Syndromic management of STI

Prepared By: Dr.Wut Yi

Syndromic management of STI

Course Objectives Understand how to identify and manage common vaginal and cervical infections based on a group of signs and symptoms called syndromes.

The Syndromic Approach

Identifies consistent groups of signs and symptoms (syndromes) and treats accordingly Provides treatment for majority of serious organisms responsible for producing a syndrome Overcomes lack of laboratory infrastructure, expensive tests and special trained personnel Overtreatment

General signs and symptoms of STIs

Sings/symptoms in women Vaginal discharge Pruritus (itching) of the vulva or vagina Lower abdominal pain in women Spotting Pain with urination (dysuria) Sexual intercourse (dyspareunia) Inflammation on exam Sings/symptoms in men Urethral d/c in men Balanitis/balanoposthitis in men Scrotal swelling Both men/women Inguinal bubo without ulcer in men or women Genital ulcers or warts in men or women

Advantages of the syndromic approach

- Easy to use. - Allows immediate treatment initiation. - It provides the opportunity to discuss risk reduction, condom promotion and compliance with medication - Inexpensive no laboratory investigations. - Treatment covers the whole range of infections known to cause the syndrome. - Partner notification system.

Disadvantages of syndromic approach

- Many patients may be over-treated. - A multidose regimen may increase noncompliance

The control of STIs is based on 3 principles

1) Education of people at risk on modes of transmission of STIs and how to reduce transmission. 2) Effective diagnosis and treatment of patients with symptoms. 3) Detection of STIs in asymptomatic carriers and in people with symptoms who would otherwise not present for consultation

The management of STIs should always include the following:

- Medical and sexual history taking - Performance of a physical examination - Establishment of a diagnosis and provision of treatment - Education and counselling of the patient on:
compliance with treatment prevention of complications of STIs risk reduction in acquiring STIs increased risk of HIV prophylactic testing for HIV (also of partner)

- Promotion and provision of condoms and demonstration of their use - Tracing and treating of sexual contacts.

SYNDROME: Vaginal Discharge/Pruritis

Inflammation is the most common pathological condition of the cervix and vagina. Usually caused by an infection Discharge can be due to cervicitis (inflammation of the cervix) or vaginitis (inflammation of the vagina)

Vaginal discharge/pruritis

Most common causes Trichomonas vaginalis Bacterial vaginosis Candida albicans Gonoccal/Chlamydial cervicitis (Rarely)

In Women

Vaginal discharge/pruritis
Discharge Itching Inflammation Odor

Candida

White, curd-like Yellowish, frothy

Yes

Yes

No

Tricho:

Yes

Yes

Yes

Bacterial vaginosis

Greyish, white

No

No

Yes

Candidiasis

Candidiasis

Vaginal discharge/pruritis

Highly predictive of vaginal infection but poorly predictive of cervical infection Thus, all women presenting with vaginal discharge should receive treatment for vaginitis and cervicitis.

Vaginal discharge/pruritis

Syndromic treatment Trichomoniasis or Bacterial vaginosis Metronidazole (Flagyl) 2g PO,once stat Metronidazole (Flagyl) 400-500mg BID x 7 Candidiasis Fluconazole 150-200mg PO, once stat Clotrimazole 500mg intravag, once stat Miconazole or clotrimazole 200mg intravag, daily x 3 Nystatin pessary daily x 5

Vaginal discharge/pruritis

Syndromic treatment Chlamydia Azithromycin 1g PO, once stat Doxycycline 100mg PO BID x14 d Erythromycin 500mg PO QID x 7 d Gonorrhea Ciprofloxacin 500mg PO, once stat Ceftriaxone 125mg IM Stat

Syndrome: Vaginal discharge + lower abdominal pain

Signs Vaginal discharge Lower abdominal tenderness on palpation Temperature > 38C Symptoms Lower abdominal pain Dyspareunia

Syndrome: Vaginal discharge + lower abdominal pain Most common causes Gonococcus Chlamydia Mixed anaerobes

Syndrome: Vaginal discharge + Lower abdominal pain

Syndromic treatment Chlamydia Azithromycin 1g PO stat Doxycycline 100mg PO BID x14 d Erythromycin 500mg PO QID x14 d Gonorrhea Ciprofloxacin 500mg PO Stat Ceftriaxone 125mg IM Stat Mixed Anaerobes Metronidazole (Flagyl) 400-500mg BID x14 d

Abdominal pain

Reasons for referral Rebound tenderness Guarding Last menstrual period overdue Recent abortion or delivery Menorrhagiaprofuse or prolonged menses Metrorrhagiairregular bleeding

Cervicitis

Symptoms Unusual vaginal discharge Dysuria (pain on urination) Dyspareunia (pain on intercourse) Abnormal bleeding

Cervicitis

Signs Swollen, reddened, and beefy cervix Cervix bleeds easily when touched Mucopurulent or copious discharge from os

Most common causes Gonococcus Chlamydia

Cervicitis
Syndromic treatment Chlamydia Azithromycin 1g PO stat Doxycycline 100mg PO BID x 7 Erythromycin 500mg PO QID x 7 Gonorrhea Ciprofloxacin 500mg PO Stat Azithromycin 2g PO Stat Ceftriaxone 125mg IM Stat

Note mucosal bleeding where purulent discharge has been wiped away.

