POLICY STATEMENT

Screening for Nonviral Sexually Transmitted Infectionsin Adolescents and Young Adults

abstractPrevalence rates of many sexually transmitted infections (STIs) arehighest among adolescents. If nonviral STIs are detected early, theycan be treated, transmission to others can be eliminated, and sequelaecan be averted. The US Preventive Services Task Force and the Centersfor Disease Control and Prevention have published chlamydia, gonor-rhea, and syphilis screening guidelines that recommend screening thoseat risk on the basis of epidemiologic and clinical outcomes data. Thispolicy statement specifically focuses on these curable, nonviral STIs andreviews the evidence for nonviral STI screening in adolescents, commu-nicates the value of screening, and outlines recommendations for routinenonviral STI screening of adolescents. Pediatrics 2014;134:e302–e311

EVIDENCE TO SUPPORT NONVIRAL STI SCREENING

The goal of sexually transmitted infection (STI) screening is to identifyand treat individuals with treatable infections, reduce transmissionto others, avoid or minimize long-term consequences, identify otherexposed and potentially infected individuals, and decrease the prev-alence of infection in a community. Healthy People 2020 objectives forsexually transmitted diseases1 include items that address screeningfor chlamydia in sexually active females younger than 25 years andset targets for decreased rates of chlamydia, gonorrhea, and syphilisin specific populations. The US Preventive Services Task Force (USPSTF),an independent panel of prevention and evidence-based medicineexperts, has published chlamydia,2 gonorrhea,3 and syphilis4,5 screen-ing guidelines that recommend screening those at risk on the basis ofepidemiologic and clinical outcomes data. The Centers for DiseaseControl and Prevention (CDC) publishes evidence-based STI screeningrecommendations for specific at-risk populations that are not ad-dressed by the USPSTF but that pose public health challenges fordisease prevention and control.6–8 Major professional medical organi-zations, including the American College of Obstetricians and Gynecol-ogists and the American Academy of Family Physicians, have alsopublished STI screening guidelines for specific populations.7–10 TheAmerican Academy of Pediatrics’ (AAP) Bright Futures guidelines forhealth supervision recommend chlamydia and gonorrhea screening asappropriate for the patient population and the clinical setting.11 RecentAAP clinical reports addressing gynecologic examinations and malereproductive and sexual health care discuss clinic issues and provider

COMMITTEE ON ADOLESCENCE and SOCIETY FORADOLESCENT HEALTH AND MEDICINE

KEY WORDSsexually transmitted infections, nonviral STIs, chlamydia,gonorrhea, syphilis, screening

ABBREVIATIONSAAP—American Academy of PediatricsCDC—Centers for Disease Control and PreventionCLIA—Clinical Laboratory Improvement AmendmentFDA—Food and Drug AdministrationMSM—males who have sex with malesNAAT—nucleic acid amplification testPID—pelvic inflammatory diseaseSTI—sexually transmitted infectionUSPSTF—US Preventive Services Task Force

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authorshave filed conflict of interest statements with the AmericanAcademy of Pediatrics. Any conflicts have been resolved througha process approved by the Board of Directors. The AmericanAcademy of Pediatrics has neither solicited nor accepted anycommercial involvement in the development of the content ofthis publication.

The recommendations in this statement do not indicate anexclusive course of treatment or serve as a standard of medicalcare. Variations, taking into account individual circumstances,may be appropriate.

All policy statements from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time.

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skills that are relevant to office-basedscreening for nonviral STIs.12,13 Theseclinical reports and CDC recom-mendations6 describe the importantelements of a sexual history. The goalof this policy statement is to review theevidence in support of nonviral STIscreening in adolescents and to edu-cate pediatricians about the value ofscreening as well as resources avail-able to support this practice. Screen-ing considerations from the CDCspecific to pregnant and HIV-infectedindividuals should be reviewed (www.cdc.gov/std/treatment).6 Guidanceabout how to incorporate chlamydiascreening into the office setting in-cluding addressing confidentiality, billing,and explanation of benefits statementscan be found at the National ChlamydiaCoalition Web site (http://ncc.prevent.org/info/healthcare-providers). Thissite provides a link to up-to-dateresources and a monograph titledWhy Screen for Chlamydia; An Im-plementation Guide for HealthcareProviders. The AAP policy statementaddressing standards for Health In-formation Technology to ensure ado-lescent privacy may be useful in theestablishment of practice proceduresand help anticipate questions regardingconfidentiality.14

