Latest / The SHEA Podcast / The Intersection of STIs and Antimicrobial Stewardship

Transcript

The Intersection of STIs and Antimicrobial Stewardship · The SHEA Podcast

• 0:08
  SPEAKER_01: Welcome to another episode of the Shay podcast.
• 0:11
  SPEAKER_01: Today we are talking about the intersection of sexually transmitted infections and antimicrobial stewardship.
• 0:17
  SPEAKER_01: My name is Jonathan Ryder, and I am an assistant professor of medicine within the Division of Infectious Diseases at University of Nebraska Medical Center in Omaha, Nebraska.
• 0:26
  SPEAKER_01: And I am a member of Shea's Antimicrobial Stewardship Committee.
• 0:30
  SPEAKER_01: I will be serving as today's host and moderator.
• 0:33
  SPEAKER_01: I'm pleased today to talk with Dr.
• 0:35
  SPEAKER_01: Aditi Ramakrishnan, who is an assistant professor in the Division of Infectious Diseases and Department of Medicine at Washington University in St.
• 0:44
  SPEAKER_01: Louis, Missouri.
• 0:45
  SPEAKER_01: She is a physician with training in HIV prevention and care, infectious diseases, medical anthropology, and clinical research.
• 0:53
  SPEAKER_01: She is also a core faculty member of the CDC-funded St.
• 0:57
  SPEAKER_01: Louis STI HIV Prevention Training Center.
• 1:01
  SPEAKER_01: Welcome, Dr.
• 1:01
  SPEAKER_01: Ramakrishnan.
• 1:03
  SPEAKER_01: Thank you for joining us today as we start thinking about how antimicrobial stewardship can impact sexually transmitted infections in a positive way.
• 1:11
  SPEAKER_01: I'm looking forward to hearing your opinions today on this topic as the rise of STIs and associated antimicrobial resistance makes this a topic of increasing concern.
• 1:21
  SPEAKER_00: Thank you for having me.
• 1:22
  SPEAKER_01: We'll start with today's first question.
• 1:24
  SPEAKER_01: Sexually transmitted infections are a growing public health threat, particularly those that are resistant to antibiotics.
• 1:30
  SPEAKER_01: However, these are often thought of as outpatient issues in a variety of settings, so may not fall under the typical purview of hospital antimicrobial stewardship.
• 1:39
  SPEAKER_01: What role do antimicrobial stewardship programs play in treating sexually transmitted infections?
• 1:46
  SPEAKER_00: That's a great question.
• 1:47
  SPEAKER_00: Both inpatient and outpatient antimicrobial stewardship efforts can contribute to improved screening and treatment of STIs, as well as guiding overall antibiotic use for those receiving treatment for STIs.
• 2:00
  SPEAKER_00: While STI care is typically thought of as an outpatient issue, inpatient care represents a missed opportunity for STI screening, treatment, and education.
• 2:11
  SPEAKER_00: There are inpatient STI care initiatives, such as here at Barnes Jewish Hospital, where I practice to screen for syphilis, for example, among individuals who are admitted, or at Boston University, there was an inpatient PrEP counseling and prescription bridge program.
• 2:27
  SPEAKER_00: Stewardship programs can support such initiatives through, for example, guiding antibiotic use for individuals already receiving DOXIPEP, both inpatient and outpatient, or overall antibiotic use for individuals who have been treated for multiple recent STIs.
• 2:43
  SPEAKER_00: So I think there's growth for this type of collaboration between stewardship and STI care in both inpatient and outpatient realms.
• 2:51
  SPEAKER_01: That's great.
• 2:52
  SPEAKER_01: So as you as you mentioned, there is kind of the new kit on the block, which is doxype or doxycycline post-exposure prophylaxis, which is a novel and effective strategy for decreasing rates of sexually transmitted infections.
• 3:05
  SPEAKER_01: However, many have raised concern about what the downstream consequences of doxypep are on antimicrobial resistance, which is a concern for stewards everywhere.
• 3:16
  SPEAKER_01: So, how do we best approach this issue?
• 3:18
  SPEAKER_01: Will there be an impact on our stewardship programs?
• 3:22
  SPEAKER_01: And what role do our stewardship programs play in mitigating the rise of antimicrobial resistance?
• 3:28
  SPEAKER_00: This is the question of the hour.
• 3:30
  SPEAKER_00: So thanks for bringing it up.
• 3:32
  SPEAKER_00: Just as some background, various recent trials, particularly the doxypep, hippergay, and doxy back studies, have demonstrated that doxycycline taken 24 to 72 hours after condomless sex significantly reduces the incidence of risk of chlamydia, syphilis, and to a lesser extent, gonorrhea.
