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National Audit Group
UK National Audit of Chlamydial Infection
Management National Audit Group
British Association for Sexual Health & HIV
National Audit Group
Case definition• Any one of the KC60 C4A, C4B, or ISD(D)5
C41A, C41B or C41R and seen in the audit interval
• GUM clinic or Sexual Reproductive Healthcare clinic
• Audit interval: 2 January and 31 March 2007 inclusively
• Sample number: first 30 patients seen in the audit interval (or all cases if less than 30 seen)
• Data collected: 3 September 2007 to 31 October 2007
National Audit Group
Participation
15 of 15 UK Regions*; 193 GUMed clinics; 6 SRH clinics (90 cases)
Number of cases
5032 (regional range 0.6-16%) – see chart3 London Regions 1618 (32%)
*Note: South East & South West Thames is “South Thames”
Essex data included in “North Thames”
National Audit Group
Number of cases (N=5032)
0
5
10
15
20
25
N Tha
mes
=81
6
S Tha
mes
=802
W M
idlan
ds =43
2
N Wes
t =38
7
Yorks
hire
=31
0
Scotla
nd =
307
S Wes
t =30
3
Wale
s =28
7
Anglia
=27
7
Trent
=26
9
Norther
n =26
6
Mer
seys
ide =
190
Oxfo
rd =
179
Wes
sex
=177
N Irel
and
=30
%
National Audit Group
Age (years)
Number
%N Regional range%
<16 88 2 0-4
16-18 801 16 12-23
19-24 2489 50 41-60
25-34 1263 25 20-31
35-44 284 6 2-8
45-54 77 2 0-3
55-64 20 0.4 0-1
>65 1 0.02 0-0.1
Not known 9 0.2 0-2
National Audit Group
Gender Number
% Regional
range%
Male, total (%N) 2546 51 46-60
Male, het (%Male
total)2365 93 85-98
MSM (%Male total) 162 6 2-12
Male unknown sex pref
(%Male total)19 1 0-5
Female (%N) 2474 49 39-54
Female preg (%
Female total)26 1 0-3%
Not known (%N) 12 0.2 0-1.5
National Audit Group
Ethnic group Number %N Regional range %
White 3929 78 58-98
Black Caribbean 211 4 0-12
Black African 124 2 0-6Black Other 84 2 0-7Chinese/SE Asian 36 0.7 0-1Indian 32 0.6 0-2Pakistani 29 0.6 0-2Bangladeshi 10 0.2 0-1Hispanic 10 0.2 0-2Arabic 7 0.1 0-1Other 153 3 0-8Not known 407 8 0-32
National Audit Group
SampleCountry Total number
casesJan-Mar 07
Number BASHH Audit
Sample
England 24870* 4408 18%
Scotland 4466† 307 7%
Wales Data awaited 287
N Ireland Data awaited 30
*Health Protection Scotland: http://www.documents.hps.scot.nhs.uk/ewr/pdf2007/0720.pdf
† Health Protection Agency. Personal Communication
National Audit Group
Reasons for testingMore than 1 reason possible
Reason Number
%N Regional range %
Symptoms 2317 46 38-53
STI screen 1707 34 27-42
Contact of chlamydia 1135 23 18-28
Based on Sexual Hx 784 16 3-31
Medico-legal case 5 0.1 0-0.06
Not documented 23 0.5 0-3
National Audit Group
Presenting features: female cases (n=2474)
ReasonNumbe
r %N Regional range %
No symptoms 1273 52 43-60
Vaginal discharge 690 28 18-35
Lower abdominal pain 306 12 6-19
Dysuria 205 8 4-14
PCB or IMB 178 7 0-10
Mucopurulent cxitis a/o cx ctact bleeding
82 3 0-7
Complications of chlamydial infection
31 1 0-3
Conjuctivitis 6 0.2 0-0.7
Pharyngeal symptoms 1 0.04 0-0.5
Other symptoms 263 11 3-31
National Audit Group
Presenting features: male cases (n=2546)
ReasonNumbe
r %N Regional range %
No symptoms 1175 46 31-50
Dysuria 858 34 28-50
Urethral discharge 685 27 23-30
Rectal symptoms 19 0.8 0-2
Lower abdominal pain 17 0.7 0-2
Complications of chlamydial infection
37 1.4 0-5
Conjuctivitis 8 0.3 0-1
Pharyngeal symptoms 3 0.1 0-0.8
Other symptoms 325 13 8-24
National Audit Group
Test method - NAATs
Overall, 4679 (93%, regional range 100-69%) cases had NAAT testing documented from at least one of urinary, cervical, vulvovaginal, urethral or rectal sampling
National Audit Group
Other chlamydial testsEIA Number of
tests
Women (n=2474) 406
Men, heterosexual (n=2365) 129
Men, homosexual (n=162) 6
Tissue culture
Total of 210 tests
DFA
Total of 9 tests
National Audit Group
Chlamydial tests in women
• 2093 (85%) women had cervical or vaginal NAATs
• of the remaining 381 not having cervical or vaginal NAATs– 134 (35%) had urine NAATs (of whom 52
(39%) had a genital examination performed)– 18 (5%) had urethral NAATS– 229 (60%) had no cervical, vulvovaginal,