CHLAMYDIA

Importance

Chlamydia trachomatis is the mostcommon reportable communicabledisease in the United States, with thehighest case rates occurring in fe-male 20- to 24-year-olds followedclosely by rates in female 15- to 19-year-olds.8 Chlamydia is common among allraces and ethnic groups; however, largeracial disparities in chlamydial burdenexist, and young women and men ofcolor are disproportionately affected.8,15

Among sexually active female 15- to 19-year-olds, chlamydia prevalence amongnon-Hispanic African Americans is more

than 5 times the prevalence amongnon-Hispanic whites (7719/100 000 pop-ulation vs 1458/100 000).8 In male 15- to19-year-olds, in whom the rates haveincreased every year since 2006, therate of chlamydia infection among non-Hispanic African Americans is 10 timesthe rate in non-Hispanic whites (2334/100 000 population vs 236/100 000).8

Rates for American Indian/Alaskan Na-tive and Hispanic populations are be-tween the rates for African Americanand white populations.

Most chlamydia infections are asymp-tomatic and may persist if left untreated.Previous infection does not confer anyclinically reliable protective immunity.16

Vaccines are not available for chla-mydia or for any of the subsequentlydiscussed nonviral STIs. Chlamydia canmanifest as cervicitis, urethritis, proc-titis, and uncommonly, pharyngitis.Complications and sequelae may in-clude pelvic inflammatory disease(PID), tubal-factor infertility, ectopicpregnancy,6,17 chronic pelvic pain,18 in-creased HIV transmission,19–23 adversepregnancy and infant outcomes,24

neonatal infections,25 epididymitis,26

and reactive arthritis.16,27

Background

The USPSTF, AAP, and American Acad-emy of Family Physicians recommendannual chlamydia screening of allsexually experienced females youngerthan 25 years. The CDC and AmericanCollege of Obstetricians and Gynecol-ogists recommend annual routinescreening of sexually experienced fe-males through the age of 25 years. TheNational Commission on PreventionPriorities ranked chlamydia screeningof young women as 1 of the 10 mostbeneficial and cost-effective preventiveservices but also among the mostunderutilized.28

The USPSTF found insufficient evidenceto recommend for or against routinechlamydia screening of young men.

Because the risk of complicationsor long-term reproductive sequelaefor chlamydia-infected males is low,screening asymptomatic males doesnot offer substantial secondary pre-vention for them. In addition, maleolder adolescents/young adults areless likely than their female counter-parts to use health care servicesand thus may be difficult to reachwith a chlamydia screening program.29

However, the CDC recommends con-sidering screening young men in clin-ical settings with high chlamydiaprevalence rates, such as jails or ju-venile corrections facilities, nationaljob training programs, and STD, highschool, or adolescent clinics, whenresources permit.6,30 Males in these set-tings with a history of multiple partnersare at greatest risk of asymptomaticchlamydia infection.31–33 The CDC alsorecommends chlamydia screening ofmales who have sex with males (MSM)at least annually for urethral and rectalinfection on the basis of reported sexualpractices and every 3 to 6 monthsif considered high risk because ofmultiple or anonymous partners, sexin conjunction with illicit drug use, orhaving sex partners who participatein these activities.6 Sex partners ofchlamydia-infected individuals duringthe 60 days before the diagnosisshould also be targeted for testingand treatment because of their highlikelihood of infection.6

Laboratory Testing

Detection of genitourinary chlamydiainfections has substantially improvedover the past 2 decades. Nucleic acidamplification tests (NAATs) are pre-ferred for C trachomatis detection inadolescents and young adults, re-gardless of symptoms.34 C trachomatisNAATs are sensitive and specific andlicensed for use with urine, urethral,vaginal, and cervical specimens. Manyof the chlamydia NAATs are approvedby the Food and Drug Administration

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(FDA) to test patient-collected vaginalswabs in the clinical setting and liquidcytology specimens.34,35 Among all ofthe aforementioned specimens, femalevaginal swab specimens and malefirst-void urine are considered the op-timal specimen types.34 Female urineremains an acceptable chlamydia NAATspecimen but may have slightly re-duced performance compared withcervical or vaginal swab specimens.34

