Edliz PDF

F
EDLIZ 2015
5th Essential Drugs List
and
Standard Treatment Guidelines
For
Zimbabwe
7th Essential Medicines List
and
Standard Treatment Guidelines
for
Zimbabwe
EDLIZ 2015
Printed by
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EDLIZ 2015
EDLIZ 7TH EDITION 2015
PUBLISHED BY:
The National Medicine and Therapeutics Policy
Advisory Committee [NMTPAC]
Ministry of Health & Child Care
Republic of Zimbabwe
Further copies may be obtained through the relevant Provincial Medical

Directorate, City Health Directorate, the NMTPAC, Ministry of Health &
Child Care (MoHCC), PO Box CY 1122, Causeway, Harare, Zimbabwe,
or the MoHCC website www.mohcc.gov.zw. Copies of the text may be
obtained on soft copy if required for teaching purposes from email
address: dps@mohcc.gov.zw or nmtpac@gmail.com EDLIZ was
prepared using Microsoft® Word.
The information presented in these guidelines conforms to current
medical, nursing and pharmaceutical practice. It is provided in good
faith. Whilst every effort was made to ensure that medicine doses are
correct, no responsibility can be taken for errors and omissions.
EDLIZ Review Co-ordinator
No part of this publication may be reproduced by any process without

the written permission of the copyright holder, exception being made for
the purpose of private study, research, criticism or review, or for
teaching, but not for sale or other commercial use.
Original Cover Design: Regina Gapa and Charon Lessing
Cover redesign & Layout: Kim Hoppenworth
Cover redesign and layout 2015: Newman B Madzikwa
© Copyright June 2015, Ministry of Health & Child Care
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EDLIZ 2015
EDLIZ REVIEW COMMITTEE

Apollo Tsitsi Samukange Emma
Borok Margaret Mujuru Hilda

Chakanyuka Christine C. Mushavi Angela
Hove Ropafadzai Madzikwa Newman B.
Mungwadzi Godfrey Ndhlovu Chiratidzo E.
Bakasa Clemenciana Sifeku Florah N.
Mudzimu Forward Wellington Maureen
Torongo Mabel Vuragu Davison N.
Nyamayaro Raphael Maunganidze Aspect
Khoza Star Basopo Victor
Madziyire Mugove G Chidakwa Claitos
Bara Wilfred
ACKNOWLEDGEMENTS
We would like to thank all the individuals who made contributions
through colleagues or discussion forums or by communicating through
electronic mail. We are grateful to all who made this edition a national
guide that serves as the standard for Zimbabwe. Thank you to all the
healthcare workers for your support.
The following attended our review workshops as well as being
instrumental in current chapter reviews:
Akinjide-Obonyo Akindele P, Dr Maunga Simbarashe, Dr
Apollo Tsitsi, Dr Maunganidze Aspect, Dr
Bakasa Clemenciana, Ms Mbuzi Tonnie, Mr
Bare Blessing, Mhazo Tichatyei, Mr
Basopo Victor, Mr Mhembere Josephine, Dr
Bepe Tafadzwa, Dr Midzi Stanley, Dr
Borok Margaret, Dr Misihairambwi Silence, Ms
Burutsa Patricia, Ms Mlilo Lindiwe, Dr
Bwakura Tapiwanashe, Dr Moyo Dothan, Mr
Cakana Andrew, Prof Moyo Mluleki, Mr
Chakanyuka Artmore, Dr Moyo Sifiso, Mr
Chakanyuka Christine C., Dr Mudombi Wisdom, Dr
Chari Godfrey, Mudzimu Forward, Mr
Charimari Lincoln, Dr Mujuru Hilda A., Dr
Chemhuru Milton, Dr Mungwadzi Godfrey, Dr
Chikanya Sonia Irene, Ms Munjanja Stephen P, Prof
Chimhini Gwendoline, Dr Mushavi Angela, Dr
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EDLIZ 2015
Chirenje Mike Z., Prof. Musiya N, Dr

Chiro Erick, Mr Musungwa Alexio, Mr
Cowan Frances M, Prof. Musvipa Mary, Ms
Deda Petunia, Ms Mutsvairo Sitembile, Ms
Dliwayo Thokozile, Ms Mwaramba Charles, Mr
Dube Siphathisiwe Noreen, Mrs Mwonzora Muchaneta, Mrs
Dube Tirivashoma, Mr Nathoo Kusum J, Prof.
Fana Golden, Dr Ncube Phumuzile, Ms
Gambanga Pauline, Dr Ndamukwa Pikirai, Mr
Glavintcheva Iskra L, Dr Ndhlovu Chiratidzo E, Prof
Gunguwo Hillary, Dr Ndlovu Misheck, Mr
Gwanzura Lovemore, Prof. Ndowa Francis, Dr
Gwata Beatrice, Mrs Nembiri Tinashe, Ms
Hove Ropafadzai Mrs Ngwende Gift W, Dr
Kambarani Rose, Prof Nkala Lee, Mr
Kandawasvika Petronella, Dr Nyadzayo Tasiana K, Mr
Khoza Star, Dr Nyakabau Anna M, Dr
Khumalo Brian, Mr Nyamayaro Raphael, Dr
Khumalo Mhlawempi, Nyaruwanga Albert, Mr
Kufa Tarisai, Dr Pasi Christopher, Dr
Kusemwa Muyambi Preetyosa, Ms Phiri Isaac, Dr
Latif AS, Prof Reid Andrew, Dr
Machisa Vimbainashe, Ms Rimai Ruth, Ms
Madhombiro Munyaradzi, Dr Samukange Emma, Mrs
Madzikwa Newman B. Mr Sandy Charles, Dr
Magombeyi Rudo, Ms Sanyanga Arthur, Mr
Magunda Farai, Shumba Godfrey, Mr
Mandimika, Florence Sibanda Elopy N, Prof
Mandire Joice, Ms Sifeku Florah N, Mrs
Mangezi Walter, Dr Sithole Dorcas, Ms
Mangoma Tariro, Ms Tagwirei Dexter, Prof
Mangwiro John C, Dr Takaruza Kelvin, Mr
Masanganise Rangarirai, Prof Tambudze Gaundencia, Ms
Masendu Maureen, Dr Tekasala Lumbu Jerry, Mr
Mashinge Farayi, Mr Ticklay Ismail, Dr
Mashoko Tsungai, Ms Vuragu Davison N, Mr
Mashumba Azza, Dr Wellington Maureen, Dr
Maswaure Laucas, Zaranyika Trust, Dr
Matonhodze Alex, Mr
Thank you!
Mrs R.F. Hove Prof. C. E. Ndhlovu

Director of Pharmacy Services NMTPAC Chairperson
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FOREWORD
It is the national objective that the health care needs of Zimbabweans
are met through the provision and proper use of essential medicines.
Sometimes we do not need to give medicines, that is, there is not
always a “pill for every ill”. Thus, there is need to use medicines
appropriately, efficiently, and effectively.
The guidelines in EDLIZ have always reflected the consensus of local
experts, and takes into consideration factors such as the Zimbabwean
setting, prevailing economic climate, practical experience as well as
evidence-based therapeutics.
This new EDLIZ has taken into account the dynamic changes in the
Burden of Disease as reflected by the inclusion of antiretroviral
medicines and treatment of other opportunistic infections other than
Tuberculosis (TB). Many of the therapeutic regimens of the previous
EDLIZ still hold true and remain the same, and should reinforce the
confidence of the prescriber in making reliable therapeutic choices.
I urge all health workers to familiarise themselves with the revised
guidelines, to prescribe within the bounds of this publication, and to
recognise the critical importance of providing a quality service to all
health care recipients through the rational use of medicines.
EDLIZ REMAINS good medicine! Use it.
Hon. Dr. P.D. Parirenyatwa

Minister of Health & Child Care
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THE ESSENTIAL MEDICINES LIST FOR

ZIMBABWE – EDLIZ 7TH EDITION
This 7th essential medicines list and standard treatment guidelines for
the most common health conditions in Zimbabwe has been endorsed by
the National Medicine & Therapeutics Policy Advisory Committee
[NMTPAC]. It is the product of many years of combined efforts by
hundreds of health workers at all levels of the health care system in
Zimbabwe – from the front line health care providers to the providers of
specialist care. It has been refined over the years as a result of its
widespread use by our healthcare workers. We continue to revise the
standard treatment guidelines and take into account medicine
developments and new healthcare problems. Thus this latest edition has
included more essential medicines.
The essential medicine list is based on the Essential Medicines
Concept. Medicines in EDLIZ are chosen to meet the health care needs
of the majority of the population, and should therefore always be
available and accessible at a price that both the patient and the nation
can afford.
Selection of medicines for inclusion

Selection of medicines for inclusion in EDLIZ has been based on the
following criteria, with special emphasis on proven evidence for their use
in the Zimbabwean setting:
 relevance to prevalent diseases

 proven efficacy and safety Safe
 adequate scientific data in a variety of Efficacious
settings Quality
 adequate quality Available
Affordable
 favourable cost-benefit ratio
Accessible
 desirable pharmacokinetics Rationally used
 possibilities for local manufacture
 available as single ingredient items
GENERIC MEDICINES
Every medicine has a chemical name and a generic name. For
example, paracetamol, its chemical name is N-(4-Hydroxyphenol)
acetamide and the international non-proprietary name (INN) or generic
name is paracetamol. The INN is the medicine's official name
regardless of who manufactures or markets it. An additional brand name
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EDLIZ 2015
is chosen by the manufacturer to facilitate recognition and association of

the product with a particular manufacturer for marketing purposes.
For most common medicines there are several branded products that all
contain the same active ingredient and therefore share the same INN.
The use of generic names for medicine procurement as well as
prescribing carries considerations of clarity, quality, and price.
Proponents of generic medicines procurement and prescribing point out
that:
 generic names are more informative than brand names and facilitate
purchasing of products from multiple suppliers, whether as brand-
name or as generic products;
 generic medicines are generally cheaper than products sold by
brand name; this is demonstrated very clearly when it comes to
antiretroviral medicines
 generic prescribing also facilitates product substitution, whenever
appropriate.
Opponents argue that the quality of generic medicines is inferior to that
of brand (innovator) products. However quality assurance and naming of
medicines are completely separate issues. Generic medicines from
reliable suppliers are as safe, effective, and high in quality as medicines
with brand names. At the same time, branded medicines from a
manufacturer with inadequate procedures for quality control can be of
poor quality, despite the brand name. Also, although any medicine can
be counterfeited, there are more incentives for counterfeiting brand-
name medicines than generic medicines. Some pharmaceutical
companies also sell their branded products under the generic name, for
a much lower price.
Bio-equivalence is often misused as an argument against the use of
generic equivalents. For many medicines, the variation in bioavailability
among individual patients is much larger than the variation among
products of different manufacturers. In fact, bioavailability is clinically
relevant for only a relatively small number of medicines such as
furosemide, digoxin, levodopa, isoniazid, theophylline and phenytoin.
Zimbabwe has a well understood generic policy which requires that all
prescribing is in the generic name and the dispenser can make generic
substitutions (unless bioavailability is an issue in which case the
prescriber should indicate accordingly).
ADVANTAGES OF EDLIZ
The benefits of the selection and use of a limited number of essential
medicines are:
 Improved medicines supply
 More rational prescribing
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 Lower costs
 Improved patient use
IMPROVED MEDICINES SUPPLY

The regular supply of medicines is difficult in many countries, and the
consequent health implications are many. Improved medicines
availability should lead to improved clinical outcomes.
With fewer essential medicines being
purchased, the mechanisms and
logistics for procurement, storage &  easier procurement,
distribution will clearly be easier. It is storage & distribution
not practical for each clinic in  lower holding stocks
Zimbabwe to attempt to procure,  lower losses
transport and warehouse all the  better quality assurance
hundreds of items in EDLIZ.
Conversely, limiting the number of medicines available at the primary
health care level makes a regular supply of medicines more practical
and possible.
With an improved supply the possibilities of holding lower quantities
exist. This has financial implications as well as reducing the likelihood of
medicines expiring or being damaged during storage.
Quality assurance can be better managed when the number of
medicines is limited, and quality checks can be performed more
frequently.
MORE RATIONAL  focused, more effective training

PRESCRIBING  more experience with fewer medicines
 no irrational treatment alternatives
In the absence of limited available
lists, the large variety of
 focused medicine information
products available on the
market contributes to  better recognition of adverse medicine
inconsistent prescribing and reactions
consequently, variation in
clinical practice even within the same health care facility. Irrational
prescribing may lead to therapeutic hazards and increased costs.
When the number of medicines is limited, training can be more focused
and the quality of care enhanced. This is especially true when the list
represents a consensus of opinion on first choice of treatment such as
in EDLIZ.
Using EDLIZ enables the prescriber to become more familiar with the
medicines they use, and better able to recognise adverse effects.
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The use of EDLIZ also eliminates irrational products from being

available for prescribing, and allows for more focused medicine
information to be provided on suitable essential medicines.
LOWER COSTS
Improved effectiveness and efficiency in
patient treatment leads to lower health care  more competition
costs. The essential medicines concept is  lower prices
increasingly being accepted as a universal
tool to promote both quality of care and cost
control.
Essential medicines are usually available from multiple suppliers. With
increased competition, more favourable prices can be negotiated.
By limiting the number of different medicines that can be used to treat a
particular clinical problem, larger quantities of the selected medicine will
be needed, with potential opportunities to achieve economies of scale.
IMPROVED PATIENT USE

Focusing on fewer medicines can enhance patient education and efforts
to promote the proper use of medicines in both patients and prescribers.
Additionally, with improved
medicine availability changes  focused education efforts
to chronic medication  reduced confusion & increased
regimens are less likely and adherence to treatment
as a consequence patients
have a better understanding of their disease, their medication and the
need for compliance.
IMPLEMENTATION OF EDLIZ AND SETTING UP OF

HOSPITAL MEDICINE AND THERAPEUTICS COMMITTEES
(HMTCS)
The advantages presented here however do not just happen. EDLIZ
itself will not ensure rational prescribing or facilitate good procurement
or quality assurance. Educational, regulatory, financial or managerial
strategies on their own are less effective in promoting the rational use of
medicines than combined strategies. The production of EDLIZ is one
such regulatory strategy, but further steps such as training and re-
training, patient education and the establishment and effective
functioning of hospital medicine and therapeutic committees (HMTCs)
have to be taken to ensure cost-effective prescribing and patient care. It
is therefore necessary for every hospital to have a forum where
medicine issues can be discussed. Ideally, a separate hospital medicine
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and therapeutics committee (HMTC) should be formed. Given the

current manpower constraints, we encourage hospitals to exploit every
opportunity such as the regular divisional meetings held in Central
Hospitals to discuss and address medicine related problems. The
NMTPAC is available to assist those hospitals that are ready to set up
an HMTC. A technical guideline to set up a HMTC developed by the
NMTPAC is available.
EXPLANATIONS & CHANGES FROM THE PREVIOUS

VERSION
This edition is essentially the same in format and layout, categorisation
as the last edition. You will need to read it carefully to note changes in
recommendations that apply to your areas of interest. Extra bulletins will
be sent out where drastic changes in medicine recommendations have
occurred.
All medicines in EDLIZ are categorised firstly by level of availability
(ABCS) in the health care system, and secondly, according to priority
(VEN). Hence in the example below, amoxicillin is available at primary
health care facility (C) level and is ranked vital (V).
Medicine Codes Adult dose Frequency Duration
amoxicillin po C V 500mg 3 times a day 7 days
LEVEL OF AVAILABILITY
C medicines are those required at primary health care level and should
be available at all levels of care.
B medicines are found at district hospital level or secondary and higher
levels of care. Some B medicines may be held at primary health care
facilities on a named patient basis – for example in the management
and follow up of chronic illnesses.
A medicines are prescribed at provincial or central hospital levels.
S medicines (specialist only) have been brought back into this edition.
These are medicines that require special expertise and /or diagnostic
tests before being prescribed.
VEN CLASSIFICATION
All medicines are also classified according to their priority. This is mostly
a tool to assist in giving priority to medicines based on economic
considerations. Thus V medicines are vital, they are considered
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lifesaving or their unavailability would cause serious harm and efforts

should always be aimed at making them 100% available.
E medicines are essential, and are given second priority. Without E
medicines there would be major discomfort or irreversible harm. And N
medicines are still necessary but are lower in priority than V and E
medicines.
This edition of EDLIZ has been produced as a result of a highly
consultative process and represents both the practical nature of the
input from health care workers and the changing nature of medicine
especially over the recent years. It has adopted an evidence-based
approach wherever possible and has balanced this with the resources
available to the health care system.
The NMTPAC is a standing committee that reviews the therapeutic

guidelines in EDLIZ on a continual basis, and always looks forward to
feedback from the providers of health care in Zimbabwe. Contact the
NMTPAC through Directorate of Pharmacy Services on
dps@mohcc.gov.zw or nmtpac@gmail.com with your comments.
Brigadier General (Dr) G. Gwinji

Permanent Secretary
Ministry of Health & Child Care
Republic of Zimbabwe
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MAJOR HIGHLIGHTS IN THE LATEST

EDLIZ
Preamble
The major changes in this latest edition of EDLIZ will be highlighted here
so that you are aware of recommendations that you need to consider in
your medicine management or supply issues. Ideally each hospital should
create its own local medicine formulary which shows which medicines are
considered very useful in that setting so that you do not have to order
medicines that your doctors will not prescribe or use. For instance you
should not keep specialist medicines if there is no specialist to prescribe
them. Hospital Medicine and Therapeutics Committees should select
medicines for use in their hospital using the EDLIZ.
New chapter
There is one new chapter – Overview of Surgical Conditions. We welcome
any comments on the utility of this chapter. Your comments will be used in
future revisions.
Antibiotics
A new cephalosporin, Cefixime, has been added to the treatment of
sexually transmitted illnesses. Azithromycin has also been added for the
treatment of gonococcus.
Immunisation
Rotavirus immunisation has now become routinely available. Human
Papilloma Virus (HPV) vaccination is currently being used in a limited
setting but it is hoped that it will be rolled out nationally in 2016.
Asthma Treatment
Given that salbutamol inhalers are more accessible, oral salbutamol has
been phased out completely. You will need to ensure that your patients
are aware of this change. Use of steroids as an inhaler should be
encouraged in place of regular oral Salbutamol. Health care workers will
need to always check that their clients can use the inhalers appropriately.
ART Guidelines (use latest ART guidelines)

Stavudine containing regimens are being phased out and will not be
available except for a limited number of patients who will still need them.
For first line therapy, tenofovir/lamivudine and efavirenz will be used in
most instances for adults, adolescents and children as well as pregnant
women.
Third line antiretroviral medicines will be available in selected hospitals.
These third line medicines will include raltegravir and darunavir. Please
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familiarise yourself with the dosing of these new medicines and the
algorithm for their use.
Malaria Treatment
The malaria medicines have also been revised. The first line therapy
remains the same as before i.e. Artemether + Lumefantrine (AL).
However, where oral quinine would have been used, we now recommend
oral artesunate and amodiaquine as a combined medicine. For pre-
referral use, rectal artesunate will be used instead of IM quinine. This new
combination of antimalarial therapy is given orally and should simplify the
management of patients with severe malaria. Instead of using parenteral
quinine for complicated malaria, intravenous artesunate will be used.
Unlike with IV quinine use, there will be no need to worry about
hypoglycaemic effects with the use of artesunate.
Tropical Diseases
You will need to familiarize yourself with the recognition and management
of Ebola which is currently causing a huge epidemic in West Africa.
Hence, our healthcare delivery centres are on the lookout for such Ebola
infections.
TB recommendations (use latest TB guidelines)
Isoniazid prophylaxis has been adopted and hence you should familiarise
yourself with the protocol for its use. Isoniazid (INH), like any other
medicines, can cause side effects. Look out for gastrointestinal symptoms,
hepatitis, skins reactions and peripheral neuropathy. Stopping the INH as
soon as possible will help to save lives. Thus patients will need to be
informed about the need to look out for these adverse events. Some of the
adverse events are rather idiosyncratic and hence not dose related. Use
the usual adverse medicines reporting forms and send forms through to
the Pharmacovigilance and Clinical Trials (PVCT) Unit at the Medicine
Control Authority of Zimbabwe (MCAZ) offices.
Metabolic and Endocrine Conditions

The use of the Basal Bolus regimen has been introduced and we hope to
phase out the reference to using Sliding Scale insulin. The Basal Bolus
Regimen is more physiological as it uses an underlying intermediate or
long acting dose of insulin once a day as well as pre-meal (prandial/bolus)
short acting or rapid acting insulin doses. By checking pre-meal glucose,
extra correctional doses can be added to the calculated prandial doses of
insulin. Thus you will need to read and familiarize yourself with these new
recommendations for diabetes therapy.
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TABLE OF CONTENTS
EDLIZ 7TH EDITION 2015 III

ACKNOWLEDGEMENTS IV
FOREWORD VI
THE ESSENTIAL MEDICINES LIST FOR ZIMBABWE – EDLIZ 7TH EDITION VII
MAJOR HIGHLIGHTS IN THE LATEST EDLIZ XIII
TABLE OF CONTENTS XV
GUIDELINES ON ANTIMICROBIAL TREATMENT AND PROPHYLAXIS 1
BASIC INFECTION PREVENTION AND CONTROL MEASURES 7
PAEDIATRIC CONDITIONS 14
IMMUNISATION 59
OBSTETRIC AND GYNAECOLOGICAL CONDITIONS 66
SEXUALLY TRANSMITTED INFECTIONS 88
HIV RELATED DISEASE 101
ANTIRETROVIRAL THERAPY 117
USE OF ARVS FOR PREVENTION OF MOTHER-TO-CHILD TRANSMISSION
OF HIV (PMTCT) 135
TUBERCULOSIS 139
TROPICAL DISEASES 151
MALARIA 167
RESPIRATORY CONDITIONS 183
CARDIOVASCULAR DISEASE 196
GASTROINTESTINAL CONDITIONS 210
RENAL TRACT CONDITIONS 223
RHEUMATOLOGICAL AND JOINT CONDITIONS 232
METABOLIC & ENDOCRINE CONDITIONS 238
NEUROLOGICAL CONDITIONS 257
MENTAL HEALTH 269
COMMON EYE CONDITIONS 280
COMMON ORAL CONDITIONS 292
EAR NOSE AND THROAT DISORDERS 296
SKIN CONDITIONS 307
BURNS 317
PAIN MANAGEMENT & CARE OF THE TERMINALLY ILL 326
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MEDICINES AND THE ELDERLY 333

HAEMATOLOGY AND BLOOD PRODUCTS 336
INTRAVENOUS FLUID REPLACEMENT 350
ANAPHYLAXIS 357
POISONING 361
MEDICINES USED IN ANAESTHESIA 378
SURGICAL CONDITIONS 397
ANTINEOPLASTIC AGENTS 408
REPORTING ADVERSE MEDICINE REACTIONS 415
MEDICINE INTERACTIONS & INCOMPATIBILITIES 432
THE 7TH ESSENTIAL LIST FOR ZIMBABWE 436
SPECIALIST ESSENTIAL MEDICINE LIST IN ZIMBABWE 446
INDEX 455
INDEX BY MEDICINE NAME 455
INDEX BY MEDICINE NAME 456
NOTES 474
NOTES 475
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GUIDELINES ON ANTIMICROBIAL
TREATMENT AND PROPHYLAXIS
GENERAL GUIDELINES 2
PRINCIPLES OF ANTIMICROBIAL USE 2
NOTES ON SPECIFIC ANTIMICROBIALS 3
PYREXIA/FEVER OF UNKNOWN ORIGIN 4
THE USE OF ANTIMICROBIALS FOR PROPHYLAXIS OF
INFECTION 5
GENERAL RECOMMENDATIONS: 5
SPECIFIC INDICATIONS: 5
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General guidelines
Antimicrobials are the most over-used class of medicines worldwide
and in Zimbabwe. Apart from the unnecessary cost and risk to the
patient, overuse encourages development of resistant organisms, a
problem that has proven serious and expensive in many countries.
Antimicrobials should be used only in patients with likely bacterial
illness requiring systemic therapy. In many cases anti-microbial
medicines will initially be given “blind” or “empirically”, the choice being
based on clinical suspicion without microbiological confirmation.
Positive identification of the pathogen and anti-microbial susceptibility
testing should be sought wherever possible as this will result in better
and more cost-effective treatment.
Principles of antimicrobial use

1. Choice of agent should be based on factors such as spectrum of
activity, anticipated efficacy, safety, previous clinical experience,
cost, and potential for resistance. These will be influenced by the
severity of illness and whether the medicine is to be used for
prophylaxis, empirical therapy or therapy directed by identification
of one or more pathogens.
2. Prophylactic therapy should be restricted to the use of a limited
range of agents of proven efficacy in invasive procedures with a
high risk of infection or where the consequences of infection are
disastrous. Most surgical prophylaxis should be parenteral and
commence just before the procedure, continuing for no more than
one or two doses after the end of the operation. The aim is to
achieve high plasma and tissue levels at the time that
contamination is most likely i.e. during the operation.
3. Empirical therapy should be based on local epidemiological data
on potential pathogens and their patterns of antibiotic
susceptibility. Appropriate specimens for Gram stain, culture and
sensitivity testing should be obtained before commencing
antimicrobial therapy. Maintain a database of susceptibility profile
in order to guide intelligent choice of empirical antibiotic therapy at
regional and national patterns.
4. Directed antimicrobial therapy for proven pathogens should
include the most effective, least toxic, narrowest spectrum agent
available. This practice reduces the problems associated with
broad-spectrum therapy, that is, selection of resistant micro-
organisms and superinfection.
5. Choice of route should be determined by the site and severity of
infection. It is important that topical antimicrobial therapy be
restricted to a few proven indications, for example, eye infections
2
because of the capacity of most agents to select resistant micro-
organisms and to cause sensitisation; topical antiseptics are
preferred in most situations.
6. Antimicrobial combinations have few indications. These
include:
 to extend the spectrum of cover, for example, in empirical
therapy or in mixed infections,
 to achieve a more rapid and complete bactericidal effect, for
example, in enterococcal endocarditis,
 to prevent the emergence of resistant micro-organisms, for
example in the therapy of tuberculosis.
Note: Doses given are for a 70kg adult with normal hepatic and renal
function. Paediatric doses are given in the chapter on Paediatric
Conditions. In the elderly, as a general rule, doses given could be lower
than the recommended adult dose (see Chapter on Medicines and the
Elderly).
Notes on Specific Antimicrobials

