Should clinicians treat STIs before culture results are available?
Overtreatment can occur when patients are treated for STIs before results are available.
Whenever patients come into the emergency department with concerns about a sexually transmitted infection (STI), we are very quick to treat them. If a man has penile discharge, we will send a culture for gonorrhea and chlamydia, and then treat him before he leaves the emergency department even if we don't have the test results back yet. We will also treat someone for gonorrhea and chlamydia if he or she presents with herpetic lesions and has had sexual intercourse with someone who was diagnosed with an STI. A woman with vaginal discharge, known exposure, or dyspareunia will also often get treated while in the emergency department before her culture results are available.
I've been told in the past that reason we are so quick to treat for gonorrhea and chlamydia is because these patients may not give reliable contact information to be notified of positive results, and there is also a chance that they may not come back for treatment if notified of their positive results. These patients also have a 72-hour window before they receive their results, and during this time they have the potential to infect others.
Unfortunately, this practice leaves me with mixed feelings. According to the CDC, there are an estimated 2.86 million cases of chlamydia and 820,000 cases of gonorrhea reported annually in the United States. If untreated, these infections can cause serious health issues such as pelvic inflammatory disease (PID) and infertility in women.1 Because of these serious consequences, I feel it is incredibly important to make sure anyone who has an STI gets treatment, and that it is better to treat even if that means some people get treated unnecessarily.
However, this practice is leading to overtreatment, which is rapidly causing resistance to drugs. In particular, there is increasing concern about the development of a ceftriaxone-resistant gonorrhea strain. Gonorrhea has a notable history for its ability to develop resistance against most recommended treatments. The recommended treatment for gonorrhea has included penicillin, sulfonamides, tetracycline, fluoroquinolones, spectinomycin, macrolides, and now cephalosporins.2 Researchers are very concerned about gonorrhea's ability to develop resistance to ceftriaxone, because it has the potential to become resistant to all antibiotics, which would create a superbug. It would take the development of a new antibiotic to combat this terrifying superbug.
So now this leaves us with a conundrum. Do we still continue to treat people by giving them antibiotics before they leave the emergency department, even before we have their cultures results? This may lead to unnecessary treatment and could increase the chance of developing a resistant strain of gonorrhea. Or do we wait until their cultures come back, with the risk that they will infect others and with the possibility that we will be unable to notify these patients of their results? Which is the lesser of 2 evils and how do we determine when we should treat?
In short, I don't think there is a really good answer. I definitely think there needs to be more of an effort to make sure we are not overtreating patients. I think the best thing we can do at this point is to talk to patients to see how they feel about being treated without the results. If a patient has obvious penile discharge, then I still feel it is best to treat. However, if a patient has a penile rash with no other symptoms and is engaging in protected sex or has a low risk, I feel it may be best to hold off on treatment until the cultures come back. This, of course, is only manageable if the patient is reliable and agrees to come back for treatment. If they appear unreliable, the safest thing to do may be to treat them while they are in the emergency department to prevent them from infecting others.
I've also been educating patients about the dangers of a potential superbug. I've found that many patients who come in for treatment for STIs have been treated for them in the past and are opting to get treated in the emergency department rather than use protection at home. I also hope by informing them of a potential superbug development, which could result in an inability to treat them in the future, that the patients would be more likely to use protection at home.
Hopefully, if we take each patient case and make a conscious decision to treat or wait, we may help the fight against a superbug. And when it comes to the battle against diseases, a little can often go a long way.
Jillian Knowles, MMS, PA-C is an emergency medicine physician assistant in the Philadelphia area.
CDC Recommends Chlamydia and Gonorrhea Screening of All Sexually Active Women Under 25. CDC. https://www.cdc.gov/std/infertility/default.htm. Accessed September 17, 2016.
Dalke B, Ivers T, O'Brien KK, et al. Gonorrhea: Treatment and Management Considerations for the Male Patient. U.S Pharm. 2016;41(8):41-44.