SYNDROMIC

MANAGEMENT OF STI
Presenter – Dr. Jeebanjyoti Mishra
Moderator – Dr Biswanath Behera
 OUTLINES
• Introduction
• Objectives
• Components
• Considerations in clinical management
• Steps
• Management of syndromes
• Syndromic management vs Etiologic management
• Limitations
 INTRODUCTION

• Diagnosis based on the identification of syndromes

• For resource poor setting

• Diagnosis and treatment in single visit

 OBJECTIVES

● Earliest diagnosis

● Correct and complete treatment

● Encourage change in risk behaviours

● Partner treatment
STEPS

1. History
2. Physical examination
3. Treatment
4. Health education on prevention
5. Provide condoms and demonstrate use
6. Offer Partner treatment
7. Follow up or refer as needed
COMPONENTS :
Counselling
and
education of
patient

Cure the Contact

patient tracing

SIX C’s

Come back
Condom
for follow-
promotion
up

Compliance
with
treatment
 SYNDROMIC MANAGEMENT OF STI/RTI
• Not for screening STI/RTI

• Presents with one or more of the following complaints:

1. Vaginal /Cervical urethral discharge
2. Vesicular and/or non -vesicular genital ulcers
3. Inguinal bubo
4. Lower abdominal and/or scrotal pain
5. Genital skin conditions
Important considerations for management of all Clients
of STI/RTI
1. Education and counselling of client and sex partner(s)
2. Treatment of partner(s)
3. Advise for sexual abstinence during the course of treatment
4. Provide condoms, educate about correct and consistent use.
5. Refer for voluntary counselling and testing (VCTC) for HIV, Syphilis and
Hepatitis B
6. Consider immunization against Hepatitis B
7. Schedule return visit after 7 days
8. If symptoms persist (Treatment failure /Re-infection) - prompt referral
SYNDROMIC CASE MANAGEMENT
FOR MANAGING STI/RTI
USE OF FLOWCHARTS IN MANAGEMENT OF STI/RTI
Determine clinical
problem

Find appropriate flow

chart

History &
examination

Make a decision –
yes/no

Leads to further
boxes & choices

Follow arrow to
end/exit path

Action box
Flowchart 1:Vaginal Discharge syndrome (Vaginitis)

HISTORY
• Menstrual history
Cau • Nature and type of Discharge
sati • Genital itching
ve •Dysuria, increased frequency
age • Presence of any ulcer, swelling on the vulval
nts or inguinal region
• Genital complaints in Sexual Partners
• Low backache
 EXAMINATION

• Trichomoniasis - greenish frothy discharge

• Candidiasis - curdy white discharge

• Bacterial vaginosis – adherent discharge

• Mixed infections - atypical discharge

• Per speculum examination (If not- treat both)

 VAGINITIS (TV+BV+CANDIDA)

• Tab. Secnidazole 2gm, single

dose or Tab. Tinidazole 500mg
BD for 5 days
• Tab. Metoclopropramide 30
minutes before to prevent
gastric intolerance
• Candidiasis : Fluconazole
150mg orally single dose or local
Clotrimazole 500mg vaginal
pessaries once
 MANAGEMENT OF CERVICAL DISCHARGE SYNDROME
(CERVICITIS)
• Abnormal vaginal discharge & Inter-menstrual bleeding
• Purulent or mucopurulent endocervical exudate
• Sustained endocervical bleeding induced by
gentle passage of a cotton swab through cervical os
• Characteristic features
• Erythematous cervix
• Mucopurulent cervical discharge
• Bimanual pelvic examination to rule out PID

Cervical discharge on
Colposcopy
 Causative Organisms
• N. gonorrhoeae
• C. trachomatis
• T. vaginalis
• HSV
• HPV

Treatment for cervical infection (chlamydia and gonorrhoea)

• Tab. Cefixime 400 mg orally, single dose
PLUS
• Tab. Azithromycin 1 gm, 1 hour before food
If vomiting occurs within 1 hour, give anti-emetic and repeat
Note:Instruction to avoid douching, For pregnant same as in non-pregnant women.
 URETHRAL DISCHARGE/BURNING
MICTURITION IN MALES

