130 Treatment of Gonorrhea and Chlamydia in Emergency Department Patients

Study Objective: To assess the feasibility of a randomized controlled trial toexamine the utility of antibiotic prophylaxis for prevention of wound infection in EDpatients with simple hand lacerations.

Methods: A randomized double-blind placebo controlled pilot trial at 2 urbanacademic centers. A convenience sample of adult (�18 year-old) patients with simplehand lacerations was enrolled after informed consent. Patients with grosslycontaminated wounds, significant crush injuries, bites, or wounds older than 12hours, and those involving bone, tendon, vessel, or nerve were excluded. Subjectswere randomized to placebo, clindamycin (300 mg every 6 hours for 7 days), orcephalexin (500 mg every 6 hours for 7 days), all in similar unidentifiable capsules.Patients were followed up at 10-14 days for evidence of infection and at 30 days forassessing their satisfaction with wound appearance. Infection was determined byeither 1) direct examination by at least 2 ED physicians, or 2) antibiotic requirementafter initial visit. Patients’ satisfaction with wound appearance was assessed using avisual analogue scale (VAS) of 1-10. Descriptive statistics are used to present the data.Continuous and categorical data are presented with median with Interquartile range(IQR), and percentages with 95% confidence intervals (CI), respectively.

Results: During a 6-month period 126 patients were approached, 80 consentedto enrollment, 79 patients (median age: 41 (IQR: 29,52), 73% male) completedfollow up (25 clindamycin, 28 placebo, and 26 cephalexin). Finger lacerations werethe most common form of injury (58%), followed by palm (23%), dorsum (10%),and undocumented (9%). Wounds were sutured in 94% of patients. Only onepatient in the placebo group had infection, indicating an infection rate of (1.3%,95%CI, 0-7.2). This patient was a 62 year-old diabetic with a 3-cm lacerationinflicted by a sharp metal edge. Medication side effects were reported in a few patients(vomiting: 1 [placebo], diarrhea: 2 [placebo], palpitation: 1 [clindamycin]). Themedian score for wound appearance satisfaction was 8 (IQR: 9,10) at 30 days.

Conclusion: The results of this pilot study confirms the feasibility of arandomized double-blind placebo controlled trial that could shed light on the role ofantibiotic prophylaxis in prevention of wound infection in patients with simple handlacerations. The risk of wound infection in these patients is low, thus requiring a largesample size for the trial.

129 Characteristics and Predictors of Outcomes forPatients With Spinal Epidural Abscess

Butterfield JM, Welch RD/Detroit Receiving Hospital, Detroit, MI; Wayne StateUniversity School of Medicine, Detroit, MI

Study Objectives: Spinal epidural abscess (SEA) is a rare condition that is oftendifficult to diagnose and can result in significant disability or death. Since successfulpatient outcomes have been attributed to early diagnosis and management, the goal ofthis study is to describe features indicative of the disease and factors associated withpatient outcomes.

Methods: This retrospective study evaluated patients diagnosed with SEA treatedat a Level 1 Trauma Center (1994-2005) who were �18 years. Data abstractedincluded presenting patient characteristics, diagnostic tests, treatment and hospitaldisposition. A logistic regression model using pre-selected presenting data and time todiagnosis was fit to predict a poor outcome (defined as disability requiring longer-term institutional care or death).

Results: 174 patients were included; mean age 50 � 8.8 years, 75.3% (95%confidence interval 68.9% - 81.7%) were male, 75.1% (68.7% - 81.6%) black, and78.7% (72.7% - 84.8%) had history of intravenous drug use (IVDU). Initialsymptoms included back or spine pain (74.7%; 68.2% - 81.2%) and 8.6% (4.9% -13.8%) had complaints of paralysis. Muscle weakness in at least one extremity wasfound in 46.0% (38.6% - 53.4%). The erythrocyte sedimentation rate was � 20mm/hr in 98.1% of patients but 50% of patients had a white blood cell count in thenormal range. The diagnosis of SEA was made within 24 hours in 58.6% (51.3% -66.0%) of patients. The table shows selected patient characteristics among the 2outcome groups. Muscle weakness at presentation was independently associated witha poor outcome (adjusted odds ratio 3.0; [95% CI 1.5 - 6.0]) but patients initiallyseen in the emergency department (ED) were less likely (0.40, [0.17 - 0.97]) to have apoor outcome. Other factors such as age, race, and IVDU were not predictive.

