What are the recommendations for screening, prevention, and treatment of sexually transmitted infections (STIs) in adolescents?

Screening, Prevention, and Treatment of STIs in Adolescents

Adolescents have the highest prevalence rates of sexually transmitted infections (STIs) compared to other age groups and require comprehensive screening, prevention, and treatment protocols to reduce morbidity and mortality. 1, 2

Epidemiology and Risk Factors

• Adolescents (15-24 years) account for approximately half of all new STI cases annually despite representing only 25% of the sexually active population 3
• Certain populations bear higher STI burden:
  • Youth of color
  • Men who have sex with men (MSM)
  • Sexually active females ≤25 years
  • Adolescents with multiple or anonymous partners
  • Those with history of previous STIs
  • Youth exchanging sex for money/drugs
  • Injection drug users 1, 2

Screening Recommendations

Chlamydia

• Routinely screen all sexually active female adolescents and young adults (≤25 years) annually 1, 2
• Consider screening sexually active males ≤25 years in high-prevalence settings 2
• Screen MSM at all exposed anatomical sites (pharyngeal, rectal, urethral) based on sexual practices 1, 2

Gonorrhea

• Routinely screen all sexually active female adolescents and young adults (≤25 years) annually 2
• Screen sexually active MSM at all exposed sites (pharyngeal, rectal, urethral) annually or every 3-6 months if high-risk 1, 2
• Consider screening other sexually active males based on individual and population risk factors 1

Syphilis

• Routine screening of heterosexual adolescents is not recommended unless in high-prevalence areas 1
• Screen all sexually active MSM annually or every 3-6 months if high-risk 1, 2
• Screen all pregnant adolescents at first prenatal visit and third trimester if high-risk 2

Trichomoniasis

• Routine screening of asymptomatic adolescents is not recommended 1
• Consider screening females with risk factors (multiple partners, history of STIs, sex work, injection drug use) 1

HIV

• Screen adolescents engaging in high-risk sexual behavior 2
• Consider more frequent screening (every 3-6 months) for high-risk individuals 2

Testing Methods

• Nucleic Acid Amplification Tests (NAATs) are preferred for chlamydia and gonorrhea screening 2
  • Urine samples are acceptable for urogenital testing
  • Site-specific testing based on sexual practices:
    • Pharyngeal testing for gonorrhea if engaging in receptive oral sex
    • Rectal testing for chlamydia and gonorrhea if engaging in receptive anal intercourse 1, 2
• Serum testing for HIV and syphilis 2
• Any positive STI test should prompt consideration for additional STI testing 2

Treatment Recommendations

Chlamydia

• Azithromycin 1 gram orally as a single dose 4
• Alternative: Doxycycline 100 mg orally twice daily for 7 days

Gonorrhea

• Due to increasing antimicrobial resistance, follow current CDC guidelines 5
• Current recommendation: Ceftriaxone 500 mg IM as a single dose
• For pharyngeal gonorrhea: Ceftriaxone 500 mg IM as a single dose

Non-gonococcal urethritis and cervicitis

• Azithromycin 1 gram orally as a single dose 4

Syphilis

• Treatment depends on stage; consult current CDC guidelines
• Primary, secondary, early latent: Benzathine penicillin G 2.4 million units IM as a single dose

Follow-up and Rescreening

• Rescreen all adolescents infected with chlamydia or gonorrhea 3 months after treatment, regardless of whether partners were treated 1, 2
• If 3-month rescreening isn't possible, retest at next healthcare visit within 12 months 1
• Consider rescreening females previously diagnosed with trichomoniasis 3 months after treatment 1

Prevention Strategies

• Comprehensive sexual education
• Consistent and correct condom use
• HPV vaccination through age 21 for males and 26 for females 2
• Verify hepatitis B vaccination status and offer if not completed 2
• Partner notification and treatment
• Abstinence or reduction in number of sexual partners

Clinical Practice Implementation

• Develop clinical procedures that incorporate:
  • STI risk assessments
  • Screening and treatment protocols
  • Prevention counseling into routine adolescent healthcare 1
• Provide education and training to staff on procedures, consent, confidentiality, and billing 1
• Develop competence with non-invasive NAAT screening methods 1
• Consider telehealth services as an effective strategy for STI education and intervention among adolescents 5

Common Pitfalls and Caveats

1. Underscreening: Many at-risk adolescents are not appropriately screened despite recommendations 6
2. Confidentiality concerns: These can be significant barriers to adolescent STI screening 3
3. Asymptomatic infections: Many STIs are asymptomatic but can still lead to significant complications 6, 3
4. Incomplete site testing: Failure to test all exposed anatomical sites based on sexual practices 1, 2
5. Inadequate follow-up: Not rescreening after treatment can miss persistent or recurrent infections 1
6. Partner treatment: Failure to ensure partners are treated can lead to reinfection 1
7. Sexual history assumptions: Providers should inquire about same- and opposite-gender partners regardless of reported sexual orientation 1

A comprehensive sexual history sensitive to ethnic, racial, and cultural factors, including those of sexual minority youth, and a sexual behavior risk assessment should guide specimen collection sites based on sexual practices 1.