Syndromic Case Management

Defining Syndromic Case Management Components Pros and Cons Comparing Classical Approaches to STI Management How to Use a Flowchart

Effective management of STI is one of the cornerstones of STI control, as it prevents the development of complications and decreases the spread of these diseases in the community. However, diagnosis of STI is a challenge in many settings. It places constraints on time, resources, costs and access to treatment. Consequently, a syndrome-based approach was developed to overcome these challenges and offer a cost-effective type for STIs cases management.

Defining Syndromic Case Management

It is a type of management that is based on syndromic diagnosis and treatment: The main STIs are classified by clinical syndromes — a combination of symptoms a patient complains of, and signs identified during the clinical examination. An STI syndrome is identified and then treated with combination therapy for the majority or most serious organisms responsible for producing a syndrome. The syndromic approach enables healthcare providers to make a diagnosis within a short time without special skills and sophisticated laboratory tests.

Algorithms or flow charts are used to guide healthcare workers through the correct identification and treatment of an STIassociated syndrome. They also offer a package of comprehensive care from history taking, examination, to counseling/education on risk reduction and partner notification and treatment.

Components

History taking Physical examination Treatment based on syndromic diagnosis. Patient education including information on: compliance nature of infection importance of partner notification and treatment therefore risk reduction and prevention of further STI transmission

HIV risk perception and assessment Counselling for STIs and HIV testing Condom promotion Partner management Clinical follow up

Pros and Cons of Syndromic Case Management

Pros

Highly sensitive Treatment is given at first visit Avoids expensive laboratory tests Can be implemented at primary care level Problem-orientated High rates of cure Over-diagnosis and overtreatment Cannot be used on asymptomatic individuals Does not address the issue of poor treatment-seeking behavior Accuracy of algorithms vary among symptoms

Cons

Comparing Classical Approaches to STI Management

Etiological Diagnosis Clinical Diagnosis

Process

Using the lab to identify the causative agent.

Pros Avoids over treatment Conforms to traditional clinical training Satisfies patients who feel not properly attended to Can be extended as screening for the asymptomatics Using clinical experience to identify the causative agent.

Saves time for patients Reduces laboratory expenses

Cons Requires skilled personnel and consistent supplies Treatment does not begin until results are available It is time-consuming and expensive Testing facilities are not available at the primary level Requires high clinical acumen Most STIs cause similar symptoms Mixed infections are common and failure to treat may lead to serious complications Doesn’t identify asymptomatic STIs

How to Use a Flowchart

A flowchart is a diagrammatic map that guides you through a series of decisions and actions you need to make. Each decision or action is enclosed in a box, with one or two routes leading out of it to another box, with another decision or action.

Each flowchart is made up of a series of three sorts of steps:

The clinical problem (the patient’s presenting symptom at the top). This is the starting point

A decision to make, usually by answering "yes" or "no" to a question

An action to take: what you need to do (different boxes suggest treatment, education and condom promotion, etc, and patient referral if necessary).

Yes

Start Step Decision

No Action

Action End

End

Challenges in STI Control

Integration of STI prevention and care in reproductive health services and in HIV/AIDS control programs. The changing epidemiology of STI. Mobilizing policy, priority setting, capacity building, and multisectoral approaches.

Activities

Activity 1: The House with the 4 Doors

Goals

Materials Methodology

Allow the participants to brainstorm and conclude that syndromic case management is the best STIs management. Flip chart, markers Audience will be divided into 3 groups, each group will discuss a way of STIs management (syndromic case management, etiological diagnosis, clinical diagnosis). The discussion will include 4 doors; the concept door, the advantage door, the disadvantage door, & the opinion door. Each group will be given a paper of flip chart to represent their house & a marker to write the discussion of the 4 doors. Later they will present their house for the other 2 groups and try to prove their house is the best. It can work both online ( by dividing them into rooms) or physical (by dividing them into groups).

15 minutes (5 for group discussion, 10 for presentation)

Expected time

Activity 2: Small pieces and a Big picture.

Goals

Materials

Methodology

Expected time

Allow participants to highlight the main steps of flow chart used in syndromic case management.

Flip chart, markers

Steps of the flowchart are written on small papers and then the participants are asked to arrange them in the correct order to complete the big picture of syndromic case management flowcharts.

10 minutes

Frequently Asked Questions (FAQs)

Q1. Is the syndromic approach scientific?

Yes. It is based on a wide range of epidemiological studies in both the industrialized and developing world. This case management approach has been used and adapted in more than 20 countries throughout the world. Validation studies have compared syndromic and laboratory diagnosis to assess the accuracy of syndromic diagnosis and found their results to be similar.

Q2. Wouldn’t it be better to treat the patient first for the most common cause and then, if the symptoms do not improve, treat for a second cause?

Many patients required to return to a health center for treatment do not do so. They may even seek treatment elsewhere. If the first course of treatment is not effective, the patient may continue to transmit the STI – at best for a few days but at worst for years.

Q3. Can the syndromic approach result in a waste of drugs because patients are being over-treated?

Over-treatment in syndromic management could be said to be a waste when patients are treated for a syndromic cause which is not the cause of the discharge. This includes, for example, treatment for gonorrhea and/or chlamydial infection as the causes of vaginal discharge in areas where they are not the predominant cause.

Q4. How much training should healthcare workers receive in order to use the syndromic approach?

Healthcare workers should be trained enough to be able to use the management flowcharts and know how to take proper sexual history as this type of management depends completely on history and observations.

References

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5. http://apps.who.int/iris/bitstream/handle/10665/43275/92415934 07_mod2_eng.pdf;jsessionid=B19B61C27D5E4C1DBA84246840C8 9894?sequence=3 https://asq.org/quality-resources/flowchart https://www.smartdraw.com/flowchart/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1744836/pdf/v080 p00174.pdf https://drive.google.com/drive/folders/14xidywrDIMSsKv26Hv52YXT-JEbz-_h?usp=sharing