Elizabeth Carlin

Treatment of sexually transmitted infections with single-dose therapy: a double-edged sword.

Since the advent of the antimicrobial era, single-dose therapy has been a valuable tool in the management of genital infection. Most of the common sexually transmitted infections (STIs) such as gonorrhoea, syphilis, trichomoniasis and chancroid can be treated in this way, as can genital infections which are not sexually transmitted such as bacterial vaginosis and genital tract candidiasis. Until recently, treatment for Chlamydia trachomatis infection required a multidose regimen, but single-dose azithromycin has now been shown to be an effective and acceptable alternative to this. Unfortunately, eradicative therapy has proven to be elusive for the viral STIs such as genital herpes simplex infection, human papilloma virus infection and human immunodeficiency virus (HIV) infection.The main advantage of single-dose therapy lies in its convenience and in its ability to ensure virtually 100% compliance. This addresses the problems of reduced clinical efficacy and the difficulties in assessing the response to therapy which complicates poor treatment compliance.However, some single-dose regimens for STIs do have drawbacks, particularly in certain situations. This may be with respect to efficacy, for example in syphilis with single-dose benzathine penicillin therapy, particularly for pregnant women and individuals infected with HI. Alternatively, it may involve toxicity, for example with single-dose metronidazole therapy for trichomoniasis or bacterial vaginosis where a higher rate of gastrointestinal adverse effects may be expected than if a lower multi-dose regimen is used. In addition, single-dose therapy, for example with nevirapine, given to the mother in labour and to the baby after delivery significantly reduces the risk of mother to child HIV transmission, but resistance mutations are frequently detected in the viral genome after the brief exposure to the drug, which could jeopardise its future use.Single-dose therapy clearly has both advantages and disadvantages. We have reviewed a range of these in a variety of situations, focussing on their applications, effectiveness, compliance and toxicity, highlighting how single-dose therapy may be a double-edged sword.

Contraception and men attending a genitourinary medicine clinic

Aims To identify mens knowledge and attitude to contraception and to determine whether there are differences in those men who have previous experience of termination of pregnancy (TOP) compared to those without experience. Method Cross-sectional survey by written questionnaire of male attenders at a genitourinary medicine (GUM) clinic. Results In total 999 men, aged 15 to 70 years, completed questionnaires, 97.2% of those eligible. Over 96% of men wishing to avoid pregnancy with regular sexual partners were using contraception. However, with casual sexual partners 36% of men would not ensure that they were covered for contraception. The majority, 68.8%, of men did not have enough knowledge to access appropriate emergency contraception. Experience of a TOP was reported by 16.5% of men. Compared to men who did not have termination experience there were no differences in contraceptive use or their knowledge of emergency contraception. Conclusion Use of contraception with regular sexual partners was good, but this was not the case with casual sexual partners or with respect to knowledge of emergency contraception. No significant differences were found in contraceptive use or attitudes between men with or without experience of TOP, but this may be influenced by several factors including the cross-sectional nature of the study. Improved targeting of men at the time of their partners termination and the development of a National Sexual Health Strategy which takes into account mens needs may address this.

The laboratory diagnosis of common genital viral infections

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Using recent infection testing algorithm tests in clinical practice

Objectives Recent Infection Testing Algorithm (RITA) tests are used in public health surveillance to identify the incidence of recently acquired HIV infection. This can then be used to direct public health interventions and evaluate their effects. We aimed to outline how RITA tests may be used in clinical practice with individual patients, as well as highlighting the cautions needed. Methods The clinical and laboratory aspects of RITA tests have been reviewed in the paper together with their clinical applications. Results For individuals, RITA tests can help to confirm primary HIV infection and can be useful with elements of partner notification. However, careful evaluation of the result is required and it should be considered in conjunction with the clinical history and findings. Conclusions There are major epidemiological and public health advantages in using RITA testing but there are also advantages to using the RITA test on an individual basis, provided that it is used appropriately.

The laboratory diagnosis of gonorrhoea and syphilis infection

Following a decline in prevalence during the 1980s and early 1990s, gonorrhoea and syphilis infections are once again posing a threat to public health. In addition, the antibiotic sensitivity pattern for gonorrhoea appears to have changed with an increased prevalence of resistance. Both syphilis and gonorrhoea appear to disproportionately affect MSM and black ethnic minorities, and are concentrated in urban areas. Their diagnosis requires microbiological tests to be performed appropriately, and a rapid diagnosis can often be provided in GUM clinics using near-patient microscopy. Early diagnosis and effective, rapid treatment is crucial in limiting the morbidity for the affected individual and the public health risks resulting from the spread of infection.

Adverse reaction to antimycobacterials administered as a combination tablet with no reaction to the same drugs in isolation

Editor,—A 37 year old Portuguese man presented to the genitourinary (GU) medicine department with constitutional symptoms. He had a history of injecting drug use and had been identified as positive for the human immunodeficiency virus (HIV) antibody in Portugal 5 years previously. He had not been in contact with medical services for a year. Confirmatory HIV antibody testing was positive. The CD4 lymphocyte count was 50 × 106/l and the viral load below the limit of detection (<40–80 copies/ml). He was admitted for …

Chlamydia testing before termination of pregnancy.

In Nottingham all women undergoing a termination of pregnancy (TOP) through the NHS sector are screened for Chlamydia trachomatis and Neisseria gonorrhoeae and receive preoperative antichlamydial prophylaxis. Nottingham has a high level of both chlamydial and gonococcal infection, hence the need to include dual screening. In order to maximise service capacity and provide sufficient access for women requesting a TOP some procedures are contracted out …

An update on pelvic inflammatory disease. Ross JDC. Sex Transm Inf 2002; 78: 18-19

The difficulties in clinically diagnosing pelvic inflammatory disease (PID), new diagnostic advances and the relation ship with intrauterine devices (IUDs) are reviewed in this article, which is well worth reading. The sensitivity and specificity of clinical diagnosis is poor with rates of 62% and 77%, respectively, even with logistic regression. Key predictors are gonococcal or chlamydial infection and an elevated temperature with a high white cell count. Transvaginal ultrasound combined with ‘power Doppler’ seems promising, as it appears capable of measuring the hyperaemia of tubal inflammation with positive and negative predictive values of 91% and 100%, respectively. It seems most useful in milder disease but larger studies are needed. Meta-analysis has identified a relative risk for symptomatic PID of 3.3 in women with IUDs. However, many studies used inappropriate control groups and sexual behaviour was not controlled for. Even if the relative risk of PID is higher in IUD users, the absolute risk remains low and is of the order of 1:1000. Most of the excess PID risk appears limited to the first few weeks after IUD insertion and therefore a major determinant is the prevalence of chlamydial and gonococcal infection. The effectiveness of antibiotic prophylaxis before insertion of an IUD is unproven. Screening for sexually transmitted infections and rapid empirical use of effective antibiotics remain the cornerstone of PID control.