Guidelines

International Journal of STD & AIDS

2023, Vol. 0(0) 1–15
British Association of Sexual Health and © The Author(s) 2023
Article reuse guidelines:
HIV (BASHH) United Kingdom national sagepub.com/journals-permissions
DOI: 10.1177/09564624231168217
guideline for the management of sexually journals.sagepub.com/home/std

transmitted enteric infections 2023

Daniel Richardson1,2 , Mark Pakianathan3, Michael Ewens4,

Holly Mitchell5, Hasan Mohammed6, Elizabeth Wiseman7, Marc
Tweed8, Kayleigh Nichols1, Waseem Rawdah1, Richard 
Cooper1,
9
Robert Macrowan , Matthew Irish9, Amy Evans4,10, and
5,
Gauri Godbole

Abstract
This is the first British Association of Sexual Health and HIV (BASHH) national guideline for the management of sexually
transmitted enteric infections (STEI). This guideline is primarily aimed for level 3 sexual health clinics; however, it may also be
applicable to other settings such as primary care or other hospital departments where individuals with STEI may present. This
guideline makes recommendations on testing, management, partner notification and public health control of STEI.

Keywords
Sexually transmitted enteric infections, men who have sex with men, Shigella spp., Giardia duodenalis, Entamoeba histolytica,
proctocolitis, enteritis, hepatitis, proctitis, antimicrobial resistance, public health, guideline
Date received: 13 March 2023; accepted: 20 March 2023

Introduction and Evaluation (GRADE) system was applied to assess the

grade of the evidence.
There are increasing rates of sexually transmitted enteric
infections (STEI) particularly amongst men who have sex
with men (MSM), including heterosexual identifying MSM Methods
and some groups of gender diverse people.1–3 This The multidisciplinary writing group reviewed the evidence for
guideline is intended to provide evidence-based guidance transmission, investigation, management, antimicrobial
on the management of both suspected and confirmed STEI
in adults. This guideline focuses on STEI organisms for
1
which there exists robust evidence for sexual transmission. University Hospitals Sussex NHS Foundation Trust, Brighton, UK
2
Brighton & Sussex Medical School, Brighton, UK
3
Guys and St Thomas’ NHS Foundation Trust, London, UK
4
Search strategy Leeds Teaching Hospitals NHS Trust, Leeds, UK
5
UK Health Security Agency, London, UK
6
PICO (Population, Intervention, Comparator, Outcome) Chelsea & Westminster NHS Foundation Trust, London, UK
7
questions were generated and used for database searches Manchester University NHS Foundation Trust, London, UK
8
Terrence Higgins Trust, Brighton, UK
conducted from Pubmed, Medline, Embase and the Cochrane 9
Community Contributor, Brighton, UK
library. (Supplemental Appendix 1) The search terms were 10
British Association of Sexual Health & HIV, Clinical Effectiveness Group,
kept broad to include all the guideline questions. Only pub- London, UK

lications in the English language were reviewed. Manuscript Joint last authors
titles, abstracts, and then selected full texts manuscripts were
Corresponding author:
reviewed and included in the review; further manuscripts Daniel Richardson, University Hospitals Sussex NHS Foundation Trust,
identified from key manuscript references were also included. Sexual Health and HIV, Eastern Road, Brighton BN2 5BE, UK.
The Grading of Recommendations Assessment Development Email: [email protected]
2 International Journal of STD & AIDS 0(0)

Figure 1. Syndromes and aetiology of sexually trasmitted enteric infections.

