Pharmacological Treatment Options for Sexually Transmitted Diseases (Cont.)

Pharmacological Treatment Options for Sexually Transmitted Diseases (cont.) Nicholas Tsourounis, PharmD Candidate 2007

Gonorrhea Syphilis Chlamydia Trichomoniasis

Product Ceftriaxone (Rocephin) Aqueous Crystalline Penecillin G Azithromycin (Zithromax, Z-Max) Metronidazole (Flagyl) Availability (Pfizerpen) Generic (Brand) Cefixime (Suprax) Doxycycline (Vibramycin, Doryx, Tinidazole (Tindamax) Benzathine Penecillin G (Bicillin Adoxa) Ciprofloxacin (Cipro) LA)

Ofloxacin (Floxin) Procaine Penecillin G (Wycillin) Erythromycin Base/Ethylsuccinate (Ery-tab, Romycin, Staticin, Levofloxacin (Levaquin) Ceftriaxone (Rocephin) Theramycin, Erythrocin, EES)

Spectinomycin (Trobicin) Doxycycline (Vibramycin, Doryx, Ofloxacin (Floxin) Adoxa) Levofloxacin (Levaquin) Tetracycline (Sumycin, Wesmycin) Amoxicillin (Amoxil) Azithromycin (Zithromax, Z-Max) Mechanism Ceftriaxone, Cefixime – Inhibits Penecillin, ceftriaxone – Inhibits Azithromycin – see syphilis Metronidazole, tinidazole - interacts of Action bacterial cell wall synthesis by bacterial cell wall synthesis by with DNA to cause a loss of helical binding to one or more of the binding to one or more of the Doxycycline – see syphilis DNA structure and strand breakage penicillin binding proteins and penicillin binding proteins and resulting in inhibition of protein blocking the final transpeptidation blocking the final transpeptidation synthesis and cell death in step of peptidoglycan synthesis, an step of peptidoglycan synthesis, an Erythromycin Base/Ethylsuccinate - susceptible organisms integral step in the production of integral step in the production of Inhibits RNA-dependent protein gram-positive bacterial cell wall gram-positive bacterial cell wall synthesis at the chain elongation synthesis synthesis step; binds to the 50S ribosomal subunit resulting in blockage of Levofloxacin, Ofloxacin, Doxycycline, tetracycline – Inhibits transpeptidation Ciprofloxacin – inhibits DNA gyrase protein synthesis by binding with the (topoisomerase II) in susceptible 30S and possibly the 50S ribosomal Ofloxacin – see gonorrhea organisms, which inhibits DNA subunit(s) of susceptible bacteria relaxation of supercoiled DNA. This Levofloxacin – see gonorrhea blocks replication, transcription, Azithromycin - Inhibits RNA- repair, recombination, and dependent protein synthesis at the Amoxicillin - Inhibits bacterial cell transposition of DNA, and also chain elongation step; binds to the wall synthesis by binding to one or promotes breakage of DNA strands. 50S ribosomal subunit resulting in more of the penicillin binding blockage of transpeptidation proteins and blocking the final Spectinomycin – selectively binds to transpeptidation step of the 30S ribosomal subunit of the peptidoglycan synthesis, an integral bacterial ribosome and inhibits step in the production of gram-

