Government of Malawi

MALAWI STANDARD
TREATMENT GUIDELINES
(MSTG)
4 EDITION 2009
th

Incorporating
MALAWI ESSENTIAL
MEDICINES LIST
(MEML) 2009

Ministry of Health

©2009 by the Ministry of Health, Malawi

First edition 1990
Second edition 1993
Third edition 1998
Fourth edition 2009

Recommended Citation
MoH, 2009, Malawi Standard Treatment Guidelines,Fourth Edition.

All parts of this publication may be reproduced in any form, provided due acknowledgement is given and
no commercial gain is involved

Copies may be obtained through:

The Secretariate
National Medicines and Medical Supplies Committee
Ministry of Health
PO Box 30377, Lilongwe 3, Malawi
Tel : (265) 01 788 371
Fax : (265) 01 788 502

Computer typeset in Calibri

Printed and bound in Malawi by:

Design Printers, P.O. Box 330, Lilongwe.

ISBN 99908-41-01-2

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MSTG 2009
Table of Contents
Foreword---------------------------------------------------------------------------------------------------------- iv
References --------------------------------------------------------------------------------------------------------- v
Acknowledgements--------------------------------------------------------------------------------------------- vi
Prescribing Guidelines ----------------------------------------------------------------------------------------- vii
Presentation of Information --------------------------------------------------------------------------------- xvi
Prescriber’s guidance points ------------------------------------------------------------------------------- xvii
Medicine administration ------------------------------------------------------------------------------------ xvii
Medicine names ----------------------------------------------------------------------------------------------- xvii
Alternative medicines ---------------------------------------------------------------------------------------- xvii
Abbreviations ------------------------------------------------------------------------------------------------- xviii
Metric Units ----------------------------------------------------------------------------------------------------- xix
1.0 Blood and blood diseases ----------------------------------------------------------------------------- 1
2.0 Cardiovascular diseases ------------------------------------------------------------------------------- 8
3.0 Central nervous system conditions --------------------------------------------------------------- 14
4.0 Ear Nose and Throat Conditions------------------------------------------------------------------- 24
5.0 Emergencies -------------------------------------------------------------------------------------------- 29
6.0 Endocrine disorders ---------------------------------------------------------------------------------- 36
7.0 Gastro-Intestinal Conditions ------------------------------------------------------------------------ 40
8.0 Hepatic Disorders ------------------------------------------------------------------------------------- 54
9.0 Infectious Diseases ------------------------------------------------------------------------------------ 55
10.0 Miscellaneous Conditions --------------------------------------------------------------------------- 91
11.0 Musculoskeletal disorders --------------------------------------------------------------------------- 92
12.0 Obstetric and Gynaecological Conditions ------------------------------------------------------- 98
13.0 Ophthalmic Conditions ------------------------------------------------------------------------------ 111
14.0 Oral and Maxillofacial Conditions----------------------------------------------------------------- 113
15.0 Parasitic diseases ------------------------------------------------------------------------------------- 118
16.0 Respiratory Conditions ----------------------------------------------------------------------------- 132
17.0 Sexually Transmitted Infections (STIs) ----------------------------------------------------------- 143
18.0 Skin conditions ---------------------------------------------------------------------------------------- 157
19.0 Vaccinations ------------------------------------------------------------------------------------------- 167
20.0 Bites, Burns and Wounds -------------------------------------------------------------------------- 168
21.0 Renal Conditions -------------------------------------------------------------------------------------- 177
22.0 Poisoning ----------------------------------------------------------------------------------------------- 182
23.0 Nutritional disorders --------------------------------------------------------------------------------- 188
24.0 Pain management and palliative care ----------------------------------------------------------- 196
INDEX ---------------------------------------------------------------------------------------------------------------201

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MSTG 2009
Foreword

Medicine is a dynamic science and therefore it is important that publications such as the
Malawi Standard Treatment Guidelines (MSTG) be revised at short intervals. Revision of the 3rd
edition of the MSTG started with a consultative meeting of stakeholders followed by editorial
meetings and finally the approval process by members of the National Medicines and Medical
Supplies Committee.

The MSTG includes key information on the selection, prescribing, dispensing and administration
of medicines. It is designed as a digest for rapid reference and it may not always include all the
information necessary for prescribing and dispensing. It should therefore be interpreted in the
light of professional knowledge and supplemented as necessary by specialised publication and
by reference to product literature.

Pursuant to the African Union Assembly Abuja Declaration of 2005, Malawi like other member
states of the Union aims at putting 15% of the National budget towards towards the health
budget. Resources, particularly financial resources for health service delivery are often scarce.
Prudent use of these resources through improved diagnosis, rational prescribing, dispensing
and use of medicines is paramount. The MSTG aims at standardizing prescribing and dispensing
practices.

The 4th edition MSTG provides prescribers and dispensers with the currently recommended
treatment as well as preventative schedules for most common disease states found in the
country.

I would like to thank all those who took time to review the previous edition. Your contributions
are greatly appreciated.

I look forward to your continued support and contributions to future reviews of the MSTG and
other relevant publications.

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MSTG 2009
References

The following are national guidelines or reference text which should be consulted for further
information on specific areas or topics:

 Malawi National Medicine List, MOHP, 2008

 Malawi Prescribers Companion, MOHP, 1993
 A Paediatric Handbook for Malawi, J A Phillips, P N Kazembe, EAS Nelson, JAF Fisher, E
Grabosch, 2nd ed. 1998)
 Common Medical Problems in Malawi, P A Reeve (ed. J J Wirima)
 Management of Sexually Transmitted Infections Using Syndromic Management
Approach, Guidelines for Service Delivery 2nd Edition, Ministry of Health/NAC, Vol 3, 2004
Malawi;
 Guidelines for the Use of Antiretroviral Therapy in Malawi, MoH, 2nd Edition, 2008.
 Manual of the National TB Control Programme in Malawi, MOHP, 1997
 Infection Prevention Standards, MoH, 2006
 Guide for the Management of Malaria, MoH National Malaria Control Programme, 2007
 A Mental Health Handbook for Malawi, M Wilkinson, 1991
 Acute Respiratory Infection Policy, MoH ARI Program,
 Cervical Cancer Service Delivery Guidelines, MoH/JHPIEGO, 2005
 Recommended Guidelines for the practice of safe blood transfusion in Malawi, National
blood Transfusion Service/MOHP NACP, 1997
 Protocols for the Management of Common Obstetrical Problems, MoH Safe Motherhood
Initiative Taskforce, 1998
 Malawi National Reproductive Health Service Delivery Guidelines, MoH Reproductive
Health Unit, 2007
 National IMCI Chart Booklet, MoH IMCI Unit, 2007,
 Prevention of Mother to Child Transmission of HIV, Handbook for Health workers, MoH,
2003
 MoH Management of HIV/AIDS Related Diseases (2008 2nd Edition)
 MOH Guide for Pre- and Post-test Counselling and AIDS Counselling information.

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MSTG 2009
Acknowledgements

The National Medicines and Medical Supplies Committee (NMMC) expreses its
gratitude to the following people and organisations without whose support and
collaboration the revision of this document would not have been possible:-
Dr. G. Chithope Mwale, Francis Chafulumira, Norman Lufesi, Richman Mwale, Dr.
Q. Mbeye-Dube, Prof. Nyengo Mkandawire, Cynthia Kamtengeni, Prof. J. Wirima,
Enock Phale, Dr. T. Dzowela, Samuel Chirwa, Dr. T. Salimu, L. Mwale, Dr. R.
Mlotha, Dr. I. Idana, Dr. J. Mlotha, Amon Nkhata, Dr. B. Makanani, Dr. G. Mateyo,
Dr. J. Van Oosterhout, Dr. D. Chipeta, Dr. W. Mulwafu, Dr. S. Chipendo, Dr. P.
Kazembe, Dr. M. Joshua, Mr. Mkandawire, Aaron Sosola, Batto Mataya, Dr. E.
Ratsma, E.Phiri, Nicholas Mwamlima, Wilfred Dodoli, Richard Ndovi, Ms C.E.
Chilomo and Patrick Tembo.

The NMMC is particularly grateful to the cooperating partners WHO and USAID
funded Management Sciences for Health Strengthening Pharmaceutical Systems
Program (MSH/SPS) for the financial and technical support provided during the
review process.

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MSTG 2009
Prescribing guidelines
Prescribing Guidelines
1. General points
Consider each of the following general points before writing a prescription:
1.1 Not all patients need a prescription for medicines. Non-medicine
treatments and/or giving of simple advice may be more suitable in certain
situations.
1.2 Good therapeutics depends on:
 Accurate diagnosis, based on thorough history-taking, necessary careful
physical examination and, if required, supporting laboratory testing
 Knowledge of the medicines available
 Careful selection of the appropriate medicines
 Prescribing correctly the selected medicines and
 Ensuring that the patient understands fully how to use each prescribed
medicine properly.

1.3 Try to resist patient demand to prescribe injections or other expensive

dosage forms. E.g. capsules and oral liquids. Always make an effort to
explain to the patient that these may not represent the best form of
treatment for the particular condition

1.4 In life threatening conditions, always prescribe the most effective medicine
available irrespective of the cost or limited availability

1.5 In order to avoid possible confusion, always prescribe medicines by their

generic name and not by the brand name e.g. diazepam (not Valium),
paracetamol (not Panado) or abbreviations i.e. PCM

1.6 Avoid prescribing combination medicines unless they have a known

significant therapeutic advantage over single ingredient preparations

1.7 When prescribing any medicine, always take into consideration factors such
as:
 Patient’s age
 Patient’s sex
 Patient’s weight
 The effect of other diseases present
 Pregnancy
 Breast-feeding
 The likely degree of patient compliance with treatment
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Prescribing guidelines

1.8 In all cases the likely benefit of any prescribed medication/s must be
weighed against potential risks

1.9 Avoid overuse of symptomatic treatments for minor self-limiting conditions

1.10 Avoid multiple prescribing (polypharmacy), especially when the diagnosis is

not clear

2. Prescribing of placebos
2.1 Avoid this whenever possible. Instead spend time reassuring and educating
the patient

2.2 If it is absolutely necessary to prescribe a placebo, always choose a safe,

cheap medicine which is not essential for the treatment of other important
conditions, e.g. multivitamin tablets or vitamin B compound tablets

2.3 Never prescribe injections as placebo

2.4 Never prescribe tranquilizers e.g. diazepam, phenobarbitone, as placebos

3. Prescription writing
Note: Whenever possible, return all incomplete, inaccurate, illegible or
unclear prescriptions to the prescriber for clarification, completion, or
correction, before they are presented for dispensing

3.1 Write all prescriptions legibly in ink. Poor writing may lead to errors in
interpretation by the dispenser which may have harmful and possibly
disastrous consequences for the patient

3.2 Write the full name and address of the patient, and sign and date the
prescription form

3.3 Write the name of the medicine or preparation using its full generic name.
Do not use unofficial abbreviations, trade names, or obsolete names as
these may cause confusion

3.4 Always state the strength of the preparation required where relevant

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Prescribing guidelines
3.5 For solid dosage forms:
 quantities of one gram or more should be written as 1g, 2.5g, 10g, etc
 quantities of less than one gram but more than one milligram should be
written as milligrams rather than fractions of a gram, e.g. 500mg and
not 0.5g

3.6 Quantities less than one milligram should be expressed as micrograms (in
full) and not as fractions of a milligram, e.g. 100 micrograms rather than 0.1
mg or 100mcg.

3.7 If decimals are used, always write a zero in front of the decimal point where
there is no other figure, e.g. 0.5mL and not .5mL

3.8 Always state the full dose regimen, i.e.

 dose size
 dose frequency
 duration of treatment
The quantity to be dispersed will be deduced from this.

3.9 Avoid use of the direction “to be used/taken as required”. Instead state a
suitable dose frequency. In the few cases where ‘as required’ is
appropriate, the actual quantity to be supplied should be stated

3.10 Avoid using unknown abbreviations. The following abbreviations can be

used when writing a prescription:

Abbreviation Meaning
b.i.d. or b.d. twice a day
prn occasionally
q4h every 4 hours
q6h every 6 hours
q8h every 8 hours
q.i.d or q.d. 4 times a day
t.i.d. or t.d. 3 times a day
o.m. every morning
o.n. every night
nocte at night
mane in the morning
n et m or n.m. night and morning
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Prescribing guidelines
p.o. by mouth
a.c before meal
p.c. after meals
stat immediately or at once
sig label

3.11 For oral liquids, doses should be stated in terms of 5mL spoonfuls for
linctuses, elixirs, syrups and paediatric preparations, and in 10mL spoonfuls
for adult mixtures

3.12 Doses other than 5mL or 10mL or multiples of these will be diluted to the
nearest equivalent 5mL or 10mL quantity for dispensing

3.13 Total volumes of liquid preparations prescribed are usually selected from
50, 100, 300 or 500mL volumes

3.14 Total quantities of solid or semi-solid preparations prescribed are usually

selected from 25, 50, 100, 200, 300, or 500g except where the product is
supplied ready packed in a particular pack size, e.g. tetracycline eye
ointment (3.5g)

3.15 Where relevant, always remember to include on the prescription any

special instructions necessary for the correct use of a medicine or
preparation, e.g. “before food” etc.

4. In-patient prescriptions
4.1 Write these prescriptions and records of dispensing and administration on
in-patient treatment cards

4.2 Only use one card per patient at any one time

4.3 Clearly state a suitable dose frequency, or time of administration on

medicines to be given ‘as required’

4.4 Always state the route of administration for all medicines prescribed

4.5 When any changes or cancellations are made to a prescription card, or if

treatment is to be stopped, clearly sign and date the card in the
appropriate place

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Prescribing guidelines

4.6 If the timing of a medicine dosage is critical, ensure that suitable

arrangements are made for the medicine to be given at the specific time/s
required

5. Guide to quantities to be supplied

5.1 Oral liquids
Adult mixtures (10 mL dose)
200mL (20 doses)
300mL (30 doses)
Elixirs, linctuses and paediatric mixtures (5mL dose)
50mL (10 doses)
100mL (20 doses)
150 mL (30 doses)

5.2 Preparations used in body cavities

E.g. ear drops, nasal drops

5.3 External preparations

Part of body Semi-solid (g)* Liquids (mL)**

Face 5-15 100
Groin and genitalia 15-25 100
Both hands 25-50 200
Scalp 50-100 200
Both arms and legs 100-200 200
Whole body 200 500

* E.g. creams, pastes, ointments etc

**e.g. lotions, applications, topical solutions, etc (for paints normally 10-
25mL is supplied)

6. Prescriptions for controlled medicines

6.1 These medicines are controlled by the Laws of Malawi, The Pharmacy
Medicines and Poisons Act, 1988. Consult the relevant sections of the Act
for details of the appropriate legal requirements in each case
6.2 Medicines covered by the Act and which are also used in the MSTG are:
 Morphine sulphate injection
 Morphine sulphate solution
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Prescribing guidelines
 Pethidine hydrochloride injection
 Morphine sulphate tablets

6.3 These medicines have potential for abuse which may be result in
dependence. Carefully record all procedures involving them in the
appropriate record books

6.4 Prescriptions for these medicines may only be written by registered

medical practitioners

6.5 The following legal requirements must also be observed when writing such
prescriptions:
a) the prescription must be in the prescriber’s own handwriting
b) it must be signed and dated
c) the prescriber’s address must be shown
d) the name and address of the patient must be stated
e) the total amount of the item to be supplied must be stated in
words and figures

6.6 It is an offence for the prescriber to issue and for the pharmacy/dispensary
to dispense prescriptions for controlled medicines, unless the
requirements of the law are fully complied with

Notes:
a) In certain exceptional circumstances, senior nurses in charge of
departments, wards, or theatres, and midwives, may also obtain and
administer certain controlled medicines as part of their work. The
relevant sections of the Act should be consulted for the details of the
appropriate legal requirements in each case
b) Hospital in-patient prescriptions for controlled medicines should be
prescribed on a separate prescription as well as written on treatment
cards or case sheets and signed/dated by the person administering
the medicine.

7. Adverse drug reactions (ADRs)

7.1 Nearly all medicines may produce unwanted or unexpected adverse effects,
some of which may be life threatening e.g. anaphylactic shock, liver failure

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Prescribing guidelines
7.2 Prescribers should immediately report any serious or unexpected adverse
effects thought to be due to a medicine to :
The Registrar,
Pharmacy, Medicines and Poisons Board,
PO Box 30241, Lilongwe.
Tel: 01 755 165/166 Fax: 01 755 204

7.3 Rules for prevention of ADRs

a) Never use a medicine unless there is a clear indication for its use
a. Only use medicines in pregnancy if absolutely essential
b. Check if the patient has had any previous reactions to the medicine
or to similar medicines
c. Remember to reduce doses when necessary e.g. in the young, the
elderly, and if liver or renal disease is present
d. Always prescribe the minimum number of medicines possible
e. Carefully explain the dose regimens to patients, especially those on
multiple medicines, the elderly and anyone likely to misunderstand
f. If possible, use medicines with which you are familiar
g. Look out for ADRs when using new or unfamiliar medicines
h. Warn patients about likely adverse effects and advise them on what
to do if they occur
i. Patients on certain prolonged treatments e.g. Anticoagulants,
corticosteroids, Insulin etc should carry a small card giving
information about the treatment

8. Paediatric prescribing
8.1 In these guidelines, paediatric medicine doses are usually given according
to body weight and not age, and are therefore expressed as mg/kg etc. The
main reason for this is that children of the same age may vary significantly
in weight.

Thus it is safer and more accurate to prescribe drugs according to body

weight. Moreover, this should encourage the good practise of weighing
children whenever possible.

8.2 When a weighing scale is not available, the following graphs showing
weight of children from 1-24 months and 2-15 years respectively can be
used to estimate the weight of a child of known age after assessment of
whether the child appears of average, small or large in size for its age.

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Prescribing guidelines

Three lines are shown on each graph

 the middle (50th percentile) line shows weight for average children
 the lower (3rd percentile) line shows weights for children who are very small
for their age
 the upper (97th percentile) line shows weights for children who are very
large for their age

Example: When prescribing for an 8 months old baby who is fatter than usual,
(i.e. larger than average weight for age):
 look along the x-axis (age) of the graph to the 8 month mark

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Prescribing guidelines
 follow the vertical line from there to the point somewhere between the
middle (50th percentile) and top of (97th percentile) lines on the graph
 from there follow a horizontal line left to cut the y-axis (weight)
 the estimated weight is around 10 kg

Example: when prescribing for an 81/2 year old thin child, (i.e. less than
average weight for age) of years:
 Look along the x-axis (age) of the graph to mid way between the 8
and 9 year marks
 Follow the vertical line from there until it meets the lower (3rd
percentile) line on the graph
 From there follow a horizontal line left to cut the y-axis (weight)
 The estimated weight is around 20.5 kg

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Prescribing guidelines
8.3 Neonates have delayed hepatic and renal excretion of medicines. Therefore
give special consideration when prescribing for children less than 30 days
old and especially premature infants.

9. Medicine interactions
9.1 Whenever prescribing a particular medicine, care should be taken to avoid
problems of interactions with other medicines, whether these are:
 also prescribed at the same time
 previously prescribed by another prescriber for the same or
another condition and currently being taken by the patient
 purchased or otherwise obtained by the patient for the purpose
of self-medication

9.2 Thus, before prescribing a medicine, always obtain details of any other
medication currently being taken by the patient

9.3 Where a medicine interacts with alcohol (e.g. metronidazole, diazepam,

anti-diabetic medicines, tricyclic antidepressants etc.) remember to counsel
the patient to avoid taking alcoholic drinks during the course of treatment
and for at least 48 hours after completion of the course

Presentation of Information
a. Arrangement of sections
Standard treatments have been grouped in sections according to either
body systems (e.g. respiratory conditions, gastrointestinal conditions, etc)
or types of disorder (e.g. parasitic diseases, nutritional disorders, etc)

Use the table of contents, pp ii, to locate the particular section required.

b. Indexing and Cross-referencing

All diseases, conditions, tables, etc are included in an index. Extensive
cross-references are given in the text, by section number and page number,
to facilitate location of other references to the subject elsewhere in the
guidelines.

Use the Index on page 201-208 to quickly find the required subject.

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Prescribing guidelines
Prescriber’s guidance points
 These are given for most standard treatments and are key points to be
considered before prescribing for a patient with a particular condition.
 Certain points as well as warnings are given added emphasis by inclusion in
a boxed border.

Medicine administration
 Unless otherwise specified, the oral route is to be used. Even when a
parental route is specified, with medicines which are well absorbed orally
and which are available as an oral dosage-form, it is often possible to
switch to oral administration once the patient has improved and is able to
swallow/tolerate oral medication
 Additional guidance on medicine administration is given, where relevant, as
bulleted points after dosage regimen.

Medicine names
 Medicines recommended for use are those on the current Malawi National
Medicine List, 2009. Generic names are used and indicated in bold type.
Where necessary, proprietary names are indicated in italic type.

Alternative medicines
 These are indicated where appropriate and available for alternative
treatment of a particular condition. They should be used only if the
recommended medicine is not available or is not suitable for a particular
patient.
 In some cases (where indicated) alternative (i.e. 2nd line) medicines may be
used when a satisfactory response has not been obtained with the
recommended (1st line) medication.

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Abbreviations

Abbreviations

ARI - Acute respiratory infections

ART - Anti retroviral therapy
BF - blood film examination
BP - blood pressure
CSF - cerebrospinal fluid
CVA - cerebrovascular accident
CXR - chest x-ray
DIC - disseminated intravascular coagulopathy
FBC - Full blood count
FFP - Fresh Frozen Plasma
g - gram
Hb - haemoglobin
HIV - Human immunodeficiency virus
i/m - intramuscular
i/v - intravenous
IU - international units
JVP - juvenile venous pressure
Kg - kilogram
L - litre
LP - lumbar puncture
LRTI - lower respiratory tract infection
mg - milligram
mL - milliliter
mmol - millimole
MU - mega (1 million) units
NGT - nasogastric tube
PCV - packed cell volume
s/c - subcutaneous
STI - sexually transmitted infections
TB - Tuberculosis
TTP - Thrombotic thrombocytopenic purpura
URTI - upper respiratory tract infection

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Metric units
Metric Units
1 kilogram (kg) = 1,000 grams (g)
1g = 1,000 milligrams (mg)
1 mg = 1,000 micrograms
1 litre (L) = 1,000 millilitres
1 ml of water =1 g
1% (m/v) = 10 mg/mL

Equivalents
1 litre = 1.8 pints
1 pint = 568.3 mL
1 kg = 2.2 pounds
1 lb = 453.4 g
1 ounce (oz) = 28.35 g

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1. Blood and blood disorders

1.0 Blood and blood diseases

1.1 Blood: Guidelines for Appropriate Use

 Refer to the National Transfusion Service/National AIDS Control programme
booklet Recommended Guidelines for the Practice of Safe Blood Transfusion
in Malawi for further details including information on:
 donor recruitment and selection,
 blood collection,
 storage procedures and records,
 laboratory testing of donor and recipient’s blood,
 transfusion reactions and
 clinical aspects of blood transfusion and administration.
 Blood transfusion although having undoubted benefits, also carries serious
risks including:
 Possible transfusion of infections (e.g. HIV and hepatitis)
 Immune-system related problems (e.g. Intravascular haemolysis)
 Circulatory overload
 It is expensive and uses a scarce human resource, therefore only prescribe
blood if:
 Less hazardous therapy has been or will be ineffective, and
 The benefits outweigh the risks involved
 The decision to transfuse blood has been based on careful assessment
of the patient which indicates that it is necessary to save life or prevent
major morbidity
 Except in the most exceptional life-threatening situations, always transfuse
blood which has been obtained from appropriately screened donors and/or
appropriately screened for infectious agents
 Ensure that compatibility testing is carried out on all blood transfused even if,
in life-threatening emergencies, this is done after it has been issued.
 Observations of patient’s vital signs should be done every 15 minutes during
blood transfusion and 4 hourly after transfusion for the next 24 hours.

1.2 Indications for whole blood or red cell suspension transfusion

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1. Blood and blood disorders

1.2.1 Severe anaemia

Neonates
 If Hb less than 9 g/dl and requiring oxygen or with haemodynamic
disturbance (e.g. shock, heart failure)

Children and infants

 If Hb less than 4 g/dl or PCV <12
 If Hb less than 6 g/dl or PCV <18 and there are clinical complications e.g.
heart failure

Dose
 Transfuse 20ml/kg of whole blood or 10ml/kg of red cell suspension
 In severely malnourished children give 10mls/kg of whole blood over 4
hours and frusemide 1mg/kg should be given with the transfusion

Pregnancy
 If Hb less than 7 g/dl at any time during pregnancy
 If Hb less than 10 g/dl during the 3rd trimester
Adults
 If Hb less than 6 g/dl
 If Hb less than 7 g/dl and there are clinical complications

Dose
 One unit of whole blood or one unit of red cell suspension will raise a
patient’s haemoglobin by 1-1.5g/dl

Pre-operatively Surgery
 If Hb less than 7 g/dl

1.2.3 Acute haemorrhage with shock (See Section 1.5 page 4, Table 1)

1.2.4. Intra-operative use (where necessary)

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1. Blood and blood disorders

Note: Do not use whole blood or red cell suspension transfusion to expand
blood volume

1.3 Platelets
 Platelets have a short half life of 5 days
 Must be transfused immediately upon arrival. Platelets should never be
stored in a refrigerator or blood bank or in the ward.
 Decision to transfuse should be based on a combination of clinical and
laboratory findings rather than empirical platelet levels.

1.3.1 Indications for platelets use

 Bleeding due to thrombocytopenia as a result of defective platelet
production such as aplastic anaemia or leukaemia
 Increased consumption e.g DIC
 Dilutional effects e.g. in massive transfusion
Note: All patients needing platelets need further investigations, please
refer to Central Hospital.
Dose
 1 unit per 10kg
 For infants under 10 kg, 5ml/kg

1.4 Fresh frozen plasma

 Contains all clotting factors
 Comes in volumes of 200-300 mls
 Fresh frozen plasma (FFP) should be thawed before use using water bath at
30-37 degrees. (If water bath is not available, a plastic basin with lukewarm
water or cold tap water can be used.) Never use hot water
 Once thawed, FFP must be used immediately. FFP must never be refrozen.
 The patient needs further investigations; please refer to the central
hospital.

1.4.1 Indications for use of fresh frozen plasma

 Replacement of single factor deficiencies (if single factor concentrates are
not available)
 Immediate reversal of warfarin effect
 Vitamin K deficiency associated with active bleeding
 Acute disseminated intravascular coagulopathy

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1. Blood and blood disorders

 Thrombotic thrombocytopenic purpura (TTP)

 May be used in massive transfusion or liver disease
Dose
15-20ml/kg
Note: No justification for use in hypovolaemia, nutritional support in protein losing states,
plasma exchange except in TTP.

1.5 Acute haemorrhage

 In massive haemorrhage i.e. from trauma it is difficult to estimate how
much blood a patient has lost. However a good estimate can be made by
calculating the patient’s normal circulating volume versus vital signs and
other organ function tests. See Table 1 below.
 Restoration of blood volume with suitable replacement fluids (see note
above) is more important than red cell replacement in the management of
previously healthy patients who have lost under 30% of their blood volume.
 The need for blood transfusion must be determined by:
 The amount and speed of blood loss
 The patient’s vital signs
Table 1: Assessment of Blood Loss (For a 70 kg adult)
Stage 1 Stage 2 Stage 3 Stage 4
Blood loss (litres) <0.75 0.75-1.5 1.5-2 >2
Pulse rate <100 >100 >120 >140
BP Normal Normal 90/60 <70
Respiratory Rate <20 >20 >30 >40
Capillary Refill <3 seconds <3 seconds >3 seconds >3 seconds
Mental State Normal Anxious Confused Lethargic
Urine output/Hour >30 mls 20-30 mls <20 mls <10 mls
Replacement fluid 2L 2-4.5L >5L plus 2 >6L plus 3 units
vol (L) units blood blood

 Replacement fluids which may be used are:

 Haemacel : Replace every 1 ml of blood lost with 1 ml of fluid
 Sodium lactate compound (Ringers lactate) i/v infusion or
Normal saline i/v infusion Replace 1 ml of blood lost with 3 mls
of fluid.
Do not use dextrose 5% or Darrow’s ½ strength in dextrose 5% as replacement
fluid

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MSTG 2009
1. Blood and blood disorders

 Maintain the airway and give oxygen by face mask first, especially
for patients in stage 3 and 4. Make sure they are breathing
adequately.
 Insert 2 large bore cannulae (gauge 14 or 16) and collect blood
samples for full blood count (FBC), grouping and cross-matching.
 Give half of the calculated dose of replacement fluid in the first
hour and give the other half over 3 hours.
 Always assess the effects of fluid therapy. Remember to give
warm fluids and cover patients to avoid hypothermia.
 Aim at improving oxygen carrying capacity first before correcting
anaemia. Remember to add maintenance fluids to the
replacement fluid plus any on-going losses.
Note: Maintenance fluids can be calculated as follows:
(i) Adults: Body weight x 1.5mls
(ii) Children: May use the rule of 4.2.1 for children or refer to
section on diarrhoea. (Section 7.5 page 42)
 Remember : deficit + maintenance + on-going loss

1.6 Adverse reactions to transfusion

 Suspect an adverse reaction if any of the following occurs:

 Severe pain at transfusion site or in the back, chest or hand
 Rise in temperature of 1oC above the baseline
 Increase in pulse rate of >20/minute above baseline
 Fall in systolic BP >20 mm Hg
 Urticaria
 Rigors
 Haemoglobinuria
 Shortness of breath,
 Wheezing
 If a reaction occurs within 15 minutes then
 Stop the transfusion.
 Set up a normal saline infusion in the opposite arm.
 Inform a clinician.
 If a reaction occurs after 15 minutes then
 Inform clinician for a decision on what action to take
 If Medical Officer is not available to assess patient within 15
minutes of being informed stop the transfusion.
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MSTG 2009
1. Blood and blood disorders

1.6.1 Mild reaction

 Signs and symptoms: itchy rash
Treatment
 Slow the transfusion
 Give Chlorpheniramine 10mg i/m stat
Alternative
 Promethazine 25 mg i/m stat
 Continue transfusion if there is no progression of symptoms after
30minutes
 If symptoms persist, treat as moderate reaction.

1.6.2 Moderate reaction

 Signs and symptoms: Severe itching, urticaria, fever,rigors,
tachycardia
Treatment
 Stop the transfusion
 Set up a normal saline infusion in the opposite arm
 Inform clinician
 Give Hydrocortisone 200mg i/v stat,
Alternative
 Chlorpheniramine 10 mg i/m stat
 If wheezing, give bronchodilator see Section 16.2.1 page 137.
 If no improvement treat as life threatening reaction

1.6.3 Life Threatening Reactions

 Stop blood transfusion, but keep i/v line open with normal saline
 Maintain airway and give oxygen
 Give Adrenaline 0.01mg/kg body weight
 Treat shock (See Section 5.1.1 page 29)

1.7 Sickle cell disease

 Educate patient and family on the nature and complications of
the disease
 Avoid factors precipitating sickle cell crises such as:
- Dehydration
- Exposure to cold
- Extreme physical exercise
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MSTG 2009
1. Blood and blood disorders

- High altitude
Treatment
Anti- malarial prophylaxis
 SP 525mg as a single dose each month
Alternatively
 Proguanil 200mg daily or Chloroquine 250mg
 Encourage to be sleeping under an insecticide treated bed net
(ITN) every night
 Folic acid 5mg daily
 In children more than 6 months old, long term antibiotic
prophylaxis
 Benzathine penicillin 1.2 MU i/m once monthly
 < 30 kg: give Benzathine penicillin 600,000 MU/dose
Alternatively
 Phenoxymethylpenicillin 250 mg 8 hourly daily
 Refer for further consultation
1.7.1 Sickle cell disease crisis
 Consider sickle cell crisis in the following:
- Dactylitis –hand foot swelling in early infancy.
- Painful crisis –involving muscle, bone, lung and intestines.
- Life threatening decline in haemoglobin levels due to
aplastic crisis,sequestration crisis and haemolytic crisis
- Priapism-sudden painful onset of a tumescent penis that
will not relax. Occurs typically in boys between 6 and 20
years old
- Stroke
Management
 Rehydration therapy
 Give analgesics usually with narcotics or non steroidal anti-
inflammatory drugs (See Section 24 page 196)
 Give oxygen
 Consider
- blood transfusion for severe anaemia
- Antibiotics
- Follow-up through monthly clinics
 Diagnose and treat the precipitating caus

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MSTG 2009
2. Cardiovascular diseases

2.0 Cardiovascular diseases

2.1 Acute Pulmonary Edema

Signs and symptoms: dyspnoea, cough {often with frothy, pink-tinged
sputum}, tachypnoea, signs of increased respiratory effort and diffuse
rales or crackles.
General measure
 Prop up patient to sitting position
 Restrict fluids
Treatment
 Oxygen therapy
 Drain pleural effusions if present.
Adults
 Frusemide 40-80 mg slow i/v (over 5 mins). Repeat if required
 Morphine 5-10 mg slow i/v and Metoclopramide 10mg i/v.
Repeat both if required.
 If no response: Give Aminophylline 250-500 mg slow i/v (over
10-20 mins)

Children
 Give Morphine 5-10 mg slow i/v (over 5 mins) Repeat every 4
hours if required
 Give Frusemide 1-2mg/kg.
 Specific treatment should be given according to the cause e.g.
hypertension

2.2 Congestive Heart Failure

Signs and symptoms include tachycardia, hepatomegaly, oedema raised
JVP.
 Extra cardiac symptoms may be the primary manifestation in children
and these may include tachypnea, wheezing, poor feeding, sweating,
cough, excessive weight gain and failure to thrive
 Look for underlying cause or precipitating and aggravating factors
(e.g. hypertension, anemia, pericardial effusion, arrhythmia, infection
and hyperthyroidism) and treat accordingly.

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MSTG 2009
2. Cardiovascular diseases

General measures
 Reduce salt intake
 Prop the patient up on pillows
 Treat underlying cause if possible, e.g. anaemia, rheumatic carditis,
hypertension
 Bed rest in severe cases, reduced activity in milder cases,
 Give oxygen if cyanosed or restless

Treatment
Adults
 Frusemide 40-160 mg daily in divided doses plus

 Enalapril 10-20 mg once or twice daily

Alternatively
 Spironolactone 25mg once daily
 If atrial fibrillation is present add Digoxin 0.25mg every 6 hours. on first
day then from day two onwards, Digoxin 0.125-0.25 mg daily
 If rapid atrial fibrillation is present (heart rate >100/min), a loading dose
of 0.75mg – 1mg in divided doses on the first day can be given
 Treat underlying cause

Note: Potassium supplementation is not required in patients on frusemide

and enalapril or spironolactone.

Children
 Give Frusemide 1-2 mg/kg orally or i/v once or twice daily

2.3 Hypertension
 Diagnosis is based on a raised blood pressure measured while patient is
at rest on at least 3 separate readings.
 Hypertension is generally asymptomatic.
 Essential hypertension is unusual in children and young adults and an
underlying cause should be excluded at hospital level
 Refer all children with hypertension to a doctor for management
 A child’s expected BP can be calculated as:
- Mean systolic BP = (age in years x 2) + 80
- Mean diastolic BP = 2/3 of systolic BP

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MSTG 2009
2. Cardiovascular diseases

 Remember to use the correct cuff size when measuring BP. It should
cover 2/3 of the upper arm
Table 2: Classification of Hypertension
Type of Systolic Diastolic
Hypertension Blood Blood
Pressure Pressure
Mild 140-159 90-99
Moderate 160-179 100-109
Severe >180 >110

General measures
 Reduce salt intake
 Stop smoking
 Regular exercise
 Loose weight
 Avoid excessive alcohol consumption
 Consider medicine treatment for mild hypertension only if the above
general measures are unsuccessful

Treatment
 Explain to the patient that treatment must be regular (every day), closely
monitored and generally has to be taken for life
 Use the following stepped treatment approach with the medicines in this
order unless there are specific contraindications, co-morbidities or side-
effects:

2.3.1 Stepped anti-hypertensive treatment approach (adults)

 Step 1: Hydrochlorthiazide 25 mg each morning, increasing the dose is not
advised
Alternatively
Bendrofluazide 2.5 mg each morning. Avoid in pregnancy and breast-
feeding
 Step 2: Hydrochlorthiazide 25mg once daily and Amlodipine 5-10mg once
daily
 Where Amlodipine is not available Nifedipine 10-20mg slow release tablets
twice daily can be used.

10
MSTG 2009
2. Cardiovascular diseases

 Step 3: Hydrochlorthiazide 25mg once daily, Amlodipine 5-10 mg once

daily and Enalapril 10-20mg once daily
 Where Enalapril is not available Captopril 12.5-50mg every 8 hours can be
used.
Note:
(i) Best to start with a lower dose of Enalapril 5mg and increase to
10mg after observation of the BP response over a few days.
(ii) Avoid Enalapril and Captopril in pregnancy and breast-feeding

 Step 4: Hydrochlorthiazide 25mg once daily, Amlodipine 5-10 mg once

daily, Enalapril 10-20mg once daily and Atenolol 50-100mg once daily.
 Where Atenolol is not available Propranolol 40mg - 80mg every 8 hours can
be used.
 Step 5: Refer to Medical Specialist

Note:
(i) Side-effects may outweigh benefits
(ii) In patients with severe hypertension or complications (heart
failure, renal failure) start medicine treatment immediately
(iii) In patients without co-morbidity, aim for a BP of around 140/90

2.3.2 Emergency antihypertensive treatment

Symptoms/Signs of hypertensive crisis: encephalopathy, convulsions, retinal
hemorrhages or blindness.
 Reduce the blood pressure in a controlled manner to avoid impaired auto-
regulation of cerebral blood flow.
 Only use parenteral therapy in:
 hypertensive heart failure
 hypertensive encephalopathy
 malignant hypertension
 eclampsia
 hypertension and dissecting aneurysm of the aorta

Note: Intravenous rapid lowering of blood pressure has several risks and
should be done under close monitoring only, preferably in a high or
intensive care setting. It is only indicated in hypertensive emergencies
mentioned above.

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2. Cardiovascular diseases

Treatment
Adults
 Hydralazine 5-10 mg i/m
 Repeat up to every 1 hour as necessary
 If heart failure:add Frusemide 40 mg i/v stat

Sub-lingual nifedipine (10 mg) should be avoided due to the unpredictable

 pressure, unless parenteral drugs are unavailable.
response of the blood

Children
 For fluid overload: Frusemide 1 mg/kg bolus i/v or i/m
 For hypertensive encephalopathy: Hydralazine 0.15 mg/kg slow i/v
- Repeat every 30-90 minutes as required
- Maximum dose: 1.7-3.6 mg/kg in 24 hours
 Long term management of hypertension would depend on the cause hence
these patients need to be referred for proper management.

2.4 Angina Pectoris

 Minimize risk factors by:
 weight reduction (if obese)
 control of hypertension
 stopping smoking
 Address other factors such as:
 high blood cholesterol
 stressful lifestyle
 excessive alcohol intake
 Encourage regular moderate exercise

2.4.1 Stable angina (infrequent attacks)

Treatment
 Aspirin 150 mg daily
o contraindicated in peptic ulcer
 and Glyceryl trinitrate 0.5 mg sublingually as required.
 Maximum 3 tablets per 15 minutes
 deteriorates on storage: keep tablets in original container for no more than
3 months after opening
 Alernatively use Isosorbide dinitrate 5-10mg sublingually as required
instead of glyceryl trinitrate
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MSTG 2009
2. Cardiovascular diseases

Prophylaxis:
 Isosorbite dinitrate 30-120 mg daily in 2 divided doses
 Atenolol 50mg daily
Alternatively
 Amlodipine 5-10mg daily may replace or be cautiously added to Atenolol.
 If pain continues despite the above treatment refer to Medical Specialist

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3. Central nervous system conditions

3.0 Central nervous system conditions

3.1 Seizures and epilepsy

3.1.1 Seizures
 Sudden abnormal function of the body, often with loss of consciousness,
and excess of muscular activity, or sometimes loss of it, or an abnormal
sensation.
 Ensure airway is clear and patient is not hurting himself. Turn patient in a
recovery position. Don’t insert any object between the teeth
 Monitor blood sugar. If hypoglycemia is suspected, give 1 ml/kg 50%
Dextrose or 5 ml/kg 10% Dextrose.
Treatment
Adults:
 Give Diazepam 5-10 mg i/v slowly. Repeat once after 10 minutes.
 If convulsions continue for another 10 minutes or are repeated more than 3
times without patient gaining consciousness between seizures, treat as
status epilepticus (Section 3.1.2 page 15). If repeated seizures, consider
antiepileptic therapy as in Section 3.1.3 page 15.
 Look for treatable causes and provoking factors (malaria, infection, tumour,
alcohol).
 Diazepam i/m absorbs slowly and unreliably: i/v or rectal routes are
preferable

3.1.1.1 Generalized seizures in children

Treatment
 Sodium valproate 20-40 mg/kg/day in 2 to 3 divided doses
Alternatively
 Phenobarbitone 5-8mg/kg daily.
or
 Carbamazepine 2.5mg/kg per dose twice dailyb,
 Increase the dose weekly by 5mg/kg until 20mg/kg is reached.

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3. Central nervous system conditions

3.1.1.2 Partial seizures in children

Treatment
 Carbamazepine 5mg/kg/day in 2 divided doses (2.5mg/kg bd),
Alternatively
 Sodium valproate 20-40 mg/kg/day in 2 to 3 divided doses

3.1.1.3 Petit mal

Treatment
 Ethosuximide 15 mg/kg at night as a single dose increased gradually if
necessary to 50 mg/kg daily in 2 divided doses

3.1.2 Status epilepticus

 Continuous seizure activity or seizures without recovery of consciousness
for > 30 minutes
 Always an emergency, mortality is high.
 Clear airway, insert iv-line, position patient in a recovery position. Don’t
insert any object between the teeth.

Treatment
Adults:
 Give Diazepam 5-10 mg i/v. Repeat every 10 minutes until the patient
stops convulsing. If patient not controlled give continuous diazepam i/v
infusion with careful attention of respiratory depression.
 Give a loading dose of anti-epileptic medicines:
 Phenytoin 15 mg/kg (600-1200 mg) i/v. Dilute with 100 ml normal saline
and give slowly, no more than 100 mg/minute.
 If still fitting after 10 minutes, then give Phenobarbitone 10 mg/kg (400-
600 mg) i/v: dilute with water for injection 1:10 and give slowly, no more
than 100 mg/minute. Or give 200 mg i/m in each buttock
 If status continues, use Paraldehyde 5 ml deep i/m in a buttock, and repeat
5 ml i/m in alternate buttock. Paraldehyde can also be given through the
rectum using asyringe with needele removed.
 Ensure that the dose is given promptly and therefore remains in the syringe
for only a short time (paraldehyde dissolves plastic)
 Check blood sugar. Give glucose, if suspicious of hypoglycemia, see Section
6.1 page 36

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3. Central nervous system conditions

 Give Thiamine 100mg i/v or i/m once daily before giving glucose if patient
suffers from alcoholism. Continue for 3 days.
 If still no improvement, consider general anaesthesia (in ICU setting
preferably).
 If patient improves, start anti-epileptic treatment as in Section 3.1.3 page
15 and continue until cause of status epilepticus is treated.

3.1.3 Epilepsy
 Repeated seizures due to a disorder of the brain cells.
 Look for treatable causes (infections, neuro-cysticercosis, tumour)
 Counsel patient: no bathing alone, careful with fire, driving and climbing.
 Young female patients should be advised to plan their pregnancy. When
they wish to get pregnant folic acid once daily should be started and
continued through the pregnancy.
 Doses may be reduced to the lowest level that still prevents convulsions.
 Treatment should not be stopped because of pregnancy: it is more
dangerous for the mother and foetus to have uncontrollable seizures than
to continue the anti-epileptic medicine.
 If patient has more than 2 seizures in a year of unknown cause, consider
starting antiepileptic therapy.
 Always start with small dose.
 Increase dose gradually over weeks or months.
 Use maximum dose of one medicine before adding another.
 Treatment should never be stopped suddenly due to risk of status
epilepticus, but rather tapered-off over weeks or months.

Treatment
 Phenobarbitone sodium 60-180 mg at night
Alternatively
 Carbamazepine 100 -200mg 1-2 times daily. Increase by 100 - 200 mg
weekly until dose is 800 mg - 1200mg per day.
Alternatively
 Sodium valproate 600 - 2000mg daily divided in 2 doses.
Alternatitvely
 Phenytoin 150 - 300mg daily divided in 1-2 doses. Can be increased to
500mg daily.

