FHI - Chapter 8

STD Syndrome Management

Preview Chapter 8

IntroductionThe essence of STD control is comprehensive case management. Patients receive immediate health benefits from prompt and effective detection and treatment. In addition, the population benefits from decreased STD incidence and prevalence due to a reduction in the duration of patient infectiousness.

The Syndromic Approach

The syndromic approach to STD case management involves the detection of a syndrome–symptoms and signs associated with a number of well-defined etiological agents. It relies on the use of a clinical flowchart–a step-by-step standardized guide to medical decision making. Once a syndrome has been identified, treatment can be provided for the majority of the organisms responsible for that syndrome. The syndromic approach is well suited to resource-poor settings and enables health-care workers to make a diagnosis within a short time without special skills and sophisticated laboratory tests.

Design of Flowcharts

A team of public health specialists should design diagnostic and therapeutic flowcharts for use at the national level. Background information on local etiologies of STD syndromes, including mixed etiologies, is essential. Data on validity and cost-effectiveness can be obtained from the literature or from special studies described in detail here. Decisions on cost-effective treatments must be based on local or regional antimicrobial susceptibility patterns, results of treatment trials, toxicity data and drug cost.

Feasibility should always be assessed before a flowchart is introduced. Such an assessment should determine whether a flowchart is operational, acceptable to provider and patient, and adaptable.

Most Common STD Syndromes and Flowcharts

Flowcharts in use that manage the most common STD syndromes include the following:

Urethral discharge syndrome in men
Epididymitis: a complication of untreated urethral syndrome
Lower genital tract syndrome (LGTS)
Pelvic inflammatory disease (PID): a complication of untreated endocervicitis
Genital ulcer syndrome (GUS)

Conclusion

Syndromic diagnosis and treatment is perfectly adapted to primary health-care settings because it is simple, rapid and does not depend on elaborate laboratory tests. By using clinical flowcharts, syndromic guidelines can be implemented in a standardized way on a large scale.

Local data on etiology and antimicrobial susceptibility are necessary in designing an effective flowchart, and there is no one flowchart that is universally applicable. Every flowchart represents a compromise between diagnostic accuracy and technical and financial realities.

A syndromic approach for managing patients with STDs is currently in use in many developing countries, resulting in well accepted, quality STD care in primary health-care settings.

Introduction

Comprehensive case management of STDs is the cornerstone of STD control. Prompt and effective case detection and treatment result in immediate health benefits for individual patients. Furthermore, reducing the duration of patients' infectiousness decreases the incidence and prevalence of STDs in the population. Curative services for STDs offer unique opportunities for health education, including the promotion of condom use for those at greatest risk of acquiring STDs and HIV infection. Finally, it is possible to detect and treat asymptomatic STDs by identifying the contacts of STD patients (see Chapter 11).

Case Management In Developing Countries

Developing-country health providers at all levels, in both the public and private sectors, are likely to be confronted with many patients with STDs. In some developing countries, STD-related complaints are among the most common reasons why adults seek health care.¹

Primary health care facilities in developing countries and other resource-poor settings face several constraints to the optimal management of patients with STDs. These constraints include:

Lack of access to the laboratory technology necessary for making etiologic diagnoses of STDs
Shortages of well-trained staff
High workloads and limited staff time available per patient.

The Syndromic Approach

In resource-poor settings the appropriate diagnostic tool should enable health care workers to make a correct diagnosis in most patients:

Without sophisticated laboratory tests
Without specialized skills
Within a short time, and preferably without the need for a repeat visit by the patient

The syndromic approach allows health care workers to make a diagnosis without sophisticated laboratory tests. This approach is based on identifying a syndrome–a group of symptoms and easily recognized signs associated with a number of well-defined etiologies. Once a syndrome has been identified, treatment can be provided for the majority of the organisms responsible for that syndrome.

