4.11 - Genital and Sexually Transmitted Infections

A) Adults

Disease / Etiology

Preferred

Alternative

Comments

Bacterial Sexually Transmitted Infections

Syphilis

 
Early Syphilis
Syphilis infection of less than 2 years duration
(Primary, Secondary and Early Latent Syphilis)
Treponema Pallidum

 
Benzathine Penicillin 2.4 MU IM single dose
OR
Procaine Penicillin G 600,000 units IM q24H for 10 days
   
Contact Tracing needed:
All partners should be screened and treated epidemiologically.

If allergic to penicillin, please refer to ID physician.

Late Latent Syphilis
Syphilis infection of more than 2 years duration


Benzathine Penicillin 2.4 MU IM weekly for 3 weeks
OR
Procaine Penicillin G 600,000 units IM q24H for 17 days

 
Contact Tracing needed.

If patient defaults Benzathine Penicillin by more than 2 weeks in between the weekly doses, the whole regimen needs to be restarted.

If allergic to penicillin, please refer to ID physician.

 
Neurosyphilis
 
Benzylpenicillin G (Aqueous crystalline penicillin G) 3 - 4 MU IV q4H for 17 - 21 days

   
CSF VDRL - 50% sensitivity but high specificity. A negative CSF VDRL does not exclude neurosyphilis.

A CSF Pleocytosis (>20 WBC/mm3) and an elevated CSF protein might be considered as diagnostic against reactive blood serology in HIV co-infection.

Repeat lumbar puncture and CSF examination every 6 months till CSF white cell count is normal.

Consider re-treatment if CSF white cell count has not normalized in 6 months or CSF VDRL has not normalized in 2 year.

Steroids are recommended when there is neurological or cardiovascular involvement (BASHH). BASHH recommendations: Prednisone 40 - 60 mg q24H for 3 days. Start anti-treponemal treatment 24 hours after starting prednisolone.

 
Syphilis in Pregnancy
 
As in non-pregnant patients with syphilis

   
Doxycycline and tetracycline contraindicated in pregnancy.

Erythromycin use is associated with high risk of failure to cure the infection in the fetus.

Therefore, all infants should be treated at birth with penicillin.

 
Congenital Syphilis
 
Benzylpenicillin G 50,000 units/kg/dose IV q12H during the first 7 days of life, then q8H thereafter for a total of 10 - 14 days
OR
Procaine Penicillin G 50,000 units/kg/dose IM q24H for 10 - 14 days

 
If penicillin allergic:
No proven alternative therapy, consider penicillin desensitization.
 

Gonorrhoea

 
Neisseria Gonorrhoeae
 
Ceftriaxone 500 mg IM single dose
+ Azithromycin 1 gm PO single dose
(for synergistic tharapeutic effect, reduction of resistance and treatment of Chlamydia trachomatis infection)

 
Cefotaxime 500 mg IM single dose

Penicillins, tetracyclines and quinolones are no longer recommended for treatment of gonorrhoea due to high resistance rates to these antibiotics worldwide.

Contact Tracing needed.


Gonococcal Epididymitis / Epididymo-orchitis
 
Ceftriaxone 500 mg IM single dose
+ Doxycycline 100 mg PO q12H for 7 days

 
Ceftriaxone 500 mg IM single dose
+ Ofloxacin 200 mg PO q12H for 14 days (if enteric organisms are suspected)

 
Oral Ofloxacin is not available in UMMC.

Disseminated Gonococcal Infection
 
Ceftriaxone 1 gm IM / IV q24H

May switch to following oral options 24 - 48H after symptoms improve (depend on sensitivity)
OR
Ciprofloxacin 500 mg PO q12H


Cefotaxime 1 gm IV q8H


Duration of therapy depends on clinical response but treatment should continue for at least 7 days.

To admit patient to hospital. 


Gonococcal Conjunctivitis

Ceftriaxone 500 mg IM q24H for 3 days
 
Azithromycin 2 gm single dose
+ Doxycycline 100 mg PO q12H for 1 week
+ Ciprofloxacin 250 mg PO q24H for 3 days

 
3 day regimen is recommended as cornea may be involved and is relatively avascular.

The eye should be irrigated with saline and water.

Chlamydia

 
Chlamydia trachomatis serovars D to K
 
Azithromycin 1gm PO single dose
OR Doxycycline 100 mg PO q12H for 7 days
 
Erythromycin Stearate 500 mg PO q6H for 7 days
OR Erythromycin Ethyl Succinate 800 mg PO q6H for 7 days
 
Doxycycline and Ofloxacin contraindicated in pregnancy.
In pregnancy, can use Erythromycin, Azithromycin or Amoxicillin.

Contact Tracing needed.

Non Specific Urethritis (NSU) / Non Gonococcal Urethritis (NGU)


Chlamydia trachomatis
Mycoplasma genitalium
Ureaplasma urealyticum
Trichomonas vaginalis


 
Similar to treatment of Chlamydia
   

Chancroid

 
Haemophilus ducreyi

 
Azithromycin 1 gm PO STAT
OR Ceftriaxone 250 mg IM STAT 
OR Ciprofloxacin 500 mg PO q12H for 3 days
OR Erythromycin Stearate 500 mg PO q6H for 7 days
OR Erythromycin Ethyl Succinate 800 mg PO q6H for 7 days

   
Needle aspirate fluctuant buboes from adjacent healthy skin.
Less commonly seen nowadays. 

