Sandbox g41

# Asymptomatic bacteriuria
- Asymptomatic bacteriuria
- Definitions
- For women: two consecutive voided urine specimens with isolation of the same bacterial strain in quantitative counts  105 cfu/mL
- For men: a single, clean-catch voided urine specimen with 1 bacterial species isolated in a quantitative count  105 cfu/mL
- For catheterized urine specimen: a single catheterized urine specimen with 1 bacterial species isolated in a quantitative count  10>2 cfu/mL
- Causative pathogens
- Escherichia coli
- Klebsiella pneumoniae
- Coagulase-negative staphylococci
- Enterococcus
- Group B streptococci
- Gardnerella vaginalis
- Pseudomonas aeruginosa, Proteus mirabilis, Providencia stuartii, Morganella morganii (common in patients with long-term urologic device in place)
- Empiric antimicrobial therapy
- Treatment of asymptomatic bacteriuria is not recommended for the following persons:
- Premenopausal, nonpregnant women
- Diabetic women
- Older persons residing in the community
- Elderly, institutionalized subjects
- Persons with spinal cord injury
- Catheterized patients while the catheter remains in situ
- Specific considerations
- Men
- Screening for or treatment of asymptomatic bacteriuria in men is not recommended.
- Women, premenopausal, nonpregnant
- Screening for or treatment of asymptomatic bacteriuria in premenopausal, nonpregnant women is not indicated.
- Women, pregnant
- Preferred regimen (1): Nitrofurantoin 100 mg PO bid for 35 days (avoid in glucose-6-phosphate dehydrogenase deficiency)
- Preferred regimen (2): Amoxicillin 500 mg tid for 35 days
- Preferred regimen (3): Amoxicillin-Clavulanate 500 mg bid for 35 days
- Preferred regimen (4): Cephalexin 500 mg tid for 35 days
- Preferred regimen (5): Fosfomycin 3 g as a single dose
- Preferred regimen (6): Trimethoprim bid for 35 days (only after first trimester)
- Women, diabetic
- Screening for or treatment of asymptomatic bacteriuria in diabetic women is not recommended.
- Older persons residing in the community
- Screening for or treatment of asymptomatic bacteriuria in older persons residing in the community is not recommended.
- Elderly institutionalized subjects
- Screening for or treatment of asymptomatic bacteriuria in elderly institutionalized residents of longterm care facilities is not recommended.
- Subjects with spinal cord injuries
- Screening for or treatment of asymptomatic bacteriuria in subjects with spinal cord injuries is not recommended.
- Patients with indwelling urethral catheters
- Screening for or treatment of asymptomatic bacteriuria in patients with indwelling urethral catheters is not recommended.
- Urologic interventions
- Screening for or treatment of asymptomatic bacteriuria before transurethral resection of the prostate is recommended.
- Preferred regimen: Trimethoprim-Sulfamethoxazole DS 1 tab bid for 3 days after obtaining urine cultures

# Ectoparasitic Infections

## Pediculosis Pubis
- Preferred regime: 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 regime: Malathion 0.5% lotion applied for 8--12 hours and washed off OR Ivermectin 250 g/kg orally, repeated in 2 weeks

## Scabies
- Preferred regime: Permethrin cream (5%) applied to all areas of the body from the neck down and washed off after 8--14 hours OR Ivermectin 200ug/kg orally, repeated in 2 weeks
- Alternative regime: Lindane (1%) 1 oz. of lotion (or 30 g of cream) applied in a thin layer to all areas of the body from the neck down and thoroughly washed off after 8 hours

