wikidoc - User contributions [en]

User:Dr.nuha

2022-09-11T05:02:54Z

Dr.Nuha: /* Pages Authored */

__NOTOC__
==Nuha Al-Howthi M.D.==
'''Nuha Al-Howthi. MD'''
[[File:Nuha alhowthi.JPG|right|250px|dr.Nuha]]

 Contact: 
Email: [mailto:nuha.1991@yahoo.com nuha.1991@yahoo.com] 

==Current Position==
'''Associate Editor-in-Chief at Wikidoc''' 

==Professional Background==
Dr. Nuha received her Bachelor of Medicine & Bachelor of Surgery (M.B.B.S) at Sana'a University, Faculty of Medicine and Health Sciences, Yemen. She is currently an Associate editor-in-chief at '''WikiDoc.'''

==Education==
*'''Sana'a University, Faculty of Medicine and Health Sciences, Yemen''' (2010-2015)
**'''Bachelor of Medicine & Bachelor of Surgery (M.B.B.S)''' 

==Clinical Experience==
*'''Doctor in training in the capital Sana’a – Yemen: Al Thowra General Hospital, Al Kuwait Educational Hospital, and Al Sabeaan Maternity and Child Hospital.''' January 2016 - December 2016.
*'''Internship At Royal Jordanian Medical Services, Amman – Jordan.''' February 2017 – February 2018.

==Achievements==
*'''training course of Sever acute malnutrition''' (2015)
*'''training course of Integrated management of childhood illness''' (2015).

==Pages Authored==

*[[COVID-19 frequently asked inpatient questions]]
*[[Dermatologic Disorders of COVID-19]]
*[[Heart murmur resident survival guide]]
*[[Heart murmur]]
*[[Chest pain]]
*[[abortion]]
*Updated CDC treatment guidelines : [[Gonorrhea medical therapy]], [[Bacterial vaginosis medical therapy]], [[Trichomoniasis medical therapy]]

Candida vulvovaginitis medical therapy

2021-09-17T16:28:36Z

Dr.Nuha: /* 4 Follow-Up */

__NOTOC__
{{Candida vulvovaginitis}}
{{CMG}} {{AE}} {{nuha}}

==Overview==
Antifungal agents are indicated in candidiasis. Commonly used drugs include [[Amphotericin]], [[Clotrimazole]], [[Nystatin]], [[Fluconazole]] and [[Ketoconazole]]. It is important to consider that ''Candida'' species are frequently part of the human body's normal oral and intestinal flora. Candidiasis is occasionally misdiagnosed by medical personnel as bacterial in nature, and treated with [[antibiotic]]s against bacteria. This can lead to eliminating the yeast's natural competitors for resources, and increase the severity of the condition.

==Medical Therapy==

===1. Uncomplicated Vulvovaginal Candidiasis<ref name="urlwww.cdc.gov">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf |title=www.cdc.gov |format= |work= |accessdate=}}</ref><ref name="urlVulvovaginal Candidiasis - STI Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/candidiasis.htm |title=Vulvovaginal Candidiasis - STI Treatment Guidelines |format= |work= |accessdate=}}</ref>===

*'''1.1 Recommended Regimens'''
**'''1.1.1 Over-the-Counter Intravaginal Agents'''
***[[Clotrimazole]] 1% cream 5 g intravaginally daily for 7–14 days OR
***[[Clotrimazole]] 2% cream 5 g intravaginally daily for 3 days OR
***[[Miconazole]] 2% cream 5 g intravaginally daily for 7 days OR
***[[Miconazole]] 4% cream 5 g intravaginally daily for 3 days OR
***[[Miconazole]] 100 mg vaginal suppository one suppository daily for 7 days OR
***[[Miconazole]] 200 mg vaginal suppository one suppository for 3 days OR
***[[Miconazole]] 1,200 mg vaginal suppository one suppository for 1 day OR
***[[Tioconazole]] 6.5% ointment 5 g intravaginally in a single application
**'''1.1.2 Prescription Intravaginal Agents'''
***[[Butoconazole]] 2% cream 5 g intravaginally in a single application OR
***[[Terconazole]] 0.4% cream 5 g intravaginally daily for 7 days OR
***[[Terconazole]] 0.8% cream 5 g intravaginally daily for 3 days OR
***[[Terconazole]] 80 mg vaginal suppository one suppository daily for 3 days
**'''1.1.3 Oral Agent'''
***[[Fluconazole]] 150 mg orally in a single dose.
**Note: the creams and suppositories in these regimens are oil based and might weaken latex condoms and diaphragms. Patients should refer to condom product labeling for further information.
**Note: Any woman whose symptoms persist after using an over-the-counter preparation or who has a recurrence of symptoms <2 months after treatment for Vulvovaginal Candidiasis should be evaluated clinically and tested.
**Note: No substantial evidence exists to support using [[Probiotic|probiotics]] or homeopathic medications for treating Vulvovaginal Candidiasis.
*'''1.2 Management of Sex Partners'''
**Uncomplicated Vulvovaginal Candidiasis is not usually acquired through sexual intercourse, and data do not support treatment of sex partners.

*1.'''3 Special Considerations'''
**1.3.1 '''Drug Allergy, Intolerance, and Adverse Reactions'''
***Topical agents usually cause no systemic side effects.
***Oral azoles occasionally cause nausea, abdominal pain, and headache.
***Clinically important interactions can occur when oral azoles are administered with other drugs.

 

===2. Complicated Vulvovaginal Candidiasis<ref name="urlwww.cdc.gov" /><ref name="urlVulvovaginal Candidiasis - STI Treatment Guidelines" />===

*2.1 '''Recurrent Vulvovaginal Candidiasis'''
**Defined as three or more episodes of symptomatic Vulvovaginal Candidiasis in <1 year.
**Preferred regimen: topical therapy for 7–14 days, OR [[fluconazole]] 100-mg, 150-mg, or 200-mg PO every third day for a total of 3 doses [days 1, 4, and 7].
**Maintenance regimen: [[fluconazole]] 100-mg, 150-mg, or 200-mg PO weekly for 6 months. (If this regimen is not feasible, topical treatments used intermittently).
**Note: ''C. albicans'' azole resistance is becoming more common, susceptibility tests, if available, should be obtained among symptomatic patients who remain culture positive despite maintenance therapy. These women should be managed in consultation with a specialist.

*2.2 '''Severe Vulvovaginal Candidiasis'''
**Preferred regimen: either 7–14 days of topical azole or [[fluconazole]] 150 mg PO in two doses 72 hours apart.

*2.3 '''Non–''albicans'' Vulvovaginal Candidiasis'''
**The optimal treatment of non–''albicans'' Vulvovaginal Candidiasis remains unknown; however, a longer duration of therapy (7–14 days) with a nonfluconazole azole regimen (oral or topical) is recommended.
**If recurrence occurs, [[boric acid]] 600 mg gelatin capsule intravaginally once daily for 3 weeks is indicated.

*2.4 '''Management of Sex Partners'''
**No data exist to support treating sex partners of patients with complicated Vulvovaginal Candidiasis.

===3. Special Considerations<ref name="urlVulvovaginal Candidiasis - STI Treatment Guidelines" />===

*3.1 '''Pregnancy'''
**Preferred regimen: topical azole for 7 days
**Note: Epidemiologic studies indicate a single 150-mg dose of [[fluconazole]] might be associated with spontaneous abortion and congenital anomalies; therefore, it should not be used.

*'''3.2 HIV Infection'''
**Treatment for uncomplicated and complicated Vulvovaginal Candidiasis among women with HIV infection should not differ from that for women who do not have HIV.
**Long-term prophylactic therapy with [[fluconazole]] 200 mg weekly has been effective in reducing ''C. albicans'' colonization and symptomatic Vulvovaginal Candidiasis, however this regimen is not recommended for women with HIV infection in the absence of complicated Vulvovaginal Candidiasis.

===4. Follow-Up===
Follow-up typically is not required. However, women with persistent or recurrent symptoms after treatment should be instructed to return for follow-up visits.

==References==
{{Reflist|2}}

[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Gynecology]]
[[Category:Obstetrics]]

Candida vulvovaginitis medical therapy

2021-09-17T16:27:43Z

Dr.Nuha:

__NOTOC__
{{Candida vulvovaginitis}}
{{CMG}} {{AE}} {{nuha}}

==Overview==
Antifungal agents are indicated in candidiasis. Commonly used drugs include [[Amphotericin]], [[Clotrimazole]], [[Nystatin]], [[Fluconazole]] and [[Ketoconazole]]. It is important to consider that ''Candida'' species are frequently part of the human body's normal oral and intestinal flora. Candidiasis is occasionally misdiagnosed by medical personnel as bacterial in nature, and treated with [[antibiotic]]s against bacteria. This can lead to eliminating the yeast's natural competitors for resources, and increase the severity of the condition.

==Medical Therapy==

===1. Uncomplicated Vulvovaginal Candidiasis<ref name="urlwww.cdc.gov">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf |title=www.cdc.gov |format= |work= |accessdate=}}</ref><ref name="urlVulvovaginal Candidiasis - STI Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/candidiasis.htm |title=Vulvovaginal Candidiasis - STI Treatment Guidelines |format= |work= |accessdate=}}</ref>===

*'''1.1 Recommended Regimens'''
**'''1.1.1 Over-the-Counter Intravaginal Agents'''
***[[Clotrimazole]] 1% cream 5 g intravaginally daily for 7–14 days OR
***[[Clotrimazole]] 2% cream 5 g intravaginally daily for 3 days OR
***[[Miconazole]] 2% cream 5 g intravaginally daily for 7 days OR
***[[Miconazole]] 4% cream 5 g intravaginally daily for 3 days OR
***[[Miconazole]] 100 mg vaginal suppository one suppository daily for 7 days OR
***[[Miconazole]] 200 mg vaginal suppository one suppository for 3 days OR
***[[Miconazole]] 1,200 mg vaginal suppository one suppository for 1 day OR
***[[Tioconazole]] 6.5% ointment 5 g intravaginally in a single application
**'''1.1.2 Prescription Intravaginal Agents'''
***[[Butoconazole]] 2% cream 5 g intravaginally in a single application OR
***[[Terconazole]] 0.4% cream 5 g intravaginally daily for 7 days OR
***[[Terconazole]] 0.8% cream 5 g intravaginally daily for 3 days OR
***[[Terconazole]] 80 mg vaginal suppository one suppository daily for 3 days
**'''1.1.3 Oral Agent'''
***[[Fluconazole]] 150 mg orally in a single dose.
**Note: the creams and suppositories in these regimens are oil based and might weaken latex condoms and diaphragms. Patients should refer to condom product labeling for further information.
**Note: Any woman whose symptoms persist after using an over-the-counter preparation or who has a recurrence of symptoms <2 months after treatment for Vulvovaginal Candidiasis should be evaluated clinically and tested.
**Note: No substantial evidence exists to support using [[Probiotic|probiotics]] or homeopathic medications for treating Vulvovaginal Candidiasis.
*'''1.2 Management of Sex Partners'''
**Uncomplicated Vulvovaginal Candidiasis is not usually acquired through sexual intercourse, and data do not support treatment of sex partners.

*1.'''3 Special Considerations'''
**1.3.1 '''Drug Allergy, Intolerance, and Adverse Reactions'''
***Topical agents usually cause no systemic side effects.
***Oral azoles occasionally cause nausea, abdominal pain, and headache.
***Clinically important interactions can occur when oral azoles are administered with other drugs.

 

===2. Complicated Vulvovaginal Candidiasis<ref name="urlwww.cdc.gov" /><ref name="urlVulvovaginal Candidiasis - STI Treatment Guidelines" />===

*2.1 '''Recurrent Vulvovaginal Candidiasis'''
**Defined as three or more episodes of symptomatic Vulvovaginal Candidiasis in <1 year.
**Preferred regimen: topical therapy for 7–14 days, OR [[fluconazole]] 100-mg, 150-mg, or 200-mg PO every third day for a total of 3 doses [days 1, 4, and 7].
**Maintenance regimen: [[fluconazole]] 100-mg, 150-mg, or 200-mg PO weekly for 6 months. (If this regimen is not feasible, topical treatments used intermittently).
**Note: ''C. albicans'' azole resistance is becoming more common, susceptibility tests, if available, should be obtained among symptomatic patients who remain culture positive despite maintenance therapy. These women should be managed in consultation with a specialist.

*2.2 '''Severe Vulvovaginal Candidiasis'''
**Preferred regimen: either 7–14 days of topical azole or [[fluconazole]] 150 mg PO in two doses 72 hours apart.

*2.3 '''Non–''albicans'' Vulvovaginal Candidiasis'''
**The optimal treatment of non–''albicans'' Vulvovaginal Candidiasis remains unknown; however, a longer duration of therapy (7–14 days) with a nonfluconazole azole regimen (oral or topical) is recommended.
**If recurrence occurs, [[boric acid]] 600 mg gelatin capsule intravaginally once daily for 3 weeks is indicated.

*2.4 '''Management of Sex Partners'''
**No data exist to support treating sex partners of patients with complicated Vulvovaginal Candidiasis.

===3. Special Considerations<ref name="urlVulvovaginal Candidiasis - STI Treatment Guidelines" />===

*3.1 '''Pregnancy'''
**Preferred regimen: topical azole for 7 days
**Note: Epidemiologic studies indicate a single 150-mg dose of [[fluconazole]] might be associated with spontaneous abortion and congenital anomalies; therefore, it should not be used.

*'''3.2 HIV Infection'''
**Treatment for uncomplicated and complicated Vulvovaginal Candidiasis among women with HIV infection should not differ from that for women who do not have HIV.
**Long-term prophylactic therapy with [[fluconazole]] 200 mg weekly has been effective in reducing ''C. albicans'' colonization and symptomatic Vulvovaginal Candidiasis, however this regimen is not recommended for women with HIV infection in the absence of complicated Vulvovaginal Candidiasis.

===4 Follow-Up===
Follow-up typically is not required. However, women with persistent or recurrent symptoms after treatment should be instructed to return for follow-up visits.

==References==
{{Reflist|2}}

[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Gynecology]]
[[Category:Obstetrics]]

Candida vulvovaginitis medical therapy

2021-09-17T16:22:29Z

Dr.Nuha:

__NOTOC__
{{Candida vulvovaginitis}}
{{CMG}} {{AE}} {{nuha}}

==Overview==
Antifungal agents are indicated in candidiasis. Commonly used drugs include [[Amphotericin]], [[Clotrimazole]], [[Nystatin]], [[Fluconazole]] and [[Ketoconazole]]. It is important to consider that ''Candida'' species are frequently part of the human body's normal oral and intestinal flora. Candidiasis is occasionally misdiagnosed by medical personnel as bacterial in nature, and treated with [[antibiotic]]s against bacteria. This can lead to eliminating the yeast's natural competitors for resources, and increase the severity of the condition.

==Medical Therapy==

===1. Uncomplicated Vulvovaginal Candidiasis<ref name="urlwww.cdc.gov">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf |title=www.cdc.gov |format= |work= |accessdate=}}</ref><ref name="urlVulvovaginal Candidiasis - STI Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/candidiasis.htm |title=Vulvovaginal Candidiasis - STI Treatment Guidelines |format= |work= |accessdate=}}</ref>===

*'''1.1 Recommended Regimens'''
**'''1.1.1 Over-the-Counter Intravaginal Agents'''
***Clotrimazole 1% cream 5 g intravaginally daily for 7–14 days OR Clotrimazole 2% cream 5 g intravaginally daily for 3 days OR Miconazole 2% cream 5 g intravaginally daily for 7 days OR Miconazole 4% cream 5 g intravaginally daily for 3 days OR Miconazole 100 mg vaginal suppository one suppository daily for 7 days OR Miconazole 200 mg vaginal suppository one suppository for 3 days OR Miconazole 1,200 mg vaginal suppository one suppository for 1 day OR Tioconazole 6.5% ointment 5 g intravaginally in a single application
**'''1.1.2 Prescription Intravaginal Agents'''
***Butoconazole 2% cream 5 g intravaginally in a single application OR Terconazole 0.4% cream 5 g intravaginally daily for 7 days OR Terconazole 0.8% cream 5 g intravaginally daily for 3 days OR Terconazole 80 mg vaginal suppository one suppository daily for 3 days
**'''1.1.3 Oral Agent'''
***Fluconazole 150 mg orally in a single dose.
**Note: the creams and suppositories in these regimens are oil based and might weaken latex condoms and diaphragms. Patients should refer to condom product labeling for further information.
**Note: Any woman whose symptoms persist after using an over-the-counter preparation or who has a recurrence of symptoms <2 months after treatment for VVC should be evaluated clinically and tested.
**Note: No substantial evidence exists to support using probiotics or homeopathic medications for treating VVC.
*'''1.2 Management of Sex Partners'''
**Uncomplicated VVC is not usually acquired through sexual intercourse, and data do not support treatment of sex partners.
**A minority of male sex partners have balanitis, characterized by erythematous areas on the glans of the penis in conjunction with pruritus or irritation. These men benefit from treatment with topical antifungal agents to relieve symptoms.

*1.'''3 Special Considerations'''
**1.3.1 '''Drug Allergy, Intolerance, and Adverse Reactions'''
***Topical agents usually cause no systemic side effects.
***Oral azoles occasionally cause nausea, abdominal pain, and headache.
***Clinically important interactions can occur when oral azoles are administered with other drugs.

 

===2. Complicated Vulvovaginal Candidiasis<ref name="urlwww.cdc.gov" /><ref name="urlVulvovaginal Candidiasis - STI Treatment Guidelines" />===

*2.1 '''Recurrent Vulvovaginal Candidiasis'''
**Defined as three or more episodes of symptomatic VVC in <1 year.
**Preferred regimen: topical therapy for 7–14 days, OR [[fluconazole]] 100-mg, 150-mg, or 200-mg PO every third day for a total of 3 doses [days 1, 4, and 7].
**Maintenance regimen: fluconazole 100-mg, 150-mg, or 200-mg PO weekly for 6 months. (If this regimen is not feasible, topical treatments used intermittently) can also be considered.
**Note: ''C. albicans'' azole resistance is becoming more common, susceptibility tests, if available, should be obtained among symptomatic patients who remain culture positive despite maintenance therapy. These women should be managed in consultation with a specialist.

*2.2 '''Severe Vulvovaginal Candidiasis'''
**Preferred regimen: either 7–14 days of topical azole or fluconazole 150 mg PO in two doses 72 hours apart.

*2.3 '''Non–''albicans'' Vulvovaginal Candidiasis'''
**The optimal treatment of non–''albicans'' Vulvovaginal Candidiasis remains unknown; however, a longer duration of therapy (7–14 days) with a nonfluconazole azole regimen (oral or topical) is recommended.
**If recurrence occurs, [[boric acid]] 600 mg gelatin capsule intravaginally once daily for 3 weeks is indicated.

*2.4 '''Management of Sex Partners'''
**No data exist to support treating sex partners of patients with complicated Vulvovaginal Candidiasis.

===3. Special Considerations<ref name="urlVulvovaginal Candidiasis - STI Treatment Guidelines" />===

*3.1 '''Pregnancy'''
**Preferred regimen: topical azole for 7 days
**Note: Epidemiologic studies indicate a single 150-mg dose of fluconazole might be associated with spontaneous abortion and congenital anomalies; therefore, it should not be used.

*'''3.2 HIV Infection'''
**Treatment for uncomplicated and complicated VVC among women with HIV infection should not differ from that for women who do not have HIV.
**Long-term prophylactic therapy with fluconazole 200 mg weekly has been effective in reducing ''C. albicans'' colonization and symptomatic VVC, however this regimen is not recommended for women with HIV infection in the absence of complicated VVC.

===4 Follow-Up===
Follow-up typically is not required. However, women with persistent or recurrent symptoms after treatment should be instructed to return for follow-up visits.

==References==
{{Reflist|2}}

[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Gynecology]]
[[Category:Obstetrics]]

Candida vulvovaginitis medical therapy

2021-09-17T16:21:56Z

Dr.Nuha:

__NOTOC__
{{Candida vulvovaginitis}}
{{CMG}}

==Overview==
Antifungal agents are indicated in candidiasis. Commonly used drugs include [[Amphotericin]], [[Clotrimazole]], [[Nystatin]], [[Fluconazole]] and [[Ketoconazole]]. It is important to consider that ''Candida'' species are frequently part of the human body's normal oral and intestinal flora. Candidiasis is occasionally misdiagnosed by medical personnel as bacterial in nature, and treated with [[antibiotic]]s against bacteria. This can lead to eliminating the yeast's natural competitors for resources, and increase the severity of the condition.

==Medical Therapy==

===1. Uncomplicated Vulvovaginal Candidiasis<ref name="urlwww.cdc.gov">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf |title=www.cdc.gov |format= |work= |accessdate=}}</ref><ref name="urlVulvovaginal Candidiasis - STI Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/candidiasis.htm |title=Vulvovaginal Candidiasis - STI Treatment Guidelines |format= |work= |accessdate=}}</ref>===

*'''1.1 Recommended Regimens'''
**'''1.1.1 Over-the-Counter Intravaginal Agents'''
***Clotrimazole 1% cream 5 g intravaginally daily for 7–14 days OR Clotrimazole 2% cream 5 g intravaginally daily for 3 days OR Miconazole 2% cream 5 g intravaginally daily for 7 days OR Miconazole 4% cream 5 g intravaginally daily for 3 days OR Miconazole 100 mg vaginal suppository one suppository daily for 7 days OR Miconazole 200 mg vaginal suppository one suppository for 3 days OR Miconazole 1,200 mg vaginal suppository one suppository for 1 day OR Tioconazole 6.5% ointment 5 g intravaginally in a single application
**'''1.1.2 Prescription Intravaginal Agents'''
***Butoconazole 2% cream 5 g intravaginally in a single application OR Terconazole 0.4% cream 5 g intravaginally daily for 7 days OR Terconazole 0.8% cream 5 g intravaginally daily for 3 days OR Terconazole 80 mg vaginal suppository one suppository daily for 3 days
**'''1.1.3 Oral Agent'''
***Fluconazole 150 mg orally in a single dose.
**Note: the creams and suppositories in these regimens are oil based and might weaken latex condoms and diaphragms. Patients should refer to condom product labeling for further information.
**Note: Any woman whose symptoms persist after using an over-the-counter preparation or who has a recurrence of symptoms <2 months after treatment for VVC should be evaluated clinically and tested.
**Note: No substantial evidence exists to support using probiotics or homeopathic medications for treating VVC.
*'''1.2 Management of Sex Partners'''
**Uncomplicated VVC is not usually acquired through sexual intercourse, and data do not support treatment of sex partners.
**A minority of male sex partners have balanitis, characterized by erythematous areas on the glans of the penis in conjunction with pruritus or irritation. These men benefit from treatment with topical antifungal agents to relieve symptoms.

*1.'''3 Special Considerations'''
**1.3.1 '''Drug Allergy, Intolerance, and Adverse Reactions'''
***Topical agents usually cause no systemic side effects.
***Oral azoles occasionally cause nausea, abdominal pain, and headache.
***Clinically important interactions can occur when oral azoles are administered with other drugs.

 

===2. Complicated Vulvovaginal Candidiasis<ref name="urlwww.cdc.gov" /><ref name="urlVulvovaginal Candidiasis - STI Treatment Guidelines" />===

*2.1 '''Recurrent Vulvovaginal Candidiasis'''
**Defined as three or more episodes of symptomatic VVC in <1 year.
**Preferred regimen: topical therapy for 7–14 days, OR [[fluconazole]] 100-mg, 150-mg, or 200-mg PO every third day for a total of 3 doses [days 1, 4, and 7].
**Maintenance regimen: fluconazole 100-mg, 150-mg, or 200-mg PO weekly for 6 months. (If this regimen is not feasible, topical treatments used intermittently) can also be considered.
**Note: ''C. albicans'' azole resistance is becoming more common, susceptibility tests, if available, should be obtained among symptomatic patients who remain culture positive despite maintenance therapy. These women should be managed in consultation with a specialist.

*2.2 '''Severe Vulvovaginal Candidiasis'''
**Preferred regimen: either 7–14 days of topical azole or fluconazole 150 mg PO in two doses 72 hours apart.

*2.3 '''Non–''albicans'' Vulvovaginal Candidiasis'''
**The optimal treatment of non–''albicans'' Vulvovaginal Candidiasis remains unknown; however, a longer duration of therapy (7–14 days) with a nonfluconazole azole regimen (oral or topical) is recommended.
**If recurrence occurs, [[boric acid]] 600 mg gelatin capsule intravaginally once daily for 3 weeks is indicated.

*2.4 '''Management of Sex Partners'''
**No data exist to support treating sex partners of patients with complicated Vulvovaginal Candidiasis.

===3. Special Considerations<ref name="urlVulvovaginal Candidiasis - STI Treatment Guidelines" />===

*3.1 '''Pregnancy'''
**Preferred regimen: topical azole for 7 days
**Note: Epidemiologic studies indicate a single 150-mg dose of fluconazole might be associated with spontaneous abortion and congenital anomalies; therefore, it should not be used.

*'''3.2 HIV Infection'''
**Treatment for uncomplicated and complicated VVC among women with HIV infection should not differ from that for women who do not have HIV.
**Long-term prophylactic therapy with fluconazole 200 mg weekly has been effective in reducing ''C. albicans'' colonization and symptomatic VVC, however this regimen is not recommended for women with HIV infection in the absence of complicated VVC.

===4 Follow-Up===
Follow-up typically is not required. However, women with persistent or recurrent symptoms after treatment should be instructed to return for follow-up visits.

==References==
{{Reflist|2}}

[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Gynecology]]
[[Category:Obstetrics]]

Candida vulvovaginitis medical therapy

2021-09-17T16:21:10Z

Dr.Nuha: /* Medical Therapy */

__NOTOC__
{{Candida vulvovaginitis}}
{{CMG}}

==Overview==
Antifungal agents are indicated in candidiasis. Commonly used drugs include [[Amphotericin]], [[Clotrimazole]], [[Nystatin]], [[Fluconazole]] and [[Ketoconazole]]. It is important to consider that ''Candida'' species are frequently part of the human body's normal oral and intestinal flora. Candidiasis is occasionally misdiagnosed by medical personnel as bacterial in nature, and treated with [[antibiotic]]s against bacteria. This can lead to eliminating the yeast's natural competitors for resources, and increase the severity of the condition.

==Medical Therapy==

=== 1. Uncomplicated Vulvovaginal Candidiasis<ref name="urlwww.cdc.gov">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf |title=www.cdc.gov |format= |work= |accessdate=}}</ref> ===

* '''1.1 Recommended Regimens'''
** '''1.1.1 Over-the-Counter Intravaginal Agents'''
*** Clotrimazole 1% cream 5 g intravaginally daily for 7–14 days OR Clotrimazole 2% cream 5 g intravaginally daily for 3 days OR Miconazole 2% cream 5 g intravaginally daily for 7 days OR Miconazole 4% cream 5 g intravaginally daily for 3 days OR Miconazole 100 mg vaginal suppository one suppository daily for 7 days OR Miconazole 200 mg vaginal suppository one suppository for 3 days OR Miconazole 1,200 mg vaginal suppository one suppository for 1 day OR Tioconazole 6.5% ointment 5 g intravaginally in a single application
** '''1.1.2 Prescription Intravaginal Agents'''
*** Butoconazole 2% cream 5 g intravaginally in a single application OR Terconazole 0.4% cream 5 g intravaginally daily for 7 days OR Terconazole 0.8% cream 5 g intravaginally daily for 3 days OR Terconazole 80 mg vaginal suppository one suppository daily for 3 days
** '''1.1.3 Oral Agent'''
*** Fluconazole 150 mg orally in a single dose.
** Note: the creams and suppositories in these regimens are oil based and might weaken latex condoms and diaphragms. Patients should refer to condom product labeling for further information.
** Note: Any woman whose symptoms persist after using an over-the-counter preparation or who has a recurrence of symptoms <2 months after treatment for VVC should be evaluated clinically and tested.
** Note: No substantial evidence exists to support using probiotics or homeopathic medications for treating VVC.
* '''1.2 Management of Sex Partners'''
** Uncomplicated VVC is not usually acquired through sexual intercourse, and data do not support treatment of sex partners.
** A minority of male sex partners have balanitis, characterized by erythematous areas on the glans of the penis in conjunction with pruritus or irritation. These men benefit from treatment with topical antifungal agents to relieve symptoms.

* 1.'''3 Special Considerations'''
** 1.3.1 '''Drug Allergy, Intolerance, and Adverse Reactions'''
*** Topical agents usually cause no systemic side effects.
*** Oral azoles occasionally cause nausea, abdominal pain, and headache.
*** Clinically important interactions can occur when oral azoles are administered with other drugs.

 

=== 2. Complicated Vulvovaginal Candidiasis<ref name="urlwww.cdc.gov" /> ===

* 2.1 '''Recurrent Vulvovaginal Candidiasis'''
** Defined as three or more episodes of symptomatic VVC in <1 year.
** Preferred regimen: topical therapy for 7–14 days, OR [[fluconazole]] 100-mg, 150-mg, or 200-mg PO every third day for a total of 3 doses [days 1, 4, and 7].
** Maintenance regimen: fluconazole 100-mg, 150-mg, or 200-mg PO weekly for 6 months. (If this regimen is not feasible, topical treatments used intermittently) can also be considered.
** Note: ''C. albicans'' azole resistance is becoming more common, susceptibility tests, if available, should be obtained among symptomatic patients who remain culture positive despite maintenance therapy. These women should be managed in consultation with a specialist.

* 2.2 '''Severe Vulvovaginal Candidiasis'''
** Preferred regimen: either 7–14 days of topical azole or fluconazole 150 mg PO in two doses 72 hours apart.

* 2.3 '''Non–''albicans'' Vulvovaginal Candidiasis'''
** The optimal treatment of non–''albicans'' Vulvovaginal Candidiasis remains unknown; however, a longer duration of therapy (7–14 days) with a nonfluconazole azole regimen (oral or topical) is recommended.
** If recurrence occurs, [[boric acid]] 600 mg gelatin capsule intravaginally once daily for 3 weeks is indicated.

* 2.4 '''Management of Sex Partners'''
** No data exist to support treating sex partners of patients with complicated Vulvovaginal Candidiasis.

=== 3. Special Considerations ===

* 3.1 '''Pregnancy'''
** Preferred regimen: topical azole for 7 days
** Note: Epidemiologic studies indicate a single 150-mg dose of fluconazole might be associated with spontaneous abortion and congenital anomalies; therefore, it should not be used.

* '''3.2 HIV Infection'''
** Treatment for uncomplicated and complicated VVC among women with HIV infection should not differ from that for women who do not have HIV.
** Long-term prophylactic therapy with fluconazole 200 mg weekly has been effective in reducing ''C. albicans'' colonization and symptomatic VVC, however this regimen is not recommended for women with HIV infection in the absence of complicated VVC.

=== 4 Follow-Up ===
Follow-up typically is not required. However, women with persistent or recurrent symptoms after treatment should be instructed to return for follow-up visits.

==References==
{{Reflist|2}}

[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Gynecology]]
[[Category:Obstetrics]]

User:Dr.Nuha

2021-09-17T15:31:30Z

Dr.Nuha: /* Pages Authored */

__NOTOC__
==Nuha Al-Howthi M.D.==
'''Nuha Al-Howthi. MD'''
[[File:Nuha alhowthi.JPG|right|250px|dr.Nuha]]

 Contact: 
Email: [mailto:nuha.1991@yahoo.com nuha.1991@yahoo.com] 

==Current Position==
'''Associate Editor-in-Chief at Wikidoc''' 

==Professional Background==
Dr. Nuha received her Bachelor of Medicine & Bachelor of Surgery (M.B.B.S) at Sana'a University, Faculty of Medicine and Health Sciences, Yemen. She is currently an Associate editor-in-chief at '''WikiDoc.'''

==Education==

*'''Sana'a University, Faculty of Medicine and Health Sciences, Yemen''' (2010-2015)
**'''Bachelor of Medicine & Bachelor of Surgery (M.B.B.S)''' 

==Clinical Experience==

*'''Doctor in training in the capital Sana’a – Yemen: Al Thowra General Hospital, Al Kuwait Educational Hospital, and Al Sabeaan Maternity and Child Hospital.''' January 2016 - December 2016.
*'''Internship At Royal Jordanian Medical Services, Amman – Jordan.''' February 2017 – February 2018.

==Achievements==

*'''training course of Sever acute malnutrition''' (2015)
*'''training course of Integrated management of childhood illness''' (2015).

==Pages Authored==

*[[COVID-19 frequently asked inpatient questions]]
*[[Dermatologic Disorders of COVID-19]]
*[[Heart murmur resident survival guide]]
*[[Heart murmur]]
*[[Chest pain]]
*[[abortion]]
*Updated CDC treatment guidelines : [[Gonorrhea medical therapy]], [[Bacterial vaginosis medical therapy]], [[Trichomoniasis medical therapy]]

Bacterial vaginosis medical therapy

2021-09-17T15:30:17Z

Dr.Nuha:

__NOTOC__
{{Bacterial vaginosis}}

{{CMG}}; {{AE}} {{SaraM}} {{nuha}}

==Overview==
Antimicrobial therapy is recommended for all symptomatic women and high risk asymptomatic pregnant women with bacterial vaginosis. [[Metronidazole]] is the drug of choice in pregnant patients.<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref>

==Medical Therapy==
Treatment is recommended for women with symptoms. Other potential benefits to treatment include reduction in the risk for acquiring ''[[trachoma|C. trachomatis]]'', ''[[gonorrhea|N. gonorrhea]]'', ''[[trichomoniasis|T. vaginalis]]'', [[HIV]], and [[herpes simplex|herpes simplex type 2]].<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref><ref name="urlBacterial Vaginosis - STI Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/bv.htm |title=Bacterial Vaginosis - STI Treatment Guidelines |format= |work= |accessdate=}}</ref>
===Management of Sex Partner===
Data from clinical trials indicate that a woman’s response to therapy and the likelihood of relapse or recurrence are not affected by treatment of her sex partner. Therefore, routine treatment of sex partners is not recommended.<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref>

===Pregnancy===
Treatment is recommended for all symptomatic pregnant women. Treatment of asymptomatic BV among pregnant women who are at high risk for preterm delivery (previous preterm birth) is recommended.<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref>
===Follow-Up===
Follow-up visits are unnecessary if symptoms resolve. Because persistent and recurrent BV are common, women should be advised to return for evaluation if symptoms recur.<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref>

===Antimicrobial Regimen===

:*'''1. Bacterial Vaginosis Treatment'''<ref>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref><ref name="urlBacterial Vaginosis - STI Treatment Guidelines2">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/bv.htm |title=Bacterial Vaginosis - STI Treatment Guidelines |format= |work= |accessdate=}}</ref>
::*Preferred regimen (1): [[Metronidazole]] 500 mg PO bid for 7 days
::*Preferred regimen (2): [[Metronidazole]] gel 0.75%, one full applicator (5 g) intravaginally, qd for 5 days
::*Preferred regimen (3): [[Clindamycin]] cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days
::*Alternative regimen (1): [[Tinidazole]] 2 g PO qd for 2 days
::*Alternative regimen (2): [[Tinidazole]] 1 g PO qd for 5 days
::*Alternative regimen (3): [[Clindamycin]] 300 mg PO bid for 7 days
::*Alternative regimen (4): [[Clindamycin]] ovules 100 mg intravaginally once at bedtime for 3 days
::*Alternative regimen (5)''':''' [[Secnidazole]] 2 g PO granules in a single dose
::*Note: [[Clindamycin]] ovules use an oleaginous base that might weaken latex or rubber products (e.g., condoms and vaginal contraceptive diaphragms). Use of such products within 72 hours following treatment with clindamycin ovules is not recommended.
::*Note: [[Secnidazole]] granules should be sprinkled onto unsweetened applesauce, yogurt, or pudding before ingestion. A glass of water can be taken after administration to aid in swallowing.
:*'''2. Management of Sex Partners'''
::*Routine treatment of sex partners is not recommended.
:*'''3. Special Considerations'''
::*'''3.1 Allergy, Intolerance, or Adverse Reactions'''
:::*Intravaginal [[Clindamycin]] cream is preferred in case of allergy or intolerance to [[Metronidazole]] or [[Tinidazole]]. Intravaginal [[Metronidazole]] gel can be considered for women who are not allergic to [[Metronidazole]] but do not tolerate oral metronidazole. It is advised to avoid consuming alcohol during treatment with nitroimidazoles. To reduce the possibility of a disulfiram-like reaction, abstinence from alcohol use should continue for 24 hours after completion of metronidazole or 72 hours after completion of tinidazole.
::*'''3.2 Pregnancy'''<ref name="urlBacterial Vaginosis - STI Treatment Guidelines3">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/bv.htm |title=Bacterial Vaginosis - STI Treatment Guidelines |format= |work= |accessdate=}}</ref>
:::*Preferred regimen (1): [[Metronidazole]] 500 mg PO bid for 7 days
:::*Preferred regimen (2): [[Metronidazole]] gel 0.75%, one full applicator (5 g) intravaginally, qd for 5 days
:::*Preferred regimen (3): oral [[clindamycin]] 300 mg BID for 7 days (data demonstrate that this treatment approach is safe for pregnant women)
:::*Note: [[Tinidazole]] should be avoided during pregnancy
:::*Note: routine screening for BV among asymptomatic pregnant women at high or low risk for preterm delivery for preventing preterm birth is not recommended.
:::*[[Breastfeeding]] mothers should be deferring breastfeeding for 12–24 hours after receiving a single 2-g dose of [[metronidazole]]. Lower doses produce a lower concentration in breast milk and are considered compatible with [[breastfeeding]]
::*'''3.3 HIV Infection'''
:::*Women with HIV who have BV should receive the same treatment regimen as those who do not have HIV infection.

