Antibiotics: Reserve for Patients With Clinical Signs of STD

Lara C. Pullen, PhD

June 14, 2016

Many patients who present to the emergency department with a suspected sexually transmitted disease (STD) are treated with antibiotics, even though their cultures are ultimately negative for bacterial infection.

Such unnecessary treatment with antibiotics is not only associated with unnecessary cost and complications from antibiotic use but may also contribute to antibiotic resistance.

Karen Jones, MPH, BSN, RN, from St. John Hospital & Medical Center, Detroit, Michigan, presented the results of her study on this subject in a poster at the Association for Professionals in Infection Control and Epidemiology (APIC) 2016 Annual Meeting in Charlotte, North Carolina. She described clinical predictors of STDs and suggested clinicians focus on those predictors to avoid unnecessary antibiotic prescribing in patients without true disease.

Jones, a former emergency department nurse, told Medscape Medical News, "In the emergency department, there is a huge disconnect with the health department." Thus, although clinicians in the emergency department realize antibiotics should not be prescribed if they are unnecessary, such prescriptions still occur. Jones said that she performed the study from the perspective of the health department to better understand the scope of the problem of overprescription of antibiotics.

She reviewed data from 1103 patients who presented to the emergency department and had genital cultures. Of these patients, 39.9% (n = 440) received treatment for Neisseria gonorrhea (GC) and Chlamydia trachomatis (CT), and 60.1% (n = 663) were untreated.

Cultures revealed, however, that only 13.6% (n = 150) of all patients were positive for GC and/or CT. Of the 440 patients who received antibiotics, 76.6% (n = 337) did not test positive for GC or CT. Conversely, 7.1% of patients not treated with antibiotics tested positive for GC and/or CT.

Jones then reviewed the patient charts to determine whether any clinical signs were associated with a positive diagnosis of GC and/or CT. In the case of female patients, cervicitis and cervical motion tenderness were associated with positive GC/CT (25.0% and 27.3%, respectively; P < .001). For male patients, penile discharge and urethritis were associated with positive GC/CT (60.3% and 57.5%, respectively; P < .001).

Pressure on Physicians to Prescribe

Jones acknowledged that there are "so many challenges" in the emergency department. Not only does the emergency department have limited resources, but many patients use those resources for an STD check. This is because, in most cases, patients do not realize there are STD clinics.

In addition, some patients present to the emergency department with a complaint that is completely unrelated to an STD and then request an STD test and antibiotics before they leave.

Laura Buford, RN, BSN, CIC, from Lakeway Regional Medical Center in Texas, who is also a former emergency department nurse, complimented the study and weighed in on the complexity of the problem. She explained to Medscape Medical News that Hospital Consumer Assessment of Healthcare Providers and Systems survey scores contribute to the pressure on clinicians to prescribe antibiotics to satisfy patients and maintain high scores. "The patient satisfaction part of it is huge," she emphasized, adding, "Definitely governmental influence is part of the problem."

Of course, physicians do not just focus on their patient satisfaction scores. They are also concerned about providing appropriate care for their patient, and this concern includes an awareness that they may not be able to get treatment to the patient at a later date.

"Can you find the person later on to get them the antibiotics if they have a positive test?" asked Buford. This is the question that goes through the minds of emergency department physicians standing poised to write a prescription for antibiotics. Jones agreed, adding, "That's why a lot of providers choose to treat if they are on the fence." They understand that follow-up can be very, very difficult.

Educating Patients

If patients pressure physicians for antibiotics, then patients are part of the problem as well. "It definitely comes down to patient education," explained Buford. She added that APIC has made an effort to educate patients so that they understand that antibiotics do not fix everything. The APIC infographic also introduces patients to the concept of antibiotic resistance and its risks for sicker patients, as well as relatively healthy patients.

Buford explained that healthcare providers should educate patients on how best to communicate their symptoms to physicians. The better they can detail their symptoms, the better physicians can identify clinical predictors of STDs. Such an education may also include information on which symptoms are of most concern and warrant a visit to a physician.

Finally, patients need to understand the importance of providing the healthcare practitioner with an accurate means of following up, so that treatment is possible should their culture test positive.

Jones and Buford have disclosed no relevant financial relationships.

Association for Professionals in Infection Control and Epidemiology (APIC) 2016 Annual Meeting: Poster 1-101. Presented June 9, 2016.

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