Practice Changing UpDates

Authors: April F Eichler, MD, MPH, Sadhna R Vora, MD

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is
complete.

Literature review current through: Jan 2022. | This topic last updated: Nov 28, 2021.

INTRODUCTION

This section highlights selected specific new recommendations and/or

updates that we anticipate may change usual clinical practice. Practice
Changing UpDates focus on changes that may have significant and broad
impact on practice, and therefore do not represent all updates that affect
practice. These Practice Changing UpDates, reflecting important changes to
UpToDate over the past year, are presented chronologically, and are
discussed in greater detail in the identified topic reviews.

INFECTIOUS DISEASES (November 2021)

COVID-19 vaccination in children 5 years and older

● For children ages 5 to 11 years, we recommend COVID-19 vaccination

(Grade 1B).

In October 2021, the US Food and Drug Administration authorized BNT162b2

(Pfizer vaccine) for individuals 5 to 11 years old based on data from
randomized trials in over 2000 children in this age group, which
demonstrated 91 percent vaccine efficacy against symptomatic COVID-19 and
immunogenicity similar to that in adolescents and young adults [1]. There
were no cases of vaccine-associated myocarditis in the trials; although the
precise risk is uncertain, it is expected to be lower than that seen in older
individuals. We agree with recommendations from the Centers for Disease
Control and Prevention to give BNT162b2 to children ages 5 to 11 years.
Clinicians should be aware that the dose and formulation used for children
are different than those for adolescents and adults. (See "COVID-19: Vaccines
to prevent SARS-CoV-2 infection", section on 'Summary and
recommendations'.)

EMERGENCY MEDICINE (ADULT AND PEDIATRIC) (November

2021)

New threshold for elevated blood lead in United States children

● For children younger than six years of age in the United States, the
reference value for an elevated blood level is 3.5 mcg/L (0.17 micromol/L).

Detectable blood lead levels (BLLs) are associated with neurocognitive deficits
in infants and children <6 years old, and targeted screening of at-risk children
is recommended. The Centers for Disease Control and Prevention has
lowered the blood lead level (BLL) threshold for action to 3.5 mcg/dL (0.17
micromol/L) from the previous level of 5.0 mcg/dL (0.24 micromol/L) [2,3]. At
or above this threshold, specific interventions should be taken based upon
the degree of BLL elevation (table 1). For children with BLLs below 3.5 mcg/dL,
the limit of detection for lead varies by laboratory, and the actual blood lead
value may be close to or above the threshold. Thus, some children may need
to be retested depending upon age or other risk factors. (See "Childhood lead
poisoning: Management", section on 'Approach'.)

INFECTIOUS DISEASES (October 2021)

Booster doses of COVID-19 vaccines in adults

 ● For adults ≥18 years of age who received a primary series of a COVID-19
vaccine, we suggest booster vaccination (Grade 2C).

Several countries have introduced booster doses of COVID-19 vaccines

because of potentially attenuated vaccine effectiveness due to waning
efficacy and variants. The US Food and Drug Administration has authorized
and the Centers for Disease Control (CDC) suggests a booster dose for all
adults 18 years or older [4-7]. For those who received BNT162b2 (Pfizer) or
mRNA-1273 (Moderna) vaccines, the booster dose should be given at least six
months after the primary series. For those who received Ad26.COV2.S
(Johnson & Johnson), the booster dose should be given at least two months
after the primary series. Any authorized vaccine can be used for the booster
dose, regardless of the vaccine used for the primary series. We now suggest
booster doses for adults, based on preliminary trials and observational
evidence suggesting improved vaccine efficacy following a booster dose. (See
"COVID-19: Vaccines to prevent SARS-CoV-2 infection", section on 'Role of
booster vaccinations/waning efficacy'.)

NEPHROLOGY AND HYPERTENSION (September 2021)

Glomerular filtration rate estimation without inclusion of a race

coefficient

● We suggest using the 2021 Chronic Kidney Disease Epidemiology

Collaboration (CKD-EPI) creatinine equation to estimate glomerular
filtration rate (GFR) for the general population (calculator 1).

Previously, the chronic kidney disease epidemiology (CKD-EPI) equation used

to estimate glomerular filtration rate (GFR) included a term for race such that,
for any given age, sex, and serum creatinine, a Black individual would have a
higher estimated GFR. The American Society of Nephrology and National
Kidney Foundation reevaluated the inclusion of race in estimating GFR and
determined that a revised creatinine-based equation (ie, the 2021 CKD-EPI
equation) that did not include race was sufficiently accurate for clinical use
[8]. We now suggest using the 2021 revised CKD-EPI equation to estimate GFR
(calculator 1). The equation applies to people with stable kidney function. (See
"Assessment of kidney function", section on 'Estimation of GFR'.)

