Teen Topics

EPT: Use it to reduce STI teen reinfection

By Anita Brakman, MS
Director of Education, Research & Training
Physicians for Reproductive Choice and Health
New York City
and Melanie Gold, DO, FAAP, FACOP
Clinical Professor of Pediatrics
University of Pittsburgh School of Medicine
Staff Physician
University of Pittsburgh Student Health Service

According to the Centers for Disease Control and Prevention, female adolescents have the highest number of cases of gonorrhea and chlamydia in the United States.1 While the overall prevalence for these infections among individuals ages 14-39 are .24% and 2.2% respectively, these rates are .92% and 3.4% for those ages 14-19.2

Adolescents' consistently higher rates of chlamydia and gonorrhea are partially due to high rates of reinfection. Recent studies have found chlamydia reinfection rates as high as 26% within 12 months, and younger patients are most likely to be reinfected, with girls ages 13 and under having reinfection rates as high as 39%.3 While many clinicians instruct patients to return to be tested for reinfection three months after initial treatment, this step does not address the underlying problem of ongoing sexual contact with untreated partners.

The American College of Obstetricians and Gynecologists (ACOG) released a committee opinion in September 2011 supporting use of expedited partner therapy (EPT) for management of gonorrhea and chlamydia.4

EPT is the delivery of medications or prescriptions by persons infected with a sexually transmitted infection (STI) to their sex partner(s) without assessment of the partner(s) by a clinician. ACOG joins medical and legal organizations including the America Academy of Pediatrics, Society for Adolescent Health and Medicine, American Medical Association, and the American Bar Association in supporting EPT as a tool for combating sexually transmitted infections.5-8

Can teens access EPT?

Adolescents can consent to receive STI treatment in all 50 states without parental consent or involvement, so legally the practice is supported for minors living in any state where EPT is legal for adults.9 This situation means adolescents can access EPT in the 30 states that now explicitly permit the practice. EPT is potentially allowable in 13 states: Alabama, Delaware, Georgia, Hawaii, Idaho, Indiana, Kansas, Maryland, Montana, Nebraska, New Jersey, South Dakota, and Virginia; it also is potentially allowable in the District of Columbia and Puerto Rico — meaning the practice may become explicitly permitted after additional actions are taken or policies clarified by state officials. Only seven states — Arkansas, Florida, Kentucky, Michigan, Ohio, Oklahoma, and West Virginia — prohibit EPT.10

While directly referring partners to see a clinician for care remains the frontline strategy, EPT can be useful for partners who are unlikely or unwilling to come in for treatment. Systematic reviews show EPT can reduce the risk of repeat positive chlamydia and gonorrhea tests in adult patients.11 However, no large-scale reviews have been conducted on studies of EPT and adolescents.

Some clinicians might express concerns regarding the safety of dispensing antibiotics to sexual partners of patients diagnosed with chlamydia or gonorrhea without requiring an office visit. Fortunately, severe allergic reactions are rare with the recommended treatments for chlamydia and gonorrhea.12-13 However, patients should be counseled and given information on mediations' potential side effects, such as transient gastrointestinal problems, to share with their partner.

In addition to discussing side effects, more in-depth counseling is essential when providing EPT. The index patient's needs for information and support should be prioritized before discussing the need to treat partners. Additionally, patients should be screened to find out if partner notification could put them in danger of physical abuse or intimate partner violence. If so, EPT would not be recommended. Furthermore, EPT would not be recommended to survivors of sexual assault or abuse.

If an adolescent can safely discuss the infection and treatment with his/her partner(s), clinicians should discuss when and how notification will take place. They should rehearse this conversation with the patient when possible. Adolescents should be given educational materials on the infections and treatments. Many states provide web sites and specific materials for distribution. The CDC STD web site at http://www.cdc.gov/std/default.htm and the online Center for Young Women's Health at http://www.youngwomenshealth.org/sexuality_menu.html#stds serve as useful tools for adolescents.

Adolescents should be advised to encourage partners to see a clinician for an evaluation even after filling an EPT prescription and taking the medication. Teens should inform their partners that the medication provided will not treat any STIs other than the ones diagnosed. Adolescents and their partners also should be instructed on the recommended seven-day waiting period after both partners have completed their treatment before engaging in sex.

EPT may not be feasible for treatment of gonorrhea infections given that the most recent 2010 CDC guidelines for treatment of gonorrhea advise 250 mg intramuscular ceftriaxone (in addition to oral doxycycline or azithromycin) as part of the first-line treatment. However, one could substitute 400 mg of oral cefixime instead of the intramuscular medication.14

EPT is not appropriate for all adolescents. Sexual partners who might be pregnant should be seen by a clinician and not receive EPT. Likewise, there is inadequate research demonstrating the effectiveness of EPT for preventing reinfection among adolescent men who have sex with men because of the possible co-infection with HIV, syphilis, or other STIs.

Detailed information on the research supporting EPT, updates on legal status, and guidance on implementation can be found on the CDC's EPT website, http://www.cdc.gov/std/ept.

References

  1. Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2009. Atlanta : CDC; 2010.
  2. Datta SD, Sternberg M, Johnson RE, et al. Gonorrhea and chlamydia in the United States among persons 14 to 39 years of age, 1999-2002. Ann Internal Med 2007; 147:89-96.
  3. Gaydos CA, Wright C, Wood BJ, et al. Chlamydia trachomatis reinfection rates among female adolescents seeking rescreening in school-based health centers. Sex Transm Dis 2008; 35:233-237.
  4. American College of Obstetricians and Gynecologists. Committee opinion number 506: Expedited partner therapy in the management of gonorrhea and chlamydia by obstetrician-gynecologists. Obstet Gynecol 2011; 118:761-766.
  5. American Academy of Pediatrics. Statement of endorsement −− expedited partner therapy for adolescents diagnosed with chlamydia or gonorrhea. Pediatrics 2009; 124:1,264.
  6. Burstein G, Elliscu A, Ford K, et al. Expedited partner therapy for adolescents diagnosed with chlamydia or gonorrhea: a position paper of the Society for Adolescent Medicine. J Adolesc Health 2009; 45:303-309.
  7. American Medical Association. Report 7 of the Council on Science and Public Health (A-06): Expedited partner therapy (patient-delivered partner therapy): An update. 2006. Accessed at: http://www.ama-assn.org/resources/doc/csaph/a06csaph7-fulltext.pdf.
  8. American Bar Association. Recommendation 116A. Accessed at: http://www.abanet.org/leadership/2007/annual/docs/hundredsixteena.doc.
  9. Guttmacher Institute. State policies in brief: Minors' access to STI services. Accessed at: http://www.guttmacher.org/statecenter/spibs/spib_MASS.pdf.
  10. Centers for Disease Control and Prevention. Legal status of expedited partner therapy (EPT). Accessed at: http://www.cdc.gov/std/ept/legal/default.htm.
  11. Trelle S, Shang A, Nartey L, et al. Improved effectiveness of partner notification for patients with sexually transmitted infections: Systematic review. Br Med J 2007; 334:354.
  12. Adimora AA. Treatment of uncomplicated genital Chlamydia trachomatis infections in adults. Clin Infect Dis 2002; 35:S183-S186.
  13. Rubinstein E. Comparative safety of the different macroslides. Int J Antimicrob Agents 2001; 18:S71-S76. 14. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010. MMWR 2010;59(No. RR-12):49-51.