Related Pages

Chlamydia contents

Essential facts

More information

Diagnosis and management

Statistics

Pamphlet
(pdf format)

Pelvic inflammatory disease

PID diagnosis and management

Follow-up of clients with chlamydia at Clinic 275 in 2001.

John Welch,  Flinders University, 2002.

Introduction

Control of sexually transmitted infections (STIs) has long been a major issue. In the last 20 years there has been a reduction in the prevalence of many bacterial STIs in Australia¹ and most other developed countries². This is believed to be in part due to more effective control; in Sweden the rate of many STIs has decreased by 40-50% since the introduction of intervention programs³. The aims of control include the interruption of transmission and prevention of complications and sequelae². Effective control depends on a number of factors including health promotion, education, adequate facilities and ongoing research¹. The success that has occurred in the last 20 years is partly due to behaviour change, development of reliable diagnostic tests, effective antibiotic therapy and contact tracing².

Chlamydia is an important sexually transmitted infection, the prevalence is believed to be approximately 1 in 20, rising to 1 in 5 for those attending sexual health clinics⁴. It is the most common bacterial STI in most developed nations^5,6. The classical presentation of chlamydia in males is urethritis, but it can sometimes cause epididymitis and proctitis (in men who have sex with men)⁴. In females the endocervix is the primary site of infection; symptoms include pelvic pain, dyspareunia, vaginal discharge, vulval irritation and dysuria⁴. Chlamydial infection is frequently asymptomatic, with some studies showing that up to 67% of infections are asymptomatic⁴. Chlamydial infection can have serious sequelae; it is a major cause of pelvic inflammatory disease (PID). Untreated PID can cause tubal damage, leading to infertility, ectopic pregnancy and chronic pelvic pain. Risk factors for chlamydial infection are young age, ethnic minority and multiple sexual partners. Since chlamydia is most common in younger age groups it can place their entire reproductive future at risk⁷. The ability of chlamydia to cause asymptomatic, chronic infection allows core groups to perpetuate infection⁴.

To control chlamydia effectively, infected individuals and their partners need to be identified and treated. The importance of contact tracing is highlighted in studies showing that over 50% of partners of those with chlamydia are infected, even if asymptomatic^3,4. These infected partners can either reinfect the individual or may infect other sexual partners. Chlamydia tests are included in the general screen offered to clients attending Clinic 275, and all clients with chlamydia are followed up for treatment and contact tracing. Contact tracing at the clinic is undertaken by professionally trained nursing staff. Face-to-face interviews are preferred, if this is difficult to arrange, a contact tracing interview is conducted by telephone.

The testing procedure at Clinic 275 depends on the presentation and gender of the client⁸. Asymptomatic male clients provide first void urine for chlamydia PCR testing, whereas males complaining of symptoms, or partners identified by contact tracing, have a urethral swab sent for PCR testing. An endocervical swab for chlamydia PCR. is collected from females. Clients are asked to return the following week for their results and are encouraged to provide contact details. If an investigation returns a positive result, the client is informed of the need for treatment at the return visit and, if necessary, contact traced. The standard treatment for chlamydia is 1g of azithromycin. All males with non-gonococcal urethritis confirmed by microscopy and contacts, male or female, are treated at first presentation. Asymptomatic males and the majority of females are treated at the second visit, usually when they return for results.

The aim of the audit was to measure the success of follow-up of clients diagnosed with genital chlamydia at Clinic 275. Three measures were used to determine the success of follow-up. The time taken to inform the client of a positive chlamydia result, the time to treatment and the time to contact tracing. Medical records at Clinic 275 are structured with a standard form for all clients. Dates of notification, treatment and contact tracing are recorded in the notes in a prescribed manner. The audit also assessed the quality of record keeping; clients notes were reviewed to ensure all recorded positives were true positive cases, that correct treatment was given and clear dating of informing, treating and contact tracing occurred.

