Syndromic management of sexually transmitted disease

sexually transmitted disease : diagnosis and managment
NACO
WHO GUIDLINES

1. MODERATOR : DR. KAVITA BHATTI By : Dr. Monicapreet K aur Syndromic management of sexually transmitted disease

2. INTRODUCTION Sexually transmitted diseases (STDs) are infections transmitted from an infected person to an uninfected person through sexual contact . STDs can be caused by bacteria, viruses, or parasites . STDs are hyperendemic in developing countries.

3. CLASSIFICATION OF STD BASED ON SYMPTOMS VAGINAL DISCAHRGE SYNDROME LOWER ABDOMINAL PAIN SYNDROME GENITAL ULCER SYNDROME GENTITAL WARTS AND PAPULES GENITAL INFESTATIONS

4. VAGINAL DISCHARGE SYNDROME causes Discharge characterstics WHIFF TEST Vaginal PH MICROSCOPIC FINDINGS Neisseria gonorrhoeae Yellow mucopurulent discharge ,profuse , odorless, nonirritating -- >4.5 Many WBC s Chlamydia trachomatis Yellow mucopurulent discharge , cervix becomes edematous and hyperemic. -- >4.5 Many WBC s Trichomonas vaginalis Profuse malodourous , yellowish green vaginal discharge +/- >4.5 Motile trichomonas Bacterial vaginosis Greyish white , homogenous discharge , adherent to vaginal walls + >4.5 Clue cells bacteria clumps Candida albicans White cottage cheese like , thick discharge with pruritis -- <4.5 Psuedohyphae and buds

5. LOWER ABDOMINAL PAIN SYNDROME CAUSES SIGNS AND SYMPTOMS Neisseria gonorrhoea Chlamydia trachomatis Anaerobes Lower abdominal pain, fever, vaginal discharge Menstrual irregularities like heavy irregular vaginal bleeding Dysmenorrhoea Dyspareunia (pain during sexual intercourse) Dysuria Low backache Temperature> 39 c Vaginal/cervical discharge, congestion or ulcers Lower abdominal tenderness or guarding Uterine/adnexal tenderness, cervical movement tenderness, presence of a pelvic mass

6. GENITAL ULCER AND SWELLING 1) Chancroid (Soft chancre) Haemophilus ducreyi Painful, “dirty” ulcers Painful enlarged lymph nodes (bubo) in the groin 2) Syphilis Treponema pallidum Occurs in 3 forms: Primary syphilis painless ulcer (chancre): external genitalia (labia) oral and anal region. enlarged painless , non suppurative rubbery lymph nodes Secondary (disseminated) syphilis After s everal weeks : non-itchy body rash on palm and sole, headaches, muscle aches, weight loss, low-grade fever. The rashes may disappear spontaneously Late syphilis seen in about 25% of untreated cases and involvement of the heart, great blood vessels and brain.

7. 3) Genital herpes (Herpes Simplex Virus ) Multiple painful vesicles later forming shallow ulcers which clear in 2 to 4 weeks and presence watery vaginal discharge Recurrent (multiple bouts) more than 50% of the time. 4) Granuloma inguinale ( Donovanosis ) Kleibsella granulomatis Develops lumps under the skin which break down to form “beefy” red, painless ulcers

8. GENITAL SKIN CONDITIONS CAUSES SIGNS AND SYMPTOMS Genital warts ( Condyloma acuminata ) HUMAN PAPPILOMA VIRUS Single or multiple soft, painless, “cauliflower” growth which appear around the anus, vulvo - vaginal area and perineum Molluscum contagiosum POX VIRUS Multiple, smooth, glistening, globular papules of varying size from a pinhead to a split pea can appear anywhere on the body. Pediculosis pubis small red papules with a tiny central clot caused by lice irritation. General or local urticaria with skin thickening may or may not be present. Genital scabies Severe pruritis (itching ),worse at night.The burrow is the diagnostic sign. It can be seen as a slightly elevated grayish dotted line in the skin

