Hello, and welcome to the California Family Health Council’s webcasts about Patient Delivered Partner Therapy, or PDPT. I’m Linda Creegan, family nurse practitioner with the California STD/HIV Prevention Training Center.
This webcast is Part 1 of a 3-part series. In this segment, I’ll be discussing the specifics of using PDPT in your clinic settings. Please listen to Parts 2 and 3 for some background information about PDPT for chlamydia and gonorrhea infections, and about California law as it relates to PDPT, and the California Family Health Council’s Azithromycin distribution program for PDPT.
PDPT is a type of expedited partner therapy, and essentially means that the provider gives medication or a prescription to the patient to take to her partner. Think of PDPT as a harm-reduction option for partner management, instead of as the first choice. This method is most feasible and effective in cases where the patient has contact with her partners, but doesn’t believe they will be willing or able to access care in a timely fashion.
In 2001, a law was passed in California that expressly permits medical providers, including physicians, nurse practitioners and physician assistants, to use PDPT for their patients with chlamydia. In 2007, the law was extended to cover PDPT for gonorrhea as well. PDPT is not feasible for the treatment of partners of persons diagnosed with syphilis, however, because treatment for syphilis requires an injection.
Here are the medication regimens currently recommended for PDPT: For chlamydia, azithromycin in and 1 gran single oral dose, And for gonorrhea, cefixime 400 mg in a single oral dose, together with azithromycin 1 gram, also in a single oral dose.
Let’s take a little detour for just a moment now to talk about some special concerns regarding PDPT for gonorrhea infections. You are no doubt aware that the treatment of gonorrhea is a special challenge, because of developing antibiotic resistance. The CDC currently recommended a dual therapy approach, that is, using 2 antibiotics for the treatment of all cases of gonorrhea, even when the chlamydia test is negative. Here you see those regimens given: the preferred combination is ceftriaxone 250 mg IM with azithromycin 1 gram.
Recently, increasing numbers of gonorrhea Isolates have shown decreased susceptibility to various antibiotics, including the cephalosoprins. In this graph, you see at the bottom of the columns towards the right in dark and lighter red, that the percentage of isolates showing some resistance to this class of antibiotics has increased markedly in the past few years. So with 2 antibiotics used together as dual therapy, we hope to delay the spread of these resistant strains.
So for gonorrhea in particular, PDPT should not be considered the first choice, but as a harm-reduction approach in cases where patients are quite sure that partners will not seek treatment in person.
This slide reiterates some important points: Regarding both chlamydia and gonorrhea infections, PDTD is used for partners who are unable or unlikely to seek care, rather than as a first line recommendation, or as a substitute for working to see that partners find a source of care for an in-person evaluation.
PDPT can be used for any partner from within the prior 2 months, or for the most recent partner if the patient hasn’t had sex with anyone in the last 2 months. PDPT can be used for both male and female partners, and the number of doses given will be determined by the # of partners the patient feels he or she needs to use this option for.
It’s very important to package written materials about the infection, about the medication, and about where to go for medical care with every dose of PDPT. Patient may not themselves be aware of limitations to use of PDPT that their partners have. For female partners, this information should include information regarding signs and symptoms of PID, so that women know to seek care immediately if they are experiencing these , because the PDPT regimen is not adequate for treatment of PID.
PDPT is not completely without risks, but in fact no treatment ever is. The risks associated with the medications themselves are minimal. It is true that PDPT might compromise the quality of care that a partner receives. When patients come to be evaluated b/o an exposure to an STD, they would be tested for other STDs; of course this is not happening for partners who take PDPT. So again, PDPT should be reserved for use in those cases where patients suspect that if they don’t take the medication to the partner, the partner will not receive treatment at all.
At times a client is co-infected with more than one STD – gonorrhea and syphilis, for instance. In these cases, PDPT should not be used. Nor should PDPT be used in cases of child sexual abuse, sexual assault or if the patient feels it may be unsafe for her to discuss the treatment with her partner. And of course if the partner is known to be allergic to one of the PDPT medication, they should not take it. Information about allergies should always be included in the information that is given with the medication.
So to summarize, here are the key counseling points about PDPT for our patients with chlamydia or gonorrhea.
For the best and most complete care, partners should find a source for medical evaluation. They can do this even after they have taken PDPT, to be tested for other infections. Information about the infection and the medication accompany the PDPT dose, and should be read carefully by the partner.
Partners with allergies or any kind of health condition that affects their ability to take medication should not use PDPT, but should see a health care provider instead.
Partners who have symptoms, like abdominal pain in women or testicular pain in men, should not take PDPT.
Partners who are pregnant can use PDPT, but should be strongly encouraged to seek care because of the contact. And even with the single dose treatment, patients and their partners should abstain from sex for seven days after taking the medication, to prevent reinfection.
The last few slides point you towards some resources, for more information about PDPT and to help your clinic to implement this option of partner treatment.
The Infertility Prevention Project here in Region IX has a great document devoted to issues of PDPT and retesting. You’ll find that posted at this website.
The California Family Health Council has examples of information factsheets in several languages, which you can use with PDPT. Here’s that web address…..
And finally, you can contact Aileen Barandas with CFHC directly with any questions you may have; here is her email address and phone number. We’ve covered the important guidelines for using PDPT with you patients. Be sure to listen to the other 2 short webcasts, about the background reasons for PDPT, and about the California Family Health Council’s PDPT Distribution program, whereby your Title X clinic can receive azithromycin, free of charge, specifically to use for PDPT. Thanks for listening, and thanks for the work you do.
