Evaluation of sexually transmitted

infections managed in a community

emergency department
Bryce R. Burkhart, PharmD
PGY-1 Pharmacy Resident, IU Health Arnett Hospital

Mentors: Alyson T. Basting, PharmD, BCCCP, John P. Bomkamp,

BCIDP, AAHIVP, Jennifer B. Slavens, PharmD, BCPS
Conflict of Interest
The speaker and mentors have no actual or potential conflict of interest in
relation to this presentation.

2
IU Health West Central Region
Indiana University Health Arnett
Community teaching hospital in Lafayette, IN
Level III trauma center – 20 beds
Indiana University Health Frankfort
Critical access hospital in Frankfort, IN
Indiana University Health White Memorial
Critical access hospital in Monticello, IN

3
 CDC 2015 STI Guideline Recommendations

Presumptive What is best Delayed

Treatment practice? Treatment
Risk Factors for Chlamydia/Gonorrhea
• Women < 25 years of age
• Individuals who have a new sexual partner
• Individuals with > 1 sexual partner
• A sexual partner with concurrent partners
• A sexual partner with a sexually transmitted infection
• Men who have sex with men
4
Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2018. https://www.cdc.gov/std/stats18/STDSurveillance2018-full-report.pdf. Published October 2019. Accessed September 7, 2020.
Workowski KA, Bolan GA. Sexually Transmitted Diseases Treatment Guidelines, 2015. MMWR. 2015; 64(3): 1-138.
 Microbiology Callback Service

Clinical
Sample Presumptive Final Test
Pharmacist
Patient
Collection/Transport Treatment Results
Chart Review
Notification

• ED Check-In
• Physician Evaluation/Order Entry
• Sample Collection
• Transport to Indianapolis (~1 hour)
7
 Microbiology Callback Service
• Antibiotic Administration
• Patient Discharge

Clinical
Sample Presumptive Final Test
Pharmacist
Patient
Collection/Transport Treatment Results
Chart Review
Notification

8
 Microbiology Callback Service

Clinical
Sample Presumptive Final Test Pharmacist
Patient
Collection/Transport Treatment Results Chart Review
Notification

• Results within 24-48 hours

9
 Microbiology Callback Service
• Pharmacist notification of positive results
• Evaluation of patient chart from ED visit

Clinical
Sample Presumptive Final Test Patient
Collection/Transport Treatment Results Pharmacist Notification
Chart Review

10
 Microbiology Callback Service

Clinical
Sample Presumptive Final Test
Pharmacist
Patient
Collection/Transport Treatment Results
Chart Review Notification

• Pharmacist attempts patient contact

• Cover letter sent after 3 unsuccessful
contact attempts

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Purpose/Methods
Purpose: To evaluate the rate of uninformed and/or untreated
positive STI results
Methods:
Multi-center, retrospective chart review
IU Health West Central Region Emergency Departments
January 2019 – December 2019

12
Inclusion/Exclusion Criteria
Inclusion Criteria
• > 18 years old
• Testing for chlamydia and/or
gonorrhea at IU Health Arnett,
Frankfort, or White Memorial EDs
Exclusion Criteria
• Hospital admission
• Transferred from the ED to an
outside healthcare facility
• Pregnancy
• Prisoners
• Indeterminate chlamydia and/or
gonorrhea test results
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Endpoints
Primary Endpoint: Rate of uninformed and/or untreated positive
STI results
Secondary Endpoints:
Rate of Delayed Treatment
Time to Delayed Treatment
Time to Final Positive STI Results
Time to Patient Notification
Rate of Overtreatment
14
 Patient Enrollment
647 patients evaluated 482 patients
for eligibility included

165 patients excluded

106 – Pregnancy
44 – Less than 18 years old
7 – Indeterminate Chlamydia and/or Gonorrhea Test Result
4 – Prisoners
2 – Hospital admission
2 – Transfer to Outside Healthcare Facility

