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Asymptomatic bacteriuria

  • Asymptomatic bacteriuria[1][2]
  • Definitions
  • For women: two consecutive voided urine specimens with isolation of the same bacterial strain in quantitative counts 􏰁≥ 105 cfu/mL
  • For men: a single, clean-catch voided urine specimen with 1 bacterial species isolated in a quantitative count 􏰁􏰁≥ 105 cfu/mL
  • For catheterized urine specimen: a single catheterized urine specimen with 1 bacterial species isolated in a quantitative count 􏰁􏰁≥ 10>2 cfu/mL
  • Causative pathogens
  • Escherichia coli
  • Klebsiella pneumoniae
  • Coagulase-negative staphylococci
  • Enterococcus
  • Group B streptococci
  • Gardnerella vaginalis
  • Pseudomonas aeruginosa, Proteus mirabilis, Providencia stuartii, Morganella morganii (common in patients with long-term urologic device in place)
  • Empiric antimicrobial therapy
  • Treatment of asymptomatic bacteriuria is not recommended for the following persons:
  • Premenopausal, nonpregnant women
  • Diabetic women
  • Older persons residing in the community
  • Elderly, institutionalized subjects
  • Persons with spinal cord injury
  • Catheterized patients while the catheter remains in situ
Note: Pyuria accompanying asymptomatic bacteriuria is not indicated for antibiotic therapy.
  • Specific considerations
  • Men
  • Screening for or treatment of asymptomatic bacteriuria in men is not recommended.
  • Women, premenopausal, nonpregnant
  • Screening for or treatment of asymptomatic bacteriuria in premenopausal, nonpregnant women is not indicated.
  • Women, pregnant[3]
  • Preferred regimen (1): Nitrofurantoin 100 mg PO bid for 3–5 days (avoid in glucose-6-phosphate dehydrogenase deficiency)
  • Preferred regimen (2): Amoxicillin 500 mg tid for 3–5 days
  • Preferred regimen (3): Amoxicillin-Clavulanate 500 mg bid for 3–5 days
  • Preferred regimen (4): Cephalexin 500 mg tid for 3–5 days
  • Preferred regimen (5): Fosfomycin 3 g as a single dose
  • Preferred regimen (6): Trimethoprim bid for 3–5 days (only after first trimester)
Note (1): Pregnant women should be screened for bacteriuria by urine culture at least once in early pregnancy, and they should be treated if the results are positive.
Note (2): Periodic screening for recurrent bacteriuria should be undertaken after therapy.
Note (3): IDSA guidelines recommend 3–7 days of antimicrobial therapy.
  • Women, diabetic
  • Screening for or treatment of asymptomatic bacteriuria in diabetic women is not recommended.
  • Older persons residing in the community
  • Screening for or treatment of asymptomatic bacteriuria in older persons residing in the community is not recommended.
  • Elderly institutionalized subjects
  • Screening for or treatment of asymptomatic bacteriuria in elderly institutionalized residents of longterm care facilities is not recommended.
  • Subjects with spinal cord injuries
  • Screening for or treatment of asymptomatic bacteriuria in subjects with spinal cord injuries is not recommended.
  • Patients with indwelling urethral catheters
  • Screening for or treatment of asymptomatic bacteriuria in patients with indwelling urethral catheters is not recommended.
Note: Antimicrobial treatment of asymptomatic women with catheter-acquired bacteriuria that persists 48 hours after catheter removal may be considered.
  • Urologic interventions[4]
  • Screening for or treatment of asymptomatic bacteriuria before transurethral resection of the prostate is recommended.
  • Preferred regimen: Trimethoprim-Sulfamethoxazole DS 1 tab bid for 3 days after obtaining urine cultures

Ectoparasitic Infections

Pediculosis Pubis

  • Preferred regime: Permethrin 1% cream rinse applied to affected areas and washed off after 10 minutes OR Pyrethrins with piperonyl butoxide applied to the affected area and washed off after 10 minutes
  • Alternative regime: Malathion 0.5% lotion applied for 8--12 hours and washed off OR Ivermectin 250 µg/kg orally, repeated in 2 weeks


