THE UNITED REPUBLIC OF TANZANIA

MINISTRY OF HEALTH AND SOCIAL WELFARE

STANDARD TREATMENT GUIDELINES (STG)

AND

THE NATIONAL ESSENTIAL MEDICINES LIST

(NEMLIT) FOR MAINLAND TANZANIA

THIRD EDITION

2007

TABLE OF CONTENTS

TABLE OF CONTENTS ..............................................................................................................................ii

FOREWORD ..............................................................................................................................................iii

ACKNOWLEDGEMENT .........................................................................................................................iv

ABREVIATIONS AND SYMBOLS ..............................................................................................................v

GASTRO INTESTINAL DISEASE CONDITIONS ...........................................................................1

2. RESPIRATORY DISEASE CONDITIONS .....................................................................................27

3. OBSTETRICAL/GYNAECOLOGICAL DISEASE CONDITIONS AND CONTRACEPTION ......43

4. CARDIOVASCULAR DISEASE CONDITIONS .............................................................................59

5. MALARIA........................................................................................................................................70

6. SKIN DISEASE CONDITIONS ......................................................................................................77

7. SEXUALLY TRANSMITTED INFECTIONS (STI) ........................................................................90

8. ORAL DISEASE CONDITIONS ...................................................................................................101

9. KIDNEY DISEASE CONDITIONS ..............................................................................................110

10. EAR, NOSE AND THROAT DISEASE CONDITIONS ................................................................113

11. EYE DISEASE CONDITIONS ......................................................................................................119

12. TUBERCULOSIS AND LEPROSY................................................................................................124

13. MUSCULO SKELETAL AND JOINT DISEASE CONDITIONS ..................................................139

14. METABOLIC AND ENDOCRINE DISEASE CONDITIONS .......................................................144

15. NERVOUS SYSTEM DISEASE CONDITIONS ............................................................................151

16. OTHER DISEASE CONDITIONS .................................................................................................162

17. VIRAL INFECTIONS ....................................................................................................................165

18. ALLERGIC REACTIONS ..............................................................................................................177

19.

HAEMATOLOGICAL DISEASE CONDITIONS ..........................................................................178

20.

NUTRITIONAL DISEASE CONDITIONS ....................................................................................184

21. MALIGNANT DISEASE CONDITIONS .......................................................................................186

22.

BITES ............................................................................................................................................188

23.

BURNS ..........................................................................................................................................190

24. FOREIGN BODIES.......................................................................................................................191

25.

PAIN .............................................................................................................................................192

26.

POISONING .................................................................................................................................193

NATIONAL ESSENTIAL MEDICINE LIST FOR TANZANIA (NEMLT)

………………………........… 194

ACKNOWLEDGEMENT

The review of the STG and NEMLIT has been successfully undertaken as a result of collaboration

between health professionals namely doctors, pharmacists, laboratory technologists and others from

the public and private sectors.

The Ministry would like to thank all those who have contributed greatly to the development of this

version in one way or another. While it is not possible to mention all who participated in the review

of this manual, the Ministry would like to acknowledge the following:

Prof. A. Massele Clinical Pharmacologist, MUCHS

Mr. J.S. Muhume Assistant Director, Pharmaceutical Services, MOHSW

Mr. Y.G. Mlavwasi Pharmacist, Muhimbili National Hospital

Mr. C.Y. Mwasha Pharmacist, School of Pharmaceutical Sciences

Dr. J. Katarahya Physician, Bugando Medical Centre

Ms. R. Aaron Pharmacist, Tanzania Food and Drug Authority

MS. M. Kinyawa Registrar, Pharmacy Council

Dr. M. Nyang’anyi Medical Ofﬁ cer, National AIDS Control Program (STI)

Mr. V. Mgaya Lab. Technologist, Ministry of Health and Social Welfare

Dr. N.G. Simkoko Medical Ofﬁ cer, National Tuberculosis & Leprosy Program

Dr. S. Chale Physician, WHO Country Ofﬁ ce

Ms. L. Nderimo Quality Control Manager, Medical Stores Department

Ms R. Shija National Professional ofﬁ cer, EDM – WHO Country Ofﬁ ce

Mr S. W. Kitundu Pharmacist, Ministr y of Health and Social Welfare

Mr W. Shango Phar macist, Ministry of Health and Social Welfare

Mr T. Mikindo Pharmacist, Kigoma Hospital

Dr. S. K. Mgude Principal, Clinical Ofﬁ cers’ School Tanga

Dr C. Winani Gynaecologist, Tumbi Hospital, Kibaha

Dr. E. Kirumbi Medical Ofﬁ cer, MOHSW

Mr H. Mchunga Pharmacist, Medical Stores Department

Dr. C. Asman Medical Ofﬁ cer, National Health Insurance Fund

Dr.E.P. Mung’ong’o Assistant Director, Private & Voluntary Services, MOHSW

The Ministry wishes also to acknowledge the members of the National Therapeutic Committee for

their input and guidance that enabled the ﬁ nalization of these guidelines. They include:

Dr. G. L. Upunda Chairman Ministry of Health & Social Welfare

Dr. Z.A. Berege Member Ministr y of Health & Social Welfare

Dr. J. G. Sayi Member Muhimbili College of Health Sciences

Dr. Y. Mgonda Member Muhimbili College of Health Sciences

Dr. A. Kitua Member National Institute for Medical Research

Dr. G. Mbaruk Member Kigoma Regional Hospital

Dr. S. Kalluvya Member Bugando Medical Centre

Dr. E. R. Samky Member Mbeya Referral Hospital

M. Ndomondo-Sigonda Member Tanzania Food and Drug Authority

Dr. G. Massenge Member Kilimanjaro Christian Medical Centre

Mr. C. W. Msemo Member Medical Stores Department

Dr. E. Nangawe Member World Health Organization

Mr. J. S. Muhume Secretary Ministry of Health & Social Welfare

The Ministry of Health and Social Welfare would like to express its gratitude to the World Health

Organization (WHO) for providing ﬁnancial and technical support in reviewing and production of

these guidelines. Thanks also extended to the Danish International Development Agency (DANIDA)

through Health Sector Programm Support, Ministry of Health and Social Welfare for funding the

review process and printing the manual.

Last but not least, the Ministry would like to thank Ms. Anna Mrimi, Ministry of Health and Social

Welfare and Ms. Joyce Komba, Tanzania Food and Drug Authority (TFDA) for typing the manual.

Wilson Mukama

PERMANENT SECRETARY

ABREVIATIONS AND SYMBOLS

BCG = Bacillus Calmette – Guerin Vaccines

BP = Blood Pressure

CCF = Congestive Cardiac Failure

CNS = Central Nervous System

CVP = Central Venous Pressure

DC = Direct Curent

Dpm = Drops Per Minute

DTLC = District Tb and Leprosy Coordinator

FBC = Full Blood Count

g = Gramme

HIV = Human Immunodeﬁ ciency Virus

HTLV = Human T-Cell Leukemia/Lymphonia Virus

i.m (I.M) = Intramuscular

i.v (I.V) = Intravenous

l(L) = litre

mmHg = Millimeters of Mercury

MU = Mega Unit

ns = Nanosecond

O = Oral

PEM = protein energy malnutrition

PHC = Primary Health Care

PID = Pelvic Inﬂ ammatory Disease

PR = Prosthion

PIH = pregnancy induced hypertension

SC = Subcutaneous

SLE = Systemic Lupus Erythematous

Tab = Tablet

TT = Tetanus Toxoid

μg = Microgram

ARI = Acute Respiratory Infection

STD = Sexually Transmitted Diseases

SSS = Salt Sugar Solution

APH = Antepartum Haemor rhage

UTI = Urinary Tract Infection

NS = Normal Saline

D&C = Dilation and Curettage

ATS = Anti Tetanus Serum

AE = Acute Epiglottis

RR = Reversal Reaction

1. GASTRO INTESTINAL DISEASE CONDITIONS

1.1 Parasitic Diseases

1.1.1 Amoebiasis

Clinical features: Amoebiasis is caused by a protozoan parasite Entamoeba histolytica.

It is usually transmitted from person to person through faecal contamination of food or

hands, but may also be transmitted vial anal sexual contact. Amoebic dysentery occurs

when the parasites invade the intestinal wall and abscesses may develop in the liver or, less

frequently, in the lung or brain as a result of haematogenous spread. Skin lesions may also

occur. Pregnant women and individuals who are malnourished or immunocompromised

are most vulnerable to systemic infection.

Treatment guidelines

Intestinal amoebiasis

Drug of choice Metronidazole (O)

Adult 750-800mg 8 hourly with food for 5 days

Children 10mg/kg weight per day

Indicative

1-3 years 200-250mg 8 hourly for 5 days

3-7 years 200-250mg 6 hourly for 5 days

7-10 years 400-500mg 8 hourly for 5 days

Above 10 years as for adult

Second choice Tinidazole (O)

Adult 2g daily as a single dose for 3 consecutive days

Children

50 mg/kg body weight in three divided doses for 3

consecutive days

Adults Secnidazole (O) 2g as a single dose

Amoebic liver abscesses

Drug of choice Metronidazole (O)

Adult 400-500mg, 8 hourly for 10 days. Repeat course

after 2 weeks if necessary

Children

1-3 years 100-200mg 8 hourly for 10 days

3-7 years 100-200mg 6 hourly, for 10 days

7-10 years 200-400mg 8 hourly, for 10 days

NOTE: Metronidazole should be taken with food. The course may be repeated after two weeks

if necessary,

Aspiration of the abscess may be necessary if it is easily accessible. Always consider the

possibility of a pyogenic abscess.

CAUTION

• Patients on metronidazole, Secnidazole and Tinidazole should not take alcohol

• Metronidazole, Secnidazole and Tinidazole are contraindicated in the ﬁ rst trimester

of pregnancy

1.1.2 Ascariasis (caused by round worms)

Clinical features: It is an infection caused by Ascaris lumbricoides. The main

clinical features are abdominal discomfort or colic, rarely they may cause intestinal

obstruction, obstructive jaundice and malnutrition.

Treatment guidelines

Drug of choice Mebendazole (O)

Adult and Children above 2 years 100mg 12 hourly for 3 days

500mg as a single dose

Albendazole 400mg as a single dose (O)

Second choice Levamisole (O)

Adult 120-150 mg as a single dose

Children below 2 years 3 mg/kg body weight as single dose

2.5 mg/kg body weight as single dose, repeated

after 7 days

1.1.3 Ancylostomiasis (caused by hookworm)

Clinical features: Ancylostomiasis (hookworm disease) is caused by infestation of the

small intestine with Ancylostoma duodenale or Necator americanus. It is one of the main causes

of anaemia in the tropics which is also the major clinical feature.

The majority of patients are asymptomatic. However, in hookworm disease the major

clinical manifestations are iron deﬁ ciency anaemia and hypoalbuminaemia.

Treatment guidelines

Drug of choice Mebendazole (O)

Adult and Children over 2 years 100mg 12 hourly for 3 days

500mg as a single dose

Albendazole 400mg (O) as a single dose

NOTE:

Both Albendazole and Mebendazole must be chewed. If ova persist, give second course

after 3 – 4 weeks

CAUTION

Albendazole is contraindicated in the ﬁ rst trimester of pregnancy and children below 2 years

1.1.4 Cestodiasis (caused by tapeworms)

Clinical features: Man gets tapeworms by eating raw or undercooked beef infected with

cysticercus bovis, the larval stage of Taenia saginata (beef tapeworm) or undercooked food

containing Cystercercus cellulosae, the larval stage of Taenia solium (pork tapeworm). Other less

common cestodes includes Diphyllobohrium latum (poorly cooked ﬁ sh) and Hymenolepsis nana

(fecael oral contamination by both human and animals especially dogs).

Most tape worm infections are symptomless and the commonest way of presentation is

the appearance of proglottides or segments in the stool. There may be mild epigastric

discomfort, nausea, weight loss and diarrhoea.

Treatment guidelines

Drug of choice Niclosamide (O)

Adult:

2g as a single dose. Chew tablets on an empty

stomach

Children: 30mg/kg body weight starts on an empty

stomach.

For Taenia solium, Taenia saginata and Diphyllobothrium latum

Adults and children over 6 years: 2g as a single dose after a light breakfast, followed

by a purgative after 2 hours.

Children 2-6 years: 1g as a single dose after a light meal, followed by

a purgative after 2 hours.

Children under 2 years 500mg as a single dose after a light meal, followed

by a purgative after 2 hours.

For Hymenolepsis nana

Adult and children over 6 years 2g as a single dose on the ﬁ rst day, then 1g daily for

6 days

Children under 2 years 500mg on the ﬁ rst day as a single dose then 250mg

daily for 6 days.

Children 2-6 years 1g on the ﬁ rst day as a single dose then 500mg

once daily for 6 days.

Counselling: Tablets should be chewed thoroughly before washing down with water.

NOTE: Praziquantel has similar efﬁ cacy on Tinea infestation

CAUTION: Contraindicated in the ﬁ rst trimester of pregnancy

1.1.5 Filariasis

Clinical features: Filariasis is a group of disorders produced by infection with

nematodes. These worms invade the lympatics, subcutaneous, and deep tissues producing

reactions ranging from acute inﬂ ammation to chronic scarring. In Tanzania the most

important species is Wuchereria bancrofti, Brugia malayi, Onchocerca volvulus and occasionally

Loa loa. The main clinical features are fever, acute lymphadenitis, orchitis, headache and

urticaria in the acute phase. It might precipitate an asthma attack in predisposed individuals.

In chronic infection the main features are elephantiasis of the limbs, scrotal elephantiasis

and hydrocoel. Loa loa causes a typical allergic inﬂ ammatory skin lesion (calabar swelling).

Occasionally, the adult worm may be seen crossing the eye subconjunctivally.

Treatment guidelines

Medicine of choice Ivermectin (O)

150mcg/kg (0.15mg/kg) body weight as a single dose. Treat

again at intervals of 6 to 12 months, depending on symptoms

or until the adult worms die out.

Diethylcarbamazine (DEC) (O)

1mg/kg body weight. Increase the dose gradually by 1mg/kg

body at an interval of 3 days to maximum of 6mg/kg body

weight. Duration of treatment is 21 days.

NOTE: Medicines will usually arrest progretion of the clinical features, but will not

reverse them. Surgical interventions may be necessary.

CAUTION: Treatment with DEC should be closely supervised since allergic

reactions are common and may be severe

1.1.6 Giardiasis

Clinical features:

It is an infection of the upper small intestine caused by the ﬂ agellate protozoan Giardia

lamblia (or G. intestinalis). Infection with this ﬂ agellate is mainly asymptomatic. However

when symptoms occur, they include acute and/or chronic diarrhoea, without blood or pus.

In few cases malabsorption syndrome may occur.

Treatment guidelines

Medicine of choice

Adult Metronidazole (O)

2g orally once daily for 3 days

400-500mg orally 8 hourly for ﬁ ve days

10mg/kg body weight 8 hourly for 7 days

Second choice Tinidazole (O)

Adult 2g orally as a single dose

Children 50-75mg/kg body weight as a single dose.

Adult Secnidazole 2g (O) as a single dose

CAUTION

• Patients on metronidazole, Secnidazole and Tinidazole should not take alcohol

• Metronidazole, Secnidazole and Tinidazole are contraindicated in the ﬁ rst

trimester of pregnancy

1.1.7 Strongyloidiasis

Clinical features: It is an intestinal infection caused by Strongyloides stercoralis. The

intestinal infection is usually asymptomatic but patients may have vague symptoms such as

abdominal pain, nausea, ﬂ atulence, vomiting, diarrhoea and even epigastric pain. Heavier

infections are more likely to produce symptoms. In immuno compromised patients (e.g

HIV/AIDS and prolonged use of steroids) disseminated infections may occur leading to

enterocolitis and gram negative bacteremia.

Treatment guidelines

Medicine of choice Thiabendazole (O)

Adults: 25mg/kg body weight (max.1.5g) 12 hourly for 3

days. Tablets must be chewed

Children Same as for adults

CAUTION: Not to be given to pregnant women

Thiabendazole treatment in immuno-compromised patients is not always effective, hence

repeated or prolonged courses of thiabendazole from 5-14 days may be required.

Ivermectin 200mg/kg (o) once daily for two days

1.1.8 Typhoid and paratyphoid

Clinical features:

These acute systemic diseases result form infection by Salmonella typhi and S.paratyphi, A

and B respectively. The clinical manifestation and duration of illness vary markedly from

one patient to another. The major clinical features are fever, severe headache, drowsiness

and muscle pains (myalgia). The course of paratyphoid tend be to shorter and less severe

compared to typhoid.

Diagnosis

-An elevated white blood cell count

-A blood culture during the ﬁ rst week of the fever can show s.typhi bacteria

-Blood platelet count shows decreased platlets

-An ELISA test on urine may show Vi antigen speciﬁ c for s.typhi bacteria

Treatment guidelines

Medicine of choice Ciproﬂ oxacin (O)

Adult and children over 15 years 500mg 12 hourly for 10 days

Alternatively Chloramphenicol (O)

Adult 500mg 6 hourly for 14 days

Childen above 1 years 12.5mg/kg body weight six hourly for 14

days

Below 1 year 120mg/kg body weight 12 hourly for 14

days

CAUTION:

Ciproﬂ oxacin is contraindicated in children below 15 years and pregnant

women. Chloramphenicol is contraindicated in the third trimester of pregnancy.

Chloramphenicol may cause aplastic anaemia which is irreversible.

1.2 Schistosomiasis

Clinical features: Schistosomiasis is caused by the ﬂ uke schistosome. The common

species found in Tanzania are S. haematobium and S. mansoni. The main clinical feature for

S.haematobium infection is a painless, terminal haematuria. For S. mansoni there may be

abdominal pain and frequent blood stained stool. In chronic form of Schistosoma mansoni,

abdominal distention and vomiting of blood and liver ﬁ brosis (Portal hypertension).

Treatment guidelines

Medicine of choice Praziquantel (O)

40mg – 60mg/kg body weight as a single

dose

Three doses of 20mg/kg body weight at an interval of 4 to 6 hours for one day

NOTE: Medicines will usually arrest progression of clinical features, but will not reverse

them. Surgical interventions may be necessary.

1.3 Shigella

Medicine of choice Co-trimoxazole (O)

Adult 960mg 12 hourly for 5 days

Children 6 weeks – 5 months 120mg 12 hourly for 5 days

6 month - 5years 240 mg 12 hourly for 5 days

6-12 years 480mg 12 hourly for 5 days

Second choice Ciproﬂ oxacin (O)

Adult 500mg 8 hourly for 5 days

Nalidixic acid (O)

500mg 8 hourly for 5 days

Children up to 10 years Erythromycin (O)

125mg 8 hourly for 5 days

Nalidixic acid (O)

250mg 8 hourly for 5 days

Yersini

Medicine of choice Doxycycline (O)

Adult only 200mg initially then 100mg once daily for 5 days

In severe infection give 200mg 12 hourly for 5 days

Campylobacter

Medicine of choice Erythromycin (O)

Adult and Children over 8 years 250-500mg 6 hourly for 5 days

Children 10mg/kg body weight six hourly for 5 days

Up to 2 years 125mg 6 hourly for 5 days

2-8 years 250mg 6 hourly for 5 days

1.4 Diarrhoea

Clinical features: Clinical Features: Diarrhoea is the passage of unusually loose or

watery stools, usually at least three times in 24 hours period. However, it is the consistency

of the stool rather than the number that is most important. Frequent passing of for med

stools is not diarrhoea. Babies fed only Breast milk often pass loose, ‘pasty’ stools, this is

not diarrhoea. Mothers usually know when their children have diarrhoea and may provide

useful working deﬁ nitions in local situations.

Young children and very old patients are particularly susceptible to the effects of

dehydration due to diarrhoea.

1.4.1 Clinical Types of Diarrhoeal diseases.

It is most practical to base treatment of diarrhoea on the clinical types of the illness, which

can easily be determined when a patient is ﬁ rst examined. Laboratory studies are very

useful with the exception of few conditions such as Cholera.

Four clinical types of diarrhoea can be recognized, each reﬂ ecting the basic underlying

pathology and altered pathology:

Acute Watery Diarrhoea• (Including Cholera): which lasts several hours or days:

the main danger is dehydration and malnutrition if feeding is not continued.

Bloody Diarrhoea• : which is also called Dysentery, the main dangers are

damage of intestinal mucosa, sepsis, and malnutrition. Other complications including

dehydration may also occur.

Persistent Diarrhoea• : Last for 14 days or longer, the main danger is malnutrition

and serious non-intestinal infections, dehydration may also occur.

Dirrhoea with Severe Malnutrition • (Marasmus or Kwashiorkor): the main

dangers are severe systemic infection, dehydration, heart failure, vitamin and mineral

deﬁ ciency.

The basis for the management of each type is to prevent or treat dangers that each

present.

1.4.2 Management of diarrhoea in children.

Over 90% of deaths from diarrhoea in under-ﬁ ves would be prevented by:

Continuing breast feeding and other feeding throughout the attack of diarrhoea •

(prevent malnutrition);

Making sure mothers know when to take the child to a health facility;•

Correct assessment, treatment and continued feeding at the health facility level (See •

MoH & SW chart and manual);

Treatment of invasive diarrhoea (bloody stool) with antibiotics;•

Treating or prevent dehydration and electrolyte imbalance with ORS ( New osmolarity •

ORS)

Reduce the duration and severity of diarrhoea and occurrence of future episodes by •

giving supplemental Zinc

Referring to hospital for investigation and treatment for severe malnutrition and •

persistent diarrhoea (lasting>14 days)

Low Osmolarity ORS

Low osmolarity ORS (245mmol/lt) has been observed to be more effective than the

Standard ORS in especially preventing dehydration.

Constitution of Low Osmolarity ORS

Ingredient Grams/

litre

Ingredient mmol/lt

Sodium choride

2.6 Sodium

Trisodium citrate

dihydrate

2.9 Citrate 10

Potassium chloride

1.5 Potassium 20

Glucose, anhydrous

13.5 Glucose, unhydrous 75

Chloride 65

Total Weight

(Gram/Litre)

20.5 Total osmolarity (mmol/Lt) 245

Zinc

The use of Zinc during diarrhoea has been shown to reduce frequency, stool volume and

recurrence of diarrhoea episode.

All children with diarrhoea should be given Zinc, 10-20mg every •

day for 10-14 days. Zinc treatment should be continued even after

diarrhoea has stopped

Use of antimicrobial and ‘antidirrhoeal’ drugs

Antimicrobials should not be used routinely. This is because, with few exceptions, it is not

possible to distinguish clinically episodes that might respond to antimicrobials. Moreover,

even for potentially responsive infections, selecting an effective antimicrobial requires

knowledge of the likely sensitivity of the causative agent, information which is usually

unavailable. I addition, use of antimicrobials adds to the cost of treatment, risk adverse

reactions and enhance the development of resistant bacteria.

Antimicrobial are reliably helpful in children with bloody diarrhoea (DYSENTERY). They

are also sometimes indicated in suspected Cholera with severe dehydration, and serious

non-intestinal infections such as pneumonia which may occur concurrently.

Anti-protozoal drugs are rarely indicated

‘Antidirrhoeal’ drugs and anti-emetics have no practical beneﬁ t for all age groups but more

so for children with acute or persistent diarrhoea. Some have dangerous, and sometimes

fatal, side-effect. These drugs should never be given to children below 5 years.

1.4.3 Determining the degree of dehydration and select a treatment plan

Assessment and management are summarized on a chart, included here in a form of

tables. Further information, copies of the Diarrhoea Management Chart and Diarrhoea

Training Manual can be obtained from the IMCI Unit of Reproductive and Child Health

Section, Ministry of Health and Social Welfare.

Other signs may be useful in assessing severe dehydration and inﬂ uence also

management:

Weight loss over a short period;•

Signs of hypovolemic shock, fast weak pulses, cold extremities, oliguria or anuria;•

Hyperventilation, deep and fast breathing indicating acidosis.•

Signs of severe malnutrition•

Assessment of Dehydration/Other problems

AB C

LOOK:

General

condition

Eyes

Thirst

Well, alert

Normal

Drinking normally,

not thirsty

Restless, irritable

Sunken

Thirsty, drinks

eagerly

Lethargic or

unconscious

Sunken

Drinks poorly, or

unable to drink

FEEL:

Skin

pinch

Goes back quickly Goes back slowly Goes back very slowly

DECIDE

NO SIGNS OF

DEHYDRATION

Two or more signs

SOME

DEHYDRATION

Two or more signs

SEVERE

DEHYDRATION

TREAT Use Treatment

Plan A

Weigh patient

if possible, use

Treatment plan B

Weigh patient if

possible, use Treatment

plan C Urgently

Treatment plans A, B and C

Plan A: Treat Diarrhoea at Home

Counsel the mother on the 3 Rules of Home Treatment..

Give Extra Fluid, Continue Feeding (including Breast feeding), When to Return

GIVE EXTRA FLUID (As much as the child will take) 1.

TELL THE MOTHER:

Breastfeed frequently and longer.

If the child is exclusively breastfed give ORS or clean water in addition to breast

milk.

If the child is not exclusively breastfed give one or more of the following: ORS

solution, food-based ﬂ uids (such as soup. plain porridge, .fresh fruit juice, green

coconut juice and yoghurt drinks), or clean water.

It is especially important to give ORS at home when:

The child has been treated with Plan B or Plan C during this visit.

The child cannot return to clinic if the diarrhoea gets worse.

Give Zinc, 10-20mg every day for 10-14 days. Zinc treatment should be continued 

even after the diarrhoea has stopped

TEACH THE MOTHER HOW TO MIX AND GIVE ORS. GIVE THE MOTHER

2 PACKETS OF ORS TO USE AT HOME,

SHOW THE MOTHER HOW MUCH FLUI D TO GIVE IN ADDITION TO

THE USUAL FUID INTAKE:

Up to 2 years 50 to 100 ml after each loose stool

2 years or more 100 to 200 ml after each loose stool

Tell the mother to:

Give frequent small sips from a cup.-

If the child vomits, wait 10 minutes. Then continue but more slowly-

Continue giving extra ﬂ uid until the diarrhoea stops-

2. CONTINUE FEEDING

INCLUDING BREAST FEEDING See “COUNSEL THE

MOTHER” chart

3. WHEN TO RETURN

Plan B: Treat Some Dehydration with ORS

Give in clinic recommended amount of ORS over 4-hour period

DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS¾

AGE Up to 4

months

4 months up

to 12 months

12 months

up to 2 years

2 years

up to 5

years

WEIGHT

<6kg 6 - < 10 kg 10-<12 kg 12 - 19 kg

In ml

200 - 400 400 - 700 700 - 900 900 - 1400

Use the child’s age only when you do not know the weight. The approximate 

amount of ORS required (in ml) can also be calculated by multiplying the child’s

weight (in kg) times 75.If the child wants more ORS than shown, give more

For infants under 6 months who are not breastfed, also give 100-200 ml clean 

water during this period

Give Zinc, 10-20mg every day for 10-14 days. Zinc treatment should be continued 

even after the diarrhoea has stopped

SHOW THE MOTHER HOW TO GIVE ORS SOLUTION¾

Give frequent small sips from a cup

If the child vomits, wait 10 minutes. Then continue, but more slowly

Continue breastfeeding whenever the child wants

AFTER 4 HOURS¾

Reassess the child and classify the child for dehydration

Select the appropriate plan to continue treatment

Begin feeding the child in clinic

IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT:¾

Show her how to prepare ORS solution at home

Show her how much ORS to give to ﬁ nish the 4-hour treatment at home

Give her enough ORS packets to complete rehydration. Also give her 2 packets 

as recommended in Plan A

Explain the 3 Rules of Home Treatment:

GIVE EXTRA FLUID See plan A for recommended ﬂ uids1.

