Factors associated with the over-treatment and under-treatment of gonorrhea and chlamydia in adolescents presenting to a public hospital emergency department

Racial and Ethnic Differences in Chlamydia and Gonorrhea Testing Locations Among Medicaid-Insured Youth

PURPOSE

Chlamydia trachomatis (CT) and Neisseria gonorrhea (GC) infections are common among 15- to 24-year-olds, with Black and Hispanic youth disproportionately affected. Understanding where youth receive CT/GC testing is necessary to address disparities in CT/GC care. Our objective was to identify if differences exist in CT/GC testing locations by race and ethnicity.

METHODS

We used 2019 MarketScan Medicaid data to examine CT/GC testing location by youth race and ethnicity.

RESULTS

There were 418,623 CT/GC tests during the study period. Tests were most frequently ordered at medical offices for all races and ethnicities, although less frequently for Black (37.6%) and Hispanic (37.3%) than for White youth (49.3%). Black youth were frequently tested in emergency departments (19.6%), while Hispanic youth were frequently tested in Federally Qualified Health Centers (19.0%).

DISCUSSION

We found significant racial and ethnic disparities in the location of CT/GC testing among Medicaid-insured-youth; these findings should be used to guide strategies that address inequities in CT/GC care.

Highly-Specific Single-Stranded Oligonucleotides and Functional Nanoprobes for Clinical Determination of Chlamydia Trachomatis and Neisseria Gonorrhoeae Infections

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.

Presumptive and Follow-Up Treatment Associated With Gonorrhea and Chlamydia Testing Episodes in Sexually Transmitted Disease Clinics: Impact of Changing Treatment Guidelines for Gonorrhea, Sexually Transmitted Disease Surveillance Network, 2015-2018

Background:

CDC recommendation for treatment of uncomplicated gonorrhea (NG) were revised in December 2020 and include ceftriaxone monotherapy when chlamydial infection was excluded. We evaluated the impact of these revised treatment recommendations using data from a network of STD clinics prior to the change in guidelines.

Methods:

We performed a cross-sectional analysis from 8 STD clinics participating in the STD Surveillance Network from Jan 2015-June 2018 assessing gonorrhea/chlamydia (CT) testing episodes, NAAT results, CT only and NG/CT treatment records, and timing of treatment. We describe the frequency of NG and CT treatment practices and what proportion of patients treated would not have had to receive an anti-chlamydial agent.

Results:

Of 190,589 episodes that occurred during the study period, 67,895 (35.6%) episodes were associated with a treatment record consistent with gonorrhea and/or chlamydia (CT only (n=37,530) or NG/CT (n=30,365)), most (~86%) were prescribed on the same-day as initial testing. Of the 67,895 episodes with corresponding treatment record(s), 42.1% were positive for either NG or CT compared to 3.7% were positive for NG or CT for those not associated with treatment records (n=122,694 episodes). Among 30,365 episodes associated with NG/CT treatment records, monotherapy would only have been indicated for 10.1% (3,081/30,365) of the episodes as they were treated on follow-up and were NG positive and CT negative.

Conclusions:

Treatment was prescribed in one third of NG/CT testing episodes, with the majority provided same day. Despite changes in NG treatment guidelines to ceftriaxone monotherapy, majority of patients would continue to receive an anti-chlamydia agent when treated for gonorrhea in these settings.

Provision of same-day treatment is common in STD clinic patients being treated for gonorrhea and chlamydia, likely resulting in patients continuing to get dual therapy despite recent treatment guideline changes.

Impact of Rapid Testing for Gonorrhea and Chlamydia in an Urban Pediatric Emergency Department

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.

Descriptive Epidemiology of Women in the Emergency Department With Gonorrhea and Chlamydial Infection in the United States

Demographic characteristics, risk factors, and clinical variables associated with gonorrhea and chlamydial infection in women being treated in emergency departments (EDs) in the United States are incompletely characterized. We used univariable and multivariable regression analyses on 17,411 encounters from women 18 years and older who presented to EDs in northeast Ohio and were tested for gonorrhea or chlamydial infection. There were 1,360 women (7.8%) who had Chlamydia trachomatis infection and 510 (2.9%) who had Neisseria gonorrhoeae infection. Those infected with C. trachomatis or N. gonorrhoeae were younger (23.8 vs. 29.2 years), unmarried (97.7% vs. 90.1%), Black (93.3% vs. 88.0%), infected with Trichomonas vaginalis (39.9% vs. 27.2%), diagnosed with urinary tract infection (15.7% vs. 10.6%), and treated for gonorrhea and chlamydial infection during the ED visit (31.6% vs. 17.4%) (all ps < .001). Women infected with C. trachomatis or N. gonorrhoeae had more urine white blood cells (WBCs) (23.9 vs. 16.4 cells per high-power field [HPF]) and leukocyte esterase (1.2+ vs. 0.8+) on urinalysis. They had more WBCs (18.5 vs. 12.4 cells/HPF) and odds of having T. vaginalis infection (12.8% vs. 8.2%) on vaginal wet preparation (all ps < .001). Women infected with C. trachomatis were more likely to be younger and not Black; they were less likely to be treated for gonorrhea and chlamydial infection in the ED and to have lower levels of urine WBCs, leukocyte esterase, and blood than those infected with N gonorrhoeae (all ps ≤ .05).

