Sexually Transmitted Infections
in the Adolescent, or
Germs of Endearment…
Ellen S. Rome, M.D., M.P.H.
Head, Section of Adolescent Medicine
Cleveland Clinic Children’s Hospital
Sexually Transmitted Diseases
in the Adolescent
• Affect at least 3 million teens in U.S.annually
• 1:8 teens ages 13-19 years has had an STD
• 1:4 sexually active teens has an STD
• 1 million cases each of HPV and chlamydia,
around 400,000 cases of N.gonorrhhoeae
• Left untreated, GC/CT cause 24,000
women/yr become infertile
• Cost of STDs per yr > $16.4 billion!
More Teen Stats
Forhan et al. Pediatrics 2009; 124:1505.
• n = 838 girls ages 14 to 19 from a nationally
representative National Health and Nutrition
Examination Survey 2003–2004
• History, PE, lab specimens for N.
gonorrhoeae, Chlamydia trachomatis,
Trichomonas vaginalis, herpes simplex virus
type 2, and human papillomavirus (any of 23
high-risk types or type 6 or 11).
Teen Sex
Foran et al, Pediatrics 2009
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1:4 of ALL kids sampled had an STI (24.1%)
37.7% of those who reported prior SA.
HPV in 18.3% = most common STI found
Chlamydia in 3.9%, HSV-2 in 2%, trich in 2%
1:4 (25.6% prevalence) of any of the STIs in
1st year of SA
• 1:5 (19.7%) had an STI even with only 1
lifetime partner.
Lessons from This Data
• Kids acquire STIs soon after coitarche, even
with few partners;
• EDUCATE EARLY
• Need to vaccinate for HPV BEFORE sexual
initiation, at 11-12 years as recommended
by AAP, ACOG, SAM, and AAFP
• Screen all SA teens for chlamydia
trachomatis
How To Ask the Questions
• Are you attracted to guys, girls, or both?
• Have you ever had sex? With guys, girls, or both?
– Oral, vaginal, anal?
– If yes, what did you use for protection?
– If condoms, did you use them sometimes, always, or
most of the time?
– Second method of contraception if having heterosexual
sex?
• Have you ever had a sexually transmitted disease?
If yes, which ones, and when? Have you ever been
pregnant?
• Has anyone ever done anything to you sexually that
made you uncomfortable? Tell me about that.
Have you ever had sex when you said, “No”?
Teens and STD’s
• With limited exceptions, all teens in
US can consent to the confidential dx
and treatment of STD’s
• Medical care for STD’s in teens can be
done WITHOUT parental consent or
knowledge
• May consent to HIV testing without
parental consent in many states
N.gonorrhoeae: Diagnosis
• Culture: gold standard, needed for sexual
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•
abuse cases
NAAT: best practice- sensitivity 90-97%
Urine testing best practice for guys,
self vaginal swab for girls per 2010 CDC
STD Treatment Guidelines
Uncomplicated Gonococcal
Infections of the Cervix, Urethra,
and Rectum: CDC 2010 Guidelines
RECOMMENDED:
• Cefixime 400 mg PO in a single dose + Azithromycin
1 g PO or doxycycline 100 mg PO bid x 7d
OR
• Ceftriaxone 250 mg IM in a single dose +
Azithromycin 1g PO or doxy 100 mg PO bid
ALTERNATIVES:
• Cefpodoxime 100 mg or cefuroxime 1 g
• Azithromycin 2 g PO (penicillin allergy)
Emerging Quinolone Resistance
• Quinolones should NOT be used for GC
treatment
• IF PID- consider Ceftriaxone 250 mg +
Azithromycin 1 g PO qweek for 2 weeks
Nongonococcal urethritis
• 23-35% caused by C.trachomatis
• Other pathogens: Ureaplasma urealyticum,
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Mycoplasma genitalium, trichomonas
vaginalis, HSV
Complications in men: epididymitis,
Reiter’s syndrome
Treatment: Azithromycin 1 g PO or
• Doxycycline 100 mg PO bid x 7 days
Recurrent and Persistent
Urethritis: 2010 CDC Guidelines
If the patient was compliant with the
initial regimen and rexposure can be
excluded:
• Metronidazole 2g PO x 1 dose
• Tinidazole 2g PO x 1 dose
PLUS
Azithromycin 1g PO if not given initially
Chlamydia trachomatis
• Most prevalent bacterial STD pathogen
• WHO: 50-70 million cases annually
• U.S.: 4 million cases annually, costs $2
•
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billion/yr to treat primary infection/sequelae
Screen annually, or 3-6 months after each
new partner
OBTAIN A CONFIDENTIAL HISTORY
Chlamydial Infection
CDC 2010 Treatment Guidelines
• Azithromycin 1 g PO x 1 dose (ok in
pregnancy)
• Doxycycline 100 mg PO bid x 7 days
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ALTERNATIVE REGIMENS
Erythromycin base 500 mg PO qid x 7 days
Erythromycin ethylsuccinate 800 mg qid x 7d
Ofloxicin 300 mg PO bid x 7 days
Levofloxacin 500 mg PO qd x 7 days
Patient-Delivered Partner Therapy
(PDPT)
Expedited Partner Therapy (EPT)
• Option for partner treatment among
heterosexual persons with chlamydia or GC
• EPT not recommended for MSM or syphilis
• Limited data for female trichomoniasis
partner management (Kissinger et al STD
2006;33:445-50). Among women with
trich, PDPT outcomes similar to standard
partner referral, but was less expensive.
Legal Status of EPT
(Expedited Partner Therapy)
• CDC tool to assist programs in each state to
understand the legal issues for using EPT as an
additional partner services tool- legal in 22 states
now
• Tool identifies legal provision that implicate a
clinician’s ability to provide chlamydia or
gonorrhea Tx for a patient’s sex partner without
prior evaluation of that partner
• Available at
www.cdc.gov/std/ept/legal/default.htm
GC/CT NAAT- what do these
initials mean???
• GC/CT – your favorite treatable STDs
• NAAT tests – Nucleic Acid Amplification Teststhe preferred way to diagnose these now
• Vaginal swabs now optimal female specimen
- approved for GenProbe's Aptima and BD's 2nd
generation ProbeTec.
ORAL AND RECTAL SWABS- NAATs available
from QUEST and Lab Corp.
Diagnosis of PID
• Problematic: asymptomatic infection can
still have serious sequelae
• Can get substantial tubal destruction even
without symptoms
• Problem of “silent PID”
• Gold standard = laparoscopy, but is $$$$,
surgical risk, need special skills
CDC 2010 Criteria for PID
• Minimum criteria: uterine OR adnexal
tenderness OR cervical motion
tenderness
• Additional useful criteria:
– Oral temperature > 101F (>38.3 C)
– Abnormal cervical or vaginal
mucopurulent discharge
– wbc’s on wet prep
– elevated sed rate or CRP
– lab evidence of CT or GC
Lab Evaluation for PID
• CBC with diff, ESR
• NAAT for GC, CT
• Beta HCG
• RPR
• ? HIV
• +/- Ultrasound
Differential Diagnosis of PID
• Must exclude diagnosis of:
- Ectopic pregnancy
- Appendicitis
- Ruptured ovarian cyst
- Endometriosis
- Normal pelvis
Hospitalize for PID if…
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Surgical emergency can’t be excluded
Pregnant
Not responding to oral antibiotics
UNABLE TO FOLLOW OR TOLERATE
OUTPATIENT ORAL TX = TEENS WHO
MAY BE NONCOMPLIANT
• Severe illness, nausea/vomiting, high fever
• Tubo-ovarian abscess
Trichomonas Vaginalis
• Incubation: 4-20 days, usually sexually
acquired (prevalence 7-33%)
• Sx: bubbly, malodorous, yellow/green/gray
discharge; dysuria; postcoital bleeding;
dyspareunia
• PE: strawberry cervix, frothy d/c, friable
• DX: wet prep, pH > 4.5
• Tx: Metronidazole 2 g PO x 1 dose for
pt/partner
Trichomonas Treatment
• Tinidazole 2g is a new trich treatment
option (fewer sx but more $$$)
• Tinidazole is equivalent to, or superior to,
metronidazole in achieving parasitologic
cure and resolution of symptoms
(Foma et al, Cochrane Database Syst
Rev 2003;2:CD000218)
Bacterial Vaginosis
