Clinical Education Initiative ADOLESCENTS AND STDS: CASE STUDIES. Tara Babu, MD

Transcription

1 Clinical Education Initiative ADOLESCENTS AND STDS: CASE STUDIES Tara Babu, MD 2/16/2017

2 Adolescents and STDs: Case Studies [video transcript] 00:00:08 - Hello, my name is Tia Babu and I'm an infectious diseases physician at the University of Rochester in Rochester, New York. I'm also faculty at the Monroe County STD Center of Excellence. Today I'm going to discuss Adolescents and STDs: Case Studies. 00:00:30 I have no financial disclosures and during my presentation I may mention some non FDA-approved diagnostic modalities or treatment alternatives that are described in the literature. 00:00:45 So let's get started. 15 to 24 year-olds make up only 25% of the sexually active population. However, they account for 50%, that's 50%, of the 20 million new cases of STD infections in the United States. 00:00:06 More than 60 communicable diseases are reported in New York State. This is a graph from the New York State Health Department which shows the communicable diseases in 2015, excluding New York City. In 2015, there were more than 102,000 cases of communicable diseases and STDs were 50% of those that were reported. The number one communicable disease reported in New York State is chlamydia, around 41,000 cases. Number two is lab-confirmed influenza and number three is gonorrhea at around 8,700 cases. 00:01:54 This slide shows the number of cases for each STD by age at diagnosis. This is data, again, from the New York State Health Department and New York State excluding New York City. The Y axis is the number of cases, the X axis is the age at diagnosis. What becomes immediately apparent for chlamydia and gonorrhea, chlamydia in pink and gonorrhea in purple, is the majority of infections are diagnosed at 15 to 25 years old, as you can see in the peaks here for chlamydia and for gonorrhea. Syphilis is blown up on the right due to the lower number of cases for syphilis in New York State. For syphilis, you can see there is a more diffuse distribution, but the highest number of cases are a little bit older than gonorrhea and chlamydia, at a peak age of 25 to 29 years old. 00:02:58 This slide is also from the New York State Health Department and it shows the distribution of chlamydia and gonorrhea among young adults aged 15 to 24 years of age, excluding New York City in New York State. The blue are gonorrhea cases, the yellow is chlamydia. You can see that there is definitely a cluster in the urban areas, for instance, Buffalo, Rochester, Syracuse, however you can see that there is also a dispersion of cases in areas that are not surrounded around urban clusters, particularly for chlamydia. 1

3 00:03:40 GC rates continue to increase. This graph is from New York state from 1992 to The blue represents males and the red represents females. And you can see that we haven't reached the highest point, which was prior to the 1990s, however there is an increase in gonorrhea cases and it is particularly in men, especially in men who have sex with men. 00:04:16 Now that we're reviewed the epidemiology of sexually transmitted diseases in adolescents, I thought it would be important to look at the scope of sexual activity. The National Youth Risk Behavioral Survey is conducted yearly and done by the CDC. And what it is is it's a survey that looks at different subject matter, so diet, exercise, violence. There is a category though for sexual behaviors related to unintended pregnancies, STD acquisition, and HIV acquisition. Teenagers are surveyed across the country who are in high school, their grades nine through 12. And they are asked several questions about their sexual activity. Over 15,000 surveys were collected and data was analyzed. 41% of ninth through 12 th graders stated that they have had sexual intercourse throughout their lifetime. 4% have had sex before the age of 13 years old. 12% had four or more partners ever. 30% had sex with one or more persons within the three months of taking the survey. Only 43% did not use a condom during their last sexual intercourse, however 10% of them had ever been tested for HIV. 00:05:56 This graph shows the percentage of high school students who used condoms during their last sexual encounter. It's divided by the total, their gender, male or female, their grade, ninth through 12th grade, and then their race, black, Hispanic, or white. And you can see overall the percentages around the same. Around, I'd say, 50% to 63%. So 50 to 63% overall used condoms during their last sexual intercourse. 00:06:35 This graph shows the percentage of high school students who were ever tested for HIV. Again, the total males and females, their grades, ninth through 12th grade, and their race, black, Hispanic, or white, and the Y axis is the percentage who have been tested. You can see the percentage is very low. It's anywhere from 7% here to 16% with the total being 10%. So 10% of these students were ever tested for HIV. 00:07:13 So now that we've reviewed some of the scope of sexual activity for high school students, I thought we should also look at college students, as they are also included in the category of adolescents. This is the National College Health Assessment survey. And again, many institutions, academic institutions across the country, universities are surveyed. Around 20,000 students were surveyed for this survey and it is from the last fall semester of So this first graph looks at the number of college students who reported having sexual partners over the past 12 months. And that includes oral sex, vaginal sex, and anal sex. So you can see here that 35% of males reported having no sexual partners within the last 12 months and 32% of females. On average when you look at it, the most males had one partner over the past 12 months. And most females at 46% had one partner over the past 12 months. I would draw your attention, though, to four or more partners within the last 12 months. 10% of males actually reported 2