The CDC recommends at least an an-nual urine chlamydial NAAT for ure-thral infection for MSM who have hadinsertive anal intercourse and an an-nual rectal swab chlamydial NAAT forthose who have had receptive anal in-tercourse.6 Although chlamydia NAATsare not approved by the FDA for rectalswab specimen testing, laboratoriesthat have met Clinical Laboratory Im-provement Amendment (CLIA) andother regulatory requirements andvalidated chlamydia NAAT performanceon rectal swab specimens may per-form these tests.6,34,36 In the evaluationof the sexual assault victim, NAATsmay be used for female vaginal swaband urine specimens. Some juris-dictions may prefer C. trachomatisculture from all sites in lower-prevalencepopulations because of greater speci-ficity, although sensitivity may becompromised.6

Disease-Specific Benefits and Risksof Screening

In randomized clinical trials, screeningasymptomatic sexually active youngwomen for chlamydia and treatingthose identified with infection reducedthe risk of subsequent PID.37,38 Otherstudies, summarized by Haggerty et al,support the association of repeatedchlamydia infection with increased re-productive sequelae.18

Clinical Considerations

Because reinfection is common, pro-viders should rescreen all male and

female patients treated for chlamydiaapproximately 3 months after treat-ment. If retesting at 3 months is notpossible, retest whenever patientsnext present for health care services inthe 12 months after the initial treat-ment. A systems-based approach ofcollecting a noninvasive specimen onall females before they are seen by thehealth care provider, such as duringnursing triage, enhances the pro-portion of sexually active females whoare screened.39–41 The National Chla-mydia Coalition produces resourcesfor health care providers to facilitateoffice-based chlamydia screening.42

Internet-based interventions to pro-mote chlamydia screening with self-collected vaginal swab specimens invarious nonclinical settings are alsobeing evaluated.43,44

GONORRHEA

Importance

Gonorrhea is the second most com-mon reportable communicable dis-ease in the United States; female 20-to 24-year-olds have the highest andfemale 15- to 19-year-olds the sec-ond highest reported gonorrhea caserates compared with any other age orgender.8 Substantial racial disparityexits for gonorrhea. The 2012 re-ported rates among male and femalenon-Hispanic African American 15- to19-year-olds are 26 times and 15times those of male and female non-Hispanic white 15- to 19-year-olds,respectively.8 A recent study has shownthat residential segregation of blackpopulations contributes to the largeracial disparity for youth by creatingdistinct social networks that perpet-uate the persistence of their endem-ically high gonorrhea rates.45 Ratesfor American Indian/Alaskan nativeand Hispanic populations are be-tween the rates for non-Hispanic Af-rican American and non-Hispanicwhite populations.

As with C trachomatis, many infec-tions are asymptomatic, and Neisseriagonorrheae can cause cervicitis, ure-thritis, proctitis, and pharyngitis. Onoccasion, gonorrhea may also lead toconjunctivitis.46 Uncomplicated gonor-rhea infection can spread to the up-per genital tract, causing PID andassociated longer-term complications,such as ectopic pregnancy, infertility,and chronic pelvic pain in females andepididymitis in males, and hematoge-nous spread can cause disseminatedgonococcal infection. Gonorrhea in-fection is also associated with increasedHIV transmission.47 In pregnancy, gonor-rhea is associated with chorioamnioni-tis, premature rupture of membranes,and preterm labor. Perinatal trans-mission can lead to ophthalmia neo-natorum. Rarely, newborn infants developlife-threatening systemic disease fromgonorrhea acquired during deliverythrough an infected birth canal.25

Background

The USPSTF recommends annual gon-orrhea screening of all at-risk, sexuallyactive females.3 Populations at highestrisk of gonorrhea infection includefemales and males younger than 25years and individuals with a history ofprevious gonorrhea infection, otherSTIs, new or multiple sex partners,inconsistent condom use, or who en-gage in sex work or drug use. TheUSPSTF found insufficient evidenceto recommend for or against routinegonorrhea screening of asymptomaticmales because of the low prevalencerates and the lower rates of morbidityrelated to untreated gonorrhea in-fection in males and because asymp-tomatic infection is less common inmales than in females.

