Can we ensure adherence to STI treatment guidelines in a world threatened by antimicrobial resistance?

Sexual health care in the UK has traditionally centred on specialist GUM (genitor-urinary medicine) services.  Since the turn of the twenty-first century primary care has played an increasing role, however.  The 2012 Health and Social Care Act is in line with this tendency, with most GP (general practitioner) practices now being commissioned to provide level 1 STI screening.  Questions have recently been raised about the conformity of care provided by GPs to national guidelines, established for the UK by the British Association for Sexual Health and HIV (BASHH) (Trotter & Okunwobi-Smith (STIs)).

So what is currently the extent of GP involvement in the UK in care of infections previously dealt with by specialist services (i.e. Chlamydia and Gonorrhoea), and how is this impacting on the treatment of these conditions?  Wetten & Hughes (W&H), in a population-based study using data from the UK Clinical Practice Research Datalink (CPRD), provide the answers to both questions.  As regards the role of GPs, the proportion of Chlamydia cases they diagnosed varied over the study period (2000-2011) between 16% and 9%, and appeared to be on a downward trajectory, while the proportion of Gonorrhoea cases fluctuated between 6% and 9%.  As for the quality of care received in general practice, there is a marked disparity between the two conditions.  Whereas, in the case of Chlamydia, 90% were prescribed a recommended therapy, of the patients presenting with Gonorrhoea only 40% received the recommended anti-microbial regimen.  Ciprofloxacin continued to used (42% of prescriptions in 2006, 20% in 2011) long after the 2005 change in national treatment guidelines favouring cephalosporins.

These findings appear to corroborate the concerns expressed by UK patients in another recent study that their expectations for appropriate in-house care or referral to specialist services were not always being met (Sutcliffe & Cassell (STIs)).

The issues raised by these UK studies around the adherence to prescribing guidelines by generalist physicians are not, of course, unique to the UK.  Similar concerns have been voiced in studies based on data emerging from the BEACH (Bettering Evaluation and Care of Health) programme in Australia (Santella & Hillman (STIs); Freedman & Mindel (STIs); Johnston & Mindel (STIs), as well as in studies from more diverse settings (Khandwalla & Rahman (STIs)).  Quite apart from the need to optimize patient outcomes and reduce the burden of infection in the population, the problem of adherence by generalists to guidelines raises more general questions.  The issue of antimicrobial resistance has prompted recent national interventions to “steward” our remaining antibiotic defences (Gonorrhoea antimicrobial resistance (STIs/blog).  Such policies will evidently depend on the adherence to guidelines, including by generalists – especially in settings where they are responsible for much of STI care.  In a world where Gonorrhoea – and perhaps one day Chlamydia – is set to become increasingly hard to treat, the problem of ensuring the conformity of generalists to universal standards of treatment is unlikely to go away.



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