CONTINUE FEEDING INCLUDING 2.

BREAST FEEDING and

See “COUNSEL THE MOTHER” chart

WHEN TO RETURN3.

Plan C: Treat severe dehydration quickly

Follow the Arrows. If answer is “Yes”, go across. If “No”, go down

START HERE

AGE First give

30 ml/kg in:

Then give

70 ml/kg in:

Infants

(under 12 months)

1 hour* 5 hours

Children

(12 months or

above)

30 minutes* 2 ½ hour

Repeat once if radial pulse is still very weak or not detectable

Reassess the child every 1-2 hours. If hydration status is not

improving, give the IV drip more rapidly.

Also give ORS (about 5 ml/kg/hour) as soon as the child can

drink: usually after 3-4 hours (infants) or 1-2 hours (children)

Reassess an infant after 6 hours and a child after 3 hours.

Classify dehydration. Then choose the appropriate plan (A,B,

or C to continue treatment,

1.3

Refer URGENTLY to hospital for IV treatment.

If the child can drink, provide the mother with ORS solution and show

her how to give frequent sips during the trip.

NOTE:

If possible, observe the child at least 6 hours after dehydration to be sure the

mother can maintain hydration giving the child ORS solution by mouth

Can you give

intravenous (IV)

fluid immediately?

Can the child drink?

YES

Start rehydration by tube (or mouth) with ORS solution: give

20ml/kg/hours:

Reassess the child every 1-2 hours:

- If there is repeated vomiting or increasing abdominal distension,

give the fluid more slowly.

- If hydration status is not improving after 3 hours, send the child for

IV therapy.

After 6 hours, reassess the child. Classify dehydration. Then choose

the appropriate plan (A, B, or C) to continue treatment.

YES

Are you trained to use a naso-

gastric (NG) tube for

rehydration

Refer URGENTLY to

hospital for IV or NG

treatment

Is IV treatment available

nearby (within 30

minutes)?

Start with IV fluid immediately. If the child can drink, give ORS by

mouth while the drip is set up. Give 100 ml/kg Ringer’s Lactate

Solution (or, if not available, normal saline), divided as follows:

1.5 Dysentry:

1.5.1 Bacillary Dysentery

Clinical features:

Bacillary dysentery is caused by bacilli belonging to the Shigella genus with three main

pathogenic groups, namely S.dysenteriae, S.ﬂ exneri and S.sonnei. In Tanzania the most

common bacillus is S ﬂ exineri. Other less common bacillus inlude Yersinia enterolytica and

Campylobacter species.

However S. dysenteriae tends to cause epidemics. The main clinical features of bacillary

dysentery are diarrhoea, colic abdominal pain and tenesmus. The diarrhoea contains

blood and purulent exudate with little faecal matter. Fever, dehydration and weakness

occur particularly if diarrhoea persists. While the above clinical features are indicative of

bacillary dysentery speciﬁ c diagnosis depends on culture of faeces. Antibiotics are only

indicated if the patient is very ill with fever.

Management

Rehydration is important if diarrhoea persists and the patient is dehydrated. Refer to

treatment for diarrhoea section 1.4.

Treatment guidelines

Antibiotics are not usually needed. Give only in severe cases in a toxic, febrile patient.

Management of Bloody Diarrhoea (DYSENTERY)

Treatment should include

– Oral Rehydration Therapy to treat or prevent dehydration and continued frequent

feeding including breastfeeding.

– Use antimicrobial effective for Shigela. At the moment it is Co-trimoxazole (O)

Bloody diarrhoea persisting after above treatment in adults is presumed to be amoebiasis.

Persistent diarrhoea with Giardia in the stool gives Metronidazole (O)

Young children with bloody diarrhoea should not be routinely treated for amoebiasis

Doses for antibiotic treatment of Diarrhoea

AGE OR

WEIGHT

COTRIMOXAZOLE

(trimethoprim + sulphamethoxazole)

(Give two times daily for 5 days)

METRONIDAZOLE

Give three times daily

for 5 days)

ADULT TABLET

80 mg

trimethoprim

+ 400 mg

sulphamethoxazole

PAEDIATRIC

TABLET

20 mg trimethoprim

+ 100 mg

suplhamethoxazole

SYRUP

40 mg

trimethoprim

+ 200 mg

suplhamethoxazole

per 5 ml

TABLET

30ML/

KG/24HR

500mg tab

TABLET

30ML/

KG/24HR

250mg

tab

2 months

up to 12

months

(4-<10kg)

1/2 2 5.0ml

12 months

up to 5

years

(10 - 19

kg)

1 4 10 ml

Adult 12

NOTE:

Management of Cholera should be done using National Guidelines for the 

Management of Cholera. The use of antibiotic should follow the established

sensitivity.

The principles of management of diarrhoea in adult are the same as in children. As 

much as possible the cause for diarrhoea in adult should be established. Special care

should be taken for patients who are immunodeﬁ cient e.g. in cases of HIV/AIDS.

However, the most common cause for diarrhoea in adult is food poisoning which

is normally self-limiting.

1.6 Cholera

Clinical features: Cholera is an acute gastrointestinal infection caused by Vibrio cholera

organisms (El Tor and V.cholera). In Tanzania only the El Tor occurs. In its severe form,

clinical features include profuse watery stools (rice water), vomiting, severe dehydration

and muscular cramps. However, in epidemics there are many subclinical or mild cases. In

suspected case notify Ministry of Health and Social Welfare (MoHSW) immediately.

For conﬁ rmation at the beginning of an outbreak, take rectal swab or stool specimen,

handle properly and transport carefully to laboratory. Treat on site without referal

wherever possilbe.

Incubation period: Commonly 2-4 days (range 1-7 days)

Management:

Rehydration is the most important step; orally in moderate cases, IV (using ringer 

lactate) in more severe cases.

Start antibiotics (see below) after the patient is rehydrated and vomiting has stopped, 

usually after 4-6 hours. Although the disease is self limiting, an effective antibiotic

will reduce the volume of diarrhoea and shorten the period during which Vibrio

cholera is excreted. Antibiotic prophylaxis may be given to all close contacts in the

same dosage as for treatment.

Start feeding 3-4 hours after oral rehydration begins. Preferably, give antibiotics 

(especially Doxycycline) with food to minimize vomiting.

1.6.1 Moderate Dehydration

Give oral rehydration, approximately 75-100ml/kg in the ﬁ rst four hours. Reassess after

four hours; if improved, continue giving ORS, in quantity corresponding to losses (eg after

each stool) or 10 to 20ml/kg. If not improved, treat as severe.

Severe dehydration Give IV ﬂ uid Ringer’s

Lactate (IV) 200ml/kg immediately as follows

Age below 1 year 100ml/kg over 6 hours

30ml/kg in the ﬁ rst hours

70ml/kg over the next two and half hours.

Age above 1 year 100ml/kg over 3 hours

30ml/kg within half an hour

70ml/kg over the next two and half hours.

Monitor frequently; give ORS in addition to IV ﬂ uids as soon as able to drink.

Reassess after 4 hours; if improved, treat as moderate dehydration, if still severe continue

with IV ﬂ uids.

Treatment

Adult and child above 12 years Doxycycline (O)

300 mg as a single dose or 5mg/kg single dose

Adult Erythromycin (O) 500mg 8 hourly for 5 days

Children

Adult Co-trimoxazole (O)

Children 48mg/kg/24 hrs in 2 divided doses for 3 days.

Give folic acid (O) 5mg once daily for the duration of the treatment.

NOTE: Doxycycline should not be used in pregnancy and children below 12 years

1.7 Ulcers and related condtions

Clinical features: The term peptic ulcetation and rarely in the ileum adjacent to a

Meckel’s diverticulum refers to an ulcer in the lower oesophagus, stomach and duodenum.

In the duodenum ulcers may develop after surgical anastomosis to the stomach. They have

in common the participation of acid-pepsin in their pathogenesis. The common ulcers are

duodenal and/or gastric. Peptic ulcer may present in many diferent ways. The commonest

is chronic, episodic pain present in many diferent ways, and may persist for months or

years. However, the ulcer may come to attention as an acute episode with bleeding or

perforation, with little or no previous history. As with duodenal ulcer, epigastric pain is

the commonest symptom of gastric ulcer.

1.7.1 Peptic ulcer general measures

Careful history and examination are essential. Lack of rapid symptomatic response to

antacids makes peptic ulceration an unlikely diagnosis. Symptoms of many unrelated

conditions mimic those of peptic ulcer. Protracted treatment without investigation to

establish the diagnosis is wasteful and potentially harmful.

NOTE:

H•

receptor antagonists should be prescribed only for ulcers proven on endoscopy

or barium meal. Where appropriate, simpler measures indicated below should be

tried ﬁ rst.

“Ulcer diets” are unnecessary. Reduce spices, and avoid foods that exacerbate pain in 1.

individual patients.

Stop smoking and avoid alcohol.2.

Limit coffee/tea to 1 cup per day. Avoid carbonated drinks.3.

Medicines to be avoided: All non-steroidal anti-inﬂ ammatory agents (NSAIDS) 4.

aspirin/aspirin compounds, steroids.

Encourage relaxation and regular exercise5.

Antacids will alleviate symptoms in most cases; when given as shown below:6.

Magnesium trisilicate compound (O)

2 chewable tablets or 20 ml mixture as necessary up to 6

times daily.

1.7.2 Gastric ulcer

Referral to a specialist is recommended

Consider peptic ulcer general measures (above)

Endoscopic biopsy to exclude malignancy in ALL cases whenever possible.

Cimetidine (O) 400 mg 12 hourly for 6 weeks

Ranitidine (O) 150mg twice daily or 300mg at night for 4 to 8 weeks

Omeprazole (O) 20mg daily for 8 weeks

Famotidine (O)40mg at night for 6 weeks

Lansoprazole (O) 30mg once daily for 4 weeks may be continued to 8 weeks

1.7.3 Duodenal ulcer

Peptic ulcer general measures (above) should be considered

Initially try antacids every 2 hours

Magnesium trisilicate compound (O)

1-2 chewable tablets or 15 ml mixture 2 hourly

Cimetidine (O) 800mg at night for 4-6 weeks

Ranitidine (O) 150mg twice daily or 300mg at night for 4 to 8 weeks

Famotidine (O) 40mg at night for 6 weeks

Omeprazole 20mg once daily for 4 weeks. In severe and recurrent cases

increase to 40mg daily

Lansoprazole 30mg once daily for 4 weeks

Helicobacter pylori

Patients with persistent or recurrent ulcers should be referred to a specialist for further

evaluation and treatment

Treatment of H. pylori

Omeprazole 40mg once daily + Amoxycillin 500mg 8 hourly + Metronidazole

400mg 8 hourly for 7 days

Lansoprazole 30mg once daily + Clarithromycin 250mg 12 hourly + Tinidazole

500mg once daily for 5 days

Then Lansoprazole 30mg once daily for one month

1.7.4 Non-ulcer Dyspepsia

Symptoms are identical to duodenal ulceration without night exacerbation with normal

endoscopy or barium meal tests.

Explanation and reassurance are important

General measures for peptic ulcers (above) including antacids.

Try milk-free diet for possible lactose intolerance

Try anxiolytic

Diazepam (O) 2.5 mg twice daily for a maximum of 6 weeks

1.7.5 Acute Gastritis

Give antacids as in peptic ulcer. Advise light diet. Alleviate the cause if possible. If it is

not possible to alleviate the cause e.g burns and symptoms are severe, then give:

Cimetidine (O) 400mg 12 hourly for 8 weeks

Omeprazole 20mg once daily for 4 weeks

1.7.6 Gastro-enteritis due to bacterial toxicins

Rehydrate with oral ﬂ uids in mild cases, and with I.V ﬂ uids in more severe cases. Give

antiemetics if necessary (adults only).

Medicine of choice Promethazine (O)

Adult 25-50mg in single or divided doses max. 75mg

Children 1mg/kg/24 in 2-3 divided doses

Promethazine (IM) 25-50mg in single or divided doses

NOTE: Antibiotics are not required except in the special circumstances given below.

Antidiarrhoeals/Antispasmodics should be avoided.

CAUTION: Cimetidine interacts with ARVs.

1.7.7 Ulcerative colitis

Clinical features: Ulcerative colitis is a chronic condition of unknown cause in which

there are changes in the structure of the mucosa and submucosa of the wall of the colon,

with widespread inﬂ ammation and superﬁ cial ulceration. Symptoms vary from diarrhoea

in mild cases to septicaemia, dehydration and malnutrition in severe forms. Diarrhoea,

with blood and mucus in the faeces, is a common sign, although the disease is conﬁ ned to

the rectum there may be paradoxically constipation.

Treatment guidelines

Refer to a specialist.

Localized disease – treat with topical steroids:

Prednisolone (enema) 20mg at night, or same dose via

rectal catheter

CAUTION: Give steroids only in conﬁ rmed cases of Ulcerative Colitis. Exclusion of

other forms of infective colitis (especially amoebic) is vital; a therapeutic

trial of metronidazole should be given.

Widespread colitis:

Sulphasalazine (O) 1 gram four times a day for acute

disease, reducing to 500mg four times a day for maintenance

(caution in G6PD deﬁ ciency)

Plus

Prednisolone (O) 30-60mg once daily for severe, acute

and extensive disease; reduce gradually according to disease

severity.

Sulphasalazine (O)

Children over 2 years Acute attack use 40-60mg/kg body weight daily

Maintenance dose 20-30mg/kg body weight daily.

NOTE: Life long follow up is required.

1.8 Other gastro-intestinal problems

1.8.1 Irritable Bowel syndrome

May present with pain, chronic diarrhoea or constipation. It is important to investigate for

and exclude organic pathology

Reassurance and explanation are essential.

A high ﬁ bre diet and eating a healthy diet are the mainstay of treatment.

a) For relief of pain due to abdominal cramps,

Hyoscine butyl bromide (O) 20mg four times a day

b) For treatment of enxiety that may be making symptoms worse

Diazepam (O) 5-10 mg 8 hourly

Give short and infrequent courses only, in order to avoid dependance.

c) If constipation is prominent,

Magnesium trisilicate compound (O) or 20ml mixture 8 hourly

When diarrhoea is a frequent problem

Loperamide (O) may help; 4mg stat, followed by 2mg after each unformed

stool until diarrhoea is controlled.

Explore psycho-social factors in resistant cases.

Consider referral to a clinical psychologist.

Prolonged use of anti-diarrhoeal drugs may exacerbate the condition; therefore avoid use

of the medicines.

1.8.2 Malabsorption syndrome

Correction of electrolyte and nuritional deﬁ ciencies is important

1.8.3 Tropical sprue

Clinical features

Tropical sprue is a digestive problem that occurs in the tropics and subtropics, whereby

the ﬁ ngerlike villi in the small intestine are not able to absorb nutrients properly, especially

vitamin B12 and folic acid. In people with tropical sprue, these villi are ﬂ attened, making

absorption difﬁ cult. Diarrhea is the main symptom of tropical sprue. People who eat

a lot of fatty foods may get more severe diarrhea than those on diets low in fat. Other

symptoms include cramps, nausea, weight loss, gas and indigestion.

Treatment guidelines:

Treatment consists of 3 – 6 months of antibiotics and folic acid.

Doxycycline (O) 100mg once daily for 1 month

Plus

Folic acid (O) 5mg once daily for 6 months.

If there is evidence of vitamin B

deﬁ ciency give vitamin B

(hydroxocobalamin

IM)

1mg repeat ﬁ ve times at weekly intervals for replacement.

Maintain if required.

1.8.4 Pernicious Anaemia

Give life- long vitamin B

as above every 3 months.

1.8.5 Acute pancreatitis

Acute pancreatitis is a sudden inﬂ ammation of the pancreas whereby enzymes that

normally are released into the digestive tract begin to damage the pancreas itself. Digestion

slows down and becomes painful, heavy acohol use and gall-stones are one of the several

factors known to trigger attacks of acute pancreatitis.

Clinical features:

The most common symptom of acute pancreatitis is upper abdominal pain. Other

symptoms may include nausea and vomiting, loss of appetite and abdominal bloating. In

severe cases, fever, difﬁ culty breathing, weakness and shock may develop.

Treatment

If symptoms are mild

Stop all alcohol consumption¾

Adopt liquid diet such as broth and soups; such simple foods may allow inﬂ ammation ¾

to get better.

Generally the patient with an acute pancreatitis should be hospitalized and treated with

pain relievers and ﬂ uids given intravenously (into a vein). If gall-stones are the cause, the

patient will be advised to have them removed.

1.8.6 Chronic pancreatitis

Chronic pancreatitis is long-term (chronic) inﬂ ammation of the pancreas that leads to

permanent damage. The most common cause for such a condition is long-term excessive

alcohol consumption

Clinical features:

The most common symptom is upper abdominal pain that may be accompanied by nausea,

vomiting and loss of appetite. As the disease gets worse and more of the pancreas is

destroyed, pain may actually become less severe. During an attack, the pain often is made

worse by drinking alcohol or eating a large meal high in fats.

Because a damaged pancreas can’t produce important digestive enzymes, people with

chronic pancreatitis may develop problems with digesting and absorbing food and nutrients.

This can lead to weight loss, vitamin deﬁ ciencies, diarrhea and greasy, foul-smelling stools.

Over time, a damaged pancreas also can fail to produce enough insulin, which results in

diabetes

Treatment

Referral is recommended

Because chronic pancreatitis cannot be cured, direct the treatment towards:

Relieving pain a. - (medications such as acetaminophen or ibuprofen for mild pain).

In some people, a narcotic pain medication may be needed and in rare cases, surgery

to open blocked ducts or remove part of the pancreas may be done to relieve pain.

Improving food absorptionb. - The patient should be recommended to follow

a low-carbohydrate, high-protein diet that also restricts some types of fats. Once

digestive problems are treated, patient will usually gain back weight and diarrhoea

improves. Another way is by giving the patient pancreatic supplements containing

digestive enzymes.

Treating diabetesc. - Treat Diabetes with careful attention to diet to help keep blood

sugar levels stable. In some people, insulin injections and other diabetic medications

are needed.

1.8.7 Disaccharides deﬁ ciency

For example, lactose intolerance

Withdrawal of offending sugar is often sufﬁ cient. Lactose deﬁ ciency means that milk and

all milk products must be withdrawn.

1.8.8 Peritonitis

Mycobacterium tuberculosis species do also cause peritonitis. Peritonitis may diffuse or

localised clinical features. Abdominal pain, tenderness and gadding are the main features.

Fires, vomiting dehydration and items are also present.

Clinical features: Is inﬂ ammation of the peritoneum causative agents are multiple

including bacterial infection secondary to gastrointestinal perforation, ascending infection

from the pelvic organs contamination following penetrating injuries or spontaneous

bacterial infection (especially in children).

Bacterial peritonitis is usually characterized by acute abdominal pain and tenderness,

dehydration, fever, hypotension, nausea and vomiting and tachycardia.Complications

include abscess formation, oliguria and shock.

Chronic peritonitis Refer TB chapter

Treatment guideline

Surgical management following restriction is the mandatory •

Associated treatment is with antibiotics depending on causative agent •

Where cause is not known antibiotics of choice are: Ampicillin, Gentamicine •

and Metronidazole.

Medicine of choice Ampicillin (IV) 1g every 6hours for 5-10 days

Plus

Gentamicin (IV) 4 mg/kg/24 hours in 3 divided doses

for 5-10 days.

Metronidazole (IV) or (O) 400-600mg every 8 hours for

5-10 days.

1.8.9 Constipation

In constipation, bowel movements either occur less often than expected or the stool is

hard, dry and difﬁ cult to pass. Most of the time, constipation is not related to an illness

or digestive disorder. Instead, the problem is caused by diet, lifestyle, medications or some

other factor that either is hardening the stool or is interfering with the stool’s ability to

pass comfortably. Some common triggers of constipation include A diet low in ﬁ bre,

inadequate ﬂ uid intake, a sedentary lifestyle, ignoring the urge to defecate, travel and

scheduling factors, laxative overuse or a side effect of medication.

Clinical Features

Fewer than three bowel movements per week, small, hard, dry stools that are difﬁ cult

or painful to pass, need to strain excessively to have a bowel movement, frequent use of

enemas, laxatives or suppositories

Treatment guidelines

Find out the type of food taken by patient•

Exclude other organic causes of partial bowel obstruction•

Encourage high ﬁ bre diet, adequate ﬂ uid intake •

Give laxatives as required but avoid chronic use•

Stimulative laxative

Bisacodyl (O) 5-10mg

Bisacodyl suppository (PR) 10mg at bed-time

Osmotic laxative Magnesium sulphate (O) 4 grams with water before

breakfast, effective within 3 hours.

Lactulose solution 3.1 – 3.7g/ml

Adults 15ml, 12 hourly

Children under one year 2.5ml, 12 hourly

Children 1 – 5 years 5ml, 12 hourly

Children 5 – 10 years 10ml, 12 hourly

1.8.10 Haemorrhoids and other peri-anal conditions

Clinical features: Hemorrhoid disease is due to enlargement or thrombosis of the

veins in the external or internal hemorrhoidal plexus. Common clinical feature is the

passage of bright-red blood or blood coating of the stool. There is a feeling of vague anal

discomfort. Thrombosed haemorrhoids can be very painful. Prolapse is a complication.

Treatment guidelines

Treat any identiﬁ ed causative condition•

Encourage high ﬁ bre diet•

Careful anal hygiene•

Saline baths•

Avoid constipation by using stool softener.•

Medicine of choice Anusol (PR) suppository one or twice a day

Bismuth subgallate with 1% hydrocortisone

ointment (PR) once or twice a day

Paracetamol (O) 500 mg every 6 hours

Second Choice Proctosedyl suppository (PR) or Ointment (PR) once or twice

a day

1.9 Liver Diseases

Liver cirrhosis

This is usually caused by chronic hepatitis and alcohol abuse. It is characterised by

progression and widespread death of liver cells associated with inﬂ ammation and ﬁ brosis,

with destruction of the liver architecture.

Clinical features: Include jaundice, hepato megally, asserts, features of increased

oestrogen levels in men, while in women there are features of increased androgen levels.

Hence loss of libido, a testicular atrophy and impotence are common among male cirrhotic.

In women predominant features are breast atrophy, menstrual disturbances including

amenorrhea. Features of portal hypertension like splenomegaly, distended abdominal

wall, vessels and varices bleeding are common. Hepatic encephalopathy is an associated

complication.

Liver ﬁ brosis

S mansoni infection over time leads to liver ﬁ brosis which usually preserves the liver

architecture and liver function. It is a common cause of portal hypertension.

Cholestutic jaundice

Cholestasis may be due to failure of hepatocytes to generate bile ﬂ ow, to obstruction to

bile ﬂ ow in the bile ducts in the portal tracts to obstruction to bile ﬂ ow in the extrahepatic

bile ducts. Intrahepatic causes of cholestasis include viral hepatitis, alcohol, primary

biliary cirrhosis, Hodgikin’s lymphoma and pregnancy. Extrahepatic causes which may be

amenable to surgical correction include choledocholithiasis and carcinoma of the biliary

tree. Parasitic infections such as Asceriasis may also cause cholestatic jaundice. The

prominent features include itching, jaundice, dark urine and pale stools.

General measures

Identify and treat the cause•

Surgical correction extruhepatic cholestis •

Stop the offending medicine •

Medical treatment

Treatment of underlying condition •

Cholestyramine (O)• 4 -16gm/day to relieve itching

CAUTION: Cholestyramine may bind other medicines in the gut (Warfarin) which

should be taken one hour before cholestyramine ingestion

1.9.1 Acute liver failure/Hepatic encephalopathy

General measures

Identify and if possible eliminate the cause (e.g drugs, viral hepatitis, septicaemia, •

toxins, alcohol or upper G.I bleeding)

Avoid use of all unnecessary drugs including diuretics and sedatives•

Provide non protein containing high calorie food (2000kCal/day)•

Medicine treatment

Doxycycline (O) 100mg twice daily through nasogastric tube;

Give laxatives to provoke diarrhoea

Magnesium sulphate (O) 4g with water twice daily, until diarrhoea is

induced or lactose

Carry out high bowel washout once

Give dextrose 10% (IV infusion) 3 litres/day with 2g (26mmol) potassium chloride •

added to every litre bag (if renal function is satisfatory)

Check for any infection and treat immediately•

If signs of bleeding are present give vitamin K (IV) 10mg•

Add

Fresh Frozen Plasma initially

Add

Platelets if count <20 x 10g/1and patient is still bleeding

If ethanol etiology is suspected give•

Thiamine (IV) 10mg before dextrose infusion and continue daily for 3 days.

As cites of chronic liver failure

Parecentesis diagnostic should be performed where possible•

Restrict intake of salt•

Not more than 1 litre of ﬂ uid per day•

Weight loss should be at 0.5 kg per day. Further reduction of weight per day could lead •

to hypovolaemia and induce liver failure.

For patients not responding to the above measures give

Spironolactone (O) 100mg once daily, increasing to 400mg daily as required.

CAUTION: No potassium supplements with these diuretics.

In case the above measures fails give Frusemide (O) start at 40mg daily increasing

gradually

NOTE: Stop if encephalopathy or uraemia develop

2. RESPIRATORY DISEASE CONDITIONS

2.1 Acute Respiratory Infections (ARI)

2.1.1 Pneumonia

Clinical features: Pneumonia is the inﬂ ammation of the lung tissue. Pneumonia

can either be primary (to the causing organism) or secondary to pathological damage in

the respiratory system. The common causative organism for bacterial pneumonia are

Streptococcal pneumoniae, Hemophilus inﬂ uenza, Staphylococcus aureus, and Mycoplasma pneumoia,

viral or parasitic e.g Pneumocystis carinii. The important clinical features are high fever 39°c,

dry or productive cough, central cyanosis, respiratory distress, chest pain and tachypnoea.

2.1.2 ARI in Children

Clinical features for children under ﬁ ve years of ag e

The important symptoms in children are coughing or difﬁ cult breathing. Classiﬁ cation

of pneumonia in children is based on respiratory rate which is either fast breathing or

chest drawing.

