Pediatric Resident Academic Half Day

1. Pediatric Resident Academic Half Day • March 21, 2013 • Dr. A. Bates, PGY5 • Pediatric Infectious Disease Fellow

2. http://www.youtube.com/watch?v=D4Y3QXOZY6E

3. Background • World Health Organization 2005: • Sexually transmitted infections among adolescents: the need for adequate health services • Since the International Conference on Population and Development in Cairo in 1994, recognition of young people’s specific sexual and reproductive health needs has gradually increased

4. Background • Attempts to date to promote the sexual health of young people have tended to focus on prevention, education and counselling for those who are not yet sexually active • While the provision of health services to those who have already engaged in unprotected sexual activity and faced the consequences, including pregnancy, STIs or sexual violence, has lagged behind

5. Background • challenges - global and local • increasing populations • antimicrobial resistance • global travel • co-infections

6. Objectives • recognize common sexually transmitted infections in adolescents • create a general management plan • special circumstances: • HIV • Post exposure prophylaxis • sexual abuse

7. What is a sexually transmitted Infection • The term STI (Sexually Transmitted Infection) is now commonly used in the place of STD (Sexually Transmitted Disease) • it is more encompassing • it includes infections that may be asymptomatic

8. What is happening on the Canadian Front? • three nationally reportable STIs • chlamydia, gonorrhea and syphilis • increasing rate of all three infections since 1997

9. Epidemiology • 15-24 yo represent ~ 25% of the sexually experienced population • they acquire ~ half of all new STDs • Compared with older adults, sexually active adolescents aged 15–19 years and young adults aged 20–24 years are at higher risk of acquiring STDs for a combination of behavioral, biological, and cultural reasons.

10. Epidemiology • multiple factors involved • adolescent females have an increased susceptibility to Chlamydia trachomatis because of increased cervical ectopy • multiple barriers - • lack of transport, discomfort with the facility/service design, concerns re: confidentiality

11. Canadian Stats 2009 • Chlamydia • AB - 366 cases/100 000 ppl • Rates (per 100 000) • 10-14 yo - 29.1 • 15-19 1041.7 • 20-24 yo - 1373.8 • steadily increasing in Canada since 1997

12. Canadian Stats 2009 • Gonorrhea • AB - 42 cases/100 000 ppl • Rates (per 100 000) • 10-14 yo - 3.8; • 15-19 102.5 • 20-24 yo - 145.2 • from 1997-2004 - rate has increased by ~ 94% • resistance - quinolones (up to 15.7% in 2005)

13. Canadian Stats 2009 • Syphilis • 15-19 yo - 52 cases • 20-24 yo - 193 cases • previously rare - by 2006 in Canada - incrased to 1 493 cases (regional outbreaks) • risk groups - MSM (HIV positive and neg) • sex workers and their clients • acquisition in endemic regions

14. Further Epidemiology of Canadian STIs • HPV - very common • not reportable so true incidence not known • Most affected - adolescent and young adult woment and ment • HSV - 1 & 2 - common • not reportable but seroprevalence indicate rates of at least 20% • very common in both adolescent and adult men and women (women > men)

15. Why the Increase? • better diagnostics (NAATs) • suboptimal youth awareness and knowledge of risk-reduction behaviours • sex is occurring at an early age (and longer throughout life) • high rates of serially monogamous relationships • adolescents (and public in general) have a poor understanding of transmission risks • vaginal, anal and oral • “party drugs” are increasingly linked to unsafe sexual behaviours

16. Why the Increase? • other unique factors with adolescents • where do they get there education from? • where do they get testing/treatment from? • social factors - peer pressure, games, etc.

