Underrecognition of cervical Neisseria gonorrhoeae and Chlamydia trachomatis infections in pregnant patients in the ED

Trends in STI testing and diagnosis rates during the COVID-19 pandemic at a large urban tertiary care center, and the role of the emergency department in STI care

Introduction

The COVID-19 pandemic has had profound effects on access to care, including outpatient sexually transmitted infection (STI) testing and treatment. Many vulnerable populations already relied on the emergency department (ED) for much of their care prior to the pandemic. This study examines trends in STI testing and positivity before and during the pandemic at a large urban medical center and evaluates the role of the ED in providing STI care.

Methods

This is a retrospective review of all gonorrhea, chlamydia, and trichomonas tests from November 1, 2018, through July 31, 2021. Demographic information and location and results of STI testing were extracted from the electronic medical record. Trends in STI testing and positivity were examined for 16 month periods before and after the COVID-19 pandemic started (March 15, 2020), with the latter divided into the early pandemic period (EPP: March 15 -July 31, 2020) and late pandemic period (LPP: August 1, 2020 - July 31, 2021).

Results

Tests per month decreased by 42.4% during the EPP, but rebounded by July 2020. During the EPP, the proportion of all STI testing originating in the ED increased from 21.4% pre-pandemic to 29.3%, and among pregnant women from 45.2% to 51.5%. Overall STI positivity rate increased from 4.4% pre-pandemic to 6.2% in the EPP. Parallel trends were observed for gonorrhea and chlamydia individually. The ED represented 50.5% of overall positive tests, and as much as 63.1% of positive testing during the EPP. The ED was the source of 73.4% of positive tests among pregnant women, which increased to 82.1% during the EPP.

Conclusions

STI trends from this large urban medical center paralleled national trends, with an early decrease in positive cases followed by a rebound by the end of May 2020. The ED represented an important source of testing for all patients, and especially for pregnant patients, throughout the study period, but even more so early in the pandemic. This suggests that more resources should be directed towards STI testing, education, and prevention in the ED, as well as to support linkage to outpatient primary and obstetric care during the ED visit.

Knowing the unknown: The underestimation of monkeypox cases. Insights and implications from an integrative review of the literature

Monkeypox is an emerging zoonotic disease caused by the monkeypox virus, which is an infectious agent belonging to the genus Orthopoxvirus. Currently, commencing from the end of April 2022, an outbreak of monkeypox is ongoing, with more than 43,000 cases reported as of 23 August 2022, involving 99 countries and territories across all the six World Health Organization (WHO) regions. On 23 July 2022, the Director-General of the WHO declared monkeypox a global public health emergency of international concern (PHEIC), since the outbreak represents an extraordinary, unusual, and unexpected event that poses a significant risk for international spread, requiring an immediate, coordinated international response. However, the real magnitude of the burden of disease could be masked by failures in ascertainment and under-detection. As such, underestimation affects the efficiency and reliability of surveillance and notification systems and compromises the possibility of making informed and evidence-based policy decisions in terms of the adoption and implementation of ad hoc adequate preventive measures. In this review, synthesizing 53 papers, we summarize the determinants of the underestimation of sexually transmitted diseases, in general, and, in particular, monkeypox, in terms of all their various components and dimensions (under-ascertainment, underreporting, under-detection, under-diagnosis, misdiagnosis/misclassification, and under-notification).

Prediction model for gonorrhea, chlamydia, and trichomoniasis in the emergency department

OBJECTIVE

History and physical examination findings can be unreliable for prediction of genitourinary tract infections and differentiation of urinary tract infections from sexually transmitted infections (STIs). The study objective was to develop a prediction tool to more accurately identify patients with STIs.

METHODS

A retrospective review of 64,490 emergency department (ED) encounters between April 18, 2014, and March 7, 2017, where patients age 18 years or older had urinalysis and urine culture or testing for gonorrhea, chlamydia, or trichomonas, was used to develop a prediction model for men and women with Neisseria gonorrhoeae or Chlamydia trachomatis, or both, and for women with Trichomonas vaginalis. The data set was randomly divided into two-thirds discovery and one-third validation. Groups were assigned through a random number generator. Backward step regression modeling was used to identify the best model for each outcome.

