The management of sexually transmitted infections: a scoping survey in primary care

Summary

This general practice-based scoping survey in London and Brighton provides information on confidence in treating STIs, indications for sampling, sample types, treatment for gonorrhoea, and accessing clinical advice and referral pathways for STIs diagnosed in the community. From the 1735 GP practices contacted, 119 GPs responded to the questionnaire. There was marked heterogeneity in confidence and knowledge in the management of STIs and better use of the national guidance would improve the management of these infections in the community. As screening for chlamydia is encouraged in the community, ⁷ confidence in managing patients with chlamydia was found to be high. There was less confidence in managing gonorrhoea; a large number of GPs would refer cases of gonorrhoea, especially extragenital gonorrhoea, to GUM, which is in line with national guidance. Likewise, cases of syphilis and genital warts would be referred to GUM, but few would refer trichomonas to GUM, perhaps as treatment is considered straightforward with metronidazole. , GUM referral is, however, preferable to enable the screening of coexisting STIs. There was confusion regarding the sample types required for molecular diagnosis and those required for culture of gonorrhoea. ECS (recommended for gonococcal culture^8,9 were still regarded a useful sample type for gonococcal NAAT testing (37%) when STVVS would suffice. Although urine is suitable in men for gonococcal NAATs,⁸ this was not understood by over half of the responders, and some GPs continue to send urine for gonococcal culture, which is not recommended.⁹ A large number of GPs opted not to treat gonorrhoea in general practice; if they did, cefixime, ciprofloxacin, or azithromycin were considered for treatment, which is not in line with the primary care national guidance. ⁴

Advice embedded within electronic requesting was popular amongst responders and access to antibiotic treatment guidance with regular reviews would benefit antimicrobial stewardship within the community.

There was good evidence that gonococcal NAAT-positive patients and their contacts would be referred to GUM in line with national guidance. ⁴

Strengths and limitations

A strength of this scoping exercise was the use of national guidance as a standard developed for STIs in the evaluation of these findings. The questionnaire was comprehensive, with provision for comments, and covered key areas of management of these patients in primary care.

However, this scoping exercise highlighted several limitations. Although designed for GPs, participant anonymity means that other practice staff might have completed the questionnaire. This may explain discrepancies in the numbers of responders for different questions. A follow-up study should focus on key questions. Another limitation was the inability to differentiate between responses from Brighton and London, which limited analysis.

The national guidance for STIs management in primary care was not provided in the mailshots and some participants might not have been aware of it. Some GPs might have presumed the BASHH guidance in the mailshot to be secondary care guidance, and this might have affected responses to questions. Provision of the guidance document might have improved the completeness of the survey and the response rate. Question clarity might have been improved by substituting the word ‘testing’ for ‘screening’, and by providing a definition for ‘high risk’. It may be that some GPs test and treat some patients in the community and then refer to GUM for further follow up, but this was not captured in this study.

Despite repeated attempts to encourage participation only 119 responses were received from the more than 1000 practices in London and Brighton. Unfortunately, this is not surprising given the many competing demands on time in general practice. The results provided should thus be interpreted as merely applying to the practices from which the information was collected. Differences in the number of emails to GPs in the two areas reflected local communication practices. This represented a potential source of bias in interpretation of the results.

Comparison with existing literature

From 1735 general practices in London and Brighton, 119 responses were obtained. This may be because some GPs may not have seen or been aware of the questionnaire as it was sent electronically as a link. It is difficult to give an indication of how representative the sampling frame was to provide a definite understanding of the management of STIs. While the findings may not reliably represent practice and knowledge in the wider community, some clear learning points emerged regarding the management of STIs.

GPs reported varying levels of confidence and knowledge in managing STIs in general practice. Whilst levels of confidence were high for chlamydia, lower levels of confidence were found for gonorrhoea. A large number of GPs were confident about treating genital herpes and this may reflect the more frequent requirement to treat recurrent rather than primary genital herpes infection. Most GPs were confident about management of patients with trichomonas infection. However, the increasing availability of molecular tests for trichomonas, the poor performance characteristics of trichomonas culture and its main utility in patients from a high-risk population (for example, Black African),¹⁰ and the investigation of coexisting STIs would suggest that GUM referral would be beneficial to patients. Most GPs would refer syphilis and genital warts cases to GUM, as advised by the guidance, ⁴ reflecting the complexity in the management of these cases.

There was some evidence of confusion regarding the testing of patients for gonorrhoea and their treatment and referral. National guidance recommends NAAT to investigate suspected cases of gonorrhoea. Despite evidence that STVVS are non-inferior to ECS and high vaginal swabs for NAAT, ^8,11 37% of GPs submitted ECS, possibly because this is the recommended sample type for culture.^8,10 National guidance⁴ recommends culture of NAAT-positive patients in order to determine antibiotic susceptibilities. For women, only 45% of GPs would submit ECS for culture, possibly because of confusion with guidance for NAAT samples. In men, urethral swabs are recommended for gonococcal culture but, surprisingly, 18% of GPs stated they would submit urine samples, possibly because urine is a suitable sample type for NAAT. Gonococcus is a fragile organism and the laboratory recovery rate¹² is poor with increased transport time. GPs may not be aware that successful culture is very dependent on getting the sample to the laboratory quickly.¹²

A considerable number of GPs said their practice would not prescribe treatment for gonorrhoea in accordance with national guidance, ⁴ which advises referral to GUM unless this is difficult to arrange. Some replies complied with the use of recommended antibiotics for treating gonorrhoea, but a few GPs would use cefixime, ciprofloxacin, and azithromycin, suggesting that information about antibiotic treatment with regular updates may improve prescribing particularly as the majority of the GPs wanted advice embedded within electronic requesting. A recent study found that only 1.7% (n = 34/1956) of all gonorrhoea cases were diagnosed in primary care and there was high correct pathway management. ¹³

Changes in STI guidance (for example, BASHH chlamydia treatment guidelines) ¹⁴ present primary care services with the challenge of keeping up to date. This may cause variation in treatment guidance followed by different local health institutions.

Reports of the emergence of multi-drug resistance in N eisseria gonorrhoeae ¹⁵ emphasises the importance of gonococcal treatment guidance with regular reviews thus improving antimicrobial stewardship in the community.

Reassuringly, most GPs would not consider management in the community of patients and their contacts with gonorrhoea who were NAAT-positive, and would refer to GUM, in accordance with national guidance ⁴ and helping to reduce further selection pressure for antimicrobial resistance.

Implications for research and practice

In a changing landscape of provision of care for STIs, these results suggest areas for targeted education and training in the management of STIs among GPs. Future work could involve a different study design with an interview process involving key questions, improved by addressing the limitations discussed above, with a limited number of GPs. This would provide meaningful data for analysis and potentially improve the management of these patients.