Management guidelines for sexually transmitted infections: A ready reckoner for postgraduates and practicing dermato-venereologists

Abstract

Sexually transmitted infections (STIs) remain a major public health problem in most parts of the world. Failure to diagnose and treat STIs at an early stage may result in serious complications, including infertility and other pregnancy comorbidities. The Centers for Disease Control and Prevention released their latest guidelines for the management of various STIs in July 2021 that replaced the 2015 guidelines. The National AIDS Control Organization under Ministry of Health and Family Welfare, Government of India released the latest guidelines for management of various STIs in late 2024. The management protocols have been changed for certain STIs, and there are also notable changes made to the syndromic management kits compared to the previous guidelines. These guidelines have not yet been updated in the current editions of standard venereology or dermatology textbooks. We have brought together the recent treatment guidelines under a single roof in this article. In addition, we have also briefed about the newer treatment options currently available for various STIs. We hope our article will serve as a useful ready reckoner for postgraduates preparing for their examinations and for practicing dermato-venereologists.

Introduction

Sexually transmitted infections (STIs) remain a major public health problem in most parts of the world. Failure to diagnose and treat STIs at an early stage may result in serious complications, including infertility and other pregnancy comorbidities. The Centers for Disease Control and Prevention (CDC) released their latest guidelines for the management of various STIs in July 2021 that replaced the 2015 guidelines.[1] The National AIDS Control Organization (NACO) under Ministry of Health and Family Welfare, Government of India released the latest guidelines for management of various STIs in late 2024.[2] The management protocols have been changed for certain STIs, and there are also notable changes made to the syndromic management kits compared to the previous guidelines. These guidelines have not yet been updated in the current editions of standard venereology or dermatology textbooks. We have brought together the recent treatment guidelines under a single roof in this article. In addition, we have also briefed about the newer treatment options currently available for various STIs.

Syndromic management for sexually transmitted infections (National AIDS Control Organization 2024)

Table 1 provides the new syndromic management guidelines as per NACO 2024.[2]

Table 1.

Syndromic management for sexually transmitted infections (National AIDS Control Organization 2024)

Colour code	Syndrome	Composition	Changes made as per new guidelines
Grey	Urethral discharge syndrome	Tablet azithromycin 1 g stat	Dose of tablet cefixime changed from 400 mg to 800 mg
	Cervical discharge syndrome	Tablet cefixime 800 mg stat
	Painful scrotal swelling
	Presumptive treatment
Green	Vaginal discharge syndrome (vaginitis)	Tablet secnidazole 2 g stat	No change
		Tablet fluconazole 150 mg stat
White	Genital ulcer disease syndrome (Nonherpetic)	Injection benzathine penicillin G 2.4 MU stat Tablet azithromycin 1 g stat Disposable syringe 10 mL with 21 G needle and sterile water 10 mL	No change
Blue	Genital ulcer disease syndrome (Nonherpetic) (allergic to penicillin/nonavailability of kit 3)	Capsule doxycycline 100 mg bd ×14 days (28 capsule) Tablet azithromycin 1 g stat	Duration of capsule. Doxycycline changed from 15 days–14 days
Red	Genital ulcer disease syndrome (herpetic)	Tablet acyclovir 400 mg tds ×7 days (21 tablets)	No change
Yellow	Lower abdominal pain PID	Tablet cefixime 800 mg stat Tablet metronidazole 400 mg bd ×14 days (28 tablet) Capsule doxycycline 100 mg bd ×14 days (28 capsule)	Dose of tablet cefixime changed from 400 mg to 800 mg
Black	Inguinal bubo under genital ulcer disease syndrome LGV proctitis under anorectal discharge syndrome	Capsule doxycycline 100 mg bd ×21 days (42 capsule)	Tablet azithromycin 1 g stat excluded
Brown	Anorectal discharge syndrome	Tablet cefixime 800 mg stat Capsule doxycycline 100 mg bd ×14 days (28 capsule)	New kit added under NACP

NACP=National AIDS control programme; LGV=Lymphogranuloma venereum; PID=Pelvic inflammatory disease

Vulvovaginal candidiasis

Table 2 provides the new management guidelines for vulvovaginal candidiasis (VVC) as per CDC 2021 and NACO 2024.[1,2]

Table 2.

Management guidelines for vulvovaginal candidiasis

NACO 2024	CDC 2021
Uncomplicated VVC	Uncomplicated VVC
Topical agents	OTC intravaginal agents
Clotrimazole 2% cream 5 g intravaginally for 3 days	Clotrimazole 1% cream 5 g intravaginally × 7–14 days
Clotrimazole 1% cream 5 g intravaginally for 7 days	Clotrimazole 2% cream 5 g intravaginally × 3 days
Clotrimazole 100 mg vaginal tablet HS for 7 days	Miconazole 2% cream 5 g intravaginally × 7–14 days
Miconazole 4% cream 5 g intravaginally for 3 days	Miconazole 4% cream 5 g intravaginally × 3 days
Miconazole 2% cream 5 g intravaginally for 7 days	Miconazole 100 mg vaginal suppository × 7 days
Miconazole 200 mg vaginal pessary HS × 3 days	Miconazole 200 mg vaginal suppository × 3 days
Oral agents	Miconazole 1200 mg vaginal suppository × 1 days
Tablet fluconazole 150/200 mg stat	Tioconazole 6.5% 5 g ointment single application
	Prescription intravaginal agents Butoconazole 2% cream 5 g intravaginal single application
	Terconazole 0.4% cream 5 g intravaginal × 7 days
	Terconazole 0.8% cream 5 g intravaginal × 3 days
	Terconazole 80 mg vaginal suppository × 3 days
	Oral agents
	Tablet fluconazole 150 mg single dose Capsule itraconazole 100 mg BD × 3 days
	Capsule itraconazole 200 mg od stat
	Nystatin suppositories 100,000 U × 14 days
Complicated VVC	Complicated VVC
Mycological remission	RVVC usually defined as three or more episodes of symptomatic VVC in <1 year
Topical azoles (1% clotrimazole/2% miconazole) 5 g intravaginally × 7–14 days	Initiation phase
	Topicals 7–14 days (or) oral fluconazole 3 doses (0, 4, 7)
(Or)	Maintenance
Tablet fluconazole 150 mg on days 0, 3, 6	Tablet fluconazole 1/week × 6 months
Maintenance	Nonalbicans
Tablet fluconazole 150 mg weekly once × 6 months	Intrinsically resistant to azoles
	Boric acid intravaginally od 600 mg gelatin capsules × 3 weeks
	Flucytosine 17% solution
Azole resistance
Boric acid 600 mg intra vaginal HS × 14 days
Nystatin 200,000 U vaginal tablet HS × 7 days
Nystatin 100,000 U vaginal tablet HS × 14 days
Pregnancy
Increased frequency and severity of VVC is seen in pregnancy
Tablet fluconazole avoided (reports of spontaneous abortions and congenital anomalies)
Miconazole 200 mg vaginal pessaries inserted once daily for 3 days	Only topical azole therapies, applied for 7 days, are recommended in pregnancy
Clotrimazole vaginal tablet 100 mg inserted at night for 7 days	Tablet fluconazole avoided
Clotrimazole 1% 5 g cream intravaginally for 7 days
Clotrimazole 2% 5 g cream intravaginally for 3 days
Miconazole 2% 5 g cream intravaginally for 7 days
Miconazole 4% 5 g cream intravaginally for 3 days
Tablet fluconazole avoided
HIV
Higher frequency of VVC (rates being proportionate with the severity of immunosuppression)
Symptomatic infections are more common in PLHIV
Increased colonisation by candida
Systemic azole exposure is associated with isolation of non-Candida albicans species from the vagina
VVC is associated with increased HIV seroconversion among HIV-negative women and increased HIV cervicovaginal levels
Treatment considerations are same for both WLHIV and HIV uninfected women Long-term prophylactic therapy with fluconazole 200 mg (weekly dose) has	Treatment for uncomplicated and complicated VVC among women with HIV infection should not differ from that for women who do not have HIV
been reported to be effective in reducing colonization of Candida albicans and symptomatic VVC
Partner treatment  VVC is not usually acquired through sexual contact. Therefore, the treatment of sexual partners is not recommended In case of acquired balanitis or balanoposthitis characterized by erythematous lesions on glans penis/foreskin, the treatment can be provided in the form of topical anti-fungal agents	Partner treatment  Uncomplicated VVC is not usually acquired through sexual intercourse, and data do not support treatment of sex partners A minority of male sex partners have balanitis, characterized by erythematous areas on the glans of the penis in conjunction with pruritus or irritation. These men benefit from treatment with topical antifungal agents to relieve symptoms Complicated VVC: No recommendations for partner treatment

