Procedures

STI IUSTI guidelines are intended for

use by specialists in the field of
Treatment sexually transmitted infections.
Nothing in these guidelines
Pocket is intended to supersede or
substitute for the normal doctor -
European patient relationship. The guidelines
are produced on behalf of the
Guidelines following organisations: IUSTI
Europe; the European Academy
of Dermatology and Venereology
2018 (EADV); the European Dermatology
Forum (EDF); the European
Society of Clinical Microbiology
and Infectious Diseases (ESCMID);
International Society for Infectious
Diseases in Obstetrics and
Gynaecology (ISIDOG). The
European Centre for Disease
Prevention and Control (ECDC)
and the European Office of the
World Health Organisation
(WHO-Europe) also contributed to
their development.

The EuroSTIpocket 2018 is a summary of the treatments and

procedures of the European guidelines published available on the
IUSTI website as of December 2017
http://iusti.org/regions/Europe/euroguidelines.htm

-2-
 Pdf format (Year) Page Pdf format (Year) Page
*UNDER REVIEW: Guideline under revision or in consultation, available or not in the IUSTI website as of December 2017. Recommendations in the

Chancroid (2017) 4 Balanoposthitis (2014) 18

Chlamydia (2015) 4 Epididymo-orchitis (2016) 23

Management of syndromes
Donovanosis (2016) 5 Non-gonococcal urethritis (2016) 24
Management of specific infections

Genital Herpes (2017) 6 Pelvic inflammatory disease (2017) 25

Gonorrhoea (2012) 7 Proctitis (2013) 26

guideline under revision might be different from the ones in this version of the EuroSTIpocket.

UNDER REVIEW

Hepatitis B and C (2017) 10 Sexually acquired reactive arthritis (2014) 28

HPV (2011) 12 Vaginal Discharge (2011) 29

UNDER REVIEW
UNDER REVIEW

Lymphogranuloma venereum (2013) 13 Vulval conditions (2016) 31

UNDER REVIEW

Mycoplasma genitalium (2016) 13

HIV testing (2014) 35

Procedures
Pediculosis Pubis (2017) 14
Organisation of a consultation
Scabies (2016) for sexually transmitted diseases (2012) 36
15
UNDER REVIEW

Syphilis (2014) 16 Partner Management (2015) 37

 MANAGEMENT OF SPECIFIC INFECTIONS
FVU: First void urine, NAAT: Nucleic Acid Antigen Test, POCT: Point of Care Test, TOC: Test of cure For 2nd line treatment see complete European guideline

FIRST LINE TREATMENT SECOND LINE TREATMENT DIAGNOSTICS

CHANCROID
Ceftriaxone 250 mg IM as a Ciprofloxacin 500 mg oral twice daily Culture (special media).
single dose. for 3 days.
OR OR NAAT.
Azithromycin 1 g PO as single dose. Erythromycin 500 mg oral thrice daily
Failures, especially in HIV positive or four times a day for 7 days. Specimen: swab/tissue.
individuals, have been reported.
CHLAMYDIA
Doxycycline 100 mg oral twice daily Erythromycin 500 mg oral twice daily NAAT.
for 7 days. for 7 days.
Preferred if rectal infection. OR Specimen: FVU, swab
OR Levofloxacin 500 mg oral four times a (cervical, urethral,
Azithromycin 1 g oral as a single dose day for 7 days. vulvovaginal, anal,
TOC if rectal infection. OR conjunctival, pharyngeal).
Ofloxacin 200 mg oral twice daily for
7 days.
TOC should be subsequently performed.

Josamycin 500 mg oral thrice daily or

1g twice daily for 7 days (Third line).

Management of specific infections -4-

In pregnancy and breastfeeding
Azithromycin 1 g oral as a single
dose.
Azithromycin 1 g oral once a week.
OR
Azithromicin 500 mg oral four times
a day.
Duration should be for at least 3 weeks
or until complete healing is achieved.
Amoxicillin 500 mg oral thrice daily
for 7 days.
OR
Erythromycin 500 mg oral four times
a day for 7 days.
Josamycin 500 mg oral thrice daily
or 1g oral twice daily for 7 days (Third
line).
DONOVANOSIS
Co-trimoxazole 160/800 mg oral Microscopy (Giemsa-stain).
twice daily.
OR Specimen: swab/tissue.
Doxycycline 100 mg oral twice daily.
OR
Erythromycin 500 mg oral four times
a day.
Duration should be for at least 3 weeks
or until complete healing is achieved.
Gentamicin 1 mg/kg thrice IM can also
be used as an adjunct if lesions are slow
to respond.
Management of specific infections -5-
 GENITAL HERPES
First-episode genital herpes Clinical signs/symptoms.
Aciclovir 400 mg oral three times a day OR Aciclovir 200 mg oral five times daily
OR Famciclovir 250 mg oral three times daily OR Valaciclovir 500 mg oral twice NAAT (specimen: swab).
daily. Duration for all is 5 days but extended to 10 as required.
Increased dosing and prolonged treatment periods in immunocompromised and HIV Antigen-test (POCT:
patients. fast, but low sensitivity;
specimen: swab).
Recurrent genital herpes (episodic treatment)
Aciclovir 800 mg oral three times daily for 2 days OR Famciclovir 1000 mg oral
twice daily for one day OR Valaciclovir 500 mg oral twice daily for 3 days (short
course therapies).
OR
Aciclovir 200 mg oral five times daily OR Aciclovir 400 mg oral three times daily
for 3-5 days OR Valaciclovir 500 mg oral twice daily OR Famciclovir 125 mg
oral twice daily (all for five days).

