Empiric Therapy
Syndromic Management
In areas where resources allow for lab tests to screen women
- Empiric therapy should be considered when:
- Prevalence of C trachomatis is high in the patient population & the patient is unlikely to return for treatment
In areas where lab tests to screen women are not available
- The justification for empiric treatment becomes stronger as the prevalence of chlamydial infections in the patient population becomes higher
- Patients w/ positive risk assessment & vaginal discharge should be offered treatment for chlamydial cervicitis
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Antibiotic Therapy
General Antibiotic Principles for C trachomatis Infections
- For improved compliance, single-agent treatment for C trachomatis is recommended
- In patients presenting w/ buboes, the decision to treat for LGV, granuloma inguinale & chancroid depends on the local prevalence of these diseases
Preferred Agents
- Azithromycin & Doxycycline are equally successful in treating genital Chlamydia infection w/ cure rates of 97% & 98% respectively
1. Macrolides
1.1 Azithromycin
- Recommended agent for anogenital chlamydial infection
- Preferred treatment if noncompliance is suspected since it is given as a single dose
- Recommended agent for pregnant patients w/ genital Chlamydia infection
- GI effects (N/V, abdominal discomfort, diarrhea & other GI disturbances, antibiotic-associated diarrhea/colitis); Other effect (candidal infections)
- Hypersensitivity reactions are uncommon (urticaria, pruritus, rash, rarely anaphylaxis); Rarely altered cardiac conduction, hepatotoxicity; Dose-related tinnitus/hearing loss have occurred w/ some macrolides
- Azithromycin & Clarithromycin tend to cause less GI disturbance than Erythromycin
- May take w/ food to decrease gastric distress
- Use w/ caution in patients w/ hepatic dysfunction & severe renal impairment
1.2 Clarithromycin
- GI effects (N/V, abdominal discomfort, diarrhea & other GI disturbances, antibiotic-associated diarrhea/colitis); Other effect (candidal infections)
- Hypersensitivity reactions are uncommon (urticaria, pruritus, rash, rarely anaphylaxis); Rarely altered cardiac conduction, hepatotoxicity; Dose-related tinnitus/hearing loss have occurred w/ some macrolides
- Azithromycin & Clarithromycin tend to cause less GI disturbance than Erythromycin
- May take w/ food to decrease gastric distress
- Use w/ caution in patients w/ hepatic dysfunction & severe renal impairment
- 250-500 mg PO 12 hrly x 7-14 days
2. Tetracyclines
2.1 Doxycycline
- Recommended agent for both anogenital infection & LGV
- Preferred 1st-line treatment for non-pregnant LGV-positive patients
- Long history of extensive successful use in the treatment of C trachomatis, but must be given x 7 days
- Patients allergic to Doxycycline may be given Azithromycin or Erythromycin
- GI effects (N/V, diarrhea, antibiotic-associated diarrhea/colitis, dysphagia, esophageal ulceration when taken w/ an insufficient amount of liqd); Dermatologic effect (photosensitivity); Misc effects (candidal infections, discoloration of teeth, interference w/ bone growth in young infants/pregnant women)
- Rarely renal dysfunction, hepatotoxicity, hematologic effects, increased intracranial pressure w/ headache & visual disturbances; Hypersensitivity reactions have occurred
- Avoid long exposure to sunlight or tanning beds
- Take w/ plenty of fluids while sitting or standing & well before retiring to bed
- Avoid in children ≤8 yr, pregnant women & in patients w/ SLE
- Use w/ caution in patients w/ renal or hepatic impairment
- 100 mg PO 12 hrly or 200 mg PO as a single dose on day 1 then 100 mg PO 24 hrly thereafter
- For LGV: 100 mg PO 12 hrly x 21 days
2.2 Minocycline
- GI effects (N/V, diarrhea, antibiotic-associated diarrhea/colitis, dysphagia, esophageal ulceration when taken w/ an insufficient amount of liqd); Dermatologic effect (photosensitivity); Misc effects (candidal infections, discoloration of teeth, interference w/ bone growth in young infants/pregnant women)