RESULTS

With use of age, race, marital status, and findings from vaginal wet preparation (white blood cells [WBCs], clue cells, and yeast) and urinalysis (squamous epithelial cells, protein, leukocyte esterase, and WBCs), the models had areas under the receiver operating characteristic curve of 0.80 for men with N gonorrhoeae or C trachomatis, or both; 0.75 for women with N gonorrhoeae or C trachomatis, or both; and 0.73 for women with T vaginalis.

CONCLUSIONS

The model estimated likelihood of ED patients having STIs was reasonably accurate with a limited number of demographic and laboratory variables. In the absence of point-of-care STI testing, use of a prediction tool for STIs may improve antimicrobial stewardship.

Vaginal leukocyte counts for predicting sexually transmitted infections in the emergency department

BACKGROUND

The use of vaginal white blood cell (WBC) counts to predict sexually transmitted infections (STIs) in the emergency department (ED) is incompletely characterized.

OBJECTIVES

Our objective was to assess the relationship between vaginal wet preparation WBC counts and STIs and to determine whether WBC counts of at least 11 WBCs per high-power field (HPF) could be useful for identifying STIs in women in the ED.

METHODS

Female ED patients 18 years or older who were evaluated in a single health system between April 18, 2014, and March 7, 2017, and had a genital wet preparation WBC result were retrospectively examined using univariable and multivariable analysis.

RESULTS

Vaginal wet preparation WBC counts were examined for 17,180 patient encounters. Vaginal WBC counts of at least 11 WBCs/HPF were associated with increased odds of having gonorrhea, chlamydia, or trichomoniasis. When this threshold was used for the diagnosis of each STI, sensitivity ranged from 48.2% to 53.9%, and specificity ranged from 67.2% to 68.8%.

CONCLUSION

Women with STIs are more likely to have higher vaginal WBC counts. However, higher vaginal wet preparation WBC counts in isolation have limited diagnostic utility for gonorrhea, chlamydia, and trichomoniasis. Incorporation of age, urine leukocyte esterase results, and vaginal WBC counts provided a better predictor of an STI than vaginal WBC counts alone.

Undertreatment of chlamydia and gonorrhea among pregnant women in the emergency department

The objective of this study is to evaluate whether pregnant women receive appropriate treatment, undertreatment, or overtreatment in the emergency department (ED) when they are tested for chlamydia and gonorrhea as compared to non-pregnant women. In a retrospective cohort study, we analyzed visits made to an urban ED from 1 July 2012 to 30 June 2014, with testing for chlamydia and gonorrhea (n = 3908). Using multiple logistic regression, we compared undertreatment and overtreatment in women controlling for pregnancy, age, race, and sexually transmitted infection International Statistical Classifications of Diseases (ICD)-9 coded diagnosis. Pregnant women were significantly more likely to be undertreated when positive for infection as compared to non-pregnant women (OR 2.94; 95% CI, 1.47–5.95) and significantly less likely to be overtreated when negative for infection (OR 0.40; 95% CI, 0.31–0.53) as compared to non-pregnant women. Pregnant women may not be receiving appropriate treatment when they present to the ED with chlamydia or gonorrhea. Attention should be paid to this group when administering chlamydia and gonorrhea treatment to ensure appropriate care and follow-up.

Management of Patients with Sexually Transmitted Infections in the Emergency Department

Sexually transmitted infections (STI) are very common infections in the United States. Most patients with STIs are evaluated and treated in primary care settings; however, many also present to the Emergency Department (ED) for initial care. Management of STIs in the ED includes appropriate testing and treatment per CDC Sexually Transmitted Diseases Treatment Guidelines. Although most patients with STIs are asymptomatic or may only exhibit mild symptoms, serious complications from untreated infection are possible. Pregnant women with STIs are particularly vulnerable to serious complications; therefore, empiric ED treatment combined with close follow-up care and referral to obstetrics are paramount.

Sexually Transmitted Infection Review for the Acute Care Pharmacist

PURPOSE

Review selected sexually transmitted infections (STIs) and treatment recommendations for pharmacists and providers practicing in the acute care setting.

SUMMARY

In 2015, the Centers for Disease Control and Prevention (CDC) published an updated guideline on the treatment of STIs with an emphasis on prevention and new diagnostic strategies to combat the growing problem of STIs in the United States. Despite this guidance, the incidence of infection has continued to grow. In October 2016, an in-depth analysis reported that 20 million new infections occur annually in the United States. With this growing burden of disease, it is pertinent that health-care providers optimize their treatment strategies to improve upon the management of STIs. Focusing on identification of asymptomatic- and symptomatic-infected persons, treatment, education, effective follow-up, and counseling for patients and sexual partners, emergency medicine pharmacists and providers can help minimize the negative long-term health consequences of STIs.

