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Gardnerella vaginalis

• Gardnerella vaginalis Return to Top

• 1.Bacterial Vaginosis

• Gardnerella vaginalis is one of the anaerobic bacteria causing Bacterial Vaginosis,which is a polymicrobial clinical syndrome

• Preferred regimen (1): Metronidazole 500 mg PO bid for 7 days
• Preferred regimen (2): Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, qd for 5 days
• Preferred regimen (3): Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days
• Alternative regimen (1): Tinidazole 2 g PO qd for 2 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
• Note: Clindamycin ovules use an oleaginous base that might weaken latex or rubber products (e.g., condoms and vaginal contraceptive diaphragms). Use of such products within 72 hours following treatment with clindamycin ovules is not recommended.

• 2. Management of Sex Partners

• Routine treatment of sex partners is not recommended.

• 3. Special Considerations

• 3.1 Allergy, Intolerance, or Adverse Reactions
• Intravaginal Clindamycin cream is preferred in case of allergy or intolerance to Metronidazole or Tinidazole. Intravaginal Metronidazole gel can be considered for women who are not allergic to Metronidazole but do not tolerate oral metronidazole. It is advised to avoid consuming alcohol during treatment with nitroimidazoles. To reduce the possibility of a disulfiram-like reaction, abstinence from alcohol use should continue for 24 hours after completion of metronidazole or 72 hours after completion of tinidazole.

• 3.2 Pregnancy

• Preferred regimen (1): Metronidazole 500 mg PO bid for 7 days
• Preferred regimen (2): Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, qd for 5 days
• Note: Tinidazole should be avoided during pregnancy

• 3.3 HIV Infection

• Women with HIV who have BV should receive the same treatment regimen as those who do not have HIV infection.

Neisseria gonorrhoeae

• Neisseria gonorrhoeae Return to Top

• Neisseria gonorrhoeae treatment

• 1. Gonococcal infections in adolescents and adults

• 1.1 Uncomplicated gonococcal infections of the cervix, urethra, and rectum

• 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)

• 1.2 Uncomplicated gonococcal infections of the pharynx

• Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1 g PO in a single dose

• 1.2.1 Management of sex partners

• Expedited partner therapy: Cefixime 400 mg PO in a single dose AND Azithromycin 1 g PO in a single dose
• Note (1): Recent sex partners (i.e., persons having sexual contact with the infected patient within the 60 days preceding onset of symptoms or gonorrhea diagnosis) should be referred for evaluation, testing, and presumptive dual treatment.
• Note (2): If the patient’s last potential sexual exposure was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated.
• Note (3): To avoid reinfection, sex partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sexual partner(s) have completed treatment and after resolution of symptoms, if present.

• 1.2.2 Allergy, intolerance, and adverse reactions

• Preferred regimen (1): Gemifloxacin 320 mg PO in a single dose AND Azithromycin 2 g PO in a single dose
• Preferred regimen (2): Gentamicin 240 mg IM in a single dose AND Azithromycin 2 g PO in a single dose
• Note: Use of ceftriaxone or cefixime is contraindicated in persons with a history of an IgE-mediated penicillin allergy (e.g., anaphylaxis, Stevens Johnson syndrome, and toxic epidermal necrolysis).

• 1.2.3 Pregnancy

• Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1 g PO in a single dose

• 1.2.4 Suspected cephalosporin treatment failure

• Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1 g PO in a single dose
• Alternative regimen (1): Gemifloxacin 320 mg PO single dose AND Azithromycin 2 g PO single dose (when isolates have elevated cephalosporin MICs)
• Alternative regimen (2): Gentamicin 240 mg IM single dose AND Azithromycin 2 g PO single dose (when isolates have elevated cephalosporin MICs)
• Alternative regimen (3): Ceftriaxone 250 mg IM as a single dose AND Azithromycin 2 g PO as a single dose (failure after treatment with cefixime and azithromycin)
• Note: Treatment failure should be considered in: (1) persons whose symptoms do not resolve within 3–5 days after appropriate treatment and report no sexual contact during the post-treatment follow-up period; (2) persons with a positive test-of-cure (i.e., positive culture ≥ 72 hours or positive NAAT ≥ 7 days after receiving recommended treatment) when no sexual contact is reported during the post-treatment follow-up period; (3) persons who have a positive culture on test-of-cure (if obtained) if there is evidence of decreased susceptibility to cephalosporins on antimicrobial susceptibility testing, regardless of whether sexual contact is reported during the post-treatment follow-up period.

• 1.3 Gonococcal conjunctivitis

• Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1 g PO in a single dose

Note: Consider one-time lavage of the infected eye with saline solution.

• 1.3.1 Management of sex partners

• Patients should be instructed to refer their sex partners for evaluation and treatment.

• 1.4 Disseminated gonococcal infection

• 1.4.1 Arthritis and arthritis-dermatitis syndrome

• Preferred regimen: Ceftriaxone 1 g IM/IV q24h for 7 days AND Azithromycin 1 g PO in a single dose
• Alternative regimen (1): Cefotaxime 1 g IV q8h for 7 days
• Alternative regimen (2): Ceftizoxime 1 g IV q 8 h for 7 days AND Azithromycin 1 g PO in a single dose

• 1.4.2 Gonococcal meningitis and endocarditis

• Preferred regimen: Ceftriaxone 1-2 g IV q 12-24 h for 10-14 days AND Azithromycin 1 g PO in a single dose

• 2. Gonococcal infections among neonates

• 2.1 Ophthalmia neonatorum caused by N. gonorrhoeae

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

• 2.1.1 Management of mothers and their sex partners

• Mothers of infants with ophthalmia neonatorum caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).

• 2.2 Disseminated gonococcal infection and gonococcal scalp abscesses in neonates

• Preferred regimen (1): Ceftriaxone 25-50 mg/kg/day IM/IV qd for 7 days
• Preferred regimen (2): Cefotaxime 25 mg/kg IV /IM q12h for 7 days.
• Note (1): The duration of treatment is 10-14 days if meningitis is documented.
• Note (2): Ceftriaxone should be administered cautiously to hyperbilirubinemic infants, especially those born prematurely.

• 2.2.1 Management of mothers and their sex partners

• Mothers of infants who have DGI or scalp abscesses caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).

• 2.3 Neonates born to mothers who have gonococcal infection

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

• 2.3.1 Management of mothers and their sex partners

• Mothers who have gonorrhea and their sex partners should be evaluated, tested, and presumptively treated for gonorrhea.

• 3. Gonococcal infections among infants and children

• 3.1 Infants and children who weigh ≤ 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis

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

• 3.2 Children who weigh > 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis

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

• 3.3 Children who weigh ≤ 45 kg and who have bacteremia or arthritis

• Preferred regimen: Ceftriaxone 50 mg/kg (maximum dose: 1 g) IM/IV q24h for 7 days

• 3.4 Children who weigh > 45 kg and who have bacteremia or arthritis

• Preferred regimen: Ceftriaxone 1 g IM/IV q24h for 7 days

Legionella pneumophila

• Legionella pneumophila Return to Top

• 1.Atypical pneumonia (Legionnaires' disease )

• 1.1 Mild pneumonia inpatient or outpatient, non immunocompromised

• Preferred regimen (1): Azithromycin 500 mg PO qd for 3-5 days
• Preferred regimen (2): Levofloxacin 500 mg PO qd for 7-10 days
• Preferred regimen (3): Ciprofloxacin 500 mg PO bid for 7-10 days
• Preferred regimen (4): Moxifloxacin 400 mg PO qd for 7-10 days
• Preferred regimen (5): Clarithromycin 500 mg PO bid for 10-14 days
• Alternative regimen (1): Doxycycline Doxycycline 200 mg PO loading dose, then 100 mg PO bid for 10-14 days
• Alternative regimen (2): Erythromycin 500 mg PO qid for 10-14 days

• 1.2 Moderate to severe pneumonia or immunocompromised

• Preferred regimen (1): Azithromycin 500 mg PO qd for for 5-7 days
• Preferred regimen (2): Levofloxacin 500 mg PO qd for 7-10 days OR 750 mg PO qd for 5-7 days
• Alternative regimen (1): Ciprofloxacin 750 mg PO bid for 14 days
• Alternative regimen (2): Moxifloxacin 400 mg PO qd for 14 days
• Alternative regimen (3): Erythromycin 750-1000 mg IV q6h for 3-7 days, then 500 mg PO qid for a total course of 21 days
• Alternative regimen (4): Clarithromycin 500 mg IV q12h for 3-7 days, and then 500 mg PO bid for a total course of 21 days
• Note (1): Severely ill patients parenteral therapy is advised until improvement is seen and oral absorption is sufficient.
• Note (2): Pontiac fever is a self-limited, short-duration febrile illness.

