3.11 - Genital and Sexually Transmitted Infections (Updated)

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

 

 

Procaine Penicillin G 600,000 units IM q24H for 10 days

OR

Doxycycline 100mg PO q12H for 14 days

 
Advise no sexual contact for 7 days after treatment is administered.

Contact Tracing needed:
All partners should be screened and treated epidemiologically. 

Penicillin based regimens are preferred treatment for syphilis

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



Procaine Penicillin G 600,000 units IM q24H for 14 days 

OR

Doxycycline 100mg PO q12H for 28 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) 4 MU IV q4H for 14 days

 

    Indications for lumbar puncture:

1.     Patients with neurological and / or ocular symptoms  or signs

2.     Non - treponema test titres do not decrease by fourfold within 12 months of therapy 

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

 


If allergic to penicillin:

IM/IV Ceftriaxone 2gm q24H for 14 days

(If no anaphylaxis to penicillin)

 

OR

 

T. Doxycycline 200mg q12H for 28 days

 

The use of steroids is controversial.

Oral prednisolone 40-60mg OD may be considered for 3 days starting 24 hours before the antibiotics

Syphilis in Pregnancy

Primary, secondary and early latent

1st and 2nd Trimester: Benzathine Penicillin 2.4 MU IM single dose

 



3rd Trimester: Benzathine Penicillin 2.4 MU IM weekly for 2 weeks (Day 1 & 8)


If penicillin allergic:

No proven alternative therapy, consider penicillin desensitization.

 


If unable to do so, alternative:

Ceftriaxone 500mg IM q24h for 10 days

Doxycycline and tetracycline contraindicated in pregnancy.

Avoid use of macrolides in early pregnancy as it is associated with increased risk of treatment failure.

Late latent syphilis and neurosyphilis

Treat as per non-pregnant patients

 

 
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 Gonorrhoea


Uncomplicated genital,  ano-rectal and pharyngeal infection

Ceftriaxone 500 mg IM single dose 

Doxycycline 100mg PO q12H for 7 days (if chlamydia not excluded)

β-lactam Allergy:

Gentamicin 240mg IM as a single dose

PLUS

*Azithromycin 2gm PO as a single dose

Pregnancy and breastfeeding: as in non-pregnant adults



Avoid unprotected sexual intercourse for 1 week following treatment

Test of cure after 2 weeks post treatment with NAAT is advisable especially with pharyngeal infection

Contact Tracing needed.

Please send gonorrhoea culture and antimicrobial susceptibility testing prior to antibiotic treatment and if treatment failure suspected.


Gonococcal Epididymitis / Epididymo-orchitis

 
Ceftriaxone 500 mg IM single dose

Doxycycline 100 mg PO q12H for
14 days

 

 


Disseminated Gonococcal Infection

 
Ceftriaxone 1 gm IM / IV q24H for 7 days



Cefotaxime 1 gm IV q8H 


To admit patient to hospital.

May be switched to Ciprofloxacin 500mg PO q12h 24-48hrs after symptoms improve and if susceptible.


Gonococcal Conjunctivitis


Ceftriaxone 500 mg IM q24H for 3 days

Anaphylaxis to Penicillin or established allergy to Cephalosporin:


Azithromycin 2 gm PO 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


 
Uncomplicated (urogenital, pharyngeal and rectal infection)


 
Doxycycline 100 mg PO q12H for 7 days

 
Azithromycin 1 gm PO single dose, then 500mg PO q24h for 2 days


 
Avoid unprotected sexual intercourse for 1 week following treatment.

Test of cure is not routinely recommended.

Contact Tracing needed.

Chlamydia in pregnancy

 

Azithromycin 1gm PO stat, then 500mg PO q24h for 2 days

Amoxicillin 500mg PO q8H for 7 days

OR

Erythromycin Ethyl succinate 800mg PO q6H for 7 days

Doxycycline is contraindicated in pregnancy

Test of cure (TOC) is recommended in pregnancy, poor compliance and persistent symptoms. Test of cure should be performed 5 weeks after treatment with NAAT

Mycoplasma genitalium


Uncomplicated urogenital infection (urethritis cervicitis)

 

Doxycycline 100 mg PO q12H for 7 days

 

Followed by

 

Azithromycin 1gm PO stat, then 500mg PO q24h for 2 days

 

 

 

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


First episode of Non-gonococcal urethritis (NGU)

 



Recurrent and persistent Non- gonococcal urethritis (NGU)

 

Doxycycline 100mg PO q12h for 7 days




If treated with Doxycycline first line: Azithromycin 1000mg PO STAT then 500mg q24h for 2 days PLUS

Metronidazole 400mg PO q12h for 5 days

If treated with Azithromycin first line: Moxifloxacin 400mg PO q24h for 10-14 days

PLUS

Metronidazole 400mg PO q24h for 5 days


Azithromycin 1000mg PO STAT then 500mg q24h for 2 days

 

Most common cause of recurrent or persistent NGU is Mycoplasma genitalium.

Contact tracing needed.

Abstain from sexual intercourse until has completed therapy and his partner(s) have been treated – at least 1 week after completion of treatment.

Follow-up is recommended after 2-3 weeks

For confirmed Mycoplasma genitalium infection, TOC in 3 weeks post treatment is recommended using PCR

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 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 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

 
Co-trimoxazole (480 mg) 2 tablets PO q12H for 3 weeks
  
OR

Ceftriaxone 1 gm IM / IV q24H 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.


Revision history: Updated on 9th Feb 2021