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Expedited Partner Therapy Can Stop Sexually Transmitted Infections

By Rachel Solnick, MD; Melissa Fleegler, MD, FACEP; Larissa May, MD; and Keith Kocher, MD, MPH | on May 18, 2021 | 4 Comments
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A 21-year-old patient presents to the emergency department with complaints of dysuria a week following exposure to a new sex partner. She has increased vaginal discharge on exam and is empirically treated for gonorrhea and chlamydia. After her ED visit, the test results are positive for gonorrhea, so the department’s follow-up nurse fills out the communicable disease reporting form to the health department.

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ACEP Now: Vol 40 – No 05 – May 2021

Meanwhile, the patient has talked to her partner about the diagnosis and urges him to seek care. Because he is asymptomatic and concerned about the cost of care, he does not get tested. A month later, the patient is reinfected by her untreated partner. This time, she waits to go to the emergency department because she is embarrassed. She finally presents with pelvic inflammatory disease and a tubo-ovarian abscess, requiring admission to the hospital.

This case represents many others that are examples of preventable morbidity. The emergency department might have helped avoid this outcome if it had provided the patient with antibiotics for her partner via expedited partner therapy (EPT). EPT is the practice of treating the partners of patients diagnosed with sexually transmitted infections (STIs) if their partners are unlikely to seek timely care. In the era of increased awareness of transmissible diseases and health equity, the time has come for emergency medicine to embrace EPT.

STIs Are a Hidden Public Health Crisis 

Though the COVID-19 pandemic has seized the world’s attention to the threat of communicable diseases for the past year, the United States’ STI epidemic has been intensifying unchecked for the past decade. The Centers for Disease Control and Prevention (CDC) estimated one in five Americans had an STI on any given day in 2018.1 From 2014 to 2018, the incidence of gonorrhea rose 63 percent, and chlamydia rose 19 percent to 1.8 million cases, the most chlamydia cases ever reported to the CDC.2

STIs are not just a problem for the American health care system; they are a specific issue for the emergency department. STI visits in the emergency department have been outpacing the general rise in all-cause ED visits.3 In certain cities, emergency departments have had a substantial increase in positive tests, with higher positivity rates than outpatient settings.4 Emergency departments see a disproportionate share of STI cases compared to other health care settings. On a national level, in 2018, emergency departments diagnosed similar proportions of all gonorrhea cases as STD clinics.5

Moreover, STIs are an issue of social justice and health equity. STIs disproportionately affect those with low health care access, racial minority and minoritized populations, and low-income populations, the same vulnerable populations that are more likely to use the emergency department for STI care.6,7 Additionally, young males without primary care access are more likely to seek care in ED settings, representing an opportunity for EPT of male partners to improve women’s reproductive health via the prevention of STI complications, including future infertility and pregnancy complications.

Adding to the urgency to stop the STI epidemic, antimicrobial resistance for gonorrhea is increasing. In December 2020, for the first time in a decade, the CDC revised its treatment guidelines for gonococcal infections.8 Among other changes, these updates recommended: 1) doubling the recommended cephalosporin doses both for parenteral treatment and pill-based therapy and 2) replacing azithromycin for concurrent treatment of suspected chlamydia with doxycycline when treating empirically for gonorrhea. These changes were made due to increasing azithromycin resistance and concerns for antimicrobial stewardship.

Pages: 1 2 3 4 | Single Page

Topics: expedited partner therapySexually Transmitted DiseaseSexually Transmitted Infection

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4 Responses to “Expedited Partner Therapy Can Stop Sexually Transmitted Infections”

  1. June 20, 2021

    Gary Roberts Reply

    Treatment of partners in the setting of STIs is medically appropriate. This article did not address the pitfalls of prescribing medication for an unknown and unseen patient whose medical history cannot be confirmed. Anaphylaxis to cephalosporins is well known and there are numerous medications with potential adverse interactions with azithromycin.

    As a physician, I am unwilling to subject an unknown patient to potential harm and am equally unwilling to incur the legal liability attached to an adverse outcome in this situation no matter how noble the cause. (health care equity)

    The (potential) patient has the responsibility in this case. ED physicians are neither qualified nor justified to act “in loco parentis” for the community.

  2. June 20, 2021

    T Reply

    What if partner has an allergy or adverse drug reaction. You never did a formal evaluation. Is their sovereign immunity?

  3. June 21, 2021

    Matt Jaeger Reply

    How do you propose we prescribe medications to a patient we don’t have a chart for, don’t have a relationship with, haven’t performed a history on, and don’t know what their allergies are? This seem like a risk I’m not willing to take. I don’t think I’m willing to start handing out prescription to unknown individuals.

    At some point, patients must take at least partial responsibility for their care and initiate a relationship with a medical provider, be it in an ER, public health clinic, walk-in clinic or a PCP.

  4. June 21, 2021

    Gary Roberts, MD, JD Reply

    While “social justice and health equity” are noble motives and lofty goals, the reality of EPT is far more gritty.

    Even granting the supposition that there may be some legal protection for the prescribing physician, what protection is there for the unexamined and unseen patient?

    Cephalosporins are well-known to have a not insignificant allergic/anaphylactic profile. The myriad potential drug interactions and adverse reactions with doxycyline are well documented.

    Nonetheless, the EPT approach is to expose patients to these risks without their consent and lacking any first-hand knowledge of their medical condition.

    It is neither the province nor the responsibility of Emergency Medicine to act in loco parentis in these situations. The patient must bear some responsibility.

    “Social justice and health equity” in this context is already being well-served. There are numerous free clinics for the treatment of STI.

    https://www.yourstdhelp.com/free_clinic_locator.html

    Noble motives and the possibility of legal protection are flimsy and totally inadequate excuses to expose unknown patients to significant risks.

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