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3. Central nervous system conditions

3.2 Acute Stroke

 Sudden non-convulsive loss of neurological function due to ischemic or
hemorrhagic vascular event.
Remember brain infection as a differential diagnosis in HIV infected
patients
 Risk factors include hypertension, diabetes, smoking, genetic disorders,
atherosclerosis, cardiac disease, atrial fibrillation, HIV and high cholesterol.
 Look for treatable cause and counsel the patient.
 85% of the strokes are ischaemic.
Treatment
 Long term Aspirin 75mg once daily
Note: Aspirin is not advised in intra-cerebral or subarachnoid hemorrhage.
 Give i/v fluids to correct any dehydration, avoid i/v glucose.
 Treat hyperglycemia (see Section 6.1 page 36).
 Treat any fever: look and treat for infections (aspiration pneumonia, urinary
track infection common).
 Give Paracetamol 1g every 8 hours orally to reduce fever.
 Keep patient half seated if increased intracranial pressure is suspected (e.g.
in drowsy or unconscious patients).
 Continue antihypertensive treatment if patient is already on treatment.
 Don’t start new antihypertensives during the first 10 days.
 If hypertension is repeatedly higher than 180/120 mmHg, start
Hydrochlorthiazide 25mg once daily orally
 Start physiotherapy on day 1.
 Start mobilisation as soon as it is possible. Consider referral to an
institutional rehabilitation unit.
3.3 Psychiatric conditions

3.3.1 General guidelines on psychotropics use

 Identify complicating factors i.e. psychological, medical, social, etc.
 Review past successful medication and other interventions.
 Weigh the risks and benefits of any intervention.
 Involve the patients and their families in all decisions around treatment.
 Target symptoms e.g. use a more sedating agent if insomnia is a problem.
 Start with low doses and go slow.
 Avoid poly-pharmacy.

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MSTG 2009
3. Central nervous system conditions

 Never stop medication suddenly. Wean off slowly.

 Take caution in special circumstances such as:
 Pregnancy and lactation.
 Elderly patients.
 HIV Infection
 Renal or hepatic impairment.
 Medicine interaction.
 Psychosocial interventions are imperative.

3.4 Organic Disorders

3.4.1 Delirium
 Impairment of consciousness, usually accompanied by global impairment of
cognitive functions, usually acute and reversible
Symptoms/signs: fluctuating level of consciousness, disorientation, perceptual
disturbances
 Look for treatable causes: systemic and CNS infections, hypoxia, hypo- or
hyperglycaemia, drugs, alcohol excess or withdrawal (delirium tremens),
mental illness, post-convulsion phase in epilepsy, head trauma, subdural
hematoma, stroke etc.
Treatment
 Identify and treat underlying cause
 Haloperidol 2 - 5mg or Chlopromazine 50 - 75mg
 use sedatives cautiously

3.4.2. Dementia
 Chronic disorder characterised by multiple cognitive deficits, including
memory loss, but no impairment of consciousness
Symptoms/signs: disturbances of orientation, memory, intellectual function,
personality changes
Treatment
 Supportive e.g. proper nutrition and exercise.
 Avoid barbiturates and benzodiazepines

3.5 Temporal Lobe Epilepsy

Symptoms/signs: Auras, illusions, hallucinations, personalization, derealisation
Treatment
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MSTG 2009
3. Central nervous system conditions

 Carbamazepine 200 - 600mg twice daily,

Alternative
 Phenytoin 100 - 150mg one daily

3.6 Alcohol Related Disorders

3.6.1 Alcohol intoxication

 Drunkenness, recent ingestion of sufficient amount of alcohol to produce
acute maladaptive behaviour
Symptoms/signs: euphoria, talkativeness, aggression, labile mood
Treatment:
 Usually supportive.

3.6.2 Alcohol Withdrawal Syndrome

 Syndrome that occurs within several hours of cessation, or reduction after
prolonged heavy consumption
Symptoms/signs: Autonomic hyper activity, hand tremor, insomnia, transient
illusions or hallucinations (visual and tactile) and seizures.
Treatment
 May need admission to hospital as an emergency
 Treat psychotic symptoms (confusion, delusions, hallucination) with
Haloperidol 2mg-10mg orally (or by deep i/m if necessary) as required until
the delirious state improves
 Sedate with Diazepam 10 mg i/v initially then orally every 8 hours
 Vitamin B1 (Thiamine hydrochloride) 100 - 200mg daily, 3-5 days, i/m
Alternatively
 Vitamin B Complex i/m then orally for 2 weeks
 Reduce dose as soon as acute phase begins to settle.
 Give fluid replacement as required.

Note:
(i) Do not discharge the patient on diazepam due to the risk of
dependence.This condition has a high mortality rate.
(ii) Delirium tremens is a medical emergency and requires supportive
measures.

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MSTG 2009
3. Central nervous system conditions

3.6.3 Wernicke (and Korsakoff) Encephalopathy

 Amnesia, confabulation and oculomotor disturbances.
 Due to Vitamin B1 deficiency in alcoholics and malnourished non-alcoholics
Treatment
 Vitamin B1 100 mg i/v or /i/m 3-7 days.
 Glucose (5-10%) i/v with multivitamins orally and/or Vitamin B complex
can be given.
 Glucose without Vitamin B1 can worsen Wernicke’s encephalopathy.
 After Vitamin B1 injections, continue with Vitamin B1 25 - 100 mg orally
once daily.
 To treat delirium tremens: see Section 3.4.1 page 18

3.6.4 Alcoholic Hallucinosis

 Syndrome characterised by vivid persistent hallucinations following a
decrease in alcohol consumption, in a dependent person.
Treatment
 Diazepam 5-10mg and Haloperidol 2-5mg stat or Chlorpromazine 50-
100mg stat

3.6.5 Physical and neurological complications of alcohol dependence

 Counsel the patient
 Abstinence may be essential
 Refer to Alcoholic Anonymous groups
 Encourage a healthy diet with high protein and vitamin content (give
vitamin B complex if necessary)
 Treat specific disorders symptomatically (e.g. gastro-intestinal disorders,
cirrhosis, neuropathy)

3.6.6 Treatment of psychological and social complications

 Counsel the patient
 Educate and support the family

3.7 Anxiety disorders

Types:
i. Panic disorder: characterized by spontaneous panic attacks
ii. Generalized anxiety disorder: excessive worry about actual
circumstances/ events
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MSTG 2009
3. Central nervous system conditions

iii.
Phobias: irrational fear of objects/ public situations.
iv.Post traumatic stress disorder: anxiety produced by extraordinary
stressful events, re-occurs as flashbacks.
v. Obsessive compulsive disorder: recurrent intrusive ideas, images
thoughts or repetitive ritualized patterns of behavior
Symptoms/signs:
Excessive anxiety and worry
Persistent excessive and unreasonable worry
Treatment
 Diazepam 2-10mg 2-4 times daily
 Fluoxetine 20-60mg daily
 Psychotherapy

3.8 Pyschiatric Emergencies

3.8.1 Attempted suicide

Risk factors: males, older age, non-married, physically unwell, mentally unwell
General Measures
 Do not leave them alone
 Take threats seriously
 Treat underlying disorders e.g. depression
 Hospitalize unless if properly supervised at home

3.8.2 Violence
 Associated disorders: psychotic disorders, substance intoxication,
withdrawal states, post ictal disturbances
 Violence predictors: previous acts of violence, verbal/physical threats,
paranoid feature, violent command hallucinations, alcohol or medicine
intoxication
General Measure:
 protect yourself, have enough people to handle patient, don’t immediately
remove physical restraints
Treatment
 Slow i/v Diazepam 10-20mg
 Intra muscular Haloperidol 5mg or Chlorpromazine 50-150mg

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MSTG 2009
3. Central nervous system conditions

3.9 Psychotic Disorders

3.9.1 Schizophrenia
Symptoms/signs: delusions, hallucinations, abnormal affect diminished level of
function, illogical thoughts
Treatment:
 Chlorpromazine 100mg once daily
Alternatively
 Haloperidol 2-30mg once daily
 If catatonic use Electroconvulsive therapy (ECT), Fluphenazine decanoate
25mg i/m monthly for chronic cases
 Psychosocial interventions and psycho-education.

3.9.2 Substance Induced Psychosis

 Psychotic features in a patient who has used psychoactive substances in
last 2 months
Symptoms/signs: Aggression, hallucinations (visual), illusions, delusions
Treatment
 Chlorpromazine 100mg twice daily for 1 month
 Haloperidol 2mg twice daily for I month ,
 Diazepam 5 -10mg twice daily for 7 days
 Counseling
 Psychotherapy

3.9.3 Post Partum Psychosis

 Psychotic illness developing days, weeks, months after delivery
 Also refer to Section 12 page 98
Treatment
 Counseling,
 Chlorpromazine 50 - 100mg twice daily for 2 weeks
 ECT in extreme cases

3.10 Mood Disorders

 Disorders characterized by a pervasive emotional tone that profoundly
influence ones outlook and perception of self, others and environment

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3. Central nervous system conditions

3.10.1 Depression
 Disorder characterised by low affect for over two weeks
Symptoms/signs: depressed mood, anhedonia, social withdrawal, weight loss/
gain, insomnia
Treatment
 Amitriptyline 100-150mg at bedtime, start from 25mg and titrate
 Fluoxetine 20mg once daily
 ECT in very severe cases

3.10.1.1 Post Partum Depression

 Severe depression beginning within 4 weeks of delivery. Most often in
women with underlying mood or other psychiatric disorder
Symptoms/signs: insomnia, emotional lability, suicide, delusions
Treatment
 Amitriptylline 50 – 100 mg at night for one month
 Imipramine 100 - 150mg at night,
 Fluoxetine 20 - 40mg in the morning
3.11 Mania
 Disorder characterised by elated mood
Symptoms/signs: erratic/disinhibited behaviour, excessive energy, excessive
spending, euphoria, delusions (grandiosity)
Treatment:
 Chlorpromazine 100mg twice daily for 1 month
 Carbamezapine 200mg - 600mg once daily for 1 month
 Haloperidol 2mg -10mg twice daily for 1 month

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MSTG 2009
5. Emergencies

4.0 Ear Nose and Throat Conditions

4.1 Mastoiditis
 A bone infection characterised by painful swelling behind or above the ear.
 Watch for complications of brain involvement (meningitis or brain abscess).
 Surgical drainage may be necessary.
 Refer patient to hospital

Treatment
Adults
 Ampicillin 1g every 8hourly for 5 days plus
 Flucloxacillin 500mg i/m, 6 hourly for 5 days plus
 Metronidazole 500mg i/v, 8 hourly for 5 days
 Analgesics as necessary See Section 24.1 page 196 on Pain Relief
Alternatively
 Ceftriaxone 2g daily for 5 days
Children
 Ampicillin 25 – 50mg/kg i/m or i/v every 8 hours for 5 days

4.2 Otitis

4.2.1 Otitis Externa

 This is an inflammation of the skin lining the external auditory canal. May
be a furuncle or diffuse.
Treatment
(a) Furuncle
 Analgesia
 Flucloxacillin 500mg every 6 hours for 5 days
Alternatively
 Cloxacillin 500mg every 6 hours for 5 days
 Make a wick of ribbon gauze impregenated with ointment containing
Hydrocortisone or Betamethasone cream and gently insert in the ear for 2
to 3 days.

(b) Diffuse Otitis Externa

 Analgesia when necessary
24
MSTG 2009
5. Emergencies

 Dry mop the ear

 Acetic acid ear drops 2% in Alcohol 6 hourly for 5 days

4.2.2 Acute Otitis Media (Children)

 Local medicine treatment is ineffective and should be avoided
Acute otitis media is often viral in origin and needs
only a simple analgesic for pain

Symptoms/Signs: Fever in about 50% of patients, sudden persistent ear pain

or pus discharge for < 2 weeks
Treatment
 Amoxycillin 15 mg/kg every 8 hours for 5 days

Alternatively
 Erythromycin 6.25 mg/kg every 6 hours for patients with penicillin allergy
 Give analgesia as required Section 24.1 page 196

4.2.3 Chronic (Suppurative) Otitis Media

 Pus discharge from the ear for over 2 weeks
 If the eardrum has been ruptured for over 2 weeks, secondary infection
with multiple organisms usually occurs
 Common in immunosuppressed patients
 This makes oral antibiotic therapy much less effective.
Treatment
 Ensure ear is alway dry.
Note: A chronically draining ear can only heal if it is dry. Drying the ear is time
consuming for both the health worker and the mother but it is the only
effective measure.
 The mainstay of treatment is topical therapy with Acetic acid ear drops 2%
in Alcohol 6 hourly for 5 days
 Demonstrate/explain carefully to the patient (or guardian in the case of a
child) how to dry the ear by wicking (see below)
 Refer for further assessment if no improvement after 3-4 weeks therapy
 Dry the ear by wicking
 Roll a piece of clean absorbent cloth into a wick and insert carefully
into the patient’s ear
 Commercially made ear buds should be avoided in cleaning the ear
 Leave for one minute
25
MSTG 2009
5. Emergencies

 Remove and replace with a clean wick

 Watch the patient/guardian repeat this until the wick is dry when
removed
 The patient/guardian should dry the ear by wicking at home at least
four times daily until the wick stays dry
 If bleeding occurs, temporarily stop drying the ear
 Do not leave anything in the ear between treatments
 The patient should avoid swimming or otherwise getting the inside of
the ear wet
 Re-assess weekly to ensure that patient/mother is drying the ear correctly
 Check for mastoiditis
Note: TB is an important cause of a chronically discharging ear in Malawi

4.3 Nose Conditions

4.3.1 Epistaxis
 Bleeding can be bilateral or unilateral.
 Causes include trauma, repeated nose pickings, infections such as
rhinosinusitis, systemic causes such as hypertension, bleeding disorders,
anaemia and leukamia etc.
Treatment
 Pinch the nose alar (wings) for 5 to 10 minutes. Let the patient lean forward
and breathe through the mouth.
Alternatively
 Apply cold pack or ice block to the forehead
 Use ribbon gauze impregnated with liquid paraffin
Alternatively
 Apply nasal packs soaked in Adrenaline
Note: Avoid use of adrenaline in hypertensive patients
 If bleeding continues, refer to hospital

4.3.2 Vestibulitis
 Diffuse infection of the skin of the anterior nares and may occur due to
frequent trauma such as occurs in constant nose picking.
 Persistent nasal discharge leads to excoriation and infection of the skin of
the nasal vestibule
Treatment
26
MSTG 2009
5. Emergencies

 Analgesia, see Section 24.1 page 196 on pain relief

 Amoxycillin 500mg 8 hourly for 5 days and
 Liquid paraffin 2 drops each nose 3 times a day

4.3.3 Sinusitis
 Inflammation of one or more sinuses that occurs most often after a viral
nasal infection or allergic rhinitis.

4.3.3.1 Bacterial Sinusitis

Symptoms/Signs: purulent nasal discharge, persistent or intermittent, pain and
tenderness over one or more sinuses, nasal obstruction, postnasal
discharge, occasional fever.
Note: (1) Sinusitis is uncommon in children under five years as sinuses are
not fully developed
(2) Unilateral foul smelling nasal discharge is a foreign body until
proven otherwise
Treatment
Adults
 Oxymetazoline 0.05% 2 drops twice a day for not more than one week
 Cetrizine 10mg daily for 3-5 days
 Analgesia, see Section 24.1 page 196
 Amoxycillin 500mg every 8 hours for 5 days
 Steam inhalations using menthol are advised

Children
 Oxymetazoline 0.025% 2 drops twice a day for not more than one week
 Phenoxymethylpenicillin 12.5 mg/kg/dose
 Amoxycillin 25 mg/kg/dose in exacerbations of chronic sinusitis and HIV
positive children who are on cotrimoxazole prophylaxis.
Alternatively if penicillin hypersensitivity:
 Erythromycin 12.5 mg/kg/dose every 6 hours for 7 days
If pain or fever (>39˚ C) give:
 Analgesic/antipyretic treatment as required

4.3.4 Allergic Rhinitis

 Recurrent inflammation of the nasal mucosa due to hypersensitivity to
inhaled allergens e.g. pollen, house dust, grasses and animal proteins.

27
MSTG 2009
5. Emergencies

Symptoms/Signs: blocked stuffy nose, watery nasal discharge, frequent

sneezing often accompanied by nasal itching and irritation, conjunctival
itching and watering, edematous pale gray nasal mucosa, mouth breathing,
snoring at night.
 Exclude other causes such as infections, vasomotor rhinitis, over use of
decongestants drops, side effects of antihypertensives and
antidepressants.
Treatment
 Allergen avoidance
 Cetrizine 10mg daily for 3-5 days plus
 Beclomethasone nasal sprays

4.3.5 Pharyngitis
 Viral pharyngitisis a painful red throat without purulence. Respiratory
viruses are a major cause.
Symptoms/Sign: sore throat and fever, diffuse congestion of the pharyngeal
wall, uvula and adjacent tissues.
Treatment
 Antibiotics are not indicated
 Home made salt mouth washes or gargles for 1 minute twice daily

4.3.6 Tonsillitis
 Acute inflammation of the tonsils. The main organism implicated in the
causation is beta-hemolytic streptococcal.
Symptoms/Signs: sore throat, difficulty and pain on swallowing, inflamed
tonsils, multiple white spots on the tonsillar surface, and sudden onset of
fever.
Treatment
 Warm salt gargles
 Phenoxymethylpenicillin 500mg, every 6 hours for 5 – 7 days
Alternatively
 Erythromycin 500mg, every 8 hours in Penicillin allergy
 Analgesia see Section 24.1 page 196 on pain relief
4.4 ENT Emergencies

4.4.1 Anaphylaxis (anaphylactic shock)

Refer to Section 5.0 page 29
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MSTG 2009
5. Emergencies

5.0 Emergencies

5.1 Shock
 Acute circulation failure resulting in inadequate tissue perfusion and
cellular hypoxia, generally with a low blood pressure.
Causes
1. hypovolemic (haemorrhage, cholera, severe vomiting, diabetic
ketoacidosis)
- cold, clammy skin; weak pulse, tachycardia
2. cardiogenic (myocardial infarction)
- signs of heart failure
3. obstructive (pericardial tamponade, tension pneumothorax)
- raised JVP, pulsus paradoxus
4 distributive (sepsis, anaphylaxis)
- fever, warm peripheries

5.1.1 Anaphylaxis (anaphylactic shock)

 This is a medical emergency in which seconds count
 Taking appropriate measures immediately may save a life
 It requires prompt treatment for laryngeal oedema, bronchospasm and
hypotension
 It is most commonly precipitated by drugs, especially after parenteral
administration including;
o antibiotics
o aspirin and other nsaids
o antiarrhythmics
o heparin
o neuromuscular blocking drugs
o injectable iron
o vaccines
 It may also be caused by
o insect stings (especially wasps and bees)
o blood products and blood transfusions
o certain foods e.g. eggs, cow’s milk, nuts
 The priority is to give Adrenaline i/m
 Determine and remove the cause
29
MSTG 2009
5. Emergencies

 Lie the patient down

 Keep the patient warm
 Elevate the patient’s legs
 Maintain airway
 Give 100% oxygen if available

Treatment
 Adrenaline 1 in 1,000 05-1 ml i/m (children 0.0.1 ml/kg)
 Adrenaline 0.01 ml/kg (adults)
 Repeat as required (several times if necessary) every 10 minutes according
to BP and pulse until improvement occurs
 Sodium chloride 0.9 % 20 mL/kg by i/v infusion over 60 minutes
 Start rapidly then adjust according to BP
 An antihistamine is a useful additional treatment given after adrenaline and
continued for 24-48 hours to prevent relapse
 Promethazine 25-50 mg by deep i/m or , in emergencies, slow i/v, as a
solution containing 2.5 mg/mL in water for injection
 Adults: max 100 mg
 Children: 6-12 years: 6.25-12.5 mg:
1-5 years: 5 mg
 Repeat dose every 8 hours
 An i/v corticosteroid is of secondary value in initial management of
anaphylaxis as its action is delayed but should be given in severe cases to
prevent further deterioration:
Adults:
 Hydrocortisone 200 mg by slow i/v push
Children:
< 1 year: 25 mg
1-5 years: 50 mg
6-12 years: 100 mg
o May be repeated as necessary

 Monitor pulse, BP, bronchospasm and general response/condition every

few minutes
 If there is continuing deterioration or no improvement the following may
be necessary:
 Aminophylline i/v as for asthma if bronchospasm persists (see Section
16.2.1 page 137)
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MSTG 2009
5. Emergencies

 Ventilation and/or tracheotomy

If acidosis is severe (blood pH<7.1) after 20 minutes
Treatment
 Give sodium bicarbonate 50 mmol by slow i/v (appr. 100 mL of 4%
solution)
 Monitor plasma pH

5.2 Management of Emergencies and Trauma in Children

 Triage all sick children soon when they arrive in hospital into three
categories in order to identify:-
a) Those with emergency signs
Emergency signs include: obstructed breathing, severe respiratory distress,
central cyanosis, signs of shock, coma, convulsions, severe dehydration
b) Those with priority signs
Priority signs{“3TPR MOB”}, tiny baby, very hot or very cold temperature,
trauma or other urgent surgical condition, pallor severe, poisoning , pain,
respiratory distress, restlessness , referral {urgent}, malnutrition, oedema
of the feet, burns
c) Those who are non urgent cases

5.2.1 Emergency management:

 Assess the airway and breathing{A,B}
- Does the child’s breathing appear obstructed? If so open as follows
o If no trauma – do chin lift, head tilt.
o If suspected trauma- do jaw thrust.
- Manage airway in choking by using back slaps, chest thrusts or
Heimlich manoeuvre in an older child.
- Is there severe respiratory distress i.e. tachypnoea ,recessions,nasal
flaring.cyanosis etc
- Oxygen therapy
- Ventilatory support if not breathing and there are signs of life - use
bag and mask.
 Assess circulation and level of consciousness
- Check if the child’s hand is cold if so
- Check capillary refill time {apply pressure to the nailbed for 5 seconds
and determine the time from the moment of release until total
recovery of the pink colour} normal is <3 seconds.
- If in shock manage as follows:
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MSTG 2009
5. Emergencies

 Manage shock, coma and convulsions

If unconscious
- put on oxygen
- check blood sugar
- place in the recovery position.
 Assess and manage severe dehydration in a child with diarhoea

5.3 Management of convulsions in children

 Establish the cause and when convulsions are controlled, treat accordingly
o In neonates convulsions are usually due to hypoglycemia, hypoxia or
infection e.g. meningitis
 Always exclude hypoglycemia as cause especially in children. If blood sugar
can not be checked, assume hypoglycemia and treat accordingly
o See Section 6.1.1 page 36 for treatment of this in children
o Hypoglycaemia is defined as <2.5 mmol/l or 3 mmol/l in severely
malnourished children.
 For persistent convulsions, see Section 5.2 page 31
General measures
o Ensure airway is clear
o Do not place any object which might be swallowed in the mouth of a
convulsing child
o Protect patient from injury and put in lateral position

Flow chart for controlling convulsions

 To control the fit
A- Airway: place in recovery position
B- Breathing: support with oxygen if necessary
C- Circulation: treat shock
D- Don’t
E- Ever
F- Forget
G- Glucose ( correct hypoglycaemia with 2ml/kg of 25% Dextrose or
2.5ml/kg of 20% dextrose or 5ml/kg of 10% dextrose)

 If the fit has been going on more than 5 minutes

↓
Diazepam
0.5mg/kg rectal or 0.25mg/kg
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MSTG 2009
5. Emergencies

 If fit still ongoing after 10 minutes or has recurred

↓
Diazepam 0.5mg/kg rectal
or 0.25mg/kg i/v

 If fit still ongoing after 10 minutes or has recurred

↓
Paraldehyde 0.2ml/kg i/m
or 0.4ml/kg rectal

 If fit still ongoing after further 10 minutes or has recurred, inform senior
health worker
↓
Phenobarbitone
10–15mg/kg i/m or i/v

 If fitivstill ongoing after further 5 – 10 minutes or in status epilepticus

↓
Discuss with seniors +/- anaesthetist
For Phenytoin administration 18mg/kg i/v infusion over 30 minutes. Give
maintenance dose 2.5-5mg/kg over 30 minutes twice daily

Note:
1) It is not recommended to give diazepam intramusculary
2) Rectal administration may be quicker and easier than i/v in fitting child. Use
a syringe with the needle removed.
3) For paraldehyde use a glass syringe preferably. If not available, use a plastic
syringe instead but ensure that the dose is given promptly and therefore
remains in the syringe for a short time (paraldehyde dissolves plastic)
4) For neonates, use Phenobarbitone 15-20mg/kg loading dose and
maintenance dose of 2.5-5mg/kg once daily.

5.4 Diabetic ketoacidosis (DKA)

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MSTG 2009
5. Emergencies

 Persons at extra risk: known insulin-dependent diabetics with poor

compliance, intercurrent infection, failure to administer insulin when ill and
not eating
 Investigate immediately blood sugar; urine dipstick for glucose and
ketones, electrolytes and urea if possible
 Hypoglycaemia, subdural haematoma (elderly), stroke, malaria, meningitis,
sepsis may also precipitate DKA
 If blood sugar levels cannot be obtained, it may be difficult to distinguish
clinically between hypoglycaemic and hyperglycaemic coma; in that case
give 50 ml 50% dextrose stat: in case of hypoglycaemia, it will wake the
patient up; in case of hyperglycaemia, it will do no harm
Treatment
 Fluids – use large bore cannula; if possible set up 2 cannulae
o In case of hypovolaemia i.e. blood pressure < 90 mm Hg or postural
drop of blood pressure > 20 mm Hg
o Give 4 litres Sodium chloride 0.9% in the first hour
o In case of no hypovolaemia i.e. good urine output, normal blood
pressure
o Give 2 litres Sodium chloride 0.9% in the first hour
 In both cases after one hour give 3 litres /24 hours + amount lost in urine
(see sliding scale for type of fluid)
 If still dehydrated after first hour, give 2 litres sodium chloride per hour
and review
 Potassium chloride 10 mmol per litre (0.75mg) in each litre until i/v fluids
are stopped

Note: Do not give potassium chloride with the first litre of sodium chloride.
 Give 10U Soluble insulin i/m stat, thereafter give insulin i/m according to
sliding scale every 2 hours
 Check blood sugar every 2 hours

5.5 Hyperosmolar non-ketotic coma (HONK)

 Persons at risk: elderly with non-insulin dependent diabetes
Signs: confused / reduced consciousness (any reason e.g. stroke or infection)
Treatment
 Fluid replacement is more important than insulin even if blood sugar is
high; however fluids should not be given too rapidly to avoid large
electrolyte shifts.
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MSTG 2009
5. Emergencies

o Give 2 litres Sodium chloride 0.9% in the first hour, then 1 litre every
hour. Adjust to slower rate if elderly patient with risk of heart failure.
o Change to Dextrose 5% when blood sugar approaches normal levels.
 Give 10U Soluble insulin i/m stat; this is usually enough.
o Do not try to lower the blood sugar rapidly at all cost by giving high
doses of insulin.
 Add Potassium chloride as indicated in Section 5.2 page 31.
 Adjust / individualize insulin treatment when fully conscious and eating
Table 3: Sliding scale for insulin dosage based on blood sugar taken 2
hourly

Blood Glucose Dose soluble Type of fluid

insulin (i/m)
HHH (very high) 10 units Sodium chloride 0.9%
>400mg/dL 10 units Sodium chloride 0.9%
(22mmol/L)
300 – 399 mg/dL 10 units Sodium chloride 0.9%
(16.5 – 22mmol/L)
200 – 299mg/dL (11 5 units Sodim chloride 0.9%
– 16.5mmol/L)
<200mg/dL 5 units Dextrose 5%
(11mmol/L)

35
MSTG 2009
6. Endocrine disorders

6.0 Endocrine disorders

6.1 Diabetes Mellitus

 The diagnosis of diabetes is based on 2 abnormal blood sugar
measurements (FBS > 7 mmol/l, 126 mg/dl or RBS >11mmol/200 mg/dl) in
an asymptomatic patient or 1 abnormal measurement if the patient has
symptoms of hyperglycaemia.
General Measures
 Establish treatment aims: some patients require strict glycaemic control
with near normal glucose values targeted, for others symptom control and
avoiding severe side effects of treatment may be the maximum achievable.
 Check BP regularly and aim for BP <130/80 mmHg see Section 2.3 page 9
 Discourage smoking
 Educate about foot care and screen annually for foot problems (neuropathy
or peripheral vascular disease)
 Screen annually for decrease in visual acuities, look for cataracts
Refer for specialist opinion if:
o Pregnant diabetic
o Acutely ill diabetic, particularly if vomiting or decreased Glasgow
Coma Score (GCS)
o Treatable complications e.g. cataracts
Treatment
 Give Aspirin 75mg daily to hypertensive diabetics aged over 50
 If a diabetic is admitted unconscious always consider the possibility of
hypoglycaemia- administer 100ml 20% or 50ml 50% dextrose/glucose
i/v even if a blood glucose measurement is not available.

6.1.1 Diabetes type 1 (Insulin dependent)

 Most children will have type 1diabetes.
 Children with diabetes should be referred for proper management and
treatment.
 These children need to be followed up every 3 months to monitor
blood sugars and long term complications of diabetes

6.1.1.1 Adults with no ketoacidosis or other acute complication:

Treatment
 Lente/Protophane Insulin 2 doses daily
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MSTG 2009
6. Endocrine disorders

 To decide the starting dose of Insulin:

o The total daily number of Insulin units will be approximately half the
patients body weight, e.g. for a 60 Kg person give 30 units
Insulin/day divided into 2 doses
o Then give 2/3 daily dose half an hour before breakfast, give 1/3 daily
dose half an hour before evening meal, preferably 12 hours apart
o Adjust Insulin dose according to fasting blood sugar (FBS) or 2 hours
post-prandial blood sugar or symptoms of hypo- or hyperglycaemia
 Metformin 500mg twice daily can be added to Insulin treatment to
improve glycaemic control and curb weight gain in adult diabetics

Note: Insulin requirements can go up when a patient is acutely ill, even if

they are not eating. NEVER stop Insulin in a type 1 diabetic.
 Diet:
o Increase fibre intake
o Reduce refined sugar intake
o Insulin treated patients require 3 meals a day containing complex
carbohydrate to avoid risk of hypoglycaemia
o Advise patients to eat more before unaccustomed exercise

6.1.1.2 Children with diabetic ketoacidosis

Signs and symptoms: vomiting, polyuria, dehydration, ketonuria and acidosis.
The blood
sugar will be high >15mmol/l
 Address airway and breathing
 i/v fluids are the most important resuscitation measure
- Give 20mls/kg bolus of normal saline or ringer’s lactate if in shock
- If not in shock give maintainance plus deficit over 24 hours if patient
is conscious or over 48 hours if unconscious.
- Maintainance requirements are as follows:
o First 10 kg body weight 100mls /kg /day
o Next 10 kg body weight 50mls/kg/day
o Each kg thereafter 20mls/kg /day.
 Add potassium chloride to i/v fluids (20 - 40 mmol/litre) when patient
urinates and peripheral circulation has improved
 Give subcutaneous injection of short acting soluble insulin 6 hourly.

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MSTG 2009
6. Endocrine disorders

6.1.2 Diabetes type 2 (Non Insulin-Dependent)

 Adjustment of diet and/or weight reduction (if obese) and increased
exercise may control blood glucose without the need for drug therapy.
 Wherever possible give a 4-6 week trial of diet before introducing oral
hypoglycaemic agents. If this is unsuccessful,
Treatment
 Metformin 500mg twice daily, increased to a maximum of 1g twice daily.

Note: (1) Metformin is the drug of choice in type 2 diabetes, particularly in

obese patients.
(2) It is contra-indicated in renal insufficiency, and severe respiratory
and cardiac disease due to risk of lactic acidosis.
 If glycaemic control still poor, add Glibenclamide 5mg daily, increasing to a
maximum of 10 mg twice daily

Note: 20% of type 2 diabetics eventually require Insulin treatment - use

principles as in type 1diabetes to initiate treatment. Use Lente
0.3U/kg bodyweight to start with.

6.2 Thyroid disorders

6.2.1 Hyperthyroidism
Causes: Graves disease, toxic multinodular goiter, toxic solitary nodule
Signs and symptoms: fatigue, nervousness or anxiety, weight loss, palpitations,
heat insensitivity, tachycardia, warm moist hands thyromegaly and tremor.
 Management should be supervised by a doctor
 Refer to tertiary level
Treatment
Adults
 Propranolol 40-120mg three times daily to control symptoms, especially
tachycardia
 Carbimazole 40mg daily for approximately 2 months then reduce dose to
10mg od
o In Graves disease continue for 18 months then stop (in large percentage
hyperthyroidism will be resolved)
o In other causes continue carbimazole and refer for surgery
Children
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MSTG 2009
6. Endocrine disorders

 Carbimazole 0.5 mg/kg once daily oral.

 Atenolol 1-2 mg/kg orally as a single daily dose.
 Refer for surgery if
o Relapsed Graves disease after carbimazole treatment
o Toxic nodule or toxic multinodular goitre
Note: If a patient develops a fever or sore throat while taking
carbimazole, neutropenia should be urgently excluded. If present then
stop Carbimazole and treat with antibiotics.

6.2.2 Hypothyroidism (Myxoedema)

 Management should be supervised by a doctor
 Refer to tertiary level
Treatment
 Thyroxine 100-150mcg (mcg) daily for life
 Elderly patients start with 25mcg then increase by 25 - 50mcg every 2
weeks up to 100mcg

6.2.2.1 Congenital Hypothyroidism

 Congenital hypothyroidism is one of the common treatable causes of
preventable mental retardation in children.
 Congenital hypothyroidism must be treated as early as possible to avoid
intellectual impairement.
Signs and symptoms: Prolonged jaundice, feeding difficulties, hypotonia, wide
open fontannelles, oedema, constipation, enlarged tongue, dry skin,
bradycardia, lethargy etc.
Treatment
 Levothyroxine 10-15 mcg/kg orally as a single daily dose for neonates and
infants and 100 mcg/kg once daily
 Requires urgent referral for confirmation of diagnosis

6.2.3 lodine deficiency disorders (Endemic goitre)

 More common in highland areas
 Much less likely since the introduction of iodised salt
 Only consult surgeons for treatment if large goiter causing obstructive
problems or cosmetically unacceptable.
Prophylaxis
 Aqueous iodine oral solution 130mg/ml single dose
 Repeat every 2 years
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MSTG 2009
7. Gastro-intestinal conditions

7.0 Gastro-Intestinal Conditions

7.1 Amoebiasis
 Give health education on feacal disposal, hand-washing and food hygiene
 Consider in dysentery unresponsive to antibiotic treatment

7.1.1 Intestinal (non-invasive) form

Treatment
Adults
 Metronidazole 800mg every 8 hourly for 5 days preferably after food
Children
 Metronidazole 7.5 mg/kg/dose every 8 hours for 5 days

7.1.2 Hepatic form (amoebic liver abscess)

Treatment
Adults
 Metronidazole 800mg every 8 hours for 10 days
o Give orally (preferably after food) or i/v (depending on the condition of
the patient)
o If necessary, repeat treatment course after 2 weeks
 Consider aspiration in cases of large abscesses or superficial abscesses
under ultrasound guidance.
Children
 Metronidazole 10 mg/kg/dose every 8 hours for 10 days
 Give orally (preferably after food) or i/v (depending on the condition of
the patient).
 If necessary, repeat course of treatment after 2 weeks

7.2 Bacillary dysentery

 If the only symptom is dehydration, give health education on hand-washing
(the single most important preventive measure), correct faeces disposal,
and food hygiene
 Ensure complete hygienic precautions by all in contact with the patient
 Isolate the patient if possible
 Investigate source of contamination and inform environmental health
authorities

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MSTG 2009
7. Gastro-intestinal conditions

 Use antibiotics only if the patient is systemically unwell or septic or

immunosuppressed
Treatment
Adults
 Ciprofloxacin 500 mg twice a day for 5 days
 Analgesic see Section 24.1 page 196
Children > 3 months
 Nalidixic acid 50 mg/kg daily in 2-4 divided doses

7.3 Cholera
 Rehydration is of prime importance
 Ensure complete hygienic precautions by all in contact with the patient,
who should be isolated if possible
 Investigate source of contamination, and inform environmental health
authorities
 Trace close contacts and give antibiotics in the same doses as below
 Main treatment is by rehydration but antibiotics can shorten the diarrhoea
episode and are therefore indicated.
Treatment
Adults
 Doxycycline 300 mg stat
Alternatively in pregnancy and children <5years:
 Erythromycin 250 mg every 6 hours for 3 days
Children >5 years:
 Erythromycin 12.5 mg/kg/dose every 6 hours for 3 days

7.4 Constipation
 Investigate and treat any identified cause
 Commonly related to inadequate dietary fiber intake and/or psychological
factors
 Advise high residue diet, e.g. papaya seeds and increased fluid intake
 Reserve medication for severe cases only confirmed by examination.

All laxatives are contraindicated if intestinal obstruction is suspected

 Do not use oral laxatives in children.

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MSTG 2009
7. Gastro-intestinal conditions

 If increased fiber and oral fluids are insufficient to cure constipation and a
laxative is considered necessary use liquid paraffin 5-10 mls daily.
 Refer all infants with constipation for specialist assessment
 Constipation in the neonate is usually due to a significant underlying
problem such as bowel atresia or Hirschsprung’s disease.
 If a neonate has not passed stools in the first 48 hours of life:
 Refer urgently for surgical and/or pediatric assessment
Treatment
Adults
 Bisacodyl 5-10mg at night
Alternatively
 Insert one glycerol suppository at night, moisten with water before
insertion.
If no response within 3-5 days:
 Refer for further management

Note: For hemorrhoids, anal fissure and other causes of persistent anal pain in
adults:
Insert one Bismuth subgallate suppository rectally each night and
morning after defecation

7.5 Diarrhoea

7.5.1 Acute Diarrhoea

 Replace fluid and electrolyte loss
 Maintain optimal hydration
 Establish and treat causal factors
 In adults with acute diarrhoea who are systemically unwell and/or have
fever, Ciprofloxacin 500 mg every twelve hours may be considered if the
patient is (suspected to be) HIV infected
 In children, if i/v fluid is indicated but is impossible to administer, consider
using the intra-osseus routes
Treatment
 Give low osmolarity WHO ORS as soon as the patient’s condition improves
 Measurement of BP and pulse may help in assessment of dehydration.

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 7. Gastro-intestinal conditions

7.5.1.1 Use of drugs in children with diarrhea

 Only use antibiotics for dysentery and suspected cholera cases with severe
dehydration
 Use Zinc 20mg per day for 10 days (>6month) or 10mg per day for 10 days
(<6month) in addition to low osmolarity ORS
 Only use antiparasitics for:
o Amoebiasis, after antibiotic treatment of bloody diarrhea for shigella has
failed or trophozoites of E.histolytica containing red blood cells are seen
in the faeces.
o Giardiasis, when diarrhea has lasted at least 14 days and cysts or
trophozoites of Giardia are seen in faeces or small bowel fluid

Antidiarrhoeals and antiemetics should never be used in children with acute

diarrhea because they have no proven value and may be dangerous

7.5.1.2 Assessment of patients for dehydration

A B C
Look at
-condition
Well, alert Restless/irritable* Lethargic/unconscious: floppy*
-eyes
-tears Normal Sunken Very weak sunken and dry
-tongue, Present Absent Absent
mouth Moist Dry Very dry
-thirst Not thirsty Thirsty
Drinks Drinks eagerly* Drinks poorly or not able to
normally drink*
Feel
Skin pinch Goes back Goes back slowly Goes back very slowly*
quickly
Decide NO SIGN OF If the patient has 2 or If the patient has 2 or more signs
DEHYDRATION more signs including at including at least one sign*
least one sign*: SOME SEVERE DEHYDRATION
DEHYDRATION
Treat Weigh if possible Weigh the patient
(see below) Use Plan A Use Plan B Use Plan C URGENTLY
Note: in severely malnourished children, skin turgor is not a reliable sign.
43
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7. Gastro-intestinal conditions

7.5.1.3 Treatment Plan A (to treat diarrhea at home)

 Use this plan to teach the mother to continue to treat her child’s current
diarrhea at home and to give early treatment for any future diarrhea.
 Explain the 3 rules for treating diarrhea at home:
1. Give child more fluids than usual to prevent dehydration
 Suitable fluids include: Low osmolality ORS, plain water, food-
based fluids (e.g. gruel, soup, rice water), breast milk, milk
feeds prepared with twice the usual amount of water.
 Give ORS if the child has been on Treatment Plan B or C or
cannot return to the health worker if the diarrhea gets worse
 Give ORS or water rather than a food-based fluid if the
child is under 6 months old and not yet on solid foods
 Give as much of these fluids as the child will take
 Use the amount shown below for ORS as a guide
 Continue giving these until the diarrhea stops
Special notes for severely malnourished children
 Dehydration tends to be overdiagnosed and its severity overestimated in
severely malnourished children because it is difficult to assess dehydration
in severely malnourished children using clinical signs alone.
 Do not use i/v route for rehydration except in cases of shock.
 In shock give oxygen, keep the child warm, establish i/v access and infuse
15mls/kg over 1 hour of ½ Strength Darrows with 5 % dextrose or Ringers
lactate with 5% dextrose.
 The child needs to be observed closely and if the respiratory rate and pulse
rate increases stop i/v fluids.
 If the child is improving but still shocked repeat the same volume of fluids
over another hour thereafter switch to oral or nasal gastric rehydration
with ReSoMal alternatively with F-75 for up to 10 hours.
 In severe dehydration give 5mls/kg of Resomal every 30 minutes for the
first 2 hours then give 5-10ml/kg/hour for the next 4-10 hours which should
be alternated with F-75 at the usual volumes.
Table 4: Ingredients for home made ResoMal
Ingredient Amount
Water 2 litres
WHO ORS One 1 litre packet
Sugar 50 g
Electrolyte/mineral solution 40mls
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MSTG 2009
7. Gastro-intestinal conditions

 In mild diarrhea without dehydration, prevent dehydration developing by

continuing milk feeds – ReSoMal is not necessary in these cases.
 Monitor carefully and frequently
 Watch for signs of heart failure due to over hydration which is common in
children with kwashiorkor.

