bug on the block that's a sort of newly identified std that folks might not knowabout might want to hear about called mycoplasma genitalium and then we'regoing to talk about hpv vaccination because there's some new developmentsand new vaccines available and then

we're going to talk about managingpartners of patients with stds and also retesting after someone's been diagnosedbecause those are key factors in sort of controlling the spread of stds and thenfinally there's going to be two great resources for providers that i want totalk about at the end so that's my top 10. well i've been hearing a lot in themedia about the rise of stds in the united states. can you talk a little bitabout that? i can. you know i'm going to actually talk for the audience about allthree of the major bacterial stds which are all reportable to the cdc and infact the first one i'm talking about,

chlamydia, is the most commonly reportedcondition to cdc of actually any reportable condition so it's justincredibly common, over a million cases reported per year and i just wantfolks to notice that on the graph here you'll see that chlamydia is increasingboth in women and men and you can see women on the top and men with the lineon the very bottom and the total population in the middle. and you'll seethat there's also increases, although they aren't asdramatic as with chlamydia, in gonorrhea and you'll see that in 2014 there's alsoa slight increase as well. and that's for both men women and the total population.and now when we look at syphilis there's a

really interesting story here and thatyou'll see syphilis overall in the total rate with the dashed line is increasingbut it's increasing much more among men than it is among women and then you'llsee the male-to-female ratio of syphilis is quite dramatically increasing becausethe number of men getting syphilis is far outweighing the number of womengetting syphilis. and i'm not sure if you realize this linda, but actually 2014is the first time since 2006 that all three of these stds have gone up atthe same time. so we have a lot to to tackle here. and then one thing that i'mnot sure if you're aware of as well is how the syphilis epidemic isparticularly affecting certain

populations including men who have sexwith men. so i just want to show this graph here which is from one of ourcolleagues at cdc but you'll notice if we look at the sort of epi curves formen who have sex with men in the green you'll see that in the you know latesixties with the stonewall riots and sort of the gay sexual revolution thatwe had a huge increase in sort of sexual behavior and increases in syphilis but then in 1981 when we had hiv andaids sort of hit the scene as you probably remember people were dying andthey were not out there having a lot of sex and so you'll see that the amount ofsyphilis just crashed. and in the late

90s early 2000s we were actually talkingabout eliminating syphilis in the united states but then you'll see that in late 1996 we had the development of antiretroviral therapy and so peoplestarted feeling better they started having more sex and unprotected sex andthen you'll see that the increases in syphilis happened again and i just wantto point out that syphilis rates among men who have sex with men are soon going to be similar to those of the nineteen eighties just in a couple of years. so asproviders we have a lot to deal with in terms of preventing infectionsin this population and other populations at risk for stds. interesting can yourefresh us though on the cdc

recommendations for std screening among some of these populations? yeah i can and i'm glad you asked aboutthat because you know we had talked about the rise and syphilis in men whohave sex with men and so cdc has for many years actually even before with the2010 guidelines have really recommended at least annual screening for stds amongmen who have sex with men who are sexually active and you know you can seeon the slide here that they're listed out for someone who doesn't already yetknow their hiv status you know they recommend an hiv test atleast annually and then testing for syphilis and urethral gonorrhea andchlamydia and then if folks are having

receptive anal sex then they should alsobe tested for rectal chlamydia and gonorrhea. and then if they're alsogiving oral sex they should also be tested pharyngeal gonorrhea. and the thing is that those tests, that testing, should be done at least annually butthen for folks who are out there having multiple partners or anonymous partnersor perhaps meeting folks online and if they're also having sex in conjunctionwith crystal meth use or other illicit drug use then those folks should probably bescreened about every three to six months. and then in the bottom of the slideyou'll notice that there are three other

std tests recommended butthey're not as firm of recommendations and not as sort offrequent screening so for herpes serology it's sort of a softrecommendation it's not universally recommended and then for hepatitis bthat is recommended at least once but then the frequency isn't reallyspecified and then for hepatitis c, that's sort of a new recommendation for thosethat are hiv-infected to screen them at least annually. and then i'm not sure ifyou're aware of this linda but the cdc's finally acknowledging that you knowtransgender populations are at risk for stds and should be acknowledged in thetreatment guidelines so 2015 is the

first year they're gonna be doing that. well yeah, so that's an exciting change. it is, it really is. this is the firsttime they're actually going to be talking about both transgender men andwomen and i think there's not a huge amount of text in this particularsection but i think it's great to raise awareness and one thing that theymention to providers such as you and i is that we really need to consider theanatomic diversity for our transgender patients and transgender women mayactually have a penis and a transgender man may actually have avagina and cervix and therefore be at risk for example for cervical cancer. andso i think what the guidelines does