Nicholas Tsourounis, PharmD Candidate 2007 Pharmacotherapy Presentation – Pharmaceutical Care Rotation University of Maryland School of Pharmacy Happy Harry’s Pharmacy Patient Care Center, Perryville, MD bacterial protein synthesis positive bacterial cell wall synthesis EFFICACY Ceftriaxone – Indicated for use in the Aqueous Crystalline Penecillin G - Azithromycin - Indicated in the Metronidazole – Indicated in the treatment of lower respiratory tract Indicated in the treatment of treatment of acute otitis media, treatment of susceptible anaerobic (Indication/Use, infections, acute bacterial otitis bacterial sinusitis, pharyngitis, and protozoal infections in the Clinical Data media, skin and skin structure Benzathine Penecillin G - tonsilitis, upper and lower respiratory following conditions: amebiasis, Support) infections, bone and joint infections, tract infections, infections of the skin trichomoniasis, skin and skin intra-abdominal and urinary tract Procaine Penecillin G - and skin structure, community structure infections, CNS infections, infections, pelvic inflammatory acquired pneumonia, bacterial intra-abdominal infections, systemic disease, uncomplicated gonorrhea, Ceftriaxone - Indicated for use in the exacerbations of COPD, pelvic anaerobic infections, antibiotic- bacterial septicemia, meningitis, and treatment of lower respiratory tract inflammatory disease, and genital associated pseudomembranous surgical prophylaxis infections, acute bacterial otitis ulcer disease, urethritis and cervicitis colitis, bacterial vaginosis, and as media, skin and skin structure due to sexually transmitted diseases. part of multidrug therapy for H Cefixime – Indicated for use in infections, bone and joint infections, pylori infections urinary tract infections, otitis media, intra-abdominal and urinary tract Doxycycline - Indicated in the respiratory infections due to infections, pelvic inflammatory treatment of infections caused by Tinidazole – Indicated in the susceptible organisms, and in disease, uncomplicated gonorrhea, susceptible Rickettsia, Chlamydia, treatment of trichomoniasis, uncomplicated cervical/urethral bacterial septicemia, meningitis, and and Mycoplasma. It is also used for giardiasis, and amebiasis and amebic gonorrhea surgical prophylaxis malaria prophylaxis, syphilis, liver disease. uncomplicated gonorrhea, Ciprofloxacin – Indicated in the Doxycycline - Indicated in the community acquired pneumonia, treatment of urinary tract infections, treatment of infections caused by anthrax,and Clostridium infections in acute uncomplicated cystitis, chronic susceptible Rickettsia, Chlamydia, penecillin allergic patients. It also bacterial prostatitis, lower respiratory and Mycoplasma. It is also used for has activity against Yersina pestis, tract infections, acute intra- malaria prophylaxis, syphilis, Francisella tularensis, Ureaplasma abdominal infections, infectious uncomplicated gonorrhea, urealytium Haemophilus ducreyi, diarrhea, typhoid fever, community acquired pneumonia, Vibrio cholerae , Campylobacter uncomplicated urethral and cervical anthrax,and Clostridium infections in fetus, Listeria, Actinomyces israelii, gonorrhea, nosocomial pneumonia, penecillin allergic patients. It also Brucella sp, Bartonella baciliformis, and as empiric therapy in febrile has activity against Yersina pestis, and Calymmatobacterium neutropenic patients Francisella tularensis, Ureaplasma granulomatus. urealytium Haemophilus ducreyi, Ofloxacin – Indicated in the Vibrio cholerae , Campylobacter Erythromycin Base/Ethylsuccinate – treatment of exacerbations of chronic fetus, Listeria, Actinomyces israelii, Indicated in the treatment of bronchitis, community acquired Brucella sp, Bartonella baciliformis, susceptible bacterial infections pneumonia, skin and skin structure and Calymmatobacterium including S pyogenes, S aureus, M infections, urethral and cervical granulomatus. pneumoniae, Legionella gonorrhea, urethritis and cervicitis, pneumophila,Chlamydia, N pelvic inflammatory disease, cystitis, Tetracycline - Indicated in the gonorrheae, E histolytica, diptheria, urinary tract infections, and treatment of susceptible bacterial syphilis, pertussis, chancroid, prostatitis infections due to gram-positive and nongonococcal urethritis, gram-negative organisms including Campylobacter gastroenteritis, Levofloxacin – Indicated for the Mycoplasma, Chlamydia, and erythrasma, and decontamination of treatment of mild, moderate, and Rickettsia. Also indicated in the the bowel. severe infections caused by treatment of acne, chronic bronchitis,