- Rarely renal dysfunction, hepatotoxicity, hematologic effects, increased intracranial pressure w/ headache & visual disturbances; Hypersensitivity reactions have occurred
- Avoid long exposure to sunlight or tanning beds
- Take w/ plenty of fluids while sitting or standing & well before retiring to bed
- Avoid in children ≤8 yr, pregnant women & in patients w/ SLE
- Use w/ caution in patients w/ renal or hepatic impairment
- 100 mg PO 12 hrly x 7 days
2.3 Tetracycline
- GI effects (N/V, diarrhea, antibiotic-associated diarrhea/colitis, dysphagia, esophageal ulceration when taken w/ an insufficient amount of liqd); Dermatologic effect (photosensitivity); Misc effects (candidal infections, discoloration of teeth, interference w/ bone growth in young infants/pregnant women)
- Rarely renal dysfunction, hepatotoxicity, hematologic effects, increased intracranial pressure w/ headache & visual disturbances; Hypersensitivity reactions have occurred
- Avoid long exposure to sunlight or tanning beds
- Take w/ plenty of fluids while sitting or standing & well before retiring to bed
- Avoid in children ≤8 yr, pregnant women & in patients w/ SLE
- Use w/ caution in patients w/ renal or hepatic impairment
- 500 mg PO 6 hrly x 7 days
Alternative Agents
3. Penicillins
3.1 Amoxicillin
- Alternative agent for anogenital infection
- Recommended agent for pregnant women
- May cause latency & re-emergence of infection rather than eradication as shown by in vitro studies
- Hypersensitivity reactions (rash, urticaria, pruritus, severe reactions eg anaphylaxis); GI effects (diarrhea, N/V, rarely antibiotic-associated diarrhea/colitis); Other effect (candidal infections)
- Rarely hematologic effect; Renal & hepatic effects have occurred; High doses may be associated w/ CNS effects (encephalopathy, convulsions)
- Avoid in patients w/ Penicillin allergy
- Use w/ caution in patients w/ renal impairment
- 500 mg PO 8 hrly x 7 days
3.2 Ampicillin
- Hypersensitivity reactions (rash, urticaria, pruritus, severe reactions eg anaphylaxis); GI effects (diarrhea, N/V, rarely antibiotic-associated diarrhea/colitis); Other effect (candidal infections)
- Rarely hematologic effect; Renal & hepatic effects have occurred; High doses may be associated w/ CNS effects (encephalopathy, convulsions)
- Avoid in patients w/ Penicillin allergy
- Use w/ caution in patients w/ renal impairment
- 250 mg-1 g PO 6 hrly
- Max dose: 4 g daily
4. Macrolide
- Alternative agent for anogenital infection & LGV
- Less efficacious than Azithromycin or Doxycycline primarily due to GI side effects that lessen patient’s compliance
- Alternative regimen for pregnant women except for the estolate salt which may cause drug-related hepatotoxicity
- GI effects (N/V, abdominal discomfort, diarrhea & other GI disturbances, antibiotic-associated diarrhea/colitis); Other effect (candidal infections)
- Hypersensitivity reactions are uncommon (urticaria, pruritus, rash, rarely anaphylaxis); Rarely altered cardiac conduction, hepatotoxicity; Dose-related tinnitus/hearing loss have occurred w/ some macrolides
- Azithromycin & Clarithromycin tend to cause less GI disturbance than Erythromycin
- May take w/ food to decrease gastric distress
- Use w/ caution in patients w/ hepatic dysfunction & severe renal impairment
4.1 Erythromycin base
- 500 mg PO 6 hrly x 7 days or
- 500 mg PO 12 hrly x 10-14 days or
- 250 mg PO 6 hrly x 14 days
- For LGV: 500 mg PO 6 hrly x 21 days
4.2 Erythromycin ethylsuccinate
- 800 mg PO 6 hrly x 7 days or
- 400 mg PO 6 hrly x 14 days
5. Quinolones
5.1 Levofloxacin
- Effective alternative treatment for anogenital infection
- Adverse Reactions:
