BASHH Guidelines Research Articles

High prevalence of anti-hepatitis A IgG in a cohort of UK HIV-negative men who have sex with men: implications for local hepatitis A vaccine policy.

BASHH guidelines recommend that 'the hepatitis A virus total antibody test can be offered to at-risk patients whose immune status is unknown … depending on local funding arrangements'. We sought to measure the local prevalence of anti-hepatitis A (HAV) IgG in HIV-negative men who have sex with men (MSM), to inform the utility of pre-vaccination screening. We assessed the prevalence of anti-HAV IgG in HIV-negative MSM who attended sexual health services in County Durham and Darlington, UK, from March to August 2017. Data were extracted from electronic patient records and analysed in Excel. Our study was granted local Caldicott approval. Seventy four per cent of 244 HIV-negative MSM who attended for review were screened. Anti-HAV IgG was detected in 42% who did not report definite previous infection or vaccination; not detected in 57.4%; and was equivocal in 0.6%. Vaccine was administered to 48% of eligible patients. The estimated financial costs of universal vaccination of MSM (£4235.40) and pre-vaccination screening with vaccination of susceptible patients (£4188.13) are similar. Pre-vaccination screening and vaccination of susceptible patients does not save resources compared to a policy of universal vaccination of MSM in our setting. Universal vaccination of MSM attending genitourinary medicine clinics may improve vaccine uptake.

P247 An audit of hepatitis b and c testing in a sexual health service – an opportunity for cost saving

IntroductionBASHH have recently updated guidelines as regards criteria for hepatitis B and C testing. Are patients accessing the service offered hepatitis B and C testing appropriately? Furthermore can this data be extrapolated to calculate potential cost reductions should audit data suggest overtesting.Methods100 case notes SHHAPT coded as T6 from 2 local clinics were scrutinised as to whether testing followed BASHH guidelines. In addition 50 case notes were randomly selected to ascertain whether a T6 code should have been applied.Results87/100 (87%) underwent hepatitis B testing of which 10/87(11%) were found to be inappropriate The reasons for testing in this 11% included sexual exposure in a low prevalence (mostly in Europe), saliva exposure, and a history of an ex-partner with multiple contacts – 38/100 underwent hepatitis C testing of which 14/38 (36%) were tested inappropriately—the reasons given included contact with men having sex with men(MSM) with no history of chemsex, contact with a HIV infected patient, sexual assault, sexual contact with an intravenous drug user and sexual exposure in Europe. In the audit of random selection of 50 casenotes- there were no cases of missed opportunities for hepatitis testing. Extrapolation of data showed that £1739 annually could be saved if all testing for hepatitis B and C was based on national guidance.DiscussionGiven the proven overtesting in the audit, guidelines are to be reiterated to clinical staff. It is hoped that this would translate to costs savings on an overstretched service pathology budget.

P140 A need to reinforce the importance of pregnancy testing and correct antibiotic regimen: a re-audit of pid management against bashh guidelines

IntroductionBASHH guidelines (2011) for the management of pelvic inflammatory disease (PID) recommend one of two antibiotic regimens for outpatient treatment. In addition, patients should be offered a pregnancy test and full screening for sexually transmitted infections (STI).Aim(s)/objectivesTo review PID management across the sexual health clinics, comparing it to the previous year’s audit and BASHH guidelines.MethodsData was retrospectively collected from December 2015 until March 2016. Data collected included whether pregnancy was excluded, STI screening, antibiotic regimen used, provision of written information, partner notification, and outcome at any follow up.Results51 patients were identified, 2 were excluded due to treatment by their GP. 100% of cases had at least one sign or symptom suggestive of PID. 47/49 (96%) of cases had STI screening; 41/49 (84%) had a HIV screen as part of this. Pregnancy was excluded in 22/49 (45%) of cases. A BASHH recommended antibiotic regimen was used in 28/49 (57%) of cases. Of the 21 of non-compliant cases, only 4/21 had a documented allergy or intolerance that precluded standard treatment.DiscussionSince the last audit, recommended antibiotic treatment for PID has improved, but remains low at 57%. Pregnancy exclusion was low at 45%, compared with 70% at the last audit. Differences in how healthcare professionals record information on the electronic system could partially account for this. Actions have been taken to improve treatment and pregnancy testing by giving individual feedback to the clinicians, with a re-audit planned to assess the outcome of these interventions.