Nicholas Tsourounis, PharmD Candidate 2007 Pharmacotherapy Presentation – Pharmaceutical Care Rotation University of Maryland School of Pharmacy Happy Harry’s Pharmacy Patient Care Center, Perryville, MD susceptible organismssuch as gonorrhea and syphilis in penicillin- Ofloxacin – Indicated in the community acquired pneumonia, allergic patients, and as part of multi- treatment of exacerbations of chronic nosocomial pneumonia, chronic drug therapy in the treatment of H. bronchitis, community acquired bronchitis, acute pyelonephritis, pylori infections. pneumonia, skin and skin structure prostatitis, skin or skin structure infections, urethral and cervical infections, and the prevention of Azithromycin - Indicated in the gonorrhea, urethritis and cervicitis, anthrax treatment of acute otitis media, pelvic inflammatory disease, cystitis, bacterial sinusitis, pharyngitis, urinary tract infections, and Spectinomycin – Indicated in the tonsilitis, upper and lower respiratory prostatitis treatment of uncomplicated tract infections, infections of the skin gonorrhea and skin structure, community Levofloxacin – Indicated for the acquired pneumonia, bacterial treatment of mild, moderate, and exacerbations of COPD, pelvic severe infections caused by inflammatory disease, and genital susceptible organismssuch as ulcer disease, urethritis and cervicitis community acquired pneumonia, due to sexually transmitted diseases. nosocomial pneumonia, chronic bronchitis, acute pyelonephritis, prostatitis, skin or skin structure infections, and the prevention of anthrax

Amoxicillin – Treatment of acute otitis media, sinusitis, and infections caused by susceptible organisms involving the respiratory tract, skin, and urinary tract. Also used as prophylaxis against bacterial endocarditis and as part of multidrug therapy for H pylori infections. SAFETY Ceftriaxone Penecillin G Azithromycin – see syphilis Metronidazole  Adverse Effects – Rash,  Adverse Effects –  Adverse Effects – flattened (Major Drug diarrhea, Increased BUN convulsions, confusion, Erythromycin - T wave, flushing, ataxia, Interactions, and LFT’s, and pain, drowsiness, fever, rash,  Adverse Effects – confusion, disulfuram like Pre-cautions, warmth, tightness, and hemolytic anemia, ventricular arrythmia, QT reactions, nausea, vomiting, Contra- induration at injection site anaphylaxis prolongation, TDP, diarrhea, metallic taste, dry indications,  Interactions – increases  Interactions – probenecid headache, fever, seizure, mouth, ab pain, furry Adverse Effects, anticoagulation effects of increases penecillin levels, abdominal pain, diarrhea, tongue, darkened urine Pregnancy Risk warfarin, uricosuric agents penecillins increase MTX N/V, ab cramping,  Interactions – cimetidine Category) decrease cephalosporin levels, tetracyclines pseudomembranous colitis increase metronidazole excretion decrease penecillin levels  Interactions – cisapride, levels, may inhibit cisapride  Warnings/Precautions -  Warnings/Precautions – use gatifloxacin, moxifloxacin, metabolism, ethanol give Modify dosage in patients with caution in patients with pimozide, sparfloxacin, disulfuram like reactions, with severe renal impaired renal function, thioridazine may increase increases the effects of impairment. Prolonged use seizure disorder, or history the risk of arrythmia. warfarin, increases levels of

