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Patient-delivered therapy of antibiotics for chlamydia trachomatis

Patient-Delivered Partner Therapy for
Chlamydia trachomatis and Neisseria gonorrhoeae:
Guidance for Medical Providers in California
California Department of Public Health
Sexually Transmitted Diseases (STD) Control Branch
California STD Controllers Association
March 27, 2007
INTRODUCTION
As of January 1, 2007, California medical providers have a new option for ensuring effective partner treatment for the sex partners of patients diagnosed with Neisseria gonorrhoeae. This new legislation expands upon the 2001 legislation allowing patient-delivered partner therapy (PDPT) for Chlamydia trachomatis. In combination, SB 648 (Ortiz, Chapter 835, Statutes of 2000) and AB 2280 (Leno, Chapter 771, Statutes of 2006) amended current law and allow physicians to prescribe, and nurse practitioners, physician assistants, and certified nurse-midwives to dispense, antibiotic therapy for the sex partners of individuals infected with Chlamydia trachomatis and Neisseria gonorrhoeae, even if they have not been able to perform an exam of the patient’s partner(s). This document is intended to provide guidance for clinical practice in the implementation of this California legislation (Health and Safety Code Section 120582). It replaces the June 2001 document, Patient-Delivered Therapy of Antibiotics for Chlamydia trachomatis, Guidance for Medical Providers in California. The following guidelines are focused on PDPT strategies and provide information on the most appropriate patients, medications, and counseling procedures recommended to maximize patient and public health benefit while minimizing risk. Summary Guidelines
Patient’s diagnosis: clinical diagnosis of Chlamydia trachomatis or Neisseria
First-choice partner management strategy: Attempt to bring partners in for
complete clinical evaluation, STD testing, counseling, and treatment. • Most appropriate patients: those with partners who are unable or unlikely to
Recommended drug regimens
o Patients diagnosed with chlamydia, but not gonorrhea: ƒ Azithromycin (Zithromax*) 1 gram (250 mg tablets x 4) orally o Patients diagnosed with gonorrhea but not chlamydia: o Patients diagnosed with both gonorrhea and chlamydia: ƒ Azithromycin (Zithromax*) 1 gram (250 mg tablets x 4) orally • Number of doses is limited to the number of known sex partners in previous
60 days (or most recent sex partner if none in the previous 60 days). • Informational materials must accompany medication and must include clear
Patient counseling: abstinence until seven days after treatment and until
seven days after partners have been treated • Patient re-testing for gonorrhea and chlamydia is recommended for three
Adverse reactions: The law does not protect providers from liability, as is the
case for any medical treatment. To report adverse reactions, email EPT@cdph.ca.gov or call 510-620-3400. * Use of trade names is for identification only and does not imply endorsement. BACKGROUND AND RATIONALE

Public health importance of chlamydia and gonorrhea

Sexually transmitted chlamydia and gonorrhea infections are significant public health
problems. More than 130,000 cases of chlamydia and 34,000 cases of gonorrhea were
reported in California in 2005, making them the top two most common reportable
communicable infections [1]. Genital infections can lead to pelvic inflammatory disease
(PID), chronic pelvic pain, ectopic pregnancy, and preventable infertility in women [2].
Patients with these infections are also at increased risk of acquiring sexually transmitted
HIV [3]. Repeat gonorrhea infections, which increase the risk of complications, occur in
up to 11 percent of women and men within six months after treatment [4, 5]. Repeat
chlamydia infections occur in up to 13 percent of patients in this same time period [6].
To prevent repeat infections, reduce complications in individuals, and reduce further
transmission of infection in the community, sex partners of infected patients must be
provided timely and appropriate antibiotic treatment.
Barriers to effective partner management

Currently, there are considerable challenges to effective partner management. Public
health efforts to notify and treat sex partners have proven successful and are
considered a cornerstone of syphilis control [7]. However, because of the high burden
of infection and limited public health resources for partner notification activities, it is
difficult for local health departments to provide investigation and partner notification for
cases of gonorrhea and chlamydia [8]. Thus, the standard of care for partner
management for gonorrhea and chlamydia cases has become patient referral, whereby
providers counsel patients about the need for partner treatment and that the
responsibility for notifying partners rests with the patient.
Although providers have the option to collect the partners’ contact information and notify
them, there are no reimbursement mechanisms and few clinics have the resources for
this activity. The effectiveness of patient referral is limited by the patient’s choice in
notifying the partner, as well as the partner’s choice in seeking treatment. In particular,
some partners may be uninsured and have limited access to medical care. Further,
infected partners who are asymptomatic may be less likely to seek needed medical
treatment.
California legislation allowing PDPT for chlamydia and gonorrhea

