Sexually Transmitted Infections - Department of …

1 Sexually Transmitted Infections MANAGEMENT GUIDELINES 2015 Adapted from: Standard Treatment Guidelines and Essential Drugs List PHCSEXUALLY Transmitted INFECTIONS3 Table of ContentsSexually Transmitted Infections Diagnosis and Management ..4 Vaginal Discharge Syndrome (VDS) ..6 Lower Abdominal Pain (LAP) ..7 Male Urethritis Syndrome (MUS) ..8 Scrotal Swelling (SSW) ..9 Genital Ulcer Syndrome (GUS) ..10 Bubo ..11 Balanitis/Balanoposthitis (BAL) ..12 Syphilis Serology and Treatment ..13 Syphilis ..15 Syphilis in Pregnancy ..16 Neonatal Conjunctivitis ..17 Treatment of More than One STI Syndrome ..19 Genital Molluscum Contagiosum (MC) ..20 Genital Warts (GW): Condylomata Accuminata ..20 Pubic Lice (PL) ..21 Treatment Protocol for Asymptomatic Partner(s) ..224 Sexually Transmitted INFECTIONSS exually Transmitted Infections Diagnosis and Management The syndromic approach to Sexually Transmitted Infection (STI) diagnosis and management is to treat the signs or symptoms (syndrome) of a group of diseases rather than treating a specific disease.

2 This allows for the treatment of one or more conditions that often occur at the same time and has been accepted as the management of choice. This guide includes the current STI syndromic management are preventable and many are treatable. Early access to care helps prevent further transmission to partners and from mother-to-child, acquisition of additional STIs, and decreases the risk of STI related complications. Screening for STIs at any and all health care visits, can promote STI prevention and management and provide an opportunity for additional health promotion and education. Where possible, STI screening and prevention should become routine and integrated into all health screening should include the following three questions of all persons aged 15-49 years, regardless of clinical presentation:n Do you have any genital discharge?

3 N Do you have any genital ulcers?n Has/have your partner(s) been treated for an STI in the last 8 weeks? Sexually Transmitted INFECTIONS5In order to perform a proper clinical assessment it is important to take a good sexual history and undertake a thorough ano-genital examination. The history should include questions concerning symptoms, recent sexual history, sexual orientation, type of sexual activity (oral, vaginal, anal sex), the possibility of pregnancy (females), use of contraceptives including condoms, recent antibiotic history, any drug allergies, and recent overseas travel. General Measuresn Counselling and education, including HIV testingn Condom promotion, provision and demonstration to reduce the risk of STIsn Compliance/adherence with treatmentn Contact treatment/partner managementn Circumcision promotion with appropriate counselling concerning condomsn Contraception and conception counsellingSuspected STIs in children should be referred to the hospital for further management.

4 Promote HIV counselling and testing. Sexually Transmitted INFECTIONS6 Patient complains of: Abnormal vaginal discharge/ dysuria or vulval itching/ burningNNConsider vaginal candidiasis AND/OR bacterial vaginosisTREATMENT Metronidazole, oral, 2 g as a single dose AND Clotrimazole vaginal pessary 500mg inserted as a single dose at night OR Clotrimazole vaginal cream, inserted with an applicator 12 hourly for 7 days LoE:IIiIf no response: Metronidazole, oral, 400 mg, 12 hourly for 7 days. LoE:IIiiIf no response after 7 days, (All cases including pregnant women) Ceftriaxone, IM, 250 mg as a single dose* LoE:IIIiii AND Azithromycin, oral, 1 g, as a single dose LoE:Iiv AND Metronidazole, oral, 2 g as a single doseIF VULVA OEDEMA/ CURD-LIKE DISCHARGE, ERYTHEMA, EXCORIATIONS PRESENT: Clotrimazole vaginal pessary 500mg inserted as a single dose at night ANDIf vulval irritation is severe: Clotrimazole vaginal cream, applied thinly to vulva 12 hourly and continue for 3 days after symptoms resolve.

5 (Maximum 2 weeks)Ask patient to return if symptoms persist. If no response: Metronidazole, oral, 400 mg, 12 hourly for 7 no response after 7 days, lower abdominal pain flowchart (LAP)ANDtreat for candidiasis if clinically < 35 years OR Partner has MUS?Abnormaldischarge confirmed?Lower abdominal pain (LAP) ORPain on moving the cervix?YYY*People who are allergic to penicillin may also react to severe penicillin allergy, angioedema, anaphylactic shock or bronchospasm, omit ceftriaxone and increase azithromycin dose to: Azithromycin, oral, 2 g, as a single dose. LoE:IvFor ceftriaxone IM injection: Dissolve ceftriaxone 250 mg in mL lidocaine 1% without epinephrine (adrenaline) LoE:IIIviTake Pap smear after treatment, if indicated according to screening : Suspected STI in children should be referred to hospital for further Discharge Syndrome (VDS) Sexually Transmitted INFECTIONS7 Discharge patientYYNYL ower Abdominal Pain (LAP) Sexually active patient complains of lower abdominal pain with/ without vaginal dischargeTake history (including gynaecological) and examine (abdominal and vaginal).

