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Bulletin No. 3 This issue of the Bulletin continues and completes the most recent CDC recommendations on the treatment of gonococcal infections. State employed PHN's will soon receive an addendum to their "standing orders" compatible with these new recommendations.
ACUTE EPIDIDYMITIS Acute epididymitis can be caused by N. gonorrhoeae, Chlamydia, or other organisms. If gonococci are demonstrated by Gram stain or culture of urethral secretions, treatment should be APPG, 4.8 million units, ampicillin, 3.5g, or amoxicillin, 3.0g, each with probenecid 1.0g. Either regimen is followed by ampicillin, 0.5g, or amoxicillin, 0.5g, orally 4 times a day for 10 days, OR tetracycline, 0.5g, orally 4 times a day for 10 days. If gonococci are not demonstrated, the above tetracycline regimen should be used.
DISSEMINATED GONOCOCCAL INFECTION Treatment Schedules There are several, equally effective treatment schedules in the arthritis-dermatitis syndrome. These include the following: Ampicillin/amoxicillin: ampicillin, 3.5g, or amoxicillin, 3.0g, orally, each with probenecid, 1.0g, followed by ampicillin 0.5g, or amoxicillin, 0.5g, 4 times a day orally for 7 days. OR Tetracycline: 0.5g, orally 4 times a day for 7 days. Tetracycline should not be used for complicated gonococcal infection in pregnant women. OR Spectinomycin: 2.0g, intramuscularly twice a day for 3 days (treatment of choice for disseminated infections caused by PPNG). OR Erythromycin: 0.5g, orally 4 times a day for 7 days. OR Aqueous crystalline penicillin G: 10 million units intravenously per day until improvement occurs, followed by ampicillin, 0.5g, 4 times a day, to complete 7 days of antibiotic treatment. Special Considerations Hospitalization is indicated in patients who may be unreliable, or have uncertain diagnosis, or have purulent joint effusions or other complications. Open drainage of joints other than the hip is not indicated. Intra-articular injection of antibiotics is unnecessary. Meningitis and Endocarditis Meningitis and endocarditis caused by the gonococcus require high-dose intravenous penicillin therapy. In penicillin-allergic patients with endocarditis, desensitization and administration of penicillin are indicated. Chloramphenicol may be used in penicillin-allergic patients with meningitis.
GONOCOCCAL INFECTIONS IN PEDIATRIC PATIENTS With gonococcal infections in children beyond the newborn period, the possibility of sexual abuse must be considered. Genital, anal, and pharyngeal cultures should be obtained from all patients before antibiotic treatment. Appropriate culture should be obtained from individuals who have had contact with the child.
PREVENTION OF GONOCOCCAL OPHTHALMIA When required by state legislation or indicated by local epidemiologic considerations, effective and acceptable regimens for prophylaxis of neonatal gonococcal ophthalmia include ophthalmic ointment or drops containing tetracycline or erythromycin OR a 1% silver nitrate solution. Special Considerations Bacitracin is not recommended. The value of irrigation after application of silver nitrate is unknown.
MANAGEMENT OF INFANTS BORN TO MOTHERS WITH GONOCOCCAL INFECTION The infant born to a mother with gonorrhea is at high risk of infection and requires treatment with single intravenous or intramuscular injection of aqueous crystalline penicillin G, 50,000 units to full-term infants or 20,000 units to low-birth-rate infants. Topical prophylaxis for neonatal ophthalmia is not adequate treatment. Clinical illness requires additional treatment.
NEONATAL DISEASE Gonococcal Ophthalmia Patients should be hospitalized and isolated for 24 hours after initiation of treatment. Untreated gonococcal ophthalmia is highly contagious. Aqueous crystalline penicillin G, 50,000 units/kg/day, in 2 doses intravenously should be administered for 7 days. Saline irrigation of eyes should be performed as needed. Topical antibiotic preparations alone are not sufficient or required when appropriate systemic antibiotic therapy is given. Complicated Infection Patients with arthritis and septicemia should be hospitalized and treated with aqueous crystalline penicillin G, 75,000 to 100,000 units/kg/day, intravenously in 2 or 3 divided doses for 7 days. Meningitis should be treated with aqueous crystalline penicillin G, 100,000 units/kg/day, divided into 3 or 4 intravenous doses, and continued for at least 10 days.
CHILDHOOD DISEASE Children who weigh 100 lbs. (45 kg) or more should receive adult regimens. Children who weigh less than 100 lbs. should be treated as follows: Uncomplicated Disease Uncomplicated vulvovaginitis, urethritis, proctitis, or pharyngitis can be treated at 1 visit with amoxicillin, 50/kg, orally with probenecid, 25 mg/kg (maximum 1.0g) OR with aqueous procaine penicillin G, 100,000 units/kg, intramuscularly plus probenecid, 25 mg/kg (maximum 1.0g). Special Considerations Topical and/or systemic estrogen therapy are of no benefit in vulvovaginitis. Long acting penicillins, such as benzathine penicillin G, are not effective. All patients should have follow-up cultures, and the source of infection should be identified, examined, and treated. Gonococcal Ophthalmia Ophthalmia in children is treated as in neonates, but the dose of penicillin is increased to 100,000 units/kg/day intravenously. Complicated Infections Patients with peritonitis and arthritis require hospitalization and treatment with aqueous crystalline penicillin G, 100,000 units/kg/day, intravenously for 7 days. Aqueous crystalline penicillin G, 250,000 units/kg/day, intravenously in 6 divided doses for at least 10 days, is recommended for meningitis. Allergy to Penicillins Children who are allergic to penicillins should be treated with spectinomycin, 40/mg/kg, intramuscularly. Children older than 8 years may be treated with tetracycline 40/mg/kg/day, orally in 4 divided doses for 5 days. For treatment of complicated disease, the alternative regimens recommended for adults may be used in appropriate pediatric doses. |
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