Episode 11 - Chlamydia with Clau

Episode 11 Chlamydia with Clau

 

The sun rises over the San Joaquin Valley, California,today is May 8, 2020. 

On April 28, 2020, the USPSTF released a final recommendation about prevention of tobacco use in children and adolescents. It is recommended that primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use among children and adolescents. Note that it doesn’t say prevention of “smoking”, it says prevention of “tobacco use” because we know that vaping is “a thing” among youth nowadays. This is a grade B recommendation, which means there is moderate to substantial benefit for this service. 

Now, an update about COVID-19. As of May 4, 2020, the CDC reports a total of 1,160,000 cases and 68,000 deaths due to COVID-19 in the USA. It has been a rough year so far for humanity! 

On May 1st, 2020, the FDA issued an Emergency Use Authorization to remdesivir for the treatment of COVID-19. Remdesivir can be used in hospitalized patients with severe disease. Remdesivir may shorten the time it takes to recover from the infection. It is given intravenously only. The issuance of an Emergency Use Authorization is different than FDA approval. Let’s stay up-to-date as this pandemic continues to evolve.

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Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.

The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. 

Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. [Music continues and fades…] 

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"As you would have people do to you, do to them; and what you dislike to be done to you, don't do to them." Taken from Al-Kafi, a Muslim book.

In a way or another, the Golden Rule is preached by many major and minor religions, “Do unto others as you would have them do unto you.” I think it’s a wonderful rule. Today we have a very sweet guest who is a very positive person and a hard worker. Welcome Dr Claudia Carranza, thanks for accepting my invitation to talk in front of the microphone… again! As you know, we ask 5 questions in this podcast, and we’ll start with question number 1.

Question Number 1: Who are you?

My name is Claudia Carranza, I am a second-year family medicine resident in the wonderful Rio Bravo Family Medicine Residency program in Bakersfield, CA. I grew up in Peru then moved to the States for college, attended a couple of community colleges before transferring to UCSD as a Biology major. Then went to Ross University School of Medicine in the Caribbean where I earned my medical degree. I did 1 year of Internal Medicine residency, and then transferred to Family Medicine and I could not be happier!

I am also a wife to a very busy IM resident, I am a Dog mom to Chewie. I don’t have lots of time for hobbies but when there’s time I like to do some strength training, dance, go on walks or runs with Chewie, cook healthy meals, bake and hang out with my hubby and friends. My favorite movie is Love Actually, and my favorite sport is swimming.

Question number 2: What did you learn this week?

This week I learned about the difference between Chlamydia Test of Cure (TOC) and Retesting. 

At our clinic, we have quite a few obstetrics patients, and they all get tested for Chlamydia as new OB patients, as part of their prenatal lab panel. When they are positive, they get treatment, and after treatment they undergo a Test Of Cure or TOC, no earlier than 3 weeks after completion of therapy. All patients with documented infection should also undergo retesting; this includes pregnant patients. 

When we have a pregnant patient who is infected we inquire about their partner and encourage the partner's treatment. Those partners, just like anyone with a documented infection, should have retesting done. 

Example: Let’s say we get a positive C. trachomatis test on one of our pregnant patients. We have to notify the patient of the results and the need for treatment. The recommended regimen for treatment is 1g oral Azithromycin given as a single dose.

If you have a patient who CANNOT tolerate Azithromycin then you may treat with either amoxicillin or erythromycin.

Recommended doses: Amoxicillin 500mg orally TID for 7 days, Erythromycin base 500mg QID for 7 days or 250mg QID for 14 days, Erythromycin ethylsuccinate 800mg QID for 7 days or 400mg QID for 14 days.

Remember after treating the patient and hopefully also their partner, the pregnant patient will need a TOC. Other patients who require a test of cure are any patients that show persistent symptoms or that were treated using a regimen with inferior cure rates, such as erythromycin or amoxicillin. 

 

 

Retesting

Retesting is done to check if a patient has been re-infected. This can be done 3 months after treatment or at their first visit thereafter within 12 months of treatment.