# Human papillomavirus infection

## Genital Warts
- Patient-Applied:
- Preferred regime: Podofilox 0.5% solution or gel OR Imiquimod 5% cream OR Sinecatechins 15% ointment
- Provider--Administered:
- Preferred regime: Cryotherapy with liquid nitrogen or cryoprobe, repeat applications every 1-2 weeks OR Podophyllin resin 10%-25% in a compound tincture of benzoin OR Trichloroacetic acid (TCA) OR Bichloroacetic acid (BCA) 80%-90% OR Surgical removal either by tangential scissor excision, tangential shave excision, curettage, or electrosurgery.
- Alternative regime: intralesional interferon, photodynamic therapy, and topical .
- Preferred regime: For women who have exophytic cervical warts, a biopsy evaluation to exclude high-grade SIL must be performed before treatment is initiated. Management of exophytic cervical warts should include consultation with a specialist.
- Preferred regime: Cryotherapy with liquid nitrogen. The use of a cryoprobe in the vagina is not recommended because of the risk for vaginal perforation and fistula formation OR TCA or BCA 80%--90% applied to warts. A small amount should be applied only to warts and allowed to dry, at which time a white frosting develops. If an excess amount of acid is applied, the treated area should be powdered with talc, sodium bicarbonate, or liquid soap preparations to remove unreacted acid. This treatment can be repeated weekly, if necessary.
- Preferred regime: Cryotherapy with liquid nitrogen OR Podophyllin 10%--25% in compound tincture of benzoin. The treatment area and adjacent normal skin must be dry before contact with podophyllin. This treatment can be repeated weekly, if necessary. The safety of podophyllin during pregnancy has not been established. Data are limited on the use of podofilox and imiquimod for treatment of distal meatal warts.
- Preferred regime: Cryotherapy with liquid nitrogen OR TCA or BCA 80%--90% applied to warts. A small amount should be applied only to warts and allowed to dry, at which time a white frosting develops. If an excess amount of acid is applied, the treated area should be powdered with talc, sodium bicarbonate, or liquid soap preparations to remove unreacted acid. This treatment can be repeated weekly, if necessary. OR Surgical removal

# Vaginal infection

## Bacterial vaginosis
- Preferred regime: 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 regime (1): Tinidazole 2 g orally once daily for 3 days
- Alternative regime (2): Tinidazole 1 g orally once daily for 5 days
- Alternative regime (3): Clindamycin 300 mg orally twice daily for 7 days
- Alternative regime (4): Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days
- Preferred regime: 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

## Trichomoniasis
T. vaginalis
- Preferred regime: Metronidazole 2 g orally in a single dose OR Tinidazole 2 g orally in a single dose
- Alternative regime: Metronidazole 500 mg orally twice a day for 7 days
- Preferred regime: 2 g Metronidazole in a single dose at any stage of pregnancy, withholding breastfeeding during treatment and for 12--24 hours after the last dose will reduce the exposure of the infant to metronidazole.

## Vulvovaginal candidiasis
- Preferred regime:
- Over-the-Counter Intravaginal Agents: Butoconazole 2% cream 5 g intravaginally for 3 days OR Clotrimazole 1% cream 5 g intravaginally for 7--14 days OR Clotrimazole 2% cream 5 g intravaginally for 3 days OR ] 2% cream 5 g intravaginally for 7 days OR Miconazole 4% cream 5 g intravaginally for 3 days OR Miconazole 100 mg vaginal suppository, one suppository for 7 days OR Miconazole 200 mg vaginal suppository, one suppository for 3 days OR Miconazole 1,200 mg vaginal suppository, one suppository for 1 day OR Tioconazole 6.5% ointment 5 g intravaginally in a single application
- Prescription Intravaginal Agents: Butoconazole 2% cream (single dose bioadhesive product), 5 g intravaginally for 1 day OR Nystatin 100,000-unit vaginal tablet, one tablet for 14 days OR Terconazole 0.4% cream 5 g intravaginally for 7 days OR Terconazole 0.8% cream 5 g intravaginally for 3 days OR Terconazole 80 mg vaginal suppository, one suppository for 3 days
- Oral Agent: Fluconazole 150 mg oral tablet, one tablet in single dose
- Recurrent Vulvovaginal Candidiasis (RVVC)
- Preferred regime: 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 followed by Oral Fluconazole (i.e., 100-mg, 150-mg, or 200-mg dose) weekly for 6 months
- Severe VVC
- Preferred regime: Topical Azole for 7-14 days OR 150 mg of Fluconazole in two sequential doses (second dose 72 hours after initial dose.
- Nonalbicans VVC
- Preferred regime: nonfluconazole Azole drug (oral or topical) for 7-14 days.
- Preferred regime: topical Azole therapies for 7 days

