Transcript Consultation for National STI Management Guidelines

TREATMENT OF GONORRHOEA
Uncomplicated Anal/ Genital Infection
URETHRAL DISCHARGE
Ciprofloxacin 500 mg orally once only
Yes
Patient
complains of
urethral
Discharge or
dysuria
No
Any other
genital
disease
Discharge
confirmed?
(Ciprofloxacin is contraindicated in
pregnancy and for children or adolescents)
OR
Cefixime 400 mg orally once only
OR
Ceftriaxone 125 mg IM once only
No
Take history
and examine.
Milk urethra
if necessary
Use
appropriate
flow chart
 4 Cs
 Ask patient
to return in
7 days if
symptoms
persist
OR
Spectinomycin 2 gm IM once only
Disseminated Gonococcal infection
Ceftriaxone 1 gm IM or intravenous once daily for
7 days
OR
Spectinomycin 2 gm IM twice daily for 7 days
TREATMENT OF CHLAMYDIA
4 Cs:
1.
3.
Compliance Counseling
Promote & provide Condoms
Counseling for STI prevention,
4.
HIV testing; Educate and
Reassure patient
Partner (Contact) treatment
2.
Yes
Treat for
Gonorrhoea and
Chlamydia
• 4 Cs
• Ask patient to return in
7 days if symptoms
persist
Uncomplicated Anal/ Genital Infection
Doxycycline 100 mg orally twice daily for 7 days
(Not to be used for pregnant women, children or
adolescents)
OR
Azithromycin 1 gm orally once only
Alternative Regimens
Amoxycillin 500 mg orally 3 times a day for 7
days
OR
Erythromycin 500 mg 4 times a day for 7 days
OR
Ofloxacin 400 mg orally twice a day for 7 days
OR
Tetracycline 500 mg orally 4 times a day for 7
days
TREATMENT OF GONORRHOEA
Uncomplicated Anal/ Genital Infection
PERSISTENT URETHRAL DISCHARGE
Patient
complains of
urethral
Discharge or
dysuria
Use
appropriate
flow chart
Yes
Any other
genital
disease
 4 Cs
 Ask patient to
return in 7
days if
symptoms
persist
No
Treat for
Trichomonas
No
Discharge
confirmed?
4 Cs:
1.Compliance
Counseling
2.Promote & provide
Condoms
3.Counseling for STI
prevention, HIV
testing; Educate and
Reassure patient
4.Partner (Contact)
treatment
Yes
Does
History
confirm reinfection or
poor
compliance
• 4 Cs
• Ask patient to
return in 7 days if
symptoms persist
Not
better
Yes
Repeat Urethral
Discharge
Treatment
(Ciprofloxacin is contraindicated in
pregnancy and for children or adolescents)
OR
Cefixime 400 mg orally once only
OR
No
Take history
and examine.
Milk urethra if
necessary
Ciprofloxacin 500 mg orally once only
Refer for
laboratory
tests and
Specialist
Care
Ceftriaxone 125 mg IM once only
OR
Spectinomycin 2 gm IM once only
TREATMENT OF CHLAMYDIA
Uncomplicated Anal/ Genital Infection
Doxycycline 100 mg orally twice daily for 7 days
(Not to be used for pregnant women, children or
adolescents)
OR
Azithromycin 1 gm orally once only
Alternative Regimens
Amoxycillin 500 mg orally 3 times a day for 7
days
OR
Erythromycin 500 mg 4 times a day for 7 days
OR
Ofloxacin 400 mg orally twice a day for 7 days
OR
Tetracycline 500 mg orally 4 times a day for 7
days
TREATMENT OF TRICHOMONAS
Metronidazole 400 or 500 mg orally twice daily for 7
days
OR
Tinidazole 500 mg orally twice daily for 7 days
GENITAL ULCERS
TREATMENT OF HSV-2
Refer for
laboratory
testing and
Specialist
treatment
Patient
complains of
genital ulcer
Yes
 Treat for HSV
 Test and Treat for
syphilis
 4 Cs
 Ask patient to
return in 7 days if
symptoms persist
No
Sore or
ulcer
present
Acyclovir 400 mg 3 times a day for 7 days
Treatment of Recurrent Episodes:
Acyclovir 400 mg 3 times a day for 5 days
Suppressive therapy:
Take history
and examine
Only
vesicles
present
Treatment of First Episode:
Yes
No
 Treat for syphilis
AND HSV
 4 Cs
 Ask patient to
return in 7 days if
symptoms persist
Acyclovir 400 mg twice a day continuously
No
Ulcer(s)
improving
TREATMENT OF SYPHILIS
Early Syphilis (Primary, Secondary or Latent
of less than 2 years duration)
Benzathine Penicillin 2.4 million IU
intramuscularly once
Yes
No
Ulcer(s)
healed
(Due to large volume it is recommended that this
dose be divided and given as 2 injections sites)
Continue
treatment
for
another 7
days
Yes
 4 Cs
 Reassure
For more detailed treatment of syphilis please
see the attached sheet
4 Cs:
1.
