Genital tract infections

Refer to BASHH website for full details.

Opportunistically screen all patients aged 15-25 years

Treat partners and refer to GUM service.

Azithromycin

• 1g single dose (2 x 500mg tablets)

Doxycycline

• 100mg twice daily for 7 days

Pregnancy, breast-feeding patients:

Azithromycin

• 1g stat (as 500mg tablets) 1 hour before or 2 hours after food, or

Amoxicillin

• 500mg every 8 hours for 7 days
• Azithromycin is the most effective option. Its use is off label in pregnancy but recommended by BASHH.
• Due to lower cure rate in pregnancy test for cure 6 weeks after treatment.
• Tetracyclines are contraindicated in pregnancy

Suspected epididymitis in men over 35 years with low risk of STI:

If high risk of STI or if treatment fails, consider referral to GUM

Treat with antibiotics as directed by recent urine cultures or

Ofloxacin

• 200mg every 12 hours for 14 days

Notes

1. 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.
2. 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

Refer to 5.1.12 Quinolones for further details

See section: 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 or in women of childbearing potential unless adequate contraception is used.
• Fluconazole is not recommended for patients who are breastfeeding.

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%

• 5g applicatorful PV for 5 nights.

Clindamycin vaginal cream 2%

• 5g applicatorful PV for 7 nights

See section 7.2.2 Vaginal and vulval infections

Patients with suspected Gonorrhoea should be referred to specialist Genito-Urinary Medicine services for treatment and contact tracing.

Refer to BASHH website for full details

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 section 7.2.2 Vaginal and vulval infections

Test for Chlamydia & N. gonorrhoea. If positive, refer all patients and contacts to GUM clinic.

Tetracyclines and quinolones are contra-indicated in pregnancy - consult obstetrician.

Recommend review after treatment to assure cure.

Metronidazole

• 400mg every 12 hours for 14 days plus

Doxycycline

• 100mg every 12 hours for 14 days

or

Metronidazole

• 400mg every 12 hours for 14 days plus

Ofloxacin

• 400mg every 12 hours for 14 days

Notes

1. 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
2. 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

Refer to 5.1.12 Quinolones for further details

Patients with suspected Gonorrhoea should be referred to specialist Genito-Urinary Medicine services for treatment and contact tracing.

Refer to BASHH website for full details

See section: 5.1.3 Tetracyclines, 5.1.11 Metronidazole, 5.1.12 Quinolones

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

• 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

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