Syndromic management of STI

STI

1. DEBRE BIRHAN UNIVERSITY COLLEGE OF MEDICINE Syndromic approach for management of STI and PID Presenter - Zelalem Mekonnen Modulator- Dr. Adissu (Gynecologist & Obstetrician ) February 2013 E.C 2/24/2021 Zelalem -C1 1

2. Objectives Define Sexually transmitted diseases Recognize a pproaches to STI Case Management Understand the syndromic approach for the management of different STIs syndromes 2/24/2021 Zelalem -C1 2

3. Sexually transmitted infections Is diverse group of infections, caused by different types of microbial agents, that are frequently transmitted by sexual contact. Other modes of transmission include: mother-to-child, blood transfusions, or other contact with blood or fomites STIs have public health importance because of their magnitude, potential complications and their interaction with HIV/AIDS . 2/24/2021 Zelalem -C1 3

4. Epidemiology of STIs According to 2016 EDHS 4% of women and men age 15-49 reported having an STI and/or symptoms of an STI in the past 12 months Among men, the percentage was 6% in Oromiya, and 5% in Harari compared to less than 1% in the Tigray and Benishangul-Gumuz. 2/24/2021 Zelalem -C1 4

5. Interaction of STIs and HIV STIs enhance the sexual transmission of HIV through primarily cause ulcers disrupt the integrity of the skin barrier Cause inflammation (gonorrhea, trichomoniasis, and chlamydial infections) Increase viral shedding & increase susceptibility to HIV 2/24/2021 Zelalem -C1 5

6. CONT… HIV infection affects STIs through HIV alters susceptibility of STI pathogens to antibiotics Increased susceptibility to STIs among immune suppressed individuals The clinical features of various types of STIs are influenced when there is co-infection with HIV. 2/24/2021 Zelalem -C1 6

7. Approaches to STI Case Management Three diagnostic approaches: Etiologic approach. Clinical approach Syndromic approach 2/24/2021 Zelalem -C1 7

8. 1. Etiologic approach I dentifying the causative agent using laboratory tests & giving treatment targeting to the pathogen identified. 2. Clinical approach Uses clinical experience to identify symptoms which are typical for a specific STI, then giving treatment targeted, to the suspected pathogen 3. Syndromic approach Identification of clinical syndrome and giving treatment targeting all the locally known pathogens which can cause the syndrome 2/24/2021 Zelalem -C1 8

9. Etiologic approach Advantages Accurate diagnosis, accurate treatment, Proper use of antibiotics Decreases over treatment and antibiotic resistance). B etter way to diagnose and treat asymptomatic infections Disadvantages Needs lab support and expertise Expensive and it is time consuming 2/24/2021 Zelalem -C1 9

10. Clinical approach Advantages Saves time for patients Reduces lab expenses Disadvantages Requires high clinical skill Mixed infections often overlooked Doesn’t identify asymptomatic STIs 2/24/2021 Zelalem -C1 10

11. Syndromic approach 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 Disadvantages O ver treatment with antibiotics, T here is risk of creating antibiotic resistance D ecreased compliance There is also increased cost of drugs. Moreover asymptomatic infection missed . 2/24/2021 Zelalem -C1 11

12. Cont.. Health care providers should undertake the following measures besides treating individual patients Partner notification and management Condom promotion and supply Health education and risk reduction counseling Linkage with HIV counseling and testing Follow-up visits for patients with STI 2/24/2021 Zelalem -C1 12

13. STI Syndromes Urethral discharge Vaginal discharge Genital ulcer Inguinal bubo Scrotal swelling Lower abdominal pain Neonatal conjunctivitis 2/24/2021 Zelalem -C1 13

14. 1. Urethral discharge syndrome is the presence of abnormal secretions from the distal part of the urethra it is the characteristic manifestation of urethritis urethral discharge is accompanied by burning sensations (dysuria) during micturition. Person with urethral discharge can also have increased frequency and urgency of urination and itching sensation of urethra. The appearance of the discharge can be purulent or mucoid, clear, white, or yellowish-green 2/24/2021 Zelalem -C1 14

