Amoxicillin trihydrate and clavulanate potassium tablets for dogs

A meta-analysis of 52 studies of regimens of oral metronidazole at a dose of 2 g daily of varying duration showed similar initial cure rates of 85%, 87%,

86%

6 Oral regimens range from 300 mg twice daily to 450 mg 3 times daily.

Oral and vaginal preparations have shown equal efficacy in direct comparisons (SOR: A ).

8 A 3-day course of vaginal clindamycin is as effective as a 5-day course (SOR: B ).

Several studies have compared clindamycin and metronidazole head to head.

They have shown similar cure rates that were not statistically different in the 75% to 90% range (SOR: A ).

4,5,10,11 Other antibiotics that have

shown

The initial regimen or an alternative regimen may be used. A longer, 10- to 14-day, course of antibiotic therapy has been recommended by one expert for treating relapses (SOR: C ). 13 Recolonizing the vagina with lactobacilli by eating yogurt or using bacteria-containing suppositories is an approach that deserves further study (SOR: C ). 14 Suppressive therapy such as intravaginal metronidazole twice weekly may also be considered as maintenance therapy to prevent recurrences (SOR: C ). A number of studies have been published on screening for BV in pregnancy using Gram stain and on treating positive cases with antibiotics.

While studies that used metronidazole for treatment have not shown consistently good results, more recent studies using clindamycin orally or intravaginally have been promising (SOR: B ). 7,15 Oral dosing at 300 mg twice daily, at 12 to 22 weeks gestation, has reduced preterm delivery for pregnant women with BV diagnosed by Nugent’s criteria (number needed to treat [NNT]=10). 7 Likewise, for women with BV treated at 13 to 20 weeks gestation, intravaginal clindamycin therapy for 3 days has reduced the incidence of preterm births (NNT=17). Clindamycin appears to be the treatment of choice for BV in pregnancy (SOR: C ) since it is considered safe (category B) throughout pregnancy, and because use of metronidazole in the first trimester is controversial. Treating vulvovaginal candidiasis (VVC) with intravaginal imidazoles reduces symptoms with NNT=3 after 1 month (SOR: A ) ( Table ).

16 No difference has been seen in outcomes with the various imidazoles or with treatment durations of 1 to 14 days. Intravaginal nystatin also decreases symptoms of VVC, with a NNT of 3 after 1 week compared with placebo (SOR: B ).

Data showing that imidazoles are more effective than nystatin are not strong (SOR: B ).

A Clinical Evidence review 16 identified 1 trial comparing intravaginal miconazole, clotrimazole, econazole, and nystatin; symptomatic relapse was lower with intravaginal imidazoles than with nystatin.

Another trial comparing clotrimazole and nystatin showed no difference in the proportion of women with persistent symptoms after 4 weeks. An open label study 17 comparing econazole, miconazole, and nystatin showed that the imidazoles had more antifungal activity, but there was no difference in clinical outcome assessment.

Diagnosis and Treatment of Chlamydia trachomatis Infection. MILLER, M.D., University of Tennessee College of Medicine, Chattanooga, Tennessee.

Abstract Urogenital Infection in Women Urogenital Infection in Men Reiter Syndrome Treatment of Urogenital Infection Chlamydial Infection in Children Prevention References.

Abstract Urogenital Infection in Women Urogenital Infection in Men Reiter Syndrome Treatment of Urogenital Infection Chlamydial Infection in Children Prevention References.

Chlamydia trachomatis infection most commonly affects the urogenital tract.

In men, the infection usually is symptomatic, with dysuria and a discharge from the penis.

Untreated chlamydial infection in men can spread to the epididymis. Most women with chlamydial infection have minimal or no symptoms, but some develop pelvic inflammatory disease.

Chlamydial infection in newborns can cause ophthalmia neonatorum.

Chlamydial pneumonia can occur at one to three months of age, manifesting as a protracted onset of staccato cough, usually without wheezing or fever.

Treatment options for uncomplicated urogenital infections include a single 1-g dose of azithromycin orally, or doxycycline at a dosage of 100 mg orally twice per day for seven days. The recommended treatment during pregnancy is erythromycin base or amoxicillin.

The Centers for Disease Control and Prevention and the U.S. Preventive Services Task Force recommend screening for chlamydial infection in women at increased risk of infection and in all women younger than 25 years. The incidence of chlamydial infection in women increased dramatically between 1987 and 2003, from 79 to 467 per 100,000.1 In part, this may be attributed to increased screening and improved reporting, but the burden of the disease still is significant. The most common site of Chlamydia trachomatis infection is the urogenital tract, and severity ranges from asymptomatic to life-threatening. Azithromycin (Zithromax) or doxycycline (Vibramycin) is recommended for the treatment of uncomplicated genitourinary chlamydial infection. Amoxicillin is recommended for the treatment of chlamydial infection in women who are pregnant.

Patients who are pregnant should be tested for cure three weeks after treatment for chlamydial infection.

