Sexually transmitted infections in adolescents: Maximizing opportunities for optimal care

Question 1

What is the most frequently reported STI in Canada?

Answer 1

Chlamydia trachomatis

Question 2

What percentage of infants born vaginally to mothers with untreated chlamydia develop the infection?

Answer 2

50%

Question 3

What age range of women is C. trachomatis most prevalent in?

Answer 3

15-24yo

Question 4

What age range of men is C. trachomatis most prevalent in?

Answer 4

20-29yo

Question 5

What symptoms tend to be present during gonorrheal infections?

Answer 5

Asymptomatic for females

Males tend to be symptomatic

Question 6

What age range of men is Neisseria gonorrhoeae most prevalent in?

Answer 6

20-29yo

Question 7

What age range of women is Neisseria gonorrhoeae most prevalent in?

Answer 7

15-19yo

Question 8

In which groups are rates of N gonorrhoeae increasing in?

Answer 8

MSM

Adolescent girls 15-19yo

Question 9

What are the most commonly infected groups with Treponema pallidum?

Answer 9

1. MSM 30-39yo
2. Sex worker and their clients
3. Individuals who have acquired infection in endemic regions of the world

Question 10

What groups are most commonly affected by HIV?

Answer 10

1. MSM
2. Individuals who have acquired infection via heterosexual contact
3. IVDU

Question 11

Which female adolescents should be screened for STI?

Answer 11

All who are sexually active or are victims of sexual assault or abuse

Question 12

Which male adolescents should be screened for STI?

Answer 12

1. If their history suggests sexual contact with person(s) with a known STI
2. A previous STI
3. Being a patient of an STI clinic previously
4. A new sexual partner or >2 sexual partners within the past year
5. Injection drug use and/or other substance use, such as alcohol or chemicals (eg, pot, cocaine, ecstasy, crystal meth), especially if associated with sexual activity
6. Unsafe sexual practices (ie, unprotected sex [oral, genital or anal]; sexual activities with risk of blood exchange [ie, sadomasochism, sharing sex toys])
7. Anonymous sexual partnering (ie, meeting on the Internet, in a bathhouse, or at a rave)
8. Sex workers and their clients
9. ‘Survival sex’ (ie, exchanging sex for money, drugs, shelter or food)
10. Street involvement or homelessness
11. Time in a detention facility
12. Experience of sexual assault or abuse

Question 13

What are the recommendations for screening for chlamydia?

Answer 13

1. All sexually active females <25yo should be screened at least annually, with additional screening for individuals with new or multiple sexual partner
2. Sexually active males of any age who have risk factors for C. trachomatis
3. Repeat screening q6m after treatment
4. NAAT is most sensitive test and can be obtained via first catch void urine, vaginal, endocervical or urethral specimens
5. If patient is asymptomatic and has no risk factors or indications for pelvic exam a urine can be obtained
6. Medico-legal gold standard culture of cervical or urethral specimen (less sensitive)
7. Test-of-cure (TOC) using NAAT 3-4 wks after completion of therapy is recommended for pre-pubertal individuals
8. TOC is recommended for post-pubertal patients if:
   a) Compliance is uncertain
   b) Alternative treatment was used
   c) Re-exposure is likely
   d) Adolescent is pregnant

Question 14

What are the screening recommendations for N gonorrhea?

Answer 14

1. All sexually active females <25yo should be screened at least annually, with additional screening for individuals with new or multiple sexual partner
2. Sexually active males of any age who have risk factors for N gonorrhea
3. For screening asymptomatic individuals: first-catch urine
4. Pharyngeal specimens if history of oral sex
5. Rectal sample if history of receptive anal intercourse
6. Culture is important to obtain sensitivity and should always be performed if:
   a) Sexual abuse is suspected
   b) Sexual assault cases
   c) Treatment failure is presumed
   d) Evaluating PID
   e) symptomatic MSM
   f) Infection acquired overseas
   g) In areas of recognized antimicrobial resistance
7. NAAT is alternative for urine, urethral, and cervical samples (validated) and rectal and pharyngeal samples (not validated) but does not provide resistance patterns
8. NAAT is not validated for children <12yo and for medico-legal specimens
9. TOC should be performed usu. 3-7d post treatment for culture or 2-3 wks post treatment for NAAT if:
   a) Pre-pubertal child
   b) Second-line or alternative therapy
   c) Antimicrobial resistance is suspected
   d) High re-exposure risks exist
   e) Adolescent is pregnant
   f) Previous treatment has failed
   g) Pharyngeal infection signs or symptoms persist following treatment
   h) all gonorrhea cases in areas of high resistance
10. Repeat NAAT screening 6m post treatment is recommended for individuals at risk for reinfection

Question 15

What are the screening recommendations for syphilis?

