Common Culprits: Gardnerella vaginalis, Prevotella species, Porphyromonas species, Bacteroides species, Peptostreptococcus species, Mycoplasma hominis, and Ureaplasma urealyticum, Mobiluncus, Megasphaera, Sneathia, and Clostridiales species, Fusobacterium species and Atopobium vaginae (now renamed Fannyhessea vaginae)
Treatment:
Metronidazole 500 mg orally twice daily for 7 days
Preferred if pregnant
Metronidazole gel 0.75% 5 g (one full applicator) intravaginally once daily for 5 days
Clindamycin 2% cream 5 g (one full applicator) intravaginally at bedtime for 7 days
Common Culprit: Chlamydia trachomatis
Treatment for Adolescents and Adults:
Doxycycline 100 mg orally twice daily for 7 days
Azithromycin 1 g orally single dose
Unable to take full course of doxycycline
Pregnant individuals
Treatment in non-neonate children (sexual abuse should be highly suspected):
For Infants and Children Who Weigh <45 kg: Erythromycin base or ethylsuccinate 50 mg/kg body weight/day orally divided into 4 doses daily for 14 days
For children weighing ≥45 kg but aged <8 years: Azithromycin 1 g orally in a single dose
For children aged ≥8 years: Azithromycin 1 g orally in a single dose or Doxycycline 100 mg orally 2 times/day for 7 days
See section Bacterial Conjunctivitis for treatment of Chlamydia trachomatis of the newborn
Common Culprit: Neisseria gonorrhoeae
Treatment:
Adolescents and Adults:
Ceftriaxone <150 kg: 500 mg intramuscularly as a single dose, ≥150 kg: 1 g intramuscularly as a single dose
Azithromycin 2 g orally as a single dose PLUS Gentamicin 240 mg if >45 kg (or 5 mg/kg if <45 kg) intramuscularly once OR Gemifloxacin 320 mg orally once
If severe allergy to Ceftriaxone
Special Considerations:
Treatment in non-neonate children <45kg (sexual abuse should be highly suspected):
Ceftriaxone 25-50 mg/kg body weight IV or IM in a single dose, not to exceed 250 mg IM
See section Bacterial Conjunctivitis for treatment of Neisseria gonorrhoeae of the newborn
Common Culprits: Neisseria gonorrhoeae and Chlamydia trachomatis (most common). May also be Mycoplasma genitalium, E. coli and colonic anaerobes, Mycobacterium tuberculosis, Haemophilus influenzae, and Streptococcus pneumonia. Considered a mixed polymicrobial infection.
Outpatient Treatment:
Ceftriaxone (<150 kg: 500mg, ≥150 kg: 1g) IM once + doxycycline 100 mg orally twice daily for 14 days + metronidazole 500 mg orally twice daily for 14 days
Ceftriaxone (<150 kg: 500mg, ≥150 kg: 1g) IM once + azithromycin 500 mg daily for one to two days then 250 mg orally for a 14-day course OR 1g once per week for two weeks+ metronidazole 500 mg orally twice daily for 14 days
Special Considerations: In patients with PCN allergy, assess the severity of the allergy. Patients may be able to receive ceftriaxone after a test-dose procedure. If unable to receive cephalosporins, few outpatient treatments for Neisseria gonorrhoeae are available. Cultures for Neisseria gonorrhoeae should be obtained and if positive have antibiotic susceptibility testing. If Neisseria gonorrhoeae is ruled out, treatment with azithromycin and metronidazole should be completed.
Common Culprit: Treponema pallidum
Treatment:
Early syphilis
Penicillin G benzathine 2.4 million units IM once (preferred)
Doxycycline 100 mg orally twice daily for 14 days
Ceftriaxone 1 g daily IM or IV for 10 to 14 days
Late syphilis
Penicillin G benzathine 2.4 million units IM once weekly for three weeks
Doxycycline 100 mg orally twice daily for four weeks
Ceftriaxone 2 g daily IM or IV for 10 to 14 days
Special Considerations: Neuro syphilis requires hospitalization for IV medication
Common Culprit: T. vaginalis
Treatment for Adult and Adolescent Females:
Metronidazole 500 mg orally twice daily for seven days
Metronidazole 2 g orally given as a single dose
Only use in those unable to take the full course of medication
Tinidazole 2 g orally given as a single dose
Special Considerations:
Children <45 kg: Metronidazole 45 mg/kg/day in divided doses every 8 hours for 7 days; maximum daily dose: 2,000 mg/day
Male Adults and Adolescents: Metronidazole 2,000 mg as a single dose
Allergy to 5-nitroimidazole drugs: low efficacy of other therapies, recommend desensitization to drug
Common Culprits: Escherichia coli (most common, 80%), Klebsiella, Proteus, Enterobacter, Citrobacter, Staphylococcus saprophyticus, Enterococcus, and Staphylococcus aureus (rare)
Outpatient Treatment:
Pediatric Population:
Upper tract involvement suspected:
Cefdinir 14 mg/kg by mouth once daily or in two divided doses for 10 days
Cefixime 8 mg/kg by mouth once daily or in two divided doses for 10 days
Ceftibuten 9 mg/kg by mouth once daily for 10 days
Ciprofloxacin 10 to 20 mg/kg per dose by mouth every 12 hours (maximum 750 mg/dose) for 10 days
Use if allergy to cephalosporins or antibiotic use in last 2 months
No upper tract involvement suspected:
Cephalexin 50 to 100 mg/kg per day by mouth in two divided doses for 5 days
No use of cephalosporin antibiotics in last 2 months
Amoxicillin-clavulanate 50 mg/kg per day by mouth (dosed by the amoxicillin component) in two or three divided doses (maximum 500 mg/dose) for 5 days
Use of cephalosporin in past 2 months
Trimethoprim/Sulfamethoxazole 8 to 12 mg/kg per day of TMP by mouth in two divided doses (maximum 60 to 100 mg every 6 hours) for 5 days
Allergy to cephalosporin or penicillin, use of cephalosporin in last 2 months
Nitrofurantoin 5 to 7 mg/kg per day by mouth divided every 6 hours (50 to 100 mg every 6 hours) for 5 days
Allergy to cephalosporin or penicillin, use of cephalosporin in last 2 months
Adolescents and Adults:
Acute simple cystitis
Nitrofurantoin monohydrate/macrocrystals 100 mg orally twice daily for 5 days
Males for 7 days
Trimethoprim-sulfamethoxazole: one double-strength tablet (160 mg/800 mg) orally twice daily for 3 days
Males for 7 days
Fosfomycin 3 g of powder mixed in water and administered orally as a single dose
Acute complicated UTI
Ciprofloxacin 500 mg orally twice daily for 5 to 7 days
Ciprofloxacin extended-release 1000 mg orally once daily for 5 to 7 days
Levofloxacin 750 mg orally once daily for 5 to 7 days
Ceftriaxone 1 g IV or IM once AND Trimethoprim/Sulfamethoxazole one double-strength tablet orally twice daily for 7 to 10 days OR Amoxicillin-clavulanate 875 mg orally twice daily for 7 to 10 days
Common Culprits: Streptococcus pyogenes (group A streptococcus), Staphylococcus aureus, Haemophilus influenzae, Streptococcus pneumoniae, Neisseria meningitidis, Moraxella catarrhalis, Escherichia coli, Enterococcus faecalis, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas species, Shigella species, Yersinia species
Treatment:
The primary intervention is more effective hygiene measures, should see symptom improvement in 2--3 weeks
With persistent symptoms and foreign body is excluded, obtain vaginal culture and treat based on culture findings