pacific-az-disseminated-gonococcal.pptx

File 6 of 7 from Arizona HIV/STI/TB Clinical Update Session Materials

Spotlight on Gonorrhea

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Mind the Clap: A Resurgence of Disseminated Gonococcal Infection? ERIC TANG, MD, MPHCLINICAL FACULTY | CALIFORNIA PREVENTION TRAINING CENTERARIZONA 2021 HIV/STI/TB CLINICAL UPDATE | APRIL 13, 2021 1 1 Roadmap Gonorrhea Overview Screening Treatment *UPDATE* Clinical Manifestations Disseminated Gonococcal Infection Diagnosis Treatment What Clinicians Can Do Additional Management Considerations Resources 2 2 Disclosure Information I have no relevant financial relationships with an entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on patients Any mention of commercial companies is not an endorsement and is for informational purposes only 3 3 Disclaimer "This presentation is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $3,278,366. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government." The views and opinions expressed in this presentation are not necessarily those of the Pacific AIDS Education and Training Centers (PAETC), the Regents of the University of California or its San Francisco campus (UCSF or collectively, University) nor of our funder the Health Resources and Services Administration (HRSA). Neither PAETC, University, HRSA nor any of their officers, board members, agents, employees, students or volunteers make any warranty, express or implied, including the warranties of merchantability and fitness for a particular purpose; nor assume any legal liability or responsibility for the accuracy, completeness or usefulness of information [,apparatus, product] or process assessed or described; nor represent that its use would not infringe privately owned rights. 4 Gonorrhea Overview 5 The State of STDs in the United States 6 Neisseria gonorrhea (GC) GC is the second most common bacterial STD Transmission During vaginal, anal, or oral sex During delivery by infected mother Causes a range of clinical syndromes Typically asymptomatic in women until complications (e.g., PID) develop In men, urethral infections usually symptomatic, but extragenital infections are mostly asymptomatic Incidence highest among adolescents and young adults 7 7 Screening for Gonorrhea(and Chlamydia) 8 Clinical scenario 27-year-old man presents to your clinic for routine visit. He has no symptoms but requests STI testing. Any additional information you want to know? Last tested for STIs 6 months ago; HIV negative; has sex with men, says he is "versatile" and last had sex with a man 3 weeks ago and had both oral and anal sex In addition to HIV and syphilis testing, what other tests should you perform? A. Urine Chlamydia/Gonorrhea B. Pharyngeal GonorrheaC. Rectal Chlamydia/GonorrheaD. All of the aboveE. None of the above 9 Clinical scenario Continued 27-year-old man presents to your clinic for routine visit. He has no symptoms but requests STI testing. Any additional information you want to know? Last tested for STIs 6 months ago; HIV negative; has sex with men, says he is "versatile" and last had sex with a man 3 weeks ago and had both oral and anal sex In addition to HIV and syphilis testing, what other tests should you perform? A. Urine Chlamydia/Gonorrhea B. Pharyngeal GonorrheaC. Rectal Chlamydia/GonorrheaD. All of the aboveE. None of the above 10 Who Should be Screened for CT/GC? < 25 annually, 25+ if at risk Pregnant <25, if at risk Females At least annually Exposed sites: genital, rectal, throat MSM(W) High prevalence settings MSW At least annually All exposed sites HIV + Every 3 months Patients on PrEP All patients, 3 months after treatment Post-Tx CDC 2015 STD Treatment Guidelines 11 11 CDC Testing Recommendations Nucleic Acid Amplification Tests (NAATs) recommended over culture Both symptomatic and asymptomatic Urogenital, pharyngeal & rectal sites Optimal specimen types: First catch urine for men Vaginal swabs for women Papp, 2014 - MMWR 12 Nucleic Acid Amplification Test (NAAT) FDA-cleared tests for oropharyngeal and rectal specimens Aptima Combo 2 Assay* Xpert CT/NG* Many labs have validated their own tests for extragenital testing, including for self-collected specimens *Company and test names are provided for informational purposes only and do not imply endorsement. 