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See the Figure for a more detailed summary of the recommendations for clinicians. USPSTF indicates US Preventive Services Task Force.

Figure.  Clinician Summary: Screening for Chlamydia and Gonorrhea
Clinician Summary: Screening for Chlamydia and Gonorrhea

NAAT indicates nucleic acid amplification test; STI, sexually transmitted infection; USPSTF, US Preventive Services Task Force.

Table.  Summary of USPSTF Rationale
Summary of USPSTF Rationale
1.
Sexually transmitted disease surveillance 2019. Centers for Disease Control and Prevention. Reviewed 2021. Accessed July 28, 2021. https://www.cdc.gov/std/statistics/2019/default.htm
2.
Kreisel  KM, Spicknall  IH, Gargano  JW,  et al.  Sexually transmitted infections among US women and men: prevalence and incidence estimates, 2018.   Sex Transm Dis. 2021;48(4):208-214. doi:10.1097/OLQ.0000000000001355PubMedGoogle ScholarCrossref
3.
Brunham  RC, Gottlieb  SL, Paavonen  J.  Pelvic inflammatory disease.   N Engl J Med. 2015;372(21):2039-2048. doi:10.1056/NEJMra1411426PubMedGoogle ScholarCrossref
4.
Farley  TA, Cohen  DA, Elkins  W.  Asymptomatic sexually transmitted diseases: the case for screening.   Prev Med. 2003;36(4):502-509. doi:10.1016/S0091-7435(02)00058-0PubMedGoogle ScholarCrossref
5.
Reekie  J, Donovan  B, Guy  R,  et al; Chlamydia and Reproductive Health Outcome Investigators; Chlamydia and Reproductive Health Outcome Investigators.  Risk of pelvic inflammatory disease in relation to chlamydia and gonorrhea testing, repeat testing, and positivity: a population-based cohort study.   Clin Infect Dis. 2018;66(3):437-443. doi:10.1093/cid/cix769PubMedGoogle ScholarCrossref
6.
American Academy of Pediatrics. Prevention of neonatal ophthalmia. In: Kimberlin  DW, Brady  MT, Jackson  MA, eds.  Red Book: 2018 Report of the Committee on Infectious Diseases. 31st ed. American Academy of Pediatrics; 2018:1047-1102.
7.
Hammerschlag  MR.  Chlamydial and gonococcal infections in infants and children.   Clin Infect Dis. 2011;53(suppl 3):S99-S102. doi:10.1093/cid/cir699PubMedGoogle ScholarCrossref
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Stamm  WE. Chlamydia trachomatis infections of the adult. In: Holmes  K, ed.  Sexually Transmitted Disease. 4th ed. McGraw-Hill; 2008.
9.
Berger  RE, Alexander  ER, Monda  GD, Ansell  J, McCormick  G, Holmes  KK.  Chlamydia trachomatis as a cause of acute “idiopathic” epididymitis.   N Engl J Med. 1978;298(6):301-304. doi:10.1056/NEJM197802092980603PubMedGoogle ScholarCrossref
10.
Jacobs  NF, Kraus  SJ.  Gonococcal and nongonococcal urethritis in men: clinical and laboratory differentiation.   Ann Intern Med. 1975;82(1):7-12. doi:10.7326/0003-4819-82-1-7PubMedGoogle ScholarCrossref
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McConaghy  JR, Panchal  B.  Epididymitis: an overview.   Am Fam Physician. 2016;94(9):723-726.PubMedGoogle Scholar
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Korenromp  EL, Sudaryo  MK, de Vlas  SJ,  et al.  What proportion of episodes of gonorrhoea and chlamydia becomes symptomatic?   Int J STD AIDS. 2002;13(2):91-101. doi:10.1258/0956462021924712PubMedGoogle ScholarCrossref
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Fleming  DT, Wasserheit  JN.  From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection.   Sex Transm Infect. 1999;75(1):3-17. doi:10.1136/sti.75.1.3PubMedGoogle ScholarCrossref
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Kalichman  SC, Pellowski  J, Turner  C.  Prevalence of sexually transmitted co-infections in people living with HIV/AIDS: systematic review with implications for using HIV treatments for prevention.   Sex Transm Infect. 2011;87(3):183-190. doi:10.1136/sti.2010.047514PubMedGoogle ScholarCrossref
15.
Procedure Manual. US Preventive Services Task Force. Published May 2021. Accessed July 28, 2021. https://uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/procedure-manual
16.
Workowski  KA, Bachmann  LH, Chan  PA,  et al.  Sexually transmitted infections treatment guidelines, 2021.   MMWR Recomm Rep. 2021;70(4):1-187. doi:10.15585/mmwr.rr7004a1PubMedGoogle ScholarCrossref
