Opportunistic urine ligase chain reaction screening for sexually transmitted diseases in adolescents seeking care in an urban emergency department

Value of Packaged Testing for Sexually Transmitted Infections for Persons who Inject Drugs Hospitalized With Serious Injection-Related Infections

Background

Persons who inject drugs (PWID) are frequently admitted for serious injection-related infections (SIRIs). PWID are also at risk for sexually transmitted infections (STIs).

Methods

We conducted a multicenter quality improvement project at 3 hospitals in Missouri. PWID with SIRI who received an infectious diseases consultation were prospectively identified and placed into an electronic database as part of a Centers for Disease Control and Prevention–funded quality improvement project. Baseline data were collected from 8/1/2019 to 1/30/2020. During the intervention period (2/1/2020–2/28/2021), infectious diseases physicians caring for patients received 2 interventions: (1) email reminders of best practice screening for HIV, viral hepatitis, and STIs; (2) access to a customized EPIC SmartPhrase that included checkboxes of orders to include in assessment and plan of consultation notes. STI screening rates were compared before and after the intervention. We then calculated odds ratios to evaluate for risk factors for STIs in the cohort.

Results

Three hundred ninety-four unique patients were included in the cohort. Initial screening rates were highest for hepatitis C (88%), followed by HIV (86%). The bundled intervention improved screening rates for all conditions and substantially improved screening rates for gonorrhea, chlamydia, and syphilis (30% vs 51%, 30% vs 51%, and 39 vs 60%, respectively; P < .001). Of patients who underwent screening, 16.9% were positive for at least 1 STI. In general, demographics were not strongly associated with STIs.

Conclusions

PWID admitted for SIRI frequently have unrecognized STIs. Our bundled intervention improved STI screening rates, but additional interventions are needed to optimize screening.

Increasing Trichomonas vaginalis testing for high-risk adolescents a pediatric emergency department

Background

Trichomonas is a common sexually transmitted infection (STI) among adolescents, causing vaginal discharge, pelvic pain, and dysuria. Affected individuals have increased susceptibility to other STIs and may have pregnancy complications. A quality improvement project was developed to increase trichomonas testing among high-risk adolescent patients from 40% in July 2014 to 100% by December 31, 2014, and sustain over 6 months.

Methods

An interdisciplinary team (providers and support staff) was assembled to address this objective. We collected 6 months of baseline data. Deploying the Institute for Healthcare Improvement Model for Improvement, we formulated an aim statement and identified key drivers. We used cause analysis to identify interventions for each problem area. Multiple Plan-Do-Study-Act cycles were undertaken, and results were monitored using control charts. Interventions included increasing awareness and education for clinical staff; changing computer order entry for the test; using order sets for STI; and adding a Licensed Professional Initiated Protocol to nurse ordering practice. These interventions were all done in conjunction with feedback to providers for individual missed cases.

Results

Over 18 months, the trichomonas testing rate rose with each intervention: from 25% (January 2014) to 98% (December 2014), which we have sustained through June 2015.

Implications and Contributions

This article demonstrates the successful use of quality improvement methodology to increase rates of Trichomonas vaginalis testing among at-risk adolescent patients. Increased testing results in increased detection and improved treatment and sexual health for our patients.

Conclusion

Improving the trichomonas testing process in the pediatric emergency department results in higher screening rates among high-risk adolescent patients.

Screening for asymptomatic chlamydia and gonorrhea in adolescent males in an urban pediatric emergency department

AIM

To determine the prevalence of Chlamydia trachomatis (CT) and Neisseria gonorrhea (GC) in young men seeking care in the emergency department (ED) for non-sexually transmitted infection (STI) related symptoms.

METHODS

This was a prospective, cross-sectional study in an urban ED. The main outcome was the rate of positive CT and GC on urine nucleic acid amplification testing in males aged 16-21 presenting with non-STI related complaints.

RESULTS

Two hundred and eighty-four patients were enrolled, 271 were included in the final data analysis [age range 16-21, median: 18 (quartiles 16-18, 19-21)]. Overall, 17 (6.3%, 95%CI: 4%-10%) tested positive for CT and 0% (95%CI: 0%-2%) were found to have GC. The proportion of sexually active subjects was 71% (95%CI: 65%-76%) and 2% (95%CI: 0.6%-4%) reported sex with men. Previous STI testing was reported in 46% (95%CI: 43%-54%) and 13% (95%CI: 8%-20%) of those patients previously tested had a history of STI. Of the patients who tested positive for CT in the ED, 88% (95%CI: 64%-98%) were successfully followed up.

