International Journal of Antimicrobial Agents 24S (2004) S4S7

Management of vaginal discharge syndrome:

how effective is our strategy?
Prashini Moodley

, A.W. Sturm
Department of Medical Microbiology, Nelson R. Mandela School of Medicine, University of Natal, Durban, South Africa
Abstract
Although syndromic management of sexually transmitted diseases in highly endemic areas provides a short-term benet to the individuals
treated, it has no impact on decreasing prevalence rates. The numerous factors that contribute to this are discussed. Rapid reinfection from a
large pool of infected symptomatic and asymptomatic individuals as well as the non-specic nature of presenting symptoms in women with
vaginal discharge syndrome are major causes.
2004 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved.
Keywords: Vaginal discharge syndrome; Symptom recognition; Condoms
1. Introduction
Sexually transmitted infections (STIs) are caused by
micro-organisms that are fastidious in nature and therefore
need intimate contact between individuals for transmission.
Since these infections have only one host, i.e. man, and no
extra-corporal reservoir, they are in principle, ideal candi-
dates for elimination. However efforts to this end have been
largely neglected. This lack of attention stemmed from the
premise that only certain, already marginalised population
groups, based on behaviour, race, social status and occupa-
tion, were at risk for contracting STIs. As a result of this
social stigmatisation, these infections were placed lower
on the ladder of health priorities. Curable STIs therefore
continue to be a large public health problem especially in
resource poor settings.
Although STIs deserve effective treatment, little attention
was paid to their management prior to the HIV era. The pub-
lic health importance of STIs has however, been increasingly
underscored over the past decade with numerous studies pro-
viding epidemiological [14] and biological [57] evidence
that implicate STIs as co-factors in the sexual transmission
of HIV. It has been suggested that in resource-poor settings,
where access to effective management strategies for HIV
infection is unaffordable, successful management of symp-
tomatic STIs (STDs) may reduce transmission of HIV. In

Corresponding author. Tel.: +27-31-2604395; fax: +27-31-2604431.