Several STD syndromes can be managed easily and rapidly using clinical flowcharts for diagnosis and treatment. A clinical flowchart (also known as an algorithm or decision tree) pictures a path of diagnostic reasoning. It is a logical, step-by-step, standardized guide to medical decision making. The World Health Organization (WHO) recommends that national STD control programs incorporate diagnostic and therapeutic flowcharts into their STD management guidelines.²

Advantages of Flowcharts

Standardization

Flowcharts rationalize and standardize clinical decision making. Their use also can standardize diagnosis, treatment and referral. Such standardization:

Makes STD reports from different health facilities comparable
Simplifies STD data collection and analysis, which in turn facilitates surveillance and planning (e.g., the purchase of drugs and other supplies)
Facilitates supervision of health care workers because the approach is the same in every health facility
Ensures that STD patients receive the same treatment for a given condition in every health facility, enhancing confidence in health services
Delays the development of antimicrobial resistance of sexually transmitted microorganisms

Training Tool

Training must reflect reality and be problem-oriented. Flowcharts are useful training tools because they are based on the presenting symptoms and show the path of diagnostic reasoning to reach a proper diagnosis and to prescribe the best treatment.³The skills of history taking and physical examination must not be neglected in this approach. Health care workers should learn to ask the most relevant questions, including questions on sexual behavior, and to look for the most important physical signs (see chapter 6). Active participation of students in the logical, step-by-step construction of flowcharts is educationally beneficial and facilitates their acceptance and use.

Design of Flowcharts

A team of public health specialists should design diagnostic and therapeutic flowcharts for use at the national level. Key people to involve in the design include the coordinators of national programs, including STD/AIDS control, primary health care, essential drug, family planning, and maternal and child health. In some situations it is advisable to ask specialists such as gynecologists, microbiologists, genito-urinary specialists and pharmacists to participate. The involvement of these specialists can help ensure their cooperation and increase the acceptance of the flowcharts.

To ensure that as many patients as possible receive correct diagnoses, background information on local etiologies of STD syndromes, including mixed etiologies, is essential in designing an STD management flowchart. Data on validity and cost-effectiveness can be obtained from the literature or from special studies (see below). Decisions on the most cost-effective treatments must be based on local or regional antimicrobial susceptibility patterns, results of treatment trials, toxicity data and the cost of the drugs.

To ensure efficient management of STDs, flowcharts should be adapted to the level of development of the health services. Feasibility is determined by:

The presence of laboratory facilities
The infrastructure available for physical examination (availability of an examination room with privacy, examination table, adequate specula, gloves and light source, and facilities to disinfect specula regularly)
The level of training of personnel (e.g., are they able to perform a speculum examination?)
Access to a higher-level health care facility
The drugs available in health care facilities
The staff time available per patient

Local and cultural perceptions about STDs and health-seeking behavior will to a large extent determine the usefulness of certain flowcharts. For example, when designing a flowchart one should consider whether a genital examination by a health care worker of the opposite sex is culturally acceptable.

Evaluation and Validation of Flowcharts

The three parameters to be assessed in the evaluation of flowcharts are:

Validity
Cost-effectiveness
Feasibility

Validity: sensitivity and specificity

Sensitivity and specificity are assessed by comparing the outcome of a diagnosis made with the flowchart with a gold standard diagnosis.

The sensitivity of the flowchart is defined as the proportion of infections detected by the flowchart (A/A+C). The specificity is the proportion of patients without infection who are correctly identified by the flowchart (D/B+D). The positive predictive value (PPV) of the flowchart represents the proportion of diagnoses confirmed by a gold standard laboratory diagnosis (A/A+B). The negative predictive value (NPV) represents the proportion of negative results confirmed by laboratory diagnosis (D/C+D; see example, Box 1).

When all patients presenting with a symptom (such as urethral discharge) are treated syndromically, all boxes in the row "flowchart-" becomes 0, and the sensitivity is always 100 percent, while the specificity is indeterminate. In that case, it is more important to assess the positive predictive value of the flowchart for different etiologies.