Haemophilus ducreyi

• Haemophilus ducreyi Return to Top

• 1. Chancroid

• Preferred Regimen (1): Azithromycin 1 g PO in a single dose
• Preferred Regimen (2): Ceftriaxone 250 mg IM in a single dose
• Preferred Regimen (3): Ciprofloxacin 500 mg PO bid for 3 days
• Preferred Regimen (4): Erythromycin base 500 mg PO tid for 7 days
• Note: 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.
• 1.1 Follow-up

• Patients should be re-examined 3–7 days after initiation of therapy. If treatment is successful, ulcers usually improve symptomatically within 3 days and objectively within 7 days after therapy. If no clinical improvement is evident, the clinician must consider whether 1) the diagnosis is correct, 2) the patient is coinfected with another STD, 3) the patient is infected with HIV, 4) the treatment was not used as instructed, or 5) the H. ducreyi strain causing the infection is resistant to the prescribed antimicrobial.
• Clinical resolution of fluctuant lymphadenopathy is slower than that of ulcers and might require needle aspiration or incision and drainage, despite otherwise successful therapy. Although needle aspiration of buboes is a simpler procedure, incision and drainage might be preferred because of reduced need for subsequent drainage procedures.

• 1.2 Management of sex partners

• Regardless of whether symptoms of the disease are present, 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.

• 1.3 Pregnancy

• Ciprofloxacin presents a low risk to the fetus during pregnancy, with a potential for toxicity during breastfeeding. Alternative drugs should be used during pregnancy and lactation

• 1.4 HIV Infection

• Persons with HIV infection who have chancroid should be monitored closely because they are more likely to experience treatment failure and to have ulcers that heal slowly. Persons with HIV infection might require repeated or longer courses of therapy, and treatment failures can occur with any regimen.

Klebsiella granulomatis

• Klebsiella granulomatis Return to Top

• Klebsiella granulomatis (formly known as Calymmatobacterium granulomatis)

• Granuloma inguinale (donovanosis)

• Preferred regimen: Azithromycin 1 g PO once a week OR 500 mg qd for 3 weeks and until all lesions have completely healed
• Alternative regimen (1): Doxycycline 100 mg PO bid for 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

Herpes simplex virus

• Herpes simplex virus Return to Top

• Genital Herpes

• 1.First Clinical Episode of Genital Herpes

• Preferred Regimen (1): Acyclovir 400 mg PO tid for 7–10 days
• Preferred Regimen (2): Acyclovir 200 mg PO five times a day for 7–10 days
• Preferred Regimen (3): Valacyclovir 1 g PO bid for 7–10 days
• Preferred Regimen (4): Famciclovir 250 mg PO tid for 7–10 days
• Note:Treatment can be extended if healing is incomplete after 10 days of therapy.

• 2.Established HSV-2 Infection

• 2.1 Suppressive Therapy for Recurrent Genital Herpes

• Preferred Regimen (1): Acyclovir 400 mg PO bid
• Preferred Regimen (2): Valacyclovir 500 mg PO qd
• Preferred Regimen (3): Valacyclovir 1 g PO qd
• Preferred Regimen (4): Famciclovir 250 mg PO bid
• Note(1):Daily therapy with Acyclovir for as long as 6 years and with Valacyclovir OR Famciclovir for 1 year
• Note(2):Valacyclovir 500 mg qd might be less effective than other Valacyclovir OR Acyclovir dosing regimens in persons who have very frequent recurrences (i.e., ≥10 episodes per year).

• 2.2 Episodic Therapy for Recurrent Genital Herpes

• Preferred Regimen (1): Acyclovir 400 mg PO tid for 5 days
• Preferred Regimen (2): Acyclovir 800 mg PO bid for 5 days
• Preferred Regimen (3): Acyclovir 800 mg PO tid for 2 days
• Preferred Regimen (4): Valacyclovir 500 mg PO bid for 3 days
• Preferred Regimen (5): Valacyclovir 1 g PO qd for 5 days
• Preferred Regimen (6): Famciclovir 125 mg PO bid for 5 days
• Preferred Regimen (7): Famciclovir 1 g PO bid for 1 day
• Preferred Regimen (8): Famciclovir 500 mg once, followed by 250 mg PO bid for 2 days

• 3. Severe Disease (disseminated infection, pneumonitis, or hepatitis) or CNS complications (e.g., meningoencephalitis).

• Preferred Regimen: Acyclovir 5–10 mg/kg IV q8h for 2–7 days or until clinical improvement is observed, followed by oral antiviral therapy to complete at least 10 days of total therapy. HSV encephalitis requires 21 days of intravenous therapy. Impaired renal function warrants an adjustment in acyclovir dosage.

• 4. Special Considerations

• 4.1 HIV Infection

• 4.1.1 Daily Suppressive Therapy in Persons with HIV

• Preferred Regimen (1): Acyclovir 400–800 mg PO bid /tid
• Preferred Regimen (2): Valacyclovir 500 mg PO bid
• Preferred Regimen (3): Famciclovir 500 mg PO bid

• 4.1.2 Episodic Infection in Persons with HIV

• Preferred Regimen (1): Acyclovir 400 mg PO tid for 5–10 days
• Preferred Regimen (2): Valacyclovir 1 g PO bid for 5–10 days
• Preferred Regimen (3): Famciclovir 500 mg PO bid for 5–10 days
• Note:For severe HSV disease, initiating therapy with Acyclovir 5–10 mg/kg IV q8 h might be necessary.

• 4.2 Genital Herpes in Pregnancy

• Suppressive therapy of pregnant women with recurrent genital herpes *
• Preferred Regimen (1): Acyclovir 400–800 mg PO bid /tid
• Preferred Regimen (2): Valacyclovir 500 mg PO bid
• Note:Treatment recommended starting at 36 weeks of gestation.

• 4.3 Neonatal Herpes

• Known or suspected neonatal herpes: Acyclovir 20 mg/kg IV q 8 h
• Note (1):treatment for 14 days if disease is limited to the skin and mucous membranes, or
• Note (2):treatment for 21 days for disseminated disease and that involving the central nervous system.

• 4.4 Acyclovir-resistant genital herpes

• Preferred Regimens: Foscarnet 40–80 mg/kg IV q8 h until clinical resolution is attained
• Alternative Regimen (1): Cidofovir 5 mg/kg IV once weekly might also be effective.
• Alternative Regimen (2):Imiquimod topical preparations should be applied to the lesions qd for 5 consecutive days.

• 4.5 Management of Sex Partners

• Preferred Regimen (1): Acyclovir 400 mg PO tid for 7–10 days
• Preferred Regimen (2): Acyclovir 200 mg PO five times a day for 7–10 days
• Preferred Regimen (3): Valacyclovir 1 g PO bid for 7–10 days
• Preferred Regimen (4): Famciclovir 250 mg PO tid for 7–10 days
• Note:The sex partners of persons who have genital herpes can benefit from evaluation and counseling. Symptomatic sex partners should be evaluated and treated

• 4.6 Allergy, Intolerance, and Adverse Reactions

• Allergic and other adverse reactions to oral Acyclovir, Valacyclovir, and Famciclovir are rare. Desensitization to acyclovir has been described.

Human papillomavirus

• Human papillomavirus Return to Top

• Anogenital Warts

• 1.Preferred regimen for External Anogenital Warts (i.e., penis, groin, scrotum, vulva, perineum, external anus, and perianus)

• 1.1 Patient-Applied:: Imiquimod 3.75% or 5% cream OR Podofilox 0.5% solution or gel OR Sinecatechins 15% ointment
• 1.2 Provider-Administered: Cryotherapy with liquid nitrogen or cryoprobe OR Surgical removal either by tangential scissor excision, tangential shave excision, curettage, laser,or electrosurgery OR Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80%-90% solution
• Note (1): Many persons with external anal warts also have intra-anal warts. Thus, persons with external anal warts might benefit from an inspection of the anal canal by digital examination, standard anoscopy, or high-resolution anoscopy.
• Note (2): Might weaken condoms and vaginal diaphragms.