13 Self-collected STI Testing Self-collected swabs accurate and acceptable Similar performance to provider-collected specimens Can be performed at lab along with blood draw/urine collection or in the exam room before/after the provider visit May save the provider time May save patient an office visit 14 CDC Extragenital Screening Recommendations Sexually active MSM (HIV+ or HIV-) Oral GC and Rectal GC/CT (in addition to urogenital GC/CT) For reported exposure, regardless of condom use during exposure Women and MSW "Less clear" but can be considered in any individual reporting exposure If GC is positive at urogenital/rectal site, recommend asking about oral exposure If reported, tx with regimen with acceptable efficacy against pharyngeal GC Transgender Men and Women Assess STD risk based of current anatomy and sexual behavior CDC 2015 STD Treatment Guidelines 15 (Uncomplicated) Gonorrhea Treatment 16 Case 1: 27 year-old, HIV-negative MSM sees you for routine STD screening. You test him for HIV, syphilis, and oropharyngeal, rectal, and urine GC/CT with NAAT. Pharyngeal GC NAAT is positive and the rest of his lab results are negative. Which of the following should you use to treat him? A. Ceftriaxone 250mg IM x 1 B. Azithromycin 1g IM x 1 C. Doxycycline 100mg BID PO x 7 days D. Both A & C E. Ceftriaxone 500mg IM x 1 17 17 Case 1 continued: 27 year-old, HIV-negative MSM sees you for routine STD screening. You test him for HIV, syphilis, and oropharyngeal, rectal, and urine GC/CT with NAAT. Pharyngeal GC NAAT is positive and the rest of his lab results are negative. Which of the following should you use to treat him? A. Ceftriaxone 250mg IM x 1 Requires hire dose B. Azithromycin 1g IM x 1 No longer recommended for uncomplicated gonorrhea treatment C. Doxycycline 100mg BID PO x 7 days Used to treat chlamydia D. Both A & C No longer recommended for treatment of uncomplicated gonorrhea E. Ceftriaxone 500mg IM x 1 18 Updated CDC GC Treatment Guidelines Released December 2020 Recommend monotherapy with ceftriaxone at a higher dose No longer recommending dual treatment with azithromycin Link to CDC MMWR for Updated Treatment Guidelines for Gonococal Infection 19 19 *New* Gonorrhea Treatment Guidelinesfor uncomplicated infections Ceftriaxone 500 mg IM x 1 for persons weighing <150kg* *For persons weighing 150kg, 1 g of IM ceftriaxone should be administered However, if chlamydia has not been excluded, treat for chlamydia with: Doxycycline 100 mg PO BID x 7 days For pregnancy, allergy, or concern for non-adherence, 1g PO azithromycin x 1 can be used New, higher dose ceftriaxone monotherapy No longer recommending dual therapy with azithromycin Update to CDC's Treatment Guidelines for Gonococcal infection, 2020; MMWR 20 *New* Alternative Gonorrhea Treatmentfor uncomplicated infections of the cervix, urethra, and rectum if ceftriaxone is not available: Cefixime 800 mg PO x 1 However, if chlamydia has not been excluded, treat for chlamydia with: Doxycycline 100 mg PO BID x 7 days For pregnancy, allergy, or concern for non-adherence, 1g PO azithromycin x 1 can be used Cephalosporin allergy: Gentamicin 240 mg IM + azithromycin 2 g PO No reliable alternative treatments are available for pharyngeal gonorrhea Get Test-of-Cure at 7-14 days post treatment for pharyngeal gonorrhea Update to CDC's Treatment Guidelines for Gonococcal infection, 2020; MMWR 21 Why the change in GC treatment recommendation? Antimicrobial stewardship Increasing azithromycin resistance in Streptococcus pneumoniae, M. genitalium, Shigella, and Campylobacter Pharmacokinetic and pharmacodynamic considerations A 250mg ceftriaxone dose does not reliably achieve adequate levels for an extended duration Changes in azithromycin susceptibility Azithromycin MIC for GC isolates has steadily increased Ceftriaxone and cefixime MICs for GC has stabilized Update to CDC's Treatment Guidelines for Gonococcal infection, 2020; MMWR 22 22 Clinical Manifestations of Gonorrhea 23 CERVICITIS, URETHRITIS STD Atlas, 1997 24 24 NORMAL TUBES/OVARIES AND PELVIC INFLAMMATORY DISEASE