Southwark Clinical Commissioning Group
Lambeth Clinical Commissioning Group
Lambeth and Southwark STI management guidelines for primary care
These sexually transmitted infection (STI) guidelines have been updated and
approved for use in local NHS primary care by Southwark Council and Lambeth
Council, and clinically recommended by NHS Lambeth Clinical Commissioning
Group (CCG) and NHS Southwark Clinical Commissioning Group (CCG). These
guidelines will contribute to meeting our strategic vision to build more effective,
responsive and high quality sexual health services.
Sexual health is a public health priority, with a focus on improving prevention, including
shifting less complex testing into self management, pharmacy and primary care services.
This will help tackle the increasing burden of STI and HIV infection, particularly in young
people, men who have sex with men, and Black African communities.
I hope general practice clinicians find the guidelines quick and easy to use, and we
welcome any feedback. I am grateful for the work of CCG Medicines Optimisation Team
colleagues, GP and GUM clinicians, particularly Drs. Michael Brady, Anatole MenonJohansson and Stephanie May in the guidelines’ production.
Ruth Wallis
Director of Public Health, Lambeth and Southwark
June 2015
Page 1 of 41
Southwark Clinical Commissioning Group
Lambeth Clinical Commissioning Group
Lambeth and Southwark STI management guidelines for primary care June 2015
Contents list
•
Quick reference STI treatment guide
•
Syndromic chart: STI management in women presenting in primary care
•
Syndromic management of STIs in men presenting in primary care
•
Hepatitis B serology & vaccination schedule
•
Gonorrhoea STI guidance for primary care in Lambeth and Southwark
•
Blood Borne Viruses (Syphillis, Human Immunodeficiency Virus; Hepatitis A, B and C)
•
STI management guidelines for primary care – male (gonorrhoea, chlamydia, non-specific
urethritis, epididymo-orchitis, balanitis, candida, trichomonas vaginalis and viral STIs)
•
STI management guidelines for primary care – female (gonorrhoea, chlamydia, pelvic
inflammatory disease, vaginal discharge and viral STIs)
Page 2 of 41
Southwark Clinical Commissioning Group
Lambeth Clinical Commissioning Group
Lambeth and Southwark STI management guidelines for primary care
Shared Lambeth and Southwark Council guidelines, with NHS Lambeth Clinical Commissioning
Group (CCG) and NHS Southwark Clinical Commissioning Group (CCG) clinical
recommendation
Quick reference STI treatment guide
Please refer to the most up to date BNF and Summary of Product Characteristics for full drug
monographs
Document control
Current Version: revised June 2013 - December 2014 (previous versions: 2005; 2008)
Lead author: Lambeth and Southwark Public Health
Review date: December 2016
Approved by:
Southwark Council Southwark Health & Social Care Partnership 1.12.14
Lambeth Council: Lambeth Staying Healthy Board 6.1.15
Clinical content recommendation: Lambeth & Southwark CCGs Joint Prescribing Committee
19.8.14: Chair’s approval of final clinical amendment 2.12.14.
Sexual health commissioning acknowledgment: Lambeth Southwark and Lewisham Sexual
health Commissioning Board 25.3.15
Written by:
Specialist leads for guideline group, and for related clinical queries: Dr Michael Brady, GUM
Consultant, Kings Camberwell Sexual Health Centre. Contact: [email protected]
Dr Anatole Menon-Johansson, Clinical Lead, Sexual & reproductive health department, Guy's &
St Thomas' Contact: [email protected]
Dr Stephanie May, Lambeth GP Sexual Health Champion, Stockwell Group Practice. Contact:
[email protected]
Sarah French, Public Health Manager: Sexual Health & Immunisation, Lambeth & Southwark
Public Health. Guideline development facilitator (non-clinical queries):
Contact: [email protected]
Quick Reference STI Treatment Guide
Approved: Southwark Health and Social Care Partnership (01.12.2014) and Lambeth Staying
Healthy Board (06.01.2015); Review date: Dec 2016
Page 3 of 41
1
Infection
1st line agent
Bacterial
vaginosis
Metronidazole
400mg bd oral 5/7
Balanitis
Clotrimazole 1%
cream bd 7/7
Candida
Female
Clotrimazole
500mg PV nocte
x1 day and
Clotrimazole 1%
cream bd 7/7
Candida
Male
Clotrimazole 1%
cream bd 7/7
Chlamydia
Azithromycin 1g
oral stat
2nd line or 1st
line alternative
agent
Metronidazole 2g
stat oral
Miconazole 2%
cream for 7/7.
Consider
Clotrimazole HC
1% cream if itch a
predominant
feature Apply bd
for 1-2 weeks
Clotrimazole
200mg PV nocte
x 3 days and
Clotrimazole 1%
cream bd 7/7
Miconazole 2%
cream for 7/7
Or consider
Clotrimazole HC
1% cream if itch a
predominant
feature. Apply bd
for 1-2 weeks
Doxycycline
100mg bd 7/7
(preferred for
pharyngeal or
rectal infections)
(not during
pregnancy)
Other
alternatives
Pregnancy
Follow up
Metronidazole
gel 0.75% PV
nocte 5 days
or Clindamycin
2% vaginal
cream PV
nocte 7 days
Refer to GUM
and if atypical
presentation
+/ - syphilis
suspected or if
persistent
Metronidazole
400mg bd oral
5/7 (avoid
high/ single
doses in
pregnancy)
Nil needed
unless
symptoms
persist
Oral
Fluconazole
150mg oral
stat (not in
breastfeeding)
and
Clotrimazole
1% cream bd
7/7
Fluconazole
150mg po stat
Clotrimazole
500mg
pessary PV
stat and
Clotrimazole
1% cream bd
7/7
Erythromycin
500mg bd 14/7
(female
patients)
Erythromycin
500mg bd 14/7
OR Amoxicillin
500mg po tds
7/7 OR
Azithromycin
1g oral stat
(unlicensed)
Nil needed
Nil needed
unless
symptoms
persist
Nil
Test of Cure
recommended
in pregnancy
only
Quick Reference STI Treatment Guide
Approved: Southwark Health and Social Care Partnership (01.12.2014) and Lambeth Staying
Healthy Board (06.01.2015); Review date: Dec 2016
Page 4 of 41
2
Infection
1st line agent
Epididymoorchitis
If suspect an STI
and not urinary
source of infection:
Cefixime 400mg
stat
PLUS Doxycycline
100mg bd for 14/7
Genital
Herpes
First episode:
Aciclovir 200mg 5
times daily 7-14/7
(double dose in
immunocompromised)
Genital Warts
Podophyllotoxin
cream (0.15%) –
easiest to apply in
both men and
women, but a
solution (0.5%) is
available. Treat
limited discrete
warts on vulval or
penile regions as
self-treatment, if
the client can
manage this. Apply
bd applications
topically for 3
consecutive days
followed by 4 days
rest – 4 week
cycles.
2nd line or 1st
line alternative
agent
OR first line
alternative
Ceftriaxone
500mg i.m. stat
(reconstituted
with 1%
Lidocaine
solution) and
Doxycycline
100mg bd for 14
days
Episodic:
Aciclovir 400mg 3
times daily 3-5/7
(start <24hrs
symptoms)
Other
alternatives
Pregnancy
Suppression:
Aciclovir
400mg bd
twice daily
Review after 6
months
Aciclovir–
consult GUM
Cryotherapy
weekly or
Imiquimod 5%
cream topically
3/7 weekly
(alternate days) 4 week cycles (16
week maximum)
Refer to GUM
Cryotherapy or
nil.
UTI first line:
treat as per
NHS Lambeth
& Southwark
Antibiotic
guidelines.
Third line
(STI): refer to
Urology
Follow up
Repeat MSU
(if previously
+ve)
Review after 6
months of
suppressive
therapy.
Continue if
HSV recurs
frequently
Review
progress after
4/52 selfapplied
treatment
For perianal warts,
Imiquimod 5%
cream topically.
Apply 3 times
weekly, overnight,
wash off 6-10
hours later, for up
to 16 weeks.
Quick Reference STI Treatment Guide
Approved: Southwark Health and Social Care Partnership (01.12.2014) and Lambeth Staying
Healthy Board (06.01.2015); Review date: Dec 2016
Page 5 of 41
3
Infection
1st line agent
Gonorrhoea
Molluscum
contagiosum
NSU
2nd line or 1st
line alternative
agent
Cefixime 400mg
OR first line
oral stat. PLUS
alternative
Azithromycin 1g
Ceftriaxone
oral stat
500mg i.m.
(unlicensed for GC) injection stat
(reconstituted
with 1%
Lidocaine
solution) PLUS
Azithromycin 1g
oral stat
(unlicensed for
GC)
Podophyllotoxin
Imiquimod 5%
cream (0.5%) is
cream applied
easier to apply
topically 3x per
than solution
week overnight 6(0.5%). Apply
10hrs,
topically for limited (unlicensed) for
discrete lesions on max. 16 weeks
penile, vulval or
perianal
(unlicensed) region
as self-treatment, if
client can manage
this. Prescribe bd
applications for 3
consecutive days
followed by 4 days
rest – 4 week
cycles
Azithromycin 1g
Non responsive
oral stat OR
NSU: treat with
Doxycycline 100mg the alternative
bd 7/7 in MSM
first line treatment
OR Erythromycin
500mg bd 14/7
OR Ofloxacin
200mg bd for 7/7
or 400mg od for
7/7
PLUS cover for
trichomonas
vaginalis (TV)
with
Metronidazole
400mg bd for 5/7
Other
alternatives
Pregnancy
Follow up
Refer to GUM:
any treatment
failures, reinfections,
MSM GC
NAAT positive
from any site
Ceftriaxone
500mg i.m.
injection stat
(reconstituted
with 1%
Lidocaine
solution) PLUS
Azithromycin
1g oral stat
(unlicensed in
GC and
pregnancy)
Repeat NAAT
and culture at
infected site 2
weeks after
treatment
Refer to GUM
Cryotherapy
weekly or nil
For persistent/
recurrent NSU:
please refer for
microscopic
analysis of a
urethral smear
at the sexual
health service
First line UTI:
Trimethoprim
200mg bd 7/7
Nil needed
unless
symptoms
persist >1/12
Quick Reference STI Treatment Guide
Approved: Southwark Health and Social Care Partnership (01.12.2014) and Lambeth Staying
Healthy Board (06.01.2015); Review date: Dec 2016
Page 6 of 41
4
Infection
PID
TV
1st line agent
2nd line or 1st
line alternative
agent
Ceftriaxone 500mg Ofloxacin 400mg
i.m. stat
bd for 14/7 plus
(reconstituted with
Metronidazole
1% Lidocaine
400mg bd for
solution) and
14/7.
Doxycycline 100mg Metronidazole
bd and
may be poorly
Metronidazole
tolerated - can be
400mg bd both for
stopped in mild to
14/7.
moderate disease
Metronidazole may if need be.
be poorly tolerated
- can be stopped in
mild to moderate
disease if need be.
Metronidazole 2g
Metronidazole
oral stat
oral 400mg bd
5/7
Other
alternatives
Pregnancy
Follow up
Ceftriaxone
500mg im stat
(reconstituted
with 1%
Lidocaine
solution) plus
Azithromycin
1g a week for
2 weeks
Refer to
Gynaecology
(PID in
pregnancy
increases
maternal &
foetal
morbidity)
Clinical review
At 5/7 if severe
symptoms or
IUD in situ –
otherwise
review after
14/7
Tinidazole 2g
oral stat
If diagnosed,
Metronidazole
400mg bd 5/7
- avoid high or
single doses
during
pregnancy and
breastfeeding
For detailed guidelines and all references, please see individual Lambeth & Southwark STI
Management primary care guidelines April 2015
Quick Reference STI Treatment Guide
Approved: Southwark Health and Social Care Partnership (01.12.2014) and Lambeth Staying
Healthy Board (06.01.2015); Review date: Dec 2016
Page 7 of 41
5
Syndromic chart: STI management in women presenting in primary care
Sexual health risk assessment
Self taken NAAT (CT & GC) test
vaginal swab is first line
Consider UTI, STI, HSV (examine for ulceration)
Dysuria
If under 25, CT testing
Asymptomatic
White, thick
discharge, vulval itch
- consider treatment
for candida
(pH <4.5)
Known contact or
high suspicion of STI,
test and/ or treat for
CT & GC
FEMALE
PATIENT
Painful & lymphadenopathy
+/ - systemic symptoms,
consider HSV
Ulceration/
blisters
Vaginal discharge
Pelvic pain /
deep dyspareunia
Clear/ white, odourless,
no irritation, pH <4.5 likely physiological
discharge
White/ grey/ yellow, fishy smelling, thin,
possibly itchy, often recurrent – test and
treat for BV or TV (pH > 5)
Painless/ atypical
- consider trauma or
excoriation
- consider syphilis
- consider tropical
ulceration if acquired
outside Europe
If pregnancy test negative,
cervical motion tenderness &
adnexal tenderness – consider
PID - acute/ chronic
If pregnancy test +ve or ectopic not excluded,
or systemically very unwell, refer to
gynaecology/ ultrasound scan
For all patients, offer testing for HIV & Syphilis.
Screen those at risk for hepatitis A, B or C virus. Offer Hepatitis A and/or B vaccination to those at continued risk
Approved: Southwark Health and Social Care Partnership (01.12.2014) and Lambeth Staying Healthy Board (06.01.2015); Review date: Dec 2016
Page 8 of 41
Southwark Clinical Commissioning Group
Lambeth Clinical Commissioning Group
Lambeth and Southwark STI management guidelines for primary care
Shared Lambeth and Southwark Council guidelines, with NHS Lambeth Clinical Commissioning Group
(CCG) and NHS Southwark Clinical Commissioning Group (CCG) clinical recommendation
Syndromic chart: STI management in women presenting in primary care
Document control
Current Version: revised June 2013 - December 2014 (previous versions: 2005; 2008)
Lead author: Lambeth and Southwark Public Health
Review date: December 2016
Approved by:
Southwark Council Southwark Health & Social Care Partnership 1.12.14
Lambeth Council: Lambeth Staying Healthy Board 6.1.15
Clinical content recommendation: Lambeth & Southwark CCGs Joint Prescribing Committee
19.8.14: Chair’s approval of final clinical amendment 2.12.14.
