Syndromic management of sexually transmissible infections in resource-poor settings: a systematic review with meta-analysis of the abnormal vaginal discharge flowchart for Neisseria gonorrhoea and Chlamydia trachomatis

Gemert, Caroline van; Hellard, Margaret; Bradshaw, Catriona S; Fowkes, Freya J. I.; Agius, Paul A.; Stoové, Mark; Bennett, Catherine M

doi:10.1071/sh17070

Cited by 25 publications

(28 citation statements)

References 29 publications

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“…While the flowcharts for abdominal pain are relatively satisfactory , those for vaginal discharge have severe limitations. Systematic reviews and meta‐analyses of the syndromic approach to diagnose and treat cervical infections (CT/NG) revealed low accuracy, resulting in a high proportion of overtreatment, incorrect treatment and missed treatment . In settings of low STI prevalence, endogenous vaginitis and BV, rather than CT/NG/MG, are the main causes of abnormal vaginal discharge .…”

Section: Resultsmentioning

confidence: 99%

“…Systematic reviews and meta‐analyses of the syndromic approach to diagnose and treat cervical infections (CT/NG) revealed low accuracy, resulting in a high proportion of overtreatment, incorrect treatment and missed treatment . In settings of low STI prevalence, endogenous vaginitis and BV, rather than CT/NG/MG, are the main causes of abnormal vaginal discharge . Attempts to increase the sensitivity and specificity of the vaginal discharge flowchart for the diagnosis of cervical infection using situation‐specific risk assessment have not been successful .…”

Section: Resultsmentioning

confidence: 99%

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Diagnosing sexually transmitted infections in resource‐constrained settings: challenges and ways forward

Ndowa²,

et al. 2019

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Introduction Sexually transmitted infections (STIs) remain prevalent and are increasing in several populations. Appropriate STI diagnosis is crucial to prevent the transmission and sequelae of untreated infection. We reviewed the diagnostic accuracy of syndromic case management and existing point‐of‐care tests (POCTs), including those in the pipeline, to diagnose STIs in resource‐constrained settings. Methods We prioritized updating the systematic review and meta‐analysis of the diagnostic accuracy of vaginal discharge from 2001 to 2015 to include studies until 2018. We calculated the absolute effects of different vaginal flowcharts and the diagnostic performance of POCTs on important outcomes. We searched the peer‐reviewed literature for previously conducted systematic reviews and articles from 1990 to 2018 on the diagnostic accuracy of syndromic management of vaginal and urethral discharge, genital ulcer and anorectal infections. We conducted literature reviews from 2000 to 2018 on the existing POCTs and those in the pipeline. Results and discussions The diagnostic accuracy of urethral discharge and genital ulcer disease syndromes is relatively adequate. Asymptomatic Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections limit the use of vaginal discharge and anorectal syndromes. The pooled diagnostic accuracy of vaginal syndromic case management for CT/NG is low, resulting in high numbers of overtreatment and missed treatment. The absolute effect of POCTs was reduced overtreatment and missed treatment. Findings of the reviews on syndromic case management underscored the need for low‐cost and accurate POCTs for the identification, first, of CT/NG, and, second, of Mycoplasma genitalium (MG) and Trichomonas vaginalis (TV) and NG and MG resistance/susceptibility testing. Near‐patient POCT molecular assays for CT/NG/TV are commercially available. The prices of these POCTs remain the barrier for uptake in resource‐constrained settings. This is driving the development of lower cost solutions. Conclusions The WHO syndromic case management guidelines should be updated to raise the quality of STI management through the integration of laboratory tests. STI screening strategies are needed to address asymptomatic STIs. POCTs that are accurate, rapid, simple and affordable are urgently needed in resource‐constrained settings to support the uptake of aetiological diagnosis and treatment.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Diagnosing sexually transmitted infections in resource‐constrained settings: challenges and ways forward

Ndowa²,

et al. 2019

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“…[6] Other criteria have included vaginal examination, vaginal microscopy or point-of-care (POC) testing. [3] POC tests for N. gonorrhoeae or C. trachomatis alone or in combination conducted on urine, vaginal or endocervical swabs collected from symptomatic or asymptomatic women have been found to have sensitivities ranging from 40% to 99% with positive predictive values of 31 -96%. [10,16] Research on cost-effectiveness and on how best to incorporate the POC testing into current VDS algorithms is needed.…”

Section: Researchmentioning

confidence: 99%

The demographic and clinical profiles of women presenting with vaginal discharge syndrome at primary care facilities in South Africa: Associations with age and implications for management

Kufa

Gumede²,

Maseko³

et al. 2018

S Afr Med J

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“… 20 – 22 A major concern is that many asymptomatically infected individuals go without diagnosis and treatment. 6 19 23 24 Moreover, vaginal discharge is common in pregnancy and will often occur even in the absence of an STI, 25 – 27 leading to overtreatment. In addition, syndromic management approach is not appropriate for aetiological agent management since it offers treatment for a group of diseases.…”

Section: Introductionmentioning

confidence: 99%

Prevalence, incidence and associated risk factors of STIs during pregnancy in South Africa

et al. 2020

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ObjectiveSTIs during pregnancy increase adverse pregnancy and birth outcomes and may increase HIV risk. STI syndromic management is standard of care in South Africa. Our study evaluated the prevalence and incidence of STIs in pregnant women and the associated risk factors.MethodsWe combined data from two prospective observational studies of pregnant women enrolled while attending their first antenatal clinic (ANC) visit in Tshwane District and Cape Town. Women ≥18 years were tested at first ANC visit and at their first postpartum visit for Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis using Xpert assays (Cepheid, USA). We evaluated the prevalence and incidence of STI and the associated risk factors using multivariable regression models.ResultsWe enrolled 669 pregnant women, 64% (n=427) from Tshwane District and 36% (n=242) from Cape Town; 80% (n=534) were women living with HIV (WLHIV) and 20% (n=135) without HIV. At enrolment, 37% (n=250) were diagnosed with at least one STI, of which 76% (n=190) were asymptomatic. STI prevalence was 40% (n=213) in WLHIV and 27% (n=37) in women without HIV (p=0.01). Baseline STI infection was associated with younger age (OR=0.95 per year, 95% CI 0.92 to 0.98), higher gestational age (adjusted OR (aOR)=1.03 per week, 95% CI 1.00 to 1.05), single relationship status (aOR=1.53, 95% CI 1.09 to 2.15) and HIV status (aOR=1.86, 95% CI 1.17 to 2.95). Of 419 participants with no STI at baseline, 21 had an incident STI during follow-up, with a mean follow-up time of 140 days. The incidence rate of STI during pregnancy and early post partum was 15 infections per 100 women-years (95% CI 9 to 23). Younger age was associated with STI incidence.ConclusionOur study shows high prevalence and incidence of STIs in pregnancy, especially in WLHIV, demonstrating the need for STI screening in ANC to prevent adverse pregnancy and birth outcomes. Most STI cases were asymptomatic and would have gone untreated with syndromic management. Aetiological STI screening is urgently needed to reduce the burden of STIs in pregnancy.

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Syndromic management of sexually transmissible infections in resource-poor settings: a systematic review with meta-analysis of the abnormal vaginal discharge flowchart for Neisseria gonorrhoea and Chlamydia trachomatis

Cited by 25 publications

References 29 publications

Diagnosing sexually transmitted infections in resource‐constrained settings: challenges and ways forward

Diagnosing sexually transmitted infections in resource‐constrained settings: challenges and ways forward

The demographic and clinical profiles of women presenting with vaginal discharge syndrome at primary care facilities in South Africa: Associations with age and implications for management

Prevalence, incidence and associated risk factors of STIs during pregnancy in South Africa

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