Abstract and Introduction
Abstract
Introduction: The purpose of this study was to determine the frequencies of negative test results among all patients aged 18 years and older receiving presumptive antibiotic treatment for chlamydia and/or gonorrhea at the Sexually Transmitted Disease Clinic of the Palm Beach County Health Department. The treatment algorithms were based on guidelines of the Centers for Disease Control and Prevention.
Methods: Clinic logs were retrospectively reviewed for a consecutive case series of all 1209 patients treated from November 1, 2007 to October 31, 2008. Urogenital specimens were collected and analyzed. Laboratory results were obtained from the Health Management System of the Palm Beach County Health Department.
Results: Of the 1209 patients, 556 (46%) were treated for chlamydia, 30 (2.5%) for gonorrhea, and 623 (51.5%) for both. The frequencies of negative results were 68% for chlamydia or gonorrhea, 70.9% for chlamydia, 86.6% for gonorrhea, and 65.2% for chlamydia + gonorrhea.
Conclusions: These data indicate that implementation of the Centers for Disease Control and Prevention guidelines by the Sexually Transmitted Disease Clinic of the Palm Beach County Health Department results in presumptive treatment of more than two-thirds of patients with negative nucleic acid amplification test results for chlamydia, gonorrhea, or both. They also suggest the potential value of developing treatment algorithms to maximize treatment of patients with positive test results and minimize treatment of those with negative test results. One possible strategy to explore is the future utility of new testing and treatment methodologies in development.
Introduction
In the United States, cases of Chlamydia trachomatis and Neisseria gonnorhoeae are the most commonly reported sexually transmitted bacterial infections (STIs). In 2009, 1,244,180 cases of chlamydia (592.2/100,000 population) and 301,174 cases of gonorrhea (99.1/100,000 population) were reported. During the same year in Florida, the corresponding numbers and rates were 72,916 (387.5/100,000 population) and 20,880 (111.0/100,000 population), respectively. During 2009 in Palm Beach County, the corresponding numbers and rates were 3834 (297.4/100,000 population) and 933 (72.4/100,000 population), respectively. Despite the high frequency of reported infections, most chlamydia and gonorrhea infections remain undiagnosed. A 2008 publication suggests that in the United States the estimated number of new cases of chlamydia and gonorrhea is approximately 2.8 million and gonorrhea approximately 600,000, respectively.
The most common site of chlamydial and gonococcal infections is the urogenital tract, and their severity ranges from asymptomatic to life threatening. Asymptomatic infections with chlamydia are common and can persist undetected in the genital tract for long periods in both men and women. As a consequence, there is continuing transmission as well as the development of complications such as pelvic inflammatory disease, chronic pelvic pain, tubal infertility, and ectopic pregnancy in women. For these and other cogent reasons, screening tests have been developed and used to increase presumptive antibiotic treatment so as to decrease complications and transmission.
Chlamydia and gonorrhea screening test results usually are not available on the same day that they are taken in most clinical settings, and asymptomatic patients are generally less likely than symptomatic patients to return for follow-up visits. The Centers for Disease Control and Prevention (CDC) have developed clinical criteria for presumptive antibiotic treatment of infections with chlamydia and gonorrhea. For women with symptoms that are consistent with mucopurulent cervicitis, presumptive treatment for chlamydia is recommended for those with risk factors for infection. These include age younger than 25 years, new or multiple sexual partners, unprotected sex, gonococcal co-infection, or sexual contacts with men with gonococcal or chlamydial infection. Presumptive treatment for gonorrhea is recommended if the prevalence is >5% or women have sexual contact with men with a gonococcal infection. For men with symptoms that are consistent with urethritis, presumptive antibiotic treatment for chlamydia and gonorrhea is recommended for those at high-risk for infection and who are unlikely to return for a follow-up evaluation.
The Sexually Transmitted Disease (STD) Clinic of the Palm Beach County Health Department (PBCHD) adhered to the STI treatment guidelines of the CDC at the time this study was performed. Furthermore, because chlamydia is found so frequently among asymptomatic index cases of gonorrhea and their sexual contacts, all such suspected index cases and their contacts are treated routinely with dual antibiotic therapy. In contrast, suspected cases of chlamydia received only azithromycin. It should be noted that the CDC now recommends dual treatment for gonorrhea, regardless of chlamydia status, although this was not the case during the study period. The use of these procedures would be optimal if the frequency of negative test results was low following antibiotic treatment for chlamydia or gonorrhea contacts. The purpose of this descriptive study was to determine the frequencies of negative test results among patients receiving presumptive antibiotic treatment for chlamydia and/or gonorrhea.