The Diagnostic Accuracy of Syndromic Management for Genital Ulcer Disease: A Systematic Review and Meta-Analysis

Objectives: Genital Ulcer Disease (GUD) carries a significant disease burden globally. With limited access to diagnostics, the 2001 World Health Organization (WHO) sexually transmitted illnesses (STI) guidelines proposed a syndromic management algorithm that required a clinical decision to determine the management of GUD. We assessed the diagnostic accuracy of this algorithm.Methods: We conducted a systematic review (Prospero: CRD42020153294) using eight databases for publications between 1995 and January 2021 that reported primary data on the diagnostic accuracy of clinical diagnosis to identify aetiological agents of GUD. Titles and abstracts were independently assessed for eligibility, and data were extracted from full texts for sensitivity/specificity. A hierarchical logistic regression model was used to derive pooled sensitivity and specificity. We used GRADE to evaluate the certainty of evidence.Results: Of 24,857 articles, 151 full texts were examined and 29 included in the analysis. The majority were from middle-income countries [(14/29 (48%) lower middle, 10/29 (34%) upper middle)]. We pooled studies where molecular testing was using to confirm the aetiology of GUD: 9 studies (12 estimates) for herpes, 4 studies (7 estimates) for syphilis, and 7 studies (10 estimates) for chancroid. The pooled sensitivity and specificity of GUD for the detection of herpes was 43.5% [95% confidence interval (CI): 26.2–62.4], and 88.0% (95% CI: 67.0–96.3), respectively (high certainty evidence); and for syphilis were 52.8% (95% CI: 23.0–80.7), and 72.1% (95% CI: 28.0–94.5) (moderate certainty evidence); and for chancroid were 71.9% (95% CI: 45.9–88.5) and 53.1% (95% CI: 36.6–68.9) (moderate certainty evidence), respectively.Conclusion: Algorithms requiring a clinical diagnosis to determine and treat the aetiology of GUD have poor sensitivities for syphilis and herpes simplex virus, resulting in significant numbers of missed cases. There is an urgent need to improve access to affordable and efficient diagnostics (e.g., point-of-care tests) to be incorporated into GUD algorithms to better guide appropriate management.Systematic Review Registration: PROSPERO, identifier: CRD42020153294.

Prevalence of sexually transmitted infections in a tertiary care centre of North India

Background: Sexually transmitted infections (STI’s) are most common notifiable infectious diseases in the world. Knowledge of prevalence of STI’s is important to implement appropriate control strategies. This study is undertaken to see any changing trends in prevalence of STI’s by comparing with previous studies.Methods: All the patients who attended STI clinic from July 2019 to June 2020 were included in the study. Diagnosis was made on basis of history, clinical examination and laboratory investigations.Results: The 2188 patients were seen from July 2019 to June 2020 in STI clinic. Mean age group of patients is 25-44 years. Scabies (31.6%) was the commonest STI seen in outpatient department followed by balanoposthitis (16.4), vaginal discharge (12.5%), human immunodeficiency virus (HIV) (11.4%), herpetic genital ulcer disease (7.9%), genital warts (5.8%), molluscum contagiosum (2.4%), syphilis (2.4%), urethral discharge (1.7%), non-herpetic genital ulcer disease (0.4%), non-gonococcal urethritis (0.4%).Conclusions: Scabies was the most common STI reported in our study followed by balanoposthitis and vaginal/cervical discharge. Among the viral STI’s, HIV is showing alarmingly rising trends and is most common viral STI seen in the study followed by herpes simplex virus (HSV). May be there is less reporting of genital herpes simplex infection due to its self-resolution. As compared to previous studies, rising trends of fungal infections are seen which can be due to syndromic management of bacterial STI’s, rising incidence of diabetes mellitus as well as illicit use of over-the-counter broad-spectrum antibiotics given by the local practitioners.

Recent Trends of Syndromic Sexually Transmitted Infections at a Tertiary Care Center in Maharashtra, India: A Retrospective Analysis

