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Moderate to severe injuries or unstable

Acute psychological trauma

Safety of child outside the hospital cannot be guaranteed.

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

As clinically indicated

Patient Monitoring

Monitor injury healing over time.

Follow up assessment for STIs that may not present acutely (e.g., HPV).

PROGNOSIS

Without intervention, child abuse is often a chronic and escalating phenomenon.

COMPLICATIONS

Sexual, physical, and emotional abuse in childhood are risk factors for poorer adult mental and physical health. Includes maltreatment and depressive disorder, drug use, suicide attempts, and risky sexual behaviors.

REFERENCES

1.Children’s Bureau. Child maltreatment 2015. http://www.acf.hhs.gov/programs/cb/resource/child-maltreatment-2015. Accessed November 14, 2017.

2.Sheets LK, Leach ME, Koszewski IJ, et al. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics. 2013;131(4):701–707.

3.Jackson AM, Rucker A, Hinds T, et al. Let the record speak: medicolegal documentation in cases of child maltreatment. Clin Ped Emerg Med. 2006;7(3):181–185.

ADDITIONALREADING

American Academy of Pediatrics. Child abuse and neglect. https://www.aap.org/en-us/advocacy-and-policy/aap-health- initiatives/resilience/Pages/Child-Abuse-and-Neglect.aspx. Accessed

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November 14, 2017.

Tilak GS, Pollock AN. Missed opportunities in fatal child abuse. Pediatr Emerg Care. 2013;29(5):685–687.

CODES

ICD10

T74.12XAChild physical abuse, confirmed, initial encounter

T74.32XAChild psychological abuse, confirmed, initial encounter T74.22XAChild sexual abuse, confirmed, initial encounter

CLINICALPEARLS

When a bruise is present, it should be considered as potentially sentinel for physical abuse if no plausible explanation is given.

High index of suspicion is important for prevention and recognition of abuse. Vague complaints and repeated visits to the office and/or ED should prompt further investigation.

Neglect is the most common and lethal form of abuse and should be aggressively reported.

Detailed exam with documentation is key.

Mandated reporting is required for suspected child abuse and neglect; the physician does not have to prove abuse before reporting.

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CHLAMYDIAINFECTION (SEXUALLY TRANSMITTED)

Casandra Cashman, MD, FAAFP

BASICS

DESCRIPTION

Chlamydia trachomatis is an intracellular membrane-bound prokaryotic organism. Chlamydia derives from the Greek word for “cloak.”

Chlamydia is the most common bacterial sexually transmitted infection (STI) in the United States (1)[A].

Transmitted through vaginal, anal, or oral sex; transmitted vertically during vaginal delivery

Most cases are asymptomatic, especially in females. Untreated disease can lead to pelvic inflammatory disease (PID), ectopic pregnancy, and infertility.

System(s) affected: reproductive

Pregnancy Considerations

Perinatal acquisition may result in neonatal pneumonia and/or conjunctivitis.

EPIDEMIOLOGY

Incidence

Mandatory reporting started in 1985; steady increase in incidence has been noted since.

1.5 million reported cases in 2014. Increasing incidence reflects broader screening, improved testing, and better reporting (rather than a large increase in disease burden). A6% increase in the United States was noted from 2014 to 2015 (1)[A].

Swedish new variant C. trachomatis (nvCT) first reported in 2006; often produces false-negative tests; largely confined to Nordic countries

Prevalence

479/100,000 in United States for 2015 (1)[A]

Young females, ethnic minorities most affected Highest prevalence ages 20 to 24 years

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Predominant sex: females > males. Females have 2 times higher reported incidence and prevalence than males. This likely reflects increased testing in females. Increasing use of highly sensitive nucleic acid amplification test (NAAT) urine screening may increase identification in males.

Infection rates 6 times higher in blacks than whites. Rates are higher in larger urban areas.

Highest male prevalence in heterosexual adolescents

Estimated to affect ~2% of young sexually active individuals in the United States

ETIOLOGYAND PATHOPHYSIOLOGY

C. trachomatis serotypes D to K associated with genital tract infections. Chlamydia is an obligate intracellular organism. Chlamydia has biphasic life cycle. Exists extracellularly as elementary body (EB) that is metabolically inactive and infectious. Once taken up by host cell (typically columnar epithelium of the genital tract), the EB prevents lysosomal phagocytosis and transforms to reticulate body (RB) which requires energy from host cell to synthesize RNA, DNA, and proteins. After taking up residence in host cells, EBs are released to infect neighboring cells or spread through sexual contact.

