Article

Suspected gonorrhea and chlamydia: Incidence and utilization of empiric antibiotics in a health system emergency department

a b s t r a c t

Background: In the ED, patients are treated empirically for suspected gonorrhea and/or chlamydia (GC). Limited studies have evaluated the treatment of Sexually transmitted diseases in conjunction with predictor var- iables. This study will allow providers to better identify patients with potential GC to streamline antibiotic treat- ment.

Objectives: The primary objective was to determine the incidence of positive assay in patients that underwent GC screening. The secondary objectives included the proportion of patients assayed that received empiric therapy and the predictive value of risk factors to identify positive assays.

Methods: This retrospective cohort study included adult patients who presented to the health-system EDs and underwent GC screening. Subjects were excluded if they were victims of sexual assault, left AMA or eloped.

Results: A total of 490 assayed patients were included, of which 84 (17%) were found to be positive for GC assay. Of the 278 patients treated empirically, 74% had a negative assay. Of the entire sample (n = 490), risk factors found to predict a positive assay (p b 0.05) included male, women b25 years of age, concomitant bacterial vagi- nosis, Pelvic inflammatory disease or trichomonas, penile discharge, inconsistent condom use, previous/ coexisting STDs, and uninsured.

Conclusions: Compared to previous reports, this study found a higher incidence of positive GC assays for patients with suspected infection. This is the first study to evaluate GC testing in both men and women in the ED, and risk factors not previously reported by the CDC were identified.

(C) 2018

Introduction

Approximately 80-90% of women with chlamydia, up to 80% of women with gonorrhea, and 40% of men with gonorrhea are asymp- tomatic on presentation [1,2]. In the emergency department (ED), pa- tients are often treated empirically for suspected gonorrhea and chlamydia (GC) due to the extended time required to receive test results and the lack of patient follow up when positive results are received [2,3].

Recently, concern has been raised around antibiotic resistance pat- terns of Neisseria gonorrhoeae. According to the Centers for Disease Con- trol and Prevention (CDC), gonorrhea has increasing resistance to multiple medications. Gonorrhea isolates more than quadrupled their resistance rate to azithromycin over the course of one year from 0.6 to

? Declaration of interest: none.

* Corresponding author.

E-mail addresses: [email protected] (J. Garlock), [email protected] (M. Cucci), [email protected] (L.A. Frazee), [email protected] (C. Mullen).

1 Present address: 1725 Pine St, Montgomery, AL 36106 United States of America.

2.5% [1]. The CDC reported that resistance to ceftriaxone ranges from

0.1 to 0.4% [1]. Despite these resistance patterns, to date, the CDC states there have been no reported cases of treatment failure to cephalospo- rins in the US [4].

Due to concerns of antibiotic resistance, research has been com- pleted to address overtreatment, undertreatment, and follow-up treat- ment success of GC. Levitt et al. conducted a prospective study of 1260 patients where 6.4% tested positive, and 38% of those patients were not treated empirically. Of the positive women who were untreated, 65% did not follow up for treatment. Conversely, of the 34% of women treated empirically, 88% were negative for gonorrhea or chlamydia [3]. Predictors of sexually transmitted diseases (STDs) have also been identified [5,6]. Women b20 years old were shown to be more likely to acquire gonorrhea, while men with a new or casual partner were at higher risk of gonorrheal infection [5]. Lack of condom use for both men and women increased the risk for gonorrhea, and even with signs of an infection, the individuals continued to be sexually active. Number of lifetime partners had no effect on the acquisition of gonor- rhea, but number of casual or new partners in men increased the risk for gonorrhea [5]. The prevalence of co-infection of gonorrhea and

https://doi.org/10.1016/j.ajem.2018.08.015

0735-6757/(C) 2018

chlamydia in women was found to be 46% in women between the ages of 15-19 [6].