Sexual health commissioning acknowledgment: Lambeth Southwark and Lewisham Sexual health
Commissioning Board 25.3.15
Written by:
Specialist leads for guideline group, and for related clinical queries: Dr Michael Brady, GUM
Consultant, Kings Camberwell Sexual Health Centre. Contact: [email protected]
Dr Anatole Menon-Johansson, Clinical Lead, Sexual & reproductive health department, Guy's & St
Thomas' Contact: [email protected]
Dr Stephanie May, Lambeth GP Sexual Health Champion, Stockwell Group Practice. Contact:
[email protected]
Sarah French, Public Health Manager: Sexual Health & Immunisation, Lambeth & Southwark
Public Health. Guideline development facilitator (non-clinical queries):
Contact: [email protected]
Approved: Southwark Health and Social Care Partnership (01.12.2014) and Lambeth Staying Healthy Board
(06.01.2015); Review date: Dec 2016
Page 9 of 41
Syndromic management of STIs in men presenting in primary care
Sexual health risk assessment
Urine sample dual NAAT test (CT&
GC) is first line
If under 25, CT testing
< 40 years, could be STI.
Screen for GC/ CT. MSU,
urine for schistosomiasis if
relevant travel history.
>40 years, MSU, PSA
and/ or digital rectal exam.
Haematospermia
<40, likely STI
epididimo-orchitis.
>40, consider UTI,
gram –ve organisms /
coliforms
Sudden onset,
severe, consider
torsion, more
common in <20
years
Testicular
pain
Asymptomatic
Dysuria +/ urethral
irritation
‘urethritis’
Test for CT & GC,
consider treatment
for NSU
>40 years, take
MSU & consider
treatment for UTI
MALE
PATIENT
Rectal
discharge
(+/- pain)
Urethral
(+/ - rectal)
discharge
Refer to GUM and/ or test and treat for CT
& GC (include GC cultures)
Itchy/ irritation
+/ - rash on
glans
Ulceration/
blisters
Consider balanitis,
candida or other
skin conditions
Painless/ atypical
- consider syphilis
- consider tropical
ulceration if
acquired outside
Europe
Painful & lymphadenopathy
+/ - systemic symptoms, consider HSV
For all patients, offer testing for HIV & Syphilis.
Screen those at risk for hepatitis A, B or C virus. Offer Hepatitis A and/ or B vaccination to those at continued risk
Approved: Southwark Health and Social Care Partnership (01.12.2014) and Lambeth Staying Healthy Board (06.01.2015); Review date: Dec 2016
Page 10 of 41
Southwark Clinical Commissioning Group
Lambeth Clinical Commissioning Group
Lambeth and Southwark STI management guidelines for primary care
Shared Lambeth and Southwark Council guidelines, with NHS Lambeth Clinical Commissioning
Group (CCG) and NHS Southwark Clinical Commissioning Group (CCG) clinical
recommendation
Syndromic chart: STI management in men presenting in primary care
Document control
Current Version: revised June 2013 - December 2014 (previous versions: 2005; 2008)
Lead author: Lambeth and Southwark Public Health
Review date: December 2016
Approved by:
Southwark Council Southwark Health & Social Care Partnership 1.12.14
Lambeth Council: Lambeth Staying Healthy Board 6.1.15
Clinical content recommendation: Lambeth & Southwark CCGs Joint Prescribing Committee
19.8.14: Chair’s approval of final clinical amendment 2.12.14.
Sexual health commissioning acknowledgment: Lambeth Southwark and Lewisham Sexual
health Commissioning Board 25.3.15
Written by:
Specialist leads for guideline group, and for related clinical queries: Dr Michael Brady, GUM
Consultant, Kings Camberwell Sexual Health Centre. Contact: [email protected]
Dr Anatole Menon-Johansson, Clinical Lead, Sexual & reproductive health department, Guy's &
St Thomas' Contact: [email protected]
Dr Stephanie May, Lambeth GP Sexual Health Champion, Stockwell Group Practice. Contact:
[email protected]
Sarah French, Public Health Manager: Sexual Health & Immunisation, Lambeth & Southwark
Public Health. Guideline development facilitator (non-clinical queries):
Contact: [email protected]
Approved: Southwark Health and Social Care Partnership (01.12.2014) and Lambeth Staying Healthy
Board (06.01.2015); Review date: Dec 2016
Page 11 of 41
Southwark Clinical Commissioning Group
Lambeth Clinical Commissioning Group
Lambeth & Southwark STI management guidelines for primary care
Shared Lambeth and Southwark Council guidelines, with NHS Lambeth Clinical Commissioning
Group (CCG) and NHS Southwark Clinical Commissioning Group (CCG) clinical recommendation
Hepatitis B serology & vaccination schedule
Hepatitis B virus serology table
Stage of
infection
Hepatitis
B surface
antigen
(HBsAg)
Hepatitis
B ‘e’
antigen
(HBeAg)
HB core
IgM
HB core
total
antibody
HB ‘e’
antibody
Hepatitis
B surface
antibody
Hepatitis
B virus
DNA
Acute
(early)
+
+
+
+
-
-
+
Acute
(resolving)
+
-
+
+
+/ -
-
-
+
+/ -
-
+
-
-
+
+
-
-
+
+/ -
-
+/ -
-
-
-
+
+/ -
+/ -
-
-
-
-
-
-
+
-
Chronic
(high
infectivity)
Chronic
infection
(the term
low
infectivity is
no longer
used)
Resolved
Successful
vaccination
Hepatitis B serology and vaccination schedule
Approved: Southwark Health and Social Care Partnership (01.12.2014) and Lambeth Staying Healthy
Board (06.01.2015); Review date: Dec 2016
1
Page 12 of 41
HBc total antibody in serum for Hepatitis B virus screening
Negative
Positive
No previous exposure to HBV.
Consider vaccination
(or anti-HBs test if previously vaccinated)
Test for HBsAg
Positive
Acute or chronic HBV carrier: test
for
- IgM anti-HBc
- HBeAg
- HBeAb
….if not already done by
laboratory
Negative
Past exposure to HBV.
No need for HBV
vaccination.
At risk of HBV reactivation if
immunosuppressed.
Repeat HBsAg 6 months after first test. If
positive, refer to liver unit
Vaccination schedule
Super Accelerated: 0, 7, and 21 days; booster at 12 months*
Accelerated:
0, 1, 2, and booster at 12 months
Standard:
0, 1, and 6 months
*The Super Accelerated course offers the advantage of a higher uptake of the full course
and more rapid development of early immunity1. This course may be unlicensed for certain
vaccinations, and prescribers should check the Summary of Product Characteristics or
most recent British National Formulary and Green Book2 for further information.
The full duration of protection afforded by hepatitis B vaccine has yet to be established
Levels of vaccine-induced antibody to hepatitis B virus decline over time, but there is
evidence that immune memory can persist in those successfully immunised
• Individuals at continuing risk of infection should be offered a single booster dose of
vaccine, once only, around five years after primary immunisation.
• Measurement of anti-HBs levels is not required either before or after this dose.
•
•
•
•
•
Non-responders: repeat vaccination course
Incompletion < 4 years - complete course (no need to restart 3 dose course)
Super accelerated course - most commonly used in GUM, and for travellers, supporting
improved completion rates, although has lower response rate.
Hepatitis B serology and vaccination schedule
Approved: Southwark Health and Social Care Partnership (01.12.2014) and Lambeth Staying Healthy
Board (06.01.2015); Review date: Dec 2016
2
Page 13 of 41
Where practical, a test for hepatitis B surface antibodies should be done ideally 4-12 weeks
after completing the course, to assess response to vaccination:
Anti-HBs >100 iu/l
Good response and immune
Anti-HBs 10 – 100 iu/l
Partial response. Only 80% of those vaccinated with the superaccelerated course will have detectable antibodies. If high risk and no antibody response,
consider a booster or repeat course. Alternatively, for those of lower risk, offer a booster at
12 months after which 95% would be positive1.
Anti-HBs <10 iu/l
Non-responder. Offer a repeat course. 10-15% of the healthy
population do not mount an effective antibody response after vaccination2. Some of these
may still be protected against clinically significant infection. Repeat Anti-HBs levels 12
weeks after booster.
Abbreviations/ Glossary
Anti-HBc
Hepatitis B core antibody
Anti-HBe
Hepatitis B 'e' antibody
Anti-HBs
Hepatitis B surface antibody
HBeAg
Hepatitis B 'e' antigen
HBsAg
Hepatitis B surface antigen
IgM
Immunoglobulin sub-class
IgG
Immunoglobulin sub-class
References
1. UK National Guideline on the Management of the Viral Hepatitides A, B & C 2008
http://www.bashh.org/guidelines
2. Department of Health ‘Green Book’ on immunisation
http://immunisation.dh.gov.uk/category/the-green-book
Hepatitis B serology and vaccination schedule
Approved: Southwark Health and Social Care Partnership (01.12.2014) and Lambeth Staying Healthy
Board (06.01.2015); Review date: Dec 2016
3
Page 14 of 41
Document control
Current Version: revised June 2013 - December 2014 (previous versions: 2005; 2008)
Lead author: Lambeth and Southwark Public Health
Review date: December 2016
Approved by:
Southwark Council Southwark Health & Social Care Partnership 1.12.14
Lambeth Council: Lambeth Staying Healthy Board 6.1.15
Clinical content recommendation: Lambeth & Southwark CCGs Joint Prescribing
Committee 19.8.14: Chair’s approval of final clinical amendment 2.12.14.
Sexual health commissioning acknowledgment: Lambeth Southwark and Lewisham Sexual
health Commissioning Board 25.3.15
Written by:
Specialist leads for guideline group, and for related clinical queries: Dr Michael Brady, GUM
Consultant, Kings Camberwell Sexual Health Centre. Contact: [email protected]
Dr Anatole Menon-Johansson, Clinical Lead, Sexual & reproductive health department,
Guy's & St Thomas' Contact: [email protected]
Dr Stephanie May, Lambeth GP Sexual Health Champion, Stockwell Group Practice.
Contact: [email protected]
Sarah French, Public Health Manager: Sexual Health & Immunisation, Lambeth &
Southwark Public Health. Guideline development facilitator (non-clinical queries):
Contact: [email protected]
Hepatitis B serology and vaccination schedule
Approved: Southwark Health and Social Care Partnership (01.12.2014) and Lambeth Staying Healthy
Board (06.01.2015); Review date: Dec 2016
4
Page 15 of 41
Southwark Clinical Commissioning Group
Lambeth Clinical Commissioning Group
Lambeth and Southwark STI management guidelines for primary care
Shared Lambeth and Southwark Council guidelines, with NHS Lambeth Clinical
Commissioning Group (CCG) and NHS Southwark Clinical Commissioning Group (CCG)
clinical recommendation
Gonorrhoea STI guidance for primary care in Lambeth and Southwark
Gonorrhoea treatment briefing
• In 2011 the British Association of Sexual Health & HIV (BASHH) updated their guidelines
for gonorrhoea (GC) treatment, recommending a change in first line therapy from oral
cefixime to intra muscular (i.m.) ceftriaxone 1
• This was largely due to decreasing susceptibility of gonorrhoea to cefixime in cultures
from swabs taken from patients presenting to Level 3 specialist services across the
country.
• Lambeth and Southwark are ranked 1st and 3rd highest in terms of acute diagnosed rates
of STI infection in England3
• Lambeth and Southwark general practices have a good level of sexual health service
provision at Level 1, and some provision at level 2 2. Whilst seeking specialist guidance,
local practices are expected to continue to provide comprehensive primary care STI
management within the scope of individual clinical competency. As a result of
consultation with local sexual health specialists and GPs, and based on previous
agreement4,a pragmatic approach has been agreed. This supports the recommendation
of cefixime as an alternative 1st line therapy to ceftriaxone for gonorrhoea treatment, in
those services who cannot easily access ceftriaxone or where intramuscular injections
are impractical. This was based on:
•
•
The wish to maintain and develop STI management in general practice
Reducing unnecessary onward referral to specialist services, delays in treatment and
resulting non-attendance (DNAs)
Understanding that local resistance levels to cefixime currently remain low
Potential difficulty in reliably providing treatment with ceftriaxone because of the small
volumes of patients with gonorrhoea seen
It was agreed to monitor GC Cefixime resistance data 6 monthly, as well as clarify the
GC management pathway.
Practices could choose to hold very small stocks of i.m. ceftriaxone to administer through
Patient Specific Directive if appropriate.
1
UK National Guideline on Gonorrhoea testing (BASHH Clinical Effectiveness Group Guidelines
2012)
2
As defined within the national Sexual Health Strategy, all practices in Lambeth are expected to
operate at Level 1, which includes HIV testing, asymptomatic male/ female testing, management of
symptomatic female STIs, discharge etc. This falls within the scope of their GMS contracts. Level 2
offers enhanced STI management to include invasive male testing, testing and diagnosis on basis of
symptoms, test of cure, warts treatment etc.
Gonorrhoea STI Guidance for Primary Care in Lambeth and Southwark
1
Approved: Southwark Health and Social Care Partnership (01.12.2014) and Lambeth Staying Healthy
Board (06.01.2015); review date: Dec 2016
Page 16 of 41
The importance of the following in treating gonorrhoea is stressed:
•
•
•
•
The absolute need for GC cultures (MC & S) prior to commencing treatment, and test
of cure
Test of cures should be performed at two weeks with a culture and NAAT from the
infected site. Partner notification and treatment and sexual abstinence should be checked
at the test of cure visit.