17.
Centers for Disease Control and Prevention.  Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae—2014.   MMWR Recomm Rep. 2014;63(RR-02):1-19.PubMedGoogle Scholar
18.
FDA clears first diagnostic tests for extragenital testing for chlamydia and gonorrhea. US Food and Drug Administration. Published May 23, 2019. Accessed July 28, 2021. https://www.fda.gov/news-events/press-announcements/fda-clears-first-diagnostic-tests-extragenital-testing-chlamydia-and-gonorrhea
19.
Cantor  A, Dana  T, Griffen  JC,  et al.  Screening for Chlamydial and Gonococcal Infections: A Systematic Review Update for the US Preventive Services Task Force. Evidence Synthesis No. 206. Agency for Healthcare Research and Quality; 2021. AHRQ publication 21-05275-EF-1.
20.
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. doi:10.15585/mmwr.mm6950a6PubMedGoogle ScholarCrossref
21.
Barrow  RY, Ahmed  F, Bolan  GA, Workowski  KA.  Recommendations for providing quality sexually transmitted diseases clinical services, 2020.   MMWR Recomm Rep. 2020;68(5):1-20. doi:10.15585/mmwr.rr6805a1PubMedGoogle ScholarCrossref
22.
Krist  AH, Davidson  KW, Mangione  CM,  et al; US Preventive Services Task Force.  Screening for hepatitis B virus infection in adolescents and adults: US Preventive Services Task Force recommendation statement.   JAMA. 2020;324(23):2415-2422. doi:10.1001/jama.2020.22980PubMedGoogle Scholar
23.
Owens  DK, Davidson  KW, Krist  AH,  et al; 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. doi:10.1001/jama.2019.9365PubMedGoogle Scholar
24.
Owens  DK, Davidson  KW, Krist  AH,  et al; 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. doi:10.1001/jama.2020.1123PubMedGoogle Scholar
25.
Bibbins-Domingo  K, Grossman  DC, Curry  SJ,  et al; US Preventive Services Task Force.  Serologic screening for genital herpes infection: US Preventive Services Task Force recommendation statement.   JAMA. 2016;316(23):2525-2530. doi:10.1001/jama.2016.16776PubMedGoogle Scholar
26.
Owens  DK, Davidson  KW, Krist  AH,  et al; US Preventive Services Task Force.  Screening for HIV infection: US Preventive Services Task Force recommendation statement.   JAMA. 2019;321(23):2326-2336. doi:10.1001/jama.2019.6587PubMedGoogle Scholar
27.
Owens  DK, Davidson  KW, Krist  AH,  et al; 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. doi:10.1001/jama.2019.6390PubMedGoogle Scholar
28.
Bibbins-Domingo  K, Grossman  DC, Curry  SJ,  et al; US Preventive Services Task Force (USPSTF).  Screening for syphilis infection in nonpregnant adults and adolescents: US Preventive Services Task Force recommendation statement.   JAMA. 2016;315(21):2321-2327. doi:10.1001/jama.2016.5824PubMedGoogle Scholar
29.
Curry  SJ, Krist  AH, Owens  DK,  et al; 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. doi:10.1001/jama.2018.11785PubMedGoogle Scholar
30.
Krist  AH, Davidson  KW, Mangione  CM,  et al; 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. doi:10.1001/jama.2020.13095PubMedGoogle Scholar
31.
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. doi:10.1097/OLQ.0b013e3181585be5PubMedGoogle ScholarCrossref
32.
Cantor  A, Dana  T, Griffen  JC,  et al.  Screening for chlamydial and gonococcal infections: updated evidence report and systematic review for the US Preventive Services Task Force.   JAMA. Published September 14, 2021. doi:10.1001/jama.2021.10577Google Scholar
33.
LeFevre  ML; US Preventive Services Task Force.  Screening for chlamydia and gonorrhea: US Preventive Services Task Force recommendation statement.   Ann Intern Med. 2014;161(12):902-910. doi:10.7326/M14-1981PubMedGoogle ScholarCrossref
34.
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. doi:10.1097/OLQ.0000000000000205PubMedGoogle ScholarCrossref
35.
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. doi:10.1136/sextrans-2014-051992PubMedGoogle ScholarCrossref
36.
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. doi:10.1016/j.ypmed.2016.04.001PubMedGoogle ScholarCrossref
37.
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. doi:10.1097/OLQ.0000000000000822PubMedGoogle ScholarCrossref
38.