2. Give the child plenty of food to prevent malnutrition

 Continue to breast-feed frequently
If the child is not breast-fed:
 give the usual milk feed
If the child is 6 months or older or already taking solid foods:
 also give cereals or another starchy food
 mix, if possible, with pulses, vegetables, and meat or
fish
 add 1-2 teaspoonfuls of vegetable oil to each serving
 give fresh fruit juice or mashed banana to provide
potassium
 give freshly prepared food
 cook and mash or grind food well to make it easier to
digest
 encourage the child to eat
 offer food at least 6 times daily
 give the same food after the diarrhea stops
 give one extra meal daily for 2 weeks

3. Take the child to the health worker if the child does not get
better in 3 days or develops any if the following:
o many watery stools
o repeated vomiting
o marked thirst
o eating or drinking poorly fever
o blood in the stool

 If the child will be given ORS at home, show the mother how to
mix ORS and how much to give after each loose stool (see
table over)
 Give enough packets for 2 days treatment

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MSTG 2009
7. Gastro-intestinal conditions

Age Amount of ORS to Amount of ORS to

(years) give after each provide fro use at
loose stool* home
Under 2 50-100 ml 500 ml per day
2-10 100-200 ml 1 L per day
Over 10 As much as wanted 2 L per day

* Describe and demonstrate the correct amount to be given using a

locally available measure, e.g. cup or coke bottle
Show the mother how to give ORS:
For a child <2 years:
 give a teaspoon every 1-2 minutes
For an older child:
 give frequent sips from a cup
If the child vomits:
 wait 10 minutes, then give ORS more slowly
If diarrhea continues after the ORS is used up:
 tell the mother to give other fluids as described in
rule 1 above or to return for more ORS
Explain how to prevent diarrhea in child:
 give only breast milk for the first 4- 6 months and continue to
breastfeed for at least the first year
 introduce clean, nutritious weaning foods at 4- 6 months
 give the child freshly prepared and well-cooked food and clean
drinking water
 make sure all family members wash their hands with soap
after using the toilet, and before eating or preparing food
 quickly dispose of the stool of young children in a latrine or by
burying

7.5.1.4. Treatment Plan B (to treat dehydration)

1. Give ORS solution for the first 4 hours:

Weight (kg) Amount (mL)
Under 5 200-400
5-8 400-600
8-11 600-800
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MSTG 2009
7. Gastro-intestinal conditions

11-16 800-1,200
16-30 1,200-2,200
Over 30 2,200-4,000

 Encourage the mother to continue breast-feeding

 Give more ORS if the patient wants it
 For infants under 6 months who are not breast-fed, also
give 100-200 ml of clean water during this period
 Observe the child carefully and help the mother give ORS
solution:
 show her how much solution to give the child
 show her how to give it (see Plan A)
 sheck from time to time to see if there are any problems
If the child vomits:
 wait 10 minutes
 then continue with ORS, but more slowly
If the eyelids become puffy:
 stop ORS
 Give breast milk
 Give ORS again (as in Plan A) when the puffiness has
gone

2. After 4 hours, reassess the child using the assessment chart. Choose a
suitable treatment plan to continue
If there are no signs of dehydration:
 use Plan A. When dehydration has been corrected the
child usually passes urine and may also be tired and fall
asleep

If signs showing some dehydration are still present:

 repeat Plan B, but start to offer food, milk and juice as
described in Plan A

If signs of severe dehydration have appeared:

 change to Plan C

If the mother must leave before completing Plan B:

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MSTG 2009
7. Gastro-intestinal conditions

 show her how much ORS to give to finish the 4 hour

treatment at home
 give her enough ORS packets to complete rehydration and
for 2 more days as shown in Plan A
 show her how to make the ORS solution
 explain to her the 3 rules in Plan A for treating the child at
home

7.5.1.5. Treatment Plan C (to treat severe dehydration quickly)

1. Start i/v fluids immediately

 If patient can drink, give ORS by mouth while the drip is set up
 Intra-ossueus route: if unable to get an i/v line in quickly,
consider using this useful method of rehydration fluid
administration if familiar with the technique:
 If an intra-osseus needle is not available, use a 21G
hypodermic needle or a large bore LP needle instead
 Ringer’s Lactate 100 ml/kg divided as in the table below
Alternatively if not available
 Normal saline
Note: Both of these i/v solutions do not contain glucose and are thus not
suitable for long-term i/v fluid therapy in children – use Darrow’s ½
strength + dextrose 5% instead
Table 5: Rate of administration of i/v rehydration fluid
Age First give 30 ml/kg in: Then give 70ml/kg in:
<12 mths 1 hour * 5 hours
>12 mths 30 minutes* 21/2 hours

* Repeat once if radial pulse is still very weak or undetectable

Alternative method of i/v rehydration fluid administration

 May be useful where the above schedule is difficult to follow
on a busy ward
 give 10 ml/kg of the i/v fluid as a bolus given over 5 minutes
using a syringe
 then give 100 ml/kg as an infusion over a further 6 hours

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MSTG 2009
7. Gastro-intestinal conditions

With either method:

 reassess the patient every 1-2 hours

If hydration is not improving:

 give the i/v fluid more rapidly
 also give ORS (approx. 5 ml/kg/hour) as soon as the patient can
drink – usually after 3-4 hours (infants) or 1-2 hours (older
patients)
 after 6 hours (infants) or 3 hours (older patients), evaluate the
patient using the assessment chart
 then choose the appropriate Plan A, B or C to continue treatment

If i/v therapy cannot be given, but is available within 30 minutes:

 send the patient immediately for i/v treatment
If the patient can drink:
 provide the mother with ORS solution
 show her how to give it during the trip

If i/v therapy cannot be given and is not available nearby, but

nasogastric therapy is available:
 start rehydration by nasogastric tube with ORS solution
 give 20 ml/kg/hour for 6 hours (i.e. a total of 120 ml/kg)
 reassess the patient every 1-2 hours
 if the child has malnutrition, give half this amount

If there is repeated vomiting or increased abdominal distention:

 give the fluid more slowly

If hydration is not improving after 3 hours:

 refer for i/v therapy
 reassess after 6 hours
 choose the appropriate treatment plan to continue treatment

If both i/v and nasogastric therapy are not available, but the patient
can drink:
 start rehydration by mouth with ORS solution
 give 20 ml/kg/hour for 6 hours (i.e. a total of 120 ml/kg)
 re-assess the patient every 1-2 hours

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7. Gastro-intestinal conditions

If there is repeated vomiting;

 give the fluid more slowly

If hydration is not improving after 3 hours:

 refer for i/v therapy
 reassess after 6 hours
 choose the appropriate treatment plan to continue treatment

If i/v and nasogastric therapy are not available and the patient cannot
drink:
 refer urgently for i/v or nasogastric therapy
 If possible, observe the patient at least 6 hours after rehydration to
be sure the mother can maintain hydration with ORS solution by
mouth
 If the patient is under 2 years old and there is cholera in the area,
treat for this (see Section 7.3 page 41) after the patient is alert

7.5.2. Chronic diarrhoea (adults)

 Defined as liquid stools for 3 or more times daily or episodically for over
1 month
 Common presentation in HIV/AIDS patients.

Treatment
Adults:
 Correct any dehydration and maintain hydration
 Consider potassium supplements
o Advice the patient to eat more potassium-rich foods if possible, e.g.
bananas, Oranges, tangerines, and other citrus fruits
 Give supplementary feeding when required/as tolerated
 Always do HIV test
 Investigate stool for presence of ova, cysts and parasites
 If the condition persists
Give cotrimoxazole 960mg every 12 hours for 7 days

 If the condition responds to treatment but recurs within 4

weeks:
o Re-treat in accordance with the initial response
 Relapse may be due to short duration of initial treatment
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MSTG 2009
7. Gastro-intestinal conditions

 If no response to cotrimoxazole within 3 days, or if no

improvement after recurrence and retreatment with
cotrimozaxole;
o Give metronidazole 800 mg every 8 hours for 7 days

 If improved after re-treatment;

o Follow up as required

 If still no response after adding metronidazole or if no

improvement after recurrence and re-treatment with
cotrimoxazole/metronidazole;
o Give albendazole 400mg twice daily for 2 weeks

 If still not improved after albendazole treatment;

o Refer for microscopic examination of stool, See note (d) below
o Multiple stool examination may increase the diagnostic
yield of parasites if present

a) If bacteria or parasite found;

o Treat accordingly
If the condition responds to treatment but recurs
within 4 weeks:
o Re-evaluate

b) If bacteria or parasite is not found, use a constipating

agent to control the diarrhoea for up to 5 days treatment
 Give loperamide 4mg initially then 2mg after each
loose stool
 Usual dose 6-8mg daily up to 16mg daily

Alternatively
 codeine phosphate 30mg every 6 hours

 If still not improved within 1 week:

 Stop treatment
 Re-evaluate
 If no treatable cause of the diarrhoea is found
 Counsel the patient
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7. Gastro-intestinal conditions

Note:
a. Do not use constipating agents in patients with bloody diarrhoea
because of the risk of inducing toxic megacolon
b. In persistent diarrhoea, perianal application of soft paraffin
(Vaseline®) may soothe anal mucosae
c. Chronic diarrhoea caused by cryptosporidium infection and
caused by HIV infection itself (HIV enteropathy) needs to be
treated with antiretroviral therapy

7.5.3. Persistent diarrhoea (children)

 Defined as liquid stool 3 or more times daily for over 14 days
 A pathogen will only be identified in a small number of cases
 Consider TB and chronic infections e.g. UTI, as uncommon causes
 Persistent diarrhoea is a common symptom of protein-energy malnutrition
(PEM) and will resolve with treatment of this
 Correct any acute dehydration and maintain hydration
 Maintain nutrition
o Including breast feeding, where appropriate

Presence of fever and/or bloody stool makes bacterial infection more likely and
malnutrition puts a child at increased risk of dying from persistent diarrhoea.
Empiric (trial) antimicrobial treatment is therefore indicated in these conditions

 If bloody stool and fever:

 Give Nalidixic acid 50 mg/kg divided in 4 doses per day for
5 days
 If malnourished giv:
 Cotrimoxazole 24 mg/kg every 12 hours for 5 days and
 Supplemental feeding and supplements
 If worsening, or not improving after 14 days:
 refer for microscopic stool examination
 consider giving Albendazole for worms (see Section 15.5
page 131)
 and/or give Metronidazole for giardiasis

7.6 Gastritis (Peptic Ulcer)

 Advise patient to avoid hot spices, alcohol, tobacco, carbonated drinks
 Encourage regular meals
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MSTG 2009
7. Gastro-intestinal conditions

Treatment
 Chew 2 Magnesium trisilicate compound tablets every 6 hours or more
frequently as required for 7days
o Take preferably before food
o Take the last dose at night
Alternatively
 Ranitidine 300mg at night or 150mg every twelve hours for 4 weeks OR
 Cimetidine 400mg every twelve hours or 800mg at night OR
 Omeprazole 20mg once daily for 2 weeks
If severe pain continues:
o Exclude perforation
If no response, or in the presence of danger signs such as weight loss and
haematemesis:
 Refer for endoscopy and further management e.g. with triple therapy
 In patients with gastric or duodenal ulcers give triple therapy for
Helicobacter pylori:
o Omeprazole 40mg once daily for 2 weeks
o Metronidazole 400mg every 8 hours for 7 -10 days
o Amoxycillin 1g every twelve hours for 7 – 10days

Aspirin and other non-steroidal anti-inflammatory drugs ( NSAIDS) e.g. indomethacin,

ibuprofen, are contraindicated in patients with a history of peptic ulcer

7.7 Vomiting
 Always look for a possible cause and treat accordingly
 Do not give symptomatic treatment without knowing the cause
 Always exclude mechanical obstruction
 Correct dehydration where necessary

Treatment
 Metoclopramide 10 mg i/m or slow i/v (over 2 minutes) 3 times daily as
required
Note: Patients less than 20 years require special caution. Observe dose
requirements and use restrictions.

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MSTG 2009
8. Hepatic disorders

8.0 Hepatic Disorders

8.1 Acute liver failure

 Withdraw the causative agent if possible e.g. drugs or alcohol
 Avoid hepatoxic drugs e.g. paracetamol
 Ensure adequate intake of glucose (dextrose)
 Induce diarrhoea with Lactulose 5ml every 6 hours and/or Neomycin
sulphate 1g every 6 hours (1 week)
 Give antibiotic prophylaxis for patients with liver failure: Ceftriaxone 2g
od iv
 Prophylaxis of bleeding: Vitamin K 10 mg i/m stat

 If the patient is drowsy or comatose

o Give an i/v infusion of dextrose 50%
o Reduce protein intake
o Do not give sedatives or hypnotics
o Refer the patient for further diagnosis and management
o Thiamine 100 mg i/v or i/m 3-7 days in case of known or
suspected alcoholic cause

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9. Infectious diseases

9.0 Infectious Diseases

9.1 HIV and related conditions

 People infected with HIV may develop HIV-related illnesses, the most
common of which is TB.

In all cases of HIV-related illness, prompt diagnosis and proper management of the problem
is crucial

 For more details refer to the following MoH guideline

 MoH Management of HIV/AIDS Related Diseases (2008 2nd Edition)
for:
o The Malawi AIDS case definition: Clinical and laboratory diagnosis
of HIV related diseases.
o Treatment of AIDS Guidelines for the Use of Antiretroviral
Therapy in Malawi 3rd edition.
o PMTCT guidelines

9.1.1 Care and Support

 General supportive care: Proper nutrition is important.
 Psychological support: Inform patients of any HIV support groups in their
community.
 Spiritual support: The spiritual needs of the patient and family should be
properly addressed.

9.1.2 Immunisation of HIV (+) children

 Unless very ill, immunise with EPI vaccines (BCG, DPT, polio and
measles) according to standard schedules see Section 19 page 167.
 Older children with clinical AIDS should not get BCG vaccine.
 Antibody response to vaccines may be less than normal but tends to be
better in the early stages of HIV infection.

9.1.3 Breast-feeding by HIV (+) mothers

 Counsel HIV (+) women on the risks of future pregnancy
 Encourage Exclusive breast feeding up to 6months.

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9. Infectious diseases

9.1.4 End organ dysfunction

 These include:
o Bone marrow (haematological abnormalities): see section on
blood diseases
o CNS
o GI, renal, cardiac systems
 For organ dysfunction directly caused by HIV, ART is indicated in
combination with supportive treatment

9.1.5 Counselling
 Refer to the MoH Guide for Pre- and Post-test Counselling and AIDS
Counselling information.
 If a child is too young, counsel the parents/guardians.
 Counselling should be private, compassionate and confidential.
 Consider modes of transmission in discussions with parents or
guardians.
 Offer HIV testing to parents of HIV-infected children, and advise them
on:
o The implications of HIV infection in themselves for further
children.
o The risk of transmitting infection sexually or as blood donors in
the future.

9.1.5.1 Pre-test counselling

 Refer to the MOH Guide for Pre- and Post-test Counselling and AIDS
Counselling information.

9.1.5.2 Post-test counselling

 Refer to the MOH Guide for Pre- and Post-test Counselling and AIDS
Counselling information.

9.1.6 Health worker safety

 Refer to the MOH/National Prevention Services booklet Recommended
Guidelines for Infection Control and Prevention

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9. Infectious diseases

9.1.7 Post-exposure prophylaxis (PEP)

 “PEP” refers to the treatment of HIV exposures using antiretroviral
drugs.
 ART started immediately after exposure to HIV may prevent HIV
infection.
 Treatment should be initiated within 1-2 hours of injury or exposure.
Where this is not possible, it is still reasonable to start PEP up to 72
hours after the exposure.
 An exposed client should receive PEP only if he or she is HIV negative,
because PEP is not nessecary if the client is HIV infected and dual
antiretroviral therapy is potentially harmful (as it can easily induce
resistance).
 PEP may be given regardless of the serostatus of the source if there is a
possibility that the source may be in the window period of
seroconversion.
Table 6: The PEP Regimen
Medicine Dose Frequency Duration
Zidovudine (AZT) One Twice a day 30 days
300mg/ Lamivudine tablet
(3TC) 150mg
(Duovir)

9.1.8 HIV infection in children

 Common presentation: diarrhoea, failure to thrive (FTT) and infections
including tuberculosis, thrush (moniliasis), pneumonia, and meningitis;
o Treat these and malnutrition appropriately.
 Immunise HIV(+) children with DTP, hepatitis B, Hib, polio, and measles
vaccines, unless they are very ill but,
 Do not give BCG to older children with clinical AIDS.
 Encourage mothers to continue breast feeding.
 Whenever possible, treat HIV(+) children as out-patients to minimise the
risk of cross-infection, as they may be immuno-compromised.
Note: A reactive HIV ELISA test in a child under 18 months, even with no
laboratory error, is not proof of HIV infection, as passively acquired
maternal antibody may be the cause

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9. Infectious diseases

9.1.9 Management of common clinical presentations in HIV (+) patients

 Treatment of these is often similar to the treatment of the same
condition in HIV(-) patients, as covered elsewhere in these guidelines.
 Differences in treatment for HIV(+) patients are indicated in the
appropriate treatment schedules.

9.1.9.1 Diarrhoea disease

See Section 7.5 page 42.

9.1.9.2 Respiratory conditions (adults)

 Common HIV associated respiratory diseases: bacterial pneumonia,
pulmonary tuberculosis, Pneumocystis jirovecii pneumonia (PCP),
lymphoid interstitial pneumonitis (LIP), pulmonary Kaposi’s sarcoma.
 Cough without dyspnoea or tachycardia and associated with a runny
nose is usually indicative of a viral URTI.

9.1.9.3 Pneumocystis jirovecii Pneumonia (PCP)

Treatment
 Cotrimoxazole oral or i/v 30 mg/kg every 8 hours for 21 days
 Whereever possible give oxygen
 Give severely dyspoenic patients Prednisolone 40mg twice a day for 5
days then 40mg once a day for 5 days then 20mg once a day for the
remaining 11 days
 Risk of recurrence after treatment is very high. For prophylaxis give
Cotrimoxazole 960mg twice a day

9.1.9.4 Respiratory conditions (children)

 Cough with or without difficulty in breathing.
 Pneumonia and pulmonary TB are common in HIV (+) children.
 Cough without dyspnoea or tachypnoea and associated with a runny
nose is usually due to a viral URTI.
Treatment
 if upper respiratory tract infection (URTI) with fever:treat as malaria, (see
Section 15.1 page 118)
o if URTI without fever: Advise mother on general supportive home
care (see Section 16.1 page 132).

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9. Infectious diseases

 if pneumonia suspected:assess severity and treat according (see Section

16.1 page 132).
 Presumed pneumonia which fails to respond to treatment may be due
other causes
o Do a chest X-ray to rule out emphysema, effusion, TB, PCP, LIP,
staphylococcal infection and other conditions common in HIV(+)
patients
o Manage according to X-ray findings
 If PCP found, treat as in Section 9.1.9.3 above
o Give Prednisolone, 1-2mg/kg every 12 hours
 If LIP found:
o Suspect LIP if chest xray shows a bilateral reticular –nodular
interstial pattern. Distinguish from pulmonary TB.
o The child may present with persistent cough, bilateral parotid
swelling, persistent generalized lymphadenopathy, hepatomegaly
and finger clubbing.
o Antibiotics for bacterial pneumonia
o Prednisolone 1-2mg/kg daily for 2 weeks,
 Decrease dose over 2-4 weeks depending on response.
o Beware of reactivation of TB

9.1.9.5 Fever (adults)

 A body temperature of over 38o C, continuously or intermittently, for
more than 24 hours in any 72 hour period.
 Fever is common in HIV(+) patients

Seriously ill patient

 Start treatment for presumed sepsis (See Section 9.7 page 87)
 Maintain hydration
 Refer urgently to hospital for further management

If patient not seriously ill

 Maintain hydration
 Check bloodslide for malaria parasites, whether positive or negative:
give presumptive 1st line antimalarial treatment (see Section 15.1.1 page
119)

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9. Infectious diseases

 Look for local causes of fever: otitis media, tonsillitis, skin infections,
pneumonia, PTB and EPTB, urinary tract infections, joint infections and
give appropriate treatment accordingly
 Consider giving antipyretic treatment
 If not improved within 3 days:
o Refer for further investigations
o Treat according to findings
 If there are no suggestive laboratory or radiological findings:
o consider empirical (trial) treatment for suspected sepsis (see
Section 9.7 page 87)
 If fever still persists but patient is clinically stable:
o Presume HIV related fever
o Give supportive care and assess for ART
o Seek a second opinion at the earliest opportunity

9.1.9.6 Fever, persistent or recurrent (children)

 Persistent fever: a body temperature of >38 degrees Celcius for more
than 5 days
 Recurrent fever: a body temperature of >38 degress celcius for more
than 1 episode in a period of 5 days
 Look for: Meningitis, septicemia, Occult bacterial infections, TB, Fungal,
viral or parasitic infections, Neoplasms
 Maintain hydration
 Maintain nutrition
 Give antipyretic treatment (see Section 10.1 page 91)

Treatment
Seriously ill child
 Start treatment for presumed sepsis (see Section 9.7 page 87)
 Start 1st line antimalarial treatment (see Section 15.1.1 page 119)
 Refer the patient.
Child not seriously ill
 If the child has completed 1st line antimalaria treatment:
o Amoxycillin 50mg/kg every 8- 12 hours for 7 days.
o This is intended to treat non-serious bacterial infections, e.g.
sinusitis, urinary tract.
 If free of fever after 3 days:
o Complete treatment course for Amoxycillin.
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o Follow up as required.
 If not improved;
o Give 2nd line antimalarial treatment (see Section 15.1.1 page 119).
o Follow up as required.
 If the child has not completed 1st line antimalarial treatment
o give 1st line antimalarial treatment (see Section 15.1.1 page 119)
 If not free of fever after 3 days:
o Refer to the next level

9.1.9.7 Upper GIT Candidiasis

 Presumptive diagnosis:
o white plagues in the mouth and lesions in the esophagus and
stomach,
o Antifungal therapy is required treat according to Oropharyngeal
conditions (see Section 14.1 page 113)

9.1.9.8 Mental disorders (adults and older children)

 Refer to Section 3.3 page 17 on psychological conditions

9.1.9.9 Primary neurological disorders (adults)

 Refer for careful assessment and investigation
 Refer to Section 3.4 page 18 on neurology disorders

9.1.9.9.1 CNS disorders

 Look for evidence of an opportunistic infection and treat the underlying
cause accordingly

9.1.9.9.1.1 Protozoal, viral, fungal and bacterial infections

 Often affects the brain in HIV (+) patients
 Carry out a lumber puncture
 Refer to relevant treatment guidelines

9.1.9.9.1.2 Cerebral toxoplasmosis

 Most frequently causes focal neurological signs in patients with
advanced immune-suppression.
 Sulphadoxine/pyrimethamine (SP) 2 tablets daily for at least 6 weeks,
followed by life-long cotrimoxazole 480mg twice daily.
 Start ART after some weeks on SP.
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 May result in complete cure

9.1.9.9.1.3 Cryptococcal meningitis

 Refer to Section 9.3.3 page 73

9.1.9.9.1.4 Tuberculosis
 Refer to Section 9.5 page 76

9.1.9.9.1.5 Syphilis
 Refer to Section 17.4 page 153
 If there is severe spasticity and ataxia:
o Presume myelopathy
o Treat as neuro-syphilis with Benzylpenicillin 5 MU i/v 6 hourly for
2 weeks OR Doxycycline 200 mg once daily for 3 weeks
o Give supportive and symptomatic treatment and counseling

9.1.9.9.1.6 AIDS Dementia

 Characterised by cognitive, behavioural and motor dysfunction, often
overlooked in advanced HIV infection. ART is indicated and may give a
favorable response.

9.1.9.9.1.7 Progressive multifocal leucoencephalopathy (PML)

 Caused by a papova (JC) virus, rapid evolution over weeks or months;
altered mental state, visual defects, motor weakness, speech
dysfunction, sensory deficits and cerebellar disorders.
 Prognosis is very poor, sometimes temporary relief from ART, no
causative treatment available.

9.1.9.9.2 Peripheral nervous system conditions

If predominantly sensory: sensory peripheral neuropathy
 If on tuberculosis treatment, treat with Pyridoxine 25mg once daily for
the duration of tuberculosis treatment
 Check if drugs that cause neuropathy are used (vincristine, stavudine,
metronidazole) and consider modifying drug treatment
 Screen for diabetes mellitus and treat accordingly if present
 Consider other causes of neuropathy: alcohol abuse, renal disease,
malignancies, vitamin B12 deficiency and treat if possible
 HIV associated peripheral neuropathy often improves with ART
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 Give supportive and symptomatic treatment:

 Amitryptilline 25-75mg nocte
 Painkillers if required (see Section 24.1 page 196)

9.1.9.10 Primary neurological disorders (children)

 Manage these in the same way as in HIV (-) children.
 Refer to hospital for careful assessment and investigation.
 Rule out treatable causes of acute episodes of neurological dysfunction
such as TB, bacterial meningitis and cerebral malaria through careful
history and examination in children.

9.1.9.11 Lymphadenopathy
 Causes: Tuberculosis, bacterial (including syphilis), fungal or viral
infections, malignancies (Kaposi's sarcoma, lymphoma), dermatological
and other conditions.
 Persistent generalized lymphadenopathy (PGL), more than 3 separate
lymph node groups affected, at least 2 nodes more than 1.5 cm in
diameter at each site, duration of more than 1 month and no local or
contiguous infection which might explain the lymphadenopathy
 Is common and due to HIV infection alone; requires no treatment
General Measures
 Ensure careful physical examination to identify any local or contiguous
infection which might explain the lymphadenopathy.
 If there is local or contiguous infection:
o Treat as indicated
 If TB is suspected
o Do fine needle aspiration for acid fast bacilli. Treat accordingly
(see Section 9.5 page 76)
 If there is a papulo-squamous rash and/or evidence of recent genital
ulcer (adults only)
o Do a TPHA or RPR
If positive, treat for syphilis see Section 17.4 page 153
 If the patient has recent symptomatic lymphadenopathy of uncertain
aetiology or if patient does not respond to empiric therapy:
o Refer for further assessment including lymph node biopsy

9.1.9.12 Failure to thrive (FTT)

 This is seen by examining the child and checking the under-5 card
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 When assessing FTT, it is vital to take a detailed dietary and social

history to determine whether the child receives sufficient calories and a
balanced diet
 Rule out TB and HIV
 Ascertain whether the child has any TB contacts
 Do chest x-ray and tuberculin PPD test, and also sputum test in an order
child
 Tuberculin PPD testing is however usually unhelpful in severe FTT
 Identify any other associated problems and treat accordingly. These may
include
o Persistent Diarrhoea (see Section 7.5.3 page 52)
o Oral thrush (see Section 14.1 page 113)
o Respiratory conditions (see Section 16 page 132)
 Assess the severity of FTT
o Inability to feed and severe apathy are important indicators of
severity
o Severe malnutrition is often associated with extensive oedema
and dermatitis
 If able to feed and not severely malnourished:
o Give a trial of home feeding
o If possible, give exact recommendations on the schedule and
content of the diet
o Assess the availability of food at home
o Encourage the mother to provide, whenever possible, a balanced
nutritious diet including, for example soya, beans, groundnuts,
bananas, other fruits, eggs, meat and fish
o Review after 2-4 weeks
 If TB is not found
o Carry out other investigations as indicated from history and
examination e.g.
 Stool analysis and urea and electrolytes
 If neither TB or other conditions are identified
o Presume HIV-related FTT
 If not able to feed and moderately or severely malnourished:
o Admit the patient
o Treat for malnutrition (see Section 23 page 188)
 If the child is taking adequate oral feeds
o Continue these for 2-3 weeks
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o Reassess the patient

 If the child is unable to take adequate oral feeds, use NGT feeding until
able to take oral feeds
 Once the child is improving
 If aneamic, give Ferrous Sulphate and Folic Acid
 If helminth infestation is suspected, treat with Albendazole
 If on re-assessment the child is not improving, refer to the higher level
 Where severe FTT is considered to be HIV-related
o Improve nutritional and supportive care
o Prolonged NGT feeding may occasionally be appropriate
o Initiate HAART

9.1.9.13 Pain relief

Refer to Section 24 page 196

9.1.9.14 Kaposi’s sarcoma

 Kaposi’s sarcoma (KS) patients need to be started on ART, as there is a
direct beneficial effect on KS at whatever stage of disease patients present.
 Full blood count must be done before starting treatment
Treatment
 2mg once a week for 6 doses
 Review after 6 weeks
If there is‘no effect’ nor side effects and /or limited stable disease then
discontinue
If there is ‘good effect’ or minimal side effects and residual disease
 continue with 2mg once every 2 weeks for six doses
 Review after 6 weeks
If there is‘no effect’ nor side effects and /or limited stable disease then
discontinue
If there is ‘good effect’ or minimal side effects and residual disease
 continue with 2mg once a month for six doses
 Final assessment of efficacy and side effects should be recorded in health
passport for future reference
 Review after 3 months after treatment (earlier as required for pain and
symptom management)

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9.1.10 Antiretroviral Treatment Regimens

9.1.10.1 First Line regimen

 Introduction of the first line regimen includes:
- Staging and management of HIV related diseases
- Group counseling on issues surrounding ART
- Individual counseling and assessment of contraindications for ART
- Baseline weight
- Other blood tests may be done (full blood count, CD4 count,
creatinine, liver enzymes) but are not mandatory
Table 7: Steps in administering 1st line ARV Therapy
First two
d4T/3TC/NVP 1 tablet in the morning plus
weeks(starter
d4T/3TC 1 tablet in the evening
pack)
d4T/3TC/NVP 1 tablet in the morning plus
Continuation pack
d4T/3TC/NVP in the evening

9.1.10.1.1 Alternative First Line regimen

 Alternative first line substitutions can be made in cases of medicine
reactions:
o Severe peripheral neuropathy: due to stavudine component
 Zidovudine (AZT) + Lamivudine (3TC) + Nevirapine (NVP)
o Liver toxicity such as hepatitis: due to nevirapine component
 Stavudine (d4T) + Lamivudine (3TC) + Efavirenz (EFZ)
o Severe skin reactions: due to nevirapine component
 Stavudine (d4T) + Lamivudine (3TC) + Efavirenz (EFZ)

9.1.10.2 Second Line regimen

 Switch to second line regimen in cases of failure to first line regimen:
Adults
 Zidovudine (AZT) + Lamivudine (3TC) + Tenofovir (TDF) +
 Lopinavir/ Ritonavir (LPV/RTV)
Children
 Didanosine (ddI) + Abacavir (ABC) + Lopinavir/Ritonavir (LPV/r)

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9.1.11 Dosage Guidelines for First Line ARV Therapy in Children in Malawi
Table 8: Doses for 1st line ARV Therapy in Children
Medicine Dose
Stavudine 2mg/kg/day
(d4T)
Lamivudine 8mg/kg/day
(3TC)
Nevirapine 8mg/kg/day
(NVP)

 i.e. target dose ratio = 1: 4: 4 (d4T:3TC:NVP)

 d4T/3TC/NVP dose ratio = 1: 3.75: 5

For d4T/3TC/NVP:

Weight Dos Dos

(kg) e e
a.m p.m
. .
<8 ¼ -
8<12 ¼ ¼
12<18 ½ ¼
18<22 ½ ½
22<28 ¾ ½
28<32 ¾ ¾
32<38 1 ¾
> 38 1 1

 The second line ARV treatment in children is a combination of abacavir,

didanosine and kaletra.

9.1.12 Cotrimoxazole prophylaxis

Adults
 Give Cotrimoxazole 480mg twice daily to any HIV infected person in
WHO clinical stage II, III or IV; any person with a CD4 count <500
cells/mm3 regardsless of symptoms; HIV + pregnant women after the
first trimester
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Children
 Give Cotrimoxazole 6-8mg/kg once daily to all HIV exposed children
from 4-6 weeks till HIV infection has definitely been ruled out, and to all
HIV infected children.
 If allergic to Cotrimoxazole, give Dapsone.

9.2 Leprosy

9.2.1 Multibacillary
 The multi-drug treatment (MDT) regimen consists of
o Monthly supervised doses of Rifampicin and Clofazimine taken on
a fixed day at 4 week intervals
o Daily unsupervised doses of Clofazimine and Dapsone
 Continue treatment until 24 monthly supervised doses of Rifampicin and
Clofazimine have been completed within a maximum of 3 years

9.2.1.1 MDT regimen for multibacillary leprosy

Table 9: MDT regimen for multibacillary leprosy
Medicine Frequency Age years/dose (mg)

0-5 6- 15
yrs 14 and
yrs over
Rifampicin Monthly 300 300 600
Clofazimine Monthly 100 200 300
Clofazimine Daily 25* 50 50
Dapsone Daily 25 50 100

*25 mg capsules of clofazimine are not available. Give a 50 mg capsule every

second day instead

9.2.2 Paucibacillary
 The MDT regimen consists of :
o A monthly supervised dose of Rifampicin taken on a fixed day at
4-week intervals
o A daily unsupervised dose of Dapsone
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 Continue treatment until 6 monthly supervised doses of Rifampicin have

been completed within a maximum period 9 months
Table 10: MDT regimen for paubacillary leprosy
Medicine Frequency Age years/dose
(mg)
0-5 6-14 15
and over
Rifampicin Monthly 300 300 600
Dapsone Daily 25 50 100

9.2.3 Leprosy reactions

 Do not stop therapy for leprosy during treatment of reactions
 Refer urgently to Leprosy Control Assistant

9.2.3.1. Severe reversal reaction; paucibacillary patients

 This is a delayed hypersensitivity allergic reaction manifesting itself as
exacerbated leprosy skin lesions and/or enlarged tender nerves with or
without nerve deficit
Treatment
 Prednisolone daily with the dose being gradually reduced every 2
weeks until a total of 12 weeks are completed ( see table)
Table 11: Prednisolone regimen for paucibacillary severe reversal reactions
Week Prednisolone
dose
(mg daily)
1-2 40
3-4 30
5-6 20
7-8 15
9-10 10
11-12 5

9.2.3.2 Severe reversal reaction; multibacillary patients

 This regimen is for multibacillary patients with a severe reversal reaction
or recent nerve damage

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Treatment
 daily Prednisolone being gradually reduced at intervals of 2 or 4 weeks
over a period of 20 weeks (see table)
Table 12: Prednisolone regimen for multibacillary severe reversal reaction
Week Prednisolone
dose
(mg daily)
1-2 40
3-6 30
7-10 20
11-14 15
15-18 10
19-20 5

9.2.3.3 Severe type 2 reaction

 This is an antigen-antibody complex reaction manifesting itself as fever,
malaise and general body pain, and also frequently and typically with
erythema nodosum leprosum (ENL)
 Rarely is iridocyclitis or orchiditis present
Treatment
 standard short-course of daily Prednisolone with the dose being
gradually reduced by 5mg every 2 days until a total of 12 days is
completed (see table below)
 Do not stop therapy for leprosy during treatment of reaction
 Refer urgently to Leprosy Control assistant
Table 13: Prednisolone regimen for severe type 2 reaction
Day Prednisolone
dose
(mg daily)
1-2 30
3-4 25
5-6 20
7-8 15
9-10 10
11-12 5

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9.2.3.4 Acute dapsone allergic reaction

 Symptoms/Signs: itching, rash, exfoliative dermatitis or Stevens-Johnson
syndrome
 Refer urgently to Leprosy Control Assistant
 Stop Dapsone
 Then observe
Treatment
 Give Antihistamines, steroids or hospitalize
o Depends on severity

9.3 Meningitis
 Refer patient to hospital as soon as diagnosis is suspected

A lumbar puncture is essential for

diagnosis

 If possible, do a lumber puncture first and send the CSF in a sterile

container along with the patient, but always start treatment before
transfer with
Treatment
Adults
 Benzyl penicillin 5MU i/v or i/m stat
 Plus (if available) Chloramphenicol 1g i/v stat

Children
 Benzyl penicillin 100,000 units/kg i/v or i/m stat
 Plus Chlorampenicol 25 mg/kg i/v stat

Neonates
Benzyl penicillin and Gentamycin i/m or i/v
 When a lumber puncture cannot be done prior to referral, this should be
done as soon as possible after admission

9.3.1 Bacterial meningitis

 In hospital, start an i/v infusion for antibiotics using Dextrose 5% (not
more than 50 mL/kg per day for an infant) and continue until oral
medication can be tolerated
 Give antibiotics for at least 14 days,
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o if there is a good response in meningococcal disease stop at 7

days
Treatment
Adults (empirical treatment pending test results)
 Ceftriaxone 2g i/v every twelve hours
Alternatively
 Chloromphenical 1g every 6 hours, i/v and
 Benzyl penicillin 5MU every 6 hours, i/v
 Continue i/v antibiotics until 48 hours after the fever has subsided
 Change to oral Amoxycillin 500mg every 8 hours and
Chloramphenicol 500mg every 6 hours to complete 14 days.

Children
 Give antibiotics for at least 7 days.
 Ceftriaxone 100mg/kg once daily i/m or i/v
Alternatively
 Chloramphenicol 25mg /kg i/v every 8 hours
plus
 Benzylpenicillin 100,000 IU/kg every 6 hours

9.3.2 Meningitis in neonates

 Usually caused by gram(-) organisms and requires treatment for 21 days
(gram(+) infection)
 Otherwise give 14 days treatment
 Careful observation is essential
 While awaiting culture and sensitivity results or if they are not available
give
o Benzyl penicillin 100,000 units/kg every 6 hours, initially slow i/v or
i/m
o Plus Gentamycin 2.5 mg/kg i/m or i/v every 8 hours or Gentamycin
5mg/kg i/m once per day if 1 week old and Gentamycin 7.5 mg/kg
once daily if over a week old.
Alternatively
o Ampicillin 50 mg/kg every 6 hours initially i/v later i/m as an
alternative to Benzyl penicillin

If still febrile after 48 hours;

o Add Cefotaxime.
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9.3.3 Cryptococcal meningitis

 Symptoms/Signs: severe headaches, not responding to non-narcotics
anaelegiscs, the patient nearly always has HIV infection with advanced
immune suppression.
 Confirm diagnosis with Indian ink stain, Cryptococcal antigen and/or
culture of the CSF.
 Refer for specialist management with Amphotericin B 0.7-1.0 mg/kg
daily infused in glucose 5% i/v solution over 4-6 hours for 2 weeks if
tolerated, followed by Fluconazole 400 mg once daily for 6 weeks and
then 200 mg once daily lifelong.
Alternatively if available
 Fluconazole 800mg orally or i/v once daily for 2 weeks, followed by
Fluconazole 400 mg once daily for 6 weeks and then 200 mg once daily
lifelong.

9.3.4 Meningococcal meningitis (prophylaxis)

 Recommended for selected groups living in very crowded conditions and
for close household contacts
Adults
 Ciprofloxacin 500 mg stat.
Alternatively
 Doxycycline 300mg stat
Children
 Doxycycline 6 mg/kg

9.4 Tetanus
 Immunization has significantly reduced the incidence of this

9.4.1 Adult tetanus

 Good nursing care of the heavily sedated patient is essential
 Give active immunization against tetanus after recovery

General measures
 Nurse the patient in a quiet area
 Maintain adequate hydration and nutrition
 Prevent aspiration of fluid into the lungs
 Clean and debride necrotic wounds thoroughly
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 Change from parenteral to oral medication as soon as possible

 Avoid provoking spasms
 Encourage active exercise after spasms have ceased
Treatment
 Diazepam 20 mg i/m or i/v Chlorpromazine 50 mg i/m or i/v given
alternately every 3 hours
Alternatively
 Diazepam infusion 40 mg in one liter of i/v dextrose or normal saline every
6-8 hours
Take care: respiratory depression may occur

o Dose sizes or frequencies of the above medicines can be increased if

necessary to control spasms
 Anti-tetanus serum 20,000 units i/v stat
o Give this after a test dose of 1,500 units s/c
 Benzyl penicillin 2 MU i/v every 6 hours for 7 days
 Metronidazole 500 mg i/v or 400 mg oral every 8 hours for 7 days
 Tetanus toxoid vaccination: give the full course

9.4.2 Neonatal Tetanus

Symptoms: poor feeding, constipation, stiffness and spasms
 Prevent if possible and aggressively treat respiratory complications as
these are the main cause of death
 Start active immunization against tetanus once the child has recovered

General measures
 Nurse the baby in an intensive care area with close observation and
attention to airway, temperature and spasms
 Maintain adequate hydration, initially with i/v fluids
 Maintain nutrition with expressed breast milk via an NGT
 Have a mucous extractor or other suction available
 Avoid i/m injections as much as possible by use of alternative routes (e.g.
NGT, rectal administration) where indicated
 Change from i/m injections to oral medication as soon as possible and
keep handling to a minimum in order to avoid provoking spasms
 Thoroughly clean the umbilical area

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Treatment
 Paraldehyde 0.2 ml/kg i/m or 0.4 ml/kg rectally (see note 1 below)
followed by
 Phenobarbitone 15 mg/kg loading dose stat initially then10 mg i/v plus 5
mg i/m
 Continue with Diazepam 0.5 mg/kg by NGT or rectally (see note 2 below)
or slow i/v and Phenobarbitione 5-10 mg/kg by NGT or i/m
 Give these drugs alternatively every 3 hours
 Anti-tetanus serum 10,000 units i/m or i/v every 6 hours for 5 days
Once spasms are controlled;
 Phenobarbitone 5-10 mg/kg once daily orally as maintenance dose

Note:
1) Paraldehyde; dissolves plastic so use a glass syringe. However if this is
not available, use a plastic syringe but make sure the drug is given
promptly and not left in the syringe before administration. The drug may
also be given rectally using a syringe after removing the needle.
2) Diazepam rectal administration (by syringe after removing the needle) is
as reliable as i/v and easier and safer to give.

9.4.3 Tetanus Prevention

 Promote tetanus toxoid vaccination (TTV) in pregnant women and all
women of child bearing age (see Section 12.3 page 100)
 Ensure adequate surgical toilet plus passive (ATS 1,500 units i/m or s/c)
and active (TTV) immunization after wounds, bites and burns

9.4.4 Tetanus toxoid vaccination (TTV)

9.4.4.1 Unimmunised or never fully immunized patients

 Give a full course of vaccination
 One dose (0.5 mL) s/c or i/m in weeks 1,4 and 8
 For women of childbearing age (see Section 12.3 page 100)

9.4.4.2 Fully immunized but last booster >10 years ago:

 Give one booster dose of 0.5 mL s/c or i/m

Fully immunized patients who have had a booster within the last 10 years do not need
treatment with tetanus antitoxin (ATS) or tetanus toxoid vaccination (TTV)
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9.5 Tuberculosis (TB)

 For detailed information on the control and management of TB refer to the
National Tuberculosis Control Programme Manual (MOH, 2007)
 Suspect pulmonary TB if coughing for 3 weeks or more, usually with one or
more of the following:
o Fever
o Chest pain
o Shortness of breath
o Loss of weight
o Hemoptysis
 Symptoms/Signs: enlarged lymph nodes (lymphadenopathy), swelling of
abdomen due to fluid (ascites), tender swelling of the back (TB spine),
sometimes weakness of the legs (TB spine), stiffness of the neck
(meningitis), confusion (meningitis)
 If TB is suspected, refer the patient to hospital
 Diagnosis and classification of pulmonary TB must be based on sputum
examination (smear microscopy for acid-fast bacilli)

Do not start TB treatment until a firm diagnosis has been made

 Effective treatment of TB and prevention of the development of medicine

resistance depends on an appropriate combination of at least 2 medicines
taken:
o Regularly
o In the correct dose
o For the full recommended duration
o Under direct observation (DOT)

Stress to the patient the importance of regular medicine taking as the basis for the
cure of TB

 HIV positive patients can be successfully treated for TB

9.5.1 Anti-Tuberculosis Medicines

 Malawi is now treating TB patients using fixed dose combinations (FDCs),
single tablets and streptomycin injection as shown below:

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a) Combination Tablets

Adult Formulations
 RHZE contains:Rifampicin 150mg, Isoniazid 75mg, Pyrazinamide 400mg,
Ethambutol 275mg
 RHE contains:Rifampicin 150mg, Isoniazid 75mg, Ethambutol 275mg
 RH contains: Rifampicin 150mg, Isoniazid 75mg

Paediatric Formulations
 RHZ contains: Rifampicin 60mg, Isoniazid 30mg, Pyrazinamide 150mg
 RH contains: Rifampicin 60mg, Isoniazid 30mg

b) Single tablets
 Z (pyrazinamide) contains: Pyrazinamide 400mg
 E (ethambutol) contains: Ethambutol 400mg, Ethambutol 100mg
 H100 (isoniazid) contains: Isoniazid 100mg

c) Injections
 S (streptomycin) contains: Streptomycin 1g

9.5.2. TB Treatment Regimens

9.5.2.1 Treatment Regimen 1 (for new patients)

 Initial intensive phase:
o Newly diagnosed TB patients are admitted for 2 weeks in hospital
where they receive daily treatment under DOT.
o The remaining 6 weeks of the intensive phase is taken daily either in
hospital or in the community according to the patient's DOT option.
o In central hospitals, patients are started on ambulatory treatment
depending on the condition of the patient from the first day, but
treatment is on daily basis just like the district hospitals.
 Continuation phase:
o Patients take medicines under supervision.
o Medicines are collected from the nearest health facilities every
fortnight.

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Table 14: Dosages of FDC formulations

ADULTS
Continuation phase
Initial phase
4 months
2 months

Body weight in kg
[RHZE] [RH]
[R150/H75/Z400/E275] [R150/H75]
Number of tablets* Number of tablets*
30-37 2 2
38-54 3 3
55-74 4 4
75 and over
5 5

CHILDREN
Body weight in kg Initial phase Continuation phase
2 months 4 months
[RHZ] E100 [RH]
(R60/H30/Z150) (R60/H30)
Number of Number of Number of tablets or
tablets tablets or sachets*
or sachets* sachets*
<7 1 1 1
8-9 1.5 1.5 1.5
10-14 2 2 2
15-19 3 3 3
20-24 4 4 4
25-29 5 5 5
Re-adjust dose as body weight increases

9.5.2.2 Treatment Regimen 2

Indications for use: relapse, return after default, treatment failure and recurrent
Tuberculosis.
 The regimen is 2SRHZE/1RHZE/5RHE

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 Regimen consists of 2 months of SRHZE daily, 1 month of RHZE daily

followed by 5 months of RHE daily, all under supervision.
Note:
(1) Sputum positive cases that have previously taken anti-tuberculosis
medicines for 1 month or more must be suspected of discharging
tubercle bacilli resistant to one or more anti-TB medicines.
(2) These patients must submit sputum specimens for medicine
sensitivity testing before starting the re-treatment regimen.
Table 15: Treatment regimen 2

ADULTS
Body Initial phase Continuation phase
weight 2 months 5 months
in kg [RHZE]
[SRHZE] [R150/H75/Z400/E275]

Streptomycin [RHZE] [Z] [RHE]

daily Number of tablets [R150/H75/E275]
injection for daily for 2 months Number of Number of tablets
2 months tablets daily daily for 5 months
for 5 months
30-37 0.5g 2 2 2
38-54 0.75g 3 3 3
55-74 1g 4 4 4
75 and 1g 5 5 5
over
CHILDREN
Body Initial phase daily doses for Initial phase daily Continuation
weight months dose for 1 month phase daily dose
in kg for
[SRHZ] and E [RHZ] and E 5 months
[RH] and E
[R60/H30/] and
E100

Streptomycin [RHZ] [E] [RHZ] [E] [RH] [E]

daily Number Number Number Number Number Number
injection of of of of of of
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tablets tablets tablets tablets tablets tablets

per day per day per day per day per day per day

<7 15mg/kg 1 1 1 1 1 1
8-9 15mg/kg 1.5 1.5 1.5 1.5 1.5 1.5
10-15 15mg/kg 2 2 2 2 2 2
15-19 15mg/kg 3 3 3 3 3 3
20-24 15mg/kg 4 4 4 4 4 4
25-29 0.5mg 5 5 5 5 5 5

9.5.3. Tuberculosis Meningitis

 The regimen for adult and childhood cases of tuberculosis meningitis is
different from above.
 The regimen is 2SRHZ/7RH and doses are as below
Table 16: Dose regimen for tuberculosis meningitis
Weight Daily during weeks 1-8 Daily during weeks 9
in kgs – 32
S RH Z RH
Over 1g 4 4 4
55
40 – 55 0.75g 3 3 3
25 – 39 0.5 2 2 2
20 – 24 15mg/kg 1.5 1.5 1.5
15 – 19 15mg/kg 1.5 1.5 1.5
9 – 14 15mg/kg 1 1 1
5 – 8 15mg/kg 0.5 0.5 0.5
0 – 4 15mg/kg 0.25 0.25 0.25

 The regimen consists of 2 months of Streptomycin, Rifinah and

Pyrazinamide given under supervision on a daily basis followed by 7
months of daily Rifinah.

