L'algoritmo diagnostico terapeutico nelle infezione sessualmente trasmesse - Marco Cusini Fondazione IRCCS Policlinico - ICAR 2019

L’algoritmo diagnostico
terapeutico nelle infezione
 sessualmente trasmesse

       Marco Cusini
Fondazione IRCCS Policlinico
 UO Dermatologia – Centro MTS

DEFINIZIONE MTS
     Malattia sessualmente trasmessa
Infezione che può essere acquisita tramite
             contatto sessuale

QUANDO E’ SESSO
COMPORTAMENTO                     MASCHI         FEMMINE
BACIO                                  1.4%         2.9%
CONT. CON CAPEZ. (fatto)              1.7%          5.3%
CONT. CON CAPEZ. (subìto)              2.0%         4.5%
CONT. CON GENIT. (fatto)              11.6%         17.1%
CONT. CON GENIT (subìto)              12.2%         19.2%
CONT. ORO-GEN. (fatto)                 37.3%        43.7%
CONT. ORO-GEN (subìto)                 37.7%        43.9%
RAPPORTO PENO-ANALE                    82.3%       79.1%
RAPPORTO PENO-VAG.                     99.7%       99.2%

Sanders SA et al. JAMA 1999 would You say You “had sex” if…?

AGENTI SESSUALMENTE TRASMISSIBILI

 BATTERI                               VIRUS
 –   Neisseria gonorrhoeae             –   Human immunodeficiency virus
 –   Chlamydia trachomatis             –   Herpes simplex virus
 –   Mycoplasma hominis                –   Human papillomavirus
 –   Ureaplasma urealyticum            –   Virus epatite A, B, C
 –   Mycoplasma genitalium             –   Cytomegalovirus
 –   Treponema pallidum                –   Virus del mollusco contagioso
 –   Gardnerella vaginalis             –   Herpes virus tipo 8
 –   Mobiluncus curtisii               PROTOZOI
 –   Mobiluncus mulieris               – Trichomonas vaginalis
 –   Haemophilus ducreyi               – Entamoeba histolytica
 –   Calymmatobacterium granulomatis   – Giardia lamblia
 –   Shigella spp                      FUNGHI
 –   Campylobacter spp                 – Candida albicans e spp.
                                       ECTOPARASSITOSI
                                       – Phthirus pubis
                                       – Sarcoptes scabiei

PERCHÉ LE LINEE GUIDA?
Per utilizzare algoritmi diagnostico terapeutici
basati sull’evidenza medica
Per fornire un mezzo educativo a studenti,
specializzandi e specialisti
Per individuare lacune nelle conoscenze attuali,
meritevoli di ulteriori studi
Per fornire alle strutture di governo indicazioni di
politica socio-sanitaria

LINEE GUIDA E IST
Epidemiologia variabile nel tempo e
nello spazio
Multidisciplinarietà
Trattamento on the spot
Prevenzione della diffusione
Attenzione per i gruppi a rischio
Norme comportamentali

TARGET LINEE GUIDA
A qualsiasi specialista può capitare di vedere una IST
Non esiste in Italia la figura dello specialista di IST
I dermatologi hanno storicamente ed
accademicamente la competenza maggiore nel campo
delle IST
Pochi sono i dermatologi con un reale interesse nel
campo
La gestione di una IST è a volte molto complicata e
l’approccio multidisciplinare è obbligatorio
Nel nostro paese l’approccio diagnostico terapeutico è
spesso molto diverso a seconda della specialità del
medico che lo applica

LINEE GUIDA IST
Nella stesura è importante considerare
l’aspetto socio-epidemiologico
Una linea guida non è solo diagnosi e
terapia
Dovrebbero essere sempre indicati i
metodi di screening e di contact tracing
Trattamento dati sensibili

IN PRATICA….

Disponibilità dei finanziamenti
Tipologia di paziente
Tempo disponibile
Risorse diagnostiche disponibili

LINEE GUIDA IN ITALIA

Linee guida internazionali (CDC IUSTI)
Linee guida nazionali (società scientifiche)
Linee guida locali (??????)

CDC e IUSTI
PREGI                    DIFETTI

 Emanate da               Lingua inglese
 organismi prestigiosi    Invecchiamento
 Basate su algoritmi      precoce
 rigorosi                 Poco diffuse
 Facile consultazione     Non raccomandate
                          dalle nostre Società
 Facile applicabilità
                          Scientifiche
 Complete                 Non raccomandate dal
                          SSN

Sexually Transmitted Diseases
 Treatment Guidelines, 2015

            MMWR
         June 15, 2015
          Volume 64
          No. RR- 03

STD Prevention and Control

 Education and counseling to reduce risk of
 STD acquisition
 Detection of asymptomatic and/or
 symptomatic persons unlikely to seek
 evaluation
 Effective diagnosis and treatment
 Evaluation, treatment, and counseling of
 sexual partners
 Preexposure vaccination--hepatitis A, B, C e
 non solo

