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WHO Guide to  Syndromic  Management of Sexually Transmitted Infections WHO Guide to  Syndromic  Management of Sexually Transmitted Infections

WHO Guide to Syndromic Management of Sexually Transmitted Infections - PowerPoint Presentation

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WHO Guide to Syndromic Management of Sexually Transmitted Infections - PPT Presentation

Family Medicine CME Laos PDR November 46 2013 Objectives To recognize various sexually transmitted infections and their syndromes Urethral discharge Genital Ulcer disease Scrotal swelling Inguinal bubo ID: 785299

days orally daily discharge orally days discharge daily case chlamydia treat dose gonorrhea treatment sexual 500mg symptoms baby vaginal

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Slide1

WHO Guide to Syndromic Management of Sexually Transmitted Infections

Family Medicine CME, Laos PDR

November 4-6, 2013

Slide2

ObjectivesTo recognize various sexually transmitted infections and their syndromes:

Urethral discharge

Genital Ulcer disease

Scrotal swelling

Inguinal bubo

Vaginal discharge

Lower Abdominal Pain

Neonatal conjunctivitis

To use the WHO flow chart to guide treatment and management

Slide3

A QuizWhich are TRUE?

You are only likely to have an STI if you have symptoms

Treating STI’s that cause discharge and ulcers may reduce transmission of HIV

STI’s cannot be passed on to children in childbirth

Most people with an STI will come to the physician

Slide4

A QuizTo treat someone with urethral discharge you can use which drugs?

Metronidazole

Doxycycline

Ceftriaxone

Penicillin

Slide5

A QuizAn ulcer on the penis or labia can be caused by:

Chancroid

Gonorrhea

Syphilis

herpes

Slide6

Why Treat Sexually Transmitted Infections?

Slide7

Quality improvement with the WHO Syndromic

Approach to STI’s

Improves QUALITY by:

Expanding diagnosis and treatment, even without laboratory confirmation

Standardizing the approach across all low resource areas

Reducing transmission of other STI’s like HIV

Emphasizing accurate HISTORY, COUNSELLING and PARTNER NOTIFICATION and TREATMENT

Slide8

Case #1 – Taking A Sexual HistoryA 21yo female comes to you worried that she may have developed a sexually transmitted infection. What do you want to ask on history?

Slide9

Taking a Sexual HistoryRemember that you being comfortable asking the questions, and asking in a nonjudgemental way will allow the patient to be more open and honest.

Getting a clear history is the key to making the correct diagnosis!

Slide10

Taking a Sexual HistoryWhat are the symptoms? Discharge? Ulcers?How long have the symptoms been present?Has she had these symptoms before?

Has she ever been diagnosed with an STI before?

How long has she been with her current sexual partner?

Do they use condoms? Every time? Other contraception?

Slide11

Taking a Sexual HistoryHow many sexual partners has she had in her lifetime?Does she have sex with men, women or both?Does she ever have sex in exchange for money, drugs, or other services?When was her last period? Are they regular?

Is sex painful?

Does she have bleeding after sex?

Slide12

Taking a Sexual HistoryHow many times has she been pregnant? When was the last delivery?Does she think her partner may have other sexual partners?Etc, etc…

Slide13

Taking a Sexual HistoryAre there any other questions that you have found particularly important to ask on sexual history in Laos?

Slide14

Case #2 - Joshua Joshua is an 18yo male coming to you complaining of discharge from his penis. He also has noticed some pain with urination for the last few days.What else do you want to know?

Slide15

JoshuaHe admits to having a new sexual partner 1 week ago, and didn’t use condomsHe has noticed burning with urination (dysuria) for the last 3 daysHe had never had these symptoms before

Slide16

Slide17

JoshuaWhat organisms are most likely causing his symptoms?Does it matter if his discharge is clear or yellow?

