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Syndromic Management of Sexually Transmitted Infections (STIs)

 Syndromic Management of Sexually Transmitted Infections


  • Sexually transmitted infections (STIs) remain a public health problem of major significance in most parts of the world
  • The incidence of acute STIs is believed to be high in many countries.
  • Failure to diagnose and treat STIs at an early stage may result in serious complications and sequelae like:
    • Infertility
    • Fetal wastage
    • Ectopic pregnancy
    • Anogental cancer
    • Premature death
    • Neonatal and infant infections
  • Burden: 340 million new episodes globally per year
  • Morbidity:
    • poor pregnancy outcomes
    • infertility in women and men
    • Infection in newborn babies
    • premature death in babies
  • Link with HIV: Facilitates transmission and acquisition of HIV

  • Sexually transmitted infections (STIs) are among the most common causes of illness in the world and have far-reaching health, social and economic consequences for many countries.
  • At the same time, resistance of several sexually transmitted pathogens to antimicrobial agents has increased, adding to therapeutic problems.
  • The individual and national expenditure on STI care is substantial
  • The emergence and spread of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) have had a major impact on the management and control of STIs.


The emergence and spread of HIV infection and AIDS have also complicated the management and control of some other STIs
  • There is a strong correlation between the spread of conventional STIs and HIV transmission, and both ulcerative and non-ulcerative STIs have been found to increase the risk of sexual transmission of HIV.
  • Due to HIV-related immunosuppression, the treatment of chancroid has become increasingly difficult in areas with a high prevalence of HIV infection.


  • Syndromic management is based on the identification of consistent groups of symptoms and easily recognized signs (syndromes), and the provision of treatment that will deal with the majority or most serious organisms responsible for producing a syndrome. WHO developed a simplified tool (a flowchart or algorithm) to guide health workers in the implementation of syndromic management
  • This is management of STls based on the presentation of symptoms and signs rather than laboratory evidence. 
  • It was introduced by WHO in 1990 for low-income countries.
  • Syndromic management has a high sensitivity but low specificity in the diagnosis of STIs
  • The term sexually transmitted Infections STIs ) refers to a variety of clinical syndromes and infections caused by pathogens that can be acquired and transmitted through sexual activity. Physicians and other health care providers play a critical role in preventing and treating STIs
  • Sexual activity entails any sexual contact in which infection can be passed.
    • Oral sex
    • Anal sex
    • Vaginal sex
    • Use of sexual toys and Vibrators
  • For Some infections like Herpes, HPV and Syphilis, no penetration needs to occur. Skin to skin contact is all that is required


  • The provision of accessible, acceptable and effective services is important for the control of STIs.
  • In most developing and industrialized countries, balanced and comprehensive program may require the strengthening of all health care providers that are able to provide STI services.
  • It is recommended that routine STI services be integrated into primary health care.
  • In a few selected cases, the specialized clinics should also be strengthened as reference centres


  • Appropriate treatment of STIs at the first contact between patients and health care providers is an important public health measure.
  • In the case of adolescent patients, there is the potential to influence future sexual behaviour and treatment-seeking practices at a critical stage of development.
  • Using national standardized treatment protocols for STIs helps to ensure that all patients receive adequate treatment at all levels of health care services.
  • The protocols can also facilitate the training and supervision of health care providers and can help to reduce the risk of development of resistance to antimicrobials
  • A standardized list of antimicrobial agents can also facilitate drug procurement. 
  • STI sign and symptoms are rarely specific to a particular causative agent
  • Laboratories are either non-existent or non-functional due to lack of resources
  • To interrupt transmission of STIs
  • To prevent development of disease, disease complications/ sequaelae
  • To reduce risk of HIV infection
  • To provide appropriate antimicrobial therapy to obtain cure of infection
  • To provide appropriate antimicrobial therapy to decrease infectiousness
  • To limit/prevent high risk behavior
  • To treat sexual partners
  • Dual infections are quite common and both clinician and laboratory may
  • miss one of them
  • Waiting time for lab. results may discourage some patient
  • Thus, effective case management consists not only of antimicrobial therapy to obtain cure and reduce infectivity but also comprehensive consideration and care of the patient’s reproductive health.
  • WHO has developed a simplified tool (a flowchart or algorithm) to guide health workers in the implementation of syndromic management of STIs.
  • It is recommended that national guidelines for the effective management of STIs be developed in close consultation with local STI and public health experts.


