VAGINITIS and SEXUALLY TRANSMITTED DISEASES
Treatments
E.J. Mayeaux, Jr., M.D.
Associate Professor of Family Medicine
Clinical Associate Professor Obstetrics and Gynecology
Louisiana State University Medical Center Shreveport, Louisiana
Chlamydia trachomatis
- doxycycline 100 mg PO bid x 7 days or tetracycline 500 mg
bid x 7 days; avoid dairy products around time of dosing.
Candida vaginitis is a common sequela.
- azithromycin (Zithromax) 1000 mg one-time dose. Take on
an empty stomach. Not well-tested in children or nursing
mothers. May be used during pregnancy.
- ofloxacin (Floxin) 300 mg PO bid x 7 days. Take on an
empty stomach. Contraindicated in children or pregnant
and lactating women.
- erythromycin 500 mg qid x 7 days- Treatment OK in
pregnancy.
- amoxicillin 500 mg TID x 7 days (less effective) -
Treatment OK in pregnancy.
- Children & Neonates: erythromycin 50mg/kg/day divided
Q6 hours.
Neisseria gonorrhea
Uncomplicated N. gonorrhea - Treatment
- ceftriaxazone (Rocephin), 250 mg IM x 1. May be
used during pregnancy.
- cefiximine (Suprax) 400 mg PO once. May be used
during pregnancy.
- ofloxacin (Floxin) 400 mg one-time PO dose.
- 4.8 million units procaine pen G IM with 1 gram
of probenecid PO beforehand.
- amoxicillin 3 gm or ampicillin 3.5 gm PO + 1 gm
probenicid.
- penicillin allergy: tetracycline 500 mg qid x 7
days.
- spectinomycin 40mg/kg up to 2 gm IM.
Disseminated N. gonorrhea - Treatment
- ceftriaxone 1 gm IV or IM q 24 hr.
- ceftizoxime 1 gm IV q 8 hr.
- spectinomycin 2 gm IM q 12 hr.
Trichomonas vaginalis
- metronidazole (Flagyl); 2.0 gm PO single dose;
250 mg tid x 7 days; or 500 mg bid x 5 days.
Avoid metronidazole during first trimester of
pregnancy. Treat both partners - same dose for males.
Warn the patient about Antabuse effect during treatment
(avoid alcohol intake) and about the possibility of amber
urine and a metallic taste. Sexual activity need not be
restricted during treatment if both partners are treated
at same time.
Yeast Infections
Yeast Infections - OTC Treatment
- miconazole (Monistat-7) 2% vaginal cream or 100
mg suppository, 1 application high in vagina qd
for 7 nights. May be used during 2nd and 3rd
trimesters.
- clotrimizole (Gyne-Lotrimin, Mycelex-7, Fem Care,
etc) 1% vaginal cream or 100 mg vaginal tablet,
qd for 7-14 nights. May be used during 2nd and
3rd trimesters.
Yeast Infections - Rx Treatment
- miconazole (Monistat), 200 mg vag. suppositories,
qd x 3 days.
- miconazole, 2% derm. and vag. cream (Monistat
Dual-Pak), qd x 3 days.
- clotrimazole (Gyne-Lotrimin) 500 mg tab per
vagina, qd x 1-2 days.
- terconazole (Terazol) 3-day suppository or 7-day
cream. Apply high in vagina qHS. for 3 or 7 days,
respectively. Good for resistant infections.
Pregnancy Class C.
- tioconazole (Vagistat) ointment. 1
applicator-full at bedtime, 1 time only.
- butoconazole (Femstat) 2% cream. Apply 1
applicator-full high in vagina for 3 to 6 nights.
May use in 2nd and 3rd trimesters.
- nystatin (Mycostatin) vaginal tablet, 1 tablet
qHS x 14 days. Pregnancy Class A.
- fluconazole (Diflucan) 150mg PO once. Good for
resistant infections but may have systemic
sequella.
Bacterial Vaginosis
This problem has no proven major sequella except in
pregnancy. It is not necessary to treat unless the
patient is symptomatic or pregnant. It will also be
present with other infection, and treating the
concomitant infection usually causes the bacterial
vaginosis to resolve. Stop all douching!! Only treat
partners if there are recurrent infections.
- metronidazole (Flagyl) 500 mg bid x 5 days, or
250 mg tid x 7 days, or 2gms PO once. May use in
the second and third trimesters.