Note that some antibiotics are becoming ineffective because micro-
organisms are generally resistant to them. Antimicrobial susceptibility
testing should therefore be sought where possible. Patients should be
counselled to complete courses even when they feel better.
Oral amoxicillin should be used in preference to oral ampicillin
because of its better absorption, efficacy and lower cost. However, the
same is not true of the injectable preparations that have similar
efficacy.
Chloramphenicol must be limited to serious infection such as typhoid,
Klebsiella pneumonia, Haemophilus influenzae infections, difficult to
treat pelvic inflammatory disease and brain abscesses and not used
indiscriminately in the treatment of fever. An exception to this is when a
broad-spectrum antibiotic is required and there is a problem with
availability. Furthermore, the oral preparation should be used
judiciously as it is more prone to cause aplastic anaemia than the
injectable formulation.
Dosage of gentamicin, streptomycin, and kanamycin
(aminoglycosides) must be carefully adjusted for weight and renal
function. Except for duration less than 3 days use or when lower doses
are used, as with TB therapy, they require peak and trough serum
levels (where available), careful monitoring of serum urea and/or
creatinine, and checking for complaints of auditory or vestibular
symptoms (adverse effects).
Patients with true penicillin allergy (that is, a pruritic rash,
angioedema or anaphylaxis) must not be given penicillin. Rashes
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EDLIZ 2015
occurring after 48 hours are rarely due to allergy and are not a
contraindication to further use. Note that, penicillins have cross-
reactivities with other medicines including cephalosporins and such
newer medicines as imipenem. Macrolides are suitable alternatives.
Persons with a history of co-trimoxazole allergy may be offered
desensitisation (see Chapter on HIV infections).
Pyrexia/Fever of unknown origin

Fever is a common presenting symptom at all ages, but in adults there
will usually be some localising symptoms or signs, which point to a
likely focus of infection. If after careful examination no clear focus of
infection is identified, the following should be considered in a
previously healthy patient admitted from the community with fever of
less than two weeks’ duration:
 Viral infections (frequently resolve after 4-5 days, or may
be the prodromal phase, for example, hepatitis)
 Malaria
 Typhoid
 Urinary tract infection
 Bacteraemia
 HIV related causes of fever
If HIV infection is suspected see guidelines in the chapter on HIV Related
Diseases.
 If the patient’s general condition is satisfactory, it is reasonable to
withhold antibiotics while carrying out a few basic investigations:
that is urinalysis (dip-stick), urine microscopy, haemoglobin, white
cell count and differential and malarial parasites which are all
within the capabilities of a district hospital laboratory. If possible,
send a blood culture to the nearest reference laboratory. Liver
function tests and urine testing for bile products are appropriate if
hepatitis is suspected.
 If no improvement occurs after 3-4 days, and there is still no
identifiable focus of infection, and there is no evidence of malaria
(at least two negative blood films), the subsequent management
of the patient should be guided by the results of the
investigations.
 In those patients who present very ill or toxic, or whose condition
deteriorates, antibiotic therapy should be initiated on the basis of
clinical suspicion (typhoid - chloramphenicol, staphylococcal
septicaemia - cloxacillin, etc), anaerobes (metronidazole).
Recommended ‘blind’ therapy for septicaemia with no identifiable
source is as follows:
4
ampicillin iv B E 2g 4 times a day Review
and gentamicin iv C V 4–5mg /kg once a day max 2 weeks
Alternative:

chloramphenicol iv B E 1g 4 times a day Review
and gentamicin iv C V 4–5mg /kg once a day max 2 weeks
The use of antimicrobials for prophylaxis of

infection
There are some instances where the use of prophylactic antibiotics is
well established. However, the use of antibiotics for prophylaxis of
infection often consumes a disproportionate amount of all antibiotics
used in the hospital setting and consideration to their appropriate use
must be given. Prophylactic antibiotic use must be within accepted
principles and guidelines.
General Recommendations:
 use the appropriate medicine (see below)
 give as a single dose where possible
 repeat when the procedure lasts longer than 3-4 hours
 give intravenously 10-15 minutes before incision, or orally 1-2
hours before incision.
Specific indications:
Surgical prophylaxis
 Vaginal operations:
Medicine Codes Adult dose Frequency
chloramphenicol iv B E 1g single dose
 Caesarean section:
ceftriaxone iv C V 1g single dose
 Hysterectomy, or Colorectal surgery e.g. appendicectomy:

ceftriaxone iv C V 1g single dose
and gentamicin iv C V 4-5mg/kg single dose
5
EDLIZ 2015
 If signs of infection after operation, give:

and metronidazole po C V 400mg 3 times a day 7 days
Also refer to Obstetrics and Gynaecology/Surgical

Conditions Chapters for further guidance.
 Urinary tract surgery e.g. prostatectomy:

ciprofloxacin po B V 500mg single dose
Other prophylaxis
 Skull base fracture with liquorrhoea (rhino/otorrhoea):
chloramphenicol iv B E 1g single dose
 Subacute bacterial endocarditis See Cardiovascular Chapter
 For meningococcal meningitis contacts. Give as soon as

diagnosis is made in the index case:
ceftriaxone im C V 250mg Single dose
 Cotrimoxazole Prophylaxis (see HIV chapter):

cotrimoxazole* C V 960mg every day for life or until
po CD4>500 for 3
months with
ARVs
*If there is a history of cotrimoxazole allergy and it was not Stevens-
Johnson syndrome then it is likely that the person can be desensitised.
6
BASIC INFECTION PREVENTION AND
CONTROL MEASURES
GENERAL NOTES 8
CATEGORIES OF INFECTION CONTROL PRACTICES
8
USE OF PERSONAL PROTECTIVE EQUIPMENT. 9
7
EDLIZ 2015
General Notes
(See National Infection Control Guidelines)
Transmission of infections in healthcare facilities can be prevented and
controlled through the application of basic infection control prevention
and control practices. The 2 tiers or categories of infection control
prevention and practices are A) standard precautions and B)
transmission based precautions. The goal of this two- tier/category
system is to minimise risk of infection and maximise safety level within
our healthcare facilities.
 Educate healthcare workers not only on what to do but why it
is important to do it.
 Emphasising outcomes helps healthcare workers see how
their routine job duties interact with the infection control
system.
Categories of Infection Control Practices:
a. Standard Precautions (previously known as Universal
Precautions) - must be applied to all patients at all times,
regardless of diagnosis or infectious status.
b. Transmission based precautions - are specific to modes of
transmission e.g. airborne, droplet or contact.
A) Standard Precautions
Treating all patients in the healthcare facility with the same basic level
of “standard” precautions involves work practices that are essential to
provide a high level of protection to patients, healthcare workers and
visitors.
These precautions include the following:
 Hand hygiene (hand washing, hand antisepsis)
 Use of personal protective equipment when handling blood
substances excretions and secretions.
 Appropriate handling of patient care equipment and soiled
linen.
 Prevention of needle stick/sharp injuries.
 Environmental cleaning and spills management.
 Appropriate handling of waste.
8
Hand Hygiene
Appropriate hand washing can minimise micro-organisms acquired on
the hands by contact with body fluids and contaminated surfaces.
Hand washing breaks the chain of infection transmission and reduces
person to person transmission.
NB: Hand washing or hand antisepsis is the simplest and most cost-
effective way of preventing the transmission of infection and thus
reducing the incidence of healthcare associated infections.
Types of Hand Hygiene
1. Hand washing is usually limited to hands and wrists, the hands

are washed for a minimum 10-18 seconds with hand washing
soap and water.
2. Hand antisepsis/Decontamination
 Decontaminate hands with a waterless alcohol based
hand gel or rub for 15-30 seconds.
This is appropriate for hands that are not visibly soiled.
3. Surgical hand antisepsis
 This removes or destroys transient micro-organisms
and confers a prolonged effect. The hands and
forearms are washed thoroughly with an antiseptic soap
for a minimum 2-3 minutes and dried with a sterile
towel. This is required before performing invasive
procedures.
NB: Hands should be dried with disposable paper towels.
Use of Personal Protective Equipment.

Types:
 Scrub Suit or Gowns
 Plastic Aprons
 Boots or shoes covers
 Caps
 Protective eye wear
 Gloves
 Gloves
 Reduce the incidence of hand contamination with infective
material which in turn reduces the opportunity for personnel
to become infected and/or the organisms to spread to other
personnel and /or patients.
 Gloves however should not replace hand washing.
9
EDLIZ 2015
Gloves are to be worn when touching the following:

 Blood
 All body fluids
 All body secretions
 All body excretions
Gloves should be removed before touching clean items (e.g.
phone, door knobs or patients’ charts.) After removing gloves,
wash hands thoroughly.
A. Important points to remember when using gloves.

 Use gloves when there is potential exposure to blood, body
fluids, excretions or secretions.
 Change gloves between patients, between procedures on
the same patient when they become soiled.
 Remove gloves before leaving the patient’s bedside and
decontaminate hands immediately with 70% alcohol hand
rub solution.
 Discard gloves after attending to each patient.
B. Boots/shoe covers
 These are used to protect the wearer from splashes of
blood, body fluids, secretions and excretions.
 Shoe covers should be disposable and waterproof.
 Waterproof boots should be washable.
C. Caps
 Disposable and waterproof caps that completely cover the
hair are used when splashes of blood and body fluids are
expected.
D. Masks
1. A surgical mask protects healthcare providers from inhaling
respiratory pathogens transmitted by the droplet routes. It
prevents the spread of infectious diseases such as varicella
(Chicken pox) and meningococcal diseases (meningococcal
meningitis.)
2. A N95 mask protects healthcare providers from inhaling
respiratory pathogens that are transmitted via the airborne
route. This helps to prevent the spread of infectious diseases
such as TB, or MDR TB.
NB: In order to prevent the spread of infection, the appropriate mask
should be worn by healthcare providers and visitors when attending to a
patient suffering from a communicable disease that is spread via the
airborne or droplet route.
10
The patient with a communicable disease via the droplet or
airborne route should wear a surgical mask when being
transferred to other departments or hospitals or in isolation room
to prevent spread of infection.
Disposable masks are for single use only and should only be
discarded after 4-6 hours use.
Precautions
a) Masks should not be worn around the neck
b) Masks cannot be worn with beards or unshaven faces.
c) Masks should completely seal the face at all times to ensure
effective filtering of micro-organisms.
E. Gowns
 Gowns made of impervious material are worn to protect the
wearer’s clothing/uniform from possible contamination with
micro-organisms and exposure to blood, body fluids,
secretions and excretions.
 Use gown once for one patient and discard.
 Healthcare workers should remove gowns before leaving the
unit.
Recommendations for use of gowns
 Lab coats or scrub suits should not be viewed as an effective
barrier to blood or other body fluids.
 Use of fluid resistant gowns, impervious gowns or plastic
aprons, if soiling of clothes with blood or other potentially
infectious material is likely, is highly recommended.
F. Plastic Aprons
 A plastic apron protects the wearers’ uniform from contact
with contaminated body fluids.
 The inside of the apron is considered clean, the outside is
considered contaminated. The neck of the apron is clean
because that part is not touched with contaminated hands.
 Wash hands thoroughly after removing apron.
Protective eyewear/Goggles
 Should be worn at all times during patient contact where
there is a possibility that patients’ body fluids may splash or
spray onto the care giver’s face/eyes (e.g. during suctioning,
intubation, endoscopy and cleaning of instruments used for
these procedures)
 During all dental, surgical, laboratory and post mortem
procedures.
 Full face shields may also be used to protect the eyes and
mouth of the healthcare worker in high risk situations.
11
EDLIZ 2015
 Re-usable goggles should be washed and decontaminated

after removal and in-between use.
Please note: All protective equipment should be removed

prior to leaving work area.
G. Needles, sharp instruments and other devices.
All equipment contaminated with blood or other body fluids

should be handled with special care. Keep in mind these
recommendations:
 Never recap needles
 Never bend or break needles
 Never remove needles from disposable syringes
 Immediately dispose of all disposable syringes and needles,

scalpel blades and other sharp instruments, after use, in a
colour-coded or labelled leak-proof puncture resistant
container.
B) Transmission based precautions.

These are designed to supplement standard precautions or protocols
and must always be used in conjunction with Standard Precautions
isolation techniques. Transmission based precautions provide extra
safety by facilitating a concerted effort to control the spread of specific
types of bacteria. Whilst mostly used for diagnosed infection, they are
useful when a specific diagnosis is suspected. Transmission based
precautions are divided into 3 basic categories:
 Contact
 Droplet
 Airborne
A. Contact Precautions:
 Reduces the risk of transmission of organisms from infected
or colonised patient through direct or indirect contact.(e.g.
Herpes Simplex, Haemorrhagic Fever Virus e.g. Ebola,
multi-drug resistant bacteria)
 Precautions include: Hand gloving/Patient placement
/Hand washing/Use of aprons and gowns/Patient care
equipment/Patient transport
12
B. Droplet Precautions:
 Reduces the risk of nosocomial transmission of pathogens
spread by large droplets particles usually within a metre (e.g.
Mumps, Diptheria, Haemophilus and Influenza.)
 Droplets may be expelled during:
Sneezing/Coughing/Talking
 Teach cough hygiene i.e. cover mouth when coughing
 Precautions include: Patient Placement/Respiratory
protection/Patient transportation.
C. Airborne Precautions:
 Designed to provide protection from extremely tiny airborne
bacteria or dust particles which may be suspended in the air
for an extended period of time.
 Used in addition to Standard Precautions for patients known
or suspected to be infected with micro-organisms transmitted
by airborne route e.g. TB, chicken pox/measles.
 Precautions include: Respiratory Protection/Patient
placement/Patient transportation
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EDLIZ 2015
PAEDIATRIC CONDITIONS
GENERAL NOTES: 15
NEONATAL CONDITIONS 15
NEONATAL INFECTIONS 20
PAEDIATRIC CONDITIONS 26
ACUTE RESPIRATORY INFECTIONS 26
MANAGEMENT OF SEVERE PNEUMONIA: 28
MANAGEMENT OF PNEUMONIA 29
MANAGEMENT OF COUGH/COLD 30
WHEEZING 30
STRIDOR 32
FOREIGN BODY 33
EMPYEMA / LUNG ABSCESS 33
DIPHTHERIA 34
PERTUSSIS 34
MANAGING A CHILD WITH A SORE THROAT 35
DIARRHOEA IN CHILDREN 36
PERSISTENT DIARRHOEA 42
INDICATIONS FOR ANTIBIOTICS IN DIARRHOEA: 42
ACUTE MALNUTRITION 44
NUTRITIONAL REHABILITATION 48
ANAEMIA: 52
PAEDIATRIC HIV INFECTION 53
MANAGEMENT OF SPECIFIC HIV RELATED
CONDITIONS 54
PAEDIATRIC MEDICINES DOSES 56
14
General Notes:
The content of this chapter reflects the major causes of infant
mortality and morbidity in Zimbabwe – prematurity, neonatal sepsis,
perinatal asphyxia, acute respiratory infections, diarrhoeal diseases,
malnutrition and, immunisable diseases. Some of the paediatric
conditions may have underlying HIV infection.
Other paediatric conditions have been described in the relevant
chapters in EDLIZ, and where possible paediatric doses have been
given.
 Note: doses are also given by age and weight wherever
possible, and volumes of liquids or injections to be
administered are indicated. Always check the concentration
of the preparation however, as preparations may change. This
should not be seen as a ‘short-cut’ to calculating the proper
dose.
Neonatal Conditions
Medicine Dosage for Infants Under 1 Month
During the first month of life absorption, metabolism and excretion
in a baby are not yet fully developed. For this reason the frequency
of medicine dosing is based on gestational age and not on the
characteristics of the medicine.
The table below gives the frequency of dosing for all medicines and
is referred to in the therapies that follow in the text.
Table 3.1 Frequency of dosage by gestational age
Gestational age > 37 weeks (term baby)
First two days 2 doses per 24 hours
3 days to 2 weeks 3 doses per 24 hours NB: Not for
> 2 weeks 4 doses per 24 hours gentamicin-
Gestational age < 37 weeks (pre-term baby) see table 3.2
First week 2 doses per 24 hours
1-4 weeks 3 doses per 24 hours
> 4 weeks 4 doses per 24 hours
For example: Benzyl penicillin dose 100,000u/kg/dose (0.1MU/kg)

Thus a 2kg pre-term baby 5 days old would receive 200,000u Benzyl
penicillin every 12hours, whilst a 2kg term baby 5 days old would
receive 200,000u every 8 hours.
Routine Management at Birth
15
EDLIZ 2015
 Do not suction mouth routinely, only if there is something (e.g.

thick meconium) to suck out.
 Dry and wrap up, preferably in a dry pre-warmed soft towel.
 Delayed cord clamping - clamping the umbilical cord after
1minute is recommended for all normal births except in IUGR,
infants of diabetic mothers and asphyxia.
 To prevent neonatal ophthalmia, instil into both eyes:
Medicine Codes Paed dose Frequency Duration
tetracycline eye oint. 1% C V instil into both once at birth
eyes only
 To prevent haemorrhagic disease of the newborn, give:

vitamin K im C V 1mg [preterm = once only single
0.5mg] dose
 Hand the baby to the mother for her to put immediately to
breast.
Resuscitation of the newborn

Essential Newborn Care
 Apply tetratcycline ointment to the eyes
 Give Vitamin K 1mg IM once
 Weigh the baby
 Put baby skin to skin with the mother
 DO NOT LEAVE THE BABY ALONE
16
Figure 3.1 Action plan to help babies breathe
17
EDLIZ 2015
Clear of meconium?
Breathing or crying? Supportive care
Good muscle tone? Yes  Provide warmth
Colour pink?  Dry
Term gestation?  Cord care
30 seconds
 Breast feeding
No
Provide warmth
Position; clear airway (as necessary)*
Dry, stimulate, reposition
Give O2 (as necessary)
check respiration, heart rate and colour

30 seconds
Apnoea Or HR <100
Breathing, pink, HR >100
Ventilate with bag and mask *
HR < 60 HR > 60
Ventilate with bag and mask *

Administer cardiac massage
30 seconds
* consider
HR < 60 intubation
Give adrenaline1ml//kg 1:10 000
Consider hypovolaemia and acidosis
Figure 3.2: Essential steps for newborn care
18
Ensuring adequate warmth and ventilation (either by mask or
intubation) is much more important than administering any
medicines.
The following may be useful:
For respiratory depression, but only if the mother was given
pethidine in labour:
Medicine Codes Paed dose Freq. Duration
naloxone neonatal 20mcg/ml B V <1kg 10mcg =0.5ml repeat as
im 1-2kg 20mcg =1ml necessary
NB: Note strength. 2-3kg 30mcg =1.5ml
>3kg 40mcg =2ml
adrenaline dilute to 1:10 000 C V 10mcg 1ml/kg
Only if the baby has no spontaneous breathing after 5 minutes of

ventilation, give a slow intravenous injection directly into
the umbilical vein:
sodium bicarbonate slow iv B N 4-6ml/kg
4.2%
or 2-3 ml/kg of 8.4% solution diluted with equal quantity of water for
injection, if only strength available.
Helping babies survive

Every newborn baby must receive the ‘Essential Care for Every
Baby’ package. Such care is essential for preventing and managing
common illnesses in the first 24hrs of life when newborn mortality is
highest.
See management algorithm on the next page
Feeding and Fluids

In general, babies should breast-feed on demand from birth. There
is no need for supplemental water or other feeds.
For babies requiring special care (low birth weight, birth asphyxia,
infection, etc) the following fluid regimen based on birth weight is
recommended:
Oral feeds
 Day 1: 60ml per kg per 24 hrs. [40ml/kg/24hrs in severe birth
asphyxia and meningitis].
19
EDLIZ 2015
 Day 2 and subsequently: Increase by 20-30ml per kg per

24hrs depending on the general condition, to 150ml/kg/24hrs.
If this is well tolerated increase further to 180-200ml/kg/24hrs.
Intravenous Fluids
If intravenous not possible, try nasogastric feeding.
 Day 1
dextrose 10% iv A N 60ml/kg/24hrs
infusion
 Days 2-4 or when otherwise required:

darrows half strength / C V Same as for oral fluids up to a
dextrose 2.5% iv with max. of 150ml/kg/24hrs –
10% dextrose infusion* inclusive of all fluids administered
or neonatalyte iv infusion B N – oral, nasogastric and
intravenous.
*This can be made up by withdrawing 30 ml from a 200 ml bag of half
strength Darrows/dextrose 2.5% and replacing with 30 ml of 50%
dextrose.
 Consider transfer to a specialist unit for babies unable to feed
and requiring intravenous fluids for longer than 3 days.
(ALWAYS KEEP THE BABY WARM)
Neonatal Infections
Table 3.2 Gentamicin dosages:
Premature or full term neonates up to 7days old
Weight Age Dose Frequency
less than1000gm 28 weeks 2.5mg/kg once every 24hrs
more than 1000gm >28weeks 2.5mg/kg every 12hrs
Neonates more than 7 days old
less than 1200gm 2.5mg/ kg every 12hrs
more than 1200gm 2.5mg/ kg every 8hrs
*consider -once daily gentamicin dosing in neonates <35 weeks

gestation: 3mg/kg every 24 hours, >35 weeks gestation: 4mg/kg
every 24hours and >37 weeks: 5mg/kg
There are usually few localising signs in infants, and accurate

diagnosis may not be possible. The following regimens are
recommended for suspected sepsis.
20
Suspected sepsis in first 48hrs:
benzylpenicillin im/iv C V 0.1MU/kg Table 2.1 5 days
and gentamicin im/iv C V 2.5mg/kg Table 2.2 5 days
Suspected sepsis after 48hrs:

gentamicin im/iv C V 2.5mg/kg Table 2.2 5 days
and cloxacillin im/iv B V 30mg/kg Table 2.1 5 days
Kanamycin 7.5mg/kg/dose BD can be used if gentamicin

unavailable
Meningitis:
benzylpenicillin im/iv C V 0.1MU/kg Table 2.1
14-21
and gentamicin im/iv C V 2.5mg/kg Table 2.2 days
and chloramphenicol iv B V 12.5mg/kg Table 2.1
Ampicillin can be used if benzyl penicillin is not available: dose=

50mg/kg
For meningitis ceftriaxone can be used as an alternative: dose =

50mg/kg/dose
Necrotising enterocolitis
Give nothing by mouth. Supportive care is vital: oxygen, intravenous
fluids, warmth, and nasogastric continuous drainage. Anticipate
complications such as bleeding, vomiting, perforation, seizures.
Refer for specialist diagnosis and care.
benzylpenicillin im/iv C V 0.1MU/kg Table 2.1 10 days
and gentamicin im/iv C V 2.5mg/kg Table 2.2 10 days
and metronidazole iv A N 7.5mg/kg Table 2.1 10 days
Neonatal tetanus
 The important principle in treating these babies is minimal
handling. Give:
benzylpenicillin im/iv C V 0.05MU per kg 12 hourly 5-7days
or procaine penicillin im C V 50mg/kg Once a 5 -7 days
day
and tetanus B E 500 – 1000 Once single
immunoglobulin im units only dose
21
EDLIZ 2015
 Control of muscle spasms:

diazepam iv C V 0.25-1mg/kg 4-8hrly, titrated
[to a max total according to
dose of 10mg] response
Or chlorpromazine C V 2mg/kg/24hrs in 4-6 divided doses
iv/im/nasogastric
and phenobarbitone B E 2.5-5mg/kg 12hrly for as long as
iv/im/nasogastric necessary
 Congenital syphilis
procaine penicillin C V 50mg/kg Once a day 10 days
Jaundice
Refer all babies developing jaundice within 24 hours of birth to a unit
capable of performing exchange transfusion.
Refer jaundiced babies who look ill.
 Jaundice developing in well babies may be treated using
phototherapy. If phototherapy equipment is not available,
expose to the sun intermittently for a maximum of two hours
(keep warm). Shade the baby’s eyes with a loose fitting
bandage over cotton wool pads. Continue until the baby is no
longer yellow.
 Give an extra 20ml/kg/24 hrs of fluid. Be very careful that the

baby does not get cold (or hot). Encourage increased
breastfeeding.
where possible check the serum bilirubin levels
Convulsions
 Always check for hypoglycaemia. If dextrose <2.2mmol/l
(45mg%) immediately give:
dextrose 50% slow iv C V 1ml/kg diluted with equal quantity of
water for injection as slow bolus
Medicine Codes Paeds Dose

dextrose 10% iv A N 4ml/kg per hour
infusion
 recheck blood sugar (dextrostix) in 30 minutes
22
 If intravenous route impossible give breast milk through
nasogastric route -10-20ml/kg initially and continue normal
requirement two hourly.
Dextrose should not be given by nasogastric tube.
Anticonvulsants:
phenobarbitone iv B E 10mg per kg over 5-10mins
repeat in 30
minutes if still
convulsing
Or diazepam iv/pr * C V 0.3mg per kg once
*Do not give diazepam with phenobarbitone or if jaundiced
 Perform lumbar puncture.
Vitamins and Iron