Specific risk factors outlined by the CDC include sexually active women b25 years of age or women over the age of 25 who have a new sexual partner, more than one sexual partners, inconsistent con- dom use, previous or coexisting STDs, exchanging sex for money or drugs and recent travel out of the U.S. with sexual contact [7,8] Risk fac- tors specifically for men include those who have sex with men (MSM), including number of lifetime partners, rate of partner exchange, and fre- quency of unprotected sex, or those with concomitant substance abuse [9]. Additional risk factors of note are penile discharge and patients without insurance [10].

To date, there have been limited studies evaluating the treatment of STDs in correlation with specific risk factors in a clinical setting. The sig- nificance of this information would allow for providers to better identify patients with potential GC in order to streamline antibiotic treatment with the goal to decrease Antibiotic utilization and potential resistance. Therefore, the aim of this study was to determine the incidence of positive assays among patients who receive GC screening in the ED. Secondary ob- jectives included determining the proportion of patients treated empiri- cally with antibiotics and identifying predictors of positive assays.

Materials and methods

This retrospective, single-system, cohort chart review evaluated the incidence of positive chlamydia and gonorrhea assays among patients who receive GC screening in the ED. This study was performed at a health system consisting of a level 1 trauma tertiary-care hospital- based ED (HBED) in a downtown urban area and three free-standing EDs (FSED) located in suburban settings with an estimated 113,000 combined ED visits annually. All adult patients who presented to an ED in the system between January 1, 2016 and December 31, 2016 and underwent GC testing using BD ProbeTec ET(TM) Chlamydia trachomatis and Neisseria gonorrhoeae amplified DNA (GC) assays were identified via microbiology records [11]. Once the source popula- tion was identified, a random number generator in excel was used to randomly select patients for inclusion. Patients were assigned a random number, and then sorted in numerical order. A convenience sample of 499 patients was used for evaluation due to time constraints. This study was approved by the Institutional Review Board and the require- ment of informed consent was waived. Patients were excluded if they were victims of sexual assault, left against medical advice (AMA) or eloped from the ED.

Fig. 1. Flow chart of patient inclusion. Approximately 25% of the source population was randomly selected for inclusion.

Table 1

Demographics.

Table 2

Demographics by ED location.

Total

Negative

Positive

p-Value

Total

Outlying

HBED

p-Value

population N = 490

assay

N = 406

assay N= 84

population N = 490

ED

N = 199

N = 291

Age

28 (8.1)

24.81

28.12

b0.001

Age

28 (8.1)

27.7 (8.2)

27.4

0.679

(6.90)

(8.24)

(8.1)

Gender

b0.001

Gender

0.003

Female

375 (77)

339 (83.5)

36 (43)

Female

375 (77)

166 (83)

209 (72)

Male Race

Caucasian

115 (23)

204 (42)

67 (16.5)

192 (47)

48 (57)

12 (14)

b0.001

Male Race

Caucasian

115 (23)

204 (42)

33 (17)

126 (63)

82 (28)

78 (27)

b0.001

African American

269 (55)

203 (50)

66 (80)

African American

269 (55)

70 (35)

199 (69)

Other

16 (3)

11 (3)

5 (6)

Other

16 (3)

3 (2)

13 (4)

Without insurance

46 (9)

28 (7)

18 (21)

b0.001

Without insurance

46 (9)

15 (7)

31 (11)

0.246

ED location

b0.001

drug allergies

1.000

Hospital-based

291 (59)

226 (56)

65 (77)

NKDA

479 (98)

195 (98)

284 (98)

Freestanding Drug allergies

NKDA

199 (41)

479 (98)

180 (44)

395 (97)

19 (23)

84 (100)

0.22

Allergy change antibiotic selection

Antibiotic selection

11 (2)

4 (2)

7 (2)

b0.001

Allergy change antibiotic

11 (2)

11 (3)

0 (0)

None

212 (43)

117 (59)

95 (33)

selection

Azithro 1 g/Ceftriax

233 (47)

64 (32)

169 (58)

Antibiotic selection

b0.001

Azithro 2 g

9 (2)

1 (0.5)

8 (3)

None

212 (43)

201 (49)

11 (13)

Ceftriax

6 (1)

