- Email: [email protected]
334 Lemierre's Syndrome: A Forgotten Complication of Acute Pharyngitis
Research Forum Abstracts inversely correlated to the rates of admission (r⫽-0.24), and AIDS patients had more admissions (mean 1.9) than patients who had CD4⬎200 (mean 1.1), p⬍0.001. Surprisingly, AIDS patients had fewer ED visits (mean 2.9) compared to those with CD4⬎200 (mean 4.6), p⬍0.001. During the study period following their diagnosis, the majority of patients (62.4%) made at least one visit to the ED and 60% had at least one hospital admission. When evaluating exclusively the first year after diagnosis, 50.4% of patients had an additional ED visit (mean 1.9 visits), and 54.4% were admitted (mean admissions 0.91), compared to an annual ED admission rate of 21.4% in 2006 and 16.8% in 2010 for our hospital. Out of the 107 admissions that occurred in the year following diagnosis, 31 (29%) were for pneumonia followed by 14 (13%) for fever. Conclusion: To our knowledge, this is the first data on ED utilization and hospital admissions for patients newly diagnosed with HIV as a result of an ED rapid HIV testing program. Patients with new diagnoses in the ED become frequent users of the ED and hospital services. The inverse correlation between CD4 count and rates of hospitalization as well as the correlation between a diagnosis of AIDS and hospitalization provide a public health and economic incentive for early diagnosis. Additionally, hospitals may use this information to support a business model for the establishment of HIV testing in EDs as it may increase reimbursements for linkage to care and subsequent hospitalizations.
334
Lemierre’s Syndrome: A Forgotten Complication of Acute Pharyngitis
Bicker E, Krivochenitser R, Flannigan M, Whalen D, Jones JS/MSU College of Human Medicine, Grand Rapids, MI; Grand Rapids MEP/Michigan State University, Grand Rapids, MI; Saint Mary’s Health Care, Grand Rapids, MI
Study Objectives: Lemierre’s syndrome is characterized by a history of an oropharyngeal infection, radiologic evidence of a secondary septic thrombophlebitis of the internal jugular vein, and resultant metastatic complications. This syndrome is most often a result of a Fusobacterium necrophorum infection a gram negative anaerobe. Lemierre’s syndrome is being increasingly recognized as an important complication from Streptococcus-negative pharyngitis, which may be a result of more judicious prescribing habits of antibiotics for pharyngitis by physicians in recent decades. The objective of this study is to assess the incidence, clinical characteristics, and microbiologic source for patients diagnosed with Lemierre’s syndrome from 4 academic medical centers. Methods: This was a retrospective analysis using a database of all patients presenting to the emergency department at 4 urban U.S. Academic medical centers, including one children’s hospital during a five-year study period. Eligible patients fulfilled the following criteria: 1) history of an oropharyngeal infection; 2) internal jugular vein thrombophlebitis; and 3) an infectious disease specialist diagnosing Lemierre’s syndrome. Clinical records were reviewed for demographic data, presenting symptoms, initial vital signs, evaluation by an emergency physician, basic laboratory and microbiologic data. Metastatic complications, hospital length of stay, complications, and mortality were assessed as well. Descriptive statistics (frequency tables, confidence intervals) will be used to summarize the data. Quantitative data were expressed as the mean ⫹ SEM, while nominal data were expressed as a percentage (frequency tables). Results: During the study period, 16 patients with Lemierre’s syndrome presented to one of the participating hospitals; 9 (56%) were female. The majority (75%) were ⬍ 24 years of age; mean age 25.8 years (range 12-76). Typical presentation was substantial increase in fever (39-41o), often associated with rigors, approximately 5 days after onset of sore throat. The majority of patients presented with cervical adenopathy (75%), lateral neck pain and swelling (69%), and arthralgia (69%). Diagnosis was confirmed by neck or chest CT with contrast (50%), ultrasonography (44%), or MRI (6%). Blood cultures isolated Fusobacterium (50%), methicillin-resistant Staphylococcus aureus (25%), anaerobic Streptococcus (12%), and Bacteroides (6%). All patients were given anticoagulation for septic emboli, broad spectrum antibiotics (7-18 days); 31% required surgery for drainage of abscess. All patients survived; the average length of hospital stay was 12 days (range 7-32). Complications included pulmonary septic emboli (63%), liver/splenic abscess (25%), septic arthritis (19%), septic shock (19%), and renal failure (13%). Conclusion: Emergency clinicians should recognize the red flags for Lemierre’s syndrome in adolescent and young adults with pharyngitis. These include worsening or prolonged symptoms, rigors, and unilateral neck swelling. Methicillin-resistant Staphylococcus aureus (MRSA) is increasingly being recognized as a cause of this syndrome.
