uk national audit of chlamydial infection management

National Audit Group

UK National Audit of Chlamydial Infection

Management National Audit Group

British Association for Sexual Health & HIV


Case notes audit

Interim results20 February

2008


Case definition• Any one of the KC60 C4A, C4B, or ISD(D)5

C41A, C41B or C41R and seen in the audit interval

• GUM clinic or Sexual Reproductive Healthcare clinic

• Audit interval: 2 January and 31 March 2007 inclusively

• Sample number: first 30 patients seen in the audit interval (or all cases if less than 30 seen)

• Data collected: 3 September 2007 to 31 October 2007


Demography


Participation

15 of 15 UK Regions*; 193 GUMed clinics; 6 SRH clinics (90 cases)

Number of cases

5032 (regional range 0.6-16%) – see chart3 London Regions 1618 (32%)

*Note: South East & South West Thames is “South Thames”

Essex data included in “North Thames”


Number of cases (N=5032)

0

5

10

15

20

25

N Tha

mes

=81

6

S Tha

mes

=802

W M

idlan

ds =43

2

N Wes

t =38

7

Yorks

hire

=31

0

Scotla

nd =

307

S Wes

t =30

3

Wale

s =28

7

Anglia

=27

7

Trent

=26

9

Norther

n =26

6

Mer

seys

ide =

190

Oxfo

rd =

179

Wes

sex

=177

N Irel

and

=30

%


Age (years)

Number

%N Regional range%

<16 88 2 0-4

16-18 801 16 12-23

19-24 2489 50 41-60

25-34 1263 25 20-31

35-44 284 6 2-8

45-54 77 2 0-3

55-64 20 0.4 0-1

>65 1 0.02 0-0.1

Not known 9 0.2 0-2


Gender Number

% Regional

range%

Male, total (%N) 2546 51 46-60

Male, het (%Male

total)2365 93 85-98

MSM (%Male total) 162 6 2-12

Male unknown sex pref

(%Male total)19 1 0-5

Female (%N) 2474 49 39-54

Female preg (%

Female total)26 1 0-3%

Not known (%N) 12 0.2 0-1.5


Ethnic group Number %N Regional range %

White 3929 78 58-98

Black Caribbean 211 4 0-12

Black African 124 2 0-6Black Other 84 2 0-7Chinese/SE Asian 36 0.7 0-1Indian 32 0.6 0-2Pakistani 29 0.6 0-2Bangladeshi 10 0.2 0-1Hispanic 10 0.2 0-2Arabic 7 0.1 0-1Other 153 3 0-8Not known 407 8 0-32


SampleCountry Total number

casesJan-Mar 07

Number BASHH Audit

Sample

England 24870* 4408 18%

Scotland 4466† 307 7%

Wales Data awaited 287

N Ireland Data awaited 30

*Health Protection Scotland: http://www.documents.hps.scot.nhs.uk/ewr/pdf2007/0720.pdf

† Health Protection Agency. Personal Communication


Reasons for testingMore than 1 reason possible

Reason Number

%N Regional range %

Symptoms 2317 46 38-53

STI screen 1707 34 27-42

Contact of chlamydia 1135 23 18-28

Based on Sexual Hx 784 16 3-31

Medico-legal case 5 0.1 0-0.06

Not documented 23 0.5 0-3


Presenting features: female cases (n=2474)

ReasonNumbe

r %N Regional range %

No symptoms 1273 52 43-60

Vaginal discharge 690 28 18-35

Lower abdominal pain 306 12 6-19

Dysuria 205 8 4-14

PCB or IMB 178 7 0-10

Mucopurulent cxitis a/o cx ctact bleeding

82 3 0-7

Complications of chlamydial infection

31 1 0-3

Conjuctivitis 6 0.2 0-0.7

Pharyngeal symptoms 1 0.04 0-0.5

Other symptoms 263 11 3-31


Presenting features: male cases (n=2546)

ReasonNumbe

r %N Regional range %

No symptoms 1175 46 31-50

Dysuria 858 34 28-50

Urethral discharge 685 27 23-30

Rectal symptoms 19 0.8 0-2

Lower abdominal pain 17 0.7 0-2

Complications of chlamydial infection

37 1.4 0-5

Conjuctivitis 8 0.3 0-1

Pharyngeal symptoms 3 0.1 0-0.8

Other symptoms 325 13 8-24


Test method - NAATs

Overall, 4679 (93%, regional range 100-69%) cases had NAAT testing documented from at least one of urinary, cervical, vulvovaginal, urethral or rectal sampling


