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Underrecognition of cervical Neisseria gonorrhoeae and Chlamydia trachomatis infections in pregnant patients in the ED
American Journal of Emergency Medicine 31 (2013) 661–663
Contents lists available at SciVerse ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Original Contribution
Underrecognition of cervical Neisseria gonorrhoeae and Chlamydia trachomatis infections in pregnant patients in the ED☆ Roman Krivochenitser MS a,⁎, Jeffrey S. Jones MD b, David Whalen MD c, Cynthia Gardiner RN d a
College of Human Medicine, Michigan State University, Grand Rapids, MI Program in Emergency Medicine, Michigan State University, Spectrum Health Hospital–Butterworth Campus, Grand Rapids, MI Department of Emergency Medicine, Saint Mary's Health Care, Grand Rapids, MI d Department of Emergency Medicine, Helen DeVos Children's Hospital, Grand Rapids, MI b c
a r t i c l e
i n f o
Article history: Received 5 October 2012 Received in revised form 15 November 2012 Accepted 16 November 2012
a b s t r a c t Study Objectives: The purposes of this study were to (1) quantify the frequency of underrecognized Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) infections in pregnant women tested in the emergency department (ED), (2) describe the characteristics of those not treated during the initial visit, and (3) determine how many pregnant women with acute cervicitis were lost to follow-up. Methods: This was a retrospective, cohort analysis of consecutive women seen in the ED of 3 academic medical centers during a 36-month study period, with positive results for GC/CT. Our key outcome measures were the proportion of pregnant women being untreated in the ED, the time to subsequent treatment, and the proportion lost to follow-up. Results: During the study period, 735 female patients had positive polymerase chain reaction study results for GC and/or CT; 179 (24%) were pregnant. Overall, 143 of these pregnant patients with cervicitis (80%) were not treated in the ED. Presenting symptoms included abdominal pain (71%), nausea (45%), vaginal discharge (35%), vaginal bleeding (34%), and urinary complaints (22%). The most common discharge diagnoses were vaginitis (37%), urinary infection (33%), threatened abortion (19%), nonspecific abdominal pain (9%), and rule-out ectopic pregnancy (6%). Of the 143 patients with sexually transmitted infection not treated in the ED, 114 (80%) were contacted by telephone and/or mail. Twenty-nine (20%) were subsequently lost to follow-up. Conclusions: Further study is warranted to enhance point-of-contact testing and identify better mechanismsfor contact and follow-up after ED discharge and more liberal policies to treat less symptomatic patients empirically. © 2013 Elsevier Inc. All rights reserved.
1. Introduction Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) are 2 of the most common bacterial sexually transmitted infections (STI) and are among the most reported diseases in the United States. An estimated 600 000 new cases of GC are reported each year [1], whereas the rate of CT infections has risen by 43.5% over the past 5 years. The high prevalence and costs associated with these infections has led the US Preventive Services Task Force to currently recommend all sexually active females including pregnant women be screened for both CT and GC [2,3]. Emergency departments (ED) are often the first health care setting where such patients present and are able to be treated [4–6]. However, there are few data describing the frequency of GC and CT pelvic infections detected by ED bacteriologic testing, but not treated initially because of unconvincing signs or symptoms. The ☆ Presented at the ACEP Research Forum in San Francisco, October 15-16, 2011. ⁎ Corresponding author. Michigan State University College of Human Medicine, Grand Rapids, MI 49503. Tel.: +1 248 8959719. E-mail address: [email protected] (R. Krivochenitser). 0735-6757/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajem.2012.11.017
purposes of this study were to (1) quantify the frequency of unrecognized GC and CT infections in pregnant women tested in the ED, (2) describe the characteristics of those not treated during the initial visit, and (3) determine how many pregnant women with acute cervicitis were lost to follow-up. 2. Methods This was a multicenter retrospective cohort analysis to assess the frequency and treatment of STI infections in pregnant women presenting to the EDs of 3 academic medical centers during an 18month study period. The study protocol was approved by the institutional review boards at each institution. Medical record analyses were conducted over a 36-month period from January 2008 to December 2010. Sexually active female patients who had positive laboratory cultures for GC or CT in the ED of Spectrum Health Butterworth Hospital, Spectrum Health Blodgett Hospital, or Saint Mary's Health Care in Grand Rapids, MI, were eligible for the study. All patients had a positive urine pregnancy test result in the ED. Those patients with repeat infections for the same