9. STD CASE MANAGEMENT The 7 steps of comprehensive STD case management are: 1. Take history for both partners. 2. Conduct physical examination. 3. Provide treatment. 4. Provide health education on prevention. 5. Provide condoms and demonstrate use. 6. Offer Partner treatment. 7. Follow up or refer as needed

10. The two main approaches to STI/RTI diagnosis and management : 1.ETIOLOGICAL APPROACH : is based on the results of laboratory tests which then determines the treatment to be administered. Reliable for management of STI, because it depends on trained laboratory technicians availability of lab supplies, and specialized equipment; there are limitation of the lab test to identify the causative organism 2. SYNDROMIC APPROACH : is based on the identification of syndrome the client reports and the signs the health care provider observes. The recommended treatments are effective for all the diseases that could cause the identified syndrome .

11. SYNDROMIC MANAGEMENT ADVANTAGES : Complete STI care offered at first visit Simple, rapid and inexpensive Patients treated for possible mixed infections Accessible to a broad range of health workers Curtails unnecessary referral to hospitals DISADVANTAGES: Risk of over-treatment Requires prior research to determine the common causes of particular syndromes Asymptomatic infections are missed

12. Benefits of using flow-charts ( alogorithm ) They can be used at any time in all types of health facilities They suggest clear decisions Each flow-chart is made up of a series of three steps . 1.The clinical problem: the patient’s presenting symptoms 2.The decision that needs to be taken: which the health care provider finds out by taking a history or examining the patient. 3.The action that needs to be carried out. Each of the exit paths leads to an action or do box. This is the box that instructs to provide kits provided by national AIDS control organisation (NACO)

13. VAGINAL DISCHARGE SYNDROME Causative organisms VAGINITIS Trichomonas vaginalis Candida albicans Gardnerella vaginalis Mycoplasma Causative organisms CERVICITIS Neisseria Gonorrhoea Chlamydia trachomatis Trichomonas vaginalis Herpes simplex virus

14. HISTORY Menstrual history to rule out pregnancy Nature and type of discharge (amount, smell , color , consistency) Genital itching Burning while passing urine , increased frequency Presence of any ulcer , swelling on the vulval or inguinal region Genital complaints in sexual Partners Low backache EXAMINATION Per speculum examination to differentiate between vaginitis and cervicitis. a) Vaginitis: Trichomoniasis - greenish frothy discharge Candidiasis - curdy white discharge Bacterial vaginosis – adherent discharge Mixed infections may present with atypical discharge b)Cervicitis: Cervical erosion /cervical ulcer/ mucopurulent cervical discharge Bimanual pelvic examination to rule out pelvic inflammatory disease(PID)

15. L aboratory investigations ( If available) “ Wet prep ” of the discharge for Trichomonas vaginalis and clue cells 10 % KOH preparation for Candida albicans Gram stain of vaginal smear for clue cells seen in bacterial vaginosis Gram stain of endocervical smear to detect gonococci TREATMENT Vaginitis ( TV+BV+Candida ) KIT-2 Tab . Secnidazole 2gm orally, single dose or Tab . Tinidazole 500mg orally, twice daily for 5 days Tab . Metoclopropramide taken 30 minutes before Tab. Secnidazole , to prevent gastric intolerance Treat for candidiasis with Tab Fluconazole 150mg orally single dose or local Clotrimazole 500mg vaginal pessaries once

16. Specific guidelines for Partner management Cervicitis : Treat all Partners for gonorrhea and Chlamydia. Vaginitis : Generally partner treatment is not required. If Partner is symptomatic, treat Partner for the symptom. Advise sexual abstinence during the course of treatment Provide condoms, educate about correct and consistent use Schedule return visit after 7 days Treatment for cervical infection (chlamydia and gonorrhoea ) KIT-1 Tab CEFIXIME 400 mg orally, single dose Plus Azithromycin 1 gram , 1 hour before lunch . If vomiting within 1 hour, give anti-emetic and repeat ŠIf vaginitis and cervicitis are present treat for both Š Pregnancy, diabetes, HIV may also be influencing factors and should be considered in recurrent infections ŠFollow-up after one week

