1. INTRODUCTION TO SYNDROMIC MANAGEMENT OF STIs

2. 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

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

4. 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

5. 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)

6. 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

7. 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

8. 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)

9. 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

10. 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

11. 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

12. 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

13. 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.

14. 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)

15. 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

16. 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

17. 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.

18. 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

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

20. 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

21. 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

22. 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

23. 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