Literature review > Issue_5 > Review on Liu et al. 

There are two approaches traditionally applied by clinicians to diagnose STDs: clinical diagnosis or etiological diagnosis. Both of them may present a number of problems, such as sophisticated equipment needed for etiological diagnosis, or low accuracy in clinical diagnosis [1]. Syndromic approach, advocated by WHO, provided an alternative way for the rapid diagnosis and treatment without requiring sophisticated, time-consuming laboratory tests or advanced medical skills. In the study by Liu et al, the syndromic management was compared with the "gold standard" of etiological tests, and the sensitivities and PPVs of WHO algorithms were 95% and 78% for urethral discharge syndrome, and 100% and 25% for genital ulcer syndrome in the males.

When the effectiveness analysis was conducted, the syndromic management was compared with "current approach". It seemed that the doctors also apply the etiological diagnosis in the settings where the data of the study were collected, according to authors' statement. But we don't know the proportion of patients who actually underwent laboratory tests and what kind of tests were applied. The current approach incorrectly treated 34% of gonococcal and/or chlamydial infections, and overtreated 31% of males without above two infections. For such an analysis, it would be better divided into two components: the accuracy of diagnosis and appropriateness of treatment.

The authors compared the cost of "current approach" and syndromic management. It should be noticed that there are national guidelines for the management of various STDs, including gonococcal and chlamydial urethritis in China. If doctors follow those guidelines, even if tests for N. gonorrhoeae (bacterial culture) and C. trachomatis (immunological methods) are taken, the expenses patients bear will not be as much as the cost mentioned in this study. For example the single injection of 2 grams of spectinomycin for gonococcal urethritis costs 8-9 USD, and 7 days of oral doxycycline costs less than 1 USD. So there are unusual medical practices by those doctors, which one should bear in mind when comparing the real expenses to patients with the theoretically estimated cost by syndromic approach. Indeed, if syndromic management is going to be implemented in China, it is important to teach doctors to apply it correctly. By the way, since the gonococcal resistance rate to ciprofloxacin is very high in China (e.g., from 17.6% to 72.7% during 1996-2001 in Guangzhou [2]), it could not be the first line drug for gonorrhea, and it may not be appropriate to estimate the cost of syndromic management based on treatment with ciprofloxacin.

Previous reports indicated that there were high rates of Trichomonas vaginalis in the urethra among men attending STD clinics [3, 4]. It is suggested that T. vaginalis may be one of the important pathogens in male urethritis. In the study by Liu et al, it was found that 107 patients with the symptoms of either urethral discharge or dysuria were negative for both N. gonorrhoeae and C. trachomatis. It will be better if the tests for T. vaginalis are performed in order to illustrate the pathogens for those patients. Also, Mycoplasma genitalium is also suggested to be one of the pathogens for male urethritis [5], especially in persistent and recurrent cases.

For the syndromic management of genital ulcer disease, the study yielded 100% sensitivity and 25% PPV, which seemed lower than the results in a report from Shanghai and Chengdu in China [6]. Since the sample size for genital ulcer disease was small (55 in total), one might not draw sound conclusions from the study regarding the performance of syndromic management of genital ulcer disease.

References:

1. World Health Organization Regional Office for The Western Pacific. Syndromic case management of sexually transmitted diseases. A guide for decision-makers, health care workers, and communicators. Manila 1997

2. Zheng HP, Cao WL, Wu XZ, et al. Antimicrobial susceptibility of Neisseria gonorrhoeae strains isolated in Guangzhou, China, 1996-2001. Sex Transm Infect. 2004 ;80(1):78.

3. Schwebke JR, Hook EW 3rd. High rates of Trichomonas vaginalis among men attending a sexually transmitted diseases clinic: implications for screening and urethritis management. J Infect Dis. 2003 ;188(3):465-8

4. Wendel KA, Erbelding EJ, Gaydos CA, et al. Use of urine polymerase chain reaction to define the prevalence and clinical presentation of Trichomonas vaginalis in men attending an STD clinic. Sex Transm Infect. 2003 Apr;79(2):151-3.

5. Jensen JS. Mycoplasma genitalium: the aetiological agent of urethritis and other sexually transmitted diseases. J Eur Acad Dermatol Venereol. 2004;18(1):1-11.

6. Wang QQ, Mabey D, Peeling RW, et al. Validation of syndromic algorithm for the management of genital ulcer diseases in China. Int J STD AIDS. 2002;13:469-74.

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