Gonorrhea - Uncomplicated Anogenital Infection (1 of 10)

1 Patient presents w/ signs & symptoms suggestive of genital tract infection

2 ASSESS PATIENT’S RISK FOR LOWER GENITAL TRACT INFECTION

3 CLINICAL ASSESSMENT • Sexual history • Physical exam - Include external, speculum & bimanual exam

EVALUATION Yes Is the lower abdomen tender?

5 DIAGNOSIS Do lab tests conﬁ rm gonorrhea or if not available, are No ALTERNATIVE signs, symptoms & risk assessment DIAGNOSIS consistent w/ an STI-related lower genital tract infection?

Yes

A Patient education B HIV/STI testingMIMS & counseling C Evaluation & treatment of sex partners D Pharmacological therapy* First-line: Ceftriaxone IM + Azithromycin or Doxycycline PO Alternative regimen: Ceﬁ xime PO + Azithromycin or Doxycycline PO

E © Follow-up *According to the 2019 British Association for Sexual Health and HIV (BASHH) national guideline for the management of infection w/ Neisseria gonorrhoeae, when antimicrobial susceptibility is unknown prior to treatment, Ceftriaxone 1 g IM single dose monotherapy is given; if it is known, Ciproﬂ oxacin 500 mg oral single dose is given Not all products are available or approved for above use in all countries. Speciﬁ c prescribing information may be found in the latest MIMS.

B1 © MIMS 2019 GONORRHEA • • • • PelvicBimanual Exam • • • • Exam Speculum Illuminated • • • • • Exam Physical • History • • • • • • • • • • Factors Risk • • • • • Proctitis - Conjunctivitis - Dyspareunia - Vulval itching orburning - bleeding vaginal Abnormal - Urethral discharge - Dysuria - discharge common -most vaginal oraltered Increased - butmay present w/: are females asymptomatic, ofthe infected Most pregnancy orectopic toinfertility leading (PID) disease It that infl infections isoneofthe common bacterial may most transmitted pelvic cause sexually ammatory gonorrhoeae diplococcus Neisseria toGram-negative secondary infection transmitted orvertically isasexually Gonorrhea Detect uterine or adnexal masses, tenderness or cervical motiontenderness orcervical tenderness masses, oradnexal uterine Detect Vaginal stain&Trichomonas forGram swab slide - culture &gonorrhea forChlamydia test swab Cervical - If resources are available, obtainspecimens infections w/cervical which erosions associated may &friability mucopus, be forcervical Observe discharges vaginal Evaluate &endocervical vaginal walls &vaginal Visualize cervix palpated shouldbe lymph nodes Inguinal analintercourse without takeplace can even Colonization - - Perianal inspection discharge infl lesions, cutaneous foranatomical irregularities, inspected genitalia shouldbe External ammation, &urethral &endocervix including the mucocutaneous regions conjunctivae,Examine pharynx ofSTI forsigns Perform general &look assessment factors Inquire risk patient’s regarding possible &identify activities sexual workerCommercial sex use drug Injection workers) sex involvementStreet (youth onthe streets, Inconsistent ofcondom use w/concurrent partner Sex partners currently partner anSTISex has 3months inthe partner last or>1sex New orconcurrent (STI) infection transmitted ofprevious sexually History Unmarried old <25 years women continuetobeatrisk Screening ofpregnantwomenisrecommendedduringthe1stprenatalvisit&3rdtrimesterif All sexuallyactivewomenathighriskareadvisedtoundergoannualscreeningforgonorrhea infection mydial cervicitis Women w/vaginaldischarge&positiveriskassessmentshouldbeoffered treatmentforgonococcal&chla- infection thanthosewhoarerisk-negative Women w/positiveriskassessment(w/≥1factorpresent)haveahigherlikelihoodoflowergenitaltract situations) genital tract infection (the following risk factors should be adjusted for local social, behavioral & epidemiological In somesettings,certaindemographic&behavioralriskfactorshavebeenfrequentlyassociatedw/lower has rectal symptoms rectal has considered ifpatient shouldbe &anoscopy practiced analintercourse exam receptive rectal has Digital or