“Nonspecific Vaginitis”, Gardnerella Vaginalis
• Alteration in normal vaginal flora
• Volatized by KOH and semen
• Sx: Fishy, malodorous discharge, irregular menses
• Diagnosis: need 3 out of 4 of these criteria
– Gray to white homogenous thin discharge
adherent to vaginal wall
– pH > 4.5
– Positive “whiff” test
– Clue cells (making up 20% of cells)
Bacterial Vaginosis and Trich
• Easy to diagnose both now by vaginal
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•
specimen
Rapid, high performance, CLIA-waived
trich and BV tests made by Genzyme
Available in a lab near you…
Bacterial Vaginosis: 2010
CDC Treatment Guidelines
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Metronidazole 500 mg PO bid x 7 day
Clindamycin cream 2%, 1 applicatorful (5g) intravaginally
qhs x 7 days
Metronidazole gel 0.75%, 1 applicatorful (5g)
intravaginally qd x 5 d
ALTERNATIVE REGIMENS:
Metronidazole 2 g PO in a single doseTinidazole 2g qd x 2 or qd x 5d
RECURRENCES: can treat with metronidazole gel 2x a
week for 4-6 months or oral nitroimidazole followed by
intravaginal boric acid and suppressive mitronidazole gel
Syphilis
• 40,000 annually in US, steady rise since
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1980, coincides with rise of illicit drug use
and rising HIV rates. Goal = complete
eradication
15% teens/young adults with syphilis + HIV
Congenital syphilis: 1:10,000 pregnancies
Organism: Treponema pallidum
1/3 exposed individuals contract infection
Syphilis
• Incubation: 10-90 days, but usually 3 weeks,
with no symptoms.
• Primary: nontender ing nodes; hard, painless
•
chancre at initial site, filled with spirochetes.
Lesion spontaneously resolves by 3-6 weeks.
Secondary: 2 wks to 6 mo after primary
chancre, fever, malaise, wt loss, HA, myalgia,
rash not sparing palms and soles
Syphilis: Diagnosis
• Indirect (nontreponemal): RPR, VDRL, ART
- antibodies as dilutions of reactive serum
- sensitive, inexpensive, easy to perform
- after Tx, see 4x decline in
nontreponemal titer = adequate treatment
- false positive: 1-2%
Prozone effect: very high titer, need serial
dilutions if high index of suspicion
Syphilis: Direct Treponemal
Tests
• FTA-ABS: fluorescent treponemal antibody
absorption test
• MHA-TP: microhemagglutination assay for
antibody to Treponema pallidum
• Specificity: 95-98%
• Remain positive after treatment
Syphilis: Treatment
CDC 2010 STD Treatment Guidelines
• Benzathine PCN G 2.4 mill U IM x one dose (eg
Bicillin LA, NOT Bicillin CR)
• Azithromycin 2 g if treatment resistant
• Check RPR at 6 and 12 months for reinfection
• Screen for HIV
• Jarisch-Herxheimer reaction: fever, HA, myalgias,
tachycardia, hypotension, tachypnea  supportive
care
Estimated Annual US Financial Costs
Associated With HPV-Related Diseases
Other
6% ($313 million) of the estimated $5 billion in total
Cervical
annual health care costs are associated with genital
cancer
warts and CINa 1 caused by HPV Types 6 and 11
Routine Pap
screening
CIN 1–3
CIN 1b
$113 million2,3
Genital warts
$200 million1
Genital warts
Falsepositive
Paps
$200 annual
million healthcare
is associated
Estimated $5 billion in total
costs, including costs for
with genital
warts Papillomavirus
alone1
® [Human
diseases for which GARDASIL
Quadrivalent
(Types 6, 11, 16, and 18) Vaccine, Recombinant] is not indicated.1
a
CIN = cervical intraepithelial neoplasia.
b
The cost for CIN 1 is based on an estimated incidence of 1.1 million cases per year, of which 10% are
due to HPV 6 and HPV 11.3,5
1. Insinga RP et al. Pharmacoeconomics. 2005;23:1107–1122. 2. Insinga RP et al. Am J Obstet Gynecol.
2004;191:114–120. 3. Clifford GM et al. Cancer Epidemiol Biomarkers Prev. 2005;14:1157–1164. 4.
