|
THE INFORMATION IN THE OBPHARMACOPOEIATM
IS INTENDED SOLELY FOR USE BY THE MEDICAL PROFESSION. IT IS NOT INTENDED FOR LAY PERSONS.
FOCUS INFORMATION TECHNOLOGY, INC. DOES NOT ASSUME ANY RESPONSIBILITY FOR ANY ASPECT OF
HEALTHCARE ADMINISTERED WITH THE AID OF THIS CONTENT. THE PRESCRIBING PHYSICIAN
MUST BE FAMILIAR WITH THE FULL PRODUCT LABELING AS PROVIDED BY THE MANUFACTURER AND RELEVANT MEDICAL LITERATURE PRIOR TO USING THE OBPHARMACOPOEIATM
.
SEXUALLY TRANSMITTED DISEASES [1]
BACTERIAL VAGINOSIS
BV is associated with having multiple sex partners, a new sex partner, douching, and lack of vaginal lactobacilli; whether BV results from acquisition of a sexually transmitted pathogen is unclear. Women who have never been sexually active are rarely affected.
All pregnant women who have symptomatic disease require treatment.
Recommended Regimens for Pregnant Women
Metronidazole 500 mg orally twice a day for 7 days
OR
Metronidazole 250 mg orally three times a day for 7 days
OR
Clindamycin 300 mg orally twice a day for 7 days
Recommended Regimens
Metronidazole 500 mg orally twice a day for 7 days
OR
Metronidazole gel, 0.75%, one full applicator (5 g) intravaginally, once
a day for 5 days
OR
Clindamycin cream, 2%, one full applicator (5 g) intravaginally at
bedtime for 7 days
Alternative Regimens
Clindamycin 300 mg orally twice a day for 7 days
OR
Clindamycin ovules 100 g intravaginally once at bedtime for 3 days
CERVICITIS
Recommended Regimens for Presumptive Treatment*
For Pregnant or Nonpregnant Women
Azithromycin 1 g orally in a single dose
OR
For NONPREGNANT Women Only
Doxycycline 100 mg orally twice a day for 7 days
* Consider concurrent treatment for gonococcal infection if prevalence of
gonorrhea is high in the patient population under assessment.
CHANCROID
Recommended Regimens
For Pregnant or Nonpregnant Women
Azithromycin 1 g orally in a single
dose
OR
Ceftriaxone 250 mg intramuscularly (IM) in a single dose
OR
Erythromycin base 500 mg orally three times a day for 7 days
OR
For NONPREGNANT Women Only
Ciprofloxacin* 500 mg orally twice a day for 3 days
* Ciprofloxacin is contraindicated for pregnant and lactating women.
Azithromycin and ceftriaxone offer the advantage of single-dose therapy.
Worldwide, several isolates with intermediate resistance to either ciprofloxacin
or erythromycin have been reported.
CHLAMYDIA
Recommended Regimens
For Pregnant or Nonpregnant Women
Azithromycin 1 g orally in a single dose
OR
Amoxicillin 500 mg orally three times a day for 7 days
OR
For NONPREGNANT Women Only
Doxycycline* 100 mg orally twice a day for 7 days
Alternative Regimens
For Pregnant or Nonpregnant Women
Erythromycin base 500 mg orally four times a day for 7 days
OR
Erythromycin base 250 mg orally four times a day for 14 days
OR
Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days
OR
Erythromycin ethylsuccinate 400 mg orally four times a day for 14 days
Test-of-cure 3–4 weeks after completing therapy in pregnant
patients.
OR
For NONPREGNANT Women Only
Ofloxacin* 300 mg orally twice a day for 7 days
OR
Levofloxacin * 500 mg orally once daily for 7 days
*Doxycycline, ofloxacin, and levofloxacin are contraindicated in
pregnant women.
GONOCOCCAL INFECTIONS
UNCOMPLICATED GONOCOCCAL INFECTIONS OF THE CERVIX, URETHRA, AND RECTUM
Recommended Regimens*
For Pregnant or Nonpregnant Women
Ceftriaxone 125 mg IM in a single dose
OR
Cefixime 400 mg orally in a single dose
OR
For NONPREGNANT Women Only
Ciprofloxacin 500 mg orally in a single dose*
OR
Ofloxacin 400 mg orally in a single dose*
OR
Levofloxacin 250 mg orally in a single dose*
PLUS
TREATMENT FOR CHLAMYDIA IF CHLAMYDIAL INFECTION IS NOT RULED OUT
**
Quinolones should not be used for infections in MSM or in those with a history
of recent foreign travel or partners’ travel, infections acquired in California
or Hawaii, or infections acquired in other areas with increased QRNG prevalence.