VVC=Vulvovaginal candidiasis; RVVC=Recurrent VVC; NACO=National AIDS Control Organization; CDC=Centers for Disease Control and Prevention

Newer Drugs

Oteseconazole

Oteseconazole is a new tetrazole antifungal which was Food and Drug Administration approved for recurrent VVC (RVVC) in 2022.[3,4] It is available as a 150 mg capsule.

Regimen

1. Only Oteseconazole D1 600 mg, D2 450 mg then D14 150 mg then weekly 150 mg till 12 weeks

2. Oteseconazole with Fluconazole: Fluconazole 150 mg on D1, 4, 7 Days 14–20 Oteseconazole 150 mg od then week 4 to week 14 Oteseconazole weekly once.

Ibrexafungerp

Ibrexafungerp is a triterpenoid antifungal drug which acts by noncompetitive inhibition of 1, 3 β D glucan synthase enzyme complex.[3,5]

Regimen

• VVC: 300 mg BD stat

• RVVC: 300 mg BD on D1 of every month for 6 months.

Bacterial vaginosis

Table 3 provides the new management guidelines for bacterial vaginosis as per CDC 2021 and NACO 2024.[1,2]

Table 3.

Management guidelines for bacterial vaginosis

NACO 2024	CDC 2021
Metronidazole 400 mg BD × 7 days	Tablet metronidazole 500 mg BD × 7 days
Metronidazole 2 g stat	Metronidazole 0.75% 5 g intravaginal gel × 5 days
Secnidazole 2 g stat	Clindamycin gel 2% 5 g intravaginally × 7 days
Tinidazole 2 g od × 2 days	Alternative regimen
Tinidazole 1 g od × 5 days	Clindamycin ovules 100 mg Intravaginally × 3 days
Clindamycin 300 mg BD × 7 days	Clindamycin 300 mg BD × 7 days
	Secnidazole 2 g oral granules stat
	Tinidazole 1 g oral OD × 5 days
	Tinidazole 2 g oral OD × 2 days
Recurrent/persistent cases	Recurrent BV≥4 episodes/year
Retreatment for 1st recurrent episode	Retreatment with metronidazole/clindamycin
Subsequent recurrence - different regimen given	Topical clotrimazole cream
Multiple recurrence: Suppressive treatment given
Metronidazole 0.75% 5 g Intravaginal gel or 750 mg Vaginal suppository twice/week × >3 months
Tablet metronidazole/tinidazole 500 mg BD × 7 days followed by
Boric acid 600 mg Intravaginally OD × 21 days metronidazole 0.75%
Intravaginal gel twice/week × 4–6 months
Tablet metronidazole 2 g + tablet fluconazole 150 mg monthly
Pregnancy
BV is associated with increased complications in pregnancy (chorioamnionitis, premature rupture of membranes, low birth weight, puerperal sepsis, postpartum endometritis)
For pregnant women Metronidazole 400 mg orally 2 times/day for 7 days	Pregnant women can be treated with any of the recommended regimens for nonpregnant women, in addition to the alternative regimens of oral clindamycin and clindamycin ovules
Metronidazole 200 mg, orally, 3 times a day for 7 days Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, twice a day for 7 days	Routine screening for BV among asymptomatic pregnant women at high or low risk for preterm delivery for preventing preterm birth is not recommended Lactation
Clindamycin 300 mg, orally, twice daily for 7 days The current evidence indicate that metronidazole therapy poses low risk during	Although multiple reported case series identified no evidence of metronidazole-associated adverse effects for breastfed infants, certain clinicians recommend deferring breastfeeding for 12–24 h after maternal treatment with a single 2-g dose of metronidazole
pregnancy and therefore, can be recommended even in the first trimester of pregnancy	Lower doses produce a lower concentration in breast milk and are considered compatible with breastfeeding
The pregnant women with abnormal vaginal discharge should receive syndromic management for NG, CT, TV, BV, and CA (if per speculum examination is not possible)
HIV
BV increases the risk for acquisition and transmission of HIV and acquisition of NG, CT, TV, Mycoplasma genitalium, HPV, and HSV-2
BV appears to recur with higher frequency among women who have HIV infection
Same treatment as those who do not have HIV	Women with HIV infection and BV should receive the same treatment regimen as those who do not have HIV
Partner treatment	Partner treatment
The routine treatment of sex partners is not recommended	No recommendations

NACO=National AIDS Control Organization; CDC=Centers for Disease Control and Prevention; BV=Bacterial vaginosis; HPV=Human papilloma virus; HSV-2=Herpes Simplex Virus type 2; NG=Neisseria gonorrheae; CT=Chlamydia trachomatis; TV=Trichomonas vaginalis; BV=Bacterial vaginosis; CA=Candida

Trichomoniasis

Table 4 provides the new management guidelines for trichomoniasis as per CDC 2021 and NACO 2024.[1,2]

Table 4.

