Genital tract infections

STI screening – people with risk factors should be screened for Chlamydia, gonorrhoea, HIV and syphilis.

Refer individual and partners to GUM service. Risk factors: under 25 years, no condom use, recent (less than 12 month)/ frequent change of partner, symptomatic partner.

Treatment options are below though in most cases a prompt referral to GUM for investigation and management is the most appropriate action

Chlamydia trachomatis and epididymitis

Refer to BASHH website for full details.

Opportunistically screen all patients aged 15-25 years

Treat partners and refer to GUM clinic.

Doxycycline
  • 100mg every 12 hours for 7 days
Azithromycin
  • 1g stat 1 hour before or 2 hours after food, or
If intolerant
Ofloxacin
  • 200mg every 12 hours or 400mg once daily for 7 days, or
Levofloxacin
  • 500mg once daily for 7 days

Notes

  1. MHRA Drug Safety Update (November 2018): Systemic and inhaled fluoroquinolones: small increased risk of aortic aneurysm and dissection; advice for prescribing in high-risk patients.
  2. MHRA Drug Safety Update (March 2019): Fluoroquinolone antibiotics: new restrictions and precautions for use due to very rare reports of disabling and potentially long-lasting or irreversible side effects

Refer to 5.1.12 Quinolones for further details

Pregnancy, breast-feeding patients
Azithromycin
  • 1g stat 1 hour before or 2 hours after food, or
Erythromycin
  • 500mg every 6 hours for 7 days, or
Amoxicillin
  • 500mg every 8 hours for 7 days

Notes

  1. Azithromycin is the most effective option. Its use is off label in pregnancy but recommended by BASHH.
  2. Due to lower cure rate in pregnancy test for cure 6 weeks after treatment.
  3. Tetracyclines are contra- indicated in pregnancy

Suspected epididymitis in men over 35 years with low risk of STI

If high risk of STI or if treatment fails, consider referral to GUM.

Treat with antibiotics as directed by recent urine cultures or 10 days oral levofloxacin 500mg once daily.

Notes

  1. MHRA Drug Safety Update (November 2018): Systemic and inhaled fluoroquinolones: small increased risk of aortic aneurysm and dissection; advice for prescribing in high-risk patients.
  2. MHRA Drug Safety Update (March 2019): Fluoroquinolone antibiotics: new restrictions and precautions for use due to very rare reports of disabling and potentially long-lasting or irreversible side effects

Refer to 5.1.12 Quinolones for further details

Vaginal candidiasis

All topical and oral azoles give 75% cure.

Various clotrimazole or fluconazole products are available to purchase over the counter, along with advice, from pharmacies. Some self-care medicines are available in shops and supermarkets. Please click here for further information and a patient leaflet.

Fluconazole
  • 150mg orally, single dose
  • Fluconazole should not be used in pregnancy or in women of childbearing potential unless adequate contraception is used
  • Fluconazole is not recommended for patients who are breastfeeding

or

Clotrimazole
  • 500mg pessary single dose

Pregnancy

In pregnancy avoid oral azoles and use intravaginal treatment.

Clotrimazole 10%
  • 5g vaginal cream, single dose or
Clotrimazole
  • 100mg pessary at night for 6 nights
Miconazole
  • Vaginal 2% cream 5 g intravaginally twice daily (7 days)

Bacterial vaginosis

Oral metronidazole is as effective as topical treatment. There is less relapse at 4 weeks with 7 days treatment than with 2g single dose.

Topical treatment gives similar cure rates but is more expensive. Vaginal preparations are unsuitable for use during menstruation.

Treating partners does not reduce relapse. Refer to GUM if recurrent.

Metronidazole
  • 400mg every 12 hours for 7 days or
  • 2g single dose, avoid if pregnant or breastfeeding
Metronidazole 0.75% vaginal gel
  • 5g applicatorful at night for 5 nights
Clindamycin 2% cream
  • 5g applicatorful at night for 7 nights

Gonorrhoea

Refer to BASHH website for full details.