Lavoué  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. doi:10.1097/OLQ.0000000000000153PubMedGoogle ScholarCrossref
39.
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. doi:10.1016/S0749-3797(99)00146-4PubMedGoogle ScholarCrossref
40.
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. doi:10.1099/jmm.0.000428PubMedGoogle ScholarCrossref
41.
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. doi:10.1016/j.jpag.2008.03.010PubMedGoogle ScholarCrossref
42.
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 Qx and GC Qx amplified DNA and Aptima AC2 assays.   Sex Transm Infect. 2019;95(2):87-93. doi:10.1136/sextrans-2018-053545PubMedGoogle ScholarCrossref
43.
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. doi:10.1128/JCM.41.8.3784-3789.2003PubMedGoogle ScholarCrossref
44.
Schoeman  SA, Stewart  CM, Booth  RA, Smith  SD, Wilcox  MH, Wilson  JD.  Assessment of best single sample for finding chlamydia in women with and without symptoms: a diagnostic test study.   BMJ. 2012;345:e8013. doi:10.1136/bmj.e8013PubMedGoogle Scholar
45.
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. doi:10.1016/j.ajog.2003.09.063PubMedGoogle ScholarCrossref
46.
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. doi:10.1136/sti.2007.029587PubMedGoogle ScholarCrossref
47.
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. doi:10.1136/bmj.e8107PubMedGoogle Scholar
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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. doi:10.1128/JCM.02460-15PubMedGoogle ScholarCrossref
49.
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. doi:10.1136/bmj.c1642PubMedGoogle ScholarCrossref
50.
Ostergaard  L, Andersen  B, Møller  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. doi:10.1086/318139PubMedGoogle ScholarCrossref
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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. doi:10.1056/NEJM199605233342103PubMedGoogle ScholarCrossref
52.
Hocking  JS, Temple-Smith  M, Guy  R,  et al; ACCEPt Consortium.  Population effectiveness of opportunistic chlamydia testing in primary care in Australia: a cluster-randomised controlled trial.   Lancet. 2018;392(10156):1413-1422. doi:10.1016/S0140-6736(18)31816-6PubMedGoogle ScholarCrossref
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US Preventive Services Task Force. Screening for chlamydial infection—including ocular prophylaxis in newborns. In:  Guide to Clinical Preventive Services: Report of the US Preventive Services Task Force. 2nd ed. US Department of Health and Human Services; 1996.
54.
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. doi:10.1016/0002-9378(90)90815-OPubMedGoogle ScholarCrossref
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US Preventive Services Task Force. Screening for gonorrhea—including ocular prophylaxis in newborns. In:  Guide to Clinical Preventive Services: Report of the US Preventive Services Task Force. 2nd ed. US Department of Health and Human Services; 1996.
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Chlamydia, gonorrhea, and syphilis. American college of obstetricians and gynecologists. Published January 2021. Accessed July 28, 2021. https://www.acog.org/womens-health/faqs/chlamydia-gonorrhea-and-syphilis
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Routine tests during pregnancy. American College of Obstetricians and Gynecologists. Updated July 2021. Accessed July 29, 2021. https://www.acog.org/womens-health/faqs/routine-tests-during-pregnancy
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Clinical Preventive Service Recommendation: sexually transmitted infections. American Academy of Family Physicians. Accessed July 28, 2021. https://www.aafp.org/family-physician/patient-care/clinical-recommendations/all-clinical-recommendations/stis.html
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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. doi:10.1542/peds.2014-1024PubMedGoogle ScholarCrossref
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    US Preventive Services Task Force
    Recommendation Statement
    September 14, 2021