CONCLUSION

The prevalence of CT infection found by screening was 6.3%. Screening and follow-up from the ED was successful. The findings justify routine STI screening in male adolescents presenting to the ED with non-STI related complaints.

Screening adolescents for sexually transmitted infections in the pediatric emergency department

OBJECTIVES

The objectives of this study were to determine the prevalence of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) infections among adolescents presenting to a pediatric emergency department (PED), to assess the association between these infections and certain risk factors, and to assess the feasibility of routine screening for sexually transmitted infections (STIs) in the PED.

METHODS

This was a prospective, observational cohort study. Three hundred seven adolescents aged 13 to 17 years in an urban PED in Bronx, NY, were enrolled in the study. Subjects provided urine samples for nucleic acid amplification testing for CT and GC and self-completed a confidential questionnaire to assess health care-seeking patterns, high-risk social behaviors, and the presence of abuse, depression, and suicidal ideation. Outcome measures include prevalence of STIs and association of STIs with responses to the confidential questionnaire.

RESULTS

Twenty subjects (6.5%) tested positive for an STI. Seventeen (5.5%) were positive for CT, 2 (0.7%) for GC, and 1 (0.3%) for both. Fourteen adolescents (70%) with a positive test were asymptomatic. Logistic regression yielded 4 factors significantly associated with an STI: female sex (odds ratio [OR], 4.02; 95% confidence interval [CI], 1.1-15.2), illicit drug use (OR, 3.3; 95% CI, 1.1-9.3), disclosure of sexual activity (OR, 9.3; 95% CI, 1.1-76.9), and report of a sexual encounter resulting in pregnancy (OR, 3.7; 95% CI, 1.3-10.4).

CONCLUSIONS

Sexually transmitted infections were common in asymptomatic adolescents presenting to the PED. We identified 4 risk factors that were significantly associated with STIs. Our findings may facilitate identification of adolescents at highest risk for STIs, help prevent further transmission of infection, and decrease morbidity in this marginalized population.

Computerized self-interviews improve Chlamydia and gonorrhea testing among youth in the emergency department

STUDY OBJECTIVE

National guidelines recommend annual Chlamydia trachomatis and Neisseria gonorrhoeae screening for sexually active youth at risk for infection. These infections have serious sequelae in women if untreated, and methods to improve testing are needed. We hypothesize that an electronic method of identifying at-risk youth will significantly increase testing for these sexually transmitted infections during emergency department (ED) visits.

METHODS

We developed an audio-enhanced computer-assisted self-interview (ACASI) to obtain sexual histories from ED patients and an embedded decision tree to create a sexually transmitted infection testing recommendation. ED health care providers were prompted by the electronic medical record to review the participant answers and testing recommendations, and to offer testing to at-risk youth. Patients aged 15 to 21 years and visiting the St. Louis Children's Hospital ED, regardless of complaint, were eligible for participation.

RESULTS

Sexually transmitted infection testing among all 15- to 21-year-old ED patients increased from 9.3% in the 3 months before the ACASI to 17.8% during the 8-month period the ACASI was available and diminished to 12.4% in the 3 months after ACASI withdrawal (P<.001). During the ACASI period, we approached 51.4% of eligible patients and enrolled 59.8% (800/1,337) of those approached. Among ACASI participants, 52.4% (419/800) received a recommendation to receive sexually transmitted infection testing. Of these patients, 52.7% (221/419) received testing in the ED and 18.1% (40/221) of those tested had positive results for chlamydia or gonorrhea, 55% of whom (22/40) had chief complaints unrelated to sexually transmitted infections. Most participants (89%) rated the ACASI easy to use.

CONCLUSION

Sexually transmitted infection testing in the ED significantly increased during ACASI use and diminished after withdrawal. The ACASI was well accepted by youth and holds promise for enhancing sexually transmitted infection testing in the ED.