15. Etiology Neisseria gonorrhea (81%) Chlamydia trachomatis (36.8%). other causative micro-organisms are mycoplasma genitalium,Trichomonas vaginalis, and Ureaplasma urealyticum. Most of the time urethral discharge is due to mixed infection of Neisseria gonorrhea and Chlamydia trachomatis 2/24/2021 Zelalem -C1 15

16. C linical manifestations N . gonorrhea has usually an acute onset with profuse and purulent discharge C . trachomatis has sub-acute onset with scant mucopurulent discharge. C ommon signs and symptoms are burning sensation during micturition, urgency and frequency of urination with itching sensation of the urethra. 2/24/2021 Zelalem -C1 16

17. The signs and symptoms of complications of the syndrome are testicular pain and swelling, arthritis, polyarthralgia, tenosynovitis, skin lesions and constitutional symptoms. 2/24/2021 Zelalem -C1 17

18. CONT.. Acute complications Disseminated gonococci syndrome Perihepatitis Acute epididymo-orchitis Chronic complications Urethral stricture Infertility Reiter’s syndrome ( arthritis, conjunctivitis, and nonspecific urethritis) 2/24/2021 Zelalem -C1 18

19. TREATMENT Ceftriaxone 250mg IM stat / Spectinomycin 2 gm IM stat Plus Azithromycin 1gm po stat/Doxycycline 100 mg po Bid for 7 days/Tetracycline 500 mg po Qid for 7 days/Erythromycin 500 mg po Qid for 7 days in cases of contraindications for Tetracycline (children and pregnancy) The preferred regimen is Ceftriaxone 250mg IM stat plus Azithromycin 1gm po stat 2/24/2021 Zelalem -C1 19

20. 2. G enital ulcer syndrome is an open sore or a break in the continuity of the skin or mucous membrane of the genitalia ETIOLOGY Herpes simplex virus, (HSV-1 and HSV-2) Treponema pallidum Haemophilius ducreyia Chlamydia trachomatis Klebsiella granulomatis ( donovanosis) 2/24/2021 Zelalem -C1 20

21. Clinical manifestation Constitutional symptoms Recurrent painful vesicles and irritations Shallow and non-indurated tender ulcers Painless indurated ulcer ( Chancre ) Regional lymph adenopathy 2/24/2021 Zelalem -C1 21

22. Common sites in male are glance penis, prepuce and penile shaft In women are vulva, perineum, vagina and cervix and can cause occasionally severe vulvo- vaginitis and necrotizing cervicitis 2/24/2021 Zelalem -C1 22

23. complications of genital ulcer syndrome G ranulomatous lesions (Gummas) on the skin, liver, bones, or other organs Tabes dorsalis and dementia, often with paranoid features Aortic aneurysm and aortic valve insufficiency Phimosis in men Destruction of the penis or auto amputation 2/24/2021 Zelalem -C1 23

24. TREATMENT 2/24/2021 Zelalem -C1 24

25. 3. Vaginal discharge syndrome Normal vaginal discharge is white mucoid, odor less &nonirritant , thin or thick based on menstrual cycle . Abnormal in color, odor and amount accompanied by pruritus- pathological 2/24/2021 Zelalem -C1 25

26. Etiology The most common causes of vaginal discharge syndrome are Neisseria gonorrhea Chlamydia trachomatis Candida albicans Trichomonas vaginalis Gardnerella vaginalis Bacterial vaginosis (Gardnerella vaginalis) is the leading cause of vaginal discharge in Ethiopia followed by candidiasis, trichomoniasis, gonococcal and chlamydia cervicitis 2/24/2021 Zelalem -C1 26

