Sandbox ID Genitourinary

Vaginal infection

Bacterial vaginosis

• Preferred regime: Metronidazole 500 mg orally twice a day for 7 days OR Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days OR Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days

• Alternative regime (1): Tinidazole 2 g orally once daily for 3 days

• Alternative regime (2): Tinidazole 1 g orally once daily for 5 days

• Alternative regime (3): Clindamycin 300 mg orally twice daily for 7 days

• Alternative regime (4): Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days

Bacterial vaginosis during pregnancy

• Preferred regime: Metronidazole 500 mg orally twice a day for 7 days OR Metronidazole 250 mg orally three times a day for 7 days OR Clindamycin 300 mg orally twice a day for 7 days

Trichomoniasis

T. vaginalis

• Preferred regime: Metronidazole 2 g orally in a single dose OR Tinidazole 2 g orally in a single dose

• Alternative regime: Metronidazole 500 mg orally twice a day for 7 days

Vulvovaginal candidiasis

Uncomplicated VVC

• Preferred regime:

• Over-the-Counter Intravaginal Agents: Butoconazole 2% cream 5 g intravaginally for 3 days OR Clotrimazole 1% cream 5 g intravaginally for 7--14 days OR Clotrimazole 2% cream 5 g intravaginally for 3 days OR [Miconazole]] 2% cream 5 g intravaginally for 7 days OR Miconazole 4% cream 5 g intravaginally for 3 days OR Miconazole 100 mg vaginal suppository, one suppository 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
• Prescription Intravaginal Agents: Butoconazole 2% cream (single dose bioadhesive product), 5 g intravaginally for 1 day OR Nystatin 100,000-unit vaginal tablet, one tablet for 14 days OR Terconazole 0.4% cream 5 g intravaginally for 7 days OR Terconazole 0.8% cream 5 g intravaginally for 3 days OR Terconazole 80 mg vaginal suppository, one suppository for 3 days
• Oral Agent: Fluconazole 150 mg oral tablet, one tablet in single dose

Complicated VVC

• Recurrent Vulvovaginal Candidiasis (RVVC)

• Preferred regime: 7-14 days of topical therapy OR a 100-mg, 150-mg, or 200-mg oral dose of Fluconazole every third day for a total of 3 doses followed by Oral Fluconazole (i.e., 100-mg, 150-mg, or 200-mg dose) weekly for 6 months

• Severe VVC

• Preferred regime: Topical Azole for 7-14 days OR 150 mg of Fluconazole in two sequential doses (second dose 72 hours after initial dose.

• Nonalbicans VVC

• Preferred regime: nonfluconazole Azole drug (oral or topical) for 7-14 days.

Cervicitis

• Preferred regime: Azithromycin 1 g orally in a single dose OR Doxycycline 100 mg orally twice a day for 7 days

Chancroid

• Haemophilus ducreyi infection

• Chancroid

• Preferred regimen: Azithromycin 1 g PO as a single dose OR Ceftriaxone 250 mg IM as a single dose OR Ciprofloxacin 500 mg PO bid for 3 days OR Erythromycin 500 mg PO tid for 7 days

Note (1): Ciprofloxacin is contraindicated for pregnant and lactating women.

Note (2): Patients should be tested for HIV infection at the time chancroid is diagnosed. If the initial test results were negative, a serologic test for syphilis and HIV infection should be performed 3 months after the diagnosis of chancroid.

Note (3): Sex partners of patients who have chancroid should be examined and treated if they had sexual contact with the patient during the 10 days preceding the patient's onset of symptoms.

Chlamydial infections

• Preferred regime: Azithromycin 1 g orally in a single dose OR Doxycycline 100 mg orally twice a day for 7 days
• Alternative regime (1): Erythromycin base 500 mg orally four times a day for 7 days

• Alternative regime (2): Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days

• Alternative regime (3): Levofloxacin 500 mg orally once daily for 7 days

• Alternative regime (4): Ofloxacin 300 mg orally twice a day for 7 days

Chlamydial infections during pregnancy

• Preferred regime: Azithromycin 1 g orally in a single dose OR Amoxicillin 500 mg orally three times a day for 7 days
• Alternative regime (1): Erythromycin base 500 mg orally four times a day for 7 days

• Alternative regime (2): Erythromycin base 250 mg orally four times a day for 14 days

• Alternative regime (3): Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days

• Alternative regime (4): Erythromycin ethylsuccinate 400 mg orally four times a day for 14 days

Genital herpes

• Genital HSV infections

• First episode of genital herpes

• Preferred regimen: Acyclovir 400 mg PO tid for 7–10 days OR Acyclovir 200 mg PO five times a day for 7–10 days OR Famciclovir 250 mg PO tid for 7–10 days OR Valacyclovir 1 g PO bid for 7–10 days

Note: Treatment can be extended if healing is incomplete after 10 days of therapy.