Compliance Counseling
2.
Promote & provide
Condoms
Counseling for STI
prevention, HIV testing;
Educate and Reassure
patient
Partner (Contact) treatment
3.
4.
TREATMENT OF GONORRHOEA
Uncomplicated Anal/ Genital Infection
SCROTAL SWELLING
Ciprofloxacin 500 mg orally once only
(Ciprofloxacin is contraindicated in
pregnancy and for children or adolescents)
OR
Patient
complains
of Scrotal
Swelling
No
History and
examination
Swelling/
Pain
Confirmed
4 Cs:
1.
3.
Compliance Counseling
Promote & provide Condoms
Counseling for STI prevention,
4.
HIV testing; Educate and
Reassure patient
Partner (Contact) treatment
2.
Yes
 Reassure
patient
 Provide
analgesics if
needed
 4 Cs
Testes
rotated or
elevated or
history of
trauma
Cefixime 400 mg orally once only
Treat for
Gonorrhoea and
Chlamydia
OR
Ceftriaxone 125 mg IM once only
OR
Spectinomycin 2 gm IM once only
No
• 4 Cs
• Ask patient to
return in 7 days if
symptoms persist
Disseminated Gonococcal infection
Ceftriaxone 1 gm IM or intravenous once daily for
7 days
OR
Spectinomycin 2 gm IM twice daily for 7 days
TREATMENT OF CHLAMYDIA
Yes
Refer for
surgical
evaluation
Uncomplicated Anal/ Genital Infection
Doxycycline 100 mg orally twice daily for 7 days
(Not to be used for pregnant women, children or
adolescents)
OR
Azithromycin 1 gm orally once only
Alternative Regimens
Amoxycillin 500 mg orally 3 times a day for 7
days
OR
Erythromycin 500 mg 4 times a day for 7 days
OR
Ofloxacin 400 mg orally twice a day for 7 days
OR
Tetracycline 500 mg orally 4 times a day for 7
days
TREATMENT OF GONORRHOEA
Uncomplicated Anal/ Genital
Infection
ANAL SYMPTOMS
Discharge
Confirm
on exam
Discharge
Confirmed
Yes
Treat for
Gonorrhoea and
Chlamydia
No
abnormality
No
Ulcers or
blisters
seen
Pain
Examination
(use
proctoscope
if cause not
seen on
inspection)
only
OR
Cefixime 400 mg orally once only
OR
Ceftriaxone 125 mg IM once only
No
Anal
symptoms
Ciprofloxacin 500 mg orally once
Warts
OR
Supportive/
symptomatic
care
Spectinomycin 2 gm IM once
only
Disseminated Gonococcal
infection
Ceftriaxone 1 gm IM or
intravenous once daily for 7 days
OR
Yes
Treat for HSV-2
Test and treat
for Syphilis
Wart removal/
needs
observation for
cancer
Spectinomycin 2 gm IM twice
daily for 7 days
TREATMENT OF CHLAMYDIA
Uncomplicated Anal/ Genital
Infection
Doxycycline 100 mg orally
twice daily for 7 days
OR
Azithromycin 1 gm orally
once only
Alternative Regimens
Amoxycillin 500 mg orally 3
times a day for 7 days
OR
Erythromycin 500 mg 4 times
a day for 7 days
OR
Ofloxacin 400 mg orally twice
a day for 7 days
OR
Tetracycline 500 mg orally 4
times a day for 7 days
TREATMENT OF HSV-2
Treatment of First Episode:
Acyclovir 400 mg 3 times a day for 7 days
Treatment of Recurrent Episodes:
Acyclovir 400 mg 3 times a day for 5 days
Suppressive therapy:
Acyclovir 400 mg twice a day continuously
4 Cs:
1.Compliance Counseling
2.Promote & provide Condoms
3.Counseling for STI prevention,
HIV testing; Educate and
Reassure patient
