GU antibiotics
Balanoposthitis
Common organisms are Candida, anaerobes, and Group B Streptococcus
Antifungal
- Clotrimazole 1% applied topically to glans q12hrs until resolution
- Nystatin cream 100,000 units/gm if infection is recurrent after clotrimazole therapy
Antibacterial
- Topical triple antibiotic ointment QID or mupirocin cream BID
Epididymitis/Epididymorchitis
- For acute epididymitis likely caused by STI [1]
- Ceftriaxone 500 mg IM in a single dose PLUS
- Doxycycline 100 mg orally twice a day for 10 days
- For acute epididymitis most likely caused by STI and enteric organisms (MSM)
- Ceftriaxone 500 mg IM in a single dose PLUS
- Levofloxacin 500 mg orally once a day for 10 days
- For acute epididymitis most likely caused by enteric organisms
- Levofloxacin 500 mg orally once daily for 10 days
For persons weighing ≥150 kg, 1 g of ceftriaxone should be administered.
Cervicitis
Presumed GC/chlamydia of cervix, urethra, or rectum (uncomplicated)[2]
Typically, treatment for both gonorrhea and chlamydia is indicated, if one entity is suspected.
Standard
- Gonorrhea
- Ceftriaxone IM x 1
- 500 mg, if weight <150 kg
- 1 g, if weight ≥150 kg
- Ceftriaxone IM x 1
- Chlamydia
- Nonpregnant: doxycycline 100 mg PO BID x 7 days
- Pregnant: azithromycin 1 g PO x 1
Ceftriaxone contraindicated
- Gonorrhea
- Gentamicin 240 mg IM x 1 PLUS azithromycin 2 g PO x 1, OR
- Cefixime 800 mg PO x 1
- Chlamydia^
- Nonpregnant: doxycycline 100 mg PO BID x 7 days
- Pregnant: azithromycin 1 g PO x 1
^Additional chlamydia coverage only needed if treated with cefixime only
Partner Treatment
- Gonorrhea
- Cefixime 800mg PO x 1
- Chlamydia
- Nonpregnant: doxycycline 100mg PO BID x 7 days, OR
- Pregnant: azithromycin 1g PO x 1
Associated Bacterial Vaginosis or Trichomonas vaginalis
Non-Pregnant
- Metronidazole 500mg PO BID for 7 days [3]
- Tinidazole 2g PO once
Pregnant
Only treat if the patient is symptomatic
- Metronidazole 500mg PO BID for 7 days [4]
Sexual Partner Treatment
- Female: Same as above
- Male: Metronidazole 2 gm PO x1 [5]
Cystitis (acute)
Outpatient
Women, Uncomplicated
- Nitrofurantoin ER 100mg BID x 5d, OR
- TMP/SMX DS (160/800mg) 1 tab BID x 3d (Females) x7days (Males), OR
- Cephalexin 250mg QID x 5d, OR
- Ciprofloxacin 250mg BID x3d
- Avoid using fluoroquinolone for the first-line treatment of uncomplicated urinary tract infections (UTIs) in women.[6]
- Fosfomycin 3 g PO once
- Lower clinical and microbiologic success compared to nitrofurantoin TID for 5 days [7]
Women, Complicated
- Ciprofloxacin 500mg BID x10-14d, OR
- Cefpodoxime 200 mg BID x10-14d
Women, Concern for Urethritis
- Ceftriaxone 250mg IM x1 AND azithromycin 1gm PO x1 AND nitrofurantoin ER 100mg BID x5d, OR
- Levofloxacin 500mg QD x 14d (covers urinary pathogens, GC, and chlamydia)
- GC resistance to fluoroquinolones is increasing
Men
- Ciprofloxacin 500mg BID x10-14d, OR
- Cefpodoxime 200 mg BID x10-14d
Inpatient Options
- Ciprofloxacin 400mg IV q12hr, OR
- Ceftriaxone 1gm IV QD, OR
- Cefotaxime 1-2gm IV q8hr, OR
- Gentamicin 3mg/kg/day divided q8hr +/- ampicillin 1–2 gm q4hr, OR
- Piperacillin/Tazobactam 3.375 gm IV q6hr, OR
- Cefepime 2gm IV q8hr, OR
- Imipenem 500mg IV q8hr
Bacterial Vaginosis
First Line Therapy[8]
- Metronidazole 500 mg PO Twice Daily for 7 days OR
- Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, Daily for 5 days OR
- Clindamycin cream 2%, one full applicator (5 g) intravaginally Nightly for 7 days
Metronidazole does not cause a disulfiram-like reaction with alcohol.[9]
Alternative Regimin
- Clindamycin 300 mg PO BID for 7 days OR
- Clindamycin ovules 100 mg intravaginally qHS for 3 days (do not use if patient has used latex condom in last 72 hours)
Other regimens have been studied and have varying efficacy compared to placebo but due to cost and availability do not represent alternatives outside of absolute contraindications to preferred regimens.
Pregnant
- Metronidazole 500mg PO Twice a day x 7 days[8]
- Metronidazole 250mg PO Three times a day has also been studied[10][11]
- Although metronidazole crosses the placenta, no evidence of teratogenicity or mutagenic effects among infants has been reported in multiple cross-sectional, case-control, and cohort studies of pregnant women[8]
Prophylaxis (Sexual Assault)
- Metronidazole 500mg PO Twice a day x 7 days[12]
Herpes
Initial Episode[13][14]
- Acyclovir OR
- 400mg PO q8hrs x 7-10 days
- or 200mg PO 5x/day x 7-10 days
- Valacyclovir 1g PO q12hrs x 7-10 days OR
- Famciclovir 250mg PO q8hrs x 7-10 days
Recurrence[13]
- Acyclovir OR
- 400mg PO q8hrs x 5 days
- or 800mg PO q12hrs x 5 days
- or 800mg PO q8hrs x 2 days
- Valacyclovir OR
- 500mg PO q12hrs x 3 days
- or 1g PO qd x 5 days
- Famciclovir
- 125mg PO q12hrs for 5 days
- or 1g PO q12hrs for 1 day
- or 500mg PO once, followed by 250mg PO q12hrs for 2 days
Suppressive Therapy[13]
- Acyclovir 400mg PO q12hrs daily OR
- Famciclovir 250mg PO q12hrs daily OR
- Valacyclovir 500mg-1g PO daily (500mg may be less effective)
Proctitis
Inflammation of the rectum (distal 10-12cm)
- Ceftriaxone 125mg IM x1 + Doxy 100mg po bid x 7d
Prostatitis
Associated with STD
Target organisms are E. coli, and STDs (GC)
- Doxycycline 100mg PO q12 hrs x14 days + Ceftriaxone 500mg IM x1
- Ciprofloxacin no longer recommended to treat gonorrhea in US
No Associated STD and Chronic Bacterial Prostatitis
Aimed at Enterobacteriaceae, enterococci, Pseudomonas
- Ciprofloxacin 500mg PO q12hrs x 28 days OR
- Levofloxacin 500mg PO daily x 28 days OR
- TMP/SMX 1 DS tablet PO q12hrs x 28 days
- Consider extension to 6 wks of empiric therapy
Septic
- Gentamycin 7mg/kg IV daily + Ceftriaxone 1g IV q12hrs
Pyelonephritis
Treatment is targeted at E. coli, Enterococcus, Klebsiella, Proteus mirabilis, S. saprophyticus.
Outpatient
Consider one dose of Ceftriaxone 1g IV or Gentamycin 7mg/kg IV if the regional susceptibility of TMP/SMX or Fluoroquinolones is <80%
- Ciprofloxacin 500mg PO BID x7 days OR
- Trimethoprim-Sulfamethoxazole DS 160/800mg PO BID x14 days OR[15]
- Cephalexin 500mg QID PO x 10-14 days (OR consider 1000mg BID if difficulty with QID regimen) OR
- Cefdinir 300mg BID PO x 10-14 days OR
- Cefpodoxime 200mg PO BID x 10 days OR[16]
- Cefixime 400mg PO daily x 10 days OR[17]
- Levofloxacin 750mg PO QD x7 days[18]
Adult Inpatient Options
- Ciprofloxacin 400mg IV q12hr OR
- Ceftriaxone 1gm IV QD (Preferred in pregnancy) OR
- Cefotaxime 1-2gm IV q8hr OR
- Gentamicin 3mg/kg/day divided q8hr +/- ampicillin 1–2 gm q4hr OR
- Piperacillin/Tazobactam 3.375 gm IV q6hr OR
- Cefepime 2gm IV q8hr OR
- Imipenem 500mg IV q8hr
Pediatric Inpatient Options
- Ceftriaxone 75mg/kg IV QD OR
- Cefotaxime 50mg/kg IV q8hrs OR
- Ampicillin 25mg/kg IV q6hrs + Gentamicin 2.5mg/kg IV q8hrs
Lymphogranuloma venereum
- Doxycycline 100mg PO BID x 21 days (first choice) OR
- Erythromycin 500mg PO QID x 21 days OR
- Preferred for pregnant and lactating females
- Azithromycin 1g PO weekly for 3 weeks OR
- Alternative for pregnant women - poor evidence for this treatment currently
- Tetracycline, Minocycline, or Moxifloxacin (x21 days) are also acceptable alternatives to Doxycycline
- Treat sexual partner
- Doxycycline 100mg PO BID x 7 days OR
- Azithromycin 1gm PO x1
Syphilis
Early Stage
This is classified as primary, secondary, and early latent syphilis less than one year.
Treatment Options:
- Penicillin G Benzathine 2.4 million units IM x 1
- Repeat dose after 7 days for pregnant patients and HIV infection
- Doxycycline 100mg oral twice daily for 14 days as alternative
Late Stage
Late stage is greater than one year duration, presence of gummas, or cardiovascular disease
Treatment Options:
- Penicillin G Benzathine 2.4 million units IM weekly x 3 weeks
- Doxycycline 100mg oral twice daily for 4 weeks as alternative
Neurosyphilis
There are 3 Major options with none showing greater efficacy than others:
- Penicillin G 3-4 million units IV every 4 hours x 10-14 days
- Penicillin G 24 million units continuous IV infusion x 10-14 days
- Penicillin G Procaine2.4 million units IM daily + probenecid 500mg oral every 6 hours for 10-14 days.
