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Expedited Partner Therapy (EPT) guidelines
Expedited partner therapy (EPT) refers to treating the sex partners of persons with a curable sexually transmitted infection (STI) without requiring that the partner first undergo a medical evaluation. In most instances, this involves giving a patient medication to give to their sex partners, or patient delivered partner therapy (PDPT).
Questions about EPT
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Is EPT effective?
Yes. There have been three published randomized controlled trials of EPT conducted in the U.S., including one conducted in King County, WA1,2,3. These studies demonstrated that EPT decreases the risk of reinfection among heterosexuals with gonorrhea or chlamydial infection, and increases the proportion of partners who receive treatment. This conclusion is further supported by a meta-analysis of randomized trials and observational studies and by a review conducted by the U.S. Centers for Disease Control and Prevention.4,5
1 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. Jan 2003;30(1):49-56.
2 Golden MR, Whittington WL, Handsfield HH, et al. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. N Engl J Med. Feb 17 2005;352(7):676-685.
3 Kissinger P, Mohammed H, Richardson-Alston G, et al. Patient-delivered partner treatment for male urethritis: a randomized, controlled trial. Clin Infect Dis. Sep 1 2005;41(5):623-629.
4 Trelle S, Shang A, Nartey L, Cassell JA, Low N. Improved effectiveness of partner notification for patients with sexually transmitted infections: systematic review. Bmj. Feb 17 2007;334(7589):354.
5 CDC. Expedited partner therapy in the management of sexually transmitted diseases. Atlanta: U.S. Department of Health and Human Services; 2006.
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Is EPT legal?
Yes. EPT is legal in Washington state. Washington state has had an EPT program since the late 1990s and tens of thousands of persons have received EPT since that time. Prior to the start of the program, the issue of EPT legality was reviewed by the Washington tate Department of Health, The Washington State Board of Medical Quality Assurance and the Washington State Pharmacy Board, all of which supported the use of EPT. Medical providers giving patients medication to give to their sex partners are required to ensure that partners receive written information about the medications, including an allergy warning. This information is included in the free EPT packs provided by Public Health and these packs have been approved by the Washington State Board of Pharmacy.
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Is EPT safe?
EPT is safe. No instances of major adverse reactions were reported in randomized trials of EPT, nor have such reactions been observed through public health surveillance undertaken with the widespread roll out of EPT in Washington State. A large study assessing the risk of missed STI diagnoses in persons receiving medical evaluations because of contact to sex partners with gonorrhea or chlamydia found that the risk of concurrent STI diagnoses (including HIV infection) was very low among heterosexuals6. HIV was relatively common among MSM seeking care as because of an exposure to gonorrhea or chlamydia and, in part, it is because of this risk that EPT is not recommended in MSM. Public Health in King County attempts to contact all MSM with gonorrhea or chlamydia with the goal of assisting them with partner notification and treatment.
6 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. Mar 15 2005;40(6):787-793.
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Are medical providers in Washington state using EPT?
Yes. Medical providers in Washington State use more EPT than in any other part of the U.S. Based on interviews with randomly selected patients, over half of heterosexuals with gonorrhea or chlamydia are offered them medication to give to their partner(s) by their medical provider, and one-third report receiving medication to give to their partner(s)7.
7 Golden MR, Kerani RP, Stenger M, et al. Uptake and Population-Level Impact of Expedited Partner Therapy (EPT) on Chlamydia trachomatis and Neisseria gonorrhoeae: The Washington State Community-Level Randomized Trial of EPT. PLoS Med. Jan 2015;12(1):e1001777.
Guidelines for use
Providers should offer heterosexual patients medication to give to their sex partners if the provider cannot otherwise assure the partners' treatment. This guideline is consistent with current guidelines from the U.S. Centers for Disease Control and Prevention and Washington State Guidelines, and has been endorsed by the Washington State Board of Medical Quality Assurance.
Instructions on how to prescribe EPT through community pharmacies
Federal guidance no longer permits purchases of these medications by DOH or PHSKC for widespread distribution. Providers can call or fax a prescription in the name of the intended recipient (i.e. the sex partner of their patient) directly to any pharmacy for gonorrhea or chlamydial EPT.
| PHSKC currently recommends the following regimens for EPT | |
|---|---|
| For gonorrhea with or without chlamydia | Cefixime 800mg PO x1 PLUS Azithromycin 2g PO x1 (ok to split the azithromycin into two 1g doses given 12 hours apart) |
| For chlamydia only | Azithromycin 1g PO x1 NOTE: The PHSKC recommended regimens differ from the CDC's 2021 STI Treatment Guidelines recommended regimens for EPT. |
The CDC has recently updated their EPT recommendations in the 2021 STD Treatment Guidelines. Notable changes include:
- The use of doxycycline 100mg PO BID for 7 days for chlamydia EPT
- An increase in the cefixime dose to 800mg PO once for gonorrhea EPT
- Recommendation to use shared decision-making with MSM regarding EPT use.
The PHSKC HIV/STD Program's EPT recommendations currently differ from each of these changes in notable ways.
- Use azithromycin 1g PO for chlamydia EPT.
This departure from CDC guidance is based on the lack of data on the use of doxycycline for EPT, the risk of doxycycline in pregnancy, and the side effect profile of doxycycline compared to azithromycin.
- For gonorrhea EPT, use 800mg cefixime PLUS 2g Azithromycin.
The addition of 2g of azithromycin is based primarily on the fact that cefixime alone, even at 800mg, is unlikely to cure pharyngeal gonorrhea. Recent data suggests that 20% of heterosexual male contacts to gonorrhea and 40% of female contacts are infected at the pharynx [Chow, EP et al STD, 2019; and McLaughlin, S et al abstract at CDC STD Prevention Conference 2020]. Two grams of azithromycin is used instead of one gram due to enhanced pharyngeal activity.
- PHSKC HIV/STD Program currently only recommends EPT for heterosexual cis-men and cis-women.
There are no data to suggest that EPT is effective for men who have sex with men (MSM), and recent data from New York found that among MSM who were told by a sexual partner that they may have been exposed to a specific sexually transmitted infection (STI), 15% were actually diagnosed with a different STI, including syphilis (5%) and HIV (1%) [Schillinger J et al Concurrent STI and HIV among men-who-have-sex-with-men presenting as contacts to chlamydia and gonorrhea; implications for expedited partner therapy. ISSTDR World Congress, July 2019]. The use of gonorrhea and chlamydia EPT among MSM has the potential to undertreat some infections, allow for further transmission of syphilis and HIV, and to allow for the development of complications related to untreated syphilis and HIV. Additionally, MSM are more likely to have antibiotic resistant gonorrhea, which is an additional consideration to the use of EPT for gonorrhea in MSM. Also, because doxycycline is a substantially more effective in treating rectal chlamydia than azithromycin, doxycycline is better choice when treating MSM for chlamydia.