Adolescents Accessing School-Based versus Family Planning Clinics: Chlamydia and Gonorrhea Testing and Treatment Outcomes

Simple Summary

Sexually Transmitted Infections, such as gonorrhea and chlamydia, are common in school-aged youths. These infections can cause significant health problems if not identified and treated early. Current estimates of how widespread these infections are among students receiving healthcare in schools, the role school-based clinics may have in gonorrhea and chlamydia testing and treatment, and information on how the COVID-19 pandemic affected testing and treatment, are lacking. This study was conducted in an urban metropolitan area in the United States, and included 2439 patients aged 13–17 years over a 2-year period. The patients were seen at four school-based and five family planning clinics. We found that 35% of those tested in school-based clinics were positive for chlamydia, and 10% were positive for gonorrhea. The rates of these infections were higher than previous reports from school settings (both pre-COVID-19 and the during COVID-19 pandemic). School-based clinics were able to treat patients with gonorrhea and chlamydia much faster (average ~6 days) than the family planning clinics (average ~18 days). This study shows us the critical role that school-based clinics play in the testing and treatment for gonorrhea and chlamydia infections, and the value of strengthening the services these clinics provide.

Abstract

The prevalence and treatment of chlamydia (CT) and gonorrhea (GC) at school-based clinics (SBCs) requires revisiting. To assess whether clinic type influences CT/GC testing and treatment for minors (individuals 13–17 years of age), our study compared four SBCs with five family planning clinics (FPCs) in the Houston, Harris County metropolitan area of Texas, USA for: (1) the prevalence of CT/GC infection (pre-COVID-19 and during COVID-19); (2) treatment rates at the last positive diagnosis; and (3) the time, in days, from testing-to-diagnosis and testing-to-treatment. Between January 2019 and December 2020, 2439 unique patients (1579 at SBCs, 860 at FPCs) were seen. Of the 1924 tests obtained, 39.2% and 15.9% were positive for CT and GC, respectively. The prevalence of CT and GC at SBCs was similar prior to COVID-19 vs. during the COVID-19 pandemic. SBCs were able to provide treatment significantly faster after diagnosis (mean, 6.07 days; 95% CI, 3.22–8.90; 94.7% were within 30 days) than FPCs (mean, 17.60 days; 95% CI, 10.15–25.12; 84.7% were within 30 days) (p = 0.0257). This comparison within our large clinic system, with consistent clinical management protocols, suggests that SBC care may be critical to ensuring optimal sexually transmitted infection management in minors.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Antibiotic Selection for Suspected Neisseria gonorrhoeae Infection Among Penicillin-Allergic Patients in the Emergency Department

Objectives

While penicillin allergies are commonly reported, their cross-reactivity with beta-lactam antibiotics is minimal. First-line treatment of gonorrheal infections includes a cephalosporin. In emergency department (ED) environments, physicians must consider these potential allergies when selecting antibiotics for a patient with symptoms concerning for sexually transmitted infection (STI).

Methods

A retrospective chart review of adult patients with symptoms concerning for STI presenting to an urban ED from January 2014 through June 2019 was performed. Chart discovery used search terms of “STI”, “STD”, “urethritis”, “vaginitis”, and “gonorrhea”. Information abstracted included patient symptoms, type of care provider, antibiotics prescribed or administered in the ED.

Results

A total of 603 patients met inclusion criteria, of which 31 reported allergies to penicillin antibiotics, and another three reported allergies to cephalosporins. Patients reporting penicillin allergy were less likely to receive a cephalosporin antibiotic (p=0.0081). Patients reporting a non-anaphylactic allergy to penicillin received a cephalosporin at a rate of 92.3%. Patients reporting a penicillin allergy under the care of only an attending physician were less likely to receive a cephalosporin antibiotic compared with those whose care teams included either a resident physician or physician assistant (p=0.00019). Patients reporting a penicillin allergy were more likely to receive alternative antibiotics beyond cephalosporins or azithromycin (p=0.048); the most frequently given additional antibiotics were metronidazole, doxycycline, and levofloxacin.