Fast breathing is deﬁ ned as

Respiratory rate>60, age less than 3 months•

Respiratory rate > 50, age between 3 months and 5 years•

Chest in drawing is when the lower part of the chest moves in when the child breaths •

in.

Table: 5 Important clinical features of pneumonia in under-ﬁ ves

AGE SIGNS CLASSIFICATION

Infants less than 2

months

Severe chest in drawing•

60 breaths per minute or •

Severe pneumonia (all young

infants with pneumonia are

classiﬁ ed as severe)

No severe chest in drawing•

Less than 60 breaths per •

minute

No pneumonia:

Cough or cold

Children from 2

months to 1 year

Chest in drawing• Severe pneumonia

No chest in drawing•

50 breaths per minute or •

Pneumonia

No chest in drawing•

Less than 50 breaths per •

minute

No pneumonia

Cough or cold

Children from 1

year to 5 year

Chest in drawing• Severe pneumonia

No chest in drawing•

40 breaths per minute or •

Pneumonia

No chest in drawing•

Less than 40 breaths per •

minute

No pneumonia

Cough or cold

Table 6: Treatment guidelines

AGE CLASSIFICATION TREATMENT IN

DISPENSARIES

AND HEALTH

CENTRES

TREATMENT

IN HOSPITALS

OR WHEN

REFERRAL IS

NOT FEASIBLE

Infants less than

2 months

Severe Pneumonia Refer urgently to

hospital after ﬁ rst

dose of Benzyl

penicillin or

chloramphenical

Benzyl penicillin +

Gentamicin

Children from

2 months to 5

years

Severe pneumonia Refer urgently to

hospital after ﬁ rst

dose of Benzyl

penicillin or

Chloramphenicol

Benzyl penicillin or

chloramphenicol

Pneumonia Co-trimoxazole Co-trimoxazole

Alternative

Procaine

Penicillin fortiﬁ ed

or Amoxycillin

No pneumonia:

Cough or cold with

honey

No antibiotics

Safe cough remedy

like tea with honey

No antibiotics

Safe cough remedy

like tea

NOTE: Co-trimoxazole is the medicine of choice for treating pneumonia in children,

it should however, not be used for infants less than 1 months. Co-trimoxazole is active

against important respiratory pathogens such as S.pneumonie, S.aureus, and H.. inﬂ uenzae.

Compliance is good as the drug is administered twice daily. It is considerably cheaper

than procaine penicillin, and the drug can be given at home

Table: 7 Dosage schedule for treatment of pneumonia

Co-trimoxazole Amoxycillin Procaine

penicillin

Benzyl

penicillin

Gentamicin Chloramphenical

Less than 2

months (3-5kg)

0.5 ml syrup/kg

12 hourly for 5 days

25mg/kg 6 hourly for

5 days(syrup or 250

mg cap)

50,000U/kg

1daily for 5 days

(i.m)

50,000U/kg 6

hourly (i.m)

25mg/kg

8hourly (i.m)

(inj.10mg/ml)

25mg/kg 6 hourly (i.m) (1gr in

4ml sterile water)

2.5ml syrup or ¼ of

480 mg tab

5ml syrup 200,000U 200,000U 1ml 0.5ml

2months up to

1year (6-9kg)

5ml syrup or ½ of

480 mg tab

10ml syrup or 1cap 400,000U 400,000U 2ml 1ml

1 year up to 3

years (10-14kg)

7.5ml syrup or 480mg

tab

10ml syrup or 1cap 800,000U 600,000U 3ml 1.5ml

3 years up to 5

years (15-19kg)

7.5ml syrup or 480

mg tab

10ml syrup or

1capsule

800,000U 800,000U 2ml

NOTE:

Avoid Co-trimoxazole in infants less than one month of age•

For the ﬁ rst week of life: Benzyl penicillin plus Gentamicin 12 hourly•

Do not give Chloramphenicol to premature neonates. Young infants more than•

1 week of age, give chloramphenicol 12 hourly

2.1.3 Wheezing

Management guidelines

In a young infant below 3 months, wheezing is a sign of serious illness REFER

IMMEDIATELY. Wheezing for infants between 3 and 12 months may be due to

bronchiolitics a viral infection, REFER. In Children more than 1 year wheezing may be due

to Asthma-REFER for assessment or give antiasthmatic. If the child is in distress, give a

rapid – acting bronchodilator and REFER.

Bronchodilator in Children 1-5 years

If a rapid acting bronchodilator is required

Medicine of Choice Adrenaline 1:1000 (SC: 0.01 ml/kg body weight by

subcutaneous (SC) injection up to maximum of 0.25 ml

may be repeated after 20 minutes.

Oral bronchodilator (for Children 1-5 years)

Salbutamol (O) 0.4 mg/kg/day divided in 3-4 doses for 5

days.

2.1.4 Croup

Clinical features: Croup is acute laryngotracheobronchitis which occurs in young

children (usually between 6 months to 3 years of age) and arises as a result of nar rowing

of the airway in the region of the lar ynx. The most common cause is viral infection

(particularly parainﬂ uenza viruses) but may also be due to bacterial infection. The

obstruction is due to inﬂ ammation and oedema.

The symptoms include paroxysmal ‘barking’ cough and insipiratory stridor, fever, wheezing

and tachypnoea. Such symptoms usually occur at night. Respiratory failure and pneumonia

are potentially fatal complications.

Treatment guidelines

No stridor at rest, give no antibiotics•

Stridor at rest or chest in drawing or fast breathing • REFER IMMEDIATELY to

hospital.

Mild Croup

Only stridor when upset, no moderate/severe ARI

Likely of viral origin•

Home care – steam inhalation•

Antibiotics • NOT required

Severe Croup (Laryngotracheobronchitis)

Stridor in a calm child at rest•

Chest in drawing•

Management Guideline

Do not examine throat – likely bacterial origin•

Treatment Guidelines

Drug of Choice Amoxycillin (O)

Adult 10mg/kg body weight 3 times a day

Child up to 8 years 125 mg every 8 hours for 7 days

Second Choice Chloramphenicol (O) 12.5 mg/kg body weight every

8 hours for 7 days.

2.1.5 Laryngeal Diphtheria

Clinical features: Is an infection caused by Corynebacterium diphtheriae. It is directly

transmitted from person to person by droplets. Children between 1-5 years of age

are most susceptible although non-immune adults are also at risk. Diphtheria may be

asymptomatic or symptoms are characterized by grayish-white membrane, composed of

dead cells, ﬁ brin, leucocytes and red blood cells is seen as a results of inﬂ ammation due

to multiplying bacteria.

Treatment guidelines

Gently examine the child’s throat – can cause airway obstruction if not carefully •

done.

Medicine of choice: Procaine penicillin (IM) once daily for 7 days

NOTE: Tracheotomy may be required for airways obstruction.

2.1.6 ARI in Adult

2.1.6.1 Community Acquired Infections

First Line management

Chest X-ray not necessary but preferable for in-patient•

First Line Treatment

Table 8 – Treatment of Community Acquired Infections

Condition Treatment Duration

Mild pneumonia

(treated on out-

patient basis)

Amoxycillin (O) 250 – 500 mg three

times a day

5 days

Alternative

Co-trimoxazole (O) 960mg

(2 tablets of 480mg) twice daily

5 days

Severe

pneumonia (in-

patient)

Benzylpenicillin (IV/IM) 1-3 MU

every six hours (may complete course

with Amoxycillin (O) as above)

If compliance doubted

5-7 days

Benzathine penicillin (IM)

2.4 MU single dose

1 day

Second line treatment: If patient is in respiratory distress, or no response after 3 days

of ﬁ rst line treatment, or patient’s condition deteriorates, then investigate. For interpretation

of X-ray and management algorithm, see Section HIV related respiratory conditions

(applicable to HIV negative patients with difﬁ cult to treat bacterial pneumonias).

Table 9 – Treatment of Community Acquired Infections

Condition Treatment Duration

A typical Pneumonias

Alternative in pregnancy or

lactation or children under

12 year

Doxycycline (O) 200 mg stat

then 100 mg daily

Erythromycin (O)

500 mg every 6 hours

7 to 10 days

Pneumocystis carnii

pneumonia (PCP)(a)

Co-trimoxazole (O) 3 to 4 tabs

of 480mg every 6 hours

PLUS

Folic acid if cytopenic

Alternatively: Dapsone 100mg daily

for those allergic to sulphonamides

14 – 21 days

Staphylococcal

Pneumonia (b)

Cloxacillin (IV) 1 to 2mg every

6 hours

Clindamycin (IV/O) 600mg

every 6 to 8 hours

14 days

Klebsiella

Pneumonia (b)

Chloramphenicol (IV)

500 mg every 6 hours +/-

Gentamicin (IV) 4 to 5 mg/kg/24

hrs in 3 divided doses

10 to 14 days

NOTE: Alternative regimen for PCP and sulphanomide allergy is the following

combination (note the high cost)

Clindamycin (O) 600mg every 6 hours

Plus

Primaquine (O) 15 mg once daily

NOTE: Alternative in Staphylococcal and Klebsiella pneumonia: Ceftazidime (IV/IM)

every 8 hours

2.1.6.2 Hospital Acquired Infections

Table 10: Treatment of Hospital Acquired Infections

Condition Treatment Duration

Empirical treatment until

bacteriology available

Ampicillin (IV) 1g every 6 hours

PLUS

Gentamicin (IV) 4 to 5mg/kg/

day in 3 divided doses

7 to 10 days

2.1.7 Chronic Bronchitis

There are many aspects of management:

Stop smoking and/or remove from hazardous environment1.

Prompt treatment of infective exacerbations2.

Antibiotics as above•

Controlled oxygen therapy•

Physiotherapy•

Bronchodilator may give some beneﬁ t3.

Medicine of choice: Ipratropium aerosol 20 – 80mg, 6 – 8 hourly

Trial of steroids if there is any possibility of reversible airways obstructions4.

Prednisolone (O) 20mg once daily for 5 days

Assess response by changes in peak ﬂ ow rate.

2.1.8 Other Respiratory Infections

Table: 11 Treatment of other Respiratory Infection

Condition Treatment Duration

Chronic Bronchitis

(infective exacerbation)

Doxycycline (O) 200mg stat 100mg

daily or

Amoxycillin (O) 250 to 500mg three

times per day

Co-trimoxazole (O) 960mg (2 tabs of

480 mg) twice daily

5 to 7 days

Acute Bronchitis Antibiotics not usually needed; if required,

treat as above

Bronchiectasis Physiotherapy and postural drainage,

antibiotic as for chronic bronchitis

Lung Abscess or

Aspiration Pneumonia

Postural drainage

PLUS

Benzylpenicillin (IV) 2.5-5 MU

Every 6 hours with or without

Metronidazole (O)

400-500 mg three times per day

Amoxycillin (O)

250 to 500mg three times per day

4 to 6 week

4 to 6 weeks

2.1.9 Asthma

This is a chronic inﬂ ammation disorder of the airways, characterised by reversible airﬂ ow

distruction. There is also inﬂ ammation of the bronchial wall.

Clinical features: Asthma is a reversible obstructive airways disease of varying severity.

The symptoms are caused by constriction of bronchial smooth muscle (bronchospasm)

oedema of bronchial mucous membrane and blockage of the smaller bronchi with plug

of mucus. It can be due to identiﬁ able trigger factors or allergens (extrinsic asthma) and is

characterized by dyspnoea, wheezing and tightness of the chest and cough etc.

Management guidelines

Maintenance therapy should be adequate•

Treatment of acute attacks•

Avoid heavy exercise•

NOTE: The management of asthma in children is similar to that in adults. Infants

under 18 months, however, may not respond well to bronchodilator. Details of asthma

medicine treatment in children are given after that of adults below.

Table: 12 Asthma Score

Symptom’s (Frequency of Attacks of wheezing) Score A

Waking at night, more than twice weekly 4

Daily, but not at night 3

Not daily, but more than once weekly 2

Less than once weekly or on exercise 1

None for 3 months 0

Frequency of use of bronchodilator Score B

>4 times daily 4

1 to 4 times daily 3

< Once daily 2

1< Once weekly 1

None for months 0

NOTE

• Scoring system can help to assess the severity of asthma.

• Peak ﬂ ow meters when available should be used to assess the progress

Asthma Score

Add symptoms score (A) to the frequency of use of bronchodilator score (B). T he •

maximum score is 8

Score (A + B)

Mild asthma 0-3

Moderate asthma 4-6

Severe asthma 7-8

2.1.9.1 Chronic asthma in adults

Treatment guidelines

Oral beta 2-stimulant is the drug of ﬁ rst choice. It may be used intermittently as needed

or on a regular basis:

Medicine of choice Salbutamol (O) 2-4mg one to four times a day

Second choice Ephedrine (O) 30mg one to 3 three times a day Or

Aminophylline (O) 15-116mg//kgg/day in 3-4 divided

doses (maximum 1100 mg/day)

NB: Loading doses required: max. 500 mg/day increase after every 3 days to

maintenance.

2.1.9.2 Moderate Asthma in adults

If no response or poor response or troublesome side effects on oral treatment then try

beta 2-stimulant in inhaler/aerosol form.

NOTE Ensure competence in inhaler technique before stopping oral preparations

Second Choice If response still not adequate add Beclomethasone 50μ 1-4 metered

inhalations per dose 3-4 times daily.

CAUTION: Rinse mouth with water after administration

2.1.9.3 Severe Asthma in adults

Same drugs as for moderate asthma, but Add: Prednisolone (O)

2.5 – 10mg daily to the above therapy, but try to keep the dose as low

as it remains effective.

Nocturnal asthma

Patients, who get night attacks, should be advised to take their medication on going to bed.

If aminophylline has not been used its addition may be highly beneﬁ cial.

Treatment of Acute Asthma attacks in Adults

General measures:

Careful monitoring of the patient’s condition is essential to assess severity, and to •

detect improvement or deterioration. In the absence of blood gas facilities, this

will depend on close assessment of physical signs such as paradox, use of accessory

muscles, colour, mental state, etc.

Humidiﬁ ed oxygen by mask at high concentration (6 litres/min) is important.•

Consider ventilation in severe cases. A short period (5-10 minutes) of ventilation •

with ether or halothane may end the attack.

After an acute attack all patients should continue with bronchodilator. A course of •

high dose prednisolone should be given again with all but the mildest attacks.

Except in mild cases follow up is essential.•

NOTE: Treatment regimen of all degrees of asthma should include a steroid, preferably

an inhaler formulation

Acute Attack in Adults

Medicine Regimens

Adrenaline 1:1000 (SC) 0.5ml (injected subcutaneously). Repeat at 1-2 hour intervals

if necessary. This is useful when asthma is too severe for inhalation.

Aminophylline (IV) slow intravenous injection (over 20 minutes) 50-500mg. if patient

has not been taking aminophylline before. If he was on aminophylline give 3mg/kg.

Plus

Prednisolone (O) 30-40 mg once daily for 5 days

Severe Acute Attacks in Adults

If poor response to initial therapy give Adrenaline as above.

Plus

Hydrocortisone (IV) 200 mg as a single dose, further IV doses are needed only, if oral

dosing is not possible. At the same time, start on Prednisolone (O) 40-60 mg once daily

for 5 days. If chest is clear, at this stage steroids can be stopped without prednisolone

tapering of the dose, otherwise reduce by 5 mg/day a maintenance of 5 mg daily until the

patient is reviewed.

Plus

Aminophylline (slow IV) 6 mg/kg over 20 minutes unless the patient was on oral

aminophylline in the past 8 hours, in which case no bolus dose is required.

2.1.9.4 Maintenance therapy in children

Table: 13 Asthma Maintenance therapy in Children

SEVERITY OF ASTHMA TREATMENT

Mild intermittent, associate

mainly with respiratory

infections

Intermittent Treatment

Salbutamol (O) 0.15 mg/kg/day to the nearest 1 mg)

in 2 to 4 divided doses

1 to 5 years: 1 to 2 mg four times a day

5 to 12 years: 2 to 4 mg four times a day

>12 years: 4 mg four times a day OR if available

salbutamol inhaler intermittently

Moderate Frequent,

triggered by infection,

allergy, exercise etc.

Continuous treatment

Salbutamol (O/Inhalation) as above

+/-Sodium cromoglycate Inhaler (if available) 1

mg (1 spincap) three to four times a day. Dose may be

increased to a maximum of 2 spincaps six times a day.

Severe persistent wheeze

and/or failure to breath

Add to the Above

Beclamethasone inhaler (50 micrograms/puff)

1 to 2 puffs three to four times a day respond to the

above (always use a spacer)

Prednisolone (O) to 2 mg/kg/day initially, reducing

to dose which controls the asthma; then attempt to give

on alternative days (5 to 10 mg dose).

NOTE: Long term prednisolone in children should be avoided unless there is no

alternative

Acute Attacks in children

The same general measures apply as in adult. Give several puffs of salbutamol metered

inhalation. If poor response

Add Adrenaline 1;1000 (sc) 0.01 ML/KG

OR Aminophylline (slow IV) 4mg/kg over 10 minutes. Do not give if oral

aminophylline was given in the last 8 hours.

Unless response to the above is dramatic and complete, start:-

Prednisolone (O) 2mg/kg/day in divided doses for 3-5 days.

Severe Acute Attack in children

If response to the above therapy is inadequate, give

Dextrose 5% IV – 100 ml/kg/day

Plus

Aminophylline (IV infusion) at 0.8 – 1mg/kg/hour

Plus

Hydrocortisone(IV) 2mg/kg every 4 hours

Change to oral therapy when possible; Prednisolone (o) 2mg/kg/day for 5 days

Prophylaxis of asthma

Sodium cromoglycate is used in the prophylactic treatment of asthma including exercise-

induced asthma. It should however, not be used for acute attacks of asthma as it has no

effect on an established asthmatic attack. Sodium cromoglycate should be used regularly.

When withdrawing treatment, the dose should be reduced gradually over a period of one

week. Sodium cromoglycate should be used for at least 4 weeks before it can be proved

as ineffective.

2.1.10 Cough

Clinical features: Cough is a symptom produced by inﬂ ammatory viscid secretions or

obstruction of the tracheobronchial system. It may be dry or productive cough. Cough

may be paroxysmal, hacking, explosive, harsh (brassy).

Treatment guidelines

Causative/precipitating factors e.g. CCF, asthma, allergies must be established and treated

accordingly. Where causative/precipitating factors cannot be detected, the following

treatments may be offered:

Non-productive irriating cough

Codeine Cough syrup (O) (sedative) give 1.5 mg every 6 hours

Linctus codeine (O) give 5-10 ml every 6 hours

Expectorants may be used to liquefy viscid secretions.

NOTE: Antibiotics should never be used routinely in the treatment of cough

2.1.11 Whooping Cough

Clinical features: whooping cough is a highly infectious disease caused by Bordetella

pertusis. It is a childhood disease. The main clinical feature is paroxysmal cough associated

with a whoop.

Treatment guidelines

In the ﬁ rst week of infection (catarrhal stage)

Medicine of choice: Erythromycin (O) 10 mg/kg body weight every

six hours for 14 days

Second choice: Chloramphenicol (O) gives 12.5 mg/kg body

weight every 6 hours for 14 days

CAUTION: Chloramphenical should be used cautiously due to potential toxicity

of aplastic anaemia

Prevention: Whooping cough is preventable by immunization with pertussis vaccine

contained in DPT triple vaccine. It is advisable to start giving it at the age of 6 weeks and

repeated twice at 4 weeks interval.

2.1.12 Allergic rhinitis

Clinical features: Allergic rhinitis is caused by sensitivity reaction in the blood vessels

of the nasal mucusal e.g. due to pollen, animal hair or feathers. It is characterized by nasal

obstruction, bouts of sneezing and excess nasal discharge which is usually watery but

occasionally thick and mucoid.

Treatment guidelines

Attempts should be made to identify the responsible allergen – which should then be

avoided whenever possible. Desensitization for speciﬁ c allergens should be done.

Ephedrine (O) give 15-30 mg every 8 hours

Chlorpheniramine (O) give 4 mg every 8 hours

Promethazine (O) give 25mg every 12 hours

For patients unresponsive to antihistamines

Prednisolone (O) give 15-30 mg every 12 hours

and then gradual tapering is recommended.

Children: Ephedrine (O) 0.5 mg/kg body weight every 8

hours

Chlorphaniramine (O) give 0.1 mg/kg weight

every 8 hours

Promethazine (O) give (O) 0.25 – 0.5 mg/kg

body weight give every 12 hours

If unresponsive to antihistamines give Prednisolone (O) as for adult dose above

Surgery is indicated in the presence of polyps and drainage of purulent sinuses.

3. OBSTETRICAL/GYNAECOLOGICAL DISEASE CONDITIONS AND

CONTRACEPTION

3.1 Infection of the Genital-Urinary Tract

3.1.1 Urinary Tract Infection During Pregnancy

Clinical features:

Urine specimen for microscopy, with blood cells, culture and sensitivity tests should be

carried out before medicines are initiated, except on acute conditions.

Treatment:

First Line: Amoxycillin (O) 250 mg every 8 hours for 5 days

Trimethoprim (O) 300 mg once daily for 5 days

Plus

Folic acid (O) 5 mg once daily for 5 days

Second Line: Nalidixic acid (O) 100 mg every 6 hours for 5 days

with food

Positive RPR or Syphilis during pregnancy

Benzathine penicillin B (IM) 2.4 MU weekly 3

doses.

For Penicillin allergic patients give Erythromycin (O) 500 mg every 6 hours a day

for 14 days

3.1.2 Vaginal Discharge during Pregnancy

Clinical features:

Take carefull history (amount, colour, presence of odor, whether leaves stains in the

undercloth etc)

In children/infants due to immature epithelium common type candidiasis

Adults: Vulvo-vaginal candidiasis is characterised by pruritic, cord like vaginal discharge,

dysuria and dysporuria.

Treatment:

Nystatin pessaries insert 1 at night for 14 days OR

Clotrimazole pessaries/vaginal cream insert/

apply once at night for 3 days OR

Ketoconazole 200 – 600mg every 24 hours for

10 days OR

Fluconazole 200mg once daily for 14 days

Tricomanial vaginitis (TV): frothy/yellow green discharge, itching and dysuria

Treatment as above

Gonococcal vaginitis: Purullent yellow discharge, dysuria

Treatment: Benzathine Penicillin 2.4 MU IM 2 doses

Erythromycin 500mg every 6 hours for Penicillin allergic

individuals)

Persisted infections with fungal organisms require rule out systemic disorder such as

diabetis mellitus.

NOTE: The dose of Erythromycin may be reduced to every 8 hours if side effects

are intolerable, but the period should be extended appropriately.

Leukorrhoea (increased whitish discharge is common during pregnancy but does

not require treatment. However it is mandatory for all discharge to be thoroughly

investigated (start with simple investigations such as smers for wet and gram stain

microscopy. Incase of STIs, treatment of partner is mandatory

CAUTION: Avoid taking both medicines concomitantly if side effects are

intolerable

Avoid metronidazole in the ﬁ rst trimester

Avoid alcohol while taking metronidazole

3.2 Abortion

Clinical features: Interruption of pregnancy (expulsion of a foetus) before it is viable,

legally at 28

week of gestation. Clinical types are recognized according to ﬁ ndings when the

patient is ﬁ rst seen. These include: Threatened abortion, inevitable abortion, incomplete

abortion, complete abortion and missed abortion. Vaginal bleeding which may be very

heavy in incomplete abortion, intermittent pain which ceases when abortion is complete

and cervical dilation in inevitable abortion. In missed abortion, dead ovum retained for

several weeks while symptoms and signs of pregnancy disappear. When infected (septic

abortion) patient presents with fever, tachycardia, offensive vaginal discharge, pelvic and

abdominal pain.

Post abortal sepsis

Pyrexia in a woman who has delivered or miscarried in the previous 6 weeks may be due to

puerperal or abortal sepsis and should be managed actively. Abdominal pain in addition to

pyrexia is strongly suggesstive. The uterus needs evacuation. However, a patient must be

administered with antibiotics preferably parenteral before evacuation.

Mild/moderate

Medicine of choice: Amoxycillin (O) 500mg every 8 hours for 10 days

Plus

Metronidazole (O) 400 – 500 mg every 8 hours for 10

days

Plus

Doxycline (O) 200 mg stat, then 100 mg daily for 10

days

Treatment Guidelines for severe cases

Body temperature higher than (38

C) and marked abdominal tenderness are signs of

severe post abortal sepsis

Medicine of Choice Benzylpenicillin (IV) 2MU every 6 hours

plus

Chloramphenicol (IV) 500 mg every 6 hours

plus

Metronidazole (O) 1 g twice daily

NOTE: If patient cannot swallow give Metronidazole (PR) 1 gm twice daily or

IV/500 mg every 8 hours

Second Choice: Ampicillin (IV) 500 mg every 6 hours

plus

Gentamicin (IM) 80 mg every 8 hours

plus

Metronidazole (O) or (PR) 1 g twice daily

NOTE: Change to oral therapy if temperature rise is controlled

-Pelvic abscess may be suspected if after 48 hours no response, in this

case laparatomy or referral may be necessary

3.3 a) Prolonged Rupture Of Membrane (PROM)

Rupture of membrane before onset of labour•

b) Pre-term premature rupture of membrane (PPROM)

Rupture of membrane before term i.e. 37 completed weeks •

Clinical features:

Characterized by leakage of watery ﬂ uid per vagina which can be demonstrated by

performing a sterile speculum examination.

Prolonged PROM for more than 12 hrs is a risk of ascending infection which led to

chorioamnionitis (injection of chorion amnion and amniotic ﬂ uid)

Treatment

PROM at term: Delivery with 24hrs

PPROM: If no sign of infection, wait for foetal maturity and give prophylaxis

Amoxyllin (0) 500mg 6hrly x 10days

Erythromycin (0) 500mg 6hrly 10 days

If there are signs of infections, pyrexia, foul smelling liquor (chorioamnionitis)

Benzly penicilline (IV) 2MU every 6hrs

Chloramphenicol (IV) 500mg every 6 hours

Urgent Delivery irrespective of gestational age

3.4 Prophylaxis for Caesarian Section

Immediately before operation give Benzylpenicillin (IV) 5MU as a single dose

plus

Chloramphenicol (IV) 1 g as single dose

NOTE – Facilitate early delivery

– Continue with antibiotics after delivery for 3-5 days

NOTE: Use of antibiotics for prophylaxis during surgery, should be evaluated from

situation to situation and not generalized

3.5 Nausea and Vomiting in Pregnancy

If vomiting is not excessive, advise to take small but frequent meals and drinks•

In persistent vomiting cases, search for other reasons e.g. UTI, Multiple or molar •

pregnancy,

Otherwise give:-•

Medicine of Choice: Promethazine (O) 25 mg at night

Chlorpheniramine (O) 4 mg at night

Second Choice (Severe cases only)

Prochlorperazine (O) 5 mg up to 3 times per day

Hyperemesis Gravidarum (Vomiting and dehydration)

Admit and give dextrose 5% IV plus Promethazine (IM) 25 mg twice daily

Prochlorperazine (IM) 12.5 mg twice daily.

