Adolescents should receive routine STI screening

AAP 2011 National Conference

BOSTON — Trichomonas is increasing in prevalence as common sexually transmitted infection among adolescent girls, according to a presentation here at the American Academy of Pediatrics 2011 National Conference and Exhibition.

Cynthia Holland-Hall MD, MPH, associate professor of Clinical Pediatrics at the Ohio State University College of Medicine, Columbus, Ohio, discussed epidemiology, screening, non-invasive testing procedures, point-of-care tests for vaginitis and updates in treatments in sexually transmitted infections (STIs).

Cynthia Holland-Hall

She recalled 2009 Youth Risk Behavior Survey data that indicated roughly half of high school students have had sex (including one-third of freshman and two-thirds of seniors), 21% of seniors have had more than four partners, 14% of all students have had more than four partners.

“These data have remained pretty stable, so we are not looking at spikes in the numbers,” she said.

Holland-Hall said that given the prevalence of sexual activity among teenage girls, National Health and Nutrition Examination Survey data from 3 years ago were not surprising.

“About one-quarter of teenagers had an STI overall, and about 38% of sexually experienced teenage girls had an STI,” she said. “Specifically, 15- to 19-year-old girls are highly prone to infection, particularly with Chlamydia. It doesn’t take a lot of high-risk behavior to become infected. A girl with one sexual partner had about a 20% chance of sexual infection.”

Screening

All sexually active females aged younger than 25 years should be screened annually for chlamydia, and women at “increased risk” should be screened for gonorrhea, according to CDC recommendations.

“As far as I’m concerned, all of my patients who are teenagers should be screened routinely,” Holland-Hall said. “Once a girl has one infection, her time to getting another infection is usually less than a year, so we are constantly testing.”

Holland-Hall noted that the CDC also recommends universal HIV screening for every patient older than 13 years: “Targeted screening and the need to obtain written consent were serving as barriers.”

All women should be tested for human papillomavirus (HPV) and cervical dysplasia beginning at age 21, and syphilis screening should be conducted on a case-by-case basis, taking into account geography, epidemiology in the region and demographic information.

As for boys, Holland-Hall highlighted the fact that there are no widely accepted guidelines for screening heterosexual adolescent males. “A female with a missed chlamydial infection is at risk for serious and expensive sequelae,” she said. “Those risks don’t exist for boys. The sequelae of missed infections are not as costly in boys. That said, I personally advocate routine screening of sexually active boys for gonorrhea and chlamydia, despite there not being a published guideline.”

It was suggested, however, that men who have sex with men (MSM) should be tested more frequently, but that there are qualifications in the language. “Testing males who have sex with males is based on sexual practices, not stated sexual orientation,” she said. “MSM data guidelines are not empirically driven, they are more based on expert opinion.”

Urine testing for chlamydia and gonorrhea is reasonable for boys, according to Holland-Hall, but she also said it is important to wait at least 1 hour since the last void and to catch the first 5 mL to 10 mL.

“For boys and girls, recent research has shown that sensitivity of urine testing may be comparable to cervical or urethral testing,” she said.

She also noted that nucleic acid amplification testing has “really revolutionized testing,” and that it was recently approved for trichomonas screening in girls.

Recent developments

Holland-Hall also highlighted the other revolution in STI testing: self-collected vaginal swabs. “CDC now states that self-collected vaginal swabs are the preferred specimen for screening in females,” she said. “They are superior to first-catch urine.”

Self-collected swabs have excellent sensitivity and specificity and are generally well accepted by adolescent girls after some instruction, according to Holland-Hall. “The specialized kit and buffer solution do create some barriers,” she said. “We hope that those problems will be solved soon.”

Rapid tests exist for trichomonas and bacterial vaginosis, but new rapid tests for chlamydia and gonorrhea are needed. “The current rapid tests for chlamydial and gonococcal infections have unacceptably low sensitivity,” Holland-Hall said.

Regarding treatment, the hot topic is that gonococcal infections have developed resistance, according to Holland-Hall. “Quinolones are no longer recommended, and cephalosporin resistance is emerging. This is reinforcing the recommendation for dual treatment.”

Cephalosporins work better at a lower dose in anogenital infections than in oropharyngeal infections, according to Holland-Hall. “Azithromycin or doxycycline may be used with ceftriaxone for uncomplicated gonococcal infections, but we should be wary of macrolide resistance.”

Adolescents should be reminded that genital warts can be spread via oral contact, and that vaccination is recommended, Holland-Hall suggested. — by Rob Volansky

Disclosures: Dr. Holland-Hall reported no financial disclosures.

For more information:

• Holland-Hall C. # F1153/F2126. Sexually Transmissible Infections in Adolescents. Presented at: AAP 2011 National Conference and Exhibition; Oct. 15-18, 2011; Boston.

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