Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

high-risk non-pregnant women

1st line – doxycycline

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INITIAL
|
high-risk non-pregnant women
1st line – 

doxycycline

High risk is defined as <25 years of age, and those with a new sex partner, a sex partner with concurrent partners, or a sex partner who has a sexually transmitted infection (STI).[1]​​

Therapy is based on the US Centers for Disease Control and Prevention STIs treatment guidelines, which recommend a 7-day course of oral doxycycline.[1]​​

Primary options

doxycycline: 100 mg orally twice daily for 7 days

Consider – ceftriaxone

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INITIAL
|
high-risk non-pregnant women
Consider – 

ceftriaxone

Additional treatment recommended for SOME patients in selected patient group

Treatment for gonococcal infection with a single dose of intramuscular ceftriaxone is also recommended if the patient is at risk of gonorrhoea or the prevalence of gonorrhoea is high locally.[1]​​

Primary options

ceftriaxone: body weight <150 kg: 500 mg intramuscularly as a single dose; body weight ≥150 kg: 1000 mg intramuscularly as a single dose

Plus – metronidazole

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INITIAL
|
high-risk non-pregnant women
|
with history of sexual assault
Plus – 

metronidazole

Treatment recommended for ALL patients in selected patient group

Metronidazole is added to the recommended drug regimen for women who have a history of sexual abuse.[1]​​

Primary options

metronidazole: 2 g orally as a single dose

ACUTE

non-pregnant women

1st line – antibiotic therapy

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ACUTE
|
non-pregnant women
|
confirmed chlamydial infection
1st line – 

antibiotic therapy

The US Centers for Disease Control and Prevention recommends doxycycline.[1]​ In 2018, the UK guidelines were updated to recommend doxycycline treatment as first-line treatment for any diagnosed chlamydia, regardless of anatomical site.[29]

Azithromycin or levofloxacin is a suitable alternative.

Systemic fluoroquinolone antibiotics, such as levofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycaemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behaviour.[30] Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, and unavailability). Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.​ 

The management of the patient's sex partners is an important consideration to prevent re-infection and further transmission.[1][28]​​​ CDC: expedited partner therapy Opens in new window

For further details of management, see Genital tract chlamydia infection.

Primary options

doxycycline: 100 mg orally twice daily for 7 days

Secondary options

azithromycin: 1 g orally as a single dose

OR

levofloxacin: 500 mg orally once daily for 7 days

Consider – ceftriaxone

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ACUTE
|
non-pregnant women
|
confirmed chlamydial infection
Consider – 

ceftriaxone

Additional treatment recommended for SOME patients in selected patient group

For concurrent gonococcal infection, the US Centers for Disease Control and Prevention recommends adding treatment with a single dose of intramuscular ceftriaxone to the regimen.[1]​​

Primary options

ceftriaxone: body weight <150 kg: 500 mg intramuscularly as a single dose; body weight ≥150 kg: 1000 mg intramuscularly as a single dose

1st line – cephalosporin monotherapy or gentamicin plus azithromycin

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ACUTE
|
non-pregnant women
|
confirmed gonorrhoea infection
1st line – 

cephalosporin monotherapy or gentamicin plus azithromycin

The US Centers for Disease Control and Prevention recommends a single dose of intramuscular ceftriaxone as a first-line regimen, preferably given under direct observation.[1]​​

In patients who have a cephalosporin allergy, a single dose of intramuscular gentamicin plus oral azithromycin may be considered; however, gastrointestinal adverse effects may limit the use of these regimens.[1]​ An infectious disease specialist should be consulted if there is known penicillin/cephalosporin allergy.

A single dose of oral cefixime is a suitable alternative regimen if ceftriaxone is not available.[1]​​

The management of the patient's sex partners is an important consideration to prevent re-infection and further transmission.[1][28]​​​ CDC: expedited partner therapy Opens in new window

For further details of management, see Gonorrhoea infection.

