Love Bugs and Drugs Managing Sexually Transmitted Infections in Teens Renée R. Jenkins, M.D., F.A.A.P. Howard University College of Medicine 37 th Annual Sanford Black Hills Pediatric Symposium June 26, 2015
Conflict Disclosure Dr. Jenkins has no conflicts of interest related to any of the guidelines being discussed financial or otherwise.
Key Presentation Issues Frequency of STI s in adolescents Assessment strategy for prevention and early detection of STI in office setting Recognition of clinical presentation of infections Diagnostic tests and their usefulness in different adolescent populations Patient management goals for adolescents Case History
Patient Presentation A 17 year old male presents to your office for his college admission form completion. He has no interim health problems since his last visit, mild seasonal allergies, responds well to nasal spray, no wheezing or skin rashes. Received Tdap and Meningococcal vaccine x 1, no TB risk. Denies tobacco use, occasional marijuana use at parties, drinks beer on weekends, doesn t drive after drinking, wears seat belt, no violent encounters, no gun in the house. Has 2 female sex partners in last 3 months. Used condoms with most recent partner until a few weeks ago when they became exclusive.
Case #3 Slide 2 Physical Examination Height 72 inches, Weight 182 lbs, BMI-24.7, BP 126/74 Sexual Maturity Rating Pubic Hair 5 HR 74/min, regular, no murmurs Muscle/Joints, full range of motion, No scoliosis Genital exam uncircumcised, urethral discharge present, scant inguinal nodes, testicles normal, descended, no varicocele Other P/E findings within normal limits
Epidemiology Adolescents are more vulnerable to Sexually Transmitted Infection
Adolescent Sexual Behavior Trends National Youth Risk Behavior Surveillance System 1991 to 2013 in high school students who have ever had sex 54% to 46.8% (2001 low 45.6) in high school students reporting sex with >4 persons 19% 15% (2009 low 13.8) used condom during last sexual intercourse 46% 59.1% (2003 high 63.0) ever taught in school about AIDS or HIV infection 83.3% 85.3% (1997 high 91.5)
National Youth Risk Behavior Surveillance System South Dakota /US Data 2013 US SD Ever had sex 46.8 40.1* Sex > 4 partners 15.0 12.2 lifetime Did not use condom 40.9 40.0 @ last intercourse
Estimated Incidence of Sexually Transmitted Diseases Among American Youth - 15-24 yo, 2000 HPV Trich V. Chlamydia Herpes Gonorrhea HIV Syphilis Hep B 0 1 2 3 4 5 Millions Weinstock, Stuart, Cates, 2004
Chlamydia Rates by Age and Sex, United States, 2012 2012-Fig 5. SR, Pg 11
Chlamydia Percentage of Reported Cases by Sex and Selected Reporting Sources, United States, 2012 *HMO=health maintenance organization; HD=health department NOTE: Of all cases, 11.4% had a missing or unknown reporting source. Among cases with a known reporting source, the categories presented represent 69.8% of cases; 30.2% were reported from sources other than those shown. 2012-Fig 8. SR, Pg 12
Gonorrhea Rates by Age and Sex, United States, 2012 2012-Fig 21. SR, Pg 21
Gonorrhea Rates, United States, 1941 2012 2012-Fig 11. SR, Pg 19
Primary and Secondary Syphilis Rates by Age and Sex, United States, 2012 2012-Fig 35. SR, Pg 35
Primary and Secondary Syphilis Reported Cases* by Stage, Sex, and Sexual Behavior, United States, 2010
Human Papillomavirus Prevalence of High-risk and Low-risk Types Among Females Aged 14 59 Years, National Health and Nutrition Examination Survey, 2003 2006 *HPV=human papillomavirus. NOTE: Error bars indicate 95% confidence intervals. Both high-risk and low-risk HPV types were detected in some females. SOURCE: Hariri S, Unger ER, Sternberg M, Dunne EF, Swan D, Patel S, et al. Prevalence of genital HPV among females in the United States, the National Health and Nutrition Examination Survey, 2003-2006. J Infect Dis. 2011;204(4):566-73. 2012-Fig 45. SR, Pg 43
Patient History and Screening Adolescents should be asked about their sexual behavior
Determining Level of Risk by History History: Partner (s) Condom Use Other risky behaviors LOW RISK Older adolescent Stable relationship Consistent Condom Use MODERATE RISK Unstable relationship Multiple partners Hx. STD or pregnancy HIGH RISK Younger adolescent Other high risk behaviors Sexually abused
CDC RecommendationsAssessment: The 5 P s PARTNERS Sexual PRACTICES PAST history of STIs PREGNANCY PROTECTION from STI
Factors Which Increase The Risk of STDs Previous history of an STD >1 sex partner in past 6 mos. Intravenous drug use Sex with a partner at risk Sex in exchange for drugs or $$ For males: sex with other males Homelessness Residence in areas where STDs are prevalent
Factors Which Increase Adolescent Risk for STD s Physical Younger at puberty Cervical Ectopy Smaller introitus leading to traumatic sex Asymptomatic nature of infection Behavioral Early Adol inability to think abstractly Middle Adol believe of invulnerability
Source: Seattle STD/HIV Prevention Training Center at the University of Washington/ Claire E. Stevens Epidemiology Normal Cervix with Ectopy
Missed Opportunities for Sexual Transmitted Infection Counseling Youth Risk Behavior Survey, 1999 data Preventive visits in past year 60.4% females, 57.5% males STD, HIV, pregnancy discussion, all students 42.8% females, 26.4% males STD, HIV, pregnancy discussion, sexually experienced students 61.4% females, 33.5% males Burstein, Lowry, Klein et al, 2003
Barriers to Sexually Transmitted Infection Screening in Young Women Patient Barriers: Concerns about privacy, fear of exam, fear of diagnosis, embarrassment Clinician Barriers: Inadequate facilities or skills for pelvic examination, discomfort with discussion of sexual issues with young person Belief that their patients are not sexually active nor likely to have CT, nor will screening reduce sequelae like of PID
Individual Approaches Open-ended Question Examples What do you think your risk is for STD? What happened the last time you had sex? What made you decide not to use a condom? What made you decide to use a condom? What do you think you can do to reduce your risk for STDs the next time you have sex?
Clinical Presentations Most adolescents are asymptomatic, but the examination should identify any relevant findings
Clinical Manifestations Urethritis Symptoms: dysuria, however, most women are asymptomatic 40%-60% of women with cervical gonococcal infection may have urethral infection
Gonococcal Urethritis: Purulent Discharge Clinical Manifestations Source: Seattle STD/HIV Prevention Training Center at the University of Washington: Connie Celum and Walter Stamm
Non-Gonococcal Urethritis: Mucoid Discharge Clinical Manifestations Source: Seattle STD/HIV Prevention Training Center at the University of Washington/UW HSCER Slide Bank
Clinical Manifestations Penile Warts Source: Cincinnati STD/HIV Prevention Training Center
Clinical Manifestations Source: Seattle STD/HIV Prevention Training Center at the University of Washington/ UW HSCER Slide Bank Perianal Warts
Clinical Manifestations Genital Warts: Location Warts commonly occur in areas of coital friction. Perianal warts do not necessarily imply anal intercourse. May be secondary to autoinoculation, sexual activity other than intercourse, or spread from nearby genital wart site. Intra-anal warts are seen predominantly in patients who have had receptive anal intercourse. Patients with visible warts can be simultaneously infected with multiple HPV types.
Clinical Manifestations Vulvar Warts Source: Reprinted with permission of Gordon D. Davis, MD.
Herpes, female www.cdc.gov
Primary Herpetic Lesion www.cdc.gov
Bartholin s abscess www.cdc.gov
Disseminated gonorrhea - skin lesion www.cdc.gov
Clinical Manifestations Normal Cervix Source: STD/HIV Prevention Training Center at the University of Washington/Claire E. Stevens
Clinical Manifestations Chlamydial Cervicitis Source: STD/HIV Prevention Training Center at the University of Washington/Connie Celum and Walter Stamm
Gonococcal Cervicitis Clinical Manifestations Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides
Diagnostic Tests There are several options available, the clinician determines the method that fits the prevalence in the community and his/her skills
www.cdc.gov
Diagnosis Diagnostic Methods Culture tests Non-culture tests Amplified tests (NAATs) Polymerase chain reaction (PCR) (Roche Amplicor) Transcription-mediated amplification (TMA) (Gen-Probe Aptima) Strand displacement amplification (SDA) (Becton-Dickinson BD ProbeTec ET) Non-amplified tests DNA probe (Gen-Probe PACE 2, Digene Hybrid Capture II) Gram stain
Diagnosis NAATs NAATs amplify and detect organismspecific genomic or plasmid DNA or rrna FDA cleared for urethral swabs from men/women, cervical swabs from women, and urine from both
Pathogenesis HPV Genotyping System Low-risk types Most visible warts caused by HPV types 6 and 11 Recurrent respiratory papillomatosis associated with HPV types 6 and 11 High-risk types HPV types 16 and 18 found in more than half of anogenital cancers Most women with high-risk HPV infection have normal Pap test results and never develop precancerous cell changes or cervical cancer
Additional Types in HPV-9
HPV Recommendation 9 Through 18 Years Human papillomavirus vaccine (HPV). (Minimum age: 9 years) Either HPV9, HPV4 or HPV2 is recommended in a 3- dose series for females aged 11 or 12 years. HPV9 or HPV4 is recommended in a 3-dose series for males aged 11 or 12 years. Administer the series to females aged 13-26 yrs and males at age 13 through 21 years if not previously vaccinated Males 22-26 yrs may be vaccinated, recommended for MSM and immunocompromised (HIV)
Treatment A comprehensive approach responsive to the needs of the patient and his/her partner
www.cdc.gov
Antimicrobial Susceptibility of N. gonorrhoeae Management Fluoroquinolones are no longer recommended for therapy for gonorrhea Ceftriaxone dose 250 mg i.m. Dual therapy recommended to cover Chlamydia Azythromycin Doxycycline
STD Screening for Adolescents Routine screening of asymptomatic patients is discouraged for: Genital Herpes HIV Testing CDC encourages all adolescents to be screened USPSTF aged 15 yo routinely, younger if at high risk Chlamydia and Gonorrhea USPSTF sexually active women < 25 yo
Prevention Partner Management Sex partners should be evaluated, tested, and treated if they had sexual contact with the patient during the 60 days preceding the onset of symptoms or diagnosis of chlamydia. The most recent sex partner should be evaluated and treated even if the time of the last sexual contact was >60 days before symptom onset or diagnosis.
Expedited Partner Treatment (EPT) Treating partners without a clinical assessment, primarily male partners of women with Chlamydia or gonorrhea May 11, 2005 CDC has concluded that EPT is a useful option to facilitate partner management ongoing evaluation will be needed to define when and how EPT can be best utilized
Prevention Prevention Counseling Nature of the infection Chlamydia is commonly asymptomatic in men and women. In women, there is an increased risk of upper reproductive tract damage with re-infection. Transmission issues Effective treatment of chlamydia may reduce HIV transmission and acquisition. Abstain from sexual intercourse until partners are treated and for 7 days after a single dose of azithromycin or until completion of a 7-day regimen.
Trichomonas Treatment Non-pregnant women & men Metronidazole oral Tinidazole oral Pregnant women Metronidazole, oral
Bacterial Vaginosis Treatment Metronidazole 500 mg x 7 days oral Metronidazole gel 0.75% daily x 5d Clindamycin Vag Cream 2% daily x 7d New alternatives Tinidazole 2 gm x 2 days or 1 gm x 5 days Clindamycin 300 mg bid x 7 days
Prevention Prevention Counseling (continued) Risk reduction The clinician should: Assess the patient s behavior-change potential. Discuss prevention strategies (abstinence, monogamy, condoms, limit number of sex partners, etc.). Latex condoms, when used consistently and correctly, can reduce the risk of transmission of chlamydia. Develop individualized risk-reduction plans.
Case #2 Reviewing the key clinical steps to optimal management
Case Study History Suzy Jones: 17-year-old high school senior coming in for college physical seeking advice about contraception Shy talking about her sexual practices Has never had a pelvic exam Has had 2 sex partners in past 6 months Does not use condoms or any other contraceptives Her periods have been regular, but she has recently noted some spotting between periods. Last menstrual period was 4 weeks ago. Denies vaginal discharge, dyspareunia, genital lesions, or sores
Case Study Physical Exam Vital signs: blood pressure 118/68, pulse 74, respiration 18, temperature 37.1 C Breast, thyroid, and abdominal exam within normal limits Genital exam reveals normal vulva and vagina The cervix appears inflamed, bleeds easily, with a purulent discharge coming from the cervical os. Bimanual exam is normal without cervical motion pain, uterine or adnexal tenderness.
Case Study Questions Case #2 1. What is the initial clinical diagnosis? 2. What are the possible etiologic agents associated with the clinical findings? 3. Which laboratory tests should be ordered or performed?
Case #2 What is your next best step in determining the etiology of this discharge? A. Nucleic acid amplification test (NAAT) B. Urethral bacterial culture C. Gram stain of discharge D. Urinalysis
Case Study Partner Management Suzy s sex partners from the past year: John Last sexual exposure 5 weeks ago Tom Last sexual exposure 7 months ago Michael Last sexual exposure 2 weeks ago 9. Which sex partners should be evaluated, tested, and treated?
Case Study Follow-Up Suzy returned for a follow-up visit at 4 months. Her repeat chlamydia test returned positive. Suzy stated that her partner, Michael, went to get tested, but the test result was negative so he was not treated. 10. What is the appropriate treatment at the 4- month follow-up visit?
Management Concerns for Adolescents Screening for HIV infection in patients treated for other STDs Consideration of birth control Check HPV vaccination status Partner management Educational counseling and Follow-up STD Reporting Requirements Abstinence 6/19/2015
Take Home Message for Clinicians Ask about sex Screen young women and men according to guidelines Ask about pregnancy prevention, intervene or refer Follow-up on patients and partners treated Report STI s consistently according to state statutes
Review Questions Which of the following is true for sex partners of a patient diagnosed with chlamydia? 1. Only the most recent sex partner needs to be referred for treatment. 2. All partners exposed in the last 60 days should be referred for treatment. 3. Only symptomatic partners need to be referred for treatment. 4. No partners need to be referred since chlamydia is not efficiently transmitted
Thank you for your attention Hope these points were helpful! Further opportunities CDC website Advocates for Youth Website