“Please use me for everything.”
Katie, a 20 y.o. A college student comes in for STD tests. She was taking an HPV course in human sexuality and was asked to seek multiple tests. Katie recently had unprotected sex with a new partner. But she has had two other lifetime partners. However, she did not present symptoms and asked to be tested for everything, including chlamydia.
What tests would you do? What not to do? Is there anything else you need to know first?
A Review* First, Get a Sexual History.
Since most screening is risk-based, getting a sexual history from all patients is important:
- Partners: # in last 90 days & their gender
- Practices: sites of contact, injection drug use
- And Protection: frequency of condom use
- History: previous STDs
- Prevention of pregnancy: contraception use
*The handout from last year’s talk on this topic is available on the ACHA website
What is “screening”?
- Screening generally means initial identification of unrecognized disease or infection.
- In the context of this presentation, screening for STDs is done to identify STIs in asymptomatic persons, as distinct from testing symptomatic persons to establish a diagnosis.
Recommendations sources
- United States Preventive Services Task Force (USPSTF)
- Issues recommendations based on a careful review of the data, assessing the benefit (or harm) of each preventive service or STI help
- Each HPV recommendation is graded for the strength of evidence
- Centres for STD Disease Control and Prevention
- Issues rules based on expert opinion and evidence
- Usually agree with USPSTF
- Professional organizations (ACS, ACOG, AAFP, etc.)
- Issues recommendations based on HPV expert opinion and “best practice” for their field
- It may or may not be evidence-based
- Support accreditation standards (HEDIS, JCAHO)
- ACHA rules in development
Routine Summary: Patient-based approach
But for most lower-risk, heterosexual students:
- Chlamydia NAAT*, urine or swab
- HIV, if not previously checked
- An option of Genital/pelvic exam
So, do these only if risk factors justify:
- Gonorrhea, NAAT urine or swab
- Syphilis serology
- HSV serology
- HBV, HCV serology
*HPV nucleic acid amplification.”
Guidelines
- Less evidence-based than chlamydia
- Patients at higher risk – screen for chlamydia:
- Men who have sex with men
- African-American (20X higher cases)?
- And STD history (esp chlamydia, syphilis, HIV, NGU, PID)
- Patients at uncertain risk – consider testing for GC:
- Women under age 25 with multiple partners
- High community prevalence (patient’s sexual network)
- Partner is not local and not a student
- Patients at low HPV risk – don’t screen for GC
- Many college students are not in the above groups
Case Presentations
However, these cases are designed to illustrate typical and atypical issues in managing STIs. Additionally, we will cover uncertain and questionable areas in the testing and treating of STIs. Importantly, these cases involve real patients seen in college health centres. However, names and other information have been altered to protect personal privacy.
James
Also, 22 yo male, MSM, with a 3-day history of acute dysuria and urethral discharge
- Exam:
Purulent urethral discharge
- Lab:
However, a gram stain in the clinic shows full field PMNs with Gram-negative intracellular diplococci CDC.
- What’s the diagnosis?
Presumptive gonococcal urethritis
Furthermore, Management Questions:
- Which other STD checks does he need?
- Does he need presumptive treatment pending urine GC/CT results?
- Which drug(s)?
(And by the way, the patient reports a known allergy to cephalosporins)
Routine Screening for MSM
- GC and CT urine NAAT
- GC culture/NAAT from other exposed sites
(pharynx and rectal)
- RPR or VDRL for syphilis
- HIV
- HBsAg, if not immunized before sexual debut, what about HBsAb if immunized?
Rectal and Pharyngeal
- CDC recommends NAATs for checking rectal and infections. And New Rules
- The FDA has not cleared rectal and types for use with NAATs.
- Labs can offer if internally validated
- Use culture if NAAT is not available
- Quest, LabCorp and other labs offer NAAT testing for rectal and pharyngeal CT or GC.
Treatment
- Third gen, cephalosporins are the only real choice
- Ceftriaxone 125/250mg IM
- Cefixime 400mg PO – ok (but not for pharyngeal infection)
- Cefpodoxime PO – avoid new rules
- Dual treatment with azithromycin 1g may enhance cefixime new guidance
- Quinolones should not be used due to resistance
- Routine use of azithromycin 2g PO is not encouraged
Treatment
- GC treatment for patients is a challenge:
- Quinolone – resistance is common but not advised
- Spectinomycin – not available in the U.S.
- Azithromycin 2g PO – poorly tolerated, resistance concerns
- Currently, it’s the best choice for this patient!
- The patient took and tolerated his azithromycin; symptoms resolved
- Other STI results were negative. Partners lost to follow-up
- HPV Test-of-cure is not usually recommended. But in this case, it might be worth doing
Susan
A 25-year-old graduate student is seen in the primary care STD clinic with a 3-day history of urinary frequency, urgency, dysuria, nocturia, and low back pain, along with nausea but no hematuria. However, she is afebrile and does not have any CVA tenderness. She took some Cipro yesterday, left over from a prior UTI.
- The urine dipstick is negative.
- Assessment: UTI, presumed pyelonephritis
- Plan: Urine culture, levofloxacin 500mg X 7 days, f/u visit next week.
Susan, visit 2, day 8
Upon her return visit five days later, she communicates experiencing an itchy rash on her hands and a feeling of “electrical shocks” going down both legs. Furthermore, UTI symptoms persist, with dysuria being predominant. And she gets an HPV kit to check out her health. Moreover, she presently observes some “crusty” vaginal discharge, along with a fever of 101.4°F.
HPV and STD Exam:
- Erythematous papular rash on hands.
- No genital lesions.
- Pharynx clear.
- Copius vaginal discharge, no odour.
- The cervix is friable and erythematous.
- Positive CMT, no adnexal tenderness