Nicholas Tsourounis, PharmD Candidate 2007 Pharmacotherapy Presentation – Pharmaceutical Care Rotation University of Maryland School of Pharmacy Happy Harry’s Pharmacy Patient Care Center, Perryville, MD may result in superinfection. of hypersensitivity to beta- Increases levels of CYP3A4 3A4 substrates, phenytoin Use with caution in patients lactams substrates. Erythromycin and phenobarbital decrease with a history of penicillin  Contraindications – levels may be increased by metronidazole levels. allergy. May cause hypersensitivity to azoles, ciprofloxacin,  Warnings/Precautions – use antibiotic-associated colitis. penecillins tetracyclines, protease with caution in pre-existing Discontinue in patients with  Pregnancy Category B inhibitors, verapamil, and hepatic disease, seizure signs and symptoms of other 3A4 inhibitors disorders, CHF, severe renal gallbladder disease. Doxycycline  Warnings/Precautions – Use failure, and may be  Contraindications -  Adverse Effects – with precaution in pre- carcinogenic in 1st trimester Hypersensitivity to intracranial hypertension, existing liver disease,  Contraindications – ceftriaxone or other pericarditis, exfoliative exacerbates MG, increases hypersensitivity to cephalosporins; do not use dermatitis, anorexia, likelihood of metronidazole, 1st trimester in hyperbilirubinemic diarrhea, dysphagia, superinfections, can cause of pregnancy neonates enterocolitis, hemolytic cardiac arrythmias  Pregnancy Category B but  Pregnancy Category B anemia, neutropenia,  Contraindications – contraindicated in 1st Cefixime anaphylaxis hypersensitivity to trimester  Adverse Effects -  Interactions – increases erythromycin, pre-existing Abdominal pain, nausea, effects of digoxin, warfarin, hepatic disease, or use with Tinidazole dyspepsia, flatulence, BZD’s, CCB’s, PDE5 ergot alkaloids, pimozide,  Adverse Effects – flattened diarrhea inhibitors, CYP3A4 and cisapride T wave, flushing, ataxia,  Interactions – added substrates, HMGCoA  Pregnancy Category B confusion, disulfuram like nephrotoxicity with inhibitors. Decreased effects reactions, nausea, vomiting, aminoglycosides and when given with antacids, Amoxicillin - diarrhea, metallic taste, dry furosemide, increases serum iron, babriturates,  Adverse Effects - agitation, mouth, ab pain, furry concentrations of carbamazepine, anxiety, insomnia, tongue, darkened urine carbemazepine, increases phenobabrital, and confusion, convulsions,  Interactions – Not evaluated anticoagulation effect of phenytoin behavioral changes, yet for this drug. warfarin  Warnings/Precautions – Do dizziness, Nausea, vomiting, Theoretically the same as  Warnings/Precautions - not use during pregnancy diarrhea, hemorrhagic Metronidazole. Modify dosage in patients due to discoloration of colitis, pseudomembranous  Warnings/Precautions - Use with severe renal bones and teeth, may cause colitis, tooth discoloration, caution with CNS diseases; impairment. Prolonged use photosensitivity rash, exfoliative dermatitis seizures and peripheral may result in superinfection.  Contraindications –  Interactions – allopurinol neuropathy, use with Use with caution in patients hypersensitivity to any increases risk of rash, caution in patients with a with a history of penicillin tetracycline, children <8 otherwise same as penecillin history of blood dyscrasias allergy. May cause y/o, severe hepatic  Warnings/Precautions – or hepatic disease. Not antibiotic-associated colitis. dysfunction, pregnancy altered dose needed with evaluated in children <3  Contraindications -  Pregnancy Category D renal impairment. years old. Hypersensitivity to cefixime  Contraindications –  Contraindications -  Pregnancy category B Tetracycline hypersensitivity to Hypersensitivity to Ciprofloxacin  Adverse Effects – amoxicillin or penecillin tinidazole, nitroimidazole  Adverse Effects – intracranial hypertension,  Pregnancy Category B derivatives, 1st trimester of neurologic events, rash, pericarditis, exfoliative pregnancy, breast feeding fever, N/V, diarrhea, dermatitis, anorexia, Ofloxacin – see gonorrhea  Pregnancy Category C but Nicholas Tsourounis, PharmD Candidate 2007 Pharmacotherapy Presentation – Pharmaceutical Care Rotation University of Maryland School of Pharmacy Happy Harry’s Pharmacy Patient Care Center, Perryville, MD abdominal pain, dyspepsia diarrhea, dysphagia, contraindicated during 1st  Interactions – metal ions enterocolitis, hemolytic Levofloxacin – see gonorrhea trimester bind cipro in GI, inhibits anemia, neutropenia, CYP 1A2, increases effects anaphylaxis of glyburide, decreases  Interactions – increases excretion of MTX, effects of digoxin, warfarin, decreases phenytoin levels, BZD’s, CCB’s, PDE5 increases effects of inhibitors, CYP3A4 warfarin, probenecid substrates, HMGCoA inhibits renal secretion inhibitors. Decreased effects  Warnings/Precautions – Use when given with antacids, with caution in patients with iron, babriturates, known CNS conditions or at carbamazepine, risk of seizures. Discontinue phenobabrital, and at first sign of tendon phenytoin inflammation or pain.  Warnings/Precautions – Do  Contraindications - not use during pregnancy Hypersensitivity to due to discoloration of ciprofloxacin, concurrent bones and teeth, may cause use of tizanidine photosensitivity  Pregnancy Category C  Contraindications – Ofloxacin hypersensitivity to any  Adverse Effects – chest/ab tetracycline, children <8 pain, headache, insomnia, y/o, severe hepatic dizziness, abnormal taste, dysfunction, pregnancy dry mouth., diarrhea, N/V,  Pregnancy Category D flatulence  Interactions - metal ions Azithromycin bind quinolones in GI,  Adverse Effects – diarrhea, inhibits CYP 1A2, increases N/V, abdominal cramping, effects of glyburide, allergic reaction decreases excretion of  Interactions – may increase MTX, decreases phenytoin levels of tacrolimus, levels, increases effects of phenytoin, carbemazepine, warfarin, probenecid cyclosporine, digoxin, ergot inhibits renal secretion alkaloids, and triazolam.  Warnings/Precautions - Use Antacids decrease peak with caution in patients with azithromycin levels known CNS conditions or at  Warnings/Precautions – use risk of seizures. Discontinue with caution in patients with at first sign of tendon hepatic dysfunction, may inflammation or pain. Rare mask or delay symptoms of cases of TDP have been gonorrhea or syphilis, may noted. Severe cause pseudomembranou Nicholas Tsourounis, PharmD Candidate 2007 Pharmacotherapy Presentation – Pharmaceutical Care Rotation University of Maryland School of Pharmacy Happy Harry’s Pharmacy Patient Care Center, Perryville, MD hypersensitivity reactions colitis or QT prolongation have occurred as well.  Contraindications – Quinolones exacerbate hypersensitivity to any Myasthenia Gravis. macrolide, concurrent use of  Contraindications – pimozide hypersensitivity to  Pregnancy Category B fluoroquinolones  Pregnancy category C Ceftriaxone – See Gonorrhea Levofloxacin  Adverse Effects –  Interactions  Warnings/Precautions  Contraindications  Pregnancy Category C

