The intervention should be combination of

BIOMEDICAL and
BEHAVIORAL interventions
Decrease in duration of infectivity to prevent further
transmission and complication
Treatment curative or suppressive
Case finding and Early treatment
Vaccination- therapeutic
Decrease exposure of susceptible individuals to
infection
Awareness /behavioral change interventions for
susceptible individuals
Behavioral change interventions for infected
persons especially persistent viral infection
Decrease efficiency of trans mission per exposure
Use of barrier methods
Vaccines protective
Use of micribiocides
 PrEP
 PEP
 Treatment as prevention
 Suppressive therapy for hsv
 Diagnosis and treatment of sti
 Prevention of maternal to child trans mission
 Contraception to prevent unplanned pregnancy among
women with hiv
 Male circumcision
 Blood safety
 Injection safety
 Microbicides
 Male and female condoms
 Other barrier methods
Promote safe sexual behavior
sexual Abstinence
Sexual debut delaying
Monogamy
Reducing number of partners
Reducing number of concurrent partners
Reducing recent sex partners
Consistent condom use
Condom use negations
Decrease substance use
Seeking care behavior
Adherence to biomedical intervention
Reaching high risk subpopulation by out reach
and peer education
Increasing knowledge on sti and hiv and to
promote health seeking behavior
Increase the knowledge on available services
 Accurate risk assessment and education and
counseling of persons at risk regarding ways to
avoid stis through change in sexual behaviors and
use of recommended prevention services
 Pre exposure vaccination for vaccine preventable
disease stis
 identification of persons with asymptomatic
infection
And persons with symptoms associated with an sti
 Effective diagnosis treatment ,counseling and
follow up of persons who are infected with an sti
 Evaluation treatment and counseling of sex
partners of persons who are infected with an sti
Based on:

 ETIOLOGICAL

 CLINICAL

 SYNDROMIC
Treatment based on exact cause (organism)
Specialists and lab facilities required
Treatment does not begin until the results obtained
Testing facilities not available at PHC level
 Experience required
 Only 50% accurate

 Mixed infections are missed

 Missed infections are left untreated

 Complications and Transmission will continue

To reduce,
 incidence and prevalence of STI,

 incidence of STI related complications

 sexual transmission of HIV infection.

 Since number of STI pathogens produce common symptoms
and signs
 WHO - promoted simplified syndromic

(1991) based approach

- diagnosis is based on group of
symptoms and signs
- provision of effective treatment that
will deal with the majority of organisms
responsible for each syndrome
 Syndromic diagnosis includes immediate treatment
for all the important causative agents.
 Making the patient Non-infectious early
 Simple
 No misdiagnosis
 No ineffective treatment
 Single visit sufficient
 No waiting period
 No social stigma – RTI
 Cost effective – saving on lab
 Treatment at the first contact of the patient reduces the
period of infection and also minimizes the chances of
loosing the patient
for treatment
 More successful cure rates

 General practitioners can also treat STIs

 Opportunities for promoting preventive measures

Partner treatment
Counsel them for
condom usage
Prescribe medicines
Follow flowcharts

Examine clinically
Risk assessment
Take case history
The approach of using simple laboratory tests in
conjunction with syndromic approach is called
enhanced syndromic management
The common STD syndromes:
1. Genital Ulcer
2. Urethral Discharge
3. Vaginal Discharge
4. Bubo (Inguinal Swellings)
5. Lower Abdominal pain in Female
6. Scrotal Swelling
7. Ophthalmia neonatorum
 Syndrome: Genital Ulcers

Syphilis Chancroid Genital Herpes

Causative Organisms
• Treponema pallidum (Syphilis)
• Haemophilus ducreyi (Chancroid)
• Klebsiella granulomatis (Granuloma inguinale)
• Chlamydia trachomatis (Lymphogranuloma venerum)
• Herpes simplex virus (Genital herpes)