- Alternative:
- Ceftriaxone 2gm IV once daily for 10-14 days
- Desensitization to the penicillin allergy is still the preferred method of treatment for patients with early and late stage disease (especially during pregnancy)
Pregnancy
- Penicillin, dosage depends on stage [19]
Urethritis (male)
Uncomplicated Infection
Treatment to cover both gonorrhea and chlamydia
Typically, treatment for both gonorrhea and chlamydia is indicated, if one entity is suspected.
Standard
- Gonorrhea
- Ceftriaxone IM x 1
- 500 mg, if weight <150 kg
- 1 g, if weight ≥150 kg
- Ceftriaxone IM x 1
- Chlamydia
- Doxycycline 100 mg PO BID x 7 days
Ceftriaxone contraindicated
- Gonorrhea
- Gentamicin 240 mg IM x 1 PLUS azithromycin 2 g PO x 1, OR
- Cefixime 800 mg PO x 1
- Chlamydia^
- Doxycycline 100 mg PO BID x 7 days
^Additional chlamydia coverage only needed if treated with cefixime only
Partner Treatment
- Gonorrhea
- Cefixime 800mg PO x 1
- Chlamydia
- Nonpregnant: doxycycline 100mg PO BID x 7 days, OR
- Pregnant: azithromycin 1g PO x 1
Recurrent or Persistent
Target M. genitalium
- Moxifloxacin 400 mg daily x 7 days
Consider coverage of trichomonas, among men who have sex with women
- Metronidazole 2 gm PO x 1, OR
- Tinidazole 2 gm PO x 1
See Also
Antibiotics by diagnosis
- Bone and joint antibiotics
- Cardiovascular antibiotics
- ENT antibiotics
- Eye antibiotics
- GI antibiotics
- GU antibiotics
- Neuro antibiotics
- OB/GYN antibiotics
- Pulmonary antibiotics
- Skin and soft tissue antibiotics
- Bioterrorism antibiotics
- Environmental exposure antibiotics
- Immunocompromised antibiotics
- Post exposure prophylaxis antibiotics
- Pediatric antibiotics
- Sepsis antibiotics
- Arthropod and parasitic antibiotics
For antibiotics by organism see Microbiology (Main)
References
- ↑ https://www.cdc.gov/std/treatment-guidelines/epididymitis.htm
- ↑ Cyr SS et al. Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. MMWR. Center for Disease Control and Prevention. 2020. 69(50):1911-1916
- ↑ Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
- ↑ CDC Trichomoniasis 2021. https://www.cdc.gov/std/treatment-guidelines/trichomoniasis.htm
- ↑ Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
- ↑ Choosing Wisely. American Urogynecologic Society. http://www.choosingwisely.org/societies/american-urogynecologic-society
- ↑ Huttner, A., Kowalczyk, A., Turjeman, A., Babich, T., Brossier, C., Eliakim-Raz, N., … Harbarth, S. (2018). Effect of 5-Day Nitrofurantoin vs Single-Dose Fosfomycin on Clinical Resolution of Uncomplicated Lower Urinary Tract Infection in Women: A Randomized Clinical Trial. JAMA: The Journal of the American Medical Association, 319(17), 1781–1789.
- ↑ 8.0 8.1 8.2 CDC Sexually Transmitted Infections Treatment Guidelines, 2021.[1]
- ↑ Is combining metronidazole and alcohol really hazardous?[2]
- ↑ Reduced incidence of preterm delivery with metronidazole and erythromycin in women with bacterial vaginosis[3]
- ↑ Effect of metronidazole in patients with preterm birth in preceding pregnancy and bacterial vaginosis: a placebo-controlled, double-blind study[4]
- ↑ Sexual Assault and Abuse and STIs – Adolescents and Adults[5]
- ↑ 13.0 13.1 13.2 Workoski KA and Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recommen and Reports. 2015; 64(3):1-140.
- ↑ https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf
- ↑ Gupta K, Hooton TM, Naber KG, et al. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women. Clinical Infectious Diseases. 2011;52(5):e103-e120. doi:10.1093/cid/ciq257
- ↑ Colgan R, Williams M. Diagnosis and treatment of acute uncomplicated cystitis. Am Fam Physician. 2011 Oct 1;84(7):771-6.
- ↑ Acute Pyelonephritis in Adults. Johnson, JR and Russo, TA. New England Journal of Medicine 2018; 378:48-59.
- ↑ Sandberg T. et al. Ciprofloxacin for 7 days versus 14 days in women with acute pyelonephritis: a randomised, open-label and double-blind, placebo-controlled, non-inferiority trial. Lancet. 2012 Aug 4;380(9840):484-90.
- ↑ Mackay G. Chapter 43. Sexually Transmitted Diseases & Pelvic Infections. In:DeCherney AH, Nathan L, Laufer N, Roman AS. eds. CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 11e. New York, NY: McGraw-Hill; 2013