Instant Chlamydia Rapid Home Self Test Kit – £15

A Chlamydia Test Shared Story

“Please use me for everything.”

Katie, a 20 y.o. A college student comes in for STD Full Panel Home Delivery tests. She was taking an HPV course in human sexuality and was asked to seek multiple tests, including HPV. Katie recently had unprotected sex with a new partner. But she has had two other lifetime partners. However, she did not present rapid symptoms and asked to be tested for everything, including chlamydia.

What tests would you do? What not to do? Is there anything else you need to know first?

A Review* First, Get a Sexual History.

Since most instant screening is risk-based, getting a sexual history from all patients is important:

Partners: # in last 90 days & their gender
Practices: sites of contact, injection drug use
And Protection: frequency of condom use
History: previous STDs
Prevention of pregnancy: contraception use

*The handout from last year’s talk on this topic is available on the ACHA website

What is “instant screening”?

Screening generally means initial identification of unrecognized disease or infection.
In the context of this presentation, screening for STDs is done to identify STIs in asymptomatic persons, as distinct from testing symptomatic persons to establish a diagnosis.

Recommendations sources:

United States Preventive Services Task Force (USPSTF)
Issues recommendations based on a careful review of the data, assessing the benefit (or harm) of each preventive service or STI help
Each HPV recommendation is graded for the strength of evidence
Centres for STD Disease Control and Prevention
Issues rules based on expert opinion and evidence
Usually agree with USPSTF
Professional organizations (ACS, ACOG, AAFP, etc.)
Issues recommendations based on Chlamydia expert opinion and “best practice” for their field
It may or may not be evidence-based
Support accreditation standards (HEDIS, JCAHO)
ACHA rules in development
Routine Summary: Patient-based approach

But for most lower-risk, heterosexual students:

Chlamydia test NAAT*, urine or swab
HIV, if not previously checked
An option of Genital/pelvic exam

So, do these only if risk factors justify:

Gonorrhea STI, NAAT urine or swab test
Syphilis serology
HSV serology
HBV, HCV serology

*Nucleic acid amplification.”

Guidelines:

Less evidence-based than chlamydia
Patients at higher risk – screen for chlamydia:
Men who have sex with men
African-American (20X higher cases)?
And positive STI test history (esp chlamydia, syphilis, HIV, NGU, PID)
Patients at uncertain risk – consider testing for GC:
Women under age 25 with multiple partners
High community prevalence (patient’s sexual network)
Partner is not local and not a student
Patients at low risk – don’t screen for GC
Many college students are not in the above groups

Case Presentations

However, these cases are designed to illustrate typical and atypical issues in managing STIs. Additionally, we will cover uncertain and questionable areas in the rapid testing and treating of STIs. Importantly, these cases involve real patients seen in college health centres. However, names and other information have been altered to protect personal privacy.

James

Also, 22 yo male, MSM, with a 3-day history of acute dysuria and urethral discharge

Exam:

Purulent urethral discharge

Lab:

However, a gram stain in the clinic shows full field PMNs with Gram-negative intracellular diplococci CDC.

What’s the diagnosis?

Presumptive gonococcal urethritis

Furthermore, Management Questions:

Which other checks does he need?
Does he need presumptive treatment pending urine GC/CT results?
Which drug(s)?

(And by the way, the patient reports a known allergy to cephalosporins)

Routine Screening for MSM
GC and CT urine NAAT
GC culture/NAAT from other exposed sites

(pharynx and rectal)

RPR or VDRL for syphilis
HIV
HBsAg, if not immunized before sexual debut, what about HBsAb if immunized?

Rectal and Pharyngeal 

CDC recommends NAATs for checking rectal and infections. And New Rules
The FDA has not cleared rectal and types for use with NAATs.
Labs can offer if internally validated
Use culture if NAAT is not available
Quest, LabCorp and other labs offer NAAT testing for rectal and pharyngeal CT or GC.

Treatment

Third gen, cephalosporins are the only real choice
Ceftriaxone 125/250mg IM
Cefixime 400mg PO – ok (but not for pharyngeal infection)
Cefpodoxime PO – avoid new rules
Dual treatment with azithromycin 1g may enhance cefixime new guidance
Quinolones should not be used due to resistance
Routine use of azithromycin 2g PO is not encouraged

Treatment

GC treatment for patients is a challenge:
Quinolone – resistance is common but not advised
Spectinomycin – not available in the U.S.
Azithromycin 2g PO – poorly tolerated, resistance concerns
Currently, it’s the best instant choice for this patient!
The patient took and tolerated his azithromycin; symptoms resolved
Other STI results were negative. Partners lost to follow-up
Test-of-cure is not usually recommended. But in this case, it might be worth doing

Susans case

A 25-year-old graduate student is seen in the primary care STD clinic with a 3-day history of urinary frequency, urgency, dysuria, nocturia, and low back pain, along with nausea but no hematuria. However, she is afebrile and does not have any CVA tenderness. She took some Instant Cipro yesterday, left over from a prior UTI.

The urine dipstick is negative.
Assessment: UTI, presumed pyelonephritis
Plan: Urine culture, levofloxacin 500mg X 7 days, f/u visit next week.

Susan, visit 2, day 8

Upon her return visit five days later, she communicates experiencing an itchy rash on her hands and a feeling of “electrical shocks” going down both legs. Furthermore, UTI symptoms persist, with dysuria being predominant. And she gets a Chlamydia kit to check out her health. Moreover, she presently observes some “crusty” vaginal discharge, along with a fever of 101.4°F.

The Exam:

Erythematous papular rash on hands.
No genital lesions.
Pharynx clear.
Copius vaginal discharge, no odour.
The cervix is friable.
Positive CMT, no adnexal tenderness