4 having four or more partners within the 12 months and 7% of females had four or more partners. When they calculated the mean, the mean males had 2.5 partners within the last 12 months and the mean females had 1.8 partners over the past 12 months. 00:09:07 When asked what type of intercourse they were having, I would draw attention to the last two columns of each group, the middle column and the last column. This really shows who has had oral sex ever in their time. The middle column is had it, but not in the last 30 days and then the last column is they've had this type of intercourse within the last 30 days. So when asked about oral sex, 69% of males have had oral sex within their lifetime and 67% of females have had oral sex within their lifetime. In terms of vaginal sex, 61% of males have had vaginal sex within their lifetime, and 65% of females have had vaginal sex within their lifetime. In regards to anal sex, 27% of males have had anal sex within their lifetime and 21% of females have had anal sex within their lifetime in this college survey. And this will get important and we'll talk about this in terms of what screening you want to do for adolescents for STDs and especially extragenital testing. 00:10:29 So you may be wondering, well if they're having these different types of sex, what is condom use like? And this was done asking these students what condom use they had within the last 30 days. So for men only 5% were using condoms when they had oral sex within the last 30 days. And females, 5%. So there is a huge gap in how many students are using condoms when they are having oral sex. 50% for males and 46% for females in terms of vaginal intercourse, and lower percentages for anal intercourse. 36% used condoms in the last 30 days for anal intercourse and 21% of females. 00:11:21 So now that we've gotten an idea of the scope of sexual activity of both high school students and college students, I thought we would talk about what the CDC defines as the populations that are at risk for sexually transmitted diseases. So according to the CDC, all sexually active persons, specifically who are adolescents or men who have sex with men, who are residents in correctional facilities, women who have sex with women, and also pregnant women. 00:11:54 So typically what are some of the risk factors for adolescents and STDs? Persons who initiate sex early in adolescence. 25% of those diagnosed with STDs are within one year of their first intercourse. So within their first year of intercourse they are at high risk for being diagnosed with an STD. Adolescents in detention centers, IV drug users, adolescents attending STD clinics, and young men who have sex with men. 00:12:30 Other risk factors for adolescents and STDs include multiple sexual partners concurrently, at the same time, sequential partnerships that are of a limited duration, or short duration in time, failing to use barrier protection during sexual intercourse, and there is thought that adolescents have an increased 3

5 biological susceptibility to infection. Cervical ectopy, which I'll talk about in the next slide, and also there has been some literature to suggest that adolescents potentially may have less, specifically adolescent women may have less IgA at the genital site, immunoglobulin to protect from contracting an STD. And there are also obstacles to accessing health care for adolescents. 00:13:30 This is a slide of cervical ectopy, as I mentioned in the slide previously, and what that is is that basically the cells within the cervix and the uterine wall protrude through the os of the cervix and could make an adolescent female more susceptible to sexually transmitted disease. 00:13:57 I mentioned that there are obstacles for adolescents to accessing healthcare and this is a great slide, I think, to really delineate some of those issues and how to make your clinic a more adolescent-friendly clinic and it was shared by the New York City PTC. So things like having teen friendly hours, but I think the theme of this slide is confidentiality and privacy. So potentially having information in the waiting room on confidentiality and to explain there will be confidential reporting and also to establish a reliable contact in order to get results. Another one is to triage in private so that the teenager or the adolescent may feel save divulging private information. Also, having an office policy that there would be time without a parent present to address issues about sexual health and also things like substance abuse. It's also important to normalize STD screening as part of a regular health visit. And one other thing might be to have some teen-friendly informational materials and magazines in the waiting room. 00:15:25 Now that we ve talked about the epidemiology, we ve talked about risk factors for STDs, we've talked about social determinants and how to make a clinic more adolescent-friendly, I think I'd like to spend the rest of this presentation just going over clinical cases and trying to highlight some of the issues with adolescents. The first two cases are just going to be more about screening and the screening guidelines for adolescents and STDs. 00:16:01 The first case is an 18 year-old who presents for his annual physical exam for sports to a regular community practice. His documentation is reviewed, his lab work is performed, he has an exam, and his documentation is completed. And he is given a clean bill of health. 00:16:24 However, what was missed? 00:16:31 Well, given that this is an STD talk I'm going to just briefly talk about the five P s on the CDC recommendation for how to take a sexual history. 4

