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Feltes A, Combs J, Reynolds M, Conroy M, Lindsey S, Dick M, Li J, Reichert E. Impact of point-of-care gonorrhea and chlamydia testing in the emergency department on reducing overtreatment rates. Am J Emerg Med 2024; 83:64-68. [PMID: 38968852 DOI: 10.1016/j.ajem.2024.06.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 06/27/2024] [Accepted: 06/27/2024] [Indexed: 07/07/2024] Open
Abstract
BACKGROUND Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections continue to increase in the United States. Advancement in technology with point-of-care (POC) testing can improve the overall treatment of sexually transmitted infections (STI) in the emergency department (ED) by shortening the time to test result and administration of accurate treatment. The purpose of this study was to assess if the POC test reduced the rate of overtreatment for CT and/or NG compared to the standard-of-care (SOC) test. METHODS This retrospective cohort study included adult patients tested for CT and NG at two urban EDs between August 2020 and October 2022. This cohort excluded hospital admissions, elopement, pregnancy, rectal and oral samples, victims of sexual assault, and diagnoses for which antimicrobial treatment overlapped that of CT/NG. The primary outcome assessed overtreatment, defined as receiving treatment in the ED or a prescription prior to discharge for patients who tested negative for CT and/or NG. Secondary outcomes included undertreatment rates, overtreatment rates in select populations, test turnaround time, and ED length of stay (LOS). RESULTS Of 327 patients screened, 97 patients were included in the SOC group and 100 in POC. Overtreatment for CT was provided in zero POC patients and 29 (29.9%) SOC patients (p < 0.001). NG was overtreated in 1 (1%) POC and 23 (23.7%) SOC (p < 0.001). POC was associated with undertreatment of CT and/or NG in two patients, compared to four patients tested with SOC. Overall, treatment was deemed inappropriate for 5 (5%) of those tested with POC, compared to 35 (36%) tested with SOC (p < 0.001). There was no difference in ED LOS (2.7 vs 3.01 h, p = 0.41). CONCLUSIONS POC testing facilitated the return of results prior to patients being discharged from the ED. Compared to standard testing, POC improved appropriateness of CT and NG treatment by reducing the rates of overtreatment.
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Affiliation(s)
- Alaina Feltes
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Julie Combs
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Maegan Reynolds
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Mark Conroy
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Sommer Lindsey
- Department of Emergency Medicine, Ohio State East Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Michael Dick
- Department of Emergency Medicine, Ohio State East Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Junan Li
- The Ohio State University College of Pharmacy, Columbus, OH, USA
| | - Erin Reichert
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Lima A, Uy D, Kostera J, Silbert S. Clinical Evaluation of the Alinity m STI Multiplex PCR Assay. Sex Transm Dis 2024; 51:480-485. [PMID: 38465972 DOI: 10.1097/olq.0000000000001964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
BACKGROUND Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are routinely tested and reported; however, Trichomonas vaginalis (TV) is the most common sexually transmitted infection (STI) in the United States and the prevalence of Mycoplasma genitalium (MG) infections is likely higher than estimated. We examined the clinical performance of the Alinity m STI assay for detection and surveillance of CT/NG/TV/MG in urine specimens from patients at a large academic medical center. METHODS Urine specimen from 198 patients was tested in this evaluation. Alinity m STI and Aptima Combo 2 CT/NG and TV assay (Panther System) results were compared, with discrepant results run on the cobas 6800 CT/NG, TV/MG assays. Analyzer turnaround times, time from loading the specimen on the analyzer to results reporting, were determined for Alinity m and Panther systems. RESULTS Overall percent agreements of the Alinity m in comparison with the Aptima and cobas assays for CT, NG, TV, and MG were 99.5% (97.2%, 99.9%), 99.5% (97.2%, 99.9%), 98.4% (95.5%, 99.5%), and 86.4% (66.7%, 95.3), respectively. There were 5 discrepant samples (CT, 1; NG, 1; TV, 3) between the Alinity m and the Aptima assays, and 3 MG discrepant samples between the Alinity m STI and cobas 6800. Two of the 5 Aptima and Alinity m discrepant samples were resolved as they yielded similar results on both Alinity m and cobas 6800. TV and MG infections comprised 54% of the positive samples and were more often asymptomatic than CT and NG infections. Analyzer turnaround time was 3 hours 25 minutes for the Aptima CT/NG, 3 hours 25 minutes for Aptima TV, and 1 hour 55 minutes for Alinity m STI assay. CONCLUSIONS The Alinity m STI assay allows for fast and simultaneous detection of the 4 major STI pathogens, which can facilitate surveillance and provide accurate results to help clinicians diagnose for initiation of appropriate treatment.
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Affiliation(s)
| | - Dominic Uy
- From the Tampa General Hospital, Tampa, FL
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Welford E, Martin TCS, Martin NK, Tilghman W, Little SJ. Relative Cost and Infectious Days Averted Associated With Rapid Gonorrhea and Chlamydia Testing Among Men Who Have Sex With Men. Sex Transm Dis 2024; 51:388-392. [PMID: 38733972 PMCID: PMC11090409 DOI: 10.1097/olq.0000000000001956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2024]
Abstract
BACKGROUND Standard-of-care nucleic acid amplification tests (routine NAATs) for Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) can take several days to result and therefore delay treatment. Rapid point-of-care GC/CT NAAT (rapid NAAT) could reduce the time to treatment and therefore onward transmission. This study evaluated the incremental cost per infectious day averted and overall cost of implementation associated with rapid compared with routine NAAT. METHODS Prospective sexually transmitted infection (STI) treatment data from men who have sex with men and transgender women in San Diego who received rapid NAAT between November 2018 and February 2021 were evaluated. Historical time from testing to treatment for routine NAAT was abstracted from the literature. Costs per test for rapid and routine NAAT were calculated using a micro-costing approach. The incremental cost per infectious day averted comparing rapid to routine NAAT and the costs of rapid GC/CT NAAT implementation in San Diego Public Health STI clinics were calculated. RESULTS Overall, 2333 individuals underwent rapid NAAT with a median time from sample collection to treatment of 2 days compared with 7 to 14 days for routine NAAT equating to a reduction of 5 to 12 days. The cost of rapid and routine GC/CT NAAT was $57.86 and $18.38 per test, respectively, with a cost-effectiveness of between $2.43 and $5.82 per infectious day averted. The incremental cost of rapid NAAT improved when at least 2000 tests were performed annually. CONCLUSIONS Although rapid GC/CT NAAT is more expensive than routine testing, the reduction of infectious days between testing and treatment may reduce transmission and provide improved STI treatment services to patients.
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Affiliation(s)
- Elliott Welford
- From the Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego
| | - Thomas C S Martin
- From the Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego
| | - Natasha K Martin
- From the Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego
| | - Winston Tilghman
- County of San Diego Health & Human Services Agency, San Diego, CA
| | - Susan J Little
- From the Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego
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Vodstrcil LA, Htaik K, Plummer EL, De Petra V, Sen MG, Williamson DA, Ong JJ, Wu J, Owlad M, Murray G, Chow EP, Fairley CK, Bradshaw CS. Near-to-patient-testing to inform targeted antibiotic use for sexually transmitted infections in a public sexual health clinic: the NEPTUNE cohort study. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2024; 44:101005. [PMID: 38292654 PMCID: PMC10825687 DOI: 10.1016/j.lanwpc.2023.101005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/04/2023] [Accepted: 12/27/2023] [Indexed: 02/01/2024]
Abstract
Background Empiric treatment of sexually transmitted infections can cause unnecessary antibiotic use. We determined if near-to-patient-testing (NPT) for Neisseria gonorrhoeae, Chlamydia trachomatis and Mycoplasma genitalium (MG) improved antibiotic-use for a range of clinical presentations. Methods Clients attending with non-gonococcal urethritis (NGU), proctitis, as STI-contacts, or for an MG-test-of-cure (MG-TOC) between March and December 2021 were recruited. Participants received near-to-patient-testing (NPT-group) for the three STIs using the GeneXpert® System (Cepheid), and concurrent routine-testing by transcription-mediated-amplification (TMA; Aptima, Hologic). Antibiotic-use among NGU or proctitis cases in the NPT-group was compared to clinic-controls undergoing routine-testing only. The proportion in the NPT-group who notified partners <24 hrs of their STI-specific result was calculated. Findings Among 904 consults by 808 NPT-participants, ≥1 STI was detected in 63/252 (25.0%) with NGU, 22/51 (43.1%) with proctitis, and 167/527 (31.7%) STI-contacts. MG was detected among 35/157 (22.3%) MG-TOC consults. Among NGU and proctitis cases, fewer in the NPT-group received empiric treatment compared to clinic-controls (29.4% [95% CI: 24.3-34.9%] vs 83.8% [95% CI: 79.2-87.8%], p < 0.001), resulting in more NPT-group cases appropriately treated (STI-specific drug/no drug appropriately; 80.9% [95% CI: 76.0-85.1%] vs 33.0% [95% CI: 27.7-38.6%], p < 0.001) and fewer mistreated (incorrect drug/treated but pathogen-negative; 17.8% [13.7-22.6%] vs 61.4% [55.6-66.9%], p < 0.001). Of 167/264 in the NPT-group with an STI who responded regarding partner-notification, 95.2% notified all/some partners; 85.9% notified them <24 hrs of the STI-specific result. Interpretation Near-to-patient-testing significantly improved antibiotic use and a high proportion of individuals rapidly notified partners of STI-specific results, highlighting the broad benefits of timely diagnostic strategies for STIs in clinical decision making and partner notification. Funding ARC ITRP Hub-grant; NHMRC.