Primary options

ceftriaxone: body weight <150 kg: 500 mg intramuscularly as a single dose; body weight ≥150 kg: 1000 mg intramuscularly as a single dose

Secondary options

gentamicin: 240 mg intramuscularly as a single dose

and

azithromycin: 2 g orally as a single dose

OR

cefixime: 800 mg orally as a single dose

Consider – doxycycline

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ACUTE
|
non-pregnant women
|
confirmed gonorrhoea infection
Consider – 

doxycycline

Additional treatment recommended for SOME patients in selected patient group

For concurrent chlamydial infection, patients should receive oral doxycycline for 7 days in addition to the above regimen.[1]​​

Primary options

doxycycline: 100 mg orally twice daily for 7 days

1st line – metronidazole or tinidazole

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ACUTE
|
non-pregnant women
|
confirmed trichomoniasis
1st line – 

metronidazole or tinidazole

Metronidazole and tinidazole are the only known effective drugs for the treatment of trichomoniasis, with up to 95% success rates.[1]​ Consider re-screening at 3 months.

The management of the patient's sex partners is an important consideration to prevent re-infection and further transmission.[1][28]​​​ CDC: expedited partner therapy Opens in new window However, different partner management interventions (e.g., patient referral, provider referral, contract referral, or expedited partner therapy) have similar efficacies.[1][28]​​

Primary options

metronidazole: 500 mg orally twice daily for 7 days

OR

tinidazole: 2 g orally as a single dose

1st line – oral or intravaginal metronidazole

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ACUTE
|
non-pregnant women
|
confirmed bacterial vaginosis
1st line – 

oral or intravaginal metronidazole

Oral and vaginal formulations of metronidazole have been shown to be equally effective. Choice depends on the patient's adherence and preference.

Primary options

metronidazole: 500 mg orally twice daily for 7 days

OR

metronidazole vaginal: (0.75% gel) insert 5 g (one applicatorful) into the vagina once daily at night for 5 days

1st line – intravaginal clindamycin cream

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ACUTE
|
non-pregnant women
|
confirmed bacterial vaginosis
1st line – 

intravaginal clindamycin cream

Intravaginal clindamycin cream is recommended as a first-line treatment option.[1]​​

Women of childbearing age need to be aware that due to its oil-based formula, clindamycin cream might weaken latex condoms and diaphragms for 5 days after use.

Primary options

clindamycin vaginal: (2% cream) insert 5 g (one applicatorful) into the vagina once daily at night for 7 days

2nd line – oral tinidazole or secnidazole

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ACUTE
|
non-pregnant women
|
confirmed bacterial vaginosis
2nd line – 

oral tinidazole or secnidazole

Oral tinidazole or secnidazole may be used as an alternative second-line regimen. Tinidazole has a longer serum half-life than metronidazole and also reaches higher levels in the genitourinary tract.

Primary options

tinidazole: 2 g orally once daily for 2 days; or 1 g orally once daily for 5 days

OR

secnidazole: 2 g orally as a single dose

2nd line – oral or intravaginal (ovules) clindamycin

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ACUTE
|
non-pregnant women
|
confirmed bacterial vaginosis
2nd line – 

oral or intravaginal (ovules) clindamycin

Oral preparations or intravaginal ovules of clindamycin may be given as second-line options.

Primary options

clindamycin: 300 mg orally twice daily for 7 days

OR

clindamycin vaginal: 100 mg ovule into the vagina once daily at night for 3 days

1st line – antiviral therapy

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ACUTE
|
non-pregnant women
|
confirmed herpes simplex virus (HSV) type 2 primary infection
1st line – 

antiviral therapy

Cervicitis can accompany genital herpes (especially primary HSV-2 infection).[1]​​

The management of the patient's sex partners is an important consideration to prevent re-infection and further transmission.[1]​​ CDC: expedited partner therapy Opens in new window

Primary options

aciclovir: 400 mg orally three times daily for 7-10 days; or 200 mg orally five times daily for 7-10 days