The importance of anal and pharyngeal site swabs and/ or referral of men who have sex
with men (MSM) to Level 3 GUM services
Vigilance for any potential treatment failures
3
Public Health England LASER reports 2011 and 2012
Updated gonorrhoea STI guidance for Primary Care in Lambeth (ratified by Lambeth PCT Medicines
Management Committee June 2012) Authors: Dr Michael Brady (Kings Camberwell Sexual Health
Centre, GUM Consultant); Dr Anatole Menon-Johansson (GSTT GUM Consultant) Dr Stephanie May,
Lambeth GP Sexual Health Champion, and Stockwell Group Practice; Sarah French, Lambeth &
Southwark Public Health - Manager (Sexual health & Immunisation); contribution from range of local
specialists and GP colleagues
4
_________________________________________________________________________
Document control
Current Version: revised June 2013 - December 2014 (previous versions: 2005; 2008)
Lead author: Lambeth and Southwark Public Health
Review date: December 2016
Approved by:
Southwark Council Southwark Health & Social Care Partnership 1.12.14
Lambeth Council: Lambeth Staying Healthy Board 6.1.15
Clinical content recommendation: Lambeth & Southwark CCGs Joint Prescribing Committee
19.8.14: Chair’s approval of final clinical amendment 2.12.14.
Sexual health commissioning acknowledgment: Lambeth Southwark and Lewisham Sexual
health Commissioning Board 25.3.15
Written by:
Specialist leads for guideline group, and for related clinical queries: Dr Michael Brady, GUM
Consultant, Kings Camberwell Sexual Health Centre. Contact: [email protected]
Dr Anatole Menon-Johansson, Clinical Lead, Sexual & reproductive health department,
Guy's & St Thomas' Contact: [email protected]
Dr Stephanie May, Lambeth GP Sexual Health Champion, Stockwell Group Practice.
Contact: [email protected]
Sarah French, Public Health Manager: Sexual Health & Immunisation, Lambeth & Southwark
Public Health. Guideline development facilitator (non-clinical queries):
Contact: [email protected]
Gonorrhoea STI Guidance for Primary Care in Lambeth and Southwark
2
Approved: Southwark Health and Social Care Partnership (01.12.2014) and Lambeth Staying Healthy
Board (06.01.2015); review date: Dec 2016
Page 17 of 41
Gonorrhoea treatment algorithm
Asymptomatic
Test - NAAT Chlamydia/ Gonorrhoea
Women – test of choice (first line): self-taken
swab vulvo-vaginal swab (most specific &
sensitive test)
If passing speculum for other reason:
endocervical swab (less specific & sensitive)
Men – first pass urine
Symptomatic
Test
Women – test of choice (first line): self taken vulvo-vaginal
swab (NAAT CT/ GC) AND endocervical charcoal swab for
GC culture
Men – urethral GC culture before urine NAAT for CT/GC
Always take NAAT AND culture if symptomatic or GC
contact, pelvic inflammatory disease, sexual assault
(including rectal, pharangeal throat swabs if appropriate).
Rectal and throat swabs for Men who have sex with men –
NAAT only if asymptomatic, NAAT and culture from sites
that are symptomatic
Positive GC result
Test must always be confirmed by GC culture (if not already
done). False positives from NAAT test may occur, especially in
low risk patients. If MC&S not done previously, do so at follow up
to positive NAAT result (before treatment). Do not delay treatment
waiting for the culture result
ALWAYS check antibiotic sensitivity from culture result
Treatment
Timing: at first diagnosis, or if GC contact
First line
Cefixime 400mg oral stat
PLUS Azithromycin 1g oral stat (unlicensed in GC and pregnancy)
OR
Ceftriaxone 500mg i.m.(reconstituted with 1% Lidocaine solution)
injection stat (can be used in pregnancy),
PLUS Azithromycin 1g oral stat (unlicensed in GC and pregnancy)
Second line
Refer to Level 3 services: any treatment failures, re-infections, men
who have sex with men who are GC NAAT positive from any site
Test of cure
All patients to ensure adherence to
medication, treatment of partners, appropriate
abstinence from sex and clearance of infection
At 2 weeks after treatment with a NAAT and a
culture from the infected site
Vigilance for any treatment failures
Partner notification
Partners within last 3 months or 2
weeks if symptomatic
Patient information
• Incubation 1-2 weeks (can be longer)
• Advise sexual abstinence 1 week or 1 week after
partner treated
• Factsheet
Gonorrhoea STI Guidance for Primary Care in Lambeth and Southwark
3
Approved: Southwark Health and Social Care Partnership (01.12.2014) and Lambeth Staying Healthy
Board (06.01.2015); review date: Dec 2016
Page 18 of 41
Southwark Clinical Commissioning Group
Lambeth Clinical Commissioning Group
Lambeth and Southwark STI management guidelines for primary care
Shared Lambeth and Southwark Council guidelines, with NHS Lambeth Clinical Commissioning Group (CCG) and NHS Southwark Clinical Commissioning
Group (CCG) clinical recommendation
STI management guidelines for primary care: Blood Borne Viruses (Syphillis, Human Immunodeficiency Virus; Hepatitis A, B and C)
Document control
Current Version: revised June 2013 - December 2014 (previous versions: 2005; 2008)
Lead author: Lambeth and Southwark Public Health
Review date: December 2016
Approval:
Southwark Council Southwark Health & Social Care Partnership 1.12.14
Lambeth Council: Lambeth Staying Healthy Board 6.1.15
Clinical content recommendation: Lambeth & Southwark CCGs Joint Prescribing Committee 19.8.14: Chair’s approval of final clinical amendment 2.12.14.
Sexual health commissioning acknowledgment: Lambeth Southwark and Lewisham Sexual Health Commissioning Board 25.3.15
Written by:
Specialist leads for guideline group, and for related clinicial queries:
Dr Michael Brady, GUM Consultant, Camberwell Sexual Health Centre, Kings College Hospital Foundation Trust
Contact: [email protected]
Dr Anatole Menon-Johansson, Clinical Lead, Sexual & Reproductive Health department, Guy's & St Thomas' Foundation Trust
Contact: [email protected]
Dr Stephanie May, Lambeth GP Sexual Health Champion, Stockwell Group Practice
Contact: [email protected]
Sarah French, Public Health Manager Lambeth & Southwark Public Health
Guideline development facilitator (and for related non-clinical queries):
Contact: [email protected]
Page 19 of 41
STI Management Guidelines primary care: blood borne viruses - Syphilis HIV
Lambeth Southwark April15
Syphilis
Human immuno-deficiency virus - HIV
BACKGROUND INFORMATION
Sexually transmitted
Main mode of transmission
Causative organism
Consider screening
Yes
Yes
Penetrative sex - vaginal, anal & oral sex
Vertical transmission rare
Penetrative sex (anal greater than vaginal, both much greater than
oral transmission).
Vertical transmission 15-40% if no interventions, blood products
before 1986 or from overseas (HIV-1; HIV-2 rare, mostly West
Africa). Veritcal transmission less than 1% if intervention
appropriately managed.
Treponema pallidum
Human immuno-deficiency viruses: HIV-1, HIV-2
Consider in all sexually active. Gay men at
highest risk, sex workers, those in sexual contact
with sex workers, sexual activity overseas outside
of Western Europe.
Recommend in all sexually active. Local HIV prevalence highest in
UK. National BHIVA Guidelines recommends testing all new
registrants at GP. Proactively offer test to highest risk groups 1)
sub Saharan Africans 2) men who have sex with men 3)
intravenous drug users
SYMPTOMS
In most cases, asymptomatic
Seroconversion
Primary syphilis, or early
symptomatic HIV
Secondary syphilis, or long
standing HIV
HIV seroconversion illness typically 2-4 weeks after exposure in at
least 50% of cases. Always offer HIV test in high risk groups with
glandular fever-type symptoms +/ - rash. If suspected, refer to
GUM in addition
Ulcer at site of infection (usually genital, oral or
rectal). Often unnoticed. Resolve spontaneously. Symptoms more likely if CD4 count < 350
6-8 weeks after primary chancre, systemic
illness, rash typically palms and soles of feet, flu
like symptoms, lymphadenopathy,'snail track'
ulcers (usually oral), condylomata lata (commonly
peri-anal)
Asymptomatic period
Early latent (<2 years after
infection)/ late syphilis (> 2 years
after infection)
Neurological involvement, cardiovascular or
Tertiary syphilis - after 10-20
gummatous disease
years untreated, or Acquired
Immunodeficiency Disease
Syndrome (AIDS)
Recurrent herpes simplex virus, recurrent chest infections. Oral
thrush, shingles, seborrhoeic dematitis, molluscums or warts,
generalised lymphadenopathy. Consider HIV test in patient with
low platelets, anaemia, any TB, increased total protein and
globulin, decreased white blood cell count, particularly
lymphopenia
AIDS. Time to AIDS from initial infection ranges from weeks to 20
years+ (mean time around 10 years). Usually CD4 count < 200.
Examples of AIDS defining illnesses: pneumocystis pneumonia
(PCP), active tuberculosis (TB), Kaposi's sarcoma, weight loss and
chronic diarrhoea
TESTS REQUIRED
Standard serological test
Screening test for syphilis (STS)
Combined HIV antibody & P24 antigen test is standard in local
laboratories
N/A
Rapid (Point of Care Test - POCT) testing is available which
usually detects antibody only. As such it may miss early infection.
Test for other STIs
1) Swab ulcer for herpes simplex viruses
2) HIV test, then refer to GUM
Yes. Risk of HIV infection increases dramatically if other STIs
present or source is seroconverting/ has high viral load
Other
If ulcer suspicious of primary syphilis, GUM will
perform dark ground microscopy for syphilis +/ PCR
Rapid HIV test
TESTS RESULTS
Positive
Positive STS. If no history of previous treatment Antigen (e.g. HIV-1 p24 antigen) may be positive from two weeks.
for syphilis, or if suspicion of re-infection, refer to Negative antigen test at 4-6 weeks is reassuring, but HIV test must
GUM. Positive result may also be from previous be repeated at 3 months to be sure.
Yaws infection, which is not sexually transmitted.
For interpretation of serology discuss with GUM
or refer to Syphilis clinics at Kings or GSTT
Negative
May be negative in primary syphilis. Re-test in 3
May be -ve or indeterminant in early seroconversion. Repeat
months if recent risk
sample to confirm infection. If negative, recommend repeat HIV
test 3 months after risk taking episode
Page 20 of 41
STI Management Guidelines primary care: blood borne viruses - Syphilis HIV
Lambeth Southwark April15
TREATMENT
Refer to GUM, or liaise with GUM if treatment in
primary or community care is desired
Refer to GUM/ HIV specialist service
Previous infection does not lead to immunity - reinfection is more common than treatment failure If HIV seroconversion suspected, refer immediately to GUM.
OTHER MANAGEMENT
Partner notification
Yes. Partners within 3 months, or longer for
secondary syphilis - refer to GUM for empirical
treatment and partner notification.
Yes. Refer to GUM health advisers. A comprehensive risk
assessment and previous HIV testing history facilitates the
identification of sexual partner(s). Partners should be screened,
and if partner tested within the 3 month window period, repeat test
at 3 months post risk-taking episode.
Patients should be referred to GUM for specialist HIV care,
For those with sexual contact > 3 months, screen
psychological support and referral to HIV voluntary & statutory
partner, and refer only if positive result.
sector support services
INFORMATION TO GIVE CLIENTS
Incubation
9-90 days
Rate of chronic carriage
All HIV+ people carry the virus, though the amount of virus (viral
All of those treated or untreated will have positive
load) varies, and this will determine rate of progression and
STS lifelong
infectiousness of individuals
Yes - 46-60% of contactable sexual partners with Any penetrative sex carries risk of HIV infection but in general,
early syphilis also have the infection.
average risk of transmission per act of exposure with an infected
Transmission > 2 years since infection is highly person: anal sex > vaginal sex > oral sex. Risk can vary
unlikely
dramatically depending on risk group of partner, presence of other
STIs, viral load etc.
Transmission to partners
Post-exposure prophylaxis (PEP) available from GUM or A&E
departments if exposed to known HIV+ person/ high risk source
within 72 hours, but needs to be started as soon as possible
(preferably within 24 hours)
Vertical transmission
Leaflet
All pregnant women are screened antenatally
Yes
All pregnant women are offered HIV test antenatally on opt-out
basis
Yes - leaflets for specific groups/ languages also available
References
The following BASHH Clinical Effectiveness Group Guidelines can be found at
http://www.bashh.org/guidelines
UK National Guidelines on the management of Syphilis 2008
UK National Guidelines for HIV testing 2008
UK Guideline for the use of post-exposure prophylaxis for HIV following sexual exposure 2011
Lambeth and Southwark STI Management guidelines for primary care
Shared Lambeth and Southwark Council guidelines, with NHS Lambeth Clinical Commissioning Group (CCG) and NHS Southwark Clinical
Commissioning Group (CCG) clinical recommendation
STI management guidelines for primary care: Blood Borne Viruses (Syphillis, Human Immunodeficiency Virus; Hepatitis A, B and C)
Document control
Current Version: revised June 2013 - December 2014 (previous versions: 2005; 2008)
Lead author: Lambeth and Southwark Public Health
Review date: December 2016
Approval:
Southwark Council Southwark Health & Social Care Partnership 1.12.14
Lambeth Council: Lambeth Staying Healthy Board 6.1.15
Clinical content recommendation: Lambeth & Southwark CCGs Joint Prescribing Committee 19.8.14: Chair’s approval of final clinical amendment 2.12.14.
