Sandbox ID Genitourinary

Asymptomatic bacteriuria

• Asymptomatic bacteriuria

• 1. Causative pathogens

• 1.1 Escherichia coli
• 1.2 Klebsiella pneumoniae
• 1.3 Coagulase-negative staphylococci
• 1.4 Enterococcus
• 1.5 Group B streptococci
• 1.6 Gardnerella vaginalis
• 1.7 Pseudomonas aeruginosa, Proteus mirabilis, Providencia stuartii, Morganella morganii (common in patients with long-term urologic device in place)

• 2. 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.

• 3. Specific considerations

• 3.1 Men

• Screening for or treatment of asymptomatic bacteriuria in men is not recommended.

• 3.2 Women, premenopausal, nonpregnant

• Screening for or treatment of asymptomatic bacteriuria in premenopausal, nonpregnant women is not indicated.

• 3.3 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
• Preferred regimen (6): Trimethoprim PO 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.

• 3.4 Women, diabetic

• Screening for or treatment of asymptomatic bacteriuria in diabetic women is not recommended.

• 3.5 Older persons residing in the community

• Screening for or treatment of asymptomatic bacteriuria in older persons residing in the community is not recommended.

• 3.6 Elderly institutionalized subjects

• Screening for or treatment of asymptomatic bacteriuria in elderly institutionalized residents of longterm care facilities is not recommended.

• 3.7 Subjects with spinal cord injuries

• Screening for or treatment of asymptomatic bacteriuria in subjects with spinal cord injuries is not recommended.

• 3.8 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.

• 3.9 Urologic interventions

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

Ectoparasitic Infections

Pediculosis Pubis

• Pediculosis Pubis

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

Scabies

• Scabies

• Preferred regimen: 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 PO, repeated in 2 weeks
• Alternative regimen: 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

• Genital Warts

External Genital Warts

• Patient-Applid:

• Preferred regimen: Podofilox 0.5% solution or gel OR Imiquimod 5% cream OR Sinecatechins 15% ointment

• Provider-Administered:

• Preferred regimen: 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 regimen: intralesional Interferon, photodynamic therapy, and topical [[Cidofovir].

Cervical Warts

• Cervical Warts

• Preferred regimen: 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

• Vaginal Warts

• Preferred regimen: 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

• Urethral Meatus Warts

• Preferred regimen: 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

• Anal Warts

• Preferred regimen: 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

• 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

Cervicitis

• Cervicitis

• Preferred regimen: Azithromycin 1 g PO in a single dose OR Doxycycline 100 mg PO bid 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

• Chlamydial infections

• Preferred regimen: Azithromycin 1 g PO in a single dose OR Doxycycline 100 mg PO bid for 7 days
• Alternative regimen (1): Erythromycin base 500 mg PO qid for 7 days
• Alternative regimen (2): Erythromycin ethylsuccinate 800 mg PO qid for 7 days
• Alternative regimen (3): Levofloxacin 500 mg PO qd for 7 days
• Alternative regimen (4): Ofloxacin 300 mg PO bid for 7 days

Chlamydial infections during pregnancy

• Preferred regimen: Azithromycin 1 g PO in a single dose OR Amoxicillin 500 mg PO tid for 7 days
• Alternative regimen (1): Erythromycin base 500 mg PO qid for 7 days
• Alternative regimen (2): Erythromycin base 250 mg PO qid for 14 days
• Alternative regimen (3): Erythromycin ethylsuccinate 800 mg PO qid for 7 days
• Alternative regimen (4): Erythromycin ethylsuccinate 400 mg PO qid for 14 days

Chorioamnionitis

• 1. Antibiotics

• Preferred regimen: Ampicillin 2 g IV q6h OR Penicillin 5x10⁶ units IV q6h AND Gentamicin 1.5 mg/kg q8h
• 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 q8h
• 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 q8h 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.