1 (0.5)

5 (2)

Azithro 1 g/Ceftriax

233 (47)

169 (42)

64 (76)

Ceftriax/Doxy

15 (3)

6 (3)

9 (3)

Azithro 2 g

9 (2)

8 (2)

1 (1)

Other

15 (3)

10 (5)

5 (2)

Ceftriax

6 (1)

6 (1)

0 (0)

Culture collection site

0.006

Ceftriax/Doxy

15 (3)

11 (3)

4 (5)

Urine

12 (2)

5 (2)

7 (2)

Other

15 (3)

11 (3)

4 (5)

Cervix

375 (77)

166 (84)

209 (72)

Culture collection site

b0.001

Urethra

101 (21)

27 (14)

74 (26)

Urine

12 (2)

9 (2)

3 (4)

Pregnancy

11 (2)

6 (4)

5 (2)

0.549

Cervix

375 (77)

339 (84)

36 (43)

HIV

2 (0.4)

0 (0)

2 (1)

0.517

Urethra

101 (21)

57 (14)

44 (53)

Positive assay

84 (17)

19 (9)

65 (22)

b0.001

Pregnancy

11 (2)

8 (2)

3 (8)

0.09

Empiric antibiotic treatment

278 (57)

82 (41)

196 (67)

b0.001

HIV

2 (0.4)

1 (0.2)

1 (1)

0.31

Empiric antibiotic treatment

278 (57)

205 (50)

73 (87)

b0.001

Categorical variables presented as n(%) and analyzed by Chi square or Fishers Exact as ap- propriate. Continuous variables presented as mean (SD) and analyzed by t-test. Level of significance p b 0.05 (two-sided). NKDA: no known drug allergies; HIV: human immuno- deficiency virus; Azithro: Azithromycin oral; Ceftriax: Ceftriaxone 250 mg intramuscular; Doxy: Doxycycline 100 mg oral twice daily for 7 days.

Data collection

Baseline demographics (age, sex, race, ED location, antibiotic drug allergies, Empiric antibiotics administered, and pregnancy status) were collected in addition to the following data: sexual orientation, in- creased risk of infection, additional risk factors, concomitant trichomo- nas, concomitant bacterial vaginosis (BV), health insurance, penile discharge, and diagnosis of pelvic inflammatory disease (PID). Defini- tion of increased risk of infection was any woman N25 years of age with a new sex partner within the past month, more than one sex part- ner, with a sex partner who has concurrent partners, or a sex partner with concurrent STD [5,7,12]. Additional risk factors were defined as any person with any of the following: inconsistent condom use, previ- ous STD within the past 12 months, coexisting STDs, exchanging sex for money or drugs and recent travel out of the U.S. with sexual contacts [7,12]. Coexisting STDs at the time of arrival to the ED included only those positive for trichomonas.

Outcomes

The primary outcome was incidence of positive assay in patients that underwent the GC screening in the ED. Patients were considered to have a positive GC assay if the Method Other Than Acceleration (MOTA) score was either low positive (2000-9999) or positive (10,000 or greater). The secondary outcomes included the proportion of patients cultured that received Empiric treatment and the predictive value of risk factors to identify positive assays. The decision to empirically treat and selec- tion of antibiotics was based on physician discretion. Subgroup analyses

Categorical variables presented as n(%) and analyzed by Chi square or Fishers Exact as ap- propriate. Continuous variables presented as mean (SD) and analyzed by t-test. Level of significance p b 0.05 (two-sided). NKDA: no known drug allergies; HIV: human immuno- deficiency virus; Azithro: Azithromycin oral; Ceftriax: Ceftriaxone 250 mg intramuscular; Doxy: Doxycycline 100 mg oral twice daily for 7 days.

were performed on the patients from the HBED excluding patients who were pregnant.

