Committee Opinion
Number 632, June 2015
(Replaces Committee Opinion Number 506, September 2011)


Committee on Gynecologic Practice
Committee on Adolescent Health Care

This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.


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Expedited Partner Therapy in the Management of Gonorrhea and Chlamydial Infection

ABSTRACT: Sexually transmitted infections (STIs) disproportionately affect women and create a preventable threat to their fertility. One factor that contributes to young women’s high rates of STIs is reinfection from an untreated sexual partner. One way to address this problem is through expedited partner therapy, the practice of treating the sexual partners of patients in whom STIs are diagnosed. Expedited partner therapy enables the obstetrician–gynecologist or other provider to give prescriptions or medications to patients to take to their partners without first examining these partners. Despite the effectiveness of expedited partner therapy, numerous legal, medical, practical, and administrative barriers hinder its routine use by obstetrician–gynecologists. The American College of Obstetricians and Gynecologists supports the use of expedited partner therapy as a method of preventing gonorrhea and chlamydial reinfection when a patient’s partners are unable or unwilling to seek medical care. Expedited partner therapy should be accompanied by patient counseling and written treatment instructions for the patient’s partner(s). Partners receiving expedited partner therapy should be encouraged to seek additional medical evaluation as soon as possible to discuss screening for other STIs, including human immunodeficiency virus (HIV)infection.


Conclusions and Recommendations

The American College of Obstetricians and Gynecologists (the College) makes the following conclusions and recommendations:

  • The College supports the use of expedited partner therapy as a method of preventing gonorrhea and chlamydial reinfection when a patient’s partners are unable or unwilling to seek medical care.
  • The College encourages members to advocate for the legalization of expedited partner therapy and to work with their health departments to develop protocols for its use.
  • Partners receiving expedited partner therapy should be encouraged to seek additional medical evaluation as soon as possible to discuss screening for other sexually transmitted infections (STIs), including human immunodeficiency virus (HIV) infection.
  • Expedited partner therapy is recommended only after an obstetrician–gynecologist or other provider has assessed the risk of intimate partner violence associated with partner notification. It is not intended for use in cases of suspected child abuse, sexual assault, or any other situation in which the patient’s safety from her abuser may be compromised.

Background

Sexually transmitted infections disproportionately affect women and create a preventable threat to their fertility. In the United States, adolescent girls and young women aged 15–24 years consistently have the highest number of cases of gonorrhea and chlamydial infection (1). One factor that contributes to young women’s high rates of STIs is reinfection from an untreated sexual partner. One way to address this problem is through expedited partner therapy, the practice of treating the sexual partners of patients in whom STIs are diagnosed. Expedited partner therapy enables the obstetrician–gynecologist or other provider to give prescriptions or medications to patients to take to their partners without first examining these partners. (2, 3).

It is preferable that partners undergo complete clinical evaluation, STI screening and HIV testing, counseling, and treatment by an obstetrician–gynecologist or other provider. However, when comprehensive medical management is not practical, the College supports the use of expedited partner therapy as a method of preventing gonorrhea and chlamydial reinfection when a patient’s partners are unable or unwilling to seek medical care. Evidence indicates that expedited partner therapy can decrease reinfection rates when compared with standard partner referrals for examination and treatment (2, 4). Although there are no data on the effectiveness of expedited partner therapy among women who have sex with women, expedited partner therapy may be an appropriate partner management option for same-sex partners of female patients. To date, there is insufficient evidence supporting the effectiveness of expedited partner therapy for the treatment of trichomoniasis or syphilis (2).

