Sexually Transmitted Diseases: Time to Revisit the Syndromic Management Approach

Background: Sexually transmitted disease is a public health challenge especially in resource limited countries. Approximately, 5 million new cases of curable STIs are reported each day, worldwide. The STI syndromic management is widely used in resource limited countries for rapid and same day treatment. The Gambia has adopted the STI syndromic management approach since 1992 and uses a combination treatment of Ciprofloxacin, Doxycycline and Metronidazole for vaginal itching and discharges in females. However, emerging antimicrobial resistance and new identified STI pathogens may pose challenges to the syndromic management approach in the Gambian setting. Study objective: To characterise Ureaplasma and other STI pathogens in women attending an STI clinic who were being treated using the syndromic management approach. Methods: Endocervical (ECS) and high vaginal (HVS) samples were collected from each participants prior treatment (N = 115, Age 20 – 49). Microbiological analysis (Candida, Streptococcus agalactiae, Neisseria gonorrhoeae, T.vaginalis and bacterial vaginosis) and real time PCR (Chlamydia trachomatis, Neisseria gonorrhoeae, Ureaplasma urealyticum/parvum and Mycoplasma genitalium) was carried out. Results: No organism was isolated from 23.5% (27/115) of the participants that reported urogenital symptoms. However, 76.5% (88/115) were infected with either one or more pathogens. The majority 45% (52/115) of participants were infected with urogenital Ureaplasma species either in the cervix, vagina or both. Ureaplasma urealyticum accounts for 19.2 % (10/52), Ureaplasma parvum 80.7% (42/52) and 32.7% (17/52) were co-infected with bacterial vaginosis. Other isolated organisms were: Bacterial vaginosis 29.6% (34/115), Candida albicans 14.8% (17/115), T.vaginalis 13.0% (15/115), Candida species 9.6% (11/115), Streptococcus agalactiae and Neisseria gonorrhoeae each at 6.1% (7/115) were also isolated. Antimicrobial susceptibility profile for Streptococcus agalactiae and Neisseria gonorrhoeae showed resistance to one or more antibiotics used in the first and second line syndromic management treatment. Chlamydia trachomatis and Mycoplasma genitalium was not detected in none of the samples. Conclusion: Confirmation of STI by syndromic management alone is not enough as emerging drug resistance and new STI organisms poses challenges to the health of the reproductive aged woman. There is a need to review the STI syndromic management guidelines and to strengthen laboratory diagnosis to reduce the burden of overuse antibiotic treatment in the Gambia. Treatment of sexual partner(s) should also be encouraged to limit treatment failure and recurrent infection