Sexual health commissioning acknowledgment: Lambeth Southwark and Lewisham Sexual Health Commissioning Board 25.3.15
Written by:
Specialist leads for guideline group, and for related clinicial queries:
Dr Michael Brady, GUM Consultant, Camberwell Sexual Health Centre, Kings College Hospital Foundation Trust
Contact: [email protected]
Dr Anatole Menon-Johansson, Clinical Lead, Sexual & Reproductive Health department, Guy's & St Thomas' Foundation Trust
Contact: [email protected]
Dr Stephanie May, Lambeth GP Sexual Health Champion, Stockwell Group Practice
Contact: [email protected]
Sarah French, Public Health Manager Lambeth & Southwark Public Health
Guideline development facilitator (and for related non-clinical queries):
Contact: [email protected]
Page 21 of 41
Hepatitis A virus
Hepatitis B virus
Hepatitis C virus
BACKGROUND INFORMATION
Sexually transmitted
Main mode of transmission
Yes
Yes
Predominantly faeco-oral
transmission
In UK, predominantly transmitted through
penetrative sexual contact or intraveneous
drug use.
Worldwide, predominantly vertical/ childhood
transmission (mother to baby).
Consider screening
Causative organism
Yes - low risk (0.2-2% per annum); 2-11% risk
of transmission in long term sexual
relationships. If HIV+, risk of sexual
transmission can be up to 40%
Predominantly sharing needles and drug
injecting equipment (including swabs, filters
and water). Snorting equipment carries
minimal risk
Gay men, intravenous drug users
Endemic areas (everywhere except W.
Europe, N America, Australasia), IV drug
users, gay men, sex workers, HIV+, sexual
assault, occupational risk
Intravenous drug users, HIV+ patients, blood
transfusion before 1991; blood products
before 1986, renal failure on dialysis, unsterile
piercing or tatooing equipment
Picorna (RNA) virus
Hepadna (DNA) virus
RNA virus in the flaviviridae family
SIGNS & SYMPTOMS OF ACUTE INFECTION
Combination or none of the
following symptoms for
Hepatitis A, B or C:
Flu like symptoms (malaise, myalgia, fatigue, fever), jaundice (with or without right upper quadrant pain), nausea, vomiting, dark
urine, pale stools, tender liver
Usually asymptomatic (80%)
TESTS REQUIRED- Acute infection
Blood tests for virology
HAV IgM and IgG
Hepatitis B core total antibody & HBsAg
HCV antibody and RNA
Liver Function test
Yes, in acute infection
Yes, if HBsAg positive
Yes
Clotting & INR
Yes, in acute infection
Yes, if HBsAg positive
Yes
Yes - if thought to be STI
Test for other STIs
TEST RESULTS
Results
Screening test results for
past exposure
IgM +ve and IgG +ve
Refer to HBV serology table
HCV antibody +ve and RNA +ve
HAV IgG
Hepatitis B core total antibody
HCV antibody. RNA tested reflexely in the
laboratory if HCV antibody is positive or
indeterminate. If RNA is negative on 2
occasions, patient has cleared infection
TREATMENT
Timing of treatment
Referral
Mostly a mild self-limiting condition Dependent on severity of symptoms.
requiring supportive treatment only Supportive treatment only.
Repeat surface antigen 6 months after first
test (before any referral). HBsAg negtive
indicates clearance of the virus from the
blood.
HBV DNA by PCR tested by specialists.
If PCR negative on 2 occasions, patient has
cleared infection from the blood.
Referral rarely needed - base on
severity of clinical symptoms
Yes - refer for follow up by liver unit
Treatment will depend on stage of infection,
genotype, liver biopsy etc.
Yes - refer to liver unit
OTHER MANAGEMENT
Other vaccinations
Partner notification
Documentation
Those testing positive, vaccinate against HBV.
Yes for at risk sexual contacts
within infectious period
This is a notifiable disease
Yes. Partners should be screened and
vaccinated where appropriate
Yes
This is a notifiable disease
This is a notifiable disease
INFORMATION TO GIVE CLIENTS
Incubation
15-45 days
Rate of chronic carriage
40-160 days
4-140 days
5-10% in adults
50-85%. 20-30% will go on to develop severe
liver disease after 14-20 years
Transmission to partners
Only infectious around time of
symptoms e.g. 2 weeks before, 1
week after jaundice
Infectious for as long as surface antigen +ve.
General advice regarding risk of transmission - General advice regarding risk of transmission do not share razors, toothbrushes, needles, or do not share razors, toothbrushes, drug use
have unprotected sex. Advise not to donate
equipment, have unprotected sex
blood
Vertical transmission
Rare
Significant risk, but preventable neonatally
with immunoglobulin vaccination, reducing
infant transmission by 90%.
5% if RNA +ve
Leaflet
Yes (and specific leaflets for gay
men available through health
promotion)
Yes
Yes
Page 22 of 41
STI management guidelines primary care: blood borne viruses - Hepatitis A,B,C
References
The following BASHH Clinical Effectiveness Group Guidelines can be found at
Lambeth Southwark April15
http://www.bashh.org/guidelines
United Kingdom National Guideline on the Management of the Viral Hepatitides A, B & C 2008
Lambeth and Southwark STI Management guidelines for primary care
Shared Lambeth and Southwark Council guidelines, with NHS Lambeth Clinical Commissioning Group (CCG) and NHS Southwark Clinical Commissioning Group
(CCG) clinical recommendation
STI management guidelines for primary care: Blood Borne Viruses (Syphillis, Human Immunodeficiency Virus; Hepatitis A, B and C)
Document control
Current Version: revised June 2013 - December 2014 (previous versions: 2005; 2008)
Lead author: Lambeth and Southwark Public Health
Review date: December 2016
Approval:
Southwark Council Southwark Health & Social Care Partnership 1.12.14
Lambeth Council: Lambeth Staying Healthy Board 6.1.15
Clinical content recommendation: Lambeth & Southwark CCGs Joint Prescribing Committee 19.8.14: Chair’s approval of final clinical amendment 2.12.14.
Sexual health commissioning acknowledgment: Lambeth Southwark and Lewisham Sexual Health Commissioning Board 25.3.15
Written by:
Specialist leads for guideline group, and for related clinicial queries:
Dr Michael Brady, GUM Consultant, Camberwell Sexual Health Centre, Kings College Hospital Foundation Trust
Contact: [email protected]
Dr Anatole Menon-Johansson, Clinical Lead, Sexual & Reproductive Health department, Guy's & St Thomas' Foundation Trust
Contact: [email protected]
Dr Stephanie May, Lambeth GP Sexual Health Champion, Stockwell Group Practice
Contact: [email protected]
Sarah French, Public Health Manager Lambeth & Southwark Public Health
Guideline development facilitator (and for related non-clinical queries):
Contact: [email protected]
Page 23 of 41
Southwark Clinical Commissioning Group
Lambeth Clinical Commissioning Group
Lambeth and Southwark STI management guidelines for primary care
Shared Lambeth and Southwark Council guidelines, with NHS Lambeth Clinical Commissioning Group (CCG) and NHS Southwark Clinical Commissioning
Group (CCG) clinical recommendation
STI management guidelines for primary care (male – gonorrhoea, chlamydia, non-specific urethritis, epididymo-orchitis, balanitis, candida,
trichomonas vaginalis and viral STIs)
Document control
Current Version: revised June 2013 - December 2014 (previous versions: 2005; 2008)
Lead author: Lambeth and Southwark Public Health
Review date: December 2016
Approval:
Southwark Council Southwark Health & Social Care Partnership 1.12.14
Lambeth Council: Lambeth Staying Healthy Board 6.1.15
Clinical content recommendation: Lambeth & Southwark CCGs Joint Prescribing Committee 19.8.14: Chair’s approval of final clinical amendment 2.12.14.
Sexual health commissioning acknowledgment: Lambeth Southwark and Lewisham Sexual Health Commissioning Board 25.3.15
Written by:
Specialist leads for guideline group, and for related clinicial queries:
Dr Michael Brady, GUM Consultant, Camberwell Sexual Health Centre, Kings College Hospital Foundation Trust
Contact: [email protected]
Dr Anatole Menon-Johansson, Clinical Lead, Sexual & Reproductive Health department, Guy's & St Thomas' Foundation Trust
Contact: [email protected]
Dr Stephanie May, Lambeth GP Sexual Health Champion, Stockwell Group Practice
Contact: [email protected]
Sarah French, Public Health Manager Lambeth & Southwark Public Health
Guideline development facilitator (and for related non-clinical queries):
Contact: [email protected]
Page 24 of 41
STI management guidelines primary care: male Chlamydia and Gonorrhoea
Lambeth Southwark April 15
Chlamydia - CT 1
Gonorrhoea - GC 2,3
Yes
Yes, more common in men who have sex with men and African
Caribbean men
Chlamydia trachomatis CT (atypical bacterium)
Neisseria gonorrhoea GC (bacterium)
Asymptomatic in 50% of men and 70% of women
Asymptomatic in 10% of men and 50% of women; pharyngeal and
rectal infection is usually asymptomatic
BACKGROUND INFORMATION
Sexually transmitted
Causative organism
SYMPTOMS & SIGNS
Dysuria
+/-
+/-
Urethral discharge
+/-
+/-
Urethral irritation
+/-
+/-
Testicular pain/ aches
+/-
+/-
Testicular swelling
+/-
rarely
Fever
-
rarely
Systemic illness
-
rarely
Local lymphadenopathy
-
rarely
TESTS REQUIRED
Asymptomatic
Urine sample dual NAAT test (CT & GC)
Urine sample dual NAAT test (CT& GC)
First catch urine (must not have passed urine for 1
hour before)
High risk groups: Take culture in addition (including rectal, throat
and urethral) where GC contact or sexually assaulted
1. Urethral swab (MC&S for GC)
For example, urethral discharge (green/ mucopurulent discharge)
or epididimo-orchitis
2. Urine sample dual NAAT test (CT& GC)
1. Urine sample NAAT test (CT &GC)
Symptomatic
2. Urethral swab (MC&S for GC) - if dual testing not available or
high risk group (see criteria above)
Rectal & throat swabs (MC& S for
GC)
MSU
Rectal CT (LGV) is increasing in men who have sex Men who have sex with men or sexual assaulted only, dependent
with men. Consider screening or referral to GUM
on type/ site of sexual activity
Not routine. Consider if symptoms suggest UTI/
proctitis
N/ A
TEST RESULTS
Results
Positive NAAT test
Positive NAAT test (Remember: CT tests at best
are 95% sensitive, so a negative CT result does not
Test must always be confirmed by GC culture (false positives from
always exclude CT. Likewise false positives may
NAAT test may occur). So, if MC&S not done previously, do so at
occur, but are rare)
follow up from +ve NAAT test
Other comments
Antibiotic sensitivity not tested for
ALWAYS check antibiotic sensitivity from culture result
TREATMENT
Refer to the current BNF and individual Summary of Product Characteristics for full prescribing information since there are unlicensed uses listed of
which the clinician should be aware.
Infection acquired outside Europe
As for infection acquired in Europe
Cefixime is best treatment here
Timing of treatment
At diagnosis, or if CT/ GC contact
At first diagnosis, or if GC contact, or on presentation if
symptomatic
First line
Azithromycin 1gm oral stat
Cefixime 400mg oral stat (see Lambeth & Southwark updated
gonorrhoea STI guidance August 2014)4
Infection acquired in Europe
PLUS Azithromycin 1g oral stat (unlicensed in GC)
Alternative first line
OR Ceftriaxone 500mg im injection stat (reconstituted with 1%
Lidocaine solution)
(This is the national BASHH/ RCGP 1st line recommendation)
PLUS Azithromycin 1g po stat (unlicensed in GC)
Second line
Doxycycline 100mg bd 7/7
(preferred for rectal infections)
Refer to GUM: any treatment failures, re-infections, men who have
sex with men who are GC NAAT positive from any site
Page 25 of 41
STI management guidelines primary care: male Chlamydia and Gonorrhoea
Lambeth Southwark April 15
OTHER MANAGEMENT
Partner notification
Yes (last 6 months)
Yes (last 3 months)
Yes
Yes
Contact slip
Follow-up
Important to check compliance, sexual abstinence, partner notification, and GC sensitivities
Test of cure
Which test
When to test
Not necessary
Urethral swab (and throat & rectal swabs in men who have sex
with men). Test of cure required for ALL to ensure adherence to
medication, treatment of partners, appropriate abstinence from sex
and clearance of infection.
Not routinely recommended if patient given 1st or
2nd line treatment
Repeat NAAT and culture at infected site 2 weeks after treatment
If client requests, note that NAAT tests may remain
positive up to 5 weeks post treatment
When to retreat
Referral to GUM
Consider retreatment if:
Consider retreatment if:
(i) Didn’t complete treatment
(i) Didn’t complete treatment
(ii) Sexual intercourse with untreated partner
(ii) Sexual intercourse with untreated partner
N/ A
(1) failed treatment
(2) resistant strains & suitable therapy not available
(3) disseminated infection (rash, joint pain, fever)
(4) sexually assaulted
INFORMATION TO GIVE CLIENTS
Incubation
Resume sexual activity
1 to 4 weeks if symptomatic
Typically 6-10 days (can be shorter or longer)
Advise sexual abstinence for 1 week, and/ or 1 week after partner(s) have been treated
Investigation & treatment of both patient and partner is essential to prevent complications (NSU/ PID/ infertility/ ectopic)
These are STIs and patient/ contacts may be asymptomatic for some time
Written information
Use fact sheet/ leaflet
References
The following BASHH Clinical Effectiveness Group Guidelines can be found at http://www.bashh.org/guidelines
1. UK National Guideline for the Management of Genital Tract Infection with Chlamydia trachomatis (BASHH 2006, currently under review)
1. Chlamydia trachomatis UK Testing Guidelines (BASHH 2010)
2. UK National Guideline on Gonorrhoea testing (BASHH 2012)
3. Management of Gonorrhoea 2011
4. Lambeth & Southwark: updated gonorrhoea STI guidance for primary care August 2014
Lambeth and Southwark STI Management guidelines for primary care
Shared Lambeth and Southwark Council guidelines, with NHS Lambeth Clinical Commissioning Group (CCG) & NHS Southwark Clinical Commissioning Group
(CCG) clinical recommendation
STI management guidelines for primary care (male – gonorrhoea, chlamydia, non-specific urethritis, epididymo-orchitis, balanitis,
candida, trichomonas vaginalis and viral STIs)
Document control
Current Version: revised June 2013 - December 2014 (previous versions: 2005; 2008)
Lead author: Lambeth and Southwark Public Health
Review date: December 2016
Approval:
Southwark Council Southwark Health & Social Care Partnership 1.12.14
Lambeth Council: Lambeth Staying Healthy Board 6.1.15
Clinical content recommendation: Lambeth & Southwark CCGs Joint Prescribing Committee 19.8.14: Chair’s approval of final clinical amendment
2.12.14.