Slide18

Causes of Urethral DischargeMost commonlyChlamydiaGonorrhea

Less likely

Trichomonas

Other bacteria

Slide19

URETHRA

L

DISCHARGE SYNDROME

Slide20

Treatment of Urethral Discharge

Gonorrhea

Chlamydia

Ciprofloxacin 500mg orally x 1 dose

Azithromycin

1g orally x 1 dose

Cefixime

400mg

orally x 1 dose

Doxycycline

100mg

orally twice daily x 7 days

Ceftriaxone

250mg IM x 1 dose

Amoxicillin 500mg orally three times daily x 7 days

Spectinomycin

2g IM x 1 dose

Erythromycin 400mg orally four time daily x 7 days

Ofloxacin

300mg orally twice daily x 7days

Tetracycline 500mg orally four times daily x 7 days

*Fluoroquinolones and tetracyclines are contraindicated in pregnancy

Slide21

More than just giving medication!Educate – on what the disease is, and how it is acquiredCounsel – on how to prevent, safe sex practicesProvide condomsOffer HIV counseling and testing

Discuss and help with partner notification and treatment

Slide22

Case #2 - JoshuaJoshua listens to your advice on safe sex practices and takes some sample condomsHe states he will advise his new partner to seek medical care to be treated (even if she has no symptoms)He agrees to HIV testing, which is negative

Slide23

23How Symptomatic are STIs?

Source: WHO HIV/AIDS/STI Initiative

Slide24

Case #3 – Joshua comes backYou saw Joshua 3 weeks ago now for urethral discharge

He was given

Azithromycin

500mg orally x 1 dose, and Ciprofloxacin 500mg orally x 1 dose

You asked him to come back after 7 days if the symptoms did not improve, but he was away working

He is now back stating that he still has discharge and burning with urination

Slide25

Case #3 – Joshua comes backWhat do you want to know now?

Slide26

Case #3 – Joshua comes backYou find out that Joshua has not been able to contact his former partner to advise her to have treatmentBUT he has not had intercourse since he took the treatment you provided, and still has urethral discharge

Slide27

N.B.

This flowchart assumes effective therapy for Gonorrhoea and Chlamydia to have been received and taken by the patient prior to this consultation.

PERSISTENT/RECURREN

T

URETHRA

L

DISCHARG

E

I

N

MEN

Slide28

Trichomonas VaginalisCommon cause of greenish, profuse vaginal discharge in womenCan be cause of discharge in menTreatment:Metronidazole 500mg orally twice daily x 7 days

Tinidazole 500mg orally twice daily x 5 days

Slide29

Case #4 - VioletViolet is a 32yo women who comes to see you about sores that itch and burn around her perineum.What else do you want to know?

Slide30

Case #4 - VioletViolet is married and has 3 children.She has had these sores before, about 1-2 episodes per year since she was in her 20’s.She has never seen a doctor about this before.

Slide31

Slide32

What are the possible causes?Herpes SimplexSyphilisChancroid

Less likely in Laos

Lymphogranuloma Venereum (LGV)

Slide33

Herpes SimplexCaused by the Herpes Simplex Virus

One of the most common causes of genital ulcers

Initially starts as grouped vesicles

These can break down to form a coalesced ulcer

The first episode is often the worst, with many lesions

Recurrences happen usually 3-4 times/year

Slide34

Herpes Simplex

Slide35

Herpes Simplex

Slide36

Herpes Simplex

Slide37

Herpes Simplex

Slide38

Herpes Simplex

Slide39

SyphilisStarts as a painless ulcer at the area of contactCan be more than one ulcerIf left untreated can develop into further stages:Primary syphilis (ulcer)

Secondary syphilis (body rash, especially hands/feet)

Latent syphilis (CNS and systemic body effects)

Slide40

SyphilisCommon cause of stillbirth and infant morbidity and mortalityImportant to treat women and their partners to prevent spread to infant

Slide41

Syphilis

Slide42

Syphilis

Slide43

ChancroidCaused by bacteria Hemophilus ducreyiPainful ulcer, that can bleed easilyMore commonly associated with sex workersCan cause inguinal lymphadenopathy that may drain pus – called Buboes

Slide44

Chancroid

Slide45

Chancroid

Slide46

Chancroid with Bubo

Slide47

1

Indications for syphilis treatment:

- RPR positive; and

-

P

atient has not been treated for syphilis recentl

y

.

2

T

reat for HSV2 where prevalence is 30% or highe

r

, or adapt to local conditions.