Pregnant women should not be treated with quinolones or ciprofloxacin.
Recommended Regimens for (men who have sex with men) MSM or Heterosexuals with a History of Recent
Travel*
For Pregnant or Nonpregnant Women
Ceftriaxone 125 mg IM in a single dose
OR
Cefixime 400 mg orally in a single dose
PLUS
TREATMENT FOR CHLAMYDIA IF CHLAMYDIAL INFECTION IS NOT RULED OUT
* Quinolones should not be used for infections in MSM or in those with a history
of recent foreign travel or partners’ travel, infections acquired in California
or Hawaii, or infections acquired in other areas with increased QRNG prevalence.
Alternative Regimens
For Pregnant or Nonpregnant Women
Spectinomycin 2 g in a single IM dose
OR
Single-dose cephalosporin regimens
OR
For NONPREGNANT Women Only
Single-dose quinolone regimens**
**Pregnant women should not be treated with quinolones or tetracyclines.
UNCOMPLICATED GONOCOCCAL INFECTIONS OF THE
PHARYNX
Recommended Regimens*
For Pregnant or Nonpregnant Women
Ceftriaxone 125 mg IM in a single dose
OR
For NONPREGNANT Women Only
Ciprofloxacin 500 mg orally in a single dose
PLUS
TREATMENT FOR CHLAMYDIA IF CHLAMYDIAL INFECTION IS NOT RULED OUT
--------------------------------------------------------------------------------
* Quinolones should not be used for infections in MSM or in those with a history
of recent foreign travel or partners’ travel, infections acquired in California
or Hawaii, or infections acquired in other areas with increased QRNG prevalence.
Recommended Regimens for MSM or Heterosexuals with a History of Recent Travel
For Pregnant or Nonpregnant Women
Ceftriaxone 125 mg IM in a single dose
PLUS
TREATMENT FOR CHLAMYDIA IN CHLAMY-DIAL INFECTION IS NOT RULED OUT
**Pregnant women should not be treated with quinolones or tetracyclines.
GONOCOCCAL CONJUNCTIVITIS
GONOCOCCAL MENINGITIS AND ENDOCARDITIS
Recommended Regimen
For Pregnant or Nonpregnant Women
Ceftriaxone 1–2 g IV every 12 hours
Therapy for meningitis should be continued for 10–14 days; therapy for
endocarditis should be continued for at least 4 weeks. Treatment of complicated
DGI should be undertaken in consultation with a specialist.
DISSEMINATED GONOCOCCAL INFECTION (DGI)
Recommended Regimen
For Pregnant or Nonpregnant Women
Ceftriaxone 1 g IM or IV every 24 hours
Alternative Regimens
For Pregnant or Nonpregnant Women
Cefotaxime 1 g IV every 8 hours
OR
Ceftizoxime 1 g IV every 8 hours
OR
Spectinomycin 2 g IM every 12 hours
OR
For NONPREGNANT Women Only
Ciprofloxacin 400 mg IV every 12 hours*
OR
Ofloxacin 400 mg IV every 12 hours*
OR
Levofloxacin 250 mg IV daily*
--------------------------------------------------------------------------------
* Quinolones should not be used for infections in MSM or in those with a
history of recent foreign travel or partners’ travel, infections
acquired in California or Hawaii, or infections acquired in other areas
with increased QRNG prevalence.
All regimens should be continued
for 24–48 hours after improvement begins, at which time therapy may be
switched to one of the following regimens to complete a full week of antimicrobial
therapy:
For Pregnant or Nonpregnant Women
Cefixime 400 mg orally twice daily
OR
For NONPREGNANT Women Only
Ciprofloxacin 500 mg orally twice daily*
OR
Ofloxacin 400 mg orally twice daily*
OR
Levofloxacin 500 mg orally once daily*
--------------------------------------------------------------------------------
* Quinolones should not be used for infections in MSM or in those with a
history of recent foreign travel or partners’ travel, infections
acquired in California or Hawaii, or infections acquired in other areas
with increased QRNG prevalence.