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Affiliation(s)
- Lenka A. Vodstrcil
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Kay Htaik
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Erica L. Plummer
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Vesna De Petra
- Microbiological Diagnostic Unit Public Health Laboratory, Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity at the University of Melbourne, Melbourne, Victoria, Australia
| | - Melodi G. Sen
- Microbiological Diagnostic Unit Public Health Laboratory, Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity at the University of Melbourne, Melbourne, Victoria, Australia
| | - Deborah A. Williamson
- Department of Microbiology, Royal Melbourne Hospital, Melbourne, Australia
- Victorian Infectious Diseases Reference Laboratory, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Jason J. Ong
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Jason Wu
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Monica Owlad
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Gerald Murray
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Women's Centre for Infectious Diseases, The Royal Women's Hospital, Parkville, Victoria, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Victoria, Australia
| | - Eric P.F. Chow
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Christopher K. Fairley
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Catriona S. Bradshaw
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
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Dighe K, Moitra P, Gunaseelan N, Alafeef M, Jensen T, Rafferty C, Pan D. Highly-Specific Single-Stranded Oligonucleotides and Functional Nanoprobes for Clinical Determination of Chlamydia Trachomatis and Neisseria Gonorrhoeae Infections. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2023; 10:e2304009. [PMID: 37870167 PMCID: PMC10754082 DOI: 10.1002/advs.202304009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 09/18/2023] [Indexed: 10/24/2023]
Abstract
Early detection of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) is the key to controlling the spread of these bacterial infections. An important step in developing biosensors involves identifying reliable sensing probes against specific genetic targets for CT and NG. Here, the authors have designed single-stranded oligonucleotides (ssDNAs) targeting mutually conserved genetic regions of cryptic plasmid and chromosomal DNA of both CT and NG. The 5'- and 3'- ends of these ssDNAs are differentially functionalized with thiol groups and coupled with gold nanoparticles (AuNP) to develop absorbance-based assay. The AuNPs agglomerate selectively in the presence of its target DNA sequence and demonstrate a change in their surface plasmon resonance. The optimized assay is then used to detect both CT and NG DNA extracted from 60 anonymized clinical samples with a clinical sensitivity of ∼100%. The limit of detection of the assays are found to be 7 and 5 copies/µL for CT and NG respectively. Furthermore, it can successfully detect the DNA levels of these two bacteria without the need for DNA extraction and via a lateral flow-based platform. These assays thus hold the potential to be employed in clinics for rapid and efficient monitoring of sexually transmitted infections.
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Affiliation(s)
- Ketan Dighe
- Department of PediatricsCentre of Blood Oxygen Transport & HemostasisUniversity of Maryland Baltimore School of MedicineBaltimoreMaryland21201USA
- Department of Chemical & Biochemical EngineeringUniversity of Maryland Baltimore CountyBaltimore CountyMaryland21250USA
- Department of Biomedical EngineeringThe Pennsylvania State UniversityUniversity ParkPA16802USA
| | - Parikshit Moitra
- Department of PediatricsCentre of Blood Oxygen Transport & HemostasisUniversity of Maryland Baltimore School of MedicineBaltimoreMaryland21201USA
- Department of Nuclear EngineeringThe Pennsylvania State UniversityUniversity ParkPA16802USA
| | - Nivetha Gunaseelan
- Department of PediatricsCentre of Blood Oxygen Transport & HemostasisUniversity of Maryland Baltimore School of MedicineBaltimoreMaryland21201USA
- Department of Chemical & Biochemical EngineeringUniversity of Maryland Baltimore CountyBaltimore CountyMaryland21250USA
- Department of Biomedical EngineeringThe Pennsylvania State UniversityUniversity ParkPA16802USA
| | - Maha Alafeef
- Department of PediatricsCentre of Blood Oxygen Transport & HemostasisUniversity of Maryland Baltimore School of MedicineBaltimoreMaryland21201USA
- Department of Chemical & Biochemical EngineeringUniversity of Maryland Baltimore CountyBaltimore CountyMaryland21250USA
- Department of Nuclear EngineeringThe Pennsylvania State UniversityUniversity ParkPA16802USA
| | - Tor Jensen
- Cancer Center at IllinoisUniversity of Illinois Urbana‐Champaign405 N. Mathews Ave.UrbanaIL61801‐2325USA
| | - Carla Rafferty
- Department of Family MedicineCarle Health1818 E Windsor Rd.UrbanaIL61802USA
| | - Dipanjan Pan
- Department of PediatricsCentre of Blood Oxygen Transport & HemostasisUniversity of Maryland Baltimore School of MedicineBaltimoreMaryland21201USA
- Department of Chemical & Biochemical EngineeringUniversity of Maryland Baltimore CountyBaltimore CountyMaryland21250USA
- Department of Biomedical EngineeringThe Pennsylvania State UniversityUniversity ParkPA16802USA
- Department of Nuclear EngineeringThe Pennsylvania State UniversityUniversity ParkPA16802USA
- Department of Materials Science and EngineeringThe Pennsylvania State UniversityUniversity ParkPA16802USA
- Huck Institutes of the Life Sciences101 Huck Life Sciences BuildingUniversity ParkPA16802USA
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Ruiz-Ramos J, Escolà-Vergé L, Monje-López ÁE, Herrera-Mateo S, Rivera A. The Interventions and Challenges of Antimicrobial Stewardship in the Emergency Department. Antibiotics (Basel) 2023; 12:1522. [PMID: 37887223 PMCID: PMC10604141 DOI: 10.3390/antibiotics12101522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 09/25/2023] [Accepted: 10/06/2023] [Indexed: 10/28/2023] Open
Abstract
Over the last decades, we have witnessed a constant increase in infections caused by multi-drug-resistant strains in emergency departments. Despite the demonstrated effectiveness of antimicrobial stewardship programs in antibiotic consumption and minimizing multi-drug-resistant bacterium development, the characteristics of emergency departments pose a challenge to their implementation. The inclusion of rapid diagnostic tests, tracking microbiological results upon discharge, conducting audits with feedback, and implementing multimodal educational interventions have proven to be effective tools for optimizing antibiotic use in these units. Nevertheless, future multicenter studies are essential to determine the best way to proceed and measure outcomes in this scenario.
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Affiliation(s)
- Jesus Ruiz-Ramos
- Pharmacy Department, Hospital Santa Creu i Sant Pau, 08025 Barcelona, Spain;
- Sant Pau Institute of Biomedical Research (IIb Sant Pau), 08025 Barcelona, Spain (A.R.)
| | - Laura Escolà-Vergé
- Infectious Diseases Department, Hospital Santa Creu i Sant Pau, 08025 Barcelona, Spain;
- CIBERINFEC, ISCIII—CIBER, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Álvaro Eloy Monje-López
- Pharmacy Department, Hospital Santa Creu i Sant Pau, 08025 Barcelona, Spain;
- Sant Pau Institute of Biomedical Research (IIb Sant Pau), 08025 Barcelona, Spain (A.R.)
| | - Sergio Herrera-Mateo
- Sant Pau Institute of Biomedical Research (IIb Sant Pau), 08025 Barcelona, Spain (A.R.)
