Overview

• Adolescents and STDs-Special Considerations Cervicitis, PID, & Other • and infections: Review GC/Chlamydia Infections • STD Syndromes: − Cervicitis Susan Blank, MD MPH ( [email protected] ) − Pelvic Inflammatory Disease Elizabeth Alderman, MD − Urethritis Professor of Clinical Pediatrics − Albert Einstein College of Medicine Children’s Hospital at Montefiore − [email protected]

Percentage of High School Students Who NYS High School Students Who Ever Had Were Currently Sexually Active,* 2011 Sexual Intercourse, 2011 (YRBS 2011)

% 23.9% - 31.3%

31.4% - 33.7%

33.8% - 37.6%

37.7% - 44.1%

No Data

* Had sexual intercourse with at least one person during the 3 months before the survey.

CDC YRBSS, 2011 Grade State Youth Risk Behavior Surveys, 2011

Adolescent Susceptibility Adolescent Sexual Health Trends to STDs  National Youth Risk Behavior Surveillance System • Physical • Cervical ectopy  ↓↓↓ in high school students who have ever had sex • Asymptomatic nature of infection ↓ →  1991-2009: ↓↓ 54% to →→ 46% • No prior immunity  ↓↓↓ in high school students reporting sex with >4 persons  1991-2009: ↓↓↓ 19% →→→ 14% • Cognitive  Used during last sexual intercourse • Concrete thinking  1991-2003: 46% →→→ 63% • Not planning ahead  2003-09: no significant change, still ~61% • Unable to judge risk for STI • Invincibility www.cdc.gov/HealthyYouth/yrbs

1 Adolescent Susceptibility Cervical Ectopy to STDs

• Behavioral – Early sexual initiation – Sexual activity with a new partner – Multiple partners – Substance use at last sex

• Social – Lack of insurance/ability to pay – Lack of “medical home” – Confidential services Normal with ectopy. Courtesy of California NNPTC

What Makes a Patient High Risk for Epidemiology of STD? STIs in Adolescents • 2 biggest risk factors Aprox. 19 million new cases – Young age Incidence per year: – Previous STI • Half occur in people 1 in 4 teen girls have – Previous Pregnancy ages 15–24 an STI (CDC 2008) Prevalence • Other factors to consider • Most asymptomatic and undiagnosed – New partner since last test 2006: 33% new STI Increased among 13–29 yo – Multiple partners Risk – Erratic/improper condom use Economic costs ~$17 billion/year Cost

Potential Barriers to STD Risk Prevalence of 5 STDs Among Females Aged 14 to Assessment 19 yrs: United States, 2003–2004

All ♀ Sexually Experienced ♀ • Belief that prevalence of STI in patients low STI Weighted Prevalence Weighted Prevalence (%) (%) • Lack of: Any STI 24.1 37.7 – Time HPV* 18.3 29.5 – Reimbursement C trachomatis 3.9 7.1 – Provider training T vaginalis 2.5 3.6 – Patient and provider comfort HSV-2 1.9 3.4 • In commercial health plans, billing statements may N gonorrhoeae 1.3 2.5 break confidentiality *HPV 6/11 & any of 23 oncogenic types

Forhan SE, et al. Pediatrics 2009;124:1505–1512.

2 Approach to the Adolescent Involving Parents/Guardians Key Strategies

• Assess developmental level • Lay groundwork for confidential relationship when child is pre-teen • Discuss confidentiality with adolescent/parent • Introduce concept of time alone at 11 year old • Appropriately ensure confidentiality, time visit alone • Encourage parental participation in care & • Brief risk assessment at most visits support of confidentiality • STI screening annually if sexually active • Have materials such as posters/brochures available • Systems for follow-up of confidential results

Development of Adolescent as Health Confidentiality Consumer • Information about teen’s treatment not disclosed without his/her permission • Respect adolescent’s evolving autonomy • Supported by national organizations • Expert consensus- (ACOG ’88, AAFP ’89, AAP • Facilitate collaborative decision-making ’89 SAHM ’92, AMA’92)

• Determined by age/developmental level

• Need to establish caveats when presenting to teens and parent/guardian

Exceptions to the Provision of Confidential Confidentiality and STD* Health Services • All 50 states and the District of Columbia allow minors to consent to STI services • Suspected physical, sexual or • 11 states require that a minor be a certain age emotional abuse (12 or 14) to consent. • 31 states include HIV in package of STI services • At risk for harm to self or others to which minors may consent • May confidentially report STIs to health • 18 states allow physicians to inform parents that department a minor is seeking or receiving STI services