Adolescent female with urinary symptoms: a diagnostic challenge for the pediatrician

OBJECTIVES

The objective of this study was to determine the accuracy with which physicians diagnose sexually transmitted infections (STIs) and urinary tract infections (UTIs) in adolescent females with urinary symptoms. Secondary aims were to determine the prevalence of STIs and UTIs in this subset of patients and to identify variables associated with a physician diagnosis of STI or UTI.

METHODS

We performed a prospective cross-sectional study of females aged 13 to 21 years who presented to an urban pediatric emergency department with urinary symptoms. Pediatric emergency medicine physicians' diagnoses of STI or UTI were compared with the criterion standard of diagnosis.

RESULTS

Of the 233 patients enrolled, 211 had complete data sets and were included for analysis. Nineteen patients (9%) had STIs. Physicians predicted STIs in 35 patients (17%), of which 9 (25%) had true infections. Sexually transmitted infections in 10 patients (53%) were underdiagnosed, in 26 patients (74%) were overdiagnosed, and in 9 patients (26%) were correctly diagnosed. One hundred twenty patients (57%) had UTIs. Physicians predicted UTIs in 156 patients (74%), of which 107 (69%) had culture-confirmed UTIs. Urinary tract infections in 13 patients (11%) were underdiagnosed, in 49 patients (31%) were overdiagnosed, and in 107 patients (66%) were correctly diagnosed. Thirteen patients (6%) had a coinfection with both an STI and a UTI.

CONCLUSIONS

Pediatric emergency medicine physicians both underdiagnose and overdiagnose STIs and UTIs in patients with urinary symptoms. This diagnostic challenge necessitates that all adolescent patients presenting with urinary symptoms should be tested for STIs and UTIs and have adequate follow-up means established to ensure timely treatment.

Emergency department Chlamydia screening through partnership with the public health department

BACKGROUND

The emergency department (ED) serves a population that may benefit from numerous screening initiatives but screening in the ED is challenging due to crowding as well as resource and time constraints. One option may be to collect specimens in the ED and then partner with the public health department (PHD) to analyze the specimens off-site and arrange follow-up treatment.

OBJECTIVES

The objective was to explore the feasibility of chlamydia screening in females using a partnership model in which the ED is responsible for urine collection and the PHD is responsible for chlamydia testing, notification, and treatment.

METHODS

A collaborative partnership-based chlamydia screening project was initiated at a large (90,000 visits/yr), urban, teaching ED from April 2007 to April 2008. Study information sheets were handed out to a convenience sample of eligible female patients and visitors (15-24 yr of age). Those wishing to participate provided a urine sample and follow-up contact information. The information sheet also asked if they had either lower abdominal pain or vaginal discharge (affirmative answer for either was considered symptomatic). Specimens collected in the ED were retrieved by PHD staff for off-site testing. The PHD contacted those participants testing positive using the patient provided contact information and arranged for treatment.

RESULTS

Of the 633 women offered screening, 296 (47%) agreed to testing and provided samples. Of the 296 tested, 38 (12.8%) were positive for chlamydia infection, and 25 (66%) received follow-up and treatment; 13 could not be contacted through information they provided. A higher percentage of symptomatic subjects (23 of 115, or 20%) tested positive for chlamydia than asymptomatic subjects (15 of 181, or 8.3%; p < 0.01).

CONCLUSIONS

This study demonstrates the feasibility of an ED-PHD partnership for chlamydia screening in young women. This model can potentially be applied to other initiatives and may improve public health screening without creating significant additional burdens for crowded EDs.

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

Failure to screen sexually active adolescents and adults for gonorrhea and chlamydia at the time of acute care visits to urban emergency departments (ED) results in missed treatment opportunities for 38% to 82% of infected persons. The prevalence of gonorrhea and chlamydia infections among ED patients presenting with genitourinary or pregnancy-related complaints or providing urine specimens as part of routine medical care ranges from 4.3% to 16.4%. Notably, prevalence among general ED patients is similar (9.7%-14.3%). Due to the asymptomatic or nonspecific presentation of these infections, expanded screening is recommended to increase detection, treatment, and partner notification. A lower threshold of empiric treatment in the ED setting is recommended due to the difficulty and incompleteness of follow-up subsequent to ED discharge. Specific recommendations to improve the quality of ED care for sexually transmitted infections and to expand detection are provided.

