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Peranan STI dalam Perebakan Jangkitan HIV

DR. ISKANDAR FIRZADA B. OSMAN Family Medicine Specialist Klinik Kesihatan Jaya Gading

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Modified Syndromic Approach (MSA)
DR. ISKANDAR FIRZADA B. OSMAN Family Medicine Specialist Klinik Kesihatan Jaya Gading

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Preliminary
   

More than 20 sexually transmitted infections (STI). Main infection via unprotected sexual intercourse. Infection via transplacental; intrapartum; breast milk. Epidemiology – true incidence is skewed; under reporting.

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Preliminary

Treatment for sexually transmitted infections (STI);  Base on aetiology.  Provided in specialist clinic in hospital. 1999 (WHO) introduced the Syndromic Approach; Modified Syndromic Approach – MSA (Malaysia);  Multiple aetiology share similar symptoms.  Multiple infections in STI.  Drugs efficacy.

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Preliminary

Incomplete treatment for STI would results in;  Drug resistance organism.  STI complications.  Unwanted effect to fetus, e.g. blindness in congenital syphilis.  Persistent infection and reinfection.

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Objective
General Objective  To effectively prevent & control sexually transmitted infections (STI). Specific Objectives 1. To ensure patient received prompt & efficient treatment. 2. To provide client-friendly services. client3. To enhance the awareness on sexually transmitted infections (STI) & the risk of infecting one, therefore, encouraging patient to utilise services renders.

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The Syndrome
Syndrome Male
Urethral discharge  Persistent urethral discharge
 

Disease
Gonorrhoea & chlamydia

Female

Lower abdominal pain / discomfort  Vaginal discharge

Gonorrhoea, chlamydia & bacterial vaginosis  Cervicitis: Gonorrhoea & chlamydia  Vaginitis: Trichomoniasis & candidiasis
 

Male & Female

Genital ulcer Conjuctival discharge

Syphilis, chancroid & herpes genitalis Ophthalmia neonatorum

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Neonate

Advantages
1. Treating multiple infections at one time. 2. Treatment start at first visit. 3. Client-friendly services. Client4. Health promotion & counseling. 5. Reducing risk of complication & co -infection. co6. Minimal laboratory investigations. 7. Enable the paramedic to manage the patient.

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First Visit

Patient
Registration Medical Assistant (MA) / Public Health Nurse (PHN) History & Physical Examination Treatment Card MSA 1

Complication? NO
Treat according to Syndrome:

YES

Refer

Genital Ulcer / Vaginal Discharge / Urethral Discharge / Persistent Urethral Discharge 1. Investigations 2. Treatment Card MSA 2 3. Notification Form 4. Contact tracing by Health Inspector

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TCA 2 weeks for follow-up follow-

FollowFollow-up Visit

Registration

Medical Assistant (MA) / Public Health Nurse (PHN) 1. 2. 3. Patient’s status & investigation’s result Notify via Notification Form (if necessary) Treatment Card MSA 2

Symptom? YES
1. 2. Repeat treatment & investigation TCA 2 weeks for follow-up follow-

NO

Discharge

Symptom? NO Discharge

YES

Refer

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Vaginal Discharge Syndrome

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Symptoms of abnormal vaginal discharge History & Physical Examination (Treatment Card MSA 1)

Abnormal vaginal discharge?

NO

Counseling & Health Promotion

YES
Lower abdominal pain?

YES

Refer to hospital

NO
Risk assessment: Partner having symptom? Or Risk factor?

NO

1. 2. 3.

Treat as VAGINITIS Advice healthy lifestyle TCA 2 weeks (review investigation)

YES
1. 2. 3. 4. 5. 6. 7. Treat as CERVICITIS & VAGINITIS Advice healthy lifestyle Counseling Promote and/or supply condom Treat partner TCA 7 days Treatment Card MSA 2 & Notification Form

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Risk Factors
1. Age < 21 years old 2. Single 3. Having new sexual partner within last 3 months 4. Having multiple sexual partners

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Laboratory Investigations
1. Vaginal swab a. Wet mount for Trichomonas vaginalis b. Gram stain for Candida albicans & ‘clue cells’ 2. Cervical swab a. Gram stain for Gonococci & pus cell b. Culture for Gonococci (AMIE's charcoal transport media) 3. VDRL; TPHA; EIA HIV 4. Pap smear

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Treatment
Cervicitis  1st Choice Oral Azithromycin 1 gm STAT  2nd Choice IM Ceftriaxone 250 mg STAT & Oral Doxycycline 100 mg BD x 10 – 14 days  3rd Choice IM Ceftriaxone 250 mg STAT & Oral Erythromycin 800 mg BD x 10 – 14 days

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Treatment
Vaginitis Oral Metronidazole 2 gm STAT & Nystatin Pessaries 100,000 unit daily x 14 days OR Clotrimazole Pessaries 200 mg daily x 3 days

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Urethral Discharge Syndrome & Dysuria (Male)

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Symptoms of urethral discharge or dysuria History & Physical Examination (Treatment Card MSA 1)

YES

Discharge?

NO

YES

TwoTwo-glass urine test positive?

NO YES
Treat as GONORRHOEA & CHLAMYDIA 1. 2. 3. 4. Advice healthy lifestyle Treat partner TCA 2 weeks (review investigations); test of cure (repeat Gram stain & culture for GC) TCA 1 week; review test of cure & treat according to 1. aetiology 2. Treatment Card MSA 2 & Notification Form Ulcer present?

