Sexually Transmitted Infections in Adolescents

1. Sexually Transmitted Infections in Adolescents Jeri A. Dyson, MD Department of General Pediatrics & Adolescent Medicine University of Florida, Jacksonville Enter the title of your presentation and your name to this title slide. When saving your presentation, please add your name and session title to the existing file name (i.e. �15th_Conf_Slides_Beal_Managing_Multiple_Diseases.ppt�) Please call Michael Ikeya at (813) 974-9005 if you have any questions.Enter the title of your presentation and your name to this title slide. When saving your presentation, please add your name and session title to the existing file name (i.e. �15th_Conf_Slides_Beal_Managing_Multiple_Diseases.ppt�) Please call Michael Ikeya at (813) 974-9005 if you have any questions.

2. Disclosure of Financial Relationships Dr. Jeri A. Dyson has no significant financial relationships with commercial entities to disclose. Use this slide if you have no significant financial relationships with any commercial entities. If you use this slide, please delete slide 3.Use this slide if you have no significant financial relationships with any commercial entities. If you use this slide, please delete slide 3.

3. Lecture Overview Obtaining History from Adolescent Patient Chlamydia Gonorrhea Pelvic Inflammatory Disease Herpes Vaginitis Human Papillomavirus/Pap Smear Update Partner Referral and PDPT

4. STI and Adolescents 15 million persons infected annually 2/3 of infections occur in persons <25 years of age Adolescents have highest rates of STI than any other SA age group Direct medical costs associated with STI in US is estimated at $13 billion annually Southern US region has the highest rates of GC, CT, and Syphilis 15 million persons are infected annually with a sexually transmitted infection. 2/3 of those infections occur in persons <25 years of age This may be shocking information to some of you but adolescents have the highest rates of STI than any other sexually active group in the US. There have been a number of factors sited as the reason for this high rate. The combination of biological, cognitive, psychological, behavioral, and social factors make adolescents more vulnerable. Rates of gonorrhea, chlamydia, and syphilis are highest in the southern region of the US compared to other regions. Higher rates have also been reported among some ethnic groups. These findings have been correlated with poverty, limited access to health care services, reporting bias, and living in high prevalence areas. 15 million persons are infected annually with a sexually transmitted infection. 2/3 of those infections occur in persons <25 years of age This may be shocking information to some of you but adolescents have the highest rates of STI than any other sexually active group in the US. There have been a number of factors sited as the reason for this high rate. The combination of biological, cognitive, psychological, behavioral, and social factors make adolescents more vulnerable. Rates of gonorrhea, chlamydia, and syphilis are highest in the southern region of the US compared to other regions. Higher rates have also been reported among some ethnic groups. These findings have been correlated with poverty, limited access to health care services, reporting bias, and living in high prevalence areas.

5. STI History Sexual History Number and type of new partners Type of sex performed Past STI and medication adherence Symptomatology: History of vaginal/penile discharge Rash, sore throat, painful defecation, dysuria, hematuria, fever, dyspareunia Notification by partner Contraception Use: Type, frequency, with which partners Let�s start at the beginning. When adolescents seek medical care for STI treatment, the most important information you can gather is their STI history. This history should be gathered in the most non-threatening, non-judgmental manner possible. That includes the number of new partners within the last month, the last week. Some adolescents have difficulty with time so I always ask �the number of new partners since the last visit� or use whichever time frame is the shortest. It�s also important to determine if the partners are high-risk partners. (i.e.- IVDU, commercial sex workers, partners with multiple partners) Some providers may think that asking about the type of sex is prying. But, the amazing thing about most adolescents is that if you don�t ask, they won�t tell. So it�s crucial to ask about type of sex acts performed. That will help determine which tests need to be performed. To make it less confrontational, I usually ask �yes or no� type questions. �Have you ever had anal sex� �oral sex� Depending on the developmental stage of the patient, I may ask, �Have you ever had anyone insert their penis into your rectum?� �Have you ever had anyone put their mouth on your vagina� on your rectum?� Always ask about symptoms or if their partner(s) have been complaining of any symptoms. When addressing contraception use, I always ask with which partners they use contraception. Research has shown that adolescents are more likely to use condoms with casual sex partners and less likely to use barrier methods with �significant partners� (which describes those with whom they feel more emotionally attached). Which is really an oxymoron: Since you don�t protect the one you love the most. Let�s start at the beginning. When adolescents seek medical care for STI treatment, the most important information you can gather is their STI history. This history should be gathered in the most non-threatening, non-judgmental manner possible. That includes the number of new partners within the last month, the last week. Some adolescents have difficulty with time so I always ask �the number of new partners since the last visit� or use whichever time frame is the shortest. It�s also important to determine if the partners are high-risk partners. (i.e.- IVDU, commercial sex workers, partners with multiple partners) Some providers may think that asking about the type of sex is prying. But, the amazing thing about most adolescents is that if you don�t ask, they won�t tell. So it�s crucial to ask about type of sex acts performed. That will help determine which tests need to be performed. To make it less confrontational, I usually ask �yes or no� type questions. �Have you ever had anal sex� �oral sex� Depending on the developmental stage of the patient, I may ask, �Have you ever had anyone insert their penis into your rectum?� �Have you ever had anyone put their mouth on your vagina� on your rectum?� Always ask about symptoms or if their partner(s) have been complaining of any symptoms. When addressing contraception use, I always ask with which partners they use contraception. Research has shown that adolescents are more likely to use condoms with casual sex partners and less likely to use barrier methods with �significant partners� (which describes those with whom they feel more emotionally attached). Which is really an oxymoron: Since you don�t protect the one you love the most.