© Gonorrhea -UncomplicatedAnogenitalInfection(2of10) 3 1 CLINICAL ASSESSMENT 2 SIGNS & SYMPTOMS MIMS RISK ASSESSMENT B2 © MIMS 2019 GONORRHEA • • • • TestsLab • • • • • • • forNgonorrhoeae Exams Lab • • - Vaginal swab if vagina is still present after GRS as directed by patient’s by Vaginal directed as GRS isstillpresent history after &sexual ifvagina symptoms swab - fortransgender women swabs First-pass &neovaginal urine - neovagina segment abowel from formicroscopy smear Gram-stained - considered: For may who have individuals be undergone specimens the (GRS), following genital surgery reconstructive fl direct acid genetic transformation test, immunoassay, enzyme uorescent test, test antibody &serological nucleic Nucleic isnotrecommended: test, lab acid hybridization orprobe ofthe tests Routine use following - &gonorrhea singlesample Chlamydia Utilizes both totest - doneat May exposure the be timeofpresentation <48hours after oreven - when exam patients pelvic useful resist Most - (>95%)&specifi sensitive Most availablec (93.9-100%)test forCtrachomatis &Ngonorrhoeae - Nucleic acidamplifi (NAAT)cation tests ismore reliable specimen forculture menstruation swab during Intracervical - - Should be obtained in all cases diagnosed by NAATs by diagnosed inallcases obtained Should be anantibiotic before isgiven - exposure <48hoursafter ifobtained negative May be - Specifi are 100%&61.8-92.6%,respectively city &sensitivity - tested again after this window period if they have not yet received epidemiological treatment have epidemiological received notyet ifthey period this window after again tested contact partner, ofsexual w/aninfected 2weeks within negative It whotested that isrecommended be patients, doneinpatients shouldbe w/orat ofgonorrhea Ctrachomatis, risk especially STIs, forotherScreening possible - If resources permit, lab tests to screen women w/ vaginal discharge considered women shouldbe w/vaginal toscreen lab tests If resources permit, - Treatment cover will the common organisms most involved incausing the orserious syndrome - signs recognized Syndromic onconsistent management &easily ofsymptoms groups isbased are notavailable STI etiology for determining Syndromic management where personnel equipment approachin healthfacilities care & trained mayused be Diff conditions erential may include other also orgynecological surgical diagnoses - the patientto evaluate forPID A fi motion tenderness should promptnding of lower abdominal tenderness or cervical the attending physician - specimens &rectal forpharyngeal Recommended - Culture smear Urethral than sensitive endocervical isless smear - - - ofgonorrhea presumptive animmediate diagnosis provide to aninitialtest as used discharge be can ofendocervical smears Microscopic examination ofGram-stained - probable indicates intracellular smear gonorrhea Gram-negative diplococci present inanendocervical - Identifi the siteestablishes diagnosis at infected cation ofNgonorrhoeae Specimens that may be used are endocervical swab, urethral discharge or self-obtained vaginal swab swab vaginal urethral discharge swab, orself-obtained are that endocervical Specimens used may be information seeChlamydia-UncomplicatedPlease Anogenital management Infection disease chart forfurther are orchlamydial) the (gonococcal cause genital iflower tractinfections discharge especially islimited ofvaginal managementUsing syndromic incases information) Treat patient Infl seePelvic accordingly (Please management disease chart forfurther Disease ammatory failure evaluation evaluation failure confi antimicrobial &monitoring, allows testing susceptibility Readily identifi rmatory cation, &treatment compared inmales tourethral specimens