GU antibiotics

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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]

Balanoposthitis

Common organisms are Candida, anaerobes, and Group B Streptococcus

Antifungal

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

Antibacterial

  • Topical triple antibiotic ointment QID or mupirocin cream BID

Epididymitis/Epididymorchitis

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

Treat sexual partner if possible

Cervicitis

Treatment covers both gonorrhea and chlamydia

Uncomplicated Infection

Cephalosporin Allergy

Partner treatment

Associated Bacterial Vaginosis or Trichomonas vaginalis

Non-Pregnant

Pregnant

  • Only treat if the patient is symptomatic and avoid breast feeding until 24hrs after last Metronidazole treatment and 72hrs after Tinidazole
  • Metronidazole 2g PO once[3]

Sexual Partner Treatment

Women with HIV Infection

  • Metronidazole 500 mg PO BID x 7 days[4]

Acute cystitis

Outpatient

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.[5]

Women, Complicated

Women, Concern for Urethritis

Men

Inpatient Options

Bacterial Vaginosis

First Line Therapy[6]

  • 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)

Prostatitis

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

Septic

Pyelonephritis

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

Outpatient

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

Herpes

Initial Episode[10]

Recurrence[10]

  • 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[10]

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:

  • Desensitization to the penicillin allergy is still the preferred method of treatment for patients with early and late stage disease (especially during pregnancy)

Pregnancy

  • Penicillin, dosage depends on stage [11]

Urethritis (male)

Treatment to cover both gonorrhea and chlamydia

Uncomplicated Infection

Cephalosporin Allergy

Partner treatment

Recurrent or Persistent

Target M. genitalium

Consider coverage of trichomonas, among men who have sex with women

  • Metronidazole 2 gm PO x 1, OR
  • Tinidazole 2 gm PO x 1

See Also

Antibiotics by diagnosis

For antibiotics by organism see Microbiology (Main)

References

  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.
  2. CDC: 2015 Sexually Transmitted Diseases Treatment Guidelines
  3. CDC Trichomoniasis 2015. https://www.cdc.gov/std/tg2015/trichomoniasis.htm
  4. CDC. Sexually transmitted diseases treatment guidelines. MMWR Recomm Rep 2010;59(No. RR-12)
  5. Choosing Wisely. American Urogynecologic Society. http://www.choosingwisely.org/societies/american-urogynecologic-society
  6. Workoski KA and Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recommen and Reports. 2015; 64(3):1-140.
  7. 7.0 7.1 7.2 CDC Pregnancy BV Treatment Guidelines.cdc.gov
  8. Colgan R, Williams M. Diagnosis and treatment of acute uncomplicated cystitis. Am Fam Physician. 2011 Oct 1;84(7):771-6.
  9. 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.
  10. 10.0 10.1 10.2 Workoski KA and Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recommen and Reports. 2015; 64(3):1-140.
  11. 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
  12. CDC: 2015 Sexually Transmitted Diseases Treatment Guidelines