Management guidelines for trichomoniasis

NACO 2024	CDC 2021
Metronidazole 400 mg BD × 7 days	Females: Tablet Metronidazole 500 mg BD × 7 days
Metronidazole 2 g stat	Males: Metronidazole 2 g oral stat
Secnidazole 2 g stat	Metronidazole gel 0.75% not recommended as it does not reach the therapeutic level in
Tinidazole 2 g stat	the urethra and perivaginal glands
Tinidazole 500 mg BD × 5 days	Other alternatives
	Tinidazole 2 g stat
	Boric acid 600 mg intravaginal
	Metronidazole resistance
	Metronidazole 2 g/day × 7 days
Persistent cases	Treatment failure
High dose oral regimen	Oral tinidazole 2 g daily+tinidazole intravaginal 500 mg bd × 14 days
Tinidazole 2 g od × 7 days	If failure → 2 g tinidazole tds+intravaginal paromomycin hs × 14 days
Metronidazole 2 g od × 7 days
Tinidazole 2 g od+intravaginal tinidazole 500 mg BD × 14 days
In case of treatment failure
1g Tinidazole tds + intravaginal paromomycin 6.25% cream 4g × 14 days
Pregnancy
It results in reproductive morbidity and increases the likelihood of preterm labor, premature rupture of membranes and low birth weight
For pregnant women	Pregnancy
Metronidazole 400 mg orally twice/day for 7 days, or	Symptomatic pregnant women, regardless of pregnancy stage, should be tested and treated
Metronidazole 200 mg, orally, 3 times a day for 7 days, or	Treatment of TV can relieve symptoms of vaginal discharge for pregnant women and reduce sexual
Metronidazole 2 g orally in a single dose, or	transmission to partners. Although perinatal transmission of trichomoniasis is uncommon, treatment
Metronidazole gel 0.75%, one full applicator (5 g)	might also prevent respiratory or genital infection in the newborn
intravaginally, twice a day for 7 days Although metronidazole crosses the placenta, there is no evidence of teratogenicity or mutagenic effects among infants reported in various research studies. The current evidence indicate that metronidazole therapy poses low risk during pregnancy and therefore, can be recommended even in the first trimester of pregnancy The pregnant women with abnormal vaginal discharge should receive syndromic management for NG, CT, TV, BV, and CA (if per speculum examination is not possible)	Tinidazole should be avoided for pregnant women Lactation Although multiple reported case series studies demonstrated no evidence of adverse effects among infants exposed to metronidazole in breast milk, clinicians sometimes advise deferring breastfeeding for 12–24 h after maternal treatment with metronidazole. In one study, maternal treatment with metronidazole (400 mg 3 times/day for 7 days) produced a lower concentration in breast milk and was considered compatible with breastfeeding over longer periods Breastfeeding should be deferred for 72 h after a single 2-g oral dose of tinidazole
HIV
Increased prevalence of trichomoniasis in PLHIV
TV enhances risk for HIV transmission and acquisition and increased risk of vertical transmission of HIV Increased risk of PID, adverse birth outcomes
The single oral dose of metronidazole 2 g has been demonstrated to be less effective in the treatment of TV among WLHIV	Metronidazole 500 mg orally 2 times/day for 7 days Retesting is recommended 3 months after treatment
Recommended regimen
Metronidazole 400 mg orally 2 times a day for 7 days
Partner treatment	Partner treatment
Expedited partner treatment	Expedited partner treatment
Abstinence till treatment completion	Abstinence till treatment completion

NACO=National AIDS Control Organization; CDC=Centers for Disease Control and Prevention; PID=Pelvic inflammatory disease; TV=Trichomonas vaginalis; NG=Neisseria gonorrhoeae; CT=Chlamydia trachomatis; BV=Bacterial vaginosis; CA=Candida; WLHIV=Women living with HIV, PLHIV=People living with HIV

Gonorrhea

Table 5 provides the new management guidelines for gonorrhea as per CDC 2021 and NACO 2024.[1,2]

Table 5.

Management guidelines for gonorrhea

NACO 2024	CDC 2021
Uncomplicated Gonococcal urethritis	Uncomplicated gonorrhea (cervicitis/urethritis/proctitis)
Ceftriaxone 500 mg IM stat (>150 kg → 1 g IM stat)	Ceftriaxone 500 mg IM single dose for patients <150 kg (>150 kg → 1 g IM)
Cefixime 800 mg stat	If chlamydia is not excluded → Capsule doxycycline 100 mg BD ×
Gentamycin 240 mg IM+azithromycin 2 g (not for pregnant females)	7 days added
	No need for test of cure
Oropharyngeal	Pharyngeal gonorrhea
Ceftriaxone 500 mg IM stat	Ceftriaxone 500 mg IM single dose for patients <150 kg (>150 kg → 1g IM)
GC conjunctivitis	Test of cure done 7–14 days after treatment (culture/NAAT)
Ceftriaxone 1 g IM, lavage of infected eye with normal saline solution
Disseminated gonococcal infection
Routine antimicrobial testing done
Ceftriaxone 1 g every 24 h (IM/IV) + Capsule Doxycycline 100 mg BD × and days (for CT)
Cefotaxime 1 g every 8 h
Ceftizoxime 1 g every 8 h
GC meningitis
Ceftriaxone 1–2 g every 24 h for 14 days
GC endocarditis
Ceftriaxone 1–2 g every 24 h for 28 days
Ophthalmia neonatorum
Erythromycin 0.5% ointment stat application in each eye at birth
Ceftriaxone 25–50 mg/kg IV/IM stat
Dual treatment for GC and CT
Ceftriaxone 500 mg IM stat+Capsule Doxycycline 100 mg BD × 7 days
Cefixime 800 mg stat+Capsule Doxycycline 100 mg BD × 7 days
Cefixime 800 mg stat+Tablet azithromycin 1 g stat
For rectal/pharyngeal disease: Doxycycline is preferred
Pregnancy
Increased risk of ectopic pregnancy (in case of tubal scaring), premature rupture of membranes, prematurity, ophthalmia neonatorum, and sepsis in infants, disseminated gonococcal infection in infants, disseminated gonococcal infection in pregnant women
The pregnant women with abnormal vaginal discharge should receive syndromic management for NG, CT, TV, BV, and CA (if per speculum examination is not possible)	Ceftriaxone 500 mg in a single IM dose plus treatment for chlamydia if infection has not been excluded
	In case of cephalosporin allergy, consultation with an infectious disease specialist or an
	STD clinical expert is recommended
	Gentamicin use is cautioned during pregnancy because of the risk for neonatal birth defects, nephrotoxicity, or ototoxicity
Treatment failure Treatment failure should be considered for persons whose symptoms do not resolve within 3–5 days after recommended treatment and report no sexual contact during the posttreatment follow-up period and persons with a positive test of cure (i.e., positive culture >72 h or positive NAAT >7 days after receiving recommended treatment) when no sexual contact is reported during the posttreatment follow-up period
Retreatment with routine drugs+Capsule doxycycline 100 mg BD 7 days	Treatment failure
Gentamycin 240 mg IM+Tablet Azithromycin 2 g 7–14 days later, test of cure done Ensure partner treatment in the preceding 60 days	Patients with suspected treatment failures should first be retreated routinely with the initial regimen used (ceftriaxone 500 mg IM), with the addition of doxycycline if chlamydia infection exists, because reinfections are more likely than actual treatment failures
	In situations with a higher likelihood of treatment failure than reinfection, relevant clinical specimens should be obtained for culture (preferably with simultaneous NAAT) and antimicrobial susceptibility testing before retreatment
	Dual treatment with single doses of IM gentamicin 240 mg plus oral azithromycin 2 g can be considered, particularly when isolates are identified as having elevated cephalosporin MICs Ensure partner treatment in preceding 60 days
HIV: Cervicitis is associated with increased cervical HIV shedding
PLHIV co-infected with NG should receive the same treatment regimen as those who do not have HIV	PLHIV co-infected with NG should receive the same treatment regimen as those who do not have HIV
Partner treatment
<60 days contact history: Evaluate and treat>60 days contact history: Treat most recent partner	Patients should be instructed to refer their sex partners during the previous 60 days for evaluation, testing, and presumptive treatment
Expedited partner treatment with cefixime 800 mg single dose, if chlamydia not ruled out then Capsule doxycycline 100 mg BD × 7 days added
Abstinence till 7 days after treatment till all partners are treated

NACO=National AIDS Control Organization; CDC=Centers for Disease Control and Prevention; PID=Pelvic inflammatory disease; TV=Trichomonas vaginalis; NG=Neisseria gonorrhoeae; CT=Chlamydia trachomatis; BV=Bacterial vaginosis; CA=Candida; WLHIV=Women living with HIV, PLHIV=People living with HIV, MIC=Minimum inhibitory concentrations; IM=intramuscular; IV=Intravenous; GC=Gonococci; STD=Sexually Transmitted Diseases; NAAT=Nucleic Acid Amplification Test

Newer Drugs

• Zoliflodacin

• Zoliflodacin is a new antimicrobial agent, a spiropyrimidinetrione compound that acts by inhibiting DNA gyrase.[6]

• Gepotidacin.