stewardship, and public health control for STEI. We aimed to (rectum). Most of the causative agents of STEI are notifiable
provide guidance for specific populations, e.g., people who are and are subject to specific health protection regulations.
pregnant, and considered scenarios where treatment may need (Figure 1) During the development of this guideline there
to be altered due to availability or cost. has been a global outbreak of Mpox in MSM which can
cause proctitis.1
Piloting & feedback
Following public panel and professional review (Clinical
Effectiveness Group (CEG) and BASHH membership web
General management of sexually
consultation), the guideline was piloted for validation by transmitted enteric infections
several BASHH pilot sites.
Clinical history
Clinical history should include a comprehensive sexual
Equality impact assessment
history (including recent chemsex or recent use of sex on
An assessment of the guideline recommendations was made premises venues), information about travel to endemic areas
according to the principals of the NICE equality policy. or sexual contact with someone returning from an area of
high endemicity.5,7,8 The occupation (e.g. food handlers) of
suspected or confirmed cases should also be considered.9,10
Patient & public involvement Bacterial STEI should be considered in sexually active
Three community members contributed to the design and MSM and other individuals who may be part of sexual
content of the draft guidelines and the patient information networks where there is an outbreak of STEI (e.g. Shigella
leaflet. The guideline was also reviewed by the BASHH sonnei).5,7,8 (Figure 2)
patient and public panel.
Recommendations
· Adults (particularly MSM) presenting with gastro-
Aetiology enteritis, or a suspected or confirmed STEI should
STEI can cause ill health characterised by diarrhoea, sepsis, have a documented sexual history as per BASHH
jaundice (in the case of Hepatitis A) and rectal symptoms.4–6 guidelines. (1C)
STEIs can be categorised by syndrome: hepatitis, enteritis · Occupation history should be taken in patients with
(small bowel), procto-colitis (large bowel), and proctitis suspected or confirmed STEI. (1B)
Richardson et al. 3

Figure 2. Management of diarrhoea in men who have sex with men and other individuals at risk of sexually transmitted enteric
infections.

Clinical examination necessary in patient presenting with diarrhoea who have

recently used antimicrobials. Following assessment, febrile
Clinical examination and assessment should include an ab- unwell patients, or those with severe diarrhoea who require
dominal and ano-genital examination, consideration for the hospital admission may require further investigations (e.g.
possibility of extra-intestinal disease (e.g. liver abscess), and blood cultures, full blood count, urea & electrolytes, C-
an assessment of disease severity and sepsis (measurement of reactive protein, coagulation screen, abdominal X-ray) to
relevant vital signs: blood pressure, pulse, temperature).11–13 identify and manage cases of severe dehydration, renal
Proctoscopic examination findings may include: mucosal impairment, haemolytic uraemic syndrome (HUS), or toxic
erythema, ulceration, muco-purulent pus, bleeding (including dilatation of the colon.12 (Figure 2)
contact bleeding).14–16 Some patients may be unable to
tolerate proctoscopy and blind rectal specimens for micro-
biological investigations may be necessary.15 Recommendations
· Patients presenting with possible STEI should have stool
Recommendations PCR testing for bacteria and parasites. (1D)
· Clinical examination should include relevant vital signs, an · Direct microscopy of stool samples for ova, cysts and
abdominal examination, ano-genital examination, and rectal parasites is unreliable and we recommend a minimum
examination using proctoscopy where tolerated. (1C) three separate sequential samples if this is the only di-
· Blind rectal specimens for microbiological investigation agnostic method available. (1D)
(without visualisation of the rectal mucosa with a proc- · Comprehensive sexually transmitted infection testing
toscope) should be taken in cases where proctoscopy is including genital, rectal, oropharyngeal and serological
not tolerated. (1D) samples should be performed on all patients with an STEI
as per current BASHH guidelines and standards. (1B)
Investigations
Stool specimens for microbiological testing are recom-
Hospital admission
mended in all patients presenting with a suspected STEI. Admission to hospital should be based on NICE guide-
Comprehensive STI testing should be performed including lines.21 Hospital assessment is advised if: the patient is
for C. trachomatis, N gonorrhoeae, T. pallidum, HIV and systemically unwell with severe dehydration, and if there
viral hepatitis.13,17–20 In cases where hepatitis A is sus- is intractable vomiting or high output diarrhoea or if there
pected, hepatitis A IgM testing should be performed (as per is a suspected serious complication such as sepsis or acute
BASHH guidelines). Clostridium difficile testing may be kidney injury.21
4 International Journal of STD & AIDS 0(0)