3.6 Anaemia During Pregnancy

Prophylaxis in antenatal Care

Ferrous sulphate (O) 200 mg twice daily

Plus

Folic acid (O) 5mg once daily.

CAUTION: Ferrous sulphate should be taken in a full stomach

Where vomiting is experienced reduce dosage to tolerable level

If patient has severe anemia in pregnancy the following clinical investigation should be

done:

Stool for ova and parasites-

Full blood count (FBC)-

Peripheral blood ﬁ lm for malaria parasites-

Urine for microscopy, culture and sensitivity test-

And HIV| test-

3.7 Hypertension in Pregnancy

3.7.1 Essential Hypertension

This is also called primary hypertension where systolic pressure raises to 140 – 159 mmHg

and/or diastolic pressure of 90 – 99 mmHg. The underlying cause of primary hypertension

is not clear.

Clinical features:

High blood pressure can cause symptoms such as headache, dizziness, fatigue, and ringing

in the ears. However it may cause no symptoms at all. High blood pressure can cause

damage to many organs, including the brain, eyes, heart and kidneys, as well as to arteries

throughout the body. If you have high blood pressure that has not been diagnosed, or

that is not being treated adequately, you are at greater risk of having a heart attack, stroke,

kidney failure and blindness.

Medicine of Choice: Methyldopa (O) 250 – 500 mg every 6-8 hours

daily

3.7.2 Pregnancy Induced hypertension (PIH)

Exclude UTI•

Check urine for protein•

Count this as a high risk antenatal patient•

3.7.3 Mild PIH

Diastolic: 90 – 100 mm, Hg no proteinuria (protein in urine)

Advice bed rest•

Weekly antenatal clinic visits•

May be given low doses of • Acetylsalicylic acid (O) 75 mg once daily

3.7.4 Moderate PIH

Diastolic: 100-110 mm Hg, no proteinuria

Consider low dose of Acetylsalicylic acid (O) 75 mg once daily plan immediate

delivery at gestation > 37 weeks.

Admit and monitor BP up to 6 times per day, and give methyldopa (O) 250 – 500 mg

every 6-8 hours daily

3.7.5 Severe PIH

Diastolic>110, give Nifedipine (Sublingual) 10 mg

The need for more doses indicates the urgency for delivery.•

3.7.6 Pre-Eclamptic Toxaemia (Proteinuria PIH)

Exclude UTI•

Check urine for protein daily•

Plan delivery at 37 weeks or before•

Consider low dose of Acetylsalicylic acid 75 mg once daily Also give:-•

Hydralazine (IM) 12.5 mg

Nifedipine (sublingual) 10 mg.

3.7.7 Imminent Eclampsia

This is proteinuria PIH characterized by visual disturbance, epigastric pain and or signs

of brisk reﬂ exes.

Prevent convulsion magnesium sulphate (mg SO4) 4g in 100mls normal saline 8 •

hourly

If diastolic pressure still > 110mmHg give antihypertensive hydralazine (im) 12.5 •

mg intermittently

Nifedipine 10mg once per day/every 12 hours•

3.7.8 Eclampsia (Proteinuria PIH with Fits)

Patient with pre-eclampsia developing convulsions.

Treatment guideline

Stop convulsions by Diazepam 10-20mg iv bolus, loading dose of mgso4 4g in •

20mls normal saline (IV) slowly for 10-15 minutes.

Maintanance dose 4g mg so4 in 1000mls normal saline 8 hourly.•

In case of recurrent seizure add 2g of MgSO4 in 10mls normal saline (iv) slowly for •

10 minutes

Give antihypertensive as above•

Plan urgent delivery within 12 hour, preferable vaginal delivery amitomy and •

induction with assisted vaginal delivery of the 2

stage

Caesarean section indicated for the obstetrical Indication•

NOTE: Maintain patient airway and secure IV line with a cannular.

Diabetes in Pregnancy (Gestational Diabetes)

Gestational diabetes develops in women during pregnancy because the mother’s body is

not able to produce enough insulin. High blood sugar levels in the mother’s body are

passed through the placenta to the developing baby. This can cause health problems.

Gestational diabetes usually begins in the second half of pregnancy, and goes away after

the baby is born. The cause of gestational diabetes is unknown. It is thought that the

hormones produced during pregnancy may block the action of insulin.

Diabetic pregnant women require management before and through out pregnancy

If possible they should be managed by specialists.•

Diabetes should be controlled by insulin and diet and not oral hypoglycaemics•

Diabetic should be advised to start insulin before conceiving•

Throughout pregnancy blood sugar should strictly be within the range of 4-6 •

mmol/L

Insulin requirement will increase as pregnancy progresses:•

Labour if possible should be in a tertiary level hospital•

When labour is induced give half the usual insulin dose ﬁ rst and start on IV infusion •

of dextrose 5% at 125 ml per hour.

Labour should be as short as possible•

Manage the patient on a sliding scale of insulin after delivery.•

3.8 Heart burn in pregnancy

Magnesium trisilicate compound tablets up to 10 tablets per day

3.9 Respiratory Distress Syndrome in newborn

Clinical features:

Respiratory Distress Syndrome may occur in newborn and in premature labour before 36

weeks gestation. The following steroids can be used to prevent this.

Medicine of choice Hydrocortisone (IV) 250 mg repeat after 24 hours

Second choice Dexamethasone (IV) 12 mg, two doses at an interval of 12 hours

NOTE: If no delivery the course can be repeated after one week

CAUTION: Anaemic patients under Beta stimulants and steroids are inclined to

congestive cardiac failure

3.10 Stimulation

Myometrial stimulants should be used with great care before delivery in highly parous •

women

Use in obstructed labour should be avoided•

Oxytocics are indicated for:-•

augmentation of labour-

Induction of labour-

Uterine stimulation after delivery-

Labour Induction: If no progress of labour is achieved give; Oxytocin (IV infusion)

as follows:

Initially 1 unit then 4 units in 1 litre Normal Saline at 15, 30, 60 drops per minute •

(dpm) until regular contractions lasting for more than 40 secondly are maintained.

When 4 units are not enough to cause maintained contractions, and it is ﬁ rst pregnancy, •

the dose can be increased (monitor) to 16, 32 then 64 units a the litre of Normal

Saline each time increasing the delivery rate through 15, 30 and 60 dpm.

Augmentation of Labour

If the membrane is already ruptured and no labour progressing, the steps above •

should be followed.

Obstructed labour could be the cause of labour failure.•

3.11 Myometrial Stimulation After Delivery

Excessive bleeding after the third stage of labour is a major cause of maternal mordidity

and mortaility. Post partum haemorrhage is deﬁ ned as excessive bleeding from the genital

tract after the third stage of labour (more than 500ml)

Major causes are;-

Uterine atony-

Tears of the vagina/vulva-

Rarely rupture of the uterus-

Bleeding disorder (e.g coagulopathics, DIC)-

In order to prevent the occurance of this condition, active management of the third stage

(ATMSL) is mandatory.

This involves the injection of an oxytocic after the delivery of the foetus followed by

controlled cord traction and uterine massage

Medicine of choice: Oxytocin (IM) 10 I.U.

Ergometrine (M) 0.25 – 0.5 mg

Misoprostol 600 microgram (mcg) orally

Misoprostol may cause mild shivering and a slight temperature rise.

Continuation of bleeding requires further investigation such as examination for tears in the

genital tract, bed side clotting time.

Patient may lose signiﬁ cant blood after normal procedure such as episiotomy and assisted

vaginal deliveries.

If bleeding continues recheck for uterine contraction, apply bimanual compression and

administor normal salineand refer (IV).

NOTE: Ergometrine is not preferred as it may cause BP rise in hypertensives patients

and patients with heart disease. It is unstable and may loose potency even within

using time. Examine the ampoule, colour change to yellow liquid may mean it is not

effective.

Store in a cool dark container and should not be used in patients known to be HIV

positive.

3.12 Myometrial Relaxation

This is done to relax the uterus in order to:

Relieve foetal distress immediately prior to caesarean section•

Stop contraction of uterine in premature labour•

Prevent uterine rupture•

Perform external cephalic version•

Medicine of Choice salbutamol (O) 4 mg every 8 hours

NOTE:

-(eg salbutamol) stimulants should NEVER be used if the patient had an

antepartum haemorrhage

-stimulants are CONTRA-INDICATED for the following

• With severe cardiac disease

• anaemia in pregnancy

3.13 Termination of Pregnancy

Abortion is illegal in Tanzania except where there is a substantial threat to the woman’s

health or life in continuing the pregnancy

3.14 Pregnancy and Lactation

General Guidelines

All medicines, if possible, should be avoided during the ﬁ rst trimester•

Well known drugs and their use in pregnancy and lactation, which have been •

documented as safe, should be preferred – AVOID new drugs

Absence from a list of medicines not to be used in pregnancy or lactation does not •

guarantee safety (annex products contraindicated in pregnancy and Laction)

During pregnancy and lactation, medicines should be prescribed only if beneﬁ t •

overweighs risk to the foetus or neonate.

3.15 Pelvic Inﬂ ammatory Diseases

Clinical features: Pelvic inﬂ ammatory disease (PID) occurs when there is infection

in the female reproductive organs. The infection can happen as an ascending infection

from the vagina, after delivery (puerperal sepsis), after an abortion (septic abortion)

postmenstrual or after Dilation and Curettage (D&C) operation. The common causative

organisms are Neisseria gonorrhea, Chlamydia trachomatis and Mycoplasma hominis. Endogenous

bacteria e.g. gram-negative aerobes and anaerobes like bacteroides, aerobic and anaerobic

streptococci, and E. coli may also cause PID. The condition can either be acute, sub-acute,

chronic or acute. The main clinical features are lower abdominal pain, backache, vomiting,

vaginal discharge, menstrual distrubance, dyspareunia, fever, infertility and tender pelvic

masses. PID predisposes to ectopic pregnancy.

Treatment guidelines

In acute PID: give Intravenous Dextrose 5%

Ciproﬂ oxacin (O) 500mg single dose

Doxycyline (O) 100 mg every 12 hourly for 14 days

And

Metronidazole (O) 400 – 500 mg every 8 hours for 10 days

Give an appropriate analgesic depending on the severity of the disease

Acetylsalicylic acid (O) 600 mg every 8 hours preferably after

food

Paracetamol (O) 500mg, 8 hourly

CAUTION: Patients on Metronidazole should not take alcohol

In chronic PID

Give an appropriate analgesic (aspirin or paracetamol) depending on the severity of the

pain.

NOTE: There is no need of antibiotics

3.16 Hormonal Contraception

Oral contraceptives (oestrogen – progestogen combinaitons) are used primarily for

prevention of conception. May also be used in treatment of dysfunctional uterine

bleeding, dysmenorrhoea or endometriosis.

The goal of therapy in the use of these products for contraception is to provide optional

prevention of pregnancy while minimizing the symptoms and long term risks associated

with excess or deﬁ ciency of the oestrogen and progestogen components.

The following questions may be asked to the woman intending to start taking contraceptives

before they are prescribed.

NOTE: Detailed information can be obtained from the Reproductive Health Clinic.

Check List Questions

NOTE: If the answer to All questions is NO the women may be given any oral

contraceptives. If in any of the questions the answer is YES.

Consult clinician.

History of severe leg pain or swelling of calf ?•

History of sugar in urine?•

History of yellow eyes or skin?•

Severe chest pain?•

Unusual shortness of breath after working or light work?•

Severe headaches (not relieved by headache tablets)•

Bleeding and/or between periods after sexual intercourse?•

Missed a menstrual period?•

Missed a menstrual period, then started bleeding?•

Very heavy menstrual periods?•

Increased frequency of menstrual periods•

History of mental disturbances?•

Goiter or history of goiter?•

35 years of age and over?•

Painful varicose veins?•

Had any surgical operations within the last 2 weeks?•

Normal delivery within 6 weeks?•

Received treatment for high blood pressure?•

History of epilepsy.•

NOTE: Establish the age of the woman intending to use contraceptives

3.17 Oral Contraceptives (OCs)

They fall into two major categories:

Combined Oral contraceptives (COCs)a)

Oestrogen 30 – 35 micrograms (as ethinylestradiol) - “Low Dose”

Oestrogen 50 micrograms + progestogen - “High Dose”

Triphasic pills – contain phased levels which closely mimic normal cyclical

hormonal acitivity

NOTE:

Lower oestrogen dose pills cause fewer side effects than higher dose pills•

Mid-cycle spotting in patients on 30 microgram COCs can be managed by •

changing to 50 microgram COCs

Menstruation on COCs will be regular, light and short•

Progestogen Only Pills (POPs)b)

These contain norethisterone, or norethindrone or norgestrel or levonorgestrel. This

type is suitable for lactating mothers or women with mild or moderate hypertension.

Menstrual irregularity is a common side effect.

Managementc)

Instruct women always to inform the doctor or nurse that they are on contraceptives •

while attending clinic or hospital.

Women on Oral Contraceptives need regular physical check-ups including blood •

pressure measurement every six months e.g. if women develop depression after

starting OCs.

Need to Withdraw COCs or POPsd)

Pregnancy•

Severe headaches especially associated with visual disturbances•

Numbness or paresis of extremities•

Unexplained chest pain or shortness of breath•

Severe leg pains•

Development of any of the absolute contra-indication conditions•

NOTE:

Medicine Reducing Effect of Oral Contraceptivesi.

The following drugs are likely to reduce the effectiveness of OCs and a woman may

become pregnant. If it is unavoidable to prescribe the following drugs, patients should be

cautioned appropriately; and if possible advised to use additional methods of contrace ption

such as condoms.

Hypnotic/sedatives and anti-migraine medication• such as barbiturates,

chloral hydrate, diazepam, phenytoin

Anti acids• : Aluminium hydroxide, magnesium hydroxide, magnesium trisilicate

Anti-tuberculosis medicines• (rifampin)

Certain antibiotics: • ampicillin and other penicillins and tetracyclines

Antiretroviral medicines• (Nevirapine, and ritonavir

NOTE:

For short term use of these drug, employing additional contraceptive methods may •

be beneﬁ cial e.g. condoms or abstaining from intercourse.

For long term use of these drugs “High Dose” COCs – 50 micrograms should be •

used or other method of contraception

Medicines made less Effective by Oral Contraceptivesii.

Prescribers might consider increasing the doses of the following drugs, known with

careful monitoring

Anticonvulsant•

Antidiabetic agents•

Anticoagulants•

Antihypertensive agents (methyldopa)•

Corticosteroid•

Hypnotics, sedatives or other CNS depressants•

3.17.2 Post Coital Contraception (“morning-after pill”)

The method is applicable mostly after rape and unprotected sexual intercourse where

pregnancy is not desired.

Within 3 days (72 hours) of unprotected sexual intercourse, give

Combined oral Contraceptive 100 microgram ethinyloestradiol and 500 micrograms

levonorgestrel (2 high dose COC tablets)

When this preparation is not available, use 3 tablets each containing 30-35 micrograms

ethinyloetradiol and 150-250 microgram levonorgestrel (3 low dose COC tablets).

Repeat this dose after twelve hours•

Advice to return to physician if menstruation does not occur within 3 weeks•

Give advice on contraceptive use•

Rape victims should also be given Erythromycin (O) 250 mg every 6 hours for 5 •

days

Offer counseling•

3.17.3 Long Term Hormonal Contraceptives

These contraceptives should be prescribed by medical doctors only or trained family

planning staff.

Injectable Contraceptivei.

Medroxyprogesterone acetate injection IM 150 mg every three months.

CAUTION: Avoid use in severe hypertension and in women without proven fertility

Implant Contraceptiveii.

Levonorgestrel in six silastic capsules is implanted in the left upper arm made under

local anesthesia.

Levonorgestrel is effective for ﬁ ve years and is recommended for women who have

completed their family or not ready for sterilization or those not able to take oestrogen

containing contraceptives.

Contraindications for Norplant

Severe hypertension•

Thromboembolism•

Active liver disease•

Sickle cell anaemia•

Undiagnosed genital bleeding•

Severe headaches•

Heart failure•

3.18 Antepartum Haemorrhage (APH)

Clinical features: Bleeding from the birth canal after the 28

week of gestation. Main

forms are placenta praevia and abruptio placenta. Bleeding is painless in placenta praevia.

Bleeding may be visible or concealed in abruptio placenta. Pain and shock in abruption

placenta correspond with degree of separation.

Treatment guidelines

Expectant therapy

Allow bed rest

Blood grouping and cross-matching

Active therapy delivery if foetus viable. If a major placental separation has occurred,

emergency delivery to minimize the possibility of disseminated

Intravascular coagulation

Give blood when indicated

3.19 Dysmenorrhoea

Clinical features: Dysmenorrhoea is painful menstruation. Dysmenorrhoea is

present if pain prevents normal acitivity and requires medication. There are 3 types of

dysmenorrhoea:

Primary (no organic cause), Secondary pathological cause e.g. PID and uterine polyposis

and membranous (cast of endometrial cavity shed as a single entity (rare). Typically, in

primary dysmenorrhoea pain occurs on the ﬁ rst day of menses, usually about the time the

ﬂ ow begins, but it may not be present until the second day. Nausea and vomiting, diarrhea

and headache may occur.

Treatment guidelines

-Allow bed rest

-Analgesics and antispasmodics such as

Hyoscine-butylbromide 20mg 8 hourly (Adult); 10mg 8 hourly (children

6-12 yrs)

Mefenamic acid 500mg every after 8 hours

Ibuprofen 200-600 mg every 8 hours (maximum 2.4 g/day)

Acetylsalicylic acid 300-600 mg every 4 hours

Diclofenac 25 mg 2-3 times a day

Women with regular complaints can easily detect length of use during their periods (2-3

days usually sufﬁ cient). Treat the underlying condition if known

NOTE: For primary dysmenorrhoea patients may be advised to start taking Ibuprofen

one or two days before menses and continue for three to four days during menses to

minimize painful menstruation

3.20 Dysfunctional uterine bleeding (DUB)

Abnormal uterine bleeding without pathological lesion in the uterus or lower genital

tract.

Diagnosis after excluding pathology in the uterus, endometrium, cervix vagina and vulva.

The physiology behind is thought to be due to anovulatory cycles and hormonal

imbalance. Other factors that can change bleeding patterns include medications,

excessive weight loss, obesity, stress or illness.

Treatment

(a) Hormonal therapy

Norethisterone (Primolut N) 5mg 12hourly for 10 -14 days

COC (E+P) Combined oral contraception 2-3 cycles.

(b) NSAIDS – e.g. Mefenamic acid 500mg every 8 hours to relieve pain

3.21 Infertility

Clinical features: This is failure to conceive after one year of regular coitus without

contraception.

Primary infertility: There has never been a history of pregnancy

Secondary infertility: There is a prior history of conception and then failed to conceive.

Treatment guidelines

Emphasis should be paid to see and investigate the couple.

Referral to the specialist for infertility workup and treatment is advised.

Treatment in all cases depends upon correction of the underlying disorder(s) suspected of

causing infertility whether primary or secondary.

4. CARDIOVASCULAR DISEASE CONDITIONS

4.1 Infections

4.1.1 Prophylaxis of subacute Bacterial Endocarditis

To reduce the risk of bacterial endocarditis, antibiotic prophylaxis should be given to

patients with congenital heart disease; acquired valvular disease (notably rheumatic heart

disease), prosthetic heart valves that undergo any of the following:

Dental procedures•

Upper respiratory tract surgery, e.g. tonsillectomy•

Urinary tract instrumentation and surgery•

Dilatation and Curettage (D & C) in presence of infection•

Surgery through infected tissues•

4.1.2 Dental and Upper Respiratory Tract Procedures

Amoxycilin (O)

Adult 3g one hour before operative procedure.

Child 50mg/kg body weight one hour before operative procedure.

For patients allergic to penicillin group, give

Erythromycin (O)

Adults 1.5 g one hour before operative procedure and then give 500

mg six hourly after operation, as long as necessary.

Children 20 mg/kg body weight followed by 10mg/kg body weight

six hourly as long as necessary.

4.1.3 Genital-Urinary procedures

Adult Ampicillin (IV) 1.5-2 g

Plus

Gentamicin (IV) 5mg/kg body weight

Child Ampicillin (IV) 50 mg/kg body weight

Plus

Gentamicin (IV) 1.5-2mg/kg body weight

Both drugs should be given half an hour before the operation begins.

4.1.4 Patient with Prosthetic Valve

Adult Cloxacillin (IV) 2g

Plus

Ampicillin (IV) 2g

Plus

Gentamicin (IV) 5mg/kg body weight

Child Cloxacillin (IV) 50 mg/kg body weight

Plus

Ampicillin (IV) 50 mg/kg body weight

Plus

Gentamicin (IV) 1.5-2 mg/kg body weight

The above medicines should be given 30 minutes prior to procedure.

NOTE: Patients with prosthesic valve should be given warfarin in places where

prothrombin time can be determined.

4.2 Rheumatic Heart Disease

Clinical features: Clinical features of the rheumatic heart disease (RHD) are closely

parallel to those of acute rheumatic fever. The main site of pathology is on the valves.

There may be initial stenosis, mixed mitral valve disease (both stenosis and regurgitation),

mitral regurgitation due to chordal shortening, aortic stenosis and incompetence, aortic

regurgitation due to aortic cusp distention, acquired tricuspid valve disease resulting in

either stenosis or regurgitation. The main clinical features of rheumatic heart disease

depend on the valve damaged. For example in pure mitral stenosis there is reduction in

exercise tolerance, breathlessness and palpitation. In the case of aortic regurgitation, when

severe, then the clinical manifestations are those of left ventricular failure.

Treatment guidelines

Prophylaxis to prevent recurrence of rheumatic fever.

A patient with rheumatic heart disease is at risk of getting recurrences of acute rheumatic

fever, which may lead to further rheumatic heart disease manifestations with more valves

being involved or more damage to already affected valves.

Benzathine penicillin 1.2 MU IM every three weeks for life

Treat complications which arise e.g congestive heart failure

Valvular replacement surgery is indicated for the treatment of valvular rheumatic heart

disease

Anticoagulants (warfarin)

These are indicated in patient with prosthetic valves where regular determination of

prothrombine time is possible.

Refer such care for prothrombine determination and warfarin administration.

4.2.1 Rheumatic Fever

Treatment of Acute Attack

Benzathine penicillin (IM) as a single dose

Children under 5 years 0.3 MU

Children 5-10 years 0.6 MU

Children above 10 years and adults 1.2.MU

Phenoxymethylpenicillin (O) for 10 days

Children under 5 years 125mg every six hours

Children 5-10 years 250 mg every six hours

Children above 10 years and adults 500 mg every six hours

Erythromycin (O) 500mg every six hours for 10 days (penicillin allergy).

4.2.3 Prophylaxis after Rheumatic Fever

Prophylaxis should be given to all patients with a history of rheumatic fever and to those with

heart valve lesions thought to be or rheumatic origin. When possible, prophylaxis should

be continued up to 30 years of age. This may be individualized in some circumstances.

Speciﬁ c situations always requiring prophylaxis at least to 30 years are

High risk to Streptococcal infections•

Proved carditis in previous attacks•

Not more than 5 years since last attack.•

Table: 14 Antibiotics Prophylaxis after Rheumatic Fever

Antibiotic Children < 12

years

Children > 12 years and

adults

Benzathine penicillin (IM)

Phenoxymethylpenicillin

(O)

1.2.MU monthly

125-250 mg twice daily

2.4 MU monthly

250 mg twice daily

Penicillin allergy

Erythromycin (O) 125-250 mg twice daily 250 mg twice daily

NOTE: Prophylaxis is given to prevent recurrence of rheumatic fever, and is not enough

to protect against infective endocarditis. Phenoxymethylpenicillin and Erythromycin are

less effective

4.3 Treatment of Acute Arthritis and Carditis

Acetylsalicylic acid (O) 100 mg/kg/24 hrs in 4-6 divided doses for both adults and

children dose to be reduced if tinnitus or other toxic symptoms are observed.

NOTE: Acetylsalicylic acid should be continued until fever, all signs of joint inﬂ ammation

and the ESR have returned to normal, and then reduce gradually over two weeks. If

symptoms recur, full doses should be restarted

In severe carditis with development of increasing heart failure or failure of response to

acetylsalicylic acid, give: Prednisolone (O) 1.5 mg/kg/24 hrs

Gradual reduction and discontinuation of prednisolone may be started after at least 3-4

weeks when there has been a substantial reduction in clinical disease activity; Acetylsalicylic

acid should be continued as above.

NOTE: Heart failure should be managed in the usual way. All patients with carditis

must be kept on strict bed rest until all evidence of active carditis has resolved and the

ESR has returned to normal. Activity should then be gradually increased.

4.4 Hypertension

Clinical features: Hypertension is elevation of blood pressure (B.P) noted on at least

three separate occasions. The disease processes associated with high arterial pressure are the

consequences of the damage caused to the heart or to the arterial wall. The consequences

of the actual level of pressure in a given person will depend not only on the measured

level but also upon certain other ‘risk’ factors such as age, race, sex, glucose intolerance,

cholesterol and smoking habit hypertension. In over 80% of hypertensive patients no

speciﬁ c cause is detectable, hence the name ‘primary hypertension.’ Hypertension can be

secondary to conditions like coarctation of the aorta, renal disease, endocrine disease, EPH

gestosis and due to the contraceptive pill. Hypertension is symptomless in the majority

of patients. Because hypertension may result in secondary organ damage and reduced life

span it should be evaluated and treated appropriately.

Classiﬁ cation

Hypertension is categorized according to the level of the diastolic blood pressure (DBP)

and systolic as follows:

Diastolic Systolic

Mild hypertension: DBP 90 – 99 mm Hg 140-159mm Hg

Moderate hypertension: DBP 100 – 109 mm Hg 100-180mmHg

Severe hypertension: DBP 110 mm Hg or above 180mm Hg and above

Lower levels of blood pressure below 130/80 mmHg

are recommended for diabetics

Malignant hypertension: Severe hypertension associated with retinal exudates,

haemorrhages or papilloedema

Diagnosis

Blood pressure may rise transiently as a result of stress e.g. when consulting a clinician

(white coat hypertension). Therefore do not diagnose hypertension on the basis of a single

reading but conﬁ rm on three separate occasions. Readings should be carefully made and

measured to the nearest 2mm Hg phase V diastolic (disappearance of sounds).

A special large cuff is needed to accurately measure BP in those in whom the

sphygmomanometer bladder does not encircle the upper arm.