GENI

T

A

L

ULCER SYNDROME

Slide48

Case #4 - VioletRecurrent problem – most likely herpesTreat for Syphilis and Chancroid as wellViolet continues to take Acyclovir at the first sign of any future sores starting, and is very happy with you as the medication helps her

Slide49

Treatment of Genital Ulcers

Herpes

Syphilis

Chancroid

First Episode:

Acyclovir 400mg orally three times daily x 7 days

Benzathine

benzylpenicillin

2.4 MU IM x 1 dose

Azithromycin

1g orally

x 1 dose

Valacyclovir

1g orally twice daily x 7 days

Procaine

benzylpenicillin

1.2 MU IM daily x 10 doses

Ceftriaxone

250mg IM x 1 dose

Recurrent episode:

Acyclovir 400mg orally three times daily x 5 days

Doxycycline

100mg orally

twice daily x 15 days

Ciprofloxacin 500mg twice daily x 3 days

Valacyclovir

1g orally once daily x 5 days

Erythromycin base 500mg orally four times daily x 7 days

Slide50

Case #5 - WilliamWilliam is a 45yo man who has noticed increasing discomfort and swelling in his scrotum for the last week.

Slide51

Case #5 - William

Slide52

Scrotal swellingWhat are the common causes?Does age or sexual history make another cause more likely?

Slide53

FIGUR

E

5

.

SCRO

T

A

L

SWELLING

Slide54

Case #5 - WilliamYou find out that William, although age 45 and married, has had a new sexual partnerYou treat him for chlamydia and gonorrhea, and he improves over the next 7 days

Slide55

A QuizWhich are TRUE?

You are only likely to have an STI if you have symptoms

Treating STI’s that cause discharge and ulcers may reduce transmission of HIV

STI’s cannot be passed on to children in childbirth

Most people with an STI will come to the physician

Slide56

A QuizTo treat someone with urethral discharge you can use which drugs?

Metronidazole

Doxycycline

Ceftriaxone

Penicillin

Slide57

A QuizAn ulcer on the penis or labia can be caused by:

Chancroid

Gonorrhea

Syphilis

herpes

Slide58

BREAK

Slide59

Welcome Back

Slide60

Another QuizWhich of the following are sexually transmitted infections that cause vaginal discharge?

Trichomonas

Chlamydia

Candidiasis

Gonorrhea

Slide61

Another QuizA baby with red eyelids and pus from the eyes comes in. Which are true?

You should treat the baby with

Ceftriaxone

plus Erythromycin

You should treat the baby with

Ceftriaxone

plus TMP/SMX

You should treat the baby’s mother for

chlamydia

& gonorrhea

You should treat the baby’s father for

chlamydia

and gonorrhea

Slide62

Another quizWhat is this?

Slide63

Case #6 - Helena

Slide64

Case #6 - HelenaHelena is a 23yo prostitute, known to you from the small community you work inShe presents with lumps in her groin that are red, painful, and some of them draining pus

Slide65

Inguinal Bubo

Slide66

Causes of Inguinal BuboChancroidLymphogranuloma Venereum (LGV)Lower limb infections

Slide67

Lymphogranuloma VenereumCaused by invasive serovars of Chlamydia TrachomatisMay begin as a painless ulcer in a small number of casesBuboes begin to form within 3-30 days from exposure

Slide68

FIGUR

E

4

.

INGUINA

L

BUBO

Slide69

Aspiration of Bubo

Slide70

Treatment of Inguinal BuboTreat for both Chancroid and LGVCiprofloxacin 500mg orally twice daily x 3 days

AND

Doxycycline 100mg orally twice daily x 7 days

Slide71

Case #6 - HelenaYou treat Helena with the appropriate antibiotics for Chancroid and LGVYou also counsel her about HIV testing. She declines HIV testing

Slide72

Case #7 - SummerSummer is a 20yo newly married lady who states she has had increased vaginal discharge and discomfort for the last few weeks.What else do you want to know?

Slide73

Causes of Vaginal DischargeSexually Transmitted InfectionsChlamydiaGonorrheaTrichomonas

Non Sexually Transmitted Causes

Bacterial vaginosis

Candida

Slide74

CandidaClassic symptoms of vaginal

candida

infection

Intense itch, possible excoriations of perineum

Perineal

redness/

erythema

White, curd like vaginal discharge

More common in pregnancy, or after antibiotics

Treatment:

Clotrimazole

500mg vaginally x 1 dose

Fluconazole

150mg orally x 1 dose

Slide75

Candida

Slide76

Candida

Slide77

Bacterial VaginosisCaused by an imbalance of naturally occurring vaginal flora

Symptoms:

Mild itch

Increased white discharge

Fishy or foul smell, especially after intercourse

Treatment:

Metronidazole

2g orally x 1 dose, or

Metronidazole

500mg orally twice daily x 7 days, or

Clindamycin

300mg orally twice daily x 7 days, or

Clindamycin

or

metronidazole

gels vaginally

Slide78

Risk factors need adaptation to local social, behavioural and epidemiological situation.

