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Melanie Cole (Host): Welcome to UAB Med Cast. I'm Melanie Cole and joining me today is Dr. Jodie Dionne-Odom. She's the Chief of Women's Health Services for UAB's 1917 Clinic. And we're discussing STS and pregnancy. Dr. Dionne, it's a pleasure to have you join us today. I'd like you to start by describing the major STI syndromes and the type of pathogens that are involved in them.

Jodie Dionne-Odom, MD, MSPH, FIDSA (Guest): Yeah, thanks for inviting me to speak about one of my favorite topics here today. So the providers and physicians who manage STI syndromes really break it into three different categories. And what we know is there's certain pathogens that cause ulcers and there's other pathogens that cause sexually transmitted diseases or STI that don't cause ulcers and there's others in women that cause vaginitis syndromes.

So for the ulcerative STI, what we're really talking about is syphilis and herpes simplex. Those are the two different infections that cause ulcers in women usually inside the vagina and the non-ulcerative STI will usually cause an infection of the cervix. So the cervicitis is caused by gonorrhea or chlamydia. And finally, the vaginitis will usually be women who present with abnormal vaginal discharge, and that's often trichomoniasis or a bacterial vaginosis. So there's about 30 different pathogens that can be transmitted sexually, that women are at risk of getting, but those are six of the most common players, most frequently seen in clinic.

Host: So, what have you been seeing in the trends for STI in women and pregnancy in Alabama and among the pregnant women Dr. Dionne, have you seen an increase in drug abuse that could be correlated with an epidemic of STI syphilis, but maybe not gonorrhea? What have you been seeing?

Dr. Dionne-Odom: Yeah. I mean, your questions are really great and they do sort of tell us where we're headed with what the research is showing us for the risk factors for getting STI in women. Unfortunately, in the US the STI rates are going in the wrong direction. Really, since 2013 rates in women had been consistently increasing. The CDC just released their 2020 surveillance report.

And there's 1.6 million cases of chlamydia that were reported to CDC nationwide. And the majority of those cases are in young women of reproductive age, between the age of 15 and 29. This is a relatively stable rate compared to last year. It's increased overall compared to the about five years ago. For gonorrhea, there are 680,000 cases, that's a 45% increase compared to last year.

And importantly, in women, in terms of thinking about pregnancy, syphilis is one of the most dreaded infections that we worry about because it passes the placenta so easily and can cause congenital syphilis. And unfortunately there's 134,000 cases of syphilis reported last year. And with a 52% increase from the year prior and as many as 2,148 cases of congenital syphilis. To give you perspective, there used to be 800, 900 cases of congenital syphilis a year. So it's really increased over 230% over the past five years with 122 stillbirths reported. And in 2021, we've already surpassed that number. We already have 2200 cases reported nationally.

So if you dig into understanding why this is happening, we've done some research with women living with HIV and also true with CDC data women without HIV showing that you're right, drug abuse is part of what's contributing to this trend. We know that some of the women are accessing care less frequently or are not being tested for syphilis because of alcohol and drugs that they're using that's keeping them out of care.

Really the major factors that we can identify that are causing this congenital syphilis increase is a lack of timely prenatal care and then inadequate treatment. Sometimes the diagnosis is made and the treatment is not given on that day. And you try to call a patient and she's unable to come back, or you just can't reach her to come back and give the benzathine penicillin.

The treatment for syphilis in pregnancy is very straightforward. Benzathine penicillin is very effective, very affordable, and we've been using it for about 50 years. So that piece is not complicated. It's really just getting the person back in, making sure you're diagnosing and treating the woman as soon as possible in pregnancy.

Host: Dr. Dionne, so what is new in your understanding of STI clinical presentation and diagnostic options? Speak about asymptomatic presentation, highly sensitive NAT testing that can be self collected. Tell us about this?

Dr. Dionne-Odom: Yeah, I think it's really important. Sometimes when people think about STI, they think about something that will bring someone into the clinic with an urgent problem, either dysuria or dyspareunia, but the majority of STI in women is asymptomatic. So they feel fine. They have no idea they have an infection and they often don't even know that they're at risk because their partner makes asymptomatic as well. You can imagine if people are asymptomatic, what we have to keep is a really high clinical suspicion for STI in these young women and test them frequently so we can get them treated. They will not present with symptoms for the most part. The exciting advance in diagnostics is we used to rely on culture for a lot of these organisms, syphilis you can't culture very well, and neither chlamydia can you culture very well.

