EVIDENCE-BASED ANSWER
Testing for gonorrhea is recommended for a patient with genital chlamydia; also test for gonorrhea and chlamydia in their sexual partner because of the high prevalence of coinfection, particularly among younger patients (strength of recommendation [SOR]: C, based on expert opinion and observational studies). Testing for syphilis and HIV is also recommended for the patient and their partner (SOR: C, based on expert opinion).
CLINICAL COMMENTARY
David B. , MD, FAAFP
Tacoma Family Medicine, Tacoma, Wash
Counsel younger adults and teens regarding the risks for STIs by taking an adequate sexual history Many outpatient labs offer combined upfront testing of chlamydia and gonorrhea—the information here supports that approach. More important, the recommendation to “screen” all patients seeking treatment for sexually transmitted infections (STIs) for HIV carries an essential underlying message: the need to talk with and counsel our patients, especially younger adults and teens, regarding their risks for STIs by taking an adequate sexual history.
The Centers for Disease Control and Prevention (CDC) suggests one organized approach using “The Five Ps”: Partners (gender, number), Prevention of pregnancy, Protection from STIs, Practices (type of sex and condom use), Past history of STIs. This important conversation not only guides decisions about completing testing for other STIs but provides an avenue for potentially life-saving conversations.
Evidence Summary
A pilot study evaluated the yield of testing patients for other STIs among patients with genital chlamydia diagnosed during opportunistic screening. The study screened patients of both sexes in primary health care settings, as well as men attending a genitourinary medicine clinic. All patients testing positive in the community were advised to attend the genitourinary medicine clinic for STI screening, partner notification, and testing of patients and their contacts. More than 90% of the patients testing positive for chlamydia attended the genitourinary medicine clinic for management (total numbers seen in the clinic; women n=1245 [957 screened in the community] and men n=490 [280 screened in the community]).
At the clinic, further workup included evaluation and testing for chlamydia, gonorrhea, trichomonas, and bacterial vaginosis. Of the patients whose initial screening was in the genitourinary medicine clinic, 28% had an additional STI. Of the patients initially screened in the community setting, 4% had another STI. Partner testing showed that 55% of male partners of female patients had an STI and 76% of female partners of male patients had one or more STI.1
The high prevalence of coinfection of chlamydia and gonorrhea has been shown in several studies. One cross-sectional study of new clients to a hospital-based STI clinic with gonorrhea, chlamydia, or both infections found 39% of 1239 women and 24% of 1141 heterosexual men with gonorrhea also had chlamydia. Thirteen percent of females and 19% of heterosexual males with chlamydia also had gonorrhea. More than half of the women and a third of the men aged 15 to 19 had both gonorrhea and chlamydia. Patients with both STIs tended to be younger than those with one.2 A study of the prevalence rate of chlamydia, gonorrhea, and their coinfection in an adolescent population (women n=131,915 and men n=71,074) of juvenile detention centers between 1997 and 2002 found that 18% of women and 13% of males with chlamydia were coinfected with gonorrhea.3 In non–STI clinic settings, gonorrhea has been found in 9% of men4,5 and 6% of women5 with chlamydia.
Recommendations from others
The American Academy of Family Physicians (AAFP) strongly recommends testing for chlamydia in all sexually active women aged 25 years or younger and those at increased risk. The AAFP recommends screening all sexually active women for gonorrhea if they are at increased risk for infection; strongly recommends screening persons at increased risk for syphilis infection; and strongly recommends screening for HIV for persons seeking treatment for STIs.6
The CDC guidelines recommend evaluation, testing and treatment of partners of persons with chlamydia. As well as testing for other STIs, the guidelines suggest Pap smear screening for women who have not been adequately screened, as they often are at high risk for later cervical cancer.7 All patients seeking treatment for STDs, including all patients attending STD clinics, should be screened routinely for HIV during each visit for a new complaint, regardless of whether the patient is known or suspected to have specific behavior risks for HIV infection.8
The Institute for Clinical Systems Improvement recommends screening for chlamydia and gonorrhea for all sexually active women aged 25 years and younger and other asymptomatic women at risk for infection. Routine screening for HIV is also recommended to all persons at high risk, including those seeking treatment for any STI.9