Volume , . : October
335
Predictors of Gonorrhea and Chlamydia in Emergency Department Patients
Mitchell PM, White LF, Rahimi LM, Jenkins D, Schechter-Perkins EM/Boston University School of Medicine, Boston, MA
Study Objectives: To describe behavioral risk factors and characteristics of ED patients seeking evaluation for suspected sexually transmitted diseases (STDs); to evaluate the diagnostic ability of the 2010 CDC high risk definition to identify patients who test positive (⫹) for either Neisseria gonnorheae (NG) or Chlamydia trachomatis (CT); and to identify characteristics most predictive of testing (⫹). Methods: A retrospective case control chart review was conducted. A random sample of 500 cases and 500 controls were selected from all patients who had a test for NG or CT sent from the ED of an urban, academic, level 1 trauma center from 1/1/10-6/30/11. Exclusion criteria were: age ⬍15, sexual assault, eloped or left against medical advice, and repeat visits 3 weeks post (⫹) test. We defined high risk patients based on CDC 2010 STD Guidelines as those with urethritis or cervicitis and at least one of the following: age ⬍ 25, new or multiple partners, or unprotected sex. We defined behavioral risk factors as: history or reported exposure to STD, unprotected sex, or new/multiple sexual partners; male genital symptoms as: urethral discharge, dysuria, testicular or prostate tenderness, lesions/swelling/rash, or genital burning/itching; female genital symptoms as: vaginal/cervical discharge or bleeding, dysuria, dyspareunia, adnexal tenderness, cervical motion tenderness, lesions/swelling/ rash, or genital burning/itching; and systemic symptoms as: fever ⬎100.4, abdominal pain, or abdominal tenderness. Data abstracted from ED medical record included demographics, chief complaint, and history and physical exam findings. Double data abstraction on a 10% random sample was completed to calculate interrater reliability. Descriptive statistics, frequencies and logistic regression modeling using generalized estimating equations to account for repeat visits, were used for analysis. Results: In 18 months, 6997 tests were sent for NG or CT. Among 1000 case and control visits were 959 unique patients. Kappa was 0.92. Demographics were: 61% age⬍25, 61% female, 90% English, 68% Black, 19% Hispanic, and 8% White. Only 24% had a chief complaint of STD check and 17% were completely unrelated to STD, abdominal pain, or genital complaint. Overall, cases v. controls had: behavioral risk factors, 70% v. 42% (p ⬍0.001), genital symptoms 57% v. 55% (p⫽0.53), and systemic symptoms 38% v. 47% (p⫽ 0.003). The 2010 CDC high risk definition had sensitivity and specificity of 0.50 and 0.68, respectively for determining case status. In multivariate analysis adjusted for race/ethnicity and language, cases were more likely than controls to: be age ⬍ 25 (OR⫽2.58, 95% CI: 1.91-3.50), have behavioral risk factors (for males OR⫽4.06, 95% CI: 2.43-6.80, for females OR⫽1.85 95% CI: 1.30-2.62), if female to not have genital symptoms (OR⫽0.68, 95% CI: 0.49-0.95), and if male to have genital symptoms (OR⫽2.06, 95% CI: 1.26-3.38). Systemic symptoms were not significantly associated with case status (OR⫽1.18, 95% CI: 0.85-1.66). Conclusion: CDC guidelines for determining high risk patients were neither sensitive nor specific for determining eventual (⫹) tests for NG or CT. Our findings are consistent with CDC high risk definition in that age and behavioral risk factors are associated with testing (⫹). However the correlation between genital symptoms and testing (⫹) varied dramatically by sex, implying that high risk should be defined separately for each sex.
