MODULE IV

SYNDROMIC MANAGEMENT
Module Objectives

Name the decisions and actions on each of the

national flow-charts
Use the national flow-charts to make a syndromic
diagnosis for a variety of STI cases
List the correct drug therapies and dosages for
each diagnosis
List STI referral centers for treatment failed
syndromes
STI syndromes
The commonly encountered STI syndromes are:
Vaginal discharge
Urethral discharge in men
Genital ulcer
Lower abdominal pain in women
Inguinal bubo
Scrotal swelling
Neonatal conjunctivitis.
Genital ulcer

4
Etiology
Vesicular
HSV2: Genital Herpes ( commonest cause of
GUD)

Non-Vesicualr
T. Pallidum: Syphilis
H. Ducreyi: Chancroid
C. Trachomatis Serovars L1-L3: LGV
[Link] (C. Granulomatis): Granuloma
ingunale
Clinical features of ulcers

Constitutional symptoms such as

fever, headache, malaise and

muscular pain
Recurrent painful vesicles and

irritations
Shallow and non-indurated
Clinical features of ulcers …
Regional lymph adenopathy

Common sites in male are glance penis,

prepuce and penile shaft

Common sites in women are vulva, perineum,

vagina and cervix and can cause occasionally

severe vulvo- vaginitis and necrotizing
cervicitis
 Complications of genital ulcer syndrome
Disease Etiology Complications

Syphilis Treponema. Secondary syphilis, Latent syphilis, Aortitis with

pallidum valvulitis, Aortic aneurysm, Gumma, Neurosyphilis

Gental. herpes Herpes simplex Recurrence, Aseptic meningitis and

virus encephalitis

Chancroid Hemoph. Penile auto-amputation

ducreyi

LGV (lymph C. trachomatis,, Genital oedema, Salphingitis,Infertility, PID

granuloma L 1,L2,L3
venereum)

Garanuloma C. Genital pseudoe-lephantiasis, inguinale

Inguinale granulomatis Adhesion, Urethral, vaginal or rectal stenosis
 Patient complains of genital sore or ulcer

Take history & examine

No •Educate on RR
Vesicular recurrent No Solitary non-recurrent • Promote &
Non-vesicular ulcer, provide condoms
Ulcers or > three ulcers
Yes Yes
Treat syphilis, chancroid, HSV2
Treat HSV2
•Educate on risk reduction
•Promote & provide condoms
•Offer HIV testing & Partner management
•Record and report

ulcers healed No
ulcers improved Refer
Yes

•Educate & provide condoms Continue Rx

•Offer HIV testing
 Recommended treatment for non -vesicular genital ulcer
Benzathine penicillin 2.4 million units
1M stat/Doxycycline (in penicillin allergy)
100 mg bid for 14 days
Plus
Ciprofloxacin 500mg bid orally for 3
days/ Erythromycin tablets 500 mg qid
for 7 days
• Plus
Acyclovir 400mg tid orally for 10 days
(or 200mg five times per day of 10 day)
Recommended treatment for vesicular, multiple first episode genital ulcer

Acyclovir 400 mg tid for 10 days.

Or
Acyclovir 200mg five times per day for 10 days
 Recommended regimens for recurrent infection
• Acyclovir, 800 mg orally, twice daily for 5 days
OR
• Acyclovir, 400mg orally, 3times daily for 5 days
OR
• Acyclovir, 200 mg orally, 5 times daily for 5 days
Urethral discharge

13
URETHRAL DISCHARGE
Causative agents
[Link] & [Link] are common
causes

Rarely other causes like M. genitalium

[Link] and Ureaplasma urealyticum
are responsible for urethritis.
...

URETHRAL DISCHARGE cont

Clinical presentations
 Burning sensation on urination & urethral
discharge are common symptoms of
urethritis in men Chlamydia
Gonorrhoea

Incubation 6 days 2-3 weeks

Dysuria 70- 40%
80%
Discharge 90% <80%
Scanty
Profuse
N.B: The clinical features of urethral discharge described for Neisseria
 URETHRAL DISCHARGE cont . . .
Complications caused by NG and CT

N. Gonorrhea N. gonorrhea or C.
• Disseminated trachomitis
gonococcal
infection (1-2%)
C. trachomitis • Epididimitis
• Urethral stricture
• Reiter's syndrome • Infertility
• Enhanced
transmission of
HIV ( five fold)
Examination of patients with urethral
discharge