The CDC recommends urethral, rectal,and oropharyngeal gonorrhea testingat least annually for MSM who engagein receptive anal or oral intercourse,respectively, as well as urine-based

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testing at least annually for MSM en-gaging in insertive anal or oral in-tercourse.6,34,48 The CDC also recommendsgonorrhea screening every 3 to 6months for MSM who are at higherrisk because of multiple or anonymouspartners, sex in conjunction with illicitdrug use (especially methamphetamines),or partners who participate in theseactivities.6,49,50

Sex partners of gonorrhea-infectedindividuals during the 60 days beforegonorrhea diagnosis should be tar-geted for testing and treatment be-cause of their high likelihood ofinfection.6 Because gonorrhea ratesvary widely by communities and pop-ulation, health care providers shouldconsider local gonorrhea epidemiologyto determine if gonorrhea screening inmale adolescents is appropriate intheir patient population.

Laboratory Testing

Recent shifts have occurred in Ngonorrheae screening options. NAATsare recommended for detection ofgenitourinary gonococcal infectionsin males and females, regardless ofsymptoms.6,34 Gonorrhea and chlamydiaNAATs are usually available as combi-nation tests from a single specimen.Like those for chlamydia, N gonorrheaeNAATs have high sensitivity and speci-ficity. Most are approved by the FDAfor use with urine and urethral, vaginal,and cervical swab specimens in theclinical setting. Some gonorrhea NAATsare also licensed to test patient-collected vaginal swab specimens ina clinical setting and liquid cytologyspecimens. Among all specimens, fe-male vaginal swab specimens andmale urine are the optimal specimentypes.34

Although gonorrhea NAATs are notapproved by the FDA for extragenitalsites, many laboratories have met CLIAand other regulatory requirements andvalidated gonorrhea NAAT testing on

rectal and pharyngeal specimens.34,36,51

NAATs cannot be used to determinegonorrhea antimicrobial resistance;thus, culture must be obtained toidentify antibiotic-resistant gonorrheastrains,8,34 although it has lower sen-sitivity especially at extragenital sitescompared with NAATs. Ideally, gonor-rhea culture is needed for evaluatingsuspected cases of treatment failure,for test of cure for patients who weretreated with an alternative regimen,and for investigating suspected child-hood sexual abuse or assault.6

Disease-Specific Benefits and Risksof Screening

Identification of gonorrhea infectionallows for treatment, prevention ofsequelae, and identification of exposedpartners; reduces further transmissionto others; and may be a marker or riskfactor for HIV transmission.

Clinical Considerations

Providers should rescreen all maleand female patients treated for gon-orrhea approximately 3 months aftertreatment at the anatomic site of in-fection because reinfection is common.Gonorrhea treatment is challengingbecause of the organism’s ability to readilydevelop antimicrobial resistance.6,8,52,53 Thepossibility of emerging cephalosporin-resistant N gonorrheae is a growingconcern.48 The CDC’s Gonococcal IsolateSurveillance Project has documentedrecent trends of decreasing cephalo-sporin susceptibility among N gonor-rheae.52 Cases of suspected gonorrheatreatment failures should be reportedto local or state health departments,and a gonococcal culture of specimensfrom exposed sites, preferably withsimultaneous NAAT and antimicrobial-susceptibility testing, should be per-formed if N gonorrheae is isolated.6

Patients with a diagnosis of un-complicated urogenital or rectal gon-orrhea who are treated with any of the

recommended or alternative regimensdo not need a test-of-cure.6 However,patients with pharyngeal gonorrhea whoare treated with an alternative regimenshould return 14 days after treatment ofa test-of-cure, using either culture orNAAT.6 If the NAAT is positive, every effortshould be made to perform a confirma-tory culture.

TRICHOMONIASIS

Importance

Trichomonas vaginalis infection is nota nationally reportable communicabledisease; however, T vaginalis genitaltract infection is believed to be themost common nonviral STI on thebasis of population studies.54 Unlikechlamydia and gonorrhea infections,which are most common among fe-male adolescents and young adults,trichomoniasis is also common amongolder females. In adolescent femalesamples, T vaginalis prevalence rateshave ranged from 2.1% to 14.4%.54–57

Although this infection is commonlyasymptomatic in females, T vaginalisinfection has been associated withvaginitis and PID.25,58,59 In some cases,it may cause preterm labor60–62 andmay increase HIV transmission.63,64 Themajority of infections (approximately80%) are also asymptomatic in males,although T vaginalis can cause urethri-tis, epididymitis, and prostatitis.65–67

