Sexually Transmitted Infections

Adolescents and young adults are disproportionately affected by sexually transmitted infections (STIs), particularly infections with gonorrhea and chlamydia. Both biology and sexual practices play a role. During adolescence, the cervix is more likely to develop cervical ectopy, consisting of columnar cells, which are more susceptible to STIs, rather than squamous cells. Sexual practices that increase risk include condom negotiation and potential for multiple sex partners. Barriers to health care, including concerns about confidentiality and lack of access, contribute to delays in diagnosis and treatment. The CDC’s 2021 Sexually Transmitted Infections Treatment Guidelines provide a comprehensive review of STIs and the STI Treatment (Tx) Guide Mobile App offers access to streamlined STI prevention, diagnostic, and treatment recommendations.

Reportable diseases: Nationally reportable STIs include chlamydia, chancroid, gonorrhea, hepatitis B virus, hepatitis C virus, HIV, and syphilis. Check with your local health department for specifics regarding reporting methods and policies.

In this section, we provide an overview of recommendations for prevention, screening, and treatment of STIs in youth.

• Prevention

• Screening

• Treatment

Prevention

Counseling: The American Academy of Pediatrics (AAP) and the Society for Adolescent Health and Medicine (SAHM) advocate policies that support adolescent consent and confidentiality regarding sexual and reproductive health. Minors can provide consent for testing and treatment of STIs in all 50 U.S. states and the District of Columbia.

The United States Preventive Services Task Force (USPSTF) has found no evidence that sexual health counseling is associated with increased sexual activity among adolescents. Discussions with adolescent and young adult patients about STIs should include the following:

• modes of transmission

• symptoms

• risk-reducing behaviors

• encouragement of “universal precautions” (e.g., barrier protection with all partners)

• routine testing since many patients with STIs are asymptomatic

Vaccination: Receipt of vaccines reduce the risk of some STIs, including human papilloma virus (HPV), hepatitis B virus, and hepatitis A virus. Vaccination status should be reviewed, with catch-up vaccines provided as needed. Parents may express concern that receipt of HPV vaccine will increase sexual activity. However, in one retrospective cohort study, HPV vaccination among 11- to 12-year-old girls was not associated with increased sexual activity-related outcome rates (including pregnancy or STIs testing and diagnosis or contraceptive counseling) after 3 years of follow-up.

Behaviors that lower risk for STI transmission include:

• abstinence

• delay of onset of sexual intercourse

• consistent and correct condom use (see Contraception in this rotation guide)

• minimizing the number of sexual partners

Screening

Asymptomatic Patients

The table below provides general guidelines (primarily from the AAP and USPSTF) for routine STI screening in asymptomatic patients. Most sexually active adolescents in the U.S. do not undergo sufficient STI testing and miss opportunities for treatment and prevention of infection. Routine screening for the following infections is not recommended in asymptomatic patients:

• bacterial vaginosis

• herpes simplex virus

• hepatitis A virus

• hepatitis B virus

Symptomatic Patients

Symptomatic patients should be tested as indicated by history and physical examination. For nucleic acid amplification tests (NAATs), the CDC recommends vaginal swabs from women and first catch urine from men. Availability of tests may vary, therefore check with local labs for the most appropriate type of test.

Treatment

Treatment guidelines are frequently updated. See the CDC’s STI Treatment Guidelines for the most updated information, detailed recommendations for high-risk patient populations, appropriate dosing, and alternative treatment regimens (e.g., medication allergy).

Always complete additional STI testing after a positive screen. For example, if a sex assigned at birth female has a positive chlamydia screen, make sure they have been tested for gonorrhea, trichomonas, HIV, and syphilis, and consider testing for hepatitis based on individual risk factors.

Consider empiric treatment while waiting for test results if a patient is symptomatic on exam, if there is a high suspicion for an STI, or if a return visit for treatment is unlikely or challenging. In patients presenting with clinical features most consistent with uncomplicated chlamydia or gonorrhea, such as urethritis and cervicitis, empiric treatment consists of ceftriaxone and doxycycline. Refer to the CDC’s STI Treatment Guidelines for appropriate empiric treatment for other clinical presentations.

First-line treatments for STIs following a positive screening test in nonpregnant adolescents and young adults:

Chlamydia trachomatis

• Assess for pelvic inflammatory disease (including assessment for cervical motion tenderness) in sex assigned at birth females and assess for epididymitis or urethritis in sex assigned at birth males because these conditions may change management.

