Chlamydia and Gonorrhea: Screening -- Sexually Active Men


General

Grade: I The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.

Specific Recommendations

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydia and gonorrhea in men.

Frequency of Service

No information available.

Risk Factor Information

No information available.


Clinical

Patient Population Under Consideration

This recommendation applies to all sexually active adolescents and adults, including pregnant women.

Assessment of Risk

Age is a strong predictor of risk for chlamydial and gonococcal infections, with the highest infection rates occurring in women aged 20 to 24 years, followed by females aged 15 to 19 years. Chlamydial infections are 10 times more prevalent than gonococcal infections in young adult women. Among men, infection rates are highest in those aged 20 to 24 years.

Other risk factors for infection include having a new sex partner, more than 1 sex partner, a sex partner with concurrent partners, or a sex partner who has an STI; inconsistent condom use among persons who are not in mutually monogamous relationships; previous or coexisting STI; and exchanging sex for money or drugs. Prevalence is also higher among incarcerated populations, military recruits, and patients receiving care at public STI clinics. There are also racial and ethnic differences in STI prevalence. In 2012, black and Hispanic persons had higher rates of infection than white persons. Clinicians should consider the communities they serve and may want to consult local public health authorities for guidance on identifying groups that are at increased risk. Gonococcal infection, in particular, is concentrated in specific geographic locations and communities.

Screening Tests

Chlamydia trachomatis and Neisseria gonorrhoeae infections should be diagnosed by using nucleic acid amplification tests (NAATs) because their sensitivity and specificity are high and they are approved by the U.S. Food and Drug Administration for use on urogenital sites, including male and female urine, as well as clinician-collected endocervical, vaginal, and male urethral specimens. Most NAATs that are approved for use on vaginal swabs are also approved for use on self-collected vaginal specimens in clinical settings. Rectal and pharyngeal swabs can be collected from persons who engage in receptive anal intercourse and oral sex, although these collection sites have not been approved by the U.S. Food and Drug Administration. Urine testing with NAATs is at least as sensitive as testing with endocervical specimens, clinician- or self-collected vaginal specimens, or urethral specimens that are self-collected in clinical settings. The same specimen can be used to test for chlamydia and gonorrhea.

Screening Intervals

In the absence of studies on screening intervals, a reasonable approach would be to screen patients whose sexual history reveals new or persistent risk factors since the last negative test result.

Treatment and Interventions

Chlamydial and gonococcal infections respond to treatment with antibiotics. Centers for Disease Control and Prevention guidelines for treatment of sexually transmitted diseases (STDs) and expedited partner therapy are available at  www.cdc.gov/std/treatment/2010/default.htm  and www.cdc.gov/std/ept/default.htm, respectively.

Posttest counseling is an integral part of management of patients with a newly diagnosed STI. The USPSTF recommends offering or referral to high-intensity behavioral counseling for patients with current or recent STIs (www.uspreventiveservicestaskforce.org/uspstf/uspsstds.htm). Posttest counseling can also serve as an educational opportunity for patients who present with STI concerns but test negative for infection. It should address safe sex practices that can reduce disease transmission or reinfection; motivational interviewing strategies may also promote risk-reducing behaviors.

To maximize adherence, the CDC recommends that drug treatment be dispensed on site. The CDC recommends that all sex partners of infected patients from the preceding 60 days be evaluated, tested, and treated for infection. It also recommends that infected patients be instructed to abstain from sexual intercourse until after they and their sex partners have completed treatment and no longer have symptoms. For a sex partner who cannot be linked to care, the CDC suggests that clinicians consider expedited partner therapy, which allows for the delivery of a drug or drug prescription to the partner by the patient, a disease investigation specialist, or a pharmacy. Because of a high likelihood of reinfection, the CDC also recommends retesting all patients diagnosed with chlamydial or gonococcal infection 3 months after treatment, regardless of whether they believe their partners have been treated.

In pregnant women, a test of cure to document eradication of chlamydial infection 3 weeks after treatment is recommended. Pregnant women diagnosed with a chlamydial or gonococcal infection in the first trimester should be retested 3 months after treatment. Gonococcal neonatal ophthalmia, which can be transmitted from an untreated woman to her newborn, may be prevented with routine topical prophylaxis at delivery. However, prevention of chlamydial neonatal pneumonia and ophthalmia requires prenatal detection and treatment.

