A Clinical Audit on Management of Syphilis STD Clinic – Ragama Nanayakkara G., Ranatunga J. STD Clinic – Ragama
Objective To audit the management of the patients with syphilis from entry to care through follow up, with a view of improving the quality of care in STD clinic Ragama.
Methodology 1. Study setting • The STD clinic Ragama, is located in the North Colombo Teaching Hospital and it is one of the main STD clinics in the district of Gampaha. • Average number of new patients registered per year is 846. • Average number of clients visited for services per year is 3500.
Map of Gampaha district
North Colombo Teaching Hospital
Methodology contd... 2. Study design Baseline evaluation of management of syphilis in comparison to the national guideline as a part of an audit cycle. 3. Study population/sample All the patients who were diagnosed as Syphilis during the year 2012 were taken as the study sample the sample size was 79.
Methodology contd... 4. Data collection Data on patients with syphilis were extracted to a structured data extraction sheet for analysis. 5. Data analysis Data were analysed using SPSS for descriptive statistics. The performance of Variables of interest were compared against the National guidelines for the management of STIs, published by the Sri Lanka College of Venereologists in 2009.
Results – sample characteristics Age • • •
Mean age of the sample was 35.5 years (SD 11.7 years) Minimum age – 17 years Maximum age – 66 years
Sex distribution (n=79)
Results – sample characteristics contd... Marital status
No of partners last 3 months
Results – sample characteristics contd... Sexual orientation
Type of partner
Percentages are not mutually exclusive
Definitions of staging Early syphilis within first two years • Primary syphilis • Secondary syphilis • Early latent syphilis: Positive serological tests without any clinical features.
Late latent Syphilis • Usually acquired more than two years earlier. • Late latent Syphilis- is characterized by sero reactivity without other clinical features.
All patients had a documented diagnosis with staging
Audited questions
Audited Questions 1. Was the history taken properly? 2. Were the correct investigations done for diagnosis of syphilis and other STIs? 3. Was the correct treatment started and completed? 4. What proportion of contact tracing/partner screening was covered? 5. Did all the partners of infectious syphilis patients receive treatment? 6. Was the necessary follow up done? 7. What proportion of defaulter tracing was done?
1. Was the history taken properly?
Audited Questions 1. Was the history taken properly? Inquiry of symptoms
100%
History taking with regard to 1. Number of partners, 2. Type of the partner, 3. Sex of the partner, 4. Condom use
98.7%
2.Were the correct investigations done for diagnosis of syphilis and other STIs?
Recommended laboratory investigations in National Guidelines
• DG microscopy for demonstration of T. pallidum Indicated when the lesions are present. • Non Treponemal serology. • Specific Treponemal Serology. • Other tests accordingly.(eg: CXR, 2D Echo, CSF, etc.)
Serology Non treponemal test – VDRL • VDRL- for screening and as a quantitative test for disease activity and response to therapy. A 4-fold rise is suggestive of a new infection, re-infection or relapse. Treponemal test – TPPA /TPHA • TPHA-to confirm positive screening test and diagnosis of late syphilis when others are nonreactive.
Audited Questions 2. Were the correct investigations done for diagnosis of syphilis and other STIs? Performance of Dark ground (DG) microscopy 100% (14/14) among patients with genital ulcers (n=14), 3 were DG positive VDRL 100% (79/79) TPPA HIV serology
100% (79/79) 100% (79/79)
GC culture
98.7% (78/79)
HIV sero-positivity rate = 6.3% 29% of patients had concurrent STIs.
3.Was the correct treatment started and completed?
Recommended treatment for early syphilis Standard treatment: • Benzathine penicillin 2.4 MU im injection single dose (after ST ). In Penicillin allergy: • Doxycycline 100 mg bd for 14 days. • Erythromycin 500mg qds for 14 days (when doxycycline is contraindicated).
Recommended treatment for late latent syphilis Standard Rx – • Benzathine penicillin 2.4 MU im ,after ST - 3 doses in 3 consecutive wks. Alternative Rx- (in Penicillin allergy) • Doxycycline 100 mg bd for 28 days. • Erythromycin 500 mg qds for 28 days (When Doxycycline is contra-indicated).