- GI effects (N/V, diarrhea, abdominal pain, dyspepsia, rarely antibiotic-associated diarrhea/colitis); CNS effects (headache, dizziness, sleep disorders, restlessness, drowsiness); Dermatologic effects (rash, pruritus, photosensitivity); Hypersensitivity reactions can range from mild (eg rash) to severe life-threatening (eg Stevens-Johnson syndrome)
- Rarely hematologic, hepatic & renal effects; Tendon inflammation &/or rupture occurs rarely
- Some quinolones have the potential to prolong the QT interval
- Administer at least 2 hr before or 3 hr after AI- or Mg-containing antacids, dietary supplements containing Zn or Fe or buffered ddl preparations
- Avoid exposure to strong sunlight or tanning beds
- Use w/ caution in patients w/ epilepsy or history of CNS disorders, in patients w/ impaired renal or hepatic function & in those w/ G6PD deficiency
- 500 mg PO 24 hrly x 7 days
5.2 Ofloxacin
- Alternative agent for anogenital infection w/ similar efficacy to Azithromycin & Doxycycline
- GI effects (N/V, diarrhea, abdominal pain, dyspepsia, rarely antibiotic-associated diarrhea/colitis); CNS effects (headache, dizziness, sleep disorders, restlessness, drowsiness); Dermatologic effects (rash, pruritus, photosensitivity); Hypersensitivity reactions can range from mild (eg rash) to severe life-threatening (eg Stevens-Johnson syndrome)
- Rarely hematologic, hepatic & renal effects; Tendon inflammation &/or rupture occurs rarely
- Some quinolones have the potential to prolong the QT interval
- Administer at least 2 hr before or 3 hr after AI- or Mg-containing antacids, dietary supplements containing Zn or Fe or buffered ddl preparations
- Avoid exposure to strong sunlight or tanning beds
- Use w/ caution in patients w/ epilepsy or history of CNS disorders, in patients w/ impaired renal or hepatic function & in those w/ G6PD deficiency
- 200-300 mg PO 12 hrly x 7 days or
- 400 mg PO 24 hrly x 7 days
5.3 Sitafloxacin hydrate
- GI effects (N/V, diarrhea, abdominal pain, dyspepsia, rarely antibiotic-associated diarrhea/colitis); CNS effects (headache, dizziness, sleep disorders, restlessness, drowsiness); Dermatologic effects (rash, pruritus, photosensitivity); Hypersensitivity reactions can range from mild (eg rash) to severe life-threatening (eg Stevens-Johnson syndrome)
- Rarely hematologic, hepatic & renal effects; Tendon inflammation &/or rupture occurs rarely
- Some quinolones have the potential to prolong the QT interval
- Administer at least 2 hr before or 3 hr after AI- or Mg-containing antacids, dietary supplements containing Zn or Fe or buffered ddl preparations
- Avoid exposure to strong sunlight or tanning beds
- Use w/ caution in patients w/ epilepsy or history of CNS disorders, in patients w/ impaired renal or hepatic function & in those w/ G6PD deficiency
- 50 mg PO 12 hrly x 7 days
6. OTHER ANTIBIOTICS
Clindamycin
- GI effects (diarrhea, severe antibiotic-related pseudomembranous colitis, N/V, abdominal pain, metallic taste); Hypersensitivity reactions (rash, urticaria, rarely anaphylaxis)
- Severe dermatologic effects have occurred (erythema multiforme, exfoliative & vesiculobullous dermatitis); Hematologic & hepatic effects have occurred; Other effects (polyarthritis, renal dysfunction, thrombophlebitis)
- Use w/ caution in patients w/ GI disease esp w/ history of colitis
- Use w/ caution in atopic patients & in patients w/ renal or hepatic impairment; monitor liver function w/ prolonged treatment
- Discontinue if diarrhea occurs
- 450-600 mg PO 6 hrly x 10-14 days
All dosage recommendations are for non-elderly adults w/ normal renal & hepatic function unless otherwise stated.
Not all products are available or approved for above use in all countries.
Products listed above may not be mentioned in the disease management chart but have been placed here based on indications listed in regional manufacturers’ product information.
Click the link below for specific prescribing information of products available in respective countries.
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