Spectinomycin – Not available anymore in US Gonorrhea Syphilis Chlamydia Trichomoniasis

Dosage &  Ceftriaxone 125mg IM x 1 P/S/early-latent syphilis:  Azithromycin 1g PO x 1  Metronidazole 2g PO x1 Administration  Cefixime 400mg PO x 1  Benzathine Penecillin G  Doxycycline 100mg BID x  Tinidazole 2g PO x1  Ciprofloxacin 500mg PO x1 50,000IU/kg IM (up to 7 days  Metronidazole 500mg PO (Include renal  Ofloxacin 400mg PO x1 2.4million IU)  Erythromycin base 500mg BID x 7 days and/or hepatic  Levofloxacin 250mg PO x1  Ceftriaxone 1g IM or IV PO QID x 7 days adjustments)  Spectinomycin 2g IM x 1 QD x 8-10 days  Erythromycin  All plus treatment for Ethylsuccinate 800mg PO Chlamydia if Chlamydia not If PCN allergy: QID x 7 days ruled out  Doxycycline 100mg BID x  Ofloxacin 400mg BID x 7 14days days  Levofloxacin 500mg PO  Tetracycline 500mg QID x QD x 7 days 14 days If pregnant  Azithromycin 2g PO x 1  Amoxicillin 500mg PO TID x 7 days Late-latent/latent/tertiary syphilis:  Erythomycin base 250mg  Benzathine Penecillin G PO QID x 14 days 50,000IU/kg IM Q week x 3  Erythromycin weeks (up to 2.4 million Ethylsuccinate 400mg PO IU/dose) QID x 14 days Neurosyphilis  Erythromycin base 500mg  Aq crystalline Penecillin G PO QID x 7 days 3-4 million IU Q4h x 10-14  Erythromycin

