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05/08/2015
Adolescents and Sexually Transmitted Infections
Aneesh K. Tosh, MD, MS
Division of Adolescent Medicine
University of Missouri ‐ Columbia
Disclosures
• I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial CME services discussed in this CME activity.
• I do not intend to discuss an unapproved/ investigational use of a commercial product/ device.
Objectives
• Recognize that adolescents and young adults are at higher risk for acquiring a sexually transmitted infection (STI)
• Identify the clinical features of the six most common STIs among adolescents
• Be able to properly diagnose and treat these common STIs
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05/08/2015
First, some good news…
Percentage of High School Students Who Ever Had Sexual Intercourse, 1991 – 2011†
†
Decreased 1991–2001, no change 2001-2011, p < 0.05.
CDC, National Youth Risk Behavior Surveys, 1991–2011
And now, the bad news…
• During 2010–2011, Chlamydia rates increased 4.0% for 15–19 y/o and 11.0% for 20–24 y/o
• 4/10 sexually active female teenagers with STI
• 2011 Youth Risk Behavior Survey
– Nearly half of the 19 million new STIs each year are among young people aged 15–24 years
– 39.8% of adolescents who had sexual intercourse during the previous 3 months did not use a condom the last time they had sex
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05/08/2015
Chlamydia—Rates by Age and Sex, United States, 2011
2011-Fig 5. SR
Gonorrhea—Rates by Age and Sex, United States, 2011
2011-Fig 21. SR
CDC
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05/08/2015
Sexually Transmitted Infections
• Human papillomavirus (HPV)
– Most common non‐reportable STI
• Chlamydia trachomatis (CT)
– Most common reportable STI
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Neisseria gonorrhoeae (NG/GC) ‐ reportable
Herpes Simplex Virus (HSV) – not reportable
Trichomonas vaginalis (TV) – not reportable
Treponema pallidum (Syphilis) ‐ reportable
Human Papillomavirus (HPV)
• Acquired via vaginal, anal, or oral intercourse
– Consider abuse if young or not sexually active
• 80% of sexually active persons will acquire HPV within three years
• Over 100 identified serotypes, may present as:
– Genital warts (condyloma acuminata)
• 90% are types 6 and 11
– Cervical cell changes/cancer • 70% are types 16 or 18
• 20% are types 31, 33, 45, 52 and 58
– Anogenital cancers or respiratory papillomas
HPV Vaccines
• Quadrivalent (Gardasil®)
– Ages 9‐26 years (Females 2006, Males 2009)
– Covers serotypes 6, 11, 16, 18
– 3‐shot series
• Nine‐valent Gardasil‐9® recently approved
– Also covers serotypes 31, 33, 45, 52 and 58
• Bivalent (Cervarix®) – Approved for women only
– Covers serotypes 16 and 18
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05/08/2015
It Works!
• Smith LM, et al "The early benefits of human papillomavirus vaccination on cervical dysplasia and anogenital warts" Pediatrics
2015; DOI: 10.1542/peds.2014‐2961.
• 26,000 teen girls in Ontario, Canada
• Among those receiving all three doses of Gardasil, compared to unvaccinated peers:
– 44% less likely to be diagnosed with cervical dysplasia
– 43% less likely to be diagnosed with genital warts during high school.
Diagnosis of Genital Warts
• Usually made by visual inspection
• Can be confirmed by biopsy when:
– Diagnosis is uncertain
– Immunocompromised patients
– Atypical warts (pigmented, indurated, or fixed)
– Unresponsive to standard treatment
CDC Recommended Regimens for External Genital Warts
• Patient‐Applied:
Podofilox 0.5% solution or gel
OR
Imiquimod 5% cream
OR
Sinecatechins 15% ointment
• Provider–Administered:
Cryotherapy with liquid nitrogen or cryoprobe. Repeat applications every 1–2 weeks.
OR
Podophyllin resin 10%–25% in a compound tincture of benzoin
OR
Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80%–90%
OR
Surgical removal either by tangential scissor excision, tangential shave excision, curettage, or electrosurgery.