Statistical analysis

Categorical data were presented as frequency and proportions, and analyzed by chi-square or Fisher’s exact test as appropriate. Odds ratios and 95% confidence intervals are reported to examine the relationship between presence of GC and risk factors. Risk factors found to be signif- icant (p b 0.05) in the univariate analysis for the prediction of positive GC assay were selected for inclusion in a multivariate logistic regression analysis. Logistic regression analysis using elimination based on the probability of the Wald statistic was used to identify effects of risk fac- tors on the likelihood that patients have a positive assay. Statistical anal- ysis was performed using IBM SPSS statistics version 24.0 and the level of significance set at p value b 0.05, two-sided. A statistician aided in the data analysis.

Table 3

Infection.

Not treated with empiric antibiotics

Treated with empiric antibiotics

p-Value

N = 212

N = 278

Gonorrhea

4 (2)

46 (16)

b0.001

Chlamydia

9 (4)

36 (13)

0.001

Gonorrhea and

2 (1)

9 (3)

0.12

Chlamydia

Presented as n(%) and analyzed by Chi square or Fishers Exact as appropriate. Level of sig- nificance p b 0.05 (two-sided).

Table 4

Predictors of positive assay.

Predictor

Negative assay

Positive assay

OR (95% CI)

p-Value

Male gender

67/406 (16)

48/84 (57)

6.75 (4.10, 11.18)

b0.001

Sexual orientation MSM

4/37 (11)

1/33 (3)

0.26 (0.03, 2.43)

0.36

Women age b25

140/339 (41)

29/36 (81)

5.9 (2.51, 13.82)

b0.001

Men age b25 yr

25/67 (37)

23/48 (48)

1.55 (0.73, 3.28)

0.26

Women age N25 yr with increased Infection risk

11/168 (6)

1/7 (14)

2.38 (0.26, 21.54)

0.40

Additional risk factors

131/406 (32)

45/84 (54)

2.42 (1.50, 3.90)

b0.001

Inconsistent condom use

86/406 (22)

33/84 (39)

2.30 (1.40, 3.79)

0.001

Previous STDs

57/406 (14)

20/84 (24)

1.91 (1.07, 3.40)

0.02

HIV

1/406 (0.2)

1/84 (1)

4.88 (0.30, 78.80)

0.31

Concomitant trichomoniasis

35/348 (10)

8/38 (21)

2.38 (1.01, 5.60)

0.05

Concomitant BV

69/324 (21)

13/31 (42)

2.70 (1.25, 5.71)

0.01

Without insurance

28/406 (7)

18/84 (21)

3.7 (1.9, 7.0)

b0.001

Penile discharge

17/67 (25)

38/48 (79)

11.18 (4.6, 27.15)

b0.001

PID

16/339 (5)

8/36 (22)

5.77 (2.27, 14.65)

0.001

Presented as n/n (%) and analyzed by Chi square or Fishers Exact as appropriate. Level of significance p b 0.05 (two-sided). STDs: sexual transmitted diseases; HIV: human immunodefi- ciency virus; BV: bacterial vaginosis; PID: pelvic inflammatory disease.

Results

Over 2000 patients seen in the ED between the dates of January 1, 2016 and December 31, 2016 were screened for STDs. A convenience sample of 499 patients were randomly included in the study with nine patients excluded, including six who eloped from the ED and three who were victims of sexual assault (Fig. 1). The majority of patients were African American (55%), female (77%), and seen in the HBED (59%) (Table 1). Of the 490 patients in the sample, 84 (17%) patients were found to have a positive assay for gonorrhea or chlamydia. Patients with a positive assay were significantly older in age (28.1 +- 8.2 vs. 24.8

+- 6.9 years), African American (80% vs. 50%), males (57% vs. 16.5%),

without health insurance (21% vs. 7%), and were seen in the HBED (77% vs. 56%) compared to those with a negative assay, respectively (Table 1).