==References==
{{Reflist|2}}
{{WH}}
{{WS}}

[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Gynecology]]
[[Category:Emergency medicine]]
[[Category:Infectious disease]]

Trichomoniasis medical therapy

2021-09-17T15:19:49Z

Dr.Nuha:

__NOTOC__
{{Trichomoniasis}}
{{CMG}}; {{AE}} {{AA}} {{nuha}}

==Overview==
[[Antimicrobial]] therapy is the standard of care for trichomoniasis in both genders once the diagnosis has been confirmed. The symptoms of trichomoniasis among infected men may disappear within a few weeks even without treatment, but asymptomatic men may continue to be infectious and should therefore be treated. [[Antimicrobial]] therapy generally includes either [[metronidazole]] or [[tinidazole]] 2 g PO in a single dose. Prolonged therapy for 7 days is indicated among patients who fail to respond to the initial course of therapy. Following successful treatment, individuals may still be susceptible to re-infection.

==Medical Therapy==
[[Antimicrobial]] therapy is the standard of care for trichomoniasis in both genders once the diagnosis has been confirmed.<ref name="pmid15489348">{{cite journal| author=Cudmore SL, Delgaty KL, Hayward-McClelland SF, Petrin DP, Garber GE| title=Treatment of infections caused by metronidazole-resistant Trichomonas vaginalis. | journal=Clin Microbiol Rev | year= 2004 | volume= 17 | issue= 4 | pages= 783-93, table of contents | pmid=15489348 | doi=10.1128/CMR.17.4.783-793.2004 | pmc=523556 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15489348 }} </ref><ref name="pmid23322080">{{cite journal| author=Coleman JS, Gaydos CA, Witter F| title=Trichomonas vaginalis vaginitis in obstetrics and gynecology practice: new concepts and controversies. | journal=Obstet Gynecol Surv | year= 2013 | volume= 68 | issue= 1 | pages= 43-50 | pmid=23322080 | doi=10.1097/OGX.0b013e318279fb7d | pmc=3586271 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23322080 }} </ref><ref name="Std"> http://www.cdc.gov/std/tg2015/trichomoniasis.htm, Accessed on September 13, 2016</ref> The symptoms of trichomoniasis in infected men may disappear within a few weeks even without treatment, but asymptomatic men may continue to be infectious and should therefore be treated.
===Antimicrobial Regimen===

:*1. '''''T. vaginalis'' infection in women'''
::*Preferred regimen: [[Metronidazole]] 500 mg PO bid for 7 days
::*Alternative regimen: [[Tinidazole]] 2 g PO in a single dose
::*Note: Patients should avoid sexual contact until they are fully cured of trichomoniasis
::*Note: Testing for other STIs, including [[HIV|HIV,]] [[syphilis]], [[gonorrhea]], and [[chlamydia]], should be performed for persons with ''T. vaginalis''.
::
::2. '''''T. vaginalis'' infection in men'''
::* Preferred regimen: [[Metronidazole]] 2 g PO in a single dose
::* Alternative regimen: [[Tinidazole]] 2 g PO in a single dose
::* Note: Patients should avoid sexual contact until they are fully cured of trichomoniasis
::*Note: Testing for other STIs, including [[HIV|HIV,]] [[syphilis]], [[gonorrhea]], and [[chlamydia]], should be performed for persons with ''T. vaginalis''.
:*2. '''''T. vaginalis'' infection in pregnant and lactating Women'''
::*2.1 '''Pregnant women'''
:::*Preferred regimen: [[Metronidazole]] 2 g PO in a single dose
::*2.2 '''Post-partum and Breastfeeding'''
:::*Preferred regimen (1): [[Metronidazole]] 500 mg PO bid for 7 days
:::*Preferred regimen (2): [[Tinidazole]] 2 g PO in a single dose
:::*Note (1): Do not breastfeed for 12-24 hrs following [[Metronidazole]] and 72 hrs following [[Tinidazole]]
:::*Note (2): Symptomatic pregnant women, regardless of pregnancy stage, should be tested and considered for treatment.<ref>Trintis, J., et al. "Neonatal Trichomonas vaginalis infection: a case report and review of literature." International journal of STD & AIDS 21.8 (2010): 606-607.</ref> Pregnant women should be advised of the risk and benefits to treatment as infection (definitely) and treatment (possibly)
:::*Note (3): Pregnant women with HIV who are treated for T. vaginalis infection should be retested 3 months after treatment.
:*3. '''''T. vaginalis'' infection in patients with HIV'''
::*Preferred regimen: [[Metronidazole]] 500 mg PO bid for 7 days
:*4. '''Persistent or recurrent trichomoniasis'''<ref name="urlwww.cdc.gov">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf |title=www.cdc.gov |format= |work= |accessdate=}}</ref>
::*4.1 '''Treatment failure:'''
::**4.1.1 In a woman after completing a regimen and has been re-exposed to an untreated partner
::***Preferred regimen: [[Metronidazole]] 500 mg PO bid for 7 days
::**4.1.2 In a woman after completing a regimen and no re-exposure has occurred:
::***Preferred regimen (1): [[Metronidazole]] 2 g PO for 7 days
::***Preferred regimen (2): [[Tinidazole]] 2 g PO for 7 days
::**4.1.3 In men after completing a regimen and has been re-exposed to an untreated partner
::***Preferred regimen: [[Metronidazole]] single 2-g dose.
::**4.1.4 In men after completing a regimen and no re-exposure has occurred:
::**Preferred regimen (1): [[Metronidazole]] 500 mg PO BID for 7 days.
::*4.2 '''Nitroimidazole-resistant ''T. vaginalis'''''
::*Antibiotic susceptibility testing recommended
::*Preferred regimen: [[Tinidazole]] or [[metronidazole]] 2 g daily for 7 days
::*Alternative regimen (1): high-dose oral [[tinidazole]] 2 g daily plus [[tinidazole]] 500 mg BID intravaginal for 14 days
::*Alternative regimen (2): If the first failed, high-dose oral [[tinidazole]] 1 g TID plus [[paromomycin]] 4 g of 6.25% intravaginal [[paromomycin]] cream nightly for 14 days.

===Treatment of Sexual Partners===

*Sexual partners of patients with trichomoniasis should be treated.<ref name="Std"> http://www.cdc.gov/std/tg2015/trichomoniasis.htm, Accessed on September 13, 2016</ref><ref>Kissinger, Patricia, et al. "Patient-delivered partner treatment for Trichomonas vaginalis infection: a randomized controlled trial." Sexually transmitted diseases 33.7 (2006): 445-450.</ref>
*Patients and their sexual partners should avoid sexual contact until they are fully cured of trichomoniasis.

===Follow-up===

*Patients should be re-evaluated at the end of the [[antimicrobial]] therapy regimen to determine whether therapy has been successful.
*Patients should be instructed that they are still susceptible to re-infection.
*Retesting is recommended for sexually active women within 3 months of treatment for initial infection. If retesting at 3 months is not possible, clinicians should retest whenever persons next seek medical care <12 months after initial treatment. <ref>Van Der Pol, Barbara, et al. "Prevalence, incidence, natural history, and response to treatment of Trichomonas vaginalis infection among adolescent women." Journal of Infectious Diseases 192.12 (2005): 2039-2044.</ref>
*Data are insufficient to support retesting men after treatment.

==References==
{{Reflist|2}}

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

[[Category:Gynecology]]
[[Category:FinalQCRequired]]
[[Category:Emergency mdicine]]
[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]

Trichomoniasis medical therapy

2021-09-17T15:19:13Z

Dr.Nuha: /* Antimicrobial Regimen */

__NOTOC__
{{Trichomoniasis}}
{{CMG}}; {{AE}} {{AA}}

==Overview==
[[Antimicrobial]] therapy is the standard of care for trichomoniasis in both genders once the diagnosis has been confirmed. The symptoms of trichomoniasis among infected men may disappear within a few weeks even without treatment, but asymptomatic men may continue to be infectious and should therefore be treated. [[Antimicrobial]] therapy generally includes either [[metronidazole]] or [[tinidazole]] 2 g PO in a single dose. Prolonged therapy for 7 days is indicated among patients who fail to respond to the initial course of therapy. Following successful treatment, individuals may still be susceptible to re-infection.

==Medical Therapy==
[[Antimicrobial]] therapy is the standard of care for trichomoniasis in both genders once the diagnosis has been confirmed.<ref name="pmid15489348">{{cite journal| author=Cudmore SL, Delgaty KL, Hayward-McClelland SF, Petrin DP, Garber GE| title=Treatment of infections caused by metronidazole-resistant Trichomonas vaginalis. | journal=Clin Microbiol Rev | year= 2004 | volume= 17 | issue= 4 | pages= 783-93, table of contents | pmid=15489348 | doi=10.1128/CMR.17.4.783-793.2004 | pmc=523556 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15489348 }} </ref><ref name="pmid23322080">{{cite journal| author=Coleman JS, Gaydos CA, Witter F| title=Trichomonas vaginalis vaginitis in obstetrics and gynecology practice: new concepts and controversies. | journal=Obstet Gynecol Surv | year= 2013 | volume= 68 | issue= 1 | pages= 43-50 | pmid=23322080 | doi=10.1097/OGX.0b013e318279fb7d | pmc=3586271 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23322080 }} </ref><ref name="Std"> http://www.cdc.gov/std/tg2015/trichomoniasis.htm, Accessed on September 13, 2016</ref> The symptoms of trichomoniasis in infected men may disappear within a few weeks even without treatment, but asymptomatic men may continue to be infectious and should therefore be treated.
===Antimicrobial Regimen===

:*1. '''''T. vaginalis'' infection in women'''
::*Preferred regimen: [[Metronidazole]] 500 mg PO bid for 7 days
::*Alternative regimen: [[Tinidazole]] 2 g PO in a single dose
::*Note: Patients should avoid sexual contact until they are fully cured of trichomoniasis
::*Note: Testing for other STIs, including [[HIV|HIV,]] [[syphilis]], [[gonorrhea]], and [[chlamydia]], should be performed for persons with ''T. vaginalis''.
::
::2. '''''T. vaginalis'' infection in men'''
::* Preferred regimen: [[Metronidazole]] 2 g PO in a single dose
::* Alternative regimen: [[Tinidazole]] 2 g PO in a single dose
::* Note: Patients should avoid sexual contact until they are fully cured of trichomoniasis
::*Note: Testing for other STIs, including [[HIV|HIV,]] [[syphilis]], [[gonorrhea]], and [[chlamydia]], should be performed for persons with ''T. vaginalis''.
:*2. '''''T. vaginalis'' infection in pregnant and lactating Women'''
::*2.1 '''Pregnant women'''
:::*Preferred regimen: [[Metronidazole]] 2 g PO in a single dose
::*2.2 '''Post-partum and Breastfeeding'''
:::*Preferred regimen (1): [[Metronidazole]] 500 mg PO bid for 7 days
:::*Preferred regimen (2): [[Tinidazole]] 2 g PO in a single dose
:::*Note (1): Do not breastfeed for 12-24 hrs following [[Metronidazole]] and 72 hrs following [[Tinidazole]]
:::*Note (2): Symptomatic pregnant women, regardless of pregnancy stage, should be tested and considered for treatment.<ref>Trintis, J., et al. "Neonatal Trichomonas vaginalis infection: a case report and review of literature." International journal of STD & AIDS 21.8 (2010): 606-607.</ref> Pregnant women should be advised of the risk and benefits to treatment as infection (definitely) and treatment (possibly)
:::*Note (3): Pregnant women with HIV who are treated for T. vaginalis infection should be retested 3 months after treatment.
:*3. '''''T. vaginalis'' infection in patients with HIV'''
::*Preferred regimen: [[Metronidazole]] 500 mg PO bid for 7 days
:*4. '''Persistent or recurrent trichomoniasis'''<ref name="urlwww.cdc.gov">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf |title=www.cdc.gov |format= |work= |accessdate=}}</ref>
::*4.1 '''Treatment failure:'''
::**4.1.1 In a woman after completing a regimen and has been re-exposed to an untreated partner
::***Preferred regimen: [[Metronidazole]] 500 mg PO bid for 7 days
::**4.1.2 In a woman after completing a regimen and no re-exposure has occurred:
::***Preferred regimen (1): [[Metronidazole]] 2 g PO for 7 days
::***Preferred regimen (2): [[Tinidazole]] 2 g PO for 7 days
::**4.1.3 In men after completing a regimen and has been re-exposed to an untreated partner
::***Preferred regimen: [[Metronidazole]] single 2-g dose.
::**4.1.4 In men after completing a regimen and no re-exposure has occurred:
::**Preferred regimen (1): [[Metronidazole]] 500 mg PO BID for 7 days.
::*4.2 '''Nitroimidazole-resistant ''T. vaginalis'''''
::*Antibiotic susceptibility testing recommended
::*Preferred regimen: [[Tinidazole]] or [[metronidazole]] 2 g daily for 7 days
::*Alternative regimen (1): high-dose oral [[tinidazole]] 2 g daily plus [[tinidazole]] 500 mg BID intravaginal for 14 days
::*Alternative regimen (2): If the first failed, high-dose oral [[tinidazole]] 1 g TID plus [[paromomycin]] 4 g of 6.25% intravaginal [[paromomycin]] cream nightly for 14 days.

===Treatment of Sexual Partners===

*Sexual partners of patients with trichomoniasis should be treated.<ref name="Std"> http://www.cdc.gov/std/tg2015/trichomoniasis.htm, Accessed on September 13, 2016</ref><ref>Kissinger, Patricia, et al. "Patient-delivered partner treatment for Trichomonas vaginalis infection: a randomized controlled trial." Sexually transmitted diseases 33.7 (2006): 445-450.</ref>
*Patients and their sexual partners should avoid sexual contact until they are fully cured of trichomoniasis.

===Follow-up===

*Patients should be re-evaluated at the end of the [[antimicrobial]] therapy regimen to determine whether therapy has been successful.
*Patients should be instructed that they are still susceptible to re-infection.
*Retesting is recommended for sexually active women within 3 months of treatment for initial infection. If retesting at 3 months is not possible, clinicians should retest whenever persons next seek medical care <12 months after initial treatment. <ref>Van Der Pol, Barbara, et al. "Prevalence, incidence, natural history, and response to treatment of Trichomonas vaginalis infection among adolescent women." Journal of Infectious Diseases 192.12 (2005): 2039-2044.</ref>
*Data are insufficient to support retesting men after treatment.

==References==
{{Reflist|2}}

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

[[Category:Gynecology]]
[[Category:FinalQCRequired]]
[[Category:Emergency mdicine]]
[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]

Trichomoniasis other diagnostic studies

2021-09-17T14:35:25Z

Dr.Nuha: /* The Solana trichomonas assay (Quidel) */

__NOTOC__
{{Trichomoniasis}}

{{CMG}}; {{AE}}{{AA}}

==Overview==
Another diagnostic test that may be helpful in the diagnosis of trichomoniasis is the whiff test.<ref name="pmid23322080">{{cite journal| author=Coleman JS, Gaydos CA, Witter F| title=Trichomonas vaginalis vaginitis in obstetrics and gynecology practice: new concepts and controversies. | journal=Obstet Gynecol Surv | year= 2013 | volume= 68 | issue= 1 | pages= 43-50 | pmid=23322080 | doi=10.1097/OGX.0b013e318279fb7d | pmc=3586271 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23322080 }} </ref>

==Other diagnostic tests==
Another diagnostic test that may be helpful in the diagnosis of trichomoniasis is the whiff test.

===Whiff test===
Vaginal infection with trichomonas vaginalis alters the vaginal pH from [[acidic]] to basic. The whiff test is based on the addition of 10% [[potassium hydroxide]] to [[vaginal]] [[secretions]]. [[Vaginal]] pH >4.5 gives off a strong, fishy odor based on the presence of amines.<ref name="pmid23322080">{{cite journal| author=Coleman JS, Gaydos CA, Witter F| title=Trichomonas vaginalis vaginitis in obstetrics and gynecology practice: new concepts and controversies. | journal=Obstet Gynecol Surv | year= 2013 | volume= 68 | issue= 1 | pages= 43-50 | pmid=23322080 | doi=10.1097/OGX.0b013e318279fb7d | pmc=3586271 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23322080 }} </ref>

 

===The Solana trichomonas assay (Quidel)===
Another rapid test for the qualitative detection of ''T. vaginalis'' [[DNA]] and can yield results <40 minutes after specimen collection. This assay is FDA cleared for diagnosing ''T. vaginalis'' from female vaginal and urine specimens from [[asymptomatic]] and [[symptomatic]] women with [[sensitivity]] >98%, compared with [[NAAT]] for vaginal specimens, and >92% for [[urine]] specimens<ref name="urlSTI Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/default.htm |title=STI Treatment Guidelines |format= |work= |accessdate=}}</ref>
 

===The Osom trichomonas rapid test (Sekisui Diagnostics)===
An [[antigen]]-detection [[test]] that uses immunochromatographic [[capillary]] flow dipstick technology by using clinician-obtained vaginal specimens. Results are available in approximately 10–15 minutes, with sensitivities of 82%–95% and specificity of 97%–100%, compared with wet mount, culture, and transcription-mediated amplification<ref name="urlSTI Treatment Guidelines" />

===The Amplivue trichomonas assay (Quidel)===
Another rapid test providing qualitative detection of ''T.'' ''vaginalis'' that has been FDA cleared for vaginal specimens from [[symptomatic]] and [[asymptomatic]] women, with [[sensitivity]] of 90.7% and [[specificity]] of 98.9%, compared with [[NAAT]]. <ref name="urlSTI Treatment Guidelines" />

The Osom assay and the Affirm VP III test is not FDA cleared for use with specimens from men.<ref name="urlSTI Treatment Guidelines" /><ref name="urlwww.cdc.gov">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf |title=www.cdc.gov |format= |work= |accessdate=}}</ref>

==References==
{{Reflist|2}}

{{WH}}
{{WS}}

[[Category:Gynecology]]
[[Category:FinalQCRequired]]
[[Category:Emergency mdicine]]
[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]

Trichomoniasis other diagnostic studies

2021-09-17T14:33:00Z

Dr.Nuha: /* Other diagnostic tests */

__NOTOC__
{{Trichomoniasis}}

{{CMG}}; {{AE}}{{AA}}

==Overview==
Another diagnostic test that may be helpful in the diagnosis of trichomoniasis is the whiff test.<ref name="pmid23322080">{{cite journal| author=Coleman JS, Gaydos CA, Witter F| title=Trichomonas vaginalis vaginitis in obstetrics and gynecology practice: new concepts and controversies. | journal=Obstet Gynecol Surv | year= 2013 | volume= 68 | issue= 1 | pages= 43-50 | pmid=23322080 | doi=10.1097/OGX.0b013e318279fb7d | pmc=3586271 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23322080 }} </ref>

==Other diagnostic tests==
Another diagnostic test that may be helpful in the diagnosis of trichomoniasis is the whiff test.

===Whiff test===
Vaginal infection with trichomonas vaginalis alters the vaginal pH from [[acidic]] to basic. The whiff test is based on the addition of 10% [[potassium hydroxide]] to [[vaginal]] [[secretions]]. [[Vaginal]] pH >4.5 gives off a strong, fishy odor based on the presence of amines.<ref name="pmid23322080">{{cite journal| author=Coleman JS, Gaydos CA, Witter F| title=Trichomonas vaginalis vaginitis in obstetrics and gynecology practice: new concepts and controversies. | journal=Obstet Gynecol Surv | year= 2013 | volume= 68 | issue= 1 | pages= 43-50 | pmid=23322080 | doi=10.1097/OGX.0b013e318279fb7d | pmc=3586271 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23322080 }} </ref>

 

=== The Solana trichomonas assay (Quidel) ===
Another rapid test for the qualitative detection of ''T. vaginalis'' [[DNA]] and can yield results <40 minutes after specimen collection. This assay is FDA cleared for diagnosing ''T. vaginalis'' from female vaginal and urine specimens from [[asymptomatic]] and [[symptomatic]] women with [[sensitivity]] >98%, compared with [[NAAT]] for vaginal specimens, and >92% for [[urine]] specimens<ref name="urlSTI Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/default.htm |title=STI Treatment Guidelines |format= |work= |accessdate=}}</ref>
 

=== The Osom trichomonas rapid test (Sekisui Diagnostics) ===
An [[antigen]]-detection [[test]] that uses immunochromatographic [[capillary]] flow dipstick technology by using clinician-obtained vaginal specimens. Results are available in approximately 10–15 minutes, with sensitivities of 82%–95% and specificity of 97%–100%, compared with wet mount, culture, and transcription-mediated amplification<ref name="urlSTI Treatment Guidelines" />

=== The Amplivue trichomonas assay (Quidel) ===
Another rapid test providing qualitative detection of ''T.'' ''vaginalis'' that has been FDA cleared for vaginal specimens from [[symptomatic]] and [[asymptomatic]] women, with [[sensitivity]] of 90.7% and [[specificity]] of 98.9%, compared with [[NAAT]]. <ref name="urlSTI Treatment Guidelines" />

The Osom assay and the Affirm VP III test is not FDA cleared for use with specimens from men.<ref name="urlSTI Treatment Guidelines" />

==References==
{{Reflist|2}}

{{WH}}
{{WS}}

[[Category:Gynecology]]
[[Category:FinalQCRequired]]
[[Category:Emergency mdicine]]
[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]

Trichomoniasis laboratory findings

2021-09-17T14:19:03Z

Dr.Nuha: /* Microscopy */

__NOTOC__
{{Trichomoniasis}}

{{CMG}}; {{AE}} {{Maliha}}, {{AA}}

==Overview==
Laboratory tests used in the diagnosis of trichomoniasis include saline microscopy, culture, and nucleic acid amplification tests (NAATs).<ref name="CDT">http://www.cdc.gov/std/tg2015/trichomoniasis.htm Accessed on September 14, 2016</ref>

==Laboratory Findings==
===Microscopy===
Wet-mount [[microscopy]]: has been used as the preferred [[diagnostic]] test, however it has low [[sensitivity]] (44%–68%) compared with culture. To improve detection, [[clinicians]] using wet mounts should attempt to evaluate slides immediately after specimen collection because [[sensitivity]] decreases quickly to 20% within 1 hour after collection.<ref name="urlTrichomoniasis - STI Treatment Guidelines2">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/trichomoniasis.htm |title=Trichomoniasis - STI Treatment Guidelines |format= |work= |accessdate=}}</ref>

Trichomoniasis is diagnosed by visually observing the trichomonads via a [[microscope]]. In women, the examiner collects the specimen during a [[pelvic examination]] by inserting a [[Speculum (medical)|speculum]] into the vagina and then using a cotton-tipped applicator to collect the sample. The sample is then placed onto a microscopic slide and sent to a laboratory to be analyzed. Trichomoniasis has been difficult to diagnose due to the poor [[Sensitivity|sensitivity]] of the tests.<ref name="Andrea&Chapin2011">{{cite journal| author=Andrea SB, Chapin KC| title=Comparison of Aptima Trichomonas vaginalis Transcription-Mediated Amplification Assay and BD Affirm VPIII for Detection of T. vaginalis in Symptomatic Women: Performance Parameters and Epidemiological Implications. | journal=J Clin Microbiol | year= 2011 | volume= 49 | issue= 3 | pages= 866–9 | pmid=21248097 | doi=10.1128/JCM.02367-10 | pmc= | url= | laysummary = http://www.eurekalert.org/pub_releases/2011-03/l-amd030811.php}}</ref><ref name="CDT">http://www.cdc.gov/std/tg2015/trichomoniasis.htm Accessed on September 14, 2016</ref>
<ref>Nye, Melinda B., Jane R. Schwebke, and Barbara A. Body. "Comparison of APTIMA Trichomonas vaginalis transcription-mediated amplification to wet mount microscopy, culture, and polymerase chain reaction for diagnosis of trichomoniasis in men and women." American journal of obstetrics and gynecology 200.2 (2009): 188-e1.</ref><ref>Stoner, Kevin A., et al. "Survival of Trichomonas vaginalis in wet preparation and on wet mount." Sexually transmitted infections (2013): sextrans-2012.</ref>

Findings on microscopy suggestive of trichomoniasis include:<ref name="pmid23633669">{{cite journal| author=Hobbs MM, Seña AC| title=Modern diagnosis of Trichomonas vaginalis infection. | journal=Sex Transm Infect | year= 2013 | volume= 89 | issue= 6 | pages= 434-8 | pmid=23633669 | doi=10.1136/sextrans-2013-051057 | pmc=PMC3787709 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23633669 }} </ref><ref name="pmid15489349">{{cite journal| author=Schwebke JR, Burgess D| title=Trichomoniasis. | journal=Clin Microbiol Rev | year= 2004 | volume= 17 | issue= 4 | pages= 794-803, table of contents | pmid=15489349 | doi=10.1128/CMR.17.4.794-803.2004 | pmc=PMC523559 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15489349 }} </ref>

*Characteristic "tumbling" motility of [[protozoa]]
*[[Leukocytes]]

 
{|
|-
!Trichomonas vaginalis!!Pap smear
|-
|[[Image:Trichomonas vaginalis.jpg|300px|]]||[[image:Trichomonas_pap_test.jpg|300px]]
|}

Two trophozoites of Trichomonas vaginalis obtained from in vitro culture. Smear was stained with [[Giemsa]].<ref name="urlDPDx - Trichomoniasis">{{cite web |url=http://www.dpd.cdc.gov/dpdx/HTML/Trichomoniasis.htm |title=DPDx - Trichomoniasis |format= |work= |accessdate=2012-12-27}}</ref>

===Culture===
Historically, culture has been the gold standard for diagnosis of trichomoniasis. However, [[sensitivity]] is somewhat low (70-89%).<ref name="ggg"> Trichomoniasis . Wikipedia.https://en.wikipedia.org/wiki/Trichomoniasis Accessed on February 4, 2016</ref>

===Nucleic Acid Amplification Tests===
Nucleic acid probe techniques, the most sensitive tests, are moderately priced and fast, but they require instrumentation and thus are not considered point-of-care. The APTIMA ''Trichomonas vaginalis'' Assay (Hologic Gen-Probe, San Diego, CA) was [[FDA]]-cleared in 2011 for use with urine, endocervical, and vaginal swabs, and endocervical specimens collected in the Hologic PreserveCyt solution (ThinPrep) from females only. [[Sensitivity]] is 95–100% and [[specificity]] is also 95–100%.<ref name="pmid26242185">{{cite journal| author=Kissinger P| title=Trichomonas vaginalis: a review of epidemiologic, clinical and treatment issues. | journal=BMC Infect Dis | year= 2015 | volume= 15 | issue= | pages= 307 | pmid=26242185 | doi=10.1186/s12879-015-1055-0 | pmc=PMC4525749 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26242185 }} </ref><ref>Nye, Melinda B., Jane R. Schwebke, and Barbara A. Body. "Comparison of APTIMA Trichomonas vaginalis transcription-mediated amplification to wet mount microscopy, culture, and polymerase chain reaction for diagnosis of trichomoniasis in men and women." American journal of obstetrics and gynecology 200.2 (2009): 188-e1.</ref><ref>Kingston, M. A., D. Bansal, and E. M. Carlin. "'Shelf life'of Trichomonas vaginalis." International journal of STD & AIDS 14.1 (2003): 28.</ref>

==References==
{{Reflist|2}}

{{WH}}
{{WS}}

[[Category:Gynecology]]
[[Category:FinalQCRequired]]
[[Category:Emergency mdicine]]
[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]

Bacterial vaginosis medical therapy

2021-09-16T18:53:42Z

Dr.Nuha: /* Medical Therapy */

__NOTOC__
{{Bacterial vaginosis}}

{{CMG}}; {{AE}} {{SaraM}}

==Overview==
Antimicrobial therapy is recommended for all symptomatic women and high risk asymptomatic pregnant women with bacterial vaginosis. [[Metronidazole]] is the drug of choice in pregnant patients.<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref>

==Medical Therapy==
Treatment is recommended for women with symptoms. Other potential benefits to treatment include reduction in the risk for acquiring ''[[trachoma|C. trachomatis]]'', ''[[gonorrhea|N. gonorrhea]]'', ''[[trichomoniasis|T. vaginalis]]'', [[HIV]], and [[herpes simplex|herpes simplex type 2]].<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref><ref name="urlBacterial Vaginosis - STI Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/bv.htm |title=Bacterial Vaginosis - STI Treatment Guidelines |format= |work= |accessdate=}}</ref>
===Management of Sex Partner===
Data from clinical trials indicate that a woman’s response to therapy and the likelihood of relapse or recurrence are not affected by treatment of her sex partner. Therefore, routine treatment of sex partners is not recommended.<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref>

===Pregnancy===
Treatment is recommended for all symptomatic pregnant women. Treatment of asymptomatic BV among pregnant women who are at high risk for preterm delivery (previous preterm birth) is recommended.<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref>
===Follow-Up===
Follow-up visits are unnecessary if symptoms resolve. Because persistent and recurrent BV are common, women should be advised to return for evaluation if symptoms recur.<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref>

===Antimicrobial Regimen===

:*'''1. Bacterial Vaginosis Treatment'''<ref>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref><ref name="urlBacterial Vaginosis - STI Treatment Guidelines2">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/bv.htm |title=Bacterial Vaginosis - STI Treatment Guidelines |format= |work= |accessdate=}}</ref>
::*Preferred regimen (1): [[Metronidazole]] 500 mg PO bid for 7 days
::*Preferred regimen (2): [[Metronidazole]] gel 0.75%, one full applicator (5 g) intravaginally, qd for 5 days
::*Preferred regimen (3): [[Clindamycin]] cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days
::*Alternative regimen (1): [[Tinidazole]] 2 g PO qd for 2 days
::*Alternative regimen (2): [[Tinidazole]] 1 g PO qd for 5 days
::*Alternative regimen (3): [[Clindamycin]] 300 mg PO bid for 7 days
::*Alternative regimen (4): [[Clindamycin]] ovules 100 mg intravaginally once at bedtime for 3 days
::*Alternative regimen (5)''':''' [[Secnidazole]] 2 g PO granules in a single dose
::*Note: [[Clindamycin]] ovules use an oleaginous base that might weaken latex or rubber products (e.g., condoms and vaginal contraceptive diaphragms). Use of such products within 72 hours following treatment with clindamycin ovules is not recommended.
::*Note: [[Secnidazole]] granules should be sprinkled onto unsweetened applesauce, yogurt, or pudding before ingestion. A glass of water can be taken after administration to aid in swallowing.
:*'''2. Management of Sex Partners'''
::*Routine treatment of sex partners is not recommended.
:*'''3. Special Considerations'''
::*'''3.1 Allergy, Intolerance, or Adverse Reactions'''
:::*Intravaginal [[Clindamycin]] cream is preferred in case of allergy or intolerance to [[Metronidazole]] or [[Tinidazole]]. Intravaginal [[Metronidazole]] gel can be considered for women who are not allergic to [[Metronidazole]] but do not tolerate oral metronidazole. It is advised to avoid consuming alcohol during treatment with nitroimidazoles. To reduce the possibility of a disulfiram-like reaction, abstinence from alcohol use should continue for 24 hours after completion of metronidazole or 72 hours after completion of tinidazole.
::*'''3.2 Pregnancy'''<ref name="urlBacterial Vaginosis - STI Treatment Guidelines3">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/bv.htm |title=Bacterial Vaginosis - STI Treatment Guidelines |format= |work= |accessdate=}}</ref>
:::*Preferred regimen (1): [[Metronidazole]] 500 mg PO bid for 7 days
:::*Preferred regimen (2): [[Metronidazole]] gel 0.75%, one full applicator (5 g) intravaginally, qd for 5 days
:::*Preferred regimen (3): oral [[clindamycin]] 300 mg BID for 7 days (data demonstrate that this treatment approach is safe for pregnant women)
:::*Note: [[Tinidazole]] should be avoided during pregnancy
:::*Note: routine screening for BV among asymptomatic pregnant women at high or low risk for preterm delivery for preventing preterm birth is not recommended.
:::*[[Breastfeeding]] mothers should be deferring breastfeeding for 12–24 hours after receiving a single 2-g dose of [[metronidazole]]. Lower doses produce a lower concentration in breast milk and are considered compatible with [[breastfeeding]]
::*'''3.3 HIV Infection'''
:::*Women with HIV who have BV should receive the same treatment regimen as those who do not have HIV infection.

