Unsuspected Gonorrhea and Chlamydia in Patients of an Urban

Adult Emergency Department

A Critical Population for STD Control Intervention
SUPRIYA D. MEHTA, MHS,* RICHARD E. ROTHMAN, MD, PHD, GABOR D. KELEN, MD,
THOMAS C. QUINN, MD, AND JONATHAN M. ZENILMAN, MD

From the *Department of Epidemiology, Johns Hopkins

School of Public Health and Hygiene; the Department of
Emergency Medicine, Johns Hopkins School of Medicine;
and the Department of Medicine, Division of Infectious
Disease, Johns Hopkins School of Medicine,
Baltimore, Maryland

Background: Urban emergency departments (EDs) providing services to patients at high risk for sexually transmitted
infection may be logical sites for intervention.
Goal: To determine the prevalence of gonorrhea (GC) and
chlamydia (CT) in an adult ED patient population, and to
assess risk factors for infection.
Study Design: Cross-sectional study of patients aged 18 to
44 in an urban ED, seeking care of any medical nature. Main
outcome was positive for GC or CT by urine ligase chain
reaction assay.
Results: Test results for GC and/or CT were positive in
13.6% of 434 18 to 31 year-olds and in 1.8% of 221 32 to 44
year-olds. Of 63 infected individuals identified by the study, 15
(23.8%) were treated at the ED visit. Age <31 detected 88% of
infections. Among 18- to 31-year-old patients, predictive risk
factors by multivariate analysis included age <25, >1 sex
partner in the past 90 days, and a history of sexually transmitted disease.
Conclusion: This study identified a high prevalence of GC
and CT in patients seeking ED services. Many of these infections were clinically unsuspected. These data demonstrate that
the ED is a high-risk setting and may be an appropriate site for
routine GC and CT screening in 18- to 31-year-old patients.

the 1992 to 1994 National Hospital Ambulatory Medical

Care Survey, found that pelvic inflammatory disease was
the most common gynecologic disorder seen, resulting in
342,000 visits per year.6 Forty-seven percent of all gynecologic visits to EDs were given discharge diagnoses of genital tract infections (including PID, lower genital tract infections, and STDs).
Many persons at risk for STDs do not have regular access
to health care. In inner-city areas, patients often use EDs for
primary healthcare concerns.711 Emergency department
populations are thought to have high rates of asymptomatic
STD infection, although data to support this are limited. A
recent study in an urban ED in St. Louis, MO, found a 9.7%
prevalence of GC and CT by urine ligase chain reaction
(LCR) among 300 patients.12 A prospective study conducted at a large Atlanta municipal hospital, found a prevalence of 9% chlamydia and 6.5% gonorrhea among 18- to
25-year-old male ED patients not seeking treatment for
STDs.13 In Philadelphia, during a large city-wide syphilis
outbreak, 4% of ED patients had syphilis.14 EDs may therefore be logical points of intervention to screen for STDs in
populations that have high prevalence of undetected infection and limited interaction with primary and preventive
health care.
In 1997, Baltimore had the highest national rates of
gonorrhea and syphilis.15 The Johns Hopkins Adult Emergency Department serves an East Baltimore community in a
high STD incidence area.16 The Johns Hopkins Hospital ED
provides health care to an urban, largely underserved population of approximately 60,000 persons.17 The Johns Hopkins Hospital ED is a comprehensive ED and level I trauma
center with approximately 48,000 annual visits, providing

THERE ARE AN estimated 4 million cases of chlamydia

and 700,000 cases of gonorrhea annually in the United
States, including unreported cases.1 Rates of infection are
highest in adolescents and young adults who are more likely
to have insufficient healthcare access. The sequelae of gonorrhea and chlamydia include pelvic inflammatory disease,
infertility, and enhanced HIV transmission.251
In emergency departments (EDs), sexually transmitted
diseases (STDs) are a large source of morbidity. Data from

This study was partly funded by an unrestricted grant from Pfizer

Pharmaceuticals. Dr. Zenilman was supported by NIH grants K24AI01633
and U19AI38533. We would like to thank medical students Michelle
Gossman, Steve Fein, and Marie Nam, Dr. John Mulligan, and Sharon
Willoughby, RN, for data collection. Also, we would like to thank the
Baltimore City Health Departments Eastern Health District STD Clinic
staff for accepting direct referrals.
Reprint requests: Jonathan M. Zenilman, 1165 Ross, 720 Rutland Avenue, Baltimore, MD 21205. E-mail: jzenilma@jhmi.edu
Received for publication February 11, 2000, revised April 26, 2000, and
accepted May 17, 2000.

