Sex disparities in chlamydia and gonorrhea treatment in U.S. adult emergency departments: A systematic review and meta-analysis

Background: Empiric antibiotic treatment for gonorrhea (GC) and chlamydia (CT) is common in U.S. emergency departments (EDs) due to the delayed availability of test results. Local studies have identified sex-based disparities in sexually transmitted infection (STI) care, with females potentially receiving less empiric treatment than males. This study evaluates how STI treatment aligns with laboratory-confirmed results to quantify potential overtreatment and undertreatment rates and investigates sex differences for these outcomes. Methods: We conducted a preregistered (PROSPERO #241429) systematic review and meta-analysis of studies published between January 2010 and January 2025 in U.S. EDs, excluding studies conducted exclusively in pediatric settings. Searches were performed in Medline, Cochrane, Embase, Scopus, Web of Science, CINAHL, and PsycINFO. Data from 19 studies encompassing 32,593 tested patients were analyzed using a random-effects model to calculate pooled estimates. Primary outcomes included GC/CT positivity, empiric treatment rates, and discordance between treatment and test results stratified by sex. Results: Overall GC/CT positivity was 14% (95% confidence interval [CI] 12%–16%): 11% (95% CI 8%–14%) in females and 25% (95% CI 23%–26%) in males. Antibiotics were given to 46% (95% CI 38%–54%) of patients: 31% (95% CI 24%–37%) of females and 73% (95% CI 65%–80%) of males. Among patients with negative test results, 38% (95% CI 30%–47%) received antibiotics (i.e., potential overtreatment): 27% (95% CI 20%–34%) of females and 64% (95% CI 55%–73%) of males. Conversely, 39% (95% CI 31%–46%) of laboratory-positive patients did not receive antibiotics (i.e., potential undertreatment): 52% (95% CI 46%–57%) of females and 15% (95% CI 12%–17%) of males. Conclusions: Significant sex-based disparities exist in ED empiric antibiotic treatment for GC/CT. Females were 3.5 times more likely than males to be potentially undertreated. These findings underscore the need for targeted interventions to reduce disparities and improve treatment accuracy. Interpretation is limited by study heterogeneity and incomplete sex-specific data.