Draft Recommendation Statement
Screening for Chlamydia and Gonorrhea
March 02, 2021
Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
- Update in Progress for Screening for Chlamydia and Gonorrhea
|Sexually active women, including pregnant persons||The USPSTF recommends screening for gonorrhea in all sexually active women age 24 years and younger and in women age 25 years and older who are at increased risk for infection.||B|
|Sexually active women, including pregnant persons||The USPSTF recommends screening for chlamydia in all sexually active women age 24 years and younger and in women age 25 years and older who are at increased risk for infection.||B|
|Sexually active men||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.||I|
Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
Chlamydia and gonorrhea are among the most common sexually transmitted infections (STIs) in the United States.1 Nearly 1.8 million cases of chlamydia and more than 500,000 cases of gonorrhea were reported to the Centers for Disease Control and Prevention (CDC) in 2018. The rate of chlamydia among women (692.7 cases per 100,000 females) is nearly double the rate among men (380.6 cases per 100,000 males). Gonorrhea is more prevalent in males (212.8 cases per 100,000 males) compared to females (145.8 cases per 100,000 females). Infections are highest among adolescents and young adults of both sexes.1
Chlamydial and gonococcal infections in women are usually asymptomatic and may lead to pelvic inflammatory disease (PID) and its associated complications, such as ectopic pregnancy, infertility, and chronic pelvic pain.2-4 Newborns of pregnant persons with untreated infection may develop neonatal chlamydial pneumonia or gonococcal or chlamydial ophthalmia.5,6 Infection in men may lead to urethritis and epididymitis.7-10 Men are often asymptomatic; however, gonorrhea is more likely than chlamydia to cause symptoms in men compared to women.11 Both types of infection can increase risk of acquiring or transmitting HIV.12,13
The USPSTF concludes with moderate certainty that screening for chlamydia in all sexually active women age 24 years and younger and in women age 25 years and older who are at increased risk for infection has moderate net benefit.
The USPSTF concludes with moderate certainty that screening for gonorrhea in all sexually active women age 24 years and younger and in women age 25 years and older who are at increased risk for infection has moderate net benefit.
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.
See the Table for more information on the USPSTF recommendation rationale and assessment. For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.14
Patient Population Under Consideration
This recommendation applies to all asymptomatic, sexually active adolescents and adults, including pregnant persons.
Assessment of Risk
Women age 25 years and older are at increased risk if they have a new sex partner, more than one sex partner, a sex partner with concurrent partners, or a sex partner who has an STI; inconsistent condom use when not in a mutually monogamous relationship; or a previous or coexisting STI. Exchanging sex for money or drugs and incarceration also increases risk.15-17 Clinicians should consider the communities they serve and may want to consult local public health authorities for information about local epidemiology and guidance on determining who is at increased risk.
Nucleic acid amplification tests (NAATs) for Chlamydia trachomatis and Neisseria gonorrhoeae infections are usually used for screening because their sensitivity and specificity are high for detecting these infections.18 The U.S. Food and Drug Administration approves NAATs for use on urogenital and extragenital sites, including urine, endocervical, vaginal, male urethral, rectal, and pharynx specimens.18,19 Urine testing with NAATs is at least as sensitive as testing with endocervical specimens, clinician- or self-collected vaginal specimens, or urethral specimens in clinical settings. The same specimen can be used to test for chlamydia and gonorrhea.20
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 or Interventions
Chlamydial and gonococcal infections respond to treatment with antibiotics. Because treatment varies depending on the individual patient, and antibiotic resistance for gonorrhea is increasing, we encourage clinicians to consult the most up-to-date guidance on treatment from the CDC.21,22
Although the prevalence of chlamydia and gonorrhea differs, the risk factors for infection overlap and the USPSTF recommends screening for both simultaneously. In its treatment guidelines, the CDC has recommendations about ways to increase adherence to treatment, interventions to decrease the likelihood of reinfection, and guidelines on treating specific groups, including pregnant persons.21-23
Other Related USPSTF Recommendations
The USPSTF has issued recommendations on screening for other STIs, including hepatitis B,24,25 hepatitis C,26 genital herpes,27 HIV,28,29 and syphilis.30,31 The USPSTF has also issued recommendations on behavioral counseling for all sexually active adolescents and for adults who are at increased risk for STIs.32
Additional Tools and Resources
The CDC provides the following resources:
- More information about STIs, including chlamydia and gonorrhea, at https://www.cdc.gov/std/default.htm
- Recommendations for STI prevention, at https://www.cdc.gov/std/prevention/default.htm
- Guidance for clinicians on providing quality STI clinical services, at https://www.cdc.gov/mmwr/volumes/68/rr/rr6805a1.htm
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 https://www.thecommunityguide.org/topic/hiv-stis-and-teen-pregnancy.
