General principle of management of patients with std

Appendix I
STD Case management
General Principles of Management of Patients with STD z Establish the diagnosis or syndrome by history (including behavioural risk assessment), physical examination and screen for other possible STDs z Routine screening and counselling even in asymptomatic patients (in particular female patients) is necessary. z Prompt, simple and standardised treatment (preferably single dose). z Health education on safer sex: monogamous relationship, proper and consistent condom use, prompt and routine medical consultation after unsafe z Secure follow-up for re-test for VDRL and HIV serology at 90 days. Treatment for Gonorrhoea
and Chlamydial infection in Men
Microscopy for gram negative diplococci and pus cells Specific culture medium and transport medium is required for culture Chlamydial antigen testing (culture or DNA testing) By syndromic
Treatment of
z Ceftibuten 400 mg in single oral dose
gonococcal urethritis:
z Spectinomycin 2 - 4 gm single i.m.i. dose
z Ceftriaxone 250 mg single i.m.i. dose
For the treatment of chlamydial urethritis:
z Doxycycline 100 mg orally twice daily for 7 days
z Tetracycline 500 mg orally four times daily for 7 days
z Erythromycin 500 mg orally four times daily for 7 days
z Azithromycin 1 gm orally in a single dose
z Clarithromycin 250 mg orally twice daily for 7 days
z Ofloxacin/ Levofloxacin 200 mg orally twice daily for 7 days
NOTE: Prolonged treatment may be necessary in cases with complications like epididymo-orchitis, tysonitis, etc.
Azithromycin 2 gm orally may be given as a single dose to treat gonorrhoea and it has also additional coverage of Treatment for Vaginitis only
Pruritus, soreness, irritation and discharge Microscopy by wet mount and/or Gram stain Culture for Trichomonas vaginalis By syndromic
Treatment:
z Tinidazole 2 gm as a single oral dose to be taken at the
clinic OR
z Metronidazole 2 gm as a single oral dose to be taken
at the clinic OR
z Metronidazole 200 mg orally three times daily/ 400
mg orally twice daily for 7 days
Do not prescribe Metronidazole and Tinidazole in the 1st trimester of pregnancy (and probably also in lactating women) and warn against drinking alcohol while taking it. z Clotrimazole vaginal pessary one tab nocte for 6 days OR
z Tioconazole vaginal pessary one tab nocte for 3 days OR
z Isoconazole vaginal pessary two tab nocte for 1 day OR
z Nystatin 100,000 unit (one pessary) nocte daily for 14 days OR
z Fluconazole 150 mg as a single oral dose OR
z Itraconazole 200 mg twice daily for 1 day
Screening for other potentially associated STDs is recommended. Other preparations for the treatment of candidasis are available, please refer to the local formulary for detail. Treatment for both Cervicitis and Vaginitis
Vaginal discharge, lower abdominal pain or Microscopy (with Gram stain) for cervical smear for Gram negative diplococci and Culture for Gonococcus (special transport and culture medium required) Chlamydial antigen testing (culture or DNA testing) By syndromic

