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1.
MMWR Morb Mortal Wkly Rep ; 69(50): 1911-1916, 2020 Dec 18.
Artículo en Inglés | MEDLINE | ID: mdl-33332296

RESUMEN

Sexually transmitted infections (STIs) caused by the bacteria Neisseria gonorrhoeae (gonococcal infections) have increased 63% since 2014 and are a cause of sequelae including pelvic inflammatory disease, ectopic pregnancy, and infertility and can facilitate transmission of human immunodeficiency virus (HIV) (1,2). Effective treatment can prevent complications and transmission, but N. gonorrhoeae's ability to acquire antimicrobial resistance influences treatment recommendations and complicates control (3). In 2010, CDC recommended a single 250 mg intramuscular (IM) dose of ceftriaxone and a single 1 g oral dose of azithromycin for treatment of uncomplicated gonococcal infections of the cervix, urethra, and rectum as a strategy for preventing ceftriaxone resistance and treating possible coinfection with Chlamydia trachomatis (4). Increasing concern for antimicrobial stewardship and the potential impact of dual therapy on commensal organisms and concurrent pathogens (3), in conjunction with the continued low incidence of ceftriaxone resistance and the increased incidence of azithromycin resistance, has led to reevaluation of this recommendation. This report, which updates previous guidelines (5), recommends a single 500 mg IM dose of ceftriaxone for treatment of uncomplicated urogenital, anorectal, and pharyngeal gonorrhea. If chlamydial infection has not been excluded, concurrent treatment with doxycycline (100 mg orally twice a day for 7 days) is recommended. Continuing to monitor for emergence of ceftriaxone resistance through surveillance and health care providers' reporting of treatment failures is essential to ensuring continued efficacy of recommended regimens.


Asunto(s)
Gonorrea/tratamiento farmacológico , Guías de Práctica Clínica como Asunto , Administración Oral , Ceftriaxona/administración & dosificación , Centers for Disease Control and Prevention, U.S. , Infecciones por Chlamydia/complicaciones , Infecciones por Chlamydia/tratamiento farmacológico , Chlamydia trachomatis , Coinfección/tratamiento farmacológico , Doxiciclina/administración & dosificación , Medicina Basada en la Evidencia , Gonorrea/complicaciones , Humanos , Inyecciones Intramusculares , Estados Unidos
2.
Clin Infect Dis ; 71(Supplement_1): S1-S3, 2020 Jun 24.
Artículo en Inglés | MEDLINE | ID: mdl-32578867

RESUMEN

The articles in this supplement address key questions on syphilis diagnostics, provide reference tables of test performances, and discuss optimal specimens and knowledge gaps. Laboratory-developed genetic direct detection tests could be most useful at the point of care and add to the currently available serologic methods of nontreponemal and treponemal tests.

3.
Sex Transm Dis ; 47(6): 412-418, 2020 06.
Artículo en Inglés | MEDLINE | ID: mdl-32413019

RESUMEN

BACKGROUND: With increasing rates of sexually transmitted infections in the United States, there is a critical need to educate health professionals on the prevention, diagnosis, and treatment of sexually transmitted infections. The National Sexually Transmitted Disease Curriculum (NSTDC, https://www.std.uw.edu) is a free, online curriculum, funded by the Centers for Disease Control and Prevention. The purpose of this article is to evaluate the reach, utilization, and engagement of users with the curriculum. METHODS: Data on NSTDC utilization was collected for 24 months after the February 1, 2017 launch. For all users, Google Analytics was used to determine total number of users, geographic location, age and sex, and average session duration. For registered users, additional data analysis included work-role, demographics, and completion of self-study modules, check-on-learning questions, and question banks. User satisfaction was measured on a 5-point Likert scale. RESULTS: During the evaluation period, 136,270 individual users accessed the NSTDC, including 24,652 registered users. Among all registered users, 10,660 (43.2%) were registered nurses, 2810 (11.4%) physicians, 4942 (20.1%) Advanced Practice Nurses and Physician Assistants, and 6213 (25.2%) nonclinicians. Among registered users, 18,533 (75.2%) completed at least 1 module, 7898 (32.0%) completed all 7 modules, and 19,804 (80.4%) answered optional check-on-learning questions. Median satisfaction with the content was (5) very satisfied (interquartile range, 4-5). CONCLUSIONS: The NSTDC is a free, guideline-based, online curriculum with novel dual functionality that has achieved extensive reach with a broad array of health professionals who engage deeply with the material. The wide usage of NSTDC demonstrates the need for high-quality, unbiased, free content in user-focused formats.