15
Patient Demographics
Patient Demographics, n = 482
Female, n (%) 325 (67.3)
Age (years), mean + SD 28.6 + 8.41
Length of Stay (hours), median [IQR] 2.87 [2.05]
Facility
Arnett ED, n (%) 383 (79.5)
White Memorial ED, n (%) 61 (12.6)
Frankfort ED, n (%) 38 (7.9)
Positive Test Results, n (%) 70 (14.5%)
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 Results – Primary Endpoint
Positive Test Results
Primary Endpoint
n = 70
Rate of Uninformed and/or Untreated*, n (%) 17 (24.3)
Rate of Uninformed, n (%) 16 (22.7)
Rate of Untreated, n (%) 3 (4.2)
Rate of Untreated and Uninformed, n (%) 2 (2.9)

*Patients may fall into both uninformed and untreated categories.*

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 Results – Secondary Endpoints
Secondary Endpoints
Rate of Delayed Treatment, n = 70 11 (15.7)
Time to Delayed Treatment (hours), median [IQR] 20.4 [18.6]
Time to Final STI Test Result (hours), mean + SD 46.3 + 21.9
Time to Patient Notification (hours), median [IQR] 21.1 [21]
Rate of Overtreatment, n = 413 249 (60.3)

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Summary of Results
Uninformed and/or untreated patient rate of 24.3%
Related to an inability to contact patients (22.7%)

Overtreatment rate of 60.4%

Average time to final STI test results 46.3 + 21.9 hours

Median length of stay 2.87 [2.05] hours

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 Conclusions
Overtreatment – Current Literature

Final STI Results – 1 to 3-day turnaround time

Length of Stay – ~3 hours per patient

Patient Management – 1 in 4 not optimally managed

21
Gaydos
Gaydos CA,
CA, Ako
Ako MC,
MC, Lewis
Lewis M,
M, et
et al.
al. Use
Use of
of rapid
rapid diagnostic
diagnostic criteria
criteria for
for chlamydia
chlamydia trachomatis
trachomatis and
and Neisseria
Neisseria gonorrhoeae
gonorrhoeae for
for women
women inin the
the emergency
emergency department
department can can improve
improve clinical
clinical management:
management: report
report ofof a
a randomized
randomized clinical
clinical trial.
trial. Ann
Ann Emerg
Emerg Med.
Med. 2018;
2018; 74(1):
74(1): 36-44.
36-44.
Anaene M,
Anaene M, Soyemi
Soyemi K,
K, Caskey
Caskey R.
R. Factors
Factors associated
associated with
with the
the over-treatment
over-treatment andand under-treatment
under-treatment ofof gonorrhea
gonorrhea and
and chlamydia
chlamydia inin adolescents
adolescents presenting
presenting to
to a
a public
public hospital
hospital emergency
emergency department.
department. Int
Int JJ Infect
Infect Dis.
Dis. 2016;
2016; 53:
53: 34-38.
34-38.
Centers for
Centers for Disease
Disease Control
Control and
and Prevention.
Prevention. Antibiotic
Antibiotic resistance
resistance threats
threats in
in the
the United
United States.
States. https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf.
https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf. Published
Published December
December 2019.
2019. Accessed
Accessed April
April 2,
2, 2021.
2021.
 Future Directions

Advantages Rapid PCR Testing Limitations

Eliminates Sample Transfer Patient Care Cost

Quicker Result Turnaround Hospital Cost
Targeted Therapy

22
Question #1
Which of the following is a risk factor for contracting chlamydia
and/or gonorrhea?
A. New sexual partner
B. A sexual partner with concurrent partners
C. A sexual partner with an STI
D. All of the above

23
Question #1
Which of the following is a risk factor for contracting chlamydia
and/or gonorrhea?
A. New sexual partner
B. A sexual partner with concurrent partners
C. A sexual partner with an STI
D. All of the above

24
Question #2
What is a risk associated with the administration of empiric
antibiotics for the treatment of a suspected STI?
A. Repeat ED visits
B. Antibiotic Resistance
C. Loss of patient to follow-up
D. Further STI Transmission

25
Question #2
What is a risk associated with the administration of empiric
antibiotics for the treatment of a suspected STI?
A. Repeat ED visits
B. Antibiotic Resistance
C. Loss of patient to follow-up
D. Further STI Transmission

26
 Evaluation of sexually transmitted
infections managed in a community
emergency department
Bryce R. Burkhart, PharmD
PGY-1 Pharmacy Resident, IU Health Arnett Hospital

Mentors: Alyson T. Basting, PharmD, BCCCP, John P. Bomkamp,

BCIDP, AAHIVP, Jennifer B. Slavens, PharmD, BCPS