Gonorrhea and chlamydia in emergency departments: Screening, diagnosis, and treatment

A National Study of Expedited Partner Therapy Use in Emergency Departments: A Survey of Medical Director Knowledge, Attitudes, and Practices

BACKGROUND

Emergency departments (EDs) are the primary source of health care for many patients diagnosed with sexually transmitted infections (STIs). Expedited partner therapy (EPT), treating the partner of patients with STIs, is an evidence-based practice for patients who might not otherwise seek care. Little is known about the use of EPT in the ED. In a national survey, we describe ED medical directors' knowledge, attitudes, and practices of EPT.

METHODS

A cross-sectional survey of medical directors from academic EDs was conducted from July to September 2020 using the Academy of Academic Administrators of Emergency Medicine Benchmarking Group. Primary outcomes were EPT awareness, support, and use. The survey also examined barriers and facilitators.

RESULTS

Forty-eight of 70 medical directors (69%) responded. Seventy-three percent were aware of EPT, but fewer knew how to prescribe it (38%), and only 19% of EDs had implemented EPT. Seventy-nine percent supported EPT and were more likely to if they were aware of EPT (89% vs. 54%; P = 0.01). Of nonimplementers, 41% thought EPT was feasible, and 56% thought departmental support would be likely. Emergency department directors were most concerned about legal liability, but a large proportion (44%) viewed preventing sequelae of untreated STIs as "extremely important."

CONCLUSIONS

Emergency department medical directors expressed strong support for EPT and reasonable levels of feasibility for implementation but low utilization. Our findings highlight the need to identify mechanisms for EPT implementation in EDs.

Opt-Out, Routine Emergency Department Syphilis Screening as a Novel Intervention in At-Risk Populations

BACKGROUND

With syphilis rates rising rapidly in the United States, novel means of reaching high-risk populations for screening and treatment are needed. Building on successful models for emergency department (ED) HIV screening, a routine opt-out syphilis screening program was implemented in a large, urban, tertiary care hospital ED in May 2019. This study aims to assess the prevalence of syphilis in this population and to evaluate the routine, opt-out syphilis screening model.

METHODS

A retrospective chart review was performed of all patients screened for syphilis in the ED from June to December 2019. Demographic information, HIV status, chief complaint, and follow-up visits were examined.

RESULTS

During the study period, 9198 people aged 18 to 64 years were screened for syphilis. Of these, 97 (1.1%) had presumed active syphilis infection (PAI), 354 (3.8%) were presumed not to have active syphilis, and 8747 (95.1%) were negative for infection. Patients with PAI were more likely to be male (67%; adjusted odds ratio, 3.5; 95% confidence interval, 2.3-5.3; P < 0.001), although the percentage of women was considerably higher than the nationally reported rate, and most were non-Hispanic Black (93.8%). Among patients with PAI, 23 (23.7%) were HIV positive. Only 18.6% of patients with PAI presented with complaints related to sexually transmitted infections.

CONCLUSIONS

Syphilis rates in this community are very high, and many infections were found in populations traditionally considered at lower risk by demographic or presenting complaint, indicating that universal screening is needed. Routine ED syphilis screening in high-prevalence communities will be critical to addressing the syphilis epidemic.

Information Technology-Assisted Screening for Gonorrhea and Chlamydia in a Pediatric Emergency Department

PURPOSE

The aim of the study was to design and implement a novel, universally offered, computerized clinical decision support (CDS) gonorrhea and chlamydia (GC/CT) screening tool embedded in the emergency department (ED) clinical workflow and triggered by patient-entered data.

METHODS

The study consisted of the design and implementation of a tablet-based screening tool based on qualitative data of adolescent and parent/guardian acceptability of GC/CT screening in the ED and an advisory committee of ED leaders and end users. The tablet was offered to adolescents aged 14-21 years and informed patients of Centers for Disease Control and Prevention GC/CT screening recommendations, described the testing process, and assessed whether patients agreed to testing. The tool linked to CDS that streamlined the order entry process. The primary outcome was the patient capture rate (proportion of patients with tablet data recorded). The secondary outcomes included rates of patient agreement to GC/CT testing and provider acceptance of the CDS.

RESULTS

Outcomes at the main and satellite EDs, respectively, were as follows: 1-year patient capture rates were 64.6% and 64.5%; 9.9% and 4.4% of patients agreed to GC/CT testing, and of those, the provider ordered testing for 73% and 72%.