662
R. Krivochenitser et al. / American Journal of Emergency Medicine 31 (2013) 661–663
pathogen were excluded, unless they were given adequate treatment and subsequent cultures from health providers were negative for the initial infectious agent. Research assistants reviewed medical records, and data were collected for chief concern, patient history, physical findings, laboratory data, diagnosis, and follow-up. Patient history included previous STI, urinary symptoms, nausea/vomiting, abnormal vaginal discharge or bleeding, fever/chills, and duration of symptoms. Physical findings focused on location and intensity of pain and abdominal tenderness. Laboratory data provided urinary analysis, pregnancy tests, Gram stain, and polymerase chain reaction (PCR) results for GC or CT. Positive PCR cultures for GC or CT were the basis for selection of the medical records and were conducted using specimens collected by physicians in the ED as part of routine care for pelvic complaints. The specimens were processed by using PCR amplification assays for both GC and CT (Abbott m2000, Des Plaines, IL). According to Marshall et al [7], the PCR assay sensitivity ranges from 93.7% to 100% and specificity ranges from 98.2% to 100% for CT. For GC, the PCR assay sensitivity ranges from 91.4% to 100% and specificity ranges from 99.3% to 100%. Treatment in the ED was noted based on physician's prescriptions of proper antibiotics based on pathogenesis according to standard Centers for Disease Control and Prevention guidelines (eg, doxycycline, ceftriaxone, and azithromycin) [8]. Information on follow-up was obtained from documented attempts by nurses or physicians to contact patients based on positive laboratory cultures in the ED. Successful follow-up was listed as contacting the patient and providing proper antibiotics. The number of attempts and the reasons for unsuccessful follow-up were also noted. Furthermore, an attempt was made to track the duration of time between diagnosis and proper treatment. Medical records were reviewed by research assistants who were trained using a set of “practice” medical records. Standardized abstraction forms were used to guide data collection. One investigator (R.K.) supervised data abstraction and ensured that data variable definitions were uniformly applied. A second investigator (J.S.J.) performed a blinded critical review of a random sample of 10% of the medical records to determine reliability. The interrater agreement for this sample of medical records was excellent (k statistic = 0.95). The primary outcome of interest was to determine the proportion of pregnant women with STIs that were untreated in the ED and the proportion of them that were lost to follow-up. Descriptive statistics (mean, SD) and frequency tables were used to describe clinical findings and demographic characteristics. Groups were compared using 2-tailed unpaired t tests and Wilcoxon rank sum tests for continuous and ordinal data, whereas nominal data were analyzed by χ 2 tests. 3. Results From January 2008 to December 2010, 735 female patients had a positive PCR culture for GC or CT, 361 (49%) of which were left untreated in the ED. Overall, 179 (24%) female patients with an STI were pregnant, with 143 (80%) not being treated in the ED. Breakdown of GC and CT testing is shown in Table. There were no significant variables between patients who were and were not treated in the ED upon presentation. These variables
included age, ethnic background, insurance, or history of STI. Furthermore, there were no specific clinical findings such as localizing signs, symptoms, location of pain, fever, Gram stain results, final diagnosis of urinary tract infection (UTI), or previous Trichomonas or bacterial vaginitis infection that resulted in an increase frequency of antibiotic use by ED physicians. The average duration of symptoms before patient presentation with a chief concern was 4.1 days. Chief concerns for untreated patients varied with abdominal pain (71%), nausea/vomiting (45%), vaginal discharge (35%), vaginal bleeding (34%), UTI symptoms (22%), pelvic pain (20%), back/flank pain (16%), and other symptoms (7%). During routine pelvic examination, 17% of untreated patients had no complaints of pain or tenderness. The most common discharge diagnoses were vaginitis (37%), UTI (33%), threatened abortion (19%), cervicitis (14%), nonspecific abdominal pain (9%), and rule-out ectopic pregnancy (6%) (Fig.). Follow-up data showed that of the 143 pregnant patients with an STI who were left untreated in the ED, 114 (80%) were contacted either by telephone or mail. The other 29 patients (20%) were lost to follow-up. The mean time interval between ED presentation and antibiotic treatment was 4.1 days (range, 2-37 days). 