GRANULOMA INGUINALE (DONOVANOSIS)
Doxycycline and ciprofloxacin are contraindicated in pregnant women.
Recommended Regimen
For NONPREGNANT Women Only
Doxycycline** 100 mg orally twice a day for at least 3 weeks and until all
lesions have completely healed
Alternative Regimens
For Pregnant or Nonpregnant Women
Azithromycin 1 g orally once per week for at least 3 weeks and until all lesions
have completely healed
OR
Erythromycin base 500 mg orally four times a day for at least 3 weeks and until
all lesions have completely healed
OR
Trimethoprim-sulfamethoxazole* one double-strength (160 mg/800 mg) tablet orally
twice a day for at least 3 weeks and until all lesions have completely healed
OR
For NONPREGNANT Women Only
Ciprofloxacin* 750 mg orally twice a day for at least 3 weeks and until all
lesions have completely healed
Therapy should be continued at least 3 weeks and until all lesions have
completely healed. Some specialists recommend the addition of an aminoglycoside
(e.g., gentamicin 1 mg/kg IV every 8 hours) to these regimens if improvement is
not evident within the first few days of therapy.
*Avoid trimethoprim-sulfamethoxazole during first trimester. 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).
HEPATITIS B IMMUNOPROPHYLAXIS
Guidelines for postexposure hepatitis B immunoprophylaxis of unvaccinated
persons who have a discrete identifiable exposure to blood or body
fluids that contain blood
| Cause of Exposure |
Suggested Action |
- Percutaneous (e.g., bite or needlestick)
or mucosal exposure to HBsAg-positive blood or body fluids that contain
blood
- Sexual or needle-sharing contact of an HBsAg-positive person
- Victim of sexual assault/abuse by a perpetrator who is HBsAg-positive
|
For Pregnant or Nonpregnant Women
Administer hepatitis B vaccine and hepatitis B immune globulin (HBIG)†
|
- Victim of sexual assault/abuse by a perpetrator
with unknown HBsAg status
- Percutaneous (e.g., bite or needlestick) or mucosal exposure to
blood or body fluids that contain blood from a source with unknown HBsAg
status
|
For Pregnant or Nonpregnant Women
Administer hepatitis B vaccine†
|
* Hepatitis B surface antigen.
† Immunoprophylaxis should be administered as soon as possible,
preferably within ≤24 hours. Studies are limited on the maximum
interval after exposure during which postexposure prophylaxis is
effective, but the interval is unlikely to exceed 7 days for
percutaneous exposures and 14 days for sexual exposures. The hepatitis
B vaccine series should be completed.
HERPES SIMPLEX
First Clinical Episode of Genital Herpes
For Pregnant or Nonpregnant Women
Acyclovir 400 mg orally three times a day for
7–10 days
OR
Acyclovir 200 mg orally five times a day for 7–10 days
OR
Famciclovir 250 mg orally three times a day
for 7–10 days
OR
Valacyclovir 1 g orally twice a day for 7–10
days
* Treatment might be extended if healing is incomplete after 10 days of
therapy.
Suppressive Therapy for Recurrent Genital Herpes
For Pregnant or Nonpregnant Women
Episodic Therapy for Recurrent Genital Herpes
For Pregnant or Nonpregnant Women
Acyclovir 400 mg orally three times a day for 5 days
OR
Acyclovir 800 mg orally twice a day for 5 days
OR
Acyclovir 800 mg orally three times a day for 2 days
OR
Famciclovir 125 mg orally twice daily for 5 days
OR
Famciclovir 1000 mg orally twice daily for 1 day
OR
Valacyclovir 500 mg orally twice a day for 3 days
OR
Valacyclovir 1.0 g orally once a day for 5 days
Severe Disease (complicated disease -e.g. disseminated infection,
pneumonitis, hepatitis, meningitis or encephalitis)
For Pregnant or Nonpregnant Women
Acyclovir 5–10 mg/kg body weight IV every 8 hours for 2–7 days or
until clinical improvement is observed, followed by oral antiviral
therapy to complete at least 10 days of total therapy.
