Ryan C A, Courtois B N, Hawes S E, Stevens C E, Eschenbach D A, Holmes K K
Department of Medicine, University of Washington, Seattle 98122, USA.
Sex Transm Infect. 1998 Jun;74 Suppl 1:S59-76.
To identify clinical epidemiological correlates of cervical and vaginal infections and assess alternative algorithms, including two new reproductive tract infection (RTI) algorithms, for syndromic management of these infections.
DESIGN, SETTING AND SUBJECTS: We prospectively studied clinical manifestations and risk correlates of cervical and vaginal infections in a randomly sampled group of 779 female patients seeking evaluation for a new problem at a Seattle STD clinic.
One experienced clinician performed standardised history, physical examination, and microscopy. Reference laboratories performed microbiological tests. Three levels of retrospective evaluation of algorithms included risk assessment and symptom review (RAS) alone; addition of speculum and bimanual examinations; and further addition of microscopy.
(1) Chief complaint of abnormal vaginal discharge predicted a significantly lower rate of gonorrhoea (GC) or chlamydial infection (CT) than rates observed with no complaint of vaginal discharge. Only the elicited symptom of yellow vaginal discharge (not the more common symptoms of increased or malodorous vaginal discharge) predicted GC or CT. Chief complaint of abnormal vaginal discharge itself predicted trichomoniasis (TV) and bacterial vaginosis (BV), not cervical infection. Candida albicans was strongly associated with the chief complaint of vulvar pruritus, not with the chief complaint of abnormal vaginal discharge. (2) Applying these algorithms in STD clinics only to women with the chief complaint of abnormal vaginal discharge, rather than to all women, decreases sensitivity for GC or CT, without increasing positive predictive value (PPV). Criteria for inclusion of patients have more effect on the performance of these algorithms than do the levels of evaluation used. (3) A modified World Health Organisation (WHO) algorithm applied only to patients with symptoms of vaginal discharge, involving treatment of RAS positives for cervical infection, followed by treatment of vaginal infections and cervicitis based on examination of RAS negatives and positives, had a sensitivity of 50% and PPV of 33% for cervical infection, and very low sensitivity for BV, TV, and for vulvovaginal candidiasis (VVC). (4) An RTI algorithm derived from these data, and applied to all STD patients, involving RAS and examination of all RAS negatives, provided treatment to all cases of BV and TV associated with symptoms of vaginal discharge; treatment of all VVC associated with symptoms of vulvar pruritus; treatment for GC and GT to all RAS positives (using easily elicited risk factors) and to RAS negatives with signs of cervicitis or PID. This algorithm had a sensitivity of 87% and a PPV of 33% for GC or CT in this population, with its 24% prevalence of GC or CT. The sensitivity for BV, TV, and VVC greatly exceeded that of the modified WHO algorithm. (5) A modified RTI algorithm, involving examination rather than treatment of RAS positive women, no examination of RAS negatives, decreased the sensitivity for cervical infection to 55% but increased the PPV to 51%.
Syndromic management of vaginal discharge offers relief of symptoms, prevention of transmission of trichomonas, and perhaps prevention of complications of BV. The 51% PPV of the modified RTI algorithm probably would warrant treatment and partner notification for GC and CT in settings with similar rates of GC and CT where more specific tests are lacking. However, as the prevalence of GC or CT decreases, the ratio of uninfected to infected who receive treatment with these algorithms would increase greatly, making the algorithms potential victims of their own success.
确定宫颈和阴道感染的临床流行病学相关因素，并评估替代算法，包括两种新的生殖道感染（RTI）算法，用于这些感染的症状管理。
设计、设置和研究对象：我们对西雅图一家性传播疾病诊所中779名因新问题前来就诊的女性患者进行随机抽样，前瞻性地研究宫颈和阴道感染的临床表现及风险相关因素。
由一名经验丰富的临床医生进行标准化病史采集、体格检查和显微镜检查。参考实验室进行微生物检测。算法的三个回顾性评估水平包括仅进行风险评估和症状审查（RAS）；增加窥阴器和双合诊检查；进一步增加显微镜检查。
（1）主诉阴道分泌物异常者淋病（GC）或衣原体感染（CT）的发生率显著低于无阴道分泌物异常主诉者。仅黄色阴道分泌物这一引出症状（而非更常见的阴道分泌物增多或有异味症状）可预测GC或CT。主诉阴道分泌物异常本身可预测滴虫病（TV）和细菌性阴道病（BV），而非宫颈感染。白色念珠菌与外阴瘙痒主诉密切相关，而非与阴道分泌物异常主诉相关。（2）在性传播疾病诊所仅将这些算法应用于有阴道分泌物异常主诉的女性，而非所有女性，会降低对GC或CT的敏感性，且不会增加阳性预测值（PPV）。患者纳入标准对这些算法性能的影响大于所采用的评估水平。（3）一种改良的世界卫生组织（WHO）算法仅应用于有阴道分泌物症状的患者，即对RAS检测为宫颈感染阳性者进行治疗，然后根据RAS检测阴性和阳性情况对阴道感染和宫颈炎进行治疗，对宫颈感染的敏感性为50%，PPV为33%，对BV、TV和外阴阴道念珠菌病（VVC）的敏感性非常低。（4）根据这些数据得出的一种RTI算法应用于所有性传播疾病患者，包括RAS检测及对所有RAS检测阴性者进行检查，对所有伴有阴道分泌物症状的BV和TV病例进行治疗；对所有伴有外阴瘙痒症状的VVC病例进行治疗；对所有RAS检测阳性者（使用容易引出的风险因素）以及有宫颈炎或盆腔炎体征的RAS检测阴性者进行GC和GT治疗。该算法在该人群中对GC或CT的敏感性为87%，PPV为33%，GC或CT的患病率为24%。对BV、TV和VVC的敏感性大大超过改良的WHO算法。（5）一种改良的RTI算法，对RAS检测阳性女性进行检查而非治疗，不对RAS检测阴性者进行检查，将宫颈感染的敏感性降至55%，但将PPV提高至51%。
阴道分泌物的症状管理可缓解症状、预防滴虫传播，并可能预防BV的并发症。改良的RTI算法51%的PPV可能在缺乏更特异性检测且GC和CT发生率相似的情况下，为GC和CT的治疗及性伴通知提供依据。然而，随着GC或CT患病率的降低，使用这些算法接受治疗的未感染者与感染者的比例将大幅增加，使这些算法可能因自身的成功而成为受害者。
