Antibiotic treatment is indicated for patients with confirmed chlamydia and their sexual contacts within the last three months or if there is a high suspicion of chlamydia (based on symptoms and/or signs).

Complicated genital infections and symptomatic anorectal infections should be discussed with a sexual health physician.

In suspected cases, empiric treatment should be commenced while awaiting laboratory results.

Advise patients to avoid unprotected sexual intercourse for seven days after treatment initiation, and for at least seven days after any sexual contacts have been treated, to avoid re-infection.

A test of cure should be done five weeks after initiation of treatment in pregnant females, if a non-standard treatment has been used, e.g. amoxicillin, if symptoms do not resolve or if the patient had extragenital symptoms (e.g. rectal or oral).

Repeat STI testing in three months.

For the Aotearoa New Zealand STI Guidelines for use in primary care, see: https://sti.guidelines.org.nz/infections/chlamydia/

Chlamydia trachomatis

Doxycycline (if uncomplicated genital or oral infection or asymptomatic anorectal infection)

Adult: 100 mg, twice daily, for seven days^*

N.B. Do not use in pregnancy; use only in breastfeeding if there are no suitable alternatives.

^*For symptomatic anorectal infections see: Proctitis – STI cause

If co-infection with gonorrhoea is suspected: Doxycycline 100 mg, twice daily, for seven days PLUS Ceftriaxone 1 g, single IM dose, (funded by endorsement on PSO or prescription, make up with 3.5 mL of 1% lignocaine)

Azithromycin (if adherence is a concern)

Adult: 1 g, single oral dose^†

^†If anorectal infection, give azithromycin 1 g, as a stat oral dose on day one and repeat on day eight

OR

Amoxicillin (can be used as an alternative to doxycycline for pregnant females or if azithromycin is contraindicated)

Adult: 500 mg, three times daily, for seven days

Antibiotic treatment is required for all patients with suspected epididymo-orchitis and their sexual contacts within the last three months (if appropriate).

A range of infections can cause epididymo-orchitis. STI pathogens are the most likely cause in males aged < 35 years, with more than one sexual partner in the past 12 months and with urethral discharge. Urinary or enteric pathogens account for other cases, usually in older males.

Test for chlamydia, gonorrhoea and urinary tract infections as indicated by history; empirical treatment should be given while awaiting results.

If symptoms are initially severe or symptoms and signs do not resolve (or worsen) after 24 to 72 hours, refer to hospital.

Advise patients to avoid unprotected sexual intercourse for two weeks after treatment initiation, and for at least seven days after any sexual contacts have been treated, to avoid re-infection.

For the Aotearoa New Zealand STI Guidelines for use in primary care, see: https://sti.guidelines.org.nz/syndromes/epididymo-orchitis/

Majority of cases in sexually active males are due to Chlamydia trachomatis or Neisseria gonorrhoeae

Also Escherichia coli, Bacteroides spp., Gardnerella vaginalis, Mycoplasma hominis, Ureaplasma urealyticum, Trichomonas vaginalis, Streptococcus agalactiae and others

If STI pathogens suspected:

Ceftriaxone

PLUS

Doxycycline

Adult: 100 mg, twice daily, for 14 days

If UTI pathogens suspected:

Amoxicillin + clavulanic acid

Adult: 625 mg, three times daily, for ten days

If required, treatment should be modified according to MSU results

If UTI pathogens suspected:

Trimethoprim + sulfamethoxazole

Adult: 960 mg, twice daily, for ten days

OR

Ciprofloxacin

Adult: 500 mg, twice daily, for ten days

Antibiotic treatment is indicated for people with confirmed gonorrhoea and their sexual contacts within the last three months or if there is a high suspicion of gonorrhoea (based on symptoms and/or signs).

In suspected cases, empiric treatment should be commenced while awaiting laboratory results.

Advise patients to avoid unprotected sexual intercourse for seven days after treatment initiation, and for at least seven days after any sexual contacts have been treated, to avoid re-infection.

A test of cure should be done five weeks after initiation of treatment in pregnant females, or if a non-standard treatment has been used or if symptoms do not resolve.

Repeat STI testing in three months.

For the Aotearoa New Zealand STI Guidelines for use in primary care, see: https://sti.guidelines.org.nz/infections/gonorrhoea/

Neisseria gonorrhoeae

Ceftriaxone

Adult: 500 mg, single IM dose (funded by endorsement on PSO or prescription, make up with 2 mL of 1%)

PLUS

Azithromycin

Adult: 1 g, single oral dose (including in females who are pregnant or breastfeeding)

If co-infection with chlamydia is suspected:

Ceftriaxone

Adult: 1 g, single IM dose (funded by endorsement on PSO or prescription, make up with 3.5 mL of 1% lignocaine)

PLUS:

Doxycycline

Adult: 100 mg, twice daily, for seven days^*

^*For symptomatic anorectal infections see: Proctitis – STI cause

Strongly recommended to discuss with a sexual health physician, however, if isolate is proven to be ciprofloxacin susceptible and an alternative is required:

Ciprofloxacin 500 mg, stat + Azithromycin 1 g, single oral dose

Antibiotic treatment is recommended for confirmed Mycoplasma genitalium infection following discussion with a sexual health physician or clinical microbiologist.

M. genitalium often co-exists with other bacterial STIs such as chlamydia or trichomoniasis.

Most people are asymptomatic and do not develop complications; spontaneous resolution of M. genitalium is possible. Routine testing is not recommended, however, it may be required for patients who present with persistent or recurrent penile urethritis who have not responded to standard empiric antibiotic treatment and sexual contacts of positive cases.

Patients with confirmed infection or sexual contacts of confirmed cases should be discussed with a sexual health physician or clinical microbiologist before initiating treatment, due to high rates of resistance.

The treatment regimen recommended for patients with confirmed M. genitalium infection depends on the presenting condition, whether the infection is macrolide susceptible and any previous antibiotic treatments that have been given for the infection.

A test of cure should be done five weeks after initiation of treatment in all patients with confirmed M. genitalium infection.

For further information, see: Mycoplasma genitalium: considerations for testing and treatment in primary care

For the Aotearoa New Zealand STI Guidelines for use in primary care, see: https://sti.guidelines.org.nz/infections/mycoplasma-genitalium/

Mycoplasma genitalium

INITIAL TREATMENT (to reduce bacterial load)

Doxycycline (as a pre-treatment to reduce bacterial load in symptomatic patients)

Adult: 100 mg, twice daily, for seven days

FOLLOWED BY EITHER:

Azithromycin (if macrolide susceptible)

Adult: 1 g, single oral dose, on day one, followed by 500 mg, once daily, on days two to four (total 2.5 g)

OR

Moxifloxacin^* (if macrolide resistant^†, macrolide resistance unknown or treatment with azithromycin has failed)

Adult: 400 mg, once daily, for seven days

N.B. If M. genitalium infection has been confirmed and it has been less than two weeks since the patient completed a course of doxycycline, a repeat pre-treatment course of doxycycline is not necessary.

^*Unapproved indication. Fully funded with Special Authority approval (application by or on recommendation of a sexual health physician).

^†If susceptibility testing confirms macrolide resistant M. genitalium and the patient is pregnant or breastfeeding, discuss with a sexual health physician

Antibiotic treatment is required for females who are symptomatic.

Pelvic inflammatory disease (PID) is usually caused by a STI, particularly in females aged < 30 years, those who have had a recent change of sexual partner or those with a previous history of gonorrhoea or chlamydia.

Recommended investigations include:

• STI testing
• Urine pregnancy test
• Urinalysis

Treatment should be initiated for patients who present with lower abdominal pain and one or more of adnexal, cervical motion or uterine tenderness. Treatment should cover infection with gonorrhoea, chlamydia and anaerobes.

Patients should be followed up within 24 to 72 hours of starting treatment. Females with severe symptoms (e.g. fever, vomiting, acute abdominal pain), symptoms that are not improving within 72 hours and pregnant females require referral for specialist assessment. Hospital referral may be required for IV antibiotics.

Advise abstinence from sexual intercourse until abdominal pain has settled and avoidance of unprotected sexual intercourse for 14 days after treatment initiation, and for at least seven days after any sexual contacts have been treated, to avoid re-infection.

For the Aotearoa New Zealand STI Guidelines for use in primary care, see: https://sti.guidelines.org.nz/syndromes/pelvic-inflammatory-disease/

Chlamydia trachomatis, Neisseria gonorrhoeae, mycoplasmas and mixed anaerobes

Ceftriaxone

Adult: 500 mg, single IM dose, (funded by endorsement on PSO or prescription, make up with 2 mL of 1% lignocaine) or single IV dose (make up with 5 mL of sterile water and administer over a period of two to four minutes)

PLUS

Doxycycline

Adult: 100 mg, twice daily, for 14 days

PLUS

Metronidazole

Adult: 400 mg, twice daily, for 14 days (metronidazole may be discontinued if not tolerated)

If pregnant, breastfeeding or if adherence is likely to be poor

Ceftriaxone 500 mg, single IM dose, (funded by endorsement on PSO or prescription, make up with 2 mL of 1% lignocaine) or single IV dose (make up with 5 mL of sterile water and administer over a period of two to four minutes)

PLUS

Azithromycin 1 g, single oral dose, on day one and 1 g, single oral dose on day eight

PLUS

Metronidazole

Adult: 400 mg, twice daily, for 14 days

N.B. Ornidazole may be considered as an alternative if metronidazole is not tolerated.

