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Feature Article

Adolescent Gynecology
Sexually Transmitted Infections: Testing and Treatment
Shafii T, Burstein GR, Blythe MJ
TheFemalePatient.2011;36(11):30-37.

Over 19 million cases of sexually transmitted infections (STIs) occur in the United States each year, with a disproportionate number among young people and racial and ethnic minority populations.

The estimated annual direct medical costs of treating STIs and their sequelae are $17 billion.1 Left untreated, STIs can cause serious women's health problems ranging from infertility to increased risk of HIV infection.2 In this article, we provide updates that are important for clinicians who care for female patients.

The US Centers for Disease Control and Prevention (CDC) Sexually Transmitted Diseases Treatment Guidelines, 2010, which updated the 2006 guidelines, advises health care providers on the most effective STI treatment regimens, screening procedures, and prevention and vaccination strategies.1

The CDC recommendations are developed in consultation with public and private sector professionals knowledgeable in the treatment of STIs. Although the CDC, through an evidence-based process, revises the printed Guidelines every 3 to 4 years, the web-based version is regularly updated and is available at www.cdc.gov/std/treament/ as well as an eBook for iPad, iPhone, and iPod Touch.

SPECIAL POPULATIONS

The CDC STD Treatment Guidelines addresses screening and management needs for specific populations that may be at increased risk for infection. Below is a summary of several of the changes found in the 2010 Guidelines.

Adolescents and Young Adult Females
There are physiologic, behavioral, and logistic factors that contribute to the increased risk for adolescents and young adult females acquiring STIs. Females aged 15 to 24 years old continue to have the highest rates of reported Chlamydia trachomatis and Neisseria gonorrhoeae compared to any other age group in the United States.2 As both chlamydia and gonorrhea often present as asymptomatic infections in females and may lead to significant morbidity if untreated, all sexually active adolescent and young adult females should be screened annually, regardless of symptoms.1

Rountine screening of asyptomatic adolescents in the general population for certain other STIs (eg, syphilis, Trichomonas vaginalis, bacterial vaginosis [BV], herpes simplex virus [HSV], human papillomavirus [HPV], hepatitis A virus [HAV], and hepatitis B virus [HBV]) is not recommended, although local recommendations may vary in areas with high disease prevalence.

Prevention Strategies

Recognizing that young women are at increased risk for STIs, health care providers have the opportunity to offer anticipatory guidance and prevention strategies to decrease risk. CDC updated recommendations for prevention include the following:

  1. Encourage immunizations with the vaccines that are currently available for the primary prevention of STIs.
      HPV vaccine is recommended for all 11-and 12-year-old females, but can be administered as young as 9 years of age, and catch-up vaccinations is recommended for all females aged 13 to 26 years.
      HBV vaccine is reommended for all adolescents and those who have not completed the vaccination series.
      HAV vaccine is recommended for all adolescents in area with existing HAV vaccination programs and may be considered in areas without such programs.
  2. Provide information regarding HIV infection, testing, transmission, and implication of infection.
  3. Integrate evidence-based sexuality education (including discussions about abstinence, consistent and correct condom use, and STI testing of new partners) into clinical practice. The US Preventive Task Force Services recommends high-intensity behavioral counseling to prevent STIs for all sexually active adolescents and client-centered risk reduction counseling for all ages.3

Women Who have Sex With Women (WSW)
Females with female partners may be at increased risk for STIs and potential exposures may go unrecognized by patients or their health care providers. While the efficiency of STI transmission is greater with penile-vaginal intercourse, infection is also spread via sex toys, skin-to-skin contact, and oral and digital sex.

The majority of self-identified WSW (53% to 99%) report having had sex with men. Therefore, WSW and women with both male and female partners should be evaluated for exposures and potential risk through same-sex and heterosexual contact, which includes screening for chlamydia and syphilis when indicated.

HPV may be spread via skin-to-skin or skin-to-mucosa contact, so all females with either male or female partners or both should be offered the HPV vaccine as recommended and routinely screened for cervical cancer as per published guidelines.

Pregnant Women
The 2010 Guidelines does not offer significant changes in regard to STI screening of pregnant females. However, the Guidelines clarifies that evidence does not support routine BV screening or HSV-2 serologic screening during pregnancy.

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UPDATED ON THE DIAGNOSIS AND MANAGEMENT OF COMMON STIs AND ASSOCIATED SYNDROMES

Gonorrhea and Chlamydia
Diagnostics
New C trachomatis and N gonorrhoeae laboratory specimen-testing options are highlighted in the 2010 Guidelines. Nucleic acid amplification tests (NAATs) are the most sensitive tests to detect C trachomatis and N gonorrhoeae and are recommended by CDC.