==References==
{{Reflist|2}}
{{WH}}
{{WS}}

[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Gynecology]]
[[Category:Emergency medicine]]
[[Category:Infectious disease]]

Bacterial vaginosis medical therapy

2021-09-16T18:48:56Z

Dr.Nuha: /* Antimicrobial Regimen */

__NOTOC__
{{Bacterial vaginosis}}

{{CMG}}; {{AE}} {{SaraM}}

==Overview==
Antimicrobial therapy is recommended for all symptomatic women and high risk asymptomatic pregnant women with bacterial vaginosis. [[Metronidazole]] is the drug of choice in pregnant patients.<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref>

==Medical Therapy==
Treatment is recommended for women with symptoms. Other potential benefits to treatment include reduction in the risk for acquiring ''[[trachoma|C. trachomatis]]'', ''[[gonorrhea|N. gonorrhea]]'', ''[[trichomoniasis|T. vaginalis]]'', [[HIV]], and [[herpes simplex|herpes simplex type 2]].<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref>
===Management of Sex Partner===
Data from clinical trials indicate that a woman’s response to therapy and the likelihood of relapse or recurrence are not affected by treatment of her sex partner. Therefore, routine treatment of sex partners is not recommended.<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref>

===Pregnancy===
Treatment is recommended for all symptomatic pregnant women. Treatment of asymptomatic BV among pregnant women who are at high risk for preterm delivery (previous preterm birth) is recommended.<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref>
===Follow-Up===
Follow-up visits are unnecessary if symptoms resolve. Because persistent and recurrent BV are common, women should be advised to return for evaluation if symptoms recur.<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref>

===Antimicrobial Regimen===

:*'''1. Bacterial Vaginosis Treatment'''<ref>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref>
::*Preferred regimen (1): [[Metronidazole]] 500 mg PO bid for 7 days
::*Preferred regimen (2): [[Metronidazole]] gel 0.75%, one full applicator (5 g) intravaginally, qd for 5 days
::*Preferred regimen (3): [[Clindamycin]] cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days
::*Alternative regimen (1): [[Tinidazole]] 2 g PO qd for 2 days
::*Alternative regimen (2): [[Tinidazole]] 1 g PO qd for 5 days
::*Alternative regimen (3): [[Clindamycin]] 300 mg PO bid for 7 days
::*Alternative regimen (4): [[Clindamycin]] ovules 100 mg intravaginally once at bedtime for 3 days
::*Alternative regimen (5)''':''' [[Secnidazole]] 2 g PO granules in a single dose
::*Note: [[Clindamycin]] ovules use an oleaginous base that might weaken latex or rubber products (e.g., condoms and vaginal contraceptive diaphragms). Use of such products within 72 hours following treatment with clindamycin ovules is not recommended.
::*Note: [[Secnidazole]] granules should be sprinkled onto unsweetened applesauce, yogurt, or pudding before ingestion. A glass of water can be taken after administration to aid in swallowing.
:*'''2. Management of Sex Partners'''
::*Routine treatment of sex partners is not recommended.
:*'''3. Special Considerations'''
::*'''3.1 Allergy, Intolerance, or Adverse Reactions'''
:::*Intravaginal [[Clindamycin]] cream is preferred in case of allergy or intolerance to [[Metronidazole]] or [[Tinidazole]]. Intravaginal [[Metronidazole]] gel can be considered for women who are not allergic to [[Metronidazole]] but do not tolerate oral metronidazole. It is advised to avoid consuming alcohol during treatment with nitroimidazoles. To reduce the possibility of a disulfiram-like reaction, abstinence from alcohol use should continue for 24 hours after completion of metronidazole or 72 hours after completion of tinidazole.
::*'''3.2 Pregnancy'''
:::*Preferred regimen (1): [[Metronidazole]] 500 mg PO bid for 7 days
:::*Preferred regimen (2): [[Metronidazole]] gel 0.75%, one full applicator (5 g) intravaginally, qd for 5 days
:::*Preferred regimen (3): oral [[clindamycin]] 300 mg BID for 7 days (data demonstrate that this treatment approach is safe for pregnant women)
:::*Note: [[Tinidazole]] should be avoided during pregnancy
:::*Note: routine screening for BV among asymptomatic pregnant women at high or low risk for preterm delivery for preventing preterm birth is not recommended.
:::*[[Breastfeeding]] mothers should be deferring breastfeeding for 12–24 hours after receiving a single 2-g dose of [[metronidazole]]. Lower doses produce a lower concentration in breast milk and are considered compatible with [[breastfeeding]]
::*'''3.3 HIV Infection'''
:::*Women with HIV who have BV should receive the same treatment regimen as those who do not have HIV infection.

==References==
{{Reflist|2}}
{{WH}}
{{WS}}

[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Gynecology]]
[[Category:Emergency medicine]]
[[Category:Infectious disease]]

Bacterial vaginosis medical therapy

2021-09-16T18:25:11Z

Dr.Nuha: /* Antimicrobial Regimen */

__NOTOC__
{{Bacterial vaginosis}}

{{CMG}}; {{AE}} {{SaraM}}

==Overview==
Antimicrobial therapy is recommended for all symptomatic women and high risk asymptomatic pregnant women with bacterial vaginosis. [[Metronidazole]] is the drug of choice in pregnant patients.<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref>

==Medical Therapy==
Treatment is recommended for women with symptoms. Other potential benefits to treatment include reduction in the risk for acquiring ''[[trachoma|C. trachomatis]]'', ''[[gonorrhea|N. gonorrhea]]'', ''[[trichomoniasis|T. vaginalis]]'', [[HIV]], and [[herpes simplex|herpes simplex type 2]].<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref>
===Management of Sex Partner===
Data from clinical trials indicate that a woman’s response to therapy and the likelihood of relapse or recurrence are not affected by treatment of her sex partner. Therefore, routine treatment of sex partners is not recommended.<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref>

===Pregnancy===
Treatment is recommended for all symptomatic pregnant women. Treatment of asymptomatic BV among pregnant women who are at high risk for preterm delivery (previous preterm birth) is recommended.<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref>
===Follow-Up===
Follow-up visits are unnecessary if symptoms resolve. Because persistent and recurrent BV are common, women should be advised to return for evaluation if symptoms recur.<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref>

===Antimicrobial Regimen===

:*'''1. Bacterial Vaginosis Treatment'''<ref>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref>
::*Preferred regimen (1): [[Metronidazole]] 500 mg PO bid for 7 days
::*Preferred regimen (2): [[Metronidazole]] gel 0.75%, one full applicator (5 g) intravaginally, qd for 5 days
::*Preferred regimen (3): [[Clindamycin]] cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days
::*Alternative regimen (1): [[Tinidazole]] 2 g PO qd for 2 days
::*Alternative regimen (2): [[Tinidazole]] 1 g PO qd for 5 days
::*Alternative regimen (3): [[Clindamycin]] 300 mg PO bid for 7 days
::*Alternative regimen (4): [[Clindamycin]] ovules 100 mg intravaginally once at bedtime for 3 days
::*Alternative regimen (5)''':''' [[Secnidazole]] 2 g PO granules in a single dose
::*Note: [[Clindamycin]] ovules use an oleaginous base that might weaken latex or rubber products (e.g., condoms and vaginal contraceptive diaphragms). Use of such products within 72 hours following treatment with clindamycin ovules is not recommended.
::*Note: '''[[Secnidazole]]''' granules should be sprinkled onto unsweetened applesauce, yogurt, or pudding before ingestion. A glass of water can be taken after administration to aid in swallowing.
:*'''2. Management of Sex Partners'''
::*Routine treatment of sex partners is not recommended.
:*'''3. Special Considerations'''
::*'''3.1 Allergy, Intolerance, or Adverse Reactions'''
:::*Intravaginal [[Clindamycin]] cream is preferred in case of allergy or intolerance to [[Metronidazole]] or [[Tinidazole]]. Intravaginal [[Metronidazole]] gel can be considered for women who are not allergic to [[Metronidazole]] but do not tolerate oral metronidazole. It is advised to avoid consuming alcohol during treatment with nitroimidazoles. To reduce the possibility of a disulfiram-like reaction, abstinence from alcohol use should continue for 24 hours after completion of metronidazole or 72 hours after completion of tinidazole.
::*'''3.2 Pregnancy'''
:::*Preferred regimen (1): [[Metronidazole]] 500 mg PO bid for 7 days
:::*Preferred regimen (2): [[Metronidazole]] gel 0.75%, one full applicator (5 g) intravaginally, qd for 5 days
:::*Note: [[Tinidazole]] should be avoided during pregnancy
::*'''3.3 HIV Infection'''
:::*Women with HIV who have BV should receive the same treatment regimen as those who do not have HIV infection.

==References==
{{Reflist|2}}
{{WH}}
{{WS}}

[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Gynecology]]
[[Category:Emergency medicine]]
[[Category:Infectious disease]]

Bacterial vaginosis medical therapy

2021-09-16T18:24:49Z

Dr.Nuha: /* Antimicrobial Regimen */

__NOTOC__
{{Bacterial vaginosis}}

{{CMG}}; {{AE}} {{SaraM}}

==Overview==
Antimicrobial therapy is recommended for all symptomatic women and high risk asymptomatic pregnant women with bacterial vaginosis. [[Metronidazole]] is the drug of choice in pregnant patients.<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref>

==Medical Therapy==
Treatment is recommended for women with symptoms. Other potential benefits to treatment include reduction in the risk for acquiring ''[[trachoma|C. trachomatis]]'', ''[[gonorrhea|N. gonorrhea]]'', ''[[trichomoniasis|T. vaginalis]]'', [[HIV]], and [[herpes simplex|herpes simplex type 2]].<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref>
===Management of Sex Partner===
Data from clinical trials indicate that a woman’s response to therapy and the likelihood of relapse or recurrence are not affected by treatment of her sex partner. Therefore, routine treatment of sex partners is not recommended.<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref>

===Pregnancy===
Treatment is recommended for all symptomatic pregnant women. Treatment of asymptomatic BV among pregnant women who are at high risk for preterm delivery (previous preterm birth) is recommended.<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref>
===Follow-Up===
Follow-up visits are unnecessary if symptoms resolve. Because persistent and recurrent BV are common, women should be advised to return for evaluation if symptoms recur.<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref>

===Antimicrobial Regimen===

:*'''1. Bacterial Vaginosis Treatment'''<ref>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref>
::*Preferred regimen (1): [[Metronidazole]] 500 mg PO bid for 7 days
::*Preferred regimen (2): [[Metronidazole]] gel 0.75%, one full applicator (5 g) intravaginally, qd for 5 days
::*Preferred regimen (3): [[Clindamycin]] cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days
::*Alternative regimen (1): [[Tinidazole]] 2 g PO qd for 2 days
::*Alternative regimen (2): [[Tinidazole]] 1 g PO qd for 5 days
::*Alternative regimen (3): [[Clindamycin]] 300 mg PO bid for 7 days
::*Alternative regimen (4): [[Clindamycin]] ovules 100 mg intravaginally once at bedtime for 3 days
::*Alternative regimen (5)''': [[Secnidazole]]''' 2 g PO granules in a single dose
::*Note: [[Clindamycin]] ovules use an oleaginous base that might weaken latex or rubber products (e.g., condoms and vaginal contraceptive diaphragms). Use of such products within 72 hours following treatment with clindamycin ovules is not recommended.
::*Note: '''[[Secnidazole]]''' granules should be sprinkled onto unsweetened applesauce, yogurt, or pudding before ingestion. A glass of water can be taken after administration to aid in swallowing.
:*'''2. Management of Sex Partners'''
::*Routine treatment of sex partners is not recommended.
:*'''3. Special Considerations'''
::*'''3.1 Allergy, Intolerance, or Adverse Reactions'''
:::*Intravaginal [[Clindamycin]] cream is preferred in case of allergy or intolerance to [[Metronidazole]] or [[Tinidazole]]. Intravaginal [[Metronidazole]] gel can be considered for women who are not allergic to [[Metronidazole]] but do not tolerate oral metronidazole. It is advised to avoid consuming alcohol during treatment with nitroimidazoles. To reduce the possibility of a disulfiram-like reaction, abstinence from alcohol use should continue for 24 hours after completion of metronidazole or 72 hours after completion of tinidazole.
::*'''3.2 Pregnancy'''
:::*Preferred regimen (1): [[Metronidazole]] 500 mg PO bid for 7 days
:::*Preferred regimen (2): [[Metronidazole]] gel 0.75%, one full applicator (5 g) intravaginally, qd for 5 days
:::*Note: [[Tinidazole]] should be avoided during pregnancy
::*'''3.3 HIV Infection'''
:::*Women with HIV who have BV should receive the same treatment regimen as those who do not have HIV infection.

==References==
{{Reflist|2}}
{{WH}}
{{WS}}

[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Gynecology]]
[[Category:Emergency medicine]]
[[Category:Infectious disease]]

Bacterial vaginosis medical therapy

2021-09-16T18:24:20Z

Dr.Nuha: /* Antimicrobial Regimen */

__NOTOC__
{{Bacterial vaginosis}}

{{CMG}}; {{AE}} {{SaraM}}

==Overview==
Antimicrobial therapy is recommended for all symptomatic women and high risk asymptomatic pregnant women with bacterial vaginosis. [[Metronidazole]] is the drug of choice in pregnant patients.<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref>

==Medical Therapy==
Treatment is recommended for women with symptoms. Other potential benefits to treatment include reduction in the risk for acquiring ''[[trachoma|C. trachomatis]]'', ''[[gonorrhea|N. gonorrhea]]'', ''[[trichomoniasis|T. vaginalis]]'', [[HIV]], and [[herpes simplex|herpes simplex type 2]].<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref>
===Management of Sex Partner===
Data from clinical trials indicate that a woman’s response to therapy and the likelihood of relapse or recurrence are not affected by treatment of her sex partner. Therefore, routine treatment of sex partners is not recommended.<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref>

===Pregnancy===
Treatment is recommended for all symptomatic pregnant women. Treatment of asymptomatic BV among pregnant women who are at high risk for preterm delivery (previous preterm birth) is recommended.<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref>
===Follow-Up===
Follow-up visits are unnecessary if symptoms resolve. Because persistent and recurrent BV are common, women should be advised to return for evaluation if symptoms recur.<ref name="CDC_MMWR-2015">Center for Disease Control and prevention. Mortality and morbidity weekly reports. Sexually transmitted disease treatment guideline. (2015) https://www.cdc.gov/std/tg2015/tg-2015-print.pdf Accessed on October 20, 2016</ref>

===Antimicrobial Regimen===

:*'''1. Bacterial Vaginosis Treatment'''<ref>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref>
::*Preferred regimen (1): [[Metronidazole]] 500 mg PO bid for 7 days
::*Preferred regimen (2): [[Metronidazole]] gel 0.75%, one full applicator (5 g) intravaginally, qd for 5 days
::*Preferred regimen (3): [[Clindamycin]] cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days
::*Alternative regimen (1): [[Tinidazole]] 2 g PO qd for 2 days
::*Alternative regimen (2): [[Tinidazole]] 1 g PO qd for 5 days
::*Alternative regimen (3): [[Clindamycin]] 300 mg PO bid for 7 days
::*Alternative regimen (4): [[Clindamycin]] ovules 100 mg intravaginally once at bedtime for 3 days
::*'''[[Secnidazole]]''' 2 g PO granules in a single dose
::*Note: [[Clindamycin]] ovules use an oleaginous base that might weaken latex or rubber products (e.g., condoms and vaginal contraceptive diaphragms). Use of such products within 72 hours following treatment with clindamycin ovules is not recommended.
::*Note: '''[[Secnidazole]]''' granules should be sprinkled onto unsweetened applesauce, yogurt, or pudding before ingestion. A glass of water can be taken after administration to aid in swallowing.
:*'''2. Management of Sex Partners'''
::*Routine treatment of sex partners is not recommended.
:*'''3. Special Considerations'''
::*'''3.1 Allergy, Intolerance, or Adverse Reactions'''
:::*Intravaginal [[Clindamycin]] cream is preferred in case of allergy or intolerance to [[Metronidazole]] or [[Tinidazole]]. Intravaginal [[Metronidazole]] gel can be considered for women who are not allergic to [[Metronidazole]] but do not tolerate oral metronidazole. It is advised to avoid consuming alcohol during treatment with nitroimidazoles. To reduce the possibility of a disulfiram-like reaction, abstinence from alcohol use should continue for 24 hours after completion of metronidazole or 72 hours after completion of tinidazole.
::*'''3.2 Pregnancy'''
:::*Preferred regimen (1): [[Metronidazole]] 500 mg PO bid for 7 days
:::*Preferred regimen (2): [[Metronidazole]] gel 0.75%, one full applicator (5 g) intravaginally, qd for 5 days
:::*Note: [[Tinidazole]] should be avoided during pregnancy
::*'''3.3 HIV Infection'''
:::*Women with HIV who have BV should receive the same treatment regimen as those who do not have HIV infection.

==References==
{{Reflist|2}}
{{WH}}
{{WS}}

[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Gynecology]]
[[Category:Emergency medicine]]
[[Category:Infectious disease]]

Gonorrhea medical therapy

2021-09-02T23:50:51Z

Dr.Nuha: /* Medical Therapy */

__NOTOC__
{{Gonorrhea}}
{{CMG}}; {{AE}} {{SaraM}} {{nuha}}

==Overview==
The mainstay of therapy for gonococcal infections is [[antimicrobial|antimicrobial therapy]]. Gonorrhea treatment is complicated by the ability of ''N. gonorrhoeae'' to develop resistance to [[antimicrobials]]; accordingly, [[Ceftriaxone]] is standard of care for treatment of gonorrhea. Routinely combining [[ceftriaxone]] with [[azithromycin]] for treatment of gonorrhea is no longer recommended.

==Medical Therapy==

*The mainstay of therapy for gonococcal infections is [[antimicrobial|antimicrobial therapy]].<ref name="urlUpdate to CDCs Treatment Guidelines for Gonococcal Infection, 2020 | MMWR2">{{cite web |url=https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm#B1_down |title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 | MMWR |format= |work= |accessdate=}}</ref>

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
|+
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF|Type of gonococcal infection}}
! style="background: #4479BA; width: 450px;" |{{fontcolor|#FFF|Regimen}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Uncomplicated Recommended regimen for urogenital, rectal, or pharyngeal gonorrhea'''
| style="padding: 5px 5px; background: #F5F5F5;" | 

*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)

*[[ceftriaxone]] 1 g IM, for persons weighing ≥150 kg (300 lb).
*[[Chlamydial]] co-infection:
**add [[doxycycline]] 100 mg PO BID 7 days. (In pregnancy [[azithromycin]] 1 g as a single dose)
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Uncomplicated Alternative regimen'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Gentamicin]] 240 mg IM as a single dose plus [[azithromycin]] 2 g PO as a single dose OR

*[[Cefixime]] 800 mg PO as a single dose.

(Add [[doxycycline]] 100 mg PO BID for 7 days if [[Chlamydia infection|chlamydial]] infection has not been excluded)

(During [[pregnancy]], [[azithromycin]] 1 g as a single dose is recommended to treat chlamydia).
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Alternative regimens for severe Cephalosporin allergy or ceftriaxone not available'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] is not available:
**A different injectable [[cephalosporin]] like [[ceftizoxime]] [500 mg IM], [[cefoxitin]] [2 g IM with [[probenecid]] 1 g PO], or [[cefotaxime]] [500 mg IM]) can be used.
**[[cefixime]] 800 mg PO OD if the other injectable [[cephalosporin]] not available.
*Severe Cephalosporin allergy
**[[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
**[[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose (alternative)
*Test of cure should be performed after 1 week
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Arthritis and arthritis-dermatitis syndrome '''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] 1 g IM/IV q24h for 7 days
*[[Cefotaxime]] 1 g IV q8h for 7 days (alternative)
*[[Ceftizoxime]] 1 g IV q8h for 7 days
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Gonococcal meningitis and endocarditis'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] 1-2 g IV q 12-24 h for 10-14 days
|}

===Antimicrobial Regimen===

:*'''Neisseria gonorrhoeae treatment'''<ref>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref><ref name="urlUpdate to CDCs Treatment Guidelines for Gonococcal Infection, 2020 | MMWR">{{cite web |url=https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm#B1_down |title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 | MMWR |format= |work= |accessdate=}}</ref><ref name="urlGonococcal Infections Among Adolescents and Adults - STI Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/gonorrhea-adults.htm |title=Gonococcal Infections Among Adolescents and Adults - STI Treatment Guidelines |format= |work= |accessdate=}}</ref>
::*1. '''Gonococcal infections in adolescents and adults'''
:::*1.1 '''Uncomplicated gonococcal infections of the urogenital, rectal, or pharyngeal gonorrhea.'''
::::*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
::::*[[ceftriaxone]] 1 g IM, for persons weighing ≥150 kg (300 lb).
::::*[[Chlamydial]] co-infection:
::::**add [[doxycycline]] 100 mg PO BID 7 days. (In pregnancy [[azithromycin]] 1 g as a single dose)
:::*1.2 '''Uncomplicated gonococcal infections of the pharynx'''
::::*pharyngeal infection is often asymptomatic and more difficult to eradicate than urogenital or anorectal gonococcal infections and may serve as a reservoir of infection.
::::*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
::::*[[ceftriaxone]] 1 g IM, for persons weighing ≥150 kg (300 lb).
::::*[[Chlamydial]] co-infection:
::::**add [[doxycycline]] 100 mg PO BID 7 days. (In pregnancy [[azithromycin]] 1 g as a single dose)
::::**No reliable alternative treatments are available for pharyngeal gonorrhea. For persons with a history of a beta-lactam allergy, a thorough assessment of the reaction is recommended
:::::*1.2.1 '''Management of sex partners'''
::::::*Expedited partner therapy: oral [[cefixime]] 800 mg orally once plus treatment for [[chlamydia]] is used for treatment of the partner.<ref name="pmid33332296">{{cite journal| author=St Cyr S, Barbee L, Workowski KA, Bachmann LH, Pham C, Schlanger K | display-authors=etal| title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. | journal=MMWR Morb Mortal Wkly Rep | year= 2020 | volume= 69 | issue= 50 | pages= 1911-1916 | pmid=33332296 | doi=10.15585/mmwr.mm6950a6 | pmc=7745960 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33332296 }}</ref>
::::::*Note (1): expedited partner therapy is not routinely recommended for men who have sex with men.
::::::*Note (2): Recent sex partners (i.e., persons having sexual contact with the infected patient within the 60 days preceding onset of symptoms or gonorrhea diagnosis) should be referred for evaluation, testing, and presumptive dual treatment.
::::::*Note (3): If the patient’s last potential sexual exposure was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated.
::::::*Note (4): To avoid reinfection, sex partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sexual partner(s) have completed treatment and after resolution of symptoms, if present.
:::::*1.2.2 '''Allergy, intolerance, and adverse reactions'''
::::::*[[Ceftriaxone]] is not available:
::::::**A different injectable [[cephalosporin]] like [[ceftizoxime]] [500 mg IM], [[cefoxitin]] [2 g IM with [[probenecid]] 1 g PO], or [[cefotaxime]] [500 mg IM]) can be used.
::::::**[[cefixime]] 800 mg orally once can be used for gonococcal therapy if the other injectable [[cephalosporin]] not available.
::::::*Severe Cephalosporin allergy:
::::::**[[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
::::::**[[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose (alternative)
::::::*Note: Use of [[Ceftriaxone]] or [[Cefixime]] is contraindicated in persons with a history of an IgE-mediated penicillin allergy (e.g., anaphylaxis, Stevens Johnson syndrome, and toxic epidermal necrolysis).
:::::*1.2.3 '''Pregnancy'''
:::::**Pregnant women with uncomplicated gonorrheal infection should be treated with the same preferred regimen as the general population.
:::::**Chlamydia coinfection should be treated with azithromycin instead of doxycycline. 
:::::*1.2.4 '''Suspected cephalosporin treatment failure'''
::::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::*Alternative regimen (1): [[Gemifloxacin]] 320 mg PO single dose {{and}} [[Azithromycin]] 2 g PO single dose (when isolates have elevated cephalosporin MICs)
::::::*Alternative regimen (2): [[Gentamicin]] 240 mg IM single dose {{and}} [[Azithromycin]] 2 g PO single dose (when isolates have elevated cephalosporin MICs)
::::::*Alternative regimen (3): [[Ceftriaxone]] 250 mg IM as a single dose {{and}} [[Azithromycin]] 2 g PO as a single dose (failure after treatment with [[Cefixime]] and [[Azithromycin]])
::::::*Note: Treatment failure should be considered in: (1) patients whose symptoms do not resolve within 3–5 days after appropriate treatment and report no sexual contact during the post-treatment follow-up period; (2) patients with a positive test-of-cure (i.e., positive culture ≥ 72 hours or positive NAAT ≥ 7 days after receiving recommended treatment) when no sexual contact is reported during the post-treatment follow-up period; (3) persons who have a positive culture on test-of-cure (if obtained) if there is evidence of decreased susceptibility to cephalosporins on antimicrobial susceptibility testing, regardless of whether sexual contact is reported during the post-treatment follow-up period.
:::*1.3 '''Gonococcal conjunctivitis'''
::::*Preferred regimen: a single 1 g IM dose of [[Ceftriaxone|ceftriaxone.]]
:::::Note: A topical fluoroquinolone, saline irrigation are also recommended.
:::::*1.3.1 '''Management of sex partners'''
::::::*Patients should be instructed to refer their sex partners for evaluation and treatment.
:::*1.4 '''Disseminated gonococcal infection'''
:::::*1.4.1 '''Arthritis and arthritis-dermatitis syndrome '''
::::::*Preferred regimen: [[Ceftriaxone]] 1 g IM/IV q24h for 7 days.
::::::*Alternative regimen (1): [[Cefotaxime]] 1 g IV q8h for 7 days
::::::*Alternative regimen (2): [[Ceftizoxime]] 1 g IV q8h for 7 days.
::::::*Note: Once clinical improvement with [[ceftriaxone]] is noted for 24 to 48 hours, the regimen can be completed with intramuscular [[ceftriaxone]] (500 mg for individuals <150 kg or 1 g for individuals ≥150 kg) every 24 hours.
:::::*1.4.2 '''Gonococcal meningitis and endocarditis'''
::::::*Preferred regimen: [[Ceftriaxone]] 1-2 g IV q 12-24 h for 10-14 days
::*2. '''Gonococcal infections among neonates'''<ref name="pmid333322962">{{cite journal| author=St Cyr S, Barbee L, Workowski KA, Bachmann LH, Pham C, Schlanger K | display-authors=etal| title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. | journal=MMWR Morb Mortal Wkly Rep | year= 2020 | volume= 69 | issue= 50 | pages= 1911-1916 | pmid=33332296 | doi=10.15585/mmwr.mm6950a6 | pmc=7745960 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33332296 }}</ref><ref name="pmid26042815">{{cite journal| author=Workowski KA, Bolan GA, Centers for Disease Control and Prevention| title=Sexually transmitted diseases treatment guidelines, 2015. | journal=MMWR Recomm Rep | year= 2015 | volume= 64 | issue= RR-03 | pages= 1-137 | pmid=26042815 | doi= | pmc=5885289 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26042815 }}</ref>
:::*2.1 '''Ophthalmia neonatorum caused by N. gonorrhoeae'''
::::*Preferred regimen: [[Ceftriaxone]] 25–50 mg/kg IV or IM in a single dose (not to exceed 250 mg)
::::*Recommended Regimen for prevention '''Erythromycin''' '''0.5% ophthalmic ointment''' in each eye in a single application at birth
:::::*2.1.1 '''Management of mothers and their sex partners'''
::::::*Mothers of infants with ophthalmia neonatorum caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
:::*2.2 '''Disseminated gonococcal infection and gonococcal scalp abscesses in neonates'''
::::*Preferred regimen (1): [[Ceftriaxone]] 25-50 mg/kg/day IM/IV q24h for 7 days
::::*Preferred regimen (2): [[Cefotaxime]] 25 mg/kg IM/IV q12h for 7 days.
::::*Note (1): The duration of treatment is 10-14 days if meningitis is documented.
::::*Note (2): Ceftriaxone should be administered cautiously to hyperbilirubinemic infants, especially those born prematurely.
:::::*2.2.1 '''Management of mothers and their sex partners'''
::::::*Mothers of infants who have DGI or scalp abscesses caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
:::*2.3 '''Neonates born to mothers who have gonococcal infection'''
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose. (not to exceed 250 mg)
:::::*2.3.1 '''Management of mothers and their sex partners'''
::::::*Mothers who have gonorrhea and their sex partners should be evaluated, tested, and presumptively treated for gonorrhea.
::*3. '''Gonococcal infections among infants and children'''
:::*3.1 '''Infants and children who weigh ≤ 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
::::*Preferred regimen: '''[[Ceftriaxone]]''' 25–50 mg/kg IV or IM in a single dose. (not to exceed 250 mg)
:::*3.2 '''Children who weigh > 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
::::*Preferred regimen: [[Ceftriaxone]] 500 mg IM in a single dose.
::::*Alternative regimen: '''[[Gentamicin]]''' 240 mg IM in a single dose PLUS '''[[Azithromycin]]''' 2 g PO in a single dose OR '''[[Cefixime]]''' 800 mg PO in a single dose
:::*3.3 '''Children who weigh ≤ 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen: [[Ceftriaxone]] 50 mg/kg IM or IV q24h for 7 days (maximum dose: 2 g)
:::*3.4 '''Children who weigh > 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen: [[Ceftriaxone]] 1 g IM or IV q24h for 7 days.

===Follow-Up===
A test-of-cure is not needed for patients who receive a diagnosis of uncomplicated [[urogenital]] or [[rectal]] gonorrhea who are treated with any of the recommended or alternative regimens. However, any person with [[pharyngeal]] gonorrhea who is treated with an alternative regimen should return 14 days after treatment for a test-of-cure using either culture or [[NAAT]]. If the [[NAAT]] is positive, effort should be made to perform a confirmatory culture before commencing retreatment.<ref name="CDC-Guidline"> Centers for disease control and prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm Accessed on September 14, 2016</ref>

*All positive cultures for test-of-cure should undergo [[antibiotic resistance|antimicrobial susceptibility]] testing
*Men or women who have been treated for gonorrhea should be retested 3 months after treatment regardless of whether they believe their sex partners were treated
*If retesting at 3 months is not possible, clinicians should retest whenever patients next present for medical care within 12 months following initial treatment

==References==
{{Reflist|2}}

{{WH}}
{{WS}}

[[Category:Gynecology]]
[[Category:FinalQCRequired]]
[[Category:Emergency mdicine]]
[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Rheumatology]]
[[Category:Dermatology]]
[[Category:Neurology]]
[[Category:Cardiology]]
[[Category:Urology]]
[[Category:Gastroenterology]]

Gonorrhea screening

2021-08-21T19:52:01Z

Dr.Nuha: /* Overview */

__NOTOC__
{{Gonorrhea}}
{{CMG}}; {{AE}} {{SaraM}}

==Overview==
The U.S. Preventive Services and Task Force (USSTF) recommends screening for gonorrhea in sexually active women age 24 years and younger and in older women who are at increased risk for infection. Currently available evidence is insufficient to assess the balance of benefits and harms of screening for gonorrhea in [[heterosexual]] men. USSTF recommends at least annual screenings for gonorrhea among men who have sex with men (MSM).

==Screening==
The U.S. Preventive Services and Task Force (USSTF) recommends screening for gonorrhea in sexually active women age 24 years and younger and in older women who are at increased risk for infection.
The table below outlines the screening recommendations for gonorrhea.<ref name="STD-guildline">{{cite web | title = 2015 Sexually Transmitted Diseases Treatment Guidelines (CDC) | url = http://www.cdc.gov/std/tg2015/screening-recommendations.htm }}</ref><ref name="Gonorrhea-recomm">Workowski KA, Bolan GA. Sexually transmitted diseases treat- ment guidelines, 2015. MMWR Recomm Rep 2015;64:60–68.</ref><ref name="USPSTF">US preventive services task forces. Gonorrhea and chlamydia screening (2014) https://www.uspreventiveservicestaskforce.org/Page/Document/ClinicalSummaryFinal/chlamydia-and-gonorrhea-screening Accessed on September 28, 2016</ref><ref name="urlGonococcal Infections Among Adolescents and Adults - STI Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/gonorrhea-adults.htm |title=Gonococcal Infections Among Adolescents and Adults - STI Treatment Guidelines |format= |work= |accessdate=}}</ref>

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
|+
! style="background: #4479BA; width: 150px;" |{{fontcolor|#FFF|Population}}
! style="background: #4479BA; width: 500px;" |{{fontcolor|#FFF|Screening Recommendations}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Women'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*Sexually active women under 25 years of age
*Sexually active women age 25 years and older if at increased risk
**Prior history of sexually transmitted infection
**A new sex partner
**More than one sex partner
**A sex partner with concurrent partners
**A sex partner who has a sexually transmitted infection
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Men Who have Sex With Men (MSM)'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*At least annually for sexually active MSM at sites of contact (urethra, rectum, pharynx) regardless of condom use
*Every 3 to 6 months if at increased risk
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Pregnant women'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*All pregnant women under 25 years of age and older women if at increased risk
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''HIV positive patients'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*For sexually active individuals, screen at first HIV evaluation, and at least annually
*More frequent screening may be indicated depending on individual risk behaviors and the local epidemiology
|}

==References==
{{Reflist|2}}

{{WH}}
{{WS}}

[[Category:Gynecology]]
[[Category:FinalQCRequired]]
[[Category:Emergency mdicine]]
[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Rheumatology]]
[[Category:Dermatology]]
[[Category:Neurology]]
[[Category:Cardiology]]
[[Category:Urology]]
[[Category:Gastroenterology]]

Gonorrhea medical therapy

2021-08-21T19:44:13Z

Dr.Nuha: /* Antimicrobial Regimen */

__NOTOC__
{{Gonorrhea}}
{{CMG}}; {{AE}} {{SaraM}} {{nuha}}

==Overview==
The mainstay of therapy for gonococcal infections is [[antimicrobial|antimicrobial therapy]]. Gonorrhea treatment is complicated by the ability of ''N. gonorrhoeae'' to develop resistance to [[antimicrobials]]; accordingly, [[Ceftriaxone]] is standard of care for treatment of gonorrhea. Routinely combining [[ceftriaxone]] with [[azithromycin]] for treatment of gonorrhea is no longer recommended.

==Medical Therapy==

*The mainstay of therapy for gonococcal infections is [[antimicrobial|antimicrobial therapy]].<ref name="urlUpdate to CDCs Treatment Guidelines for Gonococcal Infection, 2020 | MMWR2">{{cite web |url=https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm#B1_down |title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 | MMWR |format= |work= |accessdate=}}</ref>

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
|+
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF|Type of gonococcal infection}}
! style="background: #4479BA; width: 450px;" |{{fontcolor|#FFF|Regimen}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Uncomplicated Recommended regimen for urogenital, rectal, or pharyngeal gonorrhea'''
| style="padding: 5px 5px; background: #F5F5F5;" | 

*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)

*For persons weighing ≥150 kg (300 lb), 1 g of IM [[ceftriaxone]] should be administered.
*[[Chlamydial]] co-infection:
**add [[doxycycline]] 100 mg orally twice daily for 7 days. ([[azithromycin]] 1 g as a single dose is recommended to treat chlamydia During pregnancy)
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Uncomplicated Alternative regimen'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Gentamicin]] 240 mg IM as a single dose plus [[azithromycin]] 2 g orally as a single dose OR

*[[Cefixime]] 800 mg orally as a single dose.