• Gepotidacin is a triazaacenaphthylene antibiotic that inhibits bacterial DNA replication by blocking two essential topoisomerase enzymes (topoisomerase IV and the B subunit of DNA gyrase).[6]

Chlamydia trachomatis infection

Table 6 provides the new management guidelines for chlamydia trachomatis as per CDC 2021 and NACO 2024.[1,2]

Table 6.

Management guidelines for chlamydia trachomatis

NACO 2024	CDC 2021
Capsule doxycycline 100 mg bd × 7 days	Capsule doxycycline 100 mg bd × 7 days
Azithromycin 1 g stat	Alternatives
Ofloxacin 200–400 mg bd × 7 days	Azithromycin 1 g stat (or) 500 mg stat followed by 250 mg od × 4 days
Erythromycin 500 mg QID × 7 days	Levofloxacin 500 mg od × 7 days
Follow-up
Test of cure 4 weeks after treatment
Review after 3 months for repeat testing
If symptoms persist → testing for Mycoplasma genitalium and Trichomonas vaginalis done
Pregnancy  Increased risk of ectopic pregnancy (in case of tubal scaring), chorioamnionitis, postpartum sepsis, ophthalmia neonatorum, and infant pneumonia
The pregnant women with abnormal vaginal discharge should receive syndromic management for NG, CT, TV, BV, and CA (if per speculum examination is not possible)	Tablet Azithromycin 1 g stat Capsule amoxycillin 500 mg tds × 7 days Doxycycline is contraindicated in the 2nd and 3rd trimester
The doxycycline and ofloxacin regimens are not recommended in pregnancy	Levofloxacin is contraindicated in lactation
Azithromycin 1 g orally in a single dose; or Amoxicillin 500 mg orally three times/day for 7 days; or
Erythromycin 500 mg, orally, four times a day for 7 days
Partner treatment	Partner treatment
EPT for contacts <60 days	EPT for contacts <60 days
Abstinence till patient and their partners complete treatment	The most recent sex partner should be evaluated and treated, even if the time of the last sexual contact was >60 days before symptom onset or diagnosis  Abstinence till patient and their partners complete treatment
Ophthalmia neonatorum
Erythromycin base/ethyl succinate 50 mg/kg/day in 4 divided doses × 14 days
Follow up for signs of infantile hypertrophic pyloric stenosis
Chlamydia pneumonia
Erythromycin base/ethyl succinate 50 mg/kg/day in 4 divided doses × 14 days
Azithromycin 20 mg/kg/day od × 3 days

NACO=National AIDS Control Organization; CDC=Centers for Disease Control and Prevention; TV=Trichomonas vaginalis; NG=Neisseria gonorrheae; CT=Chlamydia trachomatis; BV=Bacterial vaginosis; CA=Candida; EPT=Expedited partner therapy

Mycoplasma genitalium infection

Table 7 provides the new management guidelines for mycoplasma infection as per CDC 2021 and NACO 2024.[1,2]

Table 7.

Management guidelines for Mycoplasma genitalium

NACO 2024	CDC 2021
Scenario 1: Access to macrolide sensitivity testing +	Macrolide sensitivity-based treatment
If sensitive: Capsule doxycycline 100 mg bd × 7 days followed by Tablet Azithromycin 1 g stat then 500 mg od × 3 days	If sensitive: Capsule doxycycline 100 mg bd × 7 days followed by Tablet azithromycin 1 g stat then 500 mg od × 3 days
If resistant: Capsule doxycycline 100 mg bd × 7 days followed by Tablet Moxifloxacin 400 mg od × 7 days	If resistant: Capsule Doxycycline 100 mg bd × 7 days followed by Tablet moxifloxacin 400 mg od × 7 days
Scenario 2: No access to macrolide sensitivity testing	No access to macrolide sensitivity testing
Capsule doxycycline 100 mg bd × 7 days followed by Tablet Moxifloxacin 400 mg od × 7 days Scenario 3: PID Capsule Doxycycline 100 mg bd × 14 days followed by Tablet moxifloxacin 400 mg od × 14 days	Capsule Doxycycline 100 mg bd × 7 days followed by Tablet moxifloxacin 400 mg od × 7 days
HIV	HIV
PLHIV co-infected with MG should receive the same treatment regimen as those who do not have HIV	PLHIV co-infected with MG should receive the same treatment regimen as those who do not have HIV

NACO=National AIDS Control Organization; CDC=Centers for Disease Control and Prevention; PID=Pelvic inflammatory disease; WLHIV=Women living with HIV; PLHIV=People living with HIV; MG=Mycoplasma genitalium

Herpes genitalis

Table 8 provides the new management guidelines for genital herpes as per CDC 2021 and NACO 2024.[1,2]

Table 8.

Management guidelines for Herpes genitalis

NACO 2024	CDC 2021
Primary infection	Initial infection
1st line	Acyclovir 400 mg tds × 7–10 days
Acyclovir 400 mg tds × 7 days	Valacyclovir 1 g bd × 7–10 days
Acyclovir 200 mg 5 times a day × 7 days	Famciclovir 250 mg tds × 7–10 days
Other drugs
Valacyclovir 500 mg bd × 7 days
Famciclovir 250 g tds × 7 days
Recurrent episodes	Recurrence
Episodic treatment	Episodic treatment
Acyclovir 400 mg tds × 5 days	Acyclovir 800 mg bd × 5 days
Acyclovir 800 mg bd × 5 days	Acyclovir 800 mg tds × 2 days
Acyclovir 800 mg tds × 2 days	Valacyclovir 1 g od × 5 days
Other drugs	Valacyclovir 500 mg bd × 5 days
Valacyclovir 500 mg bd × 5 days	Famciclovir 500 mg once follwed by 250 mg bd
Famciclovir 250 g bd × 5 days	Famciclovir 1 g bd × 1 day
Suppressive therapy: Indicated for individuals with 4–6 or more recurrent episodes/year or in episodes with severe symptoms or that cause distress	Famciclovir 125 mg bd × 5 days
HIV patients
Acyclovir 400 mg bd	Acyclovir 400 mg tds × 5–10 days
Valacyclovir 500 mg od	Valaciclovir 1 g bd × 5–10 days
Famciclovir 250 mg bd (500 mg bd for PLHIV/Immunocompromised)	Famciclovir 500 mg bd × 5–10 days
	Suppressive treatment
	Indications
	≥6 episodes/year
	Sero discordant couples
	Pregnancy 36 weeks onwards (HIV 32 weeks onwards)
	Acyclovir 400 mg bd
	Valacyclovir 500 mg od (<10 recurrences/year)
	Valacyclovir 1 g od (>10 recurrences/year)
	Famciclovir 250 mg bd
Pregnancy
Genital herpes in pregnancy is associated with
Abortion
IUGR
Premature delivery
Congenital HSV
Neonatal herpes
Longer duration of symptoms
Primary infections are more severe
Systemic dissemination
All pregnant women should be asked history of genital herpes and examined carefully for herpetic lesions
Women without symptoms or signs of genital herpes or its prodrome can deliver vaginally
Women with genital herpetic lesions at the onset of labor should be delivered by caesarean section to prevent neonatal herpes
Pregnant patients	Pregnancy
Only Acyclovir Regimen are recommended in pregnancy	Acyclovir 400 mg tds
Suppressive therapy (Acyclovir 400 mg bd) is recommended in all cases of recurrent episodes of genital herpes from 36th week of pregnancy	Valacyclovir 500 mg bd
HIV
Severe and/or prolonged episodes of genital or oral herpes
The lesions can be painful, and atypical
Increased shedding of HSV among PLHIV
The disease severity might also worsen during the immune reconstitution phase following ART initiation
The recommended therapy for the first episode of genital herpes remains the same for	Acyclovir 400–800 mg bd/tds
HIV-infected person	Valacyclovir 500 mg bd
However, treatment might need to be extended for complete resolution of lesions	Famciclovir 500 mg bd
Suppressive therapy is recommended for individuals with 4–6 or more recurrent episodes per year or in episodes with severe symptoms or that cause distress and should be preferred over episodic therapy among PLHIV
Suppressive antiviral therapy can be provided to all PLHIV with a history of ano-genital herpes for at least for first 6 months after initiation of ART
Episodic therapy
Valacyclovir 500 mg one dose for 5 days
Famciclovir 500 mg twice a day for 5 days
Suppressive therapy
Valacyclovir 500 mg twice daily
Famciclovir 500 mg twice daily
Partner treatment	Partner treatment
	If symptomatic: Treatment same as that of patients Asymptomatic: Evaluation of history and examination, type-specific serologic testing for HSV-2 offered. No guidelines for PEP or PrEP
Neonatal herpes
Acyclovir 20 mg/kg IV every 8 h × 14 days
In disseminated herpes/CNS involvement, then acyclovir is given at the same dose for 21 days
Severe herpes genitalis  Acyclovir 5–10 mg/kg IV every 8th h × 2–7 days/until improvement, then oral acyclovir × 14 days (21 days for encephalitis)