Examination
• Presence of vesicles
• Presence of genital ulcer single/ multiple
History • Associated inguinal lymph node swelling &
Laboratory
if present refer to respective flowchart
Investigations
• Genital ulcer/ vesicles Ulcer characteristics:
• Burning sensation in the • Painful vesicles/ ulcers, single or multiple – • RPR test for syphilis
genital region Herpes simplex
• TZANCK for MNGC
• Sexual exposure of either • Painless ulcer with shotty lymph node - Syphilis •For further
partner to high risk • Painless ulcer with no inguinal lymph nodes –
investigations refer
practices including Granuloma Inguinale
to higher centre
oro-genital sex. • Trancient genital ulcer with Ing.Bubo - LGV
• Painful ulcer with Bubo - Chancroid
Treatment

 If vesicles are multiple, painful, herpetic form ulcers

are present
 treat for herpes with
 Tab. Acyclovir 400 mg orally, 3 times a day for
7 days
If vesicles are not seen and only ulcer is seen,
treat for
syphilis & chancroid & counsel on herpes genitalis
 To cover syphilis give
 Inj Benzathine penicillin 2.4 million IU IM after test dose in
two
divided doses (with emergency tray ready)

 (Inindividuals allergic or intolerant to penicillin,

Doxycycline 100 mg
orally, twice daily for 14 days)
+
 Tab Azithromycin 1g orally single dose (Or)
 Tab. Ciprofloxacin 500 mg orally, twice a day for 3 days to
cover Chancroid
Syndrome: Urethral Discharge in Males

Causative Organisms

• Neisseria gonorrhoeae
• Chlamydia trachomatis
• Trichomonas vaginalis
RTIs, STIs: Gonorrhea, Chlamydial Infection,
Trichomoniasis

Examination Laboratory Investigations

Look for
History of
• Urethral meatus for redness &
swelling
• Urethral discharge • If urethral discharge is not seen,
• Pain or burning while then gently massage the urethra
passing from the ventral part of the
urine, increased penis towards the meatus &
frequency of urination
look for thick, creamy
greenish-yellow or mucoid
discharge
(if available)
• Gram stain examination of the
urethral smear will show
gram-negative intracellular
diplococci in case of gonorrhea,
• In non-gonococcal urethritis
>5 neutrophils per oil immersion
field in the urethral smear or
>10 neutrophils per high power
field in the sediment of the first
void urine are observed.
Treatment

Recommended regimen for Uncomplicated Gonorrhea + Chlamydia

 Tab. Cefixime 400 mg orally, single dose

+
 Tab. Azithromycin 1g orally single dose under supervision
 Advise the client to return after 7 days of start of therapy

If discharge or only dysuria persists after 7 days

 Tab. Secnidazole 2 g orally, single dose (to treat for T.vaginalis)

If individuals are allergic to Azithromycin, give Erythromycin 500 mg

4 times a day for 7 days
Management of pregnant partner

For Gonococcal infection

 Tab. Cefixime 400 mg orally, single dose

(Or)
 Ceftriaxone 125 mg by intramuscular injection

For Chlamydial infection

 Tab. Erythromycin 500 mg orally 4 times a day for 7 days
or
 Cap Amoxicillin 500 mg orally, 3 times a day for 7 days

Quinolones (like ofloxacin, ciprofloxacin, doxycycline are contraindicated

in pregnant women.
 Syndrome: Vaginal Discharge

Vaginitis Trichomoniasis Cervical Herpes Cervicitis

Causative Organisms Causative Organisms

Vaginitis Cervicitis
Trichomonas vaginalis Neisseria gonorrheae
Candida albicans Chlamydia trachomatis
Gardnerella vaginalis, Mycoplasma causing bacterial vaginosis Trichomonas vaginalis,
Herpes Simplex Virus
Examination
Per speculum examination to differentiate between Laboratory Investigations
vaginitis & cervicitis. (if available)
1. Vaginitis: Trichomoniasis - greenish frothy discharge • Wet mount microscopy of the discharge
Candidiasis – curdy white discharge for Trichomonas vaginalis & clue cells
Bacterial vaginosis – adherent discharge •10% KOH preparation for Candida
Mixed infections may present with atypical discharge albicans
2. Cervicitis: Cervical erosion /cervical ulcer/ mucopurulent • Gram stain of vaginal smear for clue cells
cervical discharge seen in bacterial vaginosis
Bimanual pelvic examination to rule out pelvic • Gram stain of endocervical smear to
inflammatory disease detect gonococci
If Speculum examination is not possible/ client is
hesitant treat both for vaginitis & cervicitis
Treatment
Vaginitis (TV+BV+Candida)