RISK FACTORS

Risk correlates with:

Number of lifetime sexual partners and number of concurrent sexual partners

No use of barrier contraception during intercourse

Black/Hispanic/Native American and Alaskan Native ethnicity

GENERALPREVENTION

Screen populations with annual prevalence >5% (1)[A].

Screen if new or >1 sex partner in past 6 months; attending an adolescent clinic, family-planning clinic, STD or abortion clinic, jail or other detention center clinic. Screen if rectal pain, discharge or tenesmus, testicular pain; test if urethral or cervical discharge.

All sexually active women ≤25 years of age should be screened at least yearly. Repeat testing in ~3 months is recommended for those who screen positive because reinfection rate is high regardless of whether the sexual partner is treated (2)[A].

Consider screening sexually active men ≤25 years of age, particularly in highrisk populations.

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Screen men who have sex with men annually using genital and extragenital screening (3)[A].

NAAT is the preferred screening test in all circumstances except child sexual abuse involving boys or rectal/oropharyngeal testing in prepubescent girls. In these cases, culture and susceptibility testing is preferred (3)[A].

Acceptable to screen women for chlamydia on same day as intrauterine device insertion—treat if positive (no need to remove IUD in this circumstance) (4) [B].

COMMONLYASSOCIATED CONDITIONS

Females

–PID: ~10% of infected patients will develop PID within 12 months if untreated.

–Infertility, ectopic pregnancy

–Chronic pelvic pain

–Urethral syndrome (dysuria, frequency, and pyuria in the absence of infection)

–Arthritis (less common)

–Spontaneous abortion

Males

–Epididymitis and nongonococcal urethritis

–Reiter syndrome (HLA-B27)

–Proctitis

Neonates

–Inclusion conjunctivitis (occurs in ~40% of exposed neonates)

–Otitis media

–Pneumonia

–Pharyngitis

Diseases caused by other chlamydial species

–Lymphogranuloma venereum (LGV): C. trachomatis serotypes L1 to L3

–Trachoma: C. trachomatis serotypes Ato C

DIAGNOSIS

Many patients are asymptomatic.

Pregnancy Considerations

Test all patients at first prenatal visit.

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Obtain test of cure 3 to 4 weeks after treatment for pregnant patients. Test for reinfection in 3 months.

Repeat test in 3rd trimester in high-risk patients (2)[A].

HISTORY

Complete sexual history, including number of sex partners (lifetime and past year), prior history of STIs, use of barrier protection, commercial sex work, oral or anal receptive intercourse, and partner fidelity

In females, the most common symptoms are:

–Mucopurulent vaginal discharge, dysuria (urethral syndrome), bartholinitis, abdominopelvic pain (endometritis, salpingitis/PID), right upper quadrant pain (Fitz-Hugh-Curtis syndrome)

In males, the most common symptoms are:

–Dysuria, urethral discharge (urethritis), scrotal pain (epididymitis), rectal pain or discharge (proctitis), acute arthritis (Reiter syndrome)

PHYSICALEXAM

Men and women: external genitalia (rash, lesions), urethral discharge, inguinal lymphadenopathy, pharyngeal exudate, and perianal lesions

Women: cervix (discharge, motion tenderness), bimanual examination for cervical motion tenderness, uterine, ovarian/adnexal tenderness or mass

LGV (C. trachomatis serovars L1, L2, or L3): Primary lesion is a small papule that may ulcerate at the site of transmission after an incubation period of 3 to 30 days. Unilateral tender lymphadenopathy. With rectal transmission, LGV causes an invasive proctocolitis.

DIFFERENTIALDIAGNOSIS

Neisseria gonorrhoeae: urethritis, proctitis, epididymitis, cervicitis, PID, Bartholin abscess

Mycoplasma or Ureaplasma urealyticum: urethritis, epididymitis, Reiter disease, PID

C. trachomatis (serotypes L1 to L3): LGV, proctitis

Trichomoniasis

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

NAAT: sensitivity >95%; specificity >99% Urine is as sensitive as cervical swab.

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Self-collected vaginal swabs are also effective.

