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Solnick RE, López LH, Martinez PM, Zucker JE. Sexually Transmitted Infections in the Emergency Department. Emerg Med Clin North Am 2024; 42:335-368. [PMID: 38641394 DOI: 10.1016/j.emc.2024.02.006] [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: 04/21/2024]
Abstract
As the United States faces a worsening epidemic of sexually transmitted infections (STIs), emergency departments (EDs) play a critical role in identifying and treating these infections. The growing health inequities in the distribution and disproportionate impact of STIs add to the urgency of providing high-quality sexual health care through the ED. Changes in population health are reflected in the new Centers for Disease Control recommendations on screening, diagnostic testing, and treatment of STIs. This review covers common, as well as and less common or emerging STIs, and discusses the state-of-the-art guidance on testing paradigms, extragenital sampling, and antimicrobial treatment and prevention of STIs.
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Affiliation(s)
- Rachel E Solnick
- Icahn School of Medicine at Mount Sinai Hospital, Department of Emergency Medicine- Research Division, 555 West 57th Street, 5th Floor Suite 5-25, New York, NY 10019, USA.
| | - Laura Hernando López
- Icahn School of Medicine at Mount Sinai Hospital, Department of Emergency Medicine- Research Division, 555 West 57th Street, 5th Floor Suite 5-25, New York, NY 10019, USA
| | - Patricia Mae Martinez
- Icahn School of Medicine at Mount Sinai Hospital, Department of Emergency Medicine- Research Division, 555 West 57th Street, 5th Floor Suite 5-25, New York, NY 10019, USA
| | - Jason E Zucker
- Columbia University Vagelos College of Physicians and Surgeons, 630 West 168th Street, Box 82, New York, NY 10032, USA
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Sheele JM, Mi L, Monas J, Mohseni M. Patient and Provider Demographics and the Management of Genitourinary Tract Infections in the Emergency Department. Emerg Med Int 2023; 2023:1522347. [PMID: 37727654 PMCID: PMC10506883 DOI: 10.1155/2023/1522347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/08/2023] [Accepted: 08/23/2023] [Indexed: 09/21/2023] Open
Abstract
Introduction Urinary tract infections (UTIs) and sexually transmitted infections (STIs) can have overlapping signs, symptoms, and findings on urinalysis. Our objective was to determine if patient or provider demographics are associated with differences in the diagnosis and management of UTIs and STIs in the emergency department (ED). Methods We analyzed 38,062 ED patient encounters from a single healthcare system between April 18, 2014, and March 7, 2017. All encounters were women ≥18 years of age and not admitted to the hospital. We performed logistic regression using patient and provider demographics, laboratory testing results, ED triage data, and ED diagnoses. Results The patient's age, race, and marital status were not associated with having an ED UTI diagnosis with a urine culture ≥10,000 colony forming units (CFUs)/mL (vs. <10,000 CFUs/mL). Patient race and the sex of the ED provider were not associated with differences in empiric antibiotic treatment for gonorrhea and chlamydia during the ED encounter. Patient's race and the sex of the ED provider were also not associated with discordance between empiric antibiotic therapy given in the ED and the results of gonorrhea and chlamydia tests that resulted following the ED encounter. Conclusion In our multivariate analyses, we did not observe that the patient's race resulted in significant differences in the diagnosis of UTIs with bacteriuria ≥10,000 CFU/mL or differences in the empiric treatment of gonorrhea and chlamydia infections among those tested for the infection in the ED. The patient's age and marital status, but not the provider's sex, were significantly associated with differences in the management of gonorrhea and chlamydia.