Sample size

To determine the sample size needed to test the validity of a flowchart, a sample size calculation for a binomial proportion is used as described below. The sample size (N) will depend on the:

Z score, which is 1.96 for the confidence level 95%
Expected sensitivity of the flowchart: p (one may also use the expected specificity or positive predictive value)
Desired precision of this expected proportion: L
Prevalence of the STD in the group to which the flowchart will be applied

Box 1: Calculating the Sensitivity and Specificity of a Flowchart
Of 255 women who presented with vaginal discharge at a primary health care center, 85 were diagnosed with cervicitis, based on symptoms and the clinical sign of endocervical mucopus. At the same time, samples were taken to perform the gold standard analysis, which consisted of culture for Neisseria gonorrhoeae and enzyme-linked immunosorbent assay (ELISA) for chlamydial infection. After adding the results of the gold standard diagnosis, we can calculate the following:
	Cervicitis by GC Culture and Chlamydia ELISA
		+	-	Total
	Flowchart+	15	70	85
	Flowchart-	30	140	170
	Total	45	210	255
Prevalence of gonococcal or/and chlamydial cervicitis in this population: 45/255 = 17.60%
Validty of the alogrithm:
	sensitivity:	15/45	=	33.3%
	specificity:	140/210	=	66.6%
	PPV:	15/85	=	17.6%
	NPV:	140/170	=	82.3%

The formula for sample size is:

      (1.96)² x p x (1 — p)
N =  ---------------------- 
               L²

Example: We want to assess the sensitivity of a flowchart on vaginal discharge for the diagnosis of gonococcal and/or chlamydial cervicitis. We expect a sensitivity of 70 percent and want a precision of 10 percent (range of sensitivity from 60 to 80 percent). The number of infections needed to test the validity of a flowchart will be:

      (1.96)² x 0.70 x 0.30
N =  ---------------------- 
               0.10²

N = 80.7, or 81 infections.

Therefore, if the prevalence of gonococcal and/or chlamydial infections in a population of women with vaginal discharge is, say, 25 percent, the sample size will be 81/0.25 = 324 symptomatic women.

Practical issues

The study population for validity testing has to be as representative as possible of the population in which a flowchart will be used. As long as enough STD patients are consulting to reach the necessary sample size within a reasonable time and a reference laboratory is available for the gold standard tests, a primary health care setting is suitable. In general, sophisticated laboratory tests are needed for gold standard diagnosis. If some patients consulting at the primary health care level have already taken drugs, it is important not to exclude them from the validity study.

When testing the validity of flowcharts, it is preferable to have two examination rooms. In one room, a health care worker can follow the directives of the flowchart and make a therapeutic decision. Then the patient can be asked to enter a second room, where a more systematic examination can be done and where specimens will be taken for the gold standard laboratory tests. Because a speculum examination is sometimes not included in STD flowcharts, using such a setting will ensure that the therapeutic decision is not based on the findings of the speculum examination.

The likely outcomes of diagnoses made using a flowchart can be simulated retrospectively, using data from history taking, physical examination and laboratory tests. This desk exercise can be very useful for evaluating modifications to flowcharts without repeating studies. For example, it could be used to assess what would happen to the specificity of a flowchart if the gram stain examination were omitted.

Interpretation of the sensitivity and specificity of a diagnostic flowchart

Example for gonococcal and/or chlamydial cervicitis

A low sensitivity of the symptoms/signs implies that only a small proportion of the gonococcal and/or chlamydial infections will be detected with the flowchart, which relies only on symptoms and signs for treatment decisions. Missed cases place the infected person at continued risk of more serious complications and result in further disease dissemination.¹

A low specificity means that many negative cases are wrongly considered positive. This results in over treatment, leading to:

Unnecessary side effects, drug costs and partner notification
The psychological cost of inappropriate labeling

Do all flowcharts need to be validated in all countries?

Most flowcharts for urethral discharge and genital ulcers have been shown to be sufficiently valid in different settings that they can be used widely without repeating a validity test. The validity of a hierarchical flowchart starting with the symptom vaginal discharge is under discussion. In a few countries, WHO and AIDSCAP are testing and comparing the classical flowchart for vaginal discharge and a flowchart based on a risk score. Other countries from the same regions can rely on these results to guide them in developing their own national flowcharts.

Cost-effectiveness

The cost-effectiveness of a flowchart can be calculated in many different ways. It is not within the scope of this chapter to describe in detail the methodology of cost calculation. Only the cost per patient will be discussed comprehensively, with general comments on the cost per case cured and long-term costs. A relative estimate of these costs can be made without sophisticated calculation based on the positive predictive value (PPV), treatment efficiency and sensitivity.

