Guidelines for the Management of Sexually Transmitted Infections

GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS

World Health Organization GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS

WHO Library Cataloguing-in-Publication Data

World Health Organization.

Guidelines for the management of sexually transmitted infections.

1.Sexually transmitted diseases - diagnosis 2.Sexually transmitted diseases - therapy 3.Anti-infective agents - therapeutic use 4.Practice guidelines I.Expert Consultation on Improving the Management of Sexually Transmitted Infections (2001 : Geneva, Switzerland)

ISBN 92 4 154626 3 (NLM classiﬁ cation: WC 142)

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Printed in Switzerland iii iii CONTENTS 1 2 5 6 vii 11 16 18 21 23

GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES

PREFACE PREFACE CONTENTS ophthalmia Gonococcal 34 infection gonococcal Disseminated 34 infection anogenital Uncomplicated 33 3.1 infections Gonococcal 33 2.1. Urethral discharge Urethral 2.1. 1.1. Background 1.1. 1.6. drugs Selection of 1.3. Case management Case 1.3. 1.5. Risk factors for STI-related cervicitis ulcers Genital 2.2. bubo Inguinal infection Vaginal 4 conjunctivitis Neonatal 2.6. 31 1.2. Rationale for standardized treatment recommendations 1.4.management Syndromic 1 or recurrent urethral discharge Persistent Genital ulcers and HIV infection swelling Scrotal 2.3. discharge Vaginal 2.4. infection Cervical pain abdominal Lower 2.5. 3 9 12 22 27 3. TREATMENT OF SPECIFIC INFECTIONS SPECIFIC OF 3. TREATMENT 33 2. TREATMENT OF STI-ASSOCIATED SYNDROMES STI-ASSOCIATED OF 2. TREATMENT 6 1. INTRODUCTION 1 GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS

3.2 Chlamydia trachomatis infections (other than lymphogranuloma venereum) 36 Uncomplicated anogenital infection 36 Chlamydial infection during pregnancy 37 Neonatal chlamydial conjunctivitis 37 Infantile pneumonia 38 3.3 Lymphogranuloma venereum 38 3.4 Syphilis 39 Clinical presentation summary 39 iv iv Syphilis and HIV infection 41 CONTENTS Syphilis in pregnancy 41 Congenital syphilis 42 Early syphilis 43 Late latent syphilis 43 Neurosyphilis 44 Congenital syphilis 45 3.5 Chancroid 46 3.6 Granuloma inguinale (Donovanosis) 47 3.7 Genital herpes infections 48 Herpes in pregnancy 48 Herpes and HIV coinfection 49 Suppressive therapy 49 3.8 Venereal (genital) warts 51 Vaginal warts 53 Cervical warts 53 Meatal and urethral warts 53 3.9 Trichomonas vaginalis infections 54 Trichomoniasis in pregnancy 54 3.10 Bacterial vaginosis 56 BV in pregnancy 57 BV and surgical procedures 57 3.11 Candidiasis 58 Vulvo-vaginal candidiasis 58 Vulvo-vaginal candidiasis in pregnancy 59 v v CONTENTS 63 64 65 66 67 68 69 70 74 75 78 59 60 62 64 70 71 N. gonorrhoeae H. ducreyi cacy for other indications 66 fi cation of the syndrome 73 fi of sexual partners cation and management 76 fi cacy fi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES Risk of reducing drug ef Access to services 5.3 Safety Cost infections Coexistent Macrolides Suphonamides Tetracyclines Quinolones 4.3 in resistance Antimicrobial supply 65 Condom Counselling Noti patient the of Education 74 Identi Antimicrobial treatment for the syndrome 74 Cephalosporins 5.2STI of management case Comprehensive 72 4.2 Comments on individual drugs 5.1 STI prevention and control The public health package for 66 72 Availability Availability acceptability and Compliance 4.4 in resistance Antimicrobial 65 Ef 4.1 of antimicrobial regimen The choice 63 Balanoposthitis and HIV infection candidiasis Vulvo-vaginal Scabies 3.12 lice Pubic 3.13 59 5 IN STI CASE MANAGEMENT CONSIDERATIONS PRACTICAL 72 4 KEY CONSIDERATIONS UNDERLYING TREATMENTS TREATMENTS UNDERLYING 4 CONSIDERATIONS KEY 63 GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS

6 CHILDREN, ADOLESCENTS AND SEXUALLY TRANSMITTED INFECTIONS 80

6.1 Evaluation for sexually transmitted infections 81 Initial examination 82 Examination at 12 weeks following assault 83 Presumptive treatment 83 Susceptibility and clinical presentation of STI in children and adolescents 83 Cervical infections 84 vi Genital ulcer disease 84 Anogenital warts 85 CONTENTS Vaginal infection 85

ANNEXES

ANNEX 1. LIST OF PARTICIPANTS, MAY 1999 87 ANNEX 2. LIST OF PARTICIPANTS, NOVEMBER 2001 89

Note on terminology

The World Health Organization recommends that the term sexually transmitted disease (STD) be replaced by the term sexually transmitted infection (STI). The term sexually transmitted infection has been adopted since 1999 as it better incorporates asymptomatic infections. In addition, the term has been adopted by a wide range of scientiﬁ c societies and publications.

Reproductive tract infections encompass three main groups of infection, particularly in women, and sometimes in men. These groups are endogenous infections in the female genital tract (e.g. candidiasis and bacterial vaginosis), iatrogenic infections that may be acquired through non-sterile medical, personal or cultural practices, and some classical STIs. As endogenous infections are not primarily sexually transmitted, clinical and public health actions as recommended for STIs may not apply to them. Given the current state of knowledge and understanding of these non-sexually transmitted infections, treatment of partners is not recommended as routine public health practice. Reassurance and patient education are critical with regard to the nature of these infections. vii vii PREFACE ciency virus (HIV) infection and ﬁ

a major impact on the ciency syndrome (AIDS) have had ﬁ GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES PREFACE In November 2001, an expert consultation on improving the management of STIs In November 2001, an expert consultation on improving focused on was convened by WHO in Geneva (see Annex 2). The consultation The former because of the syndromes of genital ulcers and vaginal discharge. as the main cause of the observed increase of herpes simplex virus type 2 (HSV2) its continued complexity genital ulcers in developing countries, and the latter for gonococcal and chlamydial and controversy as an entry point for managing cervical led to the revisions infections. Recommendations from the consultation have syndromic management of included in this publication, covering the two areas of genital ulcer disease and vaginal discharge. In 1991, WHO published recommendations for the comprehensive management In 1991, WHO published recommendations the broader context of control, prevention and care of patients with STIs within infection. WHO convened an Advisory Group programmes for STI and HIV Diseases Treatment in May 1999 to review Meeting on Sexually Transmitted in the light of recent developments (see and update treatment recommendations Annex 1). management and control of STIs. At the same time, resistance of several sexually management and control of agents has increased, adding to therapeutic transmitted pathogens to antimicrobial problems. The emergence and spread of human immunode The emergence and spread acquired immunode Sexually transmitted infections (STIs) are among the most common causes of illness among the most common causes infections (STIs) are Sexually transmitted for social and economic consequences have far-reaching health, in the world and many countries. GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS

1. INTRODUCTION

1.1. BACKGROUND

Sexually transmitted infections (STIs) remain a public health problem of major 1 signiﬁ cance in most parts of the world. The incidence of acute STIs is believed to be high in many countries. Failure to diagnose and treat STIs at an early stage may INTRODUCTION result in serious complications and sequelae, including infertility, fetal wastage, ectopic pregnancy, anogental cancer and premature death, as well as neonatal and infant infections. The individual and national expenditure on STI care can be substantial.

The appearance of HIV and AIDS has focused greater attention on the control of STIs. There is a strong correlation between the spread of conventional STIs and HIV transmission, and both ulcerative and non-ulcerative STIs have been found to increase the risk of sexual transmission of HIV.

The emergence and spread of HIV infection and AIDS have also complicated the management and control of some other STIs. For example, owing to HIV-related immunosuppression, the treatment of chancroid has become increasingly difﬁ cult in areas with a high prevalence of HIV infection.

Antimicrobial resistance of several sexually transmitted pathogens is increasing, rendering some regimen ineffective. New agents, such as third-generation cephalosporins and ﬂ uoroquinolones, capable of treating infections with resistant strains, are available but remain expensive. However, their initial high cost must be weighed against the costs of inadequate therapy, including complications, relapse and further transmission of infection.

1.2. RATIONALE FOR STANDARDIZED TREATMENT RECOMMENDATIONS

Effective management of STIs is one of the cornerstones of STI control, as it prevents the development of complications and sequelae, decreases the spread of those GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS

infections in the community and offers a unique opportunity for targeted education about HIV prevention.

Appropriate treatment of STIs at the ﬁ rst contact between patients and health care providers is, therefore, an important public health measure. In the case of adolescent1 patients, there is the potential to inﬂ uence future sexual behaviour and treatment-seeking practices at a critical stage of development.

2 It is strongly recommended that countries establish and use national standardized

INTRODUCTION treatment protocols for STIs. These can help to ensure that all patients receive adequate treatment at all levels of health care services. The protocols can also facilitate the training and supervision of health care providers and can help to reduce the risk of development of resistance to antimicrobials. Finally, having a standardized list of antimicrobial agents can also facilitate drug procurement.

It is anticipated that the recommendations contained in this document will help countries to develop standardized protocols adapted to local epidemiological and antimicrobial sensitivity patterns. It is recommended that national guidelines for the effective management of STIs be developed in close consultation with local STI and public health experts.

1.3. CASE MANAGEMENT

STI case management is the care of a person with an STI-related syndrome or with a positive test for one or more STIs. The components of case management include: history taking, clinical examination, correct diagnosis, early and effective treatment, advice on sexual behaviour, promotion and/or provision of condoms, partner notiﬁ cation and treatment, case reporting and clinical follow-up as appropriate. Thus, effective case management consists not only of antimicrobial therapy to obtain cure and reduce infectivity, but also comprehensive consideration and care of the patient’s reproductive health.

1 WHO has deﬁ ned adolescents as persons in the 10–19 years age group, while youth has been deﬁ ned as the 15–24 years age group. “Young people” is a combination of these two overlapping groups covering the range 10–24 years (A picture of health? A review and annotated bibliography of the health of young people in developing countries. Geneva, World Health Organization, 1995 [WHO/FHE/ADH/95.4]). GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS

1.4. SYNDROMIC MANAGEMENT

Etiological diagnosis of STIs is problematic for health care providers in many settings. It places constraints on their time and resources, increases costs and reduces access to treatment. In addition, the sensitivity and specifi city of commercially available tests can vary signifi cantly, affecting negatively the reliability of laboratory testing for STI diagnosis. Where laboratory facilities are available they must be staffed by suitably qualifi ed personnel with adequate training to perform technically demanding procedures, and the establishment of external quality control must be made mandatory. 3 INTRODUCTION Many health care facilities in developing countries lack the equipment and trained personnel required for etiological diagnosis of STIs. To overcome this problem, a syndrome-based approach to the management of STI patients has been developed and promoted in a large number of countries in the developing world. The syndromic management approach is based on the identifi cation of consistent groups of symptoms and easily recognized signs (syndromes), and the provision of treatment that will deal with the majority of, or the most serious, organisms responsible for producing a syndrome. WHO has developed a simplifi ed tool (a fl owchart or algorithm) to guide health workers in the implementation of syndromic management of STIs.

Syndromic management for urethral discharge in men, and genital ulcers in men and women, has proved to be both valid and feasible. It has resulted in adequate treatment of large numbers of infected people, and is inexpensive, simple and very cost-effective. However, recent data have indicated that herpes simplex virus type 2 (HSV2) is fast becoming the commonest cause of genital ulcer disease (GUD) in developing countries. This may negatively affect the treatment outcome of GUD if antiviral therapy is not appropriately instituted.

WHO’s simplifi ed generic tool includes fl owcharts for women with symptoms of vaginal discharge and/or lower abdominal pain. While the fl owcharts for abdominal pain are quite satisfactory, those for vaginal discharge have limitations, particularly in the management of cervical (gonococcal and chlamydial) infections. In general, but especially in low-prevalence settings and in adolescent females, endogenous vaginitis rather than an STI is the main cause of vaginal discharge. Attempts made to increase the sensitivity and specifi city of the vaginal discharge GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS

ﬂ owchart for the diagnosis of cervical infection, by introducing an appropriate, situation-speciﬁ c risk assessment, have not been successful. Some of the risk assessment questions based on demographics, such as age and marital status, tend to classify too many adolescents as being at risk of cervical infection. Therefore, there is a need to identify the main STI risk factors for adolescents in the local population and tailor the risk assessment accordingly. For adolescents in particular it may be preferable to base the risk factors on sexual behaviour patterns.

4 Further details on recommendations for treatment using a syndrome-based approach are given in section 2. INTRODUCTION

1.5. RISK FACTORS FOR STI-RELATED CERVICITIS

The ﬂ owcharts currently available for the management of cervical infection, referred to in section 1.4, are therefore far from ideal. Initially, it was thought that the ﬁ nding of vaginal discharge would be indicative of both vaginal and cervical infection. However, it has become clear that while vaginal discharge is indicative of the presence of vaginal infection, it is poorly predictive of cervical infection (gonococcal and/or chlamydial), particularly in adolescent females.

Some clinical signs seem to be more frequently associated with the presence of cervical infection. In the published literature, clinical observations that have consistently been found to be associated with cervical infection are the presence of cervical mucopus, cervical erosions, cervical friability and bleeding between menses or during sexual intercourse.

A number of demographic and behavioural risk factors have also been frequently associated with cervical infection. Some of those, which in some settings have been found to be predictive of cervical infection, are: being less than 21 years old (25 in some places); being unmarried; having more than one sexual partner in the previous three months; having a new partner in the previous three months; having a current partner with an STI; recent use of condoms by the partner. Such risk factors are, however, usually speciﬁ c for the population group for which they have been identiﬁ ed and validated, and cannot easily be extrapolated to other populations or to other locations. Most researchers have suggested that it is important to obtain more than one demographic risk factor in any particular patient. GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS

Adding these signs and a risk assessment to the vaginal discharge fl owchart does increase its specifi city and, therefore, its positive predictive value, although the latter remains low especially when the fl owchart is applied to populations with relatively low rates of infection.

1.6. SELECTION OF DRUGS

Antimicrobial resistance of several sexually transmitted pathogens has been increasing in many parts of the world and this has rendered some low-cost regimen 5 ineffective. Recommendations to use more effective drugs frequently raise concerns about cost and possible misuse. INTRODUCTION

A two-tier drug policy with the provision of less effective drugs at the peripheral health care level and the most effective and usually more expensive drugs only at a referral level may result in an unacceptable rate of treatment failures, complications and referrals, and may erode conﬁ dence in health services. This approach is not recommended. The drugs used for STI treatment in all health care facilities should have an efﬁ cacy of at least 95%. Criteria for the selection of drugs are listed in the box below.

Criteria for the selection of STI drugs Drugs selected for treating STI should meet the following criteria: ■ high efﬁ cacy (at least 95%) ■ low cost ■ acceptable toxicity and tolerance ■ organism resistance unlikely to develop or likely to be delayed ■ single dose ■ oral administration ■ not contraindicated for pregnant or lactating women. Appropriate drugs should be included in the national essential drugs list and in choosing drugs, consideration should be given to the capabilities and experience of health personnel. dentiality guaranteed. When ﬁ

1000) are indicative of urethritis. eld (x ﬁ

GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES STI-ASSOCIATED SYNDROMES STI-ASSOCIATED

TREATMENT OF TREATMENT

2. dealing with adolescents, the health care provider should be reassuring, experienced health care provider should be reassuring, experienced dealing with adolescents, the in anatomy and physiology associated with the and conversant with the changes e.g. the menarche in girls or nocturnal emissions in different maturation stages, care workers require training to overcome their own boys. In some situations, health with sexuality and STIs in sensitivities and to be able to address the issues associated an open and constructive manner. If microscopy is available, examination of the urethral smear may show an increased If microscopy is available, examination of the urethral stain may demonstrate the number of polymorphonuclear leukocytes and a Gram leukocytes per presence of gonococci. In the male, more than 5 polymorphonuclear high power Male patients complaining of urethral discharge and/or dysuria should be Male patients complaining of urethral discharge and/or urethra should be gently examined for evidence of discharge. If none is seen, the meatus. massaged from the ventral part of the penis towards the 2.1. URETHRAL DISCHARGE 2.1. URETHRAL Successful management of STIs requires members of staff to be respectful of patients requires members of staff to be respectful of patients Successful management of STIs Clinical examination must take place in appropriate and not to be judgemental. can be ensured and con surroundings where privacy For all these conditions (except vaginitis) the sexual partner(s) of patients should For all these conditions (except promptly treated for the same condition(s) as the also be examined for STIs and index patient. This section discusses the management of the most common clinical syndromes the most common clinical the management of This section discusses agents. Flowcharts for the management of each caused by sexually transmitted syndrome are provided. 6 6 TREATMENT OF STI-ASSOCIATED SYNDROMES GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS

The major pathogens causing urethral discharge are Neisseria gonorrhoeae (N. gonorrhoeae) and Chlamydia trachomatis (C. trachomatis). In the syndromic management, treatment of a patient with urethral discharge should adequately cover these two organisms. Where reliable laboratory facilities are available, a distinction can be made between the two organisms and speciﬁ c treatment instituted.

Recommended syndromic treatment ■ therapy for uncomplicated gonorrhoea (for details see section 3.1) 7

PLUS TREATMENT OF STI-ASSOCIATED SYNDROMES ■ therapy for chlamydia (for details see section 3.2)

Note

■ Patients should be advised to return if symptoms persist 7 days after start of therapy.

AT A GLANCE

Urethral Discharge For details, see sections 3.1 and 3.2 Treatment options for Gonorrhoea Treatment options for Chlamydia Ciprofl oxacin Doxycycline Ceftriaxone Azithromycin Cefi xime Spectinomycin Alternatives Amoxycillin Erythromycin (if Tetracycline contraindicated) Ofl oxacin Tetracycline

Note ■ WHO recommends that, where possible, single-dose therapy be used.

GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES FIGURE 1. URETHRAL DISCHARGE FIGURE 1. URETHRAL 8 8 TREATMENT OF STI-ASSOCIATED SYNDROMES GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS

PERSISTENT OR RECURRENT URETHRAL DISCHARGE Persistent or recurrent symptoms of urethritis may result from drug resistance, poor compliance or reinfection. In some cases there may be infection with Trichomonas vaginalis (T. vaginalis).

New evidence suggests a high prevalence of T. vaginalis in men with urethral discharge in some geographical areas. Where symptoms persist or recur after adequate treatment for gonorrhoea and chlamydia in the index patient and partner(s), the patient should be treated for T. vaginalis if the local epidemiological pattern so indicates. If the symptoms still persist at follow-up the patient must be 9 referred. For details, see section 3.9. TREATMENT OF STI-ASSOCIATED SYNDROMES owchart assumes effective therapy for Gonorrhoea and Chlamydia to have been received and taken by the owchart assumes effective therapy for Gonorrhoea and Chlamydia to have been ﬂ GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES

patient prior to this consultation. This

N.B. FIGURE 2. PERSISTENT/RECURRENT URETHRAL DISCHARGE IN MEN DISCHARGE URETHRAL 2. PERSISTENT/RECURRENT FIGURE 0

110 TREATMENT OF STI-ASSOCIATED SYNDROMES GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS

2.2. GENITAL ULCERS

The relative prevalence of causative organisms for GUD varies considerably in different parts of the world and may change dramatically over time. Clinical differential diagnosis of genital ulcers is inaccurate, particularly in settings where several etiologies are common. Clinical manifestations and patterns of GUD may be further altered in the presence of HIV infection.