  • Problem-oriented (responds to patient’s symptoms )
  • Highly sensitive and does not miss mixed infections
  • Treats the patient at first visit
  • Can be implemented at primary health care level
  • Use flow charts with logical steps
  • Provides opportunity and time for education and counseling

STI case management

  • STI case management is the care of a person with an STI-related syndrome or with a positive test for one or more STI.
  • For people with an STI-related syndrome or with a positive test for one or more STIs.
  • The components:
  • History taking
  • Clinical examination
  • Correct diagnosis
  • Early and effective treatment
  • Advice on sexual behavior
  • Promotion and/or provision of condoms
  • Partner notification and treatment
  • Case Recording, reporting and clinical follow up as appropriate.
  • Thus, effective case management consists not only of antimicrobial therapy to obtain cure and
  • reduce infectivity, but also comprehensive care of the patient's needs for reproductive health.

                                                            Common STIs

                                                     STI-Associated Syndromes

Drug classes used in syndromic management
  • Cephalosporins
  • Macrolides
  • Suphonamides
  • Quinolones
  • Tetracyclines

The choice of antimicrobial regimen
  • Safety
  • Low Cost
  • Availability
  • Coexistent infections
  • Single-dose
  • oral administration
  • Efficacy [at least 95%]
  • Organism resistance
  • Compliance and acceptability
  • Risk of reducing drug efficacy for others
  • Acceptable toxicity and tolerance
  • Not contraindicated for pregnant or
  • lactating women
  • Appropriate drugs should be included in the national essential drugs list
  • In choosing drugs, consideration should be given to the capabilities and experience of health personnel.

Urethral discharge

Patients should be advised to return if symptoms persist 7 days after start of therapy.
Treatment options for Chlamydia
  • Doxycycline
  • Azithromycin
Treatment options for Gonorrhea 
  • Ciprofloxacin 
  • Ceftriaxone 
  • Cefixime
  • Spectinomycin
Amoxycillin, Erythromycin (if Tetracycline contraindicated ), Ofloxacin,
Note: WHO recommends that, where possible, single-dose therapy be used.

                                          Syndrome 1: Urethral Discharge

Genital ulcers disease[GUD]
  • Prevalence of causative organisms for GUD varies considerably in different parts of the world
  • Syphilis: B enzalthine , Benzyl penicillin. Alternative: procaine
  • Chancroid : Ciprofloxacin, Erythromycin, Azithromycin. Alternative: Ceftriaxone
  • Granuloma inguinale : Azithromycin, Doxycyclin . Alternative: Erythromycin, Tetracyclin , TMP/SMX
  • L ymphogranuloma venereum LGV): Doxycyclin , Erythromycin. Alternative: Tetracyclin
  • HSV2 infections becoming an increasing cause, thus need for antiviral treatment: Acyclovir, Valaciclovir , Famciclovir

                                                Syndrome 2: Genital Ulcers

Scrotal swelling

Most common organisms are Gonorrhea and Chlamydia
Treatment options for Chlamydia: 
  • Doxycycline
  • Azithromycine
Treatment options for Gonorrhea 
  • Ciprofloxacin
  • Ceftriaxone 
  • Cefixime
  • Spectinomycin
Amoxycillin , Erythromycin (if Tetracycline contraindicated), Ofloxacin,

                                                                 Scrotal Swelling

Vaginal discharge

  • A spontaneous complaint of abnormal vaginal discharge (in terms of quantity, colour or odour ) is most commonly a vaginal infection.
  • T . vaginalis , C. albicans and bacterial vaginosis (BV) are the commonest causes of vaginal infection.
  • N . gonorrhoeae and C. trachomatis cause cervical infection, asymptomatic in a large proportion of women
  • All women presenting with vaginal discharge should receive treatment for trichomoniasis and bacterial vaginosis.
  • Bimanual, speculum & microscopic examinations are crucial
                                                     Vaginal Discharge

                     Vaginal Discharge
                       (Without Speculum Examination)

                     Vaginal Discharge
                       (Without Speculum Examination)

