Transcript Chlamydia and Adolescent Patients

Chlamydia and Adolescent
Patients

Objectives
 Describe the epidemiology, scope, and risk factors for
Chlamydial infection in adolescents
 Assess, treat, and prevent Chlamydial infection in
adolescent patients utilizing evidence-based
guidelines
 Discuss ways to improve current clinical practice
 Provide referrals for care to adolescent patients
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Adolescent STI Burden
Why it matters
CDC STI Estimates
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CDC 2013 Report: STIs and Young
People
Incidence
Prevalence
Increased
Risk
Cost
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~20 million new cases/year:
50% occur in people ages 15–24
Total infections: 110 Million
# of new infections equal among
young males (49%) and females
(51%)
Direct medical costs:
~$16 billion/year
Adolescents Face Increased Risk for
STIs
 Biological
 Behavioral
 Social/Institutional
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Chlamydia — Rates of Reported Cases by Age
and Sex, United States, 2014
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CDC STD Surveillance Report 2014
Chlamydia — Rates of Reported Cases
by State, United States and Outlying
Areas, 2014
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CDC STD Surveillance Report 2014
Chlamydia — Rates of Reported Cases
by Race/Ethnicity, United States, 2010–
2014
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CDC STD Surveillance Report 2014
STD Disparities: Meeting the Challenges
 Multiple factors contribute
to STD disparities in
African-Americans:
 Racial inequality
 High levels of uninsured
 Low educational
attainment
 High incarceration rates
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 To address STD
disparities, involvement of
affected communities at all
steps in the process is
required
Source: Valentine, J. “Addressing STD Disparities Among Adoles
Health Impact Pyramid with STD Prevention
Examples
Smallest
Impact
Behavioral counseling to
reduce STD/HIV
Counseling
& Education
Clinical
Interventions
Long-lasting
Protective Interventions
Changing the Context
To Make Individuals’ Default
Decisions Healthy
Largest
Impact
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Socioeconomic Factors
Frieden T. AJPH 2010
STD Testing and Treatment
Immunization, male
circumcision
Ubiquitous condom
availability, alcohol tax
Decrease poverty &
inequality and improve
education & housing
Social Determinants Affecting Individual
Health
 Social environment can determine the availability of
healthy sexual partners
 Challenging economic circumstances can increase
risk for STDs if affordable quality health care is not
accessible
 Community mistrust/miscommunication between
providers and patients
 negatively affects health care-setting interactions &
may lead to barriers to care-seeking
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Source: Valentine, J. “Addressing STD Disparities Among Adolescents”
Social/Institutional Risk Factors
Lack of
Insurance/$ to
Pay
Lack of
Transportation
Lack of Sex Ed
Regarding Risk
and Symptoms
Adolescent
s Not Being
Screened
and
Treated
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Concerns About
Confidentiality
Stigma
STI Protective Factors
 Peer support for contraception and condoms
 Communication with parents about sex
 Connection to family
 Connection to school and future success
 Connection to community organizations
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Who is Caring for Adolescents?
Clinical Care: Female Adolescents
Source: National Ambulatory Medical Care Survey, 2003–6
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Hoover et al., J Adol Health, 2010
Chlamydia — Percentage of Reported Cases by
Sex and Selected Reporting Sources, United
States, 2014
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CDC STD Surveillance Report 2014
Chlamydia — Proportion of STD Clinic Patients* Testing
Positive by Age, Sex, and Sexual Behavior, STD
Surveillance Network (SSuN), 2014
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CDC STD Surveillance Report 2014
Case: Erica
 Erica is a 16-year-old
female who presents
with dysuria.
 What is your initial
differential diagnosis?
 What additional
information do you
need?
