Lazaro N. Sexually transmitted infections in primary care, 1st edn. RCGP Sex, Drugs and HIV Task Group and British Association for Sexual Health and HIV, June 2006 www.bashh.org/documents/3179
Ceftriaxone 250 mg IM or if known to be a sensitive strain Ciprofloxacin 500 mg stat.
Also give Zithromax 1 gram stat or Doxycycline 100 mg bd for 1 week (because 50% of GC patients will also have chlamydia or non specific urethritis)
Non Specific Urethritis/Chlamydia
Azithromycin 1 gram stat
Alternatives: Doxycycline 100mg BD for 1 week
Erythromycin 250 mg qds for 2 weeks (500 mg bd works just as well as qds).
Pregnancy: Erythromycin is the first choice. If intolerant moxycillin can be used.
Pelvic Inflammatory Disease
Ofloxacin 400 mg bd for 2 weeks +/- metronidazole 400 mg bd for a week..
Ofloxacin 200 mg bd for 2 weeks
Metronidazole 400 mg bd for a week
Metronidazole 2 grams stat
Zidoval Gel PV x 5 nights
Clindamycin (Dalacin C 2%) nocte PV for a week
Amoxycillin 500 mg qds for 5 days.
Clotrimazole pessary 500 mg (Canesten 1) and Canesten cream.
Fluconazole (Diflucan) 150 mg PO stat.
Itraconazole (Sporanox) 200 mg bd for one day. If recurrent any treatment monthly x 6 mnths
Canesten HC useful if inflammation is a significant feature.
Sensilube (vulvo-vaginal lubricant) useful to prevent recurrences.
Acyclovir 200 mg x 5 daily for 5 days
General: Co-Dydramol x 2 tablets 4-hourly.
Local: Lignocaine gel or EMLA to allow patient to pass urine. Also, PU in bath or shower helpful. Zovirax cream may be useful in recurrences. Sensilube can prevent recurrences.
If pregnant and severe enough to warrant systemic therapy then Acyclovir (Zovirax) 200 mg x 5 per day for 5 days.
Prophylaxis Acyclovir 400 mg bd no need to monitor LFTs.
Metronidazole 400 mg bd for a week
Metronidazole 2 grams stat,
Tinidazole 2 grams stat.
Podophyllotoxin 0.1% (Warticon cream) for home use (if soft fleshy warts).
Imiquimod (Aldara) cream for three days a week for a month and review.
Good for recalcitrant warts and recurrences less likely. First line for peri-anal.
In clinic: Cryotherapy 95% Trichloroacetic acid.
Pediculosis / Scabies
Malathion 0.5% lotion (Derbac-M)
VAGINAL DISCHARGE CAUSES
1. Physiological – premenstrual, at ovulation, pregnancy
(i) Secondary to a cervicitis caused by Neisseria gonorrhoeae,
herpes simplex or Chlamydia trachomatis
(ii) True vaginal infections-Candida albicans, r;ichomonas
vaginalis and Gardnerella vaginalis
3. Foreign body/retained tampon
4. Cervical polyps
5. Neoplasms of the cervix or uterine body
6. Sensitivity to chemicals (disinfectants, antiseptics, etc.)
1. Unrealistic to investigate all fully
2. At least one-third will have classical Candida infection with pruritus
and/or a creamy discharge
Suggested scheme of management is shown in Table 13
1. Review cervical cytology status-if no recent smear, take one
2. If male partner has urethritis, suspect Chlamydia or Neisseria
3. Chlamydia an important cause of infection and infertility-difficult
to diagnose in general practice, so refer if cervicitis or urethritis in
4. With a microscope it is possible to identify ffichomonas directly by
examining the discharge in a drop of saline
5. Key difficulty is the possibility of sexually transmitted disease
(STD). Keep this possibility in the back of your mind
6. If no suspected STD, no cervicitis, no symptoms in the partner, no
local lesion or abdominal pain, then effectively the treatment is
either antifungal or metronidazole 400 mg bd for 5 days
Guidance for Clinical Health Care Workers: protection against infection with blood borne viruses recommendations of the Expert Advisory Group on AIDS and the Advisory Group on Hepatitis
Under the Health and Safety at Work etc Act (1974) (HSWA), GPs are legally obliged to make sure that all employees receive appropriate training and know the procedures for working safely. They must also carry out risk assessments and these could include assessing procedures under the Control of Substances Hazardous to Health Regulations 1994 (COSHH). These regulations would cover employees who have direct contact with patients’ blood, other potentially infectious bodily fluids or tissues. Immunisation of doctors and staff that have direct contact with these substances is recommended in the above regulations.