Cost/patient

The cost per patient C is the cost incurred by the health structure in applying a flowchart to one patient. It is the sum of all the costs of diagnosis and treatment divided by the total number of patients for whom the flowchart is used.

Or:

C = (P_d x Diagnosis) + (P_t x Treatment)

Wherein P is a proportion, Pd is the proportion of patients who will undergo diagnosis (examinations, tests) and Pt is the proportion of patients who will be treated.

Example

Take, as a consideration, 200 men attending a health center to seek treatment for urethral discharge. On clinical examination, 180 of these men had urethral discharge. Of the 180 men with urethral discharge, 140 had a positive Gram stain.

According to flowchart A (not shown), treatment for gonorrhea and chlamydial infection is given to all patients with clinically confirmed urethral discharge. According to flowchart B (not shown), a Gram stain is performed. If intracellular gram-negative diplococci (IGND) are seen on Gram stain, treatment will be given for both infections. If no IGND are seen, the patient will be treated only for chlamydial infection. We want to know which of the two flowcharts is the cheapest.

The prices used in this exercise were: U.S. $0.10 for a physical examination (gloves, disinfectant), U.S. $0.30 for a Gram stain, U.S. $0.50 for Chlamydia infection treatment (doxycycline, seven days) and U.S. $2.50 for a treatment for gonorrhea (norfloxacin, one dose).

The cost per patient applying flowchart A would be:

C = (200/200 x U.S.$0.10) + (180/200 x U.S.$3.00) = U.S.$2.80

The cost per patient applying flowchart B would be:

C = (200/200 x U.S.$0.10) + 

    (180/200 x U.S.$0.30) + 

    (140/200 x U.S.$3.00) +

     (40/200 x U.S.$0.50) = U.S.$2.57

Cost/case cured

The cost per case cured is the cost per case completely cured when a flowchart is applied to every patient. It is the sum of all costs of diagnosis and treatment divided by the number of cases diagnosed, treated and cured. If a patient had more than one infection, every infection successfully treated is considered one case cured.

The cost per case cured will be determined by the PPV of the flowchart: the higher the PPV, the lower the cost per case cured. The PPV itself is determined by the prevalence of that STD and the specificity of the flowchart.

Long-term costs

Long-term costs will be determined in part by the cost of complications and sequelae, such as urethral stricture, chronic pain, extra-uterine pregnancies and infertility. These complications can be minimized by prompt and effective treatment. If a flowchart has a low sensitivity, missed or incorrectly treated infections will result. Treatment failure is also associated with the resistance pattern of the antibiotic used. Thus the higher the sensitivity of the flowchart and the more effective the treatment, the lower the long-term costs will be. A balance must be reached between immediate costs and long-term costs.

Long-term costs also depend on days lost from work by STD patients and the number of additional people infected by someone with an STD, including secondary HIV infections. These long-term costs are very difficult to estimate.

Feasibility testing

Feasibility should always be assessed before a flowchart is introduced. Such an assessment should determine whether a flowchart is:

Operational: does a given health care facility or group of facilities have the material and skills to implement it?
Acceptable: will the method be accepted by health care workers and will STD patients comply with diagnosis and treatment?
Adaptable: can the method be adapted to different settings and changing circumstances?

Questions about whether a flowchart is operational and acceptable can be answered by analyzing available information. Acceptability and adaptability can be tested quickly in small-scale pilot studies. Patient acceptability can be assessed through "exit interviews" with patients as they leave the clinic, and health care workers can be interviewed before and after using the flowchart. Interviews and observations of health care workers are important tools for assessing the practicality as well as the acceptability of the flowchart.

Most Common STD Syndromes and Flowcharts

This section presents flowcharts currently in use to illustrate some of the different options for managing the most common STD syndromes.

Thumbnail graphic linked to larger clearer version of the same.

