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255 Prevalence of Gonorrhea and Chlamydia in the Emergency Department and Effectiveness of Presumptive Treatment
Research Forum Abstracts
253
Are We Acting Appropriately by Presumptively Treating Men More Aggressively than Women for Gonorrhea and Chlamydia in the Urban Emergency Department?
Wilson SP, Iordanova R, Knych M, Mahan M, Vohra T/Henry Ford Hospital System, Detroit, MI
Study Objectives: The 2010 Centers for Disease Control guidelines recommend presumptive treatment of Neisseria gonorrhea and Chlamydia trachomatis for men with urethritis and women with cervicitis who are at increased risk for sexually transmitted infection (STI) and in whom reliable follow-up cannot be ensured. We sought to compare the proportion of men and women tested for STI that accurately received presumptive antimicrobial treatment. Methods: A retrospective chart review was performed on 639 patient encounters that underwent both gonorrhea and chlamydia nucleic acid amplification testing (NAAT) during a single month in July of 2012 at an urban Level 1 trauma center emergency department. Each encounter was reviewed for NAAT result, if presumptive treatment was rendered and the accuracy of treatment. Presumptive antimicrobial treatment was considered accurate if a NAAT result was positive and appropriate antimicrobial treatment was rendered. Wilcoxon signed-rank test was used to compare average age of men and women tested. Chi-square and Fisher’s exact tests were used to compare the proportion of men and women with positive NAAT result, those provided presumptive treatment, and the accuracy of those treated. Results: There were 639 patient encounters reviewed. There were 82 (12.8%) men and 557 (88.9%) women. The average age of men was significantly older than women, 29.5 versus 26.3 years (P<.031). Gonorrhea was more prevalent among men, 17.1% (N¼14) versus 3.2% (N¼18) (P<.001). Chlamydia prevalence was not statistically different between men and women, 14.6% (N¼12) versus 10.6% (N¼59) (P¼.277). Men received presumptive treatment more frequently, 82.9% (N¼68) versus 37.7% (N¼210) (P<.001). Men were more frequently provided accurate presumptive treatment, 24.4% (N¼20) versus 7.7% (N¼43) (P<.001). Conclusion: Presumptive treatment for gonorrhea and chlamydia was more frequent and more accurate in men tested for STI when compared to women. Presumptive treatment may be more appropriate in men than in women. However, the significant morbidity associated with these diseases makes undertreatment concerning in women. Future studies should evaluate use of an accurate rapid assay or reliable follow-up system, which may allow for more accurate treatment in women.
254
Antibiogram Does Not Predict Escherichia Coli Resistance to Ciprofloxacin in Women Presenting With Uncomplicated Urinary Tract Infection to an Urban, Academic Medical Center Emergency Department: A Prospective, Observational Study
Al-Salamah T, Hines MC, Hayes B, Heil E, Witting M, Johnson JK, Winters M, Gaasch W, Mallemat H/University of Maryland Medical Center, Baltimore, MD
Study Objectives: The Infectious Diseases Society of America guidelines recommend that a microbe be <20% resistant to a specific antibiotic per local antibiogram in order for that antibiotic to be used. Our tertiary care hospital antibiogram, which includes isolates from complicated infections, reports a frequency of Escherichia coli (E. coli) resistance to ciprofloxacin exceeding 40%. However, this pattern may not represent isolates from uncomplicated infections. The objective of this study is to compare the frequency of E. coli resistance to ciprofloxacin from positive urine cultures in women presenting to our tertiary care hospital emergency department (ED) with a suspected uncomplicated urinary tract infection (uUTI) with the resistance frequency from our hospital antibiogram. Methods: The study design is a single center, prospective, observational study in an urban, academic medical center ED. Female patients ages 19 years and older with acute onset of urinary frequency, urgency, and/or dysuria with a positive urinalysis and clinically suspected uncomplicated cystitis or pyelonephritis were consented for study inclusion. The following patients were excluded: current pregnancy, known urological abnormalities or comorbidities, indwelling Foley catheter, Foley catheter removed within previous 14 days, known history of kidney stones, diagnosed diabetes mellitus, non-English speaking, trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis within previous six months, human immunodeficiency virus with no CD4 count on file or CD4 count <350 cells/mm3, or transferred from another health care facility. Our sample size was intended to detect, with 90% power and 5% significance, a relative decrease of 50% from our hospital’s 42% ciprofloxacin resistance, published in 2012. We compared proportions using Fisher’s exact test and calculated the confidence
Volume 64, no. 4s : October 2014
interval using exact binomial calculation. Bacteria colony counts of 10,000 colony forming units/ml are reported as a positive culture. Urine cultures containing three or more organisms of approximately the same quantitation are reported as mixed microbial flora, and were excluded, as it is standard practice by the lab to do no further workup on those samples. Antimicrobial susceptibility testing was performed using Vitek2 (Biomerieux, Durham NC). Results: Among 106 patients screened, 59 met eligibility criteria, 57 were consented, and 30 cultures positive for E. coli were included in the analysis. Among patients with uUTIs, 0/30 E. coli isolates were resistant to ciprofloxacin (0% [95% CI 0-10%]). This proportion was significantly less than the antibiogram rate of 42% (P<.001). Conclusion: In this study, E. coli isolated from urine of women in good health presenting to the ED with a suspected uUTI exhibited a far lower resistance rate to ciprofloxacin than what is reported on the institution’s antibiogram. This suggests that emergency physicians may treat this group of patients with more affordable antimicrobials, while ensuring minimal to no compromise in treatment efficacy.
