Common S exually Tra n s m i t t e d In f e c t i o n s i n Adolescents Erica J. Gibson, MDa,*, David L. Bell, Sherine A. Powerfulb
MD, MPH
a
,
KEYWORDS Sexually transmitted infections Symptoms Management Treatment Adolescent Health KEY POINTS Sexually transmitted infections (STIs) have a significant impact on the health of sexually active young people. Medical providers should be alert for both asymptomatic and symptomatic STIs. Following screening guidelines and using appropriate diagnostic testing provides for timely and effective treatment of STIs. Using effective primary treatment regimens with timely follow-up is essential for the treatment of STIs and prevention of complications. Diagnosis of an STI can be substantial for all, and in particular for adolescents. Effective empathy and counseling are essential aspects of diagnosis and treatment.
GENERAL BACKGROUND
Sexually transmitted infections (STIs) are a common cause of morbidity in sexually active adolescents and may be caused by bacteria, viruses, protozoa, parasites, or fungi. The most common viral STI is human papillomavirus (HPV), and the most common bacterial STI is chlamydia.1 Other common infections in adolescents include gonorrhea, syphilis, trichomonas, and herpes simplex virus (HSV). Some bacterial STIs, such as chlamydia, are curable with antibiotics. Others such as HSV persist in the body in dormant and active states, as there are no currently available curative treatments. Assorted complications of STIs include: Severe infections Chronic pain
a Columbia University Medical Center, New York Presbyterian Hospital, 60 Haven Avenue, B-3, New York, NY 10032, USA; b Department of Population & Family Health, Columbia University Medical Center, 60 Haven Avenue, B-3, New York, NY 10032, USA * Corresponding author. E-mail address: [email protected]
Prim Care Clin Office Pract 41 (2014) 631–650 http://dx.doi.org/10.1016/j.pop.2014.05.011 primarycare.theclinics.com 0095-4543/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
632
Gibson et al
Infertility Cancer Ectopic pregnancy Deleterious effects in utero
Half of the nearly 20 million new STIs every year in the United States occur in youth between 15 and 24 years of age. This percentage is remarkable because 15- to 24year-olds represent just 25% of the sexually experienced population in the United States.1 Because of a variety of factors, many adolescents’ sexual practices and behaviors put them at risk for acquiring STIs. These risk factors include2,3:
Early age at sexual initiation Having multiple sex partners concurrently Having sequential sex partners of limited duration Having increased biological susceptibility to infection Failing to use barrier protection consistently and correctly Experiencing multiple obstacles to accessing health care
There are significant disparities in the STI rates for young people of different ages, gender, and sexual orientation. The highest rates of STIs are in young adults and adolescents, but detection of these infections depends greatly on the different screening recommendations for each STI, as many infections are asymptomatic. In the United States, young women have the highest rates of chlamydia and HPV, whereas young men who have sex with men (MSM) are at increased risk for contracting syphilis and human immunodeficiency virus (HIV). Women who engage in sex with other women should still be considered at risk for acquiring STIs, and be offered routine screening as per recommendations for the heterosexual population. African Americans continue to have the highest STI prevalence rates in the United States, although Latinos and American Indian/Alaskan Natives also have higher rates than whites. Asians have lower rates than whites.1 Special Considerations STI prevention programs
A seminal report by Kirby4 provides a detailed review of the important characteristics of effective curriculum-based sex education programs, and states that the following factors can reduce the probability of a young person contracting an STI: Increasing abstinence (both delaying the initiation of sex and increasing the return to abstinence) Reducing the number of sexual partners Reducing the occurrence of concurrent partners Increasing the period of time between sexual partners Decreasing the frequency of sex Increasing the correct and consistent use of condoms Increasing testing and treatment of STIs Being vaccinated against STIs for which vaccines are available Being circumcised (boys) Expedited partner therapy
The Centers for Disease Control and Prevention (CDC) emphasizes 5 main areas that need to be addressed in preventing STIs, which include much of the aforesaid but also address the importance of partner evaluation and treatment.3 Expedited partner therapy (EPT) is one of the newest public health strategies to influence partner
Sexually Transmitted Infections in Adolescents
treatment, particularly for chlamydia. EPT refers to the ability of a provider to dispense medication for partners to the patient, and has been shown to be as good as or better than standard partner referral options.5,6 The American Medical Association, the American Academy of Pediatrics (AAP), The American Academy of Family Practitioners, The American College of Gynecologists, and The Society for Adolescent Health and Medicine all support EPT.7–11 EPT is legal in certain states for certain STIs.12 Condom use
