Updates on Sexually Transmitted Infections: Gonorrhea, Chlamydia, and Syphilis Testing and Treatment in the Emergency Department
- 47 Downloads
Purpose of Review
This review describes current guidelines and research on screening, diagnostics, and treatment for sexually transmitted infections (STIs) seen in the emergency department (ED).
Many studies support less invasive testing for STIs, which in turn would encourage increased screening. The diagnosis of pelvic inflammatory disease (PID) is currently based on clinical findings and further research is needed to improve diagnostic accuracy. Current antibiotic treatment guidelines are based on numerous studies. Drug-resistant gonorrhea is an issue worldwide and alternative treatments are currently being evaluated.
Highly sensitive testing has allowed for noninvasive screening. Increased screening in the ED would identify more infections and potentially prevent complications of untreated infections. Diagnosis of PID still requires a full pelvic examination given that diagnosis is based on exam findings. Antibiotic resistance is on the rise and treatment guidelines should be strictly followed. Future vaccine and novel antibiotics are currently in randomized control trials.
KeywordsSexually transmitted infection Emergency department screening Gonorrhea resistance Syphilis screening
Compliance With Ethical Standards
Conflict of Interest
The author declares that she has no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance
- 1.CDC. Sexually Transmitted Disease Surveillance 2016. US Dep Heal Hum Serv. 2017.Google Scholar
- 3.Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines. MMWR Recomm Rep. 2015:2015.Google Scholar
- 4.Shepherd, Suzanne M et. al. Pelvic inflammatory disease. Tintinalli’s emergency medicine: a comprehensive study guide 8e. 8th ed. Judith E Tintinalli et. al., editor. NY: McGraw Hill; 2016.Google Scholar
- 5.WHO. WHO Guidelines for the Treatment of Chlamydia trachomatis. Who [Internet]. 2016;340:c2637–c2637. Available from: http://www.who.int/reproductivehealth/publications/rtis/chlamydia-treatment-guidelines/en/.
- 11.• Low N, Redmond S, Uusküla A, van Bergen J, Ward H, Andersen B, Götz H, Cochrane STI Group. Screening for genital chlamydia infection. Cochrane Database Syst Rev. 2016. Review of data regarding impact of chlamydia screening. Google Scholar
- 15.Odesanmi TY, Wasti SP, Odesanmi OS, Adegbola O, Oguntuase OO, Mahmood S. Comparative effectiveness and acceptability of home-based and clinic-based sampling methods for sexually transmissible infections screening in females aged 14–50 years: a systematic review and meta-analysis. Sex Health. 2013;10:559–69.CrossRefPubMedGoogle Scholar
- 16.Mimiaga MJ, Reisner SL, Bland S, Skeer M, Cranston K, Isenberg D, et al. Health system and personal barriers resulting in decreased utilization of HIV and STD testing services among at-risk black men who have sex with men in Massachusetts. AIDS Patient Care STDs. 2009;23:825–35.CrossRefPubMedPubMedCentralGoogle Scholar
- 19.Centers for Disease Control and Prevention. Recommendations for the laboratory-based detection of chlamydia trachomatis and Neisseria gonorrhoeae—2014. MMWR Recomm Rep. 2014;63:1–19.Google Scholar
- 25.Shafer M-A, Moncada J, Boyer CB, Betsinger K, Flinn SD, Schachter J. Comparing first-void urine specimens, self-collected vaginal swabs, and endocervical specimens to detect Chlamydia trachomatis and Neisseria gonorrhoeae by a nucleic acid amplification test. J Clin Microbiol. 2003;41:4395–9.CrossRefPubMedPubMedCentralGoogle Scholar
- 26.Masek BJ, Arora N, Quinn N, Aumakhan B, Holden J, Hardick A, et al. Performance of three nucleic acid amplification tests for detection of Chlamydia trachomatis and Neisseria gonorrhoeae by use of self-collected vaginal swabs obtained via an Internet-based screening program. J Clin Microbiol. 2009;47:1663–7.CrossRefPubMedPubMedCentralGoogle Scholar
- 27.Schachter J, Chernesky MA, Willis DE, Fine PM, Martin DH, Fuller D, et al. Vaginal swabs are the specimens of choice when screening for Chlamydia trachomatis and Neisseria gonorrhoeae: results from a multicenter evaluation of the APTIMA assays for both infections. Sex Transm Dis. 2005;32:725–8.CrossRefPubMedGoogle Scholar