The Public Health Agency of Canada guidelines on STIs are available at https://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/index-eng.php.
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.15,16 Median urogenital positivity among men who have sex with men was 6% for chlamydia and 8% for gonorrhea across nine STD Surveillance Network jurisdictions in 2018.1 Infections at extragenital sites (such as the pharynx and rectum) are typically asymptomatic. Chlamydial and gonococcal infections may increase risk of acquiring or transmitting HIV.12,13
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.
A review of health care claims of 4,296 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%).33
When final, this recommendation will update the USPSTF's recommendation on screening for chlamydia and gonorrhea.
In 2014, the USPSTF recommended screening for chlamydia in sexually active women age 24 years and younger and in older women who are at increased risk for infection. It also recommended screening for gonorrhea in sexually active women age 24 years and younger and in older women who are at increased risk for infection. Both recommendations included pregnant persons. The USPSTF found insufficient evidence to assess the balance of benefits and harms of screening for chlamydia and gonorrhea in men.
Scope of Review
The USPSTF commissioned a systematic review20,34 to update its recommendation on screening for chlamydia and gonorrhea. The review evaluated the benefits and harms of screening for chlamydia and gonorrhea in all sexually active adolescents and adults, including pregnant persons. Key differences between the current review and the prior review are that the current review combined all populations, including pregnant persons, into one analytic framework; evaluated the accuracy of risk stratification and screening strategies for identifying persons at increased risk; and focused evaluation of diagnostic accuracy on anatomic site–specific testing.20,34,35 Because the USPSTF had previously determined that treatments for these infections are effective and well established, this review did not include a review of treatments.20,34
Accuracy of Screening Tests and Risk Assessment
The USPSTF found convincing evidence that clinicians could identify sexually active women at increased risk for chlamydial and gonococcal infections. It found adequate evidence that clinicians could identify sexually active men at increased risk for chlamydial and gonococcal infections. Seven new fair-quality studies with more than 93,000 participants were included in the analysis.36-41 In asymptomatic individuals, three studies that used a risk score to identify persons with chlamydial or gonococcal infections reported an area under the curve of 0.64 to 0.73.36-38 One study showed age (younger than 22 years) alone had similar accuracy to the use of more extensive risk criteria.41
The USPSTF found convincing evidence that available screening tests can accurately diagnose chlamydial and gonococcal infections in both women and men. Nine fair-quality studies in more than 16,000 participants indicated that screening for chlamydia and gonorrhea with NAATs is highly accurate for specimens from various anatomical sites and different collection methods for women and men.42-50 Sensitivity of NAAT specimens collected from urogenital sites for detecting chlamydia and gonorrhea in women ranged from 72% to 100%, excluding one outlier study. Sensitivity among collection methods, including vaginal clinician- or self-collection or urine collection, varied little. NAATs for chlamydia and gonorrhea screening in men was highly accurate, with sensitivities ranging from 89% to 100% for urethral, meatal, and urine testing. NAATs were also highly sensitive for detecting rectal and pharyngeal gonorrhea and rectal chlamydia in men (89% to 93%); they had moderate sensitivity (69%) for detecting pharyngeal chlamydia in men. Specificity for several sites was high, ranging from 90% to 100% for both infections in men and women. Specificity was not reported for gonorrhea in women at the urethra site and in men at the urethra, rectal, or pharyngeal sites.20
Benefits of Early Detection and Treatment
The USPSTF reviewed four trials and concluded that screening was associated with reduced risk of PID vs. no screening.51-54 One recent large good-quality trial of men and women (n=63,338) in primary care clinics found that screening for chlamydia was associated with a reduction in risk of hospital-diagnosed PID compared to usual care (relative risk, 0.6 [95% CI 0.4 to 1.0]), but the absolute difference was small (0.24% vs. 0.38%). No differences were seen in rates of PID or epididymitis in clinics.54 No studies reported the association between screening and disease acquisition or transmission or clinical outcomes other than PID or epididymitis.20
The USPSTF previously found fair-quality evidence that treatment of chlamydial infection during pregnancy is associated with improved outcomes for infants and mothers.55,56 The USPSTF reviewed large cohort studies of screening at the first prenatal visit in pregnant women at increased risk for infection. These studies found that treatment of chlamydial infection was associated with significantly lower rates of preterm delivery, early rupture of membranes, and infants with low birthweight compared to no treatment or treatment failure.55,56 No subsequent studies met inclusion criteria for the current USPSTF review.20,34
The USPSTF found little direct evidence on the effectiveness of screening for chlamydia in men or low-risk women in reducing infection complications or disease transmission or acquisition. It found that the overall prevalence of chlamydial infection in the general population varies widely depending on age and other risk factors. Chlamydial infection may cause urethritis and epididymitis in men, but serious complications are not common. Screening and treating young men at increased risk may reduce the incidence of chlamydial infection; however, the USPSTF found no published prospective trials of the effect of routine screening in men or comparison with the strategy of screening women and treating their male partners.20,34 The USPSTF found no studies on the benefits of screening women, including pregnant women, who are not at increased risk for infection.20,34