(Add [[doxycycline]] 100 mg orally twice daily for 7 days f [[Chlamydia infection|chlamydial]] infection has not been excluded)

(During [[pregnancy]], [[azithromycin]] 1 g as a single dose is recommended to treat chlamydia.
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Alternative regimens for severe Cephalosporin allergy or ceftriaxone not available'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] is not available:
**A different injectable [[cephalosporin]] like [[ceftizoxime]] [500 mg IM], [[cefoxitin]] [2 g IM with [[probenecid]] 1 g orally], or [[cefotaxime]] [500 mg IM]) can be used.
**[[cefixime]] 800 mg orally once can be used for gonococcal therapy if the other injectable [[cephalosporin]] not available.
*Severe Cephalosporin allergy
**[[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
**[[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose (alternative)
*Test of cure should be performed after 1 week
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Arthritis and arthritis-dermatitis syndrome '''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] 1 g IM/IV q24h for 7 days
*[[Cefotaxime]] 1 g IV q8h for 7 days (alternative)
*[[Ceftizoxime]] 1 g IV q8h for 7 days
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Gonococcal meningitis and endocarditis'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] 1-2 g IV q 12-24 h for 10-14 days
|}

===Antimicrobial Regimen===

:*'''Neisseria gonorrhoeae treatment'''<ref>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref><ref name="urlUpdate to CDCs Treatment Guidelines for Gonococcal Infection, 2020 | MMWR">{{cite web |url=https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm#B1_down |title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 | MMWR |format= |work= |accessdate=}}</ref><ref name="urlGonococcal Infections Among Adolescents and Adults - STI Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/gonorrhea-adults.htm |title=Gonococcal Infections Among Adolescents and Adults - STI Treatment Guidelines |format= |work= |accessdate=}}</ref>
::*1. '''Gonococcal infections in adolescents and adults'''
:::*1.1 '''Uncomplicated gonococcal infections of the urogenital, rectal, or pharyngeal gonorrhea.'''
::::*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
::::*For persons weighing ≥150 kg (300 lb), 1 g of IM [[ceftriaxone]] should be administered.
::::*[[Chlamydial]] co-infection:
::::**add [[doxycycline]] 100 mg orally twice daily for 7 days. ([[azithromycin]] 1 g as a single dose is recommended to treat chlamydia During pregnancy)
:::*1.2 '''Uncomplicated gonococcal infections of the pharynx'''
::::*pharyngeal infection is often asymptomatic and more difficult to eradicate than urogenital or anorectal gonococcal infections and may serve as a reservoir of infection.
::::*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
::::**For persons weighing ≥150 kg (300 lb), 1 g of IM [[ceftriaxone]] should be administered.
::::**for chlamydia co-infection add [[doxycycline]] 100 mg orally twice a day for 7 days. (During pregnancy, [[azithromycin]] 1 g as a single dose is recommended to treat chlamydia)
::::**No reliable alternative treatments are available for pharyngeal gonorrhea. For persons with a history of a beta-lactam allergy, a thorough assessment of the reaction is recommended
:::::*1.2.1 '''Management of sex partners'''
::::::*Expedited partner therapy: oral [[cefixime]] 800 mg orally once plus treatment for [[chlamydia]] is used for treatment of the partner.<ref name="pmid33332296">{{cite journal| author=St Cyr S, Barbee L, Workowski KA, Bachmann LH, Pham C, Schlanger K | display-authors=etal| title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. | journal=MMWR Morb Mortal Wkly Rep | year= 2020 | volume= 69 | issue= 50 | pages= 1911-1916 | pmid=33332296 | doi=10.15585/mmwr.mm6950a6 | pmc=7745960 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33332296 }}</ref>
::::::*Note (1): expedited partner therapy is not routinely recommended for men who have sex with men.
::::::*Note (2): Recent sex partners (i.e., persons having sexual contact with the infected patient within the 60 days preceding onset of symptoms or gonorrhea diagnosis) should be referred for evaluation, testing, and presumptive dual treatment.
::::::*Note (3): If the patient’s last potential sexual exposure was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated.
::::::*Note (4): To avoid reinfection, sex partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sexual partner(s) have completed treatment and after resolution of symptoms, if present.
:::::*1.2.2 '''Allergy, intolerance, and adverse reactions'''
::::::*[[Ceftriaxone]] is not available:
::::::**A different injectable [[cephalosporin]] like [[ceftizoxime]] [500 mg IM], [[cefoxitin]] [2 g IM with [[probenecid]] 1 g orally], or [[cefotaxime]] [500 mg IM]) can be used.
::::::**[[cefixime]] 800 mg orally once can be used for gonococcal therapy if the other injectable [[cephalosporin]] not available.
::::::*Severe Cephalosporin allergy:
::::::**[[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
::::::**[[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose (alternative)
::::::*Note: Use of [[Ceftriaxone]] or [[Cefixime]] is contraindicated in persons with a history of an IgE-mediated penicillin allergy (e.g., anaphylaxis, Stevens Johnson syndrome, and toxic epidermal necrolysis).
:::::*1.2.3 '''Pregnancy'''
:::::**Pregnant women with uncomplicated gonorrheal infection should be treated with the same preferred regimen as the general population.
:::::**Chlamydia coinfection should be treated with azithromycin instead of doxycycline. 
:::::*1.2.4 '''Suspected cephalosporin treatment failure'''
::::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::*Alternative regimen (1): [[Gemifloxacin]] 320 mg PO single dose {{and}} [[Azithromycin]] 2 g PO single dose (when isolates have elevated cephalosporin MICs)
::::::*Alternative regimen (2): [[Gentamicin]] 240 mg IM single dose {{and}} [[Azithromycin]] 2 g PO single dose (when isolates have elevated cephalosporin MICs)
::::::*Alternative regimen (3): [[Ceftriaxone]] 250 mg IM as a single dose {{and}} [[Azithromycin]] 2 g PO as a single dose (failure after treatment with [[Cefixime]] and [[Azithromycin]])
::::::*Note: Treatment failure should be considered in: (1) patients whose symptoms do not resolve within 3–5 days after appropriate treatment and report no sexual contact during the post-treatment follow-up period; (2) patients with a positive test-of-cure (i.e., positive culture ≥ 72 hours or positive NAAT ≥ 7 days after receiving recommended treatment) when no sexual contact is reported during the post-treatment follow-up period; (3) persons who have a positive culture on test-of-cure (if obtained) if there is evidence of decreased susceptibility to cephalosporins on antimicrobial susceptibility testing, regardless of whether sexual contact is reported during the post-treatment follow-up period.
:::*1.3 '''Gonococcal conjunctivitis'''
::::*Preferred regimen: a single 1 g IM dose of [[Ceftriaxone|ceftriaxone.]]
:::::Note: A topical fluoroquinolone, saline irrigation are also recommended.
:::::*1.3.1 '''Management of sex partners'''
::::::*Patients should be instructed to refer their sex partners for evaluation and treatment.
:::*1.4 '''Disseminated gonococcal infection'''
:::::*1.4.1 '''Arthritis and arthritis-dermatitis syndrome '''
::::::*Preferred regimen: [[Ceftriaxone]] 1 g IM/IV q24h for 7 days.
::::::*Alternative regimen (1): [[Cefotaxime]] 1 g IV q8h for 7 days
::::::*Alternative regimen (2): [[Ceftizoxime]] 1 g IV q8h for 7 days.
::::::*Note: Once clinical improvement with [[ceftriaxone]] is noted for 24 to 48 hours, the regimen can be completed with intramuscular [[ceftriaxone]] (500 mg for individuals <150 kg or 1 g for individuals ≥150 kg) every 24 hours.
:::::*1.4.2 '''Gonococcal meningitis and endocarditis'''
::::::*Preferred regimen: [[Ceftriaxone]] 1-2 g IV q 12-24 h for 10-14 days.
::*2. '''Gonococcal infections among neonates'''<ref name="pmid333322962">{{cite journal| author=St Cyr S, Barbee L, Workowski KA, Bachmann LH, Pham C, Schlanger K | display-authors=etal| title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. | journal=MMWR Morb Mortal Wkly Rep | year= 2020 | volume= 69 | issue= 50 | pages= 1911-1916 | pmid=33332296 | doi=10.15585/mmwr.mm6950a6 | pmc=7745960 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33332296 }}</ref><ref name="pmid26042815">{{cite journal| author=Workowski KA, Bolan GA, Centers for Disease Control and Prevention| title=Sexually transmitted diseases treatment guidelines, 2015. | journal=MMWR Recomm Rep | year= 2015 | volume= 64 | issue= RR-03 | pages= 1-137 | pmid=26042815 | doi= | pmc=5885289 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26042815 }}</ref>
:::*2.1 '''Ophthalmia neonatorum caused by N. gonorrhoeae'''
::::*Preferred regimen: [[Ceftriaxone]] 25–50 mg/kg body weight IV or IM in a single dose, not to exceed 250 mg
::::*Recommended Regimen for prevention '''Erythromycin''' '''0.5% ophthalmic ointment''' in each eye in a single application at birth
:::::*2.1.1 '''Management of mothers and their sex partners'''
::::::*Mothers of infants with ophthalmia neonatorum caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
:::*2.2 '''Disseminated gonococcal infection and gonococcal scalp abscesses in neonates'''
::::*Preferred regimen (1): [[Ceftriaxone]] 25-50 mg/kg/day IM/IV q24h for 7 days
::::*Preferred regimen (2): [[Cefotaxime]] 25 mg/kg IM/IV q12h for 7 days.
::::*Note (1): The duration of treatment is 10-14 days if meningitis is documented.
::::*Note (2): Ceftriaxone should be administered cautiously to hyperbilirubinemic infants, especially those born prematurely.
:::::*2.2.1 '''Management of mothers and their sex partners'''
::::::*Mothers of infants who have DGI or scalp abscesses caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
:::*2.3 '''Neonates born to mothers who have gonococcal infection'''
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 250 mg
:::::*2.3.1 '''Management of mothers and their sex partners'''
::::::*Mothers who have gonorrhea and their sex partners should be evaluated, tested, and presumptively treated for gonorrhea.
::*3. '''Gonococcal infections among infants and children'''
:::*3.1 '''Infants and children who weigh ≤ 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
::::*Preferred regimen: '''[[Ceftriaxone]]''' 25–50 mg/kg body weight IV or IM in a single dose, not to exceed 250 mg IM
:::*3.2 '''Children who weigh > 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
::::*Preferred regimen: [[Ceftriaxone]] 500 mg IM in a single dose.
::::*Alternative regimen: '''[[Gentamicin]]''' 240 mg IM in a single dose PLUS '''[[Azithromycin]]''' 2 g orally in a single dose OR '''[[Cefixime]]''' 800 mg orally in a single dose
:::*3.3 '''Children who weigh ≤ 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen: [[Ceftriaxone]] 50 mg/kg body weight (maximum dose: 2 g) IM or IV in a single dose daily every 24 hours for 7 days
:::*3.4 '''Children who weigh > 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen: [[Ceftriaxone]] 1 g IM or IV in a single dose daily every 24 hours for 7 days.

===Follow-Up===
A test-of-cure is not needed for patients who receive a diagnosis of uncomplicated [[urogenital]] or [[rectal]] gonorrhea who are treated with any of the recommended or alternative regimens. However, any person with [[pharyngeal]] gonorrhea who is treated with an alternative regimen should return 14 days after treatment for a test-of-cure using either culture or [[NAAT]]. If the [[NAAT]] is positive, effort should be made to perform a confirmatory culture before commencing retreatment.<ref name="CDC-Guidline"> Centers for disease control and prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm Accessed on September 14, 2016</ref>

*All positive cultures for test-of-cure should undergo [[antibiotic resistance|antimicrobial susceptibility]] testing
*Men or women who have been treated for gonorrhea should be retested 3 months after treatment regardless of whether they believe their sex partners were treated
*If retesting at 3 months is not possible, clinicians should retest whenever patients next present for medical care within 12 months following initial treatment

==References==
{{Reflist|2}}

{{WH}}
{{WS}}

[[Category:Gynecology]]
[[Category:FinalQCRequired]]
[[Category:Emergency mdicine]]
[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Rheumatology]]
[[Category:Dermatology]]
[[Category:Neurology]]
[[Category:Cardiology]]
[[Category:Urology]]
[[Category:Gastroenterology]]

Gonorrhea medical therapy

2021-08-21T19:43:00Z

Dr.Nuha: /* Follow-Up */

__NOTOC__
{{Gonorrhea}}
{{CMG}}; {{AE}} {{SaraM}} {{nuha}}

==Overview==
The mainstay of therapy for gonococcal infections is [[antimicrobial|antimicrobial therapy]]. Gonorrhea treatment is complicated by the ability of ''N. gonorrhoeae'' to develop resistance to [[antimicrobials]]; accordingly, [[Ceftriaxone]] is standard of care for treatment of gonorrhea. Routinely combining [[ceftriaxone]] with [[azithromycin]] for treatment of gonorrhea is no longer recommended.

==Medical Therapy==

*The mainstay of therapy for gonococcal infections is [[antimicrobial|antimicrobial therapy]].<ref name="urlUpdate to CDCs Treatment Guidelines for Gonococcal Infection, 2020 | MMWR2">{{cite web |url=https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm#B1_down |title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 | MMWR |format= |work= |accessdate=}}</ref>

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
|+
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF|Type of gonococcal infection}}
! style="background: #4479BA; width: 450px;" |{{fontcolor|#FFF|Regimen}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Uncomplicated Recommended regimen for urogenital, rectal, or pharyngeal gonorrhea'''
| style="padding: 5px 5px; background: #F5F5F5;" | 

*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)

*For persons weighing ≥150 kg (300 lb), 1 g of IM [[ceftriaxone]] should be administered.
*[[Chlamydial]] co-infection:
**add [[doxycycline]] 100 mg orally twice daily for 7 days. ([[azithromycin]] 1 g as a single dose is recommended to treat chlamydia During pregnancy)
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Uncomplicated Alternative regimen'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Gentamicin]] 240 mg IM as a single dose plus [[azithromycin]] 2 g orally as a single dose OR

*[[Cefixime]] 800 mg orally as a single dose.

(Add [[doxycycline]] 100 mg orally twice daily for 7 days f [[Chlamydia infection|chlamydial]] infection has not been excluded)

(During [[pregnancy]], [[azithromycin]] 1 g as a single dose is recommended to treat chlamydia.
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Alternative regimens for severe Cephalosporin allergy or ceftriaxone not available'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] is not available:
**A different injectable [[cephalosporin]] like [[ceftizoxime]] [500 mg IM], [[cefoxitin]] [2 g IM with [[probenecid]] 1 g orally], or [[cefotaxime]] [500 mg IM]) can be used.
**[[cefixime]] 800 mg orally once can be used for gonococcal therapy if the other injectable [[cephalosporin]] not available.
*Severe Cephalosporin allergy
**[[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
**[[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose (alternative)
*Test of cure should be performed after 1 week
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Arthritis and arthritis-dermatitis syndrome '''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] 1 g IM/IV q24h for 7 days
*[[Cefotaxime]] 1 g IV q8h for 7 days (alternative)
*[[Ceftizoxime]] 1 g IV q8h for 7 days
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Gonococcal meningitis and endocarditis'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] 1-2 g IV q 12-24 h for 10-14 days
|}

===Antimicrobial Regimen===

:*'''Neisseria gonorrhoeae treatment'''<ref>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref><ref name="urlUpdate to CDCs Treatment Guidelines for Gonococcal Infection, 2020 | MMWR">{{cite web |url=https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm#B1_down |title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 | MMWR |format= |work= |accessdate=}}</ref>
::*1. '''Gonococcal infections in adolescents and adults'''
:::*1.1 '''Uncomplicated gonococcal infections of the urogenital, rectal, or pharyngeal gonorrhea.'''
::::*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
::::*For persons weighing ≥150 kg (300 lb), 1 g of IM [[ceftriaxone]] should be administered.
::::*[[Chlamydial]] co-infection:
::::**add [[doxycycline]] 100 mg orally twice daily for 7 days. ([[azithromycin]] 1 g as a single dose is recommended to treat chlamydia During pregnancy)
:::*1.2 '''Uncomplicated gonococcal infections of the pharynx'''
::::*pharyngeal infection is often asymptomatic and more difficult to eradicate than urogenital or anorectal gonococcal infections and may serve as a reservoir of infection.
::::*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
::::**For persons weighing ≥150 kg (300 lb), 1 g of IM [[ceftriaxone]] should be administered.
::::**for chlamydia co-infection add [[doxycycline]] 100 mg orally twice a day for 7 days. (During pregnancy, [[azithromycin]] 1 g as a single dose is recommended to treat chlamydia)
::::**No reliable alternative treatments are available for pharyngeal gonorrhea. For persons with a history of a beta-lactam allergy, a thorough assessment of the reaction is recommended
:::::*1.2.1 '''Management of sex partners'''
::::::*Expedited partner therapy: oral [[cefixime]] 800 mg orally once plus treatment for [[chlamydia]] is used for treatment of the partner.<ref name="pmid33332296">{{cite journal| author=St Cyr S, Barbee L, Workowski KA, Bachmann LH, Pham C, Schlanger K | display-authors=etal| title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. | journal=MMWR Morb Mortal Wkly Rep | year= 2020 | volume= 69 | issue= 50 | pages= 1911-1916 | pmid=33332296 | doi=10.15585/mmwr.mm6950a6 | pmc=7745960 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33332296 }}</ref>
::::::*Note (1): expedited partner therapy is not routinely recommended for men who have sex with men.
::::::*Note (2): Recent sex partners (i.e., persons having sexual contact with the infected patient within the 60 days preceding onset of symptoms or gonorrhea diagnosis) should be referred for evaluation, testing, and presumptive dual treatment.
::::::*Note (3): If the patient’s last potential sexual exposure was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated.
::::::*Note (4): To avoid reinfection, sex partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sexual partner(s) have completed treatment and after resolution of symptoms, if present.
:::::*1.2.2 '''Allergy, intolerance, and adverse reactions'''
::::::*[[Ceftriaxone]] is not available:
::::::**A different injectable [[cephalosporin]] like [[ceftizoxime]] [500 mg IM], [[cefoxitin]] [2 g IM with [[probenecid]] 1 g orally], or [[cefotaxime]] [500 mg IM]) can be used.
::::::**[[cefixime]] 800 mg orally once can be used for gonococcal therapy if the other injectable [[cephalosporin]] not available.
::::::*Severe Cephalosporin allergy:
::::::**[[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
::::::**[[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose (alternative)
::::::*Note: Use of [[Ceftriaxone]] or [[Cefixime]] is contraindicated in persons with a history of an IgE-mediated penicillin allergy (e.g., anaphylaxis, Stevens Johnson syndrome, and toxic epidermal necrolysis).
:::::*1.2.3 '''Pregnancy'''
:::::**Pregnant women with uncomplicated gonorrheal infection should be treated with the same preferred regimen as the general population.
:::::**Chlamydia coinfection should be treated with azithromycin instead of doxycycline. 
:::::*1.2.4 '''Suspected cephalosporin treatment failure'''
::::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::*Alternative regimen (1): [[Gemifloxacin]] 320 mg PO single dose {{and}} [[Azithromycin]] 2 g PO single dose (when isolates have elevated cephalosporin MICs)
::::::*Alternative regimen (2): [[Gentamicin]] 240 mg IM single dose {{and}} [[Azithromycin]] 2 g PO single dose (when isolates have elevated cephalosporin MICs)
::::::*Alternative regimen (3): [[Ceftriaxone]] 250 mg IM as a single dose {{and}} [[Azithromycin]] 2 g PO as a single dose (failure after treatment with [[Cefixime]] and [[Azithromycin]])
::::::*Note: Treatment failure should be considered in: (1) patients whose symptoms do not resolve within 3–5 days after appropriate treatment and report no sexual contact during the post-treatment follow-up period; (2) patients with a positive test-of-cure (i.e., positive culture ≥ 72 hours or positive NAAT ≥ 7 days after receiving recommended treatment) when no sexual contact is reported during the post-treatment follow-up period; (3) persons who have a positive culture on test-of-cure (if obtained) if there is evidence of decreased susceptibility to cephalosporins on antimicrobial susceptibility testing, regardless of whether sexual contact is reported during the post-treatment follow-up period.
:::*1.3 '''Gonococcal conjunctivitis'''
::::*Preferred regimen: a single 1 g IM dose of [[Ceftriaxone|ceftriaxone.]]
:::::Note: A topical fluoroquinolone, saline irrigation are also recommended.
:::::*1.3.1 '''Management of sex partners'''
::::::*Patients should be instructed to refer their sex partners for evaluation and treatment.
:::*1.4 '''Disseminated gonococcal infection'''
:::::*1.4.1 '''Arthritis and arthritis-dermatitis syndrome '''
::::::*Preferred regimen: [[Ceftriaxone]] 1 g IM/IV q24h for 7 days.
::::::*Alternative regimen (1): [[Cefotaxime]] 1 g IV q8h for 7 days
::::::*Alternative regimen (2): [[Ceftizoxime]] 1 g IV q8h for 7 days.
::::::*Note: Once clinical improvement with [[ceftriaxone]] is noted for 24 to 48 hours, the regimen can be completed with intramuscular [[ceftriaxone]] (500 mg for individuals <150 kg or 1 g for individuals ≥150 kg) every 24 hours.
:::::*1.4.2 '''Gonococcal meningitis and endocarditis'''
::::::*Preferred regimen: [[Ceftriaxone]] 1-2 g IV q 12-24 h for 10-14 days.
::*2. '''Gonococcal infections among neonates'''<ref name="pmid333322962">{{cite journal| author=St Cyr S, Barbee L, Workowski KA, Bachmann LH, Pham C, Schlanger K | display-authors=etal| title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. | journal=MMWR Morb Mortal Wkly Rep | year= 2020 | volume= 69 | issue= 50 | pages= 1911-1916 | pmid=33332296 | doi=10.15585/mmwr.mm6950a6 | pmc=7745960 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33332296 }}</ref><ref name="pmid26042815">{{cite journal| author=Workowski KA, Bolan GA, Centers for Disease Control and Prevention| title=Sexually transmitted diseases treatment guidelines, 2015. | journal=MMWR Recomm Rep | year= 2015 | volume= 64 | issue= RR-03 | pages= 1-137 | pmid=26042815 | doi= | pmc=5885289 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26042815 }}</ref>
:::*2.1 '''Ophthalmia neonatorum caused by N. gonorrhoeae'''
::::*Preferred regimen: [[Ceftriaxone]] 25–50 mg/kg body weight IV or IM in a single dose, not to exceed 250 mg
::::*Recommended Regimen for prevention '''Erythromycin''' '''0.5% ophthalmic ointment''' in each eye in a single application at birth
:::::*2.1.1 '''Management of mothers and their sex partners'''
::::::*Mothers of infants with ophthalmia neonatorum caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
:::*2.2 '''Disseminated gonococcal infection and gonococcal scalp abscesses in neonates'''
::::*Preferred regimen (1): [[Ceftriaxone]] 25-50 mg/kg/day IM/IV q24h for 7 days
::::*Preferred regimen (2): [[Cefotaxime]] 25 mg/kg IM/IV q12h for 7 days.
::::*Note (1): The duration of treatment is 10-14 days if meningitis is documented.
::::*Note (2): Ceftriaxone should be administered cautiously to hyperbilirubinemic infants, especially those born prematurely.
:::::*2.2.1 '''Management of mothers and their sex partners'''
::::::*Mothers of infants who have DGI or scalp abscesses caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
:::*2.3 '''Neonates born to mothers who have gonococcal infection'''
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 250 mg
:::::*2.3.1 '''Management of mothers and their sex partners'''
::::::*Mothers who have gonorrhea and their sex partners should be evaluated, tested, and presumptively treated for gonorrhea.
::*3. '''Gonococcal infections among infants and children'''
:::*3.1 '''Infants and children who weigh ≤ 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
::::*Preferred regimen: '''[[Ceftriaxone]]''' 25–50 mg/kg body weight IV or IM in a single dose, not to exceed 250 mg IM
:::*3.2 '''Children who weigh > 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
::::*Preferred regimen: [[Ceftriaxone]] 500 mg IM in a single dose.
::::*Alternative regimen: '''[[Gentamicin]]''' 240 mg IM in a single dose PLUS '''[[Azithromycin]]''' 2 g orally in a single dose OR '''[[Cefixime]]''' 800 mg orally in a single dose
:::*3.3 '''Children who weigh ≤ 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen: [[Ceftriaxone]] 50 mg/kg body weight (maximum dose: 2 g) IM or IV in a single dose daily every 24 hours for 7 days
:::*3.4 '''Children who weigh > 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen: [[Ceftriaxone]] 1 g IM or IV in a single dose daily every 24 hours for 7 days.

===Follow-Up===
A test-of-cure is not needed for patients who receive a diagnosis of uncomplicated [[urogenital]] or [[rectal]] gonorrhea who are treated with any of the recommended or alternative regimens. However, any person with [[pharyngeal]] gonorrhea who is treated with an alternative regimen should return 14 days after treatment for a test-of-cure using either culture or [[NAAT]]. If the [[NAAT]] is positive, effort should be made to perform a confirmatory culture before commencing retreatment.<ref name="CDC-Guidline"> Centers for disease control and prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm Accessed on September 14, 2016</ref>

*All positive cultures for test-of-cure should undergo [[antibiotic resistance|antimicrobial susceptibility]] testing
*Men or women who have been treated for gonorrhea should be retested 3 months after treatment regardless of whether they believe their sex partners were treated
*If retesting at 3 months is not possible, clinicians should retest whenever patients next present for medical care within 12 months following initial treatment

==References==
{{Reflist|2}}

{{WH}}
{{WS}}

[[Category:Gynecology]]
[[Category:FinalQCRequired]]
[[Category:Emergency mdicine]]
[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Rheumatology]]
[[Category:Dermatology]]
[[Category:Neurology]]
[[Category:Cardiology]]
[[Category:Urology]]
[[Category:Gastroenterology]]

Gonorrhea medical therapy

2021-08-21T19:28:08Z

Dr.Nuha: /* Antimicrobial Regimen */

__NOTOC__
{{Gonorrhea}}
{{CMG}}; {{AE}} {{SaraM}} {{nuha}}

==Overview==
The mainstay of therapy for gonococcal infections is [[antimicrobial|antimicrobial therapy]]. Gonorrhea treatment is complicated by the ability of ''N. gonorrhoeae'' to develop resistance to [[antimicrobials]]; accordingly, [[Ceftriaxone]] is standard of care for treatment of gonorrhea. Routinely combining [[ceftriaxone]] with [[azithromycin]] for treatment of gonorrhea is no longer recommended.

==Medical Therapy==

*The mainstay of therapy for gonococcal infections is [[antimicrobial|antimicrobial therapy]].<ref name="urlUpdate to CDCs Treatment Guidelines for Gonococcal Infection, 2020 | MMWR2">{{cite web |url=https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm#B1_down |title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 | MMWR |format= |work= |accessdate=}}</ref>

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
|+
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF|Type of gonococcal infection}}
! style="background: #4479BA; width: 450px;" |{{fontcolor|#FFF|Regimen}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Uncomplicated Recommended regimen for urogenital, rectal, or pharyngeal gonorrhea'''
| style="padding: 5px 5px; background: #F5F5F5;" | 

*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)

*For persons weighing ≥150 kg (300 lb), 1 g of IM [[ceftriaxone]] should be administered.
*[[Chlamydial]] co-infection:
**add [[doxycycline]] 100 mg orally twice daily for 7 days. ([[azithromycin]] 1 g as a single dose is recommended to treat chlamydia During pregnancy)
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Uncomplicated Alternative regimen'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Gentamicin]] 240 mg IM as a single dose plus [[azithromycin]] 2 g orally as a single dose OR

*[[Cefixime]] 800 mg orally as a single dose.

(Add [[doxycycline]] 100 mg orally twice daily for 7 days f [[Chlamydia infection|chlamydial]] infection has not been excluded)

(During [[pregnancy]], [[azithromycin]] 1 g as a single dose is recommended to treat chlamydia.
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Alternative regimens for severe Cephalosporin allergy or ceftriaxone not available'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] is not available:
**A different injectable [[cephalosporin]] like [[ceftizoxime]] [500 mg IM], [[cefoxitin]] [2 g IM with [[probenecid]] 1 g orally], or [[cefotaxime]] [500 mg IM]) can be used.
**[[cefixime]] 800 mg orally once can be used for gonococcal therapy if the other injectable [[cephalosporin]] not available.
*Severe Cephalosporin allergy
**[[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
**[[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose (alternative)
*Test of cure should be performed after 1 week
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Arthritis and arthritis-dermatitis syndrome '''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] 1 g IM/IV q24h for 7 days
*[[Cefotaxime]] 1 g IV q8h for 7 days (alternative)
*[[Ceftizoxime]] 1 g IV q8h for 7 days
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Gonococcal meningitis and endocarditis'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] 1-2 g IV q 12-24 h for 10-14 days
|}

===Antimicrobial Regimen===

:*'''Neisseria gonorrhoeae treatment'''<ref>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref><ref name="urlUpdate to CDCs Treatment Guidelines for Gonococcal Infection, 2020 | MMWR">{{cite web |url=https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm#B1_down |title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 | MMWR |format= |work= |accessdate=}}</ref>
::*1. '''Gonococcal infections in adolescents and adults'''
:::*1.1 '''Uncomplicated gonococcal infections of the urogenital, rectal, or pharyngeal gonorrhea.'''
::::*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
::::*For persons weighing ≥150 kg (300 lb), 1 g of IM [[ceftriaxone]] should be administered.
::::*[[Chlamydial]] co-infection:
::::**add [[doxycycline]] 100 mg orally twice daily for 7 days. ([[azithromycin]] 1 g as a single dose is recommended to treat chlamydia During pregnancy)
:::*1.2 '''Uncomplicated gonococcal infections of the pharynx'''
::::*pharyngeal infection is often asymptomatic and more difficult to eradicate than urogenital or anorectal gonococcal infections and may serve as a reservoir of infection.
::::*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
::::**For persons weighing ≥150 kg (300 lb), 1 g of IM [[ceftriaxone]] should be administered.
::::**for chlamydia co-infection add [[doxycycline]] 100 mg orally twice a day for 7 days. (During pregnancy, [[azithromycin]] 1 g as a single dose is recommended to treat chlamydia)
::::**No reliable alternative treatments are available for pharyngeal gonorrhea. For persons with a history of a beta-lactam allergy, a thorough assessment of the reaction is recommended
:::::*1.2.1 '''Management of sex partners'''
::::::*Expedited partner therapy: oral [[cefixime]] 800 mg orally once plus treatment for [[chlamydia]] is used for treatment of the partner.<ref name="pmid33332296">{{cite journal| author=St Cyr S, Barbee L, Workowski KA, Bachmann LH, Pham C, Schlanger K | display-authors=etal| title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. | journal=MMWR Morb Mortal Wkly Rep | year= 2020 | volume= 69 | issue= 50 | pages= 1911-1916 | pmid=33332296 | doi=10.15585/mmwr.mm6950a6 | pmc=7745960 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33332296 }}</ref>
::::::*Note (1): expedited partner therapy is not routinely recommended for men who have sex with men.
::::::*Note (2): Recent sex partners (i.e., persons having sexual contact with the infected patient within the 60 days preceding onset of symptoms or gonorrhea diagnosis) should be referred for evaluation, testing, and presumptive dual treatment.
::::::*Note (3): If the patient’s last potential sexual exposure was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated.
::::::*Note (4): To avoid reinfection, sex partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sexual partner(s) have completed treatment and after resolution of symptoms, if present.
:::::*1.2.2 '''Allergy, intolerance, and adverse reactions'''
::::::*[[Ceftriaxone]] is not available:
::::::**A different injectable [[cephalosporin]] like [[ceftizoxime]] [500 mg IM], [[cefoxitin]] [2 g IM with [[probenecid]] 1 g orally], or [[cefotaxime]] [500 mg IM]) can be used.
::::::**[[cefixime]] 800 mg orally once can be used for gonococcal therapy if the other injectable [[cephalosporin]] not available.
::::::*Severe Cephalosporin allergy:
::::::**[[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
::::::**[[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose (alternative)
::::::*Note: Use of [[Ceftriaxone]] or [[Cefixime]] is contraindicated in persons with a history of an IgE-mediated penicillin allergy (e.g., anaphylaxis, Stevens Johnson syndrome, and toxic epidermal necrolysis).
:::::*1.2.3 '''Pregnancy'''
:::::**Pregnant women with uncomplicated gonorrheal infection should be treated with the same preferred regimen as the general population.
:::::**Chlamydia coinfection should be treated with azithromycin instead of doxycycline. 
:::::*1.2.4 '''Suspected cephalosporin treatment failure'''
::::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::*Alternative regimen (1): [[Gemifloxacin]] 320 mg PO single dose {{and}} [[Azithromycin]] 2 g PO single dose (when isolates have elevated cephalosporin MICs)
::::::*Alternative regimen (2): [[Gentamicin]] 240 mg IM single dose {{and}} [[Azithromycin]] 2 g PO single dose (when isolates have elevated cephalosporin MICs)
::::::*Alternative regimen (3): [[Ceftriaxone]] 250 mg IM as a single dose {{and}} [[Azithromycin]] 2 g PO as a single dose (failure after treatment with [[Cefixime]] and [[Azithromycin]])
::::::*Note: Treatment failure should be considered in: (1) patients whose symptoms do not resolve within 3–5 days after appropriate treatment and report no sexual contact during the post-treatment follow-up period; (2) patients with a positive test-of-cure (i.e., positive culture ≥ 72 hours or positive NAAT ≥ 7 days after receiving recommended treatment) when no sexual contact is reported during the post-treatment follow-up period; (3) persons who have a positive culture on test-of-cure (if obtained) if there is evidence of decreased susceptibility to cephalosporins on antimicrobial susceptibility testing, regardless of whether sexual contact is reported during the post-treatment follow-up period.
:::*1.3 '''Gonococcal conjunctivitis'''
::::*Preferred regimen: a single 1 g IM dose of [[Ceftriaxone|ceftriaxone.]]
:::::Note: A topical fluoroquinolone, saline irrigation are also recommended.
:::::*1.3.1 '''Management of sex partners'''
::::::*Patients should be instructed to refer their sex partners for evaluation and treatment.
:::*1.4 '''Disseminated gonococcal infection'''
:::::*1.4.1 '''Arthritis and arthritis-dermatitis syndrome '''
::::::*Preferred regimen: [[Ceftriaxone]] 1 g IM/IV q24h for 7 days.
::::::*Alternative regimen (1): [[Cefotaxime]] 1 g IV q8h for 7 days
::::::*Alternative regimen (2): [[Ceftizoxime]] 1 g IV q8h for 7 days.
::::::*Note: Once clinical improvement with [[ceftriaxone]] is noted for 24 to 48 hours, the regimen can be completed with intramuscular [[ceftriaxone]] (500 mg for individuals <150 kg or 1 g for individuals ≥150 kg) every 24 hours.
:::::*1.4.2 '''Gonococcal meningitis and endocarditis'''
::::::*Preferred regimen: [[Ceftriaxone]] 1-2 g IV q 12-24 h for 10-14 days.
::*2. '''Gonococcal infections among neonates'''<ref name="pmid333322962">{{cite journal| author=St Cyr S, Barbee L, Workowski KA, Bachmann LH, Pham C, Schlanger K | display-authors=etal| title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. | journal=MMWR Morb Mortal Wkly Rep | year= 2020 | volume= 69 | issue= 50 | pages= 1911-1916 | pmid=33332296 | doi=10.15585/mmwr.mm6950a6 | pmc=7745960 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33332296 }}</ref><ref name="pmid26042815">{{cite journal| author=Workowski KA, Bolan GA, Centers for Disease Control and Prevention| title=Sexually transmitted diseases treatment guidelines, 2015. | journal=MMWR Recomm Rep | year= 2015 | volume= 64 | issue= RR-03 | pages= 1-137 | pmid=26042815 | doi= | pmc=5885289 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26042815 }}</ref>
:::*2.1 '''Ophthalmia neonatorum caused by N. gonorrhoeae'''
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
:::::*2.1.1 '''Management of mothers and their sex partners'''
::::::*Mothers of infants with ophthalmia neonatorum caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
:::*2.2 '''Disseminated gonococcal infection and gonococcal scalp abscesses in neonates'''
::::*Preferred regimen (1): [[Ceftriaxone]] 25-50 mg/kg/day IM/IV q24h for 7 days
::::*Preferred regimen (2): [[Cefotaxime]] 25 mg/kg IM/IV q12h for 7 days.
::::*Note (1): The duration of treatment is 10-14 days if meningitis is documented.
::::*Note (2): Ceftriaxone should be administered cautiously to hyperbilirubinemic infants, especially those born prematurely.
:::::*2.2.1 '''Management of mothers and their sex partners'''
::::::*Mothers of infants who have DGI or scalp abscesses caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
:::*2.3 '''Neonates born to mothers who have gonococcal infection'''
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
:::::*2.3.1 '''Management of mothers and their sex partners'''
::::::*Mothers who have gonorrhea and their sex partners should be evaluated, tested, and presumptively treated for gonorrhea.
::*3. '''Gonococcal infections among infants and children'''
:::*3.1 '''Infants and children who weigh ≤ 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
:::*3.2 '''Children who weigh > 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1g PO in a single dose
::::*Alternative regimen: [[Cefixime]] 400 mg PO single dose {{and}} [[Azithromycin]] 1 g PO single dose.(If ceftriaxone is not available)
:::*3.3 '''Children who weigh ≤ 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen: [[Ceftriaxone]] 50 mg/kg (maximum dose: 1 g) IM/IV q24h for 7 days
:::*3.4 '''Children who weigh > 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen: [[Ceftriaxone]] 1 g IM/IV q24h for 7 days

===Follow-Up===
A test-of-cure is not needed for patients who receive a diagnosis of uncomplicated [[urogenital]] or [[rectal]] gonorrhea who are treated with any of the recommended or alternative regimens. However, any person with [[pharyngeal]] gonorrhea who is treated with an alternative regimen should return 14 days after treatment for a test-of-cure using either culture or [[NAAT]]. If the [[NAAT]] is positive, effort should be made to perform a confirmatory culture before commencing retreatment.<ref name="CDC-Guidline"> Centers for disease control and prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm Accessed on September 14, 2016</ref>

*All positive cultures for test-of-cure should undergo [[antibiotic resistance|antimicrobial susceptibility]] testing
*Men or women who have been treated for gonorrhea should be retested 3 months after treatment regardless of whether they believe their sex partners were treated
*If retesting at 3 months is not possible, clinicians should retest whenever patients next present for medical care within 12 months following initial treatment

==References==
{{Reflist|2}}

{{WH}}
{{WS}}

[[Category:Gynecology]]
[[Category:FinalQCRequired]]
[[Category:Emergency mdicine]]
[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Rheumatology]]
[[Category:Dermatology]]
[[Category:Neurology]]
[[Category:Cardiology]]
[[Category:Urology]]
[[Category:Gastroenterology]]

Gonorrhea medical therapy

2021-08-21T19:16:56Z

Dr.Nuha:

__NOTOC__
{{Gonorrhea}}
{{CMG}}; {{AE}} {{SaraM}} {{nuha}}

==Overview==
The mainstay of therapy for gonococcal infections is [[antimicrobial|antimicrobial therapy]]. Gonorrhea treatment is complicated by the ability of ''N. gonorrhoeae'' to develop resistance to [[antimicrobials]]; accordingly, [[Ceftriaxone]] is standard of care for treatment of gonorrhea. Routinely combining [[ceftriaxone]] with [[azithromycin]] for treatment of gonorrhea is no longer recommended.

