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VAGINAL DISCHARGE• It is normal for women to have a vaginal discharge. Abnormal discharges are itchy or different in colour or smell. Not all women with a discharge have an STI.• First assess and advise the patient with vaginal discharge and her partner/s 23.Is there lower abdominal pain or cervical tenderness?NoTreat for bacterialvaginosis:• Metronidazole 2gorally stat. Avoidin 1st trimesterof pregnancy. Noalcohol for 24 hoursafter metronidazole.NoPatient sexually active in last 3 months?Yes• Treat for vaginal discharge syndrome (VDS):--Cefixime 1 400mg orally stat and-- Doxycycline 100mg 12 hourly for 7 days (If pregnant orbreastfeeding, use amoxicillin 1 500mg 8 hourly for 7 daysinstead) and-- Metronidazole 2g orally stat. Avoid in 1st trimester ofpregnancy. No alcohol for 24 hours after metronidazole.• Treat the patient's partner/s 23.• Treat the baby with pus in eyes born to mother with VDS 97.YesRecognise the patient needing urgent attentionRefer same day if any of the following are present:• Recent miscarriage/delivery/abortion• Pregnant or missed or overdue period• Peritonitis (guarding or rigidity on examination)• Abnormal vaginal bleeding• Temperature ≥ 38°C• Abdominal massManagement:• If dehydrated or shocked: give IV fluids• If temp ≥ 38°C, give ceftriaxone 2 1g IV/IM stat andmetronidazole 400mg orally stat.Refer same day.If the vulva is red, scratched and inflamed, also treat for thrush:• Clotrimazole vaginal tablet 500mg inserted stat and• Clotrimazole vaginal cream applied twice a day for 6 days after symptoms resolve.• Avoid washing with soap.Persistent thrush:• Repeat clotrimazole.• Test for diabetes70 and HIV 60.Advise patient to return in 7 days if symptoms persist.Ongoing discharge, no thrush:Ask if possible re-infection or poor adherence to treatment.YesRepeat treatment. If still noimprovement, refer to doctorsame week.NoRefer to doctor same week.Treat for lower abdominal pain (LAP):• Ceftriaxone 250mg IM stat. If penicillin allergic give ciprofloxacin 500mg 12hourly for 3 days and• Doxycycline 100mg 12 hourly for 14 days (If breastfeeding, use amoxicillin500mg 8 hourly for 14 days instead) and• Metronidazole 400mg 12 hourly for 14 days (Avoid alcohol for 48 hours afterstopping treatment).• Treat the patient's partner/s 23.Review within 2–3 days.No improvementRefer to doctor same week.Improved1If severe penicillin allergic (angioedema, anaphylactic shock or bronchospasm) replace cefixime with ciprofloxacin 500 mg oral stat. If severe penicillin allergic and pregnant or breastfeeding, replace cefixime and amoxicillin with erythromycin500 mg 6 hourly for 7 days. Refer if no improvement within 48 hours. 2 Do not mix Ringer's lactate and IV ceftriaxone. Flush IV line with sodium chloride 0.9% before and after IV ceftriaxone.25