The USPSTF found no studies that directly evaluated the effectiveness of screening for gonorrhea in its current or previous reviews.20,34,35 It previously found indirect evidence of the benefits of early detection and treatment in women at increased risk based on the substantial prevalence of asymptomatic infection, the availability of accurate screening tests and effective treatments, and the high morbidity associated with untreated infection in women.57 Gonococcal infections in women are frequently asymptomatic but represent an important reservoir of infection that could lead to reproductive complications and life-threatening conditions.
Based on indirect evidence, early detection and treatment of gonorrhea in pregnant women at increased risk for infection may decrease morbidity from infection-related obstetric complications. In women not at increased risk for gonorrhea, there is a low prevalence of infection, and universal ocular prophylaxis in newborns is effective and well established. Accordingly, the USPSTF concluded that the net benefit of screening for gonorrhea in pregnant women who are not at increased risk for infection is small.
The USPSTF found little evidence on the effectiveness of screening for gonorrhea in men or low-risk women. Prevalence in these groups is low.1 Moreover, the majority of genital gonococcal infections in men are symptomatic, which can result in more timely clinical presentation and lead to diagnosis and treatment that prevents serious complications.
Harms of Screening and Treatment
The USPSTF reviewed several studies, including four recent studies (N=5,666), assessing harms of site-specific chlamydia and gonorrhea testing as well as harms of collection methods in women. The false- positive, false-negative, false alarm, and false reassurance rates varied by anatomic site but were overall generally low across all NAATs and specimen types.20,34
How Does the Evidence Fit With Biological Understanding?
Chlamydial and gonococcal infections are often asymptomatic in women. Untreated infections may progress to PID-related complications such as chronic pelvic pain, ectopic pregnancy, or infertility. Infections may also be transmitted to sex partners and newborn children. Accurate screening tests and effective antibiotic treatments are available for chlamydia and gonorrhea.
In men, gonococcal infections are more commonly symptomatic compared to women. Serious complications from infection are less common in men.
Studies on assessing risk and for whom screening may be most effective are a high priority.
- Prevalence of chlamydia and gonorrhea is high among Black, American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, and Hispanic persons. Studies providing information on differential access and effective prevention strategies for these populations may help reduce racial and ethnic disparities.
- More studies are needed to better understand the benefits and harms of screening men who have sex with men, sexually active men younger than age 24 years, men residing in high-prevalence communities, and sexual and gender minority populations.
- Studies evaluating the effectiveness of screening asymptomatic men to reduce infection complications and transmission or acquisition of either disease or HIV are needed.
- Studies with direct evidence on the effectiveness of screening pregnant persons, testing extragenital sites, cotesting for concurrent STIs, and screening intervals would help provide more information for best practices.
The CDC recommends annual chlamydia and gonorrhea testing in all sexually active women younger than age 25 years and in older women with risk factors such as new or multiple sex partners or a sex partner who has an STI. It also recommends screening for both infections in pregnant women younger than age 25 years and in older pregnant women at increased risk for infection during their first prenatal visit and again during the third trimester.15-17
The CDC recommends that clinicians consider screening for chlamydia in sexually active young men in high-prevalence areas and populations.15 It recommends annual screening for chlamydia and gonorrhea in men who have sex with men, based on exposure history, with more frequent screening in higher-risk populations. Because of high rates of STDs in persons entering correctional facilities, the CDC recommends chlamydia and gonorrhea screening at intake in women age 35 years and younger and men younger than age 30 years in correctional facilities.17,22 Because of the high likelihood of reinfection, the CDC recommends retesting all patients diagnosed with chlamydial or gonococcal infections 3 months after treatment, regardless of whether they believe their partners have been treated.22
The American College of Obstetricians and Gynecologists follows the CDC’s recommendations for annual chlamydia and gonorrhea screening in all sexually active women younger than age 25 years and in older women with risk factors. However, it recommends that all pregnant women be tested for chlamydia early in pregnancy, with a repeat test in the third trimester for women with risk factors. It recommends testing for gonorrhea in pregnant women age 25 years and younger or for those living in an area where gonorrhea is common.58,59
The American Academy of Family Physicians follows the 2014 USPSTF chlamydia and gonorrhea screening recommendations.60 The American Academy of Pediatrics’ recommendations align with the CDC’s guidelines.61
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21. St Cyr S, Barbee L, Workowski KA, et al. Update to CDC's treatment guidelines for gonococcal infection, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(50):1911-1916.