Recurrent genital herpes (supressive treatment)

Aciclovir 400 mg orally twice daily OR Aciclovir 200 mg oral four times OR
Valaciclovir 500-1000 mg oral once daily OR Famciclovir 250 mg oral twice
daily.
In pregnancy
Primary infection: Aciclovir 200 mg oral five times daily for 5-10 days -
Reactivation during 1st and 2nd trimester: Aciclovir 400 mg oral three times
daily for 5 to 10 days (usually no treatment is advised) - Preventive: Aciclovir
400 mg oral three times daily OR Valaciclovir 250 mg oral twice daily (all from
36th gestational week until delivery).

Management of specific infections -6-


Infections of the urethra, cervix and rectum in adults and adolescents
when the antimicrobial sensitivity of the infection is unknown
Ceftriaxone 500 mg IM as a single
dose together with azithromycin 2 g
oral as a single dose.
Uncomplicated infection of the pharynx
Ceftriaxone 500 mg IM as a single
dose together with azithromycin 2 g
as a single oral dose.
Genital, anorectal and pharyngeal infection when extended-spectrum
cephalosporin resistance identified
Ceftriaxone 1 g IM as a single dose
together with azithromycin 2 g oral as
a single dose.
OR
GONORRHOEA
NAAT (specimen:
swab urethral, cervical,
Cefixime 400 mg oral as a single
vulvovaginal, anal,
dose together with azithromycin 2 g
conjunctival, pharyngeal,
as a single oral dose.
FVU) - If PPV of NAAT
OR
<90% or pharyngeal
Ceftriaxone 500 mg IM as a single
NAAT pos. confirm via
dose.
independent 2nd test (NAAT
OR
with different target or
Spectinomycin 2 g IM as a single
culture).
dose together with azithromycin 2 g
oral as a single dose.
Culture (e.g. Thayer-Martin),
analysis of antibiotic
sensitivity (specimen: swab
Ceftriaxone 500 mg IM as a a single
as for NAAT, see above).
dose.
Microscopy (specimen:
plastic loop) only definitive
diagnosis in men with overt
purulent urethritis.
Management of specific infections -7-
Gentamicin 240 mg IM as a single TOC: clinical/culture 3-7
dose together with azithromycin 2 g days post treatment; NAAT
oral as a single dose. 2 weeks post treatment.
Therapy of gonococcal infections in pregnancy or when breastfeeding
During menstruation,
Ceftriaxone 500 mg IM as a single Spectinomycin 2 g IM as a single intracervical swabs for
dose. dose. culture are more reliable.
Therapy of gonococcal infections in patients with penicillin anaphylaxis
or cephalosporin allergy

Spectinomycin 2 g IM as a single When fluoroquinolone or azithromycin

dose together with azithromycin 2 g resistance are excluded.
oral as a single dose. Ciprofloxacin 500 mg oral as a single
dose.
OR
Ofloxacin 400 mg oral as a single
dose.
OR
Azithromycin 2 g oral as a single
dose.
Gonococcal epididymo-orchitis
(see also European Guideline on Epididymo-orchitis).

Ceftriaxone 500 mg IM as a single

dose together with doxycycline 100
mg oral twice daily for 10-14 days.

Management of specific infections -8-

Gonococcal pelvic inflammatory disease
(see also European Guideline on Epididymo-orchitis).
Ceftriaxone 500 mg IM as a single
dose together with doxycycline 100
mg oral twice daily together with
metronidazole 400 mg oral twice daily
for 14 days.
Therapy for disseminated gonococcal infection

Initial therapy: Ceftriaxone 1 g IM or IV every 24 hours OR Spectinomycin 2 g

IM every 12 hours. Therapy should continue for 7 days, but may be switched
24-48 hours after symptoms improve to one of the following oral regimens:
cefixime 400 mg twice daily OR ciprofloxacin 500 mg OR ofloxacin 400 mg
twice daily, if fluoroquinolone sensitivity is confirmed by appropriate laboratory
susceptibility testing.
Therapy for gonococcal conjunctivitis

Ceftriaxone 500 mg IM (Spectinomycin 2 g IM if penicillin/cephalosporin allergy)

as a single dose daily for 3 days.
OR if antibiotic resistance excluded.
Azithromycin 2 g oral as a single dose together with doxycycline 100 mg oral
twice daily for 1 week together with ciprofloxacin 250 mg oral daily for 3 days.

Therapy for ophthalmia neonatorum

Ceftriaxone 25-50 mg/kg IV or IM as a single dose, not to exceed 125 mg.

