Guidelines For The Management Of Sexually Transmitted .
WEALTLTH HO RZ ATIONWOORRLLDDHHEAOGRAGNAINI Z ATIONWHO/HIV AIDS/2001.01WHO/RHR/01.10Original: EnglishDistr.: GeneralGUIDELINESFOR THE MANAGEMENT OFSEXUALLY TRANSMITTED INFECTIONSOnline:http://www.who.int/HIV AIDS/http://www.who.int/Reproductive healthFor orders, contact :World Health OrganizationDepartment of HIV/AIDS20 Avenue Appia , CH-1211 Geneva 27, SwitzerlandPhone: 41 22 791 2111Direct fax: 41 22 791 4834E-mail: hiv-aids@who.int
WHO/HIV AIDS/2001.01WHO/RHR/01.10Original: EnglishDistr.: GeneralGUIDELINESFOR THE MANAGEMENT OFSEXUALLY TRANSMITTED INFECTIONSOnline:http://www.who.int/Reproductive healthFor orders, contact :World Health OrganizationDepartment of HIV/AIDS20 Avenue Appia , CH-1211 Geneva 27, SwitzerlandPhone: 41 22 791 4654Direct fax: 41 22 791 4834E-mail: hiv-aids@who.intWorld Health Organization
WHO/HIV AIDS/2001.01WHO/RHR/01.10Original: EnglishDistr.: GeneralGUIDELINESFOR THE MANAGEMENT OFSEXUALLY TRANSMITTED INFECTIONSWorld Health Organization
GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONSCopyright World Health Organization 2001.This document is not a formal publication of the World Health Organisation (WHO), and all rights are reserved by the Organisation.The document may, however, be freely reviewed, abstracted, reproduced or translated, in part or in whole, but not for sale or for use in conjunction with commercial purposes.The views expressed in documents by named authors are solely the responsibility of those authors.Design by RSdeSigns.com.
GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED ground11.2Rationale for standardized treatment recommendations11.3Case management21.4Syndromic management21.5Risk factors for STI-related cervicitis31.6Selection of drugs42.TREATMENT OF STI-ASSOCIATED SYNDROMES62.1Urethral discharge6iii2.29Genital ulcer11Genital ulcer and HIV infection12Inguinal bubo152.3Scrotal swelling172.4Vaginal discharge20Cervical infection21Vaginal infection212.5Lower abdominal pain262.6Neonatal conjunctivitis303.TREATMENT OF SPECIFIC INFECTIONS323.1Gonococcal infections32Uncomplicated anogenital infection32Disseminated infection33Gonococcal ophthalmia33CONTENTS2.1.1 Persistent or recurrent urethral discharge
GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONSChlamydia trachomatis infections (other than lymphogranuloma venereum)35Uncomplicated urethral, endocervical or rectal infections35Neonatal chlamydial conjunctivitis36Infantile pneumonia373.3Lymphogranuloma venereum373.4Syphilis38Early syphilis38Late latent38ivNeurosyphilis39CONTENTS3.2Syphilis and HIV infection40Syphilis in pregnancy40Congenital syphilis413.5Chancroid433.6Granuloma inguinale (donovanosis)443.7Genital herpes infections45First clinical episode45Recurrent infections45Suppressive therapy46Herpes in pregnancy47Herpes and HIV co-infections47Venereal warts47Vaginal warts49Cervical warts49Meatal and urethral warts503.9Trichomonas vaginalis infections503.10Bacterial vaginosis52Bacterial vaginosis in pregnancy53Candidiasis54Vulvovaginal candidiasis54Vulvovaginal candidiasis in pregnancy54Vulvovaginal candidiasis and HIV infection55Balanoposthitis553.83.11
GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONSScabies553.13Phthiriasis (pediculosis pubis)574.KEY CONSIDERATIONS UNDERLYING TREATMENTS584.1The choice of antimicrobial regimens584.2Comments on individual drugs614.3Antimicrobial resistance in N. gonorrhoeae624.4Antimicrobial resistance in H. ducreyi635.PRACTICAL CONSIDERATIONS IN CASE MANAGEMENT655.1The Public Health package for STI prevention and care655.2Clinical considerations665.3Education for primary prevention675.4Education and counselling during an STI consultation685.5Notification and management of sexual partners695.6Access to services716.CHILDREN, ADOLESCENTS AND SEXUALLY TRANSMITTED INFECTIONS726.1Evaluation for sexually transmitted infections73ANNEX. LIST OF PARTICIPANTS78Note 1999The World Health Organization recommends that the term sexually transmitted disease (STD) be replaced by the term sexuallytransmitted infections (STI). The term sexually transmitted infections has been adopted as it better incorporates