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25. US Preventive Services Task Force. Screening for hepatitis B virus infection in pregnant women: US Preventive Services Task Force reaffirmation recommendation statement. JAMA. 2019;322(4):349-354.
26. US Preventive Services Task Force. Screening for hepatitis C virus infection in adolescents and adults: US Preventive Services Task Force recommendation statement. JAMA. 2020;323(10):970-975.
27. US Preventive Services Task Force. Serologic screening for genital herpes infection: US Preventive Services Task Force recommendation statement. JAMA. 2016;316(23):2525-2530.
28. US Preventive Services Task Force. Screening for HIV infection: US Preventive Services Task Force recommendation statement. JAMA. 2019;321(23):2326-2336.
29. US Preventive Services Task Force. Preexposure prophylaxis for the prevention of HIV Infection: US Preventive Services Task Force recommendation statement. JAMA. 2019;321(22):2203-2213.
30. US Preventive Services Task Force. Screening for syphilis infection in nonpregnant adults and adolescents: US Preventive Services Task Force recommendation statement. JAMA. 2016;315(21):2321-2327.
31. US Preventive Services Task Force. Screening for syphilis infection in pregnant women: US Preventive Services Task Force reaffirmation recommendation statement. JAMA. 2018;320(9):911-917.
32. US Preventive Services Task Force. Behavioral counseling interventions to prevent sexually transmitted infections: US Preventive Services Task Force recommendation statement. JAMA. 2020;324(7):674-681.
33. Tao G, Irwin KL. Receipt of HIV and STD testing services during routine general medical or gynecological examinations: variations by patient sexual risk behaviors. Sex Transm Dis. 2008;35(2):167-171.
34. Cantor A, Dana T, Griffen JC, et al. Screening for chlamydial and gonococcal infections: a systematic review update for the U.S. Preventive Services Task Force. JAMA. 2021. In process.
35. LeFevre ML; U.S. Preventive Services Task Force. Screening for chlamydia and gonorrhea: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;161(12):902-910.
36. Falasinnu T, Gilbert M, Gustafson P, Shoveller J. Deriving and validating a risk estimation tool for screening asymptomatic chlamydia and gonorrhea. Sex Transm Dis. 2014;41(12):706-712.
37. Falasinnu T, Gilbert M, Gustafson P, Shoveller J. A validation study of a clinical prediction rule for screening asymptomatic chlamydia and gonorrhoea infections among heterosexuals in British Columbia. Sex Transm Infect. 2016;92(1):12-18.
38. Falasinnu T, Gilbert M, Gustafson P, Shoveller J. An assessment of population-based screening guidelines versus clinical prediction rules for chlamydia and gonorrhea case finding. Prev Med. 2016;89:51-56.
39. Javanbakht M, Westmoreland D, Gorbach P. Factors associated with pharyngeal gonorrhea in young people: implications for prevention. Sex Transm Dis. 2018;45(9):588-593.
40. Lavoue V, Morcel K, Voltzenlogel MC, et al. Scoring system avoids Chlamydia trachomatis overscreening in women seeking surgical abortions. Sex Transm Dis. 2014;41(8):470-474.
41. Miller WC, Hoffman IF, Owen-O'Dowd J, et al. Selective screening for chlamydial infection: which criteria to use? Am J Prev Med. 2000;18(2):115-122.
42. Berry L, Stanley B. Comparison of self-collected meatal swabs with urine specimens for the diagnosis of Chlamydia trachomatis and Neisseria gonorrhoeae in men. J Med Microbiol. 2017;66(2):134-136.