out inanefficient however, manner; islower discharge ofthe the specimens for vaginal procedure sensitivity discharge attempted may ofvaginal Microscopic where exam be the carried stainmay insettings Gram be nuclearleukocytes diplococcipolymorpho- within Gram-negative monomorphic as ofNgonorrhoeae visualization Permits direct antigen ornucleic confi aciddetection gonorrhea rms through demonstrated culture by orNgonorrhoeae diplococci isolated oxidase-positive Gram-negative, - Recommended specimen is the self- or physician-obtained vulvovaginal swab swab vulvovaginal orphysician-obtained isthe self- specimen Recommended - - Allows testing of susceptibility & identifying resistant strains &identifying ofsusceptibility testing Allows - - Only method used to evaluate effi toevaluate used Onlymethod - ofantibiotic “test treatment, ofcure” eg cacy

© Gonorrhea -UncomplicatedAnogenitalInfection(3of10) 4 5 EVALUATION MIMS DIAGNOSIS B3 © MIMS 2019 GONORRHEA • • • • • • STIs: ofacquiring risk their tolower onhow patients Advise • • • womenarenotavailable toscreen tests wherelab In areas • women toscreen tests forlab allow whereresources In areas Management Syndromic • • • Partner-delivered erapy • • • • • - Gonococcal infection aids in transmission & increases susceptibility to HIV toHIV susceptibility aidsintransmission&increases infection Gonococcal - may complicate Concomitant w/HIV infection management &control STIs ofsome - consent, ofthe procedure are testing part informed well as as counseling, &post-test Pretest - Testing off &should be isrecommended forHIV &treatment evaluation forSTIs seeking toallpersons ered patient’s testing Determine HIV &discuss forHIV risk patient’sSTI todiscuss consultation foranopportunity allows forSTIs &HIV factors risk ofpartners selection number &careful Limited Abstinence, condom use Tailor counseling tothe patient’s specifi factors c risk complications &treated patientsCounsel onpossible tohave ofSTI their &the evaluated partners need medication the about nature course &the informed ofthe ofthe importance oftakingfull infection Patient tobe needs - in the patient higher becomes population ejustification forempiric treatment &chlamydial stronger ofgonorrheal the prevalence as infections becomes - Empiric therapy considered when: shouldbe settings insome eapproach permitted may notbe Partner-delivered therapy include shouldalways treatment forgonorrhea forChlamydia the patient the may onetodeliver be therapy oraprescription totheir inthe ofmedication partners form In situations where concerns that exist ofafemale the partners patient treatment, sex notseek will w/gonorrhea Continue oruntil abstinence regimen the completion asingle-dose x 7days after ofa7-day regimen - have completed the treatment intercourse sexual toabstain from &theirPatients until instructed they partners &their shouldbe partners sex results ontesting treat 14days based whopresent ofexposure, for those after For treatment; patients epidemiological to give itisrecommended whopresent 14days within ofexposure, - gonococcal &chlamydial forboth &treated infection evaluated contact who had sexual All partners w/the patient 60 within shouldbe days ofinfection ofthe diagnosis transmission &reinfection off &shouldbe ofSTI partners patientsSex are infected likely tobe treatmentered STI to prevent further thus ofSTI partners patientsSex the importance notifi asymptomatic, may forpartner be cation &management Treatment issimilartopatients inpatients whoare HIV-negative ofgonococcal infection w/HIV - chlamydial cervicitis discharge off shouldbe &vaginal assessment risk Patients w/positive treatmentered & forgonococcal fortreatmentreturn &Ctrachomatis is high in the patient of Ngonorrhoeae Prevalence & the population patient is unlikely to &treated evaluated If patient’s intercourse >60 