1. MODIFIED SYNDROMIC APPROACH
Dr. Nor Azah bt Mohamad Nawi
Pakar Perubatan Keluarga
Klinik Kesihatan Bakar Arang
MSA HSB 16/08/14

2. Introduction
STIs are caused by > 30 different viruses, bacteria and parasites
4 of 8 most common STIs are curable: gonorrhoea, chlamydia, chancroid and trichomoniasis

3. SEXUALLY TRANSMITTED INFECTIONS
MALAYSIAN GUIDELINES
in the treatment of
SEXUALLY TRANSMITTED INFECTIONS  
FOURTH EDITION
2013

4. 27 years old Malay man presented with urethral discharge a week after a contact with a sex worker.
What worries him was his naïve wife is pregnant, their first child.
They defaulted the 2nd follow-up
4 weeks later, she delivered a severely prematured baby and treated as sepsis.

5. Traditional diagnosis of STI
Etiological diagnosis: use laboratory tests to identify the causative agent;
Wait for the result before start Rx
Lab tests may not be available
Clinical diagnosis: use clinical experience to identify the symptoms typical for a specific STI.
Some STI cause similar Sx, may pick wrong diagnosis, causing transmission & Cx continues

6. SYNDROMIC APPROACH TO STI Mx
1991: WHO introduced a syndromic approach: simple, client friendly, cost effective, applicable in the community at the primary care level.
STIs managed based on the clinical presentation, and treatment can be given without the laboratory test.
The main infective agents are grouped according to clinical syndromes they cause and patients are treated for all the important causes of a syndrome, using combinations of antimicrobials.

7. WHO SYNDROMIC APPROACH
Vaginal discharge
Urethral discharge
Genital ulcer
Lower abdominal pain
Scrotal swelling
Inguinal bubo
Neonatal conjunctivitis

8. Modified Syndromic Approach (MSA)
2000, MOH has identified 3 main syndromes: vaginal discharge, urethral discharge and genital ulcer.
Algorithms were based on WHO recommendations and adapted for local use.
Some basic laboratory investigations, follow-up and counseling were incorporated into the management of the three syndromes. If the test result can be ready immediately, etiological treatment is highly recommended

9. Modified Syndromic Approach (MSA)
Once a patient presented with a suspected STI, health care workers can use the MSA
to provide treatment quickly
using the most effective standardized treatment regimens, and
perform basic investigations.
Deliver effective health education aimed at
improving patient compliance to therapy
addressing their risk behaviors and
advocate partner management

10. MSA Syndrome Symptoms Signs Most Common Cause 1. Vaginal discharge
Unusual vaginal discharge
Vaginal itching
Dysuria
Dyspareunia
Lower abdominal pain
Lower back pain
Abnormal vaginal discharge
Inflammation of vaginal mucosa
Inflammation of the Cervix
Contact bleeding
VAGINITIS
Candidiasis
Trichomoniasis
CERVICITIS
Gonorrhoea
Chlamydia
2. Urethral discharge
Urethral discharge
Frequency
Urethral irritation
3. Genital ulcer
Genital sore
Genital ulcer
Enlarged inguinal lymph nodes
Herpes Simplex Virus
Syphilis
Chancroid

11. Benefits of MSA
Rx > 1 STI at the same time (60% of pt has > 1 STI).
Rx at the first visit
Client friendly
Able to reduce transmission and complications of STIs
Use minimal lab tests
Patient can be treated by paramedics

12. Disadvantages of MSA 1) Cost over diagnosis
2) Cost of over treatment when multiple anti-microbials given to patient with none or only one infection
3) may cause less precise diagnosis
4) may cause antibiotic resistant if not manage properly

13. MSA of STI Mx Patient gives complaint History + Examination
Diagnosis made
Ix taken  Laboratory / Referral Lab
Don’t forget: psychosocial hx, idea, concern & expectation.
Future plan.
Rx SAME DAY
- based on synd. +/- Ix
TCA given , Rx reviewed

14. Filled up after case/partner has positive results for STI
MSA 2003 file
NAC 2

15. FLOW CHART FOR VAGINAL DISCHARGE SYNDROME
Patient c/o VAGINAL DISCHARGE
History and Examination (OPD/MCH card)
Investigations
Vaginal swabs
Wet mount for Trichomonas vaginalis
Gram stain for C. albicans, clue cells and others
KOH examination for Candida spp
Cervical swabs
Gram stain for Gram Negative Intracellular Diplococci and pus cells
Culture for gonococci (using Amie’s charcoal transport media)
Pap smear
RPR/TPHA, HIV Ab, anti-HCV, HBsAg
Consider Urine Pregnancy Test
Pt has LOWER ABD.PAIN ?