Normal newborn babies do not require any long-term
vitamin or mineral supplementation.
 Those babies born at <36 weeks gestation and/or <1.5kg
should be given from age 2 weeks:
Medicine Code Paed dose Freq. Duration
s
vitamin D po B V 800units once a to age of
day 3mths
and folic acid po C E 5mg weekly
 and, starting from the age of one month:

s
and ferrous sulphate po C E 3-6 mg/kg once a to age of
(60mg/5mls = 12mg elemental iron day 3mths
elemental iron /5mls)
23
EDLIZ 2015
Table 3.3 Dosages for infants under one month:

Medicine Route Dosage Freq. (per
day)
Adrenaline 1:1000 iv/sc 0.01mg/kg (=10mcg/kg) -

1mg/ml injection
Aminophylline iv/ Loading: 6mg/kg over 30mins -
25mg/ml injection infuse Maintenance: 0.16mg/kg/hr
amoxicillin po 30mg/kg/dose 2 to 4
125mg/5ml syrup
Atropine sulphate iv/im/sc 0.01mg/kg -
0.6mg/ml injection
Benzylpenicillin iv/im 0.1MU/kg/dose 2 to 4
(3g) 5MU injection (=100,000 u/kg/dose)
Calcium chloride iv 0.2ml/kg over 5mins single dose
(dihydrate) injection
0.7mmol Ca/ml (10%)
Calcium gluconate iv 0.5ml/kg over 5mins -
0.22mmol Ca/ml(10%)
injection
Chloramphenicol iv/po 12.5mg/kg/dose 2 to 3
1g injection
125mg/5ml syrup
Clindamycin iv 10mg/kg over 30mins 3
1g injection
Cloxacillin iv/im/po 30mg/kg/dose 2 to 4
500mg injection
125mg/5ml syrup
Cotrimoxazole po 24mg/kg/dose 2
240mg/5ml syrup
240mg tablet
Dexamethasone im O.5mg/kg/dose 3 to 4
5mg/ml injection
Dextrose iv 5 to 10ml/kg of 5% repeatable
5% infusion 1 to 2ml/kg of 50% diluted 1:1
50% injection over 3 to 4mins
Diazepam iv/pr 0.3.mg/kg/dose repeatable -
5mg/ml injection
Digoxin iv/im Loading: 10mcg/kg at 8 hour intervals for total
0.25mg/ml of three doses
50mcg/ml syrup Po Maintenance: 10mcg/kg/24hrs 1
Erythromycin Po 40mg/kg/24 hrs 3
125mg/5ml syrup
Ferrous sulphate Po 12mg Fe/24hrs Once
12mg Fe/5ml syrup
Folic acid Po 5mg weekly
5mg tablet
Frusemide iv/im 0.5 to 2mg/kg/dose 1 to 2
10mg/ml injection
40mg tablet Po 1 to 4mg/kg/dose 2
Gentamicin im/iv ≥ 1500 g = 2.5mg/kg/dose 2
10mg/ml injection <1500g = 2,5 mg/kg/dose once
Hydrocortisone iv/im 10mg/kg/dose 3
100mg injection
Isoniazid Po 10mg/kg/24hrs once
24
50mg/5ml syrup
Kanamycin Im 7.5mg/kg/dose 1 to 2
1g injection
Metronidazole Iv 7.5 mg/kg/dose 2 to 3
5mg/ml injection
Morphine iv/im 0.1 to 0.2 mg -
15mg/ml injection
Naloxone Iv 0.02mg/kg repeatable
0.02mg/ml injection Im 0.06mg/kg repeatable
Nystatin Po 100 000u/dose 4
100 000units/ml
Penicillin procaine Im 50 mg/kg/24hrs Once
300mg/ml injection [=50 000u/kg/day]
Phenobarbitone Iv 10 to 20mg stat over 10mins -
200mg/ml injection im/po maintenance = 3 to 5mg/kg/24 1 to 2
15mg/5ml syrup hrs
Phenytoin po 4mg/kg/dose 2
30mg/5ml syrup
50mg/ml injection iv Loading: 15-20mg/kg slow (0.5mg/kg/min)
Sodium bicarbonate Iv 5ml/kg of 4.2% slowly -

4.2% infusion (or 8.4%)
Theophylline Po Loading: 6mg/kg Maintenance: 3
200mg tablet 5mg/kg/24hrs
Thyroxine Po 10mcg/kg/24 hrs Once
100mcg tablet
Vitamin D (calciferol) Po 800u/day (age >14days) Once
50 000u capsule
Vitamin K Im 1mg for ≥2500g, 0.5mg for -
(phytomenadione) <2500g
2mg/ml inj.
25
EDLIZ 2015
Paediatric Conditions
Common paediatric conditions such as acute respiratory infections
(ARI), diarrhoea, child with fever (axillary temperature 37.5oC and
above); severe malnutrition (PEM) are now incorporated in the
Integrated Management of Childhood Illness (IMCI).
General guidelines on the use of antibiotics

Paediatric doses are given in Tables 2.6 and 2.7 (Neonatal doses are
given separately in Table 2.3)
 ALWAYS DO BLOOD CULTURES IN SUSPECTED SEPSIS.
 supportive measures are often more important than antibiotics
themselves: for example, fluids in diarrhoea and vomiting;
 antibiotics should be given in the full dosage appropriate for
the age and weight of the child; dosage is best calculated
according to body weight up to 40kg (do not exceed the
adult dose);
 change to oral administration wherever possible (except for
meningitis); benzylpenicillin intramuscularly/ intravenously can
be changed to procaine penicillin intramuscularly (if response
is good) once child is afebrile.
Check for General Danger Signs:
Ask:
 if the child is not able to drink or breastfeed
 if the child is vomiting everything
 if the child has had convulsions
 if there are periods of not breathing
Look to see:
 If the child is lethargic or unconscious.
A child with any general danger sign needs urgent

attention.
Acute Respiratory Infections

Check for any general danger signs (above).
Any history of fever in a falciparum malaria area:
 take a blood slide
 treat for malaria (see chapter on Malaria)
Fever for more than 5 days: refer for assessment.
26
In areas with falciparum malaria, a child with pneumonia and a fever
of 37.5°C or more (or a history of fever) may need an antibiotic for
pneumonia and an anti-malarial for malaria.
Management of a child with cough/difficult

breathing
Note: Antihistamines and sedating cough mixtures MUST NOT be
used in managing respiratory infections. Breast milk, warm drinks
including water, and fruit are effective cough /sore throat relievers.
Pneumonia is recognised by difficulty in breathing which is either
fast breathing or chest indrawing.
Table 3.4: definition of fast breathing:

Age: Fast breathing is defined as:
< 2 months 60 breaths per minute
2 months to 12 months 50 breaths per minute
12 months to 5 years 40 breaths per minute
Chest indrawing is when the lower part of the chest moves in when
the child breathes in.
Grunting is a soft short sound that the infant makes when breathing
out.
Table 3.5: Management of pneumonia:
SIGNS CLASSIFY AS: TREATMENT
Urgent pre-referral treatments
are in bold print
Any general danger Severe pneumonia  Give first dose of an
sign or appropriate antibiotic
or very severe  Treat to prevent low blood
chest indrawing disease sugar (see below)
or  Keep the child warm
stridor in a calm  Treat wheeze if present
child  Refer URGENTLY to hospital
Fast breathing Pneumonia  Give an appropriate antibiotic
for 5 days
 Treat wheeze if present
 Advise mother to return
immediately if condition worsens
 Follow-up in 2 days
No signs of No pneumonia:  If coughing more than 21 days,
pneumonia or of cough or cold refer for assessment
very severe disease  Treat wheeze if present
 Advise mother to return
immediately if condition worsens
 Follow-up in 7 days if not
improving
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Management of severe pneumonia:

The major cause of pneumonia is infection with Streptococcus
pneumoniae or Haemophilis influenzae. These respond well to the
antibiotics recommended below if recognised early.
Note: Paediatric dose starts at 2 months in IMNCI. For babies 1-2
months check for the neonatal doses.
 Well nourished children over 6 months with severe pneumonia
can be managed with benzylpenicillin only.
 Give first dose of intramuscular benzylpenicillin and gentamicin
and refer child urgently to hospital.
 If referral not possible repeat the benzylpenicillin 6 hourly and
gentamicin once daily.
s
benzylpenicillin im C V 0.05 – 6 hourly 10 days
0.1MU/kg
and Gentamicin C V 5-7mg/kg Once 10 days
daily
Note: change to oral amoxicillin when possible
If less than 6 months add high dose cotrimoxazole for 21

days and check HIV status
Table 3.6: Cotrimoxazole dosage per age group

Age or weight adult tablet Paediatric tablet Syrup
2-6 months (4-<6kg) ¼ 1 2.5mls
6m-3yrs (6-<14kg) ½ 2 5mls

3-5yrs (14-19kg) 1 3 1ml
All HIV positive children should continue with cotrimoxazole

prophylaxis at same dose once daily. Infants confirmed HIV infected
should commence ART as soon as possible.
 If benzylpenicillin is not available, substitute with:

ampicillin iv B E 50mg/kg 6hourly 5 days
procaine C V <1yr ½ ml (= 150mg) once a 5 days
penicillin im 1-3yrs 1ml (= 300mg) day
3-5yrs 1 ½ ml (- 450mg)
Supportive measures
 Prevent low blood sugar:
 If the child is able to breast feed ask the mother to breast feed
the child
28
 If the child cannot breast feed, but is able to swallow give
expressed breast milk or a breast milk substitute. If neither are
available give sugar water = 4 level teaspoons sugar (20gm) in
200ml clean water.
 If the child is not able to swallow, give 50ml of milk or sugar
water by nasogastric tube.
 Fluids (po/iv/nasogastric) 100ml/kg/24hrs - iv fluids monitored
closely
 Nasal suction (or normal saline nasal drops) to clear the
airway.
 Continued feeding.
 Check oxygen saturation
 Give Oxygen.
Management of pneumonia
 First line:
s
amoxicillin po C V 4-<6kg = 3 5 days
6- 62.5mg times
<14kg = 125mg a day
14-19kg = 250mg
 Alternative: Refer
s
or procaine penicillin im C V <1yr = 150mg once a 5 days
1-3yrs = 300mg day
3-5yrs = 450mg
 Reassess after 2 days of antibiotic treatment If not responding

then refer, as the second line choices are limited.
 Treat fever and pain , if present with:
s
paracetamol po C E 10mg/kg 6hrly as
required.
Note: Do not give paracetamol to children under 3 months of age due
to liver immaturity, if indicated give cautiously.
Give clear instructions on

 how to take medicines
 home care:
 continue breast-feeding
 maintain nutrition by giving easy-to-digest high-
energy food 5-7 times a day
 and plenty of fluids a day.
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Advise mother to return with the child in 2 days for re-assessment,

or earlier if the child is getting worse:
 increased difficulty in breathing
 increased difficulty in drinking
 increased respiratory rate,
If the child returns with any of these, refer
Table 3.7: Monitoring the child with pneumonia:
Child Worse Child Same Child better
 Not able to drink  Fast breathing  Slower breathing
 Has chest indrawing  Fever reduced
 Has other danger signs  Eating better
Refer urgently Refer Finish course
Management of cough/cold
Home care and instructions on when to return are all that are
needed. No antibiotics, antihistamines or cough mixtures are
required.
Give clear instructions on

 home care:
 continue breast-feeding
 maintain nutrition by giving easy-to-digest high-energy
food 5-7 times a day
 and plenty of fluids a day.
Advise mother/ caregiver to return with the child in 2 days for
reassessment, or earlier if the child is getting worse:
 breathing becomes difficult
 child is not able to drink
 breathing becomes fast
 child seems worse
If the child returns with any of these, reassess.
If the temperature is above 37.5oC:
paracetamol po C E 10mg/kg 6hrly as required.
Wheezing
 In a young infant below 2 months, wheeze is a sign of serious
illness - refer.
 An infant between 2 months and 12 months may wheeze
because of bronchiolitis, which is usually a viral infection. If the
child with bronchiolitis is breathing fast, refer. If not, give home
care.
30
 In a child more than one year wheezing may be due to
asthma. If it is the first episode refer. If this child is in distress,
give a rapid-acting bronchodilator and refer.
Children with first episode of wheezing

 child under 1 year:
 If chest indrawing; or Give first dose of benzyl penicillin and refer
any danger sign; or if urgently to hospital.
fast breathing
 If no fast breathing Treat as “no pneumonia, cough/ cold”. Follow up
after 2 days.
Children with first episode of wheezing

 child 1 year and over
 If chest indrawing; or Give rapid-acting bronchodilator, oral prednisolone
any danger sign and antibiotic
Refer urgently to hospital
 If fast breathing Give oral bronchodilator;
Send home on treatment as “pneumonia”:
Follow up in 2 days
 If no fast breathing Give oral bronchodilator;
Send home on treatment as “no pneumonia, cough/
cold”;
Follow up in 7 days
Children with Previous Episodes of Wheezing

 child under 1 year
 If chest indrawing; or Give oral bronchodilator;
any danger sign Give first dose of antibiotic
Refer urgently to hospital
 If fast breathing Give oral bronchodilator;
Send home on treatment as “pneumonia”:
Follow up in 2 days
 If no fast breathing Give oral bronchodilator;
Send home on treatment as “no pneumonia, cough /
cold”;
Follow up in 7 days
Children with Previous Episodes of Wheezing

 child 1 year and over
 Start with Give a rapid acting bronchodilator
Assess the child’s condition 30 minutes later and treat
according to this assessment.
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 If chest indrawing; or Give first dose of antibiotic and prednisolone

any danger sign Refer urgently to hospital.
 If fast breathing Give oral bronchodilator
Send home on treatment as “pneumonia”
Follow up in 2 days.
 If no fast breathing Send home on treatment as “no pneumonia, cough/
cold”;
Give oral bronchodilator
Follow up in 7 days.
 Prednisolone dose in wheezing:

prednisolone po B V <1yr = Once repeat in
>1yr 10mg 6hrs if reqd.
=
20mg
 If a rapid acting bronchodilator is required:

s
salbutamol nebulised B V <1yr = 2.5mg as required
5mg/ml in 2ml sterile >1yr = 5mg
water
Or salbutamol po B V 2- = 1mg 3 times -
12mnths = 2mg a day
1-5yrs
Or adrenaline C V 0.01ml/kg up to repeat after 20mins
subcutaneously 1:1000 a max of 0.25ml if required
If asthma is suspected refer to Asthma section for
detailed management
Stridor
Definition: Harsh noise made when a child breathes in
Management of croup at the primary level

 If no stridor at rest, do not give antibiotics.
 If there is stridor at rest or chest indrawing or fast breathing
refer urgently to hospital for possible intubation or
tracheostomy and a course of cloxacillin and chloramphenicol.
Mild croup
 Stridor present only when upset.
 Likely to be of viral origin. An antibiotic is not required. Home
care.
32
Severe croup (Laryngotracheobronchitis)
This is stridor in a calm child at rest with chest indrawing.
 Refer to higher centre of care.
 Do not examine the throat in case it’s Epiglottitis!
 If referral not possible or there is a delay give
chloramphenicol and cloxacillin:
chloramphenicol iv B V 12.5mg/kg 6hourly 7 days
and cloxacillin iv B V 12.5-25mg/kg 6hourly 7 days
 Suspect Epiglottitis if child very ill, toxic and drooling saliva.
 Continue antibiotics
 Watch carefully for signs of obstruction. Intubation or a
tracheostomy may be required (poor air entry; severe chest
indrawing, restlessness, pallor).
 Minimal handling (keep on mother’s lap)
 NB. Remember cyanosis is a very late sign.
Foreign Body
Common in age 1-2 years: sudden onset (choking); sometimes
local wheeze and/or decreased air entry. May cause stridor/cough;
there is usually a history that suggests inhalation of foreign body.
 Admit for bronchoscopy in order to remove the foreign body.
 X-ray: opacity and/or air trapping
 Use antibiotics if there is fast breathing (secondary infection.)
Whenever Foreign Body is suspected consult cardiothoracic

surgeons
Retropharyngeal Abscess
 Surgical drainage is required. Give:
cloxacillin im/iv B V 25mg/kg/dose 6 hourly 7 days
and gentamicin im/iv C V 6mg/kg 24 hourly 7 days
Empyema / lung abscess

cloxacillin iv/im/po B V 12.5-25mg/kg 6hrly 6 weeks
and gentamicin im/iv C V 5-7mg/kg 24 hourly 14 days
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or kanamycin im C V 7.5mg/kg 12hrly 14 days
Empyema –should also insert a chest drain
Diphtheria
 Give antitoxin and:
benzyl penicillin im C V 100 000 unit/kg 6hrly 7 days
per dose
Pertussis
erythromycin po C V 12.5mg/kg/dose 6hrly 10 days
Management of a child with an ear problem

See also Chapter on Ear, Nose and Throat Disorders
Precautions for a child with a draining ear.

Advise the mother:
 not to leave anything in the ear, such as cotton wool, between
wicking treatments;
 not to put oil or any fluid into the ear;
 not to let the child go swimming or get water in the ear.
Mastoiditis
Tender swelling behind the ear.
 Give first dose of antibiotics, paracetamol for pain and refer to
hospital.
benzylpenicillin im C V 0.05-0.1MU/kg 6 hrly 10days
and gentamicin im C V 5-7 mg/kg 24hrly
or kanamycin im 7.5mg/kg 12 hrly
and paracetamol po C E 10mg/kg 6hrly as
required.
Acute ear infection

Pus is seen draining from the ear and discharge is reported for less
than 14 days; or ear pain.
34
 Give antibiotics and analgesia:
amoxicillin po C V 4-<6kg =62.5mg 12 hrly 5 days
6 - <14kg =125mg
14-19kg =250mg
and paracetamol po C E 10mg/kg 6hrly as
required.
 Use amoxicillin as first line in children on cotrimoxazole
prophylaxis
 Dry the ear by wicking
 Follow-up for 5 days
Chronic ear infection

Pus is seen draining from the ear and discharge is reported for 14
days or more.
 Dry the ear by wicking
 Instil quinolone drops (such as ciprofloxacin, norfloxacin, or
ofloxacin)
 Follow-up after 5 days then reassess.
 If not improving, refer to ENT specialist.
Managing a Child with a Sore Throat

Antibiotics are only needed for streptococcal sore throats to prevent
complications such as rheumatic fever. A streptococcal sore throat
presents as tender enlarged lymph nodes in front of the neck and a
white exudate on the tonsils.
Sore throat but no swollen tender glands in neck and no pus
on tonsils
 No antibiotics.
 Give paracetamol for pain.
 Feed child normally, continue breastfeeding.
 Give plenty of fluids.
Sore throat with swollen tender glands in neck or pus

on tonsils (age > 2 years)
 Give antibiotic:
procaine C V < 1yr 1/2mls(=150mg) once a 5 days then
penicillin im 1 to 3yrs 1ml(= 300mg) day penicillin V
3 to 5yrs 11/2mls( 450mg) for 5 days
or Amoxicillin po C E <3yrs = 125mg 3 times 10 days
>3yrs = 250mg a day
>12yrs = 500mg
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 Give paracetamol for pain.

 General / home care & feed child as above.
Treatment of oral candidiasis (thrush)

nystatin po B E 250 000iu after 3-6 5 days
feeds times a
or miconazole 2% gel po C V 2.5ml after feeds day
Managing a child with a blocked nose or nasal

discharge
For clear or mucous nasal discharge, do not give antibiotics; keep
nose clean with wet soft tissue or cloth and normal saline nasal
drops. For a foreign body in nose refer to hospital/admit for removal.
Diarrhoea in Children
About 90% of deaths from diarrhoea in under-fives would be
prevented by:
 giving extra home fluids or salt sugar solution (SSS) or ORS at
home at onset of diarrhoea to prevent dehydration;
 Exclusive breastfeeding for 6 months and continuing breast
feeding with solids throughout the attack of diarrhoea to
prevent malnutrition;
 making sure mothers know when to take the child to a health
facility;
 correct assessment, treatment and continued feeding at the
health facility level (see MoHCC Chart and IMNCI Manual);
 treatment of invasive diarrhoea (bloody stool) with antibiotics;
 clear instructions on discharge from the health facility for
continuing above treatments and when it may be necessary to
return for further treatment;
 referring to hospital for investigation and treatment: severe
malnutrition, persistent diarrhoea (lasting > 14 days);
 appropriate use of antibiotics, no anti-diarrhoeal or anti-
emetic medicines.
 Zinc sulphate 20mg/day for 10-14 days to all children >
6months and 10mg/day to infants less than 6 months.
If the child has diarrhoea

Ask:
 For how long?
 Is there blood in the stool?
36
Look:
 Is the child lethargic or unconscious?
 Eyes sunken?
 Able to drink or drinking poorly
 Drinking eagerly or thirsty?
Pinch the skin of the abdomen:

 Does it go back very slowly (longer than 2 seconds)?
Classify the dehydration – see table 3.4
NB: If temperature is 38.5oC or higher look for other causes of fever

and treat.
37
38
Table 3.8 Classification of Dehydration:

Signs Dehydration Management
Two or more of the following signs:  Initiate treatment for severe dehydration (Plan C),
 Lethargic or unconscious  or if another severe classification* – refer urgently to hospital with
 Sunken eyes caregiver giving frequent sips of oral rehydration fluid or by nasogastric
Severe dehydration tube on the way. Advise mother to continue breastfeeding.
 Not able to drink or drinking
poorly  If the child is 2 years or older and there is cholera in your area, give
 Skin pinch goes back very slowly antibiotic for cholera.
Two or more of the following signs:  Give fluid and food for some dehydration (Plan B).
 Restless or irritable  *If child also has a severe classification from another main symptom
 Sunken eyes refer urgently to hospital with caregiver giving frequent sips of oral
Some dehydration
 Drinks eagerly or thirsty rehydration fluid on the way. Advise mother to continue breastfeeding.
 Skin pinch goes back slowly  Advise mother when to return urgently
 Follow -up in 2 days if not improving.
Not enough signs to classify as  Give fluid and food to treat diarrhoea at home (Plan A)
‘some’ or severe dehydration No dehydration  Advise caregiver when to return immediately
 Follow -up in 2 days if not improving
* e.g. severe pneumonia, severe febrile disease, severe malnutrition
Plan A: Treat Diarrhoea at Home
Counsel the mother on the 3 Rules of Home Treatment:
 Give extra fluid
 Continue feeding
 When to return
Explain function of ORT (oral rehydration therapy) to mother

Give extra fluid (as much as the child will take)
Tell the mother:
 Breastfeed frequently and for longer each feed
 If the child is exclusively breastfed, give Sugar Salt Solution or ORS in addition to breast
milk
 If the child is not exclusively breastfed, give food-based fluids available at home
It is especially important to give ORT at home when the:

 child has been treated with Plan B or Plan C during this visit.
 child cannot return to a clinic if the diarrhoea gets worse.
Teach the mother how to prepare and give Sugar Salt Solution or ORS.
Explain to mother the reason for giving Oral Rehydration Therapy and
what it does.
Show the mother how much Sugar Salt Solution or ORS to give.
Continue to give as much of the normal feeds as the child will take AND
give Sugar Salt Solution or ORS.
Amount to give is:
Child’s weight x 100 = ml to give per 24 hours
Show mother how to measure this in a container available at home
Tell the mother:
 To give frequent small sips from a cup.
 If the child vomits, wait 10 minutes. Then continue but more slowly.
 To continue giving extra fluid until the diarrhoea stops.
 To continue (breast) feeding
 When to return
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Plan B: Treat Some Dehydration with Oral Rehydration

Therapy
In the health facility give the recommended amount of oral rehydration
therapy:
Give approximately 75ml/kg of oral rehydration therapy over four (4)
hours
 Start with 10ml per kg in first hour
 If the child wants more oral rehydration therapy than this, give more
 After the first hour give15 to 20mls per kg per hour
 If the child wants and can take more oral rehydration therapy without vomiting, give more
Show the mother how to give oral rehydration solution

 Give frequent small sips from a cup and spoon
 If the child vomits. Wait 10 minutes, then continue, but slowly
 Continue breastfeeding or other normal feeding whenever the child wants.
Reassess after 4 hours

 If no signs of dehydration  Plan A, and can send home
 If still some dehydration  Plan B, remaining in health facility
 If signs of severe dehydration  Plan C, start in health facility and refer
 Begin feeding the child if not already doing so.
If the mother must leave before completing the treatment:

 Show her how to prepare Sugar Salt Solution at home
 Show her how much Sugar Salt Solution to give to finish Plan B treatment at home
 If available give 2 packets ORS sachets to prepare and give at home.
 Explain to caregiver the reason for giving oral rehydration therapy and what it does
 Explain the 3 Rules of Home treatment:
1. Give extra fluid - See Plan A for recommended fluids
2. Continue feeding and COUNSEL the mother
3. When to return
40
Plan C: Treat Severe Dehydration Quickly
Start intravenous fluid immediately:
 Amount of fluid: 30 ml per kg body weight in 1 hour
 Type of fluid: ½ strength Darrow’s solution in 2.5% dextrose iv
 OR Ringers lactate iv
 OR if above unavailable 0.9% sodium chloride solution iv
 If the child can drink, give oral rehydration therapy while the infusion is being set up (about
5mls per kg body weight per hour).
 Caution if child malnourished or is a neonate
Reassess after one hour

If response good (Good response: child regaining consciousness and
radial pulses easily palpable or child passing good quantity of urine)
Response may be poor if child is hypoglycaemic
 Continue intravenous fluid at 10ml per kg body weight per hour for next 7 hours
 Give oral rehydration therapy (about 5mls per kg body weight per hour) as soon as the
child can drink
If response poor (Poor response: child remains unconscious or radial
pulses weak or undetectable and no urine passed)
 Repeat 30 ml per kg body weight in next hour
 Then continue intravenous fluid at 10 ml per kg body weight per hour for next 4 hours
 Continue to assess hydration status and general condition hourly
If intravenous fluid cannot be started, give by nasogastric tube

while awaiting referral
 Give 20ml per kg body weight per hour for 6 hours
 Reassess hourly: if there is repeated vomiting or abdominal distension, give fluid
more slowly
Refer urgently to hospital.