*www.guttmacher.org/statecenter/adolescents.html

3 Confidentiality and Billing

How Can I Perform STD Screening • Cannot guarantee confidentiality in many cases Confidentially? • Explanation of benefits (EOBS) may be sent by insurance company • Need to know the “paper trail issues” in your health system

Explanation of Benefits Confidentiality and Billing Medicaid vs. Private Insurance Potential Solutions • EOBs sent to policyholder or insured in most • CPT Modifier 33 aids in correctly coding for private plans preventive services falling under the Affordable • Medicaid does not routinely send EOBs for Care Act with no cost sharing confidential services in NYS • Develop system for low cost visits • Some claim statements/EOBs are general and • NY State Medicaid Family Planning Benefit do not disclose service/diagnosis

New York State Family Planning New York State Family Planning Benefit* (NYSFPB) Benefit (NYSFPB)

• Eligibility: • Public health insurance program for New Yorkers – Female or male of childbearing age needing family planning services but not able to pay – New York State resident • Intended to – U. S. citizen, national, Native American, or – increase access to confidential family planning services satisfactory immigration status – enable teens, women and men of childbearing age to prevent – Meet certain income requirements (currently under and/or reduce unintentional pregnancies 200% of the Federal Poverty Level) and • Patient can be dually insured with parents’ commercial – Not already enrolled in Medicaid or Family Health health plan and with NYSFPB Plus – Presumptive enrollment coming very soon! *http://www.health.ny.gov/health_care/medicaid/program/longterm /familyplanbenprog.htm

4 New York State Family Planning NYSFPB Benefit Services Considered Family Planning Services Covered Must Be Provided Within FP Visit/Directly Related to FP • Most FDA approved birth control methods, devices, and supplies (e.g., birth control pills, injectables, patches, • Pregnancy testing and counseling • Comprehensive health history and physical examination (inc. breast , diaphragms, IUDs) exam & referrals to PCP) NOT Mammograms • Emergency contraception services and follow-up care • Screening/STI • Screening for , urinary tract & female-related • Male and female sterilization infections • Preconception counseling and preventive screening • Screening & related diagnostic laboratory testing for medical conditions affecting choice of birth control • Family planning options before pregnancy • HIV counseling/testing • Counseling services related to pregnancy, informed consent, & STD/HIV risk counseling • Bone density scan if plan to use or using Depo-Provera • Ultrasound to assess placement of an

Confidentiality and Meaningful Use Follow-up Issues

• Always get alternative phone numbers • Patient Instructions-Need to do in 50% of visits – Confidential number in EMR • May contain confidential information • Possibly alternative address • Can give to patients 18 or older directly • Email • May need to give to adolescent, themselves – Must consider lack of confidentiality over Internet • MAPCI working with Pediatric EMR group working on ways to delete confidential information – Patient portals helpful if patient 18 years or older • Meaningful Use 2 • Caveats when establishing confidentiality

Develop Referral Network For Office Clinical Staff & Confidential Care Confidentiality • School Health • Educate staff: • College Health – Adolescent development and need for confidentiality • NYC App from NYC DOH – State laws • STD Clinics – Office policies • Planned Parenthood – Adolescent health guidelines • Mental Health Professionals – Alternative community resources (public health • Hospital based Clinics clinics, school health clinics, Planned Parenthood) • Prenatal care services • Abortion services • Adoption services

5 Changes You May Wish to Make Your Changes You May Wish to Make Practice Adolescent Friendly Your Practice Adolescent Friendly • Don’t miss primary care opportunities at sick visits • Adolescent-only office hours – Urine STI Screening • Prompt on EMR/visit note for confidential contact – Immunizations number • Adolescent template in EMR • Compile list of community resources for • Universal urine collection confidential reproductive health services/ mental • Patient walk through – with cycle time health services • Nurses/medical assistants review chief • Develop list of primary care providers that complaints/immunization records patients can be transitioned to • Handling messages/interruptions

Case 1: “I Need a Physical to Play High School Tennis” Why Screen for STDs?

• Ashley is a 16 year old girl who comes to your • Standard of care office for a sports physical. She recently became • Cost effective sexually active with her 16 year old boyfriend of • Reduces transmission/prevents complications a year. They use condoms “all the time.” No oral (PID, ) or anal sex. He had one prior sexual partner, a female who is in the same grade. Ashley is • HEDIS Measure-Chlamydia screening females <25 years asymptomatic. She does not want her parents to know she is sexually active.

