Episode 13 - Treat the Partner(s) - EPT

Episode 13: Treat the Partner(s): EPT The sun rises over the San Joaquin Valley, California, today is May 22, 2020. The COVID 19 pandemic has created a limited access to PPE in many health centers around the nation. Last week, Amazon also prioritized individual physicians for COVID-19 Supplies in providing much needed PPE for private practices. As a result, AAFP members and others working on the front lines of the pandemic have direct access to hundreds of items related to PPE, disinfectants, sanitizing products, diagnostic equipment and other materials. Way to go Amazon! Thank you for your business. Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program. We train residents and students to prevent illnesses and bring healing and hope to our community. Our mission: To Seek, Teach and Serve. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. “Don't let success determine your happiness but instead let your happiness determine your success” –Salah Barhoum What a great quote. When you are happy, you are successful. We can see our happiness as the highest level of our success. Today our guest is a successful man, Joseph Gomes. He is a very entertaining guy with a great sense of humor and very intelligent, he is known by his friends as Joe. Welcome Dr Gomes. 1. Question number 1: Who are you? My name is Dr. Joseph Gomes, I am a father of 2 twin munchkins and R2 in the Rio Bravo Family Medicine Residency program in Bakersfield, CA. I was most recently bestowed the honor of being elected as one of the 3 chief resident physicians for the 2020-2021 academic year, which I am quite excited about. I completed my undergraduate degree, a BS in Biomedical Sciences at CSUS in Sacramento, CA and completed medical school via the American University of the Caribbean School of Medicine. I like playing with my kids and eating cupcakes. 2. Question number 2: What did you learn this week? I think if I were to attempt to list all that I learned, or forgot and was reminded of this past week we would run out of time. However, I am here to talk about a topic that I don’t think gets very much attention and that’s the subject of Expedited Partner Therapy, or EPT for short. I was exposed to this concept for the first time during my intern year and was shocked that it was something that wasn’t more well-known or discussed in the resident community. EPT Definition EPT is “the clinical practice of treating the sex partners of patients diagnosed with chlamydia or gonorrhea by providing prescriptions or medications to the patient to take to his/her partner without the health care provider first examining the partner.” Patient’s sex partners from the past 60 days should be treated. EPT is for gonorrhea and chlamydia only. How would you write the prescription to treat gonorrhea if the treatment is IM Ceftriaxone? The current recommended treatment for gonorrhea is an IM dose of ceftriaxone AND a single dose of oral azithromycin 1 gram. The CDC recommends using cefixime and azithromycin in EPT. General Guidelines for EPT • Prescribe treatment for gonorrhea and chlamydia under the index patient’s name or their partners’ names. • Prescription should be accompanied by treatment instructions and warnings about taking medications • Gonorrhea health education and counseling • A statement advising that partners seek personal medical evaluation, particularly women with symptoms of PID. • No sexual intercourse for 7 days after treatment (ACOG, 2018) EPT is not recommended for: • MSM (high risk for coexisting infections, especially undiagnosed HIV infection) • Suspected child abuse • Sexual assault • Any other situation when patient safety is compromised • EPT has lower evidence in HSV, scabies, pubic lice, and trichomonas. 3. Question number 3: Why is that knowledge important for you and your patients? Per the Kern County Health Department website, based on published data from 2017, Kern County alone has approximately 1 new STI case per hour, each day. With the vast majority of these cases being Chlamydia, followed by Gonorrhea, Syphilis and lastly HIV. Of note, Hep B data was not published in 2017, but I fully expect its inclusion in the forthcoming publication. And specifically, regarding Chlamydia, Kern County is the 3rd worst in the state, following San Francisco and Alpine counties and as a county has a 38% increased average number of cases compared to other counties in the state. For syphilis, Kern is actually a bit worse. Kern County syphilis rates in 2017 were 333% higher when compared to other counties in the state. More disappointing than that, Kern County had 313% increase in CONGENITAL syphilis cases and ranked the 2nd worst in the state behind Fresno. This is a big deal. Not just in this county, but nation-wide. STI rates continue to climb and this is just one mechanism by which we can help prevent the continued spread of infection.  