STD Atlas, 1997 25 25 PHARYNGITIS, EPIDIDYMITIS, AND PROCTITIS STD Atlas, 1997 26 26 CONJUNCTIVITIS STD Atlas, 1997 27 27 DISSEMINATED GONOCOCCAL INFECTION STD Atlas, 1997 28 28 Case 2: 20-year-old woman presents with a rash Rash on arms, legs, trunk, and scalp for one day Generalized muscle aches, fever, and pain in both ankles 2 weeks prior vaginal sex with new partner without barrier protection Denies vaginal discharge or pain on urination Physical exam: erythematous pustules on the wrist and fingers, also visualized on her trunk, scalp, and both ankles. Mild swelling and pain with passive motion in the right ankle, and tenosynovitis involving the tendons of both ankles, but no appreciative joint effusions. To make the diagnosis of DGI, at what anatomic sites should diagnostic tests be performed? A. Blood (i.e. blood cultures)B. Genital (genital NAAT and culture, if available)C. Skin lesion (culture)D. All of the above Link to New England Journal of Medicine 29 29 Case 2 Continued: 20-year-old woman presents with a rash Rash on arms, legs, trunk, and scalp for one day Generalized muscle aches, fever, and pain in both ankles 2 weeks prior vaginal sex with new partner without barrier protection Denies vaginal discharge or pain on urination Physical exam: erythematous pustules on the wrist and fingers, also visualized on her trunk, scalp, and both ankles. Mild swelling and pain with passive motion in the right ankle, and tenosynovitis involving the tendons of both ankles, but no appreciative joint effusions. To make the diagnosis of DGI, at what anatomic sites should diagnostic tests be performed? A. Blood (i.e. blood cultures)B. Genital (genital NAAT and culture, if available)C. Skin lesion (culture)D. All of the above Link to New England Journal of Medicine 30 30 Case 2 blood culture: 20-year-old woman presents with a rash Rash on arms, legs, trunk, and scalp for one day Generalized muscle aches, fever, and pain in both ankles 2 weeks prior vaginal sex with new partner without barrier protection Denies vaginal discharge or pain on urination Link to New England Journal of Medicine 31 31 Disseminated Gonococcal Infection (DGI) Epidemiology and Predisposing Factors Considered to be a rare complication Estimated 0.53% of untreated gonococcal infections Host factors: female, recent menstruation, pregnancy, terminal complement deficiency Eculizumab Monoclonal C5 antibody approved for diseases associated with dysregulation of complement activation (e.g., aplastic anemia, paroxysmal nocturnal hemoglobinuria) Several DGI case reports among patients treated with eculizumab 8 cases per ongoing analysis of FDA adverse event reporting system Gleesing 2012; Hublikar S,2014; Khandelwal, 2017; Crew, 2019 33 33 Epidemiology and Predisposing Factors: Microbial Microbial factors Historically virulence factors and growth factors associated with serum resistance and increased propensity to cause DGI PorB1A DGI suspected to result from multifactorial process in which certain bacterial traits are probably necessary, but not sufficient (i.e., there are strains that cause DGI in some individuals, but are found circulating among individuals with uncomplicated gonorrhea) 34 34 Disseminated Gonococcal Infection (DGI) Clinical Manifestations N. gonorrhoeae invades bloodstream and spreads to distant sites in the body Clinical manifestations Fever, petechial/pustular skin lesions, polyarthralgias, tenosynovitis, septic arthritis Endocarditis, meningitis, osteomyelitis 35 35 Clinical Manifestations "Arthritis-dermatitis syndrome" Historically most common presentation Polyarthralgias and tenosynovitis Wrist, MCP joints, ankle Migratory, asymmetric polyarthralgia Skin lesions mostly on extremities Fever, chills, malaise "Bacteremic stage" bacteremia in up to 50% of cases Photos: KK Holmes et al. Ann Intern Med 1971; CDC Public Health Image Library 36 36 Clinical Manifestations Continued Septic (purulent) arthritis Historically less than 50% of DGI cases Monoarticular or oligoarticular Knees, wrists, ankles Direct extension can result in osteomyelitis (rare) Photos: CDC Public Health Image Library; HS Lambert et al, Slide Atlas of Infectious Diseases: Disseminated Infections, 1982. 