- 28.Stewart CMW, Schoeman SA, Booth RA, Smith SD, Wilcox MH, Wilson JD. Assessment of self taken swabs versus clinician taken swab cultures for diagnosing gonorrhoea in women: single centre, diagnostic accuracy study. BMJ. 2012;345.Google Scholar
- 29.Schoeman SA, Stewart CMW, Booth RA, Smith SD, Wilcox MH, Wilson JD. Assessment of best single sample for finding chlamydia in women with and without symptoms: a diagnostic test study. BMJ. 2012;345.Google Scholar
- 31.• Lunny C, Taylor D, Hoang L, Wong T, Gilbert M, Lester R, et al. Self-collected versus clinician-collected sampling for chlamydia and gonorrhea screening: a systemic review and meta-analysis. PLoS One. 2015;10. Recent review of studies supporting less invasive specimen collection for GC and CT screening.:e0132776.CrossRefPubMedPubMedCentralGoogle Scholar
- 32.Van Der Pol B, Quinn TC, Gaydos CA, Crotchfelt K, Schachter J, Moncada J, et al. Multicenter evaluation of the AMPLICOR and automated COBAS AMPLICOR CT/NG tests for detection of Chlamydia trachomatis. J Clin Microbiol. 2000;38:1105–12.Google Scholar
- 42.Goller JL, De Livera AM, Fairley CK, Guy RJ, Bradshaw CS, Chen MY, et al. Characteristics of pelvic inflammatory disease where no sexually transmitted infection is identified: a cross-sectional analysis of routinely collected sexual health clinic data. Sex Transm Infect. 2017;93:68–70.CrossRefPubMedGoogle Scholar
- 46.Oakeshott P, Kerry S, Aghaizu A, Atherton H, Hay S, Taylor-Robinson D, et al. Randomised controlled trial of screening for Chlamydia trachomatis to prevent pelvic inflammatory disease: the POPI (prevention of pelvic infection) trial. BMJ. 2010;c1642:340.Google Scholar
- 51.Alary M, Baganizi E, Guèdèmè A, Padonou F, Davo N, Adjovi C, et al. Evaluation of clinical algorithms for the diagnosis of gonococcal and chlamydial infections among men with urethral discharge or dysuria and women with vaginal discharge in Benin. Sex Transm Infect. 1998;74(Suppl 1):S44–9.PubMedGoogle Scholar
- 53.Francis SC, Ao TT, Vanobberghen FM, Chilongani J, Hashim R, Andreasen A, et al. Epidemiology of curable sexually transmitted infections among women at increased risk for HIV in Northwestern Tanzania: inadequacy of syndromic management. PLoS One. 2014;9:e101221.CrossRefPubMedPubMedCentralGoogle Scholar
- 59.WHO. WHO guidelines for the treatment of Treponema pallidum (syphilis). WHO Libr Cat DAta [Internet]. 2016;1–51. Available from: https://www.ncbi.nlm.nih.gov/books/NBK384904/pdf/Bookshelf_NBK384904.pdf%0Ahttp://apps.who.int/iris/bitstream/10665/249572/1/9789241549806-eng.pdf?ua=1%0Ahttp://www.bmj.com/cgi/doi/10.1136/bmj.2.398.180-b.
- 60.WHO. WHO guidelines for the treatment of Neisseria gonorrhoeae. World Heal Organ [Internet]. 2016;1–55. Available from: http://www.who.int/reproductivehealth/publications/rtis/gonorrhoea-treatment-guidelines/en/.
- 61.CDC. Update to CDC’s sexually transmitted diseases treatment guidelines, 2010: oral cephalosporins no longer a recommended treatment for gonococcal infections. MMWR. 2012;61:590–4.Google Scholar
- 65.Lau A, Kong F, Fairley CK, Donovan B, Chen M, Bradshaw C, et al. Treatment efficacy of azithromycin 1 g single dose versus doxycycline 100 mg twice daily for 7 days for the treatment of rectal chlamydia among men who have sex with men—a double-blind randomised controlled trial protocol. BMC Infect Dis. 2017;17:35.CrossRefPubMedPubMedCentralGoogle Scholar
- 67.Unemo M, Golparian D, Nicholas R, Ohnishi M, Gallay A, Sednaoui P. High-level cefixime- and ceftriaxone-resistant Neisseria gonorrhoeae in France: novel penA mosaic allele in a successful international clone causes treatment failure. Antimicrob Agents Chemother. 2012;56:1273–80.CrossRefPubMedPubMedCentralGoogle Scholar
- 71.Ducharme J. The First Case of Drug-Resistant Gonorrhea Was Confirmed | Time [Internet]. 2018 [cited 2018 May 25]. Available from: http://time.com/5222180/super-gonorrhea-drug-resistant-uk/.