9.5.4 Medicine Resistant Tuberculosis (MRT)

 Two types of medicine resistant TB:
o Primary resistance (resistance in newly diagnosed TB cases) and
o Secondary resistance (resistance in previously treated TB cases).

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a) Multi-Drug Resistant TB (MDR-TB) - resistant to both rifampicin and

isoniazid.
b) Extensively-Drug Resistant TB (XDR-TB) - also resistant to any
fluoroquinolone, and at least one of the three injectable second line
anti-TB medicines (capreomycin, kanamycin and amicacin)

9.5.4.1 Treatment of Medicine-resistant TB

 MDR-TB treatment requires use of second line anti-TB medicines which
have to be taken for 24 months.
 The patients are managed in their communities.
Table 17: MDR-TB Treatment Regime
INTENSIVE PHASE: 6 MONTHS
Patient weight Medicine Dosage
Kanamycin
750 mg
(Km)
Ethionamide
500 mg
(Et)
< 50 KGS Pyrazinamide 1000
(Z) mg
Ofloxacin (Of) 600 mg
Cycloserine
500 mg
(Cs)
1000
Kanamycin
mg
Ethionamide 750 mg
50 - 65 kgs 1500
Pyrazinamide
mg
Ofloxacin 600 mg
Cycloserine 750 mg
1000
Kanamycin
mg
Ethionamide 750 mg
2000
>65 kgs Pyrazinamide
mg
Ofloxacin 800 mg
750 mg
Cycloserine

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CONTINUATION PHASE: 18 MONTHS

Patient weight Medicine Dosage
Ethionamide 500 mg
< 50 kg Ofloxacin 600 mg
Cycloserine 500 mg
Ethionamide 750 mg
50 – 65 kg Ofloxacin 600 mg
Cycloserine 750 mg
Ethionamide 750 mg
>65 kg
Ofloxacin 800 mg

See Guidelines for the Programmatic Management of Multi-medicine Resistant

Tuberculosis in Malawi (MOH, 2008) for details.

9.5.5 Management of Anti – TB Drug Reactions

 The table below gives an outline of symptoms of the common drug
reactions and how to manage them.
Table 18: Minor side effects not requiring treatment to be stopped:

Symptoms Medicine Management

Abdominal Related to Give oral medicines to the patient last
pain, nausea rifampicin thing at night
Burning of Related to isoniazid Continue isoniazid; give pyridoxine 50
the feet peripheral mg - 75 mg daily large doses of
neuropathy pyridoxine may interfere with the action
of isoniazid (wherever possible,
pyridoxine 10 mg daily should be given
routinely with isoniazid)
Joint pains Related to Continue Pyrazinamide; use Aspirin or
Pyrazinamide non-steroidal anti-inflammatory
medicine
Red urine Related to Reassure the patient
Rifampicin
Women on Rifampicin may Alternative contraception should be
Rifampicin reduce the provided
effectiveness of the
Oral contraceptive
pill
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Table 19: Major Side effects requiring treatment to be stopped:

Symptoms Medicine Management
Deafness Related to Otoscopy to rule out other causes
Streptomycin Stop Streptomycin if no other
explanation.
Use ethambutol instead
Dizziness If true vertigo and Stop Streptomycin;
nystagmus, If just dizziness with no nystagmus, try
related to dose reduction for one week, but if no
Streptomycin better stop Streptomycin.
Use Ethambutol instead
Generalised May be due to Stop all medication
reactions rifampicin, Use different combination of medicines
including Pyrazinamide
shock, purpura and/ or
Streptomycin
Jaundice Related to drug- Stop all antituberculosis medicines until
induced hepatitis. jaundice and liver function tests revert
to normal (see below)
Skin itching Related to all anti- Stop antituberculosis medicines
tuberculosis
medicines
Visual Related to Visual examination –seek clarification
impairment Ethambutol Stop Ethambutol
Vomiting ++/ Suspect drug- Urgent liver function tests (lfts)
confusion induced hepatitis If lfts not available, stop anti-
tuberculosis medicines and observe.

9.5.6 Complications of Tuberculosis and their Management

9.5.6.1 Pulmonary Tuberculosis

 Haemoptysis (coughing blood):
o If severe, refer to hospital for bed rest, sedatives and probably
transfusion.
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o Do a chest x-ray to rule out potentially treatable conditions such as

aspergilloma or bronchiectasis.
 Pleural effusion (collection of fluid between the lungs and the chest
wall):
o Drain big pleural effusions to relieve symptoms of dyspnoea.
o Empyema (collection of pus alone) should be drained.
 Spontaneous pneumothorax (collection of air between the lungs and
the chest wall):
o This may cause sudden onset of shortness of breath.
o May require admission to hospital for drainage with an
underwater seal.
 Fibrosis (scarring) of the lungs:
o This may lead to cor-pulmonale (right-sided heart failure) in the
long term.
o Symptomatic treatment may be required.
 Bronchiectasis:
o Coughing due to residual lung damage sometimes with
expectoration of large volumes of sputum and sometimes blood.
o Symptomatic treatment may be required provided that the
sputum is negative for AAFB.

9.5.6.2 Extra-Pulmonary Tuberculosis

 Complications will depend upon the site of the disease:
 Tuberculosis of the spine: paraplegia (weakness of the lower limbs).
Refer to hospital immediately.
 TB meningitis: cranial nerve damage. Give steroids.
 TB lymphadenitis: cold abscesses and suppurating fistulae. Do I and
D.
 Pericardial effusion: heart failure. Give high doses of steroids.
 Cardiac tamponade (distress associated with shock): Refer to
tertiary level.
 Pleural effusion: respiratory failure. Do therapeutic pleural tap.
 Tuberculoma: focal seizures or neurological signs. Order CT scan for
diagnosis
 TB Abdomen: ascites. Do ascitic tap for diagnosis. Finding of lymph
nodes on ultrasound scan of the abdomen can also be diagnostic.

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9.5.7 Use of Anti-Tuberculosis Medicines in Special Situations

9.5.7.1 Pregnancy and Reproductive Health

 Streptomycin is potentially ototoxic and may cause deafness in babies.
 Streptomycin should not be given in pregnancy.
 Rifampicin stimulates formation of liver enzymes and therefore can
reduce the effectiveness of the oral contraceptive pill.
 Advise patients on TB treatment to take alternative contraception while
on rifinah.

9.5.7.2 Renal impairment and renal failure

 Give normal dosage of Rifampicin, Isoniazi and Pyrazinamide to patients
with renal failure.

Note:
Streptomycin and Ethambutol are given in reduced doses and less
frequently in patients with renal failure.

9.5.7.3 Liver impairment and liver failure

 Isoniazid, rifampicin and pyrazinamide are hepatotoxic.
 Patients with active liver disease who develop TB should not receive
pyrazinamide or rifampicin.
o Give streptomycin, isoniazid and ethambutol for intensive phase of
treatment, and isoniazid and ethambutol for maintenance treatment.
o If jaundice is acute and severe, treat initially with just streptomycin
and ethambutol.

9.5.7.4 Epilepsy
 Rifampicin reduces plasma levels of Phenobarbitone.
 Advise patients to increase the dose of phenobarbitone.

9.5.7.5 TB/ART
 Rifampicin reduces plasma levels of Nevirapine by 30%.
 Low Nevirapine levels may increase the risk of the HIV becoming
resistant to the medicine and thus compromise the effectiveness of the
ART.

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9.5.8 Corticosteroids and Tuberculosis

 Adjunctive therapy with corticosteroids, in conjunction with anti-TB
medicines, may be appropriate in tuberculosis meningitis, pericardial
and pleural disease.
 Prednisolone 40mg daily for 30 days in TB meningitis, patients with
altered consciousness, neurological defects or spinal block, followed by
a gradual reduction in dose in the succeeding weeks.
 Prednisolone 60mg for 4 weeks for pericardial effusion and constrictive
pericarditis, followed by 30 mg for the next 2 weeks and tapering to zero
over the next 2 weeks.
 Prednisolone 40mg daily for 1 - 2 weeks for large pleural effusion.

9.5.9 Management of Household Contacts of Smear-Positive TB Cases

9.5.9.1 Children aged 6 years and over

 Investigate for TB if symptoms are present
 Treat if TB is present.
Note:
National TB Program is advocating for active case finding for all household
members.

9.5.9.2 Children below 6 years:

 Screen all children using either clinical assessment, or tuberculin test or
chest x-ray including those who are household contacts of smear-positive
TB cases.
 Commence child on Isoniazid preventive therapy (5mg / kg daily for 6
months) if there is no evidence of active TB.
o If a child contact of any age has symptoms suggestive of TB, refer for
further assessment.
 Register and treat the child for TB according to the National TB Program
guidelines if diagnosed with TB.

9.5.9.3 Babies born to mothers with smear-positive Pulmonary TB

 Isoniazid (5 mg / kg daily for 6 months).
 Vaccinate with BCG at the end of 6 months.

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 Continue breast-feeding.
 Should child develop symptoms while on isoniazid preventive therapy,
investigate for active TB.
 If TB is diagnosed, stop isoniazid and institute anti-TB treatment
according to the guidelines.

9.6 Typhoid
 Prevent through clean water, improved sanitation and health education
 Diagnosis should be done by blood culture, Widal tests are inaccurate!

Treatment
 Ciprofloxacin 500mg oral or 400 mg i/v every 12 hours for 14 days
treatment the same for children

Alternatively
 Ceftriaxone 2g i/v every 24 hours for 14 days
 Switch to oral Ciprofloxacin when improving and patient able to
tolerate

If severe
 i/v treatment is preferred
 Continue for a total of 14 days, switch to oral ciprofloxacin when
improving and patient is able to tolerate oral medicines

Supportive measures:
 i/v fluids may be needed
Ensure meticulous hand washing and proper stool disposal
 Disinfect with chlorine
 Maintain good nutrition
 Give analgesic treatment for pain relief (see Section 24 page 196)
 Intestinal perforation and intestinal bleeding are complications
 Refer urgently for surgical attention if suspected

9.7 Sepsis
 Sepsis is a condition in which infection (mostly with bacteria) causes
a systemic inflammatory response resulting in severe illness

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 Try to find the cause and treat accordingly; where possible blood
culture should be done before starting treatment
 Sepsis is common in HIV infected patients and is mainly caused by
Pneumococcus and non-typhoidal Salmonella
 Always refer to hospital for systemic treatment, but in severely ill
patients before referral give:
Adults
 Chloramphenicol 1g i/v or i/m stat plus
 Gentamycin 240 mg slow i/v or i/m stat plus
 Quinine 1200mg i/v in 5% dextrose over 4 hours
Children
 Benzyl penicillin 50,000 units/kg i/v or i/m stat plus
 Gentamycin 7.5 mg/kg slow i/v or i/m stat plus
 Quinine 10 mg/kg i/m stat

 The following hospital treatment regimens are empirical and should

be amended accordingly based on the results of culture and
sensitivity testing

Hospital treatment:
Adults:
 Ceftriaxone 2g i/v 24 hourly for 10 days
 Switch to oral Co-amoxiclavulin 625 mg every 8 hours or oral
Ciprofloxacin 500 mg every 12 hours plus Amoxycillin 500 mg every
8 hours when improved

Alternatively
 Ciprofloxacilin 400 mg i/v every 12 hours or 500 mg orally every 12
hours plus
 Benzylpenicillin 2MU i/v every 6 hours
 Switch to oral Ciprofloxacin 500 mg every 12 hours plus Amoxycillin 500
mg every 8 hours, or oral Co-amoxiclavulin 625 mg every 8 hours, when
improved
 Antibiotics should be given for a minimum of 10 days

If intra-abdominal source suspected:

 Add Metronidazole 500 mg i/v or 400 mg orally every 8 hours
If still febrile after 72 hours reassess the patient
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Children
 Chloramphenicol 25 mg/kg every 8 hours, initially i/v later orally plus
 Benzyl penicillin 50,000 units/kg every 8 hours, initially slow i/v later i/m

Alternative to benzyl penicillin

 Ampicillin 40 mg/kg i/v every 6 hours until oral medication can be tolerated
then
 Amoxycillin 250 mg every 8 hours
If still febrile after 72 hours:
 Add Gentamicin 7.5 mg/kg once daily

Neonates
 Benzyl penicillin or Ampicillin/Amoxicillin as for (older) children above plus
 Gentamycin 2.5 mg/kg every 8 hours.

If severe:
 Chloramphenicol 25mg/kg i/v bolus every 6 hours until 48 hours after
fever has settled then 500 mg orally every 6 hours
 Continue for a total of 14 days
 Or Ceftriaxone 50mg/kg i/v once daily until 48hours after fever has
settled then continue with Ciprofloxacin

9.8. Chicken pox (varicella)

 Causes: varicella zoster virus
 More severe and extensive in HIV (+) patients
General Management
 Application of wet compresses or use of cool baths may help to control
itching, (scratching may lead disfigurement)
 In severe itching, give a sedative systemic antihistamine (e.g. oral
Promethazine or Chlorpherniramine).
 Keep hands clean and nails clipped short to reduce problems caused by
scratching

Treatment
Adults (symptomatic treatment):
 Apply Calamine + Sulphur 2% lotion nocte or 2 times daily
 Give Paracetamol 500mg every 4 hours

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 Has more complications in adults, in particular those that are immuno-

compromised. Varicella pneumonitis is particularly serious. Therefore
antiviral treatment is advised.
Acyclovir 800 mg 5 times a day for 7-10 days.

Children (symptomatic treatment):

 Apply calamine + sulphur 2% lotion 2 times daily
 Paracetamol 10 mg/kg every 6 hours as required (Avoid Aspirin in children).
 For severe and extensive conditions give Acyclovir 400mg every 8 hours for
7days
In case of secondary infection give antibiotics as per Section 18.1 page 157,
consider HIV test

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 11.Miscellaneous
10. Musculoskeletal disorders
Conditions

10.0 Miscellaneous Conditions

10.1 Fever
 An axillary temperature of 38˚C or over indicates significant fever and the
need for antipyretic treatment. This is not the case for adults: temperatures
in patients of up to 40.5 oCelsius can be accepted, but anti-pyretic
treatment can be given for symptomatic relief
 Investigate (by clinical assessment, assisted where available by laboratory
tests) and treat the underlying cause.
 In neonates, failure to feed may precede development of fever in cases of
septicaemia.
 A positive malaria blood slide in a patient with fever does not always mean
that the fever is caused by malaria. Treat for malaria but keep an open
mind for other causes such as sepsis. This is more likely in HIV infected
patients with advanced immune suppression.
Treatment
 Tepid sponging may be used as a supportive measure to reduce fever
Adults
Paracetamol 500 mg every 4 hours or 1000 mg every 6 to 8 hours,
maximum of 4 doses in 24 hours, preferably after food
Alternatively:
Aspirin 600mg every 6 hours
Children
Paracetamol 10 mg/kg/dose
Table 20: Paracetamol dose table for children

Age Dose per 6 Tablets Syrup

group hours (mg) (500 mg) (120 mg/5
(year) mL)
<1 125 ¼ 5 mL
1-5 250 ½ 10 mL
6-12 500 1
>12 1000 (1 g) 2
Note:
a) Antipyretic should not be given for more than 3 days
b) Prolonged fever may indicate another condition and/or failure of treatment
c) Aspirin should not be given to children less than 12 years old
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11.0 Musculoskeletal disorders

11.1 Arthritis (non-infective)

 Make specific diagnosis whenever possible and treat accordingly
 An acute mono-arthritis should always be considered to be infective until
evidence to the contrary is obtained
11.1.1 Non-specific inflammatory arthritis, and rheumatoid arthritis
Treatment
Adults
 Ibuprofen 1.2–1.8g daily in 3 divided doses after food
Alternatively:
 Aspirin 300-900 mg after food every 4 hours. Maximum of 4g daily in
divided doses
in acute conditions
 Review after 7 days
 If not responding: change to an alternative non-steroidal anti-inflammatory
drug (NSAID):
o Indomethacin 25 – 50mg every 8 hours after food for another 7
days or
o Diclofenac sodium 25-50mg every 8 hours after food or SR 75mg
every 12 hours for another 7 days
o Consider referral for specialist opinion

Children:
 Always refer to hospital
 Prior to referral, give Aspirin 20 mg/kg after food every 6 hours

11.2 Arthritis (septic)

 Always refer to hospital for systemic treatment
 Aspirate the joint for diagnostic and therapeutic purposes
 Surgical drainage may be indicated
 TB septic arthritis is treated as for other forms of extra-pulmonary TB
Treatment
Adults
 Flucloxacillin 1g i/v every 6 hours for at least 14 days plus,
 Ciprofloxacin 500mg orally every twelve hours
 A further 2-4 weeks of oral antibiotics may be required
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Alternatively if penicillin allergic use Ceftriaxone 2g i/v daily for 2 weeks

 followed by oral Erythromycin 500mg every 6 hours and
 Ciprofloxacin 500mg every 12 hours for a of duration 2-4 weeks

Children:
 Chloramphenicol 12.5 mg/kg every 8 hours for at least 14 days, or 4 weeks
if there is associated osteomyelitis
 Clinically evident by bone swelling or proven by X-rays after the initial 14
day course
Alternativlye when staphylococcal infection is suspected:
 Flucloxacillin 25 mg/kg i/v every 6 hours for 14 days

11.3 Gout

11.3.1 Acute attack

 Rest
 Ensure abundant fluid intake
Treatment
 Ibuprofen 800mg every 6 hours preferably after food in established cases
until attack subsides
Alternatively:
 Indomethacin 50-75 every 8 hours with food or
 Diclofenac sodium 25-50mg every 8 hours preferably after food
 Colchicine 1.0mg followed by 0.5mg no more frequently than every 4 hours
until pain is relieved or diarrhoea or vomiting starts. Maximum of 6mg per
course; course should not to be repeated within 3 days
 Prednisolone 30 – 50mg/day for 5 -7 days

11.3.2 Prevention of attacks

 Encourage physical exercise
 Encourage reduction in dietary protein (if intake is high)
 Avoid alcohol
Treatment
 Allopurinol 100 mg daily after food
 Only indicated in recurrent gout attacks.
 Do not start this treatment until an acute attack has completely subsided.

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 Gradually increase over 1-3 weeks to 300 mg once daily, according to

plasma or urinary uric acid concentration
 Maintenance dose: Up to 200 -600mg daily; dosage >300 mg to be given in
divided doses; may be required life long.

11.4 Musculoskeletal pain and trauma

 Joint pain, lumbago, and chronic musculoskeletal disorders are common in
adults
Adults (symptomatic treatment)
o Give analgesics
 If pain persistent or severe:
o Refer to a surgeon or a physiotherapist

11.5 Osteomyelitis

11.5.1 Acute Osteomyelitis

Adults and Children:
o Admit to hospital for rest
o Splint the affected limb as required,
o Give analgesics
 If pain is severe:
 Give Pethidine 1mg/kg i/m
 Repeat every 6 hours for a maximum 4 doses
 Drain pus surgically from the bone and send for culture and sensitivity
testing
 Do not await culture results before starting antibiotic treatment

Children Over 2 years:

 Flucloxacillin 25 mg/kg up to a maximum of 500 mg every 6 hours,
initially i/v, then orally from 48 hours after fever has settled
Alternatively:
 Chloramphenicol 25 mg/kg up to a maximum of 500mg every 8
hours, initially i/v, then orally from 48 hours after fever has settled

Children Under 2 years:

 Chloramphenicol 25 mg/kg every 8 hours, initially i/v, then orally
from 48 hours after fever has settled
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Alternatively, if staphylococcal infection is very likely:

 Flucloxacillin 25 mg/kg every 6 hours, initially i/v, then orally from 48
hours after fever has settled
 Antibiotic treatment should be continued for 4 weeks under hospital
supervision.

11.5.2 Chronic osteomyelitis

Adults and Children:
Treatment
 Surgical treatment by sequestrectomy when an adequate involucrum has
formed
 Antibiotic treatment for febrile flare-ups of infection as for acute
osteomyelitis (See Section 11.5.1 above)
 Antibiotic cover for surgery as appropriate after culture and sensitivity
testing
 Give Ibuprofen 1.2 – 1.8g daily in 3 divided doses after food
Alternatively:
 Aspirin 10mg/kg orally, preferably after food, every 6 hours up to an
adult maximum of 600 mg per dose

11.6 Rheumatic fever

 Always refer to hospital

11.6.1 Acute attack

 Benzathine penicillin 1.2MU i/m single dose
o Children <30 kg: Benzathine penicillin 600,000 units
Alternatively, if compliance can be ensured:
 Phenoxymethylpenicillin 250 mg every 6 hours for 10 days
o Children: Phenoxymethylpenicillin 12.5 mg/kg/dose
Alternatively, if penicillin allergy:
 Erythromycin 500mg every 8 hours for 10 days

11.6.2 Acute Carditis

 Strict bed rest until carditis has resolved
 Adults and children:
Treatment
o Aspirin 25mg/kg, preferably after food, every 6 hours
o Reduce dose if tinnitus or other toxic symptoms develop
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o Continue treatment with this until fever and joint inflammation are
controlled
o Then reduce dose gradually over a 2 week period
 If symptoms recur:
o Restart full dose
 In severe carditis with heart failure and not responding to aspirin:
o Add prednisolone 2 mg/kg once daily
 Reduce dose gradually after 3-4 weeks
o Treat heart failure

11.6.3 Chorea
Treatment
Adults and Children:
 Haloperidol 25 micrograms/kg every 8 hours

11.6.4 Prophylaxis of Rheumatic fever

11.6.4.1 Prevention of further attacks

 Continue treatment until at least age 25
Treatment
 Benzathine penicillin 1.2 MU i/m monthly
 Children < 30 kg: 600,000 units/dose
Alternative if compliance can be ensured:
 Phenoxymethylpenicillin 250mg every 12 hours
Alternative if penicillin allergy:
 Erythromycin 500 mg daily
 Children <30 kg: 250mg

11.6.4.2 Prophylaxis of bacterial endocarditis

 Needed to prevent bacterial endocarditis in those with previous
rheumatic fever or any heart valve abnormalities of other cause.

11.6.4.3 Before dental extraction

Prophylaxis in Adults and Children > 30 kg:
 Amoxycillin 3g oral taken 1 hour before the dental procedure
Alternatively if penicillin allergy:

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 Erythromycin 1.5g taken 1 hour before the procedure and 500 mg 6

hours later
Prophylaxis in Children > 30 kg:
 Amoxycillin 50 mg/kg taken 1 hour before dental procedure, and
repeated 6 hours later
Alternatively if penicillin allergy:
 Erythromycin 75mg/kg taken 1 hour before procedure and 25 mg/kg 6
hours later

11.6.4.4 Prophylaxis before other procedures

a)For genito-urinary surgery or instrumentation:
 Amoxycillin 1g i/v or i/m plus
 Gentamycin 2mg/kg i/v or i/m 30 minutes before the procedure, then
 Amoxycillin 500mg taken 6 hours later
o Alternative if penicillin allergy:
 Erythromycin 500mg every 6 hours for 48 hours, instead of amoxicillin

b) For obstetric and gynecological procedures:

 Not required except for those with prosthetic heart valves who should
receive prophylaxis as for dental procedures

11.7 Tropical pyomyositis

 Treatment is both medical and surgical
 Medical treatment may prevent abscess formation at the start of
infection, when the muscle is swollen, hot and painful
 Immobilize and give:
Treatment
Adult and children:
 Flucloxacillin 1g i/v every 6 hours for at least 14 days plus,
 Ciprofloxacin 500mg orally twice daily
If penicillin allergic
 Ceftriaxone 2g i/v daily for 2 weeks
 Give surgical treatment (abscess drainage) when the swelling becomes
fluctuant.

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12. Obstetric and Gynaecological conditions

12.0 Obstetric and Gynaecological Conditions

12.1 Abnormal Vaginal Bleeding

 Bleeding which deviates from the normal menstrual pattern in terms of the
amount, duration or interval
a) In young adolescents
 It is mainly physiological and pathology is very rare. Manage conservatively
o Heavy, irregular menses will cause anaemia which may be serious
o Exclude complications of pregnancy
Treatment
 Treat anaemia see Section 1.2. page 1
 Give low-oestrogen combined contraceptive tablets for a minimum of 6
months
If bleeding is very heavy:
 Give 2 tablets daily for 10 days then 1 tablet daily for 2-6 months
Note:
 Low-oestrogen combined contraceptive is contraindicated if there is
migraine or raised BP
Refer to Hospital.

If heavy menses return:

 Refer to hospital

b) In women of child-bearing age:

 Causes: complication of pregnancy, including ectopic pregnancy, use of
hormononal method of contraception or an intra-uterine device (IUD),
fibroids, choriocarcinoma, cervical cancer.
 Consider visual inspection of cervix after applying 3-5% acetic acid (VIA).
 Refer to hospital

Investigate always persistent bleeding after delivery or abortion

 If all pathology has been excluded then the bleeding is dysfunctional.

Treatment
 Cyclical Progesterone 5-10 mg daily for 14 days in the 2nd phase of the
menstrual cycle for 3 months
Alternatively

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 Low oestrogen combined contraceptive 1 tablet for 14 days in the 2nd

phase of the menstrual cycle for 3 months
 If no improvement, refer for specialist care.

c) In post-menopausal women:
 Always investigate vaginal bleeding
 Important causes are endometrial cancer and cervical carcinoma
 Always refer for hospital treatment
At hospital
 Perform a thorough vaginal examination including speculum exam,
endometrial thickness scan if greater than 4 mm then consider dilatation
and curettage and send sample for histology assessment

12.2 Ante-and Post-natal care

Refer to Reproductive Health Guidelines
 Check on tetanus immunization status see Section 12.3 below
During pregnancy and for 6 weeks after delivery:
 Folic acid 5 mg once daily
 Ferrous sulphate 200 mg once daily
 SP 3 tablets stat at the first antenatal visit after quickening
 Repeat at an interval of at least 4 weeks (1 month)
 HIV infected pregnant women must have 3 courses of SP
Pregnant women who are HIV-positive and are also taking daily cotrimoxazole
prophylaxis should NOT be given SP.
 Vitamin A (retinol) 200,000 units single dose, ideally day 2 after delivery,
or anytime within the first 2 months after delivery
 Check haemoglobin antenatally. If ≤ 9g/dl refer to hospital. If ≥9 g/dl give
Ferrous sulphate and Folic acid as above. If no response then refer.
At the hospital
 The following tests should be done
i. Full blood count
ii. Stool and urine analysis
iii. Peripheral blood film
iv. Malaria parasite check
v. HIV test

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12.3 Tetanus Toxoid Vaccination (TTV)

 All pregnant women should receive TTV
Table 21: Schedule of TTV Doses
TTV Dose Time
TT1 0.5ml s/c or Give at any contact with woman of child bearing age
st
(1 dose) i/m (15-45 years) including at 1st antenatal visit
TT2 0.5 ml s/c At least 4 weeks after TT1
nd
(2 dose) or i/m
TT3 0.5 ml s/c At least 6 months after TT2 or during a subsequent
rd
(3 dose) or i/m pregnancy
TT4 0.5 ml s/c At least 1 year after TT3 or during a subsequent
rd
(4 dose) or i/m pregnancy
TT5 0.5 ml s/c At least 1 year after TT4 or during a subsequent
rd
(5 dose) or i/m pregnancy
12.4 Vaginal Candidiasis (moniliasis)
 Common infection occurs more frequently in patients taking antibiotics,
pregnancy, HIV/AIDS patients and patients with diabetes.
Treatment
Adults:
 Clotrimazole 500mg intravaginally as single dose or Clotrimazole 200mg
intravaginally once daily for 3 days
Alternatively
 Miconazole 200mg intravaginally once daily for 3 days or
 Fluconazole 150mg orally as single dose (contra-indicated in pregnancy)
or
 Nystatin pessary 100,000 IU vaginally every 12 hours for 7 days
To avoid re-infecting her partner, the male partner should:
 Apply aqueous gentian violet paint 0.5% to the penis every 12 hours for
7 days
 Recurrent vulvalvaginal candidiasis should be refered to hospital

12.5 Dysmenorrhoea
Treatment
 Mefenamic acid 500mg every 8 hours during menses for not more than
7 days
Alternatively
 Other analgesics see Section 24.1 page 196
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If no response:
 Cyclical courses of low oestrogen combined contraceptive tablets once
daily for 3 – 6 months
If there is still no improvement
 Refer to hospital

12.6 Hypertensive disorders in pregnancy

 Blood Pressure ≥ 140/90mmHg
 Repeat Blood Pressure check after 4-6 hours
If still raised:
 Refer to hospital
At the hospital
 Admit
 Exclude pre-eclampsia

12.6.1 Pregnancy Induced Hypertension (PIH)

 Symptoms and signs: raised BP ≥ 140/90mmHg, ± oedema, proteinuria
≥+ dipstick, gestation ≥ 20 weeks
Treatment
a) If no signs of pre-eclampsia then
 Methyldopa 500mg – 1g every 8 hours until BP settles
 Review weekly

b) If more than two signs of pre-eclampsia referpatient to hospital

At the hospital
 Admit , evaluate and take full history,
 Check for signs of imminent eclampsia, check weight,urine dip stick
daily, and BP every 4 hours
 Evaluate well being and gestatation. Do ultrasound

If diastolic BP >90mm Hg and <110mm Hg then

 Methyldopa 500 - 1g every 8 hours review daily

If diastolic >110mm Hg
 Do not lower BP abruptly
 Hydralazine 5mg i/v slowly over 5 min.
 Repeat every 20 minutes until diastolic pressure is below110 mm Hg.

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 Then give Hydralazine 40mg i/v in 1 litre over 8 hours to maintain BP at

below 110 mmHg
Alternatively
 Nifedipine 10mg. Recheck BP in 20 minutes. Repeat nifedipine if
diastolic ≥110mmHg. Consult specialist.
 Watch carefully for eclampsia: If this develops see section for eclampsia
for treatment
 Consider delivery regardless of gestational age if:
o BP is difficult to control
o Urine output is decreasing
 Critical signs/symptoms persist (suggesting severe pre-eclampsia)
 Develops eclampsia

12.6.2 Pre-eclampsia
 Symptoms/Signs: Bp> 150/100, marked oedema, proteinuria ++/+++,
headache, blurred vision,epigastric pain, oliguria, hyper-reflexia
 Refer to hospital any woman with severe preeclampsia accompanied by
nurse incase the patient starts convulsing

If >34 weeks gestation:

 Stabilize patient
 Deliver within 24 hours either by induction, if cervix is favourable, or by
caesarean section

If<34 weeks gestation:

 Inform CO/MO/Specialist
 Assess fetal well being using Ultrasound scan or Cardiotocograph
 Give Dexamethasone 6mg every twelve hours i/m for 4 doses
Alternatively
Betamethasone 12mg i/m once daily for a total of 2 doses
Check
i. Full blood count, Urea & creatinine in serum
ii. liver function tests
iii. Electrolytes: sodium, potassium, and chloride
If diastolic BP >90mmHg
 Methyldopa 500mg – 1 g every 8 hours
 Give oxygen by mask
 Ensure close monitoring of vital signs and fetal heart
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 Strictly monitor fluid intake, and record output (through a Foley’s

catheter)
 Consider delivery after administering corticosteroids
Note:
a) Consider prophylactic magnesium sulphate use for severe preeclampsia
b) If need arises for prophylactic magnesium sulphate, delivery must be
effected within the next 48-72 hours.
c) Diuretics are discouraged in pregnancy except for cardiac disease
If the patient convulses treat as eclampsia

12.6.3 Eclampsia
 Convulsions in a woman with pre-eclampsia. Convulsions can occur prior
to labour, intrapartum or postpartum.
 Convulsions also do occur without previous symptoms
 Before starting treatment for eclampsia, be absolutely sure to exclude:
- Epilepsy
- Meningitis
- Cerebral malaria
Initial management:
 Prevent the patient from hurting herself
 Secure airway, aspirate secretions or vomitus
 Control convulsions with magnesium sulphate see dose below
 Refer to hospital as soon as possible accompanied by a nurse
 Give adequate oxygen supply by nasal prongs or face mask
Treatment
 At health centre give loading dose of magnesium sulphate 4 g of 20%
solution in 500 ml of normal saline infused over 10 minutes plus 5 g of
50% solution in each buttock deep i/m
 Refer immediately
 Closely monitor the respiratory rate (not less than 16), patella reflexes
and urinary output should not be less than 25mls an hour.
 Continue magnesium sulphate for 24 hours post delivery or 24 hours
after the last convulsion whichever was the last
 Maintenance dose: Magnesium sulphate 5 g of 50% solution every 4
hours deep i/m till 24 hours post-delivery or 24 hours after the last
convulsion which ever was the last.
{Addition of 1.0ml of 2% lidocaine minimizes discomfort}

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Note:
a) Once magnesium sulphate is administered a decision must be made to
deliver the pregnant woman within 12 hours

 If magnesium sulphate is not available give:

o Loading dose of Diazepam 10mg i/v slowly over 2 minutes
o Maintenance dose of Diazepam 40mg in 500mls of normal saline or
ringer's lactate
o Do not give more than 100mg in 24 hours
o Refer the patient to hospital

In case of magnesium sulphate toxicity administer calcium gluconate 1gm

as i/v stat dose and stop magnesium sulphate

Mode of delivery:
 Carry out an obstetric assessment to decide on appropriate mode
 Only allow assisted vaginal delivery if labour is progressing quickly
 Consider caesarean section if unlikely to deliver in 6-12 hours
regardless of gestational age
 Give Oxytocin 10 IU (1mL amp) by i/v push in the 3rd stage
 Do not use ergometrine
Monitoring:
 Continue careful observation (and treatment if necessary) for at least
48 hours after delivery

12.7 Prelabour rupture of membranes

 Rupture of the membranes before labour has begun
 Symptoms/Signs:Watery vaginal discharge

(a) If gestation less than 34 weeks

 No digital vaginal examination should be done
 When the diagnosis is in doubt, perform sterile speculum
examination
 Check temperature 4 hrly, inspect liquor daily, assess fetal heart rate
 Give prophylactic antibiotics:
o Erythromycin 250 mg orally every 8 hours for 7 days
o Metronidazole 400 mg orally every 8 hours for 7 days
 Give corticosterioids:
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o Betamethasone 12 mg i/m, 2 doses 24 hours apart;

Alternatively
o Dexamethasone 6 mg i/m 4 doses 12 hours apart
 If still draining, deliver at 34 weeks if there are no other
contraindications
 If signs of intra-uterine infection develop (temperature 37.5 ºC or
more, purulent or offensive liquor, fetal tachycardia), inform the
most senior person available, who should plan urgent delivery
regardless of gestatal age

(b) If gestation 34 weeks or greater

 Do sterile speculum exam to confirm draining and rule out cord
prolapse
 If membranes have been ruptured for more than 18 hours, give
prophylactic antibiotics:
o Ampicillin 2 g i/v every 6 hours
Alternatively
 Benzylpenicillin 2 million units i/v every 6 hours until delivery
 Stop 48 hour after delivery unless there are signs of sepsis
 If labour does not begin spontaneously within 24 hours, assess the
cervix and induce labour, if no contraindication to vaginal delivery. If
unsuccessful deliver by ceasarean section
 If signs of intra-uterine infection develop (temperature 37.5 ºC or
more, purulent or offensive liquor, fetal tachycardia), inform the
most senior person available, to decide on mode of delivery

12.8 Chorioamnionitis
 Intra-uterine infection
Symptoms/Signs: foul-smelling vaginal discharge after 28 weeks of pregnancy,
fever/chills, abdominal pain, fetal tarchycardia
Treatment
 Benzylpenicillin 2.5 MU i/v stat and/or
 Chloramphenicol 500 mg i/v stat

Refer to hospital
At hospital
 Give Metronidazole 500mg i/v 8 hourly, and
 Benzylpenicillin 2 MU i/v every 6 hours and
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 Gentamycin 240 mg i/m single dose daily or Chloramphenicol 500mg 6

hourly
 Continue for 48 hrs after the fever subsides, but not less than 5 days.
 Deliver urgently. Induce or accelerate labour with Oxytocin; do ceasarean
section if necessary.
 If mother has amnionitis or if membranes were ruptured for more than 18
hours before delivery, start newborn on
o Benzylpenicillin 50,000 IU/kg/dose i/m every 12 hours and
o Gentamycin 5 mg/kg i/m once daily for 5 days if birth weight >1500 g).

12.9 Mastitis
General Measures
 Apply hot compresses and a constriction bandage to support the breast and
relieve pain.
 Maintain lactation in the infected breast if there are no nipple fissures to
prevent stasis
 In severe cases, avoid engorgement by reducing milk production
Treatment
 Flucloxacillin 500 mg every 6 hours for 7 days
 Doses should be taken at least 30 minutes before meals
Alternatively
 Erythromycin 500mg 8 hourly for 5 – 7 days
 Aspirin 600 mg after food every 6 hours as needed

12.10 Breast abscess

 If breast abscess forms, drain surgically.
 Change dressing everyday
 Give treatment as above

12.11 Postpartum haemorrhage (PPH)

 Blood loss from the genital tract of more than 500ml after delivery of a
baby.
 Causes: uterine atony, retained products of conception, Genital tract
trauma, coagulation problems, ruptured uterus
 Always actively manage the 3rd stage of labour
Treatment

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 Oxytocin 10 units im given after delivery of the anterior shoulder and

controlled cord traction for delivery of placenta

12.11.1 Primary PPH

 Abnormal vaginal bleeding within 24 hours of delivery
 Resuscitate: Refer to Section 1.2 page 1
 Set up an i/v line and empty bladder
 Replace blood loss with i/v fluids / blood
 Identify and treat the cause
 If uterine atony:
o Rub up a contraction
o Set up Oxytocin 40 units infusion
o Give Misoprostol 1000mcg rectally
o Refer to hospital with nurse
 If retained placenta
o Attempt manual removal
o Refer to midwife if this fails

12.11.2 Secondary PPH

 Abnormal bleeding 24 hours or more after delivery
 Not common but is as serious as primary PPH
 Causes: retained products, often with infection
Treatment
 Set up an i/v line
 Empty bladder
 Rub up a contraction
 Oxytocin 10 units i/m
 Replace blood loss with i/v fluids/blood (see Section 1.1 page 1)
 Refer immediately for evacuation of the uterus

Supportive measures
 Amoxycillin 500 mg every 8 hours plus Metronidazole 400 mg every 8
hours
Alternatively if penicillin sensitive
 Erythromycin 250 mg every 6 hours
 Assess the need for blood transfusion
 Give i/v fluids to sustain a high degree of perfusion
If the patient is toxic start i/v antibiotics as follows:
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 Metronidazole 400 mg every 8 hours plus

 Gentamycin 4.0mg/kg body weight i/m stat
 Benzyl penicillin 2 MU i/v every 6 hours

12.11. Post-abortal haemorrhage

 Assess patient, record vital signs
 Insert i/v line
 Resuscitate and stabilize the patient (see Section 1.1 page 1)
 Carry out vaginal examination
 Remove products of conception and/or foreign bodies
 Oxytocin 10 units i/m
 Perform (or if not possible refer) evacuation or manual vacuum aspiration
(MVA) if gestation < 12 weeks
If septic treat as in Section 12.12 below

12.12 Post abortal or puerperal sepsis

 Maintain hydration: set up an i/v line and give i/v fluids (see Section 1.1
page 1)
 Paracetamol 1 g stat
 Benzyl penicillin 5 MU i/v stat
 Oxytocin 10 units i/m to contract uterus
 Counsel the patient
 Refer for evacuation of the uterus to hospital with the midwife, blood
samples, patient’s records
At hospital:
 Give analgesic for pain (see Section 24.1 page 196)
 Repeat as required to maintain uterine contraction
 Give antibiotic treatment for 7 days as follows:
For sepsis:
 Metronidazole 400 mg every 8 hours plus
 Gentamycin 4.0mg/kg body weight i/m stat
 Benzyl penicillin 2 MU i/v every 6 hours
 Consider uterine evacuation in some cases

If not improving:
 Reassess and consider the appropriate intervention:
 Change of antibiotics
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 Re-evacuation
 Laparotomy
 Referral to central hospital

12.13 Contraceptives
 Types: combined hormonal contraceptives, progestogen only
contraceptive, contraceptive devices, emergency contraceptive, barrier
methods.

12.13.1 Combined hormonal contraceptive (COCs)

 Most effective preparations for general use.
 Contain an oestrogen and a progestogen.
 Choose a preparation with the lowest oestrogen and progestogen content
which gives good cycle control and minimal side effects in the individual
woman.
Indications
 Contraception
 Menstrual disturbances

12.13.2 Progestogen only contraceptive

 Suitable alternative when oestrogens are contraindicated
 Have a higher failure rate than COCs.
 Suitable for hypertensive women, migraine, valvular heart disease and
diabetes mellitus.
 Menstrual irregularities (oligomenorrhoea, menorrhagia) are more
common but tend to resolve on long term treatment.
Dose
 1 tablet daily at same time each day starting on day 1 of the menstrual
cycle

12.13.3 Parenteral progestogens

 Injectable preparations e.g. Depo-Provera®
 Implant preparations e.g Jadelle® and Norplant®

12.13.4 Intrauterine progestogens

Indications
 Contraception

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 Menstrual disturbances

12.13.5 Non hormonal intrauterine contraceptive device

 Increased risk of PID

Indications
 Contraception after delivery, after an abortion and evacuation, at the end
of menstruation and emergency contraception
 Examples: Copper T 380®

12.13.6 Emergency Contraception

 Effective if taken within 72hrs of unprotected intercourse.
 Give Lofeminol® 4tablets every 12 hours for 24 hrs.
 If vomiting occurs within 3hrs of taking hormonal tablet, give replacement
dose and anti-emetics can be considered.
 Explain the following:
o The next period may be early or late
o A barrier method needs to be used until the next period.
o Patient should return promptly if lower abdominal pains develop to rule
out ectopic pregnancy or of any problems.
o An intrauterine contraceptive device can be inserted up to 5 days of
unprotected sexual intercourse.