A walk in the park: a case study in research ethics

Can researchers, interested in novel ways to assess HIV seroprevalence among populations which are otherwise hidden, collect condoms that have been discarded on the ground in a public sex environment and test them for HIV? Researchers, who use other types of abandoned samples, such as discarded syringes, hair or saliva samples, or excess biological samples, confront similar issues. This review evaluates whether such abandoned tissues can be studied based on U.S. Code of Federal Regulations and literature on related issues including: research involving banked tissues, blinded seroprevalence studies, and property claims that individuals might make on the samples. It also addresses broader questions of potential for stigma and risk to individuals and communities. The article concludes that the research should be permitted legally because either it does not involve human subjects, or it satisfies the requirements for waiver of consent; and that the research should also be permitted because the ethical principal of avoiding harm to individuals is fully satisfied based on a careful reading of the lessons of the tissue bank, biological property rights, and blinded seroprevalence study debates, as well as a consideration of other potential harms that might be involved.

Nucleic-acid amplification testing of urine vs. patient complaint-driven evaluation

The present pilot study compared the ability of a conventional patient complaint-driven approach to that of nucleic-acid amplification testing (NAAT) of urine to identify those individuals among an adult, urban, Emergency Department (ED) population infected with Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Trichomonas vaginalis (TV). Urine for NAAT was collected for testing after individuals had completed a questionnaire and before being seen by a physician. A total of 614 subjects were enrolled, and complete physical examinations were performed on 348 (56.6%) individuals, with women being significantly more likely to receive such an evaluation (odds ratio [OR] 3.09; 95% confidence interval [CI] 1.96-4.86); p < 0.001). A total of 153 (24.9%) of the study cohort tested positive for a least one sexually transmitted disease (STD), and only a reported history of STD (OR 1.74; 95% CI (1.18-2.57); p = 0.005) and a history of a new sexual partner in the last 3 months (OR 1.79; 95% CI 1.13-2.82); p = 0.012) were predictive of a positive STD test. NAAT of urine samples on patients who did not receive a complete physical examination resulted in a 33% (51/153) increase in diagnostic yield in this cohort of ED attendees.

Health-seeking behaviors and sexually transmitted diseases among adolescents attending an urban pediatric emergency department

INTRODUCTION

Adolescents are often seen in Emergency departments (ED) for urgent care. Rates of treatable sexually transmitted diseases (Neisseria gonorrhoeae and Chlamydia trachomatis) are highest in this age group. This study examines the prevalence of these sexually transmitted diseases (STDs) and the health seeking characteristics of adolescents presenting to an urban pediatric ED.

METHODS

Participants were enrolled between January 2000 and July 2004. Urine specimens (tested for the STDs) and a questionnaire data form (demographics and health seeking behaviors) were collected and scanned into a computer database, and results were merged for analysis. Prevalence rates were calculated for gonorrheal and chlamydial infections.

RESULTS

A total of 1,621 participants were enrolled. Prevalence rates for C. trachomatis and N. gonorrhoeae were 9.8% (95% CI 8.6, 11.1) and 3.4% (95% CI 2.6,4.2), respectively. Test results did not differ significantly by race (p= 0.29). Reporting of a regular health care provider vs no regular provider did not significantly impact the likelihood of having a positive test result, 10.7% (95% CI 9.1, 12.4) vs 12.1% (95% CI 5.4, 18.8) (p=0.69). The prevalence of STDs was higher among uninsured (16.3, 95% CI 12.3, 20.3) and those participants covered by Medicaid (13.3, 95% CI 10.6, 16.1) compared to those reporting private insurance (6.0, 95% CI 4.2, 7.7).

CONCLUSION

This study confirms a high prevalence of treatable STDs among adolescents in an urban ED setting and provides information on frequency of ED usage and health-seeking behaviors among adolescents.

Evaluation of risk score algorithms for detection of chlamydial and gonococcal infections in an emergency department setting

OBJECTIVES

To develop and evaluate screening algorithms to predict current chlamydial and gonococcal infections in emergency department (ED) settings and assess their performance.

METHODS

Between 2002 and 2005, adult patients aged 18 to 35 years attending an urban ED were screened for Chlamydia trachomatis (Ct) and Neisseria gonorrhoeae (GC) and completed a brief demographic and behavioral questionnaire. Using multiple unconditional logistic regressions, the authors developed four separate predictive models and applicable clinical risk scores to screen for infection. They developed models for females and males separately, for Ct and GC infections combined, and for Ct infection alone. The sensitivities and specificities of the clinical risk scores at different cutoffs were used to examine performance of the algorithms.