OR

famciclovir: 250 mg orally three times daily for 7-10 days

OR

valaciclovir: 1000 mg orally twice daily for 7-10 days

1st line – antiviral therapy

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ACUTE
|
non-pregnant women
|
confirmed HSV type 2 recurrent infection
1st line – 

antiviral therapy

Cervicitis can accompany genital herpes (especially primary HSV-2 infection).[1]​​

The management of the patient's sex partners is an important consideration to prevent re-infection and further transmission.[1]​​ CDC: expedited partner therapy Opens in new window

Primary options

aciclovir: 400 mg orally three times daily for 5 days; or 800 mg orally twice daily for 5 days; or 800 mg orally three times daily for 2 days

OR

famciclovir: 125 mg orally twice daily for 5 days; or 1000 mg orally twice daily for 1 day; or 500 mg orally as a single dose, followed by 250 mg twice daily for 2 days

OR

valaciclovir: 500 mg orally twice daily for 3 days; or 1000 mg orally once daily for 5 days

pregnant women

1st line – antibiotic therapy

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ACUTE
|
pregnant women
|
confirmed chlamydial infection
1st line – 

antibiotic therapy

Treatment of chlamydial infection in pregnancy is important to prevent the sequelae of infection in the mother and neonate.[1]​​

The US Centers for Disease Control and Prevention recommends azithromycin as a first-line option.[1]​ Amoxicillin is a suitable alternative.

The management of the patient's sex partners is an important consideration to prevent re-infection and further transmission.[1][28]​​​ CDC: expedited partner therapy Opens in new window

Primary options

azithromycin: 1 g orally as a single dose

Secondary options

amoxicillin: 500 mg orally three times daily for 7 days

Consider – ceftriaxone

Back
ACUTE
|
pregnant women
|
confirmed chlamydial infection
Consider – 

ceftriaxone

Additional treatment recommended for SOME patients in selected patient group

For concurrent gonococcal infection, the US Centers for Disease Control and Prevention recommends adding treatment with a single dose of intramuscular ceftriaxone to the regimen.[1]​​

Primary options

ceftriaxone: body weight <150 kg: 500 mg intramuscularly as a single dose; body weight ≥150 kg: 1000 mg intramuscularly as a single dose

1st line – cephalosporin monotherapy

Back
ACUTE
|
pregnant women
|
confirmed gonorrhoea infection
1st line – 

cephalosporin monotherapy

Treatment of gonorrhoea infection in pregnancy is important to prevent the sequelae of infection in the mother and neonate.[1]​​

The US Centers for Disease Control and Prevention recommends intramuscular ceftriaxone as a first-line regimen in pregnant women, preferably given under direct observation.[1]​​

Consultation with an infectious disease specialist is recommended if the patient has a cephalosporin allergy or there are any other considerations that preclude treatment with this regimen.

The management of the patient's sex partners is an important consideration to prevent re-infection and further transmission.[1][28]​​​ CDC: expedited partner therapy Opens in new window

Primary options

ceftriaxone: body weight <150 kg: 500 mg intramuscularly as a single dose; body weight ≥150 kg: 1000 mg intramuscularly as a single dose

Consider – azithromycin

Back
ACUTE
|
pregnant women
|
confirmed gonorrhoea infection
Consider – 

azithromycin

Additional treatment recommended for SOME patients in selected patient group

A single dose of azithromycin may be added to treat chlamydia, if chlamydial infection has not been excluded.[1]​​

Primary options

azithromycin: 1 g orally as a single dose

1st line – metronidazole

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ACUTE
|
pregnant women
|
confirmed trichomoniasis
1st line – 

metronidazole

Symptomatic women should be tested and considered for treatment regardless of stage of pregnancy. If treatment is considered, systemic metronidazole is the treatment of choice.[1]​​

