Genital tract infections

The information below is based on British Association for Sexual Health & HIV (BASHH) Guidelines: Chlamydia trachomatis (updated September 2018).

Genital chlamydial infection can cause significant short and long-term morbidity. Complications of infection include pelvic inflammatory disease (PID), tubal infertility, ectopic pregnancy, epididymo-orchitis, and lymphogranuloma venereum (LGV).

Chlamydia is the most commonly reported curable bacterial STI in the UK. The highest prevalence rates are in 15–24-year olds. Chlamydia infection has a high frequency of transmission, with concordance rates of up to 75% of partners being reported.

Risk factors for chlamydia infection include:

• Age under 25 years
• A new sexual partner
• More than one sexual partner in the last year
• Lack of consistent condom use
• Social deprivation

If chlamydia infection is suspected or confirmed, strongly recommend referral to a Genito-Urinary Medicine (GUM) clinic for management.

• Devon Sexual Health (Barnstaple, Exeter, and Torquay)
• SHiP (Sexual Health in Plymouth)

If the person declines, or is unable to attend a GUM clinic, manage in primary care.

Symptoms

At least 70% of women and 50% of men infected with chlamydia trachomatis are asymptomatic, and symptoms in men can be very mild.

Suspect chlamydia in sexually active women with:

• Increased vaginal discharge
• Post-coital and intermenstrual bleeding
• Dysuria
• Lower abdominal pain
• Deep dyspareunia

Suspect chlamydia in sexually active men with:

• Urethral discharge
• Dysuria

Symptoms of rectal chlamydia include anal discharge and anorectal discomfort, although rectal infection is usually asymptomatic.

Pharyngeal infections are usually asymptomatic.

Screening

Asymptomatic people who should be tested for chlamydia include:

• Sexual partners of those with proven or suspected chlamydial infection
• All sexually active people younger than 25 years of age, annually, or more frequently if they have changed their partner
• All people with concerns about a sexual exposure.
  • If the exposure was within the last two weeks, a test should be carried out at presentation and if negative, repeated two weeks after the exposure.
• People under the age of 25 years who have been treated for chlamydia in the previous three months
• People who have had two or more sexual partners in the previous 12 months
• All women seeking termination of pregnancy
• All men and women attending genito-urinary medicine clinics

Public Health England recommend opportunistic screening of all patients aged 15-24 years.

Test of Cure (TOC)

TOC is not routinely recommended for uncomplicated genital chlamydia infection, because residual, non-viable chlamydial DNA may be detected by nucleic acid amplification test (NAAT) for 3-5 weeks following treatment.

TOC is recommended in pregnancy, where LGV (in the absence of a definite negative result) or poor compliance is suspected, where symptoms persist, and in rectal infection when one-week doxycycline are used.

TOC should be performed no earlier than three weeks after completion of treatment.

Recommended antibiotic treatment

Uncomplicated urogenital infection, pharyngeal infection, and rectal infection

Doxycycline and ofloxacin are contraindicated in pregnancy and breast-feeding; see below for specific recommendations for pregnancy.

Doxycycline

• 100mg twice daily for 7 days

If intolerant to tetracyclines

Azithromycin

• 1g single starting dose (2 x 500mg tablets), then 500mg daily for 2 days (off-label dose)

If the above treatments are contraindicated

Ofloxacin

• 200mg twice daily for 7 days or 400mg (2 x 200mg tablets) once daily for 7 days
• Not recommended for use in children and growing adolescents
• MHRA Drug Safety Update (November 2018): Systemic and inhaled fluoroquinolones: small increased risk of aortic aneurysm and dissection; advice for prescribing in high-risk patients
• MHRA Drug Safety Update (March 2019): Fluoroquinolone antibiotics: new restrictions and precautions for use due to very rare reports of disabling and potentially long-lasting or irreversible side effects
• MHRA Drug Safety Update (December 2020): Systemic and inhaled fluoroquinolones: small risk of heart valve regurgitation; consider other therapeutic options first in patients at risk

Pregnancy

Azithromycin and erythromycin in pregnant women have similar efficacy in treating chlamydia. Azithromycin is much better tolerated than erythromycin but should only be used during pregnancy if the benefit outweighs the risk.

Azithromycin

• 1g single starting dose (2 x 500mg tablets), then 500mg daily for 2 days (off-label dose)
• BASHH recommend that women are advised there is a lack of data on pregnancy outcomes using this dosing regimen. The BNF advises to use only if adequate alternatives are not available.

