Dr Ronald McCoy: Hi everybody and welcome to the RACGP National Webinar Series. My name is Dr Ronald McCoy. I am a Senior Education Strategy Advisor at the RACGP. I would like to begin this evening’s webinar by acknowledging the Traditional Owners of the respective lands on which we are meeting today, and I would like to pay my respects to the Elders past and present. I would also like to acknowledge any Aboriginal and Torres Islander people present this evening.
So, before starting, I would like to run through some features to make sure you can interact throughout the webinar. You should be able to see the control panel, is it like image on the right of your screen. If you can only see a few icons like the image on the left, please click on the red arrow to open the rest of the control panel. The control panel provides you with tools to select your audio options, and it is also in place to ask questions during the webinar. These are a few tips and tricks that is worthwhile to know about throughout the webinar. You can send questions throughout the entire webinar. We will allow half an hour of questions and answers at the end, but we may also be able to clarify particular points during the presentation if needed. So, if they are relevant to the presentation at the time, I will try and bring them up at that time. Otherwise, I will save some questions until the end. We may not have time to get into all questions, but we will endeavour to answer as many as possible. So, to test this feature, please click where it says, “Enter a question for staff” and type in where you are located today and then press send. So, we want to see where you are. So, just try that now. So, where it says, “Enter a question for staff,” type in where you are today, and we will see what is happening. it is happening in Sydney, Devonport, Victoria, _____ Queensland all over, Adelaide, Brisbane, wow, lots of places. It is fantastic, but it looks like you have got the idea of that, and some remote places too, rural areas which are great to see. Wow, it is wonderful, we have people are from all over, and some has said they are stuck in the UK [Laughter]. So, welcome and extra browny points for attending the webinar this evening. This is fantastic. So, I am just showing our specialists where everyone comes from. So, it is fantastic, Northern Territory too. That is really important, fantastic, okay, all right.
So, I think one of the features that we can do during this webinar is that we can do poll tests. So, we are going to practice now, and you should now, I think a poll should be coming up on your screen, and the question is, can you see it? You can see the poll there, and it says, “Do you know where to locate the Australian STI Management Guidelines?” So, you can see some responses there, and you can select your response and press Submit. It is okay if you do not know where they are. That is fine because by the end of this session, you will know. So, we are just testing the feature, so that is fantastic.
I see, that is hiding behind something. Oh, great. That is very impressive. Sixty three percent of the attendees know where the guidelines are. That is pretty fantastic. All right. So, we will close that and share that, great, all right.
So, just before we start. Just if you have entered your RACGP number when registering, stay for the whole webinar and if you complete the survey, you will receive three category 2 points. And now, we can all interact. Let us get started. So, this webinar is proudly supported by the Australasian Study of HIV Medicine for Viral Hepatitis and Sexual Health Medicine, so ASHM, and tonight’s webinar is on STI testing in general practice, exploring the use of the Australian Sexually Transmissible Infection Management Guidelines. This webinar will explore the use of the Australian Sexually Transmissible Infections Management Guidelines, and it is in order to incorporate STI testing into routine general practice. The session will cover screening of asymptomatic individuals, recent updates to treatment and management, and emerging trends in epidemiology. Well, I would like to introduce our presenter for tonight’s webinar, Dr Nicholas Medland. Nicholas is a Sexual Health Physician at Melbourne Sexual Health Centre and Royal Melbourne Hospital. He has 20 years of clinical experience in HIV medicine and HIV program delivery, oversight and management, including international aid programs in Vietnam as Care and Treatment Program Chief US CDC Vietnam. In research, he has been the Assistant Director for clinical research at HIVNAT and is currently a NHMRC research fellow at the Kirby Institute, University of NSW. So, I would like to get to put your questions here, as we go to, and over to you Nick.
Dr Nicholas Medland: Great, thank you Ronald, and thank you for the nearly couple of hundred people so far, who have logged into watch our webinar tonight. I would also like to acknowledge the Traditional Owners of the land we are meeting on today and pay my respect to Aboriginal and Torres Strait Elders, past, present, and future.
Here is my conflict of interest statement.
So, as Ronald mentioned, we are going to tonight focus on the Australian STI Management Guidelines, now I could easily run a three-day seminar on the Australian STI Management Guidelines. So, we have had to pick a few really topical, important key areas to focus on tonight, and they are largely going to be syphilis and gonorrhoea, and a little bit more about general STI screenings in mycoplasma genitalium.
Again, this is a poll at the moment here. Just have you used or do you use the Australian STI Management Guidelines in your practice?
Dr Ronald McCoy: So, you can select like Yes, No, or I don’t know….
Dr Nicholas Medland: Yes, Yes, No, or I don’t know. We have got our responses come through and currently about 75 percent or 80 percent say Yes, they do.
So, that’s great. We have clearly got an audience, which is already familiar with the available resources and if you have used the guidelines, you are familiar with the STI Management Principles in Australia. 80 percent yes, very impressive.
So, here is a snapshot of the main page of the Australian STI Management Guidelines. If you have got a set of bookmarks on your web browser at work, you can bookmark stiguidelines.org.au. Also, if you enter STI Management Guidelines or Australian STI Guidelines in a google search, this will most likely come up as your first hit. And you will see there, we have got information on asymptomatic checkup, on particular STIs, particular presentations, your discharge, pain etc., special populations and then some links to the latest resources. So, I invite you either tonight if there is a bit of a slow patch and you are getting a bit bored with listening to me, maybe you will explore the guidelines for a couple of minutes and come back or look them up on your computer next time you are at work.
So, one of the main reasons I am here talking to you today, and why have we got a renewed influence in STIs in Australia, is that there have been important changes in the epidemiology of sexually transmitted infections in Australia that changed the way we screen, test, and manage these conditions? I saw that there are quite a lot of people who have entered Northern Territory and South Australia and Western Australian locations, and I am sure there are some from North Queensland. You may be familiar with epidemics of syphilis that have occurred in those areas, but actually we have got some Australia-wide changes in the epidemiology of STIs.
So, here we are. I am just looking at the most common STIs, and tonight, I will just remind you that we are focussing on bacterial STIs, so I am not really just discussing HIV or viral STIs. We are talking about the bacterial STIs or curable STIs. There are 28000 cases of gonorrhoea notified in Australia in 2017. There was a 16 percent increase in one year, and I will show you some graphs in a moment, which will show that these increases have been continuing for some period of time and are really very marked. Even up until a few years ago, gonorrhoea was predominantly an infection that you saw in gay men in urban centres, gay or bi-sexual men, in Aboriginal and Torres Strait Islander peoples in remote locations and returned travellers from Asia. And today, it has changed, and we are seeing the largest increases of gonorrhoea is in heterosexual men and in women. There are 100’000 cases of chlamydia in 2017 and mostly affecting young people. The chlamydia notification rates are perhaps a little bit more stable for the other STIs I am going to be telling you about.
Syphilis is really I think is the condition that we have seen the most alarming rises in notifications. Syphilis notifications are rising very rapidly. It is no longer restricted to men who have sex with men, returned travellers and remote communities. Increasing syphilis in heterosexuals, the largest increases or the largest relative increases in syphilis have occurred in women, and as I will discuss with you later on, there is a high rate of transmission from mother to child, transplacental, and so we have seen a re-emergence of congenital syphilis in Australia. Rates of chlamydia, syphilis, and gonorrhoea in Aboriginal or Torres Strait Islander people are higher and are increasing more rapidly.
So, I am going to show you a couple of these points in visual format. So, this is a graph of infectious syphilis notification rates and age-standardised rates between 2008 and 2017. So, the top line is in men and the bottom line is in women. So, even though the majority of infections are still in men, and when there is a great preponderance of men over women with sexually transmitted infections, that usually means that you have got increased rates in gay or bisexual men. If you are looking at this graph here, if you look back in 2010, you can see that really almost all the infections are in men, very little in women. It has gone up in every group, but the relative increase in women is the largest. We have seen an increase of at least five times over that seven years. I have not got on the graph here, but the ages of women most likely to be infected with syphilis are in their 20s or end of their 30s, and it is an absolute disaster if a pregnant women gets syphilis, or a woman with syphilis gets pregnant, and that is the real burden of disease that we are facing with syphilis at the moment.
Same sort of graph here with gonorrhoea, again men at the top, women down in the bottom. Again, increases across the board. The actual relative increases are quite large in women also. You can actually see here, and I have got some 2018 state data in Victoria and NSW, that we believe is reflected in the rest of the country for 2018 with rates of gonorrhoea going up, but the rate at which gonorrhoea is going up, is going up. So, we are getting a real sort of a ski jump shape on these notification rates. The last time rates of gonorrhoea were this high was in the 60s and 70s. Before that, after the Second World War and after the First World War, and we do know that there is really almost literally nowhere that that can stop. These rates can just keep on going up unless we do something about it, and we will be talking tonight about what we as a community of doctors and medical professionals can do about it.
This is the same graph, just keeping me on my toes here, I guess.
So, we are going to talk now about some general principles of controlling STIs. And just again, I wanted to start with a brief question about people, whether they find it uncomfortable talking about STI screening with your patients. Yes, No, and Sometimes. One’s always tempted when you are answering a problem is to model what you would like the answer to be in your ideal practice situation. So, I appreciate that people have put Sometimes down as the reason.
There we are. So, 41 percent Sometimes, 50 percent No
So, starting a conversation about STI screening. Firstly, I have mentioned that a sexual history would be considered or taking and recording a sexual history would be considered best practice. It is frequently not done all that well and not documented all that well. It can be done quite quickly. Clearly, opportunistically, if there is some aspect of sexual health, urogenital health, it is usually an easy point to start a conversation about sexual health or STI screening, certainly as a part of a reproductive health consultation. In fact, we have very good data to suggest that people who are at risk of STIs are expecting to be asked about their sexual history and their sexual behaviour, but most of the anxiety relies with the practitioner, and certainly any patient who requests any sort of checkup for STIs. And it is quite reasonable to say in terms of sexual history, people, for example, you are going to ask a question, something like, have you had any new sexual partners? Are your partners men, women, or both? Do you mind if we do some STI testing today? The acronym STI is very well known in the community, particularly with younger people, and actually you can just usually dive in and say, can we add some STI tests to your checks today?
Key points to remember about sexual health. You have noticed before, I said if you had a new sexual partner recently, it is important in your language to try to avoid making assumptions about the gender of the partner. Terms like gay or having sex with other men can be used as a lead to help your patients answer your questions honestly. There are some words that we try to avoid, words like prostitute are often considered to be judgemental terms and can inhibit the sexual history in recording the accurate information. It is important that you assure your patients that any information is confidential.
Dr Ronald McCoy: Someone has made a point Nick. They say that they ask all patients coming in for contraceptive advice, and that is a good opportunity to discuss STI screening, and also for things like cervical screening also.
Dr Nicholas Medland: Yeah. So, I think a prescription for the pill. Any discussion about contraception, I think any discussion that involves a patient’s genital or urinary tract, it is reasonable to have a discussion about STIs. We have got a risk situation in Australia with the wonderful new cervical screening guidelines, particularly younger women, are going to be having less frequent cervical screening tests. So, we are going to need to look for other hooks to have discussions, particularly with young women, so that the rates of screening for STIs does not in fact fall. Priority populations, so these are people who are known to either require more frequent STI testing, or more likely to have an STI that is not diagnosed, and these are for different reasons. Aboriginal and Torres Strait Islander people are much more likely to have an STI and that is because they and their sexual partners are less likely to attend medical care and less likely to have been tested, and less likely to have been treated. So, that is an access to health services issue. The data does not support a difference in sexual behaviour. For young people, it is a combination, young people are more likely to have STIs because they get checked or they go to the doctor less often, and they are somewhat more sexually active. Men who have sex with men, frequently if the testing is not done correctly, and men who have sex with men do tend to have more frequent STIs, but there is also an anatomical issue with some STIs, in particular gonorrhoea, chlamydia are more likely to be asymptomatic in men who have sex with men. So, these are all populations that if you can identify in your patients, that you can offer them more frequent STI testing.