INFECTIOUS DISEASES (August 2021)

Third dose of COVID-19 mRNA vaccine for immunocompromised

individuals

● For individuals with certain immunocompromising conditions (table 1), we

suggest administering a three-dose primary mRNA vaccine series rather
than a two-dose series (Grade 2C).

The US Food and Drug Administration has authorized a third dose of the
BNT162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna) COVID-19 mRNA
vaccines for individuals who have certain immunocompromising conditions,
such as active chemotherapy for cancer, hematopoietic cell or solid organ
transplant recipients, immunosuppressive therapy (eg, rituximab and other
biologic agents, antimetabolites, alkylating agents, prednisone ≥20 mg daily),
and advanced or untreated HIV [4,5]. The authorization is based upon studies
showing that the immune response to a two-dose mRNA vaccine series is
suboptimal and that administration of a third dose may improve the immune
response without causing short-term adverse events [9-13]. In agreement
with the Advisory Committee on Immunization Practices, we now suggest
giving the mRNA vaccines as a three-dose primary series in patients with any
of the conditions listed in the table (table 2). (See "COVID-19: Vaccines to
prevent SARS-CoV-2 infection", section on 'Immunocompromised individuals'.)

INFECTIOUS DISEASES (August 2021)

Monoclonal antibody combinations for post-exposure prophylaxis
against SARS-CoV-2

● We suggest post-exposure prophylaxis with casirivimab-imdevimab in

individuals who meet all the following criteria: 1) had close contact with an
individual with infection or have a high risk of exposure in an institutional
setting, 2) have risk factors for severe COVID-19 (table 2), and 3) either
have not been fully vaccinated or are expected to have an inadequate
response to vaccination (Grade 2B). Bamlanivimab-etesevimab is an
alternative.

Vaccination is the best strategy to prevent SARS-CoV-2 infection and severe

COVID-19; however, vaccination coverage is incomplete and some individuals
(eg, immunocompromised patients) have poor response to vaccination. In the
United States, the FDA has issued an emergency use authorization (EUA) to
use the monoclonal antibody combinations casirivimab-imdevimab and
bamlanivimab-etesevimab to prevent COVID-19 in select individuals over 12
years of age who have exposure to SARS-CoV-2, are at high risk for severe
disease (table 3), and have either not been fully vaccinated or are expected to
have an inadequate immune response to vaccination [14]. Authorization was
supported by trials in which casirivimab-imdevimab reduced the risk of
symptomatic COVID-19 in individuals with household exposure to SARS-CoV-2
(1 versus 8 percent with placebo) and bamlanivimab alone reduced the risk in
nursing home residents and staff who were potentially exposed at the facility
(9 versus 15 percent with placebo). We suggest post-exposure prophylaxis
with casirivimab-imdevimab (or, if unavailable, bamlanivimab-etesevimab) for
individuals who meet the EUA criteria. (See "COVID-19: Epidemiology,
virology, and prevention", section on 'Post-exposure prophylaxis for select
individuals'.)

PEDIATRICS (August 2021)

Direct oral anticoagulants for venous thromboembolism in children ≥2
years

● For most adolescents (≥12 years) with venous thromboembolism, after at

least five days of initial parenteral therapy, we suggest a direct oral
anticoagulant (DOAC; eg, dabigatran or rivaroxaban) rather than other
agents (Grade 2B). For children ages 2 to <12 years old, either a DOAC or
low molecular weight heparin is reasonable.

In 2021, the US Food and Drug Administration approved dabigatran, a direct

oral anticoagulant (DOAC), for treatment of venous thrombosis and
thromboembolism (VTE) in children ≥3 months old [15]; another DOAC,
rivaroxaban, has been approved in children in Canada and Europe [16]. These
regulatory approvals were based upon two large multicenter pediatric trials
demonstrating that dabigatran and rivaroxaban have similar efficacy and
bleeding risk compared with low molecular weight heparin (LMWH) and
warfarin [17,18]. Adolescents made up most of the trial populations, and
children <2 years were underrepresented. DOACs are an attractive option
since they are orally administered and do not require drug monitoring. We
now suggest one of the approved DOACs (dabigatran or rivaroxaban) for
treatment of VTE in adolescents, after at least five days of initial parenteral
therapy. For children ages 2 to 11 years, either a DOAC or LMWH is
acceptable. For infants and children <2 years, the efficacy and safety of
DOACs remain uncertain, and we continue to suggest LMWH. (See "Venous
thrombosis and thromboembolism (VTE) in children: Treatment, prevention,
and outcome", section on 'Direct oral anticoagulants'.)

