An audit of a novel electronic messaging treatment service for Chlamydia trachomatis at a community pharmacy

Introduction

Chlamydia trachomatis is the UK’s most common bacterial sexually transmitted infection. ¹ If uncomplicated, it can be treated with 1 g azithromycin as a single dose. Timely treatment is important to help reduce transmission, reinfection from untreated sexual contacts and complications of untreated infection. ²

In 2007, NHS Lothian Sexual Health Services introduced a service, whereby asymptomatic individuals with C. trachomatis could choose to receive a paper treatment voucher (collected in person or via post) that was redeemable for antibiotics at a community pharmacy.^2,3 Given its popularity and the increasing use of mobile phone technologies, ⁴ the service adapted this paper voucher system in April 2016 to send a voucher electronically as a text message to a mobile phone. This could be sent to patients with uncomplicated C. trachomatis or non-specific urethritis (NSU) and sexual contacts. We aimed to evaluate the use of this novel electronic voucher treatment service.

Methods

Patients diagnosed with C. trachomatis or NSU (index cases) at NHS Lothian Sexual Health Services were contacted by a health adviser (as per routine) to discuss their choice of available treatment options (Figure 1). Patients were eligible to receive the vouchers to their mobile phone if they fulfilled certain criteria (Table 1). They could also choose to receive vouchers to forward to their current or recent sexual contact(s). Vouchers each had a unique number and had to be presented within seven days at one of the 108 participating community pharmacies or else it was no longer valid for redemption. Pharmacists issued oral azithromycin 1 g at no cost to the individual, via a patient group direction (PGD), i.e. strict criteria to permit provision of specified medicines by non-prescribers (Table 2). ⁵ Pharmacists then returned a claim form to the Sexual Health Service to be reimbursed for the cost of azithromycin, plus a £5 fee.

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Figure 1.

Pathway showing treatment options for index patients and contacts.

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Table 1.

Patient eligibility criteria for receiving Chlamydia treatment vouchers.

• Age 16 or over

• Positive for Chlamydia trachomatis only

• No risk of other infections or complications

• No symptoms

• No history of repeated Chlamydia infection

• No history of intercourse with a male partner who has had sex with men

• Not a commercial sex worker

• Not currently pregnant

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Table 2.

Patient group direction exclusion criteria. ⁵

• Age under 16 years

• Women with signs and symptoms of C. trachomatis infection, e.g. lower abdominal/pelvic pain, intermenstrual or post-coital bleeding, dysuria, unusual vaginal discharge

• Men with signs and symptoms of C. trachomatis infection, i.e. dysuria, urethral discharge, painful swelling of the genitalia

• Patients who are clinically unwell (febrile and in acute pain)

• Patients with known hypersensitivity to azithromycin, erythromycin, clarithromycin or any macrolide antibiotics, or any component of the medicine

• History of liver disease

• History of severe renal impairment

• Porphyria

• Known cardiac arrhythmia

• Weight <45 kg

• Lack of informed consent

A retrospective audit was conducted of the electronic treatment voucher database to determine the number of electronic vouchers issued (April–December 2016), proportion of vouchers redeemed and characteristics associated with redemption. IBM SPSS Statistics, version 22.0 (IBM Corp., Armonk, NY, USA) was used to perform descriptive statistics and tests of normality, association and trend.

Results

Discussion

It is estimated that over the nine-month study period, at least one in four individuals testing positive for Chlamydia received an electronic text voucher and more than half of these were redeemed. This suggests that this is a popular and effective means of providing expedited treatment for uncomplicated C. trachomatis at a community pharmacy. Patients do not need to attend a sexual health clinic or make an appointment with their general practitioner (GP), both of which may be associated with waiting times for an appointment. ⁷ The advantage of the electronic voucher is that the individual does not need to collect a voucher in person or receive it by post, potentially expediting treatment further. Treatment at a local community pharmacy compared to a sexual health setting may be convenient and less stigmatising, ² easier to access and provide increased anonymity. ⁸ If patients are attending pharmacies for treatment, it will release time and resources in sexual health clinics to deal with patients with more complex problems. ³ Additionally, the PGD could easily be modified to reflect any future changes in recommended antibiotic therapy for uncomplicated Chlamydia or NSU.

This is the first study of using electronic treatment vouchers for this purpose. Given its nature as a database review, its findings are limited to the information recorded in the database. Future research should establish patient and pharmacist views on the service and the reasons for vouchers not being redeemed. The service could be expanded to include treatment of patients testing positive for Chlamydia within the GP setting.