The patient should not urinate for at least

2 hours before examination
Look for evidence of spontaneous
discharge and note the color, quality and
quantity of the discharge
Scant discharge may produce crusting at
the urethral meatus and meatal redness
suggestive of urethritis
If no discharge is found, the urethra
should be milked to bring the discharge
forward
Urethral discharge syndrome flow chart in men
complains of urethral discharge or dysuria

Take history & Examine [Milk urethra if necessary]

No Other  Educate on RR
Discharge present? STIs? No
 Promote &
provide condoms
Yes
Yes

Use appropriate flow

Treat for GC & CT chart
 Educate and counsel on risk
reduction
 Offer HTC
 Promote the use & provide condoms
 Partner management
 Record and reporting
 Advise to return in 7 days if
symptoms persist
Recommended treatment for urethral discharge and burning on urination

 Ceftriaxone 250mg IM stat/Spectinomycin 2

grams 1M stat
PLUS
 Azithromycin 1gm po stat/Doxycycline 100
mg po bid for 7 days/Tetracycline 500 mg qid
for 7 days/Erythromycin 500mg qid for 7 days
if the patient has contraindications for
tetracyclines (e.g. children)
 Remark: The
Ceftriaxone preferred
250mg IM stat regimen in Ethiopia
plus Azithromycin
1gm po stat
 Recurrent/Persistent Urethritis in men

 Could be due to
 Inadequate treatment or poor compliance and/or
 Re-infection (partner/s not managed)
 Persistent Urethritis after
azithromycin/doxycycline treatment might be caused
by doxycycline-resistant M. genitalium
 T. viginals is also known to cause Urethritis in men
 Infection by drug-resistant
organisms( [Link])
 Recommended treatment options for persistent
/recurrent Urethritis in men

Re-treat with initial regimen

 if non-compliant or re-exposure occurs with
due emphasis on drug compliance or partner
management
 Cover T. vaginalis and doxycycline resistant
M. genitalium
 If compliant with the initial regimen and re-
exposure can be excluded, the recommended
drug for persistent or recurrent urethral
discharge syndrome in Ethiopia is:
.
Cont.…..
 Metronidazole 2 gm p.o. stat/Tinidazole 1gm po
once for 3 days (Avoid Alcohol!)
PLUS
 Azithromycin 1 g orally in a single dose (only if
not used for initial episode)
 Referral
 If men require treatment with a new antibiotic
regimen and a sexually transmitted agent is
the suspected cause, all partners in the past 3
months before the initial diagnosis and any
interim partners should be referred for
evaluation and appropriate treatment
 Recurrent/Persistent Urethritis in men
flow chart
complains of Recurrent/Persistent Urethritis
in men
Take history & Examine [Milk urethra if necessary]

No • Educate on RR
Discharge confirmed? Other STIs? No • Promote & provide
condoms
Yes
Yes Use appropriate
Does Hx suggest poor flow chart
Yes
compliance/re-
infection • Repeat urethral discharge
treatment for gonorrhoea and
No Chlamydia
Treat for [Link] and [Link]

Yes
• Educate on RR
Educate and counsel on risk reduction Improved • Offer HTC
Offer HTC • Promote & provide
•Promote the use & provide condoms condoms
•Partner management
•Document and Record No
• Advise to return in 7 days if symptoms
persist Refer
Vaginal discharge

24
Common causes of vaginal discharge

 Gardnerella vaginalis ( bacterial vaginosis )

Candida albicans (VVC)

Trichomonas vaginalis

Neisseria gonorrhoeae

 Chlamydia trachomatis
Causes contd

Bacterial vaginosis (Gardnerella vaginalis) is

the leading cause of vaginal discharge in
Ethiopia followed by candidiasis,
trichomoniasis, gonococcal and chylamydia
cervicitis in that order
Initial evaluation of patients with
vaginal discharge include

Clinical speculum examination to determine

site of infection

Risk assessment if speculum isn't available

Risk factors for cervicitis

• Age less than 25 years

• Having multiple sexual partner in the
last
three months
• Having new partner in the last three
months
• Having ever traded for sex
Note :The presence of one or more risk
suggest cervicitis
Difference between vaginitis &
cervicitis
VAGINITIS CERVICITIS
Trichomoniasis, candidiasis, Gonorrhea & chlamydia
bacterial vaginosis

Most common cause of vaginal Less common cause of vaginai

discharge discharge
Easy to diagnose Difficult to diagnose

No major complications Major complications

Partner treatment unnecessary Partner treatment needed

except for [Link]
Complications of cervicitis and vaginitis

• PID
• Premature rupture of membrane
• Pre -term labour
• Infertility
• Chronic pelvic pain.
 VD or vulval/Itching /burning
Educate on risk reduction
Take Hx, examine patient (external, Promote & provide condoms
speculum & bimanual) & assess risk Recording and reporting

