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TOPICAL PROBLEMS OF DIAGNOSIS AND TREATMENT OF UROGENITAL INFECTIONS
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DEVELOPMENT OF STI PATIENT MANAGEMENT ALGORITHM
E. V. Sokolovskiy ([email protected]), A. V. Ignatovskiy
Department of Dermatology and Venereal diseases, Pavlov State Medical University, St. Petersburg, Russia.
The availability of unified standards of STI patient management became a very important question for the health care system of Russia during the last years. In past in USSR there was a number of instructions for treatment of syphilis and gonorrhea. In 2003, standards for management of patients with scabies, syphilis and gonorrhea were elaborated and approved. Implementation of those orders and protocols of patient management has allowed making the first steps towards systematization of approaches STI treatment. At the same time those protocols do not contain detailed action algorithm for diagnosis and treatment. They do not take into account, e.g. problems of microbial resistance antibacterial drugs depending on region of the country. In 2001, Central Institute of Dermatovenereology (Moscow) has elaborated "Methodical recommendations for STI treatment". However those recommendations were not mandatory for physicians of all specialties and were only available for dermatovenereolo-gists, whereas at present, a lot of physicians of other specialties are involved in STI management. Due to uncoordinated actions of physicians of various specialties, rate of genital infections continued to increase, as well as the number of complications of reproductive tract infections. This situation demanded urgent interference.
In 2000-2002, in St. Petersburg and Leningrad Oblast methodical recommendations for management of STI patients were developed and approved by Healthcare Committees. Latter recommendations were based on STI patient management materials and guidelines from Russia, Europe, Canada and USA.
The most common STIs in the world (and in Russia in particular) at present time are infections caused by Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum, Trichomonas vaginalis, Herpes virus, Human Papillomavirus and bacterial vagino-sis. In the content of European, CDC and Regional recommendations there are all 7 mentioned nosolo-gical forms presented, whereas Canadian standards contain 5 out of 7 infections and conditions, excluding Trichomonas vaginalis infection and bacterial vaginosis.
CDC, Canadian and European recommendations are instructions, that are prapared using evidence-based aproach and contain description for management of various groups of patients (pregnant, children, HIV-infected), at the same time regional methodical
recommendations have recommendation purpose and therefore not mandatory to use. At the same time regional recommendations do not have references for evidence based research.
Special place in prevention is assigned for primary prevention, which is sufficiently described in Canadian recommendations, and to less extend in European and CDC recommendations, whereas Regional recommendations do not have enough information about prevention of STIs.
CDC, European and Canadian guidelines are sufficiently complete documents that contain information on screening, prevention, and treatment of STIs in different categories of patients. It may be stated that recommendations have precise structure: making decision and diagnostics algorithms are marked into the separate columns that make reading of the documents easier. Recommendations contain complete description of the algorithm to work with patients with chlamydial and gonococcal infection, syphilis, but information concerning other urogenital infections is missing. In many cases in recommendations not enough attention paid for the questions of primary prevention, such as screening of STI, evaluation of risk, counseling. Implementation of regional methodical recommendations in St. Petersburg and Leningrad region may be considered as a positive factor, which is very important stage on the way to standardization and improvement of STI patient management. Leading specialists in dermatovenere-ology, obstetrics, gynecology, laboratory diagnostics, and infectious diseases took part in compilation of these documents. Leading place in the document is devoted questions of STI patient counseling. Basic data about STI is presented for urologists, gynecologists, that are involved in management of patients with genital infections. Aside from algorithm of diagnostics, treatment of patients there are directions on management of pregnant women and children. As disadvantages one can note still lucking information on strategy of management of patients with multiple STIs, HIV-infected, and also the absence of evidence base research in used data and not sufficient attention for primary prevention. At the same time, as many authors mention, in many countries there is the problem of use of existing standards, that requires development of effective monitoring system.