2010 CDC 2010 CDC Guidelines Guidelines Chlamydia Chlamydia Males Females • Chlamydia screening among sexually active • Screen all sexually active women <25 * at least young men should be considered in clinical annually settings with high prevalence of chlamydia: • Screen all pregnant women during first trimester −Adolescent clinics of pregnancy; consider re-screening during 3 rd −STD clinics trimester for women <25 and those at increased −Correctional facilities risk −Among MSM* • USPSTF: Evidence insufficient to recommend routine screening among males

*USPSTF Grade A Recommendation

6 2010 CDC Guidelines Adolescent STD Screening Chlamydia Chlamydia CDC/NYS Recommendations MSM • Annual C. trachomatis (CT) screen all sexually active females aged ≤25 yrs • Screen all sexually active men who have sex with men (MSM) for C. trachomatis infection at • Annual N. gonorrhoeae (GC) screen all at-risk sexually active females least annually • Females aged <25 years are highest risk for gonorrhea • Screen at sites of exposure: infection – Urethral (urine NAAT) • Offer HIV screening to all adolescents and – Rectal (rectal NAAT *) encourage testing for those at risk • Begin cervical cancer screening at age 21 in most • Pharyngeal testing not recommended cases

*Not FDA-approved; require local lab validation

2010 CDC Guidelines HIV What else?

NYS Law as of July 30, 20102010:::: • Routine screening of adolescents who are An HIV test must be offered asymptomatic for certain STDs is not to all patients between the recommended: ages of 13 and 64 when they Herpes receive health-related HPV services in a primary care setting or a hospital, either as Hepatitis A and B inpatients or as emergency- • However, young MSM and pregnant adolescent room patients. females might require more thorough evaluation

Which of the following types of tests is Chlamydia Screening most sensitive for diagnosing • Most common treatable STI in 15-19 year olds Chlamydia? 2761/100,000 A) Culture • Usually asymptomatic B) Nucleic acid amplification tests (NAATs) • Associated with significant pathology (PCR, TMA) • Screening “high risk” only females misses C) Antigen detection tests (ELISA, EIA, DFA) significant number of infections D) Non-amplified DNA probe • Should be done every 6 months in high females • Cost effective at population level • Decreases PID by 60%

7 Which of the following types of tests is Which of the following types of tests is Chlamydia: Diagnosis most sensitive for diagnosing Chlamydia? •NAATs Male urethral/urine Female vaginal/endocervical/urine/liquid cytology A) Culture Rectal and pharyngeal with local validation studies only B) Nucleic acid amplification tests (NAATs) •NonNon- ---AmplifiedAmplified Tests : (PCR, TMA) EIA: urethral/cervical/conjunctival C) Antigen detection tests (ELISA, EIA, DFA) DFA: urethral/cervical/rectal/conjunctival D) Non-amplified DNA probe •Culture Endocervical, urethral, pharyngeal or rectal specimens

Tests: Nucleic Acid Amplification Chlamydia Diagnosis: Testing Test (NAAT) • Amplified nucleic acid sequences specific to Culture NAAT EIA DFA DNA organism being detected Probe Sensitivity: Sensitivity: Sensitivity: Sensitivity: Sensitivity: • Do not require viable organisms 70% 85-90% 50-65% 65-70% 65-70% • Most sensitive chlamydia tests-90-95% Specificity: Specificity: Specificity: Specificity: Specificity: 85-95% >98% >95% 95% 95% • Endocervical, urethral, urine, and self Preferred collected vaginal swab specimens

*Chlamydia Coalition

NAATs Urine Testing

• Recommended by Bright Futures/CDC • “First void” urine used for testing for chlamydia and gonorrhea • Can detect GC and CT in single specimen • Best for asymptomatic or symptomatic boys • Best for asymptomatic screening in girls • Expensive – Convenience – Sensitivity approaches endocervical testing • Vaginal swabs is preferred female specimen for chlamydia but somewhat lower for gonorrhea

• Urine is preferred male specimen

8 “First Void” Urine Collection Case 1: Sports PhysicalPhysical----FollowFollow Up

• Consider universal urine collection at all • Ashley screens positive for chlamydia and adolescent visits is not infected with gonorrhea or HIV • At least one hour since last void • Do NOT clean with antiseptic wipes • How do you proceed? • Collect first 10cc of urine in sterile cup • Void the rest in toilet • If need urine culture: – Wipe after first 10cc void

Chlamydia

• : Gram-negative, obligate Chlamydia intracellular organism

Serovar Clinical Syndrome A, B, Ba, C Trachoma D  K Urogenital, rectal, conjunctival infections Neonatal pneumonia L1, L2, L3