CAUSATIVE AGENT
Neisseria
Chlamydia
Trichomonas
Others : Mycoplasma,HSV
Gonococcal urethritis : Inflamed
meatus with purulent discharge Enteric bacteria,Adeno virus
• History • Examination
• Urethral discharge • Redness and swelling of the
• Pain or burning while passing urethral meatus
urine • Urethral discharge
• Increased frequency of urination • Massage the urethra from the
• Sexual exposure including high ventral part of the penis towards
risk the meatus
• Practices like oro-genital sex in • Thick, creamy greenish-yellow
the previous 2 months or mucoid discharge
RECOMMENDED REGIMEN FOR UNCOMPLICATED
URETHRAL DISCHARGE (UD)

• Tab. Cefixime 400 mg orally, single

dose
PLUS
• Tab. Azithromycin 1 gm orally single
dose under supervision
OR
• Cap. Doxycycline 100 mg twice a day
for 7 days
• Last sexual contact within 60 days,
need evaluation and treatment
• Rule out HIV
 RECURRENT AND PERSISTENT
URETHRITIS
• Persistent urethritis after doxycycline for 7 days might be caused by T. vaginalis
and doxycycline-resistant U. urealyticum or M. genitalium
• Re-exposure need to be excluded
• Metronidazole 2 gm orally in a single dose OR
• Tinidazole 2 gm orally in a single dose
PLUS
• Azithromycin 1 gm orally in a single dose (if not used for initial episode)
MANAGEMENT OF GENITAL ULCER DISEASE NON-
HERPETIC SYNDROME
Presentation

• Presence of genital ulcer- single or multiple

• Ulcer characteristics:
• Painless ulcer with firm lymph nodes - Syphilis
• Painless ulcer without inguinal lymph nodes - Granuloma inguinale
• Transient painless penile ulcer with painful, enlarged inguinal lymph nodes –
LGV
• Painful ulcers usually multiple and associated with painful bubo - Chancroid
MANAGEMENT
• If vesicles are not seen and only ulcer
is seen, treat for syphilis and chancroid
• Inj. Benzathine penicillin 2.4 million IU
IM single dose after test dose in two
divided doses (with emergency tray
ready) (for syphilis)
• PLUS
• Tab. Azithromycin 1 gm orally single
dose/ Erythromycin 500 mg QID for 7
days OR
• Tab. Ciprofloxacin 500 mg BD for 3
days (Chancroid)
INDIVIDUALS ALLERGIC TO PENICILLIN

• Cap. Doxycycline 100 mg orally, twice

daily for 15 days OR

Tab. Azithromycin 2 gm as a single

dose to treat early syphilis
 MANAGEMENT OF GENITAL ULCER DISEASE
HERPETIC SYNDROME

• Multiple vesicles /superficial erosions

• Burning sensations
• Recurrence of lesions
• IP period : 5-14 days
• Tzanck smear for multinucleated
giant cell
• Rule out syphilis (RPR test )/HIV (ICTC
center) CAUSATIVE AGENT
HSV (Genital herpes )
MANAGEMENT
• Abstinence during course of
treatment
• Acyclovir 400 mg tds for 7 days
(For first/recurrent episode )
• HSV supressive therapy : Tab
Aciclovir 400 mg BD ( If > 6
/year)
• No partner treatment ,if no
lesions on partner
• Pregnant : acyclovir 400 mg tds
for last 4 weeks *
Management of Painful Scrotal Swelling syndrome in Males

HISTORY EXAMINATION
• Swelling and pain in scrotum • Redness and oedema of the overlying
skin and raised local temperature
• Pain or burning while passing
• Tenderness of the epididymis and vas
urine deferens
• Urethral discharge • Associated urethral discharge/genital
• Systemic symptoms like malaise, ulcer/inguinal lymph nodes – if present
refer to the respective flowchart
fever
• Trans-illumination test to rule out
hydrocele
 MANAGEMENT
Causative Organisms
• N.gonorrhoeae
• C. trachomatis
• Non STI infectious: tuberculosis, filariasis,
coliforms, pseudomonas, mumps virus
o Non-infectious :trauma with or without
haematoma, and torsion