 Vaginal Discharge
Bimanual and Speculum, with or without Microscope

 Vaginal Discharge
Bimanual, Speculum, and Microscope

Vaginal discharge
In primary health care settings where Gram stain can be carried out in an efficient manner , identification of Gram negative intracellular diploccoci and/or T. vaginalis can be attempted
  • Bacterial Vaginosis: Metronidazole. Alternatives: Clindamycin, Metronidazole Gel, Clindamycin cream
  • T vaginalis : Metronidazole, Tinidazole
  • Candida: Miconazole , Clotrimazole , Fluconazole. 
  • Alternative: Nystatin
  • Cervical infection: Treat for N Gonorrhea and chlamydia as above

Lower abdominal pain

  • All sexually active women presenting with lower abdominal pain should be carefully evaluated for salpingitis and/or endometritis elements of pelvic inflammatory disease (PID).
  • Routine bimanual and abdominal examination should be carried out on all women with presumptive STI as some women with PID or endometritis will not complain of lower abdominal pain.
  • Endometritis , Vaginal discharge, bleeding and/or uterine tenderness on pelvic examination suggests pelvic inflammatory disease[PID

Pelvic Inflammatory Disease (PID)

PID can be difficult to diagnose because clinical manifestations are varied.
  • Symptoms include:
  • A bdominal pain
  • Dyspareunia
  • vaginal discharge
  • Menometrorrhagia
  • Dysuria
  • Fever
  • nausea and vomiting.
  • PID becomes highly probable when any of above symptoms are seen in a woman
Signs include:
  • Adnexal tenderness, evidence of lower genital tract infection
  • Cervical motion tenderness
  • Enlargement or induration of one or both fallopian tubes, a tender pelvic mass
  • Direct or rebound tenderness
  • Elevated temperature
  • In general, clinicians should err on the side of over diagnosing and treating suspected cases.

Indications for admission for PID
  • Uncertain diagnosis
  • Suspected surgical emergencies like appendicitis and ectopic pregnancy
  • Suspected pelvic abscess
  • Severe illness
  • Pregnant patient
  • Patient can’t tolerate oral treatment
  • Patient fail to respond to outpatient therapy
PID Out patient treatment
  • Single dose ceftriaxone
  • PLUS Tabs Doxycycline , 100 mg orally, twice daily, or tetracycline, 500 mg orally, 4 times daily for 14 days
  • PLUS Tabs M etronidazole , 400 500 mg orally, twice daily for 14 days
  • Adjuncts to therapy: removal of intrauterine device (IUD) preferably after antimicrobial therapy has been commenced. Alternative contraceptive counselling is necessary.
  • Follow up Outpatients after 72 hours and admitted if no improvement

  • Ceftriaxone , 250 mg by IM stat + Doxycycline , 100 mg orally or IV, B.D metronidazole 400 500mg orally or by IV TDS
  • Clindamycin , 900 mg IV 8HRLY + Gentamicin , 1.5 mg/kg by intravenous injection every 8 hours
  • Ciprofloxacin , 500 mg orally, BD + Doxycycline , 100 mg orally or by IV, BD injection + Metronidazole , 400 500 mg orally or by IV, B.D
  • Note For all three regimen, therapy should be continued until at least two days after the patient has improved and should then be followed by either doxycycline, 100 mg orally, BD for 14, for 14 days

Advantages of syndromic management

  • Valid and feasible
  • It has resulted in adequate treatment of large numbers of infected people
  • Less expensive
  • It is simple
  • Its very cost effective.
  • Saves time for patients/physician or providers
  • Reduces laboratory expenses
  • Can improve patient compliance and satisfaction
  • Validation studies have confirmed comparable accuracy of syndromic and Lab. diagnosis with limitation of syndromic management only to vaginal discharge
  • Syndromic case management of STI has shown decrease transmission HIV and STI in population
  • Simplicity allows other health workers (other than doctors) to use the approach to make a diagnosis
  • It allows health workers more time to offer education for behavior change
  • Studies have shown clinical judgment misses 50% of cases
  • Many patients required to return to a health centre for treatment do not do so: so reduced lost to follow up.