Suggestions for Practice Regarding the I Statement

Potential Preventable Burden

Chlamydial and gonococcal infections are often asymptomatic in men but may result in urethritis, epididymitis, and proctitis. Uncommon complications include reactive arthritis (chlamydia) and disseminated gonococcal infection. Infections at extragenital sites (such as the pharynx and rectum) are typically asymptomatic. Chlamydial and gonococcal infections may facilitate HIV transmission in men and women. Median prevalence rates among men who have sex with men who were tested in STD Surveillance Network clinics in 2012 were 16% for gonorrhea and 12% for chlamydia.

Potential Harms

Potential harms of screening for chlamydia and gonorrhea include false-positive or false-negative results as well as labeling and anxiety associated with positive results.

Costs

According to the CDC, STIs in the United States are associated with an annual cost of almost $16 billion. Among nonviral STIs, chlamydia is the most costly, with total associated costs of $516.7 million (range, $258.3 to $775.0 million). Gonococcal infections are associated with total costs of $162.1 million (range, $81.1 to $243.2 million).

In 2008, estimated direct lifetime costs (in 2010 U.S. dollars) per case of chlamydial infection were $30 (range, $15 to $45) in men and $364 (range, $182 to $546) in women. Similarly, gonococcal infections were associated with direct costs of $79 (range, $40 to $119) in men and $354 (range, $182 to $546) in women.

Current Practice

A review of health care claims of 4296 male and female patients presenting for general medical or gynecologic examinations from 2000 to 2003 found that a large proportion of those with high-risk sexual behaviors did not receive STI or HIV testing during their visit. According to a review of diagnostic billing codes for patients with high-risk sexual behaviors, men were significantly less likely than women to be tested for chlamydia (20.7% vs. 56.9%) and gonorrhea (20.7% vs. 50.9%), although they were more likely to be tested for HIV (79.3% vs. 38.8%) and syphilis (39.1% vs. 27.6%).

Other Approaches to Prevention

The USPSTF has issued recommendations on screening for other STIs, including hepatitis B, genital herpes, HIV, and syphilis. The USPSTF has also issued recommendations on behavioral counseling for all sexually active adolescents and for adults who are at increased risk for STIs. These recommendations are available at www.uspreventiveservicestaskforce.org.

Useful Resources

The CDC provides more information about STDs, including chlamydia and gonorrhea, at www.cdc.gov/std/default.htm. Its recommendations for STD prevention include clinical prevention guidance (available at www.cdc.gov/std/treatment/2010/clinical.htm) and patient prevention information (available at www.cdc.gov/std/prevention/default.htm). The CDC has also issued guidance for clinicians on how to take a sexual history (available at www.cdc.gov/std/treatment/SexualHistory.pdf).

The Community Preventive Services Task Force has issued several recommendations on the prevention of HIV/AIDS, other STIs, and teen pregnancy. The Community Guide discusses interventions that have been efficacious in school settings and for men who have sex with men (available at www.thecommunityguide.org/hiv/index.html). Canadian guidelines on STIs are available at www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/index-eng.php.

Other Considerations

Implementation

Although the prevalence of chlamydia and gonorrhea differs, the risk factors for infection overlap and the USPSTF recommends screening for both simultaneously.

Research Needs and Gaps

Studies evaluating the effectiveness of different screening strategies for identifying persons who are at increased risk for infection, cotesting for concurrent STIs, and different screening intervals are needed to inform practice guidelines. Studies evaluating the effectiveness of screening asymptomatic men to reduce the consequences of infection and transmission to sexual partners are needed. Identification of subgroups for whom screening may be effective is a high priority. Possible subgroups include men who have sex with men, sexually active males younger than 24 years, and men residing in high-prevalence communities. Currently, no studies provide data about the potential adverse effects of screening in any population.

Rationale

Importance

Chlamydia and gonorrhea are the most commonly reported sexually transmitted infections (STIs) in the United States. In 2012, more than 1.4 million cases of chlamydia and more than 330,000 cases of gonorrhea were reported to the Centers for Disease Control and Prevention (CDC). Chlamydial infections are 10 times more prevalent than gonococcal infections (4.7% vs. 0.4%) in women aged 18 to 26 years.
 
Although most identified cases are reported, the incidence of chlamydia and gonorrhea is difficult to estimate because most infections are asymptomatic and are therefore never diagnosed. The CDC estimates that more than 800,000 persons are infected with gonorrhea in the United States each year, and fewer than half of these infections are diagnosed and reported.
 
Chlamydial and gonococcal infections are often asymptomatic in women; however, asymptomatic infection may lead to pelvic inflammatory disease (PID) and its associated complications, such as ectopic pregnancy, infertility, and chronic pelvic pain. Newborns of women with untreated infection may develop neonatal chlamydial pneumonia or gonococcal or chlamydial ophthalmia. Infection may lead to symptomatic urethritis and epididymitis in men, although gonorrhea is more likely than chlamydia to be symptomatic in men compared with women. Both types of infection may facilitate HIV transmission

Detection

The USPSTF found convincing evidence that screening tests can accurately detect chlamydia. The USPSTF also found convincing evidence that screening tests can accurately detect gonorrhea.