Antibiotic treatment is recommended for patients with proctitis caused by a STI.

Management can be complex, and it is recommended that patients with proctitis that could be caused by a STI are referred to a specialist sexual health clinic or discussed with a sexual health physician.

Investigations for patients with anorectal symptoms and a history of anal intercourse should include STI testing, and a rectal swab for chlamydia, syphilis, Neisseria gonorrhoeae and herpes simplex virus. If positive test for chlamydia, discuss with a sexual health physician or clinical microbiologist as they may recommend testing for Lymphogranuloma venereum (LGV). If the patient is experiencing diarrhoea, a faecal specimen should be collected to test for enteric pathogens, which can be transmitted sexually. Sexual contacts should receive STI testing.

If STI test results are negative, antibiotic treatment can be stopped. Further discussion with a sexual health physician is recommended for patients who remain symptomatic.

Advise patients to avoid unprotected sexual intercourse until treatment has been completed and symptoms have resolved.

Advice regarding a test of cure will depend on the specific pathogen. See relevant section of the guide.

Repeat STI testing in three months.

For the Aotearoa New Zealand STI Guidelines for use in primary care, see: https://sti.guidelines.org.nz/syndromes/anorectal-syndromes/

Herpes simplex viruses (HSV Types 1 and 2), Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum (syphilis), Mycoplasma genitalium

Treatment should be guided by a sexual health physician, as management may be complex, and further testing may be required. A regimen for non-specific proctitis may be:

Doxycycline

Adult: 100 mg, twice daily, for 21 days^*

PLUS

Ceftriaxone 500 mg, single IM dose (funded by endorsement on PSO or prescription, make up with 2 mL of 1% lignocaine)

PLUS

Valaciclovir

Adult: 500 mg, twice daily, for seven days

^*Treatment duration is 21 days to cover possible Lymphogranuloma venereum proctitis

Antibiotic treatment is recommended for all males with acute or chronic bacterial prostatitis.

Patients with prostatitis often present with pelvic or genitourinary pain, e.g. perineal pain, rectal pain, pain during or after ejaculation, and lower urinary tract symptoms such as urgency, dysuria, hesitancy, incomplete bladder emptying.

Acute bacterial prostatitis can be diagnosed clinically by the rapid onset of severe urinary symptoms and patients are often systemically unwell, e.g. fever, rigors, vomiting.

Consider chronic bacterial prostatitis if symptoms (usually less severe) are present intermittently or continuously for at least three months, and other causes have been excluded, e.g. STIs and prostate cancer.

A mid-stream urine sample should be collected for susceptibility testing to guide antibiotic selection and to support the diagnosis. Appropriate antibiotics are those with good penetration into prostatic tissue.

N.B. Antibiotics are not recommended for the treatment of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), i.e. prostatitis without a history of urinary tract infections or the identification of a potentially causative pathogen.

For further information, see; Prostatitis: diagnosis and management in primary care

Gram-negative bacteria are the most common cause, e.g. Escherichia coli, Klebsiella spp., Proteus spp. and Enterococcus spp.

Pseudomonas aeruginosa (in patients with an indwelling catheter or who have undergone a recent urological procedure)

Trimethoprim

Adult: 300 mg, once daily, for two to four weeks^* if acute infection, or four to six weeks if chronic infection

OR

Trimethoprim + sulfamethoxazole

Adult: 960 mg, twice daily, for two to four weeks^* if acute infection, or four to six weeks if chronic infection

^*After 14 days treatment efficacy should be reviewed. Antibiotic treatment can be withdrawn if the symptoms have resolved, or an additional 14 days of treatment may be advised depending on the patient’s symptoms, signs and test results.

Ciprofloxacin

Adult: 500 mg, twice daily, for four weeks

Antibiotic treatment is indicated for patients with confirmed trichomoniasis and their sexual partners or if there is a high suspicion of trichomoniasis (symptoms and/or signs). Co-infection with other STIs should be considered and co-existent bacterial vaginosis is common.

Empiric treatment may be commenced while awaiting laboratory results. Due to low sensitivity, culture of urethral swabs is rarely positive in males, even if infection is present.

