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GU antibiotics
From WikEM
Contents
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
- Ceftriaxone 250 mg IM in a single dose PLUS
- Doxycycline 100 mg orally twice a day for 10 days
- For acute epididymitis most likely caused by STI and enteric organisms (MSM)
- Ceftriaxone 250 mg IM in a single dose PLUS
- Levofloxacin 500 mg orally once a day for 10 days OR
- Ofloxacin 300 mg orally twice a day for 10 days
- For acute epididymitis most likely caused by enteric organisms
- Levofloxacin 500 mg orally once daily for 10 days OR
- Ofloxacin 300 mg orally twice a day for 10 days
Treat sexual partner if possible
Cervicitis/Urethritis
treatment cover gonorrhea and chlamydia jointly
- Male: Urethritis with discharge or simply dysuria
- Female: purulent discharge
Uncomplicated Infection
- Ceftriaxone 250mg IM once PLUS
- Azithromycin 1g PO once OR
- Doxycycline 100mg PO BID x 7 days
Partner treatment
- Cefixime 400mg PO once PLUS
- Azithromycin 1g PO once OR
- Doxycycline 100mg PO BID x 7 days
Cephalosporin Allergy
- Azithromycin 2g PO once PLUS
- Gentamicin 240mg IM once[2]
- In theory this high dose macrolide will provide treatment for both GC and Chlamydia
Associated Bacterial Vaginosis or Trichomonas vaginalis
Non-Pregnant
- Metronidazole 2g PO once or 500mg PO BID for 7 days
- Tinidazole 2g PO once
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
Sexual Partner Treatment
- Metronidazole 500mg PO BID x 7 days or Tinidazole 2g PO once
Women with HIV Infection
- Metronidazole 500 mg PO BID x 7 days[3]
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.[4]
Women, Complicated
- Ciprofloxacin 500mg BID x10-14d, OR
- Cefpodoxime 200 mg BID x10-14d
Women, Concern for Urethritis
- Ceftriaxone 250mg IM x1 AND azithromycin 1gm PO x1 AND nitrofurantoin ER 100mg BID x5d, OR
- Levofloxacin 500mg QD x 14d (covers urinary pathogens, GC, and chlamydia)
- GC resistance to fluoroquinolones is increasing
Men
- Ciprofloxacin 500mg BID x10-14d, OR
- Cefpodoxime 200 mg BID x10-14d
Inpatient Options
- Ciprofloxacin 400mg IV q12hr, OR
- Ceftriaxone 1gm IV QD, OR
- Cefotaxime 1-2gm IV q8hr, OR
- Gentamicin 3mg/kg/day divided q8hr +/- ampicillin 1–2 gm q4hr, OR
- Piperacillin/Tazobactam 3.375 gm IV q6hr, OR
- Cefepime 2gm IV q8hr, OR
- Imipenem 500mg IV q8hr
Bacterial Vaginosis
First Line Therapy[5]
- 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[6]
- Metronidazole 2g PO x 1 dose is also acceptable[6]
- Multiple studies have not demonstrated teratogenicity from metronidazole use[6]
Prophylaxis (Sexual Assault)
- Metronidazole 2 g PO x 1 OR
- Tinidazole 2 g PO x 1
Prostatitis
Target organisms are E.coli, and STDs (GC)
Associated with STD
- Doxycycline 100mg PO q12 hrs x14 days + Ceftriaxone 250mg IM x1
- Ciprofloxacin no longer recommended to treat gonorrhea in US
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
- Gentamycin 7mg/kg IV daily + Ceftriaxone 1g IV q12hrs
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%
- Ciprofloxacin 500mg BID x 7 days OR
- Cefpodoxime 200 mg BID x10-14 days OR[7]
- Levofloxacin 750mg PO once x 7 days[8]
Adult Inpatient Options
- Ciprofloxacin 400mg IV q12hr OR
- Ceftriaxone 1gm IV QD OR
- Cefotaxime 1-2gm IV q8hr OR
- Gentamicin 3mg/kg/day divided q8hr +/- ampicillin 1–2 gm q4hr OR
- Piperacillin/Tazobactam 3.375 gm IV q6hr OR
- Cefepime 2gm IV q8hr OR
- Imipenem 500mg IV q8hr
Pediatric Inpatient Options
- Ceftriaxone 75mg/kg IV once daily
- Cefotaxime 50mg/kg IV q8hrs
- Ampicillin 25mg/kg IV q6hrs + Gentamicin 2.5mg/kg IV q8hrs
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
Herpes
Initial Episode[9]
- 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[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]
- Acyclovir 400mg PO q12hrs daily OR
- Famciclovir 250mg PO q12hrs daily OR
- Valacyclovir 500mg-1g PO daily (500mg may be less effective)
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 IV infusion 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 [10]
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)
References
- ↑ 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.
- ↑ CDC: 2015 Sexually Transmitted Diseases Treatment Guidelines
- ↑ CDC. Sexually transmitted diseases treatment guidelines. MMWR Recomm Rep 2010;59(No. RR-12)
- ↑ Choosing Wisely. American Urogynecologic Society. http://www.choosingwisely.org/societies/american-urogynecologic-society
- ↑ Workoski KA and Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recommen and Reports. 2015; 64(3):1-140.
- ↑ 6.0 6.1 6.2 CDC Pregnancy BV Treatment Guidelines.cdc.gov
- ↑ Colgan R, Williams M. Diagnosis and treatment of acute uncomplicated cystitis. Am Fam Physician. 2011 Oct 1;84(7):771-6.
- ↑ 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.
- ↑ 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.
- ↑ 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