Oral rehydration pre-exposure prophylaxis (HIV-PrEP), hepatitis A, B and

HPV vaccinations, and vaccination relevant to outbreaks
Oral rehydration consisting of oral rehydration salts may be e.g. Mpox.6,18,35–37 Patients who are having issues with
required, taken after every loose stool passed for up to 48 h12,22,23 chemsex use including dependence should be supported
using local guidelines.
Anti-motility agents
Recommendations
The use of anti-motility agents such as loperamide is · HIV pre-exposure prophylaxis should be discussed with
controversial for the management of infectious diarrhoea HIV negative individuals diagnosed with a STEI. (1A)
and should be avoided.12,22,24,25 · Hepatitis A & B, HPV, and possibly Mpox vaccination
should be offered to patients diagnosed with a STEI if not
Contact tracing & partner management already vaccinated (1D) (Table 1).
Partner management for proctitis depends on underlying cause:
see current BASHH guidance on causes of proctitis. As E. Public health
histolytica symptoms can develop after a period of asymp- Registered medical practitioners have a statutory duty to report
tomatic colonisation, the sexual partner look-back period is less notifiable diseases to their local public health team under the
clear.26–32 There is no requirement for stool specimen testing of respective Health Protection (Notification) Regulations or
asymptomatic contacts of STEI unless E. histolytica is di- Public Health Acts in each country of the United Kingdom
agnosed or in cases of refractory giardiasis where reinfection (see Supplemental Appendix 2 for country specific guidance).
from an asymptomatic sexual contact is suspected. Individuals with diarrhoea and occupations which include the
care of children or vulnerable adults, healthcare, food handling
Recommendations or recreational water facilities should be advised to follow
· Contact tracing should include a look back period of
local public health protection guidance for the purposes of
4 weeks (since onset of symptoms) for sexual contacts of infection control or outbreak management.13 Patients should
patients with STEI (not proctitis or E. histolytica) (1D) be informed of the need for notification to local public health
· Both asymptomatic and symptomatic sexual contacts of
teams as local health protection or environmental health of-
E. histolytica should be tested and treated if stool sample ficers may need to contact them for contact tracing or as part of
is positive. (1C) outbreak management. Where clinics use GUM identification
· Symptomatic sexual contacts of other STEI should be
numbers (‘GUM IDs’; instead of first name and surname) for
treated with the same agent(s) as index cases. (1D) specimen identification on laboratory request forms, the local
(except for the causes of proctitis which should be public health teams will require notification of infection using
managed according to the relevant BASHH guideline) name, date of birth and contact details (e.g. home address,
phone number).38 This sharing of direct identifiers such as first
Prevention name and surname with local public health teams should be
clearly discussed with patients.
Patients with a confirmed or suspected STEI should be given
clear verbal and written information on their condition, with
particular emphasis on the implications for their own, their Hepatitis
partners and the wider public health. Advice regarding hand
washing particularly after using the toilet, when preparing food Hepatitis A virus
and avoiding sex until 7 days after the diarrhoea has resolved.33,34 Hepatitis A can be sexually transmitted.4,39–44 Acute hepatitis
A generally causes a self-limiting illness characterised by
Recommendations nausea, vomiting, diarrhoea, dark urine, jaundice, fever,
· Patients with STEI should be given advice on hand headache, weight loss, and abdominal pain.45
washing particularly after using the toilet, preparing food,
and avoidance of sexual contact until 7 days after di- Recommendations. See BASHH hepatitis guidelines for
arrhoea resolution. (1C) testing, management, and vaccination for hepatitis A.

Other sexual health interventions (HIV pre-exposure Enteritis

prophylaxis and vaccination)
Patients with STEI are at increased risk of other STIs and
Giardia duodenalis
HIV and may benefit from other sexual health interventions Background & clinical features. Giardia duodenalis (also
including: HIV post-exposure prophylaxis (HIV-PEP), HIV known as Giardia lamblia and Giardia intestinalis) is
Richardson et al. 5

Table 1. General management of STEIs: summary of recommendations.