43. Fang J, Husman C, DeSilva L, Chang R, Peralta L. Evaluation of self-collected vaginal swab, first void urine, and endocervical swab specimens for the detection of Chlamydia trachomatis and Neisseria gonorrhoeae in adolescent females. J Pediatr Adolesc Gynecol. 2008;21(6):355-360.
44. Nye MB, Osiecki J, Lewinski M, et al. Detection of Chlamydia trachomatis and Neisseria gonorrhoeae with the cobas CT/NG v2.0 test: performance compared with the BD ProbeTec CT Q(x) and GC Q(x) amplified DNA and Aptima AC2 assays. Sex Transm Infect. 2019;95(2):87-93.
45. Schachter J, McCormack WM, Chernesky MA, et al. Vaginal swabs are appropriate specimens for diagnosis of genital tract infection with Chlamydia trachomatis. J Clin Microbiol. 2003;41(8):3784-3789.
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47. Shrier LA, Dean D, Klein E, Harter K, Rice PA. Limitations of screening tests for the detection of Chlamydia trachomatis in asymptomatic adolescent and young adult women. Am J Obstet Gynecol. 2004;190(3):654-662.
48. Skidmore S, Kaye M, Bayliss D, Devendra S. Validation of COBAS Taqman CT for the detection of Chlamydia trachomatis in vulvo-vaginal swabs. Sex Transm Infect. 2008;84(4):277-278; discussion 278-279.
49. Stewart CM, Schoeman SA, Booth RA, Smith SD, Wilcox MH, Wilson JD. Assessment of self taken swabs versus clinician taken swab cultures for diagnosing gonorrhoea in women: single centre, diagnostic accuracy study. BMJ. 2012;345:e8107.
50. Sultan B, White JA, Fish R, et al. The"3 in 1" study: pooling self-taken pharyngeal, urethral, and rectal samples into a single sample for analysis for detection of Neisseria gonorrhoeae and Chlamydia trachomatis in men who have sex with men. J Clin Microbiol. 2016;54(3):650-656.
51. Oakeshott P, Kerry S, Aghaizu A, et al. Randomised controlled trial of screening for Chlamydia trachomatis to prevent pelvic inflammatory disease: the POPI (prevention of pelvic infection) trial. BMJ. 2010;340:c1642.
52. Ostergaard L, Andersen B, Moller JK, Olesen F. Home sampling versus conventional swab sampling for screening of Chlamydia trachomatis in women: a cluster-randomized 1-year follow-up study. Clin Infect Dis. 2000;31(4):951-957.
53. Scholes D, Stergachis A, Heidrich FE, Andrilla H, Holmes KK, Stamm WE. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Engl J Med. 1996;334(21):1362-1366.
54. Hocking JS, Temple-Smith M, Guy R, et al. Population effectiveness of opportunistic chlamydia testing in primary care in Australia: a cluster-randomised controlled trial. Lancet. 2018;392(10156):1413-1422.
55. U.S. Preventive Services Task Force. Screening for chlamydial infection—including ocular prophylaxis in newborns. In: Guide to Clinical Preventive Services: Report of the U.S. Preventive Services Task Force. 2nd ed. Washington, DC: U.S. Department of Health and Human Services; 1996.
56. Ryan GM Jr., Abdella TN, McNeeley SG, Baselski VS, Drummond DE. Chlamydia trachomatis infection in pregnancy and effect of treatment on outcome. Am J Obstet Gynecol. 1990;162(1):34-39.
57. U.S. Preventive Services Task Force. Screening for gonorrhea—including ocular prophylaxis in newborns. In: Guide to Clinical Preventive Services: Report of the U.S. Preventive Services Task Force. 2nd ed. Washington, DC: U.S. Department of Health and Human Services; 1996.
58. American College of Obstetricians and Gynecologists. Chlamydia, Gonorrhea, and Syphilis. https://www.acog.org/womens-health/faqs/chlamydia-gonorrhea-and-syphilis. Accessed February 19, 2021.
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61. Committee on Adolescence; Society for Adolescent Health and Medicine. Screening for nonviral sexually transmitted infections in adolescents and young adults. Pediatrics. 2014;134(1):e302-e311.
|Benefits of early detection and intervention and treatment||
|Harms of early detection and intervention and treatment||Adequate evidence to bound the harms of screening for chlamydia and gonorrhea in both women and men as small to none, based on the nature of the interventions, low likelihood of serious harms, and available information from studies reporting few harms. When direct evidence is limited, absent, or restricted to select populations or clinical scenarios, the USPSTF may place conceptual upper or lower bounds on the magnitude of benefit or harms.|