Although general practitioners screen only a small proportion of the eligible population,5 the majority of diagnoses of genital chlamydia infection are still made in general practice. The Queensland notifiable disease database6 for 2006 showed that 89% of all chlamydia notifications in urban areas and 78% in regional/remote areas were made by GPs, rather than clinicians in hospitals or sexual health clinics. More recent data is not available, but similar figures have been found from notification data in other Australian states.8 A previous study found a chlamydia infection prevalence of 5% in patients aged 18–25 years presenting to GPs in Mackay (northern Queensland),8 similar to rates in other Australian regions.9–11
Uncomplicated genital chlamydia infection is treated with a single 1 g dose of azithromycin. This treatment is very effective, hence proof of cure is not recommended.12 However, re-infection rates are high.13 An Australian study found 22% of women aged less than 25 years were re-infected by 12 months, with most re-infections occurring in the first 4–5 months.14 In order to identify and manage re-infection, guidelines for Australian GPs advise re-testing 3–12 months after a positive chlamydia diagnosis.12 Other guidelines also recommend re-testing at 3 months.15,16
Contact tracing is 'the process of identifying relevant contacts of a person with an infectious disease and ensuring that they are aware of the exposure'.17 There is level 1 evidence that contact tracing for chlamydia is effective in preventing transmission to partners and preventing re-infection in the index case.18
Australian states and territories address contact tracing in a range of ways. In Tasmania, GPs are contacted by the public health unit and offered the services of sexual health clinic nurses. In Victoria, contact tracing officers are employed within public health services, and may be utilised by GPs to help with contact tracing. In Queensland, no formalised process for contact tracing exists. There is some evidence that Australian GPs do not always deal with contact tracing adequately.19–21 A study in northern Queensland indicated that many GPs erroneously believe that their patients are followed up by local public health staff,19 and there were similar findings in a Western Australian study.20
This article reports on one component of a mixed methods study undertaken in northern Queensland, aiming to describe how sexually acquired chlamydia infections are managed and followed up in general practice compared with recommended guidelines, including those for re-testing and contact tracing. A secondary aim was to ascertain GPs' preferred model for a contact tracing service. This article reports on the GP questionnaire component of the study.
Method
Population and sample
General practices were recruited via the North Queensland Practice Based Research Network (NQPBRN) to participate in a mixed methods descriptive study. Individual GPs provided written consent to participate in the study. All 18 practices who had previously been involved in NQPBRN were approached to participate. Of these, nine practices and 52 GPs participated in the Mackay and Townsville region. The 52 GPs comprised all of the doctors working in these nine practices. We did not enquire why practices chose not to participate, but it is likely that participating practices had more interest in the management of chlamydia infection.
Procedure
This cross sectional survey was part of a larger survey of three parts. First, each practice audited positive chlamydia cases in the previous 12 months, then a 3 month prospective audit was conducted of the management of all patients referred by GPs for chlamydia testing. Participating GPs were then asked to complete questionnaires about their usual management of chlamydia infection and their opinions about contact tracing (Table 1). The brief semistructured questionnaire was completed before they received their results from the clinical audits. The questionnaire was developed by a small expert group using current guidelines and literature to ensure content validity. Practice nurses ensured a questionnaire was delivered to each participating GP. The de-identified questionnaires were analysed using SPSS for the quantitative questions and thematic analysis of comments.
Statistics
SPSS for Windows (release 17) was used to analyse data and generate descriptive statistics.
Ethics approval for this study was granted by the James Cook University Human Research Ethics Committee (approval number H3577).
Results
Of 52 GPs who were provided the questionnaire, 35 completed it (response rate 35/52, 67%) Participating GPs were younger (median age 40–49 years) and more predominantly female (21/35, 60%) than average for Australian GPs (median age 45–54 years; 32% women).22 We have no data on the GPs who did not complete the questionnaire.
Almost all (32/34, 94%) respondents prescribed azithromycin to patients diagnosed with genital chlamydia infection, with one respondent reporting prescribing doxycycline and one respondent reporting prescribing azithromycin or doxycycline. However, only 9/35 (26%) always treated patients before receiving test results. A total of 51% (18/35) saw the patient the same or the next day after a positive test result. The majority of GPs (30/35, 86%) reported reviewing patients for a 'proof of cure' (or test of re-infection). However, 19/35 (54%) reported performing this within the first 6 weeks after infection, with only 10/35 (29%) of GPs reporting re-testing at 7–13 weeks. In the majority of cases (28/35, 80%), GPs reported discussing contact tracing with patients, five reported that both the GP and the practice nurse do this. In one case it was done by the practice nurse and in one case it was not usually done at all.