Expedited partner treatment (EPT) for chlamydia and gonorrhea is an alternative
strategy for ensuring that sex partners get needed medication. EPT is the general term
for the practice of treating sex partners of patients diagnosed with an STD without an
intervening medical evaluation. PDPT is the most common type of EPT in which the
patient delivers the medication to his or her sex partner(s). Other types of EPT involve
alternative delivery mechanisms, such as pharmacies.
In 2001, SB 648 (Ortiz, Chapter 835 Statutes of 2000) amended California law to allow
PDPT for chlamydia, and, in January 2007, AB 2280 (Leno, Chapter 771 Statutes of
2006) further amended the law to allow PDPT for gonorrhea. The current law allows
physicians to prescribe, and nurse practitioners, physician assistants, and certified
nurse-midwives to dispense, antibiotic therapy for the male and female sex partners of
individuals infected with Chlamydia trachomatis or Neisseria gonorrhoeae, even if they
have not been able to perform an exam of the patient’s partner(s).
This legislation (Section 120582 of the Health and Safety Code) provides an exception
to the Medical Practice Act, which states that the prescribing, dispensing, or furnishing
of dangerous drugs, as defined, without a good-faith prior examination and medical
indication, constitutes unprofessional conduct. The new law provides that a licensee
acting in accordance with provisions of the law with regard to a prescription for antibiotic
therapy has not committed unprofessional conduct under this provision. This new law
provides an important means to combat a serious public health problem and prevent
adverse reproductive health outcomes.
This option allowing providers to use PDPT is not intended as the first and optimal
choice of treatment for partners of individuals diagnosed with gonorrhea and chlamydia.
However, this strategy can serve as a useful alternative when the partner is unable or
unlikely to seek care. Providers should use their best judgment to determine whether
partners will or will not come in for treatment, and to decide whether or not to dispense
or prescribe additional medication to the index patient.
Healthcare provider responsibilities for ensuring partner treatment

Patients diagnosed with chlamydia or gonorrhea infection cannot be considered
adequately treated until all their partners have been treated. All sexual contacts within
the previous 60 days from the onset of symptoms or diagnostic test results need to be
treated.
In California, physicians are still required by law to: 1) endeavor to discover the source
of infection, as well as any sexual or other intimate contacts that the patient made while
in the communicable stage of the disease (California Code of Regulations, Title 17,
Section 2636); 2) make an effort, through the cooperation of the patient, to bring these
persons in for examination and, if necessary, treatment (California Code of Regulations,
Title 17, Section 2636); and 3) report cases to the local health officer (California Code of
Regulations, Title 17, Section 2500).
Evidence for the effectiveness of EPT for chlamydia and gonorrhea

Several research studies, including randomized clinical trials, have demonstrated that
EPT is effective in facilitating partner notification and reducing recurrent infection among
index cases. A recent meta-analysis that included five clinical trials showed an overall
reduced risk (summary risk ratio 0.73, 95 percent confidence interval (CI) 0.57 to 0.93)
of recurrent infection in patients with chlamydia or gonorrhea who received EPT,
compared with those who received standard partner treatment methods [9].
One randomized trial demonstrated that partner management strategies that included
EPT as an option, compared with conventional strategies, significantly reduced
recurrent gonorrhea or chlamydial infection among heterosexual men and women [10].
In this study, EPT was more effective than standard referral in reducing recurrent
infection among patients with gonorrhea (3 percent versus 11 percent, p = 0.01),
compared with those with chlamydial infection (11 percent versus 13 percent, p = 0.17).

In a separate study, of men with urethritis, PDPT, compared with patient referral,
reduced recurrent infection rates by half, from 43 percent to 23 percent [11]. In another
study, of women with chlamydia, PDPT reduced recurrent infection rates from
15 percent to 12 percent (p = .10) [12].
A report published by the Centers for Disease Control and Prevention (CDC) in 2006
provided a thorough review of the research literature, a discussion of programmatic
issues related to EPT, and guidance for public health programs and clinicians [13].
Implementation and use of PDPT

In a national physician survey conducted in 2000, researchers at CDC found that the
practice of PDPT for chlamydia and gonorrhea was not uncommon [14, 15]. According
to a 2002 California survey, nearly half of California physicians and nurse practitioners
reported that they routinely use PDPT to treat partners of patients with chlamydia [16].
A local evaluation, in San Francisco, California, demonstrated successful
implementation, with 23 percent of STD patients receiving PDPT [17].
As of January 2007, the STD Control Branch had not received any reports of adverse
events related to PDPT for chlamydia, despite the availability of a toll-free reporting line
since 2001.
For some insurance plans in California, reimbursement for PDPT has not kept up with
policy and practice changes. Because this practice provides preventive care for the
patient by reducing recurrent infection and subsequent reproductive health
complication, the STD Control Branch encourages public and private insurers to support
this practice.

Liability issues

The current legislation allowing PDPT for sexually transmitted infections does not
protect healthcare providers from lawsuits resulting from adverse outcomes related to
the practice. This liability is no different from the liability of any other action taken by a
healthcare provider, including prescribing or dispensing medicine for any medical
condition, in which the provider remains liable. However, guidelines establish a
standard of care, and standard of care is the primary medicolegal standard for
appropriate practice. It is reassuring that, as of January 2007, the STD Control Branch
had not received any reports of lawsuits related to the practice of providing PDPT.
When the prescribing physician is a public official or employee, he or she is immune
from tort liability in California when acting within the scope of their authority
(Government Code Section 820 and 820.2). However, immunity does not apply to acts
of negligence (e.g., prescribing a dangerous or non-therapeutic regimen).
Potential pitfalls in using EPT

There are several concerns about EPT. First, the medication could cause a serious
adverse reaction, including allergy. Second, EPT may compromise the quality of care
provided to partners, particularly if it is used as a first-line approach for partners who
would otherwise seek clinical services. Appropriate care for contacts to STD includes
testing for other STDs and HIV, physical examination to rule out a complicated infection,
and risk-reduction counseling. Ideally, partners who receive EPT will still access these
clinical services. Despite these concerns, the benefits of EPT outweigh the risks, since
doing nothing for these partners is more harmful. Further, these risks may be mitigated
through patient education and written materials for partners that provide warnings and
encourage visiting a healthcare provider.
Additional concerns about EPT include misuse of the medication, waste if the
medication is not delivered or not taken, and contribution to antibiotic resistance at the
population level. Currently, there is no evidence that EPT is misused or leads to
increasing antimicrobial resistance.
GUIDELINES FOR USING PDPT FOR CHLAMYDIA AND GONORRHEA