4.
Obstet Gynecol ; 135(5): 1136-1144, 2020 05.
Artículo en Inglés | MEDLINE | ID: mdl-32282605

RESUMEN

OBJECTIVE: To identify factors associated with testing for and diagnosis of trichomoniasis in pregnancy and to describe patterns of treatment and tests of reinfection or persistence. METHODS: We conducted a retrospective cohort study of women who delivered from July 2016 to June 2018 at one institution. Testing for Trichomonas vaginalis infection was done by wet mount microscopy or by nucleic acid amplification testing for routine prenatal testing or symptomatic visits. Poisson regression was used to identify factors associated with testing for trichomoniasis and testing positive in pregnancy. Treatment and re-testing patterns also were assessed. RESULTS: Among 3,265 pregnant women, 2,489 (76%) were tested for T vaginalis infection. Of the total sample, 1,808 (55%) were tested by wet mount microscopy, 1,661 (51%) by nucleic acid amplification testing, and 980 (30%) by both modalities. The sensitivity for microscopy compared with nucleic acid amplification testing was 26%, with a specificity of 99%. Factors associated with increased likelihood of being tested included younger age (adjusted risk ratio [aRR] 0.99, 95% CI 0.99-1.00) and bacterial vaginosis (aRR 1.17, 95% CI 1.01-1.37). Prevalence of trichomoniasis was 15% among those tested by any modality (wet mount or nucleic acid amplification testing). Risk factors for trichomoniasis included younger age (aRR 0.97, P<.01), being of black race (aRR 2.62, P<.01), abnormal vaginal discharge (aRR 1.45, P<.01), and chlamydia during the current pregnancy (aRR 1.70, P<.01). Women diagnosed by microscopy had a shorter time to treatment compared with those diagnosed by nucleic acid amplification testing. Most (75%) women with positive infections had a test of reinfection; 29% of these were positive. Bacterial vaginosis was associated with decreased risk of a positive test of reinfection. CONCLUSION: Although testing for and treatment of trichomoniasis during pregnancy is not routinely recommended, the high burden of infection among some pregnant women demonstrates a need to further understand patterns of T vaginalis testing and infection. Opportunities exist for improving timely treatment of trichomoniasis and test of reinfection.


Asunto(s)
Complicaciones Infecciosas del Embarazo/diagnóstico , Diagnóstico Prenatal/métodos , Vaginitis por Trichomonas/diagnóstico , Trichomonas vaginalis , Excreción Vaginal/diagnóstico , Adulto , Femenino , Humanos , Microscopía , Técnicas de Amplificación de Ácido Nucleico , Distribución de Poisson , Embarazo , Complicaciones Infecciosas del Embarazo/epidemiología , Complicaciones Infecciosas del Embarazo/terapia , Prevalencia , Estudios Retrospectivos , Factores de Riesgo , Sensibilidad y Especificidad , Vaginitis por Trichomonas/epidemiología , Vaginitis por Trichomonas/terapia , Excreción Vaginal/epidemiología , Excreción Vaginal/microbiología , Vaginosis Bacteriana/diagnóstico , Vaginosis Bacteriana/epidemiología , Adulto Joven
5.
PLoS One ; 15(1): e0227769, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-31929602

RESUMEN

Clinical isolates of Treponema pallidum subspecies pallidum (T. pallidum) would facilitate study of prevalent strains. We describe the first successful rabbit propagation of T. pallidum from cryopreserved ulcer specimens. Fresh ulcer exudates were collected and cryopreserved with consent from syphilis-diagnosed patients (N = 8). Each of eight age-matched adult male rabbits were later inoculated with a thawed specimen, with two rabbits receiving 1.3 ml intratesticularly (IT), and six receiving 0.6 ml intravenously (IV) and IT. Monitoring of serology, blood PCR and orchitis showed that T. pallidum grew in 2/8 rabbits that were inoculated IV and IT with either a penile primary lesion specimen (CDC-SF003) or a perianal secondary lesion specimen (CDC-SF007). Rabbit CDC-SF003 was seroreactive by T. pallidum Particle Agglutination (TP-PA) and Rapid Plasma Reagin (RPR) testing, PCR+, and showed orchitis by week 6. Euthanasia was performed in week 7, with treponemal growth in the testes confirmed and quantified by qPCR and darkfield microscopy (DF). Serial passage of the extract in a second age-matched rabbit also yielded treponemes. Similarly, rabbit CDC-SF007 showed negligible orchitis, but was seroreactive and PCR+ by week 4 and euthanized in week 6 to yield T. pallidum, which was further propagated by second passage. Using the 4-component molecular typing system for syphilis, 3 propagated strains (CDC-SF003, CDC-SF007, CDC-SF008) were typed as 14d9f, 14d9g, and 14d10c, respectively. All 3 isolates including strain CDC-SF011, which was not successfully propagated, had the A2058G mutation associated with azithromycin resistance. Our results show that immediate cryopreservation of syphilitic ulcer exudate can maintain T. pallidum viability for rabbit propagation.