Disadvantages of syndromic management

  • Tends to over treat due to decreased specificity
  • Flow charts for vaginal discharge have limitations, particularly in the management of cervical infections, especially in low prevalence settings and in adolescent females, where endogenous vaginitis rather than an STI is the main cause of vaginal discharge
  • management of cervical infection is problematic
  • The most common cause of vaginal discharge is vaginitis (i.e., bacterial vaginosis, candidiasis, or trichomoniasis ), but the most serious cause, public health wise, is cervical infection. 
  • It is, therefore, recommended to incorporate a risk assessment for cervical infection in the flowchart
  • ignores asymptomatic cases
  • may overuse expensive drugs
  • notifying sexual contacts without proof of infection in the index case is difficult
  • Tracing of sexual partners especially in the adolescent group and people with multiple sexual partners is challenging
  • Requires high clinical acumen
  • Most STIs cause similar symptoms
  • Mixed infections are common and failure to treat may lead to serious complications
  • Doesn’t identify asymtomatic STIs
  • Increasing antimicrobial resistance of several sexually transmitted has rendered some low cost regimen ineffective
  • There is increased risk of possible misuse of the regimen
  • A two tier drug policy with the provision of less effective drugs at the peripheral health care level and the most effective and usually more expensive drugs only at a referral level may result in an unacceptable rate of treatment failures, complications and referrals, and may erode
  • confidence in health services
  • Homosexuality/others sexual orientations in regions where its practice is still a taboo, complicates contact tracing

5 “Ps” of syndromic management risk assessment

1. Partners: Type, number, commitment
2 . Practices: sexual orientation vaginal sex? Anal sex? Oral sex? Condoms?
3 . Prevention of pregnancy: Contraceptive practices?
4 . Protection from STIs? Condom use?
5 . Past history of STIs :Ever had an STD?” A ny of your partners had an STD?
Additional questions for HIV/viral hepatitis risk : You or any of your partners ever injected drugs ? You or any of your partners exchanged money or drugs for sex?” A nything else about your sexual practices that I need to know

Prevention of STIs

  • Accurate risk assessment, education and counseling of persons at risk on ways to avoid STIs through changes in sexual behaviors and use of recommended prevention services
  • Preexposure vaccination of persons at risk for vaccine preventable STIs
  • Identification of asymptomatically infected persons and persons with symptoms associated with STIs
  • Mass treatment using the syndromic approach has been found very effective
  • Effective diagnosis, treatment, counseling, and follow up of infected persons
  • Evaluation , treatment, and counseling of sex partners of persons who are infected with an STI
  • Pre exposure vaccination is one of the most effective methods for preventing transmission of human papilloma virus (HPV), HAV, and HBV. HPV vaccination is recommended routinely
  • Hepatitis A and B vaccines are recommended for MSM, injection drug users, chronic liver disease ( CLD) and HIV infection
  • Abstinence: The most reliable way to avoid transmission of STDs is to abstain from oral, vaginal, and anal sex or to be in a long term, mutually monogamous relationship with an uninfected partner.
  • Abstinence from sexual intercourse till completion of STI treatment other than HIV
  • Male Condoms use: when consistently and correctly, male latex condoms are highly effective in preventing the sexual transmission of STIs.

Challenges to syndromic management

  • Recent data indicates that herpes simplex virus type 2 (HSV2) is fast becoming the commonest cause of genital ulcer disease (GUD) in developing countries. Antiviral therapy addition may become necessary
  • Successful management of STIs requires members of staff to be respectful of patients and not to be judgemental .
  • Show of respect and Empathy
  • Clinical examination should take place in appropriate surroundings where privacy can be ensured and confidentiality guaranteed.
  • Inadequate staffing of health facilities
  • Training and retraining of health manpower
  • For adolescents , the health care provider should be reassuring, experienced and conversant with the changes in anatomy and physiology associated with the different maturation stages
  • Need to train health care providers to overcome their own sensitivities and to be able to address the issues associated with sexuality and STIs in an open and constructive manner
  • Adolescents often lack information about existing services, such as where they are, what times they operate, how much they cost, etc.
  • Adolescents are often reluctant to seek help for diagnosis and treatment because of embarrassment and worried about social stigmatization
  • They also fear Judgemental (negative) reactions from health workers and lack of confidentiality
  • Health services are not adolescent friendly to respond to their particular needs.

  • The sexually active group [young and middle age] is the population of greatest concern for STIs.
  • The burden of STIs is enormous with health , social and economic consequences that threaten the existence of nations.
  • Etiological diagnosis and management of STIs comes with a lot of challenges both in low and high income countries as many patients when required to return to a health facilities for treatment and follow up, do not do so.
  • Syndromic management of STIs is based on scientifically sound evidence and can be implemented in all clinical setting, especially areas with limited resources like Nigeria is thus key to the effective management/treatment of people with STIs and thus interrupting the cycle of transmission
  • Successful management of STIs requires clinical staff to be respectful of patients, maintain confidentiality and show empathy.

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