So, what does a STI test involve? You should be able to select this or select an order set in whatever practice software you are ordering. So a full STI test, so the patient says to that doctor, I would like to have an STI test, I have got a new partner, I am in a new relationship. That would involve a blood test for HIV, syphilis, and hepatitis B, and unless you have previously tested them and documented their vaccination status. Once you have documented their hepatitis B status, you do not need to do it on multiple occasions. Then, your patient needs to be screened for gonorrhoea and chlamydia. For women, that can be a vaginal or cervical swab, particularly if you are doing an examination or a cervical screening test, or first pass urine in women is an acceptable screening test for gonorrhoea or chlamydia. For heterosexual men, it is the first pass urine. For men who have sex with men, three sites need to be tested, your first pass urine, an anal swab, and a throat swab. I have little asterisks there. All of these ones can be self-collected, so I am not prepared to ask somebody else to do what I would not be prepared to do myself, and nobody wants to spend half their day swabbing people’s anuses. Your patients are quite capable of finding their own anus in the bathroom under instructions from the collecting nurse.
So, the next swab here and when you get the copy of this presentation, and at the end of the presentation, there is a link to the STIPU NSW Health Guidelines. Either you if you are collecting your own specimens or the practice nurse or the pathology collecting nurse can very easily instruct patients how to do their own vaginal or anal swabs while they are in the bathroom doing their first pass urine. It is important to do those three site tests because out of the three tests, the one that is mostly likely to be positive is the anal swab, and the one that is least likely to be positive is the first pass urine, and for gay and bisexual men, the test most frequently done is the first pass urine and the other two are often forgotten.
We have another poll. So, your patient comes in and tells you that they have received a text message from a sexual partner that they had met in the recent weeks, who have said that they have been diagnosed with chlamydia. What would be do in this situation? A: Test them and wait for the results. B: Test and treat before results. C: Just give them treatment. D: Nothing as the patient does not have any symptoms.
Very impressive. Impressively high correct answer. So, most of our guidelines will recommend testing and treatment before results.
Chlamydia, and today I will be talking to you about gonorrhoea and syphilis, early syphilis, are incredibly infectious in the early stages in that the positivity rates in people who have sexual contacts is very high and certainly justifies presumptive treatment, unless there is a reason why you do not think it is necessary.
So, a brief overview of chlamydia. Just to remind you this is a bacterial infection of mucosal membranes caused by Chlamydia trachomatis. It is usually sexually transmitted, very frequently causes asymptomatic infection in the pharynx, anorectal infection in gay and bisexual men, can cause asymptomatic cervical infection. It is an important cause of pelvic inflammatory disease and particularly with re-infection over time, it is an important cause of infertility and then ectopic pregnancy, which is where the burden of disease lies with chlamydia, is re-infection, infertility, and ectopic pregnancy.
Asymptomatic infection can persist for months or years. Urethritis in men is usually mild. Symptoms may be transient. Men are great non-presenters when they have mild symptoms and are often reassured when the mild symptoms resolve. Vaginal discharge in women may be mild and symptoms may be transient. So, again, this is a tip of the iceberg scenario, where the vast majority of patients do not have symptoms.
Diagnosis of chlamydia was doing a NAAT test from the sites that I have mentioned to you before. Almost all labs will automatically do a chlamydia and gonorrhoea test on the same specimen. GPs who are ordering the labs on the whole will do all those three-site testing, will do what appropriate coding for the billing of the tests. The three-site testing in men who have sex with men is very important.
And here is the management for uncomplicated infection. A week of doxycycline, clearly cannot be given in pregnant women. Azithromycin 1g stat. And a longer course of treatment in symptomatic ano-rectal infection in gay men, so a longer course of treatment. These pages you will see this year is a direct cut and paste data of the Australian STI Management Guidelines.
We have fairly similar follow-up recommendations for most bacterial STIs. We recommend the patient abstain from sex for seven days, there is a high rate of cure. Patients can resume sexual activity in seven days. These are notifiable conditions. Partners need to be notified, and I am going to talk to you at the end of the presentation about how people can do that. It is a good idea to retest the patient at some point. It is not so much looking at treatment failure, but we have fairly high rates of re-infection.
Dr Ronald McCoy: I have got a couple of questions at this point. So, a few people, someone has asked that when, so if a patient has had sexual contact with someone with chlamydia, when will those tests become positive, when would you test, straightaway?
Dr Nicholas Medland: So…yeah, straightway. So, within a few days actually, usually. These are antigen tests or RNA, DNA tests. So, they are looking for the presence of the organism, not like any antibody tests that can take a couple of weeks.
Dr Ronald McCoy: And, there was another question that said, would you recommend a throat swab for females who participate in oral sex?
Dr Nicholas Medland: Yeah. So, we just do not have the data there on that group. So, we are not in a position to offer to make screening recommendations either for throat swabs in women who have participated in oral sex. We have been doing it in sex workers, and we have not got recommendations around anal swabs in women either.
Dr Ronald McCoy: Okay, thanks.
Dr Nicholas Medland: So, we are going to move on now to syphilis, which I am going to really spend most of the presentation on. A patient presents with a solitary painless lesion on their penis, and you decide to test for syphilis. Which test/s would you do? Serology, a swab of the lesion, serology and swab of the lesion, or Darkfield microscopy.
I am not sure if there is anything I can teach this audience, wow, very impressive. I think actually A or C would have been correct. C, I guess is the advanced STI management correct answer. Serology would have been sufficient.
So, syphilis is a serious systemic disseminated bacterial infection, and we know now because we are seeing so much of syphilis, we know a lot more about it than we did 10 or 15 years ago. It is incredible infectious in the early weeks to months of infection. Sexual transmission occurs with inoculation at genital and extra-genital sites. It can be oral, anal, or vaginal sex. It has got this particular unusually shaped spirochete, and it has a coating on it, which allows it to evade immune control. Some people call it a stealth organism, which is why you can have such disseminated infection with only mild systemic symptoms, and it has an unusual motility that allows it to get into extravascular and the central nervous system, and across the placenta.
