STD treatment at PULSE CLINIC Thailand

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STD treatment at PULSE CLINIC Thailand

STD treatment at PULSE CLINIC Thailand

STD treatment at PULSE CLINIC Thailand


OrganismRecommended RegimenAlternative Regimen
Neisseria gonorrheaCeftriaxone 500mg inj IM statCefixime 800mg PO single dose
Chlamydia trachomatis(A-K)Azithromycin 250mg 4tabs PO single dose 
Chlamydia trachomatis(L1-L3)Doxycycline 100mg 1x2 PO 21 days 
Mycoplasma hominisDoxycycline 100mg 1x2 PO 7 daysAzithromycin 250mg 4tabs PO single dose THEN
Azithromycin 250mg 2tabs PO daily for 5 more days
Mycoplasma genitalium- Doxycycline PO bid for 7 days THEN
Moxifloxacin PO od for 7 days
- Test-of-cure at 3 wks after completion of tx
- discuss possibilities of highly resistant M.Gen
 
Ureaplasma urealyticum Azithromycin 250mg 4tabs PO single dose THEN
Azithromycin 250mg 2tabs PO daily for 5 more days
Ureaplasma parvum Azithromycin 250mg 4tabs PO single dose THEN
Azithromycin 250mg 2tabs PO daily for 5 more days
HSV I and IIAcyclovir 400 mg orally five times daily for 7 - 10 day
Prevention: Valacyclovir 500 mg orally PO OD
 
Herpes ZosterAcyclovir 800 mg orally five times daily for 7 - 10 day
Valacyclovir 1,000 mg orally three times daily for 7 days
Prednisone (Deltasone) 30 mg orally twice daily on days 1 through 7; then 15 mg twice daily on days 8 through 14; then 7.5 mg twice daily on days 15 through 21
Prevention/Vaccination
Shingrix inj IM 2 doses
dose 1 day 0
dose 2 month 2-6
Primary SyphilisBenzathine Peniciline 2.4 million unit inj IM SingleDoxycycline 100mg 1x2 PO 7 days
Secondary SyhilisBenzathine Peniciline 2.4 million unit inj IM Single
Prednisone
 30 mg orally to prevent JHR
Doxycycline 100mg 1x2 PO 7 days
Latent SyphilisBenzathine Peniciline 2.4 million unit inj IM once a week for 3 weeks 
Haemophilus ducreyi Doxycycline 100mg 1x2 PO 7 days
CMVNo treatment needed for immunocompetent. 
   
Candida albicansFemale: Clotrimazole Vg suppo 7 days 
Male balanitis: Clotrimazole ceam 7 days
 
BV
Atopobium vaginae
Bacterioides fragilis
Gardnerella vaginalis
Lactobacillus spp
Megasphaera type 1
Mobilincus
Metronidazole 400mg PO tid  7 days 
   

—Antiviral therapy has been shown to be beneficial only when patients are treated within 72 hours of onset of the herpes zoster rash. Antiviral agents are not used in combination, and selection of an agent is based on dosage schedule and cost.

 

CORTICOSTEROIDS


Orally administered corticosteroids are commonly used in the treatment of herpes zoster, even though clinical trials have shown variable results. Prednisone used in conjunction with acyclovir has been shown to reduce the pain associated with herpes zoster.15 The likely mechanism involves decreasing the degree of neuritis caused by active infection and, possibly, decreasing residual damage to affected nerves.

Some studies designed to evaluate the effectiveness of prednisone therapy in preventing postherpetic neuralgia have shown decreased pain at three and 12 months.16,17 Other studies have demonstrated no benefit.15,18

If the use of orally administered prednisone is not contraindicated, adjunctive treatment with this agent is justified on the basis of its effects in reducing pain, despite questionable evidence for its benefits in decreasing the incidence of postherpetic neuralgia. Given the theoretic risk of immunosuppression with corticosteroids, some investigators believe that these agents should be used only in patients more than 50 years of age because they are at greater risk of developing postherpetic neuralgia.15 The recommended dosage for prednisone is given in Table 1. (https://www.aafp.org/pubs/afp/issues/2000/0415/p2437.html/1000)