Now, think you are at the hospital and you have a pregnant patient that comes to triage in active labor. They brought some of their prenatal records and you know they had a positive C. trachomatis test, and she was treated but she did not have a test of cure, or you don’t have the records to confirm the results. In this case, there is usually not enough time to get a test of cure or retest prior to delivery, so these patients NEED TO BE TREATED upon admission with one of the recommended regimens. 

Of note, when treating pregnant patients; the antibiotics contraindicated during pregnancy (and lactation) are: Doxycycline, levofloxacin, ofloxacin, and erythromycin estolate.

Comment: The pregnancy categories by letters (A, B, C, D, X) were updated on June 30, 2015, by the FDA. Now, all medications are required to include three sections with explanations: Pregnancy, Lactation and Females and Males of Reproductive Potential. Erythromycin should not be used during the first trimester of pregnancy. However, it may be appropriate as an alternative agent for the treatment of chlamydial infections in pregnant women (consult current guidelines)

Treatment of the partner(s)

There are certain states in which Expedited Partner Therapy (or EPT) is permissible. This means a physician can treat the sex partner of a patient who is being treated for chlamydia; in other words, prescribe their partner medication without having examined them. California is one of the 44 states in which EPT is permissible.

 

Question number 3: Why is that knowledge important for you and your patients? 

C. trachomatis is the most commonly reported sexually transmitted disease. First of all, the reason why it is important to treat a pregnant patient is to prevent infection transmission during vaginal delivery. If infection is present during delivery the newborn is at risk for developing conjunctivitis or pneumonia. 

The most effective therapy if the newborn develops either or both is oral erythromycin; Why can we just treat the newborns? It is not that simple. There are studies that have shown an increased risk of hypertrophic pyloric stenosis (IHPS), especially if the infant is treated before 2 weeks of life. 

How likely is an infant to get IHPS if treated with erythromycin? There is a study by Rosenman and associates that compared the use of erythromycin prophylaxis with watchful waiting in a hypothetic cohort of neonates exposed to C. trachomatis. For every30infants treated with erythromycin, one additional case of pyloric stenosis would occur. This would be quite a few infants if we let chlamydia go untreated and newborns requiring treatment.

Pyloric stenosis in a nutshell is a disorder in which the pylorus or gastric outlet can become very narrow or even obstructed which leads to forceful vomiting and requires surgery to fix it.

Another caveat to treating an infant is that Erythromycin is effective in up to 90 percent of cases of conjunctivitis and approximately 80 percent of cases of pneumonia caused by C. trachomatis. Therefore, the infant needs close monitoring and at times a second round of treatment. 

I want the listeners to think for a minute and Just ask your adult self: How fun is it to take antibiotics? The answer is most likely, NOT at all fun; there are always side effects and your GI system is usually the most affected. Now imagine how a tiny little baby must feel.  I would NOT want to put an infant through this treatment unless it is ABSOLUTELY necessary, so if we can prevent it by testing  and treating mothers then let’s do that!

 

Question number 4: How did you get that knowledge? 

I mostly read UpToDate, AAFP, NEJM, and check the CDC website for updates. If I am not quite sure where I will be able to find a specific topic then sometimes I google what my question is and look through the list to see if any of the sources are reputable or if the articles are from a well known journal then I read the contents. 

 

Question number 5: Where did that knowledge come from? 

For this topic, I initially had the help of our host Dr Arreaza and then I read different articles in UpToDate, such as “Treatment of Chlamydia Trachomatis infection” and “Chlamydia trachomatis infection of the newborn”. I also read an AAFP article from American Family Physician “Chlamydia trachomatis exposure in newborn”, the CDC “Legal Status of Expedited Partner Therapy”, “Chlamydial infections”, “STDs Clinical Prevention Guidance” and finally Pubmed “Azithromycin in early infancy and pyloric stenosis.”

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OTHER SECTIONS

Speaking Medical: Cataplexy
by Terrance McGill

The Medical word of the week is Cataplexy. Cataplexy is emotionally-triggered transient muscle weakness. Most episodes are triggered by strong, generally positive emotions such as laughter, joking, or excitement. Episodes may also be triggered by anger or grief in some individuals. Cataplexy develops within three to five years of the onset of sleepiness in 60 percent of people with narcolepsy. Remember the word of the week: Cataplexy, See you next week!