Patients and methods

Patient Selection

The study was a retrospective audit of clients who presented to Clinic 275 between 1 January and 31 December 2001 and were found to be positive for chlamydia. All patients recorded in the clinic database with chlamydial infection as a diagnosis were selected for the audit.

Information

Client notes were used to extract data relevant to the audit, all data collected were anonymous. When data in client notes were not adequate, contact tracing documentation was used to verify information. Additional information included date of birth, gender, treatment, symptoms and presentation category.

Time zero was allocated to the date of chlamydia testing. The dates of informing, treatment and contact tracing were used to determine the time to informing, time to treatment and time to contact tracing, respectively. Information from the contact tracing interview was used to verify the dates if these were unclear in the client notes.

Three categories were used for presentation: asymptomatic, symptomatic and contacts. Asymptomatic clients were those without symptoms. Symptomatic patients were those presenting with urethral or vaginal symptoms or pelvic pain. Contacts were sexual partners of clients known to be infected with chlamydia, regardless of demonstrable symptoms.

Statistical Analysis

The three time frames of interest were calculated for each client. Data were analysed using Stata 7 software and Student's t-test to identify significant differences (a =0.05) between the follow up of clients, depending on age (group 1<25 years and group 2>25 years) or gender. Further analysis using t-tests was used to determine differences in follow up between the three presenting groups, asymptomatic, symptomatic and contacts.

Results

During the period 1 January to 31 December 2001, 349 clients were identified as being positive for chlamydia. Four cases were negative for chlamydia, three were miscoded and one was the result of incorrect data entry. Twenty one cases were referred to the clinic from general practitioners after positive chlamydia tests, as these patients had not been fully processed by the clinic they were excluded from the audit. Therefore, 324 clients were audited; 205 (63%) males and 119 (37%) females, mean age 25 years (range 15-55). Eight cases (2.5%) were lost to follow-up; only one was lost completely to all follow up, another client was informed of the result but did not return for treatment or contact tracing. Of the other clients lost to follow up, one was an foreign national who was treated shortly before returning overseas and could not be informed or contact traced; five clients were treated at presentation, informed of their results but declined to return for contact tracing.

Table 1: The average time in days for the three measures of success of follow up for 
              all clients, and a breakdown for the three presentations.

The average time to inform all clients of a positive result for chlamydia was 5.7 days (Table 1), median 5 days (Table 2). Ninety percent of clients were informed of their positive test result within 10 days and the maximum time was 75 days (Table 2). For the asymptomatic, symptomatic and contacts subgroups the average times to inform were 5.4, 4.8 and 6.6 respectively (Table 1).

The average time taken to treat all patients was 4.1 days (Table 1), however this includes symptomatic clients and contacts who were treated on the day of presentation. The average time to treatment of asymptomatic clients was 7.1 days (Table 1), median 6 days (Table 2). The maximum time to treatment was 35 days, though 90% of clients were treated within 13 days (Table 2).

Table 2: Three measures of success of follow up using the median time (p50), 90th
              percentile (p90) and the maximum time (Max.), for all clients and subgroups.

The average time taken to contact trace all patients was 8.9 days (Table 1); the median time for all clients and all subgroups was 7 days (Table 2). The maximum time taken to contact trace a client was 75 days, this client was in the contacts subgroup. The average for the contacts subgroup (11.8 days) was higher that of asymptomatic (7.7 days) and symptomatic (7.7 days) subgroups (Table 2). The difference in the time to contact trace between the contacts and each of the other subgroups was significant (p = 0.001).

Table 3: Comparison of the three measure of success between clients younger 
              than 25 years and those older than 25 years.

The data were also analysed to see if the age or sex of the client influenced the success of follow up. The age division was set at the mean (25 years), producing 2 groups, those younger and older than 25 years. The average time taken to inform younger clients was 4.7 days and older clients 6.2 days (p value of 0.012). The average time to contact trace was also significant (p=0.025), younger clients took 6.6 days and older clients 8.8 days. While the average time to treatment was 6.4 days in younger clients and 7.8 days in older clients, this result was not significant (Table 3).

