Guest posting: Dr Nathan Ryder, Clinical Director Sexual Health, Hunter New England Local Health District
Managing sexually transmitted infections (STIs) have always presented a number of challenges to primary care physicians. While most bacterial STIs can still be cured with single dose treatments some STIs are becoming increasingly resistant to antibiotics. Therefore it is more important than ever to be aware of current best practice guidance on STI management in primary care.
Who and when to test
Chlamydia is still the commonest curable STI. As most people with chlamydia have no symptoms the RACGP and Australian STI Guidelines recommend routine annual testing for chlamydia sexually active people less than 30 years of age. Gonorrhoea is less common, with cases mainly found in young Aboriginal people, men who have sex with men and people with sexual exposure contact outside Australia. Mycoplasma genitalium is an emerging infection known to cause urethritis and cervicitis and possibly associated with pelvic inflammatory disease. Testing for Mycoplasma genitalium is only recommended in people with symptoms of infection.
While chlamydia is still treatable with a single 1 gram dose of azithromycin, gonorrhoea is showing decreasing susceptibility to ceftriaxone. Current guidelines recommend dual therapy for gonorrhoea with ceftriaxone 500mg and azithromycin 1 gram, sexual health clinics are able to assist if access to injectable treatment is difficult. A test of cure is recommended 2 weeks after gonorrhoea treatment to ensure cure is achieved. Similarly while Mycoplasma genitalium usually responds to a single dose of azithromycin 1 gram increasingly resistant cases require use the use of moxifloxacin or pristinomycin, neither of which is PBS listed. Sexual health clinics can provide expert advice on managing persistent mycoplasma infections.
Antibiotics are only part of the story
For patients with a proven or suspected sexually transmitted infection it is important to test for other sexually transmitted pathogens, including HIV. Patients should be advised to undergo repeat testing at 3 months as re-infection is very common.
Finally patients should be supported to advise their sexual partners of the need to be tested, and treated, for the infection. The index patient can notify his or her sexual contacts and provide them with information supplied by the healthcare provider (patient referral). If the index patient prefers to notify sexual contacts anonymously, SMS and email messages may be sent via contact tracing websites, such as let them know, better to know and dramadownunder. Alternatively, with the consent of the index patient, the diagnosing clinician, delegate or other health agency can notify sexual contacts of the index patient (provider referral), though the identity of the index case should remain confidential. Sexual health clinics can provide support for complex cases. The priority and length of time over which to trace previous sexual contacts depends on the suspected or confirmed pathogen. The Australian Contact Tracing Manual is available to assist clinicians in this important public health endeavour.
Where to get more information
The Australian STI Guidelines provide concise information about the prevention, testing, diagnosis, management and treatment of STIs. The website also contains useful links and resources, such as an STI Testing tool, taking a sexual history and contact tracing, as well as patient fact sheets.
Picture: Antimicrobial resistant gonorrhoea from the CDC.