RESULTS

Among 5,537 patients successfully screened for Ct and GC, the overall prevalence of infection was 9.6%. Age was the strongest predictor of infection. Adjusting for other predictors, the prevalence odds ratio (POR) was 2.2 (95% confidence interval [CI] = 1.7 to 2.8) for Ct and GC combined and 2.9 (95% CI = 2.1 to 4.1) for Ct alone comparing females 25 years and younger to females older than 25 years. Among males, the association was stronger with an adjusted POR of 3.3 (95% CI = 2.3 to 4.7) for Ct and GC combined and 3.2 (95% CI = 2.1 to 4.7) for Ct infection alone.

CONCLUSIONS

If the decision to incorporate Ct and GC screening into routine ED care is made, age alone appears to be a sufficient screening criterion.

Implementing an HIV and Sexually Transmitted Disease Screening Program in an Emergency Department

STUDY OBJECTIVE

We assess the feasibility, effectiveness, and cost of routinely recommended HIV/sexually transmitted disease screening in an urban emergency department (ED).

METHODS

From April 2003 to August 2004, patients aged 15 to 54 years were offered rapid HIV testing, and those aged 15 to 25 years were also offered gonorrhea and chlamydia testing (nucleic acid amplification), Monday through Friday, 11 am to 8 pm. Infected patients were referred for treatment and care. Prevalence, treatment rates, and cost were assessed.

RESULTS

Among 3,030 patients offered HIV testing, 1,447 (47.8%) accepted, 8 (0.6%) tested positive, and 3 (37.5%) were linked to care. Among 791 patients offered sexually transmitted disease testing, 386 (48.8%) accepted, 320 provided urine (82.9%), 48 (15.0%) tested positive, and 42 (87.5%) were treated for gonorrhea or chlamydia. The program cost was $72,928. Costs per HIV-infected patient identified and linked to care were, respectively, $9,116 and $24,309; cost per sexually transmitted disease-infected patient treated was $1,736. The program cost for HIV/sexually transmitted disease screening was only $14,340 more than if we screened only for HIV.

CONCLUSION

Through ED-based HIV/sexually transmitted disease screening, we identified and treated many sexually transmitted disease-infected patients but identified few HIV-infected patients and linked even fewer to care. However, sexually transmitted disease screening can be added to HIV screening at a reasonable cost.

Gonorrhea prevention and clinical care in the private sector: lessons learned and priorities for quality improvement

We reviewed literature on gonorrhea prevention and clinical care in the private sector, the setting where most gonorrhea cases in the United States are now diagnosed. Although most private-sector health settings had a low prevalence of gonorrhea (0.1-2.5%), some private emergency departments and specialty clinics that serve a large number of high-risk or infected patients had prevalences ranged from 1.7% to 11.0%. Studies of diverse settings and populations suggest that, in general, diagnostic testing of symptomatic patients (69-83%), appropriate treatment (61-100%), and case reporting (64-94%) are delivered more commonly than risk assessment for asymptomatic patients (15-28%), routine screening of pregnant women (31-77%), risk-reduction counseling (35-78%), and sex partner management (0-82%). To sustain the recent declines in gonorrhea incidence in the United States, private-sector providers and health systems must continue to offer gonorrhea prevention and clinical services and consider implementing interventions to improve delivery of risk assessment, risk-reduction counseling, and partner management services.

Evaluation of Clinician-Reported Adherence to Centers for Disease Control and Prevention Guidelines for the Treatment of Chlamydia trachomatis in Two U.S. Health Plans

OBJECTIVE

The objective of this study was to assess clinician adherence to Centers for Disease Control and Prevention-recommended treatments for Chlamydia trachomatis (CT) in two health plans.

STUDY DESIGN

Using hypothetical scenarios, a 1999-2000 mail survey questioned clinicians about how they would treat a cervicitis patient (CT and gonorrhea treatment recommended) and two patients with laboratory-confirmed CT: an injection drug user (single-dose azithromycin promotes adherence) and a pregnant patient (nonteratogenic drugs recommended).