There was no significant difference in the time to inform, treat or contact trace either sex (Table 4).

Table 4: Comparison of the three measures of success between male clients (n=205)
              and female clients (n=119).

The audit also reviewed treatment regimens, all clients who received treatment (322) were treated appropriately.

An audit of documentation showed that in 81 (25%) cases, the notes were unclear as to when the client was informed of a positive chlamydia result. When treating clients, doctors record both the treatment given and the date. In all cases where clients were treated on the day of presentation (symptomatic clients and contacts) documentation was adequate. Among 188 asymptomatic clients were 55 cases (29%) where the date of treatment was incorrectly documented. In the documentation of the date of contact tracing only 5 cases (2%, n=316) were unclear. Four asymptomatic cases had coding errors, such that diagnosis and treatment of chlamydia was not properly coded, this information failing to be corrected at review. Despite this, all four cases were correctly followed up with treatment and contact tracing.

Discussion

This audit was, in part, instigated by a draft for discussion by the MSSVD/AGUM Clinical Effectiveness Group⁹; it proposes a set of standards for the treatment and satisfactory partner notification for gonorrhoea and chlamydia within the United Kingdom (UK). It recommends that satisfactory treatment should be established in 60% of clients within 4 weeks of diagnosis. This audit was designed to focus on important time periods in client follow up, the time to informing a client of a positive result, and times to treatment and contact tracing.

Clinic 275 is currently treats clients well within the time periods suggested, with a median time to treatment for all clients of two days, and the 90th percentile being 10 days. However, these figures include data for clients who were treated at first presentation, that is, those with known exposure to chlamydia and those who have demonstrable urethritis on presentation. The timeframe for the asymptomatic group is a more sensitive indicator of success of the clinic in follow up. The median time to treatment of asymptomatic clients was six days, and 90% were treated within 13 days. Therefore the clinic has clients returning for results and treatment well within the suggested timeframes from the UK guidelines.

There is a distinction between treatment and the establishment of treatment. The UK guidelines state that test of cure is unnecessary in chlamydia, and establishment of satisfactory treatment can be done via interview at a clinic or by telephone. Establishing that the treatment was well tolerated and the patient is symptom free and abstained from, or used protection during, sex is part of the standard follow up interview at Clinic 275. The audit showed that all patients with chlamydia were treated appropriately.

Few studies have looked at the length of time for follow up as a measure of success. A thesis from Sweden reports the median time between examination of the index patient and the start of contact tracing in Swedish STI and family planning clinics was 12 days⁶. At Clinic 275 the median time to contact tracing is 7 days and 90% of clients are contact traced within 18 days. Staff at Clinic 275 are effective at encouraging clients to undergo contact tracing and this is reflected in the shorter time frames to contact tracing than in similar clinics in Sweden. The 90th percentiles of asymptomatic and symptomatic subgroups for contact tracing were 13 days and 14 days respectively. However, in clients who were contacts, the 90th percentile was 24 days and this difference was significant.

It is unclear why contacts are less willing to undergo contact tracing themselves, but it could be argued that the other two subgroups have presented to the clinic independently and have a different attitude towards the clinic. Clinic staff need to re-enforce the importance of contact tracing among those who present as chlamydia contacts.

That older clients took longer to follow up than their younger counterparts was a surprise. Many would expect younger individuals to be more difficult to contact. As clients presenting to Clinic 275 only represent a subset of the total population, this may not apply elsewhere. Why older clients are more difficult to follow up is unknown, however the clinic should stress the importance of follow up when dealing with clients, particularly those over 25 years.

The drop out rate from Clinic 275 was 2.5%, far below reported losses to follow up at other clinics. The UK guidelines report only 63.7% of clients with chlamydia returning for follow up, while other studies indicate drop out rates of 20-30%¹⁰. Only two clients were not treated, both were asymptomatic on presentation.