NACO=National AIDS Control Organization; CDC=Centers for Disease Control and Prevention; PLHIV=People living with HIV; MG=Mycoplasma genitalium; CNS=Central nervous system; HSV=Herpes Simplex Virus; ART=Antiretroviral therapy; IV=intravenous; PEP=Post exposure prophylaxis; PrEP=Pre-exposure prophylaxis; IUGR=Intrauterine growth retardation

Indications of IV Acyclovir

• Immunocompromised

• Disseminated herpes simplex virus (HSV)

• Complicated Primary infection

• Neonatal HSV

• Eczema herpeticum

• Herpes encephalitis/pneumonitis/hepatitis

• Failure of oral therapy.[7]

Acyclovir Resistance

Patients with acyclovir resistance will also be resistant to Valacyclovir and Famciclovir.[8] Treatment options for such patients include:

• Foscarnet 80–120 mg/kg/day IV in 2–3 divided doses (40 mg/kg IV every 8 hourly) until clinical resolution

• Cidofovir 5 mg/kg once weekly

• Cidofovir 1% gel 2–4 times/day

• Imiquimod 5% cream.

Acyclovir Dose Adjustment in Renal Impairment

Creatinine clearance >25 → normal dose.

• 10–25 → 50% of normal dose

• <10% → 25% of normal dose.

Other Newer Treatment Options

• PRITELIVIR: Helicase Primase inhibitor

• AMENAMEVIR: Helicase Primase inhibitor

• TRIFLURIDINE: Pyrimidine nucleoside analog that is useful for HSV 1, 2, and cytomegalovirus (CMV).[9]

Topical application 8^th hourly alone or with IFN.

• ISOPRINOSINE: has antiviral and immunomodulator properties

Isoprinosine can cause elevation of serum uric acid levels, hence, there is a need for frequent monitoring.

• IDOXIURIDINE: inhibits DNA polymerase (chain terminator).

One percent ophthalmic ointment is available for HSV keratitis.

• Brincidofovir: It is the prodrug of cidofovir, used historically for smallpox infections. It is currently tried for Mpox, but frequent monitoring is needed as it can increase aminotransferases. It has shown efficacy in treating multi-drug-resistant HSV and CMV infections in some patients

• Valomaciclovir: It is a prodrug of omniclovir, a nucleoside analog with antiviral activity against herpesviruses

• N-Methanocarbathymidine: It is a thymidine analog that shows activity against herpesviruses and orthopoxviruses.

Syphilis

For management of syphilis, NACO 2024 and CDC 2021[1,2] give same guidelines which are as follows:

Early syphilis (primary/secondary/early latent/<1 year).

Injection benzathine penicillin 2.4 million units (given as 1.2 million units deep IM in each buttock) after test dose.

Alternatives

1. Capsule Doxycycline 100 mg bd × 14 days

2. Erythromycin 500 mg qid × 14 days

3. Ceftriaxone 1–2 g/day IV × 10–14 days.

Late syphilis (Late latent/Tertiary/unknown duration).

Injection Benzathine penicillin 2.4 million units (given as 1.2 million units deep IM in each buttock) after test dose once a week × 3 weeks.

Alternatives

1. Capsule Doxycycline 100 mg bd × 30 days

2. Procaine penicillin G 1.2 million units IM od × 20 days.

Neurosyphilis

Aqueous crystalline penicillin G 18–24 million units/day (given as 3–4 million units IV every 4 h. or as a continuous infusion for 10–14 days).

Alternatives

1. Procaine penicillin G 2.4 million units IM od + Probenecid 500 mg oral qid × 10–14 days

2. Ceftriaxone 1–2 g/day IV × 10–14 days.

Syphilis in Pregnancy and PLHIV

Table 9 provides the new management guidelines for syphilis in pregnancy and PLHIV as per CDC 2021 and NACO 2024.[1,2]

Table 9.

