Utility of Endocervical Gram Stain and Appropriateness of Empiric Coverage for Chlamydia trachomatis (CT) Only in Women with MPC

Background:
The 2006 Sexually Transmitted Diseases Treatment Guidelines recommend diagnosing MPC if either purulent/mucopurulent endocervical discharge or marked endocervical friability is present and add that some specialists consider Gram stain (GS) showing increased endocervical WBCs helpful in diagnosis, but that this criterion has not been standardized. Recommended treatment for MPC is directed at coverage of Chlamydia trachomatis (CT) only.

Objective:
To determine from a computerized database whether > 30 WBCs on endocervical GS with MPC is predictive of an identifiable infection, and the appropriateness of treatment for MPC directed only at CT, in the patient population seen at a dedicated sexually transmitted infection (STI) clinic, the Denver Metro Health Clinic (DMHC).

Method:
DMHC uses a computerized encounter form. Data collected includes diagnoses and laboratory results. For cases of MPC in 2006, we compared % with WBC > 30 according to whether CT, Neisseria gonorrhoeae (GC), Trichomonas, some combination of those, or no infection was identified to assess the predictive value of the WBC for infection. The % of CT, GC or Trichomonas found was used to assess whether empiric treatment to cover CT only was justified.

Result:
In 425 MPC cases, no clinically significant difference was seen in the % of patients with > 30 WBCs on GS by presence of CT, GC, Trichomonas, a combination of those or no infection. 30% had CT, 10% had GC, 9% had Trichomonas and 56% had no identified infection (concurrent infections present in some cases).

Conclusion:
In DMHC MPC with > 30 WBCs on GS is not predictive of finding CT, GC or Trichomonas. The rate of CT is high enough, and of GC and Trich low enough, to justify empiric treatment to cover CT only with MPC.

Implications:
Our data support current recommendations for diagnosis and treatment of MPC.