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
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Slide1
WHO Guide to Syndromic Management of Sexually Transmitted Infections
Family Medicine CME, Laos PDR
November 4-6, 2013
Slide2ObjectivesTo 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
Slide3A 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
Slide4A QuizTo treat someone with urethral discharge you can use which drugs?
Metronidazole
Doxycycline
Ceftriaxone
Penicillin
Slide5A QuizAn ulcer on the penis or labia can be caused by:
Chancroid
Gonorrhea
Syphilis
herpes
Slide6Why Treat Sexually Transmitted Infections?
Slide7Quality 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
Slide8Case #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?
Slide9Taking 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!
Slide10Taking 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?
Slide11Taking 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?
Slide12Taking 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…
Slide13Taking a Sexual HistoryAre there any other questions that you have found particularly important to ask on sexual history in Laos?
Slide14Case #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?
Slide15JoshuaHe 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
Slide16Slide17JoshuaWhat organisms are most likely causing his symptoms?Does it matter if his discharge is clear or yellow?
Slide18Causes of Urethral DischargeMost commonlyChlamydiaGonorrhea
Less likely
Trichomonas
Other bacteria
Slide19URETHRA
L
DISCHARGE SYNDROME
Slide20Treatment 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
Slide21More 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
Slide22Case #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
Slide2323How Symptomatic are STIs?
Source: WHO HIV/AIDS/STI Initiative
Slide24Case #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
Slide25Case #3 – Joshua comes backWhat do you want to know now?
Slide26Case #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
Slide27N.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
Slide28Trichomonas 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
Slide29Case #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?
Slide30Case #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.
Slide31Slide32What are the possible causes?Herpes SimplexSyphilisChancroid
Less likely in Laos
Lymphogranuloma Venereum (LGV)
Slide33Herpes 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
Slide34Herpes Simplex
Slide35Herpes Simplex
Slide36Herpes Simplex
Slide37Herpes Simplex
Slide38Herpes Simplex
Slide39SyphilisStarts 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)
Slide40SyphilisCommon cause of stillbirth and infant morbidity and mortalityImportant to treat women and their partners to prevent spread to infant
Slide41Syphilis
Slide42Syphilis
Slide43ChancroidCaused by bacteria Hemophilus ducreyiPainful ulcer, that can bleed easilyMore commonly associated with sex workersCan cause inguinal lymphadenopathy that may drain pus – called Buboes
Slide44Chancroid
Slide45Chancroid
Slide46Chancroid with Bubo
Slide471
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
Slide48Case #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
Slide49Treatment 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
Slide50Case #5 - WilliamWilliam is a 45yo man who has noticed increasing discomfort and swelling in his scrotum for the last week.
Slide51Case #5 - William
Slide52Scrotal swellingWhat are the common causes?Does age or sexual history make another cause more likely?
Slide53FIGUR
E
5
.
SCRO
T
A
L
SWELLING
Slide54Case #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
Slide55A 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
Slide56A QuizTo treat someone with urethral discharge you can use which drugs?
Metronidazole
Doxycycline
Ceftriaxone
Penicillin
Slide57A QuizAn ulcer on the penis or labia can be caused by:
Chancroid
Gonorrhea
Syphilis
herpes
Slide58BREAK
Slide59Welcome Back
Slide60Another QuizWhich of the following are sexually transmitted infections that cause vaginal discharge?
Trichomonas
Chlamydia
Candidiasis
Gonorrhea
Slide61Another 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
Slide62Another quizWhat is this?
Slide63Case #6 - Helena
Slide64Case #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
Slide65Inguinal Bubo
Slide66Causes of Inguinal BuboChancroidLymphogranuloma Venereum (LGV)Lower limb infections
Slide67Lymphogranuloma 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
Slide68FIGUR
E
4
.
INGUINA
L
BUBO
Slide69Aspiration of Bubo
Slide70Treatment of Inguinal BuboTreat for both Chancroid and LGVCiprofloxacin 500mg orally twice daily x 3 days
AND
Doxycycline 100mg orally twice daily x 7 days
Slide71Case #6 - HelenaYou treat Helena with the appropriate antibiotics for Chancroid and LGVYou also counsel her about HIV testing. She declines HIV testing
Slide72Case #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?
Slide73Causes of Vaginal DischargeSexually Transmitted InfectionsChlamydiaGonorrheaTrichomonas
Non Sexually Transmitted Causes
Bacterial vaginosis
Candida
Slide74CandidaClassic 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
Slide75Candida
Slide76Candida
Slide77Bacterial 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
Slide78Risk 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
Slide79Case #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
Slide80Case #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?
Slide81Case #8 – Summer, again
Slide82Can 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
Slide83Cervicitis – Chlamydia and Gonorrhea
Slide84Speculum Exam Showing Cervicitis
Slide85Chlamydia Cervicitis
Slide86Pelvic Inflammatory Disease
Slide87What Organisms Cause Pelvic Inflammatory Disease?Chlamydia
Gonorrhea
Anaerobes
Wide range of other bacteria possible
Slide88Symptoms of Pelvic Inflammatory DiseaseLower abdominal pain
Uterine tenderness on pelvic exam
Vaginal discharge and/or bleeding
Occasionally
Fever
Nausea and vomitting
Slide89Slide90FIGUR
E
9
.
LOWE
R
ABDOMINA
L
P
AIN
Slide91Treatment 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
Slide92Case #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.
Slide93Case #9 – Baby Paw
Slide94Causes 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
Slide95FIGUR
E
10
.
NEON
AT
A
L
CONJUNCTIVITIS
Slide96Treatment 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
Slide97Case #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
Slide98Slide99Another QuizWhich of the following are sexually transmitted infections that cause vaginal discharge?Trichomonas
Chlamydia
Candidiasis
Gonorrhea
Slide100Another 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
Slide101Another quizWhat is this?
Inguinal Bubo
(likely from
chancroid
)
Slide102ReviewThe 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
Slide103Questions?