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SEXUALLY-TRANSMITTED INFECTIONS
Sexually transmitted infections (STIs) which have similar signs and symptoms are grouped into syndromes:
Anogenital ulcer disease (syphilis, herpes simplex, chancroid, lymphogranuloma venereum (LGV), donovanosis, Mpox)
Urethral discharge (gonorrhoea, chlamydia, non-gonococcal urethritis, epididymo-orchitis)
Vaginal discharge (trichomoniasis, bacterial vaginosis, candidiasis, cervicitis)
Anorectal discharge (gonorrhoea, chlamydia, LGV)
Syndromic approach is essential to ensure appropriate, prompt and effective treatment.
1. ANOGENITAL ULCER DISEASE
1. ANOGENITAL ULCER DISEASE
1.1 Syphilis
Treponema pallidum
1.1.1 Primary syphilis, Secondary syphilis, Early latent syphilis (history of syphilis infection within the last 2 years)
Preferred
Benzathine Penicillin 2.4MU IM STAT
OR
Procaine Penicillin 600,000units IM q24h for 10 days
Alternative
For penicillin allergy:
Doxycycline 100mg PO q12h for 14 days
Comments
Sexual partner(s) should be examined, investigated and treated epidemiologically.
Abstain from sex for 1 week after the patient and partner(s) have completed treatment.
If drug administration is interrupted for ≥ 1 day at any point during the treatment course, the entire course may need to be restarted.
Patients should be warned of possible reactions to treatment:
Jarisch-Herxheimer reaction
Anaphylaxis/allergy
1.1.2 Late latent syphilis, Gumma (benign tertiary) syphilis, Cardiovascular syphilis
Preferred
Benzathine Penicillin 2.4MU IM weekly for 3 weeks (Day 1, 8, and 15)
OR
Procaine penicillin 600,000units IM q24h for 14 days
Alternative
For penicillin allergy:
Doxycycline 100mg PO q12h for 28 days
Comments
Sexual partner(s) should be examined, investigated and treated epidemiologically.
Abstain from sex for 1 week after the patient and partner(s) have completed treatment.
Cardiovascular syphilis: Consider prednisolone 40-60mg PO q24h for 3 days starting 24 hours before the antibiotics.
If benzathine penicillin is interrupted by ≥ 2 weeks in between the weekly doses, the entire course needs to be restarted.
1.1.3 Neurosyphilis
Preferred
Benzylpenicillin 4MU q4h IV for 14 days
OR
Procaine penicillin 2.4MU IM q24h for 14 days
PLUS
*Probenecid 500mg PO q6h for 14 days
Alternative
For penicillin allergy without anaphylaxis:
Ceftriaxone 2g IM or IV q24h for 14 days
OR
If anaphylaxis to penicillin:
Doxycycline 200mg PO q12h for 28 days
Comments
Consider Prednisolone 40-60mg PO q24h for 3 days starting 24 hours before the antibiotics.
*Indication not listed in MOH Drug Formulary.
1.1.4 Syphilis in HIV (Primary, secondary, early and late latent and neurosyphilis)
Treatment as appropriate for stage of infection.
1.1.5 Incubating syphilis / epidemiological treatment
Preferred
Benzathine penicillin 2.4MU IM STAT
Alternative
For penicillin allergy:
Doxycycline 100mg PO q12h for 14 days
Comments
--
1.2 Syphilis in Pregnancy
1.2.1 Primary syphilis, Secondary syphilis, Early latent syphilis (history of syphilis infection within the last 2 years)
Preferred
Benzathine Penicillin 2.4MU IM STAT
OR
Procaine Penicillin 600,000units IM q24h for 10 days
Alternative
For penicillin allergy:
*Desensitize and treat with penicillin as there are no proven alternatives.
If failed desensitization:
Ceftriaxone 500mg IM q24h for 10 days
OR
Azithromycin 2g PO STAT
OR
Erythromycin ethylsuccinate 800mg PO q6h for 14 days
Comments
Sexual partner(s) should be examined, investigated and treated epidemiologically.
