standard treatment guidelines for zonal hospitals

CONTENTS
ACKNOWLEDGEMENTS ......................................................................... vi
ABBREVIATIONS/NOTATIONS• ..........................................................viii
FOREWORD ................................................................................................ ix
Chapter 1
INTRODUCTION ......................................................................................... x
GENERAL GUIDANCE............................................................................. xii
HOW TO USE THE STANDARD TREATMENT GUIDELINE........... xx
Chapter 2
INFECTIOUS DISEASES ............................................................................ 1
Acquired Immuno Deficiency Syndrome (AIDS) ........................................... 1
Amebiasis ...................................................................................................... 24
Amebic Liver Abscess................................................................................... 27
Bacillary Dysentery ....................................................................................... 29
Bronchitis (Acute) ......................................................................................... 31
Cholera .......................................................................................................... 34
Gastro-Enteritis (Food-Poisoning)................................................................. 36
Giardiasis....................................................................................................... 38
Intestinal Parasitic Infestations ...................................................................... 39
Leishmaniasis ................................................................................................ 44
Leprosy.......................................................................................................... 47
Malaria........................................................................................................... 51
Meningitis...................................................................................................... 57
Oncocerciasis (Blinding Filariasis, River Blindness, Coastal Erysipelas)..... 62
Pneumocystis Carrinni Peumonia:................................................................. 65
Pneumonia ..................................................................................................... 68
Pneumonias (Aspiration) And Lung Abscesses:............................................ 75
Pyogenic Osteomyelitis ................................................................................. 77
Relapsing Fever ............................................................................................. 79
Schistsomiasis................................................................................................ 81
Septic Athritis................................................................................................ 83
Sinusitis ......................................................................................................... 84
Subacute Bacterial Endocarditis .................................................................... 86
Tetanus .......................................................................................................... 88
Tonsillitis....................................................................................................... 91
Toxoplasmosis (CNS).................................................................................... 93
Trachoma....................................................................................................... 95
Tuberculosis .................................................................................................. 97
Typhoid Fever ............................................................................................. 108
Typhus ......................................................................................................... 110
Urinary Tract Infection................................................................................ 111

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Chapter 3
SEXUALLY TRANSMITTED INFECTIONS ....................................... 114
Ano-Genital Warts....................................................................................... 115
Chancroid .................................................................................................... 117
Genital Candidiasis...................................................................................... 118
Genital Herpes ............................................................................................. 120
Gonorrhea .................................................................................................... 122
Granuloma Inguinale (Donovanosis)........................................................... 125
Lymphogranuloma Venereum (LGV) ......................................................... 127
Non Gonococcal Urethritis (NGU).............................................................. 128
Syphilis ........................................................................................................ 129
Trichomoniasis ............................................................................................ 132
Chapter 4
SKIN PROBLEMS .................................................................................... 133
Carbuncle..................................................................................................... 134
Cellulitis ...................................................................................................... 135
Eczema ........................................................................................................ 137
Erysipelas .................................................................................................... 142
Folliculitis (Superficial Pustular Folliculitis)............................................... 144
Fungal Infections ......................................................................................... 145
Furunclules (Furunculosis) .......................................................................... 150
Herpes Simplex ........................................................................................... 151
Herpes Zoster (Shingles) ............................................................................. 152
Impetigo Contagiosa.................................................................................... 154
Molluscum Contagiosum............................................................................. 156
Pediculosis Pubis ......................................................................................... 158
Scabies......................................................................................................... 160
Urticaria (Wheals, Hives) ............................................................................ 162
Chapter 5
NON-INFECTIOUS DISEASES .............................................................. 164
Acute Pulmonary Edema ............................................................................. 165
Anemia ........................................................................................................ 167
Anxiety Disorder ......................................................................................... 171
Arrhythmia (Common Rhythm Disorders).................................................. 172
Atrioventricular (AV) Block........................................................................ 179
Bronchial Asthma ........................................................................................ 181
Chronic Lymphocytic Leukemia ................................................................. 188
Chronic Myelogenous Leukemia................................................................. 191
Constipation................................................................................................. 193
Diabetic Keto Acidosis................................................................................ 195
Diabetes Mellitus......................................................................................... 197
Epilepsy ....................................................................................................... 200
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 standard treatment guidelines for zonal hospitals

Gout ............................................................................................................. 205

Heart Failure................................................................................................ 208
Hemorrhoids ................................................................................................ 210
Hypertension................................................................................................ 212
Immune Thrombocytopenic Purpura (ITP) ................................................. 218
Migraine ...................................................................................................... 220
Mood Disorders ........................................................................................... 224
Myocardial Infarction .................................................................................. 226
Nausea And Vomiting ................................................................................. 229
Non-Ulcer Dyspepsia .................................................................................. 230
Osteoarthritis ............................................................................................... 232
Peptic Ulcer (PUD)...................................................................................... 234
Portal Hypertension ..................................................................................... 237
Rheumatic Fever.......................................................................................... 239
Rheumatic Heart Disease (Chronic) ............................................................ 241
Rheumatoid Arthritis ................................................................................... 242
Schizophrenia .............................................................................................. 245
Thyrotoxicosis ............................................................................................. 247
Chapter 6
OBSTETRICS AND GYNECOLOGICAL CONDITIONS .................. 248
Anemia In Pregnancy .................................................................................. 249
Contraceptives ............................................................................................. 251
Diabetes Mellitus Complicating Pregnancy ................................................ 254
Dysfunctional Uterine Bleeding (DUB) ...................................................... 256
Dysmenorrhoea............................................................................................ 258
Evacuation Of The Uterus ........................................................................... 260
Hypertensive Disorders In Pregnancy ......................................................... 262
Nausea And Vomiting In Pregnancy ........................................................... 267
Pelvic Inflammatory Disease (PID)............................................................. 269
Post Abortal/ Puerperal Sepsis..................................................................... 272
Premature Rupture Of Membranes (PROM) ............................................... 275
Puerperal Mastitis ........................................................................................ 277
Urinary Tract Infection In Pregnancy.......................................................... 278
Sexual Assault ............................................................................................. 280
Syphilis In Pregnancy.................................................................................. 282
Vulvo Vaginal Candidiasis .......................................................................... 283
Chapter 7
PEDIATRIC DISEASES .......................................................................... 284
Amebiasis .................................................................................................... 285
Bronchial Asthma ........................................................................................ 286
Conjunctivitis .............................................................................................. 288
Croup (Acute Laryngotracheobronchitis) .................................................... 291
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Diarrheal Disease (Acute)............................................................................ 293

Giardiasis..................................................................................................... 300
Hiv/ Aids In Children .................................................................................. 301
Hypoglycemia.............................................................................................. 309
Jaundice In Neonates ................................................................................... 310
Malnutrition (Sever) .................................................................................... 311
Measles ........................................................................................................ 315
Meningitis.................................................................................................... 318
Oral Trush.................................................................................................... 321
Ostiomylitis ................................................................................................. 322
Ottis Media (Acute) ..................................................................................... 323
Pertusis (Whooping Cough) ........................................................................ 324
Pneumocystes Carini Pneumonia (PCP)...................................................... 325
Pneumonia In Children................................................................................ 327
Seizures (Neonatal)...................................................................................... 330
Sepsis (Neonatal)......................................................................................... 332
Septic Arthritis............................................................................................. 333
Sinusitis ....................................................................................................... 334
Streptococcal Pharyngitis/ ........................................................................... 335
Exudative Tonsillitis.................................................................................... 335
Syphilis (Congenital)................................................................................... 336
Tetanus (Neonatal) ...................................................................................... 338
Trachoma..................................................................................................... 339
Tuberculosis (TB) In Children..................................................................... 340
Chapter 8
ACUTE /EMERGENCY CONDITIONS ............................................... 342
Animal Bites ................................................................................................ 343
Burns ........................................................................................................... 348
Poisoning ..................................................................................................... 352
Shock ........................................................................................................... 360
Wound ......................................................................................................... 365

ANNEXES .................................................................................................. 366

ANNEX 1: Recommended Immunizatuion Schedule ................................. 366
ANNEX 2: Feeding Problems ........................................................368
ANNEX 3: Fluid And Electrolyte .............................................................. 369
ANNEX 4: The Kangaroo Mother Care ...................................................... 370
ANNEX 5: The Ethiopian Aids Case Definition For Surveillance In
Pediatrics ................................................................................. 373
ANNEX 6: Who Recommendations On Multiple Drug Therapy For
Leprosy (Table 1-4) ................................................................. 375

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ANNEX 7: Percentage Of Adult Dose Required At Various Ages And

Body Weight............................................................................ 377
ANNEX 8: Guidelines For The Management Of Pain (Including Post-
Operative Pain) ........................................................................ 378
ANNEX 9: Guidelines For Using Non-Steroidal Anti-Inflammatory
Drugs (NSAIDS) ..................................................................... 379
ANNEX 10. Symptoms And Findings When Poisoned .............................. 381
INDEX……………………………………………………………………
364

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ACKNOWLEDGEMENTS

The Standard Treatment Guidelines have been compiled after a lengthy

consultative process. They include materials from many sources and
recommendations and advice from numerous individuals and groups. The
groups included task forces, expert committees, medical schools,
professional societies listed below.

A. Task force members

Dr. Eyasu Mekonnen - Pharmacologist (member and secretary)

Dr. Kibrebeal Melaku - Internist and Pulmonologist (member)
Dr. Negussu Mekonnen - Pharmacalogist (Chairman)
Dr. Yemane Berhane - Epediomologist (member)

B. Expert group

Dr. Amha Gebremedhin - Internist and Haematologist

Dr. Bekele Alemayehu - Internist
Dr. Bogale Worku - Paediatrician
Dr. Dagnachew Shibeshi - Dermatologist and Venerologist
Dr. Zenebe Melaku - Internist, neurologist and Rheumatologist
Dr. Zufan Lakew - Gyne-obstetrician

C. Work shop Participants

Dr. Abebe Melaku - ENT Surgeon

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Dr. Abrham Deneke - Surgeon

Dr. Ali Hassen - Paediatrician
Dr. Berhan Feleke - Internist
Dr. Damte Shibru - Paediatrician
Dr. Daniel Arega - Internist
Dr. Fikre Abate - Surgeon
Dr. Gedion H/Mariam - General Practitioner
Dr. Gizaw Erene - Cardiologist
Dr. Hailemariam Legesse - Paediatrician
Dr. Hamza Abdu - Internist
Dr. Kibrebeal Melaku - Internist + Pneumonologist
Dr. Lukman Yossuf - Gyne-obstetrician
Dr. Mengistu Alemayehu - Internist
Dr. Mesfin Hunegnaw - Dermatologist
Dr. Messay Mekonnen - Surgeon
Dr. Mohammed Haji - Com. Psychartist
Dr. Shitaye Alemu - Internist
Dr. Sisay Mengistu - General Practitioner
Dr. Solomon Dabi - General Practitioner
Dr. Tefera Muche - Psychatrist
Dr. Tesfaye Berhe - Internist
Dr. Teshale Seboxa - Internist
Dr. Tollera Wolde Eyesus - Internist
Dr. Wondowossen Desta - Paediatrician
Dr. Yewndossen Tadesse - Internist + Nephrologist
Dr. Yonas Getachew - Gyne-obstetrician
Dr. Biru Mengesha - General Practitioner
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Edmealem Ejigu - Pharmacist

Rukia A/Wech - Health Assistant
Commonly used Abbreviations/notations•
ADR Adverse drug reaction
b.i.d. Medication to be given Twice daily
C/I Contraindication
DACA Drug Administration and Control Authority
D/I Drug interaction
D/S Dextrose in saline solution for intravenous use
D/W Dextrose in water solution for intravenous use
g Gram
GI Gastro Intestinal
Hrs/h Hour
i.m. Medication to be given intramuscular
i.v. Medication to be given intravenous
IU International Unit
kg Kilogram
mg Milligram
ml Milliliter
MOH Ministry of Health
N/S Normal Saline solution for intravenous use
Oby/gyn Obstetrics and gynecology
p.o. Medication to be given per mouth
prn Drug administered as necessary by the patient
q.i.d. h th
Medication t four times a day
to be given
S/E Side Effect
Stat Medication to be given in only one dose
STG Standard Treatment Guidelines
t.i.d. Medication to be given three times a day

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• Other abbreviations are defined in the text in places they are first used

FOREWORD

It is gratifying to announce and introduce the completed standard treatment

guidelines for Hospital Level.

This 1st edition of the Standard treatment guidelines is aimed at all levels
of health care both public and private through out the country and will
assist health care professionals in their treatment choices.

The standard treatment guidelines is a commendable achievement to

address the major health problems in our country and set the stage for
ensuring equits in health care delivery, as well as providing for rational
prescribing and dispensing. This guidelines is developed with the frame
work of the essential drug program and it also serves as an effective way of
containing cost of treatment for both patients and the health sector and
should also be used as a training material for health care providers.

Finally, I would like to take this opportunity to thank all members of the
technical task force expert groups and Institutions for their valuable input
in the development of this important guidelines.

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Chapter 1

INTRODUCTION

The irrational use of drugs has become a serious problem in Ethiopia. One
of the causes for irrational drug use is the absence of a standard treatment
guideline for the most common diseases in the country. Only a limited
number of diseases, such as malaria, tuberculosis and sexually transmitted
diseases have adapted standard treatment guidelines. This has led both
prescribers and dispensers to prescribe and dispense different drugs for the
same disease, making treatment non-uniform and paving the way for
irrational drug use. A collaborative effort among prescribers, dispensers
and drug consumers is required to address the problem. The formulation of
a standard treatment guideline is one of the most important measures that
could be taken to promote the rational use of drugs.

The present STG contains guides to general and special prescribing:

specific treatment guidelines for a large number of common health
conditions in Ethiopia, and relevant annexes that are useful for treatment
and prevention. Diseases are classified into sections: infectious,
noninfectious, common pediatric problems, common
obstetric/gynecological problems, common skin conditions and
acute/emergency problems. Every disease has a brief description on the
disease pattern, including ways of diagnosis and treatment. Both non-drug
and drug treatment, both first line and alternatives drugs are listed for the
treatment of a given disease. Under drug treatment, information on doses,
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course of therapy, dosage forms, side effects, contraindications and drug

interactions are given for first line and alternative drugs.

These standard treatment guidelines are designed to be used as a guide to

treatment choices and as a reference book to help in the overall
management of patients.

It is emphasized that the choices described here have the weight of

scientific evidences to support them, together with the collective opinion of
a wide group of recognized national experts.
The content of these treatment guidelines will undergo a process of
continuous review comments or suggestions for improvement are well
come. Those comments or suggestions for addition of diseases should
include evidence of prevalence as well as a draft treatment guideline using
the format set one in this guidelines. In the cases of a request for a new
drug or replacing a listed product with another product, the evidence base
must be clearly defined and included with the request.

These comments or suggestions should be sent to

The Drug Administration and Control Authority (DACA) of Ethiopia
P.O. Box 5681
Addis Ababa, Ethiopia

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General Guidance

A. Rational Use of Drugs

Effective treatment of patients requires rational use of drugs. Drugs should

only be prescribed when they are necessary, and in all cases the benefit of
administering the medicine should be considered in relation to the risks
involved. Bad prescribing habits lead to ineffective and unsafe treatment,
exacerbation or prolongation of illness, distress and harm to the patient, and
higher cost. Thus, it is very important that steps are taken to promote the
rational use of drugs in order to effectively promote the health of the public
and to use meager resources maximally. One way of promoting such
practice is developing standard treatment guidelines.

Rational approach to therapeutics requires careful evaluation of the health

problem and selecting appropriate therapeutic strategies. Making the right
diagnosis is the cornerstone for choosing the right kind of therapy. Based
on the diagnosis, health workers may select more than one therapy and the
selected therapy should be agreed with the patient. The selected treatment
can be non-pharmacological and/or pharmacological. It is important to take
into account the total cost of all therapeutic options in the selection process.

It is important to bear in mind that the patient does not always need a drug
for treatment of his/her condition. Very often, health problems can be
resolved by a change in life style or diet, use of physiotherapy or exercise,
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provision of adequate psychological support, and other non-

pharmacological treatments.

The selection process must consider benefit/risk/cost information. This step

is based on evidence about maximal clinical benefits of the drug for a given
indication (efficacy) with the minimum occurrence of adverse effects
(safety). It is well known that most drugs have adverse effects, but much of
the adverse effects observed throughout the world are caused by
inappropriate selection of drugs. The prescriber must check whether the
active substance chosen is suitable for the particular patient. As far as
possible, drug treatment should be individualized to the needs of each
patient.

B. Prescription writing

A prescription is an instruction from a prescriber to a dispenser. The

prescription is the link between the prescriber, the pharmacist (or
dispenser) and the patient. A properly written prescription is the basis for
giving appropriate information, instructions and warning to the patient. It
ensures adherence to therapy and protects the patient from unnecessary
harm related to therapy.
The prescriber is not always a doctor; he/she could be a paramedical
worker, such as a medical assistant, a midwife or a nurse. Likewise, the
dispenser is not always a pharmacist, but can be a pharmacy technician, an
assistant or a nurse. In any setting, it is important to ensure that
prescriptions are correctly interpreted and leave no doubt about the
intention of the prescriber. The prescription should be clear, legible and

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indicate precisely what should be given. The prescriber’s name and address
must be indicated on the prescription form. This will allow either the
patient or the dispenser to contact the prescriber for any clarification or
potential problem with the prescription. The following details should be
shown on the prescription:
• Date of the prescription
• Name, form and strength of the drug; the International Nonproprietary
Name of the drug should always be used
• The pharmaceutical form (for example tablet, oral solution, or
ointment) should also be stated
• The strength of the drug should be stated in standard units that are
consistent with the Systeme Internationale (SI). Abbreviations that are
not standard should be avoided. Avoid decimals whenever possible; if
unavoidable, a zero should be written in front of the decimal point.
• Directions specifying the route, dose and frequency should be clear and
explicit; use of phrases such as take as directed or take as before should
be avoided.
• The quantity of the medicinal product to be supplied should be stated.
Alternatively, the length of treatment course may be stated.

C. Adherence (compliance) with drug treatment

It is often assumed that once the appropriate drug is chosen, the

prescription correctly written, and the medication correctly dispensed, the
drug will be taken correctly and treatment will be successful.
Unfortunately, this is very often not the case, and physicians overlook one

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of the most important reasons for treatment failure - poor adherence

(compliance) with the treatment plan.
There are sometimes valid reasons for poor adherence, as with the case of a
drug that may be poorly tolerated, may cause obvious adverse effects or
may have been prescribed in a toxic dose. Failure to adhere with such a
prescription has been described as intelligent non-compliance. Bad
prescribing or a dispensing error may also create a problem, which patients
may have neither the insight nor the courage to question. Even with rational
prescribing, failure to adhere to treatment is common. Factors may be
related to the patient, the disease, the doctor, the prescription, the
pharmacist or the health system and can often be avoided.

In general, women tend to be more adherent than men, while younger

patients and the very elderly are less adherent. People living alone are less
adherent than those with partners or spouses. Conditions with a known
worse prognosis (for example cancer) or painful conditions (for example
rheumatoid arthritis) elicit better adherence rates than asymptomatic
perceived as 'benign' conditions such as hypertension. Health workers may
cause poor adherence in many ways by failing to inspire confidence in the
treatment offered, by giving too little or no explanation, by thoughtlessly
prescribing too many medications, by making errors in prescribing, or by
their overall attitude to the patient. Many aspects of the prescription may
also lead to non-adherence. It may be illegible or inaccurate; it may get
lost; it may not be refilled as intended or instructed for a chronic disease.
And it may be too complex; it has been shown that the greater the number
of medications, the poorer the adherence. Multiple doses also decrease
adherence, especially if more than two doses per day are given. Not
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surprisingly, adverse effects like drowsiness, impotence or nausea

negatively influence adherence and patients may not admit the problem.

The pharmacist’s personality and professional manner, like that of the

doctor, may have a positive impact, supporting adherence, or a negative
one, raising suspicions or concerns. This has been reported especially in
relation to generic drugs when substituted for brand name drugs.
Pharmacist information and advice can be a valuable reinforcement, as long
as it tallies with the doctor’s advice. The health care system may also be the
biggest hindrance to adherence. Long waiting times, uncaring staff,
uncomfortable environment, exhausted drug supplies, etc, are all common
problems in developing countries, and have a major impact on adherence.
An important problem is the distance of the clinic from the patient and its
accessibility. Some studies have confirmed the obvious, that patients
furthest from the clinic are least likely to adhere to treatment in the long
term.

A good health worker-patient understanding is important for effective

adherence to therapeutic regimens. Adequate time must be given to
explaining the health problem and the reason for the drug treatment. Health
workers must keep treatment regimens simple and write appropriate notes
for patients. Teamwork and collaboration with pharmacists is important
when advising the patient. It may be appropriate to Involve the partner or
another family member, when necessary.

D. Adverse Drug Reactions

An adverse drug reaction (ADR) may be defined as any response to a drug
which is noxious, unintended and occurs at doses normally used for
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prophylaxis, diagnosis, or therapy. ADRs are, therefore, unwanted or

unintended effects of a medicine, including idiosyncratic effects, which
occur during its proper use. They differ from accidental or deliberate
excessive dosage. It is well recognized that clinical trials, however
thorough, cannot be guaranteed to detect all adverse effects likely to be
caused by a drug. Health workers are thus encouraged to record and report
to their national pharmacovigilance center any unexpected adverse effects
with any drug to achieve faster recognition of serious drug-related
problems. One of the common predisposing patient factors to ADRs is
extreme age. The very old and the very young are more susceptible to
ADRs. Drugs which commonly cause problems in the elderly include
hypnotics, diuretics, non-steroidal anti-inflammatory drugs,
antihypertensives, psychotropics and digoxin. Children, and particularly
neonates, differ from adults in the way they respond to drugs. Some drugs
are likely to cause problems in neonates (for example morphine), but are
generally tolerated in children. Other drugs (for example valproic acid) are
associated with increased risk of ADRs in children of all ages. Other drugs
associated with problems in children include chloramphenicol (grey baby
syndrome), antiarrhythmics (worsening of arrhythmias), aspirin (Reye’s
syndrome).

Another common factor is the presence of co-existing illness. If besides the

condition being treated the patient also suffers from another disease, such
as kidney, liver or heart disease, special precautions are necessary to
prevent ADRs. Also, the genetic make-up of the individual patient may
predispose him/her to ADRs.

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E. Drug Interactions

Interactions may occur between drugs that compete for the same receptor
or act on the same physiological system. They may also occur indirectly
when a drug-induced disease or a change in fluid or electrolyte balance
alters the response to another drug. Interactions may occur when one
drug alters the absorption, distribution or elimination of another drug,
such that the amount which reaches the site of action is increased or
decreased. Drug interactions are some of the commonest causes of
adverse effects. When two drugs are administered to a patient, they may
either act independently of each other, or interact with each other.
Interaction may increase or decrease the effects of the drugs concerned
and may cause unexpected toxicity. As newer and more potent drugs
become available, the number of serious drug interactions is likely to
increase. It is important to remember that interactions which modify the
effects of a drug may involve non-prescription drugs, non-medicinal
chemical agents, and social drugs such as alcohol, marijuana, and
traditional remedies, as well as certain types of food. The physiological
changes in individual patients, caused by such factors as age and gender,
also influence the predisposition to ADRs resulting from drug
interactions. Patients who have been or are taking traditional herbal
remedies may develop ADRs. It is not always easy to identify the
responsible plant or plant constituent

F. Incompatibilities between drugs and IV fluids

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Drugs should not be added to blood, amino acid solutions or fat emulsions.
Certain drugs, when added to IV fluids, may be inactivated by PH changes,
by precipitation or by chemical reaction. Benzylpenicillin and ampicillin
lose potency after 6 –8 hours if added to dextrose solutions, due to the
acidity of these solutions. Some drugs bind to plastic containers and tubing,
for example diazepam and insulin.
Aminoglycosides are incompatible with penicillins and heparin.
Hydrocortisone is incompatible with heparin, tetracycline, and
chloramphenicol.

The Effect of Food on Drug Absorption

Food delays gastric emptying and reduces the rate of absorption of many
drugs; the total amount of drug are preferably taken with food, either to
increase absorption or to decrease the irritant effect on the stomach. It is
important to refer to the specific conditions for properly advising the
patient.

Narcotics and controlled substances

The prescribing of a medicinal product that is liable to abuse requires

special attention and may be subject to specific legal requirements.
Authorized health workers must use these drugs with a full sense of
responsibility. The strength, directions and the quantity of the controlled

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substance to be dispensed should be stated clearly. Required details must

be filled in the prescription form carefully to avoid alteration and abuse

How to Use the Standard Treatment Guideline

This Standard Treatment Guideline is prepared to improve the treatment

practice of health workers at all levels. It does not, however, provide all the
necessary references to establish the diagnosis of the disease/illness for
which the patient is visiting the health care system; it assumes that health
workers at various levels have the required training and competence to
make diagnosis that is appropriate for that level. In light of this the
guideline has been organized by level of use, from Zonal Hospital to Health
Station.

Once diagnosis is established, the guideline is useful to administer the most

appropriate drug, in the Ethiopian context, using the right dose of the drug
for the right duration of treatment. It also gives the recognized side effects,

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contraindications and other useful information about each drug. All drugs
included in the Standard Treatment Guideline are those that ate included in
the current National Drugs List for Ethiopia.

Diseases are categorized according to the nature of the disease, the

population most affected by the disease, and other conditions requiring
special attention. Thus, it contains major infectious and noninfectious
disease according to the first criteria; major obstetric/gynecological and
pediatric diseases according to the second criteria; and other major
conditions such as sexually transmitted diseases, skin disorders and acute
emergencies as per the third criteria. One can search the document and
obtain the necessary information based on the above criteria. For quick
reference, the list of diseases included in the STG and the drugs
recommended are organized in the index at the end of the guideline.

This is the first attempt to formulate a Standard Treatment Guideline for

the country. Your comments and suggestions on the use of the guideline
could go towards improving subsequent editions, and, therefore, you are
requested to send these to the Drug Administration and Control Authority.

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Chapter 2

INFECTIOUS DISEASES

ACQUIRED IMMUNO DEFICIENCY SYNDROME (AIDS)

AIDS is a chronic infectious disease caused by the Human Immuno-deficiency
Virus type 1 and 2. It is transmitted largely by sexual contacts. Other important
means of transmission are direct contact to contaminated blood and blood
products and from infected mother to children. It is essentially a disease of the
immune system, which results in progressive and crippling immuno-deficiency
State. This exposes infected individuals to various types of infections and the
development of malignancies. The clinical manifestation is quite variable
depending on the stage of the disease. At advanced stage, patients are at a very
high risk of being infected with less virulent organisms leading to the so-called
opportunistic infections. Refer to Table 6 for a list of AIDS defining diseases
and the WHO clinical staging of HIV/AIDS.

Diagnosis

- Demonstration of antibodies to HIV by ELISA

- Direct detection of the virus

1. Indication for initiation of ART

1.1. General Considerations for Anti-retroviral Therapy (ART): As a high

viral load is associated with HIV-related morbidity and mortality, the goal of
anti-retroviral therapy (ART) is to attain maximal and durable suppression of
viral load. Effective ART should restore and/or preserve immunologic

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function. The effectiveness of ART is assessed by clinical observations and

determination of plasma viral load and CD4 cell count. Many opportunistic
infections (OIs) can be prevented by restoring the immune system with the help
of ART. However, when OIs occur, the appropriate anti-microbial, anti-fungal
or antiviral therapy should also be given. Although toxicity and high cost of
drugs need to be considered when planning early initiation of ART, treatment
should not be delayed until the immune system is irreversibly damaged.

When decision to start anti-retroviral therapy has been reached, consideration

should be given to the regimen’s pill burden, dosing frequency, food
requirements, toxicity and possible drug interactions.

For treatment-naïve (not experienced with ART) patients, treatment is initiated

with a combination of 3 drugs (Triple Therapy); two Nucleoside Reverse
Transcriptase Inhibitors (NRTIs) generally form the backbone of most
combinations in ART. The third drug should be a protease Inhibitor (PI) or, if
this is not possible, a Non-Nucleoside Reverse Transcriptase Inhibitor
(NNRTI).

1.2. Criteria for initiating ART for Adults and Adolescents:

Criteria for initiating antiretroviral therapy in adults and adolescents with

documented HIV infection.

If CD4 Testing Available:

• WHO Stage IV disease irrespective of CD4 cell count
• WHO Stage I, II or IIIa with CD4 cell counts below 200/mm3,b

If CD4 testing Unavailable:

• WHO Stage IV disease irrespective of total lymphocyte count
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 standard treatment guidelines for zonal hospitals

b
• WHO Stage II or III disease with a total lymphocyte count below
3,c
1200/mm

a.
Treatment is also recommended for patients with advanced WHO Stage III
disease including recurrent or persistent oral thrush and recurrent invasive
bacterial infections irrespective of CD4 cell or total lymphocyte count.
b.
The precise CD4 level above 200/mm3 at which to start ARV treatment
has not been established, but the presence of symptoms and the rate of
CD4 cell decline (if measurement available) should be factored into the
decision making. A CD4 level of 200/mm3 corresponds to a CD4
percentage of approximately 15%.
c.
A total lymphocyte count of below 1200/mm3 can be substituted for the
CD4 count when the latter is unavailable and HIV-related symptoms exist.
It is less useful in the asymptomatic patient. Thus, in the absence of CD4
cell testing, asymptomatic HIV infected patients (WHO stage I) should not
be treated because there is currently no other reliable marker available in
severely resource-constrained settings.

1.3. Recommendations for initiating anti-retroviral therapy in infants and

children (see table 1)
Table 1. Recommendations for initiating anti-retroviral therapy in infants and
children
CD4 Age HIV diagnostic testing Treatment
testing recommendation
If CD4 < 18 Positive HIV virologic testa • WHO pediatric stage
Testing is months III (AIDS),
available irrespective of CD4
cell percentage b
• WHO Pediatric Stage
I disease
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 standard treatment guidelines for zonal hospitals

(asymptomatic) or
stage II disease with
CD4 percentage <
20%
HIV virologic testing not • WHO Pediatric stage
available but infant HIV III disease (AIDS)
seropositive or born to known with CD4 cell
HIV-infected mother (Note: percentage <20%
HIV antibody test must be
repeated at age 18 months to
obtain definitive diagnosis of
HIV infection)
>18 HIV antibody seropositive • WHO pediatric stage
months III disease (AIDS)
irrespective of CD4
cell percentageb
• WHO Pediatric stage
I disease
(asymptomatic) or
stage II disease with
CD4 percentage
<15%
If CD4 >18 Positive HIV virologic test • WHO Pediatric Stage
testing is months III2
not
available
HIV virologic testing not • Treatment not
available but infant HIV recommended d
seropositive or born to known
HIV-infected mother
>18 HIV antibody seropositive • WHO Pediatric stage
months III b

a
HIV DNA PCR or HIV PCR RNA or immune complex dissociated p24
antigen assays, or HIV culture.
b
Initiation of ARV can also be considered for children who have advanced
WHO Pediatric stage II disease, including severe recurrent or persistent oral
candidiasis outside the neonatal period, weight loss, fever, or recurrent
severe bacterial infection, irrespective of CD4 count.
c
The rate of decline in CD4 percentage (if measurement available) should be
factored into the decision-making.
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 standard treatment guidelines for zonal hospitals

d
Many of the clinical symptoms in the WHO Pediatric stage II and III disease
classification are not specific for HIV infection and significantly overlap
with those seen in children with-out HIV infection in resource-limited
settings; thus, in the absence virologic testing and CD4 cell assay
availability, HIV-exposed infants < 18 months of age should generally not
be considered for ART regardless of symptoms.

2. Drug regimens.

2.1. First-line ARV combination regimens for adults and adolescents

(see table 2)

Table 2: Recommended first line antiretroviral regimens in adults and

adolescents (Taken from Guidelines for use of antiretroviral drugs in Ethiopia,
February 2003: page 11)

Regimen(a) Pregnancy considerations Major toxicities

ZDV/3TC/EFZ Substitute NVP for EFZ inZDV-related anemia
or pregnant women for whom EFZ - associated CNS
ZDV/3TC/NVP effective contraception cannot
symptoms, possible
be assured teratogenicity of EEZ
NVP- associated
hepatotoxicity and
severe rash
NRTI – related side-
effects
ZDV/3TC/ABC ABC safety data limited ZDV – related anemia
(a)
ABC hypersensitivity
NRTI related metabolic
side-effects
ZDV/3TC/RTV- LPV/r safety data limited NFV ZDV-related anemia
PI(b) most supportive safety data NFV-associated diarrhea
or ZDV/TC/NFV IDV-related
nephrolithiasis
PI and NsRTI-related
metabolic side effects
(a) ZDV/3TC is listed as initial recommendation for dual NRTI
component bases on efficacy, toxicity, clinical and availability of
fixed dose formulation. Others dual NRTI components can be
substituted, including d4T/ddI and ZDV/ddI. ZDV and d4T
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 standard treatment guidelines for zonal hospitals

should never be used together because of proven antagonism.

Fixed dose formulations are preferred whenever possible as they
promote enhanced drug adherence.
(b) RTV-PI includes IDV/r, LPV/r or SQV/r

2.2. Dosages of anti-retroviral drugs for adults and adolescents (see table
3)

Table 3. Dosages of anti-retroviral drugs for adults and adolescents a

Drug class/Drug Dose

Nucleoside RTl's
Zidovudine (ZDV) 300 mg twice daily
Stavudine (d4T) 40 mg twice daily (30 mg twice daily if < 60 kg)
Lamivudine (3TC) 150 mg twice daily
Didanosine (ddl) 400 mg once daily (250 mg once daily if < 60 kg)
Abacavir (ABC) 300 mg twice daily
Non-Nucleoside RTl's
Efavirenz (EFZ) 600 mg once daily
Nevirapine (NVP) 200 mg once daily for 14 days, then 200 mg twice
daily
Protease inhibitors
Nelfinavir (NFV) 1250 mg twice daily
Indinavir/ritonavir 800mg/100 twice daily b,d
(IDV/r)
Lopinavir/ritonavir 400 mg/100 mg twice daily (533 mg/133 mg twice
(LPV/r) daily when combined with EfZ or NVP)
Saquinavir/ritonavir 1000 mg/100 mg twice daily c,d
(SQV/r)

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 standard treatment guidelines for zonal hospitals

a.
These dosages are in common clinical use. The dosages featured in this
table were selected based on the best available clinical evidence. Dosages
that can be given on a once or twice daily basis were preferred in order to
enhance adherence to therapy. The doses listed are those for individuals
with normal renal and hepatic function. Product specific information
should be consulted for dose adjustments that may be indicated with renal
or hepatic dysfunction or for potential drug interactions with other HIV
and non-HIV medications.
b
This dosage regimen is in common clinical use. Other IDV/r dosage
regimes that range from 800 mg/200 mg bid to 400 mg/100 mg bid are
also in clinical usage.
c
Both the hard-gel and soft-gel capsule formulations can be used when
SQV is Combined with RTV.
d
Dosage adjustment when combined with an NNRTI is indicated but a
formal recommendation cannot be made at this time. One consideration is
to increase the RTV component to 200 mg bid when EFZ or NVP is used
concomitantly. More drug interaction data are needed.

Second-line ARV combination regimens for adults and adolescents (see table 4)

2.3. Table 4: Second-line ARV combination regimens for adults and

adolescents

First line Second-line regimens Alternative second-line

For treatment failure regimens
For treatment failure
3TC/EFZ or DDI+RTV-PIa DDI + RTV-PI
3TC/NVP DDI +NFV or
DDI + NFV

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 standard treatment guidelines for zonal hospitals

2.4. Treatment regimen for children: The following treatment regimen is the
first choice for children:

2.4.1. First-line ARV regimens in Children

Zidovudine - Less than 90 days age 2 mg/kg four times a day

- More than 90 days age 160 mg/m2 three times a day
Plus
Lamivudine - Less than 30 days age 2 mg/kg two times a day
- More than 30 days age 4 mg/kg four times a day
Plus
Nevirapine - Less than 60 days age 120 mg/m2 two times a day for 14
days, then 200 mg/m2 two times a day
- More than 60 days age 120 mg/m2 two times a day for 14
days, then 120 mg/m2 one time a day for 14 days, then 120
mg/m2 two times a day for 14 days

(N.B.: In children on concomitant anti-tuberculosis treatment and older than

30 days, abacavir 8 mg/kg/dose twice daily replaces nevirapine)

2.5. Second-line ARV regimens in Children

Stavudine - More than 30 days age: 1 mg/kg every 12 hours

Plus
Didanosine - Less than 30 days age: 50 mg/m2 every 12 hours
- More than 30 days age: 90 mg/m2 every 12 hours
Plus
Ritonavir - More than 30 days age: 400 mg/m2 every 12 hours
(started with 250 mg/m2 every 12 hours and increased
stepwise over five days)
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 standard treatment guidelines for zonal hospitals

- Nelfinavir or lopinavir/ritonavir may be used in place of

ritonavir.

3. Monitoring ARV Treatment

3.1. Drug Adherence
• A period of extensive education and counseling before initiation of
therapy to maximize future adherence
• Ongoing attention to and reinforcement of adherence throughout the
entire course of treatment is crucial.
• Strategies to enhance adherence include:
Minimizing pill counts and dosage frequencies by
preferentially using combination pills on a once or twice
daily basis.
Enlisting the assistance of family or community
members to support patients in taking their medications.
Tackling psychosocial issues than can contribute to low
adherence to therapy.
• WHO recommends that innovative approaches to enhance adherence
to ART be developed.

• It is advisable for patients on triple therapy to be seen:

Bi-monthly; particularly at the start of treatment. Once
stabilized, patients may then be seen every three months.
At each visit, side effects and adherence to the treatment
should be discussed in depth.

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 standard treatment guidelines for zonal hospitals

3.2. Baseline clinical assessment

Should include the following:

• Documentation of past medical history (including major
illnesses, viz. tuberculosis, hospitalizations and surgeries)
• Length of time since the diagnosis of HIV,
• Current medications
• Identification of co-existing medical conditions that may
influence choice of therapy (such as TB or pregnancy)
• Current symptoms or physical signs.

• The above clinical assessment should be supplemented with review of the

expected benefits and potential side-effects of regimen chosen, possible
drug interactions (e.g. with contraceptives, ant-tuberculosis drugs), patient-
caregiver partnership, commitment to long-term treatment and adherence
to drug therapy, any perceived side-effects, and maintenance of safe sexual
practices.

• Once on ART: first follow-up visit two weeks after initiation of treatment,
every one to two months thereafter. The visits should be combined with
drug dispensing, and should be used also as an opportunity to reinforce
adherence. During each visit, patient should be evaluated for new
symptoms that may be related to drug side effects, HIV disease
progression, or undercurrent problems that may exist.
3.3. Monitoring for toxicity’s of ART

3.3.1. Clinical monitoring for toxicity of ART

• All patients require clinical evaluation every 1-2 months
for
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 standard treatment guidelines for zonal hospitals

ARV related toxicity.

3.2.2. Laboratory monitoring for toxicity of ART

• Baseline: Hemoglobin/hematocrit, white blood cell
count and differential, serum alanine aminotransferase,
serum creatinine and/or blood urea nitrogen, serum
glucose, pregnancy test. Resources permitting: serum
bilirubin, amylase, triglycerides, and cholesterol.
• Follow-up: The above investigations need to be
repeated bi-monthly, particularly at the start of
treatment. Once stabilized, investigations may then be
performed every three months and at any time when they
are indicated.

3.3. Monitoring Effectiveness of ART

Response to ART is monitored both biologically and clinically

Note: These measurements correlate well with clinical outcome.

3.3.1. Biological parameters:

a. The concentration of HIV - RNA in plasma (the "viral

load")
• The desirable "virologic" endpoint is a plasma viral load that is:
• "below the limits of detection", by the most sensitive
assay being used within 3 to 4 months of starting
treatment, and

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standard treatment guidelines for zonal hospitals

• The achievement of a minimum decline from the

baseline viral load of 1.5-2.0log by the end of the first
month of treatment.
• In general, plasma viral load is checked at baseline then
after one month of initiating therapy and two-monthly
thereafter until the virologic goal of therapy is achieved.
Following this, plasma viral load may be checked every
3 to 4 months.

N.B.: In patients with higher baseline plasma viral loads (e.g. above
100,000 copies/ml by RT-PCR) maximal suppression of viral
replication may take a longer time.

b. CD4+ cell count:

• When optimal therapy is achieved, the median
CD4+ cell rise is 100-200 cells within the first
year.
• The CD4+ cell response may lag behind the
“virologic response” in timing and at times the
two responses may even be discordant.
• In general CD4+ count, is checked at baseline,
thereafter it may be checked every 3 to 4
months.
• In places where CD4+ count cannot be done
total lymphocyte count can be used.

3.3.2. Clinical Parameters:

An increase in body weight.

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 standard treatment guidelines for zonal hospitals

Decrease in frequency and severity of OIs.

Decrease in frequency and severity of HIV related
malignancies.

4. Recommendations on Infant Feeding

• All HIV infected mothers should receive infant feeding

counseling which includes provision of general information
about the risk and benefits of infant feeding options.

• Decision needs to be made by the mother, with guidance and

support from a health care provider to select the option most
likely to be suitable for her.

• If HIV infected mother decide to breast feed then exclusive

breast-feeding should be encouraged, followed by early
weaning at 4-6 months.

• If she decides not to breast feed, she will be provided the

means of formula feeding and educated on sterility
procedures and hygiene.

• Mixed feeding (breast milk and formula) should be

discouraged, as it is associated with higher rate of
transmission.

5. Post-exposure prophylaxis

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 standard treatment guidelines for zonal hospitals

Universal precaution is the most effective way of protecting hospital staff from
accidental transmission of HIV and other blood borne pathogens. The priority
therefore must be put on training health staff in prevention methods and to
provide them with necessary safety materials and protective equipment.

Assessment of risk of exposure

Low risk exposure is:

• Exposure to a small volume of blood or blood contaminated with

fluids from asymptomatic HIV positive patients.

• Following an injury with a solid needle.

• Any superficial injury or muco-cutaneous exposure

High risk exposure

• Exposure to a large volume of blood or other potentially infectious

fluids

• Exposure to a large volume of blood or blood contaminated with

fluids from a patient with clinical AIDS or early sero-conversion
phase of HIV .

• Injury with a hollow needle

• Deep and extensive injuries.

Timing of initiation of treatment

• Should be given in the shortest time possible (within the first 1-4 hours of
exposure)

• Prophylaxis is sometimes given empirically up to 2 weeks in the case of

severe exposure when the delay has been unavoidable.

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 standard treatment guidelines for zonal hospitals

Doses for post-HIV exposure prophylaxis (see table 5)

Table 5: Post-HIV exposure prophylaxis (Taken from Guidelines for use of

antiretroviral drugs in Ethiopia, February 2003: page 11)

Risk ARV Prophylaxis Duration

Category
Low risk ZDV 300 mg bid + 3TC 150 mg bid or For 28 days
combivir 1 tab bid
High risk ZDV 300 mg bid +3TC 150 mg bid + IDV 800 mg For 28 days
8 hourly or
Combivir 1 tab bid + IDV 800 mg 8 hourly
N.B. in place of ZDV + 3TC combination when necessary d4T + 3TC or d4T
+ ddI may be used. When there is reasons not to use IDV, EFZ or NEF or
ABC, a PI may be used.

6. Brief Information on specific drugs

NRTIs
Zidovudine (AZT)
Indications: HIV infection in combination with other antiretroviral
drugs; monotherapy for prevention of maternal-fetal HIV
transmission.

S/E: blood disorders (neutropenia, anemia, leucopoenia, bone marrow

suppression more frequent with high doses and advanced stage of
disease); vomiting, diarrhea, abdominal discomfort, flatulence;
headache dizziness, convulsions, insomnia; myalgia, asthenia,
parasthaesia; rash, pruritis, dry skin, cough, urinary frequency;;

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 standard treatment guidelines for zonal hospitals

elevated liver enzymes and bilirubin, fatty liver, pancreatitis, chest

pain, influenza-like symptoms fat in abdomen and back of neck.

C/I: Very low neutrophil counts or hemoglobin values.

Dose : By mouth: 500--600 mg daily in 2-3 divided doses (at least 1 g

daily for treatment or prevention of HIV-associated neurological
dysfunction); child over 3 months 360-480 mg/m2 daily in 3-4 divided
doses; max. 200 mg every 6 hours; (at least 180 mg/m2 every 6 hours
for treatment of HIV-associated neurological dysfunction).

Dosage forms: tablet, 300 mg

Zalcitabine

Indications: HIV infection in combination with other antiretroviral

drugs.

S/E: peripheral neuropathy (discontinue immediately); oral ulcers,

nausea, vomiting. dysphagia, anorexia, diarrhea, abdominal pain,
constipation; pharyngitis, headache, dizziness, myalgia, arthralgia,
rash, pruritus, sweating, weight loss, fatigue, fever, rigors, chest
pain, anemia, leucopenia, neutropenia, thrombocytopenia,
disorders of liver function, less frequently pancreatitis,
oesophageal ulcers (suspend treatment if no response to treatment
for specific organisms), rectal ulcers, jaundice and hepatocellular
damage; other less frequent side-effects include taste, hearing and
visual disturbances, tachycardia, cardiomyopathy, congestive heart
failure, dyspnoea, seizures, tremor, movement disorders, mood
changes, sleep disturbances, alopecia, hyperuricaemia and renal
disorders.
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 standard treatment guidelines for zonal hospitals

Discontinue if deterioration in liver function tests. Hepatic

steatosis, progressive hepatomegaly or unexplained lactic acidosis

C/I: peripheral neuropathy; breast-feeding.

Dose: 375 - 750 micrograms every 8 hours (0.375-0.75 mg 3 times
daily); Child under 13 years safety and efficacy not established.
Dosage forms: tablet, 0.75 mg
Note: Used rarely due to toxicity, inconvenient dosing, and
questions regarding efficacy.

Stavudine:
Indication: progressive or advanced HIV infection
S/E: peripheral neuropathy (dose-related); pancreatitis; nausea,
vomiting, diarrhea, constipation, anorexia, abdominal discomfort, chest
pain, dyspnoea; headache, dizziness, insomnia, mood changes, asthenia,
Musculo-skeletal pain, influenza-like symptoms, rash and other allergic
reactions; lymphadenopathy; neoplasms; elevated liver enzymes and
serum amylase; neutropenia, thrombocytopenia
C/I: breast-feeding
Dose: Adult under 60 kg: 30 mg every 12 hrs preferably at least 1 hour
before food; For adults 60 kg and over: 40 mg every 12 hours; Children
over 3 month: under 30 kg, 1 mg/kg every 12 hours; Children 30 kg
and over, adult dose.
Dosage forms: tablet, 40 mg

Lamivudine:
Indications: HIV infection in combination with other antiretroviral drugs.

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 standard treatment guidelines for zonal hospitals

S/E: vomiting, diarrhoea, abdominal discomfort, cough, headache dizziness,

insomnia; malaise, fever, rash, musculoskeletal pain, alopecia; peripheral
neuropathy and pancreatitis (rare); neutropenia and anaemia (in
combination with AZT); thrombocytopenia; elevated liver enzymes and
serum amylase;
C/I: Breast-feeding
Note: Caution in renal impairment, 1iver disease and pregnancy
Dose: 150 mg every 12 hrs; Child 3 months – 12 years, 4 mg/kg every
12 hrs; max. 300 mg daily.
Dosage forms: tablet, 150 mg
Didanosine:
Indication: HIV infection in combination with other antiretroviral drugs
S/E: Hepatic disease; peripheral neuropathy, pancreatitis (avoid alcohol);
hyperuricaemia.
C/I: breast-feeding, pancreatitis
Dose: 400-mg capsule once daily (>60 kg body weight); 250 mg once
daily (<60 kg body weight); CHILD: over 3 months, 240 mg/m2 daily (180
mg/ m2 daily in combination with AZT. ddI should be taken on empty
stomach.
Dosage forms: tablet, 100 mg
Note: Can be taken at same time with other anti-retroviral that need to be
taken on an empty stomach

NNRTIs
Nevirapine:
Indications: progressive or advanced HIV infection in combination with
other antiretroviral drugs.

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 standard treatment guidelines for zonal hospitals

S/E: Rash, usually occurring in first 6 weeks, is most common side-effect;

incidence reduced if introduced at low dose and dose increased gradually;
discontinue permanently if severe rash or if rash accompanied by fever;
pruritus, blistering oral lesions, conjunctivitis, swelling muscle or joint
aches, general malaise or clinically significant liver function test
abnormality; if rash mild or moderate may continue without interruption
but dose should not be increased until rash resolves. Stevens-Johnson
syndrome and rarely toxic epidermal necrolysis; nausea, headache,
drowsiness, fatigue, fever; hepatitis reported.
C/I: breast-feeding; hepatic impairment (monitor liver function before
treatment and for at least 6 months during treatment;-in moderate or severe
abnormalities suspend treatment until liver function returns to baseline;
discontinue permanently if abnormalities recur); renal impairment;
pregnancy;
Note. If treatment interrupted for more than 7 days reintroduce with 200 mg
daily and increase dose cautiously

Dose: 200 mg daily for first 14 days then (if no rash present) 200 mg twice
daily;

Children under 16 years, safety and efficacy not established.

Dosage forms: tablet, 200 mg

Efavirenz

Indications: progressive or advanced HIV infection in combination with

other Anti-retroviral drugs.

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 standard treatment guidelines for zonal hospitals

S/E: Rash including Stevens-Johnson syndrome; dizziness, headache,

insomnia,, somnolence, abnormal dreams, fatigue, impaired concentration,
depression, psychosis; nausea; raised plasma triglycerides and cholesterol;
elevated liver enzymes (especially if seropositive for hepatitis B or C);
diarrhoea, pancreatitis.
C/I: breast-feeding
Dose: 600 mg once daily. For children over 3 years:
Body weight 13-14 kg 200 mg once daily

“ “ 15-19 kg250 mg once daily

“ “ 20 –24 kg 300 mg once daily

“ “ 25-32.5 kg 350 mg once daily

“ “ 32.5 - 39 kg 400 mg once daily

“ “ 40 kg and above adult dose.

Dosage forms: tablet, 150 mg

Protease Inhibitors (PIs)

Ritonavir

Indications: progressive or advanced HIV infection in combination with

nucleoside reverse transcriptase inhibitors

S/E: nausea, vomiting, diarrhoea, abdominal pain, taste disturbances,

dyspepsia, anorexia, throat irritation, vasodilatation, headache, paraesthesia or
hyperaesthesia, dizziness, sleep disturbances, asthenia, rash, leucopenia, raised

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 standard treatment guidelines for zonal hospitals

liver enzymes, bilirubin, triglycerides, cholesterol, lipids and acid; occasionally

flatulence, eructation., dry mouth and ulceration,cough, anxiety, fever, pain,
myalgia, weight loss, decreased thyroxine, sweating ,pruritus, electrolyte
disturbances, increased blood glucose, anaemia, neutropenia, increased,
prothrombin time, abnormal accumulation of fat.