Recommended Regimens for Daily Suppressive Therapy in Persons
Infected with HIV
For Pregnant or Nonpregnant Women
Recommended Regimens for Episodic Infection in Persons Infected
with HIV
For Pregnant or Nonpregnant Women
Acyclovir 400 mg orally three times a day for 5–10 days
OR
Famiciclovir 500 mg orally twice a day for 5–10 days
OR
Valacyclovir 1.0 grams orally twice a day for 5–10 days
HUMAN PAPILLOMA VIRUS (GENITAL WARTS)
Imiquimod, podophyllin, and podofilox should not be used during pregnancy.
Recommended Regimens for External Genital Warts
For Pregnant or Nonpregnant Women
Cryotherapy with liquid nitrogen or cryoprobe. Repeat applications every 1–2
weeks.
OR
Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80%–90%. A small amount
should be applied only to the 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 (i.e., baking soda), or liquid
soap preparations to remove unreacted acid. This treatment can be repeated
weekly, if necessary.
OR
Surgical removal either by tangential scissor excision, tangential shave
excision, curettage, or electrosurgery
OR
For NONPREGNANT Women Only
Patient-Applied:
Podofilox 0.5% solution or gel. Patients should apply podofilox solution with a
cotton swab, or podofilox gel with a finger, to visible genital warts twice a
day for 3 days, followed by 4 days of no therapy. This cycle may be repeated, as
necessary, for up to four cycles. The total wart area treated should not exceed
10 cm2, and the total volume of podofilox should be limited to 0.5 mL per day.
If possible, the health-care provider should apply the initial treatment to
demonstrate the proper application technique and identify which warts should be
treated. The safety of podofilox during pregnancy has not been established.
OR
Imiquimod 5% cream. Patients should apply imiquimod cream once daily at bedtime,
three times a week for up to 16 weeks. The treatment area should be washed with
soap and water 6–10 hours after the application. The safety of imiquimod
during pregnancy has not been established.
Provider-Administered:
Podophyllin resin 10%–25% in a compound tincture of benzoin. A small amount
should be applied to each wart and allowed to air dry. The treatment can be
repeated weekly, if necessary. To avoid the possibility of complications
associated with systemic absorption and toxicity, two important guidelines
should be followed: 1) application should be limited to <0.5 mL of podo-phyllin
or an area of <10 cm2 of warts per session, and 2) no open lesions or wounds
should exist in the area to which treatment is administered. Some specialists
suggest that the preparation should be thoroughly washed off 1–4 hours after
application to reduce local irritation. The safety of podophyllin during
pregnancy has not been established.
OR
Alternative Regimens
Intralesional interferon
OR
Laser surgery
Recommended Regimens for Cervical Warts
For women who have exophytic cervical warts, high-grade SIL must be excluded
before treatment is initiated. Management of exophytic cervical warts should
include consultation with a specialist.
Recommended Regimens for Vaginal Warts
For Pregnant or Nonpregnant Women
Cryotherapy with liquid nitrogen. The use of a cryo-probe 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.
- Trichloroacetic acid (TCA) and
bichloroacetic acid (BCA)
- Cryotherapy
- Laser therapy
- Loop electrosurgical excision (LEEP)
- Surgical removal by electrocautery
or excision
see also ref also Wiley DJ, et al.
(2002). External genital warts: Diagnosis, treatment, and prevention.
Clinical Infectious Diseases, 35(Suppl 2): S210–S224.
Recommended Regimens for Urethral Meatus Warts
For Pregnant or Nonpregnant Women
Cryotherapy with liquid nitrogen
OR
For NONPREGNANT Women Only
Podophyllin 10%–25% in compound tincture of benzoin. The treatment area must be
dry before contact with normal mucosa. This treatment can be repeated weekly, if
necessary. The safety of podophyllin during pregnancy has not been established.
Recommended Regimens for Anal Warts
For Pregnant or Nonpregnant Women
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
Cesarean delivery might be indicated for women with genital warts if the pelvic
outlet is obstructed or if vaginal delivery would result in excessive bleeding.
Pregnant women with genital warts should be counseled concerning the low risk
for warts on the larynx (recurrent respiratory papillomatosis) in their infants
or children. No controlled studies have suggested that cesarean section prevents
this condition.
LYMPHOGRANULOMA VENEREUM (LGV)
Recommended Regimen
For NONPREGNANT Women Only
Doxycycline* 100 mg orally twice a day for 21 days
Alternative Regimen
For Pregnant or Nonpregnant Women
Erythromycin base 500 mg orally four times a day for 21 days
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.
