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1
National Chlamydia Screening Programme http://www.chlamydiascreening.nhs.uk/ps/index.html Accessed 23.09.14.

2
SIGN. Management of genital Chlamydia trachomatis infection: a national clinical guideline. Scottish Intercollegiate Guidelines Network 2009. http://www.sign.ac.uk/guidelines/fulltext/109/index.html Accessed 23.09.14.RATIONALE: Treatment of partners: the treatment of partners prior to resuming sexual intercourse is the strongest predictor for preventing re-infection. Treatment in pregnancy: expert opinion is that azithromycin 1g stat is the first-line treatment for Chlamydia in pregnant women.

3
BASHH. UK National Guidelines for the Management of Genital Tract Infection with Chlamydia trachomatis. British Association for Sexual Health and HIV. 2006 http://www.bashh.org/documents/61/61.pdf Accessed 23.09.14. RATIONALE: Treatment of partners: partners should also be treated for C trachomatis infection. Re-testing: expert opinion is that a test of cure is not routinely recommended, but should be performed in pregnancy, or where non-compliance or re-exposure are suspected. The higher rate of positive tests after treatment during pregnancy is attributed to either less efficacious treatment regimen, non-compliance, or re-infection.

4
Lau CY, Qureshi AK. Azithromycin versus doxycycline for genital chlamydial infections: a meta-analysis of randomised controlled trials. Sexually transmitted diseases. 2002;29:497-502. RATIONALE: Pooled data (12 RCTs, n = 1543) found that microbiological cure was achieved in 97% of people taking azithromycin and 98% of those taking doxycycline, p = 0.296; no significant difference.

5
Brocklehurst P, Rooney G. Interventions for treating genital Chlamydia trachomatis infection in pregnancy. Cochrane Database of Systematic Reviews 1998. Issue 4. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000054/frame.html. Accessed 23.09.14. RATIONALE: Pooled data from four RCTs found that 8% of women taking azithromycin (11/145) failed to achieve microbiological cure compared with 19% of women taking erythromycin (27/145); OR 0.38, 95% CI 0.19 to 0.74). Pooled data from three RCTs found that 9% of women taking amoxicillin (17/199) failed to achieve microbiological cure compared with 15% of women taking erythromycin (28/191); OR 0.54, 95% CI 0.28 to 1.02.

6
UKTIS. The treatment of infections in pregnancy. National Teratology Information Service. 2012. (Tel: 0844 892 0909, www.toxbase.org) Accessed 23.09.14. RATIONALE: Azithromycin: There are few published data on the use of azithromycin in human pregnancy however the currently available data do not indicate that the use of azithromycin in pregnancy is associated with an increased risk of malformations. An increased incidence of cardiovascular defects and pyloric stenosis have been suggested for macrolides as a class, although causality has not been established conclusively. Erythromycin: Erythromycin is a broad spectrum macrolide antibiotic. The majority of studies do not support an association between erythromycin exposure and any malformation or any other adverse fetal effect, however associations have been made with an increased incidence of cardiova scular defects and pyloric stenosis, although causality has not been conclusively established. Amoxicillin: there is no evidence to suggest that penicillins are associated with an increased risk of malformations or other forms of fetal toxicity in human pregnancy.

7
GRASP Steering Group. GRASP 2012 report:The Gonococcal Resistance to Antimicrobials Surveillance Programme. file:///W:/Primary%20Care%20Share/Antibiotic%20guidance/2014/References/Public%20Health%20England_GRASP%202012%20Report%20(Full).pdf Accessed 24.09.14.
RATIONALE: This report describes the latest data on trends in and epidemiology of antimicrobial resistance and decreased susceptibility in gonococcal infection in England and Wales using data collected through GRASP in 2012. In 2012 in England, the number of new gonorrhoea diagnoses increased by 21.4% (especially among men who have sex with men) and young adults. Ciprofloxacin resistance is now endemic in England and Wales, accounting for 25% of all gonorrhoea isolates tested in 2012. 5.6% of isolates exhibited decreased susceptibility to cefixime, only three isolates showed decreased susceptibility to ceftriaxone (MIC ≥0.125mg/L).
Public Health England and the British Infection Association had said that, for practical issues of administration in primary care, a stat dose of oral cefixime 400mg could be substituted for IM ceftriaxone. However, resistance to cephalosporins is increasing and treatment failures have been reported with cefixime; therefore, if gonorrhoea is suspected, IM ceftriaxone is the cephalosporin of choice.

