Importance: In US emergency departments (EDs), empiric antibiotic treatment for gonorrhea (GC) and chlamydia (CT) is common due to the unavailability of immediate test results. Evidence suggests sex-based disparities in treatment practices, with females potentially receiving less empiric treatment than males. Objective: To investigate sex differences in empiric antibiotic treatment for GC and CT in EDs, comparing practices to subsequent laboratory-confirmed results. Design, Setting, and Participants: This systematic review and meta-analysis included studies from US EDs reporting GC/CT testing and empiric antibiotic treatment from January 2010 to February 2021. A total of 1,644 articles were screened, with 17 studies (n = 31,062 patients) meeting inclusion criteria. Main Outcomes and Measures: The primary outcomes were GC/CT test positivity, empiric antibiotic treatment rates, and discordance between treatment and test results, stratified by sex. Data were analyzed using a random-effects model. Results: Overall GC/CT positivity was 14% (95% CI, 11%-16%): 11% (95% CI, 8%-14%) in females and 25% (95% CI, 23%-26%) in males. Empiric antibiotic treatment was administered in 46% (95% CI, 38%-55%) of cases: 31% (95% CI, 24%-37%) in females and 73% (95% CI, 65%-80%) in males. Among patients without a confirmed infection, 38% (95% CI, 30%-47%) received treatment: 27% (95% CI, 20%-34%) of females and 64% (95% CI, 55%-73%) of males. Conversely, 39% (95% CI, 31%-48%) of patients with confirmed infections were not treated: 52% (95% CI, 46%-57%) of females and 15% (95% CI, 12%-17%) of males. Conclusions and Relevance: There is significant discordance between ED empiric antibiotic treatment and laboratory-confirmed results, with notable sex-based disparities. Females were 3.5 times more likely than males to miss treatment despite confirmed infection. These findings highlight the need for improved strategies to reduce sex-based disparities and enhance empiric treatment accuracy for GC/CT in ED settings.

The authors have declared no competing interest.

Dr. Solnick was supported by the Institute for Healthcare Policy and Innovation at the University of Michigan National Clinician Scholars Program and by grant K23MH136923-01 from the National Institutes of Health during this work.

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