Barriers to Routine Use of Expedited Partner Therapy

Evidence suggests that the benefits of expedited partner therapy in preventing gonorrhea and chlamydial reinfection outweigh the risks of possible adverse effects of antibiotics, development of antibiotic resistance related to poor treatment adherence, or missed care opportunities (2). Despite the effectiveness of expedited partner therapy, numerous legal, medical, practical, and administrative barriers hinder its routine use by obstetrician–gynecologists. The Centers for Disease Control and Prevention (CDC) maintains a web site (www.cdc.gov/std/EPT/legal/default.htm) with information about the legal status of expedited partner therapy in all 50 states and other jurisdictions (5). In the absence of a statute that expressly permits expedited partner therapy in all jurisdictions, obstetrician–gynecologists should rely on state or local legal counsel. The CDC and several state health departments have issued guidelines for practicing expedited partner therapy (2, 6–10), and its use has been endorsed by the College and other medical professional organizations (11–13). The state guidelines provide examples of expedited partner therapy documentation.

State child abuse reporting laws vary widely in terms of whether or not they require reporting the sexual activity of a minor or statutory rape as child abuse (14). This reporting requirement could reduce the likelihood that an adolescent will seek care and receive appropriate treatment. Expedited partner therapy is recommended only after the obstetrician–gynecologist or other provider has assessed the risk of intimate partner violence associated with partner notification. It is not intended for use in cases of suspected child abuse, sexual assault, or any other situation in which the patient’s safety from her abuser may be compromised.

Implementing Expedited Partner Therapy

In jurisdictions where expedited partner therapy is legally permitted, the College recommends the following principles for practice:

  • Guidelines are subject to change, so clinicians should refer to CDC or state and local guidelines for the most up-to-date guidance on the provision of expedited partner therapy, including medications that are permissible and recommended for use (www.cdc.gov/std/ept/default.htm; www.cdc.gov/std/EPT/legal/default.htm).
  • A patient’s sexual partners within the previous 2 months (or, if the patient had no partners in that time frame, the last partner) who are unable or unlikely to access medical services should be offered expedited partner therapy. Providing guidance on how the patient can inform her partner(s) about the infection can be helpful.
  • Expedited partner therapy should be accompanied by patient counseling and written treatment instructions for the patient’s partner(s) (see www.cdc.gov/std/treatment/eptfinalreport2006.pdf).
  • Partners receiving expedited partner therapy should be encouraged to seek additional medical evaluation as soon as possible to discuss screening for other STIs, including HIV infection.
  • Patients should be instructed to abstain from sexual intercourse for 7 days after they and their sexual partners have completed treatment.
  • A mechanism should be in place for patients and partners to report adverse events.
  • Obstetrician–gynecologists or other providers should consult the regulations and policies for their jurisdiction to determine allowable reimbursement options and requirements for expedited partner therapy.

Advocacy

The College encourages members to advocate for the legalization of expedited partner therapy and to work with their health departments to develop protocols for its use. This involves active collaboration with stakeholders, including other health care providers, the state STI director, pharmacy and medical boards, and state medical societies. Obtaining an opinion or other ruling from the state medical and pharmacy boards indicating that expedited partner therapy is not unprofessional conduct may be easier than passing a new statute. However, a discrete statute expressly permitting expedited partner therapy provides the strongest legal authority.

Resources

The following resources are for information purposes only. Referral to these sources and web sites does not imply the endorsement of the American College of Obstetricians and Gynecologists. These resources are not meant to be comprehensive. The exclusion of a source or web site does not reflect the quality of that source or web site. Please note that web sites are subject to change without notice.

Centers for Disease Control and Prevention. Expedited partner therapy. Available at: http://www.cdc.gov/std/ept/default.htm. Retrieved February 4, 2015.

Centers for Disease Control and Prevention. Legal/policy toolkit for adoption and implementation of expedited partner therapy. Atlanta (GA): CDC; 2011. Available at: http://www.cdc.gov/std/ept/legal/ept-toolkit-complete.pdf. Retrieved February 3, 2015.

Centers for Disease Control and Prevention. STD treatment guidelines app. Available at: http://www.cdc.gov/std/STD-Tx-app.htm. Retrieved February 3, 2015.

