Academy Exchange

Expand all | Collapse all

Rectal Chlamydia Treatment

  • 1.  Rectal Chlamydia Treatment

    Posted 03-25-2020 09:52
    ​Good morning All.

    I recently had a msm test positive for rectal chlamydia. I ordered the Azithromycin per usual. I was told by triage that Doxycycline is the recommended new option for rectal chlamydia due to absorption. I had not heard this news. I am wondering if any of you could speak on this subject.

    Thank you
    Shannon

    ------------------------------
    Shannon Stewart, ARNP, AAHIV
    Siouxland Community Health Center
    Sioux City, Iowa
    ------------------------------


  • 2.  RE: Rectal Chlamydia Treatment

    Posted 03-26-2020 06:18
    Shannon,

    I've been using azithro still. The 2020 STI guidelines are expected to recommend doxy for chlamydia treatment at all sites.

    There is a difference in treatment outcomes for rectal gonorrhea though preventing using of oral cephalosporins.

    ------------------------------
    Katy Garrett
    Portland ME
    ------------------------------



  • 3.  RE: Rectal Chlamydia Treatment

    Posted 03-26-2020 07:43
    There was some anecdotal data that suggested that there was better uptake of doxycycline in rectal tissue as compared to azithromycin. I can't find the exact source but I moved to treating all my rectal chlamydias with doxy, also a few years ago there was the suggestion of poorly recognized LGV proctitis in MSM ( based on UK  and European data) and doxycycline is the preferred therapy. Here is a quick pubmed search that suggests the same https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4364392/pdf/nihms-670389.pdf

    ------------------------------
    Quintin Robinson
    Absolute Care Medical Center & Pharmacy
    Atlanta GA
    ------------------------------



  • 4.  RE: Rectal Chlamydia Treatment

    Posted 03-26-2020 08:06

    Hi Shannon
    i treat lots of rectal CT and use Azithromycin 1 gram given in the office. I have had one patient recently with refractory rectal CT that in spite of being treated twice without cure and him denying any new sexual contact I treated with Doxy and he cleared.  Patients who have had rectal pain I go to Doxy right away and always considering that if it's LGV Doxy for 21 days is needed.  CDC recommends either Azithro 1 gm, or Doxy 100mg bid for 7 days as treatment for uncomplicated rectal CT. 

    I will await other opinions to see what others do. 

    Gary



    ------------------------------
    Gary F. Spinner PA,MPH,AAHIVS
    Southwest Community Health Center
    Bridgeport, CT
    gspinner@swchc.org
    Gary.spinner@aya.yale.edu
    ------------------------------



  • 5.  RE: Rectal Chlamydia Treatment

    Posted 03-26-2020 09:30
    Great question! One of my students did her grand rounds on this very topic last year. 

    for asymptomatic CT, ie found on screening with no symptoms, azithro seems to do just fine. For those with symptomatic CT, ie proctitis, tenesmus, colitis, doxy is where its at.Here are some references that she shared. 

    1) Khosropour, C., Dombrowski, J., Barbee, L., Manhart, L., & Golden, M. (2014). Comparing azithromycin and doxycycline for the treatment of rectal chlamdyial   infection: A retrospective cohort study. Sexually Transmitted Disease 41(2),   79-85. doi:10.1097/OLQ.0000000000000088.  (some highlights from it) 

    ---1231 were treated with azithromycin and 249 treated with doxycycline.
    ---407/1231 of azithromycin group re-tested AND 88 still had the infection
    ---95/249 of doxycycline group re-tested AND 8 still had the infection.