33

34

MEHTA ET AL

service mainly to the East Baltimore community. Seventysix percent of patients are black, 21% are white, and 62% of
patients are 18 to 44 years old.
In a previous study, we found that 2.3% of adult patients
accessing the Johns Hopkins Hospital ED are diagnosed
with and/or treated for STDs.18 Most had poor access to
primary care, and most used the ED as their usual source of
acute or urgent health care. Sixty-eight percent of patients
lived within a 10-block radius.
The purpose of this study is to determine the prevalence
of gonorrhea and chlamydia infection in an urban ED, and
determine risk factors for infection. This information can be
used to develop and implement clinical pathways for the
diagnosis and treatment of patients at high risk for STDs in
urban ED settings.
Methods
Study Population
Study protocol was approved by the Institutional Review
Board of The Johns Hopkins University School of Medicine. We included 18- to 44-year-old male and female
patients, who came to the Johns Hopkins Hospital Adult ED
between June and November 1998 for medical treatment of
any nature. Psychiatric and critically ill patients were excluded for concerns regarding competency. University students and hospital employees were excluded for reasons of
confidentiality. Patients being served in common treatment
areas where confidentiality could not be maintained were
also excluded. Research interviewers read each patients
chart to ensure study eligibility before approaching the
patient for enrollment. Those patients who were not eligible
because of compromised confidentiality or other concerns
were documented.
Data collection shifts were randomized to give even
representation to days of the week and time of day. Within
each shift, interviewers approached each consecutively eligible patient. Beds in the Johns Hopkins ED are numbered
1 to 33. For example, an interviewer may start her shift at
bed 15 and then proceed through bed 33, and then from 1 to
15. It is possible that at the same time that the interviewer
was enrolling a patient in bed 15, another eligible patient in
bed 33 was discharged. Charts were abstracted on patients
who were eligible to participate in the study but who were
missed.
Patients were sampled from 10:00 AM to 2:00 AM, peak
patient flow times, to maximize resource utilization and
patient capture. Patients were sampled 7 days per week,
with equal representation of each day of the week, over two
7-week periods separated by a 3-week break, starting on
June 23 and ending on November 15. Patients 1 to 500 were
a representative sampling of eligible patients aged 18 to 44
years. Patients 501 to 700 were sampled from 18 to 31

Sexually Transmitted Diseases

January 2001

year-olds to increase power to identify risk factors, because

an interim analysis found that the majority of infections
(88%) occur in this age group. The two age categories were
based on the ED population median age (randomization and
sampling results available from author).
Data Collection
Demographic and behavioral data on all patients screened
for gonorrhea and chlamydia were collected using a standardized questionnaire instrument at the time of ED presentation. Interviews were conducted by dedicated study interviewers. Prior STD history and HIV status was by selfreport. Sexual behavior risk history included number of sex
partners in the past 90 days, new sex partner in the past 90
days, and sex with high-risk partners (intravenous drug user,
HIV infected, in exchange for money or drugs). Patients
were administered the four CAGE questions, to assess alcohol dependency.19,20 Basic symptoms, including dysuria,
penile or vaginal discharge, and lower abdominal pain, were
assessed by interview. After the interview a urine specimen
was collected. Urine was tested for gonorrhea and chlamydia by LCR (Abbott Laboratories, Abbott Park, IL) according to the manufacturers directions. Previous study has
shown urine LCR for gonorrhea and chlamydia to have
88.6% sensitivity and 99.7% specificity.21 All study participants were counseled for HIV and offered HIV testing.
Patients clinically diagnosed with an STD were treated
before leaving the ED. Asymptomatic patients testing positive for gonorrhea or chlamydia by LCR were contacted by
study investigators and advised to return either to the ED or
the Baltimore City Health Department STD Clinics for
treatment. All patients were urged to refer their partners for
treatment and testing.
Data Analysis
Statistical analyses were performed using SPSS 7.5 for
Windows. Gonorrhea and chlamydia prevalence were calculated as the proportion with positive results of the number
tested. Positive LCR results for either gonorrhea or chlamydia was the outcome of interest in all statistical analyses.
Associations between variables were explored using Pearsons chi-square, t-test, and logistic regression. All variables
significant at the P 0.10 level by univariate analysis were
entered for logistic regression, using backwards likelihood
ratio testing.
Results
Study Sample
Patients were enrolled over a 14-week period, during
which 2,118 patients were eligible for study enrollment.
Fifty-nine patients were excluded from recruitment for con-

TABLE 1.