INFECTIOUS DISEASES (July 2021)

Approaches to reduce recurrent Clostridioides difficile infection

 ● For patients with nonfulminant Clostridioides difficile infection (CDI), we
suggest fidaxomicin over vancomycin (Grade 2C). For patients with
recurrent CDI within six months of a prior episode, we suggest
bezlotoxumab in addition to antibiotics (Grade 2C). For patients with
multiply recurrent CDI who are not candidates for fecal microbiota
transplant, we suggest suppressive oral vancomycin following treatment
of an acute episode (Grade 2C).

New guidelines on management of Clostridioides difficile infection (CDI) were

issued by the Infectious Disease Society of America (IDSA) and American
College of Gastroenterology (ACG) in June 2021 [19,20]. For patients with
nonfulminant CDI, the IDSA guidelines favor use of fidaxomicin over
vancomycin; in addition, for patients with recurrent CDI and prior episode in
the last six months, the IDSA guidelines favor use of adjunctive bezlotoxumab
(with a standard antibiotic regimen). For patients with recurrent CDI who are
not fecal microbiota transplantation candidates, the ACG guidelines suggest
use of suppressive oral vancomycin following completion of treatment. We
are in agreement with these approaches, which have been associated with a
modest reduction in risk for recurrent CDI; in the setting of cost constraints,
we prioritize them for patients at highest risk of recurrent CDI (age ≥65 years,
history of severe CDI, or immunosuppression). (See "Clostridioides difficile
infection in adults: Treatment and prevention", section on 'Nonsevere
disease'.)

INFECTIOUS DISEASES; EMERGENCY MEDICINE (ADULT AND

PEDIATRIC) (February 2021, Modified June 2021)

Adjunctive baricitinib or tocilizumab for COVID-19

● For hospitalized adults with COVID-19 who have initiated mechanical

ventilation in the prior 24 to 48 hours, we suggest adding tocilizumab to
 usual care (which includes dexamethasone) (Grade 2B).
For hospitalized
adults with COVID-19 who have initiated high-flow supplemental oxygen
or noninvasive ventilation within the prior 24 to 48 hours, we suggest
adding baricitinib or tocilizumab to usual care (Grade 2B).
For hospitalized
adults with COVID-19 who are receiving low-flow supplemental oxygen
and have both progressively increasing oxygen requirements despite
dexamethasone and significantly elevated inflammatory markers, we
suggest adding baricitinib or tocilizumab to usual care (Grade 2C).
However, if availability of these agents is limited, we prioritize them for
patients on higher levels of oxygen support.

Results from recent randomized trials suggest adjunctive use of the Janus
kinase inhibitor baricitinib or the interleukin-6 pathway inhibitor tocilizumab
has a survival benefit in hospitalized adults with severe COVID-19.

• In one unpublished randomized trial of patients who were not

receiving invasive mechanical ventilation, adding baricitinib to
standard of care reduced 28-day mortality; among those on high-flow
oxygen or noninvasive ventilation at baseline, mortality was 17.5
versus 29.4 percent with placebo [21].
• In two open-label trials that included patients on oxygen support with
a C-reactive protein level ≥75 mg/L or patients who had recently
started high-flow oxygen or more intensive respiratory support,
adding tocilizumab reduced 28-day mortality (28 to 29 percent versus
33 to 36 percent with usual care alone) [22,23].

In the majority of patients, usual care included dexamethasone. Baricitinib

and tocilizumab have not been compared directly or studied together. We
suggest either baricitinib or tocilizumab as an adjunct to dexamethasone for
select patients with severe or critical COVID-19. (See "COVID-19: Management
in hospitalized adults", section on 'IL-6 pathway inhibitors (eg, tocilizumab)'.)
PEDIATRICS (June 2021)

Elexacaftor-tezacaftor-ivacaftor for children ≥6 years with cystic fibrosis

● For patients ≥6 years old with cystic fibrosis who are homozygous for the
F508del variant, we recommend triple therapy (elexacaftor-tezacaftor-
ivacaftor) rather than dual therapy (tezacaftor-ivacaftor or lumacaftor-
ivacaftor) (Grade 1B). For patients ≥6 years old who have one F508del
mutation (heterozygotes) or other eligible mutation based on in vitro data,
we suggest triple therapy rather than dual therapy or monotherapy
(ivacaftor) (Grade 2C).