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Espanish Por Favor: Agruras 
by Yodaisy Rodriguez

The Spanish word of the week is agruras. Agruras means heartburn (the medical term is pyrosis), and it is typically described as a burning sensation in the retrosternal area, most commonly experienced in the postprandial period, but can be used as well when trying to describe reflux. The scenario will be a patient saying: “Doctor, tengo agrugras”. Agruras is probably a common complaint among our “chili pepper lovers”. Patients with agruras may require additional evaluation if they have red flags, such as weight loss, hematemesis, loss of appetite, vomiting, or more.

Now you know the Spanish word of the day, agruras, all you need to do now is asses your patient’s heartburn.

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For your Sanity
by Fermin Garmendia and Terrance McGill

—Doc, Doc
—Who’s there?
—Disease
—Disease who?
—Disease the worse disaster I’ve ever seen

What’s the anesthesiologist’s ABC? Airway, Book, Chair!

Conclusion: Now we conclude our episode number 11 “Chlamydia with Clau”. Remember to order a TEST OF CURE for ALL your positive chlamydia patients who are pregnant, and RETEST everyone after 3 months of treatment. Don’t forget to treat sexual partner (or partners) to prevent chlamydia reinfection. It is permissible to send a prescription for the partner, even if you have not seen them. Cataplexy is an interesting symptom in narcolepsy, although it’s uncommon, you need to recognize it when you see it. And, if you have a heartburn after eating your pizza, remember the Spanish word of the day, agruras. 

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This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.

If you have any feedback about this podcast, contact us by email [email protected], or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. 

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Our podcast team is Hector Arreaza, Claudia Carranza, Yodaisy Rodriguez, Terrance McGill and Fermin Garmendia. Audio edition: Suraj Amrutia. See you soon! 

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References 

“Treatment of Chlamydia trachomatis infection”  by Katherine Hsu, MD, MPH, FAAP, last updated: Mar 02, 2020, UpToDate, https://www.uptodate.com/contents/treatment-of-chlamydia-trachomatis-infection?search=Treatment%20of%20Chlamydia%20Trachomatis%20infection&source=search_result&selectedTitle=1~143&usage_type=default&display_rank=1

 

“Chlamydia trachomatis infections in the newborn” by Margaret R Hammerschlag, last updated: Nov 15, 2018, UpToDate, https://www.uptodate.com/contents/chlamydia-trachomatis-infections-in-the-newborn?search=2)%09Chlamydia%20trachomatis%20infection%20of%20the%20newborn&source=search_result&selectedTitle=1~143&usage_type=default&display_rank=1

 

“Chlamydia Trachomatis Infections: Screening, Diagnosis, and Management” by Ranit Mishori, Erica McClaskey and Vince J. Winklerprins, Georgetown University School of Medicine, Washington, District of Columbia, American Family Physician, www.aafp.org/afp, Volume 86, Number 12, December 15, 2012.

 

“Legal Status of Expedited Partner Therapy”, Centers for Disease Control and Prevention, https://www.cdc.gov/std/ept/legal/default.htm , accesed on May 6, 2020.

 

“Chlamydial infections”, Centers For Disease Control and Prevention, https://www.cdc.gov/std/tg2015/chlamydia.htm , accessed on May 6, 2020.

 

“STDs Clinical Prevention Guidance”, Centers for Disease Control and Prevention, https://www.cdc.gov/std/tg2015/clinical.htm , accessex on May 6, 2020.

 

“Azithromycin in early infancy and pyloric stenosis” by Matthew D. Eberly, Matilda B. Eide, Jennifer L. Thompson and Cade M. Nylund, Pediatrics, The Official Journal of the Amercan Academy of Pediatrics, March 2015, https://pediatrics.aappublications.org/content/135/3/483

 

“Clinical features and diagnosis of narcolepsy in adults” by Thomas E Scammell, last updated: Feb 12, 2020, UpToDate, https://www.uptodate.com/contents/clinical-features-and-diagnosis-of-narcolepsy-in-adults?search=8)%09Clinical%20features%20and%20diagnosis%20of%20narcolepsy%20in%20adults,%20Author:%20Thomas%20E%20Scammell,%20MD&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H1