16. FLOW CHART FOR VAGINAL DISCHARGE SYNDROME (cont’d)
Pt has LOWER ABD PAIN
YES
Refer to nearest hospital NO
Treat for vaginitis
Educate behaviour
F/up for 2/52 for results NO
RISK FACTORS
<21 yr-old
Single
Recent new partner – 3/12
Multiple partner
RISK ASSESSMENT
Partner has symptoms OR
Risk factor positive
YES
Treat for VAGINITIS and CERVICITIS
Educate for behavior change
Advise sex abstinence for 2 weeks
Provide condom or promote usage
Partner management
Follow-up after 7 days for results.
Repeat swab if patient remains symptomatic.
Repeat RPR, HIV Ab, HBsAg after 3/12
Notify if +ve for notifiable diseases

17. Treatment For Vaginal Discharge Syndrome (Cervicitis and Vaginitis)
FIRST CHOICE
IM Ceftriaxone 500 mg single dose
PLUS
Azithromycin 1.0 gm orally single dose
Treatment For (CERVICITIS)
SECOND CHOICE
IM Ceftriaxone 500 mg single dose
PLUS
Doxycycline 100 mg bd orally x 7 days
THIRD CHOICE
IM Ceftriaxone 500 mg single dose
PLUS
Erythromycin ES 800 mg qid orally x 7 days
Metronidazole 2 gm stat PLUS Clotrimazole pessary 200 mg od x 3/7 OR 500 mg single dose or Nystatin pessaries 100,000 u dly for 14 days
On f/up if no improvement or not effective- to continue Metronidazole 400mg bd x 7 days
PLUS Treatment for Vaginitis
OR Treat for Vaginitis only

18. Meta-analyses have concluded that there is no evidence of teratogenicity from the use of Metronidazole in women during the first trimester of pregnancy.
Metronidazole is excreted in the breast milk and gives the metallic taste. Avoid high dose of Metronidazole (2 gram single dose) if patient is breast feeding and in pregnancy
Refer FMS/Dermatologist if no improvement.

19. FLOW CHART FOR URETHRAL DISCHARGE SYNDROME IN MEN
Patient c/o urethral discharge/dysuria/irritation
History and Examination
INVESTIGATION needed:
Urethral smear
RPR/, TPPA & HIV Ab, HBsAg , anti-HCV
Treat for Gonorrhoea and Chlamydia
Educate for behavior change
Advise sex abstinence for 2 weeks
Provide condom or promote usage
Partner management
Follow-up after 7 days for assessment and results
Repeat swab if patient remains symptomatic.
Repeat RPR, HIV Ab, HBsAg after 3/12
Notify if +ve for notifiable diseases

20. Treatment For Urethral Discharge Syndrome
Treatment For Gonorrhoea and Chlamydia
FIRST CHOICE
IM Ceftriaxone 500 mg single dose
PLUS
Azithromycin 1.0 gm orally single dose
SECOND CHOICE
IM Ceftriaxone 500 mg single dose
PLUS
Doxycycline 100 mg bd orally x 7 days
THIRD CHOICE
IM Ceftriaxone 500 mg single dose
PLUS
Erythromycin ES 800 mg qid orally x 7 days

21. GENITAL ULCER

22. FLOW CHART FOR GENITAL ULCER SYNDROME
Patient c/o GENITAL ULCER or SORE
History and Examination
Investigations:
Tzank smear
Gram stain for H. ducreyi
Dark ground microscopy
RPR/TPPA, HIV Ab, anti-HCV, HBsAg
Consider Urine Pregnancy Test
Pap smear
ULCER present ?

23. FLOW CHART FOR GENITAL ULCER SYNDROME (cont’d)
ULCER present ? NO
Educate behav change
TCA after 7 days for assessment and results
Single painless/
multiple painful ulcers
YES
Painful grouped vesicles, erosions, ulcers
Treat for Syphilis and Chancroid
Educate for behavior change
Advise sex abstinence for 2 weeks
Provide condom or promote usage
Partner management
Follow-up after 7 days for results
Repeat swabs if positive
Repeat RPR, HIV Ab, HBsAg after 3/12
Genital herpes Mx
Educate for behaviour change
TCA after 7 days for results
Notify if +ve for notifiable diseases

24. Treatment For Genital Ulcer Syndrome
Treatment For Syphilis and Chancroid
FIRST CHOICE
IM Benzathine Penicillin 2.4 million units single dose
Plus
Azithromycin 1.0 gm single oral dose
SECOND CHOICE
IM Benzathine Penicilline 2.4 million units single dose
Plus
IM Ceftriaxone 250 mg single dose

25. Treatment For Genital Ulcer Syndrome
If patient allergic to penicillin, use EITHER :
Doxycycline 100 mg bd for 14 days OR
Erythromycin ES 800 mg qid for 14 days
(follow-up after 2 weeks)
Doxycycline should not be used during pregnancy, lactation and children.
Babies of mothers who are treated with Erythromycin must be treated for syphilis.
Treatment for genital herpes, refer to guidelines on genital herpes
Refer to Family Medicine Specialist/Physician/Dermatologist if patient is pregnant or has other concomitant STI or in doubt.

26. DISCUSSION
STI screening – still LOW due to low awareness, knowledge and skill among doctors and paramedics, therefore more CME, reminder and regular training are needed.
Limited lab tests for STI detection at the health clinic, therefore MSA are definitely relevant.

27. TAKE HOME MESSAGE
Try to put yourself in the patient shoes – live with curable diseases, left undetected and untreated causing morbidities and mortalities
It is not a program “to find fault or darkness side in patient life/marriage”
STI screening and management are a simple way to help a patient and the community towards a healthier life.
Therefore it is very important to identify the illness, do the screening and can be simply manage with MSA

28. THANK YOU