urinary or urethral NAATS
National Audit Group
Chlamydial tests in men
• 1723 (68%) men had urinary NAATS
• Of the remaining 823 not having urinary NAATs
• 699 (85%) had urethral tests• 124 (15%) had neither urinary nor
urethral tests
National Audit Group
Site Number of tests
%N
Regional range %
Homosexual men (n=162) 141 87 75-100
Heterosexual men (n=2365)
1668 71 61-100
Women (n=2474) 1668 67 56-92
Other tests for STIs: Syphilis
National Audit Group
Other tests for STIs: HIVSite Number
of tests%N
Regional range %
Homosexual men (n=162) 118 73 58-100
Heterosexual men (n=2365)
1580 67 56-100
Women (n=2474) 1609 65 54-92
National Audit Group
Treatment Number
%N Regional range %
Azithromycin 1 gram stat 2712 54 16-90
Doxycycline100mg bd 7d 1868 37 0-79
Erythromycin 500 mg bd 7d
12 0.2 0-1
Ofloxacin 200 mg bd 7d 3 0.1 0-0.4
Ofloxacin 400 mg bd 7d 6 0.1 0-0.5
Not documented 55 1 0-3
NO amoxycillin, Deteclo or oxytetracycline used
Treatment: uncomplicated infxn.
National Audit Group
Treatment: pregnant women
• Twenty of 26 pregnant women were treated with azithromycin
• ?suggests that most prescribers treating pregnant women consider that erythromycin is not an “adequate alternative” to azithromycin (the manufacturer’s advice stated by the British National Formulary
British National Formulary. [http://www.bnf.org/bnf/bnf/current/126828.htm]. (Accessed 09 February 2008)
National Audit Group
Information-givingInformation Numbe
r %N Regional range
%
Abstinence 4160 83 43-91
Chlamydia 3827 76 40-89
Written Info 2510 50 0-70
National Audit Group
Follow-up: modes of FUMode Numbe
r %N Regional range
%
‘Phone or txt 2144 43 25-64
In clinic 1985 39 22-58
No follow-up 1184 24 8-42
Not documented 46 1 0-2
Another agency 29 0.6 0-2
Not known 21 0.4 0-1
National Audit Group
Follow-up: time to FUMode Numbe
r %N Regional range
%
Same day 43 1 0-1
1-7 726 14 8-30
8-14 1366 27 10-38
15-21 531 11 5-18
22-28 262 5 3-9
29-365 533 11 4-11
Anomalous 60 1 0-2
Not reported 1529 31 11-48
National Audit Group
Partner notification Numbe
r % Regional
range %
Provided by a HA or other suitably trained HCP (%N=5032)
4577 91 86-91
Method documented (n= 4577)
4227 92 83-97
Outcome documented (n= 4577)
3394 74 59-87
National Audit Group
CEG standard for contact tracing
• Auditable Outcome Measures
• Partner notification recommendation: In 2004, a systematic review of UK GUM clinics’ work showed that a mean of 0.43 contacts per case of chlamydia were screened in large city clinics and 0.64 contacts per case of chlamydia were screened in other clinics
http://www.bashh.org/guidelines/2006/chlamydia_0706.pdf
National Audit Group
Note: please look at the corresponding question in the Case notes questionnaire for this table
National Audit Group
Conclusions: 1• Largest national audit to date (more clinics)
– 187 (71%) of the 262 UK GUMed clinics plus 6 SRH clinics
• Ethnic group not always recorded 8% (0-32%)• 83% aged 19 years or over• Relatively few MSM overall (3% all cases)• About ½ cases no symptoms• 1/3 attending for routine or asymptomatic screens,
– ?implications for service provision/workload reduction
National Audit Group
Conclusions: 2• Main test used are NAATs• Main testing sites in women are cervical or vulval• 73% MSM tested for HIV, range 58-100%• Main treatment is azithromycin (54% cases), but
a lot of doxycycline is also used (37% cases)• Most pregnant women treated with azithromycin• Lack of written information provided (only 50%
cases overall)• More follow-up done by ‘phone or texting than in
clinic• 25% cases no FU
National Audit Group
Conclusions: 3
• >90% of cases having PN had this provided by a HA or other suitably trained HCP
• PN outcomes not documented for 25% cases provided with PN advice
• 40% cases not documented as having treatment verified for contact(s), with wide range 0-51%
• The national estimate of average number of contacts screened per index was 0.45, with regional performances between 0.29 to 0.73