6. State Minor Consent Laws Confidentiality FL Statute � 384.30 provides that a minor may be examined and treated for sexually transmitted diseases without the consent of a parent or guardian by licensed physicians and health care professionals, the Department of Health, a public or private hospital, a clinic, or other health facility. When adolescents seek medical care for STI treatment, it�s important to cover areas of confidentiality. Confidentiality is a major concern for adolescents because many are unaware that they are legally entitled to confidential services. The consent for STI related care varies from state to state. State minor consent laws for Florida allow minors to be seen and treated without parental consent.When adolescents seek medical care for STI treatment, it�s important to cover areas of confidentiality. Confidentiality is a major concern for adolescents because many are unaware that they are legally entitled to confidential services. The consent for STI related care varies from state to state. State minor consent laws for Florida allow minors to be seen and treated without parental consent.

7. Examination Skin Oropharynx Lymphatics cervical, inguinal, clavicular Genitourinary Penile/testicular exam Vaginal/cervical Rectal

8. Lymphatic System

9. Chlamydia

10. Chlamydia-Epidemiology Chlamydia most common bacterial sexually transmitted infection in US 2.8 million new cases occur annually Highest rates (regardless of demographics or location) 15 to 19 year-old females (2,687.3 per 100,000 females) 20 to 24 year-old males (690 per 100,000 males) The estimated annual cost exceeds $2 billion Screening can lead to reduction of PID by 60% CT is the most common bacterial STI in the US with 3 million new cases annually. The latest surveillance data from 2003 show highest rates of CT in females among the 15 to 19 y.o. age group. The highest rates in males are among the 20 to 24 y.o. age group. These rates are regardless of demographics or location. These increases likely represent increased screening, use of more sensitive tests, improved reporting and the continuing burden of disease. The estimated cost of chlamydia sequelae exceeds $2 billion ANNUAL. CT is the most common bacterial STI in the US with 3 million new cases annually. The latest surveillance data from 2003 show highest rates of CT in females among the 15 to 19 y.o. age group. The highest rates in males are among the 20 to 24 y.o. age group. These rates are regardless of demographics or location. These increases likely represent increased screening, use of more sensitive tests, improved reporting and the continuing burden of disease. The estimated cost of chlamydia sequelae exceeds $2 billion ANNUAL.

