Syndromic Management – The Modern Practical Approach

1. Syndromic Management –The Modern Practical Approach

2. Three Approaches to Diagnosis of RTI / STI • Clinical approach • Etiological approach • Syndromic approach

3. Syndromic Approach • In this approach, diagnosis is based on the identification of syndromes, which are combinations of the symptoms the patient reports and the signs the health care provider observes • The recommended treatments are effective for allthe diseases that could cause the identified syndrome

4. Components of Syndromic Approach Classification by Syndrome: Classifying the main causal pathogens by the syndromes they produce Use of Algorithms: Using flowcharts to guide the management of a given syndrome Treatment and Counseling: Using often more than one treatment that addresses all the pathogens with potential to cause a given syndrome Treatment of Partners: Promoting treatment of sex partners

5. STI Risk Assessment • Providing information about risks • Ask clients to self-assess their risk without revealing specific information • It uses clients’ responses to questions about • Symptoms of STIs, • Demographic characteristics • Behavior to gauge their risk of exposure • Help them perceive their own risk

6. STI Risk Assessment Questions focus on • Age • Marital status • Current or past STI symptoms • Number of partners • Nature of relationships • The possibility of partners having other sexual partners • Current symptoms in partners

7. Classification by Syndromes • STIs are classified by syndrome • Each syndrome is made up of a combination of symptoms and clinical signs identified upon examination • The four main syndromes are: • Urethral discharge : men • Lower abdominal pain : women • Vaginal discharge : women • Genital ulcer : men or women

8. Vaginal Discharge Syndromes • Sign Discharge • Symptoms Vulvovaginal irritation, dyspareunia • Causes Causes of vaginitis or cervicitis • Flowchart • Treatment

9. Chart 1 This is used when : • The client refuses to be examined • Lack of private space, gloves, a table, or sufficient light • Lack of vaginal speculum • Mainly for paramedical workers

10. Abnormal vaginal discharge Vulval itching/ burning Take history External examination Lower abdominal Vulval edema tenderness Curd like discharge Erythema / Excoriation Treat as a Yes No case of PID Treat for Risk assessment Candida positive Yes No Treat for BV, Treat for BV Trichomonas, and Chlamydia & Trichomonas Gonococcal infection Vaginal Discharge Chart 1 Risk factors need adaptation to local social, behavioural and epidemiological situation • Educate and counsel • Promote condom use and provide condoms • Offer HIV counselling and testing if both facilities are available

11. Chart 2 • Vaginal speculum examination can distinguish between vaginitis and vaginitis with cervicitis • This is feasible when: • Sterile speculum is available • Gloves, examination table and good light are available • The client agrees • The health worker has a degree of clinicalexperience and acumen • Chart 1 with additional components

12. Abnormal vaginal discharge Vulval itching/ burning Take history External examination Lower abdominal Vulval edema tenderness Curd like discharge Cervical movement Erythema/ Excoriation tenderness Curd like discharge z Treat as a Yes No case of PID Treat for Risk assessment Candida positive Cervical Mucous Yellow vaginal discharge Yes No Treat for BV, Treat for BV Trichomonas, and Chlamydia & Trichomonas Gonococcal infection Speculum & Bimanual Chart 2

13. Chart 3 • This will provide additional information • Microscope and personnel required • Charts 1 and 2 with the added component of microscope

14. Abnormal vaginal discharge Vulval itching/ burning Take history External examination Lower abdominal Vulval edema tenderness Curd like discharge Cervical movement Erythema/ Excoriation tenderness Yeast on wet mount Treat as a Yes No case of PID Treat for Risk assessment Candida positive Yes No Treat for BV, Treat for BV Trichomonas, and Chlamydia & Trichomonas Gonococcal infection Speculum & Microscope Chart 3

15. Patient complains of vaginal discharge, vulval itching or burning Take history and examine patient (external, speculum and bimanual) Assess risk1 Lower abdominal tenderness or cervical motion tenderness present? Yes Use flowchart for lower abdominal pain 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 Vaginal Discharge Bimanual, Speculum & Microscope Source WHO, 2003

16. Perform wet mount / Gram stain microscopy of vaginal specimen Budding yeasts or pseudohyphaeseen No abnormal findings Clue cells seen plus pH>4.5 orKOH +ve Motile trichomonads 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. The determination of high prevalence levels needs to be madelocally Vaginal Discharge Bimanual, Speculum & Microscope Source WHO, 2003

17. Treatment • The syndromic treatment for vaginal discharge in all cases is – • Treat for vaginitis (trichomoniasis and BV PLUS candidiasis) • In some cases - if the risk assessment is positive and / or discharge from the cervixis detected • Treat for cervicitis (gonorrhea AND chlamydial infection)

18. Diagnosis Improvement Antibiotics Hospitalization & aggressive Rx USG, Laparoscopy, Laparotomy Treatment PlanAcute Salpingitis Rx partner No improvement

19. Laparoscopy • Important diagnostic and therapeutic tool • Laparoscopic visualization of the pelvis is the most accurate method of confirming the diagnosis of acute salpingitis • Findings consistent with salpingitis are: • Inflammation • Free pus or purulent fluid in the pouch of Douglas or pelvis • Fresh adhesions in the pelvis

20. Indications for Laparoscopy • The diagnosis is uncertain (appendicitis, ovarian torsion, etc can be excluded) • The patient is not responding to antibiotics • To obtain cultures and modify antibiotics • Laparoscopic pelvic lavage, drainage of abscesses, and lysis of adhesions • 20 to 40% of abscesses will not respond to antibiotics alone and will require either percutaneous or surgical drainage

21. Mortality • The mortality rate directly related to salpingitis has been estimated at 0.29 patients per 100,000 cases for patients aged 15 - 44 years • About 15% of cases will have tubo-ovarian abscess (TOA) which requires hospitalization • Mortality usually results from rupture of a TOA, with the rate of rupture being 5 -10% despite modern medical treatment

22. 4 Cs • Counseling • Condom • Contact tracing • Compliance with treatment

23. Advantages of Syndromic Approach • Immediate treatment • Effectiveness • Ease of use • Low costs

24. Limitations and Concerns • Limitations in diagnosing vaginal discharge Vaginal discharge is more indicative of vaginal infection, and poorly predictive of cervical infection • Ineffective against asymptomatic infections Potential for over diagnosis and over treatment for gonorrhoea and chlamydia in some settings • Existing rapid diagnostic tests are complicated and costly Need for data

25. Vaginal Discharge SyndromeRecommendations • The entry point to the flowchart will be a spontaneous complaint of vaginal discharge and not an elicited response • The prevalence level of gonorrhoea and chlamydia will be the main deciding factor for treatment of cervical infections In high prevalence areas, a woman's contact with the health services offers a good opportunity for her to be treated and cured from gonorrhoea and chlamydia

26. Take Home Message • Syndromic approach is practical especially in low resource setting • Very effective and affordable • May over treat simple vaginal infections • May not effectively cover asymptomatic women

27. Concept – Dr. Duru Shah • Contributors Dr. Vanita Raut Dr. Anahita Chauhan Dr. Asha R Dalal Dr. Ameya C Purandare • Editors Dr. Sangeeta Agrawal Dr. Reena Wani

28. We acknowledge the efforts of our : Coordinators : • Dr. Sangeeta Agrawal - Central • Dr. Narendra Malhotra - North • Dr. Hema Divakar - South • Dr. P. C. Mahapatra - East • Dr. Uday Thanawala - West In bringing the FOGSI YOUTH EXPRESS to your city.

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