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Affiliation(s)
| | - Lanyu Mi
- Mayo Clinic, Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Scottsdale, AZ, USA
| | - Jessica Monas
- Mayo Clinic, Department of Emergency Medicine, Phoenix, AZ, USA
| | - Michael Mohseni
- Mayo Clinic, Department of Emergency Medicine, Jacksonville, FL 32224, USA
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3
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Allen KS, Hinrichs R, Heumann CL, Titus MK, Duszynski TJ, Valvi NR, Wiensch A, Tao G, Dixon BE. Findings From a Scoping Review: Presumptive Treatment for Chlamydiatrachomatis and Neisseria gonorrhoeae in the United States, 2006-2021. Sex Transm Dis 2023; 50:209-214. [PMID: 36584164 PMCID: PMC10006311 DOI: 10.1097/olq.0000000000001762] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
ABSTRACT Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) are the 2 most common reported sexually transmitted infections in the United States. Current recommendations are to presumptively treat CT and/or GC in persons with symptoms or known contact. This review characterizes the literature around studies with presumptive treatment, including identifying rates of presumptive treatment and overtreatment and undertreatment rates. Of the 18 articles that met our inclusion criteria, 6 pertained to outpatient settings. In the outpatient setting, presumptive treatment rates, for both asymptomatic and symptomic patients, varied from 12% to 100%, and the percent positive of those presumptively treated ranged from 25% to 46%. Three studies also reported data on positive results in patients not presumptively treated, which ranged from 2% to 9%. Two studies reported median follow-up time for untreated, which was roughly 9 days. The remaining 12 articles pertained to the emergency setting where presumptive treatment rates, for both asymptomatic and symptomic patients, varied from 16% to 91%, the percent positive following presumptive treatment ranged from 14% to 59%. Positive results without presumptive treatment ranged from 4% to 52%. Two studies reported the percent positive without any treatment (6% and 32%, respectively) and one reported follow-up time for untreated infections (median, 4.8 days). Rates of presumptive treatment, as well as rates of overtreatment or undertreatment vary widely across studies and within care settings. Given the large variability in presumptive treatment, the focus on urban settings, and minimal focus on social determinants of health, additional studies are needed to guide treatment practices for CT and GC in outpatient and emergency settings.
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Affiliation(s)
| | - Rachel Hinrichs
- University Library, Indiana University Purdue University Indianapolis
| | | | - Melissa K Titus
- Department of Epidemiology, Richard M. Fairbanks School of Public Health, IUPUI, Indianapolis, IN
| | - Thomas J Duszynski
- Department of Epidemiology, Richard M. Fairbanks School of Public Health, IUPUI, Indianapolis, IN
| | | | | | - Guoyu Tao
- Centers for Disease Control and Prevention, Atlanta, GA
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Viottini E, Albanesi B, Casabona E, Onorati R, Campagna S, Borraccino A. Ten-Year Trend in Emergency Department Visits for Sexually Transmitted Infections among Adolescents: A Retrospective Cross-Sectional Study in Italy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:14207. [PMID: 36361087 PMCID: PMC9656796 DOI: 10.3390/ijerph192114207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/17/2022] [Accepted: 10/27/2022] [Indexed: 06/16/2023]
Abstract
UNLABELLED Sexually transmitted infections (STIs) are frequently underdiagnosed, representing a serious public health concern, especially during adolescence and in more vulnerable communities. AIM to describe the last ten years of emergency department (ED) visits for STIs among adolescents. METHODS a retrospective cross-sectional observation was carried out in the Piedmont region in Italy. Data were retrieved through the Italian National Information System database. ED visits related to specific ICD-9-CM codes carried out on 11 to 19-year-old youths between 2011 and 2020 were investigated. Age-specific, crude, and standardized rates and admission ratios, with 95% confidence intervals (CIs), were calculated to estimate the STI trend. RESULTS from a total of 1,219,075 ED visits, 339 were related to STIs, representing an increasing ratio of 28 per 100,000 visits, primarily in females. Most infections occurred in girls (83.5%) and among 17 to 19-year-olds (71.5%). A drop in both ED visits and STI cases was observed in 2020. Genital Herpes and Genital Warts were more frequent in girls while Gonorrhea was more frequent in boys. CONCLUSIONS the increasing trend of ED visits for STIs, particularly in girls, represents an emerging relevant public health issue that needs to be urgently tackled.
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Affiliation(s)
- Elena Viottini
- Department of Public Health and Paediatrics, University of Torino, 10126 Torino, Italy
| | - Beatrice Albanesi
- Department of Public Health and Paediatrics, University of Torino, 10126 Torino, Italy
| | - Elena Casabona
- Department of Public Health and Paediatrics, University of Torino, 10126 Torino, Italy
| | - Roberta Onorati
- Epidemiology Unit, Local Health Unit TO3, 10095 Grugliasco, Italy
| | - Sara Campagna
- Department of Public Health and Paediatrics, University of Torino, 10126 Torino, Italy
| | - Alberto Borraccino
- Department of Public Health and Paediatrics, University of Torino, 10126 Torino, Italy
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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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Sheele JM, Bragg KJ, Bragg B, Campos SC, Elkins JM, Niforatos JD, Thompson CL. Descriptive Epidemiology of Women in the Emergency Department With Gonorrhea and Chlamydial Infection in the United States. Adv Emerg Nurs J 2022; 44:144-157. [PMID: 35476693 DOI: 10.1097/tme.0000000000000408] [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: 11/25/2022]
Abstract
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).