Management of specific infections -9-


See Guideline for more information on management of acute and chronic hepatitis B and C.
HBV: who to test
• Local general prevalence of HBV
carriage <2%: risk assessment
should guide testing, e.g.
MSM, people who inject drugs
(PWID), sex workers, HIV-
positive individuals, people from
countries with intermediate and
high HBV endemicity, sexual
partners of HBsAg positive or
risk group patients and those
presenting after needle stick
injury
• Local general prevalence of
HBV carriage >2%: all attenders
should be offered testing unless
they are known to be immune
HEPATITIS B AND C
HBV prevention
At-risk patients who have not
been previously vaccinated: offer
monovalent hepatitis B vaccine
or combined A and B vaccine.
Ultra-rapid 0, 1, 3 week, 12 month
vaccination course is recommended
to improve adherence.
Specific hepatitis B immunoglobulin
500 i.u. IM if recent HBV exposure
(ideally within 12h and certainly
<7days).
HBV: how to test
HBV- serology (specimen:
serum).
Exclusion of carriage or past
natural infection: HBsAg, anti-
HBc.
First-line testing with either
HBsAg or anti-HBc or both is
acceptable. See guideline for
testing algorithm.
Testing for vaccine-induced
immunity: anti-HBsAb.
POCT have lower sensitivity and
specificity. Offer blood tests in
addition.
Management of specific infections - 10 -
HCV: who to test HCV prevention HCV: how to test

Risk-based testing advised: Ensure access to harm reduction HCV- serology (specimen:
• MSM who have additional risk including needle exchange if PWID. serum, plasma).
factors including HIV infection,
report of traumatic sexual Provide access to testing. If exposure >3m ago: HCV
practice, diagnosis of LGV or antibody (median window period
syphilis, previous resolved or Partner referral. 65 days).
treated hepatitis C infection,
engaging in ‘chemsex’ Advocate safer sex and provide If exposure <3m ago: HCV
• People who currently or in the accessible tailored information. Ag or HCV RNA testing will
past injected any type of drugs have higher sensitivity where
• People who practice prostitution resources allow.
• People with a past history of
needle stick injury Previous resolved HCV infection:
• People from countries of HCV Ag or HCV RNA required.
intermediate to high hepatitis C
endemicity (>2%)
• Recipients of suspected unsafe
blood products
• Current and past prisoners
• Patients with symptoms of
acute hepatitis or found to have
deranged liver function

Management of specific infections - 11 -

 HPV
External genital and perianal warts
Clinical, colposcopy,
(Patient applied) anoscopy whitening
Podophyllotoxin (0,5% solution or 0,15% cream) twice daily for 3 days, then 4 with acetic acid (1-5%),
days off therapy (4 cycles). histopathology.
OR
Imiquimod 5% cream thrice weekly for up to 16 weeks. Exclude syphilis (serology).
OR
Sinecatechines - or green tea-catechines (10% ointment) thrice daily for up to
16 weeks.
(Provider administered)
Cryotherapy.
OR
Trichloroacetic acid (TCA) 80-85% solution.
OR
Excision or curettage or electrosurgery/laser (CO2).

Vaginal, cervical, intra-meatal, intra-anal warts

Vaginal warts can be treated with either TCA or cryotherapy. Cervical warts
should be managed by a gynaecologist. Intra-meatal warts can be treated with
either TCA or various surgical techniques. TCA can be used for small volume
intra-anal warts, and imiquimod use is feasible with suitable patient motivation;
otherwise formal surgical referral is indicated for intra-anal warts.

Management of specific infections - 12 -

 LYMPHOGRANULOMA VENEREUM

Doxycycline 100 mg oral twice daily
for 21 days.
Erythromycin 500 mg oral four times
a day for 21 days.
Azithromycin in single or multiple-dose
regimens has also been proposed but
evidence is lacking.
NAAT with genotypical
differentiation of LGV
(specimen: rectal and ulcer
swabs, bubo aspirate).

MYCOPLASMA GENITALIUM
Uncomplicated infection in the absence of macrolide resistance NAAT (specimen: swab,
FVU).
Azithromycin 500 mg oral as single For uncomplicated persistent infection.
dose (stat) then 250 mg oral once Moxifloxacin 400 mg oral once daily TOC 4-6 weeks post
daily for 4 days. for 7-10 days. treatment.
OR
Josamycin 500 mg oral thrice daily Treatment failure after moxifloxacin.
for 10 days. Pristinamycin 1 g oral four times
daily for 10 days (85% cure rate) OR
Doxycycline 100 mg oral twice daily
for 14 days (30% cure rate).

Uncomplicated macrolide resistant infection

Moxifloxacin 400 mg oral once daily

for 7 - 10 days.

Management of specific infections - 13 -

Complicated M. genitalium infection (PID, epididymitis)
(see also European Guidelines on Epididymo-orchitis and on Pelvic inflammatory
disease)
Moxifloxacin 400 mg oral once daily
for 14 days (oral).

Permethrin 1% cream (washed off
after 10 minutes). Repeat after 7-10
days.
OR
Pyrethrins with piperonyl butoxide
(washed off after 10 minutes). Repeat
after 7-10 days.
PEDICULOSIS PUBIS
Phenothrin 0.2% lotion on dry hair,
wash out after 2 h.
OR
Malathion 0.5% lotion on dry hair,
wash out 12 h after application.
OR
Ivermectin 200 µg/kg orally, repeated
after 1 week (in severe cases, 400
µg/Kg repeat after 7 days).
Clinical diagnosis,
dermatoscopy.
Consider microscopic
examination.
Screening for other STI
(including HIV).
Follow-up examination
one week after the end of
treatment. The infestation is
considered cleared if there
is no active infestation (no
presence of live lice).