- Emergency Department, Hospital Santa Creu i Sant Pau, 08025 Barcelona, Spain
| | - Alba Rivera
- Sant Pau Institute of Biomedical Research (IIb Sant Pau), 08025 Barcelona, Spain (A.R.)
- Microbiology Department, Hospital Santa Creu i Sant Pau, 08025 Barcelona, Spain
- Genetics and Microbiology Department, Universitat Autònoma de Barcelona, 08025 Barcelona, Spain
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Riegler AN, Larsen N, Amerson-Brown MH. Point-of-Care Testing for Sexually Transmitted Infections. Clin Lab Med 2023; 43:189-207. [PMID: 37169442 DOI: 10.1016/j.cll.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Point-of-care testing for sexually transmitted infections is essential for controlling transmission and preventing sequelae in high-risk populations. Since the World Health Organization published the ASSURED criteria, point-of-care testing has improved for use in large population screening and rapid testing that prevents loss of clinical follow-up. Recent advancements have been advantageous for low-resource areas allowing testing at a minimal cost without reliable electricity or refrigeration. Point-of-care nucleic acid detection and amplification techniques are recommended, but are often inaccessible in low-resource areas. Future advancements in point-of-care diagnostic testing should focus on improving antibody-based assays, monitoring viral loads, and detecting antimicrobial resistance.
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Affiliation(s)
- Ashleigh N Riegler
- Department of Pathology, The University of Alabama at Birmingham, Marnix E. Heersink School of Medicine, 619 East 19th Street South, WP240J, Birmingham, AL 35249-7331, USA
| | - Natalie Larsen
- Department of Pathology, The University of Alabama at Birmingham, Marnix E. Heersink School of Medicine, 619 East 19th Street South, WP240J, Birmingham, AL 35249-7331, USA
| | - Megan H Amerson-Brown
- Department of Pathology, The University of Alabama at Birmingham, Marnix E. Heersink School of Medicine, 619 East 19th Street South, WP240J, Birmingham, AL 35249-7331, USA.
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Frost HM, Wilson ML, Roosevelt GE. Improving Management of Suspected Chlamydia and Gonorrhea in Adolescents with a Rapid Diagnostic Test. Pediatr Qual Saf 2023; 8:e634. [PMID: 36798111 PMCID: PMC9925102 DOI: 10.1097/pq9.0000000000000634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 01/14/2023] [Indexed: 02/16/2023] Open
Abstract
We aimed to determined the impact of an intervention using rapid chlamydia (CT)/gonorrhea (GC) testing on reducing unnecessary antibiotic use, undertreatment of CT and/or GC, and length of stay (LOS) in an urban safety-net pediatric emergency department. Methods Before 2020, we tested for CT/GC using a batched nucleic acid amplification test, with results available the following day. Starting in January 2020, we implemented rapid nucleic acid amplification test. Our primary outcome variables were undertreatment and overtreatment. We defined undertreatment as GC and/or CT-positive patients who did not receive appropriate treatment. We defined overtreatment as GC or CT-negative patients who received antibiotics. The balancing measure was the LOS. Results There were 758 patients evaluated in the preimplementation period (2019), 612 in the implementation period (2020), and 626 in the postimplementation period (2021). Postimplementation, overtreatment decreased from 18.4% to 8.1%. Undertreatment did not differ by period but was less common among those tested with rapid versus standard testing (12.7% versus 9.9%, P = 0.05). Median LOS increased from 166 minutes (preimplementation) to 187 minutes (implementation) and 202 minutes (postimplementation; P < 0.001). Conclusions Rapid CT/GC testing reduced unnecessary antibiotic use but increased LOS due to patients waiting for the test results before being discharged. Given the rapid increases in CT/GC rates and antimicrobial resistance, health systems should consider implementing rapid testing to appropriately direct antimicrobials to patients most likely to benefit.
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Affiliation(s)
- Holly M. Frost
- From the Department of Pediatrics, Denver Health and Hospital Authority, Denver, Colo
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, Colo
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | - Michael L. Wilson
- Department of Pathology, Denver Health and Hospital Authority, Denver, Colo
- Department of Pathology, University of Colorado School of Medicine, Aurora, Colo
| | - Genie E. Roosevelt
- Department of Emergency Medicine, Denver Health and Hospital Authority, Denver, Colo
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colo
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Commentary. Ann Emerg Med 2022; 80:71-73. [PMID: 35717114 DOI: 10.1016/j.annemergmed.2022.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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10
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Impact of Rapid Testing for Gonorrhea and Chlamydia in an Urban Pediatric Emergency Department. J Adolesc Health 2022; 70:910-914. [PMID: 35256240 DOI: 10.1016/j.jadohealth.2022.01.219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 12/02/2021] [Accepted: 01/14/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE To determine the impact of rapid testing for gonorrhea (NG) and chlamydia (CT) on accuracy of treatment in adolescents in the pediatric emergency department (ED). METHODS Retrospective study of adolescents tested for NG and CT in the pediatric ED before and after implementation of rapid testing. Treatment during initial visit, availability of test results prior to discharge, and number of follow-up phone calls made with test results were compared. Appropriate treatment was defined per Centers for Disease Control and Prevention 2015 guidelines as monotherapy for CT and dual therapy for NG. Descriptive statistics were used to compare groups. RESULTS Rapid testing improved treatment accuracy with 522 (79.3%) patients treated appropriately in the rapid testing group compared to 478 (64.7%) patients in the batched testing group (p < .001). Inaccurate treatment was more common in the batch testing group among those who tested negative (p < .001). Among those who tested positive for NG and/or CT, phone calls were made to 54 (47.8%) patients in the rapid testing group and 129 (84.3%) patients in the batched testing group to discuss positive test results (p < .001). CONCLUSION Compared to batched testing, rapid testing is associated with improved accuracy of treatment of NG and CT in the pediatric ED setting. Additionally, rapid testing is associated with decreased number of phone calls to discuss positive test results.
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11
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McWhirter L, Lou Y, Reingold S, Warsh S, Thomas-Gale T, Haynes C, Rinehart D, Wendel KA, Frost HM. Rates of Appropriate Treatment and Follow-Up Testing After a Gonorrhea and/or Chlamydia Infection in an Urban Network of Federally Qualified Health Center Systems. Sex Transm Dis 2022; 49:319-324. [PMID: 35001017 PMCID: PMC9018487 DOI: 10.1097/olq.0000000000001600] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Reinfection and partner transmission are common with Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT). We assessed treatment and follow-up laboratory testing for GC and CT and evaluated associations with patient- and system-level factors. METHODS The analysis included positive GC and/or CT nucleic acid amplification test results from patients aged 14 to 24 years at a federally qualified health center system site in Denver, CO, from January 2018 to December 2019. Outcomes assessed include treatment within 14 days, HIV/syphilis testing within 6 months, and repeat GC and CT testing within 2 to 6 months. Bivariate and multivariable regression modeling assessed associated factors. RESULTS Among 27,168 GC/CT nucleic acid amplification tests performed, 1.8% (484) were positive for GC and 7.8% (2125) were positive for CT. Within the assessed time frames, 87% (2275) of patients were treated, 54.1% (1411) had HIV testing, 50.1% (1306) had syphilis testing, and 39.9% (1040) had GC and CT retesting. Older patients were more likely to receive treatment (adjusted odds ratio 1.13; 95% confidence interval, 1.00-1.27; P = 0.05) than younger patients, whereas males were less likely to receive GC and CT retesting (adjusted odds ratio, 0.19; 95% confidence interval, 0.11-0.33; P < 0.001) than females. Patients treated on the day of testing were less likely to receive follow-up laboratory tests than those treated 2 to 14 days after. CONCLUSIONS Although most patients received antibiotic treatment, only about half received HIV/syphilis testing and less than half received GC and CT retesting. It is critical to find innovative strategies to improve treatment and follow-up management of these infections to decrease complications, reduce transmission, and combat the rising rates of sexually transmitted infections.