6 00:16:46 The first P is partners. So you want to ask your patient the number of partners they've had and you want to also do it within one, three months, a year, ever with adolescents because depending on when they've had partners they may divulge a certain number. You also may need to define, specifically for adolescents, what you mean by partners. You also want to ask the concurrency of partners, and you also want to ask if you know who are their partners having sexual intercourse with? Are their sexual intercourse partners having sex with men? With females? Are their partners substance abusers? Are their partners having multiple partners concurrently, as well? 00:17:40 The second P is practices. You want to ask what type of practices they're engaging in. Like we talked about previously, are they having oral sex? Are they having insertive oral? Receptive oral? Are they having anal sex? Are they having insertive anal sex? Receptive anal sex? And you might need to describe what insertive and receptive mean. Are they having vaginal sex? 00:18:10 Are they using protection from STDs? And not only are they just using protection, but when are they using protection? Are they using condoms with every partner? Are they using condoms in certain situations? What are the barriers to them not using condoms? Also, with adolescents you might want to ask how are they using condoms? Do they know how to appropriately use condoms? Do they know that there are expiration dates on condoms? 00:18:44 You want to ask have they had a history of STDs? Teenagers who have had a history of STDs are likely to get another infection within just a few months of having that infection. And you need to describe what STDs are, gonorrhea, chlamydia, genital warts, herpes, syphilis. 00:19:09 And what kind of pregnancy prevention? If it's a male who has sex with women you can ask them are their partners using anything for pregnancy prevention? And if you're seeing a female ask what she is doing for pregnancy prevention. 00:19:33 So when you ask our 18 year-old male who's just here for a regular screening about his sexual history, it turns out that he's had five male partners over the past year. He practices oral and anal intercourse and identifies himself as verse, which means that he engages in both insertive and receptive anal intercourse. He's not using condoms regularly. He's never been tested for a sexually transmitted disease, and actually this is the first time he's ever been asked his sexual history. 00:20:18 So, what are the guidelines for chlamydia and gonorrhea screening for adolescent males? For males chlamydia, the recommendation is, per the CDC, to consider screening young men who are in high 5

7 prevalence clinical settings or in populations with high burden of infection. That would include a correctional facility, an adolescent clinic, an STD clinic, or a patient who is men who engages in sexual activity with other men, so men who have sex with men. For gonorrhea there are currently no screening recommendations. 00:21:00 The screening recommendations for an MSM, or men who have sex with men, patient is at least annually for sexual activity for MSM at the sites of contact. So again, knowing whether they are engaging in oral and anal sex is important because you will screen them. You'll do a urethral screen, a rectal screen, and a pharyngeal screen, the pharyngeal screen just for gonorrhea, regardless of whether the patients states they're using condoms or not. The recommendation is to screen them annually, but if they are at increased risk, the screening recommendation is every three to six months. 00:21:42 The recommendation for screening for syphilis is in MSM at least annually for sexually active MSM and every three to six months if they are at an increased risk for HIV acquisition. 00:21:58 New York state law currently for HIV screening requires that an HIV-related test be offered to every individual aged 13 years and older who receives health services in any health setting. That includes hospitals, emergency rooms, hospital outpatient departments, and primary care settings. And I will, once again, refer back to that previous slide when the National Youth Behavioral Survey of the high school students, only 10% of them had been tested for HIV. Many of those students, if they had been in New York State, would qualify for this law of being offered an HIV test older than 13 years old. 00:22:43 In terms of confidentiality, New York state has no minimum age for minors to consent to HIV testing. For PrEP, the Pre-exposure Prophylaxis, adolescents can currently not consent for PrEP in New York state. 00:23:03 So for case one, the testing that we recommend doing is an HIV test, a syphilis screening, urine and rectal GC and chlamydia NAAT, and a pharyngeal GC NAAT testing. Of note, the extragenital testing of the rectum and the pharynx are not currently FDA approved, but can be validated by local labs and be done. 00:23:30 Case number two is another screening case and this time it's the female. A 21 year-old female presents for her annual physical exam to her primary care doctor. She has her lab work performed, she has her documentation completed and her physical exam done. Her sexual history is taken with her parents present and she denies being sexually active. 6

