Challenges for the venereologist in 21 st century
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Dr David Rowen, Royal South Hants
Hospital, Southampton
Challenges for the
Venereologist in the
21st Century
Dr David Rowen, Royal South Hants
Hospital, Southampton
Challenges
Microbial drug resistance
Neisseria gonorrhoeae
Chlamydia
Mycoplasma
Implementation of HPV vaccination schemes
Dr David Rowen, Royal South Hants
Hospital, Southampton
Neisseria gonorrhoeae
Standard treatments should cure 95% of
infections
Resistance rates of >5% should lead to change
in treatment protocol.
Correlation between susceptibility and outcome
of treatment is good but not absolute
Duration of carriage is site specific
Dr David Rowen, Royal South Hants
Hospital, Southampton
Neisseria gonorrhoeae
Penicillin resistance is common
Penicillinase producing N.gonorrhoeae (PPNG)
Chromosomally mediated resistance (CMR)
develops incrementally; broad range of MIC
Marked increase in PPNG in early 90’s but this
is decreasing in many places
Many centres report >80% of isolates have
CMR
Dr David Rowen, Royal South Hants
Hospital, Southampton
Quinalones
Resistance has emerged relatively recently but
first reported in 1992
>70% of isolates from SE Asia and Philippines
are resistant
Dr David Rowen, Royal South Hants
Hospital, Southampton
Cephalosporin Resistance
3rd generation Cephalosporins unaffected by β
lactamase of PPNG
Resistance is chromosomally mediated
Shift to right in MICs resulting in increasing
doses of Ceftriaxone being used
Cefixime can no longer be recommended as
MICs beyond break point whereby there is
>95% cure rate
Dr David Rowen, Royal South Hants
Hospital, Southampton
Treatment
Cheap treatment options have been lost
Expensive options may have limited life
Spectinomycin difficult to obtain
Combination treatments
Gentamicin+Azithromycin
Gemifloxacin+Azithromycin
Excellent cure rates but high rate of S/E
Chlamydia
Treatment failure with Azithromycin well
documented but at low level
Some failure thought to be due to absorption
issues
Resistance testing not widely available and
reliability has been questioned
However evidence of emerging resistance to
macrolides
Dr David Rowen, Royal South Hants
Hospital, Southampton
Dr David Rowen, Royal South Hants
Hospital, Southampton
Mycoplasma
PCR test available but rarely requested
Often NSU/cervicitis treated with single dose of
Azithromycin
This selects out resistant strains of Mycoplasma
Longer courses of Azithromycin or Doxycycline
may prevent this
Moxifloxacin is active against Azithromycin
resistant strains
HPV Vaccines
Proven efficacy in preventing genital warts and
high grade dysplasia, should prevent HPV type
16 and 18 associated malignancy
Significant cost implications in vaccination
progrmmes: Quad vaccine cost £240 in UK
Ethical issues: vaccine against STI
What strategies can be applied to resource poor
countries
Dr David Rowen, Royal South Hants
Hospital, Southampton
HPV Vaccines: cost issues
Restrict vaccination to girls
Does prevent warts in men but ~80% coverage needed
Will not impact of homosexual men in whom AIN is
more common
Shorter courses of vaccine
Little evidence to support long term efficacy
Use bivalent vaccine which is cheaper
Prevents high grade dysplasia but not warts
Dr David Rowen, Royal South Hants
Hospital, Southampton
HPV Vaccines: cost issues
Generic vaccines
Patents have long time to run
Is the technology available?
Charitable vaccination programmes
Government sponsored programmes
WHO programmes
Subsidized costs for resource poor
countries
Dr David Rowen, Royal South Hants
Hospital, Southampton
HPV vaccines: logistics
How do we deliver vaccine to large populations
especially in rural communities
Mobile clinics staffed by minimally qualified workers
How can we be sure that patients receive correct
number of inoculations?
Robust but inexpensive IT support
Patient incentives ?cash
Dr David Rowen, Royal South Hants
Hospital, Southampton
Ethical Issues
More acceptable as anti-cancer vaccine
Working with Temples, Mosques, Gudwaras and
churches may overcome some of the perceived
ethical concerns
Women more open to concept of vaccination
than men
Is it ethical to pay patients to be inoculated?
Dr David Rowen, Royal South Hants
Hospital, Southampton