And there are different stages that we all would have learnt about at medical school. The classic primary, secondary, tertiary classification. I am just going to talk a little bit about primary and secondary mostly today. Primary, this occurs at the point of inoculation, so if the person had contact with the spirochete at the cervix, rectum, mouth, penis, wherever it is, that is where they get a little lesion. It occurs about sort of two to three weeks after contact. The classic textbook primary lesion or chancre is a solitary painless lesion, but they can be painful, and they can be multiple. So, this is just a sort of a typical or a textbook presentation. Any sort of ulcer or genital lesions can be a primary syphilis lesion. Frequently, that can go unnoticed, particularly if it is anorectal or in the vagina or in the cervix.
So, these are pictures, if you sign up for an STI course, you can really get some nasty pictures at some point, are not you? So, top left, we have got a very typical chancre, and I think pretty much all of this would go thinking about syphilis if we saw that. Again, middle top on the right, two penile shaft ulcers. On the right, we have got somebody under their lip with a chancre. Bottom left, we have got a primary syphilis lesion that looks a lot like an anal fissure. I think plenty of us might think that is an anal fissure. The penile lesion in the bottom, middle of the bottom again, it is non-ulcerated. Again, it is a primary syphilis lesion, and the one on the bottom right is an intra-meatal lesion, that unless you are able to examine it carefully, you might not actually see an ulcer at all. These are all primary syphilis lesions. I am giving you examples of sort of typical-looking lesions. It is actually clinically not critical to distinguish primary and secondary. I have seen a lot of cases of syphilis. Sometimes, I can tell the difference. Sometimes, I cannot. It does not matter so much. I am just letting you know the range of possible clinical manifestations.
So, secondary syphilis. This is dissemination. So, primary is an infection at the point of inoculation. Secondary is when the patient gets disseminated. They may get systemic symptoms; fever, headache, malaise, lymphadenopathy. Tends to be fairly mild, which as I said is remarkable, given that the patient has got a disseminated bacterial infection. Most other disseminated bacterial infections, the patient is very acutely unwell. Often causes a rash at this point. It is often generalised, classically can affect soles and palms. Often not typical. I think one thing that we have learnt about syphilis is that the early research in the classic textbook discussions are often not always seen. There are a wider range in clinical manifestations. It happens a bit later. It is very frequently misdiagnosed, and very concerningly, about 3 percent of cases of secondary syphilis have some neurological or cranial nerve involvement. The eyes, the optic nerves, the auditory nerves, balance, severe headaches, or meningitis, and in the beginning, I explained to you that in Australia in 2017, there were, sorry, I am just flicking back to my printouts of the slides, there were, actually I have not got numbers. We are definitely into the thousands of cases of syphilis in Australia every year, and you can see that 3 percent where we are taking about a fairly common occurrence, and I have heard that from an eye and ear hospital in an inner capital city location in Australia, the commonest cause of admission was ocular syphilis.
So, these cases, this is secondary syphilis, and now these things I think on the whole, you would probably be less likely to pick a secondary syphilis. The top left rash, the top first second from the left rash, I do not think any of us would necessarily jump to a diagnosis of syphilis if we saw that. The palmar rash, the rash on the sole of the feet, a textbook syphilis rash involves the palms. So, you might involve that. But again, the one on the top right on the lower limb, I do not think you would pick that as syphilis. And the three down the bottom left are all genital lesions, which if you knew syphilis, you might recognise it, but if you did not, you would not necessarily. What all these pictures have in common are some sort of genital skin manifestation, or some sort of rash, which is not immediately explainable by another diagnosis. And if there is a clinical take-home point you take home from this presentation, it would be, beware a patient in a sexually active age range with a rash, particularly a rash where you do not immediately know what is causing it. So, if there is something about the rash that does not quite add up, really please test your patient for syphilis. It is easy to miss, and it is embarrassing to miss. If your patient has any sort of genital manifestation of the skin, they really do need to have syphilis excluded. It is severe if it is not diagnosed and treated, and it is curable.
Some more secondary syphilis rashes. Again, the genital ones. So, the top left and top right are both scrotum. The middle one is obviously under the foreskin in the penis, and a little down in the bottom. The one on the right, bottom right and bottom left, I really do not think anyone would come to a diagnosis of syphilis. So, just wanting to impress upon you the range of skin manifestations, and how important it is to be thinking about syphilis when you see rashes.
And this is particularly condylomata lata, which is a particular manifestation of secondary syphilis. Syphilis organisms seem to like a slightly cooler skin and the mucous membranes, so it tends to gravitate back to the genital areas, which probably explains accessible transmission. It is inoculated to the genital area then it comes back. These lesions are very rich in spirochetes.
Mucous patches. This one on the tongue, this one on the anus. Again, very infectious.
Scalp and neck, again unusual rashes in somebody of a sexually active age. Most people working in sexual health have got an embarrassing, I missed syphilis because I thought it was this or that. It is a fairly, you know it is a striking experience when it happens.
Rather than diagnosing primary versus secondary, what probably is more important is to try to determine how long somebody has had syphilis. There are early latent versus late latent. Early latent is recent infection less than 2 years. Late latent is infection last than two years. Latent syphilis is just a term we use for anybody with no symptoms.
Just a reminder that transplacental transmission occurs very easily with syphilis, resulting in stillbirth, foetal loss, preterm birth, neonatal death, and low birthweight. Congenital infection, the infant can be infected in utero or postpartum. The infection may appear uninfected. If the infant is infected and it is not diagnosed or treated, very high rates in neurological and other disabilities. So, clearly, a young woman with syphilis who gets pregnant, or a pregnant woman who gets syphilis is an absolute disaster in terms of pregnancy outcomes, and what we are trying to do here is to make you aware of this rising health issue in Australia. We have got guidelines in Australia, in addition to first trimester screening to do third trimester screening, if there at some high risk, and in outbreak areas that I see some of you are calling in from, we have got these five points of testing in congenital syphilis.
The important issue with this is the prevention of congenital syphilis, and that is to increase testing in sexually active women and heterosexual men. Opportunistic testing in asymptomatic men or women, anyone with an STI, anyone with a genital lesion, and anyone with a rash.