336
Emergency Department Compliance With CDC Guidelines for Discharge Instructions for Patients With Suspected Sexually Transmitted Infections
Jenkins D, Rahimi LM, Mitchell PM, White LF, Schechter-Perkins EM/Boston University School of Medicine, Boston, MA
Study Objective: The 2010 CDC STD Treatment Guidelines recommend that all patients seeking evaluation and/or treatment for sexually transmitted diseases (STDs) be given appropriate discharge instructions, including: abstain from sexual activity until treatment completed and partners treated; use barrier precautions; and recommendation for HIV testing. The purpose of this study was to evaluate the frequency of ED providers complying with these guidelines. Methods: A retrospective case control chart review was conducted. A random sample of 500 cases (positive for at least one of Neisseriae gonnorhea or Chlamydia trachomatis) and 500 controls were selected from all patients who had Neisseriae gonorrhea or Chlamydia trachomatis tests sent from the ED of an academic, urban, level 1 trauma center, from 1/1/10-6/30/11. Exclusion criteria were: age ⬍15, sexual assault, eloped or left against medical advice, and repeat visits 3 weeks post positive
Annals of Emergency Medicine S119
334
Lemierre’s Syndrome: A Forgotten Complication of Acute Pharyngitis
Bicker E, Krivochenitser R, Flannigan M, Whalen D, Jones JS/MSU College of Human Medicine, Grand Rapids, MI; Grand Rapids MEP/Michigan State University, Grand Rapids, MI; Saint Mary’s Health Care, Grand Rapids, MI
Study Objectives: Lemierre’s syndrome is characterized by a history of an oropharyngeal infection, radiologic evidence of a secondary septic thrombophlebitis of the internal jugular vein, and resultant metastatic complications. This syndrome is most often a result of a Fusobacterium necrophorum infection a gram negative anaerobe. Lemierre’s syndrome is being increasingly recognized as an important complication from Streptococcus-negative pharyngitis, which may be a result of more judicious prescribing habits of antibiotics for pharyngitis by physicians in recent decades. The objective of this study is to assess the incidence, clinical characteristics, and microbiologic source for patients diagnosed with Lemierre’s syndrome from 4 academic medical centers. Methods: This was a retrospective analysis using a database of all patients presenting to the emergency department at 4 urban U.S. Academic medical centers, including one children’s hospital during a five-year study period. Eligible patients fulfilled the following criteria: 1) history of an oropharyngeal infection; 2) internal jugular vein thrombophlebitis; and 3) an infectious disease specialist diagnosing Lemierre’s syndrome. Clinical records were reviewed for demographic data, presenting symptoms, initial vital signs, evaluation by an emergency physician, basic laboratory and microbiologic data. Metastatic complications, hospital length of stay, complications, and mortality were assessed as well. Descriptive statistics (frequency tables, confidence intervals) will be used to summarize the data. Quantitative data were expressed as the mean ⫹ SEM, while nominal data were expressed as a percentage (frequency tables). Results: During the study period, 16 patients with Lemierre’s syndrome presented to one of the participating hospitals; 9 (56%) were female. The majority (75%) were ⬍ 24 years of age; mean age 25.8 years (range 12-76). Typical presentation was substantial increase in fever (39-41o), often associated with rigors, approximately 5 days after onset of sore throat. The majority of patients presented with cervical adenopathy (75%), lateral neck pain and swelling (69%), and arthralgia (69%). Diagnosis was confirmed by neck or chest CT with contrast (50%), ultrasonography (44%), or MRI (6%). Blood cultures isolated Fusobacterium (50%), methicillin-resistant Staphylococcus aureus (25%), anaerobic Streptococcus (12%), and Bacteroides (6%). All patients were given anticoagulation for septic emboli, broad spectrum antibiotics (7-18 days); 31% required surgery for drainage of abscess. All patients survived; the average length of hospital stay was 12 days (range 7-32). Complications included pulmonary septic emboli (63%), liver/splenic abscess (25%), septic arthritis (19%), septic shock (19%), and renal failure (13%). Conclusion: Emergency clinicians should recognize the red flags for Lemierre’s syndrome in adolescent and young adults with pharyngitis. These include worsening or prolonged symptoms, rigors, and unilateral neck swelling. Methicillin-resistant Staphylococcus aureus (MRSA) is increasingly being recognized as a cause of this syndrome.
