1. No category

Are Emergency Physicians Too Aggressive
With Empirically Treating Gonorrhea and
Chlamydia In The Face of Rising
Resistance?
FOEM Oral Abstract Competition
ACOEP 2014 Fall Conference
Xandus Chen, DO
Co-Authors
Xandus Chen, DO
Christopher Komurek, DO
Michael Samodio, DO
Kelly King, DO
Scott Plasner, DO
Aria Health, Philadelphia
Background
 Neisseria Gonorrhea (NG) and Chlamydia
Trachomatis (CT) are the highest reported sexually
transmitted diseases (STD) in this country and
across the globe

Philadelphia is ranked #4 as of 2011
 CDC recommends a low threshold to treat higher
risk patients
Background
 Significant part of the patient population seen at
ARIA-Frankford ED are higher risk patients
 EM physicians commonly empirically treat patients
with STD complaints for NG/CT before the PCR
result are available

Results take 2-3 days
 Concern that NG/CT will develop resistance
Background
 NG resistant to prior 1st
line agents
 PCN and
fluoroquinolones
 Increased antibiotic
dosing
 Dual therapy
recommended
 Evidence that CT has
capability to express
resistant phenotypes
Objective/Hypothesis
 Objective: Establish the percentage of patients with
actual infection from those who were empirically
treated for NG/CT
 Hypothesis: Despite working with a higher risk
population in our ED, overtreatment of patients
without NG/CT infections occur at a higher rate than
expected
Methods
 Design: Retrospective study
 Setting: ARIA –Frankford ED is an urban
community ED in Philadelphia
 Patient Selection: 100 patients randomly selected
Medically evaluated at ARIA-Frankford ED
 Received empiric treatment for NG/CT
 Had endocervical or urethral sample collected for NG/CT
PCR testing

Main Outcome Measures
 Percentage of infected patients among those who
received empiric treatment
 Frequency of STD-concerning symptoms and history
Dysuria
 Discharge
 Partner concerns
 Prior STD testing
 Prior STD history

Results
 21/100 patients had positive NG/CT cultures
 11 patients had NG, 6 patients had CT, 4 had both
 When comparing patients infected with NG/CT to all
patients, higher percentage complained of STDconcerning symptoms and history
Dysuria (52% vs 28%)
 Genital discharge (81% vs 60%)
 Partner concerns (24% vs 16%)
 Prior testing (52% vs 33%)
 Prior STD history (43% vs 16%)

Comparison of Empirically Treated Patients
A11
Treated
Males
Infected
Treated
21%
Females
Infected
Treated
39%
Infected
7%
Dysuria
28%
52%
39%
53%
11%
50%
Discharge
60%
81%
61%
82%
33%
75%
Partner
16%
24%
25%
29%
5%
0%
Prior Testing
33%
52%
32%
59%
19%
25%
Prior STD
16%
43%
23%
53%
6%
0%
Concerns
Results
 17/44 male (39%) were infected
 When comparing male patients infected with
NG/CT to all male patients, higher percentage
complained of:
Dysuria (53% vs 39%),
 Penile discharge (82% vs 61%)
 Partner concerns (29% vs 25%)
 Prior STD testing (59% vs 32%)
 Prior STD history (53% vs 23%)

Comparison of Empirically Treated Patients
A11
Treated
Males
Infected
Treated
21%
Females
Infected
Treated
39%
Infected
7%
Dysuria
28%
52%
39%
53%
11%
50%
Discharge
60%
81%
61%
82%
33%
75%
Partner
16%
24%
25%
29%
5%
0%
Prior Testing
33%
52%
32%
59%
19%
25%
Prior STD
16%
43%
23%
53%
6%
0%
Concerns
Results
 4/56 females (7%) were infected
 When comparing infected females to all females,
higher percentage complained of:
Dysuria (50% vs 11%)
 Discharge (75% vs 33%)
 Prior STD testing (25% vs 19%)

 Lower percentage of infected females complained of:
Partner concerns (0% vs 5%)
 Prior STD history (0% vs 6%)

