Procedures
STI Treatment Pocket European Guidelines 2018 IUSTI guidelines are intended for use by specialists in the field of sexually transmitted infections. Nothing in these guidelines is intended to supersede or substitute for the normal doctor - patient relationship. The guidelines are produced on behalf of the following organisations: IUSTI Europe; the European Academy of Dermatology and Venereology (EADV); the European Dermatology Forum (EDF); the European Society of Clinical Microbiology and Infectious Diseases (ESCMID); International Society for Infectious Diseases in Obstetrics and Gynaecology (ISIDOG). The European Centre for Disease Prevention and Control (ECDC) and the European Office of the World Health Organisation (WHO-Europe) also contributed to their development. The EuroSTIpocket 2018 is a summary of the treatments and procedures of the European guidelines published available on the IUSTI website as of December 2017 http://iusti.org/regions/europe/euroguidelines.htm - 2 -
Pdf format (Year) Page Pdf format (Year) Page *UNDER REVIEW: Guideline under revision or in consultation, available or not in the IUSTI website as of December 2017. Recommendations in the guideline under revision might be different from the ones in this version of the EuroSTIpocket. Management of specific infections Chancroid (2017) Chlamydia (2015) Donovanosis (2016) Genital Herpes (2017) Gonorrhoea (2012) Hepatitis B and C (2017) HPV (2011) Lymphogranuloma venereum (2013) Mycoplasma genitalium (2016) Pediculosis Pubis (2017) Scabies (2016) Syphilis (2014) 4 4 5 6 7 UNDER REVIEW 10 12 UNDER REVIEW 13 UNDER REVIEW 13 14 15 16 Management of syndromes Procedures Balanoposthitis (2014) Epididymo-orchitis (2016) Non-gonococcal urethritis (2016) Pelvic inflammatory disease (2017) Proctitis (2013) Sexually acquired reactive arthritis (2014) Vaginal Discharge (2011) Vulval conditions (2016) HIV testing (2014) Organisation of a consultation for sexually transmitted diseases (2012) Partner Management (2015) 18 23 24 25 26 28 29 UNDER REVIEW 31 35 36 UNDER REVIEW 37
MANAGEMENT OF SPECIFIC INFECTIONS FVU: First void urine, NAAT: Nucleic Acid Antigen Test, POCT: Point of Care Test, TOC: Test of cure For 2nd line treatment see complete European guideline FIRST LINE TREATMENT SECOND LINE TREATMENT DIAGNOSTICS Ceftriaxone 250 mg IM as a single dose. Azithromycin 1 g PO as single dose. Failures, especially in HIV positive individuals, have been reported. Doxycycline 100 mg oral twice daily for 7 days. Preferred if rectal infection. Azithromycin 1 g oral as a single dose TOC if rectal infection. CHANCROID Ciprofloxacin 500 mg oral twice daily for 3 days. Erythromycin 500 mg oral thrice daily or four times a day for 7 days. CHLAMYDIA Erythromycin 500 mg oral twice daily for 7 days. Levofloxacin 500 mg oral four times a day for 7 days. Ofloxacin 200 mg oral twice daily for 7 days. TOC should be subsequently performed. Josamycin 500 mg oral thrice daily or 1g twice daily for 7 days (Third line). Culture (special media). NAAT. Specimen: swab/tissue. NAAT. Specimen: FVU, swab (cervical, urethral, vulvovaginal, anal, conjunctival, pharyngeal). Management of specific infections - 4 -
In pregnancy and breastfeeding Azithromycin 1 g oral as a single dose. Amoxicillin 500 mg oral thrice daily for 7 days. Erythromycin 500 mg oral four times a day for 7 days. Azithromycin 1 g oral once a week. Azithromicin 500 mg oral four times a day. Duration should be for at least 3 weeks or until complete healing is achieved. Josamycin 500 mg oral thrice daily or 1g oral twice daily for 7 days (Third line). DONOVANOSIS Co-trimoxazole 160/800 mg oral twice daily. Doxycycline 100 mg oral twice daily. Erythromycin 500 mg oral four times a day. Duration should be for at least 3 weeks or until complete healing is achieved. Gentamicin 1 mg/kg thrice IM can also be used as an adjunct if lesions are slow to respond. Microscopy (Giemsa-stain). Specimen: swab/tissue. Management of specific infections - 5 -
