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Evidence Based Strategies: The Importance of Testing for Sexually Transmitted Infections in Adolescents

Column Author:  Kylie Rellihan, MD | Pediatric Resident 

Column Editor: Kathleen J. Berg, MD, FAAP | Medical Director, Office of Evidence-Based Practice, Associate Professor of Pediatrics, University of Missouri-Kansas City School of Medicine; Clinical Assistant Professor of Pediatrics, University of Kansas School of Medicine

Sexually active adolescents are at risk for underdiagnosis and inadequate treatment of sexually transmitted infection (STI). In the United States, there are over 2.5 million new STI cases per year,1 and people ages 15-24 account for half of STI cases.2 This figure is an underestimate as it includes only the most common notifiable diseases: gonorrhea, chlamydia and syphilis. Most concerning perhaps is that from 2018 to 2022 syphilis cases rose 78.9%.1 Despite widespread STI screening recommendations,3 only roughly half of all sexually active young adult females and less than a quarter of sexually active young adult males report receiving STI testing.4 Importantly, many of these STIs can be asymptomatic; 50%-70% of people with chlamydia and 40%-50% of people with gonorrhea do not have symptoms.2 Therefore, it is crucial for providers to practice evidence-based testing and treatment of STIs to help prevent lasting effects of untreated disease.

Devastating long-term sequelae can be caused by untreated infection. There are approximately 1 million new cases of pelvic inflammatory disease each year in the U.S., most commonly caused by untreated gonorrhea and chlamydia. Approximately 100,000 of those cases have scarring so severe it leads to infertility.2 Also of note, untreated gonorrhea and chlamydia lead to increased risk of acquiring human immunodeficiency virus (HIV) due to the inflammation and immune response caused by these bacteria.2 With the dramatic rise in syphilis, there was a 183.4% increase in congenital syphilis from 2018 to 2022.1

Screening is the first step toward preventing spread of disease and long-term sequelae. Testing for STI is indicated for patients who have signs and symptoms of an STI, risk factors for an STI, or request STI testing. Signs and symptoms as well as risk factors can be found in Children’s Mercy’s STI Clinical Pathway.5 Routine testing for both males and females includes Neisseria gonorrhoeae PCR, Chlamydia trachomatis PCR, Treponema pallidum PCR, HIV antigen/antibody screen, and, if symptomatic, Trichomonas vaginalis PCR. Unlike urine collection for urine culture, urine collected for N. gonorrhoeae, C. trachomatis and T. pallidum PCRs should be a “first catch,” meaning the patient should not have voided in the prior hour nor cleaned the genital area. Consider gonorrhea and chlamydia testing on pharyngeal and/or rectal samples based on reported exposures.3,5

If results are readily available, patients should be treated appropriately for gonorrhea, chlamydia and trichomonas. These patients should follow up with their primary care providers and should be retested three months after treatment. Syphilis should be treated with penicillin G 2.4 units one time intramuscularly, and patients should then be referred to Infectious Diseases clinic for follow-up testing. A positive confirmatory HIV test should be referred to Infectious Diseases clinic for an appointment within one week. If the patient is present at time of a positive HIV confirmatory test, a complete blood count, basic metabolic panel, HIV-1 RNA qualitative load, CD4 testing, and hepatitis B surface antigen should be drawn.3,5 Additional details can be found in Children’s Mercy’s HIV Testing Clinical Pathway.6

For patients who will be discharged before test results are available, decisions on empiric treatment for gonorrhea and chlamydia should be based on risk factors (new sexual partner or known STI exposure), reliability of follow-up, and shared decision-making between the provider and patient. Trichomonas generally does not require empiric treatment.5 Recommendations on non-occupational post-exposure prophylaxis (nPEP) for HIV are detailed in the HIV Testing Clinical Pathway.6

Confidentiality should be discussed with the patient and based on their preferences. Testing and documentation should be done in a confidential manner consistent with the hospital’s or clinic’s standard processes. Adolescents should also receive counseling on notification and treatment of partners. If anonymity is desired, TellYourPartner.org helps patients send anonymous text notifications to partners. Consult a social worker if you are concerned about abuse, assault, human trafficking or any other safety issues.5

Primary care providers can have a significant impact on the future sexual and reproductive health of adolescents. All teenagers should be counseled on safe sex and healthy sexual behaviors. This discussion should include counseling on contraceptive options and providing patients with condoms if available.

 

References: 

  1. Bachmann L. CDC’s 2022 STI Surveillance Report underscores that STIs must be a public health priority. Centers for Disease Control and Prevention. Last reviewed January 30, 2024. Accessed September 30, 2024. https://www.cdc.gov/std/statistics/2022/
  2. Bishop C. The dangers of undiagnosed sexually transmitted infections. American Society for Microbiology. December 8, 2022. Accessed September 30, 2024. https://asm.org/articles/2022/december/the-dangers-of-undiagnosed-sexually-transmitted-in
  3. Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187.
  4. Ellen J. Sexually active young people are inadequately screened for sexually transmitted infection. J Adolesc Health. 2022;71(5):521-522. doi:10.1016/j.jadohealth.2022.08.003
  5. Children’s Mercy Hospital. Sexually transmitted infection (STI). Children’s Mercy Kansas City. December 2022. Accessed September 23, 2024. https://www.childrensmercy.org/health-care-providers/evidence-based-practice/cpgs-cpms-and-eras-pathways/sexually-transmitted-infection-clinical-practice-guideline/
  6. Children’s Mercy Hospital. Human immunodeficiency virus (HIV). Children’s Mercy Kansas City. February 2023. Accessed October 2, 2024. https://www.childrensmercy.org/health-care-providers/evidence-based-practice/cpgs-cpms-and-eras-pathways/human-immunodeficiency-virus-hiv-care-process-model/  
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