4.Partner (Contact) treatment
Hemorrhoids
(piles) seen
Ano-Rectal
Fissures
Treat for
Hemorrhoids
(piles)
Refer for
Surgical
evaluation
TREATMENT FOR WARTS
Treatment is meant for external genitalia and vaginal. Please refer to
gynaecologic specialist for cervical warts
Provider administered: Podophyllin 10-25% in compound of tincture
or benzoin. Apply carefully avoiding normal tissue. External genital
genitalia should be washed thoroughly in 1-4 hours. Allow the applied
medicine to dry before removing speculum. Repeat application weekly as
needed.
OR
Cryotherapy (when available). Repeat after 1-2 weeks as needed
Treat for
Gonorrhoea
and
Chlamydia
VAGINAL DISCHARGE
Patient complains of
vaginal discharge,
vulval itching or
burning
No
Yes
History,
examination
and
Risk
assessment*
High NG/CT
prevalence in
community or
high individual
risk profile
Lower
abdominal
pain
Yes
TREATMENT OF GONORRHOEA
Uncomplicated Anal/ Genital
Infection
Ciprofloxacin 500 mg orally once
only
OR
Cefixime 400 mg orally once only
OR
Ceftriaxone 125 mg IM once only
No
OR
Spectinomycin 2 gm IM once
only
Yes
Treat for BV/
Trichomonas
Use Lower
Abdominal pain
flowchart
Abnormal
discharge
or vulval
erythema
Disseminated Gonococcal
infection
Ceftriaxone 1 gm IM or
intravenous once daily for 7 days
OR
Spectinomycin 2 gm IM twice
daily for 7 days
No
Use Appropriate
flowchart
*Risk factors assessed should
include:
 Personal sexual history
(including extramarital sex)
 High risk group
membership
 Community factors such as
STI prevalence in
community.
Vulval edema/curd-like
discharge, erythema,
excoriations present
No
No
Yes
 Reassure patient
 Provide analgesics
if needed
 4 Cs
Treat for
Candida
4 Cs:
1.Compliance Counseling
2.Promote & provide Condoms
3.Counseling for STI prevention, HIV
testing; Educate and Reassure patient
4.Partner (Contact) treatment
Uncomplicated Anal/ Genital
Infection
Doxycycline 100 mg orally
twice daily for 7 days
OR
Azithromycin 1 gm orally once
only
Alternative Regimens
Amoxycillin 500 mg orally 3
times a day for 7 days
OR
Erythromycin 500 mg 4 times
a day for 7 days
OR
Ofloxacin 400 mg orally twice a
day for 7 days
OR
Tetracycline 500 mg orally 4
times a day for 7 days
TREATMENT OF BACTERIAL VAGINOSIS
Metronidazole 2 gm orally once (also treats Trichomonas)
OR
Yes
Any other
genital
disease
TREATMENT OF CHLAMYDIA
TREATMENT OF CANDIDA
Miconazole or clotrimazole 200 mg intarvaginally daily for 3 days
OR
Clotrimazole 500 mg intravaginallly once
OR
Fluconazole 150 mg orally once
Alternate Regimen
Nystatin 100,000 IU intarvaginally daily for 14 days
Clindamycin 2% vaginal cream, 5 gm intravaginally at bedtime for 7
days
OR
Metronidazole 0.75% gel, 5 gm intravaginally twice daily for 7 days
OR
Clindamycin 300 mg orally twice daily for 7 days
Treatment during Pregnancy
First Trimester (only if treatment is imperative): Metronidazole 2 gm
orally once
nd
rd
2 or 3 trimesters: Metronidazole 200- 250 mg 3 times a day for 7
days
Alternative regimen