Asunto(s)
Sífilis/microbiología , Sífilis/patología , Treponema pallidum/aislamiento & purificación , Animales , Criopreservación , Modelos Animales de Enfermedad , Humanos , Masculino , Tipificación Molecular , Conejos , Sífilis/diagnóstico , Treponema pallidum/genética , Treponema pallidum/fisiología
6.
MMWR Recomm Rep ; 68(5): 1-20, 2020 01 03.
Artículo en Inglés | MEDLINE | ID: mdl-31899459

RESUMEN

This report (hereafter referred to as STD QCS) provides CDC recommendations to U.S. health care providers regarding quality clinical services for sexually transmitted diseases (STDs) for primary care and STD specialty care settings. These recommendations complement CDC's Sexually Transmitted Diseases Treatment Guidelines, 2015 (hereafter referred to as the STD Guidelines), a comprehensive, evidence-based reference for prevention, diagnosis, and treatment of STDs. STD QCS differs from the STD Guidelines by specifying operational determinants of quality services in different types of clinical settings, describing on-site treatment and partner services, and indicating when STD-related conditions should be managed through consultation with or referral to a specialist. These recommendations might also help in the development of clinic-level policies (e.g., standing orders, express visits, specimen panels, and reflex testing) that can facilitate implementation of the STD Guidelines. CDC organized the recommendations for STD QCS into eight sections: 1) sexual history and physical examination, 2) prevention, 3) screening, 4) partner services, 5) evaluation of STD-related conditions, 6) laboratory, 7) treatment, and 8) referral to a specialist for complex STD or STD-related conditions.CDC developed the recommendations by synthesizing relevant, evidence-based guidelines and recommendations issued by other experts; reviewing current practice in the United States; soliciting Delphi ratings by subject matter experts on STD care in primary care and STD specialty care settings; discussing the scientific evidence supporting the proposed recommendations at a consultation meeting of experts and institutional stakeholders held November 20, 2015, in Atlanta, Georgia; conducting peer reviews of draft recommendations and supporting evidence; and discussing draft recommendations and supporting evidence during meetings of the CDC/Health Resources and Services Administration Advisory Committee on HIV, Viral Hepatitis, and STD Prevention and Treatment STD Work Group. These recommendations are intended to help health care providers in primary care or STD specialty care settings offer STD services at their clinical settings and to help the persons seeking care live safer, healthier lives by preventing and treating STDs and related complications.


Asunto(s)
Garantía de la Calidad de Atención de Salud , Enfermedades de Transmisión Sexual/prevención & control , Centers for Disease Control and Prevention, U.S. , Humanos , Guías de Práctica Clínica como Asunto , Estados Unidos
8.
Sex Transm Dis ; 46(5): 279-286, 2019 05.
Artículo en Inglés | MEDLINE | ID: mdl-30985632

RESUMEN

BACKGROUND: We evaluated single oral dose of delafloxacin versus single intramuscular ceftriaxone in participants with uncomplicated urogenital gonorrhea (primary objective). Secondary objectives included the efficacy, safety, and tolerability of delafloxacin versus ceftriaxone for uncomplicated urogenital, rectal, and/or pharyngeal gonorrhea. METHODS: In this open-label, multicenter study, 460 participants at 25 study centers were randomized (2:1) to receive a single 900-mg oral dose of delafloxacin or 250-mg intramuscular ceftriaxone. Neisseria gonorrhoeae culture, nucleic acid amplification test, and clinical responses were evaluated. The primary efficacy end point was the urogenital microbiological cure in the urogenital microbiological intention-to-treat population; noninferiority (NI) was assessed using a 10% NI margin. RESULTS: In the urogenital microbiological intention-to-treat population, urogenital cure rates for delafloxacin were 85.1% (194/228) versus 91.0% (91/100) for ceftriaxone (95% confidence interval, -13.18% to 1.36%). Because the lower bound of the confidence interval exceeded the prespecified -10% NI margin, delafloxacin did not demonstrate NI to ceftriaxone. Treatment failures were more often associated with N. gonorrhoeae with higher delafloxacin minimum inhibitory concentration (MIC) values. In microbiologically evaluable participants, failure occurred in 1 (0.6%) of 177 urogenital infections caused by isolates with delafloxacin MICs <0.008 µg/mL and 31 (64.6%) of 48 infections caused by isolates with delafloxacin MICs ≥0.008 µg/mL. Gastrointestinal adverse events were common with 900-mg of delafloxacin and typically included mild to moderate diarrhea, flatulence, nausea, and vomiting. The most common adverse event was diarrhea in both treatment groups. CONCLUSIONS: A single 900-mg dose of delafloxacin is not a reliable treatment of uncomplicated urogenital gonorrhea. Treatment failures were common in infections caused by N. gonorrhoeae with delafloxacin MICs ≥0.008 µg/mL. Additional testing with alternative dosing regimens could be considered.ClinicalTrials.gov Identifier: NCT02015637.