Sexual health commissioning acknowledgment: Lambeth Southwark and Lewisham Sexual Health Commissioning Board 25.3.15
Written by:
Specialist leads for guideline group, and for related clinicial queries:
Dr Michael Brady, GUM Consultant, Camberwell Sexual Health Centre, Kings College Hospital Foundation Trust
Contact: [email protected]
Dr Anatole Menon-Johansson, Clinical Lead, Sexual & Reproductive Health department, Guy's & St Thomas' Foundation Trust
Contact: [email protected]
Dr Stephanie May, Lambeth GP Sexual Health Champion, Stockwell Group Practice
Contact: [email protected]
Sarah French, Public Health Manager Lambeth & Southwark Public Health
Guideline development facilitator (and for related non-clinical queries):
Contact: [email protected]
Page 26 of 41
STI Guidelines primary care male: NSU, epididymo-orchitis
Lambeth Southwark April15
Non-specific Urethritis - NSU1
BACKGROUND
INFORMATION
Sexually transmitted
Epididymo-orchitis2
Often. Negative tests for chlamydia or gonorrhoea do
not exclude sexually transmitted NSU. Other STIs, such
Yes. Consider UTIs in men over 40.
as TV (especially in African Caribbean men) or HSV,
may be responsible.
Consider non-STI cause in recurrent cases, if sexual
history indicates (see information to give clients)
Causative organism
Multiple organisms such as mycoplasma or ureaplasma
may be responsible. NSU may be treated on the basis
of symptoms, but is a microscopic diagnosis.
Usually CT or coliform; occasionally GC
SYMPTOMS & SIGNS
usually symptomatic
Dysuria
+/-
+/-
+/- clear/ cloudy
+/-
+/+/-
+/-
+
rarely
+/-
Fever
-
+/-
Systemic illness
-
+/-
Local lymphadenopathy
-
-
Urethral discharge
Urethral irritation
Testicular pain/ aches
Testicular swelling
TESTS REQUIRED
Symptomatic
MSU
Rectal & throat swabs
(MC&S for GC)
Clinical diagnosis
1. Urethral swab (MC&S for GC)
2. Urine sample dual NAAT test (CT& GC)
1. Urethral swab (MC&S for GC)
2. Urine sample dual NAAT test (CT& GC)
In over 40s only, or symptoms suggestive of UTI
Yes in all ages
In men who have sex with men
In men who have sex with men
Yes
TEST RESULTS
Results
If any test is positive, treat as per relevant infection
guidelines
Positive NAAT test (Remember: CT tests at
best are 95% sensitive, so a negative CT
result does not always exclude CT. Likewise
false positives may occur, but are rare)
Ultrasound/ Doppler if diagnosis uncertain.
Remember TORSION
TREATMENT
Timing of treatment
First line (STI)
At diagnosis (don't wait for test results)
At diagnosis (don't wait for test results)
Azithromycin 1 gm stat oral
If suspect an STI and not urinary source of
infection: Cefixime 400mg stat PLUS
Doxycycline 100mg bd for 14/7 (Cefixime
treatment as per Lambeth & Southwark
updated gonorrhoea STI guidance August
2014)4
First line alternative (STI) OR Doxycycline 100mg bd for 7/7 in MSM (references 5- OR Ceftriaxone 500mg im stat (reconstituted
with 1% Lidocaine solution) PLUS Doxycycline
7)
100mg bd for 14/7
(this is the
national BASHH/ RCGP 1st line
recommendation)
Second line (STI)
For NSU that does not respond: treat as above with the
alternative first line treatment OR Erythromycin 500mg
bd 14/7 OR Ofloxacin 200mg bd 7/7 or 400mg od for 7/7
PLUS cover for trichomonas vaginalis (TV) with
Metronidazole 400mg bd for 5/7
[Note: a molecular test for TV is now available in all six
services of the sexual & reproductive health department
of Guy's & St Thomas']
Other alternative
For persistent / recurrent NSU: Please refer for
microscopic analysis of a urethral smear at the sexual
health service
First line (UTI)
Trimethoprim 200mg bd 7/7
Treat as per NHS Lambeth & Southwark
Antibiotic guidelines
Third line (STI)
Treat according to sensitivities if known or refer to GUM
if treatment unsuccessful.
Refer to Urology as this is complicated
Page 27 of 41
STI Guidelines primary care male: NSU, epididymo-orchitis
Lambeth Southwark April15
OTHER MANAGEMENT
Partner notification
(partners in last 3 months)
Contact slip
Follow-up
Yes
Recommended if sexually active
Yes
Important to check compliance, sexual abstinence,
partner notification, and GC sensitivities
Yes if sexually active (GUM code C5)
Not necessary
MSU (if previously +ve)
Clinical review at 14 days, check GC & MSU
sensitivities
Test of cure
Which test
2 days after stopping treatment
When to test
When to retreat
Referral to GUM
Only if failure in 2nd line therapy
If not better at 2 weeks, consider further
course of Doxycycline 14/7 only
Not necessary
If persistent symptoms after 4 weeks therapy
or urinary symptoms e.g. of outflow obstruction
Referral to Urology
INFORMATION TO GIVE CLIENTS
Incubation
Variable
Resume sexual activity
Advise sexual abstinence for 1 week, and/or 1 week after partner(s) have been treated
Investigation & treatment of both patient & partner is essential to prevent complications and re-infection
(NSU/ PID/ infertility/ ectopic)
Where STIs suspected and patient/contacts may be asymptomatic for some time
Not all NSU is caused by sexually transmitted organisms. Non STI causative factors: normal comensals,
partner with BV, irritants e.g. soaps
Written information
Use fact sheet/ leaflet
References
The following BASHH Clinical Effectiveness Group Guidelines can be found at http://www.bashh.org/guidelines
1. 2007 UK National Guideline on the Management of non gonococcol Urethritis updated Dec 2008
2. 2010 United Kingdom national guideline for the management of Epididymo-orchitis
3. NHS Lambeth: updated gonorrhoea STI guidance for primary care - ratified by Lambeth Medicines Management Committee June
2012
4. Lambeth & Southwark: updated gonorrhoea STI guidance for primary care August 2014
5. Is azithromycin adequate treatment for asymptomatic rectal chlamydia? Drummond et al, IJSA 2011; 22: 478-480
6. Treatment of asymptomatic rectal Chlamydis trachomatis: is single-dose azithromycin effective? Steedman & McMillan, IJSA 2009; 20: 16-18
7. Seven days of doxycycline is an effective treatment for asymptomatic rectal Chlamydia trachomatis infection. Elgalib et al, IJSA 2011; 22: 474-477
NHS Lambeth and Southwark STI Management guidelines for primary care
Shared Lambeth and Southwark Council guidelines, with NHS Lambeth Clinical Commissioning Group (CCG) & NHS Southwark Clinical Commissioning Group (CCG) clinical recommendation
STI management guidelines for primary care (male – gonorrhoea, chlamydia, non-specific urethritis, epididymo-orchitis,
balanitis, candida, trichomonas vaginalis and viral STIs)
Document control
Current Version: revised June 2013 - December 2014 (previous versions: 2005; 2008)
Lead author: Lambeth and Southwark Public Health
Review date: December 2016
Approval:
Southwark Council Southwark Health & Social Care Partnership 1.12.14
Lambeth Council: Lambeth Staying Healthy Board 6.1.15
Clinical content recommendation: Lambeth & Southwark CCGs Joint Prescribing Committee 19.8.14: Chair’s approval of final clinical amendment 2.12.14.
Sexual health commissioning acknowledgment: Lambeth Southwark and Lewisham Sexual Health Commissioning Board 25.3.15
Written by:
Specialist leads for guideline group, and for related clinicial queries:
Dr Michael Brady, GUM Consultant, Camberwell Sexual Health Centre, Kings College Hospital Foundation Trust
Contact: [email protected]
Dr Anatole Menon-Johansson, Clinical Lead, Sexual & Reproductive Health department, Guy's & St Thomas' Foundation Trust
Contact: [email protected]
Dr Stephanie May, Lambeth GP Sexual Health Champion, Stockwell Group Practice
Contact: [email protected]
Sarah French, Public Health Manager Lambeth & Southwark Public Health
Guideline development facilitator (and for related non-clinical queries):
Contact: [email protected]
Page 28 of 41
STI Management guidelines primary care: male balanitis, candida, TV
Balanitis1
Lambeth Southwark April15
Trichomonas vaginalis - TV2
Candida
BACKGROUND INFORMATION
Sexually transmitted
Generally not. May be allergy or
skin condition e.g. psoriasis, lichen No
planus or lichen sclerosis
Usually sexually transmitted.
Particularly prevalent in AfroCaribbean population in S London
Causative organism
Candida, secondary to CT, GC, TV,
or Syphilis. Rarely bacteria (staph, Candida albicans, a yeast
strep, anaerobes). Poor hygiene
May be a cause of NSU
Trichomonas vaginalis
SYMPTOMS & SIGNS
Usually asymptomatic
+/ +/ +/ - Occasionally in sub pre-putial
+/ - (odour also)
Discharge
space (phimosis)
+/ Dysuria
+/ +/ +/ Rash on glans
+/ Cuts
+/ +/ Foreskin swelling
TESTS REQUIRED If at no apparent risk of an STI, tests are not usually necessary. Men at risk of an STI should provide a first pass
urine for NAAT test and have a urethral swab for culture.
In severe cases only
In severe cases only
No
Sub pre-putial swab
Not necessary
Yes if urethral symptoms
Yes
Urethral swab (MC& S)
Yes
Usually
Clinical diagnosis
Urinanalysis
Severe/ recurrent - check
Severe only
No
glucosuria
+
Itch/ irritation
TESTS RESULTS
Sub pre-putial swab (Culture)
Urethral swab (MC& S)
TREATMENT
First line
or
Second line
Clotrimazole 1% cream bd 7/7
or Miconazole 2% cream 7/7.
Consider Clotrimazole HC 1%
cream if itch a predominant
feature Apply bd for 1-2 weeks
White cells and Candida
Diagnosis by microscopy only
White cells and trichomonads +/ Diagnosis by microscopy only
(<30%)
Clotrimazole 1% cream bd 7/7.
Metronidazole 2gm stat
or Miconazole 2% cream duration or Metronidazole 400mg bd 5/7
7/7.
Consider
Clotrimazole HC 1% cream if itch a
predominant feature. Apply bd for
1-2 weeks
Refer to GUM and if atypical
Fluconazole 150mg po stat
presentation +/ - syphilis suspected
or if persistent
Tinidazole 2g stat
No
No
Yes
No
No
Rarely HIV, diabetes, in severe or
recurrent cases
Not required
Yes
Yes
Consider other STIs
OTHER MANAGEMENT
Partner notification
Contact slip
Predisposing factors
Follow-up
Not required
Check compliance, partner
notification/treatment and
resolution of symptoms.
Testing for other STIs
Test of cure
Referral to GUM
Yes - offer if sexually active
No
Atypical presentation +/ - syphilis
suspected or if persistent
Yes - offer if sexually active
No
Yes
Not necessary
Guy's & St Thomas' have an RNA
test for TV in cases where a
diagnosis is difficult to establish
Recurrent infection
Occasionally
Consider diabetes & immunosupression
Suspected Metronidazole
resistance - give Tinidazole. Failure
to clear cases should be sent to
GUM
Page 29 of 41
STI Management guidelines primary care: male balanitis, candida, TV
Lambeth Southwark April15
INFORMATION TO GIVE CLIENTS
Resume sexual activity
Written information
Almost always sexually transmitted.
Men usually seen as contacts of
female partners
Advise avoiding alcohol during
Metronidazole or Tinidazole
Cream may weaken latex condoms Cream may weaken latex condoms
treatment, because of possibility of
& female diaphragms
& female diaphragms
disulfiram-like (Antabuse® effect)
reaction
Partner needs treatment. Advise
avoiding sexual intercourse
including oral sex) until patient and
Advise female partner is seen if
their partner have completed
symptomatic of candida
treatment and any follow up
Testing for other STIs
recommended
Can recur
Can recur
Can recur if partner not treated
Generally not an STI
Not an STI
Discuss genital hygiene
Avoid bath additives such as :
bubble bath / TCP / Dettol / Savlon
Use fact sheet/ leaflet
Use fact sheet/ leaflet
Use fact sheet/ leaflet
References
The following BASHH Clinical Effectiveness Group Guidelines can be found at
http://www.bashh.org/guidelines
1. Management of Balanitis 2008
2. United Kingdom National Guideline on the Management of Trichomonas vaginalis (2007, currently under revision)
NHS Lambeth and Southwark STI Management guidelines for primary care
Shared Lambeth and Southwark Council guidelines, with NHS Lambeth Clinical Commissioning Group (CCG) & NHS Southwark Clinical
Commissioning Group (CCG) clinical recommendation
STI management guidelines for primary care (male – gonorrhoea, chlamydia, non-specific urethritis, epididymo-orchitis, balanitis,
candida, trichomonas vaginalis and viral STIs)
Document control
Current Version: revised June 2013 - December 2014 (previous versions: 2005; 2008)
Lead author: Lambeth and Southwark Public Health
Review date: December 2016
Approval:
Southwark Council Southwark Health & Social Care Partnership 1.12.14
Lambeth Council: Lambeth Staying Healthy Board 6.1.15
Clinical content recommendation: Lambeth & Southwark CCGs Joint Prescribing Committee 19.8.14: Chair’s approval of final clinical amendment 2.12.14.
Sexual health commissioning acknowledgment: Lambeth Southwark and Lewisham Sexual Health Commissioning Board 25.3.15
Written by:
Specialist leads for guideline group, and for related clinicial queries:
Dr Michael Brady, GUM Consultant, Camberwell Sexual Health Centre, Kings College Hospital Foundation Trust
Contact: [email protected]
Dr Anatole Menon-Johansson, Clinical Lead, Sexual & Reproductive Health department, Guy's & St Thomas' Foundation Trust
Contact: [email protected]
Dr Stephanie May, Lambeth GP Sexual Health Champion, Stockwell Group Practice
Contact: [email protected]
Sarah French, Public Health Manager Lambeth & Southwark Public Health
Guideline development facilitator (and for related non-clinical queries):
Contact: [email protected]
Page 30 of 41
STI Management guidelines primary care: male - viral STIs
Lambeth Southwark April15
Molluscum contagiosum1
Genital ulceration - herpes simplex virus2
Genital warts - HPV3
Can be sexually transmitted
Yes
Yes
Molluscum virus
Herpes simplex virus (HSV) types 1 or 2 (both
Human papilloma virus types 6 or 11
can cause genital herpes, oral usually HSV1)
BACKGROUND INFORMATION
Sexually transmitted
Causative organism
SYMPTOMS & SIGNS
Symptomatic episodes, but asymptomatic
carriage common
Genital ulcers & lumps
Pearly round nodules with central
ubilication, but rarely ulcerated.
Occasionally become inflamed/
pustular
Usually symptomatic
Small blisters (early) or ulcers (later) on prePlane or papillomatous penile warts, may be
puce, shaft, glans & perianal area. In the later perianal or intrameatal
stages they may be crusted before healing
Genital pain & itches
-
Pain preceded by itch. Leg/buttock neuralgia
Dysuria
-
+ (inc. superficial dysuria and frequency)
+/-
Urethral discharge
-
+/-
-
Fever
-
+/- (rare with recurrences)
-
Systemic illness
-
+/- (rare with recurrences)
-
Local lymphadenopathy
-
frequently, tender
-
TESTS REQUIRED
Yes, take firm cotton swab from base of
deroofed blister/ ulcer
Viral PCR or culture
Clinical diagnosis
Yes
Yes, confirmed by PCR or culture test,
negative test does not exclude HSV. PCR is Yes - warts are a clinical diagnosis, biopsy is
the 'gold standard' test and should be the test only indicated if very atypical
of choice.
Test for other STIs
Yes
Recommended, especially syphilis, and in men
Recommended, especially HIV if florid warts
who have sex with men
TEST RESULTS
Results
N/ A
Other comments
Positive HSV PCR or culture, usually typed as N/ A
HSV1 or HSV2
HSV serology may be useful in management
of serodiscordant couples or in pregnancy refer to GUM
TREATMENT
Timing of treatment
First line
Podophyllotoxin cream (0.5%) is
easier to apply than solution
(0.5%). Apply topically for limited
discrete lesions on penile or
perianal (unlicensed) region as selftreatment, if client can manage
this. Prescribe bd applications for
3 consecutive days followed by 4
days rest - 4 week cycles
First episode: aciclovir 200mg 5 times a day
for 7-14/7 (double dose in
immunocompromised)ref. 4 .
Advise symptomatic management: analgesia
e.g topical lidocaine 5% or Instillagel (2%
lidocaine) - unlicensed use, salt baths.
Podophyllotoxin cream (0.15%) is the most
easy to apply in both men and women but a
solution (0.5%) is available. The treatment
can be applied topically for limited discrete
warts on penile region as self-treatment, if the
client can manage this. Prescribe bd
applications for 3 consecutive days followed
by 4 days rest - 4 week cycles.
For perianal warts, Imiquimod 5% cream
topically. Apply 3 times weekly, overnight,
wash off 6-10 hours later, for up to 16 weeks.
Imiquimod 5% cream topically
(unlicensed). Apply 3 times weekly,
overnight, wash off 6-10 hours
later, for up to 16 weeks.
Recurrence: symptomatic management only.
Episodic antivirals an option started within 24
hrs of symptoms. Aciclovir 400mg 3 times a
day for 3-5/7
Cryotherapy
(Intrameatal warts need cryotherapy)
OR Imiquimod 5% cream applied topically at
night 3 times/ week (max. 16 weeks). Leave
on 6-10 hours, then wash off with mild soap,
water.
Refer to GUM
Prophylaxis for those with more severe
symptoms: Aciclovir 400mg bd twice daily.
Review at 6 months
Refer to GUM
Not routinely
Not routinely
Not routinely
Offer
Offer
Offer
May require follow up if worsening
May require follow-up discussion about risks of If self treatment review after 4 weeks if not
transmission, natural history etc.
resolved
If multiple and severe or extragenital (e.g. face), consider
immuno suppression and
recommend an HIV test.
Any atypical ulceration +/- syphilis suspected.
Unable to tolerate or use self treatment
Management of chronic / reccurent symptoms
Second line
Third line
OTHER MANAGEMENT
Partner notification (consider partners in
last 3 months)
Contact slip
Follow-up
Referral to GUM
Page 31 of 41
STI Management guidelines primary care: male - viral STIs
Lambeth Southwark April15
INFORMATION TO GIVE CLIENTS
First episode can be as soon as a few days
after infection, or several years
Incubation
Months to years
Salt water bathing may alleviate symptoms
Resume sexual activity
Should not resume sexual intercourse until
If in steady relationship advise condoms until
complete resolution of clinical episode &
warts resolved, but no evidence of any benefit
advise condoms. Use condoms if partner not
as partner probably already infected
known to have HSV or with new partners
If in steady relationship advise
condoms until resolved, but no
evidence of any benefit as partner
probably already infected
Asymptomatic shedding is common,
predominantly around the time of
episodes/symptoms. Male transmission to a
susceptible female partner is around 15% per
annum
This is a self limiting infection that
will not recur.
If not in steady relationship, advise condom
use with new partners for 6+ months as HPV
shedding persists
HSV1 is common cause of first episode in
young people, and less likely to recur
Written information
Partner may never develop
molluscum growths. Encourage
patient to discuss with partner.
Partner may have asymptomatic infection
already. Encourage patient to discuss with
partner
Partner may never develop warts. Encourage
patient to discuss with partner.
Use fact sheet/ leaflet
Use fact sheet/ leaflet
Use fact sheet/ leaflet
References
The following BASHH Clinical Effectiveness Group Guidelines can be found at http://www.bashh.org/guidelines
1. United Kingdom National Guideline on the Management of Molluscum Contagiosum (2007)
2. Management of genital herpes (2007)
3. United Kingdom National Guideline on the Management of Anogenital Warts (2007)
4. Holmes K.K et al. (2008) Sexually transmitted infections 4th edition. USA: McGraw Hill
NHS Lambeth and Southwark STI Management guidelines for primary care
Shared Lambeth and Southwark Council guidelines, with NHS Lambeth Clinical Commissioning Group (CCG) & NHS Southwark Clinical Commissioning Group (CCG) clinical
recommendation
STI management guidelines for primary care (male – gonorrhoea, chlamydia, non-specific urethritis, epididymo-orchitis, balanitis, candida, trichomonas vaginalis
and viral STIs)
Document control
Current Version: revised June 2013 - December 2014 (previous versions: 2005; 2008)
Lead author: Lambeth and Southwark Public Health
Review date: December 2016
Approval:
Southwark Council Southwark Health & Social Care Partnership 1.12.14
Lambeth Council: Lambeth Staying Healthy Board 6.1.15
Clinical content recommendation: Lambeth & Southwark CCGs Joint Prescribing Committee 19.8.14: Chair’s approval of final clinical amendment 2.12.14.
Sexual health commissioning acknowledgment: Lambeth Southwark and Lewisham Sexual Health Commissioning Board 25.3.15
Written by:
Specialist leads for guideline group, and for related clinicial queries:
Dr Michael Brady, GUM Consultant, Camberwell Sexual Health Centre, Kings College Hospital Foundation Trust
Contact: [email protected]
Dr Anatole Menon-Johansson, Clinical Lead, Sexual & Reproductive Health department, Guy's & St Thomas' Foundation Trust
Contact: [email protected]
Dr Stephanie May, Lambeth GP Sexual Health Champion, Stockwell Group Practice
Contact: [email protected]
Sarah French, Public Health Manager Lambeth & Southwark Public Health
Guideline development facilitator (and for related non-clinical queries):
Contact: [email protected]
Page 32 of 41
Southwark Clinical Commissioning Group
Lambeth Clinical Commissioning Group
Lambeth and Southwark STI management guidelines for primary care
Shared Lambeth and Southwark Council guidelines, with NHS Lambeth Clinical Commissioning Group (CCG) and NHS Southwark Clinical Commissioning
Group (CCG) clinical recommendation
STI management guidelines for primary care (female – gonorrhoea, chlamydia, pelvic inflammatory disease, vaginal discharge and viral STIs)
Document control
Current Version: revised June 2013 - December 2014 (previous versions: 2005; 2008)
Lead author: Lambeth and Southwark Public Health
Review date: December 2016
Approval:
Southwark Council Southwark Health & Social Care Partnership 1.12.14
Lambeth Council: Lambeth Staying Healthy Board 6.1.15
Clinical content recommendation: Lambeth & Southwark CCGs Joint Prescribing Committee 19.8.14: Chair’s approval of final clinical amendment 2.12.14.
Sexual health commissioning acknowledgment: Lambeth Southwark and Lewisham Sexual Health Commissioning Board 25.3.15
Written by:
Specialist leads for guideline group, and for related clinicial queries:
Dr Michael Brady, GUM Consultant, Camberwell Sexual Health Centre, Kings College Hospital Foundation Trust
Contact: [email protected]
Dr Anatole Menon-Johansson, Clinical Lead, Sexual & Reproductive Health department, Guy's & St Thomas' Foundation Trust
Contact: [email protected]
Dr Stephanie May, Lambeth GP Sexual Health Champion, Stockwell Group Practice
Contact: [email protected]
Sarah French, Public Health Manager Lambeth & Southwark Public Health
Guideline development facilitator (and for related non-clinical queries):
Contact: [email protected]
Page 33 of 41
STI Management Guidelines for primary care: female chlamydia gonorrhoea
Lambeth Southwark April 15
Chlamydia - CT 1
Uncomplicated Gonorrhoea - GC2,3
Yes
Yes.
Chlamydia trachomatis CT (atypical bacterium)
Neisseria gonorrhoeae GC (bacterium)
Asymptomatic in 70% of women and 50% of men
Asymptomatic in 50% of women and 10% of men
BACKGROUND INFORMATION
Sexually transmitted
Causative organism
SYMPTOMS
Vaginal discharge
+/-
+/-
Intermenstrual bleeding
+/-
+/-
Abdominal pain / deep dyspareunia
+/-
+/-
Fever
-
-
Systemic illness
-
+/-
Local lymphadenopathy
-
rarely
Vulval pain/itch
-
-
Urinary symptoms
+/- mild dysuria
+/- mild dysuria
Urethral discharge
+/-
+/-
CLINICAL FINDINGS
Usual
Normal in most women
Normal in most
Mucopurulent cervicitis
+/-
+/-
Cervical contact bleeding
+/-
+/-
TESTS REQUIRED
Asymptomatic
Specimen of choice (first line): self taken vaginal swab (NAAT test)
(most specific and sensitive test)
Specimen of choice (first line): self taken vaginal swab (NAAT test)
(most specific and sensitive test)
If passing speculum for other reason: endocervical swab (less sensitive and If passing speculum for other reason: endocervical swab
less specific)
First pass urine is a suboptimal method (lower sensitivity)
Alternative: first pass urine
Symptomatic
Specimen of choice (first line): self taken vaginal swab (NAAT test) swab
before the patient is examined
Second line: endocervical swab (NAAT test) (less sensitive and specific)
Specimen of choice (first line): Self taken vaginal swab for NAAT test
before the patient is examined
AND endocervical charcoal swab for GC culture if symptomatic or
i) GC contact ii) pelvic inflammatory disease iii) sexually assaulted
(include rectal and throat swabs)
Second line: Endocervical swab for NAAT test and EC Charcoal swab
for GC culture
Positive NAAT test
Positive NAAT test
Remember: chlamydia tests at best are 95% sensitive, so a negative CT
result does not always exclude CT. Likewise false positives may occur, but
are rare
False positives occur in 5-10% of urine tests
Antibiotic sensitivity not tested for.
Inhibitory/ indeterminate test result: re-take test. Equivocal test result: retake test
Test must always be confirmed by GC culture (false positives from
NAAT test may occur, especially in low risk patients). So, if MC&S not
done previously, do so at follow up from +ve NAAT test. Culture also
gives GC sensitivities
ALWAYS check antibiotic sensitivity from culture result
TEST RESULTS
Results
Other comments
TREATMENT
Refer to current BNF and individual Summary of Product Characteristics for full prescribing information, since there are unlicensed uses listed of which the clinician should be
aware.
Timing of treatment
First line
At diagnosis, or if CT/ GC contact
At first diagnosis, or if GC contact
Azithromycin 1g oral stat
Cefixime 400mg oral stat
(see Lambeth & Southwark updated gonorrhoea STI guidance August
2014) 4
PLUS Azithromycin 1g oral stat (unlicensed in GC and pregnancy)
OR Ceftriaxone 500mg i.m. injection stat (reconstituted with 1%
Lidocaine solution). Can be used in pregnancy (this is the national
BASHH/ RCGP 1st line recommendation)
Alternative first line
PLUS Azithromycin 1g oral stat (unlicensed in GC and pregnancy)
Second line
Doxycycline 100mg bd 7/7. (This should be used first line if there is a risk or Refer to Level 3 services: any treatment failures, re-infections
pharyngeal or rectal infection). Not during pregnancy
Other alternatives
Erythromycin 500mg bd 14/7
In pregnancy
Erythromycin 500mg bd 14/7 OR Amoxicillin 500mg po tds 7/7
OR Azithromycin 1g oral stat can be used in pregnancy (unlicensed use).