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Affiliation(s)
| | - Yingbo Lou
- Denver Health Medical Center, Community Health Services, Denver, CO
| | - Sarah Reingold
- University of Colorado School of Medicine, Department of Internal Medicine-Pediatrics, Aurora, CO
| | - Sarah Warsh
- Denver Health Medical Center, Community Health Services, Denver, CO
| | - Tara Thomas-Gale
- Denver Health Medical Center, Community Health Services, Denver, CO
| | - Christine Haynes
- Denver Health Medical Center, Department of Internal Medicine, Denver, CO
- University of Colorado School of Medicine, Department of Medicine, Division of General Internal Medicine, Aurora, CO
| | | | - Karen A. Wendel
- Denver Health Medical Center, Department of Internal Medicine, Division of Infectious Diseases, Denver, CO
- University of Colorado School of Medicine, Department of Internal Medicine, Division of Infectious Diseases, Aurora, CO
| | - Holly M Frost
- Denver Health Medical Center, Office of Research, Denver, CO
- Denver Health Medical Center, Department of Pediatrics, Denver, CO
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO
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12
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Geisler WM, Hocking JS, Darville T, Batteiger BE, Brunham RC. Diagnosis and Management of Uncomplicated Chlamydia trachomatis Infections in Adolescents and Adults: Summary of Evidence Reviewed for the 2021 Centers for Disease Control and Prevention Sexually Transmitted Infections Treatment Guidelines. Clin Infect Dis 2022; 74:S112-S126. [PMID: 35416965 PMCID: PMC9006972 DOI: 10.1093/cid/ciac126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
To prepare for the development of the 2021 Centers for Disease Control and Prevention (CDC) sexually transmitted infections treatment guidelines, the CDC convened a committee of expert consultants in June 2019 to discuss recent abstracts and published literature on the epidemiology, diagnosis, and management of sexually transmitted infections.This paper summarizes the key questions, evidence, and recommendations for the diagnosis and management of uncomplicated Chlamydia trachomatis (CT) infections in adolescents and adults that were reviewed and discussed for consideration in developing the guidelines. The evidence reviewed mostly focused on efficacy of doxycycline and azithromycin for urogenital, rectal, and oropharyngeal CT infection, CT risk factors in women, performance of CT nucleic acid amplification tests on self-collected meatal specimens in men, and performance of newer CT point-of-care tests.
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Affiliation(s)
- William M Geisler
- Division of Infectious Diseases, Department of Medicine and Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jane S Hocking
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Toni Darville
- Department of Pediatrics and Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Byron E Batteiger
- Department of Medicine and Department of Microbiology and Immunology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Robert C Brunham
- Vaccine Research Laboratory, University of British Columbia Centre for Disease Control, Vancouver, Canada
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13
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Sheele JM, Niforatos JD, Elkins JM, Campos SC, Thompson CL. Prediction model for gonorrhea, chlamydia, and trichomoniasis in the emergency department. Am J Emerg Med 2021; 51:313-319. [PMID: 34798573 DOI: 10.1016/j.ajem.2021.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 10/29/2021] [Accepted: 11/01/2021] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Johnathan M Sheele
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL, United States of America.
| | - Joshua D Niforatos
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, United States of America
| | - Justin M Elkins
- Research Trainee, Mayo Clinic, Jacksonville, FL, United States of America
| | | | - Cheryl L Thompson
- Department of Nutrition, Case Western Reserve University, Cleveland, OH, United States of America
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14
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Fuller SS, Clarke E, Harding-Esch EM. Molecular chlamydia and gonorrhoea point of care tests implemented into routine practice: Systematic review and value proposition development. PLoS One 2021; 16:e0259593. [PMID: 34748579 PMCID: PMC8575247 DOI: 10.1371/journal.pone.0259593] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 10/21/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Sexually Transmitted Infections, including Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT), continue to be a global health problem. Increased access to point-of-care-tests (POCTs) could help detect infection and lead to appropriate management of cases and contacts, reducing transmission and development of reproductive health sequelae. Yet diagnostics with good clinical effectiveness evidence can fail to be implemented into routine care. Here we assess values beyond clinical effectiveness for molecular CT/NG POCTs implemented across diverse routine practice settings. METHODS We conducted a systematic review of peer-reviewed primary research and conference abstract publications in Medline and Embase reporting on molecular CT/NG POCT implementation in routine clinical practice until 16th February 2021. Results were extracted into EndNote software and initially screened by title and abstract by one author according to the inclusion and exclusion criteria. Articles that met the criteria, or were unclear, were included for full-text assessment by all authors. Results were synthesised to assess the tests against guidance criteria and develop a CT/NG POCT value proposition for multiple stakeholders and settings. FINDINGS The systematic review search returned 440 articles; 28 were included overall. The Cepheid CT/NG GeneXpert was the only molecular CT/NG POCT implemented and evaluated in routine practice. It did not fulfil all test guidance criteria, however, studies of test implementation showed multiple values for test use across various healthcare settings and locations. Our value proposition highlights that the majority of values are setting-specific. Sexual health services and outreach services have the least overlap, with General Practice and other non-sexual health specialist services serving as a "bridge" between the two. CONCLUSIONS Those wishing to improve CT/NG diagnosis should be supported to identify the values most relevant to their settings and context, and prioritise implementation of tests that are most closely aligned with those values.
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Affiliation(s)
- Sebastian S. Fuller
- Institute for Infection and Immunity, Applied Diagnostic Research and Evaluation Unit, St George’s University of London, London, United Kingdom
- Nuffield Department of Medicine, Health Systems Collaborative, University of Oxford, Headington, Oxford, United Kingdom
| | - Eleanor Clarke
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Emma M. Harding-Esch
- Institute for Infection and Immunity, Applied Diagnostic Research and Evaluation Unit, St George’s University of London, London, United Kingdom
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
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15
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Shetty S, Kouskouti C, Schoen U, Evangelatos N, Vishwanath S, Satyamoorthy K, Kainer F, Brand A. Diagnosis of Chlamydia trachomatis genital infections in the era of genomic medicine. Braz J Microbiol 2021; 52:1327-1339. [PMID: 34164797 PMCID: PMC8221097 DOI: 10.1007/s42770-021-00533-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 05/17/2021] [Indexed: 11/02/2022] Open
Abstract
PURPOSE Chlamydial genital infections constitute significant sexually transmitted infections worldwide. The often asymptomatic status of C. trachomatis (CT) infections leads to an increased burden on human reproductive health, especially in middle- and low-income settings. Early detection and management of these infections could play a decisive role in controlling this public health burden. The objective of this review is to provide an insight into the evolution of diagnostic methods for CT infections through the development of new molecular technologies, emphasizing on -omics' technologies and their significance as diagnostic tools both for effective patient management and control of disease transmission. METHODS Narrative review of the diagnostic methodologies of CT infections and the impact of the introduction of -omics' technologies on their diagnosis by review of the literature. RESULTS Various methodologies are discussed with respect to working principles, required specifications, advantages, and disadvantages. Implementing the most accurate methods in diagnosis is highlighted as the cornerstone in managing CT infections. CONCLUSION Diagnostics based on -omics' technologies are considered to be the most pertinent modalities in CT testing when compared to other available methods. There is a need to modify these effective and accurate diagnostic tools in order to render them more available and feasible in all settings, especially aiming on turning them to rapid point-of-care tests for effective patient management and disease control.
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Affiliation(s)
- Seema Shetty
- Department of Microbiology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Madhav Nagar, Manipal, 576104, Karnataka, India.
- United Nations University - Maastricht Economics and Social Research Institute On Innovation and Technology (UNU-MERIT), Maastricht, 6211, AX, The Netherlands.
- Manipal Centre for Infectious Diseases, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India.
| | - Christina Kouskouti
- Department of Obstetrics and Perinatal Medicine, Klinik Hallerwiese, St. Johannis-Muhlgasse 19, 90419, Nuremberg, Germany
- Division of Maternal and Fetal Medicine Department of Obstetrics and Gynaecology, Mt. Sinai Hospital University of Toronto, Toronto, ON, Canada
| | - Uwe Schoen
- BioMedHeliX (Pty) Ltd., 3 Conifer Road, Cape Town, 8005, South Africa
| | - Nikolaos Evangelatos
- United Nations University - Maastricht Economics and Social Research Institute On Innovation and Technology (UNU-MERIT), Maastricht, 6211, AX, The Netherlands
- Interdepartmental Division of Critical Care Medicine, University of Toronto, ON, Canada
- Dr. TMA Pai Endowment Chair in Research Policy in Biomedical Sciences and Public Health, Prasanna School of Public Health (PSPH), Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India
| | - Shashidhar Vishwanath
- Department of Microbiology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Madhav Nagar, Manipal, 576104, Karnataka, India
- Manipal Centre for Infectious Diseases, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India
| | - Kapaettu Satyamoorthy
- Department of Cell and Molecular Biology, Manipal School of Life Sciences, Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India
| | - Franz Kainer
- Department of Obstetrics and Perinatal Medicine, Klinik Hallerwiese, St. Johannis-Muhlgasse 19, 90419, Nuremberg, Germany
| | - Angela Brand
- United Nations University - Maastricht Economics and Social Research Institute On Innovation and Technology (UNU-MERIT), Maastricht, 6211, AX, The Netherlands
- Dr. TMA Pai Endowment Chair in Public Health Genomics, Department of Public Health Genomics, Manipal School of Life Sciences, Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India
- Department of International Health, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, 6229, GT, The Netherlands
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16
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Workowski KA, Bachmann LH, Chan PA, Johnston CM, Muzny CA, Park I, Reno H, Zenilman JM, Bolan GA. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021; 70:1-187. [PMID: 34292926 PMCID: PMC8344968 DOI: 10.15585/mmwr.rr7004a1] [Citation(s) in RCA: 784] [Impact Index Per Article: 261.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
These guidelines for the treatment of persons who have or are at risk for
sexually transmitted infections (STIs) were updated by CDC after consultation
with professionals knowledgeable in the field of STIs who met in Atlanta,
Georgia, June 11–14, 2019. The information in this report updates the
2015 guidelines. These guidelines discuss 1) updated recommendations for
treatment of Neisseria gonorrhoeae, Chlamydia trachomatis,
and Trichomonas vaginalis; 2) addition of
metronidazole to the recommended treatment regimen for pelvic inflammatory
disease; 3) alternative treatment options for bacterial vaginosis; 4) management
of Mycoplasma genitalium; 5) human papillomavirus vaccine
recommendations and counseling messages; 6) expanded risk factors for syphilis
testing among pregnant women; 7) one-time testing for hepatitis C infection; 8)
evaluation of men who have sex with men after sexual assault; and 9) two-step
testing for serologic diagnosis of genital herpes simplex virus. Physicians and
other health care providers can use these guidelines to assist in prevention and
treatment of STIs.
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17
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Sheele JM, Elkins JM, Mohseni MM, Monas J, Campos SC, Benard RB, Mead-Harvey C, Mi L. Vaginal leukocyte counts for predicting sexually transmitted infections in the emergency department. Am J Emerg Med 2021; 49:373-377. [PMID: 34246967 DOI: 10.1016/j.ajem.2021.06.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 06/02/2021] [Accepted: 06/28/2021] [Indexed: 10/20/2022] Open
Abstract
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.
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Affiliation(s)
| | - Justin M Elkins
- Research Trainee (Limited Tenure), Mayo Clinic, Jacksonville, FL, USA
| | - Michael M Mohseni
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Jessica Monas
- Department of Emergency Medicine, Mayo Clinic Hospital, Phoenix, AZ, USA
| | | | - Ronald B Benard
- Research Trainee (Limited Tenure), Mayo Clinic, Jacksonville, FL, USA
| | | | - Lanyu Mi
- Biostatistics, Mayo Clinic, Scottsdale, AZ, USA
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18
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Lack of Sexually Transmitted Infection Treatment Accuracy When Relying on Syndromic Management in an Urgent Care Setting. Sex Transm Dis 2021; 47:625-627. [PMID: 32815903 DOI: 10.1097/olq.0000000000001216] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Chlamydia and gonorrhea are 2 of the most common sexually transmitted infections, and patients are increasingly seeking care for them in urgent care clinics. Providers often rely on syndromic management because of prolonged test turnaround times, which can result in inappropriate treatment. METHODS This study retrospectively evaluated chlamydia and gonorrhea treatment accuracy of adults, men and women, 18 years and older in 4 urgent cares in Northeast Iowa, using standard nucleic acid amplification test in a 6-month time frame through medical records review. Seven hundred twenty-two visits were evaluated. RESULTS The proportion of patients who were treated at the time of their visit was 25.8% (n = 186/722), resulting in 68.8% (n = 128/186) overtreatment and 8.2% (n = 44/536) undertreatment. Logistic regression analysis found that treatment prescribed without diagnostic test results and the patient-collected vaginal swabs were predictors of inappropriate treatment. Patients who were treated in the clinic were significantly less likely to be treated appropriately compared with patients who were treated later based on test results (odds ratio, 0.04; confidence interval, 0.02-0.06). Patients who self-collected vaginal swabs had significantly lower odds of being treated appropriately (odds ratio, 0.04; confidence interval, 0.09-0.80). CONCLUSIONS Syndromic management leads to inaccurate treatment of chlamydia and gonorrhea at the time of the initial patient visit. Changes in practice in urgent care are needed to improve treatment accuracy by promoting antibiotic stewardship and decreasing forward disease transmission.
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19
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Barriers to Access to New Gonorrhea Point-of-Care Diagnostic Tests in Low- and Middle-Income Countries and Potential Solutions: A Qualitative Interview-Based Study. Sex Transm Dis 2021; 47:698-704. [PMID: 32936604 PMCID: PMC7497475 DOI: 10.1097/olq.0000000000001238] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To assess the potential market for 2 hypothetical diagnostic tests, one for Neisseria gonorrhoeae/Chlamydia trachomatis (NG/CT) detection and one for NG antimicrobial resistance (AMR) marker identification. METHODS This is a qualitative interview-based study. Semistructured interviews with global- and country-level experts were performed. Interviewees were provided with simplified versions of Foundation for Innovative New Diagnostics/World Health Organization-developed target product profiles for each test. Interviewees were asked to comment on use cases, test characteristics, and factors that may influence test adoption. RESULTS Twenty-one experts were interviewed, including 15 country-level experts (from South Africa, India, Zimbabwe, Ghana, China, Peru, Kenya, and Cambodia). Interviewees welcomed an NG/CT point-of-care test, with near-universal preference for a test that could detect symptomatic and asymptomatic infections. Interviewees also saw value in a test that could be used to screen high-risk populations. Factors that may drive adoption of the NG/CT test identified by interviewees included price, cost-effectiveness, evidence of public health benefit, and World Health Organization guidance. Interviewees felt that AMR test use would likely be limited to patients failing first-line treatment. CONCLUSIONS Although the potential target population for an NG/CT diagnostic test in low- and middle-income countries is sizeable, there are areas of uncertainty relating to the price of the test and its intended use, warranting further research to determine the most effective positioning. An NG AMR test would likely be used very selectively.
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Cherabie JN, Liang SY, Reno H. Diagnostics for Gonorrhea and Chlamydia in the Emergency Department: Fight Smarter Not Harder. Ann Emerg Med 2021; 77:411-413. [PMID: 33766272 DOI: 10.1016/j.annemergmed.2020.09.445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Joseph N Cherabie
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO
| | - Stephen Y Liang
- Divisions of Emergency Medicine and Infectious Diseases, Washington University School of Medicine, St. Louis, MO
| | - Hilary Reno
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO
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21
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Jeong J, Kim JS, Lee J, Seo YR, Yi EC, Kim KM. Neisseria gonorrhoeae Multivalent Maxibody with a Broad Spectrum of Strain Specificity and Sensitivity for Gonorrhea Diagnosis. Biomolecules 2021; 11:biom11030484. [PMID: 33807121 PMCID: PMC8004885 DOI: 10.3390/biom11030484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/19/2021] [Accepted: 03/22/2021] [Indexed: 11/16/2022] Open
Abstract
Gonorrhea is one of the most common, but still hidden and insidious, sexually transmitted diseases caused by Neisseria gonorrhoeae (gonococci). However, the diagnosis and treatment of gonorrhea are hampered by antigenic variability among gonococci, the lack of acquired immunity, and antimicrobial resistance. Further, strains resistant to cephalosporins, including ceftriaxone, the last line of defense, represent a growing threat, which prompted us to develop gonococci-specific diagnostic antibodies with broad-spectrum binding to gonococci strains to generate gonorrhea-detecting reagents. This study reports the identification of gonococci antibodies via bio-panning on gonococci cells using scFv-phage libraries. Reformatting the lead scFv-phage Clones 1 and 4 to a multivalent scFv1-Fc-scFv4 maxibody increased the sensitivity by up to 20-fold compared to the single scFv-Fc (maxibody) alone. Moreover, the multivalent maxibody showed broader cross-reactivity with clinical isolates and the ceftriaxone antibiotic-resistant World Health Organization (WHO) reference strain L. In contrast, the selected antibodies in the scFv-phage, maxibody, and multivalent maxibody did not bind to N. sicca, N. meningitides, and N. lactamica, suggesting the clinical and pharmaceutical diagnostic value of these selected antibodies for gonorrheal infections. The present study illustrates the advantages and potential application of multivalent maxibodies to develop rapid and sensitive diagnostic reagents for infectious diseases and cancer.