More adolescents are using condoms at first intercourse than in the past. Sixty-eight percent of females and 80% of males aged 15 to 19 years reported using condoms at first sex in 2010, representing a significant increase from 2002 to 2010.13 Other barrier methods, dental dams, and female condoms are infrequently used. Although condom use has increased overall, consistent condom use is still a challenge. The maturation of thinking processes, along with cultural and relationship contexts of condom use, create challenges to influence change in risk-reduction behavior toward more consistent condom use.14 The contextual challenge to choosing risk-reduction messages is that our culture presents mixed messages related to condom use: irresponsibility for wanting to have sex but responsibility for using condoms. Condoms represent responsibility on one hand and distrust in relationships on the other hand. Influencing consistent condom use will require messaging that supports personal responsibility, safety, and trust in relationships. Confidentiality
Confidentiality is an important element in providing quality care to adolescents. In primary care settings, this is achieved by structuring portions of the visit with an adolescent without the parent. Frank discussions about confidentiality improve rates of honest disclosures to the provider.15 It is important to be aware of structural barriers to confidentiality, such as the requirement for private insurance companies to send explanation of benefits (EOBs) so as to be transparent regarding medical costs and billing.3 Parents might realize that their adolescent was screened for STIs and infer sexual activity. On-site distribution of medications may also help ensure confidentiality. In choosing medication regimens many patients, in particular adolescents, adhere best to the simplest dosing regimens (eg, once-daily dosing) whenever possible, which may also promote greater degrees of confidentiality. Circumcision
Male circumcision (MC) has been associated with specific decreased risks for STIs and HIV. MC is associated with a lower risk of chancroid and syphilis, but not necessarily HSV-2.16 In Africa, where there is a higher incidence of HIV transmission among men who have sex with women, studies indicated that MC is associated with a 60% decreased risk of acquisition of HIV by heterosexual males.17–19 However, there is no protective effect for women or for MSM.17–20 Owing to the lack of generalizability of these studies to the United States, an expert panel suggests that heterosexually active noncircumcised adolescent and adult males be informed about the significant but partial efficacy of MC in reducing the risk for HIV acquisition. Condom use is still the most effective means of STI prevention; however, if an uncircumcised male chooses to consider MC, the panel recommends that he be provided with affordable access to voluntary, high-quality surgical and risk-reduction counseling services.21 Though controversial, the AAP now endorses newborn male circumcision but does not recommend universal MC.21,22
633
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Gibson et al
Health education
One challenge is to develop and engage adolescents in sexual health discussions appropriate for their developmental level. The younger adolescents are, the more likely their cognitive processing will be more concrete and that they may not be developmentally able to comprehend long-term future consequences. Younger and some older adolescents lack personal life experiences and are unable to abstractly locate themselves in a theoretical future position; or empathetically place themselves in another’s experience to influence their own behaviors. Therefore, to be effective, health education messages would need to be as specific as possible, aimed at specific risk behaviors identified. It is important for these discussions to be thorough, genuine, nonjudgmental, and confidential, to increase the likelihood of honest and full disclosures of risk behaviors. In addition, print or electronic educational materials should always be offered, as a young patient may not absorb educational information while in the clinic and/or receiving bad news or treatment. Health literacy should be assessed in all situations. MOST COMMON BACTERIAL INFECTIONS
See Table 1 for a summary. Chlamydia Organism/Transmission/Epidemiology
Chlamydia trachomatis serovars D to K are transmitted through oral, vaginal, or anal sexual contact. Female adolescents are especially at risk for contracting chlamydia for a variety of reasons: Columnar epithelium of ectocervix is more susceptible to pathogens Lower estrogen levels result in a weaker cervical mucus barrier Thinner genital tissue is more vulnerable to trauma Females between 15 and 19 and from 20 to 24 years of age have the highest chlamydia prevalence rates in the United States. Overall rates for males are much lower than for females, but are highest in the 20- to 24-year age group.1 Higher reporting rates of chlamydia in females might be due to the fact that there is greater surveillance of females. Screening
The CDC and the US Preventive Services Task Force (USPSTF) recommends that all sexually active females 25 years old or younger be screened annually for chlamydia.3 Although routine screening of young asymptomatic males is not routinely recommended, it should be considered in those who are at risk for infection. Symptoms
It is important to bear in mind that most male and female patients infected with chlamydia are asymptomatic.23,24 Symptoms can include: Females: Vaginal discharge or bleeding Dysuria Abdominal/pelvic pain Males: Testicular pain Penile discharge Dysuria