Clothing, bedding, towels and other items should be machine washed (at 50°C
or higher) or dry-cleaned or sealed and stored in a plastic bag for 2 weeks.

Management of specific infections - 14 -


Permethrin 5% cream applied head
to toe and washed off after 8–12 h.
The treatment must be repeated after
7– 14 days.
OR
Oral ivermectin (taken with food) 200
µg/kg as two doses 1 week apart.
OR
Benzyl benzoate lotion 10–25%
applied once daily at night on 2
consecutive days with re-application
at 7 days.
SCABIES
Malathion 0.5% aqueous lotion. Clinical diagnosis, detection
OR of mites (microscopy of
Ivermectin 1% lotion. scrapings, dermatoscopy),
OR histology.
Sulphur 6-33% as cream, ointment
or lotion applied on three successive
days.

Clothing, bedding, towels and other items should be machine washed (at 50 °C
or higher) or dry-cleaned or sealed and stored in plastic bag for 1 week.

Crusted scabies

A topical scabicide (permethrin 5% cream or benzyl benzoate lotion 25%)

repeated daily for 7 days then 2 times weekly until cure.
AND
Oral ivermectin 200 µg/kg on days 1, 2 and 8. For severe cases, based on
persistent live mites on skin scrapings at follow-up visit, additional ivermectin
treatment might be required on days 9 and 15 or on days 9, 15, 22 and 29.

Management of specific infections - 15 -

 SYPHILIS
Syphilis erratum (2015) J Eur Acad Dermatol Venereol 2015, 29, 1248

Early syphilis (Primary, Secondary and Early latent, i.e. acquired ≤1 year Serology (specimen:
previously) serum).

Benzathine penicillin G 2.4 million Doxycycline 200 mg oral daily (either Screening and confirmatory:
units IM as single dose (one injection 100 mg twice daily or as a single 200 CLIA/ EIA/ TPHA/ TPPA
of 2.4 million units or 1.2 million units mg dose) for 14 days. Activity: RPR/ VDRL.
in each buttock). OR
Treatment for patients with HIV should be Azithromycin 2 g oral as single dose. NAAT (early infection: swab
given as for non-HIV infected patients. from sore, biopsy).

Late latent Dark field microscopy (early

Benzathine penicillin G 2.4 million Doxycycline 200 mg oral daily (either infection: fluid from sore or
units IM (one injection 2.4 million units 100 mg twice daily or as a single 200 syphilitic condyloma).
single dose or 1.2 million units in each mg dose) during 21–28 days.
buttock) weekly on days 1, 8 and 15. If penicillin allergy consider
desensitization.

Neurosyphilis, ocular and auricular syphilis

Benzyl penicillin 18–24 million units Ceftriaxone 1–2 g IV daily during

IV daily, as 3–4 million units every 4 h 10–14 days.
during 10–14 days. OR
Procaine penicillin 1.2–2.4 million
units IM daily and probenecid 500
mg four times daily, both during
10–14 days.

Management of specific infections - 16 -

Syphilis in pregnancy

Pregnant women should be treated with the first line therapy option appropriate
for the stage of syphilis and if allergic to penicillin should be desensitized.

Congenital syphilis

See complete European guideline.

Management of specific infections - 17 -

 MANAGEMENT OF SYNDROMES
BALANOSPOSTITIS
General management of the patient with balanitis

• Sexual history taken

• Sub-preputial swab for Candida spp. and bacterial culture – should be undertaken in most cases to exclude
an infective cause or superinfection of a skin lesion or dermatosis
• Urinalysis for glucose (exclude diabetes)
• NAAT for HSV and Treponema pallidum (and/or dark ground examination for spirochaetes) – if ulceration
present
• Culture/wet prep or NAAT for Trichomonas vaginalis – particularly if a female partner has an undiagnosed
vaginal discharge
• Full routine screening for other STIs
• Dermatology opinion for dermatoses and suspected allergy
• Biopsy – if the diagnosis is uncertain and the condition persists

Candidal balanitis

Clotrimazole cream 1%. Fluconazole 150 mg stat orally– if Sub-preputial culture

OR symptoms severe. (isolation of Candida
Miconazole cream 2%. OR spp. on culture does not
Nystatin cream 100,000 units/g – if prove causality, as it may
resistance suspected, or allergy to represent colonisation).
imidazoles.

Management of syndromes - 18 -
 OR
Topical imidazole with 1%
hydrocortisone – if marked
inflammation is present.
Investigation for other
causes e.g. HIV or other
causes of
immunosuppression if
balanitis is severe or
persistent.

Anaerobic infection

Metronidazole 400–500mg twice daily Co-amoxiclav 375 mg three times Gram stain.
for 7 days. daily for 7 days. Sub-preputial culture (to
OR OR exclude other causes e.g.
Milder cases may respond to topical Clindamycin cream applied twice Trichomonas vaginalis).
metronidazole. daily until resolved. Swab for herpes simplex
virus infection if ulcerated.

