C1. Literature review Sample.doc

8/13/2019 C1. Literature review Sample.doc

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Page 1YOR/800/038433 opportunistic screening for Chlamydia trachomatis infection prior to insertion of

intrauterine contraceptive device

OPPORTUNISTIC SCREENING FOR CHLAMYDIA

TRACHOMATIS INFECTION PRIOR TO INSERTION OF

INTRAUTERINE CONTRACEPTIVE DEVICE

LITERATURE REVIEW


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INTRODUCTION

!he idea for my pro"ect arose at my first #P practice placement follo$ing discussions

$ith my colleagues shortly after my attendance at the %amily Planning Course& Current

recommendations in '( %amily Planning Clinics is to perform a set of screening s$a)s

for se*ually transmitted diseases +,!-s. )efore or at the time of insertion of intrauterine

contraceptive device +'C-. $hich usually includes high vaginal and chlamydial

s$a)s& !hat practice seemed to correspond to the practice in O)stetric and #ynaecology

departments in $hich $ored for the previous 3 years&

-uring my first #P registrar placement too particular interest and learned ho$ much

contraceptive and 2ell oman care taes place in primary care practice& 5t one of

the tutorials had a chance to discuss issues of $omen6s health contraception and

screening for ,!-s& %rom that discussion understood that testing for ,!-s and

especially for Chlamydia trachomatis infection only taes place $hen a patient is

symptomatic or there are clinical suspicions of the condition )ut not as a routine prior to

'C-&

!hat discussion prompted me to undertae a short data search in the #P practice

$ored in at that time& !hat confirmed that in a 1 year period of all $omen $ho had

coils inserted in our #P practice only these $ith clinical symptoms and signs $ere tested

for Chlamydia trachomatis infection&


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decided to search the literature to see if there is evidence that testing for chlamydial

infection should )e performed prior to 'C- insertion&

find this topic important )ecause the ma"ority of contraceptive care and se*ual health

promotion issues are dealt $ith in a primary care setting therefore it is important that it

is up to date and in accordance $ith most recent evidence )ased research and guidelines&


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AIMS

%irstly $anted to find out if there is evidence that screening for Chlamydia trachomatis

prior to 'C- insertion decreases the ris of developing Pelvic nflammatory -isease

+P-. and its complications&

,econdly if such evidence is not clear or does not e*ist $anted to no$ $hat are the

important issues around this topic that $ould suggest that such screening is appropriate

or inappropriate&

!hirdly $ished to e*plore issues related to riss of infection at the time and after

insertion of 'C-&

%inally thought it is important to learn more a)out Chlamydia trachomatis infection

and Pelvic nflammatory -isease itself its ris factors prevalence infection spread and

complications to )etter understand the natural history and dynamic of these conditions&


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METHOD

revie$ed current literature to find if there is evidence that screening for genital

infections prior to 'C- insertion decreases the incidence of Chlamydia trachomatis

infection and P-& !his $as performed )y accessing the edline and Cochrane

data)ases using the ey$ords 2Chlamydia !rachomatis 2Pelvi nflammatory -isease

2ntra 'terine Contraceptive -evices ,e*ually !ransmitted -iseases screening&

$idened my search )y visiting relevant $e)sites including 9ational nstitute of

Clinical :*celence +9C:. ,cottish ntercollegiate #uidelines 9et$or +,#9.

PRO-#Y Royal College of O)stetricians and #ynaecologists +RCO#. and -rugs and

!herapeutics ;ulletin +-!;.& also revie$ed all guidelines related to ,!-s Chlamydia

trachomatis and 'C- insertion in 9ational :lectronic


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RESULTS OF FINDINGS

Pelvic nflammatory -isease is the clinical syndrome implying infection of the upper

genital tract caused )y ascent of se*ually transmitted )acteria +mainly Chlamydia

trachomatis and 9eisseria gonorrhea. from the vagina and endocervi* to the

endometrium and %allopian tu)es +4 >.& nfective organisms can )e introduced )y

se*ual intercourse insertion of 'C- during hysteroscopy endometrial )iopsy

termination of pregnancy and infertility investigations and treatment +7 >.&

Ris factors for Chlamydia trachomatis infections include multiple partners age less

than 7 lo$ leaving school age )eing single recent change of partner ethnic group

previous se*ually transmitted diseases + 3 ?.& Chlamydia trachomatis is one of the

most common treata)le )acterial se*ually transmitted diseases& ts prevalence has

increased )y 70@ since 1?88 mainly amongst $omen under 7 years of age +3.& n most

$omen Pelvic nflammatory -isease is asymptomatic and up to A0@ have no clinical

symptoms or signs +4 >.& n others symptoms include fever malaise a)dominal and

pelvic pain and vaginal discharge& Regardless of the presentation 0@ of $omen $ith