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Affiliation(s)
- Johnathan M Sheele
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida (Drs Sheele, K. J. Bragg, and B. Bragg); Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland (Dr Niforatos); and Department of Nutrition, Case Western Reserve University, Cleveland, Ohio (Dr Thompson). Drs Cantillo Campos and Elkins (limited tenure) are research trainees at Mayo Clinic, Jacksonville, Florida
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Robertson C, Thomas A, Koyama A, Middlebrooks L, Kandaswamy S, Orenstein E, Gooding H. Missed Opportunities for Sexual History Documentation and Sexually Transmitted Infection Testing in the Pediatric Emergency Department. J Adolesc Health 2022; 70:429-434. [PMID: 34836803 DOI: 10.1016/j.jadohealth.2021.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 10/01/2021] [Accepted: 10/04/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Sexually transmitted infections (STIs) are disproportionally prevalent in adolescents, and adolescents often present to the pediatric emergency department (PED) for STI care. Prior studies have found low rates of sexual history documentation and STI testing in the PED. However, these studies have had limited sample sizes because of the burden of manual chart review. We aimed to estimate the rate of sexual history documentation and identify factors associated with STI testing in a large cohort of adolescents using natural language processing (NLP). METHODS We applied a validated NLP algorithm to all adolescent visits over a three-year period to the PED at a single large children's health care organization with a chief complaint potentially related to an STI. We utilized NLP to determine the prevalence of sexual history documentation in these patients. We applied logistic regression models to determine associations between sexual history documentation, patient demographic factors, and STI testing. RESULTS Of the 1,987 patient encounters included, only 56% had a sexual history documented, and only 40% of all patients were tested for STIs. Patients were more likely to have a sexual history documented and to be tested for STIs if they were of non-Hispanic black race/ethnicity, were >15 years of age, and had nonprivate insurance. Patients with a sexual history documented were seven times more likely to have STI testing ordered. Of patients tested (n = 728), 25% were positive for an STI. CONCLUSIONS Despite presenting to the PED with symptoms potentially related to an STI, many adolescents are not receiving recommended sexual health care. Rates of sexual history documentation and STI testing varied by demographic factors including race, age, and insurance status. Utilizing NLP technology allowed us to examine a larger sample size than previously documented in the adolescent sexual history and PED literature. This study highlights critical opportunities to improve sexual health provision and equity of care provided in the PED.
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Affiliation(s)
- Caryn Robertson
- Division of Pediatric Emergency Medicine, Atlanta, Georgia; Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta, Atlanta, Georgia.
| | - Amanda Thomas
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Atsuko Koyama
- Division of Emergency Medicine, Department of Child Health, University of Arizona, College of Medicine Phoenix, Phoenix, Arizona
| | - Lauren Middlebrooks
- Division of Pediatric Emergency Medicine, Atlanta, Georgia; Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | - Evan Orenstein
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta, Atlanta, Georgia; Division of Hospitalist Medicine, Atlanta, Georgia
| | - Holly Gooding
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta, Atlanta, Georgia; Division of General Pediatrics and Adolescent Medicine, Atlanta, Georgia
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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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Fawcett SE, Williams AA, Johnson EE, Ramsey KM. Treatment of chlamydia and gonorrhea infections during the COVID-19 pandemic using provisional Centers for Disease Control guidance. J Am Assoc Nurse Pract 2021; 34:373-380. [PMID: 34417414 DOI: 10.1097/jxx.0000000000000642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 06/25/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The COVID-19 pandemic created new challenges in controlling the transmission of sexually transmitted diseases (STDs), forcing the Centers for Disease Control and Prevention (CDC) to temporarily modify recommendations. As rapid COVID-19 testing emerged, supplies for similar testing platforms, specifically Chlamydia trachomatis and Neisseria gonorrhoeae, became compromised. LOCAL PROBLEM The local community was identified as having the highest rate of chlamydia infections in North Carolina. Concerns regarding disease transmission within the community were amplified as the project site began experiencing a critical shortage of chlamydia and gonorrhea testing kits. METHODS This quality improvement (QI) project, conducted in an emergency department, located in an underserved area with high STD infection rates, offered a prioritized approach to STD testing and treatment during a critical time with limited testing capabilities. INTERVENTIONS Program analysis evaluated the management of 227 patients preintervention and 218 patients postintervention with confirmed or suspected infection, using a testing and treatment algorithm to identify and treat those most likely to be infected while preserving testing supplies for those at higher risk for complications from infections. RESULTS Test utilization decreased by 25% (p-value = .003 via t-test), whereas a significant improvement in empiric treatment, increasing from 59% (133/227) to 73% (158/218), was also observed (p-value = .002 via chi-square analysis). CONCLUSIONS Results suggest that a testing and treatment algorithm for providers can successfully guide testing and treatment decisions, reducing onward transmission and preserving supplies for those more likely to experience complications from chlamydia and gonorrhea infections.