GENITAL HERPES First-episode genital herpes Aciclovir 400 mg oral three times a day Aciclovir 200 mg oral five times daily Famciclovir 250 mg oral three times daily Valaciclovir 500 mg oral twice daily. Duration for all is 5 days but extended to 10 as required. Increased dosing and prolonged treatment periods in immunocompromised and HIV patients. Recurrent genital herpes (episodic treatment) Aciclovir 800 mg oral three times daily for 2 days Famciclovir 1000 mg oral twice daily for one day Valaciclovir 500 mg oral twice daily for 3 days (short course therapies). Aciclovir 200 mg oral five times daily Aciclovir 400 mg oral three times daily for 3-5 days Valaciclovir 500 mg oral twice daily Famciclovir 125 mg oral twice daily (all for five days). Clinical signs/symptoms. NAAT (specimen: swab). Antigen-test (POCT: fast, but low sensitivity; specimen: swab). Recurrent genital herpes (supressive treatment) Aciclovir 400 mg orally twice daily Aciclovir 200 mg oral four times Valaciclovir 500-1000 mg oral once daily Famciclovir 250 mg oral twice daily. In pregnancy Primary infection: Aciclovir 200 mg oral five times daily for 5-10 days - Reactivation during 1st and 2nd trimester: Aciclovir 400 mg oral three times daily for 5 to 10 days (usually no treatment is advised) - Preventive: Aciclovir 400 mg oral three times daily Valaciclovir 250 mg oral twice daily (all from 36th gestational week until delivery). Management of specific infections - 6 -
GONRHOEA Infections of the urethra, cervix and rectum in adults and adolescents when the antimicrobial sensitivity of the infection is unknown Ceftriaxone 500 mg IM as a single dose together with azithromycin 2 g oral as a single dose. Uncomplicated infection of the pharynx Ceftriaxone 500 mg IM as a single dose together with azithromycin 2 g as a single oral dose. Ceftriaxone 1 g IM as a single dose together with azithromycin 2 g oral as a single dose. Cefixime 400 mg oral as a single dose together with azithromycin 2 g as a single oral dose. Ceftriaxone 500 mg IM as a single dose. Spectinomycin 2 g IM as a single dose together with azithromycin 2 g oral as a single dose. Ceftriaxone 500 mg IM as a a single dose. Genital, anorectal and pharyngeal infection when extended-spectrum cephalosporin resistance identified NAAT (specimen: swab urethral, cervical, vulvovaginal, anal, conjunctival, pharyngeal, FVU) - If PPV of NAAT <90% or pharyngeal NAAT pos. confirm via independent 2nd test (NAAT with different target or culture). Culture (e.g. Thayer-Martin), analysis of antibiotic sensitivity (specimen: swab as for NAAT, see above). Microscopy (specimen: plastic loop) only definitive diagnosis in men with overt purulent urethritis. Management of specific infections - 7 -
Gentamicin 240 mg IM as a single dose together with azithromycin 2 g oral as a single dose. Therapy of gonococcal infections in pregnancy or when breastfeeding Ceftriaxone 500 mg IM as a single dose. Spectinomycin 2 g IM as a single dose. Therapy of gonococcal infections in patients with penicillin anaphylaxis or cephalosporin allergy TOC: clinical/culture 3-7 days post treatment; NAAT 2 weeks post treatment. During menstruation, intracervical swabs for culture are more reliable. Spectinomycin 2 g IM as a single dose together with azithromycin 2 g oral as a single dose. Gonococcal epididymo-orchitis (see also European Guideline on Epididymo-orchitis). Ceftriaxone 500 mg IM as a single dose together with doxycycline 100 mg oral twice daily for 10-14 days. When fluoroquinolone or azithromycin resistance are excluded. Ciprofloxacin 500 mg oral as a single dose. Ofloxacin 400 mg oral as a single dose. Azithromycin 2 g oral as a single dose. Management of specific infections - 8 -
Gonococcal pelvic inflammatory disease (see also European Guideline on Epididymo-orchitis). Ceftriaxone 500 mg IM as a single dose together with doxycycline 100 mg oral twice daily together with metronidazole 400 mg oral twice daily for 14 days. Therapy for disseminated gonococcal infection Initial therapy: Ceftriaxone 1 g IM or IV every 24 hours Spectinomycin 2 g IM every 12 hours. Therapy should continue for 7 days, but may be switched 24-48 hours after symptoms improve to one of the following oral regimens: cefixime 400 mg twice daily ciprofloxacin 500 mg ofloxacin 400 mg twice daily, if fluoroquinolone sensitivity is confirmed by appropriate laboratory susceptibility testing. Therapy for gonococcal conjunctivitis Ceftriaxone 500 mg IM (Spectinomycin 2 g IM if penicillin/cephalosporin allergy) as a single dose daily for 3 days. if antibiotic resistance excluded. Azithromycin 2 g oral as a single dose together with doxycycline 100 mg oral twice daily for 1 week together with ciprofloxacin 250 mg oral daily for 3 days. Therapy for ophthalmia neonatorum Ceftriaxone 25-50 mg/kg IV or IM as a single dose, not to exceed 125 mg. Management of specific infections - 9 -