35

STDS IN AN URBAN EMERGENCY DEPARTMENT

Vol. 28 No. 1

Patient Characteristics, Enrolled Versus Refused

No. of
Patients

Age (y) (mean)

Enrolled
Refused
Age 1831 y
Enrolled
Refused
Black
Enrolled
Refused
Male
Enrolled
Refused
Median Triage Level*
Enrolled
Refused
Treated for GC or CT at initial ED visit
Enrolled
Refused

700
281

TABLE 2. Enrolled Patient Characteristics by Age Group, 18 31

Years Versus 32 44 Years

P-value
28.4 yrs
31.4 yrs 0.001

700
281

65%
49%

0.001

684
207

89.3%
82.1%

0.014

700
278

42%
42%

0.996

664
266

3.0
3.0

673
204

8.9%
1.5%

0.643
0.001

*Triage level ranges from 1 4, 1 critically ill or trauma patients,

2 emergent, 3 urgent, and 4 nonurgent.
GC gonorrhea; CT chlamydia; ED emergency department.

cerns of inability to assure a confidential interview. Fortysix percent of these patients were approached for enrollment
(981/2118), and 33% (700/2118) were enrolled. Of 981
patients approached, 700 patients consented to the study
(71%). Enrollment among patients aged 18 to 31 years was
77% (454/592), and 63% (246/389) among patients aged 32
to 44 years (P 0.001). Those who enrolled were on
average younger, more likely to be black, and more likely to
be treated for gonorrhea or chlamydia by the ED (Table 1).
Adequate urine samples (1 ml or greater) were obtained
from 655 of 700 patients (93.6%).
Of 700 patients, 454 were aged 18 to 31 years and 246
were aged 32 to 44 years (Table 2). The two age groups
differed significantly by gender, as only 37% of 18 to 31
year-olds were male, compared with 52% of 32 to 44
year-olds. Patients aged 18 to 31 years reported significantly
higher frequencies and intensities of high-risk behaviors. In
terms of sexual risk taking, 28% of younger patients and
16% of older patients reported a new sex partner in the past
90 days (P 0.0010), and 22% of younger patients reported
multiple sex partners in the past 90 days compared with
14% of older patients (P 0.005). Twenty-seven percent of
18 to 31 year-olds reported marijuana use in the past 90
days, compared with 18% among 32 to 44 year-old patients
(P 0.004). Conversely, 32 to 44 year-old patients reported
much higher prevalences of intravenous drug use21%
prevalence of heroin injection in the past 90 days among 32
to 44 year-olds, compared to only 4.6% among 18 to 31
year-olds (P 0.001).
Gonorrhea and Chlamydia Prevalence
The prevalence of gonorrhea or chlamydia among 18- to
31-year-old patients was 13.6%, and 1.8% among 32- to

Black (y)
1831
3244
Have health insurance
1831
3244
Have medical assistance
1831
3244
ED is regular source of care
1831
3244
No regular source of care
1831
3244
History of STD
1831
3244
Smoked/snorted cocaine
past 90 days
1831
3244
Smoked/snorted heroin
past 90 days
1831
3244
CAGE19 score 2
1831
3244

No. of
Patients

443
241

91.4
85.5

0.025

381
156

47
42

0.323

374
152

34
30

0.301

385
146

60
60

0.912

379
146

43
33

0.083

451
244

52
58

0.098

453
244

8.0
17

0.001

453
244

9.3
15

0.039

454
246

14.3
26.4

0.001

P-value

44-year-old patients. Among 434 18- to 31-year-old patients, 24 were positive for gonorrhea (5.3%) and 42 were
positive for chlamydia (9.3%). Seven of those positive for
chlamydia were also infected with gonorrhea (16.7% copositivity rate), for a total of 59 cases (13.6% prevalence,
95% CI: 10.4%16.8%). Prevalence rates were similar
when stratified by gender. Of the 275 18- to 31-year-old
women tested, 17 were positive for gonorrhea (6%) and 24
were positive for chlamydia (10.7%) for a total of 37
infected with either (13.5%). Among the 159 18- to 31-yearold men tested, 7 were positive for gonorrhea (4.1%), and
18 were positive for chlamydia (11.3%), for a total of 22
infected with either (13.8%). The prevalence decreased
sharply with increasing age (mean decrease in prevalence of
9.0% per year of age, P 0.047; Fig. 1). Of 221 32- to
44-year-old patients tested for gonorrhea and chlamydia, 2
were positive each for chlamydia and gonorrhea for a total
of 4 cases (1.8% prevalence gonorrhea or chlamydia, 95%
CI: 0.04%3.6%).
Treatment and Follow-up
Among 18 to 31 year-olds, 6.6% (18/272) of women and
4.9% (8/165) of men reported genital discharge as the chief
complaint at triage (P 0.05). Of the 63 patients identified
by the study as infected with gonorrhea or chlamydia, 15