Nicholas Tsourounis, PharmD Candidate 2007 Pharmacotherapy Presentation – Pharmaceutical Care Rotation University of Maryland School of Pharmacy Happy Harry’s Pharmacy Patient Care Center, Perryville, MD days Ethylsuccinate 800mg PO  Procaine PCN 2.4 million QID x 7 days units IM plus probenecid 500mg PO QID x 10-14 days  Ceftriaxone 2g IM or IV QD x 10-14 days Monitoring Ceftriaxone Penecillin G Azithromycin – see syphilis Metronidazole  Efficiacy - eradication of  Efficiacy - eradication of  Efficiacy – eradication of (Efficacy and infection, resolution of infection, resolution of Doxycycline – see syphilis infection, resolution of Toxicity disease-specific disease-specific disease-specific Parameters) signs/symptoms signs/symptoms Erythromycin Base/Ethylsuccinate – signs/symptoms  Toxicity- anaphylaxis,  Toxicity – anaphylaxis,  Efficacy - eradication of  Toxicity – neuropathy, neuromuscular neuromuscular infection, resolution of weakness, nausea, vomiting, hypersensitivity and hypersensitivity, and disease-specific ataxia, and seizures convulsions electrolyte imbalance signs/symptoms Cefixime  Toxicity - nausea, vomiting, Tinidazole  Efficiacy - eradication of Ceftriaxone – see gonorrhea diarrhea, prostration,  Efficiacy - eradication of infection, resolution of reversible pancreatitis, infection, resolution of disease-specific Doxycycline hearing loss with or without disease-specific signs/symptoms  Efficiacy - eradication of tinnitus or vertigo signs/symptoms  Toxicity – anaphylaxis, infection, resolution of  Toxicity - neuropathy, monitor renal and hepatic disease-specific weakness, nausea, vomiting, function periodically if signs/symptoms Ofloxacin – see gonorrhea ataxia, and seizures prolonged therapy  Toxicity - Renal, hepatic, and hematologic function Levofloxacin – see gonorrhea Ciprofloxacin test, mental status, nausea,  Efficiacy - eradication of anorexia, and diarrhea Amoxicillin infection, resolution of  Efficiacy - eradication of disease-specific Tetracycline infection, resolution of signs/symptoms  Efficiacy - eradication of disease-specific  Toxicity - acute renal failure infection, resolution of signs/symptoms and seizures for short term disease-specific  Toxicity – anaphylaxis, therapy. monitor CBC, renal signs/symptoms neuromuscular and hepatic function during  Toxicity - Renal, hepatic, hypersensitivity, crystaluria, prolonged therapy and hematologic function monitor renal, hepatic, and test, mental status, nausea, hematologic function Ofloxacin anorexia, and diarrhea periodically in prolonged  Efficiacy - eradication of therapy infection, resolution of Azithromycin disease-specific  Efficiacy - eradication of signs/symptoms infection, resolution of  Toxicity - acute renal disease-specific failure, seizures, nausea, signs/symptoms Nicholas Tsourounis, PharmD Candidate 2007 Pharmacotherapy Presentation – Pharmaceutical Care Rotation University of Maryland School of Pharmacy Happy Harry’s Pharmacy Patient Care Center, Perryville, MD and vomiting  Toxicity - Liver function tests, CBC, nausea, Levofloxacin vomiting, diarrhea, and  Efficiacy - eradication of prostration infection, resolution of disease-specific signs/symptoms  Toxicity – check for organ (renal) system failure, crystalluria, and seizures Patient Ceftriaxone, Cefixime - Do not take Penecillin G - This drug can only be Azithromycin – see syphilis Metronidazole, Tinidazole - Take Education any new medication during therapy given by injection or infusion. Report exactly as directed. May take with or unless approved by prescriber. This immediately any redness, swelling, Doxycycline – see syphilis without food. Take with food if medication is administered by burning, or pain at infusion site or medication causes upset stomach. infusion or injection. Report any signs of allergic reaction. Erythromycin Base/Ethylsuccinate - Avoid alcohol during and for 72 immediately any redness, swelling, Maintain adequate hydration. If Do not take any new prescription or hours after last dose. With alcohol burning or pain at injection/infusion being treated for sexually-transmitted OTC medications, or herbal products you may experience severe flushing, site; rash, itching, or hives. Maintain disease, partner will also need to be during therapy without consulting headache, nausea, vomiting, or chest adequate hydration. May cause treated. If you have diabetes, drug prescriber. Take exactly as directed. and abdominal pain. May discolor diarrhe. Report rash; breathing or may cause false test results. May urine. You may experience "metallic" swallowing difficulty; persistent cause confusion or drowsiness. Ofloxacin – see gonorrhea taste disturbance or nausea or diarrhea, nausea, vomiting, or Report persistent adverse effects or vomiting. Refrain from intercourse or abdominal pain; changes in urinary signs of opportunistic infection. Levofloxacin – see gonorrhea use a contraceptive if being treated pattern or pain on urination; for trichomoniasis. Report opportunistic infection, CNS Amoxicillin - Do not take any new unresolved or severe fatigue; changes, or other adverse reactions. Ceftriaxone – see gonorrhea medication during therapy unless weakness; fever or chills; mouth or Breast-feeding precaution: Consult approved by prescriber. Take entire vaginal sores; numbness, tingling, or prescriber if breast-feeding. Doxycycline, tetracycline - Take this prescription, even if you are feeling swelling of extremities; respiratory medication exactly as directed. Take better. Take at equal intervals difficulty; or lack of improvement or Ciprofloxacin, ofloxacin, all of the prescription even if you see around-the-clock. May be taken with worsening of condition. Inform levofloxacin - Do not take any new an improvement in your condition. milk, juice, or food. If you have prescriber if you are pregnant. medication during therapy unless Do not use more or more often than diabetes, drug may cause false test Breast-feeding is not recommended. approved by prescriber. Take as recommended. Preferable to take on results with urine glucose directed; on an empty stomach (1 an empty stomach, 1 hour before or 2 monitoring. May cause nausea or hour before or 2 hours after meals, hours after meals. Take at regularly vomiting. Report rash; unusual dairy products, antacids, or other scheduled times, around-the-clock. diarrhea; vaginal itching, burning, or medication). Complete full course of Avoid antacids, iron, or dairy pain; unresolved vomiting or therapy, even if symptoms resolve. products within 2 hours of taking constipation; fever or chills; Maintain adequate hydration. May tetracycline. You may experience abdominal pain; jaundice; unusual cause dizziness, lightheadedness, or photosensitivity; dizziness or bruising or bleeding; opportunistic headache; nausea, vomiting, or taste lightheadedness; or nausea/vomiting. infection; or if condition being perversion. If inflammation or tendon Report rash or intense itching, treated worsens or does not improve pain occurs discontinue use yellowing of skin or eyes, fever or by the time prescription is immediately and report to prescriber. chills, blackened stool, vaginal completed.

