5/12/11. STI s in Adolescents: Exposing the Hidden Epidemic. Why the hidden epidemic?

Transcription

1 STI s in Adolescents: Exposing the Hidden Epidemic Youth and Sexually Transmitted Infections 2011 Mary-Ann Shafer, MD Professor & Vice Chair Department of Pediatrics Division of Adolescent Medicine University of California San Francisco Do not have any vested interest in any products included in talk Will not go into every painful detail on every antibiotic dose-they are included in the handout & on the CDC Treatment Guidelines website! Why the hidden epidemic? Most sexually transmitted infections do NOT produce symptoms With the exception of AIDS, STIs are largely excluded from public discourse Social ambivalence toward sexuality 1

2 How common are STIs in the U.S.? 12 million new cases every year 4 million among teens 25% of sex active teens each year 8X GC > Canada; 50X GC >Sweden!* CT rate: 5-10% in F; ~1-3% M teen, most common in yo M & F HIV rate 2X in y M (2.5x10 5 ) Most Common STIs Chlamydia Gonorrhea Trichomonas Syphilis Herpes HPV Hepatitis B HIV / AIDS Complications. of STIs Upper Tract Infection Infertility Ectopic Pregnancy Chronic Pain Genital Infection Systemic Infection Congenital Infection Serious medical complications HIV Infection Cancer (cervical, liver) 2

3 STI Case Studies in Teens Vaginitis Mucopurulent cervicitis Abdominal pain Male with genital ulcer Case 1 Presentation 17 year-old female presents to her pediatrician- she wants STD Is sex active, new partner x 1 m Uses condoms most of the time Case Physical Exam Exam reveals noninflamed vaginal mucosa Moderate adherent white discharge Cervix normal with negative swab test STD Atlas,

4 Case Discussion: Vaginitis What is the DDX of vaginal discharge? What are risk factors for vaginitis? Which causes of vaginitis are sexually transmitted? Which lab tests should be done? Vaginitis Etiologies Bacterial Vaginosis (BV) Trichomoniasis Vulvovaginal Candidiasis (VVC) Differential diagnosis: Gonorrhea Chlamydia Atrophic vaginitis Allergy Foreign body UTI BV: Diagnostic Criteria Amsel Criteria (3 of the following 4): Homogeneous white noninflammatory d/c adheres to the vaginal walls Vaginal ph > 4.5 Positive whiff test-fishy > 20% Clue cells on saline wet mount >90% sensitive 4

5 BV: Treatment Criteria Relieve symptoms/signs of infection To Infection risk post-tab or other invasive procedures? Risk of preterm delivery? Risk of PID (BV micro ~ PID) BV: Associated Factors Polymicrobial micro- is it an STI? Due to change in Lactobacillus more anaerobes, GV, Myco hominis 50% infected women->no symptoms multiple/new sex partners, douche Treating partners not recurrence BV: Treatment Recommended regimens: Metronidazole 500 mg po bid x 7 d Metronidazole 0.75% gel vagina bid x 5 d Clindamycin 2% cream* /vagina hs x 7 d Alternative regimens: Clindamycin 300 mg PO BID x 7 d or Clindamycin ovule 100 mg vag hs x 3 NEW-Tinidazole 2 g PO qd x 2d or 1 g PO qd x 5d *oil-based cream, may weaken condoms and diaphragm 5

6 BV: Patient Counseling >50 % recur-15% x 1m, 80% x 7m Avoid douching or vaginal soaps Rx male partners not recur rate OTC lactobacillus preps no help Vaginal acidifying agents no help Case 2 Presentation 16 year-old female presents complaining of new discharge & funny bleeding at LMP Sexually active but no birth control 2 male partners in prior 2 months Case Physical Exam Cervix with mucopurulent discharge from os STD Atlas,

7 Case Discussion: Mucopurulent Cervicitis (MPC) What is the DDX? What are the causes of this condition? What tests should be performed? What are the empiric treatment options? Mucopurulent Cervicitis (MPC) GC, CT, HSV or T. vaginalis Etiology often not identified Can have no symptoms or, D/C or abnormal bleeding Exam: Cervical/ endo-cervical erosions, friability, pus Complications may lead to PID MPC: Diagnosis + Swab test: yellow pus on endo-cx swab + Friability: Cervical bleeding on swab Quantifying # WBCs on gram stain- Saline wet mount for Trichomonas Lab tests: CT & GC (NAATS)* Cx/ Ur/ Vag Empirically Rx for CT & GC if Dx MPC@ visit not all NAATS approved for vaginal 7

