Evaluating the utility of syndromic case management for three sexually transmitted infections in women visiting hospitals in Delhi, India

Abstract

Utility of syndromic case management (SCM) in women visiting obstetrics & gynecology department needs to be evaluated as it is subjective and imperfect. Consequently, antibiotic resistance has accelerated along with increased risk of infection to the partners. To understand the effectiveness and/or inadequacies of SCM, 11000 women were recruited and examined by clinicians for infection by Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Trichomonas vaginalis (TV), Bacterial vaginosis (BV) and others. Amongst these patients, 1797 (16.3%) reported vaginal discharge (VD). Other symptoms included: vaginitis (97%), cervicitis (75%), genital ulcers (60%), abnormal vaginal discharge (55%) and lower abdominal pain (48%). The patients were treated for single or co-infections using pre-packed National Aids Control Program III STI/RTI Kits. However, based on PCR diagnostics, 1453/1797 (81%) subjects were uninfected for NG/TV/CT. Amongst 344 (19%) infected patients, 257 (75%) carried infection with single pathogen (TV/NG/CT) while 87/344 (25%) were co-infected with multiple pathogens. Prevalence of TV, NG & CT was 4%, 7% and 8% respectively. Co-infection with CT + NG was highest, 51% (44/87), whereas, co-infection with CT + TV was 21% and NG + TV was 18% while co-infection with all three pathogens was 1.3%. We conclude that SCM is imprecise and successful intervention requires accurate and confirmatory diagnostic approach.

Figure: 1

(A) Distribution of infected and uninfected patients based on PCR diagnostic assay using total genomic DNA isolated from clinical samples. (B) Diagrammatic representation of distribution of infected and uninfected patients for single or mixed infection. The distribution of infection with T. vaginalis, N. gonorrhoeae and C. trachomatis out of the total symptomatic patients enrolled in the study is shown.

Figure 2

Venn diagram showing prevalence of T. vaginalis, C. trachomatis and N. gonorrhoeae infection as well as co-infection. DNA was isolated from samples collected from symptomatic patients and infection for these three pathogens was determined by PCR based diagnosis.

Figure 3

Age wise distribution of infection by T. vaginalis, C. trachomatis and N. gonorrhoeae as well as their co-infection as determined by PCR. (A) Percent prevalence was determined for patients infected with any of the three pathogens in different age groups as determined by PCR and SCM. (B) Bar diagram to show distribution of infection by T. vaginalis, C. trachomatis and N. gonorrhoeae alone as well as their co-infection in different age groups based on PCR diagnosis.

Figure 4

Percent distribution of different symptoms with reference to infections with T. vaginalis, C. trachomatis and N. gonorrhoeae as determined by PCR diagnostics. (A) Percentage of different symptoms amongst patients with vaginal discharge visiting the hospitals. (B) Percentage of different symptoms amongst patients tested positive for any of the three pathogens by PCR diagnostic assays. (C) Percent association of different symptoms among all the infected patients. (D) Relative association of different symptoms in patients infected with either T. vaginalis, or C. trachomatis or N. gonorrhoeae as determined by SCM. (E) Relative association of different symptoms in percent in patients infected with either T. vaginalis, or C. trachomatis or N. gonorrhoeae based on PCR diagnostics.