C/I: hepatic impairment: diabetes: haemophilia (possible increased bleeding):

pregnancy; breast-feeding; metabolism of many drugs inhibited and toxicity
increased if administered concomitantly.
Dose: 600 mg every 12 hours: CHILD over 2 years initially 250 mg/m2 every
12 hours, increase by 50 mg/m2 at intervals of 2-3 days to 350 mg/m2 every
12 hours (max. 600 mg every 12 hours).
Dosage forms: tablet, 100 mg

Indinavir

Indications: progressive or advanced HIV infection in combination with

nucleoside reverse transcriptase inhibitors
S/E: vomiting, diarrhoea, abdominal discomfort, dry mouth, tastes
disturbances; headache, dizziness, insomnia; myalgia, asthenia,
parasthaesia; rash (including Stevens-Johnson syndrome), pruritis, dry skin,
hyperpigmentation, alopecia; nephrolithiasis (may require interruption or
discontinuation - good hydration essential), dysuria, haematuria,
crystaluria, proteinuria; elevated liver enzymes and bilirubin, hepatitis;
blood disorders; increased blood glucose and plasma triglycerides;
accumulation of fat in abdomen and back of neck.
C/I: Breast-feeding

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 standard treatment guidelines for zonal hospitals

Dose: 800 mg (2 cap) every 8 hours, administered 1-hour before or 2 hours

after a low-fat meal.
Note: If used with didanosine, allow 1 hour between doses (antacids in
didanosine tablets reduce absorption of indinavir). Decrease dose to 600 mg
every 8 hrs if receiving concurrent ketoconazole or in hepatic impairement.
Child safety and efficacy not established. Store in original container, which
contains desiccant; without this, IDV is stable for only about 3 days.
Dosage forms: tablet, 400 mg

Nelfinavir:
Indication: Progressive or advanced HIV infection, in combination with
NRTI
S/E: Diarrhea, nausea, flatulence; rash, hepatitis, elevated creatine kinase,
neutropenia; abnormal accumulation of fat.
C/I: Breast-feeding, severe hepatic or renal impairment
Dose: 1250 mg twice daily or 750 mg 3 times daily with food
Dosage forms: tablet, 250 mg

Saquinavir:
Indication: HIV infection, in combination with NRTI
S/E: nausea, vomiting, diarrhoea, abdominal discomfort,; headache;
peripheral neuropathy, asthenia, parasthaesia; rash and other skin
eruptions; elevated liver enzymes and neutropenia when used in
combination therapy;, hepatitis; seizures; blood disorders; increased or
decreased blood glucose and; accumulation of fat in abdomen and back of
neck.
C/I: breast-feeding,, severe hepatic impairment.
Dose: 600 mg every 8 hrs, to be taken within 2 hrs after a meal.
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 standard treatment guidelines for zonal hospitals

Note: Soft gel formulation with improved absorption has replaced previous
hard gel formulation. Long-term storage in refrigerator; stable at room
temperature for 3 months.
Dosage forms: tablet, 200 mg

Table 6: Clinical Staging of HIV/AIDS

World Health Organization Classification System for HIV Infection

Clinical Stage 1
1. Asymptomatic infection
2. Persistent generalized lymphadenopathy
3. Acute retroviral infection
Performance Stage 1: asymptomatic, normal activity
Clinical Stage 2
1. Unintentional weight loss < 10% body weight

2. Minor mucocutaneous manifestations (e.g., dermatitis, prurigo, fungal nail

infections, angular cheilitis)
3. Herpes zoster within previous 5 years
4. Recurrent upper respiratory tract infections
Performance Stage 2: symptoms, but nearly fully ambulatory
Clinical Stage 3
1. Unintentional weight loss > 10% body weight
2. Chronic diarrhea > 1 month
3. Prolonged fever > 1 month (constant or intermittent)
4. Oral candidiasis
5. Oral hairy leukoplakia
6. Pulmonary tuberculosis within the previous year
7. Severe bacterial infections
8. Vulvovaginal candidiasis
Performance Stage 3: in bed more than normal but < 50% of normal
daytime during the previous month
Clinical Stage 4
1. HIV wasting syndrome
2. Pneumocystis carinii pneumonia
3. Toxoplasmosis of the brain
4. Cryptosporidiosis with diarrhea > 1 month
5. Isosporiasis with diarrhea > 1 month

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 standard treatment guidelines for zonal hospitals

6. Cryptococcosis, extrapulmonary
7. Cytomegalovirus disease of an organ other than liver, spleen or lymph node
8. Herpes simplex virus infection, mucocutaneous
9. Progressive multifocal leukoencephalopathy
10. Any disseminated endemic mycosis (e.g., histoplasmosis)
11. Candidiasis of the esophagus, trachea, bronchi, or lung
12. Atypical mycobacteriosis, disseminated
13. Non-typhoid Salmonella septicemia
14. Extrapulmonary tuberculosis
15. Lymphoma
16. Kaposi's sarcoma
17. HIV encephalopathy
Performance Stage 4: in bed > 50% of normal daytime during previous
month

AMEBIASIS
Amebiasis is both an acute and chronic cause of diarrheal disease caused by the
protozoa Entamoeba hystolytica. It is transmitted by the faeco-oral route and
infection is usually caused by ingestion of cysts from contaminated food and
drink. Its manifestations vary from asymptomatic carrier state to severe
fulminating illness with mucosal inflammation and ulceration. The diagnosis

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 standard treatment guidelines for zonal hospitals

should also be considered when a patient with bloody diarrhoea fails to show
improvement following treatment for shigellosis.
Diagnosis is made by identification of the RBC ingesting trophoizites by direct
stool examination.

INTESTINAL AMOEBIASIS
Treatment
First line:
Metronidazole, 750 mg p.o.. tid for 5-7 days. For children: 7.5-mg/kg
p.o. tid, for 5 days.
S/E: metalic taste, nausea and vomiting;
C/I: epilepsy, hepatic malfunction, pregnancy and hematological
disorders.
D/I: with disulfiram, confusion; with alcohol, disulfiram like reaction;
with cimetidine, decreased metabolism; with phenobarbital, increased
metabolism.
Dosage forms: Tablet, capsule, 250mg,; Oral suspension, 125
mg/5ml; Syrup, 4% W/V, 250mg/5ml; intravenous infusion, 5 mg/ml
in 100 ml
OR
Tinidazole, 2g p.o. stat for 3 consecutive days. For children: 50-60
mg/kg daily for 3 days. (For S/E and C/I, see under metronidazole).
Dosage forms: tablet, 150 mg, and 500 mg
Alternative:
Metronidazole, 750 mg p.o. tid for 7 days. For children: 7.5 mg/kg
p.o. tid for 5 days.(For S/E,C/I and dosage forms , see page 24)
OR

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 standard treatment guidelines for zonal hospitals

Tinidazole, 2g p.o. stat, for 3 consecutive days. For Children: 50-60

mg/kg daily for 3 days (For S/E, C/I and dosage forms, see page 24)

PLUS
Diloxanide furoate, 500 mg, tid for 10 days. For children over 25 kg,
20 mg/kg daily in 3 diveded doses for 10 days.
S/E: flatulence, vomting, urticaria, pruritis.
C/I: pregnancy.
Dosage forms: tablet, 500 mg

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 standard treatment guidelines for zonal hospitals

AMEBIC LIVER ABSCESS

Amebic liver abscess is the commonest extra-intestinal manifestations of
amebiasis. When patients are symptomatic, fever and right upper quadrant pain
are the usual manifestations. Point tenderness over the liver with or without
right side pleural effusion is also common.
Treatment
Non-Drug treatment
Aspiration of the abscess can be done when ever necessary.
Drug treatment
First line:
Metronidazole, 750 mg, p.o. tid or 500 mg IV every 6 hr, for 10 days.
For children: 7.5 mg/kg, p.o. tid, for 5 days. (For S/E, C/I and dosage
forms, see page 24)
OR
Tinidazole, 2g p.o. stat, for 3 consecutive days. For Children: 50-
60mg/kg daily for 3 days. (For S/E, C/I and dosage forms, see page
24)
PLUS
Diloxanide furoate, 500 mg tid for 10 days. For children over 25 kg,
20 mg/kg daily in 3 divided doses for 10 days.
(For S/E, C/I and dosage forms, see page 25)
Alternative:
Dehydroemetine, 1 mg/kg/24hrs, in a single dose sc or im for 8 – 10
days
S/E: precardial pain, ECG changes, hypertension, polyneuritis.
C/I: organic heart disease; primary muscular or neurological diseases.
Dosage forms: injection, 150 mg base in 5 ml ampoule.
PLUS

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 standard treatment guidelines for zonal hospitals

Chloroquine, 500 mg bid for 2 days then 500 mg daily for 21 days.
S/E: dizziness, GI discomfort and pruritus.
C/I: alcoholism, history of hypersensitivity, epilepsy and psoriasis.
D/I: antacids reduce absorption and cimetidine reduces metabolism.
Dosage forms: tablet, 150 mg base; syrup 50 mg base /5ml.Injection,
150 mg base in 5 ml ampoule.
PLUS
Diloxanide furoate, 500 mg, tid for 10 days. (For S/E, C/I and
dosage forms, see page 25)

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 standard treatment guidelines for zonal hospitals

BACILLARY DYSENTERY
Bacillary dysentery is a kind of diarrhea caused by bacteria, which invades and
destroys the intestinal epithelium. It is often caused by Shigella spp. Other less
important causes are Campylobacter species, non-typhoidal Salmonella species
and entero-invasive Escherichia coli. Transmission occurs via contaminated
water or food. Common clinical manifestations include severe abdominal
cramps, fever, mucoid or bloody diarrhoea.
Diagnosis. Direct stool examinations and stool culture
Treatment
Supportive treatment
- Correct dehydration with ORS or i.v fluids
- Relieve pain and fever if necessary.
Drug treatment
First line:
Ciprofloxacin, 500 mg p.o. bid , for 5-7 days. For children: 7.5 – 15
mg/kg/day p.o. in 2 divided doses
S/E: mild GI upset; rash and pruritus; hypersensititvity reactions
including fever, joint pain, urticaria. Discontinue the drug if
psychiatric, neurological or severe hypersensitivity reactions occur.
C/I: renal impairment, pregnancy, lactation, hypersensitivity to
quinolones
Dosage forms: tablet, 250mg; intravenous infusion, 2 mg/ml in 50 ml
and 100 ml bottle
OR
Sulfamethoxazole+trimethoprim, 800 mg/160 mg p.o. bid, for 5-7
days. For children 6 weeks – 5 months, 100/20 mg; 6 months – 5 yrs,
200/40 mg; 6 – 12 yrs, 400/80 mg bid.

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 standard treatment guidelines for zonal hospitals

S/E: nausea, vomiting; rash; blood disorders including neutrpenia,

thrombocytopenia and rarely agranulocytosis; antibiotic associated
colitis.
C/I: hepatic failure, porphyria; blood disorders.
Dosage forms: Mixture, 200 mg +40 mg in each 5 ml, Tablet
(pediatric), 100 mg + 20 mg; Tablet (adult), 400 mg + 80 mg; 800 mg
+ 160 mg.

Alternative:
Nalidixic acid, 1g p.o. qid for 5-7 days. Children: over 3 months,
50mg/kg/day in 2-4 divided doses.
S/E: Photosensitivity.
C/I: elderly patients, epilepsy.
Caution: avid direct sunlight.
Dosage forms: tablet, 500 mg, oral suspension, and 300mg/vial.
OR
Ceftriaxone, 1-2g daily as a single dose or 2 divided doses i.m. or
slow IV. For children: 20-50 mg/kg/day as a single dose or 2 divided
doses i.m. or slow IV.
S/E: diarrhea, nausea vomiting; Allergic reactions including rash,
disturbance of liver enzymes, transient hepatitis and cholestatic
jaundice.
C/I: cephalosporin hypersensityand poryphria.
Dosage form: Injection, 0.2 g, 0.5g, 1gm, 2g in vial.

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 standard treatment guidelines for zonal hospitals

BRONCHITIS (ACUTE)
Acute infection of the trachea and the bronchi is often caused by viruses.
Therefore, treatment is often symptomatic. Anti-microbial treatment is
indicated when patients develop high-grade fever and purulent sputum.
Treatment
For cough: Drug treatment should not be routinely employed
First line:
Dextromethorphan hydrobromide, 15 – 30 mg p.o. 3 to 4 times a
day.
For children: 6-12 yrs, 7.5-15 mg; 2-6 yrs, 7.5 mg 3-4 times a day.
S/E: sedation
C/I: hepatic disorder, severe asthma.
Dosage forms: tablet, 15 mg; syrup, 5 mg, 7.5 mg, 15 mg/5ml; drops,
15mg/ml.
Alternative:
Codeine phosphate, 10 - 20 mg p.o. 3 – 4 times a day. For children:
0.5 mg/kg p.o. qid.
S/E: constipation and sedation; it may lead to dependence.
C/I: respiratory insufficiency, liver disease
Dosage forms: tablets, 30 mg,
Linctus, 15 mg/5ml (expectorant)
For productive cough
Guaifenesin, 200- 400 mg p.o. qid; for children: 6-12 yrs, 100-200
mg; 2-Yrs, 50-100 mg p.o. qid.
Dosage forms: tablet, 100 mg, 200 mg; capsule, 200 mg; syrup, 100
mg/5ml.

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 standard treatment guidelines for zonal hospitals

Antibiotic treatment is indicated when bronchitis is complicated by bacterial

infections. In general, the choice of antibiotics should be based on gram stain
result.
First line:
Amoxicillin, 250- 500 mg tid p.o., for children: 20 – 40 mg/kg/day
p.o. in 3 divided doses.
S/E: hypersensitivity reactions including urticaria, fever, joint pans
rashes, angioedema, anaphylaxis, parasthesia, with prolonged use,
diarrhea and antibiotic associated colitis.
C/I: Penicillin hypersensitivity.
Dosage forms: capsule, 250 mg, 500 mg; syrup, 250 mg/5ml.
OR
Ampicillin, 500 mg p.o. daily, in 4-divided dose for 5-7 days.
S/Es: allergy
C/Is: Known hypersensitivity reactions to penicillins or
cephalosporins
Dosage forms: drop, 100 mg/ml; capsule, 250 mg, 500 mg; injection,
250mg, 500mg, 1mg in vial; oral suspension, 125 mg/ml, 250 mg/ml.
Alternative:
Erythomycin, 250-500 mg qid p.o., in 4 divided doses for 7 days. For
children: 30-50 mg/kg/day p.o. in 4 divided doses; 15-20 mg/kg/day
i.v over 5 minutes in 3-4 divided doses.
S/E: nausea, vomiting, abdominal discomfort, diarrhea (antibiotic–
associated colitis), rash and other allergic reactions, cholestatic
jaundice.
C/I: Liver disease.

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 standard treatment guidelines for zonal hospitals

Dosage forms: Capsule 250 mg; tablet (stearate), 250 mg, 500 mg;
oral suspension, 125 mg/5 ml, 200 mg /ml, 250 mg /5ml; Injection, 50
mg/ml in 2 ml ampoule.
OR
Tetracycline, 250-500 mg qid, for 5-7 days
S/E: teeth discoloration, hypersensitivity reactions, GI disturbances
D/I: forms complexes with drugs like antacids and iron preparations,
which decreases its absorption.
C/I: children under 8 yrs.
Dosage forms: tablet, 500 mg; capsule, 250 mg, 500 mg,
OR
Sulfamethoxazole + trimethoprim, 800mg/160 mg. p.o. bid for 7
days. For children 6 weeks – 5 months, 100/20 mg; 6 months – 5 yrs,
200/40 mg; 6 – 12 yrs, 400/80 mg bid. (For S/E and C/I and dosage
forms, see page 28).

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 standard treatment guidelines for zonal hospitals

CHOLERA
Cholera is an acute diarrheal disease that can cause severe dehydration and
death in a matter of few hours. It is caused by Vibrio cholera and often causes
epidemics under conditions of poor hygiene. It is often diagnosed based on
clinical grounds. Sudden onset of explosive diarrhoea is the hallmark of the
disease. The diarrhoea is classically voluminous, non-offensive, and somewhat
looks gray or “rice water”. Fever is absent. Direct stool examination by dark
field microscopy or preferably stool culture will confirm the diagnosis.
Treatment
Non-Drug Treatment
The promotion of adequate hygienic condition in the community is important
to prevent an outbreak and spread of the disease.
Symptomatic/supportive therapy: For dehydration in mild case give
ORS, prn; for children: < 2yrs: 50-100ml; 2-10yrs: 100-200ml after
each loose stool. For severe cases Ringer lactate i.v. drips
(alternatively Normal Saline) should be given 50 - 100 ml/min until
shock is reversed; thereafter, according to fluid loss. KCl solution 20 -
40 mmol/litre may be added as required.
In the absence of i.v. drips aggressive rehydration with ORS is vital.
Drug (Curative) therapy:
First Line:

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 standard treatment guidelines for zonal hospitals

Doxycycline, 100 mg bid, p.o. for 3 days. For children: 6mg/kg daily
for 3 days.
S/E: nausea, vomiting, hepato-toxiciy, hypersensitivity reactions.
C/I: renal impairment, pregnancy and breast-feeding.
Dosage forms: Capsule,100 mg ;tablet,100mg.
OR
Tetracycline 500mg p.o. q.i.d for 3-5 days. (For S/E, C/I and dosage
forms, see page 31).
Alternative:
Sulfamethoxazole + trimethoprim, 800 mg/160 mg p.o. bid. for 5
days. For children 6 weeks – 5 months: 100/20 mg; 6 months – 5 yrs:
200/40 mg; 6 – 12 yrs: 400/80 mg bid all for 5 days. (For S/E, C/I and
dosage forms, see page 32).
OR
Ciprofloxacin, 500 mg po bid , for 3-5 days (For S/E and C/I and
dosage forms, see page 28).

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 standard treatment guidelines for zonal hospitals

GASTRO-ENTERITIS (FOOD-POISONING)

Gastro-enteritis (food poisoning) is characterized by a brief but explosive

diarrheal illness in subjects following exposure to a common food source
contaminated with bacteria or bacterial toxin. Common organisms include S
.aureus, Salmonella, Clostiridium perfringes and Bacillus cereus, which are i
responsible for more than 90 % of cases.
Diagnosis is often made by history. Stool examination is also helpful to
exclude other diagnosis and to guide the right antibiotic choice. Except in
special cases (e.g. Botulism), isolation of the toxin is not cost effective.

Treatment
Supportive Treatment: is often adequate for milder cases
- Correct dehydration, if any
- Give pain killer, if required
Antibiotic treatment is indicated for more severe cases:

First line:
Ciprofloxacin, 500 mg po bid, for 3-5 days. (For S/E, C/I and dosage
forms, see page 28).
OR

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 standard treatment guidelines for zonal hospitals

Sulfamethoxazole + trimethoprim, 800mg/160 mg p.o. bid., for 5-7

days. For children 6 weeks – 5 months: 100/20 mg; 6 months – 5 yrs:
200/40 mg; 6 – 12 yrs: 400/80 mg bid. (For S/E, C/I and dosage
forms, see page 283)
Alternative
Chloramphenicol, 500mg, p.o. qid, for 7 days: For children: 25
mg/kg/d.
S/E: bone marrow depression, grey baby syndrome.
C/I: impaired hepatic function, bone marrow depression.
D/I: inhibits hepatic metabolism of several drugs like phenytoin and
warfarin.
Dosage forms: capsule, 250 mg; injection 1g in vial; oral suspension,
125 mg/5ml.

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 standard treatment guidelines for zonal hospitals

GIARDIASIS
Giardia lamblia is a ubiquitous gastrointestinal protozoa that results in clinical
pictures ranging from asymptomatic colonization to acute or chronic diarrheal
illness. Giardia lamblia infects humans through ingestion of as few as 10 cysts.
The infection is more prevalent in children than adults. The most common
presentation is diarrhea, weight loss, crampy abdominal pain and failure to
thrive.
Diagnosis is established by identifying Giardia lamblia trophozoite or cyst
from fecal or duodenal samples.

Treatment
First Line
Metronidazole, 500 mg three times a day for five days. For children,
1-3 years: 500 mg daily; 3-7 years: 600-800 mg daily; 7-10 years: 1 g
daily, all for 3 days
(For S/E, C/I and dosage forms, see page 24)
Alternative
Tinidazole, single oral dose of 2 g. For children, 50-75 mg/kg as a
single dose (may be repeated once if necessary).
(For S/E, C/I and dosage forms, see page24).

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 standard treatment guidelines for zonal hospitals

INTESTINAL PARASITIC INFESTATIONS

These are infections caused by intestinal worms (nematodes and cestodes),

which are commonly associated with poor personal and environmental
hygiene. Although they may not be fatal, they contribute to malnutrition and
diminished work capacity. Clinical manifestations include abdominal cramps,
nausea, abdominal bloating, anorexia, anemia etc.
Diagnosis: is mainly by direct stool microscopy
Treatment: see table 7

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 standard treatment guidelines for zonal hospitals

Table 7 . Treatment of common intestinal parasitic infestations

NAME OF
INFECTION;
ETIOLOGY; TREATMENT REMARK
MODE OF
TRANSMISSION
Ascariasis First line: Presence of
Piperazine, 4 g in a single dose: For children: 9 – 12 migrating
Ascaris years, 3.75 g; 6 – 8 yrs, 3 g; 4-5 yrs, 2.25 g; 1 – 3 yrs, larvae in the
lambricoids 1.5 g, <1yr, 120 mg/kg as a single dose. lungs can
S/E: nausea, vomiting, colic, diarrhea; allergic provoke
Ingestion of the reactions; drowsiness, confusion. pneumonia
larvae of the Caution: known hypersensitivity, epilepsy, and renal
parasite together or hepatic impairment.
with food D/I: piperazine and pyrantel are antagonistic.
Dosage forms: tablet (adipate), 300mg; elixir (citrate),
500mg/5ml, 622.5mg/5ml, 706mg/5ml, 750mg/5ml,
937.5mg/5ml, 1gm/5ml
Alternatives:
Levamisole, 120 – 150 mg (3 – 4 tablets) p.o. to be
taken as a single dose
S/E: mild nausea and vomiting
Dosage form: Levamisole tablets, 40 mg
Albendazole, 400 mg p.o. as a single dose, for
children: 1 – 2 years, 200 mg as a single dose. (For
S/E, C/I and dosage forms , see page 42).
Or
Mebendazole, 100 mg bid p.o. for 3 days or 500 mg as
a single dose. (S/E , C/I and dosage forms, see page
42).
Or
Pyrantel, 700 mg p.o. as a single dose,
S/E: minor GI disturbances,
C/I: known hypersensitivity.
D/I: piperazine and pyrantel are antagonistic.
Dosage forms: tablet, 125 mg; oral suspension, 250
mg base/5 ml.

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 standard treatment guidelines for zonal hospitals

Enterobiasis First line: Common in

Mebendazole, 100 mg bid p.o. for 3 days or children and
Enterobius 500 mg as a single dose. (S/E, C/I and auto
Vermicularis dosage forms, see page 42). infection
Alternatives: may occur
Ingestion of the Albendazole, 400 mg p.o. as a single dose,
eggs of the for children: 1 – 2 years, 200 mg as a single
parasite together dose. (For S/E , C/I and dosage forms, see
with food page 42)
Or
Piperazine, 4 g in a single dose: For children:
9 – 12 years, 3.75 g, 6 – 8 yrs, 3g, 4–5 yrs,
2.25 g, 1 – 3 yrs, 1.5 g, <1yr, 120mg/kg as a
single dose. (For S/E, C/I and dosage forms,
see page39).
Hookworm First line: Treat
infestation Mebendazole, 100 mg bid p.o. for 3 days or concomitant
500 mg as a single dose. (For S/E , C/I and anemia if
Necator dosage forms, see page 42). any
americanus or Alternatives:
Ancylostoma Albendazole, 400 mg p.o. as a single dose, for
duodenale children: 1 – 2 years, 200 mg as a single dose.
(For S/E ,C/I and dosage forms, see page 42).
Penetration of Or
the larvae of the Pyrantel, 700 mg p.o. as a single dose, (S/E,
parasite through C/I and dosage forms, see page 39)
skin

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 standard treatment guidelines for zonal hospitals

Strongyloidosis First line: Larvae

Thiabendazole, 1500 mg, p.o. bid, for migrate to
Strongloidexs children: 25 mg/kg p.o. for two consecutive the lungs
stercolaries days. where they
S/E:dizziness, nausea, voiting, drowsiness, cause tissue
Penetration of pruritis, headache, neuro-psychiatric destruction
the larvae of the disturbances, hepatitis and hypersensitivity and
parasite through reactions. bleeding.
skin Caution: hepatic and renal impairment Treat
Dosage forms: tablet, 500 mg; oral concomitant
suspension, 500 mg/5ml. anemia if
Alternative: any
Albendazole, 400 mg p.o. twice daily for
three consecutive days. For children: 1 – 2
years, 200 mg as a single dose. (For S/E , C/I
and dosage forms, see page 42).

Trichuriasis First line: Heavy

Mebendazole, 100 mg bid p.o. for 3 days or infestation
Tricuris 500 mg as a single dose. (For S/E C/I, and leads to
trichiua dosage forms, see page 42). bloody
Alternative: diarrhea,
Ingestion of the Albendazole, 400 mg p.o. as a single dose, for bleeding and
eggs of the children: 1 – 2 years, 200 mg. As a single weakness
parasite together dose. ( For S/E , C/I and dosage forms, see
with food page 42).

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 standard treatment guidelines for zonal hospitals

Tapeworm First line: T. solium

infestation Niclosamide, 2 g in a single dose p.o. (pork
S/E: minor GI upset, and purities. tapeworm)
Taenia Dosage forms: chewable tablet, 500mg may cause
saginata Or fatal
or Albendazole, 400 mg in a single dose p.o. cysticercosis
Taenia solium S/E: occasional diarrhea and abdominal pain.
Or C/I: pregnancy.
Hymenolepis Dosage forms: tablet, 200 mg; syrup, 100
nana mg/5 ml
Or
Ingestion of raw Alternatives:
or undercooked Praziquantel, 600 mg in a single dose p.o.
meat containing S/E: minor Gastero–intestinal upset.
the larvae of the C/I: ocular cysticercoids.
parasite Dosage forms: tablet, 600 mg.

Mebendazole, 100 mg bid for 3 days p.o.

S/E: occasional diarrhea and abdominal pain.
C/I: pregnancy.
Dosage forms: tablet, 100 mg; oral
suspension, 100 mg/5 ml

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 standard treatment guidelines for zonal hospitals

LEISHMANIASIS
Leishmaniasis is a zoonotic disease caused by protozoa, which belongs to the
genius Leishmania. Mode of transmission is effected by the bite of
phlebotomites (sand flies) from animals to humans. It has two major clinical
forms: visceral and cutaneous leishmaniasis.
• Visceral Leishmaniasis (Kalazar): It’s cardinal manifestations include
fever, marked weight loss, splenomegally and features of
pancytopenia:
• Cutaneous Leishmaniasis: This form is characterized by the
development of single or multiple firm, erythematuos papule which
occur on the exposed part of the body. It may ulcerate later in the
course of the illness.
Diagnosis
It requires the demonstration of the organism by smear or culture of aspirates
or tissue. Serological tests like ELISA and direct agglutination tests are very
helpful.
Treatment
General:
Supportive care includes treatment of concomitant infections and blood
transfusions
Specific:
A. Visceral Leishmaniasis:
First line:
Sodium stibogluconate 20 mg/Kg/day given iv or im in a single dose
for 28 consecutive days. Therapy should be repeated using the same
dose for another 40 to 60 days in patients with relapse or incomplete
response.

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 standard treatment guidelines for zonal hospitals

S/E: nausea, vomiting, abdominal pain; muscle pain, joint stiffness,

and less commonly cardiac or hepatic toxicity; rarely anaphylaxis.
C/I: significant renal impairment, breast-feeding.
Dosage forms: injection, 33% w/v in 2 and 6-ml ampoules.

Alternative :
Amphotericin B, 0.25 to 1 mg/kg by slow infusion daily or on
alternate days, or three times a week for up to 8 weeks depending on
the response.
S/E: anorexia, nause and vomiting; febrile reaction, headache, muscle
and joint pain; disturbance in renal function; cardio-vascular toxicity,
blood dyscariasis, neurological disorders including hearing loss,
diplopia, convulsion, peripheral neuropathy, abnormal liver function
(discontinue treatment), rash and anaphylactic reaction.
Caution: when given parentrally, toxicity is common and therefore
close supervision is necessary; a test dose is required. Monitor renal
and hepatic functions closely. Blood counts and plasma electrolyte
monitoring is also required.
Dosage forms: Powder for injection, 50mg in vial.
OR
Pentamidine Isethionate, 3 to 4 mg/kg i.m daily or every other day
for up to 15 doses.
S/E: reversible nephrotoxicity, acute hypotension, pancrititis,
hypoglycemia, cardiac arrhythmias, blood dyscariasis, and sterile
abscesses at the injection sites.
Caution: risk of severe hypotension following administration
(establish baseline blood pressure and administer with the patient

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 standard treatment guidelines for zonal hospitals

lying down; monitor blood pressure at regular intervals, until

treatment concluded); hepatic and renal impairment;
Dosage forms: powder for injection, 200 mg in vial.
NB. The condition called "Post Kalazar Dermal Leishmaniasis"
should be treated in the same way as the initial illness of kalazar.

B: Cutaneous LeIshmaniasis (Oriental leishmaniasis, Oriental Sore,

Leishmaniasis Tropica)
Cutaneous Leshmaniasis is caused by leishmania tropica, which is transmitted
by phlebotomus. Before ulceration occurs, there appears dermal infiltrates
consisting of large histiocytes filled with many leishman-donovan (L-D)
bodies, while during ulceration an influx of neutrophils occurs. Older lesions
develop a tuberculoid infiltrate and at this stage either the organisms are scanty
or absent.

Diagnosis is established by:

- The clinical presentation in endemic areas,
- The leishmanin intra-dermal test (Leishman Montenegro-
Donovan), and
- The demonstration of the organisms in smears.
Treatment
Sodium stibogluconate, given intramuscularly or intravenously for
10 days.
(For S/E, C/I and Dosage forms, see page 43)

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 standard treatment guidelines for zonal hospitals

LEPROSY
Leprosy is a chronic infectious disease of man which predominantly affects
peripheral nerves and the skin, although other tissues, such as the eye, mucosa
of the upper respiratory tract, muscles, bone and testis can also be involved. It
is caused by Mycobacterium leprae. Infection with M. leprae is considered to
occur through the nasal mucosa from droplet infection. The earliest clinically
detectable lesion is usually the skin and invasion of other organs takes place in
lepromatous leprosy (mainly, affecting the eye, testis and muscle). The bacilli
multiply inside macrophages - in the histocytes (skin) and Schwann cells
(nerves).
The Cardinal Signs of Leprosy are:
• Anaesthesia of the individual skin lesions or in the distribution of
peripheral nerves
• Thickened nerves, at the sites of predilection
• Skin lesions, macular or infiltrated hypopigmentation in Blacks or
copper coloured (or red) macules in the fairer coloured races
• Presence of the acid-fast bacilli Mycobacterium leprae in skin smears
in lepromatous and border line lesions.
The presence of at least one of the cardinal signs enumerated above suggests a
diagnosis of leprosy. The presence of at least two of the first three cardinal
signs enumerated indicates a definite diagnosis. Confirmation is, however, by
the fourth criteria.
Treatment:
Multibacillary leprosy: Use the following three drugs as follows for a period
of one year
Rifampicin, 600 mg p.o. once-monthly, supervised.
S/E: hepatoxicity, GI disturbances
C/I: hepatic dysfuncion, known hypersensitivity to rifampicin

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 standard treatment guidelines for zonal hospitals

Dosage forms: Capsule, 150 mg, 300 mg, and 600 mg.
OR
Dapsone, 100 mg daily, self-administered.
S/E: Hypersensitivity reactions, hemolytic anemia may occur in
individual with G6PD- deficiency. May also cause bone marrow
depression and monitoring of the CBC is required; nephrotoxicity
C/I: Hypersensitivity reactions to sulphonamides
Dosage forms: Tablet, 25 mg, 50 mg, 100 mg; Injection, 20 % in 50
ml ampoule

OR
Clofazimine, 300 mg once-monthly, supervised and 50mg daily, self-
administered. .
S/E: nausea, vomiting, abdominal pain, rash, pruritis, elevation of
blood sugar, reddish discoloration of body fluids; photosensitivity;
hepatic and renal impairment.
Dosage forms: Tablet, 100 mg.

Paucibacillary leprosy: use two drugs as below for a minimum of 6 months.

Rifampicin, 600 mg once-monthly, supervised
(For S/E , C/I and dosage forms, see page 46)
OR
Dapsone 100 mg daily, self-administered
(For S/E , C/I and dosage forms, see page 47)

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 standard treatment guidelines for zonal hospitals

Treatment of reaction
Mild reactions consisting of type 1 reactions in the absence of pain and
tenderness in nerves or type 2 reactions confined to minor skin lesions
with little systemic disturbances are treated as follows:
Aspirin, 600 mg to 1200 mg is given 4 hourly, 4 to 6 times daily until
the reaction is controlled and then the dose decreased gradually.
S/E: GI irritation; skin reaction; broncho-spasm.
C/E: GI ulceration; hemophilia; children under the age of 12.
Dosage forms: Tablet, 75 mg, 100mg (soluble), 300mg, 500mg
(enteric coated), 324 (microfined)
OR
Chloroquine, 150 mg chloroquine base is given upto 3 times daily.
(For S/E , D/I, C/I and dosage forms, see page 50)

Severe reactions may be considered when there is:

1. Risk of paralysis or anaesthesia in a patient who has neuritis,
2. Danger of skin ulcerations,
3. Risk of development of iridocyclitis or orchitis.
Treatment of severe reactions
Type 1 reaction
Prednisone is started in a single dose of 40-80 mg, according to
severity and this starting high dose should be reduced to 40 mg after a
few days. Thereafter, the dose is reduced by 5-10 mg every 2-4 weeks.
S/E: peptic ulceration; hypertension, diabetes, osteoporosis;
myopathy;
C/I: Peptic ulcer, diabetes, Cushing's disease.
Dosage form:Tablet, 1mg, 5mg.

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 standard treatment guidelines for zonal hospitals

Type 2 reactions
Prednisone (20-40 mg/day) may be used.
(For S/E, C/I and dosage forms, see page 48).
Note:
Clofazimine is indicated in patients who cannot be weaned off
corticosteroids or in those who are troubled by continuous erythema
nodosum leprosum (ENL), and also in those in whom thalidomide is
contraindicated.
Clofazimine, initially 300 mg p.o. given daily in divided doses for 2
weeks, reducing to 200 mg daily for a month or two and then to 100
mg daily according to response.
(For S/E, C/I and dosage forms, see page 47)

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 standard treatment guidelines for zonal hospitals

MALARIA
Malaria is a parasitic infection. There are four main species known to affect
humans. The most serious and life-threatening disease occurs from
Plasmodium Falciparum infection, which usually presents with acute fever,
chills, sweating and headache progressing to icterus, coagulation defects,
shock, renal and liver failure, acute encephalopathy, pulmonary and cerebral
edema, coma and death. It is a possible cause of coma and other CNS
symptoms in any person who has recently traveled to malarius areas. Prompt
treatment is essential even in mild cases. The other species, Plasmodium vivax
(benign tertian), Plasmodium malarea (quartan) and Plasmodium ovale, are not
life-threatening, except in the very young, very old and immuno-deficeint
cases.

Diagnosis can be confirmed by demonstration of malaria parasites in the blood

film. Often, repeated microscopic examinations may be necessary. It is also
helpful to estimate the degree of parasitemia, which is extremely useful not
only to predicate severity but gauge response to treatment as well.

I. Treatment
A. P. Falciparum
i. Uncomplicated P. Falciparum malaria
First line:
Chloroquine sensitive:
Chloroquine phosphate, 25 mg base/ kg over 3 days p.o. (4 tablets
p.o. stat, followed by 2 tablets after 8 hours, then 2 tablets per day for
two consecutive days.).
Children: 10 mg/kg initially, then 5 mg/kg 6, 24 and 48 hrs after the
first dose.
(For S/E, D/I, C/I and Dosage forms , see page 26)
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 standard treatment guidelines for zonal hospitals

Alternative:
Sulfadoxine 500 mg + pyrimethamine 25 mg
3 tablets orally once. If parentral preparation is required, 2 ampoules
of the injectable form (e.g. Fansidar) can be given IM or IV slowly.
Note: The total 24 hours dose should not exceed 2000mg.Oral therapy
should be started as soon as the patient regains consciousness.
Children’s dose: depends on age:
a. Less than 3 years: ½ tablet (250 mg Sulfadoxine + 25 mg Pyrimethamine
b. 4-11 years: 1 tablet = (500 mg Sulfadoxine + 25 mg Pyrimethamine)
c. 12-15 years: 2 tablets = (1000 mg Sulfadoxine + 50 mg Pyrimethamine
Parentral Sulfadoxine 500 mg + pyrimethamine 25 mg is given as follows:
Depends on age:
a. 0-4 years: 0.5-1.5 ml (1/4ampoule).
b. 5-8 years: 1.5-2 ml (3/4-1 ampoule)
c. 9-14 years: 2-3 ml ( 1-1 ½ ampoule )
S/E: Depression of hematopoiosis with high doses, rashes and insomnia.
Caution: Hepatic or renal impairment, folate supplement in pregnancy,
breast feeding, blood counts required in prolonged use, infants less than 2
months, hepatic or renal dysfunction.
Dosage forms: tablet, sulfadoxine (500 mg) + pyrimethamine (25 mg);
injection, sulfadoxine (500 mg) + pyrimethamine (25 mg) in 2.5 ml
ampoule

Quinine dihydrochloride, 600 mg (2 tablets) can be given 8 hourly for 7

days if Sulfadoxine + pyrimethamine fails.
S/E: Cinchonism, including tinnitus, headache, nausea, abdominal pain,
rashes, visual disturbances, confusion, blood disorders (including
thrombocytopenia and intra-vascular coagulation), and acute renal failure.
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 standard treatment guidelines for zonal hospitals

C/I: Hemoglobinuria, optic neuritis

Dosage forms: tablet (dihydrochloride or sulphate), 300mg, and 600mg;
injection, 300mg/ml in 1 ml ampoule.

ii. Severe and complicated P. falciparum malaria

Non-Drug treatment:
• Clear and maintain the airway.
• Position semi-prone or on side.
• Weigh the patient and calculate dosage.
• Make rapid clinical assessment.
- Exclude or treat hypoglycemia (more so in pregnant women).
- Assess state of hydration.
• Measure and monitor urine output.
- If necessary insert urethral catheter.
- Measure urine specific gravity.
• Take blood for diagnostic smear, monitoring of blood sugar ('stix'
method), haematocrit and other laboratory tests.
• Plan first 8 h of intravenous fluids including diluents for anti-malarial
drug, glucose therapy and blood transfusion.
• If rectal temperature exceeds 39°C, remove patient's clothes, use tepid
sponge,
• Lumbar puncture to exclude meningitis or cover with appropriate
antibiotic.
• Consider other infections.
• Consider need for anti-convulsant treatment
Drug Treatment
Quinine dihydrochloride:

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 standard treatment guidelines for zonal hospitals

Loading dose: 20 mg/kg in 500 ml of isotonic saline or 5 % dextrose

over 4 hours (4 ml/minute). The pediatric dose is the same but the
fluid replacement must be based on body weight.
Maintenance dose: should be given 8 hours after the loading dose of
10 mg / kg to be given 8 hourly diluted in 500 ml of isotonic saline or
5 % dextrose over 4 hours. The parentral treatment should be changed
to p.o. as soon as the patient condition improves and if there is no
vomiting. Treatment should be given for an average of seven days.
(For S/E and Dosage foms, see page 51)
PLUS
Doxycycline, 200 mg p.o. four times daily for 7 days (For S/E and
Dosage foms, see page 33)
OR
Sulfadoxine/pyrimethamine (500/25 mg), oral, 3 tablets as a single
dose, on day 3 of quinine treatment. (For S/E and Dosage foms, see
page 51)
P. Vivax
Chloroquine phosphate, 1 g, then 500 mg in 6 hours followed by
500 mg daily for 2 days, or 1 g at 0 and 24 hrs followed by 0.5 g at 48
hrs p.o
(For S/E, C/I and dosage forms, see page 26).

Followed by
Primaquine, 15mg base as a single dose daily for 14 days p.o.
S/E: Nausea, vomiting anorexia, and less commonly hemolytic
anemia, especially in patients with G6PD deficiency.

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Caution: In patients with G6PD deficiency; systemic diseases

associated with granulocytopenia, e,g. rheumatoid arthritis, and
pregnancy and breast feeding)
Dosage forms: Tablet, 7.5mg base, 15mg base
II. Chemo-prophylaxis
P. Falciparum
Chloroquine sensitive:
First Line
Chloroquine phosphate, 300 mg (as base) p.o. weekly:
For Children, Chloroquine 5mg/kg p.o weekly.
Length of Prophylaxis: Preferably taken 1 week before travel and until
4 weeks after return.
(For S/E, C/I and dosage forms, see page 26)
Chloroquine resistant:
First Line
Chloroquine phosphate, 300mg (as base) or 5 mg base/kg p.o. once
weekly
(For S/E, C/I and dosage forms, see above page 26)
PLUS
Proguanil hydrochloride, 200 mg (3 mg/kg) p.o. daily , preferably
taken 1 week before travel and until 4 weeks after return.
S/E: nausea, vomiting, diarrhea, headache, dizziness, abnormal
dreams, and insomnia.
C/I: liver or kidney dysfunction. Avoid breast-feeding.
Dosage forms: Proguanil hydrochloride tablets, 100 mg (scored)
Alterative
Doxycycline, 100 mg once daily (For S/E, C/I and dosage forms, see
page 33)
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 standard treatment guidelines for zonal hospitals

For P. vivax
Primaquine phosphate, 15 mg base p.o daily for 14 days after travel.
(For S/E, C/I and dosage forms, see page 53)

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MENINGITIS
1. ACUTE BACTERIAL MENINGITIS
Acute Bacterial Meningitis is an inflammation of the membranes of the brain
or spinal cord, i.e.of the dura matter or the pia-arachnoid matter in response to
bacterial infection. It is mainly caused by N. meningitidis, S. pneumoniae, H.
influanzae. The disease is characterized by an intense headache, fever,
intolerance to light and sound and rigidity of muscles, especially those of the
neck.
Diagnosis: clinical and CSF analysis including gram stain, culture and
sensitivity
Treatment:
Specific antibiotic treatment for bacterial meningitis depends upon
identification of the caustive organism.
Supportive Measures
The patient should be closely supervised with regular monitoring of
vital signs and neurological state.
Drug treatment
A) Community acquired, bacterial etiology unknown
Benzyl penicillin, 20-24 IU/day i.v. in 4-6 divided doses for 7 -
10days.
S/E: hypersensitivity reactions including urticaria, fever, joint pans
rashes, angio-edema, anaphylaxis, parasthesia with prolonged use,
diarrhea and antibiotic associated colitis.
C/I: Penicillin hypersensitivity.
Dosage forms: injection, 1million I.U, 5 million I.U, 10 million I.U.
20 million I.U, in vial.
PLUS

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 standard treatment guidelines for zonal hospitals

Chloramphenicol, 500mg i.v. 6 hourly. In severe infections, up to

100 mg/kg/day in 4 divided doses, 6 hourly may be used for 7 days
(For S/E, C/I and Dosage forms, see page 36)

Alternative
Ceftriaxone, i.v., 4 g/day divided in 12 hourly doses for 7 days
(For S/E, C/I and Dosage forms, see page 29)
B) Community Acquired Etiology known
N.meningitidis and S. pneumoniae

Benzyl penicillin, 20-24 MU/day i.v. in 4-6 divided doses for 7-10
days.
(For S/E, C/I and Dosage forms, see page 55)
H. influenzae
Chloramphenicol, 100 mg/kg/day i.v. in 4 divided dose for the first
48-72 hours, then 50 mg /kg/day 7-10 days. (For S/E, C/I and Dosage
forms, see page 36)
For resistant strains of N.meningitidis, S. pneumoniae and H. influenzae:
Ceftriaxone, i.v., 4 g/day divided in 12 hourly doses for at least 10-
14days.
(For S/E, C/I and Dosage forms, see page 29)
OR
Cefotaxime, i.v., 8-12 g/day in 4 divided doses, 6 hourly
(For S/E, C/I and Dosage forms, see under Ceftriaxone, page 29)

C) Hospital acquired meningitis, etiology unknown

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 standard treatment guidelines for zonal hospitals

A third generation cephalosporin, e.g., Cefotaxime, i.v., 8-12 g/day

in 4 divided doses, 6 hourly. (For S/E, C/I and Dosage forms, see
under ceftriaxone, page 29)
OR
Ceftriaxone, i.v., 4 g/day divided in 12 hourly doses.
(For S/E, C/I and Dosage forms, see page 29)
PLUS
Gentamicin, i.v., 3-5 mg/kg/day in 3 divided dose for 7-10 days
S/E: ototoxicity, nephrotoxicity
C/I: myastenia gravis
Dosage forms: Injection, 40mg/ml, 40mg/ 2ml
Listeria monocytogenes :
Ampicillin, 12 g/day i.v. in 4 divided dose.
(For S/E, C/I and Dosage forms, see page 31)
PLUS
Gentamicin, 3-5mg/kg/day i.v. in 3 divided doses, for 2-3 weeks
(For S/E, C/I and Dosage forms, see above page 56)
D. Hospital acquired, etiology known
Staphylococcus aureus -

Cloxacillin , 9-12 g/day i.v, in 4 divided doses. For 2-3 weeks

S/E: hypersensitivity reactions including urticaria, fever, joint pans
rashes, angio-edema, anaphylaxis, parasthesia, with prolonged use,
diarrhea and antibiotic associated colitis.
C/I: Penicillin hypersensitivity.
Dosage forms: Capsule, 250 mg, 500 mg; injection, 250 mg,
500mg,in vial; syrup, 125 mg, 250mg, in each ml.
For methicillin-resistant,
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Vancomycin, 1 g 12 i.v. hourly for 2 - 3 weeks

S/E: hypotension, palpitations, urticaria, nausea
C/I: patients with hearing problem
Dosage forms: Injection, 500mg in vial.
PLUS
Rifampicin, 600 mg/day i.v. for 3 weeks.
(For S/E, C/I and Dosage forms, see page 46)
Pseudomonas aeruginosa –
First Line
Ceftazidime , 8-12 g/day i.v. in 4 divided doses, 6 hourly for 10 - 14
days.
(For S/E, C/I and Dosage forms, see under ceftriaxone, page 29)

PLUS
Gentamicin, 3-5 mg/kg/day i.v. in 3 divided dose for 7-10 days. (For
S/E, C/I and Dosage forms, see page 56)
Alternative
Ceftriaxone, 4 g/day i.v. divided in 12 hourly for 7 – 10 days.
(For S/E, C/I and Dosage forms, see page 29)
PLUS
Gentamicin, 3-5 mg/kg/day i.v. in 3 divided dose for 7-10 days
(For S/E, C/I and Dosage forms, see page 56)
Enterobacteriaceae -
First Line
Ceftriaxone, 4 g/day i.v. divided in 12 hourly for 7-10 days.
(For S/E, C/I and Dosage forms, see page 29)
Alternative
Cefotaxime, 8-12 g/day i.v. in 4 divided doses, 6 hourly.
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(For S/E, C/I and Dosage forms, see page 29 under ceftriaxone)

2. CRYPTOCOCCAL MENINGITIS
Cryptococcal Meningitis is chronic meningitis caused by cryptococcus
neoformans. Develops in patients with underlying immunodeficiency.
Diagnosis: Clinical and Lumbar Puncture with CSF analysis including
Indian ink staining, CSF cryptococcal antigen, and fungal culture.
Treatment:
Non-drug treatment:
• If CSF opening pressure greater than 250 H2O mm, drain 20-
30ml of CSF daily until less than 200mm H2O
Drug treatment:
First Line
• Amphotericin B, 0.7-1.0mg/kg/day i.v. for 2 weeks (For S/E, C/I
and Dosage forms, see page 44)
PLUS
• Flucytosine, 25mg/kg p.o. qid for 14 days
S/E: nausea, vomiting, diarrhoea, skin rashes, alterations in liver
function tests, blood dyscrasias, occasionally confusion,
hallucination, convulsion.
C/I: Pregnancy, lactation, renal impairment, hepatic impairment
Caution: May cause bone marrow depression (especially in AIDS
patients); weekly blood counts are necessary on prolonged use.
Dosage forms: capsule, 250mg, 500mg; IV infusion 10mg/ml;
solution for injection, 2.5g/250ml.
Followed by
Fluconazole, 400mg/day p.o. for 8 weeks, then 200 mg/day
indefinitely
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S/E: nausea, abdominal discomfort, diarrhoea, and abnormalities

of liver enzymes, cutaneous reactions
C/I: Pregnancy, lactation, renal impairment
Dosage forms: capsule/tablet, 50mg, 100mg, 200mg; oral
suspension, 50mg/5ml, 200mg/5ml.
Alternative
Fluconazole, 400-800 p.o. mg/day for 6-10weeks, then 200 mg/day
p.o. indefinitely. For (S/E, C/I and dosage forms, see page 59)
N.B Initiation of ART would very much improve the overall prognosis of such
cases.
ONCOCERCIASIS (BLINDING FILARIASIS, RIVER BLINDNESS,
COASTAL ERYSIPELAS)
Oncocerciasis is a disease caused by onchocerca volvulus, transmitted by
several species of simulium ("Black flies") and manifested by onchodermatitis.
Mature worms and microfilariae are found in granulomatous dermal nodules
mainly on the bony prominences, the trunks and extremities in Africans and the
scalp in Central Americans. Inflammatory cells and sometimes giant cells
accumulate around the worms and occasionally calcification may occur.
Perivascular inflammatory response occurs in the dermis as a result of the
presence of microfiltration at this level of the skin. With chronicity, these
reactions are replaced by fibrosis and atrophy of the dermis and epidermis. The
presence of microfilariae in the eye causes keratitis, iritis and choroidites,
which may eventually lead to blindness.
Diagnosis is established by:
1. Clinical presentation (pruritus, oncocercoma and oncophthalmia),
with leucocytosis with relative eosinophilia
2. Examination of skin snips
3. Histological examination of the nodule (presence of adult worms and
microfilaria),
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4. Mazotti test (filarial skin test) and

Treatment
First Line
Ivermectin, single oral dose of 150 micrograms/kg is the drug of
choice. Moreover, it should be continuously given once or twice a
year for people residing in endemic area. On the other hand, for those
no more living in endemic area, single dose treatment is enough and a
repeat dose should only be given in case of relapse.
S/E: itching and rash.
C/I: children younger than 5 years, pregnancy, nursing mothers,
particularly during the first few weeks after confinement.
Dosage forms: Tablet, 3 and 6 mg (scored)
Alternative:
Diethylcarbamazine as follows: day 1, 50 mg; day 2, 50mg, three
times daily; day 4, 100mg, three times daily and days 5-21, 3mg/kg
body weight, three times daily.
S/E: severe hypersensitivity reaction, minor GI upset, headache.
Dosage forms. Tablet 50 mg; syrup-120 mg/5 ml.

PLUS
Antihistamines may be required in the first few days of treatment if
there is severe exacerbation of the diseases. Promethazine, 25 mg
two or three times a day until the prurutis subsides
S/E: drowsiness, sedation, headache, blurring of vision, GI
disturbance
Caution: Close monitoring of the patient is required during the first
few days of therapy.

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Dosage forms: Elixir, 5mg/5ml; injection, 25mg/ml 1ml and 2 ml

ampoules; suppository, 25mg, 50mg; tablet, 10mg, 25mg.

N.B.Nodulectomy may have a place for eradication of the adult worm.

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PNEUMOCYSTIS CARRINNI PEUMONIA:

PCP frequently causes pneumonia among immuno-compromized individuals. It

is caused by Pneumocystis carinni. The onset is typically subacute over 2 to 4
weeks, with prominent symptoms of fever, sweats, non-productive cough,
dyspnoea, and fatigue and weight loss.
Diagnosis: The clinical presentation of PCP is non-specific. Therefore it
should always be considered in those patients with evidence of moderate to
severe immuno-suppresion who come up with one or more of the above
symptom. When facilities allows, definite diagnosis requires demonstration of
the organism in secretions or tissue by using appropriate stain.

Therapy:
Supportive treatment:
Oxygen should be given in moderate and severe cases.
Drug treatment:
First line:
Trimethoprim+Sulphamethoxazole 15-20 mg/kg/day based on the
trimethoprim component and administered in divided doses every 6 or
8 hours. The duration of treatment is about 14-20 days depending on
severity. This drug could be given IV if the patient is not able to
swallow the drug. Pay due attention to side effects which at times
could be life treating. Steven Johnson syndrome may occur if the
patient is allowed to take the drug after the development of rash. (For
S/E, C/I and dosage forms, see page 283).
OR

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Pentamidine Isethionate, 4 mg/kg i.v. once daily for three weeks. It

should be given to those who fail to tolerate the above regimen. (For
S/E, C/I and dosage forms, see page 44).
Alternative treatment:
Clindamycin, 300-450 mg p.o every 8 h / day for 3 weeks
S/E: diarheoea (discontinue treatment); GI upset, Antibiotic-
associated colitis; jaundice and altered liver function tests.
C/I: diarrheal states
Dosage forms: Capsule, 75 mg, 150mg; injection, 150 mg/ml in
ampoule; oral solution, 15 mg/ml.

PLUS
Primaquine, 30 mg base p.o. once daily for 3 weeks.
Typically a mild rash with fever develops 7 to 10 days after
initiation of therapy. Bone marrow suppression may occur, and
CBC monitoring is useful. Possible hepato-toxicity and nephro-
toxicity may also be evaluated at the third week of therapy. (For
S/E, C/I and dosage forms, see page 53).
OR
Dapsone, 100 mg p.o per day for 3 weeks
(For S/E, C/I and dosage forms, see page 43)
PLUS
Trimethoprim, 20 mg/kg administered p.o in divided doses every 6 h
for 3 weeks. S/E: GI disturbances, pruritis, rash, bone marrow
suppression
Dosage forms: Tablets, 100 mg, 200 mg; suspension, 50 mg/ml;
injection, 20 mg/ml.