Treat the patient for Vaginitis only as above
For gonococcal cervicitis:
• Ceftibuten 400 mg orally in a single dose
• Spectinomycin 2 - 4 gm single i.m.i. dose
• Ceftriaxone 250 g
m single i.m.i. dose
For chlamydial cervicitis:
• Doxycycline 100 mg orally twice daily for 7 days
• Tetracycline 500 mg orally 4 times daily for 7 days
• Erythromycin 500 mg orally 4 times daily for 7 days
• Azithromycin 1 gm orally in a single dose
• Clarithromycin 250 mg orally twice daily for 7 days
• Ofloxacin / Levofloxacin 200 mg orally twice daily for 7 days
Levofloxacin, doxycycline, tetracycline are contraindicated in pregnant or lactating women. Azithromycin 2 gm orally may be given as a single dose to treat gonorrhoea and it has also additional coverage of For patient suspected to have acute pelvic inflammatory disease complicating cervicitis, it is extremely important to rule out serious conditions like ectopic pregnancy, appendicitis, etc. Prompt referral to the relevant specialist or A & E department is Treatment for Syphilis
Primary syphilis: non painful genital ulcer Secondary syphilis: general malaise, fever, skin rash, mouth ulcer, condylomata lata, Tertiary syphilis: latent, cardiovascular syphilis, neurosyphilis, gumma Dark ground microscopy for exudate for 3 consecutive days to demonstrate the By syndromic
P.S., S.S., E.L.S.
N.S., Ocular syphilis
cardiovascular
syphilis
• Doxycycline 100 mg • Doxycycline 100 mg • Doxycycline 100 mg • Tetracycline 500 mg • Tetracycline 500 mg • Tetracycline 500 mg • Erythromycin 500 mg • Erythromycin 500 mg • Erythromycin 500 mg P.S.= primary syphilis; S.S.= secondary syphilis; E.L.S.= early latent syphilis; L.L.S.= late latent syphilis; N.S.= neurosyphilis NOTE: 1. Doxycycline, Tetracycline should not be used during pregnancy or lactation.
2. Steroid cover with Prednisolone 30 mg daily is recommended to prevent Jarish Herxheimer reaction in the treatment of cardiovascular, neuro and ocular syphilis. 3. Baby delivered to woman with syphilis should be treated by Procaine Penicillin 50,000 units/kg i.m.i. daily for 10-15 days if the mother had not been treated by penicillin regimen during her gestation. 4. Benzathine Penicillin 2.4 megaunit i.m.i. weekly for 3 weeks is a less ideal treatment regimen for syphilis nowadays because the level achieved in the CSF is not good enough to prevent CNS involvement by the Treponema pallidum. It is, however, acceptable if the compliance to daily treatment or follow-up cannot be assured. Management of genital growth
Warty or non-warty growth over genital area or perianal area. The diagnosis include important STDs like genital wart, molluscum contagiosum or normal anatomical structures like fordyce spots, pearly penile papules (pseudo-condyloma of vulva) or skin conditions like skin tag, angiokeratoma, scabetic Diagnosis is usually based on clinical assessment according to the clinician's The role and interpretation of detecting HPV-DNA is still waiting to be defined. By syndromic
Management:
z Refer to specialist if the diagnosis is not certain. z Assess for risk factors and advise on safer sexual practice. z 0.5% purified Podophyllotoxin solution or 0.15% cream topically twice daily for 3 consecutive days weekly for up z Imiquimod 5% cream, 3 times a week for as long as 16 z Trichloroacetic acid (TCA) 30% solution weekly z Podophyllin resin 20% may also be used cautiously for selected cases and limited duration under specialist z Refer to specialist if the response is not satisfactory. Podophyllin and Podophyllotoxin are contraindicated in pregnant women. Routine use of Podophyllin is not recommended in primary health care setting. Flow-chart for Urethral
Discharge Syndrome in Men
• Educate for
• Promote/provide
• Treat for gonorrhoea and
chlamydia
• Educate for behavioural
• Promote/provide condoms
Flow-chart for
Vaginal Discharge Syndrome
• Treat for vaginitis
• Educate for behavioural
• Promote/provide condoms
• Treat for cervicitis and
vaginitis
• Educate for behavioural
• Promote/provide condoms
Refer to A & E department of hospital or relevant specialist for acute abdominal conditions like appendicitis, ectopic pregnancy, pelvic inflammatory disease. Flow-chart for
Genital Ulcer Syndrome
• Educate for behavioural
• Promote/provide condoms
• Education for behavioural change
• Promote/provide condoms
• Treat for syphilis
• Educate for behavioural change
• Promote/provide condoms
Flow-chart for
Genital Growth
• Promote/provide condoms
• Educate for behavioural change
• Ask for VDRL & HIV Ab
testing
• Promote/provide condom

Source: http://www.pdqa.gov.hk/english/pd/cme/files/std_case_management.pdf?PHPSESSID=a3bf2584e6d52fe194177f080be1a844