Modified Syndromic Approach
Malaysian Sexually Transmitted Infections 5th Guidelines
⚠️ CLINICAL PRIORITY: Treat patients at the first visit based on their SYMPTOMS. Do not wait for lab results; high default rates occur while waiting.
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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: IM Ceftriaxone 500mg OD (10 days) OR Azithromycin 2g STAT. (Doxy is contraindicated)
C. Lymphogranuloma Venereum (LGV)
Features: Painless ulcer, proctatitis, discharge, painful lymphadenitis, buboes.
- Preferred: Doxycycline 100mg BD (21 days)
- Alternative: Azithromycin 1g weekly (3 weeks) OR Erythromycin 800mg QID (21 days)
- Pregnancy: Azithromycin 1g weekly (3 weeks)
D. Chancroid
Features: Painful ulcers with necrotic base, purulent discharge, ragged edges, 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
Ulcer 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 + Doxycycline 100mg BD (7 days)
- Alternative: IM Gentamicin 240mg STAT + Azithromycin 2g STAT
T. vaginalis & M. genitalium
For persistent urethral discharge:
- Preferred: Metronidazole 400mg BD (5 days) + (Either one):
- If treated with Doxy first line: Azithromycin 500mg STAT, then 250mg OD (4 days)
- If treated with Azithro first line: Moxifloxacin 400mg OD (10-14 days)
Urethral Management
- Gram stain, C&S, NAAT, syphilis, HIV, Hep B, C
- Treat partner; TCA 14 days; Notify if confirmed
- If persistent, treat for TV/MG. Refer if no improvement
3. Vaginal Discharge
A. Candidiasis, Bacterial vaginosis
Symptoms: Abnormal discharge or vaginal erythema.
- Preferred: Pessary Clotrimazole 500mg STAT + Metronidazole 400mg BD (5-7 days)
- Alternative: Fluconazole 150-200mg STAT + Clindamycin 300mg BD (7 days)
- Pregnancy: Clotrimazole + Metronidazole (Safe in 1st trimester)
B. Gonorrhoeae, Chlamydia
Symptoms: Cervical mucopurulent discharge.
- Preferred: IM Ceftriaxone 500mg STAT + Doxycycline 100mg BD (7 days)
- Alternative: IM Gentamicin 240mg STAT + Azithromycin 2g STAT
- Pregnancy: IM Ceftriaxone 500mg STAT + Azithromycin 1g STAT
4. Lower abdominal pain / PID
Outpatient Triple Therapy
Criteria: Cervical excitation tenderness, or lower abdominal tenderness and vaginal discharge.
- Preferred: IM Ceftriaxone 500mg STAT + Doxycycline 100mg BD (14 days) + Metronidazole 400mg BD (14 days)
- Alternative: IM Ceftriaxone 500mg STAT + Azithromycin 1g/week (2 weeks) + Metronidazole 400mg BD (14 days)
PID Management & Referral
- HIV, Hep B, C, syphilis
- Refer if: No improvement after 3 days, Pregnant, Recent delivery/miscarriage, Guarding, Abnormal bleeding, or Abdominal mass.
5. Anorectal Discharge
Anorectal Coverage (GC/CT & LGV)
Passive anal sex in last 6 months and/or anal symptoms.
- GC/CT Preferred: IM Ceftriaxone 500mg STAT + Doxycycline 100mg BD (7 days)
- LGV Preferred: Doxycycline 100mg BD (21 days)
- LGV Alternative: Azithromycin 1g weekly (3 weeks)