11. Chlamydia trachomatis Intracellular organism Majority (60 � 80%) of genital infections are asymptomatic May present with urinary symptoms Female: Infection can lead to PID (20-50%) and 20% of PID patients become infertile Male: Symptoms can progress to epididymitis or orchitis

12. Chlamydia � Age- and sex-specific rates: United States, 2004, CDC

13. Chlamydia � Rates by state: United States and outlying areas, 2004, CDC

14. Chlamydia � Rates by county:United States, 2004, CDC

15. Diagnosis of Chlamydia Although Culture has 100% Specificity (no false positives). There is growing evidence that it is not 100% sensitive (no false negatives) and therefore is no longer accepted as gold standard for assessing newer diagnostic technologies. Amplified DNA Assays- NAAT Polymerase chain reaction (PCR), Ligase chain reaction (LCR), strand displacement assay, transcription mediated amplification of RNA Antigen Detection Tests Direct fluorescent antibody (DFA) assay Enzyme Immunoassay (EIA) Although Culture has 100% Specificity (no false positives). There is growing evidence that it is not 100% sensitive (no false negatives) and therefore is no longer accepted as gold standard for assessing newer diagnostic technologies. Amplified DNA Assays- NAAT Polymerase chain reaction (PCR), Ligase chain reaction (LCR), strand displacement assay, transcription mediated amplification of RNA Antigen Detection Tests Direct fluorescent antibody (DFA) assay Enzyme Immunoassay (EIA)

17. Clinical Findings

18. Chlamydia Treatment Azithromycin 1 g po X 1 Doxycyline 100 mg BID x 7 days Alternatives Erythromycin 500 mg QID x 7 days EES 800 mg QID x 7 days Ofloxacin 300 mg BID x 7 days Levofloxacin 500 mg QD x 7 days Azithromycin would be the DOC if you think the patient may not adhere to the 7 day regimen. Azithromycin should be given in the office under DOT which may decrease the likelihood of non-compliance secondary to privacy issues. If the powder form is administered, ensure that the entire contents of the packet are dissolved and consumed. Azithromycin would be the DOC if you think the patient may not adhere to the 7 day regimen. Azithromycin should be given in the office under DOT which may decrease the likelihood of non-compliance secondary to privacy issues. If the powder form is administered, ensure that the entire contents of the packet are dissolved and consumed.

19. Treatment Partner notification, screening, and treatment even if asymptomatic There is no immunity following infection, repeat infection is common Re-screen in 3-4 months recommended for females living in high prevalence areas Prognosis is great if both partners treated to avoid �ping-pong� effect Partner notification, screening, and treatment are recommended even if the patient is asymptomatic There is no immunity following a chlamydia infection so repeat infection is common The latest CDC STD guidelines recommend re-screening within 3-4 months for females living in high prevalence areas. The prognosis of CT is great if both partners are treated in a timely fashion. It is important to instruct patients to refrain from sexual activity for a total of 7 seven days to avoid the ping-pong effect. That is either during the entire doxycycline treatment, or 7 days after azithromycin therapy. Refrain means �No sex, not even with a condom. Give it a rest� Partner notification, screening, and treatment are recommended even if the patient is asymptomatic There is no immunity following a chlamydia infection so repeat infection is common The latest CDC STD guidelines recommend re-screening within 3-4 months for females living in high prevalence areas. The prognosis of CT is great if both partners are treated in a timely fashion. It is important to instruct patients to refrain from sexual activity for a total of 7 seven days to avoid the ping-pong effect. That is either during the entire doxycycline treatment, or 7 days after azithromycin therapy. Refrain means �No sex, not even with a condom. Give it a rest�

20. Notify Health Department Chlamydia is a reportable sexually transmitted infection Local Health Department should be notified once diagnosis made include mode of therapy partner notification/treatment Chlamydia is a reportable sexually transmitted infection In most states, the diagnosing laboratory will notify the local health department Once notified by the provider, you should include 1. mode of therapy and 2. tell whether partner notification/treatment has occurred Chlamydia is a reportable sexually transmitted infection In most states, the diagnosing laboratory will notify the local health department Once notified by the provider, you should include 1. mode of therapy and 2. tell whether partner notification/treatment has occurred

21. Chlamydia Complications Pelvic Inflammatory Disease Salpingitis Infertility (fallopian tube obstruction from scarring) Ectopic pregnancy Chronic Pelvic Pain

22. Gonorrhea

23. Gonorrhea-Epidemiology Gonorrhea common bacterial sexually transmitted infection In 2004 there were 330,132 new cases reported Highest rates (regardless of demographics or location) 15 to 19-year-old females (634.7 per 100,000 females) 20 to 24-year-old males (465.9 per 100,000 males) GC is a commone bacterial STI Surveillance data from 2003 show highest rates of GC in females among the 15 to 19 y.o. age group. The highest rates in males are among the 20 to 24 y.o. age group. These rates are regardless of demographics or location. GC is a commone bacterial STI Surveillance data from 2003 show highest rates of GC in females among the 15 to 19 y.o. age group. The highest rates in males are among the 20 to 24 y.o. age group. These rates are regardless of demographics or location.