Patient demographics varied between those seen at the FSEDs and HBED (Table 2). The majority of patients seen at the FSEDs were female (83%), Caucasian (63% p <= 0.001), with insurance (93%). Patients seen at the HBED were female (72%), African American (69% p <= 0.001), with in- surance (89%). Patients seen at the HBED were more likely to have a positive assay than patients seen at the FSEDs (22% vs 9%, respectively) (p <= 0.001). Regardless of assay results, patients at the HBED and FSED received empiric antibiotic treatment 67% vs 41% of the time, respec- tively (p <= 0.001). Empiric antibiotic treatment was given to 62% of the negative assay patients at the HBED compared to 36% of the negative assay patients seen at the FSEDs (p <= 0.001). Patients seen at the HBED and FSEDs with positive assays received empiric treatment at 86% and 89%, respectively.

Of the 278 patients who were treated empirically, 205 patients (74%) had a negative assay for gonorrhea or chlamydia. Of the 84 pa- tients who were positive for gonorrhea or chlamydia, 73 patients (87%) were treated empirically (Table 1). Patients with a positive assay received significantly more empiric antibiotic treatment than those with a negative assay (p b 0.001). There were 11 patients with a co-infection of gonorrhea and chlamydia, and nine (82%) of those pa- tients were treated empirically with antibiotics (Table 3). Additionally,

patients who were positive for gonorrhea or chlamydia received em- piric antibiotics 92% and 80% of the time, respectively (Table 3).

Univariate analyses of risk factors for the prediction of positive GC assay are presented in Table 4. Male sex, women b25 years of age, addi- tional risk factors, inconsistent condom use, previous STDs, concomitant trichomonas, BV, and PID, penile discharge, and patients without health insurance were all significant in the prediction of a positive assay (p b 0.05).

Regression analysis was performed to determine the effects of sex, additional risk factors, inconsistent condom use, previous STDs, and health insurance on the likelihood of a positive assay in the total study sample (Table 5). The regression model was statistically significant ?2

(3) = 73.2, p b 0.001. Of the six predictor variables included (male gen-

der, additional risk factors, inconsistent condom use, previous STDs, and health insurance), three were significant (male gender, previous STDs, and health insurance). Males were more likely to have a positive assay than females [OR 6.92 (95% CI: 4.08-11.73)]. Patients with a history of previous STDs and those without health insurance were also more likely to have a positive assay, [OR 2.68 (95% CI: 1.40-5.12) and OR 3.44 (95% CI: 1.66-7.12, respectively)].

Regression analysis was performed to determine the effects of sex specific risk factors in the female and male subsets individually (Tables 6 and 7). The regression model in the female subset was signif- icant ?2(3) = 36.6, p b 0.001 (Table 6). Of the seven predictor variables included in the model (women b25 years old, BV, PID, additional risk factor, inconsistent condom use, previous STDs, and health insurance), three were significant (women b25 years old, BV, and PID). Females were more likely to have a positive assay if they were b25 years of age, had the presence of concomitant BV, and PID, [OR 9.13 (95% CI: 3.08-27.05), OR 2.87 (95% CI: 1.27-6.49) and OR 3.51 (95% CI:

1.16-10.65), respectively].

The regression analysis performed to determine the effects of sex specific risk factors in the male subset was significant ?2(2) = 49.8, p b 0.001 (Table 7). Of the five predictor variables included in the model (penile discharge, additional risk factor, inconsistent condom use, previ- ous STDs, and health insurance) two were significant (health insurance and penile discharge). Men without health insurance or with penile

Table 5

Logistic regression total sample (n = 490).

Table 6

Logistic regression female subset (n = 375).

OR (95% CI)

p-Value

OR (95% CI)

p-Value

Male gender

6.92 (4.08, 11.73)

b0.001

Women age b 25 yr

9.13 (3.08, 27.05)

b0.001

Previous STDs

2.68 (1.40, 5.12)

0.003

BV

2.87 (1.27, 6.49)

0.011

Without insurance

3.44 (1.66, 7.12)

0.001

PID

3.51 (1.16, 10.65)

0.027

Significant adjusted Odds Ratio (OR) and 95% Confidence Interval (95% CI) presented for risk factors based on Wald Chi-Square of the regression model. Level of significance p b

0.05 (two-sided). STDs: sexually transmitted diseases.