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13.0 Ophthalmic Conditions

13.1 Conjunctivitis
 Bacterial or viral conjunctivitis is highly contagious and personal hygiene is
important in prevention and treatment
 Advise the patient to:
o Use only his/her own towels
o Wash the face and cleanse the eyes frequently
o Wash hands thoroughly before applying eye ointment
 Treat unilateral conjunctivitis with special care to avoid spread of infection
to the other eye
Treatment
 Apply Tetracycline eye ointment 1% every 8 hours for 7 days
 For neonates, see Section 13.3 below

13.2 Foreign body in the eye (superficial injury)

 Detect foreign body with 1 drop of Fluorescein eye drops 1%
Treatment
 Apply 1 drop of Amethocaine eye drops 1% to anaesthetize the eye
 Remove foreign body carefully with a cotton bud
 Apply Tetracycline eye ointment 1% every 8 hours for 7 days

13.3 Ophthalmic neonatorum

Treatment
 Gentamycin 4 mg/kg i/m single dose
 Carefully clean away any discharge from the eyes
 Apply Tetracycline eye ointment 1% to each eye every 6 hours for 3
days
Alternatively
 Instill 1-2 drops of Gentamycin eye drops 0.3% into each eye every 2
hours
 Reduce the frequency as the infection is controlled
 Continue for 48 hours after condition is cleared
 Combined topical therapy may be used as follows:
o Instill Gentamycin eye drops 0.3% during the daytime
o Apply Tetracycline eye ointment 1% at night
o Continue for 48 hours after condition is cleared
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13.4 Trachoma
Treatment
 Tetracycline eye ointment 1% every 8 hours for 6 weeks

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14. Oral and Maxillofacial conditions

14.0 Oral and Maxillofacial Conditions

14.1 Candidiasis/Oroesophageal
 Nystatin oral suspension/ pessaries 100,000 units every 6 hours for 10-
14 days
Note: pessary should be sucked and taken after food
 Review after 14 days
 Paint Gentian violet aqueous solution 0.5 % on the lesions 3 times daily
for 7 days
 Clotrimazole troches 10 mg every 8 hours for 4 weeks (children)
Alternatively
 Chlorhexidine 0.2 % mouth rinses three times a day (should not be used
together with Nystatin)
If not resolved after 7 days:
 Continue with above treatment and add
 Ketoconazole 200-400 mg twice a day for 10-14 days
 Children: 1- 4 years: Ketaconazole 50 mg every twelve hours for
10 – 14 days
 Children: 5-12 years: Ketaconazole 100 mg every twelve hours for
10 -14 days
Note:
Ketoconazole interacts with the following ARVs: Nevirapine, protease
inhibitors and Didanosine
Alternatively
Adults
 Fluconazole 50-100 mg every 6 hours for 14 days
Children
 Fluconazole 6 mg/kg on day 1, then 3 mg/kg every 6 hours for 13 days
Prophylaxis:
Adults
 Fluconazole 100 mg daily for long term
Children
 Fluconazole 3-6 mg/kg daily for long term

14.2 Caries, Toothache

Treatment
 Depends upon the extent of caries and clinical judgment:

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(a) If minimal and confined to the enamel

 Apply topical Fluoride
(b) If in enamel and dentine but not involving the pulp
 Filling
(c) If involving the pulp and there is periapical infection and/ or pulp
inflammation
 Root Canal Therapy
(d) If severe
 Tooth extraction

Note: Antibiotics are not indicated unless there is infection

Reinforce oral hygiene practices including use of fluoridated toothpaste to
all patients

14.3 Dental Abscess

Treatment:
 Consider incision and drainage
 Amoxycillin 250-500 mg every 8 hours for 7 days or
 Benzyl penicillin 1-2 MU (Children: 25,000 units/kg/dose) i/m or i/v
every 6 hours for 7 days
Alternatively
 Erythromycin 250-500 mg every 6 hours for 7 days (if allergic to
penicillins) and
 Metronidazole 200-400 mg (Children:7.5 mg/kg/dose ) every 8 hours
for 7 days
 Metronidazole 250-500 mg i/v every 8 hours for 7 days
 Aspirin 300mg every 8 hours

14.4 Gingivitis
Treatment
 Reinforce oral hygiene practices; i.e, brushing at least twice a day to
remove plaque; in the morning after breakfast and in the evening
before going to bed
 Conventional therapy; scaling and cleaning to remove all tooth surface
adherents
 Antibiotics are not indicated unless one has acute Necrotizing
Ulcerative Gingivitis (ANUG) or Linear Gingival Erythema (LGE)

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14.5 Periodontal abscess

Treatment
 Give antibiotics as for dental abscess
 Reinforce oral hygiene practices
 Scaling and polishing

14.6 Periodontitis
Treatment
 Root planing +/- antibacterial irrigant (tetracycline)
 Reinforce oral hygiene practices
 Antibiotics are not indicated unless the following exists:
o Necrotizing ulcerative Periodontitis (NUP)
o Exudate discharging from the periodontal pockets
o Patient is non-responsive to conventional therapy
o Juvenile Periodontitis
o Aggressive Periodontitis

14.7 Odontogenic and Maxillofacial infections

Symptoms/Signs: Patients who present rapid progressive swelling, difficulty
in breathing, difficulty in swallowing (dysphagia), facial space involvement,
elevated temperature, severe jaw trismus (< 10 mm), toxic appearance,
compromised host defenses
Treatment
 Incision and drainage
 Removal of the cause
o Extraction of the offending tooth or
o Treat the tooth endodontically with root canal therapy
o Sequestrectomy (removal of necrotic bone)
 Keep patient hydrated
 Give analgesics for pain relief
 Encourage high-calorie food intake
 Prescribe appropriate antibiotics for rapidly progressive swelling as
follows:
 Amoxycillin 250-500 mg every 8 hours for 7 days or Benzylpenicillin
0.5-2.0 MU i/m or i/v every 6 hours for 7 days
 Metronidazole 200-400 mg every 8 hours for 7 days or
Metronidazole 250-500 mg i/v every 8 hours for 7 days

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 Tetracycline 250 mg every six hours or 500 mg twelve hourly for 7

days
 Erythromycin 250-500 mg every 6 hours for 7 days
 Clindamycin 150-300 mg
Note: Antibiotics are indicated for diffuse swelling, compromised host
defenses, involvement of fascial spaces, severe pericoronitis,
osteomyelitis

14.8 Local Anaesthesia Toxicity in Dental Surgery

14.8.1 Mild Local Anaesthetic toxicity

 Symptoms/Signs: talkativeness, anxiety, slurred speech, confusion
Treatment
 Stop administration of local anaesthetic
 Monitor vital signs
 Observe for 1-hour

14.8.2 Moderate Local Anaesthetic toxicity

 Symptoms/Signs: stuttering speech, nystagmus, tremors, headache,
dizziness, blurred vision, drowsiness
Treatment
 Place in supine position
 Monitor vital signs
 Administer oxygen
 Observe for 1-hour

14.8.3 Severe Local Anaesthetic toxicity:

 Symptoms/Signs: seizure, cardiac dysrythmia or cardiac arrest
Treatment
 Place in supine position
 If seizures, protect from nearby objects,
 Suction oral cavity if vomiting occurs
 Administer oxygen
 Give Diazepam 5-10 mg i/v slowly as stat dose
 Transport to emergency care facility/ Intensive care unit
 Monitor vital signs

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 Summon for medical assistance

14.9 Mouth Ulcers (Sores)

 If related to HIV infection, please refer to section on Management of the
HIV-Related Diseases,
 All ulcers in the mouth regardless of the HIV-status, lasting more than three
weeks, should be referred for further management

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15. Parasitic diseases

15.0 Parasitic diseases

15.1 Malaria
Figure 1: General Plan for Malaria Diagnosis and Treatment
Patient C/O Fever or history of fever
(+/- Other symptoms or signs suggestive of malaria). No

Yes

Can you test for malaria parasites?

Yes No

Do a Blood Film or Rapid Is the possibility of Malaria is

No excluded
Diagnostic Test malaria still there?

Y
e
Parasites seen No Assess for and s
Parasites treat other Assess
or RDTs+
or RDTs causes of fever for and
Negative
treat
other
causes
This is malaria. Classify malaria according to clinical features of
fever

Severe Malaria Uncomplicated

Malaria

 Give Quinine IV/IM Give first line

+General (LA)
Management
 Admit or Refer

If there is still
fever after 72 hrs,
No
Repeat Blood film
parasites

Severe
Malaria:
If parasites are seen,
Reclassify Malaria

Patient is well:
Uncomplicated Malaria:
Give second line Patient is well:
antimalarial drug
(Amodiaquine+Artesunate)

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15.1.1 Malaria, non-severe, uncomplicated

 Refer to the MOHP National Malaria Control Programme publication Guide
for the Management of Malaria, October 2007, for full details of malaria
management
 Diagnosis: Made by microscopic examination of blood film wherever
possible or alternatively by rapid diagnostic tests (RDTs). Indications for
testing for malaria include: fever or recent history of fever, and any illness
that can be a malaria complication (coma, convulsions, anaemia, jaundice
etc.)
 Indications for repeating a diagnostic test (film or RDT) include:
a) if the first test was positive and there is persistent fever or
worsening condition despite suitable antimalarial treatment.
b) if the first test was negative and antimalarial treatment was not
given, but the patient's fever persists or condition deteriorates.
 Where microscopy or RDT is available, only treat adults for malaria if
confirmed by a positive malaria test. When microscopy and RDT are both
not available, treat on the basis of presumptive diagnosis
 Presumptive diagnosis in children < 5 years old: in the absence of laboratory
confirmed diagnosis, consider a (history of) fever in the absence of other
causes to be malaria. Additional suggestive signs of malaria include
splenomegaly and anemia
Treatment:
 First line treatment is Lumefantrine 120mg/Artemether 20mg (LA)
Table 22: Dosage Schedule for Lumefantrine-Artemether (LA -120mg/20mg
tablets)
Body weight in Kg (age No. of tablets at approximate timing of dosing
in years)
Day 1 Day 2 Day 3

Start After AM PM AM PM
dose 8 hrs

5-14.9 kg (<3) 1 1 1 1 1 1

15 – 24.9 kg (≥ 3-8) 2 2 2 2 2 2

25 – 34.9 kg (≥9-14) 3 3 3 3 3 3

≥ 35 kg (>14) 4 4 4 4 4 4

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 First dose should be given as DOT. If vomiting occurs within I hour, repeat
the dose.
 Dose is given according to body weight
 If possible each dose should be taken with milk, which improves the
absorption of lumefantrine component of the combination.
 If fever persists beyond 72 hours, do a blood tests (film or RDT), and if the
result is positive, give second line treatment.
Table 23: Dosage Schedule for Artesunate-Amodiaquine

Weight Daily dose for 3 days Daily dose for 3 days

Amodiaquine (153mg) Artesunate (50mg)
5.0 – 6.4 kg ½ ½
6.5 – 11.4 kg 1 1
12.0 – 24.9 2 2
kg
25.0 – 34.9 3 3
kg
≥ 35 .0 kg 4 4

15.1. 2 Severe Malaria

 Most severe malaria occurs in children under 5 years of age.
Table 24: Clinical manifestations and some laboratory findings
Clinical manifestations (Recognizable Some laboratory findings at
at Health Centre) referral hospital
 Impaired level of consciousness  Severe anaemia: (Hb<5 g/dl)
(cerebral malaria)  Hypoglycaemia: (<2.2mmol/l
 Respiratory distress - <40mg/dl)
(acidotic breathing)  Hyperlactataemia (lactic
 Repeated convulsions acidosis)
 Circulatory collapse  Hyperparasitaemia:
 Pulmonary oedema (250,000/l or ring stage> 5%
 Abnormal bleeding of RBCs)
 Jaundice  Electrolytes imbalance (e.g.
 Haemoglobinuria Hyponatraemia)
 Prostration
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 Although most children with malaria have a (history of) fever, this may be
variable in patients who have progressed to severe malaria
 Examine children with suspected severe malaria for other conditions (e.g.
pneumonia,meningitis) as a possible cause of their symptoms and, if found,
manage appropriately
 If severe malaria is diagnosed in an out-patient, refer the child for
hospitalization (see below)

15.1.2.1 Pre-referral treatment at peripheral units

 Refer any patient with severe malaria to the nearest hospital
 Give quinine 20mg (0.2ml) per kg body weight i/m into the upper outer
thigh. If the volume to be injected exceeds 3ml (see below), give half into
each thigh
 Where there is no scale, weight of the child can be estimated as follows:
a. For children of 3months to 12months old
Weight (Kg) = Age (months) + 9/2

b. For children of 1 year to 6years old

Weight (Kg) = [Age (in years) x 2] + 8

 Use a 10ml sterile syringe to draw 5 ml of sterile water for injection, then
into the same syringe draw up 300mg (1 ml) from an ampoule of quinine.
The syringe now contains 50mg of quinine per ml.
 Give 0.4ml/kg of this solution as the first (loading) dose - this is 20mg/kg.
Subsequent (12-hourly) doses should each be 0.2ml/kg (10mg/kg). The
dose of quinine for an adult at any one time should not exceed 1,200mg.
Injectable quinine should be for patients unable to take oral
drugs.

Table 25: Dosage of Parenteral Quinine per body weight

Body weight Quinine Number of injection

(ml) sites
Under 5 kg 1.0 ml 1
5.1 – 7.5 kg 1.5 ml 1
7.6 – 10.0 kg 2.0 ml 1
10.1 – 12.5 kg 2.5 ml 1
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12.6 – 15.0 kg 3.0 ml 1

15.1 – 17.5 kg 3.5 ml 2
17.6 – 20.0 kg 4.0 ml 2
20.1 – 22.5 kg 4.5 ml 2
22.6 – 25.0 kg 5.0 ml 2
25.1 – 27.5 kg 5.5 ml 2
27.6 – 30.0 kg 6.0 ml 2
30.1 - 32.5 kg 6.5 ml 3
32.6 - 35.0 kg 7.0 ml 3
35.1 - 37.5 kg 7.5 ml 3
37.6 - 40.0 kg 8.0 ml 3
40.1 - 42.5 kg 8.5 ml 3
42.6 - 45.0 kg 9.0 ml 3
45.1 - 47.5 kg 9.5 ml 4
47.6 - 50.0 kg 10.0 ml 4
50.1 - 52.5 kg 10.5 ml 4
52.6 - 55.0 kg 11.0 ml 4
55.1 - 57.5 kg 11.5 ml 4
57.6 - 60.0 kg 12.0 ml 4
> 60 kg 12.0 ml 4

15.1.2.2 Additional management and supportive measures

 Reduce fever:
- Tepid sponging with lukewarm (not cold) water
- Give an antipyretic (paracetamol 10 mg/kg; 6 to 8-hourly) as required
until fever is reduced. See dose tables in Section 10.1 page 91
 Ensure adequate fluid intake:
- if the patient can drink: give ORS 20 mL/kg plus one added teaspoon
of glucose powder or sugar
- if the patient cannot drink: use nasogastric tube to provide this fluid
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Repeat this after 2-4 hours

15.1.2.3 Management of Severe Malaria Patient in Hospital Setting

Consider the following (8-8-8) points in the management of patients with
severe malaria.

Box 1: Take 8 immediate measures:

1. Start resuscitation, particularly maintenance of a patent airway.

2. Establish i/v line.

3. Make a thick blood smear for immediate malaria parasite count, (if
microscopy is not available, an RDT may be useful to indicate whether
malaria infection is present or not)

4. Classify the degree of dehydration, assess patient’s fluid requirements and

correct accordingly.

5. Control fever if the axillary temperature is 38.5ºC or above: Tepid sponging

and oral or rectal paracetamol (15mg/kg every 4 to6 hours)

6. Control convulsions: maintain airway, treat with rectal diazepam (0.5mg/kg)

or slow IV diazepam (0.3mg/kg, maximum 10mg in an adult), or paraldehyde
0.1ml/kg IM. Remember to correct any hypoglycaemia or hyperpyrexia in a
convulsing patient.

7. Detect and treat hypoglycaemia: hypoglycaemia can be induced by high

parasitaemia, fasting and quinine therapy. Hypoglycaemia can recur
especially in pregnant women and children. If blood glucose ≤3mmol/l or
≤54mg/dl; give 1ml/kg of 50% dextrose IV, diluted with an equal volume of
0.9% saline or 5% dextrose, give slowly over 3-5 minutes, and check blood
glucose after 30 minutes and as required after treatment. Follow with 10%
dextrose infusion at 5ml/kg/hr. If there is no test for blood glucose, treat as if
the patient is hypoglycaemic.

8. Start Quinine i/v or i/m (if i/v not accessible), see below for dosage details.

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Box 2: Look for and deal with the following 8 complications:

1. Shock: if cold peripheries, delayed capillary refill, or Systolic BP <50mmHg in children 1-

5years or <80 mmHg in >5years, suspect sepsis. In such cases take blood samples for
culture. Give parenteral broad-spectrum antimicrobials. Correct fluid disturbance. Treat
with: 30ml/kg 0.9% Saline IV in 1 hour; then reassess. Give oxygen if possible.
2. Altered consciousness and/or convulsions. Check for hypoglycemia, hyperpyrexia and
‘subtle’ seizures. In a comatose patient, convulsions (seizures) may be ‘subtle’ – i.e. minor
movements [flicker of eyelid, mouth or finger] or unusual repetitive movements [a
rhythmical cry, unusual breathing, ‘pedalling’ of legs]. If seizure suspected, treat as in
item 6 in Box 1.
3. Severe anaemia. Consider the need for blood transfusion: Assess the degree of pallor (no
pallor, some pallor or severe pallor – look especially at palms of hands, also mucous
membranes). Assess signs that increase the danger of severe anaemia - respiratory distress,
altered consciousness, shock and hyperparasitaemia.
Note: The decision to transfuse with blood should not only be based on low laboratory
values, but on a full assessment of the patient**. As a guide, all patients with PCV<12%
or Hb<4g/dl should be transfused, whatever the clinical state; those with any of the above
danger signs may be transfused even if PCV is 13-18% or Hb 4-6g/dl. Use packed red
cells in most cases; in shock or severe acidosis, use whole blood. The volume
transfused should be 20 ml/kg.
4. Metabolic acidosis (deep, fast breathing): exclude or treat hypoglycaemia, hypovolaemia
and gram negative septicaemia. Give isotonic saline 20ml/kg of body weight rapidly or
screened whole blood 10ml/kg if PCV <18% or Hb<6g/dl.
5. Spontaneous bleeding or coagulopathy: transfuse screened fresh whole blood, give
vitamin K. 1 mg/day for infant, 2-3 mg/day for children and 5-10mg/day for adolescent, or
adult. Vitamin K should be given s/c or i/m.
6. Acute pulmonary oedema in adults: prevent by avoiding excessive rehydration.
Treatment: prop patient up; give oxygen. Stop IV fluids if pulmonary oedema is due to
over-hydration, give a diuretic (frusemide i/v 40mg for adult and 0.5-1mg/kg/dose for
children).
7. Acute renal failure in adults: detect this by monitoring fluid balance carefully. Identify
and correct any dehydration or hypovolaemia. Maintain strict fluid balance. Consider
peritoneal dialysis if oliguria persists beyond a few days.
8. Common infections and other conditions that present like severe malaria: Perform
urinalysis, lumbar puncture (unless contraindicated), blood culture if possible, and chest x-
ray.

Box 3: Monitor the following 8 observations:

Where possible use Critical Care Pathways (CCPs).
1. Level of consciousness (using coma score, see annex)
2. Vital signs every 4 hours ( temperature, pulse, respiration, blood pressure)
3. Fluid balance (urine volumes, intake volumes – i/v and oral – puffy eyes, chest sounds)
4. Increasing anaemia (pallor, heart failure with increasing liver size)
5. Occurrence of convulsions – see item 2 in Box 2
6. Blood glucose every 4 hours while unconscious and also if convulsions occur.
7. [Hb]/Packed Cell Volume – at least daily, or more often if anaemia is suspected.
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15.1.2.4 Management of severe malaria in paediatric in-patients

 Initial (‘loading’) dose of quinine 20 mg /kg body weight: inject this dose
into 10ml/kg 5% dextrose or half strength Darrows and infuse over 3 – 4
hours.
 If patient has already received quinine for this illness, the first dose i/v
infusion should be 10 mg/kg given over 3 – 4 hours without loading dose
 Subsequent doses of 10 mg/kg every 12 hours should be given in the same
way
 Continue the same i/v fluid (10 ml/kg given over 3 – 4 hours) between
doses of quinine
 Stop intravenous quinine as soon as the patient can drink, and give
age/weight appropriate doses of Lumefantrine - Artemether (LA) twice
daily for 3 days.

15.1.2.5 Management of severe malaria in adult in-patients

 Apart from cerebral malaria and anaemia, in adults other complications
may develop such as:
- Acute renal failure
- Respiratory distress syndrome (presenting as severe breathlessness)
- Disseminated intravascular coagulation (DIC) – presenting as prolonged
or spontaneous bleeding
- Jaundice from severe haemolysis or liver cell damage
 Management must be appropriate to each complication that develops.
Fluid and antimalarial drugs are given as for children. If the patient cannot
be weighed, i/v Quinine should be given as follows:
- First dose Quinine 20 mg/kg (maximum 1.2 g) given over 3 – 4 hours
- Subsequent doses Quinine 10 mg/kg every 12 hours given over 3 – 4
hours
- IV fluids should be 5% dextrose in ½-strength Darrows or Ringer’s
lactate, or 5% dextrose, about 3 litres per 24 hours
- Change to Lumefantrine Artemether (LA) twice daily for 3 days as
soon as the patient can take oral medication.

15.1.3 Treatment of uncomplicated malaria in pregnancy

 In 1st trimester of pregnancy give oral Quinine 10mg /kg body weight,
administered every 8 hours for 7 days.
 In 2nd and 3rd trimester give Lumefantrine Artemether (LA) twice daily for 3
days.
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Note: Pregnant women are susceptible to hypoglycaemia when taking quinine.

15.1.4 Treatment of severe malaria in pregnancy

 Manage complication as for any adult
 Give Quinine 20mg/kg body weight loading dose, followed by 10mg/kg 12-
hourly for 7 days, as follows:
 Start with i/v quinine in 10% glucose infusion or 5% glucose in normal saline
 If for some reason quinine cannot be given by infusion: give 10mg/kg
dosage by i/m injection (table 4) and refer immediately. Make sure you
give 10% glucose concentration or one bottle of 5% glucose before
administration of quinine; be careful not to induce pulmonary oedema.
Random blood sugar should be done before and after quinine
administration.
 Shift to oral quinine (during 1st trimester) and LA (in 2nd and 3rd trimester)
as soon as the patient can take medicines orally.

15.1.5 Malaria: selective chemoprophylaxis

 The appropriate regimen for an individual depends on the circumstances.

15.1.5.1 Risk groups

 The following high risk groups should be given antimalarial
chemoprophylaxis:
- Patients with immunosuppression caused by illness (e.g. Leukaemia, but
not HIV infection or malnutrition) or splenectomy
- Tropical splenomegaly syndrome
- Under 5s with recurrent febrile convulsions
- Individuals with sickle cell disease
- Non-immune visitors (i.e. visitors from non-malarial countries)
- Pregnant women

15.1.5.2 Antimalarial prophylaxis regimens

 Mefloquine (Lariam) 250 mg weekly.
- Contraindicated in pilots, people with a history of cardiac disease,
neurological disease or depression, and in those taking beta-blocking
drugs.
 Atovaquone-proguanil (‘Malarone’) – one tablet daily. Taken for only one
week after exposure ends.

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 Chloroquine 300 mg - 2 tablets weekly. Should be combined with daily

proguanil (see below). Chloroquine causes itching in 40% of black people.
- Contraindicated in persons with psoriasis or epilepsy. Risk of retinal
damage if taken every week for more than 6 years - advise a change!
 Proguanil (Paludrine®) 200 mg daily. Should combine with an additional
drug such as weekly chloroquine.

15.1.5.3 Intermittent Presumptive Treatmnet of Malaria in pregnancy (IPTp)

 Intermittent Presumptive Treatment of malaria in pregnancy (IPTp) is one
of the major malaria preventive strategies in Malawi.
 Give at least two doses of Sulphadoxine Pyrimethamine 525mg, 3 tablets
for each dose, after the first trimester,
 The two doses should be given at least four weeks apart, under direct
observation by health personnel.

15.2 Onchocerciasis (River blindness)

 Occurs mainly in highland areas such as Thyolo
Treatment
Adults and children > 5 kg:
 Ivermectin 150 mcg (0.15 mg)/kg single dose
Children<5 years: Should not receive Ivermectin. Instead give Albendazole
200mg
 Repeat annually or on return of symptoms
 No food for at least 2 hours before or after dosage
 Mothers should not breast-feed during treatment
Table 26: Ivermectin dose table
Weight Height Age No. of Total
(kg) (cm) (years) tabs* (mg)
> 64 > 158 > 40 4 12
45-64 141-158 25-39 3 9
26-44 120-140 14-24 2 6
15-25 90-119 5-13 1 3
<15 <90 <5 n/r n/r
*ivermectin 3 mg tablets n/r = not recommended
 Ivermectin is not recommended for
- Pregnant women (or for those who think they might be) – it is often
possible to delay treatment for a few months
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- Breast-feeding mothers with babied < 1 week old

- Children < 5 years old (i.e. < 15 kg or 90 cm height)
- Seriously ill patients

15.3 Schistosomiasis (Bilharzia)

 Prevention may be achieved through:
- Health education
- Vector control
- Improved sanitation and water supply
- Modification of the environment, e.g. Clearing of vegetation in certain
areas
- Avoidance of re-infestation

15.3.1 Schistosomiasis haematobium

Treatment
 Praziquantel 40 mg/kg as a single dose
 Children below 4 years of age Praziquantel 20mg/kg as stat dose

15.3.2 Schistosomiasis mansonii

 Consider this diagnosis in cases of:
- Unexplained chronic abdominal complaints with hepato-
splenomegaly
- Ascites with splenomegaly
- Chronic bloody diarrhoea with no fever
- Paraparesis/paraplegia
 Refer patients with above clinical features
 Treat after laboratory confirmation
Treatment
 Praziquantel 40 mg/kg as a single dose.
 Children below 4 years of age Praziquantel 20mg/kg as stat dose

15.4 Trypanosomiasis (Sleeping sickness)

 Suspect in any patient presenting with fever from areas near:
- Wildlife Reserves: Vwaza, Nkhotakota, Majete, Mwabvi
- National Parks: Kasungu, Liwonde, Lengwe
- Phirilongwe (Mangochi), Machinga, Mwanza
- Lower Shire borders with Mozambique or from any other areas where
Tsetse fly is found
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 Suspect in children from these areas who remain sick after presumptive
malaria treatment
 Increased suspicion in any sick patient from these areas with a history of:
- Headache
- Vomiting
- Weakness
- Changes in mood
- Convulsions
- Drowsiness
- Mental slowness
 Travel history is very important
 Suspect also in any patient from these areas where the cause of illness is
not otherwise apparent
 Trypanosomiasis can be acute in children (resembling malaria) and can be
more chronic in adults
 Early stage trypanosomiasis may cause myocarditis
 Examination may reveal anaemia, lymph gland enlargement and spleen
enlargement
 Nearly all cases have a hard and painful subcutaneous nodule (chancre)
which is evidence of an infected bite

15.4.1 Procedure at Health Centres

 Refer the patient immediately to the nearest hospital
 Request close family members of the patient to undergo examination at the
hospital as they may also be infected

15.4.2 Hospital management

 Request for a thick blood smear
 If negative more tests will be needed to confirm this diagnosis
 If diagnosis is confirmed by blood smear or other blood test: Start Suramin
as follows:
o Day 1: 5mg/kg
o Day 2: 20mg/kg
o Day 3: do a lumbar puncture
 If LP is normal (stage 1 trypanosomiasis): give Suramin 20mg/kg on day 3,
10, 17, 24, 31
 If LP is abnormal (stage 2 or CNS trypanosomiasis): stop suramin, start
Melarsprolol (Mel-B) as follows:
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o Day 3: 1.2mg/kg
o Day 4: 2.4mg/kg
o Day 5: 3.6mg/kg
o Day 6: 3.6mg/kg
 Repeat this 4-day melarsprolol cycle after one and two weeks

Notes on treatment regimen

 If any medicine reaction occurs (e.g. skin rash, exfoliative dermatitis,
reactive encephalitis) stop treatment and inform the clinical officer or
medical officer immediately
 Do a lumbar puncture (LP) on day 3. Subsequent treatment depends on
whether this is found to be normal or abnormal
 Freshly reconstitute the Suramin (Sur) 1 g vial of powder with 10 mL water
for injection to make a 10% solution (100 mg/mL)
 Add the required dose of 20 mg/kg (0.2 mL of injection/kg) up to a
maximum of 1 g (the whole vial) in adults of 50 kg or over to 200 mL of
dextrose 5% and infuse over 2 hours. Alternatively give the dose as a slow
i/v injection.
 Melarsoprol (Mel B) dose is 3.6 mg/kg (=0.1ml/kg). Give this as a slow i/v
push. Take great care to avoid extravasation as the medicine is highly
irritant. In adults of 50 kg or over the dose is the maximum permissible 180
mg (i.e. one 5 mL ampoule)
 Prednisolone may be added to melarsprolol with a dose of 40mg once
daily. The dose in children is 1 mg/kg once daily
 Control any seizures with Diazepam 5-10 mg slow i/v with or without the
addition of Phenytoin 150-300 mg as a single daily dose taken with water
 Anti-trypanosomal treatment may cause abortion in pregnancy, but this
must be regarded as an unavoidable risk
 Follow-up: review the patient for repeat blood film and LP at 3, 6, 12 and 24
months post-treatment

15.5 Worm infestations

15.5.1 Ascaris, Enterobius, Ancylostoma, Trichuris Infestation

 Ascaris limbricoides = roundworm, Enterobius vermicularis = pinworm,
Ancylostoma duodenale = hookworm, Trichuris trichiura = whipworm
 Hookworm can contribute considerably to anaemia especially in children
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Treatment
Adults and Children > 2 years:
 Albendazole 400 mg single dose
Children below 2 years
 Albendazole 200mg
NOTE:
 Albendazole (and mebendazole) are contraindicated in pregnancy
 Heavy trichuris infections generally require treatment for 3 consecutive
days
 In enterrobiasis, all family members must be treated concurrently

15.5.2 Strongyloides stercoralis infestation

A hyper-infection syndrome in immunosuppressed persons can occur and may
be lethal and therefore requires specialist treatment.
Treatment
 Ivermectin 200mcg/kg daily for 2 days
Alternatively
Adults
 Albendazole 400 mg daily for 5 consecutive days
Children < 2 years
 Albendazole 200 mg daily for 3 consecutive days
 Check stool 3 weeks after treatment, at least 3 specimens
 Repeat above treatment if eggs or larvae still found

15.5.3 Taenia saginata/solium (tapeworm) infestation

Treatment
Adults
 Praziquantel 10 mg/kg stat
Children < 2 years
 Praziquantel 10 mg/kg stat

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16.0 Respiratory Conditions

16.1 Acute respiratory infections (ARI) in children

 Most ARI are mild, self-limiting viral infections
 The Malawi ARI Control Programme emphasizes standard case
management as its main strategy. This includes:
o Early diagnosis
o Appropriate drug use
o Timely referral
o Advice on suitable home care
 Refer to ARI Control Programme Guidelines, MOHP 1998 for more
information
 Refer to the WHO’s Management of the Child with Cough or Difficult
Breathing for a summary of patient assessment, classification of illness and
treatment instructions

ARI Case Management

1. Refer all cases for severe disease/pneumonia to hospital for admission after
initial i/m doses of recommended antibiotics
2. Treat all pneumonia cases as out-patients with cotrimoxazole or amoxycilin
3. Do not use cough mixtures – they have no role to play in ARI management

16.1.1 Home care of children with ARI

16.1.1.1 Home care of child with ARI (2 mths – 5 yrs)

Advise mother to:
 Watch out for these danger signs (which may indicate pneumonia) and
return quickly to the health facility if any occur:
o Breathing becomes difficult
o Breathing becomes fast
o Child cannot drink
o Child becomes more ill
 Feed the child
o Continue feeding the child during illness
o Increase feeding after illness
o Clear blocked nose if interfering with feeding
 Increase fluids
o If > 6 months old, offer the child extra fluids to drink
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o Increase breast-feeding
 Soothe throat and relieve cough
o Give sips of water or other (preferably warm) fluids
 Treat fever
o Give paracetamol in the recommended dose every 6 hours until the
high fever stops (see Section 10.1 page 91)
o Increase fluids (see above)
o Do not overdress or overwrap the child, i.e. keep the child lightly
dressed
 Complete prescribed treatment
o Complete this even if the child becomes better
 Return for follow-up assessment after 2 days if child is being treated for
pneumonia.

16.1.1.2 Home care of child with ARI (young infant)

Advise mother to:
 Watch out for these danger signs and return quickly to the health facility
if any occur
o Breathing becomes difficult
o Breathing becomes fast
o Young infant not able to feed properly
o Young infant becomes more ill
 Keep the young infant warm
 Breast-feed often
 Clear blocked nose if interfering with feeding

16.1.2 Common cold (nasopharyngitis)

 Coughs are commonly associated with colds
 Antibiotics should not be given
 Often causes fever in young children which may last up to 72 hours
 In infants, nasal discharge may interfere with breast-feeding and cause
difficult in breathing
 Rule out pneumonia, otitis media, and streptococcal pharyngitis
 Advise mother on how to correctly provide suitable home care (see
Section 16.1.1 page 132)

16.1.3 Sinusitis
 Most sinusitis is viral and self-limiting, requiring no antibiotics
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 Pain in sinusitis is NOT an indicator of severity

 Steam inhalation may help drainage of blocked sinus
 Purulent nasal discharge may be caused by a foreign body in the nose
 Bacterial sinusitis is usually caused by S. pneumoniae or H. influenzae. It is
characterized by:
o Persistent purulent nasal discharge >7 days plus
o Sinus tenderness and/or
o Facial or periobital swelling and/or
o Persistent fever
 Extract tooth under antibiotic cover Benzathine penicillin 1.2g i/m stat or
Amoxycillin 3g orally stat 1hour prior to procedure and Metronidazole
400mg
 Only if there are definite signs of bacterial sinusitis give Amoxycillin 500mg
every 8 hours for 7 days or Phenoxymethylpenicillin 500 mg every 6 hours
for 7 days
Alternatively if penicillin hypersensitivity:
 Erythromycin 500 mg every 6 hours for 7 days
If there is pain or fever give:
 Analgesic/antipyretic treatment as required see Section 10.1 page 91

16.1.4 Pharyngitis, tonsillitis and its complications

 Most sore throats are due to viral infections such as adenovirus and CMV,
and should not be treated with antibiotics
 For pain or fever give analgesic treatment as required see Section 10.1 page
91
 Be sure to rule out streptococcal pharyngitis to prevent acute rheumatic
fever and other non-suppurative (endocarditis) and suppurative
complications (retropharyngeal and peritonsillar abscesses).
 Signs suggestive of bacterial pharingitis are abrupt onset of pain, fever,
tender, enlarged cervical lymph nodes, white or greyish pharyngeal
exudates, absence of lower respiratory tract signs and symptoms absence
of signs suggesting viral nasopharyngitis(e.g. rhinorrhoea, conjunctivitis,
cough)
Do not use cotrimoxazole as it is not effective

Treatment
Adults:
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 Benzathine penicillin 1.2 MU single dose i/m

Alternatively (if assured of compliance)
 Phenoxymethylpenicillin 500mg every 6 hours or Amoxycillin 500mg 8
hourly for 7 days
Alternatively in penicillin hypersensitive patients:
 Erythromycin 500mg every 6 hours for 7 days

Children > 30 kg:

 Benzathine penicillin 1.2 MU single dose i/m
Alternatively (if assured of compliance)
 Phenoxymethylpenicillin 250 mg every 6 hours or
Alternatively in penicillin hypersensitive patients:
 Erythromycin 500 mg every 12 hours

Children < 30 kg
 Benzathine penicillin 600,000 IU single dose i/m
Alternatively (if assured of compliance)
 Phenoxymethylpenicillin 12.5 mg/kg orally every 6 hours or
Alternatively in penicillin hypersensitive patients:
 Erythromycin 7.5-12.5 mg/kg orally every 6 hours
If there is pain or fever give analgesic treatment as required see Section 10.1
page 91

16.1.5 Peritonsillar and retropharyngeal abscesses

 Peritonsillar abscess (quinsy) and retropharyngeal abscess may cause
difficulty in swallowing and tenderness at the angle of the jaw
 Consider these conditions if patient is unable to drink at all:
a) Peritonsillar abscess
Treatment
Adults
 Phenoxymethylpenicillin 500mg every 6 hours or Amoxycillin 500mg
8 hourly and
 Metronidazole 400mg every 8 hours
Alternatively
 Benzylpenicillin 2 MU i/v every 6 hours
 Switch when possible (usually after 48-72 hours) to oral
Phenoxymethylpenicillin 500 mg every 6 hours or Amoxycillin
500mg 8 hourly
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 Continue for a total of 14 days antibiotic treatment

Alternatively if penicillin hypersensitivity:
 Erythromycin 500mg every 6 hours

Children
 Benzylpenicillin 25,00 units/kg/dose
 Switch when possible (usually after 48-72 hours) to oral Amoxycillin
15mg/kg every 8 hours.
 Continue for a total of 14 days antibiotic treatment
Alternatively if penicillin hypersensitivity:
 Erythromycin 12.5 mg/kg/dose
 Give analgesic/antipyretic for pain and fever (see Section 10.1 page
91)
 If pus is present and does not drain spontaneously then carry out
incision and drainage
 If quinsy is present carry out needle aspiration for analgesic and
therapeutic effect b)
b) Retropharyngeal abscess
 Surgical drainage is usually necessary
Adults
 Co-amoxiclav 625mg every 8 hours (or Co-amoxiclav 375mg plus
Amoxycillin 250mg) for 14 days
Alternatively
 Chloramphenicol 25 mg/kg every 8 hours, initially i/m or i/v later
orally for a total of 14 days antibiotic
 Analgesic for pain and fever (see Section 10.1 page 91)

Children
 Chloramphenicol 25 mg/kg every 8 hours, initially i/m or i/v. later
orally for a total of 14 days
 Analgesic/antipyretic for plan and fever (see Section 10.1 page 91)

16.1.6 Bronchitis (acute)

 Cough productive of purulent sputum, not improving after 3 days, without
signs of pneumonia
Treatment
 Amoxycillin 500mg every 8 hours for 5 days or

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 Doxycycline 200mg on first day followed by 100 mg daily for a further 5

days

16.1.7 Cervical adenitis

 Adenitis may be due to bacterial infection, TB, KS and/or HIV infection
among other causes
Treatment
 Amoxycillin 500mg every 8 hours for 10 days
Alternatively if penicillin hypersensitivity:
 Erythromycin 500mg every 6 hours or
 Doxycycline 200mg on first day followed by 100 mg daily for a further 9
days
 For pain or fever give analgesic see Section 10.1 page 91
 If no improvement, do a fine needle aspiration for AFBs

16.2 Lower respiratory tract infections

16.2.1 Asthma (recurrent wheezing)

 Exclude stridor and upper airway obstruction (inspiratory difficulty rather
than expiratory wheeze of asthma) before diagnosing and treating for
asthma.
 Wheezing can also be a sign of heart failure
 Prevention of attacks is important
 Drugs delivered by metered dose inhaler (MDI) should always be given via a
spacer device, especially during acute attacks. This will maximize effective
drug delivery and minimize side effects.
 You can make an effective spacer device using a plastic bottle. Cut a small
hole in the bottom of a plastic bottle that you can fit the inhaler
mouthpiece to with an airtight seal. Shake the inhaler before each puff
 Prime the spacer device with 2 puffs before use
 If a spacer is unavailable, check patient inhaler technique to ensure good
delivery of the drug into the lungs, not the throat.
 Antibiotics are not routinely indicated in asthma. They are indicated if
there is good evidence of a precipitating respiratory infection (e.g. fever,
bronchial breathing)

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16.2.2 Severe asthma

 Consider other causes of acute severe breathlessness with careful
examination: acute left ventricular failure, pneumothorax, pulmonary
embolus, upper airway obstruction, massive pleural effusion, severe
pneumonia.
 Severe or life threatening asthma in adults is suggested by any of the
following:
o Silent chest
o Central cyanosis
o Tachypnoea RR >30, exhaustion, inability to complete sentences
o Persistent tachycardia >110bpm, bradycardia, hypotension, pulsus
paradoxus
o Use of accessory muscles
o Confusion, agitation or coma
o Peak flow < 33% of predicted
 Arrange immediate hospitalization
Treatment
 Set up i/v line and rehydrate with 0.9% normal saline
 High flow oxygen 5l/min
 Salbutamol nebuliser solution 5 mg by nebuliser repeated initially as
required, then every 6 hours or Salbutamol 4 puffs inhaled via spacer
device and
 Hydrocortisone 200 mg i/v every 8 hours for 3 – 5 days then
o Change to prednisolone 40mg orally as a single daily dose in the
morning, with food for another 5 - 7days
o If you need to use steroids for more than 10 days, gradually taper
the dose for steroids 10mg per week initially, and decrease by 5mg
until you stop.
 Give an appropriate antibiotic therapy:
Amoxycillin 500mg every 8 hours for 5 days or Doxycycline 200 mg
on first day followed by 100 mg daily for a further 4 days
 Repeat Salbutamol dose via spacer or nebuliser every 15 -30 minutes until
improved or reassess after 1hour
If no improvement add only if not already taking theophylline
 Aminophylline 250mg slowly over 10 minutes. Beware of acute
aminophylline toxicity including cardiac arrhythmias and seizures.
If no response:

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o Give Aminophylline 250 - 500mg an i/v infusion in 1L of 5% dextrose

or 0.9% sodium chloride over 12 hours
o Magnesium sulphate 1.2 – 2.0g i/v over 20 minutes
o Adrenaline 0.5-1.0ml of 1:1000 slowly nebulised or i/m
o You may need to rescue the exhausted patient with assisted
ventilation
o Reassess continuously until the patient settles

16.2.3 Milder asthma attacks

 Carefully teach and monitor correct inhaler use technique and recommend
a spacer device
Adults:
 Salbutamol inhaler 2 puffs via a spacer device repeated as required initially,
then every 8 hours
 Keep under observation at least for 24 hours after attack
Alternatively:
 Salbutamol 2 - 4mg orally every 8 hours
 Antibiotic therapy may be indicated if signs of infection

16.2.4 Maintenance and preventive treatment of asthma - the stepwise

approach
 An environment free from cigarette and wood smoke can reduce attacks
 Check compliance and inhaler technique at each step before progressing
 Step up where required due to frequency of exacerbations
 Step down where possible:

o STEP 1: Initial treatment should be with Salbutamol inhaled via a

spacer device (see above) as required or tablets if inhalers are
unavailable
o STEP 2: If required more than once every day add preventive therapy
-inhaled steroid eg Beclamethasone 2 puffs (200mcg) twice a day via
a spacer. Increasing to 4 puffs twice a day as required
o STEP 3: Refer for specialist care if no control with steps 1 & 2

Alternatively to be used only if the above are NOT available

 Salbutamol tablets 2-4 mg orally 3-4 times daily.
 Aminophylline 100mg twice daily.
 Prednisolone 5 mg orally once daily.
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Note:
a. Use for the shortest time possible before reverting to preferred
agents
b. Where asthma is mainly a problem at night, Salbutamol before bed
may be sufficient
c. If asthma is brought on by exercise, adults can take 2puffs of
salbutamol inhaler via a spacer device a few minutes before games or
sports
d. Exercise induced asthma is usually a sign of poor control. If possible
introduce an extra level of medication according to the stepwise
approach above.
e. If asthma is brought on by exercise, older children and adults can
take 2puffs of salbutamol inhaler via a spacer device 30-60 minutes
before games or sports

16.3 Community Acquired Pneumonia (CAP)

 For all forms of pneumonia HIV testing is required.

16.3.1 Mild to moderate pneumonia

 Usually caused by pneumococcus (sudden onset)
Treatment
 Amoxycillin 500mg every 8 hours for 5-7 days
If Penicillin allergic
 Erythromicin 500mg orally every 8 hourly for 5-7 days
 Doxycycline 100mg bd for 5 – 7 days
If the patient does not improve, consider alternative diagnoses including

16.3.2 Atypical Pneumonia

 Caused by Mycoplasma pneumoniae and Chlamydia pneumoniae
 Suspect in previously healthy young adult not responding to treatment for
CAP
Treatment
 Give Erythromycin 500mg orally every 6 hours for 5 days

16.3.3 Nosocomial pneumonias

 Caused by Staphylococcus aureus, gram negative rods and Pneumococcus
Treatment
 Co-amoxiclav 1.2g i/v every 8 hours or Ceftriaxone 2g i/v once daily
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 Followed by oral Co-amoxiclav 625mg every 8 hours for 7 days

16.3.4 Severe pneumonia

 Symptom and Signs: Respiratory rate > 30/min, shock (- BP <90/60mmHg),
confusion / drowsiness central cyanosis
 Refer to district hospital
Treatment
 Benzyl penicillin 2-3MU i/v every 6 hours plus Chloramphenicol 500mg i/v
every 6 hours plus
Erythromycin 500mg every 6 hours or Doxcycline 100mg every twelve hours
 Switch to oral medication early
Alternatively
 Co-amoxiclav 1.2g i/v every 8 hours plus
 Erythromycin 500mg 6 hourly for a total of 7 days or
 Doxycycline 100mg every twelve hours for a total of 7 days antibiotic
therapy

16.4 Suppurative Lung Disease

16.4.1 Lung abscess

 Co-amoxiclav 625mg every 8 hours plus
 Metronidazole 400 mg every 8 hours
Alternatively to Co-amoxiclav
 Erythromycin 500mg every 6 hours
 Doxycycline 100mg every twelve hours
 Continue treatment for 21 to 28 days

16.4.2 Empyema
 Carry out surgical drainage
 Continue antibiotic therapy as for CAP for 21 to 28 days
 Rule out TB

16.5 Bronchiectasis
Symptoms and signs: Chronic cough and sputum production years after
treatment of pulmonary TB
 Physiotherapy to aid postural drainage of secretions every morning
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 Give prompt antibiotic therapy when secondary infection occurs

 Co-amoxiclav 625mg every 8 hours
Alternatively
 Doxycycline 200mg stat then Doxycycline 100mg once daily
 If sputum is foul smelling, add Metronidazole 400mg every 8 hours
 Treat for 14 days

16.6 Chronic Lung disease / COPD

 Acute exacerbations may present in a similar way to asthma, however the
patients will be older, and will often have smoked or been exposed to wood
smoke, e.g. cooking at home.
 Not always related to an infection.
Treatment
 Salbutamol as required.
 Always use a spacer device as described in the section on asthma above.
 Prednisolone 40mg po once daily for 10 days
If there is fever and purulent sputum then
 Amoxycillin 500mg every 8 hours for 7 days
 If a patient has more than 4 exacerbations in a year a trial of regular
inhaled Salbutamol via a spacer 2 puffs four times daily, and as required
in between can be tried.
 Long term use of oral steroids is NOT recommended.