Points to Note

Antihypertensive treatment is required for life in truly hypertensive patients•

Hypertension often has no symptoms: the aim of treatment is to lower the risk of •

end-organ damage, especially stroke

Compliance is the most important determinant of blood pressure control. •

Explanation, education and minimizing side-effects of drugs are important

Extra care should be taken with antihypertensive drugs administered to those over •

60 years of age, because of increased side-effects. Lower doses are needed

Recommended an alternative contraceptive method for women using oestrogen •

containing oral contraceptive

Evidence of end organ damage, i.e. cardiomegaly, proteinuria or uraemia, •

retinopathy or evidence of stroke, dictates immediate treatment

Patients should be reviewed every 1-3 months, and more often if necessary•

Urgent blood pressure reduction may precipitate stroke or blindness. It is only •

indicated in those patients with hypertensive crisis (see below)

The aim of treatment is to bring the diastolic BP below 90 mm Hg, without •

unacceptable side effects

Management

Change in Life style

Regular exercises and weight reduction for overweight patients•

These non-pharmacological measures should be applied in all hypertensive patients:

Dietary management •

Regular exercise•

Relaxation to calm down stress•

Discontinuation of smoking•

Avoidance of stress•

4.4.1 Mild Hypertension

Patients with mild hypertension generally can be treated by change in life–style alone but

consider total risk proﬁ le of a patient.

In diabetics for examples medical treatment preferably with a converting enzyme

inhibitor (captopril, enalapril) is recommended, to protect the kidney.

4.4.2 Moderate/Severe Hypertension

Consider drug therapy only in patients with average DBP over 100 mm Hg checked on at

least 3 occasions over 6 months in spite of changed lifestyle. Drug therapy is indicated

for all those with end organ damage. A step up approach is recommended for choice of

antihypertensive drugs.

Recommended Step-up Care

Step One Bendroﬂ uazide (O) 2.5 – 5mg daily

Hydrochlorthiazide (O) 12.5-25 mg once daily.

Step Two Hydrochlorthiazide (O) 25 mg daily

Plus

Methyldopa (O) 250 mg two to three times a day

Propranolol (O) 160-320 mg once daily

Atenolol 50 – 100mg once daily

Nifedipine modiﬁ ed release 20-30mg once daily

Step Three Captopril (O) 12.5 – 25 mg every 8 hours

4.5 Cardiac failure

Clinical features: It is a state in which an abnormality of cardiac function is responsible

for the failure of the heart to pump sufﬁ cient blood to meet tissue requirement.

Dyspnoea, orthopnea, paroxysmal nocturnal dyspnea, basal crepitation, congestive

hepatomegaly and peripheral oedema. The principles of therapy are removal of the

precipitating cause, e.g. pneumonia, correction of the underlying problem e.g. hypertension

and control of the congestive heart failure state.

NOTE: Constrictive pericarditis, liver and renal failure should be excluded before the

diagnosis of cardiac failure is made.

Precipitation factors should be sought and treated e.g.:•

Hypertension•

Infections (especially sub acute bacterial endocarditis) arrhythmias

Electrolyte imbalance

Anaemia

Drug overdose especially digoxin

Pulmonary embolism

Thyrotoxicosis

Daily weights and ﬂ uid balance (intake/output should be recorded as a simple •

measure of response to treatment. Weight loss should not exceed 1 kg per day

Restrict salt in diet•

Encourage bed rest•

Check BP daily•

4.5.1 Mild to Moderate and Severe Chronic Heart/Cardiac Failure

For most patients in sinus rhythm the following regimen is adequate:

Hydrochlorthiazide (O) 25 – 50 mg once daily, if necessary increase up to

100mg once daily

NOTE: Salt restriction and bed rest must be encouraged

If no response add Hydralazine (O) 25 mg twice a day increasing to a maximum of 50

mg two to three times a day.

BP should be monitored continuously.

For oedematous and bed ridden patients Heparin (SC) 5000 units 8 hourly day

NOTE: Duration of treatment will depend on response of the patient

4.5.2 Acute Pulmonary Oedema

Prop up in bed Oxygen 40% by mask ( 1-2 litres per minute)

Frusemide (IV) 40 – 80 mg once daily

Morphine (IV) 5-10 mg slowly over 1-2 minutes

If no response, recheck your diagnosis, then repeat with higher dose of frusemide. If

patient continues to deteriorate despite repeated doses of Frusemide then Hydralazine

(IV) may be life saving (see dosage under hypertensive crisis). Venescecting 1 unit of

blood may also be helpful.

Use and indications for Digoxin

Digoxin toxicity is a very common problem especially in the elderly and pediatric age

groups. Absolute indication is fast atrial ﬁ brillation

To digitalise (check serum potassium levels before starting) indicate recommeded serum

potassium levels

Digoxin (O)

Adults Average dose 500 mcg (0.5mg) stat followed by 125-250 mcg (0.125 – 0.25mg)

once daily

Children 10 mcg/kg/24 hours (once daily); However when starting treatment

give this dose 8 hourly in the ﬁ rst 24 hours then continue with one

dose daily.

4.6 Angina Pectoris

Clinical features: Angina pectoris is an episodic clinical syndrome resulting from

transient myocardial ischaemia which is caused by occlusive disease in the coronary arteries

usually secondary to atheromas but occasionally due to syphilitic coronary ostial stenosis,

coronary embolism or congenital abnormalities in the coronary vessels. The presenting

clinical features are a sense of oppression or tightness in the middle of chest which is

induced by exercise and is relieved by rest. The oppression or tightness lasts for a few

minutes. Prinz-metal variety of angina is experienced without exertion.

Change in lifestyle

Minimize risk factors with particular attention to:

Cessation of smoking•

Weight reduction if obese•

Control of hypertension•

Other factors which should be considered and addressed where appropriate include:

high blood cholesterol, stressful lifestyle and excessive alcohol intake. Regular moderate

exercises should be encouraged.

4.6.1 Stable Angina (Infrequent Attacks)

Acetylsalicylic acid (O) 150 mg once daily; (contraindicated in peptic ulcers)

Plus

Glyceryl trinitrate) (sublingual) 500 micrograms as required (no more than 3 tablets

every 15 minutes).

CAUTION: Acetylsalycilic acid (Aspirin) is contraindicated in patients with peptic

ulcers

NOTE: Glyceryl trinitrate deteriorates on storage. It is recommended that tablets be

kept in original container and not more than 3 months after opening. Do not leave the

container open for a long time, close immediately after use

Unstable Angina (Frequent Attacks)

Drug of choice: Isosorbide dinitrate (O) 30-120 mg/day in 12 hourly.

If no response, add:

Second line Propranolol (O) 40-80 mg every 8 hours

Atenolol (O) 50 – 100 mg once daily

Atenolol is preferred for diabetics and asthmatics. If there is no response to the

combination of nitrates and beta-blockers change to:

Nifedipine (O) 10-20 mg 8 hourly

NOTE: Nifedipine may replace or be cautiously combined with beta-blokers. If pain

continues inspite of above treatment refer patient for further management.

4.7 Myocardial Infarction (MI)

Clinical features: It is ischemic necrosis of the heart muscle due to occlusion of

coronary arteries by thrombus or sub-intimal hemorrhage at the site of atheromatous

narrowing. The cardinal symptom of MI is pain but breathlessness, vomiting and extreme

tiredness and syncope may be present. The pain occurs in the same sites as for angina

pectoris but is usually more severe and lasts longer.

Treatment guidelines

The main immediate needs are for the relief of pain and prevention or treatment of

arrhythmias and other complications

Acetylsalicylic acid 150 to 300mg mg start

Oxygen should be given

Morphine sulphate (IV) 2-4 mg every 5 minutes until pain subsides

Plus

Glyceryl trinitrate 500mcg sublingual for prophylasis

Heparin (IV) 5000 IU, 8 hourly in the acute phase and

Then

Warfarin (O) 5-10mg in 24 hours

General Measures

Bed rest•

Oxygen administration•

Set up an IV line (dextrose 5%)•

NOTE: Avoid IM injection where possible since this interferes with the measurement

of cardiac enzymes

If necessary, give oral antiemetic: Metoclopropamide 10mg; 8 hourly

NOTE: Thrombolytic/Anticoagulant therapy is only indicated in patients with infarcts

of less than 6 hours duration

Prochlorperazine (O) 5 mg every 4-6 hours when required

Streptokinase (IV) 1, 500, 000 IU intravenous in 100 ml normal saline or

dextrose 5% over 1 hour, to be preceded by hydrocortisome (IV) 100 mg as

a single dose

Plus

Heparin (IV) 20,000-30,000 IU per day in divided doses for 48 hours. To be

commenced 6 hours after streptokinase administration

Plus

Acetylsalicylic acid (O) 150 mg once daily

CAUTION:

Do Not •

give digoxin in acute infarction unless there is a supraventricular arrhythmias

which requires it

DO NOT use inotropic agents such as isoprenaline, glucagon or adrenaline, as they •

may be productive and cause an extension of the infarction indeﬁ nitely

4.7.1 Left Ventricular (Pump) failure

Treated in the normal way (see cardiac failure).

4.7.2 Arrhythmias

Bradycardia

Sinus Bradycardia

Post-infarction:

Atropine (IV) 0.6 mg to maintain pulse above 50 per minute

If chronic (sick sinus syndrome) patient requires pacemaker – refer to referral Hospital

NOTE: Post-infarction angina is treated as for angina pectoris.

4.7.3 Tachycardia

Atrial ﬁ brillation•

Direct current (D&C) cardioversion

CAUTION: If patient is on digoxin avoid it if there is mitral stenosis. Digoxin therapy

should be withdrawn 36 hrs before electric cardioversion.

Anticoagulants should be provided after D&C cardioversion for 4 weeks.

Supraventricular Tachycardia•

Consider D&C cardioversion if patient distressed.

Carotid sinus massage/valve manoeuvre

Verapamil (IV bolus) 5-10 mg

Repeat at 5 minute intervals until tachycardia controlled; max 1 g.

CAUTION: Verapamil with B-blocker combinations are dangerous. Verapamil with

digoxin combinations shoulde be used with caution.

Ventricular tachycardia•

Consider D&C cardioversion if patient distressed

Lignocaine (IV) 100 – 200 mg followed by infusion 2-4 mg per minute for 12-24

hours

Amiodarone 200-400mg daily

CAUTION: Ensure Potassium ion>3.5 mmol/1 in all arrhythmias

4.7.4 Rehabilitation

The period of bed rest, rehabilitation, and management varies in individual cases;

precipitating factors should be avoided, such as smoking, high cholesterol diet, stress, and

thrombogenic agents such as oestrogen.

4.7.5 Prevention of Re-infection

Acetylsalicylic acid (O) 150 mg daily.

The addition of B blockers may be beneﬁ cial:

Propranolol (O) 40 – 80 mg twice daily

Atenolol (O) 50 – 100 mg once daily.

Plus Simvastatin 20mg at night

5. MALARIA

Clinical features:

Malaria is an acute disease. Patients usually present with fever, chills and profuse sweating.

Howver, an individual with malaria infection may be completely asymptomatic. The clinical

features of malaria vary from mild to severe, according to the species of the parasite

present, the patient’s state of immunity, the intensity of the infection and the presence

of accompanying conditions such as malnutrition, anaemia and other diseases. The

above signs and symptoms are not speciﬁ c for malaria and can be found in other disease

conditions. Therefore, it is always necessary to ﬁ nd out other causes of illness.

Where possible, laboratory investigations are mandatory. Laboratory tests should be

interpreted in conjunction with clinical ﬁ ndings. Urgent laboratory investigations should

be made available for all patients admitted with severe malaria. Since parasite-based

diagnosis is important, rapid diagnostic tests (RDTs) may be an alternative or complement

to microscopy

The management of a patient with malaria will be determined by the clinical presentation

and the diagnosis of either uncomplicated or severe disease.

The objectives of treatment of uncomplicated malaria are:

To provide rapid and long lasting clinical and parasitological cure•

To reduce morbidity including malaria related anaemia•

To halt the progression of simple disease into severe and potentially •

fatal disease

Since the progression towards severe and fatal disease is rapid, especially in children under

ﬁ ve years of age, it is recommended that diagnosis and treatment of uncomplicated malaria

should be done within 24 hours from the onset of symptoms.

5.1 Treatment of Uncomplicated Malaria

First line: Artemether Lumefantrine (ALu).

Dosage regimen

Table 15: Dosage of Artemether 20mg & Lumefantrine 120mg (ALu) tablets

Weight

(Kg)

Age Day 1 Day 2 Day 3

Dose 1

Hours 0 8 24 36 48 60

Age Tab tab tab tab Tab tab

5 – 14

3 months up to 3

years

111111

15 – 24

3 years up to 8 years 2 2 2 2 2 2

25 – 34

8 years up to 12

years

333333

35 and

above

12 years and above 4 4 4 4 4 4

The ﬁ rst dose should be given as DOT; the second dose should strictly be given after 8

hours; subsequent doses could be given twice daily (morning-evening) in the second and

third day of treatment until completion of 6 doses. Third dose should be given 24hours

after the 1st dose followed by the treatment Internal of 12hours until completion of 6

doses.

NOTE:

ALu is not recommended for

Infants below 5kg body weight•

: Malaria is quite uncommon in infants

below 2 months of age (approximately below 5 kg). Since ALu is currently not

recommended for infant below 5kg body weight, quinine is the drug of choice

in this category

First trimester of pregnancy• : Presently, Artemisinin derivatives cannot be

recommended for treatment of malaria in the ﬁ rst trimester of pregnancy. During

the ﬁ rst trimester of pregnancy quinine should be used as drug of choice for

treatment of uncomplicated malaria. During the second and third trimesters of

pregnancy Artemether-Lumefantrine should be used as drug of choice for treatment

of uncomplicated malaria

Breast feeding mother whose infant is below 5kg body weight:•

ALU passes through milk. Safe of drug at this stage not known Quinine is drug of

choice at this category.

As far as possible malaria cases should be followed up on the third day if symptoms persist

or immediately if the condition worsens. Health workers should know where they could

refer cases that fail to respond to the recommended drug regimen for further investigations

and appropriate management

Where a patient returns between 4 to 14 days after treatment with ALu complaining of

continued symptoms of malaria, non-response should be considered and the following

recommendations followed after a full history and examination:

Where laboratory facilities are not available and malaria is still suspected, treatment •

with Quinine should be started immediately with strict follow up

Where laboratory facilities are available, a blood smear (and not RDT) should be •

examined. If parasites are found treatment with Quinine should be started and

treatment failure recorded. If parasites are not found other causes for the symptoms

should be sought and treated accordingly

Second line for uncomplicated malaria: Quinine (O)

Adults 600 mg (salt) 8 hourly for 7 days

Children 10mg/kg (salt) 8 hourly for 7 days

CAUTION: Quinine may have side effects even at this dosage tinnitus, mufﬂ ed hearing,

sometimes vertigo or dizziness. These side effects disappear a few days after completion

of the course. Hypotension and hypoglycaemia can appear especially if injected rapidly

by the intravenous route.

5.2 Treatment of Complicated Malaria

Severe Plasmodium falciparum malaria is a medical emergency. Delay in diagnosis and

provision of appropriate treatment may lead to serious complications and even death. In

Tanzania the commonest presentations of severe malaria are severe anaemia and cerebral

malaria.

NOTE: It is important that therapy is initiated without delay at a health facility in

accordance with treatment guidelines

Whe

re facilities for administration of IV quinine are not available

management should include

Early diagnosis of severe malaria based upon a complete history, physical examination •

and where possible, blood smear/rapid diagnostic test (RDT) examination for

malaria parasites. Taking and reporting of blood smear must not be allowed to delay

treatment unduly.

Provision of pre-referral treatment with intra-muscular quinine and •

Immediate referral with clinical summary, to the nearest health care facility where •

resources for the continuing care of patients with severe malaria are available

Quinine Administration (i.m.) (a)

Dilution of Quinine Dihydrochloride injection (300 mg/ml) for intra-muscular use:

dose of 10 mg of salt/kg bodyweight (not exceeding a maximum dose of 600mg).

Quinine should be diluted four times in water for injection to a concentration of

60 mg/ml. This dilution will minimize the risk of sterile abscess formation. The

calculated dose should be divided into two halves and then administered by deep

intra-muscular injection preferably into the mid anterolateral aspect of the thigh (one

injection on each side). Preferably the dose should be calculated for each single patient

according to the body weight. Table below is given for guidance

Table 16: Dilution schedule for intra-muscular Quinine administration

(Dose = 10 mg/kg of body weight)

Age

(years)

Weight

(Kg)

Volume

undiluted

Quinine

(300 mg/

ml)

Volume

of diluent

(to add

to each

dose)

Total

volume

of diluted

Quinine

(60 mg/

ml)

2 up to 4 months 4 up to 6 0.2 ml 0.8 ml 1.0 ml

4 up to 9 months 6 up to 8 0.3 ml 1.2 ml 1.5 ml

9 up to 12 months 8 up to 10 0.4 ml 1.6 ml 2.0 ml

12 months up to 3yrs 10 up to 14 0.5 ml 2.0 ml 2.5 ml

3 up to 5 15 up to 19 0.6 ml 2.4 ml 3.0 ml

5 up to 8 19 up to 25 0.7 ml 2.8 ml 3.5 ml

8 up to 12 25 up to 35 1.0 ml 4.0 ml 5.0 ml

12 up to 14 35 up to 50 1.4 ml 5.6 ml 7.0 ml

14 up to 16 50 up to 60 1.8 ml 7.2 ml 9.0 ml

16 and above 60 and above 2.0 ml 8.0 ml 10.0 ml

Where facilities for administration of IV quinine are available management

should include:

Early diagnosis of severe malaria based upon a complete history, physical examination •

and blood smear/RDT for malaria parasites. Taking and reporting of blood smear

must not be allowed to delay treatment unduly

Provision of appropriate treatment with intra-venous Quinine•

Treatment of hypoglycaemia. Hypoglycaemia remains a major problem in the •

management of severe malaria especially in young children and pregnant women. It

should be deliberately looked for and treated accordingly.

Referral with clinical summary to the nearest hospital when clinical need dictates (e.g. •

blood transfusion or intensive care)

(b) Quinine (i.v. infusion)

Quinine dose: 10 mg/kg body weight of salt, to be diluted in 5-10 ml/kg body

weight of 5% Dextrose or dextrose-saline and infused over 4 hours and repeated

every 8 hours. Infusions should be discontinued as soon as the patient is able

to take oral medication. Patients should be properly instructed to complete the

7-day treatment with quinine tablets or, alternatively, a full course of ALu may be

administered to complete treatment

The drop rate for quinine IV infusion is calculated as follows:

Drop rate per minute = amount of ﬂ uid to be infused (in ml) x 20

(drop factor)

time period to be infused (in minutes)

The table below is given for easier calculation:

Table 17: Dilution schedule and drop rate for intravenous Quinine

administration

Age

(years)

Weight(kg)

Quinine

dose

Volume of

undiluted

quinine

solution

(300mg/ml)

Amount

of ﬂ uid to

be infused

(in 4

hours)

Drop

rate per

minute

2 up to 4

months

4 up to 6

60 mg

0.2 ml 50 ml 4 drops

4 up to 9

months

6 up to 8

90 mg

0.3 ml 100 ml 8 drops

9 up to

12months

8 up to 10

120 mg

0.4 ml 100 ml 8 drops

12 up to 3yrs

10 up to 14

150 mg

0.5 ml 100 ml 8 drops

3 up to 5

15 up to 19

180 mg

0.6 ml 150 ml 13 drops

5 up to 8

19 up to 25

210 mg

0.7 ml 200 ml 17 drops

8 up to 12

25 up to 36

300 mg

1.0 ml 250 ml 21 drops

12 up to 14

36 up to 50

420 mg

1.4 ml 350 ml 30 drops

14 up to 16

50 up to 60

540 mg

1.8 ml 500 ml 42 drops

16 and above

60 and

above

600 mg

2.0 ml 500 ml 42 drops

CAUTION:

The initial dose should be halved if patient had received quinine, quinidine or •

meﬂ oquine during the previous 12 – 24 hours.

Maintenance dose should be reduced 7 mg/kg body weight in patients with impaired •

renal function

Pulse and blood pressure should be closely monitored during administration•

Direct I.V injection should NOT be given. Hypoglycaemia may occur after I.V •

administration of Quinine

Patients with Malaria who have not responded to quinine therapy should be given

parenteral Artemether.

Dose: 3.2 mg/kg Stat IM followed by 1.6 mg/kg IM daily for 6 days

General measure for severe malaria treatment

Coma• (cerebral malaria): maintain airway, nurse on side, exclude other causes of coma

( e.g. hypoglycaemia, bacteria meningitis)

Hyperpyrexia• : fanning, paracetamol

Convulsions• : treat as directed in section … (CNS disorders).

Hypoglycaemia• : urgent and repeated blood glucose screening;

In children: give 5 mls/kg of 10% dextrose OR 2.5 mls/kg of 25% dextrose as bolus; •

if 50% dextrose solution is available, it should be diluted to make 25% by adding an

equal volume of water for injection or normal saline

In adults: give 125 mls of 10% dextrose OR 50 mls of 25% dextrose dextrose as •

bolus

Where dextrose is not available, sugar water should be prepared by mixing 20 gm of •

sugar (4-level tea spoons) with 200 ml of clean water. 50 ml of this solution is given

ORALLY or by naso-gastric tube if unconscious

Severe anaemia• : transfusion of packed cells if Hb equal or less than 4 g/dl and/or

signs of heart failure and/or signs of respiratory distress

Acute pulmonary oedema• : review ﬂ uid balance and run patient on “ dry side”

but avoiding inadequate perfusion of kidneys; set up Central Venous pressure (CVP)

line, give oxygen. Intubation/ventilation may be necessary

Acute renal failure• : exclude pre-renal causes, check ﬂ uid balance and urinary

sodium. If adequately hydrated (CVP>5cm) try diuretics. Haemodialysis /

haemoﬁ ltration should be started early in established renal failure.

5.3 Management of malaria in pregnancy

Malaria is an important cause of morbidity and mortality for the pregnant woman, the

foetus and the newborn. The effects of malaria in pregnancy are related to the malaria

endemicity, with abortion more common in areas of low endemicity and intrauterine

growth retardation more common in areas of high endemicity. Early diagnosis and

effective case management of malaria illness in pregnant women is crucial in preventing

the progression of uncomplicated malaria to severe disease and death.

(a) Management of uncomplicated malaria

During history taking and physical examination, it is particularly important to elicit signs

and symptoms of severe malaria. Whenever malaria is suspected, laboratory conﬁ rmation

of malaria parasites should be performed if possible. If laboratory facilities are not

available, treatment should be started on the basis of clinical presentation. If a laborator y

is present, a negative result does not rule out malaria. RDTs have an added value, as they

can be positive even if parasites are hidden in the placenta.

Quinine is safe in pregnancy. In therapeutic doses it does not induce labour. Uterine

contractions and foetal distress with the use of quinine may be attributable to fever and

effects of malaria disease.

Presently, Artemisinin derivatives cannot be recommended for treatment of malaria in

the ﬁ rst trimester of pregnancy. However, they should not be withheld if treatment is

considered to be life saving for the mother and other antimalarial are considered to be

unsuitable. Artemether-lumefantrine (ALu) is not recommended during pregnancy in the

ﬁ rst trimester.

During the ﬁ rst trimester of pregnancy quinine should be used as drug of

choice for treatment of uncomplicated malaria.

During the second and third trimesters of pregnancy Artemether-Lumefantrine

should be used as drug of choice for treatment of uncomplicated malaria

(b) Management of severe malaria in pregnancy

Pregnant women infected with malaria are more susceptible to develop severe malaria.

They commonly present with one or more of the following signs/symptoms: high fever,

hyperparasitemia, low blood sugar, severe haemolytic anaemia, cerebral malaria, pulmonary

oedema

The management of severe malaria in pregnant women does not differ from the

management of severe malaria in other adult patients. The drug of choice for treatment

of severe malaria is intravenous quinine. The dose is 10mg quinine dihydrochloride

salt/kg body weight given by infusion in 5% dextrose over four hours, repeated every eight

hours. Infusion should be discontinued as soon as the patient is able to take medication

orally.

The risk of quinine induced hypoglycaemia is greater in pregnant than non-pregnant

women. Blood sugar should be monitored regularly and if falls below 2.5 mmol/L (< 45

mg/dl) give IV 10% or 25% dextrose. While the patient is on IV Quinine treatment, pay

particular attention to the feeding of the patient.

5.4 Intermittent preventive treatment (IPT)

The drug of choice for IPT is sulfadoxine/Pyrimethamine (SP)

SP remains the drug of choice for IPT even though it is no longer the ﬁ rst line drug

for malaria treatment. This is because the aim of IPT is to prevent the worst effects of

infection, rather than to cure a potentially life threatening illness. As such, lower efﬁ cacy

antimalaria is acceptable for IPT than for curative purposes. It is particularly important

that drugs used in pregnancy are known to be safe. It is also likely that drugs with a long

half-life are the most effective when used as IPT

The ﬁ rst IPT dose is administered between 20-24 weeks of gestational age. The second

IPT dose should be administered at 28 – 32 weeks.

NOTE: IPT should be administered as direct observed treatment (DOT) during an

antenatal care visit

6. SKIN DISEASE CONDITIONS

6.1.1 Bacteria Pyrogenic Skin Infection

Clinical features: Bacterial skin infections can be either impetigo, erysipelas or recurrent

boils. All these are caused by either staphylococus alone or together with streptococcus

but rarely streptococus alone. There are other non-bacterial skin infecitions e.g. viral

(warts, herpes simplex, herpes zoster and varicella, kaposis varicelliform eruption), fungal

(candidiasis, ringworm and tinea vesicolor), skin infestations (scabies and pediculosis)

6.1.2 Impetigo

A superﬁ cial bacterial infection causing rapidly spereading blisters and pustules. It occurs

commonly in children, usually starting on the face, especially around the mouth or nose.

Often due to Staphylococcus aureus.

Keep infected areas clean and prevent spread to others [(care with towels, clothes, bedding;

change frequently)

Bath affected parts/soak off the crusts with:

Cetrimide or chlorohexidine

Simply with soap and water.

If severe, or systematic symptoms are present (e.g. Pyrexia) add an oral antibiotic.

Systemic

Medicine of Choice Flucloxacillin (O) for 7 – 10 days

Adults 250 – 500mg four times daily (every 6 hours)

Children 50 – 100 mg/kg/24hrs every hours in equal doses.

Erythromycin (O) for 7-10 days

Adult 250 – 500mg every 6 hours

Children 25-50mg/kg/every 6 hours in a day

Topical Mupirocin ointment 2% 12 hourly

NOTE: For S. aureus erythromycin or Cloxacillin are preferable as they are likely to be

effective against these organisms.

6.1.3 Folliculitis

Superﬁ cial infection causing small pustules, each localized around a hair. Deep follicular

inﬂ ammation often occurs in the bearded areas of the face (Sycosis barbae).