36

MEHTA ET AL

Sexually Transmitted Diseases

January 2001

to the ED, to a Baltimore City Health Department STD

clinic, or to an outside provider was obtained for an additional 23 patients. Treatment confirmation was obtained for
38 of 63 (60.3%) patients. ED clinicians treated 45 patients
who were negative for gonorrhea and chlamydia by urine
LCR. Fourteen (31%) of these patients reported genital
discharge as the triage complaint.
Univariate Analysis

Fig. 1. Combined prevalence of gonorrhea or chlamydia infection

by age.

(23.8%) were appropriately treated upon initial presentation

at the ED. Nine (14.5%; triage information missing for one)
of the infected patients reported genital discharge as the
triage complaint. Eight of these patients were treated by the
ED clinician. Confirmation of treatment with appropriate
antibiotic regimen (according to the CDC 1998 Guidelines
for Treatment of Sexually Transmitted Diseases22) by return
TABLE 3.

Univariate Analysis of Factors Associated With Gonorrhea and Chlamydia Infection in Patients Aged 18 44 Years

Risk Factor

No. of Patients

No. Infected

% Infected

Odds Ratio (95% CI)

245
218
132
112
140
78
403
51
81
381
75
385
248
213
101
361
58
403

28
4
17
11
3
1
31
1
11
21
10
22
19
13
11
21
1
31

11.4
1.8
12.9
9.8
2.0
1.3
7.69
1.96
13.6
5.5
13.3
5.7
7.7
6.1
10.9
5.8
1.7
7.7

6.89 (2.3820)

19
141

6
17

33
12

3.65 (1.2011.1)

27
130

7
15

27
11.4

2.87 (1.028.03)

Age 31 y
Age 32 y
Age 1824 y
Age 2531 y
Age 3238 y
Age 3944 y
Black
Other*
New sex partner
No new sex partner
1 sex partner
1 sex partner
History of STD
No history of STD
Marijuana use
No marijuana use
Injection heroin use
No injection heroin
For males aged 1831 y
Annoyed by others criticizing your drinking
Yes
No
Ever had a drink first thing in the morning
Yes
No
*Reference category is Other (White, Asian, Hispanic).
Refers to past 90 days.
STD sexually transmitted diseases.

Variables significant at the P 0.10 level by univariate

logistic regression were included in multivariate logistic
regression (Table 3). Among 18- to 44-year-old patients,
significant variables included age 31 years or younger, black
race, new sex partner in the past 90 days, more than one sex
partner in the past 90 days, history of STD, marijuana use in
the past 90 days, and heroin injection in the past 90 days
(Table 3). Among 18 to 31 year-olds, significant variables
were similar, and included age less than 25 (median age
among 18 31 year-olds) (Table 3).
Stratified by gender, for women, significant variables by
univariate analysis included history of STD, new sex partner
in the past 90 days, and number of sex partners in the past
90 days. For men, significant variables included age less
than 24 (median age for men), marijuana use in the past 90
days, ever having a drink first thing in the morning, ever
having been annoyed by people criticizing your drinking,

11.4 (1.4887.3)
8.39 (1.0666.4)
1.69 (0.1716.5)
4.57 (0.6134)
2.69 (1.245.84)
2.53 (1.155.59)
1.28 (0.612.64)
1.98 (0.924.25)
0.21 (0.031.57)

Vol. 28 No. 1

37

STDS IN AN URBAN EMERGENCY DEPARTMENT

TABLE 4. Predictors of Gonorrhea or Chlamydia Infection by Multivariate Logistic Regression Analysis in Emergency Department Patients
Aged 18 31 Years
Model I 1844 y
N 462
Variable

OR 95% CI

P-value

Age 31

6.43
(2.2118.7)
2.30
(1.045.07)

0.0006

New sex partner past 90

days
History of STD
1 sex partner past 90 days
Age 25

Model II 1831 y
N 427
OR 95% CI

P-value

0.0389
2.01
(1.113.61)
2.22
(1.214.06)
2.2
(1.184.11)

0.0203

Model III Females

1831 y N 274
OR 95% CI

P-value

2.23
(1.034.83)
2.02
(0.954.29)

0.0413

Model IV Males 1831 y

N 151
OR 95% CI

P-value

3.69*
(1.2111.3)
5.81
(1.7020)

0.022

7.13
(1.8427.6)

0.004

0.0688

0.0096
0.0136

Ever been annoyed by

others critizing your
drinking
Penile discharge

0.005

*In model IV (males aged 18 31 y), age 24 provided a better statistical model (age 24 OR 4.50 [95% CI 1.513.5], ever been annoyed
by others criticizing your drinking OR 5.58 [95% CI 1.6319], penile discharge OR 6.75 [95% CI 1.7326]). For consistency with the overall
results, we selected age 25, which did not change the direction or magnitude of the coefficients of the other variables in this model.
OR odds ratio.

new sex partner in the past 90 days, more than one sex
partner in the past 90 days, and penile discharge. Basic
clinical signs and symptoms such as lower abdominal pain
and vaginal discharge that were assessed by the study were
not significantly associated with infection in women.
Multivariate Analysis
Four separate models estimating predictors of infection
were analyzed (Table 4): risk factors among 18 to 44
year-olds (model I), risk factors for 18 to 31 year-olds
(model II), and risk factors for 18 to 31 year-olds stratified
by gender (models III and IV).
Among the representative sample of 18 to 44 year-olds
(patients 1500; Table 4, model I), age 31 years or younger
was associated with a 6.43 increase in the odds of infection
(P 0.0006), and having had a new sex partner in the past
90 days was associated with a 2.30 increase in the odds of
infection (P 0.039). Among 18 to 31 year-olds, significant predictors of infection were a history of STD, more
than one sex partner in the past 90 days, and age 25 (Table
4, model II).
Stratified by gender, for women, only having had a new
sex partner in the past 90 days was a significant predictor at
the P 0.05 level, being associated with a 2.23 increase in
the odds of infection (95% CI: 1.03 4.83). History of STD
was marginally statistically significant, and associated with
a 2.02 increase in odds of infection (P 0.0688, Table 4,
model III). In men, age less than 24 years, ever having been
annoyed by people criticizing your drinking, and penile
discharge were all statistically significant predictors of in-

fection (Table 4, model IV). Excluding males whose presenting complaint was penile discharge (n 12) did not
significantly alter models I or II. Among males, penile
discharge dropped out of the model as a significant predictor. The associations between age and ever having been
annoyed by others criticizing your drinking remained the
same, and no other variables were significant (data available
from author).
Sensitivity and Specificity
Screening individuals aged 18 to 31 years with any one of
the characteristics from model II would have resulted in
testing 385 of 434 patients to identify 55 of 59 cases
[sensitivity 93.2%, specificity 12%, positive predictive
value (PPV) 14.3%, negative predictive value (NPV)
91.8%]. Among women, testing patients who report either
history of STD or new sex partner in the past 90 days
identifies 29 of 37 infections, while unnecessarily testing
148 of 238 uninfected women (sensitivity 78.4%, specificity 37.8%, PPV 16.4%, NPV 91.8%). Testing
among 18- to 31-year-old men who reported any of the
factors significant by multivariate analysis would have identified 21 of 22 infections, while testing 89 of 137 uninfected
men (sensitivity 95.5%, specificity 35.0%, PPV
19.1%, NPV 98%).
Discussion
We found a high prevalence of gonorrhea and chlamydia
infection among a representative sample of patients attend-