37 37 Making the Diagnosis of DGI Specimen collection Mucosal sites (urogenital, pharyngeal, rectal) Disseminated sites (e.g., skin, synovial fluid, blood, or cerebrospinal fluid) Nucleic acid amplification testing (NAAT) Culture Culture 38 38 Making the Diagnosis of DGI Continued Specimen collection Mucosal sites (urogenital, pharyngeal, rectal) Disseminated sites (e.g., skin, synovial fluid, blood, or cerebrospinal fluid) Nucleic acid amplification testing (NAAT) Culture Usually clinical diagnosis Culture 39 39 DGI Management and Treatment Consult CDC STD Treatment Guidelines Hospitalization and consultation with Infectious Disease specialist Antimicrobial treatment per CDC STD Treatment Guidelines Antimicrobial susceptibility testing (AST) on ALL isolates Link to CDC's STD Website 40 DGI Management and Treatment Continued Consult CDC STD Treatment Guidelines Hospitalization and consultation with Infectious Disease specialist Antimicrobial treatment per CDC STD Treatment Guidelines Antimicrobial susceptibility testing (AST) on ALL isolates 2021 CDC STD Treatment Guidelines Coming Soon Link to CDC's STD Website 41 DGI Treatment 42 Case 2 : Treatment of DGI What is the recommended treatment regimen for DGI arthritis and arthritis-dermatitis syndrome? A. Ceftriaxone 250mg IM/IV q24h + Azithromycin 1g PO B. Ceftriaxone 500mg IM/IV q24h C. Ceftriaxone 1g IM/IV q24h + Azithromycin 1g PO D. Ceftriaxone 1g IM/IV q24h E. Ceftriaxone 1-2g IV q12-24h + Azithromycin 1g PO 43 43 Case 2 continued: Treatment of DGI What is the recommended treatment regimen for DGI arthritis and arthritis-dermatitis syndrome? A. Ceftriaxone 250mg IM/IV q24h + Azithromycin 1g PO B. Ceftriaxone 500mg IM/IV q24h C. Ceftriaxone 1g IM/IV q24h + Azithromycin 1g PO D. Ceftriaxone 1g IM/IV q24h E. Ceftriaxone 1-2g IV q12-24h + Azithromycin 1g PO 44 44 Case 2 note: Treatment of DGI What is the recommended treatment regimen for DGI arthritis and arthritis-dermatitis syndrome? A. Ceftriaxone 250mg IM/IV q24h + Azithromycin 1g PO CTX dose to low B. Ceftriaxone 500mg IM/IV q24h CTX dose to low C. Ceftriaxone 1g IM/IV q24h + Azithromycin 1g PO D. Ceftriaxone 1g IM/IV q24h azithromycin still in 2015 recommendations E. Ceftriaxone 1-2g IV q12-24h + Azithromycin 1g PO Tx for DGI endocarditis or meningitis Note: Ceftriaxone 1g IM/IV q24h alone may be the recommended regimen once the 2021 CDC STI Treatment Guidelines are released 45 45 Treatment of Arthritis and Arthritis-Dermatitis Syndrome Recommended Regimen Ceftriaxone 1 g IM or IV every 24 hoursPLUS* Azithromycin 1 g orally in a single dose Alternative Regimens Cefotaxime OR Ceftizoxime 1 g IV every 8 hoursPLUS* Azithromycin 1 g orally in a single dose When treating for the arthritis-dermatitis syndrome, the provider can switch to an oral agent guided by antimicrobial susceptibility testing 2448 hours after substantial clinical improvement, for a total treatment course of at least 7 days. *Per CDC 2015 STD Treatment Guidelines; azithromycin may be dropped in the updated CDC 2021 STI Treatment Guidelines 46 46 Treatment of Gonococcal Meningitis and Endocarditis Recommended Regimen Ceftriaxone 12 g IV every 1224 hoursPLUS* Azithromycin 1 g orally in a single dose The duration of treatment of DGI has not been systematically studied and should be determined in consultation with an infectious-disease specialist. Guided by the results of antimicrobial susceptibility testing. Pending antimicrobial susceptibility results, treatment decisions should be made on the basis of clinical presentation. Therapy for meningitis should be continued for 1014 days. Therapy for endocarditis should be administered for at least 4 weeks. *Per CDC 2015 STD Treatment Guidelines; azithromycin may be dropped in the updated CDC 2021 STI Treatment Guidelines 47 47 Increase in DGI Cases inthe United States? CDC DGI Dear Colleague Letter Released December 5, 2019 CDC reports increase of DGI in Michigan Majority of cases reported amphetamine and some opioid injection use Link to CDC DGI Dear Colleague Letter 49 49 California Department of Public Health DGI Dear Colleague Letter Released letter for CA clinicians on December 23, 2020 Increase