Treatment:

Suspected irritants should be avoided•

Use of suitable disinfecting and cleansing agents should be encouraged•

Apropriate anti-infective skin preparations (Neomycin sulphate, gentamicin •

oxytetracycline cream/ointment or mupirocin ointment 2% can be used.

6.1.3 Furunculosis

Painful boil most frequently caused by Staphylococcus aureus. The skin around becomes

red and hot. Usually resolves itself, but improved by placing frequent hot compresses over

the boil until it breaks.

In a healthy person, review after 2 days, if not improving consider surgical incision and

drainage.

NOTE: For If the boil causes swollen lymph nodes and fever, consider systemic

antibiotics

Drug of Choice Flucloxacillin (O) for 5 – 7 days

Second Choice Erythromycin (O) for 5-7 days

Adult: 250 – 500mg every 6 hours

Children: 25 – 50 mg / kg every after 6 hours

6.1.4 Erysipelas

A superﬁ cial cellulitis with lymphatic vessel involvment, due to streptococcal infeciton.

Begins as a small break in the skin or umbilical stump (infants). The area affected has a

growing redness, accompanied by high fever and pains. Responds to oral penicillin.

Medicine of choice Phenoxymethylpenicillin (O) for 5-7 days

Adults: 250 – 500mg every 6 hours

Children: 25mg/kg/every 6 hours in a day

NOTE:

Starting with benzylpenicillin injection offers no advantage•

Erysipelas has tendency to recur in the same area, especially if there are predisposing •

factors such as chronic lymphatic oedema. In recureent episodes, increase duration

of antibiotic to 10-14 days

Bed rest, elevate the affected part and potassium permanganate or topical Mupirocin •

ointment 2% compresses may be beneﬁ cial

6.1.5 Acute Cellulitis

Inﬂ ammation of the deeper, subscutaneous tissue most commonly caused by streptococci

or staphylococci

Acute cellulitis should be differentiated from erysipelas as follows:

Raised, sharply demarcated margins from uninvolved skin erysipelas;•

Indistinct borders – acute cellulitis•

Acute cellulitis can be serious if not treated early (spreads through lymphatics and

bloodstream). Give antibiotics:

Medicine of Choice Flucloxacillin (O) for 5-7 days

Adults: 250 – 500mg every 6 hours

Children: 50 - 100mg/kg/every 6 hours in a day

Second Choice Erythromycin (O) for 5-7 days

Adults: 250 – 500mg every 6 hours

Children: 25 - 50mg/kg/every 6 hours in a day

6.1.6 Acne

Clinical features: Comedones, papulopustules and eventually nodular lesions on the

face, chest and back.

Management

Seek underlying cause e.g. over use of oils on skin, stress, anticonvulsant drugs etc.•

Encourage a healthy lifestyle – exercise, sunshine, diet, etc•

Use ordinary soap and water 2-3 times a day (harsh antibacterial cleansers or iodine-•

containing preparations may aggravate the acne)

In cases with many pustules, use:

Benzoyl peroxide 5% gel topically at night.

In severe cases of nodular acne, treat with oral antibiotics

Doxycycline (O) 100 mg twice daily for one month, then 100 mg once daily.

Continue until condition has improved; this may take 2-4 months. The patient should be

properly counselled.

Alternative for specialist use only: Tretinoin acid (topically) once daily at night.

NOTE: The acne may initially worsen, if too irritant, use every second or third night.

Patients should be encouraged to persist with treatment.

6.1.7 Paronychia

Painful red swellings of the nail folds which may be due to bacteria or yeast.

Acute Paronychia

Tenderness and presence of pus indicates the need for systemic antibiotics

Medicine of choice Phenoxymethylpenicillin (O) for 5-7 days

Adults: 250 – 500mg every 6 hours

Children: 25mg/kg/every 6 hours in a day

Second choice Flucloxacillin (O) for 5-7 days

Adults: 250 – 500mg every 6 hours

Children: 25 - 50mg/kg/every 6 hours in a day

Chronic Paronychia

Often fungal, due to candida. Avoid excessive contact with water, protect from trauma

and apply:

Miconazole or Clotrimazole cream, apply twice daily

Treat secondary infection with antibiotics as above

NOTE: For both acute and chronic paronychia, incision and drainage may be needed

6.2 SKIN FUNGAL INFECTION

6.2.1 Dermatophytosis (Ringworm)

Clinical features: It is a chronic fungal infection of the skin, hair or nails. Clinical

features depend on site of infection and species of infecting fungus. The types of fungus

and site are shown below. Ringworm on hairs is shown by loss of hair, itching and pustules.

On the skin there is a colour change.

Treatment

6.2.2 Corporis (Body Ringworm)

Round, expanding lesions with white, dust-like scales and distinct borders on the body or

face.

Responds to any of the topical antifungal agents

Medicine of choice: Compound benzoic acid (Whitﬁ eld ointment) applied

two to three times a day for up to 4 weeks.

Second choice: Clotrimazole cream 1% apply thinly three times a day, continue

for 5 to 7 days after clearing of symptoms.

Miconazole cream 2%, apply thinly two to three time a

day. Continue for 5-7 days after clearing of symptoms

6.2.3 Tinea Capitis (Scalp Ringworm)

In this case, the fungus has grown down into the hair follicle. Topical treatment is unlikely

to be effective. Treat with:

Griseofulvin (O) for more than 6 weeks

Adults 500mg once daily

Children 10mg/kg once daily

NOTE: Do not crush the tablet (micronised tablet)

6.2.4 Tinea Vesicolor (Pityriasis Versicolor)

For common fungal infection caused by a yeast. hypopigmented patches of varying size

on the chest, back arms and occasionally neck and face, no systemic treatment is required.

Apply:

Whitﬁ eld ointment, miconazole, clotrimazole, ketoconazole cream or ointment

Treat as Tinea corporis for a longer period

Continue with treatment 2 weeks after the systmptons has diappeared.

6.2.5 Tinea Pedis (Athlete’s Foot)

This is a very common fungal infection and is often the source of infection at other sites.

Treat any bacterial super infection ﬁ rst:

First choice Whiteﬁ eld lotion apply for 4 weeks

Second choice If fails to respond,

Miconazole cream 2% or Tolnaftate 1% solution

Clotrimazole cream 1% / powder for 4 weeks

If the above medication not responding use Griseofulvin as above.

ADVISE: Frequent change of socks/footwear, use of cotton socks, thorough drying

between toes after bathing, separating the opposing skin surfaces (e.g. with a piece of

gauze), will prevent infection and speed up healing.

6.3 OTHER FUNGAL DISEASE

6.3.1 Candidiasis

Clinical features: It is caused mainly by candida albicans. Clinical feature depend on the

site of infection. Thus the infection of the skin (cutaneous candidiasis) is characteerized

by red, itchy lesions often found in the folds and on the buttocks of babies. Infection of

the nails gives a swollen and painful nail bed which may discharge pus and is made worse

by contact with water. There may be destruction of the nail. Vulvae-vaginal Candidiasis

is common in women on the pill, in pregnancy and diabetics and in people on prolonged

antibiotic courses. Vulvae vaginal candidiasis is characterized by pruritic, curd-like vaginal

discharge, dysuria and dyspareunia. Disseminated Candidiasis, a complication of the

above, presents with fever and toxicity.

Treatment guidelines

(a) Oral Oesophageal fungal infections

Nystatin 100,000 IU apply either as a gargle (in adults) every 8 hours or

as oral suspension in children every 8 hours for 14 days

Miconazole oral gel apply as oral suspension in children every 8 hours

for 5 days or Fluconazole 200mg once daily for 14 days

Fluconazole 50mg daily for 7 – 14 days

(b) Vaginal infections

Nystatin Pessaries insert 1 tablet at night for 14 days

Clotrimazole pessaries/vaginal cream insert 1 tablet or apply at night for 6 days

Miconazole Pessaries/vaginal cream insert/apply once at night for 3 days

Ketoconazole 200 mg every 24 hours for 10 days

Fluconazole 200mg start may be repeated after 3 days

6.3.2 Deep fungal infection

Clinical features: The common clinical entities of deep fungal infecitions are

Nocardiosis and Actinomycosis. Actinomycosis is caused by actinomyces. Its clinical

features depend on the infected site. There is induration in the skin, sinus formation,

pain and when lungs are involved there is cough with purulent sputum. Nocardiasis is

an acute or subacute or chronic infection by nocardia species whose clinical features are

mainly in the lungs and may include pneumonia, fever and a productive cough.

Treatment guidelines: Doxycycline 100mg 12 hourly for 2-4 months for

Actinomycosis.

CAUTION: Doxycycline should not be given to pregnant women and children under

12 years of age

Alternative medicines (also for Actinomycosis)

Adults: Phenoxymethylpenicillin (O) 500 mg every 6 hours 2-4 months

Co-trimoxazole 480mg every 12 hours for 2-4 months for

Nocardiosis

Children: Phenoxymethylpenicillin (O) 25 mg/kg body weight 6 hourly

for 2-4

months

Co-trimaxazole (O) syrup 0.5 ml/kg body weight every 12 hours

for 2-4 months

NOTE: Regular blood examination must be done when Co-trimaxazole is used for

more than 14 days

Alternative medicine for Nocardiasis

Adult: Dapsone 100 mg every 24 hours for 2-4 months

Children: Dapsone 25 – 50 mg every 24 hours for 2-4 months

Co-trimoxazole 960mg (IV) every 12 hours

6.4 Scabies

Clinical features: It is caused by the mite Sarcoptes scabie burrowing into the skin.

The main clinical features are itching initially between the ﬁ ngers or on the buttocks or

genitals and latter can be generalized. In the tropics secondary streptococcal infection is

an important cause of rheumatic fever and glomerulonephritis.

Treatment guidelines

Treat• all close contacts, especially children in the same household with BBE 25%

apply every 12 hours.

Wash clothing and bedding and leave in the sun to dry•

Secondary bacterial infection (septic scores) treat with antibiotic as for impetigo for •

5 days.

The scabicide agent should only be applied once lesions are closed•

Advice that the itch may continue for several weeks•

6.5 Herpes Simplex

Clinical features: It is an acute infection characterized by superﬁ cial vesicles containing

clear ﬂ uid in the skin and mucous memberanes, particularly of the buccal area, on the

conjunctive, corneas or genitalia. It is caused by the medium sized Herpes virus homines.

The main clinical features are: tingling discomfort or itching, followed by vesicular

formation. Outbreaks of herpes simplex virus encephalitis have been reported.

Treatment guidelines

First Choice Acyclovir 400mg 8 hourly for 7 – 10 days

NOTE: Use of systemic Acyclovir is effective when given at the onset of episode

6.6 Herpes Zoster (Shingles)

Clinical features: Due to the resurgence of the varicella-zoster virus, this also causes

chickenpox. Severe burning pain precedes a rash which is vesicular and almost always

unilateral; does not cross the midline. In uncomplicated cases, the rash disppears in 24

weeks, in the haemorrhagic, necrotising form (HIV related) scarring often remains.

Treatment guidelines:

Pain Management: • Indomethacin (O) 25mg every 8 hours may be helpful in

the acute phase.

Apply topical calamine lotion or emollient. •

Take• Acyclovir (O) 800 mg 5 times a day until no new lesions appear

Wound care: • Potassium Permanganate soak (1:4000).

CAUTION:

Avoid Gentian Violet 0.5% as repeated use in this condition may cause

keloid Secondary infection (bacterial) may require treatment.

Post-Herpetic Neuralgia

After the rash is fully resolved:

Amitriptyline (O) 75 mg at night, may be increased to 150 mg at night

Carbamazepine (O) 200 mg at night; may be gradually increased to a maximum of 400

mg three times a day over 10 days

Indomethacin 25mg, 8 hourly

NOTE: Refer if there is no improvement in sever neuralgia.

Refer immediately if there is ophthalmic/pulmonary involvement.

6.7 Chicken Pox

Clinical features: Chicken pox like Herpes zoster is caused by the zoster virus. Clinical

presentation is mainly fever followed by a papula eruption. It is self limiting.

Treatment guidelines

Adult Paracetamol 1 g every 8 hours

And

Calamine lotion apply over the whole body every 24 hours

Children Paracetamol 10 mg/kg body weight every 8 hours

And

Calamine lotion, as for adult

6.8 Other skin diseases

6.8.1 Allergic Contact Dermatitis

Results from an acquired allergy after skin contact with particular chemicals (dyes, perfumes,

rubber, nickel or drugs and skin preparations containing lanolin, iodine, antihistamines,

neomycin, vioform etc). Avoid contact if allergic.

6.8.2 Eczema

(a) Atopic Dermatitis/Eczema: Often a personal or family history of atopic disease

(asthma, hay fever or atopic dermatitis). Cause not known. These persons are also more

susceptible to herpes simplex and vaccinia (but not varicella-zoster).

The clinical form may differ according to age

(b) Infantile aczema (“milk crust”) usually appears at 3 months with oozing and

crusting affecting the cheeks, forehead and scalp.

IMPORTANT If generalized exfoliative dermatitis develops, refer to a specialist

and nape of neck (thickening and licheniﬁ caiton). In adults any part or the whole of the

skin may be affected with intense itching, particularly at night. Over a period of a month,

there may be acute exacerbations and a chronic phase.

Management of Eczema

-Remove any obvious cause e.g. skin irritant or allergen (avoid irritants e.g. soap, wool and

extremes of temperature).

Emulsifying ointment - the equivalent of cream E45, Sofderm cream

Aqueous cream

-Treat itching with an oral antihistamine such as

Chlorpheniramine (O) 4 -16mg at night. Not recommended in children under 2

years.

Promethazine (O) 25 mg at night if sleeplessness is a feature.

Cetrizine 10mg once daily for 3 to 5 days

Loratadine (O): Adult (10mg); Children (6 – 12 years) – 5 mg once daily

NOTE: Avoid Alcohol

Never use topical antihistamines

-Treat any infection (usually bacterial, but occasionally viral). Choice of skin preparations

depends on whether lesions are wet (exudative) or dry/licheniﬁ ed (thickened skin with

marked skin lines).

If eczema is “weepy”, dry ﬁ rst using saline baths or bathe in.:

Potassium permanganate 1:4000 (0.025%) solution once daily for 2-4 days.

-Where large areas are involved give a course of antibiotics for 5-10 days (as for impetigo,

item no. 6.1)

-After the lesions have dried, apply an aqueous cream or zinc oxide preparation for

soothing effect. A topical corticosteroid may be useful in the acute phase. Use the mildest

topical corticosteroid which is effective, starting with:

Hydrocortisone 1% cream for wet, ointment for dry skin. Apply thinly, frequently

initially, then three times a day intermittently to prevent tachyfylaxia

NOTE: Topical corticosteroids often do more harm than good. They may produce

striae, acne lesions and hyper pigmentation. Avoid long term use; never use on weepy

or infected skin. Advise patients NOT to use them as cosmetics

CAUTION: Never use corticosteroid preparations on the face or in children unless

supervised by a specialist. More potent steroid, e.g. betamethasone should only be

prescribed by specialist

-If the skin starts scaling (condition becomes chronic), add/apply a keratolytic preparation

such as:

Benzoic acid 6% +Salicylic acid 3% (Whitﬁ eld) ointment applied twice daily.

For maintenance, an antipruritic preparation may be useful:

Coal tar ointment 5% applied twice daily.

Salicylic acid 2% and coal tar ointment 5% are to be prepared extemporaneously.

6.8.3 Urticaria

May be allergic, toxic or physical in origin. In many cases the cause is unknown (idiopathic).

Allergic urticaria may be caused by drug (e.g. penicillin), infection, contact with plants,

pollen, insect bites, or foodstuffs (e.g. ﬁ sh, eggs, citrus fruits, nuts, strawberries, tomatoes).

Physical urticaria may be caused by mechanical irritation, cold heat, sweating.

-If acute (existing for less than 3 months), exclude drug reaction (e.g. penicillin), or

infection (bacterial, viral or fungal).

-Give antihistamine by mouth:

Adult Chlorpheniramine (O) 4-16 mg once at night. Not recommended in

children under 2 years.

Promethazine (O) if sleeplessness is a feature

Adult 25 -50 mg at night

Child 0.1 – 0.2 mg/kg 2-4 times a day or 0.5 mg/kg at bedtime

Cetrizine (O) 10mg once daily or Loratadine (O) 10mg once daily

NOTE: Warn about drowsiness. If no improvement after 1 month or chronic problem,

refer. Never use topical antihistamines.

6.8.4 Psoriasis

A condition of the skin characterized by thickening and scaling (the disposition is inherited)

usually symmetrical.

Exclude precipitating factors e.g. alcohol, deﬁ ciencies of vitamin B12 or folate, stress,

infections.

To reduce scaling use a keratolytic:

Benzoic acid 6% + Salicylic acid 3% in white soft parafﬁ n applied once daily in the

evening.

Sun exposure to the lesions for half an hour or one hour daily may be of beneﬁ t. In

resistant cases

Plus

Coal tar 5% in salicylic acid 2% or zinc oxide ointment or Dithranol 0.1%+Coal tar

NOTE: Steroids are discouraged in this condition. If not responding well, refer.

6.8.5 Pellagra

Syndrome caused by deﬁ ciency of a variety of speciﬁ c factors, nicotinic acid being the

most important. Cardinal signs: diarrhea, dermatitis (sites exposed to sun and pressure)

and dementia. Treat both adults and children with:

Nicotinamide (O) 100mg once daily for two weeks or until healing is completed

ADVICE ON DIET: The diet should be rich in protein (meat, groundnuts, beans)

6.8.6 Depigmented skin (Vitiligo)

Leucoderma may be secondary to eczema, psoriasis or other skin condition treat underlying

disease. There is no causal therapy for albinism and vitiligo. Advise yearly examination

for skin cancer; use a sunscreen. An effective and cheap preparation with a sun protection

factor of 15 (SPF=15) is “PABA”

Para-amino-benzoic acid (PABA) 5% cream or lotion applied.

In the morning before going out. Continue application during the day as necessary.

6.8.7 Brucellosis (Undulant fever)

Clinical features: Brucellosis is an infection caused by Brucella organisms. Man gets

infected through exposure to infected tissue and milk or milk products. It is characterized

by seating, weakness, headache, anorexia, fever, malaise, arthralgia, weight loss, pain in the

limbs, back and rigorous. There is splenomegaly, lymphadenorpathy and hepatomegaly.

Treatment guidelines

Adults Doxycycline (O) 100mg once daily for 4 weeks

Co-trimoxazole (O) 960 mg every 12 hours for 4 weeks

Children

6 weeks – 5 years Co-trimoxazole (O) 0.5ml syrup/kg every 12 hours for 4

weeks

5-12 years Co-trimoxazole (O) 480 mg every 12 hours for 4 weeks

CAUTION: Doxycycline should not be used in children under 12 years or during

pregnancy.

6.8.8 Lichen Planus

Is a non-infectious, chronic skin disease which may be extremely itchy.

Clinical features: The rash is characteristically violaceous, shiny papules or plaques on

the wrists, distal arms and sacral area. Post inﬂ ammatory hyperpigmentation is common.

Patches of scaling baldness may develop on the scalp leading to permanent hair loss.

Treatment Guidelines Betamethasone cream apply every 8-12 hourly to

remove scales and allay itching.

For severe form system steroid are recommended.

6.8.9 Pruritic papular eruptions (PPE)

This is a skin condition characterised by papular eruptions and itching which may be

quite severe, it is associated with HIV infection. The cause is not known.

(See HIV/AIDS Management manual for details of medicines)

7. SEXUALLY TRANSMITTED INFECTIONS (STI)

7.1 General guidelines

Accurate laboratory-proven diagnosis of sexually transmitted infections (STI) is not always

possible except in a few health facilities with well equipped functional laboratory services.

For health facilities without laboratory services, one must treat on clinical grounds ie

treat a disease based on suspected causative agents diagnosed clinically or by syndromic

approach. In syndromic approach clinical syndromes are identiﬁ ed followed by syndrome

speciﬁ c treatment targeting all causative agents which can cause the syndrome. Contact

tracing is encouraged as an important means of preventing further spread. Appropriate

health education should be given at every opportunity.

First line Therapy is recommended when the patient makes his/her ﬁ rst

contact

with the health care facility

Second line therapy is administered when ﬁ rst line therapy has failed and re-

infection has been excluded.

Third line Therapy should only be used when expert attention and adequate

laboratory facilities are available, and where results of treatment can

be monitored.

In order to ensure complete cure, doses LESS than those recommended must NOT be

administered. The use of inadequate doses of antibiotics encourages the growth of

resistant organisms which will then be very difﬁ cult to treat.

7.2 Gonorrhoea

Gonococcal and chlamydial infections frequently co-exist. Therefore combined •

therapy should be given

Treatment guidelines: see under “The Syndromic Treatment of STI”.

7.3 Chancroid

Clinical features:

Presence of painful genital ulcers with undermined ragged edges. The base is covered with

dirty purulent exudates and easily bleeds on touch

Treatment guidelines:

First line Co-trimoxazole (O) 960 mg twice daily for 10 days

Second line Erythromycin (O) 500 mg 6 hourly for 10 days

Third line Ciproﬂ oxacin (O) 250 mg 8 hourly for 7 days

7.4 Epididymo-Orchitis

Clinical features: An acute severe inﬂ ammation of the epididymis, testis and spermatic

cord. Main clinical features include swollen and tender epididymis, severe pain of one or

both testes and reddened edematous scrotum. Causative organisms include ﬁ larial worms,

Chlamydia trachmatis, Neisseria gonorrhoeae, Escherichia coli as well as viruses such as which

cause mumps.

Exclude other pathology such as torsion of testis.

Treatment guidelines

First line Doxycycline (O) 100mg 12 hourly for 7 -10 days

Co-trimoxazole 960 mg every 12 hourly for 5 days

Acetylsalicylic acid 600mg every 6 hours until pain is

controlled

Second line Erythromycin (O)

Adult: 500mg every 6 hours for 10 days

Third line Kanamycin (IM) 2g, 1g in each buttock, as a single dose

Plus

Doxycycline (O) 100 mg every 12 hours for 10 days

NOTE: Patient may need to wear a scrotal support

7.5 Chlamydia infections

Clinical features:

Presence of scanty to moderate white mucoid or serious discharge and is often seen 1-3

weeks after sexual intercourse

Treatment Guidelines:

First line: Ciproﬂ oxacin (O) 500mg as a single dose

Doxycycline is added to the ﬁ rst line treatment for urethral

discharge in men and women (See Syndromic treatment ﬂ ow chart no 7.9.2).

NOTE: If doxycycline is not available, oxytetracycline may be used as an alternative

7.6 Syphilis

Clinical features: Syphilis is a chronic infectious disease caused by the spirochete

treponema pallidum. It can be acquired mainly through sexual intercourse or congenitally

when the mother transfers it to the fetus. The main classiﬁ cation of syphilis is shown

below.

Table 18: Classiﬁ cation of Syphilis

Type Stage Clinical features/presentation

Congenital Early Rhinitis with blood nasal discharge

Late Mucocutaneous lesions e.g. bullae, stigmata of

osteochondritis, osteitis (or scars)

Acquired Early Primary and

secondary syphilis

A painless chancre•

Rash,•

Non-tender lymphadenopathy, condylomata

accumilata

Late tertiary (benign

gummatous)

Interstitial keratitis, photophobia, corneal

infection, 8th cranial nerve deafness, bilateral

knee effusion, recurrent arthropathy

Quarterly

(cardiovascular and

neurosyphilis

Cardiovascular syphilis and neurosyphilis

will give clinical features associated with that

system. Also seen are gumma and osteitis

Treatment guidelines

For primary and secondary syphilis:•

Benzathine penicillin give 2.4 IU i.m as a single dose given as two injections at

separate sites

If there is penicillin allergy give:

Doxycycline (O) 100mg 12 hourly for 15 days

CAUTION: Doxycline should not be given to pregnant and breast feeding women

and children under 12 years of age

For late Syphilis:•

Benzathine penicillin give 2.4 IU i.m weekly for 3 weeks.

For congenital syphilis:•

Up to 2 years of age

Aqueous Benzyl Penicillin 100,000-150,000 IU/kg body weight per day

administered as 50,000 -75,000 IU/kg IV every 12 hours, during the ﬁ rst 7 days of

life and every 8 hours thereafter for a total of 10 days

Procaine benzylpenicillin 50,000 IU/kg body weight every 24 hours for 10

days

Over 2 years of age

Benzyl penicillin 200,000-300,000 IU/kg body weight iv or im administered

as 50,000 IU/kg every 4- 6 hours for 10-14 days

Erythromycin 7.5- 12.5 mg/kg body weight every 6 hours for 30 days

7.7 Genital warts

Clinical features: These are usually caused by papilloma group of viruses infecting

the skin or mucous membrane. The common sites affected by warts include genital region

(condylomata acuminata) hands and legs. The lesions are usually asymptomatic ﬂ eshy

growths. In the genital region, lesions are often ﬁ nger like and increase in number and size

with time. When extensive they may interfere with sexual intercourse and child birth. The

removal of the lesion does not mean cure of the infection. No treatment is completely

satisfactory.

Treatment guidelines:

Carefully apply either 10-25% Podophyllin or Silver Nitrate to the warts, and wash

off in 6 hours, drying thoroughly. Treat every 2-3 days until warts are gone. Contraindicated

in pregnancy/lactation. Do not apply on healthy surrounding skin)

Imiquimod 5% cream applied with a ﬁ nger at bedtime, left on overnight, 3 times a week

for as long as 16 weeks. (The treatment area should be washed with soap and water 6-10

hours after application).

Surgery may be useful in selected cases to remove the warts.

7.8 Cervical warts

This case should be refered to consultant/expert

Most expert advice against the use of podophyllin for cervical warts. One of the alternative

treatment mentioned above should therefore be used.

Management of Meatal and urethral warts

Accessible meatal warts may be treated with podophyllin or povidone-iodine solution. Great

care is needed to ensure that the treated area is dried before contact with normal, opposing

epithealial surface is allowed.

7.9 Trichomoniasis

Clinical features: It is caused by a ﬂ agellate protozoa Trichomonas vaginalis. It causes

inﬂ ammation of vagina and cervix in females and inﬂ ammation of urethra and prostate

gland in males. Clinical features may or may not occur. When they do they include a frothy

green/yellowish discharge, itchness, erosion of cervix.

Treatment guidelines

Adults Metronidazole give 2gm orally single dose at bed time (avoid alcohol). Give

the same treatment to partner. In pregnancy treatment with metronidazole should be

delayed until after ﬁ rst trimester.

Children 5mg/kg body weight every 8 hours for 7 days

7.10 The syndromic treatment of STI

100

101

8. ORAL DISEASE CONDITIONS

8.1 Dental infection

8.1.1 Periapical Abscess

A clinical presentation arising as a complication of inﬂ ammation of the dental pulp or

periodontal pocket. May be acute and diffuse or chronic with ﬁ stula or localized and

circumscribed. It is located in the apical aspect of the supporting bone. Clinically it may

resemble a periodontal abscess and is differentiated according to the vitality of the affected

tooth.