So, how do we diagnose syphilis. So, the main form of diagnosis of syphilis is a blood test. We have two types of blood tests. We call them treponemal or non-treponemal. It is not as complicated as it sounds. The standard, high-sensitive, specific – main diagnostic test is an EIA/CLIA. That is an enzyme-linked immunoassay, chemiluminescence immunoassay, an EMIA, whatever it is, it is an automated highly sensitive, specific test. There is a bunch of historic tests – TPPA, TPHA, they are just used to confirm them. And we have got another test, which is called an RPR, which we use to determine whether or not the patient has got active or recent infection.
We also have a couple of swab tests. A NAAT test, which will tell you if the lesion in front of you is caused by Treponema pallidum, so if you have got a lesion, you would like to know if it is caused by syphilis, you can do a NAAT test. And request that at the same time as a herpes test. It is important to know that these tests are not sufficient on their own to exclude infection. So, if it is positive, it helps you in the diagnosis, but if you think you have a patient who might have syphilis, you need to do a blood test to determine if they do or do not.
I was just going to, sorry, it is a bit hard to point out without a pointer. I just, sorry, there was a pause while I was clicking the pointer, I forgot that I was doing a webinar. So, the EIA is the yellow test down at the bottom. That is the main…. there we go, thank you. I have got a pointer here. The EIA which becomes positive soon after infection and will stay positive for the patient’s life. The RPR, which is represented as a titre, or as a _____, it will go up after the person is infected, it will come down rapidly if the person is treated. If they are not treated, it will eventually peak and come down slowly. So, we use the EIA to determine if the patient ever had syphilis, or have they ever had syphilis, and the RPR tells us whereabouts in the phase that it might be.
So, how to interpret syphilis serology? So, we have got a positive antibody test, EIA, CLIA. What we need to determine really is if the patient needs treatment or not. Whether they need a single dose of benzathine penicillin. Whether they need to be referred to hospital, or they need three weeks of benzathine penicillin.
And to make that determination, we use additional information, previous test results, a documented or highly reliable history of treatment, in the RPR.
So, a patient with positive syphilis serology does not need treatment, if they have a documented or highly reliable prior treatment history, the RPR is low. It means they do not have recent infection, and there has been no increase in the RPR since their last test. With any of these factors, if you are not sure, it is absolutely defensible to treat the patient again and document it. Nobody will criticise you for retreating or overtreating a patient for syphilis.
The treatment for syphilis that has definitely been acquired in the last two years is a single shot or two injections of benzathine penicillin. This in not benzyl penicillin, but benzathine penicillin. If the patient is seroconverted within the last two years, then they definitely only need a single shot. If you have previously treated them, and the RPR has been down, has gone down, but then it has gone back up again, they do not need, they only need that single shot. If you have got a very strong clinical suspicion of early infection, primary or secondary, a rising RPR, or positive skin PCR, then you can also treat them with a single shot.
A patient who has any sort of CNS or cranial nerve involvement needs to go to hospital and have a lumbar puncture. A pregnant patient needs to go to hospital and to be admitted and treated as an inpatient. And a patient with treatment failure, the RPR does not go down, needs to go to hospital.
Everybody else, and anybody you are not sure about, needs weekly doses of benzathine penicillin on three occasions, seven days apart.
So, the treatment of…
Dr Ronald McCoy: Just a question that has come in, so when you are ordering a serology, is it sufficient to just write syphilis serology?
Dr Nicholas Medland: Yes, you just write syphilis serology, and the lab will work out which tests to do. They will automatically do the EIA test first. If it is negative, they will just issue a negative report. If it is positive, they will do confirmatory tests and a RPR.
Dr Ronald McCoy: Thanks so much again.
Dr Nicholas Medland: So, the treatment for syphilis is benzathine penicillin 1.8g. It comes in 0.9g pre-filled syringes. So, the patient needs two of those injections. They are large injections given to each buttock, and it is done once a week for three occasions. So, today, Wednesday night, next Wednesday, the Wednesday after, and then the patient is cured. A Jarisch Herxheimer reaction – I mentioned that the organism can avoid immune control. Once you kill the organism, it loses that ability. At about four hours later, your patient will get sudden onset of fevers, sweats, joint pain, headache, and tachycardia. It is very common. It is alarming, but it is not serious. You should warn your patient about it, so that they do not end up calling your after-hour service or dialling 000 or something. They can just go to bed, take a couple of paracetamols. If the patient is allergic to penicillin, they can be treated with doxycycline, and there is the schedule there. Clearly, if the patient is pregnant, they cannot be given doxycycline. If the patient is pregnant and penicillin-allergic, they need to be desensitised.
If the patient is given doxycycline, it is important to confirm their adherence. We repeat the serology in about three months to determine that the RPR has gone down. That is important to determine if the treatment has worked, and it also helps to diagnose reinfection at a later stage. Your patient can get syphilis as many times as they like. The EIA will stay positive for life. Once they have been treated for syphilis once, the only way you will determine whether or not they have been reinfected is that the RPR had gone down, and it would go back up again. Any patient, who has been diagnosed for any STI, whether it is gonorrhoea or chlamydia, needs to be tested for all STIs that I listed on the earlier slide.
So, increase syphilis testing in your practices. Beware of the patient, of the rash. Just request syphilis serology. Use the RPR to monitor treatment and detect reinfection, if in doubt, treat.
Dr Ronald McCoy: Is there any point of care testing for syphilis?
Dr Nicholas Medland: So, tonight we have talked about Medicare testable, there is point of care testing available in project basis, but it is not available through Medicare billable testing on the whole.
Dr Ronald McCoy: Okay.
Dr Nicholas Medland: So, it is project based.
Speaking 1: Someone was asking about that
Dr Nicholas Medland: It is very important in remote communities, point of care testing.
Dr Ronald McCoy: Yeah, okay.
Dr Nicholas Medland: Okay.
Dr Ronald McCoy: Sorry, first, before we go on to this one, someone had asked, and then probably we can check at this. Someone did a biopsy on the secondary syphilis. What would you reckon they would find?
Dr Nicholas Medland: The lab can often see the spirochetes.
Dr Ronald McCoy: In the biopsy?
Dr Nicholas Medland: It is a frequent embarrassing scenario for a GP or a dermatologist, an odd looking rash, patients fail treatment with anti-fungals and topical corticosteroids for weeks and weeks. Eventually has a biopsy. The biopsy is bursting with spirochetes or it shows some typical signs, and that is the point at which the syphilis is diagnosed. Another poll question.