==Medical Therapy==

*The mainstay of therapy for gonococcal infections is [[antimicrobial|antimicrobial therapy]].<ref name="urlUpdate to CDCs Treatment Guidelines for Gonococcal Infection, 2020 | MMWR2">{{cite web |url=https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm#B1_down |title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 | MMWR |format= |work= |accessdate=}}</ref>

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
|+
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF|Type of gonococcal infection}}
! style="background: #4479BA; width: 450px;" |{{fontcolor|#FFF|Regimen}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Uncomplicated Recommended regimen for urogenital, rectal, or pharyngeal gonorrhea'''
| style="padding: 5px 5px; background: #F5F5F5;" | 

*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)

*For persons weighing ≥150 kg (300 lb), 1 g of IM [[ceftriaxone]] should be administered.
*[[Chlamydial]] co-infection:
**add [[doxycycline]] 100 mg orally twice daily for 7 days. ([[azithromycin]] 1 g as a single dose is recommended to treat chlamydia During pregnancy)
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Uncomplicated Alternative regimen'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Gentamicin]] 240 mg IM as a single dose plus [[azithromycin]] 2 g orally as a single dose OR

*[[Cefixime]] 800 mg orally as a single dose.

(Add [[doxycycline]] 100 mg orally twice daily for 7 days f [[Chlamydia infection|chlamydial]] infection has not been excluded)

(During [[pregnancy]], [[azithromycin]] 1 g as a single dose is recommended to treat chlamydia.
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Alternative regimens for severe Cephalosporin allergy or ceftriaxone not available'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] is not available:
**A different injectable [[cephalosporin]] like [[ceftizoxime]] [500 mg IM], [[cefoxitin]] [2 g IM with [[probenecid]] 1 g orally], or [[cefotaxime]] [500 mg IM]) can be used.
**[[cefixime]] 800 mg orally once can be used for gonococcal therapy if the other injectable [[cephalosporin]] not available.
*Severe Cephalosporin allergy
**[[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
**[[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose (alternative)
*Test of cure should be performed after 1 week
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Arthritis and arthritis-dermatitis syndrome '''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] 1 g IM/IV q24h for 7 days
*[[Cefotaxime]] 1 g IV q8h for 7 days (alternative)
*[[Ceftizoxime]] 1 g IV q8h for 7 days
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Gonococcal meningitis and endocarditis'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] 1-2 g IV q 12-24 h for 10-14 days
|}

===Antimicrobial Regimen===

:*'''Neisseria gonorrhoeae treatment'''<ref>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref><ref name="urlUpdate to CDCs Treatment Guidelines for Gonococcal Infection, 2020 | MMWR">{{cite web |url=https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm#B1_down |title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 | MMWR |format= |work= |accessdate=}}</ref>
::*1. '''Gonococcal infections in adolescents and adults'''
:::*1.1 '''Uncomplicated gonococcal infections of the urogenital, rectal, or pharyngeal gonorrhea.'''
::::*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
::::*For persons weighing ≥150 kg (300 lb), 1 g of IM [[ceftriaxone]] should be administered.
::::*[[Chlamydial]] co-infection:
::::**add [[doxycycline]] 100 mg orally twice daily for 7 days. ([[azithromycin]] 1 g as a single dose is recommended to treat chlamydia During pregnancy)
:::*1.2 '''Uncomplicated gonococcal infections of the pharynx'''
::::*pharyngeal infection is often asymptomatic and more difficult to eradicate than urogenital or anorectal gonococcal infections and may serve as a reservoir of infection.
::::*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
::::**For persons weighing ≥150 kg (300 lb), 1 g of IM [[ceftriaxone]] should be administered.
::::**for chlamydia co-infection add [[doxycycline]] 100 mg orally twice a day for 7 days. (During pregnancy, [[azithromycin]] 1 g as a single dose is recommended to treat chlamydia)
::::**No reliable alternative treatments are available for pharyngeal gonorrhea. For persons with a history of a beta-lactam allergy, a thorough assessment of the reaction is recommended
:::::*1.2.1 '''Management of sex partners'''
::::::*Expedited partner therapy: oral [[cefixime]] 800 mg orally once plus treatment for [[chlamydia]] is used for treatment of the partner.<ref name="pmid33332296">{{cite journal| author=St Cyr S, Barbee L, Workowski KA, Bachmann LH, Pham C, Schlanger K | display-authors=etal| title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. | journal=MMWR Morb Mortal Wkly Rep | year= 2020 | volume= 69 | issue= 50 | pages= 1911-1916 | pmid=33332296 | doi=10.15585/mmwr.mm6950a6 | pmc=7745960 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33332296 }}</ref>
::::::*Note (1): expedited partner therapy is not routinely recommended for men who have sex with men.
::::::*Note (2): Recent sex partners (i.e., persons having sexual contact with the infected patient within the 60 days preceding onset of symptoms or gonorrhea diagnosis) should be referred for evaluation, testing, and presumptive dual treatment.
::::::*Note (3): If the patient’s last potential sexual exposure was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated.
::::::*Note (4): To avoid reinfection, sex partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sexual partner(s) have completed treatment and after resolution of symptoms, if present.
:::::*1.2.2 '''Allergy, intolerance, and adverse reactions'''
::::::*[[Ceftriaxone]] is not available:
::::::**A different injectable [[cephalosporin]] like [[ceftizoxime]] [500 mg IM], [[cefoxitin]] [2 g IM with [[probenecid]] 1 g orally], or [[cefotaxime]] [500 mg IM]) can be used.
::::::**[[cefixime]] 800 mg orally once can be used for gonococcal therapy if the other injectable [[cephalosporin]] not available.
::::::*Severe Cephalosporin allergy:
::::::**[[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
::::::**[[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose (alternative)
::::::*Note: Use of [[Ceftriaxone]] or [[Cefixime]] is contraindicated in persons with a history of an IgE-mediated penicillin allergy (e.g., anaphylaxis, Stevens Johnson syndrome, and toxic epidermal necrolysis).
:::::*1.2.3 '''Pregnancy'''
:::::**Pregnant women with uncomplicated gonorrheal infection should be treated with the same preferred regimen as the general population.
:::::**Chlamydia coinfection should be treated with azithromycin instead of doxycycline. 
:::::*1.2.4 '''Suspected cephalosporin treatment failure'''
::::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::*Alternative regimen (1): [[Gemifloxacin]] 320 mg PO single dose {{and}} [[Azithromycin]] 2 g PO single dose (when isolates have elevated cephalosporin MICs)
::::::*Alternative regimen (2): [[Gentamicin]] 240 mg IM single dose {{and}} [[Azithromycin]] 2 g PO single dose (when isolates have elevated cephalosporin MICs)
::::::*Alternative regimen (3): [[Ceftriaxone]] 250 mg IM as a single dose {{and}} [[Azithromycin]] 2 g PO as a single dose (failure after treatment with [[Cefixime]] and [[Azithromycin]])
::::::*Note: Treatment failure should be considered in: (1) patients whose symptoms do not resolve within 3–5 days after appropriate treatment and report no sexual contact during the post-treatment follow-up period; (2) patients with a positive test-of-cure (i.e., positive culture ≥ 72 hours or positive NAAT ≥ 7 days after receiving recommended treatment) when no sexual contact is reported during the post-treatment follow-up period; (3) persons who have a positive culture on test-of-cure (if obtained) if there is evidence of decreased susceptibility to cephalosporins on antimicrobial susceptibility testing, regardless of whether sexual contact is reported during the post-treatment follow-up period.
:::*1.3 '''Gonococcal conjunctivitis'''
::::*Preferred regimen: a single 1 g IM dose of [[Ceftriaxone|ceftriaxone.]]
:::::Note: A topical fluoroquinolone, saline irrigation are also recommended.
:::::*1.3.1 '''Management of sex partners'''
::::::*Patients should be instructed to refer their sex partners for evaluation and treatment.
:::*1.4 '''Disseminated gonococcal infection'''
:::::*1.4.1 '''Arthritis and arthritis-dermatitis syndrome '''
::::::*Preferred regimen: [[Ceftriaxone]] 1 g IM/IV q24h for 7 days.
::::::*Alternative regimen (1): [[Cefotaxime]] 1 g IV q8h for 7 days
::::::*Alternative regimen (2): [[Ceftizoxime]] 1 g IV q8h for 7 days.
::::::*Note: Once clinical improvement with [[ceftriaxone]] is noted for 24 to 48 hours, the regimen can be completed with intramuscular [[ceftriaxone]] (500 mg for individuals <150 kg or 1 g for individuals ≥150 kg) every 24 hours.
:::::*1.4.2 '''Gonococcal meningitis and endocarditis'''
::::::*Preferred regimen: [[Ceftriaxone]] 1-2 g IV q 12-24 h for 10-14 days.
::*2. '''Gonococcal infections among neonates'''
:::*2.1 '''Ophthalmia neonatorum caused by N. gonorrhoeae'''
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
:::::*2.1.1 '''Management of mothers and their sex partners'''
::::::*Mothers of infants with ophthalmia neonatorum caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
:::*2.2 '''Disseminated gonococcal infection and gonococcal scalp abscesses in neonates'''
::::*Preferred regimen (1): [[Ceftriaxone]] 25-50 mg/kg/day IM/IV q24h for 7 days
::::*Preferred regimen (2): [[Cefotaxime]] 25 mg/kg IM/IV q12h for 7 days.
::::*Note (1): The duration of treatment is 10-14 days if meningitis is documented.
::::*Note (2): Ceftriaxone should be administered cautiously to hyperbilirubinemic infants, especially those born prematurely.
:::::*2.2.1 '''Management of mothers and their sex partners'''
::::::*Mothers of infants who have DGI or scalp abscesses caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
:::*2.3 '''Neonates born to mothers who have gonococcal infection'''
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
:::::*2.3.1 '''Management of mothers and their sex partners'''
::::::*Mothers who have gonorrhea and their sex partners should be evaluated, tested, and presumptively treated for gonorrhea.
::*3. '''Gonococcal infections among infants and children'''
:::*3.1 '''Infants and children who weigh ≤ 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
:::*3.2 '''Children who weigh > 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1g PO in a single dose
::::*Alternative regimen: [[Cefixime]] 400 mg PO single dose {{and}} [[Azithromycin]] 1 g PO single dose.(If ceftriaxone is not available)
:::*3.3 '''Children who weigh ≤ 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen: [[Ceftriaxone]] 50 mg/kg (maximum dose: 1 g) IM/IV q24h for 7 days
:::*3.4 '''Children who weigh > 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen: [[Ceftriaxone]] 1 g IM/IV q24h for 7 days

===Follow-Up===
A test-of-cure is not needed for patients who receive a diagnosis of uncomplicated [[urogenital]] or [[rectal]] gonorrhea who are treated with any of the recommended or alternative regimens. However, any person with [[pharyngeal]] gonorrhea who is treated with an alternative regimen should return 14 days after treatment for a test-of-cure using either culture or [[NAAT]]. If the [[NAAT]] is positive, effort should be made to perform a confirmatory culture before commencing retreatment.<ref name="CDC-Guidline"> Centers for disease control and prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm Accessed on September 14, 2016</ref>

*All positive cultures for test-of-cure should undergo [[antibiotic resistance|antimicrobial susceptibility]] testing
*Men or women who have been treated for gonorrhea should be retested 3 months after treatment regardless of whether they believe their sex partners were treated
*If retesting at 3 months is not possible, clinicians should retest whenever patients next present for medical care within 12 months following initial treatment

==References==
{{Reflist|2}}

{{WH}}
{{WS}}

[[Category:Gynecology]]
[[Category:FinalQCRequired]]
[[Category:Emergency mdicine]]
[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Rheumatology]]
[[Category:Dermatology]]
[[Category:Neurology]]
[[Category:Cardiology]]
[[Category:Urology]]
[[Category:Gastroenterology]]

Gonorrhea medical therapy

2021-08-21T19:13:18Z

Dr.Nuha: /* Antimicrobial Regimen */

__NOTOC__
{{Gonorrhea}}
{{CMG}}; {{AE}} {{SaraM}}

==Overview==
The mainstay of therapy for gonococcal infections is [[antimicrobial|antimicrobial therapy]]. Gonorrhea treatment is complicated by the ability of ''N. gonorrhoeae'' to develop resistance to [[antimicrobials]]; accordingly, [[Ceftriaxone]] is standard of care for treatment of gonorrhea. Routinely combining [[ceftriaxone]] with [[azithromycin]] for treatment of gonorrhea is no longer recommended.

==Medical Therapy==

*The mainstay of therapy for gonococcal infections is [[antimicrobial|antimicrobial therapy]].<ref name="urlUpdate to CDCs Treatment Guidelines for Gonococcal Infection, 2020 | MMWR2">{{cite web |url=https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm#B1_down |title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 | MMWR |format= |work= |accessdate=}}</ref>

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
|+
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF|Type of gonococcal infection}}
! style="background: #4479BA; width: 450px;" |{{fontcolor|#FFF|Regimen}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Uncomplicated Recommended regimen for urogenital, rectal, or pharyngeal gonorrhea'''
| style="padding: 5px 5px; background: #F5F5F5;" | 

*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)

*For persons weighing ≥150 kg (300 lb), 1 g of IM [[ceftriaxone]] should be administered.
*[[Chlamydial]] co-infection:
**add [[doxycycline]] 100 mg orally twice daily for 7 days. ([[azithromycin]] 1 g as a single dose is recommended to treat chlamydia During pregnancy)
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Uncomplicated Alternative regimen'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Gentamicin]] 240 mg IM as a single dose plus [[azithromycin]] 2 g orally as a single dose OR

*[[Cefixime]] 800 mg orally as a single dose.

(Add [[doxycycline]] 100 mg orally twice daily for 7 days f [[Chlamydia infection|chlamydial]] infection has not been excluded)

(During [[pregnancy]], [[azithromycin]] 1 g as a single dose is recommended to treat chlamydia.
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Alternative regimens for severe Cephalosporin allergy or ceftriaxone not available'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] is not available:
**A different injectable [[cephalosporin]] like [[ceftizoxime]] [500 mg IM], [[cefoxitin]] [2 g IM with [[probenecid]] 1 g orally], or [[cefotaxime]] [500 mg IM]) can be used.
**[[cefixime]] 800 mg orally once can be used for gonococcal therapy if the other injectable [[cephalosporin]] not available.
*Severe Cephalosporin allergy
**[[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
**[[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose (alternative)
*Test of cure should be performed after 1 week
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Arthritis and arthritis-dermatitis syndrome '''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] 1 g IM/IV q24h for 7 days
*[[Cefotaxime]] 1 g IV q8h for 7 days (alternative)
*[[Ceftizoxime]] 1 g IV q8h for 7 days
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Gonococcal meningitis and endocarditis'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] 1-2 g IV q 12-24 h for 10-14 days
|}

===Antimicrobial Regimen===

:*'''Neisseria gonorrhoeae treatment'''<ref>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref><ref name="urlUpdate to CDCs Treatment Guidelines for Gonococcal Infection, 2020 | MMWR">{{cite web |url=https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm#B1_down |title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 | MMWR |format= |work= |accessdate=}}</ref>
::*1. '''Gonococcal infections in adolescents and adults'''
:::*1.1 '''Uncomplicated gonococcal infections of the urogenital, rectal, or pharyngeal gonorrhea.'''
::::*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
::::*For persons weighing ≥150 kg (300 lb), 1 g of IM [[ceftriaxone]] should be administered.
::::*[[Chlamydial]] co-infection:
::::**add [[doxycycline]] 100 mg orally twice daily for 7 days. ([[azithromycin]] 1 g as a single dose is recommended to treat chlamydia During pregnancy)
:::*1.2 '''Uncomplicated gonococcal infections of the pharynx'''
::::*pharyngeal infection is often asymptomatic and more difficult to eradicate than urogenital or anorectal gonococcal infections and may serve as a reservoir of infection.
::::*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
::::**For persons weighing ≥150 kg (300 lb), 1 g of IM [[ceftriaxone]] should be administered.
::::**for chlamydia co-infection add [[doxycycline]] 100 mg orally twice a day for 7 days. (During pregnancy, [[azithromycin]] 1 g as a single dose is recommended to treat chlamydia)
::::**No reliable alternative treatments are available for pharyngeal gonorrhea. For persons with a history of a beta-lactam allergy, a thorough assessment of the reaction is recommended
:::::*1.2.1 '''Management of sex partners'''
::::::*Expedited partner therapy: oral [[cefixime]] 800 mg orally once plus treatment for [[chlamydia]] is used for treatment of the partner.<ref name="pmid33332296">{{cite journal| author=St Cyr S, Barbee L, Workowski KA, Bachmann LH, Pham C, Schlanger K | display-authors=etal| title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. | journal=MMWR Morb Mortal Wkly Rep | year= 2020 | volume= 69 | issue= 50 | pages= 1911-1916 | pmid=33332296 | doi=10.15585/mmwr.mm6950a6 | pmc=7745960 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33332296 }}</ref>
::::::*Note (1): expedited partner therapy is not routinely recommended for men who have sex with men.
::::::*Note (2): Recent sex partners (i.e., persons having sexual contact with the infected patient within the 60 days preceding onset of symptoms or gonorrhea diagnosis) should be referred for evaluation, testing, and presumptive dual treatment.
::::::*Note (3): If the patient’s last potential sexual exposure was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated.
::::::*Note (4): To avoid reinfection, sex partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sexual partner(s) have completed treatment and after resolution of symptoms, if present.
:::::*1.2.2 '''Allergy, intolerance, and adverse reactions'''
::::::*[[Ceftriaxone]] is not available:
::::::**A different injectable [[cephalosporin]] like [[ceftizoxime]] [500 mg IM], [[cefoxitin]] [2 g IM with [[probenecid]] 1 g orally], or [[cefotaxime]] [500 mg IM]) can be used.
::::::**[[cefixime]] 800 mg orally once can be used for gonococcal therapy if the other injectable [[cephalosporin]] not available.
::::::*Severe Cephalosporin allergy:
::::::**[[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
::::::**[[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose (alternative)
::::::*Note: Use of [[Ceftriaxone]] or [[Cefixime]] is contraindicated in persons with a history of an IgE-mediated penicillin allergy (e.g., anaphylaxis, Stevens Johnson syndrome, and toxic epidermal necrolysis).
:::::*1.2.3 '''Pregnancy'''
:::::**Pregnant women with uncomplicated gonorrheal infection should be treated with the same preferred regimen as the general population.
:::::**Chlamydia coinfection should be treated with azithromycin instead of doxycycline. 
:::::*1.2.4 '''Suspected cephalosporin treatment failure'''
::::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::*Alternative regimen (1): [[Gemifloxacin]] 320 mg PO single dose {{and}} [[Azithromycin]] 2 g PO single dose (when isolates have elevated cephalosporin MICs)
::::::*Alternative regimen (2): [[Gentamicin]] 240 mg IM single dose {{and}} [[Azithromycin]] 2 g PO single dose (when isolates have elevated cephalosporin MICs)
::::::*Alternative regimen (3): [[Ceftriaxone]] 250 mg IM as a single dose {{and}} [[Azithromycin]] 2 g PO as a single dose (failure after treatment with [[Cefixime]] and [[Azithromycin]])
::::::*Note: Treatment failure should be considered in: (1) patients whose symptoms do not resolve within 3–5 days after appropriate treatment and report no sexual contact during the post-treatment follow-up period; (2) patients with a positive test-of-cure (i.e., positive culture ≥ 72 hours or positive NAAT ≥ 7 days after receiving recommended treatment) when no sexual contact is reported during the post-treatment follow-up period; (3) persons who have a positive culture on test-of-cure (if obtained) if there is evidence of decreased susceptibility to cephalosporins on antimicrobial susceptibility testing, regardless of whether sexual contact is reported during the post-treatment follow-up period.
:::*1.3 '''Gonococcal conjunctivitis'''
::::*Preferred regimen: a single 1 g IM dose of [[Ceftriaxone|ceftriaxone.]]
:::::Note: A topical fluoroquinolone, saline irrigation are also recommended.
:::::*1.3.1 '''Management of sex partners'''
::::::*Patients should be instructed to refer their sex partners for evaluation and treatment.
:::*1.4 '''Disseminated gonococcal infection'''
:::::*1.4.1 '''Arthritis and arthritis-dermatitis syndrome '''
::::::*Preferred regimen: [[Ceftriaxone]] 1 g IM/IV q24h for 7 days.
::::::*Alternative regimen (1): [[Cefotaxime]] 1 g IV q8h for 7 days
::::::*Alternative regimen (2): [[Ceftizoxime]] 1 g IV q8h for 7 days.
::::::*Note: Once clinical improvement with [[ceftriaxone]] is noted for 24 to 48 hours, the regimen can be completed with intramuscular [[ceftriaxone]] (500 mg for individuals <150 kg or 1 g for individuals ≥150 kg) every 24 hours.
:::::*1.4.2 '''Gonococcal meningitis and endocarditis'''
::::::*Preferred regimen: [[Ceftriaxone]] 1-2 g IV q 12-24 h for 10-14 days.
::*2. '''Gonococcal infections among neonates'''
:::*2.1 '''Ophthalmia neonatorum caused by N. gonorrhoeae'''
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
:::::*2.1.1 '''Management of mothers and their sex partners'''
::::::*Mothers of infants with ophthalmia neonatorum caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
:::*2.2 '''Disseminated gonococcal infection and gonococcal scalp abscesses in neonates'''
::::*Preferred regimen (1): [[Ceftriaxone]] 25-50 mg/kg/day IM/IV q24h for 7 days
::::*Preferred regimen (2): [[Cefotaxime]] 25 mg/kg IM/IV q12h for 7 days.
::::*Note (1): The duration of treatment is 10-14 days if meningitis is documented.
::::*Note (2): Ceftriaxone should be administered cautiously to hyperbilirubinemic infants, especially those born prematurely.
:::::*2.2.1 '''Management of mothers and their sex partners'''
::::::*Mothers of infants who have DGI or scalp abscesses caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
:::*2.3 '''Neonates born to mothers who have gonococcal infection'''
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
:::::*2.3.1 '''Management of mothers and their sex partners'''
::::::*Mothers who have gonorrhea and their sex partners should be evaluated, tested, and presumptively treated for gonorrhea.
::*3. '''Gonococcal infections among infants and children'''
:::*3.1 '''Infants and children who weigh ≤ 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
:::*3.2 '''Children who weigh > 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1g PO in a single dose
::::*Alternative regimen: [[Cefixime]] 400 mg PO single dose {{and}} [[Azithromycin]] 1 g PO single dose.(If ceftriaxone is not available)
:::*3.3 '''Children who weigh ≤ 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen: [[Ceftriaxone]] 50 mg/kg (maximum dose: 1 g) IM/IV q24h for 7 days
:::*3.4 '''Children who weigh > 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen: [[Ceftriaxone]] 1 g IM/IV q24h for 7 days

===Follow-Up===
A test-of-cure is not needed for patients who receive a diagnosis of uncomplicated [[urogenital]] or [[rectal]] gonorrhea who are treated with any of the recommended or alternative regimens. However, any person with [[pharyngeal]] gonorrhea who is treated with an alternative regimen should return 14 days after treatment for a test-of-cure using either culture or [[NAAT]]. If the [[NAAT]] is positive, effort should be made to perform a confirmatory culture before commencing retreatment.<ref name="CDC-Guidline"> Centers for disease control and prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm Accessed on September 14, 2016</ref>

*All positive cultures for test-of-cure should undergo [[antibiotic resistance|antimicrobial susceptibility]] testing
*Men or women who have been treated for gonorrhea should be retested 3 months after treatment regardless of whether they believe their sex partners were treated
*If retesting at 3 months is not possible, clinicians should retest whenever patients next present for medical care within 12 months following initial treatment

==References==
{{Reflist|2}}

{{WH}}
{{WS}}

[[Category:Gynecology]]
[[Category:FinalQCRequired]]
[[Category:Emergency mdicine]]
[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Rheumatology]]
[[Category:Dermatology]]
[[Category:Neurology]]
[[Category:Cardiology]]
[[Category:Urology]]
[[Category:Gastroenterology]]

Gonorrhea medical therapy

2021-08-21T18:18:40Z

Dr.Nuha: /* Antimicrobial Regimen */

__NOTOC__
{{Gonorrhea}}
{{CMG}}; {{AE}} {{SaraM}}

==Overview==
The mainstay of therapy for gonococcal infections is [[antimicrobial|antimicrobial therapy]]. Gonorrhea treatment is complicated by the ability of ''N. gonorrhoeae'' to develop resistance to [[antimicrobials]]; accordingly, [[Ceftriaxone]] is standard of care for treatment of gonorrhea. Routinely combining [[ceftriaxone]] with [[azithromycin]] for treatment of gonorrhea is no longer recommended.

==Medical Therapy==

*The mainstay of therapy for gonococcal infections is [[antimicrobial|antimicrobial therapy]].<ref name="urlUpdate to CDCs Treatment Guidelines for Gonococcal Infection, 2020 | MMWR2">{{cite web |url=https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm#B1_down |title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 | MMWR |format= |work= |accessdate=}}</ref>

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
|+
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF|Type of gonococcal infection}}
! style="background: #4479BA; width: 450px;" |{{fontcolor|#FFF|Regimen}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Uncomplicated Recommended regimen for urogenital, rectal, or pharyngeal gonorrhea'''
| style="padding: 5px 5px; background: #F5F5F5;" | 

*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)

*For persons weighing ≥150 kg (300 lb), 1 g of IM [[ceftriaxone]] should be administered.
*[[Chlamydial]] co-infection:
**add [[doxycycline]] 100 mg orally twice daily for 7 days. ([[azithromycin]] 1 g as a single dose is recommended to treat chlamydia During pregnancy)
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Uncomplicated Alternative regimen'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Gentamicin]] 240 mg IM as a single dose plus [[azithromycin]] 2 g orally as a single dose OR

*[[Cefixime]] 800 mg orally as a single dose.

(Add [[doxycycline]] 100 mg orally twice daily for 7 days f [[Chlamydia infection|chlamydial]] infection has not been excluded)

(During [[pregnancy]], [[azithromycin]] 1 g as a single dose is recommended to treat chlamydia.
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Alternative regimens for severe Cephalosporin allergy or ceftriaxone not available'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] is not available:
**A different injectable [[cephalosporin]] like [[ceftizoxime]] [500 mg IM], [[cefoxitin]] [2 g IM with [[probenecid]] 1 g orally], or [[cefotaxime]] [500 mg IM]) can be used.
**[[cefixime]] 800 mg orally once can be used for gonococcal therapy if the other injectable [[cephalosporin]] not available.
*Severe Cephalosporin allergy
**[[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
**[[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose (alternative)
*Test of cure should be performed after 1 week
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Arthritis and arthritis-dermatitis syndrome '''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] 1 g IM/IV q24h for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose
*[[Cefotaxime]] 1 g IV q8h for 7 days (alternative)
*[[Ceftizoxime]] 1 g IV q8h for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose (alternative)
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Gonococcal meningitis and endocarditis'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] 1-2 g IV q 12-24 h for 10-14 days {{and}} [[Azithromycin]] 1 g PO in a single dose
|}

===Antimicrobial Regimen===

:*'''Neisseria gonorrhoeae treatment'''<ref>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref><ref name="urlUpdate to CDCs Treatment Guidelines for Gonococcal Infection, 2020 | MMWR">{{cite web |url=https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm#B1_down |title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 | MMWR |format= |work= |accessdate=}}</ref>
::*1. '''Gonococcal infections in adolescents and adults'''
:::*1.1 '''Uncomplicated gonococcal infections of the urogenital, rectal, or pharyngeal gonorrhea.'''
::::*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
::::*For persons weighing ≥150 kg (300 lb), 1 g of IM [[ceftriaxone]] should be administered.
::::*[[Chlamydial]] co-infection:
::::**add [[doxycycline]] 100 mg orally twice daily for 7 days. ([[azithromycin]] 1 g as a single dose is recommended to treat chlamydia During pregnancy)
:::*1.2 '''Uncomplicated gonococcal infections of the pharynx'''
::::*pharyngeal infection is often asymptomatic and more difficult to eradicate than urogenital or anorectal gonococcal infections and may serve as a reservoir of infection.
::::*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
::::**For persons weighing ≥150 kg (300 lb), 1 g of IM [[ceftriaxone]] should be administered.
::::**for chlamydia co-infection add doxycycline 100 mg orally twice a day for 7 days. (During pregnancy, azithromycin 1 g as a single dose is recommended to treat chlamydia)
::::**No reliable alternative treatments are available for pharyngeal gonorrhea. For persons with a history of a beta-lactam allergy, a thorough assessment of the reaction is recommended
:::::*1.2.1 '''Management of sex partners'''
::::::*Expedited partner therapy: [[Cefixime]] 400 mg PO in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::*Note (1): Recent sex partners (i.e., persons having sexual contact with the infected patient within the 60 days preceding onset of symptoms or gonorrhea diagnosis) should be referred for evaluation, testing, and presumptive dual treatment.
::::::*Note (2): If the patient’s last potential sexual exposure was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated.
::::::*Note (3): To avoid reinfection, sex partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sexual partner(s) have completed treatment and after resolution of symptoms, if present.
:::::*1.2.2 '''Allergy, intolerance, and adverse reactions'''
::::::*[[Ceftriaxone]] is not available:
::::::**A different injectable [[cephalosporin]] like [[ceftizoxime]] [500 mg IM], [[cefoxitin]] [2 g IM with [[probenecid]] 1 g orally], or [[cefotaxime]] [500 mg IM]) can be used.
::::::**[[cefixime]] 800 mg orally once can be used for gonococcal therapy if the other injectable [[cephalosporin]] not available.
::::::*Severe Cephalosporin allergy:
::::::**[[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
::::::**[[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose (alternative)
::::::*Note: Use of [[Ceftriaxone]] or [[Cefixime]] is contraindicated in persons with a history of an IgE-mediated penicillin allergy (e.g., anaphylaxis, Stevens Johnson syndrome, and toxic epidermal necrolysis).
:::::*1.2.3 '''Pregnancy'''
:::::**Pregnant women with uncomplicated gonorrheal infection should be treated with the same preferred regimen as the general population.
:::::**Chlamydia coinfection should be treated with azithromycin instead of doxycycline. 
:::::*1.2.4 '''Suspected cephalosporin treatment failure'''
::::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::*Alternative regimen (1): [[Gemifloxacin]] 320 mg PO single dose {{and}} [[Azithromycin]] 2 g PO single dose (when isolates have elevated cephalosporin MICs)
::::::*Alternative regimen (2): [[Gentamicin]] 240 mg IM single dose {{and}} [[Azithromycin]] 2 g PO single dose (when isolates have elevated cephalosporin MICs)
::::::*Alternative regimen (3): [[Ceftriaxone]] 250 mg IM as a single dose {{and}} [[Azithromycin]] 2 g PO as a single dose (failure after treatment with [[Cefixime]] and [[Azithromycin]])
::::::*Note: Treatment failure should be considered in: (1) patients whose symptoms do not resolve within 3–5 days after appropriate treatment and report no sexual contact during the post-treatment follow-up period; (2) patients with a positive test-of-cure (i.e., positive culture ≥ 72 hours or positive NAAT ≥ 7 days after receiving recommended treatment) when no sexual contact is reported during the post-treatment follow-up period; (3) persons who have a positive culture on test-of-cure (if obtained) if there is evidence of decreased susceptibility to cephalosporins on antimicrobial susceptibility testing, regardless of whether sexual contact is reported during the post-treatment follow-up period.
:::*1.3 '''Gonococcal conjunctivitis'''
::::*Preferred regimen: a single 1 g IM dose of [[Ceftriaxone|ceftriaxone.]]
:::::Note: A topical fluoroquinolone, saline irrigation are also recommended.
:::::*1.3.1 '''Management of sex partners'''
::::::*Patients should be instructed to refer their sex partners for evaluation and treatment.
:::*1.4 '''Disseminated gonococcal infection'''
:::::*1.4.1 '''Arthritis and arthritis-dermatitis syndrome '''
::::::*Preferred regimen: [[Ceftriaxone]] 1 g IM/IV q24h for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::*Alternative regimen (1): [[Cefotaxime]] 1 g IV q8h for 7 days
::::::*Alternative regimen (2): [[Ceftizoxime]] 1 g IV q8h for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose
:::::*1.4.2 '''Gonococcal meningitis and endocarditis'''
::::::*Preferred regimen: [[Ceftriaxone]] 1-2 g IV q 12-24 h for 10-14 days {{and}} [[Azithromycin]] 1 g PO in a single dose
::*2. '''Gonococcal infections among neonates'''
:::*2.1 '''Ophthalmia neonatorum caused by N. gonorrhoeae'''
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
:::::*2.1.1 '''Management of mothers and their sex partners'''
::::::*Mothers of infants with ophthalmia neonatorum caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
:::*2.2 '''Disseminated gonococcal infection and gonococcal scalp abscesses in neonates'''
::::*Preferred regimen (1): [[Ceftriaxone]] 25-50 mg/kg/day IM/IV q24h for 7 days
::::*Preferred regimen (2): [[Cefotaxime]] 25 mg/kg IM/IV q12h for 7 days.
::::*Note (1): The duration of treatment is 10-14 days if meningitis is documented.
::::*Note (2): Ceftriaxone should be administered cautiously to hyperbilirubinemic infants, especially those born prematurely.
:::::*2.2.1 '''Management of mothers and their sex partners'''
::::::*Mothers of infants who have DGI or scalp abscesses caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
:::*2.3 '''Neonates born to mothers who have gonococcal infection'''
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
:::::*2.3.1 '''Management of mothers and their sex partners'''
::::::*Mothers who have gonorrhea and their sex partners should be evaluated, tested, and presumptively treated for gonorrhea.
::*3. '''Gonococcal infections among infants and children'''
:::*3.1 '''Infants and children who weigh ≤ 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
:::*3.2 '''Children who weigh > 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1g PO in a single dose
::::*Alternative regimen: [[Cefixime]] 400 mg PO single dose {{and}} [[Azithromycin]] 1 g PO single dose.(If ceftriaxone is not available)
:::*3.3 '''Children who weigh ≤ 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen: [[Ceftriaxone]] 50 mg/kg (maximum dose: 1 g) IM/IV q24h for 7 days
:::*3.4 '''Children who weigh > 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen: [[Ceftriaxone]] 1 g IM/IV q24h for 7 days

===Follow-Up===
A test-of-cure is not needed for patients who receive a diagnosis of uncomplicated [[urogenital]] or [[rectal]] gonorrhea who are treated with any of the recommended or alternative regimens. However, any person with [[pharyngeal]] gonorrhea who is treated with an alternative regimen should return 14 days after treatment for a test-of-cure using either culture or [[NAAT]]. If the [[NAAT]] is positive, effort should be made to perform a confirmatory culture before commencing retreatment.<ref name="CDC-Guidline"> Centers for disease control and prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm Accessed on September 14, 2016</ref>

*All positive cultures for test-of-cure should undergo [[antibiotic resistance|antimicrobial susceptibility]] testing
*Men or women who have been treated for gonorrhea should be retested 3 months after treatment regardless of whether they believe their sex partners were treated
*If retesting at 3 months is not possible, clinicians should retest whenever patients next present for medical care within 12 months following initial treatment

==References==
{{Reflist|2}}

{{WH}}
{{WS}}

[[Category:Gynecology]]
[[Category:FinalQCRequired]]
[[Category:Emergency mdicine]]
[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Rheumatology]]
[[Category:Dermatology]]
[[Category:Neurology]]
[[Category:Cardiology]]
[[Category:Urology]]
[[Category:Gastroenterology]]

Gonorrhea medical therapy

2021-08-21T18:16:48Z

Dr.Nuha: /* Overview */

__NOTOC__
{{Gonorrhea}}
{{CMG}}; {{AE}} {{SaraM}}

==Overview==
The mainstay of therapy for gonococcal infections is [[antimicrobial|antimicrobial therapy]]. Gonorrhea treatment is complicated by the ability of ''N. gonorrhoeae'' to develop resistance to [[antimicrobials]]; accordingly, [[Ceftriaxone]] is standard of care for treatment of gonorrhea. Routinely combining [[ceftriaxone]] with [[azithromycin]] for treatment of gonorrhea is no longer recommended.