in cases noted among patients who reported experiencing homelessness and/or illicit drugs, particularly methamphetamine Link to California Department of Public Health Dear Colleague Letter 50 50 What can clinicians do? Page 51 Provider Recommendation #1 Providers should reinstate routine screening for STDs among: Individuals using illicit drugs, particularly (meth)amphetamine/IV drugs Individuals experiencing homelessness < 25 annually, 25+ if at risk Pregnant <25, if at risk Females At least annually Exposed sites: genital, rectal, throat MSM(W) High prevalence settings (or at high risk) MSW At least annually All exposed sites HIV + Every 3 months Patients on PrEP All patients, 3 months after treatment Post-Tx 52 52 Provider Recommendation #2 Providers should increase their clinical suspicion for DGI in patients with joint pain Expand differential dx beyond osteoarthritis, joint sprain, and gout Explore nature of joint pain (is it migratory?) Ask about rash and conduct skin exam, with attention to hands and feet Ask about urogenital (as well as rectal, pharyngeal) symptoms Take a social history - sexual history, drug use, and housing status Aspirate joint if there is an effusion 53 53 Provider Recommendation #3 Manage DGI cases per the CDC STD Treatment Guidelines Before initiating empiric antibiotic tx for suspected DGI, obtain: Blood cultures as well as cultures from synovial fluid/skin pustules (if applicable) NAAT and culture (if available) at genital AND extragenital sites (pharyngeal and rectal) Hospitalized and consultation with an infectious disease specialist when available are recommended for initial therapy Clinical consultation for DGI management is also available through the STD Clinical Consultation Network (Link to STD Clinical Consultation Network) 54 54 Provider Recommendation #4 Test all GC isolates from DGI cases for antimicrobial susceptibility Antimicrobial susceptibility requires CULTURE Please contact your local health department for guidance on obtaining culture if not available at your site Some public health and commercial labs also provide GC culture +/- antimicrobial susceptibility Mayo Clinic and CDC can also perform GC susceptibility testing 55 55 Provider Recommendation #5 Report all laboratory confirmed and clinically suspected cases of DGI to the local health department within 24 hours of identification 56 56 Additional Management 57 Additional management of DGI/GC If dx with gonorrhea, test for HIV, syphilis, and chlamydia (CT) Offer HIV Preexposure Prophylaxis (PrEP) indications include: Man who has sex with men (MSM) with GC (or CT or syphilis) diagnosed or reported in the past 6 months Any woman or man with GC (or syphilis) diagnosed/reported in the past 6 months 58 58 Additional management of DGI/GC Continued Treat partners Recent sex partners within the 60 days preceding onset of symptoms or diagnosis of DGI/GC should be referred for evaluation, testing, and presumptive treatment Gonococcal infection frequently is asymptomatic in sex partners of persons who have DGI Test for GC/CT at all sites of exposure To avoid reinfection, sex partners should abstain from unprotected sex for 7 days after they and their sexual partner(s) have completed treatment and after resolution of symptoms, if present. 59 59 Expedited Partner Therapy (EPT) The practice of treating the partners of patients for STDs without performing a physical exam Permissible by law in AZ for contacts of reportable communicable diseases (i.e., GC, CT) Can be used when provider cannot confidently ensure all patient's sex partners from the prior 60 days will be treated Prevents reinfection, transmission, and cost savings relative to clinic visits All dispensed drugs (including those dispensed for EPT) require the following: The dispensing doctor's name, address, and telephone number The date the drug is dispensed The patient's name The name and strength of the drug, directions for its use, and any cautionary statements 60 60 EPT Recommendations For Gonorrhea: Cefixime 800mg x 1 When chlamydia cannot be excluded: Add Doxycycline 100mg BID x 7 days Alternative (e.g., in case of pregnancy or concern for compliance, allergy): Azithromycin 