24. Gonorrhea Common bacterial infection transmitted during sexual intercourse (vaginal, oral, anal) Pharyngitis Vaginitis/cervicitis ? PID Proctitis Peritonitis, arthritis, and disseminated disease can occur 50% of women asymptomatic

25. Gonorrhea � Rates by state: United States and outlying areas, 2004, CDC

26. Gonorrhea � Rates by county: United States, 2004, CDC

27. Gonorrhea � Age- and sex-specific rates: United States, 2004, CDC

28. Clinical Findings

29. Epididymitis

30. Gonorrhea Cervicitis

31. Disseminated Gonorrhea: Skin Lesions

32. Diagnosis of Gonorrhea Gram stain (cervical/urethral) Endocervical culture Urethral discharge culture Throat swab culture Skin lesion/Joint aspiration Rectal culture

33. Gram Stain

35. Treatment Options Ciprofloxacin 500 mg po x 1* Ceftriaxone 125 mg IM x 1* Ofloxacin 400 mg po x 1 Levofloxacin 250 mg po x 1 Current treatment rec include: 500 mg of Cipro PO Cefixime 400mg tablets were discontinued in 2002 but another company received FDA approval to market the tablets in Feb 2004. Because of the prevalence of fluoroquinolone resistance in California and the Pacific Islands, including Hawaii, it is no longer a recommendation in those areas. Resistance has not been reported in NE Florida nor SE Georgia. If you suspect antimicrobial-resistant gonococcal infections, cultures are usually needed to determine susceptibility since resistance-testing can only be performed on Neiserria growing in culture. Current treatment rec include: 500 mg of Cipro PO Cefixime 400mg tablets were discontinued in 2002 but another company received FDA approval to market the tablets in Feb 2004. Because of the prevalence of fluoroquinolone resistance in California and the Pacific Islands, including Hawaii, it is no longer a recommendation in those areas. Resistance has not been reported in NE Florida nor SE Georgia. If you suspect antimicrobial-resistant gonococcal infections, cultures are usually needed to determine susceptibility since resistance-testing can only be performed on Neiserria growing in culture.

36. Follow-up and Prognosis Repeat testing indicated particularly in asymptomatic patients Prognosis is good when treated early Complications: Female: salpingitis, PID, peritonitis, bacteremia, GC arthritis, GC pharyngitis, opthalmia neonatorum, vulvovaginitis, sterility, dyspareunia. Male: periurethral abcess, GC arthritis, pharyngitis,conjunctivitis, epididymitis, prostatitis, seminal vesiculitis, cowperitis. Partner Notification

37. Pelvic Inflammatory Disease Spectrum of inflammatory disorders of upper female genital tract endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis STIs are implicated Normal vaginal flora have also been implicated

38. Pelvic Inflammatory Disease - PID Clinical diagnosis of PID is imprecise Many episodes of PID go unrecognized Maintain low threshold for diagnosis Empiric treatment should begin in SA women at risk for STIs if minimum criteria are present and no other cause identified: Uterine/adnexal tenderness or Cervical Motion tenderness

39. Additional Supportive Criteria Temperature >101 F (38.3C) Abnormal cervical or vaginal mucopurulent discharge WBCs on saline microscopy Elevated ESR and/or C-reactive protein Documentation of GC or CT infection

40. Criteria for Hospitalization Surgical emergencies Pregnancy Patient does not respond to antimicrobial therapy Patient is unable to follow or tolerate outpatient therapy Patient has severe illness, nausea/vomiting, or high fever Patient has tubo-ovarian abscess

41. PID Treatment IV Regimens Regimen A: Cefotetan or Cefoxitin 2g IV q 6 hours plus Doxycycline 100 mg po/IV q 12 x 14 days Regimen B: Clindamycin 900 mg IV q 8 hours plus Gentamicin loading dose IV/IM 2m/kg followed by 1.5 mg/kg q 8 hours.(May use single daily dosing) PO Regimens Regimen A: Ofloxacin 400 mg po BID x 14 days or Levofloxacin 500 mg qD x 14 days with/ without Metronidazole 500 mg BID x 14 days Regimen B: Ceftriaxone 250 mg IM plus Doxycycline 100 mg BID x 14 days with/without metronidazole 500 mg po BID x 14 days