NONGONOCOCCAL URETHRITIS
Recommended Regimens
For Pregnant or Nonpregnant Women
Azithromycin 1 g orally in a
single dose
OR
For NONPREGNANT Women Only
Doxycycline 100 mg orally twice a day for 7 days
Alternative Regimens
For Pregnant or Nonpregnant Women
Erythromycin base 500 mg orally four times a day for 7 days
OR
Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days
OR
For NONPREGNANT Women Only
Ofloxacin 300 mg orally twice a day for 7 days
OR
Levofloxacin 500 mg orally once daily for 7 days
PEDICULOSIS PUBIS (PUBIC LICE)
Recommended Regimens
For Pregnant or Nonpregnant Women
Permethrin 1% cream rinse applied to affected areas and washed off after 10
minutes
OR
Pyrethrins with piperonyl butoxide applied to the affected area and washed off
after 10 minutes
Alternative Regimens
For NONPREGNANTWomen Only
Malathion 0.5% lotion applied for 8–12 hours and washed off
OR
Ivermectin 250 ug/kg repeated in 2 weeks
PELVIC INFLAMMATORY DISEASE (PID)
Empiric treatment of PID should be initiated in sexually active young
women and other women at risk for STDs if they are experiencing pelvic
or lower abdominal pain, if no cause for the illness other than PID can
be identified, and if one or more of the following minimum criteria are
present on pelvic examination:
cervical motion tenderness OR uterine tenderness OR adnexal tenderness.
The following criteria for hospitalization are suggested:
surgical emergencies (e.g., appendicitis) cannot be excluded;
the patient is pregnant;
the patient does not respond clinically to oral antimicrobial therapy;
the patient is unable to follow or tolerate an outpatient oral regimen;
the patient has severe illness, nausea and vomiting, or high fever; and
the patient has a tubo-ovarian abscess.
Oral Treatment
Patients who do not respond to oral therapy within 72 hours should be
reevaluated to confirm the diagnosis and should be administered
parenteral therapy on either an outpatient or in-patient basis.
Recommended Regimen A
Levofloxacin 500 mg orally once daily for 14 days*
OR
Ofloxacin 400 mg orally once daily for 14 days*
WITH OR WITHOUT
Metronidazole 500 mg orally twice a day for 14 days
--------------------------------------------------------------------------------
* Quinolones should not be used in persons with a history of recent
foreign travel or partners’ travel, infections acquired in California or
Hawaii, or infections acquired in other areas with increased QRNG
prevalence.
Recommended Regimens B
Ceftriaxone 250 mg IM in a single dose
PLUS
Doxycycline 100 mg orally twice a day for 14 days
WITH OR WITHOUT
Metronidazole 500 mg orally twice a day for 14 days
OR
Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally
administered concurrently in a single dose
PLUS
Doxycycline 100 mg orally twice a day for 14 days
WITH OR WITHOUT
Metronidazole 500 mg orally twice a day for 14 days
OR
Other parenteral third-generation cephalosporin (e.g., ceftizoxime or
cefotaxime)
PLUS
Doxycycline 100 mg orally twice a day for 14 days
WITH OR WITHOUT
Metronidazole 500 mg orally twice a day for 14 days
Parenteral Treatment
Recommended Parenteral Regimen A
Cefotetan 2 g IV every 12 hours
OR
Cefoxitin 2 g IV every 6 hours
PLUS
Doxycycline 100 mg orally or IV every 12 hours
Parenteral therapy may be discontinued 24 hours after a patient
improves clinically, and oral therapy with doxycycline (100 mg twice a
day) should continue to complete 14 days of therapy. When tubo-ovarian
abscess is present, many health-care providers use clindamycin or
metronidazole with doxycycline for continued therapy, rather than
doxycycline alone, because it provides more effective anaerobic
coverage.
Recommmended Parenteral Regimen B (Suitable for pregnant patients)
Clindamycin 900 mg IV every 8 hours
PLUS
Gentamicin loading dose IV or IM (2 mg/kg of body weight), followed by a
maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing may be
substituted.