Scabies

  • Preferred regime: Permethrin cream (5%) applied to all areas of the body from the neck down and washed off after 8--14 hours OR Ivermectin 200ug/kg orally, repeated in 2 weeks
  • Alternative regime: Lindane (1%) 1 oz. of lotion (or 30 g of cream) applied in a thin layer to all areas of the body from the neck down and thoroughly washed off after 8 hours


Human papillomavirus infection

Genital Warts

External Genital Warts
  • Patient-Applied:
  • Provider--Administered:
  • Preferred regime: Cryotherapy with liquid nitrogen or cryoprobe, repeat applications every 1-2 weeks OR Podophyllin resin 10%-25% in a compound tincture of benzoin OR Trichloroacetic acid (TCA) OR Bichloroacetic acid (BCA) 80%-90% OR Surgical removal either by tangential scissor excision, tangential shave excision, curettage, or electrosurgery.
  • Alternative regime: intralesional interferon, photodynamic therapy, and topical [[Cidofovir].
Cervical Warts
  • Preferred regime: For women who have exophytic cervical warts, a biopsy evaluation to exclude high-grade SIL must be performed before treatment is initiated. Management of exophytic cervical warts should include consultation with a specialist.
Vaginal Warts
  • Preferred regime: Cryotherapy with liquid nitrogen. The use of a cryoprobe in the vagina is not recommended because of the risk for vaginal perforation and fistula formation OR TCA or BCA 80%--90% applied to warts. A small amount should be applied only to warts and allowed to dry, at which time a white frosting develops. If an excess amount of acid is applied, the treated area should be powdered with talc, sodium bicarbonate, or liquid soap preparations to remove unreacted acid. This treatment can be repeated weekly, if necessary.
Urethral Meatus Warts
  • Preferred regime: Cryotherapy with liquid nitrogen OR Podophyllin 10%--25% in compound tincture of benzoin. The treatment area and adjacent normal skin must be dry before contact with podophyllin. This treatment can be repeated weekly, if necessary. The safety of podophyllin during pregnancy has not been established. Data are limited on the use of podofilox and imiquimod for treatment of distal meatal warts.
Anal Warts
  • Preferred regime: Cryotherapy with liquid nitrogen OR TCA or BCA 80%--90% applied to warts. A small amount should be applied only to warts and allowed to dry, at which time a white frosting develops. If an excess amount of acid is applied, the treated area should be powdered with talc, sodium bicarbonate, or liquid soap preparations to remove unreacted acid. This treatment can be repeated weekly, if necessary. OR Surgical removal

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

Trichomoniasis

T. vaginalis

  • Alternative regime: Metronidazole 500 mg orally twice a day for 7 days
Trichomoniasis during pregnancy
  • Preferred regime: 2 g Metronidazole in a single dose at any stage of pregnancy, withholding breastfeeding during treatment and for 12--24 hours after the last dose will reduce the exposure of the infant to metronidazole.

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.
Vulvovaginal candidiasis during pregnancy
  • Preferred regime: topical Azole therapies for 7 days

Cervicitis

Chancroid

  • Chancroid (Haemophilus ducreyi infection)[6]
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): HIV-infected patients might require repeated or longer courses of therapy than those recommended for HIV-negative patients.
Note (4): 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

  • Chlamydial infections[7]
  • Chlamydial infections in adolescents and adults
Note: Patients should be instructed to refer their sex partners for evaluation, testing, and treatment if they had sexual contact with the patient during the 60 days preceding onset of the patient's symptoms or chlamydia diagnosis.
  • Chlamydial infections during pregnancy
Note: Doxycycline, ofloxacin, and levofloxacin are contraindicated in pregnant women.
  • Chlamydial infections among infants
  • Ophthalmia neonatorum caused by C. trachomatis
  • Preferred regimen: Erythromycin base or ethylsuccinate 50 mg/kg/day PO divided into 4 doses daily for 14 days
Note: The mothers of infants who have chlamydial infection and the sex partners of these women should be evaluated and treated.
  • Infant pneumonia caused by C. trachomatis
  • Preferred regimen (< 45 kg): Erythromycin base or ethylsuccinate 50 mg/kg/day PO divided into 4 doses daily for 14 days
  • Preferred regimen (≥ 45 kg & < 8 years): Azithromycin 1 g PO in a single dose
  • Preferred regimen (≥ 8 years): Azithromycin 1 g PO in a single dose OR Doxycycline 100 mg PO bid for 7 days