PDPT Webcast - Part 2 - Using Patient Delivered Partner Therapy
Using Patient Delivered PartnerTherapy (PDPT) for PartnerManagement advocate facilitate evaluate educate research
CFHC’s PDPT Trainings• This is Part 2 of a 3-part series on PDPT – Part 1: Background information about PDPT – Part 2: Using PDPT for Partner Management – Part 3: PDPT Law in California and CFHC PDPT Guidelines• For more information on PDPT:http:// www.cdph.ca.gov/pubsforms/Guidelines/Documents/CA-STD-PDPT-Guidelines-1- advocate facilitate evaluate educate research
What is PDPT? Patient delivered partner therapy (PDPT) is one form of EPT. PDPT involves providing the index client with the appropriate medication, information and educational materials for sexual partners exposed to the index client’s STI(s). PDPT is an alternative to traditional partner notification methods for testing and treatment of STIs. advocate facilitate evaluate educate research
PDPT and California Law Chlamydia trachomatis (since 2001) Neisseria gonorrhoeae (since 2007) Because optimal treatment of syphilis requires an injection, PDPT is not recommended for syphilis. advocate facilitate evaluate educate research
Antibiotics for PDPT Chlamydia: Azithromycin 1 gram orally once Gonorrhea: Cefixime 400mg orally once + Azithromycin 1 gram orally once advocate facilitate evaluate educate research
Gonorrhea Treatment: Dual Therapy Approach Ceftriaxone 250 mg Azithromycin 1 gm orally in a single dose PLUS OR IM in a single dose Doxycyline 100 mg orally twice daily for 7 days OR If ceftriaxone is not an option, Cefixime 400 mg Azithromycin 1 gm orally in a single dose PLUS OR orally in a single dose Doxycyline 100 mg orally twice daily for 7 daysCDC 2010 STD Treatment Guidelines:www.cdc.gov/std/treatment advocate facilitate evaluate educate research
Neisseria gonorrhoeae Isolates with CDC "Alert" Values or Decreased Susceptibility to Cephalosporins in Five California STD Clinics, 1987-2011 * ** Cefixime was dropped from testing panel in 2007 and reinstated in2009; Cefpodoxime was added to testing panel in 2009 advocate facilitate evaluate educate research
PDPT for Gonorrhea Not first line of partner management for GC. Other aspects of PDPT dispensing and counseling remain the same. advocate facilitate evaluate educate research
When Should PDPT Be Used? Only use PDPT if partner(s) are unable to or are unlikely to seek care. PDPT should not be a substitute for clients returning with their partners for treatment. Every attempt should be made to bring partners in for clinical evaluation and treatment. advocate facilitate evaluate educate research
Which Partners Can Get PDPT? All sex partners within previous 2 months of client’s symptoms or diagnosis. If client had no sex partners within last 60 days, then most recent sex partner(s). PDPT is appropriate for both male and female partners. There is no limit to # doses that can be distributed for sex partners. advocate facilitate evaluate educate research
Educational Materials with PDPT Written informational materials directed to the partner should ALWAYS accompany PDPT medication. Materials should discuss: Medication instructions Warnings and referrals Concern about pelvic inflammatory disease (PID) in female partners. advocate facilitate evaluate educate research
Risks of PDPT As with any treatment, there is always a risk of adverse reactions to medications. Minimal risks associated with single dose azithromycin, and cefixime. PDPT may compromise the quality of care for partners, especially if the partner is co- infected with another STI or has undiagnosed HIV infection. advocate facilitate evaluate educate research
When Should PDPT NOT BeUsed? Do not use PDPT with clients co-infected with STDs that are not treatable by PDPT medications. Do not use PDPT in cases of suspected child abuse, sexual assault, or cases where the client’s safety is in question. Do not use PDPT when it is known that partners have severe allergies to antibiotics. advocate facilitate evaluate educate research
Key PDPT Counseling Messages advocate facilitate evaluate educate research
Key PDPT Counseling Messages1. Partners should seek a complete STD evaluation as soon as possible, regardless of whether they take the medication.2. Partners should read the informational material very carefully before taking the medication. advocate facilitate evaluate educate research
Key PDPT Counseling Messages3. Partners who have allergies to antibiotics or who have serious health problems should not take the medications and should see a healthcare provider. advocate facilitate evaluate educate research
Key PDPT Counseling Messages4. 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. advocate facilitate evaluate educate research
Key PDPT Counseling Messages5. Partners who are or could be pregnant should seek care as soon as possible.6. Clients 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 re-infection. advocate facilitate evaluate educate research
Resources for PDPTImplementation advocate facilitate evaluate educate research
IPP Guidance & Toolkit CARDEA Region IX Guidance and Toolkit for the Use of Expedited Partner Therapy and Retesting at Three Months To Prevent and Detect Chlamydia and Gonorrhea Reinfections http://www.cardeaservices.org/projects/documents/R9_ EPT_Retesting_Nov08.pdf advocate facilitate evaluate educate research
CFHC Patient Education Materials Samples of the chlamydia PDPT patient education handouts in English, Spanish, Chinese, and Vietnamese are available for free on the CFHC website, as well as gonorrhea PDPT patient education handouts in English and Spanish. http://www.cfhc.org/Resources/SamplesFile/sexually -transmitted-disease.html advocate facilitate evaluate educate research
Questions? For CFHC PDPT Program information, please contact: Aileen Barandas MSN, NP STD Programs Director firstname.lastname@example.org 510.486.0412 ext 2334 advocate facilitate evaluate educate research
Medical and scientific consultation for this webcast was provided by the CaliforniaDepartment of Public Health, STD Control Branch For more information, please visit www.std.ca.gov advocate facilitate evaluate educate research