130 Treatment of Gonorrhea and Chlamydia in Emergency Department Patients

Abstract

Study Objective: To describe the frequency of effective antibiotic treatment both in the emergency department (ED) and at follow-up, among ED patients who test positive for Chlamydia trachomatis or Neisseria gonorrheae. Methods: A retrospective case control chart review was performed in which a random sample of 500 cases and 500 controls were selected from all patients who had a test for Neisseria gonorrheae or Chlamydia trachomatis sent from the ED of an urban, academic, level 1 trauma center from 1/1/10-6/30/11. Exclusion criteria were: age <15, victims of sexual assault, patients who eloped or left against medical advice, or repeat visits within 3 weeks of testing positive. Data abstracted from the ED medical record by trained research assistants included demographics, history and physical exam findings, ED antibiotic prescribed, successful contact by the follow-up nurse, and follow-up treatment. The CDC 2010 STD Treatment Guidelines were used to define effective antibiotic for each infection. Descriptive statistics, frequencies and logistic regression modeling using generalized estimating equations to account for repeat visits, were used for analysis. Double data abstraction on a 10% random sample was completed to calculate interrater reliability. Results: In 18 months, a total of 631 tests were positive for Chlamydia trachomatis and 213 were positive for Neisseria gonorrheae among 6997 specimens sent. Interrater reliability was excellent with a Kappa of 0.92. Among the 500 randomly selected cases, the demographics were: mean age 25, 51% female, 93% English, 73% Black, 17% Hispanic, 6% White, and 4% other. Of the 500 cases, 374 were positive for Chlamydia trachomatis only, 93 for Neisseria gonorrheae only, and 33 for both Chlamydia trachomatis and Neisseria gonorrheae. Of the 374 Chlamydia trachomatis only cases, 312 (83%) received effective treatment; 174 were treated in the ED and 138 treated on follow up. Of the 93 Neisseria gonorrheae only cases, 80 (86%) received effective treatment; 66 were treated in the ED and 14 were treated on follow up. For those who tested positive for both Chlamydia trachomatis and Neisseria gonorrheae, 30/33 (91%) were treated effectively; 25 were treated in the ED and 5 were treated on follow up. Overall 422/500 (84%) cases ultimately received effective antibiotic treatment for their STD, 265/422 (63%) in the ED and 157/422 (37%) on follow-up. Among the 235 cases who were not treated in the ED, 78 (33%) did not get effective antibiotics at our medical center at follow-up; 11(14%) reported treatment elsewhere, 18 (23%) were unable to be reached, 48 (62%) were reached but did not return to our medical center for appropriate antibiotics, and 1 had no documentation of call back. Among controls, 86/500 (17%) received presumptive antibiotic for either Neisseria gonorrheae, Chlamydia trachomatis, or both in the ED and none were called back for follow up treatment. Conclusion: In this ED that has a dedicated callback nurse, eventual treatment of STDs occurred in only 84% of patients who tested positive for Neisseria gonorrheae or Chlamydia trachomatis. Providers should consider presumptive treatment at time of initial ED visit more frequently when follow-up can not be assured, as follow up often did not lead to successful treatment in this population.