Abstract
IMPORTANCE: Emergency departments (EDs) play a central role in the evaluation and treatment of sexually transmitted infections, particularly for patients with limited access to outpatient care. National guidelines recommend empiric treatment for Neisseria gonorrhea and Chlamydia trachomatis when clinical concern is present or follow-up cannot be ensured. However, there are limited data on how empiric treatment is applied across pregnancy status and patient demographics in the ED setting. OBJECTIVE: To compare empiric treatment rates between pregnant and nonpregnant patients evaluated for N gonorrhea and C trachomatis infection in EDs and to examine demographic differences in empiric treatment within these groups. DESIGN, SETTING, AND PARTICIPANTS: Repeated cross-sectional study using aggregate encounter-level data from Epic Cosmos, a national deidentified electronic health record database, from January 1, 2016, to December 31, 2024, of ED patients for whom N gonorrhea or C trachomatis testing was performed. Data were analyzed from January 21 to 25, 2026. EXPOSURE: Pregnancy status at the time of the ED encounter. MAIN OUTCOMES AND MEASURES: The primary outcome was empiric treatment, defined as administration of a guideline-recommended antibiotic regimen for N gonorrhea or C trachomatis infection during the same ED encounter as the testing. Associations between patient characteristics and empiric treatment were estimated using unadjusted odds ratios with 95% CIs, calculated from aggregate counts. RESULTS: Among 4 904 343 ED encounters with N gonorrhea or C trachomatis testing, 49 419 of 454 048 pregnant patients (10.9%) and 1 699 393 of 4 450 295 nonpregnant patients (38.2%) received empiric treatment. Pregnant patients had substantially lower odds of empiric treatment than nonpregnant patients (odds ratio, 0.20; 95% CI, 0.20-0.20). For both pregnant and nonpregnant patients, empiric treatment was more common among younger patients, those with noncommercial insurance, and patients whose primary language was English. Differences by race and ethnicity were observed but varied by pregnancy status. CONCLUSIONS AND RELEVANCE: These findings suggest that in a national ED sample, empiric treatment for patients tested for N gonorrhea and C trachomatis differed markedly by pregnancy status and across demographic characteristics. These differences may reflect a combination of guideline interpretation, communication, and structural barriers to follow-up rather than uniform clinician bias. Understanding how empiric treatment aligns with population-level risk and access to care may inform more equitable management of sexually transmitted infections in ED settings.