Nicholas Tsourounis, PharmD Candidate 2007 Pharmacotherapy Presentation – Pharmaceutical Care Rotation University of Maryland School of Pharmacy Happy Harry’s Pharmacy Patient Care Center, Perryville, MD If sign of allergic reaction occurs, itching or discharge, foul-smelling discontinue use immediately and stools, excessive thirst or urination, report to prescriber. Report GI acute headache, unresolved diarrhea, disturbances; CNS changes; skin respiratory difficulty, condition does rash; vision changes; respiratory not improve, or worsening of difficulty; signs of opportunistic condition. Do not get pregnant while infection; or worsening of condition. taking this medication. Breast- Pregnancy/breast-feeding feeding is not recommended. precautions: Inform prescriber if you are or intend to become pregnant. Azithromycin - Take as directed. Breast-feeding is not recommended. Take all of prescribed medication and do not discontinue until Spectinomycin – not available in US prescription is completed. Take anymore extended release suspension 1 hour before or 2 hours after meals; immediate release suspension and tablets may be taken with or without food; tablet form may be taken with meals to decrease GI effects. Do not take with antacids that contain aluminum or magnesium. Maintain adequate hydration. If taken to treat a sexually-transmitted disease, follow advice of prescriber related to sexual intercourse and preventing transmission. May cause transient abdominal distress, diarrhea, and headache. Report signs of additional infections. Consult prescriber if breast-feeding. Cost Ceftriaxone 125mg IM x 1 - $19.99 Benzathine Penecillin G 50,000IU/kg Azithromycin 1g PO x 1 - $30 Metronidazole 2g PO x1 - $4.20 (for course of IM (up to 2.4million IU) - $93.01 treatment) Cefixime 400mg PO x 1 - $58.99 Doxycycline 100mg BID x 7 days - Tinidazole 2g PO x1 - $18.40 Ceftriaxone 1g IM or IV QD x 8-10 $22.40 Ciprofloxacin 500mg PO x1 - $2.50 days - $102.18 Metronidazole 500mg PO BID x 7 Erythromycin base 500mg PO QID x days - $14.70 Ofloxacin 400mg PO x1 - $5.86 Doxycycline 100mg BID x 14days - 7 days - $10.36 $44.80 Levofloxacin 250mg PO x1 - $11.43 Erythromycin Ethylsuccinate 800mg Tetracycline 500mg QID x 14 days - PO QID x 7 days - $30.80 Spectinomycin 2g IM x 1 – drug no $16.00 longer available within US as of Ofloxacin 400mg BID x 7 days - 9/25/06 Azithromycin 2g PO x 1 - $60 $82.04

