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Adult Treatment - Genital Tract Infections

Contact UKTIS for information on foetal risks if patient is pregnant.

STI Screening: People with risk factors should be screened for chlamydia, gonorrhoea, HIV, syphilis. Refer individual and partners to genito-urinary medicine (GUM) service. Risk factors: < 25y, no condom use, recent (<12mth)/frequent change of partner, symptomatic partner, area of high HIV.1,2

Gonorrhoea

Antibiotic resistance is now very high. Use IM ceftriaxone plus oral azithromycin and refer to genito-urinary medicine (GUM) for other sexually transmitted infections. Test of cure is essential.

Medicine Calendar

Ceftriaxone PLUS azithromycin

ceftriaxone 500mg IM and oral azithromycin 1g

stat dose for both drugs

Pelvic inflammatory disease

BASHH
NICE-CKS

Refer woman & sexual contacts to genito-urinary medicine (GUM) service 1,2 B+. Always culture for gonorrhoea & chlamydia 2 B+ If gonorrhoea likely (partner has it, severe symptoms, sex abroad) use ceftriaxone regimen as resistance to quinolones is high3 B+.

Medicine Calendar

metronidazole PLUS ofloxacin

oral metronidazole 400mg BD PLUS oral ofloxacin 400mg BD1,2,4,6 B

14 days

If high risk of gonorrhoea metronidazole PLUS doxycycline PLUS ceftriaxone

oral metronidazole 400mg BD PLUS oral doxycycline 100mg BD PLUS ceftriaxone 500mg IM stat

14 days oral antibiotics and stat ceftriaxone

Genital herpes

Advise: saline bathing,[1A+] analgesia,[1A+] or topical lidocaine for pain,[1A+] and discuss transmission.[1A+]

First episode: treat within five days if new lesions or systemic symptoms,[1A+,2D] and refer to GUM.[2D]

Recurrent: self-care if mild,[2D] or immediate short course antiviral treatment,[1A+,2D] or suppressive therapy if more than six episodes per year.[1A+,2D]

Medicine Calendar

First line: oral aciclovir

400mg TDS OR 800mg TDS (if recurrent)

400mg TDS for 5 days OR 800mg TDS for 2 days

OR valaciclovir

500mg BD

5 days

OR famciclovir

250mg TDS or 1g BD (if recurrent)

250mg TDS for 5 days or 1g BD for 1 day

Bacterial vaginosis

BASHH
PHE
NICE-CKS

Oral metronidazole is as effective as topical treatment 1 A+ but is cheaper. Less relapse with 7 day than 2g stat at 4 wks3 A+
Pregnant2 A+ /breastfeeding: AVOID 2g stat in pregnancy3 A+
Treating partners does not reduce relapse5 B+

Medicine Calendar

oral Metronidazole 1,3 A+

400mg BD or 2g (2g dose:(NOT IN PREGNANCY))

7 days 1 A+ OR 2g stat3 A+

or Metronidazole 0.75% vaginal gel 1 A+

5g applicatorful at night

5 nights 1 A+

or Clindamycin 2% cream 1 A+

5g applicatorful at night

7 nights 1 A+

Trichomoniasis

BASHH
PHE
NICE-CKS

Oral treatment needed as extravaginal infection common. Treat partners and refer to genito-urinary medicine (GUM) service for other sexually transmitted infections. 1 B+.

Metronidazole 2g single dose more adverse effects.

In pregnancy or breastfeeding: AVOID 2g single dose metronidazole. Clotrimazole for symptom relief (not cure) if metronidazole is declined 3 B+

Medicine Calendar

metronidazole (oral)4 A+

400mg BD or 2g (2g dose:(NOT IN PREGNANCY))

5-7 days 4 A+ or 2g stat 4 A+

Pregnancy for symptoms: clotrimazole 3 B+

100mg pessary at night

6 nights 3 B+

Vaginal candidiasis

BASHH
PHE
NICE-CKS

All topical and oral azoles give over 70% cure 1 A+

In pregnancy: avoid oral azoles 2 B- and use intravaginal treatment for 7 days 3 A+,2,4 B-

Recurrent (>4 episodes per year): oral fluconazole 150mg every 72 hours for three doses induction, followed by 150mg once a week for six months maintenance.

Medicine Calendar

clotrimazole 1 A+

500mg pessary or 10% cream

stat

OR miconazole

100mg pessary

14 nights

OR oral fluconazole1 A+

150mg orally

stat

Recurrent: fluconazole (induction and maintenance)

150mg oral every 72 hours then 150mg once a week

3 doses induction then 6 months maintenance

Chlamydia trachomatis/urethritis

SIGN
BASHH
PHE
NICE-CKS

Opportunistically screen all patients aged 16-24yrs1. Treat partners and refer to GUM service2,3 B+. Repeat test for cure in all at three months.

Pregnancy2 C or breastfeeding: azithromycin is the most effective option5 A+
Due to lower cure rate in pregnancy, test for cure at least three weeks after end of treatment3 C

Medicine Calendar

Azithromycin4 A+

1g

stat 4 A+

OR Doxycycline (NOT IN PREGNANCY)4 A+

100mg BD

7 days 4 A+

If PREGNANT or BREASTFEEDING- azithromycin 5 A+

1g (off-label use)

stat 5 A+

Or If PREGNANT or BREASTFEEDING- erythromycin 5 A+

500mg QDS

10-14 days 5 A+

Or If PREGNANT or BREASTFEEDING- amoxicillin 5 A+

500mg TDS

7 days 5 A+

Epididymitis

Usually due to Gram-negative enteric bacteria in men over 35 years with low risk of STI.[1A+,2D]
If under 35 years or STI risk, refer to GUM.[1A+,2D]

Medicine Calendar

Doxycycline

100mg BD

10-14 days

OR ofloxacin

200mg BD

14 days

OR ciprofloxacin

500mg BD

10 days

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).