HEPATITIS B AND C See Guideline for more information on management of acute and chronic hepatitis B and C. HBV: who to test Local general prevalence of HBV carriage <2%: risk assessment should guide testing, e.g. MSM, people who inject drugs (PWID), sex workers, HIVpositive individuals, people from countries with intermediate and high HBV endemicity, sexual partners of HBsAg positive or risk group patients and those presenting after needle stick injury Local general prevalence of HBV carriage >2%: all attenders should be offered testing unless they are known to be immune HBV prevention At-risk patients who have not been previously vaccinated: offer monovalent hepatitis B vaccine or combined A and B vaccine. Ultra-rapid 0, 1, 3 week, 12 month vaccination course is recommended to improve adherence. Specific hepatitis B immunoglobulin 500 i.u. IM if recent HBV exposure (ideally within 12h and certainly <7days). HBV: how to test HBV- serology (specimen: serum). Exclusion of carriage or past natural infection: HBsAg, anti- HBc. First-line testing with either HBsAg or anti-hbc or both is acceptable. See guideline for testing algorithm. Testing for vaccine-induced immunity: anti-hbsab. POCT have lower sensitivity and specificity. Offer blood tests in addition. Management of specific infections - 10 -
HCV: who to test Risk-based testing advised: MSM who have additional risk factors including HIV infection, report of traumatic sexual practice, diagnosis of LGV or syphilis, previous resolved or treated hepatitis C infection, engaging in chemsex People who currently or in the past injected any type of drugs People who practice prostitution People with a past history of needle stick injury People from countries of intermediate to high hepatitis C endemicity (>2%) Recipients of suspected unsafe blood products Current and past prisoners Patients with symptoms of acute hepatitis or found to have deranged liver function HCV prevention Ensure access to harm reduction including needle exchange if PWID. Provide access to testing. Partner referral. Advocate safer sex and provide accessible tailored information. HCV: how to test HCV- serology (specimen: serum, plasma). If exposure >3m ago: HCV antibody (median window period 65 days). If exposure <3m ago: HCV Ag or HCV RNA testing will have higher sensitivity where resources allow. Previous resolved HCV infection: HCV Ag or HCV RNA required. Management of specific infections - 11 -
HPV External genital and perianal warts (Patient applied) Podophyllotoxin (0,5% solution or 0,15% cream) twice daily for 3 days, then 4 days off therapy (4 cycles). Imiquimod 5% cream thrice weekly for up to 16 weeks. Sinecatechines - or green tea-catechines (10% ointment) thrice daily for up to 16 weeks. (Provider administered) Cryotherapy. Trichloroacetic acid (TCA) 80-85% solution. Excision or curettage or electrosurgery/laser (CO2). Clinical, colposcopy, anoscopy whitening with acetic acid (1-5%), histopathology. Exclude syphilis (serology). Vaginal, cervical, intra-meatal, intra-anal warts Vaginal warts can be treated with either TCA or cryotherapy. Cervical warts should be managed by a gynaecologist. Intra-meatal warts can be treated with either TCA or various surgical techniques. TCA can be used for small volume intra-anal warts, and imiquimod use is feasible with suitable patient motivation; otherwise formal surgical referral is indicated for intra-anal warts. Management of specific infections - 12 -
LYMPHOGRANULOMA VENEREUM Doxycycline 100 mg oral twice daily for 21 days. Erythromycin 500 mg oral four times a day for 21 days. Azithromycin in single or multiple-dose regimens has also been proposed but evidence is lacking. MYCOPLASMA GENITALIUM NAAT with genotypical differentiation of LGV (specimen: rectal and ulcer swabs, bubo aspirate). Uncomplicated infection in the absence of macrolide resistance Azithromycin 500 mg oral as single dose (stat) then 250 mg oral once daily for 4 days. Josamycin 500 mg oral thrice daily for 10 days. For uncomplicated persistent infection. Moxifloxacin 400 mg oral once daily for 7-10 days. Treatment failure after moxifloxacin. Pristinamycin 1 g oral four times daily for 10 days (85% cure rate) Doxycycline 100 mg oral twice daily for 14 days (30% cure rate). NAAT (specimen: swab, FVU). TOC 4-6 weeks post treatment. Uncomplicated macrolide resistant infection Moxifloxacin 400 mg oral once daily for 7-10 days. Management of specific infections - 13 -
Complicated M. genitalium infection (PID, epididymitis) (see also European Guidelines on Epididymo-orchitis and on Pelvic inflammatory disease) Moxifloxacin 400 mg oral once daily for 14 days (oral). PEDICULOSIS PUBIS Permethrin 1% cream (washed off after 10 minutes). Repeat after 7-10 days. Pyrethrins with piperonyl butoxide (washed off after 10 minutes). Repeat after 7-10 days. Phenothrin 0.2% lotion on dry hair, wash out after 2 h. Malathion 0.5% lotion on dry hair, wash out 12 h after application. Ivermectin 200 µg/kg orally, repeated after 1 week (in severe cases, 400 µg/kg repeat after 7 days). Clinical diagnosis, dermatoscopy. Consider microscopic examination. Screening for other STI (including HIV). Follow-up examination one week after the end of treatment. The infestation is considered cleared if there is no active infestation (no presence of live lice). Clothing, bedding, towels and other items should be machine washed (at 50 C or higher) or dry-cleaned or sealed and stored in a plastic bag for 2 weeks. Management of specific infections - 14 -