8 00:23:59 So what was missed here? 00:24:04 So, when her parent is asked to leave the room it turns out that she has had two male partners. She practices vaginal intercourse only, she does not use protection for STDs, she's never been tested for STDs and currently she is not using anything for pregnancy prevention. 00:24:29 The testing that would be performed here is a pregnancy test, based on her last menstrual period, a vaginal chlamydia and a gonorrhea NAAT testing, an HIV test, and a PAP smear. A wet prep can also be done to look for bacterial vaginosis and trichomonas. 00:24:50 In terms of consent, all states in the District of Columbia allow minors to consent for STI services. In New York State, minors may consent for contraception care and counseling, pregnancy tests and options counseling, STD testing and treatment, HIV testing, mental health and substance abuse counseling. 00:25:14 The guidelines for gonorrhea and chlamydia testing and screening in a non-pregnant female are to screen all sexually active females less than the age of 25 years annually. Those who are older than 25 years should be screened if they are at increased risk for STD acquisition. Also the recommendation is to repeat testing at three months post treatment. And that is for re-infection. 00:25:41 In pregnant women, the recommendation is to screen all pregnant women who are less than the age of 25 years for gonorrhea and chlamydia. Pregnant women older than 25 years who are at an increased risk for gonorrhea and chlamydia acquisition to repeat testing three months after the treatment for gonorrhea and chlamydia and to rescreen in the third trimester for chlamydia in women who are at increased risk. Also the recommendation is to do a test of cure for chlamydia three to four weeks after treatment if a pregnant woman is treated for chlamydia. 00:26:19 In terms of HIV screening, all women age 13 years and older should be offered an HIV test. All women who seek evaluation and treatment for STDs should be tested. In terms of pregnant women, all pregnant women should be screened at the first prenatal visit and they should be re-tested in the third trimester if they are at an increased risk for HIV acquisition. 7

9 00:26:46 So now I'm going to do some cases that are loosely based on cases that we may have seen at the STD clinic or asked to consult on from the community through our CEI hotline. And I have the hotline number at the end of my presentation. 00:27:06 So this is a 20 year-old who presented to our Monroe County STD clinic with yellow penile discharge for four days. His sexual history is that he prefers male partners and he engages in oral and anal sex. 00:27:26 So the testing he would receive at our STD clinic is he would receive an HIV test, he would undergo syphilis testing, a urethral gram stain would be performed, given that he has purulent discharge, a urine NAAT for gonorrhea and chlamydia would be done, a pharyngeal NAAT for gonorrhea, as he engages in oral intercourse, and a rectal NAAT for gonorrhea and chlamydia would be done as well. And again, the extragenital testing is not FDA approved, but can be done if a laboratory does local validation. 00:28:03 So the results from our studies were that he had a positive gram stain, he had greater than two PMNs on his gram stain and many intracellular gram negative diplococci. His urine NAAT also was positive for gonorrhea. 00:28:24 This patient had a diagnosis of gonorrhea urethritis. Just to discuss the diagnostic methods for gonorrhea, urethral smear, seen here is 95% sensitive to 99% specific in men. The gram stain would show gram negative intracellular diplococci, as seen here, for a neisseria gonorrhea. And it is an adequate diagnosis for men who are symptomatic. It's important to note that it is much less sensitive in men who are asymptomatic. The sensitivity decreases from 95% to 50%. Cervical smears are not a very good test in women. 50% of them are sensitive for gonorrhea, and it is also very subjective and observer dependent and not a widely used test. 00:29:24 In terms of the Nucleic Acid Amplification Tests, or the NAAT tests, there are several FDA approved NAAT platforms that detect both gonorrhea and chlamydia. The pros of these are that they're very sensitive. Sensitivity for the NAAT is greater than 95% and very specific, 99%. The organism does not even need to be alive in order to detect it. All FDA NAATs are approved for urine, male urethra specimens, cervix, and some for vaginal specimens. For throat and rectal, those have to be validated by individual labs for the extragenital testing. The cons of the NAAT, I think the biggest one would be that you cannot do antibiotic susceptibility testing. Particularly for gonorrhea where we know there is resistance, if you're concerned about resistance for gonorrhea, you need to do a culture so susceptibility testing can be done to antimicrobial therapy. Some of the other cons are due to the high sensitivity, 8