• 2. Supportive measures

• Preferred regimen: Antipyretics (Acetaminophen)

• 3. Prevention

• Preferred regimen: 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 regimen: Nitrofurantoin monohydrate/macrocrystal 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 regimen (1): Fluoroquinolones, Ofloxacin, Ciprofloxacin, and Levofloxacin, use for 3 days.
• Alternative regimen (2): β-Lactam agents, including Amoxicillin-clavulanate, Cefdinir, Cefaclor, and Cefpodoxime-proxetil, for 3–7-days

Epididymitis

• 1. Epididymitis

• Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Doxycycline 100 mg PO bid for 10 days

• 2. For acute epididymitis most likely caused by enteric organisms

• Preferred regimen: Levofloxacin 500 mg PO qd for 10 days OR Ofloxacin 300 mg PO bid 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

• Genital HSV infections

• 1. 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.

• 2. Recurrent genital herpes

• 1.1 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

• 1.2 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

• 3. 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.

• 4. Genital herpes in Hiv–infected patients

• 4.1 Suppressive therapy

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

• 4.2 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

• 5. Genital herpes in pregnancy

• Acyclovir can be administered PO 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.

• 6. Neonatal herpes

• 6.1 Disease limited to the skin and mucous membranes

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

• 6.2 Disseminated and CNS disease

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

Gonococcal infections

• Neisseria gonorrhoeae infection

• 1. 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

• 2. Uncomplicated gonococcal infections of the pharynx

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

• 3. Gonococcal conjunctivitis

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

• 4. Disseminated gonococcal infection

• Preferred regimen: Ceftriaxone 1 g IV/IM q24h
• Alternative regimen: Cefotaxime 1 g IV q8h OR Ceftizoxime 1 g IV q8h

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.

• 5. Gonococcal meningitis

• Preferred regimen: Ceftriaxone 1–2 g IV q12h for 10–14 days

• 6. Gonococcal endocarditis

• Preferred regimen: Ceftriaxone 1–2 g IV q12h for at least 4 weeks

• 7. Ophthalmia neonatorum

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

• 8. Disseminated gonococcal infection and gonococcal scalp abscesses in newborns

• Preferred regimen: Ceftriaxone 25-50 mg/kg/day IV or IM q24h for 7 days (10-14 days if meningitis is documented)
• Alternative regimen: Cefotaxime 25 mg/kg IV or IM q12h for 7 days (10-14 days if meningitis is documented)

Granuloma Inguinale

• Granuloma inguinale (donovanosis)

• 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 one double-strength (160 mg/800 mg) 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 q8h) 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

• 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): 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.

Pelvic inflammatory disease

• 1. Parenteral Treatment

• Preferred regimen (1): Cefotetan 2 g IV q12h OR Cefoxitin 2 g IV q6h AND Doxycycline 100 mg PO or IV q12h.
• Preferred regimen (2): Clindamycin 900 mg IV q8h AND Gentamicin loading dose IV or IM (2 mg/kg of body weight), followed by a maintenance dose (1.5 mg/kg) q8h. Single daily dosing (3-5 mg/kg) can be substituted.
• Alternative regimen: Ampicillin/Sulbactam 3 g IV q6h AND Doxycycline 100 mg PO or IV q12h.

• 2. Oral Treatment

• Preferred regimen (1): Ceftriaxone 250 mg IM in a single dose AND Doxycycline 100 mg PO bid for 14 days ± Metronidazole 500 mg PO bid for 14 days
• Preferred regimen (2): Cefoxitin 2 g IM in a single dose and Probenecid, 1 g PO administered concurrently in a single dose AND Doxycycline 100 mg PO bid for 14 days ± Metronidazole 500 mg PO bid for 14 days
• Preferred regimen (3): Other parenteral third-generation cephalosporin (e.g., ceftizoxime OR cefotaxime) AND Doxycycline 100 mg PO bid for 14 days ± Metronidazole 500 mg PO bid for 14 days
• Alternative regimen (1): Ceftriaxone 250 mg IM single dose and Azithromycin 1 g PO once a week for 2 weeks.
• Alternative regimen (2): Levofloxacin 500 mg PO qd OR Ofloxacin 400 mg bid for 14 days ± Metronidazole 500 mg PO bid for 14 days.

