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Revision as of 15:52, 22 March 2016

Candida vaginitis

Intravaginal Therapy

  • Clotrimazole 1 % cream applied vaginally for 7 days OR
  • Clotrimazole 2% applied vaginally for 3 days
  • Miconazole 2% cream applied vaginally for 7 days OR 4% cream x 3 days
  • Butoconazole 2% applied vaginally x 3 days
  • Tioconazole 6.5% applied vaginally x 1

Oral Therapy

  • Fluconazole 150mg PO once
    • a second dose at 72hrs can be given if patient is still symptomatic

Pregnant Patients

  • Intravaginal Clotrimazole or Miconazole are the only recommended treatments
  • Duration is 7 days
  • PO fluconazole associated with congenital malformations and spontaneous abortions[1]


Common organisms are Candida, anaerobes, and Group B Streptococcus


  • Clotrimazole 1% applied topically to glans q12hrs until resolution
  • Nystatin cream 100,000 units/gm if infection is recurrent after clotrimazole therapy


  • Topical triple antibiotic ointment QID or mupirocin cream BID


  • For acute epididymitis likely caused by STI [2]
  • For acute epididymitis most likely caused by STI and enteric organisms (MSM)
  • For acute epididymitis most likely caused by enteric organisms

For persons weighing ≥150 kg, 1 g of ceftriaxone should be administered.


Presumed GC/chlamydia of cervix, urethra, or rectum (uncomplicated)[3]

Typically, treatment for both gonorrhea and chlamydia is indicated, if one entity is suspected.


  • Gonorrhea
    • Ceftriaxone IM x 1
      • 500 mg, if weight <150 kg
      • 1 g, if weight ≥150 kg
  • Chlamydia

Ceftriaxone contraindicated

^Additional chlamydia coverage only needed if treated with cefixime only

Partner Treatment

Associated Bacterial Vaginosis or Trichomonas vaginalis



Only treat if the patient is symptomatic and avoid breast feeding until 24-hrs after last dose

Sexual Partner Treatment


Acute cystitis


Women, Uncomplicated

  • Nitrofurantoin ER 100mg BID x 5d, OR
  • TMP/SMX DS (160/800mg) 1 tab BID x 3d, OR
  • Cephalexin 250mg QID x 5d, OR
  • Ciprofloxacin 250mg BID x3d
    • Avoid using fluoroquinolone for the first-line treatment of uncomplicated urinary tract infections (UTIs) in women.[7]
  • Fosfomycin 3 g PO once
    • Lower clinical and microbiologic success compared to nitrofurantoin TID for 5 days [8]

Women, Complicated

Women, Concern for Urethritis


Inpatient Options

Bacterial Vaginosis

First Line Therapy[9]

  • Metronidazole 500 mg PO BID for 7 days OR
  • Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, qd for 5 days OR
  • Clindamycin cream 2%, one full applicator (5 g) intravaginally qHS for 7 days

Alternative Regimin

  • Tinidazole 2 g PO qd for 2 days OR
  • Tinidazole 1 g PO qd for 5 days OR
  • Clindamycin 300 mg PO BID for 7 days OR
  • Clindamycin ovules 100 mg intravaginally qHS for 3 days (do not use if patient has used latex condom in last 72 hrs)


Prophylaxis (Sexual Assault)


Associated with STD

Target organisms are E. coli, and STDs (GC)

No Associated STD and Chronic Bacterial Prostatitis

Aimed at Enterobacteriaceae, enterococci, Pseudomonas

  • Ciprofloxacin 500mg PO q12hrs x 28 days OR
  • Levofloxacin 500mg PO daily x 28 days OR
  • TMP/SMX 1 DS tablet PO q12hrs x 28 days
  • Consider extension to 6 wks of empiric therapy



Treatment is targeted at E. coli, Enterococcus, Klebsiella, Proteus mirabilis, S. saprophyticus.


