EXECUTIVE SUMMARY

More than 2 million cases of chlamydia, gonorrhea, and syphilis were reported in the United States in 2016, the highest number ever. Most of the new diagnoses were attributed to chlamydia (about 1.6 million), with 470,000 cases of gonorrhea and almost 28,000 cases of primary and secondary syphilis.

  • Cases of chlamydia increased 4.7% from 2015-2016 (1.59 million cases). The uptick was driven by a 9.2% increase among men; a 2.6% increase was noted among women.
  • For gonorrhea, statistics indicate an 18.5% increase from 2015-2016 (468,514 cases), with a 22.2% increase among men and a 13.8% upturn among women.

Your next patient is a 22-year-old female who has been sexually active with multiple partners. What is your approach to screening for sexually transmitted infections (STIs)?

According to 2016 surveillance data from the Centers for Disease Control and Prevention (CDC), in the United States more than 2 million cases of chlamydia, gonorrhea, and syphilis were reported, which is the highest number ever.1 Most of the new diagnoses were attributed to chlamydia (about 1.6 million), with some 470,000 cases of gonorrhea and almost 28,000 cases of primary and secondary syphilis, says Kimberly Workowski, MD, FACP, FIDSA, professor of medicine in the Division of Infectious Diseases at Atlanta-based Emory University.

Cases of chlamydia increased by 4.7% from 2015-2016 (1.59 million cases), notes Workowski, who presented on STI topics at the 2017 Contraceptive Technology conference in Atlanta.2 The uptick was driven by a 9.2% increase among men; a 2.6% increase was noted among women.1 For gonorrhea, statistics indicate an 18.5% increase from 2015-2016 (468,514 cases), with a 22.2% increase among men
and a 13.8% upturn among women, says Workowski. The CDC recorded an increase of 17.6% in the number of primary and secondary syphilis cases from 2015-2016 (27,814 cases). Data show a 14.7% increase in men; 89% of men identified themselves as men who have sex with men (MSM).1

Check Your Screening Protocol

Given this new information, what is your STI screening approach for the 22-year-old patient? Workowski offered the following protocol for sexually active adolescents and women younger than 25 years of age:

  • annual chlamydia and gonorrhea screening;
  • HIV serology if no previous test, and annual testing if at risk; and
  • syphilis serology if at risk (high community prevalence).

Clinicians should consider herpes simplex virus type-specific serology if there has been a partner with genital herpes, Workowski notes. No routine screening is recommended for trichomoniasis, bacterial vaginosis, or human papillomavirus.3

Screening for STIs in women older than 25 years of age should be based on women who are at increased risk, including those who have new or multiple sex partners, a partner with concurrent partners, or a partner with an STI.

Reinfection Is Common

Nucleic acid amplification tests are recommended for women and men in testing for chlamydia and gonorrhea, says Workowski. The optimal specimen is vaginal swabs in women and first-catch urine in men.

The CDC recommends oral administration of either 1 g of azithromycin in a single dose or 100 mg of doxycycline twice daily for seven days for the treatment of chlamydia infection.3 People who have chlamydia should refrain from sexual activity for seven days after receiving a single dose of antibiotics or until they have completed a seven-day course of antibiotics, to prevent spread of the infection to partners. Counsel patients that it is important for them to take all of the medication prescribed to cure the infection.

Reinfection is common, notes Workowski. In a review of 47 studies of both chlamydia and gonorrhea reinfection, the overall median proportion of females reinfected with chlamydia was 13.9% (n = 38 studies). Modeled chlamydia reinfection within 12 months demonstrated peak rates at eight to 10 months of 19-20%, data indicate. Younger age was associated with higher rates of both chlamydia and gonorrhea reinfection.4 High chlamydia reinfection rates warrant retesting three months after treatment of the initial infection, Workowski says.

Expedited partner therapy (EPT) can aid in reducing reinfection. The American College of Obstetricians and Gynecologists issued a Com-mittee Opinion in 2015 calling for providers to prescribe antibiotics for the male partners of their female patients diagnosed with chlamydia or gonorrhea to reduce the high reinfection rate.5

Check the EPT map, maintained by the CDC at http://bit.ly/2sofAfl, to see the status of EPT laws in your state. EPT currently is permissible in 41 states, potentially allowable in seven states, and prohibited in two states. The CDC has a dedicated web page with information about EPT and the status of legislation at http://bit.ly/2sxdbP9. The page contains an EPT legal/policy toolkit, which provides resources to assist states in evaluating their legal environment as it relates to EPT, and to assist them in addressing non-legal barriers to its full implementation.

REFERENCES

  1. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2016. Atlanta: U.S. Department of Health and Human Services; 2017.
  2. Workowski K. Hot topics in STI management. Presented at the 2017 Contraceptive Technology conference. Atlanta; November 2017.
  3. Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015;64(No. RR-03):1-137.
  4. Hosenfeld CB, Workowski KA, Berman S, et al. Repeat infection with Chlamydia and gonorrhea among females: A systematic review of the literature. Sex Transm Dis 2009;36:478-489.
  5. Committee opinion no 632: Expedited partner therapy in the management of gonorrhea and chlamydial infection. Obstet Gynecol 2015;125:1526-1528.