E-mail address: moodleyp@nu.ac.za (P. Moodley).
such countries, treatment of symptomatic STIs together with
the promotion of condom use is seen as an affordable means
of controlling the spread of HIV [4,810].
2. Why syndromic treatment of STDs?
The classic approach to STD case management has been
fraught with problems. Studies have repeatedly underscored
the inaccuracies associated with linking clinical observations
with aetiological diagnosis. This is compounded by the fact
that patients often present with multiple infections. In ad-
dition, in resource poor settings the diagnosis of STDs has
been hampered by the lack of trained health care personnel
and appropriate laboratory support. Classic laboratory di-
agnosis requires staff that is properly trained to collect the
required specimens. The fastidious nature of the pathogens
requires transport under optimal conditions. Detection is
labour intensive and slow, resulting in delay in obtaining
results and treatment. Although the newer PCR-based tests
may improve sensitivity, and collection and transport of
specimens are less demanding, these tests are expensive and
require specialised laboratory facilities and trained person-
nel. For the want of an appropriate point-of-care test with
reasonable sensitivity and specicity to detect the common
STI pathogens, the World Health Organisation (WHO) in-
troduced various guidelines for the syndromic treatment of
symptomatic patients [11]. The syndromic approach uses
clinical algorithms so designed that primary health care
0924-8579/$ see front matter 2004 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved.
doi:10.1016/j.ijantimicag.2004.02.003
P. Moodley, A.W. Sturm/ International Journal of Antimicrobial Agents 24S (2004) S4S7 S5
nurses in resource poor settings may arrive at an appropriate
clinical diagnosis based on a patients symptoms and clinical
signs. The clinical diagnosis is then linked to a predened
antimicrobial prescription in which drugs that have shown
efcacy against the different STI pathogens in clinical trials
are advised.
3. How simplistic is the syndromic management of
vaginal discharge syndrome?
The ultimate objective of the syndromic management
strategy is to reduce the load of sexually transmitted infec-
tions, and hence HIV transmission. This strategy is multi-
faceted and includes the recognition of symptoms by the
patient and an effective treatment regime that comprehen-
sively covers the possible aetiological agents for a dened
syndrome. The strategy also includes the appropriate health
seeking behaviour of infected individuals, recognition of
syndromes by the health care worker, partner management
(notication and treatment), behavioural counselling and
promotion of condom use. Understanding the complexity
of sexual networking and transmission dynamics is part
of such a strategy. Although the rationale and design of
syndromic case management appears simplistic, it is by no
means easy to implement.
4. The burden of disease in KwaZuluNatal, South
Africa
4.1. Introduction of syndromic management
In 1995, the Department of Health for KwaZuluNatal
adopted and modied the WHO guidelines for the treatment
of symptomatic STIs in the region. Vaginal discharge syn-
drome is treated with a stat dose of 250 mg ciprooxacin
plus doxycycline 100 mg twice daily for 7 days. This is sup-
plemented with metronidazole 2 g (stat) in the non-pregnant
female. If pelvic inammatory disease is suspected, the dose
of metronidazole increases to 400 mg thrice daily for 5 days.
During pregnancy, these drugs are replaced by ceftriaxone
125 mg intramuscularly (stat) and erythromycin 500 mg four
times daily for 7 days. Spectinomycin replaces ceftriaxone
in cases of -lactam hypersensitivity.
4.2. The impact of syndromic management on the burden
of STIs
The ultimate objective of syndromic management guide-
lines is to eradicate/reduce the load of STIs by preventing
transmission. Although these guidelines have been in place
for 7 years, STD control in KwaZuluNatal has been per-
ceived as being far from optimal with the area having one
of the highest HIV and STI prevalence rates in the world.
A comparison of prevalence rates of STIs between ante-
Table 1
Prevalence (%) of non-ulcerative STIs and bacterial vaginosis among
antenatal clinic attendees in KwaZuluNatal in 1995 and 2001
1995 2001
Neisseria gonorrhoeae 3 4
Chlamydia trachomatis 9 9
Trichomonas vaginalis 21 18
Bacterial vaginosis 52 48
HIV 20 38
natal clinic attendees in 1995 and 2001 show a stable re-
lationship despite syndromic management being instituted,
while the HIV seropositivity doubled (Table 1). The pos-
sible reasons for stable prevalence rates of an infection in
any population include effective transmission that occurs be-
fore the infected individual seeks treatment, lack of symp-
tom recognition by infected individuals, high prevalence of
asymptomatic but transmissible disease, and microbiological
failure of the treatment.
4.3. Reasons for stable prevalence rates of STIs in
KwaZuluNatal
4.3.1. A highly endemic disease and reinfection
In the Hlabisa district, STIs are highly endemic. The
prevalence of STIs and bacterial vaginosis among STDclinic
attendees when compared with antenatal clinic attendees was
similar (Table 2), with about 50% of women having at least
one of the STIs.
The results of a recent study [12], in conjunction with a
previous report [13], imply that about 20% of female STD
clinic attendees become rapidly reinfected (within 7 days),
after successful drug treatment for Neisseria gonorrhoeae
infection.
4.3.2. Condom use
Since the introduction of syndromic management for sex-
ually transmitted diseases in 1995, condoms are free and
widely available. However, as is the case in most develop-
ing countries condom use is not easily accepted [14]. The
reasons for this remain obscure. There is some evidence to
suggest that the low acceptance may be due to health care
workers failing to educate and offer condoms. In addition,
condoms are thought to promote a negative image among
traditional rural folk.
Table 2
Comparison of the prevalence (%) of STIs and bacterial vaginosis among
STD and antenatal clinic attendees
STD clinic
