The North Wales adopter, Helen Booth was tasked by the local Clinical Lead to move the process we had used for urine samples to genital samples on a similar basis to the urine rational: could sampling practices and outcomes be improved through the use of more engaged clinical comments?
The North Wales service noted they are receiving far more genital samples compared to other Public Health Wales sites. This has been a longstanding issue and Helen has looked at the data for her health board compared to other services:
It has long been the opinion of clinicians and lab managers that a proportion of these samples collected and tested are
- Missed opportunities to educate and improve the quality of the reports and ultimately patient management.
Much of microbiology is still reliant on traditional culture methods which can result in a delay in reporting:
Overall positivity for Genital samples ( microscopy and culture ) is 41%
Which begs the question, How many of these samples need to be processed rather than treated empirically, based on a thorough clinical history and detailed symptom check?” and can we change the clinical behaviour in the long-term.
The Focus initially will be to try and influence a change in diagnosis of BV and Candida.
Through Narrative Reporting, Helen hopes to influence clinical behaviours. Her initial focus is around Candida and bacterial vaginosis (BV).
Many causes of genital infections present with classic textbook symptoms, to some extent by introducing narrative reporting we hope to
- exploit the good availability of clinical details/diagnosis on the request to question whether the patient needed to have swabs taken, could they have been treated empirically or do they need to seek specialist referral
- Question the lack of accompanying clinical details on the request form and educate the user on expected symptoms linked to the reported pathogen, again offering them the scope to treat empirically or in some cases no treatment may be the recommended option.
The comments have been structured around CKS NICE guidelines and similarly to urine authorising strategically placed under the microscopy or organism code.
We aim to develop a library of statements that can be utilised to provide a standardised approach given the clinical scenario presented. Saying that each comment has the ability to be modified and adapted as the authoriser sees fit.
Below are examples and copies of comments that have been developed in response to different clinical scenarios:
Clinical information : Urethral Pain, 40 year old female.
We have advised that the available clinical detail is not a typical symptom of the condition we have reported – BV, our findings may be incidental and may not require treatment which may prompt further investigation into the nature of her symptom listed.
Clinical information : 19 year old Female , PV discharge , previous POSITIVE Chlamydia
This report highlights 2 organisms. Scanty Group B is unlikely to be significant in this scenario so we have added 2 comments, one to focus on the Trichomonas and another advising referral to a Sexual Health Clinic for full Sexual Health Screening given both the current and historic information provided.
Clinical Information : 27 year old female, PV discharge, Post IUD.
Quite vague clinical details which does not imply BV. The comment reminds the requestor of the classic presentation of BV and suggests testing may have been avoided following detailed symptom check.
Clinical information : 51 year old female, bleeding after amenorrhea, mirena in situ.
We offer a potential explanation for the symptoms described explaining our findings may be incidental and insignificant but suggest given the nature of the symptoms a referral should not be discounted.
Clinical information : 74 year old female, thrush symptoms
Given the accurate diagnosis in the clinical detail provided we suggest the investigation may not have been necessary in uncomplicated cases of vulvovaginal candidiasis.
And finally, other examples of coments developed based on guidelines, which will be woven into scenarios as they present like above and further developed:
Examples of additional narrative comments for Genital infections.
• The clinical details do not seem to indicate any identifiable infective or non-infective cause for a vaginal discharge, and with no clinical clues from the history and examination, guidelines recommend you reassure that the discharge is likely physiological.
• I note this sample was taken as a pre-IUCD screen. Guidelines advise in asymptomatic, low STI risk women, routine screening for bacterial infection is not recommended prior to IUD insertion. While we have found microscopic evidence that is compatible with bacterial vaginosis (BV) for asymptomatic women BV treatment is not usually required prior to IUCD insertion.
•I note the patient is experiencing recurrent symptoms. Where symptoms recur frequently (at least 4 times a year) despite adequate management in primary care, consider discussing with gynaecology or Sexual Health Specialists.
•The clinical details provided seemed to indicate Bacterial Vaginosis. NICE guidelines suggest in these situations, clinical examination and investigation may be omitted from women with characteristic symptoms on the assumption they are:
o low risk of STI,
o no symptoms of other conditions,
o have not had any recent Gynaecological procedure,
o not postnatal or post miscarriage,
o not pregnant,
o not pre or post termination
o and this is the first episode of suspected BV, or if recurrent, a previous episode of recognizably similar symptoms was previously diagnosed to be BV following examination.
• Microscopy and fungal culture of vaginal secretions to identify yeasts is only recommended for supporting the diagnosis and in cases of severe or recurrent vulvovaginal candidiasis, or treatment failure.
• I note this lady is getting recurrent infection — defined as four or more documented episodes in 1 year, with at least partial resolution of symptoms between episodes. Should symptoms not improve and treatment failure is unexplained, please consider referal or seek specialist advice.
•This isolate has been send to the reference lab for identification and sensitivity testing.
•Ideally, all people with suspected gonorrhoea should be referred to a genito-urinary (GUM) clinic or other local specialist sexual health service for confirmation of diagnosis.
•Gonorrhoea should be treated in primary care only if specialist services cannot be accessed within a reasonable time, or if the person is unwilling to attend despite receiving appropriate information and advice, and if the appropriate expertise is available.
•Staph aureus from a vaginal specimen is usually a reflection of perineal carriage although clearly may have a role post-op and can be associated with severe disease associated with tampon use. Please view in the light of the clinical picture.
•This may simply be a reflection of perineal carriage but the Group C/G strep may be associated with an acute vaginitis. Please review in the light of the clinical picture.
• I note we are unable to find an infective cause for the lady’s symptoms. You may need to consider a referral to gynaecology.