modified syndromic approach for sexaully transmitted disease
1.
2. The term STI, also known as STD includes a range of clinical syndrome tat
can be acquired and transmitted through sexual activities(unprotected),
non sexual activities and also via childbirth and breast feeding.
STIs are caused by > 30 different viruses, bacteria and parasites
4 of 8 most common STIs are curable:
gonorrhoea,
chlamydia
chancroid(Haemophilus ducreyi)
trichomoniasis
3.
4. MODIFIED SYNDROMIC APPROACH
Introduced in government health clinics since 1999
It allows treatment which is fast and effective
It is a patient friendly service
Allow doctors to give effective advice and counselling at first encounter
WHO advocates syndromic approach for management of STI but due to
better laboratory facilities, Malaysia encourages an aetiological approach to
STI Rx.
MSA may be considered in remote areas with poor access to laboratory
facilities
5. MOH has identified 3 main syndromes: vaginal discharge, urethral
discharge and genital ulcer.
Algorithms were based on WHO recommendations and adapted for local
use.
Some basic laboratory investigations, follow-up and counseling were
incorporated into the management of the three syndromes. If the test result
can be ready immediately, etiological treatment is highly recommended
6. Vaginal discharge syndrome is diagnosed when
a woman complains of vaginal discharge that
is in excess of the usual or if it causes
itching or discomfort.
Women develop abnormal vaginal discharge if
they have either vaginitis or cervicitis, or
both
Effective management of cervicitis is more
important from a public health point of view,
as cervicitis may have serious sequelae
10. FLOW CHART FOR VAGINAL DISCHARGE SYNDROME
Patient c/o VAGINAL DISCHARGE
History and Examination (OPD/MCH card)
Investigations
1. Vaginal swabs
a. Wet mount for Trichomonas vaginalis
b. Gram stain for C. albicans, clue cells and others
c. KOH examination for Candida spp
2. Cervical swabs
a. Gram stain for Gram Negative Intracellular Diplococci and pus cells
b. Culture for gonococci (using Amie’s charcoal transport media)
c. Chlamydia PCR or antigen detection
3. Pap smear
4. RPR/TPHA, HIV Ab, anti-HCV, HBsAg
5. Consider Urine Pregnancy Test
Pt has LOWER ABD.PAIN ?
11. FLOW CHART FOR VAGINAL DISCHARGE SYNDROME
(cont’d)
Pt has LOWER ABD PAIN
RISK ASSESSMENT
• Partner has symptoms OR
• Risk factor positive
YES
•Treat for VAGINITIS and CERVICITIS
•Educate for behavior change
•Advise sex abstinence for 2 weeks
•Provide condom or promote usage
•Partner management
•Follow-up after 7 days for results.
•Repeat swab if patient remains symptomatic.
•Repeat RPR, HIV Ab, HBsAg after 3/12
NO
•Treat for
vaginitis
•Educate
behaviour
•F/up for 2/52
for results
NO
Refer to nearest
hospital
YES
RISK FACTORS
1. <21 yr-old
2. Single
3. Recent new partner – 3/12
4. Multiple partner
Notify if +ve for
notifiable
diseases
12. Treatment For Vaginal Discharge Syndrome
(Cervicitis and Vaginitis)
Treatment For
(CERVICITIS)
FIRST CHOICE
IM Ceftriaxone 500 mg single dose
PLUS
Azithromycin 1.0 gm orally single dose
SECOND CHOICE
IM Ceftriaxone 500 mg single dose
PLUS
Doxycycline 100 mg bd orally x 7 days
THIRD CHOICE
IM Ceftriaxone 500 mg single dose
PLUS
Erythromycin ES 800 mg qid orally x 7 days
Metronidazole 2 gm stat PLUS Clotrimazole pessary 200 mg od x 3/7
OR 500 mg single dose or Nystatin pessaries 100,000 u dly for 14 days
On f/up if no improvement or not effective- to continue Metronidazole
400mg bd x 7 days
PLUS
Treatment
for Vaginitis
Refer FMS/Dermatologist if patient pregnant
and no improvement.