27. CLINICAL MANIFESTATIONS Thin , homogenous whitish discharge with fishy odor Thick , profuse, malodorous, yellow-green, frothy itchy Purulent exudate from the cervical Os White , thick and curd like discharge coating the walls of the vagina V ulvo-vaginal pruritus, irritation of vulva, dyspareunia, dysuria, and frequency of urination. 2/24/2021 Zelalem -C1 27

28. Physical examination Dry congestion of the vulva with discharge. Signs of cervicitis during speculum examination which are redness and contact bleeding from the cervix, spotting and endo cervical discharge 2/24/2021 Zelalem -C1 28

29. COMPLICATIONS Pelvic Inflammatory Disease (PID ) Peritonitis and intra-abdominal abscess Adhesions and intestinal obstruction Ectopic pregnancy Premature Rupture of Membrane (PROM ) 2/24/2021 Zelalem -C1 29

30. CONT.. Chorioamnionitis Post-partum endometritis Pre-term labor Low birth weight Infertility Chronic pelvic pain 2/24/2021 Zelalem -C1 30

31. CONT.. Common risk factors for development of vaginal discharge syndrome secondary to cervicitis : The presences of one or more risk factor suggest cervicitis • Multiple sexual partners in the last 3 month • New sexual partner in the last 3 month • Ever traded sex • Age below 25 years 2/24/2021 Zelalem -C1 31

32. Risk Assessment Positive Risk Assessment Negative Ceftriaxone 250mg IM stat / Spectinomycin 2gm IM stat Plus Azithromycin 1gm po stat/Doxycycline 100 mg po Bid for 7 days Plus Metronidazole 500 mg Bid for 7 days If discharge is white or curd-like add Clotrimazole vaginal pessary 200 mg at bed time for 3 days   Note: The preferred regimen is Ceftriaxone 250mg IM stat plus Azithromycin 1gm po stat plus Metronidazole 500 mg bid for 7 days.     Metronidazole 500 mg bid for 7 days     If discharge is white or curd-like add Clotrimazole vaginal pessary 200 mg at bed time for 3 days   2/24/2021 Zelalem -C1 32

33. 4. L ower abdominal pain/ (PID) Clinical syndrome resulting from ascending infection from the cervix and/or vagina . Inflammatory disorders of the upper female genital tract, including endometritis , salpingitis, tubo-ovarian abscess and pelvic peritonitis. The inflammation may also spread to the liver, spleen or appendix. 2/24/2021 Zelalem -C1 33

34. CONT.. The vast majority of PID with or without pelvic abscess improves with antibiotics alone and the fever usually subsides in less than 72 hours. Failure to improve within 72 hours after antibiotic treatment indicates failure of medical treatment and the patient should be referred for surgical evaluation and treatment. 2/24/2021 Zelalem -C1 34

35. ETIOLOGY PID is frequently poly-microbial. The commonest pathogens associated with PID, which are transmitted sexually, are C. trachomatis & N. gonorrhea . Other causes which may or may not be transmitted sexually include: Mycoplasma genitalium E. coli H. influenza Streptococcus 2/24/2021 Zelalem -C1 35

36. Risk factors AGE Adolescent girls are at significant risk for development of acute salpingitis The incidence of acute PID decreases with advancing age . Due to greater endocervical exposure in the ectocervix of adolescents 2/24/2021 Zelalem -C1 36

37. IUCD Multiple case-controlled studies have shown an increased risk of acute PID in women who used an IUD. It has been estimated that IUCD users have a threefold to fivefold increased risk for development of acute PID 2/24/2021 Zelalem -C1 37

38. Surgical procedures of the female genital tract About 15% of pelvic infections occur after procedures that break the cervical mucous barrier. UGTI associated with first-trimester abortions is about 1 in 200 cases 2/24/2021 Zelalem -C1 38

39. Previous acute PID Due to the sexual habits of the woman involved, such as reinfection from an untreated male partner or genital tract damage from the initial infection . may be the loss of natural protective mechanisms of the fallopian tube lining against microorganisms. 2/24/2021 Zelalem -C1 39