Asunto(s)
Antibacterianos/administración & dosificación , Ceftriaxona/administración & dosificación , Fluoroquinolonas/administración & dosificación , Gonorrea/tratamiento farmacológico , Neisseria gonorrhoeae/efectos de los fármacos , Administración Oral , Adolescente , Adulto , Anciano , Cuello del Útero/microbiología , Estudios de Equivalencia como Asunto , Femenino , Gonorrea/microbiología , Humanos , Inyecciones Intramusculares , Masculino , Persona de Mediana Edad , Neisseria gonorrhoeae/aislamiento & purificación , Faringe/microbiología , Recto/microbiología , Resultado del Tratamiento , Uretra/microbiología , Adulto Joven
9.
Sex Transm Dis ; 46(1): 9-17, 2019 01.
Artículo en Inglés | MEDLINE | ID: mdl-29994936

RESUMEN

PURPOSE: Trichomoniasis is the most prevalent nonviral sexually transmitted infection (STI) in the United States. It can present with vaginitis in women and urethritis in men, but is most often asymptomatic or occurs with minimal symptoms. It is associated with other STIs, adverse pregnancy outcomes and pelvic inflammatory disease. For these reasons, health care provider awareness of trichomoniasis is of public health importance. METHODS: To assess practitioner knowledge, attitudes, and practices concerning trichomoniasis management, the American College of Obstetricians and Gynecologists conducted an online survey in 2016 of its members, and we analyzed results from 230 respondents. RESULTS: We note discrepancies between practice and recommendations among surveyed providers: a minority of respondents routinely screen human immunodeficiency virus (HIV)-positive patients for trichomoniasis (10.7%, "most of the time"; 95% confidence interval [CI], 6.7-15.8; 33.0%, "always"; 95% CI, 26.5%-40.0%), treat trichomoniasis in HIV-positive patients with the recommended dose of metronidazole 500 mg twice a day for 7 days (25.8%; 95% CI, 20.0%-32.3%), or retest patients diagnosed with trichomoniasis 3 months after treatment (9.6%; 95% CI, 6.1%-14.3%). Only 29.0% (95% CI, 23.0%-35.5%) retreat with metronidazole 500 mg twice a day for 7 days in patients who have failed prior treatment. CONCLUSIONS: Screening for and treatment of trichomoniasis in HIV-positive patients, and retesting and retreatment for trichomoniasis in the general population appear to be suboptimal. Continuing education for providers is needed for this common but "neglected" STI.


Asunto(s)
Conocimientos, Actitudes y Práctica en Salud , Médicos/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Tricomoniasis/diagnóstico , Antiprotozoarios/administración & dosificación , Educación Médica Continua , Femenino , Ginecología , Humanos , Masculino , Metronidazol/administración & dosificación , Persona de Mediana Edad , Obstetricia , Enfermedades de Transmisión Sexual/parasitología , Encuestas y Cuestionarios , Tricomoniasis/tratamiento farmacológico , Estados Unidos , Uretritis/parasitología , Vaginitis/parasitología
10.
Ocul Immunol Inflamm ; 27(1): 131-133, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-29053397

RESUMEN

PURPOSE: To report the novel use of combined intravitreal and systemic antibiotic therapy in a patient with syphilitic panuveitis and discuss the management of ocular syphilis. METHODS: Case report Results: A 45-year old heterosexual male with human immunodeficiency virus (HIV) presented with 1 month of blurry vision in both eyes. Clinical examination revealed a bilateral panuveitis. The patient denied history of genital lesions or rash, but did complain of difficulty hearing bilaterally. Treponemal EIA was positive, the RPR titer greater than 1:512 dilution, and CSF VDRL 1:4. A diagnosis of neurosyphilis and ocular syphilis was made based on the clinical and laboratory findings. The patient was admitted for systemic intravenous antibiotic therapy, but was noted to have a penicillin allergy. Intravitreal ceftazidime was promptly administered bilaterally to achieve treponemacidal levels of antibiotic therapy. After penicillin desensitization protocol, the patient received 14 days of intravenous penicillin with clinical resolution. CONCLUSIONS: There are increasing reports of ocular syphilis in the United States and delay in diagnosis and management can lead to severe visual impairment and blindness. We report the first case of adjunct intravitreal antibiotic therapy in a penicillin allergic patient. As ocular syphilis is a form of bacterial endophthalmitis, combination intravitreal and systemic antibiotics may be considered.


Asunto(s)
Antibacterianos/uso terapéutico , Ceftazidima/uso terapéutico , Infecciones Bacterianas del Ojo/tratamiento farmacológico , Panuveítis/tratamiento farmacológico , Penicilinas/uso terapéutico , Sífilis/tratamiento farmacológico , Recuento de Linfocito CD4 , Infecciones Bacterianas del Ojo/microbiología , Infecciones por VIH/complicaciones , Humanos , Infusiones Intravenosas , Inyecciones Intravítreas , Masculino , Persona de Mediana Edad , Panuveítis/microbiología , Sífilis/microbiología
11.
Clin Infect Dis ; 67(4): 504-512, 2018 08 01.
Artículo en Inglés | MEDLINE | ID: mdl-29617982