• 3:50
  SPEAKER_00: Regarding antibiotic resistance, these studies have looked at tetracycline resistance of gonorrhea as well as commensal organisms such as staph aureus and strep.
• 3:59
  SPEAKER_00: So, for example, the doxypep study based in San Francisco, for patients who had a Nyceria gonorrhea culture available, tetracycline resistant gonorrhea was more frequent in the doxycycline group compared to standard of care.
• 4:12
  SPEAKER_00: As well as there was a slightly higher percentage of participants in the doxycycline group that had a lower overall staph aureus carriage, but increased doxycycline resistant staph aureas.
• 4:22
  SPEAKER_00: But we've learned a lot more from that study.
• 4:24
  SPEAKER_00: For example, a paper came out this past July from University of Washington in Clinical Infectious Diseases, in which the authors evaluated gonorrhea surveillance data from men who have sex with men from King County, Washington, to examine tetracycline resistance patterns and colonization with staph aureus and group-based DREP.
• 4:44
  SPEAKER_00: And what they found was that tetracycline resistant gonorrhea isolates increased, particularly after Doxy PEP was introduced in 2023.
• 4:52
  SPEAKER_00: They also found that doxy PEP use was associated with colonization with group-A strep and tetracycline resistant staph aureus.
• 5:00
  SPEAKER_00: So these findings suggest that doxypep affects the overall microbiome and antimicrobial resistance and off-target bacteria of people using this intervention, which we also know from other work as well.
• 5:13
  SPEAKER_00: But what's bottom line, what's the clinical significance of this in terms of day-to-day clinical practice?
• 5:18
  SPEAKER_00: We don't treat gonorrhea with tetracyclines.
• 5:21
  SPEAKER_00: We start with septraxone.
• 5:22
  SPEAKER_00: But these studies demonstrate that we need to conduct robust surveillance to better understand over the next few years how Doxy PEP may be changing antibiotic resistance and to better understand what is the clinical significance to be able to adapt our guidelines and practices, especially just being more flexible.
• 5:39
  SPEAKER_00: So as a clinician, I approach this challenge of balancing the benefits of Doxy PEP with the potential for antibiotic resistance through shared decision making with each patient.
• 5:49
  SPEAKER_00: But in terms of a health system response, we really need to focus funding on building up our surveillance abilities to improve our scientific understanding and to be able to prioritize developing data-driven strategies that we can use at a population level as well as with patients.
• 6:05
  SPEAKER_00: And regarding stewardship, one of the conclusions I thought was interesting from the University of Washington study was that the health department there in King County now has revised their Doxy PEP guidelines to recommend that providers avoid DOXYCYCLINE to treat skin and soft tissue infections and lower respiratory tract infections and people taking DOXIPEP.
• 6:24
  SPEAKER_00: I think that's a clear example of bridging the silos between stewardship and STI care and how stewardship and interventions can be designed with these findings in mind.
• 6:33
  SPEAKER_01: That's really uh fascinating and quite innovative as we kind of enter into these new paradigms of treatment for uh STIs.
• 6:42
  SPEAKER_01: So another area that I've found quite kind of interesting and a little bit controversial is around uh routine asymptomatic screening for gonorrhea and chlamydia in our populations of men who have sex with men who are on PrEP in particular, which is a very common practice in the United States to perform routine screening on a every you know three-month basis uh or or kind of whatever the local practices.
• 7:08
  SPEAKER_01: But there there have been some that have actually kind of argued that maybe we should no longer be doing this uh practice from some studies that were performed in in Europe, and that we should be discontinuing this kind of routine screening in this particular population related to kind of high rates of antibiotic use, uh especially with rising rates of antimicrobial resistance in gonorrhea.
• 7:30
  SPEAKER_01: So, what are kind of the pros and cons of this strategy?
• 7:33
  SPEAKER_01: And is this the future of STI uh management in the in the United States?
• 7:38
  SPEAKER_01: And what what can we kind of look forward to in the future with this uh intervention?
• 7:43
  SPEAKER_00: This is definitely a timely question.
• 7:45
  SPEAKER_00: I heard that this was a fiercely debated issue at the STIHIV World Congress in Montreal this summer.
• 7:53
  SPEAKER_00: The gono screen randomized controlled trial that you're referencing compared the effect of screening versus non-screening on gonorrhea chlamydia incidents among men who have sex with men and transgender women taking PrEP in Belgium.
• 8:06
  SPEAKER_00: And they found that non-screening was non-inferior to three-site screening every three months, as you referenced, and that antibiotic consumption was greater in the screening arm, as one would think.
• 8:17
  SPEAKER_00: This works well to reduce antibiotic consumption, unnecessary treatment in this population and context.