emphasize is that we need to take asexual history but then you also need to figure out sort of what anatomy you'redealing with and then screen accordingly. so i have two examples on the slidewhich i think you would probably agree would be sort of different in terms ofrisk and one of them might be like a forty-year-old transgender woman, this isactually based on someone i know, who has multiple male partners contrast that to a forty-year-oldtransgender woman who actually only has one female partner. so that's a really differentsort of risk profile and it's just also

to point out that just because someoneis a transgender woman you can't really tell sort of what they're sort of sexualorientation or attraction to folks might be so you really need to ask about thatas well. and then finally, this is relevant i think to both of us as women,is that std screening for women is still routinely recommended and that's beengoing on for many years so that's not really a change but i did want to pointout that now finally the us preventive services task force as well as the cdchave come together and finally agreed that sexually active adolescents andadults under 25 need to be routinely screened for chlamydia and gonorrhea.everything else actually is not

routinely recommended but it's just sortof based on risk. and then for women 25 years of age and older and that iswhat's considered an "older woman" in the cdc in the std world, which is a littledepressing i think for us, but i'm std and hiv testing is not routinely recommendedexcept for based on risk and this is different than the sort of universalrecommendation for hiv screening that's put out by cdc for all people 13 to 64.this is we're talking about sort of is routine as std testing recommended in awoman 25 years and older and it's not really routinely recommended unlessthey're having multiple partners or have other risk factors. and then forpregnancy

there's a huge list here of screeningtests that are done routinely in pregnancy but that hasn't changed for years andyears. so in addition to the transgenderscreening what are some of the critical changes in the treatment and preventionthe providers need to know in the new 2015guidelines? you know i think the biggest change is really for gonorrhea treatmentand i'm going to talk a little bit about both the changes in the treatment aswell as sort of our increasing concern about antibiotic resistant gonorrhea. andso for gonorrhea now we used to think about it is something that you could doand treat with just one shot and you're

out the door but now we actually need totreat all gonorrhea infections with two drugs and so similar to what we would dowith tuberculosis or hiv where you can't really get away with single drug therapy the same is true now for gonorrhea. so wetreat all gonorrhea infections with ceftriaxone 250 milligrams which is anintramuscular injection and then also as azithromycin one gram in a singledose. now you'll see on the slide that there is actually another recommendedregimen that's been crossed out and that was recommended in the 2010 guidelinesbut now they're seeing so much antibiotic resistance to this particularantibiotic that it's now been removed

and so it's a big change. so now wereally only have these two drugs as first-line agents for gonorrhea. and soyou know for folks that can't have access to in intramuscular injections ifthe clinic doesn't happen to have those you can use an oral alternative and thenone of the other big changes i wanted to highlight for you was now in case ofsevere allergy we used to be able to treat with one drug and now again wehave to treat with two drugs and the two drugs are listed here: they're gentamicin240 milligrams and azithromycin 2 grams or gemifloxacin 320 milligramsorally and azithromycin two grams. so again the common theme is we haveto use two drugs to treat gonorrhea and

one issue here is that the sort ofbottom line here the gemifloxacin is currently not being manufactured in theus but i know that folks are working with the manufacturer to get that goingagain because this is a drug we need for alternative treatment for gonorrhea. andi also want to point out that cdc again removed doxycycline as analternative option unless someone has a severe allergy to azithromycin. and so i'mnot sure if you saw this infographic when cdc released it but they werereally trying to sound the alarm out in the public that gonorrhea and antibiotic resistant gonorrhea is an urgentthreat to public health because i think

they really want folks to pay attentionand make sure that they're treating with two drugs for example and sticking tothe guidelines and so this is something that they released sort of anticipatinghow many cases we might expect if gonorrhea antibiotic resistancecontinues at its current pace. so it's a little bit frightening but i am gladthat cdc's paying attention to it. that seems to be a lot of information outabout it so hopefully people are getting the messages. yeah i agree. and then i'm not sure ifyou saw these data but they are a little bit sobering because we were allcelebrating last year when we saw that

antibiotic resistance for gonorrhea seemto be going down and so you might have a chance to look at the the graph that i'mshowing here on the screen that antibiotic resistance to ceftriaxonewhich is one of the recommended drugs that i had mentioned earlier started toincrease and then in 2011 it peaked and we started getting really nervousabout the fact that we might be running out of drugs to treat gonorrhea. then in 2012-2013 it started to go down so we were actually having a feeling of reliefand then in 2014 we saw an increase again so i think that means we reallycan't stop being vigilant. and so i think if yourself or other providers outthere are seeing someone and they're