Aerobic infection

Trimovate cream applied once daily. Sub-preputial culture

OR (Streptococci and
Erythromycin 500 mg oral four times a Staphylococcus aureus
day for 7 days. have both been reported;
OR other organisms may also
Co-amoxiclav 375 mg oral three times be involved).
daily for 7 days.

Sexually transmitted infections: Herpes simplex virus, Trichomonas vaginalis, Syphilis: See diagnosis and
treatment as per specific guidelines.

Management of syndromes - 19 -
Lichen sclerosus
Ultrapotent topical steroids (e.g.
clobetasol proprionate) applied once
daily until remission.
Lichen planus
Moderate to ultrapotent topical
steroids depending on severity
(for both mucosal and cutaneous
disease).
Zoon’s (plasma cell) balanitis
Circumcision.
OR
Topical steroid preparations – with or
without added antibacterial agents
e.g. Trimovate cream, applied once or
twice daily. Hygiene measures.
Topical calcineurin inhibitors Biopsy.
(pimecrolimus applied twice
daily) -concern about the risk of
malignancy.
OR
Surgery may be indicated to address
symptoms due to persistent phimosis
or meatal stenosis.
Topical and oral ciclosporin. Biopsy.
OR
Topical calcineurin inhibitors
(pimecrolimus applied twice daily
- but no specific reports in penile
disease).
OR
Circumcision.
CO2 laser. Biopsy.
OR
Topical tacrolimus – controversy
about the risk of malignancy.
Management of syndromes - 20 -
Psoriasis
Moderate potency topical steroids
(plus antibiotic and antifungal
optional). Emollients.
Circinate balanitis
See under ‘Psoriasis’. Treatment of
any underlying infection.
Topical Vitamin D preparations Consider biopsy.
(calcipotriol or calcitriol applied twice
daily).
OR
Topical bethamethasone
dipropionate/calcipotriol ointment
may be well tolerated in treatment
of anogenital psoriasis, but potent
steroids may not be indicated.
OR
Topical tacrolimus has been used in
small studies.
OR
Topical pimecrolimus.
Consider biopsy and
HLAB27 testing.
STI screening.
Management of syndromes - 21 -
Eczema (Irritant/allergic balanitides)
Hydrocortisone 1% applied once
or twice daily until resolution of
symptoms.
Seborrheic dermatitis
Antifungal cream with a mild to
moderate steroid.
Non-specific balanoposthitis
Circumcision is curative.
Fixed drug eruption
Condition will settle without treatment.
Topical steroids – e.g. mild to moderate strength twice daily until resolution. Rarely systemic steroids may be
required if the lesions are severe.
In more florid cases more potent Patch tests (referral to a
topical steroids may be required dermatologist is useful if
and may need to be combined with allergy is suspected).
antifungals and/or antibiotics. Biopsy.
Culture (to exclude
superinfection).
Oral azole e.g. itraconazole.
OR
Oral tetracycline.
OR
Oral terbinafine.
Management of syndromes - 22 -
Pre-malignant conditions: Penile carcinoma in situ of the glans (Erythroplasia of Queyrat) and of the
keratinised skin or shaft (Bowen’s disease) - Bowenoid papulosis.

Surgical excision. Imiquimod 5% cream. Biopsy.

OR
Photodynamic therapy.
OR
Laser resection.
OR
Fluorouracil cream 5%.
OR
Cryotherapy.

EPIDIDYMO-ORCHITIS
Sexually transmitted epididymo-orchitis Gram stained / methylene
blue stained urethral smear.
Ceftriaxone 500 mg IM as a single Ofloxacin 200 mg oral twice daily for Urine dipstick.
dose. 14 days. Urethral swab for N.
PLUS OR gonorrhoea culture.
Doxycycline 100 mg oral twice daily Levofloxacin 500 mg oral once daily FVU / urethral swab for
10-14 days. for 10 days. NAAT for N. gonorrhoea,
C. trachomatis and M.
genitalium.

Management of syndromes - 23 -
Epididymo-orchitis most likely secondary to enteric organisms
Ofloxacin 200 mg oral twice daily for
14 days.
OR
Levofloxacin 500 mg oral once daily
for 10 days.
NON-GONOCOCCAL URETHRITIS
Doxycycline 100 mg oral twice daily
or 200 mg oral once daily for 7 days.
Azithromycin 500 mg oral as single
dose (stat) then 250 mg oral once
daily for 4 days.
OR
Lymecycline 300 mg oral twice daily
for 10 days.
OR
Tetracycline hydrochloride 500 mg
oral twice daily for 10 days.
NB Azithromycin 1 gram stat (should
not be used routinely because of the
increased risk of inducing macrolide
antimicrobial resistance with M.
genitalium).
Mid-stream specimen of
urine for microscopy and
culture.
C-reactive protein and
erythrocyte sedimentation
rate.
Urethral swab/plastic loop/
metal device stained smear:
Microscopy to confirm
presence of urethritis.
FVU NAAT for C.
trachomatis and N.
gonorrhoea and M.
genitalium with screening
for macrolide resistance
recommended.
See specific Guideline if
patient is C. trachomatis,
N. gonorrhoea or M.
genitalium-positive.
Management of syndromes - 24 -
 PELVIC INFLAMMATORY DISEASE
Outpatient regimens NAAT for M. genitalium,
C. trachomatis and N.
Ceftriaxone 500 mg IM as single Ofloxacin* 400 mg oral twice daily for
gonorrhoea.
dose. 14 days.
FOLLOWED BY OR
Pregnancy test.
Doxycycline 100 mg oral twice daily Levofloxacin* 500 mg oral once daily
plus metronidazole 400 mg oral twice for 14 days.
Consider ultrasound and
daily for 14 days. PLUS (for either)
laparoscopy.
Metronidazole 500 mg oral twice
daily for 14 days.
OR

