Infectious Diseases Associated With Child Abuse

Sexual abuse is the persuasion or coercion of a child to engage in sexually explicit conduct. In 2018, sexual abuse accounted for 7% of the 677,529 children in the US found to be either abused or neglected. It is estimated that the lifetime prevalence of sexual abuse and sexual assault may be as high as 26.6% and 5.1% for 17-year-old females and males, respectively. Most perpetrators of child sexual abuse are adult male caregivers. Federally mandated reporting laws require that all healthcare workers report cases of suspected sexual abuse to child protective service agencies.

Medical Evaluation

In most cases of sexual abuse, the diagnosis is based on the child’s statements; rarely are physical residuals present from the abuse. The following also can be used to confirm the diagnosis: sexually reactive behaviors; penetrating genital trauma without a history of unintentional genital trauma; the presence of seminal products in a child; pregnancy; or the presence of a sexually transmitted infection (STI) (e.g., Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum, Trichomonas vaginalis ) beyond the incubation period of vertical transmission.

The decision to perform screening tests for STIs in pediatric victims of sexual abuse depends on the type of abusive exposure, the regional prevalence of STIs in the adult population, previous consensual sexual activity (in adolescents), and for prepubertal children, the presence of genital symptoms or an abnormal genital examination. Among children evaluated for abuse, the prevalence of STIs is low, and this can affect the positive predictive value of the tests used. Girardet and colleagues found an overall prevalence of STIs of 8.2% in girls (24.5% of girls with vaginal discharge and 6.3% of those without) and 0% in boys with a history of sexual abuse. The presence of one STI in any child or adolescent should prompt an evaluation to exclude other STIs. Beyond the perinatal period, during which transmission from the genital tract of an infected mother can occur, these infections usually are acquired from abusive contact.

Infectious Agents

Neisseria gonorrhoeae and Chlamydia trachomatis

The prevalence rates for N. gonorrhoeae and C. trachomatis range from 0.7% to 3.7% in prepubertal children who have been sexually abused. ^, Most children with such infections are girls with genital complaints (e.g., vaginal discharge) or with abnormal genital examinations. ^, ^, For this reason, the use of routine screening tests for N. gonorrhoeae and C. trachomatis in otherwise asymptomatic prepubertal girls after sexual abuse is not recommended. ^, Up to 14% of adolescent female victims of sexual abuse have an STI. ^, This prevalence is higher than in a nonabused, sexually active, adolescent population.

The use of nucleic acid amplification tests (NAATs) in children and adolescents who have been sexually abused has not been extensively studied. Using NAATs can be beneficial in young children because less biologic sample is required, the specimen is less susceptible to environmental changes, and a urine specimen can be used. However, caveats to using NAATs exist. Even with their high sensitivity (97%) and specificity (99%), NAATs may have low positive predictive values in prepubertal children because of the low prevalence of N. gonorrhoeae and C. trachomatis in this population. Falsely positive NAATs in prepubertal children could erroneously lead to a diagnosis of sexual abuse. ^, If NAATs are used, specimens from tests with positive results should be maintained for additional confirmatory testing ( Fig. 54.1 ). ^, NAATs may be used on extragenital samples (i.e. pharyngeal, conjunctival) to exclude infection.

FIGURE 54.1, Algorithm for Neisseria gonorrhoeae and Chlamydia trachomatis testing in prepubertal and pubertal children. NAAT, nucleic acid amplification test.

Several studies have evaluated the use of NAATs in children who have been sexually abused. Matthews-Greer and colleagues found that polymerase chain reaction (PCR) and culture were equivalent in the detection of C. trachomatis. Kellogg and associates found that although agreement among ligase chain reaction (LCR), PCR, and culture for N. gonorrhoeae was poor, there was 84% agreement for urine and vaginal PCR for C. trachomatis. These investigators concluded that urine PCR can be substituted for vaginal PCR for the detection of C. trachomatis in children and adolescents evaluated for sexual abuse. Neither of these studies confirmed a positive test result by using a second NAAT targeting a different genomic sequence.

Black and colleagues compared urine and genital swabs for N. gonorrhoeae and C. trachomatis by using PCR confirmed by a second PCR test using an alternate target. The sensitivity of urine NAATs relative to vaginal culture was 100% and resulted in a 33% increase in detection of infection. These results suggest that NAATs performed on urine, with confirmation, may replace culture diagnosis of N. gonorrhoeae and C. trachomatis in children who have been sexually abused.

Empiric antibiotic treatment for N. gonorrhoeae or C. trachomatis generally is not indicated for asymptomatic prepubertal girls who have been sexually abused. If NAATs are used, any positive test result should be confirmed by a culture or a second NAAT that targets a different genomic sequence. Empiric antibiotics should be prescribed only if the confirmatory test result is positive ( Fig. 54.1 ). One could consider empirically treating sexually abused adolescents after cultures or NAATs have been obtained because the prevalence of infection is higher and false-positive test results are less common.

Azithromycin and doxycycline are the antibiotics of choice for adolescents warranting postexposure prophylaxis (PEP) against C. trachomatis . Ceftriaxone combined with azithromycin is indicated for prophylaxis against N. gonorrhoeae ; cefixime is no longer considered first line therapy. ^,

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