The role of generalists in the care of STIs has always been important, and, in certain contexts – like the UK – looks set to increase. So it is no surprise that recent studies have raised the question of their adherence to sexual health policy guidelines in the matter of treatment regimes (Trotter & Okunwobi-Smith (STIs); Can we Ensure Adherence (STIs/blogs)) – especially given the need to steward antibiotic defences in a world of rising antimicrobial resistance (Gonorrhoea Anti-microbial Resistance (STIs/blogs). But the importance of generalists in the care of STIs also lends a heightened interest to the identification of specific clinical practice and diagnostic protocols among generalists that are associated with the misdiagnosis of – or the failure to diagnose – STIs. For instance, in an analysis of data derived from the Australian BEACH (Bettering the Evaluation and Care of Health) programme, Freedman & Mindel (STIs) (F&M) draw attention to the failure of GPs to undertake tests to exclude specific STIs and the reliance on generic symptomatic management.
Insights into the diagnostic practice of generalists in a rather different setting are provided in a recent observational cohort study of adult women over a two-month period either presenting with, or diagnosed with, genitor-urinary infections at a US Emergency Department (ED) (Tomas & Hecker (T&H)). T&H checked hospital diagnoses against the results of the urine cultures and appropriate Nucleic Acid Amplification Testing (NAAT) which they performed on those participants for whom they had not been performed routinely. They discovered an over-diagnosis of urinary tract infections of between 39% and 52% (depending on whether contaminated cultures were taken into account) and an under-diagnosis of STIs of 37%. Of the 24 missed STI diagnoses represented in the latter figure, 14 involved misdiagnosis as UTIs. What appears to be going on here is that care-providers are treating – and mis-treating – with antibiotics for UTI on the sole basis of urinalysis. Consequently, STIs are going untreated. In fact, empirical therapy for UTI is recommended in the US for women with at least one traditional lower UTI symptom and without complicating factors. But, the results of this study show that 24% of the patients diagnosed with UTI had no possible UTI-related symptoms documented. In other words, an abnormal urinalysis result was being routinely equated with the diagnosis of a UTI.
T&H recommend that urinalysis should be eliminated from triage protocols for women present with only genital symptoms. They also express the view that cost savings from not performing urine cultures may be more than outweighed by the costs of unnecessary antibiotic therapy and the longer-term costs of missed STI diagnoses.
More generally, the poor diagnostic practice exhibited in this study may usefully serve to highlight one of the characteristic failures to which the management of genitor-urinary conditions in general practice – and not just in US Emergency Departments – may be prone.