8 Chlamydia: Treatment Treat: CT+ test, exposed to CT+ partner, CT syndromes (PID, MPC) Uncomplicated: (see PID Rx coming) Azithromycin 1 g PO X 1 OR Doxycycline 100 mg BID for 7d **Alternative regimens: Erythro base, Ofloxacin or Levofloxacin Chlamydia: FU & Partner Rx Get partner in for test & Rx No sex for 7 days after Rx started Condom use always in future Return if gets worse, abd pain or fever Other labs: VDRL, GC test, HIV test Repeat CT test in 3-12 months-reinfection common in women (no TOC) Annual CT screen or more F < 25 yo Gonorrhea: clinical Up to 1/3 no symptoms Male: epididymitis, prostatitis Female: urethritis, cervicitis, PID Both: urethritis, proctitis, pharyngitis Pharyngitis: most asymptomatic, can be patchy red +/- pustular lesions ~ strep CT common co-infection with GC 8

9 Gonorrhea: Treatment ** Uncomplicated cervix, urethra, rectum Ceftriaxone 250 mg IM x1 dose or Cefixime 400 mg PO x 1 dose or Single dose cephlosporins IM & Azithromycin 1 g in single dose or Doxycycline 100 mg PO BID x 7 d **Partners x 60 days: Test/Rx or give partner deliv d Rx She comes in with abd pain too? Think PID vs GYN, GU, GI GYN: dysmenorrhea, ectopic/ IUP pregnancy, ovarian cyst/ torsion, SAB, endometriosis GU: cystitis, pyelonephritis, calculi GI: appendicitis, cholecystitis, IBD Other: pneumonia, SS crisis, trauma etc Pelvic Inflammatory Disease (PID) In US, 1 million cases annually Cervicitis endometritis salpingitis oophoritis / TOA peritonitis Polymicrobial etiology: GC, CT, Anaerobes, Aerobes, GNRs etc! Links: early sex, many partners, STDs Silent PID- no symptoms infertility 9

10 PID: Diagnosis Lower abd pain & >1 minimal criteria: Cervical motion tenderness or Uterine tenderness or Adnexal tenderness PID: Diagnosis Additional criteria: Temp > 38.3 o C Abnormal cervical or vaginal d/c WBCs on NaCl prep of vag d/c Elevated ESR or CRP GC+ &/or CT+ Imaging: ultrasound, laparoscopy PID: Diagnostic Labs Most specific: endometrial biopsy Transvag U/S or MRI (rare laparoscopy) GC/CT tests U/A, C/S if indicated and U-preg test Other labs: CBC, ESR, RPR, HIV 10

11 PID: Indications for Hospitalization Surgical emergency cannot be excluded TOA (Tubo-ovarian abscess) Dx in 20% Pregnancy Severe illness (nausea, vomiting, high T) Unable to follow or tolerate outpatient Rx Failure of outpatient Rx in h HIV+ or other immunosuppression PID: Parental Treatment Regimens Parental regimen A- til 24 hours improvement: Cefoxitin 2 g IV q 6h or Cefotetan 2 g IV q 12h AND Doxycycline 100 mg IV or PO q 12h Plus Doxycycline 100 mg PO BID to total 14d PID: Parental Treatment Regimens Parental regimen B: Clindamycin 900 mg IV q8h plus Gentamicin loading dose (2 mg/kg) maintenance (1.5 mg/kg q8h) or single daily dose (3-5 mg/kg) PLUS Doxycycline 100 mg PO bid 14d 11

12 PID: Oral Treatment Regimens* Ceftriaxone 250 mg IM once PLUS Doxycycline 100 mg bid x 14 d with/ without Metronidazole 500 mg PO bid x 14 d OR (con d) PID: More Oral Treatment Regimens OR Cefoxitin 2 g IM with probenecid 1 g PO x1 OR Other parenteral 3rd gen cephalosporin (ceftizoxime or cefotaxime) plus Doxycycline 100 mg PO BID x 14 d w/wo Metronidazole 500 mg PO BID x 14 d * If QRNG or no susceptabilities (eg NAATS) parenteral cephalosporin (add azithromycin if must use quinolones) PID: Patient Follow-Up OPD: re-examine within 72 hrs to ensure improvement; if fails IV Antibx INPT: not improve in 72 h re-eval for TOA, other GU or GI Dx or Surgery? Re-test for CT & GC 3-6 mos Sex partners < 60 days or if >60 dayshad last partner: Test/ Rx or give partner delivered Rx 12

13 Case 3 Presentation 17 year-old Mario presents with mildly painful sore on his penis for the past 5 days Self-treated topical antibiotics Medical history unremarkable Sexually active; no history of STDs, uses condoms sometimes Case Physical Exam Exam single shallow ulcer 5 mm in diameter granular base erythematous mildly tender Case 3: Discussion of GUD GUD= genital ulcer disease 13