Nicholas Tsourounis, PharmD Candidate 2007 Pharmacotherapy Presentation – Pharmaceutical Care Rotation University of Maryland School of Pharmacy Happy Harry’s Pharmacy Patient Care Center, Perryville, MD Benzathine Penecillin G 50,000IU/kg Levofloxacin 500mg PO QD x 7 IM Q week x 3 weeks (up to 2.4 days - $88.20 million IU/dose) - $279.03 Amoxicillin 500mg PO TID x 7 days Aq crystalline Penecillin G 3-4 - $9.03 million IU Q4h x 10-14 days - $1,927.44 Erythomycin base 250mg PO QID x 14 days – 18.48 Procaine PCN 2.4 million units IM plus probenecid 500mg PO QID x Erythromycin Ethylsuccinate 400mg 10-14 days - $1,134.78 PO QID x 14 days – $30.80

Ceftriaxone 2g IM or IV QD x 10-14 Erythromycin base 500mg PO QID x days - $1,430.52 7 days - $10.36

Erythromycin Ethylsuccinate 800mg PO QID x 7 days - $15.40

References www.ashp.org www.drugstore.com www.drugstore.com www.drugstore.com (Guidelines, www.drugstore.com www.walgreens.com www.walgreens.com www.walgreens.com Drug Info www.walgreens.com www.crlonline.com www.crlonline.com www.crlonline.com Sources) www.crlonline.com

Nicholas Tsourounis, PharmD Candidate 2007 Pharmacotherapy Presentation – Pharmaceutical Care Rotation University of Maryland School of Pharmacy Happy Harry’s Pharmacy Patient Care Center, Perryville, MD