Significant adjusted Odds Ratio (OR) and 95% Confidence Interval (95% CI) presented for risk factors based on Wald Chi-Square of the regression model. Level of significance p b

0.05 (two-sided). BV: bacterial vaginosis; PID: pelvic inflammatory disease.

Table 7

Logistic regression male subset (n = 115).

OR (95% CI) p-Value

Insurance 14.50 (3.30, 63.74) b0.001

Penile discharge 17.51 (5.96, 51.40) b0.001

Significant adjusted Odds Ratio (OR) and 95% Confidence Interval (95% CI) presented for risk factors based on Wald Chi-Square of the regression model. Level of significance p b

0.05 (two-sided).

discharge were more likely to have a positive assay [OR 14.50 (95% CI: 3.30-63.74) and OR 17.51 (95% CI: 5.96-51.40), respectively].

Additionally, a univariate analysis of risk factors for the prediction of positive GC assay for main hospital ED patients is presented in Table 8. Male sex, women b25 years of age, PID, penile discharge, and patients without health insurance were considered statistically significant in the prediction of a positive assay (p b 0.05).

Discussion

This retrospective cohort chart review describes the incidence of positive GC assay and the proportion of patients treated with empiric antibiotics in patients seen in the health system’s EDs. The study re- vealed that this patient sample had a higher incidence for gonorrhea and chlamydia compared to a previous study with 17% compared to 6.4%, respectively [3]. The proportion of negative assay patients who were treated empirically for gonorrhea or chlamydia were similar to an- other study, at 74% and 88.3%, respectively [3].

This study demonstrated differences in sample populations between those seen at the HBED and FSEDs, and its potential impact on assay re- sults and empiric treatment. A higher incidence of positive assay (22% HBED vs 9% FSED p <=0.001) at the HBED may lead physicians to be more inclined to starting empiric treatment. This is represented by the higher rate of negative assay patients given empiric treatment at the HBED compared to the FSEDs (62% vs 36%, respectively).

Schwebke et al. raised concerns about follow-up in patients with a positive STD result. The authors showed that 30% of patients with a pos- itive STD did not return to clinic within 30 days and identified the po- tential issues for those patients with lack of follow-up [13]. Currently at the research facility, attempts of contact through telephone and let- ters are made to patients with positive assays that are not empirically treated during the ED visit. Being able to identify patients in need of em- piric treatment will not only decrease antibiotic resistance, but improve patient outcomes. Verifying risk factors outlined by the CDC and identi- fying additional high risk patients will help develop a target population for treatment.

Results from this study are in agreement with risk factors outlined by the CDC, including women b25 years of age, additional risk factors in- cluding inconsistent condom use and previous or coexisting STDs in- cluding concomitant trichomonas [7]. Other risk factors per the CDC not in agreement with results of this study included older women who have a new sexual partner or multiple sexual partners, exchanging sex for money or drugs and recent travel out of the U.S. with sexual con- tact. This discrepancy could be attributed to the retrospective chart re- view design of the study as there was limited documentation for these risk factors. Additional risk factors found in this study not previously de- scribed were penile discharge and patients without insurance. When comparing patients in the entire health system versus the HBED (ex- cluding pregnancy and outlying EDs), the statistical difference remained except for concomitant BV or trichomonas.

Finally, the retrospective nature of this study led to a review of phy- sician Prescribing habits. It was observed that 9 (2%) patient received azithromycin 2 g oral as single agent treatment for gonorrhea and chla- mydia. The 2015 CDC STD treatment guidelines recommend combina- tion gentamicin 240 mg IM and azithromycin 2 g oral as alternative treatment of gonorrhea in the event of allergy or adverse reaction [7]. Education was provided to the ED physicians regarding the treatment recommendation for gonorrhea and chlamydia.