17. Approach • Primary prevention • Secondary prevention

18. Approach • Primary prevention • aims to prevent exposure • identify at-risk individuals • thorough assessments • patient centred counselling • education

19. Approach • Secondary prevention • reduction of STI prevalence • detection of infection in at-risk populations • counselling • timely partner notification and treating infected individuals and contacts • goal: preventing and/or limiting further spread

20. Which Statement Is True? • 1) The presence of an acute infection can increase the risk of co-infection • 2) Sequelae of women from untreated CT/GC can include infertility • 3) Persistent HPV infections plays a role in cervical dysplasia and carcinoma • 4) Chronic viral STI (i.e. HSV) can have long standing negative impacts on patient’s psychosocial well-being • 5) All the above

21. Which Statement Is True? • 1) The presence of an acute infection can increase the risk of co-infection (ie chancre and HIV) • 2) Sequelae of women from untreated CT/GC can include infertility (chronic pelvic pain, ectopic pregnancy, PID) • 3) Persistent HPV infections plays a role in cervical dysplasia and carcinoma (role for vaccine) • 4) Chronic viral STI (i.e. HSV) can have long standing negative impacts on patient’s psychosocial well-being • 5) All the above

22. Approach to Adolescents with Sexually Transmitted Infections • History • Exam • Investigations • Managements

23. HISTORY • think about STI risk factors ...

24. STI Risk Factors • sexual contact with a person with a known STI • sexually active youth under 25 yo • new sexual pertner or more than 2 in the past year • serially monogamous relationships • no contraception or SOLE use of non-barrier contraception • IVDU • substance use - ETOH, rec Rx (esp if assoc with having sex)

25. STI Risk Factors • engaging in unsafe sexual practices (sharing sex toys, sex with blood exchange, unprotected sex - oral/genital/anal) • sex workers • survival sex • street involvement, homelessness • anonymous sexual partnering (rave party, internet, bathhouse) • victims of sexual assault/abuse • previous STI

26. History • very thorough HEADDSSS history • confidentiality • empathy • non judgemental • focused sexual history

27. Sexual History • systemic symptoms • fever • weight loss • lymphadenopathy • prevention - immunizations, condoms • Rx treatments, allergies • Patient comfort • genital signs and symptoms • discharge • dysuria • abdominal pain • testicular pain • rashes and lesions

28. Sexual History • relationships: are you sexually active now or have you ever been? • incl oral, anal, and vaginal • do you have any concerns about sexual or relationship violence or abuse?

29. Sexual History • sexual risk behaviour • number of partners • sexual preference, orientation • sexual activities - give or receive oral sex? anal sex? • personal risk - sex with people from other countries, bathhouses, travelling • use of condoms?

30. Sexual History • STI history • have you ever been tested for an STI/HIV? last screening date? • have you ever had an STI in the past? if yes, what and when? • how long have symptoms been on going

31. Sexual History • Reproductive health history • use of contraception? frequency? problems? • ever been pregnant? used emergency contraception?

32. Other High Risk Behaviors • Substance use • ETOH, IVDU, sex while intoxicated • tattoos or piercings • Psychosocial history • traded sex for money, drugs, shelter? paid for sex? forced to have sex? • sexually abused (mentally, physically) • have a home? live with anyone other than family? • Encounters with the law

33. Exam • Common to both sexes • systemic signs - weight loss, fever, enlarged LNs • mucocutaneous regions (incl pharynx) • external genitalia - lesions, inflammations, genital d/c, anatomical irreg • perianal inspection

34. Exam • adolescent males • palpate scrotal contents (attn to epididymis) • retract foreskin to inspect the glans • “milk” the urethra - discharge • adolescent females • separate labia - visualize vaginal orifice • speculum exam - cervix, vaginal walls • bimanual exam - uterine or adnexal masses or tenderness

35. Investigations • Urine - first void - CT/GC (NAATs) • Serum - Syphilis EIA/RPR • anti-HIV 1/2 antibodies • HepBs Ag, HepBs Ab • HepC Ab • HepA Ab • Cervix: • Endocervical canal - swab for CT and GC culture/NAAT (1-2 cm - columnar epithelial cells); direct inoculate for N. gonorrhoeae onto culture plate or transport medium • Exocervical samples - HSV, HPV