OR

Erythromycin

• 500mg twice daily for 14 days or 500mg four times daily for 7 days

OR

Amoxicillin

• 500mg three times a day for 7 days
• Amoxicillin has a similar cure rate to erythromycin and a better side effect profile however, penicillin in vitro has been shown to induce latency and re-emergence of infection

See section: 5.1.1 Penicillins, 5.1.3 Tetracyclines, 5.1.5 Macrolides, and 5.1.12 Quinolones

All topical and oral azoles give 75% cure

Various clotrimazole or fluconazole products are available to purchase over the counter, along with advice, from pharmacies. Some self-care medicines are available in shops and supermarkets. Please click here for further information and a patient leaflet.

Clotrimazole 10%

• 5g vaginal cream, single dose

Fluconazole (oral)

• 150mg single dose
• Fluconazole should not be used in pregnancy orin women of childbearing potential unless adequate contraception is used.
• Fluconazole is not recommended for patients whoare breastfeeding
• See resources for: contraception for drugs with teratogenic potential, and prescribing in pregnancy and lactation

Clotrimazole

• 500mg pessary single dose

See 5.2.1 Triazole antifungals and 7.2.2 Vaginal and vulval infections

Pregnancy

In pregnancy avoid oral azoles and use intravaginal treatment

Clotrimazole 10%

• 5g vaginal cream, single dose or

Clotrimazole

• 100 mg pessary at night (6 nights)

Miconazole

• Vaginal 2% cream 5 g intravaginally twice daily (7 days)

See section 7.2.2 Vaginal and vulval infections

Oral metronidazole is as effective as topical treatment. There is less relapse at 4 weeks with 7 days treatment than with 2g single dose.

Topical treatment gives similar cure rates but is more expensive. Vaginal preparations are unsuitable for use during menstruation.

Treating partners does not reduce relapse. Refer to GUM if recurrent.

Metronidazole

• 400mg every 12 hours for 7 days or
• 2g single dose stat (avoid if pregnant or breastfeeding)

Metronidazole vaginal gel 0.75%

• One applicatorful (5g) inserted into the vagina once daily at bedtime for 5 consecutive nights

Clindamycin vaginal cream 2%

• One applicatorful (5g) inserted into the vagina once daily at bedtime for 7 consecutive nights
• In patients for whom a shorter treatment course is desirable, a 3 day regimen has been shown to be effective

See section 7.2.2 Vaginal and vulval infections

The information below is based on British Association for Sexual Health & HIV (BASHH) Guidelines: Gonorrhoea (updated January 2019).

Uncomplicated gonorrhoea is most common in young adults aged 15-24-year olds. Complications of infection include epididymo-orchitis, prostatitis, urethral stricture, pelvic inflammatory disease (PID), tubal infertility, ectopic pregnancy, and chronic pelvic pain.

Partner notification should be pursued in all patients identified with gonococcal infection. Notified partners should be offered testing and current or recent partners (within the past 14 days) considered for empirical treatment.

If gonorrhoea infection is suspected or confirmed, strongly recommend referral to a Genito-Urinary Medicine (GUM) clinic or other local specialist sexual health service for management and to facilitate screening for infections and for contact tracing.

• Devon Sexual Health (Barnstaple, Exeter, and Torbay) (electronic referral system available)
  • A patient can self-refer by phoning 0300 303 3989 for a consultation within 24 hours. Please give relevant treatment information to the patient to bring to clinics, i.e. results of previous cultures and any treatments.
• SHiP (Sexual Health in Plymouth)

If the person declines, or is unable to attend a GUM clinic, manage in primary care.

All patients, including sexual partners, should be advised to abstain from sex until 7 days after completion of antibiotic treatment

Arrange a dual test for Neisseria gonorrhoeae and Chlamydia trachomatis (Gonorrhoea must be specifically requested for the laboratory to test):

• in women, a vulvovaginal swab should be used
• in men, a first pass urine specimen should be used, and additionally rectal and pharyngeal sampling should be routine in all men who have sex with men

It is also recommended to offer blood tests for HIV and syphilis if testing for gonorrhoea and chlamydia.

Signs and Symptoms

Symptoms and signs of infection with gonorrhoea depend, in part, on the site of infection

Signs and symptoms of gonorrhoea in men:

• Genital gonorrhoea
  • Urethral discharge
• Rectal gonorrhoea
  • Anal discharge
  • Perianal/ anal pain or discomfort
• Pharyngeal gonorrhoea
  • Usually asymptomatic
  • Pharyngitis

Signs and symptoms of gonorrhoea in women:

• Urogenital gonorrhoea
  • Increased or altered vaginal discharge
  • Lower abdominal pain
  • Dysuria
  • Intermenstrual bleeding and menorrhagia
  • Dyspareunia
  • On examination, a mucopurulent endocervical discharge may be seen and easily induced endocervical bleeding
• Rectal gonorrhoea
  • Anal discharge
  • Perianal/ anal pain or discomfort
• Pharyngeal gonorrhoea
  • Usually asymptomatic
  • Pharyngitis

Other symptoms may be caused by complications of gonorrhoea infection, including prostatitis, epididymitis and orchitis, and pelvic inflammatory disease and rarely disseminated gonococcal infection (skin lesions, arthralgia, arthritis and tenosynovitis)

Recommended antibiotic treatment

Uncomplicated anogenital and pharyngeal infection

Promptly refer patient to a sexual health clinic for 1st line treatment with Intramuscular (IM) Ceftriaxone or consider administration in primary care if appropriate to do so.