Adults (particularly MSM) presenting with gastro-enteritis or a suspected or confirmed STEI should have a documented sexual 1C
history as per BASHH guidelines
Occupation and food history should be taken in patients with suspected or confirmed STEI 1B
Clinical examination should include relevant vital signs, an abdominal examination, ano-genital examination and rectal examination 1C
using proctoscopy where tolerated
Blind rectal specimens for microbiological investigation (without visualisation of the rectal mucosa with a proctoscope) should be 1D
taken in cases where proctoscopy is not tolerated
Patients presenting with possible STEI should have stool PCR testing for bacteria and parasites 1D
Direct microscopy of stool samples for ova, cysts and parasites is unreliable and we recommend a minimum three separate 1D
sequential samples if this is the only diagnostic method available
If an initial diagnosis of bacterial proctocolitis (Shigella spp., Campylobacter spp., STEC or Salmonella spp.) is made with a culture- 1C
independent diagnostic test (e.g. PCR), reflex stool culture and antimicrobial susceptibility testing should be performed
Comprehensive sexually transmitted infection testing including genital, rectal, oropharyngeal and serological samples should be 1B
performed on all patients with an STEI as per current BASHH guidelines and standards
Contact tracing should include a look back period for of 4 weeks (since onset of symptoms of the index) for sexual contacts of 1D
patients with STEI (not proctitis or E. histolytica)
Both asymptomatic and symptomatic contacts of E. histolytica should be tested and treated if stool sample is positive 1C
Symptomatic sexual contacts of other STEI should be treated with the same agent(s) as index cases. (1D) (except for the causes of 1D
proctitis which should be managed according to the relevant BASHH guideline)
Patients with STEI should be given advice on hand washing particularly after using the toilet, preparing food, and avoidance of sexual 1C
contact until 7 days after diarrhoea resolution
HIV pre-exposure prophylaxis should be discussed with HIV negative individuals diagnosed with a STEI 1A
Hepatitis A & B, HPV, and possibly Mpox vaccination should be offered to patients diagnosed with a STEI if not already vaccinated/ 1D
non-immune

sexually transmitted amongst MSM.46–51 Individuals can be Tinidazole and metronidazole are the most effective
asymptomatic (up to 40%); or may experience mild, self- agents to treat giardiasis. Other 5-nitroimidazole drugs
limiting diarrhoea; or have profuse watery diarrhoea in- such as secnidazole or ornidazole have milder side effects
cluding greasy, foul-smelling stools with abdominal than metronidazole, but are unlicensed in the UK and
cramping, bloating, flatulence, and weight loss.48,52–57 The harder to obtain.62,63,67 Nitroimidazole monotherapy of-
incubation period is 1–25 days (average 1 week), but can be fers 45–95% cure, however cases refractory to treatment
longer.58,59 The median duration of illness is 6 weeks, with are increasing.62,67,68 (Table 2) Refractory Giardiasis is
symptoms seldom lasting less than 1 week 59,60 Antimi- seen in up to 70% of patients with travel associated di-
crobial treatment shortens the course of disease, reduces arrhoea returning from the Indian subcontinent.69,70
complications and limits onward transmission.61–63 Parasites are cleared from stool at 3–5 days if success-
fully treated with symptom resolution in 5–7 days.71–73
Clinical history Lactose intolerance due to villous atrophy may follow;
a lactose free or low FODMAP (fermentable oligo-
Giardiasis should be considered in patients presenting with
saccharides, disaccharides, monosaccharides and polyols:
profuse watery diarrhoea associated with bloating, nausea,
short-chain carbohydrates that the small intestine absorbs
malaise, flatulence, smelly stools, steatorrhoea and weight
poorly) diet can relieve the irritable bowel-like sequelae
loss.52,56,64
(Table 2).74,75
Investigations for giardiasis
Recommendations
Stool PCR is the most sensitive assay for detection.65,66
· Anti-microbial treatment is necessary in microbio-
Giardia spp. may be detected by microscopy or serology.57
logically proven (confirmed) cases of giardiasis (1B)
As cysts are shed sporadically during infection, microscopic
· Tinidazole is the first line treatment for giardiasis (or
detection requires several stool samples for accurate diagnosis.
metronidazole if tinidazole is unavailable) (1A)
· A lactose free or low FODMAP diet is recommended
Antimicrobial treatment
relieve irritable bowel like symptoms (2C)
Antimicrobial treatment of confirmed cases cures symptoms, · Specialist advice from a parasitologist should be sought
shortens the course of the disease, reduces post infectious for the management of laboratory confirmed refractory
complications, and limits onward transmission.61–63 giardiasis (1B) (Table 3).
6 International Journal of STD & AIDS 0(0)