    Screening for Chlamydia and Gonorrhea: US Preventive Services Task Force Recommendation Statement

    US Preventive Services Task Force
    JAMA. 2021;326(10):949-956. doi:10.1001/jama.2021.14081
    Abstract

    Importance  Chlamydia and gonorrhea are among the most common sexually transmitted infections in the US. Infection rates are highest among adolescents and young adults of both sexes. Chlamydial and gonococcal infections in women are usually asymptomatic and may lead to pelvic inflammatory disease and its associated complications. Newborns of pregnant persons with untreated infection may develop neonatal chlamydial pneumonia or gonococcal or chlamydial ophthalmia. Infection in men may lead to urethritis and epididymitis. Both types of infection can increase risk of acquiring or transmitting HIV.

    Objective  To update its 2014 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for chlamydia and gonorrhea in sexually active adolescents and adults, including pregnant persons.

    Population  Asymptomatic, sexually active adolescents and adults, including pregnant persons.

    Evidence Assessment  The USPSTF concludes with moderate certainty that screening for chlamydia in all sexually active women 24 years or younger and in women 25 years or 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 24 years or younger and in women 25 years or 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.

    Recommendation  The USPSTF recommends screening for chlamydia in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection. (B recommendation) The USPSTF recommends screening for gonorrhea in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection. (B recommendation) 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 statement)

    Summary of Recommendations

    See the Summary of Recommendation figure.

    Importance

    Chlamydia and gonorrhea are among the most common sexually transmitted infections (STIs) in the US.1 Approximately 1.8 million cases of chlamydia and more than 600 000 cases of gonorrhea were reported to the Centers for Disease Control and Prevention (CDC) in 2019. The rate of chlamydia infection among women (698.9 cases per 100 000 women) was nearly double the rate among men (399.9 cases per 100 000 men). Gonorrhea infection was more prevalent in men (224.4 cases per 100 000 men) than in women (152.6 cases per 100 000 women). Infection rates are highest among adolescents and young adults of both sexes. In 2019 almost two-thirds (61.0%) of all reported chlamydia infections, and in 2018 more than half (54.1%) of new gonococcal infections, were among persons aged 15 to 24 years.1,2

    Quiz Ref IDChlamydial 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.3-5Quiz Ref ID Newborns of pregnant persons with untreated infection may develop neonatal chlamydial pneumonia or gonococcal or chlamydial ophthalmia.6,7 Infection in men may lead to urethritis and epididymitis.8-11 Men are often asymptomatic; however, gonorrhea is more likely than chlamydia to cause symptoms in men than in women.12 Both types of infection can increase risk of acquiring or transmitting HIV.13,14

    USPSTF Assessment of Magnitude of Net Benefit

    Quiz Ref IDThe US Preventive Services Task Force (USPSTF) concludes with moderate certainty that screening for chlamydia in all sexually active women 24 years or younger and in women 25 years or 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 24 years or younger and in women 25 years or 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 and the eFigure in the Supplement for information on the recommendation grade. See the Figure for a summary of the recommendation for clinicians. For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.15

    Practice Considerations
    Patient Population Under Consideration

    This recommendation applies to asymptomatic, sexually active adolescents and adults, including pregnant persons.

    In this recommendation statement, the recommendations are stratified by “men” and “women,” although the net benefit estimates are driven by biological sex (ie, male/female) rather than gender identity. Persons should consider their sex at birth and current anatomy (especially presence of a cervix/vagina) and consult with their own clinician, if necessary, to determine which recommendation best applies to them.

    Assessment of Risk

    Age is a strong predictor of risk for chlamydial and gonococcal infections, with the highest infection rates in women occurring during ages 15 to 24 years.1 Women 25 years or older are at increased risk if they have a new sex partner, more than 1 sex partner, a sex partner with concurrent partners, or a sex partner who has an STI; practice inconsistent condom use when not in a mutually monogamous relationship; or have a previous or coexisting STI. Exchanging sex for money or drugs and history of incarceration also are associated with increased risk.16 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.