• Recurrent genital herpes

• Suppressive therapy

• Preferred regimen: Acyclovir 400 mg PO bid OR Famciclovir 250 mg PO bid OR Valacyclovir 500–1000 mg PO qd for 7–10 days

• Episodic therapy

• Preferred regimen: Acyclovir 400 mg PO tid for 5 days OR Acyclovir 800 mg PO bid a day for 5 days OR Acyclovir 800 mg PO tid for 2 days OR Famciclovir 125 mg PO bid for 5 days OR Famciclovir 1000 mg PO bid for 1 day OR Famciclovir 500 mg PO once, followed by 250 mg PO bid for 2 days OR Valacyclovir 500 mg PO bid for 3 days OR Valacyclovir 1000 mg PO qd for 5 days

• Severe genital herpes

• Preferred regimen: Acyclovir 5–10 mg/kg IV q8h for 2–7 days or until clinical improvement is observed, followed by PO antiviral therapy to complete at least 10 days of total therapy.

Note (1): Acyclovir dose adjustment is recommended for impaired renal function.

Note (2): Symptomatic sex partners should be evaluated and treated in the same manner as patients who have genital lesions. Asymptomatic sex partners of patients who have genital herpes should be questioned concerning histories of genital lesions and offered type–specific serologic testing for HSV infection.

• Genital herpes in HIV–infected patients

• Suppressive therapy

• Preferred regimen: Acyclovir 400–800 mg PO bid–tid OR Famciclovir 500 mg PO bid OR Valacyclovir 500 mg PO bid

• Episodic therapy

• Preferred regimen: Acyclovir 400 mg PO tid for 5–10 days OR Famciclovir 500 mg PO bid for 5–10 days OR Valacyclovir 1000 mg PO bid for 5–10 days

• Genital herpes in pregnancy

• Acyclovir can be administered orally to pregnant women with first episode of genital herpes or recurrent genital herpes.
• Acyclovir should be administered IV to pregnant women with severe genital herpes.

• Neonatal herpes

• Disease limited to the skin and mucous membranes

• Preferred regimen: Acyclovir 20 mg/kg IV q8h for 14 days

• Disseminated and CNS disease

• Preferred regimen: Acyclovir 20 mg/kg IV q8h for 21 days

Gonococcal infections

• Neisseria gonorrhoeae infection

• Uncomplicated gonococcal infections of the cervix, urethra, and rectum

• Preferred regimen: Ceftriaxone 250 mg IM as a single dose AND (Azithromycin 1 g PO as a single dose OR Doxycycline 100 mg PO bid for 7 days)
• Alternative regimen: Cefuroxime 1 g PO as a single dose

• Uncomplicated gonococcal infections of the pharynx

• Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND (Azithromycin 1 g orally as a single dose OR Doxycycline 100 mg orally twice daily for 7 days)

• Gonococcal conjunctivitis

• Preferred regimen: Ceftriaxone 1 g IM in a single dose

• Disseminated gonococcal infection

• Preferred regimen: Ceftriaxone 1 g IV/IM every 24 hours
• Alternative regimen: Cefotaxime 1 g IV every 8 hours OR Ceftizoxime 1 g IV every 8 hours

Note: All of the preceding regimens should be continued for 24–48 hours after improvement begins, at which time therapy can be switched to Cefixime 400 mg PO bid to complete at least 1 week of antimicrobial therapy.

