Peranan STI dalam Perebakan

Jangkitan HIV

DR. ISKANDAR FIRZADA B. OSMAN

Family Medicine Specialist
Klinik Kesihatan Jaya Gading

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 Modified Syndromic Approach
(MSA)

DR. ISKANDAR FIRZADA B. OSMAN

Family Medicine Specialist
Klinik Kesihatan Jaya Gading

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 Preliminary
 More than 20 sexually transmitted infections (STI).
 Main infection via unprotected sexual intercourse.
 Infection via transplacental; intrapartum; breast milk.
 Epidemiology – true incidence is skewed; under
reporting.

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 Preliminary
 Treatment for sexually transmitted infections (STI);
 Base on aetiology.
 Provided in specialist clinic in hospital.
 1999 (WHO) introduced the Syndromic Approach;
Modified Syndromic Approach – MSA (Malaysia);
 Multiple aetiology share similar symptoms.
 Multiple infections in STI.
 Drugs efficacy.

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 Preliminary
 Incomplete treatment for STI would results in;
 Drug resistance organism.
 STI complications.
 Unwanted effect to fetus, e.g. blindness in
congenital syphilis.
 Persistent infection and reinfection.

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 Objective
General Objective
 To effectively prevent & control sexually transmitted
infections (STI).
Specific Objectives
1. To ensure patient received prompt & efficient
treatment.
2. To provide client-
client-friendly services.
3. To enhance the awareness on sexually transmitted
infections (STI) & the risk of infecting one, therefore,
encouraging patient to utilise services renders.

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 The Syndrome
Syndrome Disease
Male  Urethral discharge  Gonorrhoea & chlamydia
 Persistent urethral
discharge
Female  Lower abdominal pain /  Gonorrhoea, chlamydia &
discomfort bacterial vaginosis
 Vaginal discharge  Cervicitis:
Gonorrhoea & chlamydia
 Vaginitis:
Trichomoniasis & candidiasis
Male & Female  Genital ulcer  Syphilis, chancroid & herpes
genitalis
Neonate  Conjuctival discharge  Ophthalmia neonatorum
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 Advantages
1. Treating multiple infections at one time.
2. Treatment start at first visit.
3. Client
Client--friendly services.
4. Health promotion & counseling.
5. Reducing risk of complication & co-
co -infection.
6. Minimal laboratory investigations.
7. Enable the paramedic to manage the patient.

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 First Visit Patient
Registration

Medical Assistant (MA) / Public Health Nurse (PHN)

History & Physical Examination

Treatment Card MSA 1

YES
Complication? Refer

NO
Treat according to Syndrome:
Genital Ulcer / Vaginal Discharge / Urethral
Discharge / Persistent Urethral Discharge
1. Investigations
2. Treatment Card MSA 2
3. Notification Form
4. Contact tracing by Health Inspector

9 TCA 2 weeks for follow-

follow-up
 Registration
Follow--up Visit
Follow
Medical Assistant (MA) / Public Health Nurse (PHN)

1. Patient’s status & investigation’s result

2. Notify via Notification Form (if necessary)
3. Treatment Card MSA 2

NO
Symptom? Discharge

YES
1. Repeat treatment & investigation
2. TCA 2 weeks for follow-
follow-up

YES
Symptom? Refer

NO

Discharge
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 Vaginal Discharge Syndrome

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 Symptoms of abnormal vaginal discharge

History & Physical Examination (Treatment Card MSA 1)

Abnormal vaginal NO Counseling & Health

discharge? Promotion

YES
Lower abdominal Refer to hospital
pain? YES
NO

Risk assessment: 1. Treat as VAGINITIS

Partner having symptom? NO 2. Advice healthy lifestyle
Or 3. TCA 2 weeks (review investigation)
Risk factor?

