Gale R. Burstein

Sexually transmitted diseases treatment guidelines.

Sexually transmitted diseases (STDs) are a major health problem for adolescents. Health care providers for adolescents play a critical role in preventing and treating STDs. In May 2002, the Centers for Disease Control and Prevention published the Sexually Transmitted Diseases Treatment Guidelines 2002. These evidence-based guidelines are based on a systematic literature review focusing on information that had become available since the 1998 Guidelines for Treatment of STDs. This article reviews the new STD treatment guidelines for gonorrhea, chlamydia, bacterial vaginosis, trichomonas, vulvovaginal candidiasis, pelvic inflammatory disease, genital warts, herpes simplex virus infection, syphilis, and scabies. Although these guidelines emphasize treatment, prevention strategies and diagnostic recommendations also are discussed.

Screening for gonorrhea and chlamydia by DNA amplification in adolescents attending middle school health centers. Opportunity for early intervention.

Goal: To determine prevalence and incidence of Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) infection and assess risk factors predictive for such infections in a middle school‐based clinic sample. Study Design: 170 female students and 43 male students making 256 and 47 visits, respectively, ≥ 30 days apart, in urban middle school clinics for primary care screening, reproductive health, or illness/injury were routinely asked to provide urine specimens for GC and CT ligase chain reaction testing if sexually active in the preceding 3‐month period. Information regarding prior sexually transmitted diseases, reason for visit, and sexual risk behaviors was obtained. Results: GC: 11.4% of female student and 2.1% of male student tests were positive. Incidence was 34.0 cases/1,000 person months(95% Confidence interval [CI]: 19.5‐67.5). Median time to first positive and repeat positive test was 4.6 and 2.6 months, respectively. For CT: 16.4 % of female student and 2.1% of male student tests were positive. Incidence was 57.5 cases/1,000 person months (95% CI: 35.2‐93.8). Median time to first positive and repeat positive CT test was 6.0 and 4.8 months, respectively. Assessed risk factors failed to specify a candidate screening population. Conclusion: These data suggest that all sexually active adolescent girls in this high risk setting should be offered testing for GC and CT at least twice per year, regardless of age or other sexual risk behaviors and that STD control efforts in high risk middle schools should be encouraged.

Predictors of repeat Chlamydia trachomatis infections diagnosed by DNA amplification testing among inner city females.

Objective: To describe the epidemiology of prevalent and incident chlamydia infection in order to assess the appropriate interval for chlamydia screening; and to identify risk factors predictive of infection and repeat infections. Design: Prospective longitudinal study of a consecutive sample of 3860 sexually active females aged 12–60 years tested for C trachomatis by polymerase chain reaction in Baltimore City clinics during 11 904 patient visits over a 33 month period. Results: Chlamydia prevalence, incidence, and frequency to diagnosis of infection varied by age. Among 2073 females <25 years, chlamydia infection was found in 31.2%. The median times to first and repeat incident infections were 7.0 months and 7.6 months, respectively. Among 1787 females ≥25 years, chlamydia infection was found in 9.6%. Median times to first and repeat incident infections were 13.8 months and 11.0 months, respectively. Age <25 years yielded the highest risk of infection. Conclusions: Since a high burden of chlamydia was found among mostly asymptomatic females <25 years in a spectrum of clinical settings, we recommend chlamydia screening for all sexually active females <25 years at least twice yearly.

Adolescent Immunizations and Other Clinical Preventive Services: A Needle and a Hook?

Advances in technology have led to development of new vaccines for adolescents, but these vaccines will be added to a crowded schedule of recommended adolescent clinical preventive services. We reviewed adolescent clinical preventive health care guidelines and patterns of adolescent clinical preventive service delivery and assessed how new adolescent vaccines might affect health care visits and the delivery of other clinical preventive services. Our analysis suggests that new adolescent immunization recommendations are likely to improve adolescent health, both as a “needle” and a “hook.” As a needle, the immunization will enhance an adolescents health by preventing vaccine-preventable diseases during adolescence and adulthood. It also will likely be a hook to bring adolescents (and their parents) into the clinic for adolescent health care visits, during which other clinical preventive services can be provided. We also speculate that new adolescent immunization recommendations might increase the proportion and quality of other clinical preventive services delivered during health care visits. The factor most likely to diminish the positive influence of immunizations on delivery of other clinical preventive services is the additional visit time required for vaccine counseling and administration. Immunizations may “crowd out” delivery of other clinical preventive services during visits or reduce the quality of the clinical preventive service delivery. Complementary strategies to mitigate these effects might include prioritizing clinical preventive services with a strong evidence base for effectiveness, spreading clinical preventive services out over several visits, and withholding selected clinical preventive services during a visit if the prevention activity is effectively covered at the community level. Studies are needed to evaluate the effect of new immunizations on adolescent preventive health care visits, delivery of clinical preventive services, and health outcomes.