Selecting appropriate patients for PDPT

Appropriate patients are those with a clinical diagnosis of sexually transmitted
chlamydia or gonorrhea infection. Laboratory confirmation of the diagnosis may include
a gram stain of urethral exudate showing gram negative diplococci indicative of
gonorrhea; a positive culture test for chlamydia or gonorrhea; a positive nucleic acid
hybridization test for chlamydia or gonorrhea (e.g., GenProbe PACE 2 or Digene Hybrid
Capture 2); or a positive nucleic acid amplification test (NAAT) for chlamydia or
gonorrhea (e.g., GenProbe Aptima, Beckton Dicksenson ProbeTec, Roche polymerase
chain reaction (PCR) Amplicor). Because of their high sensitivity, NAATs are the tests
of choice for chlamydia screening and testing. In fact, only a negative NAAT negates
the need for co-treatment for chlamydia in a patient with gonorrhea [18].
Providing PDPT without laboratory confirmation should be considered when the
provider has a high clinical suspicion for chlamydia or gonorrhea infection in the index
case and there is concern about loss of follow-up.
Clinicians should attempt to bring partners in for comprehensive health care, including
evaluation, testing, and treatment. Clinical services provide the opportunity to ensure
treatment; confirm the diagnosis; examine the patient; test for other STDs, HIV, and
pregnancy; provide needed vaccinations; and offer risk-reduction counseling and
community referrals. These services constitute the standard of care for all partners of
patients infected with a sexually transmitted infection.
Thus, patients most appropriate for PDPT are those with partners who are unable or
unlikely to seek prompt clinical services. Factors to consider in the patient’s report are
that the partner is uninsured, lacks a primary care provider, faces significant barriers to
accessing clinical services, or will be unwilling to seek care. Providers should also
assess the acceptability of PDPT to both the patient and the partners receiving it.
PDPT does not preclude clinic attempts to get partners in for care. Even if PDPT is
provided, the partner should still be encouraged to seek follow-up care as soon as
possible.
Providers should assess the partner’s symptom status, particularly symptoms indicative
of a complicated infection; pregnancy status; and risk for severe medication allergies. If
the partner is pregnant, every effort should be made to contact her for referral to
pregnancy services and/or prenatal care. The local health department may be of
assistance for these special situations. For partners with known severe allergies to
antibiotics, PDPT should not be used.
The legislation permits PDPT regardless of the patient’s gender or sexual orientation.
However, the use of PDPT to treat certain partners (e.g., females, and men who have
sex with men (MSM)) may increase the risk of under-treating a complicated infection or
missing a concurrent STD/HIV infection in the partner. Further, PDPT is not appropriate
for patients co-infected with STDs not covered by PDPT medication; cases of suspected
child abuse, sexual assault, or abuse; or a situation in which the patient’s safety is in
doubt.
Recommended treatment regimens

The legislation does not mandate a specific antibiotic. The recommended antibiotic
therapy for PDPT is listed in the table below.
Infection diagnosed in index
Recommended medication for PDPT
Chlamydia only
Gonorrhea only (NAAT for
chlamydia negative)
Gonorrhea and chlamydia
patient with clinical signs of gonorrhea/chlamydia.) *Use of trade names is for identification only and does not imply endorsement. In 2005, 25 percent of gonococcal isolates in California were resistant to fluoroquinolones (e.g., ciprofloxacin, ofloxacin, and levofloxacin, among others). Thus, fluoroquinolones should not be used for treating gonorrhea in California [19]. Few oral cephalosporins have been studied and found to be effective against gonorrhea. Although cefixime remains a recommended regimen to treat uncomplicated infections of the cervix, urethra, or rectum, the tablet form is not available in the United States. If cefixime tablets become available, a single dose of 400 mg would be an appropriate medication for PDPT for gonorrhea infections [18]. Limited data support the effectiveness of cefpodoxime 400 mg, which is currently listed as an alternative regimen in the California Gonorrhea ). In general, oral cephalosporins are less effective in eradicating pharyngeal gonorrheal infection. Providers who are concerned that the partner is at risk for pharyngeal infection, specifically if the partner has been exposed to a male urethral infection at this site, should discuss with the patient that oral treatment may not cure pharyngeal gonorrhea in all patients and that the partner should still seek care. Patients infected with gonorrhea have high rates (35 percent to 50 percent) of co-infection with chlamydia [20]. Because of the high sensitivity of NAATs for chlamydial infection, a patient’s negative chlamydial NAAT result precludes the need for the patient or partner(s) to be treated for chlamydia. However, if chlamydial test results are not available or if a non-NAAT was negative for chlamydia, the patient and partner(s) should be treated for both gonorrhea and chlamydia [18]. For PDPT, unless chlamydia infection is ruled out with the use of a NAAT, azithromycin treatment is necessary for the presumptive treatment of chlamydia in patients diagnosed with gonorrhea. Ideally, to avoid confusion, the partner should be treated for the same infections as the patient has. However, some providers may opt to provide PDPT for chlamydia infection even if the patient’s chlamydia NAAT is negative. This approach is suggested in national guidelines [13]. The rationale for this approach is that chlamydia has not been adequately ruled out in the partner. Azithromycin two grams orally should not be used for PDPT. Although small studies have shown that this regimen is effective against uncomplicated gonococcal infections, it causes significant gastrointestinal distress, and may be expensive. In addition, some concerns that widespread use may lead to the emergence of antimicrobial resistance have been raised. All sex partners in the 60 days prior to diagnosis should be considered at risk for infection and should be treated. If the last sexual encounter was more than 60 days prior to diagnosis, the most recent sexual partner should be treated. The law does not specify how many partners may be treated through this strategy. Thus, patients should be provided with the number of doses necessary to treat each at-risk partner who can be contacted by the index patient. A combination of partner strategies also may be
used; for example, a patient with several partners may refer one partner to the clinic but
take PDPT for other partners.
The medication for PDPT may be dispensed or prescribed. The preferable method is
dispensing in a pre-packaged partner pack that includes medication, informational
materials, and clinic referral. If dispensing is not possible, prescriptions also can be
provided; however, these prescriptions must include informational materials for the
partner. The prescriptions can be written separately for the patient and for each of the
patient’s partners, or written as a single prescription with the name of the patient and
partner(s). Medication instructions may include “take as directed” and patients should
receive clear instructions for delivery of tablets.
Risk of adverse reactions to medications

