MODIFIED SYNDROMIC APPROACH Dr. Nor Azah bt Mohamad Nawi Pakar Perubatan Keluarga Klinik Kesihatan Bakar Arang MSA HSB 16/08/14

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

SEXUALLY TRANSMITTED INFECTIONS MALAYSIAN GUIDELINES in the treatment of SEXUALLY TRANSMITTED INFECTIONS   FOURTH EDITION 2013

27 years old Malay man presented with urethral discharge a week after a contact with a sex worker. What worries him was his naïve wife is pregnant, their first child. They defaulted the 2nd follow-up 4 weeks later, she delivered a severely prematured baby and treated as sepsis.

Traditional diagnosis of STI Etiological diagnosis: use laboratory tests to identify the causative agent; Wait for the result before start Rx Lab tests may not be available 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

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.

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

Modified Syndromic Approach (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

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  

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 Frequency Urethral irritation 3. Genital ulcer Genital sore Genital ulcer Enlarged inguinal lymph nodes Herpes Simplex Virus Syphilis Chancroid

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

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

MSA of STI Mx Patient gives complaint History + Examination Diagnosis made Ix taken  Laboratory / Referral Lab Don’t forget: psychosocial hx, idea, concern & expectation. Future plan. Rx GIVEN @ SAME DAY - based on synd. +/- Ix TCA given , Rx reviewed

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

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

FLOW CHART FOR VAGINAL DISCHARGE SYNDROME (cont’d) Pt has LOWER ABD PAIN YES Refer to nearest hospital NO Treat for vaginitis Educate behaviour F/up for 2/52 for results NO RISK FACTORS <21 yr-old Single Recent new partner – 3/12 Multiple partner 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, HBsAg after 3/12 Notify if +ve for notifiable diseases

Treatment For Vaginal Discharge Syndrome (Cervicitis and Vaginitis) FIRST CHOICE IM Ceftriaxone 500 mg single dose PLUS Azithromycin 1.0 gm orally single dose Treatment For (CERVICITIS) 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 qid orally x 7 days Metronidazole 2 gm stat PLUS Clotrimazole pessary 200 mg od x 3/7 OR 500 mg single dose or Nystatin pessaries 100,000 u dly for 14 days On f/up if no improvement or not effective- to continue Metronidazole 400mg bd x 7 days PLUS Treatment for Vaginitis OR Treat for Vaginitis only

Meta-analyses have concluded that there is no evidence of teratogenicity from the use of Metronidazole in women during the first trimester of pregnancy. Metronidazole is 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.

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

Treatment For Urethral Discharge Syndrome Treatment For Gonorrhoea and Chlamydia FIRST CHOICE IM Ceftriaxone 500 mg single dose PLUS Azithromycin 1.0 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 qid orally x 7 days

GENITAL ULCER

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

FLOW CHART FOR GENITAL ULCER SYNDROME (cont’d) ULCER present ? NO Educate behav change TCA after 7 days for assessment and results Single painless/ multiple painful ulcers YES Painful grouped vesicles, erosions, 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, HBsAg after 3/12 Genital herpes Mx Educate for behaviour change TCA after 7 days for results Notify if +ve for notifiable diseases

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 Penicilline 2.4 million units single dose Plus IM Ceftriaxone 250 mg single dose

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.

DISCUSSION STI screening – still LOW due to low awareness, knowledge and skill among doctors and paramedics, therefore more CME, reminder and regular training are needed. Limited lab tests for STI detection at the health clinic, therefore MSA are definitely relevant.

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

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