Moxifloxacin* 400 mg oral once daily

Inpatient regimens
Cefoxitin 2 g IV four times daily.
PLUS
Doxycycline 100 mg IV twice daily.
FOLLOWED BY
Doxycycline 100 mg oral twice daily
plus metronidazole 400 mg oral twice
daily to complete 14 days.
for 14 days.
Clindamycin 900 mg IV thrice daily.
PLUS
Gentamicin (2 mg/kg loading dose
followed by 1.5 mg/kg three times
daily) IV.
FOLLOWED BY EITHER
Clindamycin 450 mg oral four times
daily to complete 14 days.
OR

Management of syndromes - 25 -
 Doxycycline 100 mg oral twice daily
plus metronidazole 400 mg oral twice
daily to complete 14 days.

OR
Ofloxacin* 400 mg IV twice daily.
PLUS
Metronidazole 500 mg IV thrice daily
for 14 days.

* In women who are at high risk of gonococcal PID (e.g. when the patient’s
partner has gonorrhoea, in clinically severe disease, following sexual contact
abroad) a regimen containing ceftriaxone should be used.

PROCTITIS
See specific Guideline and treat accordingly if patient has proctitis due to For proctitis, proctocolitis
N. gonorrhoeae, C. trachomatis genotypes D-K or genotypes L1–3 (LGV), T. and enteritis caused by
pallidum or Herpes simplex virus. sexually transmissible
pathogens:
Syndromic treatment of proctitis
Doxycycline 100 mg oral twice daily for 7 days.
NAAT for C. trachomatis
PLUS
and N. gonorrhoea and/
Therapy for other suspected pathogen/s according to specific guideline.
or T. pallidum or Herpes
simplex virus.

Management of syndromes - 26 -
Syndromic treatment of proctocolitis (amoebiasis suspected) Syphilis serology (specimen:
Metronidazole 750 mg oral thrice daily for 5–10 days. serum).

Syndromic treatment of enteritis Culture of Shigella

Ciprofloxacin 500 mg oral twice daily for 5 days. spp., Salmonella spp.
OR or Campylobacter spp.
Co-trimoxazole 960 mg oral twice daily for 7 days. (specimen: feces).
OR
Azithromycin 500 mg oral once daily for 3 days. Microscopic examination
for the trophozoites of
Shigella, salmonella and campylobacter infections Entamoeba histolytica
and/or Giardia lamblia of
Consider ciprofloxacin 500 mg oral diarrhoeal stool specimens.
twice daily for 5 days.

Amoebiasis Anoscopy or
sigmoidoscopy, consider
Metronidazole 750 mg oral thice Tinidazole 2 g oral once daily for biopsy.
daily for 5 to 10 days followed by 2–3 days followed by (same as
paromomycin 10 mg/kg/day oral metronidazole). Specific enzyme
thrice daily for 5–10 days. immunoassays, direct
OR immunofluorescence tests
Diloxanide furoate 500 mg oral thice and NAAT for the detection
daily for 10 days. of antigens/DNA.
OR
Clioquinol 250 mg oral thrice daily for
10 days.

Management of syndromes - 27 -
Giardiasis

Metronidazole 500 mg oral twice daily Tinidazole 2 g oral as a single.

for 5 days.

Cryptosporidiosis and microsporidiosis

Paromomycin 500 mg oral thrice daily

for 7 days.

Non-specific proctitis

Doxycycline 100 mg oral twice daily

for 7 days.

SEXUALLY ACQUIRED REACTIVE ARTHRITIS

Constitutional symptoms Clinical features of
Rest. spondyloarthritis.
Non-steroidal anti-inflammatory
drugs. Demonstration of evidence
Genital infection of genito-urinary infection.
Refer to the relevant infection
guidelines. Further investigation (see
Arthritis Guideline).
Physiotherapy and physical therapy
Non-steroidal anti-inflammatory drugs
Intra-articular corticosteroid
injections.