10 there has to be some caution with contamination, which can lead to false positive tests, and the NAAT testing is more expensive. 00:30:46 So back to our case, our patient did have gonorrhea urethritis. The incubation time for gonorrhea is thought to be anywhere from three to seven days. It can have asymptomatic infections in about 10% of men, typically they are symptomatic. Symptoms can include dysuria or the purulent or mucopurulent discharge you see in the pictures. Signs again, exam, are that yellow purulent discharge and the discharge may be mucoid or mucopurulent in about 10% of the cases. 00:31:20 Some of the gonorrhea syndromes that can be seen in men and women, one of them is anorectal infection. It's usually acquired by anal intercourse. And actually it's usually asymptomatic but there are a broad range of symptoms that patients can have from this infection. They can have anal irritation, they can have pain with defecation, constipation, there can be some bleeding, some scant rectal bleeding. There can be some discharge seen, patients can complain of tenesmus, and also anal pruritus, which is itching. Some of the signs on exam, the mucosa can look completely normal. There can be purulent discharge, erythema, redness, and also when you do that anoscopic exam, there can be, the mucosa can start easily bleeding on exam. 00:32:15 Another gonorrhea syndrome would be conjunctivitis. It s usually through autoinoculation. The patient actually inoculates their eye with an infection in, for instance, the genital area. The signs and symptoms can be eye irritation with this very frank purulent conjunctival exudate in their eye. Also, there can be disseminated gonorrhea. It's not that frequent, but it infrequently occurs, in more women than men. And the strain that's associated with disseminated gonorrhea is actually the one that causes blood stream infection without urogenital symptoms. The manifestations are broad for disseminated gonorrhea. Basically think of it as it can kind of go anywhere. It can cause arthritis, hepatitis, myocarditis, endocarditis, it can go to the brain and cause meningitis, and it can also cause skin lesions, and tenosynovitis. 00:33:18 And this slide here shows a tenosynovitis here. This is somebody's ankle. You can see some redness and inflammation here at the tendon. So this chart and diagram here just shows some of the areas of the musculoskeletal system that are affected by gonorrhea. 25% knee, hands and wrists. A lower percent can affect the elbows and the ankles and then more infrequently shoulder, feet, and 1% can affect the jaw. 00:34:01 And here is a picture by the CDC of gonorrhea of the skin. You can see the skin lesions here. 9

11 00:34:15 Although we've been talking about gonorrhea, I'm going to lump together gonorrhea and chlamydia. So extragenital gonorrhea and chlamydia infection, the CDC recommends pharyngeal and rectal, pharyngeal gonorrhea and rectal chlamydia and gonorrhea screenings for men who have sex with men and HIV positive persons at least annually and three to six months if they are at an increased risk for acquisition. Untreated pharyngeal gonorrhea is associated with transmission to male partners and also potentially acquisition of resistance because gonorrhea in the pharynx is more difficult to cure and that's why there's a recommendation to screen for pharyngeal gonorrhea in these patients. Untreated gonorrhea and chlamydia infection in the rectum is often asymptomatic, but less is really known about the transmission, and potentially it could be associated with an increase of HIV transmission and acquisition. 00:35:21 So the CDC recommendation from the 2015 guidelines published in the MMWR are ceftriaxone 250 milligrams IM times one dose intramuscularly plus azithromycin one gram orally times one dose. Ideally they should be dispensed at the same time. Doxycycline 100 milligrams twice a day times seven days is acceptable in place of azithromycin if the patient is allergic. However there are decreased compliance rates with doxycycline verses azithromycin given that seven day course of antibiotics. 00:36:00 An alternative treatment for uncomplicated GC infections is cefixime at 400 milligrams orally times one dose plus azithromycin one gram orally times one dose. Ideally, again, they should be dispensed at the same time. Doxycycline, again, is an acceptable regiment in place of azithromycin if they have an allergy, a true allergy to azithromycin. And then I did asterisk that there is a test of cure only for those who have pharyngeal gonorrhea that are not treated with the recommended regimen and the recommendation is to perform a test of cure at 14 days with either NAAT or culture. 00:36:41 There are some treatment issues with gonorrhea. We did mention the increased resistance of gonorrhea. So the reason that dual therapy is recommended is that it is thought that it may hinder the development of antimicrobial resistance. There are limited options in cephalosporin-allergic patients. The CDC does make some recommendations in their MMWR. Spectinomycin is no longer manufactured. Azithromycin monotherapy is no longer recommended and it stopped because of the resistance to azithromycin that is likely increasing and treatment failures have been seen with monotherapy with azithromycin. The CDC does suggest gentamicin 240 milligrams intramuscularly plus a higher does of Azithromycin, two grams time one does. Or gemifloxacin 320 milligrams orally plus the higher dose of azithromycin, again at two grams given at the same time. I can tell you that in our clinic we have used this recommendation of the gentamicin 240 milligrams intramuscularly plus Azithromycin two grams times one dose for patients who have a severe cephalosporin allergy. 10

