Pediatric Primary Care Case Studies (118 page)

In deciding which studies to order, the provider needs to know what organisms to look for and the difference in and accuracy of tests.

Epidemiology

Sexually transmitted infections are considered an epidemic in the United States at this time. Their highest rates are among adolescents; almost half of the 19 million new cases yearly occur in teens (CDC, 2007). Young adults ages 15–24 years and young women between the ages of 15 and 19 have the highest rates of
N. gonorrhoeae
and
C. trachomatis
(CDC, 2006a). Youth in detention facilities; male homosexuals; injection drug users; and minorities, especially African Americans, are all at high risk.

Some factors that contribute to this epidemic in teenagers include the increasingly early age and frequency of sexual activity, inconsistent use of contraceptive and protective devices, physiologic characteristics that predispose adolescents to infection, adolescents’ lack of access to and use of health care, and societal influences. The increased use and availability of accurate screening tests for diseases, especially chlamydia, is another factor that may be contributing to the higher reported numbers of STIs.

Chlamydia Trachomatis
and Testing

Chlamydia infection is the most frequently reported bacterial STI, with a rate of 347.8 cases per 100,000 reported in 2006, up 5.6% from 2005 (CDC, 2007). Adolescent females have the highest percentage of these cases. Young women ages 15 to 19 years old account for 37% of the chlamydia infections, and 20-to 24-year-olds represent 36%. Because of the increased incidence in female adolescents, all sexually active young women in this age group should be screened at least annually because chlamydia is frequently asymptomatic. Untreated chlamydia can progress to pelvic inflammatory disease (PID); as many as 40% of women with untreated infections develop PID, and 20% of those may lose their fertility (CDC, 2007).

For sexually active adolescents with possible chlamydia, many family planning clinics use direct immunofluorescent smears. Nucleic acid hybridization tests (DNA probes) and nucleic acid amplification testing (NAAT) are acceptable alternatives for teens, especially in high-prevalence populations. Only NAATs can be done using either a cervical swab or urine and, thus, are the preferable testing method for adolescents (CDC, 2006a). It is important to note, however, that if chlamydia is suspected in younger children, a culture is the only acceptable method to diagnose this agent. Chlamydia in young children may be associated with sexual abuse and must be correctly identified. Therefore, culture results, not DNA detection, must be used.

Gonorrhea and Testing

Gonorrhea is caused by
Neisseria gonorrhoeae
, a nonmotile, gram-negative diplococcus. It is often found along with chlamydia or other STIs. The gonorrhea rate for 2006 was 120.9 cases per 100,000, which is up 5.5% from 2005 and an increase for the second year in a row (CDC, 2007). The highest rate for adolescents occurs in the 15- to 19-year-old group. There are more reported cases of GC in African Americans than whites (18:1). The infection is often asymptomatic, with as many as 80% of young women infected with GC reporting no symptoms (Stamm & McGregor, 2001). Untreated GC can also progress to PID, with the issue of infertility as a possible outcome.

The definitive test for gonorrhea in women is a culture on selective media with determination of penicillin resistance. DNA probes and NAATs are also available for GC testing (Spigarelli & Biro, 2004). NAATs are more reliable with cervical swab testing than urine testing for GC (Shrier, 2005); gram stains of vaginal discharge or cervical secretions are not recommended (CDC, 2006a).

Syphilis and Testing

Syphilis, caused by
Treponema pallidum
, is a motile spirochete with a prevalence rate of 3.3 cases per 100,000 in 2006, an increase of 13.8% from 2005. Although the majority of this increase (11.8%) was in males and primarily in men having sex with men (MSM), the rate for women increased for the second year in a row (from 0.9 per 100,000 to 1.0 in 2006). Furthermore, the rate of congenital syphilis, after being down 12% from 2004 to 2005 to 8.2 per 100,000 live births, went up to 8.5 in 2006 (CDC, 2007).

To test for syphilis, direct visualization with dark-field microscopy or direct immunofluorescent antibody (DFA) provides definitive results. Several serologic nontreponemal tests including the Venereal Disease Research Laboratories (VDRL), rapid plasma reagin (RPR), and the automated reagin test correlate with disease activity. Because they decline after treatment, they are used to monitor disease progression. Treponemal tests such as the fluorescent treponemal antibody absorption (FTA-ABS) and the microhemagglutination test for
Treponema pallidum
(MHA-TP) are confirmatory, but once positive, they usually remain so for years (CDC, 2006a).