Great, again very impressive. Untreated genital gonorrhoea infection, the correct treatment is in fact ceftriaxone 500mg plus azithromycin 1g stat.
I have spent a bit too much time talking about syphilis, so I am going to have to increase my rate here on. Sorry. I may have to dash over a couple of slides. Gonorrhoea is also a bacterial infection of the mucous membranes, sexually transmitted, frequently causes asymptomatic infection, particularly pharyngeal and anorectal. Urethral infection in men is highly symptomatic usually. It is an increasingly important cause of pelvic inflammatory disease. Just a few years ago, less than 1 percent of cases of PID in Melbourne Sexual Health Centre were gonorrhoea. Now, it is more than 7. It was used to be restricted to MSM and travellers to South East Asia, but it has now moved beyond these groups. And drug resistance is a very serious issue.
This is your classic tip of the iceberg gonorrhoea presentation, pus at the meatus, or pus at the cervix. Most gonorrhoea is asymptomatic. The only way we control gonorrhoea in the population is testing asymptomatic individuals.
NAAT testing. Almost always labs will do NAAT chlamydia and gonorrhoea testing at the same time. Anorectal and pharyngeal specimens are essential in men who have sex with men. Now, this is a point I would like to make here. We do not do bacterial culture as screening. So, in asymptomatic individuals that we want to screen, we just do the NAAT test. But if the NAAT test is positive, you are going to be recalling your patient and treating them. And you should recall them and treat them on the same day, but if you would do us a favour and order a culture before you treat them, then you will help to detect the arrival of drug-resistant gonorrhoea in our community. Currently, less than 30 percent of gonorrhoea cases in Australia have a culture. So, 70 percent just have a NAAT testing. There is no information about drug sensitivity there. So, that means that if there is a multidrug-resistant gonorrhoea in Australia, there is a 70 percent chance that that person will be treated without a culture, and then we will lose that opportunity to detect these cases. So, by virtue of you are spending your valuable spare time, listening to me talk to you about STIs, you have indicated that you have some sort of special interest in STIs, and we certainly would like GPs and primary health doctors with a special interest in STIs to be doing this extra level of testing, which is a surveillance gonorrhoea culture on the day that you treat the patient. If a patient is symptomatic, or has a syndrome, and you want to treat them on the day, those patients should have a culture taken on that day.
Dr Ronald McCoy: So, one of our audience members have asked. Are there any specific techniques to ensure with pharyngeal swabs, to sort of increase the likelihood of a positive predictive diagnoses.
Dr Nicholas Medland: So, one of the advantages of the NAAT testing, as it is much more sensitive. So, it is certainly much less of an issue with NAAT testing. The cultures are frequently negative from the pharyngeal, so you might do that culture, and it might be negative. But contact with the retropharynx in both tonsillar fossae increases the rate. We have got very good data, is that the more contact with the tip of that swab with the back of the patient’s throat, we are more likely to get some gonorrhoea genetic material. I make my patients gag just a little bit. I think I have made these points.
These are out of the guidelines. I should have put a poll in here. Do you notice anything new or different or unusual about this? I have just mentioned that the guideline for uncomplicated pharyngeal infection has changed as of December from ceftriaxone plus 2g of azithromycin. The reason we use ceftriaxone plus azithromycin is to prevent the emergence of resistance. We believe that gonococci find it more difficult to be resistant to two antibiotics, rather than one.
Patients need to abstain for seven days. You can do a proof of cure at two to four weeks, four weeks for a NAAT test, two weeks for a culture. Good idea to retest it at three months. Any patient with an STI needs to have a full STI screen.
All gonorrhoea is drug-resistant gonorrhoea. This graph here shows that the years over the last century when different antibiotics have worked. We are on borrowed time with ceftriaxone. The fact that we are combining with azithromycin in Australia is probably helping, but it will stop working at some point, and the best thing we can do for that is, as gonorrhoea cases rise, trying to do cultures as often as possible, so that when it stops working, we will know about it. That would be a great help to the public health.
Key messages on gonorrhoea. Check your guidelines because they can change. Please increase gonorrhoea testing, particularly three-site testing in MSM, and do a culture before treating the patient.
Dr Ronald McCoy: Sorry I just missed that last bit.
Dr Nicholas Medland: Yep.
Dr Ronald McCoy: So, how do you know that it is, is it the NAAT becomes clear, do you retest? Sorry I missed that.
Dr Nicholas Medland: Yeah, I said two to four weeks, you know, that probably should have been a bit clear. The NAAT test, because it is so sensitive, can be a bit slower to become negative.
Dr Ronald McCoy: Yeah.
Dr Nicholas Medland: So, if you had a positive culture, you can do the culture after two weeks.
Dr Ronald McCoy: Okay.
Dr Nicholas Medland: If you had a positive NAAT, you do the NAAT after four weeks.
Dr Ronald McCoy: Okay, I think that answers the question that someone asked.
Dr Nicholas Medland: Yeah.
Dr Ronald McCoy: Thanks.
Dr Nicholas Medland: Just a couple of slides on Mycoplasma genitalium. It is a bacterial STI with some similarities in its clinical presentations to chlamydia. The evidence regarding the management is evolving, which is, I guess a euphemism. Rapidly changing. It is an established cause of urethritis, cervicitis, and pelvic inflammatory disease, and their associations with preterm delivery and miscarriage. Drug resistance is very common, increasingly common, particularly in MSM, where it is well over 80 percent. Asymptomatic infection is common, but we do not know the significance of that, and we are absolutely not recommending asymptomatic screening because of the problems with treatment.
As I said, it can cause a urethritis, a PID, a vaginal discharge. The test is by a first pass urine in men or an endocervical or vaginal swab in women. We do not recommend screening of asymptomatic patients. We just do not have the data to suggest that we are doing people a favour. The commonest time in which people are getting tested for Mycoplasma genitalium are those with a symptomatic presentation of cervicitis, PID, urethritis, or proctitis. In sexual health centres, that is often done at initial presentation. In a lot of settings, it is if the patient has got symptoms, but is negative for gonorrhoea, chlamydia, or has persistent symptoms, and contacts we are testing for them.