12 00:38:03 This was published in the MMWR in 2016 and it's the Gonococcal Isolate Surveillance Project. Samples were looked at, isolates were looked at from 2000 to 2014 and what this really illustrates is the X-axis is years, the Y-axis is percentage of resistance, and you can see here that Tetracycline had the highest resistance from these isolates, around 25%. That group includes Doxycycline so Tetracycline is here. Here are Fluoroquinolones, and here are penicillins and I think overall the take home message here is that for all these drugs the resistance is increasing, and lower here is Azithromycin somewhere around, probably, 2.5%. 00:39:02 So, we'll go onto the next case, case number four. This is a 17 year-old female who presents with dyspareunia, pain with sex, and some vaginal discharge for about a week and comes to our STD clinic. She's had a regular partner for about two months now and over the past three months has had two partners. Over the past year she admits to having four partners. Her practices are that she engages in anal and vaginal intercourse. She also states during the history that her partner currently refuses to be tested for STDs and will not come to the STD clinic. 00:39:45 On exam you note that she has moderate amount of thin, white, homogenous vaginal discharge, but no cervical motion tenderness. This is the testing that's done for her and she has a gram stain of her cervix which shows greater than 30 PMN. No organism seen. She has a pregnancy test, which is negative. Her vaginal NAAT is positive for chlamydia, her vaginal is negative for gonorrhea. She has a rectal NAAT done for gonorrhea and chlamydia given her practices of anal intercourse, and they were negative for gonorrhea and chlamydia. Her HIV test was negative, her syphilis test, as she presented to a high prevalence setting for syphilis, our STD clinic, was negative, and her wet prep was negative for bacterial vaginosis and trichomonas. 00:40:37 She is diagnosed with chlamydia cervicitis. The incubation time for chlamydia is really not known. But greater than 80% are asymptomatic. The symptoms can be non-specific. They can be, as I said, asymptomatic, however some of the symptoms can be vaginal discharge or spotting or dyspareunia, like our patient who had pain with sexual intercourse. The signs can be very variable. As you know, can have a normal exam. 30 to 50% can present with cervicitis or endocervical discharge, you could see edematous cervix and you can see some friability of the cervix, as you can see in some of these pictures as well. 00:41:24 So I am going to discuss gonorrhea and chlamydia, even though this patient had chlamydia, but the morbidity in females of gonorrhea and chlamydia is significant. So untreated gonorrhea and chlamydia infection may result in an ascending infection and pelvic inflammatory disease, PID, in females. 15% of 11

13 untreated chlamydia can result in PID in women. Approximately 25% of women with a single episode of symptomatic PID will experience sequelae, including ectopic pregnancy, infertility, or chronic pelvic pain. The risk of ectopic pregnancy is increased six to 10 fold after an episode of PID. Tubal infertility occurs in 8% of women after one episode of PID, 20% of women after two episodes, and in 50% of women after three episodes. 00:42;27 So for our patient, she stated during the history that there was no way that her partner was going to come in to get screened and examined for an STD. So I think that this is a good place, specifically in adolescents, but in all patients, to talk about expedited partner therapy, or EPT. Really, what that is is it s delivery of antibiotic therapy by the index patient, either by giving them a prescription or actual medication. So in our patient, for instance, her partner won't come in and won't get screened, so you can actually provide her with a prescription or actual medication for her partner so that he gets treated because he won't actually see a provider for the chlamydia. So for male partners, it's important that if they come in and you give them EPT for their female partners, to inform them that the female partner still needs to seek care for assessment of possible PID. EPT is not routinely recommended for MSM patients, due to co-morbidities of other STDs and HIV. It's recommended by the CDC for gonorrhea and chlamydia since 2006 and EPT is legal in New York state for chlamydia alone since :43:46 This is just a summary of the New York state expedited partner therapy law. So EPT may be provided for partners of patients who are diagnosed through either laboratory or clinical diagnosis for chlamydial infections. Healthcare providers can ask about 60 day intervals to identify the sexual partners or they may give EPT for the most recent partner if none in the 60 day interval. The recommended EPT treatment for chlamydia is one gram of Azithromycin in a single dose. Ideal candidates are partners who are unlikely to seek timely clinical services, as in our patient case. Also it's a note that if a partner is pregnant, the partner should take the medication and should be advised to definitely seek medical care as soon as possible. 00:44:39 This is just a summary of the New York state EPT law. Again, other key provisions of the law are the EPT should not be provided to chlamydia patients who have gonorrhea or syphilis. EPT is not recommended for treating MSM due to their high risk of HIV co-morbidity in their partners. And EPT prescriptions should include the phrase EPT in the body of the prescription. 00:45:05 So I've included a prescription that we would send from our clinic. You can put EPT in the body here and then Azithromycin 250 milligrams tab, take four tablets for a dose of a gram and they should take it all at once. If you know the partner s name you can put the partner s name here or you can leave it blank if you do not know the partner's name. And the partner can take this to a pharmacy and they will be given the Azithromycin. 12