Similar to other STIs, a substantial ra-cial disparity exists, with prevalencerates 10 times higher among femalenon-Hispanic African Americans com-pared with their non-Hispanic white andMexican American counterparts.54

Background

Although the USPSTF has not publishedT vaginalis screening recommendations,CDC recommends screening HIV-infectedfemales for T vaginalis annually andsuggests that screening can be consid-ered in females at high risk of infection,including those with new or multiple

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partners, those with a history of STIs,and those who exchange sex for pay-ment or inject drugs.6

Laboratory Testing

T vaginalis is often identified throughmicroscopic examination of vaginalsecretions on a slide preparation (ie,“wet mount”). This method requiresimmediate viewing for optimal resultsand has poor sensitivity (approxi-mately 60%–70%).64,68,69 Consequently,false-negative results are commonwith microscopic identification, andtrue infections may be underrecog-nized and undertreated.68,70,71 Clinicallaboratory tests with greater sensi-tivity compared with wet mount in-clude trichomonas culture in Diamondmedia or other trichomoniasis-specificculture systems (eg, InPouch, BioMedDiagnostics, White City, OR); a CLIA-waived, antigen-detection, point-of-caretest (OSOM, Sekisui Diagnostics, Exton,PA); and a nucleic acid probe test (AffirmVPIII, Becton, Dickinson and Company,Franklin Lakes, NJ) for T vaginalis,Gardnerella vaginalis, and Candidaalbicans. A NAAT for T vaginalis (APTIMA;GenProbe, San Diego, CA) is availableand licensed for use with female cervicalor vaginal swab, urine, and PreservCytSolution specimens. A routine Papanico-laou test should not be used to diagnoseT vaginalis infection because of poorsensitivity and specificity.6 The T vaginalisNAAT has also demonstrated superiorsensitivity for trichomonas diagnosis inmen, but it is not licensed for malespecimens.64,72 Laboratories that havemet CLIA and other regulatory require-ments and validated their T vaginalisNAAT performance on male specimensmay perform this test.6,34

Disease-Specific Benefits and Risksof Screening

Benefits of routine T vaginalis screeninghave not been established. The potentialbenefits of screening high-risk individuals

for T vaginalis are to identify infectionsand initiate treatment of individuals andtheir partner(s).6

Clinical Considerations

Rescreening for T vaginalis at 3 monthsafter treatment can be considered forfemales, especially HIV-infected females.73

Studies that address this rescreeningquestion for males are not in theliterature.

SYPHILIS

Importance

Syphilis, nearly eliminated at the startof the new millennium, has reemergedas a public health threat, primarilyamong MSM. CDC data demonstrate asignificant increase in syphilis amongyoung non-Hispanic black MSM.8 During2008–2012, rates for males increasedmost significantly among 20- to 24-year-olds. In 2006, the highest reportedsyphilis rates were among men aged35 to 39 years; now rates are highestamong 20- to 24-year-olds. In 2012,syphilis rates among females decreasedoverall compared with 2010, althoughrates remain highest among femalesaged 20 to 24 years. In 2012, the primaryand secondary syphilis rate male-to-female ratio was 10.3:1.8 In 2012, 75%of primary and secondary syphilis casesin 49 states and the District of Columbiathat provided information about genderof sex partners were among MSM.8

Syphilis is a treatable systemic STIcaused by the spirochete Treponemapallidum. T pallidum is transmittedby exposure to the organism, mostcommonly through sexual contactwith infected lesions, such as chan-cres, or in the blood of a pregnantwoman through the placenta to thefetus. The most serious complicationsof untreated syphilis are neurosyphilisin the adult and congenital syphilis inthe offspring of the pregnant female.Congenital syphilis causes a range of

multisystem problems in affected infants,including intrauterine death.25

Background

The USPSTF recommends syphilis screen-ing for individuals of both genders whoat increased risk of syphilis infection,such as MSM, adults in corrections fa-cilities, commercial sex workers, peoplewho exchange sex for drugs, contactsof people with infectious syphilis, andpregnant females at the first prenatalvisit.4,5 Universal syphilis screening isnot recommended for nonpregnantfemales or heterosexual males.6 Pro-viders should consult with their localhealth department regarding localsyphilis prevalence and epidemiology,which may influence who they shouldscreen beyond pregnant adolescentsand adolescent MSM.6,73 The CDCrecommends that a syphilis serologicscreening test be performed at leastannually for sexually active MSM.6

