1. S L I D E 0 Sexually Transmitted Infections in adolescents Deepa Camenga, MD, MHS, FAAP Instructor of pediatrics, adolescent medicine Yale School of Medicine July 10, 2014 Update on diagnosis and treatment

2. S L I D E 1 WELCOME!

3. S L I D E 2 Pre-test questions Which of the following is the preferred screening test for the diagnosis of gonorrhea and chlamydia in asymptomatic women? 1.Self-collected vaginal swabs 2.A pelvic exam with collection of endocervical specimen 3.First-catch urine Which of the following screening tests are not recommended at least annually for Men who have sex with Men? 1.Syphilis serology with confirmatory testing 2.Nucleic acid amplification testing for chlamydia from oropharynx for men who have had oral intercourse 3.HIV serology

4. S L I D E 3 Deepa Camenga, MD, MHS, FAAP

5. S L I D E 4 Disclosure Statement Neither I nor any member of my immediate family has a financial relationship or interest (currently or within the past 12 months) with any entity producing health care goods or services consumed by, or used on, patients related to the content of this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device.

6. S L I D E 5 Overview At the end of this presentation, participants will: Understand the prevalence of common sexually transmitted infections in adolescents Become familiar with CDC screening guidelines for sexually transmitted infections in adolescents. Become familiar with treatment for common STIs

7. S L I D E 6 Sexually Transmitted Infections Epidemiology

8. S L I D E 7 Rate/100,000 persons

9. S L I D E 8 STIs are an epidemic in adolescents 15 million new STIs diagnosed each year –¼ in adolescents Why are STD’s so prevalent in adolescents?

10. S L I D E 9 Screening for Sexually Transmitted Infections

11. S L I D E 10 Screening for STIs STIFrequencyPopulationSites Chlamydia Gonorrhea AnnualSexually active females ≤25 yo High risk males (i.e. in adolescent clinics, correctional facilities, STD clinics) First-catch urine Endocervix Vagina Urethra HIVRoutine (regardless of behavioral risk factors) Ages 13 to 64 Among patients presenting with concern of STI HPVAnnualFemales ages 21+ Pap smear

12. S L I D E 11 Screening for STIs STIFrequencyPopulationSites Chlamydia Gonorrhea AnnualSexually active females ≤25 yo High risk males (i.e. in adolescent clinics, correctional facilities, STD clinics) First-catch urine Endocervix Vagina Urethra HIVRoutine (regardless of behavioral risk factors) Ages 13 to 64 Among patients presenting with concern of STI HPVAnnualFemales ages 21+ Pap smear Vaginal Swabs: 1.As sensitive and specific as endocervical samples 2.Self-collected swabs as sensitive and specific as clinician collected 3.A first-catch urine is acceptable. It might detect up to 10% fewer infections when compared with vaginal and endocervical swab samples. CDC 2010 Papp et. Al. MMWR. March 14, 2014 / 63(RR02);1-19

13. S L I D E 12 Self-collected vaginal swabs

14. S L I D E 13 Screening for STIs STIFrequencyPopulationSites Chlamydia Gonorrhea AnnualSexually active females ≤25 yo High risk males (i.e. in adolescent clinics, correctional facilities, STD clinics) First-catch urine Endocervix Vagina Urethra HIVRoutine (regardless of behavioral risk factors) Ages 13 to 64 Among patients presenting with concern of STI HPVAnnualFemales ages 21+ Pap smear screening enzyme immunoassay (EIA) followed by a confirmatory Western blot if positive

15. S L I D E 14 Screening for STIs STIFrequencyPopulationSites Chlamydia Gonorrhea AnnualSexually active females ≤25 yo High risk males (i.e. in adolescent clinics, correctional facilities, STD clinics) First-catch urine Endocervix Vagina Urethra HIVRoutine (regardless of behavioral risk factors) Ages 13 to 64 Among patients presenting with concern of STI HPVAnnualFemales ages 21+ Pap smear

16. S L I D E 15 Screening for STIs among MSM STIFrequencyPopulationSites Chlamydia Gonorrhea AnnualMSM Urethra Rectal Oropharyngeal for GC HIVAnnualMSM HIV SyphilisAnnualMSM VDRL, RPR CDC 2010

17. S L I D E 16 Screening for STIs in high risk females STIPopulationSites Trichomoniasis New or multiple partners History of STDs Exchange sex for payment Use injection drugs Vagina