• 2.Alternative Regimens for External Genital Warts

• 2.1 Urethral Meatus Warts

• Preferred regimen: Cryotherapy with liquid nitrogen OR Surgical removal

• 2.2 Vaginal Warts

• Preferred regimen: Cryotherapy with liquid nitrogen OR Surgical removal OR (TCA OR BCA 80%–90% solution)
• Note: The use of a cryoprobe in the vagina is not recommended because of the risk for vaginal perforation and fistula formation

• 2.3 Cervical Warts

• Preferred regimen: Cryotherapy with liquid nitrogen OR Surgical removal OR (TCA OR BCA 80%–90% solution)
• Note: Management of cervical warts should include consultation with a specialist.For women who have exophytic cervical warts, a biopsy evaluation to exclude high-grade SIL must be performed before treatment is initiated.

• 2.4 Intra-anal Warts

• Preferred regimen: Cryotherapy with liquid nitrogen OR Surgical removal OR (TCA OR BCA 80%–90% solution)
• Note: Management of intra-anal warts should include consultation with a specialist.

• 3. Specific considerations

• 3.1 Follow-up

• Most anogenital warts respond within 3 months of therapy. Factors that might affect response to therapy include immunosuppression and treatment compliance. In general, warts located on moist surfaces or in intertriginous areas respond best to topical treatment. A new treatment modality should be selected when no substantial improvement is observed after a complete course of treatment or in the event of severe side effects; treatment response and therapy-associated side effects should be evaluated throughout the course of therapy.

• 3.2 Management of sex partners

• Persons should inform current partner(s) about having genital warts because the types of HPV that cause warts can be passed on to partners. Partners should receive counseling messages that partners might already have HPV despite no visible signs of warts, so HPV testing of sex partners of persons with genital warts is not recommended.

• 3.3 Pregnancy

• Podofilox (podophyllotoxin), Podophyllin, and Sinecatechins should not be used during pregnancy. Imiquimod appears to pose low risk but should be avoided until more data are available.
• Cesarean delivery is indicated for women with anogenital warts if the pelvic outlet is obstructed or if vaginal delivery would result in excessive bleeding.
• Pregnant women with anogenital warts should be counseled concerning the low risk for warts on the larynx of their infants or children (recurrent respiratory papillomatosis).

• 3.4 HIV infection

• Data do not support altered approaches to treatment for persons with HIV infection.
• Squamous cell carcinomas arising in or resembling anogenital warts might occur more frequently among immunosuppressed persons, therefore requiring biopsy for confirmation of diagnosis for suspicious cases

• 3.5 High-grade squamous intraepithelial lesions

• Biopsy of an atypical wart might reveal HSIL or cancer of the anogenital tract. In this instance, referral to a specialist for treatment is recommended.

Trichomonas vaginalis

• Trichomonas vaginalis Return to Top

• 1. T. vaginalis infection in adults

• Preferred regimen (1): Metronidazole 2 g PO in a single dose
• Preferred regimen (2): Tinidazole 2 g PO in a single dose
• Alternative regimen: Metronidazole 500 mg PO bid for 7 days

• 2. T. vaginalis infection in pregnant and lactating Women

• 2.1 Pregnant women

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

• 2.2 Post-partum and Breastfeeding

• Preferred regimen (1): Metronidazole 2 g PO in a single dose.
• Preferred regimen (2): Tinidazole 2 g PO in a single dose
• Note (1): Do not breastfeed for 12-24 hrs following Metronidazole and 72 hrs following Tinidazole
• Note (2): Symptomatic pregnant women, regardless of pregnancy stage, should be tested and considered for treatment. Pregnant women should be advised of the risk and benefits to treatment as infection (definitely) and treatment (possibly)
• Note (3): Pregnant women with HIV who are treated for T. vaginalis infection should be retested 3 months after treatment.

• 3. T. vaginalis infection in patients with HIV

• Preferred regimen: Metronidazole 500 mg PO bid for 7 days

• 4. Persistent or recurrent trichomoniasis

• 4.1 Treatment failure

• Preferred regimen: Metronidazole 500 mg PO bid for 7 days

• 4.2 Treatment failure again

• Preferred regimen (1): Metronidazole 2 g PO for 7 days
• Preferred regimen (2): Tinidazole 2 g PO for 7 days

• 4.3 Nitroimidazole-resistant cases

• Preferred regimen: Tinidazole 2-3 g PO for 14 days

Plasmodium

• 1. Plasmodium falciparum

• 1.1 Treatment of uncomplicated P. falciparum malaria

• 1.1.1 Treat children and adults with uncomplicated P. falciparum malaria (except pregnant women in their first trimester) with one of the following recommended ACT (artemisinin-based combination therapy)

• Preferred regimen (1): Artemether 5–24 mg/kg/day PO bid AND Lumefantrine 29–144 mg/kg/day PO bid for 3 days.

• Note: The first two doses should, ideally, be given 8 h apart.
• Dosage regimen based on Body weight (kg)
• Body weight (kg)-5 to < 15- Artemether 20 mg PO bid AND Lumefantrine 120 mg PO bid for 3 days
• Body weight (kg)-15 to < 25- Artemether 40 mg PO bid AND Lumefantrine 240 mg PO bid for 3 days
• Body weight (kg)-25 to < 35- Artemether 60 mg PO bid AND Lumefantrine 360 mg PO bid for 3 days
• Body weight (kg) ≥ 35- Artemether 80 mg PO bid AND Lumefantrine 480 mg PO bid for 3 days

• Preferred regimen (2): Artesunate 2–10 mg/kg/day PO qd AND Amodiaquine 7.5–15 mg/kg/day PO qd for 3 days

• Note: A total therapeutic dose range of 6–30 mg/kg/day artesunate and 22.5–45 mg/kg/day per dose amodiaquine is recommended.
• Dosage regimen based on Body weight (kg)
• Body weight (kg)-4.5 to < 9- Artesunate 25 mg PO qd AND Amodiaquine 67.5 mg PO qd for 3 days
• Body weight (kg)-9 to < 18 - Artesunate 50 mg PO qd AND Amodiaquine 135 mg PO qd for 3 days
• Body weight (kg)-18 to < 36- Artesunate 100 mg PO qd AND Amodiaquine 270 mg PO qd for 3 days
• Body weight (kg) ≥ 36 - Artesunate 200 mg PO qd AND Amodiaquine 540 mg PO qd for 3 days

• Preferred regimen (3): Artesunate 2–10 mg/kg/day PO qd AND Mefloquine 2–10 mg/kg/day PO qd for 3 days

• Dosage regimen based on Body weight (kg)
• Body weight (kg)-5 to < 9- Artesunate 25 mg PO qd AND Mefloquine 55 mg PO qd for 3 days
• Body weight (kg)-9to < 18- Artesunate 50 mg PO qd AND Mefloquine 110 mg PO qd for 3 days
• Body weight (kg)-18 to < 36- Artesunate 100 mg PO qd AND Mefloquine 220 mg PO qd for 3 days
• Body weight (kg)- ≥ 36 - Artesunate 200 mg PO qd AND Mefloquine 440 mg PO qd for 3 days

• Preferred regimen (4): Artesunate 2–10 mg/kg/day PO qd for 3 days AND Sulfadoxine-Pyrimethamine 1.25 (25–70 / 1.25–3.5) mg/kg/day PO given as a single dose on day 1

• Dosage regimen based on Body weight (kg)
• Body weight (kg)-5 to < 10- Artesunate 25 mg PO qd for 3 days AND Sulfadoxine-Pyrimethamine 250/12 mg PO given as a single dose on day 1
• Body weight (kg)-10 to < 25- Artesunate 50 mg PO qd for 3 days AND Sulfadoxine-Pyrimethamine 500/25 mg PO given as a single dose on day 1
• Body weight (kg)-25 to < 50- Artesunate 100 mg PO qd for 3 days AND Sulfadoxine-Pyrimethamine 1000/50 mg PO given as a single dose on day 1
• Body weight (kg)- ≥50- Artesunate 200 mg PO qd for 3 days AND Sulfadoxine-Pyrimethamine 1500/75 mg PO given as a single dose on day 1

