Management of Reproductive Tract Infections/ Sexually Transmitted Infections

1. Management of Reproductive Tract Infections/ Sexually Transmitted Infections The Syndromic Approach Subodh S Gupta Dr. Sushila Nayar School of Public Health

2. STI/RTI: A Public Health Concern WHY? • Burden: • 340 million new episodes globally per year • Morbidity: • poor pregnancy outcomes • infertility in women and men • Infection in newborn babies • premature death in babies • Link with HIV: • Facilitates transmission and acquisition of HIV

3. Reproductive Tract Infections (RTI) • Iatrogenic infections • e.g. Staphylococcus aureus, Pseudomonas • Endogenous Infections • e.g. Candida albicans and bacterial vaginosis • Sexually Transmitted Infections (STI) • e.g. gonorrhoea, syphilis, herpes

4. Sexually Transmitted Diseases Symptomatic Asymptomatic

5. STI/RTI historical landmarks • Until the end of 19th century: “pre-scientific” period • 1900 to 1946: clinical and therapeutic breakthroughs • 1946 to 1965: the illusion of elimination • 1965 to 1981: the return without HIV • 1981 to 1989: HIV/AIDS epidemic, studies on STIs as facilitators of transmission • 1990 to 1997: syndromic approach revisited, more studies on STDs and transmission of HIV, intervention studies • Reproductive health concept and consensus endorsed by global community in 1994 (ICPD, Cairo) • 1998 to 2000: the need for fast and effective action • STD Policies and principles for prevention and care (1997) • Public health approach to STD control (1998) • STD Interventions for preventing HIV: what is the evidence? (2000)

6. STI transmission dynamics at population level General population Bridging population High frequency transmitters

7. STI syndromic case management: definition • Syndromic diagnosis: identification of consistent group of symptoms and easily recognised signs (syndromes) • Syndromic treatment: treat the main organisms responsible for causing the syndrome

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

9. 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

10. 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) • Lab. results often not reliable • Mixed infections often overlooked • Miss-treated/untreated infections can lead to complications and continued transmission

11. Clinical Management • Advantages:- • 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

12. 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)

13. Identifying Syndromes

14. 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

15. 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

16. Operational model of the role of health services in STI control Population with STI Aware and worried Seeking care Correct diagnosis Correct treatment Treatment completed Cure

17. 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

18. 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.

19. 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 has shown decrease transmission HIV and STI in population

20. 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

21. 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

22. 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.

23. 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

24. Objectives of an STI programme • To interrupt the transmission of sexually transmitted infections • To prevent development of disease, complications and sequelae • To reduce the risk of HIV infection • To provide appropriate antimicrobial therapy in order to: • obtain cure of infection • decrease infectiousness • To limit or prevent high risk behaviour • To ensure that sexual partners are treated in order to interrupt the chain of transmission

27. Recommended regimen Azithromycin 2G orally single dose, (for both gonococcal & chlamydial infections) Alternate regimens Option 1 Cefixime 400 mg orally, single dose, (gonococcal infection) Plus Doxycycline* 100 mg orally, twice daily for 7 days (chlamydial infection) Option 2 Inj. Ceftriaxone 250 mg I, M. single dose (for gonococcal infection) Plus Doxycycline* 100 mg orally, 2 times daily for 7 days (for chlamydial infection) *In individuals allergic/intolerant to doxycycline, Erythromycin base/stearate 500 mg orally, 4 times daily for 7 days Treat for Trichomoniasis if discharge persists even after full treatment for gonococcal and chlamydial infections.

28. IF VESICLES ARE SEEN OR/AND HISTORY OF RECURRENCES GIVEN First episode: Acyclovir 200 mg orally 5 times daily for 7 days Recurrent episodes: Acyclovir ,400 mg orally, 3 times daily for 5 days Note: There is no known cure of herpes but the course of the symptoms can be modified by acyclovir.

29. IF VESICLES ARE NOT SEEN AND NO HISTORY OF RECURRENCES GIVEN Recommended regimen Inj. benzathine penicillin,* 2.4 million units I.M, in 2 equally divided doses. Give injection in each buttock, after testing for sensitivity for penicillin (for syphilis) Plus Azithromycin 1 G, single dose, orally under supervision (for chancroid) Alternate regimen; Option 1 Inj. benzathine penicillin,* 2.4 million units I.M, in 2 equally divided doses ; give one injection in each buttock, after testing for sensitivity for penicillin (for syphilis) Plus Inj. ceftriaxone, 250 mg, single dose I.M ( for chancroid) Option 2 . (Do not use in pregnant women ) Inj. benzathine penicillin,* 2.4 million units, I.M in 2 equally divided doses. Give, one injection in each buttock, after testing for sensitivity for penicillin (for syphilis) Plus Ciprofloxacin 500mg two times a day orally for 3 days (for chancroid) *In individuals allergic/intolerant to penicillin Doxycycline 100 mg, 2 times daily, for 15 days, but in pregnant women allergic /intolerant to penicillin Erythromycin base/ stearate 500 mg, 4 times daily for 15 days. Ask these women to bring the new born baby for treatment within 7 days of birth