BNF recommends its use in pregnancy and lactation only if no alternative is
available, as safety in these situations has not yet been fully assessed
Page 34 of 41
Ceftriaxone 500mg i.m. injection stat (reconstituted with 1% Lidocaine
solution) PLUS Azithromycin 1g oral stat (unlicensed in GC and
pregnancy)
STI Management Guidelines for primary care: female chlamydia gonorrhoea
Lambeth Southwark April 15
OTHER MANAGEMENT
Partner notification
Contact slip
Follow-up
Yes - 6 months
Yes - 3 months
Yes
Yes
Important to check compliance, sexual abstinence, partner notification.
Consider re-testing 3-6 months following treatment
Test of cure required for all to ensure adherence to medication,
treatment of partners, appropriate abstinence from sex and clearance
of infection
NAAT test
NAAT and culture
Not routinely recommended if patient given 1st or 2nd line treatment
Repeat NAAT and culture at infected site 2 weeks after treatment
Test of cure
Which test
When to test
Recommended in pregnancy, or if non-compliance/ re-exposure suspected
Wait at least 5 weeks after start of treatment (6 weeks if azithromycin is
given)
NAAT tests may remain positive up to 5 weeks post treatment
When to retreat
Referral to GUM
(i) Didn’t complete treatment
(ii) sexual intercourse with untreated partner
(i) Didn’t complete treatment
(ii) sexual intercourse with untreated partner
N/ A
(1) failed treatment
(2) resistant strains
(3) disseminated infection (fever, rash, joint pain)
INFORMATION TO GIVE CLIENTS
Incubation
1 to 4 weeks if symptomatic
Resume sexual activity
Advise sexual abstinence for 1 week, and/ or 1 week after partner(s) have been treated
1-2 weeks (though can be longer)
Investigation & treatment of both patient and partner is essential to prevent complications (PID/ infertility/ ectopic)
Subsequent chlamydial infections may have worse sequelae. These are
STIs and patient/ contacts may be asymptomatic
Written information
Use factsheet/ leaflet
Use factsheet/ leaflet
References
The following BASHH Clinical Effectiveness Group Guidelines can be found at http://www.bashh.org/guidelines
1. Chlamydia trachomatis UK Testing Guidelines (BASHH 2010)
2. UK National Guideline on Gonorrhoea testing (BASHH 2012)
3. Management of Gonorrhoea (BASHH 2011)
4. Lambeth & Southwark: updated gonorrhoea STI guidance for primary care August 2014
5. Sexually Transmitted Infections in Primary Care Guideline, Second Edition 2013.
Royal College of General Practitioners (RCGP)and British Association for Sexual Health and HIV (BASHH)
http://www.rcgp.org.uk/clinical-and-research/clinical-resources/~/media/Files/CIRC/RCGP-Sexually-Transmitted-Infections-in-Primary-Care-2013.ashx
Lambeth and Southwark STI Management guidelines for primary care
Shared Lambeth and Southwark Council guidelines, with NHS Lambeth Clinical Commissioning Group (CCG) & NHS Southwark Clinical Commissioning Group (CCG) clinical recommendation
STI management guidelines for primary care (female – gonorrhoea, chlamydia, pelvic inflammatory disease, vaginal discharge and viral STIs)
Document control
Current Version: revised June 2013 - December 2014 (previous versions: 2005; 2008)
Lead author: Lambeth and Southwark Public Health
Review date: December 2016
Approval:
Southwark Council Southwark Health & Social Care Partnership 1.12.14
Lambeth Council: Lambeth Staying Healthy Board 6.1.15
Clinical content recommendation: Lambeth & Southwark CCGs Joint Prescribing Committee 19.8.14: Chair’s approval of final clinical amendment 2.12.14.
Sexual health commissioning acknowledgment: Lambeth Southwark and Lewisham Sexual Health Commissioning Board 25.3.15
Written by:
Specialist leads for guideline group, and for related clinicial queries:
Dr Michael Brady, GUM Consultant, Camberwell Sexual Health Centre, Kings College Hospital Foundation Trust
Contact: [email protected]
Dr Anatole Menon-Johansson, Clinical Lead, Sexual & Reproductive Health department, Guy's & St Thomas' Foundation Trust
Contact: [email protected]
Dr Stephanie May, Lambeth GP Sexual Health Champion, Stockwell Group Practice
Contact: [email protected]
Sarah French, Public Health Manager Lambeth & Southwark Public Health
Guideline development facilitator (and for related non-clinical queries):
Contact: [email protected]
Page 35 of 41
STI Management Guidelines for primary care: PID
Lambeth Southwark April15
Pelvic Inflammatory Disease - PID1
BACKGROUND INFORMATION
Sexually transmitted
Usually sexual transmitted (negative tests for chlamydia or gonorrhoea do not
exclude sexual transmission as other agents may be responsible)
Causative organism
Multiple, predominantly CT and GC and vaginal anaerobes
SYMPTOMS
Usually symptomatic
Vaginal discharge
Intermenstrual bleeding
Abdominal pain / deep
dyspareunia
Fever
+/+/-
Systemic illness
+/-
Local lymphadenopathy
-
+
+/-
Vulval pain/itch
-
Urinary symptoms
+/- mild dysuria
CLINICAL FINDINGS
Mucopurulent cervicitis
Cervical motion tenderness and adnexal tenderness are required to make the
diagnosis
+/-
Cervical contact bleeding
+/-
Urethral discharge
Rare
Usual
Other signs include
Pelvic masses, pyrexia, guarding, rebound and right upper quadrant tenderness
TESTS REQUIRED
Symptomatic
First line: Self taken vaginal swab for dual GC NAAT test before patient is
examined AND Endocervical MC& S for GC culture ,and HVS for Trichomonas
Second line: Endocervical swab for NAAT test, Endocervical test for culture and
HVS
Clinical diagnosis
Yes – always exclude pregnancy and UTI
TEST RESULTS
Results
Positive GC NAAT test must always be confirmed by GC culture.
Other comments
False positives from NAAT test may occur. False negative culture results also
possible from community
ALWAYS check antibiotic sensitivity of any GC isolates
TREATMENT
Timing of treatment
At diagnosis (don't wait for test results)
First line
Ceftriaxone 500mg im injection stat (in 1% lidocaine solution) plus Doxycycline
100mg oral bd for 14/7 plus Metronidazole 400mg oral bd for 14/7.
First line alternative
Ofloxacin 400mg oral bd and Metronidazole 400mg oral bd both for 14/7.
Other alternative
Pregnancy
Ceftriaxone 500mg im injection stat (in 1% lidocaine solution) plus Azithromycin
1g oral a week for 2 weeks
Refer to Gynaecology (PID in pregnancy increases maternal and foetal
mortality)
Other treatment information
Treatment of anaerobes is more important in patients with severe PID.
Metronidazole may be poorly tolerated - can be stopped in mild to moderate
disease if need be. In patients where GC is suspected, replacing Ceftriaxone
with Cefixime is not recommended as there is little evidence to support this
and, as tissue levels are likely to be lower, there are concerns about efficacy
Page 36 of 41
STI Management Guidelines for primary care: PID
OTHER MANAGEMENT
Partner notification (partners
in last 3 months)
Contact slip
Follow up
Lambeth Southwark April15
Yes – and recommend partner treatment with Azithromycin PLUS Ceftriaxone if
GC+ve
Yes
Important to check compliance, sexual abstinence, partner notification, and GC
sensitivities at clinical 14 day review. Repeat pregnancy test at 3 weeks after
unprotected sexual intercourse
Test of Cure
Which test
If GC positive - a test of cure at two weeks post treatment is required
When to test
Advise patient to re-attend at 3 days if severe symptoms, symptoms not
improving or if IUD/S in situ. Should show a substantial improvement in clinical
symptoms and signs. Failure to do so suggests the need for further
investigation, parenteral therapy and/or surgical intervention.
When to retreat
Retreat if pain continues and there is evidence in the sexual history of possible
re-infection
Referral to GUM
See 'when to test', if symptoms/ signs failure to improve
Referral to Gynaecology
INFORMATION TO GIVE
CLIENTS
Incubation
Pregnant, systemically unwell (pulse >100/min , Temp >38.5C), unable to
tolerate oral medication, uncertain diagnosis: pelvic masses, acute abdomen,
positive pregnancy test, if not improving on oral antibiotics
Variable
Resume sexual activity
Advise sexual abstinence for 2 weeks or 1 week after partner(s) have been
treated
Other
Written information
Investigation & treatment of both patient and partner is essential to prevent
complications (PID/ infertility/ ectopic). Subsequent chlamydial infection may
have worse sequelae.
Patients given metronidazole should be advised to avoid alcohol for treatment
duration, and for at least 48 hours afterwards, because of the possibility of a
disulfiram-like (Antabuse® effect) reaction
Provide factsheet/ leaflet
References
The following BASHH Clinical Effectiveness Group Guideline can be found at http://www.bashh.org/guidelines
1. Management of PID 2011 (GC Update June 2011)
2. Sexually Transmitted Infections in Primary Care Guideline, Second Edition 2013.
Royal College of General Practitioners (RCGP)and British Association for Sexual Health and HIV (BASHH)
http://www.rcgp.org.uk/clinical-and-research/clinical-resources/~/media/Files/CIRC/RCGP-Sexually-Transmitted-Infections-in-Primary-Care-2013.ashx
NHS Lambeth and Southwark STI Management guidelines for primary care
Shared Lambeth and Southwark Council guidelines, with NHS Lambeth Clinical Commissioning Group (CCG) & NHS Southwark Clinical Commissioning Group (CCG) clinical
recommendation
STI management guidelines for primary care (female – gonorrhoea, chlamydia, pelvic inflammatory disease, vaginal discharge and viral STIs)
Document control
Current Version: revised June 2013 - December 2014 (previous versions: 2005; 2008)
Lead author: Lambeth and Southwark Public Health
Review date: December 2016
Approval:
Southwark Council Southwark Health & Social Care Partnership 1.12.14
Lambeth Council: Lambeth Staying Healthy Board 6.1.15
Clinical content recommendation: Lambeth & Southwark CCGs Joint Prescribing Committee 19.8.14: Chair’s approval of final clinical amendment 2.12.14.
Sexual health commissioning acknowledgment: Lambeth Southwark and Lewisham Sexual Health Commissioning Board 25.3.15
Written by:
Specialist leads for guideline group, and for related clinicial queries:
Dr Michael Brady, GUM Consultant, Camberwell Sexual Health Centre, Kings College Hospital Foundation Trust
Contact: [email protected]
Dr Anatole Menon-Johansson, Clinical Lead, Sexual & Reproductive Health department, Guy's & St Thomas' Foundation Trust
Contact: [email protected]
Dr Stephanie May, Lambeth GP Sexual Health Champion, Stockwell Group Practice
Contact: [email protected]
Sarah French, Public Health Manager Lambeth & Southwark Public Health
Guideline development facilitator (and for related non-clinical queries):
Contact: [email protected]
Page 37 of 41
STI Management Guidelines for primary care: vaginal discharge
Lambeth Southwark April15
Candida1
Bacterial vaginosis - BV2
Trichomonas vaginalis - TV3
BACKGROUND INFORMATION The commonest causes of vaginal discharge in primary care are physiological discharge, candida infection, and
bacterial vaginosis. Conducting a sexual health risk assessment will guide appropriate management and investigation
Yes. Almost all sexually transmitted,
but fomite spread has been reported.
Particularly prevalent in African
Caribbean population in S London
Sexually transmitted
No
Causative organism
Not caused by one organism, but by an
Candida albicans, a yeast commensal in
overgrowth of anaerobic organisms
Trichomonas vaginitis (a protozoan)
all persons
that are present in the normal flora
SYMPTOMS
Discharge
Smell
Pruritus
No
White (curdy)
Nil or yeasty
Usually
White/ grey homogenous
Fishy or offensive
occasionally
Yellow-green frothy
Malodorous
+
CLINICAL FINDINGS
Vulvitis
+/+/+
+
Vaginitis
Occasionally ectocervicitis
+
Cervicitis
TESTS REQUIRED If woman is at no apparent risk of an STI, a combination of clinical history, examination and the use of vaginal pH paper will
distinguish between candida, physiological discharge and BV. A high vaginal swab (HVS) is NOT required. Women at risk of an STI should have an
HVS (for TV), a self taken vaginal swab for a dual gonorrhoea and chlamydia NAAT test, and consider an endocervical charcoal swab for gonorrhoea
culture.
pH of vaginal discharge
High vaginal swab (HVS)
TESTS RESULTS
pH of vaginal discharge
HVS (Microscopy)
HVS (Culture)
pH of vaginal discharge, ensure not contaminated by blood, water or lubricant
Place the swab in the posterior fornix (best for TV) and then wipe it along one of the vaginal walls (best for Candida).
Charcoal transport medium is recommended
< 4.5
May show white cells and Candidal
elements
Candida is diagnosed on microscopy or
cultured from an HVS
>5
>5
Grade III (Hay & Ison criteria)
Trichomonads
If seen does not need further
confirmation
Clinical diagnosis if typical discharge
and odour, pH>5
Trichomonads seen on smears should
be confirmed by HVS to exclude false
positives, though false negative HVS
also common
Metronidazole 400mg bd 5/7
Metronidazole 2g stat po
Metronidazole 2g stat po
Metronidazole 400mg bd 5 days
Diagnosis by microscopy of HVS only
Cervical cytology
TREATMENT
First line
or
Second line
In pregnancy
Clotrimazole 500mg PV nocte x1 &
Clotrimazole 1% cream bd 7/7
Clotrimazole 200mg PV nocte x3 &
Clotrimazole 1% cream bd 7/7
Fluconazole 150mg po stat &
Clotrimazole 1% cream bd 7/7
Clotrimazole 500mg PV nocte x1 &
Clotrimazole 1% cream bd 7/7.