Treatment is problematic. When it is known to be sensitive, you can treat with doxycycline for seven days, followed by azithromycin, using this regimen. So, we have this very unusual two-step treatment, where we use doxycycline for seven days to reduce the bacterial load, and then we give an antibiotic that the organism is sensitive to after that, and that is either azithromycin or moxifloxacin, which is an off-licence and non-PBS use of moxifloxacin. And if somebody has got pelvic inflammatory disease, we give moxifloxacin from the beginning for 14 days.
Always do a test of cure for Mycoplasma genitalium.
I think this might be my penultimate slide. Just about.
Dr Ronald McCoy: Some of the questions that we have been getting around contact tracing cover, is people are interested in knowing things like, with things like chlamydia, syphilis, is it lab reporting or is it the GP reporting, with partner notification, who notifies whom, and what are the various strategies involved?
Dr Nicholas Medland: Sure. So, for most common STIs, gonorrhoea, chlamydia, or syphilis, where there is no special concern, like patient has got a pregnant partner, or something like that, then it is up to you and your patient to discuss partner notification. There is a public health and a medicolegal responsibility to document that. There certainly have been legal cases, where people have said, nobody told me I needed to tell somebody. So, you need to document that you have discussed it. The commonest outcome would be the patient contacting their partner directly, and if the patient says that they will do that, and you have no reason to disbelieve them, that is adequate in the vast majority of cases. There are a couple of websites, which you have got in front of them. One is called letthemknow.org.au, which is for the general public and the drama down under is, it is just sort of a gay-friendly website, and your patient, if there are people that they would like to notify, but they feel a bit shy of doing it in person, they can go to this website, and they can enter the patient’s phone number or email address. There is a little dropdown list for the STIs, syphilis, gonorrhoea, chlamydia whatever, and that patient’s partner will receive an anonymous email or text message, and a link to where they can get testing information. This service has been evaluated. There has been very little inappropriate and malicious use of it. Alternatively, if you really want to do it, you can do it with your patient on the computer during the consultation, if that is something that you want to do. If there are significant issues, for example, syphilis in a male with a pregnant partner, or something where you think it is absolutely essential that you are able to confirm that the partner has been notified in treatment, then each health department will have partner notification offices, and it is usually available through their website, that will assist you if it is required. There was a question about notification. Usually, there is both lab and clinician notification. The notification will still go ahead, if you do not do it. It will still be reported as a case, but whether the patient is gay or straight, and whether they had the right treatment, that sort of stuff will be up to you to put on the notification input.
Some issues really, some last take-home messages. Syphilis is rising rapidly, and it is a serious threat, particularly congenital syphilis. Increasing rates of screening of asymptomatic individuals is the only way to control syphilis in our community. Think of syphilis with any genital, oral, or anal skin lesion, or any rash, particularly a rash that does not feel or look right. Consider increasing testing in women, women who might fall pregnant, male partners of women who might fall pregnant. So, that is a fairly wide net. I do note that, but ultimately, we are going to prevent congenital syphilis by creating a safe syphilis-free zone around pregnant women. Help us with the detection of multidrug resistance gonorrhoea by doing a culture before treating a patient.
So, I hope I have helped you with some aspects of the Australian STI Management Guidelines. We have discussed about STI screening. We have updated your knowledge on the treatment of syphilis and gonorrhoea and Mycoplasma genitalium.
So, we have got a bit of time for additional questions and discussion.
Dr Ronald McCoy: We have got a few. So, one of the things … early on, we were talking about opportunities for raising the topic of STI testing with you in the general practice setting, and women often present to their GP with, you know, women’s health issues, and also around contraception requests and the like. But what are some of the opportunities for raising opportunities with the male patients in the general practice setting? Are there are any sort of strategies and tips that might help people in that situation.
Dr Nicholas Medland: So, there is good evidence that men will take up STI testing if it is offered to them. So, I think, even initiating a discussion, I think it is really to just start with the discussion of STI testing. People are most comfortable with people, who they are discussing their sexual behaviour, so I think it is pretty reasonable to, for example, when you are taking some sort of preventive health history, like a vaccination would be a common one to take it. Have you been vaccinated against hepatitis A and hepatitis B? When did you last have an STI test? That would be an easy way. That is a good hook. If it has been a while, could we do some tests today? Because we are asking people to consider STI or syphilis testing, and that is a blood test, that is really when somebody is having a blood test is a good time to add a syphilis blood test. That is an opportunistic one. Clearly, if someone is having a urine test is a good time to have a gonorrhoea or chlamydia test. A lot of patients are already habituated into having a chlamydia test, and somebody you might give a chlamydia test to, it would be reasonable saying, well, now, we are recommending testing for syphilis as well, could we do a full STI test, including a blood test.
Dr Ronald McCoy: So, another question that a few people asked. What is the role of hepatitis C serology in sexually transmissible infection screening?
Dr Nicholas Medland: So, currently, hepatitis C testing is in the Australian HIV pre-exposure prophylaxis guidelines. So, gay and bisexual men on PrEP are recommended to have hepatitis C screening once a year. HIV-positive gay and bisexual men are recommended hepatitis C screening, but for the general population, hepatitis C is not sexually transmissible, but there are overlapping risk factors. So, people who inject drugs are more likely to have an STI, as well as, having hepatitis C, but strictly speaking STI testing, hepatitis C is not recommended. It is just for STI testing.
Dr Ronald McCoy: Yeah, so, obviously, if there is a history of exposure…
Dr Nicholas Medland: Yeah, drug use, and special populations where we know that hepatitis C is underdiagnosed. So, in Aboriginal and Torres Strait Islander people, for example, we know that there is a much lower hepatitis C diagnosis rate. So, you might throw in a test in that situation on a one-off basis.