42. Follow-up Patients should improve within 72 hours Reduction in cervical motion/adnexal tenderness Defervescence (fever, clinical symptoms, N/V) Outpatient adolescents with PID should be re-examined within 72 hours Patients who do not improve usually require hospitalization, additional diagnostic testing (U/S), and/or surgical consultation/ intervention (gynecology) Some specialists recommend re-screening for CT/GC 4-6 weeks in women with documented infection PARTNER NOTIFICATION AND TREATMENT!!

43. Syphilis

44. Syphilis-Epidemiology Rates of primary and secondary syphilis declined by 90% between 1990-2000 Highest rates of primary and secondary syphilis 20 to 24-year-old females (2.4 per 100,000 females) 35 to 39-year-old males (11.8 per 100,000 males) Rates increased 13.5% among men while it decreased 27.3% among women from 2002-2003 The latest surveillance data from 2003 show highest rates of RPR in females among the 20 to 24 y.o. age group. The highest rates in males are among the 35 to 39 y.o. age group. The latest surveillance data from 2003 show highest rates of RPR in females among the 20 to 24 y.o. age group. The highest rates in males are among the 35 to 39 y.o. age group.

45. Herpes - HSV

46. What is the difference between

47. Genital Herpes Common, recurrent, incurable viral STI Affects an estimated 45 million Americans (serology) 500,000 new cases each year Two serotypes: HSV 1 and 2 Frequency highest during the first year after acquisition and with HSV seropositives who are immunocompromised (HIV) Common, recurrent, incurable viral STI Affects an estimated 45 million Americans (serology) 500,000 new cases each year Two serotypes: HSV 1 and 2 Most persons undiagnosed (mild or unrecognized infections/shed virus intermittently) 5-30% of cases HSV-1, clinical recurrence less likely to occur in HSV 1 Common, recurrent, incurable viral STI Affects an estimated 45 million Americans (serology) 500,000 new cases each year Two serotypes: HSV 1 and 2 Most persons undiagnosed (mild or unrecognized infections/shed virus intermittently) 5-30% of cases HSV-1, clinical recurrence less likely to occur in HSV 1

48. HSV Recognition of genital herpes among those with HSV-2 antibody was low overall 90.9% with unrecognized infection 90% of persons with HSV-2 shed virus asymptomatically

49. Clinical Findings

50. HSV

51. Genital herpes � Initial visits to physicians� offices: United States, 1966�2004

52. Diagnosis Viral Culture Direct Antigen Detection (lesions) PCR Serology Symptomatic Lesions negative for virus Lesions can�t be sampled Lesions are healed or not present Subclinical Partner with genital herpes/ sexual history Symptoms suggestive of atypical or undiagnosed herpes Prenatal care (to determine status of pregnant woman with HSV-2 positive partner)

53. Treatment-First Episode Acyclovir 400 mg TID x 7-10 days* Famciclovir 250 TID x 7-10 days Valacyclovir 1 g BID x 7-10 days Treatment can be extended if persistent beyond 10 days Acyclovir only drug approved for treatment in pregnancy*

54. Additional Regimens Episodic/Recurrent Acyclovir 400 TID x 5 days or 800 BID x 5 Famciclovir 125 BID x 5 days Valacyclovir 500 mg BID x 5 days Daily Suppressive Acyclovir 400 mg BID Famciclovir 250 mg BID Valacyclovir 500 mg BID or 1g QD Severe Therapy Acyclovir 5-10 mg/kg IV q 8 x 5-7 days

55. Management Issues Patients should be taught about natural history of disease, recurrent episodes, asymptomatic viral shedding, sexual transmission, and value of episodic antiviral therapy Abstain from SA when lesions or prodromal symptoms present Partner Notification (testing if partner is pregnant)

56. HPV & Genital Warts

57. Human Papillomavirus Human papillomavirus (HPV) is the most common STI in the US 24 million Americans are infected with HPV In sexually active individuals 15�24 years of age, ~9.2 million are currently infected.3 An estimated 74% of new HPV infections occur in this age group More than 100 types of HPV have been identified (1/3 sexually transmitted) Infection with oncogenic HPV types is the most significant risk factor in cervical cancer etiology HPV usually causes a silent infection In sexually active individuals ages 15-24 years, approximately 9 million are currently infected with HPV. It has been reported that 74% of the new cases occur in this age group. In sexually active individuals ages 15-24 years, approximately 9 million are currently infected with HPV. It has been reported that 74% of the new cases occur in this age group.

