Pediatrics: Original Contributions
Opportunistic urine ligase chain reaction screening for sexually transmitted diseases in adolescents seeking care in an urban emergency department*,**,

Presented in part at the Southern Society for Pediatric Research, New Orleans, LA, February 1998; the American Academy of Pediatrics, San Francisco, CA, February 1998; and the International Society of Chlamydia Research, Napa, CA, June 1998.
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Abstract

Study Objective:Neisseria gonorrhoeae and Chlamydia trachomatis are the most common bacterial sexually transmitted diseases (STDs) in sexually active youth and many infections are asymptomatic or unrecognized. This study used ligase chain reaction assays for determination of prevalence of gonococcal and chlamydial infections in adolescents seeking care at an urban emergency department. Methods: An unlinked prevalence study was performed with ligase chain reaction tests on voided urine specimens from a convenience sample of adolescents 14 years or older who sought care at the Children’s Hospital of Alabama ED. Demographic data and data on care provided in the ED were determined from retrospective chart review of those patients whose urine specimens were tested. Results: Of 282 urine specimens screened, 13.5% (38) yielded positive findings on ligase chain reaction testing for either or both pathogens (20 [7%] positive for N gonorrhoeae, 23 [8%] positive for C trachomatis). In the context of acute care, gonorrhea or chlamydial infection was diagnosed in 5 (1.8%). STD prevalence did not vary significantly by age. Only 39% (15/38) of patients with infections detected by ligase chain reaction testing received potentially effective antibiotics as a result of their urgent care evaluation. Conclusion: Many adolescents use the ED for nonurgent care and unsuspected STDs are often missed. Urine ligase chain reaction testing is a sensitive, noninvasive means of detecting STDs by which unsuspected adolescent STD cases can be detected in an ED setting. [Embling ML, Monroe KW, Oh MK, Hook EW III. Opportunistic urine ligase chain reaction screening for sexually transmitted diseases in adolescents seeking care in an urban emergency department. Ann Emerg Med. July 2000;36:28-32.]

Introduction

Infections caused by Neisseria gonorrhoeae and Chlamydia trachomatis are the 2 most common reportable infectious diseases in the United States.1 Asymptomatic infections are relatively common, and although rates of these infections are highest in sexually active adolescents, their sequelae (ie, infertility, ectopic pregnancy, and chronic pelvic pain) may only become apparent years later.1, 2 Thus, interventions to promote diagnosis and treatment of these common bacterial sexually transmitted diseases (STDs) are a public health priority.

Screening of at-risk adolescents for STDs is recommended; however, health care opportunities for this group are limited. Previous studies have shown that adolescents, irrespective of the site of care, seldom receive comprehensive office-based health care.2, 3, 4 Instead, they most often present and are seen for brief, problem-oriented visits.2, 3, 4 Access to reproductive health care may be particularly difficult for this group. Barriers for seeking reproductive health care by young people include lack of STD symptom recognition, lack of knowledge regarding how to access care, lack of adequate insurance coverage, and concerns about confidentiality.3, 5, 6 For many adolescents, more so than for any other age group, the sole source of medical care is problem-oriented care provided in an acute care setting such as EDs.3, 4

Recently, diagnostic testing for gonorrhea and chlamydial infection using nucleic acid amplification technologies such as ligase chain reaction has become available; these tests provide a sensitive and specific diagnosis while also permitting simplification of specimen collection.7, 8, 9, 10 In a pilot study to evaluate the prevalence of treatable bacterial STDs in a readily accessible, potentially underserved adolescent population, we used ligase chain reaction testing on urine specimens of adolescents attending an urban ED to determine the prevalence of N gonorrhoeae and C trachomatis infections.

Section snippets

Materials and methods

This study was conducted in an ED of an urban, inner-city children’s hospital. More than 50,000 ED visits are recorded annually with more than 7,000 adolescents seen each year. A convenience sample of adolescents presenting for care at the ED between March 1997 and June 1998 were subjects of this pilot project. The protocol was approved by the Institutional Review Board for Human Subject Use. The usual emergency medicine clinical assessment and standard of care was not altered by this study

Results

The median age of study participants was 16 years. Of the 282 patients evaluated, 193 (68%) were female. Typical of patients seen in the ED and reflective of the demographic characteristics of metropolitan Birmingham, 203 (72%) of the study population were black patients. One hundred twenty (42%) of the patients had private insurance, 62 (22%) were covered by Medicaid, and 100 (36%) reported no health care insurance.

The chief complaints of participants were typical of adolescents seeking urgent

Discussion

Adolescents are an important target population in STD control efforts in the United States. Compared with other age groups, sexually active youths ages 16 to 19 years have the highest C trachomatis rates and the second highest N gonorrhoeae rates,1, 2 more often have asymptomatic infections,2, 5, 11, 12 and tend to have more limited access to health care.13, 14, 15 In addition, as gonorrhea rates have declined in recent years and as rates of chlamydial infection have begun to plateau, these

Acknowledgements

We thank Charity M. Richey, MPH, for data management and statistical assistance, and Amie Stephens and Sharron Hagy for assistance in manuscript preparation.

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    *

    Supported by National Institute of Allergy and Infectious Diseases grant No. U19-AI38514 (Project 1).

    **

    Dr. Hook is a paid consultant for several companies manufacturing nucleic acid amplification testing kits (including Abbott Diagnostics, Abbott Park, IL) and receives honoraria as part of their speaker’s bureaus.

    Address for reprints: Kathy Monroe, MD, University of Alabama at Birmingham, Department of Pediatrics, Division of Emergency Medicine, 1600 7th Avenue South, Suite 205, Midtown Center, Birmingham, AL 35233; 205-939-9587, fax 205-975-4623, E-mail [email protected].

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