Other chlamydial testsEIA Number of

tests

Women (n=2474) 406

Men, heterosexual (n=2365) 129

Men, homosexual (n=162) 6

Tissue culture

Total of 210 tests

DFA

Total of 9 tests


Chlamydial tests in women

• 2093 (85%) women had cervical or vaginal NAATs

• of the remaining 381 not having cervical or vaginal NAATs– 134 (35%) had urine NAATs (of whom 52

(39%) had a genital examination performed)– 18 (5%) had urethral NAATS– 229 (60%) had no cervical, vulvovaginal,

urinary or urethral NAATS


Chlamydial tests in men

• 1723 (68%) men had urinary NAATS

• Of the remaining 823 not having urinary NAATs

• 699 (85%) had urethral tests• 124 (15%) had neither urinary nor

urethral tests


Site Number of tests

%N

Regional range %

Homosexual men (n=162) 141 87 75-100

Heterosexual men (n=2365)

1668 71 61-100

Women (n=2474) 1668 67 56-92

Other tests for STIs: Syphilis


Other tests for STIs: HIVSite Number

of tests%N

Regional range %

Homosexual men (n=162) 118 73 58-100

Heterosexual men (n=2365)

1580 67 56-100

Women (n=2474) 1609 65 54-92


Treatment Number

%N Regional range %

Azithromycin 1 gram stat 2712 54 16-90

Doxycycline100mg bd 7d 1868 37 0-79

Erythromycin 500 mg bd 7d

12 0.2 0-1

Ofloxacin 200 mg bd 7d 3 0.1 0-0.4

Ofloxacin 400 mg bd 7d 6 0.1 0-0.5

Not documented 55 1 0-3

NO amoxycillin, Deteclo or oxytetracycline used

Treatment: uncomplicated infxn.


Treatment: pregnant women

• Twenty of 26 pregnant women were treated with azithromycin

• ?suggests that most prescribers treating pregnant women consider that erythromycin is not an “adequate alternative” to azithromycin (the manufacturer’s advice stated by the British National Formulary

British National Formulary. [http://www.bnf.org/bnf/bnf/current/126828.htm]. (Accessed 09 February 2008)


Information-givingInformation Numbe

r %N Regional range

%

Abstinence 4160 83 43-91

Chlamydia 3827 76 40-89

Written Info 2510 50 0-70


Follow-up: modes of FUMode Numbe

r %N Regional range

%

‘Phone or txt 2144 43 25-64

In clinic 1985 39 22-58

No follow-up 1184 24 8-42

Not documented 46 1 0-2

Another agency 29 0.6 0-2

Not known 21 0.4 0-1


Follow-up: time to FUMode Numbe

r %N Regional range

%

Same day 43 1 0-1

1-7 726 14 8-30

8-14 1366 27 10-38

15-21 531 11 5-18

22-28 262 5 3-9

29-365 533 11 4-11

Anomalous 60 1 0-2

Not reported 1529 31 11-48


Partner notification Numbe

r % Regional

range %

Provided by a HA or other suitably trained HCP (%N=5032)

4577 91 86-91

Method documented (n= 4577)

4227 92 83-97

Outcome documented (n= 4577)

3394 74 59-87


CEG standard for contact tracing

• Auditable Outcome Measures

• Partner notification recommendation: In 2004, a systematic review of UK GUM clinics’ work showed that a mean of 0.43 contacts per case of chlamydia were screened in large city clinics and 0.64 contacts per case of chlamydia were screened in other clinics

http://www.bashh.org/guidelines/2006/chlamydia_0706.pdf


Note: please look at the corresponding question in the Case notes questionnaire for this table


Conclusions: 1• Largest national audit to date (more clinics)

– 187 (71%) of the 262 UK GUMed clinics plus 6 SRH clinics

• Ethnic group not always recorded 8% (0-32%)• 83% aged 19 years or over• Relatively few MSM overall (3% all cases)• About ½ cases no symptoms• 1/3 attending for routine or asymptomatic screens,

– ?implications for service provision/workload reduction


Conclusions: 2• Main test used are NAATs• Main testing sites in women are cervical or vulval• 73% MSM tested for HIV, range 58-100%• Main treatment is azithromycin (54% cases), but

a lot of doxycycline is also used (37% cases)• Most pregnant women treated with azithromycin• Lack of written information provided (only 50%

cases overall)• More follow-up done by ‘phone or texting than in

clinic• 25% cases no FU


Conclusions: 3

• >90% of cases having PN had this provided by a HA or other suitably trained HCP

• PN outcomes not documented for 25% cases provided with PN advice

• 40% cases not documented as having treatment verified for contact(s), with wide range 0-51%

• The national estimate of average number of contacts screened per index was 0.45, with regional performances between 0.29 to 0.73

National Audit Group… the end

uk national audit of chlamydial infection management

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