    Screening Tests

    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.17 The US Food and Drug Administration approves NAATs for use on urogenital and extragenital sites, including urine, endocervical, vaginal, male urethral, rectal, and pharyngeal specimens.17,18 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.19

    Screening Intervals

    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, clinicians are encouraged to consult the most up-to-date guidance on treatment from the CDC.16,20

    Implementation

    Although the prevalences of chlamydia and gonorrhea differ, the risk factors for infection overlap, and the USPSTF recommends screening for both simultaneously. The USPSTF did not review evidence on screening for chlamydia and gonorrhea in persons living with HIV or taking HIV preexposure prophylaxis. The CDC provides recommendations for these and other specific groups. The CDC also describes ways to increase adherence to treatment and interventions to decrease the likelihood of reinfection.16,20,21

    Other Related USPSTF Recommendations

    The USPSTF has issued recommendations on screening for other STIs, including hepatitis B,22,23 hepatitis C,24 genital herpes,25 HIV,26,27 and syphilis.28,29 The USPSTF has also issued recommendations on behavioral counseling for all sexually active adolescents and for adults who are at increased risk for STIs.30

    Additional Tools and Resources

    The CDC provides more information about STIs, including chlamydia and gonorrhea, at https://www.cdc.gov/std/default.htm, as well as guidance for clinicians on providing quality STI clinical services, at https://www.cdc.gov/mmwr/volumes/68/rr/rr6805a1.htm.

    The National Academies of Sciences, Engineering, and Medicine provides a comprehensive systems-based approach for prevention and control of STIs at https://www.nap.edu/catalog/25955/sexually-transmitted-infections-adopting-a-sexual-health-paradigm.

    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, 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.canada.ca/en/public-health/services/infectious-diseases/sexual-health-sexually-transmitted-infections/canadian-guidelines/sexually-transmitted-infections.html.

    Suggestions for Practice Regarding the I Statement
    Potential Preventable Burden

    Quiz Ref IDChlamydial 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.16 Urogenital positivity among men who have sex with men was 6% for chlamydia and 7% for gonorrhea across 11 Sexually Transmitted Disease Surveillance Network jurisdictions in 2019.1 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.13,14

    Potential Harms

    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.

    Current Practice

    A review of health care claims of 4296 male and female patients presenting for general medical or gynecologic examinations from 2000 to 2003 found that a large proportion of patients with high-risk sexual behaviors did not receive STI or HIV testing during their visit.31 According to a review of diagnostic billing codes for 1074 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%).31

    Update of Previous USPSTF Recommendation

    This recommendation updates the USPSTF's 2014 recommendation on screening for chlamydia and gonorrhea.

    In 2014, the USPSTF recommended screening for chlamydia in sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection. It also recommended screening for gonorrhea in sexually active women 24 years or younger and in women 25 years or older 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.

    Supporting Evidence
    Scope of Review

    The USPSTF commissioned a systematic review19,32 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 a single analytic framework; evaluated the accuracy of risk stratification and screening strategies for identifying persons at increased risk; and focused evaluation of diagnostic accuracy on anatomical site–specific testing.19,32,33 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.19,32

    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.34-39 In asymptomatic individuals, 3 studies with 71 636 participants that used a risk score to identify persons with chlamydial or gonococcal infections reported an area under the curve of 0.64 to 0.73.34-36 One study showed that age (younger than 22 years) alone had accuracy similar to that for the use of more extensive risk criteria.39

    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.40-48 Sensitivity of NAAT specimens collected from urogenital sites for detecting chlamydia and gonorrhea in women ranged from 72% to 100%, excluding 1 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 urethral site and in men at the urethral, rectal, or pharyngeal sites.19

    Benefits of Early Detection and Treatment

    The USPSTF reviewed 4 trials and concluded that screening was associated with reduced risk of PID vs no screening.49-52 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 with usual care (relative risk, 0.6 [95% CI, 0.4-1.0]), but the absolute difference was small (0.24% vs 0.38%). No differences were seen in rates of PID or epididymitis in clinics.52 No studies reported the association between screening and disease acquisition or transmission or between screening and clinical outcomes other than PID or epididymitis.19