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Affiliation(s)
- Susan E Fawcett
- Medical University of South Carolina, Charleston, South Carolina
- Vidant Health, Greenville, North Carolina
| | - Amy A Williams
- Medical University of South Carolina, Charleston, South Carolina
| | - Emily E Johnson
- Medical University of South Carolina, Charleston, South Carolina
| | - Keith M Ramsey
- Vidant Health, Greenville, North Carolina
- East Carolina University Brody School of Medicine, Greenville, North Carolina
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Greenstein J, Babson V, Frisolone J, Janiszewski B, Kyvik S, Mason B, Paduch M, Igneri T, Hahn B, D'Antoni AV. Frequency of Urinary Tract Infections, Gonorrhea, and Chlamydia in Emergency Department Patients With Acute Scrotal Pain. Cureus 2021; 13:e16347. [PMID: 34395128 PMCID: PMC8357846 DOI: 10.7759/cureus.16347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2021] [Indexed: 11/14/2022] Open
Abstract
Background: Acute scrotal pain has many causes. According to the American Urological Association recommendations: history, physical examination, and ultrasound are key in diagnosing acute scrotal pain. Objective: The primary objective of this study was to evaluate the frequency of urinary tract infections (UTI) on routine Urinalysis (UA) in patients presenting with acute scrotal pain to the emergency department (ED). Methods: We conducted a multicentered retrospective chart review of patients who presented to the ED with acute scrotal pain. Patient visits from February 1, 2018 to November 1, 2019 from 13 EDs were analyzed. Demographic data, UA interpretation, urine culture, gonorrhea and chlamydia (GC) testing, clinical findings, treatment outcomes, and ultrasounds were recorded. Patients who did not have a UA and scrotal ultrasound performed or who had a diagnosis of scrotal cellulitis or soft tissue infection were excluded. Results: There were 2,392 patients included in the study. A UTI was present in 173 (7.2%) patients. Of the patients who were found to have a UTI, 100/173 (57.8%) had a concomitant ultrasound diagnosis of epididymitis/orchitis. Also, 731 patients underwent GC testing in addition to standard UA collection, and ultrasound, seven were positive for gonorrhea (0.95%), and 30 were positive for chlamydia (4.10%). Conclusions: Routine UA collection of patients presenting to the ED with acute scrotal pain should be considered, especially in patients with a concomitant ultrasound diagnosis of epididymo-orchitis. GC testing has limited yield without symptoms suggestive of sexually transmitted infections and a normal ultrasound.