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Affiliation(s)
- Jieun Jeong
- Division of Biomedical Convergence, College of Biomedical Science, Kangwon National University, Chuncheon, Gangwon 24341, Korea;
| | - Jae-Seok Kim
- Department of Laboratory Medicine, Kangdong Sacred Heart Hospital, Gangdong-gu, Seoul 05355, Korea;
- Department of Laboratory Medicine, College of Medicine, Hallym University, Chuncheon 24341, Korea
| | - Junghyeon Lee
- Department of Bio-Health Convergence, Kangwon National University, Chuncheon 24341, Korea;
| | - Yu Ri Seo
- Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, College of Medicine or College of Pharmacy, Seoul National University, Seoul 03080, Korea;
| | - Eugene C. Yi
- Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, College of Medicine or College of Pharmacy, Seoul National University, Seoul 03080, Korea;
- Correspondence: (E.C.Y.); (K.M.K.); Tel.: +82-2-740-8926 (E.C.Y.); +82-33-250-8382 (K.M.K.); Fax: +82-2-3673-2167 (E.C.Y.); +82-33-250-8382 (K.M.K.)
| | - Kristine M. Kim
- Division of Biomedical Convergence, College of Biomedical Science, Kangwon National University, Chuncheon, Gangwon 24341, Korea;
- Department of Bio-Health Convergence, Kangwon National University, Chuncheon 24341, Korea;
- Correspondence: (E.C.Y.); (K.M.K.); Tel.: +82-2-740-8926 (E.C.Y.); +82-33-250-8382 (K.M.K.); Fax: +82-2-3673-2167 (E.C.Y.); +82-33-250-8382 (K.M.K.)
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22
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Abstract
Given the large number of patients seen in the emergency department (ED) and concerns with antibiotic overprescribing, the ED is an important setting to target for antimicrobial stewardship (AS) initiatives. The ED is positioned between ambulatory and inpatient settings, making AS collaboration with clinicians and other health care providers in the hospital, long-term care facilities, and ambulatory settings critical to success. This article details ED-focused AS strategies on empiric antimicrobial selection, prompt administration, preventing ED return and readmissions, suggested collaborations between ED AS leadership and other key partners, and potential future strategies for expansion.
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23
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Patients Are Willing to Wait for Rapid Sexually Transmitted Infection Results in a University Student Health Clinic. Sex Transm Dis 2020; 47:67-69. [PMID: 31856075 DOI: 10.1097/olq.0000000000001083] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We examined the acceptability and feasibility of using a 30-minute chlamydia/gonorrhea test in a student health clinical setting. One hundred eight students were enrolled and 89.4% were willing to wait up to 20 minutes beyond the conclusion of their routine visit. The average amount of time added per clinic visit was less than 11 minutes. Patient and staff satisfaction were high.
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Hsieh YH, Lewis MK, Viertel VG, Myer D, Rothman RE, Gaydos CA. Performance evaluation and acceptability of point-of-care Trichomonas vaginalis testing in adult female emergency department patients. Int J STD AIDS 2020; 31:1364-1372. [PMID: 32998638 DOI: 10.1177/0956462420956532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We evaluated the accuracy and perception of a patient self-administered, tablet-facilitated rapid Trichomonas vaginalis (TV) point-of-care (POC) test in adult female emergency department (ED) patients.ED patients undergoing gynecologic examination were eligible. Each consented participant self-collected a vaginal swab, performed a tablet-facilitated TV rapid test using the OSOM® Trichomonas Rapid Test, and completed pre- and post-test self-surveys. After the self-test, the clinician collected one standard-of-care (SOC) vaginal swab for wet-mount testing and two for research. The research coordinator performed the TV rapid test using the clinician-collected swab, and reported the results to the clinician and patient. If the self- and coordinator-performed results were discordant, a TV nucleic acid amplification test (NAAT) was performed in a clinical laboratory. A survey was later administered to providers to assess their perceptions of the utility of the POC TV test.Of the 136 participants, 134 (98.5%) completed self-testing; two had invalid results. Comparing coordinator-performed TV rapid test adjudicated with NAAT, the sensitivity and specificity of self-administered test was 96.0% and 100%, respectively. The wet mount had a sensitivity of 52.0% and specificity of 100%. TV detection increased from 9.6% with wet mount to 18.4% with the TV rapid test. Most women (82.0%) stated self-testing was "not at all hard" (versus 66.2% before testing, p < 0.001). Clinicians indicated the TV rapid test affected their clinical management in 48.5% of cases, including 82.6% of positive cases and 41.6% of negative cases.ED patients were able to reliably collect, perform, and interpret their own POC TV test using tablet instructions. Both participants and providers reported high levels of acceptability of POC TV testing, which nearly doubled rates of TV detection.
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Affiliation(s)
- Yu-Hsiang Hsieh
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mitra K Lewis
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Valentina G Viertel
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Deanna Myer
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Charlotte A Gaydos
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Ferreyra C, Osborn J, Moussy F, Alirol E, Lahra M, Whiley D, Shafer W, Unemo M, Klausner J, Kelly Cirino C, Wi T. Developing target product profiles for Neisseria gonorrhoeae diagnostics in the context of antimicrobial resistance: An expert consensus. PLoS One 2020; 15:e0237424. [PMID: 32870912 PMCID: PMC7462286 DOI: 10.1371/journal.pone.0237424] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 06/17/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND There is a need for a rapid diagnostic point of care test to detect Neisseria gonorrhoeae (NG) infection to prevent incorrect, lack or excess of treatment resulting from current syndromic management in low-resource settings. An assay to identify NG antimicrobial resistance (AMR) is also highly desirable to facilitate antibiotic stewardship. Here we describe the development of two target product profiles (TPPs): one for a test for etiological diagnosis of NG and Chlamydia trachomatis (CT) (TPP1) and one for the detection of NG AMR/susceptibility (TPP2). METHODS Draft TPPs were initially developed based on a landscape analysis of existing diagnostics and expert input. TPPs were refined via an online Delphi survey with two rounds of input from 68 respondents. TPP characteristics on which <75% of non-industry respondents agreed were further discussed and revised by an expert working group. RESULTS The need for a test to identify NG in patients with urethral or vaginal discharge was identified as a minimal requirement of TPP1, with a test that can diagnose NG in asymptomatic patients as the optimal requirement. A sensitivity of 80% was considered acceptable, either in context of syndromic management or screening high-risk populations. For TPP2, the agreed minimal requirement was for a test to be used at level 2 healthcare facilities and above, with an optimal requirement of level 1 or above. A lateral flow format was preferred for TPP1, while it was considered likely that TPP2 would require a molecular format. A total of 31 test characteristics were included in TPP1 and 27 in TPP2. CONCLUSIONS Following the working group revisions, TPPs were posted online for public feedback for two months, and are now finalized. The final TPPs are currently guiding the development of new diagnostics that meet the defined characteristics to reach the market within two years.
