Syndromic approach from PARK TEXTBOOK OF SPM

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Syndromic Approach to STD - Park's Textbook of Preventive and Social Medicine

- Park's Textbook of Preventive and Social Medicine, pp. 381-387

What is the Syndromic Approach?

Many different agents cause sexually transmitted diseases. However, some of these agents give rise to similar or overlapping clinical manifestations. The traditional method of diagnosing STD is by laboratory tests - but these are often not available or are expensive.

Since 1990, WHO has recommended syndromic management of STDs in patients presenting with consistently recognized signs and symptoms of STD. The syndromic approach is a scientifically derived approach that offers:

Accessible and immediate treatment
Effective and efficient management using flowcharts
More cost-effective than diagnosis based on laboratory tests

Common Syndromes (Table 3)

Common syndromes and sequelae for which sexual transmission is of epidemiological importance:

Syndrome / Sequela
Male urethritis
Lower genital syndromes in women: vaginitis / cervicitis / urethritis
Genital ulceration
Proctitis / colitis
Salpingitis
Epididymitis / orchitis
Infertility / ectopic pregnancy
Postnatal and perinatal morbidity
Hepatitis / hepatic carcinoma
Genital carcinoma
Pelvic pain
Acquired Immuno Deficiency Syndrome (AIDS)

Syndrome 1: Urethral Discharge (Males) - Fig. 1

Flowchart:

Fig. 1 - Syndromic management of urethral discharge in males

(A) Partner Notification

Notification and treatment of female partners of men with urethritis is the highest priority - best way to identify women at high risk of asymptomatic gonococcal and chlamydial infections.

(B) Treatment

As dual infection is common, treatment must cover both gonorrhea and chlamydia.

Recommended regimen:

Tab. Cefixime 400 mg orally, single dose
PLUS Tab. Azithromycin 1 g orally, single dose (supervised)
Advise patient to return after 7 days

If discharge/dysuria persists after 7 days (treat for Trichomonas vaginalis):

Tab. Secnidazole 2 g orally, single dose

If symptoms still persist (non-gonococcal urethritis):

Tab. Doxycycline 100 mg twice daily for 7 days

If allergic to Azithromycin:

Erythromycin 500 mg four times daily for 7 days

(C) Partner Management

Treat all recent partners (female partners for gonorrhea and chlamydia)
Advise sexual abstinence during treatment
Provide condoms and educate on correct and consistent use
Refer for voluntary counselling and testing for HIV, syphilis, and Hepatitis B
Schedule return visit after 7 days

(D) Pregnant Partner Management

Tab. Cefixime 400 mg orally, single dose OR Ceftriaxone 125 mg IM
PLUS Tab. Erythromycin 500 mg four times daily for 7 days OR Cap. Amoxicillin 500 mg three times daily for 7 days
Contraindicated in pregnancy: Quinolones (ofloxacin, ciprofloxacin), Doxycycline

(E) Follow-up at 7 days

Check HIV, syphilis, and Hepatitis B test reports
Assess treatment failure vs. re-infection
Prompt referral if required

Syndrome 2: Vaginal Discharge (Females) - Fig. 2

Causative Organisms

Type	Organisms
Vaginitis	Trichomonas vaginalis (TV), Candida albicans, Gardnerella vaginalis / Mycoplasma (bacterial vaginosis)
Cervicitis	Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, Herpes simplex virus

History

Menstrual history (rule out pregnancy)
Nature and type of discharge (amount, smell, color, consistency)
Genital itching
Burning/frequency of urination
Ulcer or swelling on vulval/inguinal region
Genital complaints in sexual partners
Low backache

Examination (per speculum)

Vaginitis differentiation:

Trichomoniasis - greenish frothy discharge
Candidiasis - curdy white discharge
Bacterial vaginosis - adherent discharge

Cervicitis:

Cervical erosion / cervical ulcer / mucopurulent cervical discharge
Bimanual pelvic examination to rule out PID
If speculum examination not possible, treat for BOTH vaginitis and cervicitis