References

  1. Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2013. Atlanta (GA): CDC; 2014. Available at: http://www.cdc.gov/std/stats13/surv2013-print.pdf. Retrieved January 27, 2015.
  2. Centers for Disease Control and Prevention. Expedited partner therapy in the management of sexually transmitted diseases: review and guidance. Atlanta (GA): CDC; 2006. Available at: http://www.cdc.gov/std/treatment/eptfinalreport2006.pdf. Retrieved January 27, 2015. [PubMed] [Full Text]
  3. Workowski KA, Berman S. Sexually transmitted diseases treatment guidelines, 2010. Centers for Disease Control and Prevention (CDC) [published erratum appears in MMWR Morb Mortal Wkly Rep 2011 Jan 14;60(1):18]. MMWR Recomm Rep 2010;59:1–110. [PubMed] [Full Text]
  4. Trelle S, Shang A, Nartey L, Cassell JA, Low N. Improved effectiveness of partner notification for patients with sexually transmitted infections: systematic review. BMJ 2007;334:354. [PubMed] [Full Text]
  5. Centers for Disease Control and Prevention. Legal status of expedited partner therapy (EPT). Available at: http://www.cdc.gov/std/EPT/legal/default.htm. Retrieved January 27, 2015.
  6. Washington State Department of Health. Background and recommendations for incorporating patient delivered partner therapy (PDPT) by health care providers. Olympia (WA): DOH; 2004. Available at: http://www.doh.wa.gov/portals/1/Documents/Pubs/347-600-backgroundRecommendationsIncorporatingPatientDeliveredPartnerTherapy.pdf. Retrieved January 27, 2015.
  7. California Department of Public Health, Sexually Transmitted Diseases (STD) Control Branch. Patient-delivered partner therapy (PDPT) for chlamydia, gonorrhea, and trichomoniasis: guidance for medical providers in California. Sacramento (CA): CDPH; 2012. Available at: http://www.cdph.ca.gov/pubsforms/Guidelines/Documents/CA-STD-PDPT-Guidelines.pdf. Retrieved January 27, 2015.
  8. Minnesota Department of Health. Expedited partner therapy (EPT) for Chlamydia trachomatis and Neisseria gonorrhoeae: guidance for medical providers in Minnesota. St. Paul (MN): MDH; 2008. Available at: http://www.health.state.mn.us/divs/idepc/dtopics/stds/ept/EPTGuidance.pdf. Retrieved January 27, 2015.
  9. Illinois Department of Public Health, Sexually Transmitted Diseases Section. Expedited partner therapy for Chlamydia trachomatis and Neisseria gonorrhoeae: guidance for health care professionals in Illinois. Springfield (IL): IDPH; 2011. Available at: http://www.idph.state.il.us/health/std/Illinois_EPT_Guidelines.pdf. Retrieved January 27, 2015.
  10. Texas Department of State Health Services. Expedited partner therapy (EPT). Austin (TX): TDSHS; 2014. Available at: http://www.dshs.state.tx.us/hivstd/ept/default.shtm. Retrieved January 27, 2015.
  11. American Medical Association. Expedited partner therapy. In: Code of medical ethics of the American Medical Association: current opinions with annotations. 2014-2015 ed. Chicago (IL): AMA; 2015. p. 274–5.
  12. Burstein GR, Eliscu A, Ford K, Hogben M, Chaffee T, Straub D, 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;45:303–9. [PubMed] [Full Text]
  13. American Bar Association. Recommendation No. 116A. Adopted by the House of Delegates August 11-12, 2008. Chicago (IL): ABA; 2008. Available at: http://www.americanbar.org/content/dam/aba/directories/policy/2008_am_116a.authcheckdam.pdf. Retrieved January 27, 2015.
  14. Protecting adolescents: ensuring access to care and reporting sexual activity and abuse. Position paper of the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the Society for Adolescent Medicine. J Adolesc Health 2004;35:420–3.

Copyright June 2015 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920. All rights reserved.

ISSN 1074-861X

Expedited partner therapy in the management of gonorrhea and chlamydial infection. Committee Opinion No. 632. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;125:1526–8.

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