Treatment of GU infections

Question 1

What organism should be targeted in cystitis?

Answer 1

E. coli, with hopes of covering other gram negatives, and S. saprophyticus

Question 2

What are the first line treatments which need 3, 5, and 7 days of therapy?

Answer 2

3 days: TMP / SMX, and FQ (Levofloxacin and Ciprofloxacin only)

5 days: Nitrofurantoin

7 days: Beta-lactams - i.e. Cephalexin

Question 3

How long is an antibiotics course for S. saprophyticus?

Answer 3

7 days

Question 4

What is the mechanism of action of Fosfomycin?

Answer 4

Inhibits (fosfo)enolpyruvate transferase which inhibits cell wall synthesis

Question 5

What is the practical clinical use of fosfomycin?

Answer 5

Given for cystitis / lower UTI infections with drug-resistant isolates, which is safe to use in pregnancy

Question 6

What are the first line treatments for community-acquired pyelonephritis, given orally? Duration of therapy?

Answer 6

FQ (i.e. Cipro)
TMP/SMX
3rd generation Cephalosporin

Generally 7-14 days of therapy is fine, leaning towards 7

Question 7

What two drugs used to treat lower UTIs cannot be used in pyelonephritis and why?

Answer 7

Nitrofurantoin / fosfomycin -> do not reach sufficient levels in the kidney tubules

Question 8

What are the first line drugs for pyelonephritis UTI’s when hospitalization occurs?

Answer 8

IV drugs:
Fluoroquinolones, aminoglycosides, 3rd generation cephalosporins, carbapenems (not empirically)

transition to oral therapy to complete course

Question 9

What is the most common way to get a healthcare associated UTI and what organism must you cover?

Answer 9

From a Foley Catheter

Must cover P. aeruginosa

Question 10

What are the drugs of choice for healthcare associated UTI?

Answer 10

Cefepime or ceftazidime
Zosyn
Cipro / Levo
Carbapenems minus ertapenem
Aminoglycosides

Question 11

What two conditions absolutely need the treatment of asymptomatic bacteriuria?

Answer 11

1. Pregnancy
2. Urinary tract surgery / instrumentation

Neonates / renal transplant are less clear

Question 12

How do you treat candiduria?

Answer 12

You don’t. Just discontinue Foley catheter and discontinue unnecessary antibiotics

Question 13

What organism causes chancroid and how is it treated?

Answer 13

Azithromycin 1 g PO, 1 dose

Counts a 7 day course. Same treatment as Chlamydia.

Question 14

Who else should be treated in the case of chancroid?

Answer 14

Anyone making sexual contact within 10 days of the partner’s symptoms

Question 15

What is the treatment for first episode of HSV-2 genital herpes?

Answer 15

Valacyclovir twice daily x7-10 days.

Question 16

What is suppressive therapy for HSV-2?

Answer 16

Reduces frequency of HSV breakouts, best for patients with frequent (>6) per year.

Once daily Valacyclovir or 2x acyclovir

Question 17

What do you do if HSV-2 recurs?

Answer 17

5 day course of acyclovir / valacyclovir

Question 18

What is the treatment for severe disseminated HSV causing encephalitis or other major complications?

Answer 18

IV acyclovir x 2-7 days until improvement, oral therapy to complete a 10 day course

Question 19

What is the treatment for primary / secondary syphilis? What do you do if the patient has an allergy?

Answer 19

Benzathine penicillin G, 2.4 million units IM x1

If patient has allergy: desensitize. Doxycycline, ceftriaxone, and azithromycin are way less effective

Question 20

What are the treatments for latent and tertiary syphilis?

Answer 20

3 doses of Benzathine penicillin G, 2.4 million units IM, separated by 1 week

Question 21

What is the treatment for neurosyphilis (CNS involvement)?

Answer 21

24 million units of IV aqueous penicillin G x10-14 days

Literally 10x the dose

Question 22

What is the Jarisch-Herxheimer reaction? How is it treated?

Answer 22

Headache, myalgias, fever, and tachycardia occurring 1-2 hours after starting treatment of syphilis due to release of pyrogen from spirochetes, can last 1-2 days.

Treated via anti-inflammatories

Question 23

What is the treatment for Chlamydia trachomatis?

Answer 23

Azithromycin 1g PO x 1 dose

or (macrolide allergy)

Doxycycline 100 mg PO x 7 days

Question 24

What should be done for sexual partners exposed to Chlamydia-infected person?

Answer 24

If within 60 days of symptoms, come for ID consult (was 10 days for chancroid)

Question 25

What organism should be considered for non-gonoccal urethritis if doxycycline was given?

Answer 25

Mycoplasma genitalium

A second, less likely cause of non-gonococcal urethritis.

Treat with moxifloxacin (assuming they had doxy due to azithromycin allergy)

Question 26

What are two uncomplicated gonococcal infections and what is the treatment?

Answer 26

Cervicitis, urethritis

Treatment: Ceftriaxone 250 mg IM x 1

+

Azithromycin 1g PO x 1 dose (always treat for chlamydia)

Question 27

What can be given for gonococcal infection if the patient has a cephalosporin allergy?

Answer 27

Gentamicin

Question 28

What are the treatments for bacterial and fungal vaginosis?

Answer 28

Bacterial: Gardnerella - Metronidazole x 7 days
Fungal: Fluconazole x 1 dose

Question 29

What is the treatment for trichomonas vaginalis?

Answer 29

Metronidazole in a 2g x 1 dose

Or 500 mg bid x 7 days (same as Gardnerella)

Question 30

What are the organisms causing PID?

Answer 30

1. N. gonorrhea
2. C. trachomatis
3. gram negatives and anaerobes

Question 31

What is the empiric regimen for PID?

Answer 31

Cefoxitin to cover gonorrhea
+
Doxycycline to cover chlamydia

BOTH GIVEN IV until there is a response

Question 32

What are the most likely causative organisms of epididymitis?

Answer 32

C. trachomatis / N. gonorrhea

If anal intercourse: GI flora i.e. E. coli or P. aeruginosa

Question 33

What is the treatment of epididymitis?

Answer 33

Ceftriaxone IM + doxycycline

Substitute levofloxacin for doxy if enteric organisms are a concern (cover pseudomonas)