Syndromic management of sexually transmitted diseases

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Syndromic Management of Sexually Transmitted Diseases (STDs)

What is Syndromic Management?

The traditional method of diagnosing STDs relies on laboratory tests, but these are often unavailable or unaffordable in resource-limited settings. Since 1990, the WHO has recommended syndromic management of STDs - a scientifically derived approach where treatment is given immediately based on recognized clinical syndromes (clusters of symptoms and signs) rather than waiting for laboratory confirmation. It uses flowcharts and is more cost-effective than laboratory-based diagnosis.

Park's Textbook of Preventive and Social Medicine, p. 381

The Six Major Syndromes

1. Urethral Discharge in Males

Causative organisms: Neisseria gonorrhoeae (gonorrhea) + Chlamydia trachomatis

Since dual infection is common, treatment must cover both organisms.

Flowchart:

Treatment:

Drug	Dose	Purpose
Tab. Cefixime	400 mg orally, single dose	Gonorrhea
Tab. Azithromycin	1 g orally, single dose (supervised)	Chlamydia

If symptoms persist at 7 days: Tab. Secnidazole 2 g single dose (for Trichomonas vaginalis)
Azithromycin allergy: Erythromycin 500 mg four times daily x 7 days
Pregnant partner: Cefixime 400 mg single dose + Erythromycin base 500 mg four times daily x 7 days (quinolones and doxycycline are contraindicated)
Follow-up at: 7 days

2. Vaginal Discharge

Causative organisms:

Vaginitis: Trichomonas vaginalis, Candida albicans, Gardnerella vaginalis (bacterial vaginosis)
Cervicitis: Neisseria gonorrhoeae, Chlamydia trachomatis, T. vaginalis, Herpes simplex virus

Examination: Per speculum to differentiate vaginitis from cervicitis:

Trichomoniasis - greenish frothy discharge
Candidiasis - curdy white discharge
Bacterial vaginosis - adherent discharge
Cervicitis - cervical erosion / mucopurulent cervical discharge

Treatment:

Condition	Drug	Dose
Vaginitis (TV + BV)	Tab. Secnidazole OR Tab. Tinidazole	2 g single dose OR 500 mg BD x 5 days
Candidiasis	Tab. Fluconazole OR Clotrimazole pessary	150 mg single dose OR 500 mg once
Cervicitis (Gonorrhea + Chlamydia)	Tab. Cefixime + Azithromycin	400 mg + 1 g, both single dose

First trimester of pregnancy: Local clotrimazole only; oral fluconazole and oral metronidazole contraindicated
Second/third trimester: Secnidazole 2 g or tinidazole can be used
Partner management: Treat partner only if there is no improvement after initial treatment or partner is symptomatic
Follow-up at: 7 days

3. Lower Abdominal Pain in Females (Pelvic Inflammatory Disease - PID)

Causative organisms: N. gonorrhoeae, C. trachomatis, Mycoplasma, Gardnerella, anaerobes (Bacteroides, gram-positive cocci)

Differential diagnosis: Ectopic pregnancy, twisted ovarian cyst, appendicitis, abdominal tuberculosis

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

Treatment (outpatient - mild/moderate PID):

Tab. Cefixime 400 mg orally twice daily x 7 days
- Tab. Metronidazole 400 mg twice daily x 14 days
- Cap. Doxycycline 100 mg twice daily x 2 weeks (for chlamydia)
Tab. Ibuprofen 400 mg three times daily x 3-5 days (analgesia)
Remove IUD if present under antibiotic cover

Criteria for hospitalization:

Uncertain diagnosis; cannot exclude ectopic pregnancy or appendicitis
Pelvic abscess suspected
Severe illness
Pregnant patient
Failed outpatient therapy
Non-compliance
Doxycycline and metronidazole (in first trimester) are contraindicated in pregnancy.
Follow-up at: 3 days, 7 days, and 14 days

4. Genital Ulcer Disease

Causative organisms:

Organism	Disease	Ulcer Character
Treponema pallidum	Syphilis	Painless, hard, "shotty" lymph nodes
Haemophilus ducreyi	Chancroid	Painful, single, + painful bubo
Klebsiella granulomatis	Granuloma inguinale	Painless + inguinal nodes
Chlamydia trachomatis (L1-L3)	LGV	Painless + inguinal nodes
Herpes simplex virus	Genital herpes	Painful vesicles/multiple ulcers