Chorioamnionitis

  • Antibiotics [8]
  • Preferred regime: Ampicillin 2 g intravenously every 6 h OR Penicillin 5x106 units intravenously every 6 h AND Gentamicin 1.5 mg/kg every 8 h
  • NOTE (1): Cephalosporins are generally recommended for women with chorioamnionitis who are allergic to Penicillin
  • NOTE (2): In women with anaphylaxis to Penicillin a recommendation is to substitute Clindamycin 900 mg every 8 h
  • NOTE (3): In the non-obstetric population, daily dosing of Gentamicin appears to be more effective, convenient, and cost-effective as well as less toxic.
  • NOTE (4): Recommends the addition of a drug with enhanced anaerobic coverage, such as Clindamycin every 8 hours OR Metronidazole, in those cases of chorioamnionitis that require cesarean delivery
  • NOTE (5): chorioamnionitis is a contraindication to the administration of Corticosteroids. Women with intra-amniotic infection have traditionally been excluded from randomized trials of corticosteroid therapy.
  • Supportive measures
  • Preferred regime: Macrolide (Erythromycin OR Azithromycin) AND Ampicillin for 7–10 days via intravenous (2 days) followed by oral routes.
  • NOTE: Induction of labor and delivery for preterm premature rupture of membranes (PPROM) after 34 weeks’ gestation is recommended.

Cystitis

  • Acute Uncomplicated Cystitis
  • Preferred regime: Nitrofurantoin monohydrate/macrocrystals 100 mg bid 5 days (avoid if early pyelonephritis suspected) OR Trimethoprim-sulfamethoxazole 160/800 mg (one DS tablet) bid 3 days (avoid if resistance prevalence is known to exceed 20 or if used for UTI in previous 3 months) OR Fosfomycin trometamol 3 gm single dose (lower efficacy than some other recommended agents; avoid if early pyelonephritis suspected) OR Pivmecillinam 400 mg bid 5 days (lower efficacy than some other recommended agents; avoid if early pyelonephritis suspected)
  • Alternative regime (1): Fluoroquinolones, Ofloxacin, Ciprofloxacin, and Levofloxacin, use for 3 days.

Epididymitis

  • Preferred regime: Ceftriaxone 250 mg IM in a single dose AND Doxycycline 100 mg orally twice a day for 10 days
  • For acute epididymitis most likely caused by enteric organisms
  • Preferred regime: [[Levofloxacin] 500 mg orally once daily for 10 days OR Ofloxacin 300 mg orally twice a day for 10 days
  • NOTE: Patients who have uncomplicated acute epididymitis and also are infected with HIV should receive the same treatment regimen as those who are HIV negative.

Genital herpes

  • First episode of genital herpes
Note: Treatment can be extended if healing is incomplete after 10 days of therapy.
  • Recurrent genital herpes
  • Suppressive therapy
Note (1): Valacyclovir 500 mg once a day might be less effective than other valacyclovir or acyclovir dosing regimens in patients who have very frequent recurrences (i.e., ≥10 episodes per year).
Note (2): Acyclovir, Famciclovir, and Valacyclovir appear equally effective for episodic treatment of genital herpes, but famciclovir appears somewhat less effective for suppression of viral shedding.
  • Episodic therapy
  • 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
  • Episodic therapy
Note (1): For severe HSV disease, initiating therapy with Acyclovir 5–10 mg/kg IV q8h might be necessary.
Note (2): If lesions persist or recur in a patient receiving antiviral treatment, HSV resistance should be suspected and a viral isolate should be obtained for sensitivity testing.
  • Acyclovir-resistant genital herpes
  • Preferred regimen: Foscarnet 40 mg/kg IV q8h until clinical resolution is attained,
  • Alternative regimen: Cidofovir 5 mg/kg once weekly OR Imiquimod topically qd for 5 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, known or suspected
  • 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