38

MEHTA ET AL

ing an inner-city adult ED: 13.6% among 18- to 31-year-old

patients, and 1.8% among 32- to 44-year-old patients. Seventeen percent of patients infected with chlamydia were also
infected with gonorrhea, emphasizing the importance of
cotreatment for suspicion of either infection. In our multivariate analysis, the strongest predictor of infection among
18 to 44 year-olds was age 31 years or younger. Further
analysis among 18 to 31 year-olds found age less than 25
years, history of STD, and more than one sex partner in the
past 90 days to be significant predictors of infection.
Appropriate urine samples were obtained on 94% of
participants. Of the 63 infections identified, confirmation of
appropriate antibiotic treatment was obtained for 60%.
From an operational standpoint, this study was performed
successfully in a high volume inner-city ED. This study had
a high enrollment rate and was successful in collecting
complete data and in calling back patients for treatment or
referring them elsewhere. Follow-up in our study was facilitated by close cooperation with the City Health Department STD clinics. A retrospective study of ED STD identification, treatment, and follow-up showed that treatment
could not be documented for 25% of women with positive
chlamydia or gonorrhea culture who were not treated at the
initial ED visit.23 This treatment confirmation rate may not
be comparable to ours, as these women were being tested
for clinical reasons, rather than general screening. In addition, the use of a noninvasive screening method and brief
risk history assessment did not interfere with regular ED
flow, or compromise patient care.
This study had several limitations. Among 32 to 44
year-olds, the number of infected cases was small, which
resulted in a wide confidence interval about the mean, and
also prevented us from determining whether 32 to 44 yearolds had different risk factors for infection than 18 to 31
year-olds. Because the majority of disease occurred among
18 to 31 year-olds, and the prevalence of infection was very
low among 32 to 44 year-olds, we felt that a discontinuation
of screening among the older age group was justified in
terms of resources. Also, these findings are consistent with
the known age distributions of gonorrhea and chlamydia.1,15
The clinicians were not masked to study enrollment, and
were aware that patients would be tested and followed by
the study if positive. As a result, there may have been a
Hawthorne effect, in that they may have been more likely to
order laboratory tests or provide treatment, knowing that
their patients outcome and disposition would be reviewed
and followed. Conversely, some clinicians may have been
less inclined to perform pelvic exams, order diagnostic tests,
and treat, if they knew that patients would be receiving
testing, referral, and follow-up through the study. It is
difficult to quantify the impact of these opposing biases on
the study. Although the level of clinician suspicion of STD
was much lower among patients who refused study participation, this may have been a result of volunteer bias. Those

Sexually Transmitted Diseases

January 2001

patients at higher risk of infection may have been more

likely to participate, leading to higher rates of detection by
clinicians. Additionally, these data may not be generalizable
to EDs whose patients are at low risk for infection. Further,
the brief data collection period may have lent to the homogeneity of the study population. It is possible that if this
study had been conducted over a longer period of time,
temporal trends in patient demographics, behavior, infection
prevalence, or clinician behavior may have been observed.
However, the Johns Hopkins Hospital ED population has
remained relatively demographically stable over time. Previous publications17,18,24,25 report similar ethnicity and substance abuse profiles for the past several years.
We did not collect extensive behavioral data, such as
deficits of condom use. For brevity and ease of implementation, the survey was limited to two pages, based on prior
experience with surveys in this busy ED. The survey questions were limited to those factors that could be assessed as
briefly and accurately as possible. In terms of implementing
a clinical pathway in this ED, identification of high-risk
individuals may be significantly streamlined into three
pieces of information that are easily obtainable by nurse,
technician, registrar, or physician: age, history of STD, or
more than one sex partner in the past 90 days.
Although the presence of any one of these factors among
18 to 31 year-olds identified 93% of infections, this screening algorithm had a PPV of only 14.3%. In other words,
86% of patients would be tested for gonorrhea or chlamydia
unnecessarily. However, due to the high prevalence of infection and high-risk nature of this population, this screening algorithm is justified from a public health perspective.
Screening programs among asymptomatic women in family
planning clinics have shown urine LCR applied to either
universal or targeted screening to be cost-effective at prevalences greater than 6% and treatment confirmation greater
than 14%.26 Although the 60% follow-up rate in our study
population is suboptimal, this is typical for public health
clinics. Further analysis of this data will include a costeffectiveness analysis to determine cost-saving parameters
in this ED setting.
Because of the frequent asymptomatic nature of STD
infection, their nonemergent presentation, and patient reluctance to report symptoms, STDs are often overlooked as
illnesses requiring clinical pathways for management of
both symptomatic and asymptomatic presentation.
Many of the patients accessing this ED report limited
interaction with the healthcare system, and therefore would
have a low probability of detection of asymptomatic infection at another venue. This ED may serve as a point of
intervention in detecting a significant pool of gonorrhea and
chlamydia infection in a difficult to reach high-risk population. These data suggest that routine screening for gonorrhea and chlamydia by urine LCR should be offered to
patients aged 18 to 31 years in this high-risk setting.

STDS IN AN URBAN EMERGENCY DEPARTMENT

Vol. 28 No. 1

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