Treat for TV + BV
 Tab. Secnidazole 2g orally, single dose (Or)
 Tab. Tinidazole 500 mg orally, twice daily for 5 days

Treat for Candidiasis

 Tab Fluconazole 150 mg orally single dose (Or)
Local Clotrimazole 500 mg vaginal pessaries once

Treatment for cervical infection (Chlamydia & Gonorrhea)

 Tab cefixime 400 mg orally, single dose
+
 Azithromnycin 1g, 1 hour before lunch.

 If vaginitis & cervicitis are present treat for both

 Follow-up after one week

Management in pregnant women

Treatment for vaginitis TV+BV+Candida)

In first trimester of pregnancy

 Local treatment with Clotrimazole vaginal pessary/ cream only for

candidiasis.
 Metronidazole pessaries or cream intravaginally if trichomoniasis
(or) BV is suspected.
 Oral Flucanozole is contraindicated in pregnancy.

In second & third trimester - oral metronidazole can be given

 Tab. Secnidazole 2 g orally, single dose
(Or)
 Tab. Tinidazole 500 mg orally, twice daily for 5 days
 Syndrome: Lower Abdominal Pain Causative Organisms

• Neisseria gonorrheae
• Chlamydia trachomatis
• Mycoplasma, Gardnerella,
• Anaerobic bacteria
(Bacteroides sp, Gram positive cocci)

Pelvic inflammatory disease

History Examination Laboratory Investigations

• Lower abdominal pain General examination: temperature, If available
• Fever pulse, blood pressure • Wet smear examination
• Vaginal discharge Per speculum examination: vaginal/ • Gram stain for gonorrhea
• Menstrual irregularities cervical discharge, congestion/ ulcers • CBC & ESR
like heavy, irregular Per abdominal examination: lower • Urine microscopy for pus cells
vaginal bleeding abdominal tenderness/ guarding
• Dysmenorrhoea Pelvic examination: Differential Investigations
• Dyspareunia Uterine/ adnexal tenderness, cervical • Ectopic pregnancy
• Dysuria, tenesmus movement tenderness, • Twisted ovarian cyst
• Low backache Note: A urine pregnancy test should be done • Ovarian tumor
• Contraceptive use like in all women suspected of having • Appendicitis
IUD PID to rule out ectopic pregnancy. • Abdominaltuberculosis
Treatment : Out Patient treatment

 In mild or moderate PID (in the absence of tubo ovarian abscess),

out Patient treatment can be given.

 Therapy is required to cover Neisseria gonorrheae,

Chlamydia trachomatis & anaerobes.

 Tab. Cefixime 400 mg orally BD for 7 days

+
 Doxycycline, 100 mg orally, twice a day for 2 weeks
(to treat chlamydial infection)
+
 Tab. Metronidazole 400 mg orally, twice daily for 14 days

 Observe for 3 days. If no improvement (i.e. absence of fever,

reduction in abdominal tenderness, reduction in cervical movement,
adnexal & uterine tenderness) or if symptoms worsen,
refer for in-Patient treatment.
Management of Pregnant Women
Though PID is rare in pregnancy,

 Any pregnant woman suspected to have PID should be

referred to higher centre for hospitalization and treated with
a parenteral regimen which would be safe in pregnancy.
 Doxycycline is contraindicated in pregnancy.