Adverse reactions to single-dose cefpodoxime and azithromycin, beyond mild to
moderate side effects, are rare. This risk of allergy and adverse drug reactions may be
best mitigated through educational materials that accompany the medication, which
include explicit warnings and instructions for partners who may be allergic to penicillin,
cephalosporins, or macrolides, to seek medical advice before taking the medication.
Examples of partner therapy instructions and information are available in English and
.
All known adverse reactions should be reported to the California Department of Health
Services, STD Control Branch, via e-mail: EPT@cdph.ca.gov; or telephone:
(510) 620-3400. Known adverse reactions to cefpodoxime and azithromycin are as
follows:
Cefpodoxime is generally well tolerated. The most common side effects in patients receiving a single-dose regimen of 200 mg of cefpodoxime were related to the gastrointestinal system: nausea (1.4 percent) and diarrhea/loose stools (1.2 percent) [21]. No other side effects occurred with a frequency greater than one percent. Approximately one percent to three percent of patients have a primary hypersensitivity to cephalosporins; however, rates and cross-reactivity vary, depending on the molecular structure [22]. The risk of anaphylaxis with cephalosporin in the general population is 0.0001 percent to 0.1 percent [23-25]. However, patients with IgE-mediated allergy to penicillin are at increased risk for severe allergic reactions to cephalosporins. Evidence of IgE-mediated allergy include anaphylaxis, hypotension, laryngeal edema, wheezing, angioedema, and/or uticaria. Approximately 10 percent of patients report penicillin allergy; however, more than 90 percent of them are found not to be allergic and are able to tolerate the drug [26]. Cephalosporins are less allergenic than penicillin. The risk of cephalosporin reaction among patients with penicillin allergy is 5 percent to 17 percent for first-generation cephalosporins, 4 percent for second-generation, and only 1 percent to 3 percent for third- and fourth-generation cephalosporins [27]. Cefpodoxime, cefixime, and other cephalosporins recommended for the treatment of gonorrhea are all third-generation cephalosporins. In a retrospective cohort study of patients receiving penicillin and a subsequent cephalosporin, the risk of an allergic event was about ten-fold higher among those who had had a prior allergic reaction to penicillin; however, the absolute risk of anaphylaxis was very small: 1 in 100,000 [28]. Further, because the risk was similarly elevated among those subsequently given a sulfonamide antibiotic, cross-reactivity may not be an adequate explanation for the increased risk. The American Academy of Pediatrics guidelines, which establish a medicolegal standard of care, state that third-generation cephalosporins can be used to treat penicillin-allergic patients as long as the penicillin reaction is not severe (i.e., not IgE-mediated) [23, 24]. Skin testing for penicillin allergy is recommended for patients if the allergic reaction was consistent with IgE-mediated mechanism or if the history is unclear [29]. Such partners should be brought in for treatment for gonorrhea exposure. Azithromycin is generally well tolerated [30]. The most common side effects in patients receiving a single-dose regimen of one gram of azithromycin are related to the gastrointestinal system: diarrhea/loose stools (seven percent), nausea (five percent), abdominal pain (five percent), vomiting (two percent), and dyspepsia (one percent). Vaginitis occurs in about one percent of women taking azithromycin. No other side effects have been documented with a frequency greater than one percent. Anaphylaxis or severe allergy to macrolides generally, and to azithromycin specifically, is very rare.
Risk of under-treating complicated infections and missing concurrent STD/HIV

Another risk of PDPT is missing concurrent STD and HIV infections. There is particular
concern related to using PDPT in MSM because of the risk of missing an undiagnosed
HIV infection. In a multi-site study of STD/HIV co-infection among STD patients who
presented as contacts to infection, 6.3 percent of MSM had newly diagnosed HIV
infection [31]. The risk of missing new HIV infections may be less in areas with ready
access to HIV screening. Thus far, research on the effectiveness of PDPT in reducing
repeat infection has been limited to heterosexual populations.
Because oral cephalosporins are less effective in eradicating pharyngeal gonorrhea
infection, inadequate treatment of partners with pharyngeal infection is a potential
limitation of PDPT. Providers who are concerned that the partner is at risk for
pharyngeal infection should discuss with the patient that oral treatment may not cure
pharyngeal gonorrhea in all patients and that the partner should seek care.
Each of these risks can be mitigated through educational materials that clearly instruct
all PDPT recipients that they should seek care for STD and HIV testing, regardless of
whether or not they take the medication. In particular, those with specific symptoms
such as pelvic pain or testicular pain should seek medical care; pregnant women should
seek regular prenatal care and receive a test-of-cure (TOC); and MSM should seek HIV
testing. Examples of partner therapy instructions and information are available in
English and Spanish. Assistance from the local health
department also may be available for these challenging partner situations.
PDPT and pregnancy
Although PDPT is not contraindicated when a patient reports that his female partner
may be pregnant, providers should assess whether the pregnant partner is receiving
pregnancy services or prenatal care. Every effort should be made to contact the
pregnant partner and ensure appropriate care; PDPT should be considered a last
resort. The local health department may be of assistance for these special situations.
The need for a TOC for chlamydia and gonorrhea in pregnancy in three weeks should
be emphasized. Both recommended PDPT regimens are safe in pregnancy.
Doxycycline, a potential substitute for azithromycin, should not be used in pregnancy.
Key education and counseling