Chlamydia Chlamydia

Transmission: Clinical manifestations:  Anal, vaginal, oral sex  Conjunctivitis  Mother-to-child  Efficient: 65-70% of exposed sex partners concurrently  Urethritis 1 infected 11  Cervicitis Risk Factors:  Proctitis  Young age (<25)  Complications: Reiter’s Syndrome, PID,  Female epididymitis  Previous Ct infection **The majority of infections are asymptomatic

1Quinn TC et al. JAMA 1996; 276: 1737-1742. (~70-80% in females, 50% in males)

9 eMedicine.com, 2009eMedicine.com, Chlamydia Treatment Reiter’s Syndrome Adolescents and Adults –––nonnon- ---pregnantpregnant • Aseptic inflammatory arthritis that follows urethritis or Recommended regimens cle/1107206-overview http://emedicine.medscape.com/arti infectious dysentery Azithromycin 1g PO x 1 • Linked to HLA-B27; male OROROR predominance (2:1) Doxycycline 100mg PO BID x 7d • Triad: Urethritis (cervicitis) Alternative regimens Asymmetric polyarthritis /499.html http://www.aafp.org/afp/990800ap 300 mg PO BID x 7 d Conjunctivitis/Uveitis Levofloxacin 500 mg PO QD x 7 d • Management: , anti- Erythromycin base 500 mg PO QID x 7 d inflammatory agents Erythro ethylsuccinate 800 mg PO QID x 7 d

Chlamydia Treatment Case 2: Ear Infection Pregnancy

Recommended Regimens • Joey is a 17 year old sexually active boy who comes for an acute visit for ear pain. You Azithromycin 1g PO x 1 diagnose otitis media. He has not seen you in OROROR over a year and is sexually active with One Amoxicillin 500mg PO TID x 7d female partner for the past 6 months; his only sexual partner ever. Condom use “most of the • Test of cure 3 weeks after completion of therapy time” for vaginal sex and never for oral or anal • Retest in 3 months after treatment sex. • Retesting during 3 rd trimester for women at increased risk (<25, multiple sex partners)

How Do You Take Care of Joey?

A) Treat ear infection only A) Treat ear infection only B) Treat ear infection and make follow up B) Treat ear infection and make follow up appointment for STD evaluation appointment for STD evaluation C) Treat ear infection and evaluate for STD C)C)C)Treat ear infection and evaluate for STD D) Treat ear infection and give him free condoms D) Treat ear infection and give him free condoms

10 Results of STD Screen Are…..

• Positive for Gonorrhea

Gonorrhea

Gonorrhea Gonorrhea Adolescent Males Adolescent Females

• Screen all sexually active women at increased risk *, • Screen in populations with 1% or greater including: prevalence of infection among patients served • adolescent clinics, correctional facilities, Age < 25 , previous history of STIs, new/multiple sex STD clinics, MSM partners, inconsistent condom use, sex work, drug use • AAP Bright Futures recommends if appropriate to patient population and clinical setting • No screening recommendation for low-risk/low- • CDC - insufficient evidence to recommend prevalence areas routine screening in young men unless settings as above • Screen pregnant women with risk factors • feasibility • efficacy • cost *USPSTF Grade B Recommendation

2010 CDC Guidelines Gonorrhea Gonorrhea

MSM • :gonorrhoeae ::: • Screen all sexually active men who have sex Gram-negative diplococcus with men (MSM) for N. gonorrhoeae infection at least annually • Screen at sites of exposure: Transmission – Urethral (urine NAAT)  Vaginal, anal, oral sex – Rectal (rectal NAAT *)  Mother-to child – Pharyngeal (pharyngeal NAAT *)  Risk of F to M transmission: 20% with one episode, 60-80% after 4 episodes

*Not FDA-approved; require local lab validation

11 Gonorrhea Disseminated Gonococcal Infection (DGI)

Clinical Manifestations: •Septic ArthritisArthritis: 1-2 joints  Conjunctivitis •DermatitisDermatitis- ---ArthritisArthritisArthritis:  Urethritis – Painless skin lesions  Cervicitis – Asymmetrical polyarthritis,  Proctitis tenosynovitis  Pharyngitis • High fevers, chills, rigors  ComplicationsComplications: Disseminated Gonococcal • Initial treatment requires Infection (DGI), PID, Epididymitis, Genital hospitalization and IV abscesses antibiotics

DGI – Skin Lesions Gonorrhea Diagnosis •Gram Stain (symptomatic male urethral specimens) +PMNs with intracellular Gram neg. diplococci •Culture Rectal and pharyngeal specimens Urethral and endocervical specimens Conjunctival specimens •NAATs Male urethral/urine Female vaginal/endocervical/urine Rectal and pharyngeal with local validation only •NonNon- ---AmplifiedAmplified Tests

From Holmes KK et al. Disseminated gonococcal infection. Ann Intern Med 1971; 74:979-93.