1

The determination of high prevalence levels needs to be made locall

y

.

FIGUR

E

6

.

V

AGINA

L

DISCHARGE

Slide79

Case #7 - SummerWhen you examine summer, you find a thin yellow vaginal

disharge

, and no lower abdominal pain

You determine her risk

assesment

for an STI to be high, as she is 20yo and recently married so sexually active now

You prescribe treatment for

chlamydia

, gonorrhea, bacterial

vaginosis

and

trichomonas

Slide80

Case #8 – Summer, againA few weeks later, Summer comes back to see you again.She didn’t take the antibiotics you suggested last visitShe still has the vaginal discharge, but now is having lower abdominal pain and fever

What is your diagnosis now?

Slide81

Case #8 – Summer, again

Slide82

Can you do a pelvic exam and speculum exam?Doing a bimanual exam to look for cervical motion tenderness and adnexal masses

If cervical pus on speculum exam – most likely chlamydia or gonorrhea

Slide83

Cervicitis – Chlamydia and Gonorrhea

Slide84

Speculum Exam Showing Cervicitis

Slide85

Chlamydia Cervicitis

Slide86

Pelvic Inflammatory Disease

Slide87

What Organisms Cause Pelvic Inflammatory Disease?Chlamydia

Gonorrhea

Anaerobes

Wide range of other bacteria possible

Slide88

Symptoms of Pelvic Inflammatory DiseaseLower abdominal pain

Uterine tenderness on pelvic exam

Vaginal discharge and/or bleeding

Occasionally

Fever

Nausea and vomitting

Slide89

Slide90

FIGUR

E

9

.

LOWE

R

ABDOMINA

L

P

AIN

Slide91

Treatment of Pelvic Inflammatory Disease

Treat for gonorrhea,

chlamydia

and anaerobes

Ceftriaxone

250mg IM x 1 dose

PLUS

Doxycycline

100mg orally twice daily x 14 days

PLUS

Metronidazole

500mg orally twice daily x 14 days

Review patient in 3 days if treating as outpatient, if no improvement refer

Slide92

Case #9 – Baby PawA 27yo new mother brings her infant to see you as the baby has red eyes with pus coming from them.This started a few days after the birth.She has been using eye drops but it is not helping.

Slide93

Case #9 – Baby Paw

Slide94

Causes of Neonatal ConjunctivitisGonorrhea

Chlamydia

Staph

aureus

Strep species

Hemophilus

Left untreated can lead to blindness

Can often be prevented by silver nitrate eye drops, tetracycline or erythromycin eye ointment after birth

Slide95

FIGUR

E

10

.

NEON

AT

A

L

CONJUNCTIVITIS

Slide96

Treatment of Conjunctivitis in InfantsTreat for Gonorrhea and Chlamydia

Ceftriaxone 50mg/kg (max 125mg) IM injection x 1 dose

AND

Erythromycin syrup 50mg/kg/day orally, in 4 divided dose x 14 days

OR

Trimethoprim 40mg/Sulfamethoxazole 200mg orally twice daily x 14 days

Slide97

Case #9 – Baby PawYou treat Baby Paw with Ceftriaxone IM x 1 dose as well as Erythromycin syrup for 14 daysYou also treat both parents for chlamydia and gonorrheaWithin a few days the baby is looking much better

Slide98

Slide99

Another QuizWhich of the following are sexually transmitted infections that cause vaginal discharge?Trichomonas

Chlamydia

Candidiasis

Gonorrhea

Slide100

Another QuizA baby with red eyelids and pus from the eyes comes in. Which are true?

You should treat the baby with

Ceftriaxone

plus Erythromycin

You should treat the baby with

Ceftriaxone

plus TMP/SMX

You should treat the baby’s mother for

chlamydia

& gonorrhea

You should treat the baby’s father for

chlamydia

and gonorrhea

Slide101

Another quizWhat is this?

Inguinal Bubo

(likely from

chancroid

)

Slide102

ReviewThe WHO

Syndromic

Management of STI’s makes it easy to diagnose and treat even without lab services

Following the algorithm will ensure appropriate treatment for all possible infections

EDUCATION, COUNSELLING and PARTNER NOTIFICATION are essential to prevent

reinfection

Slide103

Questions?