03
September
2021
|
11:05 AM
America/New_York

414 - Flu Vaccine Contraindications/Precautions, STI Treatment Guidelines

Take 3 – Practical Practice Pointers©

From the Centers for Disease Control and Prevention

1) Certifying Contraindications for Influenza Vaccination

Immunizations are a foundation of modern public health and prevention and are an essential component of primary care. Because of our close, long-term relationships with our patients, we can be the best advocates for the value of vaccinations in this time of science denial and vaccine hesitancy. When our patients ask us to certify an adverse reaction to a vaccination, we sometimes feel caught between our desire to give the best medical advice and our desire to accommodate our patients. Compounding this difficulty are both frequently incomplete information about our patients’ medical histories and changing recommendations about what constitute contraindications and precautions.

The CDC defines contraindications and precautions for vaccinations clearly:

  • A contraindication is: “a health condition in the recipient that increases the likelihood of a serious adverse reaction to a vaccine.”
  • A precaution is: “a health condition in the recipient that might increase the chance or severity of a serious adverse reaction, might compromise the ability of the vaccine to produce immunity (such as administering measles vaccine to a person with passive immunity to measles from a blood transfusion), or might cause diagnostic confusion.”

Both contraindications and precautions can be temporary – as in the case of certain immunosuppressive therapies or pregnancy. When there is a true contraindication to a vaccine, that certification is straightforward. In contrast, precautions require us to evaluate the patient’s medical issues, perhaps educate the patient about the risks, and perhaps recommend a medical setting capable of addressing severe allergic reactions and anaphylaxis (a physician’s office with epinephrine and basic life support equipment or a hospital clinic).

During influenza season, it’s important for us to help our patients understand what constitute contraindications and precautions to influenza vaccine.

To review the types of influenza vaccine:

  • IIV – inactivated influenza vaccine, typically egg-based
  • ccIIV – inactivated influenza vaccine, not egg-based (Flucelvax)
  • RIV – recombinant influenza vaccine, not egg-based (Flublok)
  • LAIV – live, attenuated influenza vaccine, not egg-based

Influenza vaccine contraindications:

  • History of a severe allergic reaction to any component of the vaccine being considered. (Can include gelatin, antibiotics, etc., but see egg allergy info below)
  • History of a severe allergic reaction to a flu vaccine is a contraindication to that specific vaccine and to LAIV, but a precaution for other types. If one of these other flu vaccine types is considered, it should be administered in a medical setting. Working with an allergist might help define the allergy more specifically.

Influenza vaccine precautions:

  • Moderate to severe illness with or without fever (temporary precaution).
  • History of Guillain-Barre syndrome after influenza vaccination.
  • History of a severe allergic reaction to a different type of flu vaccine. If one of the other flu vaccine types is considered (not LAIV), it should be administered in a medical setting. Consider allergy consultation.

Egg Allergy:

  • Most brands of flu vaccines are egg based, except for: RIV4, ccIIV4 and LAIV.
  • Patients who have experienced only urticaria with egg exposure should get any flu vaccine.
  • Patients with other reactions (lightheadedness, dizziness, anaphylaxis) should get either RIV4 or ccIIV4; if the egg-based vaccines are used, the vaccine should be administered in a medical setting that can address severe allergic reactions.

Live Attenuated Influenza Vaccine (LAIV):

  • Contraindications:
    • Outside the age range (age range is 2-50 years)
    • Severe allergy to any component of LAIV
    • Severe allergy to ANY previous influenza vaccine
    • Therapy with aspirin or salicylates
    • Immunocompromised (by diseases or medications)
    • Close contacts of immunocompromised individuals
    • Pregnancy
    • Asthma or history of wheezing in 2- to 4-year-olds
    • Cerebrospinal fluid leaks
    • Cochlear implants
    • Recent antiviral drug use (because the vaccine will not work)
  • Precautions
    • Asthma in patients 5 years and older
    • Underlying medical conditions that would be worsened by influenza
    • Moderate to severe illness with or without fever (temporary precaution)
    • History of Guillain-Barre syndrome after influenza vaccination.

John’s Comments: Provider certification is an important part of protecting our patients’ health, and clear and accurate communication to employers and other entities is essential. It is important to take the time to educate our patients about contraindications and precautions for any vaccines so that we can achieve the highest rates possible for this valuable preventive service.