Proctocolitis

• Proctitis

• Preferred regimen: Ceftriaxone 250 mg IM AND Doxycycline 100 mg PO bid for 7 days

Prostatitis

Acute Bacterial Prostatitis

• 1. Uncomplicated (with low risk of STD pathogens)

• 1.1 Enterobacteriaceae (especially Escherichia coli)

• Preferred regimen: Ciprofloxacin 400 mg IV or 500 mg PO bid OR Levofloxacin 500–750 mg IV/PO qd
• Alternative regimen: TMP-SMX DS (160 mg TMP) bid
• Note: 2 weeks duration of therapy may be sufficient; if patient remains symptomatic, extend to 4 weeks

• 1.2 Enterococcus species

• Preferred regimen: Ampicillin 1–2 g IV q4h OR Vancomycin 15 mg/kg q12h
• Alternative regimen: Levofloxacin 750 PO qd OR Linezolid 600 mg q12h
• Note: Use intravenous therapy if systemically ill; switch to oral therapy when stable

• 1.3 Pseudomonas aeruginosa

• Preferred regimen: Ciprofloxacin 400 mg tid
• Alternative regimen: Piperacillin-tazobactam 4.5 g IV q6h

• 2. Uncomplicated (with risk of STD pathogens)

• 2.1 Neisseria gonorrhoeae or Chlamydia trachomatis

• Preferred regimen: Ceftriaxone 250 mg IM OR Cefixime 400 mg PO single dose AND Doxycycline 100 mg PO bid OR Azithromycin 500 mg PO qd
• Alternative regimen: 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

• 3 Uncomplicated, with risk of antibiotic resistant pathogen

• 3.1 Fluoroquinolone-resistant Enterobacteriaceae

• Preferred regimen: Ertapenem 1 g IV qd
• Alternative regimen: Ceftriaxone 1 g IV qd or Imipenem 500mg IV q6h OR Tigecycline 100 mg IV x 1 dose then 50 mg IV q12h

• 3.2 ES or AmpC beta lactamase producing Enterobacteriaceae

• Preferred regimen: Ertapenem 1 g IV qd
• Alternative regimen: Cefepime 2g IV q12h OR Imipenem 500 mg IV q6h OR Tigecycline 100 mg IV single dose then 50 mg IV q12h

• 3.3 Fluoroquinolone-resistant pseudomonas

• Preferred regimen: Imipenem 500 mg IV q6h
• Alternative regimen: Meropenem 500 mg IV q8h

• 4. Complicated by bacteremia or suspected prostatic abscess

• 4.1 Enterobacteriaceae or Enterococcus species

• Preferred regimen: Ciprofloxacin 400 mg IV q12h OR Levofloxacin 500 mg IV q24h
• Alternative regimen: Ceftriaxone 1–2 g IV q24h AND Levofloxacin 500–750 mg PO qd OR Ertapenem 1 g IV q24h OR piperacillin-tazobactam 3.375 g IV q6h
• 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

• Chronic Bacterial Prostatitis

• 1. Enterobacteriaceae (Enterococcus species)

• Preferred regimen: Ciprofloxacin 400 mg IV q12h OR Levofloxacin 500 mg IV q24h
• Alternative regimen: TMP-SMX single dose DS bid

• 2. Staphylococcus species

• Preferred regimen: Azithromycin 500 mg PO qd
• Alternative regimen: Doxycycline 100 mg PO bid

• Note: Duration of therapy 4–6 weeks; Consider suppressive therapy if relapses occur.

Pyelonephritis

• Pyelonephritis

• Condition 1: patients not requiring hospitalization where the prevalence of resistance of community uropathogens to fluoroquinolones is not known to exceed 10%

• Preferred regimen: Ciprofloxacin PO 500 mg bid for 7 days ± an initial Ciprofloxacin 400mg IV single dose

• 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 regimen: A once-daily oral fluoroquinolone, Ciprofloxacin 1000 mg extended release PO qd for 7 days OR Levofloxacin 750 mg PO qd 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 Ceftriaxone 1 g IM/IV or a consolidated 24-h dose of an Aminoglycoside, is recommended.

• Condition 2: When the uropathogen is known to be susceptible

• Preferred regimen: Trimethoprim-sulfamethoxazole 160/800 mg (1 double-strength tablet) bid PO 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)

• Preferred regimen: intravenous antimicrobial regimen, such as a Fluoroquinolone; an Aminoglycoside ± Ampicillin; an extended-spectrum Cephalosporin or extended-spectrum Penicillin ± an Aminoglycoside; Carbapenem

• Note: The choice between these agents should be based on local resistance data, and the regimen should be tailored on the basis of susceptibility results.