Treatment Options for Postherpetic Neuralgia*


MedicationDosage
Topical agents
Capsaicin cream (Zostrix)Apply to affected area three to five times daily.
Lidocaine (Xylocaine) patchApply to affected area every 4 to 12 hours as needed.
Tricyclic antidepressants
Amitriptyline (Elavil)10 to 25 mg orally at bedtime; increase dosage by 25 mg every 2 to 4 weeks until response is adequate, or to maximum dosage of 150 mg per day.
Nortriptyline (Pamelor)10 to 25 mg orally at bedtime; increase dosage by 25 mg every 2 to 4 weeks until response is adequate, or to maximum dosage of 125 mg per day.
Imipramine (Tofranil)25 mg orally at bedtime; increase dosage by 25 mg every 2 to 4 weeks until response is adequate, or to maximum dosage of 150 mg per day.
Desipramine (Norpramin)25 mg orally at bedtime; increase dosage by 25 mg every 2 to 4 weeks until response is adequate, or to maximum dosage of 150 mg per day.
Anticonvulsants
Phenytoin (Dilantin)100 to 300 mg orally at bedtime; increase dosage until response is adequate or blood drug level is 10 to 20 μg per mL (40 to 80 μmol per L).
Carbamazepine (Tegretol)100 mg orally at bedtime; increase dosage by 100 mg every 3 days until dosage is 200 mg three times daily, response is adequate or blood drug level is 6 to12 μg per mL (25.4 to 50.8 μmol per L).
Gabapentin (Neurontin)100 to 300 mg orally at bedtime; increase dosage by 100 to 300 mg every 3 days until dosage is 300 to 900 mg three times daily or response is adequate. (Drug levels for clinical use are not available.)

*—Additional modalities include transcutaneous electric nerve stimulation (TENS), biofeedback and nerve blocks.

ANALGESICS


Capsaicin, an extract from hot chili peppers, is currently the only drug labeled by the U.S. Food and Drug Administration for the treatment of postherpetic neuralgia.19 Trials have shown this drug to be more efficacious than placebo but not necessarily more so than other conventional treatments.20

Substance P, a neuropeptide released from pain fibers in response to trauma, is also released when capsaicin is applied to the skin, producing a burning sensation. Analgesia occurs when substance P is depleted from the nerve fibers. To achieve this response, capsaicin cream must be applied to the affected area three to five times daily. Patients must be counseled about the need to apply capsaicin regularly for continued benefit. They also need to be counseled that their pain will likely increase during the first few days to a week after capsaicin therapy is initiated. Patients should wash their hands thoroughly after applying capsaicin cream in order to prevent inadvertent contact with other areas.

Patches containing lidocaine have also been used to treat postherpetic neuralgia. One study found that compared with no treatment, lidocaine patches reduced pain intensity, with minimal systemic absorption. Although lidocaine was efficacious in relieving pain, the effect was temporary, lasting only four to 12 hours with each application.21

Over-the-counter analgesics such as acetaminophen (e.g., Tylenol) and nonsteroidal anti-inflammatory drugs have not been shown to be highly effective in the treatment of post-herpetic neuralgia. However, these agents are often useful for potentiating the pain-relieving effects of narcotics in patients with severe pain. Because of the addictive properties of narcotics, their chronic use is discouraged except in the rare patient who does not adequately respond to other modalities.

 

TRICYCLIC ANTIDEPRESSANTS


Tricyclic antidepressants can be effective adjuncts in reducing the neuropathic pain of postherpetic neuralgia. These agents most likely lessen pain by inhibiting the reuptake of serotonin and norepinephrine neurotransmitters.22

Tricyclic antidepressants commonly used in the treatment of postherpetic neuralgia include amitriptyline (Elavil), nortriptyline (Pamelor), imipramine (Tofranil) and desipramine (Norpramin). These drugs are best tolerated when they are started in a low dosage and given at bedtime. The dosage is increased every two to four weeks to achieve an effective dose.

The tricyclic antidepressants share common side effects, such as sedation, dry mouth, postural hypotension, blurred vision and urinary retention. Nortriptyline and amitriptyline appear to have equal efficacy; however, nortriptyline tends to produce fewer anticholinergic effects and is therefore better tolerated. Treatment with tricyclic antidepressants can occasionally lead to cardiac conduction abnormalities or liver toxicity. The potential for these problems should be considered in elderly patients and patients with cardiac or liver disease.

Because tricyclic antidepressants do not act quickly, a clinical trial of at least three months is required to judge a patient's response. The onset of pain relief using tricyclic antidepressants may be enhanced by beginning treatment early in the course of herpes zoster infection in conjunction with antiviral medications.20

 

ANTICONVULSANTS


Phenytoin (Dilantin), carbamazepine (Tegretol) and gabapentin (Neurontin) are often used to control neuropathic pain. A recent double-blind, placebo-controlled study showed gabapentin to be effective in treating the pain of postherpetic neuralgia, as well as the often associated sleep disturbance.23

The anticonvulsants appear to be equally effective, and drug selection often involves trial and error. Lack of response to one of these medications does not necessarily portend a poor response to another. The dosages required for analgesia are often lower than those used in the treatment of epilepsy.

Anticonvulsants are associated with a variety of side effects, including sedation, memory disturbances, electrolyte abnormalities, liver toxicity and thrombocytopenia. Side effects may be reduced or eliminated by initiating treatment in a low dosage, which can then be slowly titrated upward.

There are no specific contraindications to using anticonvulsants in combination with antidepressants or analgesics. However, the risk of side effects increases when multiple medications are used.

Effective treatment of postherpetic neuralgia often requires multiple treatment approaches. In addition to medications, modalities to consider include transcutaneous electric nerve stimulation (TENS), biofeedback and nerve blocks.