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