17. MANAGEMENT IN PREGNANT WOMEN Treatment for vaginitis ( TV+BV+Candida ) In 1 st trimester of pregnancy Local treatment with Clotrimazole vaginal pessary /cream only for candidiasis. Oral Flucanozole is contraindicated in pregnancy. Metronidazole pessaries or cream intravaginally if trichomoniasis or BV is suspected . In 2 nd and 3 rd trimester oral metronidazole can be given Tab . Secnidazole 2gm orally, single dose or Tab . Tinidazole 500mg orally, twice daily for 5 days Tab . Metoclopropramide taken 30 minutes before Tab. Metronidazole, to prevent gastric intolerance

18. Management of pregnant women with cervicitis Pregnant women with cervical discharge should be examined by doing a per speculum as well as per vaginal examination and should be treated for gonococcal as well as chlamydial infections. Cephalosporins to cover gonococcal infection are safe and effective in pregnancy ŠTab. CEFIXIME 400 mg orally, single dose or Š CEFTRIAXONE 125 mg by intramuscular injection + Tab. EZYTHROMYCIN 500mg orally four times a day for seven days orŠ Cap Amoxicillin 500mg orally, three times a day for seven days to cover chlamydial infection ŠQuinolones (like ofloxacin , ciprofloxacin), doxycycline are contraindicated in pregnant women .

19. CANDIDA TRICHOMONAS CLUE CELLS

20. Management of Lower Abdominal Pain Causative organisms Neisseria gonorrhoea Chlamydia trachomatis Mycoplasma,Gardnerella , Anaerobic bacteria ( Bacteroides sp. , gram positive cocci )

21. History Lower abdominal pain, Fever Vaginal discharge, Menstrual irregularities like heavy , irregular vaginal bleeding Dysmenorrhoea, Dyspareunia, Dysuria Low backache Contraceptive use like IUD Examination General examination: temperature , pulse, blood pressure Per abdominal examination : lower abdominal tenderness or guarding Per speculum examination : vaginal/cervical discharge, congestion or ulcers Pelvic examination : Uterine/adnexal tenderness , cervical movement tenderness Laboratory investigations ( if available ) Wet smear examination Gram stain for gonorrhoea Complete blood count ESR / CRP Urine microscopy for pus cells UPT should be done in all women with PID to rule out pregnancy .

22. Treatment (Out patient treatment ) KIT 6 In mild or moderate PID (in the absence of tubo ovarian abscess ) Tab . Cefixime 400 mg orally Stat + Tab. Metronidazole 400mg orally, twice daily for 14 days + Tab. Doxycycline , 100mg orally, twice a day for 2 weeks ( to treat Chlamydial infection ) Tab . Ibuprofen 400mg orally, three times a day for 3-5 days Tab . Ranitidine 150mg orally , twice daily to prevent gastritis Differential diagnosis Ectopic pregnancy, Twisted ovarian cyst , Ovarian tumor , Appendicitis, Abdominal tuberculosis

23. Hospitalization of Clients with acute PID should be seriously considered when: The diagnosis is uncertain Surgical emergencies e.g. appendicitis or ectopic pregnancy cannot be excluded A pelvic abscess is suspected Severe illness precludes management on an outpatient basis The woman is pregnant The Client is unable to follow or tolerate an out regimen The Client has failed to respond to outpatient therapy Syndrome specific guidelines for Partner management ●Treat all Partners ●Treat male Partners for urethral discharge (gonorrhoea and chlamydia) ●Advise sexual abstinence during the course of treatment ●Provide condoms, educate on correct and consistent use ● HIV & Syphilis testing ●Inform about the complications if left untreated and sequelae