  • Gonococcal infections (Neisseria gonorrhoeae infection)[11][12]
  • Gonococcal infections in adolescents and adults
  • Uncomplicated gonococcal infections of the cervix, urethra, and rectum
  • Uncomplicated gonococcal infections of the pharynx
  • Gonococcal conjunctivitis
  • Disseminated gonococcal infection
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 q12h for 10–14 days
  • Gonococcal endocarditis
  • Preferred regimen: Ceftriaxone 1–2 g IV q12h for at least 4 weeks
  • Gonococcal infections among children
  • Uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis
  • Preferred regimen (> 45 kg): Ceftriaxone 250 mg IM as a single dose OR Cefixime 400 mg PO as a single dose
  • Preferred regimen (≤ 45 kg): Ceftriaxone 125 mg IM in a single dose
  • Bacteremia or arthritis
  • Preferred regimen (> 45 kg): Ceftriaxone 50 mg/kg IM/IV q24h for 7 days
  • Preferred regimen (≤ 45 kg): Ceftriaxone 50 mg/kg (maximum dose: 1 g) IM/IV q24h for 7 days
  • Gonococcal infections among infants
  • Disseminated gonococcal infection and gonococcal scalp abscesses in newborns
  • Preferred regimen: Ceftriaxone 25–50 mg/kg IV/IM q24h for 7 days (10–14 days if meningitis is documented) OR Cefotaxime 25 mg/kg IV/IM q12h for 7 days (10–14 days if meningitis is documented)
  • Prophylactic treatment for infants whose mothers have gonococcal infection
  • Preferred regimen: Ceftriaxone 25–50 mg/kg IV/IM, not to exceed 125 mg
  • Ophthalmia neonatorum
  • Preferred regimen: Ceftriaxone 25–50 mg/kg IV/IM in a single dose, not to exceed 125 mg
  • Ophthalmia neonatorum prophylaxis
  • Preferred regimen: Erythromycin (0.5%) ophthalmic ointment in each eye in a single application

Granuloma inguinale

  • Granuloma inguinale (donovanosis)[13]
  • Preferred regimen: Doxycycline 100 mg PO bid for at least 3 weeks and until all lesions have completely healed
  • Alternative regimen (1): Azithromycin 1 g PO once per week for at least 3 weeks and until all lesions have completely healed
  • Alternative regimen (2): Ciprofloxacin 750 mg PO bid for at least 3 weeks and until all lesions have completely healed
  • Alternative regimen (3): Erythromycin base 500 mg PO qid for at least 3 weeks and until all lesions have completely healed
  • Alternative regimen (4): Trimethoprim-Sulfamethoxazole double-strength (160 mg/800 mg) one tablet PO bid 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

  • Lymphogranuloma venereum (Chlamydia trachomatis serovars L1, L2, or L3 infection)[14]
  • Preferred regimen: Doxycycline 100 mg PO bid for 21 days
  • Alternative regimen: Erythromycin base 500 mg PO qid for 21 days
Note (1): Azithromycin 1 g PO 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): Patients should be followed clinically until signs and symptoms have resolved.
Note (3): 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 (4): 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.

Pelvic inflammatory disease

  • Parenteral Treatment
  • Preferred regime (2): Clindamycin 900 mg IV every 8 hours AND Gentamicin loading dose IV or IM (2 mg/kg of body weight), followed by a maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing (3--5 mg/kg) can be substituted.
  • Alternative regime: Ampicillin/Sulbactam 3 g IV every 6 hours AND Doxycycline 100 mg orally or IV every 12 hours.
  • Oral Treatment
  • Preferred regime (2): Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered concurrently in a single dose AND Doxycycline 100 mg orally twice a day for 14 days ± Metronidazole 500 mg orally twice a day for 14 days
  • Alternative regime (2): Levofloxacin 500 mg orally once daily or Ofloxacin 400 mg twice daily for 14 days {{withorwithout]] Metronidazole 500 mg orally twice daily for 14 days.