58. HPV-Symptoms Males : soft, grape-like growths on the penis or around the anal region warts on the penis, bleeding secretions decreased force of urination Females : warts on the genitals or anal region pinkish, red, gray or white warts Burning/pain itching bleeding asymptomatic

59. Human Papillomavirus

60. Condyloma acuminata, penile

61. Condyloma acuminata, anal

62. Condyloma acuminata, meatal

63. Condyloma acuminata, vulva

64. Treatment Podofilox 0.5% solution/gel* Imiquimod 5%* Cryotherapy with liquid nitrogen or cryoprobe Podophyllin resin 10-25% TCA or BCA 80-90% Surgical removal Alternative: Intralesional interferon/Laser Benefits of the first two treatments is that the patient can administer the medication on their own. Eliminating the need for additional clinic visits. It is always beneficial to have the patient do the first application in front of the provider to ensure proper use. Benefits of the first two treatments is that the patient can administer the medication on their own. Eliminating the need for additional clinic visits. It is always beneficial to have the patient do the first application in front of the provider to ensure proper use.

65. Pap Smear Collection

66. Transitional Zone Pap Smears without the transitional zones are considered inadequate and must be repeated

67. Pap Smear Prep

68. Indications for Pap Smear Recommendation in healthy adolescent women �Screening should be initiated within 3 years of onset of vaginal intercourse but no later than 21 years of age.� Moscicki, AB, Current Women�s Health Report, Dec 2003, Vol. 3, No. 6: (433-7) �Cervical Cytology Screening in Teens� Natural history studies of HPV suggest that there is little risk of a significant precancerous lesion going undetected within the first 3 to 5 years after onset of sexual activity. Natural history studies of HPV suggest that there is little risk of a significant precancerous lesion going undetected within the first 3 to 5 years after onset of sexual activity.

69. HPV Regression In women 15�25 years of age, ~80% of HPV infections are transient Gradual development of cell-mediated immune response presumed mechanism In a study of 608 college women, 70% of new HPV infections cleared within 1 year and 91% within 2 years Median duration of infection = 8 months Certain HPV types are more likely to persist (eg. HPV 16 and HPV 18) Justification for these new recommendations are that approximately 80% women 15-25 years of age who have no comorbidities are likely to undergo regression of disease without treatment or further intervention. The new recommendations will assist in the over-referral and overtreatment of healthy adolescents with HPV. Justification for these new recommendations are that approximately 80% women 15-25 years of age who have no comorbidities are likely to undergo regression of disease without treatment or further intervention. The new recommendations will assist in the over-referral and overtreatment of healthy adolescents with HPV.

71. Management of ASCUS Papanicolaou Smears in Adolescents

72. Management of LSIL/CIN1 Papanicolaou Smears in Adolescents without co-morbidities the concern is that referral to colposcopy may result in an overdiagnosis of cervical lesions that will regress spontaneously, leading to inappropriate intervention, which may result in more harm than good the concern is that referral to colposcopy may result in an overdiagnosis of cervical lesions that will regress spontaneously, leading to inappropriate intervention, which may result in more harm than good

73. Management of LSIL/CIN1 Papanicolaou Smears in Adolescents with co-morbidities

74. Trichomoniasis Diffuse, malodorous, yellow-green discharge with vulvar irritation, severe pruritis, or post coital bleeding Usually sexually acquired Infection through fomites possible but not proven (may survive several hours in urine or on wet towel)

75. Clinical Findings of Trichomonas

76. Clinical Findings

77. Diagnosis Culture is the most sensitive commercially available method of diagnosis Wet mount is commonly used in practice

78. Wet Mount Flagellated parasites dancing under coverslip Increase leukocytes pH >4.5 10% KOH gives fishy odor ? + Whiff test Larger than sperm