After examination to conﬁ rm the presence of genital ulceration, treatment appropriate to local etiologies and antimicrobial sensitivity patterns should be given. 1111

In areas where both syphilis and chancroid are prevalent, for example, patients TREATMENT OF STI-ASSOCIATED SYNDROMES with genital ulcers should be treated for both conditions at the time of their initial presentation, to ensure adequate therapy in case of loss to follow-up. In areas where either granuloma inguinale or lymphogranuloma venereum (LGV) is prevalent, treatment for either or both conditions should be included for the same reason.

Recent reports from parts of Africa, Asia and Latin America indicate that GUD is more frequently a result of HSV2 infections. This has implications for the efﬁ cacy of the syndromic management of GUD if speciﬁ c antiviral treatment of HSV2 is not considered. In areas of high HIV/AIDS prevalence, the clinical presentation of these HSV2 ulcers is different from the classical descriptions.

The GUD ﬂ owchart presented in this section proposes speciﬁ c HSV2 treatment, where indicated.

Laboratory-assisted differential diagnosis is also rarely helpful at the initial visit, as mixed infections are common. In areas of high syphilis prevalence, a reactive serological test may only be a reﬂ ection of a previous infection and give a misleading picture of the patient’s present condition, and a negative test does not necessarily exclude an ulcer of primary syphilis as seroreactivity may take 2–3 weeks to show. rm these observations. ﬁ GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES

therapy for LGV where it is prevalent (for details see section 3.3) therapy for LGV where it is prevalent (for details see section therapy for granuloma inguinale where it is prevalent (for details see section 3.6) therapy for granuloma inguinale where it is prevalent OR therapy for chancroid where it is prevalent (for details see section 3.5) therapy for chancroid where it is prevalent (for details OR therapy for syphilis (for details see section 3.4) PLUS EITHER OR therapy for HSV2 infection where indicated (for details, see section 3.7)

■ ■ ■ ■ ■ Recommended syndromic treatment There is evidence to suggest that HIV infection may increase rates of treatment There is evidence to suggest when single-dose therapies are given. More research failure in chancroid, especially is needed to con herpes simplex lesions may present as persistent In immunosuppressed individuals, medical attention, as opposed to the self-limiting multiple ulcers that require in immunocompetent individuals. Thus, antiviral vesicles and ulcers which occur in such instances, to be given therapeutically treatment is particularly important education needs to be or prophylactically to offer comfort to the patient. Adequate of treatment and in given to the patient as well, to explain the nature and purpose order to avoid false expectations of cure. In chancroid, atypical lesions have been reported in HIV-infected individuals. The have been reported in HIV-infected individuals. The In chancroid, atypical lesions or multiple lesions may form that are sometimes lesions tend to be more extensive, such as fever and chills. Reports of rapidly accompanied by systemic manifestations noted by some clinicians. This emphasizes the need for aggressive lesions have been HIV-infected individuals. early treatment, especially in GENITAL ULCERS AND HIV INFECTION AND ULCERS GENITAL that the in the literature suggesting a number of anecdotal reports There have been infection. as a result of concomitant HIV of syphilis may be altered natural history and secondary of both primary have indicated atypical presentations Some reports among in treatment failure rates Some have noted an increase syphilis lesions. of penicillin. with single-dose therapies early syphilis who are treated patients with 2

112 TREATMENT OF STI-ASSOCIATED SYNDROMES GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS

AT A GLANCE

Genital Ulcer Disease For details, see sections 3.3 – 3.7 Drug options for Drug options for Drug options for Drug options for Drug options for syphilis chancroid granuloma inguinale LGV genital herpes Benzathine Ciproﬂ oxacin Azithromycin Doxycycline Acyclovir benzylpenicillin Erythromycin Doxycycline Erythromycin Valaciclovir Azithromycin Famciclovir 1133 Alternatives Alternatives Alternatives Alternatives TREATMENT OF STI-ASSOCIATED SYNDROMES Procaine Ceftriaxone Erythromycin Tetracycline benzylpenicillin Tetracycline Trimethoprim/ sulfamethoxazole Penicillin allergy and non-pregnant Doxycycline Tetracycline

Note ■ The decision to treat for chancroid, granuloma inguinale or LGV depends on the local epidemiology of the infections. ■ Speciﬁ c treatment for herpes genitalis is recommended as it offers clinical beneﬁ ts to most symptomatic patients. Health education and counselling regarding the recurrent nature of genital herpes lesions, the natural history, sexual transmission, probable perinatal transmission of the infection and available methods to reduce transmission, are an integral part of genital herpes management (see section 3.7).

c antiviral herpes ﬁ reduction and natural history of HSV2 infection reduction and natural Advise on basic care of the lesion Advise on basic care Educate and counsel on compliance, risk Educate and counsel Provide or prescribe speci Provide Offer syphilis and HIV serologic testing Offer syphilis and Promote condom use and provide condoms condom use Promote Advise to return in 7 days if lesion is not Advise to return in 7 days if lesion ■ ■ ■ ■ ■ ■

in 7 days uctuant glands uctuant ﬂ GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES

Treat for syphilis, and, depending upon depending and, syphilis, for Treat Aspirate any Educate and counsel on risk reduction risk on counsel and Educate Offer syphilis serologic testing and testing serologic syphilis Offer counselling and facilities appropriate where Review if lesion not fully healed if lesion Review Promote condom use and provide condoms condom use Promote fully healed, and sooner if there is clinical local epidemiology, either chancroid, chancroid, either dry) epidemiology, and local clean (keep or inguinale granuloma venereum lymphogranuloma policy local to according treatment (surgical incision should be avoided)be should incision (surgical HIV serologic testing where appropriate where testing serologic HIV available are availableare counselling and facilities deterioration; if so, treat for other causes of causes other for treat so, if deterioration; guidelines per as GUD Genital Ulcer Disease Management Disease Ulcer Genital Management Simplex Herpes ■ ■ ■ ■ ■ ■ 4

114 TREATMENT OF STI-ASSOCIATED SYNDROMES GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS

FIGURE 3. GENITAL ULCERS

1155 TREATMENT OF STI-ASSOCIATED SYNDROMES

1 Indications for syphilis treatment: - RPR positive; and - Patient has not been treated for syphilis recently. 2 Treat for HSV2 where prevalence is 30% or higher, or adapt to local conditions. associated uctuant. They are frequently ﬂ days oxacin, 500 mg orally, twice daily for 3 ﬂ GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES

Some cases may require longer treatment than the 14 days recommended above. Some cases may require longer be aspirated through healthy skin. Incision and Fluctuant lymph nodes should may delay healing and should not be attempted. drainage or excision of nodes treatment failure, referral for diagnostic biopsy is Where there is doubt and/or advisable. erythromycin, 500 mg orally, four times daily for 14 days erythromycin, 500 mg orally, AND twice daily for 14 days doxycycline, 100 mg orally, OR cipro

■ Note ■ ■ ■ Recommended syndromic treatment INGUINAL BUBO INGUINAL nodes in the enlargements of the lymph buboes are localised Inguinal and femoral are painful and may be groin area, which with LGV and chancroid. In many cases of chancroid an associated genital ulcer is chancroid an associated genital chancroid. In many cases of with LGV and infections of the systemic infections (e.g. transmitted local and visible. Non-sexually of inguinal can also cause swelling tuberculous lymphadenopathy) lower limb or lymph nodes. 6

116 TREATMENT OF STI-ASSOCIATED SYNDROMES GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS

FIGURE 4. INGUINAL BUBO

1177 TREATMENT OF STI-ASSOCIATED SYNDROMES

, an Klebsiella , Brucella abortus or Escherichia coli Brucella melitensis . A tuberculous orchitis, generally accompanied by . A tuberculous orchitis, generally amed (orchitis), giving rise to epididymo-orchitis. ﬂ Pseudomonas aeruginosa GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES

by acute usually manifests itself the epididymis (epididymitis) ammation of therapy for chlamydia (for details, see section 3.2) therapy for uncomplicated gonorrhoea (for details, see section 3.1) therapy for uncomplicated gonorrhoea (for details, see ﬂ If not effectively treated, STI-related epididymitis may lead to infertility. If not effectively treated, STI-related epididymitis may It is important to consider other non-infectious causes of scrotal swelling, such as It is important to consider other non-infectious causes which should be suspected trauma, testicular torsion and tumour. Testicular torsion, that needs urgent when onset of scrotal pain is sudden, is a surgical emergency referral. In pre-pubertal children the usual etiology is coliform, pseudomonas infection or In pre-pubertal children the is usually noted within a week of parotid mumps virus. Mumps epididymo-orchitis enlargement. orchitis is usually clinically more evident than an epididymitis. orchitis is usually clinically an epididymitis, is always secondary to lesions elsewhere, especially in the lungs an epididymitis, is always secondary caused by or bones. In brucellosis, usually PLUS ■ Recommended syndromic treatment ■ spp. or In older men, where there may have been no risk of a sexually transmitted infection, have been no risk of a sexually transmitted infection, In older men, where there may be responsible, for example, other general infections may 2.3. SCROTAL SWELLING 2.3. SCROTAL In of the often with tenderness testicular pain and swelling, onset of unilateral of the with erythema and oedema vas deferens, and occasionally epididymis and by sexually is more frequently caused In men under 35 years this overlying skin. is 35 years. When the epididymitis than in those over transmitted organisms be presumed to be of sexually by urethral discharge, it should accompanied gonococcal and/or chlamydial in nature. The adjacent transmitted origin, commonly testis is often also in 8

118 TREATMENT OF STI-ASSOCIATED SYNDROMES GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS

AT A GLANCE

Scrotal swelling For details, see sections 3.1 and 3.2 Drug options for Gonorrhoea Drug options for Chlamydia Ciprofl oxacin Doxycycline Ceftriaxone Azithromycin Spectinomycin 1199 Cefi xime TREATMENT OF STI-ASSOCIATED SYNDROMES Alternatives Amoxycillin Ofl oxacin

Erythromycin (if Tetracycline is contraindicated) Tetracycline

Adjuncts to therapy Bed rest and scrotal support until local inﬂ ammation and fever subside.

GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES FIGURE 5. SCROTAL SWELLING 5. SCROTAL FIGURE 0

220 TREATMENT OF STI-ASSOCIATED SYNDROMES GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS

2.4. VAGINAL DISCHARGE

A spontaneous complaint of abnormal vaginal discharge (in terms of quantity, colour or odour) is most commonly a result of a vaginal infection. It may in rare cases be caused by mucopurulent STI-related cervicitis. T. vaginalis, C. albicans and bacterial vaginosis (BV) are the commonest causes of vaginal infection. N. gonorrhoeae and C. trachomatis cause cervical infection. The clinical detection of cervical infection is difﬁ cult because a large proportion of women with gonococcal or chlamydial cervical infection is asymptomatic. The symptom of abnormal vaginal discharge is highly indicative of vaginal infection, but poorly predictive for cervical 2211 infection. Thus, all women presenting with vaginal discharge should receive TREATMENT OF STI-ASSOCIATED SYNDROMES treatment for trichomoniasis and BV.

Among women presenting with discharge, one can attempt to identify those with an increased likelihood of being infected with N. gonorrhoeae and/or C. trachomatis. To identify women at greater risk, therefore, of cervical infection, an assessment of a woman’s risk status may be useful, especially when risk factors are adapted to the local situation. Given that microscopy requires special training, is time consuming and adds relatively little given the amount of time and resources it requires, it is generally not recommended at the primary health care level. However, in settings where Gram stain can be carried out in an efﬁ cient manner, such as a referral clinic, identiﬁ cation of Gram-negative intracellular diploccoci and/or T. vaginalis can be attempted.

Knowledge of the local prevalence of gonococcal and/or chlamydia in women presenting with vaginal discharge is important when making the decision to treat for cervical infection. The higher the prevalence, the stronger the justiﬁ cation for treatment. Women with a positive risk assessment have a higher likelihood of cervical infection than those who are risk negative. Women with vaginal discharge and a positive risk assessment should, therefore, be offered treatment for gonococcal and chlamydia cervicitis.

Where resources permit, the use of laboratory tests to screen women with vaginal discharge should be considered. Such screening could be applied to all women with discharge or selectively to those with discharge and a positive risk assessment. (if Tetracycline is contraindicated) Tetracycline (if oxacin fl been used as a screening owcharts have Amoxycillin O Alternatives Erythromycin fl 3.2 and sections 3.1 GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES oxacin Doxycycline fl

xime ﬁ

Tetracyclines are contraindicated in pregnancy. therapy for chlamydia (for details, see section 3.2) therapy for chlamydia (for details, therapy for uncomplicated gonorrhoea (for details, see section 3.1) therapy for uncomplicated Tetracycline Ce Ceftriaxone Azithromycin Ceftriaxone Spectinomycin Cipro Drug options for Gonorrhoea for Chlamydia Drug options ■ For details, see AT A GLANCE A AT Cervical infection ■ ■ PLUS Recommended syndromic treatment Recommended syndromic treatment CERVICAL INFECTION CERVICAL In some countries, syndromic management management countries, syndromic In some tool to detect cervical infection among women not presenting with a genital not presenting with a infection among women tool to detect cervical detecting While this may assist in in family planning settings). complaint (e.g. over- likely that there will be substantial with cervical infections, it is some women diagnosis. Note 2

222 TREATMENT OF STI-ASSOCIATED SYNDROMES GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS

VAGINAL INFECTION

Recommended syndromic treatment ■ therapy for T. vaginalis (for details, see section 3.9) PLUS ■ therapy for BV (for details, see section 3.10) AND, WHERE INDICATED, ■ therapy for C. albicans (for details, see section 3.11)

2233 AT A GLANCE TREATMENT OF STI-ASSOCIATED SYNDROMES

Vaginal infection For details, see sections 3.9–3.11 Drug options for Drug options for BV Drug options for candida T. Vaginalis

Metronidazole Metronidazole Miconazole

Tinidazole Clotrimazole

Fluconazole

Alternatives Alternatives

Clindamycin

Metronidazole gel

Clindamycin vaginal cream Nystatin

Note ■ Patients taking metronidazole should be cautioned to avoid alcohol. ■ Use of metronidazole in the ﬁ rst trimester is not recommended unless the beneﬁ ts outweigh the potential hazards. Risk factors need adaptation to local social, behavioural and epidemiological situation. Risk factors need adaptation to local social, behavioural and epidemiological GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES

The determination of high prevalence levels needs to be made locally. FIGURE 6. VAGINAL DISCHARGE 6. VAGINAL FIGURE 1 4

224 TREATMENT OF STI-ASSOCIATED SYNDROMES GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS

FIGURE 7. VAGINAL DISCHARGE: BIMANUAL & SPECULUM, WITH OR WITHOUT MICROSCOPE

2255 TREATMENT OF STI-ASSOCIATED SYNDROMES

Risk factors need adaptation to local social, behavioural and epidemiological situation.

1 The determination of high prevalence levels needs to be made locally. Risk factors need adaptation to local social, behavioural and epidemiological situation. Risk factors need adaptation to local social, behavioural and epidemiological GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES

The determination of high prevalence levels needs to be made locally. FIGURE 8. VAGINAL DISCHARGE: BIMANUAL, SPECULUM & MICROSCOPE & MICROSCOPE SPECULUM BIMANUAL, DISCHARGE: 8. VAGINAL FIGURE 1 6

226 TREATMENT OF STI-ASSOCIATED SYNDROMES GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS

2.5. LOWER ABDOMINAL PAIN

All sexually active women presenting with lower abdominal pain should be carefully evaluated for the presence of salpingitis and/or endometritis — elements of pelvic inﬂ ammatory disease (PID). In addition, routine bimanual and abdominal examination should be carried out on all women with a presumptive STI since some women with PID or endometritis will not complain of lower abdominal pain. Women with endometritis may present with complaints of vaginal discharge and/or bleeding and/or uterine tenderness on pelvic examination. Symptoms suggestive of PID include abdominal pain, dyspareunia, vaginal discharge, menometrorrhagia, 2277 dysuria, fever, and sometimes nausea and vomiting. TREATMENT OF STI-ASSOCIATED SYNDROMES

PID is difﬁ cult to diagnose because clinical manifestations are varied. PID becomes highly probable when one or more of the above symptoms are seen in a woman with adnexal tenderness, evidence of lower genital tract infection, and cervical motion tenderness. Enlargement or induration of one or both fallopian tubes, a tender pelvic mass, and direct or rebound tenderness may also be present. The patient’s temperature may be elevated but is normal in many cases. In general, clinicians should err on the side of over-diagnosing and treating suspected cases.

Hospitalization of patients with acute PID should be seriously considered when: ■ the diagnosis is uncertain; ■ surgical emergencies such as appendicitis and ectopic pregnancy cannot be excluded; ■ a pelvic abscess is suspected; ■ severe illness precludes management on an outpatient basis; ■ the patient is pregnant; ■ the patient is unable to follow or tolerate an outpatient regimen; or ■ the patient has failed to respond to outpatient therapy.

Many experts recommend that all patients with PID should be admitted to hospital for treatment.

Etiological agents include N. gonorrhoeae, C. trachomatis, anaerobic bacteria (Bacteroides spp. and Gram-positive cocci). Facultative Gram-negative rods and Mycoplasma hominis have also been implicated. As it is impossible to differentiate between these clinically, and a precise microbiological diagnosis is diffi cult, the , 1989. 2,3,4 t. fi Ann Med ammatory disease. fl , 1977. 15(2):143-9. Contraception uence of an intrauterine device on the course of an acute salpingitis. fl ammatory disease. fl , 1981. 24(2):137-43. GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES

Tetracyclines are contraindicated in pregnancy. Tetracyclines are contraindicated Patients taking metronidazole should be cautioned to avoid alcohol. Patients taking metronidazole metronidazole, 400–500 mg orally, twice daily for 14 days metronidazole, 400–500 mg doxycycline, 100 mg orally, twice daily, or tetracycline, 500 mg orally, 4 times doxycycline, 100 mg orally, daily for 14 days single-dose therapy for uncomplicated gonorrhoea (see section 3.1. Single-dose (see section 3.1. Single-dose for uncomplicated gonorrhoea single-dose therapy have not other single-dose regimen been shown to be effective; ceftriaxone has treatments for PID) been formally evaluated as Larsson B. and Wennergren M. Investigation of a copper-intrauterine device (Cu-IUD) for possible effect on frequency M. Investigation of a copper-intrauterine Larsson B. and Wennergren Soderberg G. and Lindgren S. In of an intrauterine device and the treatment of acute pelvic in K. Removal Teisala Outpatients with PID should be followed up after 72 hours and admitted if their Outpatients with PID should be followed up after 72 hours condition has not improved. Follow-up Follow-up Thus, if the individual should wish to continue its use, it need not be removed. Thus, if the individual should wish to continue its use, is recommended If she does not want to keep the IUD, removal of the IUD the IUD is removed, after antimicrobial therapy has been commenced. When contraceptive counselling is necessary. Adjuncts to therapy: removal of intrauterine device (IUD) removal of intrauterine Adjuncts to therapy: IUD in place, treat the PID using appropriate antibiotics. If PID should occur with an any additional bene There is no evidence that removal of the IUD provides ■ Note ■ ■ PLUS PLUS ■ Recommended syndromic treatment Recommended ■ OUTPATIENT THERAPY THERAPY OUTPATIENT treatment regimen must be effective against this broad range of pathogens. The of pathogens. broad range against this be effective regimen must treatment this principle. below are based on regimen recommended and healing of pelvic in Contraception 4 2 3 21(1):63-5. 8

228 TREATMENT OF STI-ASSOCIATED SYNDROMES GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS

INPATIENT THERAPY

Recommended syndromic treatment options for PID 1. Ceftriaxone, 250 mg by intramuscular injection, once daily PLUS ■ doxycycline, 100 mg orally or by intravenous injection, twice daily, or tetracycline, 500 mg orally 4 times daily PLUS ■ metronidazole, 400–500 mg orally or by intravenous injection, twice daily, or 2299 chloramphenicol, 500 mg orally or by intravenous injection, 4 times daily TREATMENT OF STI-ASSOCIATED SYNDROMES

2. Clindamycin, 900 mg by intravenous injection, every 8 hours PLUS ■ gentamicin, 1.5 mg/kg by intravenous injection every 8 hours

3. Ciproﬂ oxacin, 500 mg orally, twice daily, or spectinomycin 1 g by intramuscular injection, 4 times daily PLUS ■ doxycycline, 100 mg orally or by intravenous injection, twice daily, or tetracycline, 500 mg orally, 4 times daily PLUS ■ metronidazole, 400–500 mg orally or by intravenous injection, twice daily, or chloramphenicol, 500 mg orally or by intravenous injection, 4 times daily

Note ■ For all three regimen, therapy should be continued until at least two days after the patient has improved and should then be followed by either doxycycline, 100 mg orally, twice daily for 14 days, or tetracycline, 500 mg orally, 4 times daily, for 14 days. ■ Patients taking metronidazole should be cautioned to avoid alcohol. ■ Tetracyclines are contraindicated in pregnancy.

GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES FIGURE 9. LOWER ABDOMINAL PAIN ABDOMINAL 9. LOWER FIGURE 0

330 TREATMENT OF STI-ASSOCIATED SYNDROMES GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS

2.6. NEONATAL CONJUNCTIVITIS

Neonatal conjunctivitis (ophthalmia neonatorum) can lead to blindness when caused by N. gonorrhoeae and treatment is delayed. The most important sexually transmitted pathogens which cause ophthalmia neonatorum are N. gonorrhoeae and C. trachomatis. In developing countries, N. gonorrhoeae accounts for 20–75% and C. trachomatis for 15–35% of cases brought to medical attention. Other common causes are Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus spp. and Pseudomonas spp. Newborn babies are generally presented because of redness and swelling of the eyelids or “sticky eyes”, or because of discharge from the eye(s). 3311 TREATMENT OF STI-ASSOCIATED SYNDROMES As the clinical manifestations and possible complications of gonococcal and chlamydial infections are similar, in settings where it is impossible to differentiate between the two infections, treatment should be provided to cover both. This would include single-dose therapy for gonorrhoea and multiple dose therapy for chlamydia.

AT A GLANCE

Neonatal conjunctivitis For details, see sections 3.1 and 3.2 Drug options for Gonorrhoea Drug options for Chlamydia Ceftriaxone Erythromycin Alternatives Kanamycin Spectinomycin

GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES FIGURE 10. NEONATAL CONJUNCTIVITIS 10. NEONATAL FIGURE 2

332 TREATMENT OF STI-ASSOCIATED SYNDROMES GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS

3. TREATMENT OF SPECIFIC INFECTIONS

3.1. GONOCOCCAL INFECTIONS

A large proportion of gonococcal isolates worldwide are now resistant to penicillins, 32 33 tetracyclines, and other older antimicrobial agents. Therefore, these drugs can no longer be recommended for the treatment of gonorrhoea. TREATMENT OF SPECIFIC INFECTIONS

It is important to monitor local in vitro susceptibility, as well as the clinical efﬁ cacy of recommended regimen.

In general it is recommended that concurrent anti-chlamydia therapy be given to all patients with gonorrhoea, as described in section 3.2, because dual infection is common. This does not apply to patients in whom a speciﬁ c diagnosis of C. trachomatis has been excluded by a laboratory test.

UNCOMPLICATED ANOGENITAL INFECTION

Recommended regimen ■ ciproﬂ oxacin, 500 mg orally, as a single dose OR ■ ceftriaxone, 125 mg by intramuscular injection, as a single dose OR ■ ceﬁ xime, 400 mg orally, as a single dose OR ■ spectinomycin, 2 g by intramuscular injection, as a single dose

Note ■ Ciproﬂ oxacin is contraindicated in pregnancy, and is not recommended for use in children and adolescents. ■ There are variations in the anti-gonococcal activity of individual quinolones, and it is important to use only the most active. orally, as a single dose oxacin, 500 mg ﬂ GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES kanamycin, 2 g by intramuscular injection, as a single dose kanamycin, 2 g by intramuscular injection, as a single dose This regimen is likely to be effective although there are no published data on its This regimen is likely to be effective although there are use in gonococcal ophthalmia. spectinomycin, 2 g by intramuscular injection, as a single dose spectinomycin, 2 g by intramuscular injection, as a single cipro ceftriaxone, 125 mg by intramuscular injection, as a single dose ceftriaxone, 125 mg by intramuscular injection, as a single For gonococcal meningitis and endocarditis the same dosages apply but for For gonococcal meningitis and therapy will need to be increased to 4 weeks. endocarditis the duration of spectinomycin, 2 g by intramuscular injection, twice daily for 7 days. There are twice daily for 7 days. 2 g by intramuscular injection, spectinomycin, for 3 days is adequate some data to suggest that therapy ceftriaxone, 1 g by intramuscular or intravenous injection, once daily for 7 days injection, once daily g by intramuscular or intravenous ceftriaxone, 1 ceftriaxone is may be required where cephalosporins (alternative third-generation will be needed) but more frequent administrations not available, ■ Alternative regimen where the recommended agents are not available Alternative regimen where the recommended agents are ■ Note ■ OR ■ ■ OR Recommended regimen A. Adult gonococcal conjunctivitis A. This is a serious condition that requires systemic therapy as well as local irrigation requires systemic therapy as well as local irrigation This is a serious condition that solutions. Irrigation is particularly important when with saline or other appropriate regimen are not available. Careful hand washing by the recommended therapeutic patients is essential. personnel caring for infected GONOCOCCAL OPHTHALMIA GONOCOCCAL ■ Note ■ OR ■ DISSEMINATED GONOCOCCAL INFECTION GONOCOCCAL DISSEMINATED regimen Recommended

34 TREATMENT OF SPECIFIC INFECTIONS 35 TREATMENT OF SPECIFIC INFECTIONS t. fi conjunctivitis. cacy. The addition of fi C. trachomatis GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES ceftriaxone 50 mg/kg by intramuscular injection, as a single dose, to a maximum ceftriaxone 50 mg/kg by intramuscular injection, as a single of 125 mg Single-dose ceftriaxone and kanamycin are of proven ef Single-dose ceftriaxone and spectinomycin, 25 mg/kg by intramuscular injection, as a single dose, to a spectinomycin, 25 mg/kg by maximum of 75 mg kanamycin, 25 mg/kg by intramuscular injection, as a single dose, to a maximum kanamycin, 25 mg/kg by intramuscular of 75 mg ceftriaxone, 50 mg/kg by intramuscular injection, as a single dose, to a maximum as a single dose, to mg/kg by intramuscular injection, ceftriaxone, 50 of 125 mg tetracycline eye ointment to these regimen is of no documented bene tetracycline eye ointment to Infants born to mothers with gonococcal infection should receive additional Infants born to mothers with gonococcal infection should treatment. ■ Recommended regimen for infants born to mothers with gonococcal infection Recommended regimen for infants born to mothers with Prevention of ophthalmia neonatorum timely eye prophylaxis. The Gonococcal ophthalmia neonatorum is preventable with birth. The application infant’s eyes should be carefully cleaned immediately after to the eyes of all infants at of 1% silver nitrate solution or 1% tetracycline ointment measure. However, the time of delivery is strongly recommended as a prophylactic ocular prophylaxis provides poor protection against Patients should be reviewed after 48 hours. Follow-up Follow-up ■ Note ■ OR Alternative regimen where ceftriaxone is not available Alternative regimen where ceftriaxone ■ Recommended regimen Recommended ■ B. Neonatal gonococcal conjunctivitisB. Neonatal gonococcal Follow-up Follow-up important. of clinical progress is Careful monitoring GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES for chlamydial infection. cacious orally, twice a day for 7 days oxacin, 300 mg fi fl Erythromycin should not be taken on an empty stomach. Erythromycin should not be taken on an empty stomach. There is evidence that extending the duration of treatment beyond 7 days does not There is evidence that extending the duration of treatment improve the cure rate in uncomplicated chlamydial infection. Current evidence indicates that 1 g single-dose therapy of azithromycin is Current evidence indicates that 1 g single-dose therapy ef Doxycyline and other tetracyclines are contraindicated during pregnancy and Doxycyline and other tetracyclines are contraindicated lactation. tetracycline, 500 mg orally, 4 times a day for 7 days o erythromycin, 500 mg orally, 4 times a day for 7 days amoxycillin, 500 mg orally, 3 times a day for 7 days amoxycillin, 500 mg orally, azithromycin, 1 g orally, in a single dose azithromycin, 1 g orally, in doxycycline, 100 mg orally, twice daily for 7 days doxycycline, 100 mg orally, spectinomycin, 25 mg/kg by intramuscular injection, as a single dose, to a injection, as a single dose, 25 mg/kg by intramuscular spectinomycin, mg maximum of 75 kanamycin, 25 mg/kg by intramuscular injection, as a single dose, to a maximum as a single dose, to mg/kg by intramuscular injection, kanamycin, 25 of 75 mg ■ ■ ■ Note ■ ■ ■ OR ■ OR ■ OR Alternative regimen OR ■ Recommended regimen ■ UNCOMPLICATED ANOGENITAL INFECTION ANOGENITAL UNCOMPLICATED 3.2. CHLAMYDIA TRACHOMATIS INFECTIONS TRACHOMATIS 3.2. CHLAMYDIA VENEREUM) THAN LYMPHOGRANULOMA (OTHER ■ OR Alternative regimen where ceftriaxone is not available is not available ceftriaxone regimen where Alternative ■

36 TREATMENT OF SPECIFIC INFECTIONS 37 TREATMENT OF SPECIFIC INFECTIONS

and 5,6 , 1998, to Obstet Gynecol , 1998, 43:509–514. N. gonorrhoeae C. trachomatis J Reprod Med oxacin are contraindicated in ﬂ , because of the possibility of mixed infection. GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES trimethoprim 40 mg with sulfamethoxazole 200 mg orally, twice daily for 14 days trimethoprim 40 mg with sulfamethoxazole 200 mg orally, erythromycin syrup, 50 mg/kg per day orally, in 4 divided doses for 14 days erythromycin syrup, 50 mg/kg per day orally, in 4 divided pregnant women. during pregnancy because of drug- Erythromycin estolate is contraindicated only erythromycin base or erythromycin related hepato-toxicity. Hence, ethylsuccinate should be used. Doxycycline (and other tetracyclines) and o Doxycycline (and other tetracyclines) azithromycin is safe to use in pregnant women. Preliminary data suggest that amoxycillin, 500 mg orally, three times a day for 7 days amoxycillin, 500 mg orally, erythromycin, 500 mg orally, 4 times a day for 7 days erythromycin, 500 mg orally, However, the number of women in the trials so far is too small to assess safety for in the trials so far is too small to assess safety for However, the number of women outcomes are unlikely to be detected. use in pregnancy as rare adverse Wehbeh HA et al. Single dose azithromycin for chlamydia in pregnant women. et al. Single dose azithromycin for chlamydia in pregnant HA Wehbeh Adair CD et al. Chlamydia in pregnancy: a randomized trial of azithromycin and erythromycin. Adair CD et al. Chlamydia in pregnancy: a randomized trial of azithromycin and erythromycin. C. trachomatis Alternative regimen ■ ■ Recommended regimen All newborn infants with conjunctivitis should be treated for both All newborn infants with conjunctivitis should be treated NEONATAL CHLAMYDIAL CONJUNCTIVITIS CHLAMYDIAL NEONATAL ■ ■ Note ■ ■ recommended treatment regimen has not been observed. treatment regimen has not recommended ■ OR CHLAMYDIAL INFECTION DURING PREGNANCY INFECTION CHLAMYDIAL regimen Recommended Follow-up Follow-up Resistance of the 7-day regimen is critical. Compliance with 91:165–168. 5 6

7 stulae-in-ano, or fi nitively established, but fi , 1963, 29:797–801. may require surgery. stulae fi has been completed, recurs after therapy t. If inclusion conjunctivitis fi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES Bulletin of the World Health Organization erythromycin treatment should be reinstituted for 2 weeks. treatment should be reinstituted erythromycin Fluctuant lymph nodes should be aspirated through healthy skin. Incision and Fluctuant lymph nodes should be aspirated through healthy patients with advanced drainage or excision of nodes may delay healing. Some and sequelae such as disease may require treatment for longer than 14 days, strictures and/or Tetracyclines are contraindicated in pregnancy. tetracycline, 500 mg orally, 4 times daily for 14 days erythromycin, 500 mg orally, 4 times daily for 14 days doxycycline, 100 mg orally, twice daily for 14 days doxycycline, 100 mg orally, The optimal duration of therapy has not been de The optimal duration of therapy than 14 days. treatment should not be less erythromycin syrup, 50 mg/kg per day (given orally in four doses) for 14 days erythromycin syrup, 50 mg/kg There is no evidence that additional therapy with a topical agent provides further with a topical agent provides that additional therapy There is no evidence bene Greaves AB. The frequency of lymphogranuloma venereum in persons with perirectal abscesses, AB. Greaves ■ Note ■ ■ Alternative regimen OR ■ ■ Recommended regimen There are limited published data on the treatment of LGV. Treatment recommendations are Treatment on the treatment of LGV. There are limited published data WHO Bulletin in 1963. comparative study published in the based on expert opinion and a 3.3. LYMPHOGRANULOMA VENEREUM 3.3. LYMPHOGRANULOMA ■ Note Recommended regimen Recommended ■ INFANTILE PNEUMONIA INFANTILE Note ■ both. 7

38 TREATMENT OF SPECIFIC INFECTIONS 39 TREATMENT OF SPECIFIC INFECTIONS ed as congenital fi and needs to be cient, fi ) or acquired (through sex or blood ) or acquired (through in utero ). The infection can be classi ). The infection T. pallidum ( provide effective treatment for syphilis. A penicillin uid (CSF) to fl GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES level of greater than 0.018 mg per litre is considered suf maintained for at least 7–10 days in early syphilis, and for a longer duration in maintained for at least 7–10 days in early syphilis, and at a dose of 2.4 million late syphilis. Long-acting benzathine benzylpenicillin, A treponemicidal level of antimicrobials needs to be achieved in the serum and A treponemicidal level of antimicrobials needs to be achieved cerebrospinal Therapeutic considerations Therapeutic (transmitted from mother to child (transmitted from CLINICAL PRESENTATION SUMMARY PRESENTATION CLINICAL and is caused by the spirochaete, disease from the outset Syphilis is a systemic Treponema pallidum 3.4. SYPHILIS In the early phase of primary syphilis the cardiolipin/non-treponemal tests, such as In the early phase of primary syphilis the cardiolipin/non-treponemal rapid plasma reagin (RPR) the Venereal Disease Research Laboratory (VDRL) and as absence of syphilis tests may be negative and should, therefore, not be interpreted infection. As its name implies, latent syphilis has no clinical manifestations. Early latent As its name implies, latent syphilis two years duration. An infection of more than two syphilis is infection of less than evidence of treponemal infection is referred to as years duration without clinical based this division on the infectiousness of syphilis late latent syphilis. WHO has Early stages are more infectious but respond better to and its response to therapy. treatment. Primary syphilis is characterised by an ulcer or chancre at the site of infection or Primary syphilis is characterised manifestations include a skin rash, condylomata inoculation. Secondary syphilis and generalised lymphadenopathy. lata, mucocutaneous lesions Acquired syphilis is divided into early and late syphilis. Early syphilis comprises the into early and late syphilis. Early syphilis comprises Acquired syphilis is divided latent stages. Late syphilis refers to late latent syphilis, primary, secondary and early cardiovascular syphilis. gummatous, neurological and transfusion). H. ducreyi , rst year after therapy. fi C. trachomatis increase in the titre of a non-treponemal test. rmed fi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES there is con clinical signs or symptoms of active syphilis persist or recur; clinical signs or symptoms of active syphilis persist or Examination of the CSF should be undertaken before repeat treatment, unless Examination of the CSF should be undertaken before repeat Patients should be reinfection and a diagnosis of early syphilis can be established. of more than two years’ re-treated with the schedules recommended for syphilis because adequately duration. In general, only one re-treatment course is indicated tests. treated patients often maintain stable, low titres of non-treponemal ■ ■ Follow-up of patients treated for syphilis Follow-up for early syphilis should be based on available The follow-up of patients treated The clinical condition of the patients should be medical services and resources. to detect reinfection during the assessed and attempts made Management of patients with cardiovascular syphilis should include consultation cardiovascular syphilis should include consultation Management of patients with with cardiovascular syphilis and neurosyphilis with a cardiologist. All patients years. The follow-up should include clinical, should be monitored for many on the clinician’s assessment of the individual patient’s serological, CSF and, based condition, radiological examinations. and the gonococcus. Parenteral, rather than oral, penicillin treatment is preferred as it provides is preferred as it provides than oral, penicillin treatment Parenteral, rather required treatment. More data are and supervised guaranteed bioavailability can be generally recommended. or oral azithromycin before either ceftriaxone effective against has the advantage of being Azithromycin units, provides a treponemicidal penicillinaemia for up to three weeks and is weeks and for up to three penicillinaemia a treponemicidal units, provides for late syphilis treatment. recommended At all stages of the disease, repeat treatment should be considered when: At all stages of the disease, repeat treatment should be Patients with early syphilis who have been treated with appropriate doses and Patients with early syphilis benzylpenicillin should be evaluated clinically and preparations of benzathine of test, after three months to assess the results serologically, using a non-treponemal six months and, if indicated therapy. A second evaluation should be performed after the condition of the by the results at this point, again after 12 months to reassess patient and detect possible reinfection.