HIV and Testing

HIV is another sexually transmitted infection that can occur in persons who engage in unprotected sexual intercourse. Adolescents in the United States are often at risk due to their sexual behaviors. Although the Youth Risk Behavior Survey for 2007 indicated a decrease in those who have ever had sexual intercourse, the decreases have leveled off. Condom use has also leveled off at about 61.5% (CDC, 2008). Thus, adolescents are still at risk for this serious disease.

Usually HIV is diagnosed by tests for antibodies against HIV-1, although some combination tests also detect antibodies against HIV-2. The first step in diagnosing this condition is the use of a sensitive screening test, either the enzyme immunoassay (EIA) or the newer rapid test. The latter test has allowed clinicians to make a significantly accurate presumptive diagnosis of HIV-1 infection within half an hour. Reactive screening tests must then be confirmed by a supplemental test such as the Western blot (WB) or an immunofluorescence assay (IFA) (CDC, 2006a).

All 50 states require most STIs to be reported; however, mandated reporting rules vary from state to state. All 50 states allow adolescents to be evaluated and to receive confidential treatment for STIs, but management of children younger than 13 years old requires coordination between the pediatric provider and child protective authorities.

Laboratory Tests for Leslie

The wet mount of vaginal secretions was checked immediately after the pelvic examination was completed. The results, which included saline for microscopic examination to look for white blood cells (WBCs), clue cells, trichomonads, and bacteria and the 10% potassium hydroxide (KOH) for whiff test and microscopic examination to look for yeast (branching hyphae and spores), were all negative. You also checked a urine specimen for pregnancy and the result was negative.

Specimens were also sent to the laboratory.

   Chlamydia: NAAT on cervical swab

   Gonorrhea: NAAT on cervical swab

Recommended blood work for rapid plasma reagin (RPR) for syphilis and an enzyme immunoassay (EIA) for HIV were declined by Leslie.

Making the Diagnosis

What is your assessment?

First, Leslie has a contraceptive need, which she has expressed and is evident from her sexual history. Second, she also has a possible sexually transmitted infection that, if diagnosed, needs treatment.

Management

   
What will be your plan, given the two diagnoses you have made?

You mentally outline your plan as follows:

•   Contraceptive need.

•   Patient education about oral contraceptive pills (OCPs).

•   Patient education about condom use.

•   Provide an Rx for OCPs.

•   Rule out a sexually transmitted infection: chlamydia, gonorrhea, syphilis, or HIV.

•   Await lab results.

•   Patient education and counseling about safer sex.

Counseling of the Adolescent

The adolescent’s perspectives about sexual activities that are appropriate for them may not match those of the primary care clinician. Teens and young adults are faced with media portrayal of sexuality at a time when they are using role models for their own behaviors. Family and community cultural norms as well as peer group pressures can affect the attitudes and beliefs about sexuality and sexual behaviors that they are developing (American Academy of Pediatrics [AAP], 2001; Brown & Brown, 2006). All these influences need to be considered and addressed when counseling the teen.

Using the answers given by the adolescent in the sexual history will help guide the counseling and education provided to the individual teen. Trust, honesty, mutual respect, an open nonjudgmental attitude, and confidentiality are extremely important to the adolescent (Burgis & Bacon, 2003). It may take several visits for the trust relationship to grow before the adolescent is willing to divulge more private thoughts and behaviors. The clinician’s job is to assure the adolescent of the confidential nature of the relationship and provide opportunities for trust to develop.

Adolescents need to know that they have choices about sexual behaviors that have different outcomes. Adolescents should be counseled that abstinence is the most effective strategy for the prevention of pregnancy, STIs, and HIV/AIDS (American Academy of Family Physicians [AAFP], 2006; AAP, 2001; American College of Obstetricians and Gynecologists [ACOG], 2005). It is a choice to remain abstinent and a choice to become sexually active, not just something that happens, and with that choice comes responsibilities. Open communication and respect for self and partner will lead to choices that include protection from STIs and pregnancy.