79. Trichomonads

80. Treatment Recommended Regimen Metronidazole 2 gm PO x 1 dose Alternate Regimen Metronidazole 500mg PO BID x 7 days Metronidazole gel is NOT recommended for treatment of Trichomoniasis

81. Trichomoniasis and other vaginal infections in women � Initial visits to physicians� offices: United States, 1966�2004

82. Bacterial Vaginosis Most prevalent cause of vaginal discharge or malodor 50% of patients asymptomatic Associated with multiple sex partners, douching, lack of lactobacilli Uncertain whether BV is from a sexually transmitted pathogen (found in virginal women)

83. Diagnosis Clinical criteria require three of the following: Homogenous, white, inflammatory discharge coating the vaginal walls Clue cells pH >4.5 Fishy odor if vaginal discharge after 10% KOH added (+ Whiff test) Culture not recommended (not specific)

84. Wet Mount Clue cells: Epithelial cells with bacteria attached have a �peppered� appearance

85. Complications of BV Premature Rupture of Membranes Preterm Labor Preterm Birth Postpartum Endometritis

86. Recommended Treatment Metronidazole 500mg PO BID x 7 days or Metronidazole gel 0.75% (1 full applicator) intravaginally QD x 5 days or Clindamycin cream 2% (1 full applicator) intravaginally qHS x 7 days Metronidazole 250mg PO TID x 7 days (In pregnant patients)

87. Patients should be advised to avoid alcohol during metronidazole treatment Clindamycin cream is oil-based and might weaken latex condoms and diaphragms

88. Partner Referral Partner Notification Cards Involvement of Health Department DIS: disease intervention specialists Expedited Partner Therapy (EPT) or Patient-delivered Partner Therapy (PDPT)* Not widely accepted Litigation issues

89. References [1] Eng TR, Butler WT (editors): The Hidden Epidemic Confronting Sexually Transmitted Diseases. Washington, DC, National Academy Press, 1997. [2] Centers for Disease Control and Prevention: Tracking the Hidden Epidemics Trends in STDs in the United States, 2000. Available at: http://www.cdc.gov. Accessed January 21, 2003. [3] Braverman PK: Sexually Transmitted Diseases in Adolescents. Clinical Pediatric Emergency Medicine 2003;4:21. [4] Centers for Disease Control and Prevention: Chlamydia Trachomatis genital infections � United States 1996. MMWR Morb Mort Wkly Report 1997;43:196. [5] Lauamm EO, Gagnon JH, Michael RT, et al. The social organization of sexuality: Sexual practices in the United States. Chicago, Illinois: University of Chicago Press, 2000. [6] Centers for Disease Control and Prevention: Youth Risk Behavior Surveillance-United States, 2003. MMWR Morb Mortal Wkly Rep 2004; 53:1. [7] Holmes KK, Sparling PF, Mardh PA, et al (editors): Sexually Transmitted Diseases, 3rd ed. New York, NY, McGraw-Hill, 1999. �

90. References 2 [8] Centers for Disease Control and Prevention: Sexually Transmitted Disease Surveillance, 2003. Atlanta, GA, U.S. Department of Health Human Services, Centers for Disease Control and Prevention, 2003. [9] Schillinger JA, Dunne EF, Chapin JB, Ellen JM, et al: Prevalence of Chlamydia trachomatis infection among men screened in 4 U.S. cities. Sex Transm Dis. 2005 Feb;32:74. [10] Ho GY, Bierman R, Beardsley L, Chang CJ, Burk RD: Natural history of cervicovaginal Papilloma virus infection in young women. N Engl J Med 1998; 338:423. [11] Moscicki AB: Human papilloma virus infection in adolescents. Pediatr Clin North Am 1999;46:783. [12] Moscicki AB, Shiboski S, Broering J, Powell K, Clayton L, Jay N, et al: The natural history of human papilloma virus infection as measured by repeated DNA testing in adolescent and young women. J Pediatr 1998;132:277. [13] Cohen MS, Weber RD, Mardh PA, Anderson DJ: Genitourinary Mucosal Defenses. Sexually Transmitted Diseases, 3rd edition; McGrqw-Hill. [14] Chacko M: Chlamydia trachomatis infection in sexually active adolescents: prevalence and risk factors. Pediatrics 1984;73:836. �

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