Laboratory Investigations (if available)

Wet mount microscopy for T. vaginalis and clue cells
10% KOH preparation for Candida albicans
Gram's stain of vaginal smear for clue cells (bacterial vaginosis)
Gram's stain of endocervical smear for gonococci

Treatment

For Vaginitis (TV + BV + Candida):

Tab. Secnidazole 2 g orally, single dose OR Tab. Tinidazole 500 mg orally twice daily for 5 days
Tab. Metoclopramide 30 minutes before Secnidazole (to prevent gastric intolerance)
Tab. Fluconazole 150 mg orally single dose OR local Clotrimazole 500 mg vaginal pessary (for candidiasis)

For Cervicitis (Chlamydia + Gonorrhea):

Tab. Cefixime 400 mg orally, single dose
PLUS Azithromycin 1 g (1 hour before lunch; if vomiting within 1 hour, give antiemetic and repeat)

If vaginitis and cervicitis both present - treat for both. Follow-up after one week.

Management in Pregnant Women

First trimester:

Local Clotrimazole vaginal pessary/cream only (for candidiasis) - oral Fluconazole is contraindicated in pregnancy
Metronidazole pessaries/cream intravaginally for trichomoniasis or BV

Second and third trimester: Oral metronidazole can be given

Tab. Secnidazole 2 g orally, single dose OR Tab. Tinidazole 500 mg twice daily for 5 days

Partner Management (Vaginal Discharge)

Treat current partner only if no improvement after initial treatment
If partner is symptomatic, treat client and partner with above protocols
Advise sexual abstinence during treatment
Provide condoms
Schedule return visit after 7 days

Syndrome 3: Lower Abdominal Pain in Females (PID) - Fig. 3

Causative Organisms

Neisseria gonorrhoeae
Chlamydia trachomatis
Mycoplasma, Gardnerella, Anaerobic bacteria (Bacteroides, gram-positive cocci)

Differential Diagnoses: Ectopic pregnancy, twisted ovarian cyst, ovarian tumor, appendicitis, abdominal tuberculosis

History

Lower abdominal pain, fever, vaginal discharge
Menstrual irregularities (heavy, irregular bleeding)
Dysmenorrhoea, dyspareunia, dysuria, tenesmus, low backache
Contraceptive use (IUD)

Examination

General: temperature, pulse, BP
Per speculum: vaginal/cervical discharge, congestion, ulcers
Per abdomen: lower abdominal tenderness or guarding
Pelvic: uterine/adnexal tenderness, cervical movement tenderness

Note: A urine pregnancy test should be done in ALL women suspected of having PID to rule out ectopic pregnancy.

Lab Investigations (if available)

Wet smear examination
Gram stain for gonorrhea
Complete blood count and ESR
Urine microscopy for pus cells

Treatment (Outpatient - Mild/Moderate PID)

Treatment must cover N. gonorrhoeae, C. trachomatis, and anaerobes:

Tab. Cefixime 400 mg orally twice daily for 7 days
PLUS Tab. Metronidazole 400 mg orally twice daily for 14 days
PLUS Doxycycline 100 mg orally twice daily for 2 weeks (for chlamydia)
Tab. Ibuprofen 400 mg three times daily for 3-5 days (analgesic)
Tab. Ranitidine 150 mg twice daily (to prevent gastritis)
Remove IUD (if present) under antibiotic cover of 24-48 hours

Observe for 3 days. If no improvement (no reduction in fever, tenderness, cervical movement tenderness) - REFER for inpatient treatment.