Elexacaftor-tezacaftor-ivacaftor is an important therapy for most patients with

cystic fibrosis (CF), but its use has been limited to adolescents and adults. The
drug combination was evaluated in a 24-week open-label study in 66 children
6 to 11 years old who were homozygous for F508del or heterozygous for
F508del with a second minimal function mutation [24]. The safety profile and
pharmacokinetics were similar to that in older individuals, and patients
experienced improvement in pulmonary function (change in FEV1, 10.2
percentage points; 95% CI 7.9-12.6); respiratory symptoms; sweat chloride;
and body weight. On the basis of this study, the US Food and Drug
Administration approved this drug for children ≥6 years with CF and eligible
genotypes (algorithm 1), and we now recommend treatment in eligible
patients starting at the age of six years. (See "Cystic fibrosis: Treatment with
CFTR modulators", section on 'Efficacy'.)

ONCOLOGY (June 2021)

Adjuvant olaparib for BRCA carriers with early breast cancer

 ● For BRCA carriers with early-stage, high-risk HER2-negative breast cancer
as defined by criteria from the OlympiA trial, we suggest adjuvant olaparib
rather than observation (Grade 2B).

Although poly (ADP-ribose) polymerase (PARP) inhibitors are used for

individuals with germline pathogenic variants in BRCA1 or BRCA2 and
advanced breast cancer, their role in early breast cancer was previously
undefined. A randomized trial (OlympiA) was conducted in over 1800 patients
with high risk, HER2-negative early breast cancer with BRCA1 or BRCA2
variants and high-risk clinicopathological factors who had received local
treatment and neoadjuvant or adjuvant chemotherapy [25]. Patients assigned
to the olaparib group had an improvement in three-year disease-free survival
relative to the placebo group (86 versus 77 percent). The benefit was
observed irrespective of hormone receptor status, and olaparib was generally
well tolerated. For BRCA carriers with high-risk disease as defined by criteria
from the OlympiA trial (table 4), we now suggest adjuvant olaparib rather
than observation. (See "Selection and administration of adjuvant
chemotherapy for HER2-negative breast cancer", section on 'Supporting
data'.)

CARDIOVASCULAR MEDICINE (June 2021)

Surgical left atrial appendage occlusion for patients undergoing cardiac

surgery

● For patients who are undergoing cardiac surgery for another indication
who have atrial fibrillation and a CHA2DS2-VASc risk score (table 1) of at
least 2, we recommend concomitant surgical left atrial appendage
occlusion (Grade 1B).

The left atrial appendage (LAA) is the primary source of thromboembolism in

patients with atrial fibrillation (AF). When patients with AF undergo cardiac
surgery, LAA occlusion is commonly performed with limited supporting
evidence. The effects of surgical LAA occlusion were studied in a trial enrolling
nearly 4800 patients with AF (with ≥2 risk factors for thromboembolism)
undergoing cardiac surgery, in which patients were randomly assigned to
surgical LAA occlusion or no occlusion and most continued oral
anticoagulation after the procedure [26]. At nearly four years of follow-up,
stroke or systemic embolism was about one-third less frequent in the
occlusion group than in the no-occlusion group, and perioperative
complications were similar in the two groups. These results support use of
surgical LAA occlusion as an adjunct to long-term anticoagulation for patients
undergoing cardiac surgery for another indication who have AF and a
CHA2DS2-VASc risk score (table 5) of at least 2. (See "Atrial fibrillation: Left
atrial appendage occlusion", section on 'For patients without contraindication
to long-term anticoagulation'.)

INFECTIOUS DISEASES (November 2020, Modified May 2021)

Vaccines to prevent SARS-CoV-2 infection

● For individuals who are eligible for vaccination according to local

allocation priorities, we recommend COVID-19 vaccination (Grade 1A).
Vaccine selection depends on local availability.