Proctocolitis

  • Proctitis

Prostatitis

Acute Bacterial Prostatitis

  • Uncomplicated (with low risk of STD pathogens)[15]
Enterobacteriaceae (especially Escherichia coli)
  • Preferred regime: Ciprofloxacin 400 mg iv or 500 mg po BID or Levofloxacin 500–750 mg iv/po QD
  • Alternative regime: TMP-SMX DS (160 mg TMP) BID
  • NOTE: 2 weeks duration of therapy may be sufficient; if patient remains symptomatic, extend to 4 weeks
Enterococcus species
  • Preferred regime: Ampicillin 1–2 g IV every 4 h OR Vancomycin 15 mg/kg every 12 h
  • Alternative regime: Levofloxacin 750 po QD OR Linezolid 600 mg every 12 h
  • NOTE: Use intravenous therapy if systemically ill; switch to oral therapy when stable
Pseudomonas aeruginosa
  • Uncomplicated (with risk of STD pathogens)
Neisseria gonorrhoeae or Chlamydia trachomatis <----------oral cephalosporins no longer a recommended treatment for gonococcal infections.
  • Alternative regime: Fluoroquinolones not recommended for gonococcal infection
  • NOTE: Treat for 2 weeks in most cases. Obtain urine nucleicacid amplification test for N.gonorrhoeae and C.trachomatis
  • Uncomplicated, with risk of antibiotic resistant pathogen
Fluoroquinolone-resistant Enterobacteriaceae
ES or AmpC beta lactamase producing Enterobacteriaceae
Fluoroquinolone-resistant pseudomonas
  • Preferred regime: Imipenem 500 mg iv every 6 h
  • Alternative regime: Meropenem 500 mg iv every 8 h
  • Complicated by bacteremia or suspected prostatic abscess
Enterobacteriaceae or Enterococcus species
  • Preferred regime: Ciprofloxacin 400 mg iv every 12 h OR Levofloxacin 500 mg iv every 24 h
  • Alternative regime: Ceftriaxone 1–2 g iv every 24 h AND Levofloxacin 500–750 mg po QD OR Ertapenem 1 g iv every 24 h OR piperacillin-tazobactam 3.375 g iv every 6 h
  • NOTE: Treat for 4 weeks. Obtain blood cultures; Consider genitourinary imaging; Change iv to po regimen when blood cultures are sterile and abscess drained.

Chronic Bacterial Prostatitis

Enterobacteriaceae (Enterococcus species)
  • Alternative regime: TMP-SMX x 1 dose DS BID
Staphylococcus species
NOTE: Duration of therapy 4–6 weeks; Consider suppressive therapy if relapses occur.

Pyelonephritis

  • Condition 1: patients not requiring hospitalization where the prevalence of resistance of community uropathogens to fluoroquinolones is not known to exceed 10%
  • Preferred regime: Ciprofloxacin orally 500 mg twice daily for 7 days ± an initial 400-mg dose of intravenous Ciprofloxacin
  • NOTE (1): If an initial one-time intravenous agent is used, a long-acting antimicrobial, such as 1 g of Ceftriaxone or a consolidated 24-h dose of an Aminoglycoside, could be used in lieu of an intravenous fluoroquinolone
  • NOTE (2): If the prevalence of fluoroquinolone resistance is thought to exceed 10%, an initial one-time intravenous dose of a long-acting parenteral antimicrobial, such as 1 g of ceftriaxone or a consolidated 24-h dose of an aminoglycoside, is recommended.
  • Alternative regime: A once-daily oral fluoroquinolone, including Ciprofloxacin 1000 mg extended release for 7 days OR Levofloxacin 750 mg for 5 days.
  • NOTE: If the prevalence of fluoroquinolone resistance is thought to exceed 10%, an initial intravenous dose of a long-acting parenteral antimicrobial, such as 1 g of Ceftriaxone or a consolidated 24-h dose of an Aminoglycoside, is recommended.
  • Condition 2: When the uropathogen is known to be susceptible
  • Preferred regime: Trimethoprim-sulfamethoxazole 160/800 mg (1 double-strength tablet) bid orally for 14 days.
  • NOTE: If trimethoprim-sulfamethoxazole is used when the susceptibility is not known, an initial intravenous dose of a long-acting parenteral antimicrobial, such as 1 g of ceftriaxone OR a consolidated 24-h dose of an aminoglycoside, is recommended.
  • NOTE: Oral β-lactam agents are less effective than other available agents for treatment of pyelonephritis. If an oral β-lactam agent is used, an initial intravenous dose of a long-acting parenteral antimicrobial, such as 1 g of ceftriaxone OR a consolidated 24-h dose of an aminoglycoside, is recommended.
  • Condition 3: Patients require hospitalization (high fever, high white blood cell count, vomiting, dehydration, or evidence of sepsis)