    2) Hamly, E. & Taylor, C. (2006). Sexually transmitted proctitis. Postgrad Med Journal 82, 733-736. doi: 10.1136/pmj.2006.048488


    ------------------------------
    Angela Kapalko
    Physician Assistant Chairperson for AAHIVM
    Philadelphia FIGHT CommunityHealth Centers
    Philadelphia PA
    akapalko@fight.org
    ------------------------------



  • 6.  RE: Rectal Chlamydia Treatment

    Posted 03-26-2020 15:06
    Edited by Anthony Sayegh 03-26-2020 15:08
    Hello,

    My understanding is that there has been some observational data that azithro may be inferior to doxy for rectal CT treatment. However, advantageously, azithro can be administered under DOT as a single dose. Some clinics choose to treat asx rectal CT with azithro and, if retesting at 3 months is positive with low suspicion for reinfection, to retreat with doxy to cover the possibility of tx failure. If the pt presents with proctitis, the recommended tx is cef plus doxy unless gram staining of rectal discharge shows gram neg diplos, in which case the tx recommendation would be cef plus azithro.

    ------------------------------
    Anthony Sayegh, FNP-C, AAHIVS
    HIV Consultant
    National Clinician Consultation Center
    University of California, San Francisco
    nccc.ucsf.edu
    ------------------------------



  • 7.  RE: Rectal Chlamydia Treatment

    Posted 03-27-2020 08:30
    Hello Shannon,

    Great question!  I have lots of experience in treating STIs as I am a sexual health provider.  I have been using azithromycin 1 gram to treat all rectal CT, but I would perform a test-of-cure (TOC) 2 weeks after treating rectal CT and I would receive a positive result.  All of these patients who retested positive denied a possible re-exposure.  So, I started treating rectal CT with doxycycline 100 mg twice daily for 7 days and have yet to receive a positive result on repeat testing (2 weeks TOC).  Please do counsel your patients about possible photosensitivity while taking doxycycline.  I live and work in Denver, CO where we are 1 mile closer to the sun then most of the US and I have had patients experience a pretty bad sun burn.  

    I hope this helps.

    ------------------------------
    Randall McDavid, MS, NP-C, FNP-BC, AAHIVS
    Director of Medical Services, Colorado Health Network
    Denver, CO
    ------------------------------



  • 8.  RE: Rectal Chlamydia Treatment

    Posted 03-27-2020 08:42
    Randall
    Thank you, yes very helpful!
    Shannon

    Sent from my Verizon, Samsung Galaxy smartphone






  • 9.  RE: Rectal Chlamydia Treatment

    Posted 03-28-2020 02:43
    Hi Randall, 

    Thanks for sharing. I've also been at this too many years..I go back to the days before Azithromycin. I do TOC in 3-4 weeks after treatment and find a pretty good success rate with Azithromycin. In my HIV patients, it's a different story. In many of my young MSM patients, I've had to retreat with Azithro and have had very few treatment failures. I'm struggling with the new guidelines which will certainly remove Azithro as first line and replace with Doxy 100 bid x 7 days. I fear we will have a high failure rate because we've seen this before, non adherence was a huge issue resulting in high failure rates. At that time we didn't screen as aggressively as we do now in asymptomatic patients, so it will be interesting to see how this goes. I'm sure there will be patients who still get Azithro..we shall see. 

    Michelle

    ------------------------------
    Michelle Ogle
    Bronx NY
    ------------------------------



  • 10.  RE: Rectal Chlamydia Treatment

    Posted 03-28-2020 10:52
    This is all GREAT information and I appreciate all the insight! I was worried, by not performing TOC (test of cure), I was missing something, so I looked up recommendations from UpToDate. It would appear this isn't recommended, but for certain populations, where our NAAT testing could be falsely positive from dead organisms rather than active disease if screened less than 3 weeks! Considering cost of care/re-treatment, patient follow up, and perhaps unnecessary repeat antibiotic exposure, we probably should not perform TOC, but re-test at 3 month intervals.
    From UpToDate:
    Hope this helps!