Treatment guidelines

For posterior teeth: Extraction of the offending tooth under local anaesthesia (to establish

drainage) is the treatment of choice followed by analgesics.

Adult: Paracetamol (O) 500mg – 1g, 4-6 hourly for 3 days

Child: No analgesics

For anterior teeth: Root canal treatment

NOTE: Incision and drainage at a hospital is mandatory in cases of deeper spaces

involvement followed by a course of antibiotics

Amoxycillin (O) 500mg, 8 hourly for 7 days

Children: (O) 25 mg/kg in 3 divided doses for 5 days

Combination with

Metronidazole 400mg 8 hourly for 7 days.

Children: (O) 7-10 years, 100mg every 8 hours

NOTE:

In acute diffuse cases it is recommended to give antibiotic cover ﬁ rst to localize

the infection followed by extraction of the offending tooth

8.1.2 Infected (Dry) socket

A post extraction complication due to failure to form clot (dry socket) or infection of

the clot due to contamination (infected socket). The condition is very painful and if not

managed could lead to osteomylitis.

Treatment guidelines

Socket debridement to stimulate fresh bleeding and new blood clot formation (May be

done under local anaesthesia with Lignocaine 2% if procedure proves to be painful).

Irrigation with Hydrogen peroxide 6%

8.1.3 Periodontal conditions

Gingivitis

Inﬂ ammatory changes in the gingival develop within a couple of days of undisturbed

bacterial growth on the cervical portion of the tooth surface. Clinically, inﬂ ammation

is initially seen as discrete colour and texture changes of the marginal tissue. After 10

to 20 days of plaque accumulation overt gingivitis is established in most individuals,

102

characterized by gingival redness and swelling and increased tendency of the soft tissue to

bleed on gentle probing.

Prevention

Oral hygiene instructions for proper self care

Acute Necrotizing Ulcerating Gingivitis (ANUG)

It is characterized by rapid destruction of gingival tissue, particularly in the area of the

interdental papillary. Patients usually present with soreness and bleeding of the gums and

foul test (fetorex ore)

Treatment guidelines

Professional cleaning with

Hydrogen Peroxide 6% (under local anaesthesia)

Metronidazole 400 mg 8 hourly for ﬁ ve days

Periodontal pocket

A periodontal pocket is a gingival pocket that has been deepened by apical migration of

the junctional epithelium and destruction of the periodontal ligament and alveolar bone.

Treatment guidelines

Scaling and polishing

Instruction on proper use of toothpicks, dental ﬂ oss

8.1.4 Infections of the Oral cavity

Infections involving the soft tissue around the jaws are usually of dental origin, developing

from periapical, periodontal or pericoronarial disease. Infections may also be associated

with traumatic injuries, retained dental remnants and pathological lesions such as cysts.

The infections are usually mixed in origin and culture of infected material will show a

variety of aerobic and anaerobic organisms can be responsible.

Treatment guidelines

Erythromycin (O) 500 mg, 8 hourly for 5 days

Cloxacillin (O) 500 mg, 8 hourly for 5 days

(a) Tuberculosis

Oral manifestations of tuberculosis are rare.

Treatment guidelines

Refer to TB and Leprosy clinic

(b) Syphilis

Hutchinson’s incisor is abnormal tooth morphology of the permanent maxillary central

incisor inpatients with congenital syphilis. Other teeth may be involved. “Barrel-shaped”

103

is the term often applied to the typical Hutchinson’s incisor. It is narrower at the incisal

edge and may have a notch of the incisal edge.

The “Mulberry molar”, molar of congenital syphilis is due to marked hyperplasia affecting

the ﬁ rst permanent molar resulting in reduction of the crown form towards occlusal

surface.

Treatment guidelines

See under STI section

Clinical features: When the herpes simplex virus affects the oral mucosa it results in

a herpetic gingivo-stomatitis, usually seen in children between the ages of two and four

years, but in recent years diagnosed in a number of older age groups. After an incubation

period of one week the patient develops fever, swollen submandibular lymph nodes and

a defuse gingivitis.

Treatment guidelines

Symptomatic and preventive

Idoxuridine ointment/solution

Acyclovir cream for lips

And

Chlorhexedine 0.1% mouth wash (diluted from 5%) for intra-oral lesions.

Acylovir cream/tablets – Active against Herpes simplex and Zoster (can be

given orally and topically.

Doses:

Herpes labialis Acyclovir Cream apply 4 hourly for 5 days

Herpes Stomatitis Acyclovir 200mg 5 times in 24 hours for 5 days

Immunocompromised Acyclovir 400mg 5 times in 24 hours for 5 days

Herpes Zoster Acyclovir 800mg 5 times in 24 hours for 7 days

(d) Candidiasis

Clinical features: Acute oral candidiasis (Thrush) is seen most commonly in the

malnourished, the severely ill, neonates and HIV-AIDS patients or oral corticosteroids

use. In chronic oral candidiasis dense chalky white plaques of keratin are formed.

Treatment guidelines

Nystatin (suspension) 100,000 units (1 ml of suspension held in the mouth

before swallowing)

Miconazole (O) gel 25 mg/ml 5-10 mls in mouth –hold it before swallowing.

104

Fluconazole (O) 200mg once daily for 14 days (2 weeks)

(e) Contact stomatitis

Clinical features:

A contact allergy is a type of reaction in which a lesion of the skin or mucus membrane

occurs at a localized site after repeated contact with the causative agent. This could be due

to anything like dentures, mouthwashes, cosmetics etc.

Treatment guidelines: Remove the cause

8.1.5 Pericoronitis

Clinical features: This is a bacterial infection around the crown of partially erupted or

unerupted wisdom tooth. The gingival abscess occurs as a result of an infection via breach

in the gingival surface. It tends to be localized within the gingivae and is not necessary

associated with a pocket.

Treatment guidelines

Irrigation of perioconal space with warm normal saline

If the cause is an upper tooth – extract it or grind offending cusps

If an abscess is present incise and cover with a combination of antibiotics.

Metronidazole (O)400mg, 8 hourly for 5 days

Plus

Amoxycillin (O)500mg 8 hourly for 5 days

8.1.6 Ludwig’s Angina

Clinical features: It is overwhelming, generalized septic cellulites of the submandibular

region. It arises from infection involving both submandibular and submental spaces with

extensive involvement of the ﬂ oor of the mouth. This is usually a result of periapical

infection of mandibular teeth spreading rapidly into one submandibular space and then

extending to involve the adjacent tissue spaces.

Treatment guidelines

Drug of choice

Metronidazole 500mg IV 8 hourly for 5 days

Plus

Ampicillin 500 mg IV 8 hourly for 5 days

If allergic to penicillin use

Erythromycin (O) 500 mg 6 hourly for 7 days

Gentamicin 80mg (IV) 12 hourly for 5 days

8.1.7 Dental Abscess

Clinical features: In this condition there is a collection of pus around the affected

tooth, which may spread into the surrounding tissue. Signs include swelling of the gum

around the affected tooth leading to facial swelling. Pus may be seen discharging from the

gum around the affected tooth.

105

Treatment guidelines

(a) Incision and drainage with daily irrigation with

Hydrogen peroxide 2%

Chlorinated lime solution

Plus Paracetamol (O) 1000mg 8 hourly for 5 days

Diclofenac Sodium 25-50 mg 8 hourly for 5 days

(b) If septic abscess, use antibiotics

Drug of choice: Erythromycin (O) 500mg 8 hourly for 7 days

Second choice: Cloxacillin (O) 500 mg 8 hourly for 5 days

Plus pain relievers as above

8.2 Post Extraction Bleeding

Commonly due to disturbing the blood clot by the patient through rinsing or inadequate

compression on the gauze, though at times may be due to bony/tooth remnants.

Treatment Guidelines

Check and repack the socket. Give proper instructions

Rule out bleeding disorders if bleeding continued after 24 hours despite step one above.

Refer for further management

8.3 Tooth sensitivities

Usually is due to attrition of teeth, abrasion or gingival recession

Treatment guidelines

Self care: Tooth brushing with toothpaste for sensitive teeth.

Professional care: Duraphat application

8.4 Dental caries

A condition where the tooth is demineralized by acid produced by bacteria on metabolizing

sugar. Starts slowly with white spots later developing to cavities in enamel, dentine and

later the pulp.

Prevention Avoid frequent use of sugary foods/drinks. Use ﬂ uoridated toothpaste

to brush your teeth at least once a day.

106

Treatment guidelines

Restore the tooth/surface with appropriate materials e.g. Silver amalgam, composites,

glassionomer, etc.

8.5 Aphthous ulceration

Aphthous ulcers are painful recurrent mucous membrane ulcerations. Usually affect the

non-keratinized oral mucous membrane. They are divided into two groups, namely minor

aphthous ulcers and major aphthous ulcers.

8.5.1 Minor aphthous ulcers

Painful ulcers on non-keratinized oral mucous membranes; there are one to ﬁ ve small

5mm round or oval shallow ulcers, recur frequently, often cyclically, heal spontaneously in

less than 3 weeks.

Treatment guidelines

Use Chlorhexideine 5% or Povidone iodine mouth washes.

Take care of oral hygiene, avoid acidic and irritant foods.

8.5.2 Major aphthous ulcers

Painful ulcers on non-keratinized oral mucous membrane, they are large 1-3 cm edged

ulcers, and several may be present simultaneously. There is marked tissue destruction

which is sometimes constantly present. Healing is prolonged often with scarring.

Treatment guidelines

Chlorhexidine 0.1% or Povidone iodine mouth wash, topical or systemic steroids

ie Prednisolone tablets

Cryosurgery occasionally, to relieve pain and promote healing

8.6 Edentulousnes

The loss of all natural teeth and subsequent resorption of the aviola bone.

Treatment guidelines

Design and construct dental prosthesis according to aesthetic and functional needs.

Materials to be used include: acrylic, porcelain, gold, etc

Malocclusions

Is an occlusal variation that may be functionally harmful or aesthetically objectionable?

Malocclusion can be classiﬁ ed as follows;

Class I

The sagittal arch relationship is normal. The anterior buccal groove of the lower permanent

molar should occlude with the anterior buccal cusp of the upper ﬁ rst permanent molar.

Class II

The lower arch is at least one half a cusp with too far distal to the upper.

107

Class III

The lower arch is at least one half a cusp with too far mesial to the upper.

Treatment guidelines

Removable orthodontic appliances are those designed to be removed by the patient for

routine cleaning. They can be active or passive.

Appliances for active tooth movement fall into two groups

Simple removable appliances which have mechanical a component to move the 1.

teeth

Myofuctional appliances, which harness the forces generated by the orofacial 2.

muscles.

Passive removable appliances may also save two functions:

Retainers used to hold the teeth following active tooth movement1.

Space maintainers, used to prevent space loss following the extraction of teeth.2.

8.8 Traumatic injuries to Teeth in Children

May result to loosening, displacement and or loss of teeth, fracture of teeth and or bone,

lacerations and bleeding. The commonest causes are alls (in sports and play) at home or

school and motor accidents. Most affected are teeth upper incisors.

Prevention

Proper design of playing g round observe road trafﬁ c rules early orthodontic treatment

Treatment guidelines

Take x-ray picture of affected tooth/teeth. Strict oral hygiene in cases of loosening and

mobility. Use hydrogen peroxide, normal saline, tooth brush. Immobilization of

affected tooth/teeth with arch bar, ss wires, acrylic splints, sutures.

Removal of fracture elements in excessive mobility degree (surgical toilet).

Anti tetanus cover (ATS or TT).

Antibiotic cover I cases of suspected contamination or extensive damage (procaine

penicillin fortiﬁ ed, phenoxymethylpenicillin).

Restoration of aesthetics (composite ﬁ lling, prosthesis).

Extraction is treatment of choice for traumatized primary teech with mobility and or

displacement.

Referral for maxillofacial management in case of extensive damage to maxillofacial

structures.

8.9 Tumours of the Oral Cavity

Can be traced to originate from tissues of the tooth germ (odontogenic epithelia,

odontogenic connective tissue)

These tumours can be divided into benign and malignant tumours.

108

(a) Benign Odontogenic Tumours

Ameloblastoma, Calcifying Odontogenic Tumour, Amelobastic ﬁ broma, Adematoid

Tumour (Adeno Ameloblastoma), Calcifying Odontogenic Tumour, Ameloblastic Fibro-

Odontoma, Odonto Ameloblastoma, Complex Odontoma, Compound Odontoma,

Odontogenic Fibroma, Odontogenic myxoma, Cementoma and Cementifying Fibroma.

Treatment guidelines

Can be mandibulectomy, Hemimandibulectomy, Enucleation, Maxillectomy,

Hemimaxillectomy

(b) Malignant Odontogenic tumours

Odontogenic Carcinomas and Odontogenic Sarcomas

Treatment guidelines

Palliative treatment (but not radiotherapy). Can be medical palliation

8.9.1 Soft Tissue and Bone Tumours (Non-Odontogenic)

These are also divided into two group;

Benign tumours

Papilloma, Heratoacanthome, Fibroma, Fibrous Epulis, Peripheral Giant Cells, Pregnancy

Tumour, Hemangioma, Lymphangioma, Lipoma and Pigmented nerves

Treatment guidelines

Surgical excision

For Haemangioma – Use sclerosing agent ﬁ rst until the tumour calciﬁ ed then you can

carry out surgical excision

Benign osteogenic tumours (arise from bone)

Osteomas, Myxomas, Chondromas, Ewing’s tumour, Central giant cell and Fibro-

osteoma.

Treatment guidelines: Surgical excision

Malignant soft and bone tumours

Squamous cell carcinoma, Sarcoma, Lymphosarcoma, Myosarcoma, Chondrosarcoma,

Fibrosarcoma, Adenosarcoma, Adenocystic carcinoma and Epidermoid carcinoma.

Treatment guidelines

Palliative – but this depends on stage of the tumour: stage I and II surgical excision

(squamous Cell carcinoma) with wide margin then curative radiotherapy. Others, surgical

excision, radiotherapy followed by chemotherapy, if lesion is not advanced or in stage I

and II.

109

8.9.2 Lymphomas

Burkitt’s tumour is an undifferentiated lymphoblastic lymphoma. It shows close association

and infection with the Epstein Barr virus.

Clinical features: The clinical picture varies with age of the patient, the typical jaw

tumour being the commonest in the younger patient.

Treatment guidelines

Early detection and referral

Curative treatment comprises of combination chemotherapy

Palliation with cyclophosphamide is of good but temporary beneﬁ t.

These should be treated after a deﬁ nitive histopathological report.

8.10 Shedding of Primary (Milk) Teeth

Phenomenon occurring between aged of 5-12 years. Milk teeth should be left to fall out

by themselves unless otherwise indicated. Parents should be counselled accordingly. Early

loss of primary teeth may lead to crowding of per manent teeth.

8.11 Eruption of Teeth

Starts usually at ﬁ ve months of age. Symptoms associated with it like fever and diarrhoea

are normal and self limiting unless any other causes can be established. The following

conditions usually are associated with tooth eruption should be referred to dental personnel:

eruption cysts, gingival cysts of the newborn, pre/natal teeth.

110

9. KIDNEY DISEASE CONDITIONS

9.1 Glomerulonephritis

Clinical features: The term glomerulonephritis covers a number of glomerular

reactions in which glomerular inﬂ ammation is either a primary reaction or a secondary

consequence of a systemic disorder.

Acute glomerulonephritis occurs most commonly in children and adolescents. Usually it

follows infection with nephrogenic strains of B-haemolytic streptococci. Early treatment

of infected scabies is a good preventive measure. Major clinical features include oedema,

proteinuria and hypoproteinemia. 90% percent of patients make complete and permanent

recovery even if no treatment is given. The remaining 10% may develop chronic

glomerulonephritis followed by renal failure.

Treatment guidelines

Treatment is supportive designed to maintain ﬂ uid and electrolyte balance and provide

enough calories until spontaneous recovery of renal function occurs. Treat underlying

cause where applicable. Allow bed rest and control diet and ﬂ uid intake

Medicine of choice

Adult Amoxycillin (O) 500 mg 8 hourly for 5 - 7 days

Procaine penicillin fortiﬁ ed (PPF) 1.2 MU

Children Amoxycillin (O) 12.5 mg/kg body weight every 8 hourly

for 7 days

Procaine penicillin fortiﬁ ed (PPF)

NOTE: If blood pressure is high, treat accordingly

9.2 Pyelonephritis

Clinical features: Pyelonephritis is an inﬂ ammation of renal parenchymal and renal

pelvis. Infections usually occur by the ascending route. It is commonly caused by gram-

negative organisms like E. Coli. Clinical features include: chills, fever, ﬂ ank pain and

vomiting.

General Management

Where facilities are available, do culture and sensitivity test to determine the antibiotic

choice.

Give oral ﬂ uids or IV depending on severity of the case to increase urine output.

Treatment guidelines

Adult Amoxycillin (O) 500 mg every 8 hours for 7 – 10 days

Co-trimoxazole (O) 960 mg every 12 hours for 7 – 10 days

Trimethoprim (O) 300 mg once daily for 7 - 10 days

111

Plus

Potassium citrate (O) 1-2 g well diluted with water three times a day.

If serious, give Ampicillin (IV) 500 mg every 6 hours for 5 to 10 days

Plus

Gentamicin (IV) 4 mg/kg/24 hours in 3 divided doses for 5 to 10 days.

Children Co-trimoxazole (O)

6 weeks – 5 years 0.5 ml/kg every 12 hours for 7 days

6- 12 years 480 mg every 12 hours for 7 days

Amoxycillin (O)

Up to 10 years 10mg/kg every 8 hours for 7 days

Above 10 years 250 – 500 mg ever y 8 hours for 7 days

Nitrofurantoin (O)

Over 3 months 3-6 mg/kg body weight every 6 hours for 7 days

If serious, give Ampicillin (IV)

Under 10 years 10 mg/kg every 6 hours for 7 days

Plus

Gentamicin (IV) 2.5 – 5 mg/kg body weight/24 hours in

divided doses every 8 hours for 7 days

NOTE: a) In pregnancy, Amoxycillin is the medicine of choice followed by co-

trimoxazole a second line. If Trimethoprim is used give folic acid 5 mg once daily for

the of the duration of course.

b) A shorter course of up to 3 days may be enough for uncomplicated infections in

women. A duration of 7 to 10 days may be necessary for men and children and for

recurrent attacks or previous pyelonephritis in women.

9.3 Nephrotic Syndrome

Clinical features: It is a syndrome charactirised by massive proteinuria (> 3.5 g/24

hours), hypoalbuminemia (<30 g/litre) and massive oedema. Hyperlipidaemia and

increased congulability of blood are important features.

Nephrotic Syndrome may be due to primary glomerular disease or secondary to other

diseases, systemic diseases such as diabetes mellitus and infections e.g. Hepatitis B, HIV

and malaria

Treatment guidelines

Treat underlying cause where applicable•

Allow bed rest•

Give high protein diet if renal function is normal•

Encourage consumption of potassium rich foods e.g. bananas, papaws, sweet potatoes •

and pigeon peas

Restrict salt and water intake•

Try and induce diuresis•

112

Medicine of choice Diuretics

Adult Frusemide (O) 40-200mg every 12 hrs

plusSpironolactine (o) 25mg three times daily

Prednisolone (O) 40-60mg once daily – 6-8 wks

In adults steroid therapy is often unsuccessful

Anticoagulants

These are indicated in case of chronic nephrotic syndrome because of the danger of

thrombocilism.

Heparin 5000Units every eight hours

Children

Follow similar schedule with the following dosage

Frusemide 1mg/kg body weight every 24 hours

Prednisolone 1 mg/kg body weight daily for 6 – 8 weeks, tail the dose to avoid

relapse.

Heparin 15 – 25 units/kg body weight by IV Or 250 units/kg body weigh (s.c) every

12 hours.

113

10. EAR, NOSE AND THROAT DISEASE CONDITIONS

10.1 Otitis (externa and media)

Clinical features: This is an inﬂ ammatory condition of both the external auditory

meatus and/or the middle ear. The clinical features are itching and pain in the dry, scaling

ear canal. There may be a water or purulent discharge and intermittent deafness. Pain

may become extreme when the ear canal becomes completely occluded with edematous

skin and debris. In otitis media (acute or chronic) the clinical features are ear pain, a

sensation of fullness in the ear and hearing loss, aural discharge. Onset usually follows an

upper respiratory tract infection. Chronic otitis media is associated with perforation of

the eardrum.

10.1.1 Otitis Externa

Treatment guidelines

Exclude an underlying chronic otitis media before commencing treatment•

Instruct the patient to thoroughly clean and dry the ear.•

Adult and children

Aluminium diacetate drops 13%; instill 3-4 drops every 6 hours after cleaning and

drying the ear for 5 days.

10.1.2 Otitis Media

Deﬁ nitions

(a) Acute otitis media: Acute purulent exudates in the middle ear without discharge

(acute suppurative otitis media)

(b) Secretory otitis media Multifactorial non-purulent inﬂ ammatory condition in

the middle ear with serous or mucous discharge. Also a residual condition after acute

otitis.

six months period.

Acute otitis media usually follows a viral infection; the bacterial infection is caused by:

Pneumococci•

Haemophilus inﬂ uenzae•

Group A streptococci•

Maraxella catarrhalis•

Clinical features

Acute otitis media

Previous common cold•

Pain•

Restlessness•

Usually feverish•

Hearing often reduced•

Possible discharge of pus from ear•

114

Simplex otitis Media

May present one or more of the above symptoms in a less pronounced form but without

any discharge from the ear.

Secretory otitis Media

Little or no pain•

Gradual loss of hearing•

“Popping” in the ear (rarely)•

Often discovered by chance•

Treatment guidelines

(a) Symptomatic treatment of acute otitis media and simplex otitis

Analgesics (e.g. Paracetamol • 10 mg/kg body weight every 6-8 hours, or

Acetylsalicylic acid). Avoid Acetylsalicylilc acid if it is viral infection

Elevation of the upper part of the body•

Decongestive nasal drops or nasal spray e.g. • Ephedrine hydrochloride

Oral decongestants and antihistamines are not indicated.•

(b) Treatment of Acute Otitis

It should be treated with antibiotics or paracentesis. Culture of a discharge (if any) could

be of a great help to identify the causative bacteria.

Medicine of choice Amoxycilin (O)

Adult 250 – 500 mg every 6 hours for 5 days

Children up to 5 years: 6 mg/kg every 6 hours for 7 days

6-12 years: 250 mg every 6 hours for 7 days

NOTE: Treatment periods shorter than ﬁ ve days increase the risk of treatment failure

Second choice Erythromycin if allergic to penicillins

Adult and children above 8 years 250 – 500 mg every 6-8 hours for 5 days

If the patient is severely affected by fever and pain or the symptoms continue without

improvement, antibiotics should be given. The treatment schedule for acute otitis media

should be as follows:

(d) Referral to specialist:

Children with high fever who are toxic affected or children with severe pain that •

persists in spite of treatment

Treatment failure without improvement after change of antibiotics•

“Ear Children”•

Otitis in the normal (or better hearing) ear combined with permanent hearing loss in •

the other ear.

115

(e) Treatment of Secretory otitis

Initial inspection•

Nasal drops, oral decongestants and antihistamines have no demonstratable effect on •

this condition

Secretory otitis with hearing loss that does not improve should be referred to a •

specialist

10.2 Acute Rhinitis and Sinusitis

Clinical features: Rhinitis is caused by a variety of viruses. Acute sinusitis starts with

obstruction of the ostium, followed by reduced ventilation, retention of discharge and

bacteria multiplication. If the ostium is blocked for a longer period, sinus empyema may

occur. The bacteria most often causing purulent sinusitis are pneumococci and Haemophillus

inﬂ uenza which in some studies are shown to be equally common. Maraxella catarrhalis and

group A streptococci also occur. In sinusitis of dental origin, anaerobic bacteria are often

found.

Deﬁ nition

Acute rhinitis: A viral inﬂ ammatory condition in the nasal mucous membrane, usually

part of a more wide-spread infection of the upper respiratory tract.

Acute purulent sinusitis: Bacterial infection with pus accumulation in one or more

of the sinuses

Acute serous sinusitis: An inﬂ ammation in one or more sinuses with ﬂ uid accumulation

but without pus formation.

(a) Treatment guidelines for Acute Rhinitis and serous sinusitis

Elevation of the head•

Nasal drops or spray e.g. Ephedrine hydrochloride 1% for adult and 0.5% for children •

or Beclomethasone spray. 1-2 drop/puffs every 8 hours a day for 3 days

Oral drugs to reduce swelling of the mucous membrane, antihistamines and antibiotics •

are not indicated.

(b) Treatment guidelines for Purulent Sinusitis

Symptomatic Treatment

Elevation of the head•

Nasal drops or spray e.g. Ephedrine hydrochloride 1% for adult and 0.5% for children •

or Beclomethasone spray. 1-2 drop/puffs every 8 hours a day for 3 days

Oral drugs to reduce swelling of the mucous membrane or anti-histamines are not •

indicated.

Medicine of choice Phenoxymethylpenicillin

Adult 250 – 500 mg every 6 hours for 10 days

Children up to 5 years 6 mg/kg every 6 hours for 10 days

5 – 12 years 250 mg every 6 hours for 10 days

116

Second choice Doxycycline

For Adults only and

Children above 12 years 200 mg on the ﬁ rst day as a single dose then

100 mg from the following day every 24 hours for

10 days

NOTE: Doxycycline for adult only and children above 12 years

Co-trimoxazole

Children

6 weeks – 5 years: 0.5 ml/kg ever y 12 hours for 10 days

6-12 years: 480 mg every 12 hours for 10 days

Amoxycillin

Adult 500 mg every 8 hours for 10 days

Children

Up to 10 years 10 mg/kg every 8 hours for 10 days

Children with ethmoiditis present as an acute periorbital inﬂ ammation or orbital •

cellulitis must be hospitalized immediately

Adults with treatment failure and pronounced symptoms•

If sinusitis of dental origin is suspected•

Recurrent sinusitis, >3 times a year•

Cases where sinus puncture or operation may be indicated.•

10.3 Pharyngotonsillitis

Clinical features: It is an acute inﬂ ammation of the pharynx and/tonsils, characterized

by fever and pain.

Pharyngotonsillitis is caused by virus or bacterial. Clinical important pathogens are groups

A beta-haemolytic streptococci and Epstein – Barr virus (EBV) in practice group A beta-

haemolytic streptococci is an indication for treatment with antibiotics.