40 TREATMENT OF SPECIFIC INFECTIONS 41 TREATMENT OF SPECIFIC INFECTIONS and HIV, T. pallidum neurosyphilis is probably low. Although data are cacy in fi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES Penicillin desensitisation of pregnant women with syphilis requires that the Penicillin desensitisation of pregnant women with syphilis feasible at most primary procedure be performed in a hospital setting. This is not procedure. health care settings and cannot be recommended as a routine lacking, consideration should probably be given to using an extended course of a lacking, consideration should probably be given to using penicillin allergy is not third-generation cephalosporin in pregnant women whose manifested by anaphylaxis. The effectiveness of erythromycin in all stages of syphilis and its ability to prevent The effectiveness of erythromycin in all stages of syphilis and many failures the stigmata of congenital syphilis are both highly questionable, have been reported. Its ef SYPHILIS IN PREGNANCY regarded as a separate group, requiring close Pregnant women should be detect possible reinfection after treatment has been surveillance, in particular to treat their sexual partner(s). Pregnant patients at given. It is also important to are not allergic to penicillin, should be treated with all stages of pregnancy, who schedules recommended for the treatment of non- penicillin according to the dosage pregnant patients at a similar stage of the disease. Recommended therapy for early syphilis in HIV-infected patients is no different Recommended therapy for with HIV. However, some authorities advise from that in patients not infected more intensive treatment with a regimen examination of the CSF and/or with the dual infections of appropriate for all patients SYPHILIS AND SYPHILIS HIV INFECTION HIV infection to undergo testing for syphilis should be encouraged All patients with clinical and its implications for high frequency of dual infection because of the the differential should be considered in management. Neurosyphilis assessment and of congenital individuals. In cases disease in HIV-infected diagnosis of neurological if her test is to undergo testing for HIV; should be encouraged syphilis, the mother follow-up. should be referred for positive, the infant regardless of the clinical stage of syphilis. In all cases, careful follow-up is necessary of syphilis. In all cases, careful follow-up is necessary regardless of the clinical stage to ensure adequacy of treatment. and late (becomes rst two years of life) fi c serology may aid diagnosis. fi have found it rst prenatal visit. Some programmes fi remain, negative. Any rmed that serological tests are, and fi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES of pregnancy and at delivery in populations cial to repeat the tests at 28 weeks fi antibody carried over from mother to baby usually disappears within three months mother to baby usually disappears within three months antibody carried over from of birth. Where available, IgM-speci Congenital syphilis may occur if the expectant mother has syphilis, but the Congenital syphilis may occur given penicillin during pregnancy. All infants of risk is minimal if she has been be examined at birth and at monthly intervals for three seropositive mothers should months until it is con clinically and serologically, Early congenital syphilis generally responds well, both in seriously ill children with to adequate doses of penicillin. Recovery may be slow Those in poor extensive skin, mucous membrane, bone or visceral involvement. such as pneumonia. nutritional condition may succumb to concurrent infections, with a high incidence of congenital syphilis. with a high incidence of congenital with a single All infants born to seropositive mothers should be treated IU/kg whether or not the intramuscular dose of benzathine benzylpenicillin, 50 000 penicillin). Hospitalization mothers were treated during pregnancy (with or without who were seropositive. is recommended for all symptomatic babies born to mothers CSF (up to two years Symptomatic infants and asymptomatic infants with abnormal of age) should be treated as for early congenital syphilis. Prevention of congenital syphilis is feasible. Programmes should implement Prevention of congenital syphilis for syphilis in pregnant women. Screening for syphilis effective screening strategies should be conducted at the apparent later in life). bene Congenital syphilis is divided into early ( Congenital syphilis CONGENITAL SYPHILIS CONGENITAL Follow-up Follow-up be serological tests should quantitated non-treponemal Following treatment, be and re-treatment should monthly intervals until delivery, performed at of reinfection or relapse. there is serological evidence undertaken if

42 TREATMENT OF SPECIFIC INFECTIONS 43 TREATMENT OF SPECIFIC INFECTIONS 2.4 million IU by intramuscular injection, at a 2.4 million IU by intramuscular 8 1.2 million IU by intramuscular injection, daily for 10 1.2 million IU by intramuscular 9 GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES single session. Because of the volume involved, this dose is usually given as two single session. Because of the injections at separate sites consecutive days benzathine benzylpenicillin, 2.4 million IU by intramuscular injection, once benzathine benzylpenicillin, 2.4 million IU by intramuscular weekly for 3 consecutive weeks erythromycin, 500 mg orally, 4 times daily for 14 days doxycycline, 100 mg orally, twice daily for 14 days doxycycline, 100 mg orally, 4 times daily for 14 days tetracycline, 500 mg orally, procaine benzylpenicillin, benzathine benzylpenicillin, Benzathine benzylpenicillin synonyms: benzathine penicillin G; benzylpenicillin benzathine; benzathine penicillin. Benzathine benzylpenicillin synonyms: benzathine penicillin G; benzylpenicillin benzylpenicillin synonyms: procaine penicillin G. Procaine ■ Recommended regimen LATE LATENT SYPHILIS LATENT LATE of treponemal (infection of more than two years’ duration without evidence infection) ■ Alternative regimen for penicillin-allergic pregnant patients Alternative regimen for penicillin-allergic OR ■ Alternative regimen for penicillin-allergic non-pregnant patients Alternative regimen for penicillin-allergic ■ Alternative regimen ■ ■ Recommended regimen Recommended EARLY SYPHILIS EARLY not more than two years’ duration) or latent syphilis of (primary, secondary, TREATMENT REGIMEN FOR SYPHILIS REGIMEN TREATMENT 8 9 12–24 million IU by intravenous injection, 12–24 million IU by intravenous 10 GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES Aqueous benzylpenicillin synonyms: benzylpenicillin potassium; benzylpenicillin sodium; crystalline penicillin, Aqueous benzylpenicillin synonyms: benzylpenicillin potassium; benzylpenicillin Some authorities recommend adding benzathine benzylpenicillin, 2.4 million IU Some authorities recommend adding benzathine benzylpenicillin, weekly, after completing by intramuscular injection, in 3 consecutive doses once Benzathine these regimen, but there are no data to support this approach. does not give adequate benzylpenicillin, 2.4 million IU by intramuscular injection therapeutic levels in the CSF. procaine benzylpenicillin, 1.2 million IU by intramuscular injection, once daily, procaine benzylpenicillin, 1.2 4 times daily, both for 10–14 days and probenecid, 500 mg orally, aqueous benzylpenicillin, erythromycin, 500 mg orally, 4 times daily for 30 days erythromycin, 500 mg orally, tetracycline, 500 mg orally, 4 times daily for 30 days tetracycline, 500 mg orally, doxycycline, 100 mg orally, twice daily for 30 days mg orally, twice daily for doxycycline, 100 procaine benzylpenicillin, 1.2 million IU by intramuscular injection, once daily for by intramuscular injection, 1.2 million IU procaine benzylpenicillin, days 20 consecutive administered daily in doses of 2–4 million IU, every 4 hours for 14 days administered daily in doses Note ■ This regimen should be used only for patients whose outpatient compliance can be This regimen should be used only for patients whose outpatient assured. ■ Alternative regimen ■ NEUROSYPHILIS Recommended regimen ■ Alternative regimen for penicillin-allergic pregnant patients Alternative regimen for penicillin-allergic OR ■ Alternative regimen for penicillin-allergic non-pregnant patients for penicillin-allergic Alternative regimen ■ Alternative regimen Alternative ■ penicillin G potassium; penicillin G sodium. 10

44 TREATMENT OF SPECIFIC INFECTIONS 45 TREATMENT OF SPECIFIC INFECTIONS ndings fi cacy is not yet well fi of life and every 8 hours rst 7 days fi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES AND Infants with abnormal CSF were abnormal. Antimicrobials other than penicillin (e.g. erythromycin) are not were abnormal. Antimicrobials other than penicillin (e.g. Some experts treat all infants with congenital syphilis as if the CSF Some experts treat all infants with congenital syphilis as procaine benzylpenicillin, 50 000 IU/kg by intramuscular injection, as a single procaine benzylpenicillin, 50 000 IU/kg by intramuscular daily dose for 10 days aqueous benzylpenicillin 100 000–150 000 IU/kg/day administered as 50 000 aqueous benzylpenicillin 100 000–150 000 IU/kg/day administered IU/kg/dose IV every 12 hours, during the thereafter for a total of 10 days The central nervous system may be involved during any stage of syphilis. Clinical may be involved during any stage of syphilis. Clinical The central nervous system (e.g. optic or auditory symptoms, or cranial evidence of neurological involvement of the CSF. However, examination of the nerve palsies) warrants examination in all patients with syphilis of more than two years’ CSF is also highly desirable in order to evaluate the possible presence of duration, or of uncertain duration, Some experts recommend consulting a neurologist asymptomatic neurosyphilis. neurosyphilis. Careful follow-up is essential. when caring for a patient with tetracycline, 500 mg orally, 4 times daily for 30 days mg orally, 4 times daily tetracycline, 500 have not treatment of neurosyphilis to penicillin for the The above alternatives studies. Although their ef been evaluated in systematic doxycycline, 200 mg orally, twice daily for 30 days mg orally, twice daily for doxycycline, 200 documented, third-generation cephalosporins may be useful in the treatment of documented, third-generation neurosyphilis. A. Early congenital syphilis (up to 2 years of age) A. Early congenital syphilis (up Note ■ OR ■ ■ CONGENITAL SYPHILIS CONGENITAL ■ ■ Note OR ■ Alternative regimen for penicillin-allergic non-pregnant patients patients non-pregnant penicillin-allergic regimen for Alternative ■ Recommended regimen . H. ducreyi rst month of life fi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES erythromycin, 7.5–12.5 mg/kg orally, 4 times daily for 30 days erythromycin, 7.5–12.5 mg/kg aqueous benzylpenicillin, 200 000–300 000 IU/kg/day by intravenous or IU/kg/day by intravenous 200 000–300 000 aqueous benzylpenicillin, hours for 50 000 IU/kg/dose every 4–6 injection, administered as intramuscular 10–14 days recommended for congenital syphilis except in cases of allergy to penicillin. to penicillin. of allergy except in cases syphilis for congenital recommended children. should not be used in young Tetracyclines Follow-up Follow-up of improvement or All patients should be followed up until there is clear evidence to be less effective, but cure. In patients infected with HIV, treatment may appear syphilis. Since chancroid this may be a result of coinfection with genital herpes or failure is likely to be seen and HIV infection are closely associated, and therapeutic up weekly until there is clear with increasing frequency, patients should be followed evidence of improvement. The infection is common in several parts of the world including Africa, the The infection is common in Owing to widespread antimicrobial resistance in all Caribbean and south-east Asia. and penicillins are not recommended for treatment geographical areas, tetracyclines single-dose treatments with effective of chancroid. To enhance compliance, antibiotics are preferred. Management of lesions be kept clean. Fluctuant No special treatment is required. Ulcerative lesions should the surrounding healthy lymph nodes should be aspirated as required through healing and is not skin. Incision and drainage or excision of nodes may delay recommended. The causative organism is a Gram-negative facultative anaerobic bacillus, The causative organism is a 3.5. CHANCROID ■ Alternative regimen for penicillin-allergic patients, after the Alternative regimen for penicillin-allergic Recommended regimen Recommended ■ B. Congenital syphilis of 2 or more years B. Congenital syphilis

46 TREATMENT OF SPECIFIC INFECTIONS 47 TREATMENT OF SPECIFIC INFECTIONS Klebsiella ). The disease Calymmatobacterium granulomatis a day rst day, then 500 mg orally, once fi , (previously known as daily for 3 days oxacin, 500 mg orally, twice fl GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES The addition of a parenteral aminoglycoside such as gentamicin should be The addition of a parenteral aminoglycoside such as gentamicin carefully considered for treating HIV-infected patients. trimethoprim 80 mg/sulfamethoxazole 400 mg, 2 tablets orally, twice daily for a trimethoprim 80 mg/sulfamethoxazole 400 mg, 2 tablets minimum of 14 days erythromycin, 500 mg orally, 4 times daily tetracycline, 500 mg orally, 4 times daily azithromycin, 1 g orally on doxycycline, 100 mg orally, twice daily ceftriaxone, 250 mg by intramuscular injection, as a single dose ceftriaxone, 250 mg by intramuscular erythromycin base, 500 mg orally, 4 times daily for 7 days base, 500 mg orally, 4 times erythromycin 1 g orally, as a single dose azithromycin, cipro ■ Note ■ OR ■ ■ OR Alternative regimen OR ■ Recommended regimen ■ 3.6. GRANULOMA INGUINALE (DONOVANOSIS) 3.6. GRANULOMA intracellular Gram-negative bacterium Donovanosis is caused by the ■ until all lesions have completely epithelialized. Treatment should be continued Alternative regimen granulomatis progressive, ulcerative lesions without regional presents clinically as painless, are highly vascular and can easily bleed on contact. lymphadenopathy. The lesions OR ■ OR ■ Recommended regimen regimen Recommended ■ of rst sign fi uence the natural history of fl t from antiviral therapy, therefore fi episodic therapy if treatment is started t from fi will have recurrent rst episode of genital herpes infection fi episode of genital herpes, treat with oral acyclovir. rst clinical fi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES or its analogues, is started as soon as ed if systemic therapy with acyclovir, fi options for such treatment should be discussed with all patients. Many patients options for such treatment should be discussed with all who have recurrent disease bene If episodic treatment during the prodrome or within one day after onset of lesions. with antiviral therapy, or a of recurrences is chosen, the patient should be provided initiated at the prescription for the medication, so that treatment can be prodrome or genital lesions. episodes of genital lesions. Episodic or suppressive antiviral therapy will shorten the Episodic or suppressive antiviral therapy will shorten episodes of genital lesions. Many patients bene duration of genital lesions. possible following the onset of symptoms. Treatment can be expected to reduce possible following the onset the duration of pain, the time required for healing, the formation of new lesions, it does not appear to in and viral shedding. However, Vaginal delivery in women who develop primary genital herpes shortly before Vaginal delivery in women who develop primary genital born to women with delivery puts babies at risk for neonatal herpes. Babies late in pregnancy are poor recurrent disease are at very low risk. Genital cultures taking and physical predictors of shedding during delivery. Careful history HERPES IN PREGNANCY During the Recurrent infections Most patients with a There is no known cure for genital herpes, but the course of symptoms can be There is no known cure for modi The primary cause of genital herpes is the herpes simplex virus type 2 (HSV2) herpes simplex virus type of genital herpes is the The primary cause of the world, populations in many parts highly prevalent in human infection. It is health The major public common cause of GUD worldwide. and is the most to its potential role in facilitating HIV transmission. importance of HSV2 relates 3.7. GENITAL HERPES INFECTIONS 3.7. GENITAL Follow-up Follow-up resolved. until signs and symptoms have be followed up clinically Patients should recurrent disease. Topical therapy with acyclovir produces only minimal shortening with acyclovir produces only minimal shortening recurrent disease. Topical therapy episodes and is not recommended. of the duration of symptomatic

48 TREATMENT OF SPECIFIC INFECTIONS 49 TREATMENT OF SPECIFIC INFECTIONS cult. fi cient mutants for which standard fi patients cacy have been documented among fi In some cases t from chronic suppressive therapy. fi severe mucocutaneous cient, persistent and/or fi cant acyclovir resistance among immunocompetent fi rst clinical episode clinical rst fi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES acyclovir, 400 mg orally, 3 times daily for 7 days valaciclovir, 1 g orally, twice daily for 7 days acyclovir, 200 mg orally, 5 times daily for 7 days ulcerations may occur, often involving large areas of perianal, scrotal or penile areas of perianal, scrotal occur, often involving large ulcerations may dif making a clinical diagnosis may be painful and atypical, skin. The lesions The natural history of herpes sores may become altered. Most lesions of herpes The natural history of herpes respond to acyclovir, but the dose may have to be in HIV-infected persons will for longer than the standard recommended period. increased and treatment given bene Subsequently, patients may de the patients may develop thymidine-kinase antiviral therapy becomes ineffective. OR ■ OR ■ Recommended regimen for ■ TREATMENT OPTIONS FOR GENITAL HERPES OPTIONS FOR GENITAL TREATMENT Daily suppressive therapy reduces the frequency of genital herpes recurrences Daily suppressive therapy reduces who have frequent recurrences (six or more by more than 75% among patients and ef recurrences per year). Safety SUPPRESSIVE THERAPY In people whose immunity is de In people whose HERPES AND HIV COINFECTION AND HIV COINFECTION HERPES examination serve as a guide to the need for caesarean section in mothers with in mothers with section need for caesarean a guide to the serve as examination lesions. genital herpes Suppressive treatment with acyclovir reduces, but does not eliminate, asymptomatic Suppressive treatment with acyclovir reduces, but does therapy may prevent viral shedding. Therefore, the extent to which suppressive HSV transmission is unknown. patients. receiving daily therapy with acyclovir for as long as six years, and with valaciclovir acyclovir for as long as six years, and with valaciclovir receiving daily therapy with Suppressive therapy has not been associated with the and famciclovir for one year. emergence of clinically signi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES acyclovir, 5–10 mg/kg IV, every 8 hours for 5–7 days or until clinical resolution is acyclovir, 5–10 mg/kg IV, every 8 hours for 5–7 days or attained Some experts recommend discontinuing acyclovir after one year of continuous use Some experts recommend discontinuing acyclovir after continuous dose that will so that the recurrence rate can be reassessed. The lowest empirically. suppress recurrences in an individual can only be determined famciclovir, 250 mg orally, twice daily valaciclovir, 1000 mg orally, once daily valaciclovir, 500 mg orally, once daily valaciclovir, 500 mg orally, acyclovir, 400 mg orally, twice daily, continuously acyclovir, 400 mg orally, twice famciclovir, 125 mg orally, twice daily for 5 days famciclovir, 125 mg orally, twice valaciclovir, 1000 mg orally, once daily for 5 days valaciclovir, 1000 mg orally, valaciclovir, 500 mg orally, twice daily for 5 days valaciclovir, 500 mg orally, acyclovir, 800 mg orally, twice daily for 5 days acyclovir, 800 mg orally, twice acyclovir, 200 mg orally, 5 times daily for 5 days mg orally, 5 times daily for acyclovir, 200 5 days mg orally, 3 times daily for acyclovir, 400 famciclovir, 250 mg orally, 3 times daily for 7 days mg orally, 3 times daily for famciclovir, 250 ■ Recommended regimen for severe disease Note ■ ■ ■ OR ■ OR ■ OR Recommended regimen for suppressive therapy Recommended regimen for suppressive OR ■ OR ■ OR ■ OR ■ ■ OR ■ Recommended regimen for recurrent infection Recommended OR ■

50 TREATMENT OF SPECIFIC INFECTIONS 51 TREATMENT OF SPECIFIC INFECTIONS nger. fi of HPV may give rise to invasive carcinoma of the cervix. It is c types fi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES acyclovir, 10 mg/kg intravenously, 3 times a day for 10–21 days intravenously, 3 times acyclovir, 10 mg/kg acyclovir, 400 mg orally, 3–5 times daily until clinical resolution is attained mg orally, 3–5 times daily until acyclovir, 400 The available treatments for visible anogenital warts are either: patient-applied The available treatments for visible anogenital warts are frequent clinic visits; or (podophyllotoxin or imiquimod), removing the need for may be applied with a cotton provider-administered. Podophyllotoxin 0.5% solution swab. The gel can be applied with a recommended practice to examine the cervix in all female STI patients, and to recommended practice to examine the cervix in all female Papanicolaou examination. perform regular cervical smears in this population for appear, incorrectly, to be However, a high percentage of smears in adolescents may abnormal. Speci Sexual partner(s) should be examined for evidence of warts. Patients with anogenital examined for evidence of warts. Patients with anogenital Sexual partner(s) should be that they are contagious to sexual partners. The use of warts should be made aware help reduce transmission. condoms is recommended to 3.8. VENEREAL (GENITAL) WARTS (GENITAL) 3.8. VENEREAL (HPV) is the causative agent for this common STI. The human papilloma virus do not lead to serious complications, except Genital warts are painless and especially in pregnant women. The removal of where they cause obstruction, the infection has been cured. No treatment is the lesion does not mean that clinical situations podophyllin, podophyllotoxin completely satisfactory. In most is used to treat external genital and perianal warts. or trichloroacetic acid (TCA) solid carbon dioxide or cryoprobe is preferred Cryotherapy with liquid nitrogen, Cryotherapy is non-toxic, does not require by many physicians when available. properly, does not result in scarring. anaesthesia and, if carried out ■ Recommended regimen for neonates Recommended Recommended regimen in severe herpes simplex lesions with coinfection with HIV with lesions with coinfection simplex in severe herpes regimen Recommended ■ equal to that of podophyllin, but cacy is fi 3 times a nger at bedtime, left on overnight, fi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES TCA 80–90%, applied carefully to the warts, avoiding normal tissue, followed by TCA 80–90%, applied carefully to the warts, avoiding normal (baking soda) to powdering of the treated area with talc or sodium bicarbonate . remove unreacted acid. Repeat application at weekly intervals it is less toxic and appears to cause less erosion anal warts. Large amounts some experts advise against the use of podophyllin for easily absorbed. Its use of podophyllin should not be used because it is toxic and during pregnancy and lactation is contraindicated where available, podophyllotoxin 0.5%, one of the active constituents of where available, podophyllotoxin 0.5%, one of the active podophyllin resin, is recommended. Its ef podophyllin 10–25% in compound tincture of benzoin, applied carefully to the podophyllin 10–25% in compound External genital and perianal warts should be warts, avoiding normal tissue. Podophyllin washed thoroughly 1–4 hours after the application of podophyllin. be allowed to dry applied to warts on vaginal or anal epithelial surfaces should should be repeated at before the speculum or anoscope is removed. Treatment weekly intervals The safety of both podophyllotoxin and imiquimod during pregnancy has not The safety of both podophyllotoxin been established. week for as long as 16 weeks. The treatment area should be washed with soap and The treatment area should be washed with soap and week for as long as 16 weeks. Hands must be washed with soap and water water 6–10 hours after application. immediately after application. imiquimod 5% cream applied with a imiquimod 5% cream applied podophyllotoxin 0.5% solution or gel, twice daily for 3 days, followed by 4 days daily for 3 days, followed 0.5% solution or gel, twice podophyllotoxin 4 times (total volume of podophyllotoxin the cycle repeated up to of no treatment, 0.5 ml per day) should not exceed Provider-administered Provider-administered ■ OR ■ ■ ■ ■ Note ■ OR Self-applied by patient Self-applied by ■ A. Chemical Recommended regimen for venereal warts for venereal regimen Recommended

