YAJEM-57159; No of Pages 2
American Journal of Emergency Medicine xxx (2017) xxx–xxx
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American Journal of Emergency Medicine
journal homepage: www.elsevier.com/locate/ajem
Is there an association between trichomoniasis and other sexually
transmitted infections in adolescent ED patients?
Keywords:
Trichomoniasis
STI
Adolescent
Coinfection
Emergency Department
Trichomoniasis is a common sexually transmitted infection (STI)
caused by the protozoan, Trichomonas vaginalis (TV), which causes vag-
initis and cervicitis. TV coinfection with chlamydia, gonorrhea or both
may account for over 2% of STI cases per year [1]. While TV infection is
clearly a public health issue, few published studies have assessed TV
prevalence in the adolescent emergency department (ED) population
or its association with an increased risk of coinfection with other STIs.
The goals of this study were: 1) to compare the prevalence of TV in
the adolescent versus adult female population; and 2) to determine if
findings on wet mount microscopy were associated with two other sex-
ually transmitted infections: Chlamydia trachomatis (CT) and Neisseria
gonorrhoeae (NG).
We conducted a retrospective, cohort analysis of consecutive fe-
males seen at seven EDs in West Michigan from August 2010 to July
2013. Affiliated institutions included three rural medical centers, three
university-affiliated hospitals and a children's tertiary care facility. All
patients underwent a pelvic exam with endocervical specimens submit-
ted for wet mount microscopy for TV, and polymerase chain reaction
(PCR) assays for chlamydia and gonorrhea. Demographics, clinical find-
ings, and laboratory test results were obtained from ED records using
standardized abstraction forms. Inter-rater reliability was determined
using kappa statistics. The primary outcome measure was a positive
likelihood ratio of patients with positive TV that are co-infected with
CT and/or NG. Adult and adolescent (ages 13–19) groups were com-
pared using 2-tailed unpaired t-tests and Wilcoxon rank sum tests for
continuous and ordinal data, while nominal data was analyzed by chi-
square tests.
During the 36-month study period, 8413 consecutive females were
evaluated for STIs; 1432 were adolescents (17.0%). A total of 275 adoles-
cents had at least one documented STI (19.2%; 95% CI = 17.1 to 21.2%);
101 patients tested positive for TV (7.1%, 95% CI = 5.8 to 8.4%). In the
adult population, 1537 had at least one documented STI (22.0%; 95%
CI = 21.0 to 23.0%) and 569 patients tested positive for TV (8.1%, 95%
CI = 7.5 to 8.7%). TV was the most common STI in adult women,
while CT was the most prevalent in the adolescent age group (8.7%).
Coinfection rates were significantly lower in the adolescent age
group (9.8% vs. 16.1%, P b 0.001). Statistical analysis revealed a weakly
positive association with other STIs in adults with TV (+ LR = 1.75,
95% CI = 1.4 to 2.1), but not in adolescent patients (+LR = 0.79, 95%
CI = 0.5 to 1.3).
https://doi.org/10.1016/j.ajem.2017.12.019
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Please cite this article as: Ouellette L, et al, , American Journal of Emergency Medicine (2017), https://doi.org/10.1016/j.ajem.2017.12.019
In our ED study population, TV was the most common STI in adult
women and was associated with a slightly increased risk of coinfection
with other STIs. In the adolescent age group, CT was the most prevalent
STI. There was no association between the presence of TV and coinfec-
tion with other STIs in young patients. This supports previous studies
which also found that TV is not a reliable marker for concurrent infec-
tion with CT or NG [2]. Lo et al. have found however, that having elevat-
ed numbers of white cells present on wet preps increases the
probability of a likely NG or CT infection [2]. Lacking rapid point-of-
care testing in the ED, this may be a suitable substitute to indicate that