• Preferred regimen (5): Dihydroartemisinin 2–10 mg/kg/day PO qd AND Piperaquine16–27 mg/kg/day PO qd for 3 days

• Dosage regimen based on Body weight (kg)
• Body weight (kg)-5 to < 8- Dihydroartemisinin 20 mg PO qd AND Piperaquine 160 mg PO qd for 3 days
• Body weight (kg)-8 to < 11- Dihydroartemisinin 30 mg PO qd AND Piperaquine 240 mg PO qd for 3 days
• Body weight (kg)-11 to < 17 - Dihydroartemisinin 40 mg PO qd AND Piperaquine 320 mg PO qd for 3 days
• Body weight (kg)-17 to < 25- Dihydroartemisinin 60 mg PO qd AND Piperaquine 480 mg PO qd for 3 days
• Body weight (kg)-25 to < 36- Dihydroartemisinin 80 mg PO qd AND Piperaquine 640 mg PO qd for 3 days
• Body weight (kg)-36 to < 60- Dihydroartemisinin 120 mg PO qd AND Piperaquine 960 mg PO qd for 3 days
• Body weight (kg)-60 < 80 - Dihydroartemisinin 160 mg PO qd AND Piperaquine 1280 mg PO qd for 3 days
• Body weight (kg)- >80- Dose of Dihydroartemisinin 200 mg PO qd AND Piperaquine 1600 mg PO qd for 3 days

• 1.1.2 Reducing the transmissibility of treated P. falciparum infections In low-transmission areas in patients with P. falciparum malaria (except pregnant women, infants aged < 6 months and women breastfeeding infants aged < 6 months)

• Preferred regimen: Single dose of 0.25 mg/kg Primaquine with ACT

• 1.2 Recurrent Falciparum Malaria

• 1.2.1 Failure within 28 days

• Note:The recommended second-line treatment is an alternative ACT known to be effective in the region. Adherence to 7-day treatment regimens (with artesunate or quinine both of which should be co-administered with + tetracycline, or doxycycline or clindamycin) is likely to be poor if treatment is not directly observed; these regimens are no longer generally recommended.

• 1.2.2 Failure after 28 days

• Note: all presumed treatment failures after 4 weeks of initial treatment should, from an operational standpoint, be considered new infections and be treated with the first-line ACT. However, reuse of mefloquine within 60 days of first treatment is associated with an increased risk for neuropsychiatric reactions, and an alternative ACT should be used.

• 1.3 Reducing the transmissibility of treated P. falciparum infections In low-transmission areas in patients with P. falciparum malaria (except pregnant women, infants aged < 6 months and women breastfeeding infants aged < 6 months)

• Note: Single dose of 0.25 mg/kg bw Primaquine with ACT

• 1.4 Treating uncomplicated P. falciparum malaria in special risk groups

• 1.4.1 Pregnancy

• First trimester of pregnancy : Quinine AND Clindamycin 10mg/kg/day PO bid for 7 days
• Second and third trimesters : Mefloquine is considered safe for the treatment of malaria during the second and third trimesters; however, it should be given only in combination with an artemisinin derivative.
• Note (1): Quinine is associated with an increased risk for hypoglycaemia in late pregnancy, and it should be used (with clindamycin) only if effective alternatives are not available.
• Note (2): Primaquine and tetracyclines should not be used in pregnancy.

• 1.4.2 Infants less than 5kg body weight : with an ACT at the same mg/kg bw target dose as for children weighing 5 kg.
• 1.4.3 Patients co-infected with HIV: should avoid Artesunate + SP if they are also receiving Co-trimoxazole, and avoid Artesunate AND Amodiaquine if they are also receiving efavirenz or zidovudine.
• 1.4.4 Large and Obese adults: For obese patients, less drug is often distributed to fat than to other tissues; therefore, they should be dosed on the basis of an estimate of lean body weight, ideal body weight. Patients who are heavy but not obese require the same mg/kg bw doses as lighter patients.
• 1.4.5 Patients co-infected with TB: Rifamycins, in particular rifampicin, are potent CYP3A4 inducers with weak antimalarial activity. Concomitant administration of rifampicin during quinine treatment of adults with malaria was associated with a significant decrease in exposure to quinine and a five-fold higher recrudescence rate
• 1.4.6 Non-immune travellers : Treat travellers with uncomplicated P. falciparum malaria returning to nonendemic settings with an ACT.
• 1.4.7 Uncomplicated hyperparasitaemia: People with P. falciparum hyperparasitaemia are at increased risk of treatment failure, severe malaria and death so should be closely monitored, in addition to receiving an ACT.

• 2. Treatment of uncomplicated malaria caused by P. vivax, P. ovale, P. malariae or P. knowlesi

• 2.1 Blood Stage infection

• 2.1.1. Uncomplicated malaria caused by P. vivax

• 2.1.1.1 In areas with chloroquine-sensitive P. vivax

• Preferred regimen: Chloroquine total dose of 25 mg/kg PO. Chloroquine is given at an initial dose of 10 mg/kg, followed by 10 mg/kg on the second day and 5 mg/kg on the third day.

• 2.1.1.2 In areas with chloroquine-resistant P. vivax

• Note: ACTs containing Piperaquine, Mefloquine OR Lumefantrine are the recommended treatment, although Artesunate + Amodiaquine may also be effective in some areas. In the systematic review of ACTs for treating P. vivax malaria, Dihydroartemisinin + Piperaquine provided a longer prophylactic effect than ACTs with shorter half-lives (Artemether + Lumefantrine, Artesunate + Amodiaquine), with significantly fewer recurrent parasitaemias during 9 weeks of follow-up.

• 2.1.2 Uncomplicated malaria caused by P. ovale, P. malariae or P. knowlesi malaria

• Note: Resistance of P. ovale, P. malariae and P. knowlesi to antimalarial drugs is not well characterized, and infections caused by these three species are generally considered to be sensitive to chloroquine. In only one study, conducted in Indonesia, was resistance to chloroquine reported in P. malariae. The blood stages of P. ovale, P. malariae and P. knowlesi should therefore be treated with the standard regimen of ACT or Chloroquine, as for vivax malaria.

• 2.1.3 Mixed malaria infections

• Note: ACTs are effective against all malaria species and so are the treatment of choice for mixed infections.

• 2.2 Liver stages (hypnozoites) of P. vivax and P. ovale

• Note: To prevent relapse, treat P. vivax or P. ovale malaria in children and adults (except pregnant women, infants aged < 6 months, women breastfeeding infants < 6 months, women breastfeeding older infants unless they are known not to be G6PD deficient and people with G6PD deficiency) with a 14-day course of primaquine in all transmission settings. Strong recommendation, high-quality evidence In people with G6PD deficiency, consider preventing relapse by giving primaquine base at 0.75 mg base/kg bw once a week for 8 weeks, with close medical supervision for potential primaquine-induced adverse haematological effects.]

• 2.2.1 Primaquine for preventive relapse

• Preferred regimen: Primaquine 0.25–0.5 mg/kg/day PO qd for 14 days

• 2.2.2 Primaquine and glucose-6-phosphate dehydrogenase deficiency

• Preferred regimen: Primaquine 0.75 mg base/kg/day PO once a week for 8 weeks.
• Note: The decision to give or withhold Primaquine should depend on the possibility of giving the treatment under close medical supervision, with ready access to health facilities with blood transfusion services.

• 2.2.3 Prevention of relapse in pregnant or lacating women and infants

• Note: Primaquine is contraindicated in pregnant women, infants < 6 months of age and in lactating women (unless the infant is known not to be G6PD deficient).

• 3. Treatment of severe malaria

• 3.1 Treatment of severe falciparum infection with Artesunate

• 3.1.1 Adults and children with severe malaria (including infants, pregnant women in all trimesters and lactating women):-

• Preferred regimen: Artesunate IV/IM for at least 24 h and until they can tolerate oral medication. Once a patient has received at least 24 h of parenteral therapy and can tolerate oral therapy, complete treatment with 3 days of an ACT (add single dose Primaquine in areas of low transmission).

