STD Quarterly
Repeat chlamydia infection: Improve partner notification and treatment
Use CDC guidance to enhance current practice strategies
The next patient in your exam room is a 25-year-old single woman who has come in for her quarterly contraceptive injection. At her last visit, she tested positive for chlamydia. She was given a prescription to treat the infection and counseled to have her partner come in for treatment as well. When her lab results are returned prior to your present exam, results are positive for chlamydia.
If repeat chlamydia infections are common in your clinic, you are not alone. According to research presented at the recent National STD Prevention Conference, data indicate higher-than-expected rates of repeat chlamydia infection among young women.1,2
An analysis by the Richmond-based California Department of Health Services shows at least one in 10 women tested for chlamydia through the state family planning program and at a large health maintenance organization were infected again within six months, with adolescent women most affected.1 Results from a similar report from the New York City Department of Health and Mental Hygiene show that one in eight women diagnosed with chlamydia citywide in recent years had a repeat infection within one year of their initial diagnosis; nearly a third of repeat infections occurred within three months.2 Young women were especially at risk, according to the analysis. Researchers found the reinfection rate for young women ages 10-19 was about twice that seen in women ages 25-29.2
According to the Centers for Disease Control and Prevention (CDC), such findings reinforce the need for comprehensive sexually transmitted disease (STD) prevention and treatment services for young people. This prevention and treatment should include not only chlamydia screening for all sexually active women younger than the age of 26, but also continued follow-up for infected women and their sexual partners, according to the CDC.
"These new data show that we need to improve efforts to keep young women chlamydia-free after they receive initial treatment," says John Douglas Jr., MD, director of the division of STD prevention at the CDC's National Center for HIV, STD, and TB Prevention. "That means providing education on risk reduction, ensuring that women's sexual partners are diagnosed and treated for chlamydia, implementing innovative approaches such as providing women with medicine that they can take directly to their partners, and providing routine rescreening of women after treatment to permit earlier detection and treatment of reinfection."
California takes action
Why is it so important to successfully treat chlamydia the first time? The principal danger of reinfection for women is the increased risk for pelvic inflammatory disease (PID), with each repeat infection increasing the risk for PID as well as ectopic pregnancy.3,4
California has taken steps to address the challenges of chlamydia infection, says Gail Bolan, MD, chief of the STD Control Branch for the California Department of Health Services in Richmond. The state was the first in the nation to legalize patient delivered partner therapy (PDPT) for chlamydia treatment. Since 2001, state legislation has allowed physicians to prescribe and nurse practitioners, physician assistants, and certified nurse midwives to dispense antibiotic therapy for male and female partners of infected patients, even if providers have not been able to perform an exam of the partner(s).
There have been challenges in implementing legislation, says Bolan. The Centers for Medicare and Medicaid Services has issued an interpretation stating that providers cannot issue medication to those who are not an enrollee of the state's MediCal or family planning programs, she states. "We are in the process of trying to find funding mechanisms to pay for PDPT so that it can be more widely used when appropriate," says Bolan.
The state also is looking at innovative ways to expand partner therapy, including delivery of medication to partners by public health field workers, states Bolan. It also is eyeing use of pharmacies to facilitate partner therapy, whereby pharmacies could issue partner treatment when initial treatment prescriptions are filled. Researchers also are looking at new ways to facilitate rescreening, including the possible use of self-collected vaginal swabs, Bolan reports. Data suggest that such self-collected swabs are appropriate specimens for diagnosing chlamydial infection by nucleic acid amplification tests.5
Thanks to the Chlamydia Action Coalition, a public/private partnership of the California STD Control Branch, the University of California at San Francisco, and the California HealthCare Foundation in Oakland, provider and public awareness has been raised about the importance of successful chlamydia treatment, says Bolan.
Use new CDC guidelines
Research shows that expedited partner care can decrease the patient's risk of reinfection and increase the number of treated partners.6-8
Based on such research, the CDC has issued specific guidance on expedited partner therapy.9 Although ongoing evaluation will determine when and how expedited partner therapy can best be used, the CDC issued the guidance for clinicians to use it as an additional strategy in partner management.
Also look to the newly released 2006 Sexually Transmitted Diseases Treatment Guidelines for guidance when it comes to chlamydia rescreening. According to the new document, clinicians and health care agencies should consider advising all women with chlamydial infection to be retested approximately three months after treatment. Providers also are strongly encouraged to retest all women treated for chlamydial infection whenever they next seek medical care within the following three to 12 months, regardless of whether the patient believes that her sex partners were treated, it states.10
Limited evidence is available on the benefit of retesting for chlamydia in men previously infected, advise the guidelines; however, some specialists suggest retesting men approximately three months after treatment.10
References
- Chow JM, Guo J, Gilson D, et al. Repeat chlamydia and gonorrhea infection using case-based surveillance reports and laboratory-based prevalence monitoring data, California, 2003-2004. Presented at the 2006 National STD Prevention Conference. Jacksonville, FL; May 2006.
- Klingler E, Pathela P, Cordova D, et al. Burden of repeat Chlamydia trachomatis infection in young women in New York City. Presented at the 2006 National STD Prevention Conference. Jacksonville, FL; May 2006.
- Stamm W. Chlamydia trachomatis infections of the adults. In: Holmes KK, Sparling PF, Mardh PA, et al. Sexually Transmitted Diseases. 3rd ed. New York City: McGraw-Hill; 1999, pp. 407–422.
- Hillis SD, Owens LM, Marchbanks PA, et al. Recurrent chlamydial infections increase the risks of hospitalization for ectopic pregnancy and pelvic inflammatory disease. Am J Obstet Gynecol 1997; 176(1 Pt 1):103-107.
- Schachter J, McCormack WM, Chernesky MA, et al. Vaginal swabs are appropriate specimens for diagnosis of genital tract infection with Chlamydia trachomatis. J Clin Microbiol 2003; 41:3,784-3,789.
- Schillinger JA, Kissinger P, Calvet H, et al. Patient-delivered partner treatment with azithromycin to prevent repeated Chlamydia trachomatis infection among women: A randomized, controlled trial. Sex Transm Dis 2003; 30:49-56.
- Golden MR, Whittington WL, Handsfield HH, et al. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. N Engl J Med 2005; 352:676-685.
- Kissinger P, Mohammed H, Richardson-Alston G, et al. Patient-delivered partner treatment for male urethritis: A randomized, controlled trial. Clin Infect Dis 2005; 41:623-629.
- Centers for Disease Control and Prevention. Expedited Partner Therapy in the Management of Sexually Transmitted Diseases. Atlanta: U.S. Department of Health and Human Services; 2006.
- Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2006. MMWR 2006; 55(RR-11):40.
Resources
- Visit the Chlamydia Action Coalition's web site, www.ucsf.edu/castd/chlamydia_coalition.html, for information on chlamydia care. Click on "Clinical Guidelines" to access a Chlamydia Care Quality Improvement Toolbox that contains a comparison of chlamydia testing technologies, a guide to sexual history taking, and patient therapy instruction sheets for patient delivered partner therapy in English and Spanish.
- Visit the Centers for Disease Control and Prevention (CDC) National Center for HIV, STD, and TB Prevention's web site, www.cdc.gov/std, to download the Expedited Partner Therapy in the Management of Sexually Transmitted Diseases and the 2006 Sexually Transmitted Diseases Treatment Guidelines. Under "Key Resources" on the right side of the page, click on "Publications" to access both documents.
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