# Presentation: 378441

## Utility of Urethral Gram Stain among Male STD Clinic Attendees

- Adbul S. Palakkathodi, MD1; _**Catherine Lindsey, MPH**__**1**_; Tom Peterman, MD, MSc1; Mary Kamb, MD, MPH1; Gail Bolan, MD2; John M. Douglas, Jr., MD3; C. Kevin Malotte, DrPH4; Judy Rogers, MS5; Jonathan Zenilman, MD6; for the Project RESPECT Study Group
- 1National Center for HIV, STD, and TB Prevention, CDC, Atlanta, GA; 2San Francisco Health Department, San Francisco, CA; 3Denver Public Health Department, Denver, CO; 4California State University, Long Beach, CA; 5New Jersey Department of Health, Newark, NJ; 6Baltimore City Health Department, Baltimore, MD

## Background

- Urethral Gram Stain (UGS) is a simple,
- 	quick, inexpensive test that identifies gonococcal and nongonococcal urethritis
- Some clinics screen all men; others only
- 	men with signs or symptoms of urethritis

## Objective

- Assess the utility of UGS among male STD clinic patients with and without signs or symptoms of urethritis

## Methods

- Data from Project RESPECT, a 5-site randomized control trial of HIV counseling and testing
- Three sites, Baltimore, Long Beach, and Newark, routinely performed UGS on all patients, regardless of signs or symptoms

## Urethritis: >5 white blood cells (WBC) per x1000 	power field
Gonorrhea (GC): Gram-negative intracellular 	diplococci (GNID) or urethral culture positive
Non-gonococcal urethritis (NGU): urethritis with 	no GNID
Chlamydia (CT): positive urine PCR plus positive 	urethral culture OR positive EIA
Symptoms of urethritis: 
		Patient complaint of dysuria (pain when 	urinating) or discharge from the penis
Signs of urethritis: 
		Urethral discharge noted on exam

- Gonorrhea (GC): Gram-negative intracellular 	diplococci (GNID) or urethral culture positive
- Non-gonococcal urethritis (NGU): urethritis with 	no GNID
- Chlamydia (CT): positive urine PCR plus positive 	urethral culture OR positive EIA
- Symptoms of urethritis:
- 		Patient complaint of dysuria (pain when 	urinating) or discharge from the penis
- Signs of urethritis:
- 		Urethral discharge noted on exam

## Sensitivity, specificity, and predictive values of UGS 
		GC: 	GNID compared to GC culture
		CT: 	urethritis compared to CT tests 			(patients with urethritis treated 			presumptively for CT)

Baseline visits of men who had UGS, urethral GC culture, and CT tests (urine PCR or urethral swab culture or EIA)

- 		GC: 	GNID compared to GC culture
- 		CT: 	urethritis compared to CT tests 			(patients with urethritis treated 			presumptively for CT)
- Baseline visits of men who had UGS, urethral GC culture, and CT tests (urine PCR or urethral swab culture or EIA)

## Results

- NGU=nongonococcal urethritis

- Urethral Gram stain finding and final diagnoses, by site (%)

## 790

**Men ****with**** signs or symptoms: **
**Gram stain findings and final diagnoses**

- 35.1

- 21.5

## 89.4

**Men ****with**** signs or symptoms: **
**Gram stain findings and final diagnoses**

- 264

## 611

**Men ****with**** signs or symptoms: **
**Gram stain findings and final diagnoses**

- 25.9

## 347

**Men ****with**** signs or symptoms: **
**Gram stain findings and final diagnoses**

- 30.0

## 485

**Men ****without**** signs or symptoms: **
**Gram stain findings and final diagnoses**

- 1.6

- 10.3

## 3

**Men ****without**** signs or symptoms: **
**Gram stain findings and final diagnoses**

- 100.0

## 72

**Men ****without**** signs or symptoms: **
**Gram stain findings and final diagnoses**

- 15.3

## 69

**Men ****without**** signs or symptoms: **
**Gram stain findings and final diagnoses**

- 15.9

## Frequency of infection, based on Gram stain

- Men with signs or symptoms:
- 	790 Gram stains, 264 detected GC, 158 CT
- 	368 GC and/or CT-infected persons treated 					(54 individuals had both GC and CT)
- 	47% of Gram stains resulted in treatment of GC and/or CT-			infected persons
- Men without signs or symptoms:
- 	485 Gram stains, 3 detected GC, 11 CT
- 	14 GC or CT-infected persons treated
- 	3% of Gram stains resulted in treatment of GC or CT-infected 		persons

## Gram stain test characteristics among men with and without signs or symptoms

| 
Signs or symptoms | 
Sensitivity | 
Specificity | Positive predictive value | Negative predictive value |
| --- | --- | --- | --- | --- |
| 
with | 85% | 95% | 89% | 92% |
| 
without | 38% | 100% | 100% | 99% |

**Gram stain test characteristics among men ****with ****and**** without**** signs or symptoms**

| 
with | 93% | 27% | 26% | 93% |
| --- | --- | --- | --- | --- |
| 
without | 22% | 86% | 15% | 91% |

| Final diagnosis |
| --- |
| Gonorrhea |
|  |
| Chlamydia |
|  |

## Limitations

- Data were collected at STD clinics where the majority of patients are symptomatic
- 		Symptomatic GC and CT were over-	represented
- Only data from 3 clinics were included
- 		Small variations suggest findings may be 	different in other settings

## Conclusions

- UGS is very important for the detection and 	early treatment of GC and CT in male STD 	clinic patients with signs or symptoms of 	urethritis
- UGS is less important in males without signs 	or symptoms, but UGS did detect 1 case 	per 35 tests
- GC culture and definitive CT tests should also 	be performed on all male clinic patients to 	detect cases missed by UGS