<p><strong>OBJECTIVES: </strong>To evaluate clinician adherence to guidelines for documentation of sexual history and screening for sexually transmitted infection (STI)/HIV infection during routine adolescent well visits. Secondary objectives were to determine patient and clinician factors associated with sexual history documentation and STI/HIV testing.</p>

<p><strong>STUDY DESIGN: </strong>Retrospective, cross-sectional study of 1000 randomly selected 13- to 19-year-old routine well visits at all 29 pediatric primary care practices affiliated with a children's hospital. We evaluated frequency of documentation of sexual history and testing for gonorrhea (GC)/chlamydia (CT) and HIV testing. Multivariable logistic regression was performed to identify factors associated with documentation and testing.</p>

<p><strong>RESULTS: </strong>Of the 1000 patient visits reviewed, 212 (21.2%; 95% CI, 18.7-23.7) had a documented sexual history, of which 45 adolescents' (21.2%; 95% CI, 15.7-26.8) encounters were documented as being sexually active. Overall, 26 (2.6%; 95% CI, 1.6-3.6) patients were tested for GC/CT and 16 (1.6%; 95% CI, 0.8-2.4) were tested for HIV infection. In multivariable analyses, factors associated with sexual history documentation included older patient age, non-Hispanic black race/ethnicity, nonprivate insurance status, and care by female clinician. Factors associated with GC/CT testing included male gender, non-Hispanic black race/ethnicity, and nonprivate insurance. HIV testing was more likely to be performed on older adolescents, those of non-Hispanic black race/ethnicity, and those with nonprivate insurance.</p>

<p><strong>CONCLUSIONS: </strong>Pediatric primary care clinicians infrequently document sexual histories and perform STI and HIV testing on adolescent patients. Future studies should investigate provider beliefs, clinical decision-making principles, and perceived barriers to improve the sexual health care of adolescents and evaluate interventions to increase rates of adolescent sexual health screening.</p>

<p><strong>INTRODUCTION: </strong>Community-associated methicillin resistant Staphylococcus aureus (CA-MRSA) has emerged as the most common cause of skin and soft-tissue infections (SSTI) in the United States. A nearly three-fold increase in SSTI visit rates had been documented in the nation's emergency departments (ED). The objective of this study was to determine characteristics associated with ED performance of incision and drainage (I+D) and use of adjuvant antibiotics in the management of skin and soft tissue infections (SSTI).</p>

<p><strong>METHODS: </strong>Cross-sectional study of the National Hospital Ambulatory Medical Care Survey, a nationally representative database of ED visits from 2007-09. Demographics, rates of I+D, and adjuvant antibiotic therapy were described. We used multivariable regression to identify factors independently associated with use of I+D and adjuvant antibiotics.</p>

<p><strong>RESULTS: </strong>An estimated 6.8 million (95% CI: 5.9-7.8) ED visits for SSTI were derived from 1,806 sampled visits; 17% were for children &lt;18 years of age and most visits were in the South (49%). I+D was performed in 27% (95% CI 24-31) of visits, and was less common in subjects &lt;18 years compared to adults 19-49 years (p&lt;0.001), and more common in the South. Antibiotics were prescribed for 85% of SSTI; there was no relationship to performance of I+D (p=0.72). MRSA-active agents were more frequently prescribed after I+D compared to non-drained lesions (70% versus 56%, p&lt;0.001). After multivariable adjustment, I+D was associated with presentation in the South (OR 2.36; 95% CI 1.52-3.65 compared with Northeast), followed by West (OR 2.13; 1.31-3.45), and Midwest (OR 1.96; 1.96-3.22).</p>

<p><strong>CONCLUSION: </strong>Clinical management of most SSTIs in the U.S. involves adjuvant antibiotics, regardless of I+D. Although not necessarily indicated, CA-MRSA effective therapy is being used for drained SSTI.</p>

<p><strong>OBJECTIVES: </strong>The objective was to estimate the frequency of pregnancy testing among adolescent emergency department (ED) patients and to determine factors associated with testing.</p>