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NB. In moderate and severe cases, steroids should be added, regardless of the
drug regimen used, in the following manner:
- 40 mg twice daily for 5 days,
- Then 20 mg twice daily for 5 days,
- Then 20 mg once daily until therapy is complete.
- No tapering from the 20 mg dose is necessary.
Prophylaxis:
Prophylaxis against PCP should be commenced in the following conditions:
When the CD4 cell count drops below 200 cells/ml or
When there is clinical signs of advanced immune deficiency
or
Soon after the patient completes treatment for active PCP
infection.

The following regimen is recommended:

Trimethoprim+Sulphamethoxazole - One double strength tablet daily or 3
times weekly
Dapsone, 100 mg daily (For S/E, C/I and dosage forms: see page 283 and 47
respectively)
Aerosal pentamidine - 300 mg via nebulizer every 4 weeks.

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PNEUMONIA
Pneumonia refers to acute inflammation of the lungs. The clinical presentation
and the etiology vary greatly depending on the age, the infecting organism, the
geographical location, the immune status and site of acquisition. The most
important pathogens which cause community acquired pneumonia in immuno-
competent adults includes Strep. Pneumoniae, followed by Mycoplasmal
Pneumonea, Chlamydia Pneumoniae, Legionella spp and others. It is also
important to remember that Pneumocystis carini and Mycobacterium
Tuberculosis have now become a common cause of community acquired
pneumonia in immuno-compromised individuals.
Hospital acquired pneumonia refers to the type of pneumonia, which occurs
after 48 hours of admission to a hospital. Multi-resistant bacteria such as
staphylococci, enterococci, enterobacteria, Peudomonas aeroginosa and other
aerobic bacteria may be responsible for such infections. This is more so in
those who acquired the infection 5-7 days after hospitalization.
The most important symptoms include cough, fever, chest pain and
tachypnoea. Extra-pulmonary features such as confusion or disorientation may
be the only signs in the elderly, immuno-compromised patients and
malnourished children.

Diagnosis: Gram stain of the sputum remains the main stay of diagnosis.
Blood culture may be positive in ¼ to 1/3 of cases and is important to isolate
the causative agent for proper antibiotic choice. Chest X-ray may also be
helpful not only to confirm the diagnosis, but also to estimate the extent of the
lesion and to exclude other diagnosis.
Treatment:
Drug treatment:
I. Community acquired ambulatory patients (Mild Pneumonia):

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First line
Amoxicillin, 500 mg p.o. every 8 hours for 5 to 7 days.
(For S/E, C/I and dosage forms see page 31).
OR
Erythromycin, 500 mg p.o every 6 hours for 5-7 days in cases of
atypical
Pneumonias. (For S/E, C/I and dosage forms see page 31).
Doxycycline, 100 mg p.o. every 12 hours for 7-10 days.
(For S/E, C/I and dosage forms, see page 33).
Alternative
Procaine penicillin, 800,000 I: U i.m. daily for 5-7 days.
(For S/E and C/I, see under Benzyl penicillin, page 55)
Dosage forms: injection (buffered), 4,000,000 IU in vial

II. Community acquired hospitalized patients (Severe Pneumonia):

Non-Drug treatment:
Bed rest
Frequent monitoring of temperature, blood pressure and pulse rate in
order to detect complications early and to monitor response to
therapy.
Give attention to fluid and nutritional replacements.
Administer Oxygen via nasal prongs or facial mask
Analgesia for chest pain

Drug treatment:
The Antibiotic choice should be aimed at the most likely causative agent.
A. Pneumonia due to common organism:

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Benzyl penicillin, IV, 2 million IU 6 hourly for 7-10 days. (For S/E,C/I
and Dosage forms, see page 55).
PLUS
Gentamicin 5-7 mg/kg i.v. Daily in divided doses for 7 days
(For S/E ,C/I and Dosage forms, see page 56).
OR
Ceftriaxone, 1 g i.v.or i.m every 12-24 hours for 7 days.
(For S/E and C/E, see page 29)
Alterative treatment
(In case of penicillin allergy or strong suspicion of infection by
mycoplasma)
Erythromycin, 500 mg p.o. every 6 hours for 7-10 days.
(For S/E, C/I and dosage forms, see page 31)
OR
Doxycycline, 200 mg p.o. immediately, followed by 100 mg twice
daily for 7-10 days. (For S/E, C/I and dosage forms see page 33).
B. Pneumonia due to Gram-negative bacteria, especially in the elderly
First Line
Ampicillin, 1 g i.v. 6 hourly for 7-10 days
(For S/E, C/I and dosage forms, see page 31).
PLUS
Gentamicin, 3-5 mg/ kg i.v. as a loading dose, followed by 1.5
mg/kg/day in 3 divided doses, 8 hourly for a minimum of 7 days.
(For S/E, C/I and dosage forms , see page 56) .
Alternative
Benzyl penicillin, 2 million IU i.v. 6 hourly for 7-10 days.
(For S/E, C/I and Dosage forms, see page 55).
PLUS
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 standard treatment guidelines for zonal hospitals

Gentamicin, 5-7 mg/kg i.v. Daily in divided doses for 7 days

(For S/E, C/I and dosage forms , see page 56)

C. Pneumonia due to Staphyloccocus Aureus should be treated as follows:

Cloxacillin, 1-2 g i.v or i.m. every 6 hours for 10-14 days.
(For S/E and C/E, see page 57)
Dosage forms: Capsule, 250 mg, 500 mg; injection, 250 mg, 500mg
in vial; syrup, 125 mg, 250mg in each ml.
III. Hospital acquired pneumonias (Nosocomial Pneumonias):
The antibiotic choice should depend on the epidemiology and susceptibility of
local pathogens. Antimicrobials effective against gram-positives and gram-
negatives should be given in combination. Suitable combinations include, for
example:
First line
Cloxacillin, 1-2 g i.v. Every 6 hours for 7 days
(For S/E, C/E and dosage forms, see page 57)
PLUS
Gentamicin, 5-7mg/kg i.v. daily in divided doses for 7 days.
(For S/E, C/I and dosage forms, see page 56)
OR
A third generation cephalosporin, e.g. Ceftazidime, 1 gm i.v every
8 hourly or ceftriaxone, 1-2 g i.v.or i.m 12 hourly for 7 days. (For S/E
and C/I, see page 29).
Dosage form: Injection, 0.5 g, 1g, 2g, in vial.

PLUS either
Gentamicin, 5-7 mg/kg i.v daily in divided doses for 7 days.
(For S/E, C/I and dosage forms, see page 56).
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 standard treatment guidelines for zonal hospitals

OR
Ciprofloxacin, 500 mg p.o./i.v. every 12 hours for 7 days.
(For S/E, C/I and dosage forms, see page 28).

Specific cause known:

1. Staphylococcus aureus -
Cloxacillin, 0.5-1 gm 6 hourly i.v for 7 days
(For S/E, C/I and Dosage forms, see page 57)
If methicillin-resistant,
Vancomycin, 1 g i.v.12. hourly for 7 days
(For S/E, C/I and Dosage forms, see page 57)
PLUS
Rifampicin, 600 mg/day i.v. for 7-10 days.
(For S/E, C/I and Dosage forms, see page 46)

2. Pseudomonas aeruginosa –
Ceftazidime, 1-2 gm i.v. 8 hourly for 7-10 days
(For S/E, C/I and dosage forms, see under Cefrtiaxone page 29)
OR
Ceftriaxone, 1-2 g i.v or i.m. 12 hourly for 7-10 days.
(For S/E, C/I and Dosage forms, see page 29)
PLUS
Gentamicin, i.v., 3-5 mg/kg/day in 3 divided dose for 7-10 days
(For S/E, C/I and Dosage forms, see page 56)

3. Enterobacteriaceae -

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standard treatment guidelines for zonal hospitals

Ceftriaxone, 4 g/day i.v. or i.m. divided in 12 hourly doses.

(For S/E, C/I and Dosage forms,see page 29)

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 standard treatment guidelines for zonal hospitals

PLUS
Gentamicin, 3-5 mg/kg/day i.v. in 3 divided dose for 7-10 days
(For S/E, C/I and Dosage forms, see page 56)

4. Legionella Pneumophila
Erythromycin, 1 g i.v 6 hourly for 10 days.
(For S/E, C/I and dosage forms, see page 31)
OR
Ciprofloxacin, 750 mg p.o every 12 hourly for 10 days.
(For S/E, C/I and Dosage forms, see page 28)

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 standard treatment guidelines for zonal hospitals

PNEUMONIAS (ASPIRATION) AND LUNG ABSCESSES :

Lung abscess refers to a localized area of destruction of lung parenchyma,
which results in tissue necrosis and suppuration. Although mostly caused by
bacteria, they can also be caused by other organisms such as Tuberculosis,
fungi and even protozoa. Penicillin sensitive anaerobic bacteria such as pepto-
streptococcus spp., as well as aerobic bacteria such as Streptococcus pyogenes
and Streptococcus viridans most frequently cause lung abscesses along with
aspiration pneumonias. Predisposing factors include impaired consciousness of
various causes including anesthesia, bronchial obstruction, alcohol dependence,
and cerebro-vascular accidents. The predominant symptoms are cough, fever
and chest pain. The sputum often is copious, purulent and offensive.
Diagnosis. Chest x-ray confirms the diagnosis. Gram stain and culture help to
identify the specific causative agent. AFB and KOH examination of sputum
should be done if TB or fungal causes are strongly considered consecutively.
Treatment:
First line:
Benzyl penicillin, 1-2 million IU i.v or i.m every 4-6 hours for about
4 weeks.
(For S/E, C/I and Dosage forms, see page 55)
PLUS
Metronidazole, 500 mg i.v every 8-12 hours for 10-14 days.
(For S/E, C/I and dosage forms, see page 24).
Alternative
Amoxicillin 500 mg + clavulanic acid 125 mg, p.o. every 8 hours for
10-14 days
S/E: Hepatitis, cholestatic jaundice; rash, including Stevens-Johnson
syndrome,

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 standard treatment guidelines for zonal hospitals

C/I: penicillin hypersensitivity, history of co-amoxiclov- or penicillin-

associated jaundice or hepatic dysfunction.
Dosage forms: chewable tablet, 125/31.25mg, 250/62.5mg; tablet
(film coated), 250/62.5 mg, 500/125; oral suspension, 125/31.25mg in
each 5 ml, 250/62.5 mg in each 5 ml.
PLUS
Clindamycin, 600mg i.v every 8 hours for 14 days (when clinical
improvement occurs, 300-450 mg p.o. every 6-8 hours may be
substituted).
(For S/E, C/I and Dosage forms, see page 63)

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 standard treatment guidelines for zonal hospitals

PYOGENIC OSTEOMYELITIS
Pyogenic Osteomyelitis is an acute infection of the bone and its structures
caused by pyogenic bacteria. This infection may be acquired either by
hematogenous, contiguous, or direct inoculation following trauma or surgery. It
is commonly caused by Staphyloccocus aureus.
Diagnosis: Clinical, CBC, X-ray of the affected bone.
Treatment:
Non-drug treatment:
Rest/immobilisation
Surgical drainage
Comments:
• Drainage by orthopedic surgeon. If the temperature and local
tenderness persist after 24 hours of adequate antibiotics
subperiosteal abscess must be looked for and drained. The pus
should be sent for culture. (If the diagnosis is made early and
antibiotics are started early, drainage may not be necessary.)
Drug treatment:
First line:
Cloxacillin, 2 g i.v. 6 hourly for 7-10 days, followed by Cloxacillin, 500 mg
p.o. 6 hourly for 2-4 weeks.
(For S/E, C/I and Dosage forms, see on page 57)

Comments:
• Alternative treatment guided by sensitivity tests, or if patient is
allergic to penicillin.
• For pain and fever – Analgesic/antipyretic e.g. Paracetamol, 500
- 1,000 mg p.o. as needed (4-6 times daily) can be given.
S/E: hypersensitivity skin reactions rare; rash, blood disorder

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C/I: hepatic and renal disease

Dosage forms: tablets, 100 mg, 500 mg; syrup, 120 mg/5 ml;
suppository, 125 mg, 250 mg; drops, 100 mg/ml

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RELAPSING FEVER
Relapsing fever is a louse-borne disease that is caused by the spirochaetes,
Borrelia recurrentis. The disease is common among the homeless and in those
living in overcrowded living conditions. It is endemic in our country but
outbreaks do also occur from time to time. It is characterized by recurrent acute
episodes of spirochetemia and short febrile periods alternating with spirochetal
clearance and pyrexia. Other febrile diseases like thyphus, thyphoid fever,
malaria and meningitis should be considered in the differential diagnosis of
relapsing fever.
Diagnosis is made by blood film microscopic examination.

Treatment
Non Drug treatment
- Delousing
- Shaving of the scalp
Drug treatment
First line
Procaine penicillin, 400,000 units i.m. stat. For children: 25,000-
50,000 units.
(For S/E, C/I, and dosage forms, see under Benzyl penicillin, page
55)
Check blood film after 12 hours of treatment. If negative, give
tetracycline 250 mg three times daily for three consecutive days. If the
blood film remained positive, repeat the same dose of procaine
penicillin and continue with tetracycline later as described above.
Alternative

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 standard treatment guidelines for zonal hospitals

Tetracycline hydrochloride, 500mg p.o. stat. The same dose could

be repeated the following day (For S/E, C/I and dosage forms, see
page 32)
N.B
1. Some patients may develop a kind of reaction following treatment
with antibiotics. It is known as the Jarisch-Herxheimer reaction and is
believed to be due to a rapid clearance of the spirochetes. In severe
cases, significant arterial hypotension with pulmonary edema may
supervene. Such complications require prompt and appropriate cardio-
vascular support.
2. In resistant cases, consider other concomitant infection like
thyphus.

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SCHISTSOMIASIS
Schistosomiasis is caused by three major trematodes, which includes
Schistsoma Mansoni, Schistsoma Japonicum and, and Schistsoma
Haematobium. The previous two species inhabit venules of the intestines
where as the latter are found mostly in the venules of the urinary tract. Human
infection occurs as a result of penetration of the unbroken skin by the free-
swimming cercariae. This often occurs in individuals who have frequent
contact with water bodies heavely infested with appropriate snails.
Diagnosis is by identification of the ova in the feces in cases of S. mansoni and
S. japonicum and urine in case of S. haematobium or tissues in all cases.

Treatment
First line:
Praziquantel, 40 mg/kg in 2 diveded doses 4-6 hours apart on one
day or 1200 mg p.o. as a single dose or 2 divided doses for both S.
haematobium and S. mansoni
S/E: minor Gastero–intestinal upset.
C/I: ocular cysticercoids.
Dosage forms: tablet, 600 mg.
Alternatives:
Metrifonate, 600 mg p.o. tid at 14 days interval for S. haematobium.
S/E: nausea, colic, lassitude
C/I: recent exposure to insecticides
D/I: Respiratory paralysis when given with depolarizing
neuromuscular blockers
Dosage forms: tablet, 100mg.

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 standard treatment guidelines for zonal hospitals

Oxamniquine, 1250 mg (30 mg/kg) p.o. once for S. mansoni.

S/E: headache, dizziness, drowsiness and minor GI disturbances.
C/I: should not be used in pregnancy.
Dosage forms: capsule, 250 mg; suspension, 250-mg/5 ml

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SEPTIC ATHRITIS
This is an invasion of the joints by microorganisms. It may occur secondary to
haematogenous spread (80-90%), contiguous spread (10-15%), and direct
penetration of microorganisms secondary to trauma, surgery or injection. It is
commonly caused by S. aureus, S. pyogenes, N. gonorrhoeae, and othe Gram
negatives.
Diagnosis: Clinical; synovial fluid analysis including Gram stain and
culture; X-ray of the affected joint
Treatment:
Non-drug treatment:
• Aspiration/drainage when indicated
• Splintage, but early mobilisation if joints are mobile.
• The joint must be splinted with a POP slab or skin traction to
relieve pain and prevent contractures

Drug Treatment:
Cloxacillin, i.v, 2 g every 6 hr for 4-6 weeks
(For S/E, C/I and Dosage forms, see page 57)

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SINUSITIS
Sinusitis is an inflammation of the mucosal lining of the paranasal sinuses. It
could be caused by viruses, bacteria or could be allergic in nature. The most
common bacteria that cause sinusitis are Streptoccocus pneumonae and
Hemophilus influnenza. Clinical presentation varies with the specific sinus
involved. In general, it includes a purulent nasal discharge, feeling of fullness
or pain over the face, and head ache. The affected sinus may be tender and
swollen.
Diagnosis is mainly clinical, but X-rays of the sinuses may be helpful
particularly in chronic cases.
Treatment
Non-drug treatment: steam inhalation
Drug treatment:
A. For nasal congestion:
First line:
Oxymetazoline, one drop 1 – 3 times daily until the symptoms are
controlled, but not longer than a week.
S/E: local irritation, nausea, headache after excessive use tolerance
with diminished effect, rebound congestion.
Caution: avoid prolonged use.
Dosage forms: drop, 0.025% for pediatrics and 0.05% for adults
OR
Xylometazoline, one drop 1 – 3 times daily.
(S/E and C/I are the same as for oxymetazoline)
Alternatives:
Phenylephrine, one drop 4 hourly. (S/E and C/I are the same as for
oxymetazoline)
Dosage forms: drop, 0.25% for pediatrics and 1% for adults

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Caution: The use of topical nasal decongestants (oxymetazoline,

xylometazoline, phenylephrine and ephedrine) can give rise to
rebound phenomenon on prolonged use; short-term use not exceeding
7 days is recommended. These drugs should not be used together with
MAOI, as this may cause a hypertensive crisis.

B. For bacterial infection:

First line:
Amoxicillin, 250- 500 mg tid p.o. For children: 20 – 40 mg/kg/day
p.o. in 3 divided doses for 7 days.
(For S/E and C/I and dosage forms, see page 31).
OR
Sulfamethoxazole + trimethoprim, 800mg/160 mg p.o. bid, for 7
days. For children 6 weeks – 5 months, 100/20 mg; 6 months – 5 yrs,
200/40 mg; 6 – 12 yrs, 400/80mg bid.
(For S/E, C/I and Dosage forms, see page 283)
Alternative:
Amoxicillin-clavulanic acid, 250/125mg tid, for children: 20-40/5-
10mg/kg/day in 3 divided doses for 7 days.
(For S/E, C/I and Dosage forms, see page 71)

Chronic sinusitis: Most cases requires surgical drainage, besides antibiotic

treatment as outlined above.

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SUBACUTE BACTERIAL ENDOCARDITIS

It is an infection of the endocardium of the heart. Fever is present in almost all
patients, and features of anemia, arthralgia and myalgia may also be seen.
Petechial rash and splenomegaly are important physical findings. Streptococci
viridans cause the majority of cases of subacute bacterial endocarditis; the rest
are due to organisms like Entrococci, Staphylococci and others. Some
procedures like dental or pelvic manipulations, and catetherization may result
in transient bacteremia and predisposes to SBE.

Diagnosis is based on clinical findings. Confirmation can be made through

blood culture as well as echocardiography .

Treatment

For Streptococci viridans infection

Penicillin G, 12-18 million IU i.v. per day in divided doses four
hourly for 4 weeks.
(For S/E and C/I , see under benzyl penicillin page 55)
Dosage forms: Injection, penicillin G, sodium crystalline, 1,000,000
IU in vial, 5,000,000 IU in vial, 10,000,000 IU in vial, 20,000,000 IU
in vial.
PLUS
Gentamicin, 1mg/kg iv tid, for the first 2 weeks.
(For S/E, C/I and Dosage forms, see page 56)

If the patient is allergic to penicillin, use:

Vancomycin, 15 mg/kg IV every 12 hours for 4 weeks
(For S/E, C/I and Dosage forms, see page 53)

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 standard treatment guidelines for zonal hospitals

For Enterococci infection

Penicillin G, 18-30 million IU per day i.v. for 4-6 weeks. (For S/E,
C/I and Dosage forms, see page 55)
PLUS
Gentamicin, 1 mg/kg i.v. every 8 hours for 4-6 weeks. (For S/E, C/I
and Dosage forms, see page 56)

For Staphylococcal infection

Methicillin–susceptable:
Cloxacillin, 2 g i.v. every 4 hours for 4-6 weeks,
(For S/E, C/I and Dosage forms, see page 57)

Methicillin – resistant:
Vancomycin, 15mg/kg i.v. every 12 hours for 4 weeks.
(For S/E, C/I and Dosage forms, see page57)

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TETANUS
It is s a neurologic syndrome caused by a neurotoxin elaborated by Clostridium
tetani at the site of injury. It can largely be prevented by appropriate
immunization. The most common and important clinical features include
trismus (lockjaw), localized or generalized muscular rigidity and spasm. The
presence of arrythmia, extreme oscillation in blood pressure, diaphoresis,
laryngeal spasm and urinary retention may suggest autonomic dysfunction.

Diagnosis is usually established on clinical grounds. .

Treatment
Non-drug treatment:
- Admit patients to a quite place, and in severe cases, to MICU if
possible for a continuous cardio-pulmonary monitoring.
- Wound care which includes thorough cleansing and debridment
- Intubation or tracheostomy, in severe cases.
Drug treatment
A. Control of spasm-
Diazepam, 10 mg i.v should be given every 4 hourly, the dose being
titrated depending on the response. Large doses as much as 250 mg a day
could be used.
S/E: drowsiness, fatigue, hypotension, paradoxical excitement .
C/I: acute pulmonary insufficiency.
Dosage forms: tablet, 2 mg, 5 mg, 10 mg; suppository, 5 mg, 10 mg;
injection, 5mg/ml in 2ml ampoule.
PLUS
Chlorpromazine, 25-50 mg i.m every 6 hourly alternated with diazepam.
S/E: bone marrow suppression, drowsiness, apathy, alteration in liver
function, cutaneous reactions, occasionally tardive dyskinesia.

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C/I: bone marrow depression, coma caused by CNS depressants.

Dosage forms:- Tablet, 25mg, 50mg, 100mg; drop, 25mg/ml in 10ml
bottle, 40mg/ml in 10ml and 30ml bottles; syrup, 25mg/5ml; injection,
25mg/ml in 1ml and 2ml ampoules, 50mg/ml in 2ml ampoule.
B. Antibiotic treatment:
Metronidazole, 500 mg p.o. tid for 7-10 days
(For S/E, C/I and Dosage forms, see page 24)
C. Neuromuscular blockade
Suxamethonium, 20-100 mg i.v. depending on the effect with
mechanical ventilation may be employed inpatients with severe
laryngeal spasm.
S/E: tachycardia, hypertension or hypotension; bronchospasm,
apnoea, prolonged respiratory depression.
C/I: family history of malignant hypertension; severe liver disease.
Dosage forms: powder for injection, 100 mg, 500mg in vial
D. Tetanus, Human immunoglobulin, 500 IU i.m. once and TAT 10,000 IU
i.m after a skin test.
E. Control of Autonomic dysfunction like hypertension and supra-ventricular
tachycardia can be treated with Beta-blockers.
Propranolol, 60 mg p.o daily in three-divided dose
S/E: bronchospasm, bradycardia, may mask insulin induced
hypoglycemia, insomnia, fatigue and hypertriglyceridemia.
C/I in those who have a heart block and heart failure; asthma.
Dosage forms:; Tablet, 10mg, 40mg; injection, 1mg/ml in 1ml
ampoule

N.B

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Provide active immunization with appropriate booster doses in those

who were never immunized in the past.

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TONSILLITIS
It is an acute inflammation of the tonsils, usually due to Group A
streptococcus or, less commonly, to viruses. Sore throat and pain on
swallowing are the characrestic features. Most patients will also have
headache, malaise and fever.
Diagnosis: is often clinical. Throat culture may help to establish the specific
etiology.

Treatment:
Drug treatment:
If viral:
Only symptomatic therapy.
Paracetamol, 500 mg p.o 1-2 tablets 6 hourly on p.r.n basis.
(For S/E, C/I and Dosage forms, see page 73)
If bacterial:
First line
Amoxicillin, 250-500 mg tid, p.o. for 7 days. For children: 20-
40mg/kg/day in 4 divided doses. (For S/E and C/I see page 31).
Dosage forms: capsule, 250mg, 500mg; syrup, 250mg/5ml.
OR
Ampicillin, 500mg, qid, p.o. for 7 days. For children: 50-
100mg/kg/day in 4 divided doses. (For S/E and C/I and, see page 31).
Dosage forms: Capsule, 250mg, 500mg; oral suspension, 125mg/5ml,
250mg/5ml; injection,( sodium), 250 mg, 500mg,1 g in vial.
OR
Procaine penicillin, 800,000 IU i.m daily for 5-7 days
(For S/E and C/I, see under Benzyl penicillin, page 55).

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Alternative
Erythromycin can be given in cases of penicillin allergy as 250 mg every 6
hrs for 5 days;

For children, 30-50 mg/kg/day in 4 divided doses.

(For S/E, C/I and dosage forms, see page 31)
Prophylaxis
Benzathine penicillin, 1.2 million units im once monthly. For
individuals with known valvular heart disease and rheumatic fever,
such treatment should continue for a prolonged period.
(For S/E and C/I, see page 55)
Dosage forms: Vials, 0.6 , 1.2 and 2.4 million IU

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TOXOPLASMOSIS (CNS)

CNS Toxoplasmosis is an infection of the central nervous system by the

protozoan Toxoplasma gondii. The disease develops in individuals with
underlying immunodeficiency, usually occurring as a reactivation.

Diagnosis: Clinical and Neuro-imaging (CT scan or MRI of the brain).

Serology test for anti-toxo Ig-G antibody. If negative, it may help to exclude
the diagnosis. On the other hand positive test or high titer for Ig-M would
suggest a more recent infection.

Treatment:
First line
Sulfadiazine, 1-2g p.o.q 6h for six weeks
S/E: crystal urea, rash
C/I: severe liver, renal and hematological disorders, known
hypersensitivity to Sulfonamides, children under 6 years old
Dosage forms: tablets, 500mg.
PLUS
Pyrimethamine, 25-100mg, p.o. q.i.d.
S/E: Rash, fever, neutropenia
C/I: folate deficiency
Dosage forms: Tablets, 25mg.
PLUS
Folinic acid, 10-20 mg p.o. qid for six weeks
S/E: allergy
C/I: pernicious anaemia
Dosage forms: Tablet, 500mg.
Followed by
Maintenance pyrimethamine, 25mg/day p.o.
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PLUS
Sulfadiazine, 1g, p.o. 6 hrly and Folinic acid, 10-20 mg p.o. qid.
Folinic acid (For S/E, C/I and Dosage forms, see page 88)

OR
Sulfadoxine/pyremethamine, 1000 mg/50 mg, p.o. bid for two days,
then one tablet/day for life.
(For S/E, C/I and Dosage forms, see page 37)
PLUS
Folinic acid, 10-20mg ,p.o. per day
OR
Clindamycin, initially 200-400mg i.v. q6h
(For S/E, C/I and Dosage forms, see page 63)
PLUS
Pyrimethamine, 25-100 mg/day p.o. plus folinic acid, 10-20 mg/day
p.o.
(For S/E, C/I and Dosage forms, see page 88)
Followed by
Clindamycin, 300-900 mg, p.o. q8h plus pyrimethamine25-
100mg/day
(For S/E, C/I and Dosage forms, see on page 63)

Comments:
• Administration of Dexamethasone is recommended in
patients with altered sensorium and clinical evidence of
marked increase in intra-cranial pressure.

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TRACHOMA
Refers to a chronic form of conjunctivitis caused by Chlamidia trachomatis. It
is characterized by a progressive conjunctival follicular hyperplasia, corneal
neo-vascularization, and scarring of the conjunctiva, cornea and eyelids.
Trachoma is the most important preventable cause of blindness in the world.
Diagnosis: is often made on the typical physical signs. Two of the following
four criteria are diagnostic:
• Lymphoid follicles on the upper tarsal conjunctiva
• Typical conjunctival scaring
• Vascular pannus
• Limbo follicles
Chlamidia trachomatis may be isolated from culture of the conjunctival
discharge. .

Non-Drug treatment.
• Wash and keep the eye clean
• Limit irritation from glare

Drug treatment
First line:
Tetracycline eye ointment, 1%, or Tetracycline eye drops, 0.5 –
1% twice daily for 6-8 weeks. (Drops: apply 2 drops into each eye
twice daily)
(For S/E and C/I , see page 32)
Dosage forms: Drops -6ml (0.5%, 1%). Ointment -3.5gm (1%).
OR
Doxycycline, may be added 100 mg twice daily for 7 days. (For S/E,
C/I and dosage forms , see page 33).

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Alternative:
Chloramphenicol eye drops, 0.5 % 4-6 hourly or Chloramphenicol eye
ointment, 1 % 4-6 hourly for the same duration mentioned above. (For S/E
and C/I, see page 36)
Dosage forms: Drops-5ml, 10ml (0.5%).
In severe and complicated cases, refer to an ophtalmologist.

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TUBERCULOSIS
Tuberculosisis a chronic bacterial infection caused by a group of bacteria,
Mycobacteriaa, the most common of which is Mycobacterium tuberculosis.
Less frequently, it can be caused by Mycobacterium bovis and Mycobacterium
africanum. The clinical picture is quite variable and dependens on the specific
organ affected by the disease. Although the lung is the most commonly
affected organ, almost all parts of the body can be infected with this bacterium.
HIV infection has now become one of the most important risk factors for the
development of active tuberculosis.

Diagnosis:
Smear microscopy remains the most important diagnostic tool. Histo-pathology
and radiography are also helpful, particularly in those patients who do not
produce sputum.

Treatment:
The treatment of tuberculosis has now been standardized by putting patients
into different categories based on the smear status, seriousness of the illness
and previous history of treatment for TB. Accordingly, the national TB control
program office has adopted the following treatment guidelines, in which

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the different forms of tuberculosis are categorized and their respective

regimens recommended.

Category I.
Includes those new patients who have smear-positive Pulmonary TB and those
who are seriously ill; smear-negative Pulmonary and Extra-pulmonary TB
cases.
The treatment regimen for this category is 2 S (RHZ) / 6 (EH) or 2 (ERHZ) /
6EH.

Table 8. SCC regimen for new cases: 2(RHZ)/6(EH) or 2(ERHZ)/ 6EH

Adolescents and adults
Duration of
Drugs Pre-treatment weight
Treatment
20-29 30-37 38-54 >55 kg
kg kg kg

Intensive phase (RHZ) 1 2 3 4

(8 weeks) 150/75/400
S or 1 ½ g im ¾ g im ¾g im 1 g im
E 400 1 1½ 2 3
Continuation phase
(EH) 400/150
(6months)
1 1½ 2 3
• For patients >50 years, the maximum dose of Streptomycin should not exceed
750 mg.
• During the intensive phase of DOTS, the drugs must be collected daily and
must be swallowed under the direct observation of a health worker. During the

1
Streptomycin should not be given to pregnant women and must be replaced
by Ethambutol.

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continuation phase, the drugs must be collected every month and self-
administered by the patient.
Table 9. SCC regimen for children of 6 years or below and seriously ill
children 7–14 years old: 2S(RHZ)/4(RH) or 2(RHZ)/4(RH)
Child pre-treatment weight
Duration of treatment Drugs < 7 kg 7- 10-12 13-19
9 kg kg
kg
Intensive phase RHZ ½ ¾ 1
-
(8 weeks) 150/75/400
S2 - ¼ gm ¼ gm
-
im im
Continuation phase (4
RH 150/75 - ½ ¾ 1
months)
• S is to be used as the fourth drug in the intensive phase if the child is
smear-positive or seriously ill.
• During the intensive phase of DOTS, the drugs must be taken under the
direct observation of a health worker or the mother. During the intensive
phase, the mother can collect the drugs on a weekly basis. During the
continuation phase, the drugs must be collected every month and taken
under the direct observation of the mother.
Category II
This category is applied to a group of TB patients:
• Who relapsed after being treated and declared free from the disease,
OR
• In those patients who are previously treated for more than one month
with SCC or LCC, and found to be smear positive up on return, OR
• Who still remains smear positive while under treatment ,at month five
and beyond.

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• The treatment regimen for this category is: 2 SE (RHZ) / 1E (RHZ) / 5

E3 (RH)3.
Table 10. Re-treatment regimen: 2 SE (RHZ) / 1E(RHZ) / 5E3(RH)3 3
Adolescents & adults pre-
treatment weight
Duration of 20-29 30-37 38-54 > 55
Drugs
Treatment kg kg kg kg
RHZ
150/75/400 1 2 3 4
½ gm ¾ gm ¾ gm 1 gm
Intensive phase S im im im im
(8 weeks)
E 400 1 1½ 2 3
RHZ
150/75/400 1 2 3 4
Intensive phase
(third month) E 400 1 1½ 2 3

Continuation RH 150/75 1½ 2 3 4
phase H 100 ½ 1 2 3
(5 months, 3 x
weekly) E 400 1 1 3 4
• Streptomycin should not be included in the re-treatment for pregnant women.
• Throughout the duration of re-treatment, including the continuation phase, the
drugs must be taken under the direct observation of a health worker.

3
5E3(RH)3 = 5 'months' (20 weeks) of treatment with a combination of E, R
and H, three times a week on alternate days (e.g. Monday, Wednesday,
Friday, etc.)

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Category III
This refers to patients who have smear negative Pulmonary TB, Extra-
pulmonary
TB and TB in Children.
The regimen consists of 8 weeks treatment with, Rifampicin, Isoniazid and
Pyrazinamide during the intensive phase followed by Ethambutol and Isoniazid
six months [2(RHZ)/6(EH)].

Table 11. Short course chemotherapy regimen for smear-negative PTB

and EPTB: 2 (RHZ) / 6(EH). For children < than 20 kg see dosage in
table 5.

Children & adults pre-treatment

weight
Duration of
20-29 30-37 38-54 >55kg
Treatment Drugs
kg kg kg
RHZ
Intensive phase 150 / 75 /
1½ 2 3 4
(8 weeks) 400
Continuation
EH 400 /
phase
150 1 1½ 2 3
(6 months)

Long course chemotherapy (LCC):

Table 12. Long course regimen for TB: 2 S (EH) / 10 (EH)

Duration of Child, adolescents & adults pre-

treatment Drugs treatment weight (kg)
10- 20- 30- 38- ≥55
<9 19 29 37 54
Intensive phase S (gm) .125 .25 g .5 g .75 g .75 g 1g
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(8 weeks) EH
400/150 1 1.5 2 3
Continuation EH
phase 400/150 1 1.5 2 3
(10 months)
• For patients > 50 years, the dose of Streptomycin should not exceed 750 mg
• Streptomycin should not be given to pregnant women. These patients must be
treated with EH for 12 months. Preferably all pregnant women should be
treated with SCC (with Ethambutol instead of Streptomycin).
• Children in this group, who are 6 years or below, only receive H in the
continuation phase. Children older than 6 years may receive E and H, but have
to be regularly asked if they have complaints of visual problems.
• Long course chemotherapy may be preferred in case of jaundice or in patients
with underlying serious liver disease.

Category IV

Treatment of chronic cases

Chronic cases can be described as those cases that continue to be smear-
positive after completion of a fully supervised (initial phase and continuation
phase) treatment with the treatment regimen. These patients are considered
essentially incurable with currently available regimens in Ethiopia. As these
patients cannot yet be effectively cured, family members should be advised as
to how to prevent transmission.

Treatment of special cases

Treatment during pregnancy and breast-feeding
Note the following:

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Inquire about possibility of pregnancy before starting as well

as during, TB treatment of women in the childbearing age
Preferably all pregnant women should be treated with DOTS.
Avoid Streptomycin because of the risk of toxic effects on
the fetus. Replace Ethambutol in place of Streptomycin.
Breast-feeding and chemotherapy should not be
discontinued.
When a breast-feeding mother has PTB, the infant should,
regardless of prior vaccination with BCG, be given chemo-
prophylaxis and then be vaccinated with BCG if not
vaccinated before.

Treatment of patients also infected with HIV

Patients infected with HIV usually respond equally well to TB treatment as
those without HIV infection, with a few exceptions:
They should always be treated with short course chemotherapy.
Use new and disposable syringe for each injection.
Initiation of ART in the course of treatment for tuberculosis should follow the
WHO guidelines (see table 13).

Table 13. Antiretroviral therapy for individuals with tuberculosis co-

infection
Situation Recommendations
Pulmonary TB and CD4 Start TB therapy. Start one of these ART's as
count < 50/mm3 or extra- soon as TB therapy is tolerated:
pulmonary TB ZDV/3TC/ABC
ZDV/3TC/EFZ
ZDV/3TC/SQV/r
ZDV/3TC/NVP
Pulmonary TB and CD4 Start TB therapy. Start one of these regimens

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50-200/mm3or total after completing 2 months of TB therapy:

lymphocyte ZDV/3TC/ABC
count below 1200/mm3 ZDV/3TC/EFZ
ZDV/3TC/SQV/r
ZDV/3TC/NVP

Pulmonary TB and CD4 Treat TB. Monitor CD4 counts if available.

> 200/mm3 or total Start ART according to Annex-5 after
lymphocyte count> completion of TB treatment.
1200/mm3

Note:
• WHO recommends that people with TB/HIV complete their TB therapy
prior to beginning ARV treatment, unless there is a high risk of HIV
disease progression and death during the period of TB treatment (i.e. a
CD4 count < 200/mm3 or disseminated TB is present).
• If a non-nucleoside regimen is used, EFZ would be the preferred drug as
its potential to aggravate the hepatotoxicity of TB treatment appears less
than that of NVP. However, its dosage needs to be increased to
800mg/day.
• Except for SQV/r, protease inhibitors are not recommended during TB
treatment with rifampicin due to interactions with the latter drug.

Treatment of patients with renal failure

Avoid Streptomycin and Ethambutol; give 2 RHZ / 4 RH.

Treatment of patients with (previously known) liver disease (e.g. hepatitis,

cirrhosis)
1. The dose of Rifampicin for these patients should not exceed 8mg per kg and
for Isoniazid it should not exceed 4 mg per kg. In the case of jaundice, the
treatment regimen should be changed to 2 SEH /10 EH.
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2. All drugs should be taken together as a single daily dose, preferably on an

empty stomach.

Treatment of patients with TB and leprosy

Patients having both TB and leprosy require appropriate anti-TB chemotherapy

in addition to the standard MDT. Rifampicin will be common to both regimens
and it must be given in the doses required for TB. Once the anti-TB course is
completed, the patient should continue his anti-leprosy treatment.

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Table 14. Symptom-based approach to management of anti TB drug side

effects.

Side-effects Drugs Management

Anorexia, Give tablets as last
Rifampicin
a. Minor nausea, thing at night.
abdominal pain.
Joint pains Pyrazinamide Aspirin
[Continue anti Burning Pyridoxine 100mg
Isoniazid
TB drugs] sensation in feet. daily.
Orange/red urine Rifampicin Reassurance
Stop streptomycin,
Deafness Streptomycin use ethambutol
instead.
Stop streptomycin,
Dizziness Streptomycin use ethambutol
b. Major instead.
Most anti-TB Stop all anti-TB
Jaundice
drugs drugs and jaundice
clears.
[Stop drug(s) Vomiting and Most anti-TB Stop all anti-TB
responsible] confusion. drugs drugs until the
situation improves.
Stop ethambutol and
Visual Ethambutol
do proper ophthalmic
impairment.
evaluation.
Shock, purpura
Rifampicin Stop Rifampicin and
and acute renal
give appropriate
failure.
supportive Rx..

N.B
List of drugs used for the treatment of TB in Ethiopia:
Streptomycin (S) 1 gm (vial)
Ethambutol (E) 400 mg tablet
Isoniazid (H) 100 mg, 300 mg tablet
Rifampicin (R) 150 mg, 300mg tablet

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Pyrazinamide (Z) 500 mg tablet

Drugs available in fixed dose combination (FDC) are:
Rifampicin, Isoniazid and Pyrazinamide (RHZ) 150/75/400 mg
Ethambutol and Isoniazid (EH) 400 /150 mg.
Rifampicin and Isoniazid (RH) 150 /75 mg.

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TYPHOID FEVER
Typhoid fever is an acute febrile illness caused mainly by Salmonella typhi.
The mode of transmission is via contaminated food or water. It is clinically
characterized by a gradual increase in body temperature associated with
headache, malaise and chills. Sometimes it may cause outbreaks.
Diagnosis
• Culture of blood, stool or urine
• Serological examination, such as the Widal test is also helpful
Treatment
Symptomatic treatment
Use of antipyretics, e.g. paracetamol to control fever
Drug treatment
First line:
Chloramphenicol, 500mg p.o. q.i.d, for 14 days: For children:
25mg/kg. (For S/E, C/I and dosage forms, see page 36)
Alternative:
Amoxicillin, 1g, qid p.o., for children: 20 – 40 mg/kg/day p.o.in 3
divided doses for 14 days. (For S/E, C/I and dosage forms, see page
31)
OR
Sulfamethoxazole + trimethoprim, 800 mg/160 mg p.o. bid for 14
days. For children 6 weeks – 5 months, 100/20 mg; 6 months – 5 yrs,
200/40 mg; 6 – 12 yrs, 400/80 mg bid (For S/E, C/I and dosage
forms, see page 283)
OR
Ceftriaxone, 1g daily as a single dose or 2 divided doses i.m. or iv for
5-7 days. For children: 20-50mg/kg/day as a single dose or 2 divided
doses i.m. or slow iv

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(For S/E, C/I and dosage forms, see page 29)

OR
Ciprofloxacin, 500 mg p.o, twice daily for 7 days
(For S/E, C/I and dosage forms, see page 28 )

For severe cases:

Chloramphenicol, 1g, IV bolus every 6 hrs, until 48 hrs after fever has settled,
followed by 500 mg p.o., qid for a total of 14 days. For children: 25mg/kg, iv.
bolus every 6 hrs, until 48 hrs after fever has settled, followed by 525 mg/kg
p.o., qid for a total of 14 days. (For S/E, C/I and dosage forms, see page 36)

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TYPHUS
Thyphus is a ricketisial disease, which causes an acute febrile illness
characterized by an abrupt onset of fever, severe headache and prostration.
Important differential diagnosis includes relapsing fever, bacterial meningitis,
and thyphoid fever. It is a disease commonly seen among destitute individual
with poor personal hygiene.
Diagnosis is by Weil Felix serology test.

Treatment
Tetracycline, 250mg, qid p.o. for 7 days
(For S/E, C/I and dosage forms, see page 32)
OR
Chloramphenicol, 500mg p.o. qid, for 7 days: For children: 25mg/kg.
(For S/E, C/I and dosage forms, see page 36)
OR
Doxycycline, 200mg in a single or 2 divided doses for seven days
(For S/E, C/I and dosage forms, see page 33)

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URINARY TRACT INFECTION

UTI refers to inflammation of the urinary tract, which includes the renal
parenchyma (pyelonephritis), the bladder (cystitis), the prostate in males
(prostatitis) and the urethra (urethritis). The range of possible symptoms caused
by UTI is extremely broad, from no symptoms to symptoms referable the lower
urinary tract (e.g. dysuria and frequency), to symptoms indicative of an upper
UTI (e.g. loin pain and costo-vertebral angle tenderness), to full-blown septic
shock. The vast majority of acute symptomatic infections occur in young
women. Acute symptomatic urinary infections are unusual in men under 50. It
is also important to note that asymptomatic bacteriuria is very common in
elderly men and women. Escherichia coli causes approxmatley 80 % of acute
infections in patients without catheters, stone or other urologic abnormalities.
On the other hand, organisms like klebsiella, enterobacteria, proteus, serratia
and psuedomonas assume greater importance in recurrent infections and
infections associated with urologic manipulations as in catheter associated
nosocomial infections.

Diagnosis: Clinical
Urine analysis and Gram stain showing pyuria and
bacteriuria
Urine culture. Bacterial colony count of 105 organisms per
milliliter or greater in urine generally indicates urinary tract
infection.

Treatment
A) Acute, Uncomplicated UTI in women :
First line:

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Sulfamethoxazole+trimethoprim, 800mg/160 mg p.o. bid, for 3-5

days.
(For S/E, C/I and Dosage forms, see page 283)
Alternative
Norfloxacin, 400mg p.o. bid, for 3-5 days. .
S/E: mild GI upset; rash and pruritus; hypersensititvity reactions
including fever, joint pain, urticaria. Discontinue the drug if
psychiatric, neurological or severe hypersensitivity reactions occur.
C/I: renal impairment, pregnancy
Dosage forms: tablet, 400mg

OR
Amoxicillin, 250-500mg, tid, p.o. for 3-5 days. For children: 20-40
mg/kg/day in 4 divided doses. (For S/E, C/I and Dosage formssee
page 31)

B). Acute, Uncomplicated Upper UTI (Pyelonphritis) in women:

The same antibiotics used for Lower UTI could be used, but the
period of treatment should extend for 7-10 days.
N.B. 1. In severe cases, antibiotics should be given parentrally for the
first 48-72 hours.
2. In severe cases addition of aminoglycosides like Gentamycin
could be considered

C.) UTI in Men:

First line:
Sulfamethoxazole+trimethoprim, 800 mg/160 mg p.o. bid, for 10-
14 days.

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(For S/E, C/I and Dosage forms, see page 283)

Alternative
Norfloxacin, 400 mg po bid, for 10-14 days. .
(For S/E, C/I and Dosage forms, see page 106)
OR
Amoxicillin, 250-500 mg tid, p.o. for 10-14 days. For children: 20-
40mg/kg/day in 4 divided doses. (For S/E , C/I and Dosage forms see
page 31)

D. For recurrent and resistant cases of UTI:

An intensive urologic evaluation is mandatory and antibiotic choice

should be guided by drug sensitivity test from urine culture.

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Chapter 3

SEXUALLY TRANSMITTED INFECTIONS

Anogenital warts
Chancroid
Genital candidiasis
Genital herpes
Gonorrhea
Lymphogranuloma venereum (LGV)
Nongonococcal Urethritis
Syphilis
Trichomoniasis

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ANO-GENITAL WARTS
Genital Warts (mainly Condylomata Acuminata) are most commonly
associated with HPV 6 and 11. The warts usually appear 1 to 6 months after
infection. Initially they appear as tiny soft, moist, pink or red swellings which
grow rapidly and may develop stalks; later on, they become confluent giving
the appearance of cauliflower.
Diagnosis:
• Clinical
• Histo-pathological, if required
Treatment
No treatment is completely satisfactory; eradication is difficult because of the
surrounding subclinical infection.
First line:
Podophyllin paint 25%, applied sparingly to each wart and allowed
to air dry. The compound is washed off 1 to 4 hours after application
(maximum time of stay on the treated area should not exceed 6 hours).
Apply twice daily for 3 consecutive days; such three-day courses of
treatment may be conducted at weekly intervals, if required.
S/E: Local irritation; hypokalemia, peripheral neuropathy, bone
marrow suppression and coma may occur due to systemic absorption.
C/I: Pregnancy, breast feeding; children.
Dosage form: Podophyllin paint ,25%
Caution: Do not apply to open wounds and the face. Very irritant to
the eyes; not recommended for cervical, vaginal or intraurethral warts.
Application to a large area could result in systemic absorption and
toxicity.

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Alternative therapy:
Surgical:
Cryotherapy with liquid nitrogen or cryoprobe applied for 2 or 3
courses
OR
Curettage or electro surgery
OR
Surgery using local anesthetics: shave or scissors excision.

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CHANCROID
Chancroid is caused by the Gram-negative bacillus Haemophilus ducreyi. It
produces a characteristic ulcer that is soft, friable and non-indurated with
ragged undermined margin and is foul-smelling. The ulcer is covered with
yellow-gray exudates surrounded by erythema. Within 1-2 weeks, painful
inguinal lymphadenitis, more often unilateral, develops in 30% to 60 % of
cases. 25% of cases have progression of the lymphadenitis into a suppurative
bubo which may spontaneously rupture and develop ulceration.
Diagnosis:
- Gram stain
- Culture is required for a definitive diagnosis
Drug Therapy:
First line
Erythromycin, 500 mg p.o, 4 times daily for 7 days
(For S/E, C/I and Dosage forms, see page 31)
OR
Ciprofloxacin, 500 mg p.o., twice daily for five days
(For S/E, C/I and Dosage forms, see page 28)
Alternative:
Ceftriaxone, 250mg i.m. as a single dose
(For S/E, C/I and Dosage forms, see page 29)
OR
Sulfamethoxazole + Trimethoprim, 480 mg p.o. bid for 7 days
(For S/E, C/I and Dosage forms, see page 283)
Note:
Approximately 10% of patients with chancroid are co-infected with T.
pallidum or HSV, which warrants evaluation for such co-existent
infections.

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GENITAL CANDIDIASIS
Genital candidiasis is caused by Candida albicans. The presenting features
differ in men and women. Genital candidiasis in women is characterized by
itching or irritation of the vagina and vulva. There may be a light vaginal
discharge and the vaginal wall is usually covered with a white cheese-like
material. In men the disease often has no symptoms; rarely the end of the penis
(the glans) and the prepuce (in uncircumcised men) may be sore and irritated.
Diagnosis: wet smear
Treatment
Non-drug treatment:
• washing the vagina with soap and water and drying with a clean towel

Drug treatment:
First line:
Clotrimazole cream (vaginal), 1% applied intra-vaginally for 3-14
days
OR
Clotrimazole pessary, 100 mg and 500 mg; insert into the vagina 100
mg pessaries for 6 nights, or 200 mg pessaries for 3 nights, or 500 mg
pessaries for one night.
S/E: local irritation, possibly including burning, oedema, erythema.
Dosage forms: cream (vaginal), 1%; tablet (vaginal insert), 100mg,
500 mg.

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OR
Nystatin pessary, 100,000Units; 1 or 2 pessaries are inserted into the
vagina for at least 14 nights (and when necessary up to 28 nights).
They may be supplemented with the cream for vulvities and to treat
other superficial sites of infection.
S/E: nausea, vomiting, diarrhoea at high doses.

Dosage forms: cream (vaginal), 100,000 units/gm.; pessary, 100,000

units/gm;
Alternative
Ketoconazole, 200mg once daily with food, usually for 14 days
(extended for one more week if response is inadequate).
S/E: nausea, vomiting, abdominal pain, headache, rashes, urticaria,
pruritus.
C/I: hepatic impairment, porphyria.
Dosage form: tablet, 200mg; syrup,100mg/5ml.

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GENITAL HERPES
Genital herpes, which is caused by HSV-2, is one of the commonest causes of
painful genital ulcers. The first symptoms of itching, tingling and soreness, that
begin 4 to 7 days after infection, are followed by patches of redness on which
develop painful vesicles. The vesicles break and fuse to form circular, painful
sores that become crusted after a few days.
Diagnosis is clinical.

Drug Treatment:
First line:
Acyclovir, 200mg p.o. 5 times daily for 5 days. Child under 2 years,
100mg. p.o. 5 times daily for 5 days; over 2 years, same dose as adult.
S/E: rashes, gastrointestinal disturbances rises in bilirubin and liver
related enzymes, increases in blood urea and creatinine, decreases in
haematological indices, headache, fatigue.
C/I: current administration of steroids.
Dosage forms: Tablet, 200mg; ointment, 3.5 gm.
AND/OR
Acyclovir ointment, applied to the lesion every 4 hours for 5 days,
started at first sign of attack.
Dosage form: 5% ointment, 3.5gm.

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Note:
• Therapy is continued until clinical resolution is obtained although
some physicians recommend treatment for duration of 7 to 10 days.
• Acyclovir cream may be applied 4 to 5 times daily directly on the
sore.

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GONORRHEA
Gonorrhea is caused by the Gram-negative diplococcus Neisseria gonorrhea.
Its incubation period is 2-10 days. The clinical features are: urethritis with
dysuria and mucopurulent discharge (may be asymptomatic in a large
proportion of females), prostates, salpingitis and PID.
Diagnosis:
• Gram stain will classically reveal Gram-negative intracellular
diplococci.
• Culture
Drug treatment
1. Gonococcal Urethritis
First line
Spectinomycin, 2 gm by deep i.m. injection as a single dose.
S/E: nausea, dizziness, urticaria; pain at site of injection.
Dosage forms: Powder for solution for injection, 2g in vial.
OR
Ciprofloxacin, 500 mg orally as a single dose.
(For S/E, C/I and Dosage forms, see page 28)
Alternative:
Ceftriaxone, 250 mg i.m. as a single dose
(For S/E, C/I and Dosage forms, see page 29)
OR
For patients who cannot take tetracycline (e.g. pregnancy)
Erythromycin base or stearate, 500 mg orally 4 times a day for 7 days
(For S/E, C/I and Dosage forms, see page 31)

Management of sex partners: Persons exposed to gonorrhea within the

preceding 30 days should be examined and treated presumptively.

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Treatment failures:
• Persistence of symptoms after treatment should be evaluated by
culture (and sensitivity) and treated appropriately.
• Re-infection, rather than treatment failure, is commoner and indicates
a need for improved sex partner referral and patient education.
2. Disseminated Gonococcal Infection (DGI)
Approximately 1 to 2% of patients with gonorrhea develop disseminated
infection. Gonococcal dissemination typically develops within 2 to 3 weeks
after first infection. Commonly infects the superficial mucous membranes.
Treatment is best started after admission of the patient to hospital with
intravenous antibiotics for the initial therapy.

