Mycoplasma genitalium #GPCMEsouth

Edward Coughlan is a sexual health physician at Christchurch hospital. He recently spoke at both GPCME south and to the training registrars. His first talk was on Mycoplasma genitalium and had the title “The new black” which reflects the sexual health worlds recent interest and research going on around M. Gen.

So lets start at the very beginning which is apparently a reasonable place to start.

Mycoplasma genitalium was first isolated from men with urethritis in 1980 by – Tully,Talyor-Robinson- Lancet 1981;1:1288-91 (might need to check in a library to find this it’s the building you use to get free wifi) M. Gen. Is very small with 582,970 base pairs  in a circular chromosome,coding for 521 genes. Has no cell wall. But is very adherent to the urinary tract. It has a flask like shape see the photo from 1981 publication and electron microscope images.

 

Mycoplasma Genitalium flask

This was followed by a lull whilst the technology caught up. Once PCR arrived the studies have shown that  M. Genitalium is a major cause of non-gonococcal urethritis. range is variable from 10-20% depending on population group making it the most common after chlamydia. Currently the gold standard test is nucleic acid amplification technique (NAAT) this can be done from urine or swabs.

Now when I mentioned M. Gen. on Twitter a reasonable number of people thought this was the sexual health physicians making our lives hard or the diagnosis is irrelevant as the treatment is the same.

See discussion: https://twitter.com/MDaware/status/368223586315550720

 But recent studies have looked at this and the 1g stat dose of azithromycin which was shown to be 95% effective in the earlier studies has  dropped to lower than 80% in the last large case series. But more importantly those who don’t respond to the initial 1g dose have a very low cure rate of 30-40% if the azithromycin stat dose is repeated. The results for doxycycline are much worse with higher initial resistance patterns around 70%. The current 1g “Z-Pack” and go approach is selecting for resistant strains of M. Gen.

As recurrent Non-gonococcal non -chlamydial urethritis are the patients most likely to have M. Gen these are the patients we should be testing. So how can you prevent its resistance? using a 500mg stat dose followed by 4 days of 250mg worked well for 95% of patients. Which leaves you with a small group 1 in 20 who are resistant.

So what then? Pharmac has just approved Moxifloxacin special authority for Azithromycin resistant M. Gen. SA funding is for a 7 day course of 400mg daily. This is for NAAT confirmed M. Gen. after failing the long azithromycin course.

In short if you are treating patients for urethritis you should know about M. Gen. If someone has recurrence of their Urethritis then you should be thinking about it and testing and if they have “treatment resistant” Non-gonnococcal non-chlamydial  urethritis M. Gen. should be your first thought.

References:

Wikstrom  STI 2006 82 ;276 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564707/

 
Bjornelius STI 2008, 84,72-76 http://sti.bmj.com/content/84/1/72.abstract
 

  

 
 
 
H Sen Yew et al. J Clin Microbiol. 2011 April; 49(4): 1695–1696.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3122813/
  
 

Travel medicine with Marc Shaw part 1 #GPCMEsouth

Marc Shaw is a travel doctor based in Auckland (we wont hold this against him)  professor of public health at James Cook University, Australia (We might hold this against him) Worldwise Travellers Health & Vaccination Centres NZ  medical director and consultant for New Zealand academy of sport.

marc_shaw

 Marc Shaw DrPH, FRGS, FRNZCGP, FACTM, FFTM (ACTM), FFTM RCPS (Glas), DipTravMed.

Prof Shaw gave 3 talks at the GPCME south conference on travel medicine. I will try to convey the essence of the talks some key points and his sense of humour which I’m told is very important in travel medicine.

The first was preparing the last minute traveller. A common general practice presentation.

The talk started with a quote by Billy Crystal   ‘By the time a man is wise enough to watch his step, he’s too old to go anywhere’

Marc was clear that the major role of a travel health professional is to convert a pre-contemplator into a contemplator. You need to balance what the patient wants and the level of risk.

As a big fan of any aid memoire when he suggested his T.R.A.V.E.L. Acronym I was very interested.

T TRANSMISSION of Infections and Dis-ease, discussion around insect avoidance use of repellents, other forms of transmission and ways to avoid “Dis-ease” whilst travelling.

 R REMEDIES Prescriptions x 2 CACHES Usual medications, a card with them on it in case of lost meds and a smaller collection in separate location if possible.