Audited Questions Was the correct treatment started and completed? Treatment initiated
72/79
91%
Previously treated
2%
Referred
1%
Defaulted treatment
5%
Type of treatment Penicillin
68/79
94%
Doxycycline
3/79
4%
Other (Erythro.)
1/79
1%
Reasons for non-penicillin therapy as documented - Positive ST (2), Age more than 50 years (1)
• Treatment was completed in all, except one who had S4L. • 2 patients were probably treated past but details unclear ,therefore retreated.
4. What proportion of contact tracing/partner screening was covered?
Recommended management of sexual partner in Early syphilis • All sexual partners within last 3 months should be screened for syphilis. Epidemiological Treatment • All sexual contacts should receive epidemiological treatment irrespective of their serological results. • Partner notification may have to extend to 2 years for patients with secondary syphilis with clinical relapse or in early latent syphilis.
Recommended management of sexual partners in late syphilis
• Sexual partners up to 2 years should be screened for syphilis and treat if found positive.
Audited Questions 4. What proportion of contact tracing/partner screening was covered? (n=79) Category
Proportion
Percentage
Contacts traced (At least one contact)
24/79
30%
None
51/79
64%
4/79
5%
Number of contacts traced
17/35
48.5%
contacts not traced
16/35
45.7%
2/35
5%
Not mentioned
Contact tracing in early syphilis (n=35)
no contact tracing details recorded
5. Did all the partners of infectious syphilis patients receive treatment?
Audited Questions Did all the partners of infectious syphilis patients receive treatment? Proportion of traced contacts of early syphilis (n=17) who received epi-treatment. ( In one file epi-treatment details were not recorded)
16/17
94%
Proportion of contacts of early syphilis epi-treated.
16/35
45.7%
Proportion of patients whose partner treatment was not done.
19/35
54%
Stranded level of contact tracing/ partner screening is not included in National guideline.
• All contacts were identified and epi- treated only in 8 patients of audited population (22%) n=35
6. Was the necessary follow up done?
Recommendation by National guidelines • All pts. should be followed by regular VDRL tests as follows: • Early syphilis: at months… 1,2,3,6,12,18 & 24 • For late latent syphilis: at months .. 3,6,12 18 & 24 • Those with concomitant HIV infection,annual F/U for life.
Audited Questions Was the necessary follow up done? Provision of follow up dates
100%
Follow up in infectious syphilis? Early syphilis
Late syphilis
3/12 month FU
6/12 month FU
24 (68.5%)
13 (37%)
25 (57%)
24 (54%)
42 (55%) patients have defaulted at some stage of management up to their 6 months follow up.
7. What proportion of defaulter tracing was done?
Audited Questions What proportion of defaulter tracing was done? Attempted
11/42
26%
Not mentioned
31/42
73%
Defaulter tracing was attempted in 11 patients but out come was documented in only 8 files.
Possible reasons and lower coverage of contact tracing /Partner screening and follow up
• Some partners were unidentifiable anonymous contacts. (1/4 th of audit population had casual sex during last 3/12 and 87% ever had a casual partner whom they didn’t feel committed). • Deficiency in counselling about importance of follow up.
Reasons contd…… • No proper contact details due to incomplete documentation (TP no./Address). • Lack of staff for counseling . • In year 2012 no PHI at the clinic , that may be reflected by poor contact tracing, defaulter tracing and follow up.
Recommendations to improve the future patient care. Significant room for improvement in areas of patient follow up. • Proper documentation at all level of management. (need extra few minutes) • To prevent unnecessary retreatment, written treatment details should provide to the patients. • Proper maintenance of contact tracing, defaulter tracing registers.
Recommendation contd. • Strengthening of current peer-led programmes for contact tracing and cluster management. • As a significant percentage (14% ) were referred by peer- led programmes, the importance of maintaining the above programmes even after the funding is over should be taken in to consideration.
Recommendation contd. • Indepth counselling on the importance of follow up. • Staff should spend more time on contact tracing and defaulter tracing. • Motivation of staff through continuous supervision. • Periodical reaudits.
Evidence of good practice
“Bear the responsibilities and Care the patients�
Acknowledgement
• • • •
Dr. Ajith Karawita Dr. Thilani Ratnayake Dr. Darshani Wijayawickrama Ms. J.I. Kulatunga and all the staff of STD clinic Ragama.