Gonorrhea is the main cause of urethritis among clinic attenders in most developing countries. In recent years, however, as diagnostic techniques for chlamydia have become more sensitive, the role of chlamydial and mixed infections in causing urethritis in developing countries is also becoming better defined.^4,5 Some clinicians rely on the characteristics of urethral discharge to differentiate between gonococcal and non-gonococcal urethritis (NGU). Gonococcal urethritis tends to be more purulent and NGU more mucoid. However, these clinical signs are not sufficiently discriminatory to predict the etiology or cause of urethral discharge in a given patient.⁶ In addition, they can be confounded by prior, ineffective treatments patients may have taken before coming to a clinic.

Two examples of flowcharts for urethral discharge are shown in Figures 1 and 2. The first example (Figure 1) is a simple syndrome management treating every man with a complaint of urethral discharge for gonococcal and NGU. A sequential treatment (first, treatment for gonorrhea and, if this fails, treatment for NGU) has been the policy in the past in some countries in order to limit unnecessary treatments. However, because of a large proportion of missed chlamydial infections, and because many patients fail to come back, this approach can no longer be recommended.

In the second flowchart (Figure 2), Gram stain is added to a syndromic approach. Depending on the result of the Gram stain, a syndromic treatment or a treatment for NGU will be given. This approach offers the advantage of reducing unnecessary treatments (including expensive gonorrhea drugs) for the patient and his partner by increasing the specificity of the flowchart.

A flowchart including Gram stain can only be considered when laboratory facilities are available. Results should be given within a reasonable time so that patients do not have to return to the health facility for treatment the next day.Acute epididymitis in men ages 15 to 35 is most often STD-related.⁷In the 1930s, before antibiotics were available, epididymitis occurred in 10 to 30 percent of cases of gonococcal urethritis.⁸ Figure 3 shows an example of a flowchart for epididymitis.

The symptoms of cervicitis and vaginitis overlap. Abnormal (in amount, color or odor) vaginal discharge is the symptom most commonly presented, but it is more predictive for vaginitis than for cervicitis.^9,10 The sensitivity of the symptom vaginal discharge for cervicitis varies from 25 percent (prostitutes in Zaire)11 to 48 percent (STD patients in USA).¹² Cervical mucopus and induced endocervical bleeding have a high specificity (83 to 99 percent) but a low sensitivity (1 to 43 percent) as clinical signs for cervicitis.^11,13 Examples of flowcharts for LGTS are shown in Figures 4 and 5.Figure 4 shows a flowchart for situations in which a speculum examination is not possible. The most probable cause of a woman complaining of vaginal discharge is vaginitis. Cervicitis is a less frequent cause of a consultation for vaginal discharge, but the complications of untreated cervicitis are much more serious.

Several studies in pregnant and asymptomatic women have demonstrated that risk markers, rather than signs and symptoms, are predictive for gonococcal and/or chlamydial cervicitis.^11,13 The World Health Organization proposed incorporating a risk assessment as part of the diagnostic flowcharts for symptomatic women to increase their sensitivity. With this flowchart, a woman with a complaint of vaginal discharge is treated systematically for vaginitis (the most probable cause of vaginal discharge and the reason for her visit to the health center), but at the same time her risk for cervicitis is assessed. If her risk assessment is positive, she will receive treatment for gonococcal and chlamydial infection as well. The risk assessment flowchart for LGTS still needs more validation and adaptation to different cultural settings. The feasibility and acceptability of asking these highly personal questions (such as number of partners) should also be assessed.

In situations where a speculum examination is possible, the clinician can try to differentiate between various etiologies of vaginal discharge. The clinical sign mucopus, however, is not sensitive enough to be the only indication for cervicitis treatment (see Figure 5).

An alternative for differentiating etiologies for vaginitis can be offered by simple laboratory tests, if the infrastructure is available. Direct examination of a vaginal wet mount is useful for detecting trichomonads and yeast forms. Determination of the vaginal pH and amine odor with 10 percent potassium hydroxide solution can be helpful in the diagnosis of bacterial vaginosis. But no simple laboratory test has been developed so far for detecting cervicitis. Adding Gram stain for the detection of intracellular gram-negative diplococci or leukocytes in the endocervix does not offer any advantage, as the sensitivity will drop dramatically.^9,10 The leukocyte esterase dipstick, which has a good sensitivity for detecting male urethritis,14 had a sensitivity of only 47 percent for the detection of cervicitis.¹⁵PID is a common complication of untreated gonococcal and/or chlamydial cervicitis and results in tubal scarring and occlusion. This can lead to ectopic pregnancy–a serious, possibly life-threatening complication. Most infertility problems in the developing world are attributed to prior upper genital tract infections.¹⁶

An example of a clinical flowchart for detecting PID is shown in Figure 6. Because of the serious complications of PID, the flowchart should start with a very sensitive symptom. Lower abdominal pain is more sensitive for PID than fever.¹⁷ It is important that surgical and obstetrical emergencies such as peritonitis and extra-uterine pregnancy are immediately referred.