Conclusions 

Patients with penicillin allergies represent a recurring challenge for ED physicians when faced with antibiotic selection for STI symptoms concerning for gonorrheal infection. Those with penicillin allergies are significantly less likely to receive a cephalosporin antibiotic, though these remain the only universally accepted treatment for gonorrheal infections. These findings highlight the significant need for further physician and public education on allergies and antibiotic selection.

Lack of Sexually Transmitted Infection Treatment Accuracy When Relying on Syndromic Management in an Urgent Care Setting

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.

A review of current guidelines and research on the management of sexually transmitted infections in adolescents and young adults

Adolescents and young adults are at high risk for sexually transmitted infections (STIs). Providers have the responsibility to accurately manage these infections to prevent medical complications and the spread of STIs. This article will review the epidemiology, screening recommendations, diagnostic tests, and treatment guidelines for STIs most commonly encountered in this population: Chlamydia trachomatis, Neisseria gonorrhoeae, Herpes simplex virus, and Trichomonas vaginalis, as well as the sexually associated infection bacterial vaginosis. This review will discuss ongoing research that explores ways to improve the management of STIs in adolescents and young adults.

Single and Repeated Use of the Emergency Department for Chlamydia and Gonorrhea Care

OBJECTIVE

Chlamydia and gonorrhea infection rates are rising in the United States, and the emergency department (ED) is increasingly a site where individuals seek care for these infections, sometimes more than once. This article investigates how individuals who use the ED more than once and receive chlamydia and gonorrhea care differ from individuals who are single users of the ED, as well as characteristics associated with being a repeat user of the ED.

METHODS

We analyzed 46,964 visits made by individuals who attended 1 of 4 EDs from January 1, 2010, to May 31, 2016, and received a test for chlamydia and gonorrhea infection. We used negative binomial regression to test the ability of age, sex, race, infection status, and insurance status to predict number of visits.

RESULTS

Individuals who used the ED more than once and received chlamydia and gonorrhea care were at their first visit more likely to be younger (incident rate ratio [IRR], 0.98; 95% confidence interval [CI], 0.97-0.98 per year) nonpregnant female (IRR, 1.23; 95% CI, 1.06-1.42), black (IRR, 1.27; 95% CI, 1.04-1.57), and have no or public insurance compared with single users of the ED.

DISCUSSIONS

Individuals likely to make multiple visits to the ED and receive chlamydia and gonorrhea care may be identifiable on their first visit and potentially directed elsewhere during subsequent visits for more comprehensive and potentially less expensive sexually transmitted disease care.

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

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

A Research Agenda for Emergency Medicine-based Adolescent Sexual and Reproductive Health

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.

Factors associated with unsuccessful follow-up in patients undertreated for gonorrhea and chlamydia infections

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.

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

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.

Unveiling the Multilocus Sequence Typing (MLST) Schemes and Core Genome Phylogenies for Genotyping Chlamydia trachomatis

Multilocus sequence typing (MLST) has become a useful tool for studying the genetic diversity of important public health pathogens, such as Chlamydia trachomatis (Ct). Four MLST schemes have been proposed for Ct (data available from Chlamydiales MLST databases). However, the lack of a sole standardized scheme represents the greatest limitation regarding typing this species. This study was thus aimed at evaluating the usefulness of the four MLST schemes available for Ct, describing each molecular marker's pattern and its contribution toward a description of intra-specific genetic diversity and population structure. The markers for each scheme, showed a variable power of dicrimination, exhibiting in some cases over estimation in the determination of Sequence Types (STs). However, individual analysis of each locus's typing efficiency and discrimination power led to identifying 8 markers as having a suitable pattern for intra-specific typing. analyzing the 8 candidate markers gave a combination of 3 of these loci as an optimal scheme for identifying a large amount of STs, maximizing discrimination power whilst maintaining suitable typing efficiency. One scheme was compared against core genome phylogenies, finding a higher typing resolution through the last approach. These results confirm once again that although complete genome data, in particular from core genome MLST (cgMLST) allow a high resolution clustering for Ct isolates. There are combinations of molecular markers that could generate equivalent results, with the advantage of representing an easy implementation strategy and lower costs leading to contribute to the monitoring and molecular epidemiology of Ct.

An increase in sexually transmitted infections seen in US emergency departments

Surveillance data show that there is an increase in the incidence of sexually transmitted infections (STI) and we believe that because of this increased incidence, coupled with a deteriorating public health infrastructure, these STIs are being seen more often in emergency departments. Therefore, we used six years of the most recently available nationally-representative emergency department data to show an increase in the number of emergency department visits where a sexually transmitted infection was treated. We further described the population for these visits.