14 00:45:32 So what is the treatment of uncomplicated chlamydia? The CDC-recommended treatment is Azithromycin one gram orally in a single dose or doxycyline 100 milligrams twice a day for seven days. Alternative regimens include erythromycin, ofloxacin, or levofloxacin as seen here. 00:45:55 Now that we've reviewed case four, we'll go onto case five. And this is loosely based on a phone call we received on our phone line, where we provide STD advice. 00:46:13 So an 18 year old male college student presents with a diffuse rash which started a week ago and has not improved. He presented to his University Health Service. 00:46:25 And his rash looked something like this. He has lesions on his palm, on his feet, and also on his chest. 00:46:35 On sexual history, it turns out that he has had multiple male partners that he's met online, he practices both oral and anal intercourse, he's not using condoms, and he's never been tested for sexually transmitted disease. 00:46:54 So his testing that's done, he had a syphilis test which was EIA positive, RPR was found to be 1:128, which was positive. HIV testing he had both an RNA test, which was negative and a antigen antibody test, which was negative. And then he had a gonorrhea/chlamydia urine and rectal NAAT, which were negative and a gonorrhea oral NAAT, which was negative. 00:47:28 So firstly I thought I could review the reverse syphilis algorithm. So the recommendation currently by the CDC is to do the syphilis screening, which is done by your lab. Some labs still use the RPR followed by a treponemal confirm test and some labs are using the reverse algorithm screening seen here. So first I'll just go over the different screenings. So your lab could potentially use an EIA or a CIA, which is a treponemal test. So you can see the T, NT, and T here. The T represents a treponemal test. So these are amino acids screened for antibodies to treponemal pallidum. So if your test is negative, potentially, you don't have syphilis or the patient could have early syphilis and just not made antibodies to the syphilis, to the treponema pallidum and so the clinical presentation needs to be considered and also potentially the patient, if you have a high suspicion, you could repeat the EIA in a few weeks. If your EIA is positive then the next step in the reverse algorithm is to do an RPR. The RPR is the Rapid Plasma Reagin test which, then the traditional screening up until somewhat recently and it is a non-treponemal test. So it looks for antibody against cell breakdown product that was infected by treponema pallidum. So it has a lot of reasons for false positives, but the one thing that RPR really does for us is it quantitates. It s really the test that will give us a quantitative titer of syphilis. So for instance our patient had a 1:128, which is a 13

15 very high titer. If the RPR is non-reactive then the reverse algorithm reflexes either, depending on your lab, to a fluorescent treponemal antibody absorb assay, or the treponema pallidum particle agglutination assay. And this, again, is another treponemal test and the reason it's done is to validate the first test, the EIA or the CIA test, to make sure that this wasn't a false positive. Now, if your second treponemal test is positive then you need to evaluate for whether this patient needs to be treated for syphilis or potentially whether they have been treated for syphilis in the past and these tests are just remaining positive. If this test is non-reactive, then either this patient does not have syphilis and maybe the EIA is a false positive or, potentially, this is again early syphilis and these tests haven t turned positive. 00:50:24 So this just is show the sensitivity of tests and how they vary by stage. I think the important thing to note about this is, although it doesn't show here, is the EIA and the TPTA and this is the FTA-antibody test so all these treponemal tests, they can stay positive for life. Once somebody's been infected by syphilis, they can all stay positive, so you've got to figure out whether the patient has been treated before and just continues to have these positive tests or whether reinfection has occurred. And the way to really figure out reinfection is with the RPR. The RPR will become positive and then it will go negative over the lifetime. You can see that there is this incubation time here and even in primary syphilis where these testings will all be negative. And it takes a lag before any of these tests turn positive. 00:51:29 So, I thought I would go over the staging for syphilis. The way I think about syphilis is two ways. One is communicability and then the other one is by the signs and symptoms of having syphilis. So first we'll talk about communicability. So 12 months, 12 months is the breakdown for communicability. So there's early syphilis, which includes the incubating time, primary, secondary, and early latent. And this is when a patient can be contagious and give syphilis. After 12 months, patients then can have late latent tertiary syphilis after many years and they are no longer contagious and this would be in the late syphilis stage. I will draw your attention to perinatal transmission can happen at any point. And also on this graph that is not included, neurosyphilis typically happens in the early syphilis time, but it can happen throughout syphilis, as well. So now that we've talked about the idea of early syphilis and late syphilis based on communicability, let's talk about the staging of syphilis by signs and symptoms. So there's incubating, primary, secondary, and then this idea of latent. Latent is when they are asymptomatic. And there is early latent which occurs before 12 months and late latent which occurs after 12 months. So incubating is thought to happen between zero to 90 days when they have been infected by syphilis before they actually show signs of primary syphilis. Primary syphilis is thought to happen anywhere between around two to three weeks. The primary syphilis that occurs is the chancre, which is a kind of asymptomatic, non-tender ulceration that eventually goes away. Patients can also have in the genital area inguinal lymphadenopathy which is not painful, which will eventually go away. It's important to note that chancres, you might think of them as being just on the genital area, it can be on the anal area, and there are reports of having chancres in the mouth, as well. Especially when I talked about those students who weren't using condoms for oral sex, they can acquire syphilis orally. So when the chancre goes away after several months, around two to three months you can develop secondary syphilis. Secondary 14