8
Ross JDC, Cronjé HS, Paszkowski T, Rakoczi I. Moxifloxacin versus ofloxacin plus metronidazole in uncomplicated pelvic inflammatory disease: results of a multicentre, double blind, randomised trial. Sex Transm Infect 2006;82(6):446-51. RATIONALE: This trial in 564 patients with uncomplicated PID in hospitals from 13 countries, compared oral metronidazole 500mg twice daily with either oral ofloxacin 400mg twice daily or moxifloxacin 400mg once daily. Clinical resolution with both regimens was 90% and bacteriological cure was similar. Metronidazole is included in the regimen to improve the coverage for anaerobic bacteria. Anaerobes are of relatively greater importance in patients with severe PID. Ofloxacin and moxifloxacin should be avoided in patients who are at high risk of gonococcal PID because of increasing quinolone resistance in the UK (eg when the patient‟s partner has gonorrhoea, in clinically severe disease, following sexual contact abroad). Quinolones should also be avoided as first line empirical treatment for PID in areas where >5% of PID is caused by quinolone resistant Neisseria gonorrhoea.

9
Ison CA, Mouton JW, Jones K. Which cephalosporin for gonorrhoea? Sex Transm Infect 2004;80:386-88. RATIONALE: This study used previously published pharmacokinetic data on cefixime, ceftriaxone and cefuroxime to model the length of time tissue concentrations to these drugs would be above the MIC 90 (concentration needed to kill 90% of gonorrhoea isolates). Cefuroxime concentrations are too low. Ceftriaxone attains the optimal concentrations to prevent the development of step-wise mutations and resistance in Neisseria gonorrhoea.

10
British Association for Sexual Health and HIV.
2006 UK National Guideline for the Management of Genital Tract Infection with Chlamydia trachomatis. http://www.bashh.org/documents/65.pdf Accessed 23.09.14.
Covers the symptoms and signs of Chlamydia and recommended diagnostic tests.
 2005 United Kingdom National Guideline for the Management of Pelvic Inflammatory Disease. http://www.bashh.org/documents/118/118.pdf Accessed 23.09.14
Recommended regimens: the recommended regimens for outpatient management are either ofloxacin plus metronidazole for 14 days, or a stat dose of IM ceftriaxone plus metronidazole and doxycycline for 14 days. Ofloxacin should be avoided in women who are at high risk of gonococcal PID, because of increasing quinolone resistance in the UK. Treatment of partners: partners should be screened for gonorrhoea and chlamydia.
 2010 National guideline for the management of epididymo-orchitis http://www.bashh.org/documents/3546.pdf Accessed 23.09.14.

11
Meads C, Knight T, Hyde C and Wilson J. The clinical effectiveness and cost-effectiveness of antibiotic regimens for pelvic inflammatory disease. West Midlands Health Technology Assessment group. 2004. http://www.rep.bham.ac.uk/2004/Pelvic_Inflammatory_Disease.pdf Accessed 23.09.14. RATIONALE: This systematic review identified 34 trials of antibiotic treatment for PID. Most studies were small, open-label, and of poor methodological study. One small trial was found that compared oral ofloxacin plus metronidazole with clindamycin plus gentamicin. The cure rate was 15/15 for ofloxacin plus metronidazole plus 17/18 for clindamycin plus gentamicin. The systematic review found one trial of ceftriaxone plus doxyxcyline, two trials of cefoxitin plus probenecid and doxycycline, and three trials of cefoxitin plus doxycycline compared to other antibiotics. Meta-analysis of these six studies found no difference in cure rates between IM ceftriaxone plus doxycycline and the comparator antibiotics.

