2025 Southeastern Residency Conference

Title:
Chlamydia return rates in the ED in a community-based health system following treatment with doxycycline or azithromycin
 
Authors: 
Witney Butler
Devon Burhoe
Erica Merritt
Joseph Crosby


Background:
Sexually transmitted infections (STIs) are a major public health concern, with 1.6 million Chlamydia cases reported in 2022. Emergency Departments (EDs) play a key role in treatment, yet many patients still receive azithromycin despite CDC guidelines favoring doxycycline. Studies show doxycycline is more effective due to its sustained drug levels, while a single dose of azithromycin may be less effective in high bacterial loads or resistance. Comparing return rates between treatments, considering demographics and pharmacist follow-up, could inform hospital protocols. Logistic regression analysis may provide insights to optimize Chlamydia management and reduce ED return visits.


Methods:
This was a retrospective, observational cohort chart review that evaluated adult patients who tested positive and were treated for Chlamydia within a community-based health system and returned within 30 days after their initial visit. Patients were excluded if pregnant or tested negative for Chlamydia. A computer-generated list identified patients with a positive Chlamydia test from December 1, 2021, to August 31, 2024. Subjects were reviewed for study inclusion or exclusion based on the criteria.  Information was gathered from the subjects' electronic health records, including the prescribed antibiotic and whether they returned to the ED within 30 days for a STI complaint. If the patient was seen multiple times within the study period, there must have been at least 6 months between visits to be counted as a new study entry in the data. Patients were evaluated based on demographic characteristics including gender, sexual orientation, age, race, co-infections, insurance type, and if there was follow up by a pharmacist with a documented note in the patient’s chart. Pharmacists only contacted the patient if the test was positive and the patient was not treated correctly for Chlamydia. 


Results:
Of the 1,664 ED encounters with a positive Chlamydia test, 33 patient encounters met inclusion criteria by returning to the ED within 30 days. For comparison, a control group of 33 patients who did not return within 30 days was randomly selected. Logistic regression analysis indicated that antibiotic choice does not significantly impact 30-day return rates for patients treated for Chlamydia (p = 0.067). Logistic regression analysis also showed that ages 18-45 years old, male sex, and African American race were associated with higher odds of 30-day ED return, while having insurance reduced the odds by 46%. Compared to no antibiotics, doxycycline and azithromycin significantly reduced return odds by 76% and 61%, respectively. Co-infection with gonorrhea was also associated with lower return rates which reduced the odds by 44%.

Conclusion: 
Antibiotic selection does not appear to significantly impact 30-day ED return rates for patients with Chlamydia, suggesting it may not be a primary factor in patient return visits. More data in a larger, prospective trial is needed to determine if there is a true relationship between initial antibiotic choice and return visit to the ED. Further research should also explore adherence monitoring strategies or microbiological data to refine STI management protocols in community-based health systems.

Resident follow-up email:
butlerwi@sjchs.org