CONCLUSIONS

Implementation of this computerized screening tool embedded in the clinical workflow resulted in patient capture rates of almost two-thirds and clinician CDS acceptance rates >70% with limited patient agreement to testing. This screening tool is a promising method for confidential GC/CT screening among youth in an ED setting. Additional interventions are needed to increase adolescent agreement for GC/CT testing.

Use of a Rapid Diagnostic for Chlamydia trachomatis and Neisseria gonorrhoeae for Women in the Emergency Department Can Improve Clinical Management: Report of a Randomized Clinical Trial

STUDY OBJECTIVE

In emergency departments (EDs), diagnosis and treatment of Chlamydia trachomatis and Neisseria gonorrhoeae are challenging. We conducted a randomized clinical trial to assess rapid C trachomatis and N gonorrhoeae testing on overtreatment and undertreatment of women evaluated for C trachomatis and N gonorrhoeae.

METHODS

Women undergoing pelvic examinations and C trachomatis and N gonorrhoeae testing (n=254) were randomized to control or rapid test groups. The control group received standard-of-care C trachomatis and N gonorrhoeae nucleic acid amplification tests of endocervical specimens, with 2- to 3-day turnaround times. For the rapid test group, clinicians collected an extra endocervical swab for GeneXpert C trachomatis and N gonorrhoeae rapid testing, in addition to the standard-of-care nucleic acid amplification test swab. Rapid results were immediately provided, and all patients were treated according to providers' clinical judgment.

RESULTS

In the rapid test group, 7.9% of patients had positive test results for C trachomatis; 3.9% had positive test results for N gonorrhoeae. In the control standard-of-care group, 10.2% of patients had positive nucleic acid amplification test results for C trachomatis; 5.5% had positive results for N gonorrhoeae. Undertreatment for both C trachomatis and N gonorrhoeae in the ED was 0% for the rapid test group and 43.8% for the control standard-of-care group. Clinicians overtreated 46.5% of uninfected standard-of-care control patients for C trachomatis compared with 23.1% of uninfected rapid test patients. For patients uninfected with N gonorrhoeae, clinicians overtreated 46.7% of standard-of-care control patients compared with 25.4% of rapid test patients. The length of stay did not differ significantly between groups.

CONCLUSION

Rapid C trachomatis and N gonorrhoeae testing in the ED led to a significant reduction in overtreatment for women without infections compared with the standard-of-care control group. Additionally, in the rapid test group there was significant improvement in appropriate treatment for patients with infections.

Trends in pelvic inflammatory disease emergency department visits, United States, 2006-2013

BACKGROUND

Pelvic inflammatory disease is a female genital tract disorder with severe reproductive sequelae. Because of the difficulties in diagnosing pelvic inflammatory disease, it is not a reportable condition in many states. Females seeking care in emergency departments are a sentinel population for pelvic inflammatory disease surveillance.

OBJECTIVE

The objective of the study was to determine trends in diagnoses of acute pelvic inflammatory disease in a nationally representative sample of emergency departments.

STUDY DESIGN

All emergency department visits among females aged 15-44 years with an International Classification of Diseases, ninth revision, Clinical Modification diagnosis code indicating pelvic inflammatory disease during 2006-2013 were assessed from the HealthCare Utilization Project Nationwide Emergency Department Sample. Total and annual percentage changes in the proportion of pelvic inflammatory disease emergency department visits were estimated using trend analyses.