4. Discussion Although screening is routinely done in the ED in accordance with Centers for Disease Control and Prevention recommendations, there is severe under recognition of CT and GC infections with little done to ensure follow-up treatment [9]. Patients who do receive follow-up treatment may take an average of 36 days after their initial ED visit to seek treatment [10,11]. The delay in treatment can cause irreversible to damage to the fetus. Screening is especially important in pregnant women who risk transmission of their infection to the fetus [3]. Studies have also shown that infected women have many pregnancy complications including increased rates of preterm delivery, premature rupture of membranes, low birth weight, and intrauterine growth retardation [12,13]. Overall, about 2% of women have adverse pregnancy outcomes, and chlamydial PID is seen as the most important preventable cause of infertility and adverse pregnancy outcomes. This study shows that although pregnant patients are thoroughly examined in the ED for STIs, most (80%) are discharged without treatment. This validates other studies that have shown high prevalence rates of STIs among pregnant patients. According to recent reviews, the prevalence of CT alone in pregnant patients varies between 2% and 30%, with higher rates in populations of low socioeconomic standing [14–16]. Emergency departments are often the first and only point of contact that many of these patients have to the health establishment. This study also shows that there are a variety of symptoms that pregnant patients with STI present with and no clear demarcation for when to begin empirical treatment. Our study did not break down the percentage of treated patients based on
Untreated Patients: Chief Complaint Abdominal pain
16% 7% 20%
71%
Vaginal discharge
22%
Vaginal bleeding
Table Treated and untreated patients with GC and CT presenting to the ED
GC CT Both Total
Nausea/vomiting
UTI symptoms
Treated
Untreated
P
5 26 5 36
26 110 7 143
.145
Pelvic pain
34% 45% 35%
Back/flank pain Other
Fig. N gonorrhoeae/C trachomatis chief concerns upon presentation.
R. Krivochenitser et al. / American Journal of Emergency Medicine 31 (2013) 661–663
their trimester on presentation. However, a large portion of our patients were newly diagnosed as pregnant in the ED. The most common chief concern was abdominal pain, and one theory for the lack of empirical treatment of STIs could be that ED physicians attributed these symptoms to new-onset pregnancy. Pregnant patients with STIs have higher rates of preterm delivery, low birth weight, and intrauterine retardation among other adverse effects [4]. Antibiotic treatment for pregnant patients is very effective, with few and minor reported complications [7,17]. The high rates of loss to follow-up (80%), therefore, suggest that the guidelines for empiric treatment of STIs in pregnant patients need to be reconsidered. Follow-up practices should also be adjusted to ensure better contact and faster treatment for pregnant patients after initial ED presentation. Increased communication between ED and health departments could accelerate treatment and reduce the risk of adverse outcomes. There are a few study limitations that must be noted. Because this was a retrospective medical record review, there was no way to control for clinical evaluations performed by different examiners. Thus, documentation may not have been uniform. Furthermore, a retrospective study limited our ability to study the percentage of pregnant patients who refused empiric antibiotic treatment in the ED, opting to wait for test results instead. Furthermore, regional and cultural differences might provide different results in other settings and may not be applicable to all patients. This study was conducted in an urban northern setting with a diverse population. Lastly, there was lack of follow-up on patients who could not be reached by telephone. Once again, this reinforces the need for more efficient follow-up methods in tracking patients. In conclusion, in our study population, most pregnant women who were found to have either GC or CT were not treated in the ED. This is evidence that there needs to be improved point-of-contact detection of STIs for patients presenting with urinary- or pregnancy-related complaints. The guidelines for empirical treatment of STIs should also be revised for pregnant patients to include more liberal policies for less symptomatic patients. Future research will focus on enhancing
663