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Indications for Pap Testing
• Among adolescents, genital HPV infection is transient and has no clinic manifestations or sequelae
• The USPSTF (2012) recommends against screening for cervical cancer in women younger than age 21 years.
• Annual pelvic examination should be performed among sexually active patients
Chlamydia
• Most common reportable STI
• >50% asymptomatic
• Symptoms
– Males
• Urethritis ‐ clear, mucoid, or mucopurulent discharge
– Females • Cervicitis ‐ mucopurulent endocervical discharge
• Urethritis – dysuria, pyuria (nitrate negative UA)
• Abdominal and/or pelvic pain, menometrorrhagia**
Diagnostic Testing
• While endocervical or urethral culture is still the gold standard in women, the nucleic acid amplification tests (NAAT) offer real‐world advantages
• Urine‐based testing is the standard in males
• Urine‐based testing with equivalent specificity
• Sensitivity is equivalent to culture except for GC in women
• Can detect gonorrhea with same sample
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05/08/2015
CDC Recommended Treatment of Uncomplicated Genital Chlamydia
• Azithromycin 1 g orally in a single dose
• OR
• Doxycycline 100 mg orally twice a day for 7 days
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Alternative Regimens
Erythromycin base 500 mg orally four times a day for 7 days
OR
Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days
OR
Levofloxacin 500 mg orally once daily for 7 days
OR
Ofloxacin 300 mg orally twice a day for 7 days
Gonorrhea
• Second most common reportable STI
• May be asymptomatic
• Symptoms
– Males – urethritis, purulent discharge
– Females • Cervicitis – endocervial discharge • Urethritis
• Abdominal and/or pelvic pain, menometrorrhagia
• Diagnosis similar to CT (NAAT or culture)
2012 CDC Gonorrhea Treatment Changes
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Oral Cephalosporins No Longer a Recommended Treatment for Gonococcal Infections
Recommended regimen
– Ceftriaxone 250 mg in a single intramuscular dose
PLUS
– Azithromycin 1 g orally in a single dose OR doxycycline 100 mg orally twice daily for 7 days
Alternative regimens
1) If ceftriaxone is not available:
– Cefixime 400 mg in a single oral dose
PLUS
– Azithromycin 1 g orally in a single dose OR doxycycline 100 mg orally twice daily for 7 days
PLUS Test‐of‐cure culture in 1 week
2) If the patient has severe cephalosporin allergy:
– Azithromycin 2 g in a single oral dose
PLUS Test‐of‐cure culture in 1 week
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05/08/2015
Annual STI Screening: Non‐Pregnant Females
• The USPSTF recommends annual chlamydia and gonorrhea screening for all sexually active women younger than 25 years (including adolescents), even if they are not engaging in high‐risk sexual behaviors
• And 3 month screening for reinfection among those with a history of STI**
• The USPSTF recommends HIV and syphilis screening for women who engage in high‐risk sexual behavior
• having multiple current partners, prior STI, having a new partner, using condoms inconsistently, having sex while under the influence of alcohol or drugs, having sex in exchange for money or drugs.
• Cervical specimen is gold standard but vaginal/urine based testing is becoming more commonplace
Annual STI Screening – Males
• The USPSTF does not recommend STI screening for men who are not at increased risk. • However I offer to each of my sexually active male patients.
• The USPSTF recommends HIV and syphilis screening for men engaging in high‐risk sexual behaviors (same as previous slide).
