Predicting Subsequent Infection in Patients Attending Sexually Transmitted Disease Clinics

High rates of persistent and recurrent chlamydia in pregnant women after treatment with azithromycin

BACKGROUND:

Chlamydia trachomatis is a common bacterial sexually transmitted infection that can persist or recur after antibiotic treatment. Universal screening for chlamydia in pregnancy is recommended to prevent adverse birth outcomes. Single-dose oral azithromycin has been the first-line therapy for chlamydia in pregnancy since 2006.

OBJECTIVE:

In the setting of limited data and rising sexually transmitted infection rates in the United States, our goal was to document rates and risk factors for persistent or recurrent chlamydia after azithromycin treatment in pregnancy.

STUDY DESIGN:

This retrospective cohort study included pregnancies with urogenital chlamydia and follow-up testing in women who delivered at an Alabama facility between November 2012 and December 2017. Pregnancies with prescribed azithromycin therapy and repeat chlamydia testing ≥21 days later were included. Chlamydia trachomatis nucleic acid amplification testing was performed on genital swab or urine samples. Descriptive characteristics and birth outcomes were compared for categories stratified by repeat test results: persistence (+ +), recurrence (+ − +), or clearance (+ −). Logistic regression models were used to identify demographic and clinical risk factors for persistent or recurrent chlamydia in pregnancy.

RESULTS:

Among 810 women with 840 pregnancies with repeat chlamydia testing after azithromycin treatment, 114 (14%) had persistence and an additional 72 (9%) had recurrence later in pregnancy. The median time to repeat testing was 30 days (interquartile range, 24–49 days). Concomitant gonorrhea or syphilis in pregnancy was independently associated with persistent or recurrent chlamydia (adjusted odds ratio, 1.6; 95% confidence interval, 1.1–2.4).

CONCLUSION:

Persistent or recurrent chlamydia after azithromycin treatment was detected in nearly 1 in 4 pregnancies with repeat testing in our urban center, highlighting the importance of performing a test of cure and ensuring partner therapy to reduce recurrent chlamydia risk.

Testing the Interpersonal-Behavior model to explain intentions to use patient-delivered partner therapy

Background

Patient-delivered partner therapy (PDPT) is an evidence-based method of partner treatment, but further research was needed to understand theoretical underpinnings of potential PDPT use.

Purpose

We sought to develop and test a theoretical framework to understand PDPT intentions.

Methods

A Midwestern sample of sexually transmitted infection clinic patients were recruited to participate in a three-phase study incorporating semi-structured interviews (n = 20, total), cognitive interviews (n = 5), and surveys (n = 197; M_age = 31.3, 61% male, 91% Black or African-American). Thematic analysis was conducted to identify major themes, which guided development and testing of a theoretical framework on PDPT intentions using structural equation modeling.

Results

We identified themes of information (knowledge); motivation (individual and partner protection beliefs, partner and provider motivation-to-comply); social support (sexual health and general); and behavioral skills (partner notification, medication delivery, and communication skills self-efficacy) in thematic analysis. The developed Interpersonal-Behavior model demonstrated good model fit in structural equation modeling [χ2(36) = 95.56, p<0.01; RMSEA = 0.09 (0.07–0.11, 90%C.I.); CFI = 0.94; SRMR = 0.05]. Information was associated with motivation (β = 0.37, p<0.001) and social support (β = 0.23, p = 0.002). Motivation was associated with social support (β = 0.64, p<0.001) and behavioral skills (β = 0.40, p<0.001), and social support was associated with behavioral skills (β = 0.23, p = 0.025). Behavioral skills were associated with higher PDPT intentions (β = 0.31, p<0.001), partially mediated the association of motivation with intentions (β_direct = 0.53, p<0.001; β_indirect = 0.12, 95%CI: 0.03–0.30), and fully mediated the association of social support with intentions (β_indirect = 0.07, 95%CI: 0.00–0.21).

Conclusions

The Interpersonal-Behavior model seems appropriate for PDPT intentions but should be tested longitudinally with PDPT outcomes and other interpersonal health behaviors.

Longitudinal association of gonorrhea and bacterial vaginosis with repeat chlamydia diagnoses among U.S. Army women: a retrospective cohort analysis

BACKGROUND

Historically, sexually transmitted infections have affected the health of the U.S. military. To determine whether gonorrhea, bacterial vaginosis, genital herpes, and trichomoniasis are predictors of repeat chlamydia diagnoses among U.S. Army women, medical data reported into the Defense Medical Surveillance System during the 2006-2012 period were analyzed.