NAATs are Food and Drug Administration (FDA)-cleared for use with urine, cervical, and urethral specimens, and many NAATs are cleared for use with provider- or patient-collected vaginal swabs. The patient-collected vaginal swab is the preferred, noninvasive, female specimen because of improved test performance, although urine remains a great NAAT specimen option.

Although NAATs are not FDA-cleared for use with rectal or oropharyngeal swab specimens, many laboratories have met the Clinical Laboratory Improvement Amendments (CLIA) requirements to offer N gonorrhoeae and C trachomatis NAAT testing on rectal swab specimens and N gonorrhoeae NAAT testing on oral swabs.

Treatment
Gonococcal antimicrobial resistance remains an issue in the United States. Penicillin, tetracycline, and quinolones are no longer gonorrhea treatment options. Due to concerns about the emergence of cephalosporin-resistant gonorrhea in the United States, CDC now recommends dual therapy, ie, 2 antibiotics, for gonoccocal infections at all anatomic sites (Tables 1, 2).

Ceftriaxone is preferred over cefixime for dual therapy with azithromycin preferred over doxycycline due to emerging resistance.4 If ceftriaxone is not an option, dual therapy with cefixime 400 mg orally plus azithromycin 1 g in a single dose or doxycycline 100 mg twice daily for 7 days is an alternative. Although cefixime is administered orally, there is limited efficacy of cefixime for treatment of pharyngeal infection.

In addition, CDC's Gonococcal Isolate Surveillance Project, which monitors antimicrobial N gonorrhoeae susceptibilities, has identified a trend of decreasing gonorrhea sensitivities to cefixime.4 If a patient experiences cefixime treatment failure, CDC advises clinicians to re-treat the patient with ceftriaxone 250 mg intramuscularly (IM) and azithromycin 2 g orally.

In May, 2011, the first US case of a high-level azithromycin resistant N gonorrhoeae infection was detected in Hawaii.5 Although CDC does not recommend azithromycin alone for routine gonorrhea treatment, an azithromycin 2-g oral dose may be prescribed for patients with a cephalosporin allergy. If this regimen is used, a test-of-cure with culture should be performed 1 week after treatment. If culture is not available, a NAAT can be used as soon as 1 week after treatment. With a positive NAAT result, a culture should be done to confirm.

Follow-up
Return to sexual activity with untreated partners results in high chlamydia and gonorrhea reinfection rates. CDC recommends retesting patients treated for gonorrhea or chlamydia approximately 3 months after treatment or the next time the patients present for medical care, regardless of patients' relationship status with their partners or whether they believe that their sex partners were treated.

Partner Management:
Expedited Partner Therapy (EPT)

The 2010 Guidelines emphasizes the important role of partner management in STI prevention. Partner treatment not only directly benefits the infected individual, but also prevents reinfection and disrupts STI transmission networks. The Guidelines highlights the importance of EPT and the clinical practice of treating the sex partners of patients diagnosed with an STI without previous medical evaluation of the partners.

According to the 2010 Guidelines and CDC EPT guidance,6 EPT should be considered for the treatment of gonorrhea and chlamydia in heterosexual partners when other management strategies are impractical or unsuccessful. As of August 10, 2011, 30 states and 1 city have made EPT possible or even legally permissible, and many state health departments have developed EPT implementation guidelines.

In addition, EPT has been endorsed by many professional organizations, such as the American Academy of Pediatrics, American Bar Association, American College of Obstetricians and Gynecologists, American Medical Association, and Society for Adolescent Health and Medicine. The 2010 Guidelines also discusses new evidence supporting using the Internet to facilitate partner notification.

Pelvic Inflammatory Disease (PID)
Treatment
As a result of the emergence of quinolone-resistant N gonorrhoeae, regimens that include a quinolone agent are no longer recommended for PID treatment. Alternative oral regimens may be found in the CDC Guidelines (Table 3).

One randomized trial has demonstrated short-term effectiveness with azithromycin (1 g orally once a week for 2 weeks) when given in combination with ceftriaxone (250 mg IM in a single dose). Clinicians who use an alternative PID treatment regimen should consider adding metronidazole to treat anaerobic organisms in the polymicrobial infection, especially when BV is present.

Vaginitis
Diagnostics
Vaginitis diagnostic evaluation can be challenging. Historically, BV has been diagnosed by clinical criteria (eg, Amsel's Diagnostic Criteria that includes microscopy) or with Gram stain. However, in many providers' offices, these methods are no longer available. The sensitivity of microscopic examination of vaginal secretions immediately after the slide preparation for T vaginalis is only 60% to 70%. New vaginitis diagnostic tools include the availability of CLIA-waived, rapid vaginal tests where results are available in 10 minutes.

