approach to STI and its management in a nutshell

About STI

1. MODIFIED SYNDROMIC APPROACH STD DR. BHUSHAN TELHURE [ASST.PROF] DR VPMC ADGAON NASHIK 422003 KLINIK KESIHATAN SEREMBAN 2 1

2. Introduction

3. Traditional diagnosis of STI

4. SYNDROMIC APPROACH TO STI Mx

5. WHO SYNDROMIC APPROACH Vaginal discharge Urethral discharge Genital ulcer Lower abdominal pain Scrotal swelling Inguinal bubo Neonatal conjunctivitis

6. Modified Syndromic Approach ( MSA)

7. Modified Syndromic Approach ( MSA) Once a patient presented with a suspected STI, health care workers can use the MSA to provide treatment quickly using the most effective standardized treatment regimens, and perform basic investigations. Deliver effective health education aimed at improving patient compliance to therapy addressing their risk behaviors and advocate partner management  

8. MSA 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

9. Benefits of MSA

10. Disadvantages of MSA

11. MSA of STI Mx Patient gives complaint History + Examination Diagnosis made Ix taken  Laboratory / Referral Lab Rx GIVEN @ SAME DAY - based on synd. +/- Ix TCA given , Rx reviewed Don’t forget: psychosocial hx, idea, concern & expectation. Future plan.

12. FLOW CHART FOR VAGINAL DISCHARGE SYNDROME Patient c/o VAGINAL DISCHARGE History and Examination (OPD/MCH card) Investigations Vaginal swabs Wet mount for Trichomonas vaginalis Gram stain for C. albicans , clue cells and others KOH examination for Candida spp Cervical swabs Gram stain for Gram Negative Intracellular Diplococci and pus cells Culture for gonococci (using Amie’s charcoal transport media) Pap smear RPR/TPHA, HIV Ab , anti-HCV, HBsAg Consider Urine Pregnancy Test Pt has LOWER ABD.PAIN ?

13. 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 <21 yr -old Single Recent new partner – 3/12 Multiple partner Notify if + ve for notifiable diseases

14. Lower Abdominal Pain - Female TREATMENT. CEFTRIAXONE; DOXYCYLINE; METRONIDAZOLE

15. 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 OR Treat for Vaginitis only

16. Meta-analyses have concluded that there is no evidence of teratogenicity from the use of Metronidazole in women during the first trimester of pregnancy. Metronidazole is excreted in the breast milk and gives the metallic taste . Avoid high dose of Metronidazole (2 gram single dose) if patient is breast feeding and in pregnancy Refer FMS/Dermatologist if no improvement.

17. FLOW CHART FOR URETHRAL DISCHARGE SYNDROME IN MEN Patient c/o urethral discharge/ dysuria /irritation History and Examination INVESTIGATION needed: Urethral smear 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

18. 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

19. GENITAL ULCER

20. FLOW CHART FOR GENITAL ULCER SYNDROME Patient c/o GENITAL ULCER or SORE History and Examination Investigations: Tzank smear Gram stain for H. ducreyi Dark ground microscopy RPR/TPPA, HIV Ab , anti-HCV, HBsAg Consider Urine Pregnancy Test Pap smear ULCER present ?

21. FLOW CHART FOR GENITAL ULCER SYNDROME (cont’d) Painful grouped vesicles, erosions, ulcers ULCER present ? YES Genital herpes Mx Educate for behaviour change TCA after 7 days for results Educate behav change TCA after 7 days for assessment and results NO Single painless/ multiple painful ulcers Treat for Syphilis and Chancroid 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 swabs if positive Repeat RPR, HIV Ab , HBsAg after 3/12 Notify if + ve for notifiable diseases

22. 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

23. Treatment For Genital Ulcer Syndrome 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. Babies of mothers who are treated with Erythromycin must be treated for syphilis. Treatment for genital herpes, refer to guidelines on genital herpes Refer to Family Medicine Specialist/Physician/Dermatologist if patient is pregnant or has other concomitant STI or in doubt.

24. TAKE HOME MESSAGE STI screening and management are a simple way to help a patient and the community towards a healthier life. Therefore it is very important to identify the illness, do the screening and can be simply manage with MSA

25. THANK YOU