METHODS

For all inpatient and outpatient medical records, the first and second International Classification of Diseases, version 9 (ICD-9) diagnostic positions were reviewed for each chlamydia case to determine the occurrence of repeat diagnoses. The Andersen-Gill regression model, an extension of the Cox model for multiple failure-time data, was used to study associations between predictors and repeat chlamydia diagnoses.

RESULTS

Among 28,201 women with a first chlamydia diagnosis, 5145 (18.2%), 1163 (4.1%), 267 (0.9%), and 88 (0.3%) had one, two, three, and four or more repeat diagnoses, respectively. Overall, the incidence of repeat chlamydia was 8.31 cases per 100 person-years, with a median follow-up time of 3.39 years. Gonorrhea (hazard ratio (HR) = 1.58, 95% CI: 1.44-1.73) and bacterial vaginosis (HR = 1.40, 95% CI: 1.09-1.79) were significant predictors for repeat chlamydia. These estimated hazard ratios were attenuated, but remained significant, after controlling for age, race/ethnicity, marital status, and military rank. No significant association was found for genital herpes (HR = 1.13, 95% CI: 0.55-2.29) and trichomoniasis (HR = 1.43, 95% CI: 0.43-4.68).

CONCLUSIONS

This large cohort study suggests that gonorrhea and bacterial vaginosis were associated with repeat chlamydia diagnoses among U.S. Army women. These findings can be used in formulating new interventions to prevent repeat chlamydia diagnoses.

Using Integrative Data Analysis to Examine Changes in Alcohol Use and Changes in Sexual Risk Behavior Across Four Samples of STI Clinic Patients

BACKGROUND

Patients in sexually transmitted infection (STI) clinics report high levels of alcohol use, which are associated with risky sexual behavior. However, no studies have examined how changes in alcohol use relate to changes in sexual risk behavior.

PURPOSE

We used parallel process latent growth modeling to explore how changes in alcohol use related to changes in sexual behavior across four samples of clinic patients.

METHODS

Patients participating in HIV prevention trials from urban clinics in the Northeastern and Midwestern USA (N = 3761, 59 % male, 72 % Black) completed measures at 3-month intervals over 9-12 months. Integrative data analysis was used to create composite measures of alcohol use across samples. Sexual risk measures were counts of partners and unprotected sex acts. Parallel process models tested whether alcohol use changes were correlated with changes in the number of partners and unprotected sex.

RESULTS

Growth models with good fit showed decreases that slowed over time in sexual risk behaviors and alcohol use. Parallel process models showed positive correlations between levels of (rs = 0.17-0.40, ps < 0.001) and changes in (rs = 0.21-0.80, ps < 0.05) alcohol use and number of sexual partners across studies. There were strong associations between levels of (rs = 0.25-0.43, ps < 0.001) and changes in (rs = 0.24-0.57, ps < 0.01) alcohol use and unprotected sex in one study recruiting hazardous drinkers.

CONCLUSIONS

Across four samples of clinic patients, reductions in alcohol use were associated with reductions in the number of sexual partners. HIV prevention interventions may be strengthened by addressing alcohol use.

The Information-Motivation-Behavioral Skills Model Revisited: A Network-Perspective Structural Equation Model Within a Public Sexually Transmitted Infection Clinic Sample of Hazardous Alcohol Users

The information–motivation–behavioral skills (IMB) model is useful for understanding sexual risk behavior, but has not been tested with hazardously-drinking sexually transmitted infection (STI) clinic patients, a subpopulation at greater HIV risk, or with a network-perspective sexual risk behavior outcome. Participants (N = 569) were STI clinic patients who screened positive for hazardous drinking and risky sexual behavior. Sexual risk behavior (SRB) was operationalized as a latent variable with three indicators: (1) number of sexual partners, (2) number of unprotected sex occasions with primary partner, and (3) number of unprotected sex occasions with non-primary partner(s). Preliminary analyses suggested SRB was best operationalized as a latent variable with two indicators, while unprotected sex with primary partners should be considered separately. In structural models with good fit, the IMB model was generally supported. The IMB model functioned differently for non-primary and multiple partners compared to primary partners in STI clinic patients with hazardous alcohol use.

Substance use and STI acquisition: Secondary analysis from the AWARE study

OBJECTIVES

Sexually transmitted infections (STIs) are significant public health and financial burdens in the United States. This manuscript examines the relationship between substance use and prevalent and incident STIs in HIV-negative adult patients at STI clinics.

