Department of Reproductive Health and Research (RHR), World Health Organization
Guidelines for the management
Revised version - 2003 - 98 pages
For-sale publication* - Order number 1150565
Swiss francs 20. - In developing countries Sw.fr. 14. WHO bookshop
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*A limited number of copies are available from the Reproductive Health Documentation Centre, on special request, free of charge to developing countries.
Sexually transmitted infections (STIs) remain a public health problem of major signifi cance 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, including infertility, fetal wastage, ectopic pregnancy, anogental cancer and premature death, as well as neonatal and infant infections. The individual and national expenditure on STI care can be substantial.
The appearance of HIV and AIDS has focused greater attention on the control of 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.
The emergence and spread of HIV infection and AIDS have also complicated the management and control of some other STIs. For example, owing to HIV-related immunosuppression, the treatment of chancroid has become increasingly diffi cult in areas with a high prevalence of HIV infection.
Antimicrobial resistance of several sexually transmitted pathogens is increasing, rendering some regimen ineffective. New agents, such as third-generation cephalosporins and fl uoroquinolones, capable of treating infections with resistant strains, are available but remain expensive. However, their initial high cost must be weighed against the costs of inadequate therapy, including complications, relapse and further transmission of infection.
RATIONALE FOR STANDARDIZED TREATMENT RECOMMENDATIONS
Effective management of STIs is one of the cornerstones of STI control, as it prevents the development of complications and sequelae, decreases the spread of those infections in the community and offers a unique opportunity for targeted education about HIV prevention.
Appropriate treatment of STIs at the fi rst contact between patients and health care providers is, therefore, an important public health measure. In the case of adolescent (1) patients, there is the potential to influence future sexual behaviour and treatment-seeking practices at a critical stage of development.
It is strongly recommended that countries establish and use national standardized treatment protocols for STIs. These can help 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. Finally, having a standardized list of antimicrobial agents can also facilitate drug procurement.
It is anticipated that the recommendations contained in this document will help countries to develop standardized protocols adapted to local epidemiological and antimicrobial sensitivity patterns. It is recommended that national guidelines for the effective management of STIs be developed in close consultation with local STI and public health experts.
STI case management is the care of a person with an STI-related syndrome or with a positive test for one or more STIs. The components of case management include: history taking, clinical examination, correct diagnosis, early and effective treatment, advice on sexual behaviour, promotion and/or provision of condoms, partner notifi cation and treatment, case 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 consideration and care of the patient’s reproductive health.
Etiological diagnosis of STIs is problematic for health care providers in many settings. It places constraints on their time and resources, increases costs and reduces access to treatment. In addition, the sensitivity and specificity of commercially available tests can vary significantly, affecting negatively the reliability of laboratory testing for STI diagnosis. Where laboratory facilities are available they must be staffed by suitably qualified personnel with adequate training to perform technically demanding procedures, and the establishment of external quality control must be made mandatory.
Many health care facilities in developing countries lack the equipment and trained personnel required for etiological diagnosis of STIs. To overcome this problem, a syndrome-based approach to the management of STI patients has been developed and promoted in a large number of countries in the developing world. The syndromic management approach 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 of, or the most serious, organisms responsible for producing a syndrome. WHO has developed a simplified tool (a flowchart or algorithm) to guide health workers in the implementation of syndromic management of STIs.
Syndromic management for urethral discharge in men, and genital ulcers in men and women, has proved to be both valid and feasible. It has resulted in adequate treatment of large numbers of infected people, and is inexpensive, simple and very cost-effective. However, recent data have indicated that herpes simplex virus type 2 (HSV2) is fast becoming the commonest cause of genital ulcer disease (GUD) in developing countries. This may negatively affect the treatment outcome of GUD if antiviral therapy is not appropriately instituted.
WHO’s simplified generic tool includes flowcharts for women with symptoms of vaginal discharge and/or lower abdominal pain. While the flowcharts for abdominal pain are quite satisfactory, those for vaginal discharge have limitations, particularly in the management of cervical (gonococcal and chlamydial) infections. In general, but especially in low-prevalence settings and in adolescent females, endogenous vaginitis rather than an STI is the main cause of vaginal discharge. Attempts made to increase the sensitivity and specificity of the vaginal discharge flowchart for the diagnosis of cervical infection, by introducing an appropriate, situation-specific risk assessment, have not been successful. Some of the risk assessment questions based on demographics, such as age and marital status, tend to classify too many adolescents as being at risk of cervical infection. Therefore, there is a need to identify the main STI risk factors for adolescents in the local population and tailor the risk assessment accordingly. For adolescents in particular it may be preferable to base the risk factors on sexual behaviour patterns.
Further details on recommendations for treatment using a syndrome-based approach are given in section 2. 1.5.
RISK FACTORS FOR STI-RELATED CERVICITIS
The flowcharts currently available for the management of cervical infection, referred to in section 1.4, are therefore far from ideal. Initially, it was thought that the finding of vaginal discharge would be indicative of both vaginal and cervical infection. However, it has become clear that while vaginal discharge is indicative of the presence of vaginal infection, it is poorly predictive of cervical infection (gonococcal and/or chlamydial), particularly in adolescent females.
Some clinical signs seem to be more frequently associated with the presence of cervical infection. In the published literature, clinical observations that have consistently been found to be associated with cervical infection are the presence of cervical mucopus, cervical erosions, cervical friability and bleeding between menses or during sexual intercourse.
A number of demographic and behavioural risk factors have also been frequently associated with cervical infection. Some of those, which in some settings have been found to be predictive of cervical infection, are: being less than 21 years old (25 in some places); being unmarried; having more than one sexual partner in the previous three months; having a new partner in the previous three months; having a current partner with an STI; recent use of condoms by the partner. Such risk factors are, however, usually specifi c for the population group for which they have been identifi ed and validated, and cannot easily be extrapolated to other populations or to other locations. Most researchers have suggested that it is important to obtain more than one demographic risk factor in any particular patient. Adding these signs and a risk assessment to the vaginal discharge fl owchart does increase its specifi city and, therefore, its positive predictive value, although the latter remains low especially when the fl owchart is applied to populations with relatively low rates of infection.
SELECTION OF DRUGS
Antimicrobial resistance of several sexually transmitted pathogens has been increasing in many parts of the world and this has rendered some low-cost regimen ineffective. Recommendations to use more effective drugs frequently raise concerns about cost and possible misuse.
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 confi dence in health services. This approach is not recommended. The drugs used for STI treatment in all health care facilities should have an effi cacy of at least 95%. Criteria for the selection of drugs are listed in the box below.
Criteria for the selection of STI drugs
Drugs selected for treating STI should meet the following criteria:
Appropriate drugs should be included in the national essential drugs list and in choosing drugs, consideration should be given to the capabilities and experience of health personnel.
(1) WHO has defined adolescents as persons in the 10–19 years age group, while youth has been defined as the 15–24 years age group. “Young people” is a combination of these two overlapping groups covering the range 10–24 years (A picture of health? A review and annotated bibliography of the health of young people in developing countries. Geneva, World Health Organization, 1995 [WHO/FHE/ADH/95.4]).