First Line:
Ceftriaxone, 1 gm, i.m. or i.v. every 24 hours for 7 days
(for S/E, C/I and dosage forms, see page 29)
Alternative:
Cefotaxime or Cefuroxime i.v.1 gm every 8 hours for 7 days
(For S/E, C/I and Dosage forms, see under ceftriaxone, page 29)

OR
For patients who are allergic to β-lactam drugs,
Ciprofloxacin, 500 mg b.i.d. for 7 days
(For S/E, C/I and dosage forms, see page 28)
OR
Spectinomycin, 2 g (4 g in severe cases) i.m. b.i.d. for 3-7 days
(For S/E and dosage forms, see page 115)
Note:

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The i.v. or i.m. antibiotic should be continued for 24 to 48 hours after

symptoms are resolved. The patient is then discharged with one of the
following oral antibiotics for a total of one week:
Cefuroxime, 400 mg b.i.d for 7 days
OR
Ciprofloxacin, 500 mg b.i.d for 7 days
(For S/E, C/I and dosage forms, see page 28)
Because concurrent chlamydial infections occur in approximately half of the
cases, the patient should be presumptively treated for chlamydial infection with
oral tetracycline or doxycycline (see under NGU).

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GRANULOMA INGUINALE (DONOVANOSIS)

Granuloma Inguinale (GI) is caused by a gram negative, facultative, obligate
intracellular bacillus, Calymmatobacterium granulomatis. After an incubation
period of 8 days to 12 weeks (most commonly 2 weeks), single or multiple
subcutaneous nodules or papules develop at the sites of inoculation. The
lession(s) enlarge and erode to form painless ulcerations with clean, friable
bases and distinct, raised, rolled margins. Several lesions may become
confluent, with persistent extension. Without treatment, progressive mutilation
and destruction of local tissue results.
Diagnosis: Direct visualization of inclusion bodies (Donovan bodies) by
Wright stain or Giemsa stain may be required for definitive diagnosis.
However the diagnosis if often made clinically.

Drug Treatment:
First line:
Doxycycline, 100 mg p.o. twice a day for 15 days.
(For S/E, C/I and Dosage forms, see page 33)
OR
Erythromycin, 500 mg p.o. four times a day for 15 days.
(For S/E, C/I and Dosage forms, see page 31)
OR
Ciprofloxacin, 750mg p.o., twice a day for three weeks.
(For S/E, C/I and Dosage forms, see page 28)
Note:
• If lesions still persist, the above regimens should be continued until all
lesions thoroughly heal.
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• If the lesions do not appear to be responding within the first few days
of antibiotics, the addition of an aminoglycoside can be considered.
• Even with effective therapy, relapse may occur within 6 to 18 months.
• Gentamicin (1mg/kg iv every 8 hours) should be strongly considered
in HIV-positive patients.

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LYMPHOGRANULOMA VENEREUM (LGV)

LGV is an uncommon sexually transmitted disease accounting for 2 to 10% of
genital ulcer disease. It is caused by the obligate intracellular bacterium
Chlamydia trachomitis, specifically serotypes L1, L2, and L3, which are more
invasive and virulent when compared with the other chlamydia serotypes.
The course of the disease in LGV consists of 3 separate stages (primary,
secondary and tertiary stages). The Primary stage begins with small painless
papulo-pustules that may erode to form a small asymptomatic herpetiform
ulcer. The secondary stage consists of painful inflammation and infection of
the inguinal and/or femoral lymph nodes.
Approximately 1/3 of patients develop “groove sign”. The painful lymph
nodes, known as buboes, may become fluctuant and rupture in 1/3 of patients.
The tertiary stage of the disease is more often present in women and is
characterized by rectal involvement (genito-anorectal syndrome)
Diagnosis is made by isolation of the organism on culture using specific
cyclohexamide treated McCoy cells or diethylamine treated Hela cells and cell
typing of the isolate.

Drug Treatment:
First line:
Erythromycin, 500 mg p.o. 4 times daily for 15-21 days.
(for S/E, C/I and Dosage forms, see page 31).
OR
Sulfamethoxazole + Trimethoprim, 480 mg p.o. bid. for 7 days
(For S/E, C/I and dosage forms, see page 28, 283)
Note:

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Aspiration or incision and drainage of fluctuant lymphnodes may be

required for prevention of ulcer formation and the relief of inguinal
pain.
NON GONOCOCCAL URETHRITIS (NGU)
NGU is usually caused by Chlamydia trachomitis (obligate intracellular
parasites), but occasionally Ureaplasm urealyticum and Trichomonas vaginalis
may be the causative microorganisms.

Diagnosis of Chlamydia trachomitis is made with the help of

immunofluorescent test and cell culture. .

Drug Treatment:
First line
Tetracycline, 500 mg p.o. q.i.d. for 7 days
(For S/E, C/I and dosage forms, see page 31)
OR
Doxycycline, 100 mg p.o. b.i.d. for 7 days
(For S/E, C/I and dosage forms, see page 33)
Alternative:
Ciprofloxacin, 500mg p.o, twice a day for 7 days.
(For S/E, C/I and Dosage forms, see page 28)

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SYPHILIS
Syphilis is a chronic, contagious disease caused by the spirochaete Treponema
Pallidum. The incubation period may vary from 9 to 90 days. The clinical
picture depends on the stage of the disease. The classical painless chancre at
the site of the inoculation characterizes the primary stage of the disease. The
secondary stage characterized by eruption of papulomacular, non-pruritic
lesions involving both the skin and mucous membrane. Late symptomatic
(tertiary) syphilis often presents many years after inoculation. This stage of
syphilis may have mucocutaneous manifestations, such as superficial nodular
lesion, painless cutaneous gumma, destructive and granulomatous lesions
involving mainly the nervous and cardiovascular system.
Latent syphilis
• Characterized by positive serologies without any concurrent signs and
symptoms of infections.
• Individuals may remain asymptomatic for life, even though the T.
pallidum organisms continue to multiply.
• Despite no treatment, only 1/3 of these cases progress to late
symptomatic (tertiary) syphilis.
Diagnosis:
• Clinical
• Microscopy - by dark field examination or direct immunofluorescent
microscopy
• Serology
i. Specific treponemal tests such as TPHA or FTA-Ab
ii. Nonspecific treponemal tests

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a. the Venereal Disease Research Laboratory

(VDRL) test
b. the Rapid Plasma Region (RPR) test

Note:
a. With both tests (VDRL and RPR), the titer results correspond with
disease activity and should reduce four fold within 6 to 12 month
after treatment and become undetectable several years thereafter.
b. False positive results occur in collagen vascular disease, advancing
age, narcotic drug use, chronic liver disease, several chronic diseases
such as tuberculosis or HIV and several acute infections such as
Herpes
c. Therefore, positive results should be confirmed by the following
specific (treponemal) tests:
• Microhemagglutination assay for T.Pallidum (MTA - TP)
• Fluorescent treponemal antibody absorption tests (FTA -
ABS) and
• TPHA
In secondary Syphilis, all serologies should be reactive, whereas in late syphilis
nontreponemal tests may be negative or weakly positive (reactive) whereas
treponemal tests are usually reactive.

Drug Treatment:
First Line:
Primary, secondary and latent phase (infection less than one year):
Benzathine penicillin G, 2.4 million IU, as a single i.m.
injection
(For S/E, C/I and Dosage forms, see page 55)
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Alternative:
In case of penicillin allergy, Erythromycin, 500 mg four times a day
for 7 days.
(For S/E, C/I and Dosage forms, see page 31)
OR
Doxycycline, 100 mg p.o twice daily, for two weeks
(For S/E, C/I and Dosage forms, see page 33)
Note:
• If antibody titers do not decrease fourfold within 6 months for patients
with primary or secondary syphilis, treatment failure or re-infection
should be considered and evaluation for possible HIV infection should
be initiated
• Patients with secondary syphilis should be followed up more closely
for early detection of relapse or re-infection, with monthly follow-up
for the 1st year and quarterly visits for the 2nd year.
• Attainment of sero-negativity:
1. With early and proper treatment, primary syphilis will be
sero-negative within one year.
2. In secondary syphilis, seronegativity is attained within two
years of proper treatment.
3. Titers may not decrease as expected in late syphilis.

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TRICHOMONIASIS

Trichomoniasis is caused by a single-celled organism with a whip like tail,

Trichomonas Vaginalis. In some populations, trichomonas may account for 5
to 10% of all cases of NGU.
Diagnosis:
• Wet smear
• Culture may be required occasionally

Drug Treatment:
First Line:
Metronidazole, 500 mg p.o. b.i.d. for 7 days
(For S/E, C/I and dosage forms, see 24)

Alternative:
Metronidazole, 2 g taken as a single dose.

Note:
HIV-positive individuals with trichomoniasis should receive the same
treatment as persons who are HIV-seronegative.

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Chapter 4

SKIN PROBLEMS

Carbuncle
Cellulitis
Eczema
Erysipelas
Folliculitis
Fungal infections
Furnclules
Herpes simplex
Herpes Zoster
Impetigo Contagiosa
Molluscum contagiosum
Pediculosis pubis
Scabies
Urticria

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CARBUNCLE
Carbuncle is a deep infection of two or more confluent furuncles, with separate
heads, accompanied by intense inflammatory changes in the surrounding and
underlying connective tissues, including the subcutaneous fat. It has the same
etiology as furuncule.
Treatment

Non-Drug treatment:

For early lesions warm compresses are useful. In localized furuncles with
definite fluctuation, incision with drainage should be made.
Drug treatment:
Antibiotic therapy should begin as soon as cultures are taken. Pending
result or where there is no facility for culture, one of the following
drugs are used:
Cloxacillin or Erythromycin -dose is similar as in furuncules. (for
S/E, C/I and dosage forms, see page 57 and 31 respectively)

Treatment:
1. Topical therapy consists of application of normal saline compresses, of
1% Genitian Violet 3 to 4 times daily or topical dressing consisting of
2% Mupirocin.
2. Systemic therapy (oral or parenteral -same us for impetigo except that
the duration of therapy should be extended for 2 weeks )

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CELLULITIS
Cellulitis is an acute inflammation of the subcutaneous tissue and the skin and
occurs most commonly as a complication of a wound or ulcer or other skin
lesion but may occur also abruptly on seemingly normal skin. Differentiation
between cellulitis and erysipelas is difficult. However, erysipelas is said to
have a sharp margin and is considered to be localised superficially. Cellulitis is
caused most frequently by streptococcus pyogenes, but other bacteria such as
Haemophilus influenzae and gram-negative organisms of the Mina-Herellea
group can also cause cellulitis.
Diagnosis: Clinical
Treatment
Non-drug treatment:
Supportive care including bed rest, application of warm compresses and
elevation of an affected limb is useful.
Drug treatment:
First line
Procaine penicillin, 1.2 million IU intramuscularly daily for 10 days.
Children: 50000 IU/kg/24 hrs. in a single dose for 10 days.
If no improvement occurs within a day, penicillin resistant
staphylococcus should be suspected and semi-synthetic penicillin
(cloxacillin, 0. 5 -1 g every 4 hrs) should be administered until the
fever subsides, (usually 2-3 days). Then, Cloxacillin 500 mg p.o. QID
should be continued for 7 days. Hospitalized patients should be
treated as in erysipelas. (for S/E, C/I and dosage forms, see under
benzyl penicillin, page 55)
Alternative:
Erythromycn,, dosage similar as in erysipelas. (for S/E, C/I and
dosage forms, see page 31)
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Note:
In all children with facial or periorbital cellulites, coverage for
Haemophilus should be provided with
OR
Chloramphenicol, 50-100 mg/kg/24 hrs. divided into 4 doses for 7-
10 days.
(For S/E, C/I and dosage forms, see page 35, 36)

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ECZEMA
Atopic dermatitis is a chronically relapsing skin disease of early infancy,
childhood, adolescence and to a lesser extent also seen in adults.It consists of
erythematous papules and vesicles with a tendency to rupture and in chronic
cases is characterised by lichenification. AD is associated with severe pruritus
and resolves without leaving trace or sequelae.
Diagnosis: Clinical
Treatment
Drug treatment:
General Principles
A. Topical

In general oozing lesions should be treated with saline compresses or 1%

Genitian violet 2-3 times daily until the lesions dry (usually 2 days). Then
topical creams, pastes and ointments containing corticosteroids should be
applied once or twice daily until the lesion heals (at least one or two weeks). It
is necessary to avoid non-specific irritants (like woollen clothes).

Topical steroids should be used to treat dermatitis (eczema) until the skin
clears at which time the steroid application should be stopped
Group IV creams or ointments are used for red, scaling skin (See the table
below)
Group III creams for subacute lesions
Group I and II creams or ointments are used for chronic and lichenified skin.

Prednisone, 10-20-30mg morning dose, p.o. may be used for extensive flares
for 7-10 days.

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B. Systemic
• Consists of anti-allergic treatment with anti-histamines e.g.
promethazine, terfenadine, (for dosage see treatment of
urticaria) and in severe cases systemic corticosteroids.
• Sometimes, it may be necessary to use drugs acting on the
nervous system: neuroleptic drugs (e.g. thioridazine,
chlorpromazine - for dosage, S/E and C/I see treatment of
schizophrenia) or anxiolytic drugs (e.g. diazepam).
• There are some reports of good results of PUVA therapy in
certain centres (for resistant cases).

In general, the treatment of eczematous dermatitis depends upon the clinical

stages of the disease (acute, subacute and chronic):

i) Acute lesions require wet dressings, and application of 1% Genitian violet

2-3 times daily usually for 2 days to be followed by topical steroids.
ii) Sub-acute and chronic lesions should be treated with corticosteroid
creams or ointments. It is important to inform patients that scratching and
rubbing the skin will prolong the disorder. Hence, treatment should be directed
to stopping the pruritus, which prevents the mechanical trauma of scratching.

Antibiotics may be used in oozing lesions to suppress staphylococcal

infections. Dosage and duration of treatment is similar as in management of
other bacterial diseases (see pyoderma) .

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Potency of Topical Steroid Skin Ointments/Creams

Group I-very high potency adrenocorticoids
Generic name Strength(%)

1. Betamethasone dipropionate 0.05

2. Clobetasol propionate 0.05

Group II- High potency adreno-corticoids

Generic name Strength%
Betamethasone dipropionate 0.05

Dexamethasone 0.05-0.25

Triamcinolone acetonide 0.05

Group III- Medium potency Adreno-corticosteroids

Generic name Strength%

Betamethasone valerate 0.05-0.1

Flucortolone valerate 0.1

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Triamcinolone acetonide 0.015-0.1

Group IV- Low-potency Adeno-corticoids

Generic name Strength%
Hydrocortisone acetate 0.1-1
Methyl prednisolone 0.25-1

Use - very high potency

1. Used as an alternative to systemic aderenocorticoid therapy when

local areas
are involved.
2. Used on thick, chronic lesions of psoriasis; there is a high
likelihood of skin atrophy
3. Used for short periods of time on small surface area
4. Not used with occlusion dressing

Use- high potency Adrenocorticoids

- Used for more severe eczematons dermatoses, lichen simplex
chronicus, psoriasis, etc.
- Used for intermediate duration, with the exception of thickened areas
of skin and in chronic condition
- Used on the face or intertriginous areas for short periods of time

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Use - Medium - Potency Adrenocorticoids

- Used for chronic dermatoses, hand eczema, and utopic eczema.
- Used for a limited period of time on the face and intertriginous areas.

Use - Low Potency Adrenocorticoids

- Safe for chronic ( longtime) application
- Safest for use on the face and intertrigenous areas
- Safest for use under occlusion
- Safest for use on young children and infants

Frequently seen adverse effects of topical steroid therapy:

Atrophy of the epidermis, steroid acne steroid rosacea, striae, Disturbances of

wound healing puerpura, hypertrichosis, perioral dermatitis, rarely
photosensitivity, disturbances of pigmentation and granuloma infantum glutale,
glaucoma and cataract.

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ERYSIPELAS

Erysipelas is an acute infection of the deep dermis and subcutaneous tissues.

Predisposing factors include mechanical trauma, endogenous infection, venous
and lymphatic system disorders (as in erysipelas recurrences). General
susceptibility is increased by malnutrition, alcoholism and
dysgammaglobulinemia. It is usually caused by Group A streptococci, but
occasionally Group G may be isolated.

Diagnosis is established on the following:

• presence of acute inflammation of the deep dermis which is well
circumscribed from the surrounding normal skin,
• abrupt onset and short course and
• Association with constitutional symptoms such as high temperature
and convulsions.
Treatment
Non- drug treatment:
Bed rest, limb elevation and immobilization, warm compresses and analgesia
add to the patient comfort and speed resolution of illness.

Drug treatment:

First line
Procaine Penicillin, 1.2 million IU intramuscularly daily for 7 to 10
days. Children: 50000 IU/kg/24 hrs. in single dose for 7 -10 days.
Severe cases require intravenous therapy with crystalline penicillin in
hospital until the fever subsides, at which time treatment is continued
with Procaine penicillin. Relapsing erysipelas requires a small
maintenance dose of penicillin or erythromycin for months or years.
(For S/E, C/I and dosage forms, see under benzyl penecillin, page
55)
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Alternative:
In penicillin-allergic patients, Erythromycin should be used in
dosages given for furunculosis (see page 31).

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FOLLICULITIS (SUPERFICIAL PUSTULAR FOLLICULITIS)

Folluculitis is an inflammatory state involving the superficial exit of the
follicles .If left untreated, it may involve the whole of the follicles and its
surroundings (folliculitis, perifolliculitis)

Treatment
Non-Drug treatment:
Thorough cleaning of the affected area with antibacterial soap and water twice
daily.

Drug treatment:
Topical:
Mupirocin, applied 2 or 3 times daily until the lesions heal
completely (usually a week to 10 days)
Dosage form: ointment, 2% in15 gm pack
Systemic treatment:
First line:
Cloxacillin, 500 mg p.o. QID for 7 to 10 days. Children: 50-100 mg
/kg /24 hrs. p.o divided in to 4 doses for 7-10 days
Children:50-100 mg/100 mg/24hrs.p.o. divided into 4 doses for 7-10
days.
(for S/E, C/I and dosage forms, see page 57)

Alternative:
Erythromycin, 250-500mg p.o. QID for a duration of 10 days.
Children: 30-50 mg/kg/24 hrs. divided in to 4 doses for 7 -10 days.
(For S/E, C/I and dosage forms, see page 31)

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FUNGAL INFECTIONS

Fungal Infections (superficial) usually affect all parts of the skin from head to
toes. These include:
1. Infection of the scalp, Tinea capitis
2. Infection of the skin of the trunk and extremities, Tinea corporis
3. Infection of the axillae, groin, Tinea cruris
4. Infection of the nails, Tinea unguium (Onychomycosis)
5. Infection of the palms and soles, Tinea palmo-plantaris
6.Infection of the clefts of the fingers and Toes, Tinea interdigitalis
Treatment:
i.Topical
The application of topical anti-fungals is usually enough for Tinea corporis and
cruris)
First line:
Whitfield’s ointment applied twice a day until the infection clears
(usually for 2-3 weeks).
S/E: photosensitivity.
Dosage forms: Ointment, 3% salicylic acid with 6% benzoic acid in
25 gm pack
OR
Clotrimazole cream or ointment. Same dose as for candidiasis (For
S/E, C/I and dosage forms, see page 112)
Systemic Therapy:
First Line therapy
1. Griseofulvin (duration of treatment see table on page 141).
Adult < 50 kg body weight, 500 kg p.o. daily after food
> 50 kg body weight ,500 mg p.o. twice daily after food
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Children 10 - 15mg /kg body weight in divided doses

S/E: hypersensitivity reactions, neutropenia, headache, nausea,
vomiting, rashes and photosensitivity.
C/I: liver failure, prophyria, pregnancy and hypersensitivity
Dosage forms: tablets,125mg,500mg ; Suspensions, 100mg(125
mg./5ml)

2nd Line - duration of treatment see-table I on page 107.

i. Ketoconazole
ii. Itraconazole
iii. Miconazole

Candidiasis
Definition: - It is an inflammatory change of variable clinical features
occurring on the mucous membranes, the skin and the fingers. The causative
agent is candida albicans. Candida albicans is a saprophytic organism found on
the mucous membranes and the skin.
Treatment
First Line: (Topical therapy may give satisfactory result).
Clotrimazole: Could be administered in one of the following manner
- Applied 2-3 times daily until the lesion heal (usually for 2-3 weeks) .
- Insert 5gm vaginal cream at night as a single dose.
- Insert 200mg vaginal pessary for 3 nights, or 100mg for 6 nights
- S/E: local irritation, burining, oedema, erythema.
- Dosage forms : cream/ointment; 1%, vaginal cream, 10% ; vaginal
tablet, 100mg, 200mg
Alternative:

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1. Econazole applied 2-3 times daily until the lesion heal ( 2

weeks).
S/E : Local irritation, burning, oedema, erythema
Dosage forms: cream/ointment, 1%, 2% in 15gm pack.
2. Miconazole: Applied twice daily until the lesion heal ( 2
weeks)
S/E: Local irritation, burning, oedema, erythema.
Dosage forms: cream/ointment, 1% in15gm pack
3. Ketoconazole cream/ointment/shampoo, 2% applied twice a
day until the infection clears (usually for 2-3 weeks).
(for S/E, C/I and dosage forms, see page 113)
4. Econazole cream or ointment, 1 %, applied twice a day
until the infection clears (usually for 2-3 weeks).
S/E: same as ketoconazole
Dosage forms: Cream/ointment, 1%, 2% in 15 gm pack

ii. Systemic:

Systemic therapy may be tried in resistant cases or disseminated

candidiasis:

First line:

Ketoconazole, 200 -400mg/day p.o. for 2 weeks. Children: 3mg/kg

daily for 2 weeks
(For S/E, C/I and dosage forms, see page 113)

OR
Nystatin, 500,000 Units p.o. every 6 hours, doubled in severe cases,
for 10 days. Children dose: 100,000 Units every 6 hours for 10 days.
S/E: nausea, vomiting, diarrhoea at high doses.
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Dosage forms: suspension, 100,000 IU

Alternative:
Itraconazole, 200 mg p.o. daily for 1-2 weeks. not recommended for
children
(For S/E, C/I and dosage forms, see table I on page 141).
OR
Miconazole, 250mg. p.o. every 6 hours for 10 days
(For S/E and dosage forms, see table on page 140).

I. Common Oral Anti-fungal Drugs and Their Dosage

Alternative
First line therapy Generally not
recommended for children
Griseofulvin Ketoconazole Fluconazole Itraconazole

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Alternative
First line therapy Generally not
recommended for children
Tinea corporis & Adult(>50kg/ Adult: 200- 150mg once 200 mg daily
cruris Body wt.:500mg 400mg/day a week p.o p.o
p.o. daily p.o. Duration: 3- Duration:
Children: Children: 4 weeks 1-2 weeks
5-7mg/kg/day 3mg/kg/day
Duration: 2-6 Duration: 2
weeks weeks

Tinea capitis Same dose as Not 150 mg p.o 200 mg p.o.

above recommended daily daily
Duration: 6-8 Duration: Duration:
weeks(occasionally 3 weeks 4-6 weeks
up to 12 weeks

Tinea unguium Adult: >50kgm bd. 150 mg p.o Finger nails

(Onychomycosis) wt 500mg p.o.BID Not once a week 200 mg p.o.
Children: recommended Duration: daily
10-15mg/kg body 9 moths Duration:
wt. 6 weeks
Duration: Toe nails
6-18 months 200 mg p.o
daily
Duration:
12 weeks
Tinea pedis Adult: 500 p.o. Not 150 mg p.o 400 mg
daily recommended once a week p.o.daily
Children: 5- Duration: Duration:
7mg/kg/day 3-4 weeks 4 weeks
Duration:
6-12 weeks

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FURUNCLULES (FURUNCULOSIS)

Furuncle (or Boil) is an acute, round, tender, circumscribed, deep

perifollicular abscess, which develops central suppuration with necrotic plug.
The course of furuncules is short and they resolve in the course of a few days.
Diagnosis: Clinical

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Furunculosis is defined as multiple furuncles in different stage of development

often associated with metabolic disturbance such as diabetes and kidney
diseases.

Treatment
Non-Drug treatment:
For early lesions warm compresses. In localized furuncles with definite
fluctuation, incision with drainage should be made.
Drug treatment:
First line:
Cloxacillin, 500 mg, p.o. QID for 7-10 days. Children: 50-100
mg/kg/24 hrs. p.o. divided into 4 doses for 10-15 days. (For S/E, C/I
and dosage forms, see page 57)
Alternative
Erythromycin, 250-500 mg p.o. QID for 7-10 days. Children: 30-50
mg/kg/24 hrs. divided into 4 doses for 7-10 days. (For S/E, C/I and
dosage forms, see page 31)
OR
Cefotaxime, 2-4 g i.m. or i.v. daily in 2-4 divided doses for 10-15
days. Children: 25-50-mg/kg/24 hrs. divided into 4 doses for 10 -15
days. (For S/Es, C/Is and Dosage forms, see under Ceftriaxone, page
29)

HERPES SIMPLEX
Herpes simplex skin lesion is characterized by grouped microvesicles which
soon rupture to form yellow crust. The site of predilection is the adjacent areas
of mucous membranes and skin. It has a tendency to recur. Infection with H.
Simplex virus is so common in man as to be regarded as almost universal;
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antibodies can be demonstrated in the plasma of virtually every individual aged

2 years and over. A fetus may be infected with the Herpes virus hominis in
utero. .
The mode of transmission is probably by droplet infection. Infection takes
place in two stages, during the first few years of life and after puberty.
Diagnosis is made on the bases of the following findings:
• pustular vesicles with umbilication in the centre,
• fast dissemination of the lesions,
• appearance on abnormal skin areas such eczematous lesions and
• Association with fever and other constitutional symptoms.
• Identification of the virus is diagnostic.
Treatment
Drug treatment:
Mild cases:-
Topical therapy including disinfectant solutions or antibiotics and drying
agents (e.g. 1% Genition violet) may be used. Topical acyclovir may also be
used 5 times daily in mild cases.
Acyclovir, 200 mg, p.o. 5 times daily for 5 to 7 days. Children <2 years: half
adult dose. Children >2 years: adult dose. (For S/E, C/I and dosage forms, see
page 114)
Note:

Secondary bacterial infection can be treated with systemic antibiotics (see

pyoderma).

HERPES ZOSTER (SHINGLES)

Herpes zoster is a skin lesion characterized by vesicles and bullae following
multiple contiguous dermatomes, usually in a unilateral distribution and

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associated with severe pain. It is more commonly seen among HIV infected
patients.

Diagnosis is based on the following symptoms:

• the presence of grouped vesicles and bullae on the background of

oedematous and erythematous skin,
• appearance of vesicles and bullae on one side of the vertebrae, but
involving multiple dermatomes in a ribbon fashion and
• Association with severe pain.

Treatment
Acyclovir, 200mg p.o. 5 times daily for 7 days, or 5 mg/kg body
weight i.v. every 8 hours for 7 days.
Topical acyclovir may also be applied 5 times daily in mild cases or
in addition to systemic therapy in severe forms. (For S/E, C/I and
dosage forms, see page 114)
Note:
Broad spectrum antibiotics (tetracycline, amoxicillin, etc.) might be
needed to avoid secondary infection (see pyoderma). After the
vesicles have resolved, if the patient complains of neuralgia low dose
systemic steroid, e.g. l5-30mg of daily prednisone or its equivalent,
may be used. Topical therapy in the acute state includes disinfectant
solution or antibiotics.

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IMPETIGO CONTAGIOSA
Impetigo contagiosa is a contagious superficial infection of the skin consisting
of vesicles and bullae that soon rupture to form honey yellow crust. It is caused
by streptococci or staphylococci or by both organisms. Infection is acquired
either from external sources by direct contact or through objects or from
internal infection, e.g. nasopharyngeal sources. Impetigo contagiosa is highly
infectious and is common in children.

Diagnosis is mainly clinical:

• the existence of flaccid vesicul-opustules which rupture rapidly and
heal without scarring
• distribution over the exposed surface of the face
• its sudden onset
• short course
Treatment
Non-Drug treatment:
Careful removal of crusts by bathing with normal saline or hydrogen
peroxide ensures a more rapid healing.
Drug treatment:
i. Topical:
Mupirocin, 2% ointment is effective both for streptococcal and
staphylococcal infections; topical antibiotics are applied 2 to 3 times
daily. (for S/E and dosage forms, see 146)
OR
Genitian violet, applied 2- 3 times daily for a couple of days (for
oozing lesions helps as an antiseptic and drying agent, amount
determined by the physician depending on the extent of the lesion)

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Note: Bacterial ointments are usually applied after the wet lesion has
dried.
S/E: stains clothes and skin; mucosal ulcerations
Dosage forms: solution, 0.5%, 1%

ii. Systemic
First line:
Cloxacillin Dose is similar as in furunculosis. (For S/E, C/I and
dosage forms, see page 57)

Alternative:
Erythromycin Dose is similar as in furunculosis. (For S/E, C/I and
dosage forms, see page 31)

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MOLLUSCUM CONTAGIOSUM

Molluscum Contagiosum is a common childhood disease. Its second peak in

incidence occurs in young adults because of sexual transmission. It is caused
by the Pox virus.

Diagnosis is mainly based on the characteristic typical morphology of the

lesions

Treatment
Note: Because the lesion generally resolves spontaneously and is self-limited,
treatment may not be required if the lesions are few in number. When treatment
is decided it should not be excessive nor over-aggressive. However, treatment
is advisable in healthy persons to prevent autoinoculation or transmission to
close contacts and sexual partners. Major forms of treatment comprise surgical,
cyto-destructive or antiviral treatments.

Drug treatment:
A. Cyto-destructive -Chemical application
First line:
Iodine, applied 2-3 times per week until the lesions disappear (1-2
weeks).
S/E: rare complication of ulcer
Dosage form: solution, 2%.
Alternative:
Tretinoin (Retinoic Acid), applied twice daily in addition to
cryotherapy.
S/E: Irritation, erythema, peeling, changes in pigmentation,
photosensitivity.

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C/I: Pregnancy, eczema, broken or sunburned skin, personal or family

history of epithelioma.
Dosage forms: cream, 0.025%; gel, 0.01%, 0.025%; lotion, 0.025%,
0.05%; ointment, 0.05%.
OR
Silver nitrate + Potassium Nitrate, usually 2 to 3 applications are
adequate (performed at weekly intervals )
Dosage forms: toughened pencil , silver nitrate + potassium nitrate
(95% + 5%),
Surgery
• Curettage- with or without electrodessication under local anesthesia
• Cryotherapy -with liquid nitrogen usually applied for 1 to 3 courses
weekly

Note:

1. Therapy based on physical removal of the lesions is considered best.

2. Sexual partners should also be examined and treated. Treatment is

aimed at removal of the lesions or at least the central core of each
lesion. This is thought to initiate the lost immune response via injury
to the epidermis and release of viral antigens.

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PEDICULOSIS PUBIS
Pediculosis Pubis is caused by the ectoparasite Phthirus pubis. The presence
of pruritic red papules is the main clinical feature of the disease. The hairs of
the pubic region are first affected.
Diagnosis is based on clinical findings such as mite attached to the hair base
and the presence of nits.

Treatment:
Non-drug treatment:
• Nits can be removed manually with fine-toothed combs or forceps.
• All contaminated clothes and linens should be decontaminated or
removed from body contact for 72 hours.
• Shaving the hairs of the pubis removes the nits & the ectoparasites.

Drug treatment:
First line:
Permethrin, applied to the affected area, and rinsed after 10 minutes
S/E: pruritus, erythema, and stinging of the scalp, rarely rashes and
oedema.
Dosage forms: cream, 1%
Alternative:
Lindane, applied to the affected area, and washed after 4 minutes
S/E: local irritation, rarely aplastic anaemia and central nervous
system toxicity. Avoid contact with the eyes and mucous membranes.
C/I: pregnant and lactating women, children <2 years of age
Dosage forms: cream, 1%

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Note:
Lindane lotion, 1% is more widely used than lindane shampoo. The
lotion is left for 12 to 24 hours, followed by a thorough washing and
removal of the remaining nits.

• If symptoms persist after one week and eggs or lice are found on re-
examination, the treatment should be repeated.
• Sexual partners should also be examined and treated to prevent
recurrent infection.
OR
Benzyl benzoate, 25%; for children: 12.5% applied to the infected
area
S/E: skin irritation, burning sensation especially on the genitalia,
excoriations, occasionally rashes.
Dosage forms: lotion, 25%

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SCABIES
Scabies is a persistent and intensely itchy skin eruption due to the mite
Sarcoptes scabiei. The disease is commonly seen in people with low socio-
economic status and poor personal hygiene. Clinical findings consist of red
papules and burrows in the axillae, groin and digital web spaces associated
with complaints of nocturnal pruritus. In infants, the face, palms and soles are
often involved and blisters may develop.
Diagnosis is made on the basis of clinical findings described above.

Drug Treatment:

First line:
Benzyl Benzoate, applied to the entire body, neck to toe for 3 to 5
consecutive evenings. For children 12.5%. Bath should be taken
before the first and after the last application. (For S/E and dosage
forms, see page 151)

Sulphur, thinly applied to the entire body for 3 consecutive nights.

The patient should wash thoroughly before each new application and
24 hours after the last treatment.
S/E: skin irritation.
C/I: pregnancy or lactation, children younger than 2 years
Caution: avoid contact with eyes, mouth and mucous membranes.
Dosage forms: ointment, 5%, 10%.

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Note:
1. Washing clothes in hot water or ironing after normal washing are
important
means of decontamination.
2. Any person who has close contact with the infected patient should be
treated.
3. If itching persists one week after treatment, it is worth repeating the
treatment for the 2nd time. If it persists one week after the second
treatment, one can use crotamiton or calamine cream or lotion and
systemic antihistamines.
4. Secondary bacterial infections should be treated accordingly.

First Line for the treatment of itching:

Calamine, apply thinly to the affected area
Dosage forms: lotion (oily), 5%
Alternative:
Crotamiton, apply thinly to the affected area
S/E: skin irritation.
C/I: acute exudative dermatoses
Caution: avoid contact with eyes and broken skin
Dosage forms: cream/lotion, 10%

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URTICARIA (Wheals, hives)

Urticaria is a common vascular reaction pattern in which the primary lesion is
characteristically a wheal, itchy transient swelling which may be rose coloured
or porcelain-like. The lesion occurs quickly and disappears within some hours
without leaving any trace. Urticaria is associated with itching and there are
many varieties of urticaria. The causes of urticaria are many: food, food
additives, drugs, aspirin, infections (bacterial, virus), infestations (parasites),
emotional stress, physical factors (cold, heat, light (UV), menthol –(found in
cigarettes, candy and mints, cough drops, aerosol sprays and topical
medications); inhalants, alcohol, collagen vascular diseases and neoplasms.

Diagnosis is established by:

1) observation of monomorphic wheals,

2) short time course

3) presence of pruritus and

4) healing of the lesion without leaving any trace.

Treatment :
See the table below
Table:Drugs Useful for Urticaria
H1-Receptor Formulation Recommended therapy
Antagonist
First Generation Antihistamines
Chlorpheniramine Tablet, 4mg,8mg,12mg Adult: 8-12mg once
Syrup, 2.5mg/5ml. daily or twice daily.
Child: 0.5mg/kg/24 hrs.

Promethazine Tablet, 10 mg, 25mg, Adult: 10 mg p.o T.I.D

Hydrochloride Elixir, 5mg/5ml. p.o
Suppository,25 mg and Child:

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50mg 2-5 years,5-15 mg/ day

Injection,25 mg/ml in 1 5-10 years,10-25 mg/
ml and 2 m ampoules day.

Second Generation Antihistamines

Loratadine Tablet, 10mg Adult: 10mg p.o. once
Syrup, 5mg/5ml daily
Child: 2-12 years-5mg
p.o. daily
>12 years & >30 kg
10mg p.o. daily
Cetirizine Tablet, 5 mg and10mg Adult: 5-10mg p.o. once
hydrochloride Oral solution,1 mg/ml daily
Child,2-6 years ,5 mg
/day
Or 2.5 mg b.i.d

Note:
Treatment should continue until the urticaria disappears and for a few
days thereafter.
S/E: For first generation antihistamines: drowsiness and dry mouth
For second generation antihistamines: weight gain, rarely sedation and
arrhythmia

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Chapter 5
NON-INFECTIOUS DISEASES
Acute pulmonary edema
Anemia
Anxiety
Atrioventricular block
Bronchial asthma
Chronic Lymphocytic Leukemia
Chronic Myelogenous Leukemia
Constipation
Diabethic ketoacedosis
Diabetis mellitus
Epilepsy
Idiopathic seizures with absence, tonic clonic or myoclonic seizures:
Gout
Hemorrhoids
Hypertension
Immune thrombocytopenic purpuria
Migraine
Mood disorders
Myocardial infarction
Nausea and Vomiting
Nonulcer dyspepsia
Osteoarthritis
Peptic ulcer
Portal hypertension
Rheumatic fever
Rheumatic hearth disease
Rheumatoid arthritis
Schizophrenia
Tyrotoxicosis

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ACUTE PULMONARY EDEMA

Acute pulmonary edema is characterized by rapid transudation of excess fluid
in the lungs secondary to increased pulmonary artery wedge pressure. With
full-blown pulmonary edema, patient is anxious and tachypenic, produces
frothy and blood-tinged sputum. Findings on the chest are bilateral rales and
rhonchi. Chest radiography may show diffuse haziness of the lung fields with
greater density in the hilar region. The cause of heart failure may be left atrial
outflow impairment- e.g. mitral stenosis; left ventricallar dysfunction- e.g.
ischemic heart disease; left ventricular volume overload and left ventricular out
flow tract obstruction.
Diagnosis can be made clinically and by chest radiography.
Treatment:
Supportive care
• 100% oxygen via facemask
• If oxygenation remains inadequate use mechanical ventilation.
• Apply rotating cuff and keep the patient at semi-sitting position.
Drug treatment
Morphine, i.v. 2-5 mg, over 3 minutes, which can be repeated at 15
minutes interval.
S/E: diaphoresis, nausea hypotension & bradycardia.
C/I: head injury, elevated intra-cranial pressure
Dosage forms: Injection (hydrochloride), 10 mg/ml in 1 ml ampoule;
tablet (sulphate), 5mg, 10mg, 15mg, 20mg, 30mg; granules for oral
suspension, 20mg, 60mg; capsule (modified release), 20mg, 50mg,
100mg.
PLUS
Furosemide, i.v. 40 mg followed by 80 mg 1 hour later if required.

S/E : hyponatraemia, hypokalaemia and hypomagnesaemia alkalosis

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C/I precomatose states associated with liver cirrhosis, renal failure

with anuria
Dosage forms: tablet, 40 mg, 80 mg; injection, 10mg/ml in 2ml
ampoule

PLUS
Nitroglycerin, 0.5mg sublingual
S/E: hypotension;
C/I: systolic blood pressure less than 100mm Hg, clinical
suspicion of right
ventricular infarction.
Dosage forms: tablet (sublingual) , 0.5 mg .
PLUS
Dopamine, i.v, 5-10 µg/kg per min.
S/E: tachyarrhythmea.
C/I: idiopathic hypertrophic subaortic stenosis
Dosage forms: powder for injection, 250mg in vial.

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ANEMIA
Megaloblastic Anemia
Megaloblastic anemia (MA) is a descriptive morphologic term that refers to
abnormal hematopoiesis characterized by dyssynchronous nuclear and
cytoplasmic maturation. More than 95% of megaloblastic anemias are due to
deficiency or deranged metabolism of either cobalamin (vitamin B12) or folate.
Folate deficiency MA is more common in Ethiopians. All the causes of
megaloblastic anemia produce a common set of hematologic, laboratory and
histologic abnormalities in the host. Folate deficient patients are usually
malnourished. Neuropsychiatric manifestations are encountered in cobalamin
deficiency, but not in folate deficiency states.
Diagnosis:
1. Complete blood count and red blood cell indices
2. Peripheral blood smear examination and reticulocyte count
3. Serum cobalamin and folate levels and RBC folate content
4. Bone marrow aspiration and/or biopsy
Treatment:
General:
• Correctable or treatable causes must be identified and accordingly dealt with.
• Patients should be advised to take dairy products (cobalamin) and green
vegetables (folate).
Drug Treatment:
Specific therapy is directed toward replacing the deficient factor.
Vitamin B12 (cobalamin)
A typical regimen for the correction of vitamin B12 deficiency is the
administration of 1 mg vitamin B12 i.m. twice during the first week, followed
by 1 mg weekly until the blood count is normal.Treatment (1 mg every 2-3
months) is continued for life if the cause cannot be corrected.

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S/E: Itching, fever chills, hot flushes, nausea and dizziness.

Dosage forms: Injection, 100 mcg/ml, 1000 mcg/ml in 1 ml ampoule.

Folic Acid
Folate deficiency MA is treated with folate replacement therapy, 5 mg
per os for 4 months; child up to 1 year, 500 micrograms/kg daily; over
1 year, as adult dose. Higher doses may be required in malabsorption
states.
C/I: Folate-dependent malignancies
Dosage forms: Tablet, 200 mcg, 1 mg, 5 mg; injection, 5 mg/ml in 1
ml ampoule.
Caution: Folic acid should never be given without vitamin B12 in
undiagnosed megaloblastic anemia or other vitamin B12 deficiency
states.
Note:
The hematologic picture normalizes in about 2 months in both
cobalamin and folate replacement therapy. Large doses of folate may
produce hematologic response in cobalamin deficiency states. This
masks the cobalamin deficiency state and allows the neurologic
damage to progress. Therefore, if both folate and cobalamin are
deficient, cobalamin is administered first, followed by folate.

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Anemia
Iron Deficiency Anemia (IDA)
Iron deficiency denotes a deficit in total body iron resulting from iron
requirements that exceed its supply. IDA is a manifestation of an underlying
disease condition and is not in itself a complete diagnosis. Common causes of
IDA include: increased iron requirements (growth-spurt, pregnancy and
lactation), blood loss (blood donation, frequent phlebotomy, chronic bleeding),
worm infestation (hookworm), and inadequate iron supply (malnutrition,
malabsorption). The symptoms of IDA include fatigue, giddiness, headache,
tinnitus, palpitations, sore tongue and dysphagia and are not specific to IDA.
Diagnosis:
1. Complete blood count and red blood cell indices
2. Peripheral blood smear examination and reticulocyte count
3. Serum ferritin level and bone marrow iron studies
4. Stool for ova and parasites and occult blood, digital per rectum examination,
upper and lower GI radiologic and endoscopic studies, and genitourinary
gynecologic and urologic examinations complete the workup of a patient with
IDA.
Treatment:
General:
• The underlying cause of anemia should be identified and treated or corrected.
• Patients should be encouraged to take diet with optimal bioavailable iron
such as meat.
• Patients with symptomatic anemia (such as congestive heart failure) should
be
transfused packed red blood cells, cautiously.

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Drug Treatment
First Line
Ferrous sulfate, 325 mg tablets (65 mg elemental iron), or any other
iron salt, taken tid between meals to maximize absorption is the
treatment of choice. Treatment is continued for at least 3 months
following correction of the anemia to replenish iron stores.
S/E: Nausea, abdominal cramps and dyspeptic symptoms,
constipation or diarrhea. For patients who do not tolerate ferrous
sulfate tablets, they may be advised to take it with meals, or to start a
smaller dose, or to change the brand to ferrous gluconate or fumarat
tablets or elixir forms.
D/I: Antacids, tetracyclines, chloramphenicol, and quinolone
antibiotics interfere with the absorption and metabolism of iron.
Alternative
Iron dextran, 50 mg/ml in 2 ml ampoule; administered by deep i.m.
injection. The amount of iron required for i.v. administration can be
calculated from the deficit and an additional of 500 to 1000mg iron is
added to replenish the iron stores. Total dose of iron to be injected in
mg = Body weight (kg) x 2.3x (15 - patient’s Hb) + 500-1000 mg.
S/E: pain, swelling, and staining at site of injection; nausea, vomiting
and taste disturbances; hypersensitivity reactions.
C/I: history of allergic reactions (including asthma); severe hepatic or
renal impairment; pregnancy.
Dosage forms: Injection, 50 mg/ml in 2 ml ampoule
Note:
Iron parenteral therapy is rarely indicated; indications include oral
iron intolerance despite modifications in dosage and regimen,
malabsorption, presence of an inflammatory bowl and active peptic
ulcer disease, inability or unwillingness by the patient to take oral
iron. A dose of 25mg (0.5ml) IV is given first to test for a
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hypersensitivity reactions and the patient is observed closely for

possible complications.

ANXIETY DISORDER

Anxiety Disorder is a pathological state characterized by a feeling of dread

accompanied by somatic signs that indicate a hyperactive autonomic nervous
system. It is differentiated from fear, which is a response to a known cause.
Psychosocial stress may occur without any apparent cause.

Diagnosis: Clinical, DSM-IV criteria

Treatment:
Non-drug treatment:
• Psychotherapy especially cognitive -behaviour psychotherapy

Drug treatment:
First line
Diazepam, 2.5 mg, p.o. tid for not more than 4 weeks, 2-10 mg
i.v. for acute agitation
(for S/E, C/I and dosage forms, see page 84)
Alternative
Oxazepam, p.o, 15-30 mg 3-4 times daily
S/E: drowsiness, fatigue, hypotension
C/I: acute pulmonary insufficiency
Dosage forms: tablet, 10 mg

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ARRHYTHMIA (COMMON RHYTHM DISORDERS)

Arrhythmia: It is a disorder of cardiac rhythm, which may be divided into
disorders of impulse formation, disorders of impulse conduction or
combination of both. At present, diagnostic tools do not permit unequivocal
determination of the electro-physiological mechanisms responsible for a
particular arrhythmia. Common rhythm disorders are conveniently classified as
follows:

A. Tachyarrhythmias

Atrial fibrillation (AF)

Paroxysmal supra-ventricular tachycardia (PSVT)
Ventricular tachycardia

B. Bradyarrhthmias
• Heart Blocks

1. Atrial Fibrillation

Diagnosis depends on electrocardiographic recognition of the following

features:

Absence of discrete p-waves but undulating base line with irregular QRS
complex

Treatment

Non Drug treatment

• Immediate cardio-version may be necessary when it is associated with
hemodynamic instability.
• Carotid sinus massage or Valsalva maneuvers may be helpful in
terminating the tachycardia.

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Note: carotid sinus massage should not be attempted in patients with bruits
over the carotid arteries.

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Drug Treatment
If there is no hemo-dynamic change, primary goal is slowing the ventricular
rate as follows:

First line:
Propranolol 10-40mg p.o..3-4 times daily.
(for S/E, C/I and dosage forms, see page 85)
OR
Verapamil, 40-80 mg P.O 2-3 times daily.
S/E: Cardiogenic shock advanced heart block, uncompensated heart
failure
C/I: atrial fibrillation and rapid ventricular response through an
accessory pathway.
Dosage forms; injection, 2.5mg /ml ampoule.
Alternative
Digoxin, 0.25 - 0.375 mg daily (first time drug if the arrhythmia is
associated with left Ventricular dysfunction).
S/E: digoxin toxicity (anorexia, nausea, vomiting, visual disturbance,
arrhythmia
specially block and ventricular premature beats).
C/I: ventricular arrythmias in the absence of congestive cardiac
failure, Wolf-
Parkinson-White syndrome
Dosage forms: tablet, 0.25mg; injection, 0.1mg/ml in 1ml ampoules,
0.25 mg /ml
N.B Sub sequent measure is conversion to sinus rhythm.

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Precaution
• If the arrhythmia had persisted for more than 48hr, conversion to
sinus rhythm should be attempted after 3 weeks of anti-
coagulation with warfarin to INR value of at least 1.8 and should
be continued for 4 weeks after conversion.
• In-patients with underlying long standing chronic rheumatic heart
disease, or long standing AF or if the left atrial dimension is
greater than 5 cm on echocardiography, conversion is often
unsuccessful.

OR

Pharmacologic conversion can be tried as follows:

Quinidine 300-600 mg 4 times daily as required and tolerated
S/E: Nausea, vomiting, diarrhea, abdominal pain anorexia, tinnitus,
hearing loss,
visual disturbances, confusion, delirium, psychosis and torsades
pointes.
C/E: quinidine hypersensitivity
N.B.
Quinidine should be started after AV conduction is decreased by
drugs like propranolol, verapamia or digoxin

2. Paroxysmal supra-ventricular tachycardia

Diagnosis: -
Electrocardiography: - Regular narrows QRS complex tachycardia. P-
wave may be seen preceding or following the QRS complex or may
not be seen at all.
Treatment
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Acute termination
Drug treatment
First line:
Verapamil, 5mg IV can be repeated once or twice 10 min apart.
(ForS/E, C/I and Dosage forms, see page 165)
Alternative:
Digoxin, 0.5 to 1 mg IV over a period of 10 to 15 min followed by
0.25 mg every 2-4 hours with a total dose less than 1.5mg with in 24-
hour period. (For S/E, C/I and Dosage forms, see page 165)

Prevention of recurrence
Propranolol 10-40mg p.o..3-4 times daily.
(For S/E, C/I and Dosage forms, see page 85)

3. VENTRICULAR TACHYCARDIAS:
These groups of tachycardias originate below the bifurcation of the bundle of
His. Generally, they accompany some form of structural heart disease, most
commonly, ischemic heart disease.
Diagnosis: is suggested by a wide-complex QRS tachycardia at a rate
exceeding 100 beats per minute.

Treatment:

Symptomatic ventricular tachycardia generally needs treatment.

1. For Acute termination:

First line:

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Lidocaine, 1-1.5 mg/kg i.v. can be repeated with in 3 min to a

maximum of 3mg/kg. S/E: respiratory depression and convulsion;
hypotension, bradycardia; rarely hypersensitivity.
C/I: hypo-volumia, complete heart block.
Dosage forms: tablet (sulphate), 200 mg
Alternative
Procainamide, 25-50 mg i.v. over one-min period then repeated
every 5 min until the arrhythmia is controlled, hypotension results, or
the QRS complex is prolonged more than 50%.
S/E: QRS prolongation and torsedes points.
Dosage forms: tablet, 250 mg; injection (hydrochloride), 100 mg/ml
in 10 ml ampoule

2. Prevention of recurrence

First line:

1. Propranolol, p.o 20-160 mg in divided doses. (For S/E, C/I and

Dosage forms, see page 85)

OR

2. Amiodarone, initially 200 mg three times daily, to be reduced

gradually to 100-200 mg daily for maintenance.
S/E: pulmonary fibrosis, photedermatitis, paresthesia, tremor,ataxia,
canstipation, hepatocellular necrosis;
D/I: it reduces clearance of warfarin, quinidine, procainamide and
flecanide.
Dosage form: tablet, 200 mg.

Alternative
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Verapamil 40-80 mg p.o. three times daily. (For S/E, C/I and
Dosage forms, see page 165)

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ATRIOVENTRICULAR (AV) BLOCK

This is caused by acute processes such as myocardial infarction, digitals
intoxication, beta and/or calcium channel blockers, and infections like
myocarditis. It may also be caused by a variety of infiltrative and degenerative
diseases.
Diagnosis: is based on Electrocardiographic findings.
First degree AV block:- Characterized by prolonged PR internal more than
0.25(200ms)

Second degree AV block: Some atrial impulses fail to conduct to the

ventricles.

Type 1: progressive prolongation of the PR interval before block of

an atrial impulse.

Type 2: conduction fails suddenly without preceding change in PR

interval
3rd degree AV block: - No atrial impulse propagates to the ventricles
Symptomatic AV block
A. For Acute termination
Atropine i.v. 0.5 –2mg.
S/E: dry mouth, constipation, blurred vision, photophobia, and
elevated intra-ocular pressure, and cardiac arrhythmias.
C/I: closed angle glaucoma, atony of GI tract or bladder
S/P: cardiac failure, tachyarrythmias
Dosage forms: injection, 1mg/ml in 1ml ampoule

B. AV blocks requiring pacemaker permanently

1. 2nd degree type 2 block
2. Wide complex 3rd degree AV block
3. Chronically symptomatic AV blocks
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BRONCHIAL ASTHMA
Bronchial asthma is a chronic respiratory problem associated with reversible
airflow obstruction. It has now become an established fact that airway
inflammation plays a major role in the pathogenesis of asthma. Clinically it is
characterized by episodic shortness of breath, usually accompanied by
wheezing and coughing. Common precipitating factors include exposures to
cold weather, upper respiratory tract infections, bad smells, exercise, ingestion
of drugs like aspirin and beta-blockers…etc. The course of an acute asthmatic
attack is often unpredictable. Therefore, one should never underestimate the
severity of a given asthmatic attack and close monitoring and appropriate
management should be employed until the patient clearly comes out of the
attack. Concerning the chronic form of the disease, one should always try to
classify the disease based on severity before initiating treatment Accordingly, it
is classified as intermittent or persistent asthma. The latter is again divided into
mild, moderate and severe persistent asthma.

