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 Formulary Chapter 27: Antimicrobial Guide - Full Chapter
27.11  Expand sub section  Genital Tract Infections
 note 

Genital tract infections

Sexual Health Wirral

Website: sexualhealthwirral.nhs.uk
Appointment number: 03001 235474 - Professional advice = Option 2
Address: Gemini Centre, St Catherine’s Health Centre, Derby Road, Birkenhead, CH42 0LQ

Bacterial vaginosis
Formulary

Metronidazole 400 mg BD for 7 days OR 2 g STAT* dose
Note there is greater relapse with 2 g dose

If pregnant or unable to abstain from alcohol: Metronidazole 0.75% vaginal gel 5 g applicatorful at night for 5 nights OR Clindamycin 2% cream 5 g PV at night for 7 nights

Avoid Metronidazole 2 g dose in pregnancy.

*Warning Avoid in pregnancy

Refer to GUM or Sexual Health Services if diagnosis is uncertain or the infection is recurrent or troublesome.
 
Link  BASHH
Link  BNFC Clindamycin
Link  BNFC Metronidazole
   
Candida balanitis
Formulary
Clotrimazole cream 1%. Apply 2-3 times a day for 2 weeks
Check for underlying problems
 
Link  BNFC Clotrimazole
   
Candidiasis, vaginal
Formulary

Fluconazole* 150 mg oral STAT dose OR
Clotrimazole pessary 500 mg OR Clotrimazole 10 % vaginal cream NOCTE STAT

AND Clotrimazole 1% cream TDS for 7 days

In pregnancy: avoid oral azoles and use Clotrimazole 500 mg pessary NOCTE STAT (without applicator) and 1% cream TDS for 7 days

*Warning Avoid in pregnancy

Investigate recurrent cases (4 or more episodes annually) and refer if appropriate.

 

 
Link  BASHH
Link  BNFC Clotrimazole
Link  BNFC Fluconazole
   
Chlamydia infection
Formulary

First line: Doxycycline* 100 mg BD for 7 days

Second line: Azithromycin† 1 g STAT, followed by 500 mg OD for 2 days

If at risk of pregnancy or breastfeeding:

  • Azithromycin† 1 g STAT, followed by 500 mg OD for 2 days
  • (recommended first line, most effective, but off-label) OR
  • Erythromycin 500 mg QDS for 7 days OR
  • Erythromycin 500 mg BD for 14 days OR
  • Amoxicillin 500 mg TDS for 7 days

Pregnant patients should be given a test of cure 3 weeks after completing therapy, regardless of the antibiotic used, due to lower cure rate in pregnancy.

For suspected epididymitis in men: Ofloxacin 200 mg BD 14 days OR
Doxycycline 100 mg BD 14 days

If risk of rectal infection: Doxycycline* 100 mg BD for 7 days
For example, all women, and men who have sex with men. Patients and any partners should be referred to GUM even if treated locally.

*Warning Avoid in pregnancy

† The use of azithromycin is appropriate for the treatment of chlamydia in pregnancy

Doxycycline* is now recommended first line. Emerging co-infection with macrolide resistant Mycoplasma genitalium is likely due to widespread use of azithromycin†.

Treat partners and refer to local Sexual Health or GU service.

Look for signs of PID or epididymitis and refer to appropriate guidance.

Offer and encourage full STI screening. If gonorrhoea is not excluded, use of azithromycin† alone may contribute to the development of resistance.

Advise patients to refrain from any sexual activity until they and their partner(s) have completed treatment or, in the case of Azithromycin, one week after the STAT dose.