METHODS

A secondary analysis of Project AWARE was performed based on 5012 patients from 9 STI clinics. STIs were assessed by laboratory assay and substance use by self-report. Patterns of substance use were assessed using latent class analysis. The relationship of latent class to STI rates was investigated using Poisson regression by population groups at high risk for STIs defined by participant's and partner's gender.

RESULTS

Drug use patterns differed by risk group and substance use was related to STI rates with the relationships varying by risk behavior group. Substance use treatment participation was associated with increased STI rates.

CONCLUSIONS

Substance use focused interventions may be useful in STI clinics to reduce morbidity associated with substance use. Conversely, gender-specific sexual health interventions may be useful in substance use treatment.

Assessing Patient Exposure to a Video-Based Intervention in STD Clinic Waiting Rooms: Findings From the Safe in the City Trial

Safe in the City, a video intervention for clinic waiting rooms, was previously shown to reduce sexually transmitted disease (STD) incidence. However, little is known about patients' recall of exposure to the intervention. Using data from a nested study of patients attending clinics during the trial, we assessed whether participants recalled Safe in the City, and, if so, how the intervention affected subsequent attitudes and behaviors. Analyses were restricted to responses to a 3-month follow-up questionnaire among participants who were exposed to the video (n = 708). Impact was measured as participants' reports of the video's effect on behaviors and attitudes. Associations were evaluated using multivariable logistic regression. Of participants who were exposed, 685 (97%) recalled viewing the video, and 68% recalled all three vignettes. After watching the video, participants felt more positive about condoms (69%) and comfortable acquiring condoms (56%), were reminded of important information about STDs and condoms (90%), and tried to apply what they learned to their lives (59%). Compared with those who recalled viewing one or two vignettes, participants who recalled viewing all three vignettes reported more positive attitudes toward condoms and peer/provider communication. These findings demonstrate that a low-resource video intervention for waiting rooms can provide sufficient exposure to positively influence STD-related attitudes/behaviors.

An exploratory analysis of individuals with multiple episodes of different reportable diseases, Montreal, 1990-2012

OBJECTIVES

Studies of public health reporting have only examined multiple episodes of the same communicable disease within an individual. We aimed to characterize Montreal residents with multiple reportable disease episodes from 1990 to 2012, while accounting for all types of reportable diseases.

STUDY DESIGN

Retrospective cohort study.

METHODS

We performed an exploratory analysis using descriptive statistics, contingency tables, and logistic regression.

RESULTS

There were 157,839 individuals with at least one disease report and a total of 179,455 disease reports. The 9.8% of subjects with more than one episode accounted for 20.7% of all reported episodes. Among subjects with four or fewer episodes, 54.0% were women, while 74.3% of subjects with five or more episodes were men. Subjects with multiple episodes were more likely to be reported for sexually transmitted infections than were persons with a single episode [difference of proportions: 10.4% (95% CI: 10.0%-10.9%)] and to reside in the neighbourhood encompassing Montreal's gay village.

CONCLUSIONS

Individuals with multiple communicable disease reports place a large burden on public health officials. These results may help guide investigation and prevention efforts to reduce the number of excess episodes.

Demographic and behavioural characteristics predict bacterial STI reinfection and coinfection among a cross-sectional sample of laboratory-confirmed gonorrhea cases in a local health region from Saskatchewan, Canada

OBJECTIVES

We aimed to identify demographic and behavioural determinants associated with risk of repeat STI infection and coinfection with gonorrhea and chlamydia in the Regina Qu'Appelle Health Region, Saskatchewan.

METHODS

We extracted data from a cross-sectional sample of laboratory confirmed gonorrhea cases between 2003 and 2012 from the notifiable disease files of the Regina Qu'Appelle Health Region. Risk factors for repeater status were examined using logistic regression and for coinfection with gonorrhea and chlamydia using mixed-effects logistic regression to account for multiple diagnoses for individual clients.

RESULTS

Data from 1,143 cases (representing 1,027 unique individuals) and 1,524 reported contacts (representing 1,383 unique individuals) were extracted from the 10-year period. Factors associated with repeat infection entries in the database included younger age at first visit (p = 0.01), coinfection (p = 0.01), and sex trade involvement (p &lt; 0.01). Factors associated with coinfection at the time of diagnosis included younger age at diagnosis (p &lt; 0.001) and reported alcohol or drug abuse (p = 0.04).

CONCLUSION

In one of the first epidemiologic studies on gonorrhea in Saskatchewan, we have identified age, engagement in the sex trade, and drug and alcohol abuse as potential markers to identify clients with a high risk of reinfection and coinfection in the Regina Qu'Appelle Health Region. This information can help health care professionals in Saskatchewan's urban centres personalize their approach to counselling and treatment to optimize patient outcomes and disease control efforts, including potentially using expedited partner therapy and/or dual therapy where indicated.

Demographic and behavioural characteristics predict bacterial STI reinfection and coinfection among a cross-sectional sample of laboratory-confirmed gonorrhea cases in a local health region from Saskatchewan, Canada

OBJECTIVES

We aimed to identify demographic and behavioural determinants associated with risk of repeat STI infection and coinfection with gonorrhea and chlamydia in the Regina Qu'Appelle Health Region, Saskatchewan.

METHODS

We extracted data from a cross-sectional sample of laboratory confirmed gonorrhea cases between 2003 and 2012 from the notifiable disease files of the Regina Qu'Appelle Health Region. Risk factors for repeater status were examined using logistic regression and for coinfection with gonorrhea and chlamydia using mixed-effects logistic regression to account for multiple diagnoses for individual clients.

RESULTS

Data from 1,143 cases (representing 1,027 unique individuals) and 1,524 reported contacts (representing 1,383 unique individuals) were extracted from the 10-year period. Factors associated with repeat infection entries in the database included younger age at first visit (p = 0.01), coinfection (p = 0.01), and sex trade involvement (p &lt; 0.01). Factors associated with coinfection at the time of diagnosis included younger age at diagnosis (p &lt; 0.001) and reported alcohol or drug abuse (p = 0.04).

CONCLUSION

In one of the first epidemiologic studies on gonorrhea in Saskatchewan, we have identified age, engagement in the sex trade, and drug and alcohol abuse as potential markers to identify clients with a high risk of reinfection and coinfection in the Regina Qu'Appelle Health Region. This information can help health care professionals in Saskatchewan's urban centres personalize their approach to counselling and treatment to optimize patient outcomes and disease control efforts, including potentially using expedited partner therapy and/or dual therapy where indicated.

Retention of clinical trial participants in a study of nongonococcal urethritis (NGU), a sexually transmitted infection in men

Nongonococcal urethritis (NGU), an inflammation of the urethra not caused by gonorrhea, is the most common urethritis syndrome seen in men in the United States. It is a sexually transmitted infection commonly caused by Chlamydia trachomatis, a pathogen which occurs more frequently in African-American men compared to white men. The purpose of this study was to investigate factors related to retention of study participants in a randomized, double-blinded clinical trial that evaluated four treatment regimens for the treatment of NGU. After the one-week treatment period, follow-up visits were scheduled during days 15-19 and days 35-45. Participants were phoned prior to scheduled appointments to encourage attendance, and contacted after missed appointments to reschedule their clinic visits. Of the 305 male study participants, 298 (98%) were African-American, 164 (54%) were 25 years of age or younger, and 80 (31%) had a post-secondary school education. The overall retention rate was 75%. Factors associated with study completion were educational level attained and clinical center. Participants with higher levels of education were more likely to complete the study. Clinical centers with the highest retention rates also provided the highest monetary incentives for participation. The retention rate for this study suggests that strategies are needed for improving the proportion of study participants that complete a clinical trial among young men with a sexually transmitted disease. These strategies may include increasing contacts with study participants to remind them of scheduled study visits using text messaging or social media and the use of financial incentives.

Home versus clinic-based specimen collection for Chlamydia trachomatis and Neisseria gonorrhoeae

Sexually transmitted infections (STIs) are a major public health concern that must be addressed with innovative screening methods to supplement traditional approaches. Home-based screening with self-collected urine or vaginal specimens is a highly feasible and acceptable method, and shows promise in improving STI screening rates in both men and women. Home collection kits have been offered in a variety of settings, with results ranging from very modest improvements in screening rates to 100-fold increases beyond the rates observed with clinic-based screening. This article describes and evaluates the effectiveness and limitations of various home screening strategies used for the detection of STIs.