255
Prevalence of Gonorrhea and Chlamydia in the Emergency Department and Effectiveness of Presumptive Treatment
Wilson SP, Knych M, Iordanova R, Mahan M, Vohra T/Henry Ford Hospital System, Detroit, MI
Study Objectives: Neisseria gonorrhea and Chlamydia trachomatis are a major cause of pelvic inflammatory disease, ectopic pregnancy and infertility. The indolent nature of these infections and significant time delay of the current gold standard diagnostic test, the nucleic amplification test (NAAT) make definitive diagnosis of these common sexually transmitted infections (STI) on the initial presentation to emergency department (ED) impossible. Therefore, the most recent 2010 Centers for Disease Control guidelines recommend presumptive treatment in women with cervicitis and men with urethritis who are at an increased risk for STI and in whom follow-up cannot be ensured. Patients seen in urban EDs often have increased risk and difficulty with follow-up, therefore, presumptive therapy for all patients with a concern for STI is thought to be the common practice in this setting. This potential overuse of antibiotics is particularly concerning due to growing resistance to antimicrobials by gonorrhea over the last decade. We sought to determine the proportion of patients with gonorrhea and chlamydia and the accuracy of presumptive antimicrobial treatment. Methods: A retrospective chart review was performed on 639 patient encounters that underwent both gonorrhea and chlamydia testing during a single month in July 2012 at an urban Level 1 Trauma Center ED. Each encounter was reviewed for the NAAT result. A patient was considered positive for STI if they had a positive NAAT for either gonorrhea or chlamydia. Patient encounters were also reviewed for receiving presumptive treatment during the initial patient encounter. Presumptive antimicrobial treatment was considered accurate if a NAAT result was positive and appropriate antimicrobial treatment was rendered. Descriptive statistics were used. Results: A total of 639 patient encounters were reviewed; 557 (87.2%) were female and the median age was 23 years old. Thirty-two (5.0%) were positive for gonorrhea and 71 (11.1%) were positive for chlamydia. Ninety-one (14.2%) were considered positive for STI. Two hundred seventy-eight (43.5%) patients received presumptive antimicrobial treatment. Of those receiving presumptive treatment, 63 (22.7%) were STI positive while 215 (77.3%) had no detectable STI. In the untreated patients, 28 (4.4%) were STI positive. Conclusion: Over three quarters of patients who received presumptive antibiotics were overtreated, yet nearly five percent of the tested population missed treatment. There appears to be a significant opportunity for more targeted diagnosis and treatment of a disease with significant morbidity. Future studies may focus on developing a point of care test or rapid assay to promote antimicrobial stewardship and potential cost savings.
256
An Examination of Causative Bacteria and Susceptibility Patterns in Urinary Isolates Obtained in the Emergency Department and Immediate Care Setting
Cirone M, Probst B/Advocate Christ Medical Center, Oak Lawn, IL; Loyola Stritch School of Medicine, Maywood, IL
Background: There are an estimated 2.7 million emergency department (ED) visits each year for urinary tract infections (UTI) in the United States. ED and outpatient
Annals of Emergency Medicine S91
253
Are We Acting Appropriately by Presumptively Treating Men More Aggressively than Women for Gonorrhea and Chlamydia in the Urban Emergency Department?