Management of syndromes - 28 -

Bacterial vaginosis
Metronidazole 400 - 500 mg oral
twice daily for 5 to 7 days.
OR
Intravaginal metronidazole gel
(0.75%) once daily for 5 days.
OR
Intravaginal clindamycin cream (2%)
once daily for 7 days.
Vaginal candidosis
Oral preparations include:
Fluconazole 150 mg as a single dose.
OR
VAGINAL DISCHARGE
Metronidazole 2 g oral as a single Clinical / microscopy (3 of 4
dose. criteria):
OR 1. Homogeneous gray-white
Tinidazole 2 g oral as a single dose. discharge
OR 2. pH of vaginal fluid > 4.5
Tinidazole 1 g oral once a day for 5 3. Fishy odour (if not
days. recognizable, use few drops
OR of 10% KOH)
Clindamycin 300 mg oral twice daily 4. Clue cells present on wet
for 7 days. mount microscopy
OR (specimen: vaginal swab).
Dequalinium chloride 10 mg vaginal
tablet once daily for 6 days. Gram stained smear
with Gardnerella and/or
Mobiluncus morphotypes,
clue cells and few or absent
Lactobacilli.
Clinical: increased
discharge, often itchy, with
absence of odour.
Management of syndromes - 29 -
Itraconazole 200 mg twice daily for Tests: microscopy or
one day. culture evidence of yeasts
Intravaginal treatments include: (Sabouraud agar).
Clotrimazole vaginal tablet 500 mg
once or 200 mg once daily for 3 days.
OR
Miconazole vaginal ovule 1200 mg as
a single dose or 400 mg once daily
for 3 days.
OR
Econazole vaginal pessary 150 mg as
a single dose.

Trichomonas vaginalis

Metronidazole 400-500 mg oral twice Microscopy or culture or

daily for 5 to 7 days. NAAT.
OR
Metronidazole 2 g oral as a single.
dose
OR
Tinidazole 2 g oral as a single dose.

Management of syndromes - 30 -
 VULVAL CONDITIONS
General advice for all vulval conditions

• Avoid contact with soap, shampoo and bubble bath. Simple emollients can be used as a soap substitute and
general moisturizer
• Avoid tight fitting garments which may irritate the area
• Avoid use of spermicidally lubricated condoms
• Patients should be given a detailed explanation of their condition, with particular emphasis on any long-term
health implications, which should be reinforced by giving them clear and accurate written information about
the condition
• Consent should be sought for the patient’s GP to be informed about the diagnosis and management
(See Guideline for detailed management of each condition).

Vulvar dermatitis
A topical steroid (e.g. 1% Calcineurin inhibitors. Biopsy rarely needed.
hydrocortisone ointment) for mild Patch testing useful if
cases and mometasone furoate OR allergic contact dermatitis.
betamethasone valerate 0.025% for Culture.
more severe disease; daily for 7-10
days.
Vulvar psoriasis
Topical corticosteroids prescribed in Consider biopsy.
sequential or rotational therapeutic
regimens: mid potency topical
steroids followed by low potency
topical steroids

Management of syndromes - 31 -
OR
Topical vitamin D analogues in mono-
therapy or in combination with topical
corticosteroids.
OR
Coal-tar preparations (e.g. 1-5% liquor
carbonis detergens in aqueous cream)
in mono-therapy or in combination
with topical corticosteroids.

Lichen simplex chronicus

Improvement of skin barrier function Topical calcineurin inhibitors Biopsy rarely needed.
(saline soaks, followed and later twice daily for up to 12 weeks Patch testing useful if
replaced by lubricants) Identifying (pimecrolimus 1% cream, tacrolimus allergic contact dermatitis.
underlying disease, if any. 0.1% ointment). Culture.
In severe disease, superpotent OR Serum ferritin.
topical corticosteroid, e.g. clobetasol Narrow band ultraviolet B, delivered
propionate 0.05% ointment, once or by comb-like instrument.
twice daily.
In case of nighttime scratching:
mildly sedative antihistamine (e.g.
hydroxyzine), or tricyclic (e.g.
amitriptyline).

Management of syndromes - 32 -
Lichen sclerosus
Potent or ultra-potent topical Topical calcineurin inhibitors. Consider investigation for
steroids (e.g. mometasone furoate or OR autoimmune disease.
clobetasol proprionate). Systemic retinoids.
OR
Phototherapy.
OR
Surgery.

Lichen planus
Ultrapotent topical steroids (e.g.
clobetasol proprionate).
An ultra-potent topical steroid
with antibacterial and antifungal
(e.g. clobetasol with neomycin
and nystatin) or an alternative
preparation.
OR
Topical calcineurin inhibitors.
Consider biopsy.
Patch testing useful if
allergic contact dermatitis.
Culture.
Consider investigation for
autoimmune disease.

Vulvodynia
Local anaesthetics (e.g. 5% lidocaine
ointment or 2% lidocaine gel).
Oral pain modifiers (e.g. amitriptyline).
Psychosexual interventions.

Management of syndromes - 33 -
Vulvar intraepithelial neoplasia
Surgical cold knife excision. Biopsy
OR
Laser CO2 therapy.
OR
Loop electrosurgical procedure.
OR
Imiquimod cream.
OR
Follow up without treatment
(spontaneous regression).