Sterile pyuria

  • Sterile pyuria
  • Definitions
  • Pyuria: the presence of 10 or more white cells per cubic millimeter in a urine specimen, 3 or more white cells per high-power field of unspun urine, a positive result on Gram’s stain of an unspun urine specimen, or a urinary dipstick test that is positive for leukocyte esterase[16]
  • Sterile pyuria: the persistent finding of white cells in the urine in the absence of bacteria, as determined by means of aerobic laboratory techniques (on a 5% sheep-blood agar plate and MacConkey agar plate)[17]
  • Bacteriuria: bacterial colony counts of more than 1000 colony-forming units (CFU) per milliliter in urine[18]
  • Infectious etiologies
  • Gynecologic infection
  • Urethritis due to chlamydia, Neisseria gonorrhoeae, mycoplasma, or ureaplasma
  • Prostatitis
  • Balanitis
  • Appendicitis
  • Viral infection of the lower genitourinary tract
  • Genitourinary tuberculosis
  • Fungal infection
  • Parasitic disease such as trichomoniasis or schistosomiasis
  • Non-infectious etiologies
  • Current use of antibiotics
  • Recently treated urinary tract infection (within past 2 weeks)
  • Presence or recent use of a urinary catheter
  • Recent cystoscopy or urologic endoscopy
  • Urinary tract stones
  • Foreign body such as surgical mesh in the urethra or a retained stent
  • Urinary tract neoplasm
  • Pelvic irradiation
  • Urinary fistula
  • Polycystic kidney
  • Rejection of a renal transplant
  • Renal-vein thrombosis
  • Interstitial nephritis or analgesic nephropathy
  • Papillary necrosis
  • Interstitial cystitis
  • Inflammatory disease such as systemic lupus erythematosus or Kawasaki’s disease
  • Pathogen-directed antimicrobial therapy[20]
  • Tuberculosis
  • Gonorrhea
  • Chlamydia
  • Mycoplasma and ureaplasma
  • Genital herpes
  • Trichomoniasis
Note: Treat patient’s sex partner if trichomoniasis is diagnosed in patient.
  • Fungal infections
  • Schistosomiasis
  • Preferred regimen: Praziquantel 20 mg/kg PO bid for 1–2 days