Various vaccines to prevent SARS-CoV-2 infection have become available in

different countries. In the United States, the COVID-19 mRNA vaccines
BNT162b2 (Pfizer-BioNTech COVID-19 vaccine) and mRNA 1273 (Moderna
COVID-19 vaccine) and the COVID-19 adenovirus vector vaccine Ad26.COV2.S
(Janssen COVID-19 vaccine) have received emergency use authorization for
use in individuals 18 years and older; BNT162b2 is also authorized for use in
children and adolescents 12 through 17 years [4-6]. The mRNA vaccines are
each given as two intramuscular doses separated by a few weeks; the
adenovirus vector vaccine is a single intramuscular dose. In large placebo-
controlled trials, these vaccines were highly effective in preventing
laboratory-confirmed COVID-19, especially severe/critical disease [27-29].
Local and systemic adverse effects (pain, fever, fatigue, headache) are
common but usually nonsevere. Ad26.COV2.S is associated with an extremely
small risk of thrombosis with thrombocytopenia, but its benefits outweigh
this rare risk [30]. (See "COVID-19: Vaccines to prevent SARS-CoV-2 infection".)

NEUROLOGY (April 2021)

Second course of IVIG not beneficial for patients with severe Guillain-
Barré syndrome

● For patients with Guillain-Barré syndrome treated initially with IVIG who
show further deterioration or no improvement, we suggest against
retreating with IVIG because it exposes patients to adverse risks without
additional benefit (Grade 2C).

For patients with severe Guillain-Barré syndrome (GBS) whose symptoms

worsen or fail to improve after a course of intravenous immune globulin
(IVIG), a repeat course has sometimes been given, despite uncertain benefit.
In a randomized trial of 93 patients with GBS and a poor predicted outcome,
those assigned to a second course of IVIG (given two to four days after
completion of the first course) had similar disability but more adverse effects,
including thromboembolic complications, than those who were assigned to
placebo [31]. Based on these data, we suggest against retreating with a
second course of IVIG for patients with GBS. (See "Guillain-Barré syndrome in
adults: Treatment and prognosis", section on 'Approach to patients who
relapse or worsen'.)

ONCOLOGY (April 2021)

Postoperative nivolumab after initial chemoradiotherapy for esophageal
and esophagogastric junction cancer

● For patients with localized esophageal or esophagogastric junction cancer

who have residual disease in the surgical specimen after initial
chemoradiotherapy, we suggest nivolumab for one year (Grade 2B),
although we discontinue it if disease recurs during treatment.

Patients with localized esophageal or esophagogastric junction (EGJ) cancer

who are treated with neoadjuvant chemoradiotherapy and have residual
disease at the time of resection remain at high risk for recurrence and death
from cancer, yet optimal postoperative management is unknown. In the
CheckMate 577 trial of nearly 800 such patients, adjuvant nivolumab for up to
one year doubled median disease-free survival compared with placebo (22.4
versus 11 months) without adversely affecting health-related quality of life
[32]. Benefits were seen across all patient subgroups (histology, location,
initial and posttreatment disease stage) and did not depend on programmed
cell death ligand-1 status. Overall survival data are not yet mature. Despite
the lack of data on survival, given the morbidity of disease recurrence, we
now suggest one year of adjuvant nivolumab for patients with resected
esophageal or EGJ cancer who have residual disease in the surgical specimen
after initial chemoradiotherapy. This approach has been endorsed by an
updated guideline on the treatment of locally advanced esophageal
carcinoma [33]. (See "Radiation therapy, chemoradiotherapy, neoadjuvant
approaches, and postoperative adjuvant therapy for localized cancers of the
esophagus", section on 'After preoperative therapy'.)

OBSTETRICS, GYNECOLOGY AND WOMEN'S HEALTH (February

2021)

Low-dose aspirin for those with previous pregnancy loss (miscarriage)

 ● For individuals who have experienced one or two pregnancy losses, we
suggest initiation of low-dose aspirin prior to conception (Grade 2C).

While low-dose aspirin (LDA; 81 mg) improves pregnancy outcomes for

individuals at high risk for preeclampsia or with antiphospholipid syndrome,
LDA did not show statistically significant benefits in a placebo-controlled trial
in over 1200 patients with one or two previous pregnancy losses. A limitation
of the trial was the low rate of adherence. In a new analysis of this trial using
detailed adherence data and adjustment for confounders, LDA started
preconception and continued throughout pregnancy was associated with
approximately 30 percent fewer pregnancy losses and 30 percent more live
births compared with placebo [34]. Based on these findings and the safety
profile of LDA in other pregnant populations, we now suggest preconception
initiation of LDA for individuals who have experienced one or two pregnancy
losses, but not for those who are nulliparous or who have not had a prior
loss. (See "Pregnancy loss (miscarriage): Comparison of treatment options
and discussion of related care", section on 'Review of data'.)