NO

Refer Flow Chart Genital Ulcer
Counseling & health promotion TCA 2 weeks (review investigation)

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Laboratory Investigations
1. Urethral smear a. Gram stain for Gonococci & pus cell b. Culture for Gonococci (AMIE’s charcoal transport media) 2. Two-glass urine test Two3. VDRL; TPHA; EIA HIV

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Treatment
Gonorrhoea & Chlamydia  1st Choice Oral Azithromycin 1 gm STAT  2nd Choice IM Ceftriaxone 250 mg STAT & Oral Doxycycline 100 mg BD x 10 – 14 days  3rd Choice IM Ceftriaxone 250 mg STAT & Oral Erythromycin 800 mg BD x 10 – 14 days

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Treatment
Gonorrhoea & Chlamydia IF Ceftriaxone & Azithromycin NOT available  1st Choice IM Spectinomycin 2 gm STAT & Oral Doxycycline 100 mg BD x 10 – 14 days  2nd Choice IM Spectinomycin 2 gm STAT & Oral Erythromycin 800 mg BD x 10 – 14 days

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Persistent Urethral Discharge Syndrome (Male)

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Symptoms of persistent urethral discharge / dysuria History & Physical Examination (Treatment Card MSA 1) Discharge?

NO YES

1. 2. 1. 2. 3.

Health promotion Refer Dermatologist Repeat treatment Treat partner Health promotion

YES
Reinfection or NonNon-compliance?

NO
1. 2. 3. 4. 5. 6. 7. Treat as Trichomonas vaginalis & Ureaplasma urealyticum Advice healthy lifestyle Counseling Promote and/or supply condom Treat partner TCA 7 days Notification Form 1. 2. 3. Advice healthy lifestyle Counseling Promote and/or supply condom

Getting better?

YES

NO

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Refer to hospital

Laboratory Investigations
1. Urethral smear a. Gram stain for Gonococci & pus cell b. Culture for Gonococci (AMIE’s charcoal transport media) 2. Two-glass urine test Two3. VDRL; TPHA; EIA HIV

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Treatment
Trichomoniasis & Ureaplasma urealyticum  1st Choice Oral Azithromycin 1 gm STAT  2nd Choice IM Ceftriaxone 250 mg STAT & Oral Doxycycline 100 mg BD x 10 – 14 days  3rd Choice IM Ceftriaxone 250 mg STAT & Oral Erythromycin 800 mg BD x 10 – 14 days

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Treatment
Trichomoniasis & Ureaplasma urealyticum IF Ceftriaxone & Azithromycin NOT available  1st Choice IM Spectinomycin 2 gm STAT & Oral Doxycycline 100 mg BD x 10 – 14 days  2nd Choice IM Spectinomycin 2 gm STAT & Oral Erythromycin 800 mg BD x 10 – 14 days

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Genital Ulcer Syndrome

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Symptoms of genital ulcer History & Physical Examination (Treatment Card MSA 1) Ulcer / Vesicle?

NO

1. 2. 3.

Health promotion Counseling VDRL; TPHA; EIA HIV

YES
TCA 2 weeks (review investigations)

Ulcer & no vesicle

Small ulcer & vesicle

Refer to M&HO or FMS; treat as HERPES GENITALIS
1. 2. 3. 4. 5. 6. Treat as SYPHILIS & CHANCROID Advice healthy lifestyle Treat partner FollowFollow-up treatment for confirm SYPHILIS If initial investigations negative; repeat VDRL; TPHA; EIA HIV after 3 months Notification Form

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Laboratory Investigations
1. 2. 3. 4. Dark ground microscopy Gram stain for Haemophilus ducreyi Tzank smear for multinucleated giant cells VDRL; TPHA; EIA HIV

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Treatment
Syphilis & Chancroid  1st Choice IM Benzathine Penicillin 2.4 mega unit weekly x 2 weeks & Oral Azithromycin 1 gm STAT  2nd Choice IM Benzathine Penicillin 2.4 mega unit weekly x 2 weeks & IM Ceftriaxone 250 mg STAT

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Treatment
Syphilis & Chancroid
 NOTE 1. If patient developed allergic reaction to the first dose of Benzathine Penicillin, DO NOT proceed with the second dose. 2. If patient allergic towards penicillin, use alternative; Oral Doxycycline 100 mg BD x 14 days OR Oral Erythromycin 800 mg BD x 14 days 3. Oral Doxycycline is contraindicated in pregnancy & during lactation. 4. If pregnant mother is treated with erythromycin, the baby must be treated as congenital syphilis according to CPG.

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Neonatal Conjunctivitis Syndrome

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Sign of eye discharge (neonate) History & Physical Examination (Treatment Card MSA 1) Refer to M&HO or FMS

M&HO or FMS present?

NO

Refer to hospital

YES
Conjunctival swab: Gram stain & culture for Gonococci 1. 2. 3. 4. 5. 6. Treat as GONORRHOEA & CHLAMYDIA Treat mother & spouse for GONORRHOEA & CHLAMYDIA Health promotion Counseling TCA 3 days Notification Form

Getting better?

NO

Refer Ophthalmologist

YES

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Reassure parents

Treatment
Neonatal Conjunctivitis IM/IV Ceftriaxone 25 – 50 mg/kg/dose STAT (max. 125 mg) & Oral Erythromycin 50 mg/kg/day QID x 10 – 14 days Clean eye with Normal Saline. Saline.

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Reference
Manual Pengurusan Pesakit Kelamin (STI) Melalui ‘Modified Syndromic Approach’ Di Peringkat Penjagaan Kesihatan Primer; Cawangan AIDS/STI, Kementerian Kesihatan Malaysia; Ogos 2000

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Thank You
DR. ISKANDAR FIRZADA B. OSMAN
MD (USM), MMed (Family Medicine) (USM), MAFPM (Mal.), FRACGP (Australia), FAFPM (Mal.), Fellow in Adolescent Health (Melbourne)

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