RESULTS

While the number of emergency department visits among females aged 15-44 years during 2006-2013 increased (6.5 million to 7.4 million), the percentage of visits due to pelvic inflammatory disease decreased from 0.57% in 2006 to 0.41% in 2013 (total percentage change, -28.4%; annual percent change, -4.3%; 95% confidence interval, -5.7% to -2.9%). The largest decreases were among those aged 15-19 years (total percent change, -40.6%; annual percentage change, -6.6%; 95% confidence interval, -8.6% to -4.4%) and living in the South (total percentage change, -38.0%; annual percentage change, -6.2%; 95% confidence interval, -7.8% to -4.6%). Females aged 15-19 years who lived in the South had a 47.9% decrease in visits due to pelvic inflammatory disease (annual percentage change, -8.4%, 95% confidence interval, -10.4 to -6.5). Patients living in ZIP codes with the lowest median income (<$38,000) had the highest percent of visits with a pelvic inflammatory disease diagnosis; the smallest declines over time were in patients living in ZIP codes with the highest median income (i.e., >$64,000, total percent change, -24.4%; annual percent change, -3.8%; 95% confidence interval, -5.2% to -2.4%). The percentage of emergency department visits due to pelvic inflammatory disease was highest among patients not charged for their visit, self-paying, or those covered by Medicaid, with total percentage changes in these 3 groups of -27.8%, -30.7%, and -35.1%, respectively. Patients with Medicaid coverage had the largest decrease in visits with a diagnosis of pelvic inflammatory disease (total percent change, -35.1%; annual percent change, -5.8%; 95% confidence interval, -7.2% to -4.3%).

CONCLUSION

Nationally representative data indicate the percentage of emergency department visits with a pelvic inflammatory disease diagnosis decreased during 2006-2013 among females aged 15-44 years, primarily driven by decreased diagnoses of pelvic inflammatory disease among females aged 15-19 years and among women living in the southern United States. Despite declines, a large number of females of reproductive age are receiving care for pelvic inflammatory disease in emergency departments. Patients with lower median income and no or public health insurance status, which may decrease access to and use of health care services, consistently had the highest percentage of emergency department visits due to pelvic inflammatory disease. Future research should focus on obtaining a better understanding of factors influencing trends in pelvic inflammatory disease diagnoses and ways to address the challenges surrounding surveillance for this condition.

A Qualitative Analysis of Adolescent and Caregiver Acceptability of Universally Offered Gonorrhea and Chlamydia Screening in the Pediatric Emergency Department

STUDY OBJECTIVE

We qualitatively explore adolescent and parent or guardian attitudes about benefits and barriers to universally offered gonorrhea and chlamydia screening and modalities for assessing interest in screening in the pediatric emergency department (ED).

METHODS

A convenience sample of forty 14- to 21-year-olds and parents or guardians of adolescents presenting to an urban and community pediatric ED with any chief complaint participated in individual, semistructured, confidential interviews. Topics included support of universally offered gonorrhea and chlamydia screening, barriers and benefits to screening, and modalities for assessing interest in screening. Data were analyzed with framework analysis.

RESULTS

Almost all adolescents (37/40; 93%) and parents (39/40; 98%) support offering ED gonorrhea or chlamydia screening. Benefits included earlier diagnosis and treatment, convenience and transmission prevention (cited by both groups), and improved education and long-term health (cited by parents/guardians). Barriers included concerns about confidentiality and cost (cited by both groups), embarrassment (cited by adolescents), and nondisclosure to parents or guardians (cited by parents/guardians). Adolescents preferred that the request for gonorrhea or chlamydia screening be presented in a private room, using tablet technology. Both groups noted that the advantages to tablets included confidentiality and adolescents' familiarity with technology. Adolescents noted that tablet use would address concerns about bringing up gonorrhea or chlamydia screening with clinicians, whereas parents or guardians noted that tablets might increase screening incidence but expressed concern about the lack of personal interaction.

CONCLUSION

Universally offered gonorrhea and chlamydia screening in a pediatric ED was acceptable to the adolescents and parents or guardians in this study. Offering a tablet-based method to assess interest in screening may increase participation.

Screening for Asymptomatic Gonorrhea and Chlamydia in the Pediatric Emergency Department

BACKGROUND

Because adolescents rely heavily on emergency services for health care, a pediatric emergency department (PED) visit may be their only opportunity for sexually transmitted infection (STI) screening. The primary objectives of this study were to determine the proportion of Neisseria gonorrheae (GC) and Chlamydia trachomatis (CT) infections in asymptomatic PED adolescents and patient-perceived barriers to STI screening.

METHODS

A convenience sample of patients aged 14 to 21 years presenting to an urban PED with nongenitourinary complaints was offered screening for GC and CT. Regardless of declining or accepting screening, all were asked to complete a questionnaire designed to identify barriers to screening.