Benefits of Early Detection and Intervention or Treatment

The USPSTF found adequate direct evidence that screening reduces complications of chlamydial infection in women who are at increased risk, with a moderate magnitude of benefit.
 
The USPSTF found adequate evidence that screening for gonorrhea results in a moderate magnitude of benefit based on the large proportion of cases that are asymptomatic, the effectiveness of antibiotic treatment to reduce infections, and the high morbidity associated with untreated infections.
 
The USPSTF found inadequate evidence that screening for chlamydia and gonorrhea reduces complications of infection and transmission or acquisition of either disease or HIV in men. The magnitude of benefit is unknown.

Harms of Early Detection and Intervention or Treatment

The USPSTF found adequate evidence that the harms of screening for chlamydia and gonorrhea are small to none.

USPSTF Assessment

The USPSTF concludes with moderate certainty that screening for chlamydia is associated with moderate net benefit in all sexually active women aged 24 years or younger and in older women who are at increased risk for infection.
 
The USPSTF concludes with moderate certainty that screening for gonorrhea is associated with moderate net benefit in all sexually active women aged 24 years or younger and in older women who are at increased risk for infection.
 
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydia and gonorrhea in men.


Others

The CDC recommends annual screening for chlamydia in all sexually active females aged 25 years or younger and in older women with specific risk factors (for example, those who have new or multiple sex partners and those reporting that their sex partner may have a concurrent sex partner), as well as screening for gonorrhea in sexually active females who are at increased risk for infection (such as those aged <25 years). The CDC does not recommend routine screening for chlamydia and gonorrhea in the general population. It recommends that clinicians consider screening for chlamydia in sexually active young men in high-prevalence settings. The CDC recommends annual screening for chlamydia and gonorrhea in men who have sex with men, based on exposure history, with more frequent screening in populations at highest risk. The CDC recommends screening for chlamydia and gonorrhea upon intake in juvenile detention or jail facilities in females aged 35 years or younger. It also recommends screening for gonorrhea in high-risk pregnant women and for chlamydia in all pregnant women at the first prenatal visit. The CDC recommends retesting in the third trimester in pregnant women with continued risk for infection and in those who test positive at their first prenatal visit. Because of the high likelihood of reinfection, the CDC also recommends retesting all patients diagnosed with chlamydial or gonococcal infections 3 months after treatment, regardless of whether they believe their partners have been treated. The American Congress of Obstetricians and Gynecologists recommends screening for chlamydia and gonorrhea in sexually active females aged 25 years or younger. It also recommends screening for chlamydia in women older than 25 years who have risk factors (such as new or multiple sex partners) and for gonorrhea in asymptomatic women who are at high risk for infection (such as those with a previous gonococcal infection, other STIs, or new or multiple sex partners, as well as inconsistent condom use, commercial sex work, or illicit drug use). The American Academy of Pediatrics recommends routine annual screening for chlamydia and gonorrhea in all sexually active females aged 25 years or younger. It recommends routine annual screening for rectal and urethral chlamydia in sexually active adolescent and young adult males who have sex with males if they engage in receptive anal or insertive intercourse, respectively, and routine annual screening for pharyngeal, rectal, and urethral gonorrhea if they engage in receptive oral, anal, or insertive intercourse, respectively. It recommends screening every 3 to 6 months for persons in this population if they are at high risk (for example, if they have multiple or anonymous partners, sex in conjunction with illicit drug use, or sex partners who participate in these activities). It also recommends screening adolescents and young adults who have been exposed to chlamydia or gonorrhea in the past 60 days from an infected partner. Clinicians should consider annual screening for chlamydia in sexually active males in settings with high prevalence rates, such as jail or juvenile correction facilities, national job training programs, STD clinics, high school clinics, and adolescent clinics (for patients who have a history of multiple partners). Clinicians should consider annual screening for gonorrhea in other sexually active and young adult males on the basis of individual and population-based risk factors. The American Academy of Family Physicians recommends screening for chlamydia and gonorrhea in sexually active females aged 24 years or younger and in older women who are at increased risk for infection. It concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydia and gonorrhea in men. Canadian guidelines recommend screening for chlamydia in all sexually active males and females younger than 25 years and retesting at 6 months after treatment in infected patients. They also recommend screening for chlamydia and gonorrhea at the first prenatal visit and again during the third trimester in pregnant women who test positive or are at increased risk for infection.


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