Implementing Mycoplasma genitalium testing across a London-based sexual health service: A quality improvement project

Introduction

Mycoplasma genitalium (MG) is a sexually transmitted bacterium associated with non-gonococcal urethritis (NGU), epididymo-orchitis, and pelvic inflammatory disease (PID). ¹ The British Association for Sexual Health and HIV (BASHH) recommend MG testing in patients with NGU, PID and epididymo-orchitis as well as test of cure at five weeks and testing of current sexual partners. ² Our aim was to ensure all patients presenting with clinically-indicated conditions (CICs), NGU, PID and epididymo-orchitis, were appropriately tested for MG across three sexual and reproductive health clinics during a five-month quality improvement project (QIP).

Methods

Five weeks of baseline data (number of MG tests per CIC) were collected prior to implementing changes. Subsequently, a stakeholder group of nurses, administrators and doctors was established to identify barriers to testing. Changes were implemented using the Plan-Do-Study-Act (PDSA) framework. The three PDSA cycles were: (1) All relevant staff had IT access to order MG tests, (2) Departmental MG testing educational event in conjunction with posters in clinical areas, (3) Sending reminder emails in real time to clinicians who did not test in the presence of a CIC.

The data collection occurred over 21 weeks; a three-week assessment period was left between each PDSA. A random sample of ten patients per CIC each week were included to identify the proportion tested for MG. Weekly numbers of inappropriate MG tests (when not clinically indicated) were collected at four intervals throughout the QIP.

Results

The median testing rate for NGU patients increased from 60% at baseline to 90% by the end of the QIP (Figure 1). A shift (≥6 points above the median) was observed starting prior to and following PDSA1 (IT access), with a sustained increase from PDSA2 (education event) onwards. The weekly median number of patients with PID (8) and epididymo-orchitis (2) were low. There were no shifts in testing rates for PID from a baseline of 63%. Due to low patient numbers, no meaningful results could be interpreted for epididymo-orchitis (Figure 2).

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Figure 1.

Run chart demonstrating the trend of appropriate MG testing rates for patients diagnosed with NGU. MG: Mycoplasma genitalium; NGU: non-gonococcal urethritis.

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Figure 2.

Run chart demonstrating the trend of appropriate MG testing rates for patients diagnosed with PID. MG: Mycoplasma genitalium; PID: pelvic inflammatory disease.

Rates of inappropriate testing were found to be 13% (10/75), 7% (4/57), 15% (7/45) and 8% (5/62), at weeks 8, 10, 13 and 21 respectively, with a median rate of 11%.

Discussion

Following QIP implementation, a sustained increase in MG testing was seen in NGU patients, reaching testing rates of 90%. However, there was no significant change in PID testing rates. This could be explained by the greater number of steps required to test females compared to males (an extra vulval-vaginal swab following a PID diagnosis rather than one pre-collected urine sample). Interestingly, NGU testing rose prior to PDSA1, possibly due to a greater awareness in the clinical team following our stakeholders meeting. To tackle low PID MG testing rates we suggest prompts in clinical areas (microscope stations and examination rooms) as well as training for all incoming staff and regular departmental updates on MG testing rates.

Inappropriate testing rates were high at 11% and remained constant throughout the QIP, resulting in additional median weekly costs of roughly £180 (based on a £30 initial MG test) with additional expense for resistance testing (∼£100 per test). Moreover, there is no evidence that testing and treating outside CICs provides benefit, but could result in anxiety, unnecessary antibiotics and potential harm. ² Additional training on clinical and financial implications of inappropriate testing should be ongoing in our department. On reflection, we found our reminder emails to staff who did not test for MG (PDSA3) re-enforced learning in real time which sustained high testing rates; this strategy could also be used to reduce inappropriate MG testing.

The QIP success was based on early engagement and involvement of stakeholders. These included nurses, the results team, consultants, registrars and medical students. Furthermore, we engaged the department as a whole through educational programmes, regular progress updates via emails and individual feedback to clinicians who did not test to reinforce learning in real time.

MG testing is becoming increasingly available in the UK with more clinics taking up testing following the implementation of a national guideline. Funding and laboratory constraints continue to be significant testing barriers. ³ Due to high rates of MG antimicrobial resistance, there is increasing pressure to test and treat clinical MG disease appropriately. ⁴ Other clinics might consider implementing MG testing; we outline a QIP that demonstrates how to integrate testing into a busy multi-site, sexual health service to improve testing uptake while not increasing inappropriate testing.

Summary

MG is a sexually transmitted infection associated with NGU, PID and epididymo-orchitis. Recent national guidelines recommended testing for MG in these aforementioned CICs. A QIP was carried out over 5 months across three sexual health clinics completing three PDSA cycles with the aim of optimising testing rates in CICs. This resulted in sustained increased testing rates for NGU but no changes for PID and epididymo-orchitis. Inappropriate testing rates were high (median 11%) and remained constant throughout the QIP. As MG testing is expanding across the UK, we outline a QIP integrating MG testing into a busy multi-site, sexual health service improving testing uptake while not increasing inappropriate testing.