P- develop chronic pelvic pain 0@ )ecome infertile and 10@ of these $ho conceive

develop ectopic pregnancy +4 >.& !he pro)lem is regarded as largely underestimated and

overlooed )y health professionals +11.&

One study $as conducted in a surgery in the aefield area Yorshire& !he aim of this

study $as to assess the prevalence of Chlamydia trachomatis infection using


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opportunistic screening +urine sample. in $omen )et$een 13 and 4 years old& >0@ of

those targeted chose not to su)mit the sample& n those $ho su)mitted a sample the

prevalence $as nearly 11@ +.&

5 cohort study $hich $as conducted in the '( )et$een 1?>8B A4 and involved 1A03

married parous $omen )et$een 7B 3? years of age found that the rate of P- $as

higher in users of 'C-s than in nonB users& !he dra$)ac of this study is that $omen

in the control group used other methods of contraception such as oral contraceptives

+including progesteronBonly pill. and diaphragms $hich are no$n to reduce the

transmission and infection rates for ,!-s +>1.&

5 ;railian study $as carried out using a group of 40A $omen $ho $ished to use a coil

as a method of contraception& ? of them had symptoms or signs of P- so 'C- $as

not offered& 'C-s $ere not inserted in $omen suspected of having infection& Of these

$ho had 'C- inserted 1? $ere su)seDuently found to have Chlamydia trachomatis

infections $omen returned $ith symptoms and 1A $ere asymptomatic& %rom this

study it is impossi)le to conclude $hether they had infection prior to the coil insertion

or if the infection $as introduced at the time of instrumentation or if it $as acDuired

after$ards& !hese results reinforce the need for careful selection of patients for 'C-s

insertion thorough counselling for symptoms and need for action should the infection

occur +1.&


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5 national screening program for genital chlamydial infection $as rolled out from 00

+10.& nitially the screening program $ill )e started in 10 sites )uilding on successful

pilots in Portsmouth and irral& !his $ill )e an opportunistic screening program $hich

$ill mainly target $omen $ho access services such as %amily Planning Clinics& !he

design of the program $ill )e guided )y the study currently looing at the rates of

infection $ith chlamydia +1.& !he decision to consider a national screening program

follo$ed recommendations made )y the Chief edical Officer6s :*pert 5dvisory #roup

on Chlamydia trachomatis +?.& !he group concluded opportunistic screening for genital

chlamydial infection should )e offered to all #enitourinary Clinic attendees as there is

evidence of consistently high prevalence rates of this infection&

5ll $omen seeing termination of pregnancy $ould )e screened as there is compelling

evidence that the procedure increases the ris of infection ascending during the

procedure +)oth medical and surgical. to cause pelvic infection& 5ll $omen under 7

years of age and $omen over 7 years of age $ith a ne$ partner or $ho had t$o or

more partners in last 1 months $ould )e screened )ecause of a study )ased in '(

$hich found that if this strategy $as used only 4?@ of $omen $ould )e tested )ut

8A@ of chlamydial infection $ould )e detected +3 ?.&

!he :*pert 5dvisory #roup also recommended that $omen undergoing instrumentation

of the uterus +$hich includes insertion of 'C-s. should )e considered for screening +3

? 10.& !hey emphasise that there is limited evidence suggesting that screening )efore


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Page ?YOR/800/038433 opportunistic screening for Chlamydia trachomatis infection prior to insertion of


'C- insertion reduces ris of P- +10. and the prevalence of Chlamydia infection in

$omen receiving 'C-s is liely to )e lo$ as most of them are multiparous and over

7 years of age +?.& 9evertheless the Royal College O)stetricians and #ynaecologists

recommends that all $omen under 37 should )e screened prior to 'C- insertion +10.&

!he %amily Planning Clinic association states that it is good practice to screen for

infection in all $omen )efore 'C- insertion +8.&

!he recent -rugs and !herapeutics ;ulletin article suggests the possi)le plan of action

)efore 'C- insertion +>.& !hey postulate that careful and detailed history is taen

assessing se*ual history relevant history of partners practices and se*ually transmitted

diseases& Chlamydia testing should )e offered to all at ris including under 7s thoe

$ith more than one partner and those $ith a history of se*ually transmitted diseases&

5ppropriate ris assessment should identify individuals unliely to reDuire such testing&

!o minimise the lielihood of complications it suggests to avoiding inserting the 'C-

in any $omen $ith proven or suspected infection +1 A.& t may ho$ever )e inserted in a

$oman in $hom infection has )een successfully treated provided that her +and her

partner6s. se*ual practices no longer put her at ris& Prophylactic anti)iotics are said to

)e unliely to improve outcomes in $omen $ith lo$ ris of se*ually transmitted

diseases and should not )e used +A.& !he ris of infection through insertion of the coil

could )e reduced )y using long lasting devices +7 years. and thus reducing the num)er

of reBinsertions +>.&


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5ll $omen receiving 'C-s should )e counselled a)out increased ris of Chlamydial

infection and development of P- $ithin 3 $ees after insertion as $ell as the

possi)ility of ectopic pregnancy and infertility should the P- develop +4 7 >.& omen

should also )e told of the symptoms of infection so they could see medical advice and

treatment early +> 8.&


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DISCUSSION

!hough there is no direct research or study $hich e*amines if opportunistic screening

for Chlamydial infection prior to 'C- insertion reduces the ris of this infection and