2010 CDC Guidelines Gonorrhea Treatment Gonorrhea Treatment Uncomplicated Cervical, Urethral, Rectal Infections Uncomplicated Cervical, Urethral, Rectal Infections

Recommended Regimens Other singlesingle----dosedose injectable cephalosporinscephalosporins:::: Ceftriaxone 250mg IM x 1 Ceftizoxime 500mg IM OR, IF NOT AN OPTION Cefoxitin 2g IM plus probenecid 1g PO x 1 Cefixime 400mg PO x 1 Cefotaxime 500mg IM OR Single-dose injectable cephalosporin regimens Alternative Regimens Cefpodoxime 400mg PO x 1 PLUS Cefuroxime axetil 1g PO x 1 Azithromycin 1g PO x 1 Azithromycin 2g PO x 1 OR Doxycycline 100mg BID x 7 days

12 2010 CDC 2010 CDC Guidelines Guidelines Gonorrhea Treatment Gonorrhea Treatment Uncomplicated Pharyngeal Infections Cephalosporin

Recommended Regimens • Use of cephalosporins should be contraindicated Ceftriaxone 250mg IM x 1 only in those with a history of a severe reaction to PCN (e.g. anaphylaxis, Stevens Johnson PLUS syndrome, and TEN)

Azithromycin 1g PO x 1 • Azithromycin 2g PO x 1 is effective, but its use OR should be limited due to concerns over Doxycycline 100mg BID x 7 days development of macrolide resistance (MMWR 2011; 60:579-581)

Chlamydia/Gonorrhea FollowFollow----upupupup Chlamydia/Gonorrhea Partner Management

• Patients treated for uncomplicated infections do • Sex partners during the 60 days preceding onset not need a test of cure of symptoms or diagnosis should be evaluated, tested and treated • Re-infection is common •Retest 333-3---66 months after treatmenttreatment, or when the • Abstinence for 7 days after single-dose patient next seeks care within the following 12 treatment or until after completion of a 7-day months regimen •EPT for Chlamydia infections only: www.nyc.gov/health/ept

Test of Reinfection Case 3- -Part 1

 High CT and GC reinfection rates • Josie is a 15 year old sexually active girl who  untreated partners re-exposure comes to your office with vaginal discharge and  new partners new exposure dysuria. You do a speculum examination and  Retest ♀ and ♂ for CT and/or GC ~3 months see: after treatment or whenever persons next present for care  Consider retest ♀ for TV at 3 months after treatment  Regardless if believes sex partners treated

13 YN/

Cervicitis http://www.brooksidepress.org/Products/Military_OBG Textbook/Discharge/Discharge.htm

Cervicitis Cervicitis EtiologyEtiology: DefinitionDefinition: • Chlamydia and Gonorrhea (<50%) • Purulent or mucopurulent exudate visible in the endocervical canal (“mucopurulent cervicitis”) • Non-GC/Ct Cervicitis: AND/OR genitalium • Easily induced bleeding (friability) at the endocervical os Other signs: • Irritant mucositis (chemical douches, deodorants) Vaginal wet mount with >10 WBCs/hpf Edema of (edematous ectopy) • Role of Bacterial Vaginosis--?

Mycoplasma genitalium

• Found in men with urethritis , and treatment that eradicates M genitalium is associated with clinical cure • Also found in women with cervicitis , and there is evidence that it is a causative agent in PID

• A small bacterium with fastidious growth requirements; difficult to culture • No available commercial lab test • Variable sensitivity to tetracyclines and macrolides

14 Cervicitis

DiagnosisDiagnosis: • NAAT testing for GC and Ct • Evaluate for Bacterial Vaginosis and Trichomonas (culture or Ag-detection, if available) • Consider HSV • Standardized diagnostic testing for M. genitalium not commercially available •Assess for signs of PID

Cervicitis ---Management Cervicitis –––Presumptive Treatment

Treatment OptionsOptions: Recommended regimens • Treat presumptively for Ct:  Young (<25), new or multiple sex partners, hx of Azithromycin 1g PO x 1 unprotected sex OROROR  If follow-up is uncertain Doxycycline 100mg PO BID x 7d • Treat presumptively for GC and Ct: • Concurrent treatment for GC if risk/prevalence  If risk factors as above and/or high local • Treat for Trichomonas and Bacterial Vaginosis, prevalence (>5%) if detected • Await results of diagnostic tests: • Refer partners for evaluation and treatment  Low-risk, good follow-up, sensitive tests used (NAATs )