Permethrin 5% cream applied head to toe and washed off after 8 12 h. The treatment must be repeated after 7 14 days. Oral ivermectin (taken with food) 200 µg/kg as two doses 1 week apart. Benzyl benzoate lotion 10 25% applied once daily at night on 2 consecutive days with re-application at 7 days. SCABIES Malathion 0.5% aqueous lotion. Ivermectin 1% lotion. Sulphur 6-33% as cream, ointment or lotion applied on three successive days. Clinical diagnosis, detection of mites (microscopy of scrapings, dermatoscopy), histology. Clothing, bedding, towels and other items should be machine washed (at 50 C or higher) or dry-cleaned or sealed and stored in plastic bag for 1 week. Crusted scabies A topical scabicide (permethrin 5% cream or benzyl benzoate lotion 25%) repeated daily for 7 days then 2 times weekly until cure. AND Oral ivermectin 200 µg/kg on days 1, 2 and 8. For severe cases, based on persistent live mites on skin scrapings at follow-up visit, additional ivermectin treatment might be required on days 9 and 15 or on days 9, 15, 22 and 29. Management of specific infections - 15 -
Syphilis erratum (2015) J Eur Acad Dermatol Venereol 2015, 29, 1248 SYPHILIS Early syphilis (Primary, Secondary and Early latent, i.e. acquired 1 year previously) Serology (specimen: serum). Benzathine penicillin G 2.4 million units IM as single dose (one injection of 2.4 million units or 1.2 million units in each buttock). Treatment for patients with HIV should be given as for non-hiv infected patients. Late latent Benzathine penicillin G 2.4 million units IM (one injection 2.4 million units single dose or 1.2 million units in each buttock) weekly on days 1, 8 and 15. Doxycycline 200 mg oral daily (either 100 mg twice daily or as a single 200 mg dose) for 14 days. Azithromycin 2 g oral as single dose. Doxycycline 200 mg oral daily (either 100 mg twice daily or as a single 200 mg dose) during 21 28 days. If penicillin allergy consider desensitization. Screening and confirmatory: CLIA/ EIA/ TPHA/ TPPA Activity: RPR/ VDRL. NAAT (early infection: swab from sore, biopsy). Dark field microscopy (early infection: fluid from sore or syphilitic condyloma). Neurosyphilis, ocular and auricular syphilis Benzyl penicillin 18 24 million units IV daily, as 3 4 million units every 4 h during 10 14 days. Ceftriaxone 1 2 g IV daily during 10 14 days. Procaine penicillin 1.2 2.4 million units IM daily and probenecid 500 mg four times daily, both during 10 14 days. Management of specific infections - 16 -
Syphilis in pregnancy Pregnant women should be treated with the first line therapy option appropriate for the stage of syphilis and if allergic to penicillin should be desensitized. Congenital syphilis See complete European guideline. Management of specific infections - 17 -
General management of the patient with balanitis MANAGEMENT OF SYNDROMES BALANOSPOSTITIS Sexual history taken Sub-preputial swab for Candida spp. and bacterial culture should be undertaken in most cases to exclude an infective cause or superinfection of a skin lesion or dermatosis Urinalysis for glucose (exclude diabetes) NAAT for HSV and Treponema pallidum (and/or dark ground examination for spirochaetes) if ulceration present Culture/wet prep or NAAT for Trichomonas vaginalis particularly if a female partner has an undiagnosed vaginal discharge Full routine screening for other STIs Dermatology opinion for dermatoses and suspected allergy Biopsy if the diagnosis is uncertain and the condition persists Candidal balanitis Clotrimazole cream 1%. Miconazole cream 2%. Fluconazole 150 mg stat orally if symptoms severe. Nystatin cream 100,000 units/g if resistance suspected, or allergy to imidazoles. Sub-preputial culture (isolation of Candida spp. on culture does not prove causality, as it may represent colonisation). Management of syndromes - 18 -