Table 2. Treatment recommendations for confirmed or suspected sexually transmitted Giardia duodenalis.

First line (1A) Tinidazole 2g PO stat (unlicensed in the UK)

Alternative agents
Metronidazole 2g PO OD for 3 days
Or 400 mg PO TDS for 5–7 days
Secnidazole 2 g PO stat (though unavailable at time of writing in the
UK)
Alternative agents (2C) Paromomycin 500 mg PO TDS for 5-days (unlicensed, suitable in
pregnancy)
Nitazoxanide 500 mg PO TDS for 3 days (unlicensed, caution in
pregnancy and should be avoided in breastfeeding)
Refractory Giardia (confirmed on microscopy/PCR following Discuss with microbiology or parasitology
treatment failure of 1st treatment and reinfection excluded)
The guideline writing group recognise that the availability and the cost of some of these medicines may limit accessibility. Discussion with
parasitology/infectious diseases/microbiology should guide treatment

Table 3. Enteritis: summary of recommendations.

Anti-microbial treatment is necessary in microbiologically proven (confirmed) cases of giardiasis 1B

Tinidazole is the first line treatment for giardiasis (or metronidazole if tinidazole is unavailable) 1A
A lactose free or low FODMAP diet is recommended to relieve irritable bowel like symptoms 2C
Specialist advice from a parasitologist should be sought for the management of laboratory confirmed refractory giardiasis 1B

Empirical treatment Procto-colitis

The role of empirical treatment is unknown, and not rec- Bacterial procto-colitis
ommended as highly sensitive PCR testing is now widely
available. Background. S. flexneri, S. sonnei, C. jejuni, C. coli, STEC
and S. Typhi can be sexually transmitted1,80–82 The pro-
tozoan infection, E. histolytica can cause proctocolitis and is
Pregnancy & breastfeeding sexually transmissible.29,32,51,83–87 Most cases of sexually
transmitted proctocolitis are self-limiting but some may
Tinidazole should not be used in the first trimester of
develop severe dysentery, and sepsis.88
pregnancy and should only be used in the second and third
trimester if the benefit outweighs the risk. Breastfeeding
Clinical features of sexually transmitted procto-colitis. Shigella
should be withheld during tinidazole treatment and for 72-
spp., STEC, Campylobacter spp. and S. Typhi share similar
h after.76 There is no evidence for teratogenicity with the
short incubation periods between 1-10 days.8,82,89 MSM with
use of metronidazole, however, high dose metronidazole
bacterial procto-colitis have symptoms lasting 4–30 days,
(2g) should be avoided in pregnancy and breastfeeding
with an average of 10 days.8 Patients present with watery
due to limited data.77,78 Secnidazole has been shown to
diarrhoea (or less frequently bloody diarrhoea), abdominal
have a positive impact in reducing birth complications in
pain, fever (including night sweats), rectal symptoms (in-
women with bacterial vaginosis however the manu-
cluding urgency, tenesmus, passing mucus and blood) nau-
facturers make no recommendation regarding use during
sea, vomiting and fatigue.8,90
pregnancy, and it is unlicensed in the UK. Paromomycin is
not absorbed systemically following oral administration
Complications
but data in pregnancy and breastfeeding is limited: the
manufacturers make no recommendation regarding Hospitalisation for severe colitis, bacteraemia and sepsis,
pregnancy and advise caution in breastfeeding.79 Nita- dehydration, acute kidney injury and intestinal perforation is
zoxanide is unlicensed for Giardiasis and should only be not uncommon.82,88 Reactive arthritis can be triggered by
used during pregnancy if the benefit outweighs the risk. It sexually acquired S.flexneri or S.sonnei and Campylobacter
should be avoided during the first trimester and in breast spp.91,92 Toxin mediated encephalitis has been described in an
feeding. adult MSM with S.flexneri.93 Acute demyelinating peripheral
Richardson et al. 7

neuropathies (Guillain Barre syndrome) is associated with comorbidities (frailty, inflammatory bowel disease, immu-
Campylobacter spp.94,95 HUS is a rare complication of STEC nocompromised, including advanced HIV). (1B)
and S. flexneri.96
Shigella spp. There are frequent outbreaks of sexually trans- Pregnancy & breastfeeding
mitted S. sonnei and S. flexneri in MSM.8,18,34,35,80,81,88,97–110
Extensively resistant sexually transmitted shigella has been The effects of antimicrobials in pregnancy and breast-
reported in MSM, including antimicrobial resistance to azi- feeding should be considered and discussed with micro-
thromycin, quinolones, aminoglycosides, co-trimoxazole and biology before any antimicrobial treatment.
ceftriaxone.111–120
Protozoal procto-colitis
Campylobacter spp. Sporadic outbreaks of sexually trans-
mitted C. coli and C. jejuni are reported in MSM.81,121–126 Entamoeba histolytica
Macrolide and ciprofloxacin antimicrobial resistant Cam-
Background. E. histolytica can be sexually transmitted in
pylobacter coli and jejuni outbreaks amongst MSM have
MSM (particularly in MSM living with HIV), and in het-
been reported.127–129
erosexual men and women.27,29,31,32,51,83–87,143–146 E. his-
Shiga toxin-producing E.coli (STEC). An outbreak of STEC tolytica causes a procto-colitis (and rarely distal ileitis) and
(O117:H7 VT1) was reported amongst MSM in the UK.130 can be complicated by liver abscess formation.26,147,148
Antimicrobials can up-regulate toxin release in some strains
of E.coli (and Shigella spp.), triggering the HUS, making Clinical features
the role of empirical antibiotics uncertain in patients pre-
Most patients (up to 90%) are asymptomatic.29,51,147 Those
senting with bloody diarrhoea.96,131,132
who become symptomatic may develop amoebic dysentery
Salmonella spp. Outbreaks of sexually transmitted S. Typhi (procto-colitis) or extra-luminal disease (including liver
have been reported in small clusters of MSM in the United abscesses). The incubation period for procto-colitis is
States, however, their role in sexually transmited procto- generally 1–3 weeks, but can be several months.26,32
colitis is likely to be small.81,109,133–135
Investigations
Management
PCR testing offers the most accurate diagnostic tool.149,150
The use of empirical antibiotics is NOT recommended where Microscopy alone cannot distinguish between cysts of non-
diarrhoea is mild and of unknown aetiology, as treatment is pathogenic species and pathogenic E. histolytica.26,151
likely to be of minimal benefit particularly in the context of Repeating microscopy of separate stool samples may be
increasing antimicrobial resistance 12,22,111,117,118,136–138 required over a period of 10 days to improve diagnostic
yield (as cysts may only be intermittently shed).
Recommendations
· Patients with suspected or confirmed bacterial sexually Recommendations
transmitted proctocolitis (shigellosis, campylobacter- · PCR assays for Entamoeba histolytica on stool samples is
iosis, STEC or enteric fever) should usually be managed the diagnostic method of choice. (1C)
conservatively, without empirical or susceptibility testing
guided antimicrobials. (1B) Antimicrobial treatment
Metronidazole may be less effective than tinidazole at
Antimicrobials
reducing clinical symptoms, but as effective at clearing
Extensively drug resistant sexually transmitted Shigella spp., parasites.28 Metronidazole may be more likely than tini-
Campylobacter spp., and STEC have been reported and an- dazole to cause adverse effects such as nausea.28 Alcohol
timicrobials will have a limited effect.12,82,111–114,116,118–120,139 should be avoided because of the risk of disulfiram-
Additionally, there is concern over the use of empirical an- like effect associated with 5-Nitroimidazoles.147,152 Pa-
timicrobial for cases of STEC and the potential to increase romomycin is currently the only available luminal
toxin release and HUS.140–142 agent.30,147,153–155 (Table 4)
Recommendations
· Empirical (presumptive) or susceptibility testing guided Recommendations
antimicrobials for patients with suspected or proven sexu- · All patients with confirmed E. histolytica should be
ally transmitted proctocolitis should only be considered treated, including asymptomatic sexual contacts. (1C)
when: the patient is hospitalised, pyrexial, the diarrhoea has · Patients with E. histolytica require sequential treatment
been present for at least 7 days and/or there are significant with two agents: an amoebicidal tissue active agent
8 International Journal of STD & AIDS 0(0)

