ASHM Report Back

Clinical posts from members and guests of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) from various international medical and scientific conferences on HIV, AIDS, viral hepatitis, and sexual health.

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WHO STI Treatment Guidelines 2017

 

Good morning from the 2017 HIV/STI Conference in Rio De Janeiro. There may be a cross over in some topics with other ASHM bloggers but over the course of the congress we will be blogging about different items.

This morning commenced with WHO treatment updates and guidelines, which had not been updated since 2003. The WHO updated guidelines and their objectives focused on ensuring they have international guidelines for the effective treatment of Neisseria Gonorrhoea, Chlamydia Trachomatis and Syphilis.

The majority of all treatment guidelines have already been adopted by Australian STI Management guidelines (STIPU) and are in place, but the key points taken will be outlined below.

* Neisseria Gonorrhoea (Assoc. Prof. Magnus Unemo - Director Swedish Reference Lab) - Dual Therapy (Ceftriaxone 250mg IMI with Azithromycin 1g Oral) recommended in all cases (Ano-Rectal, Oropharyngeal and Genital), unless resistance to Azithromycin is known, then single therapy with Ceftriaxone 250mg or Cefitixime 400mg can be used but again this only in specific cases and specialist advise should be obtained.
NB: STIPU do recommend 500mg Ceftriaxone IMI as do a number of other clinics worldwide. 

- Reinfection is treated again with dual therapy, but consideration could be given to treat with 500mg Ceftriaxone IMI with 2g Azithromycin Orally.

* Chlamydia Trachomatis (Nicola Low - University of Bern)

Guidelines were again similar to what STIPU guidelines in Australia recommend with a strong enforcement around Doxycycline versus Azithromycin in Ano-Rectal cases.

- 1g Azithromycin oral for Uncomplicated genital infections or Doxycycline 100mg Oral twice daily as alertantive treatment.

- Ano Rectal infections, there was a important point about ensuring Doxycycline 100mg BD for 7 days was used as first line treatment, and that Azithromcyin not be used as a treatment option. 

- For LGV, Doxycycline 100mg BD for 21 days is now recommended treatment versus the previous 14 x day treatment. 

- An important change from the 2003 guidelines was that Erythromycin was considered first line treatment in pregnancy, but now Azithromycin is the recommended treatment for women with a Chalmydia infection during pregnancy.

It should also be noted that Nicola Low mentioned there was not enough evidence for Azitrhomycin extra dosing to be used to treat Ano-Rectal Chlamydia as previously done for patients who might have had issues with Doxycline dosing adherence.

Treponema Pallidum (Syphilis) - Dr. Francis Ndowa (Zimbabwe).

Australian STIPU guidelines already reflect current guidelines.

- Early Syphilis -  2.4million units (1.8g) Benazthine Penicillin IMI as a single dose is still recommended as first line treatment or Doxycyclinne oral 100mg BD for 14 x days if there is a Penicillin allergy. 
(NB: Numerous other alternatives given, but not enough information was transcribed to write about)

- Late Syhpilis (>2 years) - 1.8g Benzathine Penicillin IMI as three doses spilt into 3 x weeks (i.e.: Every seven days), which is current to Australian guidelines. 

Genital Herpes Simplex Virus (HSV) - Prof. David Lewis - (Australia).

19.2 million new HSV2 diagnoses in 2012 for people aged 15-49 (11.3% Global prevalence)

6 x recomendations which show commence treatment straight away on first initial episode. Evidence showed a reduction in symptoms 2-4 days less than placebo and HSV shedding in 9.2 days
NB: See Brett Hadlow's blog for information around medication dosage recommendations).

For cases under four occurrences a year, treatment again is recommended with a 2.5 day reduction in viral shedding.

For cases over four reoccurrences, repressive therapy is recommended over suppressive and a twice daily dose of Acyclovir (400mg) or 500mg Valaciclovir once daily. Evidence showed less frequent HSV occurrence, and reduced shedding.

Overall it was good to see Australia is working within the WHO guidelines to combat STI prevention and ensure appropriate treatment.

For current Australian STI Guidelines, please see http://www.sti.guidelines.org.au

Photo 1: Blogging in my hotel room with Brett Hadlow looking over Barra Da Tijuca Beach.

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This morning saw the kick off of the STI and HIV World Congress in Rio de Janeiro Brazil.

First off this morning was the 2016 WHO Treatment guidelines - last updated in 2003.

Noting that the new guidelines will be released in 3 stages.

 

(A.Prof, Director) Magnus Unemo of Swedish Reference Laboratory

Neisseria Gonorrhoea:

Treatment recommendations for Dual therapy over single therapy.

Ano-rectal and UI-

- Ceftriaxone 250mg and 1G Azithromycin 

- Cefixime 400mg PO and 1G Azithromycin.

Oral N.Gonorrhoea-

- Ceftriaxone 250mg and 1G Azithromycin.

- Cefixime 400mg PO and 1G Azithromycin.

It's of importance that currently in Australian Guidelines 500mg of Ceftriaxone is recommended and the WHO recommend 500mg in it's 2nd line treatment when 1st line therapy has suspected treatment failure.

Representitives from the UK and Europe also stated that are currently using 500mg as first line therapy due to high prevalence of resistance.

 

Dr Nicola Low (University of Bern)

Chlamydia trachomatis 

Take home message- changes in guidelines

- Use of Doxycycline over Azithromycin for Ano-rectal infection.

- 100mg Doxycycline BD for 7 days.

LGV - Treat with Doxycycline 100mg BD for 21 days - was 14 days in previous guidelines. 

 

Dr Francis Ndowa (Zimbabwe, WHO consultant)

Syphilis

Primary, Secondary and Early latent (2 years or less)

Treatment is with (2.4 million units) 1.8g Benzethine Penicillin IMI Single dose.

Alternate Treatment - Procaine 1.2 IU IMI Daily for 10- 14 days.

 

Late Syphilis (more than 2 years)

Treatment is 2.4 Million units Benzethine Penicillin IMI one dose one week apart for 3 consecutive weeks.

In penicillin Allergy - 100MG Doxycycline BD for 30 days.

 

Dr David Lewis (Sydney, Australia)

HSV

19.2 Million new HSV infections in 15 - 49 year olds world wide in 2012.

Recommendation 1 - 1st Episode of HSV infection - treat.

Recommendation 2 - Treatment recommendation Use Aciclovir over Valciclovir or famciclovir.

Dosage 400mg TDS for 10 days.

Recommendation 3 and 4 - Recurrent symptoms treat within 24 hours of symptoms or prodromal phase with Aciclovir 400mg PO TDS for 5 days, 800mg BD for 5 days or 800mg TDS for 2 days

Valciclovir 500mg PO BD for 3 days.

Recommendation 5 - For recurrences of more than 4 per year consider suppressive therapy for 1 year and then reassess. Aciclovir 400mg BD for 1 year.

 

Dr Manica Balasegaram (Global Antibiotic Research and Development Partnership, GARDP)

Spoke about the development of new treatments for STIs and in particular showed a snap shot of a road map for development of new treatments for N.Gonorrhoea with the main goal of new treatment by 2023.

Main goals of accelerating new agents to be used and investigating existing antibiotics that could be used in new combinations. It's exciting to see that we are looking to the future in regards to Antibiotic stewand ship and treatment of emerging resistance.

 

ASHM is pleased to launch our recently updated General Practitioners and HIV resource. You can download the resourc… https://t.co/UVP72mrTeP

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