• 3.1.2 Young children weighing < 20 kg

• Preferred regimen:Artesunate 3 mg/kg per dose IV/IM q24h
• Alternatives regimen: use Artemether in preference to quinine for treating children and adults with severe malaria

• 3.2.Treating cases of suspected severe malaria pending transfer to a higher-level facility (pre-referral treatment)

• 3.2.1 Adults and children

• Preferred regimen: Artesunate IM q24h
• Alternative regimen: Artemether IM OR Quinine IM

• 3.2.2 Children < 6 years

• Preferred regimen: Where intramuscular injections of artesunate are not available, treat with a single rectal dose (10 mg/kg) of Artesunate, and refer immediately to an appropriate facility for further care.
• Note: Do not use rectal artesunate in older children and adults.

• 3.3 Pregancy

• Note: Parenteral artesunate is the treatment of choice in all trimesters. Treatment must not be delayed.

• 3.4 Treatment of severe P. Vivax infection

• Note: parenteral artesunate, treatment can be completed with a full treatment course of oral ACT or chloroquine (in countries where chloroquine is the treatment of choice). A full course of radical treatment with primaquine should be given after recovery.

• 3.5 Additional aspects of management in severe malaria

• Fluid therapy: It is not possible to give general recommendations on fluid replacement; each patient must be assessed individually and fluid resuscitation based on the estimated deficit.
• Blood Transfusion :In high-transmission settings, blood transfusion is generally recommended for children with a haemoglobin level of < 5 g/100 mL(haematocrit < 15%). In low-transmission settings, a threshold of 20% (haemoglobin,7 g/100 mL) is recommended.
• Exchange blood transfusion: Exchange blood transfusion requires intensive nursing care and a relatively large volume of blood, and it carries significant risks. There is no consensus on the indications, benefits and dangers involved or on practical details such as the volume of blood that should be exchanged. It is, therefore, not possible to make any recommendation regarding the use of exchange blood transfusion.

Acanthamoeba

• Acanthamoeba Return to Top

• 1.Keratitis

• Preferred regimen: Miltefosine OR Voriconazole.

• 2. Acanthamoeba Granulomatous Amebic Encephalitis and Disseminated Disease

• Preferred regimen: Adults: Success with IV Pentamidine AND Sulfadiazine AND Flucytosine AND (Fluconazole OR Itraconazole )
• Note: Two children responded to oral treatment : TMP-SMX AND Rifampin AND Ketoconazole

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Balamuthia mandrillaris

• Balamuthia mandrillaris Return to Top

• Chronic granulomatous meningitis

• Preferred regimen (1): Pentamidine AND Clarithromycin
• Preferred regimen (2): Azithromycin AND Fluconazole AND Sulfadiazine AND Flucytosine

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Naegleria fowleri

• Naegleria fowleri Return to Top

• Primary amoebic meningoencephalitis

• Preferred regimen: (Amphotericin B 1.5 mg/kg/day IV q12h for 3 days, followed by Amphotericin B 1 mg/kg/day IV q24h for 11 days) AND (Amphotericin B 1.5 mg/kg/day intrathecal q24h for 2 days, followed by Amphotericin B 1 mg/kg/day intrathecal qd for 8 days) AND Azithromycin 10 mg/kg/day IV/PO q24h for 28 days AND Fluconazole 10 mg/kg/day IV/PO q24h for 28 days AND Rifampin 10 mg/kg/day IV/PO q24h for 28 days AND Miltefosine 50 mg PO bid/tid for 28 days AND Dexamethasone 0.15 mg/kg IV q6h for 4 days

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Babesia microti

• Babesia microti Return to Top

• Babesiosis

• 1. Mild/moderate disease
• Preferred regimen: Atovaquone 750 mg PO bid AND Azithromycin 600 mg PO qd for 7-10 days

• 2. Severe disease:

• Preferred regimen: Clindamycin 600 mg PO tid AND Quinine 650 mg PO tid for 7–10 days
• Preferred regimen: Clindamycin 1.2 g IV q12h
• Note (1): For overwhelming infection in asplenic patients and immunocompromised patients, treat for 6 or more weeks.
• Note (2): Consider transfusion if 􀂕10% parasitemia.

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Leishmania

• Leishmania Return to Top
• Leishmaniasis

• 1. Cutaneous Leishmaniasis

• Different Leishmania species cause Old World versus New World (American) cutaneous leishmaniasis. In the Old World (the Eastern Hemisphere), the etiologic agents include Leishmania tropica, L. major, and L. aethiopica, as well as L. infantum and L. donovani. The main species in the New World (the Western Hemisphere) are either in the L. mexicana species complex (L. mexicana, L. amazonensis, and L. venezuelensis) or the subgenus Viannia (L. [V.] braziliensis, L. [V.] guyanensis, L. [V.] panamensis, and L. [V.] peruviana). The Viannia subgenus is also referred to as the L. (V.) braziliensis species complex.
• 1.1 Systemic Therapy (Parenteral)

• Preferred Regimen (1): Sodium stibogluconate 20 mg/kg IV/IM q24h for 10-20 days
• Preferred Regimen (2): Meglumine antimoniate 20 mg/kg IV/IM q24h for 10-20 days
• Alternative Regimen (1): Liposomal amphotericin B 3 mg/kg/day IV infusion for 6-10 days
• Alternative Regimen (2): Pentamidine 2-3 mg/kg/day IV/IM for 4-7 days
• Note: Data supporting the use of amphotericin B for treatment of cutaneous (and mucosal) leishmaniasis are anecdotal; standard dosage regimens have not been established. In the United States, pentamidine isethionate is uncommonly used for treatment of cutaneous leishmaniasis. Its limitations include the potential for irreversible toxicity and variable effectiveness.

• 1.2 Systemic Therapy (Oral)

• Adults and adolescents at least 12 years of age, who weigh from 33-44 kg
• Preferred Regimen:Miltefosine 50 mg PO q12h for 28 days
• Adults and adolescents at least 12 years of age, who weigh >45 kg

• Preferred Regimen:Miltefosine 50 mg PO q8h for 28 days
• Alternative Regimen (1): Ketoconazole 600 mg qd for 28 days OR qd for 6 weeks
• Alternative Regimen (2): Fluconazole 200 mg qd for 6 weeks
• Note:The FDA-approved indications are limited to infection caused by three particular species, all three of which are New World species in the Viannia subgenus—namely, Leishmania (V.) braziliensis, L. (V.) panamensis, and L. (V.) guyanensis. The "azoles" showed modest activity against some Leishmania species in some cases, but are not FDA approved

• 1.3 Local Therapy

• List of possible local therapies
• Cryotherapy (with liquid nitrogen OR Thermotherapy (use of localized current field radiofrequency heat) OR Intralesional administration of SbV OR Topical application of Paromomycin (such as an ointment containing 15% Paromomycin/12% methylbenzethonium chloride in soft white paraffin)

• 2. Visceral Leishmaniasis

• Visceral leishmaniasis usually is caused by the species L. donovani and L. infantum (L. chagasi generally is considered synonymous with L. infantum)
• 2.1 Systemic Therapy (Parenteral)

• Preferred Regimen (1): Liposomal amphotericin B 3 mg/kg/day IV for 5 days, then once on day 14 and once on day 21 (Total dose: 21 mg/kg)
• Preferred Regimen (2): Sodium stibogluconate 20 mg/kg IV/IM q24h for 28 days
• Preferred Regimen (3): Meglumine antimoniate 20 mg/kg IV/IM q24h for 28 days
• Alternative Regimen: Amphotericin B deoxycholate 0.5-1 mg/kg IV q24h (Total dose: 15-20 mg/kg)
• Note: In immunosuppressed patients, dose is 4 mg/kg/day for 5 days, then once on day 10, 17, 24, 31, and 38 (Total dose: 40 mg/kg)

• 2.2 Systemic Therapy (Oral)

• Adults and adolescents at least 12 years of age, who weigh from 33-44 kg
• Preferred Regimen: Miltefosine 50 mg PO q12h for 28 days
• Adults and adolescents at least 12 years of age, who weigh >45 kg
• Preferred Regimen: Miltefosine 50 mg PO q8h for 28 days

Mycoplasma pneumoniae

• Mycoplasma pneumoniae Return to Top

• 1. Atypical pneumonia

• Preferred regimen (1): Azithromycin 500 mg PO qd on day 1 and 250 mg PO qd on days 2 to 5
• Preferred regimen (2): Clarithromycin 500 mg PO qd for 14 days
• Preferred regimen (4): Moxifloxacin 400 mg PO qd for 14 days
• Preferred regimen (5): Levofloxacin 750 mg PO qd for 14 days

• Alternative regimen: Doxycycline 100 mg PO bid for 14 days

Chlamydia trachomatis

• Chlamydia trachomatis Return to Top

• 1 Chlaymydial infections

• 1.1 Chlamydial Infections in Adolescents and Adults

• Preferred regimen (1): Doxycycline 100 mg PO bid for 7 days
• Preferred regimen (2): Azithromycin 1 g PO in a single dose
• 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.
• 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.