Sexually Transmitted Infections in Adolescents
Diagnosis
At present, nucleic acid amplification tests (NAATs) are the preferred method for testing for chlamydia. The current NAATs on the market test for chlamydia and gonorrhea simultaneously. Females: The best sample is obtained from a patient- or provider-collected vaginal swab or endocervical sample; research has shown that vaginal swabs identify as many infected patients as cervical swabs and that acceptance of selfswabbing by patients is high.25,26 Urine samples are sensitive and specific; a first void sample of 10 to 30 mL should be obtained 1 hour or later after last void. Males: Urine screening is the preferred strategy.27 Most NAATs are not cleared by the Food and Drug Administration (FDA) for rectal and pharyngeal specimens. However, some laboratories have met Clinical Laboratory Improvement Amendments (CLIA) requirements, and have validated NAAT testing on rectal and pharyngeal swabs.28 Management
If history, physical examination, or laboratory results indicate chlamydia infection, treat with antibiotics as per the CDC sexually transmitted diseases treatment guidelines, 2010.3 To maximize compliance, directly observed treatment on-site should be provided for STIs whenever possible. Preferred treatment regimen: Azithromycin 1 g by mouth (PO) 1 or Doxycycline 100 mg PO twice daily (BID) 7 days Patients should be instructed to abstain from sexual intercourse for 7 days after completion of treatment. Persons who have already had chlamydia and were treated can be reinfected, so it is recommended that all adolescents who test positive for chlamydia be screened again in 3 to 6 months for reinfection. A test of cure is no longer recommended.3 EPT for chlamydia is legal in many states and should be provided whenever possible. Chlamydia is a CDC-mandated reportable disease, so reporting is required as per individual state department of health requirements. Gonorrhea Organism/Transmission/Epidemiology
Neisseria gonorrhoeae is transmitted through oral, vaginal, or anal sex. Gonorrhea is the second most commonly reported STI, with rates highest among the adolescent and young adult age groups.3,24 Screening
Widespread screening for gonorrhea is not recommended.3 Health care providers should consider local gonorrhea epidemiology when making screening decisions. The CDC supports USPSTF recommendations: Females: Target sexually active females 25 years old or younger, including those who are pregnant, who are at increased risk of infection. Among the risk factors to consider are3: - Previous STI infection
635
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Gibson et al
Table 1 Most common STIs in adolescents: quick reference Preferred Outpatient Diagnostic Tests
Primary CDC Treatment Guidelines3
Females: 25 y, yearly Males: Only those at risk for infectiona
NAAT
Azithromycin 1 g PO 1 or Doxycycline 100 mg PO BID 7 db
Males and females at risk for infectiona
NAAT
Ceftriaxone 250 mg IM 1 plus azithromycin 1 g PO 1 or Doxycycline 100 mg PO BID 7 db
Symptoms in Adolescents
Screening Recommendations3,5
Chlamydia
1. 2. 3. 4.
Asymptomatic Discharge Dysuria Pelvic/abdominal pain
Gonorrhea
1. 2. 3. 4.
Asymptomatic Discharge Dysuria Pelvic/abdominal pain
Syphilis
MSM: Annual screening 1. Primary: painless papule/ Others: selective and based on chancre, swollen lymph nodes local epidemiology 2. Secondary: reddish-brown rash, condyloma lata, systemic symptoms 3. Tertiary: infection spreads to various organ systems
Trichomonas
1. Asymptomatic 2. Diffuse, frothy, yellow-green vaginal discharge
Not routinely recommendeda
VDRL and RPR nontreponemal Primary: benzathine penicillin G tests with confirmatory FTA-ABS 2.4 million units IM 1c treponemal test for positives
TMA and RAT
Metronidazole 2 g PO 1 or Tinidazole 2 g PO 1 dose
HPV
1. Asymptomatic 2. Genital warts
Females: Pap smear for cervical neoplasia at age 21 y
Pap smear, HPV serology should not be sent for patients younger than 30 y
1. Warts: patient or provider applied topical regimens 2. Cervical neoplasia managementd
HSV
1. Asymptomatic 2. Blisters/ulcerations 3. Headache, fever, malaise
Not routinely recommendeda
Viral culture, polymerase chain reaction, antibody-based tests
Primary episode: Acyclovir 400 mg PO TID 7–10 d Valacyclovir 1 g PO BID 7–10 d Recurrence: Acyclovir 800 mg PO BID 5 d Valacyclovir 500 mg PO BID 3 de
HIV
1. Asymptomatic 2. Acute retroviral syndrome: fever, malaise, lymphadenopathy, rash
Should be offered at least once Conventional or rapid EIA to all patients age 13–64 y
Per-patient status and most recent CDC guidelines
Sexually Transmitted Infections in Adolescents
Abbreviations: BID, twice daily; CDC, Centers for Disease Control and Prevention; EIA, enzyme immunoassay; FTA-ABS, fluorescent treponemal antibody– absorbed; HIV, human immunodeficiency virus; HPV, human papillomavirus; HSV, herpes simplex virus; IM, intramuscularly; MSM, men who have sex with men; NAAT, nucleic acid amplification testing; Pap, Papanicolaou; PO, by mouth; RAT, rapid antigen testing; RPR, rapid plasma reagin; TID, 3 times daily; TMA, transcription-mediated amplification assay; VDRL, Venereal Disease Research Laboratory. a See text for situations when screening might be recommended. b See text for pelvic inflammatory disease regimen. c See text for secondary and tertiary treatment regimens. d See text for details of management. e See text for extensive additional primary treatment regimens.