<p><strong>METHODS: </strong>This was a retrospective cross-sectional study using the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2005 through 2009 of ED visits by females ages 14 to 21 years. The frequency of pregnancy testing among all visits was estimated for potential reproductive health complaints and for those associated with exposure to potentially teratogenic radiation. Multivariable logistic regression modeling was performed to calculate adjusted probabilities and odds ratios (ORs) with 95% confidence intervals (CIs) to evaluate factors associated with pregnancy testing by patient characteristics.</p>

<p><strong>RESULTS: </strong>The authors identified 11,531 visits, representing an estimated 41.0 million female adolescent ED visits. Of these, 20.9% (95% CI = 19.3% to 22.5%) included pregnancy testing. Among visits for potential reproductive health complaints and those associated with exposure to potentially teratogenic radiation, 44.5% (95% CI = 41.3% to 47.8%) and 36.7% (95% CI = 32.5% to 40.9%), respectively, included pregnancy testing. Among the entire study population, we found statistically significant differences in pregnancy testing by age, race or ethnicity, hospital admission, and geographic region (p &lt; 0.001 for all).</p>

<p><strong>CONCLUSIONS: </strong>A minority of female adolescent ED visits included pregnancy testing, even if patients presented with potential reproductive health complaints or received exposure to ionizing radiation. Small but statistically significant differences in pregnancy testing rates were noted based on age, race or ethnicity, ED disposition, and geographic region. Future studies should focus on designing quality improvement interventions to increase pregnancy testing in adolescent ED patients, especially among those in whom pregnancy complications or the risk of potentially teratogenic radiation exposure is higher.</p>

<p><strong>PURPOSE: </strong>In 2002, the Centers for Disease Control and Prevention (CDC) broadened the pelvic inflammatory disease (PID) diagnostic criteria to increase detection and prevent serious sequelae of untreated PID. The impact of this change on PID detection is unknown. Our objectives were to estimate trends in PID diagnosis among adolescent emergency department (ED) patients before and after the revised CDC definition and to identify factors associated with PID diagnoses.</p>

<p><strong>METHODS: </strong>We performed a retrospective repeated cross-sectional study using the National Hospital Ambulatory Medical Care Survey from 2000 to 2009 of ED visits by 14- to 21-year-old females. We calculated national estimates of PID rates and performed multivariable logistic regression analyses and tests of trends.</p>

<p><strong>RESULTS: </strong>During 2000-2009, of the 77 million female adolescent ED visits, there were an estimated 704,882 (95% confidence interval [CI], 571,807-837,957) cases of PID. After the revised criteria, PID diagnosis declined from 5.4 cases per 1,000 United States adolescent females to 3.9 cases per 1,000 (p = .03). In a multivariable model, age ≥17 years (odds ratio, 2.14; 95% CI, 1.25-3.64) and black race (odds ratio, 2.04; 95% CI, 1.36-3.07) were associated with PID diagnosis.</p>

<p><strong>CONCLUSIONS: </strong>Despite broadened CDC diagnostic criteria, PID diagnoses did not increase over time. This raises concern about awareness and incorporation of the new guidelines into clinical practice.</p>

<p><strong>OBJECTIVE: </strong>Limited data exist regarding knowledge of and compliance to the Centers for Disease Control and Prevention's universal adolescent human immunodeficiency virus (HIV) screening recommendations. Our objective was to assess current guideline knowledge, practice, and perceived barriers to emergency department (ED)-based adolescent HIV screening.</p>

<p><strong>METHODS: </strong>We administered an anonymous Web-based cross-sectional survey from May 1, 2012, to June 30, 2012, to 1073 physicians from the American Academy of Pediatrics Section on Emergency Medicine LISTSERV. Survey participants were included if they (1) practiced as attending-level physicians, (2) practiced primarily in pediatric emergency medicine or general emergency medicine, and (3) provided clinical care for patients younger than the age of 21 years. The survey examined respondent demographics, knowledge, attitudes, beliefs, practices, and barriers to ED-based HIV screening. Standard descriptive statistics and comparative analyses were performed.</p>

