A 21-year-old patient presents to the emergency department with complaints of dysuria a week following exposure to a new sex partner. She has increased vaginal discharge on exam and is empirically treated for gonorrhea and chlamydia. After her ED visit, the test results are positive for gonorrhea, so the department’s follow-up nurse fills out the communicable disease reporting form to the health department.
Explore This IssueACEP Now: Vol 40 – No 05 – May 2021
Meanwhile, the patient has talked to her partner about the diagnosis and urges him to seek care. Because he is asymptomatic and concerned about the cost of care, he does not get tested. A month later, the patient is reinfected by her untreated partner. This time, she waits to go to the emergency department because she is embarrassed. She finally presents with pelvic inflammatory disease and a tubo-ovarian abscess, requiring admission to the hospital.
This case represents many others that are examples of preventable morbidity. The emergency department might have helped avoid this outcome if it had provided the patient with antibiotics for her partner via expedited partner therapy (EPT). EPT is the practice of treating the partners of patients diagnosed with sexually transmitted infections (STIs) if their partners are unlikely to seek timely care. In the era of increased awareness of transmissible diseases and health equity, the time has come for emergency medicine to embrace EPT.
STIs Are a Hidden Public Health Crisis
Though the COVID-19 pandemic has seized the world’s attention to the threat of communicable diseases for the past year, the United States’ STI epidemic has been intensifying unchecked for the past decade. The Centers for Disease Control and Prevention (CDC) estimated one in five Americans had an STI on any given day in 2018.1 From 2014 to 2018, the incidence of gonorrhea rose 63 percent, and chlamydia rose 19 percent to 1.8 million cases, the most chlamydia cases ever reported to the CDC.2
STIs are not just a problem for the American health care system; they are a specific issue for the emergency department. STI visits in the emergency department have been outpacing the general rise in all-cause ED visits.3 In certain cities, emergency departments have had a substantial increase in positive tests, with higher positivity rates than outpatient settings.4 Emergency departments see a disproportionate share of STI cases compared to other health care settings. On a national level, in 2018, emergency departments diagnosed similar proportions of all gonorrhea cases as STD clinics.5
Moreover, STIs are an issue of social justice and health equity. STIs disproportionately affect those with low health care access, racial minority and minoritized populations, and low-income populations, the same vulnerable populations that are more likely to use the emergency department for STI care.6,7 Additionally, young males without primary care access are more likely to seek care in ED settings, representing an opportunity for EPT of male partners to improve women’s reproductive health via the prevention of STI complications, including future infertility and pregnancy complications.
Adding to the urgency to stop the STI epidemic, antimicrobial resistance for gonorrhea is increasing. In December 2020, for the first time in a decade, the CDC revised its treatment guidelines for gonococcal infections.8 Among other changes, these updates recommended: 1) doubling the recommended cephalosporin doses both for parenteral treatment and pill-based therapy and 2) replacing azithromycin for concurrent treatment of suspected chlamydia with doxycycline when treating empirically for gonorrhea. These changes were made due to increasing azithromycin resistance and concerns for antimicrobial stewardship.