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Gibson et al
New or multiple sex partners Inconsistent condom use Universal screening for adult females up to the age of 35 years should be conducted at intake in jail facilities or based on local institutional prevalence data. Males: Screening should be considered in those who are at risk for infection. MSM who engage in receptive anal or oral sex should be screened for rectal and pharyngeal gonorrhea infection.3 -
Symptoms
Most females with gonorrhea are asymptomatic, so screening is critical. Most men with infection have symptoms. Symptoms can appear 2 to 5 days after infection. Often the infection lies dormant for up to 30 days.29 Symptoms can include: Females: Dysuria Vaginal discharge or bleeding Males: Dysuria Purulent discharge Sore throat (rare) Complications
Females: Pelvic inflammatory disease Infertility Spontaneous abortion in the first trimester Ectopic pregnancy Males: Epididymitis Prostatitis Increased susceptibility to acquiring HIV29 Diagnosis
NAATs represent the preferred approach for testing for oral, urine, vaginal, and anal specimens.3 As with chlamydia testing, patient- or provider-collected vaginal swabs are the preferred method of collection in women. Most NAATs are not FDA-cleared for rectal and pharyngeal specimens. However, some laboratories have met CLIA requirements and have validated NAAT testing on rectal and pharyngeal swabs.28 Cultures and antibiotic sensitivity testing are preferred for subsequent testing for antibiotic resistance. Gram stains in symptomatic males with urethral discharge can be considered diagnostic. Management
If history, physical examination, or laboratory results indicate gonorrhea infection, treat with antibiotics as per the CDC guidelines. Preferred treatment regimen3: Ceftriaxone 250 mg intramuscularly (IM) 1 Plus: Azithromycin 1 g PO 1 or doxycycline 100 mg BID 7 days
Sexually Transmitted Infections in Adolescents
Dual therapy has been recommended since 2010 because of the decreased susceptibility of Neisseria gonorrhea to cephalosporins.30 The additional oral therapy also covers chlamydia, which is a frequent coinfection with gonorrhea. On a global level, strains of gonorrhea show resistance to treatments such as ciprofloxacin (Europe, Asia, Central Asia, the South Pacific, California, Hawaii), penicillin, tetracycline, and spectinomycin.31,32 Persons who have already had gonorrhea and have undergone treatment can be reinfected, so it is recommended that all adolescents who test positive for gonorrhea be screened again in 3 to 6 months for reinfection. Given the newer recommendation against oral therapy alone for the treatment of gonorrhea (cefixime plus azithromycin or doxycycline), EPT is not as feasible, even though in certain states it is legal for gonorrhea.8,10,11 Gonorrhea is a CDC-mandated reportable disease, so reporting is required as per individual state department of health requirements. Syphilis Organism/Transmission/Epidemiology
The spirochete bacterium Treponema pallidum is transmitted through unprotected oral, vaginal, or anal sexual contact.3,33 The prevalence of syphilis among adolescents is not as high as in other STIs. Rates are higher among young adult men, particularly among the MSM population.1 Screening
Routine screening is not recommended except for: Persons at increased risk for syphilis, in particular, MSM3 All pregnant women Screening of other patients should be selective and based on local health department epidemiology.3 Symptoms Early syphilis
Defined as the stages of syphilis (primary, secondary, and early latent) that tend to occur within the first year of the infection.3 Primary syphilis: Begins between 14 and 21 days after exposure Small painless papule emerges, evolves into small painless ulcer called a chancre, accompanied by swollen lymph nodes24,25 Initial chancre resolves on its own after 3 to 6 weeks Secondary syphilis: Occurs a few weeks to a few months after primary stage In untreated patients, occasionally relapses can occur for up to 5 years A symmetric reddish-brown rash emerges on abdomen and extremities, including palms and soles Condyloma lata; weeping lesions in the genitals and anus might also occur Other signs and symptoms such as fever, malaise, weight loss, sore throat, hair loss, weight loss, anorexia, and fever can also occur Various signs and symptoms contribute to syphilis being known as the “great imitator” Can resolve on its own, even in the absence of therapy
639
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Gibson et al
Early latent syphilis: Patients are potentially infectious in early latent stage (
MD, MPH
a
,
KEYWORDS Sexually transmitted infections Symptoms Management Treatment Adolescent Health KEY POINTS Sexually transmitted infections (STIs) have a significant impact on the health of sexually active young people. Medical providers should be alert for both asymptomatic and symptomatic STIs. Following screening guidelines and using appropriate diagnostic testing provides for timely and effective treatment of STIs. Using effective primary treatment regimens with timely follow-up is essential for the treatment of STIs and prevention of complications. Diagnosis of an STI can be substantial for all, and in particular for adolescents. Effective empathy and counseling are essential aspects of diagnosis and treatment.