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Affiliation(s)
- Josh Greenstein
- Emergency Medicine, Staten Island University Hospital, Staten Island, USA
| | - Victoria Babson
- Emergency Medicine, Central Harnett Hospital, Lillington, USA
| | | | - Brianna Janiszewski
- Cardiothoracic Surgery, University of Rochester Medical Center, Rochester, USA
| | | | - Brooke Mason
- Otolaryngology, Jersey Shore University Medical Center, Neptune City, USA
| | | | - Tara Igneri
- Physician Assistant Program, Wagner College, Staten Island, USA
| | - Barry Hahn
- Emergency Medicine, Staten Island University Hospital, Staten Island, USA
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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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12
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Chinnock B, Yore M, Mason J, Kremer M, Farshidpour L, Lopez D, Castaneda J. Self-obtained vaginal swabs are not inferior to provider-performed endocervical sampling for emergency department diagnosis of Neisseria gonorrhoeae and Chlamydia trachomatis. Acad Emerg Med 2021; 28:612-620. [PMID: 33460481 DOI: 10.1111/acem.14213] [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: 11/09/2020] [Revised: 01/09/2021] [Accepted: 01/13/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Provider-performed endocervical sampling (PPES) in the diagnosis of Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) may be difficult to perform in a busy emergency department (ED) due to patient preference, availability of the pelvic examination room, or provider availability. Our objective was to assess if self-obtained vaginal swabs (SOVS) were noninferior to PPES in the ED diagnosis of NG/CT using a rapid nucleic acid amplification test (NAAT). METHODS We conducted a prospective observational cohort study in a single ED. Participants were adult female English- and Spanish-speaking patients in whom the ED provider felt that NG/CT testing was warranted. Each patient had SOVS and PPES performed. For SOVS, a research associate reviewed a one-page handout describing the procedure but gave no other assistance. Patients answered survey questions regarding acceptability of SOVS and symptomatology. We established a minimum sensitivity of 90% for SOVS to be considered clinically noninferior to standard PPES. RESULTS A total of 533 patients completed enrollment and answered survey questions, 515 of whom had laboratory results for both SOVS and PPES. There were 86 patients with a positive result: 29 with NG, 47 with CT, and 10 with coinfection. SOVS had a sensitivity of 95% (95% confidence interval = 88% to 99%) for the detection of NG/CT when compared to PPES. SOVS were felt to be an acceptable collection method in 93% of patients and 75% preferred SOVS to PPES. CONCLUSION SOVS are noninferior to PPES in NG/CT diagnosis using a rapid NAAT in ED patients and surveys indicate high patient acceptability.
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Affiliation(s)
- Brian Chinnock
- Department of Emergency Medicine UCSF–FresnoMedical Education Program Fresno California USA
| | - Mackensie Yore
- Department of Emergency Medicine UCSF–FresnoMedical Education Program Fresno California USA
| | - Jessica Mason
- Department of Emergency Medicine UCSF–FresnoMedical Education Program Fresno California USA
| | - Mallory Kremer
- Department of Obstetrics and Gynecology University of Washington Seattle Washington USA
| | - Leyla Farshidpour
- University of California–Davis School of Medicine Sacramento California USA
| | - Diana Lopez
- University of California–Davis School of Medicine Sacramento California USA
| | - Jannet Castaneda
- Department of Emergency Medicine UCSF–FresnoMedical Education Program Fresno California USA
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Safety and Effectiveness of Same-Day Chlamydia trachomatis and Neisseria gonorrhoeae Screening and Treatment Among Gay, Bisexual, Transgender, and Homeless Youth in Los Angeles, California, and New Orleans, Louisiana. Sex Transm Dis 2020; 47:19-23. [PMID: 31688719 DOI: 10.1097/olq.0000000000001088] [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
BACKGROUND Gay, bisexual, transgender, and homeless youth are at risk of sexually transmitted infections. As part of an adolescent human immunodeficiency virus prevention study, we provided same-day Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) testing and treatment. We aimed to evaluate the feasibility and effectiveness of same-day CT and NG treatment on the proportion of participants receiving timely treatment. METHODS We recruited adolescents with high sexual risk behaviors aged 12 to 24 years from homeless shelters, lesbian, gay, bisexual, and transgender organizations, and community health centers in Los Angeles, California, and New Orleans, Louisiana from May 2017 to June 2019. Initially, participants were offered point-of-care pharyngeal, rectal, and urethral/vaginal CT and NG testing and referral to another clinic for treatment. After March 2018 in Los Angeles and November 2018 in New Orleans, we provided same-day treatment (and partner treatment packs) for study participants. We measured the proportion of participants who received same-day treatment and the median time to treatment. We collected frequency of partner treatment and any reported adverse treatment-related events. RESULTS The proportion of participants receiving same-day CT and NG treatment increased from 3.6% (5/140) to 21.1% (20/95; Δ17.5%; 95% confidence interval, 9.2%-26.9%) after implementation of same-day testing and treatment. The median time to treatment decreased from 18.5 to 3 days. Overall, 36 participants took a total of 48 partner treatment packs. There were no reported treatment-related adverse events. CONCLUSIONS Providing sexually transmitted infection treatment to adolescents at the same visit as testing is feasible and safe, and can increase the proportion of individuals receiving timely treatment.