If macrolide is used, for neonate assessment and treatment at birth.
*The benefit of treatment outweighs the risk of allergic reaction in skin test and desensitization. Refer to Appendix 3 for the penicillin desensitization protocol.
1.2.2 Late latent syphilis, Gumma (benign tertiary) syphilis, Cardiovascular syphilis
Preferred
Benzathine Penicillin 2.4MU IM weekly for 3 weeks (Day 1, 8, and 15)
OR
Procaine penicillin 600,000units IM q24h for 14 days
Alternative
For penicillin allergy:
Erythromycin ethylsuccinate 800mg PO q6h for 28 days
Comments
Sexual partner(s) should be examined, investigated and treated epidemiologically.
If macrolide is used, for neonate assessment and treatment at birth.
Cardiovascular syphilis: Consider prednisolone 40-60mg PO q24h for 3 days starting 24 hours before the antibiotics.
1.2.3 Neurosyphilis
Preferred
Benzylpenicillin 4MU q4h IV for 14 days
OR
Procaine penicillin 2.4MU IM q24h for 14 days
PLUS
*Probenecid 500mg PO q6h for 14 days
Alternative
For penicillin allergy without anaphylaxis:
Ceftriaxone 2g IM or IV q24h for 14 days
Comments
Consider Prednisolone 40-60mg PO q24h for 3 days starting 24 hours before the antibiotics.
*Indication not listed in MOH Drug Formulary.
1.3 Genital Herpes
Herpes simplex virus (HSV) Type 1 and 2
1.3.1 First episode
Preferred
Acyclovir 400mg PO q8h for 7-10 days
Alternative
*Valacyclovir 1g PO q12h for 7-10 days
Comments
Physical supportive measures (saline bathing, analgesia, local anaesthetics) are recommended.
Oral antiviral drugs indicated within 5 days of the start of the episode and while new lesions are still forming.
Topical antivirals are less effective than oral agents and not recommended, due to the association with acyclovir resistant strain.
Addition of topical antivirals to oral treatment is of no benefit.
*Not listed in MOH Drug Formulary.
1.3.2 Recurrent episode
Preferred
Short course:
Acyclovir 800mg PO q8h for 2 days
5-day course:
Acyclovir 800mg PO q12h for 5 days
Alternative
Short course:
*Valacyclovir 500mg PO q12h for 3 days
5-day course:
*Valacyclovir 1g PO q24h for 5 days
Comments
*Not listed in MOH Drug Formulary.
1.3.3 Suppressive therapy
If ≥ 6 recurrences/year, severe, prolonged or with psychosocial problems.
Preferred
Acyclovir 400mg PO q12h for up to 1 year, then reassess.
If break-through recurrences occur:
Increase to Acyclovir 400mg PO q8h for 7-10 days
Alternative
*Valacyclovir 500mg PO q24h for up to 1 year, then reassess
If ≥ 10 recurrences/year:
*Valacyclovir 1g PO q24h for up to 1 year, then reassess
Comments
*Not listed in MOH Drug Formulary.
1.3.4 Severe disease
Requiring hospitalisation.
Preferred
Acyclovir 5-10mg/kg/dose IV q8h for 10-14 days
Alternative
--
Comments
--
1.3.5 First episode (in pregnancy)
Preferred
Acyclovir 400mg PO q8h for 7-10 days
For 3rd trimester acquisition:
Continue treatment till delivery
Alternative
*Valacyclovir 500mg PO q12h for 7-10 days
Comments
*Not listed in MOH Drug Formulary.
1.3.6 Recurrent episode (in pregnancy)
Preferred
Acyclovir 400mg PO q8h
Treatment recommended starting at 36 weeks’ gestation.
Alternative
*Valacyclovir 500mg PO q12h
Treatment recommended starting at 36 weeks’ gestation.
