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Disease /
Etiology
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Preferred
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Alternative
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Comments
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Bacterial
Sexually Transmitted Infections
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Syphilis
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Early Syphilis
Syphilis infection of less than 2 years duration
(Primary, Secondary and Early Latent Syphilis)
Treponema Pallidum
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Benzathine Penicillin 2.4 MU IM single dose
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Procaine Penicillin G 600,000 units IM
q24H for 10 days
OR
Doxycycline 100mg PO q12H
for 14 days
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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.
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Late Latent Syphilis
Syphilis infection of more than 2 years duration
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Benzathine Penicillin 2.4 MU IM weekly for 3 weeks
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Procaine
Penicillin G 600,000 units IM q24H for 14 days
OR
Doxycycline 100mg PO q12H
for 28 days
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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.
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Neurosyphilis
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Benzylpenicillin G (Aqueous crystalline penicillin
G) 4 MU IV q4H for 14 days
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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
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Syphilis in Pregnancy
Primary, secondary and
early latent
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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)
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If penicillin allergic:
No proven alternative therapy, consider
penicillin desensitization.
If unable to do so, alternative:
Ceftriaxone 500mg IM q24h for 10 days
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Doxycycline and tetracycline contraindicated in pregnancy.
Avoid use of macrolides in
early pregnancy as it is associated with increased risk of treatment failure.
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Late latent syphilis and
neurosyphilis
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Treat
as per non-pregnant patients
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Congenital Syphilis
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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
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If penicillin allergic:
No proven alternative therapy, consider penicillin desensitization.
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Gonorrhoea
Neisseria Gonorrhoea
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Uncomplicated genital, ano-rectal and pharyngeal infection
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Ceftriaxone 500 mg IM single dose
+
Doxycycline 100mg PO q12H for 7 days (if chlamydia not
excluded)
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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
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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.
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Gonococcal Epididymitis / Epididymo-orchitis
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Ceftriaxone 500 mg IM single dose
+
Doxycycline 100 mg PO q12H for 14 days
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Disseminated Gonococcal Infection
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Ceftriaxone 1 gm IM / IV q24H for 7 days
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Cefotaxime 1 gm IV q8H
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To admit patient to hospital.
May
be switched to Ciprofloxacin 500mg PO q12h 24-48hrs after symptoms improve
and if susceptible.
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Gonococcal Conjunctivitis
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Ceftriaxone 500 mg IM q24H for 3 days
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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
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3 day regimen is recommended as cornea may be involved and is relatively
avascular.
The eye should be irrigated with saline and water.
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Chlamydia
Chlamydia
trachomatis serovars D to K
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Uncomplicated
(urogenital,
pharyngeal and rectal infection)
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Doxycycline 100 mg PO q12H for
7 days
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Azithromycin 1 gm PO single dose, then 500mg PO
q24h for 2 days
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Avoid unprotected sexual intercourse
for 1 week following treatment.
Test of cure is not routinely recommended.
Contact Tracing needed.
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Chlamydia in pregnancy
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Azithromycin 1gm PO
stat, then 500mg PO q24h for 2 days
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Amoxicillin 500mg PO q8H for 7 days
OR
Erythromycin Ethyl succinate 800mg PO q6H for 7 days
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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
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Mycoplasma genitalium
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Uncomplicated urogenital infection (urethritis cervicitis)
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Doxycycline 100 mg PO
q12H for 7 days
Followed by
Azithromycin 1gm PO
stat, then 500mg PO q24h for 2 days
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Non
Specific Urethritis (NSU) / Non Gonococcal Urethritis (NGU)
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First episode of Non-gonococcal urethritis (NGU)
Recurrent and persistent Non- gonococcal urethritis (NGU)
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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
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Azithromycin 1000mg PO STAT then 500mg q24h for 2 days
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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
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Chancroid
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Haemophilus ducreyi
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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
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Needle aspirate fluctuant buboes from adjacent
healthy skin.
Less commonly seen nowadays.
Contact Tracing needed.
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Lymphogrnuloma
Venereum (LGV)
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Chlamydia trachomatis serovars L1, L2, L3
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Doxycycline 100 mg PO q12H for 21 days
OR
Azithromycin 1 gm PO weekly for 3 weeks
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Erythromycin Ethyl Succinate 800 mg PO q6H for 21 days
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Drainage of infected buboes may be required.
Contact Tracing needed.
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Granuloma
Inguinale (Donovanosis)
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Klebsiella granulomatis
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Azithromycin 1 gm PO weekly for 3 weeks
OR
Azithromycin 500 mg PO q24H for 7 days
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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
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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.
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Trichomoniasis
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Trichomonas vaginalis
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Metronidazole 400 mg PO q12H for 5 - 7 days
OR
Metronidazole 2 gm PO single dose
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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.
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