Metronidazole 2 gm orally once
OR
Clindamycin 300 mg orally twice daily for 7 days
OR
Metronidazole 0.75% gel, 5 gm intravaginally twice daily for 7 days
OUTPATIENT TREATMENT OF LOWER
ABDOMINAL PAIN
LOWER ABDOMINAL PAIN
Ceftriaxone 125 mg IM once only
OR
Appropriate
surgical or
gynecological
referral
Patient complains of
lower abdominal pain
History and
examination (including
gynecological exam)
Any of the following
present:
 Missed or overdue
period
 Recent delivery/
abortion/ miscarriage
 Adnominal guarding
and/or rebound
tenderness
 Abnormal vaginal
bleeding
 Abdominal mass
 intrauterine device
Yes
No
Cervical
motion
tenderness
or lower
abdominal
tenderness
and vaginal
discharge
Any other
illness
found
No
Yes
Appropriate
management
Refer or
Specialist
care
• Manage for
PID
• 4 Cs
• Review in 5
days
No
Patient
improved
Yes
4 Cs:
1.Compliance Counseling
2.Promote & provide Condoms
3.Counseling for STI
prevention, HIV testing;
Educate and Reassure
patient
4.Partner (Contact) treatment
Spectinomycin 2 gm IM once only
PLUS
Doxycycline 100 mg orally twice daily for 7 days
OR
Tetracycline 500 mg orally 4 times a day for 7 days
(both Doxycylcine and Tetracycline are
contraindicated for pregnant women)
PLUS
Metronidazole 400 mg orally twice daily for 14 days
ALL PATIENTS NOT
IMPROVING WITH
OUTPATIENT THERAPY
MUST BE ADMITTED FOR
FURTHER TREATMENT
Continue until treatment
completed




Reassure patient
Provide analgesics if needed
4 Cs
Ask patient to return as needed
Treatment of Syphilis
All patients being considered for STI management must be considered for syphilis testing: All those who test
positive must be treated
Early Syphilis (Primary, Secondary or Latent of less than 2
years duration)
Benzathine Penicillin 2.4 million IU intramuscularly once
(Due to large volume it is recommended that this dose be
divided and given as 2 injections sites)
Alternative Regimen
Procaine Benzyl Penicillin 1.2 million IU intramuscularly once
daily for 10 days
Alternative Regimen (for Penicillin allergic patients and nonpregnant patients)
Doxycycline 100 mg orally twice a day for 14 days
OR
Tetracycline 500 mg orally twice a day for 14 days
Alternative Regimen (for Penicillin allergic patients and
pregnant patients)
Erythromycin 500 mg orally 4 times a day for 14 days
Late Latent Syphilis (Infection of more than 2 years duration)
Benzathine Penicillin 2.4 million IU intramuscularly once a week
for 2 consecutive weeks
(Due to large volume it is recommended that this dose be divided
and given as 2 injections sites)
Alternative Regimen
Procaine Benzyl Penicillin 1.2 million IU intramuscularly once
daily for 20 days
Alternative Regimen (for Penicillin allergic patients and nonpregnant patients)
Doxycycline 100 mg orally twice a day for 30 days
OR
Tetracycline 500 mg orally 4 times a day for 30 days
Alternative Regimen (for Penicillin allergic patients and
pregnant patients)
Erythromycin 500 mg orally 4 times a day for 30 days