RESUMEN

Background: In this phase 2 study, we evaluated the efficacy and safety of oral gepotidacin, a novel triazaacenaphthylene bacterial type II topoisomerase inhibitor, for the treatment of uncomplicated urogenital gonorrhea. Methods: Adult participants with suspected urogenital gonorrhea were enrolled and completed baseline (day 1) and test-of-cure (days 4-8) visits. Pretreatment and posttreatment urogenital swabs were collected for Neisseria gonorrhoeae (NG) culture and susceptibility testing. Pharyngeal and rectal swab specimens were collected if there were known exposures. Participants were stratified by gender and randomized 1:1 to receive a 1500-mg or 3000-mg single oral dose of gepotidacin. Results: The microbiologically evaluable population consisted of 69 participants, with NG isolated from 69 (100%) urogenital, 2 (3%) pharyngeal, and 3 (4%) rectal specimens. Microbiological eradication of NG was achieved by 97%, 95%, and 96% of participants (lower 1-sided exact 95% confidence interval bound, 85.1%, 84.7%, and 89.1%, respectively) for the 1500-mg, 3000-mg, and combined dose groups, respectively. Microbiological cure was achieved in 66/69 (96%) urogenital infections. All 3 failures were NG isolates that demonstrated the highest observed gepotidacin minimum inhibitory concentration of 1 µg/mL and a common gene mutation. At the pharyngeal and rectal sites, 1/2 and 3/3 NG isolates, respectively, demonstrated microbiological cure. There were no treatment-limiting adverse events for either dose. Conclusions: This study demonstrated that single, oral doses of gepotidacin were ≥95% effective for bacterial eradication of NG in adult participants with uncomplicated urogenital gonorrhea. Clinical Trials Registration: NCT02294682.


Asunto(s)
Acenaftenos/administración & dosificación , Antibacterianos/administración & dosificación , Enfermedades Urogenitales Femeninas/tratamiento farmacológico , Gonorrea/tratamiento farmacológico , Compuestos Heterocíclicos con 3 Anillos/administración & dosificación , Enfermedades Urogenitales Masculinas/tratamiento farmacológico , Acenaftenos/farmacología , Administración Oral , Adolescente , Adulto , Anciano , Antibacterianos/farmacología , Esquema de Medicación , Femenino , Enfermedades Urogenitales Femeninas/microbiología , Compuestos Heterocíclicos con 3 Anillos/farmacología , Humanos , Masculino , Enfermedades Urogenitales Masculinas/microbiología , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Neisseria gonorrhoeae/efectos de los fármacos , Neisseria gonorrhoeae/aislamiento & purificación , Enfermedades Faríngeas/microbiología , Enfermedades del Recto/microbiología , Adulto Joven
12.
Open Forum Infect Dis ; 4(4): ofx198, 2017.
Artículo en Inglés | MEDLINE | ID: mdl-29181418

RESUMEN

A 47-year-old man with HIV infection presented 10 years after initial secondary syphilis diagnosis and treatment for routine follow-up. His HIV was well controlled on antiretroviral therapy. Rapid plasma reagin was 1:1, and TP-PA was reactive. Physical examination revealed a wide pulse pressure, a systolic murmur, and an early diastolic decrescendo murmur. Echocardiogram revealed moderate to severe aortic regurgitation, and subsequent computed tomography angiogram showed a 6.8-cm fusiform aneurysm of the proximal ascending aorta. Aortic valve and ascending hemiarch replacement were performed. Pathology showed adventitial inflammation with plasma cells, gumma-like amorphous areas surrounded by histiocytes, and giant cells with calcified plaques. Cardiovascular syphilis, while rare, remains a relevant cause of aortic aneurysm, even in previously treated patients. The physical exam can be critical in identifying this potentially fatal complication.

13.
J Infect Dis ; 216(suppl_2): S427-S430, 2017 07 15.
Artículo en Inglés | MEDLINE | ID: mdl-28838075

RESUMEN

This article lays out the research priorities for Mycoplasma genitalium research agreed upon by the participants in a 2016 National Institutes of Allergy and Infectious Diseases-funded Technical Consultation focused on this organism. The state of current knowledge concerning the microbiology, epidemiology, clinical manifestations of infection, treatment, and public health significance of M. genitalium reviewed at the meeting is described in detail in the individual articles included in this supplemental edition of the Journal of Infectious Diseases. Here we summarize the points made in these articles most relevant to the formulation of the research priorities listed in this article. The most important recommendation resulting from this Technical Consultation is the initiation of clinical trials designed to determine definitively whether screening for and treatment of M. genitalium infections in women and their sexual partners improve reproductive health in women and/or prevent human immunodeficiency virus transmission.


