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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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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
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Benzathine Penicillin 2.4 MU IM weekly for 3 weeks
OR
Procaine Penicillin G 600,000 units IM q24H for 17 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 |
Benzylpenicillin G (Aqueous crystalline penicillin G) 3 - 4 MU IV q4H for 17 - 21 days
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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.
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Syphilis in Pregnancy |
As in non-pregnant patients with syphilis
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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.
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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
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If penicillin allergic:
No proven alternative therapy, consider penicillin desensitization. |
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Gonorrhoea
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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)
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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.
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Gonococcal Epididymitis / Epididymo-orchitis |
Ceftriaxone 500 mg IM single dose
+
Doxycycline 100 mg PO q12H for 7 days
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Ceftriaxone 500 mg IM single dose
+
Ofloxacin 200 mg PO q12H for 14 days (if enteric organisms are suspected)
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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
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Cefotaxime 1 gm IV q8H
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Duration of therapy depends on clinical response
but treatment should continue for at least 7 days.
To admit patient to hospital.
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Gonococcal Conjunctivitis |
Ceftriaxone 500 mg IM q24H for 3 days |
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
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Chlamydia trachomatis serovars D to K |
Azithromycin 1 gm PO single dose
OR
Doxycycline 100 mg PO q12H for 7 days
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Erythromycin Ethyl Succinate 800 mg PO q6H for 7 days
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Doxycycline and Ofloxacin contraindicated in pregnancy.
In pregnancy, can use Erythromycin, Azithromycin or Amoxicillin.
Contact Tracing needed.
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Non Specific Urethritis (NSU) / Non Gonococcal Urethritis (NGU)
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Chlamydia trachomatis
Mycoplasma genitalium
Ureaplasma urealyticum
Trichomonas vaginalis
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Similar to treatment of Chlamydia |
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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 |
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
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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 |
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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Pelvic Inflammatory Disease
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Chlamydia trachomatis
Neisseria Gonorrhoeae
Gardnerella vaginalis
Haemophilus influenza
Enteric Gram negative rods
Streptococcus agalactiae
Ureaplasma urealyticum
Mycoplasma hominis
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Outpatient Regimen
(For mild to moderate PID):
Ceftriaxone 500 mg IM single dose
+
Doxycycline 100 mg PO q12H
(or Azithromycin 1 gm PO / week)
+
Metronidazole 400 mg PO q12H
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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. |
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Bacterial vaginosis
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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.
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Vaginal Candidiasis
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Candida albicans |
Topical therapy
Clotrimazole pessary 500 mg single dose
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Topical therapy
Nystatin pessary 100,000 unit 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)
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Nystatin pessary 100,000 unit is not available in UMMC.
Oral therapy is contraindicated in pregnancy. |
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Viral Sexually Transmitted Infections
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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
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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.
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