Not Part of Routine Screening
• Per USPSTF, the following are not recommended for routine screening (males and non‐pregnant females):
– Hepatitis B
– Hepatitis C
– HSV
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05/08/2015
Herpes Simplex Virus (HSV)
• HSV‐1 – more commonly orolabial
• HSV‐2 – more commonly anogenital
• First episode
– Multiple lesions, more severe, last longer
• Recurrent Infection
– Tingling prodrome 1‐2 days prior, less severe, more common in HSV‐2
• Progression
– Papules ‐> Vesicles ‐> Ulcers ‐> Crusts ‐> Clearing
HSV Testing
• Viral culture
– Gold standard
– High specificity, sensitivity wanes with resolution
– Preferred for genital lesions or abuse cases
• PCR and Antigen tests
– Increased sensitivity
– PCR preferred for CSF samples
• Tzanck Cytology
– No longer commonly used for diagnosis
CDC Recommended Treatment for First Genital HSV Episode
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Acyclovir 400 mg orally three times a day for 7–10 days
OR
Acyclovir 200 mg orally five times a day for 7–10 days
OR
Famciclovir 250 mg orally three times a day for 7–10 days
OR
Valacyclovir 1 g orally twice a day for 7–10 days
*Treatment can be extended if healing is incomplete after 10 days of therapy.
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05/08/2015
CDC Recommended Treatment for Recurrent Genital HSV Episodes
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Acyclovir 400 mg orally three times a day for 5 days
OR
Acyclovir 800 mg orally twice a day for 5 days
OR
Acyclovir 800 mg orally three times a day for 2 days
OR
Famciclovir 125 mg orally twice daily for 5 days
OR
Famciclovir 1000 mg orally twice daily for 1 day
OR
Famciclovir 500 mg once, followed by 250 mg twice daily for 2 days
OR
Valacyclovir 500 mg orally twice a day for 3 days
OR
Valacyclovir 1 g orally once a day for 5 days
Trichomoniasis
• Anaerobic organism
• Symptoms of vaginitis
– “Frothy” vaginal discharge and itching
– Classic presentation of cervical petechie (strawberry cervix) rare
• Can be asymptomatic
Trichomoniasis – Diagnosis
• Saline Wet Mount
– Flagellated trichomonads
– pH>4.5
• Culture
– Gold standard in forensic cases
• Vaginal NAAT or Urine PCR specimen more sensitive than wet mount
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05/08/2015
Wet Prep: Trichomoniasis Saline: 40X objective
PMN
Yeast
buds
Trichomonas*
Trichomonas*
PMN
*Trichomonas shown for size reference only: must be motile for identification
Source: Seattle STD/HIV Prevention Training Center, from CDC
Squamous
epithelial
cells
STD Curriculum
CDC Recommended Treatment of Trichomoniasis
• Metronidazole 2 g orally in a single dose
OR
Tinidazole 2 g orally in a single dose
• Alternative Regimen
Metronidazole 500 mg orally twice a day for 7 days
Patients should abstain from alcohol during treatment
Syphilis
• Primary
– Chancre – classically painless ulcer with smooth, firm borders
– Resolves in 1‐5 weeks
• Secondary
– Appears 2‐8 weeks after chancre, resolves in 2‐10 weeks
– Patches that may involve the palms and soles
• May be mistaken for pityriasis rosea
– Condyloma lata
• Tertiary (gummatous, neurosyphilis, cardiovascular)
– >3 years after initial infection
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05/08/2015
?Condyloma Confusion?
• Condyloma acuminata
– From HPV
• Condyloma lata
– From syphilis
• Lata is Less common
Syphilis ‐ Testing • Non‐treponemal for qualitative screening
– RPR/VDRL
– Looks for anti‐lipid antibodies in host
– Normalize after treatment
• If positive, then treponemal testing
– MHA‐TP
– FTA‐ABS
– Looks for T. pallidum antibodies
– Stay positive for life even after treatment
CDC Recommended Treatment of Syphilis • Primary and Secondary
– Benzathine penicillin G 2.4 million units IM in a single dose
• Tertiary Syphilis
– Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units IM each at 1‐week intervals
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Management of Partners
• Partners of those testing positive for STI must be treated.
• Reportable cases may be managed by public health department.
• Expedited Partner Therapy (EPT)
– In most states, including MO and all surrounding states, providers may prescribe STI treatment to non‐patients.
– As of April 2015, EPT is prohibited in FL, KY, OH, and WV.
References
• CDC Clinical Slides and STD Curriculum
http://www.cdc.gov/Std/training/
• CDC Treatment Guidelines
http://www.cdc.gov/std/treatment/2010/
‐ An app is available
Contact Information
[email protected]
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