Topical imidazole with 1% hydrocortisone if marked inflammation is present. Investigation for other causes e.g. HIV or other causes of immunosuppression if balanitis is severe or persistent. Anaerobic infection Metronidazole 400 500mg twice daily for 7 days. Milder cases may respond to topical metronidazole. Aerobic infection Trimovate cream applied once daily. Erythromycin 500 mg oral four times a day for 7 days. Co-amoxiclav 375 mg oral three times daily for 7 days. Co-amoxiclav 375 mg three times daily for 7 days. Clindamycin cream applied twice daily until resolved. Gram stain. Sub-preputial culture (to exclude other causes e.g. Trichomonas vaginalis). Swab for herpes simplex virus infection if ulcerated. Sub-preputial culture (Streptococci and Staphylococcus aureus have both been reported; other organisms may also be involved). Sexually transmitted infections: Herpes simplex virus, Trichomonas vaginalis, Syphilis: See diagnosis and treatment as per specific guidelines. Management of syndromes - 19 -
Lichen sclerosus Ultrapotent topical steroids (e.g. clobetasol proprionate) applied once daily until remission. Lichen planus Moderate to ultrapotent topical steroids depending on severity (for both mucosal and cutaneous disease). Zoon s (plasma cell) balanitis Circumcision. Topical steroid preparations with or without added antibacterial agents e.g. Trimovate cream, applied once or twice daily. Hygiene measures. Topical calcineurin inhibitors (pimecrolimus applied twice daily) -concern about the risk of malignancy. Surgery may be indicated to address symptoms due to persistent phimosis or meatal stenosis. Topical and oral ciclosporin. Topical calcineurin inhibitors (pimecrolimus applied twice daily - but no specific reports in penile disease). Circumcision. CO 2 laser. Topical tacrolimus controversy about the risk of malignancy. Biopsy. Biopsy. Biopsy. Management of syndromes - 20 -
Psoriasis Moderate potency topical steroids (plus antibiotic and antifungal optional). Emollients. Circinate balanitis See under Psoriasis. Treatment of any underlying infection. Topical Vitamin D preparations (calcipotriol or calcitriol applied twice daily). Topical bethamethasone dipropionate/calcipotriol ointment may be well tolerated in treatment of anogenital psoriasis, but potent steroids may not be indicated. Topical tacrolimus has been used in small studies. Topical pimecrolimus. Consider biopsy. Consider biopsy and HLAB27 testing. STI screening. Management of syndromes - 21 -
Eczema (Irritant/allergic balanitides) Hydrocortisone 1% applied once or twice daily until resolution of symptoms. Seborrheic dermatitis Antifungal cream with a mild to moderate steroid. Non-specific balanoposthitis Circumcision is curative. Fixed drug eruption In more florid cases more potent topical steroids may be required and may need to be combined with antifungals and/or antibiotics. Oral azole e.g. itraconazole. Oral tetracycline. Oral terbinafine. Patch tests (referral to a dermatologist is useful if allergy is suspected). Biopsy. Culture (to exclude superinfection). Condition will settle without treatment. Topical steroids e.g. mild to moderate strength twice daily until resolution. Rarely systemic steroids may be required if the lesions are severe. Management of syndromes - 22 -
Pre-malignant conditions: Penile carcinoma in situ of the glans (Erythroplasia of Queyrat) and of the keratinised skin or shaft (Bowen s disease) - Bowenoid papulosis. Surgical excision. Imiquimod 5% cream. Photodynamic therapy. Laser resection. Fluorouracil cream 5%. Cryotherapy. EPIDIDYMO-CHITIS Biopsy. Sexually transmitted epididymo-orchitis Ceftriaxone 500 mg IM as a single dose. PLUS Doxycycline 100 mg oral twice daily 10-14 days. Ofloxacin 200 mg oral twice daily for 14 days. Levofloxacin 500 mg oral once daily for 10 days. Gram stained / methylene blue stained urethral smear. Urine dipstick. Urethral swab for N. gonorrhoea culture. FVU / urethral swab for NAAT for N. gonorrhoea, C. trachomatis and M. genitalium. Management of syndromes - 23 -
Epididymo-orchitis most likely secondary to enteric organisms Ofloxacin 200 mg oral twice daily for 14 days. Levofloxacin 500 mg oral once daily for 10 days. Mid-stream specimen of urine for microscopy and culture. C-reactive protein and erythrocyte sedimentation rate. NON-GONOCOCCAL URETHRITIS Doxycycline 100 mg oral twice daily or 200 mg oral once daily for 7 days. Azithromycin 500 mg oral as single dose (stat) then 250 mg oral once daily for 4 days. Lymecycline 300 mg oral twice daily for 10 days. Tetracycline hydrochloride 500 mg oral twice daily for 10 days. NB Azithromycin 1 gram stat (should not be used routinely because of the increased risk of inducing macrolide antimicrobial resistance with M. genitalium). Urethral swab/plastic loop/ metal device stained smear: Microscopy to confirm presence of urethritis. FVU NAAT for C. trachomatis and N. gonorrhoea and M. genitalium with screening for macrolide resistance recommended. See specific Guideline if patient is C. trachomatis, N. gonorrhoea or M. genitalium-positive. Management of syndromes - 24 -