Contact Tracing needed.

Lymphogrnuloma Venereum (LGV)

 
Chlamydia trachomatis serovars L1, L2, L3
 
Doxycycline 100 mg PO q12H for 21 days
OR
Azithromycin 1 gm PO weekly for 3 weeks


Erythromycin Stearate 500 mg PO q6H
OR
Erythromycin Ethyl Succinate 800 mg PO q6H for 21 days


Drainage of infected buboes may be required.

Contact Tracing needed.

Granuloma Inguinale (Donovanosis)

 
Klebsiella granulomatis

Azithromycin 1 gm PO weekly for 3 weeks
OR
Azithromycin 500 mg PO q24H for 7 days
 
TMP - SMX (TMP 80 mg / SMX 400 mg) 2 tablet PO q12H for 3 weeks
OR
Ceftriaxone 1 gm IM / IV q24H for 3 weeks
OR
Erythromycin Stearate 500 mg PO q6H for 3 weeks
OR
Doxycycline 100 mg PO q12H for 3 weeks

 
Duration: 3 weeks 

Treatment should be continued until the lesions have healed.

Add Gentamicin 1 mg/kg IM / IV q8H in patients whose lesions do not respond in the first few days to other agents.

Contact Tracing needed.

Trichomoniasis

 
Trichomonas vaginalis
 
Metronidazole 400 mg PO q12H for 5 - 7 days
OR
Metronidazole 2 gm PO single dose

   
High dose Metronidazole or Tinidazole is not recommended in pregnancy or breastfeeding.

Avoid alcohol (antabuse effect) with Metronidazole.

In Metronidazole resistant trichomoniasis, use higher doses of Metronidazole e.g. 2 gm daily for 3 - 5 days or Clotrimazole intra-vaginal cream.

Contact Tracing needed.

Pelvic Inflammatory Disease

 
Chlamydia trachomatis
Neisseria Gonorrhoeae
Gardnerella vaginalis
Haemophilus influenza
Enteric Gram negative rods
Streptococcus agalactiae
Ureaplasma urealyticum
Mycoplasma hominis

 
Outpatient Regimen
(For mild to moderate PID):

IM Ceftriaxone 500 mg single dose
+
Doxycycline 100 mg PO q12H
(or Azithromycin 1 gm PO / week)
+
Metronidazole 400 mg PO q12H

 
Inpatient Regimen
(For moderate to severe PID):

Ceftriaxone 2 gm IV q24H
+
Doxycycline 100 mg PO q12H
+
Metronidazole 400 mg PO q12H
 
Duration: 14 days

Beta-lactam allergy : can use Clindamycin and Gentamicin (BASHH).

Male partners should be contacted and offered screening for chlamydia and gonorrhea.

Treat all male partners with Azithromycin 1 gm PO single dose.

Bacterial vaginosis


Gardnerella vaginalis
Mycoplasma hominis 
Provetella sp 
Mobiluncus

Metronidazole 400 mg PO q12H for 5 - 7 days
OR
Metronidazole 2 gm PO single dose
 
Intravaginal Metronidazole 0.75% gel q24H for 5 days
OR
Intravaginal Clindamycin 2% cream q24H for 7 days
OR
Clindamycin 300 mg PO q12H for 7 days

Treatment is indicated for symptomatic women, women undergoing gynaecological procedures and pregnant women.

Avoid alcohol with Metronidazole. 

Routine screening and treatment of male partners not indicated.

Patients should be advised to avoid vaginal douching and the use of shower gels and strong scented soap.

No evidence of teratogenicity of use Metronidazole in the first trimester of pregnancy.

Vaginal Candidiasis


Candida albicans

Topical therapy
Clotrimazole pessary 500 mg single dose
OR
Clotrimazole pessaries 200 mg q24H for 3 nights

Topical therapy
Nystatin pessaries 100,000 units q24H for 2 weeks
OR
Oral Therapy
Fluconazole 150 mg PO single dose
(Pregnancy Category C)
OR Itraconazole 200 mg PO q12H for 1 day
(Pregnancy Category C)

 
Oral therapy is contraindicated in pregnancy.

Viral Sexually Transmitted Infections


GENITAL HERPES
Herpes simplex virus 1 and 2

First episode - all for 5 days
Aciclovir 200 mg PO 5 times / day
OR
Aciclovir 400 mg PO q8H
OR
Valaciclovir 500 mg to 1 gm PO q12H

Episodic therapy
Aciclovir 400 mg PO q8H for 5 days
OR
Aciclovir 800 mg PO q8H for 2 days (short course)
OR
Valaciclovir 500 mg PO q12H for 3 days (short course)

Suppressive therapy
Aciclovir 400 mg PO q12H
OR
Aciclovir 200 mg PO 3 - 5 times / day
OR
Valaciclovir 500 - 1000 mg PO q24H

 
Consider suppressive therapy if frequent recurrences (> 6 per year), severe, prolonged or with psychosocial problems.

> 5 days of treatment required only in those with new lesions or those with severe signs and symptoms.

HSV 1: an increasing cause of genital HSV. 

Treat for 6 - 12 months.

Discontinue after 12 months to assess frequency of recurrences.