15 Case 33----Part 22----AbdominalAbdominal Pain

• Josie returns to your office 3 weeks later with abdominal pain. Her boyfriend did not get evaluated or treated. She has continued to have Pelvic Inflammatory unprotected sex. Disease

Sequelae of Untreated GC & Chlamydia in Pelvic Inflammatory Women Normal Disease (PID )))

Infertility http://iuhsisa.org/USMLE/Reproduction/FemaleReproductio

Untreated 20%** • Infection and Chlamydia 20-40% Ectopic of the 9%** Pelvic Pregnancy female upper genital Inflammatory tract Disease Untreated • Caused by PID 23% Recurrent PID Gonorrhea 10-40% microorganisms 36%** ascending from the lower genital tract Chronic Pelvic n1.htm Pain • Polymicrobial etiology

**CDC Update:”Some Facts About Chlamydia, March 1997

Pelvic Inflammatory Disease Pelvic Inflammatory Disease Risk Factors EtiologyEtiology:::: • Gonorrhea (30-80%) and Chlamydia (20-40%) • Adolescence • Organisms of the vaginal flora: • Multiple sexual partners G. vaginalis Anaerobes • History of prior PID; history of GC or Ct H. influenzae Enteric gram neg. rods • Male partner with GC or Ct Strep. Agalactiae • Recent (within 3 weeks) upper genital tract procedure e.g. • Other sexually transmitted organisms: IUD placement Mycoplasma spp. Ureaplasma urealyticum • Bacterial Vaginosis CMV • Current douching

16 Pelvic Inflammatory Disease Pelvic Inflammatory Disease Diagnosis Clinical Manifestations: Minimum CriteriaCriteria::::  Lower abdominal pain/cramping • Cervical motion tenderness OR uterine  Vaginal Discharge tenderness OR adnexal tenderness  Dysuria • No single historical, physical or lab finding is both  Fever/Chills sensitive and specific for diagnosis of acute PID  Nausea/Vomiting Additional Criteria:  RUQ Pain (Perihepatitis) • Temp > 38.3 C (101 F)  Post-coital/irregular bleeding • Abnormal discharge; abundant WBCs on wet mount  “Silent” PID • Elevated ESR/C-reactive protein • + GC/Ct laboratory test

FitzFitz----HughHugh Curtis Differential Diagnosis of PID PeriPeri----hepatitishepatitis • Acute Appendicitis • Right upper quadrant abdominal pain • Ectopic Pregnancy • May have lower quadrant pain • Ruptured, Bleeding, Torsion of • May have cervical motion tenderness • Pelvic • Normal liver function tests • Inflammatory Bowel Disease • Elevated ESR/C-reactive protein • • Generally, positive test for • Renal/Ureteral Stones chlamydia/gonorrhea

Pelvic Inflammatory Disease Pelvic Inflammatory Disease Outpatient Treatment Outpatient Treatment Recommended regimens Alternative regimens Use quinolones only if cephalosporin therapy is not feasible Ceftriaxone 250mg IM x 1 PLUS and prevalence/risk of GC is low OROROR Doxycycline 100mg Levofloxacin 500 mg PO QD x 14 d OR Cefoxitin 2g IM x 1 + BID x 14d Ofloxacin 400 mg PO BID X 14 d Probenecid 1g PO x 1 +/- Metronidazole 500 mg PO BID x 14 d**

OROROR WITH or WITHOUT Other regimens rd Ceftriaxone 250mg IM x 1 PLUS Other parenteral 3 gen Metronidazole 500mg 2010 CDC Azithromycin 1g PO qweek x 2 Guidelines Cephalosporin (e.g. BID x 14d ceftizoxime or cefotaxime) +/- Metronidazole 500mg BID x 14 d

17 Pelvic Inflammatory Disease Pelvic Inflammatory Disease Criteria for Hospitalization FollowFollow----upupupup

• Unable to rule out surgical emergency • Stress importance of adherence to oral regimen • Re-examine within 72 hours; hospitalization usually • Pregnancy required if no clinical improvement • Inability to tolerate or poor clinical response to • Treat sex partners: Male sex partners 60 days outpatient treatment regimen preceding onset of symptoms • Severe symptoms—nausea/vomiting, high • For + GC/Ct: repeat testing in 3-6 months fever • HIV testing • Evidence of tubo-ovarian abscess

Pelvic Inflammatory Disease Case 3, Part 3- “It Hurts When I Special Considerations Pee” • Pregnant women with suspected PID should be • Josie brings her boyfriend in for treatment. He is hospitalized and treated with IV antibiotics 17 years old and complains of intermittent pain • Women with HIV may be more likely to develop on urination. You examine him and see…. tubo-ovarian abscess; but no evidence for more aggressive management • IUD: Increased risk of PID is confined to first 3 weeks after insertion; evidence insufficient to recommend removal of an IUD in women diagnosed with acute PID, but close follow-up is mandatory

