Jangkitan HIV
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Modified Syndromic Approach
(MSA)
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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
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
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
YES
Lower abdominal Refer to hospital
pain? YES
NO
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
YES NO
Discharge?
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
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
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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
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)
M&HO or FMS NO
present?
Refer to hospital
YES
Conjunctival swab: Gram stain & culture for Gonococci
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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