Reassess hydration status 6 hours after starting fluids
 If no signs of dehydration Plan A
 If still some signs of dehydration Plan B remaining in health facility
 If signs of severe dehydration  Plan C and refer urgently to hospital
 Begin feeding the child if not already doing so
Child should be referred urgently to hospital if at any time

assessment shows poor response.
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Persistent diarrhoea
 Severe persistent diarrhoea is diarrhoea lasting 14days or more
and dehydrated. Start rehydration and refer to hospital.
 Persistent diarrhoea is diarrhoea lasting more than 14days or
more but no dehydration. Advise on feeding (below), give vitamin
A, and follow up in 5days.
General notes: persistent diarrhoea
 if breastfeeding, give more frequent, longer breast feeds, day and
night
 milk feeds should be mixed with maize meal porridge to reduce the
concentration of lactose
 sour milk is better tolerated than fresh milk
 give fermented porridge if available
 foods rich in vitamin A, folic acid and zinc should be given – liver,
kidney, dark green vegetables, fish, beans, groundnuts, breast
milk, or vitamin supplements.
Indications for antibiotics in diarrhoea:

Bloody diarrhoea, cramps and fever (dysentery):
 First line:
nalidixic acid po B V 4-<10kg = 125mg 4 5 days
>10kg = 250mg times
5 –12yrs = 375mg a day
or ciprofloxacin po B V 5-17yrs 20mg/kg Twice 3 days
(max a day
1.5gm/day
 Follow up after 2 days.

 Second line (intestinal amoebiasis):
metronidazole po C V 10mg/kg 3 times a 5 days
day
Cholera:
CASE DEFINITION: rice watery diarrhoea, with or without vomiting,
causing severe dehydration or death
In suspected cases notify the Provincial Medical Director immediately,
and obtain current cholera guidelines. See also the chapter on
gastrointestinal conditions.
 Rehydration is most important. The mainstay of cholera
management is rehydration, intravenously or orally.
 The use of antibiotics is strictly limited to very few indications such
as: (i) severe dehydration (ii) high attack rate within a household or
42
congregate settings (iii) as prophylaxis in (ii). Start antibiotics after
the patient is rehydrated and vomiting has stopped – usually after
4-6hrs.
 Always confirm recommended medicines for the outbreak
ciprofloxacin po B V 20mg/kg Twice a day 3 days
Or azithromycin po C V 20mg/kg Single dose
Composition of fluids
Sugar Salt Solution (SSS)
 6 level teaspoons of any household sugar (white or brown),
 ½ level teaspoon of salt (coarse salt may have to be ground fine),
dissolved in
 1000ml of clean water measured in any 1000ml bottle (soft drink, oil
etc). [The water is boiled only if from a contaminated source and is
cooled before adding ingredients.]
‘Home fluids’
Any fluids including water, tea, thin porridge, ‘mahewu’, but
avoiding cold drinks with high sugar content.
Oral Rehydration Solution: Full Formula has now
been replaced with low osmolarity ORS formula.
It has low levels of glucose and salt to achieve osmolarity of
245mOsm/L resulting in improved efficacy and decreased stool output.
It is safe and effective even in children with cholera.
Made in hospital pharmacies as follows:
Low osmolarity ORS

ingredient weight
*Trisodium citrate
sodium chloride 2.6 dihydrate may be
trisodium citrate dihydrate* 2.9g replaced by sodium
potassium chloride 1.5g bicarbonate 2.5
glucose, anhydrous 13.5 grams/litre.
Water to 1 litre
However, ORS may be available in packets (sachets) in certain

situations according to current ministry policy.
Give Zinc sulphate 20mg/day for 10-14days with every bout of
diarrhoea. Give 10mg/day in infants below 6 months.
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Acute malnutrition
(Marasmus and Kwashiorkor)
Growth monitoring
Regular weight and height measurements during growth monitoring are
very important to assess the nutritional status of each child.
Growth faltering
Refers to a child whose weight remains static or is going down on 3
consecutive monthly weighing.
Low-weight-for-age refers to the weight for age below -2 SD on child
health card.
 Counselling of the mother should start from the time loss of
weight or static weight is identified.
 If no improvement by the third consecutive month, the child should
be referred.
 Check for malnutrition and anaemia – see chart below.
Table 3.9: Classification of acute, moderate and severe malnutrition in

children
Age Group Measurement Classification
Index
Severe Acute Moderate Acute
Malnutrition Malnutrition
Children Less Classify severe if presence of any of the following:
than 6 Months
 Bilateral pitting oedema
 Weight for Length ≤ SD (WHO)
 Infant too weak or feeble to suckle effectively
 Mother reports breastfeeding failure AND infant is not
gaining weight at home
Children 6 to Weight for Height ≤3 SD (WHO) ≤2 & ≥3 SD (WHO)
59 Months (W/H)
Mid-upper Arm <115 mm ≥ 115 mm&<125 mm

Circumference
(MUAC)
Bilateral Pitting Yes No

Oedema
Children and Body Mass Index ≤3 SD (WHO) OR ≤2 & ≥3 SD (WHO)

Adolescents (5 (BMI) for Age visible wasting
to 18 Years ) Bilateral pitting Yes No
oedema
44
Acute malnutrition and complications( See latest National
Protocols)
Patients with severe or moderate acute malnutrition AND complications
should be admitted for inpatient care. Complications should be
managed according to national protocols for different age groups.
Routine Medicines to Accompany Inpatient Therapeutic

Feeding
Provide routine medicines in both Phases I and II per national protocol

as appropriate for age and complications of patient.
Treatment of hypoglycemia in Severe Acute Malnutrition
Hypoglycemia and hypothermia usually occur together and are signs of

infection. Check for hypoglycemia whenever hypothermia
(axillary<35.0oC; rectal<35.5oC) is found. Frequent feeding is important
in preventing both conditions.
If the child is conscious and has hypogylcemia give:
Medicine Codes Child Dose Frequency Duration

10% glucose C E 50ml bolus Once
solution
Or 10% sucrose
solution
Then F-75 C E 3ml/kg/Feed Every 30 2 hours
minutes
11ml/kg/Feed 2 hourly 2 days
The glucose or sucrose solution (1 rounded teaspoon of sugar in 3.5

tablespoons water), can be given orally or by nasogastric (NG) tube. If
the child is unconscious, lethargic or convulsing give IV sterile 10%
glucose (5ml/kg), followed by 50ml of 10% glucose or sucrose by Ng
tube. Then give starter F-75.
Treatment of Infection in Severe malnourished children
The usual signs of infection, such as fever, and infections are often
absent in severe malnutrition. Therefore, presume infection in severe
malnutrition and give routinely broad-spectrum antibiotic(s) AND
measles vaccine if child is > 6months and not immunized (delay if the
child is in shock).
45
EDLIZ 2015
1. If the child has no complications, give cotrimoxazole paediatric

suspension orally or amoxicillin
Cotrimoxazole C E BW >4kg 5ml Twice daily 5 days
BW<4kg 2.5ml
or Amoxicillin C E 15mg/kg 8 hourly 5 days
2. If the child is severely ill (apathetic, lethargic) or has complications

(hypoglycaemia, hypothermia, raw skin/fissures, respiratory tract or
urinary tract infection) give IV/IM ampicillin AND gentamicin.
 If seriously unwell give benzylpenicillin and gentamicin or

kanamycin. If condition less severe, consider oral broad-spectrum
antibiotics (cotrimoxazole or amoxicillin).
Child
Medicine Codes Dose Duration
Frequency
/(kg/feed)
Ampicillin IM/IV C V 50mg/kg 6 hourly 2 days
then Amoxicillin po* C V 15mg/kg 8 hourly 5 days
and Gentamicin im/iv C V 7.5mg/kg Once daily 7 days
If the child fails to improve after 48 hours
Chloramphenicol
ADD B V 25mg/kg 8 hourly 5 days
IM/IV
If the child has chronic diarrhoea
Metronidazole
ADD C V 7.5mg/kg 8 hourly 7 days
po
* If amoxicillin is not available continue with ampicillin but give orally 50mg/kg
every 6 hours
NOTE: Avoid steroids as these depress immune function.

For parasitic worms, give albendazole.
Treatment of dehydration in Severe Malnourished Children

Severe acute malnourished children with profuse watery diarrhoea and
signs such as sunken eyes, slow skin pinch, absent tears, dry mouth,
very thirsty, reduced urine output, rapid pulse and respirations. These
should be considered as severely dehydrated.
Do not use the IV route for rehydration except in cases of shock and
then do so with care, infusing slowly to avoid flooding the circulation
and overloading the heart. Do not give standard oral rehydration salts
solution (90 mmol sodium/l) to severely malnourished children as it
46
contains too much sodium and too little potassium. Give special
Rehydration Solution for Malnutrition (ReSoMal).
/(kg/feed)
ReSoMal C E 5ml/kg Every 30 minutes 2 hours
Then 5 -10ml/kg/hr Determined by stool 4 -10hrs
loss , vomiting and
how much the child
wants,
Replace the ReSoMal doses at 4, 6, 8 and 10 hours with F-75 if

rehydration is continuing at these times, then continue feeding with F-75
When ReSoMal is not available prepare as follows:

Ingredient Amount
Water (boiled & cooled) 2 litres
WHO-ORS One 1 litre-packet*
Sugar 50 g
Combined Vitamin and Mineral mix 3g
(CMV)*
If CMV* is not available, Electrolyte/mineral solution can be prepared as

follows:
Quantity grams molar content of 20
ml
Potassium Chloride: KCl 224 24 mmol
Tripotassium Citrate: C6H5K3O7.H2O 81 2 mmol
Magnesium Chloride: MgCl2.6H2O 76 3 mmol
Zinc Acetate: Zn(CH3COO)2.2H20 8.2 300 μmol
Copper Sulphate: CuSO4.5H2O 1.4 45 μmol
Water: Make up to 2500 ml
Weigh the ingredients and make up to 2500 ml. Add 20 ml of

electrolyte/mineral solution to 1000 ml of milk feed. Aadd selenium if
available (sodium selenate 0.028 g, NaSeO4 10H20) and iodine
(potassium iodide 0.012g, KI) per 2500 ml.
Vitamin and mineral therapy supplementation in severe acute

malnutrition:
vitamin A po C V <6mnths 50,000iu once at the clinic and
6– 12mths 100,000iu one dose at home -2
1-5yr 200,000iu doses only
and ferrous sulphate po C E 4-<6kg 6mg Fe once a 14 days
47
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6 - <10kg 12mg day

1-3yrs 18mg
3-5yrs 24mg
and folic acid po C E <6kg 2.5mg once a 14 days
>6kg 5mg day
and albendazole po C E ≥2 years 400 mg Single On
dose discharge
from SC/
direct
admission
to OTP
Ferrous sulphate suspension has 12mg Fe/5mL
Vitamins and Electrolytes

multivitamin syrup po B E 5-10ml Daily 1 month
and folic acid po C E 5mg weekly 3 months
and vitamin A po C V <6mths 50,000 iu once at the clinic
6– 12mths 100,000 iu and one dose at
1-5yr 200,000 iu
home -2 doses
only
 In all kwashiorkor and marasmic-kwashiorkor children give:

electrolyte mixture po* B - 1ml/kg
4 times until no
or potassium chloride B - 1-2mmol/ kg a day oedema
mixture po
Nutritional rehabilitation
(at the referral level)
General guidelines:
 Keep malnourished children in a special area where they can be
constantly monitored.
 Malnourished children should be isolated from other patients
because they are very susceptible to infection,
 Try not to separate the caregiver from the child; they should share a
bed where possible.
 Keep the child in a warm environment. Properly cover the child
with clothes, including a hat, and blankets. The child must be dried
48
immediately and properly after bathing. Bath time should be
minimal and, done during the day.
 Attempt to incorporate an educational message into each
intervention.
 Intravenous infusions should be avoided except when essential,
as for severe dehydration with shock or septic shock.
 Intramuscular injections should be given with care in the thigh, using
the smallest possible gauge needle and volume of fluid.
 The room temperature should be kept at 28-32 degrees Celsius.
This will seem uncomfortably warm for active, fully clothed staff, but
is necessary for small, immobile children who easily become
hypothermic.
 Those children who do not need emergency treatment for
complications should be admitted directly to outpatient therapeutic
programme (OTP) and started on Ready to Use (RTU) feed e.g.
plumpy nut, as soon as possible.(refer to nutrition guidelines)
Therapeutic Feeding
The therapeutic diet for malnourished children consists of two formulas,
F-75 and F-100 or Ready to use Therapeutic Food (RUTF). F-75 (75
kcal/100 ml), is used during the initial phase of treatment, while F-100
or RUTF (100 kcal/100 ml) is used during the rehabilitation phase, after
the appetite has returned.
Table 3.9 Inpatient Therapeutic Feeding Recommendations (Phase

1)
Phase 1 (Stabilization care)
Age Group Product and Prescription
 Give Diluted F-100 at 130 ml/kg of body weight per day

Children <6
Months  Breastfed children should always be offered breast milk
before the therapeutic milk, and always on demand
 Give F-75 at 130 ml per kg of body weight per day until the
patient re-gains appetite.
Children 6 to  Start with 2 hourly feeds (12 feeds per day), and gradually
59 Months decrease the frequency of feeding and increase the volume
of each feed until the patient is getting 3-hourly feeds (8
feeds per day)
49
EDLIZ 2015
In the stabilization phase give F75 formula as above. These provide

130ml/kg/day. If there is oedema, reduce the volume to 100 ml/kg/day.
Give F-75 from a cup or from a spoon, dropper or syringe if the child is
very weak feed. If the appetite is poor, coax and encourage the patient
to finish the feed. If intake does not reach 105ml /kg/day despite
frequent feeds, coaxing and re-offering, use a nasogastric tube. If the
child is breastfed, encourage continued breastfeeding but also give
prescribed amounts of F75 to make sure the child’s needs are met.
Transfer to F100 formula as soon as appetite has returned (usually
within 7days) and oedema has subsided.
Table 3.10 Inpatient Therapeutic Feeding Recommendations

(Phase 2)
Phase 2 (Transition and Rehabilitation)
Age Group Product and Prescription
Children <6  Give twice the volume offered during phase I

Months
 Replace F75 with F-100 at 150ml per kg of body weight per

day
Children 6
 Gradually introduce RUTF in small amounts until the child
to 59
can consume ¾ Sachet per day
Months
 When accepted, provide RUTF at 130kcal per kg of body
weight per day
In the rehabilitation phase a vigorous approach to feeding is required to

achieve very high intakes and rapid weight gain of >10 g gain/kg/d. The
recommended milk-based F-100 contains 100 kcal and 2.9 g
protein/100 ml. Readiness to enter the rehabilitation phase is signalled
by a return of appetite, usually about one week after admission. A
gradual transition is recommended to avoid the risk of heart failure
which can occur if children suddenly consume huge amounts.
To change from F75 to F100 formula replace F-75 with the same
amount of F- 100 for 48 hours then, increase each successive feed by
10 ml until some feed remains uneaten. The point when some remains
unconsumed is likely to occur when intakes reach about 30 ml/kg/feed
(200 ml/kg/d). F-100 can be replaced by an alternative Ready-to-use
therapeutic food (RUTF) once the appetite has returned.
If commercial formulas F75 and F100 are not available,
prepare as follows. DO NOT USE HIGH ENERGY MILK.
50
Amount
Ingredient
F-75 F-100
Fresh Cow’s Milk 300ml 900ml
Sugar 100g 50g
Vegetable oil 20ml 25ml
Vitamin & Mineral mix (CMV) 3g(½ scoop) 3g(½ scoop)
Add Water to make 1000ml 1000ml
For alternate ingredients refer to Protocol for management of acute

malnutrition
Home management
 Regularly monitor child’s weight: For children less than 1year old
monitor weight every month and for those 1year and above, check
weight every 2 months.
 Encourage exclusive breastfeeding up to 6 months (no additional
fluids/foods), introducing other foods in addition to breast milk at 6
months, breastfeeding up to two years. For young children,
continue breastfeeding on demand.
 RUTF is a food and medicine for children with Kwashiorkor or
Marasmus only. It should not be shared.
 Children with Kwashiorkor or Marasmus often do not like to eat.
Give small regular meals of RUTF and encourage the child to eat
often (if possible eight meals a day).
 Always offer the child plenty of cooled, boiled water to drink while
he or she is eating RUTF.
 Keep food clean and covered. Hygienic food handling and
preparation. Use soap for children’s hands and face before
feeding. Wash hands with soap and water after visiting the toilet.
 Children with Kwashiorkor or Marasmus get cold quickly. Always
keep the child covered and warm.
 When a child has diarrhoea, never stop feeding. Give extra food
and extra clean water.
As soon as the child gets better, introduce the fortified, family

type diet.
51
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Anaemia:
Test and treat for Hookworm (see Tropical Diseases) After
recovery from the acute state treat with ferrous sulphate.
albendazole po C E <2yrs 200mg one dose only
>2yrs 400mg
And ferrous sulphate po C E 6 - <10kg 12mg once a 30 days
1-3yrs 18mg day
3-5yrs 24mg
Treatment of Severe anaemia

Children with severe anaemia should be treated with daily iron and folic
acid supplementation. After completing 3 months of therapeutic
supplementation, children should continue preventive supplementation
regimen. Children with kwashiorkor or marasmus should be assumed
to be severely anemic. However, oral iron supplementation should be
delayed until the child regains appetite and starts gaining weight,
usually after 14 days.
52
Paediatric HIV infection
See Latest National Guidelines on Antiretroviral Therapy.Also refer to
Chapters 8 and 9 here.
Paediatric HIV infection can be significantly reduced by implementing
an effective PMTCT program. Symptomatic HIV infection may be
difficult to distinguish from other childhood conditions such as
respiratory infections, diarrhoea and malnutrition. Suspect HIV related
disease if two or more of the following signs are present:
 severe or recurrent pneumonia
 generalised lymphadenopathy
 hepato-splenomegaly
 failure to thrive
 severe/recurrent oro-pharyngeal candidiasis.
 finger clubbing
In the majority of cases, the route of transmission is from mother to
child. Ensure pre-test counselling of parents/caregivers before testing
the child for HIV infection. Antibody detection tests are not diagnostic of
true infection before 18 months due to persistence of maternal
antibodies in the child. Prior to the age of 18 months, a DNA
polymerase chain reaction (PCR) test for HIV is now being used i.e.
DBS testing.
General Guidelines for HIV care in children

 Nutrition: advise the caregiver on high calorie diet and other
essential nutrients for the child. Safe food and water practices
 Hydration: oral rehydration, together with dietary advice is most
important in the management of persistent diarrhoea. Intravenous
fluids may be needed during severe diarrhoeal episodes.
 Immunisation: BCG should be given to all children at birth.
Immunisation is contraindicated only where there is symptomatic
HIV infection. The current recommendation is to give the other live
vaccines, measles and oral poliomyelitis vaccine even in immune-
compromised children. [See chapter on Immunisation.]
 Home care: is preferable to hospital admission for chronic care.
 Counselling: the family will require support in facing the emotional
and financial demands of the child’s chronic ill health as well as
those arising from the parents’ own HIV status. Facilitate access to
OI clinics.
53
EDLIZ 2015
Management of Specific HIV related Conditions
Bacterial infections
In the HIV infected child infections are likely to be more frequent, of
longer duration with a poorer response to treatment. Septicaemia,
meningitis, pneumonia and abscesses frequently occur before any
other features of HIV infection are evident. The causative organisms,
however, are likely to be similar to those found in non-HIV-infected
children and the standard guidelines on the choice of antibiotics apply.
(However, in a child with severe pneumonia where Pneumocystis
jiroveci pneumonia (PCP) is suspected, a course of high dose
cotrimoxazole (60mg/kg every 8hrs) is indicated.
Once a child is diagnosed as having HIV-related pneumonia
cotrimoxazole prophylaxis should be commenced:

cotrimoxazole po C V < 6mths = 120mg once a for life
6-12mths = 240mg day
>1 year = 480mg
There is an increased risk of tuberculosis infection in the HIV infected

child. Where TB is confirmed, or with a diagnosis of probable TB, use
the anti-TB treatment regimens recommended in the Chapter on
Tuberculosis.
Recurrent/ persistent diarrhoea: current evidence suggests that no
single pathogen is responsible for the persistence of episodes of
diarrhoea (>14 days). Follow the diarrhoea management guidelines in
the section on diarrhoea.
Chronic otitis media, oral candidiasis, eczema/ papular rash, and
anaemia, may be related to HIV infection but are managed according to
standard guidelines.
Lymphocytic interstitial pneumonitis (LIP) is more commonly seen,
presenting after the first year of life. Short term steroids have been used
with good effect in children with severe respiratory symptoms. Give first
dose of antibiotic (see management of pneumonia) and refer for
specialist diagnosis.
54
CHAPTER 2
Table 3.11 Dose by age and weight for commonly used medicine:
benzylpenicillin Gentamicin cotrimoxazole paracetamol amoxicillin procaine
0.05-0.1MU/kg 7.5mg/kg 10mg/kg 16mg/kg penicillin
Age Weight
6 hourly 12hourly 12hourly 6hourly 8 hourly 50mg/kg once
daily
5MU (3gm) vial of 1gm vial of syrup of syrup of syrup of 300mg/ml
500mg/ml 250mg/ml 200mg+40mg 120mg/5ml *use 125mg/5ml - use injection
[add 6ml water to [add 4ml water to per 5ml nearest 2.5ml vol nearest 2.5ml vol
5MU vial] 1gm vial]
2-4 months 4 - <6kg 0.3MU (0.4ml) 40mg (0.16ml) 100/20mg (2.5ml) 50mg (2.5ml) 62.5mg (2.5ml)
4-9 months 6 - <10kg 0.4MU (0.5ml) 50mg (0.2ml) 200/40mg (5ml) 100mg (3-5ml) 125mg (5ml)
9- 10 <12kg 0.5MU (0.6ml) 75mg (0.3ml) 200/40mg (5ml) 120mg (5ml) 125mg (5ml) 150mg (0.5ml)
12months -
1-3 years 12 <14kg 0.7MU (0.8ml) 100mg (0.4ml) 300/60mg (7.5ml) 120mg (5-7ml) 300mg (1.0ml)
-
3-5 years 0.8MU (1.0ml) 125mg (0.5ml) 300/60mg (7.5ml) 250mg (10ml) 250mg (10ml) 450mg (1.5ml)
5-12 years 1MU (1.2ml) 200mg (0.8ml) 400/80mg (10ml) 375mg (15ml) 375mg (15ml) 600mg (2.0ml)
PAEDIATRIC CONDITIONS
55
EDLIZ 2015
Paediatric Medicines Doses