Asunto(s)
Infecciones por Mycoplasma/diagnóstico , Infecciones por Mycoplasma/epidemiología , Mycoplasma genitalium , Salud Pública/tendencias , Investigación/tendencias , Adulto , Antibacterianos/uso terapéutico , Ensayos Clínicos como Asunto , Consenso , Farmacorresistencia Microbiana , Femenino , Infecciones por VIH/prevención & control , Infecciones por VIH/transmisión , Humanos , Infecciones por Mycoplasma/tratamiento farmacológico , National Institutes of Health (U.S.) , Guías de Práctica Clínica como Asunto , Estados Unidos
14.
J Infect Dis ; 216(suppl_2): S420-S426, 2017 07 15.
Artículo en Inglés | MEDLINE | ID: mdl-28838079

RESUMEN

Although Mycoplasma genitalium is increasingly recognized as a sexually transmitted pathogen, at present there is no defined public health response to this relatively newly identified sexually transmitted infection. Currently available data are insufficient to justify routinely screening any defined population for M. genitalium infection. More effective therapies, data on acceptability of screening and its impact on clinical outcomes, and better information on the natural history of infection will likely be required before the value of potential screening programs can be adequately assessed. Insofar as diagnostic tests are available or become available in the near future, clinicians and public health agencies should consider integrating M. genitalium testing into the management of persons with sexually transmitted infection (STI) syndromes associated with the infection (ie urethritis, cervicitis, and pelvic inflammatory disease) and their sex partners. Antimicrobial-resistant M. genitalium is a significant problem and may require clinicians and public health authorities to reconsider the management of STI syndromes in an effort to prevent the emergence of ever more resistant M. genitalium infections.


Asunto(s)
Infecciones por Mycoplasma/epidemiología , Mycoplasma genitalium/aislamiento & purificación , Salud Pública , Enfermedades Bacterianas de Transmisión Sexual/epidemiología , Antibacterianos/uso terapéutico , Farmacorresistencia Bacteriana , Femenino , Humanos , Masculino , Infecciones por Mycoplasma/complicaciones , Infecciones por Mycoplasma/tratamiento farmacológico , Parejas Sexuales , Enfermedades Bacterianas de Transmisión Sexual/complicaciones , Enfermedades Bacterianas de Transmisión Sexual/microbiología
15.
Clin Infect Dis ; 64(11): 1573-1581, 2017 Jun 01.
Artículo en Inglés | MEDLINE | ID: mdl-28449115

RESUMEN

Background.: Hepatitis C virus (HCV) infection is the most common chronic blood-borne infection in the United States and a leading cause of morbidity and mortality. Previous analyses of the US National Health and Nutrition Examination Survey (NHANES) indicated approximately 3.6 million noninstitutionalized persons with antibody to HCV (anti-HCV). However, state-level prevalence remains less understood and cannot be estimated reliably from NHANES alone. Methods.: We used 3 publicly available government data sources to estimate anti-HCV prevalence in each US state among noninstitutionalized persons aged ≥18 years. A small-area estimation model combined indirect standardization of NHANES-based prevalence with logistic regression modeling of mortality data, listing acute or chronic HCV infection as a cause of death, from the National Vital Statistics System during 1999-2012. Model results were combined with US Census population sizes to estimate total number and prevalence of persons with antibody to HCV in 2010. Results.: National anti-HCV prevalence was 1.67% (95% confidence interval [CI], 1.53-1.90), or 3 911 800 (95% CI, 3 589 400- 4 447 500) adults in 2010. State-specific prevalence ranged from 0.71% (Illinois) to 3.34% (Oklahoma). The West census region had the highest region-specific prevalence (2.14% [95% CI, 1.96-2.48]); 10 of 13 states had rates above the national average. The South had the highest number of persons with anti-HCV (n = 1561600 [95% CI, 1 427 700-1 768 900]). The Midwest had the lowest region-specific prevalence (1.14% [95% CI, 1.04%-1.30%]). Conclusions.: States in the US West and South have been most impacted by hepatitis C. Estimates of HCV infection burden are essential to guide policy and programs to optimally prevent, detect, and cure infection.


Asunto(s)
Anticuerpos contra la Hepatitis C/sangre , Hepatitis C Crónica/epidemiología , Hepatitis C/epidemiología , Adulto , Anciano , District of Columbia/epidemiología , Monitoreo Epidemiológico , Femenino , Hepacivirus/genética , Hepacivirus/inmunología , Hepacivirus/aislamiento & purificación , Hepatitis C/inmunología , Hepatitis C/mortalidad , Hepatitis C/virología , Hepatitis C Crónica/virología , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Encuestas Nutricionales , Prevalencia , ARN Viral/sangre , Factores de Riesgo , Estados Unidos/epidemiología , Adulto Joven
16.
Gastroenterology ; 153(1): 113-122, 2017 07.
Artículo en Inglés | MEDLINE | ID: mdl-28390869