14 GUD: STD Pathogens* Herpes simplex virus (HSV) -most common in teens/young adults Syphilis (Treponema pallidum) Chancroid (Hemophilus ducreyi) * associated with increased HIV risk GUD: STD Pathogens Chancroid Chancroid (Hemophilus ducreyi) Uncommon, sporadic outbreaks 1 or more painful genital ulcers Negative tests for syphilis, HSV Tender suppurative inguinal nodes Rx: Azithromycin 1 g PO x 1, others GUD: Differential Diagnosis Other STD pathogens: Acute HIV Lymphogranuloma venereum (Chlamydia trachomatis, L1-3) Granuloma inguinale (Calymmatobacterium granulomatis) 14

15 Differential: Common GUD Item Syphilis HSV Chancroid Etiology T. Pallidum Herpes virus H. Ducreyi Incubation 2-3 weeks (10-90 d) 2-7 d in d Painful NO! YES, Bilateral- 1 0 YES, Uni-, tender Lymph nodes Bilateral, firm, nontender Bilateral, tender- 1 0 Unilateral, tender painful GUD: Differential Diagnosis Other causes-non sexually transmitted: Candidiasis Psoriasis Trauma Reiter s Behçet s syndrome Scabies Squam cell Ca Fix Drug Erupt Apthae GUD: Laboratory Testing Darkfield microscopy (if available) Stat RPR (if available) or regular RPR DFA: Direct fluorescent Ab-T. pallidum VDRL/ RPR: Nontreponemal tests HSV culture or PCR (NEW) Hemophilus ducreyi culture-common? STD screen (GC, CT, HIV) 15

16 Mario s GUD Case Test Results RPR was ( - ) GC & CT tests were ( - ) HSV culture/ PCR was ( + ) Get HSV type specific testing: 50% of 1 st episodes HSV-1 Fewer recurrences/less shedding HSV: Treatment Initial episode: Acyclovir 400 mg TID x 7-10 d Acyclovir 200 mg 5x/day x 7-10 d Valacyclovir 1 gm PO qd x 7-10 d Famiciclovir 250 mg PO TID x 7-10 d Suppressive Rx: Frequent Recurrent HSV: Acyclovir 400mg PO TID Valacyclovir 500 mg PO/ 1 g PO qd Famiciclovir 250 mg PO BID HSV: Treatment- Episodic Episodic Therapy- Recurrent Genital HSV: Acyclovir 400mg TID x 5 d or 800 mg BID x 5 d or 800 mg TID x 2 d or Valacyclovir 500 mg BID x 2 days or 1 Gm qd x 5 d or Famiciclovir 125 mg PO BID x 5 d or 500 mg x 1 then 250 mg BID 2d or 1 Gm BID x one day (2 doses) 16

17 HPV Prevention-Vaccines Vaccines prevent cancer & genital warts Bivalent vaccine (Cervarix ) protects against high risk types 16, 18 (70% Ca) Quadrivalent (Gardasil ) protects against cervical cancer high risk 16, 18 & types 6, 11 genital warts Recommend all girls age 11-12y (9-26y) prior to onset of sexual activity Consider recommendation for all boys What about HPV & Paps? Now have vaccines that protect against most oncogenic strains (16,18) Do not screen with Pap until 21 yo, may see minor changes related to new HPV infection-no intervention->most resolve STI annual screens YES Vaccine best preventive measure! MALE CT SCREENING?** STD, Job Corps, <30 y in military & jails, juvenile detention, < 25 y in high rate communities Use urine NAATs-CT/GC; pool urine OK Partners of CT(+) men refer for Rx Expedited partner Rx works Consider young males for HPV vaccine ** Male CT Screening Consult, CDC

18 Δ CDC Treatment Guidelines 2010 Few major changes from 2006 Adolescent Males CT screening recommended in high risk areas/ institutions (jail, etc.) HSV Rx minor dosage changes HPV vaccination for all girls y (9-26 y) and consider all boys/males Most Important Things to Remember Teens do listen to advice from docs More important to take 5 minutes to talk prevention than doing entire PE Encourage abstinence ok if also talk safety if sexually active Sexual violence is common-screen/refer Getting them to change 1 behavior better than expecting a whole makeover -takes time Don t forget boys: Sperm Ownership works Resources for Providers, Teens and Parents 18

19 References (provider tools!!!) 104_sexualhealthtoolkit2010bw.pdf (toolkit on sexual health very good!) mmwrhtml/rr5912a1.htm (2010 current) Klausner JP, Hook EW: Current Diagnosis and Treatment of STDs. McGraw-Hill, The End! 19