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Sexual History: The Five Ps
 Partners
 Gender(s), Number (three months, lifetime)
 Prevention of pregnancy
 Contraception, EC
 Protection from STIs
 Condom use
 Practices
 Types of sex: anal, vaginal, oral
 Past history of STIs
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www.stdhivtraining.net
Prevention Counseling
AAP
Patient-centered, age-appropriate anticipatory guidance;
Integrate sex ed into clinical practice; can use educational
materials;
Prevention guidance, including abstinence, safer sexual practices,
and condoms
ACOG
Counseling for all sexually active individuals
AAFP
High-intensity behavioral counseling (HIBC)
CDC*
HIBC; interactive counseling approaches, i.e., client-centered
STD/HIV prevention counseling; motivational interviewing; videos
and large group presentations to provide information
USPSTF
Intensive behavioral counseling for all sexually active adolescents
and adults at high-STI risk
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Erica: Sexual History Results
 Several episodes of unprotected sex in the last few
weeks with one male partner (her only lifetime)
 Not on hormonal contraception but uses condoms
most of the time
 Engages in oral (giving and receiving) and vaginal
sex
 No known history of STIs
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Erica: History of Present Illness Results
 Erica tells you she has burning with urination and a
“yellowish” discharge. She reports itchiness.
 She denies abdominal pain and fever and reports no
bumps or lesions.
 What is the differential diagnosis?
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Differential Diagnosis
 You observe discharge in the vault but not in the os.
 You suspect vaginitis.
 What are the causes of vaginitis?
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Differential Diagnosis
Dysuria
Genital Tract
Infection
Vaginitis
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Trichomonas
Bacterial
Vaginitis
Candida
Vaginitis
Additional Concerns
 Because Erica is a sexually
active
16-year-old, she is also at risk for
cervicitis.
 What are the most common
causes of cervicitis?
 Chlamydia
 Gonorrhea
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Chlamydia
Curable bacterial STI
Most common reportable communicable disease
Highest-reported rates among adolescent and young
adult females (Aged 15–24)
Usually asymptomatic
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Chlamydia Symptoms
Females:
Up to ~80–90%
asymptomatic
Males:
Up to 90%
asymptomatic
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• Heavy or prolonged menses
• Spotting
• Dysmenorrhea
• Dyspareunia
• Vaginal discharge
• Penile discharge
• Dysuria
Clinical Syndromes Caused by C.
trachomatis
Males
Females
Infants
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Local
Infection
Complication
Sequelae
Conjunctivitis
Urethritis
Proctitis
Epididymitis
Reiter’s syndrome
(rare)
HIV risk
Chronic arthritis
(rare)
Conjunctivitis
Urethritis
Cervicitis
Proctitis
Endometritis
Salpingitis
Perihepatitis
Reiter’s syndrome
(rare)
HIV risk
Infertility
Ectopic pregnancy
Chronic pelvic pain
Chronic arthritis
(rare)
Conjunctivitis
Pneumonitis
Pharyngitis
Rhinitis
Eye and lung
infections
Rare, if any
Non-Gonococcal Urethritis:
Mucoid Discharge
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Source: Seattle STD/HIV Prevention Training Center
at the University of Washington/UW HSCER Slide Bank
Swollen or Tender Testicles
(epididymitis)
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Source: Seattle STD/HIV Prevention Training
Center at the University of Washington
Normal Cervix
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Source: STD/HIV Prevention Training Center at the
University of Washington/Claire E. Stevens
Chlamydial Cervicitis
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Source: STD/HIV Prevention Training Center at the
University of Washington/Connie Celum and Walter Stamm
Normal Human Fallopian Tube Tissue
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Source: Patton, D.L. University of Washington, Seattle, Washington
C. trachomatis Infection (PID)
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Source: Patton, D.L. University of Washington, Seattle, Washington
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Chlamydia Screening
♀ Routine Annual Chlamydia Screening
AAP
all sexually active ≤25 yrs
ACOG
all sexually active adolescents
AAFP
all sexually active <24 yrs
CDC
all sexually active <25 yrs
USPSTF
all sexually active <24 yrs
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Chlamydia Screening: Males
Routine Screening NOT
recommended for men
Correctional facilities
STI clinics
Selective screening in
high-prevalence
populations should be
considered
Adolescent-serving clinics
MSM
Multiple partners
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AAFP, CDC, USPSTF, AAP Recommendations
USPSTF CT Risk Factors
 Age
 ♀ ages 15-24 years,
 ♂ ages 20-24 years
 New sex partner, >1 sex
partner, sex partner w/
STI infection
 Inconsistent condom use
 H/O or coexisting STIs
 Exchanging sex for
money or drugs.