Management of syndromes - 34 -

Screening: serology test, POCT
• Fourth generation screening
assays that simultaneously test
for anti-HIV antibodies and p24
antigen are recommended.
Assays available in Europe
have excellent sensitivities
(99.78–100%) and specificities
(99.5–99.93%)
• Rapid, POCT facilitate access to
HIV testing and ensure results
are returned and are acted upon
immediately. It is recommended
that health-care providers
familiarize themselves with the
performance characteristics of
the test adopted as these inform
PROCEDURES
HIV TESTING
HIV screening and confirmatory tests
Confirmation of reactive serology results
• Reactive screening test results
should be confirmed in a laboratory
with experience in HIV confirmation
• Confirmatory algorithms vary.
Generally, they include at least one
additional antibody or antibody/
antigen serology test that employs
a different platform from the initial
screening test. An antibody test is
also used to differentiate between
HIV types. The final laboratory report
must clearly indicate whether the
patient has an HIV-1, HIV-2 or dual
infection
• Repeat serology testing of a second
sample is recommended to rule out
mislabelling and confirm patient
Recent HIV infection
• HIV-1 RNA testing is
indicated in patients
with suspected primary
HIV infection who show
negative or indeterminate
serology results; if HIV-1
RNA is detected, infection
should be confirmed
by demonstrating
seroconversion in a sample
collected 1–2 weeks later.
Low HIV-1 RNA (<1000
copies/mL) values should
be interpreted with caution
and not considered as
indicative of infection in the
absence of further evidence
Procedures - 35 -
 Screening: serology test, POCT
use and counselling. Health-
care providers should be aware
that rapid HIV tests (including
combined antibody/antigen tests)
offer reduced sensitivity relative
to laboratory-based tests and
may therefore give false negative
results in early HIV infection
Confirmation of reactive serology results Recent HIV infection
identity. It may be replaced by
testing a plasma sample for HIV-
1 RNA, provided the viral load is
>1000 copies/mL. In patients with
a lower or undetectable viral load,
a second serum sample should
be collected for repeat serological
testing

ORGANIZATION OF A CONSULTATION FOR SEXUALLY TRANSMITED DISEASES

This guideline is intended to serve as a framework for those Personnel.
working in any location where sexually transmitted infections are Case note and specimens.
managed. It offers recommendations which will need to be adapted Ethics.
depending on local facilities and policies, and is not intended to be History obtained from the patient.
all encompassing. This guideline should be read in conjunction with Physical examination of the patient.
other European guidelines on the management of specific infections. Investigations.
Results and treatment.
Partner notification/contact tracing.
Follow-up.

Procedures - 36 -
 PARTNER MANAGEMENT
Partner management is the process of identifying the contacts of a person infected by a sexually transmitted
infection (STI) and referral to a health care provider for appropriate management. It represents a public health activity.

Disease Period to trace contacts Epidemiological treatment

(alphabetical order) (from onset of symptoms)
Chancroid 10 days Yes

Chlamydia trachomatis infection 6 months Yes

(including Lymphgranuloma
venereum)
Donovanosis (Granuloma inguinale) Up to 1 year according to Yes
estimated time of infection.
Epididymo-orchitis 6 months Yes
Gonorrhoea 3 months Yes
Hepatitis A According to estimated time of No. Consider testing and/or
infection or 2 weeks before the onset vaccination of sexual and
of jaundice. household contacts.
Hepatitis B* According to estimated time of No. Consider testing and/or
infection or 2 weeks before the onset vaccination of sexual and
of jaundice. household contacts.
Hepatitis C* As far back as estimated time of No
infection if index case and/or contact
is HIV positive (men who have sex with
men only).
*Possible vertical transmission may require screening of children.

Procedures - 37 -
 Disease Period to trace contacts Epidemiological treatment
(alphabetical order) (from onset of symptoms)

HIV 3 months in recent infection or since Postexposure prophylaxis

last negative HIV test or guided by the where indicated by national
sexual history if untested. guidelines.

Non-gonococcal urethritis 4 weeks Yes

Pelvic inflammatory disease 6 months Yes

Phthirius pubis infestation 3 months Yes

Scabies 2 months Yes

Syphilis Primary 3 months Yes

Secondary 6 months Yes
Early latent 2 years Yes
Late latent and tertiary Up to 30 years No

Trichomonas vaginalis infection 2 months Yes

Partner management should be offered at follow-up visits, if there are new sexual contacts who are either HIV negative or of unknown HIV status or if other STIs are
detected.

Comments to be sent to Dr Martí Vall-Mayans, STI Unit Vall d’Hebron-Drassanes, Barcelona: m.vall@vhebron.net

Procedures - 38 -
European STI Guidelines Project Editorial Board
Keith Radcliffe, UK – Editor-in-Chief Representatives
Martí Vall-Mayans, Spain
Andy Winter, UK Gilbert Donders, Belgium – ISIDOG
Deniz Gökengin, Turkey Mario Poljak, Slovenia – ESCMID
Marco Cusini, Italy Gianfranco Spiteri, Malta – ECDC
Mikhail Gomberg, Russia George-Sorin Tiplica, Romania – EADV
Jorgen Skov Jensen, Denmark Lali Khotenashvili, Georgia - WHO-Europe
Raj Patel, UK Michel Janier, France – UEMS

Source: STI Unit Vall d’Hebron-Drassanes, Barcelona

Jonathan Ross, UK Alexander Nast, Germany– EDF
Jackie Sherrard, UK Oral syphilitic chancre Gonococcal urethritis
Magnus Unemo, Sweden
Willem van der Meijden, Netherlands
Norbert Brockmeyer, Germany

Lymphogranuloma venereum proctitis Vulval condiloma acuminata

Procedures