==Medical Therapy==

*The mainstay of therapy for gonococcal infections is [[antimicrobial|antimicrobial therapy]].

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
|+
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF|Type of gonococcal infection}}
! style="background: #4479BA; width: 450px;" |{{fontcolor|#FFF|Regimen}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Uncomplicated Recommended regimen for urogenital, rectal, or pharyngeal gonorrhea'''
| style="padding: 5px 5px; background: #F5F5F5;" | 

*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)

*For persons weighing ≥150 kg (300 lb), 1 g of IM [[ceftriaxone]] should be administered.
*[[Chlamydial]] co-infection:
**add [[doxycycline]] 100 mg orally twice daily for 7 days. ([[azithromycin]] 1 g as a single dose is recommended to treat chlamydia During pregnancy)
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Uncomplicated Alternative regimen'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Gentamicin]] 240 mg IM as a single dose plus [[azithromycin]] 2 g orally as a single dose OR

*[[Cefixime]] 800 mg orally as a single dose.

(Add [[doxycycline]] 100 mg orally twice daily for 7 days f [[Chlamydia infection|chlamydial]] infection has not been excluded)

(During [[pregnancy]], [[azithromycin]] 1 g as a single dose is recommended to treat chlamydia.
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Alternative regimens for severe Cephalosporin allergy or ceftriaxone not available'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] is not available:
**A different injectable [[cephalosporin]] like [[ceftizoxime]] [500 mg IM], [[cefoxitin]] [2 g IM with [[probenecid]] 1 g orally], or [[cefotaxime]] [500 mg IM]) can be used.
**[[cefixime]] 800 mg orally once can be used for gonococcal therapy if the other injectable [[cephalosporin]] not available.
*Severe Cephalosporin allergy
**[[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
**[[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose (alternative)
*Test of cure should be performed after 1 week
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Arthritis and arthritis-dermatitis syndrome '''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] 1 g IM/IV q24h for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose
*[[Cefotaxime]] 1 g IV q8h for 7 days (alternative)
*[[Ceftizoxime]] 1 g IV q8h for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose (alternative)
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Gonococcal meningitis and endocarditis'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] 1-2 g IV q 12-24 h for 10-14 days {{and}} [[Azithromycin]] 1 g PO in a single dose
|}

===Antimicrobial Regimen===

:*'''Neisseria gonorrhoeae treatment'''<ref>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref>
::*1. '''Gonococcal infections in adolescents and adults'''
:::*1.1 '''Uncomplicated gonococcal infections of the urogenital, rectal, or pharyngeal gonorrhea.'''
::::*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
::::*For persons weighing ≥150 kg (300 lb), 1 g of IM [[ceftriaxone]] should be administered.
::::*[[Chlamydial]] co-infection:
::::**add [[doxycycline]] 100 mg orally twice daily for 7 days. ([[azithromycin]] 1 g as a single dose is recommended to treat chlamydia During pregnancy)
:::*1.2 '''Uncomplicated gonococcal infections of the pharynx'''
::::*pharyngeal infection is often asymptomatic and more difficult to eradicate than urogenital or anorectal gonococcal infections and may serve as a reservoir of infection.
::::*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
::::**For persons weighing ≥150 kg (300 lb), 1 g of IM [[ceftriaxone]] should be administered.
::::**for chlamydia co-infection add doxycycline 100 mg orally twice a day for 7 days. (During pregnancy, azithromycin 1 g as a single dose is recommended to treat chlamydia)
::::**No reliable alternative treatments are available for pharyngeal gonorrhea. For persons with a history of a beta-lactam allergy, a thorough assessment of the reaction is recommended
:::::*1.2.1 '''Management of sex partners'''
::::::*Expedited partner therapy: [[Cefixime]] 400 mg PO in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::*Note (1): Recent sex partners (i.e., persons having sexual contact with the infected patient within the 60 days preceding onset of symptoms or gonorrhea diagnosis) should be referred for evaluation, testing, and presumptive dual treatment.
::::::*Note (2): If the patient’s last potential sexual exposure was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated.
::::::*Note (3): To avoid reinfection, sex partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sexual partner(s) have completed treatment and after resolution of symptoms, if present.
:::::*1.2.2 '''Allergy, intolerance, and adverse reactions'''
::::::* [[Ceftriaxone]] is not available:
::::::**A different injectable [[cephalosporin]] like [[ceftizoxime]] [500 mg IM], [[cefoxitin]] [2 g IM with [[probenecid]] 1 g orally], or [[cefotaxime]] [500 mg IM]) can be used.
::::::**[[cefixime]] 800 mg orally once can be used for gonococcal therapy if the other injectable [[cephalosporin]] not available.
::::::*Severe Cephalosporin allergy:
::::::**[[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
::::::**[[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose (alternative)
::::::*Note: Use of [[Ceftriaxone]] or [[Cefixime]] is contraindicated in persons with a history of an IgE-mediated penicillin allergy (e.g., anaphylaxis, Stevens Johnson syndrome, and toxic epidermal necrolysis).
:::::*1.2.3 '''Pregnancy'''
:::::**Pregnant women with uncomplicated gonorrheal infection should be treated with the same preferred regimen as the general population.
:::::**Chlamydia coinfection should be treated with azithromycin instead of doxycycline. 
:::::*1.2.4 '''Suspected cephalosporin treatment failure'''
::::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::*Alternative regimen (1): [[Gemifloxacin]] 320 mg PO single dose {{and}} [[Azithromycin]] 2 g PO single dose (when isolates have elevated cephalosporin MICs)
::::::*Alternative regimen (2): [[Gentamicin]] 240 mg IM single dose {{and}} [[Azithromycin]] 2 g PO single dose (when isolates have elevated cephalosporin MICs)
::::::*Alternative regimen (3): [[Ceftriaxone]] 250 mg IM as a single dose {{and}} [[Azithromycin]] 2 g PO as a single dose (failure after treatment with [[Cefixime]] and [[Azithromycin]])
::::::*Note: Treatment failure should be considered in: (1) patients whose symptoms do not resolve within 3–5 days after appropriate treatment and report no sexual contact during the post-treatment follow-up period; (2) patients with a positive test-of-cure (i.e., positive culture ≥ 72 hours or positive NAAT ≥ 7 days after receiving recommended treatment) when no sexual contact is reported during the post-treatment follow-up period; (3) persons who have a positive culture on test-of-cure (if obtained) if there is evidence of decreased susceptibility to cephalosporins on antimicrobial susceptibility testing, regardless of whether sexual contact is reported during the post-treatment follow-up period.
:::*1.3 '''Gonococcal conjunctivitis'''
::::*Preferred regimen: a single 1 g IM dose of [[Ceftriaxone|ceftriaxone.]]
:::::Note: A topical fluoroquinolone, saline irrigation are also recommended.
:::::*1.3.1 '''Management of sex partners'''
::::::*Patients should be instructed to refer their sex partners for evaluation and treatment.
:::*1.4 '''Disseminated gonococcal infection'''
:::::*1.4.1 '''Arthritis and arthritis-dermatitis syndrome '''
::::::*Preferred regimen: [[Ceftriaxone]] 1 g IM/IV q24h for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::*Alternative regimen (1): [[Cefotaxime]] 1 g IV q8h for 7 days
::::::*Alternative regimen (2): [[Ceftizoxime]] 1 g IV q8h for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose
:::::*1.4.2 '''Gonococcal meningitis and endocarditis'''
::::::*Preferred regimen: [[Ceftriaxone]] 1-2 g IV q 12-24 h for 10-14 days {{and}} [[Azithromycin]] 1 g PO in a single dose
::*2. '''Gonococcal infections among neonates'''
:::*2.1 '''Ophthalmia neonatorum caused by N. gonorrhoeae'''
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
:::::*2.1.1 '''Management of mothers and their sex partners'''
::::::*Mothers of infants with ophthalmia neonatorum caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
:::*2.2 '''Disseminated gonococcal infection and gonococcal scalp abscesses in neonates'''
::::*Preferred regimen (1): [[Ceftriaxone]] 25-50 mg/kg/day IM/IV q24h for 7 days
::::*Preferred regimen (2): [[Cefotaxime]] 25 mg/kg IM/IV q12h for 7 days.
::::*Note (1): The duration of treatment is 10-14 days if meningitis is documented.
::::*Note (2): Ceftriaxone should be administered cautiously to hyperbilirubinemic infants, especially those born prematurely.
:::::*2.2.1 '''Management of mothers and their sex partners'''
::::::*Mothers of infants who have DGI or scalp abscesses caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
:::*2.3 '''Neonates born to mothers who have gonococcal infection'''
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
:::::*2.3.1 '''Management of mothers and their sex partners'''
::::::*Mothers who have gonorrhea and their sex partners should be evaluated, tested, and presumptively treated for gonorrhea.
::*3. '''Gonococcal infections among infants and children'''
:::*3.1 '''Infants and children who weigh ≤ 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
:::*3.2 '''Children who weigh > 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1g PO in a single dose
::::*Alternative regimen: [[Cefixime]] 400 mg PO single dose {{and}} [[Azithromycin]] 1 g PO single dose.(If ceftriaxone is not available)
:::*3.3 '''Children who weigh ≤ 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen: [[Ceftriaxone]] 50 mg/kg (maximum dose: 1 g) IM/IV q24h for 7 days
:::*3.4 '''Children who weigh > 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen: [[Ceftriaxone]] 1 g IM/IV q24h for 7 days

===Follow-Up===
A test-of-cure is not needed for patients who receive a diagnosis of uncomplicated [[urogenital]] or [[rectal]] gonorrhea who are treated with any of the recommended or alternative regimens. However, any person with [[pharyngeal]] gonorrhea who is treated with an alternative regimen should return 14 days after treatment for a test-of-cure using either culture or [[NAAT]]. If the [[NAAT]] is positive, effort should be made to perform a confirmatory culture before commencing retreatment.<ref name="CDC-Guidline"> Centers for disease control and prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm Accessed on September 14, 2016</ref>

*All positive cultures for test-of-cure should undergo [[antibiotic resistance|antimicrobial susceptibility]] testing
*Men or women who have been treated for gonorrhea should be retested 3 months after treatment regardless of whether they believe their sex partners were treated
*If retesting at 3 months is not possible, clinicians should retest whenever patients next present for medical care within 12 months following initial treatment

==References==
{{Reflist|2}}

{{WH}}
{{WS}}

[[Category:Gynecology]]
[[Category:FinalQCRequired]]
[[Category:Emergency mdicine]]
[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Rheumatology]]
[[Category:Dermatology]]
[[Category:Neurology]]
[[Category:Cardiology]]
[[Category:Urology]]
[[Category:Gastroenterology]]

Gonorrhea medical therapy

2021-08-21T12:42:07Z

Dr.Nuha: /* Overview */

__NOTOC__
{{Gonorrhea}}
{{CMG}}; {{AE}} {{SaraM}}

==Overview==
The mainstay of therapy for gonococcal infections is [[antimicrobial|antimicrobial therapy]]. Gonorrhea treatment is complicated by the ability of ''N. gonorrhoeae'' to develop resistance to [[antimicrobials]]; accordingly, a single dose of [[Ceftriaxone]], and for chlamydial co-infection add [[Ceftriaxone|doxycycline]].

==Medical Therapy==

*The mainstay of therapy for gonococcal infections is [[antimicrobial|antimicrobial therapy]].

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
|+
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF|Type of gonococcal infection}}
! style="background: #4479BA; width: 450px;" |{{fontcolor|#FFF|Regimen}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Uncomplicated Recommended regimen for urogenital, rectal, or pharyngeal gonorrhea'''
| style="padding: 5px 5px; background: #F5F5F5;" | 

*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)

*For persons weighing ≥150 kg (300 lb), 1 g of IM [[ceftriaxone]] should be administered.
*[[Chlamydial]] co-infection:
**add [[doxycycline]] 100 mg orally twice daily for 7 days. ([[azithromycin]] 1 g as a single dose is recommended to treat chlamydia During pregnancy)
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Uncomplicated Alternative regimen'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Gentamicin]] 240 mg IM as a single dose plus [[azithromycin]] 2 g orally as a single dose OR

*[[Cefixime]] 800 mg orally as a single dose.

(Add [[doxycycline]] 100 mg orally twice daily for 7 days f [[Chlamydia infection|chlamydial]] infection has not been excluded)

(During [[pregnancy]], [[azithromycin]] 1 g as a single dose is recommended to treat chlamydia.
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Alternative regimens for severe Cephalosporin allergy'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
*[[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose (alternative)
*Test of cure should be performed after 1 week
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Arthritis and arthritis-dermatitis syndrome '''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] 1 g IM/IV q24h for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose
*[[Cefotaxime]] 1 g IV q8h for 7 days (alternative)
*[[Ceftizoxime]] 1 g IV q8h for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose (alternative)
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Gonococcal meningitis and endocarditis'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] 1-2 g IV q 12-24 h for 10-14 days {{and}} [[Azithromycin]] 1 g PO in a single dose
|}

===Antimicrobial Regimen===

:*'''Neisseria gonorrhoeae treatment'''<ref>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref>
::*1. '''Gonococcal infections in adolescents and adults'''
:::*1.1 '''Uncomplicated gonococcal infections of the urogenital, rectal, or pharyngeal gonorrhea.'''
::::*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
::::*For persons weighing ≥150 kg (300 lb), 1 g of IM [[ceftriaxone]] should be administered.
::::*[[Chlamydial]] co-infection:
::::**add [[doxycycline]] 100 mg orally twice daily for 7 days. ([[azithromycin]] 1 g as a single dose is recommended to treat chlamydia During pregnancy)
:::*1.2 '''Uncomplicated gonococcal infections of the pharynx'''
::::*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
::::**For persons weighing ≥150 kg (300 lb), 1 g of IM [[ceftriaxone]] should be administered.
::::**for chlamydia co-infection add doxycycline 100 mg orally twice a day for 7 days. (During pregnancy, azithromycin 1 g as a single dose is recommended to treat chlamydia)
::::**No reliable alternative treatments are available for pharyngeal gonorrhea. For persons with a history of a beta-lactam allergy, a thorough assessment of the reaction is recommended
:::::*1.2.1 '''Management of sex partners'''
::::::*Expedited partner therapy: [[Cefixime]] 400 mg PO in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::*Note (1): Recent sex partners (i.e., persons having sexual contact with the infected patient within the 60 days preceding onset of symptoms or gonorrhea diagnosis) should be referred for evaluation, testing, and presumptive dual treatment.
::::::*Note (2): If the patient’s last potential sexual exposure was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated.
::::::*Note (3): To avoid reinfection, sex partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sexual partner(s) have completed treatment and after resolution of symptoms, if present.
:::::*1.2.2 '''Allergy, intolerance, and adverse reactions'''
::::::*Preferred regimen (1): [[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
::::::*Preferred regimen (2): [[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
::::::*Note: Use of [[Ceftriaxone]] or [[Cefixime]] is contraindicated in persons with a history of an IgE-mediated penicillin allergy (e.g., anaphylaxis, Stevens Johnson syndrome, and toxic epidermal necrolysis).
:::::*1.2.3 '''Pregnancy'''
::::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
:::::*1.2.4 '''Suspected cephalosporin treatment failure'''
::::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::*Alternative regimen (1): [[Gemifloxacin]] 320 mg PO single dose {{and}} [[Azithromycin]] 2 g PO single dose (when isolates have elevated cephalosporin MICs)
::::::*Alternative regimen (2): [[Gentamicin]] 240 mg IM single dose {{and}} [[Azithromycin]] 2 g PO single dose (when isolates have elevated cephalosporin MICs)
::::::*Alternative regimen (3): [[Ceftriaxone]] 250 mg IM as a single dose {{and}} [[Azithromycin]] 2 g PO as a single dose (failure after treatment with [[Cefixime]] and [[Azithromycin]])
::::::*Note: Treatment failure should be considered in: (1) patients whose symptoms do not resolve within 3–5 days after appropriate treatment and report no sexual contact during the post-treatment follow-up period; (2) patients with a positive test-of-cure (i.e., positive culture ≥ 72 hours or positive NAAT ≥ 7 days after receiving recommended treatment) when no sexual contact is reported during the post-treatment follow-up period; (3) persons who have a positive culture on test-of-cure (if obtained) if there is evidence of decreased susceptibility to cephalosporins on antimicrobial susceptibility testing, regardless of whether sexual contact is reported during the post-treatment follow-up period.
:::*1.3 '''Gonococcal conjunctivitis'''
::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
:::::Note: Consider one-time lavage of the infected eye with saline solution.
:::::*1.3.1 '''Management of sex partners'''
::::::*Patients should be instructed to refer their sex partners for evaluation and treatment.
:::*1.4 '''Disseminated gonococcal infection'''
:::::*1.4.1 '''Arthritis and arthritis-dermatitis syndrome '''
::::::*Preferred regimen: [[Ceftriaxone]] 1 g IM/IV q24h for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::*Alternative regimen (1): [[Cefotaxime]] 1 g IV q8h for 7 days
::::::*Alternative regimen (2): [[Ceftizoxime]] 1 g IV q8h for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose
:::::*1.4.2 '''Gonococcal meningitis and endocarditis'''
::::::*Preferred regimen: [[Ceftriaxone]] 1-2 g IV q 12-24 h for 10-14 days {{and}} [[Azithromycin]] 1 g PO in a single dose
::*2. '''Gonococcal infections among neonates'''
:::*2.1 '''Ophthalmia neonatorum caused by N. gonorrhoeae'''
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
:::::*2.1.1 '''Management of mothers and their sex partners'''
::::::*Mothers of infants with ophthalmia neonatorum caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
:::*2.2 '''Disseminated gonococcal infection and gonococcal scalp abscesses in neonates'''
::::*Preferred regimen (1): [[Ceftriaxone]] 25-50 mg/kg/day IM/IV q24h for 7 days
::::*Preferred regimen (2): [[Cefotaxime]] 25 mg/kg IM/IV q12h for 7 days.
::::*Note (1): The duration of treatment is 10-14 days if meningitis is documented.
::::*Note (2): Ceftriaxone should be administered cautiously to hyperbilirubinemic infants, especially those born prematurely.
:::::*2.2.1 '''Management of mothers and their sex partners'''
::::::*Mothers of infants who have DGI or scalp abscesses caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
:::*2.3 '''Neonates born to mothers who have gonococcal infection'''
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
:::::*2.3.1 '''Management of mothers and their sex partners'''
::::::*Mothers who have gonorrhea and their sex partners should be evaluated, tested, and presumptively treated for gonorrhea.
::*3. '''Gonococcal infections among infants and children'''
:::*3.1 '''Infants and children who weigh ≤ 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
:::*3.2 '''Children who weigh > 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1g PO in a single dose
::::*Alternative regimen: [[Cefixime]] 400 mg PO single dose {{and}} [[Azithromycin]] 1 g PO single dose.(If ceftriaxone is not available)
:::*3.3 '''Children who weigh ≤ 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen: [[Ceftriaxone]] 50 mg/kg (maximum dose: 1 g) IM/IV q24h for 7 days
:::*3.4 '''Children who weigh > 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen: [[Ceftriaxone]] 1 g IM/IV q24h for 7 days

===Follow-Up===
A test-of-cure is not needed for patients who receive a diagnosis of uncomplicated [[urogenital]] or [[rectal]] gonorrhea who are treated with any of the recommended or alternative regimens. However, any person with [[pharyngeal]] gonorrhea who is treated with an alternative regimen should return 14 days after treatment for a test-of-cure using either culture or [[NAAT]]. If the [[NAAT]] is positive, effort should be made to perform a confirmatory culture before commencing retreatment.<ref name="CDC-Guidline"> Centers for disease control and prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm Accessed on September 14, 2016</ref>

*All positive cultures for test-of-cure should undergo [[antibiotic resistance|antimicrobial susceptibility]] testing
*Men or women who have been treated for gonorrhea should be retested 3 months after treatment regardless of whether they believe their sex partners were treated
*If retesting at 3 months is not possible, clinicians should retest whenever patients next present for medical care within 12 months following initial treatment

==References==
{{Reflist|2}}

{{WH}}
{{WS}}

[[Category:Gynecology]]
[[Category:FinalQCRequired]]
[[Category:Emergency mdicine]]
[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Rheumatology]]
[[Category:Dermatology]]
[[Category:Neurology]]
[[Category:Cardiology]]
[[Category:Urology]]
[[Category:Gastroenterology]]

Gonorrhea medical therapy

2021-08-21T12:32:32Z

Dr.Nuha: /* Medical Therapy */

__NOTOC__
{{Gonorrhea}}
{{CMG}}; {{AE}} {{SaraM}}

==Overview==
The mainstay of therapy for gonococcal infections is [[antimicrobial|antimicrobial therapy]]. Gonorrhea treatment is complicated by the ability of ''N. gonorrhoeae'' to develop resistance to [[antimicrobials]]; accordingly, a combination therapy with [[Azithromycin]] and a [[cephalosporin]] is used to improve treatment efficacy and potentially slow the emergence and spread of [[antibiotic resistance]].<ref>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref>

==Medical Therapy==

*The mainstay of therapy for gonococcal infections is [[antimicrobial|antimicrobial therapy]].
*Gonorrhea treatment is complicated by the ability of ''[[Neisseria gonorrhoeae]]'' to develop resistance to [[antimicrobials]]; accordingly, a combination therapy with [[Azithromycin]] and a [[cephalosporin]] is used to improve treatment efficacy and potentially slow the emergence and spread of resistance.
*[[Ceftriaxone]] and [[cefixime]] exist as the last remaining options for empirical first-line treatment of ''[[Neisseria gonorrhoeae]]''.<ref name="CDC-Guidline"> Centers for disease control and prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm Accessed on September 14, 2016</ref>

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
|+
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF|Type of gonococcal infection}}
! style="background: #4479BA; width: 450px;" |{{fontcolor|#FFF|Regimen}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Uncomplicated Recommended regimen'''
| style="padding: 5px 5px; background: #F5F5F5;" | 

* [[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)

* For persons weighing ≥150 kg (300 lb), 1 g of IM [[ceftriaxone]] should be administered.
* [[Chlamydial]] co-infection:
** add [[doxycycline]] 100 mg orally twice daily for 7 days. ([[azithromycin]] 1 g as a single dose is recommended to treat chlamydia During pregnancy)
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Uncomplicated Alternative regimen'''
| style="padding: 5px 5px; background: #F5F5F5;" |
* [[Gentamicin]] 240 mg IM as a single dose plus [[azithromycin]] 2 g orally as a single dose OR

* [[Cefixime]] 800 mg orally as a single dose.

(Add [[doxycycline]] 100 mg orally twice daily for 7 days f [[Chlamydia infection|chlamydial]] infection has not been excluded)

(During [[pregnancy]], [[azithromycin]] 1 g as a single dose is recommended to treat chlamydia.
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Alternative regimens for severe Cephalosporin allergy'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
*[[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose (alternative)
*Test of cure should be performed after 1 week
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Arthritis and arthritis-dermatitis syndrome '''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] 1 g IM/IV q24h for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose
*[[Cefotaxime]] 1 g IV q8h for 7 days (alternative)
*[[Ceftizoxime]] 1 g IV q8h for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose (alternative)
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Gonococcal meningitis and endocarditis'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] 1-2 g IV q 12-24 h for 10-14 days {{and}} [[Azithromycin]] 1 g PO in a single dose
|}

===Antimicrobial Regimen===

:*'''Neisseria gonorrhoeae treatment'''<ref>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref>
::*1. '''Gonococcal infections in adolescents and adults'''
:::*1.1 '''Uncomplicated gonococcal infections of the cervix, urethra, and rectum'''
::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
::::*Alternative regimen: [[Cefixime]] 400 mg PO in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose (if ceftriaxone is not available)
:::*1.2 '''Uncomplicated gonococcal infections of the pharynx'''
::::*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
::::** For persons weighing ≥150 kg (300 lb), 1 g of IM [[ceftriaxone]] should be administered.
::::** for chlamydia co-infection add doxycycline 100 mg orally twice a day for 7 days. (During pregnancy, azithromycin 1 g as a single dose is recommended to treat chlamydia)
::::** No reliable alternative treatments are available for pharyngeal gonorrhea. For persons with a history of a beta-lactam allergy, a thorough assessment of the reaction is recommended
:::::*1.2.1 '''Management of sex partners'''
::::::*Expedited partner therapy: [[Cefixime]] 400 mg PO in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::*Note (1): Recent sex partners (i.e., persons having sexual contact with the infected patient within the 60 days preceding onset of symptoms or gonorrhea diagnosis) should be referred for evaluation, testing, and presumptive dual treatment.
::::::*Note (2): If the patient’s last potential sexual exposure was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated.
::::::*Note (3): To avoid reinfection, sex partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sexual partner(s) have completed treatment and after resolution of symptoms, if present.
:::::*1.2.2 '''Allergy, intolerance, and adverse reactions'''
::::::*Preferred regimen (1): [[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
::::::*Preferred regimen (2): [[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
::::::*Note: Use of [[Ceftriaxone]] or [[Cefixime]] is contraindicated in persons with a history of an IgE-mediated penicillin allergy (e.g., anaphylaxis, Stevens Johnson syndrome, and toxic epidermal necrolysis).
:::::*1.2.3 '''Pregnancy'''
::::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
:::::*1.2.4 '''Suspected cephalosporin treatment failure'''
::::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::*Alternative regimen (1): [[Gemifloxacin]] 320 mg PO single dose {{and}} [[Azithromycin]] 2 g PO single dose (when isolates have elevated cephalosporin MICs)
::::::*Alternative regimen (2): [[Gentamicin]] 240 mg IM single dose {{and}} [[Azithromycin]] 2 g PO single dose (when isolates have elevated cephalosporin MICs)
::::::*Alternative regimen (3): [[Ceftriaxone]] 250 mg IM as a single dose {{and}} [[Azithromycin]] 2 g PO as a single dose (failure after treatment with [[Cefixime]] and [[Azithromycin]])
::::::*Note: Treatment failure should be considered in: (1) patients whose symptoms do not resolve within 3–5 days after appropriate treatment and report no sexual contact during the post-treatment follow-up period; (2) patients with a positive test-of-cure (i.e., positive culture ≥ 72 hours or positive NAAT ≥ 7 days after receiving recommended treatment) when no sexual contact is reported during the post-treatment follow-up period; (3) persons who have a positive culture on test-of-cure (if obtained) if there is evidence of decreased susceptibility to cephalosporins on antimicrobial susceptibility testing, regardless of whether sexual contact is reported during the post-treatment follow-up period.
:::*1.3 '''Gonococcal conjunctivitis'''
::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
:::::Note: Consider one-time lavage of the infected eye with saline solution.
:::::*1.3.1 '''Management of sex partners'''
::::::*Patients should be instructed to refer their sex partners for evaluation and treatment.
:::*1.4 '''Disseminated gonococcal infection'''
:::::*1.4.1 '''Arthritis and arthritis-dermatitis syndrome '''
::::::*Preferred regimen: [[Ceftriaxone]] 1 g IM/IV q24h for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::*Alternative regimen (1): [[Cefotaxime]] 1 g IV q8h for 7 days
::::::*Alternative regimen (2): [[Ceftizoxime]] 1 g IV q8h for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose
:::::*1.4.2 '''Gonococcal meningitis and endocarditis'''
::::::*Preferred regimen: [[Ceftriaxone]] 1-2 g IV q 12-24 h for 10-14 days {{and}} [[Azithromycin]] 1 g PO in a single dose
::*2. '''Gonococcal infections among neonates'''
:::*2.1 '''Ophthalmia neonatorum caused by N. gonorrhoeae'''
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
:::::*2.1.1 '''Management of mothers and their sex partners'''
::::::*Mothers of infants with ophthalmia neonatorum caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
:::*2.2 '''Disseminated gonococcal infection and gonococcal scalp abscesses in neonates'''
::::*Preferred regimen (1): [[Ceftriaxone]] 25-50 mg/kg/day IM/IV q24h for 7 days
::::*Preferred regimen (2): [[Cefotaxime]] 25 mg/kg IM/IV q12h for 7 days.
::::*Note (1): The duration of treatment is 10-14 days if meningitis is documented.
::::*Note (2): Ceftriaxone should be administered cautiously to hyperbilirubinemic infants, especially those born prematurely.
:::::*2.2.1 '''Management of mothers and their sex partners'''
::::::*Mothers of infants who have DGI or scalp abscesses caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
:::*2.3 '''Neonates born to mothers who have gonococcal infection'''
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
:::::*2.3.1 '''Management of mothers and their sex partners'''
::::::*Mothers who have gonorrhea and their sex partners should be evaluated, tested, and presumptively treated for gonorrhea.
::*3. '''Gonococcal infections among infants and children'''
:::*3.1 '''Infants and children who weigh ≤ 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
:::*3.2 '''Children who weigh > 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1g PO in a single dose
::::*Alternative regimen: [[Cefixime]] 400 mg PO single dose {{and}} [[Azithromycin]] 1 g PO single dose.(If ceftriaxone is not available)
:::*3.3 '''Children who weigh ≤ 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen: [[Ceftriaxone]] 50 mg/kg (maximum dose: 1 g) IM/IV q24h for 7 days
:::*3.4 '''Children who weigh > 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen: [[Ceftriaxone]] 1 g IM/IV q24h for 7 days

===Follow-Up===
A test-of-cure is not needed for patients who receive a diagnosis of uncomplicated [[urogenital]] or [[rectal]] gonorrhea who are treated with any of the recommended or alternative regimens. However, any person with [[pharyngeal]] gonorrhea who is treated with an alternative regimen should return 14 days after treatment for a test-of-cure using either culture or [[NAAT]]. If the [[NAAT]] is positive, effort should be made to perform a confirmatory culture before commencing retreatment.<ref name="CDC-Guidline"> Centers for disease control and prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm Accessed on September 14, 2016</ref>

*All positive cultures for test-of-cure should undergo [[antibiotic resistance|antimicrobial susceptibility]] testing
*Men or women who have been treated for gonorrhea should be retested 3 months after treatment regardless of whether they believe their sex partners were treated
*If retesting at 3 months is not possible, clinicians should retest whenever patients next present for medical care within 12 months following initial treatment

==References==
{{Reflist|2}}

{{WH}}
{{WS}}

[[Category:Gynecology]]
[[Category:FinalQCRequired]]
[[Category:Emergency mdicine]]
[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Rheumatology]]
[[Category:Dermatology]]
[[Category:Neurology]]
[[Category:Cardiology]]
[[Category:Urology]]
[[Category:Gastroenterology]]

Bipolar disorder causes

2021-08-16T09:43:59Z

Dr.Nuha: /* Psychosocial factors */

__NOTOC__
{{Bipolar disorder}}
{{CMG}} {{AE}} {{nuha}}
==Overview==
A number of factors can be involved in bipolar disorder including [[genetic]], [[biochemical]], [[Psychodynamics|psychodynamic]], and [[Environmental factor|environmental]] factors. paternal age increase the risk of bipolar disorder in one’s offspring that could be due to increased [[genetic]] [[mutations]] during [[spermatogenesis]]. Stressful life events may be associated with onset of bipolar disorder and a more severe course of illness.The disorder runs in families. More than two-thirds of people with bipolar disorder have at least one close relative with the disorder or with unipolar [[Major depressive disorder|major depressio]]<nowiki/>n. Bipolar disorder is associated with [[immune system]] dysregulation.

