12

(NEW-January 2010)

Your patient has…Genital Ulcer Disease (GUD)

Under Specimen collection and testing for all patients with anogenital ulcers

• Swab of lesion, ulcer or fluid from vesicle for HSV testing (culture/NAAT) and for dark-field microscopy or FA for T.pallidum (where available).

• Swab of lesions for HSV (culture or NAAT)

and dark-field examination or direct/indirect fluorescent antibody (DFA/IFA) or NAAT (e.g., PCR) test on swabs from ulcers. Contact your local laboratory regarding these tests, as they are not widely available.

Note: Dark-field microscopy and direct/indirect fluorescent antibody tests are not reliable for rectal lesions, as there may be cross-reaction with non-pathogenic treponemes in anal specimens. NAAT (e.g., PCR) testing may be an option for such specimens.

• Serology for syphilis:
   - Non-treponemal test (RPR/VDRL) and

- Treponemal test (MHA-TP/TP-PA/FTA-ABS) or treponemal specific EIA

• Serology for suspected primary syphilis:

- Should include a non-treponemal test (e.g., RPR/VDRL).
- In regions experiencing outbreaks of syphilis and where NTT is the screening test, it may be appropriate to screen at baseline with both non-treponemal and treponemal tests

OR

- A treponemal-specific enzyme immunoassay (EIA) AND if the treponemal-specific EIA is positive, confirmation by a second treponemal-specific test is recommended (e.g., TP-PA, MHA-TP, FTA-ABS or INNO-LIA™).

15

(NEW-January 2010)

Your patient has…Intestinal Symptoms
(continued)
If lesions are present

• Syphilis serology as dark-field microscopy and fluorescent antibody tests are not reliable for rectal lesions.

• Syphilis serology should be performed in all patients with lesions. If the initial serologic testing is negative and syphilis is suspected, serological testing should be repeated in 2-4 weeks.

Note:  Dark-field examination and direct/indirect fluorescent antibody tests (DFA/IFA) are not reliable for rectal lesions, as there may be cross-reaction with non-pathogenic treponemes in rectal specimens.  NAAT (e.g., PCR) testing may be an option for such specimens.

18

Your patient has…
Papular Genital Lesions

Your patient has…
Papular Anogenital Lesions

19

Your patient has…Pelvic Inflammatory Disease (PID)
Under Clinical Evaluation and specimen collection
Vaginal swab for wetmount, Gram stain and culture

Vaginal swab for wetmount, PH test, whiff test, Gram stain and culture

24

Treatment Recommendations
Statement on quinolone resistant N. gonorrhoeae
The statement has been updated as indicated

Due to the rapid increase in quinolone resistant Neisseria gonorrhoeae, quinolones such as ciprofloxacin and ofloxacin are no longer preferred drugs for the treatment of gonococcal infections in Canada.

Quinolones may be considered as an alternative treatment option ONLY IF:

(1) antimicrobial susceptibility testing is available and quinolone susceptibility is demonstrated OR

(2) where antimicrobial testing is not available, a test of cure is essential.

24
(Updated January 2010)

N/A

Flouroquinolone warning

For all infections where treatment recommendations include fluoroquinolones.

Note:  Fluorquinolone associated tendon rupture (generally Achilles tendon) has been reported predominantly in the elderly on prior systemic treatment with glucocorticoids. At any sign of tendonitis, a physician should be consulted and the quinolone treatment should be discontinued. Quinolones should not be used in patients with a clear history of tendon disorders related to quinolone treatment because they may be at risk of developing tendon disorders again when re-exposed to a quinolone. Please consult the FDA website
http://www.fda.gov/Drugs/DrugSafety/Postmarket
DrugSafetyInformationforPatientsandProviders
/ucm126085.htm
and the latest product monograph for details.

30

Treatment Recommendations
Gonorrhea
Text under the Preferred, Notes and Alternative sections for Gonorrhea have been revised.

Refer to the Gonococcal Infections chapter of the complete Guidelines, page 9, Table 7, text under the Preferred and Alternatives headings plus the accompanying Notes for the table.

33
(NEW- January 2010)

Treatment Recommendations
Under Infectious Syphilis

Preferred

• Benzathine penicillin G 2.4 million units IM in a single dose [A-II; A-III for HIV-infected individuals]

Infectious Syphilis in all non-pregnant adults

Preferred

• Benzathine penicillin G 2.4 million units IM in a single dose* [A-II for NON-HIV; A-III for HIV-infected individuals]
  * Some experts recommend 3 weekly doses (total of 7.2 million units) of benzathine penicillin G in HIV-infected individuals.

Alternative (only in exceptional circumstances)

• Ceftriaxone 1 g IV or IM daily for 10 days [B-II]

Alternative (only in exceptional circumstances)†

• Ceftriaxone 1 g IV or IM daily for 10 days [B-II]

 †The efficacy data supporting the use of these agents is limited, and as such they should only be used in exceptional circumstances and when close patient follow-up is assured.

Treatment Recommendations
Under Non-Infectious Syphilis

Alternative (only in exceptional circumstances)

• Ceftriaxone 1 g IV or IM daily for 10 days [C-III]

Non-Infectious Syphilis in all non-pregnant adults

Alternative (only in exceptional circumstances)†

• Ceftriaxone 1 g IV or IM daily for 10 days [C-III]

†The efficacy data supporting the use of these agents is limited, and as such they should only be used in exceptional circumstances and when close patient follow-up is assured.

36
(NEW- January 2010)

Partner Notification

Trace-back period:
(refer to chart)

Trace-back period*:
(add an asterisk to the column header)

(Note to be added below the table)
* Trace-back period refers to the time period prior to symptom onset or date of specimen collection (if asymptomatic).

The length of time for the trace-back period should be extended:

1) to include additional time up to the date of treatment
2) if the index case states that there were no partners during the recommended trace-back period, then the last partner should be notified
 3) if all partners traced (according to recommended trace-back period) test negative, then the partner prior to the trace-back period should be notified.

40
(NEW –January 2010)

Table: Interpretation of Serologic Tests for Syphilis

Replace with the revised table “Table 2: Guide to interpretation of serologic tests for syphilis” found within the revised Syphilis chapter (January 2010), pages 7-12, in the complete Guidelines.

41
(NEW –January 2010)

Table: Post-Treatment Monitoring of Non-Treponemal Tests (NTTs)

Refer to the following tables in the revised Syphilis chapter (January 2010), in the complete Guidelines.

Table 6: Monitoring of serologic tests and other follow-up on page 21.

Table 8a: Summary of medical management of immunocompetent women found to have reactive syphilis serology during pregnancy on page 24.

Table 8b: Management of infants born to women with reactive treponemal tests (TTs) during pregnancy on pages 25-28.

Table: Assessing Adequate Serologic Response to Treatment

Refer to the updated Table 7: Adequate serologic response, page 21 in the revised Syphilis chapter (January 2010) in the complete Guidelines.

43

Algorithms
Syndromic Management of Urethritis, where it is indicated:
If “No gram stain results available” then
“Treat for urethritis due to chlamydia and consider treating for gonorrhea”

If “No gram stain results available and the individual is high-risk for STI and follow-up cannot be assured” then
“Treat for chlamydia and gonorrhea” 

44

Algorithms
Management of Urethritis-Gram stain results available, where it is indicated:
If "< 5 PMNs per high power field" then "Defer treatment until results are available. If positive; treat accordingly"

If “< 5 PMNs per high power field” then “Defer treatment unless the individual is high risk for infection and follow up is not assured in which case treat for gonorrhea and chlamydia”

45
(NEW- January 2010)

Algorithms
Minimum Screening and Treatment Recommendations for Anogenital or Oral Ulcers

• Perform syphilis serology, both non-treponemal test (RPR, VDRL) and treponemal tests (MHA-TP/TP-PA/FTA-ABS) or syphilis EIA where available (if primary syphilis is suspected, repeat screening in 2-4 weeks if initially negative).

• Serology for suspected primary syphilis should include a non-treponemal test (e.g., RPR/VDRL).
  

- In regions experiencing outbreaks of syphilis and where NTT is the screening test, it may be appropriate to screen at baseline with both non-treponemal and treponemal tests

OR

- A treponemal-specific enzyme immunoassay (EIA) AND if the treponemal-specific EIA is positive, confirmation by a second treponemal-specific test is recommended (e.g., TP-PA, MHA-TP, FTA-ABS or INNO-LIA™).

If the initial serologic testing is negative and syphilis is suspected, serological testing should be repeated in 2-4 weeks.

Footnote# 1. Not recommended for oral or rectal lesions.

1. Not recommended for oral or rectal lesions. For syphilis see page 6. For HSV see pages 4-5 (in the respective chapters of the complete Guidelines).

General

N/A

Discuss HPV vaccination with females.