12
RCOG. Management of Acute Pelvic Inflammatory Disease. Green Top Guideline No.32. Royal College of Obstetricians & Gynaecologists. 2008. www.rcog.org.uk Accessed 23.09.14. RATIONALE: Recommended regimens: the recommended regimens are broad spectrum to cover N. gonorrhoea, C. trachomatis, and anaerobes. For outpatient management, either ofloxacin plus metronidazole for 14 days, or a stat dose of IM cefuroxime plus metronidazole and doxycycline for 14 days are recommended. Broad-spectrum treatment is warranted in PID because of the consequences of untreated infection (ectopic pregnancy, infertility, pelvic pain). Cefoxitin has a better evidence base for the treatment of PID than ceftriaxone, but it is not readily available in the UK. Ceftriaxone is therefore recommended. Although the combination of doxycycline and metronidazole (without IM ceftriaxone) has previously been used in the UK to treat PID, there are no clinical trials that adequately assess its effectiveness and its use is not recommended. Replacing intramuscular ceftriaxone with an oral cephalosporin (eg cefixime) is not recommended because there is no clinical trial evidence to support its use, and tissue levels are likely to be lower which might impact on efficacy. Reports of decreasing susceptibility of Neisseria gonorrhoea to cephalosporins also supports the use of parenteral based regimens at a dose of 500mg ceftriaxone when gonococcal PID is suspected (to maximise tissue levels and overcome low level resistance).

13
GRASP Steering Group. GRASP 2008 report: trends in antimicrobial resistant gonorrhoea. Health Protection Agency. 2009.
http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/Gonorrhoea/AntimicrobialResistance/ Accessed 23.09.14. RATIONALE: Ciprofloxacin resistance is now endemic in England and Wales, accounting for 28% of all gonorrhoea isolates tested in 2008. The Health Protection Agency and the Association of Medical Microbiologists had said that, for practical issues of administration in primary care, a stat dose of oral cefixime 400mg could be substituted for IM ceftriaxone. However, resistance to cephalosporins is increasing and treatment failures have been reported with cefixime; therefore, if gonorrhoea is suspected, IM ceftriaxone is the cephalosporin of choice.

14
Ross JDC, Cronjé HS, Paszkowski T, Rakoczi I. Moxifloxacin versus ofloxacin plus metronidazole in uncomplicated pelvic inflammatory disease: results of a multicentre, double blind, randomised trial. Sex Transm Infect 2006;82(6):446-51. RATIONALE: This trial in 564 patients with uncomplicated PID in hospitals from 13 countries, compared oral metronidazole 500mg twice daily with either oral ofloxacin 400mg twice daily or moxifloxacin 400mg once daily. Clinical resolution with both regimens was 90% and bacteriological cure was similar. Metronidazole is included in the regimen to improve the coverage for anaerobic bacteria. Anaerobes are of relatively greater importance in patients with severe PID. Ofloxacin and moxifloxacin should be avoided in patients who are at high risk of gonococcal PID because of increasing quinolone resistance in the UK (e.g. when the patient‟s partner has gonorrhoea, in clinically severe disease, following sexual contact abroad). Quinolones should also be avoided as first line empirical treatment for PID in areas where >5% of PID is caused by quinolone resistant Neisseria gonorrhoea.

15
Ison CA, Mouton JW, Jones K. Which cephalosporin for gonorrhoea? Sex Transm Infect 2004;80:386-88. Accessed 22.09.14. RATIONALE: This study used previously published pharmacokinetic data on cefixime, ceftriaxone and cefuroxime to model the length of time tissue concentrations to these drugs would be above the MIC 90 (concentration needed to kill 90% of gonorrhoea isolates). Cefuroxime concentrations are too low. Ceftriaxone attains the optimal concentrations to prevent the development of step-wise mutations and resistance in Neisseria gonorrhoea.

16
Arredondo JL, Diaz V, Gaitan H et al. Oral clindamycin and ciprofloxacin versus intramuscular ceftriaxone and oral doxycycline in the treatment of mild-to-moderate pelvic inflammatory disease in outpatients. Clin Infect Dis 1997;24(2):720-727. RATIONALE: In this clinical trial in South American outpatients, clinical cure was attained with 97% (65/67) in the oral clindamycin and ciprofloxacin group compared to 95% (61/64) in the ceftriaxone and doxycycline group.

The POCAST project is funded by the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College London and by the Imperial College Healthcare Charity (Grant Ref No:7006/P36U).