February 2011revised.indd

February 2011
A Monthly Newsletter of the Communicable Disease Division New Treatment Guidelines for
Consider Cholera
Sexually Transmitted Diseases
Since a cholera outbreak was confirmed in Haiti on October 21, 2010, a total of 121,518 cases have been reported, resulting in 63,711 hospital- n December 2010, the CDC released updated treat- izations and 2,591 deaths. Additional cases of cholera have been confirmed ment guidelines for sexually transmitted diseases, in the neighboring Dominican Republic and in Florida. All confirmed cases expanding and revising them from 2006. Updates include in the U.S. were among travelers from Haiti.
new diagnostic evaluation for cervicitis and trichomoniai- sis, new treatment recommendations for bacterial vagino- Travelers who develop watery diarrhea within five days after returning sis and genital warts, and the criteria for spinal fluid ex- from cholera-affected areas should seek health care and report their travel amination to evaluate for neurosyphilis. New information histories.
is included about the emergence of azithromycin-resistant Recognizing and Treating Cholera: Cholera is an acute bacterial
syphilis and the increasing prevalence of antimicrobial- enteric disease with sudden onset of profuse watery diarrhea and vomit- resistant gonorrhea, as well as the sexual transmission of ing. If severe, it can lead to severe dehydration, shock, acidosis, and death hepatitis C. Updates include guidelines for pre-exposure vaccination, topical microbicides and antiretrovirals, and diagnostic evaluation after sexual assault. Clinicians should inquire about recent travel when evaluating patients presenting with severe watery diarrhea and vomiting with severe dehydra- Two human papillomavirus (HPV) vaccines are available tion, particularly after recent travel from Haiti. The patient may complain for females ages 9-26 to prevent cervical pre-cancer and of painful cramping in the legs due to electrolyte disturbances. cancer. They include Gardasil, a quadrivalent vaccine, and Cervarix, a bivalent vaccine. Routine vaccination with Clinical suspicion should be increased, and milder diarrheal illnesses are either vaccine is recommended for girls 11 or 12 years, more suspect in persons returning from Haiti, or in persons with a recent with catch-up vaccination recommended for females aged history of ingestion of raw seafood. The incubation period of cholera is 13-26 years. Gardasil also prevents genital warts and can be administered to males ages 9-26. xual Trans(HCV)
Diagnosis: When cholera is suspected, a stool specimen should be col-
Recent data indicate that sexual transmission of HCV can lected for culture of Vibrio cholerae. Notify the lab about the possibility occur, especially among HIV-infected persons. An esti- of cholera so they will culture on TCBS agar. Do not wait for a positive mated 10% of people with acute HCV infection report culture before starting aggressive rehydration.
contact with a known HCV-infected sex partner as their Treatment: The severe cholera patient may have lost more than 10% of
only risk for infection. Sexual transmission of HCV has body weight and need swift volume replacement. Cholera deaths can be been reported among HIV infected men having sex with prevented by the aggressive administration of fluids. This will correct the men (MSM) in several European cities and in New York dehydration, shock, and acidosis. Antibiotic treatment is less important but City. Practices associated with these clusters of infection include serosorting (HIV infected MSM), group sex, and the use of cocaine and other nonintravenous drugs during sex.ical Antiretrovirals
Recommended Treatment for Cholera
Effective topical microbicides for the prevention of HIV and STD have not been identified. Randomized, con- Medication
AdultRegimen
ChildRegimen
trolled trials for products including BufferGel (a vaginal Doxycycline
2Ͳ4mg/kginasingledose
buffering agent), Carraguard (a carrageenan deriva- tive), SAVVY (a surfactant), and PRO2000 vaginal gel (a Azithromycin
1ginasingledose
20mg/kginasingledose
synthetic polyanion polymer that blocks cellular entry Tetracycline
of HIV) all failed to show a protective effect against HIV. times/dayfor3days
for3days
The use of the antiretroviral tenofovir gel during sexual Ciprofloxacin
20mg/kginasingledose
intercourse reduced the rate of HIV acquisition by 39% OR500mg2times/dayfor3days
Erythromycin 500mg,4times/dayfor3days
STD Guidelines, continued on page 2 Boulder County Public Health, 3450 Broadway, Boulder, CO 80304 303-441-1100 www.BoulderCountyHealth.org STD Guidelines, continued from page 1 in a study of South African women, with more studies underway to determine optimal Fluids: Patients with mild to moderate