Consider one dose of Ceftriaxone 1g IV or Gentamycin 7mg/kg IV if the regional susceptibility of TMP/SMX or Fluoroquinolones is <80%

Adult Inpatient Options

Pediatric Inpatient Options

Lymphogranuloma venereum

  • Doxycycline 100mg PO BID x 21 days (first choice) OR
  • Erythromycin 500mg PO QID x 21 days OR
    • Preferred for pregnant and lactating females
  • Azithromycin 1g PO weekly for 3 weeks OR
    • Alternative for pregnant women - poor evidence for this treatment currently
  • Tetracycline, Minocycline, or Moxifloxacin (x21 days) are also acceptable alternatives to Doxycycline
  • Treat sexual partner


Initial Episode[15][16]


  • Acyclovir OR
    • 400mg PO q8hrs x 5 days
    • or 800mg PO q12hrs x 5 days
    • or 800mg PO q8hrs x 2 days
  • Valacyclovir OR
    • 500mg PO q12hrs x 3 days
    • or 1g PO qd x 5 days
  • Famciclovir
    • 125mg PO q12hrs for 5 days
    • or 1g PO q12hrs for 1 day
    • or 500mg PO once, followed by 250mg PO q12hrs for 2 days

Suppressive Therapy[15]


Early Stage

This is classified as primary, secondary, and early latent syphilis less than one year.

Treatment Options:

  • Penicillin G Benzathine 2.4 million units IM x 1
    • Repeat dose after 7 days for pregnant patients and HIV infection
  • Doxycycline 100mg oral twice daily for 14 days as alternative

Late Stage

Late stage is greater than one year duration, presence of gummas, or cardiovascular disease

Treatment Options:


There are 3 Major options with none showing greater efficacy than others:

  • Penicillin G 3-4 million units IV every 4 hours x 10-14 days
  • Penicillin G 24 million units continuous IV infusion x 10-14 days
  • Penicillin G Procaine2.4 million units IM daily + probenecid 500mg oral every 6 hours for 10-14 days.
  • Alternative:
  • Desensitization to the penicillin allergy is still the preferred method of treatment for patients with early and late stage disease (especially during pregnancy)


  • Penicillin, dosage depends on stage [17]

See Also

Antibiotics by diagnosis

For antibiotics by organism see Microbiology (Main)


  1. Molgaard-Nielsen D et al. Association Between Use of Oral Fluconazole During Pregnancy and Risk of Spontaneous Abortion and Stillbirth. JAMA. 2016;315(1):58-67.
  3. Cyr SS et al. Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. MMWR. Center for Disease Control and Prevention. 2020. 69(50):1911-1916
  4. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: icon
  5. CDC Trichomoniasis 2015.
  6. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: icon
  7. Choosing Wisely. American Urogynecologic Society.
  8. Huttner, A., Kowalczyk, A., Turjeman, A., Babich, T., Brossier, C., Eliakim-Raz, N., … Harbarth, S. (2018). Effect of 5-Day Nitrofurantoin vs Single-Dose Fosfomycin on Clinical Resolution of Uncomplicated Lower Urinary Tract Infection in Women: A Randomized Clinical Trial. JAMA: The Journal of the American Medical Association, 319(17), 1781–1789.
  9. Workoski KA and Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recommen and Reports. 2015; 64(3):1-140.
  10. 10.0 10.1 10.2 CDC Pregnancy BV Treatment
  11. Gupta K, Hooton TM, Naber KG, et al. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women. Clinical Infectious Diseases. 2011;52(5):e103-e120. doi:10.1093/cid/ciq257
  12. Colgan R, Williams M. Diagnosis and treatment of acute uncomplicated cystitis. Am Fam Physician. 2011 Oct 1;84(7):771-6.
  13. Acute Pyelonephritis in Adults. Johnson, JR and Russo, TA. New England Journal of Medicine 2018; 378:48-59.
  14. Sandberg T. et al. Ciprofloxacin for 7 days versus 14 days in women with acute pyelonephritis: a randomised, open-label and double-blind, placebo-controlled, non-inferiority trial. Lancet. 2012 Aug 4;380(9840):484-90.
  15. 15.0 15.1 15.2 Workoski KA and Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recommen and Reports. 2015; 64(3):1-140.
  17. Mackay G. Chapter 43. Sexually Transmitted Diseases & Pelvic Infections. In:DeCherney AH, Nathan L, Laufer N, Roman AS. eds. CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 11e. New York, NY: McGraw-Hill; 2013