• Gonococcal meningitis

• Preferred regimen: Ceftriaxone 1–2 g IV every 12 hours for 10–14 days

• Gonococcal endocarditis

• Preferred regimen: Ceftriaxone 1–2 g IV every 12 hours for at least 4 weeks

• Ophthalmia neonatorum

• Preferred regimen: Ceftriaxone 25–50 mg/kg IV or IM in a single dose, not to exceed 125 mg

• Disseminated gonococcal infection and gonococcal scalp abscesses in newborns

• Preferred regimen:

Granuloma Inguinale

• Granuloma inguinale (donovanosis)

• Preferred regime: Doxycycline 100 mg orally twice a day for at least 3 weeks and until all lesions have completely healed

• Alternative regime (1): Azithromycin 1 g orally once per week for at least 3 weeks and until all lesions have completely healed

• Alternative regime (2): Ciprofloxacin 750 mg orally twice a day for at least 3 weeks and until all lesions have completely healed

• Alternative regime (3): Erythromycin base 500 mg orally four times a day for at least 3 weeks and until all lesions have completely healed

• Alternative regime (4): Trimethoprim-sulfamethoxazole one double-strength (160 mg/800 mg) tablet orally twice a day for at least 3 weeks and until all lesions have completely healed

• NOTE(1): The addition of an Aminoglycoside (e.g., Gentamicin 1 mg/kg IV every 8 hours) to these regimens can be considered if improvement is not evident within the first few days of therapy.
• NOTE(2): Patients should be followed clinically until signs and symptoms have resolved.

• NOTE(3): Persons who have had sexual contact with a patient who has granuloma inguinale within the 60 days before onset of the patient's symptoms should be examined and offered therapy. However, the value of empiric therapy in the absence of clinical signs and symptoms has not been established.

• NOTE(4): Pregnancy is a relative contraindication to the use of sulfonamides. Pregnant and lactating women should be treated with the erythromycin regimen, and consideration should be given to the addition of a parenteral aminoglycoside (e.g., gentamicin). Azithromycin might prove useful for treating granuloma inguinale during pregnancy, but published data are lacking. Doxycycline and ciprofloxacin are contraindicated in pregnant women.

• NOTE(5): Persons with both granuloma inguinale and HIV infection should receive the same regimens as those who are HIV negative; however, the addition of a parenteral Aminoglycoside (e.g., Gentamicin) can also be considered.

Lymphogranuloma venereum

• Preferred regime: Doxycycline 100 mg orally twice a day for 21 days

• Alternative regime: Erythromycin base 500 mg orally four times a day for 21 days

• NOTE (1): azithromycin 1 g orally once weekly for 3 weeks is probably effective based on its chlamydial antimicrobial activity. Fluoroquinolone-based treatments might also be effective, but extended treatment intervals are likely required.
• NOTE (2): Pregnant and lactating women should be treated with erythromycin. Azithromycin might prove useful for treatment of LGV in pregnancy, but no published data are available regarding its safety and efficacy. Doxycycline is contraindicated in pregnant women.
• NOTE (3): Persons with both LGV and HIV infection should receive the same regimens as those who are HIV negative. Prolonged therapy might be required, and delay in resolution of symptoms might occur.

Syphilis

Syphilis Among non-HIV-Infected Persons

Treponema pallidum

Primary and Secondary Syphilis

• Preferred regime: Benzathine penicillin G 2.4 million units IM in a single dose
• Pediatric regime: Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million units in a single dose

Latent Syphilis

• Early Latent Syphilis

• Preferred regime: Benzathine penicillin G 2.4 million units IM in a single dose
• Pediatric regime: Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million units in a single dose

• Late Latent Syphilis or Latent Syphilis of Unknown Duration

• Preferred regime: Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units IM each at 1-week intervalspediatric
• Pediatric regime: [[Benzathine penicillin G[[ 50,000 units/kg IM, up to the adult dose of 2.4 million units, administered as 3 doses at 1-week intervals (total 150,000 units/kg up to the adult total dose of 7.2 million units)

Tertiary Syphilis

• Preferred regime: Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units IM each at 1-week intervals

Neurosyphilis

• Preferred regime: Aqueous crystalline penicillin G 18--24 million units per day, administered as 3--4 million units IV every 4 hours or continuous infusion, for 10--14 days
• Alternative regime: Procaine penicillin 2.4 million units IM once daily AND Probenecid 500 mg orally four times a day, both for 10--14 days

Syphilis Among HIV-Infected Persons

Primary and Secondary Syphilis Among HIV-Infected Persons

• Preferred regimen: Benzathine penicillin G 2.4 million units IM in a single dose.