Answer 15

1. All pregnant adolescents should be screened for syphilis early in pregnancy and at delivery
2. Individuals at high risk for syphilis should be screened at 28-32wks GA
3. Individuals at very high risk (sex trade work in outbreak region) should have monthly testing in pregnancy
4. Enzyme immunoassays (EIAs) are more sensitive screening tests for syphilis, non-treponemal tests (RPR) may yield false-negative results in early primary syphilis
5. If treponemal specific EIA is positive a second treponemal confirmatory test is required
6. f/u RPR testing post treatment is recommended for all stages of syphilis w/ reactive RPR at 1, 3, 6, 12m for infectious case and at 12 and 24m post treatment for latent case

Question 16

What screening tests/samples should be used to detect chlamydia?

Answer 16

NAAT is the most sensitive and specific test. Can be performed on urine, urethral swabs, vaginal or cervical swabs*
A culture of cervical or urethral specimen is the test of choice for medico-legal cases (eg, child abuse). Confirmation by NAAT using a different set of primers or DNA sequencing may be used
Serology should not be used for diagnosis

Question 17

What follow-up testing should be done for chlamydia?

Answer 17

Test-of-cure 3 to 4 weeks after treatment:
If compliance is uncertain
If second-line or alternative treatment was used
If re-exposure risk is high
In the pregnant adolescent
In prepubertal children

Question 18

What screening tests/samples should be done to detect syphilis?

Answer 18

Serology remains the usual diagnostic test unless the patient has lesions compatible with syphilis
Treponemal-specific EIA is a more sensitive screening test than nontreponemal tests; however, testing algorithms vary across jurisdictions
If treponemal-specific assay is positive, a second treponemal test is usually required

Question 19

What follow-up testing should be done for syphilis?

Answer 19

Follow-up testing depends on the nature of infection, as follows:
Primary, secondary, early latent infection: Repeat serology at 1, 3, 6 and 12 months after treatment
Late latent: Repeat serology 12 and 24 months after treatment

Question 20

What screening tests/samples should be done to detect gonorrhea?

Answer 20

NAAT can be used to detect gonorrhea from urine, and urethral, vaginal and cervical swabs in symptomatic and asymptomatic individuals*
NAAT is the only method available in some jurisdictions
Culture allows for antimicrobial susceptibility testing and should be performed if a patient does not promptly respond to therapy, given concerns regarding antimicrobial resistance
Cultures should be submitted for asymptomatic or symptomatic MSM, who have an increased incidence of antibiotic resistance
For rectal and pharyngeal testing, discuss preferred specimens with the testing laboratory
Culture preferred for throat specimens
For medico-legal purposes, a positive result obtained from NAATs should be confirmed using culture or a different set of primers, or by DNA sequencing techniques

Question 21

What follow-up testing should be done for gonorrhea?

Answer 21

Test-of-cure (culture 3 to 4 days post-treatment or NAAT 3 to 4 weeks later) if:
Second-line or alternative treatment was used
Antimicrobial resistance is a factor
Compliance is uncertain
Re-exposure risk is high
An adolescent is pregnant
Previous treatment failure
Pharyngeal or rectal infection
A child is prepubertal
Signs, symptoms persist post-treatment

Question 22

What screening tests/samples should be done to detect HIV?

Answer 22

Serum EIA is initial screening test
Western Blot or other confirmatory test is then performed
Screen all patients seeking evaluation and treatment for sexually transmitted infections
Ensure appropriate counselling

Question 23

What follow-up testing should be done for HIV?

Answer 23

EIA antibodies may be detected at 3 weeks with fourth-generation HIV antibody screening tests, but can take up to 6 months with older tests. Follow-up testing should be planned when an initial test is negative after a known exposure

Question 24

What samples should be collected for an asymptomatic male with risk factors?

Answer 24

First-catch urine or
Urethral swab for Chlamydia trachomatis, Neisseria gonorrhoeae

Serology for:
Syphilis
HIV

Other serological tests to consider:
Hepatitis A (particularly with oral-anal contact)
Hepatitis B (if no history of vaccine)
Hepatitis C (particularly in an injection drug user)

Question 25

What samples should be collected for an asymptomatic female with risk factors?

Answer 25

First-catch urine or Vaginal swab for C trachomatis, N gonorrhoeae* Serology for: Syphilis HIV Other testing to consider: Hepatitis A serology (particularly with oral-anal contact) Hepatitis B serology (if no history of vaccine) Hepatitis C serology (particularly in an injection drug user)

Question 26

What samples should be collected for males with symptoms of urethritis?

Answer 26

Urethral swab for Gram stain and culture for gonorrhea (NAAT may also be used where available) AND First-catch urine for C trachomatis (NAAT)

Question 27

What samples should be collected for women with symptoms of cervicitis?

Answer 27

Vaginal or cervical swab for Gram stain, N gonorrhoeae culture and C trachomatis (NAAT or culture) Swab of cervical lesions (if present) for herpes simplex virus Vaginal swab for wet-mount

Question 28

What samples should be collected for suspected pharyngeal gonococcal infection?

Answer 28

Swab the posterior pharynx and the tonsillar crypts | Use the swab to directly inoculate the appropriate culture medium, or place it in a transport medium

Question 29

What samples should be collected for symptoms of vaginitis?

Answer 29

Collect pooled vaginal secretions, if present If no vaginal secretions are present, swab the vaginal wall in the posterior fornix to prepare a smear or place the swab in a transport medium Wet-mount and Gram stain smears are useful in the diagnosis of microbial vulvovaginitis, candidiasis, bacterial vaginosis and trichomonas. Because of the low sensitivity of direct microscopy, culture or polymerase chain reaction may also be used, where available, for trichomonas Collection of vaginal specimens from adolescents is usually performed as part of a speculum examination Vaginal-wash specimens are preferred, especially in prepubertal girls. If not possible, use swabs moistened with water Use very thin swabs in young children

Question 30

What is the recommended treatment of uncomplicated anogenital gonococcal infection in children and youth >9yo?

Answer 30

Preferred treatment: Ceftriaxone 250mg IM x 1 PLUS azithromycin 1g PO x 1 OR Cefixime 800mg PO x 1 PLUS azithromycin 1g PO x 1 Alternative treatment: Spectinomycin 2g IM X 1 PLUS azithromycin 1g PO x 1 OR azithromycin 2g PO x 1

Question 31

What is the recommended treatment of uncomplicated anogenital gonococcal infection in children and youth <9yo?

Answer 31

Preferred treatment: Ceftriaxone 50mg/kg (max 250mg) IM x 1 PLUS azithromycin 20mg/kg (max 1g) PO x 1 OR Cefixime 8mg/kg (max 400mg/dose) PO BID x 2 doses PLUS azithromycin 20mg/kg (max 1g) PO x 1 Alternative treatment: Spectinomycin 40mg/kg (max 2g) IM X 1 PLUS azithromycin 20mg/kg (max 1g) PO x 1

Question 32

What is the recommended treatment of uncomplicated pharyngeall gonococcal infection in children and youth >9yo?

Answer 32

Preferred treatment: Ceftriaxone 250mg IM x 1 PLUS azithromycin 1g PO x 1 Alternative treatment: Cefixime 800mg PO x 1 PLUS azithromycin 1g PO x 1 OR azithromycin 2g PO x 1

Question 33

What is the recommended treatment of uncomplicated pharyngeal gonococcal infection in children and youth <9yo?

Answer 33

Preferred treatment: Ceftriaxone 50mg/kg (max 250mg) IM x 1 PLUS azithromycin 20mg/kg (max 1g) PO x 1 Alternative treatment: Cefixime 8mg/kg (max 400mg/dose) PO BID x 2 doses PLUS azithromycin 20mg/kg (max 1g) PO x 1

Question 34

What are the recommendations for gonococcal infections in neonates birth to 1mo?

Answer 34

Ceftriaxone 25-50mg/kg (maximum 125mg) No macrolides due to association w/ pyloric stenosis

Question 35

Why is azithromycin preferred over doxycycline?

Answer 35

Significant rates of tetracycline resistant gonorrhea Concerns with compliance with 7d therapy Contraindicated in pregnant and breastfeeding women an children <9yo

Question 36

What is the major risk of azithromycin monotherapy?

Answer 36

Treatment failure due to high rates of azithromycin resistance Significant GI SE Only consider if history of severe allergy to cephalosporins

Question 37

What are some contextual issues that might impact treatment of STIs?

Answer 37

1. Primary prevention measures include vaccination against hepatitis B virus and human papillomavirus, condom use and behavioural change. 2. Effective secondary preventive strategies include partner notification, and treatment and screening for STIs in asymptomatic young adults. 3. Providing education and management strategies for the partners of individuals with STIs are essential for infection control and patient well-being. 4. The STIs noted above are reportable diseases, and clinicians should be familiar with the reporting process for their area and comply in a timely fashion. Public health authorities can assist with contact tracing when indicated. 5. Directly observed therapy is important to improve compliance with antimicrobial treatment of STIs among adolescents. 6. Check for the presence of multiple STIs, including HIV, because the same risk factors are shared by different STIs. 7. TOC is recommended for prepubertal children with N gonorrhoeae and/or chlamydia infections. 8. Retesting at six months is indicated for adolescents and adults with N gonorrhoeae and/or chlamydia because the risk for reinfection is a major concern in this age group.