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.

Caroline Van Gemert,Paul A Agius,Catherine M Bennett,Mark Stoove,Freya J I Fowkes,Margaret Hellard,Catriona S Bradshaw

doi:10.1071/sh17070

Abstract

Syndromic management of sexually transmissible infections is commonly used in resource-poor settings for the management of common STIs; abnormal vaginal discharge (AVD) flowcharts are used to identify and treat cervical infection including Neisseria gonorrhoea and Chlamydia trachomatis. A systematic review and meta-analysis was undertaken to measure the diagnostic test performance of AVD flowcharts, including both World Health Organization (WHO)- and locally-adapted AVD flowcharts. A systematic search of multiple electronic databases was conducted to locate eligible studies published between 1991 and 2014. Flowcharts were categorised into one of 14 types based on: 1) use of WHO guidelines or locally-adapted versions; 2) use of risk assessment, clinical examination or both; and 3) symptomatic entry. Summary diagnostic performance measures calculated included summary sensitivity, summary specificity and diagnostic odds ratio. Thirty-six studies, including data on 99 flowcharts, were included in the review. Summary sensitivity estimates for WHO flowcharts ranged from 41.2 to 43.6%, and for locally adapted flowcharts from 39.5 to 74.8%. Locally adapted flowcharts performed slightly better than the WHO flowcharts. A difference in performance was not observed between use of risk assessment or clinical examination. The AVD flowchart performed slightly better when it was not restricted to symptomatic women only. There was considerable variation in the performance of the AVD flowchart but overall it was a poor diagnostic tool regardless of whether risk assessment or clinical examination was included, or whether the flowchart was WHO or locally developed. Many women were treated unnecessarily and many women with cervical infection were not detected. We caution against their continued use for management of cervical infection.

Highlights

Women in resource-poor settings are disproportionately affected by curable sexually transmissible infections (STIs), dominated by Neisseria gonorrhoea (NG) and Chlamydia trachomatis (CT).[1,2] Untreated cervical infections can cause serious complications including infertility, cervical cancer, spontaneous abortion, premature delivery and low birthweight.[3]
The titles and abstracts of these studies were assessed against the inclusion criteria; a total of 250 studies were excluded on the basis of not being relevant (n = 172), not meeting the eligibility criteria (n = 75) or full text not able to be retrieved (n = 3)
Pooled diagnostic performance estimates suggest improved performance when the abnormal vaginal discharge (AVD) flowchart was not restricted to participants with self-reported AVD symptoms (Table 2)

Summary

Introduction

Women in resource-poor settings are disproportionately affected by curable sexually transmissible infections (STIs), dominated by Neisseria gonorrhoea (NG) and Chlamydia trachomatis (CT).[1,2] Untreated cervical infections can cause serious complications including infertility, cervical cancer, spontaneous abortion, premature delivery and low birthweight.[3]. Syndromic management of sexually transmissible infections is commonly used in resource-poor settings for the management of common STIs; abnormal vaginal discharge (AVD) flowcharts are used to identify and treat cervical infection including Neisseria gonorrhoea and Chlamydia trachomatis. A systematic review and meta-analysis was undertaken to measure the diagnostic test performance of AVD flowcharts, including both World Health Organization (WHO)- and locally-adapted AVD flowcharts. Flowcharts were categorised into one of 14 types based on: 1) use of WHO guidelines or locally-adapted versions; 2) use of risk assessment, clinical examination or both; and 3) symptomatic entry. Conclusions: There was considerable variation in the performance of the AVD flowchart but overall it was a poor diagnostic tool regardless of whether risk assessment or clinical examination was included, or whether the flowchart was WHO or locally developed. We caution against their continued use for management of cervical infection

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