==Causes==

===[[Psychosocial]] factors===

*[[Paternal age effect|Paternal age]] increase the risk of bipolar disorder in [[offspring]] due to increased [[genetic mutations]] during [[spermatogenesis]]. As an example, a national registry study found that the risk of bipolar disorder in offspring of fathers 45 years and older was six times greater.<ref name="pmid24499422">{{cite journal| author=Chudal R, Gissler M, Sucksdorff D, Lehti V, Suominen A, Hinkka-Yli-Salomäki S | display-authors=etal| title=Parental age and the risk of bipolar disorders. | journal=Bipolar Disord | year= 2014 | volume= 16 | issue= 6 | pages= 624-32 | pmid=24499422 | doi=10.1111/bdi.12182 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24499422 }}</ref>

*[[Stress]] and a history of childhood [[physical abuse]] associated with onset of bipolar disorder and a more severe course of [[illness]].<ref name="pmid22806701">{{cite journal| author=Sugaya L, Hasin DS, Olfson M, Lin KH, Grant BF, Blanco C| title=Child physical abuse and adult mental health: a national study. | journal=J Trauma Stress | year= 2012 | volume= 25 | issue= 4 | pages= 384-92 | pmid=22806701 | doi=10.1002/jts.21719 | pmc=3805363 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22806701 }}</ref><ref name="pmid25597794">{{cite journal| author=Janiri D, Sani G, Danese E, Simonetti A, Ambrosi E, Angeletti G | display-authors=etal| title=Childhood traumatic experiences of patients with bipolar disorder type I and type II. | journal=J Affect Disord | year= 2015 | volume= 175 | issue= | pages= 92-7 | pmid=25597794 | doi=10.1016/j.jad.2014.12.055 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25597794 }}</ref>

 
===[[Heritability]] or [[inheritance]]===

*More than two-thirds of people with bipolar disorder have at least one close relative with the disorder or with unipolar [[Major depressive disorder|major depression.<ref> {{Citation | last = McGuffin | first = P | last2 = Rijsdijk | first2 = F | last3 = Andrew | first3 = M | last4 = Sham | first4 = P | last5 = Katz | first5 = R | last6 = Cardno | first6 = A | title = The Heritability of Bipolar Affective Disorder and the Genetic Relationship to Unipolar Depression | journal = Archives of General Psychiatry | volume = 60 | issue = 5 | pages = 497-502 | year = 2003 | url = http://archpsyc.ama-assn.org/cgi/content/abstract/60/5/497 }} </ref>]][./Bipolar_disorder_causes#cite_note-4 <nowiki>[4]</nowiki>]
*[[Genes]] that are involved in bipolar disorder have been studied, but no single [[gene]] has been identified.<ref name="pmid23663951">{{cite journal| author=Craddock N, Sklar P| title=Genetics of bipolar disorder. | journal=Lancet | year= 2013 | volume= 381 | issue= 9878 | pages= 1654-62 | pmid=23663951 | doi=10.1016/S0140-6736(13)60855-7 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23663951 }}</ref> it may involve many [[genes]] with small effects.<ref name="pmid16603476">{{cite journal| author=Finn CT, Smoller JW| title=Genetic counseling in psychiatry. | journal=Harv Rev Psychiatry | year= 2006 | volume= 14 | issue= 2 | pages= 109-21 | pmid=16603476 | doi=10.1080/10673220600655723 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16603476 }}</ref>
*Studies found several [[genetic]] variants are associated with bipolar disorder. One possible [[locus]] is [[CACNA1C]], which codes for a [[calcium channel]] that is involved in channel gating.<ref name="pmid236639512">Craddock N, Sklar P (2013) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=23663951 Genetics of bipolar disorder.] ''Lancet'' 381 (9878):1654-62. [http://dx.doi.org/10.1016/S0140-6736(13)60855-7 DOI:10.1016/S0140-6736(13)60855-7] PMID: [https://pubmed.gov/23663951 23663951]</ref><ref name="pmid18711365">{{cite journal| author=Ferreira MA, O'Donovan MC, Meng YA, Jones IR, Ruderfer DM, Jones L | display-authors=etal| title=Collaborative genome-wide association analysis supports a role for ANK3 and CACNA1C in bipolar disorder. | journal=Nat Genet | year= 2008 | volume= 40 | issue= 9 | pages= 1056-8 | pmid=18711365 | doi=10.1038/ng.209 | pmc=2703780 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18711365 }}</ref> other [[genes]] are ''[[ANK3]],'' and ''[[CLOCK]]'' [[genes]] especially bipolar type I disorder.<ref name="pmid18317468">{{cite journal| author=Sklar P, Smoller JW, Fan J, Ferreira MA, Perlis RH, Chambert K | display-authors=etal| title=Whole-genome association study of bipolar disorder. | journal=Mol Psychiatry | year= 2008 | volume= 13 | issue= 6 | pages= 558-69 | pmid=18317468 | doi=10.1038/sj.mp.4002151 | pmc=3777816 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18317468 }}</ref><ref name="pmid17379666">{{cite journal| author=Roybal K, Theobold D, Graham A, DiNieri JA, Russo SJ, Krishnan V | display-authors=etal| title=Mania-like behavior induced by disruption of CLOCK. | journal=Proc Natl Acad Sci U S A | year= 2007 | volume= 104 | issue= 15 | pages= 6406-11 | pmid=17379666 | doi=10.1073/pnas.0609625104 | pmc=1851061 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17379666 }}</ref>
*A [[meta-analysis]] suggests that other [[biologic]] pathways are [[cardiac]] [[Adrenergic|β-adrenergic]] [[Cell signaling|signaling]], [[cardiac hypertrophy]] signaling, [[Corticotropin-releasing hormone|corticotropin releasing hormone]] [[Cell signaling|signaling]], [[endothelin 1]] [[Cell signaling|signaling]], [[glutamate]] [[Cell signaling|signaling]], and [[phospholipase C]] [[Cell signaling|signaling]].<ref name="pmid24718920">{{cite journal| author=Nurnberger JI, Koller DL, Jung J, Edenberg HJ, Foroud T, Guella I | display-authors=etal| title=Identification of pathways for bipolar disorder: a meta-analysis. | journal=JAMA Psychiatry | year= 2014 | volume= 71 | issue= 6 | pages= 657-64 | pmid=24718920 | doi=10.1001/jamapsychiatry.2014.176 | pmc=4523227 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24718920 }}</ref>
*In addition, a meta-analysis studies identified three [[Single nucleotide polymorphism|single-nucleotide polymorphisms]] on [[Chromosome|chromosomes]] 3 and 10. One of them is located on a brain expressed [[gene]] that encodes [[Calcium channels|calcium channel subunits]]; [[calcium signaling]] regulates [[neuronal]] [[growth]] and [[development]].<ref name="pmid23453886">{{cite journal| author=Serretti A, Fabbri C| title=Shared genetics among major psychiatric disorders. | journal=Lancet | year= 2013 | volume= 381 | issue= 9875 | pages= 1339-1341 | pmid=23453886 | doi=10.1016/S0140-6736(13)60223-8 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23453886 }}</ref><ref name="pmid23453885">{{cite journal| author=Cross-Disorder Group of the Psychiatric Genomics Consortium| title=Identification of risk loci with shared effects on five major psychiatric disorders: a genome-wide analysis. | journal=Lancet | year= 2013 | volume= 381 | issue= 9875 | pages= 1371-1379 | pmid=23453885 | doi=10.1016/S0140-6736(12)62129-1 | pmc=3714010 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23453885 }}</ref>

===[[Inflammation]]===

*Bipolar disorder is associated with [[immune system]] dysregulation. [[Cytokines]] (eg, [[Interleukin 4|interleukin-4]] and [[tumor necrosis factor-alpha]]) and [[Cytokine receptor|cytokine receptors]] are elevated in patients with bipolar disorder<ref name="pmid23419545">{{cite journal| author=Modabbernia A, Taslimi S, Brietzke E, Ashrafi M| title=Cytokine alterations in bipolar disorder: a meta-analysis of 30 studies. | journal=Biol Psychiatry | year= 2013 | volume= 74 | issue= 1 | pages= 15-25 | pmid=23419545 | doi=10.1016/j.biopsych.2013.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23419545 }}</ref>
*A meta-analysis found that levels of [[C-reactive protein|C reactive protein]] were higher in patients than controls, and the difference was small to moderate.<ref name="pmid25742201">{{cite journal| author=Dargél AA, Godin O, Kapczinski F, Kupfer DJ, Leboyer M| title=C-reactive protein alterations in bipolar disorder: a meta-analysis. | journal=J Clin Psychiatry | year= 2015 | volume= 76 | issue= 2 | pages= 142-50 | pmid=25742201 | doi=10.4088/JCP.14r09007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25742201 }}</ref>

===[[Biochemical]] factors===

*A number of [[neurotransmitters]] have been linked to this [[disorder]].
*[[Catecholamine]] [[hypothesis]], state that increase in [[epinephrine]] and [[norepinephrine]] causes [[mania]] and a decrease in [[epinephrine]] and [[norepinephrine]] causes [[depression]].
*Drugs that increase levels of [[Monoamine|monoamines]], including [[serotonin]], [[norepinephrine]], or [[dopamine]], can all potentially trigger [[mania]] for instance [[Abuse|drug of abuse]] like [[cocaine]].<ref name="pmid291795762">{{cite journal| author=Starzer MSK, Nordentoft M, Hjorthøj C| title=Rates and Predictors of Conversion to Schizophrenia or Bipolar Disorder Following Substance-Induced Psychosis. | journal=Am J Psychiatry | year= 2018 | volume= 175 | issue= 4 | pages= 343-350 | pmid=29179576 | doi=10.1176/appi.ajp.2017.17020223 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29179576 }}</ref>
*Patients with substance use-induced psychosis may develop schizophrenia or bipolar disorder within five years.<ref name="pmid29179576">{{cite journal| author=Starzer MSK, Nordentoft M, Hjorthøj C| title=Rates and Predictors of Conversion to Schizophrenia or Bipolar Disorder Following Substance-Induced Psychosis. | journal=Am J Psychiatry | year= 2018 | volume= 175 | issue= 4 | pages= 343-350 | pmid=29179576 | doi=10.1176/appi.ajp.2017.17020223 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29179576 }}</ref>
*A [[Postmortem|postmortem study]] of the [[frontal lobes]] of individuals with these disorders revealed that the [[glutamate]] levels were increased<ref name="pmid175742162">{{cite journal| author=Hashimoto K, Sawa A, Iyo M| title=Increased levels of glutamate in brains from patients with mood disorders. | journal=Biol Psychiatry | year= 2007 | volume= 62 | issue= 11 | pages= 1310-6 | pmid=17574216 | doi=10.1016/j.biopsych.2007.03.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17574216 }}</ref>.

===Neurophysiologic factors===

*A meta-analysis shows that decreased activation of [[Grey matter|gray matter]] in a cortical-cognitive brain network, which has been associated with the emotion regulation in patients with bipolar disorder. <ref name="pmid21470688">{{cite journal| author=Houenou J, Frommberger J, Carde S, Glasbrenner M, Diener C, Leboyer M | display-authors=etal| title=Neuroimaging-based markers of bipolar disorder: evidence from two meta-analyses. | journal=J Affect Disord | year= 2011 | volume= 132 | issue= 3 | pages= 344-55 | pmid=21470688 | doi=10.1016/j.jad.2011.03.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21470688 }}</ref>
*There is functional and [[anatomic]] alterations in [[brain]] networks. for instance, there is activation in [[ventral]] [[Limbic system|limbic]] [[brain]] regions that mediate the experience of [[emotions]]. <ref name="pmid214706882">{{cite journal| author=Houenou J, Frommberger J, Carde S, Glasbrenner M, Diener C, Leboyer M | display-authors=etal| title=Neuroimaging-based markers of bipolar disorder: evidence from two meta-analyses. | journal=J Affect Disord | year= 2011 | volume= 132 | issue= 3 | pages= 344-55 | pmid=21470688 | doi=10.1016/j.jad.2011.03.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21470688 }}</ref>

 
==References==

{{reflist|2}}
{{WH}}
{{WS}}

Bipolar disorder history and symptoms

2021-08-05T01:28:18Z

Dr.Nuha: /* Overview */

__NOTOC__
{{Bipolar disorder}}
{{CMG}} {{AE}} {{nuha}}
==Overview==
Bipolar disorder is a cyclic illness where people periodically exhibit elevated (Manic) and depressive episodes. Most people will experience a number of episodes, averaging 0.4 to 0.7 a year with each lasting 3-6 months. Late adolescence and early adulthood are peak years for the onset of the illness. These are critical periods in a young adult's social and vocational development, and they can be severely disrupted by disease onset. Clinical assessment for patients with a manic, hypomanic, or mixed episode, or those with a bipolar depression episode, including information about the patient’s clinical and psychosocial status, medical and psychiatric comorbidities, current and past medications as well as medication compliance, and substance use.

==History and Symptoms==
Bipolar disorder is a cyclic illness where people periodically exhibit elevated (Manic) and depressive episodes. Most people will experience a number of episodes, averaging 0.4 to 0.7 a year with each lasting 3-6 months.<ref>
{{Citation
| last = Kessler
| first = RC
| last2 = McGonagle
| first2 = KA
| last3 = Zhao
| first3 = S
| last4 = Nelson
| first4 = CB
| last5 = Hughes
| first5 = M
| last6 = Eshleman
| first6 = S
| last7 = Wittchen
| first7 = HU
| last8 = Kendler
| first8 = KS
| title = Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States
| journal = Archives of General Psychiatry
| volume = 51
| issue = 1
| pages = 8-19
| year = 1994
| url = http://archpsyc.ama-assn.org/cgi/content/abstract/51/1/8
}}
</ref> Late adolescence and early adulthood are peak years for the onset of the illness.<ref name="Christie88">{{cite journal|author=Christie KA, Burke JD Jr, Regier DA, Rae DS, Boyd JH, Locke BZ |year=1988 |title=Epidemiologic evidence for early onset of mental disorders and higher risk of drug abuse in young adults |journal=Am J Psychiatry |volume=145 |pages=971-975 |id=|url=http://www.ajp.psychiatryonline.org/cgi/content/abstract/145/8/971 (abstract) |accessdate = 2007-07-01 }}</ref><ref>Goodwin & Jamison. p121</ref> These are critical periods in a young adult's social and vocational development, and they can be severely disrupted by disease onset.

===Prodrome===
Prodromal signs and symptoms such as irritability, anxiety, mood liability (“mood swings”), agitation, aggressiveness, sleep disturbance, and hyperactivity may precede onset of bipolar disorder.

===Manic episodes===
The course of illness in mania may be marked by a sudden onset, and episodes progress quickly over a few days. The duration of manic episodes ranges from weeks to months.<ref name="DSMV3">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>

*Involve clinically significant changes in mood, energy, activity, behavior, sleep, and cognition.
*Abnormally elevated, irritable, and labile mood is a core symptom required to diagnose mania.
*Classic mania is marked by an unusually good, euphoric, or high mood, which may be accompanied by disinhibition, disregard for social boundaries, expansiveness.
*Another core diagnostic symptom of mania is persistently increased energy and activity.
*Increased planning and activity is typically marked by impulsivity, poor judgement.
*Patients are often unable to complete the many tasks or projects that are started.
*Manic patients generally have an exaggerated sense of wellbeing and self-confidence, which may extend to grandiosity of psychotic proportions.
*There is decreased need for sleep.
*Common cognitive symptoms of mania include increased mental activity, racing thoughts, distractibility, and difficulty distinguishing between relevant and irrelevant thoughts; these symptoms result in flight of ideas.
*In addition, patients may not recall events that occur during manic episodes.
*Manic speech is generally loud, pressured or accelerated, and difficult to interrupt.

 

===Hypomania <ref name="DSMV4">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>===

*Hypomanic episodes are characterized by changes in mood, energy, activity, behavior, sleep, and cognition that are similar to those of mania, but less severe.
*psychotic symptoms do not occur in hypomania, and hypomania never necessitates hospitalization.
*The course of hypomania is such that it generally begins suddenly and progresses quickly over one to two days. Episodes typically resolve within several weeks.

===Major depression===

*Episodes of major depression involve clinically significant changes in mood, behavior, energy, sleep, and cognition.
*Bipolar major depression is generally characterized by dysphoria, as well as slowing in the pace of mental and physical activity (eg, speech is slow and soft, and output reduced).
*Interest in pleasurable activities (eg, sex) is minimal, energy is low, and memory and concentration are impaired.
*Appetite is typically diminished and accompanied by weight loss.
*Sleep disturbances (insomnia or hypersomnia) often occur in bipolar depression.
*Other features of major depression include poor eye contact, poor hygiene, messy appearance, feelings of hopelessness and helplessness,

 

===Mixed features===

*Episodes of bipolar mania, hypomania, and major depression can be accompanied by symptoms of the opposite polarity, and are referred to as mood episodes with mixed features (eg, major depression with mixed features or hypomania with mixed features).
*Manic or hypomanic episodes with mixed features are characterized by episodes that meet full criteria for mania or hypomania, and at least three of the following symptoms during most days of the episode:<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
**Depressed mood
**Diminished interest or pleasure in most activities
**Psychomotor retardation
**Low energy
**Excessive guilt or thoughts of worthlessness
**Recurrent thoughts about death or suicide, or suicide attempt

*Major depressive episodes with mixed features are characterized by episodes that meet full criteria for major depression, and at least three of the following symptoms during most days of the episode:<ref name="DSMV2">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
**Elevated or expansive mood
**Inflated self-esteem or grandiosity
**More talkative than usual or pressured speech
**Flight of ideas
**Increased energy
**Decreased need for sleep

*Red flags for mixed features include the presence of clinically significant agitation, anxiety, or irritability.
*Patients with mixed features are at greater risk for suicidal ideation and comorbid anxiety disorders and substance use disorders.<ref name="pmid23223893">{{cite journal| author=Swann AC, Lafer B, Perugi G, Frye MA, Bauer M, Bahk WM | display-authors=etal| title=Bipolar mixed states: an international society for bipolar disorders task force report of symptom structure, course of illness, and diagnosis. | journal=Am J Psychiatry | year= 2013 | volume= 170 | issue= 1 | pages= 31-42 | pmid=23223893 | doi=10.1176/appi.ajp.2012.12030301 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23223893 }}</ref>
*The esponse to treatment is often poorer in mood episodes with mixed features than in pure bipolar major depression or pure mania.<ref name="pmid20368510">{{cite journal| author=Solomon DA, Leon AC, Coryell WH, Endicott J, Li C, Fiedorowicz JG | display-authors=etal| title=Longitudinal course of bipolar I disorder: duration of mood episodes. | journal=Arch Gen Psychiatry | year= 2010 | volume= 67 | issue= 4 | pages= 339-47 | pmid=20368510 | doi=10.1001/archgenpsychiatry.2010.15 | pmc=3677763 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20368510 }}</ref>

==References==

{{reflist|2}}
{{WH}}
{{WS}}

Bipolar disorder history and symptoms

2021-08-05T01:26:37Z

Dr.Nuha: /* History and Symptoms */

__NOTOC__
{{Bipolar disorder}}
{{CMG}} {{AE}} {{nuha}}
==Overview==
==History and Symptoms==
Bipolar disorder is a cyclic illness where people periodically exhibit elevated (Manic) and depressive episodes. Most people will experience a number of episodes, averaging 0.4 to 0.7 a year with each lasting 3-6 months.<ref>
{{Citation
| last = Kessler
| first = RC
| last2 = McGonagle
| first2 = KA
| last3 = Zhao
| first3 = S
| last4 = Nelson
| first4 = CB
| last5 = Hughes
| first5 = M
| last6 = Eshleman
| first6 = S
| last7 = Wittchen
| first7 = HU
| last8 = Kendler
| first8 = KS
| title = Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States
| journal = Archives of General Psychiatry
| volume = 51
| issue = 1
| pages = 8-19
| year = 1994
| url = http://archpsyc.ama-assn.org/cgi/content/abstract/51/1/8
}}
</ref> Late adolescence and early adulthood are peak years for the onset of the illness.<ref name="Christie88">{{cite journal|author=Christie KA, Burke JD Jr, Regier DA, Rae DS, Boyd JH, Locke BZ |year=1988 |title=Epidemiologic evidence for early onset of mental disorders and higher risk of drug abuse in young adults |journal=Am J Psychiatry |volume=145 |pages=971-975 |id=|url=http://www.ajp.psychiatryonline.org/cgi/content/abstract/145/8/971 (abstract) |accessdate = 2007-07-01 }}</ref><ref>Goodwin & Jamison. p121</ref> These are critical periods in a young adult's social and vocational development, and they can be severely disrupted by disease onset.

=== Prodrome ===
Prodromal signs and symptoms such as irritability, anxiety, mood liability (“mood swings”), agitation, aggressiveness, sleep disturbance, and hyperactivity may precede onset of bipolar disorder.

=== Manic episodes ===
The course of illness in mania may be marked by a sudden onset, and episodes progress quickly over a few days. The duration of manic episodes ranges from weeks to months.<ref name="DSMV3">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>

* Involve clinically significant changes in mood, energy, activity, behavior, sleep, and cognition.
* Abnormally elevated, irritable, and labile mood is a core symptom required to diagnose mania.
* Classic mania is marked by an unusually good, euphoric, or high mood, which may be accompanied by disinhibition, disregard for social boundaries, expansiveness.
* Another core diagnostic symptom of mania is persistently increased energy and activity.
* Increased planning and activity is typically marked by impulsivity, poor judgement.
* Patients are often unable to complete the many tasks or projects that are started.
* Manic patients generally have an exaggerated sense of wellbeing and self-confidence, which may extend to grandiosity of psychotic proportions.
* There is decreased need for sleep.
* Common cognitive symptoms of mania include increased mental activity, racing thoughts, distractibility, and difficulty distinguishing between relevant and irrelevant thoughts; these symptoms result in flight of ideas.
* In addition, patients may not recall events that occur during manic episodes.
* Manic speech is generally loud, pressured or accelerated, and difficult to interrupt.

 

=== Hypomania <ref name="DSMV4">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref> ===

* Hypomanic episodes are characterized by changes in mood, energy, activity, behavior, sleep, and cognition that are similar to those of mania, but less severe.
* psychotic symptoms do not occur in hypomania, and hypomania never necessitates hospitalization.
* The course of hypomania is such that it generally begins suddenly and progresses quickly over one to two days. Episodes typically resolve within several weeks.

=== Major depression ===

* Episodes of major depression involve clinically significant changes in mood, behavior, energy, sleep, and cognition.
* Bipolar major depression is generally characterized by dysphoria, as well as slowing in the pace of mental and physical activity (eg, speech is slow and soft, and output reduced).
* Interest in pleasurable activities (eg, sex) is minimal, energy is low, and memory and concentration are impaired.
* Appetite is typically diminished and accompanied by weight loss.
* Sleep disturbances (insomnia or hypersomnia) often occur in bipolar depression.
* Other features of major depression include poor eye contact, poor hygiene, messy appearance, feelings of hopelessness and helplessness,

 

=== Mixed features ===

* Episodes of bipolar mania, hypomania, and major depression can be accompanied by symptoms of the opposite polarity, and are referred to as mood episodes with mixed features (eg, major depression with mixed features or hypomania with mixed features).
* Manic or hypomanic episodes with mixed features are characterized by episodes that meet full criteria for mania or hypomania, and at least three of the following symptoms during most days of the episode:<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
** Depressed mood
** Diminished interest or pleasure in most activities
** Psychomotor retardation
** Low energy
** Excessive guilt or thoughts of worthlessness
** Recurrent thoughts about death or suicide, or suicide attempt

* Major depressive episodes with mixed features are characterized by episodes that meet full criteria for major depression, and at least three of the following symptoms during most days of the episode:<ref name="DSMV2">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
** Elevated or expansive mood
** Inflated self-esteem or grandiosity
** More talkative than usual or pressured speech
** Flight of ideas
** Increased energy
** Decreased need for sleep

* Red flags for mixed features include the presence of clinically significant agitation, anxiety, or irritability.
* Patients with mixed features are at greater risk for suicidal ideation and comorbid anxiety disorders and substance use disorders.<ref name="pmid23223893">{{cite journal| author=Swann AC, Lafer B, Perugi G, Frye MA, Bauer M, Bahk WM | display-authors=etal| title=Bipolar mixed states: an international society for bipolar disorders task force report of symptom structure, course of illness, and diagnosis. | journal=Am J Psychiatry | year= 2013 | volume= 170 | issue= 1 | pages= 31-42 | pmid=23223893 | doi=10.1176/appi.ajp.2012.12030301 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23223893 }}</ref>
* The esponse to treatment is often poorer in mood episodes with mixed features than in pure bipolar major depression or pure mania.<ref name="pmid20368510">{{cite journal| author=Solomon DA, Leon AC, Coryell WH, Endicott J, Li C, Fiedorowicz JG | display-authors=etal| title=Longitudinal course of bipolar I disorder: duration of mood episodes. | journal=Arch Gen Psychiatry | year= 2010 | volume= 67 | issue= 4 | pages= 339-47 | pmid=20368510 | doi=10.1001/archgenpsychiatry.2010.15 | pmc=3677763 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20368510 }}</ref>

==References==

{{reflist|2}}
{{WH}}
{{WS}}

Bipolar disorder history and symptoms

2021-08-05T00:43:13Z

Dr.Nuha:

__NOTOC__
{{Bipolar disorder}}
{{CMG}} {{AE}} {{nuha}}
==Overview==
==History and Symptoms==
Bipolar disorder is a cyclic illness where people periodically exhibit elevated (Manic) and depressive episodes. Most people will experience a number of episodes, averaging 0.4 to 0.7 a year with each lasting 3-6 months.<ref>
{{Citation
| last = Kessler
| first = RC
| last2 = McGonagle
| first2 = KA
| last3 = Zhao
| first3 = S
| last4 = Nelson
| first4 = CB
| last5 = Hughes
| first5 = M
| last6 = Eshleman
| first6 = S
| last7 = Wittchen
| first7 = HU
| last8 = Kendler
| first8 = KS
| title = Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States
| journal = Archives of General Psychiatry
| volume = 51
| issue = 1
| pages = 8-19
| year = 1994
| url = http://archpsyc.ama-assn.org/cgi/content/abstract/51/1/8
}}
</ref> Late adolescence and early adulthood are peak years for the onset of the illness.<ref name="Christie88">{{cite journal|author=Christie KA, Burke JD Jr, Regier DA, Rae DS, Boyd JH, Locke BZ |year=1988 |title=Epidemiologic evidence for early onset of mental disorders and higher risk of drug abuse in young adults |journal=Am J Psychiatry |volume=145 |pages=971-975 |id=|url=http://www.ajp.psychiatryonline.org/cgi/content/abstract/145/8/971 (abstract) |accessdate = 2007-07-01 }}</ref><ref>Goodwin & Jamison. p121</ref> These are critical periods in a young adult's social and vocational development, and they can be severely disrupted by disease onset.

*The '''manic phase''' may last from days to months. It can include the following symptoms:

:*Easily distracted
:*Little need for sleep
:*Poor judgment
:*Poor temper control
:*Reckless behavior and lack of self control
::*Binge eating, drinking, and/or drug use
::*Poor judgment
::*Sex with many partners (promiscuity)
::*Spending sprees
:*Very elevated mood
::*Excess activity (hyperactivity)
::*Increased energy
::*Racing thoughts
::*Talking a lot
::*Very high self-esteem (false beliefs about self or abilities)
:*Very involved in activities
:*Very upset (agitated or irritated)

*These symptoms of [[mania]] occur with '''bipolar disorder I'''. In people with '''bipolar disorder II''', the symptoms of mania are similar but less intense.

*The '''depressed phase''' of both types of bipolar disorder includes the following symptoms:

:*Daily low mood or sadness
:*Difficulty concentrating, remembering, or making decisions
:*Eating problems
::*Loss of appetite and weight loss
::*Overeating and weight gain
:*Fatigue or lack of energy
:*Feeling worthless, hopeless, or guilty
:*Loss of pleasure in activities once enjoyed
:*Loss of self-esteem
:*Thoughts of death and [[Suicide (patient information)|suicide]]
:*Trouble getting to sleep or sleeping too much
:*Pulling away from friends or activities that were once enjoyed

*There is a high risk of [[Suicide (patient information)|suicide]] with bipolar disorder. Patients may abuse alcohol or other substances, which can make the symptoms and suicide risk worse.

*Sometimes the two phases overlap. Manic and depressive symptoms may occur together or quickly one after the other in what is called a '''mixed state'''.

===Cognition===
Recent studies have found that bipolar disorder involves certain [[cognitive deficit]]s or impairments, even in states of [[remission (medicine)|remission]]. <ref>
{{Citation
| last = Martínez-Arán
| first = A
| last2 = Vieta
| first2 = E
| last3 = Reinares
| first3 = M
| last4 = Colom
| first4 = F
| last5 = Torrent
| first5 = C
| last6 = Sánchez-Moreno
| first6 = J
| last7 = Benabarre
| first7 = A
| last8 = Goikolea
| first8 = JM
| last9 = Comes
| first9 = M
| last10 = Salamero
| first10 = M
| title = Cognitive Function Across Manic or Hypomanic, Depressed, and Euthymic States in Bipolar Disorder
| journal = American Journal of Psychiatry
| volume = 161
| issue = 2
| pages = 262-270
| year = 2004
| date = February 2004
| url = http://ajp.psychiatryonline.org/cgi/content/abstract/161/2/262
}}
</ref><ref>
{{Citation
| last = Rossi
| first = A
| last2 = Arduini
| first2 = L
| last3 = Daneluzzo
| first3 = E
| last4 = Bustini
| first4 = M
| last5 = Prosperini
| first5 = P
| last6 = Stratta
| first6 = P
| title = Cognitive function in euthymic bipolar patients, stabilized schizophrenic patients, and healthy controls
| journal = Journal of Psychiatric Research
| volume = 34
| issue = 4-5
| pages = 333-339
| date = July 2000
| year = 2000
| doi = 10.1016/S0022-3956(00)00025-X
}}
</ref><ref>
{{Citation
| title = Second Biennial Conference of the International Society for Bipolar Disorders, 2–[[4 August]] [[2006]], Edinburgh, Scotland, Thursday, [[August 3]], Cognitive Function in BD
| journal = Bipolar Disorders
| volume = 8
| issue = Supplement 1
| pages = 2–3
| date = August 2006
| doi = 10.1111/j.1399-5618.2006.00379_2.x
}}
</ref>
Deborah Yurgelun-Todd  of [[McLean Hospital]] in [[Belmont, Massachusetts|Belmont]], [[Massachusetts]] has argued these deficits should be included as a core feature of bipolar disorder. According to McIntyre et al. (2006), <blockquote>
Study results now press the point that neurocognitive deficits are a primary feature of BD; they are highly prevalent and persist in the absence of overt symptomatology. Although disparate neurocognitive abnormalities have been reported, disturbances in attention, [[visual memory]] and [[executive function]] are most consistently reported.<ref name="cog_[[17" november]]="">{{cite journal|author=Roger S. McIntyre, MD, Joanna K. Soczynska, and Jakub Konarski|year=2006|title=Bipolar Disorder: Defining Remission and Selecting Treatment|journal=Psychiatric Times|cite= October 2006, Vol. XXIII, No. 11|url=http://www.psychiatrictimes.com/article/showArticle.jhtml?articleId=193400986}}. </ref>
</blockquote> However, in the April-June 2007 issue of the Journal of Psychiatric Research, Spanish researchers reported that people with bipolar 1 who have a history of psychotic symptoms do not necessarily experience an increase in cognitive impairment.

===Creativity===
{{main|Creativity and mental illness}}

A number of recent studies have observed a correlation between creativity and bipolar disorder, although it is unclear in which direction the cause lies, or whether both conditions are caused by some third, unknown, factor.
It has been hypothesized that temperament may be one such factor.

==References==

{{reflist|2}}
{{WH}}
{{WS}}

Other specified bipolar disorder due to another medical condition diagnostic criteria

2021-08-05T00:33:56Z

Dr.Nuha:

__NOTOC__
{{Bipolar disorder}}
{{CMG}} {{AE}} {{nuha}}

==Diagnostic Criteria==

=== DSM-V Diagnostic Criteria for Other specified bipolar disorder due to another medical condition:<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref> ===

* This category applies to presentations in which symptoms characteristic of a bipolar and related disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the bipolar and related disorders diagnostic class.
* In this situations the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific bipolar and related disorder. This is done by recording “other specified bipolar and related disorder” followed by the specific reason (e.g., “short-duration cyclothymia”).

=== Examples of presentations that can be specified include the following: ===

* '''Short-duration hypomanic episodes (2-3 days) and major depressive episodes:'''

A lifetime history of one or more major depressive episodes in individuals whose presentation has never met full criteria for a manic or hypomanic episode but who have experienced two or more episodes of short-duration hypomanic that meet the full symptomatic criteria for a hypomanic episode but that only last for 2-3 days. The episodes of hypomanic symptoms do not overlap in time with the major depressive episodes, so the disturbance does not meet criteria for major depressive episode, with mixed features.

* '''Hypomanic episodes with insufficient symptoms and major depressive episodes:'''

A lifetime history of one or more major depressive episodes in individuals whose presentation has never met full criteria for a manic or hypomanic episode but who have experienced one or more episodes of hypomanic that do not meet full symptomatic criteria (i.e., at least 4 consecutive days of elevated mood and one or two of the other symptoms of a hypomanic episode, or irritable mood and two or three of the other symptoms of a hypomanic episode). The episodes of hypomanic symptoms do not overlap in time with the major depressive episodes, so the disturbance does not meet criteria for major depressive episode, with mixed features.

* '''Hypomanic episode without prior major depressive episode:'''

One or more hypomanic episodes in an individual whose presentation has never met full criteria for a major depressive episode or a manic episode. If this occurs in an individual with an established diagnosis of persistent depressive disorder (dysthymia), both diagnoses can be concurrently applied during the periods when the full criteria for a hypomanic episode are met.

* '''Short-duration cyclothymia (less than 24 months):'''

Multiple episodes of hypomanic symptoms that do not meet criteria for a hypomanic episode and multiple episodes of depressive symptoms that do not meet criteria for a major depressive episode that persist over a period of less than 24 months (less than 12 months for children or adolescents) in an individual whose presentation has never met full criteria for a major depressive, manic, or hypomanic episode and does not meet criteria for any psychotic disorder. During the course of the disorder, the hypomanie or depressive symptoms are present for more days than not, the individual has not been without symptoms for more than 2 months at a time, and the symptoms cause clinically significant distress or impairment.

==References==
{{Reflist|2}}

[[Category:Psychiatry]]
[[Category:Overview complete]]

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Unspecified bipolar disorder diagnostic criteria

2021-08-05T00:17:53Z

Dr.Nuha: /* Diagnostic Criteria */

__NOTOC__
{{Bipolar disorder}}
{{CMG}} {{AE}} {{nuha}}

==Diagnostic Criteria==

* This category applies to presentations in which symptoms characteristic of a bipolar and related disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the bipolar and related disorders diagnostic class.<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>

* The unspecified bipolar and related disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific bipolar and related disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis (e.g., in emergency room settings).<ref name="DSMV2">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>

==References==
{{Reflist|2}}

[[Category:Psychiatry]]
[[Category:Overview complete]]

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Bipolar disorder other diagnostic studies

2021-07-26T13:34:23Z

Dr.Nuha:

__NOTOC__
{{Template:Bipolar disorder}}

{{CMG}} {{AE}} {{nuha}} 
==Overview==

Other diagnostic studies for bipolar disorder include Electroencephalography, which should be done only to rule out seizure disorder and brain tumor, or helpful during ECT, and while the patients on medications like antidepressants or lithium.
==Other Diagnostic Studies==

===Electroencephalography===
electroencephalography (EEG) is unnecessary in the evaluation of bipolar disorder. However, some reasons for ordering EEG in patients with bipolar illness may be appropriate and include the following:<ref name="pmid270222642">{{cite journal| author=Atagün Mİ| title=Brain oscillations in bipolar disorder and lithium-induced changes. | journal=Neuropsychiatr Dis Treat | year= 2016 | volume= 12 | issue= | pages= 589-601 | pmid=27022264 | doi=10.2147/NDT.S100597 | pmc=4788370 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27022264 }}</ref>

*To rule out a seizure disorder and brain tumor.
*EEG may be helpful during ECT is used to determine the occurrence and duration of seizure.
*Some patients may have seizures when on medications, especially antidepressants; in addition, lithium can cause diffuse slowing throughout the brain.<ref name="pmid27022264">{{cite journal| author=Atagün Mİ| title=Brain oscillations in bipolar disorder and lithium-induced changes. | journal=Neuropsychiatr Dis Treat | year= 2016 | volume= 12 | issue= | pages= 589-601 | pmid=27022264 | doi=10.2147/NDT.S100597 | pmc=4788370 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27022264 }}</ref>

==References==

{{reflist|2}}

[[Category:Needs content]]

Bipolar disorder other diagnostic studies

2021-07-26T13:31:56Z

Dr.Nuha:

__NOTOC__
{{Template:Bipolar disorder}}

 
==Overview==

Other diagnostic studies for bipolar disorder include Electroencephalography, which should be done only to rule out seizure disorder and brain tumor, or helpful during ECT, and while the patients on medications like antidepressants or lithium.
==Other Diagnostic Studies==

=== Electroencephalography ===
electroencephalography (EEG) is unnecessary in the evaluation of bipolar disorder. However, some reasons for ordering EEG in patients with bipolar illness may be appropriate and include the following:<ref name="pmid270222642">{{cite journal| author=Atagün Mİ| title=Brain oscillations in bipolar disorder and lithium-induced changes. | journal=Neuropsychiatr Dis Treat | year= 2016 | volume= 12 | issue= | pages= 589-601 | pmid=27022264 | doi=10.2147/NDT.S100597 | pmc=4788370 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27022264 }}</ref>

*To rule out a seizure disorder and brain tumor.
*EEG may be helpful during ECT is used to determine the occurrence and duration of seizure.
* Some patients may have seizures when on medications, especially antidepressants; in addition, lithium can cause diffuse slowing throughout the brain.<ref name="pmid27022264">{{cite journal| author=Atagün Mİ| title=Brain oscillations in bipolar disorder and lithium-induced changes. | journal=Neuropsychiatr Dis Treat | year= 2016 | volume= 12 | issue= | pages= 589-601 | pmid=27022264 | doi=10.2147/NDT.S100597 | pmc=4788370 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27022264 }}</ref>

==References==

{{reflist|2}}

[[Category:Needs content]]

Bipolar disorder MRI

2021-07-26T13:22:08Z

Dr.Nuha: /* MRI findings */

__NOTOC__
{{Template:Bipolar disorder}}

{{CMG}} {{AE}} {{nuha}}
==Overview==

*There are no [[MRI]] scan findings associated with bipolar disorder.