Derkay CS. Arch Otolaryngol Head Neck Surg. 1995;121:1386–1391. 5. Schiffman M et al. Arch Pathol
Lab Med. 2003;127:946–949.
HPV Vaccine-Use It!
• Virus-like particle (VLP) subunit vaccines
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•
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made of the major capsid protein L1 of
the genital HPVs – immunogenic and safe
Induce a strong cell-mediated AND humoral
response
Induces best immunity in early adolescence,
approved for girls 9-26 years AND BOYS
Same schedule as Hep B- 0, 2 months, 6 months
AAP Recommendations
• Give to girls ages 11-12 years old
• Can give to girls ages 9-26 years and boys!
• Catch-up for girls older than 12 and <27
years, even if they are already sexually
active
• Give even with an abnormal pap previously
(may not be infected with all strains)
The New PAP:
Prevention Assessment Program
• Prevention: HPV Vaccine
• Assessment: STI testing (urine NAAT)
• Program: Counsel, counsel, counsel!
– Contraceptive counseling if heterosexual
– STI prevention counseling- abstinence,
condoms
– Recommend immunizations
Herpes Simplex Virus:
CDC 2010 Treatment Guidelines
• Acyclovir 400 mg PO tid x 7-10 d
• Acyclovir 200 mg PO 5x a day for 7-10
days
• Famciclovir 250 mg PO tid for 7-10 days
• Valacyclovir 1g PO bid x 7-10 days
• May extend treatment if healing
incomplete COUNSEL and prevent
spread!
Herpes Simplex Virus:
CDC 2010 Treatment Guidelines:
Episodic Recurrent Infections
Shorter course therapy for recurrences
• Acyclovir 400 mg PO tid x 5 days
• Acyclovir 800 mg PO tid a day for 2d
• Acyclovir 800 mg PO bid x 5d
• Famcicylovir 1g PO bid x 1d
• Famciclovir 125 mg PO bid x 5d
• Valacyclovir 500 mg PO bid x 3d
• Valacyclovir 1 g PO qd x5d
Herpes Simplex Virus:
CDC 2010 Treatment Guidelines:
Daily Suppressive Therapy
• Acyclovir 400 mg PO bid
• Famciclovir 250 mg PO bid
• Valacyclovir 500 mg PO once a day
•
decreases rate of HSV2 transmission in
discordant heterosexual couples
Consider Rx as part of strategy to prevent
transmission when used by those with
multiple partners (including MSM) and
those HIV+ pts who are symptomatic)
Valacyclovir 1000 mg PO once a day
Chancroid
• Endemic in some areas of US and in
third world
• Cofactor for HIV transmission
• 10% with chancroid have syphilis or
HIV
• Organism: H. ducreyii
• 1/3 present with painful ulcer + tender
nodes
CHANCROID
• Definitive Dx: culture on special media
sensitivity still only <80%
• Probable dx: painful genital ulcer,
negative test for T.pallidum, and
HSV negative
• Tx: Azithromycin 1g PO
Ceftriaxone 250 mg IM
Cipro 500 mg PO bid x 3d
Erythomycin 500 mg PO qid x 7d
Genital Ulcers and Nodes
Disease
Ulcer
Syphilis
Painless
Painless nodes
chancre
Painful ulcer Tender nodes
Chancroid
Lymphadenopathy
Herpes
Painful
Tender nodes
simplex virus vesicle/ulcer
Pediculosis Pubis
• Diagnosis: visual = creepy, crawly things!
• Treatment:
– Permethrin 1% crème rinse applied to
affected areas and washed off after 10 minutes
– Lindane 1% shampoo applied for 4 minutes
to the affected area then thoroughly washed
off. (not recommended for pregnant/lactating
women or children under 2 years)
–Pyrethins with piperonyl butoxide applied to
the affected area and washed off after 10
minutes
SUMMARY
• Establish confidentiality and ask the key
questions
• Screen all sexually active patients 3-6
•
•
months after any new partner (urine
NAAT or vaginal swab NAAT) or qyr
Treat patients, and get partners treated
appropriately
The new PAP: prevent, assess, family
planning/counselling