Syphilis

  • Syphilis (Treponema pallidum)[21]
  • Non–HIV-infected persons
  • Primary and secondary syphilis
  • Latent syphilis
  • Early latent syphilis
  • Late latent syphilis or unknown duration
  • Preferred regimen (adult): Benzathine penicillin G 2.4 MU IM for 3 doses, each at 1-week intervals
  • Preferred regimen (pediatric): Benzathine penicillin G 50,000 units/kg (up to 2.4 MU) IM, administered as 3 doses at 1-week intervals
  • Tertiary syphilis
  • Neurosyphilis
Note: Benzathine penicillin G 2.4 MU IM once per week for up to 3 weeks may be considered after completion of above mentioned regimens to provide a comparable total duration of therapy.
  • HIV-infected persons
  • Primary and secondary syphilis
  • Latent syphilis
  • Early latent syphilis
  • Late latent syphilis or unknown duration
  • Tertiary syphilis
  • Neurosyphilis
Note: Benzathine penicillin G 2.4 MU IM once per week for up to 3 weeks may be considered after completion of above mentioned regimens to provide a comparable total duration of therapy.
  • During pregnancy
  • Preferred regimen: Pregnant women should be treated with the Penicillin regimen appropriate for their stage of infection.
  • Congenital syphilis
  • Infants with proven or highly probable disease AND (abnormal physical examination consistent with congenital syphilis OR nontreponemal serologic titer fourfold higher than the mother's titer OR a positive darkfield test of body fluids)
Note (1): If more than 1 day of therapy is missed, the entire course should be restarted.
Note (2): Maternal history of infection with T. pallidum and treatment for syphilis must be considered.
  • Infants who have a normal physical examination AND nontreponemal serologic titer the same or less than fourfold the maternal titer AND (mother was not treated adequately OR mother has no documentation of having received treatment OR mother was treated with Erythromycin or another non-Penicillin regimen OR mother received treatment < 4 weeks before delivery)
Note: If the mother has untreated early syphilis at delivery, 10 days of parenteral therapy may be considered.
  • Infants who have a normal physical examination AND nontreponemal serologic titer the same or less than fourfold the maternal titer AND mother was treated during pregnancy AND treatment was appropriate for the stage of infection AND treatment administered > 4 weeks before delivery AND mother has no evidence of reinfection or relapse
Note: Another approach involves not treating the infant, but rather providing close serologic follow-up in those whose mother's nontreponemal titers decreased fourfold after appropriate therapy for early syphilis or remained stable or low for late syphilis.
  • Infants who have a normal physical examination AND nontreponemal serologic titer the same or less than fourfold the maternal titer AND mother's treatment was adequate before pregnancy AND mother's nontreponemal serologic titer remained low and stable before and during pregnancy and at delivery (VDRL < 1:2; RPR < 1:4)
Note (1): If the child has no clinical manifestations of disease, the CSF examination is normal, and the CSF VDRL test result is negative, treatment with up to 3 weekly doses of Benzathine penicillin G 50,000 U/kg IM may be considered.
Note (2): Any child who is suspected of having congenital syphilis or who has neurologic involvement should be treated with a single dose of Benzathine penicillin G 50,000 U/kg IM after the 10-day course of Aqueous crystalline penicillin G.