asymptomaticinfections. In addition, the term has been adopted by a wide range of scientific societies and publications.Reproductive tract infections encompass three main groups of infection, particularly in women, and sometimes in men. These groupsare endogenous infections in the female genital tract (e.g. candidiasis and bacterial vaginosis), iatrogenic infections that may beacquired through non-sterile medical, personal or cultural practices and classical STI. Currently, research is being conducted to betterunderstand the determinants of endogenous infections. They are not primarily sexually transmitted; thus, clinical and public healthactions as recommended for STI may not apply to these infections. Given the current state of knowledge and understanding of theseinfections treatment of partners is not recommended as routine public health practice. Reassurance and patient education are criticalwith regard to the nature of these endogenous infections.vCONTENTS3.12
GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONSPREFACESexually transmitted infections (STI) are among the most common causes of illness inthe world and have far-reaching health, social and economic consequences for manycountries.viiIn 1991,WHO published recommendations for the comprehensive management ofpatients with STI within the broader context of control, prevention and care programmesfor STI and HIV infection.WHO convened an Advisory Group Meeting on SexuallyTransmitted Diseases Treatment in May 1999 to review and update treatmentrecommendations in the light of recent developments (see annex).This publication presents the revised recommendations, both for a syndromic approachto the management of patients with STI symptoms and for the treatment of specific STI,based on global epidemiological surveillance data. It also provides information on thenotification and management of sexual partners and on STI in children and adolescents.PREFACEThe emergence and spread of HIV infection and AIDS have had a major impact on themanagement and control of STI. At the same time, resistance of several sexuallytransmitted pathogens to antimicrobial agents has increased, adding to therapeuticproblems.
GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS1. INTRODUCTIONThe appearance of the human immunodeficiency virus (HIV) and the acquiredimmunodeficiency syndrome (AIDS) has focused greater attention on the control of STI.There is a strong correlation between the spread of conventional STI and HIVtransmission and both ulcerative and non-ulcerative STI have been found to increase therisk of sexual transmission of HIV.The emergence and spread of HIV infection and AIDS complicated the management andcontrol of some other STI. For example, the treatment of chancroid has becomeincreasingly difficult in areas with a high prevalence of HIV infection, due to the HIVrelated immunosuppression.Antimicrobial resistance of several sexually transmitted pathogens is increasing,rendering some regimens ineffective.New agents, such as third-generation cephalosporins and fluoroquinolones, capable oftreating infections with resistant strains are available but are expensive. However, theirinitial high cost must be weighed against the cost of inadequate therapy, which may leadto complications, relapse, further spread and selection for antimicrobial resistance.1.2. RATIONALE FOR STANDARDIZED TREATMENT RECOMMENDATIONSEffective management of STI is one of the cornerstones of STI control, as it prevents thedevelopment of complications and sequelae, decreases the spread of these diseases in thecommunity and offers a unique opportunity for targeted education about HIV1INTRODUCTION1.1. BACKGROUNDSexually transmitted infections (STI) remain a public health problem of majorsignificance in most parts of the world.The incidence of acute STI is believed to be highin many countries and failure to diagnose and treat STI at an early stage may result inserious complications and sequelae, including infertility, foetal wastage, ectopicpregnancy, anogenital cancer and premature death, as well as neonatal and infantinfections.The individual and national expenditure for STI care can be substantial.
GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONSprevention. Appropriate treatment of STI patients at their first encounter with a healthcare provider is, therefore, an important public health measure.When this involvesadolescent1 patients, there is the potential to influence future sexual behaviour andtreatment-seeking practices at a critical stage of development.2INTRODUCTIONThe use of appropriate standardized protocols is strongly recommended in order toensure adequate treatment at all levels of the health service. Such standardized treatmentalso facilitates the training and supervision of health providers, delays the developmentof antimicrobial resistance in sexually transmitted agents such as Neisseria gonorrhoeae (N.gonorrhoeae) and Haemophilus ducreyi (H. ducreyi), and is an important factor in rational drugprocurement.It is anticipated that the following recommendations will help countries to developstandardized protocols adapted to local epidemiological and antimicrobial sensitivitypatterns. It is recommended that national guidelines for the effective management of STIbe developed in close consultation with local STI and public health experts.1.3. CASE MANAGEMENTSTI case management is the care of a person with an STI-related syndrome or with apositive test for one or more STI.The components of case management include: historytaking, examination, correct diagnosis, early and effective treatment, advice on sexualbehaviour, promotion and/or provision of condoms, partner notification and treatment,case reporting and clinical follow-up as appropriate.Thus, effective case managementconsists not only of antimicrobial therapy to obtain cure and reduce infectivity, but alsocomprehensive care of the patient’s needs for reproductive health.1.4. SYNDROMIC MANAGEMENTAetiological diagnosis of STI is problematic in many settings. It places constraints on time,resources, costs and access to treatment. In addition, the sensitivity and specificity ofcommercially available tests can vary significantly, thus, affecting negatively, the reliabilityof laboratory testing for STI diagnosis. In settings where laboratory facilities are available1 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. “Youngpeople” is a combination of these two overlapping groups covering the range 10-24 years (A Picture of Health: A review and annotated bibliographyof the health of young people in developing countries (1995), UNICEF, WHO).
GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONSthere must be suitably qualified personnel with adequate training to perform technicallydemanding procedures, and the establishment of external quality control is mandatory.Syndromic management for urethral discharge in men and genital ulcers in men andwomen has proved to be both valid and feasible. It has resulted in adequate treatment oflarge numbers of infected people, and is inexpensive, simple and very cost-effective.WHO also developed syndromic case management algorithms for women withsymptoms of vaginal discharge and/or lower abdominal pain. However, it is important torecognize the limitations of the vaginal discharge algorithms, particularly in themanagement of cervical (gonococcal and chlamydial) infections. In general, butespecially in low prevalence settings and in adolescent females, endogenous vaginitisrather than STI is the main cause of vaginal discharge.While attempts have been made toincrease the sensitivity and specificity of the vaginal discharge algorithm for thediagnosis of cervical infection, through the introduction of an appropriate, situationspecific risk assessment, both remain low.Moreover, some of the risk assessment questions based on demographics, such as age andmarital status, tend to incorrectly classify too many adolescents as at risk of cervicalinfection.Therefore, there is a need to identify the main STI risk factors for adolescents inthe local population and tailor the risk assessment accordingly. For adolescents inparticular it may be preferable to base the risk factors on sexual behaviour patterns.Recommendations for treatment using a syndrome-based approach are given in section 2.1.5. RISK FACTORS FOR STI-RELATED CERVICITISThe algorithms currently available for the management of cervical infection are far fromideal. Initially, it was thought that the finding of vaginal discharge would be indicative of3INTRODUCTIONFew developing country health facilities have the laboratory equipment or skills requiredfor aetiological diagnosis of STI.To overcome this, a syndrome-based approach to themanagement of STI patients was developed and promoted in a large number of countriesin the developing world. Syndromic management is based on the identification ofconsistent groups of symptoms and easily recognized signs (syndromes), and theprovision of treatment that will deal with the majority or most serious organismsresponsible for producing a syndrome.WHO developed a simplified tool (a flowchart oralgorithm) to guide health workers in the implementation of syndromic management.
GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONSboth vaginal and cervical infection. However, it has become clear that while vaginaldischarge is indicative of the presence of vaginal infection, it is poorly predictive ofcervical infection (gonococcal and/or chlamydial), particularly in adolescent females.Some clinical signs seem to be more frequently associated with the presence of cervicalinfection. In the published literature, clinical observations that have been consistently foundto be associated with cervical infection are the presence of cervical muco-pus, cervicalerosions, cervical friability and bleeding between menses or during sexual intercourse.4INTRODUCTIONA number of demographic and behavioural risk factors have also been frequentlyassociated with cervical infection. Some of those which, in some settings, have beenfound to be predictive of cervical infection are age below 21 years (or 25 in somesettings), being unmarried, more than one sexual partner in the last 3 months, newpartner in the previous 3 months, currently partner has a sexually transmitted infectionand recent use of condoms by the partner. Such risk factors are, however, usually specificfor the population group for which they have been identified and validated, and cannoteasily be extrapolated to other populations or to other countries. Most researchers havesuggested that more than 1 demographic risk factor in any particular patient is morevalid than just a single one, but that clinical signs can be valid as a single factor.Adding these signs and a risk assessment to the vaginal discharge algorithm does increase itsspecificity and, thus, the positive predictive value, although the latter remains low, especiallywhen the algorithm is applied to populations with relatively low rates of infection.1.6. SELECTION OF DRUGSAntimicrobial resistance of several sexually transmitted pathogens has been increasing inmany parts of the world and this has rendered some low-cost regimens ineffective.Recommendations to use more effective drugs frequently raise concerns about cost andpossible misuse.A two-tier drug policy with the provision of less effective drugs at the peripheral healthcare level and the most effective and usually more expensive drugs only at a referral levelmay result in an unacceptable rate of treatment failures, complications and referrals, andmay erode confidence in health services.This approach is not recommended.The drugsused for STI in all health care facilities should be at least 95% effective. Criteria for theselection of drugs are listed in the box below.
GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS5INTRODUCTIONCriteria for the selection of STI drugsDrugs selected for treating STI should meet the following criteria: high efficacy (at least 95%) low cost acceptable toxicity and tolerance organism resistance unlikely to develop or likely to be delayed single dose oral administration not contraindicated for pregnant or lactating women.Appropriate drugs should be included in the national Essential Drugs list and in choosingdrugs, consideration should be given to the capabilities and experience of health personnel.
GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS2. TREATMENT OFSTI-ASSOCIATED SYNDROMESThis section discusses the management of the most common clinical syndromes causedby sexually transmitted agents. Flow charts (algorithms) for the management of eachsyndrome are provided.6TREATMENT OF STI-ASSOCIATED SYNDROMESFor all these conditions (except vaginitis) the sexual partner(s) of patients should also beexamined for STI and promptly treated for the same condition(s) as the index patient.Successful management of STI requires that staff are respectful of patients and are notjudgmental. Examination must be done in appropriate surroundings where privacy canbe ensured and confidentiality guaranteed.When dealing with adolescents, the healthcare provider should be reassuring, experienced and conversant with the changes inanatomy and physiology associated with the different maturation stages e.g. themenarche in young girls or nocturnal emissions in boys. In some situations, health careworkers require training to overcome their own sensitivities and be able to address theissue of sexuality and STI in an open and constructive manner.2.1. URETHRAL DISCHARGEMale patients complaining of urethral discharge and/or dysuria should be examined forevidence of discharge. If none is seen, the urethra should be gently massaged from theventral part of the penis towards the meatus.If microscopy is available, examination of the urethral smear may show an increasednumber of polymorphonuclear leukocytes and a gram stain may demonstrate thepresence of gonococci. In the male, more than 5 polymorphonuclear leukocytes per highpower field (x 1000) are indicative of urethritis.The major pathogens causing urethral discharge are N. gonorrhoeae and Chlamydia trachomatis(C. trachomatis). In the syndromic management, treatment of a patient with urethraldischarge should adequately cover these two organisms.Where reliable laboratoryfacilities are available, a distinction may be made between the two organisms and specifictreatment instituted.
GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONSRecommended syndromic treatment therapy for uncomplicated gonorrhoea (for details see section 3.1)PLUS therapy for chlamydia (for details see section 3.2) Patients should be advised to return if symptoms persist 7 days after start of therapy.AT A GLANCEUrethral Discharge7For details, see section 3.1 and 3.2Treatment options for illinErythromycin (if Tetracycline contraindicated)OfloxacinTetracyclineWHO recommends that, where possible, single dose therapy be utilized.TREATMENT OF STI-ASSOCIATED SYNDROMESTreatment options for /Sulfamethoxazole
GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONSFIGURE 1. URETHRAL DISCHARGEPatient complains ofurethral discharge or dysuriaTake history and examine.Milk urethra if necessary.8TREATMENT OF STI-ASSOCIATED SYNDROMESDischarge confirmed?YESTREAT FORGONORRHOEA ANDCHLAMYDIA EducateCounselPromote and providecondomsOffer HIV counselling andtesti
3.5 Chancroid 43 3.6 Granuloma inguinale (donovanosis) 44 3.7 Genital herpes infections 45 First clinical episode 45 Recurrent infections 45 Suppressive therapy 46 Herpes in pregnancy 47 Herpes and HIV co-infections 47 3.8 Venereal warts 47 Vaginal warts 49 Cervical warts 49 Meatal and urethral warts 50 3.9 Trichomonas vaginalis infections 50 3.10 Bacterial vaginosis 52 Bacterial vaginosis in .
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