further investigation for possible coinfection is necessary.
It is difficult to estimate the true burden of TV infection in the USA
simply because it is not a reportable disease and there is no surveillance
system in place to track infections. In addition, the diagnosis of tricho-
moniasis involves visualization of motile trichomonads on a saline wet
mount of vaginal fluid. Although this diagnostic test has been used for
many years, it has a poor sensitivity and is highly user-dependent [3,
4]. More sensitive diagnostic tests for TV are now available, but must
be weighed against their added costs, including waiting time and need
for follow-up. No test has been shown to be more cost-effective than
the wet mount in an emergency setting [4].
Mild or asymptomatic infections with CT and NG are common, and
untreated infection can lead to severe health consequences. Centers
for Disease Control and Prevention urges physicians to have a low
threshold for diagnosing pelvic inflammatory disease and initiating em-
piric antibiotic therapy for CT and NG [5]. In the ED setting, the difficul-
ties evaluating patients for STIs are compounded by the transient
physician-patient encounter, delayed return of GC and NG study results,
and problems ensuring follow-up [6]. Due to these difficulties, and the
logical belief that high-risk sexual behavior tends to produce infection
with multiple organisms, emergency physicians may choose to treat
for GC and CT when they have a positive Trichomonas result [6,7]. The
findings from our study do not support this strategy. Until real-time
testing for STIs becomes widely available, treatment decisions should
be based on prevalence rates of disease, clinical presentation, and clini-
cian gestalt.
References
[1] Abou Tayoun AN, Burchard PR, Caliendo AM, et al. A multiplex PCR assay for the si-
multaneous detection of Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomo-
nas vaginalis. Exp Mol Pathol 2015;98(2):214–8.
[2] Lo BM, Schott CK, Visintainer CM, et al. The utility of wet prep in predicting Neisseria
gonorrhoeae and Chlamydia trachomatis. J Emerg Med 2012;43(6):964–9.
[3] Gaydos CA, Klausner JD, Pai NP, et al. Rapid and point-of-care tests for the diagnosis of
Trichomonas vaginalis in women and men. Sex Transm Infect 2017. https://doi.org/10.
1136/sextrans-2016-053063.
[4] Wilkerson RG. Association of Trichomonas infection with gonorrhea or Chlamydia. J
Emerg Med 2011;40(1):69–70 [author reply 70-1].
[5] Centers for Disease Control and Prevention. Sexually transmitted diseases treatment
guidelines 2015. MMWR Recomm Rep, 64; 2015; 79(RR-03).
[6] Krivochenitser R, Bicker E, Whalen D, Norman C, Jones JS. Adolescent patients with
sexually transmitted infections: who gets lost to follow-up? J Emerg Med 2014;
47(5):507–12.
[7] Wegner S, Yen MJ, Witting M. Evidence against the “booty pack”: trichomonas not as-
sociated with gonorrhea or Chlamydia. J Emerg Med 2009;37(2):124–6.
2 Is there an association between trichomoniasis and other sexually transmitted infections in adolescent ED patients?

Lindsey Ouellette MPH1 Jeffrey Jones MD

Michigan State University College of Human Medicine, Department of Michigan State University College of Human Medicine, Department of
Emergency Medicine, United States Emergency Medicine, United States
Spectrum Health Hospitals, Grand Rapids, MI, United States
Corresponding author at: 15 Michigan St NE Suite 701, Grand Rapids, MI
Kristen Eischens MD2 49503, United States.
Lindsey Retterath MD2 E-mail address: Jeffrey.Jones@spectrumhealth.org.
Colleen Bush MD2
Erica Tavares MD2 30 November 2017
Spectrum Health Hospitals, Grand Rapids, MI, United States Available online xxxx

1
15 Michigan St NE 736, Grand Rapids, MI 49503.
2
15 Michigan St NE, Suite 701, MC 038, Grand Rapids, MI 49503.

Please cite this article as: Ouellette L, et al, , American Journal of Emergency Medicine (2017), https://doi.org/10.1016/j.ajem.2017.12.019