- metronidazole vaginal gel - 1 applicator bid for
5 days.
- clindamycin (Cleocin) cream 2% - 1 applicator qHS
for 7 days. May use in all trimesters.
- clindamycin (Cleocin) 300mg PO bid for 7 days.
Contraindicated in the 1st trimester.
- ampicillin 500 mg qid or amoxicillin 500mg tid
for 7 days - alternative, not as effective.
- intravaginal sulfonamides (Femguard, Sultrin,
Triple Sulfa, etc.) 1 tablet or applicator-full
bid for 7-10 days. Ask about sulfa allergies! Are
not as effective as other therapies.
- AVC cream and suppository - 1 applicator-full or
suppository 1 - 2 times/day for 2 to 4 weeks.
Acts as a vaginal buffer to restore normal pH and
flora.
SYPHILIS (Treponema pallidum)
- Early - primary, secondary or latent <1yr Benzathine Pen 2.4 million units IM
- Latent > 1yr, unknown duration, tertiary -
Benzathine Pen 2.4 million units IM q wk x3
- Neurosyphilis - Aq Pen G 2-4 MU IV Q4h x 10-14
days
- Alternative: Doxycyline 100mg bid 14d early and 4
wks latent > 1yr
Syphilis - Perinatal Treatment
- Procaine PCN G 50K units/Kg IM Qday for 10-14
days
- Aq PCN G 100 - 150K units/Kg/day divided Q12
hours for 7 days then Q 8 hours for 3 - 7 days.
- Allergic: Skin testing and desensitization
- Erythromycin inadequate treatment for the fetus
- Serology should be repeated monthly in pregnancy
- then at 3, 6, 9 and 12 months following Tx
Herpes Simplex Virus (HSV)
- acyclovir 5mg/Kg IV over 60 minutes Q8 hours for
5 days for severe primary outbreak.
- acyclovir (Zovirax), 200 mg PO 5x/day or 400mg
Tid for 7 - 10days for primary infection or 5
days for recurrent infection. Recurrent may also
use 800mg Bid
- Burow's solution, sitz baths, cool compresses -
recurrences.
- Watch for candida or bacterial superinfections
and treat appropriately.
- Suppression - acyclovir (Zovirax), 400mg bid
continuously
Chancroid - (Haemophilus ducreyi)
- Rocephin 250 mg IM, azithromycin 1 Gm PO,
erythromycin 500mg qid for 7 days.
- trimethoprim/sulfamethoxazole D.S. (Bactrum,
Septra) 1 PO bid for 7 days.
- Augmentin 500/125mg PO tid for 7 days.
- ciprofloxicin (Cipro) 500mg PO bid for 3 days.
Granuloma Inguinale - Calymmatobacterium granulomatis
- tetracycline 500 mg qid or Doxycycline 100mg bid
for 3-6 weeks
- erythromycin 500mg qid for 7 days.
- trimethoprim/sulfamethoxazole (Bactrum, Septra) 1
PO bid for 2 - 3 weeks.
- Response should be seen in 7 days.
- Treatment should continue until lesions
completely heal.
- May leave scarring and fibrosis of vulva.
Lymphogranuloma Venereum (LGV)
- Doxycycline 100 mg bid x 21 days
- Erythromycin 500 mg qid x 21 days
- Sulfisoxazole 500 mg qid x 21 days
- Aspirate fluctuant nodes to prevent sinus
formation ( I & D contraindicated)
Pediculosis Pubis
- permethrin (Rid, Nix) cream rinse and wash off in
10 minutes.
Scabies - Sarcoptes scabiei
- permethrin (Rid, Nix) 5% cream to all areas and
wash off in 8-14 hours, or Lindane (Kwell)
- Treat family members and environment.
PID Diagnosis
Uncomplicated Outpatient PID Treatment
- Rocephin 250 mg IM + Doxycycline 100 mg bid
- erythromycin 50mg PO qid x 14 days.
- Re-evaluate in 72 hrs and admit if not improved.
Uncomplicated Inpatient PID Treatment
- Cefotetan 2 gm q 12
- Cefoxitin 2 gm q 6h + Doxycycline 100 mg po q 12
hrs x 14 days.
Complicated (TOA or Complex) PID Treatment
- Clindamycin 900 mg q 8 hr
- Metronidazole 400 mg q 8h + Gentamycin loading +
maintenance
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