52 TREATMENT OF SPECIFIC INFECTIONS 53 TREATMENT OF SPECIFIC INFECTIONS GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES pap smear No TCA or podophyllin management should include consultation with an expert management should include consultation with an expert podophyllin 10–25%. Allow to dry before removing speculum podophyllin 10–25%. Allow TCA 80–90% cryotherapy with liquid nitrogen cryotherapy with liquid nitrogen electrosurgery electrosurgery surgical removal cryotherapy with liquid nitrogen, solid carbon dioxide, or a cryoprobe. Repeat dioxide, or a cryoprobe. liquid nitrogen, solid carbon cryotherapy with 1–2 weeks applications every Urethroscopy is necessary to diagnose intra-urethral warts, but they should be Urethroscopy is necessary to diagnose intra-urethral warts, prefer electrosurgical suspected in men with recurrent meatal warts. Some experts MEATAL AND URETHRAL WARTS AND URETHRAL WARTS MEATAL 10–25%, in compound Accessible meatal warts may be treated with podophyllin Great care should tincture of benzoin, or podophyllotoxin 0.5%, where available. with normal, opposing be taken to ensure that the treated area is dry before contact are reported. epithelial surfaces is allowed. Low success rates with podophyllin ■ ■ ■ Recommendations for treatment of cervical warts CERVICAL WARTS WARTS CERVICAL should not be started until the results from a cervical Treatment of cervical warts for experts advise against the use of podophyllin or TCA smear test are known. Most cervical warts. ■ ■ OR ■ OR Recommended regimen VAGINAL WARTS WARTS VAGINAL ■ OR ■ OR B. Physical B. Physical ■ of rst trimester fi uorouracil or thiotepa may fl , is almost exclusively sexually transmitted in , is almost exclusively sexually INFECTIONS be advised ed and treated, and patients should fi T. vaginalis infection has been shown to be associated with adverse pregnancy infection has been shown to be associated with adverse GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES TRICHOMONAS VAGINALIS agellated protozoan, agellated fl podophyllin 10–25% cryotherapy against sexual intercourse until both the index patient and the partner(s) are treated. both the index patient and the partner(s) are treated. against sexual intercourse until as asymptomatic in men but is increasingly recognized Trichomoniasis is frequently non-chlamydial urethritis. a cause of symptomatic non-gonococcal, T. vaginalis be effective, but neither has been adequately evaluated. Podophyllin should not be evaluated. Podophyllin neither has been adequately be effective, but used. TRICHOMONIASIS IN PREGNANCY pre-term delivery and outcomes, particularly premature rupture of membranes, in symptomatic women. low birth weight. This association is particularly important treating trichomoniasis on Further studies are needed to demonstrate the impact of the prevention of adverse pregnancy outcomes. the Although metronidazole is not recommended for use in has the best chance of pregnancy, treatment may be given where early treatment a lower dose should be preventing adverse pregnancy outcomes. In this instance and meta-analyses used (2 g single oral dose rather than a long course). Studies metronidazole use during have not demonstrated a consistent association between pregnancy and tetatogenic or mutagenic effects in newborns. Sexual partner(s) should be noti Sexual partner(s) should be Management of sexual partners Management of sexual partners The 3.9. ■ ■ OR Recommended treatments Recommended removal. Intra-urethral instillation of a 5% cream of of a 5% cream instillation Intra-urethral removal. adults. The infection may be asymptomatic. Symptomatic trichomoniasis presents asymptomatic. Symptomatic trichomoniasis presents adults. The infection may be and vulval itching in women, and urethritis in with an offensive vaginal discharge men.

54 TREATMENT OF SPECIFIC INFECTIONS 55 TREATMENT OF SPECIFIC INFECTIONS orally, twice daily for seven orally, twice daily for seven 11 GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES Other 5-nitroimidazoles are also effective, both in single and in multiple dose Other 5-nitroimidazoles are also effective, both in single regimen. metronidazole, 400 mg or 500 mg orally, twice daily for 7 days metronidazole, 400 mg or 500 mg orally, twice daily for tinidazole, 500 mg orally, twice daily for 5 days The reported cure rate in women ranges from 82% to 88% but may be increased to ranges from 82% to 88% but may be increased to The reported cure rate in women 95% if sexual partners are treated simultaneously. tinidazole, 2 g orally, in a single dose tinidazole, 2 g orally, in a single metronidazole, 2 g orally, in a single dose metronidazole, 2 g orally, in Metronidazole is available in either 200 mg or 250 mg capsules. ■ Note OR ■ Alternative regimen ■ Note ■ ■ ■ OR Recommended regimen for vaginal infections Recommended regimen for vaginal Patients not cured with the repeated course of metronidazole may be treated with a of metronidazole may be with the repeated course Patients not cured 2 g orally, daily, together with 500 mg applied regimen consisting of metronidazole 3–7 days. Vaginal preparations of metronidazole are intravaginally each night for of world, but are only recommended for the treatment available in many parts of the the primary therapy of trichomoniasis. An alternative refractory infections, not for or 500 mg metronidazole regimen consists of 400 mg Follow-up Follow-up Reinfection days if symptoms persist. be asked to return after seven Patients should often cured following initial treatment excluded. Patients not should be carefully Resistance to the seven-day regimen. to repeat treatment with respond favourably failure. and may be one cause of treatment has been reported, the 5-nitroimidazoles days. 11 t. It is fi Mycoplasma and rst trimester of fi sp. in the vagina by high Gardnerella vaginalis Lactobacillus altered vaginal rm the relationship between fi . The cause of the microbial alteration is not fully understood. . The cause of the microbial alteration is not fully understood. GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES acquisition of HIV. ora and the fl Infants with symptomatic trichomoniasis or with urogenital colonization Infants with symptomatic trichomoniasis of life should be treated with metronidazole. persisting past the fourth month metronidazole, 5 mg/kg orally, 3 times daily for 5 days metronidazole, 5 mg/kg orally, tinidazole, 500 mg orally, twice daily for 5 days tinidazole, 500 mg orally, twice metronidazole, 400 mg or 500 mg orally, twice daily for 7 days metronidazole, 400 mg or 500 Asymptomatic women with trichomoniasis should be treated with the same should be treated with the women with trichomoniasis Asymptomatic women. regimen as symptomatic Metronidazole is generally not recommended for use in the is generally not recommended Metronidazole Patients taking metronidazole or other imidazoles should be cautioned not to not should be cautioned imidazoles or other taking metronidazole Patients after taking drug, and up to 24 hours while they are taking the consume alcohol the last dose. pregnancy (see text above). pregnancy (see Bacterial vaginosis (BV) is a clinical syndrome resulting from replacement of Bacterial vaginosis (BV) is a clinical syndrome resulting the normal hydrogen peroxide-producing 3.10. BACTERIAL VAGINOSIS 3.10. BACTERIAL ■ Note Recommended regimen for neonatal infections Recommended regimen for neonatal ■ ■ ■ OR Recommended regimen for urethral infections Recommended regimen for urethral ■ ■ ■ concentrations of anaerobic bacteria, such as micro Whereas trichomoniasis is an STI, BV is an endogenous reproductive tract infection. Whereas trichomoniasis is an STI, BV is an endogenous to be of bene Treatment of sexual partners has not been demonstrated hominis Additional studies are needed to con recommended that predisposing factors such as the use of antiseptic/antibiotic recommended that predisposing factors such as the use eliminated. vaginal preparations or vaginal douching be reduced or

56 TREATMENT OF SPECIFIC INFECTIONS 57 TREATMENT OF SPECIFIC INFECTIONS rst trimester of pregnancy, but fi the risks of any adverse effects, rst trimester, then in order to reduce fi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES clindamycin, 300 mg orally, twice daily for 7 days clindamycin 2% vaginal cream, 5 g intravaginally, at bedtime for 7 days clindamycin 2% vaginal cream, 5 g intravaginally, at bedtime for 5 days metronidazole 0.75% gel, 5 g intravaginally, twice daily metronidazole, 2 g orally, as a single dose Patients taking metronidazole should be cautioned not to consume alcohol while Patients taking metronidazole should be cautioned not the last dose. they are taking the drug and up to 24 hours after taking metronidazole, 400 mg or 500 mg orally, twice daily for 7 days metronidazole, 400 mg or 500 OR ■ ■ OR ■ ■ OR Alternative regimen it may be used during the second and third trimesters. If treatment has to be given and third trimesters. If treatment has to be given it may be used during the second during the ■ Note lower doses are recommended. ■ Recommended regimen for BV Recommended regimen for BV Women with BV scheduled to undergo reproductive tract surgery or a therapeutic to undergo reproductive tract surgery or a therapeutic Women with BV scheduled with metronidazole. abortion should receive treatment BV AND SURGICAL PROCEDURES Metronidazole is not recommended for use in the Metronidazole is not recommended BV IN PREGNANCY BV IN PREGNANCY adverse an increased incidence of that BV is associated with There is evidence delivery and of membranes, preterm (e.g. premature rupture pregnancy outcomes and those with women should be treated, Symptomatic pregnant low birth weight). asymptomatic be screened to detect pre-term delivery should a history of previous re-treated. of symptoms should be women with recurrence infections. Pregnant of preterm without a prior history pregnant women Screening of asymptomatic delivery is not recommended. rst trimester ammation of ammation fi fl ). Up to 20% of women with the infection may be asymptomatic. If ). Up to 20% of women with the infection may be asymptomatic. GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES above) rst trimester of pregnancy (see text metronidazole 0.75% gel, 5 g intravaginally, twice daily for 7 days metronidazole 0.75% gel, 5 clindamycin, 300 mg orally, twice daily for 7 days clindamycin, 300 mg orally, metronidazole, 2 g orally, as a single dose metronidazole, 2 g orally, as metronidazole 2 g orally, as a single dose, if treatment is imperative during the if treatment is imperative 2 g orally, as a single dose, metronidazole fi metronidazole, 200 or 250 mg orally, 3 times daily for 7 days, after 200 or 250 mg orally, 3 times metronidazole, C. albicans Therapy generally involves topical application of any of a wide variety of imidazoles Therapy generally involves topical application of any of terconazole) or nystatin. (e.g. miconazole, clotrimazole, econazole, butoconazole, require shorter courses of Although they are generally more expensive, imidazoles treatment and appear to be more effective than nystatin. Vulvo-vaginal candidiasis is usually not acquired through sexual intercourse. Vulvo-vaginal candidiasis is usually not acquired through it may be considered Although treatment of sexual partners is not recommended, male partners may have for women who have recurrent infection. A minority of penis or in balanitis, which is characterised by erythema of the glans the glans penis and foreskin (balanoposthitis). VULVO-VAGINAL CANDIDIASIS CANDIDIASIS VULVO-VAGINAL candidiasis is caused by Candida albicans In the majority of cases, vulvo-vaginal ( soreness and a non-offensive symptoms occur, they usually consist of vulval itching, may reveal vulval vaginal discharge, which may be curdy. Clinical examination vulval oedema. erythema (redness) or excoriations from scratching and 3.11. CANDIDIASIS ■ ■ OR ■ OR Alternative regimen ■ Recommended regimen for pregnant women Recommended ■ Follow-up Follow-up may be persist as re-treatment be advised to return if symptoms Patients should needed.

58 TREATMENT OF SPECIFIC INFECTIONS 59 TREATMENT OF SPECIFIC INFECTIONS the glans penis and the foreskin. ammation involving fl it is characteristically found in men with underlying C. albicans GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES mg orally, as a single dose uconazole, 150 miconazole or clotrimazole, 200 mg intravaginally, daily for 3 days miconazole or clotrimazole, 200 mg intravaginally, daily clotrimazole, 500 mg intravaginally, as a single dose fl Other underlying factors uconazole is not useful in preventing recurrences. When caused by immunsuppressive disease or uncontrolled diabetes mellitus. ■ OR ■ OR ■ Recommended regimen for vulvo-vaginal candidiasis Balanoposthitis refers to an in BALANOPOSTHITIS It is recommended that predisposing factors such as antibiotic use, the use of It is recommended that predisposing preparations or vaginal douching be reduced antiseptic/antibiotic vaginal treatment of a rectal focus with oral nystatin or or eliminated. Simultaneous fl candidiasis include uncontrolled diabetes mellitus, for recurrent vulvo-vaginal use. immunosuppression, and corticosteroid RECURRENCES Candidiasis at several sites, including the vulva and vagina, is an important Candidiasis at several sites, is often quite severe and frequently relapses. Prolonged correlate of HIV infection. It and chronic suppressive therapy is frequently treatment is generally required employed. VULVO-VAGINAL CANDIDIASIS AND HIV INFECTION AND HIV CANDIDIASIS VULVO-VAGINAL VULVO-VAGINAL CANDIDIASIS IN PREGNANCY CANDIDIASIS VULVO-VAGINAL are not oral treatments, they are now some effective single-dose Although there used to treat topical azoles should be or effective. Therefore, only known to be safe use during have been investigated for Of those treatments that pregnant women. and clotrimazole, butoconazole most effective are miconazole, pregnancy, the terconazole. , is transmitted by protracted direct bodily , is transmitted by protracted Sarcoptes scabiei considered, as an allergic reaction may be the ammatory therapy may be fl GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES nystatin cream, twice daily for 7 days nystatin cream, twice daily miconazole 2% cream, twice daily for 7 days miconazole 2% clotrimazole 1% cream, twice daily for 7 days clotrimazole 1% nystatin, 100 000 IU intravaginally, daily for 14 days IU intravaginally, daily nystatin, 100 000 Special considerations Special considerations therapy. A single Pruritus sometimes persists for several weeks after adequate there is no clinical repeat treatment after one week may be appropriate if only if live mites can improvement. Additional weekly treatments are warranted assured, topical be demonstrated. If reinfection can be excluded and compliance anti-in The causative mite, 3.12. SCABIES Alternative regimen ■ ■ within one hour. Proteases The mites can burrow into the skin of a contact person reaction which leads to (enzymes) in mite faecal matter generate a hypersensitivity weeks after infestation. the characteristic symptom of pruritus (itch), usually 2–6 ■ OR through sexual contact. However, there are situations contact. In adults this is often through close body contact not related to sexual in which scabies is transmitted people live or spend time at very close quarters, such activity. This can occur when housing and in institutions such as nursing homes as in schools, overcrowded order to prevent social stigmatization, the labelling and psychiatric hospitals. In avoided when the likely cause is body contact. In of scabies as an STI should be are different for patients presenting addition, the management recommendations related to non-sexual bodily with sexually acquired scabies. For outbreaks of scabies contact, treatment of all people involved is critical. Recommended topical application regimen for balanoposthitis topical application regimen Recommended Alternative regimen Alternative ■

60 TREATMENT OF SPECIFIC INFECTIONS 61 TREATMENT OF SPECIFIC INFECTIONS nal application nal ﬁ nal application nal ﬁ GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES sulphur 6%, as above crotamiton 10%, as above Lindane is not recommended for pregnant or lactating women. Lindane is not recommended for pregnant or lactating Resistance to lindane has been reported in some areas. sulphur 6% in petrolatum, applied to the entire body from the neck down nightly sulphur 6% in petrolatum, applied and should bathe for 3 nights; patients may bathe before reapplying the product 24 hours after the crotamiton 10% lotion, applied to the entire body from the neck down nightly crotamiton 10% lotion, applied thoroughly 24 hours after the second application; an for 2 nights and washed off in some geographical areas (crotamiton has the extension to 5 nights is necessary action) advantage of an antipruritic permethrin cream 5% applied to the entire body from the neck down, benzyl benzoate 25% lotion, may bathe before reapplying the drug and should nightly for 2 nights; patients bathe 24 hours after the lindane 1% lotion or cream, applied thinly to all areas of the body from the neck to all areas of the body from or cream, applied thinly lindane 1% lotion after 8 hours down and washed off thoroughly ■ OR ■ OR Recommended regimen Treatment of scabies in infants, children under 10 years of age, pregnant or lactating Treatment women ■ ■ Note OR ■ ■ OR OR ■ OR ■ ■ Recommended regimen Recommended Treatment of scabies in adults, adolescents and older children in adults, adolescents of scabies Treatment reason for the clinical manifestation. Clothing or bed linen that has possibly been has possibly bed linen that Clothing or manifestation. for the clinical reason should be prior to the start of treatment by the patient in the two days contaminated well, or dry-cleaned. washed and dried , is the cause of pubic lice. The infestation is usually , is the cause of pubic lice. The Phthirus pubis GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES Lindane is not recommended for pregnant or lactating women. Lindane is not recommended for pregnant or lactating permethrin 1%, as above pyrethrins plus piperonyl butoxide, applied to the infested and adjacent hairy pyrethrins plus piperonyl butoxide, minutes; retreatment is indicated after 7 days if lice areas and washed off after 10 at the hair-skin junction. Clothing or bed linen that are found or eggs are observed by the patient in the two days prior to the start of may have been contaminated and dried well, or dry-cleaned. treatment should be washed lindane 1% lotion or cream, rubbed gently but thoroughly into the infested area lindane 1% lotion or cream, washed off after 8 hours; as an alternative, lindane and adjacent hairy areas and minutes and then thoroughly washed off 1% shampoo, applied for 4 permethrin 5% cream, applied in the same way as the sulphur regimen described regimen described as the sulphur same way applied in the 5% cream, permethrin above transmitted by sexual contact. Patients usually seek medical care because of pruritus. transmitted by sexual contact. Infestation of the eyelashes should be treated by the application of an occlusive Infestation of the eyelashes should be treated by the application days to smother lice and nits. ophthalmic ointment to the eyelid margins daily for 10 The ointment should not be applied to the eyes. ■ Special considerations Note ■ OR OR ■ Recommended regimen ■ 3.13. PUBIC LICE 3.13. PUBIC The louse, Sexual contacts and close household contacts should be treated as above. should be treated as above. and close household contacts Sexual contacts Contacts ■

