van Gemert Caroline, Hellard Margaret, Bradshaw Catriona S, Fowkes Freya J I, Agius Paul A, Stoove Mark, Bennett Catherine M
Burnet Institute, 85 Commercial Road, Melbourne, Vic. 3004, Australia.
Central Clinical School, The Alfred Centre, 99 Commercial Road, Melbourne, Vic. 3004, Australia.
Sex Health. 2018 Feb;15(1):1-12. doi: 10.1071/SH17070.
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.
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.
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.
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.
性传播感染的综合征管理常用于资源匮乏地区常见性传播感染的管理；异常阴道分泌物（AVD）流程图用于识别和治疗包括淋病奈瑟菌和沙眼衣原体在内的宫颈感染。开展了一项系统评价和荟萃分析，以衡量AVD流程图的诊断测试性能，包括世界卫生组织（WHO）的流程图和本地改编的AVD流程图。
对多个电子数据库进行系统检索，以查找1991年至2014年期间发表的符合条件的研究。根据以下因素将流程图分为14种类型之一：1）使用WHO指南或本地改编版本；2）使用风险评估、临床检查或两者兼用；3）症状性条目。计算得出的汇总诊断性能指标包括汇总敏感性、汇总特异性和诊断比值比。
该评价纳入了36项研究，包括99个流程图的数据。WHO流程图的汇总敏感性估计范围为41.2%至43.6%，本地改编流程图的汇总敏感性估计范围为39.5%至74.8%。本地改编的流程图表现略优于WHO流程图。在使用风险评估或临床检查之间未观察到性能差异。当AVD流程图不限于仅对有症状的女性使用时，其表现略好。
AVD流程图的性能存在很大差异，但总体而言，无论是否包括风险评估或临床检查，也无论流程图是WHO的还是本地制定的，它都是一种较差的诊断工具。许多女性接受了不必要的治疗，许多宫颈感染的女性未被检测到。我们告诫不要继续使用它们来管理宫颈感染。