References:

  • Pinkbook | General Recommendations | Epidemiology of VPDs | CDC [Internet]. 2021 [cited 2021 Aug 30]. Link
  • CDC. Who Should and Who Should NOT Get Vaccinated [Internet]. Centers for Disease Control and Prevention. 2021 [cited 2021 Aug 30]. Link
  • Grohskopf LA. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices, United States, 2021–22 Influenza Season. MMWR Recomm Rep [Internet]. 2021 [cited 2021 Aug 30];70. Link

 

From the CDC and not about COVID

2) Updated Sexually Transmitted Infections Treatment Guidelines

The term “sexually transmitted infection” (STI) refers to a pathogen that causes infection through sexual contact, whereas the term “sexually transmitted disease” (STD) refers to a recognizable disease state that has developed from an infection. Physicians and other health care providers have a crucial role in preventing and treating STIs and this is particularly pertinent given that a CDC sexually transmitted disease surveillance report released in April found that in 2019, the last year for which data were available, the overall number of reported cases of STIs increased for the sixth consecutive year.

Prevention and control of STIs are based on the following five major strategies:

  • Accurate risk assessment and education and counseling of persons at risk regarding ways to avoid STIs through changes in behaviors and use of prevention services
  • Pre-exposure vaccination for vaccine-preventable STIs
  • Identification of persons with an asymptomatic infection and persons with symptoms associated with an STI
  • Effective diagnosis, treatment, counseling, and follow-up of persons who are infected with an STI
  • Evaluation, treatment, and counseling of sex partners of persons who are infected with an STI

The CDC recently updated the 2015 guidelines for the diagnosis and treatment of STIs. Some treatment recommendations for some of the more common infections include:

Neisseria Gonorrhea: For uncomplicated GC infections of the cervix, urethra, rectum, or pharynx:

  • Ceftriaxone 500 mg IM x 1 weight <300 lb (150 kg)
  • Ceftriaxone 1 gm IM x 1 weight ≥300 lb (150 kg) (300 lb)
  • If chlamydia has not been excluded, treat with doxycycline 100 mg orally twice daily for 7 days. Don’t treat empirically – test and if negative, don’t’ treat.
  • During pregnancy, azithromycin 1 gm x 1 recommended to treat chlamydia.

 NOTE:

  • If ceftriaxone not available, gentamicin 240 mg IM as a single dose PLUS azithromycin 2 g orally as a single dose OR cefixime 800 mg orally as a single dose.

Chlamydia trachomatis

  • Doxycycline: 100 mg PO BID for 7 days
  • Alternative regimens: Azithromycin 1 g PO in a single dose OR levofloxacin 500 mg PO once daily for 7 days

Trichomonas vaginalis

  • Women: Metronidazole 500 mg PO BID for 7 days
  • Men: Metronidazole 2 g PO in a single dose
  • Alternative regimen for women and men: Tinidazole 2 g PO in a single dose

Bacterial Vaginosis:

  • Metronidazole at 500 mg PO BID for 7 days OR
  • Metronidazole gel 0.75% one full applicator (5 g) intravaginally once daily for 5 days OR
  • Clindamycin cream 2% one full applicator (5 g) intravaginally at bedtime for 7 days

Alternative treatment regimens for bacterial vaginosis are as follows:

  • Clindamycin at 300 mg PO BID for 7 days OR
  • Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days (oleaginous base used in ovules may weaken rubber or latex products [eg, condoms, diaphragms]; using such products ≤72 hours after treatment with clindamycin ovules not recommended) OR
  • Secnidazole 2 g oral granules in a single dose OR
  • Tinidazole at 2 g PO once daily for 2 days OR
  • Tinidazole at 1 g PO once daily for 5 days

Pelvic Inflammatory Disease

The recommended intramuscular or oral regimens for PID:

  • Ceftriaxone at 500 mg IM in a single dose (for persons weighing ≥150 kg, administer 1 g of ceftriaxone) PLUS
  • Doxycycline at 100 mg PO BID for 14 days with metronidazole at 500 mg PO BID for 14 days

OR

  • Cefoxitin at 2 g IM in a single dose and probenecid at 1 g PO administered concurrently in a single dose PLUS
  • Doxycycline at 100 mg PO BID for 14 days with metronidazole at 500 mg PO BID for 14 days

OR

  • Other parenteral third-generation cephalosporin (eg, ceftizoxime, cefotaxime) PLUS
  • Doxycycline at 100 mg PO BID for 14 days with metronidazole at 500 mg PO BID for 14 days

Mark’s Comments:

This guideline is a very comprehensive reference that includes many nuances regarding the diagnosis and treatment of STIs. Note that oral azithromycin is no longer recommended for GC infections. One potential practice-changer for me is the option to use of tinidazole as a single dose for the treatment of trichomoniasis or 2-day regimen for BV, particularly in populations where medication adherence is a challenge.

Reference:

Workowski KA et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70(4):1-187. Link

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Mark and John

Carilion Clinic Department of Family and Community Medicine

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Email: mhgreenawald@carilionclinic.org