Urethritis

Source : Seattle STD/HIV Prevention Training Center at the University of Washington/UW HSCER Slide Bank

18 Urethritis

EtiologyEtiology: •Infectious Gonorrhea urethritis: ~20% Non-Gonorrhea urethritis (NGU): ~80% •NonNon- ---infectiousinfectious Irritants, allergy Autoimmune (e.g. Reiter’s Syndrome)

Urethritis: NGU Urethritis: Clinical Features

EtiologyEtiology:: Clinical Features NGU ††† GUGUGU • Chlamydia trachomatis 15-55% Incubation 7-14 days 2-8 days • 15-25% Onset Gradual Abrupt • Ureaplasma urealyticum 10-40% Dysuria Mild Severe • Trichomonas vaginalis < 5% • Herpes Simplex Virus < 5% Discharge • Candida albicans < 1% -Quality Mucoid Purulent ‡ • Enterics (insertive anal) Unknown -Quantity Less More • Adenovirus Unknown • Unknown > 50% † ~ 1/3 men with NGU in STD clinic setting are asymptomatic ‡ 25% GU presents with scant or minimally purulent d/c From Burstein GR, CID 1999; 28 (Suppl 1): S66-73

Urethritis

DiagnosisDiagnosis: • Presence of mucopurulent or purulent discharge • Gram stain: > 5 WBCs/hpf oil immersion • Positive leukocyte esterase or > 10 WBCs/hpf on first void urine • Test for GC and Ct (Urine NAATs)

19 NonNon----GonorrheaGonorrhea Urethritis (NGU) Recurrent and Persistent Urethritis Treatment (NGU) Recommended Regimens Differential DiagnosisDiagnosis:::: Azithromycin 1g PO x 1 1. Re-exposure to untreated partner OROROR 2. Incomplete treatment Doxycycline 100mg PO BID x 7d 3. Persistent infection : Alternative Regimens  Mycoplasma , Ureaplasma Erythromycin base 500 mg PO QID x 7d  Trichomoniasis EES 800 mg PO QID x 7days 5. Non-infectious causes; chronic Levofloxacin 500 mg PO QD x 7days /chronic syndrome Ofloxacin 300 mg BID x 7days (referral to ) • Sex partners from preceding 60 days should be evaluated and treated

Recurrent and Persistent Urethritis (NGU) Case 4- “I’m Swollen Down There”

Recommended Regimens • Mike is a 17 year old young man who comes to Metronidazole 2g PO x 1 the Emergency Room with 2 day history of OROROR swollen right testicle. He is bisexual and has had Tinidazole 2 g PO X 1 2 female and 3 male partners in his lifetime. PLUS Currently, he has 1 female partner and uses Azithromycin 1g PO x 1 (if doxycycline condoms “most of the time” was first line treatment)

Other Regimen 2010 CDC Moxifloxacin 400mg qd x 7-10 days Guidelines

Epididymitis

20 Normal Epididymitis Acute Epididymitis

• Pain, swelling, and inflammation of the epididymis, <6 weeks • Pathophysiology: retrograde flow of infected urine into the ejaculatory duct • Chronic epididymitis: symptoms > 6 weeks

Galejs LE. Am Fam Physician. 1999; 59 (4) Junnila J. Am Fam Physician. 1998; 57 (4)

Acute Epididymitis Epididymitis Etiology Diagnostic Considerations • Men aged < 35 yearsyears: History and genital exam:exam Chlamydia (60-80%) History and genital exam Gonorrhea (5-20%) • Tender/swollen testicle and spermatic cord Ureaplasma urealyticum • Palpable swelling and tenderness of the epididymis Mycoplasma spp . • +/- urethral discharge and hydrocoele E. coli and other coliforms (insertive anal sex) • Evaluate for testicular torsion , if indicated

•Chronic infectious epididymitis: DiagnosisDiagnosis:::: TB, Brucellosis, Filariasis • Gram stain: > 5 WBCs/hpf oil immersion • Positive leukocyte esterase or > 10 WBCs/hpf on first void urine • Urine NAATs for GC/Ct and urine culture

Epididymitis Epididymitis Treatment Treatment 2010 CDC Guidelines Recommended regimens Ceftriaxone 250 mg IM in a single dose • If risk for both GC/Ct and enteric organisms PLUS (i.e. MSM, insertive anal intercourse), Doxycycline 100 mg twice daily for 10 days recommend ceftriaxone + fluoroquinolone • Bedrest, scrotal elevation, analgesics, NSAIDS For infections most likely caused by enteric organisms: • Re-evaluate within 72 hours; if no improvement, Ofloxacin 300 mg twice daily for 10 days refer to ED OROROR Evaluation and treatment of sex partners Levofloxacin 500 mg once daily for 10 days

21 Case 4-Part 2- “It Hurts When I Try to Go” • Mike returns for follow up to your office 2 months later. He now has a new partner who is male. Mike has had receptive anal sex, as well as oral Proctitis sex. Mike is complaining of pain on defecation.