sexual shouldbe the partner was latest sexual previous days diagnosis, before Gonorrhea -UncomplicatedAnogenitalInfection(4of10) © C EVALUATION & TREATMENT OF SEX PARTNERS SEX OF & TREATMENT EVALUATION Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing B D HIV/STI TESTING & COUNSELING PHARMACOLOGICAL THERAPY A MIMS PATIENT EDUCATION B4 © MIMS 2019 GONORRHEA • Macrolides • Spectinomycin • • • Cephalosporins • • • • Infection Treatment Ngonorrhoeae forUncomplicated Anogenital • • • • w/Ctrachomatis co-infected often are w/Ngonorrhoeae infected patients because recommended is &Ctrachomatis therapy Ngonorrhoeae for Dual testing results testing ofChlamydia 2ndantimicrobial Preferred irrespective agent inaddition toCeftriaxone - Azithromycin orinpatients whoare pregnant to cephalosporins incombination inpatients analternative ofAzithromycin regimen allergic as w/asingleoraldose used May be orCefi Have noadvantage Ceftriaxone over ofeffi interms xime - orpharmacokinetics cacy Cefpodoxime) or Cefoxitin w/Probenecid Ceftizoxime, (Cefotaxime, cephalosporins Single-dose Alternative agents: - - Cefi xime Eff at allsites infections treatmentective forNgonorrhoeae - - inpregnant patients given except be May also forDoxycycline - - Ceftriaxone - &quinolones tetracyclines penicillins, Many resistant are now gonococcal isolates tosulfonamides, - Antimicrobial therapy patterns shouldconsider ofantimicrobial toNgonorrhoeae local sensitivity toenhance isrecommended therapy compliance single-dose forNgonorrhoeae Directly observed, Information aboutsexualbehavior&recenttravelhistoryareimportanttoensuresuitabilityoftreatmentgiven emergence probably down & will slow ofantimicrobial resistance Treatment w/the eff most transmission,prevent complications, agents reduce infection gonorrhea ective will information seeChlamydia-UncomplicatedPlease Anogenital management Infection disease chart forfurther are notavailable, infections forboth tools patients treated If the diagnostic proper shouldbe &expense exposure A specifi mayc diagnosis enhance notifi partner cation, improve compliance antibiotic w/treatment, &decrease the cost oftherapy because forchlamydial than isless theof gonococcal infections cost infection oftesting cost-effRoutine dual therapy be can in which for populations chlamydial accompaniesective infection 10-30% - - - foratest-of-cure toreturn 1week at Patient after the advised siteofinfection shouldbe - to IMinjection contraindications is notavailable analternative orhas agent orifpatient as given May refused ifCeftriaxone be eff limited showed Also gonorrhea intreating pharyngeal ectiveness - - resistance gonorrhoeae concentrations minimum inhibitory increased that thatevidences showed may emergence predict ofN Currently a1st-line as notrecommended treatment optionforpatients dueto w/gonococcal infections in the blood levels bactericidal high&maintained Studies provides that have of250-mgdose shown singleIMinjection inpatients allergic isused toorintolerant Doxycycline ofAzithromycin - or7-day ofAzithromycin ofDoxycycline regimen dose the eff most as Considered treatment incombination ective foruncomplicated w/asingleoral gonorrhea, - gonorrhea resistance dataIf local are unavailable, dualtherapy singletherapy over issuggested fortreatment ofgenital to be susceptible susceptible to be consideredMay inpregnant women be onlyifother are alternatives unavailable drug &ifisolate isdetermined treatmentgonorrhea gonococcal resistance duetoincreasing isnotrecommended however, tocephalosporins; allergy monotherapy tohave severe for known anoptioninpersons May be prevalence ofgonococcal resistanceprevalence convenience duetoits compliance than Doxycycline therapy,Better &increased ofsingle-dose &lower compared ofCeftriaxone tosingleIMdose as levels &highbactericidal sustained notprovide Studies that does have shown 400-mgsingleoraldose 1st-line agents therapy duetothe recommended Dual isalso emerging &the resistance lack ofalternative tocephalosporins