RESUMEN

BACKGROUND & AIMS: Patients with chronic hepatitis C virus (HCV) infection have high rates of sustained virologic response (SVR) after 12 weeks of treatment with the nucleotide polymerase inhibitor sofosbuvir combined with the NS5A inhibitor velpatasvir. We assessed the efficacy of 8 weeks of treatment with sofosbuvir and velpatasvir plus the pangenotypic NS3/4A protease inhibitor voxilaprevir (sofosbuvir-velpatasvir-voxilaprevir). METHODS: In 2 phase 3, open-label trials, patients with HCV infection who had not been treated previously with a direct-acting antiviral agent were assigned randomly to groups given sofosbuvir-velpatasvir-voxilaprevir for 8 weeks or sofosbuvir-velpatasvir for 12 weeks. POLARIS-2, which enrolled patients infected with all HCV genotypes with or without cirrhosis, except patients with genotype 3 and cirrhosis, was designed to test the noninferiority of 8 weeks of sofosbuvir-velpatasvir-voxilaprevir to 12 weeks of sofosbuvir-velpatasvir using a noninferiority margin of 5%. POLARIS-3, which enrolled patients infected with HCV genotype 3 who had cirrhosis, compared rates of SVR in both groups with a performance goal of 83%. RESULTS: In POLARIS-2, 95% (95% confidence interval [CI], 93%-97%) of patients had an SVR to 8 weeks of sofosbuvir-velpatasvir-voxilaprevir; this did not meet the criterion to establish noninferiority to 12 weeks of sofosbuvir-velpatasvir, which produced an SVR in 98% of patients (95% CI, 96%-99%; difference in the stratum-adjusted Mantel-Haenszel proportions of -3.2%; 95% CI, -6.0% to -0.4%). The difference in the efficacy was owing primarily to a lower rate of SVR (92%) among patients with HCV genotype 1a infection receiving 8 weeks of sofosbuvir-velpatasvir-voxilaprevir. In POLARIS-3, 96% of patients (95% CI, 91%-99%) achieved an SVR in both treatment groups, which was significantly superior to the performance goal. Overall, the most common adverse events were headache, fatigue, diarrhea, and nausea; diarrhea and nausea were reported more frequently by patients receiving voxilaprevir. In both trials, the proportion of patients who discontinued treatment because of adverse events was low (range, 0%-1%). CONCLUSIONS: In phase 3 trials of patients with HCV infection, we did not establish that sofosbuvir-velpatasvir-voxilaprevir for 8 weeks was noninferior to sofosbuvir-velpatasvir for 12 weeks, but the 2 regimens had similar rates of SVR in patients with HCV genotype 3 and cirrhosis. Mild gastrointestinal adverse events were associated with treatment regimens that included voxilaprevir. ClinicalTrials.gov numbers: POLARIS-2, NCT02607800; and POLARIS-3, NCT02639338.


Asunto(s)
Antivirales/uso terapéutico , Carbamatos/uso terapéutico , Hepatitis C Crónica/tratamiento farmacológico , Compuestos Heterocíclicos de 4 o más Anillos/uso terapéutico , Compuestos Macrocíclicos/uso terapéutico , Sofosbuvir/uso terapéutico , Sulfonamidas/uso terapéutico , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Antivirales/administración & dosificación , Antivirales/efectos adversos , Carbamatos/administración & dosificación , Carbamatos/efectos adversos , Quimioterapia Combinada , Femenino , Compuestos Heterocíclicos de 4 o más Anillos/administración & dosificación , Compuestos Heterocíclicos de 4 o más Anillos/efectos adversos , Humanos , Compuestos Macrocíclicos/administración & dosificación , Compuestos Macrocíclicos/efectos adversos , Masculino , Persona de Mediana Edad , Sofosbuvir/administración & dosificación , Sofosbuvir/efectos adversos , Sulfonamidas/administración & dosificación , Sulfonamidas/efectos adversos , Respuesta Virológica Sostenida , Adulto Joven
17.
Sex Transm Dis ; 44(1): 13-16, 2017 01.
Artículo en Inglés | MEDLINE | ID: mdl-27898574

RESUMEN

BACKGROUND: The recommended regimen for treating uncomplicated gonorrhea has changed over time, due to the emergence of antimicrobial resistance. We assessed physician knowledge of the recommendation for treating uncomplicated urogenital gonorrhea in adolescents and adults using ceftriaxone and azithromycin dual therapy. METHODS: We analyzed DocStyles 2015 survey data from 1357 primary care physicians practicing for at least 3 years who provided screening, diagnosis, or treatment for sexually transmitted diseases to one or more patients in an average month. Logistic regression and χ analyses were used to identify factors associated with knowledge of dual therapy. RESULTS: Among the options of treatment with ceftriaxone alone, azithromycin alone, both of these, or spectinomycin plus levofloxacin, 64% of physicians correctly preferred ceftriaxone plus azithromycin. Knowledge of the recommended dual therapy decreased with increasing years of practice, ranging from 74% among physicians with 3-9 years of practice to 57% among those practicing for ≥24 years (adjusted odds ratio, ORa, for ≥24 vs 3-9 years of practice, 0.50; 95% confidence interval [CI], 0.35-0.70). Knowledge of dual therapy decreased with higher socioeconomic status of patients (ORa for high income vs poor/lower middle income patients, 0.47; 95% CI, 0.32-0.69). Physicians who pursued continuing medical education using journals, podcasts, and government health agencies were more likely to report dual therapy than those who did not use these sources (ORa, 2.09; 95% CI, 1.31-3.33). CONCLUSIONS: Knowledge of the recommended regimen for treating gonorrhea decreased with increasing years of practice and with higher socioeconomic status of patients.