Background: Sexually transmitted infections (STIs) constitute a major public health problem in both developed and developing countries. Human immunodeficiency virus (HIV) and STIs are linked in their similar mode of transmission, with STIs facilitating the acquisition and transmission of HIV. The prevalence pattern of individual STIs may evolve over time necessitating a corresponding change in management strategies. Objectives: The study was conducted to determine the burden and any change in the etiological trend among attendees of an STIs clinic at a tertiary care hospital. Methods: This retrospective study analyzed data retrieved from consecutive patients attending an STIs clinic over two years (July 2018 to July 2020). Results: Overall, 1916 patients were diagnosed with STIs. The predominant age group was 25 - 44 years (59.23%). Genital ulcer disease was the foremost syndrome (1213, 63.3%). Overall, herpetic genital ulcer was the most common (682, 35.6%), followed by non-herpetic ulcers (531, 27.7%). Vaginal discharge, lower abdominal pain, and urethritis were found in 461 (24%), 219 (11.43%), and 23 (1.27%) of the patients, respectively. Amongst 237 (12.36%) In HIV seropositive attendees, genital ulcer disease (herpetic) was the most common syndrome (179, 75.53%), followed by vaginal discharge (42, 17.72%), lower abdominal pain (9, 3.8%), and urethritis (7, 2.9%). Conclusions: A definite change in the profile of STIs was observed with ulcerative STIs (particularly herpes genitalis) constituting the major burden against a discernible back drop of decreasing non-herpetic STIs. A systematic, regional, periodic synopsis would not only help to follow and document the dynamic trends, but also can help to assess the effectiveness of control programs.

Granuloma Inguinale

Granuloma ingunale (GI) or donovanosis is a genital ulcer disease caused by theCalymmatobacterium granulomatis. It is a Gram-negative, facultative, obligateintracellular and pleomorphic bacterium. This bacterium has phylogeneticallyclosed to and placed within the Klebsiella genus. Clinically, the disease is com-monly characterized as painless, slowly progressive ulcerative lesions on thegenitals or perineum without regional lymphadenopathy. The lesions are highlyvascular and bleed easily on contact Extragenital lesions may occur but are rareand more common in newborns from mothers with GI genital lesions. Thisdisease is often neglected, therefore it is often misdiagnosed and inaccuratetherapy. Treatment time is 3 weeks or until clinical cure has been achieved forall proposed regimens. It often occurs both in men and women of reproductiveage (20-40 years). This article consists of several theoretical references that havebeen viewed to have a better understanding of GI.

Granuloma Inguinale

Granuloma ingunale (GI) or donovanosis is a genital ulcer disease caused by theCalymmatobacterium granulomatis. It is a Gram-negative, facultative, obligateintracellular and pleomorphic bacterium. This bacterium has phylogeneticallyclosed to and placed within the Klebsiella genus. Clinically, the disease is com-monly characterized as painless, slowly progressive ulcerative lesions on thegenitals or perineum without regional lymphadenopathy. The lesions are highlyvascular and bleed easily on contact Extragenital lesions may occur but are rareand more common in newborns from mothers with GI genital lesions. Thisdisease is often neglected, therefore it is often misdiagnosed and inaccuratetherapy. Treatment time is 3 weeks or until clinical cure has been achieved forall proposed regimens. It often occurs both in men and women of reproductiveage (20-40 years). This article consists of several theoretical references that havebeen viewed to have a better understanding of GI.

The global and regional burden of genital ulcer disease due to herpes simplex virus: a natural history modelling study

IntroductionHerpes simplex virus (HSV) infection can cause painful, recurrent genital ulcer disease (GUD), which can have a substantial impact on sexual and reproductive health. HSV-related GUD is most often due to HSV type 2 (HSV-2), but may also be due to genital HSV type 1 (HSV-1), which has less frequent recurrent episodes than HSV-2. The global burden of GUD has never been quantified. Here we present the first global and regional estimates of GUD due to HSV-1 and HSV-2 among women and men aged 15–49 years old.MethodsWe developed a natural history model reflecting the clinical course of GUD following HSV-2 and genital HSV-1 infection, informed by a literature search for data on model parameters. We considered both diagnosed and undiagnosed symptomatic infection. This model was then applied to existing infection estimates and population sizes for 2016. A sensitivity analysis was carried out varying the assumptions made.ResultsWe estimated that 187 million people aged 15–49 years had at least one episode of HSV-related GUD globally in 2016: 5.0% of the world’s population. Of these, 178 million (95% of those with HSV-related GUD) had HSV-2 compared with 9 million (5%) with HSV-1. GUD burden was highest in Africa, and approximately double in women compared with men. Altogether there were an estimated 8 billion person-days spent with HSV-related GUD globally in 2016, with 99% of days due to HSV-2. Taking into account parameter uncertainty, the percentage with at least one episode of HSV-related GUD ranged from 3.2% to 7.9% (120–296 million). However, the estimates were sensitive to the model assumptions.ConclusionOur study represents a first attempt to quantify the global burden of HSV-related GUD, which is large. New interventions such as HSV vaccines, antivirals or microbicides have the potential to improve the quality of life of millions of people worldwide.