Indications for Hospitalization

Diagnosis is uncertain
Surgical emergency (appendicitis, ectopic pregnancy) cannot be excluded
Pelvic abscess is suspected
Severe illness
Woman is pregnant
Patient cannot tolerate/follow outpatient regimen
Failed to respond to outpatient therapy

Pregnancy in PID

Doxycycline is contraindicated in pregnancy
Metronidazole generally not recommended in first 3 months (but do not withhold in severely acute PID)

Partner Management (PID)

Treat all partners in past 2 months
Treat male partners for urethral discharge (gonorrhea and chlamydia)
Schedule return visit after 3 days, 7 days, and 14 days

Syndrome 4: Genital Ulcer Disease - Fig. 4 & 5

Causative Organisms

Treponema pallidum (syphilis)
Haemophilus ducreyi (chancroid)
Herpes simplex virus type 2

History

Single painless ulcer - suggestive of syphilis
Painful ulcer (single or multiple) - suggestive of chancroid or herpes
Painful ulcer usually single, sometimes with painful bubo - chancroid

Lab Investigations

RPR test for syphilis
For further investigations, refer to higher centre

Treatment

If vesicles or multiple painful ulcers present (herpes):

Tab. Acyclovir 400 mg orally, three times a day for 7 days

If vesicles absent and only ulcer present (syphilis + chancroid), treat both:

To cover syphilis:

Inj. Benzathine penicillin 2.4 million IU IM after test dose, in two divided doses (with emergency tray ready)
If allergic to penicillin: Doxycycline 100 mg twice daily for 14 days

PLUS to cover chancroid:

Tab. Azithromycin 1 g orally single dose OR Tab. Ciprofloxacin 500 mg twice daily for 3 days

Treatment extended beyond 7 days if ulcers have not epithelialized.

Refer to higher centre if:

Not responding to treatment
Genital ulcers co-existent with HIV
Recurrent lesion

Partner Management (Genital Ulcer)

Treat all partners who had contact in the last 3 months
Partners should be treated for syphilis and chancroid
Advise sexual abstinence during treatment
Refer for voluntary counselling and testing for HIV, syphilis, and Hepatitis B
Schedule return visit after 7 days

Management of Pregnant Women (Genital Ulcer)

Contraindicated: Quinolones, doxycycline, sulfonamides
Inj. Benzathine penicillin 2.4 million IU IM after test dose
For primary/secondary/early latent syphilis: second dose 1 week after initial dose
If allergic to penicillin: Tab. Erythromycin 500 mg four times daily for 15 days
- (Erythromycin estolate is contraindicated in pregnancy due to hepatotoxicity - use erythromycin base or ethyl succinate only)
Neonate should be treated for syphilis after delivery

Syndrome 5: Inguinal Bubo - Fig. 6

Syndromic management of inguinal bubo (lymphogranuloma venereum, chancroid with bubo).

Key Principles of the Syndromic Approach

Principle	Detail
When to use	When lab support unavailable or unaffordable
WHO recommendation	Since 1990
Management tool	Flowcharts (Figs. 1-6)
Advantage	Immediate, accessible, cost-effective treatment
Dual coverage	Treat for multiple likely pathogens simultaneously
Partner management	Essential component for all syndromes
Follow-up	Mandatory at 7 days (3 days for PID)
Referral	Treatment failure, co-existing HIV, severe illness, pregnancy complications

"The syndromic approach is a scientifically derived approach and offers accessible and immediate treatment, that is effective and efficient; management of STD using flowcharts is more cost-effective than diagnosis based on laboratory tests." - Park's SPM

Summary Table: Syndromic Treatment at a Glance

Syndrome	Key Pathogens	First-line Treatment
Urethral discharge (M)	Gonorrhea + Chlamydia	Cefixime 400 mg + Azithromycin 1 g
Vaginal discharge - vaginitis	TV + BV + Candida	Secnidazole 2 g + Fluconazole 150 mg
Vaginal discharge - cervicitis	Gonorrhea + Chlamydia	Cefixime 400 mg + Azithromycin 1 g
Lower abdominal pain (PID)	GC + CT + Anaerobes	Cefixime + Metronidazole + Doxycycline
Genital ulcer (vesicles)	Herpes	Acyclovir 400 mg TDS x 7 days
Genital ulcer (no vesicles)	Syphilis + Chancroid	Benzathine penicillin 2.4 MU + Azithromycin 1 g
Inguinal bubo	LGV, Chancroid	Per flowchart (Fig. 6)

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