62 TREATMENT OF SPECIFIC INFECTIONS 63 KEY CONSIDERATIONS UNDERLYING TREATMENTS in cacy, and/or cacy, ﬁ these cacy against ﬁ , therapeutic ef H. ducreyi Treatment regimen for these groups should be nearly 100% and N. gonorrhoeae

, and efforts should be made to promote health-seeking behaviour in these , and efforts should be made to promote health-seeking

TREATMENTS TREATMENTS GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES sensitivity is recommended. If resistance levels and cure rates are not known sensitivity is recommended. If resistance levels and cure cannot be transferred reliably from one population (or in some cacy data when choosing from available regimen. STI cacy is the most important criterion fi fi 4. KEY CONSIDERATIONS UNDERLYING UNDERLYING CONSIDERATIONS 4. KEY situations, from one sub-population) to another. Thus, ideally, assessments situations, from one sub-population) to another. Thus, the populations where the should be based on well-designed studies conducted in in the local epidemiology treatment will be applied. As a consequence of changes of resistant Ef populations, preferably through the use of a participatory approach with peer populations, preferably through the use of a participatory educators and peer health care providers. In order to reduce the risk of development and transmission of resistant strains of development and transmission of resistant strains of In order to reduce the risk of special programmes for sexually transmitted pathogens to the wider population, at high risk, such as sex effective case management should be designed for groups workers and their clients. therapy regimen should, ideally, cure at least 95% of those infected with a bacterial cure at least 95% of those infected with a bacterial therapy regimen should, ideally, cure rates should be used only with great caution since STI. Regimen yielding lower susceptibility patterns, they may select for resistant in a population of unstable own usefulness. Such caution should be applied to strains and rapidly limit their of between 85% and 95%. Regimen with still lower cure regimen yielding cure rates rates are unacceptable. effective Ef EFFICACY EFFICACY 4.1. THE CHOICE OF ANTIMICROBIAL REGIMEN ANTIMICROBIAL THE CHOICE OF 4.1. infections changes over time. Periodic surveillance of clinical ef infections changes over time. Periodic surveillance of clinical in an area, the regimen used should be those which can reasonably be expected to in an area, the regimen used should be those which can vitro cacy fi in ef ne small differences fi against relatively resistant cacy, even fi than the cautioned not to use less cacy, practitioners are fi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES recommended dosages. recommended In order to ensure ef In order to ensure adolescents is uncertain and limits their uoroquinolones in pregnant women and between highly effective antimicrobial regimen. effective antimicrobial regimen. between highly Cost is a major limiting factor in all locations. Kanamycin is chosen in preference Cost is a major limiting factor in all locations. Kanamycin in some parts of the to spectinomycin, for example, in the treatment of gonorrhoea the total cost of various developing world, because of its lower cost. In calculating associated with less effective regimen, however, it is important to consider the costs complications, and therapies: repeat treatment, further transmission of infection, most appropriate regimen selection for increased microbial resistance. Choosing the Sensitivity analyses can may be facilitated by the use of a formal decision analysis. sometimes compensate for uncertainties in primary data. COST COST organisms, and low toxicity. The prominence of third-generation cephalosporins in the recommended regimen The prominence of third-generation cephalosporins in results from their combination of high ef Toxicity is a second major concern in STI treatments because of the frequency Toxicity is a second major concern reinfected and their consequent exposure to repeated with which patients become addition, treatment of resistant STI agents often courses of antimicrobials. In high serum levels of antimicrobials, in some requires achievement of relatively or more. Combination regimen further increase the cases for periods of seven days Pregnancy, which is relatively common in sexually risk of adverse drug reactions. of STIs, represents a special situation in which active groups with a high incidence fetal safety become important. The safety of the additional considerations of fl areas, doxycycline is not used because of the danger use in these groups. In some are contraindicated in pregnancy and children of photosensitization. Tetracyclines under eight years. SAFETY SAFETY ■ Note produce acceptable cure rates under the most adverse ecological conditions. Few conditions. ecological the most adverse rates under acceptable cure produce to de trials are large enough comparative clinical

64 KEY CONSIDERATIONS UNDERLYING TREATMENTS 65 KEY CONSIDERATIONS UNDERLYING TREATMENTS ) may be increased in prolonged. ed and fi H. ducreyi, T. pallidum included in STI cacy of oral preparations must be fi . In most cases, dual therapy is now required for simultaneous . In most cases, dual therapy is now required for simultaneous GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES N. gonorrhoeae COEXISTENT INFECTIONS COEXISTENT may be a common When several STIs are prevalent in a population, coinfection coinfections with single occurrence. Unfortunately, the ability to treat common to the tetracyclines drugs has been reduced by the development of resistance in gonococcal and chlamydial infections. Coincident chancroid and syphilis require a gonococcal and chlamydial infections. Coincident chancroid several sexually transmitted multi-drug regimen. The severity of disease caused by pathogens (e.g. herpes simplex virus, The geographical distribution and availability of drugs vary considerably. The The geographical distribution and availability of drugs by their inclusion on regional availability of some excellent drugs could be improved national essential drugs lists. AVAILABILITY In some societies, oral regimen are strongly preferred to injections, whereas among are strongly preferred to injections, whereas among In some societies, oral regimen be seen as the only acceptable form of treatment. In other groups, injections may spread of HIV infection, preference should be given view of the emergence and the risks associated with needle-stick injuries. to oral regimen in order to reduce Patient education on the ef Extra effort is required to achieve compliance among adolescent patients as they Extra effort is required to achieve They may also not want others to know that are often less tolerant of side-effects. Health workers must ensure that instructions are fully they are taking medication. regimen are involved—including the implications understood—especially if several of failure to complete treatment. COMPLIANCE AND ACCEPTABILITY COMPLIANCE limits is a problem which seriously with STI treatment regimen Patient compliance and as those involving erythromycin of multidose regimen such the effectiveness be given regimen should therefore Single-dose or very-short-course tetracyclines. shown to health education have been counselling and preference. Appropriate of clinical management. and should be a part increase compliance HIV infection and AIDS, and treatment must be intensi management. cacy of this fi . The use of multiple drugs to treat polymicrobial . The use of multiple drugs the advantage of being an oral preparation. It xime has fi N. gonorrhoeae ceftriaxone in the treatment of gonorrhoea and chancroid cacy of fi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES In addition to treating uncomplicated anogenital gonorrhoea, single-dose In addition to treating uncomplicated anogenital gonorrhoea, conjunctivitis and ceftriaxone is effective in gonococcal ophthalmia neonatorum, use doses of ceftriaxone pharyngeal infection. Because of its cost it is tempting to development of resistance below 125 mg. However, this is likely to accelerate the and such regimen are not recommended. has been well documented. There is a strong positive correlation between the has been well documented. There is a strong positive correlation minimum inhibiting concentrations of penicillins and cephalosporins. is also likely to be effective against chancroid, but has not yet been evaluated in this is also likely to be effective against chancroid, but has not condition. The ef Several third-generation cephalosporins have been shown to be effective in the Several third-generation cephalosporins treatment of gonorrhoea. Ce CEPHALOSPORINS 4.2. COMMENTS ON INDIVIDUAL DRUGS 4.2. COMMENTS ON INDIVIDUAL Simultaneous treatment with several agents has been used to prevent the emergence several agents has been used to prevent the emergence Simultaneous treatment with during therapy for tuberculosis. The ef of resistance in individuals RISK OF REDUCING DRUG EFFICACY FOR OTHER INDICATIONS FOR OTHER EFFICACY REDUCING DRUG RISK OF centres. not be reserved for referral but expensive drugs should More effective care level quickly discourages effective regimen at the primary The use of less fosters the rapidly available care and seeking the most readily and patients from to resistance developing infection and the risk of antimicrobial transmission of selected antibiotics. technique in preventing the emergence of resistance in STI populations is unknown. emergence of resistance in STI populations is unknown. technique in preventing the a number of antimicrobials is sometimes acquired Unfortunately resistance to simultaneously by simultaneous infection (e.g. tetracycline processes (e.g. PID) or presumed cases of gonorrhoea), is widely practised and for chlamydial coinfection in recommended.

66 KEY CONSIDERATIONS UNDERLYING TREATMENTS 67 KEY CONSIDERATIONS UNDERLYING TREATMENTS

, , 2001, 28(9): N. gonorrhoeae N. gonorrhoeae ed in “Pregnancy Sex Transm Dis Sex Transm ﬁ 2000 Oct 18; 284(15):1917-9 JAMA JAMA . 12,13,14 Chlamydia trachomatis, Neisseria gonorrhoeae, Neisseria gonorrhoeae, Chlamydia trachomatis, 1997, 8:299-302. Haemophilus ducreyi uenza and ﬂ Randomized studies comparing the use of a single-dose azithromycin Randomized studies comparing the use of a single-dose Int J STD AIDS, Int J STD 15 GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES Dillon R, Li H, Sealy J, Ruben M. The Caribbean GASP Network, Prabhakar P. Antimicrobial susceptibility of Neisseria P. Network, Prabhakar The Caribbean GASP M. Dillon R, Li H, Sealy J, Ruben category B - found safe in animal studies no data in humans. Pregnancy Centre for Disease Control and Prevention. Fluoroquinolone resistance in Neisseria gonorrhoeae, Hawaii, 1999, and Fluoroquinolone resistance in Neisseria Centre for Disease Control and Prevention. Azithromycin and erythromycin resistant Neisseria gonorrhoeae following treatment A. A, Mcmillan H, Moyes Young Although oral azithromycin taken as a 2 g dose is effective against Although oral azithromycin It is characterized by a broader spectrum of activity and lower incidence of adverse spectrum of activity and lower incidence of adverse It is characterized by a broader It has a low plasma concentration, but a high and events and drug interactions. concentration resulting in extensive tissue distribution prolonged cellular and tissue This makes it an ideal antimicrobial for the and intracellular accumulation. deep tissues. On account of its long tissue half-life a management of infections in g is recommended in the treatment of genital chlamydia single daily oral dosage of 1 infection. it for routine treatment of this infection WHO does not currently recommended gastrointestinal intolerance at this dose level. because of the drug’s increased and three Caribbean countries (Trinidad, Guyana and Furthermore, studies in Brazil reported the emergence of isolates of St Vincent) and the USA have azithromycin. with reduced sensitivity to Preliminary data indicate that azithromycin is safe for pregnant women, although Preliminary data indicate that azithromycin is safe for been small and the the number of women in the trials of the drug to date have classi duration of follow-up rather short. The drug is currently category B”. Azithromycin has also been shown to be effective against other STIs such as Azithromycin has also been shown to be effective against are needed before a chancroid, donovanosis and early syphilis, but more data can be made. general recommendation for its use in these infections MACROLIDES the macrolide is structurally related to is an azalide antibiotic, which Azithromycin Gram- erythromycin against some It is slightly less potent than erythromycin. variety of activity against a wide but demonstrates a superior positive organisms organisms, including Gram-negative Haemophilus in 15 13 14 12 508-14 gonorrhoeae isolates from three Caribbean Countries: Trinidad, Guyana and St. Vincent. Guyana and St. Vincent. Trinidad, gonorrhoeae isolates from three Caribbean Countries: decreased susceptibility to azithromycin in N. gonorrhoeae, Missouri, 1999, with azithromycin.

17 , 1998, 43(6):509-14. J Reprod Med side-effects were cantly fewer gastrointestinal fi drugs used in humans. rst effective systemic antibacterial fi In one study, signi In one study, 16 GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES presence of As there are no data on the versus 93.0%, P > 0.05). cacy (88.1% fi Wehbeh HA et al. Single-dose azithromycin for Chlamydia in pregnant women. et al. Single-dose azithromycin for Chlamydia in pregnant HA Wehbeh The most commonly known combination of this type is trimethoprim/sulphamethoxazole (formerly known as co- noted in the azithromycin group than in the erythromycin group (11.9% versus erythromycin group (11.9% group than in the noted in the azithromycin treatment and erythromycin had similar while both azithromycin 58.1%, P < 0.01), ef mothers be administered to nursing in breast milk the drug should azithromycin alternatives. Available data on the safety of only when there are no suitable on can be provided even at the primary health care level azithromycin suggest that it are appropriately educated to advise patients to condition that health care workers mild adverse effects. be aware of the drug’s potential The addition of trimethoprim to sulphonamides gives a combination drug The addition of trimethoprim to sulphonamides gives They are primarily bacteriostatic and act by interfering with bacterial synthesis of They are primarily bacteriostatic in the liver and excreted by the kidneys. Generally folic acid. They are metabolized making them preferable to other antibacterials. they are administered orally, resistance to these drugs, their role and importance However, with rise in bacterial been largely replaced by other antibacterials that are has decreased and they have more effective and less toxic. SULPHONAMIDES Sulphonamides were the regimen with erythromycin for the treatment of chlamydia in pregnant women pregnant women chlamydia in treatment of for the with erythromycin regimen rates, it also improve the cure only did azithromycin substantially found that not courses of with use of standard of side-effects associated reduced the occurrence erythromycin. Sulphonamides are not recommended in the last trimester of pregnancy as they may Sulphonamides are not recommended in the last trimester for the treatment of induce jaundice in the neonate; they are also not recommended that is more effective owing to the synergetic action of the two components; the that is more effective owing to the synergetic action of by inhibiting simultaneously combination also helps to decrease bacterial resistance this combination has two sequential steps of bacterial metabolism. However, STIs such as chlamydia and reached the limit of its usefulness in the management of use this combination for gonorrhoea. Although there are some countries that still antimicrobial agent for this the treatment of gonococcal infections, it is not an ideal infection. 16 17 trimoxazole).

68 KEY CONSIDERATIONS UNDERLYING TREATMENTS 69 KEY CONSIDERATIONS UNDERLYING TREATMENTS , 2002, MMWR varies oxacin has been fl oxacin is considered fl . N. gonorrhoeae is limited. uoroquinolones fl 18 N. gonorrhoeae (QRNG) has become common in parts of Asia (QRNG) has become common greatest potential when given as oxacin has the uoroquinolones against uoroquinolones fl fl to quinolones will continue to spread across the globe. It to quinolones will continue to spread across the globe. N. gonorrhoeae N. Gonorrhoeae gonococci reported c. In 1996 the proportions of quinolone-resistant fi for the promise as oral agents uoroquinolones show considerable activity of individual fl GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES in vitro Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. Sexually transmitted diseases treatment Centers for Disease Control and Prevention. 300 mg twice daily for seven days. This is effective against both gonorrhoea and 300 mg twice daily for seven days. This is effective against Resistance of Experience in the treatment of chlamydial infection with is imperative that surveillance for antimicrobial resistance be strengthened in order is imperative that surveillance for antimicrobial resistance to guide treatment recommendations. Of the currently studied agents, o In the USA, QRNG is becoming increasingly common in western regions. In the USA, QRNG is becoming increasingly common of gonorrhoea in the State Quinolones are no longer recommended for the treatment of Hawaii, and are to be used cautiously in California. in these areas ranged from less than 1% in New Zealand to 15% in the Republic in these areas ranged from less Special Administrative Region of China, 53% in of Korea, 24% in Hong Kong Cambodia and 66% in the Philippines. treatment of gonorrhoea. Their use is contraindicated in pregnancy and they are not in pregnancy and Their use is contraindicated treatment of gonorrhoea. and adolescents, although cipro recommended for use in children Quinolone-resistant and the Paci Earlier agents such as rosoxacin are no longer recommended. However, some recommended. However, such as rosoxacin are no longer Earlier agents of the new QUINOLONES infections in neonates and nursing mothers because the hepatic enzymes system in enzymes system the hepatic mothers because and nursing in neonates infections neonates is immature. to be the agent with the greatest activity against to be the agent with the greatest The licensed in Denmark for the single-dose prophylaxis of meningococcal disease in licensed in Denmark for the children. evidence of increased minimal inhibitory concentrations considerably. There is some with less active agents. Cipro in strains isolated after treatment 51(RR-6):1–80 18 cance fi : N. gonorrhoeae has been observed since the introduction has been observed since the N. GONORRHOEAE cance today is that chromosomal-resistant , penicillinase-producing gonococci, and , penicillinase-producing gonococci, fi can be substituted cacy are available. These fi N. gonorrhoeae N. gonorrhoeae gonorrhoea. cacy of traditional regimen for treating fi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES plasmid-mediated resistance affects penicillins and tetracyclines. plasmid-mediated resistance chromosomal resistance involves penicillins and a wide range of other therapeutic penicillins and a wide range of other therapeutic chromosomal resistance involves spectinomycin, erythromycin, quinolones, agents such as tetracyclines, thiamphenicol, and cephalosporins; The effectiveness and usefulness of current surveillance of gonococcal resistance The effectiveness and usefulness of current surveillance monitoring gonococcal are limited, and a simple instrument for assessing and standardization of sensitivity antimicrobial resistance needs to be developed. Lack of methods should be testing methodology continues to be a problem. Standard sensitivity used and should include a set of reference strains. Disc-diffusion the limited availability of testing remains poorly standardized, one problem being antimicrobial discs of the correct content. in relation to the clinical use of ceftriaxone, this trend is disturbing. The high-level in relation to the clinical use of ceftriaxone, this trend is is also chromosomally spectinomycin resistance reported sporadically in gonococci mediated. Chromosomal resistance in Chromosomal resistance in Chromosomally resistant ■ strains are all increasing and have had a plasmid-mediated, tetracycline-resistant major impact on the ef a number of antimicrobial agents that have been strains are often resistant to between penicillin and the used to treat gonorrhoea. There is also cross-resistance not yet of any signi second- and third-generation cephalosporins. Although There are two main types of antimicrobial resistance in There are two main types of ■ 4.3. ANTIMICROBIAL RESISTANCE IN RESISTANCE ANTIMICROBIAL 4.3. A number of tetracyclines of equal ef A number of tetracyclines Its signi of sulphonamides in the 1930s. TETRACYCLINES chlamydial infection, but the usefulness of the regimen is limited by the duration of by the duration is limited of the regimen but the usefulness infection, chlamydial by the drug’s high cost. may affect compliance, and therapy, which for doxycycline and tetracycline hydrochloride as appropriate. and tetracycline hydrochloride for doxycycline