Conclusion: We report the largest single site series of patients with SEA. Patientswho presented with the finding of muscle weakness in at least one extremity weremore likely while those initially treated in the ED were less likely to have pooroutcomes. Further work comparing patients with SEA to those with similarsymptoms but no disease is warranted to help elucidate factors that may help guideearly diagnostic strategies.

130 Treatment of Gonorrhea and Chlamydia in EmergencyDepartment Patients

Schechter-Perkins EM, Rahimi LM, Jenkins D, White L, Mitchell PM/BostonUniversity School of Medicine, Boston, MA; Boston University School ofMedicine, Boston, MA

Study Objective: To describe the frequency of effective antibiotic treatment bothin the emergency department (ED) and at follow-up, among ED patients who testpositive for Chlamydia trachomatis or Neisseria gonorrheae.

Methods: A retrospective case control chart review was performed in which arandom sample of 500 cases and 500 controls were selected from all patients whohad a test for Neisseria gonorrheae or Chlamydia trachomatis sent from the ED ofan urban, academic, level 1 trauma center from 1/1/10-6/30/11. Exclusioncriteria were: age �15, victims of sexual assault, patients who eloped or leftagainst medical advice, or repeat visits within 3 weeks of testing positive. Dataabstracted from the ED medical record by trained research assistants includeddemographics, history and physical exam findings, ED antibiotic prescribed,successful contact by the follow-up nurse, and follow-up treatment. The CDC2010 STD Treatment Guidelines were used to define effective antibiotic for eachinfection. Descriptive statistics, frequencies and logistic regression modelingusing generalized estimating equations to account for repeat visits, were used foranalysis. Double data abstraction on a 10% random sample was completed tocalculate interrater reliability.

Results: In 18 months, a total of 631 tests were positive for Chlamydiatrachomatis and 213 were positive for Neisseria gonorrheae among 6997 specimenssent. Interrater reliability was excellent with a Kappa of 0.92. Among the 500randomly selected cases, the demographics were: mean age 25, 51% female, 93%English, 73% Black, 17% Hispanic, 6% White, and 4% other. Of the 500 cases, 374were positive for Chlamydia trachomatis only, 93 for Neisseria gonorrheae only, and 33for both Chlamydia trachomatis and Neisseria gonorrheae. Of the 374 Chlamydiatrachomatis only cases, 312 (83%) received effective treatment; 174 were treated inthe ED and 138 treated on follow up. Of the 93 Neisseria gonorrheae only cases, 80(86%) received effective treatment; 66 were treated in the ED and 14 were treated onfollow up. For those who tested positive for both Chlamydia trachomatis and Neisseriagonorrheae, 30/33 (91%) were treated effectively; 25 were treated in the ED and 5were treated on follow up. Overall 422/500 (84%) cases ultimately received effectiveantibiotic treatment for their STD, 265/422 (63%) in the ED and 157/422 (37%)on follow-up. Among the 235 cases who were not treated in the ED, 78 (33%) didnot get effective antibiotics at our medical center at follow-up; 11(14%) reportedtreatment elsewhere, 18 (23%) were unable to be reached, 48 (62%) were reached butdid not return to our medical center for appropriate antibiotics, and 1 had nodocumentation of call back. Among controls, 86/500 (17%) received presumptiveantibiotic for either Neisseria gonorrheae, Chlamydia trachomatis, or both in the EDand none were called back for follow up treatment.

Conclusion: In this ED that has a dedicated callback nurse, eventualtreatment of STDs occurred in only 84% of patients who tested positive forNeisseria gonorrheae or Chlamydia trachomatis. Providers should considerpresumptive treatment at time of initial ED visit more frequently when follow-upcan not be assured, as follow up often did not lead to successful treatment in thispopulation.

Research Forum Abstracts

Volume , . : October Annals of Emergency Medicine S47