point-of-contact testing and ensuring better mechanisms for followup and contact upon discharge from the ED. References [1] CDC. Sexually transmitted disease surveillance, 2004. Atlanta, GA: USA: Department of Health and Human Services, CDC, National Center for HIV, STD, and TB Prevention; 2005. [2] Screening for chlamydial infection: U.S. Preventive Services Task Force Recommendation statement. Ann Intern Med 2007;147(2):128-34. [3] U.S. Preventive Services Task Force. Screening for gonorrhea: recommendation statement. Ann Fam Med 2005;3(3):263-7. [4] Baker DW, Stevens CD, Brook RH. Regular source of ambulatory care and medical care utilization by patients presenting to a public hospita1 emergency department. JAMA 1994;271:1909-12. [5] Gift TL, Hogben M. Emergency department sexually transmitted disease and human immunodeficiency virus screening: findings from a national survey. Acad Emerg Med 2006;13(9):993-6. [6] Al-Tayyib AA, Miller WC, Rogers SM, Leone PA, Gesink Law DC, Ford CA, et al. Health care access and follow-up of chlamydial and gonococcal infections identified in an emergency department. Sex Transm Dis 2008;35(6):583-7. [7] Marshall R, et al. Characteristics of the m2000 automated sample preparation and multiplex real-time PCR system for detection of Chlamydia trachomatis and Neisseria gonorrhoeae. J Clin Microbiol 2007;45:747-51. [8] Centers for Diseases Control, Prevention. Guidelines for the treatment of sexually transmitted diseases. MMWR Recomm Rep 2010;59(RR-12):1–110. [9] Yealy DM, Greene TJ, Hobbs GD. Underrecognition of cervical Neisseria gonorrhoeae and Chlamydia trachomatis infections in the emergency department. Acad Emerg Med 1997;4(10):962-7. [10] Kelly JJ, Dalsey WC, McComb J, et al. Follow-up program for emergency department patients with gonorrhea or chlamydia. Acad Emerg Med 2000;7(12):1437-9. [11] Matson SC, Pomeranz AJ, Kamps KA. Early detection and treatment of sexually transmitted disease in pregnant adolescents of low socioeconomic status. Clin Pediatr (Phila) 1993;32(10):609-12. [12] Blas MM, Canchihuaman FA, Alva IE, Hawes SE. Pregnancy outcomes in women infected with Chlamydia trachomatis: a population-based cohort study in Washington State. Sex Transm Infect 2007;83(4):314-8. [13] Fitz Simmons J, Callahan C, Shanahan B, Jungkind D. Chlamydial infections in pregnancy. J Reprod Med 1986;31(1):19-22. [14] McGregor JA, French JI. Chlamydia trachomatis infection during pregnancy. Am J Obstet Gynecol 1991;164:1782-9. [15] Faro S. Chlamydia trachomatis infection in women. J Reprod Med 1985;30:273-8. [16] American College of Obstetricians and Gynecologists. Gonorrhea and chlamydial infections. ACOG Tech Bull No. 190, March 1994. [17] Allaire A, Nathan L, Martens MG. Chlamydia trachomatis: management in pregnancy. Infect Dis Obstet Gynecol 1995;3(2):82-8.
Contents lists available at SciVerse ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Original Contribution
Underrecognition of cervical Neisseria gonorrhoeae and Chlamydia trachomatis infections in pregnant patients in the ED☆ Roman Krivochenitser MS a,⁎, Jeffrey S. Jones MD b, David Whalen MD c, Cynthia Gardiner RN d a
College of Human Medicine, Michigan State University, Grand Rapids, MI Program in Emergency Medicine, Michigan State University, Spectrum Health Hospital–Butterworth Campus, Grand Rapids, MI Department of Emergency Medicine, Saint Mary's Health Care, Grand Rapids, MI d Department of Emergency Medicine, Helen DeVos Children's Hospital, Grand Rapids, MI b c
a r t i c l e
i n f o
Article history: Received 5 October 2012 Received in revised form 15 November 2012 Accepted 16 November 2012
a b s t r a c t Study Objectives: The purposes of this study were to (1) quantify the frequency of underrecognized Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) infections in pregnant women tested in the emergency department (ED), (2) describe the characteristics of those not treated during the initial visit, and (3) determine how many pregnant women with acute cervicitis were lost to follow-up. Methods: This was a retrospective, cohort analysis of consecutive women seen in the ED of 3 academic medical centers during a 36-month study period, with positive results for GC/CT. Our key outcome measures were the proportion of pregnant women being untreated in the ED, the time to subsequent treatment, and the proportion lost to follow-up. Results: During the study period, 735 female patients had positive polymerase chain reaction study results for GC and/or CT; 179 (24%) were pregnant. Overall, 143 of these pregnant patients with cervicitis (80%) were not treated in the ED. Presenting symptoms included abdominal pain (71%), nausea (45%), vaginal discharge (35%), vaginal bleeding (34%), and urinary complaints (22%). The most common discharge diagnoses were vaginitis (37%), urinary infection (33%), threatened abortion (19%), nonspecific abdominal pain (9%), and rule-out ectopic pregnancy (6%). Of the 143 patients with sexually transmitted infection not treated in the ED, 114 (80%) were contacted by telephone and/or mail. Twenty-nine (20%) were subsequently lost to follow-up. Conclusions: Further study is warranted to enhance point-of-contact testing and identify better mechanismsfor contact and follow-up after ED discharge and more liberal policies to treat less symptomatic patients empirically. © 2013 Elsevier Inc. All rights reserved.