The desirability of different resources aiming to improve contact tracing are presented in Table 1.
Table 1. Opinions of 35 GPs from northern Queensland with respect to statements relating to contact tracing resources
| Strongly agree
N=35 (%) | Agree
N=35 (%) | Neutral
N=35 (%) | Disagree
N=35 (%) | Strongly disagree
N=35 (%) |
|---|
| I would find a hardcopy/print resources designed for patient contacts useful (eg. leaflet) |
23 (65.7) |
6 (17.1) |
4 (11.4) |
1 (2.9) |
1 (2.9) |
| I would find printable electronic resources designed for patient contacts useful |
19 (54.3) |
12 (34.3) |
4 (11.4) |
0 |
0 |
| I would like access to a specialist contact tracer |
8 (22.9) |
14 (40) |
13 (37.1) |
0 |
0 |
| I would like to refer all cases of chlamydia directly to a specialist contact tracer from the notifiable disease register |
6 (17.1) 7 |
7 (20) |
14 (40) |
7 (20) |
1 (2.9) |
| I would like the notifiable disease register to refer the patient directly to a specialist contact tracer |
11 (31.4) |
9 (25.7) |
8 (22.9) |
4 (11.4) |
3 (8.6) |
| I am happy to continue contact tracing for chlamydia infection and I do not need extra resources |
Nil |
3 (8.6) |
18 (51.4) |
12 (34.3) |
2 (5.7) |
Discussion
A number of limitations should be acknowledged in analysing and generalising our findings. The participating GPs were not representative of Australian GPs in age or gender. The sample was a small number of GPs in one regional area (northern Queensland). The practices involved were part of a practice based research network and therefore may be more knowledgeable of current guidelines than the general practice population.
Management
Close to all (32/34, 94%) respondents reported prescribing azithromycin for uncomplicated chlamydia infection, in keeping with Australian guidelines.16 Single dose treatments are thought to be best for treatment of chlamydia infection because of compliance and public health issues.16 However, guidelines recommend empirically treating patients with symptoms and any confirmed contacts of positive cases.16 In our study, only 26% of GPs reported doing this. Despite this, positive infections were reported to be treated promptly, with 51% (18/35) seeing the patient the same or the next day after a positive test result.
Re-testing
Re-testing within 3–4 weeks post-treatment is not recommended as false positive results may occur.23,24 Guidelines recommend delaying re-testing until at least 6 weeks after treatment.12
In our study, although 30/35 GPs reported reviewing patients for a 'proof of cure' (or test of re-infection), 19 of these reported that they did this in the first 6 weeks. Overall, GPs are re-testing patients too early, and it may be helpful to familiarise GPs with current guidelines. We did not explore the reasons for this timing – it is possible that this early re-testing is opportunistic or triggered by prepresentation related to symptoms or concerns about partner compliance.
Contact tracing
In our questionnaire we attempted to explore what resources GPs would find useful for contact tracing. Most respondents reported they would find both hardcopy and electronic resources for patient contacts useful, consistent with findings of another study.20 The majority of respondents indicated that they would like the notifiable disease register to refer the patient directly to a specialist contact tracer. In our previous research around half of GP respondents erroneously believed that the local public health unit staff were automatically conducting contact tracing for chlamydia infection.19 It seems that most GPs would be happy for this process to take place.
Conclusion
Although the majority of GPs reported treating uncomplicated chlamydia infection correctly with azithromycin, very few (26%) reported using empirical treatment. Most GPs reported testing for re-infection earlier than guidelines suggest. Most GPs would like hard copy and electronic resources to help with contact tracing. Automatic contact tracing by the notifiable disease registers and specialist contact tracers would be welcomed by this group of GPs. General practitioners in this region – and probably elsewhere – would likely benefit from education clarifying current re-testing procedures, methods and resources. Public health units and sexual health services should consider ways of providing such education to GPs.
Conflict of interest: none declared.
Acknowledgements
The authors wish to acknowledge the assistance and input of GPs in northern Queensland.