Selected Papers from the 1999 Society for Academic Emergency Medicine Meetings
Post-Exposure Prophylaxis for Rabies
The authors report the results of the rabies arm of the EMERGEncy ID NET study group, which consists of 11 EDs in the United States. These centers serve as the population base for the ongoing study of various emerging infections. Data were prospectively collected on animal exposure demographics and post-exposure prophylaxis (PEP) practices in an attempt to determine the appropriateness of therapy given or withheld. The gold standard for PEP practices varies with regional rabies epidemiological trends, and was determined in conjunction with local public health department recommendations. Of 2055 animal contacts, approximately 80% were with dogs, 13% with cats, 0.5% with raccoons, 0.2% with bats, and 6.5% with other animals. One hundred-thirty-one (6%) patients received PEP, and in 47% of those cases it was given inappropriately. Perhaps more concerning is the finding that in 114 (6%) of cases, PEP should have been administered and was not.
Comment by Richard Harrigan, MD, FAAEM, FACEP
Post-exposure prophylaxis after potential exposure to the rabies virus is important in that the disease virtually is 100% fatal if contracted, yet is 100% preventable if PEP is administered correctly. What makes the issue of PEP prophylaxis difficult is that, unlike heart failure and asthma therapy, administration of rabies prophylaxis is not something the emergency physician does every day. Therefore, the issues of when and how to treat may not be at our fingertips; the data presented in this abstract certainly illustrate this point. Emergency physicians should be familiar with the recently published Centers for Disease Control and Prevention (CDC) guidelines concerning human rabies prevention,1 which were reprinted in the Annals of Emergency Medicine.2 Highlights of the current PEP recommendations were presented in a recent issue of Emergency Medicine Alert.3 Consideration should be given to deriving a treatment algorithm for your ED, based on the CDC recommendations and regional rabies epidemiology as per your local public health department. This algorithm could be posted in the ED or integrated into the department computer system. The data presented by Moran and colleagues suggest that an emphasis should be placed on defining at-risk animals for transmission of the virus, the circumstances of exposure, and the availability of that animal (if it were a dog, cat, or ferret) for observation. (Source: Moran GJ, et al. Appropriateness of emergency department rabies post-exposure prophylaxis for animal exposures in the United States [abstract]. Acad Emerg Med 1999;6:376.)
1. Centers for Disease Control and Prevention. Human rabies prevention—United States, 1999. Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morb Mortal Wkly Rep MMWR 1999; 48(RR 1):1-21.
2. Centers for Disease Control and Prevention. Human rabies prevention—United States, 1999. Recommendations of the Advisory Committee on Immunization Practices (ACIP). Ann Emerg Med 1999;33:590-597.
3. Harrigan RA. Update: Rabies 1999. Emerg Med Alert 1999;5:77-79.
Prevalence of Gonorrhea and Chlamydia
The purpose of this study was to determine the age-based prevalence of "unrecognized" gonorrhea (GC) and chlamydia trachomatis (CT) in a large, inner-city, university teaching hospital. This was viewed as a first step toward developing an ED-based screening program for sexually transmitted diseases. Urine samples were tested by a ligase chain reaction (LCR) assay in 700 patients aged 18-44 years.
Among the 434 patients who were 18-31 years old, 59 (13.6%) cases were positive for GC or CT by urine LCR. Among the 221 patients in the 32-44 year age group, only four (1.8%) cases were positive. Of those infected, 48 (76.2%) went "unrecognized" (did not receive appropriate treatment) by clinicians in the ED. Therefore, the prevalence of unrecognized GC or CT in the 18- to 31-year-old group was 10.4%.
Comment by Stephanie Abbuhl, MD, FACEP
The high prevalence rates in this study are alarming and remind us of the disturbingly silent nature of some STDs. These results are consistent with a similar study of 13,200 new female U.S. Army recruits using urine LCR assays where the overall prevalence of chlamydial infection was found to be 9.2%, with a peak of 12.2% among the 17-year-olds.1 I am philosophically in favor of GC/CT screening because it is epidemic, associated with significant morbidity, readily diagnosed, and treatable. Unfortunately, there are two practical issues that limit the feasibility of this kind of a screening program: 1) the urine LCR assay is labor intensive and time consuming and not available at point of service; and 2) the charge for each LCR assay runs in the $60-$90 range. (Source: Mehta S, et al. Detection of unrecognized gonorrhea and chlamydia using a urine ligase chain reaction assay [abstract]. Acad Emerg Med 1999;6:376.)
1. Gaydos CA, et al. Chlamydia trachomatis infections in female military recruits. N Engl J Med 1998;339:739-744.
Generalized use of the urine ligase chain reaction assay for detection of gonorrhea and chlamydia:
a. is easily attained due to the simplicity of this bedside test.
b. is limited due to impaired sensitivity for gonorrhea.
c. is limited by the high cost of the test.
d. is limited due to impaired sensitivity for chlamydia.