<p><strong>RESULTS: </strong>A total of 220 responses were obtained; 29 responses were excluded and 191 responses were included in the study. Most of the participants were from urban, free-standing children's hospitals and had an annual ED volume of more than 61,000 patient visits. Respondent knowledge of the Centers for Disease Control and Prevention guidelines was low; less than 40% of the respondents identified correct consent requirements. Only 15.4% of the respondents reported screening for HIV more than 10 times for the prior 6 months. Most frequently cited barriers included concerns for privacy (67.4%), follow-up (67%), and cost-effectiveness (65.4%). Human immunodeficiency virus screening facilitators included availability of health educators (83%), established follow-up (74.7%), and rapid HIV tests (65.2%).</p>

<p><strong>CONCLUSIONS: </strong>Emergency department clinicians exhibit poor knowledge of adolescent HIV screening recommendations. Current universal screening practices remain low; barriers to screening are numerous. Future efforts should disseminate guideline knowledge, increase rapid HIV testing and health educator availability, as well as reduce adolescent-specific barriers.</p>

<p>In pediatric bloodstream infections with fluoroquinolone (FQ)-resistant Escherichia coli and Klebsielia species, we noted an association between FQ resistance and extended-spectrum beta-lactamase (ESBL) production (OR, 12; 95% CI: 2.28-83.8). A case control study revealed no significant risk factors (including prior antibiotic use) for FQ resistance among ESBL E coli and Klebsiella species (ESBL-EK).</p>

<p><strong>OBJECTIVES: </strong>The objectives were to estimate the frequency of pregnancy testing in emergency department (ED) visits by reproductive-aged women administered or prescribed teratogenic medications (Food and Drug Administration categories D or X) and to determine factors associated with nonreceipt of a pregnancy test.</p>

<p><strong>METHODS: </strong>This was a retrospective cross-sectional study using 2005 through 2009 National Hospital Ambulatory Medical Care Survey data of ED visits by females ages 14 to 40&nbsp;years. The number of visits was estimated where teratogenic medications were administered or prescribed and pregnancy testing was not conducted. The association of demographic and clinical factors with nonreceipt of pregnancy testing was assessed using multivariable logistic regression.</p>

<p><strong>RESULTS: </strong>Of 39,859 sampled visits, representing an estimated 141.0 million ED visits by reproductive-aged females nationwide, 10.1 million (95% confidence interval [CI]&nbsp;=&nbsp;8.9 to 11.3 million) estimated visits were associated with administration or prescription of teratogenic medications. Of these, 22.0% (95% CI&nbsp;=&nbsp;19.8% to 24.2%) underwent pregnancy testing. The most frequent teratogenic medications administered without pregnancy testing were benzodiazepines (52.2%; 95% CI&nbsp;=&nbsp;31.1% to 72.7%), antibiotics (10.7%; 95% CI&nbsp;=&nbsp;5.0% to 16.3%), and antiepileptics (7.7%; 95% CI&nbsp;=&nbsp;0.12% to 15.5%). The most common diagnoses associated with teratogenic drug prescription without pregnancy testing were psychiatric (16.1%; 95% CI&nbsp;=&nbsp;13.6% to 18.6%), musculoskeletal (12.7%; 95% CI&nbsp;=&nbsp;10.8% to 14.5%), and cardiac (9.5%; 95% CI&nbsp;=&nbsp;7.6% to 11.3%). In multivariable analyses, visits by older (adjusted odds ratio [AOR]&nbsp;= 0.57, 95% CI&nbsp;=&nbsp;0.42 to 0.79), non-Hispanic white females (AOR&nbsp;= 0.71; 95% CI&nbsp;=&nbsp;0.54 to 0.93); visits in the Northeast region (AOR&nbsp;= 0.60; 95% CI&nbsp;=&nbsp;0.42 to 0.86); and visits during which teratogenic medications were administered in the ED only (AOR&nbsp;= 0.74; 95% CI&nbsp;=&nbsp;0.57 to 0.97) compared to prescribed at discharge only were less likely to have pregnancy testing.</p>

<p><strong>CONCLUSIONS: </strong>A minority of ED visits by reproductive-aged women included pregnancy testing when patients were prescribed category D or X medications. Interventions are needed to ensure that pregnancy testing occurs before women are prescribed potentially teratogenic medications, as a preventable cause of infant morbidity.</p>