Management guidelines for syphilis in pregnancy and people living with HIV

Pregnancy
Routine screening of HIV and syphilis is indicated in pregnancy
Penicillin G is the only known effective antimicrobial for treating fetal infection and preventing congenital syphilis
NACO 2024	CDC 2021
Benzathine Penicillin G is the only effective antimicrobial for the treatment of pregnant women with syphilis to prevent vertical transmission Once a presumptive diagnosis of penicillin allergy had been established, the desensitization of penicillin allergy can be performed in cases where there are no other suitable options to treat syphilis	Pregnant women seropositive for syphilis should be considered infected unless an adequate treatment history is clearly documented in the medical records and sequential serologic antibody titers have decreased as recommended for the syphilis stage Certain evidence indicates that additional therapy is beneficial for pregnant women to prevent congenital syphilis
	For women who have primary, secondary, or early latent syphilis, a second dose of benzathine penicillin G 2.4 million units IM can be administered 1 week after the initial dose
	When syphilis is diagnosed during the second half of pregnancy, management should include a sonographic fetal evaluation for congenital syphilis. A second dose of benzathine penicillin G 2.4 million units IM, after the initial dose might be beneficial for fetal treatment in these situations
	Women treated for syphilis during the second half of pregnancy are at risk for premature labor or fetal distress if the treatment precipitates the
	Jarisch-Herxheimer reaction. No data are available to support that corticosteroid treatment alters the risk for treatment-related complications during pregnancy Missed doses>9 days between doses are not acceptable for pregnant women receiving therapy for late latent syphilis. An optimal interval between doses is
	7 days for pregnant women. Pregnant women who miss a dose of therapy should repeat the full course of therapy
HIV
There is an increased risk of neurologic complications and higher rates of inadequate serologic response with the recommended regimens in HIV-syphilis coinfection
Though rare, unusual responses for treponemal and nontreponemal tests might be observed among people living with HIV with syphilis coinfection which may involve
Higher/fluctuated posttreatment serological titers than expected
False negative serological test results and delayed appearance of sero-reactivity
“Prozone phenomenon” causing a false negative serological test report is common in PLHIV
NACO 2024	CDC 2021
All persons with HIV and latent syphilis infection should undergo a thorough neurologic, ocular, and optic examination Neurosyphilis, ocular syphilis, and oto-syphilis should be considered as the differential diagnosis when there are neurological, ocular, and other signs and symptoms among persons with HIV infection CSF examination should be reserved for those with an abnormal neurologic examination (e.g., cranial nerve dysfunction, meningitis, stroke, acute or chronic altered mental status, or loss of vibration sense) Treatment must be considered in all PLHIV when the clinical findings are suggestive of syphilis, but serological titers are nonreactive, or their interpretation is unclear Injection Benzathine Penicillin should be considered the preferred choice of treatment for syphilis among PLHIV The patients should be evaluated clinically and serologically for possible treatment failure at 3, 6, 9, 12, and 24 months after therapy Using ART as per current guidelines might improve clinical outcomes among persons coinfected with HIV and syphilis	All persons with HIV and syphilis infection should receive a careful neurologic ocular and otic examination Persons with HIV infection and neurosyphilis should be treated according to the recommendations for persons with neurosyphilis and without HIV infection

NACO=National AIDS Control Organization; CDC=Centers for Disease Control and Prevention; PLHIV=People living with HIV; ART=Antiretroviral therapy; CSF=Cerebrospinal fluid; IM=intramuscular

Partner Treatment

Sexual partners of patients with early syphilis (primary/secondary/early latent/<1 year) within 180 days → presumptive treatment given even if serological tests are negative.

Evaluation of Partners

• Within 3 months + duration of symptoms when the patient is diagnosed with primary syphilis

• Within 6 months + duration of symptoms when the patient is diagnosed with secondary syphilis

• Within 1 year, when the patient is diagnosed with early latent syphilis (<1 year).

Follow-up

• The clinical and serological evaluation should further be conducted at 6, 9, and 12 months after complete treatment

• Serologic titers should not be repeated before 8 weeks after completion of treatment. It should be preferably repeated at least after 12 weeks of treatment

• The fourfold reduction in titres indicates successful treatment. This fourfold reduction is usually achieved after 6 months in most of the cases

• If the titer values persist at the same level or increase after 12 weeks or there are clinical manifestations of syphilis, treatment failure or reinfection can be suspected, and complete treatment should be given according to the treatment protocol.

Congenital Syphilis

Table 10 provides the new management guidelines for congenital syphilis as per CDC 2021 and NACO 2024.[1,2]

Table 10.

Management guidelines for congenital syphilis (National AIDS Control Organization 2024 and Centers for Disease Control and Prevention 2021)

Scenario/risk category	Clinical history and examination	Evaluation	Treatment
Scenario 1 Confirmed proven/highly probable congenital syphilis	Abnormal physical Examination or RPR titre ≥4 fold of that of mother	CSF analysis (cell count, protein, VDRL) CBC, Long bone X rays, Chest X ray, Liver function Tests, Cranial USG, Ophthal examination, Auditory brainstem response	Regardless of evaluation results → IV Aqueous crystalline Penicillin G 100,000 to 150,000 units/kg/day administered as 50,000 units/kg/dose IV every 12 h during first 7 days and every 8 h for next 3 days Treatment alternatives Procaine penicillin G 50,000 U/kg/day IM single dose ×10 days
Scenario 2 Possible congenital syphilis	Normal physical Examination AND RPR titre <4 fold of that of mother AND mother untreated/inadequately treated/nonpenicillin regimen/treatment initiated <30 days before delivery	CSF analysis ( cell count, protein, VDRL) CBC, Long bone X rays	If evaluation is abnormal/uninterpretable/incomplete or if follow up uncertain → IV Aqueous crystalline Penicillin G ( as above) If evaluation normal/follow up certain→IM Benzathine penicillin G 50,000 U/kg/dose once
Scenario 3 Less likely congenital syphilis	Normal physical Examination AND RPR titre <4 fold of that of mother AND mother treated adequately, treatment initiated >30 days	None	If follow-up uncertain →IM Benzathine penicillin G 50,000 U/kg/dose once if follow up certain → No need treatment
Scenario 4 Unlikely congenital syphilis	Normal physical Examination AND RPR titre <4 fold of that of mother AND mother treated adequately before pregnancy	None	If follow up uncertain → IM Benzathine penicillin G 50,000 U/kg/dose once if follow up certain → No need treatment

CSF=Cerebrospinal fluid; CBC=Complete blood count; IM=intramuscular; IV=Intravenous; RPR=Rapid Plasma Reagin test; VDRL=Venereal Disease Research Laboratory test

Chancroid

Table 11 provides the new management guidelines for chancroid as per CDC 2021 and NACO 2024.[1,2]

Table 11.

Management guidelines for Chancroid

NACO 2021	CDC 2021
Tablet Azithromycin 1 g stat	Tablet Azithromycin 1 g stat
Injection Ceftriaxone 250 mg IM single dose	Injection Ceftriaxone 250 mg IM single dose
	Ciprofloxacin 500 mg bd × 3 days (contraindicated in pregnant and lactating mothers)
	Erythromycin base 500 mg tds × 7 days
	Follow up after 7 days of treatment
HIV: Slow healing of ulcers, hence close monitoring is recommended PLHIV with chancroid may experience rapidly aggressive and erosive ulcers to a level of destroying the genital organs
Same treatment as non-HIV but prone to treatment failure These patients might require repeated or longer course of therapy	Persons with HIV infection who have chancroid infection should be monitored closely because they are more likely to experience chancroid treatment failure and to have ulcers that heal slowly
	Persons with HIV might require repeated or longer courses of therapy, and treatment failures can occur with any regimen
Partner treatment	Partner treatment
All partners in last 10 days of onset of symptoms examined and treated	Regardless of whether disease symptoms are present, sex partners during the last 10 days of patients with chancroid should be examined and treated

NACO=National AIDS Control Organization; CDC=Centers for Disease Control and Prevention; PLHIV=People living with HIV; IM=intramuscular

Lymphogranuloma venereum

Table 12 provides the new management guidelines for lymphogranuloma venereum as per CDC 2021 and NACO 2024.[1,2]

Table 12.