GENERAL BACKGROUND
Sexually transmitted infections (STIs) are a common cause of morbidity in sexually active adolescents and may be caused by bacteria, viruses, protozoa, parasites, or fungi. The most common viral STI is human papillomavirus (HPV), and the most common bacterial STI is chlamydia.1 Other common infections in adolescents include gonorrhea, syphilis, trichomonas, and herpes simplex virus (HSV). Some bacterial STIs, such as chlamydia, are curable with antibiotics. Others such as HSV persist in the body in dormant and active states, as there are no currently available curative treatments. Assorted complications of STIs include: Severe infections Chronic pain
a Columbia University Medical Center, New York Presbyterian Hospital, 60 Haven Avenue, B-3, New York, NY 10032, USA; b Department of Population & Family Health, Columbia University Medical Center, 60 Haven Avenue, B-3, New York, NY 10032, USA * Corresponding author. E-mail address: [email protected]
Prim Care Clin Office Pract 41 (2014) 631–650 http://dx.doi.org/10.1016/j.pop.2014.05.011 primarycare.theclinics.com 0095-4543/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
632
Gibson et al
Infertility Cancer Ectopic pregnancy Deleterious effects in utero
Half of the nearly 20 million new STIs every year in the United States occur in youth between 15 and 24 years of age. This percentage is remarkable because 15- to 24year-olds represent just 25% of the sexually experienced population in the United States.1 Because of a variety of factors, many adolescents’ sexual practices and behaviors put them at risk for acquiring STIs. These risk factors include2,3:
Early age at sexual initiation Having multiple sex partners concurrently Having sequential sex partners of limited duration Having increased biological susceptibility to infection Failing to use barrier protection consistently and correctly Experiencing multiple obstacles to accessing health care
There are significant disparities in the STI rates for young people of different ages, gender, and sexual orientation. The highest rates of STIs are in young adults and adolescents, but detection of these infections depends greatly on the different screening recommendations for each STI, as many infections are asymptomatic. In the United States, young women have the highest rates of chlamydia and HPV, whereas young men who have sex with men (MSM) are at increased risk for contracting syphilis and human immunodeficiency virus (HIV). Women who engage in sex with other women should still be considered at risk for acquiring STIs, and be offered routine screening as per recommendations for the heterosexual population. African Americans continue to have the highest STI prevalence rates in the United States, although Latinos and American Indian/Alaskan Natives also have higher rates than whites. Asians have lower rates than whites.1 Special Considerations STI prevention programs
A seminal report by Kirby4 provides a detailed review of the important characteristics of effective curriculum-based sex education programs, and states that the following factors can reduce the probability of a young person contracting an STI: Increasing abstinence (both delaying the initiation of sex and increasing the return to abstinence) Reducing the number of sexual partners Reducing the occurrence of concurrent partners Increasing the period of time between sexual partners Decreasing the frequency of sex Increasing the correct and consistent use of condoms Increasing testing and treatment of STIs Being vaccinated against STIs for which vaccines are available Being circumcised (boys) Expedited partner therapy
The Centers for Disease Control and Prevention (CDC) emphasizes 5 main areas that need to be addressed in preventing STIs, which include much of the aforesaid but also address the importance of partner evaluation and treatment.3 Expedited partner therapy (EPT) is one of the newest public health strategies to influence partner
Sexually Transmitted Infections in Adolescents
treatment, particularly for chlamydia. EPT refers to the ability of a provider to dispense medication for partners to the patient, and has been shown to be as good as or better than standard partner referral options.5,6 The American Medical Association, the American Academy of Pediatrics (AAP), The American Academy of Family Practitioners, The American College of Gynecologists, and The Society for Adolescent Health and Medicine all support EPT.7–11 EPT is legal in certain states for certain STIs.12 Condom use
More adolescents are using condoms at first intercourse than in the past. Sixty-eight percent of females and 80% of males aged 15 to 19 years reported using condoms at first sex in 2010, representing a significant increase from 2002 to 2010.13 Other barrier methods, dental dams, and female condoms are infrequently used. Although condom use has increased overall, consistent condom use is still a challenge. The maturation of thinking processes, along with cultural and relationship contexts of condom use, create challenges to influence change in risk-reduction behavior toward more consistent condom use.14 The contextual challenge to choosing risk-reduction messages is that our culture presents mixed messages related to condom use: irresponsibility for wanting to have sex but responsibility for using condoms. Condoms represent responsibility on one hand and distrust in relationships on the other hand. Influencing consistent condom use will require messaging that supports personal responsibility, safety, and trust in relationships. Confidentiality