© Gonorrhea -UncomplicatedAnogenitalInfection(5of10) D Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing MIMS PHARMACOLOGICAL THERAPY (CONT’D) B5 © MIMS 2019 GONORRHEA • • TreatmentOther Regimens • • • • • Quinolones • • • • • • • • Solithromycin, Zolifl Delafl Gepotidacin, odacin, oxacin, Sitafl oxacin &Avarofl oxacin Other therapeutic agents currently investigated for gonorrhea treatmentbeing include Ertapenem, Adverse eff are mostly gastrointestinal ects - allergic orresistance) (eg reaction given severe be cannot considered May an option when be Ceftriaxone - highrates ofeffhave shown intreating genital gonorrhea ectivity Injectable Gentamicin ororalGamifl antibiotic which regimens oxacin are combined w/oralAzithromycin new anaphylaxis orpenicillin allergy losporin alternative agents as given may inpatients excluded, these be When w/ cepha- quinolone been resistance has totreatment prior quinolone-sensitive as isknown ifaninfection given May be - where ofresistance prevalence is<5% inareas used May be activeaccordingmost resistance patterns tolocal onlythe touse ere &itisnecessary inthe quinolones are anti-gonococcal variations ofindividual activity Quinolone-resistant No longer treatment forgonorrhea recommended resistance rate duetoincreasing inmany areas Test-of-cure completion after done1week oftreatment shouldbe - antimicrobial w/ unknown susceptibility the treatment after orsymptoms w/persistent patients tothose w/alternative signs &those regimens treated priority authorities haveSome that recommended doneinallpatients giving ofcure shouldbe w/gonococcalinfection test notifipartner cation totreatment, reaction adverse ortreatment ofre-infection, resistance, &drug on &check failure possibility toconfiHelpful compliancerm inquire ofpatient about w/the treatment, ensureofsymptoms, resolution Typically treatment from toretreatment prior failure distinguished are which duetoreinfection shouldbe - identifiInfections treatment after ed - - treatmentgonorrhea include failure the following: forprobable criteria inNgonorrhoeae, cephalosporins tothe emergingDue resistance toextended-spectrum management forfurther specialist disease toaninfectious referred & be &Azithromycin Patients w/Ceftriaxone whohadtreatment treated shouldbe w/alternative failure regimens dual therapy, w/adualtherapy re-treat ofhigher dose singletherapy,If treatment after happened failure iftreatment after w/dualtherapy; happened re-treat failure w/the treatment recommended accordingfailed &re-treat regimen results tosusceptibility doneinpatientsshould be whohave ofNgonorrhoeae testing &susceptibility Culture specimens ofrelevant ishigh infection 3months therapy forgonococcal the after ifrisk retested &during 3rdPregnant women trimester shouldbe patient forimproved partners &referral ere ofsex education aneed may be - - Ideally performed w/culture or, performed Ideally ifnotavailable, w/NAAT treatment) after forNgonorrhoeae (2weeks - - - ≥0.125mcg/mLorCefiMIC ≥0.25mcg/mL MIC xime Pre- or post-treatment antimicrobial of testing susceptibility treatment treatment)≥7 days following after & activity sexual &without (culture treatment ≥72hoursafter orNAAT forNgonorrhoeae positive positive subsequently tested positive Patient w/laboratory-confi & regimen w/cephalosporin-based &treated infection Ngonorrhoeae rmed - patients inasymptomatic after or2weeks &symptoms persistent signs done72 Others have ofcure tobe test recommended completionhours after oftherapy inpatients w/ reinforced istreated &partner abstinence sexual patients w/the regimen, recommended orcondom are re-treated is Reinfected use antimicrobial susceptibility testing should be performed performed antimicrobial shouldbe testing susceptibility Confi doneifNAAT’s culture shouldbe rmatory phenotypic ifculture ispositive, ispositive; result