Advise patients to avoid unprotected sexual intercourse for seven days after treatment initiation, and for at least seven days after any sexual contacts have been treated, to avoid re-infection.

A test of cure is not usually required unless there is a risk of re- exposure or symptoms persist.

Repeat STI testing in three months as re-infection is common.

For the Aotearoa New Zealand STI Guidelines for use in primary care, see: https://sti.guidelines.org.nz/infections/trichomoniasis/

Trichomonas vaginalis

Metronidazole

Adult: 400 mg, twice daily, for seven days; or 2 g, single oral dose^*

N.B. Manufacturers recommend to avoid metronidazole for trichomoniasis in the first trimester of pregnancy. Single dosing can be used in breastfeeding; milk should be discarded for 24 hours following dose.

^*Single-dose treatment is associated with an increased risk of adverse effects and diminished efficacy but may be appropriate if adherence is an issue

Ornidazole

Adult: 500 mg, twice daily, for five days; or 1.5 g, single oral dose

N.B. Manufacturers of ornidazole advise to only use in pregnancy if potential benefit outweighs risk (animal studies suggest no adverse effects). There are no data in breastfeeding. STI guidelines recommend to avoid ornidazole in pregnancy.

Antibiotic treatment is required for males who are symptomatic and their sexual contacts within the last three months.

Non-specific urethritis is a diagnosis of exclusion. A first void urine sample should be taken to exclude gonorrhoea and chlamydia (consider a urethral swab for herpes simplex virus if patient has meatitis, inguinal lymphadenopathy or severe dysuria). Advise patients to avoid unprotected sexual intercourse for seven days after treatment initiation, and for at least seven days after any sexual contacts have been treated, to avoid re-infection.

In patients with symptoms persisting for more than two weeks, or with recurrence of symptoms, consider retesting or refer to a sexual health clinic or urologist.

A test of cure is not usually required unless patient remains symptomatic following treatment or Mycoplasma genitalium was the causal pathogen.

Repeat STI testing in three months.

For the Aotearoa New Zealand STI Guidelines for use in primary care, see: https://sti.guidelines.org.nz/syndromes/urethritis/

Urethritis not attributable to Neisseria gonorrhoeae or Chlamydia trachomatis is termed non-specific urethritis and there may be a number of organisms responsible, e.g. Mycoplasma genitalium or Trichomonas vaginalis

If discharge is minimal, or not visible:

Doxycycline

Adult: 100 mg, twice daily, for seven days

OR

If significant visible discharge or known contact with gonorrhoea:

Ceftriaxone

Adult: 500 mg, single IM dose (funded by endorsement on PSO or prescription, make up with 2 mL of 1% lignocaine)

PLUS

Azithromycin

Adult: 1 g, single oral dose

OR

If confirmed chlamydia or gonorrhoea infection:

Ceftriaxone

Adult: 1 g, single IM dose (funded by endorsement on PSO or prescription, make up with 3.5 mL of 1% lignocaine)

PLUS

Doxycycline

Adult: 100 mg, twice daily, for seven days

If adherence to doxycycline is a concern or an alternative is required:

Azithromycin

Adult: 1 g, single oral dose

Antibiotic treatment is indicated for adults with symptoms and signs of cystitis (lower urinary tract infection).

Urine culture is not necessary to diagnose cystitis in females with uncomplicated cystitis – most cases can be reliably diagnosed according to clinical presentation (urine dipstick may be required to confirm infection or if there is uncertainty or atypical features).

Laboratory microscopy, urine culture and sensitivity testing may be required only in certain circumstances, including:

• When dipstick testing is negative, but cystitis is still strongly suspected after considering differential diagnoses
• People with recurrent urinary tract infections, atypical symptoms or persistent symptoms despite antibiotic treatment
• People with suspected pyelonephritis
• Females with complicating factors, e.g. pregnancy, catheterisation, urinary tract abnormalities, immunosuppression, renal impairment, diabetes
• Other high-risk groups, including males and people living in residential care facilities

N.B. Routine urine dipstick screening for asymptomatic bacteriuria is not recommended and should not be treated in patient groups other than pregnant females. Pregnant females should be screened via urine culture for asymptomatic bacteriuria at their first antenatal appointment.

For further information, see: Urinary tract infections (UTIs) – an overview of lower UTI management in adults

Also see Urinary tract infection – pyelonephritis

Escherichia coli, Staphylococcus saprophyticus, Proteus spp., Klebsiella spp., Enterococcus spp.