# Cervicitis
- Cervicitis
- Preferred regimen: Azithromycin 1 g PO in a single dose OR Doxycycline 100 mg PO bid for 7 days

# Chancroid
- Chancroid (Haemophilus ducreyi infection)
- Preferred regimen: Azithromycin 1 g PO as a single dose OR Ceftriaxone 250 mg IM as a single dose OR Ciprofloxacin 500 mg PO bid for 3 days OR Erythromycin 500 mg PO tid for 7 days

# Chlamydial infections
- Chlamydial infections
- Chlamydial infections in adolescents and adults
- Preferred regimen: Azithromycin 1 g PO in a single dose OR Doxycycline 100 mg PO bid for 7 days
- Alternative regimen (1): Erythromycin base 500 mg PO qid for 7 days
- Alternative regimen (2): Erythromycin ethylsuccinate 800 mg PO qid for 7 days
- Alternative regimen (3): Levofloxacin 500 mg PO qd for 7 days
- Alternative regimen (4): Ofloxacin 300 mg PO bid for 7 days
- Chlamydial infections during pregnancy
- Preferred regimen: Azithromycin 1 g PO in a single dose OR Amoxicillin 500 mg PO tid for 7 days
- Alternative regimen (1): Erythromycin base 500 mg PO qid for 7 days
- Alternative regimen (2): Erythromycin base 250 mg PO qid for 14 days
- Alternative regimen (3): Erythromycin ethylsuccinate 800 mg PO qid for 7 days
- Alternative regimen (4): Erythromycin ethylsuccinate 400 mg PO qid for 14 days
- Chlamydial infections among infants and children
- Ophthalmia neonatorum caused by C. trachomatis
- Preferred regimen: Erythromycin base or ethylsuccinate 50 mg/kg/day PO divided into 4 doses daily for 14 days
- Pneumonia caused by C. trachomatis
- Preferred regimen (< 45 kg): Erythromycin base or ethylsuccinate 50 mg/kg/day PO divided into 4 doses daily for 14 days
- Preferred regimen ( 45 kg & < 8 years): Azithromycin 1 g PO in a single dose
- Preferred regimen ( 8 years): Azithromycin 1 g PO in a single dose OR Doxycycline 100 mg PO bid for 7 days

# Chorioamnionitis
- Antibiotics 
- Preferred regime: Ampicillin 2 g intravenously every 6 h OR Penicillin 5x106 units intravenously every 6 h AND Gentamicin 1.5 mg/kg every 8 h
- NOTE (1): Cephalosporins are generally recommended for women with chorioamnionitis who are allergic to Penicillin
- NOTE (2): In women with anaphylaxis to Penicillin a recommendation is to substitute Clindamycin 900 mg every 8 h
- NOTE (3): In the non-obstetric population, daily dosing of Gentamicin appears to be more effective, convenient, and cost-effective as well as less toxic.
- NOTE (4): Recommends the addition of a drug with enhanced anaerobic coverage, such as Clindamycin every 8 hours OR Metronidazole, in those cases of chorioamnionitis that require cesarean delivery
- NOTE (5): chorioamnionitis is a contraindication to the administration of Corticosteroids. Women with intra-amniotic infection have traditionally been excluded from randomized trials of corticosteroid therapy.
- Supportive measures
- Preferred regime: Antipyretics (Acetaminophen)
- Prevention 
- Preferred regime: Macrolide (Erythromycin OR Azithromycin) AND Ampicillin for 710 days via intravenous (2 days) followed by oral routes.
- NOTE: Induction of labor and delivery for  preterm premature rupture of membranes (PPROM) after 34 weeks gestation is recommended.