P- +10. there is a lot of research related to various aspects of Chlamydial infection

$hich in turn allo$s us to dra$ ne$ conclusions leading to improvement of e*isting

practice&

!here are studies that prove increased prevalence of Chlamydial infection +. recognise

that most cases are asymptomatic and carry very high rates of complications +4.& !here

is evidenceB)ased research $hich esta)lishes ris factors for the condition +3.& !here is

also proven evidence that any intrauterine instrumentation including 'C- insertion

increase the ris of Chlamydial infection +7.&

On the )asis of this research the Chief edical Officer6s :*pert 5dvisory #roup on

Chlamydia infection formulated a national screening program $hich includes

recommendation for screening prior to 'C- insertion +?.&

!hese recommendations are echoed in $idely availa)le national guidelines $hich are

pu)lished across the country such as the ,cottish ntercollegiate #uidelines 9et$or

+11. PRO-#Y +10. 9ational :lectronic =i)rary of .& n summary they all recommend that opportunistic screening should )e


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performed and it should )e proceeded )y appropriate ris factor assessment and

supported )y adeDuate counselling&


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CONCLUSIONS

)elieve that the topic of screening for Chlamydial infection )efore insertion of the coils

is important and relevant to general practice& %or this reason as soon as prepared the

findings of my search presented them at the clinical multidisciplinary meeting in my

practice& understand that my search helped )oth doctors and nurses in the practice to

consolidate e*isting no$ledge a)out Chlamydial infection& !he presentation lead to

discussion and e*change of e*perience )et$een doctors& !he practical issues such as

$hich test is )est for screening ho$ to counsel patients ho$ to organise appointments

to )e most time efficient $ere discussed& )elieve that my presentation and findings $ill

lead to an improvement in e*isting practice& t $ill mae it more uniform and

consistent as all team mem)ers +)oth doctors and practice nurses. are no$ more a$are

of the ris group for chlamydial infection and $ill use opportunistic screening not only

at the time of the coil insertion )ut also in such situations as cervical smear taing if it is

appropriate&

!his literature search $as also very useful to me& t helped me realise that genital

Chlamydial infection though asymptomatic in most cases has a very high complication

rate& t helped me to learn a)out ris factors for contracting this condition and gave me

guidance for my o$n practice&

n summary it )ecame evident that all $omen coming for insertion of 'C- should )e

first of all checed if they )elong to a ris group for Chlamydial infection +under 7


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years old $ith more than partners in the last year previous ,!-s ne$ partner.& !hey

should also )e ased a)out symptoms such as pelvic pain and vaginal discharge& f the

patient falls into criterion of high ris for Chlamydial infection the screening test should

)e offered and the 'C- inserted after the test results come )ac negative& f the

Chlamydial test comes )ac positive the $oman should )e treated and advised

regarding contact tracing& hen repeated tests come )ac negative the 'C- could )e

inserted& 5ll $omen in the lo$ ris group +over 7 years of age $ith one partner in long

term relationship no previous ,!-s. can have the coil inserted $ithout screening for

Chlamydia trachomatis infection& 5ll $omen should )e told a)out a small ris of

infection follo$ing the procedure and $arned that if symptoms of malaise pelvic pain

and vaginal discharge develop they should see medical attention&

#eneral Practitioners are reDuired to deliver Duality care to their patients and to practice

evidence )ased medicine& Currently a large part of contraceptive care and service taes

place in primary care setting& #enerally 'C-s are a convenient ine*pensive relia)le

form of contraception& !he insertion of the coil reDuires though training is not difficult

and carries only a small rate of complications& ncorporating the opportunistic screening

)efore coil insertion into current practice $ill allo$ #eneral Practitioners not only to

decrease their patient mor)idity and avoid complications )ut it $ill also contri)ute to

their patient satisfaction&


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LITERATURE

1& !he ris of inadvertent intrauterine device insertion in $omen carries of

endocervical Chlamydia trachomatis& %audas 5 !elles : Cristofoletti = %audes

- Castro , >B>? ,ept 00&

A& 5nti)iotic prophyla*is for intrauterine contraceptive device insertion& #rimes -5

,chul (%& !he Cochrane =i)rary ssue 3 00&


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Page 1>YOR/800/038433 opportunistic screening for Chlamydia trachomatis infection prior to insertion of


8& ntrauterine contraceptive devices& ;elfield !& %P5 contraceptive hand)ooF a guide

for family planning and other health professionalsF ?3B 107& %amily Planning

5ssociation& =ondon 1???&

?& ,ummary of conclusions of CO6s :*pert 5dvisory #roup Report on Chlamydia

!rachomatis& -ept& of 14&

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C1. Literature review Sample.doc