© Gonorrhea -UncomplicatedAnogenitalInfection(6of10) (QRNG) is common in parts of Europe, US, Middle East, Asia &the Pacifi Asia MiddleEast, ofEurope, iscommon US, inparts (QRNG) N gonorrhoeae c Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not D Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing PHARMACOLOGICAL THERAPY (CONT’D) E MIMS FOLLOW-UP B6 isolates showed Ceftriaxone Ceftriaxone showed isolates N gonorrhoeae © MIMS 2019 GONORRHEA aayi 1-2g/day IM Kanamycin 5mg/kg Gentamicin (TM)] Trimethoprim & (SMZ) [Sulfamethoxazole Co-trimoxazole All dosage recommendations are for non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults non-elderly for are recommendations dosage All Drug Drug Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed Gonorrhea -UncomplicatedAnogenitalInfection(7of10) ≥14 days 12 hrly for TM PO SMZ/80 mg 400 mg treatment: Long-term 2 days 12 hrly for TM PO SMZ/160 mg 800 mg © 12-24 hrly divided 24 hrly IM wt body Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Dosage Dosage Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing ANTIBACTERIAL COMBINATIONS • • • Instruction Special • Reactions Adverse • • Instructions Special • Reactions Adverse • • Instructions Special • Reactions Adverse Dosage Guidelines AMINOGLYCOSIDES dysfunction & those w/folate &those defidysfunction ciency Use w/caution inpatients w/renal impairment hepatic orsevere defi ciency anemia duetofolicacid megaloblastic disorders especially Use w/ extreme caution ornotat allinpatients w/hematological inpatientsContraindicated allergic tosulfonamides syndrome) (Stevens-Johnson reactions Hypersensitivity photosensitivity); pruritus, GI eff (N/V,ects eff Dermatological diarrhea); anorexia, (rash, ects MIMS hypocalcemia orcochlear impairment, or vestibular renal dysfunction, preexisting Parkinson’s), (eg myastheniaweakness gravis, patients w/ w/muscleUse w/caution inpatients w/conditions associated isrecommended trough levels therefore, concentrations & serum monitoring peak measuring by the ofnephrotoxicity &ototoxicity; risk increase levels High plasma reactions instability);gait Hypersensitivity Neuromuscular effadministered); (neuromuscular paralysis, ects renal when have failure other been nephrotoxic drugs vertigo); Renal effdizziness, nephrotoxicity, (reversible ects acute effOtotoxic loss, ototoxicity inhearing resulting (irreversible ects hypocalcemia orcochlear impairment, or vestibular renal dysfunction, preexisting Parkinson’s), (eg myastheniaweakness gravis, patients w/ w/muscleUse w/caution inpatients w/conditions associated renal impairment inpatients w/ function &auditory/vestibular levels Monitor serum ofappetite) loss Other effagranulocytosis); (N/V,ects disturbances, visual dyspnea, Hematologic eff transient leukopenia, (anemia, ects Mg &Klevels); Ca, reduced bilirubin, &serum phosphatases eff Metabolic reactions; alkaline transaminases, (elevated ects Hypersensitivity confusion); headache, cramps, convulsions, tics, eff eff CNS creatinine, oliguria); serum (elevated ects (muscular ects effOtotoxic tinnitus); Renal dizziness, (impaired hearing, ects B7 Remarks Remarks © MIMS 2019 GONORRHEA 1 Please see dosage recommendations see under &Tetracycline Macrolide Please dosage guidelinetables. sulbactam Cefoperazone/ asingledose 250-500mgIMas Inhibitor w/β-Lactamase Cephalosporin asingledose 1gIMas asingledose as 200mgPO asingledose 500mg-1 gIMas Ceftriaxone Ceftizoxime asingledose 500mgIMas Cefpodoxime Cefotaxime Cefoperazone Cefi xime Generation ird Cefuroxime Cefoxitin Generation Second (Cephalexin) Cefalexin First Generation Azithromycin All dosage recommendations are for