Confidentiality is an important element in providing quality care to adolescents. In primary care settings, this is achieved by structuring portions of the visit with an adolescent without the parent. Frank discussions about confidentiality improve rates of honest disclosures to the provider.15 It is important to be aware of structural barriers to confidentiality, such as the requirement for private insurance companies to send explanation of benefits (EOBs) so as to be transparent regarding medical costs and billing.3 Parents might realize that their adolescent was screened for STIs and infer sexual activity. On-site distribution of medications may also help ensure confidentiality. In choosing medication regimens many patients, in particular adolescents, adhere best to the simplest dosing regimens (eg, once-daily dosing) whenever possible, which may also promote greater degrees of confidentiality. Circumcision
Male circumcision (MC) has been associated with specific decreased risks for STIs and HIV. MC is associated with a lower risk of chancroid and syphilis, but not necessarily HSV-2.16 In Africa, where there is a higher incidence of HIV transmission among men who have sex with women, studies indicated that MC is associated with a 60% decreased risk of acquisition of HIV by heterosexual males.17–19 However, there is no protective effect for women or for MSM.17–20 Owing to the lack of generalizability of these studies to the United States, an expert panel suggests that heterosexually active noncircumcised adolescent and adult males be informed about the significant but partial efficacy of MC in reducing the risk for HIV acquisition. Condom use is still the most effective means of STI prevention; however, if an uncircumcised male chooses to consider MC, the panel recommends that he be provided with affordable access to voluntary, high-quality surgical and risk-reduction counseling services.21 Though controversial, the AAP now endorses newborn male circumcision but does not recommend universal MC.21,22
633
634
Gibson et al
Health education
One challenge is to develop and engage adolescents in sexual health discussions appropriate for their developmental level. The younger adolescents are, the more likely their cognitive processing will be more concrete and that they may not be developmentally able to comprehend long-term future consequences. Younger and some older adolescents lack personal life experiences and are unable to abstractly locate themselves in a theoretical future position; or empathetically place themselves in another’s experience to influence their own behaviors. Therefore, to be effective, health education messages would need to be as specific as possible, aimed at specific risk behaviors identified. It is important for these discussions to be thorough, genuine, nonjudgmental, and confidential, to increase the likelihood of honest and full disclosures of risk behaviors. In addition, print or electronic educational materials should always be offered, as a young patient may not absorb educational information while in the clinic and/or receiving bad news or treatment. Health literacy should be assessed in all situations. MOST COMMON BACTERIAL INFECTIONS
See Table 1 for a summary. Chlamydia Organism/Transmission/Epidemiology
Chlamydia trachomatis serovars D to K are transmitted through oral, vaginal, or anal sexual contact. Female adolescents are especially at risk for contracting chlamydia for a variety of reasons: Columnar epithelium of ectocervix is more susceptible to pathogens Lower estrogen levels result in a weaker cervical mucus barrier Thinner genital tissue is more vulnerable to trauma Females between 15 and 19 and from 20 to 24 years of age have the highest chlamydia prevalence rates in the United States. Overall rates for males are much lower than for females, but are highest in the 20- to 24-year age group.1 Higher reporting rates of chlamydia in females might be due to the fact that there is greater surveillance of females. Screening
The CDC and the US Preventive Services Task Force (USPSTF) recommends that all sexually active females 25 years old or younger be screened annually for chlamydia.3 Although routine screening of young asymptomatic males is not routinely recommended, it should be considered in those who are at risk for infection. Symptoms
It is important to bear in mind that most male and female patients infected with chlamydia are asymptomatic.23,24 Symptoms can include: Females: Vaginal discharge or bleeding Dysuria Abdominal/pelvic pain Males: Testicular pain Penile discharge Dysuria
Sexually Transmitted Infections in Adolescents
Diagnosis