Urethritis

  • Nongonococcal urethritis
  • Recurrent and persistent urethritis

References

  1. ↑ Nicolle, Lindsay E.; Bradley, Suzanne; Colgan, Richard; Rice, James C.; Schaeffer, Anthony; Hooton, Thomas M.; Infectious Diseases Society of America; American Society of Nephrology; American Geriatric Society (2005-03-01). "Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 40 (5): 643–654. doi:10.1086/427507. ISSN 1537-6591. PMID 15714408.
  2. ↑ "Guidelines on Urological Infections".
  3. ↑ "Guidelines on Urological Infections".
  4. ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  5. ↑ Workowski, Kimberly A.; Berman, Stuart; Centers for Disease Control and Prevention (CDC) (2010–12–17). "Sexually transmitted diseases treatment guidelines, 2010". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 59 (RR–12): 1–110. ISSN 1545-8601. PMID 21160459. Check date values in: |date= (help)
  6. ↑ Workowski, Kimberly A.; Berman, Stuart; Centers for Disease Control and Prevention (CDC) (2010–12–17). "Sexually transmitted diseases treatment guidelines, 2010". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 59 (RR–12): 1–110. ISSN 1545-8601. PMID 21160459. Check date values in: |date= (help)
  7. ↑ Workowski, Kimberly A.; Berman, Stuart; Centers for Disease Control and Prevention (CDC) (2010–12–17). "Sexually transmitted diseases treatment guidelines, 2010". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 59 (RR–12): 1–110. ISSN 1545-8601. PMID 21160459. Check date values in: |date= (help)
  8. ↑ Tita AT, Andrews WW (2010). "Diagnosis and management of clinical chorioamnionitis". Clin Perinatol. 37 (2): 339–54. doi:10.1016/j.clp.2010.02.003. PMC 3008318. PMID 20569811.
  9. ↑ Fishman SG, Gelber SE (2012). "Evidence for the clinical management of chorioamnionitis". Semin Fetal Neonatal Med. 17 (1): 46–50. doi:10.1016/j.siny.2011.09.002. PMID 21962477.
  10. ↑ Workowski, Kimberly A.; Berman, Stuart; Centers for Disease Control and Prevention (CDC) (2010–12–17). "Sexually transmitted diseases treatment guidelines, 2010". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 59 (RR–12): 1–110. ISSN 1545-8601. PMID 21160459. Check date values in: |date= (help)
  11. ↑ Workowski, Kimberly A.; Berman, Stuart; Centers for Disease Control and Prevention (CDC) (2010–12–17). "Sexually transmitted diseases treatment guidelines, 2010". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 59 (RR–12): 1–110. ISSN 1545-8601. PMID 21160459. Check date values in: |date= (help)
  12. ↑ Centers for Disease Control and Prevention (CDC) (2012–08–10). "Update to CDC's Sexually transmitted diseases treatment guidelines, 2010: oral cephalosporins no longer a recommended treatment for gonococcal infections". MMWR. Morbidity and mortality weekly report. 61 (31): 590–594. ISSN 1545-861X. PMID 22874837. Check date values in: |date= (help)
  13. ↑ Workowski, Kimberly A.; Berman, Stuart; Centers for Disease Control and Prevention (CDC) (2010–12–17). "Sexually transmitted diseases treatment guidelines, 2010". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 59 (RR–12): 1–110. ISSN 1545-8601. PMID 21160459. Check date values in: |date= (help)
  14. ↑ Workowski, Kimberly A.; Berman, Stuart; Centers for Disease Control and Prevention (CDC) (2010–12–17). "Sexually transmitted diseases treatment guidelines, 2010". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 59 (RR–12): 1–110. ISSN 1545-8601. PMID 21160459. Check date values in: |date= (help)
  15. ↑ Lipsky BA, Byren I, Hoey CT (2010). "Treatment of bacterial prostatitis". Clin Infect Dis. 50 (12): 1641–52. doi:10.1086/652861. PMID 20459324.
  16. ↑ Horan, Teresa C.; Andrus, Mary; Dudeck, Margaret A. (2008-06). "CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting". American Journal of Infection Control. 36 (5): 309–332. doi:10.1016/j.ajic.2008.03.002. ISSN 1527-3296. PMID 18538699. Check date values in: |date= (help)
  17. ↑ Wise, Gilbert J.; Schlegel, Peter N. (2015-03-12). "Sterile pyuria". The New England Journal of Medicine. 372 (11): 1048–1054. doi:10.1056/NEJMra1410052. ISSN 1533-4406. PMID 25760357.
  18. ↑ Kwon, Jennie H.; Fausone, Maureen K.; Du, Hongyan; Robicsek, Ari; Peterson, Lance R. (2012-05). "Impact of laboratory-reported urine culture colony counts on the diagnosis and treatment of urinary tract infection for hospitalized patients". American Journal of Clinical Pathology. 137 (5): 778–784. doi:10.1309/AJCP4KVGQZEG1YDM. ISSN 1943-7722. PMID 22523217. Check date values in: |date= (help)
  19. ↑ Dieter, R. S. (2000). "Sterile pyuria: a differential diagnosis". Comprehensive Therapy. 26 (3): 150–152. ISSN 0098-8243. PMID 10984817.
  20. ↑ Wise, Gilbert J.; Schlegel, Peter N. (2015-03-12). "Sterile pyuria". The New England Journal of Medicine. 372 (11): 1048–1054. doi:10.1056/NEJMra1410052. ISSN 1533-4406. PMID 25760357.
  21. ↑ Workowski, Kimberly A.; Berman, Stuart; Centers for Disease Control and Prevention (CDC) (2010–12–17). "Sexually transmitted diseases treatment guidelines, 2010". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 59 (RR–12): 1–110. ISSN 1545-8601. PMID 21160459. Check date values in: |date= (help)
  22. ↑ Workowski, Kimberly A.; Berman, Stuart; Centers for Disease Control and Prevention (CDC) (2010–12–17). "Sexually transmitted diseases treatment guidelines, 2010". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 59 (RR–12): 1–110. ISSN 1545-8601. PMID 21160459. Check date values in: |date= (help)
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