Syphilis

GONORRHOEA
    Resistance in gonococci has usually developed first in
    the WHO Western Pacific Region (frequently Japan)
    followed by international spread.
     Many bacterial species share their mechanisms of
    resistance through horizontal gene transfer and
    subsequent recombination.
    Horizontal gene transfer is particularly possible in the
    pharynx , which harbours many non-gonococcal
    Neisseria spp, and can facilitate the emergence and
    spread of antimicrobial resistance particularly in high-
    frequency transmitting populations, such as MSM and
    commercial sex workers….
Sexually transmitted infections: challenges ahead
Magnus Unemo*, Catriona S Bradshaw*, Jane S Hocking et al. Lancet Infect
Dis 2017 17: e235–79

Gonorrohea cont
The prevalence of multidrug-resistant (MDR)gonococcal
strains substantially increased during the past decade.
 The first extensively drug-resistant (XDR) gonococcal
strains, displaying high-level resistance to ceftriaxone
(minimum inhibitory concentration [MIC] of 2–4 mg/L)
and retained resistance to previously used therapeutic
antimicrobials, have also been isolated in Japan, France,
and Spain
Many additional ceftriaxone-resistant strains might
already be circulating but are undetected because of
suboptimal antimicrobial resistance surveillance in many
settings

Gonorrohea cont (2)
Dual antimicrobial therapy is recommended for treatment
where up-to-date, local, and high-quality antimicrobial
resistance surveillance data do not support other therapy
 Solithromycin, gepotidacin, and particularly zoliflodacin
can be promising for gonorrhoea treatment and deserve
further attention.
Ultimately, as for chlamydia, a gonococcal vaccine might
be the only sustainable solution for gonorrhoea control.

Chlamydia (escluso LGV)
Epidemiologia (18 – 26 anni) : prevalenza: 3 -5.3% (♀)
2,4 -7.3 (♂)
Contagio diretto attraverso le mucose (rischio di contagio
10% per singolo atto- 55% in relazione stabile di sei
mesi)
Clearance spontanea circa 50% dopo un anno
Infezione asintomatica nel 70-90% ♀ e in 50% ♂
Infezione anale 3- 10% (MSM) 8.4% ♀ con infezione
urogenitale
Infezione faringea 0,5% - 2,3% (MSM)

Indications for laboratory testing (Level of
     evidence IV; Grade C recommendation)
.
    Risk factor(s) for C. trachomatis infection and/or other STI (age

Chlamydia diagnosis
Nucleic acid amplification tests (NAATs), identifying C.
trachomatis specific nucleic acid (DNA or RNA) in clinical
specimens, are recommended to be used for
diagnostics, due to their superior sensitivity, specificity,
and speed (incubation 1-3 days)
The recommended first choice specimens for diagnosis
of urogenital chlamydial infections with NAATs are first-
void urine for men (up to 20 ml sampled>1 h after
previous micturition) (testing of semen specimens is not
recommended) and (health-care worker- or self-
collected) vulvo-vaginal swabs for women

Chlamydia diagnosis
Annual C. trachomatis testing in STI or
sexual health clinics is recommended for
all sexually active young women and men
(

Mycoplasma genitalium
The prevalence of M. genitalium in men with NCNGU ranges from 10% to
35%, thus contributing significantly to the overall burden of disease. In
comparison, M. genitalium is detected in only 1% to 3.3% of men and
women in the general population
In a recent meta-analysis, significant associations were found between M.
genitalium and cervicitis [pooled odds ratio (OR) 1.66], and PID (pooled OR
2.14). M. genitalium has been associated with preterm birth (pooled OR
1.89), and spontaneous abortion (pooled OR 1.82)
In a recent meta-analysis, persistent M. genitalium was associated with a
pooled OR of 26 for persistent urethritis. Thus, failure to eradicate M.
genitalium leads to persistent or recurrent disease in the vast majority of
men with persistent infection and diagnosis and optimal treatment is
extremely important.
In sexually transmitted infection (STI) patients, the prevalence is usually
from 60% to 85% of that of C. trachomatis, but in the general population, the
ratio is generally significantly lower

Mycoplasma genitalium
             Treatment
  Efficacia doxiciclina 30 - 40%
  Efficacia Azitromicina 1gr 85% (resistenza 40%)
  Efficacia azitromicina EC 95% (resistenza 40%)
  Efficacia Josamicina 80% (stesso profilo resistenza)
  Efficacia moxifloxacina >95% (resistenza 30%)
  Efficacia pristinamicina >95% (resistenza ???)

Le linee guida indicano diversi scheni terapeutici a
  seconda dei profili di resistenza

Welcome to IUSTI-Europe Congress 2019
Dear Friends and Colleagues,

It is a great pleasure and an honour to extend to you a warm invitation to the 33rd IUSTI-
Europe Congress on Sexually Transmitted Infections, to be held September 05 – 07,
2019 in Tallinn, Estonia. The meeting will take place in the historic venue of the Estonian
National Opera in the heart of the medieval city.

Organizers of the congress are determined to promote a stimulating atmosphere
conducive to learning and debate as well as provide opportunities to network with
colleagues. To help you make the most of your visit to Tallinn we will also host a number
of memorable social events.