At present, nucleic acid amplification tests (NAATs) are the preferred method for testing for chlamydia. The current NAATs on the market test for chlamydia and gonorrhea simultaneously. Females: The best sample is obtained from a patient- or provider-collected vaginal swab or endocervical sample; research has shown that vaginal swabs identify as many infected patients as cervical swabs and that acceptance of selfswabbing by patients is high.25,26 Urine samples are sensitive and specific; a first void sample of 10 to 30 mL should be obtained 1 hour or later after last void. Males: Urine screening is the preferred strategy.27 Most NAATs are not cleared by the Food and Drug Administration (FDA) for rectal and pharyngeal specimens. However, some laboratories have met Clinical Laboratory Improvement Amendments (CLIA) requirements, and have validated NAAT testing on rectal and pharyngeal swabs.28 Management
If history, physical examination, or laboratory results indicate chlamydia infection, treat with antibiotics as per the CDC sexually transmitted diseases treatment guidelines, 2010.3 To maximize compliance, directly observed treatment on-site should be provided for STIs whenever possible. Preferred treatment regimen: Azithromycin 1 g by mouth (PO) 1 or Doxycycline 100 mg PO twice daily (BID) 7 days Patients should be instructed to abstain from sexual intercourse for 7 days after completion of treatment. Persons who have already had chlamydia and were treated can be reinfected, so it is recommended that all adolescents who test positive for chlamydia be screened again in 3 to 6 months for reinfection. A test of cure is no longer recommended.3 EPT for chlamydia is legal in many states and should be provided whenever possible. Chlamydia is a CDC-mandated reportable disease, so reporting is required as per individual state department of health requirements. Gonorrhea Organism/Transmission/Epidemiology
Neisseria gonorrhoeae is transmitted through oral, vaginal, or anal sex. Gonorrhea is the second most commonly reported STI, with rates highest among the adolescent and young adult age groups.3,24 Screening
Widespread screening for gonorrhea is not recommended.3 Health care providers should consider local gonorrhea epidemiology when making screening decisions. The CDC supports USPSTF recommendations: Females: Target sexually active females 25 years old or younger, including those who are pregnant, who are at increased risk of infection. Among the risk factors to consider are3: - Previous STI infection
635
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Gibson et al
Table 1 Most common STIs in adolescents: quick reference Preferred Outpatient Diagnostic Tests
Primary CDC Treatment Guidelines3
Females: 25 y, yearly Males: Only those at risk for infectiona
NAAT
Azithromycin 1 g PO 1 or Doxycycline 100 mg PO BID 7 db
Males and females at risk for infectiona
NAAT
Ceftriaxone 250 mg IM 1 plus azithromycin 1 g PO 1 or Doxycycline 100 mg PO BID 7 db
Symptoms in Adolescents
Screening Recommendations3,5
Chlamydia
1. 2. 3. 4.
Asymptomatic Discharge Dysuria Pelvic/abdominal pain
Gonorrhea
1. 2. 3. 4.
Asymptomatic Discharge Dysuria Pelvic/abdominal pain
Syphilis
MSM: Annual screening 1. Primary: painless papule/ Others: selective and based on chancre, swollen lymph nodes local epidemiology 2. Secondary: reddish-brown rash, condyloma lata, systemic symptoms 3. Tertiary: infection spreads to various organ systems
Trichomonas
1. Asymptomatic 2. Diffuse, frothy, yellow-green vaginal discharge
Not routinely recommendeda
VDRL and RPR nontreponemal Primary: benzathine penicillin G tests with confirmatory FTA-ABS 2.4 million units IM 1c treponemal test for positives
TMA and RAT
Metronidazole 2 g PO 1 or Tinidazole 2 g PO 1 dose
HPV
1. Asymptomatic 2. Genital warts
Females: Pap smear for cervical neoplasia at age 21 y
Pap smear, HPV serology should not be sent for patients younger than 30 y
1. Warts: patient or provider applied topical regimens 2. Cervical neoplasia managementd
HSV
1. Asymptomatic 2. Blisters/ulcerations 3. Headache, fever, malaise
Not routinely recommendeda
Viral culture, polymerase chain reaction, antibody-based tests
Primary episode: Acyclovir 400 mg PO TID 7–10 d Valacyclovir 1 g PO BID 7–10 d Recurrence: Acyclovir 800 mg PO BID 5 d Valacyclovir 500 mg PO BID 3 de
HIV
1. Asymptomatic 2. Acute retroviral syndrome: fever, malaise, lymphadenopathy, rash
Should be offered at least once Conventional or rapid EIA to all patients age 13–64 y
Per-patient status and most recent CDC guidelines
Sexually Transmitted Infections in Adolescents
Abbreviations: BID, twice daily; CDC, Centers for Disease Control and Prevention; EIA, enzyme immunoassay; FTA-ABS, fluorescent treponemal antibody– absorbed; HIV, human immunodeficiency virus; HPV, human papillomavirus; HSV, herpes simplex virus; IM, intramuscularly; MSM, men who have sex with men; NAAT, nucleic acid amplification testing; Pap, Papanicolaou; PO, by mouth; RAT, rapid antigen testing; RPR, rapid plasma reagin; TID, 3 times daily; TMA, transcription-mediated amplification assay; VDRL, Venereal Disease Research Laboratory. a See text for situations when screening might be recommended. b See text for pelvic inflammatory disease regimen. c See text for secondary and tertiary treatment regimens. d See text for details of management. e See text for extensive additional primary treatment regimens.