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Affiliation(s)
- Cecilia Ferreyra
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Jennifer Osborn
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | | | - Emilie Alirol
- Global Antibiotic R&D Partnership (GARDP), Geneva, Switzerland
| | - Monica Lahra
- WHO Collaborating Centre for Sexually Transmitted Infections and Antimicrobial Resistance, New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, Australia
- Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - David Whiley
- Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia
| | - William Shafer
- Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, Georgia, USA and Veterans Affairs Medical Center, Decatur, Georgia, United States of America
| | - Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs, Örebro University Hospital, Örebro, Sweden
| | - Jeffrey Klausner
- Division of Infectious Diseases, University of California and David Geffen School of Medicine Los Angeles, Los Angeles, CA, United States of America
| | | | - Teodora Wi
- World Health Organization (WHO), Geneva, Switzerland
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Fisk KM, Derouin A, Holm G, Hicks L. Getting it Right: The Impact of Point-of-Care Testing for Gonorrhea and Chlamydia in the Urgent Care Setting. J Nurse Pract 2020. [DOI: 10.1016/j.nurpra.2020.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Bergquist EP, Trolard A, Kuhlmann AS, Loux T, Liang SY, Stoner BP, Reno H. Undertreatment of chlamydia and gonorrhea among pregnant women in the emergency department. Int J STD AIDS 2019; 31:166-173. [PMID: 31865863 DOI: 10.1177/0956462419880379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Eleanor P Bergquist
- College for Public Health and Social Justice, Saint Louis University, St. Louis, MO, USA
| | - Anne Trolard
- Institute of Public Health, Washington University in St. Louis, St. Louis, MO, USA
| | - Anne S Kuhlmann
- College for Public Health and Social Justice, Saint Louis University, St. Louis, MO, USA
| | - Travis Loux
- College for Public Health and Social Justice, Saint Louis University, St. Louis, MO, USA
| | - Stephen Y Liang
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA.,Department of Medicine, Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Bradley P Stoner
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA.,Department of Anthropology, Washington University in St. Louis, St. Louis, MO, USA
| | - Hilary Reno
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
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Miller MK, Chernick LS, Goyal MK, Reed JL, Ahmad FA, Hoehn EF, Pickett MS, Stukus K, Mollen CJ. A Research Agenda for Emergency Medicine-based Adolescent Sexual and Reproductive Health. Acad Emerg Med 2019; 26:1357-1368. [PMID: 31148339 DOI: 10.1111/acem.13809] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 04/29/2019] [Accepted: 05/11/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective was to identify key questions for emergency medicine (EM)-based adolescent sexual and reproductive health and to develop an evidence-based research agenda. METHODS We recruited national content experts to serve as advisory group members and used a modified Delphi technique to develop consensus around actionable research questions related to EM-based adolescent reproductive and sexual health care. Author subgroups conducted literature reviews and developed the initial list of research questions, which were iteratively refined with advisory members. External stakeholders then independently rated each item for its importance in expanding the evidence base (1 = not important to 5 = very important) via electronic survey. RESULTS Our final list of 24 research questions included items that intersected all sexual and reproductive health topics as well as questions specific to human immunodeficiency virus/sexually transmitted infections (HIV/STIs), pregnancy prevention, confidentiality/consent, public health, and barriers and facilitators to care. External stakeholders rated items related to HIV/STI, cost-effectiveness, brief intervention for sexual risk reduction, and implementation and dissemination as most important. CONCLUSIONS We identified critical questions to inform EM-based adolescent sexual and reproductive health research. Because evidence-based care has potential to improve health outcomes while reducing costs associated with HIV/STI and unintended pregnancy, funders and researchers should consider increasing attention to these key questions.
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Affiliation(s)
- Melissa K. Miller
- Department of Pediatrics Division of Emergency Medical Services Children's Mercy Hospitals and Clinics Kansas City MO
| | - Lauren S. Chernick
- Department of Emergency Medicine and Pediatrics Columbia University New York NY
| | - Monika K. Goyal
- Department of Pediatrics Children's National Medical Center The George Washington University Washington DC
| | - Jennifer L. Reed
- Division of Emergency Medicine Cincinnati Children's Hospital Medical Center Cincinnati OH
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH
| | - Fahd A. Ahmad
- Department of Pediatrics Washington University School of Medicine St. Louis MO
| | - Erin F. Hoehn
- Division of Emergency Medicine Cincinnati Children's Hospital Medical Center Cincinnati OH
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH
| | | | - Kristin Stukus
- Department of Pediatrics Division of Emergency Medicine Nationwide Children's Hospital Columbus OH
| | - Cynthia J. Mollen
- Department of Pediatrics Division of Emergency Medicine Children's Hospital of Philadelphia Philadelphia PA
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BundlED Up: A Narrative Review of Antimicrobial Stewardship Initiatives and Bundles in the Emergency Department. PHARMACY 2019; 7:pharmacy7040145. [PMID: 31683859 PMCID: PMC6958310 DOI: 10.3390/pharmacy7040145] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 10/28/2019] [Accepted: 10/30/2019] [Indexed: 12/03/2022] Open
Abstract
Antimicrobial stewardship (ASP) is becoming an increasingly high priority worldwide, yet the emergency department (ED) is an area where stewardship is often neglected. Implementing care bundles, guidelines, and protocols appears to be a rational strategy for ED stewardship given the inherently dynamic and hectic environment of care. Multiple questions still exist such as whether to target certain disease states, optimal implementation of ASP interventions in the ED, and the benefit of unique ED-specific guidelines and protocols. A narrative review was performed on interventions, guidelines, and bundles implemented in the ED setting, in an effort to improve ASP or management of infectious diseases. This review is meant to serve as a framework for the reader to implement these practices at their own institution. We examined various studies related to ASP interventions or care bundles in the ED which included: CNS infections (one study), skin and soft-tissue infections (one study), respiratory infections (four studies), urinary tract infections and sexually transmitted infections (eight studies), sepsis (two studies), culture follow-up programs (four studies), and stewardship in general or multiple infection types (five studies). The interventions in this review were diverse, yet the majority showed a benefit in clinical outcomes or a decrease in antimicrobial use. Care bundles, guidelines, and antimicrobial stewardship interventions can streamline care and improve the management of common infectious diseases seen in the ED.
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Performance of the Atlas Genetics Rapid Test for Chlamydia trachomatis and Women's Attitudes Toward Point-Of-Care Testing. Sex Transm Dis 2019; 45:723-727. [PMID: 29771869 DOI: 10.1097/olq.0000000000000865] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE This study compared performance of the Atlas io polymerase chain reaction-based, point-of-care (POC) assay for Chlamydia trachomatis (CT), to Aptima Combo 2, a standard of care nucleic acid amplification assay, and evaluated patient attitudes toward POC testing. METHODS Women 14 years or older undergoing CT screening/testing were recruited from Teen Health Center and a sexually transmitted disease clinic. Participants provided self-obtained vaginal swabs for testing with the Atlas io and Aptima Combo 2, and completed questionnaires assessing attitudes toward POC testing. RESULTS Of 296 women recruited, 284 (192 from sexually transmitted disease clinic, 92 from Teen Health Center) had Aptima Combo 2 and Atlas io results available; 273 completed the questionnaire. Average age was 27.4 years (SD, 10.8 years). Sensitivity and specificity of the Atlas io test were 83.9% (26/31 specimens; 95% confidence interval [CI], 70.9-96.8%) and 98.8% (250/253 specimens; 95% CI, 97.5-100%), respectively. When specimens with discrepant results were included in the analyses, adjudicated sensitivity and specificity were 92.9% (26/28 specimens; 95% CI, 83.3 to 100%) and 98.8% (253/256 specimens; 95% CI, 97.5 to 100%), respectively.A majority (70%) of women preferred to collect vaginal self-swab if a POC test were available. Most (61%) were willing to wait up to 20 minutes, and 26% were willing to wait up to 40 minutes for results, if they could be treated before leaving clinic. CONCLUSIONS A POC polymerase chain reaction test detecting CT had high sensitivity and specificity when testing prospective, vaginal swab samples. Availability of CT results during patients' visits may decrease time to treatment.
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Gaydos CA, Ako MC, Lewis M, Hsieh YH, Rothman RE, Dugas AF. 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. Ann Emerg Med 2019; 74:36-44. [PMID: 30392736 PMCID: PMC6494710 DOI: 10.1016/j.annemergmed.2018.09.012] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 08/08/2018] [Accepted: 09/11/2018] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Charlotte A Gaydos
- Division of Infectious Diseases, Johns Hopkins University, Baltimore, MD; Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD.
| | | | - Mitra Lewis
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD
| | - Yu-Hsiang Hsieh
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD
| | - Richard E Rothman
- Division of Infectious Diseases, Johns Hopkins University, Baltimore, MD; Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD
| | - Andrea F Dugas
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD
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Burkins J, DeMott JM, Slocum GW, Gottlieb M, Peksa GD. Factors associated with unsuccessful follow-up in patients undertreated for gonorrhea and chlamydia infections. Am J Emerg Med 2019; 38:715-719. [PMID: 31182361 DOI: 10.1016/j.ajem.2019.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/02/2019] [Accepted: 06/03/2019] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Neisseria gonorrhea (GC) and Chlamydia trachomatis (CT) are two commonly encountered sexually transmitted infections in the Emergency Department (ED). METHODS The study was a single-center, retrospective cohort of patients screened for GC/CT infections at an urban, academic medical center ED. Participants were identified through electronic medical record reports. Patients were excluded if they absconded, were discharged against medical advice, or had a chief complaint of sexual assault. Patients were classified as having tested positive or negative for GC/CT and further classified as having received adequate treatment, overtreatment, or undertreatment. The undertreatment group was further assessed for successful versus unsuccessful follow-up. The primary aim was to determine factors associated with unsuccessful follow-up in patients undertreated. Secondary aims included rate of overtreatment, rate of undertreatment, and method of contact in patients with successful follow-up. RESULTS A total of 10,452 patients were included. Of the 456 undertreated patients, follow-up was successful in 425 (93.2%) patients and unsuccessful in 31 (6.8%) patients. No history of STIs was associated with a higher rate of unsuccessful follow-up in patients undertreated for GC/CT infections (52.9% versus 74.2%, difference = -21.3%, 95% CI -37.4%, -5.1%). Rate of overtreatment was 19.1%, and rate of undertreatment was 46.5%. Phone contact was the most frequent method of successful contact, which occurred in 98.6% of patients. CONCLUSIONS GC/CT infections continue to be overtreated in the ED. Based on this study, no history of prior sexually transmitted infections was associated with unsuccessful follow-up in patients undertreated for GC/CT infections after discharge from the ED.