• Treatment of uncomplicated infection: oral doxycycline twice daily for 7 days

  • Doxycycline has been associated with less treatment failure than single-dose azithromycin, but the benefits of directly observed therapy should be considered.

• Advise patients to abstain from sexual activity for 7 days after treatment and their partners’ treatment.

• Perform a test of reinfection in 3 months. Wait at least 4 weeks after treatment to perform a test of reinfection.

Neisseria gonorrhoeae

• Assess for pelvic inflammatory disease (including cervical motion tenderness) in sex assigned at birth females and assess for epididymitis or urethritis in sex assigned at birth males.

• Treatment:

  • if chlamydia has been excluded: intramuscular (IM) ceftriaxone one dose

  • if chlamydia has not been excluded: oral doxycycline (twice daily for 7 days); oral azithromycin is also acceptable (the CDC favors doxycycline because of increased efficacy against rectal infection)

    • chlamydia coinfection is presumed in the absence of a negative test

    • antibiotic choice depends on the patient’s ability to complete treatment

• Advise patients to abstain from sexual activity for 7 days after treatment and their partners’ treatment.

• Perform a test of reinfection in 3 months. Wait at least 4 weeks after treatment to test for reinfection.

Trichomonas vaginalis

• Assess for pelvic inflammatory disease (including assessment for cervical motion tenderness) in sex assigned at birth females and assess for possible epididymitis or urethritis in sex assigned at birth males because these conditions may change management.

• Treatment: oral metronidazole (twice daily for 7 days for persons assigned female sex at birth; one dose for persons assigned male sex at birth)

• Advise patients to abstain from sex until they and their partners are completely treated and symptoms have resolved.

• Perform a test of reinfection in 3 months. Wait at least 4 weeks after treatment to test for reinfection to avoid a positive result from the initial infection.

Syphilis (primary, secondary, or early latent syphilis [<1 year])

• Treatment: IM benzathine penicillin G

• Perform a nontreponemal test of treatment failure and reinfection at 6 and 12 months. For those with latent syphilis, an additional nontreponemal test should be performed at 24 months.

HIV: If new diagnosis, arrange age-appropriate HIV specialty care.

Expedited Partner Therapy

The SAHM recommends that providers use expedited partner therapy (EPT) for STI care for patients exposed in the last 60 days to partners with known chlamydia or gonorrhea infections when in-person evaluation and treatment is impractical or unsuccessful.

Chlamydia trachomatis: The CDC recommends EPT for chlamydia treatment in heterosexual couples. Providers most often give patients a prescription for their sexual partner(s) or contact(s) within 60 days of diagnosis. Treatment is azithromycin. Refer to the CDC STI Treatment Guidelines for appropriate dosing.

Neisseria gonorrhoeae: The CDC recommends EPT where it is permissible by state law and the partner is unable or unlikely to seek treatment. The partner may be treated with a single oral dose of cefixime if concurrent chlamydial infection has been excluded. Otherwise, the partner can be treated with a single dose of oral cefixime plus oral doxycycline. See the CDC’s recommendations for dosing information.

Trichomonas vaginalis: EPT may be considered for treatment of trichomonas infection in sexual partners where it is permissible by state law. However, partner intervention has not been consistently shown to reduce reinfection rates.

HIV Prophylaxis

• Preexposure prophylaxis (PrEP): PrEP should be considered to help prevent HIV in high-risk patients, including youth with multiple partners, young men who have sex with men, youth who inject drugs, youth who are sexually exploited or engage in sex work, and young transgender women who have sex with men. Treatment for otherwise healthy adults and adolescents includes daily treatment with a two-drug regimen (tenofovir disoproxil fumarate with emtricitabine) as prophylaxis against HIV. Patients require follow-up for medication and lab monitoring. Refer to the CDC PrEP guidelines for further guidance.

• Nonoccupational postexposure prophylaxis (nPEP): nPEP should be considered after exposure to body fluids that might contain HIV outside of a health care setting, including through sexual activity or injection drug use. Treatment for otherwise healthy adults and adolescents should be initiated within 72 hours of exposure and typically includes a 28-day course of a three-drug regimen. Refer to the CDC nPEP guidelines for further guidance.

Note: Baseline laboratory testing should be obtained before initiation of PrEP and nPEP.