Is Expedited Partner Therapy Ready for Your Emergency Department?

 

JoshuaFaucherBy Josh Faucher, MD, JD // Edited by Michael Barrie, MD

 

 

A 24 year-old male presents to your rural ED’s fast-track area with purulent penile discharge and dysuria.  These have been present for the past week, and he recently began intercourse with a new female sexual partner.  They have not used barrier contraception.  He denies hematuria, fevers, genital lesions, or other associated symptoms; his physical exam is within normal limits other than purulent penile discharge.  Rapid urine testing is positive for Neisseria gonorrhea infection; the patient is treated empirically in the ED with one-time doses of ceftriaxone and azithromycin.  He denies any other recent sexual partners.  The patient’s sexual partner works full time but is uninsured, and in your rural area there are no local STD clinics that are easily accessible for partner follow-up.  Your patient asks if he can have a prescription to conveniently treat possible infection in his female partner at home, saving the time and cost of an additional ED visit or delayed outpatient follow-up.  Can you provide the sexual partner any treatment without seeing her directly as a patient?

Introduction

For reasons of access, cost, or convenience, patients with uncomplicated sexually transmitted diseases (STDs) are frequently encountered in the ED.   The Center for Disease Control’s 2015 Sexually Transmitted Disease Treatment Guidelines include a rather strong endorsement of expedited partner therapy (EPT; also known as patient-delivered partner therapy) for the sexual partners of such patients:

“Unless prohibited by law or other regulations, medical providers should routinely offer EPT to heterosexual patients with chlamydia or gonorrhea infection when the provider cannot confidently ensure that all of a patient’s sex partners from the prior 60 days will be treated.”1

EPT involves writing an additional prescription for treatment of these STDs either to be filled by the patient’s sexual partner, or for the patient to distribute themselves to identified sexual partners.  This can achieve treatment of probable STD infections in sexual contacts without requiring in-person follow-up.  The utility of this practice lies in the potential to quickly treat vectors of disease that might otherwise have protracted or missed follow-up, thereby efficiently preventing further spread of infectious disease or re-infection of your original patient.

Downsides when compared to the traditional referral and in-person evaluation method might include a loss of opportunity to counsel additional contacts about safe sex and risk factors for STDs, a loss of local culture data for information on susceptibilities and patterns of local infections, and possible adverse effects from ad-hoc provision of prescription drugs to patients not seen in person.  When EPT was originally promoted, the legal permissibility of prescribing antibiotics to unseen patients was also not yet clear.

The Scientific Evidence for EPT

The largest clinical trial comparing EPT against formal partner referral for preventing recurrence of both gonorrhea and chlamydia in women and heterosexual men appears to have been conducted by Golden and colleagues, published in the New England Journal of Medicine in 2005.2  The authors had just over 900 participants completing the study in each arm, but the challenges of getting a representative sample to look at this population is revealed by their loss to follow-up of over 30% of those originally randomized in the trial.  Persistent or recurrent gonorrheal or chlamydial infection at follow-up was less prevalent for subjects whose partners received EPT compared to standard referral, with a relative risk of 0.75 (95% CI 0.59 to 0.98).  Gonorrhea experienced a greater reduction in presence than chlamydia (73 percent compared to 15 percent, respectively).  Subjects provided EPT also reported more frequent receipt of treatment by partners and fewer sexual encounters with untreated partners than those provided partner referral.

While Golden’s results were promising, the confidence interval for the primary outcome was wide, and the sampling methods and loss to follow-up may have yielded a non-representative sample.  The author’s EPT method also included subjects who declined to contact their partners themselves, and where EPT was provided by clinic staff collecting contact information and anonymously contacting subject’s sexual partners.  Such practices might be outside the scope of resources in your emergency department, causing EPT to reach a smaller proportion of your patient’s partners than in this trial.