followed by a luminal agent to prevent invasion and unclear.170–172 Recently, there has been an outbreak of
transmission of cysts. (1C) Mpox amongst MSM globally (including the UK) including
· First line treatment for patients with E. histolytica is Ti- a proctitis syndrome.173 We have not included any specific
nidazole 2g orally once/day for 3 days or metronidazole management recommendations regarding Mpox, as these
orally 800mg TDS for 5 days followed by paromomycin are likely to be covered in a new Mpox guideline (Table 6).
500 mg TDS PO for 7 days with meals. (1C) (Table 5)
Investigations
E. dispar, E. moshkovskii, Blastocyctis hominis and Di-
Direct microscopy can be useful for the diagnosis of N.
entamobea fragilis, E Bangladeshi, Entamoeba coli, E.
gonorrhoeae and T. Pallidum.14,162,174,175 Patients with
hartmanni, E. polecki, Endolimax nana, Iodamoeba bütschlii
proctitis should be tested for HIV, hepatitis C, and hepatitis
are generally not thought to be pathogenic, expert guidance
A & B if non-immune, as per BASHH guidelines. In-
should be sought if these species are identified in symptomatic
dividuals with ongoing symptomatic proctitis with negative
patients where no other cause for symptoms is found.147,156
microbiology who remain symptomatic following antimi-
Follow-up: Entamoeba histolytica. Repeat stool examination is crobial testing and treatment require further investigation by
not necessary if there is symptom resolution after completion specialist gastroenterology teams176,177 (Figure 3).
of treatment, however E. histolytica is a notifiable infection in
the UK and subject to public health processes.157 Recommendations
· Comprehensive sexually transmitted infection testing
Pregnancy and breastfeeding. See section on Giardia: preg-
should be performed in patients with proctitis (as per
nancy and breastfeeding.
BASHH guidelines) including rectal testing for N.
gonorrhoeae, HSV, C. trachomatis (including the L
Proctitis genotype: lymphogranuloma venereum), T. pallidum
(serology and direct molecular testing) (1C)
Background
N. gonorrhoeae, HSV, C. trachomatis [D-K genotypes], C.
trachomatis [L1-3 genotypes] (LGV), T. pallidum and
Empirical treatment
Mpox are all causes of symptomatic proctitis and poly- Recommendations
microbial infection is not uncommon.13,14,17,158–169 The · Patients with a possible sexually transmitted proctitis
role of M. genitalium in symptomatic proctitis is currently should be considered for empirical treatment for

Table 4. Sequential antimicrobial treatment of Entamoeba histolytica.

Amoebicidal agent Tinidazole 2 g OD for 3 days

Or
Metronidazole 800 mg PO TDS for 5 days
Followed by
Luminal/Cysticidal eradication agent Paromomycin 500 mg PO TDS for 7 days
The guideline writing group recognise that the availability and cost of some medicines may limit their use in practice. Discussion with
parasitology/infectious diseases/microbiology should guide treatment

Table 5. Proctocolitis: summary of recommendations.

