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.
1. Anogenital Ulcer Disease
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)
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)
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.
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.
- 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)
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
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)
- 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
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
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
- 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
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)
- 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
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
- 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.
- 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