    ------------------------------
    Kurtis Mohr
    Premise Health
    Orlando FL
    ------------------------------



  • 11.  RE: Rectal Chlamydia Treatment

    Posted 03-29-2020 03:24
    Thank you for the information, Kurtis-

    I think we all need to take into account the patient population we're working with. As I stated in my note, my young MSM patients with HIV, at least some of them require TOC. For the reason you mentioned, I have them come back in 1 month for TOC. Remember, most of our patients are followed q 6 months, not 3 months. For many of my HIV+ patients, it is important to document cure because of the high rates of treatment failure in that group. I admit, I'm not an avid up to date reader but I follow the CDC, STD treatment guidelines. Not all populations need to have TOC but I would caution against not doing TOC in young MSM HIV+ patients, they hav a high failure rate with rectal Chlamydia infections. This is the main reason treatment guidelines will likely be changed to Doxy as first line. I would agree that a 3 month follow up is fine but for some of my kids a return visit at 1 month also allows me to monitor adherence, etc. In my older patients and those with durable viral suppression, I'm less likely to do TOC. 

    Just want to make sure we consider the patient population, including HIV status, age and if they are virally suppressed when making TOC decisions.

    ------------------------------
    Michelle Ogle
    Bronx NY
    ------------------------------



  • 12.  RE: Rectal Chlamydia Treatment

    Posted 03-29-2020 07:56
    Again, thank you all for your guidance and great information. I have only been working in this population for 4 years, so unlike most of you with years of experience I appreciate the different perspectives you come from. I am a firm believer in the healthcare profession if you don't learn something new daily or weekly that is amazing. I dave not been doing TOC but from this decision I will be going forward. Michelle, I do have many you MSM that I will definately be focusing on TOC, due to noncompliance. My older MSM are virally suppressed and I am not so concerned with noncompliance.
    Again, thank you. I will also take this to my colleagues as we have high rates of STIs in our smaller midwest community.

    Sent from my Verizon, Samsung Galaxy smartphone






  • 13.  RE: Rectal Chlamydia Treatment

    Posted 03-29-2020 14:03
    Edited by Anthony Sayegh 03-29-2020 14:04
    Partner delivered therapy (PDT) if available in your state is so important. Reinfection is more probable than treatment failure. Folks need to be counseled that all of their sex partners within the past 60 days need epi-treatment, and this can be done with PDT. Also it is so important to remember to counsel folks on the need to wait seven days after they and their partners take the treatment before resuming sex to prevent reinfection. This is especially true when using single-dose azithro.

    ------------------------------
    Tony Sayegh, FNP-C, AAHIVS
    HIV Consultant
    National Clinician Consultation Center
    University of California, San Francisco
    nccc.ucsf.edu
    ------------------------------



  • 14.  RE: Rectal Chlamydia Treatment

    Posted 03-29-2020 14:09
    We do have partner treatment.  We also have a great Title X program for sexual health!

    Sent from my Verizon, Samsung Galaxy smartphone






  • 15.  RE: Rectal Chlamydia Treatment

    Posted 03-26-2020 19:49
    Thank you all for the information. I appreciate the resources as well.

    ------------------------------
    Shannon Stewart, ARNP, AAHIV
    Siouxland Community Health Center
    Sioux City, Iowa
    ------------------------------



  • 16.  RE: Rectal Chlamydia Treatment

    Posted 03-27-2020 03:54
    Yes, observational data favors Doxy over Azithro for rectal CT, and that is what the Seattle King County PH STD Clinic is doing, but the good news is that a RCT is wrapping up to answer this question once and for all, so stay tuned!  

    My inside sources tell me that we should expect to see Azithro basically removed from the 2020 CDC STD guidelines for both GC and CT...

    ------------------------------
    Hillary Liss
    University of Washington
    Seattle WA
    ------------------------------



  • 17.  RE: Rectal Chlamydia Treatment

    Posted 03-29-2020 17:05
    Thanks to everyone for such an amazing discussion!

    It is so important to share practices, perspectives and learn what what works and where we can improve. I hope everyone enjoyed this as much as I have! This is a safe space for these type of discussions where we learn from one another share ideas. 

    Thanks, Shannon for leading such an informative discussion. 

    Stay safe my friends!

    Michelle

    ------------------------------
    Michelle Ogle
    Bronx NY
    ------------------------------