Asunto(s)
Protocolos Clínicos , Gonorrea/tratamiento farmacológico , Conocimientos, Actitudes y Práctica en Salud , Médicos de Atención Primaria/psicología , Pautas de la Práctica en Medicina , Adulto , Antibacterianos/uso terapéutico , Azitromicina/uso terapéutico , Ceftriaxona/uso terapéutico , Distribución de Chi-Cuadrado , Quimioterapia Combinada , Femenino , Humanos , Levofloxacino/uso terapéutico , Modelos Logísticos , Masculino , Persona de Mediana Edad , Atención Primaria de Salud/métodos , Espectinomicina/uso terapéutico
18.
Proc Natl Acad Sci U S A ; 113(38): 10678-83, 2016 09 20.
Artículo en Inglés | MEDLINE | ID: mdl-27601663

RESUMEN

Maternal innate and adaptive immune responses are modulated during pregnancy to concurrently defend against infection and tolerate the semiallogeneic fetus. The restoration of these systems after childbirth is poorly understood. We reasoned that enhanced innate immune activation may extend beyond gestation while adaptive immunity recovers. To test this hypothesis, the transcriptional profiles of total peripheral blood mononuclear cells following delivery in healthy women were compared with those of nonpregnant control subjects. Interestingly, interferon-stimulated genes (ISGs) encoding proteins such as IFIT1, IFIT2, and IFIT3, as well as signaling proteins such as STAT1, STAT2, and MAVS, were enriched postpartum. Antiviral genes were primarily expressed in CD14(+) cells and could be stratified according to genetic variation at the interferon-λ3 gene (IFNL3, also named IL28B) SNP rs12979860. Antiviral gene expression was sustained beyond 6 mo following delivery in mothers with a CT or TT genotype, but resembled baseline nonpregnant control levels following delivery in mothers with a CC genotype. CT and TT IFNL3 genotypes have been associated with persistent elevated ISG expression in individuals chronically infected with hepatitis C virus. Together, these data suggest that postpartum, the normalization of the physiological rheostat controlling IFN signaling depends on IFNL3 genotype.


Asunto(s)
Hepacivirus/inmunología , Hepatitis C/inmunología , Inmunidad Innata/genética , Péptidos y Proteínas de Señalización Intracelular/genética , Proteínas Adaptadoras Transductoras de Señales , Adulto , Proteínas Reguladoras de la Apoptosis , Proteínas Portadoras/genética , Femenino , Regulación de la Expresión Génica/inmunología , Genotipo , Hepacivirus/genética , Hepacivirus/patogenicidad , Hepatitis C/genética , Hepatitis C/virología , Humanos , Péptidos y Proteínas de Señalización Intracelular/inmunología , Leucocitos Mononucleares/inmunología , Leucocitos Mononucleares/metabolismo , Receptores de Lipopolisacáridos/inmunología , Relaciones Materno-Fetales , Polimorfismo de Nucleótido Simple , Periodo Posparto , Embarazo , Proteínas/genética , Proteínas de Unión al ARN
20.
Clin Infect Dis ; 61 Suppl 8: S785-801, 2015 Dec 15.
Artículo en Inglés | MEDLINE | ID: mdl-26602618

RESUMEN

Gonorrhea is the second most commonly reported notifiable disease in the United States and is associated with serious health sequelae, including pelvic inflammatory disease, infertility, and ectopic pregnancy. Treatment for gonorrhea has been complicated by antimicrobial resistance. Neisseria gonorrhoeae has developed resistance to each of the antimicrobials that were previously recommended as first-line treatment regimens, and current treatment options are severely limited. This article summarizes the key questions and data that were discussed at the Sexually Transmitted Diseases (STD) Treatment Guidelines Expert Consultation meeting in April 2013, and the rationale for the 2015 Centers for Disease Control and Prevention STD treatment guidelines for gonococcal infections in adolescents and adults. Key issues addressed include whether to change the dosage of ceftriaxone and azithromycin used in the recommended dual treatment regimen, whether to continue to list dual treatment with cefixime and azithromycin as an alternative treatment regimen, and management of gonococcal infections in persons with severe cephalosporin allergy or suspected treatment failure.


Asunto(s)
Gonorrea/tratamiento farmacológico , Adolescente , Adulto , Antibacterianos/farmacología , Antibacterianos/uso terapéutico , Ceftriaxona/farmacología , Ceftriaxona/uso terapéutico , Centers for Disease Control and Prevention, U.S. , Manejo de la Enfermedad , Femenino , Gonorrea/epidemiología , Gonorrea/microbiología , Humanos , Neisseria gonorrhoeae/efectos de los fármacos , Guías de Práctica Clínica como Asunto , Embarazo , Estados Unidos/epidemiología , Adulto Joven
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