Sterile pyuria

• Sterile pyuria

• 1. Definitions

• 1.1 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
• 1.2 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)
• 1.3 Bacteriuria: bacterial colony counts of more than 1000 colony-forming units (CFU) per milliliter in urine

• 2. Causes

• 2.1 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

• 2.2 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

• 3. Pathogen-directed antimicrobial therapy

• 3.1 Tuberculosis

• Preferred regimen: Isoniazid AND Rifampin AND Ethambutol AND Pyrazinamide for 3–6 months

• 3.2 Gonorrhea

• Preferred regimen: Ceftriaxone 250 mg IM in a single dose, THEN (Azithromycin 1 g PO in a single dose OR Doxycycline 100 mg PO bid for 7 days)

• 3.3 Chlamydia

• Preferred regimen: Azithromycin 1 g PO in single dose OR Doxycycline 100 mg PO bid for 7 days
• Alternative regimen: Erythromycin base 500 mg PO qid for 7 days

• 3.4 Mycoplasma and ureaplasma

• Preferred regimen: Azithromycin OR Levofloxacin OR Moxifloxacin

• 3.5 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 days

• 3.6 Trichomoniasis

• Preferred regimen: Metronidazole 2 g PO in a single dose OR Tinidazole 2 g PO in a single dose

Note: Treat patient’s sex partner if trichomoniasis is diagnosed in patient.

• 3.7 Fungal infections

• Preferred regimen: Fluconazole OR posaconazole OR Echinocandins OR Amphotericin B

• 3.8 Schistosomiasis

• Preferred regimen: Praziquantel 20 mg/kg PO bid for 1–2 days

Syphilis

• Syphilis

• 1. Primary and Secondary Syphilis

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

• 2. Latent Syphilis

• 2.1 Early Latent Syphilis

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

• 2.2 Late Latent Syphilis or Latent Syphilis of Unknown Duration

• Preferred regimen: Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units IM each at 1-week intervalspediatric
• Pediatric regimen: 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)

• 3. Tertiary Syphilis

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

• 4. Neurosyphilis

• Preferred regimen: 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 regimen: Procaine penicillin 2.4 million units IM qd AND Probenecid 500 mg PO qid, both for 10-14 days

• 5. Syphilis Among Hiv-Infected Persons

• 5.1 Primary and Secondary Syphilis Among Hiv-Infected Persons

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

• 5.2 Latent Syphilis Among Hiv-Infected Persons

• 5.2.1 Early latent

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

• 5.2.2 Late latent

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

• 6. Neurosyphilis Among HIV-Infected Persons

• Preferred regimen: 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 regimen: Procaine penicillin 2.4 million units IM qd AND Probenecid 500 mg PO qid, both for 10-14 days

• 7. Syphilis During Pregnancy

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

• 8. Congenital Syphilis

• 8.1 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 regimen: Aqueous crystalline penicillin G 100,000-150,000 units/kg/day, administered as 50,000 units/kg/dose IV q12h during the first 7 days of life and q8h 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.

• 8.2 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 regimen: Aqueous crystalline penicillin G 100,000--150,000 units/kg/day, administered as 50,000 units/kg/dose IV q12h during the first 7 days of life and q8h 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.

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

• 8.4 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 regimen: 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

• Urethritis
• 1. Nongonococcal Urethritis

• Preferred regimen: Azithromycin 1 g PO in a single dose OR Doxycycline 100 mg PO bid for 7 days
• Alternative regimen (1): Erythromycin base 500 mg PO qid for 7 days
• Alternative regimen (2): Erythromycin ethylsuccinate 800 mg PO qid for 7 days
• Alternative regimen (3): Levofloxacin 500 mg PO qd for 7 days
• Alternative regimen (4): Ofloxacin 300 mg PO bid for 7 days

• 2. Gonococcal Urethritis

• Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1 g PO in a single dose
• Alternative regimen: Cefixime 400 mg PO in a single dose AND Azithromycin 1 g PO in a single dose (if ceftriaxone is not available)

• 3. Recurrent and Persistent Urethritis

• Preferred regimen: Metronidazole 2 g PO in a single dose OR Tinidazole 2 g PO in a single dose AND Azithromycin 1 g PO in a single dose for 7 days