Sexual risk reduction interventions for patients attending sexually transmitted disease clinics in the United States: a meta-analytic review, 1986 to early 2009

Sexually transmitted disease (STD) patients are more likely to experience a future STD including human immunodeficiency virus (HIV). The aim of this study was to examine the efficacy of behavioral interventions to reduce sexual risk behavior and incident STDs among patients attending STD clinics in the United States. A meta-analysis of 32 studies with 48 separate interventions targeting STD patients (N = 67,538) was conducted. Independent raters coded study, sample, and intervention characteristics. Effect sizes, using both fixed- and random-effects models, were calculated. Potential moderators of intervention efficacy were assessed. Relative to controls, intervention participants increased their condom use and had fewer incident STDs, including HIV, across assessment intervals (d (+)s ranging from 0.05 to 0.64). Several sample (e.g., age and ethnicity) and intervention features (e.g., targeting intervention to a specific group) moderated the efficacy of the intervention. Behavioral interventions targeted to STD clinic patients reduce sexual risk behavior and prevent HIV/STDs. Widespread use of behavioral interventions in STD clinics should be a public health priority.

Association between provision of initial family planning services and unintended pregnancy among women attending an STD clinic

BACKGROUND

Most sexually transmitted disease (STD) clinics focus solely on STD treatment and prevention. However, women seeking care are also at high risk for unintended pregnancy. We sought to examine the relationship between baseline demographic and clinical characteristics and incident pregnancy among women provided initial contraceptive services in an STD clinic.

METHODS

Computerized record review of women attending an STD clinic who initiated contraception, were seen at least twice within a 4-year period (repeat attendees), and indicated no intention of pregnancy were included in these analyses. Associations between baseline demographic, behavioral, and clinical characteristics and incident pregnancy were assessed using multivariate logistic regression.

RESULTS

Among 4617 women seen from 2003 to 2006, 710 (15%) were repeat attendees and 3907 (85%) were single attendees (seen only during a single year). Among the repeat attendees, 642 (90%) indicated no interest in pregnancy, of whom 124 (19%) had a subsequent pregnancy. Using multivariate analysis and controlling for age and race/ethnicity, incident pregnancy was associated with previous pregnancy (OR 2.57, 95% CI 1.63-4.04), <or=150% federal poverty level (OR 2.22, 95% CI 1.05-4.71), and no contraceptive use at last sex (OR 1.67, 95% CI: 1.11-2.52). Incident pregnancy was not associated with educational level, sexual frequency, age of first pregnancy, number of partners, prior therapeutic abortion, or provision of effective contraception at the initial STD clinic visit.

CONCLUSIONS

Certain baseline characteristics identified a subset of women seen in an STD clinic that were associated with future unintended pregnancy. Targeted interventions addressing these factors are needed.

Repeat infection with Chlamydia and gonorrhea among females: a systematic review of the literature

Determining the magnitude of chlamydia and gonorrhea reinfection is critical to inform evidence-based clinical practice guidelines related to retesting after treatment. PubMed was used to identify peer-reviewed English language studies published in the past 30 years that estimated reinfection rates among females treated for chlamydia or gonorrhea. Included in this analysis were original studies conducted in the United States and other industrialized countries that reported data on chlamydia or gonorrhea reinfection in females. Studies were stratified into 3 tiers based on study design. Reinfection rates were examined in relation to the organism, study design, length of follow-up, and population characteristics. Of the 47 studies included, 16 were active cohort (Tier 1), 15 passive cohort (Tier 2), and 16 disease registry (Tier 3) studies. The overall median proportion of females reinfected with chlamydia was 13.9% (n = 38 studies). Modeled chlamydia reinfection within 12 months demonstrated peak rates of 19% to 20% at 8 to 10 months. The overall median proportion of females reinfected with gonorrhea was 11.7% (n = 17 studies). Younger age was associated with higher rates of both chlamydia and gonorrhea reinfection. High rates of reinfection with chlamydia and gonorrhea among females, along with practical considerations, warrant retesting 3 to 6 months after treatment of the initial infection. Further research should investigate effective interventions to reduce reinfection and to increase retesting.

Effect of a brief video intervention on incident infection among patients attending sexually transmitted disease clinics

BACKGROUND

Sexually transmitted disease (STD) prevention remains a public health priority. Simple, practical interventions to reduce STD incidence that can be easily and inexpensively administered in high-volume clinical settings are needed. We evaluated whether a brief video, which contained STD prevention messages targeted to all patients in the waiting room, reduced acquisition of new infections after that clinic visit.