1. Introduction Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) are 2 of the most common bacterial sexually transmitted infections (STI) and are among the most reported diseases in the United States. An estimated 600 000 new cases of GC are reported each year [1], whereas the rate of CT infections has risen by 43.5% over the past 5 years. The high prevalence and costs associated with these infections has led the US Preventive Services Task Force to currently recommend all sexually active females including pregnant women be screened for both CT and GC [2,3]. Emergency departments (ED) are often the first health care setting where such patients present and are able to be treated [4–6]. However, there are few data describing the frequency of GC and CT pelvic infections detected by ED bacteriologic testing, but not treated initially because of unconvincing signs or symptoms. The ☆ Presented at the ACEP Research Forum in San Francisco, October 15-16, 2011. ⁎ Corresponding author. Michigan State University College of Human Medicine, Grand Rapids, MI 49503. Tel.: +1 248 8959719. E-mail address: [email protected] (R. Krivochenitser). 0735-6757/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajem.2012.11.017
purposes of this study were to (1) quantify the frequency of unrecognized GC and CT infections in pregnant women tested in the ED, (2) describe the characteristics of those not treated during the initial visit, and (3) determine how many pregnant women with acute cervicitis were lost to follow-up. 2. Methods This was a multicenter retrospective cohort analysis to assess the frequency and treatment of STI infections in pregnant women presenting to the EDs of 3 academic medical centers during an 18month study period. The study protocol was approved by the institutional review boards at each institution. Medical record analyses were conducted over a 36-month period from January 2008 to December 2010. Sexually active female patients who had positive laboratory cultures for GC or CT in the ED of Spectrum Health Butterworth Hospital, Spectrum Health Blodgett Hospital, or Saint Mary's Health Care in Grand Rapids, MI, were eligible for the study. All patients had a positive urine pregnancy test result in the ED. Those patients with repeat infections for the same
662
R. Krivochenitser et al. / American Journal of Emergency Medicine 31 (2013) 661–663
pathogen were excluded, unless they were given adequate treatment and subsequent cultures from health providers were negative for the initial infectious agent. Research assistants reviewed medical records, and data were collected for chief concern, patient history, physical findings, laboratory data, diagnosis, and follow-up. Patient history included previous STI, urinary symptoms, nausea/vomiting, abnormal vaginal discharge or bleeding, fever/chills, and duration of symptoms. Physical findings focused on location and intensity of pain and abdominal tenderness. Laboratory data provided urinary analysis, pregnancy tests, Gram stain, and polymerase chain reaction (PCR) results for GC or CT. Positive PCR cultures for GC or CT were the basis for selection of the medical records and were conducted using specimens collected by physicians in the ED as part of routine care for pelvic complaints. The specimens were processed by using PCR amplification assays for both GC and CT (Abbott m2000, Des Plaines, IL). According to Marshall et al [7], the PCR assay sensitivity ranges from 93.7% to 100% and specificity ranges from 98.2% to 100% for CT. For GC, the PCR assay sensitivity ranges from 91.4% to 100% and specificity ranges from 99.3% to 100%. Treatment in the ED was noted based on physician's prescriptions of proper antibiotics based on pathogenesis according to standard Centers for Disease Control and Prevention guidelines (eg, doxycycline, ceftriaxone, and azithromycin) [8]. Information on follow-up was obtained from documented attempts by nurses or physicians to contact patients based on positive laboratory cultures in the ED. Successful follow-up was listed as contacting the patient and providing proper antibiotics. The number of attempts and the reasons for unsuccessful follow-up were also noted. Furthermore, an attempt was made to track the duration of time between diagnosis and proper treatment. Medical records were reviewed by research assistants who were trained using a set of “practice” medical records. Standardized abstraction forms were used to guide data collection. One investigator (R.K.) supervised data abstraction and ensured that data variable definitions were uniformly