For complete evaluation of content, convenience of use and fulfillment of existing recommendations
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TOPICAL PROBLEMS OF DIAGNOSIS AND TREATMENT OF UROGENITAL INFECTIONS
by practitioners it is necessary to provide for effective forms of control.
The system of quality control may include the following stages:
First stage — internal control — should be done directly at the medical institution by administration, possibly — by chief of department. This control should be regular and consist of control of the correctness of use of the existing recommendations for diagnostics and treatment by each physician. The form of this control is monitoring of case histories (outpatient's cards). This control can result into administrative decisions on the level of medical institution.
Second stage — external control, namely analysis of case histories (outpatient's cards) by external independent experts with further statistical analysis. This would allow gathering data about completeness and correctness of fulfilling the recommendations for STI patient management, revealing and analyzing cases of inadequate use of recommendations, updating existing recommendations. Information, gathered at this stage could be analyzed on the regional and country level. This form of control has retrospective character.
Third stage — external control — is questionnaire (possible anonymous) of doctors with further statistical analysis by external independent experts. This stage would allow revealing doctors' attitude for practical use of recommendations, finding out preferred variants and schemes of management of the patients, convenience of use of recommendations in practice, and also the level of professional skills. Data gathered at this stage could be analyzed on the regional and country level.
Naturally every stage has certain advantages and disadvantages, that's why it is necessary to use all three stages in monitoring system.
Implementation of constantly working three stage quality control system for STI patient management could become an instrument for effective control for fulfilling the recommendations, and it would help to assure healthcare quality.
Thus, it is necessary to acknowledge need for development and implementation of STI patient management algorithms. At the same time it is important that such document would be developed with participation of all STI patient managing specialists.
THE USE OF BEDSIDE MICROSCOPY FOR EXAMINING UROGENITAL SMEARS IN THE OPTIMIZATION OF DIAGNOSIS OF SEXUALLY TRANSMITTED INFECTIONS
N. Е. Vorobyova 1, А. М. Savitcheva 1 ([email protected]), А. Vagoras 2, Е. Sokolovskiy 3, А. Hallen 4, М. Domeika 5
1 D. O.Ott Research Institute of Obstetrics and Gynecology, St. Petersburg, Russia,
2 Department of Dermatovenerology, Institute of Experimental Medicine, Vilnius, Lithuania;
3 Department of Dermatovenereology, I. P. Pavlov State Medical University, St. Petersburg, Russia;
4 Clinic of Dermatovenereology, Department of Medical Sciences, Uppsala University, Uppsala, Sweden;
5 Clinical Microbiology, Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
■ Sexually transmitted infections (STIs), especially in women, may result in infertility, lingering pelvic pain and pelvic adhesions, which may need surgical intervention. For these reasons, timely diagnosis of such infections is of paramount importance. The microscopy of genital smears performed by a physician during a patient visit (bedside microscopy) has been found to substantially reduce the time needed for a specific diagnosis, and in most cases, the physician can prescribe a proper treatment on the patient's first visit. In contrast, the traditional method of sending samples to a laboratory is time consuming for both the physician and the patient. Specificity of bedside microscopy in the hands of a skilled physician borders on 100%. If needed, a repeated sample can be taken immediately. With bedside microscopy, there is an opportunity to use limited laboratory resources more purposefully for further analyses.
Moreover, physicians using bedside microscopy have greater authority with their patients.
Within the Russian-Swedish project "Improvement of diagnosis and treatment of sexually transmitted infections" in the St. Petersburg and Leningrad regions, many dermatovenereologists and gynecologists were trained in bedside microscopy of urogenital smears.
Introduction
Sexually transmitted infections (STIs) are the primary cause of reproductive tract diseases. Most of these infections are asymptomatic. If STIs are not diagnosed and treated in time, they can lead to such complications as pelvic inflammatory diseases, infertility, ectopic pregnancy, as well as complications of
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VOL LVI SUPPLEMENT may/2007
ISSN 1684-0461