Abnormal discharge No
present?
Use LAP flowchart
Yes
Yes •Educate on risk reduction
Lower abdominal tenderness or •Promote & provide condoms
•Offer HIV testing
cervical motion tenderness • partner(s) management
•Recording and reporting
No • Advise to return in
Yes
Treat GC, CT, TV,BV 7 days if symptoms persist

Is Risk assessment +?
No Vulvar oedema/curd like
Discharge, Erythema, Excoriations Yes Treat for
present? VVC
Treat for BV,TV No
Educate, Offer HTC
Promote & provide condoms
Recording and reporting
Recommended treatment for vaginal discharge
RISK ASSESMENT POSITIVE RISK ASSESMENT NEGATIVE
Ceftriaxone 250mg IM
stat/Spectinomycin 2 gm IM
stat Metronidazole 500 mg
Plus bid for 7 days
Azithromycin 1gm po
stat/Doxycycline 100 mg po
bid for 7 days
Plus
Metronidazole 500 mg bid for If discharge is white or
7 days curd-like add
Clotrimazole vaginal
If discharge is white or curd- pessary 200 mg at bed
like add Clotrimazole vaginal time for 3 days
pessary 200 mg at bed time
for 3 days
The prefered regimen is
Ceftriaxone 250mg IM stat
 pregnant
women

• Metronidazole is not recommended for use in the

first trimester of pregnancy
• Treatment may be given where early treatment has
the best chance of preventing adverse pregnancy
outcomes
- Metronidazole, 200 or 250 mg orally, 3 times daily
for 7 days, after first trimester
- Metronidazole 2g orally, as a single dose, if
treatment is imperative during the first trimester
of pregnancy
• LOWER ABDOMINAL PAIN
LOWER ABDOMINAL PAIN
(PID)
• PID - Ascending infection of the uterus,
fallopian tubes, ovaries, &peritoneum
Sexually transmitted
Causes include [Link], [Link] &
Anaerobes i.e (poly microbial)
 Bilateral lower abdominal pain & vaginal
discharge support diagnosis
PID contd
• Other surgical and gyneycological causes
of lower abdominal pain such as appendicitis
&, ectopic pregnancy should be ruled out
• Women with HIV may have severe PID
 Diagnosis of PID

• Diagnosis is often difficult & inconsistent

clinical presentations are common
• History should include
-Erratic bleeding
- Missed period
- Recent delivery
- Miscarriage
 Diagnosis contd
• Physical examination
- Check temperature
- Palpate abdomen for tenderness, rebound
tenderness, guarding & mass
- Check for vaginal bleeding & abnormal discharge,
cervical and/or adnexal tenderness
Diagnosis contd
 Empiric treatment should be initiated in
sexually active young women and other
women at risk for STls, if the following
minimum criteria are present and no other
cause(s) for the illness can be identified:
- Uterine/adnexal tenderness or
- Cervical motion tenderness
Complications of PID

• Peritonitis and intra-abdominal abscess

• Adhesion and intestinal obstruction
• Ectopic pregnancy
• Infertility
• Chronic pelvic pain
Indications for hospitalizations in
PID
Uncertain diagnosis/Acute abdomen can not
be excluded
 Pelvic abscess is suspected
 Severe illness precludes management on an
outpatient basis
Pregnancy
The patient is unable to follow or tolerate an
outpatient regimen
The patient has failed to respond to
outpatient therapy
 PID in HIV patient
 complains of lower abdominal pain

Take history & examine (abdominal & vaginal)

cervical excitation,
•Missed/ overdue period, tenderness or Any other
•Pregnancy lower abdominal
tenderness & VD No illness?
•Recent delivery/ abortion No
/Miscarriage
• Abdominal guarding/ Yes Yes
rebound tenderness Manage
• Vaginal bleeding Treat for PID
•Abdominal mass & review in 3 days appropriately

improved? No Refer
Yes patient for
Yes
• Continue treatment admission
• Refer patient for surgical or
• Educate on RR
gynaecological assessment • Offer HTC
• set up IV line • Condom use
• Resuscitate if required •partner(s)treatment
•Recording and reporting
Recommended treatment for PID
Out patient In patent
Ceftriaxone 250 mg IM stat/ Ceftriaxone 250 mg IV/IM daily
Spectinomycin 2 gm IM stat /Spectinomycin 2 gm im bid
Plus Plus
Azithromycin 1gm po stat/Doxycycline Azithromycin 1gm po daily
tablet 100 mg po bid for 14 days /Doxycycline tablet 100 mg po bid for
Plus 14 days
Metronidazole 500 mg bid for 14 days Plus
Admit if there is no improvement within Metronidazole 500 mg bid for 14 days
72 hours or chloramphenicol 500 mg IV qid.
The prefered regimen is
Ceftriaxone 250mg IM stat
plus Azithromycin 1gm po
stat plus Metronidazole 500
mg bid for 14 days