(n = 209)
Antenatal clinic
(n = 245)
P
All STIs 48 44 0.3
Neisseria gonorrhoeae 12 7 0.07
Chlamydia trachomatis 15 11 0.3
Trichomonas vaginalis 28 20 0.7
Bacterial vaginosis 36 32 0.4
S6 P. Moodley, A.W. Sturm/ International Journal of Antimicrobial Agents 24S (2004) S4S7
4.3.3. Partner notication and treatment
The treatment of partners of infected patients serves two
purposes: it prevents reinfection of the original patient and
the spread of STIs in the community. In South Africa no-
tication is attempted via the index case. This is often not
accomplished due to various social consequences, including
embarrassment, fear of violence and conict within a rela-
tionship. The number of current sexual partners as well as
the casual nature of a relationship may also impact on part-
ner treatment rates [15].
The rate of partner notication and treatment during rou-
tine surveillance at a health facility in the Hlabisa district
revealed that only around 5% of asymptomatic partners of
index cases are treated. In a controlled study, setting where
301 female patients on days 3, 5, 7 and 14 following initial
syndromic treatment for vaginal discharge disease were fol-
lowed, it was found that the rate of partner notication with
treatment increased from 5% in the routine clinic setting to
12% in the research setting. An unresolved question is which
level of effective partner treatment is needed to impact on
transmission.
4.3.4. Poor symptom recognition
Pivotal to the success of syndromic management is the
recognition of symptoms by the patient and infection signs
by the health care provider. In our setting, a large percent-
age of these infections in women either go untreated or are
treated after a substantial delay. This is largely attributed to
the high frequency of asymptomatic or unrecognised infec-
tions. Approximately 25% of women in rural South Africa
have an STI and that less than 10% of these infections are
appropriately treated.
While the accuracy of recognition of the male discharge
and genital ulcer syndromes is high, this is signicantly less
for the female discharge syndrome. Symptoms and signs
of this syndrome can be divided as discharge from vagina
and/or cervix, dysuria, vulvo-vaginal itch and lower abdom-
inal pain. Women with a discharge STI can present with one
or a combination of these symptoms. Since each of these is
non-specic, it is not always easy for the patient or health
care worker to decide that there is an abnormal situation.
The patient may be asymptomatic, may be symptomatic but
may not recognise the symptoms as being abnormal, or the
symptoms may be completely unrecognised.
Hence, syndromic management of female discharge may
fail because the syndrome is not recognised and continued
transmission occurs.
The WHO guidelines state that a patient who presents
with vaginal discharge has to be examined by a health care
worker to conrm the presence of the discharge before treat-
ment. However, given the high prevalence rates in our area
and the problems with diagnosis of this syndrome, we have
recommended that the WHO guidelines be modied for a
local setting. All patients who present with symptoms of
this syndrome will be examined to exclude any other abnor-
mality, and will be treated for vaginal discharge syndrome
regardless of whether the health care worker conrms the
presence of a discharge or not.
4.3.5. Efcacy of antimicrobials used in syndromic
management
N. gonorrhoeae easily lends itself to antimicrobial sus-
ceptibility testing and is therefore commonly studied. In our
area the MIC
90
of ciprooxacin for isolates 0.015 mg/l
[16,17], and the patients whose isolates showed increased
MICs did not result in clinical failure [18]. These results sug-
gest that the high, stable prevalence rates of STIs in our set-
ting reects reinfection after effective treatment rather than
treatment failure.
4.4. Risk assessment
The main advantage of syndromic management is that
the patient receives effective treatment at the rst visit for
the common causes of the presenting symptom. A major
concern is over-treatment and its related development of
antimicrobial resistance.
This is particularly a problem in management of vaginal
discharge since the cause may be of a non-STI nature, may
be an STI of cervical origin or it may be an STI of vaginal
origin. In an attempt to differentiate cervical from vaginal
infections, risk assessment scores have been used in some
settings. The potential advantage of such an approach is that
the number of antimicrobials prescribed for this syndrome is
decreased by two in patients with a purely vaginal aetiol-
ogy that manifests in discharge. However, although this ap-
proach may work in low-prevalence areas, it has been shown
to be largely ineffective [19]. In our area where the preva-
lence of STIs are similar among STD clinic attendees and
antenatal clinic attendees (Table 2), and where mixed infec-
tions are common, the sensitivity and specicity of risk as-
sessments is too low to warrant implementation. This prac-
tice is therefore discouraged.
5. Conclusion
Syndromic management is currently the best approach for
the management of sexually transmitted infections in de-
veloping countries. However, our results on the efcacy of
syndromic management for vaginal discharge disease, raise
concerns about the effectiveness of this approach against
a background where STIs have reached epidemic propor-
tions and the majority of infections go unrecognised and un-
treated, and those that are treated become rapidly reinfected.
Although syndromic management of vaginal discharge syn-
drome may be effective in the individual, it does not limit
the spread of disease in high prevalence areas. A priority
should therefore be an attempt to decrease the overall burden
of STIs in the area, thus making the epidemic manageable.
In this regard, a properly conducted round of mass treatment
in conjunction with improved community health and health
P. Moodley, A.W. Sturm/ International Journal of Antimicrobial Agents 24S (2004) S4S7 S7
care delivery, may turn the ineffective syndromic approach
in high prevalence communities, into an effective one.
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