Urinary tract and sexually transmitted infections (STIs) in women are misdiagnosed by emergency departments (EDs) nearly half the time, data indicate in new research.1 These misdiagnoses result in overuse of antibiotics and increased antibiotic resistance, which is a problem for reproductive health clinicians who treat STIs on a regular basis.
Distinguishing between these syndromes can be challenging because of overlapping symptomatology (painful or difficult urination, frequency, urgency) and the fact that both are associated with abnormalities on urinalysis, researchers note. To perform the current study, researchers conducted a two-month observational cohort study to determine the accuracy of clinical diagnoses of urinary tract infections and STIs in adult women presenting with genitourinary symptoms or diagnosed with genitourinary infections at MetroHealth Medical Center in Cleveland, an urban academic emergency department. For all urine specimens, urinalysis, culture, and nucleic acid amplification testing for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis were performed.
Of the 264 women studied, providers diagnosed 175 (66%) with urinary tract infections, 100 (57%) of whom were treated without performing a urine culture during routine care. Combining routine care and study-performed urine cultures, only 84 (48%) of these women had a positive urine culture, the researchers report. Sixty (23%) of the 264 women studied had one or more positive STI tests, 22 (37%) of whom did not receive treatment for an STI within seven days of the ED visit, data indicate. Fourteen (64%) of these 22 women were diagnosed with a urinary tract infection instead of an STI. Ninety-two percent of the women studied had an abnormal urinalysis finding (greater-than-trace leukocyte esterase level, positive nitrite test result, or pyuria). The positive and negative predictive values of an abnormal urinalysis finding were 41% and 76%, respectively.
“Less than half the women diagnosed with a urinary tract infection actually had one,” says Michelle Hecker, MD, a study co-author and an assistant professor in the Department of Medicine, Division of Infectious Diseases at Case Western Reserve University, Cleveland. “Sexually transmitted infections were missed in 37% of the women, many of whom were wrongly diagnosed with urinary tract infections.”
Resistance is growing
Reproductive health clinicians are mindful of the growing threat of antibiotic resistance.
The development of antibiotic resistance in Neisseria gonorrhoeae has been labeled as an urgent public health threat by the Centers for Disease Control and Prevention (CDC). Since antibiotics were first used for treatment of gonorrhea, Neisseria gonorrhoeae has progressively developed resistance to the antibiotic drugs prescribed to treat it: sulfonilamides, penicillin, tetracycline, and fluoroquinolones, such as ciprofloxacin. Neisseria gonorrhoeae developed resistance to sulfanilamide in the 1940s, penicillins and tetracyclines in the 1980s, and fluoroquinolones by 2007.
Just-released CDC STI treatment guidelines recommend dual therapy with the injectable cephalosporin ceftriaxone and azithromycin to treat all uncomplicated gonococcal infections among U.S. adults and adolescents.2 Dual therapy is recommended to address the potential emergence of gonococcal cephalosporin resistance.3
“Given the ability of N. gonorrhoeae to readily develop antibiotic resistance, it is critical to continuously monitor gonococcal antibiotic resistance and encourage research and development of new treatment regimens for gonorrhea,” the CDC states.
The effectiveness of cephalosporins for treating gonorrhea is decreasing rapidly, warned the CDC in 2012.4 (Contraceptive Technology Update reported on the problem. See “Threat is up for gonorrhea that is multi-drug resistant,” May 2012, and “Options running out for gonorrhea treatment,” September 2011 STI Quarterly supplement.)
The CDC conducts surveillance for U.S. antimicrobial resistance to Neisseria gonorrhoeae through its Gonococcal Isolate Surveillance Project (GISP), which was established in 1986. Each year, 25-30 sites and four to five regional laboratories across the country participate in the project. Data from this project have been reported and have directly contributed to the CDC’s STD Treatment Guidelines in recent years.
Clinicians who come in contact with a Neisseria gonorrhoeae specimen with decreased cephalosporin susceptibility and any gonorrhea cephalosporin treatment failure are asked to report such instances to the CDC through their state/local public health authorities. (See resource listing at end of this story for CDC contact information.)
Remind patients that if symptoms continue for more than a few days after receiving treatment for gonorrhea, they should return to a healthcare provider to be re-evaluated.
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Tomas ME, Getman D, Donskey CJ, et al. Overdiagnosis of urinary tract infection and underdiagnosis of sexually transmitted infection in adult women presenting to an emergency department. J Clin Microbiol 2015; 53(8):2,686-2,692.
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Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015; 64(No. RR-3):1-137.
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Centers for Disease Control and Prevention. Antibiotic-Resistant Gonorrhea Basic Information. Accessed at http://1.usa.gov/1DMnTlA.
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Bolan GA, Sparling PF, Wasserheit JN. The emerging threat of untreatable gonococcal infection. N Engl J Med 2012; 366:485-487.
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Reports of apparent failures of infections to respond to treatment with CDC-recommended therapies should be reported to Robert Kirkcaldy, MD, MPH, Surveillance & Data Management Branch, Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta. E-mail: [email protected].
