INTRODUCTION TO SYNDROMIC MANAGEMENT OF STIs

Objectives KEY CONCEPTS you will learn: Problems associated with classic approaches to treating STIs Main features of syndromic case management Various advantages of syndromic approach Steps in using flow charts

Classical approaches to STI management Etiologic diagnosis – using lab to identify the causative agent Clinical diagnosis –using clinical experience to identify causative agent

Etiologic Management Advantages:- Avoids over treatment Conforms to traditional clinical training Satisfies patients who feel not properly attended to Can be extended as screening for the asymptomatics

Problems of etiologic approach Requires skilled personnel and consistent supplies Treatment does not begin until results are available It is time consuming and expensive Testing facilities are not available at primary level Some bacteria fastidious and difficult to culture (H.ducrey, C.trachomatis)

Problems of etiologic approach…Cont’d Lab. results often not reliable Mixed infections often overlooked Miss-treated/untreated infections can lead to complications and continued transmission

Clinical Management Advantages:- Disadvantages:- Saves time for patients Reduces laboratory expenses Disadvantages:- Requires high clinical acumen Most STIs cause similar symptoms Mixed infections are common and failure to treat may lead to serious complications Doesn’t identify asymtomatic STIs

Syndromic Approach Syndrome – is group of symptoms patient complains about and clinical signs you observe during examination Different organisms that cause STIs give rise to only limited number of syndromes There are seven syndromes (aim is to identify and manage accordingly)

Identifying Syndromes MOST COMMON CAUSE Vaginal discharge Vaginitis(trichomniasis, candidisis) Cervicitis(gonorrhea, chlamydia) Urethral discharge Gonorrhea, chlamydia Genital ulcer Syphilis, chancroid, herpes Lower abdominal pain Gonorrhea, chlamydia, mixed anaerobes Scrotal swelling Inguinal bubo LGV, Chancroid Neonatal conjunctivitis

Why Syndromic Approach? STI sign and symptoms are rarely specific to a particular causative agent Laboratories are either non-existent or non-functional due to lack of resources Dual infections are quite common and both clinician and laboratory may miss one of them Waiting time for lab. results may discourage some patients Failure of cure at first contact

Key Features of Syndromic Management Problem oriented (responds to patient’s symptoms ) Highly sensitive and does not miss mixed infections Treats the patient at first visit Can be implemented at primary health care level Use flow charts with logical steps Provides opportunity and time for education and counseling

The Five Steps in Syndromic STI Case Management History taking and examination Syndromic diagnosis and treatment, using flow charts Education and counseling on HIV testing and safer sex, including condom promotion and provision Management of sexual partners Recording and reporting

Criteria for the selection of STI drugs Availability Low cost High efficacy (at least 95%) Acceptable toxicity and tolerance (safety) Organism resistance unlikely to develop or likely to be delayed Single dose Oral administration Not contraindicated for pregnant or lactating women.

Frequently raised issues on the syndromic approach Issues related to scientific ground It is based on wide range of epidemiological studies Validation studies have confirmed comparable accuracy of syndromic and Lab. diagnosis with limitation of syndromic management only to vaginal discharge Syndromic case management of STI in Tanzania has shown decrease transmission HIV and STI in population (MWANZA TRIAL)

Frequently raised issues on the syndromic approach Issues related to simplicity of management Simplicity allows other health workers (other than doctors) to use the approach to make a diagnosis It allows health workers more time to offer education for behavior change

Frequently raised issues on the syndromic approach Issues related to service provider’s clinical skills and experience studies have shown clinical judgment misses 50% of cases Issues related to use of multiple drugs studies have shown that it is less expensive

Frequently raised issues on the syndromic approach Issues related to treating a single pathogen causing STI based on prevalence Many patients required to return to a health centre for treatment do not do so.

Frequently raised issues on the syndromic approach Issues related to the use of simple laboratory tests such as Gram’s stain it should not be at the expense of delayed treatment or at risk of patient non return Remember that effective treatment of people with STIs is the best way of interrupting the cycle of transmission

Limitations of syndromic management Misses sub-clinical infection Needs validation study Require prior research to determine the common causes of particular syndromes Needs training

Syndromic Flow Charts A flow chart is a diagram (map) representing steps to be taken through a process of decision making Can be used at any health facility prompt treatment is provided at initial visit many people with STI have access to treatment provides opportunity for preventive and promotive measures

Each flow chart is made up of three steps The clinical problem (patient’s presenting symptom) Problem box A decision to make usually by answering yes or no to a question Decision box An action to take (what you need to do) Action box

Enlarged and Painful Inguinal Lymph nodes? Take History & Examine Ulcer (s) Present? Use Genital Ulcer Flow Chart Clinical Problem Decision Box Action Box Yes No

Key Points Most STI patients present at a primary health care facility In STI control the aim should be to give prompt effective treatment at first level of contact in the health system Treatment of STIs is not always simple or effective