Note May be asymptomatic or mild symptoms of infection

 
Link  BASHH
Link  SIGN
Link  BNFC Doxycycline
Link  BNFC Azithromycin
Link  BNFC Erythromycin
Link  BNFC Amoxicillin
   
Endometritis, postpartum or following gynaecological procedure or surgery
Formulary

New or changed and offensive discharge within 10 days post partum or post-gynae procedure: Co-amoxiclav 500/125 mg TDS for 7 days

In non-severe penicillin allergy: Cefalexin 500 mg TDS AND Metronidazole 400 mg TDS for 7 days

Refer patients with significant systemic symptoms or if symptoms fail to improve after 7 days
 
Link  BNFC Cefalexin
Link  BNFC Co-amoxiclav
Link  BNFC Metronidazole
   
Epididymitis or epididymo orchitis
Formulary

If > 35 years old and there is low suspicion of STI treat empirically.

If likely enteric organisms: Ciprofloxacin 500 mg BD for 14 days OR Ofloxacin 200 mg BD for 14 days

Sexual history is imperative.

If < 35 years old or if high suspicion of sexually transmitted infection at any age refer to GUM or Sexual Health services.

Submit MSU

Recent investigations or catheterisation are risk factors.

All patients with sexually transmitted epididymo-orchitis should be screened for other sexually transmitted infections. Sexual partners will also need treatment and screening.

All patients with urinary tract pathogen confirmed epididymo-orchitis should be investigated for structural abnormalities and urinary tract obstruction by a urologist.

 
   
Episiotomy or Caesarean section wound infection
Formulary

Co-amoxiclav 500/125 mg TDS for 7 days

In non-severe penicillin allergy: Cefalexin 500 mg TDS AND Metronidazole 400 mg TDS for 7 days

 
 
   
Gonorrhoea
Formulary
 
Refer all people with suspected gonorrhoea to a GUM clinic or other local specialist sexual health service for culture, treatment, and partner notification.
 
   
Herpes, genital (primary cases only)
(Refer all patients to GUM/Sexual Health Service for virological confirmation. Phone local department same day)
Formulary
Aciclovir 400 mg TDS for 5 days

Treat if suspected based on clinical appearance and history.

It may be preferable to initiate treatment in primary care if there would be a delay of > 24 hours until the patient was assessed in GUM or Sexual Health Service.

 
Link  BASHH
Link  BNFC Aciclovir
   
Pelvic sepsis or pelvic inflammatory disease
(Under review)
Formulary

Metronidazole 400 mg BD for 14 days AND
Ofloxacin* 400 mg BD for 14 days

*Warning Avoid in pregnancy

Consider Chlamydia infection. MUST be referred to GUM or Sexual Health Services for contact tracing and follow-up.

It may be preferable to initiate treatment in primary care if there would be a delay of > 24 hours until the patient was assessed by GUM or Sexual Health Service.

If gonorrhoea likely, refer to GUM or Sexual Health Service.

Consider gynaecological referral if systemically unwell.

 

 
Link  BASHH 2019 update
Link  BNFC Metronidazole
Link  BNFC Ofloxacin
   
Trichomoniasis
Formulary

Metronidazole 400 mg BD orally for 7 days OR 2 g STAT* dose

In pregnancy or breastfeeding:
Avoid 2 g single dose of Metronidazole. Consider Clotrimazole 100 mg pessary at night for 6 nights for symptom relief. Clotrimazole has no activity against Trichomonas and should only be considered if Metronidazole is refused. Important alleviating symptoms without treating the infection will only delay accessing treatment and risk complications and onward transmission.

*Warning Avoid in pregnancy

MUST be referred to GUM or Sexual Health Services for contact tracing and follow-up. Sexual partners should be treated simultaneously.
 
Link  BASHH
Link  BNFC Clotrimazole
Link  BNFC Metronidazole
   
Vaginal discharge in children
Formulary
Be guided by swab and culture sensitivity as often unexpected pathogens such as H influenzae, pneumococci or group A streptococci are present.
Consider all possible causes including foreign bodies and abuse. If abuse suspected refer urgently to paediatricians and consider safeguarding issues.
 