Patients with suspected or confirmed sexually transmitted proctocolitis should usually managed conservatively without empirical or 1B
susceptibility testing guided antimicrobials
Empirical (presumptive) or susceptibility testing guided antimicrobials for patients with suspected or proven sexually transmitted 1B
proctocolitis should only be considered when: the patient is hospitalised, pyrexial, the diarrhoea has been present for at least
7 days and/or there are significant comorbidities (frailty, inflammatory bowel disease, immunocompromised, including advanced
HIV)
PCR assays for Entamoeba histolytica on stool samples is the diagnostic method of choice 1C
All patients with confirmed E. histolytica procto-colitis should be treated, including asymptomatic sexual contacts 1C
Patients with E. histolytica require sequential treatment with two agents: An amoebicidal tissue active agent followed by a luminal 1C
agent to prevent invasion and transmission of cysts
First line treatment for symptomatic patients with E. histolytica is Tinidazole 2 g orally once/day for 3 days or metronidazole orally 1C
800 mg TDS for 5 days followed by paromomycin 500 mg TDS PO for 7 days with meals
Richardson et al. 9

C. trachomatis (including Lymphogranuloma venereum) Follow up

(1D), N. gonorrhoeae (1C) and HSV (1D). (Table 7)
Patients with severe proctitis should have a clinical review
after 7 days. If microbiology tests are negative and the
Pregnancy & breastfeeding patient with proctitis remains symptomatic, rectal M.
See relevant BASHH guidelines for management of genitalium testing and referral to gastroenterology should
N. gonorrhoeae, C. trachomatis (including LGV) and be considered.171,172,178 If the symptoms of proctitis have
HSV. resolved and C. trachomatis NAAT testing is negative,

Table 6. Investigations in patients with symptomatic proctitis.

Microscopy Gram stain of rectal sample

Dark field microscopy (DFM) from anal ulcer(s)
N. gonorrhoeae Using NAAT and culture
C. trachomatis Using NAAT including LGV genotype
Herpes simplex virus Using PCR
T. pallidum Using DFM, PCR and serology
Mpox (See BASHH/UKHSA guidance)
Other sexually transmitted infections HIV
Hepatitis A (if non-immune)
Hepatitis B (if non-immune)
Hepatitis C

Figure 3. Management of suspected sexually transmitted proctitis.

Table 7. Proctitis; summary of recommendations.

Comprehensive sexually transmitted infection testing should be performed in patients with proctitis (as per BASHH guidelines) 1C
including rectal testing for N. gonorrhoeae, HSV, C. trachomatis (including the L genotype: Lymphogranuloma venereum) and T.
pallidum (serology and direct molecular testing)
Patients with a possible sexually transmitted proctitis should be considered for empirical treatment for C. trachomatis (including 1D
lymphogranuloma venereum)
Patients with a possible sexually transmitted proctitis should be considered for empirical treatment for N. gonorrhoeae 1C
Patients with a possible sexually transmitted proctitis should be considered for empirical treatment for HSV 1D
10 International Journal of STD & AIDS 0(0)

doxycycline therapy can be discontinued after 1 week. If Declaration of Conflicting Interests

a pathogen has been isolated, then follow up and test of The author(s) declared no potential conflicts of interest with
cure (where indicated) should follow the relevant BASHH respect to the research, authorship, and/or publication of this
guideline. article.

Funding
Auditable outcomes
The author(s) received no financial support for the research, au-
· All patients with suspected or confirmed STEI (not thorship, and/or publication of this article.
proctitis) should have a documented sexual history, travel
history, recreational drug history (including chemsex)
ORCID iD
and occupational history. (performance standard 97%)
· All patients presenting with suspected or confirmed STEI Daniel Richardson  https://orcid.org/0000-0003-0955-6307
should have a documented discussion on transmission
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