Sexually transmitted infections in adolescents: Maximizing opportunities for optimal care Flashcards Preview

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Flashcards in Sexually transmitted infections in adolescents: Maximizing opportunities for optimal care Deck (37):
1

What is the most frequently reported STI in Canada?

Chlamydia trachomatis

2

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

50%

3

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

15-24yo

4

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

20-29yo

5

What symptoms tend to be present during gonorrheal infections?

Asymptomatic for females
Males tend to be symptomatic

6

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

20-29yo

7

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

15-19yo

8

In which groups are rates of N gonorrhoeae increasing in?

MSM
Adolescent girls 15-19yo

9

What are the most commonly infected groups with Treponema pallidum?

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

10

What groups are most commonly affected by HIV?

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

11

Which female adolescents should be screened for STI?

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

12

Which male adolescents should be screened for STI?

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

13

What are the recommendations for screening for chlamydia?

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

14

What are the screening recommendations for N gonorrhea?

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

15

What are the screening recommendations for syphilis?

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

16

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

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

17

What follow-up testing should be done for chlamydia?

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

18

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

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

19

What follow-up testing should be done for syphilis?

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

20

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

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

21

What follow-up testing should be done for gonorrhea?

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

22

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

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

23

What follow-up testing should be done for HIV?

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

24

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

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)

25

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

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)

26

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

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

27

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

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

28

What samples should be collected for suspected pharyngeal gonococcal infection?

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

29

What samples should be collected for symptoms of vaginitis?

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

30

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

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

31

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

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

32

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

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

33

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

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

34

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

Ceftriaxone 25-50mg/kg (maximum 125mg)

No macrolides due to association w/ pyloric stenosis

35

Why is azithromycin preferred over doxycycline?

Significant rates of tetracycline resistant gonorrhea

Concerns with compliance with 7d therapy

Contraindicated in pregnant and breastfeeding women an children <9yo

36

What is the major risk of azithromycin monotherapy?

Treatment failure due to high rates of azithromycin resistance

Significant GI SE

Only consider if history of severe allergy to cephalosporins

37

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

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.

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