Wilson SP, Iordanova R, Knych M, Mahan M, Vohra T/Henry Ford Hospital System, Detroit, MI
Study Objectives: The 2010 Centers for Disease Control guidelines recommend presumptive treatment of Neisseria gonorrhea and Chlamydia trachomatis for men with urethritis and women with cervicitis who are at increased risk for sexually transmitted infection (STI) and in whom reliable follow-up cannot be ensured. We sought to compare the proportion of men and women tested for STI that accurately received presumptive antimicrobial treatment. Methods: A retrospective chart review was performed on 639 patient encounters that underwent both gonorrhea and chlamydia nucleic acid amplification testing (NAAT) during a single month in July of 2012 at an urban Level 1 trauma center emergency department. Each encounter was reviewed for NAAT result, if presumptive treatment was rendered and the accuracy of treatment. Presumptive antimicrobial treatment was considered accurate if a NAAT result was positive and appropriate antimicrobial treatment was rendered. Wilcoxon signed-rank test was used to compare average age of men and women tested. Chi-square and Fisher’s exact tests were used to compare the proportion of men and women with positive NAAT result, those provided presumptive treatment, and the accuracy of those treated. Results: There were 639 patient encounters reviewed. There were 82 (12.8%) men and 557 (88.9%) women. The average age of men was significantly older than women, 29.5 versus 26.3 years (P<.031). Gonorrhea was more prevalent among men, 17.1% (N¼14) versus 3.2% (N¼18) (P<.001). Chlamydia prevalence was not statistically different between men and women, 14.6% (N¼12) versus 10.6% (N¼59) (P¼.277). Men received presumptive treatment more frequently, 82.9% (N¼68) versus 37.7% (N¼210) (P<.001). Men were more frequently provided accurate presumptive treatment, 24.4% (N¼20) versus 7.7% (N¼43) (P<.001). Conclusion: Presumptive treatment for gonorrhea and chlamydia was more frequent and more accurate in men tested for STI when compared to women. Presumptive treatment may be more appropriate in men than in women. However, the significant morbidity associated with these diseases makes undertreatment concerning in women. Future studies should evaluate use of an accurate rapid assay or reliable follow-up system, which may allow for more accurate treatment in women.
254
Antibiogram Does Not Predict Escherichia Coli Resistance to Ciprofloxacin in Women Presenting With Uncomplicated Urinary Tract Infection to an Urban, Academic Medical Center Emergency Department: A Prospective, Observational Study
Al-Salamah T, Hines MC, Hayes B, Heil E, Witting M, Johnson JK, Winters M, Gaasch W, Mallemat H/University of Maryland Medical Center, Baltimore, MD
Study Objectives: The Infectious Diseases Society of America guidelines recommend that a microbe be <20% resistant to a specific antibiotic per local antibiogram in order for that antibiotic to be used. Our tertiary care hospital antibiogram, which includes isolates from complicated infections, reports a frequency of Escherichia coli (E. coli) resistance to ciprofloxacin exceeding 40%. However, this pattern may not represent isolates from uncomplicated infections. The objective of this study is to compare the frequency of E. coli resistance to ciprofloxacin from positive urine cultures in women presenting to our tertiary care hospital emergency department (ED) with a suspected uncomplicated urinary tract infection (uUTI) with the resistance frequency from our hospital antibiogram. Methods: The study design is a single center, prospective, observational study in an urban, academic medical center ED. Female patients ages 19 years and older with acute onset of urinary frequency, urgency, and/or dysuria with a positive urinalysis and clinically suspected uncomplicated cystitis or pyelonephritis were consented for study inclusion. The following patients were excluded: current pregnancy, known urological abnormalities or comorbidities, indwelling Foley catheter, Foley catheter removed within previous 14 days, known history of kidney stones, diagnosed diabetes mellitus, non-English speaking, trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis within previous six months, human immunodeficiency virus with no CD4 count on file or CD4 count <350 cells/mm3, or transferred from another health care facility. Our sample size was intended to detect, with 90% power and 5% significance, a relative decrease of 50% from our hospital’s 42% ciprofloxacin resistance, published in 2012. We compared proportions using Fisher’s exact test and calculated the confidence
Volume 64, no. 4s : October 2014
interval using exact binomial calculation. Bacteria colony counts of 10,000 colony forming units/ml are reported as a positive culture. Urine cultures containing three or more organisms of approximately the same quantitation are reported as mixed microbial flora, and were excluded, as it is standard practice by the lab to do no further workup on those samples. Antimicrobial susceptibility testing was performed using Vitek2 (Biomerieux, Durham NC). Results: Among 106 patients screened, 59 met eligibility criteria, 57 were consented, and 30 cultures positive for E. coli were included in the analysis. Among patients with uUTIs, 0/30 E. coli isolates were resistant to ciprofloxacin (0% [95% CI 0-10%]). This proportion was significantly less than the antibiogram rate of 42% (P<.001). Conclusion: In this study, E. coli isolated from urine of women in good health presenting to the ED with a suspected uUTI exhibited a far lower resistance rate to ciprofloxacin than what is reported on the institution’s antibiogram. This suggests that emergency physicians may treat this group of patients with more affordable antimicrobials, while ensuring minimal to no compromise in treatment efficacy.