Note: For inpatient PID, ceftriaxone, spectinomycin or

azithromycin should continue for 24hrs after the patient
remain clinically improved, after which doxycycline and
metronidazole should continue for a total of 14 days
 Scrotal swelling

• Causes depend on the age of patients

• [Link] & [Link] are common causes
in patients younger than 35 years
• Scrotal swelling in patients older than 35 years
is commonly caused by gram negative
bacteria
&TB
• Other infectious causes of scrotal swelling
could be brucellosis, mumps, onchocerciasis or
infection with W. babcrofti
Scrotal swelling

• In pre-pubertal children the usual etiology

is coliform, pseudomonas or mumps virus
• Mumps epidedimorchitis is usually noted
within a week of parotid enlargement
• Other causes of scrotal swelling
- testicular torsion
- Trauma
- Tumor
- incarcerated inguinal hernia
Complications of STI caused scrotal swelling

• Epididymitis
• Infertility
• Impotence
• Prostatitis
complains of scrotal swelling/pain

Take history and examine

•Reassure patient/educate
No •Promote and provide condoms
Swelling/pain
confirmed? •Analgesics

Yes

Testis rotated or No Treat GC & CT

elevated, or •Educate on RR
history of trauma? •Promote & provide condoms
•partner(s) management
Yes
•Offer HIV testing
Refer immediately •Recording and reporting
for surgical opinion •Review in 7 days or earlier if
necessary, if worse, refer
Recommended treatment of scrotal swelling

Ceftriaxone 250 mg IM stat/Spectinomycin

2 gm IM stat
Plus
Azithromycin 1gm po stat/Doxycycline 100
mg PO bid for 7 days/Tetracycline 500 mg
PO bid for 7 days

The prefered regimen is Ceftriaxone 250mg

IM stat plus Azithromycin 1gm po stat
Inguinal Bubo

49
Inguinal Bubo

Common causes of inguinal

bubo include
1. C. trachomatis (serovar L1, L2, and L3),
2. H. ducreyi and
3. C. granulomatis

N.B: Surgical incisions are contraindicated

and the pus should only be aspirated using a
hypodermic needle.
 complains of inguinal swelling

Take history and Examine

No No Educate on RR
Inguinal/femoral Other
STIs Condom use
bubo(s) present?
Yes Yes
Ulcer(s) present?
Yes Use appropriate flowchart
No
Rx LGV, chancroid, GI
•Educate on RR
Use GU
•Provide condoms
•partner(s) management
flowchart
•Offer HIV testing
•Reporting and recording
•Advise to return in 7days
Recommended treatment

Ciprofloxacin 500 mg bid orally for 3 days

Plus
Doxycycline 100mg bid orally for 14
days/Erythromycin 500 mg po qid for 14 days

 Note : Penicillin should be replaced with

doxycycline when we use genital ulcer flow chart to
treat bubo with ulcer or
 you can simple add Acyclovir on bubo
treatment protocol
NEONATAL CONJUNCTIVITIS
Neonatal Conjuctivitis

• Neonatal conjuctivitis (ophthalmia neonatorum)

is
defined as purulent conjuctivitis occurring in a
baby
less than one month of age.
• Sight-threatening condition
• The most important causes are gonorrhoea and
chlamydia
• If caused by gonorrhoea, blindness often follows
Contd.

