OB/GYN antibiotics

Bacterial Vaginosis

First Line Therapy

• 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

• Metronidazole 250mg PO q8h x 7 days
• Metronidazole 2g PO x 1 dose is also acceptable
• Multiple studies have not demonstrated teratogenicity from metronidazole use

Prophylaxis (Sexual Assault)

• Metronidazole 2 g PO x 1 OR
• Tinidazole 2 g PO x 1

Candida vaginitis

Uncomplicated

There is little resistance to azole medications; treatment often dictated by patient preference.

• Fluconazole 150mg PO once (preferred)
  • A second dose at 72hrs may be given if patient is still symptomatic
• 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

Complicated

Severe or immunosuppressed

• Fluconazole 150mg PO q72h x 3 doses

Non-albicans species

• For example, C. glabrata, C. krusei and other atypical Candida spp.
• Boric acid vaginal suppository intravaginal qday x ≥14 days
  • Can be fatal if taken orally
• If empirically treated and later is found to have non-albicans Candida spp., no change in therapy is needed if patient is improving (otherwise switch to boric acid.

Recurrent (≥ 4 infections in a year)

• Treat as for uncomplicated (see above)
• Once therapy completed, prescribe long-term treatment
  • Fluconazole 150mg PO qweek x 6 months, OR
  • Intravaginal medication, such as clotrimazole 500mg PV qweek or 200mg PV twice a week

Pregnant Patients

• Intravaginal clotrimazole or miconazole are the only recommended treatments
• Duration is 7 days
• PO fluconazole associated with congenital malformations and spontaneous abortions

Cervicitis

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

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
  • Nonpregnant: doxycycline 100 mg PO BID x 7 days
  • Pregnant: azithromycin 1 g PO x 1

Ceftriaxone contraindicated

• Gonorrhea
  • Gentamicin 240 mg IM x 1 PLUS azithromycin 2 g PO x 1, OR
  • Cefixime 800 mg PO x 1
• Chlamydia^
  • Nonpregnant: doxycycline 100 mg PO BID x 7 days
  • Pregnant: azithromycin 1 g PO x 1

^Additional chlamydia coverage only needed if treated with cefixime only

Partner Treatment

• Gonorrhea
  • Cefixime 800mg PO x 1
• Chlamydia
  • Nonpregnant: doxycycline 100mg PO BID x 7 days, OR
  • Pregnant: azithromycin 1g PO x 1

Associated Bacterial Vaginosis or Trichomonas vaginalis

Non-Pregnant

• Metronidazole 500mg PO BID for 7 days
• Tinidazole 2g PO once

Pregnant

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

• Metronidazole 500mg PO BID for 7 days

Sexual Partner Treatment

• Female: Same as above
• Male: Metronidazole 2 gm PO x1

Endometritis

<48hrs Post Partum

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

• (Prefered first line) Clindamycin 900mg q8hrs PLUS Gentamicin 5mg/kg IV q24hours (same efficacy and more cost effective vs. 1.5mg/kg) or 1.5mg/kg IV q8hrs OR
• Doxycycline 100mg IV PO q12hrs daily PLUS
  • Ampicillin/Sulbactam 3g IV q6hrs
  • Cefoxitin 2g IV q6hrs daily

>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

• Acyclovir OR
  • 400mg PO q8hrs x 7-10 days
  • or 200mg PO 5x/day x 7-10 days
• Valacyclovir 1g PO q12hrs x 7-10 days OR
• Famciclovir 250mg PO q8hrs x 7-10 days

Recurrence

• 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

• Acyclovir 400mg PO q12hrs daily OR
• Famciclovir 250mg PO q12hrs daily OR
• Valacyclovir 500mg-1g PO daily (500mg may be less effective)

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
  • Doxycycline 100mg PO BID x 7 days OR
  • Azithromycin 1gm PO x1

Mastitis

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

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

• Uncomplicated mastitis → 10 days of antibiotics (regardless of MRSA suspicion)
• Dicloxacillin 500mg PO q6hrs, considered first line if breastfeeding given safety for infant OR
• Cephalexin 500mg PO q6hrs OR
  • Add TMP/SMX 2DS tabs PO q12hrs if suspect MRSA
• Clindamycin 450mg PO q8hrs (also provides MRSA coverage) OR
• Amoxicillin/Clavulanate 875mg PO q12hrs OR
• Azithromycin 500mg PO x1 on day 1, then 250mg PO daily for days 2-5

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

• Ceftriaxone 500mg IM (1g if >150kg) x1 + doxycycline 100mg PO BID x14d + metronidazole 500mg PO BID x14d
  • Metronidazole
    • Recommended for empiric treatment of PID by the CDC
    • Recommended empirically by European guidelines
• Cefoxitin 2 g IM in a single dose and Probenecid, 1 g PO administered concurrently in a single dose + Doxycycline 100 mg PO BID x 14 days + metronidazole

Inpatient Antibiotic Options

• Recommended: Ceftriaxone 1gm IV q24hr OR Cefoxitin 2gm IV q6hr OR cefotetan 2gm IV q12hr) + doxycycline PO or IV 100 mg q12hr + Metronidazole 500mg IV or PO Q12hr OR
• Clindamycin 900mg IV q8h + gentamicin 2mg/kg loading -> 1.5 mg/kg q8hr IV OR
• Ampicillin-sulbactam 3gm IV q6hr + doxycycline 100mg IV/PO q12hr

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:

• Penicillin G Benzathine 2.4 million units IM weekly x 3 weeks
• Doxycycline 100mg oral twice daily for 4 weeks as alternative

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:
  • Ceftriaxone 2gm IV once daily for 10-14 days

• 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

Trichomonas vaginalis

Non-Pregnant

• Metronidazole 500mg PO BID for 7 days
• Tinidazole 2g PO once

Pregnant

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

• Metronidazole 500mg PO BID for 7 days

Sexual Partner Treatment

• Female: Same as above
• Male: Metronidazole 2 gm PO x1

See Also

Antibiotics by diagnosis

• Bone and joint antibiotics
• Cardiovascular antibiotics
• ENT antibiotics
• Eye antibiotics
• GI antibiotics
• GU antibiotics
• Neuro antibiotics
• OB/GYN antibiotics
• Pulmonary antibiotics
• Skin and soft tissue antibiotics
• Bioterrorism antibiotics
• Environmental exposure antibiotics
• Immunocompromised antibiotics
• Post exposure prophylaxis antibiotics
• Pediatric antibiotics
• Sepsis antibiotics
• Arthropod and parasitic antibiotics

For antibiotics by organism see Microbiology (Main)

External links

• Drugs and Lactation Database (LactMed), National Institutes of Health, US National Library of Medicine