The Health Department guidance Protecting health care workers and patients from Hepatitis B and the 1996 and 2004 addenda (see above reference to the website, Annex 1) states that all health care workers who perform exposure prone procedures (EPPs) should be immunised. They should have their response to the vaccine checked and nonresponders to vaccination should be investigated for infection in order to minimise risk to patients. This guidance also states that workers whose Hepatitis B status is unknown should be tested before carrying out EPPs.
Immunisation provides protection in up to 90 per cent of patients vaccinated, but is not a substitute for good infection control procedures.
The BMA website provides a specimen Hepatitis B immunisation policy in the general practice staff (non medical) specimen handbook. Advice on suitable immunisation policies can also be obtained from the Occupational Health Service, which works with reference to guidelines published in Immunisation against Infectious Disease (see Annex 1 in the above website).
In relation to confidentiality, the BMA Website offers the following guidance:
“It is extremely important that hepatitis B infected health care workers have the same right of confidentiality as any patient seeking or receiving medical care. Occupational health notes are separate from other hospital notes and occupational health physicians are ethically and professionally obliged not to release information without the consent of the individual. There are occasions when an employer may need to be advised that a change of duties should take place, but hepatitis B status itself will not normally be disclosed without the health care worker’s consent. However, where patients are, or have been, at risk of exposure to hepatitis B from an infected healthcare worker, it may be necessary in the public interest for the employer to have access to confidential information”.
Treatment Oral metronidazole 400mg twice daily for five days.
Referral Refer patient and partner to Sexual Health Clinic for counselling, contact tracing and further management.
Overgrowth of mixed intestinal flora and gardenella vaginalis
Rx Oral metronidazole 400mg twice daily for five days.
Clindamycin 2% vaginal cream, one applicatorful at night for five nights in early pregnancy
Referral Refer recurrent infection to Sexual Health Clinic as patients require counselling regarding pre-disposing factors.
Screening Send specimen for chlamydia PCR.
Women – cervical swab, first void urine or vaginal swab. Men – first void urine.
Treatment Uncomplicated infection: Azithromycin 1g stat OR doxycycline 100mg twice daily for 7 days. Pregnancy: Erythromycin 500mg twice daily for 7 days.
Referral Urgently to Sexual Health Clinic for STI screening, counselling, treatment and partner notification.
Anaerobes, Chlamydia trachomatis, Neisseria gonorrhoeae
Metronidazole 400mg twice daily plus ofloxacin 400mg twice daily for 14 days (except in pregnancy).
To Sexual Health Clinic. In 75% of patients, pelvic inflammatory disease is due to a sexually transmitted pathogen.
Intensely painful often recurrent genital ulcers or blisters due to Herpes simplex (Type I and II)
Primary: Refer to Sexual Health immediately by telephone. Viral swab is mandatory before commencing treatment. Aciclovir 200mg five times daily for 5 days. Analgesia if required and topical lignocaine cream. Be aware of urinary retention, which requires admission to hospital for catheterisation.
Recurrent: Refer to Sexual Health Clinic for further management (episodic vs suppressive therapy).
Referral Refer all patients to Sexual Health as these patients require significant counselling and viral culture.
multiple tender ragged ulcers with necrotic base and undermined edge on penis/vulva/thighs with local lymphadenopathy
Neisseria gonorrhoeae, Chlamydia trachomatis, and non-specific pathogens.