applied. A second investigator (J.S.J.) performed a blinded critical review of a random sample of 10% of the medical records to determine reliability. The interrater agreement for this sample of medical records was excellent (k statistic = 0.95). The primary outcome of interest was to determine the proportion of pregnant women with STIs that were untreated in the ED and the proportion of them that were lost to follow-up. Descriptive statistics (mean, SD) and frequency tables were used to describe clinical findings and demographic characteristics. Groups were compared using 2-tailed unpaired t tests and Wilcoxon rank sum tests for continuous and ordinal data, whereas nominal data were analyzed by χ 2 tests. 3. Results From January 2008 to December 2010, 735 female patients had a positive PCR culture for GC or CT, 361 (49%) of which were left untreated in the ED. Overall, 179 (24%) female patients with an STI were pregnant, with 143 (80%) not being treated in the ED. Breakdown of GC and CT testing is shown in Table. There were no significant variables between patients who were and were not treated in the ED upon presentation. These variables
included age, ethnic background, insurance, or history of STI. Furthermore, there were no specific clinical findings such as localizing signs, symptoms, location of pain, fever, Gram stain results, final diagnosis of urinary tract infection (UTI), or previous Trichomonas or bacterial vaginitis infection that resulted in an increase frequency of antibiotic use by ED physicians. The average duration of symptoms before patient presentation with a chief concern was 4.1 days. Chief concerns for untreated patients varied with abdominal pain (71%), nausea/vomiting (45%), vaginal discharge (35%), vaginal bleeding (34%), UTI symptoms (22%), pelvic pain (20%), back/flank pain (16%), and other symptoms (7%). During routine pelvic examination, 17% of untreated patients had no complaints of pain or tenderness. The most common discharge diagnoses were vaginitis (37%), UTI (33%), threatened abortion (19%), cervicitis (14%), nonspecific abdominal pain (9%), and rule-out ectopic pregnancy (6%) (Fig.). Follow-up data showed that of the 143 pregnant patients with an STI who were left untreated in the ED, 114 (80%) were contacted either by telephone or mail. The other 29 patients (20%) were lost to follow-up. The mean time interval between ED presentation and antibiotic treatment was 4.1 days (range, 2-37 days). 4. Discussion Although screening is routinely done in the ED in accordance with Centers for Disease Control and Prevention recommendations, there is severe under recognition of CT and GC infections with little done to ensure follow-up treatment [9]. Patients who do receive follow-up treatment may take an average of 36 days after their initial ED visit to seek treatment [10,11]. The delay in treatment can cause irreversible to damage to the fetus. Screening is especially important in pregnant women who risk transmission of their infection to the fetus [3]. Studies have also shown that infected women have many pregnancy complications including increased rates of preterm delivery, premature rupture of membranes, low birth weight, and intrauterine growth retardation [12,13]. Overall, about 2% of women have adverse pregnancy outcomes, and chlamydial PID is seen as the most important preventable cause of infertility and adverse pregnancy outcomes. This study shows that although pregnant patients are thoroughly examined in the ED for STIs, most (80%) are discharged without treatment. This validates other studies that have shown high prevalence rates of STIs among pregnant patients. According to recent reviews, the prevalence of CT alone in pregnant patients varies between 2% and 30%, with higher rates in populations of low socioeconomic standing [14–16]. Emergency departments are often the first and only point of contact that many of these patients have to the health establishment. This study also shows that there are a variety of symptoms that pregnant patients with STI present with and no clear demarcation for when to begin empirical treatment. Our study did not break down the percentage of treated patients based on
Untreated Patients: Chief Complaint Abdominal pain
16% 7% 20%
71%
Vaginal discharge
22%
Vaginal bleeding
Table Treated and untreated patients with GC and CT presenting to the ED
GC CT Both Total
Nausea/vomiting
UTI symptoms
Treated
Untreated
P
5 26 5 36
26 110 7 143
.145
Pelvic pain
34% 45% 35%
Back/flank pain Other
Fig. N gonorrhoeae/C trachomatis chief concerns upon presentation.