Cervicitis

Cervicitis

Cervicitis

Other counseling

Avoid alcohol with antibiotic treatment Supply condoms Counsel regarding risk reduction Partner treatment Follow-up after completion of treatment Repeat VIA after treatment if necessary

Genital ulcer disease

Most common causes

Genital herpes Chancroid Syphillis Associated with an increased risk of HIV infection

Genital Herpes

Characterized by multiple, painful vesicles grouped together First episode - Bilateral Recurrences - Unilateral

Genital herpes - First episode

Genital herpes - recurrent

Genital herpes - recurrent

Genital herpes - recurrent

Chancroid

Cause: Haemophilus ducreyi (gram negative coccobacilli) Single or multiple ulcers on the labia, vagina, or anus with or without swollen inguinal lymph nodes and cervicitis.

May be co-infected with HIV, herpes, or Treponema pallidum (syphilis) Refer

Syphilis

Cause: Treponema pallidum (gram negative bacteria) Characterized by painless ulcer or chancre on the vulva, vagina, or cervix

Co-infection with HIV is common Refer

Syphilis ulcer

In Men and women

Genital ulceration in men or women

- Organisms: Syphilis Treponema pallidum Genital herpes Herpes simplex virus type1 or 2 Lymphogranuloma venerium Chlamydia trachomatis L1-3 - Symptoms and signs

Management

Herpes simplex management: Counselling with emphasis on recurrences Keep lesions clean and dry Lesions with secondary infection should be treated Pain relief Severe infection should be treated with acyclovir 400-800mg PO tds until resolution.(5 times/day in PLHA)

Management

Drug treatment of non-herpetic genital ulcers Benzathine benzyl penicillin, IMI 2,4 MU stat plus Erythromycin, 500mg 4 times a day PO for 7 days or Penicillin-allergic patients: Erythomycin 500mg 4times a day PO for 14 days. Request patient to return after 7 days

Syphilis screening in pregnant women Take blood for RPR/VDRL. If positive, treat pregnant woman with: Benzathine penicillin 2,4 MU IMI once a week for 3 weeks or In penicillin-allergy: erythromycin 500mg PO 4 times a day for 28 days. Plus treat all asymptomatic neonates of mothers with positive RPR test during pregnancy with: Benzathine penicillin 50 000 IU/kg IMI stat.

Inguinal swelling/bubo (no ulcer present) in men or women

Symptoms and Signs Swelling in one or both groins Swelling may be painful and tender Non-drug treatment

Inguinal swelling/bubo (no ulcer present) in men or women (continued)

Drug treatment Benzathine benzyl penicillin 2,4 MU IMI stat plus Doxycycline 100mg PO twice a day for 14 days or In case of drug allergy or other contra-indications: Erythromycin 500mg PO 4 times a day for 14 days. * If Erythromycin is given in stead of penicillin, omit doxycycline. Erythromycin is safe in pregnancy and breast feeding.

In Men

rethral discharge / burning micturition in men

Organisms: Gonorrhoea - Neisseria gonorrhoea Non-gonococcal urethritis Chlamydia trachomatis serotypes D-K Ureaplasma urealyticum Clinical features: Small to large amount of mucus or pus at end of penis (urethral discharge) Staining of underwear Burning and/or pain on passing urine Frequency of urine (Other bacterial urinary tract infections should be excluded)

Management

Drug treatment Ciprofloxacin 500mg PO as a single dose (stat) Doxycycline 100mg PO twice a day for 7 days - Drug treatment for female partner Ciprofloxacin 500mg PO stat Metronidazole* 2g PO stat Doxycycline 100mg PO twice a day for 7 days

Management

Non-drug treatment Counsel on compliance and risk reduction Provide condoms and promote consistent use Take blood for RPR/VDRL to test for syphilis Notify partner to be treated Ask to follow-up in 7 days - Always look for other STIs

Urethral Discharge (Men) continued

Follow-up after 7 days - Persistent or recurrent urethritis - In case of drug allergy or other contra-indications Spectinomycin 2 g IMI or ceftriaxone 125mg IMI stat (In stead of ciprofloxacin) Erythromycin 500mg PO 4 times a day for 7 days (In stead of doxycycline)

Any Question?

THANKS