Volume , . : October
335
Predictors of Gonorrhea and Chlamydia in Emergency Department Patients
Mitchell PM, White LF, Rahimi LM, Jenkins D, Schechter-Perkins EM/Boston University School of Medicine, Boston, MA
Study Objectives: To describe behavioral risk factors and characteristics of ED patients seeking evaluation for suspected sexually transmitted diseases (STDs); to evaluate the diagnostic ability of the 2010 CDC high risk definition to identify patients who test positive (⫹) for either Neisseria gonnorheae (NG) or Chlamydia trachomatis (CT); and to identify characteristics most predictive of testing (⫹). Methods: A retrospective case control chart review was conducted. A random sample of 500 cases and 500 controls were selected from all patients who had a test for NG or CT sent from the ED of an urban, academic, level 1 trauma center from 1/1/10-6/30/11. Exclusion criteria were: age ⬍15, sexual assault, eloped or left against medical advice, and repeat visits 3 weeks post (⫹) test. We defined high risk patients based on CDC 2010 STD Guidelines as those with urethritis or cervicitis and at least one of the following: age ⬍ 25, new or multiple partners, or unprotected sex. We defined behavioral risk factors as: history or reported exposure to STD, unprotected sex, or new/multiple sexual partners; male genital symptoms as: urethral discharge, dysuria, testicular or prostate tenderness, lesions/swelling/rash, or genital burning/itching; female genital symptoms as: vaginal/cervical discharge or bleeding, dysuria, dyspareunia, adnexal tenderness, cervical motion tenderness, lesions/swelling/ rash, or genital burning/itching; and systemic symptoms as: fever ⬎100.4, abdominal pain, or abdominal tenderness. Data abstracted from ED medical record included demographics, chief complaint, and history and physical exam findings. Double data abstraction on a 10% random sample was completed to calculate interrater reliability. Descriptive statistics, frequencies and logistic regression modeling using generalized estimating equations to account for repeat visits, were used for analysis. Results: In 18 months, 6997 tests were sent for NG or CT. Among 1000 case and control visits were 959 unique patients. Kappa was 0.92. Demographics were: 61% age⬍25, 61% female, 90% English, 68% Black, 19% Hispanic, and 8% White. Only 24% had a chief complaint of STD check and 17% were completely unrelated to STD, abdominal pain, or genital complaint. Overall, cases v. controls had: behavioral risk factors, 70% v. 42% (p ⬍0.001), genital symptoms 57% v. 55% (p⫽0.53), and systemic symptoms 38% v. 47% (p⫽ 0.003). The 2010 CDC high risk definition had sensitivity and specificity of 0.50 and 0.68, respectively for determining case status. In multivariate analysis adjusted for race/ethnicity and language, cases were more likely than controls to: be age ⬍ 25 (OR⫽2.58, 95% CI: 1.91-3.50), have behavioral risk factors (for males OR⫽4.06, 95% CI: 2.43-6.80, for females OR⫽1.85 95% CI: 1.30-2.62), if female to not have genital symptoms (OR⫽0.68, 95% CI: 0.49-0.95), and if male to have genital symptoms (OR⫽2.06, 95% CI: 1.26-3.38). Systemic symptoms were not significantly associated with case status (OR⫽1.18, 95% CI: 0.85-1.66). Conclusion: CDC guidelines for determining high risk patients were neither sensitive nor specific for determining eventual (⫹) tests for NG or CT. Our findings are consistent with CDC high risk definition in that age and behavioral risk factors are associated with testing (⫹). However the correlation between genital symptoms and testing (⫹) varied dramatically by sex, implying that high risk should be defined separately for each sex.
336
Emergency Department Compliance With CDC Guidelines for Discharge Instructions for Patients With Suspected Sexually Transmitted Infections
Jenkins D, Rahimi LM, Mitchell PM, White LF, Schechter-Perkins EM/Boston University School of Medicine, Boston, MA
Study Objective: The 2010 CDC STD Treatment Guidelines recommend that all patients seeking evaluation and/or treatment for sexually transmitted diseases (STDs) be given appropriate discharge instructions, including: abstain from sexual activity until treatment completed and partners treated; use barrier precautions; and recommendation for HIV testing. The purpose of this study was to evaluate the frequency of ED providers complying with these guidelines. Methods: A retrospective case control chart review was conducted. A random sample of 500 cases (positive for at least one of Neisseriae gonnorhea or Chlamydia trachomatis) and 500 controls were selected from all patients who had Neisseriae gonorrhea or Chlamydia trachomatis tests sent from the ED of an academic, urban, level 1 trauma center, from 1/1/10-6/30/11. Exclusion criteria were: age ⬍15, sexual assault, eloped or left against medical advice, and repeat visits 3 weeks post positive
Annals of Emergency Medicine S119