non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults non-elderly for are recommendations dosage All Drug Drug Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed Gonorrhea -UncomplicatedAnogenitalInfection(8of10) 4g/day ofsulbactam dose: Max 12 hrly (1:1) ratio 2-4 g/day divided or1.5-3g/day IV/IM orDoxycycline Azithromycin Plus Azithromycin orDoxycycline Azithromycin Plus asingledose as 400 mgPO 1gPO w/Probenecid asingledose 1.5 gIMas or asingledose as 1 gPO asingledose as 1gPO Probenecid Plus asingledose 2 gIMas 6hrly 250-500 mgPO © asingledose as 2 gPO allergy: cephalosporin For w/severe patients asingledose as 1 gPO w/cephalosporin: If given Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Dosage Dosage Guidelines Dosage CEPHALOSPORINS MACROLIDES

MIMS1 1 B8 • • Instructions Special • • Reactions Adverse & severe renal impairment& severe Use w/caution inpatients w/hepatic dysfunction distress gastric todecrease May takew/food macrolides w/ some occurred has loss tinnitus/hearing Dose-related Rarely conduction, cardiac altered hepatotoxicity; rarely rash, anaphylaxis); pruritus, (urticaria, are reactions uncommon Hypersensitivity infections) diarrhea/colitis); Other eff (candidalect & other antibiotic-associated GIdisturbances, GI eff (N/V,ects diarrhea discomfort, abdominal • • • Instructions Special • • • Reactions Adverse impairment or GI disease (eg colitis)impairment orGIdisease Use w/caution inpatients w/ renal chance sensitivity ofcross to Penicillin, there 10% may be Use w/caution inpatients allergic gastric distress May betakenw/foodtodecrease cephalosporins sidechain-containingNMTT frequently &occur most w/ reported have been bleeding) without hypoprothrombinemia (w/or &/or time(aPTT), thromboplastin partial activated prolonged prothrombinProlonged time(PT), hepatic &renaleffects haveoccurred convulsions); Rarely hematologic, effCNS (encephalopathy,ects w/ associated may be High doses (candidal infections) Other effvertigo, fatigue); ect effcolitis); CNS (headache, ects diarrhea/ antibiotic-associated eff N/V, (diarrhea, ects rarely GI anaphylaxis); eg reactions severe rash, pruritus, (urticaria, reactions Hypersensitivity Remarks Remarks © MIMS 2019 GONORRHEA tazobactam tazobactam Piperacillin/ Inhibitor Penicillin w/β-Lactamase Antipseudomonal Erythromycin sulbactam) Ampicillin/ of Pro-drug (Sultamicillin: sulbactam Ampicillin/ Ampicillin Co-amoxiclav) clavulanate, (Amoxicillin/ clavulanic acid Amoxicillin/ (Amoxycillin) Amoxicillin Inhibitors β-Lactamase w/ orwithout Aminopenicillins benzylpenicillin Na/procaine Benzylpenicillin All dosage recommendations are for non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults non-elderly for are recommendations dosage All Drug Drug Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed Gonorrhea -UncomplicatedAnogenitalInfection(9of10) PO 30 min prior toinj 30minprior PO 1g Probenecid given May be asingledose 2 gIMas 250-500 mg PO 6hrly 250-500 mgPO stearate: Erythromycin 6hrly6 hrly or1-2g/day IV divided 25-50 mg/kg/day IV : lactobionate Erythromycin 6hrly 400-800 mgPO : ethylsuccinate Erythromycin 6hrly 250-500 mgPO estolate: Erythromycin © 1gPO Probenecid plus singledose as 1.5 gIM/IV or singledose as 2.25 gPO 1-2hr over doses or 2equal 24hrly in1 infusion 2-4 gIV hrly or 8-12 IM/IV 500 mg2doses 4-6hrly or 500 mgIM/IV 8hrly 375-625 mgPO 12hrly divided or asingledose as 3 gPO singledose 1.2-2.4 MIUIMas Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Dosage Dosage MACROLIDES (CONT’D) Dosage Guidelines MIMSPENICILLINS B9 • • • Instructions Special • Reactions Adverse • • Instructions Special • • Reactions Adverse component ofthe formulation orany any macrolideErythromycin, antibiotics, Avoid to inpatients w/hypersensitivity impairment, myasthenia gravis Use w/caution inpatients w/hepatic distress