EMERGENCY MEDICINE (ADULT AND PEDIATRIC); OBSTETRICS,

GYNECOLOGY AND WOMEN'S HEALTH (February 2021)

Levonorgestrel intrauterine device for emergency contraception

● For patients who desire an intrauterine device (IUD) for emergency

contraception, we suggest a copper IUD or a levonorgestrel 52 mg IUD
rather than other hormonal IUDs (Grade 2C).

Until now, the copper TCu380A intrauterine device (copper IUD) was the only
IUD option for use as emergency contraception (EC). In a randomized,
noninferiority trial in 711 females who presented within five days of
unprotected intercourse and had a negative urine pregnancy test, the copper
IUD and the levonorgestrel intrauterine device 52 mg (LNG 52) resulted in
similar pregnancy rates (0.0 and 0.3 percent, respectively) [35]. Based on this
trial, we now suggest either the copper IUD or the LNG 52 IUD to individuals
who desire an IUD for EC. Some patients may prefer the lighter menstrual
bleeding or amenorrhea associated with LNG 52 IUD use. Use of the LNG 52
IUD represents off-label use for this indication. (See "Emergency
contraception".)

INFECTIOUS DISEASES; OBSTETRICS, GYNECOLOGY AND

WOMEN'S HEALTH; PRIMARY CARE (ADULT); FAMILY MEDICINE
AND GENERAL PRACTICE; EMERGENCY MEDICINE (ADULT AND
PEDIATRIC) (January 2021)

Anaerobic coverage for treatment of pelvic inflammatory disease

● For outpatients with mild to moderate pelvic inflammatory disease, we

suggest adding metronidazole to the standard treatment regimen of
ceftriaxone plus doxycycline (Grade 2C).

Anaerobic bacteria are frequently recovered from the upper genital tract of
women with acute pelvic inflammatory disease (PID), but whether antibiotic
regimens for PID should include anaerobic coverage has been controversial.
In a trial of 233 women with mild to moderate PID who were treated with
ceftriaxone and doxycycline and randomly assigned to additionally receive
either metronidazole (500 mg twice daily) or placebo for 14 days, clinical
improvement rates at three days were similar in the two groups [36].
However, at 30 days, women in the metronidazole group had a lower rate of
pelvic tenderness (9 versus 20 percent) and a nonsignificant trend towards a
higher 30-day clinical cure rate (96 versus 90 percent). Adherence was similar
in both groups. Given the potential additional benefits of anaerobic coverage,
we now add metronidazole to standard outpatient therapy for PID. (See
"Pelvic inflammatory disease: Treatment in adults and adolescents", section
on 'Anaerobic bacteria'.)

INFECTIOUS DISEASES; PRIMARY CARE (ADULT); FAMILY

MEDICINE AND GENERAL PRACTICE; OBSTETRICS,
GYNECOLOGY AND WOMEN'S HEALTH (January 2021)

Single-dose ceftriaxone for treatment of gonococcal infections

● For suspected or confirmed uncomplicated urogenital or anorectal

gonococcal infection, we suggest ceftriaxone in a single 500 mg
intramuscular dose rather than other regimens (Grade 2C). For individuals
who weigh ≥150 kg, we give a 1 g dose.

In the United States, the Centers for Disease Control and Prevention updated
its guidance on treatment of gonococcal infections to recommend ceftriaxone
as the preferred regimen, given as a single intramuscular dose of 500 mg for
individuals who weigh <150 kg or 1 g for individuals who weigh ≥150 kg [37].
Previous recommendations were for combination therapy with a lower dose
of ceftriaxone plus azithromycin. However, the previous preference for
combination therapy was based on a theoretical benefit, which is now
outweighed by decreasing susceptibility to azithromycin in Neisseria
gonorrhoeae. A higher dose of ceftriaxone is recommended because of
concern that lower doses are unlikely to be effective against isolates with
higher minimum inhibitory concentrations to ceftriaxone, which have
increased in prevalence. Presumptive treatment of chlamydia with
doxycycline is warranted if chlamydia coinfection has not been ruled out. We
agree with these updated guidelines. (See "Treatment of uncomplicated
Neisseria gonorrhoeae infections", section on '"High" dose intramuscular
ceftriaxone'.)
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