70 KEY CONSIDERATIONS UNDERLYING TREATMENTS 71 KEY CONSIDERATIONS UNDERLYING TREATMENTS strains now contain is complicated by the is complicated can also carry a large plasmid can also carry a large plasmid H. ducreyi H. ducreyi oxacin are suitable alternatives, fl H. DUCREYI N. gonorrhoeae, H. ducreyi centres provide data. sensitivity testing. Very few culties of performing resistance has not been reported to either drug, although frequent resistance has not been reported fi has developed resistance to a number of different antimicrobials, but different antimicrobials, but resistance to a number of has developed in vitro GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES Plasmid-mediated resistance has been found against ampicillin, sulphonamides, Plasmid-mediated resistance and streptomycin. All tetracycline, chloramphenicol technical dif H. ducreyi resistance in Singapore in the early 1980s, of two strains isolated with the exception the erythromycin remains has not been reported, therefore, to erythromycin and cipro recommended treatment. Ceftriaxone since with ceftriaxone among both HIV-positive and treatment failures were observed conducted in Nairobi, Kenya, in 1991. Single-dose HIV-negative patients in a study to be another promising alternative, but further data azithromycin therapy appears are required. 4.4. ANTIMICROBIAL RESISTANCE IN RESISTANCE ANTIMICROBIAL 4.4. in of antimicrobial susceptibility The surveillance beta-lactamase coding plasmids, several of which have been described. Neither beta-lactamase coding plasmids, effective against chancroid. Tetracycline resistance penicillin nor ampicillin is now is also widespread. As with Plasmid-controlled aminoglycoside-inactivating enzymes have reduced the Plasmid-controlled aminoglycoside-inactivating enzymes in south-east Asia. At usefulness of these antimicrobials in treating chancroid present this is not the case in Africa or elsewhere. Resistance to sulphonamides is now widespread, and strains with reduced Resistance to sulphonamides is now widespread, and strains prevalent in south-east sensitivity to trimethoprim are becoming increasingly remain sensitive to Asia, in parts of Africa and in north America. Where strains with a sulphonamide trimethoprim, treatment with this agent alone or combined remains effective. capable of mobilizing smaller, non-conjugative resistance plasmids. Trimethoprim non-conjugative resistance plasmids. Trimethoprim capable of mobilizing smaller, occur in the absence of plasmids. and tetracycline resistance can of the syndrome, antimicrobial cation fi

and management of sexual partners. cation ﬁ for populations at risk—such as female and male sex workers, c services ﬁ GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES MANAGEMENT

comprehensive case management of STI conjunctivitis prevention and care of congenital syphilis and neonatal early detection of symptomatic and asymptomatic infections. speci and prisoners adolescents, long-distance truck drivers, military personnel integration of STI prevention and care into primary health care, reproductive integration of STI prevention clinics and others health care facilities, private promotion of health care-seeking behaviour promotion of health care-seeking promotion of safer sexual behaviour promotion of safer sexual behaviour a full range of activities from condom condom programming—encompassing management of supplies and distribution promotion to the planning and 5. PRACTICAL CONSIDERATIONS IN STI CASE IN STI CASE 5. CONSIDERATIONS PRACTICAL One of the essential components of the public health package is comprehensive case One of the essential components of the public health package management of STIs, which comprises identi 5.2. COMPREHENSIVE CASE MANAGEMENT OF STIs 5.2. COMPREHENSIVE CASE MANAGEMENT ■ ■ ■ ■ ■ ■ ■ ■ The public health package for STI prevention and control: essential components for STI prevention and The public health package 5.1. THE PUBLIC HEALTH PACKAGE FOR STI PREVENTION AND CONTROL FOR STI PREVENTION PACKAGE THE PUBLIC HEALTH 5.1. of STIs can be achieved using a combination of Effective prevention and control health package”. The essential components of this responses constituting the “public package are shown below. treatment for the syndrome, education of the patient, condom supply, counselling, treatment for the syndrome, education of the patient, condom and noti

72 PRACTICAL CONSIDERATIONS IN STI CASE MANAGEMENT 73 PRACTICAL CONSIDERATIONS IN STI CASE MANAGEMENT

cation and partner treatment fi rst port of call of the patient fi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES of further STI transmission risk reduction and prevention HIV risk perception and assessment compliance infection of nature noti partner of importance effective management of infected individuals seeking care effective management of infected individuals seeking care individuals. treatment and education of the sexual partners of infected education of individuals at risk on modes of disease transmission and means of education of individuals at risk on modes of disease transmission reducing the risk of transmission subjects who are detection of infection in asymptomatic subjects and in services symptomatic but unlikely to seek diagnostic and therapeutic − clinical follow up when appropriate and feasible. − establishment of a syndromic or laboratory based diagnosis establishment of a syndromic using the most effective antimicrobial for the curative or palliative therapy, pathogen, at the (where counselling services are available), patient education and counselling including information on: − − − history taking, including behavioural, demographic and medical risk assessment history taking, including behavioural, of the genital area, an activity which, in some physical examination, particularly with greater sensitivity and understanding settings, needs to be treated The prevention of STIs is based primarily on changing the sexual behaviours that The prevention of STIs is based primarily on changing put people at risk and on promoting the use of condoms. There are four major components of STI control: ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ For individuals seeking evaluation for an STI, appropriate care consists of the For individuals seeking evaluation following components: IDENTIFICATION OF THE SYNDROME OF IDENTIFICATION any health must be assured within of providing STI case management The feasibility component private sector. An essential within the public or care setting, whether may also on the source of care, there for consultation. Depending will be privacy adequate table or couch with facilities such as an examination be need to provide supplies. equipment and laboratory syringes, specula, sterilization lighting, gloves, nition, are at risk for these fi owcharts or laboratory tests—the fl with a patient with an STI. Effective rst point of contact fi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES availability and use of effective antimicrobials is an absolute requirement. The drugs is an absolute requirement. use of effective antimicrobials availability and at the must be available in the private sector. also be available and used treatment must The promotion of condom use requires health authorities to ensure that there is an The promotion of condom use requires health authorities at health facilities and at other adequate supply of good-quality, affordable condoms of condoms is another way distribution points in the community. Social marketing of increasing access to condoms. CONDOM SUPPLY CONDOM SUPPLY A consultation for an STI is a unique opportunity to provide education on the A consultation for an STI is to people who, by de prevention of HIV and STIs providing STI services. Condoms should be available in any health care facility Although condoms do not Instruction in their proper use should also be provided. used they greatly reduce provide absolute protection from any infection, if properly should also be addressed the risk of infection. The question of pregnancy prevention instructed on where to and dual protection emphasized. Adolescents should be access advice on contraception and future supplies of condoms. EDUCATION OF THE PATIENT OF EDUCATION among other things, about the nature of the infection Patients should be informed, the full course of medication. and the importance of taking treat patients with STIs should make resources Clinics and practitioners who of safer sexual behaviour. Behavioural assessment is available for the promotion and patients should be educated in methods of an integral part of the STI history STIs and HIV, including abstinence, careful selection lowering their risk of acquiring of partners and use of condoms. infections. Adolescents are an especially important target group for primary infections. Adolescents are their active sexual and reproductive life lies ahead. prevention because much of an be less inclined to appreciate the risks of acquiring Furthermore, adolescents may STI. ANTIMICROBIAL TREATMENT FOR THE SYNDROME TREATMENT ANTIMICROBIAL is used for diagnosis— Whichever means

74 PRACTICAL CONSIDERATIONS IN STI CASE MANAGEMENT 75 PRACTICAL CONSIDERATIONS IN STI CASE MANAGEMENT cient to enable patients fi dential process in which a care fi ect on issues associated with STIs and to explore fl ned here as an interactive con fi an essential part of an for prevention and is cation. This is education fi is de disclosure and the risk of violence or stigmatizing reactions from dentiality, fi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES spouse, partner(s), family or friends con dealing with an incurable STI, such as herpes genitalis, which may be transmitted dealing with an incurable STI, such as herpes genitalis, to the partner(s) or spouse and introduce condom preventing future infections, including strategies to discuss use with partner(s) or spouse assessing the patient’s risk for HIV and deciding whether or not to undergo testing assessing the patient’s risk for HIV and deciding whether for HIV of STIs, such learning about, and coming to terms with, worrisome complications as infertility and congenital syphilis informing the partner(s) or spouse about the STI diagnosis (options: either the informing the partner(s) or spouse about the STI diagnosis or spouse) patient or the health care provider informs the partner(s) Issues that should be addressed in a counselling session include: Issues that should be addressed in a counselling session possible lines of action. There is often a need for skills building and practising possible lines of action. There require multiple visits. Counselling is more time- different behaviours. This may means of information provision and also requires consuming than the traditional empathy and understanding of the social and from health care workers more as well as the ability to overcome their own attitudes economic situation of a patient, and avoid making judgements. provider helps a patient to re ■ ■ ■ ■ ■ ■ However, merely providing information is usually not suf However, merely providing STI consultation. STI consultation. COUNSELLING COUNSELLING to discuss for the health worker for an STI provides an opportunity A consultation for HIV/ basis, his or her risk factors the patient, on a one-to-one and explore with this consists and treatment. Frequently issues related to prevention STIs and other use and and their prevention, condom of information about STIs of the provision partner noti Counselling accurately to assess their own risk of infection, deal with the challenges of informing risk of infection, deal with the challenges of informing accurately to assess their own infections, or deal with the complications of STIs. their partner(s), prevent future an STI consultation may provoke emotional Some issues which arise during counselling is needed in addition to education. reactions in the patient. Therefore, ed, the ed, fi and dential risk assessment fi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES planning for risk reduction planning for risk have the counselling skills, the privacy, and the time (usually 15–20 minutes), the time (usually 15–20 minutes), skills, the privacy, and have the counselling follow-up discussions, as appropriate. including the availability for identify the needs of the client, who may feel anxiety about a particular aspect feel anxiety about a particular of the client, who may identify the needs for con have a particular need of the STI, or may enabling patients to take control of their own life and their responsibilities for life and their responsibilities to take control of their own enabling patients disease prevention. Contacting the sex partners of clients with an STI, persuading them to present Contacting the sex partners of clients with an STI, persuading and themselves at a site offering STI services, and treating them—promptly These actions, effectively—are essential elements of any STI control programme. of social and however, should be carried out with sensitivity and consideration such as rejection and cultural factors to avoid ethical and practical problems violence, particularly against women. NOTIFICATION AND MANAGEMENT OF SEXUAL PARTNERS PARTNERS OF SEXUAL AND MANAGEMENT NOTIFICATION In many developing countries, where health resources are scarce, counselling In many developing countries, available. However, it is recognized that some of services are not always generally and communication the qualities needed in counselling—compassion, sensitivity possess and apply on a daily skills—are qualities that many health workers already of formal training in basis in their interactions with patients. Even in the absence their patients in a counselling, health workers should be encouraged to engage behavioural options, dialogue about STIs to explore risk assessment and personal if such support is and to identify those requiring further emotional support available. patient should be referred to a nearby counselling service, if this is available. If it is a nearby counselling service, if this is available. If it is patient should be referred to may be designated to provide the counselling. not, then a health or social worker and should be accorded the necessary space and time This person should be trained While not all adolescents will need to be referred for to provide the counselling. need to be able to talk to someone they counselling, they have a well-recognized Having links to local support groups involved can trust and who is well-informed. the clinical advice given at the clinic and encourage with young people can reinforce in the future if required. patients to return to the clinic These resources are usually not available at a busy STI clinic or general outpatient not available at a busy STI clinic or general outpatient These resources are usually that when a counselling need is identi clinic. It is, therefore, suggested ■ Before offering counselling to STI patients, the care provider needs to: the care provider needs to: counselling to STI patients, Before offering ■ ■

76 PRACTICAL CONSIDERATIONS IN STI CASE MANAGEMENT 77 PRACTICAL CONSIDERATIONS IN STI CASE MANAGEMENT offers an cation and management fi laboratory tests are available. nitive fi can be adopted for c). The following three strategies fi rmation fi a way that all information remains cation should be conducted in such diagnosed, irrespective whenever an STI is cation should be considered fi fi by provider referral. In patient referral, an cation can be by patient referral or GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES fi and non-coercive. The aim is to ensure dential. The process should be voluntary fi the likelihood of spread if epidemiological treatment is not given. the likelihood of spread if epidemiological treatment is the seriousness of the disease the availability of effective diagnostic tests the likelihood of a person returning for follow-up the available infrastructure for follow-up of patients the availability of effective treatment delay treatment until the results of de the risk of infection offer immediate epidemiological treatment (treatment based solely on the offer immediate epidemiological investigation diagnosis of the index patient) without any laboratory specimens for subsequent offer immediate epidemiological treatment, but obtain laboratory con The strategy selected will depend on: Management of sexual partners is based on knowledge of the index patient’s Management of sexual partners diagnosis (syndromic or speci that the sexual partners of STI patients, including those without symptoms, are that the sexual partners of STI referred for evaluation. the treatment of partners: Partner noti con infected patient is encouraged to notify partner(s) of their possible infection without to notify partner(s) of their possible infection without infected patient is encouraged care providers while in provider referral, health the direct involvement of health care workers notify a patient’s partner(s). care providers or other health Noti of where care is provided. of where care opportunity to identify and treat people who otherwise would not receive treatment. otherwise would not receive identify and treat people who opportunity to Partner noti ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ The sexual partners of STI patients are likely to be infected and should be offered should be offered infected and are likely to be STI patients partners of The sexual by referral reinfection can be prevented transmission of STIs and treatment. Further STI patients Female partners of male for diagnosis and treatment. of sexual partners noti thus, partner may well be asymptomatic; c groups c fi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES WHO recommends that epidemiological treatment (with the same treatment treatment (with the same treatment that epidemiological WHO recommends be given to all sexual partners. for the index patient) should regimen used It is recommended that routine STI services be integrated into primary health care. STI services be integrated into primary health care. It is recommended that routine (sometimes called categorical clinics) may be Clinics specializing in STI treatment settings for speci particularly useful in providing primary care in urban It is often argued that high-quality STI care should be delivered by specialist clinical STI care should be delivered by specialist clinical It is often argued that high-quality However, inaccessibility, unacceptability and the staff in categorical STI clinics. resources required make this an impractical method of many human and economic public. service provision for the general 5.3 ACCESS TO 5.3 ACCESS SERVICES TO for the effective services is important of accessible, acceptable and The provision will have countries, patients In most developing and industrialized control of STIs. to seek STI care. Possible sources are found within a choice of services from which sector and the informal sector. In ensuring universal the public sector, the private it should be recognized that patients seek access to appropriate STI programmes, sources. In many countries most STI care is obtained care from a mixture of these balanced and comprehensive programme may require outside the public sector. A care providers that are able to provide STI services. the strengthening of all health Note ■ Adolescents often lack information about existing services, such as where they are, Adolescents often lack information about existing services, if they know about these what times they operate, how much they cost, etc. Even and treatment. They are services they are often reluctant to seek help for diagnosis such as sex workers and their clients, migrant workers, truckers, and any other such as sex workers and their clients, migrant workers, a concentration of STI group with poor access to health care. Because they have primary care services, expertise, these clinics can also offer referral services for etc. In a few selected cases the hospital outpatient departments, private practitioners, centres to train health specialized clinics should also be strengthened as reference (e.g. the prevalence care providers in STI treatment, epidemiological information susceptibility), and of etiological agents within the syndromes and antimicrobial validity of algorithmic operational research (e.g. studies on the feasibility and approaches).

78 PRACTICAL CONSIDERATIONS IN STI CASE MANAGEMENT 79 PRACTICAL CONSIDERATIONS IN STI CASE MANAGEMENT initiatives under dentiality. There are fi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES way in many countries to make health services more adolescent-friendly and more more adolescent-friendly countries to make health services way in many their particular needs. responsive to often embarrassed and worried about social stigmatization. They also fear negative also fear negative They social stigmatization. worried about and often embarrassed con health workers and lack of reactions from ed fi in C. trachomatis ADOLESCENTS AND ADOLESCENTS 19 of a sexually transmissible agent in a child beyond the neonatal cation fi nes children as persons between the ages of 0 and 9 years. fi

GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES SEXUALLY TRANSMITTED TRANSMITTED INFECTIONS SEXUALLY

WHO de

19 6. CHILDREN, period, in the vast majority of cases, is suggestive of sexual abuse. However, period, in the vast majority of cases, is suggestive of sexual with exceptions do exist: for example, rectal or genital infection The identi Health care providers have not always been aware of the link between sexual abuse Health care providers have not always been aware of the been sexually abused and STI in children. Previously, children thought to have with an STI were also not were not routinely screened for STI. Children diagnosed to have acquired the investigated for the source of infection, but were assumed of a contaminated towel or infection by non-sexual means, such as through the use sleeping quarters. through contact with an infected person in overcrowded A standardized approach to the management of STIs in children and adolescents A standardized approach to sexually abused is important because the infection who are thought to have been which remains undiagnosed and untreated may may be asymptomatic. An STI at a later stage and may be transmitted to result in an unanticipated complication others. During the past decade, the sexual abuse and assault of children and adolescents During the past decade, the as serious social problems requiring the attention of have come to be recognized the variety of professionals who deliver social and policy-makers, educators, and begin to document the serious effects of sexual abuse health services. As researchers health of this group, the management of the victims on the mental and physical aspect of child and adolescent health care in both the is emerging as an important worlds. industrialized and the developing young children may be caused by perinatally acquired infection, which may persist young children may be caused by perinatally acquired have been identi for up to three years. In addition, BV and genital mycoplasma

80 PRACTICAL CONSIDERATIONS IN STI CASE MANAGEMENT 81 CHILDREN, ADOLESCENTS AND SEXUALLY TRANSMITTED INFECTIONS rmed and considered. fi suspect abuse cult to identify. Health workers who fi evidence other evidence. When the only c for abuse without con ndings should be carefully fi fi They should be trained to elicit a good medical and sexual dentiality. fi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES alleged offender known to have an STI or to be at high risk for STIs alleged offender known to have an STI or to be at high symptoms and signs of an STI on physical examination. Special care must be taken in collecting the required specimens in order to avoid Special care must be taken in collecting the required specimens The clinical manifestations undue psychological and physical trauma to the patient. compared to those of of some STIs may be different in children and adolescents A paediatric speculum adults. Some infections are asymptomatic or unrecognised. sexual assault victims. is rarely, if ever, needed in examination of pre-pubescent are more important Indeed, in these situations, skill, sensitivity and experience undertaking examinations than any specially developed technology. Practitioners ■ Situations involving a high risk of STIs and a strong indication for testing include: Situations involving a high risk of STIs and a strong indication ■ history and know how to overcome the patient’s fear of pelvic examination. history and know how to overcome the patient’s fear of Health care workers dealing with children and adolescents must show respect and with children and adolescents must show respect and Health care workers dealing maintain con 6.1. EVALUATION FOR SEXUALLY TRANSMITTED INFECTIONS FOR SEXUALLY 6.1. EVALUATION adolescents for sexual assault or abuse should be Examination of children and further trauma. The decision to evaluate the individual arranged so as to minimize case-by-case basis. for STIs must be taken on a in both abused and non-abused children. Genital warts, although suggestive of suggestive warts, although Genital children. abused and non-abused in both speci assault, are not to a sexually the detection of antibodies isolation of an organism or of abuse is the agent, transmissible It must be stressed that the psychological and social support services should be It must be stressed that the of these patients. included for complete management In children and adolescents, cases of sexual abuse of both sexes are probably far abuse of both sexes are probably adolescents, cases of sexual In children and relatives, Most cases involve than is commonly recognized. more widespread or adolescent. contact with the child adults in close and legitimate friends and other The perpetrator may be dif for specialized counselling, social support and must consider the options available redress.