Diagnosis
- Suggestive clinical history
- Objective tests by using peak flow meters and spirometers are
essential not only to make the diagnosis for certain but also to
grade severity of the disease.

Treatment
Non-drug treatment
Prevention of exposure to known allergens and inhaled irritants.
Drug treatment
Drugs are required for the treatment of acute asthmatic exacerbations
as well as for the treatment of chronic asthma.

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TREATMENT OF ACUTE ASTHMA ATTACKS IN ADULTS:

General measures:
• Patient’s condition should be carefully monitored to assess
severity, and to detect signs of improvement or deterioration. In
the absence of blood gas monitoring facilities, clinical evaluation
by using some important physical signs, such as the respiratory
rate, pulse rate, use of accessory muscles, color, paradoxical
movement of the diaphragm, speech, level of consciousness are
essential.
• Humidified oxygen by mask at high concentration (6 litres/min)
is important.
• Rehydrate the patient if necessary.
• Antibiotics should not be routinely given unless there is a
convincing evidence for bacterial respiratory infection, such as
fever, pleuritic chest pain and bronchial breath sound or chest x-
ray evidence of consoldation.
Drug Treatment
I. INITIAL MANAGEMENT
First line
Salbutamol, MDI, 200 micrograms by aerosal inhalation. Could be
repeated every 20 minutes for the first hour.
S/E: headache, nervousness, dizziness, palpitation, tachycardia, fine
tremor, muscle cramp, paradoxical broncho-spasm.
C/I: cardiac arrythmias
Dosage forms: Oral inhalation (aerosol) preparation, 100mcg per
dose; tablet, 2 mg, 4mg; syrup, 2 mg/5ml; nebulizer solution, 5 mg/5
ml, 20 ml ampoule.
OR
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Aminophylline, 5mg/kg by slow i.v push over 5 minutes. The same

dose could be repeated after 30 minutes.
S/E: GI disturbances, headache, irritability, nervousness, insomnia,
and tremor
C/I: hypertension, ischemic heart disease, epilepsy, hyperthyroidism,
congestive cardiac failure
Dosage forms: Tablet, 100mg, 225mg, 350mg; injection,
250mg/10ml in 10 and 20 ml ampoule

OR
Salbutamol, 2.5-5 mg undiluted could be given via a nebulizer over 3
minutes, repeat every 20 minutes for the first one hour
(For S/E, C/I and Dosage forms, see page 171)
Alternatives
Adrenaline, 1:1000, 0.5ml sc. Repeat after ½ to 1 hour if patient
doesn’t respond.
S/E: headache, nervousness, dizziness, cardiac arrythmias
C/I: cardiac arrythmias
Dosage forms: injection, 0.1% in 1 ml ampoule

II. IF RESPONSE TO INITIAL THERAPY IS POOR, GIVE THE

FOLLOWING:
First line
Insert intravenous line and start aminophylline,
• If patient has taken oral theophedrine or aminophylline in the
past 8 hours, start i.v. infusion at 0.6 mg/kg/hr
• If patient has not been taking theophylline preparation, give a
loading dose of 3-5 mg/kg in dextrose and water over 20
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minutes. Thereafter, the maintenance dose can be given with

a continuous infusion in dextrose 5 % at a dose of 0.6 mg/ kg
/hour until recovery.
(For S/E, C/I and Dosage forms, see page 172)
OR
Nebulized salbutamol as above but the dose may be increased to 10
mg if side effect permits (For S/E, C/I and Dosage forms, see page
171)
PLUS
Hydrocortisone, i.v., 200 mg as a single dose. Further i.v. doses are
needed only if oral dosing is not possible.
S/E: GI disturbances, hyperglycemia, headache, and psychiatric
reactions
Caution: hypertension, infection, diabetes, osteoporosis
Dosage forms: tablet (acetate), 5mg, 10mg,; powder for injection;
25mg/ampoule, 500mg vial; injection (sodium succinate), 50mg/ml in
2ml ampoule, 125mg/ml

AND / OR
Prednisolone, 40-60 mg p.o. should be started immediately,
preferably after the first bolus of hydrocortisone, and given at least for
a minimum of 5-7 days.
S/E: GI disturbances, such as dyspepsia and peptic and oesophageal
ulcers; candidiasis; musculoskeletal effects, such as osteoporosis,
bone fractures and proximal myopathy; endocrine effects, such as
adrenal suppression, Cushing’s syndrome, menstrual irregularities,
weight gain, hirsutisim; increased susceptibility to infection and
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impaired healing; euphoria, depression, isomnia, aggravation of

epilepsy and schizophrenia; glaucoma; hypersensitivity reaction
including anaphylaxis.
C/I: systemic infection; use of live vaccines in those receiving
immunosuppressive therapy.
Dosage forms: Tablet, 1 mg, 3.5 mg, 5 mg, 10 mg; injection, 10
mg/ml, 25 mg/ml in 2 ml ampoule.
Caution: Use the lowest effective dose for the shortest period
possible; withdraw gradually after systemic use.
III. MAINTENANCE THERAPY FOR CHRONIC ASTHMA IN
ADULTS:
Requires prolonged use of anti-inflammatory drugs mainly in the form
inhalers.
1.INTERMITTENT ASTHMA:
First line:
Salbutamol, inhalation - 200 microgram/puff, not more than 3 times a
week (For (S/E, C/I and Dosage forms, see page 171)
Alternative:
Ephedrine + Theophylline (11mg + 120mg) p.o. 100 mg, two to
three times a day
S/E: GI disturbances, headache, irritability, nervousness, insomnia,
tremor
C/I: hypertension, ischemic heart disease, epilepsy, hyperthyroidism,
congestive cardiac failure
Dosage forms: Tablet, 120 mg theophylline + 11 mg ephedrine;
syrup, 0.30% theophylline + 0.24% ephedrine; elixir, 30 mg
theophylline + 6 mg ephedrine per 5 ml

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2. PERSISTENT MILD ASTHMA:

First line:
Salbutamol, inhalation, 200 micro gram/puff to be taken, as needed
but
not more than 3-4/day (For S/E, C/I and Dosage forms, see on page
171)
OR
Ephedrine + Theophylline (11mg + 120mg) p.o. 100 mg, two to
three times a day
PLUS
Beclomethasone oral inhalation 1000mcg /daily for two weeks
S/E: GI disturbances, hyperglycemiaheadache, and psychiatric
reactions
C/I: hypertension, infection, diabetes, and osteoporesis
Dosage forms: oral inhalation (aerosol), 50 mcg/dose, and 100
mcg/dose
Plus if required
Prednislone, p.o. 5-10 mg on alternate days. Doses of 20-40 mg daily
for seven days may be needed for short-term exacerbations in patients
not responding to the above. S/E, C/I and Dosage forms: see on page
173)

3. PERSISTENT MODERATE ASTHMA:

First line
Salbutamol, inhalation as needed not more than 3-4 times a day.
(For S/E, C/I and Dosage forms, see page 171)

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PLUS
Beclomethasone 2000mcg, p.o. daily for two weeks and reduce to
1000 mcg if symptoms improves
(For S/E, C/I and Dosage forms, see above)

4. SEVERE PERSISTENT ASTHMA:

First line:
Salbutamol, inhalation not more than 3-4 times a day
(For S/E, C/I and Dosage forms, see page 171)

PLUS
Beclomethasone, 2000 mcg, p.o. daily and
(For S/E, C/I and Dosage forms, see on page 175)
OR
Prednisolone, 0.5 mg, p.o. a day.
(For S/E, C/I and Dosage forms, see page 173)

GENERAL COMMENT ON TREATMENT OF ASTHMA:

Increasing intensity: When asthma is not brought under control with

current treatment even though treatment has been taken correctly;
medication dose is doubled with each step.

Decreasing intensity: When the objective of treatment have been

reached and maintained over some weeks; medication dose is halved
at each step; the minimum treatment needed must be determined.

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CHRONIC LYMPHOCYTIC LEUKEMIA

CLL is the most common type of lymphoid leukemia in western populations,

accounting for almost 30% of all leukemias. It the second most common
leukemia in Ethiopians. The cause of CLL in the majority of cases is not
known. The clinical course of CLL is highly variable and survival is closely
correlated with the stage of disease at diagnosis.

The symptoms and signs of CLL relate to tissue infiltration (lymphadenopathy,

organomegaly), peripheral blood cytopenias (anemia, bleeding, infections), or
immune suppression (infections and malignancies).

Diagnosis:
1. Complete blood count and differential
2. Peripheral blood smear and bone marrow examination
3. Chest x-ray and abdominal ultrasound studies
4. Biochemical studies and uric acid level
5. An absolute lymphocyte count of 10,000/µL in the peripheral blood and
30%
lymphocytes in the bone marrow establish the diagnosis of CLL.

Treatment:
General:
• Patients with early stage and asymptomatic disease should be
observed without
treatment.
• Infections, if present, should be treated aggressively
• Patients with symptomatic anemia should be transfused packed red
blood cells.
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Allopurinol, 100mg p.o. tid is given before the initiation of specific

treatment
(see under Chronic Myelogenous Leukemia)
S/E: nausea, vomiting, skin rash, headache, peripheral neuropathy,
acute gout.
C/I: pregnancy, lactation, severe renal disorder, acute gout.
Dosage forms: Tablets, 100mg.

Drug Treatment:

The following are indications for the initiation of specific therapy:

1. Persistent or progressive systemic symptoms
2. Bulky lymphadenopathy that causes mechanical obstruction or bothersome
cosmetic deformities
3. Evidence of bone marrow failure (anemia and/or thrombocytopenia),
immune
hemolysis or immune thrombocytopenia.

First Line:
Chlorambucil, 0.1 to 0.2mg/kg p.o. daily for 3 to 6 weeks. It is then
discontinued after the desired effect is achieved. Alternatively, 15 to
30mg/m2 po may be given over 3 to 4 days every 14 to 21 days.
Prednisolone, 0.5-1mg/kg may be added, particularly in the presence
of hemolytic anemia
S/E: Myelosuppression, GI disturbances, leukemogenic,
C/I: Lactation, pregnancy.
Dosage forms: Tablet, 2mg, 5 mg
Alternative:
Cyclophosphamide is another alternative that is given 2 to 4 mg/kg
p.o. daily until the desired effect is achieved(systemic symptoms
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improve and the size of enlarged lymph nodes and organomegaly are
decreased). Prednisolone may be added, particularly if hemolytic
anemia is present as with Chlorambucil.
S/E: Myelosuppression, GI disturbances, hemorrhagic cystitis, etc.
C/I: Pregnancy, lactation.
Dosage forms: Tablet 50mg; powder for injection, 200 mg, 500 mg in
vial.

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CHRONIC MYELOGENOUS LEUKEMIA

Chronic myelogenous leukemia (CML) is a myeloproliferative disease
characterized by a proliferation of myeloid cells without loss of their capacity
to differentiate initially.
CML runs a generally mild course until it transforms to a frankly leukemic
(blastic) phase. Although CML constitutes only 14% of all leukemias in
Western populations, it is the most common leukemia in Ethiopians. Ionizing
radiation in high doses is the only known risk factor for CML.

Diagnosis:
1. Complete blood count and differential
2. Peripheral blood smear examination
3. Bone marrow aspiration and/or biopsy
4. Leukocyte alkaline phosphatase score
5. Biochemical studies and uric acid
6. The diagnosis is correctly confirmed by the demonstration of the
Philadelphia chromosome that results from a balanced translocation of
genetic material between the long arms of chromosomes 9 and 22

Treatment:
General:
• Patients with symptomatic anemia should be transfused packed red
blood cells.
• Dehydration and electrolyte imbalance, if present should be
corrected.

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• Allopurinol, 100 mg tid should be started before the initiation of

specific treatment.
(For S/E, C/I and Dosage forms, see page 178)

Drug Treatment:
Palliative chemotherapy:

First Line:
Hydroxyurea is the agent of choice for palliative chemotherapy and
is given 2 to 4 g/day p.o. initially depending on the cell count. The
dose is then adjusted to the blood counts. It should be stopped or
withheld if the WBC count drops to < 10,000/µL.
S/E: Nausea, vomiting, myelosuppression, etc.
C/I: Lactation, pregnancy.
Dosage forms: Capsule ,500mg
Alternative:
Busulphan 4 to 8mg/day and is adjusted to the blood counts. It is then
stopped when the WBC count drops to below 20,000/µL.
S/E: Myelosuppression, hyperpigmentation, pulmonary fibrosis
C/I: Lactation, pregnancy.
Dosage Form: Tablet, 2mg, 0.5 mg
Note:
These chemotherapeutic agents may achieve hematologic remission in
almost all patients and also significantly improve the quality of life.
They do not, however, lead to cytogenetic remission and therefore, do
not change the natural history of the disease to a significant degree.

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CONSTIPATION
Constipation is difficult to define. In general it may be defined as infrequent or
seemingly incomplete evacuation. It may be caused by either organic or
functional disorders. A diligent search for the underlying cause should be
performed before resorting to symptomatic treatment.
Diagnosis: Clinical
Treatment
Non-drug treatment:
- Removal of the underling cause
- More fiber diet intake
- High residue diet intake,
- Increased fluid intake
Drug treatment:
Only for severe cases (Not recommended for children less than 4 years
old.)
I. Short term relief of severe constipation
Magnesium sulphate, p.o., 10-20 mg in a glass of water, preferably
before breakfast.
S/E: colic
C/I: acute gastro-intestinal conditions
Dosage forms: Magnesium sulphate crystals in sachets
II. For chronic constipation
Cascara, 40mg, p.o. at night.
S/E: mild
C/I: insignificant
Dosage forms: tablet, 125mg

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OR
Bisacodyl, 5 – 10mg, p.o. at night or 10mg rectally in the morning.
For children (above 4 years): 5mg rectally in the morning.
S/E: mild
C/I: insignificant
Dosage forms: tablet, 5mg; suppository, 5mg, 10mg.

OR
Glycerin suppository 1 gm , rectally at night after moistening with
water
S/E: loose stool
C/I: insignificant
Dosage forms: suppository, 1g, 1.36g, 2g, 2.76g
OR
Liquid paraffin, 10ml, p.o., every 8-12 hrs as required.
S/E: loose stool
C/I: insignificant
Dosage forms: semi-liquid preparation.

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DIABETIC KETO ACIDOSIS

It is a clinical condition that may be defined as a triad of hyperglycemia,
acidosis and ketosis. Usually, it occurs in the setting of type 1 diabetes mellitus
and is primarily caused by relative or absolute insulin deficiency. Common
precipitating factors are infection and omission of insulin dose. Patients may
also come with diabetic ketoacidosis on initial presentation.
Diagnosis is based on clinical findings, and determination of blood sugar and
urine ketone.
Treatment
Non drug treatment

Correct or treat the precipitating factor

Drug treatment

Insulin, 20 units of regular insulin (10 units IM, 10 units IV), followed by 5
units IM every hour in adults, (0.1 IU/kg/h. in children). Blood glucose
should be checked every 2 hours. If after the 1st two hours the blood
glucose level has not fallen significantly, dose of IM insulin can be doubled.
When the patients is completely out of ketoacidosis, regular insulin is given
4 hourly subcutaneously according to the random blood sugar (RBG) level
as follows:
If RBG > 250mg/dl 12 Units
If RBG - 180-250mg/dl 8 Units
If RBG - 120-180mg/dl 4 Units
If RBG < 120 mg/dl 0 Units
S/E: hypoglycemia , lipohypertrophy
C/I: hypoglycemia
Dosage forms: injection, insulin zinc suspension /insulin lente (HPB), 40
unit/ml, 100 unit/ml in 10 ml vial.

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PLUS
Fluid replacement:
Normal saline (0.9%) IV should be given rapidly as soon as the
patient arrives. 5% dextrose can be given when the blood sugar
reaches 250-300 mg/dl. Total fluid given may be as high as 10 liters
depending on the patient’s response and urine output.
Dosage forms: injection, 0.9% (Normal saline), 10 ml, 20 ml, 500ml,
1000ml
PLUS
Electrolyte: Potassium replacement should be according to serum potassium
values. Potassium, 20m Eq/h, if renal function is normal is generally safe.
S/E: renal failure.
Dosage forms: injection, 20mEq/10m/ ampoule of KCL

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DIABETES MELLITUS
It is a group of metabolic disorders characterized by hyperglycemia resulting
from defects in insulin secretion, insulin action, or both. The chronic
hyperglycemia of diabetes is associated with long-term damage, dysfunction,
and failure of various organs, especially the eyes, kidneys, nerves, heart and
blood vessels. The vast majority of cases of diabetes fall into two broad ehio-
pathogenetic categories. In one category (type I diabetes), the cause is an
absolute deficiency of insulin secretion. Individuals, at increased risk of
developing this type of diabetes can often be identified by serological evidence
of an autoimmune pathologic process occurring in the pancreatic islets and by
genetic markers. In the other much more prevalent category (type II diabetes),
the cause is a combination of resistance to insulin action and an inadequate
compensatory insulin secretary response. In the latter category, a degree of
hyperglycemia sufficient to cause pathologic and functional changes in various
target tissues, but without clinical symptoms, may be present for a long period
of time before diabetes is detected.

Diagnostic Criteria
- Poly-symptoms PLUS casual plasma glucose greater than or
equal to 200 mg/dl.
- Fasting blood sugar glucose greater than or equal to 120 mg/dl.
- 2 hours plasma glucose greater than or equal to 200 mg/dl during
an oral glucose tolerance test (OGTT).

N.B In the absence of unequivocal hyperglycemia with acute metabolic

decomposition, these criteria should be confirmed by repeating on a different
day

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Treatment
Non drug treatment
- Regular physical exercise
- Diet control (avoid simple sugars, low saturated fat and
cholesterol).
Drug treatment
Type 1 diabetes mellitus
Insulin (Remember that there is no single standard for insulin
administration)
Adults of normal weight may be started with 20-25 units of
intermediate acting insulin a day and increased to maintain a blood
sugar level of 80-120 mg/dl. Fast acting insulin may also be
considered in situations where control of post- pradial hyperglycemia
is essential.
(For S/E, C/I and Dosage forms, see page 184)
Type 2 diabetes mellitus
Glibenclamide, p.o. 2.5 to 20 mg, daily or divided into two doses
S/E: hypoglycemia;
C/I: hepatic impairment, renal insufficiency;
D/I: with alcohol, flushing.
Dosage form: Tablet, 5 mg
AND/OR
Metformin (often used for obese patients), 500-2000 mg p.o. daily in
divided doses.
S/E: anorexia, nausea, vomiting, abdominal discomfort and diarrhea;
C/I: renal diseases, hepatic disease, alcoholism.
Dosage forms: Tablet, 500 mg.
Diabetic foot ulcer:

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Appears to be due to abnormal pressure distribution secondary to

diabetic neuropathy. Callus formation is usually the initial
abnormality. Vascular disease with diminished blood supply
contributes to development of ulcers, and infection is common, often
caused by multiple organisms. Patients should be advised to inspect
their feet daily and to keep them clean and to wear properly fitting
shoes. Moreover, those patients with neuropathy should be advised
not to walk barefooted.
Diagnosis: Clinical
Gram stain and culture from the discharge.
X- ray of the affected foot
Treatment:
Non Drug Treatment
Proper wound care, including debridement
Drug Treatment
First Line
Ampicillin, i.v, 1 g 6 hourly for 2-3 weeks (For S/E, C/I and Dosage
forms, see page 31)
PLUS
Gentamicin 5-7 mg/kg i.v daily in divided doses for 10-14 days
(For S/E, C/I and Dosage forms, see page 56)
OR
A third generation cephalosporin, e.g.Ceftazidime, 1 gm i.v every 8
hourly or ceftriaxone 1-2 g i.v. or i.m 12 hourly for 7-10 days.
(For S/E and C/I see under ceftriaxone page 29).
Dosage form: Injection, 0.5 g, 1g, and 2g, in Vial.
PLUS
Gentamicin, 5 mg/kg i.v daily in divided doses for 10-14 days.

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(S/E, C/I and dosage forms, see page 56).

PLUS
Metronidazole, 750 mg, p.o. tid or 500mg IV every 6 hr, for 10-14
days.
(For S/E, C/I and dosage forms, see page 24)
EPILEPSY
Epilepsy is a paroxysmal neurologic disorder characterized by a sudden onset
of sensory perception or motor activity with or without loss of consciousness
due to aberrant cortical electrical activity. Its etiology is often unkown.
Secondary causes include congenital, perinatal injuries, intra cranial tumors,
vascular, metabolic and others.

Diagnosis: Clinical and EEG. Additional investigations like CT scan are

required if there is suspicion of secondary causes.
Treatment:
Non-drug treatment:
• Advice on a healthy lifestyle with good sleep habits and the
avoidance of excessive alcohol and caffeine.
• The patient should know the name and the dose of his medication
and should be warned of the consequences of poor compliance
Comments:
• Epileptics are not allowed to drive a motor vehicle unless the
patient has had a two-year attack-free period.
• Refer all adult onset epilepsy, complicated or atypical
epilepsy, and if there is a progressive increase in
uncontrollable attacks.
• Pregnancy is better avoided in patients with difficult to
control epilepsy.
Drug Treatment:
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Tonic-clonic, partial focal, or partial complex seizure with and

without secondary Generalization:
First line
Phenobarbitone, 60-180 mg/day p.o. in divided doses
S/E: sedation, skin rash, decreased libido, confusion, ataxia
C/I: acute intermittent porphyria
Caution: impaired renal or hepatic function, during pregnancy and
lactation, in the elderly.
Dosage forms: Tablet, 15mg, 30mg, 100mg; elixir, 20mg/5ml; injection
(sodium), 25mg/ml, 100mg/ml,
Alternatives
Phenytoin (Diphenyl hydantion) 5 mg/kg/day, p.o. in single or
divided doses. Maximum dose is 400 mg/day the usual maintenance
dosage 200-300 mg/day
S/E: gum hyperplasia, hirsutism, lymphadenopathy, facial coarsening,
ataxia, incoordination, and confusion
Caution: pregnancy, liver dysfunction, and lactation.
Dosage forms: tablet, 50mg, 100mg; capsule, 50mg, 100mg;
suspension 30 mg/5ml; powder for injection (sodium) 250 mg in vial.
OR
Carbamazepine, 600-1,800 mg/day p.o. in 2 divided doses
S/E: GI irritation, aplastic anaemia, hepatotoxicity, ataxia, dizziness,
diplopia, vertigo
C/I: hypersensitivity to tri-cyclic compounds, AV block
Caution: pregnancy, hepatic or renal impairment, lactation, severe CV
disease
Dosage forms: tablet, 100mg, 200mg; syrup, 100mg/5ml.
Comments:
• The aim is to use monotherapy i.e. a single anticonvulsant,
until the seizures are controlled or intolerable side effects
occur.
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• Therapy should not be initiated after 1 attack only and only if

evidence of epilepsy has been established.
• Anti-convulsants may make oral contraceptives ineffective.
• Monitor plasma levels for efficacy and toxicity, if possible
• Increase gradually to maintenance dose.

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IDIOPATHIC SEIZURES WITH ABSENCE, TONIC CLONIC OR

MYOCLONIC SEIZURES:

TYPICAL ABSENCES:
Treatment
Drug treatment:

First line:
Ethosuximide, average dose 250-500 mg p.o. 3 times daily
S/E: GI irritation, bone marrow suppression, skin rash, ataxia,
lethargy, headache
Caution: pregnancy, hepatic or renal impairment, lactation.
Dosage forms: capsule, 250mg; syrup, 250mg/5ml.
Comments:
• Not indicated for other seizures.
• To be prescribed by a specialist only.
Alternative:
Sodium valproate, average dose 500 mg twice daily p.o. ,
maximum
2, 500 mg/day
S/E: GI irritation, hepatotoxicity, thrombocytopenia, weight gain,
transient
alopecia, tremor, sedation, ataxia.
C/I: hepatic dysfunction
Dosage forms: Tablet, 200mg, 500mg; syrup, 200mg/5ml.
Comments:
• Dosages should be increased gradually over 6 weeks.
• To be prescribed by a specialist only

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MYOCLONIC JERKS:
Clonazepam, 0.5-2 mg p.o. 3 times daily
S/E: anorexia, ataxia, sedation, and lethargy.
C/I: acute pulmonary insufficiency
Dosage forms: tablet, 0.5mg, 1mg, 2mg; injection, 1mg/ml in 1ml
ampoule.

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GOUT
Gout is inflammatory reaction to urate crystals in joints. It occurs as a result of
precipitation of urate crystals in joints .It usually occurs in the presence of
hyperuricemia, which could be either idiopathic or secondary
Diagnosis: clinical and demonstration of urate crystals in the synovial fluid.
Hyperuricemia may be present, but is not diagnostic.
Treatment:
Non-drug treatment:
Acute attack: rest and immobilization.
Chronic gout: lifestyle modification, including continued high fluid
intake, avoidance of purine-rich food.
Drug Treatment:
Acute Gout
First line
NSAIDs,
e.g. Indometacin, 50 mg p.o. 4-6 hourly for 24-48 hours; thereafter
25-50 mg 3 times daily for symptomatic relief for the duration of the
attack.
OR
Indomethacin, 100 mg rectally, 12 hourly for 24-48 hours; thereafter
100 mg daily for symptomatic relief for the duration of the attack.
S/E: GI disturbances, headache, dizziness; GI ulceration and bleeding;
CNS disturbances; thrombocytopenia; hyperglycemia; blurred vision.
C/I: epilepsy, parkinsonism, psychiatric disturbances
Dosage forms: capsule, 25 mg, 50 mg, 75 mg; suppository, 100 mg;
syrup, 25 mg/5ml.
Caution: Suppositories may cause rectal irritation and bleeding; do
not use in proctatis and haemorrhoids.

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AND/OR
Colchicine, 0.5-1 mg p.o. initially, followed by 0.5 mg every 30
minutes to 1 hour for a total dose of 6 mg or until relief has been
obtained, or until severe nausea/vomiting/diarrhoea occur.
S/E: nausea, vomiting, diarrhoea, abdominal pain, bone marrow
depression,
C/I: serious GI, renal, hepatic, or cardiac disorders, blood dyscrasias.
Dosage forms: tablet, 0.5mg; injection, 0.5mg/ml in 2ml ampoule.

Alternative
Prednisolone, 30-40 mg/day p.o. may be needed in some cases.
Rheumatologist may use intra-articular corticosteroids in exceptional
cases (For S/E, C/I and Dosage forms, see page 173)

Chronic Gout:
First line
Allopurinol, 100 mg p.o. daily, increasing weekly by 100 mg to 400
mg daily, the mean dose is 300 mg/day (For S/E, C/I and Dosage
forms, see page 178)
Alternative
Probenecid, 500 mg p.o. 12 hourly.
S/E: pruritis, headache, dizziness, hypersensitivity reactions, anemia
C/I: blood dyscrasias, uric acid kidney stones
Dosage forms: tablet, 500mg.
Comments:
• Allopurinol should not be initiated within one month after an
acute attack.
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• Administer prophylactic NSAID or colchicine when initiating

therapy.
• Take more fluid with probenicid treatment
• Allopurinol should be given together with probenicid

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HEART FAILURE
Heart failure is a syndrome of inability of the heart to pump blood at an output
sufficient to meet the requirements of the metabolizing tissues and/or to do so
only at an abnormally elevated diastolic volume or pressure. Presenting
symptoms are weakness, dyspnea, orthopnea and body swelling. Patients may
have elevated JVP, gallop rhythm, hepatomegaly and leg edema. The cause of
heart failure can be valvular diseases, myocardial diseases, intra-cardiac shunts
and others.
Diagnosis can be made clinically supported with radiography and
echocardiography examinations.

Treatment
Non-drug treatment:
Reduce sodium intake and physical activity.

Drug treatment:
First line:
Digoxin, 0.125 –0.375 mg, p.o. daily.
(For S/E, C/I and Dosage forms, see page 165)
PLUS
Furosemide, 40-240mg, p.o. divided in to 2-3 doses daily.
(For S/E, C/I and Dosage forms, see page 157)
PLUS
Potassium chloride, 600 mg p.o. once or twice daily
S/E: hypo-excitability
C/I: renal impairment
Dosage forms: Tablet, 500 mg, 600 mg , 750 mg , 1g.

AND/ OR
Enalopril, 5-40mg p.o. once or divided into two doses daily.

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S/E: cough, angio-edema, hyperkalemia, rash, loss of taste,

leukopenia.
C/I: life threatening side effects during earlier exposure (angio-
edemia, anuric
renal failure) and pregnancy,
Caution: Should be used with caution in systolic blood pressure < 80
mmHg, serum creatinine level > 3mg/l, bilateral renal artery stenosis
and serum potassium > 5.5 mmol.
Dosage forms: Tablet, 2.5mg, 5mg, 10mg, 20mg, 40mg.

AND/OR
Spironolactone, 25-100mg p.o. once daily or divided in to two doses.
S/E: gynecomastia.
C/I: hyperkalemia, acute renal failure
Dosage forms: tablet, 25mg, 100 mg

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HEMORRHOIDS
Hemorrhoids can be external or internal. As a rule external hemorrhoids are
asymptomatic until the complication of thrombosis or rupture supervenes. In
either case, the presentation is severe pain with a peri-anal lump, often after
straining. Internal Hemorrhoids are painless and often manifested with bright
red rectal bleeding (usually with or following bowel movements), which is the
most common symptom of this condition. Prolapse with defecation or other
straining activities are also common.
Diagnosis: clinical
Treatment
Non-drug treatment:
- Personal hygiene,
- Avoid constipation.
Drug treatment:
First line
Bismuth subgallate, insert one suppository in the rectum bid, or use
topical application, bid for five days.
S/E: rare
Dosage forms: Dosage forms: suppository, bismuth subgallate
(59mg) + bismuth oxide (24mg) + Peru Balsam (49mg) + zinc oxide
(296mg); ointment, Bismuth Subgallate (2,25%) + bismuth oxide
(0.875%) + Peru Balsam (1.875%) + zinc oxide (10.75%)

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Alternatives
Bismuth subgallate with hydrocortisone, insert one suppository in
the rectum bid, or use topical application, bid for five days.
(For S/E and C/I , see above 160)
Dosage forms: Suppository, bismuth subgallate (59mg) + bismuth
oxide (24mg) + Peru Balsam (49mg) + zinc oxide (296mg) +
hydrocortisone acetate (10mg) + benzyl Benzoate (33mg); ointment.
Bismuth subgallate (2,25%) + bismuth oxide (0.875%) + Peru Balsam
(1.875%) + zinc oxide (10.75%) + hydrocortisone acetate
(0.25%)+benzyl benzoate (1.25%)

OR
Lidocaine + aluminium acetate + zinc oxide + hydrocortisone
acetate, one suppository or topical application bid for five days.
S/E: rare
Dosage forms: suppository, lidocaine (60mg)+aluminium acetate
(50mg)+zinc oxide(500mg)+ hydro-cortisone acetate(5mg); ointment:
lidocaine(50mg) + aluminium acetate (35mg) +zinc oxide (180mg) +
hydro-cortisone acetate(2.5mg)

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HYPERTENSION
Hypertension is state of elevated blood pressure, which is commonly
asymptomatic. It often leads to lethal complications like coronary artery
disease, cerebro-vascular accidents, heart and renal failures, and retinopathy. In
90-95% of cases, the cause is unknown; the rest are due to renal, endocrine,
neurogenic and other abnormalities.

Diagnosis is based on measurement of blood pressure on three separate

occasions. Accordingly, a systolic blood pressure of 140 mm Hg or greater and
/or a diastolic blood pressure of 90 mm Hg or greater, taken on two different
occasions in an individual who is not acutely ill, establishes the diagnosis of
hypertension.

Classification and risk assessment:

Blood pressure in, mm Hg
Category systolic Diastolic

Optimal control <120 and <80

Normal <130 and <85

High-Normal 130-139 or 85-89

Hypertension
Stage1 140-159 or 90-99
Stage 2 160-179 or 100-109
Stage 3 > 180 or > 110

Major Risk factors

• Smoking, dyslipedemia, diabetes mellitus

• Age > 60yrs, Sex (men and postmenopausal women),

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• Family history of cardio-vascular disease in women < 65 or

men<55years
• Target organ damage (TOD) or Clinical cardiovascular disease
(CCD)

Hypertensive Crisis: - There are two major forms:

1. Hypertensive Emergencies

These are situations that require immediate blood pressure reduction to prevent
or limit target organ damage. The conditions include hypertensive
encephalopathy, intracranial hemorrhage, unstable angina, acute myocardial
infarction, pulmonary edema and dissecting aortic aneurysm, and eclampsia.

2. Hypertensive Urgencies
These are situations in which it is desirable to reduce the blood pressure within
a few hours. These include upper level of stage 3 hypertension, hypertension
with optic disk edema, progressive target organ complication and severe pre-
operative hypertension.

Treatment

General principles of treatment

Blood Risk group A Risk group B (At least Risk group C

pressure (No risk factor, 1 risk factor, No (TOD/CCD) and/or
stage (mm No TOD / diabetes, No diabetes, with or
Hg) CCD) TOD/CCD) without other risk
factors
High Lifestyle Lifestyle Modification Drug therapy
Normal modification

Stage 1 Lifestyle Lifestyle Drug therapy

modification modification(up to 6
(up to 12 months)

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months)
Stage 2 Drug therapy Drug therapy Drug therapy
and 3

Non Drug treatment

• Reduce salt intake

• Reduce weight if overweight
• Regular exercise
• Reduce intake of saturated fat and cholestrol
• Quit smoking

Drug treatment

Any one of the following classes of drugs could be used as first step agents:
Diuretics, Beta blockers, Calcium antagonists and Converting enzyme
inhibitors.
A. First line drugs for non -Emergency conditions
Hydrochlorothiazide, 12.5- 50 mg/day, p.o.
S/E: hypokalemia, hyponatrimia, glucose intolerance, hyperuricemia
C/I: gouty arthritis, diabetis mellitus, hypokalemia, dyslipidemia,
severe renal impairment
Dosage forms: tablet, 25mg
AND/OR
Nifedipine, 10 –40 mg, p.o., tid.
S/E: flushing, oedema of ankle, headache, gingival hypertrophy
C/I: unstable angina, hypotension
D/I: Cimetidine may enhance it’s anti-hypertensive effect
Dosage forms: tablet, 10 mg, 20 mg; capsule, 5 mg, 10 mg, 20 mg
AND/OR

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Propranolol 40-160 mg p.o divided in to 2-4 doses,

( For S/E, C/I and Dosage forms/ see on page 85)
Alterative
Enalapril, 2.5- 40mg p.o., once or divided into two doses daily.
(For S/E, C/I and Dosage forms: see on page 196)
Caution: Should be used with caution in systolic blood pressure < 80
mmHg, serum creatinine level > 3mg/l, bilateral renal artery stenosis
and serum potassium > 5.5 mmol.
AND /OR
Methyldopa, 250-2000 mg p.o. in divided doses
S/E: dry mouth, water and salt retention, and drowsiness, drug
fever,hepatitis.
C/I: active hepatic disease
Dosage forms: tablet, 250 mg, and 500 mg

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OR
Hydralazine, 10-20 mg, slow i.v. can be given in severe
hypertension.
S/E: nausea, headache, weakness, palpitation, flushing, aggravation of
angina.
C/I: porphyria, aortic stenosis, lupus erythematosis renal failure
Dosage forms: injection, 20m/ml in 1ml ampoule
OR
Atenolol, 50 – 100 mg p.o daily.(For S/E,C/I, see under propanolol,
page 85)
Dosage forms: tablet, 50 mg, 100 mg

C. Treatment of Hypertensive Emergency

Hydralazine, 5 mg i.v. every 15-min should be given until the mean arterial
blood pressure is reduced by 25% (within minutes to 2 hours), then towards
160/100 mm Hg within 2-6 hours. Depending on the underlying
condition/target organ damage, furosemide, 40 mg i.v. can be used according
to blood pressure response.

D. Treatment of Hypertensive Urgency

Nifedipine, 20-120 mg p.o in divided doses per day could be used. .(For
S/E,C/I and Dosage forms, see page 202)
OR
Captopril, 25-50 mg p.o three times daily
S/E: tachycardia, weight loss, stomatitis, photosensitivity
C/I: porphyria
Dosage forms: Tablet, 12.5 mg, 25 mg, 50 mg, 100 mg.

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N.B.
Choice of the type of drug should be dependent on the underlying
clinical situation. If there is acute coronary syndrome, dihydropyridine
type of calcium channel blockers (e.g. nifidipine) are contraindicated.

Table 1. List of common Anti-hypertensive drugs and their dosage

Name Dose (in mg)
Diuretics, e.g. Hydrochlortiazide 12.5-50 mg per day
Beta- Blockers, e.g. Propranalol 40-160 b.i.d
Calcium channel blockers, e.g. Nefidipine 10-40 mg t.i.d
Anti-adrenergic agents, e.g. Methyl-dopa 250-500 mg b.i.d.-t.i.d.
ACE Inhibitors, e.g. Enalapril 2.5-40 per day

Table 2. Drugs used in the treatment of hypertensive crisis

Drug Route Initial Dose Range Onset - Duration
dose peak
Effects
Nitroprusside I.V 0.5 0.5 to 10 1 to 2 min 2 to 3
µg/kg µg/kg per min min
per min
Hydralazine I.V 10 mg 5 to 20 mg 5 to 15min 2 to 6 hr
every 20-30
min
Nifedipine P.O 10 mg 10 to 20 mg 2 to 20 3 to 6 hr
every 15 min min
Captopril P.O 6.25 to 12.5 50 mg 30 to 90 4 to 6 hr
12 .5 mg every 8 hr min
Propranolol I.V 0.5 to 1 0.5 mg every 1 to 2 min 4 to 12 hr
mg 5 min
( maximum 6
mg)

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IMMUNE THROMBOCYTOPENIC PURPURA (ITP)

ITP is an autoimmune disorder characterized by a low platelet count and
mucocutaneous bleeding. It is caused by the production of antiplatelet
antibodies that results in their clearance and destruction by the
reticuloendothelial system. ITP in adults, unlike children, is a chronic, indolent
disorder.
Diagnosis:
1. Complete blood count, including platelet count
2 Peripheral blood smear examination
3. Bone marrow aspiration and/or biopsy
4. The diagnosis of ITP is suggested by an isolated thrombocytopenia in the
absence of other causes, such as HIV infection.
Treatment:
General:
• Patients with a platelet count of >30,000/µL, who are asymptomatic should
be
observed without treatment.
• Females in their childbearing ages should be offered oral contraceptive pills
to avoid
excessive bleeding.
• Patients with wet purpura and retinal hemorrhages (impending CNS
bleeding) should
be admitted to hospital for observation and expectant treatment.
Drug Treatment:
For patients with abnormal hemostasis and a platelet count of <
30,000/µL,

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Prednisolone 1-2 mg/kg (one tablet is 2.5 or 5 mg) p.o. or its

equivalent is given daily for 4-6 weeks, tapering it slowly when the
platelet count rises to >100,000/µL. (for S/E, C/I and Dosage forms,
see page 173)
Note:
Splenectomy is indicated in patients who fail to achieve satisfactory
hemostatic response to acceptable doses of corticosteroids (<15
mg/qid of prednisolone) or who do not respond to steroids.

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MIGRAINE
Migraine is a paroxysmal recurrent headache unilateral or bilateral lasting 4-72
hours. Often preceded by aura and accompanied by nausea and/or vomiting. Its
etiology is unknown. Serotonin metabolism abnormalities may play a role.
Diagnosis: Clinical
Treatment:
Non-drug treatment:
• Patients should be reassured that this is a benign condition.
• They should attempt to identify foods or drinks and other
situations, which precipitate the attack and try to diminish
patterns of tension.
Drug Treatment:

ACUTE TREATMENT, MILD ATTACKS:

First line
Analgesics, e.g. Acetylsalicylic acid, soluble, 600-900 mg p.o. once,
followed by 300 mg half hourly up to a maximum dose of 1800 mg
S/E: Dyspepsia, fatigue, nausea, and diarrhea
C/I: Hypersensitivity, active peptic ulcer disease
Dosage forms: tablet, 100mg (soluble), 300mg, 500mg (enteric
coated)
Alternative
Paracetamol, 500-1000 mg p.o. 4-6 hourly, p.r.n (For S/E, C/I and
Dosage forms, see page 73)
Comments:
• Initiate therapy during the attack or at the very onset of the
headache

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If nausea and vomiting is troublesomean anti-emetic,

e.g.Metoclopramide, p.o. 10 mg 3 times daily can be used.
S/E: drowsiness, fatigue, dizziness, weakness
C/I: epilepsy, pheochromocytoma, and mechanical bowel obstruction,
concomitant administration of atropine like drugs.
S/P: concomitant administration of phenothiazines.
Dosage forms: tablet, 10mg; syrup, 5mg/5ml; injection, 5mg/ml in
2ml ampoule; drop, 0.2mg/drop.

MORE SEVERE ATTACKS, ESPECIALLY WITH A DEFINED AURA:

First line
NSAIDs, e.g. Ibuprofen, p.o., 600-1 200 mg/day, in 2-3 divided
doses
S/E: Gastritis, gastrointestinal bleeding
C/I: Active peptic ulcer disease
Dosage forms: Tablet, 200mg, 400mg; capsule, 300mg; syrup,
100mg/5ml.
AND/OR
Ergot preparations e.g. Ergotamine tartrate and Caffeine {cafe-
ergot}, 1mg +100 mg p.o. 1-2 tablets immediately, followed by 1/2-1
tablet every 30 minutes to a maximum of 4 tables per attack or 10
tablets per week, or until vomiting occurs.
S/E:nausea, vomiting, abdominal pain, muscle cramps, occasionally
precordial pain, myocardial ischaemia and rarely infarction; repeated
high dose may cause ergotism with gangrene and confusion
C/I: peripheral vascular disease, coronary heart disease, hepatic or
renal

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impairment, inadequately controlled hypertension, pregnancy, and

breast feeding
Dosage forms: tablet, 1mg +100mg; suppository, 2mg +100mg.

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PROPHYLAXIS:
First line
Propranolol, 20 mg/day p.o. in divided doses; titrate the dose up to
adequate response (seldom requires more than 160 mg/day)
(For S/E, C/I and Dosage forms, see page 85)
OR
Amitriptyline, 10-25 mg p.o. at bedtime, titrate dose up to adequate
response. It seldom requires more than 75-150 mg as a single bedtime
dose
S/E: dry mouth, sedation, blurred vision, constipation, nausea,
difficulty with micturition, postural hypotension, arrythmias
C/I: recent myocardial infarction, arrythmias, severe liver disease
Dosage forms: tablet, 10 mg, 25 mg, 50 mg.
Comments: - Regular, daily prophylactic therapy is advised if attacks are
frequent or severe i.e. more than 2-3 per month.
- Success rate: 60-70%

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MOOD DISORDERS
Mood disorders are characterized by abnormal feelings of depression or
euphoria with associated psychotic features in some severe cases. Mood
disorders are divided into depressive and bipolar disorders. The etiology is
unkown.
Diagnosis: Clinical; DSM-IV Criteria

Treatment:
A. DEPRESSIVE DISORDERS
Non-drug treatment
• Psychotherapy - usually cognitive/ behavioral
• Interpersonal therapy (IPT)
• Group therapy and Family therapy.
Drug treatment
Amitriptyline, 75-150 mg/day, p.o. titrate up to 300 mg/day
S/E, C/I and Dosage forms: see on page 210)
Alterantive:
Imipramine, 25-100 mg/day p.o.
S/E: similar to Amitriptyline
C/I: similar to Amitriptyline
Dosage forms: tablet, 10 mg, and 25 mg.
OR
Fluoxetine, 20-40 mg daily p.o.
S/E: GI irritation, dry mouth, nervousness, anxiety, headache,
hypotension, hypersensitivity reactions
C/I: Should be avoided in manic phase..
Dosage forms: capsule, 20 mg.

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Comments:
• Start with lower than therapeutic doses and titrate up to
therapeutic doses within about 7 days - treat for at least 6 months;
suicide risk should always be evaluated.
B. BIPOLAR DISORDERS
Non-drug treatment
• Psychotherapy - usually cognitive/behavioral
• Supportive psychotherapy
• Group therapy and Family therapy
Drug Treatment
First line:
Haloperidol, 5 - 40 mg/day p.o. in divided doses 5 -10 mg i.m.
S/E: extrapyramidal effects such as dystonic reactions and
akathisia
C/I: Parkinsons disease
Dosage forms: tablet, 1mg, 2 mg, 5 mg; oral liquid, 2 mg/ml;
injection , 5 mg/ml in 1 amoule
Alternative:
Chlorpromazine, 100 – 1000 mg/day p.o. in divided doses
(For S/E, C/I and Dosage forms, see page 84)
OR
Carbamazepine, 200-600 mg p.o. 2-3 times daily. S/E, C/I and
Dosage forms, see page 190)
Comment:
• Treatment with carbamazepine is effective, but usually after the
manic episode has been controlled by an antipsychotic
(haloperidol).

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MYOCARDIAL INFARCTION
Myocardial infarction occurs when there is an abrupt decrease in coronary
blood flow following a thrombotic occlusion of a coronary artery previously
narrowed by atherosclerosis. Pain is the most frequent presenting complaint in
patients with myocardial infarction. Typically, the pain involves the central
portion of the chest anteriorly and/or the epigastrium. However, myocardial
infarction may be painless. The incidence of infarction is greater in patients
with diabetes mellitus and it also increases with age.
Diagnosis is made by Electrocardiography, presence of ST elevation and /or Q
waves in leads overlying the infracted region; echocardiography: presence of
wall motion abnormalities, and systolic and/or diastolic dysfunction.
Treatment
Non-drug treatment:
Bed rest for the 1st 12 hours; if no other complication exists patient can sit
up within 24 hours.
Diet high in fiber, potassium and magnesium; low in sodium, saturated fat
and cholesterol.
Drug treatment:
Oxygen, 2-4 l/min, via facemask, if patient is hypoxic (low O2
saturation)
PLUS
Nitroglycerin, 0.5mg, sublingual, every 5 min up to 3 doses. (For
S/E, C/I and Dosage forms, see page 158)
PLUS
Acetylsalicylic acid, 80-325 mg p.o. daily.
S/E: dyspepsia, fatigue, nausea, and diarrhea
C/I: hypersensitivity, active peptic ulcer disease
Dosage forms: tablet, 100mg (soluble), 300mg, 500mg(enteric
coated)
PLUS

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Diazepam, 5mg p.o. 3-4 times daily.

(For S/E, C/I and Dosage forms, see page 84)

PLUS
Morphine (for control of pain), 2-4 mg i.v. every 5 min until the
desired level of analgesia is achieved or until unacceptable side effects
occurs. (For S/E, C/I and Dosage forms, see page 157).
PLUS
Heparin:
For all patients with myocardial infarction (MI), 7500 units subcutaneously
every 12 hours until the patient is ambulatory. For patients at increased risk of
systemic or pulmonary thromboembolism, (anterior MI, severe left ventricular
dysfunction, congestive heart failure, history of embolism, echocardiographic
evidence of mural thrombus, or atrial fibrillation), heparin 5000 i.v. bolus
followed by infusion of 1000 units per hour . The activated partial
thromboplastin time should be maintained between 1.5 to 2 times the control
value.
S/E: bleeding, allergy, reversible allopecia, osteoporosis, thrombocytopenea,
paradoxical thromboembolism.
C/I: hypersensitivity to the drug, active bleeding, hemophilia,
thromboeytopenia , purpura, severe hypertension, intracranial hemorrhage,
infective endocarditis, & during or after neuro surgical procedures.
Dosage forms: Injection, 1000 IU/ml, 5000 U/ml in 5 ml ampoules; 5000
IU/ml, 12,500 IU/ml, in 1ml ampoules; 24000 USP IU/5 ml
PLUS
This followed by Warfarin for at least 3 months
S/E: hemorrhage in the fetus during pregnancy, fetal malformation,
cutaneous necrosis.
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C/I: bleeding, breast feeding, pregnancy

Dosage forms: tablet, 2mg, 5mg, 10mg.

PLUS
Enalapril, 5 - 40 mg p.o once or divided into two to three doses daily.
(For S/E, C/I and Dosage forms, see on page 196)
PLUS
Propranolol, 40-480 mg p.o divided in to 2-3 doses, S/E, C/I and
Dosage forms: see on page 85)

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NAUSEA AND VOMITING

Nausea refers to the feeling of an imminent desire to vomit where as vomiting
refers to the forceful oral expulsion of gastric contents. They may occur
independently of each other but generally are closely related. They are
common manifestations of many organic and functional disorders. One should
therefore look for and correct any underlying causes. Effective therapy usually
depends on correction of the underlying cause.
Treatment
Non-drug treatment:
Removal of the underlined cause, correct dehydration, if any
Drug treatment:
First line
Meclizine hydrochloride, 25-50mg. p.o
S/E: sedation.
C/I: active work such as deriving
Dosage forms: Tablets, 12.5mg, 25mg
Alternative
Metoclopramide, 10mg, p.o. tid or im or iv 1 – 3 times a day. For
children: maximum 0.5 mg/kg daily
(For S/E, C/I and Dosage forms, see page 208)
OR
Chlorpromazine, 12.5 - 25 mg IM 12 hrly.
(For S/E, C/I and Dosage forms, see page 84)

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NON-ULCER DYSPEPSIA
Non-ulcer dyspepsia is a chronic, recurrent, often meal-related epigastric
discomfort, pain or fullness. The location of the pain and the relationship to
meals resembles the classic description of PUD except that no evidence for
ulcer will be found by either endoscopy or barium studies.

Diagnosis is often made on clinical grounds but endoscopy or barium meal

studies might be required to exclude ulcer.

Treatment
First line:
Mixtures of Aluminium hydroxide and Magnesium trisilicate, 10 -
30 ml or
2 – 4 chewable tablets p.o. taken between meals prn.
S/E: rare and mild
C/I: insignificant
Dosage forms: suspension, 310 mg + 620 mg in 5 ml; tablet
(chewable), 120 mg + 250 mg; 250 mg + 500 mg.
OR
Mixtures of Magnesium hydroxide and aluminium hydroxide, 10 - 30
ml or
2 – 4 chewable tablets, p.o. between meals prn.
Dosage forms: chewable tablet, 400mg + 400 mg, 195mg + 220mg in 5
ml.

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OR
Magnesium trisilicate 2 – 4 chewable tablets, p.o. between meals
prn.
Dosage forms: chewable tablet, 500 mg.
OR
Magnesium hydroxide, 10 - 30 ml or 2 – 4 chewable tablets, p.o.
between meals PRN.
Dosage forms: chewable tablet, 300mg + 311mg; Mixture,
375mg/5ml, 7.75%.

Alternative:
Cimetidine: 400 mg twice daily, with breakfast and at night, or 800
mg at night for 2 weeks. For children, oral, 20-40 mg/kg/day,
neonates 10-20mg/kg, in 4 divided doses.
S/E: galactorrhea, gynacomastia, impotence.
C/I: insignificant
D/I: may enhance the effect of drugs like warfarin, phenytoin, and
lidocaine.
Dosage forms: tablet, 200 mg, 400 mg, 800 mg; chewable tablet, 200
mg; syrup, 200 mg/5 ml; injection, 200 mg/ml in 2 ml ampoule

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OSTEOARTHRITIS
Osteoarthritis is a progressive loss of joint cartilage with reactive changes at
joint margins and subchondral bone. The exact cause is unknown, but
biomechanical as well as biochemical factors are implicated in the
pathogenesis.

Diagnosis: Clinical and X-ray studies of affected joints

Treatment:
Non-drug treatment:
• Patient and family education
• Attend to predisposing factors such as weight reduction, exercise
• Rest during acute painful episodes
• Support and alleviate weight bearing in affected joints.
• Physiotherapy
• Surgery
Drug Treatment:
First line
Paracetamol, 500-1000 mg p.o.as needed (4-6 times daily) is the
treatment of choice when only pain relief is needed
(For S/Es, C/Is, D/Is and Dosage forms, see page 73)
Alternatives
Low dose NSAIDs e.g. Ibuprofen, 600-1,200 mg/day p.o.in
divided doses as needed (ForS/E, C/I and Dosage forms, see
page 209)
OR
Combination of Paracetamol and NSAID can also be given.
Intra-articular steroid such as Methyl predinsolone acetate when
there is evidence of persistent inflammation with joint swelling.

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(For S/E, C/I and Dosage forms, see page 73 & 131)

Comments:
• As pain relief is the main objective, in the absence of
inflammation (osteo-arthrosis), NSAID's should be avoided, as
these patients often have concomitant conditions for which
NSAIDs may be contra-indicated. The elderly and those with
cardiovascular or gastrointestinal disease or renal function
impairment are especially at risk.
• Referral criteria includes: Pathological fracture/dislocation,
intractable pain, infection, doubtful diagnosis and when joint
replacement is considered.

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PEPTIC ULCER (PUD)

PUD is a mucosal lesion of the stomach or duodenum. It is believed to occur
when gastro-duodenal mucosal defenses are unable to protect the epithelium
from the corrosive effects of acid and pepsin. H. Pylori infection is also an
important risk factor.
Epigastric pain, which comes 90 minutes to 3 hours after eating, is the most
frequent symptom. Other suggestive symptoms include right upper quadrant
pain, abdominal fullness, nausea and vomiting.
Diagnosis: The correct diagnosis may require endoscopic examination. Tests
to detect H. pylori are also important. These include urease assay, histology,
culture and serology.
Treatment:
Non drug treatment:
I) PUD only
First Line:
Mixtures of Magnesium trisilicate and Aluminium hydroxide, 10 -
30 ml or 2 – 4 chewable tablets, p.o. between meals and at bedtime for
4 weeks.
Dosage forms: chewable tablet, 400mg + 400 mg, 195mg + 220mg in
5 ml.
OR
Cimetidine, 400 mg p.o. twice daily, with breakfast and at night, or
800 mg at night for 4 - 6 weeks. GU may require 6 weeks of 400 mg
bid treatment. For children, IV or oral, 20-40 mg/kg/day, neonates 10-
20mg/kg, in 4 divided doses.
(For S/Es, C/Is, D/Is and Dosage forms, see page 218)
OR
Famotidine, 40 mg, p.o. at night for 4 – 6 weeks.

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S/E: GI disturbances
C/I: insignificant
Dosage forms: Tablet, 20 mg, and 40 mg.
Alterative
Ranitidine, 150 mg p.o. bid or 300 mg at bedtime for 4 – 6 weeks.
Maintenance therapy: 150 mg at bedtime.
S/E: GI disturbances
C/I: insignificant
Dosage forms: Tablet, 150 mg; injection, 10 mg/ml in 5 ml ampoule,
25 mg/ml in 10 ml ampoule
Alternatives:
Omeprazole, 20 mg p.o. once daily for 4 weeks (DU) or 8 weeks
(GU).
S/E: GI disturbances.
C/I: pregnancy, lactation
D/I: may enhance the effect of drugs like warfarin and phenytoin
Dosage forms: capsule, 20 mg

II) PUD associated with H. pylori

First Line:
Amoxicillin, 1g, p.o. twice daily
(For S/Es, C/Is, D/Is and Dosage forms, see page 31)
PLUS
Clarithromycin, 500mg p.o. twice daily
S/E: minor diarrhea
C/I: insignificant
Dosage forms: Tablet, 250 mg, 500 mg
PLUS
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Omeprazole, 20mg p.o. twice daily (or 40mg once daily), all for 7 -
14 days
(For S/E, C/I and dosage forms, see above page 222)
Alternatives:
Amoxicillin, 1g, p.o. twice daily
(For S/E, C/I, D/I and Dosage forms, see page 31)
PLUS
Metronidazole, 500mg, p.o. twice daily
(For S/E, C/I, D/I and Dosage forms, see page 24)

PLUS
Omeprazole, 20 mg p.o. twice daily (or 40 mg once daily), all for 7 -
10 days. (For S/E, C/I and dosage forms, see page 222)

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PORTAL HYPERTENSION
Portal hypertension is an abnormal elevation of the portal pressure exceeding
30 cm of saline. It occurs due to increased resistance to the portal blood flow.
Common causes include cirrhosis of the liver, portal vein thrombosis,
schistosomiasis and Budd-chiari syndrome. It may clinically manifest itself in
one or more of the following: upper GI bleeding, ascites, splenomegally; and if
cirrhosis is the cause, with acute and chronic hepatic enchephalopathy.
Diagnosis
• Clinical
• Ultrasound examination may reveal portal vein thrombosis or
fibrosis.
Principles of management of Portal hypertension
Non-drug treatment
• Take adequate bed rest
• Control ascites by dietary salt restriction, and cautious
mechanical fluid removal
• Reduce protein intake
• Remove cause and aggravating factors if possible.
Other treatments may include:
• Blood transfusion may be needed in cases of variceal bleeding
• Sclerotherapy for variceal bleeding
• Surgery, if recommended, e.g., portal venous shunt

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Drug treatment
For ASCITES AND EDEMA:
Spironolactone, p.o, 25-50 mg 3 times daily
(For S/Es, C/Is, D/Is and Dosage forms, see page 197)
AND/ OR
Furosemide, initially low dose, 20-40 mg /day i.v. Titrate the dose
carefully until the desired effect is achieved.
(For S/Es, C/Is, D/Is and Dosage forms,: see page 157)

For HEPATIC ENCEPHALOPATHY:

Magnesium sulfate, 5-15g, p.o 12 hourly
(For S/E, C/I, D/I and Dosage forms, see page 182)
OR
Lactulose, 10-30 ml p.o. tid
S/E: rare and mild
C/I: galactosaemia
Dosage forms: powder, 10g sachet; syrup, 3.3g/5ml (not on NDL)
AND
Ampicillin, 500 mg p.o. 6 hourly
(For S/E, C/I, D/I and Dosage forms, see page 31)
OR
Neomycin, 1-2 g p.o. 6hourly and may be used intermittently one
week at a time, for long-term use.
S/E:ototoxic, nephrotoxic, neurotoxic, allergic reactions,
membranous- enterocollitis
C/I: hypersensitivity to this drug, renal impairment
Dosage forms: tablet, 500mg

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RHEUMATIC FEVER
It is a systemic disease that primarily affects the heart and joints, which follows
group streptococcal upper respiratory tract infections. It is characterized by five
major manifestations like carditis, migratory polyarthritis, Syndenham’s
chorea, subcutaneous nodules and erythema marginatum, and minor
manifestations like fever arthralgia, elevated acute phase reactants, and
prolonged PR interval on electrocardiography. Its cause is believed to be an
immunologic reaction to group A streptococcal infection of the respiratory
tract.
Diagnosis shall be based on the modified Jones criteria: either two major
criteria, or one major criterion and two minor criteria,
PLUS
Evidence of an antecedent streptococcal infection (e.g, positive throat
culture or rapid antigen test;
AND/OR
Elevated or increasing streptococcal antibody test. The modified Jones
criteria need not be fulfilled in patients presenting with Syndenham’s
chorea, indolent carditis, and recurrence of acute rheumatic fever.
Treatment
Drug treatment:
Benzathine penicillin G I.M. 1.2 million units stat.
(For S/E, C/I, and D/I see under benzyl penicllin, page 55)
If patient is allergic to penicillin
Erythromycin, 250mg four times po daily for 10 days. (For S/E, C/I,
D/I and Dosage forms, see page 31)
PLUS
Aspirin, up to 2g four times daily for 4-6 weeks and gradually tapered
over 2 weeks, (For S/E, C/I and Dosage forms, see page 48)
AND/OR
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standard treatment guidelines for zonal hospitals

Prednisolone, up to 30 mg p.o. four times daily. During the tapering

of steriod over 4-6 weeks aspirin should to add to prevent a rebound.
(For S/E, C/I, D/I and Dosage forms, see page 173)

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RHEUMATIC HEART DISEASE (CHRONIC)

This is a delayed consequence of rheumatic fever, which mainly affects the
mitral and aortic values.

Diagnosis: see note under rheumatic fever

Treatment

The most important management is administration of secondary

prophylaxis as follows:
Drug treatment:
First line:
Benzanthine penicillin G, 1.2 million units i.m. every 3-4 weeks
should be given as a secondary prophylaxis for a minimum of 10
years or until the age of 40 years which ever is longer. (For S/E, C/I
and dosage forms, see under benzyl penicillin, see page 55)
Alternative
Penicillin V, 250 mg p.o. daily
Dosage forms: Tablet, 125 mg, 250 mg, 500,000 IU; oral suspension,
125 mg/5 ml, 50,000 IU/ml
(For S/E, C/I and dosage forms, see under Penicillin G, page 55)
OR
Sulfadiazine 1gm, p.o once daily
(For S/Es, C/Is, D/Is and Dosage forms, see page 88)
In case of penicillin and sulfadiazine allergy, Erythromycin 250 p.o
mg twice daily can be used.
Once patients begin to be symptomatic better to consider surgical
correction of the value lesion

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RHEUMATOID ARTHRITIS
Rheumatoid Arthritis is a chronic systemic inflammatory disease of unknown
etiology with predilection for joint involvement. Its etiology is not known, but
it is presumed to involve autoimmune reactions.
Diagnosis: American College of Rheumatology criteria: 4 of the 7 criteria must
be
present.
Treatment:
Non-Drug treatment:
• Should be managed by co-ordinated multidisciplinary care
(including Physiotherapy and Occupational therapy).
• Acute flare-ups: Rest affected joints, use of day and/or night
splints
Drug Treatment:
First line
Non-steroidal anti-inflammatory Drugs
Aspirin, 600-1200mg p.o. tid daily,
(For S/E, C/I, D/I and Dosage forms, see page 48)
OR
Ibuprofen, 400-800 mg p.o. 3 times daily
(For S/E, C/I and Dosage forms, see page 209)
OR
Indomethacin, 25-50 mg p.o. 3 times daily,
(For S/E, C/I and Dosage forms, see page 193)
OR
Indomethacin, 100 mg rectal at night, as part of the total daily dose
of NSAID, may be needed in some patients for severe nocturnal pain.
(For S/E, D/I and Dosage forms, see page 193)

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Comments:
Reduced NSAID doses have to be used in the elderly and inpatients
with impaired renal function. Concomitant use of more than one
NSAID only increases toxicity, and has no additional benefit.
Cimetidine, 200 mg p.o. twice daily may be considered for those at
risk for gastrointestinal side
(FornS/E, C/I and Dosage form, see on page 218)
Alternatives
A. Disease-modifying Anti-rheumatic Drugs (DMARD):
Chloroquine phosphate, 150-300 mg p.o. as base daily
(For S/E, C/I and Dosage forms, see page 26)
AND/OR
Methotrexate, 7.5 mg p.o. weekly,
N.B. patients on methotrexate should be placed on
supplementary folic acid, oral, 5 mg daily
S/E: Dizziness, fatigue, headache, bone marrow suppression,
hepatotoxicity, rashes, photosensitivity, interstitial
pneumonitis
C/I: Pregnancy, lactation, chronic liver disease, alcoholism,
preexisting blood dyscrasis
Dosage forms: Tablet, 2.5mg, 10mg.
AND/OR
Azathioprine, 50-100 mg/day p.o.
S/E: Nausea, vomiting, leukopenia, thrombocytopenia, rash.
C/I: Pregnancy
Dosage forms: Tablet, 50mg.

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Comments:
• Patients not responding to NSAIDs and non-pharmacological therapy
within 4-6 weeks, should seek specialist advice for consideration of
therapy with disease-modifying anti-rheumatic medication (DMARD)
• DMARDs must be used only if adequate monitoring for toxicity is
regularly performed. This applies particularly to retinal toxicity
caused by chloroquine and bone marrow depression and liver damage
caused by methotrexate.
• Doses of most of these are gradually titrated to a maintenance dose.
OR
B. Oral Corticosteroids
Prednisolne, 30-40 mg/day p.o. for 1-2 weeks with rapid tappering to
minimize side effects. Use for longer duration at doses of 5-
7.5mg/day.
(For S/E, C/I and Dosage forms, see page 173)
OR
C. Intra-articular Corticosteroids
Methylprednisolone acetate, 20-80 mg intra-articular depending on
the joint
S/E: tendon rupture, osteonecrosis,
C/I: infection in or around the joints
Dosage form: Injection (aqueous suspension), 40mg/ml in 1ml and
2ml ampoules.
Comments:
• Should be given by Rheumatologist.
• Should be used only in patients with isolated persistent
monoarticular synovitis.
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• Should not be given more than 2 – 3 times a year.

SCHIZOPHRENIA
Schizophrenia is a psychiatric disorder characterized by psychotic symptoms
that significantly impair functioning and that involve disturbances in feeling,
thinking, and behavior. The etiology is unknown.
Diagnosis: clinical; DSM-IV Criteria
Treatment
Non-drug treatment:
• Supportive psychotherapy and psycho-educational group therapy
for patients and family members
Drug Treatment:
EMERGENCY PHASE
First line
Chlorpromazine hydrochloride, 25 mg, i.m. and raise to 200 mg
daily for acute attacks
(For S/E, C/I and Dosage forms, see page 84)
Alternative
Haloperidol, 5-10 mg i.m/i.v. over 30-60 minutes. Daily dose may go
as high as 40 mg.
(For S/E, C/I, D/I and Dosage forms, see page 212)

STABILIZATION PHASE
First line
Haloperidol, 1-15 mg/day p.o..
(For S/E, C/I and Dosage form, see page 212)

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Alternative
Chlorpromazine, 75- 300 mg/day p.o. in divided doses.
(For S/E, C/I and Dosage forms, see page 84)
MAINTENANCE (CHRONIC THERAPY)
First line
Haloperidol, 1-15 mg/day p.o..
(For S/E, C/I and Dosage forms, see page 212)

Alternatives
Chlorpromazine, 75- 300 mg/day p.o. in divided doses.
(For S/E, C/I and Dosage forms, see page 84)

OR
Fluphenazine decanoate, 12.5-100 mg i.m. every 3-4 weeks
S/E: similar to chlorpromazine, extrapyramidal features are more
frequent
C/I: similar to chlorpromazine
Dosage forms: Injection, (Depot, Oily), 25mg/ml in 1ml and 2ml
ampoules and in 10ml vial

Comment:
• After 6 months in remission the drug can be withdrawn for a
trial period to see if relapse occurs, at which point therapy is
instituted.

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THYROTOXICOSIS
Thyrotoxicosis is a clinical state resulting from excess thyroid hormone in the
body. It is clinically characterized by weight loss, palpitation, and shortness of
breath, weakness, heat intolerance and nervousness.
Diagnosis
• Is mainly clinical,
• Determination of serum thyroid hormones confirms the diagnosis and
• TSH radioactive iodine uptake is also helpful.
Treatment
First Line
Propylthiouracil, 100-450 mg p.o. daily divided into three to four
doses.
S/E: leukopenia, allergy, agranulocytosis, hepatitis, drug fever,
arthralgia;
C/I: impaired liver function
Dosage forms: tablet, 25mg, 100mg
Note: Duration of treatment depends on the specific cause of the
hyperthyroidism. In Grave’s disease, PTU can be stopped after 1-2 years of
treatment. In case of Toxic nodular goiter, treatment with PTU should be
continued almost indefinitely.
Alternative
Carbimazole, 20-60 mg p.o. daily in two to three divided doses.
S/E: allergy, arthraigia, hepatitis, drug fever and agranulocytosis.
C/I: impaired liver function
Dosage forms: tablet, 5 mg
PLUS
Propranolol, 10-120 mg p.o. daily divided in to 2-3 doses. (For S/E,
C/I and Dosage forms, see page 85)
Note:

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Propranolol is given until anti-adrenergic sings and symptoms

subside.
Radioactive iodine (131 I), 150-370 MBq (4-10 millicuries)
Chapter 6

OBSTETRICS AND GYNECOLOGICAL CONDITIONS

Anaemia in pregnancy
Contraceptives
Diabetes mellitus complicating pregnancy
Dysfunctional uterine bleeding
Dysmenorrhoea
Evacuation of the uterus
Hypertensive disorders in pregnancy
Nausea and vomiting in pregnancy
Pelvic inflammatory disease
Post abortal/puerperal sepsis
Premature rapture of membranes
Puerperal mastitis
Pyelonephritis
Sexual assault
Syphilis in pregnancy
Vulvo vaginal candidiasis

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ANEMIA IN PREGNANCY
Hemoglobin (Hgb) level below 11 gm /dl in the first and third trimesters of
pregnancy and below 10.5 gm/dl in the second trimester of gestation. The
causes are the same as in non-pregnant women. Iron demand is increased by a
factor of 4-5 during pregnancy. Iron deficiency anemia is the most common
kind of anemia in pregnancy.
Diagnosis Clinical: Nonspecific symptoms like weakness, dizziness,
palpitation, shortness of breath. Physical examination may reveal significant
pallor of the conjunctiva and other parts of the body.
Laboratory: Hgb < 11
Treatment: Depends on the severity of anemia
Non drug treatment:
Iron rich diet
Drug treatment:
Ferrous sulphate, 300 mg p.o. tid for 1-3 months.
(For S/E, C/I and Dosage forms, see page 162)
PLUS
Folic acid, 5mg /day, p.o.
(For S/E and C/I, see page 160)
Dosage forms: Tablet, 200 mg, 1 mg, 5 mg; Injection, 5 mg/ml in
1ml ampoule
Sustained release capsule, 150 mg dry ferrous sulphate and 0.5 mg
folic acid
Severe anemia: Requires admission and blood transfusion in the presence of
complications.

Prevention
Avoid frequent childbirth

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Prevent hemorrhage during pregnancy & childbirth

Advise on adequate nutrition
Prevent malaria
Treat hookworm infection
Supplement iron/folic acid to all pregnant women

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CONTRACEPTIVES
Contraceptives include different kinds of methods used to prevent the
occurrence of pregnancy. Natural methods, barrier methods, intrauterine
contraceptive devices, hormonal methods and permanent methods of
contraception exist for use. Hormonal contraceptives are one of the most
effective methods that are prescribed to a client based on informed choice.

HORMONAL CONTRACEPTIVES
1. Combined Oral Contraceptives (COC):
A group of contraceptive medications composed of synthetic estrogens &
progesterone in different doses; 20 mcg or 50 mcg of estrogen and 0.15 -1
mg of progesterone in each tab
S/E: Gastro intestinal disturbance, loss of libido
C/I: Pregnancy, Cardiac illness, Thromb-embolic conditions, genital tract
malignancies, Hepatic dysfunction, Migraine headaches.
Drug interaction: -Care needs to be taken while prescribing
anticonvulsants, hypnotics, antibiotics and antacids to a women using
COC since these drugs may reduce the effectiveness of COC. COC may
reduce the effectiveness of drugs like anti convulsants, anticoagulants,
antidepressants, steroids, sedatives and hypoglycemic agents
Dose: one tab /day starting from the first day of menses
Dosage forms:
levonorgesterol+ethnylestradiol and iron:
tablet, 0.15mg + 0.03mg; 0.25mg + 0.05mg; 0.5mg + 0.05mg; 0.3mg +
0.03mg
Norethindrone + ethnylestradiol: tablet, 0.5mg + 0.035mg
Norethindrone + mestranol and iron: tablet, 1mg + 0.05mg
2. Progesterone Only Contraceptives:

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Indicated in case of estrogen contraindication as in lactating mothers,

diabetics, hypertensives
S/E: Irregular vaginal bleeding, head ache, mood changes, weight
changes, acne, functional ovarian cysts
C/I: Pregnancy, genital malignancies, cardiovascular diseases, hepatic
disease
2-1. Progesterone only pills:
Lynestrenol, 0.5 mg
Dosage form: tablet, 0.5mg,
2-2. Injectables
Medroxyprogesterone acetate, 150 mg deep IM injection within the
first 5 days of the cycle to be repeated every three months
S/E: Same as in the POC and delay in return of fertility
Dosage forms: injection (aqueous suspension) ,150 mg/ml in 1 ml
vial
2-3. Implants:
Levonorgesterel in six silastic capsules Implanted in the left upper
arm under local anesthesia, effective up to five years
Dosage forms:-Levonorgesterel 36 mg/implant capsule of 6 implants
Levonorgesterel 75 mg/ implant of two Implants

3. Emergency contraception (EC):

Contraception aimed at preventing pregnancy after unplanned sexual
exposure in a woman who is not on regular contraception.
EC cannot be used as a regular method of contraception.
COC with 50 microgram of estrogen 2tabs 12hrly
OR
COC with 35 microgram of estrogen 4tabs 12hrly within 72 hrs of
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Unplanned sexual exposure for two doses

S/E: nausea and vomiting, menstrual disturbance
C/I: as in COC, POP
Alternative
IUD Insertion within five days of unplanned exposure after ruling
out the existence of infection

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DIABETES MELLITUS COMPLICATING PREGNANCY

Diabetes is one of the most common medical problems complicating
pregnancy. Diabetes in pregnancy can be gestational or pre-gestational.
Women with pre-gestational diabetes need to have preconception counseling to
achieve good glycemic control at the time of conception and organogenesis to
avoid congenital abnormality. Oral hypoglycemic agents are contraindicated
during pregnancy.

Gestational diabetes: - Carbohydrate intolerance of variable severity with

onset or first recognition during pregnancy.
Diagnosis: - Laboratory: Abnormal OGTT
High-risk mothers for GDM that need to be screened at booking
• Family history of DM
• Obese, Hypertensives
• Age over 30 yrs.
• Previous delivery of macrosomic fetus
• Previous pregnancy complicated by GDM
• Unexplained fetal losses
• Persistent glucosuria
Treatment:
Non Drug treatment
1. Diet:
• Three meals and three snacks /day
• Diet with 40-50% carbohydrate, 20% protein and 30-40% fat
content.
• 10% of calorie at breakfast, 30% at lunch and dinner and 30 % at
snack.
2. Exercise:
• Walking or exercise using the upper part of the body is
recommended
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• Maintain the fasting plasma glucose level to be < 105 mg/dl and
the two hours post-prandial <120 mg/ dl
Drug treatment
If the glycemic control is unsatisfactory with diet and exercise, start
insulin therapy
Insulin, combination of 1/3rd short and 2/3rd intermediate acting insulin is
used to maintain the FBS to 60-90 mg/dl 1-hr post-prandial values at<120
mg/dl
(For S/Es and C/Is, see page 184)
Dosage forms:
• Insulin zinc suspension/insulin lente injection, 100 units/ml in 10 ml
vial
• Insulin soluble /Neutral injection, 100 units/ml in 10 ml vial
• Isophane/NPH insulin injection, 100 units/ml in 10 ml vial
• Biphasic insulin injection (highly purified), 100 units/ml in 10 ml vial

• Biphasic isophane insulin injection, 50/50, 30/70, 100 units/ml in 10

ml vial
Plan of delivery
• If the glycemic control on diet and exercise is satisfactory, follow the
pregnancy until term with close fetal surveillance until spontaneous
onset of labor
• If the glycemic control is unsatisfactory, plan delivery after
ascertaining the lung maturity
Intra-partum / Intra-operative Glycemic management:
1. Withhold the AM insulin injection for planned delivery
2. Start IV infusion with 5% D/W at 100 ml/hr
3. Start Insulin infusion with regular insulin at 0.5 unit/hr
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4. Monitor maternal glucose levels hourly and adjust insulin infusion

5. Closely follow the fetal heartbeat
Post partum management:-The need for insulin declines postpartum , therefore
adjust the dose based on sliding scale.
DYSFUNCTIONAL UTERINE BLEEDING (DUB)
Dysfunctional uterine bleeding is an abnormal uterine bleeding with no
obvious organic cause. It is often associated with anovulatory cycle. It is
commonly seen in the two extremes of life: Peri-menarcheal and peri-
menopausal.
Diagnosis: is made by excluding all other obvious causes of uterine bleeding.

1. Anovulatory dysfunctional uterine bleeding:

Treatment: The objective of treatment is
a) To control active bleeding
b) Restore normal cycle
First line
Control of active bleeding:-
Norethisterone 5 mg 6 hourly p.o. for 2-3 days followed by 5 mg p.o.
daily for ten days Dosage form: tablet, 5mg
OR
Medoxyprogesterone, 10-25 mg/6 hrly p.o.until bleeding stops plus
norethisterone, 5 /day p.o. for ten days
(For S/E, C/I and Dosage forms, see page 239)
OR
3. High dose of conjugated estrogens 25 mg IV every 2 to 4 hrs for 24
hrs, 10 mg /day p.o. in 4 divided doses for 10 days or until the
bleeding is stopped then oral estrogen 10 mg/day for 21-25 days. (For
S/E, C/I and dosage forms see page 239)

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Medoxyprogesterone 10- mg/day p.o. for the last 7-10 days

Alternative:
High dose of Combined oral Contraceptive pills (COC) 3-4 tablets
/day until the bleeding is controlled and then the standard dose of
the COC one tablet/day for 21 days
B. Restoration of the cycle: -
• Combined oral contraceptive pills for 3-4 months
• Norethisterone 5mg/day from day 14-24 each month for three
months
C. Surgical: MVA, Dilatation and curettage, Endometrial ablation,
Hystetrectomy
D. Ovulation Induction if fertility is desired

2. ovulatory dysfunctional uterine bleeding:

Ovulatory dysfunctional uterine bleeding occurring along with ovulatory cycle
is commonly diagnosed by the presence of clinical evidence of ovulation and
confirmed by hormone analysis and/or endometrial biopsy. It can be due to
follicular or luteal phase defect.
1. Drug Treatment
First line: NSAID
Ibuprofen, 400 mg 3 times /day. Drugs are given through the
bleeding or through the first three days of the bleeding
(For S/E, C/I and Dosage form, see page 209)
Alternative:
Danazol, 200-400 mg daily for 12 weeks
C/I: - pregnancy, lactation, genital tumors, cardiac, renal, or hepatic
dysfunction

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S/E: -nausea, dizziness, menstrual disturbance, and emotional

instability
Dosage forms: capsule 100, 200-mg tabs
2. Surgical treatment:
• Manual (Electrical) Vacuum Aspiration,
• Dilatation & Curettage,
• Endometrial ablation,
• Hysterectomy

DYSMENORRHOEA
Dysmenorrhoea is pain during menses. It occurs in about 50 % of
menstruating women. It may be primary or secondary. Primary
Dysmenorrhoea is believed due to increased endometrial prostaglandin
production. Whereas secondary Dysmenorhoea is due to outflow obstruction,
pelvic tumors, infections, endometriosis etc.
Diagnosis: Clinical

Treatment:
Primary dysmenorrhoea :
Non Drug: Reassurance
First line: NSAID
Acetylsalicylic acid, 600 mg, P.O. every 8 hrs for 2- days
(For S/E, C/I and Dosage forms, see page 208)
OR
Ibuprophen 400 mg, p.o. every 8 hrs
(For S/E, C/I, D/I and Dosage forms, see page 209)
Note: The drugs have to be administered prior to the onset of
menses or at the onset of pain every 6 to 8 hours.

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Alternative
Monophasic Combined oral contraceptive pills. If Contraception
is also needed (For S/E, C/I and Dosage forms, see on page 238)
Secondary dysmenorrhoea : Treat the underlying causes

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EVACUATION OF THE UTERUS

Termination of pregnancy is legally prohibited in Ethiopia, except in situations
where the continuation of the pregnancy threatens the life of the mother.
Evacuation of the uterus is medically indicated in situations like incomplete,
inevitable, missed abortion, GTD, RPC and termination of pregnancy for
medical indication. It is safe to the mother if it is performed in the first
trimester of pregnancy.
Methods: 1. Manual Vacuum Aspiration or Electrical Vacuum
Aspiration:
• Safe until the 12th week of gestation
• Analgesia/ Anesthesia: Paracervical block, Narcotic analgesia
• Prophylaxtic antibiotics; Ampicilline 1gm i.v. 30 min before the
procedure and then 6 hrly for 24 hrs
• Contraceptive option: - COC, Inject able, Implants, IUD or Barrier
method
• Follow-up after one week,
2. Dilatation & curettage:
• Safe only up to 12 weeks of gestation
• Analgesia/Anesthesia: General, narcotic analgesics, paracervical block
• Prophylactic antibiotics, Contraception and follow-up is same as IN
No. 1
3. Induction with pitocin: This is best done if GA is > 14 weeks
• Induction with pitocin after priming the cervix with
PGE2 3mg at 12,and 6 oclock the night before the planned
termination
Misoprestol 10-25 mg 12, and 6 oclock the night before the
planned termination

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Insertion of inflated catheter in the cervix, or condom catheter

method,
Supplement with Evacuation & Curettage (E&C) if the expulsion is
incomplete.
• Don’t rupture the membranes until the cervix is well dilated
• Avoid frequent vaginal examination.
• Administer analgesics and antibiotics as required
• Provide contraceptives and follow-up appointment on discharge
4. Hysteretomy : if induction with pitocin fails
5. Hysterectomy if any additional indication

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HYPERTENSIVE DISORDERS IN PREGNANCY

Hypertension is one of the common medical problems complicating pregnancy.
It is also one of the three major causes of maternal death. It may manifest as
chronic hypertension, chronic hypertension with superimposed preclampsia,
pregnancy induced hypertension, pre eclampsia or eclampsia. Its causes are not
well defined.
Diagnosis: - Clinical
Laboratory: Proteinuria

1. CHRONIC HYPERTENSION:
Hypertension existing before pregnancy or diagnosed before the 20th week of
gestation
Comments:
• Adjust the dose of antihypertensive drugs depending on the
change in BP measurement,
• Avoid the use of Diuretics
• If there is no worsening of the hypertension delivery can be
planned as non- hypertensive pregnant women

2. PREGNANCY INDUCED HYPERTENSION

A rise in BP> 140/90 mm. Hg after the 20th week of gestation
measured twice at least six hours apart or a single measurement of diastolic
BP>110

PRECLAMPSIA
• Rise in BP > 140/90 plus proteinuria of > 300 mg/ 24 hrs or 100
mg/dl in at least two randomly collected urine specimen at least 6

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hrs apart or plus two or more using dipstick after the 20th week of
gestation.

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Mild preclampsia
• Diastolic blood pressure between 90 and 110 and absence of
severe signs
Severe preclampsia
• Diastolic BP > 110 mm of Hg, measured twice atleast six hours
apart or a single measurment of >120
• Proteinuria > 5gm/24 hrs
• Abnormal liver/ renal function tests,
• Hyperbilirubinemia, thrombocytopenia
• Hemolytic anemia,DIC
• Headache, visual disturbance and upper abdominal pain
• Oliguria
• IUGR,
• Pulmonary edema.
• Exaggerated Deep Tendon Reflexes
• Convulsions

Treatment
Mild preclampsia:
Non drug treatment:
Rest at home with Frequent Follow-up
Plan termination of pregnancy at term.
If it progresses to severe manage as severe case

Severe preclampsia:
a) Control of Hypertension
o Prevent of convulsion and

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o Terminate pregnancy: Intensive monitoring of the

maternal V/S and the fetal heartbeat in a viable fetus is
essential.

Control of Hypertension
Drug treatment:
First line
Methyldopa 250-750 mg. p.o. 3-4 times/day.
(For S/Es, C/Is, D/Is and Dosage forms: see page 203)
OR
Hydralazine 5 mg IV whenever the diastolic BP> 110 mm of Hg
every 20 minutes (For S/Es, C/Is, D/Is and Dosage forms: see page
204)

Alternative
Nifedipine 10 mg sublingual whenever the Diastolic BP > 110 mm of
Hg.
(For S/Es, C/Is and Dosage forms: see page 202)
Prevention of convulsion:
Drug treatment:
First line
Magnesium sulphate, loading dose of 4 gm as 20% solution. IV
over 10-15 minutes followed by 10 gm as 50% IM injection divided
on two sides. Maintenance dose of 5 gm every 4 hrs as 50%
concentration over 2 minutes. 2 gm. IV as 50% soln. over 2 min. if
convulsion recurs;
Reduce maintenance dose of MgSO4 by half if signs of renal
derangement.
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(For S/Es, C/Is and Dosage forms, see page 182)

Management of Magnesium toxicity:
Drug treatment:
Clinical manifestations of magnesium toxicity include decreased respiratory
rate, heart rate, oliguria, & depressed DTR. If DTR is depressed discontinue
MgS04 and monitor the patient closely. If Respiratory rate <12/min administer
Calcium gluconate 1 gm as 10% - 10 ml amp IV over 2 minutes

Alternative
Diazepam 30 IU/ 1000 ml of D/W,(D/S) 20 drops / min and
increase the drops as needed depending on the patients sedation
status.
(For S/E, C/I, D/I and Dosage forms, see page 84)

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NAUSEA AND VOMITING IN PREGNANCY

Nausea and vomiting are common complaints in the first trimester of
pregnancy affecting about 50% of mothers. Severe in multiple gestations and
gestational throphoblastic diseases. Protracted vomiting associated with
dehydration, starvation, weight loss, electrolyte disturbances, acidosis and
ketonuria is known as hyperemesis gravidarum. The cause is not exactly
known.
Diagnosis of Hyperemesis gravidarum: -
Clinical: History and Physical Examination
Laboratory: - Ketonuria
Screen for UTI, GTD, & Multiple gestation
Treatment:
Non-Drug treatment:
For uncomplicated nausea and vomiting of pregnancy give reassurance, advice
on small, high calorie frequent feeding & emotional support.
Drug treatment:
Hyperemesis gravidarum need admission for in-patient care.
• Rehydrate with N/S, Ringers lactate, D/W, D/S eight hourly
• Calorie replacement: 40% Glucose 2 vials (40 ml) in each bag.
• Add Vit. B complex 2 ampoules in each bag
• Control vomiting:
First line
Chlorpromazine,12.5 - 25 mg i.m. 12 hrly. Until vomiting is
controlled and then p.o. (For S/E, C/I and Dosage forms, see page 84)

Alternative
Promethazine 25 mg 12 hrly, 25 mg tabs PO 12 hourly.
S/E: drowsiness.
Dosage forms: injection, 25 mg /ml 1 ml & 2 ml ampoules; tablet,
10 mg, 25 mg, elixir 5mg/5ml and Suppositary 25mg, 50mg
OR

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Metclopromide, 10 mg IM 12 hrly.
(For S/E, C/I, D/I and Dosage forms, see page 208)

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PELVIC INFLAMMATORY DISEASE (PID)

Pelvic inflammatory disease refers to infection of the genital tract above the
internal OS. The common manifestations include fever, lower abdominal
tenderness, cervical excitation tenderness, adnexal tenderness and abnormal
vaginal discharge. It is caused by polymicrobial organisms such as gonoccocus,
chlamdia trachomatis, Mycoplasma hominis and other intestinal and vaginal
normal flora.

Diagnosis:
Clinical: Fever, lower abdominal tenderness, and cervical excitation
tenderness, adnexal tenderness and abnormal vaginal discharge
Laboratory: leucocytosis with neutrophilia and raised ESR
Culture and sensitivity of blood, pus, or vaginal
discharge
Vaginal/Swab: evidence of cervicitis
Ultrasonography: Evidence of inflammatory collection
Laparascopy: visualization of hyperemic tubes, purulent discharge
Laparatomy: Abscess collection or inflammation of the pelvic organs

Treatment:
Drug treatment

1. ACUTE PID (Out patient treatment)

First line:
Ceftriaxone, 250 mg IM stat
Doxycyclline, 100 mg p.o. 12 hrly. (For S/E, C/I and dosage forms,
see page 33)
PLUS
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Metronidazole, 500mg p.o. 6hrly for a week. (For S/E, C/I and
dosage forms, see page 24)
2. ACUTE PID (Inpatient treatment)
Admission criteria includes parity, age, pregnancy, HIV, history of
infertility and the facility
a. Drug treatment
Requires hospitalization and administration of IV medication until 48
hrs after the fever has subsided, then to be administered as p.o /i.m
medication for 10-14 days.
First line:
Ampicilline, 500 – 1000 mg i.v. 6 hourly, followed by 500 mg p.o.
6 hrly
(For S/E, C/I, D/I and Dosage forms, see page 31)
PLUS
Gentamicin, 80 mg i.v., 8 hourly followed by i.m. injection of
similar dose
(For S/E, C/I, D/I and Dosage forms, see page 56)
PLUS
Chloramphenicol/ Metronidazole, 500 mg, i.v., 8 hourly followed
by 500 mg p.o. 6 hrly (For S/Es, C/Is, D/Is and Dosage forms: see
page 36/24)
Alternative
Ceftriaxone, 1 g/day, i.v. (For S/E, C/I, D/I and Dosage forms, see
page 29)
PLUS
Gentamicin, 80 mg, 8 hourly i.m. (For S/E, C/I, D/I and Dosage
forms, see page 56)

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PLUS
Metronidazole, 500mg 8 hourly p.o. (For S/Es, C/Is, D/Is and
Dosage forms: see page 24)
OR
Clindamycin, 450 – 600 mg, i.v. 8 hourly (For S/E, C/I, D/I and
Dosage forms, see page 63)
AND/OR
Doxycycline, 100 mg p.o. 12 hourly until 48 hrs after the fever has
subsided (For S/E, C/I, D/I and Dosage forms, see page 33)

b. Surgical treatment
Laparatomy and drainage of abscess, salping-oopherectomy, Colpotomy,
Hysterectomy with or without salping-oopherectomy.

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POST ABORTAL/ PUERPERAL SEPSIS

Post abortal/ puerperal sepsis is a kind of infection, which complicates
abortion/ delivery. They are caused by a number of microorganisms including
gram positive, gram negative and anaerobes.
Diagnosis:
Clinical: history of abortion or delivery with evidence of sepsis
Laboratory: Anemia, leuckocytosis with neutrophilia, positive blood culture,
pus culture,
Ultra sound: evidence of retained products of conception, or evidence of
abscess collection as tubo-ovarian complex, pelvic abscess or generalized
peritonitis

Treatment: Require hospitalization

Drug treatment: Includes IV antibiotics until 48 hrs after the fever has
subsided followed by IM / PO dose for 10-14 days, Anti pyretics and
analgesics as required
First line:
Ampicillin, 1 gm i.v. 6 hourly. (For S/E, C/I and dosage forms see page
31)
PLUS
Chloramphenicol, 1 gm i.v. 6 hourly
(For S/E, C/I and dosage forms, see page 38)
OR
Metronidazole, 500 mg i.v. 6 hourly. (For S/E, C/I and dosage forms,
see page 24)
OR
Clindamycin, 600 mg i.v. 6 hourly. (For S/E, C/I and dosage forms, see
page 63)
PLUS
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Gentamicin, 80 mg i.v. 8 hourly until 48 hrs after the fever has subsided
(For S/Es, C/Is, D/Is and Dosage forms, see page 56)
Followed by
Ampicillin, 500 mg p.o. 6 hourly. (For S/E, C/I and dosage forms ,
see page 31)

PLUS
Gentamicin, 80 mg i.v. 8 hourly for 10 – 14 days.
(For S/E, C/I and dosage forms, see page 56)
PLUS
Chloramphenicol, 500 mg p.o. 6 hourly.
(For S/E, C/I and dosage forms, see page 38)
OR
Metronidazole, 500 mg p.o. 8 hourly.
(For S/E, C/I and dosage forms, see page 24)
Alternative:
Ceftriaxone 1gm iv/day For 7-10 days
(For S/E, C/I and dosage forms, see page 29)
PLUS
Clindamycin, 450 mg i.v. 6hrly .
(For S/E, C/I and dosage forms, see page 63)
OR
Metronidazole, 500 mg p.o. 8 hourly. (For S/E, C/I and dosage
forms, see page 24)
PLUS
Gentamicin, 80mg IV 8hrly.
(For S/E, C/I and dosage forms, see page 56)
2. Surgical treatment
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• Evacuation of the uterus,

• Laparatomy and drainage of abscess,
• Salpigo-opherectomy &/or hysterectomy depending on the
clinical situation
3. Additional treatment; Heparin 2500-5000 may be given in selected cases
to prevent DIC

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PREMATURE RUPTURE OF MEMBRANES (PROM)

Premature rupture of membranes is rupture of the fetal membranes after the
28th week of gestation and before labor. It includes preterm PROM (PROM
before the gestational age of 37 weeks) and term PROM (PROM after the 37th
week of gestation). The exact cause of PROM is not known.
Diagnosis:
Clinical: -speculum examination reveals leakage of clear fluid through the
cervical os
Laboratory: -
• Nitrazine paper test
• Ferning test
• Nile blue sulphate test
• Vaginal Swab for culture and sensitivity
Treatment: depends on gestational age presence of infection, condition of the
fetus and spontaneous healing of the membrane.

1. Pre-term PROM
a. Preterm PROM without chorioamnionitis:
Admit
Bed rest
Avoid vaginal examination,
Avoid coitus and
Closely follow for any indicator of intramniotic infection
Drug treatment

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First line:
Ampicillin, 2 gm IV 6 hourly for 48 hrs followed by Ampicillin 500
mg p.o. 6 hourly or 7-10 days. (For S/E, C/I and dosage forms , see
page 31)
Alternative:
Erythromycin, 500 mg IV 6 hourly for 48 hrs followed by
Erythromycin 500 mg p.o. 6 hourly for 7-10 days
(For S/E, C/I, D/I and Dosage forms, see page 31)

2. Pre-term/Term PROM with chorioamnionitis.

Use ampicillin, chloramphenicol or gentamycin and terminate
pregnancy.
Admit to the labor ward and facilitate delivery as feasible

3. Term PROM with no evidence of chorioamnionitis:

Admit to the labor ward & follow for evidence of infection
Induce if no spontaneous labor after 8 hrs of latency period

4. Prolonged PROM: - Rupture of membranes for more than 12 hrs

Ampicillin, 2 gm i.v. 6 hourly in labor until delivery and then 500
mg 6 hourly for 7 days. (For S/E, C/I and dosage forms, see page
31)

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PUERPERAL MASTITIS
Puerperal mastitis is breast inflammation that develops during the first month
after delivery. It is commonly caused by Staph aureus.
Diagnosis:
Clinical: Fever, chills, flu like symptoms, breast pain with warm,
erythromatous indurated, engorged and tender breast (one or both
breasts) and ± axillary lymphadenopathy ± Fluctuating breast mass.
Laboratory: Leucocytosis with left shift
Gram stain and culture of the pus from the breast abscess if any
Treatment:
Non Drug Treatment:
Suction, Analgesic, Antipyretic and Breast-feeding of the healthy breast

1. If the symptom is mainly Local :

Drug treatment
Cloxacilline 500 mg p.o. 6 hourly for 7-10 days
(For S/E, C/I, D/I and Dosage forms, see page 57)

2. If there is evidence of Sepsis

a. Drug treatment
Requires hospitalization
Cloxacillin 500 mg i.v. 6 hourly until the fever and clinical symptoms
subside and continue with oral Cloxacillin for 7-10 days.
(For S/E, C/I and dosage forms, see page 57)
b. Surgical treatment
Drainage of breast abscess
NB: Don’t wait until fluctuation, if there is induration tap and confirm the
diagnosis

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URINARY TRACT INFECTION IN PREGNANCY

There are different types of urinary tract problems that need special attention
during pregnancy. These include asymptomatic bacteruria, cystitis and
pyelonephritis.
E.coli is the most common cause of urinary tract infection in pregnancy.

1. ASYMPTOMATIC BACTERURIA
Diagnosis
Laboratory:
Urine analysis,
Urine culture
Treatment
Drug treatment
Best when the choice of antibiotics is based on culture and sensitivity result
First line:
Amoxicillin, 500 mg p.o. 8 hourly for three days
(For S/E, C/I, D/I and Dosage forms, see page 31)
Alternative:
Nitrofurantoin, 100 mg p.o. 6 hrly for three days.
S/E: hemolytic anemia in the newborn.
C/I: late pregnancy, GI Disturbance.
Dosage forms: capsule (macrocrystalls), 50mg, 100mg; tablets
50mg, 100mg.
OR
Trimetoprim + sulphamethoxazole 2 tabs 12 hrly for three days.
(For S/E, C/I and Dosage forms, see page 28, 283)

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2. CYSTITIS:
Treatment is the same as asymptomatic bacteruria but for 7 days
3. PYELONEPHRITIS :
Pyelonephritis is a serious medical problem in pregnancy that can lead to
complications like miscarriage, preterm labour, and sepsis. The most common
manifestations include headache, fever, chills, nausea &/or vomiting, flank
pain and dysuria.
Diagnosis: -
Laboratory:
Urine analysis showing bacteruria and pyuria,
Gram stain and urine culture
leucocytosis with neutrophilia,
Treatment:
Admit
Drug treatment
First line:
Ampicillin, 2gm IV 6 hourly until 48 hrs after the fever subsided
and then 500 mg po. for 10-14 days (For S/E, C/I, D/I and Dosage
forms, see page 31)
PLUS
Gentamicin, 80 mg IV 8 hrly until 48 hrs after the fever subsided
and then IM for 10-14 days (For S/E, C/I, D/I and Dosage forms,
see page 56)
Alternative:
Cephotaxime, 500 mg-1 gm IV 12 hrly. until 48 hrs after the fever
subsided and then then IM
S/E: granulocytopenia, GI disturbance, and positive coomb’s test
C/I: hypersensitivity reaction
Dosage forms: 0.5g, 1g in vial
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SEXUAL ASSAULT
Sexual assault is defined as any sexual act performed on another person
without consent. Physician evaluating the victim of sexual assault should aim
to provide adequate medical care and collect evidences. Rape is the most
common reported sexual assault.
Diagnosis:
Clinical: History and physical examination
Laboratory: Identification of spermatozoa from specimen over the genitalia or
high vaginal swab
General Principles of Management
• Medical or surgical treatment of acute injury.
• Screen for STI, HIV, Hepatitis B Infection and pregnancy at initial
visit ,repeat screening for HIV, HbsAg at three and six months.
• Prevention of STI.
• Prevention of Pregnancy
• Rehabilitation
• Medical recording should be meticulous and management approach
should be multidisciplinary
Treatment
1. Treatment of infection such as gonococcal ,trichomonas and chlamydial
Ceftriaxone, 125 mg IM in single dose
(For S/E, C/I and dosage forms, see page 29)
PLUS
Metronidazole, 2 gm orally in single dose,
(For S/E, C/I and dosage forms, see page 24)

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PLUS
Doxycycline, 100 mg orally two times a day for 7 days
(For S/E, C/I and dosage forms , see page 33)
In Child Abuse
Ceftriaxone, 125-250 mg IM
Erythromycin, Syrup /kG

2. Prevention of Pregnancy
Provide emergency contraception, within 72 hrs after exposure
Combined oral contraceptive pills with 50-mcg estrogens, two tabs 12
hrs apart for two doses.
Combined oral contraceptive pills with 30-mcg-estrogen, four tabs 12
hrs apart for two doses.
IUD insertion up to 5 days following exposure

NB. Screen for infection and pregnancy before inserting IUD

3. Rehabilitation :
Counseling and psychological support.

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SYPHILIS IN PREGNANCY
A common sexually transmitted disease, which can cause significant
intrauterine infection and congenital damage to the fetus. It has primary or
secondary lesion in acute infection. It is caused by Treponema pallidum.
Routine screening is done at booking and at the third trimester of pregnancy
Diagnosis: -
Microscopy: -by dark field examination or direct immuno-
fluorescent
Microscopy
Serology
i. specific treponemal tests such as TPHA or FTA-Ab
ii. nonspecific treponemal tests
a. the veneral disease research laboratory (VRDL)
test
b. the rapid plasma reagin (RPR) test
Treatment
Drug treatment:
First line:
Benzathine penicillin, 2.4 Mil IU every week for three consecutive
weeks. Treat the partner similarly (For S/E and C/I, see page 55
under benzyl penicillin)
Dosage forms: injection, 0.6,1.2, 2.4 million IU in vial
Alternative:
Erythromycin, 500 mg p.o. 6 hourly for 14 days
(For S/E, C/I, D/I and Dosage forms, see page 31)

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VULVO VAGINAL CANDIDIASIS

Vulvo vaginal candidiasis is a common cause of pruritic vaginal discharge. The
main manifestations include pruritis vulvae, whitish curd like vaginal
discharge, vulval irritation, dyspareunia, and splash (external) dysuria. It is
commonly caused by Candida albicans.
Diagnosis: Laboratory: KOH test, Culture
Treatment:
Drug treatment
First line:
Nystatin, Suppository 100,000 IU per vaginum, daily for 14 days.
(For S/E and C/I and dosage forms, see page 112)
OR
Clotrimazol, 100 mg vaginal tabs 1 /day for 6 days or 2 times /day
for three days or 200mg 1/day for 03 days or 500m vaginal tabs single
dose
or 1% cream-5 gm 10-14 days (For S/E and C/I , see page 112)
Alternative:
Miconazole, 200 mg vaginal supp for three days or 100 mg vaginal
tabs for 7 days or 2% cream 5 gm Intra vaginal for 7 days. (For S/E
and C/I , see page 140)
Chronic Vulvo Vaginal Candidiasis: -
Ketaconazole, 400 mg /day or 200 mg twice /day for 5-10 days. Then
100 mg /day for 6 months as
Alternative:
Fluconazole, 150 mg p.o. stat, then 100 mg ketoconazole /day for 6
months prophylaxis. (For S/E and C/I , see page 59)

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Chapter 7
PEDIATRIC DISEASES
Amebiasis
Bronchial Asthma
Conjunctivitis
CROUP (Acute laryngotracheobronchitis)
Diarrheal disease (Acute)
Giardiasis
HIV/ AIDS in Children
Hypoglycemia
Jaundice in neonates
Malnutrition (sever)
Measles
Meningitis
Oral trush
Ostiomylitis
Ottis media (ACUTE)
Pertusis
Pneumocystes carini pneumonia
Pneumonia in children
Seizures (Neonatal)
Sepsis (Neonatal)
Septic arthritis
Sinusitis
Streptococcal pharengitis
Syphilis (congenital)
Tetatanus (Neonatal)
Trachoma
Tuberculosis
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COMMON PEDIATRIC DISEASES

AMEBIASIS
Food and drinks contaminated with Entameba histolytica cyst and direct fecal
oral contact are the most common means of infection. Most infected
individuals are asymptomatic. The most common clinical manifestations of
amebiasis are due to focal invasion of the intestinal epithelium and
dissemination to the liver. Diarrhea is frequently associated with tenusmus,
stools are blood stained and contain a fair amount of mucus with a few
leukocytes. Occasionally amebic dysentery is associated with sudden onset of
fever, chills and severe diarrhea. Hepatic amebiasis is a very serious
manifestation of disseminated infection.
Diagnosis is based on detecting the organism in stool samples or tissue biopsy
samples or rarely in aspirates of liver abscess.

Treatment
Metronidazole, 15 mg/kg three times a day for 10 days.
(For S/E, C/I, D/I and Dosage forms, see page 24)
Alternative:
Dehydroemetine, 1 mg/kg /24 hours im/sc for ten days.
(For S/E, C/I, D/I and Dosage forms,: see page 26)

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BRONCHIAL ASTHMA
Asthma is a disease characterized by reversible airway obstruction, airway
inflammation and increased airway responsiveness to a variety of stimuli
(hyper-reactive airway). The onset of childhood asthma is before the age of 5
years in more than half of the patients. Approximately one half of children “out
grow” their asthma by adolescence, but recurrence is common in adulthood.
There is no single diagnostic test for asthma in young children, although a
number of challenge tests may be helpful in older children and adults.

Diagnosis is mainly clinical. Chronic and recurrent episodes of coughing and

wheezing, specially if aggravated or triggered by exercise, viral infection or
inhaled allergens are highly suggestive of asthma.

Treatment:
Asthma therapy includes basic concepts of avoiding allergens improving
vasodilatation, and reducing mediator–induced inflammation.

Acute asthma
Epinephrine, 0.01-0.02ml/kg sc, and repeat the dose every 20
minutes for three doses.
S/E: transient headache, palpitation, anxiety, and dysarrythemia.
Dosage forms: injection, 0.1% in 1ml ampoule
AND/OR
Salbutamol: 0.1-0.2mg/kg(1-2 puffs ) 3-4 times a day or 0.075-
0.1mg/kg p.o. 3 times a day. (For S/E, C/I, D/I and Dosage forms,:
see page 171)
Note:
Corticosteriods as aerosols or tablets are also recommended in severe
asthma.

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Status Asthmaticus
If a patient coutinues to have significant respiratory distress despite
administration of sympathomimetics drugs with or without theophylline, the
diagnosis of status asthmaticus should be considered.
Status Asthmaticus is a clinical diagnosis defined by increasingly severe
asthma that is not responsive to drugs that are usually effective.

Treatment
Drug treatment: Children with status asthmaticus require hospitalization and
aggressive therapy with bronchodilators, corticosteroids and oxygen.
Prednisolone, 1-2 mg /kg every six hours
(For S/E, C/I, D/I and Dosage forms, see page 178)
N.B.
- The potential for growth retardation should be considered
- Dose and duration should be as limited as possible

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CONJUNCTIVITIS
1. NEONATAL CONJUNCTIVITIS
Conjunctivitis in the newborn is commonly due to infection with Neisseria
gonorrhoeae or Chlamydia trachomatis. The etiologic agent can sometimes be
distinguished by the timing of infection: infection with gonococcus typically
occurs on day 2 to 5, while infection with Chlamydia occurs between 5 to 14
days. Gram stain and culture of the exudates from eye discharge should be
performed. Conjunctivitis in the newborn might have occurred from
prophylactically administered silver nitrate drops; in this case the inflammation
occurs within the first days of life. Gonococcal conjunctivitis (ophthalmic
neonatorum) is a serious infection in neonates and, if untreated, it progresses to
corneal ulceration and deeper infection of the globe, leading to blindness.

Treatment
Drug Treatment: Locally acting as well as systemic drugs are used.
1. Topical Drugs
First Line
Tetracycline eye drops, 1%
(For S/E and C/I, see page 31)
Dosage forms: eye drops, 1%; tetracycline eye ointment, 1%.
Second line
Chloramphenicol eye drops, 0.5%
(For S/E and C/I, see page 35)
Dosage forms: eye drops, 0.4%, 0.5%, 1%, 5%; eye ointment, 1%,
5%
OR

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Gentamicin eye drops, 0.3% (For S/E, C/s, D/I and Dosage forms:
see page 56)
Dosage forms: eye drop, 0.3%

2. Systemic Drugs
First Line
Penicillin G Sodium Crystalline, 50,000 IU/kg every 6 hours for ten
days.
(For S/E, C/I and dosage forms, see page 55 under benzyl penicillin )
N.B.
Most gonococcal strains are now resistant to penicillin.
Alternative
Ceftriaxone, 50 mg/kg to a maximum of 125 mg as a single i.m.
injection
(For S/E, C/I and dosage forms, see page 29)

Prophylaxis of gonococcal conjunctivitis:

Clean the newborn’s eye with 0.9% saline or clean water using sterile
gauze
Apply one drop into each eye any of the above antibiotic eye
ointments or silver nitrate eye drops, 1% once.

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2. CONJUNCTIVITIS IN INFANTS AND CHILDREN

Acute purulent conjunctivitis is characterized by more or less generalized
conjunctival hyperemia, edema, muco-purulent exudates and a varying degree
of ocular discomfort. It is usually a result of bacterial infection.
Diagnosis is clinical.

Treatment
Non-drug Treatment:
Acute purulent conjunctivitis usually responds to warm compression.
Drug Treatment: Frequent topical instillation of antibiotic eye drops is useful.
Tetracycline, 2 drops every 4 hours;, apply ointment 2-4 times every
24 hours.
(For S/E and C/I, see page 31)
Dosage forms: Eye drops,0.5%, 1%; Ointment, 1%
OR
Chloramphenicol, 2 drops every 4 hours; apply ointment 2-4 times
per day.
(For S/E and C/I, see page 35)
Dosage forms : Eye drops,0.5%; Ointment, 1%
Alternative:
Gentamicin eye drops, 2 drops every 2 hours.
(For S/E, and C/I, see page 56)
Dosage forms: Drops, 0.3%; Ointment, 0.3%

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CROUP (ACUTE LARYNGOTRACHEOBRONCHITIS)

Infectious croup is a syndrome caused by upper airway obstruction due to
infection of the larynx and trachea. The spectrum of the syndrome ranges from
laryngotracheobronchitis epiglotitis to diphtherial and other bacterial tracheitis.
The clinical picture is characterized by dyspnea, hoarseness, a brassy cough
and stridir. Infants and young children develop more severe disease because of
their narrow upper airway. Many of these infectious processes also involve the
lower airways.

Spasmodic croup occurs in young children between the ages of 1 and 3 years
usually at night and resolves within several hours. Children with spasmodic
croup will often develop these symptoms recurrently with mild viral upper
respiratory illness.
Scroup scoring
0 1 2 3
stridor none Mild moderate severe on
at rest inspiration and
expiration
none on markedly
reduced air
entery
retraction none Mild moderate severe and
marked use of
accessary muscles
air entery normal Mild moderate Marked

color normal Normal normal dusky or cyanosis

level of normal Restless anxious lethargic
consciousness when agitated depressed
disturbed restless
Score
1. 5 mild
2. 5-6 mild to moderate
3. 7-8 moderate most cases admitted
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4. 8 severe or if the child has any one of severe category needs

admission for tracheostomy.

Treatment
Non-Drug Treatment:
Humidified air given by vaporizer or inhalation of steam at home or
by croup tent in the hospital is the mainstay of therapy. A few
patients may need intubation or tracheotomy.
Drug Treatment:
Dexamethasone: for severe cases, single dose 0.6mg/kg i.m.
(For S/E and C/I , see under Prednisolone, page 132)
Dosage forms: Tablet 0.5 mg, 1mg, 2mg; Injection 4mg/ml, 25mg/ml,
50mg/ml.

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DIARRHEAL DISEASE (ACUTE)

Acute diarrheal disease is a common problem in infants and children and its
complications - dehydration and malnutrition - are major causes of morbidity
and mortality in developing countries. Clinically it is useful to distinguish two
syndromes produced by gastrointestinal infection: watery diarrhea and bloody
diarrhea. The leading cause of diarrhea in infants is the rotavirus followed by
enteric adenoviruses. Shigella is most frequently a pathogen in children
between 1 to 5 years with bloody diarrhea. Other bacterial pathogens include
campylobacter, Salmonella and Escerichia Coli.
Classification
1. No dehydration: No enough sign to classify as “some” or “severe”
dehydration.
2. Some dehydration: if there are two of the following signs,
Restless irritable
Sunken eyes
Drinks eagerly, thirsty
Sikn pinch goes back slowly
3. Severe dehydration: If there are two of the following signs,
Lethargic or unconcious
Sunken eyes
Not able to drink or drinking poorly
Skin pinch goes back very slowly
4. Severe persistent dirrhoea: if diarrhoea lasts for 14 days or more
and dehydration is present.
5. Persistent diarrhoea: diarrhoea lasting for 14 days or more and there
is no dehydration.
6. Dysentry: if there is blood in the stool.
Diagnosis: Clinical; severety should be graded.

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Treatment
Non-Drug Treatment: Since the major morbidity relates to dehydration and
malnutrition, emphasis in management should focus on rehydration and
nutrition.

Drug Treatment:
Specific treatment depends on the degree of dehydration
1. If no dehydration, follow plan A: treat diarrhoea at home.
Counsel the mother on the three rules of home treatment:
Give extra fluid, Continue feeding and Advise the mother when to return.
a. Give extra fluid ( as much as the child will take)
Tell the mother:
- breastfeed frequently and for longer at each feed\
- if the child is exclusively breastfed give ORS or clean water in
adition to beast milk.
- if the child is not exclusively breastfed, give one or more of the
following: - ORS solution,food based fluids( such as soup,rice
water, 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 a clinic if the diarrhoea gets worse.
Teach the mother how to mix and give ORS; give the mother two
packets of ORS to use at home.
Show the mother how much fluid to give in addition to the usual
fluid intake:
- Upto two years - 50 to 100 ml after each loose stool
- Two years or more - 100 to 200 ml after each loose stool
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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 fluid until the diarrhoea stops
b. Continue feeding
c. Council the mother on when to return.

2. Treatment plan B. Treat some dehydration with ORS

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

4 DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4

HOURS

Age Upto 4 4 Months up to 12 months up 2 years up

Months 12 months to 2 years to 5 years
Weight 6 kg 6-10 kg 10-12 kg 12-19 kg
ORS in 200- 400-700 700-900 900-1400
ml 400

• 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 shows, give more.
• For infants under 6 months who are not breastfed, also give 100-
200 ml clean water during this period.

4 SHOW THE MOTHER HOW TO GIVE ORS SOLUTION.

• 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.

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4 AFTER 4 HOURS:
• Reassess the child and classify the child for dehydration.
• Select the appropriate plan to continue treatment.
• Begin feeding the child in clinic.

4 IF THE MOTHER MUST LEAVE BEFORE COMPLETING

TREATMENT:
• Show her how to prepare ORS solution at home.
• Show her how much ORS to give to finish 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:

1. GIVE EXTRA FLUID

See plan A for recommended fluid

2.CONTINUE FEEDING

3.TELL THE MOTHER WHEN TO RETURN

3.Treatment plan C: treat severe dehydration quickly.

Follow the Arrows. If Answer is "YES", Go Across. If "NO", Go Down.

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START HERE • Start IV fluid immediately. If the child can drink, give ORS by
Can you give Yes mouth while the drip is set up. Give 100 ml/kg Ringer's Lactate
intravenous Solution (or, if not available, normal saline), divided as follows:
(IV) fluid
immediately AGE First give 30 Then give
ml/kg in: 70ml/kg in:

Infants 1 hour* 5 hours

(Under 12 months)
Children 30 minutes* 2 ½ hours
12 months up to 5 years)

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

No • 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

is IV treatment Yes • Refer URGENTLY to hospital for IV treatment

available nearby • If the child can drink, provide the mother with ORS solution
(within 30 and show her how go give frequent sips during the trip
minutes)?

No • Start rehydration by tube (or mouth) with ORS solution

give 20 ml/kg/ hour for 6 hours (total of 120 ml/kg).
Are you trained to • Reassess the child every 1-2 hours:
use a naso-gastric - If there is repeated vomiting or increasing abdominal
(NG) tube for distensionn, give the fluid more slowly.
rehydration? Yes - If hydration status is not improving after hours, send the
No child for IV therapy
• After 6 hours, reassess the child. Classify dehydration.
Can the child Then choose the appropriate plan (A, B, or C) to continue
drink? treatment.
No
Refer URGENTLY NOTE:
TO hospital for IV or • If Possible, observe the child at least 6 hours after
NG treatment rehydration to be sure the mother can maintain hydration
giving the child ORS solution by mouth
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Treatment of severe persistent diarrhoea

Non drug treatment:

Treat dehydration before referal
Drug treatment:
Vitamin A, 50,000 IU for children less than 6 months of age, 100,000
IU for 6 – 12 months and 200,000 IU for those older than 12 months .

Treatment of persistent diarrhoea

Non drug treatment:
Advice the mother on feeding the child with persistent diarrhoea
Drug treatment:
Vitamin A, 50,000 IU for children less than 6 months of age, 100,000
IU for 6 – 12 monthsmonths, 200,000 IU for greater than 12 months,
p.o. single dose
S/E: diarrhea, vomiting, irritability, drowsiness
C/I: renal impairment
D/I: cholestyramine or colestipol reduces its absorption
Dosage forms: capsule, 25,000 IU, 50,000 IU, 100,000 IU; oral
suspension, 150,000 IU/ml(concentrate), 50,000 IU/ml: tablet, 50,000
IU, 100,000 IU, 200,00 IU; injection, under 200,000 IU/ml

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Treatment of Dysentry
Drug treatment: Give antibiotic recommended for shigella in your area for
five days.

First line
Cotrimoxazole, 4 mg/kg trimethoprim 20mg/kg sulphamethaxozole twice a
day for five days.
S/E: headache, mental depression, nausea, vomiting, diarrhea,
hypersensitivity, Stevens Johnson’s syndrome.
C/I: infants under 6 weeks (risk of kernicterus), jaundice, hepatic
failure, blood disorder, porphyria
Dosage forms: Pediatric tablet- trimethoprim 20mg and
sulphamethoxazole 100mg; Tablet trimethoprim 80 and
sulphamethoxazole 400mg; Suspension - trimethoprim 40 and
sulphamethoxazole 200mg; Ampoule 5ml (trimethoprim 80mg
and sulphamethoxazole 400mg).

Alternative:
Nalidixic acid, 2 months to 4 months 62.5 mg p.o.; 4 months to 12
months 125 mg p.o.; 12 months to 5 years 250 mg p.o. qid for 5 days.
(For S/E, C/I and dosage forms, see page 29)

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GIARDIASIS
Giardia lamblia is a ubiquitous gastrointestinal protozoa that results in clinical
pictures ranging from asymptomatic colonization to acute or chronic diarreal
illness. Giardia lamblia infect humans through ingestion of as few as 10 cysts.
The infection is more prevalent in children than adults. The most common
presentation is diarrhea, weight loss, crampy abdominal pain and failure to
thrive. Diagnosis is established by identifying Giardia Lamblia trophozoite or
cyst from fecal or duodenal samples obtained from infected children.

Treatment.
Metronidazole, 15 mg/kg three times a day for five days. (For S/E,
C/I, D/I and Dosage forms, see page 24)
Alternative
Tinidazole, single oral dose of 50 mg/kg. ( For S/E and C/I, see
under metronidazole, page 24)
Dosage forms: tablet 150mg, 500mg.

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HIV/ AIDS IN CHILDREN

HIV/AIDS is caused by the human immunodeficiency virus and the affected
child is more vulnerable to a wide variety of infections. HIV infection causes
chronically progressing clinical condition that begins with few or no
symptoms. The vast majority of HIV infected children acquired the virus from
their mothers. The rate of mother to child transmission (MTCT) of HIV is
estimated to range from 25-45%. Evidence from industrially developed
countries shows that such transmission can be greatly reduced to less than 5%
by using anti-retroviral therapy during pregnancy. An efficient ANC is
mandatory before implementing MTCT reduction program.

Prevention of MTCT
Zidovudine (ZDV) therapy
At 36 weeks, start ZDV 300mg twice daily orally till onset of labor.
At onset of labor give ZDV 300 mg every 3 hours orally until
delivery.
At post partum advise no breast-feeding.
Dosage forms: capsule 100mg, 250mg, Tablets 150mg, 300mg, IV
infusion 10mg/ml Syrup 50mg/5ml
(For S/E and C/I, see page 15)
Alternative
Nevirapine, 200mg orally to mother at the onset of labour .
Nevirapine 3-4mg /kg orally to the new born with in 72hours after
birth
Dosage forms: tablet 200mg, oral solution 80mg/vial.(For S/E and
C/I, see 18). For detail information, see the same topic under adult
section on page )

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The Ethiopian AIDS case definition for surveillance in

pediatrics [Revised February 2002]

I. AIDS in a child <12 years of age is defined with evidence of

positive HIV test in the presence of 3 major signs alone in the
absence of other known causes of immunosuppression.

II. AIDS in a child <12 years of age is defined without laboratory

evidence of HIV infection in the presence of: 2 major and 2 minor
signs or 3 major and 1 minor sign in the absence of other known
causes of immunosuppression

III. AIDS in a child < 12 years of age is defined if patient fulfills the
1987CDC surveillance case definition

Major signs /disease

1. Failure to thrive
2. Repeated /persistent lower respiratory tract infection (LRTI)
3. Chronic recurrent diarrhea for more than 1 month (continuous
/intermittent).
4. Unexplained prolonged fever.1month (continuous /intermittent).
Fever should not be counted as a major sign in the presence of lower
respiratory tract infection (LRTI).

Minor signs/disease
1. Generalized lymphadenopathy
2. Repeated or persistent common infections
3. Unexplained neurological disorders or developmental delay and/or
microcephaly.
4. Hepatosplenomegally/or splenomegally
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5. Extensive varicella infections or molluscum contagiousum.

6. Confirmed maternal HIV infection

1.3. Recommendations for initiating antiretroviral therapy in infants

and children

CD4 Age HIV diagnostic testing Treatment

Testing recommendation
If CD4 <18 Positive HIV virologic test a • WHO pediatric
Testing is months stage III (AIDS),
available irrespective of
CD4 cell
percentage b
• WHO Pediatric
Stage I disease
(asympotomatic)
or stage II disease
with CD4
percentage < 20%
HIV virologic testing not • WHO Pediatric
available but infant HIV stage III disease
seropositive or born to (AIDS) with CD4
known HIV-infected mother cell percentage <
(Note: HIV antibody test 20%
must be repeated at age 18
months to obtain definitive
diagnosis of HIV infection)
•
≥18 HIV antibody seropositive WHO pediatric
months stage III disease
(AIDS)
irrespective of
CD4 cell
percentage b
• WHO Pediatric
stage I disease
(asymptomatic) or
stage II disease
with CD4
percentage <15%
If CD 4 ≥ 18 Positive HIV virologic test • WHO Pediatric
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testing is months Stage IIIb

not
available
HIV virologic testing not • Treatment not
available but infant HIV recommended d
seropositive or born to
known HIV-infected mother
≥ 18 HIV antibody seropositive • WHO Pediatrics
months stage III b
a
HIV DNA PCR or HIV PCR RNA or immune complex dissociated
p24 antigen assays, or HIV culture.
b
Initiation of ARV can also be considered for children who have
advanced WHO Pediatric stage II disease including such as severe
recurrent or persistent oral candidiasis outside the neonatal period,
weight loss, fever, or recurrent severe bacterial infection, irrespective
of CD4 count.
c
The rate of decline in CD4 percentage ( if measurement avaialbe)
should be factored into the decision-making.
d
Many of the clinical symptoms in the WHO Pediatric stage II and III
disease classification are not specific for HIV infection and
significantly overlap with those seen in children with out HIV
infection in resource-limited settings; thus, in the absence virologic
testing and CD4 cell assay availability, HIV exposed infants <18
months of age should generally not be considered for ART regardless
of symptoms.

1. Drug regimens

First-line
ARV combination regimens for adults and adolescents:

Zidovudine (ADV) plus Lamivudine (3TC) plus Efavirenz (EFZ) or

Nevirapine (NVP)
OR
Zidovudine (ADV) plus Lamivudine (3TC) plus Abacavir (ABC)

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OR
Zidovudine (ADV) plus Lamivudine (3TC) plus ritonavir ( RTV) or
Nelfinavir (NFV)

Second -line ARV combination regimens for adults and adolescents:

First - line Second -line Ulternative second -line regimen for

regimesn regimens treatment
Treatment failure
3TC/EFZ or DDI + RTV - Pla DDI+RTV-PI
3 TC/NVP DDI+NFV or
DDI+NFV

Treatment regimen for children:

First-line ARV regimens in Children

Zidovudine - Less than 90 days age 2 mg/kg four times a day
- More than 90 days age 160mg/m2 three times a
day
PLUS

Lamivudine - Less than 30 days age 2 mg/kg two times a day

- More than 30 days age 4 mg/kg four times a day

PLUS
Nevirapine - Less than 60 days of age: 120 mg/m2 two times a
day for 14 days, then 200 mg/m2 two times a day
- More than 60 days: 120 mg/m2 two times a day for
14 days, then 120 mg/m2 one time a day for 14 days,
then 120 mg/m2 two times a day for 14 days

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(NB: In children on concomitant anti-tuberculosis treatment and older than 30

days, abacavir 8 mg/kg/dose twice daily replaces nevirapine)

Second-line ARV regimens in Children

Stavudine - More than 30 days age: 1 mg/kg every 12 hours
PLUS
Didanosine - Less than30 days age: 50 mg/m2 every 12 hours
- More than 30 days age: 90 mg/m2 every 12 hours
PLUS
Ritonavir - More than 30 days age: 400 mg/m2 every 12 hours
(Started with 250 mg/m2 every 12 hours and
increased stepwise over five days)
- Nelfinavir or lopinavir/ritonavir may be used in
place of ritonavir.

Recommendations Infant Feeding

• All HIV infected mothers should receive infant feeding counseling which
includes provision of general information about the risk and benefits of
infant feeding options.

• Decision needs to be made by the mother, with guidance and support from
a health care provider to select the option most likely to be suitable for her.

• If HIV infected mother decide to breast feed then exclusive breast-feeding

should be encouraged, followed by early weaning at 4-6 months.

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HYPOGLYCEMIA
Hypoglycemia in the newborn is defined as a blood glucose level less than
40mg/dl irrespective of gestation and day of life.
Diagnosis is made by determining blood glucose level (see above).

Treatment

Drug Treatment:
Dextrose 10% solution, give a minimum bolus of 2 ml/kg i.v. over one
minute, continue infusion at a rate of 6 mg/kg/minute; check the blood glucose
after 15 minutes. If normal, continue at the same infusion rate; if low, increase
the infusion rate by 2 mg/kg /minute. If blood glucose still remains low, keep
on increasing the glucose infusion rate by 2 mg/kg/minute every 15 minute to a
maximum of 12-14 mg/kg /minute.

N.B. Both symptomatic and asymptomatic newborn infants have to be treated

with glucose. While treating hypoglycemia don’t forget to consider and treat
associated problems like polycythemia, sepsis, etc.
Prevention of hypoglycemia is by initiation of early breast feeding.

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JAUNDICE IN NEONATES
Jaundice is such a common occurrence in the newborn that the physician is
often consulted to delineate between what has been called “physiologic”
jaundice and pathologic jaundice.
Diagnosis:
1. “Physiologic” jaundice appears between the 3rd and 10th day of life
and total bilirubin value is under 12 mg/100 ml in term babies and
under 15 mg/100 ml in pre- term babies.
2. “Pathologic” jaundice is diagnosed when the jaundice appears in
the first 24 hours of life, cord bilirubin of 5 mg /100ml ,a rise of
bilirubin of 5 mg perday and when the total bilirubin is more than 12
mg/100 ml in term and 15 mg/100ml in pre-term babies and when
the jaundice persists beyond the 10th day of life in term and 15th day of
life in pre-term babies. On these instances etiologic diagnosis must
be made.
3. Kernicterus is the clinical toxicity of bilirubin during neonatal
period. The disorder is produced by deposition of fat-soluble bilirubin
in the nuclear areas of the frequently affected sites. Diagnosis can be
made by a thorough review of maternal history of drugs, blood group
Rh, VDRL, coombs test, peripheral blood smear of the baby. Physical
examination, such as that displaying hepatosplenomegaly, is very
important.
Treatment:
• Phototherapy using either day light (white light) or blue light.
• Exchange transfusions with 2 volume of cross-matched blood.
Size of exchange transfusion and replacement of infant’s blood; donor volume
as fraction of percentage of blood volume is shown in the table below.
Infants blood volume exchange Removed and replaced by
0.5 40%
1 63%

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2 87%
3 95%

MALNUTRITION (SEVER)
Severe malnutrition is defined as the presence of edema of both feet, and
severe wasting (70 % weight for height or less than three standard deviations)
or clinical signs of severe malnutrition. Malnutrition remains one of the most
common causes of morbidity and mortality among children throughout the
world. Approximately 9% of children below the age of five are at risk of death
or severe impairment of growth and psychological development.
Diagnosis is clinical.

Treatment: Management of the child with severe malnutrition is divided in to

three phases.
I. Dietary Treatment
Phase I
Initial treatment: Life-threatening problems such as infections should be
identified and treated in a hospital or a residential care facility. Specific
deficiencies are corrected, metabolic reversed, and feeding is begun.
Phase II
Rehabilitation: intensive feeding is given to recover most of the lost weight,
emotional and physical stimulation are increased, the mother or care giver is
trained to continue care at home. Preparations are made for discharge.
Phase III
Follow up after discharge, the child and the child’s family is followed to
prevent a relapse and assure the continued physical, mental and emotional
development of the child. A typical time frame for the management of the child
with severe malnutrition is shown in the table below.

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Time Frame for the Management of the Child with Severe Malnutrition

Activities Day Days Weeks Weeks 7-

1-2 3-7 2-6 26
Phase I Phase II Phase III
Hypoglycemia -------

Hypothermia -------

Dehydration -------

Correct electrolyte imbalance -------

Treat infection -------

Begin feeding -------

Correct micronutrient Without iron---- With iron---------------

deficiencies -
Increase feeding to recover lost --------------------------
weight -
Prepare for discharge --------------------------
-
Stimulate emotional and sensorial ---------------------------------------
development -

kwash milk recipe

ingridient Amount calories protien

whole milk 950ml 636.5 30.5gm
vegitable oil 45ml 405.5 -
sugar 35ml 100 -
KCL 2.9gm -- -
Mg 4ml - -
Total 1000ml 114.5/100gm 3.2mg/100ml

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Treatment of Hypothermia: Feed the child immediately. Keep the

child in kangaroo position, or cover the child with warm blanket.

II. Drug Treatment:

1. Treatment of hypoglycemia: glucose (10%), 50ml p.o. or
sucrose solution (10%), 50 ml p.o. or by NG tube followed by first
feed; if the child is unconscious give glucose, i.v.
2. Treatment of infection:
Ampicillin, 50 mg/kg i.m/i.v, 6 hourly for seven days (For S/E, C/I
and Dosage forms, see page 31)

PLUS
Gentamicin, 7.5mg/kg i.m/i.v, once daily for seven days
(For S/E, C/I and Dosage forms ,see page 56)
PLUS
If the child fails to improve within 48 hours, add Chloramphenicol,
25-mg/kg i.m/i.v, 6 hourly for five days.
(For S/E, C/I and Dosage forms ,see page 36)
3. Micronutrient supplementation: Give micronutrient supplements for at
least 2 weeks.
• A multivitamin supplement
• Folic acid, 5 mg on day one then 1 mg daily.
• Dosage forms: Tablets 200mcg, 1mg, 5mg; Injections 5mg/ml in 1 ml
ampoule
• Zinc*, 2 mg/kg/day , 2 mg/kg/day
• Copper*, 0.3mg/kg /day
• Iron*, 3 mg/kg/day after the child starts to gain weight

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• Vitamin A, 50,000 IU, for children less than 6 months; 100,000 IU

for 6-12 months; 2000,000 IU for greater than 12 months,p.o. single
dose:
(For S/E, C/I and Dosage forms ,see page 282)

N.B. :
The indicated dosage should not be exceeded.

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MEASLES
Measles, which is caused by the measles virus, is a highly contagious infection
that spreads by droplets. The incubation period is about 2 weeks. Infected
children are contagious 4 days before and 4 days after the appearance of the
rash. Children with measles have fever, conjunctivitis, coryza, cough, Koplik
spots (small white spots on the buccal mucosa) and a generalized
erythematyous maculopapular rash. The complications of measles include otitis
media, croup, pneumonia, diarrhea and encephalitis.
Diagnosis is clinical.
Measels could be classified as:

1. Severe complicated measles: this classification is considered when there is

clouding of the cornea deep or extensive mouth ulcres in a patient who has
history of measles during the last three months.
Teatment
Drug treatment:
Vitamin A, , 50,000 IU, for children less than 6 months; 100,000 IU for 6-12
months; 2000,000 IU for greater than 12 months, , single dose
(For S/E, C/I and dosage forms, see page 282)
Treat the eye infection with tetracycline. See page 25
Treat mouth ulcers with gentian violet, paint the mouth with half strength
twice daily
Dosage form: solution, 0.5%, 1%
Needs hopitalization for severe disease

2. Measles with eye or mouth complication: This classication is made when

the child who has history of measles during the last three months develops pus
draining from the eye or mouth ulcers.

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Treatment
Drug treatment:
Vitamin A, , 50,000 IU, for children less than 6 months; 100,000 IU for 6-12
months; 2000,000 IU for greater than 12 months, p.o. single dose
(For S/E, C/I and dosage forms, see page 282)
Treat the eye infection with tetracycline. See page 90
Treat mouth ulcers with gentian violet. paint the mouth with half strength
twice daily Dosage form: solution, 0.5%, 1%

3. Measles : the clssification of measels is made when there is only measles

now or with in the last three months.

Treatment
Non-Drug Treatment:
Bed rest and fluid intake. Isolate child from school for 10 days
Drug Treatment
1. Symptomatic: for pyrexia and pain use Paracetamol (For S/E, C/I
and Dosage forms, see page 73).
2.Vitamin A, 50,000 IU, for children less than 6 months; 100,000 IU
for 6-12
months; 2000,000 IU for greater than 12 months, once per day for two
days p.o. (For S/E, C/I and Dosage forms, see page 282).
3. Gamma-globulins (human):0. 25ml/kg i.m once not later than 5
days after exposure.
S/E: transient fever, rash, malaise chills, rarely anaphylaxis.
Dosage forms: injection, 16.5% in 2 ml, 5 ml and 10 ml.
Caution: Live virus vaccines should be administered at least 3 weeks
before or 3 months after an injection of normal immunoglobulin.
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N.B.
Immune-compromised children who are exposed to measles should
receive immunoglobulin regardless of their immunization status.
Protection is for 2-4 weeks.
4. Give antibiotics for complicated cases, as necessary.
N.B.
Prevention is important by active immunization of children > 1 year
old who have not had the disease.

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MENINGITIS
1. Neonatal
Meningitis in the neonatal period may be caused by bacteria, viruses, fungi or
protozoa. Meningitis may be associated with sepsis or present it self as a focal
infection . The most common bacterial causes of neonatal meningitis are GBS,
E. coli and Listeria. The initial signs and symptoms may be indistinguishable
from those of other infectious and non-infectious diseases of the newborn.
These include lethargy, seizure, full fontanel and rarely nuchal rigidity.
Diagnosis is confirmed by examination of cerebrospinal fluid.

Drug Treatment:
First Line:
Ampicillin, 200mg/kg/day, i.v. every 6 hours for 14-21 days.
(For S/E and dosage forms , see page 31)
PLUS
Gentamicin, 5 mg/kg /day, i.m. every 8 hours for 14-21 days
(For S/E and dosage forms, see page 56)

If there is no response to the first line antibiotics within 48-72 of initiation of

antibiotics, or if the infant has hospital acquired infection, or if the mother had
culture proven gram-negative infection, a third generation cephalosporine (e.g.
Ceftriaxone) with an aminoglycoside (e.g. Gentamicin) should be initiated.

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Meningitis
2. Pyogenic
This is an acute and one of the most potentially serous infections in infants and
children that affects of the centaral nervous system. The signs and symptoms of
meningitis are variable and depend on the age of the patient. In infants whose
cranial sutures are still open, fever, vomiting, irritability, lethargy, convulsion
and buldging of the anterior fontanele may be present. During the first two
years of life in particular the findings are often subtle or nonspecific. In older
children focal neurologic signs, such as a sixth nerve palsy, may be more
prominent, and signs of meninigial irritation, such as nuchal rigidity ,kernig
sign or Brudziniski sign are usually present. Examination of cerebrospinal fluid
is mandatory if there is clinical suspicion of meningitis. Increased number of
white cell count, Low level of CSF glucose and elevated protein level are the
usual findings. Gram stain and Culture will reveal the microorganisim which is
responsible. The usual ethioloic agents in causing meningitis in children are: H.
influenzae, N meningitidis and S. pneumoniae.
Diagnosis of meningitis is based on clinical manifestation and cerebrospinal
fluid examination.
Treatment
First line
Chloramphenicol, 50mg/kg i.v. stat followed by 100 mg/kg/24
hours divided in to four doses( Q 6 hourly)
(For S/E, C/I and dosage forms, see page 35)
PLUS
Crystalline penicillin, 50,000IU/ kg i.v. stat followed by
250,000IU/kg/24 hours IV divided in 8 doses (Q3hourly)
(For S/E, C/I and dosage forms, see under benzyl penicillin page 55)

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N.B.
Duration of treatment depends on the ethiology but in general course
of treatment ranges between 10-15 days.

Alteranative
Haemophilus Influenza B: Chloramphenicol, 100mg/kg/day i.v.
Q6hourly for 10 days
(For S/E. C/I and dosage forms, see page 35)
Pneumococcus : penicillin G 250,000IU /kg/day i.v. Q4 hourly for 10
days
(For S/E. C/I and dosage forms, see benzyl penicillin page 55)
Meningococcus: penicillin G 250,000IU /kg/day i.v. Q4 hourly for 7
days
(For S/E. C/I and dosage forms, see benzyl penicillin page 55)
OR
Ceftriaxone, 100mg/kg IV , IM once daily for 10 days for all cases
(S/E, C/I and dosage forms: see page 29)

Adjunct to treatment with antibiotics

Dexamethasone, 0.6mg/kg/day div Q9 hours for four
(For S/E and C/I , see under Prednisolone, page 132)
Dosage forms: tablet 0.5 mg, 1mg, 2mg; Injection 4mg/ml, 25mg/ml,
50mg/ml

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ORAL TRUSH
Punctate or diffuse erythema and white-beings pseudomembranous plaques on
the oral mucosa. The lesions may become confluent plaques involving
extensive regions of the mucosa. Plaques can be removed with difficulty to
reveal a granular base that bleeds easily. After the neonatal period, the presence
of oral thrush-without antibiotic treatment or lasting over 30 days despite
treatment or recurring is highly suggestive HIV infection.

Treatment
Nystatin (100 000) units/ ml) suspension. Give 1-2 ml into the mouth
4 times a day for 7 days. (S/E, C/I and dosage forms: see page 112)
Alternative
Miconazole 2% two times a day for four days or until lesion
disappears
(For S/E, C/I and dosage forms: see page 140)
OR
Ketoconazole: cream 2% two times a day until lesion disappears.
S/E and C/I : see page 113
Dosage form: cream 2%, ointment
OR
Gentian violet, paint the mouth with half strength twice daily
S/E and C/I: see page 146
Dosage form: solution, 0.5%, 1%

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OSTIOMYLITIS
It is an infectious process primarly involving the bones. it occurs when
organisims circulating in the bloodstream enter the bone and lodge in the distal
end of the metaphysis, where the circulation is sluggish. There is point
tenderness an important diagnostic sign. At the 10-12 the day of illness bone
distruction and periosteal new bone formation are evident on X –ray
examination. The child with ostiomylitis is usually febrile, with an elevated
WBC count and increased sedimentation rate. Aspiration of the site, providing
a diagnostic specimen for gramstain and culture is recommended.
Stapylococcus aureus is the most comment ethioilogic agent.

Diagnosis of ostiomylitis is made clinically and by laboratory investigations

including blood culture and X ray study of the affected site.

Treatment
Drug treatment:
Cloxacillin, 50-100mg/kg/day divided every six hours for 3-6 weeks
(S/E, C/I and dosage forms: see page 57)

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OTTIS MEDIA (ACUTE)

Acute Otitis Media is characterized by inflammation and/or accumulation of
fluid in the middle ear. The most common bacterial causes are Streptococcus
pneuminiae, nontypable Haemophilus influenza, and Moraxella Caterrhalis.
Diagnosis: History of upper respiratory tract infection and ear pain.
Examination of the ears shows red, bulging tympanic membranes or pus
discharging ears.
Treatment
Non-drug treatment:
Dry the ear by wicking

Drug treatment:
First line:
Co-trimoxazole, 4 mg/kg trimethoprim 20mg/kg sulphamethaxozole twice a
day for five days. (S/E, C/I and dosage forms: see page 28, 283)
Alternative
Amoxicillin, 20-40 mg/kg/24 hours divided into 3 doses p.o. for five
days
(S/E, C/I and dosage forms: see page 31)

Chronic otitis media: discharging ear for more than two weeks.

Treatment
Treatment is usually non-drug, such as dry the ears with frequent
wicking.

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PERTUSIS (WHOOPING COUGH)

Pertusis or whooping cough is a highly contagious clinical syndrome caused by
a variety of agents including Bordetella pertussis, other Bordetella species and
adeno virus. Pertussis can be divided in to catarrhal, paroxysmal and
convalescent stages . The catarrhal stage is marked by nonspecific upper
respiratory tract symptoms including nasal discharge and low grade fever. The
characteristic paroxysmal stages follows during which repetitive coughs are
followed by an inspiratory whoop. These episodes may be associated with
cyanosis and vomiting, marked lymphocytosis is common. The convalescent
stage begins after 4-6 weeks. Appropriate and timely immunization is
protective.

Treatment

Non-drug:
Nutritional support
Drug:
Erythromycin, 12.5mg/kg orally four times a day for ten days.
(S/E, C/I and dosage forms: see page 31)

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PNEUMOCYSTES CARINI PNEUMONIA (PCP)

A presumptive diagnosis of pneumocystis pneumonia can be made in a child
who has severe or very sever pneumonia and bilateral interstitial infiltrate on
chest x-ray. Consider the possibility of pneumocystis pneumonia in children,
known or suspected to have HIV, whose ordinary pneumonia does not respond
to treatment. Pneumocystis pneumonia occurs most frequently in infants
(especially those <6 months of age) and is often associated with hypoxia. Fast
breathing is the most common presenting sign.
Diagnosis: Clinical and suggestive CXR picture
Treatment
Drug treatment:
First line
Cotrimoxazole, trimethoprim 5mg/kg/day, sulfamethoxazole 25
mg/kg/day, 4 times a day for 3 weeks.
(S/E, C/I and dosage forms : see page 28, 283)
Alternative
Pentamidine (4mg/kg once per day) by IV infusion for 3 weeks.
S/E: renal imparment, pancreatitis, leucopenia, hypoglycemia
C/I: diabetis, renal damage
Dosage form: nebulizer solution, 300 mg/vial; powder for injection,
200 mg/vial
Children who react adversely to trimethoprim-sulfamethoxazole are
usually aged under 1 year and often become hypoxic, and require
oxygen therapy for several days. Their response to treatment is poor
and the case-fatality rate is high. Recovery from hypoxia can be
prolonged.
Prohpylaxis

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Trimetoprim 150mg/m2 /24 hours and Sulfamethoxazole 750mg/m2

/24 hours orally divided Q 12 hours 3 days /week on consequitive
days
Alternative
1. Same dose given Q24 hours
2. Same dose given Q12 hours 7 days a week
3. Same dose given Q132 hours on alternative days 3days /week
NB. Children who have had PCP should receive life long prophylasis

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PNEUMONIA IN CHILDREN
Pneumonia defined as inflammation of lung parchayma, is caused virtually by
every classes of microorganisms and a specific etiologic diagnosis is often
difficult in children. Viruses and mycoplasma pneumoniae are the primary
agents causing pneumonia followed by bacteria. WHO recommends diagnosis
of pneumonia when children under five have acute on-set cough with
tachypnea. Pneumonia can be classified as severe pneumonia, pneumonia or
no pneumonia.
Severe Pneumonia is diagnosed when there is cough or difficult breathing
plus at least either of the following signs: lower chest in drawing, nasal flaring,
or grunting in young infants. Fast breathing or abnormal breath sounds may
also be present.
Pneumonia is diagnosed when a coughing child also develops fast breathing
but no signs for severe pneumonia.
No pneumonia cough or cold; if no sign for pneumonia or severe pneumonia.
Diagnosis is clinical and chest X ray. The decision to treat a child who has
pneumonia is usually made clinically. Antibiotic therapy is directed at the most
likely pathogens as suggested by the child’s age, clinical presentation
(including severity of illness).

Treatment
1. No pneumonia but only cough or cold
Soothe the throat; relieve the cough with a safe remedy.
Non drug treatment:
Safe remedies to recommend:

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Breast milk for exclusively breast-fed infants

Home fluids such as tea with honey, fruit juices
Harmful remedies to discourage: cough syrups containing diphenyl
hydramine and or codeine
Drug Treatment:
Paracetamol, 10-15 mg /kg up to 4 times a day for the relieve of high
fever equal to or above 39 0C .
(For S/E, C/I and dosage forms: see page 73)
2. Pneumonia
Drug treatment:
First line
Cotrimoxazole (4-mg/kg-trimethoprim-20mg/kg sulphamethaxozole
twice a day for five days. (S/E, C/I and dosage forms : see page 28,
283)
Alternative
Amoxicillin, 15 mg /kg PO three times daily. (For S/E, C/I, see page 31)
Dosage: capsule, 250mg, 500mg; Injection, 250mg, 500mg in vial; Syrup,
250mg/5ml.

3. Severe Pneumonia
Drug treatment:
Benzyl penicillin 50,000units/kg/24hrs IM or IV every 6 hours for at
least 3 days. (For S/E, C/I and Dosage forms, see page 55).
When the child improves switch to oral Amoxicillin: 15-mg/ kg 3
times a day. The total course of treatment is 5 days.

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If the child doesn’t improve with in 48 hours, switch to Chloramphenicol 25

mg/kg every 8 hours IM/IV until the child has improved and continue orally
for the total course of 10 days (S/E, C/I and dosage forms: see page 35)

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SEIZURES (NEONATAL)

Seizures can be the most dramatic indication of neurologic

abnormality in the newborn, yet most neonatal seizures are subtle or
even silent. There are five types of neonatal seizures: subtle seizures
(presenting with apnea, starring, lip smacking, chewing or eye
blinking); focal clonic; multifocal clonic; tonic, and myoclonic
seizures. The causes of neonatal seizures include metabolic, toxic,
structural and infectious diseases.
Diagnosis: clinical

Drug Treatment:
Phenobarbital, i.m/i.v/p.o. 4-6 mg kg/day loading dose, followed by
5 mg/kg in two divided doses. (S/E, C/I and dosage forms: see page
189)
Alternative
Phenytoin, i.m/i.v/p.o. 4-6 mg kg/day loading dose, followed by 5
mg/kg in two divided doses. (S/E, C/I and dosage forms: see page
190)
If seizures are associated with,

A. Hypocalcaemia (Hypocalcaemic tetany):

Calcium gluconate solution, 10% 1-2 ml/kg/; repeat PRN after 6
hours.
S/E: bradycardia, cardiac arrest, extra vascular leakage may cause
local necrosis.
Dosage forms: syrup 4gm/15ml; injection, 10% solution, 10 ml.

B. Hypoglycemia:

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Glucose 10%, (For Dosage, see under Hypoglycemia, page 291)

C. Vitamin B 6 deficiency:
Vitamin B 6 (pyridoxine): 50mg i.m. as single dose.
Dosage form: injection, 50mg/ml in 2ml.

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SEPSIS (NEONATAL)
Neonatal sepsis is defined as bacterimia with systemic manifestation in the
absence of other primary systemic problems during the first 28 days of life.
Diagnosis is clinical and blood culture. Neonatal sepsis can be divided in to
two subtypes:
Early onset sepsis: occurs with in the first 72 hours of life. It is caused by
organisms prevalent in the genital tract of the mother or in the labour room,
which includes mainly group B streptococci and E coli. Majority of the
neonates with early onset sepsis clinically manifest with respiratory distress
due to intrauterine pneumonia. Early onset sepsis has usually fulminant course
and high mortality.
Late onset sepsis: the onset is delayed for a minimum of four days in most
cases symptoms appear by the end of first week of life. About 2/3 cases of late
onset septicemia are caused by gram negative bacilli while the rest are
contributed by gram positive organisms. Meningitis is more frequent.
Treatment
Non-Drug treatment: Supportive care which includes maintenance of normal
body temperature including Kangaroo care, adequate calorie and fluid supply,
and Correction of associated metabolic abnormalities.
Drug treatment:
Till the culture report is collected start with broad-spectrum antibiotics, which
includes penicillin and Amino glycoside.
Ampicillin, 100 mg /kg/day every 6-8 hours i.m. for 10 days. (For S/E
and dosage forms , see page 31)
PLUS
Gentamicin 5 mg/kg /day i.m. every 8 hours. For 10 days (For S/E and
Dosage foms, see page 56)
Alternative
Penicillin G Sodium Crystalline. 50,000IU/kg every 6 hours for ten
days.
(For S/E and dosage forms ,see under benzyl penicillin page 55)
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PLUS
Gentamicin 5 mg/kg /day i.i. every 8 hours for 10 days.
(S/E, C/I and dosage forms : see page 56)
SEPTIC ARTHRITIS
Septic or pyogenic arthritis is an inflammation of the joint caused by pyogenic
microorganisms. It can result from hematogenous dissemination of
bacteria,contigous spread of an ostiomylitis or direct innoculation of
microorganisms in to the joint cavity as a result of penetration trauma.
Haemophilus influenzae and Staphylococcus aureus are the most common
agents causing seprtic arthritis.
Clinical manifestation: the most common feature of septic arthritis is acute
inflammation localized to the region of the joint. This may produce pain,
tenderness, swelling, erythema and decreased range of motion.
Diagnosis is both clinical and labortatory investigation.

Treatment
Non drug treatment:
Irrigation and drainage of the joint
Immobilization of the joint in a functional position

Drug treatment
Cloxacillin 50-100mg/kg/day divided every six hours for 4-6 weeks
(S/E, C/I and Dosage forms: see page 57)

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SINUSITIS
Sinusitis, inflammation of the sinuses, probably occurs with most cases of viral
nasopharyngitis. Acute purulent sinusitis should be suspected in children with
severe or prolonged viral upper respiratory tract infection. S. pneumoniae, non
typable H.influenzae and M.catarrhalis are the common bacterial pathogens.
In addition to fever and purulent nasal discharge, children with acute sinusitis
may have headache, localized focal tenderness and periorbotal edema. The
complication of acute sinusitis includes orbital cellulites and cavernous sinus
thrombosis. Diagnosis can be made by radiological examination reveals
calcification of sinuses with air fluid level. Complicated sinus requires
drainage

Treatment:
Drug treatment:
First line
Cotrimoxazole, Trimethoprim 4 mg/kg sulfamethoxazole 20 mg/kg
PO twice per day. (S/E and dosage forms, see page 28, 283)

Alternative
Amoxicillin, 15 mg /kg PO three times daily. (For S/E, C/I and
dosage forms, see page 31)

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STREPTOCOCCAL PHARYNGITIS/
EXUDATIVE TONSILLITIS
Streptococcal pharyngitis (sore throat) is a common occurrence and the basis of
numerous physician contacts. If signs and symptoms of upper respiratory tract
(URI) are present, it is suggesting a viral etiology. In children with sore throat
and fever who do not have URI symptoms, the major pathogen of concern is
group A beta hemolytic streptococcus, which causes acute morbidity and can
produce both supurative (e.g. peritonsilar abscess) and non supurative
complications (glomerulonephritis and rheumatic fever).

Diagnosis: In infants, the disease is usually manifested by the classic syndrome

of fever, headache and sore throat. Examination of the pharynx usually reveals
an intensely red tonsils with moderate to marked exudates.
Drug Treatment:
Antibiotics shorten the clinical course if administered early. Treatment also is
effective in preventing acute rheumatic fever.
First Line:
Benzathine penicillin, i.m as a single dose according to age: children
under 2 years of age, 300,000IU; 2-6 years 600,000IU; 7-10 years
900,000 IU; and over 10 years, 1.2 million IU. S/E, C/I and dosage
forms: see page 55
PLUS
Paracetamol, 10-15 mg /kg p.o. up to 4 times a day for the relieve of
high fever. (For S/E, C/I and Dosage forms, see page 73)
Caution: Aspirin should not be used because of its association with
Reye’s syndrome in children with influenza virus or varicella
infection
Alternative
Erythromycin, 12.5mg/kg orally four times a day for ten days.
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(For S/E, C/I and Dosage forms, see page 31)

SYPHILIS (CONGENITAL)
Congenital syphilis is acquired transplacentaly early in pregnancy and is
responsible for 10% of fetal deaths in urban Ethiopia. The etiology is T.
palladium. Clinical manifestations are rarely seen at birth, and the early
symptoms of congenital syphilis such as anemia, poor Weight gain and
irritability are not diagnostic. Therefore, for early diagnosis a high index of
suspicion is necessary. In Ethiopia where syphilis is common, positive
serologic test for syphilis (VDRL) alone can be taken as evidence for
congenital syphilis in infants under the age of months. Delay in treatment of
congenital syphilis leads to tissue damage: cornea, teeth, bone, palate, the
nervous system, etc. Diagnosis of congenital syphilis is clinical and positive
VDRL in the newborn infant. CSF pleocytosis in which white lymphocytes
dominate, increased protein and positive VDRL reaction are diagnostic of
neurosyphilis . The possibility of syphilis and HIV co-infection is high.
Syphilis is a family disease and all members of the family of the index case
must be investigated and treated promptly.

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Treatment
Drug treatment:
For Newborn:
Crystalline penicillin G 50,000 u/kg/day, iv divided into 2 doses
for10 days, and neurosyphilis for three weeks. S/E, C/I and dosage
forms: see page 55)
OR
Benzathine penicillin G 50.000u/kg, i.m. weekly for 3 week.
(S/E, C/I and Dosage forms: see under benzyl penicillin page 55)

For 1 month to 2 years child:

Procaine penicillin G 15,000u/kg/day i.m. in a single dose, 10days
S/E, C/I and dosage forms: see unde benzyl penicillin page 55)
OR
Benzathine penicillin 100,000u/kg i.m. weekly for 3 weeks
(S/E, C/I and Dosage forms: see under benzyl penicillin page 55)

For older Children:

Procaine penicillin 1 million units i.m.daily, 10 days
(S/E, C/I and dosage forms see under benzyl penicillin page 55)
OR
Benzathine penicillin 2.4 million units i.m.weekly for 3 weeks.
(S/E, C/I and Dosage forms: see under benzyl penicillin page 55)

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TETANUS (NEONATAL)
Neonatal tetanus is caused by the neurotoxin tetano-sapsmin produced by
Clostridium titani, which infects the umbilical stump. The incubation period is
5 to 14 days. Affected infants develop difficulty in sucking and swallowing,
“lockjaw”, generalized hyper tonicity spasms and opisthotonos. Once signs
develop the disease progresses to a fatal out come in 60-70% of cases.
Neonatal disease may occur if maternal immunity is lacking and infection is
introduced at the time of delivery.

Diagnosis is mainly clinical.

Prevention: The administration of the toxoid vaccine to all mothers prior to

pregnancy and proper newborn umbilical hygiene can effectively prevent this
disease.

Treatment
Tetanus immuno globulin (TIG), 500 – 3000 IU i.m.
Dosage forms: injection, 3000 IU
AND
Penicillin G Sodium Crystalline, 50,000IU/kg/24hrs every 6 hours
for ten days
(For S/E, C/I and dosage forms, see under benzyl penicillin page 55)
AND
Chlorpromazine, 1.6 mg/kg/24 hours divided in to 4 doses IV/IM.
(S/E, C/I and dosage forms: see page 84)

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TRACHOMA
Refers to a chronic form f conjunctivitis caused by Chlamidia trachomatis. It is
characterized by a progressive conjunctival follicular hyperplasia, corneal neo-
vascularization, and scarring of the conjunctiva, cornea and eyelids.
Diagnosis: is often made on the typical physical signs. Culture from the
conjunctival discharge may also isolate C.trachomatis.

Non-Drug treatment.
Wash and keep the eye clean.
Limit irritation from glare
Drug treatment
First line:
Tetracycline eye ointment, 1%, twice daily for about 6-8 weeks.
Drops 2-drops
(For S/E, C/I and dosage forms: see page 31)
OR
Doxycycline may be added 100 mg twice daily for 7 days.
(For S/Es, C/Is and dosage forms: see page 33).
Alternative:
Chloramphenicol eye drops 0.5 % 4-6 hourly or Chloramphenicol
eye ointment, 1 % 4-6 hourly for the same duration mentioned above.
(For S/E, C/I and dosage forms: see page 35)

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TUBERCULOSIS (TB) IN CHILDREN

TB is a chronic infectious disease caused in most cases by Mycobacterium
tuberculosis. Occationally it can be caused by Mycobacterium bovis or
Mycobacterium africanum
Diagnosis of TB in children is difficult because of the presence of a wide range
of non-specific symptoms. It is important to make a clear distinction between
infection and disease: in infection, only the Mantoux test may be positive
(>10mm), but the child is healthy and does not have any signs and does not,
therefore, need anti TB treatment. If there is TB-disease there are clear signs
and symptoms.
Symptoms and signs may be confusing in children co-infected with HIV.
Diagnosis rests largely on the results of clinical history, a history of TB contact
in the family, clinical examination, x-ray examination and tuberculin testing.
In most cases, sputum cannot be obtained and if obtained may be negative
because the bacterial load is generally low. Attempts should always be made,
however, to obtain a sputum sample for direct smear microscopy. Early
morning gastric aspirates may yield AFBs and can be carried out if
spontaneous sputum cannot be obtained.
Children should be strongly suspected of having TB when they are contacts of
a known adult case of pulmonary TB and have clinical signs and symptoms
(recent weight loss or failure to gain weight and/or cough or wheezing > 2
weeks).
In the absence of confirmation, the diagnosis of active TB can be made and
treatment commenced when any one of the following conditions is met:
• Radiological picture of miliary pattern.
• Pathologic findings compatible with TB from a biopsy or surgically
removed lesion.

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Doubtful cases who are suspected of having TB but who do not meet the
criteria for the diagnosis should be seen after 6-8 weeks for re-evaluation.

II. Table 1. Criteria for the diagnosis of tyuberculosis in children

Suspected tuberculosis

An ill child with a history of contact with a confirmed case of pulmonary

tuberculosis

Any child:
• Not regaining normal health after measles or whooping cough
• With loss of weight, cough and wheeze not responding to antibiotic
therapy for respiratory disease
• With painless swelling of superficial lymph nodes

Probable tuberculosis

A suspect case and any of the following:

• Positive (10 mm in diameter) induration on tuberculin testing (see
appendix V)
• Suggestive appearance on chest radiograph (e.g. unilateral
hilar/mediastinal lymphnode enlargement with or without lobar or
segmental opacity, miliary patter, pleural effusion, infiltrates and
cavitations)
• Suggestive histological appearance of biopsy material

Confirmed tuberculosis

• Detection by microscopy or culture of tubercle bacilli from secretions or

tissues
• Identification of tubercle bacilli as Mycobacterium, tuberculosis by culture

Treatment
Short course chemotherapy as Category III
the treatment regimen for this category is 2(RHZ)/6EH

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this regimen consists of 8 weeks treatment with Rifampicin , Isoniazid

and Pyrazinamide during the intensive phase followed by six months
ethambutol and Isoniazid

Chapter 8
ACUTE /EMERGENCY CONDITIONS
Animal bites
Rabies
Snake bites and scorpion stings
Burns
Poisoning
Barbiturates
Carbonmonoxide
Pesticides
Shock
Wound

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ANIMAL BITES
Dog bites are the most common kind of animal bite, followed by cat bites;
other bites are from snakes and rarely humans. Infected dog and cat bites are
usually characterized by a localized cellulitis and pain at the site of injury.
Infections from dog and cat wound bites are predominantly due to Pasteurella
multocida and Staphylococcus aureus.

