Risk assessment, symptoms, and signs as predictors of vulvovaginal and cervical infections in an urban US STD clinic: implications for use of STD algorithms.

OBJECTIVE: To identify clinical epidemiological correlates of cervical and vaginal infections and assess alternative algorithms, including two new reproductive tract infection (RTI) algorithms, for syndromic management of these infections. DESIGN, SETTING AND SUBJECTS: We prospectively studied clinical manifestations and risk correlates of cervical and vaginal infections in a randomly sampled group of 779 female patients seeking evaluation for a new problem at a Seattle STD clinic. METHODS: One experienced clinician performed standardised history, physical examination, and microscopy. Reference laboratories performed microbiological tests. Three levels of retrospective evaluation of algorithms included risk assessment and symptom review (RAS) alone; addition of speculum and bimanual examinations; and further addition of microscopy. RESULTS: (1) Chief complaint of abnormal vaginal discharge predicted a significantly lower rate of gonorrhoea (GC) or chlamydial infection (CT) than rates observed with no complaint of vaginal discharge. Only the elicited symptom of yellow vaginal discharge (not the more common symptoms of increased or malodorous vaginal discharge) predicted GC or CT. Chief complaint of abnormal vaginal discharge itself predicted trichomoniasis (TV) and bacterial vaginosis (BV), not cervical infection. Candida albicans was strongly associated with the chief complaint of vulvar pruritus, not with the chief complaint of abnormal vaginal discharge. (2) Applying these algorithms in STD clinics only to women with the chief complaint of abnormal vaginal discharge, rather than to all women, decreases sensitivity for GC or CT, without increasing positive predictive value (PPV). Criteria for inclusion of patients have more effect on the performance of these algorithms than do the levels of evaluation used. (3) A modified World Health Organisation (WHO) algorithm applied only to patients with symptoms of vaginal discharge, involving treatment of RAS positives for cervical infection, followed by treatment of vaginal infections and cervicitis based on examination of RAS negatives and positives, had a sensitivity of 50% and PPV of 33% for cervical infection, and very low sensitivity for BV, TV, and for vulvovaginal candidiasis (VVC). (4) An RTI algorithm derived from these data, and applied to all STD patients, involving RAS and examination of all RAS negatives, provided treatment to all cases of BV and TV associated with symptoms of vaginal discharge; treatment of all VVC associated with symptoms of vulvar pruritus; treatment for GC and GT to all RAS positives (using easily elicited risk factors) and to RAS negatives with signs of cervicitis or PID. This algorithm had a sensitivity of 87% and a PPV of 33% for GC or CT in this population, with its 24% prevalence of GC or CT. The sensitivity for BV, TV, and VVC greatly exceeded that of the modified WHO algorithm. (5) A modified RTI algorithm, involving examination rather than treatment of RAS positive women, no examination of RAS negatives, decreased the sensitivity for cervical infection to 55% but increased the PPV to 51%. CONCLUSIONS: Syndromic management of vaginal discharge offers relief of symptoms, prevention of transmission of trichomonas, and perhaps prevention of complications of BV. The 51% PPV of the modified RTI algorithm probably would warrant treatment and partner notification for GC and CT in settings with similar rates of GC and CT where more specific tests are lacking. However, as the prevalence of GC or CT decreases, the ratio of uninfected to infected who receive treatment with these algorithms would increase greatly, making the algorithms potential victims of their own success.

Reproductive tract infections in primary healthcare, family planning, and dermatovenereology clinics: evaluation of syndromic management in Morocco.

OBJECTIVE: To determine where and with what symptoms women seek care for reproductive tract infections (RTI) in Morocco and to guide allocation of resources for training and treatment for RTIs. METHODS: A primary healthcare centre (PHC), a family planning centre (FPC), and a specialty dermatovenereology clinic (SC) were selected in each of three urban areas. Women with symptoms of vaginal discharge, lower abdominal or pelvic pain, or genital lesions (genital ulcer or warts) underwent interviews, physical examinations, serological testing for human immunodeficiency virus (HIV) and syphilis, and collection of vaginal fluid for microscopic examination, and urine for detection of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) by ligase chain reaction (LCR). RESULTS: Over 8 months, 1238 women enrolled, including 61.8% at PHCs, 34.8% at FPCs, and 3.4% at SCs. Overall, 54% complained of vaginal discharge, of whom 8.8% had GC or CT infection and 30.1% had trichomoniasis (TV) or bacterial vaginosis (BV); 24.9% complained of lower abdominal pain with or without vaginal discharge, of whom 7.3% had GC or CT and 22.6% had TV or BV. GC or CT infections were found in 10.1% of PHC and 5.4% of FPC patients; while TV and/or BV infections were found in 28.7% and 22.8%, respectively. GC or CT infection was associated with perceived risk behaviours of the male partner (for example, belief partner is unfaithful) more often than with reported risk behaviours of the women themselves. For vaginal infections, a modified World Health Organisation (WHO) test algorithm for vaginal discharge involving risk assessment plus speculum and bimanual examination was 98.0% sensitive at PHCs and 90.8% at FPCs, with positive predictive value (PPV) of 33.4% at PHCs and 26.8% at FPCs. For GC or CT infections this algorithm was 60.6% sensitive at PHCs and 85.7% sensitive at FPCs; but PPV was only 9.9% and 9.0% respectively, little higher than the background prevalence of these infections. An RTI algorithm (Morocco specific) had comparable sensitivity and PPV for vaginal infection, and for cervical infection was less sensitive but had much higher PPV (26.9% for PHCs and 26.7% for FPCs). CONCLUSION: Women with complaints of vaginal discharge and/or lower abdominal pain presented to PHC and FP clinics, not to SCs. PHCs and FPCs should therefore receive resources for management of vaginal discharge. Both the test algorithm and the new RTI algorithm were useful in allocating treatment for vaginal infection, but only the RTI algorithm discriminated in selecting women with cervical infection. Even with the RTI algorithm, which limited treatment for cervical infection to risk assessment positive patients with signs of cervical infection or PID, the PPV for cervical infection was low, potentially resulting in frequent overtreatment and problems of partner notification.