Comments
*Not listed in MOH Drug Formulary.
1.4 Other Anogenital Ulcer Diseases
1.4.1 Chancroid
Haemophilus ducreyi
Preferred
Azithromycin 1g PO STAT
Alternative
Ceftriaxone 250mg IM STAT
OR
Ciprofloxacin 500mg PO q12h for 3 days
OR
Erythromycin ethylsuccinate 800mg PO q8h for 7 days
Comments
Sexual partner(s) within 10 days before onset of the patient’s symptoms should be examined and treated even in the absence of symptoms.
Patients should be re-examined 3-7 days after initiation of therapy.
Successful treatment: Ulcers improve symptomatically within 3 days and substantial re-epithelization occurs within 7 days after onset of therapy.
In pregnancy/breastfeeding, to use azithromycin, ceftriaxone or erythromycin.
1.4.2 Lymphogranuloma Venereum (LGV)
Chlamydia trachomatis serovars L1,2,3
Preferred
*Doxycycline 100mg PO q12h for 21 days
Alternative
Azithromycin 1g PO weekly for 3 weeks
OR
Erythromycin ethylsuccinate 800mg PO q6h for 21 days
Comments
Sexual partner(s) within 60 days should be evaluated and treated if symptomatic. If asymptomatic, they should be empirically treated for exposure with doxycycline 100mg PO q12h for 7 days.
Proctitis and anorectal discharge are common especially in the MSM population.
Fluctuant buboes: Should be aspirated through healthy adjacent skin. Surgical incision contraindicated.
If an alternative treatment regimen is given or pregnant, consider test-of-cure 4 weeks after completion of treatment.
*Doxycycline is contraindicated in pregnancy.
1.4.3 Granuloma Inguinale (Donovanosis)
Klebsiella granulomatis
Preferred
Azithromycin 1g PO weekly or 500mg q24h
Alternative
*Doxycycline 100mg PO q12h
OR
Trimethoprim/Sulfamethoxazole 160/800mg PO q12h
OR
Erythromycin ethylsuccinate 800mg PO q6h
Comments
Sexual partner(s) within 60 days before onset of the patient’s symptoms must be screened and treated.
Duration of treatment: at least 3 weeks or until all lesions have completely healed.
*Doxycycline is contraindicated in pregnancy.
1.5 Mpox
Monkeypox virus
Refer to Guidelines on Mpox Management in Malaysia.
2. URETHRAL DISCHARGE
2. URETHRAL DISCHARGE
2.1 Gonorrhoea
Neisseria gonorrhoeae
2.1.1 Uncomplicated (cervix, urethra, rectum, pharynx)
Preferred
Cervix, urethra, rectum:
Ceftriaxone 500mg IM STAT (if BW>150kg, 1g IM STAT)
PLUS
*Doxycycline 100mg PO q12h for 7 days
(if Chlamydia has not been excluded)
Pharynx:
Ceftriaxone 500mg IM STAT (if BW>150kg, 1g IM STAT)
PLUS
*Doxycycline 100mg PO q12h for 7 days
(if Chlamydia has not been excluded)
Alternative
Cervix, urethra, rectum:
Cephalosporin allergy:
Gentamicin 240mg IM STAT
PLUS
Azithromycin 2g PO STAT
Pharynx:
Anaphylaxis or severe reaction to cephalosporin:
Consult for expert opinion
Comments
Sexual partner(s) within 60 days should be examined, investigated and treated epidemiologically irrespective of the test results.
Abstain from sex for 1 week after the patient and partner(s) have completed treatment and symptoms are resolved.
*Doxycycline is contraindicated in pregnancy.
2.1.2 In Pregnancy
Preferred
Ceftriaxone 500mg IM STAT
(if BW>150kg, 1g IM STAT)
PLUS
Azithromycin 1g PO STAT
(if Chlamydia has not been excluded)
Alternative
Anaphylaxis or severe reaction to cephalosporin:
Consult for expert opinion
Comments
Sexual partner(s) within 60 days should be examined, investigated and treated epidemiologically irrespective of the test results.