Diagnosis: clinical

Principles of Management:

document the mechanism of injury; unprovoked animal bites are

particularly dangerous as such animals may have rabies

if possible, obtain an immunization history of the animal; if no history

is available, observe the animal for 10 days. If the animal is a suspect
for rabies or lost, administer:
• Human rabies immunoglobulin

• Human diploid cell strain vaccine (HDCSV) (for details

see under Rabies)

determine the patient's tetanus immune status; if status is inadequate

or unknown, administer:

o Tetanus immune globulin in TAT

o Tetanus toxoid (for details see under Snake
Bites and Scorpion Stings)
• Close observation of the patient’s condition
• Psychological support and reassurance
• Ventilatory and cardiovascular support, if required (it may be
necessary to refer the patient if such facilities are not available)
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• Wounded extremities should be immobilized and elevated.

• Puncture wounds and bites are usually not sutured (stitched)
unless they involve the face.

Note: Local wound infection may develop in as little as 24 hours.

Non-Drug Treatment
All bite wounds require immediate, thorough cleansing with fresh tap
water. The wound must be scrubbed with soap and water to remove
foreign material. Dead tissue from the wound should be removed with
a sterile scissors or scalpel.

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Drug Treatment
Cleansing with a sterile solution of Normal Saline,
OR/AND
Disinfectants and Cleansing Agents,e.g. Chlorhexidine + Cetrimide
solution
S/E: occasional sensitivity

For secondary infection:

Give appropriate antibiotic, e.g. Amoxicillin + Clavulanate.
Treatment should be given for 10-14 days (For doses, S/E , C/I and
dosage forms, see page 31)
For Pain:
Give NSAIDs, e.g. Paracetamol, p.o 500-1000 mg as needed (4-6 times daily)

1. RABIES
Rabies is a zoonotic infection of warmblooded animals caused by the rabies
virus. In Ethiopia the disease is transmited to humans via dog, and rarely, cat
bites; the bites are usually unprovoked. The incubation period is usually 1- 2
months (rarely longer). The onset is marked by a prodrome of non-specific
symptoms, which include anorexia, malaise, fatigue, fever, myalgia and
headache. The bitten area, which may already have healed, becomes painful and
irritable. Neurological signs (anxiety, depression, hallucinations, short periods of
aggressiveness such as thrashing or biting) are manifested when the virus enters
the nervous system. Hydrophobia is a characteristic symptom of rabies, marked
by laryngeal spasm in response to the sight, sound and feel of water.
Diagnosis: clinical

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Treatment
Non-Drug Treatment
• Therapy is symptomatic for established disease.
• Thorough cleansing and careful management of the wound is
very important
• Nurse patient in a quiet, darkened room.
• Nutritional, respiratory and cardiovascular support when required.

Drug Treatment (post exposure prophylaxis)

Human rabies immunoglobulin, 20 IU/kg, should be given immediately
(half the dose around the area of the wound, the other half – IM in the
deltoid area).
S/E: Rare, but irritation may occur at site of injection; immune globulin
products may give rise to anaphylaxis,, angioneurotic edema, and
nephritic syndrome.
Dosage forms: 150 and 300 IU per mL
Note: Store in refrigerator; do not freeze (discard if vaccine has been
frozen)
PLUS
Human diploid cell strain vaccine (HDCV), 1 mL, IM, given on days 0,
3, 7, 14 and 28.
S/E: Abdominal pain, chills, dizziness, fatigue, headache, irritation at site
of injection; immune complex-like reaction (hives or skin rash) during
booster dose administration.
Dosage forms: Greater than or equal to 2.5 IU rabies antigen per mL of
reconstituted suspension.
Note:
Use reconstituted vaccine immediately
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2. SNAKE BITES and SCORPION STINGS

In addition to the measures indicated under "Principles of Management" and
disinfecting and cleansing above, give Snake venom antiserum polyvalent for
snake bites, and Scorpion antivenom for scorpion stings (see insert for dosing
instructions).

Note:
anti-venoms may give rise to acute anaphylaxis: agents listed in
section ___ should be at hand.

PLUS
Tetanus toxoid, IM, 0.5mL once for primary or booster immunisation
S/E: Allergic reactions (rarely may include anaphylaxis), fever, lymph
adenopathy, neurologic reaction (confusion, headache, seizures,
sleepiness, vomiting, irritability); redness or lump at site of injection
Dosage forms: Ampoule, 05 ml
For pain:
Analgesic, e.g. Paracetamol, p.o. 500-1000mg 4-6 times a day (For
doses, S/E and C/I and dosage forms, see page 73)
Alternative
For severe pain, give
Opiod analgesic, e.g. Morphine injection, as required (For doses, S/E
and C/I and dosage forms, see page 157)

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BURNS
Burn is an area of tissue damage caused by heat (including electricity), by caustic
chemical, or by radiation. Burns are classified according to the depth of tissue
damage: first-degree burns produce a redness of the skin, and they heal without
scarring; Second-degree burns cause the destruction of deeper structures within the
skin, resulting in blistering; Third-degree burns destroy the full thickness of the
skin, leaving an open area. Large areas of burnt skin cause the loss of body fluid
into the surrounding tissues, which can lead to dehydration and the rapid onset of
shock, particularly in children.

A. Supportive measures
• Stabilize vital signs and support vital organs
• Wound management:
o Assess degree (depth) and surface area (extent)
o Irrigate with tap water and clean with soap and water, or
cleanse with chlorhexidine + cetrimide or other cleansing
agent
o Chemical burns should be flushed with water until all
burning pain has stopped, and all contaminated clothes
should be removed.
o Debride dead and necrotic tissue
• Oxygen

Drug treatment
1. Minor burns
• Treated in an outpatient setting
• The wound is debrided of all loose skin blisters are better not excised
in First Degree burn and open wound management is preferred.

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• All dirt is removed by cleansing with mild soap and irrigation with
isotonic saline solution
• The wound is then covered with Silver sulfadiazine and properly
dressed
• The first dressing change and dressing evaluation are performed 24-48
hrs after injury

Silver sulfadiazine cream 1%, apply daily with sterile applicator for
treatment and prophylaxis of infection in burn wounds (also adjunct in
treatment of infection in leg ulcers and pressure sores),

S/E: allergic reaction, hepatic and renal impairment.

C/I: Late-term pregnancy, breast-feeding, sensitivity to

sulphonamides, neonates. Systemic toxicity in the form of blood
disorders and rashes may occur after topical application to a large area
of the skin.
Dosage forms: Silver sulfadiazine cream 1%,
Caution: Do not use Silver sulfadiazine near the eyes.
OR
Fusidic acid, cream 2%; apply to skin 3-4 times daily
S/E: Local hypersensitivity reactions (rare)
Dosage forms: cream and ointment, 2%

2. Moderate and Severe burns

Fluid resucitation
• Ringer lactate solution, during the first 24 hrs
• Dextrose in water, 5% to be administered after the first 24
hrs
PLUS
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Cimetidine, i.m. or slow i.v. injection, 200mg-400mg, every 4-6

hours (For S/E, C/I and dosage forms, see page 218)

Alternative
Omeprazole, 20 mg, p.o. once daily for 4 weeks (DU) or 8 weeks
(GU). (If upper GIT bleeding present) For S/E, C/I and dosage forms,
see page 222)
OR
Oral antacids: magnesium trisilicate 500 mg with aluminium
hydroxide 250 mg tabs to be chewed 1 hr before and 3 hrs after meals
and at bedtime. (For S/E, C/I and dosage forms, see page 221)
OR
Sucralfate, 1 gm four times a day, one hr before each meal and at bed
time
S/E: constipation or diarrhoea, backache, dizziness, nausea, stomach
cramps, allergic reactions (rash, hives, itching)
C/I: renal failure
dosage forms: Tablet, 1 gm (scored)
PLUS
Tetanus toxoid booster or primary immunization, IM, 0.5 mL. (For
S/E, C/I and dosage forms, see page 328)

B. Pain Management:
First Line:
Analgesic, e.g. Paracetamol, p.o. 500-1000mg 4-6 times a day (For
doses, S/E and C/I and dosage forms, see page 73)
Alternative:

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Morphine hydrochloride injection ( for severe pain only), 10-20 mg

IM (or SC, provided the patient is not oedematous), repeat every 4
hours if necessary.
S/E: nausea and vomiting, CNS and respiratory depression (see
page122 for specific antidote); prolonged use leads to dependence.
C/I: acute respiratory depression
Dosage forms: injection, 10 mg/ml, 20 mg/ml in 1 ml ampoule; caps
(modified release), 20 mg, 50 mg, 100 mg, 200 mg; granules for oral
suspension, 20 mg, 60 mg, 100 mg, 200 mg, per sachet; oral solution,
10 mg/5ml, 100 mg/5ml; tablet, 100 mg, 500 mg

WOUND MANAGEMENT
See under Minor burns
• Apply local antibiotic or Vaseline coated dressing
• Oral antibiotics are usually recommended in case of
definite infection. If infection develops, continue antibiotics for at
least 5 days after all signs of infection have cleared.

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POISONING
Poisoning refers to the development of harmful effects following exposure to
chemicals. Poisoning may be local (to they eyes, skin, lungs or gastro-intestinal
tract); systemic, or both, depending on dose, absorption, distribution, potency
and host susceptibility. Exposures most frequently involve cleaning agents,
analgesics, cosmetics, plants, cough and cold preparations and hydrocarbons.
Most exposures are acute, accidental, and occur at home resulting in minor or
no toxicity; children up to the age of 6 are most frequently affected. Sometimes
poisoning results from suicidal attempts.

Diagnosis is made by identifying, and if possible, quantifying the poison by the

substance container, laboratory tests and clinical features. Every attempt should
be made to obtain detailed information from the patient or his attendant about
the circumstances of poisoning.

Note: Neurologic or endocrine diseases, including hypoglycemia, should be

ruled out in comatose poisoned patients.

General Principles of Management

A. Supportive Measures

• Avoid further exposure to the poison by removing clothes and

washing the body (for external exposure), or by inducing emesis by
mechanical means or with the help of an emetic agent (for systemic
exposure)

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• Treatment should address the "ABCs" (airway, breathing, circulation)

without delay; asses the level of consciousness of the patient, and,
where appropriate, perform assisted ventilation and oxygenation.
Correct hypotension and hypoglycemia with appropriate iv infusions
• Maintain body temperature
• Transport the patient head downwards on a stretcher and nurse in this
position in the ambulance.

Control seizures, e.g. with Phenobarbital (For doses, S/E and C/I
and dosage forms see page 189)

B. Removal of Poison

1. Emesis

Ipecacuanha (Ipecac) syrup, 15-30 ml p.o. (10-20 ml for children),

followed by 2-3 glasses of water. The dosage may be repeated once
(after 20-30 minutes) if emesis has not occurred.
S/E: excessive vomiting and mucosal damage; cardiac effect if
absorbed
C/I: avoid in poising with corrosive or petroleum products owing to
risk of aspiration; unconscious patient.
Caution: Emesis should not be done on a patient who is comatose,
convulsing, or when corrosive substances like strong acids or alkali,
or petroleum products have been ingested. Ipecac syrup should not be
used for strychnine poisoning.
Dosage form: syrup, 7% powdered ipecac
Note:

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Gastric lavage is an effective alternative if poison has been swallowed

not more than 6 hours ago. Gastric lavage could be followed by the use
activated charcoal.

2.Use of Adsorbents

Activated charcoal, 50-100 g suspended in 100-150 mL water

S/E: constipation

Dosage forms: activated charcoal tablets, 125 mg, 250 mg

Note:

Activated charcoal must be administered after ipecacuanha syrup,

when these agents are used together (if activatd carbon has been used
before ipecac, it is wise to use the drug again when emesis has been
accomplished). Some substances are not well adsorbed by activated
charcoal (i.e., lithium, iron, lead, methanol).

3. Catharsis
Saline cathartics, such as magnesium sulfate, are useful to hasten the GI transit
time of the poison and thus decrease its absorption; they also counter the
constipating effect of activated charcoal and facilitate the elimination of the
adsorbed poison when used together.
Magnesium sulfate 15 – 20 gm (30 to 40 ml of a 50% solution) in a
glass of water (For S/E and C/I, see page 182)
Dosage forms: magnesium sulfate crystals

4. Forced diuresis:

A loop diuretic, e.g. Frusemide, i.v. stat 20-40 mg, to be repeated as

required.
(For S/E, C/I and dosage forms, see page 157)
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POISONING WITH SPECIFIC AGENTS

1. BARBITURATES

Barbiturates mainly act in the CNS and, as a consequence, affect other organ
systems. Direct effects include sedation and hypnosis at lower dosages; they
can induce respiratory depression at higher doses. Patients with underlying
chronic obstructive pulmonary disease (COPD) are more susceptible to these
effects, even at doses that would be considered therapeutic in healthy
individuals. Barbiturate overdose fatality is usually secondary to respiratory
depression. Major complications associated with barbiturate poisoning include
pneumonia, shock, hypoxia, and coma. Other associated life-threatening
complications include acute renal failure and pulmonary edema.

The patient with barbiturate toxicity may present with any or all of the
following symptoms:

• Neurologic: Lethargy, coma, hypothermia, decreased pupillary light

reflex, nystagmus, strabismus, vertigo, slurred speech, ataxia,
decreased deep tendon reflexes

• Psychiatric: Impairment in thinking (e.g. memory disturbances, poor

judgment, limited attention span), irritability, combativeness, paranoia

• Respiratory: Respiratory depression, apnea, hypoxia,

• Cardiovascular: Tachycardia, bradycardia, hypotension, diaphoresis,

shock

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• Skin - Barbiturate blisters (ie, bullous lesions typically found on the

hands, buttocks, and knees)

Diagnosis: Clinical (see above)

Treatment

Treatment for the patient with barbiturate toxicity is predominantly supportive.

• Aggressively initiate fluid therapy if the patient has a low blood

pressure or appears to be in hypovolemic shock

• Initiate treatment with pressors (eg, norepinephrine, dopamine) if

shock persists or worsens.

• GI decontamination: Perform GI decontamination once the airway is

protected and hemodynamic stabilization addressed. Activated
charcoal orally or by nasogastric tube is recommended for all patients
with potential barbiturate toxicity.

• Alkalinization of the urine enhances the elimination of phenobarbital

and, likely, other long-acting barbiturates. Urinary alkalinization is
not recommended for short-acting barbiturate toxicity.

Sodium bicarbonate, 1-2 mEq/kg i.v. bolus, followed by an i.v drip of 1000
ml of D5W to which 100-150 mEq of sodium bicarbonate has been added;
initiate drip rate at 3 times maintenance IVF rate and titrate drip rate to urinary
pH. Goal is to maintain a urinary pH >7.5 and urine output >2 ml/kg/h.
Child:Administer as in adults.

C/I: Documented hypersensitivity; alkalosis (pH >7.5); volume overload;

severe hypernatremia; hypocalcemia; severe pulmonary edema;
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Caution: in electrolyte imbalances such as in patients with CHF, cirrhosis,

edema, corticosteroid use, or renal failure; when administering, avoid
extravasation, which can cause tissue necrosis. Serum potassium level must be
>4 mEq/L because urinary alkalinization cannot occur in the presence of
hypokalemia; can cause alkalosis, decreased plasma potassium, hypocalcemia,
and hypernatremia;

2. CARBON MONOXIDE
Poisoning with carbonmonoxide is common where there is incomplete
combustion of carbon fuel, especially charcoal. Acute poisoning
results in headache, nausea and vomiting, mental confusion and
agitation. Severe toxicity causes confusion, impaired thinking, and
may progress to coma, convulsions, and death.
Diagnosis:
Clinical: history of prolonged exposure to smoke from charcoal in a
closed environment

Treatment

In addition to general supportive measures, remove the patient to open air.

Drug Treatment

Oxygen, 100%

3. PESTICIDES

Organochlorine insecticides (e.g. DDT, Aldrin, Dieldrin, Heptachlor),

organophosphorous insecticides (e.g. Parathion, Dichlorovos) and
Carbamate insecticides (e.g. Carbaryl, Baygon, Mobam) can cause
occupational or accidental poisoning. Organochlorine and Carbamate
insecticides produce their toxicity by inhibiting acetylcholinesterase and thus
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leading to excessive cholinergic activity. The onset after exposure may be

within minutes or could be delayed for up to 12 hours, depending on the
amount and route of exposure. The major presenting features are: fatigue,
headache, nausea, vomiting, abdominal pain and dyspnea; in severe cases:
seizures, loss of consciousness, paralysis, incontinence, cyanosis, hypotension,
muscle fasciculations and increased bronchial secretions, excessive salivation
and pin-point pupil. Carbamate poisoning exhibits a similar clinical picture to
organophosphate toxicity. However, carbamates have poor CNS penetration
and cause minimal CNS symptoms.

Diagnosis: Mainly clinical. If conditions allow, the level of serum

cholinesterase should be determined.

Serum cholinesterase activity Severity of poisoning

21%-50% mild
11%-20% moderate
0%-10% severe
Treatment

1. Non-Drug Treatment;

o Ventilatory support by frequent suctioning from the oropharynx and

upper airway when secretions are present
o Thorough rinsing with water when dermal exposure is significant;
contaminated clothing should be removed, carefully placed in plastic
bag and discarded.

2. Supportive Drug Treatment:

Ipecac-induced emesis or gastric lavage and the use of activated
charcoal are indicated for swallowed pesticides (For doses, S/E and

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C/I and dosage forms, see under Non-specific Drug Treatment of

poisoning)
3. Specific Drug Treatment
Atropine Sulphate, 2 mg stat, i.m. or i.v. given every 20 to 30
minutes until signs of full atropinization are observed (flushed and
dry skin, dilated pupil, dry mucus membrane). The dose should then
be tapered and continued until definite improvement occurs and is
maintained, sometimes for two days or more,
(For doses, S/E and C/I, see page 169)

PLUS
Pralidoxime Mesylate (P2S, 2-PAM) i.v., diluted to 10-15 ml with
water for injection and given over 5-10 minutes, 30 mg/kg initially,
followed by 1-2 further doses if necessary. Children: 20-60 mg/kg as
required depending on severity of poisoning and response.
S/E: drowsiness, dizziness, nausea, tachycardia, disturbances of
vision, headache, hyperventilation, muscle weakness.
C/I: Poisoning with carbamates or organophosphorous compounds
that have no anticholinesterase activity.
Note:
Pralidoxime is effective only if given within 24 hrs of exposure.
Treatment of acute poisoning due to DDT and other Organochlorine
insecticides is largely symptomatic. Diazepam i.v., Phenobarbital
or Calcium gluconate i.v. may be useful to control convulsions when
present. (For doses, S/E and C/I see page 84, 189 or 311)

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SHOCK
Shock is a state in which there is failure of the circulatory system to maintain
adequate cellular perfusion, resulting in reduction of delivery of oxygen and
other nutrients to tissues.
Non-drug Management
• Maintain airway; intubation may be required
• Cardiorespiratory resucitation, with monitoring of vital parameters
Drug treatment

A. Anaphylactic shock
First Line:
Adrenaline 1:1000, SC or deep IM 0.5-1 ml; may be repeated every
10 min until improvement in blood pressure and pulse rate occurs
(maximum dose: 5 mg/day)
(For doses, S/E and C/I, see page 172)
OR
Adrenaline 1:10000, IV, 3-5 ml given slowly
(For doses, S/E and C/I, see page 172)
Dosage form: injection, 0.1% in 1 ml ampoule
PLUS
Sodium chloride solution 0.9% (normal saline)

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Second Line:
Hydrocortisone 100 mg-300mg i.v. immediately
(For doses, S/E and C/I, see page 173)
Dosage form: injection (sodium succinate), 50 mg/ml in 2 ml
ampoule, 125 mg/ml; powder for injection, 500 mg in vial; tablet
(acetate), 5 mg, 10 mg
PLUS
Aminophylline, i.v., 250 mg over 10-20 minutes
(For doses, S/E and C/I, see page 172)
OR
Antihistamines, e.g. Promethazine solution 2.5 mg/ml, i.v., 25-50
mg immediately
(For doses, S/E, C/I and Dosage forms, see page 61)
OR
Chlorpheniramine 10-20 mg may be given by slow i.v. injection
over 1 minute instead
S/E: drowsiness, headache, psychomotor impairment, and anti-
muscarinic effects
C/I: should be used with caution in prostatic hypertrophy, urinary
retention, glaucoma, and hepatic disease
Dosage Form: Syrup 2mg/5ml; tablet 4mg,10mg.
Note:
• To make a 1: 10000 dilution mix 1 ml adrenaline with 10 ml sodium
chloride solution 0.9% (normal saline)
• i.v. route should be used with extreme care

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B. Cardiogenic shock
Inotropic drugs – dopamine i.v., 2-20 mcg/kg/min diluted with
dextrose 5% n
water, or in sodium chloride solution 0.9%;
(For doses, S/E, C/I and Dosage forms, see page 158)
AND/OR
Dobutamine i.v., 2.5-15 micrograms/kg/min diluted in dextrose 5%.
S/E: tachycardia, raised blood pressure;
Caution: severe hypotension complicating cardiogenic shock
Dosage form: powder for injection, 250 mg per vial
PLUS
Ringer-lactate solution i.v., 1-2 L
S/E: anxiety, tremor, tachycardia, headache, cold extremities
OR
Adrenaline 1:10000, IV, 3-5 ml given slowly
(For S/E, C/I and dosage forms, see page 172)
C. Hypovolemic shock, not due to hemorrhages:

Infusion of fluid (Normal Saline or Ringer lactate); if hemorrage, transfusion of

packed RBC or whole blood until Hgb level reaches 10gm/dl.
Note: Cardiogenic shock should be treated in specialized units, with constant
monitoring wth ECG

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D. Septic shock:
• Knowledge and identification of likely pathogens and nidus of
infection is vital for appropriate antibiotic treatment.
• Adequate organ system perfusion with i.v. fluids
• In case of adrenal insufficiency :
Hydrocortisone 50gm i.v. every 6 hrs (For S/E, C/I and dosage
forms, see page 173)
PLUS
Vasopessors (e.g. Dopamine, 2 to 10 microgram/kg/min; (For S/E,
C/I and dosage forms, see page 158)
OR
Dobutamine, 2.5 to 10microgram/kg/min) intravenous infusion, the
dosage is increased every 2 to 5 min up to a maximum of 20 to 50
microgram/kg/min until main SBP reaches 90 (For S/E, C/I and
dosage forms, see page 343)

The following antibiotics could be used for initial treatment.

First Line:
Ampicillin, i.v, 1 g 6 hourly for 7-10 days
(For S/E, C/I and dosage forms, see page 31) .
PLUS
Gentamicin, i.v. 3-5 mg/ kg as a loading dose, followed by 1.5
mg/kg/day in 3 divided doses, 8 hourly for a minimum of 7 days.
(For S/E, C/I and dosage forms, see page 56) .
Note: Metronidazole infusion may be used if anaerobics are suspected (For
S/E, C/I and dosage forms, see page 24) .

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Second Line:
Ceftriaxone, 1-2g daily as a single dose or 2 divided doses i.m. or
slow IV. For children: 20-50mg/kg/day as a single dose or 2 divided
doses i.m. or slow IV.
(For S/E, C/I and dosage forms, see page 29) .
PLUS
Getamicin, i.v. 3-5 mg/ kg as a loading dose, followed by 1.5
mg/kg/day in 3 divided doses, 8 hourly for a minimum of 7 days. (For
S/E, C/I and dosage forms, see page 56) .
Alternative
Cloxacillin 1-2 g i.v. every 6 hours for 7 days
(S/E, C/I and dosage forms, see page 57)
PLUS
Gentamycin 5-7 mg/kg i.v. Daily in divided doses for 7 days
(For S/E, C/E and dosage forms, see page 56)
PLUS
A third generation cephalosporin, e.g. Ceftazidime 1 gm i.v every
8 hourly or ceftriaxone 1-2 g i.v.or i.m 12 hourly for 7 days.
(For S/E ,C/I and dosage forms, see page 29).

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WOUND
Drug treatment
For infected wounds:
Wounds
A wound is a break in the structure of an organ or tissue caused by an external
agent. Bruises, grazes, tears, cuts, punctures, and burns are all examples of
wounds.
The management of wound depends on the type of wound (dry, exuding,
necrotic) and the stage of healing process (cleansing, granulation,
vascularisation, epithelialisation).

Drug Treatment
Disinfectants and Cleansing Agents:
Chlorhexidine + Cetrimide solution
OR
Hydrogen peroxide 6% - for disinfection, cleansing and deodorizing
wounds and ulcers
C/I: large and deep wounds
OR
Iodine Solutions (Iodine solution 2%)
OR
Povidone iodine solution 4%, 7.5%, 10% – for minor cuts, wounds
and infections of the skin. Apply twice a day.
S/E: hypersensitivity reactions (rare); may interfere with thyroid
function tests.
C/I: thyroid disorder, patients on lithium

Note:
Concurrent use of a systemic anti-infective agent may be required for
a deeper kin infection
For infected wounds use appropriate topical anti-infective agent

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ANNEXES

ANNEX 1: RECOMMENDED IMMUNIZATUION SCHEDULE

Recommended schedule for immunization according to EPI program

Age Vaccination
Birth BCG
OPV-0
2 months OPV-1
DPT-1
3 months OPV-2
DPT-2
4 months OPV-3
DPT-3
9 months Measles

Recommended schedule of immunization for children attending clinic at later

age but before 5 years.

Age Vaccination
First visit BCG if mantoux test is negative
OPV-1
DPT-1
Second visit (after one month) OPV-2
DPT-2
Third visit (after one month) OPV-3
DPT-3
Measles

Hepatitis B vaccine (Engrix B 10 microgram)is also available and three

doses are recommended (at birth, at one month and at six months of age)
Booster dose is given after 10 years.

Vaccine Type of Route of Adverse reaction

vaccine administration
BCG Life attenuated Intradermal
DPT Toxoid (DT) IM Fever, anaphylaxis,
Inactivated crying, & shock
bacteria (P)
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OPV Life attenuated Oral Paralysis

virus
Measles Life attenuated Subcutaneous Fever
virus

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ANNEX 2: FEEDING PROBLEMS

Feeding of normal baby:
Mother should be told to start feeding the baby with in one to two hours after
delivery. First feed should be the breast milk and there is no need for any test
feed with water or dextrose. First few feeds should be supervised and records
of feeds should be documented.

Feeding of a preterm, small for date (SGA) and infants of diabetic mothers
( IDM): Infants less than 1500 grams should receive all the fluids and calories
intravenously for the first 24 hours. SGA and IDM babies should be started
feeding by one hour of age, First few feeds may be given by NG tube and they
should be fed at least two hourly if sucking is poor. Once sucking is well
established and blood sugar is normal these babies should be given to the
mother for supervised breast feeding.

Feeding of term asphyxiated infants:

Mildly asphyxiated infants should feed like any healthy baby but must be
closely supervised for the first 12 hours.Babies with severe asphyxia should be
started with 2/3 maintenance IV fluids and strict intake records should be
maintained routinely.

Evidence for adequate nutrition

Weight gain should be 20 – 30 g/kg/day for premature infants and 10 g/kg/day
for full term infants

Adequate growth requires:

100-120 kcal / kg/day in term infants
115-130 kcal /kg/day for preterm infants
150 kcal /kg/day for very low birth weight infants.
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ANNEX 3: FLUID AND ELECTROLYTE

Normal maintenance requirements (volume of fluid/kg/day)
Day 1 60 m1/kg/day
Day 2 80 m1/kg/day
Day 3 100 m1/kg/day
Day 4 120 m1/kg/day
Day 5 140 m1/kg/day
Day 6 & above 150 m1/kg/day

Additional allowance:

1. Increase insensible water loss:

a. Radiant warmer 20 m1 /kg / day

b. Photo therapy 20 m1 /kg / day

c. Increase body temperature 10-20 m1 /kg/ day

2. Increase loss water from other roots:

Example: neonatal entrocolitis , GI aspirates , diarrhea. The

loss in the above conditions are variable, they should be
replaced volume for volume.

Stomach contents should be replaced with half saline with KCL loss small
intestinal contents is replaced with normal saline and KCL.

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ANNEX 4: THE KANGAROO MOTHER CARE

Kangaroo Mother Care (KMC), is defined as early, prolonged and continuous
skin to skin contact between a mother and her low birth weight infants (LBWI),
both in hospital and after early discharge until at least the 40th week of
postnatal gestational age. KMC does not need sophisticated equipment, and
for its simplicity it can be applied almost everywhere including peripheral
hospitals. Kangaroo Mother Care also contributes to the humanization of
neonatal care and the containment of cost, for these features, it may also be
attractive for neonatal units in high-income countries.

Kangaroo care a program of skin-to-skin contact between mother (any family

members) and a LBWI, is part of the revolution in the care of premature
infants. Since its first description in 1983 in Bogota, Colombia, KMC has
drawn the attention of international agencies and the scientific community
leading to a publication of more than 200 papers and abstracts.

The Multi center study including the neonatal unit of Addis Ababa, Ethiopia
showed that LBWI in KMC had better growth, early discharge from hospital,
lower cost, acceptable by both hospital staff and mothers when compared to the
conventional method of care. KMC is not only feasible but also easily grasped
by the hospital staff and accepted by the community. The feasibility of the
KMC is also testified by the growing number of reported experiences and by
its inclusion in national guidelines for perinatal care. The neonatal unit of
Tikur Anbessa hospital also uses KMC as a routine care for all babies weighing
less than 2000 grams since 1997.

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The benefits of Kangaroo Mother Care: Many studies showed that Kangaroo
Mother Care offers the preterm infants many physical and emotional benefits,
which includes:
• A stable heart rate
• More regular breathing
• Improve dispersion of oxygen throughout the body
• Prevention of cold stress and also warming babies who are already in
cold stress, Kangaroo transportation where transport incubators are
not there to keep the warm chain
• Longer period of sleep (during which the brain matures)
• More rapid weight gain and earlier discharge from hospital
• Reduction of purposeless activity which simply burns calories at the
expense of infants growth and health
• Decreased crying
• Opportunities to breast feed and enjoy all the healthful benefits of breast
milk
• Earlier bonding

The KMC works so beautifully because of three factors affecting the infant:
1. It creates conditions similar to those with which the infant had
become familiar in Utero, such as the proximity of the mother’s heart beat
sounds and her voice couples with the gentle rhythmic rocking of her breathing
2. It provides containment and allows for flexion and prevent heat loss
and provides heat from the skin to skin contact
3. Protects the infant and offers him a re-prieve from the stressful
elements of NICU

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When to Discharge from Kangaroo position:

The decision of discharging from Kangaroo position is made by the baby it self
(at about the 40th week of postnatal gestational age and weight of about 2000
grams). The baby will be restless and the mother could not maintain the
Kangaroo position any more then this is the time to go out of the kangaroo
“pouch”

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ANNEX 5: THE ETHIOPIAN AIDS CASE DEFINITION FOR

SURVEILLANCE IN PEDIATRICS
[REVISED FEBRUARY 2002]

IV. AIDS in a child <12 years of age is defined with evidence of

positive HIV test in the presence of 3 major signs alone in the
absence of other known causers of immunosuppression.

V. AIDS in a child <12 years of age is defined without laboratory

evidence of HIV infection in the presence of: 2 major and 2 minor
signs or 3 major and 1 minor sign in the absence of other known
causes of immunosuppression

VI. AIDS in a child < 12 years of age is defined if patient fulfills the
1987CDC surveillance case definition

Major signs /disease

5. Failure to thrive
6. Repeated /persistent lower respiratory tract infection (LRTI)
7. Chronic recurrent diarrhea for more than 1 month (continuous
/intermittent).
8. Unexplained prolonged fever.1month (continuous /intermittent).
Fever should not be counted as a major sign in the presence of lower
respiratory tract infection {LRTI).

Minor signs/disease
7. Generalized lymphadenopathy
8. Repeated or persistent common infections

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9. Unexplained neurological disorders or developmental delay and/or

microcephaly.
10. Hepatosplenomegally/or splenomegally
11. Extensive varicella infections or molluscum contagiousum.
12. Confirmed maternal HIV infection

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ANNEX 6: WHO RECOMMENDATIONS ON MULTIPLE DRUG

THERAPY FOR LEPROSY (TABLE 1-4)

The basic WHO recommendations on multiple drug therapy for leprosy, using
adult doses (Technical report series 675, 1982)

Table 1. Multibacillary leprosy (adult dosage)

Duration A minimum of 2 years (or 24 monthly doses within a 36-

month period) in all cases, but wherever possible until
slit-skin smears are negative
Number of drugs three: Rifampcin, Dapsone and clofazimine.
used
Dosage:
Rifampicin 600mg once - monthly, supervised
Dapsone 100mg daily, self-administered
Clofazimine 300mg once - monthly, supervised and
50mg daily, self-administered.
Surveillance minimum of 5 years after stopping
treatment, with clinical, and bacteriological examination
at least every 12 months

Note: Ethionamide/prothionamide, in a daily self-administered dose of 250-

375mg, may be used if the skin pigmentation or other side effects of
clofazimine render this drug totally unacceptable.

Table 2. Paucibacillary leprosy (adult dosage)

Duration 6 months (or 6 monthly doses within a 9 month period).

Number of drugs Two: Rifampicin and Dapsone
used

Dosage: 600mg once - monthly, upervised 100mg daily, self-

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Rifampicin adminstered.
Dapsone
Surveillance Minimum of 2 years after stopping treatment with clinical
examination at least every 12 months

Dosages based on age for children

Table 3. Multibacillary leprosy (3 drugs - Dapsone, Rifampicin

Clofizimine

Dapsone daily Rifampicine Clofazimine Clofazimine

Age groups dose, Monthly Unsupervised Monthly
Unsupervised dose, dose dose
Supervised Supervised
Upto 5 years
25mg 150-300mg 100mg once 100mg
weekly
6 -14 years 50-100mg 300-450mg 150mg once 150-200mg
weekly
15 years and 100mg 600mg 50mg daily 300mg
above (i.e use
adult dose)

Table 4. Paucibacillary Leprosy (2 drugs-Dapsone and Rifampicin)

Age groups Dapsone: daily dose, Rifampicin, monthly

unsupervised doses supervised
Upto 5 years 25mg 150-300mg
6-14 years 50-100mg 300-450mg
15 years and above i.e. 100mg 600mg
use adult dose

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ANNEX 7: PERCENTAGE OF ADULT DOSE REQUIRED AT

VARIOUS AGES AND BODY WEIGHT

Age Mean weight Percentage of

for age (Kg) adult dose

Newborn (full term) 3.5 12.5

2 months 4.5 15
4 months 6.5 20
1 year 10 25
3 years 15 33.3
7 years 23 50
10 years 30 60
12 years 39 75
14 years 50 80
16 years 58 90
Adult 68 100

Note: The percentage method is derived from the surface area formula for
children. This table is to be used only for drugs with a high therapeutic index.
The clinical response of the child, age- or disease-related changes in drug
clearance and any adverse effects that might present should be given due
consideration when calculating doses.

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Patient score 0
ANNEX 8: GUIDELINES FOR THE MANAGEMENT OF PAIN
Regular Pracetamol
(INCLUDING POST-OPERATIVE PAIN)
1g qds PO/PR
or Patient satisfied

Mild pain
Pain score 1 Able to take NSAIDS
Not adequate

Adequte
Add Diclofenac 50mg PO/PR tds
Yes
No

Moderate Pain Diclofenac 50mg PO/PR tds (if NSAID tolerant)

Pain score 2 Paracetamol 1g QDS
NotPO/PR
adequate
+
Add weak opioid eg Codine 30-60mg qds

Consider administering Paracetamol + weak opiate

as combined drug
Remember to prescribe laxative

Stop weak opiate

Severe Pain Not+adequate
Continue Paracetamol NSAID (if tolerant)
Pain score 3
+ Add opioid drug eg Morphine IM, PCA or oral
Continue laxative + consider prescribing anti-emetic

Pain score should be assessed after asking the patient to take a deep breath,
cough and move.
0+ No pain
1 Mild pain - able to continue with whatever patient is doing

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2 Moderate pain - beginning to interfere with activities, less

able to
concentrate
3 Severe pain - unable to think of anything else

ANNEX 9: GUIDELINES FOR USING NON-STEROIDAL ANTI-

INFLAMMATORY DRUGS (NSAIDS)
Patient has musculoskeletal pain. History,
examination and investigations suggest
inflammatory disorder?

Yes
No

Patient has active peptic Use simple

analgesics
ulceration, renal impairment, (eg paracetamol)
severe heart failure or Good response?
asthma?

No Yes No
Yes

Trial of short-half life NSAID taken Consider further investigations;

if no
when necessary contraindications short-term trial
of
(eg ibuprofen, Diclofenac) NSAIDs
Good response & well tolerated? Good response?

Yes No
No
Yes

Consider Consider further

Trial of longer half life investigation
intermittent

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 standard treatment guidelines for zonal hospitals

NSAID taken regularly ?Physical therapy

Courses of (eg Naproxen, ) ?Specialist referral
NSAIDs
Good responses & well tolerated?
Yes No

Good response, but not tolerated Tolerated, but poor

response
Consider alternative NSAID, alternative Consider alternative
NSAID,
route (eg rectal) or co-prescribe or use of compound
simple
for side-effects eg gastroprotective analgesics
agents Good response?
Good responses & well tolerated?
No
Yes

Yes No
Consider further investigation
Consider physical therapy
Need for more aggressive
treatment?
Good response but not
tolerated Consider alternative NSAID, No Yes
or further investigations

eg endoscopy Consider specialist

referral
Use simple analgesics,
consider specialist referral

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ANNEX 10. SYMPTOMS AND FINDINGS WHEN POISONED

WITH SOME COMMON DRUGS

Symptoms and physical Antidote

findings
Drug Laboratory findings

Paracetamol Nausea, vomiting, After 24 hrs, increased AST n-Acetylcystei

malaise, right upper (>1,000 IU/L is
quadrant abdominal characteristic), increased
pain, jaundice, ALT, increased bilirubin
confusion,
somnolence; coma
may develop later

Tricyclic CNS excitability, ECG findings of increased Bicarbonate

antidepres- confusion, blurred QRS interval > 0.10
sants vision, dry mouth, seconds, sinus tachycardia,
fever, mydriasis, conduction abnormalities
seizures, coma,
arrhythmias,
hypotension,
tachycardia,
respiratory
depression; physical
condition can rapidly
change

Benzodia- Drowsiness, lethargy, No characteristic findings Flumazenil

zepines dysarthria, ataxia,
hypotension,
hypothermia, coma,
respiratory
depression with
severe overdoses

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 standard treatment guidelines for zonal hospitals

Narcotics Drowsiness, nausea, With severe respiratory Naloxone

(opioid) vomiting, miosis, depression, hypoxemia,
respiratory hypercarbia, respiratory
depression, acidosis, rhythm
cyanosis, coma, disturbances, pulmonary
seizures, bradypnea, edema
noncardiac
pulmonary edema

AST=aspartate aminotransferase; ALT=alanine aminotransferase; CNS=central

nervous system; ECG=electrocardiogram.

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 standard treatment guidelines for zonal hospitals

INDEX
Aquired Immuno Deficiency
A Syndrome (Aids), 1
Abacavir, 6 Arrhythmia, 164
Acetylsalicylic Acid, 208, 213 Ascariasis, 39
Activated Charcoal, 334 Aspirin, 48
Acute Bacterial Meningitis, 55 Asymptomatic Bacteruria,
Acute Conditions, 323 262
Acute Atrial Fibrillation, 164
Laryngotracheobronchitis. Atrioventricular (Av) Block,
See Croup 169
Acute Pulmonary Edema, 157 Atropine, 169
Acyclovir, 114 Azathioprine, 230
Adrenaline, 172
Albendazole, 42 B
Allopurinol, 178 Bacillary Dysentery, 28
Aluminium Hydroxide And Barbiturates, 335
Magnesium Trisilicate, 217 Beclomethasone, 175
Amebiasis, 24 Benzyl Benzoate, 151
In Pediatrics, 269 Benzyl Penicillin, 55
Amebic Liver Abscess, 26 Bisacodyl, 183
Aminophylline, 172 Bismuth Subgallate, 198
Amiodarone, 168 Blinding Filariasis, 60
Amitriptyline, 210 Bronchial Asthma, 170
Amoxicillin, 31 In Pediatrics, 270
Amoxicillin + Clavulanic Acid, Bronchitis (Acute), 30
71 Burns, 329
Amphotericin B, 44 Busulphan, 181
Ampicillin, 31
Anemia, 159, 161 C
Anemia
In Pregnancy, 236 Calamine, 153
Animal Bites, 324 Calcium Gluconate, 311
Candidiasis, 139
Captopril, 204
Anxiety Disorder, 163 Carbamazepine, 190
Carbimazole, 234
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 standard treatment guidelines for zonal hospitals

Carbon Monoxide, 337 Contraceptives, 238

Carbuncle, 127 Cotrimoxazole, 283
Cascara, 182 Crotamiton, 153
Catharsis, 335 Croup
Ceftriaxone, 29 In Pediatrics, 275
Cellulitis, 128 Cryptococcal Meningitis, 58
Cephotaxime, 263 Cyclophosphamide, 178
Chancroid, 111 Cystitis, 263
Chlorambucil, 178
Chloramphenicol, 35 D
Chlorhexidine + Cetrimide,
Danazol, 244
326
Dapsone, 47
Chloroquine, 26
Dehydroemetine, 26
Chloroquine Phosphate, 50
Depressive Disorders, 211
Chlorpheniramine, 342
Dexamethasone, 132
Chlorpromazine, 84
Dextromethorphan
Cholera, 33
Hydrobromide, 30
Chronic Lymphocytic
Dextrose 10%, 291
Leukemia, 177
Diabetes Mellitus, 186
Chronic Myelogenous
Pregnancy, 241
Leukemia, 180
Diabetic Keto Acidosis, 184
Cimetidine, 218
Diarrheal Disease
Ciprofloxacin, 28
In Pediatrics, 277
Clarithromycin, 222
Diazepam, 84
Clindamycin, 63
Didanosine, 6, 8, 17
Clinical Staging Of Hiv/Aids,
Diethylcarbamazine, 61
22
Digoxin, 165
Clofazimine, 47, 49
Diloxanide Furoate, 25
Clonazepam, 192
Diphenyl Hydantion. See
Clotrimazole, 112, 139
Phenytoin
Cloxacillin, 57, 73
Dobutamine, 343
Coastal Erysipelas, 60
Donovanosis. See Granuloma
Cobalamin. See Vitamin B12
Inguinale
Codeine Phosphate, 30
Dopamine, 158
Colchicine, 194
Doxycycline, 33
Combined Oral
Dysentry, 283
Contraceptives, 238
Dysfunctional Uterine
Conjunctivitis
Bleeding, 243
In Pediatrics, 272
Dysmenorrhoea, 245
Constipation, 182
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 standard treatment guidelines for zonal hospitals

E Furosemide, 157
Furuncle, 143
Econazole, 139
Furunclules, 143
Eczema, 130
Furunculosis. See Furunclules
Efavirenz, 6, 19
Fusidic Acid, 330
Electrolyte, 185
Emergency Conditions, 323
G
Emergency Contraception,
239 Gamma-Globulins, 298
Emesis, 334 Gastric Lavage, 334
Enalopril, 196 Gastro-Enteritis, 35
Enterobiasis, 40 Genital Candidiasis, 112
Ephedrine + Theophylline, Genital Herpes, 114
174 Genitian Violet, 146
Epilepsy, 189 Gentamicin, 56
Epinephrine, 270 Gestational Diabetes, 241
Ergot Preparations, 209 Giardiasis, 37, 284
Ergotamine Tartrate And Glibenclamide, 187
Caffeine, 209 Glycerin, 183
Erysipelas, 135 Gonorrhea, 115
Erythomycin, 31 Gout, 193
Ethosuximide, 191 Granuloma Inguinale, 118
Evacuation Of The Uterus, Griseofulvin, 138
246 Guaifenesin, 30
Exudative Tonsillitis, 316 Gynecological Conditions, 235

F H
Famotidine, 221 Haloperidol, 212
Ferrous Sulfate, 162 Heart Failure, 196
Fluconazole, 59 Hemorrhoids, 198
Flucytosine, 59 Heparin, 214
Fluoxetine, 211 Herpes Simplex, 144
Fluphenazine Decanoate, 233 Herpes Zoster, 145
Folic Acid, 160 Hiv/ Aids
Folinic Acid, 88 In Children, 285
Folliculitis, 137 Hookworm, 40
Food-Poisoning. See: Gastro- Hormonal Contraceptives, 238
Enteritis Human Diploid Cell Strain
Forced Diuresis, 335 Vaccine, 327
Fungal Infections, 138
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 standard treatment guidelines for zonal hospitals

Human Rabies K
Immunoglobulin, 327
Ketoconazole, 113, 303
Hydralazine, 204
Hydrochlorothiazide, 202
L
Hydrocortisone, 173
Hydrogen Peroxide, 346 Lactulose, 225
Hydroxyurea, 181 Lamivudine, 6, 8, 17
Hypertension Leishmaniasis, 43
In Pregnancy, 248 Leishmaniasis
Hypertension, 200 Cutaneous, 45
Hypoglycemia, 291 Visceral, 43
Leprosy, 46
I Levonorgesterel, 239
Lidocaine, 167
Ibuprofen, 209
Lidocaine + Aluminium
Idiopathic Seizures, 191
Acetate + Zinc Oxide +
Imipramine, 211
Hydrocortisone Acetate,
Immune Thrombocytopenic
199
Purpura, 206
Lindane, 150
Impetigo Contagiosa, 146
Liquid Paraffin, 183
Implants, 239
Lopinavir/Ritonavir, 6
Indinavir, 20
Lung Abscesses, 71
Indinavir/Ritonavir, 6
Lymphogranuloma Venereum,
Indometacin, 193
120
Insulin, 184
Lynestrenol, 239
Intestinal Amoebiasis, 24
Intestinal Parasitic
M
Infestations, 38
Iodine, 148 Magnesium Hydroxide And
Ipecac. See Ipecacuanha Aluminium Hydroxide, 217
Ipecacuanha, 334 Magnesium Sulphate, 182
Iron Deficiency Anemia, 161 Magnesium Trisilicate And
Iron Dextran, 162 Aluminium Hydroxide, 221
Iud, 265 Malaria, 50
Malnutrition, 293
J Measles, 297
Mebendazole, 42
Jaundice
Meclizine Hydrochloride, 216
In Neonates, 292
Medroxyprogesterone, 239
Megaloblastic Anemia, 159

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 standard treatment guidelines for zonal hospitals

Meningitis, 55 Non-Ulcer Dyspepsia, 217

Neonatal, 300 Norfloxacin, 106
Pyogenic, 301 Normal Saline, 185
Metformin, 187 Nucleoside Reverse
Methotrexate, 230 Transcriptase Inhibitors,
Methyldopa, 203 15
Methylprednisolone Acetate, Nystatin, 112, 140
231
Metoclopramide, 208 O
Metrifonate, 77
Obstetrics, 235
Metronidazole, 24
Omeprazole, 222
Miconazole, 140
Oncocerciasis, 60
Migraine, 208
Oral Trush
Molluscum Contagiosum, 148
In Pediatrics, 303
Mood Disorders, 211
Osteoarthritis, 219
Morphine, 157
Ostiomylitis
Morphine Hydrochloride, 331
In Pediatrics, 304
Mupirocin, 137
Ottis Media
Myocardial Infarction, 213
In Pediatrics, Acute, 305
Myoclonic Jerks, 192
Oxamniquine, 78
Myoclonic Seizures, 191
Oxazepam, 163
Oxymetazoline, 80
N
Nalidixic Acid, 29 P
Nausea And Vomiting, 216
Paracetamol, 73
In Pregnancy, 252
Paroxysmal Supra-
Nelfinavir, 6, 21
Ventricular Tachycardia,
Neomycin, 225
166
Nevirapine, 6, 8, 18
Pediatric Diseases, 268
Niclosamide, 42
Pediculosis Pubis, 150
Nifedipine, 202
Pelvic Inflammatory Disease,
Nitrofurantoin, 262
253
Nitroglycerin, 158
Penicillin, 82
Non Gonococcal Urethritis,
Pentamidine, 307
121
Pentamidine Isethionate, 44
Non-Infectious Diseases, 156
Peptic Ulcer, 221
Non-Nucleoside Reverse
Permethrin, 150
Transcriptase Inhibitors,
Pertusis
18
In Pediatrics, 306
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 standard treatment guidelines for zonal hospitals

Pesticides, 338 Q
Phenobarbitone, 189
Quinidine, 166
Phenytoin, 190
Quinine Dihydrochloride, 51
Piperazine, 39
Pneumocystes Carini
R
Pneumonia, 307
Pneumocystis Carrinni Rabies, 326
Peumonia, 62 Radioactive Iodine, 234
Pneumonia, 65 Ranitidine, 222
In Childern, 309 Relapsing Fever, 75
Pneumonias (Aspiration), 71 Retinoic Acid. See Tretinoin
Poisoning, 333 Rheumatic Fever, 226
Portal Hypertension, 224 Rheumatoid Arthritis, 229
Post Abortal, 256 Rifampicin, 46
Potassium Chloride, 196 Ringer Lactate, 330
Povidone Iodine Solution, 346 Ringer-Lactate, 343
Pralidoxime Mesylate, 339 Ritonavir, 8, 20
Praziquantel, 42, 77 River Blindness, 60
Preclampsia, 248
Prednisolone, 173, 178 S
Prednisone, 48
Salbutamol, 171
Premature Rupture Of
Saquinavir, 21
Membranes, 259
Saquinavir/Ritonavir, 6
Primaquine, 53
Scabies, 152
Probenecid, 194
Schistsomiasis, 77
Procainamide, 168
Schizophrenia, 232
Progesterone Only
Scorpion Stings, 328
Contraceptives, 238
Seizures
Proguanil Hydrochloride, 54
Neonatal, 311
Promethazine, 61, 252
Sepsis
Propranolol, 85
Neonatal, 313
Propylthiouracil, 234
Septic Arthritis, 314
Protease Inhibitors, 20
Septic Athritis, 79
Puerperal Mastitis, 261
Sexual Assault, 264
Puerperal Sepsis, 256
Sexually Transmitted
Pyelonephritis, 263
Infections, 108
Pyogenic Osteomyelitis, 73
Shock, 341
Pyrantel, 39
Anaphylactic, 341
Pyrimethamine, 88
Cardiogenic, 343

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 standard treatment guidelines for zonal hospitals

Hypovolemic, 343 Tinidazole, 24

Septic, 344 Tonic Clonic Seizures, 191
Silver Nitrate, 149 Tonsillitis, 86
Silver Sulfadiazine, 330 Toxoplasmosis, 88
Sinusitis, 80, 315 Trachoma, 320
Skin Problems, 126 Trachoma, 90
Snake Bites, 328 Tretinoin, 148
Sodium Bicarbonate, 337 Trichomoniasis, 125
Sodium Stibogluconate, 43 Trichuriasis, 41
Sodium Valproate, 191 Trimethoprim+Sulphamethox
Spectinomycin, 115 azole. See Cotrimoxazole
Spironolactone, 197 Tuberculosis
Status Asthmaticus, 271 In Children, 321
Stavudine, 6, 8, 16 Tuberculosis, 92
Streptococcal Pharyngitis, 316 Typhoid Fever, 102
Strongyloidosis, 41 Typhus, 104
Subacute Bacterial
Endocarditis, 82 U
Sucralfate, 331
Urinary Tract Infection, 105
Sulfadiazine, 88
Urinary Tract Infection
Sulfadoxine + Pyrimethamine,
In Pregnancy, 262
51
Urticaria, 154
Sulfamethoxazole+Trimethop
rim. See: Cotrimoxazole
V
Sulphur, 152
Suxamethonium, 85 Vancomycin, 57
Syphilis Ventricular Tachycardias, 167
Congenital, 317 Verapamil, 165
In Pregnancy, 266 Vitamin A, 282
Syphilis, 122 Vitamin B12, 159
Vulvo Vaginal Candidiasis,
T 267
Tapeworm, 42
W
Tetanus, 84
Neonatal, 319 Warfarin, 214
Tetanus Toxoid, 328 Whooping Cough. See
Tetracycline, 31 Pertusis
Thiabendazole, 41 Wound, 346
Thyrotoxicosis, 234 Wound Management, 332

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standard treatment guidelines for zonal hospitals

Z Zalcitabine, 15
Zidovudine, 6, 7, 15

390