Sandbox mona

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

• 1.1Patient-Applied::Imiquimod 3.75% or 5% cream ORPodofilox 0.5% solution or gel OR Sinecatechins 15% ointment
• 1.2Provider-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
• Regimens :Cryotherapy with liquid nitrogen OR Surgical removal
• 2.2Vaginal Warts
• Regimens: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
• 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
• Regimens :Cryotherapy with liquid nitrogen OR Surgical removalOR 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.

• 1.Granuloma Inguinale (Donovanosis)

• Preferred regimen:Azithromycin 1 g PO once per week OR 500 mg PO qd for 3 weeks
• Alternative regimen:Doxycycline 100 mg PO bid for 3 weeks ORCiprofloxacin 750 mg PO bid for 3 weeks ORErythromycin base 500 mg PO qid for 3 weeks OR Trimethoprim-sulfamethoxazole one double-strength (160 mg/800 mg) PO bid for 3 weeks
• Note:continue treatment until all lesions have completely healed

• 2Pregnant and lactating women

• Preferred regimen:treated with a macrolide regimen (erythromycin or azithromycin). The addition of an aminoglycoside (gentamicin 1 mg/kg IV every 8 hours) can be considered if improvement is not evident within the first few days of therapy.

• 3HIV Infection

• Preferred regimen:Azithromycin 1 g PO once per week OR 500 mg PO qd for 3 weeks and until all lesions have completely healed
• Alternative regimen:Doxycycline 100 mg PO bid for 3 weeks ORCiprofloxacin 750 mg PO bid for 3 weeks OR Erythromycin base 500 mg PO qid for 3 weeks OR Trimethoprim-sulfamethoxazole one double-strength (160 mg/800 mg) PO bid for 3 weeks
• Note:The addition of an aminoglycoside (gentamicin 1 mg/kg IV every 8 hours) can be considered if improvement is not evident within the first few days of therapy.

• 1.Bacterial Vaginosis

• Preferred regimen: Metronidazole 500 mg PO bid for 7 days ORMetronidazole gel 0.75%, one full applicator (5 g) intravaginally, qd for 5 days ORClindamycincream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days
• Alternative regimen: Tinidazole 2 g PO qd for 2 daysORTinidazole 1 g PO qd for 5 daysORClindamycin 300 mg PO bid for 7 daysOR Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days
• Note(1): Gardnerella vaginalis is one of the anaerobic bacteria causing Bacterial Vaginosis,which is a polymicrobial clinical syndrome
• Note(2):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: Metronidazole 500 mg PO bid for 7 days ORMetronidazole 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.

• Influenza A and B

• Adults

POseltamivir (Tamiflu)75 mg bid for 5 days OR Zanamivir(Relenza) 10 mg (two 5-mg inhalations)bid OR Peramivir(Rapivab) One 600 mg dose, via intravenous infusion for 15-30 minutes

• Children

• Oseltamivir If younger than 1 yr old: 3 mg/kg/dose bid; If 1 yr or older, dose varies by child’s weight:

15 kg or less, the dose is 30 mg bid ;  >15 to 23 kg, the dose is 45 mg bid ; >23 to 40 kg, the dose is 60 mg bid;  >40 kg, the dose is 75 mg bid  for 5 days OR Zanamivir(Relenza) 10 mg (two 5-mg inhalations)bid 

• Note:FDA approved and recommended Peramivir(Rapivab) for use in adults ≥18 yrs