PHM Session: 2021 Sexually Transmitted Infection (STI) Guideline Updates: What the Pediatric Hospitalist Needs to Know
Presenters: Jason Zucker, MD, Columbia University, New York, and Candice McNeil, MD, MPH, Atrium Health Wake Forest Baptist, Winston-Salem, N.C.
As the assistant director of the New York City STD/HIV Prevention Training Center and co-medical director of the Southeast STD/HIV Prevention Training Center, Drs. Zucker and McNeil shared their expertise on this ever-evolving topic. As of 2020, there were more than 2 million cases of chlamydia and gonorrhea, about 130,000 cases of syphilis, and a 235% increase in cases of congenital syphilis. Direct medical costs to treat these conditions, in addition to Human Immunodeficiency Virus (HIV), Hepatitis B, Herpes simplex Virus-2, and trichomoniasis are estimated to be $16 billion annually. While youth ages 15 to 24 comprise just 13% of the population, they account for 26% of sexually transmitted infection (STI) cases, and we know that approximately 65% of youth over the age of 18 are sexually active. The need for a high-quality sexual health history was emphasized and techniques were shared (see below). It was also noted that time pressure, specimen collection, and minor-consent concerns often prevent providers from screening appropriately for sexual health conditions. Most patients are comfortable self-swabbing and collect such samples faster and better than their medical providers.
After this review, the audience was guided through an interactive case-based discussion of various presenting complaints for STIs, grounded in the 2021 Centers for Disease Control and Prevention (CDC) STI guidelines. The following updates were emphasized:
Syphilis: Diagnostic categories based on history, examination, rapid plasma reagin (RPR), and laboratory results include proven, possible, less likely, and unlikely infection. A history must include a review of vision and hearing concerns to evaluate for neurosyphilis. If concerns arise, 10 days of penicillin V (PCN) should be used; otherwise, high-dose penicillin can be provided via one or multiple intramuscular doses (dependent upon diagnostic category). Pregnant mothers with syphilis must be treated at least four weeks prior to delivery. The CDC diagnostic and treatment category charts should be used.
HIV: Pre-exposure prophylaxis (PrEP) is underutilized and should be encouraged for the prevention of HIV infection. The absolute number of infections is higher in heterosexuals than in men who have sex with men.
Monkeypox: Consider it! It can be spread by fomites, direct contact with lesions, or contact with respiratory secretions. Two pediatric cases have occurred. To test, lesions must be swabbed vigorously with two swabs, which are sent for Orthopoxvirus testing (confirmatory to CDC). Most patients receive supportive care, and rarely, antiviral medications. Contacts should be vaccinated.
Mycoplasma genitalium: This has become an emerging pathogen of those with non-gonococcal urethritis or cervicitis (up to 25% of cases). You can test with a genital or urine nucleic acid amplification test (NAAT). Emerging macrolide resistance is a concern for those with persistent symptoms (44 to 90%, and also 0 to 15% fluoroquinolone resistance in the U.S.).
Looking for more education? The National STD Curriculum can be found at www.std.uw.edu and is being updated to the 2021 CDC guidelines. Once complete, this will launch as the second edition. It’s free!
- An appropriate sexual health history should consider gender neutrality as well as potential sexual encounter type. Consider using the CDC’s five Ps for history taking: Partners, Practices, Protection from STIs, Past history of STIs, and Pregnancy Intention. Example questions:
- What is/are the gender(s) of your sex partners?
- Are you currently having sex of any kind?
- What parts of your body are involved?
- As of 2020, all U.S. jurisdictions have laws that explicitly allow a minor of a particular age (as defined by each state) to give informed consent to receive STI diagnosis and treatment services.
- Complete STI testing includes HIV, RPR, genitourinary, pharyngeal, and rectal gonorrhea, and chlamydia testing. Hepatitis C testing is recommended sometime during one’s lifetime. Routine testing is not recommended for trichomonas unless there is a high community prevalence.
- Pregnant patients should be screened for syphilis at presentation, at 28 weeks, and at delivery if high risk.
- Men who have sex with men, patients receiving PrEP, or those with HIV should be screened for syphilis every three to six months.
- All other sexually active individuals should be tested annually for syphilis.
- Extragenital testing is recommended for everyone, as rectal autoinoculation can occur without anal sex. Consider offering a self-swab for all patients.
- Current treatment recommendations:
- Gonorrhea—ceftriaxone 500 mg (weight-based)
- Chlamydia—100 mg doxycycline every 12 hours for seven days
- Pelvic Inflammatory Disease—add metronidazole
- Mycoplasma genitalium—resistance-directed, sequential treatment with doxycycline and moxifloxacin
Dr. Erin King is a pediatric hospitalist at Children’s Minnesota, Minneapolis, Minn. She currently serves as the director of graduate medical education at Children’s Minnesota, overseeing the supervision of NP, PA, and medical student, resident, and fellowship trainees. She was previously the associate program director for the pediatric residency at Children’s Minnesota. She enjoys these diverse roles and has shared her resident teaching, peer observation and feedback, and research work on a national level.