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New or multiple sex partners Inconsistent condom use Universal screening for adult females up to the age of 35 years should be conducted at intake in jail facilities or based on local institutional prevalence data. Males: Screening should be considered in those who are at risk for infection. MSM who engage in receptive anal or oral sex should be screened for rectal and pharyngeal gonorrhea infection.3 -
Symptoms
Most females with gonorrhea are asymptomatic, so screening is critical. Most men with infection have symptoms. Symptoms can appear 2 to 5 days after infection. Often the infection lies dormant for up to 30 days.29 Symptoms can include: Females: Dysuria Vaginal discharge or bleeding Males: Dysuria Purulent discharge Sore throat (rare) Complications
Females: Pelvic inflammatory disease Infertility Spontaneous abortion in the first trimester Ectopic pregnancy Males: Epididymitis Prostatitis Increased susceptibility to acquiring HIV29 Diagnosis
NAATs represent the preferred approach for testing for oral, urine, vaginal, and anal specimens.3 As with chlamydia testing, patient- or provider-collected vaginal swabs are the preferred method of collection in women. Most NAATs are not FDA-cleared for rectal and pharyngeal specimens. However, some laboratories have met CLIA requirements and have validated NAAT testing on rectal and pharyngeal swabs.28 Cultures and antibiotic sensitivity testing are preferred for subsequent testing for antibiotic resistance. Gram stains in symptomatic males with urethral discharge can be considered diagnostic. Management
If history, physical examination, or laboratory results indicate gonorrhea infection, treat with antibiotics as per the CDC guidelines. Preferred treatment regimen3: Ceftriaxone 250 mg intramuscularly (IM) 1 Plus: Azithromycin 1 g PO 1 or doxycycline 100 mg BID 7 days
Sexually Transmitted Infections in Adolescents
Dual therapy has been recommended since 2010 because of the decreased susceptibility of Neisseria gonorrhea to cephalosporins.30 The additional oral therapy also covers chlamydia, which is a frequent coinfection with gonorrhea. On a global level, strains of gonorrhea show resistance to treatments such as ciprofloxacin (Europe, Asia, Central Asia, the South Pacific, California, Hawaii), penicillin, tetracycline, and spectinomycin.31,32 Persons who have already had gonorrhea and have undergone treatment can be reinfected, so it is recommended that all adolescents who test positive for gonorrhea be screened again in 3 to 6 months for reinfection. Given the newer recommendation against oral therapy alone for the treatment of gonorrhea (cefixime plus azithromycin or doxycycline), EPT is not as feasible, even though in certain states it is legal for gonorrhea.8,10,11 Gonorrhea is a CDC-mandated reportable disease, so reporting is required as per individual state department of health requirements. Syphilis Organism/Transmission/Epidemiology
The spirochete bacterium Treponema pallidum is transmitted through unprotected oral, vaginal, or anal sexual contact.3,33 The prevalence of syphilis among adolescents is not as high as in other STIs. Rates are higher among young adult men, particularly among the MSM population.1 Screening
Routine screening is not recommended except for: Persons at increased risk for syphilis, in particular, MSM3 All pregnant women Screening of other patients should be selective and based on local health department epidemiology.3 Symptoms Early syphilis
Defined as the stages of syphilis (primary, secondary, and early latent) that tend to occur within the first year of the infection.3 Primary syphilis: Begins between 14 and 21 days after exposure Small painless papule emerges, evolves into small painless ulcer called a chancre, accompanied by swollen lymph nodes24,25 Initial chancre resolves on its own after 3 to 6 weeks Secondary syphilis: Occurs a few weeks to a few months after primary stage In untreated patients, occasionally relapses can occur for up to 5 years A symmetric reddish-brown rash emerges on abdomen and extremities, including palms and soles Condyloma lata; weeping lesions in the genitals and anus might also occur Other signs and symptoms such as fever, malaise, weight loss, sore throat, hair loss, weight loss, anorexia, and fever can also occur Various signs and symptoms contribute to syphilis being known as the “great imitator” Can resolve on its own, even in the absence of therapy
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Early latent syphilis: Patients are potentially infectious in early latent stage (