Management guidelines for lymphogranuloma venereum

NACO 2024	CDC 2021
Doxycycline 100 mg BD × 21 days	Doxycycline 100 mg BD × 21 days
Azithromycin 1 g once a week × 3 weeks	Erythromycin base 500 mg qid × 21 days
Erythromycin 500 mg qid × 14 days (extended as per assessment)	Azithromycin 1 g once a week × 3 weeks Followed by test of cure (NAAT) 4 weeks later
Pregnancy	Pregnancy
Azithromycin/Erythromycin given, after treatment, Test of cure 4 weeks after initial NAAT +ve	Doxycycline might be associated with discoloration of teeth; however, the risk is not well defined. Doxycycline is compatible with breastfeeding Azithromycin 1 g weekly for 3 weeks
	Pregnant women treated for LGV should have a test of cure performed 4 weeks after the initial CT NAAT-positive test
HIV: The treatment recommendations remain similar for PLHIV but the resolution may be delayed, treatment failures are also more common These patients might require repeated or longer course of therapy	HIV: Persons with LGV and HIV infection should receive the same regimens as those who do not have HIV. Prolonged therapy might be required because a delay in resolution of symptoms might occur
Partner treatment	Partner treatment
Partners of last 60 days evaluated and treated If partner asymptomatic → Capsule Doxycycline 100 mg BD × 7 days	Persons who have had sexual contact with a patient who has LGV within the 60 days before onset of the patient’s symptoms should be evaluated, examined, and tested for chlamydial infection, depending on anatomic site of exposure Asymptomatic partners should be presumptively treated with a chlamydia regimen (doxycycline 100 mg orally 2 times/day for 7 days)
Follow up: Retested (NAAT) 3 months after treatment or atleast within 12 months after treatment

LGV: Lymphogranuloma venereum; NACO=National AIDS Control Organization; CDC=Centers for Disease Control and Prevention; CT=Chlamydia trachomatis; PLHIV=People living with HIV; NAAT=Nucleic Acid Amplification Test

Donovanosis

Table 13 provides the new management guidelines for donovanosis as per CDC 2021 and NACO 2024.[1,2]

Table 13.

Management guidelines for donovanosis

NACO 2024	CDC 2021
Azithromycin 1 g/week or 500 mg od × > 3 weeks	Azithromycin 1 g/week or 500 mg od × 3 weeks or till complete healing Alternatives
Doxycycline 100 mg bd × 3 weeks	Doxycycline 100 mg bd × 3 weeks until lesions heal
Erythromycin 500 mg qid × > 3 weeks	Ciprofloxacin 750 mg bd × 3 weeks
Trimethoprim + Sulfomethoxazole 160/800 mg bd × > 3 weeks	Erythromycin base 500 mg qid × > 3 weeks
	Trimethoprim + Sulfomethoxazole DS (160 mg/800 mg) bd × > 3 weeks
Pregnancy	Pregnancy
No specific recommendations are mentioned for treatment of Donovanosis in pregnancy 76	Use of doxycycline in pregnancy might be associated with discoloration of teeth; however, the risk is not well defined
	Doxycycline is compatible with breastfeeding
	Sulfonamides can be associated with neonatal kernicterus among those with glucose-6-phospate dehydrogenase deficiency and should be avoided during the third trimester and while breastfeeding
	For these reasons, pregnant and lactating women with granuloma inguinale should be treated with a macrolide regimen (erythromycin or azithromycin)
HIV
Slow healing of ulcers
More risk of treatment failure
Persons with granuloma inguinale and HIV infection should receive the same regimens as those who do not have HIV	Persons with granuloma inguinale and HIV infection should receive the same regimens as those who do not have HIV
Close monitoring is needed
The patients might require repeated or longer course of therapy
Partner treatment	Partner treatment
Partners of last 60 days evaluated and treated	Persons who have had sexual contact with a patient who has granuloma inguinale within the
	60 days before onset of the patient’s symptoms should be examined and offered therapy
	However, the value of empiric therapy in the absence of clinical signs and symptoms has not been established

NACO=National AIDS Control Organization; CDC=Centers for Disease Control and Prevention

Pelvic inflammatory disease

Table 14 provides the new management guidelines for pelvic inflammatory disease as per CDC 2021 and NACO 2024.[1,2]

Table 14.

Management guidelines for pelvic inflammatory disease

NACO 2024	CDC 2021
Tablet Cefixime 800 mg stat + Capsule Doxycycline 100 mg bd	Oral regimens
× 14 days + Tablet Metronidazole 400 mg BD × 14 days	Ceftriaxone 500 mg (>150 kg → 1 g) IM in a single dose + Doxycycline 100 mg orally 2 times/day for 14 days with metronidazole 500 mg orally 2 times/day for
Ceftriaxone 500 mg IM stat + Capsule Doxycycline 100 mg bd × 14 days + Tablet Metronidazole 400 mg BD × 14 days Cefoxitin 2 g + Probenecid 1 g stat + Capsule Doxycycline 100 mg bd × 14 days + Tablet Metronidazole 400 mg BD × 14 days	14 days Cefoxitin 2 g IM in a single dose + probenecid 1 g oral concurrently in a single dose + Doxycycline 100 mg orally 2 times/day for 14 days with metronidazole 500 mg orally 2 times/day for 14 days Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime) +
	Doxycycline 100 mg orally 2 times/day for 14 days with metronidazole 500 mg orally 2 times/day for 14 days
	Parenteral regimens
	Ceftriaxone 1 g by every 24 h + Doxycycline 100 mg orally or IV every 12 h + Metronidazole 500 mg orally or IV every 12 h
	Cefotetan 2 g IV every 12 h + Doxycycline 100 mg orally or IV every 12 h
	Cefoxitin 2 g IV every 6 h + Doxycycline 100 mg orally or IV every 12 h
	Alternatives
	Ampicillin-sulbactam 3 g IV every 6 hours + Doxycycline 100 mg orally or IV every 12 h Clindamycin 900 mg IV every 8 h + Gentamicin loading dose IV or IM (2 mg/kg body weight), followed by a maintenance dose (1.5 mg/kg body weight) every 8 h; single daily dosing (3–5 mg/kg body weight) can be substituted
Pregnancy	Pregnancy
Pregnant women with PID should be hospitalized and provided with parenteral therapy	Pregnant women suspected of having PID are at high risk for maternal morbidity and preterm delivery
	These women should be hospitalized and treated with IV antimicrobials in consultation with an infectious disease specialist
HIV	HIV
The treatment recommendations are same for WLHIV as there is not much evidence on superiority of intensive management of PID among WLHIV	More likely to have a tubo-ovarian abscess, higher rates of concomitant M. hominis and streptococcal infections Treatment options same as non-HIV
Partner treatment	Partner treatment
Partners of 60 days presumptively treated for GC and CT	Partners of 60 days presumptively treated for GC and CT

PID=Pelvic inflammatory disease; NACO=National AIDS Control Organization; CDC=Centers for Disease Control and Prevention; WLHIV=Women living with HIV; IM=intramuscular; IV=Intravenous; GC=Gonococci; CT=Chlamydia trachomatis

Acute epididymitis

Table 15 provides the new management guidelines for acute epididymitis as per CDC 2021 and NACO 2024.[1,2]

Table 15.

