Underrecognition of Cervical Neisseria gonorrhoeae and Chlamydia trachomatis Infections in the Emergency Department

Abstract

Objectives: 1 ) To quantify the frequency of underrecognized Neisseria gonorrhoeae and Chlamydia trachomatis cervical infections in women tested in the ED, 2) to describe and compare the characteristics of those treated and not treated during the initial visit, and 3) to quantify the delay interval until treatment was provided. Methods: A 2-year, retrospective consecutive case series was performed from June 1, 1992, to May 31, 1994. There were 148 women with 2 1 discrete occurrence of culture-proven cervical N. gonorrhoeae or C. trachomatis infection studied. All the patients were evaluated in a university-affiliated, tertiary care hospitalbased ED with a large rural referral area. The main outcome measures were the proportions of patients with positive cultures both treated and not treated in the ED, the clinical characteristics of each group, and the proportion remaining untreated or experiencing treatment delays of >2 weeks after attempted phone, mail, and public health follow-up. Results: Of 157 occurrences of positive cultures for N . gonorrhoeae or C. trachomatis, 86 (53%) were treated with a regimen suggested by the CDC prior to ED release. The proportion of women with isolated C. rrachomatis infections that were underrecognized and untreated initially was larger than the proportions with isolated N. gonorrhoeae or combined infections (79% vs 27% and 53%, respectively, p < 0.OOOl). Women with findings suggestive of advanced disease (history of fever or chills, or examination evidence of temperature >38"C, purulent vaginal discharge, or any uterine/salpinx/ovarian tenderness) were more often recognized and treated with appropriate antibiotics initially (p = 0.02 to <0.00001 for all). After phone, mail, and public health follow-up, treatment could not be' documented for 25% of the occurrences, in all cases due to an inability to locate the patient. An additional 20% of the women did not receive treatment for 14-60 days. Conclusions: In this population, both N. gonorrhoeae and C. trachornatis cervical infections are frequently underrecognized in the ED, with isolated C. rrachomatis infections associated with significantly higher proportions of underrecognition. Many affected women remain untreated for extended intervals, creating public and individual health risks. Improved point of contact detection, follow-up, and treatment policies are needed to limit these risks.

Follow‐up Program for Emergency Department Patients with Gonorrhea or Chlamydia

“…8,13 Emergency physicians practicing in GC/CT-prevalent endemic areas who see patients with these diagnoses should have a higher index of suspicion and consider empiric treatment. This study confirms the magnitude of underrecognized STDs in the ED as shown by Yealy et al 7 …”

“…This phenomenon was also experienced in Yealy et al's study, where treatment for 25% of their positive female patients could not be documented due to an inability to locate the patients. 7 Some of the patients in our study refused treatment; it is unknown whether they received treatment elsewhere. These shortcomings confirm the missed opportunities to treat patients at their initial presentations.…”

“…5,6 Many females, especially in urban areas, use the ED for diagnosis and treatment of STDs. Prior studies by Yealy et al 7 and Kelly et al 8 identified underrecognition of culture-proven GC and CT in female patients in EDs. The Yealy study 7 also emphasized the inability of an ED follow-up system to achieve adequate follow-up treatment for patients with positive results.…”

Improving Notification of Sexually Transmitted Infections: A Quality Improvement Project and Planned Experiment

“…However, clinical practice in our ED was similar to that of others: notify patients with an STI only if they were not treated at their visit. 5 We found that adolescent women who believed they had an STI were more likely to abstain from sexual activity and to notify their partners than those who were unaware of their STI. However, women who were treated with antibiotics but did not believe they tested positive for STIs did not change their behavior.…”

“…After an ED visit, some estimate that only 29% of untreated women are treated within 14 days, and 60% are lost to follow-up. 5,7,[8][9][10] Sexually transmitted disease clinics report that ∼50% are treated within 14 days, and 20% to 30% are lost to follow-up. [8][9][10] In our adolescent clinic, we contacted 69% of untreated women within 7 days, and ,10% were lost to follow-up.…”