|Sexually Transmitted Diseases (STD) Syndromic Management (AIDSCAP/FHI, 1997, 54 p.)|
|DESIGN OF STD FLOWCHARTS|
Gonorrhea is the main cause of urethritis among clinic attendees 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. 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.17 In addition, they can be confounded by prior, ineffective treatments patients may have taken before coming to the clinic.
Two examples of flowcharts for urethral discharge are shown in Figures 2 and 3. The first example (Figure 2) is a simple syndromic management, treating every man with a complaint of urethral discharge for gonorrhea 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.
Figure 2 - Management of Urethral Discharge - HONDURAS
In the second flowchart (Figure 3), 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.
Figure 3 - Management of Urethral Discharge - JAMAICA
A flowchart including Gram stain can only be considered when laboratory facilities are available. Results should be given within a reasonable time so patients do not have to return to the health facility for treatment the next day. This approach reduces the risk of serious complications, acute morbidity associated with either gonorrhea or chlamydia, and further transmission of the causative organism.