STI-associated syndromes guide: Syndromic management

This guide provides an overview of the management and empiric treatment of STI-associated syndromes.

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Introduction

This guide provides an overview of the management of the following sexually transmitted infection (STI)-associated syndromes: anogenital ulcers, cervicitis, epididymitis, pelvic inflammatory disease (PID), proctitis, urethritis and vaginitis.

These syndromes may be caused by an STI, another infection or have a non-infectious cause. The probability that a syndrome is caused by an STI, a non-sexually transmitted infection or a non-infectious cause varies by syndrome and a person's risk.

Although STIs may present as a syndrome, many STIs are frequently asymptomatic. Sexually transmitted and blood-borne infection (STBBI) screening permits early detection and treatment of asymptomatic infections, thereby preventing or limiting complications and lessening the potential for transmission. When an STI has been identified, refer to the etiology-specific guide(s) for guidance and information on:

In this guide, syndromic management of STIs refers to the management of an individual based on signs and symptoms, prior to laboratory confirmation of the etiologic agent(s). The recommended empiric treatments are based on the most common STIs associated with each syndrome. In some situations, the empiric treatment may vary from that recommended in the etiology-specific guide because a longer regime of antibiotics or a different combination of antibiotics is needed to adequately treat complicated (e.g. those that are frequently polymicrobial) and deep-seated infections.

Consult Health Canada and product monographs for warnings, contraindications and side effects of treatments outlined in this guide.

Common STI-associated syndromes

Pathogen Associated syndromes

Chlamydia trachomatis(CT)Footnote 1

  • Cervicitis
  • Urethritis
  • Epididymitis
  • PID
  • Proctitis
  • Anogenital ulcers (CT serotype L1, 2 or 3, causing lymphogranuloma venereum)

Neisseria gonorrhoeae (GC)Footnote 2

  • Cervicitis
  • Urethritis
  • Epididymitis
  • PID
  • Proctitis

Herpes simplex virus (HSV)Footnote 3

  • Anogenital ulcers
  • Cervicitis
  • Urethritis
  • Proctitis

Mycoplasma genitaliumFootnote 4

  • Cervicitis
  • Urethritis
  • PID
  • Proctitis

Treponema pallidum, subspecies pallidum (Syphilis)

  • Anogenital ulcers
  • Proctitis

Trichomonas vaginalis (TV)

  • Vaginitis
  • Cervicitis
  • Urethritis

Note: Many pathogens can also cause extra-genital manifestations (e.g. disseminated GC infections, CT or GC pharyngeal infections, HSV orolabial lesions, syphilis-related skin rash, alopecia, mucous patches, neurosyphilis).

Management of symptomatic individuals

Clinical assessment

Clinical assessment of symptomatic individuals should include:

A syndrome may have more than one infectious cause. Transmission routes are similar for many STBBIs and co-infection is common. Anyone suspected of having a specific STI should be screened for other STBBIs. Depending on type of sexual activity, it may be necessary to screen for STBBIs at multiple anatomical sites.

CT and GC are the most common bacterial STIs in Canada and co-infection is common. Test people for both CT and GC if either is suspectedFootnote 5. Nucleic acid amplification tests (NAATs) can detect both GC and CT from a single specimenFootnote 5Footnote 6. Validated NAATs for extra-genital specimens are available in many jurisdictions. Due to increasing rates of antimicrobial resistant GC (AMR-GC), there is a need for sensitivity information. If feasible, when GC is suspected, collect swabs for culture (in addition to samples for NAAT). Check with your local laboratory for information on available testing methods.

Empiric treatment

The decision to treat empirically or to wait for test results should reflect the:

Empiric treatment is useful to manage symptoms, to control transmission and to prevent complications. At the same time, different STIs may have similar presentations or conversely, the same STI may present in different ways. Waiting for test results before treatment allows for the appropriate use of antibiotics, which can enhance health outcomes, reduce AMR and decrease unnecessary or inadequate treatment. Delaying treatment until test results are available may be preferable when the clinical condition is not severe, risk factors suggest that it's unlikely that an STI is the cause of symptoms and the person agrees to abstain from sex while waiting for test results.

Consider providing empiric treatment as a public health preventive measure, to prevent the development of infection in a sexual contact of a person with a confirmed STI. As a case in point, many Canadian provinces and territories are experiencing a significant increase in infectious and congenital syphilis and therefore empiric treatment of contacts of suspected cases of infectious syphilis may be appropriate. If empiric treatment is provided for a suspected STI, advise the person to abstain from sexual activity until therapy is completed, symptoms have resolved, and sex partners have been adequately treated. If abstinence is in doubt, recommend the use of barrier protection for oral, genital and anal sex.

Follow-up

A test of cure (TOC) may be recommended depending on the pathogen, site of infection and treatment regimen. For some pathogens, a TOC is always recommended while for others, it is recommended in specific situations only. In cases of syphilis, post-treatment serologic testing can assess treatment response. It should be done at recommended intervals according to stage of infection.

In the case of persistent or recurrent symptoms, consider the following causes or contributing factors:

Offer repeat screening for STBBIs based on ongoing risk factors and continued potential for exposure. Repeat screening is generally recommended 3-6 months after treatment for an STI, due to the potential for reinfection.

Integrate STBBI prevention strategies such as counselling, vaccination and education on preventive practices into care. If clinically indicated:

Reporting and partner notification

Case finding, partner notification and treatment are critical to reduce the spread of STBBIs. Partner notification has public health benefits (e.g. infectious disease surveillance and control) and reduces the risk of reinfection.

STBBI reporting requirements vary by jurisdiction. Refer to provincial and territorial regulations for reporting requirements when a STBBI is identified.

References

Footnote 1

Hsu K. Clinical manifestations and diagnosis of Chlamydia trachomatis infections. UpToDate 2019.

Return to footnote 1 referrer

Footnote 2

Ghanem KG. Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents. UpToDate 2020.

Return to footnote 2 referrer

Footnote 3

Albrecht MA. Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection. UpToDate 2019.

Return to footnote 3 referrer

Footnote 4

David H Martin. Mycoplasma genitalium infection in men and women. UpToDate 2019.

Return to footnote 4 referrer

Footnote 5

Lyss SB, Kamb ML, Peterman TA, Moran JS, Newman DR, Bolan G, et al. Chlamydia trachomatis among patients infected with and treated for Neisseria gonorrhoeae in sexually transmitted disease clinics in the United States. Ann Intern Med2003;139(3):178-185.

Return to footnote 5 referrer

Footnote 6

Creighton S, Tenant-Flowers M, Taylor CB, Miller R, Low N. Co-infection with gonorrhoea and chlamydia: how much is there and what does it mean? Int J STD AIDS 2003;14(2):109-113.

Return to footnote 6 referrer

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