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 A B H , Margaret Hellard A B , Catriona S. Bradshaw C D , Freya J. I. Fowkes A B E F , Paul A. Agius A B , Mark Stoove A B and Catherine M. Bennett G
+ Author Affiliations
- Author Affiliations
A Burnet Institute, 85 Commercial Road, Melbourne, Vic. 3004, Australia.
B Department of Epidemiology and Preventative Medicine, Monash University, The Alfred Centre, 99 Commercial Road, Melbourne, Vic. 3004, Australia.
C Central Clinical School, The Alfred Centre, 99 Commercial Road, Melbourne, Vic. 3004, Australia.
D Melbourne Sexual Health Clinic, 580 Swanston Street, Carlton, Vic. 3053, Australia.
E Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Vic. 3010, Australia.
F Department of Infectious Diseases, Central Clinical School, Monash University, Level 2, The Burnet Institute, 85 Commercial Road, Melbourne, Vic. 3004, Australia.
G Centre for Population Health Research, Deakin University, Geelong, Vic. 3220, Australia.
H Corresponding author. Email: caroline.vangemert@burnet.edu.au
Sexual Health 15(1) 1-12 https://doi.org/10.1071/SH17070
Submitted: 30 March 2017 Accepted: 19 June 2017 Published: 25 August 2017
Journal compilation © CSIRO 2018 Open Access CC BY-NC-ND
Abstract
Background: 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. Methods: 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. Results: 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. 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. 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.
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