OB/GYN antibiotics

Bacterial Vaginosis

First Line Therapy

• 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.

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
• Metronidazole 250mg PO Three times a day has also been studied
• 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

Prophylaxis (Sexual Assault)

• Metronidazole 500mg PO Twice a day x 7 days

Candida vaginitis

Uncomplicated

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

• Fluconazole 150mg PO once (preferred)
  • A second dose at 72hrs may be given if patient is still symptomatic
• Intravaginal therapy
  • Clotrimazole 1 % cream applied vaginally for 7 days OR
  • Clotrimazole 2% applied vaginally for 3 days
  • Miconazole 2% cream applied vaginally for 7 days OR 4% cream x 3 days
  • Butoconazole 2% applied vaginally x 3 days
  • Tioconazole 6.5% applied vaginally x 1

Complicated

Severe or immunosuppressed

• Fluconazole 150mg PO q72h x 3 doses

Non-albicans species

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

Recurrent (≥ 4 infections in a year)

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

Pregnant Patients

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

Cervicitis

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

Typically, treatment for both gonorrhea and chlamydia is indicated, if one entity is suspected.

Standard

• Gonorrhea
  • Ceftriaxone IM x 1
    • 500 mg, if weight <150 kg
    • 1 g, if weight ≥150 kg
• Chlamydia
  • Nonpregnant: doxycycline 100 mg PO BID x 7 days
  • Pregnant: azithromycin 1 g PO x 1

Ceftriaxone contraindicated

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

^Additional chlamydia coverage only needed if treated with cefixime only

Partner Treatment

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

Associated Bacterial Vaginosis or Trichomonas vaginalis

Non-Pregnant

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

Pregnant

Only treat if the patient is symptomatic

• Metronidazole 500mg PO BID for 7 days

Sexual Partner Treatment

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

Endometritis

<48hrs Post Partum

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

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

>48hrs Post Partum

• Doxycycline 100mg IV or PO q12hrs + Metronidazole 500mg IV or PO q8hrs daily
  • Use Metronidazole with caution in breastfeeding mothers its active is present in breast milk at concentrations similar to maternal plasma concentrations

Herpes

Initial Episode

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

Recurrence

• Acyclovir OR
  • 400mg PO q8hrs x 5 days
  • or 800mg PO q12hrs x 5 days
  • or 800mg PO q8hrs x 2 days
• Valacyclovir OR
  • 500mg PO q12hrs x 3 days
  • or 1g PO qd x 5 days
• Famciclovir
  • 125mg PO q12hrs for 5 days
  • or 1g PO q12hrs for 1 day
  • or 500mg PO once, followed by 250mg PO q12hrs for 2 days

Suppressive Therapy

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

Lymphogranuloma Venereum

• Doxycycline 100mg PO BID x 21 days (first choice) OR
• Erythromycin 500mg PO QID x 21 days OR
  • Preferred for pregnant and lactating females
• Azithromycin 1g PO weekly for 3 weeks OR
  • Alternative for pregnant women - poor evidence for this treatment currently
• Tetracycline, Minocycline, or Moxifloxacin (x21 days) are also acceptable alternatives to Doxycycline
• Treat sexual partner
  • Doxycycline 100mg PO BID x 7 days OR
  • Azithromycin 1gm PO x1

Mastitis

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

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

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

PID

Antibiotics

• No sexual activity for 2 weeks;
• Treat all partners who had sex with patient during previous 60 days prior to symptom onset

Outpatient Antibiotic Options

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

Inpatient Antibiotic Options

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

Syphilis

Early Stage

This is classified as primary, secondary, and early latent syphilis less than one year.

Treatment Options:

• Penicillin G Benzathine 2.4 million units IM x 1
  • Repeat dose after 7 days for pregnant patients and HIV infection
• Doxycycline 100mg oral twice daily for 14 days as alternative

Late Stage

Late stage is greater than one year duration, presence of gummas, or cardiovascular disease

Treatment Options:

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

Neurosyphilis

There are 3 Major options with none showing greater efficacy than others:

• Penicillin G 3-4 million units IV every 4 hours x 10-14 days
• Penicillin G 24 million units continuous IV infusion x 10-14 days
• Penicillin G Procaine2.4 million units IM daily + probenecid 500mg oral every 6 hours for 10-14 days.
• Alternative:
  • Ceftriaxone 2gm IV once daily for 10-14 days

• Desensitization to the penicillin allergy is still the preferred method of treatment for patients with early and late stage disease (especially during pregnancy)

Pregnancy

• Penicillin, dosage depends on stage

Trichomonas vaginalis

Non-Pregnant

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

Pregnant

Only treat if the patient is symptomatic

• Metronidazole 500mg PO BID for 7 days

Sexual Partner Treatment

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

See Also

Antibiotics by diagnosis

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

For antibiotics by organism see Microbiology (Main)

External links

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