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For Primary Care| Top tips

Top Tips: Sexually Transmitted Infections (Part 1)

Dr Toni Hazell Provides 10 Top Tips on Sexually Transmitted Infections—Part One of this Two-part Series Covers General History Taking, With a Focus on Chlamydia

Read This Article to Learn More About:
  • taking a full sexual history and screening asymptomatic patients
  • new treatment recommendations for chlamydia
  • when a test of cure for chlamydia is necessary
  • handling partner notification.

1. Take a Full Sexual History

Taking a full sexual history is key to assessing the risk of a sexually transmitted infection (STI). People will usually answer direct questions and will not be embarrassed if their doctor is matter-of-fact. A sexual history should be taken for any patient who presents with symptoms suggestive of an STI (e.g. pelvic pain, discharge, dysuria, or irregular bleeding) and should include the components listed in Box 1.

Box 1: What to Ask About When Taking a Sexual History1,2

For patients presenting with symptoms suggestive of an STI, ask about:

  • the presenting complaint, including duration and associated symptoms
  • date of last intercourse, with whom (man or woman, regular or casual partner) and whether condoms are used always/sometimes/never
  • type of sexual contact (vaginal/oral/anal and whether the patient had insertive or receptive intercourse, or both)
  • risk factors for blood-borne viruses
  • previous STIs and whether treatment was taken in full
  • medical, menstrual, and contraceptive history
  • any other concerns (this could include disclosure of sexual orientation, risk of sexual violence, and concerns about confidentiality and partner notification).

STI=sexually transmitted infection

2. Asymptomatic Patients can be Screened Without Examination

With the closure of many genitourinary medicine (GUM) services,3,4 patients may present to their GP for a routine screen. The NICE Clinical Knowledge Summary (CKS) on chlamydia provides recommendations on when to test for chlamydia in asymptomatic people (see Box 2).5

Box 2: Chlamydia Testing in Asymptomatic People5

Asymptomatic people who should be tested for chlamydia include:

  • sexual partners of those with proven or suspected chlamydial infection
  • all sexually active people younger than 25 years of age, annually, or more frequently if they have changed their partner
  • all people with concerns about a sexual exposure
    • if the exposure was within the last 2 weeks, a test should be carried out at presentation and if negative, repeated 2 weeks after the exposure
  • people under the age of 25 years who have been treated for chlamydia in the previous 3 months
  • people who have had two or more sexual partners in the previous 12 months
  • all women seeking termination of pregnancy
  • all men and women attending genitourinary medicine clinics.

Screening of asymptomatic women can be performed by self-taken vulvovaginal swabs, which have a higher sensitivity than a urine sample and are generally considered acceptable to the patient.6 A full screen can be achieved by means of a self-taken swab to test for chlamydia and gonorrhoea, and a blood test for HIV and syphilis, with no need for a genital examination. Men can be tested by means of a first-catch urine sample, although not all labs will accept these from primary care.

3. Know that Chlamydia is the Most Common STI

In 2017 there were 422,147 diagnoses of STIs made in England, of which 48% were chlamydia, 14% were genital warts, and 11% were gonorrhoea. In the population of men who have sex with men (MSM), gonorrhoea (43%) is more common than chlamydia (31%). Groups at the highest risk of STIs are those aged between 15 and 24 years, black ethnic minorities, and MSM.7

4. Be Aware That the Treatment for Chlamydia Has Changed

First-line treatment for uncomplicated chlamydia used to be a 1 g single dose of azithromycin (SDA) or 7 days of doxycycline 100 mg twice daily, but in September 2018 the British Association for Sexual Health and HIV (BASHH) updated its recommendations, advising that doxycycline 100 mg twice daily for 7 days should become the only first-line treatment for any diagnosis of chlamydia.8 This change is for two reasons:8

  1. SDA is less effective compared with doxycycline for treating rectal chlamydia. Studies have shown that many women diagnosed on vaginal swab will also have rectal chlamydia, whether or not they have anal intercourse. Undertreated rectal chlamydia infection may potentially contribute to re-infection rates.
  2. There is increasing resistance of Mycoplasma genitalium to SDA. M. genitalium  is an increasingly common STI, which often co-exists with chlamydia, and diagnostic tests are rarely available.

The NICE CKS on chlamydia has been updated to reflect this change.5 If doxycycline is not tolerated, or is contraindicated (e.g. in pregnant women), then azithromycin should be prescribed as a 1 g stat dose followed by 500 mg once daily for 2 days (i.e. double the dose previously recommended). As an alternative to azithromycin, erythromycin 500 mg twice daily for 10­–14 days can be prescribed, or (for non-pregnant adults) ofloxacin 400 mg once daily for 7 days (contraindicated in children and growing adolescents). See the NICE CKS for further prescribing information.5

5. Refer All Patients With Chlamydia to a GUM Clinic, but Don’t Forget to Advise Partner Testing if a GUM Clinic is Unavailable

The NICE CKS advises that all patients with chlamydia are referred to a GUM clinic for partner notification;5 however, this is not always practical in areas where services are limited. A GUM clinic will arrange partner notification and testing but if the patient is unwilling or unable to attend a GUM clinic, then their partner will still need to be tested and should inform whoever is providing the test that they are a contact; they should then be treated before their result comes back. The original patient and partner should avoid sexual contact until 1 week after both parties have completed treatment. GUM clinics can assist with contact tracing in more complex cases (e.g. where there are multiple partners), even if they have not seen the index case.5 If a patient is tested for chlamydia within 2 weeks of a concerning sexual encounter and the test comes back negative, the test should be repeated when at least 2 further weeks have passed.5

