Modified Syndromic Approach

Malaysian Sexually Transmitted Infections 5th Guidelines

⚠️ Treat patient at the first visit based on their SYMPTOMS. Don't wait for lab results. Some STI patients default follow ups.

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1. Anogenital Ulcer Disease

A. Genital Herpes (HSV)

Features: Multiple painful vesicles ± shallow ulcers.

  • Preferred: Acyclovir 400mg TDS (7–10 days)
  • Alternative: Valaciclovir 1g BD (7–10 days)
  • Pregnancy: Acyclovir 400mg TDS (7–10 days)
B. Primary Syphilis

Features: Single painless ulcer ± lymphadenopathy.

  • Preferred: IM Benzathine Penicillin 2.4 MU STAT
  • Alternative: Doxycycline 100mg BD (14 days)
  • Pregnancy: IM Benzathine Penicillin 2.4 MU STAT. Desensitize if allergic. If failed desensitisation: IM Ceftriaxone 500mg OD (10 days) OR Azithromycin 2g STAT (Doxycycline is contraindicated in pregnancy)
C. Lymphogranuloma Venereum (LGV)

Features: Painless ulcer, proctatitis, urethral/vaginal/cervical discharge, painful lymphadenitis, buboes.

  • Preferred: Doxycycline 100mg BD (21 days)
  • Alternative: Azithromycin 1g weekly for 3 weeks.
    OR Erythromycin 800mg QID (21 days)
  • Pregnancy: Azithromycin 1g weekly for 3 weeks.
D. Chancroid

Features: Single/multiple painful ulcers with necrotic base, purulent discharge and ragged undetermined edges, painful lymphadenitis, buboes.

  • Preferred: Azithromycin 1g STAT.
  • Alternative: IM Ceftriaxone 250mg STAT
    OR Ciprofloxacin 500mg BD (3 days)
    OR Erythromycin 800mg TDS (7 days)
  • Pregnancy: Azithromycin 1g STAT.
Management

  • Syphilis RDT, RPR, TPPA, NAAT, HIV, Hep B, C
  • Epidemiological treatment for partner
  • TCA 7 days. Modify treatment based on results
  • Notify if laboratory confirmed syphilis or chancroid
  • Refer Dermatologist/ID if non healing ulcer

2. Urethral Discharge (Men)

Gonorrhoea & Chlamydia

Symptoms: Urethral discharge (Pus/Watery), Dysuria, Penile irritation.

  • Preferred: IM Ceftriaxone 500mg STAT
    PLUS Doxycycline 100mg BD (7 days)
  • Alternative: IM Gentamicin 240mg STAT
    PLUS Azithromycin 2g STAT
Trichomonas vaginalis & Mycoplasma genitalium

For persistent urethral discharge

  • Preferred: Metronidazole 400mg BD (5 days)
    PLUS (either one):
    o If treated with Doxycycline first line: Azithromycin 500mg STAT, then 250mg OD (4 days)
    o If treated with Azithromycin first line: Moxifloxacin 400mg OD (10-14 days)
Management

  • Gram stain, C&S, NAAT, syphilis, HIV, Hep B, C
  • Treat partner
  • TCA 14 days
  • Notify if laboratory confirmed
  • If persistent, treat for Trichomonas vaginalis and Mycoplasma genitalium. Refer if no improvement

3. Vaginal Discharge

A. Candidiasis, Bacterial vaginosis

Symptoms: Abnormal discharge or vaginal erythema.

  • Preferred: Pessary Clotrimazole 500mg STAT
    PLUS Metronidazole 400mg BD (5-7 days)
  • Alternative: Fluconazole 150-200mg STAT
    PLUS Clindamycin 300mg BD (7 days)
  • Pregnancy: Pessary Clotrimazole 500mg STAT
    PLUS Metronidazole 400mg BD (5-7 days) - safe in 1st trimester
B. Gonorrhoeae, Chlamydia

Symptoms: Cervical mucopurulent discharge.

  • Preferred: IM Ceftriaxone 500mg STAT
    PLUS Doxycycline 100mg BD (7 days)
  • Alternative: IM Gentamicin 240mg STAT
    PLUS Azithromycin 2g STAT
  • Pregnancy: IM Ceftriaxone 500mg STAT
    PLUS Azithromycin 1g STAT
Management

  • HIV, Hep B, C, syphilis
  • If mucopurulent discharge, treat for gonococcal and chlamydial. Order wet mount, gram stain, C&S, NAAT
  • Notify if laboratory confirmed
  • TCA 14 days

4. Lower abdominal pain / PID

Outpatient Triple Therapy

Criteria: Cervical excitation tenderness, or lower abdominal tenderness and vaginal discharge.

  • Preferred: IM Ceftriaxone 500mg STAT
    PLUS Doxycycline 100mg BD (14 days)
    PLUS Metronidazole 400mg BD (14 days)
  • Alternative: IM Ceftriaxone 500mg STAT
    PLUS Azithromycin 1g per week for 2 weeks
    PLUS Metronidazole 400mg BD (14 days)
Management

  • HIV, Hep B, C, syphilis
  • Refer if
    o No improvement after 3 days
    o Pregnant
    o Recent delivery/abortion/miscarriage
    o Abdominal guarding
    o Abnormal vaginal bleeding
    o Abdominal mass

5. Anorectal Discharge

Gonorrhoeae & Chlamydia Coverage

Persons with passive anal sex in the last 6 months and/or anal symptoms.

  • Preferred: IM Ceftriaxone 500mg STAT
    PLUS Doxycycline 100mg BD (7 days)
  • Alternative: IM Gentamicin 240mg STAT
    PLUS Azithromycin 2g STAT
  • Pregnancy: IM Ceftriaxone 500mg STAT
    PLUS Azithromycin 1g STAT
C. Lymphogranuloma Venereum (LGV)

  • Preferred: Doxycycline 100mg BD (21 days)
  • Alternative: Azithromycin 1g weekly for 3 weeks.
    OR Erythromycin 800mg QID (21 days)
  • Pregnancy: Azithromycin 1g weekly for 3 weeks.
Management

  • Gram stain/C&S/NAAT
  • HIV, Hep B, Hep C and syphilis
  • TCA 7 days. Treat for LGV if failed treatment
  • Treat for herpes simplex if ulcer present
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