Laboratory Testing

Syphilis serologic tests are available toscreen for syphilis. A single positiveserologic syphilis test result is notdiagnostic.6,34 A diagnosis of syphilisrequires both treponemal and non-treponemal test results, along with acomprehensive clinical evaluation.6,34

In the United States, the traditionalsyphilis laboratory screening strategyis to perform a nontreponemal test,such as a rapid plasma reagin orVenereal Disease Research Laboratorytest, followed by a treponemal test,such as a T pallidum particle aggluti-nation (TP-PA), enzyme immunoassay,or chemiluminescent immunoassay forconfirmation. Alternatively, some clini-cal laboratories offer the reverse se-quence syphilis screening algorithmwith treponemal enzyme immunoassayor chemiluminescent immunoassayand confirm active disease with quan-titative nontreponemal tests.8,34 Addi-tional details on this syphilis testing

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algorithm are available from the Asso-ciation of Public Health Laboratories.6,25,74

Disease-Specific Benefits and Risksof Screening

Benefits of syphilis detection and treat-ment include the elimination of a po-tentially serious multisystem diseaseand prevention of cases of congenitalsyphilis. Syphilis screening can producefalse-positive test results, which requirefurther evaluation.

Clinical Considerations

A recent evidence-based review sup-ports syphilis screening and treatmentduring pregnancy to prevent congenitalsyphilis.75 People who have symptom-atic syphilis might seek treatment ofnew onset of genital ulcers, lymph-adenopathy or cutaneous or mucosalrashes, hair loss, or neurologic symp-toms consistent with syphilis6,25 andshould be tested for it. Follow-up test-ing is critical to confirm treatment ef-fectiveness.6

CLINICAL IMPLICATIONS ANDCONCLUSIONS

Female and male adolescents andyoung adults have high STI prevalencerates compared with other age groups.Certain adolescent populations beara higher STI burden, such as youthof color and MSM.8 A comprehensivesexual history sensitive to ethnic, racial,and cultural factors, including thoseof sexual minority youth, and a sexualbehavior risk assessment (vaginal,oral, and anal sex) should guide sitesof specimen collection on the basisof sexual behavior. Clinicians shouldinquire about same- and opposite-gender sexual partners, regardlessof reported sexual orientation. Thereare few available national data re-garding STIs in transgender youth,although older transgender pop-ulations are at high risk of STIs, in-cluding HIV.76,77

Detection of infection creates theopportunity to treat asymptomaticdisease, prevent adverse sequelae,prevent further transmission to oth-ers, identify likely infected partnersfor testing and treatment, and reducethe burden of disease. Risks associatedwith screening include false-positiveresults, especially in low-prevalencepopulations, and false-negative results,which may leave diseases undetectedand untreated. A positive screeningresult for any STI may be associatedwith self-blame and stigma for someindividuals, which may have emo-tional, behavioral, and relationshiprepercussions.78–81 The presence ofany STI puts an individual at greaterrisk of other STIs, and an evaluationfor other STIs, including HIV should beconsidered. Pediatricians can take anactive role in reducing disease preva-lence and adverse sequelae by identify-ing and treating undiagnosed infectionsin addition to prevention counseling,promotion of condom use and safe sexpractices, rescreening infected patientsafter treatment, and offering expeditedpartner therapy, where legally permis-sible and recommended,82,83 to preventnew and recurrent infections.84

RECOMMENDATIONS

The American Academy of Pediatrics(AAP) recommends the following:

1. Routine laboratory screening fornonviral STIs as per the followingpublished screening recommenda-tions for sexually active adolescents.The following screening recommen-dations summarize published federalagency and medical professionalorganizations’ clinical guidance forall sexually active adolescents:

a. Chlamydia

i. Routinely screen all sexuallyactive female adolescents andyoung adults (≤25 years) forC trachomatis annually.

ii. Routinely screen sexuallyactive adolescent and youngadult MSM for rectal andurethral chlamydia annuallyif they engage in receptiveanal or insertive intercourse,respectively. Screen every 3 to6 months if high risk becauseof multiple or anonymouspartners, sex in conjunctionwith illicit drug use, or hav-ing sex partners who partic-ipate in these activities.

iii. Screen adolescents and youngadults exposed to chlamydiain the past 60 days from aninfected partner.

