The Performance of the Vaginal Discharge Syndromic Management in Treating Vaginal and Cervical Infection: A Systematic Review and Meta-Analysis

Abstract

BackgroundThis review aimed to synthesize and analyze the diagnostic accuracy and the likelihood of providing correct treatment of the syndromic approach Vaginal Discharge Flowchart in managing cervical infections caused by Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT), and vaginal infections caused by Trichomonas vaginalis (TV) and Bacterial vaginosis (BV) and Candida albicans. This review will inform updating the WHO 2003 guidelines on Vaginal Discharge syndromic case management.MethodsA systematic review was conducted on published studies from 01-01-2000 to 30-03-2015 in multiple databases. Studies evaluating the diagnostic accuracy and validation of the WHO Vaginal Discharge Flowchart were included. Validation parameters including sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) and the 95% confidence intervals for the different types of the flowchart were taken as outcomes, re-calculated, and analysed using a fixed model meta-analysis for data pooling. The level of agreement between the index and reference test were determined by the Cohen’s Kappa co-efficiency test. Each individual study was assessed on quality using the QUADAS-2 tool.FindingsThe search yielded 2,845 studies of which 16 met the eligibility criteria for final analysis. The diagnostic performance to identify cervical infections was low and resulted in a high proportion of over and missed treatment. The four flowcharts had a sensitivity between 27.37% in history and risk assessment and 90.13% with microscopy, with the inverse in specificity rates. The treatment performances between the flowcharts were inconsistent. The same applies to the use of vaginal discharge flowchart for treating vaginal infections. For vaginal infections the vaginal discharge flowchart had a good performance in flowchart 3 with 91.68% of sensitivity; 99.97% specificity; 99.93% PPV and 0.02% who missed their treatment and 8.32% of women who were over treated by the vaginal discharge flowchartConclusionThe vaginal discharge flowchart should focus on management of vaginal infection. It could be used as an intermediate approach for cervical infections for sex workers until a point of care test is available in resource poor settings.

Accuracy of syndromic management in targeting vaginal and cervical infections among symptomatic women of reproductive age attending primary care clinics in Dakar, Senegal

“… found an Se of 53% in women in South India, similar to our results, with more appropriate Sp (60%) than we did. A recent systematic review examining the likelihood of providing correct treatment per the vaginal discharge flow chart showed that 52% of women were correctly managed for vaginal infection caused by TV/BV, which is consistent with our finding (51%).…”

“…However, Zemouri et al . assessed the benefit of the syndromic approach through a systematic review and meta‐analysis and found that nearly 70% of the patients received correct treatment. This conflicting finding could be partly explained by the fact that the review included certain categories of the population, such as sex workers and pregnant women, who were excluded from our study.…”

“…Therefore, the effectiveness of the vaginal discharge syndromic algorithm must be evaluated on the basis of the likelihood of providing correct treatment. Moreover, the performance of syndrome‐based management of RTIs/STIs has shown variation based on geographical location , which may be influenced in part by the prevalence of the infection, type of pathogens responsible for the infection, as well as the diagnostic method. Thus, for regions that promote the use of the WHO syndromic algorithm for the management of STIs, the approach must be validated and adapted at the country/local level .…”

Syndromic management of sexually transmissible infections in resource-poor settings: a systematic review with meta-analysis of the abnormal vaginal discharge flowchart for Neisseria gonorrhoea and Chlamydia trachomatis

“…A previous systematic review with meta-analysis of WHO-based AVD flowcharts for cervical and vaginal infections concluded that the diagnostic performance for identifying cervical infections was low, and that the AVD flowchart should focus on management of vaginal infection only. 12 Prior literature reviews have also reported a lower than acceptable performance of the AVD flowchart. 6,13,14 A formal synthesis of data using both WHO and locally-developed AVD flowcharts is paramount for the review and possible revision of clinical guidelines.…”

Health Belief Model on Psychosocial Factors Influencing HIV/AIDS Prevention Behavior on Lesbian Community in Surakarta

“…An abnormal discharge or pathological, the vagina fluid will be odorous, yellowish and cause itch. Zemouri et al (2016) state that the abnormal discharge is caused by the bacteria, parasite or fungus in the vagina. One of the factors that can cause this would be using antiseptic that can change the vagina's pH.…”