METHODS AND FINDINGS

In a controlled trial among patients attending three publicly funded STD clinics (one in each of three US cities) from December 2003 to August 2005, all patients (n = 38,635) were systematically assigned to either a theory-based 23-min video depicting couples overcoming barriers to safer sexual behaviors, or the standard waiting room environment. Condition assignment alternated every 4 wk and was determined by which condition (intervention or control) was in place in the clinic waiting room during the patient's first visit within the study period. An intent-to-treat analysis was used to compare STD incidence between intervention and control patients. The primary endpoint was time to diagnosis of incident laboratory-confirmed infections (gonorrhea, chlamydia, trichomoniasis, syphilis, and HIV), as identified through review of medical records and county STD surveillance registries. During 14.8 mo (average) of follow-up, 2,042 patients (5.3%) were diagnosed with incident STD (4.9%, intervention condition; 5.7%, control condition). In survival analysis, patients assigned to the intervention condition had significantly fewer STDs compared with the control condition (hazard ratio [HR], 0.91; 95% confidence interval [CI], 0.84 to 0.99).

CONCLUSIONS

Showing a brief video in STD clinic waiting rooms reduced new infections nearly 10% overall in three clinics. This simple, low-intensity intervention may be appropriate for adoption by clinics that serve similar patient populations.

TRIAL REGISTRATION

http://www.ClinicalTrials.gov (#NCT00137670).

Bacterial vaginosis, race, and sexually transmitted infections: does race modify the association?

BACKGROUND

There are significant racial disparities in the prevalence of sexually transmitted infections (STIs) in the United States. The purpose of this study was to evaluate whether the association of bacterial vaginosis and incident STI is modified by race even after adjustment for sexual practices and other potential confounding variables.

METHODS

We evaluated the association of bacterial vaginosis (BV) and STI acquisition in a group of 523 women at high risk for unplanned pregnancies and STI. BV was diagnosed by both Gram stain and Amsel criteria. STIs included Chlamydia trachomatis, Neisseria gonorrhoeae, pelvic inflammatory disease, trichomoniasis, syphilis, and HIV. Cox regression estimated the associations and the synergy index assessed whether race modified the association of BV and incident STI.

RESULTS

Sixteen percent of participants developed an STI during the 2-year follow-up. Compared with white women without BV at baseline, the adjusted hazard ratios were as follows: white women with BV = 0.59; African American women without BV = 1.96; and African American women with BV = 2.86. The synergy index of 3.38 implies a combined association of BV and African American race with STI in excess of each factor individually.

CONCLUSIONS

African American race modifies the association of BV and incident STI. Future research should strive to determine the relative contributions of other factors, such as biologic variation, social network or the consequences of socioeconomic position, in this disparity.

Chlamydia trachomatis reinfection rates among female adolescents seeking rescreening in school-based health centers

BACKGROUND

Chlamydia trachomatis (CT) infections are common among adolescents attending high and middle schools. The study objective was to determine the reinfection rates of CT for females attending school-based health centers.

METHODS

Adolescents attending school-based health centers who reported they were sexually active were screened for CT using nucleic acid amplification tests on cervical or urine samples. Between 1996 and 2003, 10,609 female students were tested. The overall annual prevalence for unduplicated students in a calendar year ranged from 15.1% to 19.5%. Reinfection was defined as a positive test result occurring between 30 and 365 days after an initial positive result.

RESULTS

There were 897 female students who tested positive for CT and returned for at least 1 subsequent test between 30 and 365 days later. Of these, 236 had 1 or more subsequent positive tests for a cumulative incidence of reinfection in 1 year of 26.3% (95% confidence interval = 23.4-29.2%). Young age at first infection was significantly associated with increased risk of subsequent infection (P <0.01). Across sites, the cumulative incidence of reinfection in these female students ranged from 14.3% to 38.9%.

CONCLUSIONS

The chlamydia cumulative incidence of reinfection in these female adolescents attending high and middle schools was high and supports the Centers for Disease Control and Prevention recommendation to screen adolescents frequently, especially those with a history of a previous chlamydia infection.

Update on the management of gonorrhea in adults in the United States

Gonorrhea, the second most commonly reported notifiable disease, is an important cause of cervicitis, urethritis, and pelvic inflammatory disease. The selection of appropriate therapy for gonorrhea (i.e., safe, highly effective, single dose, and affordable) is complicated by the ability of Neisseria gonorrhoeae to develop resistance to antimicrobial therapies. This article reviews the key questions and data that informed the 2006 gonorrhea treatment recommendations of the Centers for Disease Control and Prevention. Key areas addressed include the criteria used to select effective treatment for gonorrhea, the level of antimicrobial resistance at which changing treatment regimens is recommended, the epidemiology of resistance, and the use of quinolones, cephalosporins, and other classes of antimicrobials for the treatment of uncomplicated gonorrhea.