• 1.2 Chlamydial Infections in patients with HIV Infection

• Preferred regimen (1): Doxycycline 100 mg PO bid for 7 days
• Preferred regimen (2): Azithromycin 1 g PO in a single dose
• Preferred regimen (3): Azithromycin 1 g PO in a single dose
• 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.

• 1.3 Pregancy

• Preferred regimen: Azithromycin 1 g PO in a single dose
• Alternative regimen (1): Amoxicillin 500 mg PO tid for 7 days
• Alternative regimen (2): Erythromycin base 500 mg PO qid for 7 days
• Alternative regimen (3): Erythromycin base 250 mg PO qid for 14 days
• Alternative regimen (4): Erythromycin ethylsuccinate 800 mg PO qid for 7 days
• Alternative regimen (5): Erythromycin ethylsuccinate 400 mg PO qid for 14 days
• Note:Doxycycline, Ofloxacin, and Levofloxacin are contraindicated in pregnant women

• 1.4 Management of sex partners

• Preferred regimen (1): Doxycycline 100 mg PO bid for 7 days
• Preferred regimen (2): Azithromycin 1 g PO in a single dose
• 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.
• Note (1): Recent sex partners (i.e., persons having sexual contact with the infected patient within the 60 days preceding onset of symptoms or Chlamydia diagnosis) should be referred for evaluation, testing, and presumptive dual treatment.
• Note (2): If the patient’s last potential sexual exposure was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated.
• Note (3): To avoid reinfection, sex partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sexual partner(s) have completed treatment and after resolution of symptoms, if present

• 2. Chlamydial infection among neonates

• 2.1 Ophthalmia Neonatorumcaused by C. trachomatis

• Preferred regimen: Erythromycin base or ethylsuccinate 50 mg/kg/ day PO qid for 14 days
• Alternative regimen: Azithromycin suspension 20 mg/kg /day PO qd for 3 days
• Note: The mothers of infants who have chlamydial infection and the sex partners of these women should be evaluated and treated.

• 2.2 Infant Pneumonia

• Preferred regimen: Erythromycin base or ethylsuccinate 50 mg/kg/ day PO qid for 14 days
• Alternative regimen: Azithromycin suspension 20 mg/kg /day PO qd for 3 days

• 3.Chlamydial infection among infants and childern

• 3.1 Infants and childern who weigh < 45 kg

• Preferred regimen: Erythromycin base or ethylsuccinate 50 mg/kg/ day PO qid for 14 days

• 3.2 Infants and childern who weigh ≥45 kg but who are aged <8 years

• Preferred regimen: Azithromycin 1 g PO in a single dose

• 3.3 Infants and childern aged ≥8 years

• Preferred regimen (1): Azithromycin 1 g PO in a single dose
• Preferred regimen (2): Doxycycline 100 mg PO bid for 7 days

• 4. Lymphogranuloma venereum (LGV)

• 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.
• Note (4): Persons who have had sexual contact with a patient who has LGV within the 60 days before onset of the patient’s symptoms should be examined and tested for urethral, cervical, or rectal chlamydial infection depending on anatomic site of exposure. They should be presumptively treated with a chlamydia regimen ( Azithromycin 1 g PO single dose OR Doxycycline 100 mg PO bid for 7 days).

Brucella

• Brucella Return to Top

• Brucellosis ,

• 1.Uncomplicated brucellosis in adults and children ≥8yrs of age

• Preferred regimen: Doxycycline 100 mg PO bid for 6 weeks AND Streptomycin 1 g/day IM for 2-3 weeks
• Alternative regimen (1): Doxycycline 100 mg/day PO for six weeks ANDGentamicin 5mg/kg IM for 7-days
• Alternative regimen (2): Gentamicin 5mg/kg/day IV/ IM for 7-10 days AND Rifampicin 600–900 mg/day PO for six weeks

• 2. Complications of brucellosis

• 2.1 Spondylitis

• Preferred regimen:Doxycycline for 3 months AND Streptomycin for 2 to 3 weeks.

• 2.2 Neurobrucellosis

• Preferred regimen: Ceftriaxone 2 mg IV q12h for 1 month AND Doxycycline 100 mg PO bid for 4-5 month AND Rifampicin 600–900 mg/day PO for 4-5 month

• 2.3 Brucella endocarditis

• Preferred regimen: Doxycycline AND an Aminoglycoside for at least 8 weeks, and therapy should be continued for several weeks after surgery when valve replacement is necessary
• Note: Rifampicin OR Trimethoprim/sulfamethoxazole are used for their ability to penetrate cell membranes

• 3. Pregnancy

• Preferred regimen:Rifampin 900 mg PO qd for 6 weeks
• Note: Adding Trimethoprim-sulfamethoxazole can be considered, but this option should probably be avoided preceding the 13th week and after the 36th week of gestation because of concern about teratogenicity and kernicterus.

• 4.For children < 8 yrs of age

• Preferred regimen (1): TMP/SMZ 8/40 mg/ kg/day PO bid for 6 weeks AND Streptomycin 30 mg/kg/day IM q24h for 3 weeks
• Preferred regimen (2): Gentamicin 5 mg/kg/day IM/ IV q24h for 7-10 days
• Alternative regimen (1): TMP/SMZ AND Rifampicin 15 mg/kg/day PO for 6 weeks
• Alternative regimen (2): Rifampicin AND an Aminoglycoside

Avian influenza

• Avian influenza Return to Top

• Bird flu (Avian influenza)

• 1. Preferred regimen:Oseltamivir 75 mg PO qd for a minimum 10 days

• Note: Patients with severe disease may have diarrhea and may not absorb oseltamivir efficiently

• 2. Patients with Avian Influenza who have diarrhea and malabsorption

• Preferred regimen (1): Zanamivir 10 mg inhaled bid for minimum 5 days
• Preferred regimen (2): Peramivir600 mg IV as a single dose for 1 day
• Note (1): Preliminary evidence demonstrates that Neuraminidase inhibitor can reduce the duration of viral replication and improve survival among patients with avian influenza. In cases of suspected avian influenza, one of the following 3 neuraminidase inhibitors should be administered as soon possible, preferably within 48 hours of symptom onset.
• Note (2): The use of Corticosteroids is not recommended.
• Note (3): Physicians may consider increasing either the recommended daily dose and/or the duration of treatment in cases of severe disease.
• Note (4): The use of Amantadine is not recommended as most H5N1 and H7N9 avian influenza viruses are resistant to it.
• Note (5): Supportive care is also an important cornerstone of the care of patients with avian influenza. Considering the severity of the illness and the possible complications, patients may require fluid resuscitation, vasopressors, intubation and ventilation, paracentesis, hemodialysis or hemofiltration, and parentral nutrition.

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• Neisseria gonorrhoeae Return to Top
  ==

• Neisseria gonorrhoeae, treatment

• 1. Gonococcal infections in adolescents and adults

• 1.1 Uncomplicated gonococcal infections of the cervix, urethra, and rectum

• 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)

• 1.2 Uncomplicated gonococcal infections of the pharynx

• Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1 g PO in a single dose

• 1.2.1 Management of sex partners

• Expedited partner therapy: Cefixime 400 mg PO in a single dose AND Azithromycin 1 g PO in a single dose
• Note (1): Recent sex partners (i.e., persons having sexual contact with the infected patient within the 60 days preceding onset of symptoms or gonorrhea diagnosis) should be referred for evaluation, testing, and presumptive dual treatment.
• Note (2): If the patient’s last potential sexual exposure was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated.
• Note (3): To avoid reinfection, sex partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sexual partner(s) have completed treatment and after resolution of symptoms, if present.