   
 ....
Key
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
Track Changes
Display tracking information
click to search medicines.org.uk
Link to adult BNF
click to search medicines.org.uk
Link to children's BNF
click to search medicines.org.uk
Link to SPCs
SMC
Scottish Medicines Consortium
Cytotoxic Drug
Cytotoxic Drug
CD
Controlled Drug
High Cost Medicine
High Cost Medicine
Cancer Drugs Fund
Cancer Drugs Fund
NHSE
NHS England
Homecare
Homecare
CCG
CCG

Traffic Light Status Information

Status Description

Green

Medicines considered suitable for non-specialist prescribing in primary or secondary care.  

Amber Recommended

Requires specialist assessment to enable patient selection. †Amber Recommended medicines must meet criteria: (1) Requires specialist assessment to enable patient selection (2) Following specialist assessment, the medicine is suitable for prescribing in Primary Care.  

Amber Initiated

Amber Initiated. Requires specialist initiation of prescribing. Prescribing to be continued by the specialist until stabilisation of the dose is achieved and the patient has been reviewed. Amber Initiated medicines must meet criteria: (1) Requires specialist assessment to enable patient selection (2) Medicine is suitable for on-going prescribing in Primary Care (3) Requires short to medium term specialist prescribing and monitoring of efficacy or toxicity until the patientís dose and condition is stable   

Amber Retained

Amber Patient Retained. Requires specialist initiation of prescribing. Prescribing to be continued by specialist until stabilisation of the dose is achieved and the patient had been reviewed. Patient remains under the care of specialist (ie not discharged) as occasional specialist input may be required. Amber Patient Retained medicines must meet criteria: (1)Requires specialist assessment to enable patient selection (2)Medicine is suitable for on-going prescribing in Primary Care (3) Requires short to medium term specialist prescribing and monitoring of efficacy or toxicity until the patientís dose and condition is stable (4) May require occasional specialist input indefinitely and therefore the patient should not be discharged from specialist care   

Amber

Medicines recommended or initiated by specialists in primary or secondary care. Non-specialist prescribing in primary care may follow according the RAG criteria. In process of being superceded by Amber Recommended, Amber Initiated and Amber Patient Retained.  

Purple

Shared Care. Medicines are considered suitable for Primary Care prescribing and/or management, following specialist initiation of therapy, with on-going communication between the Primary Care prescriber and specialist, within the framework of a Shared Care Agreement. Medicines designated as requiring Shared Care require on-going input from both Specialist and Primary Care clinicians and patients should not be discharged from Specialist care. Where prescribing and monitoring are required under shared care, it is implicit that the responsibility for both of these tasks rests with the prescriber. A Shared Care Agreement will always be available for Shared Care medicines and this document will include a Shared Care Agreement pro-forma which will be completed by all involved clinicians. This pro-forma will record agreement to take on defined aspects of care e.g. monitoring and/or on-going prescribing for the individual patients. A policy detailing clinician responsibilities in Shared Care Agreements must be referred to in all cases of Shared Care. All drugs to be included in this category must meet Shared Care criteria 1 to 3: SC1 Requires specialist assessment to enable patient selection and also initiation, stabilisation and review of treatment and the patient`s condition. SC2 Prescribing and/or management of the drug in Primary Care with specialist support and input, within the framework of the Shared Care Agreement is safe and convenient and that there is an appropriate mechanism for individual patient access in Primary Care. SC3 Requires specific long-term monitoring (blood test or other measurement) for adverse effects and / or efficacy of the drug to be completed in Primary Care, and requires on-going specialist support for the dose changes or management of adverse effects. Monitoring is required on a regular basis (typically four times a year). Implicit in any shared care agreement is the understanding that participation is at the discretion of the Primary Care prescriber subject to their clinical confidence.   

Red

Primary care prescribing of these medicines is NOT recommended. These treatments should be initiated by specialists only; ongoing prescribing is retained within secondary care.   

Black

Not recommended for use. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist.   

Grey

Not recommended for use at this time. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist. Further guidance will be issued when more information or evidence is made available.  

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