16 syphilis is when patients really have that burden of treponema in their blood so they develop the rash, like our patient did, they could have lymphadenopathy, flu-like symptoms, there's a whole list of symptoms patients could have with secondary syphilis. Fevers, malaise, and like I said, a flu-like illness. They can also have multiple lesions, unlike the chancre which is just one lesion. Then they can go into this phase of early latent where they have no symptoms, but they are still infectious. Late latent is when they are still not having symptoms, but after 12 months they're thought not to be infections anymore, and then after many years they can develop tertiary syphilis, which causes cartilaginous infection, infections of the heart, aortitis, and call also infect the central nervous system. And you can see perinatal transmission can occur at any time if the mother is infected to the baby. 00:55:06 These are just some pictures of primary syphilis. You can see the chancre here, the peaked up border. And here is one on somebody's face. 00:55:20 So the management varies by stage. Early syphilis, which includes the incubating time, primary, secondary, early latent, and the partners of these patients will all be recommended to receive benzathine penicillin 2.4 milliunits intramuscularly times one. Or doxycycline 100 milligrams twice a day for 14 days. It's recommended that they have a repeat RPR because it's a quantitative test. You can see in our patient had the very high titer because it was secondary syphilis, that's when the RPR really peaks. You would repeat the RPR at six, 12, and 24 months. It's recommended to contact the state health department to report the case and interview and test partners anywhere from three months to a year previously and they would get prophylactic treatment for partners who were within the previous 90 days due to that incubation time of syphilis. 00:56:18 For late latent, that is patients who are asymptomatic or who are greater than a year from infection, they receive benzathine penicillin 2.4 milliunits intramuscularly over the span of three weeks, they receive it weekly. Or they can get doxycycline 100 milligrams twice a day for 28 days. You repeat that RPR at six, 12, and 24 months and no routine treatment of sexual partners is recommended. And you may need to assess long term partners and also children as well for potential prenatal treatment, or acquisition. And when you're doing the repeat RPR you really want to see the titer go down by a fourfold dilution. So, for instance, going down two titers. Not just one titer, but two titers to make sure that the patient is actually improving. So, for instance, our patient was at 128 so we would like to see a titer drop to 32. So from 128 to 64 to 32. So at least a full drop with treatment. 00:57:38 So in conclusion, adolescents are at a high risk for sexually transmitted diseases. HIV testing in New York state should be offered to anyone who is 13 years or older. The CDC does recommend the five P's for sexual history. And very important, and I would emphasize this again, it's not just important to do the traditional screening for sexually transmitted diseases, but to find out in that sexual history whether 15

17 these patients are engaging in oral and anal intercourse because you really should be testing them for oral gonorrhea, pharyngeal gonorrhea, and rectal gonorrhea and chlamydia if they are engaging in those sexual practices. Finally, it's important to consider EPT testing for patients, patients with chlamydia in New York state if their partners will not seek medical care. 00:58:40 Thank you. And this is the CEI hotline. You can call us to ask for advice on STDs, HIV, Hep C, or those whoa are need of post exposure prophylaxis, or pre exposure prophylaxis. [Video End] 16