• 1.2.2 Allergy, intolerance, and adverse reactions

• Preferred regimen (1): Gemifloxacin 320 mg PO in a single dose AND Azithromycin 2 g PO in a single dose
• Preferred regimen (2): Gentamicin 240 mg IM in a single dose AND Azithromycin 2 g PO in a single dose
• Note: Use of ceftriaxone or cefixime is contraindicated in persons with a history of an IgE-mediated penicillin allergy (e.g., anaphylaxis, Stevens Johnson syndrome, and toxic epidermal necrolysis).

• 1.2.3 Pregnancy

• Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1 g PO in a single dose

• 1.2.4 Suspected cephalosporin treatment failure

• Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1 g PO in a single dose
• Alternative regimen (1): Gemifloxacin 320 mg PO single dose AND Azithromycin 2 g PO single dose (when isolates have elevated cephalosporin MICs)
• Alternative regimen (2): Gentamicin 240 mg IM single dose AND Azithromycin 2 g PO single dose (when isolates have elevated cephalosporin MICs)
• Alternative regimen (3): Ceftriaxone 250 mg IM as a single dose AND Azithromycin 2 g PO as a single dose (failure after treatment with cefixime and azithromycin)
• Note: Treatment failure should be considered in: (1) persons whose symptoms do not resolve within 3–5 days after appropriate treatment and report no sexual contact during the post-treatment follow-up period; (2) persons with a positive test-of-cure (i.e., positive culture ≥ 72 hours or positive NAAT ≥ 7 days after receiving recommended treatment) when no sexual contact is reported during the post-treatment follow-up period; (3) persons who have a positive culture on test-of-cure (if obtained) if there is evidence of decreased susceptibility to cephalosporins on antimicrobial susceptibility testing, regardless of whether sexual contact is reported during the post-treatment follow-up period.

• 1.3 Gonococcal conjunctivitis

• Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1 g PO in a single dose
• Note: Consider one-time lavage of the infected eye with saline solution.

• 1.3.1 Management of sex partners

• Patients should be instructed to refer their sex partners for evaluation and treatment.

• 1.4 Disseminated gonococcal infection

• 1.4.1 Arthritis and arthritis-dermatitis syndrome

• Preferred regimen: Ceftriaxone 1 g IM/IV q24h for 7 days AND Azithromycin 1 g PO in a single dose
• Alternative regimen (1): Cefotaxime 1 g IV q8h for 7 days
• Alternative regimen (2): Ceftizoxime 1 g IV q 8 h for 7 days AND Azithromycin 1 g PO in a single dose

• 1.4.2 Gonococcal meningitis and endocarditis

• Preferred regimen: Ceftriaxone 1-2 g IV q 12-24 h for 10-14 days AND Azithromycin 1 g PO in a single dose

• 2. Gonococcal infections among neonates

• 2.1 Ophthalmia neonatorum caused by N. gonorrhoeae

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

• 2.1.1 Management of mothers and their sex partners

• Mothers of infants with ophthalmia neonatorum caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).

• 2.2 Disseminated gonococcal infection and gonococcal scalp abscesses in neonates

• Preferred regimen (1): Ceftriaxone 25-50 mg/kg/day IM/IV qd for 7 days
• Preferred regimen (2): Cefotaxime 25 mg/kg IV /IM q12h for 7 days.
• Note (1): The duration of treatment is 10-14 days if meningitis is documented.
• Note (2): Ceftriaxone should be administered cautiously to hyperbilirubinemic infants, especially those born prematurely.

• 2.2.1 Management of mothers and their sex partners

• Mothers of infants who have DGI or scalp abscesses caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).

• 2.3 Neonates born to mothers who have gonococcal infection

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

• 2.3.1 Management of mothers and their sex partners

• Mothers who have gonorrhea and their sex partners should be evaluated, tested, and presumptively treated for gonorrhea.

• 3. Gonococcal infections among infants and children

• 3.1 Infants and children who weigh ≤ 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis

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

• 3.2 Children who weigh > 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis

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

• 3.3 Children who weigh ≤ 45 kg and who have bacteremia or arthritis

• Preferred regimen: Ceftriaxone 50 mg/kg (maximum dose: 1 g) IM/IV q24h for 7 days

• 3.4 Children who weigh > 45 kg and who have bacteremia or arthritis

• Preferred regimen: Ceftriaxone 1 g IM/IV q24h for 7 days

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Neisseria meningitidis

• Neisseria meningitidis Return to Top

• 1. Meningococcal meningitis or meningococcemia, treatment

• 1.1 Adults

• 1.1.1 Penicillin MIC < 0.1 mcg/mL

• Preferred regimen (1): Penicillin G 4 MU IV q4h for 7 days
• Preferred regimen (2): Ampicillin 2 g IV q4h for 7 days
• Alternative regimen (1): Ceftriaxone 4 g/day IV q12-24h for 7 days
• Alternative regimen (2): Cefotaxime 8-12 g/day IV q4-6h for 7 days
• Alternative regimen (3): Chloramphenicol 4-6 g/day IV q6h for 7 days

• 1.1.2 Penicillin MIC 0.1-1.0 mcg/mL

• Preferred regimen (1): Ceftriaxone 4 g/day IV q12-24h for 7 days
• Preferred regimen (2): Cefotaxime 8-12 g/day IV q4-6h for 7 days
• Alternative regimen (1): Cefepime 2 g IV q8h for 7 days
• Alternative regimen (2): Chloramphenicol 4-6 g/day IV q6h for 7 days
• Alternative regimen (3): Moxifloxacin 400 mg IV q24h for 7 days
• Alternative regimen (4): Meropenem 2 g IV q8h for 7 days

• 1.2 Neonates (birth-7 days old)

• 1.2.1 Penicillin MIC < 0.1 mcg/mL

• Preferred regimen (1): Penicillin G 0.15 MU/kg/day IV q8-12h for 7 days
• Preferred regimen (2): Ampicillin 150 mg/kg/day IV q8h for 7 days
• Alternative regimen (1): Cefotaxime 100-150 mg/kg/day IV q8-12h for 7 days
• Alternative regimen (2): Chloramphenicol 25 mg/kg/day IV q24h for 7 days

• 1.2.2 Penicillin MIC 0.1-1.0 mcg/mL

• Preferred regimen: Cefotaxime 100-150 mg/kg/day IV q8-12h for 7 days
• Alternative regimen: Chloramphenicol 25 mg/kg/day IV q24h for 7 days

• 1.3 Neonates (8-28 days old)

• 1.3.1 Penicillin MIC < 0.1 mcg/mL

• Preferred regimen (1): Penicillin G 0.2 MU/kg/day IV q6-8h for 7 days
• Preferred regimen (2): Ampicillin 200 mg/kg/day IV q6-8h for 7 days
• Alternative regimen (1): Cefotaxime 150-200 mg/kg/day IV q6-8h for 7 days
• Alternative regimen (2): Chloramphenicol 50 mg/kg/day IV q12-24h for 7 days

• 1.3.2 Penicillin MIC 0.1-1.0 mcg/mL

• Preferred regimen : Cefotaxime 150-200 mg/kg/day IV q6-8h for 7 days
• Alternative regimen : Chloramphenicol 50 mg/kg/day IV q12-24h for 7 days

• 1.4 Infants and children

• 1.4.1 Penicillin MIC < 0.1 mcg/mL

• Preferred regimen (1): Penicillin G 0.3 MU/kg/day IV q4-6h for 7 days
• Preferred regimen (2): Ampicillin 300 mg/kg/day IV q6h for 7 days
• Alternative regimen (1): Ceftriaxone 80-100 mg/kg/day IV q12-24h for 7 days
• Alternative regimen (2): Cefotaxime 225-300 mg/kg/day IV q6-8h for 7 days
• Alternative regimen (3): Chloramphenicol 75-100 mg/kg/day IV q6h for 7 days

• 1.4.2 Penicillin MIC 0.1-1.0 mcg/mL

• Preferred regimen (1): Ceftriaxone 80-100 mg/kg/day IV q12-24h for 7 days
• Preferred regimen (2): Cefotaxime 225-300 mg/kg/day IV q6-8h for 7 days
• Alternative regimen (1): Cefepime 150 mg/kg/day IV q8h for 7 days
• Alternative regimen (2): Chloramphenicol 75-100 mg/kg/day q6h for 7 days
• Alternative regimen (3): Meropenem 120 mg/kg/day IV q8h for 7 days

• Note (1): Dexamethasone has not been shown to be beneficial in meningococcal meningitis and should be discontinued once this diagnosis is established.
• Note (2): Clinical data are limited on the use of fluoroquinolones for therapy for meningococcal meningitis but may be considered in patients not responding to standard therapy or when disease is caused by resistant organisms.