13. Male patients complaining of urethral discharge should be examined for evidence of discharge.
If none is seen, urethra should be gently massaged from the ventral part of the penis towards the
meatus.
Features of the discharge
Gonorrhoea Creamy white or yellow,
odourless
NGU Mucoid or mucoid purulent
urethral discharge, malodourous
Trichomoniasis Copious, green, frothy
14. FLOW CHART FOR URETHRAL DISCHARGE
SYNDROME IN MEN
Patient c/o urethral discharge/dysuria/irritation
History and Examination
INVESTIGATION needed:
1. Urethral smear
a. Gram stain and culture for GC
b. Chlamydia PCR or antigen detection
2. RPR/, TPPA & HIV Ab, HBsAg , anti-HCV
Treat for Gonorrhoea and Chlamydia
Educate for behavior change
Advise sex abstinence for 2 weeks
Provide condom or promote usage
Partner management
Follow-up after 7 days for assessment and results
Repeat swab if patient remains symptomatic.
Repeat RPR, HIV Ab, HBsAg after 3/12
Notify if +ve for
notifiable
diseases
15. Plastic loop swab
• Insert swab 2-4 cm into
urethra
• Put collected swab into
transport media tube
Sampling
16. Treatment For Urethral Discharge Syndrome
Treatment For Gonorrhoea and Chlamydia
FIRST CHOICE
IM Ceftriaxone 500 mg single dose
PLUS
Azithromycin 1.0 gm orally single dose
SECOND CHOICE
IM Ceftriaxone 500 mg single dose
PLUS
Doxycycline 100 mg bd orally x 7 days
THIRD CHOICE
IM Ceftriaxone 500 mg single dose
PLUS
Erythromycin ES 800 mg qid orally x 7 days
17. The frequency with which genital ulcers are caused by
specific organisms varies dramatically in different
parts of the world.
Malaysian guidelines for STI mentioned that any
anogenital ulcer should be considered to be due to
syphilis unless proven otherwise.
19. Clinical approach to genital ulcers
History
Onset and relationship with sexual intercourse ( incubation period ) :
- few days ( herpes, chancroid )
- few weeks to few months ( chancre )
Number of ulcers :
- solitary : chancre, Behcet’s disease
- multiple : herpes, chancroid, Behcet’s disease
20. History
Painful or not ?
- painless : chancre
- painful : chancroid, primary herpes
Any similar attacks before ?
-yes : herpes, fixed drug eruption, Behcet’s disease
Drug history : esp antibiotics, pain killer, antiepileptic drugs
History of trauma - chemical or mechanical
Epidemiology: behavior characteristic of the patients, travel history
(chancroid, chancre)
Clinical approach to genital ulcers
21. Physical Examinations
A) Genital region:
1) no. of ulcers and pain :
- solitary and painless : chancre
- solitary and painful : trauma, Ca, TB, Behcet’s disease
- Multiple and painless: secondary syhphilis, recurrent herpes
- Multiple and painful: primary herpes, chancroid, Bechet’s disease
2) Base of the ulcers:
- Indurated: Ca, Chancre
Clinical approach to genital ulcers
22. Physical examinations of genital
3) Ulcers depth:
- superficial: Herpes
- Deep: chancroid
4) Lymphadenopathy?:
-absent: recurrent herpes
-unilateral: chancroid or LGV. Tender and suppurate
- bilateral: primary syhphilis. Firm, non tender
Clinical approach to genital ulcers
23. FLOW CHART FOR GENITAL ULCER SYNDROME
Patient c/o GENITAL ULCER or SORE
History and Examination
Investigations:
1. Tzank smear
2. HSV antigen or culture
3. Gram stain for H. ducreyi
4. Dark ground microscopy
5. RPR/TPPA, HIV Ab, anti-HCV, HBsAg
6. Consider Urine Pregnancy Test
7. Pap smear