Many studies have tried to describe a "typical" clinical picture for the different etiological diagnoses of GUS, but have failed.^18—22 Descriptions such as regular shape, smooth base, undermined edge, friability, tenderness and purulence are not sufficiently discriminatory (even for experienced clinicians) to make an etiological diagnosis in most cases. In a study in South Africa of 210 patients with genital ulcers, clinical diagnosis was compared with a gold standard laboratory test. Clinical diagnosis had a positive predictive value of 89 percent for chancroid, 47 percent for syphilis and 19 percent for genital herpes.¹⁸Dual infections were common, making an etiological diagnosis even more difficult. Without sophisticated laboratory tests, an etiological diagnosis of GUS is impossible.

The relative frequencies of the different causes of GUS vary between geographical areas (see Table 1) but can also vary in time. For example, two studies on the etiologies of GUS, in Rwanda in 1986 and 1992, found that there was a shift in the relative frequencies of the different etiologies. As the prevalence of HIV infection increased, herpes became more important as an etiology of GUS.23

In many developing countries, the etiologies of GUS most frequently found are syphilis and chancroid. Both are treated with simple antibiotics (erythromycin and benzathine penicillin, respectively).

An antiviral therapy for herpes is not available in most primary health care settings. It is important to treat for chancroid and syphilis, even if some of the genital ulcers treated are actually caused by herpes.

In Rwanda, three different approaches were compared for the management of syphilis and/or chancroid. The syndromic approach (Figure 7) resulted in 99 percent of the patients with syphilis and/or chancroid correctly managed. For the approach based on the result of a Rapid Plasma Reagin (RPR) test (if RPR positive, treat for syphilis, if RPR negative, treat for chancroid) and for a clinical etiological approach, the proportions of correctly managed patients were 82 percent and 38 percent, respectively.²³

Including an RPR test in a hierarchic model is not an improvement in genital ulcer case management, because many chancroid cases are missed. However, based on the Rwanda data, including an RPR test in a syndromic approach (treating all RPR positive patients for both syphilis and chancroid, and all RPR negative patients for chancroid alone), leads to a reduction in unnecessary syphilis treatment of patients and their partners.²³

Congenital STD Syndromes

See Chapter 9 for information on these syndromes.

Comprehensive Case Management

In addition to diagnosis and treatment, comprehensive case management includes partner treatment, health education, and condom education, promotion and distribution. To remind health care workers of these aspects of case management, short messages could be added to the flowchart as shown in Box 2.

Partner Treatment

Partners of patients with an STD are likely to be infected themselves and should be offered treatment. Partner notification and referral can be one of the most important ways to detect and treat asymptomatic patients. Confidentiality, a nonjudgmental attitude and the absence of coercion are important for the success of partner notification. WHO recommends that epidemiological treatment (treatment based solely on the diagnosis of the index patient without any laboratory investigation) be given to all partners.²

An important implication of the low positive predictive value of some flowcharts is the over treatment of partners, resulting in unnecessary drugs given and the psychological cost of inappropriate labeling (see Chapter 11).

Health Education

Patients seeking STD treatment may be particularly receptive to educational messages, recognizing the personal vulnerability evidenced by their symptoms. With HIV in the picture, people are more likely to welcome advice. Health education focuses on reducing risky behavior such as through the use of condoms or other mechanical barriers, and stresses the importance of partner treatment (see Chapter 10). As time is usually very limited during a consultation, there is a real danger that this opportunity for face-to-face education will be missed.

Condom Distribution

The global effectiveness of condoms for preventing STDs depends on the efficacy of the method and user acceptability. Condom demonstration by the health care provider during the contact with the STD patient is a good way to recruit new users (see Chapter 5).