- 73.Bignell C, Mb B, Frcp B, Unemo M, Professor A, Jensen JS. 2012. European guideline on the diagnosis and treatment of gonorrhoea in adults. [cited 2018 Apr 30]; Available from: http://www.iusti.org/regions/Europe/pdf/2012/Gonorrhoea_2012.pdf.
- 74.Yu R, Yin Y, Wang G, Chen S, Zheng B, Dai X, et al. Worldwide susceptibility rates of Neisseria gonorrhoeae isolates to cefixime and cefpodoxime: a systematic review and meta-analysis. Chaturvedi V, editor. PLoS One. Public Library of Science; 2014;9:e87849.Google Scholar
- 76.Ison CA, Hussey J, Sankar KN, Evans J, Alexander S. Gonorrhoea treatment failures to cefixime and azithromycin in England, 2010. Euro Surveill. 2011;16.Google Scholar
- 77.Unemo M, Golparian D, Syversen G, Vestrheim DF, Moi H. Two cases of verified clinical failures using internationally recommended first-line cefixime for gonorrhoea treatment, Norway, 2010. Euro Surveill. 2010;15.Google Scholar
- 78.Lewis DA, Sriruttan C, Muller EE, Golparian D, Gumede L, Fick D, et al. Phenotypic and genetic characterization of the first two cases of extended-spectrum-cephalosporin-resistant Neisseria gonorrhoeae infection in South Africa and association with cefixime treatment failure. J Antimicrob Chemother. 2013;68:1267–70.CrossRefPubMedGoogle Scholar
- 81.CDC. Update to CDC’s sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR. 2007;56:332–6.Google Scholar
- 84.Ness RB, Soper DE, Holley RL, Peipert J, Randall H, Sweet RL, et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) randomized trial. Am J Obstet Gynecol. 2002;186:929–37.CrossRefPubMedGoogle Scholar
- 85.Savaris RF, Fuhrich DG, Duarte R V, Franik S, Ross J. Antibiotic therapy for pelvic inflammatory disease. Cochrane Database Syst Rev. John Wiley & Sons, Ltd; 2017.Google Scholar
- 86.Bai ZG, Wang B, Yang K, Tian JH, Ma B, Liu Y, et al. Azithromycin versus penicillin G benzathine for early syphilis. Cochrane Database Syst Rev. John Wiley & Sons, Ltd; 2012.Google Scholar
- 89.A2058G Prevalence Workgroup. Prevalence of the 23S rRNA A2058G point mutation and molecular subtypes in Treponema pallidum in the United States, 2007 to 2009. Sex Transm Dis. 2012;39:794–8.Google Scholar
- 91.Walker GJ, JA G. Antibiotics for syphilis diagnosed during pregnancy. Cochrane Database Syst Rev. 2001.Google Scholar
- 92.Yang C-J, Lee N-Y, Chen T-C, Lin Y-H, Liang S-H, Lu P-L, et al. One dose versus three weekly doses of benzathine penicillin G for patients co-infected with HIV and early syphilis: a multicenter, prospective observational study. PLoS One. 2014;9:e109667. Public Library of ScienceCrossRefPubMedPubMedCentralGoogle Scholar
- 95.Tsai J-C, Lin Y-H, Lu P-L, Shen N-J, Yang C-J, Lee N-Y, et al. Comparison of serological response to doxycycline versus benzathine penicillin G in the treatment of early syphilis in HIV-infected patients: a multi-center observational study. PLoS One. 2014;9:e109813. Speck RF, editorCrossRefPubMedPubMedCentralGoogle Scholar
- 97.Ferreira A, Young T, Mathews C, Zunza M, Low N. Strategies for partner notification for sexually transmitted infections, including HIV. Cochrane Database Syst Rev. 2013.Google Scholar