Fluconazole should not be used in
pregnancy or breastfeeding
Metronidazole gel 0.75% PV nocte 5
days or Clindamycin 2% vag cream PV
nocte 7 days
If diagnosed, Metronidazole 400mg bd
5/7 - avoid high or single doses during
pregnancy and breastfeeding (refer to
BNF for further information)
Page 38 of 41
Tinidazole 2g stat
If diagnosed, Metronidazole 400mg bd
5/7 - avoid high or single doses during
pregnancy and breastfeeding (refer to
BNF for further information)
STI Management Guidelines for primary care: vaginal discharge
OTHER MANAGEMENT
Partner notification
Contact slip
Predisposing factors
Lambeth Southwark April15
No
No
Rarely - diabetes, HIV, if
severe/recurrent
No
No
Yes
Yes
Yes, consider STIs
Consider other STIs
Not required
Not required
Check compliance, partner
notification/treatment and resolution of
symptoms.
Depends if indicated by sexual history
Depends if indicated by sexual history
Yes
No
No
Unnecessary unless:
(i) Requested by client
(ii) Persistent symptoms
Follow-up
Testing for other STIs
Test of cure
Re-treat if :
(i) SI with untreated partner
(ii) Failed to complete treatment
Recurrent infection
Review diagnosis and consider GUM
referral if appropriate. Also consider
diabetes and immunosupression. For
more detail on recurrent infection see
guidelines
http://www.bashh.org/documents/1798
Review diagnosis and consider GUM
referral if appropriate. For more details
re: recurrent infection see BASHH
guidelines
Suspected Metronidazole resistance give Tinidazole. Failure to clear cases
or those who are allergic to
metronidazole should be sent to GUM
Not an STI
Not an STI
Almost always sexually transmitted
Common
Common
Testing for other STIs recommended
Advise avoiding alcohol during
Metronidazole treatment, because of
possibility of disulfiram-like (Antabuse®
effect) reaction
Advise avoiding alcohol during
Metronidazole or Tinidazole treatment,
because of possibility of disulfiram-like
(Antabuse® effect) reaction
INFORMATION TO GIVE CLIENTS
Vaginal gel/ cream treatment may
weaken latex condoms and diaphragms
SF - Vaginal gel/ cream treatment may
weaken latex condoms and
diaphragms
There is no evidence to treat
asymptomatic partners
Discuss predisposing factors
Partner needs treatment. Advise
avoiding sexual intercourse including
oral sex) until patient and their partner
have completed treatment and any
follow up
Can recur
Can recur
Can recur if partner not treated
Avoid douching and bath additives such
as : bubble bath / TCP / Dettol / Savlon
Avoid douching and bath additives such
Partner may have no symptoms and
as : bubble bath / TCP / Dettol /
their tests may be negative
Savlon.
Use factsheet/ leaflet
Use factsheet/ leaflet
Resume sexual activity
Written information
Use factsheet/ leaflet
Tip: remember that physiological discharge is common
References
The following BASHH Clinical Effectiveness Group Guidelines can be found at http://www.bashh.org/guidelines
1. United Kingdom National Guideline on the Management of Vulvovaginal Candidiasis (2007)
2. UK National Guideline for the management of Bacterial Vaginosis 2012
3. Management of Trichomonas vaginalis infection (2014)
4. Sexually Transmitted Infections in Primary Care Guideline, Second Edition 2013.
Royal College of General Practitioners (RCGP)and British Association for Sexual Health and HIV (BASHH)
http://www.rcgp.org.uk/clinical-and-research/clinical-resources/~/media/Files/CIRC/RCGP-Sexually-Transmitted-Infections-in-Primary-Care-2013.ashx
Lambeth and Southwark STI Management guidelines for primary care
Shared Lambeth and Southwark Council guidelines, with NHS Lambeth Clinical Commissioning Group (CCG) & NHS Southwark Clinical Commissioning Group (CCG) clinical recommendation
STI management guidelines for primary care (female – gonorrhoea, chlamydia, pelvic inflammatory disease, vaginal discharge and viral STIs)
Document control
Current Version: revised June 2013 - December 2014 (previous versions: 2005; 2008)
Lead author: Lambeth and Southwark Public Health
Review date: December 2016
Approval:
Southwark Council Southwark Health & Social Care Partnership 1.12.14
Lambeth Council: Lambeth Staying Healthy Board 6.1.15
Clinical content recommendation: Lambeth & Southwark CCGs Joint Prescribing Committee 19.8.14: Chair’s approval of final clinical amendment 2.12.14.
Sexual health commissioning acknowledgment: Lambeth Southwark and Lewisham Sexual Health Commissioning Board 25.3.15
Written by:
Specialist leads for guideline group, and for related clinicial queries:
Dr Michael Brady, GUM Consultant, Camberwell Sexual Health Centre, Kings College Hospital Foundation Trust
Contact: [email protected]
Dr Anatole Menon-Johansson, Clinical Lead, Sexual & Reproductive Health department, Guy's & St Thomas' Foundation Trust
Contact: [email protected]
Dr Stephanie May, Lambeth GP Sexual Health Champion, Stockwell Group Practice
Contact: [email protected]
Sarah French, Public Health Manager Lambeth & Southwark Public Health
Guideline development facilitator (and for related non-clinical queries):
Contact: [email protected]
Page 39 of 41
STI Management Guidelines for primary care: female - viral
Lambeth Southwark April15
Genital ulceration - Herpes simplex virus1
Genital warts - Human papilloma virus2
Molluscum contagiosum1
BACKGROUND INFORMATION
Sexually transmitted
Causative organism
Yes
Yes
Herpes simplex virus (HSV) types 1 or 2 (both can
Human papilloma virus (HPV) Types 6 and 11
cause genital herpes)
Can be sexually transmitted
Molluscum virus
SYMPTOMS
Vaginal discharge
Intermenstrual bleeding
Abdominal pain / deep
dyspareunia
Fever
Systemic illness
Local lymphadenopathy
Vulval pain/itch
Urinary symptoms
Symptomatic episodes, but asymptomatic
carriage common
rarely
rarely
-
-
rarely
-
-
+/- (rare with recurrences)
+/- (rare with recurrences)
frequently
pain preceded by itch/tingling
+ (inc. superficial dysuria and frequency)
occasionally, mild itch
-
Genital ulcers
Genital lumps
CLINICAL FINDINGS
Usual
Mucopurulent cervicitis
Cervical contact bleeding
Urethral discharge
Other signs include:
TESTS REQUIRED
Usually symptomatic
+
-
blisters (before ulcers)
Pearly round nodules with central ubilication, but
rarely ulcerated. Occasionally become inflamed/
pustular
+
Small blisters (early) or ulcers (later). The latter
may be crusted
rarely, unless primary infection
rarely
Plane or papillomatous warts, most commonly at
posterior forchette, may be perianal
Local tender lymphadenopathy
Viral PCR / culture
Yes, take firm cotton swab from base of deroofed
blister/ ulcer
Clinical diagnosis
Yes, confirmed by PCR or culture test, negative
test does not exclude HSV. PCR is the 'gold
standard' test and should be the test of choice.
Yes - warts are a clinical diagnosis, biopsy is only
indicated if very atypical
Yes
Test for other STIs
Recommended
Recommended, especially HIV if florid warts
Yes
TEST RESULTS
Results
Other comments
Positive HSV PCR or culture test, usually typed
as HSV1 or HSV2
HSV serology may be useful in management of
serodiscordant couples or in pregnancy - refer to
GUM
N/ A
N/ A
Cervical smears do not need to be carried out
more commonly than recommended by the NHS
Cervical Screening Programme
TREATMENT
Timing of treatment
First line
First episode: aciclovir 200mg 5 times a day for 714/7 (double dose in immunocompromised) ref.5 .
Advise symptomatic management: analgesia e.g
5% lidocaine ointment or Instillagel (lidocaine 2% unlicensed indication) tds prn, salt baths
Podophyllotoxin cream (0.15%) is the most easy to
apply in both men and women, but a solution
(0.5%) is available. The treatment can be applied
for limited discrete warts on vulval region as selftreatment, if the client can manage this. Prescribe
as bd applications for 3 consecutive days followed
by 4 days rest - four week cycles.
First line for perianal warts Imiquimod cream (5%)
applied topically at night 3 times/ week (maximum
16 weeks). Leave on 6-10 hours, then wash off
with mild soap, water.
Second line
Recurrence: symptomatic management only.
Episodic antivirals are an option when started
within 24 hrs of symptoms. Aciclovir 400mg 3
times a day for 3-5 days
Imiquimod 5% cream (maximum 16 weeks) applied Imiquimod 5% cream topically (unlicensed) Apply 3
topically at night 3 times/ week. Leave on 6-10
times weekly, overnight, wash off 6-10 hours later,
hours, then wash off with mild soap, water.
for up to 16 weeks.
OR Cryotherapy
Intrameatal warts need cryotherapy.
Third line
Prophylaxis: Aciclovir 400mg bd twice daily.
Review at 6 months
Refer to GUM
Refer to GUM
Aciclovir - consult GUM
Cryotherapy or nil.
Cryotherapy weekly or nil
In pregnancy
Page 40 of 41
Podophyllotoxin cream (0.5%) is easier to apply
than solution (0.5%). Apply topically for limited
discrete lesions on vulval or perianal (unlicensed)
region as self-treatment, if client can manage this.
Prescribe as bd applications for 3 consecutive days
followed by 4 days rest - 4 week cycles
STI Management Guidelines for primary care: female - viral
OTHER MANAGEMENT
Partner notification
(consider partners in last 3
months)
Contact slip
Follow-up
Referral to GUM
Lambeth Southwark April15
Not routinely
Not routinely
Not routinely
Offer
May require follow-up discussion about risks of
transmission, natural history etc.
Offer
Offer
If self treatment after 4 weeks
Any atypical ulceration +/- syphilis suspected, esp Unable to tolerate or use self treatment or if
if acquired outside of Europe
treatment required for vaginal warts
May require follow up if worsening
If multiple and severe or extra-genital (e.g. face),
consider immuno suppression and recoomend and
HIV test. GUM referral
Or if patient has specific concerns e.g. pregnancy
Other referral
Cervical warts - to colposcopy if persist >6 months
INFORMATION TO GIVE CLIENTS
Incubation
First episode can be as soon as a few days after
infection, or several years
Months to years
Salt water bathing may alleviate symptoms
Resume sexual activity
Written information
Should not resume SI until complete resolution of If in steady relationship, advise condoms until
clinical episode. Use condoms if partner not
warts resolved, but no evidence of any benefit as
known to have HSV or with new partners
partner probably already infected
Asymptomatic shedding is common,
predominantly around the time of attacks.
Transmission to a susceptible male partner is
around 5% per annum.
HSV 1 is common cause of first episode in young
people, and less likely to recur
If in steady relationship, advise condoms until
resolved, but no evidence of any benefit as partner
probably already infected
This is a self limiting infection that will not recur.
Partner may have asymptomatic infection already Partner may never develop warts
Partner may never develop molluscum growths.
Encourage patient to discuss with partner.
Use factsheet/ leaflet
Use fact sheet/ leaflet
Use factsheet/ leaflet
References
The following BASHH Clinical Effectiveness Group Guidelines can be found at http://www.bashh.org/guidelines
1. Management of genital herpes (2007)
2. United Kingdom National Guideline on the Management of Anogenital Warts (2007)
3. United Kingdom National Guideline on the Management of Molluscum Contagiosum (2007)
4. Sexually Transmitted Infections in Primary Care Guideline, Second Edition 2013.
5. Holmes K.K et al. (2008) Sexually transmitted infections 4th edition. USA: McGraw Hill
Royal College of General Practitioners (RCGP)and British Association for Sexual Health and HIV (BASHH)
http://www.rcgp.org.uk/clinical-and-research/clinical-resources/~/media/Files/CIRC/RCGP-Sexually-Transmitted-Infections-in-Primary-Care-2013.ashx
Lambeth and Southwark STI Management guidelines for primary care
Shared Lambeth and Southwark Council guidelines, with NHS Lambeth Clinical Commissioning Group (CCG) & NHS Southwark Clinical Commissioning Group (CCG) clinical recommendation
STI management guidelines for primary care (female – gonorrhoea, chlamydia, pelvic inflammatory disease, vaginal discharge and viral STIs)
Document control
Current Version: revised June 2013 - December 2014 (previous versions: 2005; 2008)
Lead author: Lambeth and Southwark Public Health
Review date: December 2016
Approval:
Southwark Council Southwark Health & Social Care Partnership 1.12.14
Lambeth Council: Lambeth Staying Healthy Board 6.1.15
Clinical content recommendation: Lambeth & Southwark CCGs Joint Prescribing Committee 19.8.14: Chair’s approval of final clinical amendment 2.12.14.
Sexual health commissioning acknowledgment: Lambeth Southwark and Lewisham Sexual Health Commissioning Board 25.3.15
Written by:
Specialist leads for guideline group, and for related clinicial queries:
Dr Michael Brady, GUM Consultant, Camberwell Sexual Health Centre, Kings College Hospital Foundation Trust
Contact: [email protected]
Dr Anatole Menon-Johansson, Clinical Lead, Sexual & Reproductive Health department, Guy's & St Thomas' Foundation Trust
Contact: [email protected]
Dr Stephanie May, Lambeth GP Sexual Health Champion, Stockwell Group Practice
Contact: [email protected]
Sarah French, Public Health Manager Lambeth & Southwark Public Health
Guideline development facilitator (and for related non-clinical queries):
Contact: [email protected]
Page 41 of 41