31. Patient complains of vaginal discharge, vulval itching or burning Take history and examine Assess risk1 • Educate and counsel • Promote condom use and provide condoms • Offer HIV counselling and testing if both facilities are available Abnormal vaginal discharge or vulval eryrthema? Any other genital disease? No No Yes Use appropriate flowchart for additional treatment Yes TREAT FOR BACTERIAL VAGINOSIS AND TRICHOMONAS VAGINALIS High GC/CT prevalence setting2 or risk assessment positive? Lower abdominal tenderness? No No Yes Yes Vulval oedema/curd-like discharge, erythema, excoriations present? Use flowchart for lower abdominal pain TREAT FOR GONOCOCCAL INFECTION, CHLAMYDIA TRACHOMATIS, BACTERIAL VAGINOSIS AND TRICHOMONAS VAGINALIS. No • Educate and counsel • Promote condom use and provide condoms • Offer HIV counselling and testing if bothfacilities are available Yes TREAT FOR CANDIDA ALBICANS 1 Risk factors need adaptation to local social, behavioural and epidemiological situation. 2 The determination of high prevalence levels needs to be made locally. Vaginal discharge Source WHO, 2003

32. Patient complains of vaginal discharge, vulval itching or burning Take history and examine patient (external, speculum and bimanual) Assess risk1 Perform wet mount microscopy of vaginal specimen for TV and yeast cells (optional) Yes Lower abdominal tenderness or cervical motion tenderness present? Use flowchart for lower abdominal pain No Cervical mucopus or erosions or High GC/CT prevalence setting2 or risk assessment positive? TREAT FOR BACTERIAL VAGINOSIS AND TRICHOMONAS VAGINALIS No • Educate and counsel • Promote condom use and provide condoms • Offer HIV counselling and testing if both facilities are available • ------------------------------------- • Manage and treat partner if cervical mucopus present • Manage and treat partner if microscopy demonstrates TV Yes Vulval oedema/curd-like discharge, vulval erythema, excoriations present or yeast cells on microscopy? TREAT FOR GONOCOCCAL INFECTION, CHLAMYDIA TRACHOMATIS, BACTERIAL VAGINOSIS AND TRICHOMONAS VAGINALIS. No Yes 1 Risk factors need adaptation to local social, behavioural and epidemiological situation 2 The determination of high prevalence levels needs to be made locally TREAT FOR CANDIDA ALBICANS Vaginal discharge: Bimanual & speculum, with or without microscope Source WHO, 2003

33. Patient complains of vaginal discharge, vulval itching or burning Take history and examine patient (external, speculum and bimanual) Assess risk1 Yes Use flowchart for lower abdominal pain Lower abdominal tenderness or cervical motion tenderness present? No Cervical mucopus or erosions or High GC/CT prevalence setting2 or risk assessment positive? No Yes TREAT FOR GONOCOCCAL INFECTION AND CHLAMYDIA TRACHOMATIS plus vaginal infection according to speculum and microscope examination findings Perform wet mount/Gram stain microscopy of vaginal specimen Clue cells seen plus pH>4.5 orKOH positive? Motile trichomonads Budding yeasts or pseudohyphae seen No abnormal findings TREAT FOR TRICHOMONASVAGINALIS TREAT FOR CANDIDA ALBICANS TREAT FOR BACTERIALVAGINOSIS Educate and counsel  Promote condom use and provide condoms  Manage and treat partner  Offer HIV counselling and testing if both facilities are available  Ask patient to return if necessary 1Risk factors need adaptation to local social, behavioural and epidemiological situation 2 The determination of high prevalence levels needs to be madelocally Vaginal discharge: Bimanual, speculum & microscope Source WHO, 2003

34. Operational model of the role of health services in STI case management Population with STI Aware and worried Seeking care Correct diagnosis • Promotion of health care seeking behaviour • Improve quality of care • Attitudes of personnel Correct treatment Treatment completed Cure

35. Operational model of the role of health services in STI case management Population with STI Aware and worried Seeking care • Syndromic approach • Include STI drugs in essential list • Prescribe single dose • Counsel about compliance Correct diagnosis Correct treatment Treatment completed Cure

36. Operational model of the role of health services in STI case management Population with STI Aware and worried asymptomatic STI Seeking care Correct diagnosis • Partner notification • Case finding • Screening • Selective mass treatment Correct treatment Treatment completed Cure