T. vaginalis eld fi from a specimen T. pallidum cient if the child or adolescent has fi from specimens collected from from specimens collected from to incubate. cient time for infections should be used. fi C. trachomatis , HIV and hepatitis B virus. The choice of agents for N. gonorrhoeae and testing for uorescent antibody fl an additional follow- cient time for antibodies to develop, fi T. pallidum N. gonorrhoeae of clue cells or other indicators of BV as an indicator of sexual cance fi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES collected from vesicles or ulcers in children of all ages and in adolescents. collected from vesicles or ulcers in children of all ages and exposure in the presence or absence of vaginal discharge is unclear. exposure in the presence or absence of vaginal discharge microscopy or direct Collection of a serum sample to be preserved for subsequent analysis if follow- Collection of a serum sample to be preserved for subsequent occurred more than up serological tests are positive. If the last sexual exposure be tested immediately 12 weeks before the initial examination, serum should which suitable tests are for antibodies to sexually transmitted agents. Agents for available include serological tests should be made on a case-by-case basis. serological tests should be made on a case-by-case basis. Tissue culture for herpes simplex virus (where available) and dark- Tissue culture for herpes simplex virus (where available) Wet-mount microscopic examination of a vaginal swab specimen for Wet-mount microscopic examination of a vaginal swab Cultures for infection. The presence of clue cells suggests BV in a child with vaginal discharge. infection. The presence of clue cells suggests BV in a child The signi the pharynx and anus in both sexes, the vagina in girls, and the urethra in the pharynx and anus in both not be collected from pre-pubertal girls. In boys. Cervical specimens should urethral discharge is an adequate substitute for an boys, a meatal specimen of Only standard culture intraurethral swab specimen when a discharge is present. systems for the isolation of ■ ■ ■ ■ INITIAL EXAMINATION EXAMINATION INITIAL any follow-up examination should include: An initial examination and The scheduling of examinations should be based on the history of assault or abuse. based on the history of assault of examinations should be The scheduling after the last approximately one week is recent, a follow-up visit, If initial exposure to collect the physical examination and will be needed to repeat sexual exposure in order to allow suf additional specimens, Similarly, to allow suf weeks after the last sexual exposure is also necessary up visit at approximately 12 may be suf to collect sera. A single examination and specimen collection should be specially trained in child and adolescent abuse/ adolescent in child and specially trained should be collection and specimen assault evaluation. been abused over an extended period of time and/or the last alleged episode of been abused over an extended before the patient presents for medical evaluation. abuse has occurred some time for scheduling examinations is a general guide. The following recommendation

82 CHILDREN, ADOLESCENTS AND SEXUALLY TRANSMITTED INFECTIONS 83 CHILDREN, ADOLESCENTS AND SEXUALLY TRANSMITTED INFECTIONS , HIV and T. pallidum GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES In the majority of cases, the presentation of STIs is similar to that seen in adults. At In the majority of cases, the presentation of STIs is similar tract undergoes changes the time of puberty and adolescence, the female genital SUSCEPTIBILITY AND CLINICAL PRESENTATION OF STI IN CHILDREN AND ADOLESCENTS AND OF STI IN CHILDREN PRESENTATION AND CLINICAL SUSCEPTIBILITY and adults, and There are differences in the epidemiology of STIs in adolescents regarded as being more though clinical presentations are similar, adolescents are of morbidity. Some of biologically susceptible to infection and at increased risk practice of reporting these differences have been obscured through the common (15–24 years) and through adolescents (10–19 years) in the same category as youth and pregnant. general inattention to young females who are married Presumptive treatment for children who have been sexually assaulted or abused Presumptive treatment for children since girls appear to be at lower risk of ascending is not widely recommended adult women and regular follow-up can usually be infection than adolescent or or their parents/guardians may be very concerned assured. However, some children is perceived to be low by about the possibility of contracting an STI, even if the risk may be an appropriate the health care practitioner. Addressing patient concerns indication for presumptive treatment in some settings. There are few data upon which to establish the risk of a child acquiring an STI as a to establish the risk of a child acquiring an STI as a There are few data upon which is believed to be low in most circumstances, though result of sexual abuse. The risk position is inadequate. documentation to support this PRESUMPTIVE TREATMENT The prevalence of infections with the above agents varies greatly among agents varies greatly among of infections with the above The prevalence to know whether risk factors are present in the communities. It will be important hepatitis B virus tests must be interpreted carefully, abuser/assailant. Results of be transmitted by non-sexual modes as well as sexually. since hepatitis B virus may be made on a case-by-case basis. Again, the choice of tests must hepatitis B virus. hepatitis B virus. EXAMINATION AT 12 WEEKS FOLLOWING ASSAULT WEEKS FOLLOWING 12 AT EXAMINATION exposure following the last sexual at approximately 12 weeks An examination to infectious agents to develop. to allow time for antibodies is recommended should be considered: for the following agents Serological tests , which infects the columnar , which infects the columnar N. gonorrhoeae infection is asymptomatic in the majority of cases. infection. Moreover, C. trachomatis GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES Presentation of syphilis is the same in adolescents and adults. The stages of primary Presentation of syphilis is the same in adolescents and and serological responses chancre, secondary syphilis manifestations, latent syphilis are the same in both groups. GENITAL ULCER DISEASE GENITAL Similarly, bleeding, post- Symptoms which may occur in the adolescent are inter-menstrual coital bleeding and an increase in vaginal secretions. CERVICAL INFECTIONS CERVICAL infection in females will be asymptomatic. Approximately 85% of gonococcal urethritis or proctitis. In However, there may be vulval itching, minor discharge, pre-pubescent girls, a purulent vulvo-vaginitis may occur. In pre-pubescent girls the columnar epithelium extends from the endo-cervical In pre-pubescent girls the columnar of the cervix. This cervical ectropion, normally present canal to the porto-vaginalis adolescents, is associated with an increased risk of in 60–80% of sexually active C. trachomatis Susceptibility this exposed surface. Exposure to oncogenic epithelium, readily colonises papilloma virus, enhances the risk of dyskaryosis and pathogens, such as the human because cervical mucus production and carcinoma at an early age. Additionally, until ovulation begins, the risk of complications is humoral immunity are absent exposed to infection as opposed to the physically higher in the immature adolescent infection and subsequent PID are consequently more mature woman. Ascending pre-pubescent adolescents and those in early puberty. frequent in the sexually active in response to increasing levels of ovarian hormones. Along with anatomical and anatomical Along with ovarian hormones. levels of to increasing in response The mucus begins to secrete mucus. changes, the vaginal epithelium physiological which a white vaginal discharge, the adolescent girl to develop secretion causes of the discharge is a poor predictor Generally, therefore, vaginal is physiological. infection. gonococcal or chlamydial presence of either

84 CHILDREN, ADOLESCENTS AND SEXUALLY TRANSMITTED INFECTIONS 85 CHILDREN, ADOLESCENTS AND SEXUALLY TRANSMITTED INFECTIONS ssuring ﬁ as in adults. at lesions, much the same ﬂ is sexually transmitted and causes an is sexually transmitted T. vaginalis , candidiasis and BV are the three common pathological causes of an pathological causes of an BV are the three common , candidiasis and is uncommon in adolescents prior to puberty. If present, the adolescent is uncommon in adolescents GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES BV does not produce a vulvitis and the adolescent will not complain of itching or BV does not produce a vulvitis soreness. abnormal vaginal discharge. abnormal vaginal It may also soreness and irritation. discharge with vulval offensive malodorous present no symptoms at all. C. albicans itching, dyspareunia, a peri-anal soreness or a may have a discharge, vulval vulvitis may be cyclical in nature and correspond at the introitus. Attacks of candida to menstruation. T. vaginalis VAGINAL INFECTION INFECTION VAGINAL ANOGENITAL WARTS ANOGENITAL or as condylomatous, papular Warts present GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES

86 CHILDREN, ADOLESCENTS AND SEXUALLY TRANSMITTED INFECTIONS 87 CHILDREN, ADOLESCENTS AND SEXUALLY TRANSMITTED INFECTIONS ces ﬁ lié à l’Université Laval, Canada ﬁ , Venereal Disease Division, Department of Communicable Diseases Control, Disease , Venereal , Horizons, Washington, DC, USA Regional of Regional DC, USA , Horizons, Washington, , National AIDS/STD Control Programme, Ministry of Health, Uganda Ministry of Health, AIDS/STD Control Programme, , National , AIDS Coordination Programme, NACP, Zimbabwe NACP, AIDS Coordination Programme, , , Istituto Superiore di Sanita, Laboratorio di Epidemiologia e Biostatistica, Centro , Istituto Superiore di Sanita, Laboratorio di Epidemiologia e Biostatistica, , Clinica las Americas, Colombia , Clinica las , Centre hospitalier af , State Centre of STD, Latvia , Medical School, University of Zimbabwe, Zimbabwe , Medical School, University of Zimbabwe, , Family Health International, Kenya , Family Health International, Kenya , Disease Control Division (STD/AIDS), Ministry of Health, Malaysia , Division of STD/HIV Prevention, Centers for Disease Control and Prevention, USA USA Centers for Disease Control and Prevention, , Division of STD/HIV Prevention, , Coordenação Nacional de Doenças Sexualmente Transmissiveis e AIDS, Ministerio da e Transmissiveis , Coordenação Nacional de Doenças Sexualmente , Epidemiology and Community Medicine, University of Antwerp, Belgium University of , Epidemiology and Community Medicine, , Departamento de Enfermedades de Transmision Sexual, Ministério de Salud Pública, Sexual, Ministério Transmision Enfermedades de , Departamento de , South African Institute for Medical Research, University of Witwatersrand, South Africa South University of Witwatersrand, Research, African Institute for Medical , South , Venereology-Dermatology Hospital, Viet Nam Hospital, Viet , Venereology-Dermatology , Institut Alfred Fournier, France Alfred Fournier, , Institut , Union Africaine contre les Maladies Vénériennes et les Tréponématoses, Centre des MST, Centre des MST, Tréponématoses, Africaine contre les Maladies Vénériennes et les , Union , National AIDS Control Programme, Tanzania Tanzania AIDS Control Programme, , National

GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES

Operativo AIDS, Italy Dr Johannes van Dam Dr Barbara Suligoi Dr Barbara Dr R.O. Swai Thinh Dr Tram Saude, Esplanada dos Ministerios, Brazil Dr Beatriz Orozco Ali Rohani Dr bte Dr Carolyn Ryan Dr F. Moherdaui Dr F. Ndoye Dr Ibra Institut d’Hygiène, Sénégal Dr Elisabeth Madraa Dr J.E. Malkin Dr Evaristo Marowa Prof. A. Meheus Dr Ilze Jakobsone Dr Maina Kahindo Prof. Ahmed Latif Uruguay Alary Prof. Michel Anupong Dr Chitwarakorn Dr Ron Ballard Dr Hilda Abreu Dr Hilda Ministry of Public Health, Thailand Ministry of Public Health, ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

LIST OF PARTICIPANTS LIST DISEASE TRANSMITTED ON SEXUALLY GROUP ADVISORY THE MEETING OF 1999 MAY 11–14 GENEVA, TREATMENT ANNEX 1 ANNEX , Regional Adviser, HIV/AIDS/STD HIV/AIDS/STD Adviser, , Regional , Regional Coordinator, HIV/AIDS/STD Coordinator, , Regional , Regional Adviser, HIV/AIDS/STD Adviser, , Regional , Regional Adviser, HIV/AIDS/STD Adviser, , Regional , Regional Adviser, HIV/AIDS/STD HIV/AIDS/STD Adviser, , Regional , Regional Adviser, HIV/AIDS/STD HIV/AIDS/STD Adviser, , Regional , WHO, Child and Adolescent Health (CAH) , WHO, Child and , WHO/Initiative on HIV/AIDS and STD (HSI) , WHO/Initiative on HIV/AIDS and STD , STP, WHO, Reproductive Health and Research (RHR) Health and Research WHO, Reproductive , STP, , UNAIDS/Department of Policy, Strategy & Research (PSR) Strategy & Research , UNAIDS/Department of Policy, , WHO, Communicable Disease (CDS) , WHO, Communicable Disease (CDS) , WHO, Reproductive Health and Research (RHR) Health and Research , WHO, Reproductive , STP, WHO, Initiative on HIV/AIDS and STD (HSI) WHO, Initiative on HIV/AIDS and , STP, , WHO, Reproductive Health and Research (RHR) Health and Research , WHO, Reproductive GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES Ms Vivian Lopez Ms Bidia Deperthes Dr Ya Diul Mukadi Ya Dr Dr Monir Islam Dr V. Chandra-Mouli Dr V. Dr Francis Ndowa Dr Francis Dr Kevin O’Reilly Dr Antonio Gerbase SEARO: Dr Jai Narain WPRO: Dr Gilles Poumerol EMRO: Dr Puru Shrestha EMRO: Dr Puru Gromyko Alexander EURO: Dr AMRO: Dr Fernando Zacarias AMRO: Dr Fernando AFRO: Dr Mamadou Ball AFRO: Dr Mamadou ■ ■ ■ ■ ■ ■ ■ ■ WHO SECRETARIAT WHO SECRETARIAT ■ ■ ■ ■ ■ REGIONAL OFFICES REGIONAL ■

88 LIST OF PARTICIPANTS 89 LIST OF PARTICIPANTS , Governo do Amazonas, Instituto de Dermatologia Tropical e Tropical de Dermatologia Amazonas, Instituto , Governo do , National STD/AIDS Control Programme, Department of Health Services, Department Control Programme, , National STD/AIDS , Venereal Disease Division, Department of Communicable Diseases Control, Disease , Venereal , Centre national de Référence des MST/SIDA, Central African Republic , Centre national de Référence des MST/SIDA, Central , HIV/STI Prevention and Care, The Population Council, India The Population and Care, , HIV/STI Prevention , National Center for STD and Leprosy Control, Institute of Dermatology, CAMS, Control, Institute of Dermatology, , National Center for STD and Leprosy , Department Obstetrics and Gynaecology, Medical Academy of Latvia, Latvia Medical , Department Obstetrics and Gynaecology, , Technical Support/Prevention, Family Health International, USA Family Health International, Support/Prevention, Technical , , Médecins sans frontières, Switzerland , Unité de Recherche en Santé des Populations, Hôpital du St-Sacrement, Canada Hôpital du St-Sacrement, en Santé des Populations, , Unité de Recherche , Switzerland , STD Control Unit, STD/AIDS Control Programme, Ministry of Health, Uganda , STD Control Unit, STD/AIDS Control Programme, , Medical Research Council, Research Programme on AIDS, Uganda on Programme Council, Research , Medical Research , Syphilis & Chlamydia Branch, CDC, USA , Syphilis & Chlamydia Branch, CDC, , Population Council, India , Population , Department of Preventive and Social Medicine, University College of Medical , Department of Preventive , Disease Control, Department of State of Health and Social Welfare, Medical , Disease Control, Department of State of Health and Social Welfare, , STD/AIDS Control Programme, Ministry of Public Health, Morocco , STD/AIDS Control Programme, , USA

GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES

Dr K.B. Manneh Headquarters, The Gambia Dr Anatoli Kamali Dr Fred Kambugu Prof. Gunta Lazdane Dr Heiner Grosskurth Dr Pushpa Gupta Hawkes Dr Sarah Dr Gina Dallabetta Ms Kate Flore Gresenguet Dr Gérard Sciences, GTB Hospital, Shahadara, India China Anupong Dr Chitwarakorn Dr Nadine Cornier Prof. Ron Ballard Dr Adele Schwartz Benzaken Dr Xiang-Sheng Chen Colombo, Sri Lanka Alami Dr Kamal Alary Prof. Michel Antal Dr Georg M. Brazil Venerologia, Thailand Ministry of Public Health, Dr Iyanthi Abeyewickreme Dr Iyanthi ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

LIST OF PARTICIPANTS LIST SEXUALLY OF THE MANAGEMENT ON IMPROVING CONSULTATION INFECTIONS RANSMITTED 2001 28–20 NOVEMBER DES NATIONS, PALAIS GENEVA, ANNEX 2 ANNEX , HSI Focus , STI Task Force Secretariat Task , STI , Venereal Disease Division, Ministry of Public Health, Thailand Division, Ministry of Public Health, Disease , Venereal , STD Programme, Botswana , STD Programme, , Regional Adviser, HIV/AIDS/STD Adviser, , Regional , STI Focal Point , Epidemiology and Community Medicine, University of Antwerp, Belgium of Community Medicine, University , Epidemiology and , Horizons Program, Population Council, USA Population , Horizons Program, , Director, HIV/Prevention (HIV) HIV/Prevention , Director, , HIV/AIDS Cluster Team, TSD, UNFPA, USA TSD, UNFPA, Team, , HIV/AIDS Cluster , HIV/Prevention, STI Unit (HIV/STI) , HIV/Prevention, , Clinical Research Unit, Department of Infectious and Tropical Diseases, London Diseases, London Tropical of Infectious and Unit, Department Research , Clinical , National Center for STD and Leprosy Control, China , National Center for STD and Leprosy , HIV/Prevention, STI Unit (HIV/STI) , HIV/Prevention, , HIV/Prevention (HIV) , HIV/Prevention , STI Unit Projet RETRO-CI, Côte d’Ivoire RETRO-CI, , STI Unit Projet , International Activities National Centre for HIV, STD and TB Prevention, CDC, Division CDC, TB Prevention, STD and for HIV, Activities National Centre , International , HIV/Prevention (HIV) , HIV/Prevention , MRC Laboratories, The Gambia , MRC Laboratories, zur Rahman zur , National AIDS Control Programme, Ghana Programme, AIDS Control , National ﬁ , NCHADS STD Unit National Center for HIV/AIDS Dermatology and STD, Cambodia , NCHADS STD Unit National Center , Reference Centre for STD Department of Clinical Microbiology and Infectious Diseases, Centre for STD Department of , Reference GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES Institute for Medical Research, South Africa South Institute for Medical Research, of STD Prevention, USA of STD Prevention, School of Hygiene and Tropical Medicine (LSHTM), UK Tropical and School of Hygiene Dr Kevin O’Reilly Dr Antonio Gerbase Dr David Mabey Dr Francis Ndowa Dr Francis Dr Isabelle de Zoysa EURO: Dr Ulrich Laukamm-Josten Thuy Thanh Thi WPRO: Dr Nguyen AFRO: Dr Mamadou Ball Tawilah EMRO: Dr Jihane Dr K. Yeboah Dr K. Dr Htun Ye Dr Htun Dr Qian-Qiu Wang Dr Beryl West Dr Bea Vuylsteke Dr Pachara Sirivongrangson Dr Pachara Dr Johannes van Dam Dr Phal Sano Dr A.B.M. Ma Dr Caroline Ryan Dr Julitta Onabanjo Prof. André Z. Meheus André Z. Prof. Dr Philippe Mayaud Dr Philippe ■ ■ ■ ■ WHO SECRETARIAT WHO SECRETARIAT ■ ■ ■ ■ ■ REGIONAL OFFICES REGIONAL ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

90 LIST OF PARTICIPANTS 91 LIST OF PARTICIPANTS , Communicable Diseases/Tuberculosis (CDS/TB) , Communicable Diseases/Tuberculosis , Communicable Disease Surveillance & Response (CSR/DRS) & Response , Communicable Disease Surveillance , Communicable Diseases/Tuberculosis (CDS/TB) , Communicable Diseases/Tuberculosis , Reproductive Health and Research (RHR) Research Health and , Reproductive , Child and Adolescent Health (CAH) , Child and , Reproductive Health and Research (RHR) and Research Health , Reproductive , Special Programme for Research and Training in Tropical Diseases (TDR) Tropical in Training and for Research , Special Programme , HIV/Prevention, STI Unit (HIV/STI) STI , HIV/Prevention, , HIV/Prevention (HIV) , HIV/Prevention , Essential Drugs and Medicines Policy (EDM) , Essential Drugs and Medicines Policy , Special Programme for Research and Training in Tropical Diseases (TDR) Tropical in Training and for Research , Special Programme , Reproductive Health and Research (RHR) and Research Health , Reproductive GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES Dr Salah-Eddine Ottmani Annapaola De Felici Dr Munderi Dr Paula Dr Mark Perkins Dr Rosanna Peeling Dr Robert Scherpbier Dr Monir Islam Dr Nathalie Broutet Mrs Bidia Deperthes Dr Sibongile Dludlu Dr Sibongile Dr George Schmid Chandra-Mouli Dr V. ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■