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Sexually Transmitted Infections prevention, screening, treatment

Sexually Transmitted Infections prevention, screening, treatment. J. Dennis Fortenberry MD MS Section of Adolescent Medicine Indiana University School of Medicine. School of Medicine. Sexually Transmitted Infections Why STI are important in health care (especially for adolescents).

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Sexually Transmitted Infections prevention, screening, treatment

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  1. Sexually Transmitted Infectionsprevention, screening, treatment J. Dennis Fortenberry MD MS Section of Adolescent Medicine Indiana University School of Medicine School of Medicine • .

  2. Sexually Transmitted InfectionsWhy STI are important in health care (especially for adolescents) • Most people become sexually active during adolescence • About 50% of new STI each year are in 15 – 24 year olds Sutton’s Law, attributed to the famous bank robber, Willie Sutton: - Why do you rob banks? - Because that’s where the money is.

  3. Sexually Transmitted InfectionsU.S. Chlamydia Rates among women and men, by age - per 100,000 Population (2007) 1.1 million cases Centers for Disease Control & Prevention, 2009

  4. Sexually Transmitted InfectionsIndiana Chlamydia Rates among women and men - per 100,000 Population (2007) Centers for Disease Control & Prevention, 2009

  5. Sexually Transmitted Infections Prevention

  6. Sexually Transmitted InfectionsMore successful approaches to STI prevention • Target behavior • Sexual behavior • Partner communication • Condom use • Screening and treatment • Education • Skills building and skills practice • Empowerment Kirby DB et al. Sex and HIV education programs: their impact on sexual behaviors of young people throughout the world. Journal of Adolescent Health. 40(3):206-17, 2007

  7. Sexually Transmitted InfectionsLess successful approaches to STI preventionCondyloma acuminata

  8. Sexually Transmitted InfectionsLess successful approaches to STI prevention • Threats and fear • Facts and data • Silence • Stigmatization • Abstinence only Fortenberry et al. Relationships of stigma and shame to gonorrhea and human immunodeficiency virus screening. Am J Public Health, 92:378-381, 2002.

  9. Sexually Transmitted InfectionsAbstinence-only as an inadequate public health STI prevention strategy • Fails to account for method failure • Non-developmental • Withholding of health information • Heterosexual bias Underhill K. Sexual abstinence-only programmes to prevent HIV infection in high income countries: Systematic review. Br J Med. 2007; 335:248-259 Trenholm C, et al. Impact of 4 Title V Section 510 abstinence education programs-Final report. Mathematica Policy Research Inc. 2007 Santelli J, et al. Abstinence-only education policies and programs: a position paper of the Society for Adolescent Medicine. J. Adolesc Health; 38:83-87, 2006

  10. Sexually Transmitted Infections Screening

  11. Sexually Transmitted InfectionsScreening as an STI prevention strategy • Many STI asymptomatic • Chlamydia • Gonorrhea • HIV • Failure to recognize risk • Stigma Centers for Disease Control & Prevention, 2006

  12. Sexually Transmitted InfectionsUS Preventive Services Task ForceRecommendations for Chlamydia screening • Older non-pregnant women at increased risk • All pregnant women at risk • No recommendations for screening of men • All sexually active women < 25 years US Preventive Services Task Force. Annals of Internal Medicine, 2007; 147:128-134. Rietmeijer K, et al. Chlamydia trachomatis positivity rates among men tested in selected venues in the United States: a review of the recent literature. Sex Trans Dis. 35:S8 – S18, 2008

  13. Sexually Transmitted InfectionsUS Preventive Services Task ForceRecommendations for Chlamydia screening • Older non-pregnant women at increased risk • All pregnant women at risk • No recommendations for screening of men • All sexually active women < 25 years

  14. Sexually Transmitted InfectionsAge at first coitus – Indianapolis % with no coital experience Tu et al. unpublished data

  15. Sexually Transmitted InfectionsTime from 1st coitus to 1st STI testby age at 1st coitus Median age of 1st test = 15 years Tu et al. Arch Pediatr Adolesc Med (in press)

  16. Sexually Transmitted InfectionsScreening for Sexual Activity in AdolescentsWhen, how and who, what • When • Any health maintenance visit age 10 and older • Any “appropriate” sick visit • After discussion of confidentiality • Parents etc out of room • How and who • “Do you have a boyfriend or girlfriend right now?” “Have you ever had sex with that person?” “Have you done anything sexual with that person?” • Yes • No • Not really • What • Penile/vaginal • Oral/genital • Penile/anal Ford CA, et al. Anticipatory guidance regarding sex: views of virginal female adolescents. J Adolesc Health 19:179-183, 1996. Reddy DM, et al. Effect of mandatory parental notification on adolescent girls' use of sexual health care services. JAMA. 288:710-714, 2002.

  17. Sexually Transmitted InfectionsScreening for Chlamydia (and Gonorrhea)Nucleic Acid Amplification Tests • Polymerase Chain Reaction (PCR) • Ligase Chain Reaction (LCR) • Strand Displacement Amplification (SDA) • Transcription-Mediated Amplification (TMA) • Hybrid Capture

  18. Sexually Transmitted DiseasesNucleic Acid Amplification TestsAdvantages • High sensitivity and specificity • Multiple tests on same sample • Can be used in non-traditional venues • Variety of specimen types • Cervical/urethral • Urine • Vaginal: consider self-obtained Cook RL, et al. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Int Med. 142(11):914-25, 2005

  19. Sexually Transmitted DiseasesOther screening tests to consider • Human immunodeficiency virus • Herpes simplex 2 • Syphilis • Trichomonas Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR 55(RR14):1-17, 2006.