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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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Tejani C, Sivitz AB, Farrukh S, Patel K. In reply. Ann Emerg Med 2019; 74:165-166. [PMID: 31248496 DOI: 10.1016/j.annemergmed.2019.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Cena Tejani
- Department of Emergency Medicine, Children's Hospital of New Jersey at Newark Beth Israel Medical Center, Newark, NJ
| | - Adam B Sivitz
- Department of Emergency Medicine, Children's Hospital of New Jersey at Newark Beth Israel Medical Center, Newark, NJ
| | - Shamyla Farrukh
- Departent of Emergency Medicine, Staten Island University Hospital, Staten Island, NY
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Tejani C, Sivitz A, Farrukh S, Patel K. In reply. Ann Emerg Med 2019; 73:425-426. [PMID: 30902177 DOI: 10.1016/j.annemergmed.2018.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Cena Tejani
- Department of Emergency Medicine, Children's Hospital of New Jersey at Newark Beth Israel Medical Center, Newark, NJ
| | - Adam Sivitz
- Department of Emergency Medicine, Children's Hospital of New Jersey at Newark Beth Israel Medical Center, Newark, NJ
| | | | - Kavita Patel
- Department of Emergency Medicine, Hassenfeld Children's Hospital at New York University Langone, New York, NY
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Pugsley RA, Peterman TA. Presumptive and Follow-up Treatment for Gonorrhea and Chlamydia Among Patients Attending Public Health Department Clinics in Virginia, 2016. Sex Transm Dis 2019; 46:199-205. [PMID: 30742592 PMCID: PMC10798379 DOI: 10.1097/olq.0000000000000922] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Presumptive antibiotic treatment is common for suspected chlamydia (CT) and gonorrhea (GC) infections before laboratory confirmation to prevent complications, reduce loss-to-follow-up, and interrupt transmission. We assessed this practice in sexually transmitted disease (STD) and family planning clinics. METHODS We performed a retrospective analysis of data from clinics in Virginia in 2016 using administrative data merged with electronic laboratory reporting data. After stratifying by patient and clinic characteristics, we calculated how often patients with positive CT/GC tests were treated presumptively or during a follow-up visit, and how many patients with negative tests were treated presumptively. RESULTS Of 63,889 patient visits with valid laboratory results from 131 clinics, 13% tested positive for CT or GC. Overall, presumptive treatment was given to 45.2% of persons with positive tests and 10.1% of persons with negative tests. Among the 9443 patients presumptively treated, 40.7% had positive test results. Presumptive treatment was more common in STD clinics compared with family planning clinics (22% vs. 4%) and for males with positive tests compared to females (65% vs. 24%); smaller variations were observed across age, race/ethnicity, and diagnosis categories. Twenty-six percent of patients with positive tests who were not treated presumptively had no treatment recorded within 30 days. CONCLUSIONS Presumptive treatment for CT/GC was commonly used in this clinic population. It improved treatment coverage and reduced time to treatment, though some uninfected persons were treated. The impact of presumptive treatment on partner notification and treatment requires further study.
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Diagnosis and Treatment of Sexually Transmitted Infections in the Emergency Department. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2019. [DOI: 10.1016/j.cpem.2019.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Farrukh S, Sivitz AB, Onogul B, Patel K, Tejani C. The Additive Value of Pelvic Examinations to History in Predicting Sexually Transmitted Infections for Young Female Patients With Suspected Cervicitis or Pelvic Inflammatory Disease. Ann Emerg Med 2018; 72:703-712.e1. [PMID: 30251627 DOI: 10.1016/j.annemergmed.2018.05.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 04/24/2018] [Accepted: 05/02/2018] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVE We evaluate the additive value of pelvic examinations in predicting sexually transmitted infection for young female patients with suspected cervicitis or pelvic inflammatory disease in a pediatric emergency department (ED). METHODS This was a prospective observational study of female patients aged 14 to 20 years who presented to an urban academic pediatric ED with a complaint of vaginal discharge or lower abdominal pain. Enrolled patients provided a urine sample for chlamydia, gonorrhea, and trichomonas testing, which served as the criterion standard for diagnosis. A practitioner (pediatric ED attending physician, emergency medicine or pediatric resident, pediatric ED fellow, or advanced practice provider) obtained a standardized history from