The CDC guidelines note that EPT has not been studied for treatment of contacts with trichomonas or syphilis, and also recommend that EPT not be provided for men who have sex with men (MSM) based on the limited available clinical evidence of effectiveness, and the >5% prevalence of undiagnosed HIV infection in partners of MSM diagnosed with gonorrhea or chlamydia.1 Some authors have explored EPT in this specific population, including Kerani and others in 2013.3 They compared EPT in combination with, and against, an online partner referral website, as well as standard partner referral, but unfortunately experienced severe difficulty obtaining adequate enrollment and halted their study early with only 53 total subjects.   The study arms had significant differences in both race/ethnicity of subjects and type of infection, despite randomization.  The authors found that EPT recipients had 54% more mean partners treated than those with standard partner referral, but the means ratio had a wide 95% confidence interval of 1.01 to 2.34.

Prescribing Within the Limits of the Law

The legal status of EPT varies based on the public health laws of each state, although the vast majority now supports the practice according to a CDC website outlining the legal status in each jurisdiction.4   When it comes to my home state of Ohio, the CDC outlines some preexisting case law that could be viewed as a legal threat to Ohio providers seeking to prescribe EPT.  A 2005 case from the Ohio Court of Appeals, Reed v. State Med. Bd. Ohio, details the court’s rejection of a physician’s appeal of a state medical board decision to revoke her license.5 The case describes Dr. Reed’s prescription of a higher-than-usual doses of amoxicillin, along with multiple refills provided for as patient to fill so, as Dr. Reed said, “she could give them to her husband if she felt like it, which a lot of these people do”.  It’s not clear that the board’s decision to sanction a physician in this circumstance, which appears to be questionably justified prescribing, would clearly apply to the more widely accepted practice of EPT.  The case also details other grievances held by the medical board against Dr. Reed, such as prescribing controlled substances including Xanax, Darvocet, and Soma to patients exhibiting “drug-seeking behavior” without justifying her prescriptions with basic records recording any sort of history or physical.

Despite that case and others, the CDC states that EPT is legally recognized as permissible in Ohio, largely because of a specific statute authorizing the practice.  It came to life as House Bill 124, which was moved quickly through the Ohio state legislature in the fall and winter of 2015 (under the guide of two physician legislators, Sate Reps. Stephen Huffman and Terry Johnson)  before being signed by Governor Kasich and becoming effective on March 23, 2016.6  The bill specifically authorizes physicians and other providers to write EPT prescriptions with the patient’s partner named on the prescription, or with the words “expedited partner therapy” or letters “EPT” displayed on the prescription label.  It also provides immunity from civil liability, criminal prosecution, or professional discipline for providers prescribing EPT within the scope of the law.

A More Complete Perspective on EPT

Considering the whole picture, public health authorities have clearly embraced EPT as a useful tool to combat reinfection and spread of gonorrhea and chlamydia, and legal authorities in the majority of states have expressly authorized its use by physicians to combat STDs.  The scientific evidence for the practice could be stronger, and is limited to certain populations and conditions, but is held back by the difficulty of studying the practice in a vulnerable population around a sensitive subject.  While there doesn’t appears to be an specific evidence looking at EPT in emergency departments, this could be a useful tool in an area of the health care system where obtaining follow up for patients and their partners is an ever relevant issue, and you should consider the possible benefit EPT might have for patients (and their partners) in your ED.

References

  1. Workowski, KA, and Bolan, GA. Sexually Transmitted Treatment Guidelines, 2015. MMWR Recomm Rep 2015;64(No. RR-3):8-9.
  1. Golden, et al. Effect of Expedited Treatment of Sex Partners on Recurrent or Persistent Gonorrhea or Chlamydial Infection. N Eng J Med 2005;352:676-85.
  1. Kerani, et al. A Randomized, Controlled Trial of inSPOT and Patient-Delivered Partner Therapy for Gonorrhea and Chlamydial Infection Among Men Who Have Sex With Men. Sexually Transmitted Diseases 2013;38:941-46.
  2. CDC. Legal Status of Expedited Partner Therapy (EPT). CDC Sexually Transmitted Diseases website.  https://www.cdc.gov/std/ept/legal/.  January 9, 2017.  Accessed April 8, 2017.
  3. Reed v. State Med. Bd. Ohio, 833 N.E.2d 814 (Ohio Ct. App. 2005).
  4. House Bill 124. The Ohio State Legislature website.  https://www.legislature.ohio.gov/legislation/legislation-summary?id=GA131-HB-124.  March 23, 2016.  Accessed April 8, 2017.

 

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