Documentation of clinic notes is standardised and generally of a high quality, however two sections require improvement. In 25% of cases, the notes were unclear about when the client was informed of a positive chlamydia result. As the mean time to inform indicates, the contact tracers are effective with the majority of clients informed of a positive result before returning to the clinic. The date when the client is informed, usually by the contact tracer, is entered into both the client notes and the contact tracing documents. In some cases this information was not entered correctly into the client notes, or alternatively, the contact tracer was not able to contact the client before their return to the clinic. Doctors give clients all results, irrespective of whether a contact tracer has informed the patient of a particular result; in addition to noting the date of informing the client, doctors should note whether the client has been previously informed of the positive result by the contact tracers.

The other area of documentation that was not clear was the dating of treatment. As the notes are very structured; treatment is written and dated in the treatment section of client notes. It is standard practice that treatment given at the initial consultation does not require dating. However, in 30% of cases where treatment for chlamydia was given at a follow up consultation, the treatment was either entered or dated incorrectly. While the notes were sufficiently clear to show that all clients were treated appropriately, more care needs to be taken by the medical staff to fill out the notes correctly. In the documentation of contact tracing, the notes were only unclear in 2% of cases.

The audit also looked at the coding of notes, which allows them to be entered into a database. In four cases diagnosis and treatment of chlamydia was entered into the notes appropriately, but failed to be coded correctly. Similarly, there were four cases which had been incorrectly coded or entered into the database as chlamydia, but were not chlamydia cases. This represents an error rate of 2.3%.

This audit indicates that Clinic 275 was successful in the follow up of clients with chlamydia during 2001. Follow up of clients occurred well within recommended timeframes from UK guidelines and within timeframes achieved from similar clinics in Sweden. Some improvement is possible in documentation, but it is generally of a high standard. Further insight into the clinic's success in follow up may be gained by an audit investigating the yield of contact tracing, success of treating those contact traced and the timeframes involved in follow up of contacts traced from the initial contact tracing interview.

References

1. Marks, C, Tideman, RL and Mindel, A, 1997, Evaluation of sexual health services within Australia and New Zealand, Medical Journal of Australia; 166: 348-352.

2. Catchpole, MA, 1996, The role of epidemiology and surveillance systems in the control of sexually transmitted diseases, Genitourinary Medicine; 72: 321-329.

3. Ripa, T, 1990, Epidemiologic control of genital chlamydia trachomatis infections,

4. Scandinavian Journal of Infectious Disease; 69 (Suppl): 157-167.

5. Ross, J, 1997, Chlamydial infections: how to find them and what to do with them, AIDS Patient Care and STDs; 11: 415-419.

6. Zimmerman-Rogers, H, Potterat, JJ, Muth, SQ, Bonney, MS, Gree, DL, Taylor, JE and White, HA, 1999, Establishing efficient Partner notification periods for patients with chlamydia, sexually Transmitted Diseases; 26: 49-54.

7. Ramstedt, K, 1991, An epidemiological approach to sexually transmitted diseases- with special reference to contact tracing and screening, Acta Dermato-Venereologica Supplementum; 157: 1-45.

8. Cowan, FM and Mindel, A, 1993, Sexually transmitted diseases in children: adolescents, Genitourinary Medicine; 69: 141-147

9. Clinic 275 Operations Manual: Clinical Practices. STD Services 1998, Amendment July 2000.

10. MSSVD/AGUM Clinical Effectiveness Group, UK National Outcome Standards for gonorrhoea and chlamydia, Draft for discussion.

11. Carlin, EM and Barton, SE, 1996, Azithromycin as the first-line treatment of non-gonococcal urethritis (NGU): a study of follow-up rates, contact attendance and patients’ treatment preference, International Journal of STD and AIDS; 7: 185-189.

12. Van Duynhoven, Y, Schop, WA, van der Meijden, W and van de Larr, M, 1998, Patient referral outcome in gonorrhoea and chlamydial infections, Sexually Transmitted Infections; 74: 323-330.

Top of Page