the patient to assess for cervicitis or pelvic inflammatory disease according to the Centers for Disease Control and Prevention criteria. They then recorded the likelihood of cervicitis or pelvic inflammatory disease on a 100-mm visual analog scale. The same practitioner then performed a pelvic examination and again recorded the likelihood of cervicitis or pelvic inflammatory disease on a visual analog scale with this additional information. Using the results of the urine sexually transmitted infection tests, the practitioner calculated and compared the test characteristics of history alone and history with pelvic examination. RESULTS Two hundred eighty-eight patients were enrolled, of whom 79 had positive urine test results for chlamydia, gonorrhea, or trichomonas, with a sexually transmitted infection rate of 27.4% (95% confidence interval [CI] 22.6% to 32.8%). The sensitivity of history alone in diagnosis of cervicitis or pelvic inflammatory disease was 54.4% (95% CI 42.8% to 65.5%), whereas the specificity was 59.8% (95% CI 52.8% to 66.4%). The sensitivity of history with pelvic examination in diagnosis of cervicitis or pelvic inflammatory disease was 48.1% (95% CI 36.8% to 59.5%), whereas the specificity was 60.7% (95% CI 53.8% to 67.3%). The information from the pelvic examination changed management in 71 cases; 35 of those cases correlated with the sexually transmitted infection test and 36 did not. CONCLUSION For young female patients with suspected cervicitis or pelvic inflammatory disease, the pelvic examination does not increase the sensitivity or specificity of diagnosis of chlamydia, gonorrhea, or trichomonas compared with taking a history alone. Because the test characteristics for the pelvic examination are not adequate, its routine performance should be reconsidered.
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Affiliation(s)
| | - Adam B Sivitz
- Department of Emergency Medicine, Newark Beth Israel Medical Center, Newark, NJ; Children's Hospital of New Jersey, Newark, NJ
| | | | - Kavita Patel
- Department of Emergency Medicine, Newark Beth Israel Medical Center, Newark, NJ; Children's Hospital of New Jersey, Newark, NJ
| | - Cena Tejani
- Department of Emergency Medicine, Newark Beth Israel Medical Center, Newark, NJ; Children's Hospital of New Jersey, Newark, NJ.
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Tavares E, Ouellette L, Law J, Joseph T, Zhan J, Ardary C, Nicholson A, Jones J. Effect of provider type and sex on empiric treatment of STD infections in adolescent patients. Am J Emerg Med 2018; 36:1918-1919. [PMID: 29544904 DOI: 10.1016/j.ajem.2018.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 02/27/2018] [Accepted: 03/02/2018] [Indexed: 10/17/2022] Open
Affiliation(s)
- Erica Tavares
- Michigan State University College of Human Medicine, Department of Emergency Medicine, United States; Department of Emergency Medicine, Spectrum Health Hospitals, United States
| | - Lindsey Ouellette
- Michigan State University College of Human Medicine, Department of Emergency Medicine, United States
| | - Junwen Law
- Michigan State University College of Human Medicine, Department of Emergency Medicine, United States; Department of Emergency Medicine, Spectrum Health Hospitals, United States
| | - Timothy Joseph
- Michigan State University College of Human Medicine, Department of Emergency Medicine, United States; Department of Emergency Medicine, Spectrum Health Hospitals, United States
| | - Jennifer Zhan
- Michigan State University College of Human Medicine, Department of Emergency Medicine, United States; Department of Emergency Medicine, Spectrum Health Hospitals, United States
| | - Christopher Ardary
- Michigan State University College of Human Medicine, Department of Emergency Medicine, United States; Department of Emergency Medicine, Spectrum Health Hospitals, United States
| | - Adam Nicholson
- Department of Emergency Medicine, Helen DeVos Children's Hospital, United States
| | - Jeffrey Jones
- Michigan State University College of Human Medicine, Department of Emergency Medicine, United States; Department of Emergency Medicine, Spectrum Health Hospitals, United States.
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Miller MK, Pickett ML, Reed JL. Adolescents at Risk for Sexually Transmitted Infection Need More Than the Right Medicine. J Pediatr 2017; 189:23-25. [PMID: 28739182 DOI: 10.1016/j.jpeds.2017.06.072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 06/29/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Melissa K Miller
- Division of Emergency Medicine Children's Mercy Hospital Kansas City, Missouri.
| | - Michelle L Pickett
- Division of Emergency Medicine Children's Hospital of Wisconsin Milwaukee, Wisconsin
| | - Jennifer L Reed
- Division of Emergency Services Cincinnati Children's Hospital and Medical Center Cincinnati, Ohio
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