Gonorrhea, you can, but with this new molecular NAT testing, we can do highly sensitive and specific testing on a urine sample, on a cervical swab, but the preferred method is a patient collected vaginal swab. These vaginal secretions will pool and the PCR is so sensitive that you send the patient to the bathroom with a swab and the likelihood of detecting the organism if it's there, is at about 98 to 99%. So really terrific tests. Some people don't like to come to clinic, not surprisingly. So some of the new research advances are, can we have home delivered STI testing for someone to do it in the comfort of their own house. Where they can send the testing in and be treated even in the absence of a medical visit, if they prefer that. Ideally in pregnancy, one of the benefits we have is we are seeing women pretty frequently to follow their pregnancy. So those all are good opportunities to talk about STI and to test so that treatment can be offered. But the new tests are really good. You can't get any better than the numbers for sensitivity and specificity that our NAT testing has.

Host: Doctor, what's the latest in STI treatment and prevention. Tell us a little bit about CDC and the RCT data that you've collected. Tell us what's going on.

Dr. Dionne-Odom: So the CDC updates their STD or now STI treatment guidelines about every five years. So I was part of the process that developed it. It was just published in 2021 and they really do an exhaustive review of all of the studies that have been published in the past five years, looking for the highest quality evidence or randomized controlled trials, but even retrospective studies, observational studies, anything that's new that we can figure out how best to treat STI.

Some of the RCTs that were done that changed STI treatment guidelines this time, one of the big ones is now the first line treatment for chlamydia is doxycycline. We have studies showing higher efficacy of doxycycline compared to azithromycin for chlamydia. So the recommendation for doxycycline is a 100 milligrams twice a day for seven days.

So we have to talk to patients to make sure they take all of that therapy. It's a little bit more complicated than a single dose azithromycin, but with a higher efficacy, it's clearly worth it. There's also been a simplification of the gonorrhea treatment. In the last iteration of the treatment guidelines, we were treating patients with gonorrhea with dual drugs, giving them ceftriaxone and azithromycin. But now we've taken azithromycin off that list with a recognition that it wasn't really adding enough benefit. And the dose of ceftriaxone has increased to 500 milligrams. So, a change in the gonorrhea treatment as well.

The other changes, the treatment for trichomoniasis and women with and without HIV is now to treat for seven day duration. We used to use single dose in women without HIV, but we have a well done study and RCT showing significant treatment efficacy with a seven day 500 bid dose of metronidozole. So those are the, some of the newest studies that have informed our treatment recommendations, but we obviously want new medications, better prevention tools. And a lot of researchers are working on that right now.

Host: Well then what are researchers at UAB and around the world working on to improve STI outcomes in women and pregnancy? Tell us what's new and exciting in preventive vaccines, oral treatments, anything you'd like other providers to know about.

Dr. Dionne-Odom: Yeah. So I think the very first thing to say is that we need to continue to prioritize studies in pregnant women. I think historically, there's been this idea that pregnant women are vulnerable and that we should not study them. And you can tell from the epidemiology and when we care for our patients, pregnant women are clearly at risk of STI.

So we need options that we can give them, that are safe and effective and the best way to prove that is through well-designed clinical trials. So some examples of clinical trials that are ongoing is new antibiotics. We're doing a study of a new oral fluoroquinolones for gonorrhea treatment, called zoliflodacin.

And it would be very exciting to have a new oral antibiotic that we could use in place of ceftriaxone since intramuscular ceftriaxone can be problematic to give some times. We're also working hard on vaccines. So we have a trial right now, that is giving uninfected adults meningococcal vaccine to see if it provides protection against getting gonorrhea, actually, and this has worked in some observational studies, but this is the first multicenter prospective study to see if we can prevent gonorrhea in this way.

Vaccines are wonderful because we can give them to people before they're exposed and they can provide protection over long periods of time. So you don't have to worry about screening and treating as frequently if you have an effective vaccine on board. Now that said, these studies that I've mentioned are not being done in pregnant women yet, but if there's efficacy in the non-pregnant women, the next study that would be done is a study in pregnancy, to see if it works there too.

A study that I'm working on in Cameroon to try to prevent STI in pregnant women is to add azithromycin to antibiotics that women are taking there already, when they're living with HIV to see if the addition of monthly azithromycin can reduce the rate of gonorrhea, chlamydia, syphilis and lead to babies who are healthier with a higher birth weight and have better birth outcomes overall.

So those are just a few of the many studies that are ongoing. There's really a lot of interest, I think right now, nationally and internationally, as these rates are going up to say, what can we do to make it better? We need better tools, and good data in women who are pregnant or thinking of becoming pregnant

Host: Thank you so much, Dr. Dionne, what a great guest you are. This was so informative. Thank you again for joining us. And a physician can refer a patient to UAB medicine by calling the MIST line at 1-800-UAB-MIST, or you can always visit our website at UABmedicine.org/physician. That concludes this episode of UAB Med Cast. I'm Melanie Cole.