40. Frequent sexual activity, early onset of sexual activity, multiple sex partners, and a recent new sex partner are associated with risk for developing PID. 2/24/2021 Zelalem -C1 40

41. PID protective factors OCP M echanism of protection- probably due to: cervical mucus thickening short menstrual flow period - shorter interval for bacterial invasion ovulation inhibition  no nidus for abscess formation on ovary Barrier contraceptives ( mechanical and chemical)- 60% decrease with consistent use 2/24/2021 Zelalem -C1 41

42. Hegar criteria for the Diagnosis if one major plus two minor or Two major criteria. M ajor criteria 1. Cervical motion tenderness 2. Uterine tenderness 3.Adnexal tenderness . 2/24/2021 Zelalem -C1 42

43. Minor criteria One or more of minor criteria can be used to diagnosis of PID: oral temperature >101°F (>38.3°C ); abnormal cervical mucopurulent discharge presence of abundant numbers of WBC on saline microscopy of vaginal fluid; elevated erythrocyte sedimentation rate; elevated C-reactive protein; and laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis. 2/24/2021 Zelalem -C1 43

44. CLINICAL MANIFESTATION Lower abdominal pain Abnormal vaginal discharge Inter-menstrual or post coital bleeding Dysuria Backache 2/24/2021 Zelalem -C1 44

45. CONT. Fever , nausea and vomiting Cervical excitation tenderness Adnexal tenderness Rebound tenderness Adnexal mass 2/24/2021 Zelalem -C1 45

46. Differential Diagnosis of Pelvic Inflammatory Diseas e Ectopic pregnancy Septic abortion Ruptured ovarian cyst Endometriosis Acute appendicitis Urinary tract infection Nephrolithiasis 2/24/2021 Zelalem -C1 46

47. Fitz-Hugh-Curtis syndrome Perihepatic inflammation and adhesions , develop in 1% - 10% RUQ pain,pleuritic pain,& RUQ tenderness. M istakenly diagnosed as either acute cholecystitis or pneumonia Due to vascular or transperitoneal dissemination of either N. gonorrhoeae or C. trachomatis to produce the perihepatic inflammation. 2/24/2021 Zelalem -C1 47

48. For outpatient For inpatient Ceftriaxone 250 mg IM stat /Spectinomycin 2gm i.m stat Plus Azithromycin 1gmpo stat/Doxycycline 100 mg po b.i.d for 14 days Plus Metronidazole 500 mg po b.i.d for 14 days Admit if there is no improvement within 72 hours Note : The preferred regimen is Ceftriaxone 250mg IM stat plus Azithromycin 1gm po stat plus Metronidazole 500 mg bid for 14 days Ceftriaxone 250 mg i.m/ i.v /Spectinomycin 2 gm i.m bid Plus Azithromycin 1gm po daily /Doxycycline 100 mg po b.i.d for 14 days Plus Metronidazole 500 mg po b.i.d for 14 days 2/24/2021 Zelalem -C1 48

49. Hospitalization of patients with acute PID should be seriously considered when: surgical emergencies such as appendicitis and ectopic pregnancy cannot be exclude pelvic abscess is suspected severe illness precludes management on an outpatient basis CONT.. 2/24/2021 Zelalem -C1 49

50. CONT.. T he patient is pregnant The patient is unable to follow or tolerate an outpatient regimen Patient has failed to respond to outpatient therapy. PID in HIV patients 2/24/2021 Zelalem -C1 50

51. COMPLICATIONS Peritonitis and intra-abdominal abscess Adhesions and intestinal obstruction Ectopic pregnancy Infertility Chronic pelvic pain Recurrent PID Tubo-ovarian Abscess 2/24/2021 Zelalem -C1 51

52. Tubo-ovarian Abscess Tubo-ovarian abscess (a mass consisting primarily of an abscess cavity within an anatomically defined structure such as the ovary), pyosalpinx TOA is diagnosed when a patient with PID has a pelvic mass that is palpable during bimanual examination . About 75% of women with tubo -ovarian abscess respond to antimicrobial therapy alone Failure of medical therapy suggests the need for drainage of the abscess 2/24/2021 Zelalem -C1 52