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 Incarcerated populations,
military recruits, and
patients receiving care at
public STI clinics.
 Racial Disparities:
 Blacks and Hispanics
higher CT rates vs.
whites
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Men Who Have Sex With Men (MSM)
 CDC recommends at least yearly urethral and rectal
screening for MSMs who, in the last year, have
participated in:
 Insertive anal intercourse
 Receptive anal intercourse
 Receptive oral intercourse (GC only)
 Screening is recommended regardless of condom use
 For high risk sex behavior, should screen every 3-6
months
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http://www.cdc.gov/std/tg2015/specialpops.htm#MS
M
Women Who Have Sex with Women
(WSW)
 Regardless of reported same-sex behavior, providers
should consider:
 Screening all females for chlamydia and gonorrhea as
per recommendations
 Offering routine cervical cancer screening and HPV
vaccine in accordance with current guidelines.
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http://www.cdc.gov/std/tg2015/specialpops.htm#
WSW
Transgender Males and Females
 Assess STD- and HIV-related risks based on current
anatomy and sexual behaviors
 diversity of transgender persons regarding surgical
affirming procedures, hormone use, and their patterns
of sexual behavior
 providers must remain aware of common STD Sx and
screen for STDs on basis of behavior and sexual
practices
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Confidentiality and Billing
Confidentiality and Billing
 Cannot guarantee confidentiality in many cases
 Explanation of benefits (EOB) may be sent by
insurance company
 Teen patient may request for EOB to be sent to
alternative address by health plan
 Need to know the “paper trail issues” in your health
system
 Need to have Plan B for confidential services
 www.itsyoursexlife.com/gyt/
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Explanation of Benefits (EOBs)
Medicaid vs. Commercial Insurance
 EOBs sent to policyholder or insured in most
commercial plans
Some health plans NOT sending EOBs if only
copayment due
 Medicaid does not routinely send EOBs
 EOBs do not disclose service/diagnosis
Parent can obtain that info from health plan
 No control over lab bills/statements
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Chlamydia Tests and Treatment
Case: Evaluating Cervicitis
 How do you evaluate Erica for
cervicitis?
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Chlamydia Diagnosis
Culture
NAAT
EIA
DFA
Sensitivity:
70%
Specificity:
85%–95%
Sensitivity:
85%–90%
Specificity:
>98%
Sensitivity:
50%–65%
Specificity:
>95%
Sensitivity:
65%–70%
Specificity:
95%
Preferred
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DNA
Probe
Sensitivity:
65%–70%
Specificity:
95%
NAAT vs. Culture
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Schachter J,et al. Sex Transm Dis. 2008;35:637–42.
Chlamydia NAAT Screening:
Preferred Noninvasive Genitourinary Specimens
 ♀: Vaginal swab
• Vaginal swab samples are as sensitive as endocervical
swab specimens
• Urine samples acceptable
– ♀urine may have ↓ performance compared to cervical
swab samples
 ♂: Urine
 Urethral swab samples may be ↓ sensitive than urine
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www.cdc.gov/std/laboratory/2014LabRec/default.htm
FDA Clearance
 All NAATs
 Urethral swabs from males
 Cervical swabs
 Urine from males and females
 Certain NAATs
 Vaginal swabs
 Non-FDA cleared for:
 Rectal
 Pharyngeal
 (Many laboratories have met regulatory CLIA
requirements)
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How to Order Screen
Non-genital GC/CT NAATs can be done by
clinical laboratory with CLIA approval
Gen-Probe APTIMA
testing
QUEST diagnostics test LabCorp diagnostics
codes
test codes
Pharyngeal
70051X
188698
Rectal
16506X
188672
Urine/Urethral
13363X
183194
Relevant CPT Billing Codes:
CT detection by NAAT: 87491
GC detection by NAAT:
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87591
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www.cdc.gov/std/tg2015/default.htm
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Chlamydia Treatment
Azithromycin 1g
Orally
Single Dose
Alternatives:
Erythromycin
or
Levofloxacin
or
Ofloxacin
O
R
Doxycycline 100mg
orally
Twice a day x 7 days
Pregnancy
Alternative
Regimens:
• Amoxicillin
• Erythromycins
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http://www.cdc.gov/std/tg2015/chlamydia.htm
Azithromycin vs Doxy for urogenital CT
 567 youth detention (12 - 21 yo ♀&♂) participants
receiving directly observed therapy
 Doxy group: no treatment failures
 Azithromycin group: 5 (3.2%) failures
 Overall efficacy:
 Doxycycline 100%
 Azithromycin 97%
 Did not establish non-inferiority of azithro
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Geisler, et al. NEJM. 2015; 373: 2512-21.