6 Emphasize HIV testingLower abdominal tenderness with/ without vaginal dischargeRefer all patients for gynaecological or surgical ILL PATIENTSSet up an IV line and treat shock if present. If referral is delayed > 6 hours: Ceftriaxone, IV, 1g (Do not dilute with lidocaine 1%) AND Metronidazole, oral, 400 mgFor pain, add:* Ibuprofen, oral 400 mg 8 hourly with food LoE:III*If severe penicillin allergy, angioedema, anaphylactic shock or bronchospasm, omit ceftriaxone and increase azithromycin dose to: Azithromycin, oral, 2 g as a single dose. LoE:IvFor ceftriaxone IM injection: Dissolve ceftriaxone 250 mg in mL lidocaine 1% without epinephrine (adrenaline). LoE:IIIviTREATMENT Ceftriaxone, IM, 250 mg single dose* LoE:IIIiii AND Azithromycin, oral, 1 g as a single dose LoE:IIvii AND Metronidazole, oral, 400 mg 12 hourly for 7 days LoE:IIIviiiPain not improving after 48 72 hours: refer urgently for gynaecological assessmentTreat as UTIR eferNNUrinalysis results or symptoms consistent with UTI AND absence of cervical motion tendernessAny of the following present.

7 Pregnancy Missed period Recent delivery, TOP or miscarriage Abdominal guarding and/or rebound tenderness Abdominal vaginal bleeding Abdominal mass Fever > 38 CImproved after 7 daysSEXUALLY Transmitted INFECTIONS8 EMPHASISE PARTNER(S) TRACINGMale Urethritis Syndrome (MUS) Patient complains of urethral discharge or dysuriaTake history, including sexual orientation and examine. If no visible discharge; ask patient to milk urethra. Emphasise HIV testing and partner(s) ceftriaxone 250 mg treatment failure: Ceftriaxone, IM, 1 g single dose ** LoE:IIIix AND Azithromycin, oral, 2 g as a single dose AND Metronidazole, oral, 2 g as a single dose, if not already givenRefer all ceftriaxone treatment failures within 7 days for gentamicin, IM, 240 mg as a single dose. LoE:IIIix, xIf severe penicillin allergy, angioedema, anaphylactic shock or bronchospasm:*omit ceftriaxone, IM, 250 mg and increase azithromycin dose to azithromycin, oral, 2 g as a single dose LoE:Iv**omit ceftriaxone, IM, 1 g and refer to a centre for gentamicin, IM, 240 mg as a single dose plus azithromycin, oral, 2 g as a single dose.

8 LoE:IIIix, xFor ceftriaxone IM injection: Dissolve ceftriaxone 250 mg in mL lidocaine 1% without epinephrine (adrenaline). Dissolve ceftriaxone 1 g in mL lidocaine 1% without epinephrine (adrenaline). LoE:IIIviDischargeYTREATMENT Ceftriaxone, IM, 250 mg single dose* LoE:IIIii AND Azithromycin, oral, 1 g as a single dose LoE:IivIf sexual partner has VDS, add: Metronidazole, oral, 2 g as a single doseUrethral discharge persists after 7 daysSEXUALLY Transmitted INFECTIONS9 Scrotal Swelling (SSW)Take history and examine. Emphasize HIV pain add: Ibuprofen, oral, 400 mg 8 hourly with food LoE:IIIR efer for surgical opinionRefer urgently if suspected torsion*If severe penicillin allergy, angioedema, anaphylactic shock or bronchospasm, omit ceftriaxone and increase azithromycin dose to: Azithromycin, oral, 2 g as a single dose LoE:I, IIIvFor ceftriaxone IM injection: dissolve ceftriaxone 250 mg in mL lidocaine 1% without epinephrine (adrenaline).

9 LoE:IIIviTREATMENT Ceftriaxone, IM, 250 mg as a single dose* LoE:IIIiiiAND Azithromycin, oral, 1 g as a single dose LoE:IivReview after 7 days or earlier if necessaryComplete treatment and discharge rotated and elevated OR History of trauma OR Other non-tender swelling not thought to be due to sexual activity?Scrotal swellingORpain confirmed?Improving? Sexually active patient complains of scrotal swelling/ painSEXUALLY Transmitted INFECTIONS10 Genital Ulcer Syndrome (GUS) Take history and examine for ulcers and, if present, buboes. Emphasise HIV genital herpes. Emphasise HIV HIV positive or unknown HIV status: LoE:III Aciclovir, oral, 400 mg 8 hourly for 7 daysPenicillin allergic men and non-pregnant women: Perform a baseline RPR and replace benzathine penicillin with: Doxycycline, oral, 100 mg 12 hourly for 14 to return for a follow-up RPR 6 months later.

10 LoE:III*Penicillin allergic pregnant women/ breast feeding women, refer for confirmation of new syphilis infection and possible penicillin desensitisation. LoE:IIIxii**For benzathine benzylpenicillin, IM, MU: Dissolve benzathine benzylpenicillin MU in 6 mL lidocaine 1% without epinephrine (adrenaline). LoE:IIIxiiiDischarge patientEmphasise HIV no improvement: Azithromycin, oral, 1 g as a single dose LoE:IIIxiIf no response after 48 hours (If bubo present, use bubo flowchart) Benzathine benzyl penicillin*, IM, MU immediately as a single dose** If HIV positive or unknown HIV status, add: Aciclovir, oral, 400 mg 8 hourly for 7 days LoE:IIIPain relief if indicated. Review all cases in 1 active within the last 3 months?Ulcer(s) healedor clearly improving?Patient complains of genital sore or ulcer with/ without painNYSEXUALLY Transmitted INFECTIONS11 BuboPatient complains of hot tender inguinal swelling with surrounding erythema and/or oedemaTake history and examine.