53. Evaluation Laparoscopy limited as a method of diagnosing the early stages of PID, It is important to R/O non-PID surgical emergencies, such as appendicitis, endometriosis Laparoscopy strongly indicated for patients who are not responding to therapy to confirm the diagnosis, obtain cultures from the cul-de-sac or fallopian tubes, and drain pus if necessary 2/24/2021 Zelalem -C1 53

54. Ultrasonography Ultrasound is helpful in distinguishing an adnexal mass, especially in patients who demonstrate a lack of response to antimicrobial therapy in the initial 48 to 72 hours of therapy. 2/24/2021 Zelalem -C1 54

55. 5 . S crotal swelling syndrome Caused by trauma, tumor, and torsion of the testis or inflammation of the epididymis. Mostly the inflammation of the epididymis is caused by STD. Among patients who are younger than 35 years, the swelling is likely to be caused by sexually transmitted infection. 2/24/2021 Zelalem -C1 55

56. ETIOLOGY SCROTAL SWELLING SYNDROME Infectious scrotal swelling caused by: N . gonorrhea C . trachomatis T . pallidum Mumps virus Filarial disease Non-infectious cause Testicular torsion, trauma , Incarcerated inguinal hernia 2/24/2021 Zelalem -C1 56

57. CLINICAL MANIFESTATIONS OF SCROTAL SWELLING Pain and swelling of the scrotum Tender and hot scrotum on palpation Edema and erythema of the scrotum Dysuria frequency and urethral discharge 2/24/2021 Zelalem -C1 57

58. COMPLICATIONS OF SCROTAL SWELLING SYNDROME • Destruction and scarring of testicular tissues • Infertility • Impotence • Prostatitis 2/24/2021 Zelalem -C1 58

59. TREATMENT 2/24/2021 Zelalem -C1 59

60. 6 . I nguinal bubo syndrome ( S wollen glands ) Is swelling of inguinal lymph nodes as a result of STIs ETIOLOGY Chlamydia trachomatis (L1, L2 and L3) Treponema pallidum Haemophilius ducreyi Klebsiella granulomatis ( donovanosis) 2/24/2021 Zelalem -C1 60

61. CLINICAL MANIFESTATIONS Constitutional symptoms of fever, headache Tender unilateral or bilateral lymphadenopathy forms a classical “groove sign” in the inguinal area Fluctuant abscess formation which form coalesce mass (bubo) 2/24/2021 Zelalem -C1 61

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63. COMPLICATIONS Fistula or sinus formation Multiple draining sinus Extensive ulceration of genitalia Extensive scarring Chronic untreated LGV may result in lymphatic obstruction, elephantiasis of the genitalia. Note : surgical incisions are contraindicated; instead aspirate pus with needle through the health skin . 2/24/2021 Zelalem -C1 63

64. TREATMENT OF INGUINAL BUBO 2/24/2021 Zelalem -C1 64

65. 7. NEONATAL CONJUNCTIVITIS O cular redness, swelling and drainage which may be purulent due to pathogenic agents or irritant chemicals in infants less than 4 weeks of age . Common etiologic causes of neonatal conjunctivitis are: N . gonorrhea C . trachomatis S . pneumoniae H . influenzae S . aureus 2/24/2021 Zelalem -C1 65

66. COMMON RISK FACTORS OF NEONATAL CONJUNCTIVITIS Maternal infection with STI Exposure of the infant to infectious organisms Inadequacy of ocular prophylaxis immediately after birth Premature rupture of membrane Ocular trauma during delivery Prematurity 2/24/2021 Zelalem -C1 66

67. CLINICAL MANIFESTATIONS Red and edematous conjunctiva Edematous eye lead Discharge which may be purulent Orbital cellulitis in more serious cases 2/24/2021 Zelalem -C1 67