P241 Where there’s tea, there’s hope! – experience of green tea extract for treatment of genital warts

IntroductionCatephen® 10% ointment is novel extract from green tea which is licenced for genital wart treatment and included in BASHH guidelines (2015). Recommended application is 3 times daily for 16 weeks. We present real life data of Catephen® experience.MethodsReview of patients treated with Catephen® and adjuvant cryotherapy between August 2016 – February 2017. Clinical outcomes and tolerability data were collected.Results33 patients identified, median age 26 years (32 male, 1 female). 2 HIV positive. Affected site; penis 23/33, perianal 7/33, both 2/33 and vulva 1/33. All cases were recurrences. 6 patients excluded as lost to follow-up. To date 17/28 have completed 16-week course Catephen® or achieved full clearance prior to this. Outcomes are still awaited for 2/27 patients and 8/27 discontinued treatment early. Of the 17 who have completed treatment, 11(65%) had total clearance and 6(35%) partial clearance. Mean time to clearance was 8 weeks with penile warts appearing to respond better than perianal. Catephen® was well tolerated with 43% stating they had fewer side effects than with previous treatments. Overall discontinuation rate was 8/27 (30%) with 1 report of vulval pain, 1 report of stained clothing and 6 reporting unsatisfactory response (mean duration of Catephen® use 6.5 weeks). An additional 3 patients reported skin discomfort but continued treatment.DiscussionCatephen® ointment appears well tolerated with satisfactory clearance rates. It appears to be an acceptable alternative to other topical treatments for genital warts. To date there is no trial data on continued use after 16 weeks.

P069 Post exposure prophylaxis after sexual exposure: management in ed and gum

IntroductionPost-exposure prophylaxis following sexual exposure (PEPSE) is a method of preventing HIV infection. 2015 BASHH guidelines identify criteria for when PEPSE should and could be offered. Our aim was to...

P197 An interpretative phenomenological analysis to explore the experiences of patients after speaking with a health adviser about partner notification

IntroductionPartner notification (PN) is pivotal in controlling spread of sexually transmitted infections (STI) by reducing onward transmission and preventing reinfection. We explored the experiences of patients undergoing PN after being...

O12 LGV testing: are we identifying all cases in a timely manner?

IntroductionBASHH recommends Lymphogranuloma venereum (LGV) testing of Chlamydia trachomatis (CT)-positive specimens from men who have sex with men (MSM) presenting with proctitis, and all rectal CT from HIV-positive MSM. Until...

P029 Auditing gonorrhoea treatment and antibiotic sensitivity

IntroductionWith diagnoses of Gonorrhoea on the rise and increased rates of resistance being reported, nurses carried out and audit to establish the level of compliance with current British Association of Sexual Health and HIV guidelines in relation to the treatment of patients diagnosed with GC and to analyse antibiotic sensitivity.MethodsRetrospective case note review of episodes coded B was carried out looking at age, ethnicity, sexual orientation, co-infections, treatment, resistance, number of partners in past 3 months, test of cures and follow up serology.Results69 cases reviewed, 33 MSM, 32 heterosexual, 4 bisexual. 10 patients were known HIV positive, 12 patients had 1 other co-infection, 4 had 2 other co-infections.66 (96%) treated with first therapy of Ceftriaxone 500mg IM/Azithromycin 1G, 19 of these were also given Doxycycline 100mg twice daily for 1 week. 2 (3%) treated with Ceftriaxone 500mg IM/Doxycycline 500mg twice daily for 1 week. 45 (65%) fully sensitive to recommended antibiotics 13 (19%) reduced sensitivity to 1 antibiotic group 8 (11%) reduced sensitivity to 2 antibiotic groups. 4 (5%) reduced sensitivity to 3 antibiotic groups Our 5 cases of high level Azithromycin resistance were included. No cultures were resistant to CeftriaxoneDiscussionTreatment and management was in line with BASHH guidelines, it also highlights the developing problem with resistant infection, the importance of monitoring antibiotic sensitivity and effective partner notification in the effort to treat the infection adequately and reduce risk of transmission.

P169 Gonorrhoea culture audit in a community setting

IntroductionGonorrhoea (GC) accounted for 10% of all STI diagnoses in 2015. Diagnoses increased by 11% from 2014 to 2015, continuing an established trend beginning in 2012. BASHH guidelines recommend that...