RESULTS

Sixty-eight percent of those approached participated (n = 719). Those who agreed to STI screening were more likely to be nonwhite (61.4% vs. 38.6%, P = 0.001) and publically insured (63.3%) versus privately insured (29.3%) or no insurance (7.58%). Four hundred three (56%) participants provided urine samples, and of those, 40 (9.9%) were positive for an STI. Controlling for other demographics, race was a significant predictor, with the odds of testing positive for nonwhite participants 5.90 times that of white participants. Patients who refused testing were more likely to report not engaging in sexual activity (54.3% vs. 42.4%, P = 0.009) and less likely to perceive that they were at risk for STIs.

CONCLUSIONS

There are high proportions of GC and CT among asymptomatic adolescents visiting an academic urban PED. A universal PED STI screening program may be an important component of STI reduction initiatives, especially among adolescents who do not perceive that they are at risk and may not receive testing elsewhere.

Differences in Treatment of Chlamydia trachomatis by Ambulatory Care Setting

Chlamydia trachomatis (CT) is the most commonly reported sexually transmitted infection (STI) in the US and timely, correct treatment can reduce CT transmission and sequelae. Emergency departments (ED) are an important location for diagnosing STIs. This study compared recommended treatment of CT in EDs to treatment in physician offices. Five years of data (2006-2010) were analyzed from the National Ambulatory Medical Care Survey, and the National Hospital Ambulatory Medical Care Surveys (NHAMCS), including the Outpatient survey (NHAMCS-OPD) and Emergency Department survey (NHAMCS-ED). All visits with a CT diagnosis and those with a diagnosis of unspecified venereal disease were selected for analysis. Differences in receipt of recommended treatments were compared between visits to physician offices and emergency departments using Chi square tests and logistic regression models. During the 5 year period, approximately 3.2 million ambulatory care visits had diagnosed CT or an unspecified venereal disease. A greater proportion of visits to EDs received the recommended treatment for CT compared to visits to physician offices (66.1 vs. 44.9 %, p < .01). When controlling for patients' age, sex and race/ethnicity, those presenting to the ED with CT were more likely to receive the recommended antibiotic treatment than patients presenting to a physician's office (OR 2.16; 95 % CI 1.04-4.48). This effect was attenuated when further controlling for patients' expected source of payment. These analyses demonstrate differences in the treatment of CT by ambulatory care setting as well as opportunities for increasing use of recommended treatments for diagnosed cases of this important STI.

Adherence to Centers for Disease Control and Prevention Gonococcal Treatment Guidelines Among Chicago Health Care Providers, 2011-2012

BACKGROUND

Expansion of antimicrobial resistance in Neisseria gonorrhoeae requires rapid adaptation of treatment guidelines and responsive provider practice. We evaluated patient factors associated with provider adherence to the Centers for Disease Control and Prevention gonococcal treatment recommendations among Chicago providers in 2011 to 2012.

METHODS

Laboratory-confirmed cases of uncomplicated urogenital gonorrhea were classified via surveillance data as originating from Chicago Department of Public Health (CDPH) or non-CDPH providers. Recommended treatment was determined according to the Centers for Disease Control and Prevention sexually transmitted disease treatment guidelines: April 2011-July 2012 (period 1) and August-December 2012 (period 2, after August 2012 revision). Multivariable log-binomial regression identified factors associated with recommended treatment over time, stratified by provider type.

RESULTS

April 2011 through December 2012, 16,646 laboratory-confirmed gonorrhea cases were identified, of which 9597 (57.7%) had treatment information: 2169 CDPH cases and 7428 non-CDPH cases. Documented recommended treatment increased for CDPH (period 1: 71.3%, period 2: 80.8%; P < 0.01) and non-CDPH providers (period 1: 63.5%, period 2: 68.9%; P < 0.01). Among CDPH cases, statistically significant factors associated with recommended treatment were male sex (adjusted prevalence rate ratio [aPRR], 1.16) white versus black race (aPRR, 0.68), same-day treatment (aPRR, 1.07), and period 2 (aPRR, 1.11). Among non-CDPH cases, statistically significant factors were as follows: male sex (aPRR, 1.10), other versus black race (aPRR, 0.91), same-day treatment (aPRR, 1.31), greater number of within-facility reported cases (aPRRs ranging from 1.22 to 1.41), and at least 50% within-facility missing treatment data (aPRR, 0.84).

CONCLUSIONS

Recommended treatment improved over time, yet remains suboptimal. Efforts to reduce variability and improve provider adherence to recommended treatment are urgently needed.