16.7 Pulmonary Embolism

 Treat with 6 months Warfarin therapy if available, but only if INR
monitoring and specialist supervision are available.
 Long term treatment may be necessary in certain circumstances,
including recurrent cases.
 Look for a triggering cause.

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17.0 Sexually Transmitted Infections (STIs)

 Refer to the Management of Sexually Transmitted Infections Using
Syndromic Management Approach, Guidelines for Service Providers,
MoH, 3rd edition May 2008 for more detailed information.
 All patients who present with STI symptoms should be offered HIV Testing
and Counselling.

Prompt and effective treatment of STIs helps prevent spread of HIV infection

General Management
 Ensure adequate privacy in patient management.
 Establish a correct diagnosis whenever possible.
 Make efforts to trace, treat and counsel all sexual contacts.
 Provide health education and counseling on each return visit.
 Advice on ‘safer sex’ practices to prevent re-infection, i.e. abstinence,
correct use and storage of condoms, mutual faithfulness of uninfected
partners, decrease in number of sexual partners, use of non-penetrative
sexual techniques and the importance of partner notification and
treatment.
 Offer a supply of condoms at each patient visit

Periodically check the patient’s understanding of the above issues by asking him/her
to repeat the information given

17.1 Syndromic management of STIs

 The syndromic approach is based on the fact that most common causes of
an STI infection generally present with certain groups of signs and
symptoms (syndrome) and treatment given is supposed to target the
commonest possible causes of that syndrome.
 Common STI syndromes:
 Genital ulcer disease (GUD) Section 17.1.1 page 144
 Urethral discharge Section 17.1.2 page 145
 Genito-urinary symptoms in women Section 17.1.3 page 145
 Lower abdominal pain (women) Section 17.1.4 page 146
 Acute scrotal swelling Section 17.1.5 page 149
 Enlarged inguinal lymph nodes (bubo) Section 17.1.6 page 149
 Balanitis/balanopostitis Section 17.1.7 page 150

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17.1.1 Genital ulcer disease (GUD)

Common Causes: genital herpes, chancroid and syphilis may be present
concurrently.
 Genital herpes is the most prevalent amongst the three.
 Treat patients with GUD for the above three infections
General Management
 Aspirate fluctuant lymph nodes (buboes) through adjacement normal (i.e.
not inflamed) skin.
 Do not incise.
 Ask patients to return if non-fluctuant nodes become fluctuant
Treatment
 Ciprofloxacin 500mg orally stat and
 Benzathine penicillin 2.4 MU i/m stat
 Acyclovir 800mg every 12 hours orally for 7 days
 Tell patient to return for follow-up care in 7-10 days, see below
Note: Acyclovir is indicated only in symptomatic GUD clients
If patient allergic to penicillin:
o Erythromycin 500mg every 6 hours for 15 days plus
o Acyclovir 800mg orally every 12 hours for 7 days
If patient allergic to penicillin/Ciprofloxacin and pregnant or lactating:
o Erythromycin 500mg every 6 hours for 15 days and acyclovir 800mg
every 12 hours for 7 days
 Infants born to mothers treated for GUD with Erythromycin alone:
o Benzathine Penicillin 500,000 IU/kg as a single dose

Follow-up care of GUD

 Inform the patient to return 7-10 days after starting treatment.
 If the ulcers have not healed or are getting worse, repeat GUD treatment if
there is evidence of noncompliance.
 If the client complied fully and there is no improvement:
o Give Azithromycin 2g stat.
o Review in further 7-10 days
o If no improvement, refer for specialist opinion
o If improved, follow patient’s progress until completely healed
o No further antibiotics are required at this time
 If the ulcers have improved but not completely healed:
o Repeat chancroid treatment Ciprofloxacin 500mg single dose
o Review in further 7-10 days
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o Subsequent action as above

 If the ulcers have completely healed:
o Reinforce counseling and patient education
o Promote/provide condoms

17.1.2 Urethral Discharge/Urethritis in Men (UD)

Symptoms/Signs: discharge or dysuria
 Common causes: Neisseria gonorrhoea, Chlamydia trachomatis and
trichomonas vaginalis.
 Common in males
Note: If there is dysuria but no discharge and no sexual contact in the last 2
weeks, seek other causes, like urinary tract infection, prostates or
schistosomiasis
Treatment
 Gentamycin 240mg i/m stat plus
 Doxycycline 100mg every 12 hours with food for 7 days
 Metronidazole 2g stat
Alternative to Doxycline in pregnancy/lactation:
 Erythromycin 500mg every 6 hours for 7 days
 Review after 7 days
 If symptoms persist or recur:
o Rule out re-infection
o Assess compliance
o Retreat as above if noncompliant or there is evidence of reinfection
o Review after further 7 days
 If symptoms still persist, refer for further investigation

17.1.3 Abnormal Vaginal Discharge in Women (AVD)

Causes: vaginal infection, cervical infection, endometrial infection/pelvic
inflammatory disease (PID)
 Common causes of vaginal infections: trichomonas vaginalis, candida
albicans and bacterial vaginosis.
 Common Causes of cervical infections: neisseria gonorrhoeae and
chlamydia trachomatis.
Note: Vaginal discharge is normal during and after sexual activity; at various
points through-out the menstrual period; and during pregnancy and
lactation.

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General Management
 Do risk assessment to identify women at risk of cervical infection
o treat for vaginitis to those with negative risk assessment
o treat for cervicitis and vaginal infection to those with positive risk
assessment.
 Treat all women with vaginal discharge and a positive risk assessment for
gonococcus and Chlamydia infection, plus trichomoniasis and bacterial
vaginosis t should be.
o If the discharge is white and curd-like also treat for candidiasis.
 Treat all women with vaginal discharge and a negative risk assessment for
trichomoniasis and bacterial vaginosis
o If the discharge is white and curd-like, also treat for candidiasis.
Treatment
 If vaginal discharge is present and the risk assessment is positive:
o Gentamycin 240mg i/m stat plus
o Doxycycline 100mg orally every 12 hours for 7 days, plus
o Metronidazole 2g orally single dose
 If the discharge is white or curd-like add 1 Clotrimazole Pessary 500mg
inserted intra-vaginally stat
 If vaginal discharge is present and risk assessment is negative:
o Metronidazole 2g orally single dose stat
 If the discharge is white or curd-like add 1 Clotrimazole Pessary 500mg
inserted intra-vaginally STAT
 If no discharge is found and risk assessment is positive:
o Gentamycin 240mg i/m stat plus
o Doxycycline 100mg orally every 12 hours for 7 days
 If no discharge is found and risk assessment is negative:
o Reassure client, counsel, educate and provide condoms.
o Advise client to come back if symptoms persist.
o Offer HIV testing after providing information and counselling
Examination of GUS in women should never be omitted only for convenience of the
health worker

17.1.4 Lower abdominal pain in women (LAP Syndrome)

 A serious condition which should be considered in every woman with lower
abdominal pain.
Note: Not every woman with lower abdominal pain has PID.

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Be sure to include any conditions which require immediate surgical or

gynaecological treatment
 Symptoms/Signs: fever, lower abdominal pain, pain on discharge, vaginal
discharge, cervical tenderness, and often adnexal tenderness or masses on
bimanual examination.
 Symptoms/Signs of acute illness requiring immediate gynaelogical/surgical
attention: Missed or overdue or delayed period; recent abortion, delivery
or miscarriage; metrorrhagia; abdominal guarding or rebound tenderness;
Active vaginal bleeding.
General Management
 If the patient has a missed/overdue period or abnormal vaginal bleeding:
o Consider referral see Section 17.1.4.1 page 148 for in-patient
treatment
o When referring, ensure patient’s general condition is stable
 If the patient is very ill, bleeding heavily or in stock:
o Set up an iv drip and commence resuscitation measures
 If the patient does not have missed/overdue period or abnormal vaginal
bleeding but does have any of the following:
o Recent delivery; Recent/suspected abortion; Rebound tenderness;
Abdominal guarding
o Give first dose of treatment for PID.
o Refer immediately for hospital admission after resuscitating the
patient should this be required.
o See Section 17.1.4.1 page 148 for in-patient treatment
 Admit if the patient: is obviously sick; is pregnant; vomits oral medication or
if adequate follow-up care cannot be provided.
Treatment
 If the patient does not have missed/overdue period or abnormal vaginal
bleeding, does not have any of the signs/symptoms listed in b) but does
have cervical excitation tenderness or fever:
o Gentamycin 240mg i/m stat,
o Doxcycline 100mg 12 hourly and
o Metronidazole 400mg 12 hourly for 10 days.
o Remove any IUCD if any and offer other means of contraception
o Treat partner for gonococcal and chlamydial infection
o Review patient after 72 hours:
 If improved, complete 10-day course of treatment for PID
 If not improved, refer for gynaecological or surgical consultation
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o See Section 17.1.4.1 below for in-patient treatment

 If the patient does not have missed/overdue period or abnormal vaginal
bleeding, does not have any of the signs/symptoms listed in b), and not
have cervical excitation tenderness or fever:
o Determine whether the patient has any other genitourinary
complaint/syndrome and manage as per appropriate syndrome:
o Ask her to return if the abdominal pain persists

17.1.4.1 Lower Abdominal Pain in Women (PID): In-patient treatment

 Signs or symptoms of acute PID requiring admission: Failure to respond to
syndromic treatment regime Section 17.4.1 page 153 within 72 hours;
Presence of tender pelvic mass which may be an abscess or an ectopic
pregnancy; History or suspicion of recent induced abortion, delivery or
miscarriage; Active vaginal bleeding; Missed, overdue or delayed period;
regnancy; Metrorrhagia; Vomiting of oral medication.
The patient should be admitted if follow-up care cannot be guaranteed

Treatment
If toxic:
o i/v fluids and parenteral antibiotics.
o Gentamycin 1.5 mg/kg slow i/v or i/m every 8 hours plus
o Chloramphenicol 500mg i/v every 6 hours
o Metronidazole 500mg i/v every 8 hours
When improved and able to swallow:
o add Doxycycline 100mg every 12 hours and
o switch from parenteral to oral Metronidazole 400mg every 12 hours
for 10 days
For pain and fever
o Analgesic (see Section 24.1 page 196)
If pain is severe:
o Pethidine 100 mg i/m or orally
o Repeat every 3-6 hours, as required
Note: Acute PID may be due to puerperal or post-abortion sepsis.
Admit treat with parenteral antibiotic therapy.
o Evacuate the uterus within 12 hours of antibiotic therapy regardless
of the patient’s temperature
 Provide supportive care such as blood transfusion, iv fluids and

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 Closely monitor vital signs.

17.1.5 Acute scrotal swelling or pain

General Management
 Distinguish from scroll swelling/pain due to:
o Other long-standing causes, e.g. Scroll hydrocele, varicocele, inguinal
hernia
o Recent/acute illness, e.g. Testicular torsion or trauma, inguinal hernia
Thorough history and physical examination are necessary to exclude potentially life-
threatening conditions and to determine whether immediate surgical attention is
required
Treatment
 Even if the presumptive diagnosis is an STI, treat all patients and partners
for gonorrhoea and chlamydia infection:
 Gentamycin 240mg i/m stat and
 Doxcycline 100mg every 12 hours for 7 days.
 In preganant or lactating mothers Doxcycline should be replaced with
Erythromycin 500mg every 6 hours for 7days.
 Additional therapy for the patient:
o bed rest with the scrotum elevated
o cold compresses to help reduce swelling
 If there is no evidence of painful and/or swollen scrotum, look for signs of
another STI and if present treat appropriately

17.1.6 Enlarged inguinal nodes (bubo)

 Both chancroid and lymphogranuloma venereum (LGV) can cause bubo.
 Exclude the following conditions which may also cause enlarged inguinal
lymph nodes: septic skin lesions on thigh, foot, leg, toes, buttock, anus,
perineum, scrotum, penis, labia, vulva and vagina, systemic infections e.g.
Hepatitis B. HIV infectious, mononucleosis, syphilis, TB, other infections e.g.
bubonic plague, cat scratch fever, trypanosomiasis, lymphoma, leukemia,
Kaposi’s sarcoma.
 Exclude other conditions which may cause groin swelling unrelated to
enlarged lymph nodes including: inguinal hernia, lipoma, a boil in overlying
skin.
 Confirm presence of bubo by careful examination
All patients with bubo should be carefully examined for signs of other STIs

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Treatment
 If bubo present and genital ulcer present, treat as for genital ulcer disease
syndrome
 If bubo present, and painful, fluctuant or recent onset (under 2 weeks) and
no genital ulcer present: treat patient and partner for LGV
 Doxycycline 100mg every 12 hours with food for 14 days
Alternatively in pregnancy/lactation
 Erythromycin 500mg every 6 hours for 14 days
 If bubo fluctuant, aspirate through adjacent normal skin (do not incise)
 If enlarged inguinal lymph node present, but not painful, fluctuant or of
recent onset (under 2 weeks) and no genital ulcer present: look for other
causes of inguinal swelling:
o e.g. generalized lymphadenopathy (rule out secondary syphills and
HIV), hernia, tumour.
 Refer for biopsy if indicated
 If bubo not present but other signs of STI found, treat accordingly
 If bubo not present and other signs of STI not found, reassure,
educate/counsel the patient
 Promote/provide condoms

17.1.7 Balanitis/balanopostitis (BA Syndrome)

 Cause: fungal infection, trichomonal infection and medicine reactions
 Common and persistent in persons with diabetes and with
immunosuppression caused by HIV infection
The most common reason for balanitis is poor genital hygiene
General Management
 Ask patient about any recent topical application of medicines (including
traditional medicines)
 Ask patient if partner/s have vaginal itching or discharge – this may indicate
candidiasis or trichomoniasis
 Examine the patient carefully for presence of genital ulcers and urethral
discharge
Treatment
 If the foreskin is retractable and ulcer/s present, or if the foreskin is not
retractable:
o Treat as for genital ulcer Disease syndrome.
 If the foreskin is retractable, no ulcer, but urethral discharge present:
o Treat as for urethral discharge
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 If the foreskin is retractable, no ulcer, no urethral discharge, but erythema

or erosions present:
o Treat for candida infection
 Apply Gentian Violet 1% aqueous solution to glans penis daily for
7 days.
o Treat partners with Clotrimazole pessary 500mg inserted vaginally once.
o Advise on genital hygiene, including frequent washing of penis with soap
and water
o Review patient in 7-10 days:
 If symptoms persist:
o Treat patient and partner for trichomoniasis with Metronidazole 2g
stat.
o Advise client to avoid alcohol during treatment and for 48 hours after
dose
 If symptoms resolved and no signs of STI:
o Reassure, educate/counsel
o Promote/provide condoms
 If foreskin is retractable, no ulcer, no urethral discharge, no erythema or
erosions and no signs of STI:
o Reassure, educate/counsel
o Promote/provide condoms
17.2 Genital warts
 Distinguished from condyloma of secondary syphills, and molluscum
contagioum
 Besides local caustic applications, surgical removal or electrocautery may
be used for treatment:
o For more extensive growth
o When topical applications have failed
o When topical application are contra-indicated
Treatment
 Apply Compound Podophyllin Paint to the lesions at weekly intervals
 Apply Yellow Soft Paraffin to avoid normal tissue
 Use only for scattered growth
 When applied to vulval mucosa or to meatal warts, allow to dry before
coming back into contact with normal epithelium
 Remove the paint by washing off after 1-4 hours
Note: Do not use this therapy during pregnancy

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 If no effect after 4-6 weeks, stop treatment and consider alternative

methods of removal
Alternatively to Podophyllin Paint, and for treating vulvar warts:
 Apply Silver Nitrate Stick (pencil) once daily

17.3 Neonatal Conjuctivitis

 These serious conditions rapidly progress and threaten sight
 Admit patient to hospital
 Closely monitor until the infection has resolved
 Give antimicrobial therapy without delay
 Irrigate the eyes frequently with normal saline
At birth give all neonates a single prophylactic application of tetracycline eye
ointment

Treatment
Adults and all parents of infected babies:
 Gentamycin 240 mg i/m single dose
Infants with signs of conjunctivitis:
 Isolate immediately
 Institute a rigorous system of barrier nursing with careful attention to
hygiene
 Gentamycin 5mg/kg i/m once (7.5mg /kg if the infant is older than 7 days)
and
 Erythromycin 12.5mg/kg orally every 6 hours for 14 days.
Alternatively for Gentamycin,
 Cefotaxime 50mg/kg i/m as a single dose (maximum 125mg)
 Tetracycline eye ointment 1% applied in each eye every 6 hours for 3 days
o Clean away any discharge before application
 Wash eyes with clean water/saline ideally every 2 hours until the purulent
discharge is cleared
 Treat Father with
o Gentamycin 240mg i/m stat, and
o Doxycycline 100mg every 12 hours for 7 days
 Treat Mother with:
o Gentamycin 240mg i/m stat, and
o Erythromycin 500mg every 6 hours for 7 days
Alternative topical agent:
 Gentamycin eye drops 0.3%, 1.2 drops into each eye every 2 hours
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 Reduce dose frequency as the infection is controlled

 Continue for 48 hours after healing
17.4 Syphillis
 Use this regime for patients with syphilis confirmed by laboratory testing
 In treatment of secondary syphilis, a Herxheimer reaction (malaise, fever,
headache, rigors) may sometimes occur within 6-12 hours of initial
treatment
Treatment
 Treat this with Aspirin 600mg every 6 hours

17.4.1 All syphilis except neurosyphilis

 Includes:
o Early syphilis: primary (ulcer), secondary (generalized skin rashes,
condylomata lata) or latent syphilis of not more than 2 years duration
o late syphilis: benign, cardiovascular and latent syphilis of more than 2
years; syphilis of indeterminate duration
o congenital syphilis in children
 Treat as late syphilis all patients with a positive RPR or VDRL and no
documented syphilis serology in the last 2 years.

17.4.1.1 Early syphilis in adults

Treatment
 Benzathine Penicillin one dose of 2.4 MU i/m
o Divide as 1.2 MU into each buttock
Alternatively, if hypersensitivity to penicillin:
 Doxycycline 100mg every 12 hours for 15 days
Note: In pregnancy/lactation, substitute Doxycycline with Erythromycin
500mg every 6 hours for 15 days

17.4.1.2 Late syphilis in adults

Treatment
 Benzathine Penicillin 3 doses of 2.4 MU i/m at weekly intervals
o Divide each weekly dose 1.2 MU into each buttock: total (3 doses) is
7.2 MU
Alternatively, if hypersensitivity to penicillin:
 Doxycline 100mg orally every 12 hours for 30 days
 Note: In pregnancy/lactation, substitute Doxycycline with Erythromycin 500
mg every 6 hours for 30 days
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Notes for pregnant patients

 Any history of penicillin hypersensitivity must be reliable as these patients
are put at serious disadvantage because they cannot be given tetracyclines
 The child must be treated for congenital syphilis at birth as Erythromycin
does not readily cross the placenta

17.4.2 Congenital syphilis in children

 Treat with a single dose of Benzathine penicillin 50 000 IU/kg i/m in all
infants born to sero-positive mothers whether or not the mothers were
treated during pregnancy (with or without penicillin) unless they have
features of congenital syphilis.
 Thoroughly examine for congenital syphilis all infants born to women with
reactive serologic tests: look for ascites, oedema, jaundice,
hepatosplenomegaly, rhinitis, nasal discharge, hoarse cry, skin rash, and/or
pseudoparalysis of any extremity.
 Treat infants with these symptoms as early congenital syphilis:
Treatment
 Benzylpenicillin 50 000 IU/kg/dose i/v every 12 hours, during the first 7
days of life and every 8 hours thereafter for a total of 10 days,
 Children with late congenital syphilis (more than 2 years) are treated as
follows:
o Benzylpenicillin 50 000 IU/kg/dose i/v every 4 to 6 hours 10 to 14
days,
Alternatively, in penicillin allergic children
o Give Erythromycin syrup 12.5mg 6 hourly for 30 days.
 The risk of penicillin hypersensitivity in the 1st month of life can be safely
discounted

17.4.3 Neurosyphilis
 Higher penicillin doses are necessary to ensure that levels in the CSF do not
fall below required amount throughout the course of treatment
Treatment
Adults:
 Benzylpenicillin 4MU i/v every 6 hours for 14 days then
 Benzathine Penicillin 2.4 MU i/m once weekly for 3 consecutive weeks
Alternativly e if confirmed hypersensitivity to penicillin:
 Doxycycline 200mg every 12 hours for 30 days

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Note: In pregnancy: substitute Doxycycline with Erythromycin 500mg every 6

hours for 30 days
17.5 Trichomoniasis, vaginal
 Coincident bacterial vaginosis reduces the effectiveness of single dose
Metronidazole treatment
 Asymptomatic male partners should also be treated
Treatment
 Adults:
o See AVD Syndrome (Section 17.1.3 page 145)
 Infants with symptomatic trichomoniasis or urogenital colonization
persisting after the 4th month
o Metronidazole 5 mg/kg every 8 hours for 5 days

17.6 Management of Children and Adolescents Victims of Sexual Assault and

Rape

 Assess and treat serious injuries first

 Obtain verbal consent to conduct physical examination
 Take full history and document all findings (use appendix 2 – “examination
1
record” as recording framework)
 Conduct full physical examination and document all findings
 Document all facts regarding the assault
Manage physical effects of the assault such as wounds and bruises – including
2 antibiotics to prevent wound infection, tetanus booster if required,
medication for pain relief or anxiety
Provide emergency contraception if the victim has started menarche and
presents within 72 hours post-assault
3
 Postinor-2 – take 1 tablet orally, to be repeated after 12 hours or
 Lo-Femenal 4 tabs to be repeated after 12 hours
Treat presumptively for STIs (or conduct laboratory investigations if available):
 Benzathine Penicillin < 25 kg: 600,000 IU stat.
> 25 kg 1,200,000 IU stat
4
 Gentamycin 6mg/kg single dose
 Erythromycin 12.5mg/kg every 6 hours for 7 days
 Metronidazole 5mg/kg every 8 hours for 7 days
 Provide HIV Testing and Counselling
5
 Conduct an HB baseline reading (if available)
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 If the victim presents within 72 hours of penetrative assault, and is HIV

negative upon initial testing, and consents to PEP treatment -
 Provide HIV PEP
 If the victim has HB ≤ 8 g/dl Duovir must be replaced with LamivirS
Duovir - BD * 30 days OR ELSE
Lamivir S - BD * 30 days
< 14 kg - ¼ 25-35 kg – ¾
tablet tablet
15- 24 kg – ½ > 35 kg – 1
tablet tablet
 Provide counselling on post-traumatic stress to victim and guardian
 Assess safety of the victim
6
 Refer to other support services, such as the Victim Support Unit in the
Police
 Advise on dates for follow up visits
 Record Findings and treatment in “Examination Record” and provide copy
7
to the victim for submission to the police, if appropriate
Record all findings and treatment in health passport

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18.0 Skin conditions

18.1 Bacterial skin infections

18.1.1 Impetigo, Folliculitis, Furunculosis and Carbuncles

 Causes: Staphylococcal aureus and Streptococcal pyogenes.
General management
 Keep infected areas clean- wash daily with soap and water
 For children, instruct the mother
 Prevent spread to others – take care with towels and clothes and
change/clean bedding frequently
 Remove crusts with warm water
Treatment
 Apply Gentian Violet paint 0.5 % on wet lesions
Alternatively
Adults
 5% Salicylic acid with 5% Sulphur
Children
 2% Salicylic acid with 5% Sulphur ointment
 If extensive or involving hairy areas: Flucloxacillin 125-500mg every 6 hours
for 5-7 days or
 Erythromycin 125-500mg every 8 hours for 5-7 days.
If no response, refer to hospital
 For furunculosis and carbuncle – clean the affected area with water and
soap.
 Do incision and drainage if fluctuant
 Give systemic antibiotics as above.

18.1.2 Ecthyma
 An ulcerative streptococcal pyogenes skin infection which can easily be
confused with impetigo.
 Only recognized upon removal of a scab where a punched out ulcer may be
seen.
General Management
 Remove crusts
 Give systemic antibiotics for 14 – 28 days

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18.1.3 Neonatal Pustulosis/ Bullae

 Causes: Staphylococcal aureus or Streptococcal pyogenes, syphilis
(Treponema pallidum)
Treatment:
 Potassium permanganate baths
 Benzylpenicillin 50,000 units/kg i/m or i/v every 12 hours for 5 days plus
 Gentamycin 2.5mg/kg i/m or i/v every 12 hours for 5 days
 Check the mother’s VDRL or TPHA – if positive treat see Section 17.4 page
153

18.1.4 Erysipelas
 Well demarcated, erythematous superficial skin lesion with some blisters.
 Commonly caused by a beta- haemolytic group-A streptococci.
Treatment
 Benzyl Penicillin 2MU i/m every 6 hours
o When temperature drops or when condition improves change to
Erythromycin 500mg every 6 hours for 5-7days.
 Apply GV paint every twelve hours

18.1.5 Cellulitis
 Poorly defined erythematous lesion.
 This is bacterial infection of the deeper part of the dermis and the upper
part of the subcutaneous tissue
Treatment
 Flucloxacillin 125 -500mg every 6 hours for 7 – 10 days
If penicillin hypersensitive give
 Erythromycin 500mg every 6 hours for 7 -10 days
If the patient is systemically unwell, then give
 Benzyl Penicillin 2 MU i/m every 6 hours for 7 – 10 days or oral antibiotics
 Elevate the leg(s) on a pillow to reduce swelling.

18.1.6 Staphylococcal Scalding Skin Syndrome – Lyell’s disease

 A febrile, rapidly evolving generalized and blistering desquamative skin
condition in which the skin exfoliates in sheets.
 Commonly affects neonates and young children, rare in adults unless one is
immune compromised
General Supportive Measures
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 Replace fluid
 Flucloxacillin or Cloxacillin 250 – 500 mg every 6 hours for 7days.
 Cortico-steroids are contra indicated

18.2 Erythema Multiforme/Steven Johnson’s Syndrome

18.2.1 Erythema multiforme – Minor (Iris Type)

 Prodromal symptoms are generally absent and there is relative sparing of
the mucus membrane and the trunk
 Target lesions (Iris) are characterized by dark centre and inner pale ring and
an erythematus type outer border.
Treatment (Symptomatic)
 Potassium Permanganate baths twice a day
 Calamine lotion if vesicular origin or popular eruptions
 Identify the cause and treat. If the cause is medicine, stop the medicine
 Chlorpheniramine 4mg 8 hourly for 7 days

18.2.2 Steven Johnson’s Syndrome/Vesicobullous type

 Potentially fatal condition
 Often caused by hypersensitivity to medication.
 Always ask for use of antiretroviral therapy (nevirapine), sulfa drugs, and
penicillines. These need to be stopped immediately
Treatment (Symptomatic)
 Normal Saline a must – put up i/v line.
 Add Dextrose
 Identify the cause and treat. If the cause is medicine, stop the medicine
 Prednisolone 60 – 80mg once daily for 7days; 40mg once daily for 3days;
30mg once daily for 3 days; 20mg once daily for 3 days; 10mg once daily
for 3 days; 5mg once daily for 3 days
 Keep patient warm
 Potassium Permanganate baths twice daily
 GV Paint on fresh lesions
 Acyclovir course if of viral origin
 Give Ceftriaxone 2g i/v once daily

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18.3 Toxic Epidermal Necrolysis (TEN)

 Management is like in Steven Johnson’s Syndrome.
 Often caused by hypersensitivity to medication. Always ask for use of
antiretroviral therapy (nevirapine), sulfa drugs, and penicillines. These need
to be stopped.
 Refer to the hospital
Treatment
 Prednisolone 80mg once daily for 1 week; 70mg once daily for 3 days;
60mg once daily for 3 days; 50mg once daily for 3 days; 40mg once daily
for days; 30mg once daily for days; 20mg once daily for days; 10mg once
daily for days; 5mg once daily for 3 days – Stop
 Normal Saline a must – put up i/v line.
 Identify the cause and treat.
 Give Ceftriaxone 2g i/v once daily
 High protein diet is recommended.

18.4 Fixed Medicine Eruption

 Diagnosis is clinical and in relation to history
 Stop the offending medicine
 Use potent topical steroids e.g. Betamethasone cream twice daily
 If severe:
o Chlorpheniramine 4-8mg at bed time for 7 -14 days

18.5 Urticaria
 If deep dermis and subcutaneous tissues are involved it is called
angioedema.
General Management
 Explain the condition to the patient
 Remove the cause if known
Treatment
 Give antihistamines –Promethazine 25mg i/m or orally at night or every 8
hours or at night for 1 to 2 weeks or till 48 to 72 hours after submission of
the wheals
Alternatively
 Chlorpheniramine 4-8mg at night or every 8 hours for 1-2 weeks
 Albendazole 400mg stat
 Calamine lotion at night or twice daily
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 Adrenaline 0.5ml sub-cutaneously in severe urticaria with tracheal

angioedema

18.6 Eczema (dermatitis)

 An inflammatory itchy skin condition.
 Types: Atopic (seborrhoeic (indogenous)), Allergic (irritant contact eczema
(exogenous))
Treatment
 Determine the type of eczema
 Eczemas are often secondarily infected (impetigo), systemic antibiotic
treatment should be added if indicated
 In HIV (+) children, extensive seborrhoeic dermatitis may occur.
o Potassium Permanganate baths twice a day.
o And topical steroidse.g. Hydrocortisone 1% cream or ointment or
Sulphur 5%with emulsifying ointment twice a day.
o If no response, give second line topical steroids or group 3 e.g.
Betamethasone creams.
 If secondary bacterial infection occurs:
o Treat with systemic antibiotics: Flucloxacillin or Erythromycin.
General Management
 Counsel the patient on the condition.
 Treatment depends on the texture of the affected skin.
 Remove any obvious precipitating factors (allergic or contact eczema) ask
about soaps detergent, vaseline, cosmetics, clothings etc.
 Use antihistamine to relieve itching.
Treatment
Adults:
 Promethazine 25 mg orally at night.
Children:
 Promethazine 1 mg/kg.
Alternatively
 Chlorpheniramine 4-16mg at night for 2 weeks.
 Use antibiotics for secondary infection.
 Give systemic antibiotic treatment only if lesions are infected or signs of
systemic infection are present

Note: First line treatment failures can do better with Betamethasone

cream/ointment or Crude coal tar 5 % ointment.
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18.6.1 Acute eczema

 Sudden eruption with erythema, vesicles and sometimes bullae, often with
serous exudates (wet appearance)
Management
 Wet or oozing lesions - dry them first with Calamine lotion 2 times a day
 Give Chlorpheniramine 4mg at night for 7 days

18.6.2 Subacute eczema

 Lesions take several days to erupt, are red but not wet or may be slightly
wet. Few vesicles.
Management
 Normal or slightly wet lesions- use Hydrocortisone 1% cream twice a day
 Give Chlorpheniramine 4mg at night for 7 days

18.6.3 Chronic eczema

 Develops after months/years, thickened dry and scaly skin, (lichenification),
deep cracks (can bleed) scratch marks, sometimes infected
Management
 Dry skin lesions
o Hydrocortisone ointment 2 times daily
Alternative
o Potent steroid e.g. Betamethasone 0.1%

18.7 Fungal skin infections

18.7.1 Tinea
 Types: Capitis, corporis, pedis ,cruris, unguium.
 Instruct patients on the importance of treatment compliance in order to
eradicate the infection
Treatment
 For wet lesions
o Dry by soaking or mopping with Potassium Permanganate
Alternatives
o Calamine Lotion or Gentian violet Paint
o Then, Compound benzoic acid ointment or Clotrimazole cream
 In chronic or extensive cases and those involving hairy areas:

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o Add Griseofulvin 500mg orally daily with food, single dose or in 2

divided doses, 4-6 weeks
o Children: 10mg/kg/dose
Notes:
 Tinea corporis, cruris, pedis treat for 4 weeks
 Tinea capitis treat for 6 weeks
 Tinea unguium of the fingernails treat for 12 months
 Tinea unguium of the toe nails treat for 2 years.
Alternative systemic antifungals
 Ketoconazole and Fluconazole.
 In HIV (+) patients all Tineas may be extensive.

18.8 Viral skin infections

18.8.1 Herpes simplex

 Types: Type 1 (affects lips), Type 2 (affects genitals but can interchange due
to oral sex)
Treatment
 In case of bacterial superinfection see Section 18.1 page 157
 Use salt mouth wash or chlorhexidine solution
 Acyclovir Cream or GV Paint or Silver Sulphadiazine Cream Application
twice a day
 Aspirin 300mg or Paracetamol (avoid Aspirin in children as it may cause
Reye’s syndrome)
 In severe conditions give Acyclovir 200-400mg every 8 hours for 5 to 7 days
and consider checking HIV.

18.8.2 Varicella (Chicken pox)

 Refer to Section 9.8 page 75

18.8.3 Herpes zoster (shingles))

 Causes: varicella zoster virus.
 A common presentation in HIV(+) patients
Treatment
 Acyclovir 800mg 5times a day for 5-7 days; best within 24 -72hours from
onset of the lesions.

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 Calamine lotion or Acyclovir cream bd on intact lesions till they break or

 GV paint , or topical antibiotic cream twice a day
 For pain relief refer to Section 24.4 page 197
 For ophthalmic herpes zoster treat as above and refer to eye department.
 Refer for HIV Testing

18.9 Prurigo/Pruritus
 Symptoms/Signs: itching.
 Causes: Iron deficiency, anaemia, lymphoma, leukaemia.
Treatment
 Adults and Children (symptomatic treatment):
 Apply Calamine Lotion 2-3 times daily
 Promethazine 25mg single dose at night or
 Chlorpheniramine 4-8mg at night for 2 weeks
o Children: 1 mg/kg/ dose
 Emolients like Emulsifying plain ointment applications or baths b.d. may
help reduce itching
 Investigate the cause, and treat accordingly

18.10 Scabies
 Secondary infection is common and may mask the condition.
 Treat the whole family and any other close contacts
Treatment
 Wash the whole body with mild soap and water, preferably at night, and
dry up
 Apply Benzyl Benzoate Application 25% to the whole body from the neck
down
 Ensure all parts of the skin are covered
 Allow the medication to dry and to remain on the skin for at least 10 hours
or over night
 Next morning wash off the application with soap and water
 Wash all contaminated clothes, beddings and towels and use already
washed clothes
 Repeat the above treatment on day 5
Alternative for benzyl benzoate application
 Lindane 1% lotion, single dose applied as above.
Note:

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 Avoid Lindane in children less than 2 years old

 In children under 1year, also treat the face (except the area surrounding
the eyes)
 For children under 5 years, Use 12.5% benzyl benzoate application
 Prepare this by diluting one part 25% benzyl benzoate application with
an equal part of water
In cases of severe or extensive infection, especially with secondary bacterial
infection:
 Give a systemic antibiotic see Section 18.1 page 157
o 5% Salicylic acid and sulphur ointment twice a day
o Consider checking HIV.
If itching is problematic:
o Give reassurance
o Itching may persist for up to 2-3 weeks
If severe:
o Chlorpheniramine 4-8 mg at night for 2-3 weeks

18.11 Tropical ulcer

 Improve nutrition and diet
Treatment
 Clean ulcer with Hydrogen peroxide solution (20 vol)
Alternatively:
 Cetrimide 15% +Chlorhexidine solution 1.5% diluted 1 in 20 or Potassium
permanganate soaks 1ml in 10,000mls of water
 Debride the wound if necrotic
 Daily Potassium permanganate soaks or cleaning
 Dress the wound with Zinc paste with sulphur regularly till healed
 Rest with leg elevated
 Do a skin graft if wound is clean and shows granulation
If local infection presents:
 Phenoxymethylpenicillin 500mg every 6 hours for 7 days or
 Erythromycin 250mg every 6 hours for 7 days
o Children 12.5 mg/kg body weight in 4 divided doses
 If possible, carry out culture and sensitivity testing to determine suitable
antibiotic therapy
 Refer the patient to the hospital

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18.12 Onchocerciasis
Refer to Section 15.2 page 127

18.13 Buruli Ulcer

 This is an ulcerative skin condition caused by Mycobacterium ulcerans
Treatment
 Depends on stage of condition, but if ulcerated
o Daily wound dressing with saline
o Medicine therapy is disappointing
o Surgery

18.14 Leprosy

Refer to Section 9.2 page 68

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19. Vaccinations

19.0 Vaccinations
● For tetanus toxoid vaccination (TTV) see Section 12.3 page 100
Table 27: Vaccination schedule for children

At birth: BCG 0.05 ml intradermally

 Children > 1 year 0.1 ml
Polio 0: 2 drops orally (= “zero dose”)
6 weeks: PENTAVALENT 1: 0.5 ml IM
Polio 1: 2 drops orally
10 weeks: PENTAVALENT 2 : 0.5 ml IM
Polio 2 : 2 drops orally
14 weeks: PENTAVALENT 3 : 0.5 ml IM
Polio 3 : 2 drops orally
6 months: Oral Vitamin A
9 months: MEASLES: 0.5 ml deep S/C
12 months: Oral Vitamin A

PENTAVALENT = DPT, Hepatitis B and Heamophilus influenza type B

Notes:
a) Aim to complete this schedule within the first year of life
b) BCG vaccination: give this as early as possible in life, preferably at birth –
complications are uncommon. BCG is contraindicated in symptomatic HIV
infection
c) Measles vaccination: normally give this when a full 9 months of age is
reached.
d) Can give an extra dose which is recommended for groups at high risk of
measles death, such as children in refugee camps, HIV- positive infants and
during outbreaks of measles
e) Pentavalent/polio : the minimum interval between doses is 4 weeks
f) Tetanus toxoid vaccination: give a full course of this:
o To all women see Section 12.3 page 100
o After administration of anti-tetanus serum (ATS) to any previously
unimmunised patient
o If over 10 years has elapsed since the last booster dose

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20. Bites, burns and wounds

20.0 Bites, Burns and Wounds

20.1 Animal Bites

 Avoid suturing any kind of bite wound
 Thorough cleansing and debridement of the wound is essential
 The combination of local wound treatment, passive immunization with
rabies immunoglobulin (RIG), and vaccination with anti-rabies vaccine is
recommended for all severe exposures to rabies (see Table 28 page 169)
 Since prolonged rabies incubation periods are possible, persons who
present for evaluation and treatment even months after having been bitten
should be treated in the same way as if the contact occurred recently

Thorough prompt local treatment of all bite wounds and scratches which may be
contaminated with rabies virus is very important as elimination of the rabies virus at the
site of infection by chemical and physical means is the most effective method of
protection

 As part of local treatment in all cases of possible exposure, carefully instill

rabies immunoglobulin RIG, if available, in the depth of the wound and
infiltrate around the wound. See Table 28 page 169 for dose information
 Avoid contact with the patient’s saliva which is potentially infective. If
possible, wear eye protection as patients may spit and infection through
the conjunctiva can occur
Treatment
Adults and Children:
 Give Tetanus Toxoid Vaccination (TTV) see Section 12.3 page 100
 Flush and cleanse (scrub) the wound with cetrimide 15% + chlorhexidine
solution 1.5% diluted 1 in 20 with water
Alternatively:
 Wash with Hydrogen peroxide solution (10 vol ) or soap or detergent
 Rinse with normal saline and dress with a weak iodine solution or iodine
cream
 Give Anti-Rabies Vaccine, only if necessary according to the
recommendations in Table 28 page 169.
 Give Co-amoxiclav 625mg every 8 hours plus
 Metronidazole 400mg every 8 hours
 If possible, capture and observe the animal for 10 days. If the animal is still
alive after this time period, it does not have rabies

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20. Bites, burns and wounds

 Human bites should be managed as animal bites except for the use of anti
rabies vaccine.

