|
.gif)
|
|
How useful are high
vaginal swabs in general practice? Results of a multicentre study.
Jungmann E,
Johnson AM, Ridgway G, Durrant K, Robinson AJ
Int J STD AIDS 2004;15:238-39
|
| by |
Gina Ogilvie MD MSc
Associate Director, STD/AIDS Control
BC Centre for Disease Control
Vancouver, British Columbia |
|
In this study, Jungmann et al. provide a preliminary glimpse into the question of the utility of the high vaginal swab (HVS) from the laboratory perspective and provide practitioners and researchers with further questions for examination.
As mandated by the National Health Service in the UK, there is an effort to increase the use of primary care clinicians in the management of sexually transmitted infections, and these authors are endeavoring to examine one of the common practices in management of vulvovaginal symptoms (VVS) in primary care, the HVS. The authors report that HVS represent significant portion of microbiology laboratories workload, and thus there is a need to examine their utility in detail. To underscore the need for clinical management guidelines for these physicians or laboratories, the authors embark on an evaluation of the analysis of HVS at three local laboratories.
The authors examine standard operating procedures (SOP) for evaluation of the HVS received by 3 London area laboratories. Three laboratory practices with samples from 242 practices are reviewed, but it is not known if these laboratories or general practices are representative of the overall practices in the United Kingdom in their approaches. There is little information on how or why these as opposed to other laboratories were chosen (ie were these the highest volume laboratories in London?). For international
readers, a description of these laboratories, including funding structure (private or publicly run facilities), and whether they are public health laboratories, would be informative, as this may influence some of the operating procedures.
The heterogeneity in the standard operating procedures for the specimens is well noted. Although all the labs cultured for
Candida spp., the approach for specimens for T. vaginalis,
N. gonorrhoeae and clue cells was different at each setting. This supports one of the authors’ assertions regarding the need to establish standardized procedures upon which the laboratories in the UK can base their practices.
The authors identify a low prevalence of serious STIs, but in clinical management, the exclusion of a diagnosis can often be as important as the inclusion of diagnosis, in terms of reassuring the patient of the absence of pathology, or directing the clinician in another line of diagnostic evaluation. Because clinical indication as opposed to clinical history is provided, we may not capture how the clinicians intended to utilize their results, and thus more accurately determine if indeed these specimens were being appropriately requested.
This paper would be strengthened by further data on the true extent of the problem. Given the presence of sexual health clinics, how often do primary care practitioners manage VVS? What are the current recommendations for the clinical management of VVS? Is the use of the HVS indeed widely used by practitioners for the management of VVS? For what indications do clinicians request HVS? Do practitioners utilize local microscopy? How does local microscopy impact on specimens sent to the laboratories? What percentage of laboratory workload does HVS represent?
Regardless, these findings may indicate a need to bolster the comfort level of the practitioners in making clinical diagnoses of vulvovaginal symptoms using established clinical criteria. At the same time, clinicians need to be sure that the specimens they submit are being evaluated in a consistent manner, in order to rule out diagnoses of concern.
This paper underscores the array of protocols and procedures that can exist even within a single municipality for evaluation of laboratory specimens. Perhaps the most important concept this paper highlights is the need for evidence-based recommendations to guide management and to provide a benchmark to which procedures can be compared. And, as with most research studies, it also provides further questions for examination.
|