Notes on Paediatric Medicines Doses:
 for infants under one month see Tables 3.1,3.2 and 3.3;
 read the “dosage” column carefully in conjunction with the
“doses/day” column;
 do not exceed the adult dose: the dosage per kg is not applicable for
children > 40kg;
 For antibiotics, the number of doses/day should be chosen
according to both the baby’s gestational age and postnatal age.
Do not exceed the frequency recommended in the table.
Table 3.12 Dosages for Children and Infants Over 2 Months
Medicine Route Dose Frequ

ency
Acetylcysteine Iv 150mg/kg over 15mins -
200mg/ml injection then 50mg/kg over 4hours
then 100mg/kg over 16hours
Adrenaline 1:1000 Sc 0.01ml/kg, repeat after 20mins -
1 mg/ml injection Im 0.3 to 0.5ml IM
Aminophylline Iv Loading: 6mg/kg over 30mins -
25mg/ml injection Po
Amoxicillin Po 16mg/kg 8hrly
125mg/5ml syrup
Ampicillin im/ iv mild 12.5 mg/kg 6hrly
500mg injection severe 25mg/kg
Atropine sulphate Im Pre-operatively 0.02mg/kg -
0,6mg/ml injection
Benzylpenicillin iv/ im 50 000 – 100 000u/kg 6hrly
3 g injection = 5MU (0.05 –0.1MU/kg)
Chloramphenicol iv/ mild 12.5mg 6hrly
1g injection; 125mg/5ml syr im/po severe (meningitis) 25mg/kg
Chlorpromazine iv/ 0.75mg /kg 4 times
25mg/ml injection 50mg/5ml im/po a day
syrup
Clindamycin po /im mild 4mg/kg 6hrly
75mg/5ml syrup; 250mg severe 10mg/kg
capsule; 1g injection
Cloxacillin iv/ 12.5 to 25mg/kg 6hrly
125mg/5ml syrup; 250mg im/po
capsule; 0.5g injection
56
Table 3.13 Dosages for Children and Infants Over 2 Months: [contd.]
ency
Codeine Phosphate O 0.4mg/kg 6hrly
30mg tab (>1yr = 0.75mg/kg)
Cotrimoxazole Po normal dose 30mg/kg 12hrly
120mg tab; 480mg tab; high dose 60mg/kg 8hrly
240mg/5ml syrup
Diazepam iv/ pr/ 0.2 to 0.5 mg/kg/24 hours Var
5mg/ml injection po
Digoxin Po initial 0.01mg (10mcg)/kg 8hrly
62,5mcg tab / 50mcg/ml elixir for 3
doses
maintenance 0.005mg 12hrly
(5mcg)/kg
Erythromycin Po 6.25 to 12.5mg/kg 6hrly
125mg/5ml syrup
Ethambutol Po 15mg/kg once a
400mg tab day
Ferrous Sulphate Po 2mg iron /kg 3 times
60mg iron tab / a day
12mg iron/5ml syrup
Folic acid Po 1 to 2mg/kg once a
5 mg day
Frusemide im/ iv O.5mg to 1mg/kg once a
10mg/ml injection; 40 mg tab po 1 to 3mg/kg day
Gentamicin iv/ im 7.5 mg/kg once a
20mg/ml injection; 40mg/ml day
Griseofulvin Po 5mg /kg 12hrly
125 mg tab; 500mg tab
Hydrochlorothiazide Po 0.5mg /kg 12
25mg tablet hourly
Hydrocortisone Iv 100 to 200 mg/dose depending -
100mg injection on indication
Isoniazid Po 10 to 20mg/kg once a
100mg tab; 50 mg/5ml syrup day
Kanamycin Im 7.5mg/kg 12hrly
1g injection
Ketoconazole Po 5 to 10mg/kg once a
200mg tab;100 mg/5ml day
Metronidazole pr / iv severe anaerobic inf. 7.5mg/kg
200mg tab / 1gm suppository Po intestinal amoebiasis 10mg /kg 8hrly
5mg/ml inj
Po giardiasis 5mg/kg
Morphine Sulphate im/o Up to 0.25mg/kg per dose -
15mg/ml injection;
5mg/5ml syrup
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Table 3.14 Dosages for Children and Infants Over 2 Months: [contd.]
ency
Nitrofurantoin Po 1.5 mg/kg (age >3mnth) 4 times
50mg tab a day
Paracetamol Po 10mg/kg 6hrly
125 mg tab; 500mg tab;
120mg/5ml syrup
Penicillin V Po 12.5mg/kg 6hrly
125mg/5ml syrup; 250mg
tablet
Pethidine iv/ im/o 1mg/kg not
50mg/ml injection less
than
4hrly
Phenobarbitone iv/im/ 5mg/kg once at
30mg tab; 15mg/5ml mixture; po night
200mg/ml inj.
Prednisolone Po 1 to 2 mg/kg once a
5mg tab scored day
Procaine penicillin Im 50mg/kg once a
300mg/ml injection day
Promethazine Po /im 0.3mg/kg 3 times
25mg tab; 5mg/ml syrup; a day
25mg/ml injection
Propanolol Po /im 1mg/kg 3 times
40mg tab a day
Ranitidine Po 1-6 months 1mg/kg 3 times
150mg tab 6m-3yrs 2-4mg/kg 2 times
a day
3-12yrs 2-4 mg/kg (up to 5mk/kg 2 times
max 300mg) a day
Rifampicin Po 10 to 20mg/kg Daily
300mg cap, 100mg/5ml
syrup
Salbutamol Neb nebulised 2.5mg in 2mls saline -
4mg tab; 2m/5ml syrup; po/ inh. maintenance 0.1mg/kg 3 times
5mg/ml solution; 100mcg a day
dose inhaler
Streptomycin Im 20mg/kg Daily
5 g injection
Theophylline Po 5mg/kg (max 4 doses/ 24hrs) 6hrly
200mg tab, 60mg/5ml syrup (age > 6 months)
Thyroxine sodium Po 10 to 50mcg/kg once a
100microgram tab day
58
IMMUNISATION
GENERAL NOTES 60
ADVERSE EVENTS 60
IMMUNISATION SCHEDULE FOR CHILDREN 61
TETANUS IMMUNISATIONS FOR ADULTS 64
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General Notes
The terms immunisation and vaccination will be used interchangeably
in this chapter. Further information on immunisation, the cold chain
etc, may be found in the Manual for the Zimbabwe Expanded
Programme on Immunisation (ZEPI). Information relating to rabies
can be found in the chapter on tropical diseases.
Adverse events
 All adverse events following immunisation should be reported
using the ‘Adverse Events Following Immunisation’ (AEFI)
form. Health workers should refer to the ZEPI AEFI guidelines
and Standard Operating Procedures.
Diseases Preventable by Immunisation

 Diphtheria
 Measles
 Rubella
 Hepatitis B
 Pertussis (whooping cough)
 Poliomyelitis
 Rabies
 Tetanus
 Tuberculosis
 Some pneumonias, septicaemia and meningitis (caused by
Haemophilus Influenza type B and Streptococcus
pneumoniae)
 Diarrhoea, vomiting and systematic upset due to Rotavirus
infection.
 Cancer caused by Human Papilloma Virus infection.
Open vial policy

 Open vials of DPT, DPT-HepB-Hib (Pentavalent), DT, TT,
OPV, HPV and HepB may be used in subsequent sessions for
a maximum of 28 days (ZEPI Policy) provided the vaccine has
not expired, the VVM has not reached the discard point, the
vial has not been contaminated, the vaccine has been kept in
appropriate cold chain condition.
 Reconstituted vials of measles, BCG and HPV vaccines must
be discarded as per manufacturer’s instructions or at the end
of the session whichever comes first.
Effectiveness of Vaccines in HIV Infected Individuals

EPI recommended vaccines have shown satisfactory sero-
conversion rates in early stages of HIV infection. However the
60
proportion of responders decreases with progression from HIV
infection to AIDS.
 Children with known or asymptomatic HIV infection
should receive all EPI vaccines according to the
schedule.
 BCG vaccine should not be given to children with clinical
symptoms of HIV infection.
IMMUNISATION SCHEDULE FOR CHILDREN
See Table 4.1. This schedule is the only schedule to be used in

Zimbabwe. Ages given are minimum ages for each vaccination.
Children should receive doses at these stated ages or at the first
contact after reaching that age (maximum age limits are: BCG 11
months, Rotavirus 32 weeks, and Pentavalent 23 months).
 Always check the dosage instructions in the manufacturer’s
information supplied with the vaccine, as the strength may vary
between manufacturers.
 Always remember to record the batch number of the vaccine
on the child’s health card when entering the date of
immunisation.
 Always ensure that the emergency box is available and is
stocked with appropriate emergency medicines.
Table 4.1: Immunisation schedule by age

Name of Age of Route Site Dosage
Vaccine administrati
on
BCG At birth or Intrader Insertion 0,05 ml
first contact mal of right
before one deltoid
year muscle
OPV1 6 weeks Oral Oral 2-3 drops
DPT- 6 weeks Intramu Right 0,5 ml
HepB- scular anterolater
Hib1 al aspect
of mid-
thigh
61
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Name of Age of Route Site Dosag

Vaccine admin e
istrati
on
Pneumococc 6 Intramuscular Left 0,5 ml
al 1 weeks anterolater
al aspect
of mid-
thigh
Rotavirus 1 6 Oral Oral 1,5 ml
weeks
OPV2 10 Oral Oral 2-3
weeks drops
DPT-HepB- 10 Intramuscular Right 0,5 ml
Hib2 weeks anterolater
al aspect
of mid-
thigh
al aspect
of mid-
thigh
Inactivated 14 Intramuscular 2,5cm
Polio weeks from PCV
vaccine site
OPV3 14 Oral Oral 2-3
weeks drops
DPT-HepB- 14 Intramuscular Right 0,5 ml
Hib3 weeks anterolater
al aspect
of mid-
thigh
al aspect
of mid-
thigh
Measles 9 Subcutaneous Left 0,5 ml
and month deltoid
Rubella 1 s muscle
(MR)
62
Name of Age of Route Site Dosage
Vaccine adminis
tration
Measles and 18 Subcutaneous Left 0.5ml
Rubella 2 months deltoid
(MR) muscle
DPT Booster 18 Intramuscular anterolat 0,5 ml
months eral
aspect of
mid-
thigh
OPV 18 Oral Oral 2-3
Booster months drops
NB:
 IPV and MR vaccines will be introduced in 2015
 MR second dose at 18 months will be introduced in 2015
 HPV Vaccine Demonstration runs 2014/15 in Marondera and
Beitbridge for 10 year olds with full national scale up to 9-13
year old girls planned for 2016
 IPV is administered about 2,5cm from PCV site.
 All vaccines should be kept at temperatures of +2°C to +8°C.
 EPI Unit shall update all service providers on new trends
regarding vaccines.
Integrating Routine Immunization with other Interventions

A strategy commonly known as EPI plus provides a platform for
delivery of other health interventions such as Vitamin A
supplementation, deworming, distribution of Insecticide Treated
Nets for malaria prevention and early infant diagnosis (DBS) of
HIV infection. Currently ZEPI has integrated vitamin A
supplementation into the routine EPI program. Any immunization
contact is an opportunity to screen mothers and infants for
eligibility to receive Vitamin A.
Table 4.2: Vitamin A schedule (Every six (6) months)
Target for Immunization Vitamin A
Vitamin A contact dose
Routine Immunization
Infants 6 – 11
Measles/Polio 100 000IU
months
NIDs/Campaigns
Routine Immunization
Children 12 – 59
Measles/Polio 200 000 IU
months
NIDs/Campaigns
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Tetanus Immunisations for Adults

An adult woman with a complete course of childhood immunisations
including boosters should need only one booster dose of tetanus
toxoid vaccine, (recommended at first pregnancy) which should
protect for life.
Table 4.3 Tetanus Immunisation
TT Minimum interval Protection
TT 1 At first contact with a person of > 15 None or uncertain
years or at first ANC visit
TT 2 At least 28 days after TT 1 3 years
TT 3 At least 6 months after TT 2 5 years
TT 4 At least 1 year after TT 3 10 years
TT 5 At least 1 year after TT 4 Lifelong
For any adult with incomplete course, see Table 4.4.
Table 4.4 Catch up – tetanus
Doses received as a child Doses needed as an adult
No DPT immunisation 5 dose according to schedule (Table
4.3)
3 primary course DPT 2 doses one month apart plus 1 dose
one year later. In pregnancy TT3 to be
given at least 6months after TT2.
3 primary course DPT + 1 booster DPT 2 doses one year apart
(18 months)
3 primary course DPT + 1 DPT booster 1 dose
+ 1 DT booster (5 years)
NB: WHO has recommended that countries switch from tetanus

toxoid containing vaccines (TT) to tetanus-diptheria vaccine (Td),
but Zimbabwe has not adopted this policy yet.
Immunisation details for available vaccines

 Always check the dosage instructions in the manufacturer’s
information supplied with the vaccine as strengths may vary.
 In the event of a measles epidemic, children between 6 and 9
months can be vaccinated. However the measles vaccination
must be repeated again after 9 months and another dose at 18
months.
 The minimum interval for HB2 and HB3 is 5 months, if given as
a mono dose.
CONTRAINDICATIONS TO VACCINATIONS
There are very few absolute contraindications to vaccines. .
Fever, diarrhoea, mild respiratory infection and malnutrition
are not contraindications to vaccines.
64
 BCG vaccine should not be given to a child with symptomatic
HIV infection but polio and measles/rubella vaccines should be
given to children with HIV and AIDS together with other
vaccines.
 A second or third dose of Pentavalent and DTP at 18 months
should not be given to a child who severely reacted to a
previous dose of Pentavalent (Note DTP because of the whole
cell Pertussis may cause severe anaphylaxis, collapse, or
convulsions). DT should be given instead.
 A child with an evolving neurological disease such as
uncontrolled epilepsy or progressive encephalopathy should
not be given Pentavalent or DTP. Give DT instead.
NB: The current DPT contains whole cell pertussis.
INTERVAL BETWEEN MULTI-DOSES OF THE SAME
ANTIGEN
 The minimum interval between doses is 28 days.
 If any dose of an antigen for subsequent doses is delayed,
vaccinations on the next attendance should be continued as if
the usual interval had elapsed (i.e. 4 weeks have elapsed).
All the EPI antigens are safe and effective when administered
simultaneously i.e. during the same vaccination session but on
different sites. Pentavalent, Pneumococcal, Rotavirus, IPV
and OPV are given simultaneously.
 If a vaccine dose is given at less than the recommended 28
days interval, it should not be counted as a valid dose and
therefore should be repeated at the appropriate interval of 28
days from the previous dose. This applies to vaccines given
during campaigns such as child health days, national
immunisation days or in reaction to outbreaks of vaccine
preventable diseases.
HOSPITAL ADMISSION POLICY ON IMMUNISATION

 To reduce nosocomial transmission, Measles vaccine
should be given on admission to all children six months to
15 years. This admission dose must be recorded on the
graph side of the child health card corresponding with the
age at which it was given and written vertically. If the child
is 9 months and receives the first dose on admission this
is charted on the appropriate section of the card.
 Health workers should ascertain the vaccination status for
all admitted children including those without a child health
card and give the appropriate antigens.
 Children who are very ill on admission should be
vaccinated as soon as their condition has improved.
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OBSTETRIC AND GYNAECOLOGICAL

CONDITIONS
GENERAL NOTE: 67
HORMONAL CONTRACEPTION 67
ORAL CONTRACEPTIVES 68
MEDICINES INTERACTIONS WITH ORAL
CONTRACEPTIVES 69
LONG TERM HORMONAL CONTRACEPTIVES 70
EMERGENCY CONTRACEPTION 71
INFECTIONS OF THE GENITO-URINARY TRACT
DURING PREGNANCY 71
POST MISCARRIAGE SEPSIS 72
ACUTE PELVIC INFLAMMATORY DISEASE (PID) 73
PROPHYLAXIS FOR CAESAREAN SECTION 74
NAUSEA AND VOMITING IN PREGNANCY 75
ANAEMIA DURING PREGNANCY 75
CARDIAC DISEASE IN PREGNANCY 76
HYPERTENSION IN PREGNANCY 77
DIABETES IN PREGNANCY 80
ANAESTHESIA, ANALGESIA, ANTACIDS 80
USE OF STEROIDS PRE-TERM LABOUR 81
CERVICAL RIPENERS/ LABOUR INITIATORS
(PROSTAGLANDINS) 81
MYOMETRIAL STIMULANTS (OXYTOCICS) 82
TERMINATION OF PREGNANCY 83
MEDICINES IN PREGNANCY AND LACTATION 85
66
General Note:
Medicines should be avoided if at all possible throughout pregnancy,
and especially during the first trimester. However, medicines may be
required for a number of conditions commonly encountered during
pregnancy; medicines which are appropriate and safe are covered in
the sections that follow. At the end of the chapter is a list of those
medicines which should be avoided or used with caution during
pregnancy or lactation.
Hormonal Contraception
Important: Ensure a free and informed choice by providing
counselling on the advantages and disadvantages of contraceptive
methods. Oral, injectable and implants do not protect against HIV.
For added protection there is need to use a ‘barrier’ contraceptive
such as a male condom, a female condom or diaphragm.
Hormonal contraception only is covered in brief here. Comprehensive
guidelines are provided by the Zimbabwe National Family Planning
Council (ZNFPC); follow these wherever possible. Instructions for
use, contraindications etc, are also found in the manufacturers'
package inserts.
Checklist for those not trained in family planning:

Before prescribing oral contraceptives ask the following questions. If
answers to all these questions are ‘no’, the woman may be given
any oral contraceptives. If any of the answers are ‘yes’, a doctor
must first see her.
 History of severe leg pain or swelling of calf?
 History of sugar in urine?
 History of yellow eyes or skin?
 Severe chest pain?
 Unusual shortness of breath after walking or light work?
 Severe headaches (not relieved by headache tablets)?
 Bleeding between periods or after sexual intercourse?
 Missed a menstrual period?
 Missed a menstrual period, and then started bleeding?
 Very heavy menstrual periods?
 Increased frequency of menstrual periods?
 History of mental disturbances?
 Goitre or history of goitre?
 35 years of age and over?
 Painful varicose veins?
 Had any surgical operation within last 2 weeks?
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 Previous treatment for high blood pressure?

 History of epilepsy?
Oral Contraceptives
IMPORTANT: Instruct the woman to always inform the doctor or
nurse that she is taking oral contraceptives when she attends a clinic
or hospital. Encourage clients to have a check up every two years or
when she develops a problem.
Ensure that the supplies given to the woman allow her to have an
extra pack of pills always available. Also provide a supply of condoms
with the first pack of pills for additional protection if the client is not
menstruating. Encourage use of condoms as well to protect against
STIs especially HIV.
Oral contraceptives fall into two main categories.

Combined oral contraceptives (COCs)
These contain synthetic oestrogen and progestogen. Those with
oestrogen content 30-35 micrograms (as ethinyloestradiol) are ‘low
dose’ while those containing 50 micrograms of oestrogen are
referred to as ‘high dose’. Taken daily they inhibit ovulation.
‘Triphasic pills’ contain phased levels to more closely mimic normal
cyclical hormonal activity.
The lower oestrogen dose pills have fewer side effects than higher
dose pills (notably, reduced risk of thrombo-embolism) while
maintaining a high rate of effectiveness. Menstruation on COCs will
be regular and light.
Progestogen only pills (POPs)

These contain synthetic progestogen e.g. norethisterone or
norgestrel. Progestogens protect against pregnancy by thickening
the cervical mucus. This type is particularly suitable for lactating
mothers.
Menstrual irregularities are a more common side effect.
CAUTION: Progestogen Only Pills have a significant failure rate in
non-lactating women. They should be taken at the same time each day.
Conditions warranting withdrawal of oral contraceptives

 pregnancy or suspected pregnancy
 severe headaches especially associated with visual
disturbances
 numbness or paresis of extremities
 unexplained vaginal bleeding
 suspected or known carcinoma of the breast
 known liver tumour
68
 unexplained chest pain or shortness of breath
 severe leg pains;
 development of any of the absolute contra-indications
mentioned in the manufacturer’s information sheet.
Medicines Interactions with Oral

Contraceptives
Medicines reducing the effect of oral contraceptives
Caution is needed when prescribing any of the following medicines
to any woman taking oral contraceptives; they reduce the
effectiveness of the oral contraceptive and pregnancy is more likely:
 Anti-convulsants: carbamazepine, ethosuximide,
phenobarbitone, phenytoin, primidone.
 Antibacterials: rifampicin
If the medicine is only going to be used for a short time the woman
should be advised to take extra contraceptive precautions for the
duration of the therapy, and seven days after treatment, for
example, condoms or abstinence from intercourse. If the medicine
is to be used on a long-term basis the woman should be advised to
use another suitable method of contraception.
Medicines which are made less effective by oral

contraceptives
Doses of particular medicines may need to be increased, with
careful monitoring:
 Anticoagulants
 Anti-convulsants (phenytoin)
 Antidepressants (imipramine)
 Anti-hypertensive agents (methyldopa)
 Corticosteroids
 Hypnotics, sedatives or other CNS depressants (diazepam,
phenothiazines)
 Anti-asthmatic agents
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Long term hormonal contraceptives

 Injectable Contraceptive

medroxyprogesterone C V 150mg once every 3 months
acetate im
or norethisterone B N 200mg once every 2 months
enanthate im
CAUTION: In hypertension and in women without proven fertility do
not administer medroxyprogesterone [Depo-provera ®]. Side effects of
medroxyprogesterone are similar to those of Progestogen Only Pills
i.e. headaches, irregular uterine bleeding, nausea and vomiting,
weight changes and depression. Transient infertility and irregular
cycles may occur after discontinuation.
Note: Norethisterone enanthate can be given up to 2 weeks (14 days)
early or 2 weeks (14 days) late.
 Implant Contraceptives
Levonorgestrel implant [Jadelle is effective for five years
(reversible by surgical removal). It is suitable for women who
have probably completed their family but are not yet ready for
sterilisation. It may also be suitable for some women who
cannot take oestrogen-containing contraceptives.
levonorgestrel implant B N 2 rods once only once in
5yrs
Etonogestrel B N 1 rod once only once in
3yrs
CONTRAINDICATIONS: hypertension; thrombo-embolism; active
liver disease; undiagnosed genital bleeding, severe headaches,
malignancy of breast (known or suspected); malignancy of cervix,
uterus or ovaries (known or suspected), cerebro-vascular or coronary
artery disease, pregnancy or suspected pregnancy.
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Emergency Contraception
 Hormonal OC -Within 72 hours of unprotected intercourse,
give:
combined oral C V 2 tablets repeat after
contraceptive pill 12 hours
50mcg ethinyloestradiol + 150-250mcg levonorgestrel
or combined oral C V 4 tablets repeat after
30-35mcg ethinyloestradiol + 150-250mcg
levonorgestrel
Levonorgestrel 750mcg C V 1 tablet Repeat
after 12
hours
Note: Advise to return if menstruation does not occur within 3 weeks.
Give appropriate contraceptive advice.
Emergency contraception: intrauterine device method
 IUCD- copper T within 5 days of unprotected intercourse
Infections of the Genito-Urinary Tract

during Pregnancy
Urinary tract infection during pregnancy
Urine specimen for microscopy, culture and sensitivity where
possible. Urine strips can also be used to detect UTI especially at
the primary health care centre level.
 First line:
amoxicillin po C V 500mg 3 times a day *7 days
or ciprofloxacin po B V 500mg 2 times a day 7 days
 Second line:
norflocaxin B N 400mg 2 times a day *7 days
or nalidixic acid po B V 500mg 4 times a day *7 days
*Note: Duration for UTI in pregnancy longer than other general UTI.
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Third line: as per culture and sensitivity.
Positive RPR or Syphilis during pregnancy

 Both partners to be counselled and treated with:
benzathine penicillin im C V 2.4MU once a week 3 doses
(=1.44g)
See chapter on Sexually Transmitted diseases for further information
Vaginal discharge during pregnancy

The discharge can be due to candidiasis, bacterial vaginosis or
trichomoniasis. A clinical diagnosis should be made before
treatment.
miconazole vag C N 100mg once a day 3 days
pessary
or clotrimazole pessary C V 500mg Once daily 3 days
and metronidazole po C V 400mg 3 times a day 7days
Creams of miconazole and clotrimazole can also be used
Caution: Avoid metronidazole in 1st trimester.
Post Miscarriage Sepsis

Pyrexia in a woman who has delivered or miscarried in the previous
6 weeks may be due to puerperal or post miscarriage sepsis and
should be managed actively. Abdominal pain in addition to pyrexia
is strongly suggestive. The uterus may need evacuation. Suction
curettage or manual vacuum aspiration are safer than sharp
curettage and are the recommended first line procedures.
Note: Every year a few women die because what is thought to be post-
miscarriage sepsis is in reality fever from malaria causing abortion.
Post-miscarriage sepsis will need a laparotomy if the patient does not
respond to antibiotic therapy and evacuation of uterus.
 Mild/moderate sepsis:
and doxycycline po C V 100mg 2 times a day 10 days
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Acute Pelvic Inflammatory Disease (PID)
Acute PID refers to the acute syndrome attributed to the ascent of
microorganisms, not related to pregnancy or surgery, from the
vagina and cervix to the endometrium, fallopian tubes and adnexal
structures. Gonorrhoea, chlamydia, mycoplasma, anaerobic
bacteria and gram-negative organisms can cause acute PID.
Mild / Moderate Pelvic Inflammatory Disease

 First line:
Amoxicillin po C V 500mg 3 times a day 7 days
 Second line:

norfloxacin po C E 800mg once a day single dose
 Alternative in penicillin allergic patients

only erythromycin po C V 500mg 4 times a day 10 days
Severe pelvic inflammatory disease

Temperature greater than 38oC with marked abdominal
tenderness. Patients need IV fluids and IV medicines.
benzylpenicillin iv C V 2.5MU 6 hourly 48-72hrs
and chloramphenicol iv B V 500mg 6 hourly 48-72hrs
and metronidazole pr B V 1g 12 hourly 72hrs
* Note: Duration as determined by patient’s response. Switch to oral
after review. Avoid use of chloramphenicol for greater than 7 days.
 Alternative
ampicillin iv B E 500mg 6 hourly 48-72hrs
and gentamicin im C V 160mg 12 hourly 48-72hrs
and metronidazole pr B V 1g 12 hourly 72hrs
* Note: Duration as determined by patient’s response. Switch to oral
after review.
If no response within 48 hours suspect pelvic abscess: may need
laparotomy or referral. Change to oral administration after
temperature has settled.
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Prolonged Rupture of Membranes

oxytocin infusion B V 1 unit initially
Then 4 units in 1L sodium chloride 0.9% at
(see induction of labour) 15, 30, 60 drops per minute until
regular contractions
or misoprostol po B V 25 mcg 4 hourly max 3
doses,
or misoprostol pv B V 50 mcg 24 hourly max 1
doses
Note: For oral administration, dissolve Misoprostol 200mcg in 200ml
of normal saline or water for injection. This gives a concentration of
1mcg per ml.
 If >12 hours or pyrexial in labour. Early delivery should be
effected:
benzylpenicillin iv C V 2MU 6 hourly until
and chloramphenicol iv B V 500mg 6 hourly delivery
and metronidazole iv A N 500mg 8 hourly Until
delivery
Switch to oral antibiotics for 7 days after delivery:

Prophylaxis for Caesarean Section

 As the patient is put on theatre trolley:
benzylpenicillin iv C V 5MU once only single dose
or ceftriaxone iv C V 1 gm once only single dose
or Cefuroxime iv B V 750 mg once only single dose
and chloramphenicol iv B V 1g once only single dose
 If during caesarean section there is evidence of infection treat
for a week with the above regime:
74
Nausea and Vomiting in Pregnancy
If during the first trimester and if vomiting is not excessive, advise
small frequent bland meals and drinks.
Antacids may give symptomatic relief if gastritis is present. If
vomiting persists, look for underlying cause e.g. urinary tract
infection, molar pregnancy, and multiple pregnancies.
Give:
Medicine Codes Adult Frequency Duration
dose
promethazine po C N 25mg once at night* as required
or chlorpheniramine po C E 4mg once at night* 5 days
or metoclopramide C N 10mg 3 times a day as required
*Note: If severe, the dose may be given two to three times a day.
Hyperemesis Gravidarum (Vomiting and Dehydration)

Admit or refer for intravenous fluids and give:
dose
prochlorperazine im B E 12.5mg twice a day as needed
or promethazine im B V 25mg twice a day as needed
For reducing the risk of neural tube defects

folic acid po C E 5mg once a day Preconceptionally
and up to 3
months of
pregnancy
Anaemia during Pregnancy

Prophylaxis in Antenatal Care
ferrous sulphate po C E 200mg once a day Throughout
pregnancy
and folic acid po C E 5mg once a week Throughout
pregnancy
or Combined ferrous and C E Once daily Throughout
folic acid po pregnancy
* Start at booking for antenatal care. Continue prophylaxis for 6
weeks after delivery. Also give dietary advice.
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Treatment of Microcytic Anaemia

Before 36 weeks gestation:
ferrous sulphate po C E 200 3 times a day -
and folic acid po C E 5mg once daily -
CAUTION: Iron preparations should be taken after food to avoid
gastrointestinal irritation. If vomiting occurs, reduce dosage to that
which can be tolerated.
Severe anaemia in pregnancy requires full investigation:
 stool for ova and parasites;
 peripheral blood film for malarial parasites;
 full blood count;
 mid-stream specimen of urine for microscopy, culture and
sensitivity;
 and HIV test.
Severe anaemia (Hb < 8 gms) after 36 weeks of gestation requires
admission and possible transfusion, as well as oral iron therapy.
(See the chapter on Blood).
Cardiac disease in Pregnancy

Types of cardiac disease:
 rheumatic heart disease accounts for over 95% of conditions
 hypertension
 puerperal cardiomyopathy
 congenital heart disease
 post-operative cardiac patients
Antenatal Management
The woman should be managed by a specialist obstetrician and
physician together, and should be seen more frequently than usual.
In the antenatal period avoid fluid overload, anaemia and infection.
Any infection should be treated aggressively with the appropriate
antibiotics.
Treatment:
See treatment of heart failure in the chapter on cardiovascular
conditions.
Anticoagulants for patients on long term anticoagulation (e.g.
valve replacement) - warfarin should be avoided in the first
trimester. Use heparin or low molecular weight heparin for the first
13 weeks, and change back to warfarin between weeks 13 – 37.
After 37 weeks change back to heparin until after delivery. Warfarin
can be commenced 24hrs after delivery.
76
Labour in cardiac patients
Cardiac disease patients should not be induced – they usually have
easy vaginal deliveries, which can be assisted by forceps delivery
or vacuum extraction to avoid stress.
 Give a single dose of ampicillin at the onset of labour:
ampicillin iv B V 1g once only single dose
 Keep the resuscitation trolley at hand.
 Nurse in a propped up position
 Do not give ergometrine. Use oxytocin:
Medicine Codes Adult dose Frequenc Duration
y
oxytocin C V 10units once at delivery of the
anterior shoulder
 Post-natally keep the woman in high care for 24 hours.

Contraception:
At 6 weeks after delivery, use the progesterone only oral
contraceptive or injectable medroxyprogesterone acetate.
Hypertension in Pregnancy
Women who develop hypertension during pregnancy (after 20
weeks) have pregnancy-induced hypertension (PIH) which is a
potentially serious condition possibly requiring early or urgent
delivery (see below).
Pregnant women who have essential hypertension may also
develop superimposed PIH and merit the same treatment.
Methyldopa is the recommended anti-hypertensive throughout
pregnancy.
CAUTION: Avoid diuretic medicines during pregnancy.
Essential Hypertension
Monitor for development of proteinuria.
methyldopa po C V 250-500mg 3-4 times a day review
If not responding refer to district level, where a combination of

methyldopa and nifedipine can be used:
and nifedipine SR po B V 20mg 2 times a day review
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Pregnancy Induced Hypertension

 Monitor closely and check urine for protein (exclude urinary
tract infection). Manage as high-risk antenatal patient.
 Any pregnant woman (especially primigravida) with a rise of
diastolic pressure > 15 mm may have severe pregnancy
induced hypertension, even with a BP < 140/90.
Mild Pregnancy Induced Hypertension

Diastolic 90-100 mm Hg; no proteinuria.
 Bed rest at home.
 Weekly antenatal visits.
 Admit if there is a past history of foetal loss or eclampsia
Moderate Pregnancy Induced Hypertension

Diastolic 100-110 mm Hg; no proteinuria.
 Admit, monitor blood pressure 4 hourly, and give:
and nifedipine SR po B V 20mg 2 times a day review
 At gestation > 37 weeks, plan delivery.
Severe Pregnancy induced hypertension

 Diastolic > 110mm Hg; in first 20 weeks of pregnancy -this is
likely to be essential hypertension. Severe PIH in the second
half of pregnancy needs careful monitoring for proteinuric PIH.
Manage as for moderate pregnancy induced hypertension. If
not controlled add hydralazine as follows:
Nifedipine SR po B V 20mg Twice a day review
plus hydralazine im B V 10mg every 4 hours review
Severe Pre-Eclampsia (Proteinuric pregnancy-induced

hypertension)
Manage as an inpatient. Plan to deliver at 37 weeks or
before.
 Monitor blood pressure 4 hourly.
 Check urine for protein daily (exclude urinary tract infection).
 Watch for signs of eclampsia.
 If diastolic > 110 mmHg check blood pressure hourly and
continue giving medicines as for severe PIH (above).
78
Imminent Eclampsia
Proteinuric pregnancy induced hypertension with symptoms of
visual disturbance or epigastric pain and/or signs of brisk reflexes:
 Plan urgent delivery. Prevent convulsions with:

magnesium sulphate C V 4 gm iv in 20mls of Normal Saline over 20
minutes plus 5 gm in each buttock as the
loading dose, followed by 5gm in alternate
buttocks every four hrs until 24 hours after
delivery
 Check blood pressure at least hourly. If diastolic pressure > 110
mmHg give anti-hypertensives as for severe PIH (above).
Eclampsia
This is pregnancy-induced hypertension with epileptiform fits.
 Ensure clear airway.
 Stop convulsions with:
magnesium sulphate C V 4 gm iv in 20mls of Normal Saline over 20
minutes plus 5 gm in each buttock as the
loading dose, followed by 5gm in alternate
buttocks every four hrs until 24 hours after
delivery, or 24 hrs after the last fit whichever
is the later.
 Plan urgent delivery, within 6 hours.
 Monitor carefully:
 Patellar reflex
 Respiration (respiratory rate must not be less than 16/min)
 Urine output > 100mls in 4 hours
 All nurses, midwives and doctors attending to pregnant women
should familiarise themselves with the magnesium sulphate
regimen. Once competence is achieved in its administration,
the regimen should be used at all levels. At the primary level,
the intravenous component of the loading dose may be
omitted, but the intramuscular component (10 grams) should
always be given.
 Check blood pressure at least hourly. If diastolic pressure
>110mmHg give:
hydralazine im B V 10mg once -
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Diabetes in Pregnancy
Pregnant diabetics require management before and throughout
pregnancy. Some women may develop diabetes while pregnant
(gestational diabetes), usually in the second trimester. Ideally, all
pregnant diabetics should be managed by specialists. For general
information refer to the relevant section in the chapter on diabetes.
 Strict blood sugar control preconceptually is advised.
 Good blood sugar control with insulin, diet and exercise is
essential. All known diabetics should have their glucose
control assessed before conceiving if possible.
 Throughout pregnancy blood sugar control should be kept
strictly within the range 4-6mmol/L. Control should be
measured by regular blood sugar profile (admit and take 4
hourly blood glucose levels for 24 hours). Insulin requirements
will increase as pregnancy progresses, so profiles will be
necessary at frequent intervals of approximately 2 weeks.
 Labour should be in a tertiary level hospital. Well-controlled
diabetics may be allowed to go into labour spontaneously up to
term provided the foetus is clinically well. If labour is induced,
give half the usual insulin dose in the morning and start an
intravenous infusion of dextrose 5% at 1 litre per hour. Labour
should not be prolonged. After labour, manage the patient on a
sliding scale of insulin.
Anaesthesia, Analgesia, Antacids

 For indigestion
magnesium trisilicate po C N 10-20ml as required
 Prior to general anaesthetics

Prior to going to theatre for caesarean sections, or any pregnant
woman about to have a general anaesthetic, give:
sodium citrate po B N 15ml once only -
CAUTION: Particulate antacids (e.g. magnesium trisilicate) may be
harmful to the lungs if aspirated; sodium citrate is favoured if
available.
 For severe pain in labour
pethidine im B V 50-100mg 4-6 hourly max. 3 doses
or morphine im B V 5mg 4 hourly as required
and promethazine im B V 25mg once a day max. 3 doses
80
 Note: To avoid respiratory depression in the neonate the last
dose should be given if delivery is not anticipated within the
next 2 hours, and no more than two doses should be given
during labour.
 For caesarean section, spinal anaesthesia is now the standard
method to be used. All doctors and nurse anaesthetists should
become competent in this method.
If the neonate is breathing poorly after pethidine was given to the
mother, give respiratory support plus naloxone. See the section in
Neonatal Conditions.
For the incision and subsequent suturing of

episiotomies
lignocaine 1% local C V Up to max once -
infiltration of 10ml
CAUTION: Avoid injecting into a vein! Draw back several times
during infiltration.
Use of steroids pre-term labour

Steroids are used to prevent respiratory distress syndrome of the
newborn in premature labour before 35 weeks gestation. Most
useful between 28-35 weeks gestation.
 Give the mother:
dexamethasone im C V 12mg for 2 doses 12
hours apart
Cervical ripeners/ labour initiators

(Prostaglandins)
Use prostaglandins (PG) with caution in multiparous women.
Excessive uterine contractions can lead to uterine rupture,
particularly if the cervix is not ripe.
Cervical ripeners: Prostaglandins are powerful medicines, although
classed as cervical ripeners they are better called labour initiators,
only to be used on a good indication. The higher the parity, the
higher the chances of uterine rupture.
 The safest and simplest method of ripening the cervix:
misoprostol pv B V 50 mcg Once daily Max 1 dose
misoprostol po B V 25mcg 4 hourly Max 3 doses
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Traction method
Where no medicines are available, a size 14 Foley’s catheter can
be inserted through the cervix under clean conditions, and then
inflated with 40ml water. By strapping to the leg under tension,
gentle traction is applied.
Myometrial Stimulants (Oxytocics)

Oxytocics are used for:
 induction of labour;
 augmentation of labour;
 uterine stimulation after delivery.
Use them with great caution before delivery in highly parous women;
avoid in obstructed labour. Oxytocin does not work very well in the
case of induction without rupture of the membranes. This may result
in unnecessary caesarean section and/or vertical transmission of
HIV.
Induction of Labour
 Artificial rupture of membranes. If labour fails to progress, give :
oxytocin iv infusion C V Initially 1 unit,
Then 4 units in 1L sodium chloride 0.9% at
15, 30, 60 drops per minute – until regular
contractions are maintained.
 If 4 units is insufficient, and it is the woman’s first pregnancy:
Increase the dose stepwise with regular monitoring – 16, 32 then 64 units
in the litre of sodium chloride 0.9% - each time increasing the delivery rate
through 15, 30 and 60 drops per minute.
misoprostol pv B V 50 mcg every 24 hrs (max 2 doses)
or misoprostol po B V 25 mcg every 4 hours (max 4 doses)
Augmentation of Labour
Membranes already ruptured and labour not progressing: follow the
same steps and precautions as above. Obstructed labour should be
considered as a cause if labour fails to progress.
Active management of the third stage of labour
oxytocin C V 10 units Once with the
appearance of the
anterior shoulder
 If the uterus remains relaxed OR THERE IS POST PARTUM

HAEMORRHAGE in spite of above measures and manual
stimulation, give:
82

oxytocin iv infusion C V 20 units in 1L of sodium chloride 0.9%
running in at 10 – 60 drops per minute.
or misoprostol pr C V 600mcg once only
Termination of Pregnancy
Legal Conditions for Abortion:
 where the pregnancy results from rape, whether or not the
rapist is caught;
 where there is a substantial threat to the woman’s health or life
in continuing the pregnancy (e.g. she suffers from very high
blood pressure, diabetes or another serious medical or
surgical condition);
 where there is a significant risk, or it is known that the foetus
has a serious medical condition or malformation (e.g. HIV,
rubella in first trimester, or Down’s Syndrome).
Recommended Methods
 medical methods as recommended below using
misoprostol as the first preferred option
 manual vacuum aspiration in the first trimester with or
without prior use of misoprostol
 suction curettage in the first trimester with or without prior
use of misoprostol
 dilatation and curettage in the first trimester and early
second trimester with or without prior use of misoprostol
 cover with antibiotics where appropriate
Termination of Pregnancy
First trimester (up to 13 weeks)
Cervical ripening pre instrumentation

dose
misoprostol pv B V 400mcg 4 hours before once only
procedure
Induced abortion
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misoprostol pv B V 600mcg 12 hourly Max 2 doses
Missed abortion
misoprostol pv B V 600mcg 12hourly Max 2 doses
Incomplete abortion
misoprostol po B V 600mcg Single
dose
SECOND TRIMESTER (14 TO 27 WEEKS)
Induced abortion
Intra uterine fetal death (13-17 weeks)

Intra uterine fetal death (18-27weeks)

Third trimester (28-40weeks)
Intra uterine fetal death (27-43weeks)

misoprostol po B V 25mcg 4 hourly max 4 doses
or misoprostol pv B V 50mcg 24 hourly max 2 doses
Induction of labour
misoprostol pv B V 50mcg 24 hourly max 2 doses
or misoprostol po B V 25 mcg 4 hourly max x3 doses
Rape and Sexual Assault: Prophylaxis against infections and

pregnancy
STI prophylaxis for sexual assault survivors (see STI/ART

guidelines):
84
 should be given STI prophylaxis/post exposure prophylaxis:
amoxicillin po C V 500mg 8 hourly 7 days
and doxycycline po C V 100mg twice a day 7 days
and zidovudine, C V See ART
lamivudine, guidelines
lopinavir/ritonavir
 Offer counselling and HIV test at the time of the rape and three
months later.
Post Coital Contraception (‘Morning-after pill’) / Emergency

Contraception
This method is particularly appropriate after rape and unprotected

sexual intercourse.
 Within 72 hours of unprotected intercourse, give:
combined oral C V 2 tablets repeat after -
50mcg ethinyloestradiol + 150-250mcg levonorgestrel
or combined oral C V 4 tablets repeat after
30-35mcg ethinyloestradiol + 150-250mcg levonorgestrel
or Levonorgestrel 750mcg C V 1 tablet Repeat after 12 hrs
Note: Advise to return if menstruation does not occur within 3 weeks.

Give appropriate contraceptive advice.
Medicines in Pregnancy and Lactation

Note: the tables below include commonly used medicines, but the
absence of a medicine from these tables does not necessarily imply no
risk. Always check if unsure.
General principles
 Medicines should be prescribed during pregnancy and lactation
only if the expected benefit to the mother outweighs the risk to
the foetus or neonate;
 all medicines should be avoided if possible during the first
trimester;
 well known medicines, which have been extensively used
during pregnancy or lactation, should be used in preference to
new medicines;
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Table 5.1 Medicines to be avoided/used with caution during

breastfeeding
Medicine Recommendations
Alcohol Small quantities probably not harmful
Aspirin Avoid – risk of Reye’s syndrome
Atropine Avoid
Bromocriptine Avoid
Carbimazole May cause hypothyroidism in infant
Chloramphenicol may cause bone marrow toxicity in infant
Diazepam / Nitrazepam Avoid repeated doses
Doxycycline Caution, although probably minimal levels in the milk.
Ergotamine Toxic to infant, may inhibit lactation
Lithium Monitor mother’s levels carefully
Oestrogen High level may affect milk flow
Oral anti-coagulants Caution, risk of haemorrhage
Phenobarbitone Inhibits infants sucking reflex
Radioactive iodine Avoid breastfeeding for 24hrs after diagnostic doses,
contraindicated in therapeutic does.
Sulphonamides Caution – significant risk of kernicterus
Thiazides Caution. Doses are usually too small (25-50mg) to be
harmful. Large doses may suppress lactation.
Table 5.2: Medicines to be used with caution or avoided in

pregnancy [Cont]
Medicine Trim Note Rationale / advice
.
Albendazole 1 Avoid Potentially teratogenic. Wait until after delivery.
2&3 Caution
Alcohol All Avoid Small quantities probably not harmful
Amitriptyline 3 Caution Convulsions in neonate.
Androgens All Avoid Virilisation of female foetus.
Antiemetics All Caution Use promethazine or chlorpheniramine ONLY if
vomiting is severe.
Antiepileptics All Caution Benefits outweigh risks - monitor blood levels
and adjust dose accordingly. Use single
medicine if possible. See individually listed
medicines.
Aspirin 3 Avoid Low dose aspirin in PIH is safe in 2 and 3.
1&2 Caution
Atenolol 3 Caution Neonatal hypoglycaemia, bradycardia,
Propranolol intrauterine growth retardation.
1&2 Avoid
Carbimazole 2&3 Caution Refer to specialist.
Chloramphenicol 3 Caution ‘Grey baby syndrome’ avoid long courses.
Cotrimoxazole All Avoid Risk of teratogenicity and
methaemoglobinaemia.
Diazepam 3 Caution Neonatal respiratory depression, drowsiness,
Nitrazepam hypotonia. Avoid regular and prolonged use.
86
Doxycycline All Avoid Dental discolouration, maternal hepatotoxicity
with large doses.
Ergotamine All Avoid
Gentamicin All Avoid May cause auditory or vestibular nerve damage,
risk greatest with streptomycin and kanamycin,
Kanamycin
small with gentamicin.
Heparin All Caution Maternal bone demineralisation/
thrombocytopenia.
Laxatives- All Caution
stimulant
Lithium All Avoid Needs careful control of levels.
Metronidazole 1 Avoid Avoid high doses.
2&3 Caution
NSAIDS -Other All Avoid Paracetamol is preferred for analgesia in
standard doses.
Opiates 3 Caution Neonatal respiratory depression, gastric stasis in
mother with risk of aspiration in labour.
Oral all Avoid Change to insulin.
hypoglycaemics
Podophyllin all Avoid
Phenobarbitone 1&3 Caution Congenital malformations. Prophylactic use of
vitamin K and folate is recommended.
Phenytoin
Praziquantel 1 Avoid Wait.
Prednisolone All Caution If essential cover neonate for adrenal
suppression.
Pyrimethamine/ 1&3 Avoid Give with folic acid.
Sulphadoxine 2 Caution
Quinine All Caution High doses teratogenic. Benefit outweighs risk

Reserpine All Avoid
Sulphonamides 3 Avoid Risk of teratoenicity, methaemaglobinaemia,
kernicterus.
Streptomycin All Avoid May cause auditory or vestibular nerve damage,
risk greatest with streptomycin and kanamycin.
Thiazides All Caution May cause neonatal thrombocytopenia. Avoid for
treatment of hypertension.
Vaccines – live All Avoid
Vitamin A 1 Avoid High dose may be teratogenic in early
pregnancy.
Warfarin 1 Avoid Subcutaneous heparin may be substituted in the
first trimester and the last few weeks of
2&3 Caution pregnancy in those with prosthetic heart valves,
deep vein thrombosis and pulmonary embolism.
PMTCT
Follow the current national guidelines.
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SEXUALLY TRANSMITTED INFECTIONS

URETHRAL DISCHARGE IN MEN 89
VAGINAL DISCHARGE IN WOMEN 91
RECURRENT OR VESICULAR GENITAL LESIONS 94
GRANULATING ULCERS WITHOUT BUBOES 96
BUBOES WITHOUT ULCERS 96
ACUTE EPIDIDYMO-ORCHITIS 97
SYPHILIS 97
GENITAL WARTS (CONDYLOMATA ACUMINATA) 99
MOLLUSCUM CONTAGIOSUM 99
PEDICULOSIS PUBIS (PUBIC LICE) 99
OPHTHALMIA NEONATORUM 100
88
General Guidelines
Accurate laboratory-proven diagnosis of sexually transmitted
infections (STI) is not always possible. Management guidelines
recommended in this section are based on the diagnosis of STI -
associated syndromes. This involves the provision of the complete
management package including provision of antibiotics for the STI
syndrome, provision of health education, promoting risk reduction
behaviour and treatment compliance, provision of condoms,
providing information on partner referral and treatment and
arranging for follow-up examination. (To prevent further spread it is
essential that all contacts of persons with STI be traced and
treated).
First line therapy is recommended when the patient makes his/her
first contact with the health care facility.
Second line therapy is administered when first line therapy has failed,
re-infection and poor treatment compliance have been excluded, and
other diagnoses have been considered.
Third line therapy should only be used when expert attention and
adequate laboratory facilities are available, and where results of
treatment can be monitored.
To ensure complete cure, doses less than those recommended
must not be administered. The use of inadequate doses of
antibiotics encourages the growth of resistant organisms, which will
then be very difficult to treat.
Urethral Discharge in Men

The commonest causes are Neisseria gonorrhoea and chlamydia
trachomatis and the two often co-exist. Trichomonas vaginalis
causes a urethral discharge in men. All males with urethral
discharge and all women with cervicitis should be treated for both
gonorrhoea and chlamydia in view of the fact that the two coexist
and present with similar symptoms and signs. Any sexual
partners in the preceding three months should be treated
presumptively for the same infections and any other
conditions found on examination.
 First Line:
kanamycin im C V 2g[1g into each one dose only
buttock]
or ceftriaxone C V 250mg IM one dose only
And doxycycline po C V 100mg twice a day 7 days
or azithromycin po C V 1g one dose only
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 If the patient still has a urethral discharge, or evidence of

urethritis 7 days after start of treatment, suspect re-infection,
poor treatment compliance or antimicrobial resistance in
Neisseria gonorrhoeae. If reinfection is suspected re-start first
line treatment. Otherwise refer the patient for investigations
and appropriate treatment.
 Second Line:
ceftriaxone im C V 250mg one dose only
or cefixime po B V 400mg one dose only
and metronidazole po C V 2g one dose only
If these medicines are not available locally, refer to the next level.
Figure 6.1: First line Management of Urethral Discharge in Men
Take history & examine client

Urethral discharge present?
YES
NO
Signs of other STI’s present?

kanamycin 2g single dose
or
ceftriaxone 250mg single dose
plus NO YES
doxycycline 100mg 2 times a day
for 7 days, with food.
Give health education on treatment,

Reassure:
NOaccordinglyYES
compliance, risk reduction, use of Treat
condoms. Advise on risk
Ask patient to have partner(s) reduction, use of
treated condoms
Arrange for follow-up after 7 days Advise to return if
symptoms persist
Urethral discharge persists?