CONCLUSION

In the emergency department setting, clinical pharmacists and providers can play a crucial role in preventing and treating STIs and should continue to expand and keep current their knowledge of this topic.

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.

Adolescent women with sexually transmitted infections: who gets lost to follow-up?

BACKGROUND

Adolescent patients comprise the highest rate of Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) in the United States. These patients often initially present to the emergency department (ED) with vague symptoms.

OBJECTIVES

1) Quantify the frequency of underrecognized GC and CT cervical infections in adolescent women tested in the ED; 2) describe and compare the characteristics of those treated and not treated during the initial visit; and 3) quantify the delay interval until treatment was provided.

METHODS

This was a retrospective, cohort analysis of consecutive females (ages 13-19 years) seen at four academic medical centers over a 36-month period with positive results for GC/CT. Our key outcome measures were the proportion of adolescent females being untreated in the ED, the time to subsequent treatment, and the proportion lost to follow-up.

RESULTS

During the study period, 382 female adolescents had positive polymerase chain reaction studies for GC or CT or both; 266 (70%) were not treated in the ED. Untreated patients were significantly more likely to have a discharge diagnosis of urinary tract infection (23% vs. 11%, p < 0.008), new pregnancy (29% vs. 8%, p < 0.001), and vaginitis (24.8% vs. 5%, p < 0.001). Subsequently, only 11.7% (31/266) of the untreated patients fit the Centers for Disease Control and Prevention guidelines for empiric treatment of pelvic inflammatory disease. After telephone, mail, and public health follow-up, treatment could be documented for only 59% of the patients.

CONCLUSION

The majority of adolescent women found to have GC or CT or both in the ED were not treated at presentation.

Clinical focus: infections in pregnancy

Pregnant women are particularly susceptible to a number of infectious diseases, such as influenza, hepatitis E, malaria, and tuberculosis. The management of many other infections-including urinary tract infections, human immunodeficiency virus, and sexually transmitted diseases-is also made more complex by pregnancy; even if some infections do not pose a great risk to the expectant mother, they can impact fetal and neonatal development, thus posing a treatment challenge to physicians. By focusing on the most important diseases that physicians may encounter in pregnant patients, this review outlines the challenges associated with managing important infectious diseases in the pregnant population and references the most recent evidence and international treatment guidelines.

Sexually transmitted infections among patients with herpes simplex virus at King Abdulaziz University Hospital

Background

Herpes simplex virus (HSV) infection is one of the commonest viral sexually transmitted infections (STIs). The aim of this study was to evaluate the prevalence of STIs among HSV positive patients at a tertiary hospital in Jeddah. Secondary objective of the study included the description of the demographic and clinical profile of patients with HSV and HIV co-infection.

Methods

A retrospective chart review of the medical records was performed for HSV positive women who presented to the emergency room and outpatient department of King Abdulaziz University Hospital, Jeddah, Saudi Arabia between January 1, 2003 and August 30, 2011. Data were collected from the medical records of all the patients and analyzed using the Statistical Package for the Social Sciences.

Results

Three hundred forty-three HSV positive patients were included in this study. Co-infection with HIV was documented in 45 patients (13.1%). Other STIs included chlamydia (n = 43, 12.5%), gonorrhea (n = 44, 12.8%), hepatitis B infection (n = 8, 2.3%), and cytomegalovirus infection (n = 37, 10.8%). Nineteen patients (5.5%) had a total of 47 term pregnancies and five abortions post HSV diagnosis. Genital ulcer disease was diagnosed in 11 (57.9%) of the cases during labor. One newborn developed neonatal herpes infection and subsequently showed delayed psychomotor development during follow up. Genital herpes was diagnosed in one patient’s partner; however, there was no documentation of screening for STIs in the partners of the other patients.

Conclusions

Sexually transmitted infections are relatively common among HSV positive patients at King Abdulaziz University Hospital. Amongst these, HIV is the most common, with a prevalence of 13.1%. Further studies are warranted to evaluate STIs in Saudi Arabia. Health policy makers should adopt a protocol to screen for STIs in the partners of persons who are positive for any STI as early detection and appropriate treatment can improve the outcome.