PELVIC INFLAMMATY DISEASE Outpatient regimens Ceftriaxone 500 mg IM as single dose. FOLLOWED BY Doxycycline 100 mg oral twice daily plus metronidazole 400 mg oral twice daily for 14 days. Inpatient regimens Cefoxitin 2 g IV four times daily. PLUS Doxycycline 100 mg IV twice daily. FOLLOWED BY Doxycycline 100 mg oral twice daily plus metronidazole 400 mg oral twice daily to complete 14 days. Ofloxacin* 400 mg oral twice daily for 14 days. Levofloxacin* 500 mg oral once daily for 14 days. PLUS (for either) Metronidazole 500 mg oral twice daily for 14 days. Moxifloxacin* 400 mg oral once daily for 14 days. Clindamycin 900 mg IV thrice daily. PLUS Gentamicin (2 mg/kg loading dose followed by 1.5 mg/kg three times daily) IV. FOLLOWED BY EITHER Clindamycin 450 mg oral four times daily to complete 14 days. NAAT for M. genitalium, C. trachomatis and N. gonorrhoea. Pregnancy test. Consider ultrasound and laparoscopy. Management of syndromes - 25 -
Doxycycline 100 mg oral twice daily plus metronidazole 400 mg oral twice daily to complete 14 days. Ofloxacin* 400 mg IV twice daily. PLUS Metronidazole 500 mg IV thrice daily for 14 days. * In women who are at high risk of gonococcal PID (e.g. when the patient s partner has gonorrhoea, in clinically severe disease, following sexual contact abroad) a regimen containing ceftriaxone should be used. PROCTITIS See specific Guideline and treat accordingly if patient has proctitis due to N. gonorrhoeae, C. trachomatis genotypes D-K or genotypes L1 3 (LGV), T. pallidum or Herpes simplex virus. Syndromic treatment of proctitis Doxycycline 100 mg oral twice daily for 7 days. PLUS Therapy for other suspected pathogen/s according to specific guideline. For proctitis, proctocolitis and enteritis caused by sexually transmissible pathogens: NAAT for C. trachomatis and N. gonorrhoea and/ or T. pallidum or Herpes simplex virus. Management of syndromes - 26 -
Syndromic treatment of proctocolitis (amoebiasis suspected) Metronidazole 750 mg oral thrice daily for 5 10 days. Syndromic treatment of enteritis Ciprofloxacin 500 mg oral twice daily for 5 days. Co-trimoxazole 960 mg oral twice daily for 7 days. Azithromycin 500 mg oral once daily for 3 days. Shigella, salmonella and campylobacter infections Consider ciprofloxacin 500 mg oral twice daily for 5 days. Amoebiasis Metronidazole 750 mg oral thice daily for 5 to 10 days followed by paromomycin 10 mg/kg/day oral thrice daily for 5 10 days. Diloxanide furoate 500 mg oral thice daily for 10 days. Clioquinol 250 mg oral thrice daily for 10 days. Tinidazole 2 g oral once daily for 2 3 days followed by (same as metronidazole). Syphilis serology (specimen: serum). Culture of Shigella spp., Salmonella spp. or Campylobacter spp. (specimen: feces). Microscopic examination for the trophozoites of Entamoeba histolytica and/or Giardia lamblia of diarrhoeal stool specimens. Anoscopy or sigmoidoscopy, consider biopsy. Specific enzyme immunoassays, direct immunofluorescence tests and NAAT for the detection of antigens/dna. Management of syndromes - 27 -
Giardiasis Metronidazole 500 mg oral twice daily for 5 days. Tinidazole 2 g oral as a single. Cryptosporidiosis and microsporidiosis Paromomycin 500 mg oral thrice daily for 7 days. Non-specific proctitis Doxycycline 100 mg oral twice daily for 7 days. Constitutional symptoms Rest. Non-steroidal anti-inflammatory drugs. Genital infection Refer to the relevant infection guidelines. Arthritis Physiotherapy and physical therapy Non-steroidal anti-inflammatory drugs Intra-articular corticosteroid injections. SEXUALLY ACQUIRED REACTIVE ARTHRITIS Clinical features of spondyloarthritis. Demonstration of evidence of genito-urinary infection. Further investigation (see Guideline). Management of syndromes - 28 -
VAGINAL DISCHARGE Bacterial vaginosis Metronidazole 400-500 mg oral twice daily for 5 to 7 days. Intravaginal metronidazole gel (0.75%) once daily for 5 days. Intravaginal clindamycin cream (2%) once daily for 7 days. Vaginal candidosis Oral preparations include: Fluconazole 150 mg as a single dose. Metronidazole 2 g oral as a single dose. Tinidazole 2 g oral as a single dose. Tinidazole 1 g oral once a day for 5 days. Clindamycin 300 mg oral twice daily for 7 days. Dequalinium chloride 10 mg vaginal tablet once daily for 6 days. Clinical / microscopy (3 of 4 criteria): 1. Homogeneous gray-white discharge 2. ph of vaginal fluid > 4.5 3. Fishy odour (if not recognizable, use few drops of 10% KOH) 4. Clue cells present on wet mount microscopy (specimen: vaginal swab). Gram stained smear with Gardnerella and/or Mobiluncus morphotypes, clue cells and few or absent Lactobacilli. Clinical: increased discharge, often itchy, with absence of odour. Management of syndromes - 29 -
