The Diagnostic Accuracy of Syndromic Management for Genital Ulcer Disease: A Systematic Review and Meta-Analysis

Objectives: Genital Ulcer Disease (GUD) carries a significant disease burden globally. With limited access to diagnostics, the 2001 World Health Organization (WHO) sexually transmitted illnesses (STI) guidelines proposed a syndromic management algorithm that required a clinical decision to determine the management of GUD. We assessed the diagnostic accuracy of this algorithm.Methods: We conducted a systematic review (Prospero: CRD42020153294) using eight databases for publications between 1995 and January 2021 that reported primary data on the diagnostic accuracy of clinical diagnosis to identify aetiological agents of GUD. Titles and abstracts were independently assessed for eligibility, and data were extracted from full texts for sensitivity/specificity. A hierarchical logistic regression model was used to derive pooled sensitivity and specificity. We used GRADE to evaluate the certainty of evidence.Results: Of 24,857 articles, 151 full texts were examined and 29 included in the analysis. The majority were from middle-income countries [(14/29 (48%) lower middle, 10/29 (34%) upper middle)]. We pooled studies where molecular testing was using to confirm the aetiology of GUD: 9 studies (12 estimates) for herpes, 4 studies (7 estimates) for syphilis, and 7 studies (10 estimates) for chancroid. The pooled sensitivity and specificity of GUD for the detection of herpes was 43.5% [95% confidence interval (CI): 26.2–62.4], and 88.0% (95% CI: 67.0–96.3), respectively (high certainty evidence); and for syphilis were 52.8% (95% CI: 23.0–80.7), and 72.1% (95% CI: 28.0–94.5) (moderate certainty evidence); and for chancroid were 71.9% (95% CI: 45.9–88.5) and 53.1% (95% CI: 36.6–68.9) (moderate certainty evidence), respectively.Conclusion: Algorithms requiring a clinical diagnosis to determine and treat the aetiology of GUD have poor sensitivities for syphilis and herpes simplex virus, resulting in significant numbers of missed cases. There is an urgent need to improve access to affordable and efficient diagnostics (e.g., point-of-care tests) to be incorporated into GUD algorithms to better guide appropriate management.Systematic Review Registration: PROSPERO, identifier: CRD42020153294.

Prevalence of sexually transmitted infections in a tertiary care centre of North India

Background: Sexually transmitted infections (STI’s) are most common notifiable infectious diseases in the world. Knowledge of prevalence of STI’s is important to implement appropriate control strategies. This study is undertaken to see any changing trends in prevalence of STI’s by comparing with previous studies.Methods: All the patients who attended STI clinic from July 2019 to June 2020 were included in the study. Diagnosis was made on basis of history, clinical examination and laboratory investigations.Results: The 2188 patients were seen from July 2019 to June 2020 in STI clinic. Mean age group of patients is 25-44 years. Scabies (31.6%) was the commonest STI seen in outpatient department followed by balanoposthitis (16.4), vaginal discharge (12.5%), human immunodeficiency virus (HIV) (11.4%), herpetic genital ulcer disease (7.9%), genital warts (5.8%), molluscum contagiosum (2.4%), syphilis (2.4%), urethral discharge (1.7%), non-herpetic genital ulcer disease (0.4%), non-gonococcal urethritis (0.4%).Conclusions: Scabies was the most common STI reported in our study followed by balanoposthitis and vaginal/cervical discharge. Among the viral STI’s, HIV is showing alarmingly rising trends and is most common viral STI seen in the study followed by herpes simplex virus (HSV). May be there is less reporting of genital herpes simplex infection due to its self-resolution. As compared to previous studies, rising trends of fungal infections are seen which can be due to syndromic management of bacterial STI’s, rising incidence of diabetes mellitus as well as illicit use of over-the-counter broad-spectrum antibiotics given by the local practitioners.

Multilocus sequence typing of Treponema pallidum subsp. pallidum in Barcelona

Aim: To implement the multilocus sequence typing (MLST) methodology in syphilis samples previously characterized by enhanced CDC typing (ECDCT) and macrolide resistance. Materials & methods: MLST was performed on genital ulcer and blood samples by analyzing a region of the tp0136, tp0548 and tp0705 loci using Sanger sequencing. Results: Up to 59/85 (69.4%) of genital ulcer and 4/39 (10.3%) of whole blood samples were fully typed. The most frequent profiles were 1.3.1 (56%) and 1.1.1 (11%). All the 1.3.1 samples typed carried the A2058G mutation, responsible for macrolide resistance. MLST and ECDCT showed similar overall typing yields. Conclusion: Several allelic profiles of T. pallidum subsp. pallidum were identified and classified into two major genetic clades in Barcelona. Our results were similar to that described in Europe.

Recent Trends of Syndromic Sexually Transmitted Infections at a Tertiary Care Center in Maharashtra, India: A Retrospective Analysis

Background: Sexually transmitted infections (STIs) constitute a major public health problem in both developed and developing countries. Human immunodeficiency virus (HIV) and STIs are linked in their similar mode of transmission, with STIs facilitating the acquisition and transmission of HIV. The prevalence pattern of individual STIs may evolve over time necessitating a corresponding change in management strategies. Objectives: The study was conducted to determine the burden and any change in the etiological trend among attendees of an STIs clinic at a tertiary care hospital. Methods: This retrospective study analyzed data retrieved from consecutive patients attending an STIs clinic over two years (July 2018 to July 2020). Results: Overall, 1916 patients were diagnosed with STIs. The predominant age group was 25 - 44 years (59.23%). Genital ulcer disease was the foremost syndrome (1213, 63.3%). Overall, herpetic genital ulcer was the most common (682, 35.6%), followed by non-herpetic ulcers (531, 27.7%). Vaginal discharge, lower abdominal pain, and urethritis were found in 461 (24%), 219 (11.43%), and 23 (1.27%) of the patients, respectively. Amongst 237 (12.36%) In HIV seropositive attendees, genital ulcer disease (herpetic) was the most common syndrome (179, 75.53%), followed by vaginal discharge (42, 17.72%), lower abdominal pain (9, 3.8%), and urethritis (7, 2.9%). Conclusions: A definite change in the profile of STIs was observed with ulcerative STIs (particularly herpes genitalis) constituting the major burden against a discernible back drop of decreasing non-herpetic STIs. A systematic, regional, periodic synopsis would not only help to follow and document the dynamic trends, but also can help to assess the effectiveness of control programs.

Etiologies of genital inflammation and ulceration in symptomatic Rwandan men and women responding to radio promotions of free screening and treatment services

Introduction The longstanding inadequacies of syndromic management for genital ulceration and inflammation are well-described. The Rwanda National Guidelines for sexually transmitted infection (STI) syndromic management are not yet informed by the local prevalence and correlates of STI etiologies, a component World Health Organization guidelines stress as critical to optimize locally relevant algorithms. Methods Radio announcements and pharmacists recruited symptomatic patients to seek free STI services in Kigali. Clients who sought services were asked to refer sexual partners and symptomatic friends. Demographic, behavioral risk factor, medical history, and symptom data were collected. Genital exams were performed by trained research nurses and physicians. We conducted phlebotomy for rapid HIV and rapid plasma reagin (RPR) serologies and vaginal pool swab for microscopy of wet preparation to diagnose Trichomonas vaginalis (TV), bacterial vaginosis (BV), and vaginal Candida albicans (VCA). GeneXpert testing for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) were conducted. Here we assess factors associated with diagnosis of NG and CT in men and women. We also explore factors associated with TV, BV and VCA in women. Finally, we describe genital ulcer and RPR results by HIV status, gender, and circumcision in men. Results Among 974 men (with 1013 visits), 20% were positive for CT and 74% were positive for NG. Among 569 women (with 579 visits), 17% were positive for CT and 27% were positive for NG. In multivariate analyses, factors associated with CT in men included younger age, responding to radio advertisements, <17 days since suspected exposure, and not having dysuria. Factors associated with NG in men included not having higher education or full-time employment, <17 days since suspected exposure, not reporting a genital ulcer, and having urethral discharge on physical exam. Factors associated with CT in women included younger age and < = 10 days with symptoms. Factors associated with NG in women included younger age, lower education and lack of full-time employment, sometimes using condoms vs. never, using hormonal vs. non-hormonal contraception, not having genital ulcer or itching, having symptoms < = 10 days, HIV+ status, having BV, endocervical discharge noted on speculum exam, and negative vaginal wet mount for VCA. In multivariate analyses, only reporting >1 partner was associated with BV; being single and RPR+ was associated with TV; and having < = 1 partner in the last month, being pregnant, genital itching, discharge, and being HIV and RPR negative were associated with VCA. Genital ulcers and positive RPR were associated with being HIV+ and lack of circumcision among men. HIV+ women were more likely to be RPR+. In HIV+ men and women, ulcers were more likely to be herpetic rather than syphilitic compared with their HIV- counterparts. Conclusions Syndromic management guidelines in Rwanda can be improved with consideration of the prevalence of confirmed infections from this study of symptomatic men and women representative of those who would seek care at government health centers. Inclusion of demographic and risk factor measures shown to be predictive of STI and non-STI dysbioses may also increase diagnostic accuracy.

Granuloma Inguinale

Granuloma ingunale (GI) or donovanosis is a genital ulcer disease caused by theCalymmatobacterium granulomatis. It is a Gram-negative, facultative, obligateintracellular and pleomorphic bacterium. This bacterium has phylogeneticallyclosed to and placed within the Klebsiella genus. Clinically, the disease is com-monly characterized as painless, slowly progressive ulcerative lesions on thegenitals or perineum without regional lymphadenopathy. The lesions are highlyvascular and bleed easily on contact Extragenital lesions may occur but are rareand more common in newborns from mothers with GI genital lesions. Thisdisease is often neglected, therefore it is often misdiagnosed and inaccuratetherapy. Treatment time is 3 weeks or until clinical cure has been achieved forall proposed regimens. It often occurs both in men and women of reproductiveage (20-40 years). This article consists of several theoretical references that havebeen viewed to have a better understanding of GI.

Granuloma Inguinale

Granuloma ingunale (GI) or donovanosis is a genital ulcer disease caused by theCalymmatobacterium granulomatis. It is a Gram-negative, facultative, obligateintracellular and pleomorphic bacterium. This bacterium has phylogeneticallyclosed to and placed within the Klebsiella genus. Clinically, the disease is com-monly characterized as painless, slowly progressive ulcerative lesions on thegenitals or perineum without regional lymphadenopathy. The lesions are highlyvascular and bleed easily on contact Extragenital lesions may occur but are rareand more common in newborns from mothers with GI genital lesions. Thisdisease is often neglected, therefore it is often misdiagnosed and inaccuratetherapy. Treatment time is 3 weeks or until clinical cure has been achieved forall proposed regimens. It often occurs both in men and women of reproductiveage (20-40 years). This article consists of several theoretical references that havebeen viewed to have a better understanding of GI.