The OSOM® Trichomonas Rapid Test (Sekisui Diagnostics, Framingham, MA), an immunochromatographic capillary flow dipstick technology, looks and works exactly like a rapid strep test.

The OSOM BVBLUE® Test (Sekisui Diagnostics, Framingham, MA) detects elevated vaginal fl uid sialidase activity, an enzyme produced by BV-associated bacteria, including Gardnerella, Bacteroides, Prevotella, and Mobilincus. If a blue or green color appears 10 minutes after a vaginal swab is placed in a testing vessel with medium and buffer, the test is positive; if the vessel contents are yellow, the test is negative. These tests have Current Procedural Terminology codes.

The Affirm™ VP III (Becton Dickenson, San Jose, CA), a nucleic acid probe test, which tests for T vaginalis, G vaginalis, and C albicans, is a CLIA moderate complexity test with results available within 45 minutes. A NAAT for T vaginalis was developed by Gen Probe (San Diego, CA) for use on their APTIMA assay platform. The test is FDA-approved for testing all female specimens on which a gonorrhea and chlamydia test can be run.

Treatment and Follow-Up
Although metronidazole and clindamycin remain the recommended BV treatment regimens, two new alternative BV treatment regimens are tinidazole 2 g orally once daily for 2 days or tinidazole 1 g orally once daily for 5 days are options for patients. Tinidazole is contraindicated in patients where pregnancy cannot be ruled out.

Since there is a high rate of reinfection among patients diagnosed and treated for T vaginalis, providers may consider rescreening female patients for T vaginalis 3 months after treatment. Tinidazole 2 g orally may also be considered as a treatment regimen for T vaginalis in women who are not pregnant, especially for those with repeat infections.

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MORE INFORMATION

The complete treatment guidelines, as well as information on webinars, ordering information regarding hard copies of the Guidelines, wall charts, and pocket guides and downloading iPhone and eBook versions can be viewed and downloaded at www.cdc.gov/std /treatment/2010 or contact CDC-INFO at 800-CDC-INFO (800-232-4636), 24 hours/day, or e-mail cdcinfo@cdc.gov.

Dr Shafii and Dr Blythe report no actual or potential confl icts of interest in relation to this article. Dr Burstein is a consultant and on the speaker's bureau for one of the HPV vaccines, Gardasil (Merck, Inc).

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Taraneh Shafii, MD, MPH, is Assistant Professor of Pediatrics, University of Washington School of Medicine, Seattle, WA. Gale R. Burstein, MD, MPH, is Associate Professor of Clinical Pediatrics, Division of Adolescent Medicine, University at Buffalo Pediatrics Associates, Buffalo, NY. Margaret J. Blythe, MD, is Professor of Pediatrics & Adjunct Professor of Gynecology, Indiana University School of Medicine, Indianapolis, IN.

References

  1. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2009. Atlanta: U.S. Department of Health and Human Services; 2010. Available at: www.cdc.gov/std/stats/. Accessed on July 21, 2011.
  2. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2010. MMWR [online]. 2010;59(RR12):1-110. Available at: www.cdc .gov/std/treatment/2010. Accessed on July 21, 2011.
  3. U.S. Preventive Services Task Force. Behavioral Counseling to Prevent Sexually Transmitted Infections: U.S. Preventive Services Task Force Recommendation Statement. AHRQ [online]. 2008;08-05123-EF-2. Available at: www .uspreventiveservicestaskforce.org/uspstf08/sti/stirs.htm. Accessed on July 21, 2011.
  4. Centers for Disease Control and Prevention. Cephalosporin Susceptibility Among Neisseria gonorrhoeae Isolates --- United States, 2000—2010. MMWR [online]. 2011;60:873- 877. Available at: www.cdc.gov/mmwr/preview/mmwrhtml /mm6026a2.htm. Accessed on July 21, 2011.
  5. Centers for Disease Control and Prevention. Azithromycin resistance in Hawaii. Dear Colleague Letter, May 24, 2011. Available at: www.cdc.gov/std/gonorrhea/DCL-Azithro- GC-May-24-2011.pdf. Accessed on July 21, 2011.
  6. Centers for Disease Control and Prevention. Expedited partner therapy in the management of sexually transmitted diseases. Atlanta, GA: US Department of Health and Human Services, 2006. Available at: www.cdc.gov/std/treatment /EPTFinalReport2006.pdf. Accessed on July 21, 2011.

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