255
Prevalence of Gonorrhea and Chlamydia in the Emergency Department and Effectiveness of Presumptive Treatment
Wilson SP, Knych M, Iordanova R, Mahan M, Vohra T/Henry Ford Hospital System, Detroit, MI
Study Objectives: Neisseria gonorrhea and Chlamydia trachomatis are a major cause of pelvic inflammatory disease, ectopic pregnancy and infertility. The indolent nature of these infections and significant time delay of the current gold standard diagnostic test, the nucleic amplification test (NAAT) make definitive diagnosis of these common sexually transmitted infections (STI) on the initial presentation to emergency department (ED) impossible. Therefore, the most recent 2010 Centers for Disease Control guidelines recommend presumptive treatment in women with cervicitis and men with urethritis who are at an increased risk for STI and in whom follow-up cannot be ensured. Patients seen in urban EDs often have increased risk and difficulty with follow-up, therefore, presumptive therapy for all patients with a concern for STI is thought to be the common practice in this setting. This potential overuse of antibiotics is particularly concerning due to growing resistance to antimicrobials by gonorrhea over the last decade. We sought to determine the proportion of patients with gonorrhea and chlamydia and the accuracy of presumptive antimicrobial treatment. Methods: A retrospective chart review was performed on 639 patient encounters that underwent both gonorrhea and chlamydia testing during a single month in July 2012 at an urban Level 1 Trauma Center ED. Each encounter was reviewed for the NAAT result. A patient was considered positive for STI if they had a positive NAAT for either gonorrhea or chlamydia. Patient encounters were also reviewed for receiving presumptive treatment during the initial patient encounter. Presumptive antimicrobial treatment was considered accurate if a NAAT result was positive and appropriate antimicrobial treatment was rendered. Descriptive statistics were used. Results: A total of 639 patient encounters were reviewed; 557 (87.2%) were female and the median age was 23 years old. Thirty-two (5.0%) were positive for gonorrhea and 71 (11.1%) were positive for chlamydia. Ninety-one (14.2%) were considered positive for STI. Two hundred seventy-eight (43.5%) patients received presumptive antimicrobial treatment. Of those receiving presumptive treatment, 63 (22.7%) were STI positive while 215 (77.3%) had no detectable STI. In the untreated patients, 28 (4.4%) were STI positive. Conclusion: Over three quarters of patients who received presumptive antibiotics were overtreated, yet nearly five percent of the tested population missed treatment. There appears to be a significant opportunity for more targeted diagnosis and treatment of a disease with significant morbidity. Future studies may focus on developing a point of care test or rapid assay to promote antimicrobial stewardship and potential cost savings.
256
An Examination of Causative Bacteria and Susceptibility Patterns in Urinary Isolates Obtained in the Emergency Department and Immediate Care Setting
Cirone M, Probst B/Advocate Christ Medical Center, Oak Lawn, IL; Loyola Stritch School of Medicine, Maywood, IL
Background: There are an estimated 2.7 million emergency department (ED) visits each year for urinary tract infections (UTI) in the United States. ED and outpatient
Annals of Emergency Medicine S91