P208 In an era of antibmicrobial stewardship is epidemiological treatment for syphilis still justified?

IntroductionThe BASHH guidelines for syphilis recommend the offer of epidemiological treatment or re-screening at 12 weeks (12w) after exposure for asymptomatic sexual contacts. We reviewed local practice and compliance with...

P026 Neisseria gonorrhoeae (GC): changing pattern of antibiotic sensitivity and persistence of DNA detection 2007 – 2016

IntroductionNucleic acid amplification testing (NAAT) is used in GUM clinics to diagnose GC infection; however its in-built sensitivity potentially detects DNA from non-viable organisms following successful treatment. BASHH guidelines stipulate that test of cure with NAAT (TOC) should take place 2 weeks post-treatment.This study aims to determine whether this is an adequate time interval to perform TOC. We also analysed the changing pattern of antibiotic sensitivity between 2007 – 2016.MethodsAll GC cases at our clinic between 01/01 and 30/06 in 2007–2016 were identified, assessed for antibiotic sensitivity and analysed for TOC data from 2013–2016.ResultsOf 131 cases in 2016, culture and sensitivities were available for 80, with TOC in 63.Abstract P026 Table 1Susceptibility to Antibiotic groups2007 (%)2009 (%)2011 (%)2012 (%)2013 (%)2014 (%)2015 (%)2016 (%)Fully sensitive to antibiotic testing panel4667594979594355Reduced susceptibility to 12715203810202323Reduced susceptibility to 215101686132115Reduced susceptibility to 3122532856Reduced susceptibility to 41TOC was performed between 6 and 77 days post-treatment with mean, median and mode of 18, 14 and 14 days respectively.DiscussionNo cultures were resistant to ceftriaxone. This is the first year a case has shown reduced susceptibility to 4 antibiotic groups. From 2015-2016 there has been an increase in GC fully sensitive to the antibiotic testing panel.Our data supports BASSH guidelines for TOC 2 weeks post-treatment.

P056 Providing written information in the electronic era – is it time for a re-think?

IntroductionRecent BASHH guidelines state that patients should be directed to clear, accurate written or web-based information and this is often an auditable outcome. We stopped providing paper leaflets in 2016...

P248 Genital warts and treatment options: clinical audit

IntroductionGenital warts are a common presenting condition in sexual health clinics. There are different treatment options available within BASHH guidelines depending on the size and location of warts. Home treatment reduces follow up clinic attendance.MethodWe randomly selected 30 patients attending our integrated sexual health service with new genital warts and audited their management against local guidance that home treatment with Imiquimod should be used first line for 4 weeks, unless contraindicated.ResultsOf the 30 patients, 18 were male and 12 were female. 14/30 were prescribed Imiquimod only. 7 patients had Cryotherapy only and 9 were also given cryotherapy before Imiquimod. 9/11 who received cryotherapy requested this treatment. 6/11 had documented reasons why it was deemed appropriate to have cryotherapy (unable to apply cream themselves, site of lesion). Interestingly, all 9/9(100%) who had received combination treatment reported clinical resolution within 4 weeks. 6/7(86%) who had cryotherapy only clinically resolved after 3 consecutive applications. 11/14(79%) treated with Imiquimod only resolved within 4 weeks, one deferred. 11/19(58%) treated with Imiquimod experienced side effects and five patients (5/11) sought medical advice. There were no reported complications following cryotherapy application.DiscussionDespite imiquimod being the recommended first line initial treatment for genital warts in our service, some patients received cryotherapy treatment in isolation or a combination of imiquimod and cryotherapy. The patients receiving cryotherapy were likely to have requested this treatment and had less side effects. All patients who received imiquimod and cryotherapy had resolution of genital warts in four weeks.

P147 An audit into the optimum time for neisseria gonorrhoeae test of cure following treatment in sexual health centres