RESULTS

Seven hundred forty-three (82%) of the 907 nonretired clinicians receiving the survey completed it. Eighty-one percent (N=599) reported providing recent CT care. Of these, 70.1% reported they would presumptively treat patients with cervicitis for CT and gonorrhea, 17.1% for CT only, and 11.7% for neither pathogen. Of the 580 clinicians addressing drug injectors, 61.7% reported they would prescribe azithromycin. Most (88.8%) of the 343 clinicians seeing pregnant patients reported they would prescribe Centers for Disease Control and Prevention (CDC)-recommended antibiotics. Reported adherence varied by clinician specialty and sources of treatment guidance.

CONCLUSIONS

Most clinicians reported treatment consistent with CDC guidelines.

Diagnostic Tests for Chlamydial and Gonorrheal Infections

Chlamydia trachomatis and Neisseria gonorrhoeae are the two most prevalent bacterial sexually transmitted infections reported in the United States. The purpose of this article is to review the various tests available for diagnosing C. trachomatis and N. gonorrhoeae. The nucleic acid amplification tests are preferred owing to their high sensitivity and specificity and use on specimens obtained noninvasively. Non-amplified non-culture tests, such as the DNA probe test, remain a choice for settings in which nucleic acid amplification tests are not available or affordable. Culture is recommended for use on conjunctival, oropharyngeal, and rectal specimens and in cases of suspected abuse. In addition, for gonorrhea, culture is recommended when screening in populations with a low prevalence of infection. Point-of-care tests are limited by low sensitivity and should be used for only populations unlikely to return for follow-up.

Innovative Approaches to the Prevention and Control of Bacterial Sexually Transmitted Infections

Bacterial STI continues to be a major problem in developed nations. Research and evolving standards of public health practice are cause for optimism and concern. Innovations in case-finding and treatment, particularly the application of NAATs to test for chlamydial infection in nonclinical settings, are successes that merit more widespread application. EPT, selective STI screening in men, and rescreening are all promising, but are not yet in widespread use and may face significant operational barriers. To date, public health efforts to alter sexual behavior, at least through specific interventions, are more discouraging. Although some behavioral interventions have been effective, none has been widely instituted. Moreover, the likelihood that existing behavioral interventions will be widely applied seems remote. Future research efforts in this area will need to focus less on proof-of-concept efficacy trials and more on developing and testing sustainable, cost-effective interventions that focus on those at greatest risk and that can be scaled-up within the existing public health infrastructure.

Diagnosis and treatment of common sexually transmitted diseases

Sexually transmitted diseases (STDs) are common and often are asymptomatic. This article reviews the presentation and treatment recommendations for some of the most common symptomatic STDs, as well as reviews recent advances in diagnostic methods that may impact patient care.

Evaluation of a rapid antigen detection test for Neisseria gonorrhoeae in urine sediment for diagnosis of gonococcal urethritis in males

We evaluated a rapid antigen detection method with an immunochromatographic assay for Neisseria gonorrhoeae (NOW Gonorrhea Test) by using urine samples from patients with urethritis to diagnose gonococcal infection in males. Among 58 male patients who underwent urethral swab culture, 34 cases (58.6%) were found to have N. gonorrhoeae infection. The sensitivity and specificity of the NOW Test compared with the results of standard culture were 94.1% (32/34) and 95.8% (23/24), respectively. The predictive values of positive NOW and negative NOW were 96.9% (32/33) and 92.0% (23/25), respectively. The detection limit of this assay was determined as 5 x 10(4) cfu/ml using N. gonorrhoeae suspension as an antigen. In contrast to standard cultures, gonococcal antigens in specimens were still detectable by this method up to 45 h of storage at either room temperature or 4 degrees C. Considering the rapidity and ease of this method, our results suggest that the NOW method might be a useful and reliable diagnostic screening tool for gonococcal urethritis.

Screening for Chlamydia and gonorrhea by strand displacement amplification in homeless adolescents attending youth shelters in Korea

We conducted the screening of sexually transmitted infections to define the prevalence of genital Chlamydia trachomatis and Neisseria gonorrhoeae infections and status of sexual risk behavior among homeless adolescents (10-19 yr old) in Korea. Adolescents who ran away from home and are under the care of youth shelters in ten cities in Korea served as the study population. Participants filled out a self-administered questionnaire related to sexuality. First-void urine was analyzed for chlamydial and gonococcal infection by strand displacement amplification (BDProbTec ET, BD Diagnostic Systems, MD, U.S.A.). A total of 175 adolescents from 15 youth shelters took part in the study. Their median age was 16 yr, and 54.9% of them reported having sexual intercourse at least once. The prevalence of C. trachomatis and N. gonorrhoeae among homeless adolescents was 12.6% and 15.4%, respectively. Factors significantly associated with the infections were number of sexual partners during the past year and lifetime. This is the first community-based sexually transmitted infection (STI) screening among adolescent in Korea. Screening programs targeting sexually active adolescents are important for detection of STIs. They should be considered an alternative population-based surveillance system in order to control STIs nationally.