1g PO x 1 Providing meds better than Rx if possible Should be accompanied by instructions/warnings e.g., allergies; need for in-person evaluation, particularly women who are pregnant and/or with symptoms of pelvic inflammatory disease Link to AzDHS EPT FAQ for Medical Professionals Link to AzDHS EPT Fact Sheet for Physicians 61 61 Link to Tellyourpartner.org 62 Take Home Points Reinstate routine STD screening Treat uncomplicated GC with ceftriaxone 500 mg IM monotherapy DGI is increasing in the US increase your clinical suspicion for DGI for patients with joint pain Obtain NAAT and culture specimens at all exposed anatomic sites for patients with suspected DGI Report GC/DGI cases to your local health department Treat partners and if needed, by expedited partner therapy 63 63 Resources 64 Page 64 Additional DGI resources DGI FAQ for Medical Providers Patient education flyers/cards for clinics Link to DGI FAQ for Medical Providers Flyer also available in Spanish! If interested in these resources, contact [email protected] 65 65 MORE Clinical Guidelines and Electronic Consultation Link to CDC STD Treatment Guidelines STD Clinical Consultation Network Link to STD Clinical Care Network CDC STD Treatment Guidelines App Available now, free Search for "STD TX" 66 66 Additional Resources with Links Link to CDC 2020 Update to Treatment for Gonococcal Infections Link to CDC DGI Case Reporting form Link to Dear Colleague Letter: STD Care and Prevention Guidance During Disruption of Clinical Services due to the COVID-19 pandemic (April 6, 2020) Link to Transportation of Specimens for Culture of Neisseria gonorrhoeae Link to Recommendations for the Laboratory-Based Detection of C. trachomatis and N. gonorrhoeae 2014 67 67 Thank you Contact information: [email protected] Acknowledgements: Kathleen Jacobson Lizzete Alvarado Kelly Johnson Rosalyn PlotzkerIna Park Nicole Burghardt Denise Gilson Ryan Murphy Edwin Lopez Lupe Espain Bryan Hughes Tazima Jenkins-BarnesHillary Berman-Watson Laura Quilter Brian Raphael Jim Kent William Nettleton Justin Holderman Alison Ridpath Becca Scranton Nessa MeshkatyMelissaLee Barger Will Geisler Stephanie Cohen Julie Dombrowski Page 68 Extra Slides 69 CDC 2015 STD Treatment Guidelines Chlamydia Treatment Recommended first-line treatment: Azithromycin 1 g PO in a single dose Single dose regimen Can be directly observed Use when non-adherence is a concern OR Doxycycline 100mg PO BID x 7 days Contraindicated in pregnancy CDC 2015 STD Treatment Guidelines 70 Evidence supporting doxycycline better than azithromycin for CT? Slides courtesy of Will Geisler 71 A Randomized Trial of Azithromycin vs. Doxycycline for the Treatment of Rectal Chlamydia in Men who Have Sex with Men (DMID Protocol 17-0092) Julie Dombrowski, Michael R. Wierzbicki, Lori Newman, Jonathan Powell, Ashley Miller, Dwyn Dithmer, Olusegun Soge, Kenneth H. Mayer 2020 STD Prevention Conference Objectives: Placebo controlled RCT comparing: Azithromycin 1g x 1 vs doxycycline 100mg BID x 7d for rectal CT Primary outcome: microbiologic cure at 4 weeks Secondary outcomes: microbiologic cure at 2w; effect of LGV on cure Participants: MSM testing NAAT(+) for rectal CT at two STI clinics in Seattle and Boston, with no or low-level symptoms (itch, irritation) Dombrowski et al, STD Prevention Conf 2020 73 73 Microbiologic Cure at Four Weeks, by Treatment Group n=70/70 n=48/65 n=80/88 n=63/89 n=46/46 n=37/48 % with Negative NAAT at 4 weeks Absolute Difference 26% (95% CI: 16-36%) p<0.001 20% (95% CI: 9-31%) p<0.001 23% (95% CI: 11-37%) p<0.001 Conclusion: Doxycycline 100mg BID x 7d substantially better than azithromycin 1g x1 for rectal CT in MSM Dombrowski et al, STD Prevention Conf 2020 CT Treatment CDC 2015 STD Treatment Guidelines *Recommended first-line treatment: Azithromycin 1 g PO in a single dose Single dose regimen Can be directly observed Use when non-adherence is a concern OR Doxycycline 100mg or PO BID x 7 days Contraindicated in pregnancy Better for rectal infections; underdiagnosed/tx in females? *Per CDC 2015 STD Treatment Guidelines; doxycycline may be first-line tx, with azithromycin as alternative tx in the updated CDC 2021 STI Treatment Guidelines 75