• 2. Meningococcal meningitis, prophylaxis for household and close contacts

• 2.1 Adults

• Preferred regimen (1): Rifampin 600 mg PO bid for 2 days
• Preferred regimen (2): Ciprofloxacin 500 mg single dose
• Preferred regimen (3): Ceftriaxone 250 mg IM single dose

• 2.2 Children < 15 years

• Preferred regimen: Ceftriaxone 12 mg IM single dose

• 2.3 Children ≥ 1 month

• Preferred regimen: Rifampin 10mg /kg PO bid for 2 days

• 2.4 Children < 1 month

• Preferred regimen: Rifampin 5 mg/ kg PO bid for 2 days

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Coxiella burnetii

• Coxiella burnetii Return to Top

• Q fever

• 1. Acute Q fever

• 1.1 Adults

• Preferred Regimen: Doxycycline 100 mg PO bid for 14 days

• 1.2 Children

• 1.2.1 Children with age ≥8 years

• Preferred regimen: Doxycycline 2.2 mg/kg PO bid for 14 days (maximum 100 mg per dose)

• 1.2.2 Children with age <8 years with high risk criteria

• Preferred regimen: Doxycycline 2.2 mg/kg PO bid for 14 days (maximum: 100 mg per dose)

• 1.2.3 Children with age <8 years with mild or uncomplicated illness

• Preferred regimen: Doxycycline 2.2 mg/kg PO bid for 5 days (maximum 100 mg per dose).

• 1.2.3 Children with age < 8 years with mild or uncomplicated illness,who remains febrile past 5 days of treatment

• Preferred regimen: Trimethoprim/Sulfamethoxazole 4-20 mg/kg PO bid for 14 days (maximum: 800 mg per dose)

• 1.3 Pregnant women

• Preferred regimen: Trimethoprim/Sulfamethoxazole 160 mg/800 mg PO bid throughout pregnancy

• 2. Chronic Q fever

• 2.1 Endocarditis or vascular infection

• Preferred regimen: Doxycycline 100 mg PO bid AND Hydroxychloroquine 200 mg PO tid for ≥18 months
• Note: childern and pregnant women- consultation Recommended

• 2.2 Noncardiac organ disease

• Preferred regimen: Doxycycline 100 mg PO bid AND Hydroxychloroquine 200 mg PO tid
• Note: childern and pregnant women- consultation Recommended

• 2.3 Postpartumwith serologic profile for chronic Q fever

• Preferred regimen: Doxycycline 100 mg PO bid AND Hydroxychloroquine 200 mg PO tid for 12 months
• Note (1): Women should only be treated postpartum if serologic titers remain elevated >12 months after delivery (immunoglobulin G phase I titer ≥1:1024). Women treated during pregnancy for acute Q fever should be monitored similarly to other patients who are at high risk for progression to chronic disease (e.g., serologic monitoring at 3, 6, 12, 18, and 24 months after delivery)
• Note (2): Post-Q fever fatigue syndrome- no current recommendation

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African trypanosomiasis

• African trypanosomiasis Return to Top

• Sleeping sickness

• 1. East african trypanosomiasis

• 1.1 T. b. rhodesiense, hemolymphatic stage

• 1.1.1 Adult

• Preferred regimen: Suramin 1 gm IV on days 1,3,5,14, and 21

• 1.1.2 Pediatric

• Preferred regimen: Suramin 20 mg/kg IV on days 1, 3, 5, 14, and 21

• 1.2 T. b. rhodesiense, CNS involvement

• 1.2.1 Adult

• Preferred regimen: Melarsoprol 2-3.6 mg/kg/day IV for 3 days.After 7 days, 3.6 mg/kg/day for 3 days. Give a 3rd series of 3.6 mg/kg/d after 7 days.

• 1.2.2 Pediatric

• Preferred regimen: Melarsoprol 2-3.6 mg/kg/day IV for 3 days.After 7 days, 3.6 mg/kg/day for 3 days. Give a 3rd series of 3.6 mg/kg/d after 7 days

• 2. West african trypanosomiasis

• 2.1 T. b. gambiense, hemolymphatic stage

• 2.1.1 Adult

• Preferred regimen: Pentamidine 4 mg/kg/day IM/ IV for 7-10 days

• 2.1.2 Pediatric

• Preferred regimen: Pentamidine 4 mg/kg/day IM/IV for 7-10 days
• Note (1): Pentamidine should be used during pregnancy and lacation only if the potential benefit justifies the potential risk
• Note (2): IM/IV Pentamidine have a similar safety profile in children age 4 months and older as in adults. Pentamidine is listed as a medicine for the treatment of 1st stage African trypanosomiasis infection (Trypanosoma brucei gambiense) on the WHO Model List of Essential Medicines for Children, intended for the use of children up to 12 years of age.

• 2.2 T. b. gambiense, CNS involvement

• 2.2.1 Adult

• Preferred regimen: Eflornithine 400 mg/kg/day IV qid for 14 days

• 2.2.2 Pediatric

• Preferred regimen: Eflornithine 400 mg/kg/day IV qid for 14 days
• Note (1): Eflornithine should be used during pregnancy and lactation, only if the potential benefit justifies the potential risk
• Note (2): The safety of Eflornithine in children has not been established. Eflornithine is not approved by the Food and Drug Administration (FDA) for use in pediatric patients. Eflornithine is listed for the treatment of 1st stage African trypanosomiasis inTrypanosoma brucei gambiense infection on the WHO Model List of Essential Medicines for Children, intended for the use of children up to 12 years of age.

American trypanosomiasis

• American trypanosomiasis Return to Top

• Chagas disease

• 1. Preferred regimen(1):

• Patients of age < 12 years- Benznidazole 5-7.5 mg/kg/ day PO bid for 60 days
• Patients of age 12 years or older- Benznidazole 5-7 mg/kg/day PO bid for 60 days

• 2. Preferred regimen(2):

• Patients of age ≤ 10 years- Nifurtimox 15-20 mg/kg/day PO tid/ qid for 90 days
• Patients of age 11-16 years- Nifurtimox 12.5-15 mg/kg/day PO tid/ qid for 90 days
• Patients of age 17 years or older- Nifurtimox 8-10 mg/kg/day PO tid/ qid for 90 days

• Note: In the United States, Nifurtimox and Benznidazole are not FDA approved and are available only from CDC under investigational protocols.

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Chlamydophila psittaci

• Chlamydophila psittaci Return to Top

• 1. Pneumonia

• 1.1 Adult

• Preferred regimen (1): Doxycycline 100 mg PO bid daily for 10-21 days
• Preferred regimen (2): Tetracycline 500 mg PO qid for 10-21 days
• Alternative regimen: Minocycline

• 1.2 Pediatric

• 1.2.1 Mild infection, Infants >3 months

• Preferred regimen: Azithromycin 10 mg/kg PO qd on day 1, then 5 mg/kg PO q24h for 4 days; (Maximum 500 mg for 1st dose, 250 mg for subsequent doses)

• 1.2.2 Moderate-severe infection, Infants >3 months

• Preferred regimen: Azithromycin 10 mg/kg IV q24h for 2 days, then 5 mg/kg PO qd for 3 days; (Maximum 500 mg/dose IV; 250 mg/dose PO)

• 1.3 Pregnant Patients

• Preferred regimen: Azithromycin 500 mg PO on day 1 followed by 250 mg qd on days 2-5 OR 500 mg IV as a single dose for at least 2 days, followed by 500 mg PO qd for 7- 10 days