Parenteral therapy can be discontinued 24 hours after a patient
improves clinically; continuing oral therapy should consist of
doxycycline 100 mg orally twice a day or clindamycin 450 mg orally four
times a day to complete a total of 14 days of therapy. When tubo-ovarian
abscess is present, many health-care providers use clindamycin for
continued therapy, rather than doxycycline, because clindamycin provides
more effective anaerobic coverage.
Alternative Parenteral Regimens
Levofloxacin 500 mg IV once daily*
WITH OR WITHOUT
Metronidazole 500 mg IV every 8 hours
OR
Ofloxacin 400 mg IV every 12 hours*
WITH OR WITHOUT
Metronidazole 500 mg IV every 8 hours
OR
Ampicillin/Sulbactam 3 g IV every 6 hours
PLUS
Doxycycline 100 mg orally or IV every 12 hours
* Quinolones should not be used in persons with a history of recent
foreign travel or partners’ travel, infections acquired in California or
Hawaii, or infections acquired in other areas with increased QRNG
prevalence.
SYPHILIS
Parenteral penicillin G is the only therapy with documented efficacy for
syphilis during pregnancy.
Pregnant women with syphilis in any stage who report
penicillin allergy should be desensitized and treated with penicillin. Skin
testing for penicillin allergy might be useful in pregnant women; such testing
also is useful in other patients (see Management of Patients Who Have a History of
Penicillin Allergy).
Primary and Secondary Syphilis
Recommended Regimen for Adults*
Benzathine penicillin G 2.4 million units IM in a single dose
Alternative Regimen
Doxycycline 100 mg orally twice daily for 14 days
Failure of nontreponemal test titers to decline fourfold within 6 months
after therapy for primary or secondary syphilis might be indicative of
probable treatment failure. Persons for whom titers remain serofast
should be reevaluated for HIV infection.
Early Latent Syphilis (Seroreactivity without other evidence of disease
and acquired syphilis within the preceding year. )
Benzathine penicillin G 2.4 million units IM in a single dose
Late Latent Syphilis or Latent Syphilis of Unknown Duration (Seroreactivity without other evidence of disease)
Benzathine penicillin G 7.2 million units total, administered as 3 doses
of 2.4 million units IM each at 1-week intervals
Tertiary Syphilis (Gumma and cardiovascular syphilis but not to all neurosyphilis)
Benzathine penicillin G 7.2 million units total, administered as 3 doses
of 2.4 million units IM each at 1-week intervals
Neuroyphilis
Recommended 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 once daily
PLUS
Probenecid 500 mg orally four times a day, both for 10–14 days
SCABIES
Scabies in adults frequently is sexually acquired, although scabies in children
usually is not.
Bedding and clothing should be decontaminated (i.e., either
machine-washed, machine-dried using the hot cycle, or dry cleaned) or
removed from body contact for at least 72 hours. Fumigation of living
areas is unnecessary.
Recommended Regimen
Permethrin cream 5% applied to all areas of the body from the neck
down and washed off after 8–14 hours
OR
Ivermectin* 200 ug/kg orally, repeated in 2 weeks
Alternative Regimens
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
*Infants, young children, and pregnant or lactating women should not
be treated with lindane. They can be treated with permethrin.
Ivermectin is not recommended for pregnant or lactating patients. The
safety of ivermectin in children who weigh <15 kg has not been
determined.
SEXUAL ASSUALT
TRICHOMONAS
Vaginal trichomoniasis has been associated with adverse pregnancy
outcomes, particularly premature rupture of membranes, preterm delivery,
and low birthweight. However, data do not suggest that metronidazole
treatment results in a reduction in perinatal morbidity. Although some
trials suggest the possibility of increased prematurity or low
birthweight after metronidazole treatment, limitations of the studies
prevent definitive conclusions regarding risks of treatment
(173,174).
Treatment of T. vaginalis might relieve symptoms of vaginal
discharge in pregnant women and might prevent respiratory or genital
infection of the newborn and further sexual transmission. Clinicians
should counsel patients regarding the potential risks and benefits of
treatment. Some specialists would defer therapy in asymptomatic pregnant
women until after 37 weeks’ gestation. In addition, these pregnant women
should be provided careful counseling regarding condom use and the
continued risk of sexual transmission.