==MRI findings==

*There are no [[MRI]] scan findings associated with bipolar disorder. However, in selected cases can be valuable to exclude an organic etiology for mood symptoms, such as a [[brain tumor]] or [[multiple sclerosis]] in cases of recent onset [[mania]].<ref name="pmid20975827">{{cite journal| author=Hilty DM, Leamon MH, Lim RF, Kelly RH, Hales RE| title=A review of bipolar disorder in adults. | journal=Psychiatry (Edgmont) | year= 2006 | volume= 3 | issue= 9 | pages= 43-55 | pmid=20975827 | doi= | pmc=2963467 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20975827 }}</ref><ref name="pmid25317368">{{cite journal| author=Culpepper L| title=The diagnosis and treatment of bipolar disorder: decision-making in primary care. | journal=Prim Care Companion CNS Disord | year= 2014 | volume= 16 | issue= 3 | pages= | pmid=25317368 | doi=10.4088/PCC.13r01609 | pmc=4195640 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25317368 }}</ref>

==References==

{{reflist|2}}

[[Category:Needs content]]

Bipolar disorder electrocardiogram

2021-07-26T13:20:12Z

Dr.Nuha: /* Electrocardiogram */

__NOTOC__
{{Template:Bipolar disorder}}

{{CMG}} {{AE}} {{nuha}}
==Overview==
There are no ECG findings associated with Bipolar disorder. The use of lithium is associated with both atrial and ventricular electrical instability, even when lithium levels are in the therapeutic range. ECG is important before starting lithium or tricyclic antidepressant therapy. 
==Electrocardiogram==

*There are no ECG findings associated with Bipolar disorder.

*Reduced vagal tone and higher levels of inflammatory biomarkers may distinguish Bipolar disorder from major depression and reveal an underlying pathophysiology of depression involving ANS dysfunction and chronic immune system dys-regulation.<ref name="HageBritton2017">{{cite journal|last1=Hage|first1=Brandon|last2=Britton|first2=Briana|last3=Daniels|first3=David|last4=Heilman|first4=Keri|last5=Porges|first5=Stephen W.|last6=Halaris|first6=Angelos|title=Low cardiac vagal tone index by heart rate variability differentiates bipolar from major depression|journal=The World Journal of Biological Psychiatry|volume=20|issue=5|year=2017|pages=359–367|issn=1562-2975|doi=10.1080/15622975.2017.1376113}}</ref>

*In the study, patients with bipolar disorder had higher blood levels of inflammation biomarkers than patients with major depression.<ref name="HageBritton20172">{{cite journal|last1=Hage|first1=Brandon|last2=Britton|first2=Briana|last3=Daniels|first3=David|last4=Heilman|first4=Keri|last5=Porges|first5=Stephen W.|last6=Halaris|first6=Angelos|title=Low cardiac vagal tone index by heart rate variability differentiates bipolar from major depression|journal=The World Journal of Biological Psychiatry|volume=20|issue=5|year=2017|pages=359–367|issn=1562-2975|doi=10.1080/15622975.2017.1376113}}</ref>
*The use of lithium is associated with both atrial and ventricular electrical instability, even when lithium levels are in the therapeutic range. TCA and some of the anti-psychotics, can affect the heart and cause conduction problems. In older patients with bipolar disorder, on lithium or tricyclic antidepressant therapy, ECG is important before starting these medications .<ref name="AltinbasGuloksuz2014">{{cite journal|last1=Altinbas|first1=Kursat|last2=Guloksuz|first2=Sinan|last3=Caglar|first3=Ilker Murat|last4=Caglar|first4=Fatma Nihan Turhan|last5=Kurt|first5=Erhan|last6=Oral|first6=Esat Timucin|title=Electrocardiography changes in bipolar patients during long-term lithium monotherapy|journal=General Hospital Psychiatry|volume=36|issue=6|year=2014|pages=694–697|issn=01638343|doi=10.1016/j.genhosppsych.2014.07.001}}</ref>

==References==

{{reflist|2}}

[[Category:Needs content]]

Bipolar disorder electrocardiogram

2021-07-26T13:14:13Z

Dr.Nuha: /* Overview */

__NOTOC__
{{Template:Bipolar disorder}}

{{CMG}} {{AE}} {{nuha}}
==Overview==
There are no ECG findings associated with Bipolar disorder. The use of lithium is associated with both atrial and ventricular electrical instability, even when lithium levels are in the therapeutic range. 
==Electrocardiogram==

* There are no ECG findings associated with Bipolar disorder.

* Reduced vagal tone and higher levels of inflammatory biomarkers may distinguish Bipolar disorder from major depression and reveal an underlying pathophysiology of depression involving ANS dysfunction and chronic immune system dys-regulation.<ref name="HageBritton2017">{{cite journal|last1=Hage|first1=Brandon|last2=Britton|first2=Briana|last3=Daniels|first3=David|last4=Heilman|first4=Keri|last5=Porges|first5=Stephen W.|last6=Halaris|first6=Angelos|title=Low cardiac vagal tone index by heart rate variability differentiates bipolar from major depression|journal=The World Journal of Biological Psychiatry|volume=20|issue=5|year=2017|pages=359–367|issn=1562-2975|doi=10.1080/15622975.2017.1376113}}</ref>

* In the study, patients with bipolar disorder had higher blood levels of inflammation biomarkers than patients with major depression.<ref name="HageBritton20172">{{cite journal|last1=Hage|first1=Brandon|last2=Britton|first2=Briana|last3=Daniels|first3=David|last4=Heilman|first4=Keri|last5=Porges|first5=Stephen W.|last6=Halaris|first6=Angelos|title=Low cardiac vagal tone index by heart rate variability differentiates bipolar from major depression|journal=The World Journal of Biological Psychiatry|volume=20|issue=5|year=2017|pages=359–367|issn=1562-2975|doi=10.1080/15622975.2017.1376113}}</ref>
* The use of lithium is associated with both atrial and ventricular electrical instability, even when lithium levels are in the therapeutic range.<ref name="AltinbasGuloksuz2014">{{cite journal|last1=Altinbas|first1=Kursat|last2=Guloksuz|first2=Sinan|last3=Caglar|first3=Ilker Murat|last4=Caglar|first4=Fatma Nihan Turhan|last5=Kurt|first5=Erhan|last6=Oral|first6=Esat Timucin|title=Electrocardiography changes in bipolar patients during long-term lithium monotherapy|journal=General Hospital Psychiatry|volume=36|issue=6|year=2014|pages=694–697|issn=01638343|doi=10.1016/j.genhosppsych.2014.07.001}}</ref>

==References==

{{reflist|2}}

[[Category:Needs content]]

Bipolar disorder electrocardiogram

2021-07-26T12:42:11Z

Dr.Nuha:

__NOTOC__
{{Template:Bipolar disorder}}

{{CMG}} {{AE}} {{nuha}}
==Overview==
There are no ECG findings associated with Bipolar disorder.
 
==Electrocardiogram==
There are no ECG findings associated with Bipolar disorder.
==References==

{{reflist|2}}

[[Category:Needs content]]

Bipolar disorder electrocardiogram

2021-07-26T12:41:44Z

Dr.Nuha:

__NOTOC__
{{Template:Bipolar disorder}}

{{CMG}} {{AE}}
==Overview==
There are no ECG findings associated with Bipolar disorder.
 
==Electrocardiogram==
There are no ECG findings associated with Bipolar disorder.
==References==

{{reflist|2}}

[[Category:Needs content]]

Bipolar disorder electrocardiogram

2021-07-26T12:41:11Z

Dr.Nuha:

__NOTOC__
{{Template:Bipolar disorder}}

'''Editor-In-Chief:''' C. Michael Gibson, M.S., M.D. [[Mailto:charlesmichaelgibson@gmail.com|[1]]] '''Associate Editor(s)-in-Chief:'''
==Overview==
There are no ECG findings associated with Bipolar disorder.
 
==Electrocardiogram==
There are no ECG findings associated with Bipolar disorder.
==References==

{{reflist|2}}

[[Category:Needs content]]

Bipolar disorder MRI

2021-07-26T12:28:47Z

Dr.Nuha: /* MRI findings */

__NOTOC__
{{Template:Bipolar disorder}}

{{CMG}} {{AE}} {{nuha}}
==Overview==

*There are no MRI scan findings associated with bipolar disorder.

==MRI findings==

*There are no MRI scan findings associated with bipolar disorder. However, in selected cases can be valuable to exclude an organic etiology for mood symptoms, such as a brain tumor or multiple sclerosis in cases of recent onset mania.<ref name="pmid20975827">{{cite journal| author=Hilty DM, Leamon MH, Lim RF, Kelly RH, Hales RE| title=A review of bipolar disorder in adults. | journal=Psychiatry (Edgmont) | year= 2006 | volume= 3 | issue= 9 | pages= 43-55 | pmid=20975827 | doi= | pmc=2963467 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20975827 }}</ref><ref name="pmid25317368">{{cite journal| author=Culpepper L| title=The diagnosis and treatment of bipolar disorder: decision-making in primary care. | journal=Prim Care Companion CNS Disord | year= 2014 | volume= 16 | issue= 3 | pages= | pmid=25317368 | doi=10.4088/PCC.13r01609 | pmc=4195640 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25317368 }}</ref>

==References==

{{reflist|2}}

[[Category:Needs content]]

Bipolar disorder

2021-07-26T12:27:49Z

Dr.Nuha:

__NOTOC__

'''For patient information click [[Bipolar disorder (patient information)|here]]'''
{{Infobox_Disease |
Name = {{PAGENAME}} |
Image = |
Caption = |
DiseasesDB = 7812 |
ICD10 = {{ICD10|F|31||f|30}} |
ICD9 = {{ICD9|296.80}} |
ICDO = |
OMIM = 125480 |
OMIM_mult = {{OMIM2|309200}} |
MedlinePlus = 000926 |
MeshID = D001714 |
}}
{{Bipolar disorder}}
{{CMG}} {{AE}} {{nuha}}

{{SK}} Manic depression; bipolar affective disorder
==[[Bipolar disorder overview|Overview]]==

==[[Bipolar disorder historical perspective|Historical Perspective]]==

==[[Bipolar disorder classification|Classification]]==

==[[Bipolar disorder pathophysiology|Pathophysiology]]==

==[[Bipolar disorder causes|Causes]]==

==[[Bipolar disorder differentiating Bipolar disorder from other diseases|Differentiating Bipolar disorder from other Diseases]]==

==[[Bipolar disorder epidemiology and demographics|Epidemiology and Demographics]]==

==[[Bipolar disorder risk factors|Risk Factors]]==

==[[Bipolar disorder complications and prognosis|Complications and Prognosis]]==

==Diagnosis==

[[Bipolar disorder criteria|Diagnostic Criteria]] | [[Bipolar disorder history and symptoms|History and Symptoms]] | [[Bipolar disorder physical examination|Physical Examination]] | [[Bipolar disorder laboratory findings|Laboratory Findings]] | [[Bipolar disorder electrocardiogram|Electrocardiogram]] | [[Bipolar disorder MRI|MRI]] | [[Bipolar disorder other diagnostic studies|Other Diagnostic Studies]]

==Treatment==

[[Bipolar disorder medical therapy|Medical Therapy]] | [[Bipolar disorder cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Bipolar disorder future or investigational therapies|Future or Investigational Therapies]]

==See also==

*[[Mood (psychology)]]
*[[Emotion]]

{{Mental and behavioural disorders}}

[[ar:تعكر المزاج الثنائي القطب]]
[[ca:Trastorn bipolar]]
[[cs:Maniodepresivní psychóza]]
[[da:Maniodepressiv sindslidelse]]
[[de:Bipolare Störung]]
[[et:Bipolaarne häire]]
[[es:Trastorno bipolar]]
[[fr:Trouble bipolaire]]
[[gl:Trastorno bipolar]]
[[ko:조울증]]
[[hr:Bipolarni poremećaj]]
[[it:Psicosi maniaco-depressiva]]
[[he:הפרעה דו-קוטבית]]
[[lt:Maniakinė depresija]]
[[mk:Биполарно растројство]]
[[hu:Bipoláris zavar]]
[[nl:Bipolaire stoornis]]
[[ja:双極性障害]]
[[no:Bipolar lidelse]]
[[pl:Choroba afektywna dwubiegunowa]]
[[pt:Distúrbio bipolar]]
[[ru:Биполярное аффективное расстройство]]
[[simple:Bipolar disorder]]
[[sr:Манично-депресивна психоза]]
[[fi:Kaksisuuntainen mielialahäiriö]]
[[sv:Bipolärt syndrom]]
[[tr:Bipolar bozukluk]]
[[zh:躁鬱症]]

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[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Psychiatry]]

Bipolar disorder MRI

2021-07-26T12:27:27Z

Dr.Nuha:

Bipolar disorder laboratory findings

2021-07-26T12:15:20Z

Dr.Nuha: /* Other laboratory tests */

__NOTOC__
{{Template:Bipolar disorder}}

{{CMG}} {{AE}}{{nuha}}

 
==Overview==
No laboratory test is required to establish the diagnosis of bipolar disorder. However, laboratory tests can help to exclude alternative etiologies for mood symptoms. Laboratory tests may include a [[urine]] [[toxicology]] screen and a [[complete blood count]]. Fasting [[glucose]] and [[lipid]] assessments are important for establishing the presence of [[diabetes]] or [[hyperlipidemia]].

==Bipolar disorder laboratory findings==

*There are no diagnostic laboratory findings associated with Bipolar disorder. However, bipolar disorder enclose both [[depression]] and [[mania]] and it could be due to many reversible causes, an extensive range of tests is indicated<ref name="pmid22534227">{{cite journal| author=Price AL, Marzani-Nissen GR| title=Bipolar disorders: a review. | journal=Am Fam Physician | year= 2012 | volume= 85 | issue= 5 | pages= 483-93 | pmid=22534227 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22534227 }}</ref>
*Many number of [[medications]] that used to treat bipolar disorder have many side effect, for instance [[lithium]] requires an intact [[genitourinary system]] and can affect certain other systems.<ref name="pmid225342272">{{cite journal| author=Price AL, Marzani-Nissen GR| title=Bipolar disorders: a review. | journal=Am Fam Physician | year= 2012 | volume= 85 | issue= 5 | pages= 483-93 | pmid=22534227 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22534227 }}</ref>
*[[Complete blood counts|A complete blood count]] with differential is to rule out [[anemia]] as a cause of [[depression]] in bipolar disorder.<ref name="pmid253173684">{{cite journal| author=Culpepper L| title=The diagnosis and treatment of bipolar disorder: decision-making in primary care. | journal=Prim Care Companion CNS Disord | year= 2014 | volume= 16 | issue= 3 | pages= | pmid=25317368 | doi=10.4088/PCC.13r01609 | pmc=4195640 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25317368 }}</ref>
*[[Erythrocyte sedimentation rate]] to look for any underlying disease process such a [[Systemic lupus erythematosus|lupus]] or an [[infection]].
*[[Blood glucose|Fasting blood glucose]] level is indicated to rule out [[diabetes]], as well as atypical [[antipsychotics]] are associated with [[weight gain]] and trouble with [[blood glucose]] regulation in patients with [[diabetes]].<ref name="pmid253173683">{{cite journal| author=Culpepper L| title=The diagnosis and treatment of bipolar disorder: decision-making in primary care. | journal=Prim Care Companion CNS Disord | year= 2014 | volume= 16 | issue= 3 | pages= | pmid=25317368 | doi=10.4088/PCC.13r01609 | pmc=4195640 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25317368 }}</ref>
*Patients that will be on [[lithium]] therapy checking [[Electrolyte|electrolytes]] is indicated, because low [[sodium]] levels may lead to higher [[lithium]] levels and [[lithium]] toxicity.
*Check the [[Calcium|serum calcium]] as any changes in serum [[calcium]] is associated with [[Mental status examination|mental status changes]] (eg, [[hyperparathyroidism]]). An elevated [[calcium]] blood level can cause [[depression]] or [[mania]].<ref name="pmid253173682">{{cite journal| author=Culpepper L| title=The diagnosis and treatment of bipolar disorder: decision-making in primary care. | journal=Prim Care Companion CNS Disord | year= 2014 | volume= 16 | issue= 3 | pages= | pmid=25317368 | doi=10.4088/PCC.13r01609 | pmc=4195640 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25317368 }}</ref>
*In patients with [[depression]] as a result of not eating, low serum [[protein]] levels increase the availability of certain [[medications]], because these drugs have less [[protein]] to which to bind.
*[[Thyroid function tests]] to rule out [[hyperthyroidism]] ([[mania]]) and [[hypothyroidism]] ([[Major depressive disorder|depression]]). [[lithium]] can cause [[hypothyroidism]], for that [[Thyroid function test|thyroid tests]] should be obtained.<ref name="pmid233803162">{{cite journal| author=Krishna VN, Thunga R, Unnikrishnan B, Kanchan T, Bukelo MJ, Mehta RK | display-authors=etal| title=Association between bipolar affective disorder and thyroid dysfunction. | journal=Asian J Psychiatr | year= 2013 | volume= 6 | issue= 1 | pages= 42-5 | pmid=23380316 | doi=10.1016/j.ajp.2012.08.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23380316 }}</ref>
*In a study, they found out that patients with bipolar disorder are two times more commonly associated with thyroid dysfunction than individuals without bipolar disorder.<ref name="pmid23380316">{{cite journal| author=Krishna VN, Thunga R, Unnikrishnan B, Kanchan T, Bukelo MJ, Mehta RK | display-authors=etal| title=Association between bipolar affective disorder and thyroid dysfunction. | journal=Asian J Psychiatr | year= 2013 | volume= 6 | issue= 1 | pages= 42-5 | pmid=23380316 | doi=10.1016/j.ajp.2012.08.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23380316 }}</ref>
*[[Creatinine]] and [[blood urea nitrogen]] should be checked because [[kidney failure]] can present as [[depression]], treatment with [[lithium]] can affect urinary clearances.
*[[Liver]] and [[Lipid|lipid panel]] should be evaluated as many [[Antipsychotics|anti-psychotics]] [[medications]] cause changes in patients [[Lipid profile|lipid profiles]], resulting in [[dyslipidemia]] and [[liver damage]].<ref name="pmid25317368">{{cite journal| author=Culpepper L| title=The diagnosis and treatment of bipolar disorder: decision-making in primary care. | journal=Prim Care Companion CNS Disord | year= 2014 | volume= 16 | issue= 3 | pages= | pmid=25317368 | doi=10.4088/PCC.13r01609 | pmc=4195640 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25317368 }}</ref>

===Other laboratory tests===

*[[Wilson disease]] is a rare condition that is easily missed. Urine [[copper]] level testing may be performed to rule out [[Wilson disease]], although not a routine screening test in bipolar disorder.<ref name="pmid18402634">{{cite journal| author=Machado AC, Deguti MM, Caixeta L, Spitz M, Lucato LT, Barbosa ER| title=Mania as the first manifestation of Wilson's disease. | journal=Bipolar Disord | year= 2008 | volume= 10 | issue= 3 | pages= 447-50 | pmid=18402634 | doi=10.1111/j.1399-5618.2007.00531.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18402634 }}</ref><ref name="pmid18789784">{{cite journal| author=Benhamla T, Tirouche YD, Abaoub-Germain A, Theodore F| title=[The onset of psychiatric disorders and Wilson's disease]. | journal=Encephale | year= 2007 | volume= 33 | issue= 6 | pages= 924-32 | pmid=18789784 | doi=10.1016/j.encep.2006.08.009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18789784 }}</ref>
*Testing for [[HIV AIDS|human immunodeficiency virus (HIV)]] is important because [[AIDS]] causes changes in [[mental status]], including [[dementia]] and [[depression]].<ref name="urlHIV and psychiatric comorbidities: What do we know and what can we do?">{{cite web |url=https://www.apa.org/pi/aids/resources/exchange/2013/01/comorbidities |title=HIV and psychiatric comorbidities: What do we know and what can we do? |format= |work= |accessdate=}}</ref>

===Substance and Alcohol Screening===

*[[Alcohol abuse]] and illicit drugs can present as [[mania]] or [[depression]]. For example, [[amphetamines]] and [[cocaine]] can present as a [[mania]] like disorder, and [[barbiturate]] can present as a [[depression]] like disorder.<ref name="pmid23332720">{{cite journal| author=Kenneson A, Funderburk JS, Maisto SA| title=Risk factors for secondary substance use disorders in people with childhood and adolescent-onset bipolar disorder: opportunities for prevention. | journal=Compr Psychiatry | year= 2013 | volume= 54 | issue= 5 | pages= 439-46 | pmid=23332720 | doi=10.1016/j.comppsych.2012.12.008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23332720 }}</ref>

*Many patients with bipolar disorder, also have high rate of substance use disorders as a result it is associated with significant morbidity and mortality.<ref name="pmid23332720" />

==References==

{{reflist|2}}

[[Category:Needs content]]

Bipolar disorder laboratory findings

2021-07-26T12:05:39Z

Dr.Nuha:

__NOTOC__
{{Template:Bipolar disorder}}

{{CMG}} {{AE}}{{nuha}}

 
==Overview==
No laboratory test is required to establish the diagnosis of bipolar disorder. However, laboratory tests can help to exclude alternative etiologies for mood symptoms. Laboratory tests may include a [[urine]] [[toxicology]] screen and a [[complete blood count]]. Fasting [[glucose]] and [[lipid]] assessments are important for establishing the presence of [[diabetes]] or [[hyperlipidemia]].

==Bipolar disorder laboratory findings==

*There are no diagnostic laboratory findings associated with Bipolar disorder. However, bipolar disorder enclose both depression and mania and it could be due to many reversible causes, an extensive range of tests is indicated<ref name="pmid22534227">{{cite journal| author=Price AL, Marzani-Nissen GR| title=Bipolar disorders: a review. | journal=Am Fam Physician | year= 2012 | volume= 85 | issue= 5 | pages= 483-93 | pmid=22534227 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22534227 }}</ref>
*Many number of medications that used to treat bipolar disorder have many side effect, for instance lithium requires an intact genitourinary system and can affect certain other systems.<ref name="pmid225342272">{{cite journal| author=Price AL, Marzani-Nissen GR| title=Bipolar disorders: a review. | journal=Am Fam Physician | year= 2012 | volume= 85 | issue= 5 | pages= 483-93 | pmid=22534227 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22534227 }}</ref>
*A complete blood count (CBC) with differential is to rule out anemia as a cause of depression in bipolar disorder.<ref name="pmid253173684">{{cite journal| author=Culpepper L| title=The diagnosis and treatment of bipolar disorder: decision-making in primary care. | journal=Prim Care Companion CNS Disord | year= 2014 | volume= 16 | issue= 3 | pages= | pmid=25317368 | doi=10.4088/PCC.13r01609 | pmc=4195640 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25317368 }}</ref>
*Erythrocyte sedimentation rate to look for any underlying disease process such a lupus or an infection.
*Fasting blood glucose level is indicated to rule out diabetes, as well as atypical antipsychotics are associated with weight gain and trouble with blood glucose regulation in patients with diabetes.<ref name="pmid253173683">{{cite journal| author=Culpepper L| title=The diagnosis and treatment of bipolar disorder: decision-making in primary care. | journal=Prim Care Companion CNS Disord | year= 2014 | volume= 16 | issue= 3 | pages= | pmid=25317368 | doi=10.4088/PCC.13r01609 | pmc=4195640 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25317368 }}</ref>
*Patients that will be on lithium therapy checking electrolytes is indicated, because low sodium levels may lead to higher lithium levels and lithium toxicity.
*Check the serum calcium as any changes in serum calcium is associated with mental status changes (eg, hyperparathyroidism). An elevated calcium blood level can cause depression or mania.<ref name="pmid253173682">{{cite journal| author=Culpepper L| title=The diagnosis and treatment of bipolar disorder: decision-making in primary care. | journal=Prim Care Companion CNS Disord | year= 2014 | volume= 16 | issue= 3 | pages= | pmid=25317368 | doi=10.4088/PCC.13r01609 | pmc=4195640 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25317368 }}</ref>
*In patients with depression as a result of not eating, low serum protein levels increase the availability of certain medications, because these drugs have less protein to which to bind.
*Thyroid function tests to rule out hyperthyroidism (mania) and hypothyroidism (depression). lithium can cause hypothyroidism, for that thyroid tests should be obtained.<ref name="pmid233803162">{{cite journal| author=Krishna VN, Thunga R, Unnikrishnan B, Kanchan T, Bukelo MJ, Mehta RK | display-authors=etal| title=Association between bipolar affective disorder and thyroid dysfunction. | journal=Asian J Psychiatr | year= 2013 | volume= 6 | issue= 1 | pages= 42-5 | pmid=23380316 | doi=10.1016/j.ajp.2012.08.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23380316 }}</ref>
*In a study to assess the relationship between bipolar disorder and thyroid dysfunction, they found out that patients with bipolar disorder are two times more commonly associated with thyroid dysfunction than individuals without bipolar disorder.<ref name="pmid23380316">{{cite journal| author=Krishna VN, Thunga R, Unnikrishnan B, Kanchan T, Bukelo MJ, Mehta RK | display-authors=etal| title=Association between bipolar affective disorder and thyroid dysfunction. | journal=Asian J Psychiatr | year= 2013 | volume= 6 | issue= 1 | pages= 42-5 | pmid=23380316 | doi=10.1016/j.ajp.2012.08.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23380316 }}</ref>
*Creatinine and blood urea nitrogen should be checked because kidney failure can present as depression, treatment with lithium can affect urinary clearances.
*Liver and lipid panel should be evaluated as many anti-psychotics medications cause changes in patients lipid profiles, resulting in dyslipidemia and liver damage.<ref name="pmid25317368">{{cite journal| author=Culpepper L| title=The diagnosis and treatment of bipolar disorder: decision-making in primary care. | journal=Prim Care Companion CNS Disord | year= 2014 | volume= 16 | issue= 3 | pages= | pmid=25317368 | doi=10.4088/PCC.13r01609 | pmc=4195640 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25317368 }}</ref>

===Other laboratory tests===

*Wilson disease is a rare condition that is easily missed. Urine copper level testing may be performed to rule out Wilson disease, although not a routine screening test in bipolar disorder.<ref name="pmid18402634">{{cite journal| author=Machado AC, Deguti MM, Caixeta L, Spitz M, Lucato LT, Barbosa ER| title=Mania as the first manifestation of Wilson's disease. | journal=Bipolar Disord | year= 2008 | volume= 10 | issue= 3 | pages= 447-50 | pmid=18402634 | doi=10.1111/j.1399-5618.2007.00531.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18402634 }}</ref><ref name="pmid18789784">{{cite journal| author=Benhamla T, Tirouche YD, Abaoub-Germain A, Theodore F| title=[The onset of psychiatric disorders and Wilson's disease]. | journal=Encephale | year= 2007 | volume= 33 | issue= 6 | pages= 924-32 | pmid=18789784 | doi=10.1016/j.encep.2006.08.009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18789784 }}</ref>
*Testing for human immunodeficiency virus (HIV) is important because AIDS causes changes in mental status, including dementia and depression.<ref name="urlHIV and psychiatric comorbidities: What do we know and what can we do?">{{cite web |url=https://www.apa.org/pi/aids/resources/exchange/2013/01/comorbidities |title=HIV and psychiatric comorbidities: What do we know and what can we do? |format= |work= |accessdate=}}</ref>
*Syphilis in its later stage alters mental status, so screening may be indicated in selected patients.

===Substance and Alcohol Screening===

*Alcohol abuse and illicit drugs can present as mania or depression. For example, amphetamines and cocaine can present as a mania like disorder, and barbiturate can present as a depression like disorder.<ref name="pmid23332720">{{cite journal| author=Kenneson A, Funderburk JS, Maisto SA| title=Risk factors for secondary substance use disorders in people with childhood and adolescent-onset bipolar disorder: opportunities for prevention. | journal=Compr Psychiatry | year= 2013 | volume= 54 | issue= 5 | pages= 439-46 | pmid=23332720 | doi=10.1016/j.comppsych.2012.12.008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23332720 }}</ref>

*Many patients with bipolar disorder, also have high rate of substance use disorders as a result it is associated with significant morbidity and mortality.<ref name="pmid23332720" />

==References==

{{reflist|2}}

[[Category:Needs content]]

Bipolar disorder laboratory findings

2021-07-26T11:27:21Z

Dr.Nuha:

__NOTOC__
{{Template:Bipolar disorder}}

{{CMG}} {{AE}}

 
==Overview==

*The overview section should include the disease name in the first sentence.
*The goal is to summarize the laboratory findings page in several sentences. This section can be the same as the laboratory findings segment on the overview page.

 
==Bipolar disorder laboratory findings==

* There are no diagnostic laboratory findings associated with Bipolar disorder. However, bipolar disorder enclose both depression and mania and it could be due to many reversible causes, an extensive range of tests is indicated
* Many number of medications that used to treat bipolar disorder have many side effect, for instance lithium requires an intact genitourinary system and can affect certain other systems.
* A complete blood count (CBC) with differential is to rule out anemia as a cause of depression in bipolar disorder.
* Check the red blood cell and white blood cell counts for signs of bone marrow suppression, as anticonvulsants may depress the bone marrow.
* Erythrocyte sedimentation rate to look for any underlying disease process such a lupus or an infection.
* Fasting blood glucose level is indicated to rule out diabetes, as well as atypical antipsychotics are associated with weight gain and trouble with blood glucose regulation in patients with diabetes.
* Patients that will be on lithium therapy checking electrolytes is indicated, because low sodium levels may lead to higher lithium levels and lithium toxicity.
* Check the serum calcium as any changes in serum calcium is associated with mental status changes (eg, hyperparathyroidism). An elevated calcium blood level can cause depression or mania.
* In patients with depression as a result of not eating, low serum protein levels increase the availability of certain medications, because these drugs have less protein to which to bind.
* Thyroid function tests to rule out hyperthyroidism (mania) and hypothyroidism (depression). lithium can cause hypothyroidism, for that thyroid tests should be obtained.
* In a study to assess the relationship between bipolar disorder and thyroid dysfunction, they found out that patients with bipolar disorder are two times more commonly associated with thyroid dysfunction than individuals without bipolar disorder.
* Creatinine and blood urea nitrogen should be checked because kidney failure can present as depression, treatment with lithium can affect urinary clearances.
* Liver and lipid panel should be evaluated as many anti-psychotics medications cause changes in patients lipid profiles, resulting in dyslipidemia and liver damage.

=== Other laboratory tests ===

* Wilson disease is a rare condition that is easily missed. Urine copper level testing may be performed to rule out Wilson disease, although not a routine screening test in bipolar disorder.
* Antinuclear antibody testing to rule out lupus.
* Testing for human immunodeficiency virus (HIV) is important because AIDS causes changes in mental status, including dementia and depression.
* Syphilis in its later stage alters mental status, so screening may be indicated in selected patients.

=== Substance and Alcohol Screening ===

* Alcohol abuse and illicit drugs can present as mania or depression. For example, amphetamines and cocaine can present as a mania like disorder, and barbiturate can present as a depression like disorder.

* Many patients with bipolar disorder, also have high rate of substance use disorders as a result it is associated with significant morbidity and mortality.

==References==

{{reflist|2}}

[[Category:Needs content]]

Bipolar disorder physical examination

2021-07-25T15:36:42Z

Dr.Nuha:

{{CMG}} {{AE}} {{nuha}}

==Overview==

*Physical examination of patients with bipolar disorder is usually normal.{{Bipolar disorder}}

 
==Physical Examination==
Bipolar disorder is characterized by periods depression that alternate with periods of mania. Physical examination of patients with bipolar disorder is usually normal. A mental status examination physical examination should assess patients for:<ref name="pmid16866240">{{cite journal| author=Work Group on Psychiatric Evaluation. American Psychiatric Association Steering Committee on Practice Guidlines| title=Psychiatric evaluation of adults. Second edition. American Psychiatric Association. | journal=Am J Psychiatry | year= 2006 | volume= 163 | issue= 6 Suppl | pages= 3-36 | pmid=16866240 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16866240 }}</ref>

*Major depression for 2 weeks being either a depressed mood or loss of pleasure, and presence of at least five of the following symptoms:
**Depressed mood
**Markedly diminished interest in nearly all activities
**marked weight loss or gain or significant loss or increase in appetite
**Hypersomnia or insomnia
**Psychomotor retardation or agitation
**Loss of energy or fatigue
**Feelings of worthlessness or excessive guilt
**Decreased concentration ability
**Preoccupation with death or suicide.
*[[Mania]]: feature at least 1 week of profound mood disturbance, characterized by elation, irritability, or expansiveness and at least 3 of the [[Bipolar I disorder diagnostic criteria|diagnostic criteria]]
**Grandiosity
**Diminished need for sleep
**Excessive talking
**Racing thoughts
**Clear evidence of distractibility
**Increased level of goal-focused activity at home, at work.
**Excessive pleasurable activities.
*Hypomania characterized by an elevated, or irritable mood of at least 4 consecutive days duration. for diagnosis it require at least three of the symptoms of mania.
*Impulsive or risk-taking behaviors
*Suicidal thoughts and behavior
*Risk factors for suicide attempts and deaths.
*In addition to current symptoms, it is important to ascertain the number, frequency, intensity, and duration of past mood episodes.

Examination using the Mental Status Examination as well as assessment of the following:

*Appearance
*Affect/mood
*Thought content
*Perception
*Suicide/self-destruction
*Homicide/violence/aggression
*Judgment/insight
*Cognition
*Physical health
__NOTOC__
==References==

{{reflist|2}}

{{WH}} {{WS}}
[[Category:Needs content]]