Nitrofurantoin^*

Adult: 100 mg (modified release, Macrobid), twice daily, for five days; or 50 mg (immediate release, Nitrofuran), four times daily, for five days

^*Avoid after 36 weeks gestation in pregnant females, and in patients with creatinine clearance < 60 mL/min

Treat for seven days in pregnant females and in males, regardless of antibiotic choice.

Cefalexin

Adult: 500 mg, twice daily, for three days

OR

Trimethoprim^*

Adult: 300 mg, once daily at night, for three days

^*Avoid during the first trimester of pregnancy

If susceptibility testing indicates resistance to commonly available antibiotics, discuss treatment with an infectious diseases physician or clinical microbiologist.

Antibiotic treatment is indicated for all children with suspected cystitis.

Hospital referral for antibiotic treatment is recommended for children:

• Aged < 6 months
• With severe illness (including pyelonephritis)
• With renal tract abnormality

Children with recurrent cystitis should be referred for paediatric assessment.

All children with suspected urinary tract infection should have a urine sample for microscopy, culture and sensitivity testing collected (clean catch, midstream urine, catheter) as it may be a marker for previously undetected renal malformations, particularly in younger children. In older children it can be an indicator for bladder and/or bowel dysfunction.

For information on collecting a urine specimen in children, see: https://starship.org.nz/guidelines/urinary-tract-infection/

Escherichia coli, Proteus spp., Klebsiella spp., Enterococcus spp.

Cefalexin

Child: 25 mg/kg/dose (maximum 500 mg/dose), three times daily, for three days^*

^* Give for seven days in moderate to severe infection

Trimethoprim + sulfamethoxazole

Child > 8 weeks: 24 mg/kg/dose (maximum 960 mg/dose), twice daily, for three days^*

OR

Amoxicillin clavulanate

Child: 30 mg/kg/dose (maximum 625 mg/dose), three times daily, for three days^*

OR

Nitrofurantoin (immediate release tablets)

Child: 1.5 mg/kg/dose (maximum 50 mg/dose), four times daily, for three days^*

^*Give for seven days in moderate to severe infection

Antibiotic treatment (oral) is required for all patients with mild symptoms of pyelonephritis (upper urinary tract infection); adult patients with more severe symptoms (e.g. vomiting, dehydration, high fever), may require hospital referral for treatment. However, if the patient meets eligibility criteria for treatment in the community and appropriate monitoring is available, give one dose of IV (or IM) ceftriaxone or IV gentamicin (refer to local protocols or NZF for dosing information), followed by standard oral treatment.

All infants and children require hospital referral for treatment. Pregnant females require immediate obstetric referral.

Urine culture is recommended for all patients with suspected pyelonephritis. Renal tract ultrasound may also be appropriate depending on the clinical situation.

Escherichia coli, Proteus spp., Klebsiella spp., Enterococcus spp.

Cefalexin

Adult: 1 g, three to four times daily, for ten days

Trimethoprim + sulfamethoxazole

Adult: 960 mg (two tablets), twice daily, for ten days

OR

Amoxicillin clavulanate

Adult: 625 mg, three times daily, for ten days

OR

Ciprofloxacin only if Pseudomonas suspected/confirmed or organism resistant to the other alternatives

Adult: 500 mg, twice daily, for seven days

N.B. If symptoms have not fully resolved, courses can be extended up to 14 days (or ten days for ciprofloxacin)

Antibiotic treatment is recommended for females who are symptomatic, pregnant or if an invasive procedure is planned, e.g. insertion of an intrauterine contraceptive or surgical abortion.

Approximately half of females found to have bacterial vaginosis are asymptomatic; antibiotic treatment is not necessary in these cases if there are no other risk factors. Treatment of male sexual contacts is not usually necessary.

For the Aotearoa New Zealand STI Guidelines for use in primary care, see: https://sti.guidelines.org.nz/infections/bacterial-vaginosis/

Gardnerella vaginalis, Bacteroides spp., Peptostreptococcus spp. and Mobilunculus spp.

Metronidazole

Adult: 400 mg, twice daily, for seven days; or 2 g, single oral dose^*

N.B Manufacturers recommend to avoid metronidazole for bacterial vaginosis in the first trimester of pregnancy.

^*If adherence to treatment is a concern, however, this is associated with a higher relapse rate

Ornidazole

Adult: 500 mg, twice daily, for five days

N.B. Manufacturers of ornidazole advise to only use in pregnancy if potential benefit outweighs risk (animal studies suggest no adverse effects). STI guidelines recommend to avoid ornidazole in pregnancy. There are no data in breastfeeding.

OR

Clindamycin

Adult: 300 mg, twice daily, for seven days