Gonorrhea and chlamydia in the emergency department: Continued need for more focused treatment for men, women and pregnant women

Abstract

Introduction

Delay in current nucleic acid amplification testing for Neisseria gonorrhoeae and Chlamydia trachomatis has led to recommendations for presumptive treatment in patients with concern for infection and unreliable follow-up. In the urban setting, it is assumed that many patients have unreliable follow-up, therefore presumptive therapy is thought to be used frequently. We sought to measure the frequency of disease and accuracy of presumptive treatment for these infections.

Methods

This was an observational cohort study performed at an urban academic Level 1 trauma center ED with an annual census of 95,000 visits per year. Testing was performed using the APTIMA Unisex swab assay (Gen-Probe Incorporated, San Diego, CA). Presumptive therapy was defined as receiving treatment for both infections during the initial encounter without confirmation of diagnosis.

Results

A total of 1162 patients enrolled. Infection was present in 26% of men, 14% of all women and 11% of pregnant women. Despite high frequency of presumptive treatment, > 4% of infected patients in each category went untreated.

Conclusion

Inaccuracy of presumptive treatment was common for these sexually transmitted infections. There is an opportunity to improve diagnostic accuracy for treatment.

Introduction

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are two common sexually transmitted infections and the leading preventable causes of infertility, ectopic pregnancy and pelvic inflammatory disease [1], [2], [3]. The Centers for Disease Control and Prevention (CDC) have estimated that there are nearly 2 million new cases of these sexually transmitted infections nationally each year [3]. The inaccuracy of the history, physical exam and time delay with diagnostic testing has made it impossible to confirm these infections during the initial emergency department (ED) visit.

As such, the CDC has recommended presumptive treatment be considered in patients for whom there is concern for a sexually transmitted infection (STI) and unreliable outpatient follow-up [4]. In the urban setting, such a scenario is common, and subsequent presumptive therapy is frequently inaccurate [5], [6], [7], [8], [9], [10]. For instance, in a pilot study, we had previously estimated that up to 4% of patients presenting to the urban ED are left untreated, despite overtreatment rates exceeding 33% [10].

We sought to further quantify this phenomenon by measuring the frequency of disease, and accuracy of presumptive treatment for men, women and pregnant women in an urban ED.