YES
1. Treat as CERVICITIS & VAGINITIS
2. Advice healthy lifestyle
3. Counseling
4. Promote and/or supply condom
5. Treat partner
6. TCA 7 days
12 7. Treatment Card MSA 2 & Notification Form
 Risk Factors
1. Age < 21 years old
2. Single
3. Having new sexual partner within last 3
months
4. Having multiple sexual partners

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 Laboratory Investigations
1. Vaginal swab a. Wet mount for Trichomonas vaginalis
b. Gram stain for Candida albicans & ‘clue
cells’
2. Cervical swab a. Gram stain for Gonococci & pus cell
b. Culture for Gonococci (AMIE's charcoal
transport media)
3. VDRL; TPHA; EIA HIV
4. Pap smear

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 Treatment
Cervicitis
 1st Choice
Oral Azithromycin 1 gm STAT
 2nd Choice
IM Ceftriaxone 250 mg STAT &
Oral Doxycycline 100 mg BD x 10 – 14 days
 3rd Choice
IM Ceftriaxone 250 mg STAT &
Oral Erythromycin 800 mg BD x 10 – 14 days

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 Treatment
Vaginitis
Oral Metronidazole 2 gm STAT &
Nystatin Pessaries 100,000 unit daily x 14 days
OR
Clotrimazole Pessaries 200 mg daily x 3 days

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 Urethral Discharge Syndrome &
Dysuria (Male)

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 Symptoms of urethral discharge or dysuria

History & Physical Examination (Treatment Card MSA 1)

YES NO
Discharge?

YES Two-glass urine

Two-
test positive?

NO

YES NO
Ulcer present?
Treat as GONORRHOEA & CHLAMYDIA
1. Advice healthy lifestyle
2. Treat partner
Refer Flow Chart
3. TCA 2 weeks (review investigations); test of cure
(repeat Gram stain & culture for GC) Genital Ulcer
4. TCA 1 week; review test of cure & treat according to
aetiology 1. Counseling & health promotion
2. TCA 2 weeks (review investigation)
18 5. Treatment Card MSA 2 & Notification Form
 Laboratory Investigations
1. Urethral smear
a. Gram stain for Gonococci & pus cell
b. Culture for Gonococci (AMIE’s charcoal
transport media)
2. Two
Two--glass urine test
3. VDRL; TPHA; EIA HIV

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 Treatment
Gonorrhoea & Chlamydia
 1st Choice
Oral Azithromycin 1 gm STAT
 2nd Choice
IM Ceftriaxone 250 mg STAT &
Oral Doxycycline 100 mg BD x 10 – 14 days
 3rd Choice
IM Ceftriaxone 250 mg STAT &
Oral Erythromycin 800 mg BD x 10 – 14 days

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 Treatment
Gonorrhoea & Chlamydia
IF Ceftriaxone & Azithromycin NOT available
 1st Choice
IM Spectinomycin 2 gm STAT &
Oral Doxycycline 100 mg BD x 10 – 14 days
 2nd Choice
IM Spectinomycin 2 gm STAT &
Oral Erythromycin 800 mg BD x 10 – 14 days

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 Persistent Urethral Discharge
Syndrome (Male)

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 Symptoms of persistent urethral discharge / dysuria

History & Physical Examination (Treatment Card MSA 1)

NO 1. Health promotion
Discharge?
2. Refer Dermatologist
YES
1. Repeat treatment
Reinfection or YES 2. Treat partner
Non--compliance?
Non
3. Health promotion
NO
1. Treat as Trichomonas vaginalis & Ureaplasma urealyticum
2. Advice healthy lifestyle
3. Counseling
4. Promote and/or supply condom
5. Treat partner
6. TCA 7 days
7. Notification Form

1. Advice healthy lifestyle

YES 2. Counseling
Getting better?
3. Promote and/or supply condom
NO
Refer to hospital
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 Laboratory Investigations
1. Urethral smear
a. Gram stain for Gonococci & pus cell
b. Culture for Gonococci (AMIE’s charcoal
transport media)
2. Two
Two--glass urine test
3. VDRL; TPHA; EIA HIV

