Women’s Health

For patients in whom oral therapy is appropriate (see comments) use:

Amoxicillin 500mg PO TID

PLUS

Metronidazole 500mg PO BID

PLUS

STI pack (Cefixime 400mg PO and Azithromycin 1g PO) single dose

For patients in whom IV therapy is indicated (see comments) use:

Ceftriaxone 2g IV OD

PLUS

Metronidazole 500mg IV BID

PLUS

Azithromycin 1g PO single dose (if septic use 500mg IV OD)

If patient is in septic shock ADD:

Amikacin 28mg/kg IV OD as a first dose in patients with creatinine clearance >60ml/minute. Use 16-20mg/kg if creatinine clearance <60ml/minute. For subsequent doses see Aminoglycoside dosing section.

If amikacin is not available and patient is likely to have normal renal function give Gentamicin 7mg/kg IV single dose. If renal function is likely to be abnormal give Gentamicin 4-5mg/kg.

Change to oral antibiotics when improving according to susceptibility results. If susceptibility results are not available use:

Amoxicillin 500mg PO TID

PLUS

Metronidazole 500mg PO BID

Send first pass urine for PCR, swab vagina with bacterial swab for culture, and with viral (dry) swab for PCR. If systemically unwell send blood cultures prior to antibiotics.

Patients with any of the following should receive IV therapy:

• Pregnancy
• Inability to tolerate oral therapy
• Severe pain
• Fever ≥ 38 degrees
• Systemic features
• Sepsis
• Suspicion of tubo-ovarian abscess

Duration:

If using IV therapy change to oral antibiotics when clinically improving. Use single doses only of azithromycin and cefixime. Treat for total of 14 days.

If a sexually transmitted pathogen is detected, see Chapter 8: Genital In- fections.

Mild:

Amoxicillin/Clavulanic acid 500/125mg PO TID

Alternative:

Co-trimoxazole 160 / 800mg PO BID

PLUS

Metronidazole 500mg PO BID

Severe:

Ampicillin 2g IV QID

PLUS

Gentamicin 4-5mg/kg IV OD

PLUS

Metronidazole 500mg IV BID

If patient is in septic shock replace Gentamicin with:

Amikacin 28mg/kg IV OD as a first dose in patients with creatinine clearance >60ml/minute. Use 16-20mg/kg if creatinine clearance <60ml/minute. For subsequent doses see Aminoglycoside dosing section.

If amikacin is not available and patient is likely to have normal renal function give above regime but increase Gentamicin to 7mg/kg IV for first dose.

Do not continue gentamicin or amikacin beyond 72 hours.

If patient is septic give antibiotics within 1 hour or presentation.

Send blood cultures if systemically unwell. Send first pass urine for PCR, swab vagina with bacterial swab for culture, and with viral (dry) swab for PCR.

Duration:

Mild: Treat for 7 days
Severe: Continue IV antibiotics until afebrile for 24-48 hours and clinically improved, then stop.

If a sexually transmitted pathogen is detected, see Chapter 8: Genital Infections.

Ampicillin 2g IV QID

PLUS

Gentamicin 4-5mg/kg

If patient is in septic shock replace Gentamicin with:

Amikacin 28mg/kg IV OD as a first dose in patients with creatinine clearance >60ml/minute. Use 16-20mg/kg if creatinine clearance <60ml/minute. For subsequent doses see Aminoglycoside dosing section.

If patient is septic give antibiotics within 1 hour of presentation.

Send blood cultures if septic. Consider sending amniotic fluid for microscopy and culture.

Duration:

After vaginal delivery unless patient is septic stop antibiotics. After caesarian section give one further dose of each antibiotic then stop.

If patient develops fevers post-delivery treat as post-partum endometritis.

Unless there is significant erythema following drainage, antibiotics are not required.