R. Krivochenitser et al. / American Journal of Emergency Medicine 31 (2013) 661–663
their trimester on presentation. However, a large portion of our patients were newly diagnosed as pregnant in the ED. The most common chief concern was abdominal pain, and one theory for the lack of empirical treatment of STIs could be that ED physicians attributed these symptoms to new-onset pregnancy. Pregnant patients with STIs have higher rates of preterm delivery, low birth weight, and intrauterine retardation among other adverse effects [4]. Antibiotic treatment for pregnant patients is very effective, with few and minor reported complications [7,17]. The high rates of loss to follow-up (80%), therefore, suggest that the guidelines for empiric treatment of STIs in pregnant patients need to be reconsidered. Follow-up practices should also be adjusted to ensure better contact and faster treatment for pregnant patients after initial ED presentation. Increased communication between ED and health departments could accelerate treatment and reduce the risk of adverse outcomes. There are a few study limitations that must be noted. Because this was a retrospective medical record review, there was no way to control for clinical evaluations performed by different examiners. Thus, documentation may not have been uniform. Furthermore, a retrospective study limited our ability to study the percentage of pregnant patients who refused empiric antibiotic treatment in the ED, opting to wait for test results instead. Furthermore, regional and cultural differences might provide different results in other settings and may not be applicable to all patients. This study was conducted in an urban northern setting with a diverse population. Lastly, there was lack of follow-up on patients who could not be reached by telephone. Once again, this reinforces the need for more efficient follow-up methods in tracking patients. In conclusion, in our study population, most pregnant women who were found to have either GC or CT were not treated in the ED. This is evidence that there needs to be improved point-of-contact detection of STIs for patients presenting with urinary- or pregnancy-related complaints. The guidelines for empirical treatment of STIs should also be revised for pregnant patients to include more liberal policies for less symptomatic patients. Future research will focus on enhancing
663
point-of-contact testing and ensuring better mechanisms for followup and contact upon discharge from the ED. References [1] CDC. Sexually transmitted disease surveillance, 2004. Atlanta, GA: USA: Department of Health and Human Services, CDC, National Center for HIV, STD, and TB Prevention; 2005. [2] Screening for chlamydial infection: U.S. Preventive Services Task Force Recommendation statement. Ann Intern Med 2007;147(2):128-34. [3] U.S. Preventive Services Task Force. Screening for gonorrhea: recommendation statement. Ann Fam Med 2005;3(3):263-7. [4] Baker DW, Stevens CD, Brook RH. Regular source of ambulatory care and medical care utilization by patients presenting to a public hospita1 emergency department. JAMA 1994;271:1909-12. [5] Gift TL, Hogben M. Emergency department sexually transmitted disease and human immunodeficiency virus screening: findings from a national survey. Acad Emerg Med 2006;13(9):993-6. [6] Al-Tayyib AA, Miller WC, Rogers SM, Leone PA, Gesink Law DC, Ford CA, et al. Health care access and follow-up of chlamydial and gonococcal infections identified in an emergency department. Sex Transm Dis 2008;35(6):583-7. [7] Marshall R, et al. Characteristics of the m2000 automated sample preparation and multiplex real-time PCR system for detection of Chlamydia trachomatis and Neisseria gonorrhoeae. J Clin Microbiol 2007;45:747-51. [8] Centers for Diseases Control, Prevention. Guidelines for the treatment of sexually transmitted diseases. MMWR Recomm Rep 2010;59(RR-12):1–110. [9] Yealy DM, Greene TJ, Hobbs GD. Underrecognition of cervical Neisseria gonorrhoeae and Chlamydia trachomatis infections in the emergency department. Acad Emerg Med 1997;4(10):962-7. [10] Kelly JJ, Dalsey WC, McComb J, et al. Follow-up program for emergency department patients with gonorrhea or chlamydia. Acad Emerg Med 2000;7(12):1437-9. [11] Matson SC, Pomeranz AJ, Kamps KA. Early detection and treatment of sexually transmitted disease in pregnant adolescents of low socioeconomic status. Clin Pediatr (Phila) 1993;32(10):609-12. [12] Blas MM, Canchihuaman FA, Alva IE, Hawes SE. Pregnancy outcomes in women infected with Chlamydia trachomatis: a population-based cohort study in Washington State. Sex Transm Infect 2007;83(4):314-8. [13] Fitz Simmons J, Callahan C, Shanahan B, Jungkind D. Chlamydial infections in pregnancy. J Reprod Med 1986;31(1):19-22. [14] McGregor JA, French JI. Chlamydia trachomatis infection during pregnancy. Am J Obstet Gynecol 1991;164:1782-9. [15] Faro S. Chlamydia trachomatis infection in women. J Reprod Med 1985;30:273-8. [16] American College of Obstetricians and Gynecologists. Gonorrhea and chlamydial infections. ACOG Tech Bull No. 190, March 1994. [17] Allaire A, Nathan L, Martens MG. Chlamydia trachomatis: management in pregnancy. Infect Dis Obstet Gynecol 1995;3(2):82-8.