Itraconazole 200 mg twice daily for one day. Intravaginal treatments include: Clotrimazole vaginal tablet 500 mg once or 200 mg once daily for 3 days. Miconazole vaginal ovule 1200 mg as a single dose or 400 mg once daily for 3 days. Econazole vaginal pessary 150 mg as a single dose. Tests: microscopy or culture evidence of yeasts (Sabouraud agar). Trichomonas vaginalis Metronidazole 400-500 mg oral twice daily for 5 to 7 days. Metronidazole 2 g oral as a single. dose Tinidazole 2 g oral as a single dose. Microscopy or culture or NAAT. Management of syndromes - 30 -
General advice for all vulval conditions Avoid contact with soap, shampoo and bubble bath. Simple emollients can be used as a soap substitute and general moisturizer Avoid tight fitting garments which may irritate the area Avoid use of spermicidally lubricated condoms Patients should be given a detailed explanation of their condition, with particular emphasis on any long-term health implications, which should be reinforced by giving them clear and accurate written information about the condition Consent should be sought for the patient s GP to be informed about the diagnosis and management (See Guideline for detailed management of each condition). Vulvar dermatitis VULVAL CONDITIONS A topical steroid (e.g. 1% hydrocortisone ointment) for mild cases and mometasone furoate betamethasone valerate 0.025% for more severe disease; daily for 7-10 days. Vulvar psoriasis Topical corticosteroids prescribed in sequential or rotational therapeutic regimens: mid potency topical steroids followed by low potency topical steroids Calcineurin inhibitors. Biopsy rarely needed. Patch testing useful if allergic contact dermatitis. Culture. Consider biopsy. Management of syndromes - 31 -
Topical vitamin D analogues in monotherapy or in combination with topical corticosteroids. Coal-tar preparations (e.g. 1-5% liquor carbonis detergens in aqueous cream) in mono-therapy or in combination with topical corticosteroids. Lichen simplex chronicus Improvement of skin barrier function (saline soaks, followed and later replaced by lubricants) Identifying underlying disease, if any. In severe disease, superpotent topical corticosteroid, e.g. clobetasol propionate 0.05% ointment, once or twice daily. In case of nighttime scratching: mildly sedative antihistamine (e.g. hydroxyzine), or tricyclic (e.g. amitriptyline). Topical calcineurin inhibitors twice daily for up to 12 weeks (pimecrolimus 1% cream, tacrolimus 0.1% ointment). Narrow band ultraviolet B, delivered by comb-like instrument. Biopsy rarely needed. Patch testing useful if allergic contact dermatitis. Culture. Serum ferritin. Management of syndromes - 32 -
Lichen sclerosus Potent or ultra-potent topical steroids (e.g. mometasone furoate or clobetasol proprionate). Lichen planus Ultrapotent topical steroids (e.g. clobetasol proprionate). Vulvodynia Local anaesthetics (e.g. 5% lidocaine ointment or 2% lidocaine gel). Oral pain modifiers (e.g. amitriptyline). Psychosexual interventions. Topical calcineurin inhibitors. Systemic retinoids. Phototherapy. Surgery. An ultra-potent topical steroid with antibacterial and antifungal (e.g. clobetasol with neomycin and nystatin) or an alternative preparation. Topical calcineurin inhibitors. Consider investigation for autoimmune disease. Consider biopsy. Patch testing useful if allergic contact dermatitis. Culture. Consider investigation for autoimmune disease. Management of syndromes - 33 -
Vulvar intraepithelial neoplasia Surgical cold knife excision. Laser CO2 therapy. Loop electrosurgical procedure. Imiquimod cream. Follow up without treatment (spontaneous regression). Biopsy Management of syndromes - 34 -
Screening: serology test, POCT Fourth generation screening assays that simultaneously test for anti-hiv antibodies and p24 antigen are recommended. Assays available in Europe have excellent sensitivities (99.78 100%) and specificities (99.5 99.93%) Rapid, POCT facilitate access to HIV testing and ensure results are returned and are acted upon immediately. It is recommended that health-care providers familiarize themselves with the performance characteristics of the test adopted as these inform PROCEDURES HIV TESTING HIV screening and confirmatory tests Confirmation of reactive serology results Reactive screening test results should be confirmed in a laboratory with experience in HIV confirmation Confirmatory algorithms vary. Generally, they include at least one additional antibody or antibody/ antigen serology test that employs a different platform from the initial screening test. An antibody test is also used to differentiate between HIV types. The final laboratory report must clearly indicate whether the patient has an HIV-1, HIV-2 or dual infection Repeat serology testing of a second sample is recommended to rule out mislabelling and confirm patient Recent HIV infection HIV-1 RNA testing is indicated in patients with suspected primary HIV infection who show negative or indeterminate serology results; if HIV-1 RNA is detected, infection should be confirmed by demonstrating seroconversion in a sample collected 1 2 weeks later. Low HIV-1 RNA (<1000 copies/ml) values should be interpreted with caution and not considered as indicative of infection in the absence of further evidence Procedures - 35 -