# Cystitis
- Acute Uncomplicated Cystitis
- Preferred regime: Nitrofurantoin monohydrate/macrocrystals 100 mg bid 5 days (avoid if early pyelonephritis suspected) OR Trimethoprim-sulfamethoxazole 160/800 mg (one DS tablet) bid 3 days (avoid if resistance prevalence is known to exceed 20 or if used for UTI in previous 3 months) OR Fosfomycin trometamol 3 gm single dose (lower efficacy than some other recommended agents; avoid if early pyelonephritis suspected) OR Pivmecillinam 400 mg bid 5 days (lower efficacy than some other recommended agents; avoid if early pyelonephritis suspected)
- Alternative regime (1): Fluoroquinolones, Ofloxacin, Ciprofloxacin, and Levofloxacin, use for 3 days.
- Alternative regime (2): -Lactam agents, including Amoxicillin-clavulanate, Cefdinir, Cefaclor, and Cefpodoxime-proxetil, for 37-days

# Epididymitis
- Preferred regime: Ceftriaxone 250 mg IM in a single dose AND Doxycycline 100 mg orally twice a day for 10 days
- For acute epididymitis most likely caused by enteric organisms
- Preferred regime:  500 mg orally once daily for 10 days OR Ofloxacin 300 mg orally twice a day for 10 days
- NOTE: Patients who have uncomplicated acute epididymitis and also are infected with HIV should receive the same treatment regimen as those who are HIV negative.

# Genital herpes
- Genital herpes
- First episode of genital herpes
- Preferred regimen: Acyclovir 400 mg PO tid for 710 days OR Acyclovir 200 mg PO five times a day for 710 days OR Famciclovir 250 mg PO tid for 710 days OR Valacyclovir 1 g PO bid for 710 days
- Recurrent genital herpes
- Suppressive therapy
- Preferred regimen: Acyclovir 400 mg PO bid for 710 days OR Famciclovir 250 mg PO bid for 710 days OR Valacyclovir 1000 mg PO qd for 710 days OR Valacyclovir 500 mg PO qd for 710 days
- Episodic therapy
- Preferred regimen: Acyclovir 400 mg PO tid for 5 days OR Acyclovir 800 mg PO bid a day for 5 days OR Acyclovir 800 mg PO tid for 2 days OR Famciclovir 125 mg PO bid for 5 days OR Famciclovir 1000 mg PO bid for 1 day OR Famciclovir 500 mg PO once, followed by 250 mg PO bid for 2 days OR Valacyclovir 500 mg PO bid for 3 days OR Valacyclovir 1000 mg PO qd for 5 days
- Severe genital herpes
- Preferred regimen: Acyclovir 510 mg/kg IV q8h for 27 days or until clinical improvement is observed, followed by PO antiviral therapy to complete at least 10 days of total therapy.
- Genital herpes in HIV-infected patients
- Suppressive therapy
- Preferred regimen: Acyclovir 400800 mg PO bidtid OR Famciclovir 500 mg PO bid OR Valacyclovir 500 mg PO bid
- Episodic therapy
- Preferred regimen: Acyclovir 400 mg PO tid for 510 days OR Famciclovir 500 mg PO bid for 510 days OR Valacyclovir 1000 mg PO bid for 510 days
- Acyclovir-resistant genital herpes
- Preferred regimen: Foscarnet 40 mg/kg IV q8h until clinical resolution is attained,
- Alternative regimen: Cidofovir 5 mg/kg once weekly OR Imiquimod topically qd for 5 days
- Genital herpes in pregnancy
- Acyclovir can be administered orally to pregnant women with first episode of genital herpes or recurrent genital herpes.
- Acyclovir should be administered IV to pregnant women with severe genital herpes.
- Neonatal herpes, known or suspected
- Disease limited to the skin and mucous membranes
- Preferred regimen: Acyclovir 20 mg/kg IV q8h for 14 days
- Disseminated and CNS disease
- Preferred regimen: Acyclovir 20 mg/kg IV q8h for 21 days

# Gonococcal infections
- 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
- 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.
- If the patients last potential sexual exposure was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated.
- 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
- 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)
- 1.3 Gonococcal conjunctivitis
- Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1 g PO in a single dose
- 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: Cefotaxime 1 g IV q8h for 7 days OR 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: Ceftriaxone 25-50 mg/kg/day  IM/IV qd for 7 days OR Cefotaxime 25 mg/kg IV /IM  q12h for 7 days.
- 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
- Neisseria gonorrhoeae, prophylaxis
- 1. Ophthalmia neonatorum
- Preferred regimen: Erythromycin 0.5% ophthalmic ointment in each eye in a single application at birth
- Alternative regimen: Ceftriaxone 2550 mg/kg IV/IM in a single dose, not to exceed 125 mg (if erythromycin ointment is not available)

# Granuloma inguinale
- Granuloma inguinale (donovanosis)
- Preferred regimen: Doxycycline 100 mg PO bid for at least 3 weeks and until all lesions have completely healed
- Alternative regimen (1): Azithromycin 1 g PO once per week for at least 3 weeks and until all lesions have completely healed
- Alternative regimen (2): Ciprofloxacin 750 mg PO bid for at least 3 weeks and until all lesions have completely healed
- Alternative regimen (3): Erythromycin base 500 mg PO qid for at least 3 weeks and until all lesions have completely healed
- Alternative regimen (4): Trimethoprim-Sulfamethoxazole double-strength (160 mg/800 mg) one tablet PO bid for at least 3 weeks and until all lesions have completely healed

# Lymphogranuloma venereum
- Lymphogranuloma venereum (Chlamydia trachomatis serovars L1, L2, or L3 infection)
- Preferred regimen: Doxycycline 100 mg PO bid for 21 days
- Alternative regimen: Erythromycin base 500 mg PO qid for 21 days

# Pelvic inflammatory disease
- Parenteral Treatment
- Preferred regime (1): Cefotetan 2 g IV every 12 hours OR Cefoxitin 2 g IV every 6 hours AND Doxycycline 100 mg orally or IV every 12 hours.
- Preferred regime (2): Clindamycin 900 mg IV every 8 hours AND 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 (3--5 mg/kg) can be substituted.
- Alternative regime: Ampicillin/Sulbactam 3 g IV every 6 hours AND Doxycycline 100 mg orally or IV every 12 hours.
- Oral Treatment
- Preferred regime (1): Ceftriaxone 250 mg IM in a single dose AND Doxycycline 100 mg orally twice a day for 14 days  Metronidazole 500 mg orally twice a day for 14 days
- Preferred regime (2): Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered concurrently in a single dose AND Doxycycline 100 mg orally twice a day for 14 days  Metronidazole 500 mg orally twice a day for 14 days
- Preferred regime (3): Other parenteral third-generation cephalosporin (e.g., ceftizoxime OR cefotaxime) AND Doxycycline 100 mg orally twice a day for 14 days  Metronidazole 500 mg orally twice a day for 14 days
- Alternative regime (1): Ceftriaxone 250 mg IM single dose and Azithromycin 1 g orally once a week for 2 weeks.
- Alternative regime (2): Levofloxacin 500 mg orally once daily or Ofloxacin 400 mg twice daily for 14 days {{withorwithout]] Metronidazole 500 mg orally twice daily for 14 days.

# Proctocolitis
- Proctitis
- Preferred regime: Ceftriaxone 250 mg IM AND Doxycycline 100 mg orally twice a day for 7 days

