Treatment of sexually transmitted diseases in most places in the world is empiric in nature, based on the presenting clinical syndrome of the patient. A generation ago, the laboratory diagnosis of STDs was fairly rudimentary. No NAAT testing, viral culture and serology only for HSV, etc. Add this to the fact that getting some of the patients back for a second visit isn’t always easy and it is easy to understand why the Sexual Health community have traditionally gone for this model of care.
However things are changing, and changing fast…
Our ability to accurately diagnose STDs has increased markedly over the past decade. C. trachomatis, N. gonorrhoeae, HSV are now all routinely diagnosed by NAAT testing in most laboratories. “Emerging” organisms such as Mycoplasma genitalium are now coming onto the radar of STD clinicians, primarily because we can now diagnose it…
Whilst empiric treatment works (most of the time anyway), it does have its downsides. Empiric therapy on a population basis usually leads to overtreatment. Resistance to N. gonorrhoeae has reached worrying levels for both fluoroquinolones and ceftriaxone. Resistance of M. genitalium to macrolides has been increasing, most probably in areas where azithromycin is used empirically for urethritis.
We need to be careful we don’t create a rod for our own back…
It may be that Sexual Health needs to start exploiting the progress in laboratory diagnostics that has been made over the past few years and start moving away from empiric based management of STIs. Some NAAT tests are now available (e.g. Cepheid CT/NG) that can give a result in around 90 minutes. Thus it could theoretically be possible to see the patient, take the samples, send the patient away for a coffee, test the samples in the clinic with an automated benchtop PCR analyser, and see the patients back in an hour or two with the results and directed management.
This might well be the future of STD clinics…
Michael
Even more fascinating than that Michael. The future could be a totally automated, online virtual STD clinic. You go to the website, enter your own sexual history (no more embarrassing questions by a stranger), and the system figures out based on that what tests you need. A self-collection kit is then sent to you via the mail, you take your own samples in the privacy and comfort of your own bathroom, and then send them back to the lab. The first human-to-human interaction will be when the clinician looks up the results and brings you to clinic for treatment and discussion of positive results (if any). If someone has got the money and the technical expertise to set it up, I’m up for the clinical side of it!
That takes disruption of the Sexual Health Service to a whole new level Massimo!
The Dean Street Clinic, Soho, London, has been operating under this type of format for a couple of years now. See http://dean.st/56deanstreet
Good to know Julie, thanks for your comment.