During routine and incidental medical visits, health care professionals should be asking young patients open-ended questions to elicit information about sexual history, STIs, and associated risks. Because youth are not frequent users of the health care system, any visit is an opportunity for STI assessment. Table 1 shows a list of behavioural and other factors associated with increasing risk for STIs. Test types and specimen requirements should be discussed with the local laboratory before collection Tables 2 and 3.
Local public health units can assist in this process. Chlamydia: All sexually active youth younger than 25 years of age should be offered screening at least annually, with more frequent screening offered to individuals with additional STI risk factors Table 1. After treatment, screening should be repeated every six months if the risk of reinfection persists.
First-catch void urine, vaginal including self-collected , endocervical or urethral specimens are all suitable for NAAT testing. A noninvasive screening specimen e. A culture using cervical or urethral specimens remains the test of choice for medico-legal purposes but is a less sensitive test than NAAT. Consultation with your local laboratory is advised. Test-of-cure TOC using NAAT three to four weeks after completion of therapy is recommended in adolescents when compliance is uncertain, an alternative treatment was used, re-exposure is likely, or the adolescent is pregnant.
Gonorrhea: Screening should occur in the same groups as for chlamydial disease. A first-catch urine sample or self-collected vaginal swab is recommended for screening asymptomatic individuals, particularly when urethral and cervical samples are not practical.
Pharyngeal specimens should be obtained when there is a history of oral sex, and rectal samples if there is a history of receptive anal intercourse. Cultures provide the best opportunity for determining the resistance pattern of an isolate. Culture with susceptibility testing is particularly important given the emerging antimicrobial resistance of N gonorrhoeae , and should always be performed in the following circumstances, if possible: in sexual assault cases; when treatment failure is presumed; in evaluating pelvic inflammatory disease; in symptomatic MSM; and when infection is believed to have been acquired overseas or in an area of recognized antimicrobial resistance.
As the most sensitive testing method, NATT is often used in place of culture to detect gonorrhea although it does not provide antibiotic susceptibility information. NAAT is validated for urine, vaginal, urethral and cervical samples. NAATs validated for these sites can also detect rectal and oropharyngeal infections, but are currently not licensed in Canada for this purpose.
However, clinicians should consult regularly with their regional laboratories because recommendations change over time. In light of the rising rates of gonococcal resistance to cephalosporins and azithromycin and resulting treatment failures, combination therapy for gonorrhea is recommended. TOC by culture performed three to seven days post-treatment is preferred. If a culture cannot be obtained, NAAT testing may be performed two to three weeks post-treatment because NAAT remains positive for longer than a culture following adequate therapy.
Repeat screening using NAAT six months after completing therapy is recommended for individuals at risk for reinfection. NAAT is the most sensitive and specific test. For pharyngeal and rectal specimens, NAAT may be considered; discuss with testing laboratory.
Serology remains the usual diagnostic test unless the patient has lesions compatible with syphilis Treponemal-specific screening assays e.
Primary, secondary, early latent infection: Repeat serology at 1, 3, 6, and 12 months after treatment Late latent infection: Repeat serology 12 and 24 months after treatment Neurosyphilis: Repeat 6, 12, and 24 months after treatment.
Serology is the key diagnostic test. A screening assay is initially performed and, if positive, a Western Blot or other confirmatory test is automatically performed.
Screen all patients seeking evaluation and treatment for STIs Ensure appropriate counselling. Antibodies may be detected at 3 weeks with fourth-generation HIV antibody screening tests, but can take up to 6 months with older tests. Hepatitis C. Anogenital lumps. Anogenital ulcers. Skin rash and lesions — general. Sex-associated diarrhoea. Anorectal syndromes. Genital dermatology. Pelvic inflammatory diseases PID. Vaginal discharge. Urethritis — penile. Aboriginal and Torres Strait Islander People.
Sex workers. People in custodial settings. Adult sexual assault. People who use drugs. Regional and remote populations. In patients with suspected primary syphilis or late latent syphilis, the NTT may be non-reactive in which case it is appropriate to add a treponemal test to the initial screen, or in the case of primary syphilis, to repeat the NTT after weeks.
In regions experiencing outbreaks of syphilis it may be appropriate to screen at baseline with both non-treponemal and treponemal tests. The revised guidelines provide a new guide for the interpretation of serological tests for syphilis Figure V. Benzathine penicillin G is still the treatment of choice. Caribbean , pinta e. To be effective, treatment needs to be started as early as possible during the development of a recurrent lesion - preferably fewer than 6 hours famciclovir [B-I] to 12 hours valacyclovir [B-I] after the first symptoms appear.
Suppressive therapy is intended for patients with frequently recurring genital herpes, generally for those with recurrences at least every 2 months or 6 times per year.
For patients with fewer recurrences, episodic therapy is recommended Table VI. For pregnant women, treatment with acyclovir has been shown to be effective in reducing recurrences, asymptomatic shedding, and the need for cesarean section, but does not completely eliminate maternal-to-child transmission of herpes simplex virus HSV.
Table VI. All treatments are associated with local skin reactions which can be managed by decreasing the intensity of the treatment. Efficacy rates are difficult to determine due to lack of uniformity in clinical trials. This product should not be used by pregnant women or by women who are not using a highly effective and reliable method of contraception. In addition these treatments should not be used for cervical, meatal, vaginal or anal condyloma. Imiquimod acts as an immune modulator.
It is not considered to be safe for use during pregnancy and should not be used by pregnant women. For HPV, all treatments of external genital warts are associated with skin reactions which can be managed by decreasing the intensity of the treatment. Efficacy rates are hard to determine due to lack of uniformity in the clinical trials. Table VII. Apply to warts every 12 hours for 3 consecutive days of each week, avoiding surrounding skin. The cycle can be repeated for up to 6 weeks with the total dose per day not to exceed 0.
Leave at least one day between applications. Wash off after hours [A-I]. Table VIII. Cefixime is no longer a recommended treatment.
This article outlines only a small proportion of the recommendations outlined in the Canadian Guidelines on Sexually Transmitted Infections Edition. References 1. Public Health Agency of Canada.
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