20.1.1 Post- exposure immunization

 Give anti-rabies vaccines to all patients unvaccinated against rabies,
together with local wound treatment, and in severe cases, rabies
immunoglobulin (see Table 28 page 169)

20.1.2 Administration of anti-rabies vaccine

 Use intra-dermal injection regimes for Anti RabiesVaccine whenever
possible
 Give a 0.1 ml dose of Anti Rabies vaccine intradermally in either the
forearm or upper arm, on days 0, 3 and 7
 Then give 0.1 ml of Anti Rabies vaccine at one site on days 30 and 90
Alternative intramuscular regime:
 Give one 1 ml dose of Anti Rabies vaccine i/m on days 0, 3, 7, 14 and 30

Suitable injection sites

 In adults: always inject the anti-rabies vaccine into the deltoid area of the
arm
 In young children: the anterolateral area of the thigh may also be used.
Never use the gluteal area for vaccination as it is then much less effective.
Table 28: Recommendations for Anti-Rabies Vaccination
NATURE OF CONDITION OF ANIMAL RECOMMENDED ACTION
EXPOSURE At time of 10 days
exposure later
1. Saliva in contact Healthy Healthy Do not vaccinate
with skin, but no Rabid Do not vaccinate
skin lesion Suspect Healthy Do not vaccinate
Rabid Do not vaccinate
2. Saliva in contact Healthy Healthy Do not vaccinate
with skin that has Rabid Vaccinate
lesions, minor bites Suspect Healthy Vaccinate, but stop course if
on trunk or animal healthy after 10 days
proximal limbs Rabid Vaccinate
unknown Vaccinate
3. Saliva in contact Domestic or wild Vaccinate, and give
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with mucosae, rabid animal or antirabies serum

serious bites (face, suspect
head, fingers, or Healthy domestic animal
multiple bites) Vaccinate, but stop course if animal healthy after 10 days

20.1.3 Post-exposure immunization in previously vaccinated patients

 In persons known to have previously received full pre-or post-exposure
treatment with rabies vaccine within the last 3 years:
 Give one booster dose of 0.1 ml Anti Rabies Vaccine intradermally on days
0 and 3
Alternative intramuscular regime:
 Give one booster dose of 1 ml Anti Rabies Vaccine i/m as above
 If completely vaccinated more than 3 years before or if incompletely
vaccinated, give a complete post-exposure vaccination course
20.2 Burns
 Remember the ABCs of life support
 Assess the severity of the burn (see table below)
 Refer patients with burns of more than 15% (children: > 10%) of body
surface area (BSA) to hospital on iv fluid therapy for resuscitation and burns
dressing
 Refer all deep burns or burns of the face, neck or hands and perineum for
further assessment
 Burns across joints should be immobilized and later encourage passive
movement to prevent from contractures
 If the burn is more than 40%, mortality is almost 100% therefore referral to
a tertiary hospital may not be necessary
 Circumferential burns of the limbs and trunk require immediate bed side
escharotomy (see diagram of the site of incisions)

 Burns by nature are usually initially sterile. The aim of treatment is to

speed healing while minimizing the risk of infection
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 In the sick burned patient (fever+diarrhoea+/- a rash):

 Have a high index of suspicion of toxic shock syndrome
 Naso gastric tube insertion is helpful as gastric dilatation is common
 Give anti-acids to prevent gastric stress ulcers (see Section 7.6 page 52)
 Do a blood culture and malarial parasites
 Start intravenous flucloxacillin

20.2.1 Calculation of Body Surface Area Affected check with group that did this
to get a better picture

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Adults and Children:

 Give i/v fluid replacement according to the calculation below
 With mild burns (< 15% adults BSA burned or < 10% children) give oral fluid
replacement therapy using as much ORS as the patient will tolerate
Adults: With 15% or more and children with 10% or more require i/v fluid
resuscitation.
 Calculate according to Parkland formula:-
Adults: 4mls per /kg body wt/ TBSA
Children: 3mls per kg body wt/TBSA + maintenance
 Maintenance for children

20.2.2 Calculation of i/v fluid replacement

 The object is to maintain normal physiology as reflected by urine, vital signs
and mental status
 Use Ringer’s lactate i/v infusion or (if this is not available) normal saline,
adding to each 1L 100 ml of dextrose 50% ml/kg x % BSA burned of solution
for plasma expansion (eg. Haemaccel ®
 A general formula and dosage schedule that may be used for the first 24
hours is:
Total volume of i/v infusion required (before above additions) = 4
ml/kg x % BSA burned plus normal daily requirement
 Give 50% of this total in the first 8 hours calculated from the time of burn
 Give 50% in the next 16 hours
 Give analgesic treatment (Section 24.1 page 196)
 Strong analgesia (e.g. Morphine or Pethidine) will be required for the first
48 hours
 Under aseptic conditions, gently cleanse the lesion with cetrimide 15% +
chlorhexidine 1.5% diluted 1 part in 20 parts water
Alternative: Cleanse with hydrogen peroxide solution (10 vol) or soap and
water
 Never use alcohol-based solutions
 Repeat the cleansing each day debriding the lesion and removing necrotic
tissue as necessary
 Give tetanus toxoid vaccination (see Section 12.3 page 100)
If patient is developing signs of tetanus
 Give tetanus antitoxin (ATS) 1,500 units s/c or i/m

Once the lesion is clean/clear of necrotic tissue:

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 Refer for skin grafting, if necessary, otherwise

 Dress the burn with paraffin gauze dressing
 Cover this with dry gauze dressing thick enough to prevent seepage
through to the outer layers
 Change the dressing after 2-3 days, and then as necessary

If the burn becomes infected:

 Apply silver sulphadiazine cream 1% twice daily
 Before application, completely remove any old topical medication
 Cover with sterile gauze

If the patient becomes ill after burn infection:

 Carry out culture and sensitivity testing on the exudates
 Treat with systemic antibiotic(s) according to findings

20.3 Open wound

Management
 Clean and suture fresh wound (ie. > 6 hours old)
 Any skin damage overlying a fracture makes it an open fracture

Note: It is important to ascertain the cause of the wound. Do not suture

penetrating wound.
Refer to the hospital.
 Clean fresh wounds with Cetrimide 15% + Chlorhexidine solution 1.5%
diluted 1 in 20 parts water
Alternatively
 Hydrogen peroxide solution (10 vol)
 For local infiltration or as a peripheral nerve block use Lignocaine
hydrochloride injection 1% maximum dose: adults 25ml; children 0.4 ml/kg

Alternatively
 Lignocaine 1% + adrenaline 1:200,000 injection Maximum dose: adults 40
ml, children 0.7 ml/kg

Note: Do not use anaesthetics containing adrenaline for anaethesia in digits

or appendages due to risk of ischaemic necrosis

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 Always remember to give Tetanus Toxoid Vaccination (Section 12.3 page

100)
 If patient has signs of tetanus give Tetanus Antitoxin Serum (ATS) 1,500 IU
s/c or i/m
 If wound is grossly contaminated give Tetanus Antitoxin Serum 3,000 IU
s/c or i/m

20.4 Insect stings and bites

20.4.1 Envenomation by insects

 Bees, wasps: Usually benign, but may provoke either laryngeal oedema or
anaphylactic shock (see Section 5.1.1 page 29)
 Spiders, scorpions: The majority of spiders are benign. If a truly toxic
species is thought to be responsible apply first aid and supportive measures
as for snake bite (see Section 20.5 below)

20.4.2 Snake bite

 Venom diffuses mainly via the lymphatics, not via blood vessels,
tourniquets are thus of little use
a) First Aid Treatment
 Cleanse the would with Cetrimide + Chlorhexidine solution 15% + 5%
diluted 1 in 20
Alternatively
 Hydrogen peroxide solution (10 vol)
 Apply film constant pressure to the site of the bite
 Apply a crepe bandage firmly to the entire limb
 Immobilize the patient for 12 hours observation
 Reassurance

Not all patients with snake-bite should be given Anti-venom

Administration of Snake Anti-venom

 Ensure that the anti-venom solution is clear
 Draw up 0.5 ml of adrenaline 1/1000 injection in a syringe ready for use s/c
if needed
 Give 100 ml of the polyvalent antivenom as an iv infusion, diluted in 300 ml
of normal saline
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 Children: dilute in 0.4 ml/kg of saline

 Give the infusion slowly for the first 15 minutes (most reactions occur
within this period
 Thereafter increase the rate gradually until the whole infusion is completed
within 1 hour

If there is a history of allergy:

 The patient may still need to be given anti-venom because of systemic
poisoning, but take particular care
If a reaction occurs:
 Hydrocortisone may need to be administered in addition to adrenaline
If there is no clinical improvement by the end of the infusion:
 Repeat the same dose as above

Note: Reserve Polyvalent snake antivenom (anti-snakebite serum) for

patients with one or more of these signs and symptoms, hypotension,
vomiting, neurotoxicity, haemotoxicity.

b) Supportive therapy
 Give reassurance – most snake bites are not dangerous
 Treat shock if any (see Section 5.1.1 page 29)
 Give an antihistamine:
Adults:
 Promethazine 25 mg/day or up to 8 hourly
Children > 6 months:
 1 mg/kg/day given in divided doses every 12 hours
 Give Tetanus Toxoid Vaccination (Section 12.3 page 100)
If patient is developing signs of tetanus:
 Give Tetanus Antitoxin (ATS) 1,500 IU s/c or i/m
 Benzyl penicillin 2.4 MU once daily for 5 days
o Children: 25,000 units/kg daily
 Eventually excise sloughs and graft skin early

20.5 Superficial injury, bruise, minor cut

General management
 Cleanse the wound with Cetrimide 15% + Chlorhexidine solution 1.5%
diluted 1 in 20 parts water
Alternatively
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 Hydrogen peroxide solution (10 vol)

If the patient is unimmunised or not fully immunized and the wound is grossly
contaminated:
 Tetanus Toxoid Vaccination (Section 12.3 page 100)
If the wound is dirty
 Benzylpenicillin 2.4 MU i/m stat
Children 25,000 units/kg
Then
 Phenoxymethylpenicillin 250 mg every 6 hours for 5 days
(Children 25,000 units/kg)
 If Penicillin hypersensivity:
 Erythromycin 250 mg every 6 hours for 5 days

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21.0 Renal Conditions

 Starts with upper complicated then acute lower Urinary tract conditions

21.1 Cystitis/Urethritis
Treatment
 Ensure adequate fluid intake
 For acute uncomplicated (all nonpregnant women, symptoms duration less
than 1 week, not men or catheterized patients) give Ciprofloxacin 250mg
orally every 2 hours for 3 days
Alternatively
 Nitrofurantoin 100mg every 6 hours with food for 7 days
 Consider urine microscopy, culture and sensitivity if no response or
recurrent infections to guide treatment

21.2 Complicated Urinary tract Infections

 Includes men, pregnant women, catheterized patients, patients with
abnormal urinary tracts and those with symptoms > 1 week
Treatment
 Give Ciprofloxacin 250mg orally twice a day for 5 days or
 Co-amoxiclav 375 mg 8hourly for 7 days
Alternatively
 Give Gentamycin 240mg i/m or i/v stat
 Followed by any of the above oral antibiotics
 Consider urine microscopy, culture and sensitivity if no response or
recurrent infections to guide treatment

21.3 Upper Urinary tract Infections

 Pyelonephritis:
 Significant fever, rigors, vomiting, flank pain
Treatment
 Ciprofloxacin 250mg orally twice a day for 10-14 days or
 Co-amoxiclav 375 mg 8hourly for 10-14 days
 i/v fluids if clinically indicated
Alternatively
 Gentamycin 240mg i/m or i/v stat
 Followed by any of the above oral antibiotics for 10-14 days
 Refer patients with recurrent UTI for further investigations
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21.4 Acute nephritic syndrome

 Most often occurs as a complication of a streptococcal infection
 Usually manifests itself 1-5 weeks after an episode of pharyngitis,
impetigo, or infected scabies
 Affects mainly children <3 years old, and adults, who should be referred to
a doctor
General measures:
 Monitor BP, urine output, weight
 Avoid added salt
 Treatment is usually supportive
Adults:
 Phenoxymethylpenincillin 500 mg every 6 hours for 7 days
If oedematous:
 Frusemide 40-80 mg once daily
If hypertension is present:
 Treat accordingly (Section 2.3 page 9)

21.5 Nephrotic syndrome

 Confirm the diagnosis: proteinuria, hypo-albuminaemia, edema, high
cholesterol
 Investigate a possible cause
General measures:
 Adequate protein intake
 Restrict salt intake
 Monitor fluid intake and output
 Daily weight measurements
Treatment
Adults
 Frusemide 40-80 mg as a single dose each morning
 Enalapril 10-20 mg once daily (use with caution, stop if renal function
deteriorates)
 A trial of steroids is indicated (responsiveness to steroids in adults is less
than in children). Prednisolone 50-60 mg once daily for up to two months,
tapering off is required after response.
If Schistosomiasis is diagnosed or suspected as cause:
 Praziquantel 40 mg/kg single dose

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If presentation is acute:
 Phenoxymethlyl penincillin 500 mg every 6 hours for 7 days
 Refer to Nephrologist

21.6 Renal colic

Treatment
 Intravenous fluids
 Either Morphine or Pethidine. (Section 24.9 page 199)
 Hyoscine butylbromide 20 mg deep i/m stat
 Repeat after 30minutes if necessary
 Ensure fluid intake of 3-4 litres/day after the crisis
 Intravenous Pyelography is usually indicated

21.7 Renal failure (acute)

 Patients with acute renal failure should be referred to a hospital
 Carefully check the use of any drug in renal failure and reduce drug doses
where required, see below
Symptoms and Signs include: oliguria, oedema, vomiting
 Look for clues for the cause of renal failure which include, shock, acute
glomerulonephritis, use of herbal remedies containing nephrotoxins
Management
 Assess the hydration status of the patient
 Patients who are dehydrated will need fluid resuscitation
 Patients who are fluid overloaded will need fluid restriction and/or diuretics
 Restrict salt intake
 Weigh the patient daily
 Carefully monitor fluid intake and output on a chart
 Reduce the rate of rise of urea:
o Give adequate calories
o Restrict protein in the diet
 Treat hyperkalaemia:
o Restrict potassium intake by restricting fruits, vegetables, meat and
feezy drinks
o If potassium is > 6.5mmol/l give Insulin 10 Units in 50ml of 50% dextrose
infusion over 30mins
o Give a potassium binding resin 30-60g orally
 Refer patient for dialysis if not responding to measures above
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Indications for dialysis include:

o Hyperkalaemia
o Fluid overload
o Metabolic acidosis
o Pericarditis
o Confusional state (encephalopathy)
Note:
 Treat complications of renal failure such as convulsions, hypertension
 Do an HIV and Hepatitis B test before referral for dialysis

21.7.1 Use of medicines in renal failure/impairment

Note: Take great care when prescribing any medicine and carefully check
medicine prescribing information (e.g. in BNF, MNF) regarding use in
renal failure /impairment
Usually safe medicines:
 Doxycycline
 Erythromycin
 Penicillin
 Phenytoin
 Rifampicin

Use with care in reduced doses:

 Amoxycillin
 Chloramphenicol (avoid in severe impairment)
 Cotrimoxazole
 Diazepam
 Digoxin
 Insulin
 Isoniazid-containing medicines
 Pethidine(increase dose interval, avoid in severe impairment)
 Phenobarbitone
 Propranolol
 Antiretroviral medicines

Avoid using:
 ACE inhibitors (eg. Captopri)
 Aspirin and other NSAIDS (eg. Ibuprofen, Indomethacin)

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 Codeine
 Ethambutol
 Gentamycin
 Nalidixic acid
 Nitrofurantoin
 Streptomycin

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22.0 Poisoning

22.1 General principles of treatment

 Determine details of the poisoning:
- What was the poison?
- When did the poisoning take place?
- What kind of poisoning took place? e.g. by swallowing, inhalation,
contact with the skin or eyes
- How much was taken?
 Prevent further exposure to the poison (if possible)
- Remove contaminated clothing
- Wash contaminated skin with soap and lots of cold water
Management
 Conserve body heat (if necessary)
 Maintain respiration
 Clear the airway
 Breathing-Maintain ventilation – use artificial respiration if necessary,
patient may need ventilation
 Maintain BP/treat shock
- Correct hypotension
- Elevate the legs
- Correct hypertension
- In refractory shock discuss with anesthetist
 Maintain fluid balance
 Monitor fluid intake and output

22.2 Swallowed poisons

Treatment
 Prevent gut absorption
 Empty the stomach (if appropriate)
- Only do this if within 4 hours of the poisoning and if the patient is
conscious
 Do not empty the stomach if:
- A corrosive substance was swallowed, e.g strong acid or alkali, bleach
- Paraffin or a petroleum product was swallowed
- The patient is unconscious or convulsing
- The subsistence is not known

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 Treat any complications as necessary

- E.g. hypothermia, hypoglycaemia, convulsions, electrolyte or acid/base
disturbances

22.2.1 Methods of emptying the stomach

1. Induction of vomiting
 Give Ipecacuanha emetic mixture
 Children < 18 months: 10ml.
 Children > 18 months: 15ml
 Adults: 15-30 ml.
 Repeat after 20 mins if ineffective
 Follow this with 15 ml/kg of water
Note: It is essential to prevent any vomit from entering the lungs

2. Stomach wash-out (gastric lavage)

 Should only be done by staff familiar with the procedure
 Lie the patient head down on the left side
 Pass a wide gauge soft rubber tube (Ryle’s tube) into the stomach
 Tube should be wide enough to allow large particles to pass through. e.g.
tablets
- Pour 300ml tap water down the tube
- For children > 5years: use 100-200 ml water
- For children < 5 years: use normal saline instead of water
- Aspirate with the patient in the head down position, taking special note
of the airway
- Repeat lavage until aspirated fluid is clear

22.2.2 Use of activated charcoal

 50-100g activated charcoal will prevent absorption of most medicines given
within 1 hour of ingestion
 Only effective if given within 4 hours of poisoning when most of the poison
is still in the stomach
 Only give activated charcoal after vomiting (induced or otherwise) has
ceased
 Do not use ordinary charcoal – it will have no effect
 Do not use activated charcoal in the following situations:
- If the patient is unconscious, drowsy or having fits, because of the risk of
choking
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- At the same time as, or just before giving, ipecacuanha or any oral
antidote as it may bind these and prevent them working
- For poisoning by acids, alkalis, alcohol, iron and petroleum products

22.2.2.1 Administration of activated charcoal

 Add 50 g (children: 1 g/kg) to 400 ml water in a bottle
 Mix well by shaking until all the powder is wet
 Administer by the gastric lavage tube (unless the patient agrees to drink the
charcoal slowly)
 Repeat if required after 4-6 hours

22.3 Paraffin, petrol and other petroleum products

 Includes paint thinners, organic solvents, etc
 The main danger from these is damage to lung tissue and liquid
pneumonitis following aspiration
General measures
 Take great care to prevent the substance entering the lungs
 Do not make the patient vomit
 Do not do gastric lavage except:
- Where the amount of paraffin, etc, swallowed was high (> 10 ml/kg) as
these levels may cause brain damage
- Only after endotracheal intubation under anaethesia
 Treat any pulmonary oedema and pneumonia as required
 Giving un absorbable oral liquid, e.g medicinal liquid paraffin

22.4. Iron poisoning

 A dose of 20 ml/kg of iron syrup or 2-3 iron tablets/kg may be fatal in
children. Abdominal X-ray may show the number of tablets swallowed
 In severe cases there are risks of vomiting and gut haemorrhage in the
acute stage and liver necrosis and shock after 1-2 days. Therefore observe
the patient for at least 48 hours
 Remove any tablets by inducing vomiting and/or by gastric lavage
In less serious cases:
 Desferrioxamine 5-10g orally or by nasogastric tube in 50-100 ml of sodium
bicarbonate solution 5%
In serious cases:

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 Desferrioxamine 15 mg/kg/hour by i/v infusion in dextrose 5% or normal

saline solution
o Max: 80 mg/kg in each 12 hour period
 Continue until free of symptoms for 24 hours

22.5 Salicylate (Aspirin) poisoning

 Gastric empting is delayed
 Always empty the stomach
 Give repeated doses of activated charcoal to delay absorption of any
remaining poison (See Section 22.2.2.1 page 184)
 Watch for and treat hypoglycaemia, convulsions and metabolic acidosis
 In severe cases:
 Darrow’s ½ strength in dextrose 5% infusion with added sodium
bicarbonate (30 mmol/litre) may be needed to increase renal excretion
or ringers lactate
22.6 Organophosphate or carbamate poisoning
 Very toxic chemicals found in insecticides and pesticides, eg. Some rat
poisons
 Poisoning may be by ingestion, inhalation or absorption through the skin
 Presents with anxiety, restlessness, small pupils, increased secretions and
bradycardia
Management
 Remove any contaminated clothing
 Establish and maintain airway
 Artificial respiration with oxygen may be required at any stage during the
first 24 hours after poisoning
 Empty the stomach if poison swallowed
 If there is skin contact with the poison, wash them thoroughly
 Wear rubber gloves to prevent contamination
 Do not rub the skin
 Shave hair if heavily contaminated
 Give Atropine 1.2mg i/v or i/m (children: 0.05 mg/kg)
 Then give 0.6 mg (children: 0.05 mg/kg) every 10 minutes as required to
achieve and maintain atropinisation (hot dry skin, dry mouth, widely dilated
pupils, fast pulse)
In severe organophosphate poisoning:
 Give an initial Atropine dose of 4-6mg (children: 2 mg)
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 Repeat 2 mg every 10 minutes as required to achieve and maintain full

atropinisation
 Total needed in first 24 hours is usually < 50 mg
 High dose Atropine may be required for several days
In severe organophosphate poisoning only and in cases not responding to
atropine:
 Give Pralidoxime mesylate 1-2g concurrently with Atropine
Children: 20-40 mg/kg
 Administer by slow i/v (over 15-30 minutes) as a 5% solution in water for
injections
 If i/v not possible: give i/m or s/c
 repeat once or twice at 4-6 hour intervals if needed
 If possible: monitor treatment by determination of blood-cholinesterase
concentrations

Do not give pralidoxime (or other oximes) in carbamate poisoning

22.7 Paracetamol poisoning

 Paracetamol is an ingredient of many over the counter pain cold flu
remedies
 A dose over 150 mg/kg (ie. approx 10 g in an adult) may cause severe liver
and (less frequently) kidney damage within hours of ingestion
 In the first 24 hours there may be nausea and vomiting or there may be no
sign of poisoning
 Persistence of these symptoms and associated right subcostal pain and
tenderness usually indicates hepatic necrosis
 Liver damage reaches a maximum 3-4 days after poisoning and may be fatal

Even if there are no significant early symptoms, overdose patients should be

urgently transferred to hospital

If overdose occurs within 4 hours of admission:

 Empty the stomach to remove ingested medicine
 If respiration is depressed: do not use emesis – use airway protected gastric
lavage instead
 Keep patient warm and quiet
 Observe carefully for at least 3-4 days
 Monitor fluid, electrolytes, blood glucose, liver and kidney function
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 Give supportive care and correct fluid and electrolyte balance as required

If within 24 hours of overdose with over 10g of paracetamol:

 Give the specific antidote N-acetylcystine as an i/v infusion in Glucose 5%
o Initially give 150mg/kg in 200ml over 15 minutes
o Then give 50 mg/kg in 500 ml over 4 hours
o Then give 100mg/kg in 1 over 16 hours
If a serious reaction occurs:
 Stop the infusion
 Treat the reaction (see Section 5.1.1 page 29)
 Restart the infusion

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23.0 Nutritional disorders (adults)

23.1 Definition of malnutrition

Adults:
 Severe malnutrition = BMI<16 or presence of bilateral oedema with MUAC
<21.9cm (oedema should be assessed by a clinician for medical causes) or
MUAC < 19cm (to be used only if BMI cannot be taken)
 Moderate malnutrition = BMI 16-16.9 or MUAC 19 - 21.9cm (to be used
only if BMI cannot be taken)

Pregnant and lactating women

 Severe malnutrition = MUAC <19cm
 Moderate malnutrition (where SFP is not present) = MUAC 19 - 21.9cm

Adolescents 12-18 years

 Severe malnutrition = Weight/Height <70% or presence of bilateral
oedema (oedema should be assessed by a clinician for medical causes)
 Moderate malnutrition = Weight/Height between 70-79%
Children
 Severe malnutrition - child who is < 70% of expected weight for age, or
<80% but with generalized oedema or MUAC <11 cm for a child who is >
6
/12
 Moderate malnutrition – child who is > 70% of expected weight for age, or
<80% but with mild edema of the feet or MUAC 11-11.9cm.
 Mild malnutrition - child who is failing to gain weight for 3 months or who
is below the green path (< 85% expected weight for age)

23.2 Management of Malnutrition in Adolescents and Adults

 Refer to Government of Malawi, Ministry of Health, Interim Guidelines for
the Management of Acute Malnutrition in Adolescents and Adults
 All ambulatory adults and patients should be treated as outpatients
 The ready to use therapeutic food (RUTF) should be used in combination
with a normal diet

23.2.1 Treatment of severe malnutrition

 2 pots of Ready to use therapeutic food (RUTF) (260g, 2700 kcal) per day
 6 sachets of RUTF (92g, 3000 kcal) per day

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 If patients achieves BMI of 17 or MUAC of 22cm (in adolescents

weight/height >70%) then treat as moderate malnutrition (see Section
23.2.2 below)

23.2.2 Treatment of moderate malnutrition

 1 pot of RUTF (260g, approx 1500 kcal) per day OR
 3 sachets RUTF (92g per sachet, 1500 kcal) per day OR
 9kg of Likuni Phala (containing 10% sugar) and one litre of
 Vegetable oil per month (1500 kcal per day)

23.2.3 Outpatient follow up

 Follow up patients monthly.
 Plot their weight gain.
 All patients not responding after three months should be reviewed by a
clinician.
 If not medically indicated, treatment can continue for up to six months
after initiation, or if HIV infected up to three months after commencing
ART.

23.2.4 Use of milk based formulations F75 and F100e u

 Patients requiring NG feeding cannot tolerate RUFT or are severely ill
require milk
based formulations F75 and F100 feeds.
 Milk based formulations are given in two phases.
 Patients should be weighed twice weekly.

23.2.4.1 Phase 1
 Use F75 to stabilize patient
 Treat infections and other urgent medical problems
 Provide sufficient energy and nutrients to stop further loss of muscle and
fat tissue
 Correct fluid and electrolyte imbalance
 Give at least 5-6 feeds per day.
 Night feeds may be helpful, particularly with NG tube feeding.

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How to prepare F75

 Mix one packet of F75 with 2 litres of cooled boiled water to make 2400ml
of formula.
 Give the amounts as in the Table 29 below unless patient is receiving i/v
fluids in which case amounts should be reviewed.
 Intravenous fluids are discouraged in severe malnutrition as they have little
nutritional value, and can cause fluid overload.
Table 29: Amounts of F75 given to patients in Phase 1

 Patients should not eat any other foods or fluids, during Phase 1 unless
they
have diarrhoea.
 Patients with diarrhea should be given ORS (Resomal).

23.2.4.2 Transition Phase

 Change to F100 as soon as the patients appetite returns
 Control the amount of F100 during the transition phase to avoid the risk of
heart failure.
 RUTF may be introduced at this stage in addition to F100 so patients are
familiar with it when they reach Phase 2.
 Give 1 pot (or 3 sachets) of RUTF over the 2 day transition period as a taste
dose.
 The patient is not required to finish the RUTF.
 The number of feeds, their timing and the volumes given remains exactly
the same.
F100 (100ml = 100kcal) is used in the transition phase.
 Patients should normally move to Phase 2 after 2 days on Transition phase.
 Patients with NG feeding tubes should remain on transition phase
quantities but these should be reviewed if NG feeding continues for more
than two weeks

How to prepare F100

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23. Nutritional disorders

 Mix one packet of F100 with 2 litres of cooled boiled water to make 2400ml
of formula.
 Give the amounts as in the Table 30 below to each patient unless receiving
i/v fluids in which case amounts should be reviewed.
Table 30: Amounts of F75 given to patients in Phase 1

23.2.4.3 Phase 2
 Aim of phase 2 is to achieve rapid weight gain and rebuild lost tissues and
this requires more energy, protein and micronutrients than were needed
for Phase 1.
 F100 without iron is given during this phase.
 Give the amounts as in Table 31 below to each patient
Table 31: Amounts of F100 given in Phase 2

 Give one tablet of Fefol 200mg or Ferrous sulphate 200mg per day in phase
2 if clinically indicated.
 If inpatient is well and can tolerate solid food, RUTF should be used in
Phase 2 instead of F100.
 RUFT treatment is the same as per for outpatients and should be used
alongside a normal diet.
 Give the amounts below until patients BMI reaches 17
o 2 pots of RUTF (260g, 2700 kcal) per day
o 6 sachets of RUTF (92g, 3000 kcal) per day
 Once patient achieves a BMI of 17 or MUAC 22cm (if BMI can not be taken),
or
Weight/Height>80% they should be transferred to treatment for moderate
malnutrition
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23.2.5 Discharge criteria (when to stop treatment of malnutrition)

 Adults - BMI of 18.5 and bilateral oedema has gone for 10 consecutive
days or MUAC 23cm (to be used only if BMI can not be taken)
 Pregnant and lactating women up to 6 months after delivery - MUAC 23cm
 Adolescents 12-18 years - Weight/Height >85% and bilateral oedema has
gone for 10 consecutive days

23.3 Malnutrition (protein-energy) in Children

23.3.1 Mild malnutrition

 Do a full assessment, especially looking for underlying disease such as TB,
HIV infection, etc
 Ensure weekly attendance at nutrition clinic
 Give food supplements
 Give Vitamin A 100,000 units as a single dose

23.3.2 Moderate malnutrition

 Refer to Supplementary Feeding Programme centre.
 Do a full assessment, especially looking for underlying disease such as TB,
HIV infection, etc.
 Give Vitamin A 200,000 units
o Child < 1 year: 100,000 units
o Ferrous sulphate paediatric mixture 2.5 mL
o Folic acid 5 mg daily
o Albendazole 400 mg stat

23.3.3 Severe malnutrition

 Must be admitted to hospital
 Do a full assessment, especially looking for underlying disease such TB, HIV
infection, etc
 Assess dehydration (see Section 7.5.1.4 page 46)
o Skin turgor is not a reliable sign in these children
o Look for tears, sunken eyes or fontanelle
o Assess urine output.

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 Prevent and/or correct dehydration (see Section 6.1 page 36))

 The fluid tolerance of these children is limited. ReSoMal and
especially i/v solutions may cause fluid overload and heart failure
Avoid fluid overload in severe malnutrition

o Non-dehydrated children with mild diarrhea should continue milk

feeds to prevent dehydration – they do not need ReSoMal
o whenever possible, rehydrate these children orally using ReSoMal
o to prepare this see above )
o If i/v rehydration is necessary, limit this to a few hours. Continue
feeding and rehydrate orally as soon as possible see above.
o Start an intensive feeding regime with high energy milk:
o Administration via NGT is necessary in many children with poor
appetite
o Start with 2-hourly feeds then reduce to 3-hourly
o Start with F-75 refer to severe malnutrition manual
o Move to F-100 when the child is stable refer to severe malnutrition
manual.
Frequent feeds spaced throughout the whole 24 hours
are essential to prevent hypoglycaemia

 Provide antibiotic cover for 5 days

o Cotrimoxazole 24 mg/kg every 12 hours
Alternatively if sepsis suspected or child very ill:
o Benzylpenicillin 50,000 units/kg i/m or i/v every 6 hours, and
o Gentamycin 6 mg/kg i/m or i/v once daily
 Alternatively to Gentamycin:
o Chloramphenicol 25 mg/kg i/m or i/v every 8 hours
If the child improves, then switch to oral Ciprofloxacillin for 5 days.
 Give supplements:
o Vitamin A (retinol) 200,000 units on days 1,2 and 8
o Children < 1 yr :100,000 units (½ capsule)
o Give Multivitamin syrup 5 mL daily for 1 week
o Potassium 1 mmol/kg every 6 hours for 2 weeks mixed with feeds
 To prepare a stock solution: add 7.5g of potassium chloride to 1L
of pure water. This gives 1 mmol potassium chloride/mL
 One potassium chloride slow-release (Slow K ® tablet = 13 mmol
of K+
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From day 7:
 Ferrous sulphate paediatric mixture 2.5 mL every 12 hours for 2 weeks plus
Folic acid 5mg daily for 5 days
 Albendazole 400 mg single dose, when recovering
 Children<2 give 200 mg
 Treat complications:
a) Hypothermia:
 Re-warm
 Consider the possibility of sepsis or hypoglycaemia
b) Hypoglycaemia:
 Give Dextrose 50%
 See Section 5.4 page 33 for dilution, dose,
administration
 Then give F_75 orally or via NGT as soon as possible and
recheck the blood sugar after 1 hour.

Hypothermia and hypoglycaemia are frequently signs of sepsis. Consider

sepsis treatment if present

c) Cardiac failure:
o Frusemide 1-2 mg/kg i/v or i/m
o Digoxin is contraindicated in kwashiorkor
d) Severe anemia:
o Transfuse 10 mL/kg packed cells
e) Mouth ulceration:
o If not severe use GV paint.
If severe like cancrum oris use:
o Benzylpenicillin 25,000 units/kg per dose I/m every 6 hours
and
o Metronidazole 7.5 mg/kg every 8 hours for 7 days
f) Skin ulcers:
o Soak lesion with potassium permanganate 1% solution for 10-
15 minutes then
o Apply a paraffin gauze dressing

23.4 Pellagra
 Usually multiple vitamin deficiency is present and other vitamins may
therefore be necessary
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 Nicotinamide 50 mg every 8 hours for 28 days

23.5 Vitamin A deficiency, xerophthalmia

 Vitamin A is a prophylactic vitamin A supplementation to all children 6
months-5 years old (every 6 months) nursing mothers and to risk groups at
every available opportunity

Xerophthalmia is a medical emergency

Treatment
Adults
 Vitamin A 200,000 units/ dose on days 1, 2, and 8
Children
 Vitamin A < 1:100,000 units/ dose (=½ capsule) on days 1, 2, and 8

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24. Pain management and palliative care

24.0 Pain management and Palliative care

 Palliative care is an approach that improves the quality of life of patients
and their families facing the problems associated with life threatening
illness, through the prevention and relief of pain and suffering by means of
early identification and impeccable assessment and treatment of pain and
other problems – physical, psychosocial and spiritual

24.1 Principles of analgesic use for chronic pain

 By the clock
o Regular analgesia is necessary as patients require prevention
therapy towards their persistent pain
o Medication given when required for chronic pain does not work.
 By the mouth: oral medication is the standard preferred in chronic pain.
 By the ladder
o Three step analgesic ladder with treatment moving up as pain
increases should be used when prescribing analgesics.

 By the patient: Dosage is determined on an individual basis.

24.2 Mild Pain

 Paracetamol 500mg - 1g very 4-6 hours (max 4g daily)
 NSAIDS anti – inflammatory effects are good for metastatic bone and soft
tissue pains.
 Aspirin 300-900mg every 4-6 hours,

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 Ibuprofen 1.2-2.4g daily in 3-4 divided doses (max 2.4g daily), children
>7kg 20mg/kg (max 40mg/kg/day)
Note:
a) Do not give NSAIDS to children under 16 years because of the risk
of Reye’s syndrome.
b) Aspirin causes gastric irritation and ulceration, therefore
administer with food and milk
c) Do not use aspirin or other NSAIDs (e.g. ibuprofen, indomethacin,
diclofenac) in patients with symptoms suggesting gastritis or
peptic ulcer disease, pregnancy or bleeding disorders.
d) Do not use two NSAIDS at the same time, but where pain control
with paracetamol or an NSAID alone is inadequate, a combination
of the two drugs may be effective

24. 3 Moderate Pain

 Codeine phosphate 30-60mg every 4 hours (max 240mg daily), children >
1 year 3mg/kg in divided doses every 4 hours.
 Can be combined with non-opiates and/or adjuvants, but not with
morphine.
 Tramadol 50-100 mg every 8 hours oral.
 Always prescribe codeine with a laxative (not tramadol) e.g. Bisacodyl
10mg at night, unless the patient has diarrhoea.

24.4 Severe Pain

 Use these along with non-opiods for severe pain
 Oral Morphine (1 mg/ml) solution starting dose 2.5ml 4 hourly titrating
upwards every 12 hours to achieve pain control
 In opiate naïve patients where no oral morphine solution is available start
with Morphine 10mg tablets twice daily and titrate upwards (take 24-28
hours to reach steady state level).
 May be given together with step 1 drugs (non-opioids) and/or adjuvants.
 Always prescribe a laxative e.g. Bisacodyl 10mg at night unless the patient
has diarrhea.
 Nausea and vomiting are common side effects and may require medical
management, see below.
 Morphine does not have a ceiling effect and must be titrated up to gain
effective control of pain
Note:
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Pethidine is no longer recommended for use in chronic pain due to its

short duration of action and its side effects.
24.5 Adjuvant analgesics
 Miscellaneous group of drugs which relieve pain in specific circumstances.
 Generally given in addition with analgesics from the ladder.

24.5.1 Corticosteroids
 Can be helpful in reducing tumour related oedema e.g. liver capsule pain,
nerve compression. Combination of a steroid and opioid is usually
effective.
 Dexamethasone 4 - 8mg in divided doses daily for a minimum of 10 days
or Prednisolone 30 - 50mg daily for 10 days
 Then reduce gradually to lowest effective dose, depending on prognosis.

24.5.2 Anti-depressants and Anti –convulsants

 Helpful for neuropathic pain, which may present as burning, pricking,
allodynia, paraesthesia or sharp, shooting pain.
 Amitryptiline 25mg at night. Dose can be increased slowly up to 75mgs.
 Phenytoin 100mg every twelve hours; maybe increased slowly to 100mgs
tds.
 Carbamazepine 100 - 200 mg every 8 hours.

24.5.3 Antispasmodics
 Helpful in relieving visceral distension pain and colic.
 Hyoscine butylbromide 10-20mg every 8 hours tds orally or i/m..

24.5.4 Muscle relaxants

 Helpful in painful muscle spasms (cramps) and myofascial pain.
 Diazepam 2.5mg every 8 hours may be beneficial.

24.6 Management of neuropathic pain

 Causes: HIV infection, diabetes mellitus, drug side effects i.e. (isoniazid,
stavudine, vincristine) and other chemotherapeutic agents.
 Start with simple analgesia e.g. Ibruprofen 200-400mg every 8 hours
 If the patient is taking isoniazid start Pyridoxine 50 mg every 8 hours for
the duration of treatment;

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 Iin patients on T30 and TB treatment Pyridoxine 25 mg should be started

prophylactically, at the start of TB treatment
 Add Amitryptilline 12.5mg-25mg (up to 75mg) at night if pain is not
controlled
 Add oral Morphine liquid 2.5mg four hourly if pain is not controlled and
titrate upwards until pain is controlled
 If severe peripheral neuropathy with motor deficit occurs on ARVs
(stavudine is the commonest offender) refer to the MOH ART guidelines

Note: Neuropathic pain may not respond fully to opiates in which case the
oral morphine may be continued and an alternative adjuvant e.g.
Carbamazepine 100mg every twelve hours should be tried

24.7 Nausea and Vomiting

 Identify cause and treat
 Review drug treatment and stop unnecessary drugs
 Treat pain adequately using the analgesic ladder antiemetics
 Metoclopramide 10mg every 8 hours – given 30 minutes before eating –
can speed gastric emptying
 Promethazine 25mg every 8 hours
 If ineffective use Haloperidol 0.5-1.5mg at night, or trial of steroids:
Prednisolone 30mg daily or Dexamethasone 4mg daily for 5 days

24.8 Hiccup
 Look for treatable causes such as uremia and raised intra-cranial pressure.
Treatment
 Chlorpromazine 25mg every twelve hours or when required during
attacks (although its sedative effect may distress the patient).
 Metoclopramide 10mg every 8 hours or when required.
 Haloperidol 0.5mg every twelve hours orally or 1.5mg i/m during attacks.

24.9 Management of acute pain

 Paracetamol and NSAIDs (aspirin and brufen) are effective in many cases,
 For doses and other information see Section 10.1 page 91 on chronic pain.
 Inhaled Nitrous oxide provides fast onset and short acting analgesic effect
and therefore has a special role in, for example, obstetrics and wound
dressing.
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 Ketamine is used for emergency analgesia and anaesthesia.

 Opiods are first line treatment for severe acute pain including procedures
related pain
Dose
Adults:
 Pethidine 50-100mg i/m 4 hourly; restrict use to 48-72 hours duration.
 Morphine 10mg i/m; 2.5mg i/v every 4 hours, oral morphine liquid
(1mg/ml) 2.5ml every 4 hours
Children:
 1-12 months Morphine s/c or i/m 200ug/kg,
 1-5 years Morphine s/c or i/m 2.5-5mg,
 6-12 years Morphine s/c or i/m 5-10mg 4 hourly,
Oral morphine liquid 200ug/kg every 4 hours
Note:
a) Concomitant use of laxatives and anti-emetics is recommended to
avoid constipation
b) Addiction is not a problem with opioid use in acute pain.
c) Respiratory depression may occur if opiates are given to patients
without pain or at too high a dose.
d) Key principle for safe and effective use of opioids is to titrate the
dose against the desired pain relief and minimize unwanted effects.
e) If the patient is still complaining of pain after all of the drug has been
delivered and absorbed then it is safe to give another, usually
smaller, dose.
f) If the second dose is also ineffective repeat the process or change the
route of administration to achieve faster control.
g) Delayed release formulations, e.g MST tablets should not be used in
acute pain

24.10 Local anaesthetic blocks

 Regional anaesthesia (epidural, caudal, or specific LA blocks) can provide

useful post-operative pain relief,
 It should be performed by trained staff who are aware of the risks and dose
requirements.

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Index

INDEX rheumatoid, 92
Abscess septic, 92
dental, 114 Ascaris, 131
lung, 141 Asthma, 116
peritonsilar, 135 maintenance therapy, 139
retropharyngeal, 135 mild attacks, 137
Acute respiratory infections preventive treatment, 139
children, See ARI, 132 Atopic dermatitis, 162
Adenitis Bacillary dysentery, 40
cervical, 137 Balanitis, 150
AIDS Balanopostits, 150
counseling, 55 BCG vaccination, 167
health worker safety, 56 Bee stings, 174
Alcohol dependence syndrome, 19 Bilharzia, 128
Alcoholic hallucinosis, 20 Bite
Allergic dermatitis, 162 animal, 168
Amoebiasis insect, 174
Hepatic, 40 scorpion, 174
amoebic liver abscess, 40 snake, 174
Anemia, spider, 174
severe, definition of, 1 Blood
Anaphylactic shock, 29 guidelines for appropriate use, 1
Animal bites, 168 indications for transfusion, 1
Ante-and post-natal care, 99 transfusion, 1
Antihypertensive medicine Breast abscess, 106
dosages, 10 Bronchitis
Antipyretic treatment, 91 acute, 136
Anti-rabies vaccination, 169 Bruise, 175
Anxiety neurosis, 20 Bubo, 149
ARI Burns, 170
case management policy, 132 body surface area calculation, 171
children, 132 i/v fluid replacement, 172
home care Candidiasis
children, 132 oral, 113
young infant, 133 vaginal, 100
Arthritis Carbuncles, 157
non-infective , 92 Cardiovascular diseases, 8
non-specific inflammatory, 92 Carditis, acute, 95
Index

Caries, 113 persistent, children 52

Central nervous system Diphtheria, 167
conditions, 14 Dysentery
Cervical adenitis, 137 bacillary, 40
Chickenpox, 75, 137 Dysmenorrhoea, 100
Cholera, 35 Dysuria, 145
Chorea, 81 Ear cleansing, 25
Colds, 113 Ear conditions, 24
Common cold, 113 Eclampsia, 103
Congenital syphilis, 130 Eczema, 162
Congestive heart failure, 8 Emergencies
children, 9 anaphylactic shock, 29
Conjunctivitis, 111 Empyema, 141
neonatal, 152 Endocrine disorders, 36
Consciousness Enlarged inguinal lymph
assessing level of, 31 nodes, 149
Constipation, 41 Epilepsy, 14
Contact dermatitis 162 Eye
Convulsions, 32 foreign body in, 111
Persistent – see Epilepsy, 14 superficial injury, 111
Cut, minor, 175 Fever, 91
Cystitis, 177 antipyretic treatment, 91
Dehydration paracetamol dose table, 91
assessment or, 43 Fits
oral treatment, 44 (children), see Convulsions, 32
severe, treatment of, 48 Foreign body
Delirium tremens, 18 in the eye, 111
Dental abscess, 114 inhaled, 184
Depression, 23 Fungal skin infections, 162
Dermatitis, 161 Furunculosis, 157
Diabetes Gastritis, 52
mellitus, 36 Gastro-intestinal conditions, 35
type 1 (Insulin dependent), 36 Genital
type 2 (non-Insulin- dependent) 38 herpes, 144
Diarrhoea hygiene, 150
acute, 42 swelling, 149
chronic, adults, 50 ulcer disease, 144
home treatment, 44 warts, 151

202
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Index

Genitourinary symptoms in women depressive illness, 61

see GUS, 145 diarrhoea disease, 58
Guardiasis, 50 encephalopathy
Gingivitis, 114 progressive, 62
Goiter, endemic, 39 end organ dysfunction, 56
Gout, 93 failure to thrive, 63
acute attack, 93 fever, persistent, adult, 59
pain, 93 fever, recurrent, children, 60
prevention of attacks, 93 health worker safety, 56
Grand mal, 15 immunization of children, 55
GUS in women kaposi’s syndrome, 65
follow-up care, 145 lymphadenopthy, 63
Hemorrhage mental disorders, 61
acute, 4 pain relief, 65
post-abortal , 108 persistent generalized
post-partum, 106 lymphadenopathy, 63
Heart failure primary neurological
congestive, 8 disorders, 63
hypertensive, 12 respiratory infections, 58
mild-moderate, 9 sensory neuropathy, 62
Helminthiasis, 131 syphilis, 62
Hepatic disorders, 54 CNS, 61
Hepatitis, 57 thrush, 61
Herpes treatment of clinical presentations,
genital, 144 58
simplex, 163 tuberculous meningitis, 62
zoster, 163 upper GIT candidiasis, 61
HIV infection, 55 HIV related conditions, 55
acute confusional state, 61 Hookworm, 131
acute psychosis, 61 Hypertension, 9
anxiety, 61 accelerated, 10
breast-feeding, 55 medicine dosage, 10
care and support, 55 emergency treatment, 11
cerebral toxoplasmosis, 61 in pregnancy, 101
children, 55 mild, 9
counseling, 56 moderate, 9
cryptoccoccal meningitis, 62 pregnancy-induced, 101
dementia, 62 severe, 9

203
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Index

Hypertensive administration of i/m quinine, 121

disorders in pregnancy, 101 Malnutrition, 188
encephalopathy, 11 mild, 188, 192
heart failure, 12 moderate, 188, 192
Hyperthyroidism, 38 protein-energy, 192
Hypothyroidism, 39 severe, 188, 192
Impetigo, 157 Mania, 23
Infectious diseases, 55 Mastitis, 106
Inhaled foreign body, 184 Measles vaccination, 167
Injury, superficial, 111 Meningitis, 71
Insect stings and bites, 174 bacterial, 71
Intestinal amoebiasis, 40 cryptococcal, 73
Iodine deficiency disorders, 38 meningococcal, prophylaxis, 73
Irritant contact dermatitis, 161 neonates, 72
Joint pain, 93 Moniliasis, 57, 100
Leprosy, 68, 166 Mouth sores, 117
acute dapsone allergic reaction, 71 Musculoskeletal disorders, 92
multibacilliary, 68 pain and trauma, 92
paucibacilliary, 68 Nasopharyngitis, 134
reactions, 69 Neurosyphilis, 154
severe reversal reaction, 69 Nephritic syndrome, 178
type 2 reaction, 70 Obstetric and gynaecological
Lower abdominal pain in women, 148 conditions, 98
Lumbago, 94 Onchocerciasis, 127
Lung abscess, 141 Open wound, 173
Malaria, 118 Ophthalmic gonococcal
lumefantrine-artemether dose table, neonatorum, 111
119 Ophthalmic conditions, 111
artesunate-amodiaquine dose table, Oral and maxillofacial conditions, 113
120 Osteomyelitis, 94
non-severe, 119 acute, 94
paediatric in-patients, 125 chronic, 94
older children and adult in patient, Otitis
125 externa, 24
prevention in pregnancy, 127 acute, 25
proguanil 126 chronic suppurative, 25
severe, 120 Pain
additional management, 122 acute musculoskeletal, 94

204
MSTG 2009
Index

acute pulmonary oedema, 8 use of activated charcoal, 183

contractures, 170 swallowed, 182
dysmenorrhoea, 100 Polio vaccination, 167
gout, 93 Post-abortal
mild to moderate, 196, 197 haemorrhage, 108
moderate to severe, 197 Sepsis, 87
muscle spasms, 198 Post-partum haemorrhage, 106
myocardial infarction, 29 See PPH
Paracetamol dose table, 91 primary, 107
Parasitic diseases, 118 secondary, 107
Pellagra, 194 Pregnancy-induced
Pelvic inflammatory hypertension (PIH), 101
disease (PID), 148 Prurigo, 164
Peptic ulcer, 52 Psychosis, 22
Peritonsillar abscess, 135 depressive, 22
Petit mal, 15 schizophrenia, 22
Pharyngitis toxic, 22
viral, 28 Pyomyositis
PIH, 101 tropical, 97
mild, 101 Quinsy, 135
moderate, 101 Rabies,
severe, 101 immunoglobulins, 169
Pneumocystis jirovecii passive immunization, 169
pneumonia (PCP), 58 post exposure vaccination, 169
Pneumonia,140 pre-exposure immunization,
classical 140 169
severe, 141 vaccination
Poisoning, 182 recommendations, 169
carbamates, 185 vaccine administration, 169
emptying the stomach, 183 vaccine, intra-dermal
gastric lavage, 183 regimes, 160
general principles of Respiratory conditions, 112
treatment, 182 Respiratory tract infections, 132
iron, 184 Lower, 137
organophosphates, 185 upper, 132
paracetamol, 186 retropharyngeal abscess, 135
paraffin, petrol, etc, 184 Reye’s syndrome, 163, 196
salicylates, 185 Rheumatic fever, 95

205
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Index

acute attack, 95 neonatal pustules

acute carditis, 95 viral
Chorea, 96 chicken pox, 163
prophylaxis 96 herpes simplex, 163
before dental extraction, 96 herpes zoster, 163
before other procedures, 97 prurigo, 164
prevention of further attacks, scabies, 164
96 shingles, 163
Rheumatoid arthritis, 92 tropical ulcer, 165
River blindness, 127 Sleeping sickness, 129
Roundworm, 131 Snake anti venom
Scabies, 164 administration, 174
Schistosomiasis, 128 Snake bite, 174
haematobium, 128 Spider bite, 174
mansonii, 128 Status asthmaticus, 138
Scorpion bite, 174 Status epilepticus (adults), 14
Scrotal STI
pain, acute, 149 common syndromes, 143
Seborrhoeic dermatitis, 161 syndromic management, 143
Sepsis Stings
adults, 87 bee, 146
post-abortal, 108 insect, 146
puerperal, 108 wasp, 146
Sexually transmitted diseases Strongyloidiasis, 131
see STI, 143 Superficial injury, 175
Shingles, 163 Syphilis
Shock congenital, 154
anaphylactic, 29 early, 153
Sickle cell disease, 6 late, 153
Sinusitis, 27, 133 neurosyphilis, 154
Skin conditions Taeniasis, 131
dermatitis, 161 Tapeworm, 131
eczema, 161 Tetanus
principles of treatment, 161 adult, 73
impetigo, 157 neonatal, 74
infections vaccination, 75
bacterial, 157 Tetanus toxoid vaccination, 75
fungal, 162 Thyroid disorders, 38

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Index

Tinea Typhoid, 87
corporis, 162 Ulcer
skin infection, 162 genital, 144
Toothache, 113 peptic, 52
Trachoma, 112 tropical, 165
Transfusion Urethral discharge
blood, 1 in males, 145
Trichomoniasis Urethritis, 145
Infants, 155 URTI see respiratory tract infections,
vaginal, 155 upper
Trichuriasis, 131 Vaccination
Tropical anti-rabies, 169
pyomyositis, 97 BCG, 167
splenomegaly, 126 DPT, 167
ulcer, 165 measles, 167
Trypanosomiasis, 129 pentavalent, 167
Hospital treatment, 129 polio, 167
Tuberculosis, 76 schedule for children, 167
ART, 85 tetanus toxoid, 75
complications, 83 Vaginal
drug abbreviations, 76 bleeding abnormal, 98
paediatric formulations, 77 bleeding acute, 98
drug doses candidiasis, 155
adults, 78, 79 discharge, 145
children, 78, 79 itching, 155
drug reactions, 82 trichomoniasis, 155
epilepsy, 85 Varicella, 89, 163
extra pulmonary, 84 Vitamin A deficiency, 195
medicine resistant TB, 80 Vomiting, 53
treatment, 81 Warts
meningitis, 80 genital, 151
pregnancy and reproductive health, Wasp stings, 174
85 Wheezing
prophylaxis in children, 86 recurrent, 137
renal impairment and failure, 85 Whipworm, 131
liver impairement and failure, 85 Worm infestation, 131
treatment regimens, 77 Wound
use of steroids, 86 bruise, 175

207
MSTG 2009
Index

dirty, 175
minor cut, 175
open, 175
penetrating, 175
superficial injury, 175
Xerophthalmia, 195

208
MSTG 2009
1.    Anaesthetics  
 
1.1   General anaesthetics  
 
1  Halothane       inhalation        DVA 
2  Ketamine HCI      inj, 50 mg/mL, 10 mL amp    DVA 
3  Thiopentone sodium    injection, 0.5 g vial PFR    DVA 
4  Ether, anaesthetic    inhalation        DVA 
5  Nitrous oxide       medical gas         CEB 
 
1.2   Local anaesthetics  
 
1  Lignocaine HCI     injection, 1%, 25 ml vial    HEA 
2  Lignocaine HCI     dental cartridges,      HEA 
  + adrenaline       2% + 1/80,000, 2.2 mL 
3  Lignocaine HCI     injection, heavy spinal,    DVA 
  + glucose       5% + 7.5% 
4  Lignocaine HCI     gel, 2%, 30 g tube       DEA 
5  Lignocaine HCI     injection, 2%, 20 mL vial    CVB 
6  Lignocaine HCI     spray, 10%        CEB 
 
1.3  Preoperative medication  
 
1  Atropine sulphate    injection, 600 micrograms/mL  DVA 
          1 mL amp 
2  Diazepam      inj, 5 mg/mL, 1 mL amp    DVA 
3  Morphine sulphate     inj, 15 mg/mL, 1 mL amp    DVA 
4  Pethidine HCI      inj, 50 mg.mL, 2 mL amp    DVA 
5  Diazepam      tablet, 5 mg        DEA 
6  Promethazine     tablet, 25 mg         DEA 
7  Promethazine HCI    elixir, 5 mg/5 mL      DEA  
8  Promethazine HCI    inj, 25 mg/mL, 2 mL amp    DEA 
9  Morphine sulphate     tablet, slow‐release, 10 mg    DVB 
 
2.  Analgesics, antipyretics, and related agents 
   
2.1  Non‐opioid analgesics, antipyretics 
 
1  Aspirin       tablet, 300 mg1      HVA 
2  Paracetamol      tablet, 500 mg       DVA 
3*  Diclofenac sodium    tablet, 25 mg         DEA 
4*  Ibuprofen      tablet, 200 mg       DEA 
5  Indomethacin      tablet, 25 mg        DEA 

1
Max. supply at H level = 6 tablets only 9except when used for arthritis)
 6  Mefenamic acid    capsule, 250mg      DVA 
 
2.2  Opioid analgesics and antagonists  
 
1  Morphine sulphate     inj, 15 mg/mL, 1 mL amp    DVA 
2  Pethidine HCI      inj, 50 mg.mL, 2 mL amp    DVA 
3  Codeine phosphate    tablet, 15 mg        DEA   
4*  Dihydrocodeine tartrate    tablet, 30 mg         DEA 
5  Naloxone HCI      injection, neonatal,      DEA 
          20 micrograms/mL, 2 mL amp 
6  Morphine sulphate     tablet, slow‐release, 10 mg    DVB 
7  Morphine sulphate    solution, 5mg/5ml, PFR    DVA     
8  Tramadol      capsule, 50mg       DEB 
               
3.  Antiallergics  
 
3.1  Antihistamines 
 
1  Chlorpheniramine maleate   tablet, 4 mg         HEA 
2  Chlorpheniramine maleate  injection, 10mg/ml, amp    DVA 
3  Promethazine     tablet, 25 mg         DEA 
4  Promethazine HCI    elixir, 5 mg/5 mL      DEA  
5  Promethazine HCI    inj, 25 mg/mL, 2 mL amp    DEA 
6  Cetirizine      tablet, 10mg        DEB 
 
6.2  Medicines used in nasal allergy  
 
1  Beclomethasone dipropionate nasal spray, 50micrograms/spray  DEB 
 
4.  Antidotes and other medicines used in poisonings  
 
1.  Ipecacuanha       emetic mixture, paediatric     HEA 
2.  Atropine sulphate     inj, 600 micrograms.mL    DVA 
          1 ML amp 
3*  Acetylcysteine     inj, 200 mg/mL, 10 mL amp    DVB 
4*  Activated charcoal     powder        DVB 
5*  Desferrioxamine    injection, 500 mg vial (PFR)    DVB 
6  Pralidoxime mesylate   inj, 200 mg/mL, 5 mL amp    DVB 
 
5.  Antiepiletics and anticonvulsants  
 
1  Paraldehyde      injection, 10 mL amp      HVA 
2  Phenobarbitone sodium  tablet, 30 mg2       HVA 

2
At H level, for use in epilepsy only
 3  Phenobarbitone sodium  inj, 200 mg/mL, 1 mL amp3    HVA 
4  Diazepam      inj, 5 mg/mL, 2 mL amp    DVA 
5*  Magnesium sulphate    inj, 500 mg/m, 2 mL amp     DVA 
6  Pheytoin sodium    tablet, 100 mg       DVA 
7  Phenytoin sodium    inj, 50mg/ml, amp      DVA 
8  Carbamazepine     tablet, 200 mg       DEB 
9  Sodium valproate     tablet, 200 mg       CVB 
10  Ethosuximide      capsule, 250 mg       CEB 
 
6.  Anti­infectives  
 
6.1  Anthelmintics  

6.1.1  Intestinal anthelmintics  
 
1  Albendazole       tablet, 200 mg       HEA 
2  Niclosamide       tablet, chewable, 500 mg    DEB 

6.1.2.  Antifilarials 
 
1  Ivermectin      tablet, 6 mg        DVB 

6.1.3  Antischistosomals  
 
1  Praziquantel      tablet, 600 mg       HEA 
 
6.2  Antibacterials  

6.2.1.  Penicillins and cephalosporins 
 
1  Benzathine       injection, 1.44 g vial PFR    HVA 
  Benzylpenicillin    (=2.4 MU) 
2  Benzylpenicillin    inj, 4 g vial PFR (=5 MU)    HVA 
3  Phenoxymethypenicillin  tablet, 250 mg       HVA 
4  Amoxycillin      capsule, 250 mg      DVA 
5  Amoxycillin      elixir, 125 mg/5 mL      DVA 
6  Amoxicillin + clavulanic acid  tablet, 500 + 125mg      CEA 
7  Ampicillin sodium    inj, 250 mg vial PFR      DVA 
8  Flucloxacillin      capsule, 250 mg      DVA 
9  Flucloxacillin      elixir, 125 mg/5 mL      DVA 
10  Flucloxacillin      inj, 250 mg vial PFR      DVA 
11  Cefotaxime      inj, 500 mg PFR      DVA       
12  Cephalexin      capsule, 250 mg       DVA 
13  Cloxacillin      capsule, 250mg      DEA 
3
At H level, for use in convulsions only
14  Ceftriaxone      inj, 1g PFR        DVA 
15  Procaine penicillin    injection, 4.8 MU vial      CVB 
 

6.2.2  Other antibacterials  
   
1  Chloramphenicol sodium   injection, 1 g vial PFR  HVA 
  Succinate 
2  Co‐trimoxazole    tablet, 480 mg       HVA 
  (Sulphamethoxazole +  (400 mg + 80 mg) 
  Trimethoprim) 
3  Doxycline      tablet, 100 mg       HVA 
4  Erythromycin      tablet, e/c, 250 mg base    HVA 
5  Gentamicin      injection, 40 mg       HVA 
          (as sulphate) mL, 2 mL vial   
6  Metronidazole     tablet, 200 mg       HVA 
7  Chloramphenical    capsule, 250 mg 
8  Erythromycin ethyl    susp, 125 mg/5 mL      DVA 
  succinate       (of erythromycin base) 
9  Metronidazole     inj, 5 mg/mL, 100 mL vial    DVA 
          (for i/v infusion) 
10*  Metronidazole     suspension, 200 mg/5 mL    DVA 
11  Nalidixic Acid      tablet, 500 mg       DVA 
12  Chloramphenicol    suspension, 125 mg/5 mL    DEA 
13  Gentamicin      paediatric injection, 10 mg    DEA 
          (as sulphate)/mL, 2 mL vial 
14  Nitrofurantoin     tablet, 50 mg        DEA 
15  Ciprofoxacin      tablet, 250 mg       CVB 
16*  Nitrofurantoin     suspension, 25 mg/5 mL    CVB 
17  Sodium fusidate    tablet, 250 mg       CVB 
18  Azithromycin      capsule, 250mg      CEA 

6.2.3  Antileprosy medicines 
 
1  Clofazimine      capsule, 50 mg      DVA 
2  dapsone      tablet, 100 mg       DVB   
3  Rifampicin      capsule, 150 mg      DVB 
 
6.2.4  Antituberculosis medicines 
 
1  Ethambutol HCI    tablet, 400 mg       DVA 
2  Isoniazid (INH)     tablet, 100 mg       DVA 
3  Isoniazid + ethambutol  tablet, 150 mg + 400 mg    DVA 
          (fatol ®) 
4  Pyrazinamide      tablet, 400 mg       DVA 
5  Rifampicin + isoniazid tablet, 100 mg + 50 mg      DVA 
 6  Streptomycin sulphate  injection, 5 g vial PFR      DVA 
7  Capreomycin      injection 1g, vial PFR      CVA 
8  Kanamycin      injection 1g vial PFR      CVA 
9  Amicacin      injection 1g vial PFR      CVA 
10  Ethionamide      tablet 250mg        CVA 
11  Ofloxacin      tablet, 400mg        CVA 
12  Cycloserine      tablet 250mg        CVB     
 
6.3  Antifungals (oral/parenteral/vaginal) 
 
1  Nystatin      pessary, 100,000 units4    HVA 
          (with applicator) 
2  Clotrimazole       vaginal tablets , 100mg    DEA 
3  Gentian violet      paint, aq, 0.5%, 500 mL    HEA 
4  Ketoconazole      table, 200 mg        DVA 
5*  Ketoconazole      suspension, 100 mg/5 mL    DVA 
6  Griseofulvin      tablet, 125 mg       DEA 
7  Fluconazole      capsule, 250 mg       DVA 
8  Fluconazole       i/v infusion, 2 mg/mL, 25mL    DVA 
9  Fluconazole      oral liquid, 50mg/ml      DVA 
 
6.4  Antiprotozoal medicines 

6.4.1  Antiamoebics 
 
1.  Metronidazole     tablet, 200 mg       HVA 
2*  Metronidazole     suspension, 200 mg/5 mL    DVA 
 

6.4.2 Antimalarials  
1 Artemether+ Lumefantrine   tablet, 20mg + 120mg     HVA 
2 Artesunate + Amodiaquine  tablet,          DVA 
3  Sulfadoxine + Pyrimethamine tablet, 25 mg + 500 mg     HVA 
  (SP) 
4  Quinine dyhydrochloride   inj, 300 mg/mL, 2 mL amp    HVA 
5  Proguanil HCI      tablet, 100 mg       DVA 
6  Quinine sulphate     tablet, 300 mg       DVA 
7  Chloroquine phosphate   tab, 250 mg (150 mg base)    DEB 
8*  Halofantrine      suspension, 100 mg/5 mL    CVB 
9  Mefloquine hydrochloride  tablet, 250mg        CEB 

6.4.3  Antitrypanosomals 
 
1  Melarasoprol B    inj, 3.6% solution, 6 mL amp    DVB 

4
May be used for oral thrush (pessary is sucked)
 2  Suramin sodium     injection, 1 g vial PFR      DVB 

6.4.4  Anti‐toxoplasmosis medicines 
 
1  Co‐trimoxazole    tablet, 480 mg       HVA 
 
6.5 Antiviral medicines 
 
6.5.1  Antiherpes medicines 
1  Acyclovir      tablet, 200mg        HVA 
2  Acyclovir      cream          HVA 
 
6.5.2   Antiretrovirals 
 
6.5.2.1 Nucleoside/Nucleotide reverse transcriptase inhibitors 
 
1 Didanisone (ddI)    tablet,chewable, 50mg 
2 Stavudine (d4T)    tablet, 30mg 
3 Lamivudine (3TC)    tablet, 150mg 
4 Tenofovir (TDF)    tablet, 300mg 
5 Abacavir (ABC)    tablet, 300mg 
6 Zidovudine(AZT)    tablet, 300mg 
 
6.5.2.2 Non nucleoside/Nucleotide reverse transcriptase inhibitors 
 
1  Efavirenz (EFV)    tablet, 600mg 
2  Nevirapine (NVP)    tablet, 200mg        HVA 
 
6.5.2.3 Non nucleoside/Nucleotide reverse transcriptase inhibitors 
 
1  Lopinavir + Ritonavir (LPV/r)  capsule 133.33mg + 33.3mg 
 
6.5.2.4 Fixed dose combinations 
1 Stavudine (d4T) + Lamivudine (3TC) 
+ Nevirapine (NVP)    tablet, 30mg + 150mg +200mg 
2 Zidovudine (AZT) + Lamivudine (3TC) 
+ Nevirapine (NVP)    tablet, 300mg + 150mg + 200mg 
3 Zidovudine (AZT) + Lamivudine 
(3TC)        tablet, 300mg + 150mg 
 
 
 
7.  Anti­migraine medicines 
 
1  Propranolol HCI    tablet, 40 mg         DVA 
  
8.  Antineoplastic and immunosuppressant medicines 
 
1  Actinomycin D     inj, 500 microgram vial     CVB 
          PFR (with mannitol) 
2  Busulphan      tablet, 2 mg         CVB 
3  Cyclophosphamide     injection, 200 mg vial PFR    CVB 
4  Vincristine sulphate     injection, 1 mg vial PFR    CVB 
5  Chlorambucil      tablet, 2 mg        CEB 
6  Cyclophosphamide    tablet, 50 mg        CEB 
7  Melphalan      tablet, 2 mg        CEB 
8  Methotrexate      tablet, 2.5 mg        CEB 
9  Methotrexate      inj, 2.5. mg/mL, 1 mL amp    CEB 
 
9  Antiparkinsonism medicines  
 
1  Benzhexol HCI     tablet, 5 mg        DEA 
2  Bromocriptine     tablet, 2.5. mg       CEB 
3  Levodopa + carbidopa   tablet, 250 mg + 25 mg     CEB 
 
10  Medicines affecting the blood  
 
10.1  Antianaemics   
   
1  Ferrous sulphate +    tablet, 200 mg + 0.5 mg    HVA 
  Folic acid  
2  Ferrous sulphate     mixt, paediatric, 60 mg/5 mL    HEA 
3  Folic acid       tablet, 5 mg         HEA 
4  Iron sorbitol      injection, 5% (50 mg/mL)    DVB 
          2 mL amp 
5  Hydroxocobalamin    inj, 1 mg/mL, 1 mL amp    CVB 
 
10.2  Medicines affecting coagulation 
 
1  Phytomenadione     injection, 1 mg/0.5 mL amp    DVA 
2  Phytomenadione     inj, 10mg/mL 1mL amp    CEA 
3  Warfarin sodium    tablet, 1 mg         CVB 
4  Heparin sodium    inj, 5,000, IU/mL, 5 mL vial     CEB 
5  Protamine sulphate     inj, 10 mg/mL, 5 mL amp    CEB 
 
 
 
10.2  Medicines to treat hyperkalaemia 
1  Potassium binding resin  powder        DVA 
  (sodium polystyrene sulfonate 
   Kayexalate®)   
 
 
11.  Blood products and plasma substitutes  
 
1  Gelatin (as polygeline)  i/v infusion, 500 mL pack    DVA 
          (Haemaccel ®) 
 
12  Cardiovascular medicines 
 
12.1  Antianginal drugs  
 
1  Prapranolol HCI    tablet, 40 mg        DVA 
2  Glceryl trinitrate     tablet, 500 micrograms     DEB 
3*  Isosorbide dinitrate     tablet, 10 mg        DEB 
4  Nifedipine       capsule, 10 mg      CVB 
5  Nifedipine       tablet, slow‐release, 20 mg    CEB 
 
12.2  Antidysrhythmic medicines 
 
1  Propranolol HCI    tablet, 40 mg         DVA 
2  Lignocaine HCI     inj, 1%, 25 mL vial       CEB 
 
12.3  Antihypertensives 
 
1  Hydralazine HCI    injection, 20 mg amp PFR    DVA 
2  Prapranolol HCI    tablet, 40 mg        DVA 
3  Reserpine       tablet, 250 micrograms     DVA 
4  Hydralazine HCI    tablet, 25 mg        DEA 
5  Methyldopa       tablet, 250 mg       DEA 
6  Reserpine       inj, 1 mg/mL, 1 mL amp    DEA 
7  Captopril      tablet, 12.5 mg       CVB 
8  Nifedipine       capsule, 10 mg      CVB 
9  Nifedipine       tablet, slow‐release, 20 mg    CEB 
10  Prazosin      tablet, 1 mg        CEB 
11  Enalapril      tablet, 2.5 mg        DVA 
12  Amlodipine      tablet, 5mg        DEA 
13  Atenolol      tablet, 50mg or 100mg    DVA 
 
12.4  Antihypotensive medicines 
 
1  Ephedrine sulphate     inj, 30 mg/mL, 1mL amp    DVA 
2  Dopamine HCI     inj, 40 mg/mL, 5 mL amp    CVB 
3  Methoxamine HCI    inj, 20 mg/mL, 1 mL amp    CEB 
 
12.5  Cardiac glycosides  
 
1  Digoxin       tablet, 250 micrograms     DVA 
2  Digoxin      inj, 250 micrograms/mL    DVA 
          2 mL amp   
3  Digoxin       tab, paed, 62.5 micrograms     DVA 
4  Digoxin       elixir, 50 micrograms/mL    DVA 
 
13  Dermatological medicines  
 
13.1  Antifungals (topical) 
 
1  Benzoic acid +     ointment, 6% + 3%, 500 g    HEA 
  Salicylic acid  
2*  Clotrimazole       cream, 1%, 20g      DEA 
  (or equivalent alternative) 
3  Sodium thiosulphate     lotion, aq., 10%, 500 mL    DEA 
 
13.2  Anti‐infectives and cleansing agents  
 
1  Calamine lotion +     lotion, aqueous, 500 mL     HEA 
  Sulphur 2% 
2  Gentian violet      paint, aq., 0.5%, 500 ml    HEA 
3  Potassium permanganate   3%, 500 mL        HEA 
  Solution      (for dilution)        HEA 
4  Salicylic acid +      ointment, 5% + 5%, 500g    HEA 
  Sulphur      (in YSP base) 
5  Iodine        solution, weak, 500 mL    DEA 
6  Zinc ointment +    ointment, 500 g      DEA 
  Sulphur 5% 
7  Zinc paste compound +  paste, 500 g        DEA 
  Sulphur 5%       
8  Hydrogen peroxide     solution, 20 volume, 500 mL    DEB 
9  Salicylic acid +     ointment, 5% + 5%, 500 g    CEB 
  Sulphur       (In EO base) 
10  Silver sulphadiazine     cream, 1%, 500 g      CEB 
11  Brilliant green     paint, 0.1%, 500 mL      CEB 
 
13.3  Anti‐inflammatories and antipruritics  
 
1  Calamine lotion +     lotion, aqueous, 500 mL     HEA 
  Sulphur 2% 
2  Hydrocortisone     ointment, 1%, 15 g      DEA 
3  Betamethasone    ointment, 0.15, 15 g      CEB 
  (as valerate) 
 4  Calamine       lotion, aqueous, 500 mL    CEB 
 
13.4  Keratoplastics and keratolytics  
 
1  Podophyllum resin    paint, alcoholic, 15%, 20 mL    DEA 
          (compound benzoin tincture) 
2*  Benzoyl peroxide     gel, 5%, 30 g         DEA 
3  Salicylic acid       lotion, 5%, 500 mL      DEA 
          (in alcohol 70%) 
4  Salicylic acid      ointment, 5%, 500 g       DEA 
          (in YSP base) 
5  Salicylic acid 2% +    shampoo, 500 mL       DEA 
  Coal tar solution 15% +  (in soap spirit base) 
  Sulphur 2% 
6*  Salicylic acid      collodion, 12%       DEA 
7  Coal tar       crude coal tar, 500 g       CEB 
8  Dithranol 0.5% in zinc +  paste, 500g        CEB 
  Salicylic acid paste     
9  Salicylic acid      ointment, 500 g       CEB 
  (crude coal tar 5%    (in YSP base) 
10  Zinc paste compound +  paste, 500 g        CEB 
  Crude coal tar 5% 
 
13.5  Scabicides and pediculocides  
 
1  Benzyl benzoate     application, 25%, 500 mL  HEA 
2  Lindane      cream/lotion 1%    CEB 
 
 
13.6  Other topical preparations 
 
1.  Emulsifying ointment    ointment, 500 g    HEA 
2*  Ethyl Chloride      spray        HEA 
3  Zinc oxide (in EO base0  ointment, 15%, 500 g    HEA 
4*  Silver nitrate       stick (pencil) toughened  DEA 
5  Yellow soft paraffin    ointment      DEA 
 
14.  Diagnostic agents    
 
14.1  Ophthalmic diagnostic agents  
 
1  Fluorescein sodium    eye drops, 1% (Minims)  DEA 
 
14.2  Radiocontrast media  
 
1  Barium sulphate     oral powder for suspension,  DEA 
          98%, 340 g pack 
2  Barium sulphate     oesophageal cream, 70%,  DEA 
          800 g tube 
3  Barium sulphate    enema       DEA 
4  Sodium diatrizoate +    injection, 10% + 66%    DEB   
  Meglumine diatrizoate   20 mL amp 
5  Barrium sulphate     disponsable enema, 93%,   CEB 
400 g pack   
6  Effervescent agent (carbex)  granules, 25 g sachet    CEB 
7  Effervescent agent (carbex)  solutions      CEB 
8  Lopanoic acid      tablet, 500 mg     CEB 
9  lopamidol       injection, 6.12 g/10 mL amp  CEB 
10  Meglumine iothalamate   injection, 60%, 50 mL bottle  CEB   
11  Meglumine ioglycamate  i/v infusion, 17%, 100mL vial   CEB 
12  Propyliodone       susp, aq, 50%, 20 mL vial  CEB 
13  Sodium diatrizoate +    solution, aq. Hypertonic,  CEB 
  Meglumine diatrizoate  oral/rectal, 10% +66%, 100 mL 
14  Sodium iothalamate     injection, 70%, 20 mL amp  CEB 
15  Magnevist 
   (gadopentetate dimeglumine) 
16 Gadolinium 
17 Mei optonix screen cleaner 
18 Ultravist370/300 mg/ml 
19 Xenetix 300 
20      X‐prep (bowel Evacuant) 

 
 
14.3  Test substances  
 
1  Albustix ®      reagent strip, 50 strips   HVA 
  (for protein in urine) 
2  Clinistix ®      reagent strip, 50 strips   HVA 
  (for glucose in urine) 
3  Ketostix ®      reagent strip, 50 strips   HVA 
  (for ketones in urine) 
4  Blood group test serum  dropper bottle 5 mL    DVA 
  (Anti‐A) 
5   Blood group test serum  dropper bottle 5 mL    DVA 
  (Anti‐B) 
6   Blood group test serum  dropper bottle 5 mL    DVA 
  (Anti‐AB) 
7   Blood group test serum  dropper bottle 5 mL    DVA 
  (Anti‐D) (Rho) 
 8  Glucostx ®      reagent strip, 50 strips   HVA 
  (for blood glucose) 
9  VDRL carbon antigen    test reagent, 50 mL bottle   DEA 
  (VD 24, 25) 
10  Pregnacy test      latex slide test kit    DEA 
11  Bovine albumin    soln, dropper bottle, 5 mL  CVB 
 
15  Disinfectants  
 
1  Cetrimide + chlorhexidine   solution, 15% + 1.5%    HVA 
          (For dilution) 
2  Black disinfectant    solution 9for dilution)   HVA 
3  Glutaraldehyde    solution, buffered, 2%   DEA 
 
16.  Diuretics  
 
1  Hydrochlorothiazide     tablet, 25 mg       DVA 
  Or Bendrofluazide     tablet, 5 mg  
2  Frusemide       tablet, 40 mg       DVA 
3  Frusemide      inj, 10 mg/mL, 2 mL amp  DVA 
4  Mannitol       inj, 20%, 250 mL bottle  DEA 
5  Spironolactone    tablet, 25 mg      DEA 
 
17.  Gastrointestinal medicines 
 
17.1  Antacids and other antiulcers medicines  
 
1  Magnesium trisilicate co  tablet, chewable     HEA 
2  Cimetidine       tablet, 400 mg     CVB 
3  Ranitidine      tablet, 150 mg     CEB 
4  Bismuth chelate     liquid, 120 mg/5 mL, 560 mL  CEB 
  (tripotassium dictratobismuthate) 
5  Omeprazole      tablet, 10mg      DVA     
 
17.2  Antiemetics  
 
1  Metoclopramide HCI    inj, 5 mg/mL, 2 mL amp  DEA 
2  Promethazine HCI    tablet, 25 mg      DEA 
3  Promethazine HCI    elixir, 5 mg/5 mL    DEA 
4  Promethazine HCI    inj, 25 mg/mL, 2 mL amp  DEA 
 
 
17.3  Antihaemorrhoidals 
 
1  Bismuth subgallate co.  suppository      DEA 
  
17.4  Antispasmodics 
 
1  Atropine sulphate     inj, 600 micrograms/mL  DVA 
          1 mL amp 
2  Hyoscine butylbromide  inj, 20 mg/mL, 1mL amp  DEA 
3  Propantheline bromide   tablet, 15 mg       DEA 
 
17.5  Cathartics 
 
1  Bisacodyl      tablet, 5 mg      DEA 
2  Glycerol      suppository (child) 2 g DEA 
3  Magnesium sulphate    enema, 50%, 130 mL    DEB 
 
17.6  Medicines used in diarrhoea 
 

17.6.1  Oral rehydration preparations 
 
1  Oral rehydration salts   low osmolarity powder in sachet  
          for 1 litre      HVA 
  (ORS)        (WHO citrate formula) 
2  ReSoMal      powder for 1 litre    DVA 

17.6.2  Medicines for diarrhoea in children 
1  Zinc         tablets, 20mg      HVA 
 
 

17.6.2  Antimotility drugs  
 
1  Codeine phosphate     tablet, 15 mg       DEA 
2*  Loperamide HCI    tablet, 2 mg       DEA 
 
 
18.   Hormones and other endocrine medicines 
 
18.1  Adrenal hormones and synthetic substitutes 
 
1  Hydrocortisone    inj, i/v, 50 mg/mL, 2 mL amp  DVA 
          (as sodium succinate) 
2  Prednisolone      tablet, 5 mg      DVA 
3  Dexamethasone     inj, 5 mg/mL, 5mL vial DVA 
          (as sodium phosphate) 
4  Dexamethasone    tablet, 500 micrograms  DEA 
 5  Hydrocortisone acetate  tablet, 20 mg      CVB 
6  Hydrocortisone acetate  injection, aqueous susp,  CVB 
  (i/m or intra‐articular)   25 mg/mL, 5 mL vial 
7  Fludrocortisone acetate  tablet, 100 mircograms   CVB 
8  Bromocriptine     tablet, 2.5 mg      CEB 
 
18.2  Oestrogens  
 
1  Oestrogens, conjugated  tablet, 625 micrograms   CEB 
 
18.3  Insulins and other antidiabetic medicines 
 
1  Glibenclamide     tablet, 5 mg      DVA 
2  Insulin, soluble     injection, 100 units/mL  DVA 
  (Human Actrapid ®)    10 mL vial 
3  Insulin zinc suspension  injection, 100 units/mL  DVA 
  (Human Monotard ®)    10 mL vial 
4  Metformin HCI    tablet, 500 mg     DVA 
 
18.4  Contraceptives  
 

18.4.1.  Hormonal contraceptives 
 
1  Norgestrel + ethinyl estradiol tablet, 0.3mg + 0.03mg  HVA 
  Combined, low‐oestrogen 
2  Medroxyprogesterone   inj, aqueous suspension,  HVA   
  acetate      150 mg/mL, 10 mL vial 
3  Norgestrel      tablet, 0.75mg     HVA 
  Progestogen – only 
4  Levonorgestrel     surgical implant, 75mg  DVA     
5  Levonorgestrel    tablets, 750 micreograms  DEB 

18.4.2  Intra‐uterine devices (IUD) 
 
1  Copper containing IUD  wire, 176mg      DVB 

18.4.3  Barrier contraceptives  
 
1  Condom with spermicide   (nonoxinol)      HVA 
 
18.5  Ovulation inducers  
 
1  Clomiphene citrate     tablet, 50 mg       CEB 
 
18.6  Progestogens  
 
1  Norethisterone    tablet, 5 mg       DEA 
 
18.7  Thyroid hormones and antithyroid agents  
 
1  Iodine        aqueous soln, oral, 30 mL  DEA 
          (ligol’s iodine)  
2  Carbimazole       tablet, 5 mg       CVA 
3  Thyroxine sodium    tablet, 100 micrograms  CVA 
 
19.  Immunologicals  
 
19.1  Immunological diagnostic agents 
 
1  Tuberculin purified    injection solution    DVA 
  Protein derivative (PPD)  1 mL amp/vial 
 
19.2  Sera and immunoglobulins  
 
1  Anti D (RHo)      inj, 250 micrograms/mL,  DVA 
  Immunoglobulin (Human)   1 mL amp 
2  Antirabies serum    injection, 1,000 IU/5 mL vial  DVA 
3  Diphtheria antitoxin    injection, 20,000 IU/vial  DVA 
4  Tetanus antitoxin    injection, 20,000 IU/vial  DVA 
5  Tetanus antitoxin    injection, 1,500 IU/vial  DVA 
6  Gas‐gangrene antitoxin  injection, 25,000 IU/vial  DEB 
  Mixed  
 
19.3  Vaccines  
 
19.3.1  Vaccines for universal immunisation 
 
1  BCG vaccine       injection, 20 dose vial PFR  HVA 
2  Diphtheria‐pertissis‐    inj, 20‐dose (10 mL) vial  HVA   
tetanus (DPT) vaccine   (triple vaccine) 
(adsorbed) 
3  Measles vaccine, live    inj, 10‐dose (5mL) vial HVA 
          PFR 
4  Poliomyelitis vaccine    oral suspension, 20‐dose  HVA 
  live        dispenser 
5  Tetanus vaccine     injection, 10 mL vial    HVA 
6  Pentavalent vaccine    injection, 2 dose vial    HVA 
  (diphtheria, tetanus, pertussis 
  Hepatitis B, heamophilus  
Influenza) 
 
19.3.2  Vaccines for specific individuals  
 
1  Rabies vaccine     inj, 1‐dose (0.5 mL) vial  DVA 
          (PFR + diluent amp) 
2  Yellow fever vaccine    inj, 10‐dose (5 mL) vial   CEB 
          (PFR + diluent amp) 
 
20  Muscle relaxants (peripherally acting) and cholinesterase inhibitors 
 
1  Suxamethonum chloride  inj, 50 mg/mL, 2 mL amp  DVA 
2  Edrophonium chloride  inj, 10 mg/mL, 1 mL amp  CVB 
3  Alcuronium chloride     inj, 5 mg/mL, 2mL amp  CEB 
4  Neostigmine      inj, 2.5 mg/mL, 1 mL    CEB 
  methylsulphate 
5  Vecuronium bromide    injection, 10 mg vial PFR  CEB 
 
21.  Ophthalmological preparations  
 
2.1.  Anti‐infectives 
 
1  Tetracycline HCI    eye oint, 1%, 3.5 g tube  HVA 
2  Chloramphenicol    eye oint, 1%, 3.5 g tube  DVA 
3  Gentamicin      eye drops, 0.3%, 5 mL DVA 
  (as sulphate) 
4  Chloramphenicol    eye drops, 0.5%, 5 mL CEB 
5  Idoxuridine      eye drops, 0.1%, 5 mL CEB 
6  Miconazole       eye drops, 1%, 10 mL    CEB 
 
21.2  Anti‐inflammatories 
 
1  Dexamethasone    eye drops, 0.1%, 5 mL CVA 
2  Methylprednisolone acetate  inj, 40 mg/mL, 2 mL vial  CEB 
Acetate       (for sub‐conjunctival)  
 
21.3  Local anaesthetics  
 
1  Amethocaine HCI    eye drops, 1%, 10 mL    DEA 
 
21.4  Miotics and antiglaucoma drugs  
 
1  Acetazolamide     tablet, 250 mg     DVA 
2  Pilocarpine HCI    eye drops, 1%, 10 mL    CVA 
3  Timolol maleate    eye drops, 0.25%    CVA 
          5 mL metered dose unit 
4  Acetazolamide     injection, 500 mg vial PFR  CEB 
5  Glycerol      oral solution, 50%    CEB 
 
21.5  Mydriatics and cycloplegis 
 
1  Atropine sulphate     eye oint, 1%, 3.5 g tube  DVA 
2  Cyclopentolate HCI    eye drops, 0.5%, 5 mL   DEA 
3  Tropicamide       eye drops, 0.5%, 5 mL   CEB 
 
21.6  Diagnostic agents 
 
1  Fluorescein sodium    eye drops, 1%, 5ml    DEA 
 
 
22 Obstetric medicines  
 
22.1  Oxytocics  
 
1*   Ergometrine maleate +  inj, 500 micrograms +   HVA 
  Oxytocin (syntometrine ®) 
2  Oxytocin      inj, 10 IU/mL, 1 mL amp  DVA 
3  Dinoprostone      vag, gel, 200 micrograms/mL CVB 
          2.5. mL (500 micrograms) 
4  Dinoprostone      vaginal tablet, 3 mg     CEB 
 
22.2  Myometrial relaxants  
 
1  Salbutamol sulphate     tablet, 4 mg       HVA 
2  Salbutamol sulphate     inj, 1 mg/mL, 5 mL amp  DVA 
 
 
 
22.3  Medicines used in severe PIH and eclampsia  
 
1*  Magnesium sulphate    inj, 500 mg/mL, 2 mL amp  DVA 
 
22.3  Medicines used in primary PPH 
 
1  Misoprostol      tablet, 200micrograms  DVA  
 
23  Peritoneal dialysis solutions 
 
1  Dianeal + dextrose     1.5% intraperitoneal dialysis  CVB 
          Soln, 1 L bottle  
2  Dianeal + dextrose     4.25% intraperitoneal dialysis CVB 
          Soln, 1 L bottle  
 
24  Psychotherapeutic medicines 
 
1  Chlorpromazine HCI    inj, 25 mg/mL, 2 mL amp  HEA 
2  Chlorpromazine HCI    tablet, 25 mg      HEA 
3  Amitriptyline HCI    tablet , 25 mg      DVA 
4  Amitriptyline HCI    injection, 10 mg/mL    CEB 
5  Chlorpromazine HCI    tablet, 100 mg     DVA 
6  Diazepam      inj, 5 mg/mL, 2 mL amp  DVA 
7  Fluphenazine decanoate  inj, oily, 25 mg/mL     DVA 
          2 mL amp 
8  Diazepam      tablet,5 mg       DEA 
9  Chlormethiazole    capsule, 192 mg base    DEA 
10  Haloperidol      tablet, 1.5 mg      DEA 
11  Haloperidol      tablet, 1.5 mg      DEA 
12*  Carbamazepine    tablet, 200 mg     DEB 
13*  Haloperidol decanoate   inj, oil, 50 mg/mL, 1 mL amp  CEB 
14*  Pericyazine       tablet, 4 mg       CEB 
15*  Procyclidine HCI    tablet, 5mg      CEB 
16*  Procyclidine HCI    inj, 5 mg/mL, 2 mL amp  CEB 
17*  Promazine       tablet, 25 mg       CEB 
18*  Thioridazine      tablet, 100 mg     CEB 
19  Fluoxetine      tablet, 20mg      CVA 
20  Imipramine      tablet, 10mg      CVB 
 
25.   Respiratory system medicines 
 
25.1  Antiasthmatics  
 
1  Adrenaline       inj, 1/1,000, 1 mL amp  HVA 
2  Aminophyline      inj, 25 mg/mL, 10 mL amp  HVA 
3  Salbutamol sulphate     tablet, 4 mg       HVA 
4  Aminophylline     tablet, 100 mg     HVA 
5  Salbutamol Sulphate     inj, 1 mg/mL, 5 mL amp  DVA 
6  Salbutamol Sulphate     aerosol inhalation    DVA 
          100 micrograms/dose, 
          200 – dose unit 
7  Salbutamol Sulphate     respirator solution, 1 mg/mL  DVA 
          Single dose nebuliser amps  
8  Beclomethasone     aerosol inhalation,    CVB 
  Diproprionate      50 micrograms/dose, 
          200‐dose unit  
9  Sodium cromoglycate   spincap, 20 mg    CEB 
          (for use with an insufflator) 
 
26.  Replacement fluids and electrolytes  
 
26.1  Oral preparations  
 
1.  Oral rehydration salts,   powder in sachet for I L   HVA 
  (ORS)        (WHO low osmolarity) 
2  potassium chloride     tablet, slow release, 600 mg  DVA 
 
26.2  Parenteral preparations 
 
1  Glucose (dextrose)    injection, 50%, 20 mL amp  HVA 
2  Sodium lactate comp    i/v infusion, 1L pack    HVA 
  (Ringer‐lactate or Hartmann’s solution) 
3  Water for injections    for i/v use, 10 mL amp   HVA 
4  Glucose (dextrose)    i/v infusion, 5%, 1L pack  DVA 
5  Glucose (dextrose)    i/v infusion, 10%, 100 L pack  DVA 
6  Potassium chloride    injection, 20%, 10 mL amp  DVA 
7  Sodium bicarbornate    injection, 4%, 50 mL vial  DVA 
8  Sodium chloride     i/v infusion, 0.9%, 1L pack  DVA 
9  Sodium lactate + glucose  i/v infusion, 1L (adult) pack  DVA 
  (Darrow’s ½ strength in dextrose 5% 
10  Sodium lactate + glucose   i/v infusion, 200 mL (paed)  DVA 
 
27  Vitamins and minerals  
 
1  Vitamin A      capsule, 200,000 IU    HVA 
          (liquid or gel filled) 
2  Vitamin B Co. strong     tablet        HEA 
3  Nicotinamide      tablet, 50 mg      DEA 
4  Pyridoxine HCI     tablet, 20 mg      DEA 
5  Thiamine      inj, 100mg/ml     DEB 
6  Vitamins, multiple    syrup        DEA   
7  Vitamins, multiple    tablet        DEA   
8  Calcium gluconate     tablet, chewable, 500 mg   DEB 
9  Vitamins, multiple    injection, i/v, high‐potency  DEB 
          10 mL (in 2 amps) 
10  Calciferol, high‐strength  tablet, 10,000 IU    CVB 
11  Calcium gluconate    injection, 10%, 10 mL, amp  CEA 
 
 
 
28.  Preparations for the ear and oropharynx 
 
28.1  Preparations for the ear 
 
1  Gentian violet      paint, aq., 0.5%, 500 mL  HEA 
2  Sodium bicarbonate     ear drops, 5%, 25 mL    DEA 
3  Betamethasone    ear drops, 0.1%, 10 mL  DEB 
  Sodium phosphate (or equivalent) 
4  Acetic acid      ear drops, 2%      HEB   
 
28.2  Preparations for the oropharynx 
 
1  Gentian violet      paint, aq., 0.5%, 500 mL  HEA 
2  Nystatin      oral suspension,    DEA 
          100,000 IU/mL, 20 mL 
          (with graduated dropper) 
 
 
29.  Medicines used for gout 
 
1  Allopurinol      tablet, 100 mg     DEA 
2  Colchicine      tablet, 500 micrograms  DVB 
 
30.  Laxatives 
 
1  Lactulose      solution, 3.1mg/5ml    CVA 
2  Liquid paraffin     solution      HVA