Outbreaks, Alerts and Hot Topics

The Birds, the Bees and the CDC

Co-authors: Diane Petrie, FNP-BC, AAHIVS; Melissa Smith, FNP-C; and Katie Stangler, CPNP, CCRN

Column Editor: Chris Day, MD | Pediatric Infectious Diseases | Director, Transplant Infectious Disease Services; Medical Director, Travel Medicine | Assistant Professor of Pediatrics, University of Missouri-Kansas City School of Medicine; Clinical Assistant Professor of Pediatrics, University of Kansas School of Medicine

More than half of all sexually transmitted infections (STIs) occur in 15- to 24-year-olds, highlighting the disparities in access to care among adolescents and young adults (AYA). Despite disruptions to daily routines and social distancing during the pandemic, AYA STI rates continue to rise. Data published in April 2022 (2020 STD Surveillance Report-CDC) showed rates of STIs decreased in mid-2020 only to recover and increase by the end of that year. Gonorrhea rose by 10%, and both primary and secondary syphilis increased by 7%. Interestingly, chlamydia rates decreased by 13%, but this decrease has since been attributed to reduced access to testing and care, rather than a true decrease in infections. Preliminary data for 2021 shows the rates of many infections continue to rise. With decreased access to care for STIs and reduced engagement in primary care for teens, health care providers must prioritize adolescent sexual health.

Sexual Health Policy Statements by the American Academy of Pediatrics highlight the need for confidential and comprehensive sexual and reproductive health care for all adolescents. State laws allow minors to consent for their health care based on their status (e.g., an emancipated minor or a pregnant or parenting teenager) and based on the services they seek (e.g., STI diagnosis and treatment, contraception, pregnancy care, substance abuse counseling and treatment, or mental health care). Confidentiality can be a challenge in many care settings, but teens need to know that their personal information can and will remain private so they can feel comfortable accessing care for sexual health.

Less engagement in health care services following the pandemic coupled with rising STI infection rates make this a crucial time to lean into screening, testing and treating AYA in need of these services. One barrier for AYA sexual health is both teen and provider discomfort with obtaining a sexual history. Using a simple screening tool or questionnaire during every visit with AYA is one way to simplify and normalize the process of STI screening in your practice. Computer or device-based screening tools can lead to increased engagement by AYA.

In 2021, the Centers for Disease Control and Prevention (CDC) published STI treatment guidelines, which include updated treatment recommendations for gonorrhea, chlamydia and trichomoniasis. The CDC continues to recommend annual STI screening for all sexually active AYA and screening every three to six months for those with higher risk sexual behaviors. Evidence supports the use of doxycycline as first-line treatment for chlamydia infections of the urogenital, rectal and oropharyngeal sites. Azithromycin can be used as an alternative treatment but is less effective for rectal infections. Ceftriaxone remains first-line treatment for gonorrhea infections, but the standard dose increased to 500 mg IM for patients 45-150 kg. For trichomoniasis, the preferred treatment is metronidazole, 500 mg BID for seven days for females. For males, 1000 mg metronidazole in a single dose can continue to be used as first-line treatment. High trichomoniasis prevalence in the Kansas City Metro area suggests providers should consider testing whenever specimens are obtained to evaluate for a bacterial STI. The CDC provides a helpful app for providers to reference all recommendations in an accessible way.

Children’s Mercy is near completion of a comprehensive guideline on STI screening, testing and treatment. The finalized algorithm will soon be available on the Children’s Mercy Evidence Based Practice page under Clinical Practice Guidelines.

AYA accessing care for any reason is always an important opportunity to screen for sexual health concerns and ensure we are providing appropriate, guideline-based sexual health care. Each of us can do our part to address this significant health need for our patients.

References:

Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187. doi:10.15585/mmwr.rr7004a1

Goyal MK, Shea JA, Hayes KL, et al. Development of a sexual health screening tool for adolescent emergency department patients. Acad Emerg Med. 2016;23(7):809-815.