Tab. Cefixime 400 mg orally, single dose

PLUS
Tab. Azithromycin 1 gm, 1 hour before food
If vomiting occurs within 1 hour, give anti-emetic and repeat
 MANAGEMENT OF INGUINAL BUBO

HISTORY EXAMINATION
• Groin = Localized enlargement of lymph
• Painful swelling in inguinal region nodes (tender & fluctuant)
• Preceding history of genital ulcer • Inflammed skin over swelling
• Sexual exposure of either partner • Multiple sinuses
(oro-genital sex) • Oedema of genitals & lower limbs
• Systemic symptoms : malaise, fever • Genital ulcer/ urethral discharge : refer
to respective flowchart
 Flowchart 7: Management of Inguinal Bubo

Causative organisms
C. trachomatis Serovars
L1,L2,L3 (LGV)
H. ducreii (Chancroid)

Inguinal Bubo
TREATMENT
• Cap. Doxycycline 100 mg BD for 21 days
PLUS
• Tab. Azithromycin 1 gm single dose
OR
• Ciprofloxacin 500 mg BD for 3 days
(chancroid)

• Bubo : I & D, Aspirate if fluctuant

• In severe cases (vulval oedema) : vulvectomy

may be required ( Higher center )
MANAGEMENT OF LOWER ABDOMINAL PAIN SYNDROME

• Spectrum of inflammatory disorders of upper female genital tract,

including any combination of endometritis, salpingitis, tubo-ovarian
abscess & pelvic peritonitis

• Causative Organisms
• N. gonorrhoeae
• C.trachomatis
• Mycoplasma
• Gardnerella
• Anaerobic bacteria (Bacteroides sp, gram positive cocci)
 HISTORY EXAMINATION

• Lower abdominal pain, Fever , Vaginal • General examination: Temp., Pulse, BP

discharge • P/S examination :
• Dysmenorrhoea .Dyspareunia Discharge/Congestion/Ulcers
• Dysuria, tenesmus • P/A examination : lower abdominal
• Low backache tenderness or guarding
• Contraceptive use (IUD) • Pelvic examination:
uterine/adnexal tenderness
cervical movement tenderness
Note: UPT to rule out ectopic pregnancy
 TREATMENT

• Tab. Cefixime 400 mg orally STAT

PLUS
• Tab. Metronidazole 400 mg orally, BD for
14 days (Anaerobic infection)
PLUS
• Cap. Doxycyline, 100 mg orally, twice a
day for 14 days (Chlamydial infection)
• Remove IUD , under antibiotic cover of 24
- 48 hours
• Observe for 3 days
• If No improvement / Symptoms worsen :
Refer for inpatient treatment
Investigations (Resource poor setting)
• Wet mount microscopy of the discharge :T. vaginalis
• 10% KOH preparation : Candida albicans
• Gram stain of vaginal smear for clue cells: Bacterial vaginosis
• Gram stain of endocervical smear to detect gonococci (Low SN,SP)
• Leucorrhoea (>10 WBC /HPF) : chlamydial and gonococcal infection of
the cervix
• > 5 N/oil immersion field (1000X) in the urethral smear or > 10
neutrophils/HPF in the sediment of the first void urine:NGU
Cont..
• Ulcer : Gram stain(Chancroid), Leishman stain (Donovanosis )
• Tzanck smear : Multinucleated giant cells
• PID :
• Complete blood count and ESR
• Urine microscopy for pus cells
• Wet smear/ examination/Gram stain for gonorrhoea
• RPR test for syphilis
• Refer to ICTC for HIV counselling and testing
 SYNDROME SYNDROME SPECIFIC GUIDELINE FOR PARTNER
MANAGEMENT
Vaginal discharge – • Not required
BV/Candida • Treat current partner ( only if no improvement )
• If partner is symptomatic, treat client
Trichomonas For Trichomonas infection: treat ( last 30 days ) , Sexual abstinence

Cervicitis/Urethral discharge • Treat ( last 30 days) , Sexual abstinence during the course of treatment
/Burning micturation males