18. S L I D E 17 Nucleic acid amplification test for GC/CT Only non-culture test recommended for routine use Detect small amounts of CT/GC nucleic acids Samples –Endocervix –Urethra –Urine –Vaginal wall –Rectum and Oropharynx** **Not FDA-cleared but recommended by CDC CDC 2010 Papp et. Al. MMWR. March 14, 2014 / 63(RR02);1-19

19. S L I D E 18 Diagnosis of Trichomoniasis Microscopy –70% sensitive When microscopy is not available: NameMethod of Detection TimeSensitivity/ Specificity Affirm VP III **Also G. vaginalis, C. albicans DNA hybridization on vaginal swab POCT- 45 minutes63%-95%/ 95% OSOM Trichomonas Rapid Test Immuno- chromatographic technology POCT-10 minutes88%/ 98% APTIMA Trichomonas Vaginalis Assay **Also GC/CT NAAT on vaginal/urine specimin Send to lab97-100%/ 87-100%

20. S L I D E 19 When is a pelvic exam indicated? With the availability of urine-based and vaginal-swab STI testing, examination with a speculum in an asymptomatic patient is not necessar y for diagnosing asymptomatic STIs

21. S L I D E 20 Indications for a Pelvic Exam in Adolescents Persistent vaginal discharge Dysuria or urinary tract symptoms in a sexually active female Dysmenorrhea unresponsive to nonsteroidal anti-inflammatory drugs Amenorrhea Abnormal vaginal bleeding Lower abdominal pain Contraceptive counseling for an intrauterine device or diaphragm Perform Pap test Suspected/reported rape or sexual abuse Pregnancy Braverman PK. Et. Al Pediatrics Vol. 126 No. 3 September 1, 2010 pp. 583 -590.

22. S L I D E 21 Treatment for Common Sexually Transmitted Infections Chlamydia Gonorrhea Trichomonas

23. S L I D E 22 Chlamydia

24. S L I D E 23 Chlamydia Treatment: 1 gram of azithromycin Partner needs to be treated If allergic to azithromycin, refer to CDC guidelines for a variety of alternate treatments Retest at 3 months

25. S L I D E 24 Gonorrhea

26. S L I D E 25 Treatment High rate of co-infection with chlamydia Treatment: Preferably ceftriaxone 250mg IM plus either azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice daily for 7 days. Partner treatment essential Retest at 3 months

27. S L I D E 26 Trichomoniasis

28. S L I D E 27 Trichomoniasis Treatment –oral metronidazole 2 gram x1 Partner treatment is essential –NAAT of urine or culture diagnostic in males Cannot use topical metronidazole

29. S L I D E 28 A word about Pelvic Inflammatory Disease Caused by: GC/CT Anaerobic bacteria Facultative bacteria Negative GC, CT does not necessarily mean those organisms are not causing PID 15-40% of untreated chlamydia and 9-15% of untreated gonorrhea  PID

30. S L I D E 29 Pelvic Inflammatory Disease Diagnostic criteria –Sexually active female –Pelvic or lower abdominal pain with no other cause identified –One or more of the following Cervical motion tenderness Uterine tenderness Adnexal tenderness

31. S L I D E 30 Pelvic Inflammatory Disease Outpatient management –Ceftriaxone 250mg IM x1 –Doxycycline 100 mg po bid for 14 days –+/- Metronidazole 500mg po bid for 14 days –Follow up in 3 days for repeat exam For allergic patients, refer to CDC guidelines

32. S L I D E 31 Pelvic Inflammatory Disease Inpatient management –Hospitalize patients who: Very sick at presentation (vomiting, high fever etc.) Pregnant HIV positive Tubo-ovarian abscess Not responding to outpatient therapy Noncompliance with outpatient therapy

33. S L I D E 32 The Ultimate Reference!

34. S L I D E 33 Resources CDC 2010 Treatment Guidelines Summary Available from CT DPH (860-509-7275 )

35. S L I D E 34 Post-test questions Which of the following is the preferred screening test for the diagnosis of gonorrhea and chlamydia in asymptomatic women? 1.Self-collected vaginal swabs 2.A pelvic exam with collection of endocervical specimen 3.First-catch urine Which of the following screening tests are not recommended at least annually for Men who have sex with Men? 1.Syphilis serology with confirmatory testing 2.Nucleic acid amplification testing for chlamydia from oropharynx for men who have had oral intercourse 3.HIV serology

36. S L I D E 35 Summary Offer GC/CT screening annually to adolescent patients who are sexually active (urine, vaginal swabs are easy and non- invasive) Offer MSM yearly GC/CT, “opt-out” HIV and syphilis screening Consider using rapid POCT for Trichomoniasis