It is best to defer breastfeeding for 12 to 24 hours after treatment; however, several case series found no evidence of adverse effects in infants exposed to metronidazole in breast milk. The US Centers for Disease Control and Prevention suggests a lower-dose regimen, which is more compatible with breastfeeding over longer periods of time.[1]​​

The management of the patient's sex partners is an important consideration to prevent re-infection and further transmission.[1][28]​​​ CDC: expedited partner therapy Opens in new window However, different partner management interventions (e.g., patient referral, provider referral, contract referral, or expedited partner therapy) have similar efficacies​.[1][28]

Primary options

metronidazole: 500 mg orally twice daily for 7 days

1st line – oral or intravaginal metronidazole

Back
ACUTE
|
pregnant women
|
confirmed bacterial vaginosis
1st line – 

oral or intravaginal metronidazole

Oral and vaginal formulations of metronidazole have been shown to be equally effective. Choice depends on patient compliance and preference.

Primary options

metronidazole: 500 mg orally twice daily for 7 days

OR

metronidazole vaginal: (0.75% gel) insert 5 g (one applicatorful) into the vagina once daily at night for 5 days

1st line – oral or intravaginal clindamycin

Back
ACUTE
|
pregnant women
|
confirmed bacterial vaginosis
1st line – 

oral or intravaginal clindamycin

Symptomatic pregnant women can be treated with either of the oral or vaginal regimens recommended for non-pregnant women.[1]​​

Primary options

clindamycin vaginal: (2% cream) insert 5 g (one applicatorful) into the vagina once daily at night for 7 days

Secondary options

clindamycin: 300 mg orally twice daily for 7 days

OR

clindamycin vaginal: 100 mg ovule into the vagina once daily at night for 3 days

1st line – antiviral therapy

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ACUTE
|
pregnant women
|
confirmed HSV type 2 primary infection
1st line – 

antiviral therapy

In addition to acute treatment, initiation of prophylaxis with acyclovir or valaciclovir at 36 weeks' gestation has been shown to decrease the rate of caesarean sections for active HSV infections at term, although it has not been shown to affect neonatal morbidity or mortality.[1]​​

The management of the patient's sex partners is an important consideration to prevent re-infection and further transmission.[1]​​ CDC: expedited partner therapy Opens in new window

Primary options

aciclovir: 400 mg orally three times daily

OR

valaciclovir: 500 mg orally twice daily

1st line – antiviral therapy

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ACUTE
|
pregnant women
|
confirmed HSV type 2 recurrent infection
1st line – 

antiviral therapy

In addition to acute treatment, initiation of prophylaxis with acyclovir or valaciclovir at 36 weeks' gestation has been shown to decrease the rate of caesarean sections for active HSV infections at term, although it has not been shown to affect neonatal morbidity or mortality.[1]​​

The management of the patient's sex partners is an important consideration to prevent re-infection and further transmission.[1]​​ CDC: expedited partner therapy Opens in new window

Primary options

aciclovir: 400 mg orally three times daily

OR

valaciclovir: 500 mg orally twice daily

ONGOING

recurrent/resistant infections

1st line – repeat investigations and retreatment

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ONGOING
|
recurrent/resistant infections
1st line – 

repeat investigations and retreatment

Patients who have persistent symptoms after treatment should be re-evaluated for treatment failure or possible re-exposure to gonorrhoea or chlamydia.[1]​ If relapse and re-infection with a specific organism have been excluded, bacterial vaginosis is not present, and sex partners have been evaluated and treated, management options for persistent cervicitis are undefined, and it is not clear if repeated or prolonged antibiotic treatment is helpful.

The aetiology of persistent cervicitis, including the potential role of Mycoplasma genitalium, is unclear, but it is reasonable to test for M genitalium in cases of clinically significant cervicitis that persist after azithromycin or doxycycline therapy, if re-exposure and non-adherence to treatment are unlikely.[1]​ Treatment can be started on the basis of the results of diagnostic testing.[8] In treated women with persistent symptoms that are clearly attributable to cervicitis, referral to a gynaecologist may be appropriate.

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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