24. FLOW CHART FOR GENITAL ULCER SYNDROME (cont’d)
Painful grouped
vesicles, erosions,
ulcers
ULCER
• Genital herpes and Chancroid Mx
•Educate for behaviour change
•TCA after 7 days for results
Single painless/
Multiple ulcers
•Advise sex abstinence for 2 weeks
•Provide condom or promote usage
•Partner management
•Follow-up after 7 days for results
•Repeat swabs if positive
•Repeat RPR, HIV Ab, HBsAg after
3/12
Notify if +ve for
notifiable
diseases
•Treat for Syphilis
•Educate for behavior
change
25. Treatment For Genital Ulcer Syndrome
Treatment For Syphilis and Chancroid
FIRST CHOICE
IM Benzathine Penicillin 2.4 million units single dose
Plus
Azithromycin 1.0 gm single oral dose
SECOND CHOICE
IM Benzathine Penicilline 2.4 million units single dose
Plus
IM Ceftriaxone 250 mg single dose
Treatment For Genital Herpes
T. Acyclovir 200mg 5x/day or 400mg TDS or 800mg BD
for 5 days treatment
26. If patient allergic to penicillin, use EITHER :
Doxycycline 100 mg bd for 14 days OR
Erythromycin ES 800 mg qid for 14 days
(follow-up after 2 weeks)
Doxycycline should not be used during pregnancy, lactation and
children.
Refer to Family Medicine Specialist/Physician/Dermatologist if
patient is pregnant or has other concomitant STI or in doubt.
Treatment For Genital Ulcer Syndrome
27. Points to ponder:
Overall diagnosis based on Hx and physical examination alone may not be
accurate
Ideally all genital ulcers: screening for HIV and Syphilis MUST be done
Ix for Herpes, chanchroid and other STD done selectively based on clinical
suspicions
Treatment for most likely Dx (based on clinical and epidemiological
data)must be started early.
In certain instances, treatment is initiated for additional conditions because
because for Dx uncertainty.
Clinical approach to genital ulcers
28. Syndrome Symptoms Signs Most Common Cause
1. Vaginal
discharge
Unusual vaginal discharge
Vaginal itching
Dysuria
Dyspareunia
Lower abdominal pain
Lower back pain
Abnormal vaginal discharge
Inflammation of vaginal mucosa
Inflammation of the Cervix
Contact bleeding
VAGINITIS
Candidiasis
Trichomoniasis
CERVICITIS
Gonorrhoea
Chlamydia
2. Urethral
discharge
Urethral discharge
Dysuria
Frequency
Urethral irritation
Urethral discharge Gonorrhoea
Chlamydia
3. Genital ulcer Genital sore Genital ulcer
Enlarged inguinal lymph nodes
Herpes Simplex Virus
Syphilis
Chancroid
29. SUMMARY
Syndome Main cause Rx first choice)
Vaginal discharge Gonorrhoea
Chlamydia
Trichomonas vaginalis
Candidiasis
IM Ceftriaxone 500 mg
T. Azithromicin 1 G
T. Metronidazole 2 G
Clotimazole pessary 500 mg
Urethral discharge Gonorrhoea
Chlamydia
IM Ceftriaxone 500 mg
T. Azithromicin 1 G
Genital ulcer Syphilis
Chancroid
Genital herpes
IM B. penicillin 2.4 megaunit
T. Azithromicin 1 G
5 days Rx
T. Acyclovir 200 mg 5x/day or
400 mg tds or 800 mg bd
30. Benefits of MSA
1. Rx > 1 STI at the same time (60% of pt
has > 1 STI).
2. Rx at the first visit
3. Client friendly
4. Able to reduce transmission and
complications of STIs
5. Use minimal lab tests
31. Disadvantages of MSA
1) Cost of over diagnosis
2) Cost of over treatment when multiple anti-microbials
given to patient with none or only one infection
3) may cause less precise diagnosis
4) may cause antibiotic resistant if not manage properly
32. MSA 2003 file
Filled up after case/partner
has positive results for STI
4.10.2011 NAC 2