    Quiz Ref IDThe USPSTF previously found fair-quality evidence that treatment of chlamydial infection during pregnancy is associated with improved outcomes for infants and mothers.53,54 The USPSTF reviewed large cohort studies of screening at the first prenatal visit in pregnant women (with a total of 11 544 participants) 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 birth weight compared with no treatment or treatment failure.53,54 No subsequent studies met inclusion criteria for the current USPSTF review.19,32

    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 very limited published randomized trials or observational studies of the effect of routine screening in men or comparison with the strategy of screening women and treating their male partners.19,32 The USPSTF found no studies on the benefits of screening women, including pregnant women, who are not at increased risk for infection.19,32

    The USPSTF found no studies that directly evaluated the effectiveness of screening for gonorrhea in its current or previous reviews.19,32,33 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.55 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.

    The USPSTF found no studies comparing the effectiveness of cotesting for concurrent STIs or using different screening intervals.19,32

    Harms of Screening and Treatment

    The USPSTF reviewed several studies, including 4 recent studies (n = 5666), 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 anatomical site but were overall generally low across all NAATs and specimen types.19,32

    No studies of psychosocial harms, such as anxiety, related to testing met inclusion criteria for this or prior reviews.19,32

    Response to Public Comment

    A draft version of this recommendation statement was posted for public comment on the USPSTF website from March 2 through March 29, 2021. Several comments expressed concern that the USPSTF found insufficient evidence to screen men and did not provide separate recommendations for specific high-risk populations. The USPSTF did not identify enough evidence to support that screening men for chlamydia and gonorrhea improves health outcomes by reducing infection complications or disease transmission or acquisition, including HIV. In the Research Needs and Gaps section, the USPSTF calls for more research on screening in men and other groups such as men who have sex with men; the lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ+) community; and racial and ethnic minorities. The USPSTF also clarified to whom the recommendation applies regarding sex and gender in the Practice Considerations section. Some comments requested that universal, rather than risk-based, screening be recommended for women 25 years or older. Based on available disease prevalence data and accuracy of risk assessment tools, the USPSTF found that younger age was a strong predictor of disease risk, which was clarified in the Practice Considerations section. Comments also asked for clarification on screening intervals. Given the lack of available evidence on optimal screening frequency, the USPSTF provides a reasonable approach for rescreening in the Practice Considerations section.

    How Does 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 with women. Serious complications from infection are less common in men.

    Research Needs and Gaps

    Studies on assessing risk and for whom screening may be most effective are a high priority.

    • Studies evaluating the effectiveness of screening asymptomatic men to reduce infection complications and transmission or acquisition of either disease or HIV are needed.

    • Studies are needed to better understand the benefits and harms of screening specific populations at risk such as men who have sex with men, members of the LGBTQ+ community, and persons with nonbinary gender identity.

    • Prevalence of chlamydia and gonorrhea is high among American Indian/Alaska Native, Black, Hispanic/Latino, and Native Hawaiian/Pacific Islander persons. Studies providing information on differential access and effective prevention strategies for these populations may help reduce racial and ethnic disparities.

    • 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.

    Recommendations of Others

    The CDC recommends annual chlamydia and gonorrhea testing in all sexually active women younger than 25 years and in older women at increased risk of infection (ie, those who have a 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 25 years and in older pregnant women at increased risk for infection during their first prenatal visit and again during their third trimester if risk remains high.16

    The CDC recommends that clinicians consider screening for chlamydia in sexually active young men in high-prevalence areas and populations. It recommends annual screening for chlamydia and gonorrhea at appropriate anatomical sites of exposure in men who have sex with men, with more frequent screening if risk behaviors persist or if they or their sex partners have multiple partners. The CDC recommends screening transgender individuals on the basis of their sexual practices and anatomy. Because of high rates of STIs in persons entering correctional facilities, the CDC recommends chlamydia and gonorrhea screening at intake in correctional facilities in women 35 years or younger and in men younger than 30 years. 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.16

    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 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 25 years or younger or for those living in an area where gonorrhea is common.56,57

    The American Academy of Family Physicians follows the 2014 USPSTF chlamydia and gonorrhea screening recommendations.58 The American Academy of Pediatrics recommendations align with the CDC guidelines.59

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    Article Information

    Corresponding Author: Karina W. Davidson, PhD, MASc, Feinstein Institutes for Medical Research at Northwell Health, 130 E 59th St, Ste 14C, New York, NY 10032 (chair@uspstf.net).

