This post is a summary and discussion of the following article from JAMA Pediatrics:

Reed JL, Palmer CA, Casper TC, et al. Gonorrhea and Chlamydia Screening for Adolescents and Young Adults in Emergency Departments. JAMA Pediatr. Published online September 08, 2025. doi:10.1001/jamapediatrics.2025.2139

Adolescents account for nearly half of the 2.5 million newly diagnosed sexually transmitted infections (STIs) in the US each year. Many rely on the emergency department (ED) as their primary source of health care, yet fewer than 1% of ED patients are screened for gonorrhea and chlamydia (GC/CT) under current practice. Missing these infections can lead to reproductive complications and ongoing transmission.

This multicenter trial asked whether targeted (risk-score–based) or universal (offered to all) screening approaches would detect more infections than usual clinician-driven care.

This was a pragmatic, multicenter, type 3 hybrid stepped-wedge crossover trial, which means it was designed to reflect real-world practice, took place at six tertiary-care pediatric EDs, and rolled out the interventions in sequence so that each site eventually experienced both usual care and intervention phases. Because it was a type 3 hybrid trial, the primary focus was on implementation — how feasible and effective it was to integrate screening into the ED workflow — while also measuring important clinical outcomes like infection detection rates.

  • Population: Patients 15–21 years old (98,413 ED visits)
  • Exclusions: Critically ill, suspected sexual assault or abuse, cognitive impairment or altered mental status, unable to consent, non-English speaking
  • Interventions:
    • Usual care: Testing ordered at clinician discretion
    • Targeted screening: Tablet-based sexual health survey (cSHS) generated a risk score (low, at-risk, high) that triggered clinical decision support (CDS) in the EHR
    • Universal screening: All eligible patients were offered GC/CT testing, and CDS fired based on the patient’s decision rather than survey results
  • Primary Outcome: GC/CT detection rate per 1,000 eligible visits (2-week intervals)
  • Secondary Outcomes: Testing rates, CDS adherence, patient acceptance, ED length of stay
  • Testing Volume:
    • Usual care: 1,432/18,633 visits (7.7%)
    • Targeted: 3,216/41,082 visits (7.8%)
    • Universal: 2,856/38,698 visits (7.4%)
  • Detection Rates (per 1,000 visits):
    • Targeted: +2.59 vs usual care (95% CI 2.46–2.73)
    • Universal: +1.81 vs usual care (95% CI 1.67–1.94)
  • Risk-Stratified Testing: In targeted screening, testing rates rose with risk level: 3.2% low risk, 43% at risk, 58% high risk (P < .001).
  • Positivity Rates: Slightly lower in targeted (16.8%) and universal (15.6%) phases compared to usual care (19.3%), consistent with broader testing of asymptomatic patients.

Targeted screening resulted in the highest population-level detection rates, but both strategies improved over usual care. This means:

  • If you have resources for only one approach, targeted screening may yield more infections detected per 1,000 visits.
  • Offering screening via a tablet or automated process encourages testing. Many teens will accept screening when explicitly offered.
  • Workflow integration is key. Uptake was just 15.1% of eligible visits, likely limited by staff capacity during the COVID-19 pandemic. Automating screening or allowing patients to access the survey via their own devices could improve reach.
  • Clinicians were more likely to order tests when CDS reflected patient choice (universal phase), suggesting shared decision-making strengthens adherence.
  • Implementation occurred during the COVID-19 pandemic, which likely reduced survey administration due to staffing shortages and infection control concerns.
  • Non-English-speaking patients were excluded, which is a small but important population for future work.
  • Requires IT support (EHR integration and tablet workflow), which may be challenging for some institutions.

Both targeted and universal GC/CT screening approaches in the pediatric ED improved infection detection compared to usual care, with targeted screening identifying the most infections at a population level. These results support building scalable, integrated screening workflows to catch more asymptomatic STIs in adolescents and young adults.

Reed JL, Palmer CA, Casper TC, et al. Gonorrhea and Chlamydia Screening for Adolescents and Young Adults in Emergency Departments. JAMA Pediatr. Published online September 08, 2025. doi:10.1001/jamapediatrics.2025.2139