gastric todecrease May take w/food abnormal LFTs) loss, hearing ventricular arrhythmia, weakness, phlebitis, eff inj site anaphylaxis, urticaria, (seizure, ects GI eff (N/V,ects Other pain,diarrhea); abdominal Use w/ caution inpatients w/renal impairment Avoid inpatients w/Penicillin allergy effCNS (encephalopathy,ects convulsions) w/ associated may be highdoses have occurred; Rarely hematologic eff renal &hepatic effects; ects eff (candidalect infections) diarrhea/colitis); Other antibiotic-associated occur); GIeff N/V, (diarrhea, ects rarely can anaphylaxis eg reactions severe pruritus, urticaria, (rash, reactions Hypersensitivity Remarks Remarks © MIMS 2019 GONORRHEA Spectinomycin acid Pipemidic Ofl oxacin Norfl oxacin Levofl oxacin Ciprofl oxacin Tetracycline Minocycline Doxycycline rgDosage Drug All dosage recommendations are for non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults non-elderly for are recommendations dosage All rgDosage Drug rgDosage Drug 6-12 hrly 250-500 mgPO 4days least 12 hrly for at 100 mgPO then PO Initially 200mg 12 hrly x 7 days 100 mgPO cephalosporin: w/ Given Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products 12 hrly 400 mgPO 7 days 24 hrly for 400 mgPO single dose a as 800 mgPO 12-24 hrly 250-500 mgPO as a single dose asingledose as 250-500 mgPO 4 g dose: Max single dose a 2 gIMas placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed © Gonorrhea -UncomplicatedAnogenitalInfection(10of10) Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Please see the end of this section for the reference list. reference the for section this of end the see Please • Instruction Special • • Reactions Adverse • • • • Instructions Special • • Reactions Adverse patients being treated for gonorrhea w/Spectinomycin patients forgonorrhea treated being toall at &3mth the isadvised diagnosis timeofgonorrhea after syphilis for test Serologic ordelayMay ofincubating mask symptoms syphilis. doses w/ repeated Hematologic eff seen occasionally &liver functions alterations inkidney ects, rarely anaphylaxis) (urticaria, reactions chills); Hypersensitivity GI eff eff CNS (nausea); ect & fever insomnia, headache, (dizziness, ects • • • Instructions Special • • • Reactions Adverse Use w/ caution inpatients w/renal or hepatic impairment Avoid inpregnant women &inpatients w/SLE Take w/plenty offluids whilesitting tobed orstanding&well retiring before Avoid tosunlight ortanningbeds longexposure havereactions occurred intracranial Hypersensitivity disturbances; pressure &visual w/headache hepatotoxicity,Rarely renal dysfunction, hematologic eff increased ects, women) infants/pregnant discoloration interference inyoung ofteeth, growth w/bone infections, effliquid); Dermatologic Other eff (photosensitivity); ect (candidal ects ulceration esophageal when taken w/aninsuffidysphagia, cient amount of GI eff (N/V, ects diarrhea/colitis, antibiotic-associated diarrhea, w/ impaired renal or hepatic function & in those w/G6PDdefiw/ impaired &inthose renal orhepatic function ciency inpatients disorders, ofCNS orhistory Use w/caution inpatients w/epilepsy Avoid tostrong sunlight exposure ortanningbeds preparationsDidanosine orFe supplements containing orbuff Zn dietary antacids, ered Al-orMg-containing or3hrafter 2hrbefore Administer at least have quinolones Some the potential toprolong the QT interval Rarely hematologic eff hepatic & renal effects; ects syndrome) (eg Stevens-Johnson mild (eg tosevere/life-threatening rash) range from can reactions Hypersensitivity photosensitivity); pruritus, eff Dermatologic drowsiness); restlessness, disorders, sleep (rash, ects eff diarrhea/colitis); CNS antibiotic-associated dizziness, (headache, ects GI eff rarely diarrhea, (N/V,ects pain,dyspepsia, abdominal diarrhea, Dosage Guidelines OTHER ANTIBIOTIC TETRACYCLINES QUINOLONES