Screening: serology test, POCT use and counselling. Healthcare providers should be aware that rapid HIV tests (including combined antibody/antigen tests) offer reduced sensitivity relative to laboratory-based tests and may therefore give false negative results in early HIV infection Confirmation of reactive serology results identity. It may be replaced by testing a plasma sample for HIV- 1 RNA, provided the viral load is >1000 copies/ml. In patients with a lower or undetectable viral load, a second serum sample should be collected for repeat serological testing Recent HIV infection GANIZATION OF A CONSULTATION F SEXUALLY TRANSMITED DISEASES This guideline is intended to serve as a framework for those working in any location where sexually transmitted infections are managed. It offers recommendations which will need to be adapted depending on local facilities and policies, and is not intended to be all encompassing. This guideline should be read in conjunction with other European guidelines on the management of specific infections. Personnel. Case note and specimens. Ethics. History obtained from the patient. Physical examination of the patient. Investigations. Results and treatment. Partner notification/contact tracing. Follow-up. Procedures - 36 -
PARTNER MANAGEMENT Partner management is the process of identifying the contacts of a person infected by a sexually transmitted infection (STI) and referral to a health care provider for appropriate management. It represents a public health activity. Disease (alphabetical order) Chancroid Chlamydia trachomatis infection (including Lymphgranuloma venereum) Period to trace contacts (from onset of symptoms) 10 days 6 months Epidemiological treatment Yes Yes Donovanosis (Granuloma inguinale) Up to 1 year according to estimated time of infection. Epididymo-orchitis 6 months Gonorrhoea 3 months Hepatitis A According to estimated time of infection or 2 weeks before the onset of jaundice. Hepatitis B* According to estimated time of infection or 2 weeks before the onset of jaundice. Hepatitis C* As far back as estimated time of infection if index case and/or contact is HIV positive (men who have sex with men only). *Possible vertical transmission may require screening of children. Yes Yes Yes No. Consider testing and/or vaccination of sexual and household contacts. No. Consider testing and/or vaccination of sexual and household contacts. No Procedures - 37 -
Disease (alphabetical order) HIV Non-gonococcal urethritis Pelvic inflammatory disease Period to trace contacts (from onset of symptoms) 3 months in recent infection or since last negative HIV test or guided by the sexual history if untested. 4 weeks 6 months Epidemiological treatment Postexposure prophylaxis where indicated by national guidelines. Yes Yes Phthirius pubis infestation 3 months Yes Scabies 2 months Yes Syphilis Primary 3 months Yes Secondary Early latent 6 months 2 years Yes Yes Late latent and tertiary Up to 30 years No Trichomonas vaginalis infection 2 months Yes Partner management should be offered at follow-up visits, if there are new sexual contacts who are either HIV negative or of unknown HIV status or if other STIs are detected. Comments to be sent to Dr Martí Vall-Mayans, STI Unit Vall d Hebron-Drassanes, Barcelona: m.vall@vhebron.net Procedures - 38 -
European STI Guidelines Project Editorial Board Keith Radcliffe, UK Editor-in-Chief Martí Vall-Mayans, Spain Andy Winter, UK Deniz Gökengin, Turkey Marco Cusini, Italy Mikhail Gomberg, Russia Jorgen Skov Jensen, Denmark Raj Patel, UK Jonathan Ross, UK Jackie Sherrard, UK Magnus Unemo, Sweden Willem van der Meijden, Netherlands Norbert Brockmeyer, Germany Representatives Gilbert Donders, Belgium ISIDOG Mario Poljak, Slovenia ESCMID Gianfranco Spiteri, Malta ECDC George-Sorin Tiplica, Romania EADV Lali Khotenashvili, Georgia - WHO-Europe Michel Janier, France UEMS Alexander Nast, Germany EDF Oral syphilitic chancre Lymphogranuloma venereum proctitis Gonococcal urethritis Vulval condiloma acuminata Source: STI Unit Vall d Hebron-Drassanes, Barcelona Procedures