- Hey, what's up Z-Pac?
It's your boy ZDoggMD.
Okay, today I wanna talk about
something catastrophically important
and that is sexually transmitted disease,
and no, I'm not gonna call it "sexually
transmitted infections" 'cause that's dumb,
and I won't let the word Nazis win.
We don't call it the Center for Infection Control, or CIC,
it's the Center for Disease Control.
Enjoy yourself.
Here's the problem.
Sexually transmitted diseases are
flourishing in the US and A.
We are at epidemically high levels.
In other words, we've never had levels of sexually
transmitted infections at the point where we are now.
Not only that but we're seeing resistance to antibiotics
and standard treatments for things like Gonorrhea
which is severely problematic.
So what I wanna talk about today is something
that a lot of clinicians don't even know is a thing
and that is EPT, or Expedited Partner Therapy.
Lemme back up.
Let's say you come in and you're
diagnosed with chlamydia or gonorrhea.
At this point, the doctor knows something
that you might also know which is most likely
your partner is also infected,
and it is also common for these infections
to be completely without symptoms in the partner.
So that means that if you go back to that partner,
even after getting your course of antibiotics
or your one-time treatment and you're supposed
to wait seven days after the initiation of treatment
to have sex, of course most people won't,
and you're supposed to, you know, test all your partners
for the past 60 days because they could be infected,
it doesn't hardly ever actually happen
because number one, people are lazy,
number two, people are cray, number three,
we don't have resources, right,
and so for that reason, the partner's probably
a reservoir of infection, the patient goes back,
gets reinfected, and this is a huge problem
because not only do you get reinfected,
that partner can also spread disease to other people
and promote the onset of resistance to the treatment.
So, what has historically happened is doctors tell
the patient, "listen bro" or "gal, you need to tell your
partner to come in, and here's some resources,
have 'em come in, we will test them,
we will screen them for other
sexually transmitted infections,
we'll screen them for pregnancy if it's a woman,
and we'll do counseling, and we'll
treat them as necessary.
Well, it turns out, the data has shown
that this is not a very effective strategy
because people don't follow up,
they don't have the resources,
they don't talk to their partners,
lots of different things happen.
So there was a study in 2014 looking at what happens if
you actually just go ahead and treat the sexual partner
of the patient you're treating currently.
This is called expedited partner treatment.
Now, immediately, many doctors are gonna be triggered,
and nurse practitioners and PAs are gonna be triggered.
They're gonna go "wait, wait, wait, wait, wait, wait, wait!"
Every single board of medicine in the United States
would flip out and do flip out when you treat patients
that you've never seen, don't have a
relationship with, and haven't examined.
This is common ethics; you don't treat patients
you don't have a relationship with.
Why?
Because you can cause harm.
You don't know what their allergies are,
you don't know what their other conditions are,
you haven't screened them, you haven't counseled them,
so this sounds like a terrible idea, right?
Well, in 2014 they studied this.
What happens if you just call in a prescription
for the partner of the patient you're seeing?
And only really for patients that aren't gonna come in,
they don't have the resources, etc,
or you give the patient the prescription
to give to their partner.
Well, it turns out that the data showed
that they were more likely that the partners got treated,
there was a lower risk of reinfection of your patient,
so in other words, outcomes were better.
Okay, so this was actually a really eyeopening concept
that you could actually treat a patient
that you don't have a relationship with.
Now, here's the thing, is it legal?
Well, it turns out in most states it is.
The exceptions are Kentucky and South Carolina.
In those states it's not yet legal
to treat a partner without seeing them.
There are a few states, a handful I think, six states
including Puerto Rico where it's ambiguous.
You don't really know.
Now, you can imagine the risk of this.
You're treating a patient, you don't know what their
allergies are, you don't know what other medicines
they're on, and you don't know their comorbidities are,
but on balance, the CDC, Center for Disease Control,
not infection control, has said that on balance,
it's a positive and they recommend it
because the risks of this treating a partner
are outweighed by the benefits, reducing reinfection,
reducing transmission, and reducing resistance.
So, for this reason, it turns out, and I agree with this,
it's a harm reduction strategy
that we can treat partners without seeing them,
and that CDC guidelines say you can do this,
and if you review in things like UpToDate
Etc., they also advocate this.
Now, they also advocate more studies.
So we need bigger studies to see
what are the downsides of this.
Are we having, you know allergies,
are we showing changes in resistance patterns,
are we finding that there are other adverse events?
One of the biggest difficulties is of course now
you lose a chance to counsel and screen the partner.
What if the partner has HIV and it's untested,
what if the partner has syphilis and it's untested
and you're just looking at gonorrhea and chlamydia?
So these are big problems, and this is why the CDC itself
says for men who have sex with men they don't recommend this
because it's more likely in those relationships
that you could have gonorrhea of the pharynx,
resistant diseases, and HIV that's untreated,
and so just blindly treating the partner remotely
doesn't make sense in those populations
and it needs more study.
So that's the nuance of this.
Now how would you do this, because now gonorrhea,
for example, the indications given rising resistance,
they're saying actually there's no good oral treatment
as a single dose like there used to be.
It used to be you could just give an oral,
you know, cephalosporin like Cefixime, something like that.
Now they're saying no, you have to come in
and get a 250 mg IM injection of Ceftriaxone,
but they're making an exception
for expedited partner therapy.
They're saying well, in this case, you can do two drugs,
oral Cefixime and oral Azithromycin,
give it together, and hope for the best,
because there's still harm reduction in that
compared to no treatment at all,
and that should be your placebo is no treatment at all,
and the data seems to suggest that's worse
than expedited partner therapy.
So the call to action, Z-Pac, educate your fellow caregivers
about this, think about it in patients that you're treating
whose partner isn't gonna come in,
and that's they key thing, you just don't think they
have the wherewithal to come in and follow up with
the appointment, and spread the word,
and if your state has outlawed this or is vague about it,
maybe you wanna lobby for legislation
that's gonna change that.
Talk to your own medical board and go to the CDC's website.
We'll put links in the comments and in the web post for this
where you can learn more about whether your state
is covered and what the details
of this are in terms of legality.
They have more details at CDC's website.
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and we out, peace!
- Damn that was informative!
(ZDoggMD laughs)