Acceptability of urine screening for Neisseria gonorrheae and Chlamydia trachomatis in adolescents at an urban emergency department

OBJECTIVE

The objective of this study was to determine the acceptability of urine screening for Neisseria gonorrhoeae and Chlamydia trachomatis in adolescents in a pediatric emergency department.

STUDY DESIGN

We used a prospective enrollment of adolescents aged 14-20 visiting an urban pediatric emergency department.

MAIN OUTCOME MEASURES

The main outcome measure was acceptance of urine STD screening rates.

RESULTS

Of 1231 potential participants, 879 (71%) agreed to participate and 352 (29%) declined screening. Participants were similar to those refusing to participate in terms of gender. In multivariate analysis, age, race/ethnicity, and insurance status were associated with variation in sexually transmitted disease (STD) test acceptance, whereas the presence of a parent was not. Despite similar training, 1 of 3 recruiters had significantly lower acceptance rates than her peers. Overall, 10% of patients enrolled were found to have one or both infections.

CONCLUSION

Urine screening for STDs can be efficiently conducted in an emergency department setting. This screening appears to be acceptable to most patients.

Urine based screening for asymptomatic/undiagnosed genital chlamydial infection in young people visiting the accident and emergency department is feasible, acceptable, and can be epidemiologically helpful

OBJECTIVE

To assess the acceptability and the feasibility of urine based Chlamydia trachomatis screening in asymptomatic young people aged 16-35 years attending an inner city accident and emergency (A&E) department.

DESIGN

Cross sectional study.

SETTING

A&E department in a teaching hospital, in south London, UK.

METHOD

From July to November 2001 a urine based chlamydia screening test was offered to 719 consecutive A&E attendees aged 16-35 years and their companions. Participants were given an information sheet and were asked to complete a demographic and sexual health questionnaire. Following informed consent, eligible participants provided first pass urine specimens. Specimens were tested for C. trachomatis using nucleic acid amplification.

RESULTS

Of the A&E attendees asked, 76.5% (550/719) agreed to participate. Prevalence of genital chlamydial infection was 4.2% (18/432; 95% confidence interval (CI) 2.5 to 6.6). 12 of the positive participants (66.7%; 95% CI 40.99 to 86.65) were women, of whom seven were Afro-Caribbean. Nine of the chlamydia positive participants (50%; 95% CI 26.0 to 73.9) were aged 25 years. Three of the positive urine specimens were from companions, of whom a total of 143 were screened. All the positive participants were contactable, and were offered treatment.

CONCLUSION

Urine based screening for undiagnosed genital chlamydial infection in the A&E department was acceptable and feasible. The department provides a unique site for screening young patients and companions, men and women.

Asymptomatic sexually transmitted diseases: the case for screening

BACKGROUND

The United States has the highest prevalence of sexually transmitted diseases in the developed world. Control strategies should address the most frequent reasons why curable sexually transmitted diseases are not treated.

METHODS

We approached 1,631 persons ages 18-29 in various sites and offered them screening for gonorrhea and chlamydial infection and surveys regarding past genitourinary symptoms. For those with past symptoms we abstracted medical records or conducted additional interviews. From these data we estimated the total number of persons who had gonorrhea or chlamydial infections in the previous year, the proportion treated, and the primary reasons for nontreatment.

RESULTS

The prevalence of gonorrhea was 2.3% and that of chlamydial infection was 10.1%. We estimate that 45 and 77% of all cases of gonorrhea and chlamydial infection, respectively, were never symptomatic and that 86 and 95% of untreated cases of gonorrhea and chlamydial infection, respectively, were untreated because they were never symptomatic. The remaining 14 and 5% of untreated cases of gonorrhea and chlamydia, respectively, were not treated because persons did not receive medical care for symptoms.