# Prostatitis

## Acute Bacterial Prostatitis
- Uncomplicated (with low risk of STD pathogens)
- Preferred regime: Ciprofloxacin 400 mg iv or 500 mg po BID or Levofloxacin 500750 mg iv/po QD
- Alternative regime: TMP-SMX DS (160 mg TMP) BID
- NOTE: 2 weeks duration of therapy may be sufficient; if patient remains symptomatic, extend to 4 weeks
- Preferred regime: Ampicillin 12 g IV every 4 h OR Vancomycin 15 mg/kg every 12 h
- Alternative regime: Levofloxacin 750 po QD OR Linezolid 600 mg every 12 h
- NOTE: Use intravenous therapy if systemically ill; switch to oral therapy when stable
- Preferred regime: Ciprofloxacin 400 mg TID
- Alternative regime: Piperacillin-tazobactam 4.5 g iv every 6 h
- Uncomplicated (with risk of STD pathogens)
- Preferred regime: Ceftriaxone 250 mg IM OR Cefixime 400 mg po x 1 dose AND Doxycycline 100 mg po BID OR Azithromycin 500 mg po QD
- Alternative regime: Fluoroquinolones not recommended for gonococcal infection
- NOTE: Treat for 2 weeks in most cases. Obtain urine nucleicacid amplification test for N.gonorrhoeae and C.trachomatis
- Uncomplicated, with risk of antibiotic resistant pathogen
- Preferred regime: Ertapenem 1 g iv QD
- Alternative regime: Ceftriaxone 1 g iv QD or Imipenem 500mg iv every 6 h OR Tigecycline 100 mg iv x 1 dose then 50 mg iv every 12 h
- Preferred regime: Ertapenem 1 g iv QD
- Alternative regime: Cefepime 2g iv every 12 h OR Imipenem 500 mg iv every 6 h OR Tigecycline 100 mg iv x 1 dose then 50 mg iv every 12 h
- Preferred regime: Imipenem 500 mg iv every 6 h
- Alternative regime: Meropenem 500 mg iv every 8 h
- Complicated by bacteremia or suspected prostatic abscess
- Preferred regime: Ciprofloxacin 400 mg iv every 12 h OR Levofloxacin 500 mg iv every 24 h
- Alternative regime: Ceftriaxone 12 g iv every 24 h AND Levofloxacin 500750 mg po QD OR Ertapenem 1 g iv every 24 h OR piperacillin-tazobactam 3.375 g iv every 6 h
- NOTE: Treat for 4 weeks. Obtain blood cultures; Consider genitourinary imaging; Change iv to po regimen when blood cultures are sterile and abscess drained.

## Chronic Bacterial Prostatitis
- Preferred regime: Ciprofloxacin 400 mg iv every 12 h OR Levofloxacin 500 mg iv every 24 h
- Alternative regime: TMP-SMX x 1 dose DS BID
- Preferred regime: Azithromycin 500 mg po QD
- Alternative regime: Doxycycline 100 mg BID

# Pyelonephritis
- Condition 1: patients not requiring hospitalization where the prevalence of resistance of community uropathogens to fluoroquinolones is not known to exceed 10%
- Preferred regime: Ciprofloxacin orally 500 mg twice daily for 7 days  an initial 400-mg dose of intravenous Ciprofloxacin
- NOTE (1): If an initial one-time intravenous agent is used, a long-acting antimicrobial, such as 1 g of Ceftriaxone or a consolidated 24-h dose of an Aminoglycoside, could be used in lieu of an intravenous fluoroquinolone
- NOTE (2): If the prevalence of fluoroquinolone resistance is thought to exceed 10%, an initial one-time intravenous dose of a long-acting parenteral antimicrobial, such as 1 g of ceftriaxone or a consolidated 24-h dose of an aminoglycoside, is recommended.
- Alternative regime: A once-daily oral fluoroquinolone, including Ciprofloxacin 1000 mg extended release for 7 days OR Levofloxacin 750 mg for 5 days.
- NOTE: If the prevalence of fluoroquinolone resistance is thought to exceed 10%, an initial intravenous dose of a long-acting parenteral antimicrobial, such as 1 g of Ceftriaxone or a consolidated 24-h dose of an Aminoglycoside, is recommended.
- Condition 2: When the uropathogen is known to be susceptible
- Preferred regime: Trimethoprim-sulfamethoxazole 160/800 mg (1 double-strength tablet) bid orally for 14 days.
- NOTE: If trimethoprim-sulfamethoxazole is used when the susceptibility is not known, an initial intravenous dose of a long-acting parenteral antimicrobial, such as 1 g of ceftriaxone OR a consolidated 24-h dose of an aminoglycoside, is recommended.
- NOTE: Oral -lactam agents are less effective than other available agents for treatment of pyelonephritis. If an oral -lactam agent is used, an initial intravenous dose of a long-acting parenteral antimicrobial, such as 1 g of ceftriaxone OR a consolidated 24-h dose of an aminoglycoside, is recommended.
- Condition 3: Patients require hospitalization (high fever, high white blood cell count, vomiting, dehydration, or evidence of sepsis)
- Preferred regime: intravenous antimicrobial regimen, such as a Fluoroquinolone; an Aminoglycoside  Ampicillin; an extended-spectrum Cephalosporin or extended-spectrum Penicillin  an Aminoglycoside; Carbapenem
- NOTE: The choice between these agents should be based on local resistance data, and the regimen should be tailored on the basis of susceptibility results.

# Sterile pyuria
- Sterile pyuria
- Definitions
- Pyuria: the presence of 10 or more white cells per cubic millimeter in a urine specimen, 3 or more white cells per high-power field of unspun urine, a positive result on Grams stain of an unspun urine specimen, or a urinary dipstick test that is positive for leukocyte esterase
- Sterile pyuria: the persistent finding of white cells in the urine in the absence of bacteria, as determined by means of aerobic laboratory techniques (on a 5% sheep-blood agar plate and MacConkey agar plate)
- Bacteriuria: bacterial colony counts of more than 1000 colony-forming units (CFU) per milliliter in urine
- Causes
- Infectious etiologies
- Gynecologic infection
- Urethritis due to chlamydia, Neisseria gonorrhoeae, mycoplasma, or ureaplasma
- Prostatitis
- Balanitis
- Appendicitis
- Viral infection of the lower genitourinary tract
- Genitourinary tuberculosis
- Fungal infection
- Parasitic disease such as trichomoniasis or schistosomiasis
- Non-infectious etiologies
- Current use of antibiotics
- Recently treated urinary tract infection (within past 2 weeks)
- Presence or recent use of a urinary catheter
- Recent cystoscopy or urologic endoscopy
- Urinary tract stones
- Foreign body such as surgical mesh in the urethra or a retained stent
- Urinary tract neoplasm
- Pelvic irradiation
- Urinary fistula
- Polycystic kidney
- Rejection of a renal transplant
- Renal-vein thrombosis
- Interstitial nephritis or analgesic nephropathy
- Papillary necrosis
- Interstitial cystitis
- Inflammatory disease such as systemic lupus erythematosus or Kawasakis disease
- Pathogen-directed antimicrobial therapy
- Tuberculosis
- Preferred regimen: Isoniazid AND Rifampin AND Ethambutol AND Pyrazinamide for 36 months
- Gonorrhea
- Preferred regimen: Ceftriaxone 250 mg IM in a single dose, then (Azithromycin 1 g PO in a single dose OR Doxycycline 100 mg PO bid for 7 days)
- Chlamydia
- Preferred regimen: Azithromycin 1 g PO in single dose OR Doxycycline 100 mg PO bid for 7 days
- Alternative regimen: Erythromycin base 500 mg PO qid for 7 days
- Mycoplasma and ureaplasma
- Preferred regimen: Azithromycin OR Levofloxacin OR Moxifloxacin
- Genital herpes
- Preferred regimen: Acyclovir 400 mg PO tid for 710 days or Acyclovir 200 mg PO five times a day for 710 days OR Famciclovir 250 mg PO tid for 710 days OR Valacyclovir 1 g PO bid for 7 days
- Trichomoniasis
- Preferred regimen: Metronidazole 2 g PO in a single dose) OR Tinidazole 2 g PO in a single dose
- Fungal infections
- Preferred regimen: Fluconazole OR Posaconazole OR Echinocandins OR Amphotericin B
- Schistosomiasis
- Preferred regimen: Praziquantel 20 mg/kg PO bid for 12 days

# Syphilis
- Syphilis (Treponema pallidum)
- NonHIV-infected persons
- Primary and secondary syphilis
- Preferred regimen (adult): Benzathine penicillin G 2.4 MU IM in a single dose
- Preferred regimen (pediatric): Benzathine penicillin G 50,000 units/kg (up to 2.4 MU) IM in a single dose
- Latent syphilis
- Early latent syphilis
- Preferred regimen (adult): Benzathine penicillin G 2.4 MU IM in a single dose
- Preferred regimen (pediatric): Benzathine penicillin G 50,000 units/kg (up to 2.4 MU) IM in a single dose
- Late latent syphilis or unknown duration
- Preferred regimen (adult): Benzathine penicillin G 2.4 MU IM for 3 doses, each at 1-week intervals
- Preferred regimen (pediatric): Benzathine penicillin G 50,000 units/kg (up to 2.4 MU) IM, administered as 3 doses at 1-week intervals
- Tertiary syphilis
- Preferred regimen: Benzathine penicillin G 2.4 MU IM for 3 doses, each at 1-week intervals
- Neurosyphilis
- Preferred regimen: Aqueous crystalline penicillin G 34 MU IV q4h or continuously for 1014 days
- Alternative regimen: Procaine penicillin G 2.4 MU IM q24h for 1014 days AND Probenecid 500 mg PO qid for 1014 days
- HIV-infected persons
- Primary and secondary syphilis
- Preferred regimen: Benzathine penicillin G 2.4 MU IM in a single dose
- Latent syphilis
- Early latent syphilis
- Preferred regimen: Benzathine penicillin G 2.4 MU IM in a single dose
- Late latent syphilis or unknown duration
- Preferred regimen: Benzathine penicillin G 2.4 MU IM for 3 doses, each at 1-week intervals
- Tertiary syphilis
- Preferred regimen: Benzathine penicillin G 2.4 MU IM for 3 doses, each at 1-week intervals
- Neurosyphilis
- Preferred regimen: Penicillin G 34 MU IV q4h or continuously for 1014 days
- Alternative regimen: Procaine penicillin G 2.4 MU IM q24h for 1014 days AND Probenecid 500 mg PO qid for 1014 days
- During pregnancy
- Preferred regimen: Pregnant women should be treated with the Penicillin regimen appropriate for their stage of infection.
- Congenital syphilis
- Infants with proven or highly probable disease AND (abnormal physical examination consistent with congenital syphilis OR nontreponemal serologic titer fourfold higher than the mother's titer OR a positive darkfield test of body fluids)
- Preferred regimen: Aqueous crystalline penicillin G 50,000 U/kg IV q12h during the first 7 days of life and q8h thereafter for a total of 10 days OR Procaine penicillin G 50,000 U/kg IM in a single daily dose for 10 days
- Infants who have a normal physical examination AND nontreponemal serologic titer the same or less than fourfold the maternal titer AND (mother was not treated adequately OR mother has no documentation of having received treatment OR mother was treated with Erythromycin or another non-Penicillin regimen OR mother received treatment < 4 weeks before delivery)
- Preferred regimen: Aqueous crystalline penicillin G 50,000 U/kg IV q12h during the first 7 days of life and q8h thereafter for a total of 10 days  OR Procaine penicillin G 50,000 U/kg IM in a single daily dose for 10 days OR Benzathine penicillin G 50,000 U/kg IM in a single dose
- Infants who have a normal physical examination AND nontreponemal serologic titer the same or less than fourfold the maternal titer AND mother was treated during pregnancy AND treatment was appropriate for the stage of infection AND treatment administered > 4 weeks before delivery AND mother has no evidence of reinfection or relapse
- Preferred regimen: Benzathine penicillin G 50,000 U/kg IM in a single dose
- Infants who have a normal physical examination AND nontreponemal serologic titer the same or less than fourfold the maternal titer AND mother's treatment was adequate before pregnancy AND mother's nontreponemal serologic titer remained low and stable before and during pregnancy and at delivery (VDRL < 1:2; RPR < 1:4)
- Preferred regimen: Aqueous crystalline penicillin G 50,000 U/kg q46h for 10 days

# Urethritis
- Urethritis
- Nongonococcal urethritis
- Preferred regimen: Azithromycin 1 g PO in a single dose OR Doxycycline 100 mg PO bid for 7 days
- Alternative regimen (1): Erythromycin base 500 mg PO qid for 7 days
- Alternative regimen (2): Erythromycin ethylsuccinate 800 mg PO qid for 7 days
- Alternative regimen (3): Levofloxacin 500 mg PO qd for 7 days
- Alternative regimen (4): Ofloxacin 300 mg PO bid for 7 days
- Recurrent and persistent urethritis
- Preferred regimen: Metronidazole 2 g PO in a single dose OR Tinidazole 2 g PO in a single dose AND Azithromycin 1 g PO in a single dose