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 Treatment
Trichomoniasis & Ureaplasma urealyticum
 1st Choice
Oral Azithromycin 1 gm STAT
 2nd Choice
IM Ceftriaxone 250 mg STAT &
Oral Doxycycline 100 mg BD x 10 – 14 days
 3rd Choice
IM Ceftriaxone 250 mg STAT &
Oral Erythromycin 800 mg BD x 10 – 14 days

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 Treatment
Trichomoniasis & Ureaplasma urealyticum
IF Ceftriaxone & Azithromycin NOT available
 1st Choice
IM Spectinomycin 2 gm STAT &
Oral Doxycycline 100 mg BD x 10 – 14 days
 2nd Choice
IM Spectinomycin 2 gm STAT &
Oral Erythromycin 800 mg BD x 10 – 14 days

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 Genital Ulcer Syndrome

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 Symptoms of genital ulcer

History & Physical Examination (Treatment Card MSA 1)

1. Health promotion
NO 2. Counseling
Ulcer / Vesicle?
3. VDRL; TPHA; EIA HIV
YES
TCA 2 weeks (review investigations)

Ulcer & no vesicle Small ulcer & vesicle

Refer to M&HO or
FMS; treat as
HERPES
GENITALIS
1. Treat as SYPHILIS & CHANCROID
2. Advice healthy lifestyle
3. Treat partner
4. Follow--up treatment for confirm SYPHILIS
Follow
5. If initial investigations negative; repeat VDRL; TPHA; EIA HIV after 3 months
6. Notification Form
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 Laboratory Investigations
1. Dark ground microscopy
2. Gram stain for Haemophilus ducreyi
3. Tzank smear for multinucleated giant cells
4. VDRL; TPHA; EIA HIV

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 Treatment
Syphilis & Chancroid
 1st Choice
IM Benzathine Penicillin 2.4 mega unit weekly x 2
weeks &
Oral Azithromycin 1 gm STAT
 2nd Choice
IM Benzathine Penicillin 2.4 mega unit weekly x 2
weeks &
IM Ceftriaxone 250 mg STAT

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 Treatment
Syphilis & Chancroid
 NOTE
1. If patient developed allergic reaction to the first dose of
Benzathine Penicillin, DO NOT proceed with the second
dose.
2. If patient allergic towards penicillin, use alternative;
Oral Doxycycline 100 mg BD x 14 days
OR
Oral Erythromycin 800 mg BD x 14 days
3. Oral Doxycycline is contraindicated in pregnancy & during
lactation.
4. If pregnant mother is treated with erythromycin, the baby
must be treated as congenital syphilis according to CPG.
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 Neonatal Conjunctivitis Syndrome

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 Sign of eye discharge (neonate)

History & Physical Examination (Treatment Card MSA 1)

Refer to M&HO or FMS

M&HO or FMS NO
present?
Refer to hospital

YES
Conjunctival swab: Gram stain & culture for Gonococci

1. Treat as GONORRHOEA & CHLAMYDIA

2. Treat mother & spouse for GONORRHOEA & CHLAMYDIA
3. Health promotion
4. Counseling
5. TCA 3 days
6. Notification Form

NO
Getting better? Refer Ophthalmologist

YES
33 Reassure parents
 Treatment
Neonatal Conjunctivitis
IM/IV Ceftriaxone 25 – 50 mg/kg/dose STAT (max.
125 mg) &
Oral Erythromycin 50 mg/kg/day QID x 10 – 14 days
Clean eye with Normal Saline.
Saline.

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 Reference
Manual Pengurusan Pesakit Kelamin (STI) Melalui
‘Modified Syndromic Approach’ Di Peringkat
Penjagaan Kesihatan Primer; Cawangan AIDS/STI,
Kementerian Kesihatan Malaysia; Ogos 2000

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 Thank You
DR. ISKANDAR FIRZADA B. OSMAN
MD (USM), MMed (Family Medicine) (USM),
MAFPM (Mal.), FRACGP (Australia), FAFPM (Mal.),
Fellow in Adolescent Health (Melbourne)

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