CONCLUSIONS

The primary reason that gonorrhea and chlamydial infections are untreated is that infected persons never have symptoms. The most effective method to control these sexually transmitted diseases is routine screening at high-volume sites.

Prevalence and factors associated with gonorrhea and chlamydial infection in at-risk females presenting to an urban emergency department

BACKGROUND

Patients without a regular healthcare source are less likely to be tested, diagnosed, and treated effectively for sexually transmitted diseases (STDs). Emergency departments (EDs) are a major healthcare source for patients without health insurance or primary care providers.

GOAL

This study evaluated the prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae in women aged 15 to 35 years presenting to a metropolitan ED with genitourinary or pregnancy-related complaints and the frequency with which patients were effectively treated for these infections during routine ED care.

STUDY DESIGN

Women completed an interviewer-administered questionnaire and submitted urine for ligase chain reaction (LCR) testing for C trachomatis and N gonorrhoeae.

RESULTS

The combined prevalence of gonorrhea and chlamydia was 16.4% (n = 62), and factors associated with infection included younger age and greater numbers of sex partners over 30 days. Problem-oriented care failed to detect infection in most cases, and 58% of infected women left the ED without effective therapy. Through a close working relationship with the local health department, we documented that 92% had received effective follow-up therapy.

CONCLUSION

Continued efforts to refine and develop tools for the diagnosis and management of cervical infections for at-risk women seen in EDs are warranted.

Generalizability of STD screening in urban emergency departments: comparison of results from inner city and urban sites in Baltimore, Maryland

BACKGROUND

A previous study in an inner city emergency department (ED) in Baltimore, Maryland, showed a high prevalence of gonorrhea and chlamydia infection among ED patients.

GOAL

The goal was to compare results from an inner city ED to results from an urban ED in Baltimore, in terms of study population and setting, risks for infection, and factors associated with nonparticipation in the study.

METHODS

This was a cross-sectional study of patients aged 14 to 44 years at two EDs. Outcomes for multivariate logistic regression analyses were (1). positive for gonorrhea or chlamydia by urine ligase chain reaction assay and (2). nonparticipation in the study. Comparative analyses were limited to patients aged 18 to 31 years.

RESULTS

Patients differed significantly between EDs by participation rate, distribution of race/ethnicity, healthcare access, and behavioral risks, although the prevalence of infection did not differ. Risks for infection at the inner city ED were younger age, history of STD, and recent number of sex partners. Risks for infection at the urban ED were female gender and recent number of sex partners. At both EDs, being African American was associated with increased chance of participating, whereas lack of any genitourinary complaint was associated with nonparticipation. At the urban ED, women and patients approached for study enrollment during the day were also less likely to participate.

CONCLUSION

ED-based screening for STDs can be an effective intervention for unrecognized infections. However, assessing population characteristics is necessary to develop targeted screening methods and clinical algorithms and to improve participation of patients and program sustainability.

Appropriate use of nonculture tests for the detection of sexually transmitted diseases in children and adolescents

The introduction of nucleic acid amplification tests (NAATs) has been the most important advance in the diagnosis of sexually transmitted diseases (STDs) since tissue culture replaced inoculation of eggs for culture and isolation of Chlamydia trachomatis from clinical specimens. Because nucleic acid amplification is exquisitely sensitive, theoretically capable of detecting as little as a single gene copy, and highly specific, it offers the opportunity to use noninvasive sampling (ie, urine). This ability in turn means that these tests might be used in nontraditional settings, such as schools and in the field, which may be very helpful in providing services to homeless adolescents. However, none of these tests is approved or recommended by the manufacturers for rectal specimens from adults, and they are not approved for rectogenital specimens from children. In addition to medical implications, the identification of a sexually transmitted disease (STD), especially in a young child, also has legal implications. Because of the legal implications, the highest specificity is needed and is more important than is sensitivity in this situation. Data on the use of these tests in prepubertal children are insufficient to permit their use at this time. What may be appropriate for screening a sexually active adult in an STD clinic may not be appropriate for evaluating a child victim of suspected sexual abuse. Although missing possible sexual abuse is a major concern, the ramifications of a false-positive test for an STD, which can lead to erroneous reports of sexual abuse and possibly unjustified prosecution and incarceration, also must be considered.