• 8:23
  SPEAKER_00: But I think one thing we need to think about with the US is that it can't easily be generalized easily to diverse populations such as ours, where we have huge variations in access to health care, the history of not offering appropriate treatment for STI care to certain populations, and we're still reckoning with that history and fragmented health systems.
• 8:43
  SPEAKER_00: The study also did not include cisgender women, and untreated STIs can have consequences, as we all know, such as pelvic inflammatory disease and infertility.
• 8:53
  SPEAKER_00: And so discontinuing screening among men who have sex with men and transgender women, it can eventually impact cisgender women as these populations may overlap at times.
• 9:01
  SPEAKER_00: But I do think that these studies are part of an important evolution in our clinical practices and guidelines.
• 9:06
  SPEAKER_00: And these findings may help us engage in shared decision making with our patients about what's relevant to them, relevant screening, relevant treatment going forward.
• 9:15
  SPEAKER_00: And certainly I think it's important for us to continue to reflect and adapt our practices based on newer data and studies, but also important to think about context and how can we adapt based on the context.
• 9:27
  SPEAKER_01: Yeah, that's great.
• 9:28
  SPEAKER_01: I think it's always interesting to see new emerging data and how we uh approach and incorporate it uh in the larger context of uh what's going on.
• 9:36
  SPEAKER_01: So we've talked a lot about antibiotics with uh uh Doxy Pep and and uh routine screening and treatment.
• 9:44
  SPEAKER_01: But besides just antibiotic use, what should stewardship programs consider when looking at STI care on the whole?
• 9:53
  SPEAKER_00: That's a great question.
• 9:54
  SPEAKER_00: Doxy Pep is just one tool that is part of sexual health care, which can help individuals feel more in control of their sexual health and more empowered.
• 10:03
  SPEAKER_00: We're learning about antibiotic resistance and what that actually means clinically for patients and populations over time.
• 10:10
  SPEAKER_00: I think stewardship and STI programs can synergize to A, develop interventions to address missed opportunities for screening and treatment, both inpatient and outpatient, and B, strategies to guide shared decision making and prudent use of antibiotics in this realm.
• 10:27
  SPEAKER_00: As data is pouring in, there's a lot of opportunity for developing both provider and patient education as well.
• 10:33
  SPEAKER_00: And I think both the fields can really collaborate and draw from what they've worked on in the past to developing more tools and education around this area.
• 10:44
  SPEAKER_01: Excellent.
• 10:45
  SPEAKER_01: So as we as we look to the future of our care of patients with sexually transmitted infections, how can our stewardship programs best engage?
• 10:56
  SPEAKER_00: Traditionally, stewardship, HIV care, and STI care are siloed.
• 11:01
  SPEAKER_00: You know, when you're when you become an ID fellow, the message is to typically tip pick a niche.
• 11:06
  SPEAKER_00: I remember that I was focused on antimicrobial stewardship when I began fellowship and eventually I ended up in the niche of HIV STI care.
• 11:14
  SPEAKER_00: And until now, I'm only now thinking about the connections between the two.
• 11:19
  SPEAKER_00: So there aren't a lot of built-in connections between these fields, but there really should be.
• 11:23
  SPEAKER_00: I think as we've discussed today, there's a lot of room for collaboration, synergy, and growth between the fields of stewardship and STI care.
• 11:30
  SPEAKER_00: The two fields can engage in developing education strategies to guide antibiotic use in the context of DoxyPEP, both inpatient and outpatient, and strategies borrowing from the antibiotic stewardship handshake model to design improved shared decision making for providers and patients regarding STI treatment in both inpatient and outpatient care.
• 11:51
  SPEAKER_00: I think the first step is realizing that there's such a rich opportunity for bridging the worlds of stewardship and STI care to move forward.
• 11:58
  SPEAKER_01: I agree.
• 11:59
  SPEAKER_01: I think there's a lot of opportunities for us to improve both in the hospital and in the outpatient setting, as you stated.
• 12:07
  SPEAKER_01: So thank you so much, Dr.
• 12:08
  SPEAKER_01: Ramakrishnan, for sharing your perspectives and experiences today.
• 12:12
  SPEAKER_01: It's such an interesting topic that really does show how we can make an impact on the care of patients with sexually transmitted infections.
• 12:19
  SPEAKER_00: Thank you so much, Dr.
• 12:21
  SPEAKER_00: Ryder, Dr.
• 12:22
  SPEAKER_00: Kandaya, and Shay for inviting me to discuss this timely topic.
• 12:28
  SPEAKER_01: All right, that concludes this episode of the Shape Podcast.
• 12:31
  SPEAKER_01: Thank you for tuning in.
• 12:32
  SPEAKER_01: We encourage you to check back for more episodes launching soon.