Non Herpetic ulcer • Treat for syphilis and chancroid with same regimen.
• Client in last 3 months prior to the onset of ulcer
• Sexual abstinence during the course of treatment or till the lesions heal

Herpetic ulcer • No partner treatment for herpes (in the absence of

active episode/ lesions)
• Advise sexual abstinence during the course of
treatment or till the lesions heal

Painful scrotal swelling • Treat partner ( contact within 60 days )

• Sexual abstinence during the treatment

Lower abdominal pain • Treat ( contact within 60 days ) , Male partners for urethral discharge
• Provide condoms, educate on correct and consistent use
Management during pregnancy
• Cervical discharge/Urethritis/Painful scrotal swelling : same as non pregnant (grey
kit )
• Vaginal discharge :
• Per speculum examination (abortion, PROM)
• Clotrimazole vaginal pessary/cream
• Tab Metronidazole 400 mg bid for 7 days for BV/TV
• Lower abdominal pain : Yellow kit , need referral
• Ulcer non herpetic:
• RPR positive :Inj. Benzathine penicillin 2.4 million IU IM single dose (with emergency tray
ready) (for syphilis)
• If allergic to penicillin : Eryhromycin *
• Ulcer herpetic :
• Dose is same as non pregnant
• Genital herpetic lesions at the onset of labour : caesarean section( neonatal herpes )
• Tab. Acyclovir 400 mg three times a day during the last four weeks of pregnancy
Key counselling message
• Educate and counsel client and sex partner(s) regarding STI/RTI, safer
sex practices
• Importance of taking complete treatment
• Provide condoms, educate about their correct and consistent use.
• Treat partner(s) as per syndrome recommendations
• Advise sexual abstinence during the course of treatment
• Schedule return visit after 7 days
Follow up
Follow up after 7 days
• To document symptomatic cure/ results of tests done for HIV and syphilis/
• If symptoms/signs persist assess whether it is due to lack of
treatment compliance / treatment failure /re-infection and
advise prompt referral
• For inguinal swelling After 7, 14 and 21 days
• Painful scrotal swelling if symptoms persist after treatment, need referral
• For syphilis
• Follow up at 3, 6, 12 and 24 months
• During each follow up visit, conduct clinical examination, qualitative, and quantitative non-
treponemal tests (RPR/VDRL)
• Retreatment :serological evidence of re-infection or relapse
Comparison between Etiologic and Syndromic approach
Etiologic approach Syndromic approach
1. Possible to get an exact diagnosis using Diagnosis may be wrong in certain cases e.g. in case of
laboratory tests vaginal discharge syndrome, the approach is not
effective to manage gonorrhoea and chlamydia
infection

2. Avoids over-treatment Over-treatment of patient as well as partner may

happen

3. Patient must return for test results and must The patient is diagnosed and treated in one visit
wait for treatment till the lab results comes

4. More chances of lost to follow up No loss to follow up

5. Expensive as trained laboratory technicians as Relatively inexpensive as it avoids use of laboratory
well as infrastructure and supplies are needed tests
Limitations of syndromic management

Asymptomatic infection
• 75% of primary episodes of herpes are
asymptomatic or produce only mild or
unrecognized symptoms.

• 75% of women with chlamydia are symptom-free,

yet this STI/RTI can lead to pelvic inflammatory
disease (PID), which, in turn, can lead to infertility
and ectopic pregnancy.
References:
• National Guidelines on Prevention, Management and Control of
Reproductive Tract Infections and Sexually Transmitted Infections, July
2014.
• A text book of Indian Association for the study of STD & AIIDS, V K
Sharma,Second Edition
THANK YOU
Laboratory investigations (If available)
• Wet mount microscopy 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
MANAGEMENT OF PREGNANCY AND PARTNER

PARTNER PREGNANCY
• For BV/Candida :Not required • Per speculum examination
• For Trichomonas: treat all • Metronidazole 400 mg tds for 7
partners within last 30 days days
• Abstinence during treatment • Fluconazole is contraindicated
• Clotrimazole cream/pessary