• In developing countries, gonorrhoea

accounts for 20 - 75% and chlamydia for 15-
35% of cases of Neonatal conjuctivitis
• Common presentation are redness, swelling
of the eye lid &discharge from the eye (sticky
eye)
• For babies older than one month, the cause
is
unlikely to be an STI
Prevention of neonatal conjuctivitis

• As soon as the baby is born, carefully wipe

both eyes with dry, clean cotton wool;
• Then apply 1 % tetracycline eye ointment
into the infant's
eyes
 Neonate with eye discharge

Take history and Examine

•Reassure mother
No •Advise to return if
Bilateral or unilateral necessary
swollen eyelids with
purulent discharge

Yes
Yes
Rx child for GC & Chlamydia
Rx the mother and partner(s) for
for GC & Chlamydia Improved
•For the mother and partner (s) only:
• Educate on RR
No
• Provide condoms Refer
• Offer HIV testing
• Advise to return in 3days
Recommended treatment for neonatal
conjuctivitis

SYNDROME TREATMENT
Neonatal conjuctivitis Ceftriaxone 50mg/kg IM stat-
maximum dose 125
mg/Spectinomycin 25 mg/kg IM
stat- maximum dose 75mg
Plus
Erythromycin 50 mg/kg PO in four
divided doses for 14days
REMARKS ON DRUGS USED FOR
TREATMENT OF STls
Remarks on Drugs Used for Treatment
of STIs
 Combination of ceftriaxone with azithromycin is
the preferred regimen to treat syndromes
caused by [Link] and C. trachomatis:
 Both drugs act on [Link] which the most
resistant STI causing organism
 Azithromycin delay resistance of [Link] to
ceftriaxone
 Stat treatment
Remarks on Drugs Used for
Treatment of STIs
ERYTHROMYCIN should be taken in
empty stomach because bio availability
is affected by food, GI upset is
recognized side effect
CIPROFLOXACIN should not be given to
pregnant women or children
SPECTINOMYCIN could cause renal
damage
Metronidazole avoid alcohol
Metronidazole decrease alcohol elimination
by the liver ( disulfiram like effect)
Remarks on Drugs Used for Treatment
of STIs

 DOXY CYCLIN & TETRACYCLIN contraindicated

in pregnant women &children ( not
recommended for < 8 years of age)

 TETRACYCLIN should not be taken with milk

 ACYCLOVIR the only drug available for

treatment of herpes in Ethiopia, it is safe & can
be used during pregnancy.
 Acyclovir cream is not effective for treatment
genital herpes
FOLLOW UP VISIT FOR PATIENTS
WITH STI
Follow up visit for patients with STIs
Importance of follow up visit
Some patients may not respond to initial
treatment &reassessment may be needed to
R/o re-infection, persistence or treatment
failure or Misdiagnosis
The response to treatment may not be
dramatic with concomitant HIV
HTC could be offered during follow up visit
Give opportunity to reassess on risk
reduction
To ensure partner/s treatment
Treatment failure
If patient didn’t respond to the initial treatment
it is good to rule out possible re-infection,
treatment incompliance, treatment failure and
misdiagnosis.
Once re-infection, treatment incompliance are
ruled out then patient should be work up in line
with treatment failure using etiologic approach
especially for Neisseria gonorrhea resistance
using culture and sensitivity
For other STI causing microorganisms since
there is no culture and sensitivity, only
etiological identification is enough.
 Diagnostic modalities

Organism Golden standard Confirmatory

[Link] Culture PCR ( polymerase chain reaction)

[Link] PCR PCR

[Link] Wet mount PCR

Syphylis TPHA ( treponemal hemoagglutinin test)

Do you have these laboratory services in your facility ?

N.B : Diagnostic labs for STI etiologies are highly sophisticated and costly and are not available in in
majority of the facilities
Diagnostic modalities
The golden standard diagnostic modalities
for STI are highly expensive and almost
inaccessible at facilities level
All facility are expected to send sample to
their nearby facility or regional laboratory
where this facilities can be given for patient
suspected with syndromic treatment failure
Location of Laboratories
 Currently Culture and sensitivity tests for
Neisseria gonorrhea are currently available
 Addis Ababa – EPHI, Zewditu memorial hospital Yekatit 12
Hospital, Black lion Hospital,
 Oromia – Adama regional lab, Nekemt regional lab and
Jimma Hospital, Metu regional lab
 Amhara – Bahrdar regional lab, Dessie regional lab and
Gondar university hospital
 Tigray – Mekele regional lab
 SNNP R– Hawassa regional lab, Arbaminch regional lab,
Hosaena regional lab, and Mizan tepi hospital
 Harrari – Harar regional lab
Location of Laboratories
Currently Culture and sensitivity tests for
Neisseria gonorrhea are available only at
some private facilities and regional
laboratories while PCR is only available at
EPHI and few private setup
Misdiagnosis
Sometimes other gynecological,
dermatological, surgical and medical
disorder can be misdiagnosed as STI
syndromes and it will be wise to consider if
patients fails to syndromic management.
Therefore, patient should be
workup/referred for non STI cause in
parallel with treatment failure workup
Time for case discussion 4.1