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Affiliation(s)
- Jaxson Burkins
- Department of Pharmacy, Mount Sinai Hospital, Chicago, IL, USA
| | - Joshua M DeMott
- Department of Pharmacy, Rush University Medical Center, Chicago, IL, USA
| | - Giles W Slocum
- Department of Pharmacy, Rush University Medical Center, Chicago, IL, USA
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Gary D Peksa
- Department of Pharmacy, Rush University Medical Center, Chicago, IL, USA; Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA.
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Cuylaerts V, De Baetselier I, Muvunyi CM, Mwambarange L, Smet H, Rusine J, Musengamana V, van de Wijgert J, Crucitti T. Implementation and evaluation of the Presto combined qualitative real-time assay for Chlamydia trachomatis and Neisseria gonorrhoeae in Rwanda. Afr J Lab Med 2019; 8:739. [PMID: 31049303 PMCID: PMC6489157 DOI: 10.4102/ajlm.v8i1.739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 10/05/2018] [Indexed: 11/29/2022] Open
Abstract
Background The Presto combined qualitative real-time assay for Chlamydia trachomatis and Neisseria gonorrhoeae (Presto CT/NG PCR assay) is appealing for developing countries, because it can be used with multiple DNA extraction methods and polymerase chain reaction (PCR) platforms. Objectives The objective of the study was to implement and evaluate the Presto CT/NG PCR assay at the National Reference Laboratory (NRL) in Kigali, Rwanda, where no real-time PCR assays for the detection of C. trachomatis or N. gonorrhoeae were available. Methods The Presto CT/NG PCR assay was first evaluated at the Institute of Tropical Medicine (ITM) in Antwerp, Belgium. Next, NRL laboratory technicians were trained to use the assay on their ABI PRISM 7500 real-time PCR instrument and their competencies were assessed prior to trial initiation. During the trial, endocervical swabs were tested at the NRL, with bi-monthly external quality control testing monitored by the ITM. The final NRL results were evaluated against extended gold standard testing at the ITM, consisting of the Abbott m2000 RealTime System with confirmation of positive results by an in-house real-time PCR assay for C. trachomatis or N. gonorrhoeae. Results Of the 192 samples analysed using the Presto assay at the NRL, 16 samples tested positive for C. trachomatis and 17 tested positive for N. gonorrhoeae; four of these were infected with both. The sensitivity and specificity of the Presto assay were 93.3% (95% confidence interval [CI]: 68.1% – 99.8%) and 99.4% (95% CI: 96.8% – 100%) for C. trachomatis and 100% (95% CI: 76.8% – 100%) and 98.8% (95% CI: 95.8% – 99.9%) for N. gonorrhoeae. Conclusion C. trachomatis and N. gonorrhoeae testing with the Presto assay was feasible in Kigali, Rwanda, and good performance was achieved. Keywords qPCR; Chlamydia trachomatis; Neisseria gonorrhoeae.
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Affiliation(s)
- Vicky Cuylaerts
- Institute of Tropical Medicine, Department of Clinical Sciences, STI Reference Laboratory, Antwerp, Belgium
| | - Irith De Baetselier
- Institute of Tropical Medicine, Department of Clinical Sciences, STI Reference Laboratory, Antwerp, Belgium
| | - Claude M. Muvunyi
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | - Hilde Smet
- Institute of Tropical Medicine, Department of Clinical Sciences, STI Reference Laboratory, Antwerp, Belgium
| | - John Rusine
- National Reference Laboratory, Ministry of Health, Kigali, Rwanda
| | | | - Janneke van de Wijgert
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Tania Crucitti
- Institute of Tropical Medicine, Department of Clinical Sciences, STI Reference Laboratory, Antwerp, Belgium
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Silva ML, Cargnello C, Aulois-Griot M, Dumartin C. Antibiotic misuse: How to evaluate the costs? Med Mal Infect 2019; 49:485-494. [PMID: 30954321 DOI: 10.1016/j.medmal.2019.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 11/08/2018] [Accepted: 03/13/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Few studies have assessed the costs associated with the misuse of antibiotics in hospitals in France, despite the value of health economic data to inform antibiotic stewardship activities. We aimed to identify the methodological tools used to assess the cost of antibiotic misuse in hospitals. METHODS We performed a literature review using the major electronic medical databases. An index of relevance was developed to assess the intrinsic quality of selected articles. RESULTS Four hundred and three articles were retrieved, but 35 were selected for analysis. Most studies investigated the inadequate choice of the antibiotic molecule (n=17), the incorrect treatment duration (n=9), and the administration of an inappropriate dosage (n=7). Only three studies were medical/economic evaluations of specific interventions, such as prescription control by pharmacists or the implementation of a new diagnostic test. Considering our aim, the relevance of the studies was limited: few had defined the economic assessment as the primary objective or had detailed the method for calculating costs. Nevertheless, the misuse evaluation was usually better described. CONCLUSIONS Despite these limits, key factors for measuring antibiotic misuse (i.e., molecule choice, dosage) in relation to the costs (i.e., over/under prescription, hospital stay, staff remuneration) might serve as the basis for the development of a reference methodology to value the costs of misuse. The application of this methodology on identified situations of antibiotic misuse would help hospital decision-makers to justify resource allocation for implementing antimicrobial stewardship activities.
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Affiliation(s)
- M L Silva
- Unité Inserm 1219, UFR sciences pharmaceutiques- laboratoire de droit et économie pharmaceutiques, université de Bordeaux, 146, rue Léo-Saignat, case postale 81, 33076 Bordeaux, France.
| | - C Cargnello
- Unité Inserm 1219, UFR sciences pharmaceutiques- laboratoire de droit et économie pharmaceutiques, université de Bordeaux, 146, rue Léo-Saignat, case postale 81, 33076 Bordeaux, France
| | - M Aulois-Griot
- Unité Inserm 1219, UFR sciences pharmaceutiques- laboratoire de droit et économie pharmaceutiques, université de Bordeaux, 146, rue Léo-Saignat, case postale 81, 33076 Bordeaux, France
| | - C Dumartin
- Unité Inserm 1219, UFR sciences pharmaceutiques- laboratoire de droit et économie pharmaceutiques, université de Bordeaux, 146, rue Léo-Saignat, case postale 81, 33076 Bordeaux, France; CHU Bordeaux, CPIAS Nouvelle Aquitaine, hôpital Pellegrin - bâtiment Le Tondu, 33076 Bordeaux, France
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Abstract
The emergency department (ED) is the hub of the US health care system. Acute infectious diseases are frequently encountered in the ED setting, making this a critical setting for antimicrobial stewardship efforts. Systems level and behavioral stewardship interventions have demonstrated success in the ED setting but successful implementation depends on institutional support and the presence of a physician champion. Antimicrobial stewardship efforts in the ED should target high-impact areas: antibiotic prescribing for nonindicated respiratory tract conditions, such as bronchitis and sinusitis; overtreatment of asymptomatic bacteriuria; and using two antibiotics (double coverage) for uncomplicated cases of cellulitis or abscess.
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Affiliation(s)
- Michael Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 800 University Bay Drive, Suite 300, Madison, WI 53705, USA.
| | - Robert Redwood
- Department of Family Medicine and Community Health, University of Wisconsin Madison School of Medicine and Public Health, 1100 Delaplaine Ct, Madison, WI 53715
| | - Larissa May
- Department of Emergency Medicine, University of California Davis, 4150 V Street, Suite 2100, Sacramento, CA 95817, USA
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