24. MANAGEMENT OF GENITAL ULCERS Causative organisms Treponema pallidum (syphilis) Haemophilus ducreyi ( chancroid ) Klebsiella granulomatis (granuloma inguinale ) Chlamydia trachomatis ( lymphogranuloma venerum ) Herpes simplex (genital herpes) Examination Presence of vesicles Presence of genital ulcer- single or multiple Associated inguinal lymph node swelling if present Ulcer characteristics: Painful vesicles/ulcers, single or multiple - Herpes simplex Painless ulcer with painless enlarged lymph node - Syphilis Transient Ulcer with inguinal lymph nodes - LGV Painful ulcer sometimes single giant ulcer associated with painful bubo - Chancroid LABORATORY TEST (if available ) RPR for syphilis PCR for herpes

25. If vesicles are not seen and only ulcer is seen, treat for syphilis and chancroid . KIT 3 Inj BENZATHAINE PENICILLIN 2.4 million IU IM after test dose in two divided doses + Tab. AZITHROMYCIN 1g orally single dose or Tab. CIPROFLOXACIN 500mg orally, twice a day for three days to cover chancroid Treatment KIT 5 If vesicles and multiple painful ulcers are present treat for herpes : Tab. ACYCLOVIR 400mg orally, three times a day for 7 days

26. Syndrome specific guidelines for Partner management : ●Treat all Partners who are in contact with client in last 3 months ●Partners should be treated for syphilis and chancroid ●Advise sexual abstinence during the course of treatment ●Provide condoms, educate about correct and consistent use HIV & Syphilis testing ●Schedule return visit after 7 days In individuals allergic or intolerant to penicillin KIT 4 Tab. DOXYCYCLINE 100mg orally, twice daily for 14 days + Tab. AZITHROMYCIN 1g orally single dose or Tab . CIPROFLOXACIN 500mg orally, twice a day for three days Treatment should be extended beyond 7 days if ulcers have not epithelialized. If both ulcers & blisters are present or when the provider is not able to differentiate between the two then treat for both

27. Management of Pregnant Women ●Quinolones (like ofloxacin , ciprofloxacin), doxycycline, sulfonamides are contraindicated in pregnant women . ● Inj BENZATHINE PENICILLINE 2.4 million IU IM after test dose A second dose of BENZATHINE PENICILLIN 2.4 million units IM should be administered 1 week after the initial dose for women who have primary, secondary, or early latent syphilis . ●Pregnant women who are allergic to penicillin should be treated with Tab. ERYTHROMYCIN 500mg orally four times a day for 15 days ●Women without symptoms or signs of genital herpes or its SAFE can deliver vaginally. ●Women with genital herpetic lesions at the onset of labour should be delivered by caesarean section to prevent neonatal herpes. .

28. TREATMENT OF ANOGENITAL WARTS 20% Podophyllin in compound tincture of benzoin applied to the warts, while carefully protecting the surrounding area with Vaseline, to be washed off after 3 hours. TREATMENT OF CERVICAL WARTS Podophyllin is contra-indicated. Biopsy of warts to rule out malignant change. Cryo cauterization is the treatment of choice.

29. TREATMENT OF MOLLUSCUM CONTAGIOSUM Individual lesions usually regress without treatment in 9-12 months. Each lesion should be thoroughly opened with a fine needle or scalpel. The contents should be exposed and the inner wall touched with 25% phenol solution or 30% trichloracetic acid. TREATMENT OF PEDICULOSIS PUBIS Permethrin 1% cream rinse applied to affected areas and wash off after 10 minutes TREATMENT OF GENITAL SCABIES Permethrin cream (5%) applied to all areas of the body from the neck down and washed off after 8--14 hours. Benzyl benzoate 25% lotion, to be applied all over the body, below the neck, after a bath, for two consecutive nights. Client should bathe in the morning, and have a change of clothing. Bed linen is to be disinfected.

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