IntroductionNeisseria gonorrhoeaeis the second most common bacterial sexually transmitted infection worldwide and has evolved resistance to several antibiotic classes. BASHH Guidelines 2011 currently recommend ceftriaxone 500mg IM plus azithromycin 1g stat as first line treatment and also recommend a test of cure (TOC) at 14 days. In our centre the time period between treatment and TOC was reduced to 14 days in July 2016. Anecdotal evidence suggests that this may be producing a higher false positive rate.MethodsClinical notes for all positive gonorrhoea tests (pharyngeal, rectal, urethral, cervical) in a 3-month period were reviewed. Positive TOC were identified and reasons for these assessed (reinfection, treatment failure, false positive). Cycle threshold (CT) values were used to help identify false positives.Results7.5% of TOC results performed at 14 days were likely false positive (no risk of reinfection or treatment failure, high CT values), compared with 2.7% of TOC performed after 14 days. 8.3% of pharyngeal samples and 12.5% of urinary samples were false positive. There were no false positives found for rectal and vulvovaginal samples.DiscussionThere is a significantly higher rate of false positives when a TOC is performed at 14 days and they are more prevalent in pharyngeal and urinary samples. This has a negative impact on both patient and health care provider time and can lead to unnecessary retreatment. Potential interventions could be to extend the TOC time period, include CT values for all TOC results or move to a less sensitive NAAT for TOC.

An evaluation study of the Becton-Dickinson ProbeTec Qx (BDQx) Trichomonas vaginalis trichomoniasis molecular diagnostic test in two large, urban STD services

ObjectivesThe BASHH guidelines recommend molecular tests to aid diagnosis of Trichomonas vaginalis (TV) infection; however many clinics continue to use relatively insensitive techniques (pH, wet-prep microscopy (WPM) and culture). Our...

P230 Review of syphilis management at a busy urban STI clinic

Background/introduction Appropriate management of syphilis is vital in order to avoid late complications. A retrospective cohort study of patients with positive serology at an urban STI clinic where the BASHH guidelines are followed was undertaken. Aim(s)/objectives Evaluate: Documentation of syphilis stage , Treatment , Interval between treatment and first follow-up RPR , RPR 12 months post treatment - determine those with negative RPR; fourfold reduction in RPR or documented as “serofast”. Methods A list of positive serology between April 2013 and March 2014 was generated. Patients managed at clinic were identified and their electronic record reviewed. Descriptive column statistics were used for data analysis. Results 93 cases of syphilis were managed. Median age 35 years (range 20–74); 82 (88%) cases male; 47 (51%) HIV positive. Stage was documented in 45 (48%). Of those with undocumented stage, RPR >/=1:8 in 29, 25 were treated with single benzathine-penicillin. 85 received penicillin- based treatment, 48 (52%) received single dose benzathine penicillin. 8 received doxycycline. Median interval from treatment to subsequent RPR 40 days (range14- 219). 12 months post treatment, 48 (52%) had negative or “neat” RPR. 58 (62%) a fourfold reduction. In those with a positive RPR, 4 were deemed to be “serofast”. Discussion/conclusion Syphilis continues to be a common infection in men. The majority of patients were treated with penicillin as per BASHH guidelines. There is room for improvement in documenting stage of infection and outcome in those who fail to have a fourfold reduction in RPR at 12 months.

P094 Chlamydia trachomatis(CT) positivity rate at 2 weekNeisseria gonorrhoeae(NG) test of cure (TOC)

Background/introduction Whilst guidelines recommend NG TOC 2 weeks after treatment, there is little data on the optimum time to perform a TOC for CT in those for whom this is indicated. Current BASHH guidelines recommend deferring TOC for at least 3 weeks after treatment because residual chlamydial DNA may persist. Aim(s)/objectives Patients who are treated for NG and CT co-infection re-attending for subsequent NG TOC are tested for both infections by NAAT providing the opportunity to evaluate the CT positivity rate at re-attendance. Methods A retrospective case review of co-infected GC/CT positive (analysed with Cepheid GeneXpert) patients tested in a’London sexual health clinic over 12 consecutive months was’performed. TOC details were evaluated, and appropriate antibiotic treatment according to BASHH guidelines was assessed. Results 480 patients tested positive for both infections and 132 attended for TOC within 21 days of treatment (median 15 days, IQR 14–17). Of these 131 were male, of whom 126 MSM; median age was 35 y and median number of sexual partners in previous 3 months was 5. Site of CT infection was rectal (94), urethral (49), throat (11), vulvovaginal (1). At TOC, 6 (4.5%) had a persistent positive CT NAAT: rectum (3), urethra (3). One patient with persistent rectal CT had received treatment with azithromycin; the other 5 received BASHH preferred treatment. By comparison, 3 (2.3%) had a positive NG NAAT at TOC. Discussion CT positivity 15 days after treatment is low, suggesting that TOC at 2 weeks may be a possible management strategy.