All individuals with gonorrhoea diagnosed by laboratory tests should have cultures taken for susceptibility testing prior to antibiotic treatment. Cultures should be taken from all anatomical sites that have tested positive for gonorrhoea.

Ceftriaxone IM*

• 1g intramuscularly as a single dose (off-label dose)
• Do not delay treatment whilst awaiting culture result

If the person declines, or is unable to attend a GUM clinic, and is unsuitable for administration of IM Ceftriaxone in primary care oral antibiotic alternatives may be considered, but only after sensitivities are known, and after advice has been sought from GUM clinics.

Oral regimens

When antimicrobial susceptibility is known prior to treatment

Ciprofloxacin (monotherapy)

• 500mg orally as a single dose

Alternative oral regimens

When antimicrobial susceptibility is known prior to treatment

Cefixime*

• 400mg orally as a single dose (off-label indication)

PLUS

Azithromycin

• 2g orally as a single dose (off-label dose) (prescribe as 4 x 500mg tablets)

*Ceftriaxone and cefixime are suitable treatment options in penicillin-allergic patients, unless there is a history of severe hypersensitivity (e.g. anaphylactic reaction) to any beta-lactam antibacterial agent (penicillins, cephalosporins, monobactams, and carbapenems).

See section: 5.1.2 Cephalosporins, carbapenems, and other beta-lactams, 5.1.5 Macrolides, and 5.1.12 Quinolones

Complicated infections and pregnancy

If gonorrhoea infection is complicated (i.e. conjunctival), or if infection is suspected or confirmed in pregnancy, refer to a Genito-Urinary Medicine (GUM) clinic for management, see contact details above.

Test of Cure (TOC)

All patients diagnosed with gonorrhoea should be advised to return for TOC.

• If the person is asymptomatic, swab and send to laboratory for testing, from all originally positive sites (followed by culture if positive), 3 weeks after completion of treatment
• If signs or symptoms persist, test with culture, performed at least 3 days after completion of treatment

Refer to GUM and treat partners simultaneously.

In pregnancy or breastfeeding avoid 2g single dose metronidazole.

Topical clotrimazole gives symptomatic relief (not cure) if metronidazole declined.

Metronidazole

• 400 mg every 12 hours for 5-7 days or
• 2g single dose stat (avoid if pregnant or breastfeeding)

Clotrimazole

• 100 mg pessary at night for 6 nights

See section7.2.2 Vaginal and vulval infections

Updated guidance from the British Association of Sexual and HIV (BASSH) recommends that testing for PID is extended to include Mycoplasma genitalium to direct the choice of antibiotics. Until access to this test is routinely available to primary care in Devon, patients with suspected PID should be referred to specialist Genito-Urinary Medicine (GUM) services for full assessment; including testing, contact tracing, and treatment management.

Diagnosis

A diagnosis of PID should be considered and referral to the GUM services for full assessment, in any sexually active woman who has recent onset, lower abdominal pain associated with local tenderness on bimanual vaginal examination, in whom pregnancy has been excluded and no other cause for the pain has been identified. The risk of PID is highest in women aged under 25 not using barrier contraception and with a history of a new sexual partner. The diagnosis of PID based only on positive examination findings, in the absence of lower abdominal pain, should only be made with caution

Clinical features

Symptoms

The following features are suggestive of a diagnosis of PID

• lower abdominal pain which is typically bilateral (but can be unilateral)
• abnormal vaginal or cervical discharge which is often purulent
• deep dyspareunia
• abnormal vaginal bleeding, including post coital bleeding, inter-menstrual bleeding and menorrhagia
• secondary dysmenorrhoea

Signs

• lower abdominal tenderness which is usually bilateral
• adnexal tenderness on bimanual vaginal examination – a tender mass is sometimes present
• cervical motion tenderness on bimanual vaginal examination
• fever (>38°C) in moderate to severe disease

The differential diagnosis of lower abdominal pain in a young woman includes:

• ectopic pregnancy – pregnancy should be excluded in all women suspected of having PID
• acute appendicitis – nausea and vomiting occurs in most patients with appendicitis but only 50% of those with PID. Cervical movement pain will occur in about a quarter of women with appendicitis
• endometriosis – the relationship between symptoms and the menstrual cycle may be helpful in establishing a diagnosis
• complications of an ovarian cyst e.g. torsion or rupture – symptoms are often of sudden onset
• urinary tract infection – often associated with dysuria and/or urinary frequency
• irritable bowel syndrome – disturbance in bowel habit and persistence of symptoms over a prolonged time period are common. Acute bowel infection or diverticular disease can also cause lower abdominal pain usually in association with other gastrointestinal symptoms.
• functional pain (pain of unknown aetiology) – may be associated with longstanding symptoms

Sexual Health Contact Details:

• Devon Sexual Health (Barnstaple, Exeter, and Torbay)
  • A patient can self-refer by phoning 0300 303 3989 for a consultation within 24 hours. Please give relevant treatment information to the patient to bring to clinics, i.e. results of previous cultures and any treatments
  • electronic referral system is also available
• SHiP (Sexual Health in Plymouth)
  • A patient can self-refer by phoning 01752 431124

Current and recent partners (within the last 6 months) of women with PID should be contacted and offered advice, screening, treatment, and contact tracing, this may include empirical therapy for partners e.g. doxycycline 100mg twice daily for 7 days.

All patients should be advised not to have sex until they and any current partners have completed antibiotic treatment.

Refer to hospital for inpatient management if the patient:

• cannot take oral antibiotics
• shows signs of moderate or severe disease
• is pregnant

Antibiotic treatment

Exclude pregnancy prior to consideration of antibiotic treatment.

Patients with suspected PID should be referred to specialist GUM services for 1st line treatment with ceftriaxone IM plus oral doxycycline and metronidazole. The GUM service will conduct testing and contact tracing.

If the person declines, or is unable to attend a GUM service, and either intramuscular administration of ceftriaxone is not possible in primary care or is not clinically appropriate, the oral only antibiotic regimen below may be considered.

If the patient is to be treated in primary care, the following steps should be taken:

Before starting treatment:

• Using a vulvovaginal swab, arrange a dual test for Neisseria gonorrhoeae and Chlamydia trachomatis (gonorrhoea must be specifically requested for the laboratory to test)
• Complete an endocervical swab (for gonorrhoea culture and sensitivity)
• Offer blood tests for HIV and syphilis if testing for gonorrhoea and chlamydia

Recommended regimen

Ceftriaxone IM

• 1g intramuscularly as a single dose (off-label dose)
• Do not delay treatment whilst awaiting culture result
  

PLUS

Doxycycline Oral

• 100mg orally twice daily for 14 days

PLUS

Metronidazole Oral

• 400mg orally twice daily for 14 days

Oral only regimen

Doxycycline Oral

• 100mg orally twice daily for 14 days

Metronidazole Oral

• 400mg orally twice daily for 14 days

See sections 5.1.2 Cephalosporins, carbapenems, and other beta-lactams, 5.1.3 Tetracyclines, and 5.1.11 Metronidazole

Review the patient at 72 hours. If no improvement, consider a referral to hospital.

Consider further review, either in clinic or by phone, 2 weeks after treatment to assess clinical response, compliance and partner treatment. If symptoms have not resolved, refer to the GUM service for assessment.

Test of cure is only necessary if initial testing for gonorrhoea was positive; see gonorrhoea slider guidance.

Guidance adapted from Sexually Transmitted Infections in Primary Care (RCGP 2013)

If the diagnosis is unclear then take a viral swab for HSV/VZV. Also see risk factors for additional STI screening.

Oral antivirals are indicated within 5 days of start of episode or while new lesions are still forming, or if symptoms persist.

Aciclovir tablets

• 400mg every 8 hours or 200mg five times a day for 5 days
• Review after 5 days and continue if new lesions still appearing, complex disease, or immunosuppressed
• Severe cases require urgent referral
• Refer to GUM if patient suffers more than 6 occurrences a year

Supportive treatment:

• Saline bathing, topical petroleum jelly, lidocaine ointment for a few days when required

Recurrent episodes

Prodromal symptoms occur up to 48 hours before appearance of lesions, often milder than the initial episode with faster resolution. Symptoms = milder/self-limiting, therefore manage in partnership with patient.

Options are:

Supportive treatment

• Saline bathing, topical petroleum jelly, lidocaine ointment, for a few days when required

Episodic prescription:

• Standby prescription for next episode to start at prodrome

Aciclovir tablets

• 200mg five times a day for 5 days or
• 400mg eight hourly for 3-5 days or
• 800mg eight hourly for 2 days