National study reveals marked disparities in immediate STI care based on pregnancy status

A repeated cross-sectional study published in JAMA Network Open revealed that pregnant patients evaluated for sexually transmitted infections (STIs) in emergency departments (EDs) are substantially less likely to receive empiric treatment compared to nonpregnant patients. Analyzing data from over 4.9 million encounters, researchers found that pregnancy status, along with various demographic factors, significantly influenced whether clinicians administered antibiotics before laboratory results were confirmed.¹

In the United States, Neisseria gonorrhea and Chlamydia trachomatis account for approximately 6.4 million new infections annually, according to the study authors. These infections are associated with pelvic inflammatory disease, ectopic pregnancy, and infertility. During pregnancy, untreated STIs pose additional risks, such as preterm birth, low birth weight, neonatal pneumonia, and conjunctivitis. Because EDs often serve as the primary point of care for individuals facing structural barriers to healthcare, the Centers for Disease Control and Prevention recommends empiric treatment when follow-up cannot be reliably ensured.²

The study utilized aggregate encounter-level data from a national deidentified electronic health record database, covering the period from January 1, 2016, to December 31, 2024. The research team analyzed data from 4,904,343 ED encounters where testing for N gonorrhea or C trachomatis was performed.¹

The primary outcome was empiric treatment, defined as the administration of guideline-recommended antibiotics during the same ED encounter as the testing. Of the total encounters, 454,048 involved pregnant patients, whereas 4,450,295 involved nonpregnant patients. Researchers estimated the associations between patient characteristics and treatment rates using unadjusted odds ratios with 95% confidence intervals.

Disparities in treatment rates by pregnancy status

The results revealed a marked difference in treatment frequency based on pregnancy status. Among nonpregnant patients, 1,699,393 of 4,450,295 (38.2%) received empiric treatment. In contrast, only 49,419 of 454,048 pregnant patients (10.9%) were treated empirically. This resulted in pregnant patients having substantially lower odds of receiving immediate treatment compared to nonpregnant patients (odds ratio, 0.20; 95% CI, 0.20-0.20).

“The substantially lower empiric treatment rate among pregnant patients may reflect heightened caution regarding antibiotic exposure during pregnancy, particularly in the absence of confirmation of a definitive diagnosis,” the study authors wrote.

However, the study suggests these competing considerations contribute to significant gaps in immediate care for a population at high risk for adverse neonatal outcomes.

Demographic variations in empiric care

Beyond pregnancy status, the study identified several demographic factors associated with higher rates of empiric treatment. In both pregnant and nonpregnant groups, immediate treatment was more common among younger patients, those with noncommercial insurance, and individuals whose primary language was English. Differences based on race and ethnicity were also observed, though these variations differed depending on the patient's pregnancy status.

The researchers concluded that these findings reflect a complex interplay of guideline interpretation, communication issues, and structural barriers to follow-up care. The study highlights that empiric treatment for N gonorrhea and C trachomatis in a national ED sample is not applied uniformly, and understanding these differences may help inform more equitable STI management strategies that align with population-level risks and access to care, particularly for pregnant individuals navigating the emergency healthcare system.

Reference:

1. Gottlieb M, Moyer E, Slocum GW, et al. Sexually Transmitted Infection Treatment Rates Among Pregnant vs Nonpregnant Patients in Emergency Departments. JAMA Netw Open. 2026;9(4):e264911. doi:10.1001/jamanetworkopen.2026.4911
2. Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187. doi:10.15585/mmwr.rr7004a1