Treatment:

Vesicles or multiple painful ulcers (herpes): Tab. Acyclovir 400 mg three times daily x 7 days
Ulcer without vesicles (syphilis + chancroid):
- Inj. Benzathine penicillin 2.4 million IU IM (after test dose, with emergency tray ready)
- - Tab. Azithromycin 1 g single dose OR Tab. Ciprofloxacin 500 mg twice daily x 3 days (for chancroid)
Penicillin allergy: Doxycycline 100 mg twice daily x 14 days

In pregnancy:

Quinolones, doxycycline, sulfonamides are contraindicated
Benzathine penicillin 2.4 million IU IM; second dose 1 week later for primary/secondary/early latent syphilis
Herpes with active lesions at delivery: caesarean section; acyclovir may be given orally for severe cases
Erythromycin estolate is contraindicated (hepatotoxicity); use erythromycin base or erythromycin ethyl succinate

Partner management: Treat all contacts in past 3 months for syphilis and chancroid.

5. Scrotal Swelling (Epididymo-orchitis)

Causative organisms (STI-related): N. gonorrhoeae, C. trachomatis

Differential diagnosis: TB, filariasis, coliforms, pseudomonas, mumps, trauma, hernia, hydrocele, testicular torsion, testicular tumors

Key examination: Transillumination test to rule out hydrocele

Treatment:

Tab. Cefixime 400 mg orally twice daily x 7 days
- Cap. Doxycycline 100 mg twice daily x 14 days
Supportive: bed rest, scrotal elevation with T-bandage, analgesics

If quick and effective therapy is not given, testicular scarring and sub-fertility may result.

Pregnant partner: Doxycycline contraindicated; use erythromycin base or amoxicillin

6. Inguinal Bubo

Causative organisms: Chlamydia trachomatis serovars L1, L2, L3 (LGV), Haemophilus ducreyi (chancroid)

Differential diagnosis: Mycobacterium tuberculosis, filariasis, acute infections of the skin of the pubic area, genitals, buttocks, anus, and lower limbs

Flowchart:

Treatment:

Cap. Doxycycline 100 mg orally twice daily x 21 days (for LGV)
- Tab. Azithromycin 1 g single dose OR Tab. Ciprofloxacin 500 mg twice daily x 3 days (for chancroid)

Important: A bubo should never be incised and drained at a primary health centre, even if fluctuant - there is a high risk of fistula formation. If fluctuant, refer for aspiration at a higher centre.

Pregnant partner: Erythromycin base 500 mg orally four times daily x 21 days (quinolones, doxycycline contraindicated).

Follow-up at: 7 days and 21 days.

Common Principles Across All Syndromes

Treat empirically and immediately - do not wait for lab results
Partner management is mandatory - treat all recent partners (usually contacts within past 2-3 months)
Advise sexual abstinence during the course of treatment
Provide condoms and educate on correct, consistent use
Refer for VCT (voluntary counselling and testing) for HIV, syphilis, and Hepatitis B
Pregnancy precautions: Quinolones, doxycycline, sulfonamides, oral fluconazole, and erythromycin estolate are all contraindicated in pregnancy
Refer to higher centre if no response to treatment, recurrent lesions, or complications arise

Summary Table: Syndromes and First-Line Treatment

Syndrome	Key Organisms	First-Line Treatment
Urethral discharge	Gonorrhea + Chlamydia	Cefixime 400 mg SD + Azithromycin 1 g SD
Vaginal discharge (cervicitis)	Gonorrhea + Chlamydia	Cefixime 400 mg SD + Azithromycin 1 g SD
Vaginal discharge (vaginitis)	TV + BV + Candida	Secnidazole 2 g SD + Fluconazole 150 mg SD
Lower abdominal pain (PID)	GC + CT + Anaerobes	Cefixime + Metronidazole + Doxycycline
Genital ulcer (vesicles)	HSV	Acyclovir 400 mg TDS x 7 days
Genital ulcer (no vesicles)	Syphilis + Chancroid	Benzathine penicillin 2.4 MIU IM + Azithromycin 1 g SD
Scrotal swelling	Gonorrhea + Chlamydia	Cefixime 400 mg BD x 7d + Doxycycline 100 mg BD x 14d
Inguinal bubo	LGV + Chancroid	Doxycycline 100 mg BD x 21d + Azithromycin 1 g SD

SD = single dose; BD = twice daily; TDS = three times daily

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

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