    Accepted for Publication: August 4, 2021.

    The US Preventive Services Task Force (USPSTF) members: Karina W. Davidson, PhD, MASc; Michael J. Barry, MD; Carol M. Mangione, MD, MSPH; Michael Cabana, MD, MA, MPH; Aaron B. Caughey, MD, PhD; Esa M. Davis, MD, MPH; Katrina E. Donahue, MD, MPH; Chyke A. Doubeni, MD, MPH; Alex H. Krist, MD, MPH; Martha Kubik, PhD, RN; Li Li, MD, PhD, MPH; Gbenga Ogedegbe, MD, MPH; Lori Pbert, PhD; Michael Silverstein, MD, MPH; Melissa A. Simon, MD, MPH; James Stevermer, MD, MSPH; Chien-Wen Tseng, MD, MPH, MSEE; John B. Wong, MD.

    Affiliations of The US Preventive Services Task Force (USPSTF) members: Feinstein Institutes for Medical Research at Northwell Health, Manhasset, New York (Davidson); Harvard Medical School, Boston, Massachusetts (Barry); University of California, Los Angeles (Mangione); Albert Einstein College of Medicine, New York, New York (Cabana); Oregon Health & Science University, Portland (Caughey); University of Pittsburgh, Pittsburgh, Pennsylvania (Davis); University of North Carolina at Chapel Hill (Donahue); Mayo Clinic, Rochester, Minnesota (Doubeni); Fairfax Family Practice Residency, Fairfax, Virginia (Krist); Virginia Commonwealth University, Richmond (Krist); George Mason University, Fairfax, Virginia (Kubik); University of Virginia, Charlottesville (Li); New York University, New York, New York (Ogedegbe); University of Massachusetts Medical School, Worcester (Pbert); Boston University, Boston, Massachusetts (Silverstein); Northwestern University, Chicago, Illinois (Simon); University of Missouri, Columbia (Stevermer); University of Hawaii, Honolulu (Tseng); Pacific Health Research and Education Institute, Honolulu, Hawaii (Tseng); Tufts University School of Medicine, Boston, Massachusetts (Wong).

    Author Contributions: Dr Davidson had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The USPSTF members contributed equally to the recommendation statement.

    Conflict of Interest Disclosures: Authors followed the policy regarding conflicts of interest described at https://www.uspreventiveservicestaskforce.org/Page/Name/conflict-of-interest-disclosures. All members of the USPSTF receive travel reimbursement and an honorarium for participating in USPSTF meetings.

    Funding/Support: The USPSTF is an independent, voluntary body. The US Congress mandates that the Agency for Healthcare Research and Quality (AHRQ) support the operations of the US Preventive Services Task Force (USPSTF).

    Role of the Funder/Sponsor: AHRQ staff assisted in the following: development and review of the research plan, commission of the systematic evidence review from an Evidence-based Practice Center, coordination of expert review and public comment of the draft evidence report and draft recommendation statement, and the writing and preparation of the final recommendation statement and its submission for publication. AHRQ staff had no role in the approval of the final recommendation statement or the decision to submit for publication.

    Disclaimer: Recommendations made by the USPSTF are independent of the US government. They should not be construed as an official position of AHRQ or the US Department of Health and Human Services.

    Additional Contributions: We thank Kathleen Irwin, MD, MPH (formerly of AHRQ), Tina Fan, MD, MPH (AHRQ), and Brandy Peaker, MD, MPH (AHRQ), who contributed to the writing of the manuscript, and Lisa Nicolella, MA (AHRQ), who assisted with coordination and editing.

    Additional Information: The US Preventive Services Task Force USPSTF makes recommendations about the effectiveness of specific preventive care services for patients without obvious related signs or symptoms. It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment. The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision-making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms. Published by JAMA®–Journal of the American Medical Association under arrangement with the Agency for Healthcare Research and Quality (AHRQ). ©2021 AMA and United States Government, as represented by the Secretary of the Department of Health and Human Services (HHS), by assignment from the members of the United States Preventive Services Task Force (USPSTF). All rights reserved.

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