Treatment guidelines – group A beta-haemolytic streptococci Infections

As general rule pharyngotonsillitis caused by group A beta-haemolytic streptococci •

should be treated with antibiotics

If treatment is begun early, duration of the illness can be shortened.•

Antibiotics can hinder the spread of infection and reduce the risk of complications.•

117

Medicine of Choice Amoxycillin

Adults 250 mg every 8 hours for 10 days

Plus

Paracetamol 10 mg/kg body weight every 8 hours until

fever controlled

Children See under treatment of pur ulent sinusitis

Plus Paracetamol 10 mg/kg body weight every 8 hours

until fever controlled.

Second choice Erythromycin

Adults and Children over 8 years 250 – 500 mg every 8 hours for 10 days

Children up to 8 year 10 mg/kg every 8 hours for 10 days

Plus

Paracetamol 10mg/kg every 8 hours for 10 days

NOTE: Duration of treatment is 10 days. Shorter treatment period increases risk of

therapy failure

10.4 Laryngitis

Clinical features: This is an acute infectious inﬂ ammation in the larynx. The etiologic

agent is normally a virus. Viral infection may give rise to bacterial superinfection. The

picture of the disease is different in children and adults.

Acute subglottic laryngitis (pseudocroup) occurs mainly in children under the age of seven.

Edema of the mucous membrane of the subglottic space causes breathing difﬁ culties,

especially on inspiration. Laryngitis in Children may require active treatment.

Treatment guidelines

(a) Symptomatic treatment

General advice and treatment at home

Parents should behave calmly and avoid frightening the child•

Raise the upper part of the body•

Keep the air damp and cold•

Give extra ﬂ uid•

Nasal drops or spray may be helpful•

If symptoms persist or worsen, seek medical advice•

(b) Medicine treatment in general practice

Epinephrine (Adrenaline) inhalation effectively reduces symptoms, but the •

effect may be short – lived

Dosage

Preparation of racemic Epinephrine solution for inhalation

118

If severe symptoms persist or worsen or recur after Epinephrine inhalation •

hospitalization is indicated

Table 19: Treatment guidelines of laryngitis in older children and adults

Age Racemic Epinephrine (20 mg/ml) 0.9% Saline

0-6 months 0.1 ml 2 ml

6-12 months 0.15 ml 2 ml

>12 0.2 ml 2 ml

NOTE: The total ﬂ uid volume is inhaled in 5 minutes with the use of inhalator

Symptomatic Treatment

Voice rest •

Ban smoking•

Antitussive•

Nasal drops or spray•

Extra ﬂ uid intake•

Treatment with antibiotics

Not indicated

10.5 Acute Epiglotitis (AE)

Clinical features: Acute infectious inﬂ ammation of the epiglottitis, supraglottic and

hypopharynx. Epiglottitis is a potentially lethal disease. Oedema of the epiglottis may

cause acute airway obstruction. Epiglotitis occur both in children and adults. Haemophilus

inﬂ uenzae is often the cause.

AE is characterized by throat pain, difﬁ cult swallowing, drooling, husky voice, fever often

high and with chills, patients prefer sitting posture, laborious inspiration, cough in some

cases and anxiety.

NOTE: When epiglotitis is strongly suspected, the patient should be referred immediately

to a specialist for hospitalization without further examination, as incision of the throat

may be dangerous

Treatment guidelines

Immediate hospitalization•

Transport the patient in sitting, with oxygen supplementation•

Be prepared to treat respiratory failure (intubation or tracheotomy)•

Antibiotics may be given if transport lasts more than one hour.•

119

11. EYE DISEASE CONDITIONS

11.1 Prevention/Management

Proper diet (Vitamin A and proteins)•

Personal and environmental hygiene•

Measles immunization•

EARLY treatment of eye diseases by qualiﬁ ed health personnel•

EARLY referral of serious eye diseases and injuries•

DO NOT use non-sterile or herbal medicines in the eye•

The following cases may need referral to an eye specialist

Cataract – cloudiness in the otherwise clear lens•

Glaucoma -high pressure in the eye•

Perforating injuries with loss of vision •

Retinoblsatoma (white pupil) – cataract or tumour in children•

Corneal scars; old injury, ulcer, malnutrition, measles•

Unexplained vision loss•

Severe eye pain•

CAUTION: Avoid use of steroid eye preparations; conditions requiring treatment with

steroids need conﬁ rmation by a specialist

Steroids may worsen infection like trachoma, increase intra-ocular pressure, cataracts, delay

healing and worsen corneal ulcers of viral origin.

11.2 Red Eye

Corneal Foreign Bodies and infections

Clinical features: Pain, gritty sensation, excessive lacrimation, red eye and reduced

vision

Treatment guidelines

Attempt removal of foreign body with a cotton-topped applicator•

If successful, instill antibiotic ointment e.g. • Chloramphenicol/Oxytetracycline

eye ointment, pad and review the following day

If unsuccessful, instill antibiotic ointment (as above ), pad and REFER•

If in any doubt REFER•

11.3 Corneal Abrasion

Clinical features: Often associated with a foreign body or other minor injuries. Patient

complains of pain, gritty sensation and tearing.

Treatment guidelines

Apply antibiotic ointment (e.g. • Chloramphenicol/Oxytetracycline eye

ointment ) and pad

Review after 24 hours. If signs and symptoms persist, REFER•

120

Table 20: The Red Eye – a Guide to locating the site of the problems

Symptosm

and signs

Conjunctiva Cornea Uvea i.e Iris, Ciliary

Body and Choroid

Acute

Glaucoma

1.History of

trauma or

irritation

Common

No No

2.Blurring of

vision

No Yes Yes Severe

with haloes

around lights

Photophobia

No Yes Yes No

4. Type of

pain

No real pain.

May have itch

or “gritty”

sensation

Both

superﬁ cial

pricking and

deep pain

Deep pain and

circumoribital

achinig

Severe, deep

pain with

headache and

nausea

5. Discharge

Usually

some, may

be copious

Usually

some

especially if

ulcerated

6.Position of

maximum

redness

Generalized,

including

eye lid and

conjunctiva

All around

cornea but

maximal

nearest the

ulcer or injury

Encircling cornea Encircling

cornea

7.Intraocular

pressure

Normal Normal Sometimes low Markedly

raised (usually

over 50

mmHg)

8.Pupil size

and response

Normal May be small Small, reaction to

light sluggish

Dilated, ﬁ xed

11.4 Penetrating Injury

Treatment Guidelines

No topical drops or ointment. Give tetanus toxoid (IM) 0.5 ml.

Medicine of choice: Amoxycillin 500 mg every 8 hours for 10 days

Second choice: Erythromycin

Adults and children over 8 years

250 – 500 mg every 8 hours for 10 days

121

Children up to 8 years 10 mg/kg every 8 hours for 10 days

NOTE: Pad the eye and REFER immediately

11.5 Chemical Burns

The burns can be due to acid or alkaline solutions which enter the eye accidentally. Severe

pain, loss of vision, blepharospasm and tears are presenting symptoms.

Management

Immediately wash the eye and surrounding tissues with plenty of water, milk or any bland

liquid. Continue irrigating for up to 30 minutes then REFER to hospital.

ATTENTION: This is a medical emergency that requires immediate attention to

prevent permanent loss of vision. Sterility may be ignored temporarily, the chemical

needs to be diluted and washed away quickly.

11.6 Conjuctivitis

Clinical Features: Conjunctivitis is an inﬂ ammatory condition which may be caused

by viruses, bacteria or allergic reactions. Bacterial conjunctivitis is the commonest form

of eye infections. Known causative bacteria include Streptococcus pneumonia and

Staphylococcus aureus. Infection from these organisms is usually bilateral and causes

copious purulent discharge with no pain and no blood vision.

Treatment guidelines

Medicine of Choice

First line Chloramphenicol eye drops 1% hourly, 3hourly, 4 hourly then

6hly for at least 5 – 7 days.

Second line Gentamycin 1% eye drops apply hourly until the discharge clears

then 3hourly, 4 hourly then 8 hours for 5-7 days

11.6.1 Conjunctivitis of the Newborn

Clinical features: A discharging sticky eye with red swollen conjunctiva and swollen

eyelids in any baby during the ﬁ rst 28 days of life.

Treatment Guidelines

Gentamycin 1% eye ointment every hour for 4 days then continues every 6 hours for

10 days.

122

Initiate systemic antibiotics preferably Procaine Penicillin (I.M.) 600,000 I.U and REFER

infant and PARENTS to hospital (IM) 60,000 IU

NOTE: See also Sexually Transmitted Disease “Ophthalmia neonatorum’’

Table 21: Conjunctivitis

Signs and

symptoms

Acute

bacteria

Viral Allergic Chronic,

endemic

Trachoma

1. Discharge

Purulent Watery or

none

Mucoid None, Watery or

purulent

2. Itching

None None Marked None

3. One or

both eyes?

One or

both

One or both Both Both

4.Recurrences

Unusual Unusual Usually Usually

Treatment

Frequent

antibiotic

eye

ointment

or eye

drops for

5 days

Usually-self-

resolving. If

in doubt treat

as bacterial or

REFER

Educate/

reassure. Cold

compresses,

zinc sulphate

drops or

antihistamine

drops or

sodium

cromoglycare

drops. If

no relief of

symptoms,

REFER

Tetracycline eye

ointment three

times a day for

6 weeks. Advise

on hygiene.

If interned

eyelashes,

REFER

11.7 Unilateral Painful eye

Painful eye is commonly due to iritis, corneal disease of glaucoma.

Management

Persistent watering of an infant’s eye suggests either congenital glaucoma or blocked tear

duct. REFER.

11.8 Congenital Trachoma

Persistent watering of an infant’s eye suggests either congenital glaucoma or blocked tear

duct.

REFER.

11.9 Trachoma

Trachoma is highly contagious, chronic inﬂ ammatory disease of the eye and a common

cause of blindness worldwide.

123

Clinical features: Trachoma is a keratoconjunctivitis caused by Chlamydia trachomatous.

Transmission is usually by contact with fomites in unhygienic conditions. The clinical

manifestation of the disease initially starts as a simple eye infection with itchy eye with

profuse watery discharge. If untreated, the disease condition may progress to scarring

and blindness.

Treatment guidelines

Medicine of choice: Azithromcycin 600mg single dose

NOTE:

If inturned eye lashes (trichiasis, entropion) present pull out the lashes and REFER •

patient to specialist.

Provide education in personal and environmental hygiene for prevention of •

trachoma

11.10 Xerophthalmia/Vitamin A Deﬁ ciency

Clinical features: Xerophthalmia is a condition occurring due to lack of vitamin A in

the diet, most commonly in pre-school children, leading to corneal damage and blindness.

It is often associated with malnutrition, measles and malabsorption syndromes. The most

important early syndrome is night blindness, inability to see in dim light.

General Preventive measure

Promotion of breast-feeding•

Measles immunization•

Promote foods rich in vitamin A or supplement•

Prophylactic tetracycline eye ointment and vitamin A treatment course in all measles •

children

Treatment Guidelines

Give to all children/adult with signs and symptoms of Xerophthalmia•

Vitamin A

Immediately 200,000 IU

Following day 200,000 IU

After 1-4 weeks 200,000 IU

NOTE:

For children aged less than one year, reduce the dosage to 100,000 IU. Vitamin A •

is safe if used as directed

Nutritional rehabilitation is indicated•

124

12. TUBERCULOSIS AND LEPROSY

12.1 TUBERCULOSIS

Clinical features: Tuberculosis is a chronic bacterial infection, debilitating disease caused

by Mycobacteria, the most common of which is Mycobactrium tuberculosis. Less frequently,

it can be caused by Mycobacterium bovis and Mycobacterium africanus. The clinical picture is

quite variable and depends on the speciﬁ c organ affected by the disease. The disease can

take the following forms: Pulmonary, meningitis, lymphadenitis, osteoarticular, potts

disease, intestinal, renal, peritoneal and cutaneous. Due to the association of TB and HIV

infection, the prevalence of TB is increasing and patients are more seriously ill than before.

Tuberculosis is a public health problem and all cases must be notiﬁ ed to the Ministry of

Health and Social Welfare.

12.1.1 Control of Tuberculosis

Important key points are:

Treatment should be short, effective and provided free of charge•

TB services should reach all areas, integrated in Primary Health Care (PHC) system •

and ensure widespread use of BCG vaccination and case ﬁ nding (especially sputum

positive patients)

Prevention

BCG vaccination is given at birth or at ﬁ rst contact with the child after birth. It is given

intradermally on the right upper arm, above the insertion of the deltoid muscle.

NOTE: The batch number of the vaccine and the date of manufacture must be recorded

on the antenatal card. Dosages are recommended by EPI Programme. BCG should be

given to all babies.

Non-healing ulcers after vaccination with BCG (up to 8 weeks) or regional lymphadenopathy

can be treated with:

Isoniazid (O) 5 mg/kg body weight daily for 6 months and needle aspiration in case of

an abscess.

12.1.2 Case Management

Diagnosis

Smear microscopy remains the most important diagnostic tool. Histopathology and

radiography are also helpful, particularly in those patients who do not produce sputum.

Sputum

Each patient should have direct smear microscopy (DSM) on 3 sputum specimens for

diagnosis. DSM should be repeated at the end of the intensive phase to conﬁ rm sputum

conversion.

125

Sputum of TB patients MUST be sent or taken to the TB Reference Laboratory when:

Sputum conversion to negative has not taken place•

There is concern that the patient has developed drug resistance•

Culture and sensitivities are required.•

Chest X-rays

This has to be done upon:

Admission for diagnosis•

Completion of outpatient treatment•

NOTE: To reduce the rate of exposure of the patients, any other ﬁ lms can be taken

only where speciﬁ cally indicated. An X-ray at the end of the intensive phase is not likely

to provide any additional beneﬁ t.

126

The diagnosis of TB in children can be very difﬁ cult owing to the wide range of symptoms.

Sputum cannot often be obtained from children and in any case it is often negative even

on culture. Symptoms in children are not typical. The diagnosis should therefore be based

on clinical ﬁ ndings, family history of contact with a smear positive case, X-ray examination

and tuberculin testing, culture (if available) and non-response to broad spectrum antibiotic

treatment. A score chat below can help to reach the diagnosis of tuberculosis. Older

children who are able to cough up sputum should go through the same assessment as

adults using smear microscopy as the “gold standard”.

127

Table 22: SCORE CHART FOR THE DIAGNOSIS OF TUBERCULOSIS IN CHILDREN

SCORE IF SIGN OR SYMPTOM IS PRESENT

0 1 2 3 4 Score

GENERAL FEATURES

Duration illness less than

2 weeks

2-4 weeks More than 4 weeks

Failure to thrive or

weight loss

weight

gain

weight

gain

Weight

loss

TB contact none Reported

not proven

Proven smear-/EP Proven

Smear +

Tuberculin test Positive

Malnutrition Not improved

after 4 weeks

Chronic infant disease Recurrent No response to

antibiotics

LOCAL FEATURES

Chest x-ray TB suggestive

feature like

inﬁ ltration, cavity

or hilar lymph

nodes

Lymph nodes Cervical, sub-

mandibular

Swelling of bone or

joint

Suggestive feature

on X-ray

Ascitis With abdominal

mass

Meningitis Chronic CNS signs

Angle deformity of

the spine

X-ray

feature

TOTAL SCORE

A score of 9 or more indicates a high likelihood of tuberculosis

Tuberculin Testing

The tuberculosis skin test is valuable as a diagnostic tool in young children. In a child who did not

receive a BCG vaccine an induration of 10mm or more is interpreted as positive. If the child did

receive a BCG, the induration should be a t least 15mm to be positive.

A positive result may indicate:

Active infection (especially when strongly positive)•

Previous infection or•

Previous BCG•

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4 Months

continuation

phase, daily

observed OR

6 Months

continuation,

monthly

supply,self

administered

(RH)

150/75

½ tablet 1 2 3 4

(EH)

400/150

¼ tablet 1/2 1 2 2

NOTE: Absence of a response does not exclude TB because individuals with HIV may

not have sufﬁ cient immunity for a positive Mantoux Test despite active TB

12.1.3 Treatment Categories

Table 23: TB patients are grouped in four main categories,

Category Patients

Category I New sputum smear positive PTB (positive pulmonary TB)

New patients with severe forms of EPTB ( extra pulmonary TB)

Category II Relapse, Treatment failure and sputum smear positive return after

default

Category III New sputum smear negative and EPTB (less severe forms)

Category IV Chronic cases

12.1.3.1 Table 24: Treatment Guidelines Category I; 2{RH}ZE/6{EH}

Duration of

treatment

DRUG CHILD

Pre-treatment weight

ADULTS

Pre-treatment

weight

5-10 kg 11 – 20

21 – 30

< 50kg > 50kg

Intensive

phase: 2

months, daily

supplied and

observed

treatment

(RHZE)

150/75/

400/275

(FDC)

½ tablet 1 2 3 4

R = Rifampicin H = Isoniazid Z = Pyrazinamide E = Ethambutol

Maximum recommended daily dosage of rifampicin in FDC 750 mg

129

1 month

intensive

phase, daily

supplied and

observed

treatment

(RHZE)

150/75/

400/275

½ tablet 1 2 3 4

5 Months

continuation

phase, 3

weekly

observation

{RH}

150/

150**

tablet

1 2 3 4

400

tablet

1 ½

tablet**

3 ** 4**

The numbers indicate number of tablets to be taken daily for treatment according to body

weight and content of tablets.

These recommendations are based upon dosages by body weight: Rifammpicin 10mg/

kg; Isoniazid 5mg/kg; Pyrazinamide 25 mg/kg; Ethambutol 25 mg/kg; If Ethambutol

is given for any reason for more than 8 weeks, the daily dose must be reduced to 15 mg/

kg body weight.

Some important notes

The oral drugs should preferably be given on an empty stomach in a single dose•

The oral drugs must be swallowed under direct supervision of a health facility •

worker or at home undersupervisionof of suppor ter of the choice.

12.1.3.2 Treatment guidelines Category II; 2 S{RH}ZE/1{RH}ZE/5{RH}3E3

Duration of

treatment

DRUG CHILD

Pre-treatment weight

ADULTS

Pre-treatment

weight

5-10 kg 11 – 20

21 – 30

< 50kg >

50kg

2 months

intensive

phase, daily

supplied and

observed

treatment

S (i.m) 15mg/kg 15mg/kg 500mg 750mg 1 g*

(RHZE)

150/75/

400/275

½ tablet 1 2 3 4

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* Patients older than 50 years of age should not exceed a dose of 750 mg

Streptomycin. Streptomycin should not be given to pregnant women

** Notice the higher dose-formulation of RH and increase in dosage of Ethambutol

in the three weekly regimen

NOTE

If Ethambutol is to be given for more than 8 weeks reduce to 15 mg/kg body •

weight

Ethambutol should not be given to children•

12.1.3.3 Treatment guidelines Category III; 2 {RHZE}/4{RH}

Duration of treatment: 6 months

DOT: Daily for full duration of treatment

12.1.3.4 Treatment guidelines Category IV; Chronic patients

No regimen available yet in Tanzania

These are patients who remain or become sputum smear positive after completing fully

supervised re-treatment regimen. It is important to identify patients with Multi Drug

Resistant (MDR) TB among chronic patients. Not every chronic patient is MDR-TB

case. Many of these patients, although persistently smear positive, may still harbour

bacilli partially or fully sensitive to the common anti-TB drugs.

A “chronic” TB patient with unknown susceptibility pattern should always

ﬁ rst submit sputum samples for drug susceptibility testing to the central TB reference

laboratory before any further actions taken.

12.1.3.5 Treatment in special cases

Pregnancy Always ask woman if is pregnant before commencing treatment. Most

anti-TB drugs are safe during pregnancies except streptomycin, which causes permanent

deafness in the foetus therefore it should be avoided during pregnancy.

Breastfeeding Full TB treatment is safe and is the best way to prevent tuberculosis

in the baby. Mother and child can stay together for the entire duration of treatment. In

mothers with pulmonary tuberculosis, the baby should receive INH preventive treatment

(5mg/kg) for 6 months followed by BCG vaccination.

Oral contraceptives Rifampicin interacts with oral contraceptives and reduces the

efﬁ cacy of this contraception. Women using oral contraceptives should be advised to use

pills with a higher dose of oestrogen (50mcg) or change to another method.

Liver disease Most anti-TB drugs can cause liver damage. In case a patient develops

jaundice, treatment should be stopped and restarted as soon as the jaundice resolves.

In severely ill patients start streptomycin and ethambutol only. If the patient improves

follow with a gradual step-up introduction of Isoniazid followed by Rifampicin until full

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dose. Monitor liver functions and clinical picture. If the condition deteriorates stop the

drug which was last added.

Patients with established chronic liver-disease should not receive Pyrazianamide. The

treatement given is 2 RHE/6EH for Category I and III patients and 2 SRHE/6RHE for

Category II patients.

Renal failure Isoniazid, Rifampicin and Pyrazinamide are almost entirely excreted

by the liver and therefore safe to use. Streptomycin and Ethambutol are excreted by the

kidneys and should either be avoided or given in a reduced dose. The safest regimen

for patients with renal failure is 2 RHZ/4 RH combined with pyridoxine to prevent

Isoniazide induced peripheral neuropathy.

HIV There is a danger of interaction between Rifampicin and protease inhibitors in

HIV positive patients receiving antiretoviral (ARV) treatments. Rifampicin stimulates

the activity of the liver enzyme system, which metabolises protease inhibitors (PI) and

Nucleoside Reverse Transcriptase Inhibitors (NsRTIs). This can lead to decreased blood

levels of PIs and NsRTIs. Of the NsRTIs the concentration of Nevirapine is signiﬁ cant

redeced and hence Nevirapine and Rifampicine should not be used concomintantly.

On other hand PIs enhance the liver enzyme system which inﬂ uences the blood levels

of rifampicin resulting in ineffective TB treatment or drug toxicity. NsRTIs can cause

peripheral neuropathy, which can result in an added toxicity caused by Isoniazid.

12.1.3.6 The role of adjuvant steroid therapy

Steroid therapy given in additional to anti-TB treatment is beneﬁ cial in tuberculosis

meningitis, pleural TB with large effusion and TB pericarditis.

The recommended dosage in TB meningitis and TB pericarditis is 40-60mg/daily for

1 – 4 weeks, gradually decreasing the dosage over several weeks.

Other less frequent conditions, which can beneﬁ t from steroid treatment, are:

TB laryngitis with airway obstructiono

Massive lymphadenopathy with signs of obstruction of e.g airwayo

TB of renal tract to prevent uretic scarringo

Tb of adrenal glands causing hypo-adrenalismo

Severe hypersensitivity reaction to anti-TB drugs o

Although steroids are immunosuppressant they can be used in HIV positive patients as the

overall beneﬁ t of steroids, in the context of above conditions, outweighs the risk of other

opportunistic infections.

12.2 LEPROSY

Clinical features: It is a chronic granulomatous disease caused by Mycobacterium

leprae, an acid and alcohol fast bacillus that has a very slow multiplication. Leprosy is the

commonest cause of peripheral neuritis in the world. The major clinical features therefore

include hypopigmented anaesthetic macula or nodular and erythematous skin lesions and

nerve thickening. It is classiﬁ ed into ﬁ ve different levels according to nuclear of bacilli

found in the lesion.

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12.2.1 General Information about Leprosy

Leprosy is a chronic infectious disease caused by Mycobacterium leprae. It mainly affects the

skin, the peripheral nerves and the mucous membranes. It is a disease mainly of human

beings, which affects people of all races, all ages and both sexes.

Patients harbouring many bacilli in their bodies, the multi bacillary patients, are the main

sources of infection. If not treated, they spread the disease in the community and infect

others through coughing and sneezing (droplet infection). These infectious patients

represent only about 25% of the registered leprosy patients in Tanzania. The other

75% of patients with few leprosy bacilli, the paucibacillary patients are less infectious.

Skin contact with leprosy patients is no longer considered to be an important means of

transmission.

The different manifestation of leprosy are due to differences in the degree of resistance

(immunity) of the human body and not due to different kinds of bacilli.

The majority of people (about 85%) have a strong resistance to M. Leprae that even when

infected they do not develop the disease. They are immune. About 75% of children who

get infected with leprosy bacilli have such a high resistance that they overcome the disease

themselves, without treatment, at very early stage. People who have a fairly high but

incomplete immunity to leprosy bacilli will develop paucibacillary leprosy.

There are only very few people in the community (5-10%) whose immunity to M. Leprae is

naturally very low. When somebody from this group of people is infected by M.Leprae, the

bacilli may multiply freely and attain large numbers causing multi-bacillary leprosy.

12.2.2 When Leprosy should be suspected

Patients should be suspected of having leprosy when they show one or more of the

following signs or symptoms:

One or more pale or reddish, hypo-pigmented patch(es) on the skin with or without •

loss of sensation

Painless swellings or lumps in the face and/or earlobes•

Enlarged and/or tender nerves•

Burning sensations in the skin•

Numbness or tingling of the feet and/or hands•

Weakness of eyelids, hands and/or feet•

Painless wounds or burns on the hands and/or feet•

Such patients need to be examined by trained health worker.

12.2.3 Diagnosis of Leprosy

The diagnosis of leprosy must be based on the history of the symptoms and careful clinical

examination of the person for signs of le prosy. Only in rare instances a laboratory and

other investigation may be needed to conﬁ rm the diagnosis of leprosy.If one is not sure of

dignosis,the suspect should be seen by the DTLC or other personel trained in leprosy.

133

History taking

Proper history taking and collection of certain information on the patient are very

important for understanding the patient’s situation and for tracing a lost patient.

The following must be obtained:

General information: all three names, sex, year of birth,occupation, full address •

including the name of of villag e/street leader and distance from home to clinic.

Main complaints, including date of onset, site of ﬁ rst lesions,subsequent changes and •

development of the disease,previous treatment received.

Information regarding other leprosy cases in patient’s household.•

Physical examination

Physical examination should always be carried out with adequate light available and with

enough privacy for the person to feel at ease.

The patient is asked to undress. To ensure that no important sign is missed, a patient must

be examined systematically. A well tried system is to examine the patient as follows:

Start with examination of the skin, ﬁ rst head, then neck, shoulders, arms, trunk, •

buttocks and legs. Look for any discouration of the skin, thickening or swelling.

Then palpation of the nerves; starting with the head and gradually going to the feet•

Then the examination of other organs•

Examination of the skin smear•

Finally the examination of eyes, hands and feet for disabilities.•

Complications due to nerve damage

Patients should be examined for the following complications which result from nerve

damage:

Injury to cornea and loss of vision due to incomplete blink and/or eye closure•

Skin cracks and wounds on palms and sole with sensation loss•

Clawed ﬁ ngers and toes•

Drop foot•

Wrist drop•

Shortening and scarring ﬁ ngers and toes with sensation loss. Mark and draw also •

wounds, clawing and absorption levels on the maps using the appropriate marks.

A dignosis of leprosy should be made if ONE of the following CARDINAL SIGNS is

presents

Skin lesion with loss of sensation•

One or more enlarged peripheral nerves•

A skin smear positive for leprosy baccili •