Comparison of Empirically Treated Patients
A11
Treated
Males
Infected
Treated
21%
Females
Infected
Treated
39%
Infected
7%
Dysuria
28%
52%
39%
53%
11%
50%
Discharge
60%
81%
61%
82%
33%
75%
Partner
16%
24%
25%
29%
5%
0%
Prior Testing
33%
52%
32%
59%
19%
25%
Prior STD
16%
43%
23%
53%
6%
0%
Concerns
Discussion
 79% of patients did not
have NG/CT
 NG was 50% more
prevalent than CT
infections
 Males had higher
incidence of infection
(39%)
 Females had lower
incidence of infection
(7%)
Discussion
 Patients who were positive for NG/CT more
commonly complained of STD-concerning symptoms
and history
 Complaints were nonspecific
Discharge was the most common complaint of infected
patients (82%)
 48% of males WITHOUT infection also complained of
discharge

 5 patients were positive for CT/NG several times
within 3-5 month span
Discussion
 Disadvantage of overtreatment
Increasing resistance
 Higher cost of medical care
 Longer time spent in ED
 Risk of allergic reaction
 Increased risk of C. Difficile infection
 Anxiety and social stigma of STD infection

Discussion
 Disadvantage of postponing treatment until positive
PCR results
Patients lost to follow up
 Continued transmission disease
 Consequences of no treatment:

 PID
 Epididymitis
 Infertility
(men and women)
 Vertical transmission
 Disseminated gonorrhea
Limitations
 Sample size
 Physician variable collection techniques
 Numbers of patients with specific complaints were
dependant on
Patients providing information
 Medical documentation
 Prior ARIA hospital visits

Conclusion
 Significant overtreatment in ED for NG/CT (79%)
 Low threshold to treat males
 Collect cultures for repeat infections
 STD-concerning symptoms and history are
nonspecific
 Still recommend judicious empiric treatment for
NG/CT
References
1. CDC. (2014, January). CDC Fact Sheet: Reported STDs in the United
States. Retrieved from http://www.cdc.gov/std/
2. Feyler, Nan (June 18, 2012). Philadelphia Department of Public
Health, Health Notification, Gonorrhea Treatment Verification.
Retrieved from
https://hip.phila.gov/xv/Portals/0/HIP/Health_Alerts/2012/PDPH
HAN_Notification_2_GonorrheaTreatmentVerification_061812.pdf
3. CDC. (February 15, 2013). CDC Grand Rounds: The Growing Threat
of Multidrug-Resistant Gonorrhea. Retrieved from
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6206a3.htm
4. Ohnishi, M., Golparian, D., Shimuta, K., Saika, T., Hoshina, S.,
Iwasaku, K., Nakayama. S., Kitawaki, J. (2011). Is Neisseria
Gonorrhoeae Initiating a Future Era of Untreatable Gonorrhea?:
Detailed Characterization of the First Strain with High-Level
Resistance to Ceftriaxone. Antimicrobial Agents and
Chemotherapy, 55(7), 3538-45.
5. Sandoz, K. M., Rockey, D. D., (2010). Antibiotic Resistance in
Chlamydiae. Future Microbiology. 5(9), 1427–1442.
References
6. Somani, J., Bhullar, V. B., Workowski, K. A., Farshy, C. E., Black, C. M.
(2000). Multiple Drug–Resistant Chlamydia trachomatis Associated
with Clinical Treatment Failure.
7. The Journal of Infectious Diseases, 181(4), 1421–7.
8. Tyndall, M. W., Kidula, N., Sande, J., Ombette, J., Temmerman, M.
(1999). Predicting Neisseria gonorrhoeae and Chlamydia trachomatis
infection using risk scores, physical examination, microscopy, and
leukocyte esterase urine dipsticks among asymptomatic women
attending a family planning clinic in Kenya. Sex Transm Dis. 26(8), 47682.
9. Pettifor, A., Walsh, J., Wilkins, V., Raghunathan, P. (2000). How Effective
Is Syndromic Management of STDs? A Review of Current Studies.
Sexually Transmitted Diseases, 27(7), 371–385.
10. Andric, B., Drowos, J., Trepka, M. J., Suciu, G., Alonso, A., Hennekens, C.
H. (2013). High Frequencies of Negative Pretreatment Results Following
Presumptive Antibiotic Treatment for Chlamydia and Gonorrhea.
Southern Medical Journal. 106(5), 321-326.
11. Ng, L. K., Martin, I. E., (2005). The Laboratory Diagnosis of Neisseria
Gonorrhoeae. Can J Infect Dis Med Microbiol. 16(1), 15–25.
Thank you
Questions?