Ideally, the medications and educational material should be given to the patient to
deliver to the partner. If a prescription is used, then the provider should give the patient
both the educational material and the prescription, and encourage the patient to deliver
both the medication and accompanying informational material to the partner. Examples
of partner therapy instructions and information are available in English and Spanish
.
Providers should discuss the following key counseling messages with their patient when
prescribing PDPT:
• Partners should seek a complete STD evaluation as soon as possible, regardless • Partners should read the informational material very carefully before taking the • Partners who have allergies to antibiotics or who have serious health problems should not take the medications and should see a healthcare provider. • Partners who have symptoms of a more serious infection (e.g., pelvic pain in women, testicular pain in men, fever in women or men) should not take the PDPT medications and should seek care as soon as possible. • Partners who are or could be pregnant should seek care as soon as possible. • Patients and partners should abstain from sex for at least seven days after treatment and until seven days after all partners have been treated, in order to decrease the risk of recurrent infection. • Partners should be advised to seek clinical services for re-testing three months
Patient follow-up and re-testing at three months

To ensure the effectiveness of PDPT, providers should schedule both male and female
patients to return for re-testing for gonorrhea and chlamydia three months after
treatment.
RESOURCES

California EPT resources:

Materials are available in English and Spanish, and include instructions for chlamydia treatment, gonorrhea treatment, and combination treatment (both chlamydia and gonorrhea). ƒ Adverse reaction reporting via email: EPT@cdph.ca.gov; or telephone: (510) 620-3400 ƒ Information on California le. Search California Law, Health and Safety Code, Keyword “120582”. ƒ For information on local chlamydia and gonorrhea control efforts, please call your local STD control program, visit the California Department of Health Services STD webs, or call the California Department of Health Services STD Control Branch at (510) 620-3400. ƒ The California STD/HIV Prevention Training offers courses in the clinical management of STDs, as well as partner management and counseling. Please or call (510) 625-6000.
California STD Clinical Practice Guidelines (all available online at:

ƒ California Gonorrhea Treatment Guidelines (revised 2006) ƒ California STD Treatment Guidelines for Adults and Adolescents (two-page ƒ California Gonorrhea Screening Guidelines for Women in Family Planning and CDC STD Practice Guidelines

ƒ . ƒ Expedited Partner Therapy in the Management of Sexually Transmitted
References cited:

1. California Department of Health Services. Gonorrhea 2001-2005 Provisional Tables. www.std.ca.gov Accessed March 2007. 2. Hook EW, Handsfield HH. Gonococcal infections in the adult. In: Holmes KK, Sparling PF, Mardh P-A, et al., eds. Sexually Transmitted Diseases, 3rd Edition. New York, NY: McGraw-Hill, 1999:451-466 3. Wasserheit JN. Epidemiological synergy. Interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases. Sex Transm Dis 1992;19:61-77 4. Mehta SD, Erbelding EJ, Zenilman JM and Rompalo AM. Gonorrhoea reinfection in heterosexual STD clinic attendees: longitudinal analysis of risks for first reinfection. Sex Transm Infect 2003;79:124-8 5. Peterman TA, Tian LH, Metcalf CA, et al. High incidence of new sexually transmitted infections in the year following a sexually transmitted infection: a case for rescreening. Ann Intern Med 2006;145:564-72 6. Whittington WL, Kent C, Kissinger P, et al. Determinants of persistent and recurrent Chlamydia trachomatis infection in young women: results of a multicenter cohort study. Sex Transm Dis 2001;28:117-123 7. Oxman AD, Scott EA, Sellors JW, et al. Partner notification for sexually transmitted diseases: an overview of the evidence. Can J Public Health 1994;85 Suppl 1:S41-7 8. Golden MR, Hogben M, Handsfield HH, St. Lawrence JS, Potterat JJ and Holmes KK. Partner notification for HIV and STD in the United States: low coverage for gonorrhea, chlamydial infection, and HIV. Sex Transm Dis 2003;30:490-496 9. Trelle S, Shang A, Nartey L, Cassell JA and Low N. Improved effectiveness of partner notification for patients with sexually transmitted infections: systematic review. BMJ 2007;334:354-61 10. Golden MR, Whittington WL, Handsfield HH, et al. Effect of expeditied treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. N Engl J Med 2005;352:676-85 11. Kissinger P, Richardson-Alson G, Leichliter J and et al. Patient-delivered partner treatment for male urethritis: a randomized, controlled trial. Clin Infect Dis 2005;41:623-9 12. Schillinger JA, Kissinger P, Calvet H, et al. Patient-delivered partner treatment with azithromycin to prevent repeated Chlamydia trachomatis infection among women: a randomized, controlled trial. Sex Transm Dis 2003;30:49-56 13. Centers for Disease Control and Prevention. Expedited partner therapy in the management of sexually transmitted diseases. Atlanta, GA: U.S. Department of Health and Human Services, 2006. www.cdc.gov/std/ept (http://www.cdc.gov/std/treatment/EPTFinalReport2006.pdf). Accessed March 2007. 14. St Lawrence JS, Montano DE, Kasprzyk D, Phillips WR, Armstrong K and Leichliter JS. STD screening, testing, case reporting, and clinical and partner notification practices: a national survey of US physicians. Am J Public Health 2002;92:1784-8 15. Hogben M, McCree DH and Golden MR. Patient-delivered partner therapy for sexually transmitted diseases as practiced by U.S. physicians. Sex Transm Dis 2005;32:101-105 16. Packel LJ, Guerry S, Bauer HM, et al. Patient-delivered partner therapy for chlamydial infections: attitudes and practices of California physicians and nurse practitioners. Sex Transm Dis 2006;33:458-63 17. Klausner JD, Chaw JK. Patient-delivered therapy for chlamydia: putting research into practice. Sex Transm Dis 2003;30:509-11 18. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006;55:1-94. Available online at: www.cdc.gov/std/treatment. 19. California Department of Health Services. California Gonorrhea Treatment Guidelines. Revised December 2006. www.std.ca.gov Accessed March 2007. 20. Dicker LW, Mosure DJ, Berman SM and Levine WC. Gonorrhea prevalence and coinfection with chlamydia in women in the United States, 2000. Sex Transm Dis 2003;30:472-6 21. Pfizer Product Information. Vantin® Tablets and Oral Suspension cefpodoxime proxetil tablets and cefpodoxime proxetil for oral suspension, USP. Pfizer, 2006. http://www.pfizer.com/pfizer/download/uspi_vantin.pdf. Accessed March 2007. 22. Romano A, Torres MJ, Namour F, et al. Immediate hypersensitivity to 23. Pichichero ME. A review of evidence supporting the American Academy of Pediatrics recommendation for prescribing cephalosporin antibiotics for penicillin-allergic patients. Pediatrics 2005;115:1048-57 24. Pichichero ME. Cephalosporins can be prescribed safely for penicillin-allergic 25. Kelkar PS, Li JT-C. Cephalosporin allergy. N Engl J Med 2001;345:804-809 26. Solensky R. Drug hypersensitivity. Med Clin North Am 2006;90:233-60 27. Greenberger PA. 8. Drug allergy. J Allergy Clin Immunol 2006;117:S464-70 28. Apter AJ, Kinman JL, Bilker WB and et al. Is there cross-reactivity between penicillins and cephalosporins? Am J Med 2006;119:354.e11-20 29. Gruchalla RS, Pirmohamed M. Clinical practice. Antibiotic allergy. N Engl J Med 30. Rubinstein E. Comparative safety of the different macrolides. Int J Antimicrob 31. Stekler J, Bachmann L, Brotman RM, et al. Concurrent sexually transmitted infections (STIs) in sex partners of patients with selected STIs: implications for patient-delivered partner therapy. Clin Infect Dis 2005;40:787-93 Examples of PDPT Partner Information Materials DIRECTIONS FOR SEX PARTNERS OF PERSONS WITH CHLAMYDIA DIRECTIONS FOR SEX PARTNERS OF PERSONS WITH GONORRHEA DIRECTIONS FOR SEX PARTNERS OF PERSONS WITH CHLAMYDIA AND GONORRHEA URGENT and PRIVATE
IMPORTANT INFORMATION ABOUT YOUR HEALTH
PLEASE READ THIS VERY CAREFULLY.
Your sex partner has recently been treated for chlamydia. Chlamydia is a sexually transmitted disease (STD) that you can get from having any kind of sex (oral, vaginal, or anal) with a person who already has it. You may have been exposed. The good news is that it’s easily treated. You are being given a medicine called azithromycin (sometimes known as “Zithromax”) to treat your chlamydia. Your partner may have given you the actual medicine, or a prescription that you can take to a pharmacy. These are instructions for how to take azithromycin. The best way to take care of this infection is to see your own doctor or clinic provider
right away. If you can’t get to a doctor in the next several days, you should take the
azithromycin.
Even if you decide to take the medicine, it is very important to see a doctor as soon as
you can, to get tested for other STDs. People can have more than one STD at the
same time. Azithromycin will not cure other infections. Having STDs can increase your
risk of getting HIV, so make sure to also get an HIV test.
SYMPTOMS
Some people with chlamydia have symptoms, but many do not. Symptoms may include pain in your testicles (balls), pelvis, or lower part of your belly. You may also have pain when you urinate (pee) or when having sex. Many people with chlamydia do not know they are infected because they feel fine. BEFORE TAKING THE MEDICINE
Before you take the medicine, please read the following: The medicine is very safe. However, DO NOT TAKE if any of the following are true:
• You are female and have lower belly pain; pain during sex; vomiting; or fever. • You are male and have pain or swelling in the testicles (balls) or fever. • You have ever had a bad reaction, rash, breathing problems, or allergic reaction after taking azithromycin or other antibiotics. People who are allergic to some antibiotics may be allergic to other types. If you do have allergies to antibiotics, you should check with your doctor before taking this medicine. • You have a serious long-term illness, such as kidney, heart, or liver disease. • You are currently taking another prescription medication, including medicine for If any of these circumstances exist, or if you are not sure, do not take the azithromycin. Instead, you should talk to your doctor as soon as possible. Your doctor will find the best treatment for you. WARNINGS
If you do not take medicine to cure chlamydia, you can get very sick. If you are a woman, you might not be able to have children. If you are pregnant, it is safe to take the azithromycin, but you should still get a full check-up. HOW TO TAKE THE MEDICINE
• You can take these pills with or without food. • You should have four pills of azithromycin. Each pill contains 250mg of the medicine. You should take all four pills with water at the same time. You need to take all four pills to be cured. • Do NOT take antacids (such as Tums, Rolaids, or Maalox) for one hour before or two hours after taking the azithromycin pills. • Do NOT share or give this medication to anyone else! SIDE EFFECTS
You may experience some side effects, including:
These are well-known side effects and are not serious.
ALLERGIC REACTIONS