dehydration can be given an appropriate oral Strains of treatment-resistant Neisseria gonorrhoeae are emerging and increasing in rehydration salt solution such as Rehydra- prevalence. Treatment failures with oral cephalosporins have been documented in Southeast Asia in patients with N. gonorrhoeae. Based on prior experience with Salts (ORS). Only solutions that contain quinolone-resistant N gonorrhoeae, it is probable that cephalosporin-resistant strains the proper balance of electrolytes should be may spread to the Unites States. Due to these reports, ceftriaxone 250 mg intramus- given. Patients with severe dehydration or cularly or cefixime 400 mg orally are recommended for urogenital infection. Since those with intractable vomiting need intrave- coinfection with chlamydia is common, therapy with azithromycin or doxycycline is nous therapy with Ringer’s lactate solution. Intravenous fluid should be given quickly to If a penicillin allergy exists, several therapies may be effective in non-pregnant patients restore circulation, followed by oral fluids as with primary or secondary syphilis, including doxycycline 100 mg orally twice daily for 14 days, or tetracycline 500 mg 4 times daily for 14 days. Gastrointestinal side effects are less likely with doxycycline, so compliance is more likely. Azithromycin based on the degree of dehydration. Severely as a single 2-g oral doze is effective for treating early syphilis; however, chomozomal dehydrated adults may require several liters mutations associated with its resistance and treatment failures have been documented of fluid immediately to restore an adequate in the United States. Treatment should be used with caution, and only when penicillin circulating volume. Cholera patients will
and doxycycline is not feasible. Azithromycin should not be used in MSM or pregnant have significant ongoing fluid losses
women. Treatment U
that should be measured and replaced.
 Lymphogranuloma venereum proctocolitis (LGV) is being increasingly recognized, Antibiotics: Based on antimicrobial sus-
especially among HIV-positive MSM. In persons with painful perianal ulcers or ceptibility testing on strains from the ongo- those detected on anoscopy, presumptive therapy should include treatment for ing cholera outbreak in Haiti, the following LGV, which is doxycycline 100 mg twice daily for 21 days.
antimicrobial regimens may be used to treat  A new patient-applied treatment for genital warts is available. The treatment of confirmed or suspected cases of cholera pos- 15% sinecatechins ointment should be applied by the patient 3 times daily until sible linked to this outbreak. Oral suspensions of most of these medications are available for  A new alternative treatment for bacterial vaginosis is 2 g of tinidazole taken daily for 3 days, or 1 g taken daily for 5 days. Clinical management guidelines, including  For episodic outbreaks of herpes simplex virus, an additional treatment option is antibiotic treatment, are available on the CDC 500 mg of famciclovir followed by 2 days of 250 mg taken twice daily.  There are also some data that moxifloxacin -- 400 mg daily for 7 days -- is effective era/clinicalmanagement/ in nongonococcal urethritis treatment failures due to Mycoplasma genitalium.
A training manual for health care providers is The complete updated guidelines are available online for printing at www.cdc.gov/ std/treatment/2010/ or by contacting CDC-INFO at 800-CDC-INFO (800-232- http://www.cdc.gov/haiticholera/pdf/hait- 4636), 24 hours/day, or e-mail [email protected]. A podcast featuring lead author Dr. Kimberly Workowski is posted on the same website. Wall charts, pocket guides, iphone and ebook versions will be released soon on the same website. Reporting: All suspected or confirmed
Local Sexual Health Resources
Boulder County Public Health immediately The Boulder Valley Women’s Health Center provides gynecological and family plan- at 303.413.7500. Patients should not swim ning services to women, men, and teens. Their services are provided on a sliding scale while ill with diarrhea or for two weeks after down to $0 for patients below 100% of the federal poverty line. Services include:  Annual exams with Pap smears and breast exams Contributed by: Gina Bare, RN, and  Birth control counseling and supplies, including long-term, permanent, and emer-  Pregnancy tests, including decision counseling  Subsidized services for gynecological abnormalities and complex care  Abortion careThe Youth Services program provides free and confidential clinic time for youth under age 20, a peer education program, and a sexual health website specifically for teens (www.teenclinic.org), including an anonymous text message line. For more informa- tion, visit www.boulderwomenshealth.org or call 303.442.5160.
Communicable Disease Control Program 303-413-7500 • Emergency Preparedness Program 303-413-7562 HIV/STI Outreach Program 303-413-7522 • TB Program 303-413-7517

Source: http://www.bouldercounty.org/doc/publichealth/epiconfeb2011.pdf