Women with chlamydial infection should be rescreened for infection three to four months after completion of antibiotic therapy.

All women who are 25 years or younger or at increased risk of sexually transmitted diseases should be screened for chlamydial infection annually. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 1313 orhttps://www.aafp.org/afpsort.xml . Azithromycin (Zithromax) or doxycycline (Vibramycin) is recommended for the treatment of uncomplicated genitourinary chlamydial infection. Amoxicillin is recommended for the treatment of chlamydial infection in women who are pregnant.

Patients who

are

Women with chlamydial infection should be rescreened for infection three to four months after completion of antibiotic therapy. All women who are 25 years or younger or at increased risk of sexually transmitted diseases should be screened for chlamydial infection annually.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series.

For information about the SORT evidence rating system, see page 1313 orhttps://www.aafp.org/afpsort.xml . Abstract Urogenital Infection in Women Urogenital Infection in Men

Reiter

The cervix tends to bleed easily when rubbed with a polyester swab or scraped with a spatula.

Chlamydial infection cannot be distinguished from other urogenital infections by symptoms alone.

Clinical microscopy and the amine test (i.e., significant odor release on addition of potassium hydroxide to vaginal secretions) can be used to help differentiate chlamydial infection from other lower genital tract infections such as urinary tract infection, bacterial vaginosis, and trichomoniasis.3 In addition, chlamydial infection in the lower genital tract does not cause vaginitis; thus, if vaginal findings are present, they usually indicate a different diagnosis or a coinfection. trachomatis infection develop urethritis; symptoms may consist of dysuria without frequency or urgency. A urethral discharge can be elicited by compressing the urethra during the pelvic examination.

Urinalysis usually will show more than five white blood cells per high-powered field, but urethral cultures generally are negative. Women with chlamydial infection in the lower genital tract may develop an ascending infection that causes acute salpingitis with or without endometritis, also known as PID.

Symptoms tend to have a subacute onset and usually develop during menses or in the first two weeks of the menstrual cycle.2 Symptoms range from absent to severe abdominal pain with high fever and include dyspareunia, prolonged menses, and intramenstrual bleeding.

Twenty percent of women who develop PID become infertile, 18 percent develop chronic pelvic pain, and 9 percent have a tubal pregnancy.2 The Centers for Disease Control and Prevention (CDC) recommends that physicians maintain a low threshold for diagnosing PID and that empiric treatment be initiated in women at risk of sexually transmitted disease (STD) who have uterine, adnexal, or cervical motion tenderness with no other identifiable cause.2.

Culture techniques are the preferred method for detecting C.

trachomatis infection, but they have been replaced in some instances by nonculture techniques.

The newest nonculture technique is the nucleic acid amplification test, of which there are several. These tests have good sensitivity (85 percent) and specificity (94 to 99.5 percent) for endocervical and urethral samples when compared with urethral cultures.4 In women with urogenital disease, nucleic acid amplification tests can be used with an endocervical sample or a urine specimen to diagnose chlamydia.

The CDC recommends that anyone who is tested for chlamydial infection also should be tested for gonorrhea.2 This recommendation was supported by a study5 in which 20 percent of men and 42 percent of women with gonorrhea also were found to be infected with C. Abstract Urogenital Infection in Women

Urogenital

trachomatis infection in approximately 15 to 55 percent of men, although the prevalence is lower among older men.2 Symptoms, if present, include a mild to moderate, clear to white urethral discharge. This is best observed in the morning, before the patient voids. To observe the discharge, the penis may need to be milked by applying pressure from the base of the penis to the glans.

The diagnosis of

nongonococcal

trachomatis infection in men with suspected urethritis, the nucleic acid amplification technique to detect chlamydial and gonococcal infections is best (see Urogenital Infection in Women).4 Empiric treatment should be considered for patients who are at high risk of being lost to follow-up. Untreated chlamydial infection can spread to the epididymis. Patients usually have unilateral testicular pain with scrotal erythema, tenderness, or swelling over the epididymis. Men 35 years or younger who have epididymitis are more likely to have C. trachomatis as the etiologic agent than are older men. Abstract Urogenital Infection in Women Urogenital Infection in Men Reiter Syndrome Treatment of Urogenital Infection Chlamydial Infection in Children Prevention References.

A rare complication of untreated chlamydial infection is the development of Reiter syndrome, a reactive arthritis that includes the triad of urethritis (sometimes cervicitis in women), conjunctivitis, and painless mucocutaneous lesions. Reactive arthritis develops in a small percentage of individuals with chlamydial infection.

Women can develop reactive arthritis, but the male-to-female ratio is 5:1. The arthritis begins one to three weeks after the onset of chlamydial infection.

The joint involvement is asymmetric, with multiple affected joints and a predilection for the lower extremities. The mucocutaneous lesions are papulosquamous eruptions that tend to occur on the palms of the hands and the soles of the feet. The initial episode usually lasts for three to four months, but in rare cases the synovitis may last about one year.