Note:
 Metronidazole is generally not recommended during the
first three months of pregnancy.
 However, it should not be withheld for a severely acute PID,
which represents an emergency.
 Syndrome: Inguinal Bubo
RTIs/STIs: LGV, Chancroid
History
• Swelling in inguinal region
which may be painful
• Preceding history of
genital ulcer/ discharge
• Sexual exposure of either
partner to high risk
practices including
oro-genital sex
• Systemic symptoms like
malaise, fever
Causative Organisms
Chlamydia trachomatis serovars
L1, L2, L3, causative agent of
Lymphogranuloma venerum (LGV)
Haemophilus ducreyi
causative agent of Chancroid
Examination
Look for
• Localized enlargement of lymph
nodes in groin which may be tender Laboratory
& fluctuant Investigations
• Inflammation of skin over the swelling
• Presence of multiple sinuses Diagnosis is on
• Edema of genitals and lower limbs clinical grounds
• Presence of genital ulcer/ urethral
discharge & if present refer to
respective flowchart
Treatment

For LGV

 Cap. Doxycycline 100 mg orally twice daily for 21 days

For Chancroid

 Tab Azithromycin 1g orally single dose

(or)
 Tab. Ciprofloxacin 500 mg orally, twice a day for 3 days
 Syndrome: Scrotal Swelling

Causative Organisms

• Neisseria gonorrhoeae
• Chlamydia trachomatis
RTIs/STIs : Gonorrhea, Chlamydial
Infection

Laboratory Investigations
Examination
History of (If available)
Look for
• Swelling & pain in • Gram stain examination of the
• Scrotal swelling
scrotal region urethral smear will show gram
• Redness & edema of the overlying
• Pain/ burning while negative intracellular diplococci in
skin
passing urine case of complicated gonococcal
• Tenderness of the epididymis &
• Systemic symptoms infection
vasdeferens
like malaise, fever • In non-gonococcal
• Associated urethral discharge/ genital
• Sexual exposure of urethritis >5 neutrophils per OIF
ulcer/ inguinal lymph nodes & if
either partner to high in the urethral smear/ >10
present refer to the respective flowchart
risk practices neutrophils per HPF in the
• A transillumination test to rule out
including oro-genital sex sediment of the first void urine are
hydrocoele should be done.
observed.
 TREATMENT

 Treat for both gonococcal & chlamydial infections

 Tab Cefixime 400 mg orally BD for 7 days

+
 Cap. Doxycycline 100 mg orally, twice daily for 14 days
 New - born with discharging eyes

Take history & examine baby

No •Reassure mother
Conjunctivitis present ?
•Review if symptoms present

Yes

•Treat baby for Gonococcal & Chlamydial infections

•Treat mother & father for Gonococcal & Chlamydial infections
 TREATMENT

 Inj.Ceftriaxone 50 mg / Kg single dose

+
Erythromycin 50 mg / Kg / day / 4 divided dose x 14 days
(Or)
 Kanamycin 25 mg / Kg single dose
+
Erythromycin 50 mg / Kg / day / 4 divided dose x 14 days
Kit No. Syndrom Color Contents
e
Kit 1 UD, ARD, Grey Tab. Azithromycin 1g (1)
Cervicitis and Tab. Cefixime 400mg (1)
Kit 2 Vaginitis Green Tab. Secnidazole 2g (1)
and Tab. Fluconazole 150mg (1)
Kit 3 GUD White Inj. Benzathine penicillin 2.4 MU (1)
and Tab. Azithromycin 1g (1)
and Disposable syringe 10ml with 21 G needle (1)
and Sterile water 10ml (1)
Kit 4 GUD Blue Tab. Doxycycline 100mg (30)
and Tab. Azithromycin 1g (1)
Kit 5 GUD Red Tab. Acyclovir 400mg (21)
Kit 6 LAP Yellow Tab. Cefixime 400mg (1)
and Tab. Metronidazole 400mg (28)
and Cap. Doxycycline 100mg (28)
Kit 7 IB Black Tab. Doxycycline 100mg (42)
And Tab. Azithromycin 1g (1)
 Syndromic approach for STIs is a
useful and practical strategy for offering,
high quality,effective and acceptable care for
prevention and treatment of
sexually transmitted infections
 Anti microbial Susceptibility of Etiological agents
 Change in the pattern of prevalence of STI

are to be monitored on a regular basis for the effective

implementation of syndromic management.
THANK YOU