Nongonococcal Urethritis—A New Paradigm

Urethritis in men has been categorized historically as gonococcal or nongonococcal (NGU). The major pathogens causing NGU are Chlamydia trachomatis and Ureaplasma urealyticum. Trichomonas vaginalis may be involved occasionally. In up to one-half of cases, an etiologic organism may not be identified. In this review we present recent advances in the diagnosis and management of NGU and discuss how they may be applied in a variety of clinical settings, including specialized STD clinics and primary health care practices. In particular, the development of the noninvasive urine-based nucleic acid amplification tests may warrant rethinking of the traditional classification of urethritis as gonococcal urethritis or NGU. Diagnostic for Chlamydia are strongly recommended because etiologic diagnosis of chlamydial urethritis may have important public health implications, such as the need for partner referral and reporting. A single 1-g dose of azithromycin was found to be therapeutically equivalent to the tetracyclines and may offer the advantage of better compliance.

Chlamydia screening in a Health Plan before and after a national performance measure introduction.

Objective: To evaluate chlamydia-screening policies, testing practices, and the proportion testing positive in response to the new Health Plan Employer Data and Information Set (HEDIS) chlamydia-screening performance measure in a large commercial health plan. Methods: We interviewed health plan specialty departmental chiefs to describe interventions used to increase chlamydia screening and examined electronic medical records of 15- to 26-year-old female patients—37,438 from 1998 to 1999 and 37,237 from 2000 to 2001—who were classified as sexually active by HEDIS specifications to estimate chlamydia testing and positive tests 2 years before and after the HEDIS measure introduction. Results: In January 2000, the obstetrics and gynecology department instituted a policy to collect chlamydia tests at the time of routine Pap tests on all females 26 years old or younger by placing chlamydia swabs next to Pap test collection materials. Other primary care departments provided screening recommendations and provider training. During 1998–1999, 57% of eligible female patients seen by obstetrics and gynecology exclusively and 63% who were also seen by primary care were tested for chlamydia; in 2000–2001 the proportions tested increased to 81% (P < .001) and 84% (P < .001). Proportions tested by other primary care specialists did not increase substantially: 30% in 1998–1999 to 32% in 2000–2001. The proportion of females testing positive remained high after testing rates increased: 8% during 1998–1999 and 7% during 2000–2001, and the number of newly diagnosed females increased 10%. Conclusion: After the obstetrics and gynecology department introduced a simple systems-level change in response to the HEDIS measure, the proportion of females chlamydia-tested and number of newly diagnosed females increased. Level of Evidence: II-2

Provider willingness to screen all sexually active adolescents for chlamydia

Objectives: To assess differences in provider willingness to screen all sexually active male and female adolescents for chlamydia and to determine whether concerns about cost effectiveness of screening are related to provider willingness to screen for chlamydia. Methods: All primary care providers in a managed care organisation self administered a survey about screening all sexually active adolescents for chlamydia. Results: Respondents were 217 physicians (MDs) and 121 nurse practitioners (NPs) or physician assistants (PAs). Excluding obstetrician/gynaecologists, more providers were willing to routinely screen adolescent females than males for chlamydia (67% v 49% respectively; p<0.001). Independent predictors of provider willingness to screen both males and females included belief that routine screening is cost effective and being a NP/PA v an MD. Belief that chlamydia screening is easier in females than males independently predicted less willingness to screen males. Conclusion: Information that reduces provider concern about the cost effectiveness of screening may increase provider willingness to screen adolescents for chlamydia. Availability of urine based tests may reduce provider beliefs that females are easier to screen than males and increase chlamydia screening in males.

An Economic Evaluation of a School-Based Sexually Transmitted Disease Screening Program

Background A school-based sexually transmitted disease (STD) screening program was implemented in eight New Orleans public high schools to detect chlamydia and gonorrhea. Goal The goal was to assess the incremental cost-effectiveness of replacing non-school-based screening with the school-based screening program. Study Design A decision-analysis model was constructed to compare costs and cases of expected pelvic inflammatory disease (PID) in the school-based screening scenario versus a non-school-based screening scenario. Cost-effectiveness was quantified and measured as cost per case of PID prevented. Results Under base-case assumptions, at an intervention cost of

Adolescent chlamydia testing practices and diagnosed infections in a large managed care organization

86,449, the school screening program prevented an estimated 38 cases of PID, as well as

Expedited Partner Therapy for Adolescents Diagnosed with Chlamydia or Gonorrhea: A Position Paper of the Society for Adolescent Medicine

119,866 in treatment costs for PID and its sequelae, resulting in savings of