The effect of introduction of a guideline on the management of vaginal discharge and in particular bacterial vaginosis in primary care

Background. Bacterial vaginosis (BV) is the commonest cause of vaginal discharge, and its association with obstetric and gynaecological complications is being recognized increasingly. It was our impression that BV was poorly understood and underdiagnosed in family practice. Objective. The aim of this study was to explore the management of patients with vaginal symptoms by family practitioners and to see if the management changed after the assimilation of best practice guidelines. Method. Family practitioners were invited to complete a baseline questionnaire of their perceived practice, and to record actual practice when consulted about vaginal symptoms, for a minimum of 4 weeks. Consensus best practice guidelines were then provided and practice recorded for a similar period. Results. Baseline data was received from 34 practitioners and suggested that the symptoms and signs of different vaginal infections were not well known. Most symptomatic patients were only investigated at re-presentation with unresolved symptoms or at recurrence, and 43% of respondents treated with empirical antifungals as a first line approach. Pregnant patients were only occasionally asked about symptoms and only occasionally examined if symptomatic. Preguideline practice data from 30 practitioners showed 1.2 patient consultations/week, of which 60% were examined and 55% had a high vaginal swab (HVS) sent. Only 2% had near-patient tests done. Post-guideline data from 23 family practitioners showed a lower recorded consultation rate at 0.7/week, but 90% of these were examined, 77% had an HVS sent and 69% had near-patient tests done. Of the 36 HVS examined by Gram stain, 19 (53%) showed Lacrobacillus predominant flora and 10 (28%) suggested BV. Seven (19%) were borderline or ungradable. Only three (8%) showed yeasts, one of which also showed BV. Conclusions. Baseline data supported our impression that BV was under-recognized, Guidelines appeared to improve the rate of investigation of women consulting with vaginal symptoms.