Management of STIs/RTIs
Chapter 8. Management of symptomatic STIs/RTIs

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STI case management and prevention of new infections

Many of the above conditions are sexually transmitted and additional steps are required for effective management. Prompt and effective management of STIs reduces the chance of complications for the individual and prevents new infections in the community.

STI case management includes more than diagnosis and treatment. Even when STIs are correctly treated, treatment failure or reinfection commonly occurs. Some people stop taking their medicines as soon as they start to feel better; or they fail to arrange for their sex partners to be treated; or they do not use condoms or abstain from sex during treatment. Drug resistance may also be a reason for treatment failure. Good STI management must always address these issues.

 

Treatment compliance

For treatment of STI to be effective, a full curative dose must be taken (this is also true for non-sexually transmitted RTI). Single-dose treatments thus have an important advantage over multidose treatments which must be taken over several days. When single-dose treatment is not available, health care providers should convince patients of the importance of taking all the medicine prescribed. Patients should be told to finish all the medicine even if they feel better after a few days. They should be warned not to share medicines with others or save pills for a later time. Local chemists should be advised not to sell partial doses of antibiotics to patients who cannot afford to purchase a full treatment dose. If treatment is not provided free for patients at the clinic, try to find solutions for patients who cannot afford to purchase the necessary medicines.

Patients should be advised to avoid unprotected sex until they (and any partners) have completed treatment and are free of symptoms. When single-dose treatments are given, they should wait one week. The following is some additional advice related to specific syndromes:

• Patients with ulcers should be re-examined weekly and advised to wait until ulcers have healed (re-epithelialized) before resuming sexual activity.
• Women treated for PID should avoid sexual intercourse during treatment or use condom.
• Women treated for bacterial vaginosis or candidiasis can resume intercourse as soon as they feel comfortable.

 

Counselling and education about STI

People may be more likely to adopt safer sexual behaviour following treatment for an STI. Health care providers should thus make the most of each clinic visit as an opportunity to promote prevention. By discussing the likely circumstances in which the STI may have been acquired, patients can be encouraged to consider safer behaviour that might protect them from infection in the future. Counselling on prevention should always include discussion of the complications of STIs�including infertility and increased risk of HIV infection�as well as condom promotion, demonstration of how to put on a condom and advice on safer sex (Chapter 4).

 

Partner management (notification, referral and treatment)

A person who is successfully treated for an STI will experience relief of symptoms, but may return later with a reinfection if sexual partners are not also treated. Such partners may or may not have symptoms and, if untreated, may continue to spread infection to others in the community. It is thus extremely important to find ways to help patients notify their partners and arrange for treatment (partners may include not only current partner(s) but all partners within the last three months).

There are several ways that health care facilities can assist with partner notification:

• Patients can be encouraged to contact their sexual partners themselves. They can be given referral slips for their partners that explain how to arrange a clinic visit. The simplest type of referral slip (see example below) includes information (a diagnosis or code) to indicate the syndrome diagnosed in the index patient (the original patient who had symptoms). Other information that may be useful for monitoring partner referral rates is the record number of the index patient. (Note that any information referring to the index patient should always be coded to protect confidentiality.)
• Clinic or health department staff with special training in contact-tracing techniques can notify partners and arrange for necessary treatment.
• A two-step strategy can be used where patients are first asked to contact partners themselves. If unsuccessful after 1�2 weeks, clinic or health department staff attempt to trace the contact for treatment.
• Regardless of the notification strategy, clinics should ensure that partners have easy access to treatment. This may mean finding ways to avoid long waiting times and waiving normal clinic fees. This is important because many asymptomatic partners are reluctant to wait or pay for services when they feel healthy.

 

In general, partners should be treated for the same STI as the index patient, whether or not they have symptoms or signs of infection.

Not all RTIs are sexually transmitted, however, and this can complicate matters. Care must be taken not to mislabel or stigmatize someone as having an STI when the diagnosis is not clear. Women with vaginal discharge, for instance, usually have endogenous vaginal infection that is not related to STI. Attempting to notify and treat sexual partners would be both unnecessary (partners do not need treatment) and potentially damaging to their relationship�distrust, violence and divorce are possible consequences of partner notification. Health care providers should therefore be as sure as possible about the presence of an STI before notifying and treating partners, and should recognize that other explanations are possible for most RTI symptoms. Table 8.2 summarizes partner management and counselling messages for common STI/RTI syndromes.

 

Table 8.2. Partner notification management strategies by syndrome

Syndrome	Possible explanations	Partner management	Treatment tables	Counselling message
Genital ulcer	STI very likely	Treat partners for GUD	5/6	STI prevention counselling
Urethral discharge (men)	STI very likely	Treat partners for cervical infection (gonorrhoea and chlamydia)	2	STI prevention counselling
Lower abdominal pain	PID, often STI. But other genitourinary or gastrointestinal causes possible	Treat partners for urethral discharge (gonorrhoea and chlamydia)	8	Partner treatment a precaution to reduce complications and preserve fertility
Vaginal discharge	Endogenous (non-STI) infection most likely	No partner treatment unless relapse (then give treatment for trichomoniasis)	1	Usually not sexually transmitted

 

Special care is required in notifying partners of women with lower abdominal pain who are being treated for possible pelvic inflammatory disease. Because of the serious potential complications of PID (infertility, ectopic pregnancy), partners should be treated to prevent possible reinfection. It should be recognized, however, that the diagnosis of PID on clinical grounds is inaccurate, and the couple should be adequately counselled about this uncertainty. It is usually better to offer treatment as a precaution to preserve future fertility than to mislabel someone as having an STI when they may not have one.

 

Which sexual partners should be notified and offered treatment? This depends on the incubation period of the STI, the duration of symptoms and the stage of disease. General guidelines for some common STI syndromes and specific STIs are presented in Table 8.3.

 

Table 8.3. Recommended partner treatment schedule

STI/RTI	Treat all partners in pasta�	By syndrome
Chancroid	10 days	GUD�3 months
LGV	1 month
Syphilis�primary	3 months
Syphilis�secondary	6 months
Syphilis�latent	1 year
Gonorrhoea	3 months	Cervical infection or urethral discharge�2 months
Chlamydia	3 months
Trichomoniasis	Current partner	Vaginal discharge�current partner only if no improvement after treatment. If partner is symptomatic, treat patient and partner using the syndromic approach.
Yeast infection	Current partner
PID	2 months	Lower abdominal pain�2 months

^a. These periods are estimates only and providers should keep an open mind. In most cases where the infection is likely to be sexually transmitted, the last sexual partner should be treated even if the last sexual contact was outside the likely period of infection.

 

Follow-up visits, treatment failure and reinfection

Are follow-up visits really necessary? It can be useful for health care providers to see some patients again, to find out whether treatment relieved symptoms and achieved a clinical cure. Routine follow-up visits can be an inconvenience for patients, however, and an unnecessary burden on busy clinic staff. Syndromic management provides effective treatment for the most common STIs/RTIs and most patients will get better quickly. It is usually not necessary to have them come back just for a �check up� if they have taken their medicine and are feeling better. However, it is a good idea to advise patients to come back if no improvement is seen after a week of treatment (2�3 days for PID). Patients with genital ulcers should be encouraged to return after 7 days, because ulcers often take longer to heal (treatment should be extended beyond 7 days if ulcers have not epithelialized�formed a new layer of skin over the sore).

When patients with an STI/RTI do not get better, it is usually because of either treatment failure or reinfection. Try to decide which by asking the following questions:

 

Treatment failure

• Did you take all your medicines as directed?
• Did you share your medicine with anyone, or stop taking medicines after feeling some improvement?

Also consider the possibility of drug resistance. Was treatment based on the national treatment guidelines? Are cases of treatment failure increasing?

 

Reinfection

• Did your partner(s) come for treatment?
• Did you use condoms or abstain from sex after starting treatment?

Recurrence is also common with endogenous vaginal infections, especially when underlying reasons (douching, vaginal drying agents, hormonal contraceptives) are not addressed. See Chapter 2 for more information on ways to prevent endogenous infections.

Box 8.2 may help you decide what to do in those cases where symptoms do not improve. Remember, flowcharts are not perfect�some patients may need to be referred.

 

Box 8.2. Treatment failure or reinfection�what to do at the follow-up visit

Syndrome	Follow-up interval	If treatment failure suspecteda	If reinfection or recurrence is likelyb
Vaginal discharge	Some improvement usually seen within few days for vaginitis. Symptoms should be gone within one week. Note: BV is often recurrent.	Retreat patient. Re-examine and consider treating for yeast infection or cervical infection if these were not treated at the first visit.	Re-treat patient and treat partner for trichomoniasis. Tell patient with recurrent BV to avoid douching and vaginal drying agents. Pregnancy, diabetes or HIV infection may be factors in repeat yeast infection; antibiotics and, sometimes, oral contraceptive use may also be factors.
Lower abdominal pain	Follow up in 2�3 days (earlier if symptoms get worse). Some improvement usually seen within 1�2 days for PID. It may take a few weeks to feel better (chronic PID may cause pain for years).	Consider hospitalization for intravenous treatment. Extend duration of treatment if improvement but symptoms persist.	Women should be advised to abstain from sex during treatment for acute PID. Partners should be treated for gonorrhoea and chlamydia.
Genital ulcer	Improvement usually seen within 1 week for GUD. Complete healing may take a few weeks.	Extend duration of treatment if improvement but symptoms persist. Treatment for other GUD (HSV-2, granuloma inguinale, lymphogranuloma venereum) may be needed.	Partners should be treated for chancroid and syphilis.
Urethral discharge	Rapid improvement usually seen within a few days. Symptoms should be gone within 1 week.	Make sure that treatment for both gonorrhoea and chlamydia was given. If compliance was poor, treat again. Treatment failure unlikely for gonorrhoea if effective single-dose treatment used.	Partners should be treated for gonorrhoea and chlamydia.
		In some areas, trichomoniasis is an important cause of urethral discharge �> consider treatment.	Include partner treatment.
Inguinal bubo	Improvement usually seen within 1 week. It may take a few weeks for complete healing.	Follow-up visits every 1�2 days may be needed to drain bubo.	Partners should be treated for chancroid and lymphogranuloma venereum.

^a. For treatment failure, consider re-treatment with another treatment option. Refer if symptoms persist.

^b. For re-exposure during treatment, consider re-treatment with same antibiotics. Refer if symptoms persist.