Sexual history taking in the emergency department - more specificity required

BACKGROUND

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) are the most reported diseases in the United States, and emergency departments (ED) serve a population presenting with increased infection risk. However, identifying patients for whom sexually transmitted infection (STI) screening is appropriate requires accurate sexual history reporting.

STUDY OBJECTIVES

To examine the consistency with which ED patients answer general and specific sexual activity questions, and how responses relate to perceived STI risk.

METHODS

Urban ED patients aged 15-34 years completed a sexual history survey containing sexual activity and perceived infection risk questions and provided urine and pharyngeal specimens for CT/GC analysis.

RESULTS

Participants included 192 males and 301 females with a mean age of 25.2 years and were 65.7% white and 33.3% black. Thirty-eight (7.7%) were infected with CT or GC. In patients denying sexual activity in the past year (general question), 40.7% of such males and 45.0% of females also reported some form of specific sexual activity (activity misclassification). Among self-identified heterosexuals, 7.2% males and 7.5% females reported some form of homosexual activity (orientation misclassification; OM). OM individuals were more likely to perceive themselves at risk of infection both orally (odds ratio 2.92, confidence interval 1.12-7.63) and genitally (odds ratio 3.36, confidence interval 1.55-7.30).

CONCLUSIONS

Given that reported sexual activity and age are the only criteria for routine female screening, and that homosexual activity is one of the few screening criteria for males, our results show that a substantial proportion of ED patients eligible for screening may not be identified by reliance upon general sexual history questions.

[Prevalence of Chlamydia trachomatis, Neisseria gonorrhoeae and Mycoplasma genitalium infections in the emergency department]

STUDY OBJECTIVE

To estimate the prevalence of Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Mycoplasma genitalium (MG) in patients under 31 years of age admitted to the emergency department of the University Hospital of Montpellier, for which a urinalysis was performed.

PATIENTS AND METHODS

CT, NG and MG specific real-time PCRs were performed in the urine samples from 301 patients between July 2010 and January 2011.

RESULTS

CT DNA was detected in 11% of patients, NG DNA in 3.7% of patients and MG DNA in one patient. Seventy-five percent of male patients and only 13% of women were diagnosed with sexually transmitted infection (STI). No patient with leucocyturia below 10(4)/mL had a positive PCR result for one of the three bacteria. Of the patients with leucocyturia greater or equal to 10(4)/mL, CT was detected in 23.4% of men and 11% of women, NG in 19.2% of men and 1% of women, and MG in 2.1% of men.

CONCLUSION

The prevalence of NG and CT detection in our population was high while that of MG was low. The diagnosis was facilitated by the use of PCR on the urine sample although this sample is not recommended for the molecular detection of bacterial agents of STIs and may explain the low detection of MG. The study allowed diagnosing STIs in 14.3% of our patient population.

Research priorities for human immunodeficiency virus and sexually transmitted infections surveillance, screening, and intervention in emergency departments: consensus-based recommendations

This article describes the results of the human immunodeficiency virus (HIV) and sexually transmitted infections (STI) prevention in the emergency department (ED) component of the 2009 Academic Emergency Medicine Consensus Conference entitled "Public Health in the ED: Surveillance, Screening, and Intervention." The objectives were to use experts to define knowledge gaps and priority research questions related to the performance of HIV and STI surveillance, screening, and intervention in the ED. A four-step nominal group technique was applied using national and international experts in HIV and STI prevention. Using electronic mail, an in-person meeting, and a Web-based survey, specific knowledge gaps and research questions were identified and prioritized. Through two rounds of nomination and refinement, followed by two rounds of election, consensus was achieved for 11 knowledge gaps and 14 research questions related to HIV and STI prevention in EDs. The overarching themes of the research priority questions were related to effectiveness, sustainability, and integration. While the knowledge gaps appear disparate from one another, they are related to the research priority questions identified. Using a consensus approach, we developed a set of priorities for future research related to HIV and STI prevention in the ED. These priorities have the potential to improve future clinical and health services research and extramural funding in this important public health sector.

Emergency department management of adolescents with urinary complaints: missed opportunities

Practice recommendations for the evaluation of adolescents with urinary complaints advise taking a sexual history and testing for sexually transmitted infections (STIs). In this emergency department chart review, 30% lacked a documented sexual history and 49% of sexually active patients were not STI tested, representing missed opportunities for diagnosis of STIs.