Conclusion

The syndromic approach makes it possible for almost every health care worker to offer prompt diagnosis and treatment to patients with STD symptoms. Because it is simple, rapid and does not require sophisticated laboratory tests, syndromic diagnosis and treatment is perfectly adapted to primary health care settings.

Through clinical flowcharts, syndromic guidelines can be distributed and implemented in a standardized way on a large–even national–scale. Moreover, flowcharts facilitate and improve training of health care workers in STD management.

A single, universally applicable model for STD flowcharts does not exist. Local data on etiology and antimicrobial susceptibility are needed to design an effective flowchart. The validity and cost-effectiveness of different approaches can in many situations be estimated from the literature or assessed in special studies. Before the introduction of new flowcharts, feasibility and acceptability should be assessed in the given health infrastructure. A flowchart will always be a compromise between diagnostic accuracy and technical and financial realities.

Genital ulcers in men and women and urethritis in men can be adequately managed using a syndromic approach based on symptoms and clinical signs only. For lower genital tract syndrome in women, the new concept of adding a risk score to the syndrome management holds promise as a more sensitive way to detect cervicitis. Ongoing validation and acceptability studies will further demonstrate the advantages of this approach compared with the classical clinical approach.

In many developing countries a syndromic approach for the management of patients with STD is currently being used, resulting in well accepted, quality STD care in primary health care settings. The achievements of an STD control program depend to a large extent on the successful management of STDs at a patient's point of first encounter with the health care system.

Acknowledgments

Our special thanks go to Anne Buvé and Marie Laga of the Institute of Tropical Medicine, Antwerp, Belgium, for comments.

Appendix 1WHO Treatment Recommendations

Urethral dischargeTreatment for gonorrhea and chlamydial infection

Gonorrhea:

Ciprofloxacin 500 mg tab. as a single oral dose

Ceftriaxone 250 mg IM as a single dose

Cefixime 400 mg tab. as a single oral dose

Spectinomycin 2 g IM as a single dose

Alternative regimens which may be useful in some countries, depending on the prevalence of resistant gonococci:

Kanamycin 2 g IM as a single does

Trimethoprim (80mg)/sulfamethoxazole (400 mg) 10 tablets orally for 3 days.

Chlamydial infection

Doxycycline 100 mg tab. orally twice daily for 7 days

Tetracycline 500 mg tab. orally 4 times daily for 7 days

Alternative regimen for patients in whom tetracyclines are contraindicated:

Erythromycin 500 mg tab. orally 4 times daily for 7 days

Epididymitis

Treatment for gonorrhea and chlamydial infection (see "urethral discharge")

Lower genital tract syndrome

Vaginitis: treat for candidiasis and trichomoniasis/bacterial vaginosis

Candidiasis

Nystatin 100,000 units intravaginally daily for 14 days

Miconazole or clotrimazole 200 mg intravaginally daily for 3 days

Clotrimazole 500 mg intravaginally as a single dose

Trichomoniasis/Bacterial vaginosis

Metronidazole 2 g orally in a single dose

Metronidazole 400—500 mg orally twice daily for 7 days

Cervicitis: treat for gonorrhea and chlamydial infection (see "urethral discharge")

Ciprofloxacin is contra-indicated during pregnancy

Doxycycline and tretracycline are contra-indicated during pregnancy

PID

Outpatient therapy: Treatment for gonorrhea and chlamydial infection for 14 days and Metronidazole 400—500 mg orally twice daily for 14 days.

Genital ulcers

Treatment for syphilis and chancroid

Syphilis:

Benzathine penicillin G 2.4 MU IM in a single session

Aqueous procaine penicillin G 1.2 MU IM daily for 10 consecutive days

Chancroid:

Erythromycin 500 mg tab. orally 3 times daily for 7 days

Alternative regimens:

Ciprofloxacin 500 mg tab. as a single oral dose

Ceftriaxone 250 mg IM as a single dose

Spectinomycin 2 g IM as a single dose

Trimethoprim (80 mg)/sulfamethoxazole (400 mg) 2 tablets twice daily for 7 days.

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