68. COMPLICATIONS : Pseudo membrane formation Corneal edema Thickened palpebral conjunctiva Corneal perforation Blindness 2/24/2021 Zelalem -C1 68

69. PREVENTION OF NEONATAL CONJUNCTIVITIS Wiping the baby’s both eyes with dry and clean cotton cloth as soon as the baby is born. Apply 1% tetracycline eye ointment into the eyes of the newborn infant. Properly open the eye of the infant and place the ointment on the lower conjunctival sacs. 2/24/2021 Zelalem -C1 69

70. The recommended treatment of neonatal conjunctivitis in Ethiopia 2/24/2021 Zelalem -C1 70

71. Syphilis in pregnancy is a systemic infection caused by the spirochete Treponema pallidum, which is of particular concern during pregnancy because of the risk of transplacental infection of the fetus. 2/24/2021 Zelalem -C1 71

72. In Ethiopia, syphilis prevalence among ANC follow up in 2012 was 1%, indicating a low prevalence of syphilis in pregnant women RPR >5% indicates high prevalence . All pregnant women: screen at the first prenatal encounter Women at high risk of infection: repeat screening at 28 to 32 weeks and at delivery 2/24/2021 Zelalem -C1 72

73. The stage of syphilis is clinically important because it impacts the treatment regimen and the risk of vertical transmission Primary syphilis P apule , painless , at the site of inoculation. U lcerates to produce the classic chancre of primary syphilis, a 1 to 2 cm painless ulcer Associated with mild to moderate regional lymphadenopathy that is often bilateral. 2/24/2021 Zelalem -C1 73

74. Cont. Chancres heal within 3 to 6 wk , even in the absence of treatment. The primary stage of syphilis missed in women b/c the lesion is on vaginal or cervical mucosa 2/24/2021 Zelalem -C1 74

75. 2. Secondary syphilis D isseminated begins 6 wk to 6 months after the appearance of the chancre A generalized maculopapular skin rash palms , soles & mucous membranes S paring the face , is characteristic of this stage of the infection. Generalized lymphadenopathy accompanies the skin rash .. 2/24/2021 Zelalem -C1 75

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78. Cont. fever , pharyngitis, weight loss, and large genital lesions called condylomata lata .. The rash typically resolves within 2 to 6 wks Secondary syphilis is commonly the stage when women present to a health care provider 2/24/2021 Zelalem -C1 78

79. 3. Latent syphilis asymptomatic . untreated, patients will have signs & symptoms of secondary or late syphilis. latent syphilis may transmit the infection to the fetus early latency -the first year following secondary syphilis late latency - > 1 years 2/24/2021 Zelalem -C1 79

80. 4. Tertiary (late) syphilis one-third of untreated patients Tertiary syphilis is characterized by slowly progressive signs and symptoms Gumma formation & cardiovascular disease . 5 to 20 years after the disease has become latent. 2/24/2021 Zelalem -C1 80

81. Laboratory Dark field microscopy Nontreponemal RPR (rapid plasma reagin) test standard VDRL slide test 2/24/2021 Zelalem -C1 81

82. Potential adverse pregnancy outcome Miscarriage Preterm birth Stillbirth Impaired fetal growth Congenital infection Neonatal mortality 2/24/2021 Zelalem -C1 82

83. Preferred regimen A single dose of benzathine penicillin G 2.4 million units intramuscularly for women with primary, secondary, or early latent disease Late latent, tertiary, and disease of unknown duration, three doses of benzathine penicillin G 2.4 million unit intramuscularly at weekly If a dose is missed for more than 14 days, the full three-dose course of therapy should be started again 2/24/2021 Zelalem -C1 83

84. References Ethiopian National guidelines for the management of sexually transmitted infections using the syndromic approach ;February, 2015 Te L indes operative gynecology 11 th edition Up- todate 17.1 2/24/2021 Zelalem -C1 84

85. THE END 2/24/2021 Zelalem -C1 85