iv. Consider screening sexuallyactive males annually in set-tings with high prevalencerates, such as jails or juve-nile corrections facilities, na-tional job training programs,STD clinics, high school clin-ics, and adolescent clinicsfor patients who have a his-tory of multiple partners.

b. Gonorrhea

i. Routinely screen all sexuallyactive female adolescentsand young adults (<25 years)for N gonorrheae annually.

ii. Routinely screen sexuallyactive adolescent and youngadult MSM for pharyngeal,rectal, and urethral gonor-rhea infection annually if en-gaging in receptive oral oranal intercourse or insertive in-tercourse, respectively. Screenevery 3 to 6 months if highrisk because of multiple oranonymous partners, sex inconjunction with illicit druguse, or having sex partnerswho participate in these ac-tivities.

iii. Screen adolescents and youngadults exposed to gonorrhea

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in the past 60 days from aninfected partner.

iv. Consider screening othersexually active and youngadult males annually onthe basis of individualand population-based riskfactors, as discussed in thebody of the text. For informa-tion on local prevalencerates, contact the local orstate health departments.CDC gonorrhea surveillancedata at state and county lev-els are available at www.cdc.gov/std/stats/default.htm.

c. Trichomoniasis

Routine T vaginalis screening ofasymptomatic adolescents is notrecommended. However, individualand population-based risk factors,including new or multiple partners,a history of STIs, exchanging sex forpayment, or injecting drugs, mayput females at higher risk of infec-tion, and they may require a morethorough STI evaluation, includingscreening for T vaginalis.d. Syphilis

The routine screening of nonpreg-nant, heterosexual adolescents isnot recommended. However, screen-ing is recommended for all sexu-ally active adolescent and youngadult MSM annually or every 3 to 6

months if high risk and can be con-sidered for youth whose behaviorsput them at higher risk. Providersshould consult with their localhealth department regarding localsyphilis prevalence and associatedrisks that may influence practicedecisions.

2. Rescreen all adolescents infectedwith chlamydia or gonorrhea 3months after treatment, regard-less of whether they believe thattheir sex partners were treated.Providers should consider rescreen-ing females previously diagnosedwith trichomoniasis 3 months aftertreatment. If retesting at 3 monthsis not possible, retest wheneverpatients next present for healthcare services in the 12 months afterinitial treatment.

3. Develop clinical procedures usingprepared resources to incorporateSTI risk assessments, screeningand treatment, and preventioncounseling into routine health carefor sexually active adolescents, whichinclude the following:

a. Providing education and train-ing opportunities to staff onprocedures and related issues,including consent, confidential-ity, and billing.

b. Developing competence with non-invasive NAAT screening.

4. Advocate to minimize barriers toSTI screening without breaches ofconfidentiality and to minimize

other barriers, including accessand stigma.

LEAD AUTHORPamela J. Murray, MD, MHP, FAAP

COMMITTEE ON ADOLESCENCE, 2011–2012Paula K. Braverman, MD, FAAP, ChairpersonWilliam P. Adelman, MD, FAAPCora C. Breuner, MD, MPH, FAAPDavid A. Levine, MD, FAAPArik V. Marcell, MD, FAAPPamela J. Murray, MD, MPH, FAAPRebecca F. O’Brien, MD, FAAP

LIAISONSLoretta E. Gavin, PhD, MPH – Centers for DiseaseControl and PreventionRachel J. Miller, MD – American College ofObstetricians and GynecologistsHatim A. Omar, MD, FAAP – Section on Adoles-cent HealthJorge L. Pinzon, MD, FAAP – Canadian PediatricSocietyBenjamin Shain, MD, PhD – American Academyof Child and Adolescent Psychiatry

STAFFKaren SmithMark Del Monte, JD

SOCIETY FOR ADOLESCENT HEALTHAND MEDICINE

LEAD AUTHORGale R. Burstein, MD, MPH, FAAP

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2. US Preventive Services Task Force.Screening for chlamydial infection: U.S.Preventive Services Task Force recom-mendation statement. Ann Intern Med.2007;147(2):128–134

3. US Preventive Services Task Force.Screening for gonorrhea: recommen-dation statement. Ann Fam Med . 2005;3(3):263–267

4. US Preventive Services Task Force.Screening for syphilis infection in preg-nancy 2009. 2011. Available at: http://www.uspreventiveservicestaskforce.org/uspstf/uspssyphpg.htm. Accessed January 22, 2014

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