Treat partners and refer to GUM service

Resistance rates in the UK for gonnorrhea has rendered cefixime less effective. If it is used, monitor closely for treatment failure and consider national reporting if this occurs

Treatment choice where the organism's sensitivity is not known is IM ceftriaxone and oral azithromycin.

In the event of severe cephalosporin allergy discuss with a Microbiologist or GUM physician.

In all cases these regimens also cover overt or undiagnosed secondary chlamydial infections but not PID or epydidmitis where longer quinolone or doxycycline therapy is still required .

Ceftriaxone
  • 500mg IM

PLUS

Azithromycin (oral)
  • 1g stat dose
Refuses IM injection
Cefixime (oral)
  • 400mg stat dose

PLUS

Azithromycin (oral)
  • 1g stat dose

Persisting symptoms or signs: test with culture, performed at least 72 hours after completion of therapy. If asymptomatic, test with NAATs where available, followed by culture if NAAT-positive. Test two weeks after completion of antibiotic therapy.

Allergic to cephalosporins
Azithromycin (oral)
  • 2g as a single dose. Monitor closely for treatment failure

Trichomoniasis

Refer to GUM and treat partners simultaneously.

In pregnancy or breastfeeding avoid 2g single dose metronidazole.

Topical clotrimazole gives symptomatic relief (not cure) if metronidazole declined.

Metronidazole
  • 400mg every 12 hours for 5-7 days
  • 2g single dose, avoid if pregnant or breastfeeding
Clotrimazole
  • 100mg pessary for 6 nights

Pelvic Inflammatory Disease

Test for Chlamydia & N. gonorrhoea. If positive, refer all patients and contacts to GUM clinic.

Tetracyclines and quinolones are contra-indicated in pregnancy - consult obstetrician.

Recommend review after treatment to assure cure.

Metronidazole
  • 400mg every 12 hours for 14 days plus
Doxycycline
  • 100mg every 12 hours for 14 days

Or

Metronidazole
  • 400mg every 12 hours for 14 days plus
Levofloxacin
  • 500mg once daily

Notes

  1. MHRA Drug Safety Update (November 2018): Systemic and inhaled fluoroquinolones: small increased risk of aortic aneurysm and dissection; advice for prescribing in high-risk patients.
  2. MHRA Drug Safety Update (March 2019): Fluoroquinolone antibiotics: new restrictions and precautions for use due to very rare reports of disabling and potentially long-lasting or irreversible side effects

Refer to 5.1.12 Quinolones for further details

If gonorrhoea is likely (partner has it, severe symptoms or sex abroad) give an initial dose of:

Ceftriaxone
  • 500mg IM

Followed by doxycycline/ metronidazole as above, or refer to GUM

Genital herpes

Refer to BASHH website for full details.

Oral antivirals indicated within 5 days of start of episode or while new lesions are still forming or if symptoms persist

If diagnosis is unclear then take a viral swab for HSV/VZV. Also see risk factors for additional STI screening

Aciclovir
  • 400mg every 8 hours or 200mg five times a day for 5 days.
  • Review after 5 days and continue if new lesions still appearing, complex disease, immunosuppressed
  • Severe cases require urgent referral
  • Refer to GUM if patient suffers more than 6 occurrences a year

Supportive treatment:

  • saline bathing, topical petroleum jelly, lidocaine ointment for a few days when required
Recurrent episodes

Symptomatic recurrence rate after 1st episode is 4/year (HSV2) and 1/year (HSV1). Most reoccurrences decline in frequency over time.

Prodomol symptoms occur up to 48 hours before appearance of lesions, often milder than the initial episode with faster resolution. Symptoms = milder/self-limiting, therefore manage in partnership with patient.

Options are:

  • Supportive treatment, saline bathing, topical petroleum jelly, lidocaine ointment, for a few days when required
  • Episodic prescription: standby prescription for next episode to start at prodrome
Aciclovir
  • 200mg five times a day for 5 days or
  • 400mg eight hourly for 3-5 days or
  • 800mg eight hourly for 2 days

 

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