concerned that the person might havegonorrhea treatment failure i think the first thing that they might want to dois get a gonorrhea culture so that we can test to see what antibiotics thatparticular isolate might be susceptible to. and then you'd want to repeat thetreatment with one of the combinations of drugs that i had mentioned to youearlier and then you also want to call your local health department becausethey definitely want to know if you see it a case of antibiotic-resistantgonorrhea and the cdc is also published their phone number for theepidemiologist who is actually responsible for these cases and thatnumber is also on the screen and then

you also want to make sure all thepartners within 60 days get the same treatment that the patient receivedbecause if you're dealing with a really violent strain here you really want tostop it as soon as possible and then you'll really want to bring that patientback and make sure that they're cured and you know do a swab of their throat or rectum or have themdo a urine specimen and check them again to make sure they were actually cured ofthe infection which i'm sure makes sense. you know one of the other things that iwanted to talk to you about was a new sort of bug that has been identified andgiven a new section in the guidelines and

this bug is called mycoplasma genitalium. it's not as if we haven't known about it but this is the first time it's sort ofgetting its own proper section in the guidelines and that is because folks arerecognizing that it's contributing to about thirty percent of the urethritisthat's persistent so that sort of inflammation of the male urethra thatdoes not get better after initial antibiotic treatment. so this bug isabsolutely a player in sexual transmission and persistent andsymptomatic urethritis in men. the issue is we don't have a diagnostic test forit which as you can imagine would make it challenging but the other issueis that there are very few antibiotics

we can use to treat this particularinfection, so you can use azithromycin which is better than doxycyclinewhich is another drug that's used for urethritis, but unfortunately astudy done in about 2013 showed that that drugs efficacy is nowdeclining so we really only have one antibiotic called moxifloxacin that willwork against this particular bug. so if you see a theme that we're sort ofgetting down to just a few drugs that we can use for any of these particular stds.it's been in the media, too. yeah, it's a little scary. it is a little bit scary. and soone thing i want to point out is that if somebody has this persistent you knowdischarge or burning when they're going

to the bathroom you might suspect thatthey have this infection with mycoplasma genitalium and so the cdc guidelineshave actually now been issued to include moxifloxacin which as i mentioned is thethe right antibiotic to treat that particular bug. so even if we can't testfor it, if you have a patient is coming in who's just not getting better, then youknow the thing to do would be to do one of these regimens that includes moxifoxacin and folks can see that on the slide as well. and then i also wanted totalk because this is a very sort of exciting thing in the prevention world,linda, because i know you and i have both hoped for vaccines for stds,you know, for a very long time and

finally at least for hpv we now havethree vaccines available in the us, which i think is really exciting. and there's abivalent vaccine with two types that are cancer-causing types that cause cervicalcancer as well as head and neck cancer and anal cancer then we have aquadrivalent vaccine that prevents also the cancer-causing types as well as 2 non-oncogenic types that cause genital warts, that's type 6 and 11. and thenthere's also another product by the same company which is the 9-valent ornonavalent vaccine that has not only the quadrivalent types but then five othercancer-causing types. the nice thing is is that just indecember of 2015 the fda finally

harmonized all the age recommendationsand so now that 9-valent or nonavalent vaccine is approved for females andmales 9 to 26 years of age so it's very exciting. i mean i think providers might beconfused about you know what they should do when they have, you know, half a stockof the quadrivalent and they're switching over to the 9-valent. but ithink the acip put out a nice statement, and i'm just going to read it to folkshere, but they said that you know if vaccination providers don't haveavailable the actual hpv vaccine product that they previously administered, orthey're in a setting transitioning to

the 9-valent vaccine, that they reallycan use any product to complete the series so it's really flexible, you knowwhat i mean, in terms of letting the provider sort of use whatever they haveon hand. and then the other thing that i wanted to mention that people ask me allthe time is should we revaccinate people who got either the bi-valent or the quadrivalent now that we have something new and you know maybe betterwith nine types, and the answer really is no. right now there's not going to be anyrecommendation from the advisory committee on immunization practices torevaccinated people and start them all over again.

