Guidance on the Use of Expedited Partner Therapy in the Treatment of Gonorrhea
Expedited Partner Therapy (EPT) is a partner treatment approach where partners of patients who test positive for certain sexually transmitted diseases are provided medication without previous medical evaluation. Because of EPT’s effectiveness in reducing reinfection rates, CDC has recommended its use since 2006 among heterosexual partners of patients diagnosed with chlamydia or gonorrhea when it is unlikely the partners will seek timely evaluation and treatment.1
However, surveillance data from the Gonococcal Isolate Surveillance Project has prompted concerns that the United States may be in the early stages of the development of clinically significant gonococcal resistance to oral cephalosporins, in which case cefixime would not only be a less effective treatment for gonorrhea but may also hasten the development of resistance to other more effective injectable cephalosporins. Thus, CDC no longer recommends the routine use of orally-administered cefixime for the treatment of gonorrhea in the United States. Rather, for treatment of uncomplicated urogenital, anorectal, and pharyngeal gonorrhea, CDC recommends that combination therapy be used with a single intramuscular dose of ceftriaxone 250 mg plus either a single dose of azithromycin 1 g orally or doxycycline 100 mg orally twice daily for 7 days.
Since EPT is not possible where treatment involves an injection, the new CDC gonorrhea treatment recommendations have implications for the use of EPT in the treatment of gonorrhea. This document is intended to provide guidance to providers who choose to use EPT for gonorrhea, and to answer frequently asked questions.
1. In light of CDC’s recent changes to its gonorrhea treatment recommendations, can EPT be used for gonorrhea?
- Under these new guidelines every effort should be made to ensure that a patient’s sex partners from the past 60 days are evaluated and treated with a recommended regimen (ceftriaxone 250 mgIM plus either a single dose of azithromycin 1 g orally or doxycycline 100 mg orally twice daily for 7 days). However, because that is not always possible, providers can still consider EPT for heterosexual partners of patients diagnosed with gonorrhea who are unlikely to access timely evaluation and treatment. EPT is not routinely recommended for MSM because of a high risk for coexisting infections, especially undiagnosed HIV infection, in their partners.
2. Since CDC no longer recommends exclusively oral treatment for gonorrhea, and since CDC recommends that a patient return for a test-of-cure when oral cefixime is used as an alternative treatment, how does CDC recommend EPT be practiced for gonorrhea?
- If a heterosexual partner of a gonorrhea patient cannot be linked to evaluation and treatment in a timely fashion, EPT with cefixime and azithromycin should still be considered, as not treating partners is significantly more harmful than is practicing EPT for gonorrhea. As has always been the case, medication or prescriptions provided as part of EPT should be accompanied by treatment instructions, appropriate warnings about taking medications (if the partner is pregnant or has an allergy to the medication), general gonorrhea health education and counseling, and a statement advising that partners seek personal medical evaluation, particularly women with symptoms of PID.2 Now, with the new CDC recommendations, instructions for partners should also include a recommendation that the partner receive a test-of-cure approximately one week after finishing their medication. Given that the partner receiving EPT may have little or no access to health care, information as to where they can receive a test-of-cure or other personal medical evaluations should also be provided.
1. Centers for Disease Control & Prevention (CDC). Sexually Transmitted Disease Surveillance 2010. Atlanta: U.S. Department of Health and Human Services; 2011. Accessible at: http://www.cdc.gov/std/treatment/2010/clinical.htm#part. Accessed Aug. 6, 2013.
2. Expedited Partner Therapy. August 9, 2012. Available at: http://www.cdc.gov/std/ept/default.htm. Accessed Aug. 6, 2013.