Genital Warts Human Papilloma Virus HPV
Doctors should strongly recommend HIV testing whenever this enters the differential diagnosis including any unusual manifestation of bacterial, fungal or viral disease:
infection with tuberculosis
suspected Pneumocystis carinii pneumonia
suspected cerebral toxoplasmosis
persistent genital ulceration
presence of another blood-borne or sexually transmitted infection, e.g. syphilis, hepatitis B
suspected primary infection with a seroconversion illness (e.g. flu-like illness, suspected glandular fever with negative Epstein-Barr virus serology)
unusual tumours, i.e. cerebral lymphoma, non-Hodgkin’s lymphoma or Kaposi’s sarcoma
unexplained thrombocytopenia or lymphopenia
unusual skin problems such as severe sebhorroeic dermatitis, atypical psoriasis or extensive molluscum; re-occurring herpes zoster or herpes zoster in a young person
persistent generalised lymphadenopathy or unexplained lymphoedema
neurological problems including peripheral neuropathy or focal signs due to a space-occupying intracerebral lesion
unexplained weight loss or diarrhoea, night sweats, or pyrexia of unknown origin
any other unexplained ill health or diagnostic problem
In addition, for problems which require immunosupression, the exclusion of HIV should be considered prior to treatment.
How to test for HIV
If established infection is suspected, an HIV antibody test should be performed on venous blood
Patients should be tested on presentation, but as HIV antibodies do not appear in the blood until some weeks after infection this test should be repeated 12 weeks after any suspected contact with the virus. Patients, however, may be infectious to others during the period prior to seroconversion (the ‘window period’) and should be advised of this. Detection of the virus using polymerase chain reaction during the window period is possible but false positive tests occur and the test is not licensed for this indication
When primary infection is suspected (including needle stick injury) expert advice should be sought from an HIV specialist together with advice from the local laboratory on which tests should be performed from those locally available and, in the case of needlestick injury, the guidance on post-exposure prophylaxis from the Expert Advisory Group on AIDS should be consulted
A confirmatory test should be used by the laboratory
All HIV positive patients should have a repeat test performed on a different blood sample
All equivocal test results should be repeated and the patient referred to a genito-urinary medicine (GUM) or HIV specialist
Obtaining consent for HIV testing
Testing should be undertaken only with the individual’s specific informed verbal consent which should be documented
A leaflet may be used to provide information to the patient and thus increase uptake of HIV testing
In addition, it is necessary to talk with the patient to explain the reasons for testing, assess risk behaviour and determine most recent risk behaviour and ‘window period’
Pre-test discussion should include the following:
the benefits of testing to the individual (and significant others)
a risk assessment, including date of last risk activity to determine window period (see above)
how confidentiality will be preserved
information on insurance issues where relevant
details of how the result will be given
information about HIV transmission and risk reduction as necessary
Further discussion should take place with those with occupational issues, e.g. who currently or in the future may perform exposure-prone procedures. These should be referred for expert advice to an HIV specialist. Further discussion may also be necessary for other individuals, e.g. those with a psychiatric history/high level of anxiety/sexual or relationship issues, and rape/sexual assault victims
Testing should be considered for all patients if the outcome could affect their treatment. For patients who are unconscious or unable to understand what is being said to them, testing should be considered on a case-by-case basis according to their healthcare needs and in discussion with an HIV specialist
Care should be taken with the results of tests on unconscious patients, for example on ITU where patients’ relatives may wish to know information about the status of a patient who is not able to consent to its disclosure
If a healthcare worker has occupational exposure, and testing of the source patient is considered necessary, the patient’s consent should be obtained. The obtaining of consent and the testing should not be undertaken by the injured healthcare worker but by another responsible doctor. Each hospital should have a policy for dealing with such events. The guidance from the Expert Advisory Group on AIDS should be consulted
A written protocol should be available to ensure consistent standards, which can be audited
Feedback of results
Arrangements for communicating the results should be discussed with the patient at the time of testing. Ideally this should be face to face where a positive result is likely or for certain patients with particular issues. (In the future, use of near patient tests may be appropriate in certain circumstances to enable results to be given on the same day). All HIV positive patients should be referred to a GUM or HIV specialist for further advice and management. Post-test discussion in a GUM clinic should be offered if required
RCP HIV testing for patients attending general medical services. 2005 http://www.rcplondon.ac.uk
Follow guidelines on prevention of needlestick injuries and safe dispose of sharps.
Hospital staff should normally report to the Occupational Health Department when it is open, but are advised to attend the A&E dept out of hours.
Clean and irrigate the area thoroughly.
Take 5mls blood from the member of staff injured and send it to Virology for Hepatitis SA.
Label forms do Occupational Health Dept.
The staff member should be told to attend Occupational Health Dept within 48 hours.
If possible blood from contaminating source patient should also be collected and sent to lab for checking