Very serious allergic reactions include:

• Difficulty breathing/tightness in the chest; • Hives (bumps or welts on your skin that itch intensely). If you experience any of these, call 911 or go to the nearest emergency room
immediately!
NEXT STEPS

Now that you have your azithromycin, do not have sex for the next seven days after you
have taken the medicine. It takes seven days for the medicine to cure chlamydia. If
you have sex without a condom, or with a condom that breaks, during those first seven
days, you can still pass on the infection to your sex partners. You can also get
re-infected yourself.
If you have any other sex partners, tell them you are getting treated for chlamydia, so they can get treated too. People who are infected with chlamydia once are very likely to get it again. It is a good idea to get tested for chlamydia and other STDs three months from now to be sure you did not get another infection. If you have any questions about the medicine, chlamydia, or other STDs, please call: [Each local health jurisdiction (LHJ) will list its phone number here.] For a free STD exam, testing, and medicine, you can come to: [Each LHJ will list local clinics here.] Congratulations on taking good care of yourself! URGENT and PRIVATE
IMPORTANT INFORMATION ABOUT YOUR HEALTH
PLEASE READ THIS VERY CAREFULLY.
Your sex partner has recently been treated for gonorrhea. Gonorrhea is a sexually transmitted disease (STD) that you can get from having any kind of sex (oral, vaginal, or anal) with a person who already has it. You may have been exposed. The good news is that it’s easily treated. You are being given a medicine called cefpodoxime (sometimes known as “Vantin”) to treat your gonorrhea. Your partner may have given you the actual medicine, or a prescription that you can take to a pharmacy. These are instructions for how to take cefpodoxime. The best way to take care of this infection is to see your own doctor or clinic provider right away. If you can’t get to a doctor in the next several days, you should take the cefpodoxime. Even if you decide to take the medicine, it is very important to see a doctor as soon as you can to get tested for other STDs. People can have more than one STD at the same time. Cefpodoxime will not cure other infections. Having STDs can increase your risk of getting HIV, so make sure to also get an HIV test. SYMPTOMS
Some people with gonorrhea have symptoms, but many do not. Symptoms may include having an unusual discharge from the penis, vagina, or anus. You may also have pain when you urinate (pee). Many people with gonorrhea do not know they are infected because they feel fine.
BEFORE TAKING THE MEDICINE

Before you take the medicine, please read the following: The medicine is very safe. However, DO NOT TAKE if any of the following are true: • You are female and have lower belly pain; pain during sex; vomiting; or fever. • You are male and have pain or swelling in the testicles (balls) or fever. • You have one or more painful and swollen joints, or a rash all over your body. • You have ever had a bad reaction, rash, breathing problems, or an allergic reaction to cefpodoxime or other antibiotics. People who are allergic to some antibiotics may be allergic to other types. If you do have allergies to antibiotics, you should check with your doctor before taking this medicine. • You have a serious long-term illness, such as kidney, heart, or liver disease. • You are currently taking another prescription medication, including medicine for If any of these circumstances exist, or if you are not sure, do not take the cefpodoxime. Instead, you should talk to your doctor as soon as possible. Your doctor will find the best treatment for you. WARNINGS
If you performed oral sex on someone who was infected with gonorrhea, the medicine may not work as well. You should see a doctor to get stronger medicine. If you do not take medicine to cure gonorrhea, you can get very sick. If you’re a woman, it can make you unable to have children. If you are pregnant, it is safe to take the cefpodoxime, but you should still get a full check-up. HOW TO TAKE THE MEDICINE
• Take these pills with food. This will decrease the chances of having an upset stomach and will increase the amount your body absorbs. • You should have two pills of cefpodoxime. Each pill contains 200 mg of the medicine. Take both pills with water at the same time. You need to take both pills to be cured. • Do NOT take antacids (such as Tums, Rolaids, or Maalox) for one hour before or • Do not share or give the cefpodoxime to anyone else!
SIDE EFFECTS

You may experience some side effects, including:


These are well-known side effects and are not serious.
ALLERGIC REACTIONS

Very serious allergic reactions include:

• Difficulty breathing/tightness in the chest; • Hives (bumps or welts on your skin that itch intensely). If you experience any of these, call 911 or go to the nearest emergency room
immediately!
NEXT STEPS

Now that you have your cefpodoxime, do not have sex for the next seven days after you
have taken the medicine. It takes seven days for the medicine to cure gonorrhea. If
you have sex without a condom, or with a condom that breaks, during those first seven
days, you can still pass on the infection to your sex partners. You can also get
re-infected yourself.
If you have any other sex partners, tell them you are getting treated for gonorrhea, so they can get treated too. If you think you do have symptoms of a gonorrhea infection and they do not go away within seven days after taking this medicine, please go to a doctor for more testing and treatment. People who are infected with gonorrhea once are very likely to get it again. It is a good idea to get tested for gonorrhea and other STDs three months from now, to be sure you did not get another infection. If you have any questions about the medicine, gonorrhea, or other STDs, please call: [Each local health jurisdiction (LHJ) will list its phone number here.] All calls are confidential. For a free STD exam, testing, and medicine, you can come to: [Each LHJ will list local clinics here.] Congratulations on taking good care of yourself! URGENT and PRIVATE
IMPORTANT INFORMATION ABOUT YOUR HEALTH
PLEASE READ THIS VERY CAREFULLY.
Your sex partner has recently been diagnosed with one or more sexually transmitted diseases (STDs). This means you may have been exposed to gonorrhea and chlamydia. You can get gonorrhea and chlamydia from having any kind of sex (oral, vaginal, or anal) with a person who already has them. The good news is that they are easily treated. You are being given two different types of medicine. One is called cefpodoxime (sometimes known as “Vantin”). It will cure gonorrhea. The other is called azithromycin (sometimes known as “Zithromax”). It will cure chlamydia. Your partner may have given you both medicines, or a prescription that you can take to a pharmacy. These instructions are for how to take cefpodoxime and azithromycin. The best way to take care of these infections is to see your own doctor or clinic provider
right away. If you can’t get to a doctor in the next several days, you should take both
medicines.
Even if you decide to take the medicines, it is very important to see a doctor as soon as
you can, to get tested for other STDs. People with gonorrhea are likely to also be
infected with chlamydia. You should take the pills for both.
You may have been exposed to other STDs that cefpodoxime and azithromycin will not
cure. It is still important that you get tested for other STDs. Having STDs can increase
your risk of getting HIV, so make sure to also get an HIV test.
SYMPTOMS

Some people with gonorrhea and chlamydia have symptoms, but many do not.
Symptoms of gonorrhea and chlamydia may include having an unusual discharge from
the penis, vagina, or anus. You may also have pain when you urinate (pee), or pain in
your groin, testicles, pelvis, or lower belly. Women may experience pain during sex.
Many people with gonorrhea and chlamydia do not know they are infected because they feel fine. BEFORE TAKING THE MEDICINE
Before you take the medicine, please read the following: The medicines are very safe. However, DO NOT TAKE if any of the following are true: • You are female and have lower belly pain; pain during sex; vomiting; or fever. • You are male and have pain or swelling in the testicles (balls) or fever. • You have one or more painful and swollen joints, or a rash all over your body. • You have ever had a bad reaction, rash, breathing problems, or allergic reaction after taking cefpodoxime, azithromycin, or other antibiotics. People who are allergic to some antibiotics may be allergic to other types. If you do have allergies to antibiotics, you should check with your doctor before taking these medicines. • You have a serious long-term illness, such as kidney, heart, or liver disease. • You are currently taking another prescription medicine, including medicine for If any of these circumstances exist, or if you are not sure, do not take these medicines. Instead, you should talk to your doctor as soon as possible. Your doctor will find the best treatment for you. WARNINGS
If you performed oral sex on someone who was infected with gonorrhea, the medicine may not work as well. You need to see a doctor to get stronger medicine. If you do not take medicine to cure gonorrhea or chlamydia, you can get very sick. If you’re a woman, you might not be able to have children. If you are pregnant, it is safe to take these medicines, but you should still get a full check-up. HOW TO TAKE THE MEDICINE
• Take the medicines with food. This will decrease the chances of having an upset stomach, and will increase the amount your body absorbs. • You should have two pills of cefpodoxime (200mg each), and four pills of azithromycin (250 mg each). Take all six pills with water at the same time. You need to take all six pills in order to be cured. • Do NOT take antacids (such as Tums, Rolaids, or Maalox) for one hour before or • Do NOT share or give these medicines to anyone else!
SIDE EFFECTS
You may experience some side effects, including:
These are well-known side effects and are not serious.
ALLERGIC REACTIONS

Very serious allergic reactions include:

• Difficulty breathing/tightness in the chest; • Hives (bumps or welts on your skin that itch intensely). If you experience any of these, call 911 or go to the nearest emergency room
immediately!
NEXT STEPS
Now that you have your medicines, do not have sex for the next seven days after you have taken the medicines. It takes seven days for the medicines to cure gonorrhea and chlamydia. If you have sex without a condom, or with a condom that breaks, during those first seven days, you can still pass on the infection to your sex partners. You can also get re-infected yourself. If you have any other sex partners, tell them you are getting treated for gonorrhea and chlamydia, so they can get treated too. If you think you do have symptoms of a gonorrhea infection and they do not go away within seven days after taking this medicine, please go to a doctor for more testing and treatment. People who are infected with gonorrhea and chlamydia once are very likely to get infected again. It is a good idea to get tested for gonorrhea, chlamydia, and other STDs three months from now to be sure you did not get another infection. If you have any questions about the medicine, gonorrhea, chlamydia, or other STDs, please call: [Each local health jurisdiction (LHJ) will list its phone number here.] All calls are confidential. For a free STD exam, testing, and medicine, you can also come to: [Each LHJ will list local clinics here.] Congratulations on taking good care of yourself! For more information on gonorrhea, chlamydia, and other STDs, please visit .

Source: http://m.cchealth.org/std/pdf/patient_delivered_partner_therapy_2007.pdf

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NFL VIRTUAL TAILGATE REGISTRATION CONTEST OFFICIAL RULES & REGULATIONS 1. GENERAL The NFL VIRTUAL TAILGATE REGISTRATION CONTEST (the " Contest” ) is open to legal residents of Canada and shall be construed according to the laws of the Province of Ontario, Canada. YOU MUST HAVE REACHED THE AGE OF MAJORITY IN YOUR PROVINCE/ TERRITORY OF RESIDENCE AT THE TIME OF ENTRY TO

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