MODIFIED SYNDROMIC APPROACH SEXUALLY TRANSMITTED DISEASE

MANAGEMENT OF STD

1. MODIFIED
SYNDROMIC
APPROACH
STD
Dr. Izatul
FarhanahBinti
Ra’aid
KLINIK KESIHATAN SEREMBAN 2 1

2. Introduction
STIs are caused by >
30 different viruses,
bacteria and parasites
4 of 8 most common
STIs are curable:
gonorrhoea,
chlamydia, chancroid
and trichomoniasis

3. Traditional
diagnosis
of STI
Clinical diagnosis: use clinical experience to
identify the symptoms typical for a specific
STI.
Some STI cause similar Sx, may pick
wrong diagnosis, causing transmission &
Cx continues
Etiological diagnosis: use laboratory tests to
identify the causative agent;
Wait for the result
before start Rx
Lab tests may not
be available

4. SYNDROMIC APPROACH TO STI Mx
1991: WHO introduced a syndromic approach: simple, client friendly,
cost effective, applicable in the community at the primary care level.
STIs managed based on the clinical presentation, and treatment can
be given without the laboratory test.
The main infective agents are grouped according to clinical
syndromes they cause and patients are treated for all the important
causes of a syndrome, using combinations of antimicrobials.

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

6. Modified SyndromicApproach
(MSA)
2000, 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

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
Rx > 1 STI at the same time (60% of pt has > 1 STI).
Rx at the first visit
Client friendly
Able to reduce transmission and complications of
STIs
Use minimal lab tests
Patient can be treated by paramedics

10. Disadvantages
of MSA
1) Cost 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

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. MSA 2003 file
◦Filled up after case/partner has
positive results for STI
4.10.2011 NAC 2

13. FLOW CHART FOR VAGINAL DISCHARGE SYNDROME
Patient c/o VAGINAL DISCHARGE
History and Examination (OPD/MCH card)
Investigations
Vaginal swabs
Wet mount for Trichomonasvaginalis
Gram stain for C. albicans, clue cells and others
KOH examination for Candida spp
Cervical swabs
Gram stain for Gram Negative Intracellular Diplococciand 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 ?

14. 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, HBsAgafter 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
1.Multiple partner
Notify if +vefor
notifiable
diseases

15. If
answer
to ALL ALL
questions NO
is NO




If answer to ANY question is YES:



If answer to ANY question is YES:












Patient complains of lower abdominal pain
Take history and
examine abdomen
History and Risk Assessment:

Questions Yes No
1. Have you a missed or
overdue period?

2. Have you had a recent
delivery or miscarriage?

3. Is there rebound tenderness
or guarding of the abdomen?

4. Is there any vaginal
bleeding?


Questions Yes No
Temperature
> 38?

Pain during
abdominal
examination?

Vaginal
discharge?


Follow
up if
pain
persists
REFER PATIENT
or evaluate for
possible surgical
problem or PID
 Treat for PID:
 Ceftriaxone 250 mg IM as a
single dose AND
 Doxycycline 100 mg. by mouth
twice daily for 14 days AND
 Metronidazole 500 mg by
mouth twice daily for 14 days
 Promote & provide condoms
 Treat partner
Followup after 3 days or
sooner if pain persists Lower
Abdominal Pain
-Female

16. Treatment For Vaginal Discharge Syndrome
(Cervicitis and Vaginitis)
Treatment For
(CERVICITIS)
FIRST CHOICE
IM Ceftriaxone 500 mg single dose
PLUS
Azithromycin1.0 gm orally single dose
SECOND CHOICE
IM Ceftriaxone 500 mg single dose
PLUS
Doxycycline100 mg bdorally x 7 days
THIRD CHOICE
IM Ceftriaxone 500 mg single dose
PLUS
Erythromycin ES 800 mg qidorally x 7 days
Metronidazole2 gm stat PLUS Clotrimazolepessary200 mg odx 3/7
OR 500 mg single dose or Nystatinpessaries100,000 u dlyfor 14
days
On f/up if no improvement or not effective-to continue
Metronidazole400mg bdx 7 days
PLUS
Treatment for
Vaginitis
OR Treat for Vaginitis only

17. ◦Meta-analyses have concluded that there is no
evidence of teratogenicityfrom the use of
Metronidazolein women during the first trimester of
pregnancy.
◦Metronidazoleis 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.

18. FLOW CHART FOR URETHRAL DISCHARGE
SYNDROME IN MEN
Patient c/o urethral
discharge/dysuria/irritation
History and Examination
INVESTIGATION needed:
1.Urethral smear
2.RPR/, TPPA & HIV Ab, HBsAg ,
anti-HCV
Treat for Gonorrhoeaand 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, HBsAgafter 3/12
Notify if +vefor
notifiable
diseases

19. Treatment For Urethral Discharge Syndrome
Treatment For Gonorrhoeaand Chlamydia
FIRST CHOICE
IM Ceftriaxone 500 mg single dose
PLUS
Azithromycin1.0 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 qidorally x 7 days

20. GENITAL ULCER

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

22. 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 behavchange
•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, HBsAgafter
3/12
Notify if +vefor
notifiablediseases

23. 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 Penicilline2.4 million units single
dose
Plus
IM Ceftriaxone250 mg single dose

24. 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.

25. Inguinal Bubo
(lump)

26. TAKE HOME MESSAGE
◦Try to put yourself in the patient shoes –live with curable
diseases, left undetected and untreated causing morbidities
and mortalities
◦It is not a program “to find fault or darkness side in patient
life/marriage”
◦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

27. THANK YOU