Management guidelines for acute epididymitis

NACO 2024	CDC 2021
Scenario 1: When likelihood of NG/CT	Most likely caused by chlamydia or gonorrhea
Ceftriaxone 500 mg IM in a single dose + Capsule Doxycycline 100 mg orally bd × 10 days	Ceftriaxone 500 mg* IM in a single dose + Doxycycline 100 mg orally 2 times/day for 10 days
Scenario 2: For MSM who are insertive partners or heterosexual men who are involve in unprotected anal sex  Ceftriaxone 500 mg IM in a single dose + Tablet Levofloxacin 500 mg orally od × 10 days	Most likely caused by chlamydia, gonorrhea, or enteric organisms (men who practice insertive anal sex) Ceftriaxone 500 mg* IM in a single dose + Levofloxacin 500 mg orally once daily for 10 days
Scenario 3: When likelihood of enteric organisms only Tablet Levofloxacin 500 mg orally od × 10 days	Most likely caused by enteric organisms only: Levofloxacin 500 mg orally once daily for 10 days
HIV	HIV
Men with HIV infection who have uncomplicated acute epididymitis should receive the same treatment regimen as those who do not have HIV	Other etiologic agents have been implicated in acute epididymitis among men with HIV, including CMV, salmonella, toxoplasmosis, Ureaplasma urealyticum, Corynebacterium species, Mycoplasma species, and Mima polymorpha Men with HIV infection who have uncomplicated acute epididymitis should receive the same treatment regimen as those who do not have HIV
Partner treatment	Partner treatment
Sexual partners of persons within last 60 days preceding symptom should be evaluated, tested, and presumptively treated for chlamydia and gonorrhea	Men who have acute sexually transmitted epididymitis confirmed or suspected to be caused by NG or CT should be instructed to refer all sex partners during the previous 60 days before symptom onset for evaluation, testing, and presumptive treatment EPT is considered for whom linkage to care is anticipated to be delayed

*For persons weighing ≥150 kg, 1 g of ceftriaxone should be administered. NACO=National AIDS Control Organization; CDC=Centers for Disease Control and Prevention; CMV=Cytomegalovirus; MSM=Men who have sex with men; NG=Neisseria gonorrhoeae; CT=Chlamydia trachomatis; IM=intramuscular; EPT=Expedited partner therapy

Human papilloma virus

The management guidelines for HPV as per NACO 2024 and CDC 2021[1,2] are as follows:

Provider-administered therapy

1. Cryotherapy with liquid nitrogen or cryoprobe

2. Surgical removal → tangential scissor excision, tangential shave excision, curettage, laser, or electrosurgery

3. Trichloroacetic acid or bichloroacetic acid 80%–90% solution

4. Podophyllum resin 20%.

Patient-applied Therapy

1. Imiquimod 3.75% or 5% cream applied overnight thrice a week for up to 16 weeks (not recommended in pregnancy)

2. Podophyllotoxin 0.5% solution or 0.5%–1.5% cream twice daily for 3 days, followed by 4 days of no treatment (this cycle can be repeated up to four times)

3. Sinecatechins 15% ointment.

Table 16 provides an overview of treatment options for warts.[10]

Table 16.

Overview of treatment options for warts

Topical agents	Intralesional agents	Physical modalities	Systemic agents
Caustic agents	BCG	Cryotherapy	Zinc
TCA 80%–90%	PPD	Photodynamic therapy	Ranitidine
BCA 80%–90%	MMR	Heat	Cimetidine
SA 20%–40%	Candidal antigen	Lasers: CO2 fractional, Nd-Yag	Levamisole
Formalin 2%–3%	Vitamin D	Surgical: Electrosurgery, cautery	IFN
Formaldehyde 40%	Interferon alpha		Retinoids
Phenol 88%
Silver nitrate
Formic acid
Wart paint (SA+LA 16.7% each incollodion base)
Cantharidin
Whitfield ointment (SA 3% + BA 6%)
Antiviral agents
Cidofovir 1%–3%
Interferon
Immunomodulators
5% imiquimod
15% sinecatechins
Maxacalcitol
BCG
Contact sensitizers
DPCP
SADBE
DNCB
Antimitotic agents
20% Podophyllin
0.5% Podofilox
Antimetabolite
5% FU
Topical retinoids

TCA=Trichloro acetic acid; BCA=Bichloroacetic acid; SA=Salicylic acid; LA=Lactic acid; BCG=Bacillus Calmette–Guérin vaccine; DPCP=Diphenylcyclopropenone; SADBE=Squaric acid dibutylester; DNCB=Dinitrochlorobenzene; PPD=Purified protein derivative; MMR=Measles, mumps, rubella vaccine; IFN=Interferon

Note:

1. Podophyllin should not be applied to the cervix, vagina, or anal canal where the squamocolumnar junction is vulnerable to dysplastic changes. The solution should be allowed to dry completely after application to prevent irritation

2. Patients should apply a thin layer of Imiquimod to external, visible warts, then rub in the cream until it vanishes. The area is washed with soap and water 6–10 h after treatment. Imiquimod may weaken condoms and diaphragms, and sexual contact is not recommended while the cream is on the skin

3. There are cases reported for dyspareunia following surgical excision/cautery of genital warts (especially in females).

Vaccines

• Gardasil

• Cervarix

• Gardasil-9

• Cervavac.

Pregnancy

• Ano-genital warts can proliferate and become friable during pregnancy. Although removal of warts can be considered during pregnancy, resolution might be incomplete or poor

• Podofilox, podophyllin, trichloroacetic acid, and sinecatechins should not be used during pregnancy. Although imiquimod poses low risk, it should be avoided during pregnancy

• Rarely, HPV types 6 and 11 can cause respiratory papillomatosis among infants and children. However, the route of transmission (i.e., transplacental, perinatal, or postnatal) is not completely understood

• Cesarean delivery is indicated for women with anogenital warts in case of obstruction or if vaginal delivery would result in excessive bleeding.

HIV

• There are greater chances of development of anogenital warts among PLHIV than noninfected persons in the case of infection with HPV types 6 and 11

• HPV types 16, 18, 31, 33, and 35 can be associated with anogenital warts with foci of high-grade squamous intraepithelial lesion among PLHIV

• The lesions can be multiple and larger in size and may not respond to the therapy among PLHIV, and have a higher chance of recurrence after treatment

• There are greater chances of squamous cell carcinomas arising or resembling anogenital warts among immunocompromised PLHIV. Therefore, biopsy is recommended for confirmation of diagnosis in suspicious cases

• WLHIV have a six-fold increased risk of cervical cancer in comparison to women without HIV.

Partner Management

• Examination should be done; treatment is given if warts are present

• Partner to be counselled that they may already have HPV despite no visible signs of warts.

Proctitis/proctocolitis/enteritis

The new management guidelines as per CDC 2021[1] are as follows. No specific guidelines have been recommended as per NACO 2024.[2]

Acute Proctitis

Ceftriaxone 500 mg IM in a single dose (1 g for >150 kg) plus.

Doxycycline 100 mg orally 2 times/day for 7 days.

Proctocolitis or Enteritis

Treatment is directed to the specific enteric pathogen identified. Multiple stool examinations might be necessary for detecting Giardia, and special stool preparations are required for diagnosing cryptosporidiosis and microsporidiosis.

Follow-up

Retesting for the respective pathogen should be performed 3 months after treatment.

Partner Treatment

• Partners who have had sexual contact with persons treated for gonorrhea or chlamydia <60 days before the onset of the person symptoms should be evaluated, tested, and presumptively treated for the respective infection

• Sex partners should abstain from sexual contact until they and their partners are treated

• No specific recommendations are available for screening or treating sex partners of persons with diagnosed sexually transmitted enteric pathogens; however, partners should seek care if symptomatic.

Conclusion

The objectives of these guidelines are to provide updated, evidence-informed clinical and practical recommendations on the management of various STIs. Components of comprehensive STI case management include making a correct and timely diagnosis, providing effective treatment, reducing/preventing high-risk behavior through education, counseling, promoting safe sexual practices, including condom usage, and partner screening and treatment. We hope our article will serve as a useful ready reckoner for postgraduates preparing for their examinations and for practicing dermato-venereologists.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.