Abstain from sex for 1 week after the patient and partner(s) have completed treatment and symptoms are resolved.
2.1.4 Disseminated gonococcal infection (DGI)
Preferred
With arthritis-dermatitis syndrome:
Ceftriaxone 1g IV or IM q24h for 7 days
With purulent arthritis:
Ceftriaxone 1g IV or IM q24h for 7-14 days
With meningitis:
Ceftriaxone 1-2g IV q12h-24h for 10-14 days
With endocarditis:
Ceftriaxone 1-2g IV q12h-24h for 4-6 weeks
Alternative
With arthritis-dermatitis syndrome:
Cefotaxime 1g IV q8h for 7 days
Comments
Sexual partner(s) within 60 days should be examined, investigated and treated epidemiologically irrespective of the test results.
Abstain from sex for 1 week after the patient and partner(s) have completed treatment and symptoms are resolved.
2.1.5 Conjunctivitis
Refer Ocular Infections section
2.2 Chlamydia
Chlamydia trachomatis
2.2.1 Uncomplicated (cervix, urethra, rectum, pharynx)
Preferred
Doxycycline 100mg PO q12h for 7 days
Alternative
Azithromycin 1g PO STAT
OR
*Levofloxacin 500mg PO q24h for 7 days
Comments
Sexual partner(s) within 60 days should be examined, investigated and treated epidemiologically, irrespective of the test results.
Abstain from sex for 1 week after the patient and partner(s) have completed treatment and symptoms are resolved.
* Indication not listed in MOH Drug Formulary.
2.2.2 In pregnancy
Preferred
Azithromycin 1g PO STAT
Alternative
Amoxicillin 500mg PO q8h for 7 days
Comments
Sexual partner(s) within 60 days should be examined, investigated and treated epidemiologically, irrespective of the test results.
Abstain from sex for 1 week after the patient and partner(s) have completed treatment and symptoms are resolved.
2.3 Non-Gonococcal Urethritis (NGU)
Common organisms:
Chlamydia trachomatis
Mycoplasma genitalium
Ureaplasma spp.
Trichomonas vaginalis
Adenoviruses
Herpes simplex virus (HSV)
2.3.1 First episode
Preferred
Doxycycline 100mg PO q12h for 7 days
Alternative
Azithromycin 500mg PO STAT, then 250mg q24h for 4 days
Comments
Sexual partner(s) within 60 days should be examined, investigated and treated epidemiologically, irrespective of the test results.
Abstain from sex for 1 week after the patient and partner(s) have completed treatment and symptoms are resolved
Consider empiric treatment for chlamydia for sexual partner(s).
2.3.2 Recurrent and persistent
Preferred
If treated with doxycycline as first line:
Azithromycin 500mg PO STAT, then 250mg PO q24h for the next 4 days
PLUS
Metronidazole 400mg PO q12h for 5 days
If treated with azithromycin as first line:
*Moxifloxacin 400mg PO q24h for 10-14 days
PLUS
Metronidazole 400mg PO q24h for 5 days
Alternative
--
Comments
Sexual partner(s) within 60 days should be examined, investigated and treated epidemiologically, irrespective of the test results.
Abstain from sex for 1 week after the patient and partner(s) have completed treatment and symptoms are resolved
Consider empiric treatment for chlamydia for sexual partner(s).
*Indication not listed in MOH Drug Formulary
2.4 Epididymo-orchitis / Epididymitis
2.4.1 STI - related
Preferred
Ceftriaxone 500mg IM STAT
PLUS
Doxycycline 100mg PO q12h for 10 days
Alternative
--
Comments
Abstain from sex until the patient and partner(s) have completed treatment and symptoms are resolved.
To review the diagnosis if no clinical improvement after 3 days.
Review at 2 weeks to assess treatment compliance, partner(s) notification and resolution of symptoms.
Look out for complications i.e., hydrocoele, abscess, infarction, infertility.
2.4.2 STI-related but Unlikely Gonorrhoea
Preferred
Doxycycline 100mg PO q12h for 10 days
Alternative
--
Comments
Abstain from sex until the patient and partner(s) have completed treatment and symptoms are resolved.
To review the diagnosis If no clinical improvement after 3 days.
Review at 2 weeks to assess treatment compliance, partner(s) notification and resolution of symptoms.
Look out for complications i.e., hydrocoele, abscess, infarction, infertility.
2.4.3 Non-STI Related (Enteric / Urinary Organisms)
Preferred
*Levofloxacin 500mg PO q24h for 10 days
Alternative
*Ofloxacin 200mg PO q12h for 14 days
Comments
*Indication not listed in MOH Drug Formulary.
3. VAGINAL DISCHARGE
3. VAGINAL DISCHARGE
3.1 Trichomoniasis
Trichomonas vaginalis
Preferred
Metronidazole 400mg PO q12h for 7 days
OR
Metronidazole 2g PO STAT*
Alternative
--
Comments
Sexual partner(s) should be treated simultaneously.
Abstain from sex for 1 week after the patient and partner(s) have completed treatment and symptoms are resolved.
*Single high dose metronidazole is associated with gastrointestinal side effects and higher failure rate, especially if partner(s) are not treated concurrently.
3.2 Cervicitis
Preferred
*Doxycycline 100mg PO q12h for 7 days
Alternative
Azithromycin 1g PO STAT
Comments
Presumptive treatment of chlamydia.
*Doxycycline is contraindicated in pregnancy.
3.3 Bacterial Vaginosis
Common organisms: Anaerobic bacteria (E.g.: Prevotella sp., Mobiluncus sp., Gardnerella vaginalis, Mycoplasma hominis)
Preferred
Metronidazole 400mg PO q12h for 7 days
OR
Metronidazole 2g PO STAT*
Alternative
Clindamycin 300mg PO q12h for 7 days
Comments
Not an STI but frequently detected during STI screening.
*Single high dose metronidazole is associated with gastrointestinal side effects.
3.4 Vulvovaginal candidiasis
Candida spp.
3.4.1 Uncomplicated Infection
Preferred
Clotrimazole 500mg as a single vaginal pessary STAT
Alternative
Fluconazole 150-200mg PO STAT
Comments
--
3.4.2 Complicated Infection (Severe Vaginitis Symptoms)
Preferred
Fluconazole 150-200mg PO q72h for 2 doses (Day 1 and 4)
Alternative
Clotrimazole 500mg vaginal pessary q72h for 2 doses (Day 1 and 4)
Comments
--
3.4.3 Recurrent Infection (≥ 3 Episodes of Symptomatic Vulvovaginal Candidiasis in <1 year)
Preferred
Fluconazole 150-200mg PO q72h for 3 doses (Day 1,4 and 7), then weekly for 6 months
Alternative
Clotrimazole 500mg vaginal pessary weekly for 6 months
Comments
Treat each episode with a longer course of topical azole.
3.4.4 In Pregnancy
Preferred
Clotrimazole pessary 500mg as a single vaginal pessary STAT
Alternative
Topical azole at least for 1 week
Comments
Oral azole is contraindicated in pregnancy.
References:
Workowski K.A et al. CDC Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep.
Malaysian Guidelines in the Treatment of Sexually Transmitted Infections. 5th edition. 2023
Guidelines for the Management of Symptomatic Sexually Transmitted Infections. Geneva: World Health Organization.2021.
British Association for Sexual Health and HIV (BASHH) National Guidelines on specific infections.
Gilbert, David N., et al. The Sanford Guide to Antimicrobial Therapy Mobile. VA, USA: Antimicrobial Therapy, Inc. 2019.
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