Med. Kits + first aid advice.

G.P. letter re meds & med. conditions can be needed for a number of medications. Antipsychotics are a major one for this most countries need some documentation for these to be carried across boarders. Medic Alert Bracelet may be needed for some.

Antimalarial Medication + SEs Treatments: self-treatment. Preference for malarone over doxycycline but understanding the cost issue.

 A ACCIDENTS Accidents/Injury Prevention Simple measures the best, good footwear, seatbelt use, helmets. Accidents and injuries make up a majority of the overseas illness but often seen as not significant risks in the settling. I understand the feeling as whilst travelling you do get a “hot frog” type situation when before you know it your riding a motorbike without a helmet and not worried in the slightest.

AIR TRAVEL Jet Lag suggested travelling east-to-west as much as possible, getting out in the sunshine and taking time to recover. expect half a day for each time zone crossed.

ADVENTURE As the numbers of people going heli-snorkeling or para-fishing  are rapidly increasing you will be seeing more of these through your door. A pragmatic approach needs to be taken, you may not think base jumping with a speargun is a great idea but do what you can to reduce their risks whilst doing so. Scuba Diving is a special note, check dive tables ect.

ANIMALS Bites, the importance of rabies vaccination and explaining the place of immunoglobulin which can be very difficult to access in some areas.

V VIOLENCE Avoiding areas: this covers both the high risk locations and areas of higher risk within regions. The risks to travellers have changed greatly in the last few years and as conditions are so volatile it is worth checking travel advisories from government and travel agencies.

VACCINATIONS and adverse reactions I really liked the table which balances the impact and incidence giving you the degree of preventable risk.

Risk vaccination  

ref: http://www.ncbi.nlm.nih.gov/pubmed/15996464

E EATING / DRINKING Ingestion. High risk foods, how to reduce your risk. the classic example being Roadside>Buffet>Restaurant

EXAMINATION Pre- and Post- travel. All travellers should have a good physical check up before leaving for their journey and also on returning.

ENVIRONMENT Expedition Medicine/Altitude. If on an expedition check the itinerary are they going high, low, high ect. Do they have a expedition doctor?

EMERGENCIES Insurance/evacuation: Insurance is widely available, people in complex situations may need a broker but most can and should be covered in someway(eg: exceptions of existing conditions)

“If a patient cannot afford to have travel insurance of some form they cannot afford to travel”

L LIFESTYLE ‘Sex Drugs Rock and Roll’ This one explains itself really. Harm prevention.

So that’s a pretty beefy way of remembering things but hopefully will help remember what should be covered. As always if concerns or unsure there are many resources for travel advice online and via the various govt. agencies. Onto a couple of other thoughts from the talk.

 Travel related illness: the gender differences.

59000 travellers in 57 world wide travel medicine clinics.

Women more likely to have diarrhoea, GI problems, Colds, UTIs and adverse reactions to drugs esp: antimalarials. But much less likely to develop STIs.

Men much more likely to get a febrile illness, malaria, dengue, rickettsia. Men are known to be less compliant with mosquito repellant ect.  Acute mountain sickness or frostbite this may reduce in future years but currently men have a strong majority when it comes to “extreme illness”.  STIs which is thought to be related to the common travel observation that majority of men sleep with locals and women with other travellers.

“You should advise your patients to keep it in their pants it is a Holy-day after all”

Ref: http://cid.oxfordjournals.org/content/50/6/826.full.pdf

Prof Shaw also talked about his pharmaceutical medical kit which is extensive! Some medications are more appropriate for some patients than others and the balance needs to be upheld between the safety of disease and treatment/Side effects.

Pharmaceutical Medical Kit – suggestions:
•Medication for: allergies, insect bites, colds and ‘flu, and diarrhoea
•Antibiotics for: ear, eye, respiratory, stomach and skin infections
•Fever therapy (aspirin / paracetamol), and water treatments
•Medication for anti-fungal infections
•Medication for motion sickness, nausea and vomiting
•Anti-malaria medicines (where appropriate)
•A sufficient supply of any regular medication (with spares!)
•Diarrhoeal Pack: Immodium, Noroxin/Azithro, Tinidazole, ORS

If only the travellers who often end up in ED were this prepared.

As this has ended up pretty large will split this into part one and two. In part two i’ll cover the talks on mass travel events and the South Americas!