Chlamydia Treatment
 Doxycycline delayed release 200 mg tabs (Doryx)
  GI upset
 Qday x 7 days
 $
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Oropharyngeal Chlamydia
 Clinical significance unclear
 Routine oropharyngeal CT screening not
recommended
 Can be sexually transmitted to genital sites
 Treat oropharyngeal chlamydia with Azithromycin or
doxy
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STI Partner Management Strategies
Provider
Referral
• Partners contacted by index
patient’s provider or by a disease
intervention specialist
Patient
Referral
• Index patient assumes primary
responsibility to notify and refer
his/her partners at risk
Expedited
Partner
Therapy
(EPT)

• Providers (1) give patient medication
intended for the partners (2) write
partners’ prescriptions for medication
CDC Recommends EPT
 EPT: Delivery of medications or prescriptions by
persons infected with an STD to their sex partners
without clinical assessment of the partners.
 EPT laws vary by state:
 Permitted in 40 states and Washington, D.C.
 Potentially Allowable in 8 states (AL, GA, DE, KS, OK,
SD, VA, NJ and Puerto Rico)
 Prohibited in 2 states (Kentucky & West Virginia)
 Heterosexual sex partners should be evaluated,
tested, and treated if:
 Had sexual contact with patient during or >60 days of
symptom onset/diagnosis of chlamydia or gonorrhea
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https://www.cdc.gov/std/ept/legal/default.htm
Updated July 2016
Repeat Testing After Treatment
 Pregnant females
 Repeat testing, preferably by NAAT, 3 weeks after
completion of recommended therapy
 Non-pregnant females
 Test of cure not recommended unless:
• Compliance is in question, symptoms persist, or
reinfection is suspected
 Repeat testing recommended 3-4 months after
treatment
• Especially adolescents; high prevalence of repeat
infection
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Erica: Wrap-Up
 Administer EC and write advanced prescription
 HIV test
 HPV vaccine
 Give appointment to return in 3 months
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www.cdc.gov/std/tg2015/default.htm

www.cdc.gov/std/tg2015/screening-recommendations.htm
Want to know more about STDs?
There’s an app for that.
CDC Treatment Guidelines
App for Apple and Android
http://www.cdc.gov/std/tg2015/

STD Clinical Questions
Plan A: call health
department

STD Clinical Consultation Network
(STDCCN)
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8 Regional PTCs
STD Clinical Consultation Network
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www.STDCCN.org
Provider Resources:
Sexually Transmitted Infections
 National Chlamydia Coalition: ncc.prevent.org
 U.S. Centers for Disease Control and Prevention
 Statistics and Surveillance Reports:
www.cdc.gov/std/stats/default.htm
 Expedited Partner Therapy: www.cdc.gov/STD/ept/default.htm
 Screening & Treatment Guidelines:
www.cdc.gov/std/treatment/2010/default.htm
 American Social Health Association:
 www.ashastd.org/std-sti/hpv.html
 U.S. Department of Health and Human Services
womenshealth.gov/faq/stdhpv.htm
 USPSTF: www.uspreventiveservicestaskforce.org/uspstopics.htm
 ACOG: www.acog.org/Resources-And-Publications
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