36. Investigations • Lesions • vesicles - deroof and swab - HSV PCR • ulcers - HSV PCR; Syphilis - dark field microscopy, PCR, DFA/IFA • Pharynx - posterior pharynx and tonsillar crypts (culture) • Rectum - CT, GC, HSV

37. Investigations • Urethra • thin, dry flex swab, moistened (3-4 cm males; 1-2 cm females) rotate slowly -> prepare a slide; inoculate on culture/transport medium • “milking” penis 3-4x helps • Vaginal • collect pooled vaginal secretions; or swab in posterior fornix (usually done during speculum exam) • Warts/Other HPV infections • scrape exocervical for superficial epithelial cells; use cytobrushes to collect from squamo-columnar junction • HPV DNA

38. Post Test Counselling • organism/syndrome specific advise • education about transmission, safer sex practices • case reporting requirements • partner notification • use of motivational interviewing strategies (both primary and secondary prevention)

39. Common Signs/Symptoms

40. Which of the Statements are True? • 1) patients with organisms causing urethritis almost always have symptoms • 2) patients should abstain from unprotected sex until 7 days after starting treatment • 3) when collecting urine for NAAT for CT/GC, collection of mid-stream urine is recommended • 4) if abuse is suspected, NAAT testing is sufficient

41. Which of the Statements are True? • 1) patients with organisms causing urethritis almost always have symptoms - up to 25% are asymptomatic (esp NGU) • 2) patients should abstain from unprotected sex until 7 days after starting treatment • 3) when collecting urine for NAAT for CT/GC, collection of mid-stream urine is recommended - first-catch urine • 4) if abuse is suspected, NAAT testing is sufficient - need a culture

42. Asymptomatic • Neisseria gonorrhoaea • Chlamydia trachomatis • Syphilis • HSV 1 & 2 • HPV • HIV • Viral hepatitis

43. Urethritis • urethral discharge • burning on urination • irritation of the distal urethra or meatus • meatal erythema • Gonococcal urethritis - urethritis develops 2 to 6 days • NGU urethritis - 1 to 5 wks (avg 2-3) after acquisition

44. Urethritis Pathogens

45. Urethritis Pathogens • N. gonorrhea • C. trachomatis • Trichomonas vaginalis • HSV • Mycoplasma genitalium • Ureaplasma urealyticum • * Adenovirus • * Candida albicans

46. Chlamydia Background • caused by Chlamydia trachomatis serovars D to K • under diagnosed • usual incubation is 2 to 3 wks (up to 6 wks) • without treatment, infection can persist for many months • individuals with N. gonorrhea are usually co-infected with C. trachomatis • Screen sexually active females under 25 years

47. Chlamydia Signs/Symptoms • females - most often asymptomatic; cervicitis, vaginal discharge, dysuria, conjunctivitis • males - often asymptomatic; urethral discharge, urethritis, dysuria, conjunctivitis, proctitis • neonates/infants - conjunctivitis in neonates; pneumonia in infants < 6 months

48. Chlamydia Testing • NAATs are the most sensitive and specific • done on urine, urethral and cervical (blood and mucus can affect test) • culture preferred for medico-legal purposes and recommended for throat specimens • serology not useful for acute genital chlamydial infections • conjunctival swab for culture, DFA

49. Chlamydia Treatment • Preferred: • Azithromycin 1g PO x 1 or Doxy 100mg PO BID x 7/7 • Infants with conjunctivitis: • need systemic treatment - Erythromycin x 14 d (can use Azithro once > 1 mo)

50. Chlamydia Aftermath • Major sequelae: • female - PID, ectopic pregnancy, chronic pelvic pain, reactive arthritis, infertility • males - epididymo-orchitis, reactive arthritis