so those are sort of the major changesthat i anticipated in the guidelines that i thought were the mostimportant for the audience to know. you did mention partner treatment and i'mwondering if you could expand a little bit on treating stds and partners andhelping ensure that stds don't spread in the community. you know that's a hugeissue linda because as you know it takes at least two orsometimes three or four people to tango and if you don't stop the spreadof the infection, as you know it will sometimes cause an outbreak or actuallyspread through a community really quickly, so partner management is soimportant and i think the ideal thing as

you would probably agree is if we couldactually bring the person in for care that would be wonderful but as you knowthat doesn't always happen because people don't have access to care orthey're just reluctant to come in for other reasons and so the other thingthat we could do is, you know, for example if i were calling you up and wanting youto come and get treated for an std i could ask you to bring your partner withyou and treat you both at the same time. that's called concurrent patient andpartner treatment. so that's now listed in the cdc guidelines as an option ifyou're speaking to your partner still after being diagnosed diagnosed with anstd you could actually bring them in and

you can both be treated at once. theother thing that cdc is really pushing heavily is this idea of expeditedpartner treatment. have you heard of that before? i have, yeah. so that would be you know if youtold me my partner is not coming in for treatment and you know i would reallylike to give this person something so that they don't actually need to come inand see a provider, in the state of california that has been legal forchlamydia since 2001 and for gonorrhea since 2007. so actually i'mtotally within my rights to give you a package of medication and have you takethat to your partner and i actually

don't need to do an exam on that partner. this is not ideal, i think it's better tobring, you know, your partner in, but at any rate, this is a legal practice forchlamydia and gonorrhea here in california. and even though cdc doesrecommend this sort of practice just for heterosexuals or men having sex withwomen, women have been having sex with men, the truth is our guidelines here in thestate really don't discriminate based on gender of sex partners. so we do havepractices that are using it for men who have sex with men, for example. and i just want toshow on this map

you know this map, maybe 10 years ago, hadmany more red states than green states and you'll see that the green states arewhere this practice is allowable by law and you can see that the entire unitedstates is almost green. so we've made so much progress,linda, in the past few years and many states have worked really hard to getthis done. and you know i think as you mentioned, you know stopping the spreadof stds in the community is really important and one factor that's at playis that people who get stds often get reinfected soon after they leave youroffice. and in fact about fifteen percent of women with chlamydia will get itagain within three to six months. and so

now one thing i wanted to point out withthe guidelines is that the cdc recommends that any woman with chlamydia,gonorrhea or trichomonas actually get rescreened at three months after theyget treated because all three of those are so commonly really you know they'rethey're commonly sort of acquired again either through new partners or through apartner who isn't treated in time. and then also they finally added that menwho test positive for chlamydia and gonorrhea also should be retestedbecause again they're also a factor for heterosexual women in getting reinfectedand sort of ping-ponging the infection back and forth. and the other thing thati know you're really aware of as someone

who's been active in the field of hiv,that anyone with an std could be at risk for hiv as well so cdc does recommendthat if someone is diagnosed with a bacterial std that they should gettested for the other bacterial stds and definitely get screened for hiv. so theguidelines might seem really comprehensive but it might bechallenging for providers to sift through some of that information. arethere resources available that can help with that? yes there are, and in fact this is myfavorite part of the discussion because cdc's really invested in making theseguidelines more accessible and easier to

reference and so i just want topoint out for those folks that have either a smartphone using the android orthe apple platform that there is a free app from cdc and so you can actuallylook through the guidelines you can download this obviously from either, youknow, the the app store on apple or wherever you download your android apps and you caneither do a condition quick pic so you can look conditions up really quickly orif you want to geek out you can read the entire document all hundred and thirtyseven pages of it on your phone. i do want to point out there are somelook-alikes who'll try to charge you but this app is absolutely free so youshouldn't be fooled. and the other thing

i wanted to point out for folks is thatsometimes you can't get the answer just from theapp or just from reading a document so we actually a national consultationservice which was launched just a couple years ago and that's actually as partof the national network of prevention training centers, of which california is,you know, but one of those centers, we actually have an online portal forproviders which is stdccn.org and so folks can put in their consult onlineand it will be triaged to the appropriate expert faculty and we answer thoseconsults between one to five business days depending on the urgency. and then forfolks that are old-fashioned and really

just want to pick up the phone they cancall us and in our region we have a toll-free number and that's 1-855-std-atoz. thanks ina. the app and the consultationline are really great uses of technology, it's nice to see that we're keeping, youknow, abreast of what people are using. yeah i agree, it's really exciting. and ireally appreciate you taking the time and breaking all of this down for ustoday. it was really helpful. thanks for having me. so we hope this has been a valuableresource for you and for more information please be sure to check outthe california ptc website. thanks again

ina, really exciting information. thankslinda.