Latent Syphilis Among HIV-Infected Persons

• early latent

• Preferred regimen: Benzathine penicillin G 2.4 million units IM in a single dose.

• late latent

• Preferred regimen: Benzathine penicillin G at weekly doses of 2.4 million units for 3 weeks.

Neurosyphilis Among HIV-Infected Persons

• Preferred regime: Aqueous crystalline penicillin G 18--24 million units per day, administered as 3--4 million units IV every 4 hours or continuous infusion, for 10--14 days
• Alternative regime: Procaine penicillin 2.4 million units IM once daily AND Probenecid 500 mg orally four times a day, both for 10--14 days

Syphilis During Pregnancy

• Preferred regime: Pregnant women should be treated with the penicillin regimen appropriate for their stage of infection

Congenital Syphilis

• condition 1 : Infants with proven or highly probable disease and (1)an abnormal physical examination that is consistent with congenital syphilis;（2）a serum quantitative nontreponemal serologic titer that is fourfold higher than the mother's titer;¶ or（3）a positive darkfield test of body fluid(s).

• Preferred regime: Aqueous crystalline penicillin G 100,000--150,000 units/kg/day, administered as 50,000 units/kg/dose IV every 12 hours during the first 7 days of life and every 8 hours thereafter for a total of 10 days OR Procaine penicillin G 50,000 units/kg/dose IM in a single daily dose for 10 days
• NOTE: If more than 1 day of therapy is missed, the entire course should be restarted. Data are insufficient regarding the use of other antimicrobial agents (e.g., ampicillin). When possible, a full 10-day course of penicillin is preferred, even if ampicillin was initially provided for possible sepsis. The use of agents other than penicillin requires close serologic follow-up to assess adequacy of therapy. In all other situations, the maternal history of infection with T. pallidum and treatment for syphilis must be considered when evaluating and treating the infant.

• condition 2: Infants who have a normal physical examination and a serum quantitive nontreponemal serologic titer the same or less than fourfold the maternal titer and the (1)mother was not treated, inadequately treated, or has no documentation of having received treatment; (2)mother was treated with erythromycin or another nonpenicillin regimen;†† or (3)mother received treatment <4 weeks before delivery.

• Preferred regime: Aqueous crystalline penicillin G 100,000--150,000 units/kg/day, administered as 50,000 units/kg/dose IV every 12 hours during the first 7 days of life and every 8 hours thereafter for a total of 10 days OR Procaine penicillin G 50,000 units/kg/dose IM in a single daily dose for 10 days OR Benzathine penicillin G 50,000 units/kg/dose IM in a single dose
• NOTE:If the mother has untreated early syphilis at delivery, 10 days of parenteral therapy can be considered.

• condition 3:Infants who have a normal physical examination and a serum quantitative nontreponemal serologic titer the same or less than fourfold the maternal titer and the (1)mother was treated during pregnancy, treatment was appropriate for the stage of infection, and treatment was administered >4 weeks before delivery and (2)mother has no evidence of reinfection or relapse.

• Preferred regime: Benzathine penicillin G 50,000 units/kg/dose IM in a single dose

• condition 4: Infants who have a normal physical examination and a serum quantitative nontreponemal serologic titer the same or less than fourfold the maternal titer and the (1)mother's treatment was adequate before pregnancy and (2)mother's nontreponemal serologic titer remained low and stable before and during pregnancy and at delivery (VDRL <1:2; RPR <1:4).

• Preferred regime: No treatment is required; however, benzathine penicillin G 50,000 units/kg as a single IM injection might be considered, particularly if follow-up is uncertain.

Urethritis

Nongonococcal Urethritis

• Preferred regime: Azithromycin 1 g orally in a single dose OR Doxycycline 100 mg orally twice a day for 7 days

• Alternative regime (1): Erythromycin base 500 mg orally four times a day for 7 days

• Alternative regime (2): Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days

• Alternative regime (3): Levofloxacin 500 mg orally once daily for 7 days
• Alternative regime (4): Ofloxacin 300 mg orally twice a day for 7 days

Recurrent and Persistent Urethritis

• Preferred regime: Metronidazole 2 g orally in a single dose OR Tinidazole 2 g orally in a single dose AND Azithromycin 1 g orally in a single dose