OB/GYN antibiotics

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Bacterial Vaginosis

First Line Therapy[1]

  • 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)

Pregnant

Prophylaxis (Sexual Assault)

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[3]

Cervicitis

Presumed GC/chlamydia of cervix, urethra, or rectum (uncomplicated)[4]

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

Standard

  • 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

Non-Pregnant

Pregnant

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

Sexual Partner Treatment

Men

Endometritis

<48hrs Post Partum

Treatment is targeted against polymicrobial infections, most often 2-3 organisms of normal vaginal flora

>48hrs Post Partum

  • Doxycycline 100mg IV or PO q12hrs + Metronidazole 500mg IV or PO q8hrs daily
    • Use Metronidazole with caution in breastfeeding mothers its active is present in breast milk at concentrations similar to maternal plasma concentrations

Herpes

Initial Episode[9][10]

Recurrence[9]

  • 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[9]

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

Mastitis

  • No need to routinely interrupt breastfeeding with puerperal mastitis.
  • For mild symptoms <24 hours, supportive care may be sufficient[11]
    • Effective milk removal (frequent breast feeding - use pumping to augment milk removal)
    • Analgesia (NSAIDs)

Treatment directed at S. aureus and Strep and E. coli

PID

Antibiotics

  • No sexual activity for 2 weeks;
  • Treat all partners who had sex with patient during previous 60 days prior to symptom onset

Outpatient Antibiotic Options

Inpatient Antibiotic Options

Syphilis

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:

Neurosyphilis

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)

Pregnancy

Trichomonas vaginalis

Non-Pregnant

Pregnant

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

Sexual Partner Treatment

Men

See Also

Antibiotics by diagnosis

For antibiotics by organism see Microbiology (Main)

External links

References

  1. Workoski KA and Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recommen and Reports. 2015; 64(3):1-140.
  2. 2.0 2.1 2.2 CDC Pregnancy BV Treatment Guidelines.cdc.gov
  3. 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.
  4. 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
  5. 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: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
  6. CDC Trichomoniasis 2015. https://www.cdc.gov/std/tg2015/trichomoniasis.htm
  7. 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: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
  8. Mackeen AD, Packard RE, Ota E, Speer L. Antibiotic regimens for postpartum endometritis. Cochrane Database Syst Rev. 2015 Feb 2;2015(2):CD001067. doi: 10.1002/14651858.CD001067.pub3. PMID: 25922861; PMCID: PMC7050613
  9. 9.0 9.1 9.2 Workoski KA and Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recommen and Reports. 2015; 64(3):1-140.
  10. https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf
  11. Amir LH. ABM Clinical Protocol #4: Mastitis, Revised March 2014. Breastfeeding Medicine. 2014;9(5):239-243. doi:10.1089/bfm.2014.9984.
  12. Levine BL. 2011 EMRA Antibiotic Guide. EMRA. Pg 78.
  13. Hayes BD. Trick of the Trade: IV ceftriaxone for gonorrhea. October 9th, 2012 ALiEM. https://www.aliem.com/2012/10/trick-of-trade-iv-ceftriaxone-for/. Accessed October 23, 2018.
  14. Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm
  15. Ness RB et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol 2002;186:929–37
  16. 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: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
  17. 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: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
  18. Ross J, Guaschino S, Cusini M, Jensen J, 2017 European guideline for the management of pelvic inflammatory disease. Int J STD AIDS. 2018 Feb;29(2):108-114. doi: 10.1177/0956462417744099. Epub 2017 Dec 4.
  19. CDC PID Treatment http://www.cdc.gov/std/treatment/2010/pid.htm
  20. 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: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
  21. 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
  22. 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: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
  23. CDC Trichomoniasis 2015. https://www.cdc.gov/std/tg2015/trichomoniasis.htm
  24. 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: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon