All information is correct at time of printing and is subject to change without notice. The Devon Formulary and Referral Website is not in any way liable for the accuracy of any information printed and stored by users. For the most up-to-date information, please refer to the website.
STI screening – people with risk factors should be screened for Chlamydia, gonorrhoea, HIV and syphilis.
Refer individual and partners to GUM service. Risk factors: under 25 years, no condom use, recent (less than 12 month)/ frequent change of partner, symptomatic partner.
Treatment options are below though in most cases a prompt referral to GUM for investigation and management is the most appropriate action.
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:
If chlamydia infection is suspected or confirmed, strongly recommend referral to a Genito-Urinary Medicine (GUM) clinic for management.
If the person declines, or is unable to attend a GUM clinic, manage in primary care.
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:
Suspect chlamydia in sexually active men with:
Symptoms of rectal chlamydia include anal discharge and anorectal discomfort, although rectal infection is usually asymptomatic.
Pharyngeal infections are usually asymptomatic.
Asymptomatic people who should be tested for chlamydia include:
Public Health England recommend opportunistic screening of all patients aged 15-24 years.
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.
Doxycycline and ofloxacin are contraindicated in pregnancy and breast-feeding; see below for specific recommendations for pregnancy.
See section: 5.1.3 Tetracyclines
See section: 5.1.5 Macrolides
Drug Safety Updates for Ofloxacin (refer to 5.1.12 Quinolones for further details).
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.
See section: 5.1.5 Macrolides
OR
See section: 5.1.5 Macrolides
OR
See section: 5.1.1 Penicillins
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.
See 5.2.1 Triazole antifungals and 7.2.2 Vaginal and vulval infections
In pregnancy avoid oral azoles and use intravaginal treatment
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.
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.
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):
It is also recommended to offer blood tests for HIV and syphilis if testing for gonorrhoea and chlamydia.
Symptoms and signs of infection with gonorrhoea depend, in part, on the site of infection
Signs and symptoms of gonorrhoea in men:
Signs and symptoms of gonorrhoea in women:
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)
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.
See section: 5.1.2 Cephalosporins, carbapenems, and other beta-lactams
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.
When antimicrobial susceptibility is known prior to treatment
See section: 5.1.2 Cephalosporins, carbapenems, and other beta-lactams
PLUS
*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: 5.1.5 Macrolides
When antimicrobial susceptibility is known prior to treatment
Drug Safety Updates for Ciprofloxacin (refer to 5.1.12 Quinolones for further details).
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.
All patients diagnosed with gonorrhoea should be advised to return for TOC.
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.
See section 7.2.2 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.
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
Symptoms
The following features are suggestive of a diagnosis of PID
Signs
The differential diagnosis of lower abdominal pain in a young woman includes:
Sexual Health Contact Details:
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:
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:
PLUS
PLUS
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.
Supportive treatment:
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
Episodic prescription: