New Options for Treating Chlamiydia Contacts

Senate Bill 648, authored by Senator Deborah Ortiz, amended Sections 2242 and 3502.1 of the Business and Professions Code, changed Section 120500 of the Health and Safety Code and added Section 120582.

These changes allow physicians, nurse practitioners, physicians' assistants and certified nurse midwives to prescribe antibiotic therapy for sex partners of individuals infected with genital Chlamydia trachomatis without conducting clinical assessments or performing examinations of those partners.

Prior to this new law's special exception to the "good faith examination" requirement, providing treatment for a patient's partners, sight unseen, was considered unprofessional conduct.

The rationale underlying this new law is largely a risk-benefit analysis that favors the treatment of partners, even when they are unavailable for examination and treatment in a traditional clinic setting.

Chlamydia infection is a huge problem in California, with an estimated 600,000 new infections each year. In Sacramento County, rates of reported chlamydia infection have been steadily increasing since 1997 despite vigorous efforts to counter this trend.

Young women in the 15-19 year age range are most affected, followed by men age 20-24 years of age. Overall, it is estimated that 5 to 10 percent of adolescent girls in California are currently infected with chlamydia. The morbidity associated with this infection is well known to include pelvic inflammatory disease, tubal infertility and ectopic pregnancy.

However, if treated promptly, most infections are readily cleared. The current treatment regimen of azithromycin 1 gram orally is simple as well as relatively inexpensive and safe.¹ Therefore, on balance, it makes sense to remove barriers to partner treatment, since failure to treat partners otherwise results in re-infection and increased morbidity.

It is still best, whenever possible, to examine and counsel sex partners of patients with chlamydia infections. This is the optimal method of gathering a complete health history, identifying risk for adverse drug reactions, screening for concurrent infection with other sexually transmitted diseases, and offering prevention-oriented counseling.

Nonetheless, it is often not possible to persuade sex partners to present themselves for examination and treatment. In that case, treatment for the identified infection is better than no evaluation or treatment at all.

As a safeguard that will promote responsible prescribing under this law, the California State Department of Health Services was authorized to develop and adopt regulations to implement Health and Safety Code Section 120582. A current draft of their proposed guidelines can be found on the California Chlamydia Action Coalition's website at www.ucsf.edu/castd under "SB 648 Legislation - Patient Delivered Therapy," or it may be obtained by calling the California Department of Health Services STD Control Branch at 510-540-2657.

Any practitioner who plans to provide treatment using this new law should review this information in detail. The guidelines offer practical information on patient selection, contraindications to patient-delivered medication, and an information sheet for patients.

Highlights of the guidelines include emphasis on treatment of male partners who are otherwise unlikely to seek medical services. Individuals, male or female, who are symptomatic or significantly at risk for complicated infections should not be treated without examination. In particular, females generally present a risk for pelvic inflammatory disease or pregnancy and are not good candidates to receive patient-delivered treatment.

Patients who are good candidates for treatment without examination must be counseled on the importance of taking the medication in a timely fashion, and on abstaining from sex for seven days after treatment and until all partners have been treated. They should also be made aware of medical contraindications necessitating a different approach altogether. Naturally, the medication must be accompanied by instructions for taking it.

Nurse practitioners, physicians' assistants and nurse midwifes may also offer treatment under these guidelines. It is important that offices and clinics using these practitioners develop written protocols to enable this treatment to occur in a manner consistent with the health professional's scope of practice and in accordance with applicable law.

Finally, it is important to report any adverse reactions associated with this new approach to treatment. California Department of Health Services STD Control Branch maintains a toll-free number for this purpose at 866-556-3730. Becauise this new law is a departure from traditional treatment, it is particularly important for the health care community to help monitor and evaluate its impact.

Allowing patients with chlamydia infection to deliver treatment to sex partners, who would otherwise resist medical examination, overcomes a significant obstacle in the battle against chlamydia infection. This is a cautious extension of the limits of prescribing practices that have bound physicians in the past.

Only time and monitoring will reveal if a decrease in chlamydia infection will be realized. For many physicians, this kind of flexibility is a long-awaited development and is cause for optimism.

The Sacramento County Department of Health and Human Services is a resource for area physicians seeking information on sexually transmitted and other reportable diseases. Call 916-875-5881, or go to http://www.scph.com.

TaitKa@SacCounty.net

1. While some clinicians still use doxycycline because of its lower cost, most experts prefer azithromycin because the somewhat higher price (approximately $13.00 per 1-gram dose) is well worth the convenience of single dose therapy compared with twice-daily dosing for one week.