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Vol. 114. Núm. 4.
Páginas 353-355 (Abril 2023)
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Vol. 114. Núm. 4.
Páginas 353-355 (Abril 2023)
Case and Research Letter
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Impact of a Training Directed to the Emergency Health Professionals on the Managements of Sexual Transmission Infection Patients
Impacto de la formación dirigida a los profesionales sanitarios de urgencias sobre el manejo de los pacientes con enfermedades de transmisión sexual
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C. Salas-Marqueza,b,
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cristi.csm@gmail.com

Corresponding author.
, R. Bosch Garcíab,c,d, F. Rivas Ruize, M. De Troya Martína
a Departamento de Dermatología y Venereología, Hospital Costa del Sol, Marbella (Málaga), Spain
b Programa de Doctorado de Biomedicina, Universidad de Málaga, Spain
c Universidad de Medicina de Málaga, Departamento de Dermatología y Venereología, Universidad de Málaga, Spain
d Departamento de Dermatología y Venereología, Hospital Clínico Virgen de la Victoria, Málaga, Spain
e Departamento de Investigación, Hospital Costa del Sol, Marbella (Málaga), Spain
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C. Salas-Marquez, R. Bosch García, F. Rivas Ruiz, M. De Troya Martín
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To the Editor,

The incidence of sexually transmitted infections (STIs) has increased during the last two decades in Europe.1 The Costa del Sol Hospital (HCS), located in southern Spain and serving a population of 404,000 inhabitants; has witnessed this increase in STI cases. There were 242 new cases in 2016 and 313 in 2017 including Herpes simplex virus (VHS), Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and syphilis, in spite of prevention and training campaigns on STIs. STIs are frequent in consultations of the emergency departments (ED)2 where they remain frequently undetected due to the lack of symptoms in many affected individuals or the failure to seek routine medical care.3 The medical history of patients with STIs referred to the Dermatology Unit of HCS revealed that the ED clinicians did not ask them about their sexual behaviour, and that their tests and treatments were often inappropriate. Therefore, an improvement of the management of STIs in ED interventions was needed.3 ED staff should be current STIs treatment guidelines described by the U.S. Center for Disease Control and Prevention (CDC) in their Sexually Transmitted Diseases Treatment Guidelines.

We conducted one-day training sessions on the management of STIs for all emergency health professionals who could attend, and a copy of the presentations and leaflets was provided for all computers in the emergency department. The training consisted of two parts: first, the main symptoms of each STI were explained, and the professionals were briefed on the type as well as the manner of asking questions in order to identify people at risk. The second part was focused on teaching how to choose the proper swab, complementary test, and empiric treatment if needed, in accordance to the CDC guidelines4 (Table 1). The briefing was accompanied with an information brochure (Table 2). A total of 301 patients for which urethral and cervical cultures had been performed at the ED of the centre between January 2016 and December 2017 were monitored (Table 3). In order to assess the impact of the training sessions, the medical history of these patients was retrieved in compliance with the Biomedical Research Law. The relevance of these tests was assessed with reference to the symptoms reported in the medical history. The suitability of prescribed empirical treatments and their effectiveness were checked for that both the microbiological isolates and the antibiogram matched the treatment. The statistical significance (p<0.05) of the observed differences between the data from both years, before and after the training, were analysed by means of a Chi-Square (SPSS v.15). Results are summarised in Table 3.

Table 1.

Relevant points outlined in the STIs brief for professionals of emergency department.

Anamnesis and identification of risky factors  Swab  Recommendations 
* Symptoms and chronology* Risky factors (e.g. age, same-sex partner, new sexual partners, number of sexual partners)* Risky sexual practices (e.g. non habitual partner, without protection)  * Identification of proper swabs according to presumptive pathology* Identification of suitable diagnostic tests and serology to be requested according to the presumptive diagnosis  * For patients with suspected sexually transmitted infections* For sexual partners* Referral to the Dermatology and Venereology Unit of the Medical Centre if necessary 
Table 2.

Information on physical examination and choice of suitable diagnostic tests exposed in the examination rooms of the emergency department (brochure). The colours are those swab routinely used in the study hospital. PCR: polymerase chain reaction. Recommendations regarding the choice of the empirical treatment or referral to Dermatology Unit posted in the examination room of the emergency department (brochure).

