Sensitivity and Specificity of Empiric Treatment for Sexually Transmitted Infections in a Pediatric Emergency Department

Abstract

Objective To determine test characteristics of provider judgment for empiric antibiotic provision to patients undergoing STI testing. Study design We conducted a retrospective cross-sectional electronic health record review of all patients aged 13–19 years who had GC and CT testing sent from an urban, academic pediatric ED in 2012. We abstracted data including patient demographics, chief complaint, STI test results, and treatment. We calculated test characteristics comparing clinician judgment for presumptive STI treatment with the reference standard of the actual results of STI testing. Results Of 1223 patient visits meeting inclusion criteria, 284 (23.2%) had a positive GC and/or CT test result. Empiric treatment was provided in 615 encounters (50.3%). Provider judgment for presumptive treatment had an overall sensitivity of 67.6% (95%CI 61.8, 73.0) and a specificity of 55% (95%CI 51.7, 58.2) for accurate GC and/or CT detection. Conclusions Many adolescents tested for GC and CT receive empiric treatment at the initial ED visit. Provider judgment may lack sufficient sensitivity and specificity for identifying infected patients, resulting in the potential for under-treatment of true disease, overtreatment of uninfected patients, or both.

In reply:

“…Current recommendations call for different treatments for cervicitis and pelvic inflammatory disease, but the pelvic examination findings of cervical motion tenderness and adnexal tenderness lack interrater reliability and do not correlate well with sexually transmitted infection tests. 5,6 Finally, foreign bodies will be missed without the pelvic examination, but these are rare findings, and in our study the number of pelvic examinations needed to be performed to find 1 foreign body was 288.…”

Self‐obtained vaginal swabs are not inferior to provider‐performed endocervical sampling for emergency department diagnosis of Neisseria gonorrhoeae and Chlamydia trachomatis

“…Currently, delays in diagnosis for standard NAAT combined with common asymptomatic or minimally symptomatic presentation, and poor diagnostic value of pelvic examination leads to significant clinical uncertainty. This uncertainty can result in both under‐ and overtreatment of NG/CT in female patients, with rates of 32% to 53% and 14% to 88%, respectively, in the ED setting 21–25 . Development of a highly accurate, rapid NAAT giving results in 90 minutes has opened the possibility of confirmatory diagnostic testing and treatment on the index ED visit.…”

A Research Agenda for Emergency Medicine–based Adolescent Sexual and Reproductive Health

“…Genitourinary (GU) complaints are common among adolescents presenting to the ED, but providers often lack the knowledge, comfort, time, and skills to provide evidence‐based sexual health care . Many ED providers do not follow evidence‐based STI testing and treatment guidelines; further, they lack accuracy in identifying which patients tested for STIs need empiric treatment, contributing to under‐ and overtreatment for STIs Many sexually active females in the ED report recent unprotected intercourse, making them eligible for pregnancy prophylaxis with emergency contraception (EC) . However, this opportunity to provide intervention is often missed as many adolescents are not routinely asked about recent unprotected sex or offered timely EC, except in cases of sexual assault .…”