Recommended Regimens
Metronidazole 2 g orally in a single dose
OR
Tinidazole 2 g orally in a single dose
Alternative Regimen
Metronidazole 500 mg orally twice a day for 7 days
If treatment failure occurs with metronidazole 2 g single dose and
reinfection is excluded, the patient can be treated with metronidazole 500 mg
orally twice daily for 7 days or tinidazole 2 g single dose. For patients
failing either of these regimens, clinicians should consider treatment with
tinidazole or metronidazole at 2 g orally for 5 days. If these therapies are not
effective, further management should be discussed with a specialist.
Consultation and T. vaginalis susceptibility testing is available from
CDC (telephone: 770-488-4115; website:
http://www.cdc.gov/std).
VULVOVAGINAL CANDIDIASIS (VVC), UNCOMPLICATED
Only topical azole therapies, applied for 7 days, are recommended for use among pregnant women.
Recommended Regimens
For Pregnant or Nonpregnant Women
Intravaginal Agents:
Clotrimazole 1% cream 5 g intravaginally for 7–14 days
(Over the counter as
Gyne-Lotrimin Clotrimazole Vaginal Cream 1% 45 gm)
OR
Clotrimazole 100 mg vaginal tablet for 7 days
OR
Miconazole 2% cream 5 g intravaginally for 7 days
(Over
the counter as
Monistat 7 Miconazole Vaginal Cream 2% 45 gm)
OR
Miconazole 100 mg vaginal suppository, one suppository for 7 days
(Over the counter as
Monistat 7, 100 mg suppositories)
OR
Nystatin 100,000-unit vaginal tablet, one tablet for 14 days
(Mycostatin)
OR
Terconazole 0.4% cream 5 g intravaginally for 7 days
(Terazol 3)
For NONPREGNANT Women Only
Butoconazole 2% cream 5 g intravaginally for 3 days
(Over the counter as
Femstat 3 Butoconazole Vaginal Cream 2% 45 gm)
OR
Butoconazole 2% cream 5 g (Butaconazole1-sustained release), single
intravaginal application
(Femstat)
OR
Clotrimazole 100 mg vaginal tablet, two tablets for 3 days
(Lotrimin)
OR
Miconazole 200 mg vaginal suppository, one suppository for 3 days*
(Monistat)
OR
Miconazole 1,200 mg vaginal suppository, one suppository for 1 day*
(Monistat)
OR
Tioconazole 6.5% ointment 5 g intravaginally in a single application*
(Vagistat 1)
OR
Terconazole 0.8% cream 5 g intravaginally for 3 days
OR
Terconazole 80 mg vaginal suppository, one suppository for 3 days
For NONPREGNANT Women Only
Oral Agent:
Fluconazole 150 mg oral tablet, one tablet in single dose
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* Over-the-counter preparations.
Nonalbicans VVC
The optimal treatment of nonalbicans VVC remains unknown. Options
include longer duration of therapy (7–14 days) with a nonfluconazole
azole drug (oral or topical) as first-line therapy. If recurrence
occurs, 600 mg of boric acid in a gelatin capsule is recommended,
administered vaginally once daily for 2 weeks. This regimen has clinical
and myco-logic eradication rates of approximately 70%
RECURRENT VULVOVAGINAL CANDIDIASIS (RVVC)
Four or more episodes of symptomatic VVC in 1 year,
(e.g., 7–14 days of topical therapy or a 100 mg, 150 mg, or 200 mg
oral dose of fluconazole every third day for a total of 3 doses (day 1,
4, and 7) to attempt mycologic remission before initiating a maintenance
antifungal regimen.
Maintenance Regimens
Oral
fluconazole (i.e., 100-mg, 150-mg, or 200-mg dose)
(SAFETY IN PREGNANCY HAS NOT BEEN ESTABLISHED) weekly for 6
months is the first line of treatment. If this regimen is not feasible,
some specialists recommend topical clotrimazole 200 mg twice a week,
clotrimazole (500-mg dose vaginal suppositories once weekly), or other
topical treatments used intermittently.
Severe vulvovaginitis (i.e., extensive vulvar erythema, edema,
excoriation, and fissure formation) is associated with lower clinical
response rates in patients treated with short courses of topical or oral
therapy. Either 7–14 days of topical azole or 150 mg of fluconazole in
two sequential doses (second dose 72 hours after initial dose) is
recommended.
REFERENCES
1.
CDC Sexually Transmitted Diseases Treatment
Guidelines , 2006
MMWR August 4, 2006/ 55 (RR-11)
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