Why is this important? To prevent what is referred to as the “Ping Pong” effect. The phenomenon in which sexual partners re-infect each other with the same sexually transmitted disease (STD). First, an individual who has the STD infects his or her partner. The partner may then re-infect the individual, after the individual has been cured from that particular STD. This often occurs because individuals and their partners may or may not be aware that they have an STD, since symptoms are not always present. The 3 major players include Gonorrhea, Chlamydia and Trichomoniasis.  EPT is permitted in all 50 states, save for one, South Carolina. Get it together South Carolina! 4. Question number 4: How did you get that knowledge? I prefer self-study and read by myself the topics that interest me. Also, I enjoy watching videos such as the AAFP 2020 Lectures Series for Board Review. 5. Question number 5: Where did that knowledge come from? Websites used: CDC website, Kern County Public Health Website, Z-dogg MD podcast, which I highly recommend, published as Incident Report 197 in 2018. Additional information: Something I did not know is that through the Kern County Public Health department, those who have been diagnosed with an STI can anonymously notify their sexual partner via their website at KernPublicHealth.com (https://dontspreadit.com/). This is a fantastic resource as a myriad of factors contribute to neglecting to notify sexual partners, including, but not limited to undue shame, guilt, hostility and the obvious avoidance of confrontation. The public health department eliminates much of this through their website. Speaking Medical (Medical word of the Week): Fasciculation by Dr Monica Kumar A fasciculation is a small involuntary muscle contraction and relaxation also known as a muscle twitch. Approximately 70 percent of fasciculations are benign in etiology. However, the remaining 30 percent of the cases can be due to hypomagnesemia, benzodiazepine withdrawals, acetylcholinesterase inhibitor use, caffeine use, rabies, and other lower motor neuron disorders such as ALS, poliomyelitis, and spinal muscular atrophies. In order to further evaluate the etiology behind the fasciculations, a thorough neuromuscular examination should be performed. Further evaluation with an electrolyte panel, electromyography, nerve conduction studies, neuromuscular ultrasound, or muscle biopsy can also be performed in determining the cause. If you have a patient with eye twitching, it may be a fasciculation, but it also could be them winking at you. Espanish Por Favor (Spanish Word of the Week): Enfermo by Dr Claudia Carranza The Spanish word of this week is enfermo. Enfermo or enferma means ill/sick in Spanish. This word comes from Latin root “infirmus”, which can be broken down into “in” and “firmus” meaning “not firm”. This is understood as “not standing” or “not well”. Patients can come to you with the complaint: “Doctor, estoy enfermo” or “Doctor, me siento enfermo o enferma”, which means: “Doctor I’m ill, or I feel sick”. At this point, you will know they do not feel well and you can start investigating what’s going on. Now you know the Spanish word of the week, “ENFERMO”. Have a great week! For Your Sanity (Joke of the Week) by Dr Verna Marquez and Dr Steven Saito Teacher: "Kids, what does the chicken give you?" Student: "Meat!" Teacher: "Very good! Now what does the pig give you?" Student: "Bacon!" Teacher: "Great! And what does the fat cow give you?" Student: "Homework!" —What’s the difference between a rectal thermometer and an oral thermometer? —The taste. —Doctor, my ear is ringing, what should I do? —You should answer it! Now we conclude our episode number 13 “Treat the Partner(s): EPT”. For partners who are unlikely to seek medical attention, Cefixime and Azithromycin is the current recommended regimen for gonorrhea; and azithromycin 1-gram single dose is the recommended treatment for chlamydia. This practice is not only permissible, but it is endorsed by the CDC, AAFP, ACOG, and many other organizations. Also, next time a patient winks at you, think of the word fasciculation. If your patient tells you they are enfermos, don’t panic, you are being trained to cure your ill patients. This is the end of Rio Bravo qWeek. We say goodbye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. Our podcast team is Hector Arreaza, Claudia Carranza, Monica Kumar, Verna Marquez, and Steven Saito. Audio edition: Suraj Amrutia. See you soon! References:  “Expedited Partner Therapy”, Centers for Disease Control and Prevention, https://www.cdc.gov/std/ept/default.htm, accessed on May 18, 2020.  ACOG Committee Opinion, Number 737, June 2018, https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/06/expedited-partner-therapy, accessed on May 18, 2020.  “Treating an STD Patient’s Partner WITHOUT Seeing Them??”, ZDogg MD, November 5th, 2018, https://zdoggmd.com/incident-report-197/  STDs in Kern County 2017 Data Update, Kern County Public Health Department: https://kernpublichealth.com/wp-content/uploads/STDs-in-Kern-County-update-2017-web.pdf  Anonymous Partner Notification: https://dontspreadit.com/