Postal survey of management of cervical Chlamydia trachomatis infection in English and Welsh general practices

Subjects, methods, and results

In June 1994 we sent a confidential postal questionnaire to a random stratified sample of 500 general practices drawn from all 98 family health services authorities in England and Wales. The introductory letter was addressed to the practice managers, who were asked to give the questionnaire to the general practitioner most involved in smear testing. The questionnaire included an open question on the management of chlamydia infection. Non-responders were sent a second questionnaire.

We received 374 completed questionnaires, a response rate of 75%. Of the practices which provided details, 63 were in rural areas, 180 in towns, and 51 in inner cities; 315 said that their local laboratory provided a chlamydia service and 264 had tested a woman for chlamydia in the previous year. However, eight practices had experienced difficulty in obtaining appropriate swabs or slides. Half the general practitioners usually offered advice on avoiding sexually transmitted infections to young women having gynaecological examinations.

Table 1 shows the characteristics of respondents and their management of women with chlamydia infection. We compared the antibiotics used by general practitioners, where specified, with Centers for Disease Control guidelines.3 These recommend a seven day course of doxycycline 100 mg twice daily, tetracycline 500 mg four times a day, or erythromycin 500 mg four times a day. A single dose of azithromycin 1 g may also be used.4 Treatment was judged inappropriate if a less suitable antibiotic or if no or an inadequate dose or duration of treatment was given. We assumed that women referred directly to a genitourinary department would attend and receive appropriate antibiotics and contact tracing.

General practitioners aged under 35 were more likely than older doctors to refer women with chlamydia infection to a genitourinary clinic (odds ratio 2.16; 95% confidence interval 1.30 to 3.60). For those treating the patient in the practice, factors which increased the likelihood of prescribing appropriately were young age, female doctor, group practice, and having requested chlamydia tests in the past year. After age was adjusted for, only having requested chlamydia tests remained significant.

Factors which increased the likelihood of treating or referring the sexual partner were young age, group practice, training practice, requesting chlamydia tests, and having a patient with a positive result. After age was adjusted for, training practice was no longer significant.

Comment

A third of practices had had a patient with a positive chlamydia result in the past year, implying adequate endocervical sampling. However, only 30% of general practitioners would have referred a woman with chlamydia infection to a genitourinary clinic for contact tracing, follow up, and screening for coexistent infection. Good communication between genitourinary physicians and general practitioners is important, but appropriate management should be available in general practice for women who refuse to attend a genitourinary clinic.2 5 Recommended treatment could be more clearly stated in the British National Formulary,4 and general practitioners should emphasise the importance of treating partners.3

This study targeted the doctor most interested in smear testing, which biased the sample towards younger, female general practitioners. Respondents might be expected to be better than their colleagues at managing chlamydia infection and to have different attitudes to sexual health.1 However, this study suggests that although many practices have facilities for chlamydia testing, the management of infected women may be incomplete.

We thank Professor S Hilton, Dr P Hay, and Dr D Carrington for advice and the general practitioners for completing the questionnaires.