Anal Canal Proctitis

• Inflammation of the rectum (distal 10-12 cm) • Associated with receptive anal intercourse • Symptoms: rectal pain, tenesmus, constipation, mucopurulent discharge , hematochezia • Etiology: − Neisseria gonorrhea − Chlamydia trachomatis (including LGV strains) − Trepomena pallidum −

Ryan DP. NEJM. 2000: 342 (11)

Proctitis: Etiology ProctitisProctitis:: Treatment

Recommended regimen Ceftriaxone 250mg IM x 1 PLUS Doxycycline 100mg PO BID x 7 days

• If painful perianal ulcers present, treat for HSV • If LGV is suspected (e.g. mucosal ulcers detected on anoscopy), doxycycline should be continued for 21 days.

Klausner JD et al. CID. 2004; 38:300-2.

22 2010 CDC Proctitis Diagnosed in NYC STD Guidelines Clinics, 2008 –––2009* Primary Prevention of STD • Vaccinate against HPV , HBV , HAV Total No anal/rectal Anal/rectal • Screen sexually active adolescents at preventive care symptoms symptoms Etiology NNN visits or at acute visits if no screening in last year N (%) N (%) AllAllAll386 261 (68) 122 (32) • Health care providers should integrate sexuality education into clinical practice: GCGCGC147 74 (50) 73 (50) – Counsel adolescents about sexual risk behaviors C. trachomatis 215 182 (89) 33 (11) – Educate patients about prevention strategies -abstinence LGV 242424 8 (33) 16 (67) -consistent and correct condom use

*Rectal/anal symptoms noted as part of chief complaint; etiology lab-confirmed

2010 CDC Guidelines Other prevention guidance… Useful Websites

Persons in corrections www.aap.org —The American Academy of Pediatrics (AAP) • GC/CT screening of all adolescent females and older http://www2.aap.org/sections/adolescenthealth/default.cfm AAP Section women at increased risk of Adolescent Health • Syphilis screening based on local epidemiology http://brightfutures.aap.org/ Bright Futures Women who have sex with women www.aapdistrictii.org NY State American Academy of Pediatrics • HPV vaccination www.prch.org —Physicians for Reproductive Choice and Health Pregnant women www.adolescenthealth.org —The Society for Adolescent Health and • Routine syphilis, HepBsAg, Ct screening Medicine • GC, Hep C screening if increased risk www.naspag.org North American Society for Pediatric and Adolescent Gynecology • No routine HSV, BV, or trichomoniasis screening

Useful Websites Provider Resources http://www.aclu.org/reproductiverights The Reproductive NY State AAP Teen Health Care Bill of Rights Freedom Project of the American Civil Liberties Union PRCH’s Minors’ Access to Confidential Reproductive Healthcare Cards and Emergency Contraception: A Practitioner’s Guide www.advocatesforyouth.org —Advocates for Youth ARHP’s Reproductive Health Model Curriculum www.guttmacher.org —Guttmacher Institute The American College of Obstetricians and Gynecologists Toolkit www.cahl.org —Center for Adolescent Health and the Law www.acog.org/bookstore/Tool_Kit_for_Teen_Care_P348C84.c fm www.siecus.org —The Sexuality Information and Education Emergency contraception: www.not-2-late.com Council of the United States Chlamydia Coalition http://ncc.prevent.org/ www.arhp.org —The Association of Reproductive Health Professionals

23 Patient Resources Patient Resources

American Social Health Association : www.iwannaknow.org Center for Young Women’s Health : Planned Parenthood Teens: www.teenwire.com/ www.youngwomenshealth.org/ TeensHealth : http://teenshealth.org/teen/ Young Men’s Health : http://youngmenshealthsite.org/ Healthy Children : www.healthychildren.org/ The Children Now : www.talkingwithkids.org/ Gay & Lesbian Youth Services : www.freewebs.com/glyss/ MTV collaboration with Kaiser Family Foundation: www.itsyoursexlife.com/

• Thank you to – Anne Lifflander, MD, MPH – Gale Burstein, MD, MPH

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