EVALUATION OF SYNDROMIC PATIENT-MANAGEMENT ALGORITHM FOR URETHRAL DISCHARGE

Objective: To determine feasibility, validity, and cost effectiveness of the syndromic approach to male patients with urethral discharge in Bandung, Indonesia. Methods: The WHO algorithm on urethral discharge w ith no microscopy available was evaluated. Patients presented with a c omplaint of urethral discharge and if discharge was confirmed the algo rithm was applied. Treatment covered gonococcal and chlamydial infecti on (ciprofloxacin 500 mg single oral dose plus doxycycline 100 mg, twi ce daily orally for 7 days). The gold standard for validation was gono coccal culture and chlamydia antigen detection. Results: 140 male pati ents with a complaint of urethral discharge were enrolled; 119 had con firmed discharge and entered the decision tree: 107 were followed and 104 (97%) were clinically cured. Of the three patients with persistent discharge, one had a purulent urethral discharge, diagnosed as gonoco ccal urethritis and he was probably reinfected; two patients had a ser ous discharge and microbiological tests were negative. Overall, 106 ou t of 107 patients (99%) were microbiologically cured. Sensitivity of t he algorithm is 100% and its positive predictive value (PPV) is 75% or 97% if validated against gold standard microbiological tests or Gram stain, respectively. Cost per patient is rupiah (Rp)5.894 ($US2.56) fo r the algorithm compared with Rp43.024 ($18.70) for full microbiologic al diagnosis. The cost estimate for an algorithm of urethral discharge with microscopy available is Rp6.432 ($2.80) Conclusion: The ''sympto m and sign'' algorithm is fully adapted to the prevailing situation in primary healthcare settings, is acceptable to healthcare workers and patients (who are effectively treated at their first visit), is highly cost effective, is 100% sensitive (no false negatives, which is not t he case with microbiological diagnosis), and has a high PPV, between 7 5% and 97%. It is an excellent patient management tool and a sound bas is for partner notification so that it should have a major impact on S TD/HIV control and prevention in both men and women.