If infection persists following drainage use:

Amoxicillin/Clavulanic acid 500/125mg (child 25/6.25 mg/kg) PO TID

Alternative:

Cotrimoxazole 160/800 mg (child 4/20 mg/kg) PO BID

The mainstay of treatment is surgical drainage. If recurrent or complicated infection send pus for culture.

Duration:

Treat for 7 days

Clotrimazole pessary 500mg PV single dose

Alternative:

Clotrimazole 1% cream PV OD

OR

Nystatin 100 000 units PV OD

If topical therapy is not tolerated and patient is not pregnant use:

Fluconazole 150mg PO single dose

Perform microscopy on wet mount of vaginal discharge and measure pH. In candidiasis vaginal pH is typically normal (4-4.5).

If there is any doubt regarding the diagnosis, or if patient has recurrent or resistant symptoms, take a swab of the affected area for microscopy and culture, prior to antifungal therapy.

Treatment failure is most commonly due to misdiagnosis.

Duration:

Clotrimazole pessary: Give single dose

Clotrimazole 1% cream: Treat for 6 nights.

Metronidazole 2g PO single dose

Alternative:

Metronidazole 500mg PO BID

OR

Clindamycin (preferred in pregnancy) 300mg PO BID

Treatment of male sexual partners is not currently recommended.

Perform microscopy on wet mount of vaginal discharge to look for clue cells. Measure pH: in BV this is >4.5. Perform whiff-amine test; this is positive if a fishy odor is produced upon adding 10% KOH to vaginal discharge.

Send vaginal swab to laboratory for microscopy; culture is unnecessary in BV.

BV is a risk factor for preterm delivery, HIV acquisition and transmission, and other STI acquisition. It is associated with pelvic inflammatory disease. Test all women with BV for other sexually transmitted infections including HIV and syphilis. See Chapter 8: Genital Infections

Duration:

Metronidazole 2g: Give single dose

Metronidazole 500mg and Clindamycin: Treat for 7 days

Cefazolin 2g TID IV

Alternative:

Ampicillin 2g QID IV

OR

Benzylpenicillin 5 million IU (3g) IV for one dose, followed by 3 million IU (1.8g) Q4H IV until delivery

OR

Clindamycin 600mg TID IV

Consider screening for Group B Streptococcal colonization with vaginal swab 3-5 weeks prior to expected delivery.

Duration:

Begin 4 hours prior to expected delivery and stop at time of delivery.

Only give antibiotics if gestation is <34 weeks.

Azithromycin 1g IV / PO once only

PLUS

Ampicillin 2g QID for 48 hours

Followed by:

Amoxicillin 500mg TID PO

Prolonged PROM has been associated with increased risk of chorioamnionitis, abruption, and cord prolapse, however maintaining the pregnancy to gain further foetal maturity may be beneficial.

34 weeks or more: Plan delivery. Labour induction unless contraindication, GBS prophylaxis, single corticosteroid course may be considered up to 36 weeks.

32-33 complete weeks: Expectant management. GBS prophylaxis, single corticosteroid course, antimicrobial to prolong latency

24-31 complete weeks: Expectant management. GBS prophylaxis, single corticosteroid course, antimicrobial to prolong latency, consider tocolytics, MgSO4 for neuroprotection may be considered

Duration:

Stop antibiotics after 7 days or delivery whichever is sooner.

Give prophylactic antibiotics if STI testing cannot be performed, or patient is unlikely to return for treatment.

Ceftriaxone 500mg IM single dose

PLUS

Azithromycin 1g PO single dose

PLUS

Metronidazole 2g single dose

If testing is available offer screening for STIs:

• Urine for Chlamydia and Gonorrhoea PCR
• Vaginal, throat and/or rectal bacterial and viral (dry) swabs for culture and PCR
• HIV, HBV, and Syphilis serology

See Chapter 8: Genital Infections

If unvaccinated for hepatitis B and HBsAg negative (or unable to test) give first dose HBV vaccine, then repeat at 1-2, and 4-6 months.

Consider anti-retroviral prophylaxis if high risk for HIV.