Limitations

The primary limitation is use of a retrospective design, leading to op- portunity for missing and incomplete data, which could have led to var- iations in results. We attempted to reconcile this limitation by including health system data from FSED’s covering a radius of 12 miles from the HBED [14,15]. This increased the number of patients available to include in the study, which would minimize the impact of missing or incom- plete data. The study sample was the largest of its kind as evidenced in the literature and first to evaluate predictors of a positive assay in a clinical setting. Additionally, including patients from the FSEDs pro- vided a more diverse sample population. As mentioned previously, the design could have led to limited documentation of risk factors. Condom use was not well documented in all charts and trichomonas was not tested in all men.

There are several additional limitations to this study. Some patients could have a false positive or negative based on the specificity and sen- sitivity of the gonorrhea and chlamydia assays. The assay used has a 96% sensitivity and 98.8% specificity for gonorrhea and 90.7% sensitivity and 96.6% specificity for chlamydia. Of note, patients with a urine specimen have a higher incidence of false negatives than those whose specimen is collected via the cervix or urethra. Urine samples have a 13-17% rate of false negatives [11]. Only 2% (n = 12) of our sample population had urine as the specimen collection source, therefore this limitation

Table 8

Predictors of positive assay hospital-based ED (n = 291).

Predictor Negative assay Positive assay OR (95% CI) p-Value

Male gender 45/223 (20) 37/63 (59) 5.63 (3.09, 10.24) b0.001

Sexual orientation MSM 2/22 (9) 0 (0) 0 (0) 0.22

Women age b 25 yr 76/178 (43) 20/26 (77) 4.47 (1.71, 11.68) 0.001

Men age b 25 yr 16/45 (36) 17/37 (46) 1.54 (0.63, 3.75) 0.34

Women age N25 yr with increased infection risk 5/86 (6) 1/6 (17) 3.24 (0.31, 33.28) 0.34

Additional risk factors 90/223 (40) 31/63 (49) 1.43 (0.82, 2.51) 0.21

Inconsistent condom use 55/223 (25) 21/63 (33) 1.53 (0.83, 2.80) 0.17

Previous STDs 47/223 (21) 15/63 (24) 1.17 (0.60, 2.27) 0.64

HIV 1/223 (0.4) 1/63 (1.6) 3.58 (0.22, 58.07) 0.39

Concomitant trichomoniasis 31/185 (17) 7/27 (26) 1.73 (0.67, 4.44) 0.28

Concomitant BV 44/171 (26) 9/21 (43) 2.16 (0.85, 5.48) 0.10

Without insurance 15/223 (7) 16/63 (25) 0.21 (0.10, 0.46) b0.001

Penile discharge 14/45 (31) 30/37 (81) 9.49 (3.36, 26.76) b0.001

PID 10/178 (6) 5/26 (19) 4.00 (1.25, 12.83) 0.03

Presented as n/n (%) and analyzed by Chi square or Fishers Exact as appropriate. Level of significance p b 0.05 (two-sided). STDs: sexual transmitted diseases; HIV: human immunodefi- ciency virus; BV: bacterial vaginosis; PID: pelvic inflammatory disease.

would not likely have affected the results. Antibiotic treatment and se- lection was left to the discretion of the physician. Decision to treat and antibiotic selection may have varied based on the treating physician. Fi- nally, patient allergies may also have impacted empiric treatment for patients with suspected STDs. It was discovered while completing the chart review that some patients were offered empiric antibiotics, but refused.

Conclusion

According to this evaluation within a health-system ED setting, we found a higher incidence of positive GC assays for those patients with suspected infection than previously reported in the literature. Addition- ally, the majority of those patients found to have a positive assay re- ceived empiric therapy. This analysis is in agreement with the majority of risk factors outlined by the CDC. Furthermore, additional risk factors not reported by the CDC were identified, including men pre- senting with penile discharge and patients without health insurance. Further prospective research is needed to validate these findings. To our knowledge, this is the first study to evaluate STDs in both men and women in the ED population, and risk factors not previously re- ported by the CDC were identified.

Declaration of interest

Authors of this article have nothing to disclose concerning possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter of this presentation.

Funding

This research did not receive any specific grant from funding agen- cies in the public, commercial, or not-for-profit sectors.

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