P161 Managing Sexual assault in an integrated Sexual health service: ensuring quality and pathways into care

<h3>Background/introduction</h3> Reported sexual assaults have increased in England &amp; Wales since operation Yewtree. Sexual health services are ideally placed to manage and support victims of sexual assault. Clear patient pathways underpin the quality of care victims of sexual assault receive. <h3>Aim(s)/objectives</h3> To assess our outcomes against the 2011 BASHH guidelines on the management of complainants of sexual assault. <h3>Methods</h3> We undertook a case note review of all SA attendances to the CNC between August 2014 and July 2015 <h3>Results</h3> 114 sexual assault patients were seen, 87% (99/114) were female, the median age was 23 years (13–66) and 96% (110/114) were white British or white other. 41% (47/114) were referred by the Sexual Assault Referral Centre (SARC), 49% (56/114) self-referred. 24% (27/114) reported being assaulted in an outside area, 16% (18/114) at a public venue and 20% (23/114) at the accused’s home. 35% (40/114) attended within 72 hours of the assault, 22% (2/114) within 7 days, 17% (19/114) within 2 weeks, 21% (24/114) within 3 months and 4% (5/114) within a year. 99% (43/44) were appropriately assessed for PEPSE, 89% (64/72) were offered prophylactic antibiotics, 50/51 (99%) of women were assessed for emergency contraception. 63% (72/114) reported the assault to the police, 37% (9/28) who didn’t report were offered third Party Reporting. STI infection rate was 6/114 (5%). <h3>Discussion/conclusion</h3> Our results suggest that our current management is in keeping with BASHH guidelines and that local referral pathways support patient care.

P112 X factor makeover for 4thyear medical student lectures

Background/introduction Traditionally Year 4 Medical students at Bristol University receive 4 hours of didactic lecture based teaching on sexual health topics. Overall, the feedback is satisfactory but student evaluations consistently denounce the volume of information contained in the lectures. Aim(s)/objectives To support learner diversity and increase student participation, we decided to revamp the delivery of the sexual health curriculum. Methods We made the lectures available on the student intranet for background reading and signposted the students towards additional sources of information such as BASHH guidelines. During a study day, 60 students in groups of 5 or 6 were asked to teach their peers using case studies on topics such as vaginal discharge, genital ulcers and sexual assault. Teaching methods included game shows, a rap about syphilis and role-play. There were prizes for the top three presentations (through peer grading) and a prize for the most innovative. A questionnaire, and open discussion were used to obtain feedback on both the old and new teaching formats. Results Overwhelmingly the students preferred and gained more from the student led case based presentations. They felt more engaged and would recommend it for future groups. Some students felt it was also important to have an opportunity to ask questions about the online lectures in future. Discussion/conclusion Through this alternative approach to learning new information, we have catered for different learning styles and created a positive learning environment. Peer teaching can be very effective in encouraging critical thinking and producing deeper learning outcomes.

P167 Managing rectal GC : room for improvement

Background/introduction Most (~60%) rectal gonorrhoea (GC) occur in MSM with 25% symptomatic at presentation. Those with rectal GC are at increased risk of other STIs. BASHH provide guidelines on GC management and targets to be achieved in testing, treatment and partner notification. Aim(s)/objectives To compare our clinic’s performance in managing rectal GC compared to the national recommendations. Methods Retrospective case-note review of confirmed cases of rectal GC on NAAT between 1 st November 2011 and 31 st March 2015. Data were obtained from clinic notes, the clinic database and laboratory results. Audit standards were based on BASHH guidelines in managing GC. Results 184 cases from 156 men: 61% White, 12% Black, median age 31 (IQR 26,37) years, 71% MSM 29% bisexual, 58% symptomatic. Triple site testing was done in 91%. Rectal GC cultures were taken in 55%. Adequate treatment was given to 94%. Quinolone resistance occurred in 31%. Partner notification was done in 43%. 14% had other STIs (syphilis, LGV, chlamydia and HSV). There were 2 new diagnoses of HIV at the time of GC diagnosis, and 2 further cases at 3 months follow-up. Discussion/conclusion Management of rectal GC did not reach the BASHH targets on any recommendation, suggesting that improvements in managing rectal GC are needed within our clinic. Re-testing and re-attendance were poor. Staff has received further training and a re-audit in 2017 will assess improvement. We have established a robust call/recall system to enable early diagnosis of HIV which was significant in our cohort of men with rectal GC.