  20. Sexually Transmitted DiseasesOther Prevention Strategies • Condom use • Immunization

  21. Sexually Transmitted InfectionsCondom use for STI prevention • Consistent evidence for effectiveness • Chlamydia • Gonorrhea • Genital herpes • Human papillomaviruses • Syphilis • HIV • Efficacy for pregnancy prevention • Decline in use over time within relationships • Condom failure • Breakage • Slippage • Incorrect use Holmes KK et al. Effectiveness of condoms in preventing sexually transmitted infections. Bulletin of the World Health Organization 82:454-461, 2004 Fortenberry JD et al Condom use as a function of time in new and established adolescent sexual relationships. Am J Public Health 92:211-213, 2002

  22. Sexually Transmitted InfectionsInstructions for correct condom use • Open package near top • Check orientation but don’t unroll the condom • Unroll completely over erect penis • Check the tip • Lubricant • Practice

  23. Sexually Transmitted InfectionsImmunization for STI Prevention • Hepatitis B • Human papillomavirus prevention • Quadrivalent vaccine (types 6, 11, 16, 18) • Women ages 9 – 26 • FDA decision on indication for older women and for adolescent men expected within year

  24. Sexually Transmitted Infections Diagnosis and Treatment

  25. Sexually Transmitted InfectionsSTI syndromes common in adolescence • Genital Discharge / Dysuria Syndromes • Genital Ulcer / Lymphadenopathy • Pelvic pain syndrome • Dermatologic Syndromes Shew ML, Fortenberry JD. Sexually Transmitted Diseases. in: Finberg L, Kleinman R (eds). Saunder’s Manual of Pediatric Practice. 3rd ed. (2007)

  26. Sexually Transmitted Infections Diagnosis and TreatmentDischarge syndromes

  27. Sexually Transmitted Infectionshttp://www.cdc.gov/std/default.htm Sexually Transmitted Diseases Treatment Guidelines – 2006 New guidelines will be released in early 2010

  28. Sexually Transmitted InfectionsGonococcal urethritis

  29. Sexually Transmitted InfectionsGonococcal cervicitis

  30. Sexually Transmitted InfectionsPrinciples of Chlamydia & Gonorrhea Treatment • Consider co-treatment • Don’t use quinolones for gonorrhea treatment unless sensitivity is known • Chlamydia • Doxycycline 100 mg BID x 7 days • Azithromycin 1 gram • Gonorrhea • Ceftriaxone 125 mg IM • Cefixime 400 mg orally

  31. Sexually Transmitted InfectionsCriteria for BV Diagnosis • Characteristic white/gray discharge • Vaginal fluid pH > 4.5 • Fishy amine odor after adding KOH • Presence of clue cells

  32. Sexually Transmitted InfectionsGram Stain - Normal Vaginal Epithelial Cell

  33. Sexually Transmitted InfectionsVaginal Gram Stain

  34. Sexually Transmitted InfectionsClue Cells

  35. Sexually Transmitted InfectionsBacteria associated with Bacterial Vaginosis • Reduction or absence of Lactobacillis species • Gardnerella vaginalis • Prevotella spp. • Atopobium vaginae • Leptotrichia aminonii • Bacterial vaginosis-associated bacterium (BVAB) Fredericks et al. Molecular identification of bacteria associated with bacterial vaginosis. N Engl J Med. 353:1899-1911, 2005.

  36. Sexually Transmitted InfectionsBacterial Vaginosis Treatment • Metronidazole gel, 0.75% 5 gram applicator daily for 5 days • Metronidazole 500 mg BID for 7 days • Clindamycin Cream, 2% 5 gram applicator daily for 7 days

  37. Sexually Transmitted InfectionsFrothy Discharge Associated with Vaginal Trichomoniasis

  38. Sexually Transmitted InfectionsTrichomonas Treatment • Metronidazole 2.0 grams orally • Metronidazole 500 mg orally BID for 7 days • Tinidazole 2.0 grams orally

  39. Sexually Transmitted Infections Diagnosis and TreatmentGenital ulcer syndromes

  40. Sexually Transmitted InfectionsPrimary syphilis-chancre

  41. Sexually Transmitted InfectionsPrimary syphilis - chancre

  42. Sexually Transmitted DiseasesPrimary/Secondary Syphilis Treatment • Benzathine Penicillin G, 2.4 million units IM • Benzathine Penicillin G, 50,000 units/kg IM (children)

  43. Sexually Transmitted InfectionsPrimary herpes

  44. Sexually Transmitted InfectionsGenital Herpes

  45. Sexually Transmitted InfectionsGenital Herpes - First Episode • Acyclovir 400 mg TID for 7 - 10 days • Famciclovir 250 mg TID for 7 - 10 days • Valacyclovir 1000 mg BID for 7 - 10 days

  46. Sexually Transmitted InfectionsGenital Herpes Suppression • Acyclovir 400 mg BID • Famciclovir 250 mg BID • Valacyclovir 1000 mg QD

  47. Sexually Transmitted Infections Diagnosis and TreatmentPelvic/Genital Pain

  48. Sexually Transmitted InfectionsDiagnosis of Pelvic/Genital Pain • Pelvic inflammatory disease • Not pregnant • No evidence of other cause • Tenderness of pelvic structures • Epididymitis/orchitis • No evidence of testicular torsion

  49. Sexually Transmitted InfectionsTreatment of Pelvic/Genital Pain • Pelvic inflammatory disease* • Ceftriaxone 250 mg IM plus • Doxycycline 100 mg BID for 14 days • Metronidazole 500 mg BID for 14 days • Epididymitis/orchitis • Ceftriaxone 250 mg IM plus • Doxycycline 100 mg BID for 10 days * Several regimens are described in CDC treatment guidelines

  50. Sexually Transmitted Infections Diagnosis and TreatmentDermatologic syndromes

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