6. Check if Young Patients Have Been Tested for Chlamydia via the NCSP

Established in 2003, the National Chlamydia Screening Programme (NCSP)9 aims to increase the diagnosis of chlamydia, thus preventing the complications of untreated disease and reducing the rates of onward transmission to partners. Other aims include the normalisation of chlamydia testing in people aged under 25 years, so that it becomes standard to have a test when changing partners, and to ensure that all people in this age group are well informed about the infection. The programme offers a test once a year, or on each change of sexual partner if this is more frequent than annually. In 2017, 1.3 million tests were carried out, but this number is falling year-on-year10 so it is important that healthcare practitioners are vigilant about the need to screen and test this population.

People aged under 25 years can be tested in various settings, including the following:

  • sexual and reproductive health services
  • online—by requesting a home testing kit from a website that is part of the screening programme11
  • general practice
  • services which offer termination of pregnancy
  • pharmacies.

The NCSP programme covers the whole range of care associated with chlamydia screening (testing, providing results, treatment, and partner notification) so patients do not have to come to their GP with the result.

7. Recognise When a Test of Cure is Necessary

The decision on whether to re-test patients diagnosed with chlamydia to ensure that they have been cured is not straightforward, and depends on which guideline is being followed. BASHH does not recommend a test of cure for most patients with chlamydia, the exceptions being people diagnosed in pregnancy and people with rectal chlamydia.6 However, NICE is more cautious, recommending a re-test 5 weeks (and no sooner than 3 weeks) after treatment for all people with chlamydia.5

In 2013 the NCSP’s policy changed to recommend a re-test for everyone, 3 months after their initial chlamydia diagnosis. This is not framed as a ‘test of cure’, but as looking for new infections, because the months after a positive chlamydia diagnosis are a time of high risk for re-infection.12

With treatment guidance changing from a single dose of antibiotics to a 1-week course,5,8 it is conceivable that, if patients do not take the full course of antibiotics, failure rates of treatment may increase. This could be a factor in deciding which guideline to follow and whether to recommend a test of cure for all patients with chlamydia. A test of cure need not mean that the patient must come back for another appointment—they could be given a self-take swab at the time of the original diagnosis and be instructed to use it at least 3 weeks later.

8. Know when to Suspect Lymphogranuloma Venereum

Lymphogranuloma venereum (LGV) is a subtype of chlamydia that is increasingly common in MSM and usually presents with proctitis. In the author’s experience, most MSM will access a GUM clinic directly if they have a suspicion of having an STI (clinics often run specialist MSM sessions) but LGV should be suspected in primary care if a patient presents with tenesmus, bloody diarrhoea, anorectal discharge, discomfort, or an altered bowel habit. These symptoms may present in a consultation that is not superficially to do with sexual health but they should prompt the taking of a sexual history and an HIV test, as LGV is much more common in those who are HIV positive. Taking rectal samples is not something that GPs do very often, but if done it is important to highlight on the request form that the patient has symptoms of proctitis as this will prompt the laboratory to test for LGV.6 Treatment of LGV, or for those patients with HIV who have rectal chlamydia and have not been tested for LGV, is with 3 weeks of doxycycline 100 mg twice daily. These patients should be referred to a GUM clinic and must have a test of cure.

9. Remember the Complications of Chlamydia

One of the most significant aspects of chlamydia is the risk of complications, with a possible impact on female fertility many years later. Pelvic inflammatory disease (PID) is almost always caused by an STI, the most common being chlamydia and M. genitalium.13 It is, however, common for vaginal/cervical swabs to be negative by the time a woman presents with PID and this should not make the practitioner question the diagnosis, which is clinical. BASHH advises that:

A diagnosis of PID should be considered (and usually empirical antibiotic treatment offered), in any sexually active woman who has recent onset lower abdominal pain associated with local tenderness on bimanual vaginal examination, in whom pregnancy has been excluded and no other cause for the pain has been identified.’14

Possible first-line treatment regimens for PID include:13

  • one-off intramuscular ceftriaxone injection (500 mg) followed by oral doxycycline (100 mg twice daily) plus oral metronidazole (400 mg) twice daily for 14 days
  • oral ofloxacin (400 mg twice daily) plus oral metronidazole (400 mg) twice daily for 14 days.

See the NICE CKS for further prescribing information.13

10. Don’t Forget Partner Notification

Partner notification should be arranged by the GUM clinic, but many patients will not want to attend if they have been treated in primary care. Partner notification is usually straightforward; practitioners can give the patient a written note to give to their partner(s) saying ‘the person with this note is a contact of chlamydia, please test and treat as appropriate’ which the partner can then take to any GUM clinic. If a patient is concerned about their confidentiality then encourage them to contact the GUM clinic as they will be used to dealing with this situation. In cases where, for example, a phone call coming from a clinic in a certain town may breach the patient’s confidentiality, clinics can contact their counterparts in other areas of the country and ask them to notify the partner.

Practitioners should adopt a pragmatic and non-judgmental approach when dealing with partner notification and all issues surrounding a patient who has, or is at risk of, an STI.

Dr Toni Hazell

Part-time GP, Greater London

Former Clinical Assistant in Sexual Health and HIV