Sandbox-GU-Yaz

Asymptomatic bacteriuria

• Treatment of asymptomatic bacteriuria is only recommended for the following patient populations

• Pregnant women
• Patients pending urological procedure
• Women with catheter-acquired bacteruria that persists 48 hours following removal of indwelling catheter (antimicrobial therapy may be considered)
• Renal transplant recipients (antimicrobial therapy may be considered but evidence is insufficient)

• Treatment of asymptomatic bacteriuria is not recommended for the following patient populations

• Premenopausal, nonpregnant women
• Diabetic women
• Older persons residing in the community
• Elderly, institutionalized patients
• Individuals with spinal cord injury
• Catheterized patients while the catheter remains in situ
• Note: Pyuria accompanying asymptomatic bacteriuria is not indicated for antibiotic therapy.

• Asymptomatic bacteriuria

• 1. Causative pathogens

• Escherichia coli
• Klebsiella pneumoniae
• Coagulase-negative staphylococci
• Enterococcus
• Group B streptococci
• Gardnerella vaginalis
• Pseudomonas aeruginosa
• Proteus mirabilis
• Providencia stuartii
• Morganella morganii

• 2. Specific considerations

• 2.1 Women, pregnant

• 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 PO tid for 3–5 days
• Preferred regimen (3): Amoxicillin-Clavulanate 500 mg PO bid for 3–5 days
• Preferred regimen (4): Cephalexin 500 mg PO tid for 3–5 days
• Preferred regimen (5): Fosfomycin 3 g PO single dose
• Alternative regimen, second/third trimester only: Trimethoprim PO bid for 3–5 days
• 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): Monthly screening for recurrent bacteriuria should be undertaken following therapy.
• Note (3): IDSA guidelines recommend 3–7 days of antimicrobial therapy.

• 2.2 Urologic interventions

• Preferred regimen: Trimethoprim-Sulfamethoxazole DS 1 tab PO bid for 3 days after obtaining urine cultures
• Note: Screening for or treatment of asymptomatic bacteriuria prior to transurethral resection of the prostate (TRUS) is recommended

Ectoparasitic infections

Pediculosis Pubis

• Pediculosis Pubis

• Preferred regimen (1): Permethrin 1% cream rinse applied to affected areas and washed off after 10 minutes
• Preferred regimen (2): Pyrethrin with Piperonyl butoxide applied to the affected area and washed off after 10 minutes
• Alternative regimen (1): Malathion 0.5% lotion applied for 8-12 hours and washed off
• Alternative regimen (2): Ivermectin 250 µg/kg PO singled dose and then repeated in 2 weeks

Scabies

• Scabies

• Preferred regimen (1): Permethrin cream 5% applied to all areas of the body from the neck down and washed off after 8-14 hours
• Preferred regimen (2): Ivermectin 250 µg/kg PO singled dose and then repeated in 2 weeks
• Alternative regimen: Lindane 1% lotion 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

• 1. Genital Warts

• External Genital Warts

• 1.1 Patient-Applied

• Preferred regimen (1): Podofilox 0.5% solution/gel bid for 3 days followed by 4 days of no therapy. Cycle to be repeated as needed up to 4 cycles in total
• Preferred regimen (2): Imiquimod 5% cream qhs 3 times per week for up to 16 weeks
• Preferred regimen (3): Sinecatechin 15% ointment tid for up to 16 weeks

• Note (1): Sinecatechin should not be washed off after use
• Note (2): Sinecatechin may weaken condoms and diaphragms. It is recommended that sexual activity is avoided during application of Sinecatechin

• 1.2 Provider-Administered

• Preferred regimen (1): Cryotherapy with liquid nitrogen, repeat applications in 2 weeks if needed OR Cryotherapy with cryoprobe, repeat applications in 2 weeks if needed
• Preferred regimen (2): Podophyllin resin 10%-25% in a compound tincture of benzoin skin solution for 1-4 hours once per week up to 6 weeks or until resolution of the wart
• Alternative regimen (1): Interferon intralesional administration 3 times per week for 3 weeks
• Alternative regimen (2): Cidofovir 1% topical application qd 5 days per week up to 8 weeks
• Alternative regimen (3): Trichloroacetic acid (TCA) 80%-90% skin solution once weekly up to 6 weeks
• Note: The treatment area and adjacent normal skin must be dry before contact with Podophyllin.
• Note: Following the application of TCA, excessively treated area should be powdered with talc, sodium bicarbonate, or liquid soap preparations to remove unreacted acid.

• 2. Vaginal Warts

• Preferred regimen: Cryotherapy with liquid nitrogen, repeat applications in 2 weeks if needed.
• Note (1): 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.
• Note (2): 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.

• 3. Urethral Meatus Warts

• Preferred regimen (1): Cryotherapy with liquid nitrogen, repeat applications in 2 weeks if needed
• Preferred regimen (2): Podophyllin resin 10%-25% in a compound tincture of benzoin skin solution for 1-4 hours once per week up to 6 weeks or until resolution of the wart.

• Note: The treatment area and adjacent normal skin must be dry before contact with Podophyllin.

• 4. Anal Warts

• Preferred regimen (1): Cryotherapy with liquid nitrogen, repeat applications in 2 weeks if needed
• Preferred regimen (2): Trichloroacetic acid (TCA) 80%-90% skin solution once weekly up to 6 weeks

Vaginal infection

Bacterial vaginosis

• Bacterial vaginosis

• Preferred regimen: Metronidazole 500 mg PO bid 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 regimen (1): Tinidazole 2 g PO qd for 3 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

Bacterial vaginosis during pregnancy

• Bacterial vaginosis during pregnancy

• Preferred regimen: Metronidazole 500 mg PO bid for 7 days OR Metronidazole 250 mg PO tid for 7 days OR Clindamycin 300 mg PO bid for 7 days

Trichomoniasis

T. vaginalis

• Preferred regimen: Metronidazole 2 g PO in a single dose OR Tinidazole 2 g PO in a single dose
• Alternative regimen: Metronidazole 500 mg PO bid for 7 days

Trichomoniasis during pregnancy

• Trichomoniasis during pregnancy

• Preferred regimen: 2 g Metronidazole PO 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

• Vulvovaginal candidiasis

Uncomplicated VVC

• Preferred regimen:

• 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

• 1. Recurrent Vulvovaginal Candidiasis (RVVC)

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

• 2. Severe VVC

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

• 3. Nonalbicans VVC

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

Vulvovaginal candidiasis during pregnancy

• Preferred regimen: topical Azole therapies for 7 days