Physical examination  Cutaneous, inguinal chains, oral mucosa, external genitalia and perianal
SwabExudatesWhite cap: STUART transport medium 
Red cap: Gram 
Yellow cap: swab for PCR Chlamydia trachomatis, Neisseria gonorrhoeae 
Ulcers  Suspicion HSV: white cap with rose medium culture 
Serology  Human immunodeficiency virus, Herpes simplex virus (HSV), Hepatitis B virus, Hepatitis C virus; Chlamydia trachomatis; Syphilis   
Main symptoms  Presumptive diagnosis  Suitable swab  Empiric treatment and quick referral to Dermatology and Venereology Unit 
ExudatesNeisseria gonorrhoeaeGram cultureCeftriaxone 500mg (single dose) 
Azithromycin 1g orally (single dose) 
Cefixime 400mg (single dose) 
Ciprofloxacin 500mg (single dose) 
Chlamydia trachomatisPCRDoxycycline 100mg (each 12h for 7 days) 
Azithromycin 1g (single dose) 
UlcersSyphilis  Dark field  Penicillin (dose related to stage) 
Herpes simplex virus  PCRTzanck  Valaciclovir 1g each 12h (5 or 10 days according to it is the first episode or there is recurrence) 
TumoursCondylomasØImiquimod 5% (3 times by day, a week) 
Green tea dry extract (3 times by day during 16 weeks) 
Podophyllotoxin (2 times by day during 3 days) 
Molluscum  Ø  Does not require emergency treatment 
Carcinoma  Ø  Does not require emergency treatment 
Table 3.

Summary of the survey of clinical history of the patients from ED between January 2016 and December 2017. Interview: sexual anamnesis, including questions on sexual behaviour. PCR CT/NG: specific swab for PCR of Neisseria gonorrhoeae and Chlamydia trachomatis. PCR HSV: specific swab for PCR of Herpes simplex virus. S. proper: the use of the proper swab, according to the symptoms reported in the clinical history, was checked. Accurate empirical treatment: the prescription of an accurate empirical treatment was checked in relation to their effectiveness by analyzing both the microbiological isolates and the antibiogram.

Period/variables  20162017p 
  January–May  June–December  January–December  January–May  June–December  January–December   
PatientsMale/female  10/0  22/103  32/103 (Total 135)  23/4  35/104  58/108(Total 166)   
Interviews made/total patients  0/10  17/125  17/135 (13%)  14/27  26/139  40/166 (24%)  0.017 
PCR CT/NGTest requested/total patients  0/10  8/125  8/135 (6%)  26/27  21/139  47/166 (28%)  <0.001 
PCR HSVTest requested/total patients  0/10  0/125  0/135 (0%)  4/27  11/139  15/166 (9%)  <0.001 
Proper swab requested/total patients  2/10  20/125  22/135 (16%)  13/27  28/139  41/166 (25%)  >0.05 
SerologyTest requested/total patients  1/10  9/125  10/135 (7%)  11/27  13/139  24/166 (14%)  >0.05 
Accurate empirical treatment prescribed/total patients  4/10  27/125  31/135 (23%)  12/27  46/139  58/166 (35%)  0.033 

We could note how two training sessions on ED professionals significantly improved the management of STIs in the HCS. Our data show that, before the training sessions, ED professionals omitted asking questions about patients’ sexual behaviour and did not select a complementary test or treatment corresponding to their clinical suspicion. Similarly to what has been concluded in other works,5 the omission of sexual behaviour questions could account for the inappropriate testing6 or lack thereof7 and treatment of the infections particularly with STIs with symptoms similar to others diseases. After our training there was a global improvement. In 2017 ED professionals collected more information of sexual behaviour in the medical history and at the same time we observed an increase of the use of specific swabs without which certain infections would often remain without diagnosis. In addition some hospitals have set up a contact system for patients with a positive result of NG and CT who have not received proper treatment.8 This is implemented in our hospital, also including HVS and HIV. Consequently, the importance of having ED professionals use the proper swabs and request the proper STIs tests, lies in that it makes it possible to efficiently track the patient with these infections and prescribe an accurate treatment. The treatments recommended in the clinical guidelines for the management of STIs are not frequently followed by the emergency physicians.5 In our study, an improvement of the prescribed treatments was observed after training reaching a percentage, which fall in to the range reported in the literature. This general positive impact reflected in our results has also been observed in other studies on STI9 in other areas, like maternity, where training has been shown to play a crucial role in improving quality of care.10 In summary, the training has led to a significant improvement in the handling of symptomatic patients with STIs arriving to the ED in our hospital. These results could be consolidated if this procedure could be applied to a broader sample. We are therefore currently working in developing education of particularly exposed groups such as teenagers.

Conflict of interests

The authors declare that they have no conflict of interest.

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