Dr Ronald McCoy: Another question that somebody had, so it is with regards to syphilis serology testing. So, if someone has had a very recent exposure, a good, you know, an example of this would be maybe sexual assault. How long does it take for a syphilis serology to…
Dr Nicholas Medland: So, syphilis test is an antibody test. So, like HIV, there is a window period in which time infection will occur, in which it takes some time to develop antibodies. Unlike HIV, the window period is not so precisely characterised. So, by the time somebody has got a lesion, they have almost always got antibodies, but in terms of excluding infection, in which you can tell somebody who has been exposed, they definitely do not have it, it is probably around the six to eight week mark, though positive people will often be positive within two or three weeks. Does that make sense?
Dr Ronald McCoy: Yes, that makes sense, but I think it is important to keep in mind that, that there is that variation.
Dr Nicholas Medland: Yeah, and it is a different scenario. One is somebody who has been exposed, who is very worried and is traumatised, and when is the earliest time you can tell them they are definitely not infected. That is a quite long time. In terms of somebody who might be at risk or might have symptoms, how soon might you pick it up, it would be quite a bit sooner.
Dr Ronald McCoy: Yeah. So, somebody has asked a question. How to collect the sample for culture, if there is no urethral discharge, like you know that, that there might be a history of exposure, and that is…
Dr Nicholas Medland: So, thank you for asking that question because I did not mention it. So, on the whole, we ask you to repeat the test that was positive, except order a culture. So, if it was a swab, a throat swab, an anal swab, a vaginal or cervical swab, if that was positive on the NAAT test, just do that again, and this time it was, order a culture. The vast majority of men with urethral gonorrhoea are symptomatic, and you are probably going to be treating them on the day, and there usually is discharge. There are rare cases of gonorrhoea without discharge, I think you could probably be excused for not ordering a culture on that situation, or you could have tried the lab to do a culture when they first passed urine. You do not need to do a urethral insertion swab.
Dr Ronald McCoy: Someone has asked, I think it is because maybe it is something that they have read in the guidelines. So, you have got a heterosexual female or male requesting STI check, do you include gonorrhoea, I think you would these days
Dr Nicholas Medland: Yeah.
Dr Ronald McCoy: I believe the current guidelines just advise chlamydia, as well as syphilis and hepatitis B.
Dr Nicholas Medland: So, we are asking you tonight to add a gonorrhoea test.
Dr Ronald McCoy: Yeah.
Dr Nicholas Medland: I am not sure particularly, but I will have a look at the guidelines.
Dr Ronald McCoy: I think that sometimes people will get a bit confused because some of the college guidelines, particularly about the Red Book talk about that, but they are just talking about asymptomatic screening and the difference is if someone if requesting an STI check and correct me if I am wrong, from what you have said, they straightaway identify themselves probably as being at a much higher risk, so they are not general population, so the risk of getting some positive infection actually probably statistically increases quite a lot.
Dr Nicholas Medland: And actually, we are in a bit of a stage of flux with, you know, for example, the College Red Book guidelines has got recommendations for chlamydia screening for young women, for example, and there are risk factor assessments for other screens, but we are, you know between versions of guidelines, we are seeing rises in notifications, so I think there is awareness about having a low threshold for offering additional tests.
Dr Ronald McCoy: Yeah, that is fine.
Dr Ronald McCoy: Just looking through some of the questions. If a patient is allergic to penicillin and cephalosporin, what antibiotic can be used for gonorrhoea, you said doxycycline, no, no, that will not work. So, what is the recommendation?
Dr Nicholas Medland: So, in the whole what we will do, you need a culture in that situation, not before you treat them, but there are recommendations there. It depends on the site, but we usually give a larger dose of azithromycin would be the commonest drug in the situation. And there are recommendations about what the nature of the beta-lactam allergy was.
Dr Ronald McCoy: Yes, I think that covers most of the questions. Yes, that is it.
Dr Nicholas Medland: Thank you audience for having so many questions.
Dr Ronald McCoy: That is really good. There have been quite a lot of questions. There are more questions here, but you have actually answered them as we went along. So, and I think that is pretty well it at that point of time. There we are. So, this your last opportunity for questions now. Well, there are a few more actually, just come in, feel like I’m on a telethon there. So, here we go. If a female presents with intermenstrual bleeding and/or postcoital bleeding, would you routinely advise testing for Mycoplasma genitalium, as well as chlamydia and gonorrhoea, and of course, a cervical test.
Dr Nicholas Medland: Yeah, probably not.
Dr Ronald McCoy: No. Not in that situation again. Yes, and I think that is pretty well it. So, thanks so much Nick for giving this…
Dr Nicholas Medland: Ah, yes. Quickly some resources…
Dr Ronald McCoy: I think, yes. I was just going to think, some of these resources that are available to people were available from ASHM. So, can you just go through some of these.
Dr Nicholas Medland: Yeah, with guidelines we have mentioned this, as you will have links for all of these. Australian STI Guidelines. Bookmark them. I have mentioned about the… New South Wales Health have got a testing tool, an STI testing tool. They are the guidelines for asymptomatic testing men who have sex with men. There is a link in the presentation actually to the specimen self-collection guideline instructions. The Australian Contact Tracing Manual that is a part of the notification manual, and there are other resources there on ASHM, and if you want to look at a collection of dirty pictures, some of which you have seen tonight, we have got MSHC STI Atlas there as well.
Dr Ronald McCoy: That is the Melbourne Sexual Health Centre.
Dr Nicholas Medland: Yes.
Dr Ronald McCoy: Yeah, okay. That is where it all happens.
And these are also some important resources for patients.
Dr Nicholas Medland: Yeah.
Dr Ronald McCoy: I think you have talked about some of them.
Dr Nicholas Medland: Yeah. So, you can just write these websites down on a piece of paper or show the patient. You can ask them to google it, and they can notify their partner using these. And as again, ASHM has got its own good website with some multicultural and multilanguage STI information at the All Good website.
Dr Ronald McCoy: Okay. So, I think that that wraps it for tonight because we are actually running out of time, I think. So, I would like to thank Nick Medland for coming tonight for his focus on STI testing in a general practice setting, and we will have follow-up evaluation emails. So, keep an eye out for those, and if you can really give us feedback, that would be really helpful, so we can improve these presentations, and also just for future presentations as well. So, anything else there.
Dr Nicholas Medland: Thank you very much. Thank you for your attention.
Dr Ronald McCoy: Thanks very much for joining us tonight.