Labs potentially positive for up to 3 weeks after treatment

Test for concurrent gonorrhea, HIV, syphilis; cervical cancer (PAP) screening as clinically indicated

Follow-Up Tests & Special Considerations

See “Patient Monitoring.”

TREATMENT

GENERALMEASURES

Offer concurrent testing for gonorrhea, HIV (after counseling and consent), and possibly syphilis. Ensure cervical cancer screening up to date.

Consider treating gonorrhea empirically.

Test and treat all partners (most recent partner and all partners within the past 60 days).

MEDICATION

First Line

http://www.cdc.gov/std/tg2015/chlamydia.htm

Treatment of chlamydial urethritis, cervicitis (including sexual partners of infected persons)

Azithromycin 1 g PO single dose or

Doxycycline 100 mg PO BID for 7 days First-line PID treatment (outpatient)

–Ceftriaxone 250 mg IM × 1 PLUS doxycycline 100 mg PO for 14 days with or without metronidazole 500 mg PO BID for 14 days or

–Cefoxitin 2 g IM × 1 with probenecid 1 g PO × 1 PLUS doxycycline 100 mg PO for 14 days with or without metronidazole 500 mg PO BID for 14 days

Azithromycin and ceftriaxone may be given simultaneously in the office to treat both chlamydia and gonorrhea. This reduces nonadherence (2)[A].

Asymptomatic rectal chlamydia can be treated with doxycycline 100 mg BID × 7 days. Azithromycin 1 g for 1 day is slightly less effective but can also be used, especially if compliance or medication availability is an issue (5,6)[A].

ALERT

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Use azithromycin with caution in patients with known QT prolongation, hypokalemia, hypomagnesemia, bradycardia, or with concurrent antiarrhythmic use.

Pregnancy Considerations

Tetracyclines (doxycycline) and quinolones (ofloxacin, levofloxacin) are contraindicated in pregnant women.

Consider the following as alternatives:

–Azithromycin 1 g PO or

–Amoxicillin 500 mg PO TID for 7 days (2)[A] or

–Erythromycin base 500 mg PO QID for 7 days

ALERT

Tetracyclines and quinolones are contraindicated in young children:

<45 kg: erythromycin base or ethinyl succinate 500 mg/kg/day PO QID for 14 days

>45 kg but <8 years: azithromycin 1 g PO × 1 day

>8 years: adult regimen

Rule out sexual abuse in children with chlamydia.

Second Line

For chlamydial urethritis/cervicitis

Erythromycin base 500 mg PO QID for 7 days OR erythromycin ethylsuccinate 800 mg PO QID for 7 days

Levofloxacin 500 mg PO daily for 7 days or ofloxacin 300 mg PO BID for 7 days

ADDITIONALTHERAPIES

Patient-delivered partner therapy (PDPT) or expedited partner therapy (EPT): Provide medications or prescriptions to take to sexual partners of persons infected with STIs without clinical assessment.

EPT reduces recurrence more effectively than traditional partner referral.

http://www.cdc.gov/std/ept/legal/

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Inpatient treatment of PID: pregnancy, lack of response or intolerance to oral

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medicines, suspicion of poor compliance, severe clinical illness, pelvic abscess, and possible need for surgical intervention

Otherwise, treat PID as outpatient unless moderately or severely ill.

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Abstain from sexual contact for at least 7 days after treatment (single-dose treatment) or until completion of the full course of other antibiotics.

Patient Monitoring

Test of cure not routinely recommended except in pregnancy. Do not repeat NAAT <3 weeks after testing; may be falsely positive due to nonviable organisms

Test of cure in 3 to 4 weeks in pregnancy as well as test for reinfection in 3 months

Consider rescreening high-risk pregnant women in 3rd trimester even if initial screening negative.

Test for reinfection (not cure) 3 months after treatment or, if not possible then, at next presentation to medical care if within 12 months.

Treat sexual partners.

PATIENT EDUCATION

Safe sexual practices, barrier contraception, abstinence

Complete antibiotic course (patient and partners)

PROGNOSIS

Prognosis is good following therapy.

COMPLICATIONS

Chlamydia infection enhances HIV transmission in both genders.

Females: tubal infertility (most common cause of acquired infertility), tubal (ectopic) pregnancy, chronic pelvic pain

– Annual screening of sexually active women would prevent 61% of chlamydia-related PID.

Males: transient oligospermia and postepididymitis urethral stricture (rare)

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