Ceftriaxone
NO YES
250mg im stat* or
Cefixime 400mg
NO po stat
Discharge Reinfection likely ? plus
patient Compliance with metronidazole po
Reinforce health treatment poor? 2g stat
education Offer condoms
Offer condoms YES
Restart treatment
NO
REFER
90
 If the client received Ceftriaxone at the initial consultation and
there is no re-infection (non-compliance does not apply here
because patient will have received single dose IM injection), then
the second ceftriaxone dose should be Ceftriaxone 500mg im
stat.
 If kanamycin was given at the initial consultation the Ceftriaxone
250mg IM stat is appropriate.
Vaginal Discharge in Women

All women with a vaginal discharge must have a vaginal
examination. Some vaginal discharges are normal. However, any
woman concerned about a vaginal discharge should be examined
and the patient managed appropriately.
All women presenting with abnormal vaginal discharge should
receive treatment for bacterial vaginosis and trichomoniasis.
Additional treatment for yeast infection is indicated only when
clinically apparent (curd-like discharge, redness of the vulva and
vulva itching). Yeast infection is a common cause of vaginitis in
pregnancy.
Treatment for cervical infection both gonococcal and chlamydial
infection should be given in situations where infection seems likely
or the risk of developing complications is high. Treatment for
cervical infection should be added to the treatment for vaginal
infections if suspected (for example a patient’s partner has urethral
discharge), or if the signs of cervical infection (mucopurulent
cervical discharge or easy bleeding) are seen on speculum
examination.
First line treatment vaginal discharge

 Therapy for bacterial vaginosis and trichomoniasis
metronidazole po C V 400mg 3 times/day 7 days
or clindamycin po B E 300mg 2 times/day 7 days

and metronidazole po C V 2g Once only
PLUS
Therapy for yeast infection if curd-like white discharge, vulvo-

vaginal redness and itching are present
miconazole pv C V 200mg every night 3 days
or clotrimazole pv B E 100mg Once a day 7 days
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or nystatin pessary C V 200,000iu At night 7 days
PLUS
Therapy for cervical infection if partner has urethral discharge
or mucopurulent cervicitis / easy bleeding.

kanamycin im C V 2g [1g into One dose only
each
buttock]
or ceftriaxone in C V 250mg im One dose only
AND doxycycline po C V 100mg Twice a day 7 days
or azithromycin C V 1g One dose only
Second line treatment vaginal discharge:

Check for compliance and re-infection.
 Second Line:
Medicine Codes Adult dose Frequency Duration
or cefixime po C V 400mg one dose only
and metronidazole po C V 2g one dose only
If these medicines are not available locally, refer to the next level.
CAUTION IN PREGNANCY: See chapter Obstetric and

Gynaecological Conditions. Doxycycline should not be used during
pregnancy, or in lactating women. In pregnant women chlamydial
infection is best treated with azithromycin or erythromycin (if not
available) while kanamycin should be used for gonococcal infection.
92
Figure 6.2: First line management of vaginal discharge using a
speculum
Patient complaining of abnormal vaginal discharge
Take history and examine client

including speculum examination.
Vaginal discharge present?
YES
NO Signs of
other STI?
Discharge is profuse, yellow NO
and /or offensive?? •Patient at risk of
cervicitis
NO
YES
White and/or curd like?
Treat for yeast infection
Treat
YES appropriately
Miconazole 200mg PV for 3

nights
kanamycin 2g single dose

NO
Patient at risk of cervicitis? or ceftriaxone 250mg
single dose
plus
YES
doxycycline 100mg twice
NO
a day for 7 days
kanamycin 2g or azithromycin 1g once
single dose or only
ceftriaxone 250mg
single dose
plus
metronidazole 400mg 3 times a
doxycycline 100mg day for 7 days
twice a day for 7 •Give health
days or education, offer
azithromycin 1 g condoms, give
once only counselling and
plus testing for HIV.
metronidazole Offer services
400mg 3 times a Signs of other STIs? NO for
day for 7 days management of
sexuals
partners where
YES
appropariate
Treat
appropriately
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Genital Ulcers in Men & Women (with or without

buboes)
The commonest cause of genital ulcers in both men and women is
genital herpes simplex virus type 2 infection. Syphilis and chancroid
also cause genital ulcers but their prevalence has dropped
significantly. Clinical differentiation between the causes of genital
ulcers is inaccurate except if the patient gives a clear history of
recurrent attacks of vesicular lesions that may crust and heal
spontaneously or if the clinical appearance of the lesions are those
of superficial ulcers, when the diagnosis of genital herpes may be
suspected. It should be noted that syphilis may remain undetected
in the body for long periods of time and clinical manifestations may
only occur when long-term complications develop. Syphilis,
although rare nowadays, should be ruled out in all patients
presenting with genital ulcers. Immunosuppressed persons with HIV
infection frequently develop attacks of genital herpes that produce
lesions, which persist and require treatment with acyclovir. Hence it
is important to bear in mind all these three diagnoses whenever
managing persons with genital ulcers syndromically.
First Line treatment of genital ulcers:

Advice on local hygiene such as washing twice a day with salt water
(1 teaspoon salt to 1 litre water) and give the following:
benzathine penicillin im C V 2.4Megauni Once only
ts(1.44gm) night
and ciprofloxacin C V 500mg Twice a day 3 days
And acyclovir C V 400mg Three times 5 days
a day
or acyclovir C V 200mg Five times 5 days
a day
In case of penicillin allergy, use doxycycline 100mg twice a day for
20 days
CAUTION IN PREGNANCY: see chapter on Obsteric and
Gynaecological Conditions. Doxycycline should not be used
during pregnancy or in lactating mothers. In pregnant women
genital ulcers are best treated with erythromycin 500mg four times a
day for 14 days or 30 days depending on stage of syphilis (<2yrs or
> 2yrs)
Recurrent or vesicular genital lesions

Recurrent herpes in HIV negative people will almost always heal
spontaneously without treatment. Lesions seen early in the episode
(when still vesicular) or that are failing to heal should be treated as
herpes simplex virus infection as follows:
94
acyclovir po B V 400mg Three times 7 days
a day
Figure 6.3: Management of Genital Ulcers: First Line
Patient complains of  Educate and counsel

genital sore or ulcer  Promote and provide condoms
 Offer HIV testing and counselling
 Review if symptoms persist
Take a history and

examine patient
NO
NO Any other STI YES

Sore/Ulcer
present? present?
Treat according to
appropriate flowchart
YES
Ulcer NO 5. Educate and counsel

6. Promote and provide condoms
present?
7. Offer HIV testing and counselling
YES
Treat for chancroid and syphilis with Review

Benzathine penicillin 2.4MIU stat and in
Ulcer healed or
Ciprofloxacin 500mg twice a day for 3
healing?
days and acyclovir 400mg 3 times a day 7 days
for 5 days
YES NO
 Local hygiene
 Educate and counsel on risk reduction
1. Promote and provide condoms
2. Offer HIV testing and counselling
3. Partner management No further
4. Advise to return in 7 days Refer for
management
investigation
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Granulating Ulcers Without Buboes

These are most likely to be lesions of granuloma inguinale, a
condition also known as Donovanosis and caused by
Calymmatobacterium granulomatis. It should be remembered that
persons who are immunosuppressed may not develop a bubo and
occasionally persistent genital ulcers without bubo formation may
occur as a result of chancroid in persons with immunosuppression
and HIV infection.
First line:
benzathine penicillin im C V 2.4MU one dose only
(1.44g)
And azithromycin po C V 1g Once only followed by
500mg daily until ulcer
healed*
or doxycycline po C V 100mg 2 times a day until ulcer is
healed
 or, in penicillin allergy

erythromycin po C V 500mg 4 times a day 14 days
* review patients on a weekly basis
Second line:
cotrimoxazole po C V 960mg twice a day until ulcer is
healed
Buboes Without Ulcers

This usually occurs in persons with lymphogranuloma venereum
(LGV) which is caused by the L-types of Chlamydia trachomatis.
The main effect of the infection is on the lymphatics and patients
may present with penile and vulval lymphoedema together with
inguinal buboes. A small transient genital ulcer, which may heal on
its own, may precede the swelling and buboes. The bubo is typically
multilocular and may be grooved by the inguinal ligament.
96
First Line:
doxycycline po C V 100mg twice a day 14 days
Second line, or in pregnant women:

erythromycin po C V 500mg 4 times a day 14 days
Acute epididymo-orchitis
Acute scrotal swelling may occur in persons with acute epididymo-
orchitis, testicular torsion and scrotal trauma, and in those with
irreducible or strangulated inguinal hernia. Patients should be
examined carefully in order to exclude these conditions.
First Line:
kanamycin im C V 2g [1g into One dose only
each buttock]
or ceftriaxone im C V 250mg One dose only
and doxycycline po C V 100mg twice a day 10 days
Second Line:
cefixime po C V 400mg One dose only
Syphilis
Early Syphilis
Includes primary, secondary and latent syphilis of less than 2 years
duration:
benzathine penicillin im C V 1.44g [2.4 MU] one dose only
or doxycycline po (in C V 100mg 2 times a 14 days
penicillin allergy) day
or erythromycin po C V 500mg 4 times a 14 days
day
Late Syphilis and syphilis during pregnancy

Includes latent syphilis of more than 2 years duration, latent
neurosyphilis, gummatous, cardiovascular & neurosyphilis, and
syphilis of unknown duration:
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benzathine penicillin im C V 1.44g once a week 3 doses
(2.4MU)
or doxycycline po (in C V 100mg 2 times a 30 days
penicillin allergy NOT day
pregnancy)
or erythromycin po (in C V 500mg 4 times a 30 days
pregnancy) day
 Pregnant women are now routinely tested for syphilis using a
rapid diagnostic kit (TPHA equivalent). Pregnant women with
syphilis require close surveillance especially to identify re-
infection after treatment.
 Partner Treatment: Note the importance of having partner
treated and provide Contact Tracing Slip.
 Babies born to women found to have syphilis during pregnancy
should be treated even if the mother had been adequately
treated during pregnancy:
benzathine penicillin im C V 30mg/kg one dose only
[=50 000u/kg]
Congenital Syphilis (babies clinically infected):

procaine penicillin im C V 50mg/kg once a day 10 days
[=50 000u/kg]
or erythromycin po (in C V 12.5mg/kg 4 times a day 10 days
penicillin allergy)
Neurosyphilis:
procaine penicillin im C V 600mg [=1ml once a day 21 days
in each buttock]
Pelvic Inflammatory Disease

See chapter Obstetrics & Gynaecology
98
Genital warts (Condylomata Acuminata)
 External, Genital, Perianal:
podophyllin paint 20% B N wash off once a week review
after 4 hrs
CAUTIONS: For external use only. Do NOT use podophyllin in
pregnancy. Do not apply to the cervix, urethra or anal mucosa.
 Cervical, urethral, rectal and vaginal warts:
Do not use podophyllin. Treat by cryotherapy, electro-cautery,
or by surgical excision.
Molluscum Contagiosum
The lesions of molluscum contagiosum may resolve spontaneously.
In most instances, they do not have to be treated unless
cosmetically unacceptable. If not acceptable, each lesion should be
pricked with a sharpened “orange-stick” or needle and the contents
of the lesion expressed. This alone may be sufficient, or each lesion
can then be touched carefully with liquefied phenol.
Lesions of molluscum contagiosum may become extensive and
large in immunosuppressed persons with HIV infection. If the
lesions are very extensive and are very large then the patient
should be offered VCT, referred to the OI Clinic or for specialist
attention.
Pediculosis pubis (Pubic lice)

Patients with pediculosis pubis and their sexual partners should be
treated as follows:
benzyl benzoate 25% B N apply from once at night 3 nights,
emulsion * neck down wash off next repeat if
[irritant] morning necessary
*Dilute with one part water (1:1) for children. Repeat treatment after no
*Dilute with three parts water (1:3) for infants. more than 10 days.
Note: apply to hairy areas, do not shave. Caution: Do not use G.B.H
in pregnancy and lactation - refer mothers to district level for benzyl
benzoate.
Second line therapy

gamma benzene C V Wash off Reapply 7 to 10 days
hexachloride 1% lotion after 24hrs later to kill hatched lice.
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Ophthalmia Neonatorum
This is defined as conjunctivitis with discharge occurring in a
neonate within the first month of life. The condition is commonly
caused by gonococcal, chlamydial and bacterial infection. The
condition is preventable by detecting and treating maternal
gonococcal and chlamydial infection during pregnancy and by
instilling 1% tetracycline eye ointment carefully into the
conjunctival sacs of every baby as soon as possible after birth.
Ophthalmia Neonatorum is treated as follows:
kanamycin im C V 25mg/kg Once single dose
or ceftriaxone im C V 50mg/kg Once Single dose
and erythromycin po C V 16mg/kg 3 times a day 14 days
Treat the parents and the baby for gonococcal and chlamydial
infection as described above. Also provide health education and
counselling to the parents.
100
HIV RELATED DISEASE
CLINICAL PRESENTATION 102
GENERAL NOTES 102
COTRIMOXAZOLE PROPHYLAXIS: 103
ISONIAZID PREVENTATIVE THERAPY (IPT): 104
PERSISTENT GENERALISED LYMPHADENOPATHY
(PGL) 106
ORAL AND OESOPHAGEAL CANDIDIASIS (THRUSH)
106
HIV RELATED DIARRHOEA - ACUTE 107
IF BLOODY DIARRHOEA: 107
HIV RELATED DIARRHOEA - CHRONIC 107
HIV RELATED WASTING SYNDROME 108
HIV RELATED RESPIRATORY CONDITIONS 109
HEADACHE AND PROBLEMS OF THE NERVOUS
SYSTEM 110
CRYPTOCOCCAL MENINGITIS 111
AIDS DEMENTIA COMPLEX 113
HIV RELATED SKIN CONDITIONS 113
HERPES ZOSTER (SHINGLES) 114
POST-HERPETIC NEURALGIA 114
HERPES SIMPLEX 115
MEDICINE REACTIONS 115
KAPOSI’S SARCOMA (KS) 116
PALLIATIVE CARE IN HIV 116
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General guidelines
These guidelines aim to encourage a consistent clinical management
approach and draw a balance between possible interventions and
available resources. Further information is available in the Guidelines for
Antiretroviral Therapy in Zimbabwe. Always refer to the latest edition of
these guidelines.
Clinical presentation
Clinical presentation in HIV infection varies greatly, from
asymptomatic infection in a normal, fit individual to life threatening
conditions. The majority of infected persons remain healthy for a
varying period, often many years, but may transmit the virus to
others during unprotected sex.
General Notes
All patients should be offered HIV counselling and testing services (PITC).
A documented proof of a positive HIV test result should be availed before
a patient is enrolled into the Chronic HIV Care program. .
For notes on the management of HIV infection and related conditions in
children, see also “Paediatric Infections”.
The goal is to provide the earliest possible diagnosis of HIV
infection, diagnose opportunistic infections (OIs) promptly and
implement therapeutic measures that will extend and improve the
quality of life. Please refer to the Guidelines for Antiretroviral
Therapy in Zimbabwe for more detail about how to deal with OIs
and how to use the ARVs. Most early problems can be adequately
and effectively treated so that the HIV infected persons continue to
lead a normal and productive life. A continuum of care should be
provided from the nearest possible facility to the home or
workplace.
If a patient presents at the primary care level (“C level”) or district
hospital (“B level”), follow EDLIZ as far as possible, then refer to the
next level. Keep referrals to a minimum and only where essential for
investigations requiring specialised facilities and specialist advice.
Check where your nearest OI/ART Clinic is.
The following are fundamental to the management of HIV related
illness, but cannot be covered fully here (Refer to the national
guidelines):
 counselling: pre-testing, post-test, crisis/support;
 health education for prevention of further transmission of HIV,
positive living;
 Maintenance of good nutrition, vitamin and mineral
supplements.
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 Prevention, diagnosis and treatment of OIs
 Use of antiretroviral medicines
Cotrimoxazole prophylaxis:
Cotrimoxazole has been shown to prolong life and reduce hospital
admissions in those with symptomatic HIV or AIDS.
Cotrimoxazole prophylaxis should be given to the following:
 All patients with WHO clinical stages 2, 3, and 4 disease
 All patients with CD4 counts equal or less than 350 cells/mm3
 Pregnant women with CD4 counts equal or less than 350
cells/mm3
 All children born to HIV-positive mothers from six weeks of age
until they are tested and confirmed to be HIV negative
 Cotrimoxazole prophylaxis should be started as soon as any of
the above conditions are suspected; this should be done at
every entry point and not just be left to the OI clinics.

dose
cotrimoxazole po C V 960mg Once a day for life or until
CD4>350 for 6
months for
patients on ART
Cotrimoxazole prophylaxis in children
Give once daily orally according to the following table.
Table 7.1 Cotrimoxazole Prophylaxis in Children
Age Dose (ml)
Suspension Adult Paediatric

(240 mg / 5 tablets tablets
ml) (480 (120 mg)
mg)
up to 6 months 2.5 ¼ 1
6 months to 3 years 5 ½ 2
Over 3 years 10 1 3
If allergic to cotrimoxazole, try desensitization
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 Cotrimoxazole prophylaxis should be commenced at least one

to two weeks before the commencement of ART. This allows
time to identify those who might be allergic to cotrimoxazole.
 This prophylaxis should be continued indefinitely.
 For patients who are allergic to cotrimoxazole, consider using
Dapsone or desensitization. Desensitization can be offered
rapidly or over a longer period of time. Do not desensitize
anyone who has had an anaphylactic reaction to cotrimoxazole
or a severe skin rash such as Stevens-Johnson syndrome
Isoniazid Preventative Therapy (IPT):

Isoniazid preventative therapy is the provision of the medicine
isoniazid to people at high risk of developing active tuberculosis
(TB). People living with HIV are 20 to 37 times more likely to
develop active TB from latent TB than those without HIV, making
HIV infection the strongest risk factor for TB disease. TB is
responsible for more than a quarter of deaths of people living with
HIV. IPT has been shown to reduce the incidence of TB in HIV-
infected people with LTBI by 33-62%.
Among PLHIV, IPT is likely to provide protection against the risk of
developing TB by decreasing the risks of:
 Progression of recent infection
 Reactivation of latent M. Tuberculosis
In addition, IPT programs decrease the rate of TB in the community
and improve TB control.
Note: Isoniazid, like any other medicines, can cause side effects.
Look out for gastrointestinal symptoms, hepatitis, skins reactions
and peripheral neuropathy.
Contraindications to IPT:
 Active TB (confirmed or suspected)
 Known or suspected hypersensitivity to INH
 Self-reported chronic liver disease or symptoms suggesting
active hepatitis( jaundice, nausea, vomiting, right upper
quadrant pai, dark urine, pale stools)
 Excessive alcohol use
 History of convulsions and psychosis
 Moderately severe peripheral neuropathy
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 Other medications e.g. phenytoin, carbamazepine, warfarin1
Inclusion Criteria for Children for IPT
1. Negative TB screening (no current cough, no fever, good

weight gain) or evaluation found no active TB.
And child fits into one of the following categories:
i. Routinely: All HIV exposed and HIV infected children
between the ages of 12 and 15 years, regardless of
contact history
ii. After any contact with TB: All HIV exposed and HIV
infected children above 15yrs and HIV uninfected children
less than 5yrs having had contact with any case of TB
iii. Post TB treatment: All HIV exposed and HIV infected
children <15 years of age immediately following the
successful completion of TB treatment.
2. Caregiver demonstrates a good understanding of IPT and no
known risk factors for poor adherence are identified.
NB: Investigations for TB should be done according to national

guidelines.
Inclusion Criteria for Adults and Adolescents including

Pregnant Woment for IPT (≥15 years):
Inclusion Criteria:
1. ALL CONFIRMED HIV INFECTED ADULTS who are:
 On ART for more than 3 months or

 Post TB treatment (immediately following the successful
completion of TB treatment).
 Contacts of PTB
2. No signs or symptoms of Tuberculosis (Based on the adult TB

screening criteria)
Good understanding of IPT and willingness to adhere
1
Isoniazid preventive therapy in HIV infected adults and
children: Questions and Answers for clinicians, AIDS & TB
Unit,MOHCC, April 2014
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EDLIZ 2015
Exclusion Criteria:
 Being on Nevirapine containing regimen. Switch to

Efavirenz
 plus see previously mentioned contraindications
Dosages for Isoniazid:

 The recommended dose of INH in adults and adolescents is
5mg/kg/day to a maximum of 300mg/day.
 The recommended dose of INH in children is 10mg/kg/day
(with a daily maximum dosage not supposed to exceed
300mg). Refer to the table below for guidance on the
recommended weight bands versus INH to be administered:
Table 7.2: Dosage of Isoniazid per weight

Weight Number of 100mg tablets of INH to be Dose
range administered per dose (total dose given
(kg) 10mg/kg/day) (mg)
≤5 ½ tablet 50
5.1-9.9 1 tablet 100
10-13.9 1 ½ tablet 150
14-19.9 2 tablets 200
20-24.9 2 ½ tablets 250
≥ 25 3 tablets or one adult tablet 300
Pyridoxine dosage for adults and children:

Adults: pyridoxine (vitamin B6): 25mg/day
Children: 25mg/day
Persistent Generalised Lymphadenopathy

(PGL)
DEFINITION: Lymph nodes >1.5 cm in two or more areas, not due to
another cause such as TB and persisting for 1 month or more.
No treatment is required, but exclude other causes of PGL,
particularly TB, Kaposi’s Sarcoma, lymphomas or syphilis.
Oral and Oesophageal Candidiasis (Thrush)

– Refer to Chapter on Common Oral Conditions
Candida infections are commonly encountered in patients with HIV
infection. Oral thrush may precede AIDS but is a sign of waning
immunity that heralds the development of AIDS. Oesophageal
thrush is an indicator of more severe cellular immunodeficiency.
CAUTION: Neither of these conditions occurs exclusively in patients
with HIV infection. For example, oral thrush may follow treatment
106
with broad spectrum antibiotics or be associated with any debilitating
disease.
HIV Related Diarrhoea - Acute

DEFINITION: Three or more liquid stools daily for 2 to 14 days in
patients with symptomatic HIV infection.
Management of diarrhoea should be broadly along the same lines
as that described in the chapter on Gastrointestinal Conditions.
Anti-diarrhoeals should NOT be used in the initial treatment of
acute diarrhoea, especially in the case of children or with
bloody diarrhoea.
If no improvement after 5 days, attempt to identify pathogen: stool
microscopy; culture and sensitivity. Treat according to result.
 If no diagnosis:
metronidazole po C V 400mg 3 times a day 7 days
 If no improvement OR very ill/toxic:
And chloramphenicol po B V 500mg 4 times a day 7 days
If bloody diarrhoea:
nalidixic acid B V 500mg 4 times a day 5 days
Or ciprofloxacin po B V 500mg Twice a day 5 days
HIV Related Diarrhoea - Chronic

DEFINITION: Three or more liquid stools daily continuously or
episodically for more than 1 month in patients with symptomatic HIV
infection.
Management
 Assess for dehydration, malnutrition, and check electrolytes for
hypokalaemia.
 Rehydrate as required, maintain nutrition.
 Initial treatment of diarrhoea with blood in stool and/or fever as
for acute diarrhoea.
 If diarrhoea (without blood / fever) continues after conservative
management for 14 days, and exclusion of common causes of
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EDLIZ 2015
acute diarrhoea, symptomatic anti-diarrhoeal treatment may be

appropriate:
Loperamide po C N 4mg stat, As needed Review
then 2mg
after every
loose stool
codeine phosphate po B V 30 – 60mg < 4 times a day 7 days
CAUTION: Only use if diarrhoea is disabling. Before constipating agents

are given, treatment for helminth infection may be tried.
 If diarrhoea continues or recurs within 3 weeks, and no

pathogen identified: repeat microscopy and C/S.
 If diarrhoea persists and the patient is severely
immunocompromised, start ART as soon as possible.
HIV Related Wasting Syndrome

DEFINITION:
Weight loss of more than 10%, plus either unexplained chronic
diarrhoea for more than one month, or unexplained prolonged fever
for more than one month.
This places the patient in WHO Clinical Stage 4 HIV disease and
hence patient should be considered for ART.
 It is important to exclude treatable conditions, especially TB,
and to treat them appropriately.
 Emaciation: encourage a high calorie and protein diet. Add
mineral and vitamin supplementation:
nicotinamide po B E 50mg once a day review
and pyridoxine po B E 25-50mg once a day review
and thiamine po A N 50mg once a day review
 alternative:
vitamins, multi po C E 2 tablets once a day continual
Further Management
 Treat according to results of investigations. Keep referrals to a
minimum and only refer if alternative diagnosis is suspected.
 Prepare for and initiate antiretroviral therapy
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HIV Related Respiratory Conditions
A multitude of different manifestations of respiratory complications
may occur in patients with HIV infection. These include bacterial
pneumonias, pulmonary tuberculosis, Pneumocystis jiroveci
pneumonia (PCP) and pulmonary Kaposi’s sarcoma. All HIV
infected patients should be screened for TB at every visit using the
standard TB screening tools.
Management depends on the severity of the condition, location and
mobility of the patient. Outpatient management is preferred
wherever possible in adults. Only severe cases requiring
investigations and inpatient admission should be referred.
Treat initially as for other respiratory conditions. For acute infection
(less than 2 weeks) that does not warrant admission:
or erythromycin po (in C V 500 4 times a 7 days
penicillin allergy) day
or doxycycline po (in C V 100mg 2 times a day 7 days
penicillin allergy)
If severe symptoms i.e. respiratory distress, cyanosis, tachycardia,

hypotension or altered mental state, consider admission:
benzylpenicillin iv or im C V 1.5gm 6 hourly 7 days
(=2.5MU)
A stat dose may be given at primary care level prior to transfer.
Note: Switch to oral amoxicillin to complete the course
If there is no response, get a chest x-ray and follow management
guidelines in the chapter on respiratory conditions.
Then start on prophylactic cotrimoxazole:
cotrimoxazole po C V 960mg every day for life or until
CD4 >350
Pneumocystis jiroveci pneumonia (PCP)

An opportunistic infection caused by Pneumostis jiroveci. Patients
present with progressive shortness of breath and possibly cyanosed
with few or no chest signs.
 Manage with:
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EDLIZ 2015
cotrimoxazole po C V 1920mg 3 times a day 21 days

(4 tabs)
If they are allergic, try cotrimoxazole desensitisation
For infant or Child over 1 month:

10 mg/kg every 12 hours for 21 days. Total daily dose may
alternatively be given in 3–4 divided doses orally.
 or in sulphonamide allergy:
clindamycin po C V 450-600mg 6 hourly
21 days
and primaquine po C V 50mg once a day
 If any tachypnoea or cyanosis is present, add:

prednisolone po B V 40mg twice a day 5 days
The prednisolone po B V 40mg Once a day 5 days
n
The prednisolone po B V 20mg Once a day 11 days
n
Give folic acid 5mg daily whenever a person is taking high

dose cotrimoxazole
 After PCP has been treated give cotrimoxazole prophylaxis
indefinitely especially for children (Follow current ART
Guidelines). This also applies to any other patients with
AIDS defining disease.
Medicine Codes Adult dose Frequenc Duration
y
cotrimoxazole po C V 960mg once a day Indefinitely
< 6mths = 120mg
6-12mths = 240mg
>1 year = 480mg
 If still no response, consider malignancy, for example, Kaposi’s

sarcoma.
Headache and Problems of the Nervous

System
The symptom of headache is commonly encountered in patients
with HIV infection. Careful evaluation and follow up is required to
exclude meningitis and other CNS infections. Refer for lumbar
puncture and other investigations if duration is more than 7 days or
if the headache is associated with fever, vomiting, neck stiffness,
seizures, confusion and not responding to pain killers. Also refer to
Section on Neurological Conditions
110
Other commonly encountered neurological conditions in HIV
infection include AIDS dementia complex, peripheral neuropathy,
Guillan-Barré syndrome, facial nerve palsy and stroke.
Cryptococcal Meningitis
Cryptococcal meningitis is caused by Cryptococcus Neoformans
and is less acute in onset than bacterial meningitis. Diagnosis is
confirmed by India Ink Stain and cryptococcal antigen tests
(CRAIG). May occur as part of the Immune Reconstitution
Syndrome (IRIS). Treatment of cryptococcal disease must be with
amphotericin B based regimens. Ideally amphotericin B must be
combined with flucytosine. However in our setting, combination
therapy with amphotericin B and fluconazole is recommended.
In the absence of amphotericin B, high dose of fluconazole can
be used as alternative therapy. Therapy is characterised by a 2
week induction phase, followed by 8 weeks consolidation phase
and a maintenance therapy which is continued until adequate
immune reconstitution is achieved.

amphotericin B iv B V 0.7mg/kg Once a day 2 weeks
(infusion)
plus fluconazole po B V 800mg Once a day 2 weeks
then fluconazole po B V 800mg Once a day 8 weeks
Then fluconazole po B V 200mg Once a day Until CD4
count >200
cells/mm3
for 6
months
If iv Amphotericin B is not available:

fluconazole po B V 1200 mg Once a day 2 weeks
then fluconazole po B V 800mg Once a day 8 weeks
then fluconazole po B V 200mg Once a day Until CD4
count >200
cells/mm3
for 6
months
For neonate, infant or child initial test dose of Amphotericin B 100

micrograms/kg (maximum 1 mg) included as part of first dose, then
250 micrograms/kg daily, gradually increased up to 1 mg/kg daily
(maximum of 1.5 mg/kg daily).
Prolonged treatment is usually necessary.
If treatment is interrupted for longer than 7 days, recommence at
250 micrograms/kg daily and increase gradually.
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EDLIZ 2015
Then:
Neonate under 2 weeks;
Medicine Codes Dose Frequency
fluconazole po B V 6–12 mg/kg every 72 hours
Fluconazole (Oral):
Neonate 2–4 weeks
fluconazole po B V 6–12 mg/kg every 48 hours
Infant or Child
fluconazole po B V 6–12 mg/kg (maximum 800
mg) daily
Treatment should continue according to response and should be for

at least 8 weeks for cryptococcal meningitis.
Prevention of relapse of cryptococcal meningitis in AIDS

patients after completion of primary
Mortality and morbidity from cryptococcal meningitis is high with a

significant proportion attributable to raised intracranial pressure
(ICP). Management of raised ICP is critical to ensure good clinical
outcomes. If the ICP is > 25cm of water, remove 10-30ml of CSF
and continue with daily lumbar punctures until CSF pressures have
normalised (< 25cm of water). A repeat lumbar puncture at 2 weeks
after initiation of appropriate induction of antifungal therapy is not
necessary except in the setting of persistently elevated ICP and
evidence of poor clinical response.
Management of Amphotericin B associated toxicities
Amphotericin B, particularly amphotericin deoxycholate is

associated with renal tubular toxicities and can lead to electrolyte
abnormalities such as hypokalemia and hypomagnesemia. It can
also result in anaemia and administration related febrile reactions.
 Amphotericin B is often provided as a powder and should be
mixed with 5% dextrose water. It should NEVER be
mixed with normal saline or half normal saline as this
will result in precipitation of the amphotericin B. To minimize
renal toxicities, amphoterin B must be administered
slowly over 4 hours. Initial therapeutic doses should be
given as Amphotericin B 0.7-1mg/kg/day.
 Prehydration with 500ml -1000ml (1L) of normal saline with
20mEq of potassium chloride is recommended based on the
112
volume status of the patient. Patients must receive oral
potassium supplementation such as 1200mg twice a day.
The potassium supplementation minimizes the extent of
hypokalemia that can develop. Where available
supplementation with magnesium trisilicate 500mg orally
twice daily is also recommended.
 Renal function must be monitored at baseline. U&Es should
be measured twice weekly.
If the creatinine doubles, a dose of amphotericin B can be

omitted and prehydration increased to 1L of normal saline every
8 hours and creatinine rechecked. If creatinine normalises,
prehydrate with 1L normal saline with 20mEq KCl and restart at
amphotericin B (0.7mg/kg/day) given over 4 hours. Monitor renal
function weekly.
If repeat creatinine remains elevated or continues to increase,

amphotericin B should be discontinued and high dose
fluconazole 1200mg orally once daily initiated.
AIDS dementia complex

Characterized by progressive impairment in cognitive function that
is accompanied by behavioural changes and motor abnormalities.
Exclude other causes of dementia.
Highly active antiretroviral therapy (HAART) is the best treatment to
offer. Provide supportive care for the patient and their family. If
psychotic or depressive features are prominent, refer for/add
specific therapy to cover these conditions. (See the chapter on
Psychiatric Conditions).
HIV Related Skin Conditions

Skin manifestations of HIV infection may be the result of
opportunistic infections or HIV itself. The usual treatment regimens
are valid, but often a more aggressive application is required:
duration of treatment may need to be longer and relapse is common
when treatment is stopped.
Persons with HIV/AIDS should be informed of the likelihood of
increased photosensitivity, as many develop hyperpigmentation of
the face and the “V” of the neck. Excessive exposure to the sun
should be avoided.
See also chapter on Skin Conditions for guidelines on common skin
conditions; chapter on Sexually Transmitted Infections for guidelines
on molluscum contagiosum and condyloma acuminata.
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Herpes Zoster (Shingles)

Caused by a reactivation of Varicella Zoster virus infection.

acyclovir po B E 800mg 5 times a day 7days
 Give analgesia:
indomethacin po B E 25mg 3 times a day review
 Add :
amitryptiline po B E 25mg Once at night Review
 and skin care:
calamine topical C N topically Often as required
and povidone iodine topical B E daily, for wound care, as required
Avoid gentian violet as repeated use in this condition may cause
keloids. Keep the affected area warm.
Patients should be started on Cotrimoxazole prophylaxis
Refer immediately if there is ophthalmic/pulmonary involvement.
Acyclovir is needed and therapy should be started early. Generally,
five days after presentation acyclovir is ineffective in altering the
course of the infection.
Secondary infection (bacterial) may require treatment.
Post-Herpetic Neuralgia
After the rash is fully resolved:
amitriptyline po B E 25 mg-75mg every as required
night
increased to 150mg if required.
or carbamazepine po B V 100 - 200mg every
night
increased over 10 days to a max of
400mg (dose divided in 3).
114
Folliculitis
See the chapter on Skin Conditions. If severe treat for Impetigo
(see the chapter on Skin Conditions).
Herpes Simplex
 Counsel regarding infectivity of genital herpes.
 Local lesion care: keep clean with regular washing with soap
and water.
 In very severe cases or patients with low CD4 count acyclovir
should be considered.(See STI chapter)
 Bacterial superinfection may complicate lesions and will require
antibiotics
 Suppressive therapy may be required for recurrent HSV
infections:
acyclovir po B E 400mg 2 times a day 4 weeks then
review
Seborrheic Dermatitis
 Consider hydrocortisone 1% topically as well as an antifungal
cream such as miconazole cream 2%.
 Coal tar preparations may be helpful.
Prurigo or papular pruritic dermatoses

Caused by scratching and excoriation. Can be very disabling.
 Oral antihistamines e.g. chlorpheniramine or promethazine.
 Calamine lotion.
Medicine Reactions
These are frequently caused by cotrimoxazole, nevirapine,
efavirenz, TB medicines and many others.
Non- severe rashes
 Do not stop medicines
 Educate the patient
 Review frequently until rash resolves
 Provide symptomatic relief with antipruritics or emulsifying
ointment
If reaction is severe,
 Withdraw medicine.
 Decide on alternative medicine if needed.
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Kaposi’s Sarcoma (KS)

Patients with KS are in WHO clinical stage 4 and should be initiated
on ART as soon as possible irregardless of the CD4 count.
Antiretroviral medicines are indicated, but chemotherapy may also
be required. If possible, refer patients for specialist opinion prior to
starting ART (this might avoid IRIS which may occur with extensive
KS) and get a tissue diagnosis before referral. KS patients (good
general health, early KS, ≤5 lesions) may respond to ART alone but
most patients will need chemotherapy. Assess for signs and
symptoms of inner organ involvement.
Early or trivial KS may respond to ART alone but many patients
present late and with a heavy tumour burden. Thus these patients
need chemotherapy to reduce the tumour burden and then ART.
Immune reconstitution with ART occurs and may worsen the KS
dramatically.
Note that patients with non-Hodgkin lymphoma (NHL), Hodgkin
lymphoma (HL), cervix cancer, squamous cell conjunctival
carcinoma are likely to be HIV positive and will need ART and
treatment for the cancer (chemotherapy, surgery, radiotherapy).
Palliative Care in HIV

See the chapter on Pain Management & Care of the Terminally Ill.
116
ANTIRETROVIRAL THERAPY
GENERAL NOTES 118
MEDICAL CRITERIA FOR INITIATING ART IN
ADOLESCENTS/ ADULTS 119
SITUATIONS WHERE IT MAY BE NECESSARY TO DEFER
ART INITIATION 120
ADHERENCE TO ART 121
RECOMMENDED TREATMENT REGIMENS FOR
ADOLESCENTS AND ADULTS 121
SUBSTITUTION IN THE EVENT OF MEDICINE TOXICITY /
ADVERSE EVENTS AND UNAVAILABILITY 124
USE OF ARVS IN PATIENTS WITH TB 126
USE OF ARVS IN CHILDREN 128
CARE OF AN HIV-EXPOSED INFANT 129
CRITERIA TO INITIATE ART IN CHILDREN 130
MONITORING CHILDREN ON ART 131
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EDLIZ 2015
General Notes
Appropriate and effective provision of ARVs needs to be provided by
those who have received standardised training in the management of
opportunistic infections as well as in the use of antiretroviral medicines.
For more details on the use of ARVs refer to the current Antiretroviral
Therapy for the Prevention and Treatment of HIV in Zimbabwe.
Attempts should be made to train healthcare workers in HIV
management
Comprehensive HIV/AIDS care requires that there be provision of

counselling; either VCT or PITC, laboratory capacity for baseline
assessment and monitoring as well as to diagnose commonly
encountered opportunistic infections such as TB and cryptococcal
meningitis. Pharmacy personnel should also be trained in OI/ART
management as they will be required to ensure rational prescribing and
proper dispensing of the antiretroviral medicines. In addition, they will
also be required to ensure that their hospital/clinic has adequate ARV
medicine supplies.
Goals of ART
The aims of antiretroviral therapy (ART) are:

 Maximal and durable suppression of replication of HIV,
 Restoration and/or preservation of immune function,
 Reduction of HIV-related morbidity and mortality,
 Improvement of quality of life.
 Prevention of mother-to-child transmission of HIV (vertical
transmission), and
 Reduction of transmission of HIV from infected to uninfected
individuals through use of ARVs by the infected individual now
commonly known as ‘Treatment as prevention’.
Criteria for initiating ART in adolescents and adults

Prior to starting ART, patients should be assessed for readiness to take
ARVs; the ARV regimen; dosage and scheduling; the likely potential
adverse effects; and the required monitoring. Both medical and
psychosocial issues need to be addressed before initiating ART.
Patients should be adequately counseled about adopting appropriate
life style measures such as safer sexual practices (including
appropriate use of condoms), and any other psychosocial problems
that may interfere with adherence (e.g., alcohol, psychiatric disorders)
should be addressed. At each clinic visit always screen for tuberculosis
using a TB symptom checklist, advise patients about adequate nutrition
and the importance of medicine adherence and regular follow up care.
118
People taking ARVs should also be regularly asked on whether they
are taking other medicines including herbal remedies that may interfere
with the efficacy of ARVs.
Early treatment initiation is associated with clinical and HIV prevention

benefits, improving survival and reducing the incidence of HIV infection
at the community level. Increasing evidence also indicate that
untreated HIV may be associated with the development of severe non-
AIDS defining conditions including cardiovascular disease, kidney
disease, liver disease and neurocognitive disorders. Recent results
from the HPTN 052 Study strongly support the use of ART to prevent
HIV transmission among sero-discordant couples.
Medical Criteria for initiating ART in adolescents/ adults
ART should be provided to all people with confirmed HIV diagnosis

and with a CD4 count of ≤ 500cels /mm3.
As a priority, initiate ART in all individuals with severe/advanced HIV

disease (WHO clinical stage 3 or 4) or CD4 count less or equal to 350
cells/ mm3. It is also recommended to initiate ART in the following
categories of patients regardless of CD4 cell count:
 Active TB disease
 Pregnant and breast-feeding women with HIV
 Individuals with HIV in sero-discordant relationships
 HBV co-infection with severe chronic liver disease
Patients with CD4 <100
Patients with low CD4 below 100 should be fast-tracked for treatment
initiation. They should be screened for symptomatic TB and
cryptococcal disease. They should receive Cotrimoxazole and INH
prophylaxis like all other patients and should be closely monitored for 3
months as this is their highest risk period for bacterial infections and
TB or cryptococcal IRIS. Health workers should educate them and their
families to report immediately to a health facility if they are unwell
whilst their CD4 is< 100.
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EDLIZ 2015
Adults and Adolescents with a documented positive HIV test and

meeting any one of the following criteria:
Criteria Treatment Decision
Severe or advanced
Treat all regardless of CD4 cell
symptomatic HIV infection (WHO
count
clinical stage 3 or 4)
Treat CD4 ≤ 500 cells/mm3 (CD4
Asymptomatic/mild HIV disease
≤ 350 cells/mm3 as a priority)
Treat infected partner regardless
HIV sero-discordant couples
of CD4 cell count
Treat all HIV Positive TB patients
TB co-infection
regardless of CD4 cell count
Treat regardless of CD4 count in
Hepatitis B co-infection presence of chronic severe liver
disease
HIV positive Pregnant and Treat all regardless of CD4 cell
lactating women count
The revised medical criteria of initiating ARVs at CD4 count ≤ 500

cells/ mm3 means that many more PLHIV will be eligible for ART and
that will include many healthier people
Psychosocial criteria for initiating ART
Consider the following psychosocial criteria when initiating ART:

 Has the patient completed the prescribed counselling session(s)?
 Is a treatment partner available and/or has disclosure been made
to that treatment partner (strongly encouraged)?
 Is there an easy method of following up on the patient?
 Is the patient ready to take medications indefinitely?
Situations where it may be necessary to defer ART initiation

A patient may be deferred (delayed) from starting therapy if the patient
 has cryptococcal meningitis,
 needs further psychosocial counselling (e.g., for alcohol
problems),
 has TB (defer starting ART for at least 2 weeks)
 needs further information on HIV and AIDS,
 Very ill patient and unable to swallow oral medication (palliative
care is then offered to such a patient).
120
SUCH PATIENTS SHOULD BE OFFERED CONTINUED
MONITORING AND CLOSE FOLLOW-UP AS WELL AS
COUNSELLING SO THAT ART CAN BE COMMENCED AT AN
APPROPRIATE TIME.
Adherence to ART
WHO defines treatment adherence as ‘the extent to which a person’s

behaviour- taking medications, following a diet and/or executes lifestyle
changes’ corresponds with agreed recommendations from a health
care provider.
Efforts to support adherence should start before ART initiation and
should include basic information about HIV, the ARV medicines,
expected adverse events, preparations for long-term ART. Effective
adherence support interventions include client-centred behavioural
counselling and support, support from peer educators trained as
“expert patients,” community treatment supporters and mobile text
messaging. Other interventions involve encouraging people to disclose
their HIV status and providing them with adherence tools such as pill
boxes, diaries, and patient reminder aids. During follow-up, patients
should be assessed for adherence to whatever treatment plan has
been agreed upon (Integrated HIV training curriculum, MoHCC).
Recommended treatment regimens for adolescents and adults

The choice of medicine regimen is based on the “essential medicine”
concept and the rational use of medicine. To maximise adherence, use
of FDC medicines is strongly encouraged.
A large number of medicines and medicine combinations have been
used in the treatment of persons with HIV infection. The choice of
ARVs has been based on evidence of efficacy and safety, on
availability and cost of medications, as well as on the side effects
profile and the potential for development of resistance. The national
ART programme will use the following FDCs in the first line regimens:
Dual combinations:
 tenofovir (TDF) 300mg + lamivudine (3TC) 300mg zidovudine
(AZT) 300mg + lamivudine (3TC) 150mg
 The above dual FDC should be used in combination with single
formulation of:
 Efavirenz (EFV) 600mg once daily
 Nevirapine (NVP) 200mg twice a day (after the 2 weeks of once a
day nevirapine)
Triple combinations:
 Tenofovir 300mg+ Lamivudine 300mg+Efavirenz(EFV) 600mg
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 Zidovudine 300mg + Lamivudine 150mg + Nevirapine(NVP)

200mg
Please note that the national ART programme has phased out
Stavudine-based regimens.
Tenofovir (TDF) plus Lamivudine (3TC) plus Efavirenz (EFV) is the
preferred first-line regimen, which obviously would necessitate a
change in the currently used second-line regimens.
Preferred First-line regimen

Initiation and Maintenance
Triple combination of
Tenofovir (300mg) + Lamivudine (300mg)+ Efavirenz (600mg) once a
day.
Caution: Tenofovir (TDF)

TDF may be associated with acute kidney Injury or chronic kidney
disease as well as reduced bone mineral density in pregnant women.
Clinical considerations when using TDF
 Patients should be initiated on TDF even in the absence of
laboratory monitoring capacity. However, efforts should be made
to strengthen laboratory monitoring of patients
 Routine blood pressure monitoring.
 Urine dipsticks may be used to detect glycosuria or severe TDF
nephrotoxicity in individuals without diabetes using TDF-
containing regimens.
 If the creatinine test is routinely available, use the estimated
glomerular filtration rate at baseline before initiating TDF
regimens.
 Do not initiate TDF when the estimated glomerular filtration rate is
<50 ml/min, or in long term diabetes, uncontrolled hypertension
and renal failure.
Calculation of GFR or Creatinine clearance in ml/min using Cockcroft

Gault Equation
Male: 1.23 X (140-age)x wt in Kg/ Creatinine (in micromols/L)
Female: 1.04 X (140-age) x wt in kg/ Creatinine (in micromols/L
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Where there is need for a starter pack when using nevirapine,
prescribe as follows:
Two Weeks Starter Pack
Morning Dose Evening Dose
Dual combination of Tenofovir Nevirapine (200mg)

(300mg) + Lamivudine (300mg)
After the starter pack has been completed, if there are no adverse
events such as rashes, “step up” the dose of the Nevirapine. “Stepping
up” means giving Nevirapine twice a day plus FDC Tenofovir +
Lamivudine once daily as in the table below.
Step Up After the First Two Weeks
Dual combination of Tenofovir 300mg + nil

Lamivudine 300mg
Nevirapine 200mg Nevirapine 200mg
Caution: When Nevirapine is used as 1st line ART; introduce the

Nevirapine gradually (i.e., a leading-in dose). Patients are more likely
to develop adverse medicine reactions such as Stevens-Johnson
syndrome or hepatitis if started on the full regimen including nevirapine
twice a day. If the patient has been using Efavirenz and needs to
change to Nevirapine, just start using the Nevirapine at twice-a-day
dosing (i.e., no need for the leading-in dose)
Alternative Starter pack:

 Dual Zidovudine 300 mg plus Lamivudine 150 mg orally twice a day
plus
 Nevirapine 200 mg orally once a day
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 Stepping up, after the first two weeks:
Give triple combination of Zidovudine (300mg) + Lamivudine (150g) +

Nevirapine (200mg) twice a day.
Alternative First-Line Regimen, Two-Week Starter Pack
Zidovudine 300mg + Lamivudine Zidovudine 300mg + Lamivudine

150mg 150mg plus Nevirapine 200mg
B. Stepping up, after the first two weeks:
Step Up After the First Two Weeks
Zidovudine 300mg + Lamivudine Zidovudine 300mg + Lamivudine

150mg + plus Nevirapine 200mg 150mg + plus Nevirapine 200mg
Substitution in the event of medicine toxicity /

adverse events and unavailability
If the patient has suspected adverse medicine events, therapy should
be altered as follows (change of a single medicine in a multi-medicine
regimen is permitted—that is, the offending medicine may be replaced,
preferably with an alternative medicine of the same class):
 Given Zidovudine toxicity such as anaemia or neutropenia,
Zidovudine will be replaced by Tenofovir.
 If a patient reacts to Nevirapine, substitute with Efavirenz 600 mg
orally once daily at night.
 In the event of lactic acidosis, the current ARVs should be
discontinued and ART restarted after checking for normalization of
the lactate levels. In case of severe psychiatric reaction on EFV
give NVP.
 In case creatinine clearance is known and < 50ml/min give AZT.
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An alternative to Lamivudine (3TC) is emtricitabine (FTC); these
medicines are considered pharmacologically equivalent In the event
that you come across a patient on Tenofovir/emtricitabine /Efavirenz,
you may substitute emtricitabine with Lamivudine.
For patients presenting with renal impairment; consult/ refer for

specialist opinion.
Second-line treatment recommendation for adults

and adolescents
Ideally, patients who fail to respond to first-line treatment should be

treated with a different regimen that contains medicines that were not
included in the first regimen. The second-line regimen will still consist
of two NRTIs but with a PI. The second-line regimen should be initiated
only after assessing treatment adherence and failure and in
consultation with a specialist in HIV and AIDS treatment or the clinical
mentorship team at the OI/ART clinic, as the recommendation will be
based on what the patient is already taking or has taken in the past.
Clinical mentors should be consulted where there is doubt about what
to do. More adherence counselling will be required in preparation for
the planned new therapy.
Table 8.1: Preferred second line regimens for adults and adolescents
including pregnant and breastfeeding women
Target Population Preferred second line regimens
Adolescents ≥10 years, If TDF was used in first AZT + 3TC + ATV/r or
line ART LPV/r
Adults, Pregnant and
Breastfeeding women If AZT was used in first TDF + 3TC + ATV/r or
line ART LPV/r
HIV and TB co-infection Patients receiving Same NRTI backbone as

Rifampicin recommended for adults
and adolescents plus
double dose LPV/r
(800mg/200mg BD
HIV and HBV co- AZT + TDF +3TC +

infection ATV/r or LPV/r*
Note: * ATV/r is the preferred PI in all cases
 Those patients with Hepatitis B infection will always need

Tenofovir and Lamivudine among their medicines.
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 Patients currently on abacavir plus didanosine plus a PI

should be transitioned to the above regimens.
 For adults who cannot tolerate both TDF and AZT use ABC/3TC
and ATV/r or LPV/r
 Abacavir /Lamuvudine 600 mg /300mg orally once daily
 plus
 Atazanavir/ritonavir one daily or Lopinavir/ritonavir twice daily
Third-line treatment recommendation for adults and adolescents
Those failing second-line therapy will need to be referred for specialist

assessment which may include viral load and genotype testing prior to
recommending the third-line medicines. Adherence needs to be
reinforced all the time. in adults, raltegravir (400mg) twice a day and
darunavir (600mg) twice daily and ritonavir (100mg) twice daily will be
used as well as any other medicines as determined by the laboratory
tests where available.
Use of ARVs in patients with TB

(refer to the latest national TB guidelines or TB/HIV guidelines)
TB is the most common OI encountered among people with HIV
infection in Zimbabwe. Since the advent of the pandemic of HIV
infection, TB has remained a serious public-health problem. Studies
have shown that up to 50% of people with HIV infection develop TB
and that up to 85% of patients with TB have HIV infection. In addition,
TB accounts for a third of HIV-related deaths. There is a need to
integrate the HIV and TB services, as TB and HIV coinfection is
common. All patients living with HIV should be screened for TB at
every visit using the standard TB screening tools. Rifampicin
interacts adversely with some antiretroviral agents such as PIs and
Nevirapine. The preferred regimen for HIV positive TB patients is
Tenofovir plus Lamivudine and Efavirenz.
Patients with TB who are not yet on ART

In patients who have HIV-related TB but are not yet on ART, treatment
of TB takes priority. ART should be started at least two weeks after the
start of TB therapy i.e. during the intensive phase when the patient has
stabilised on TB treatment regardless of their CD4 count status.
TB/HIV co-infected patients with severe immunosuppression such as
CD4 count less than 50 cells/mm3, should receive ART early i.e. within
the first 2 weeks of initiating TB treatment. Cotrimoxazole prophylaxis
should be provided with the commencement of the TB therapy if the
patient is not on it already.
Patients who develop TB when already on ART
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Treat TB as per national TB guidelines.
Use of ARVs in Patients with Cryptococcal

Meningitis
Prevention of Cryptococcal Disease
Patients initiating ART with undiagnosed cryptococcal disease are at
higher risk of early mortality than patients who are pre-emptively
diagnosed and treated for cryptococcal disease. All patients initiating
ART should be clinically screened for evidence of symptomatic
cryptococcal disease – headache, neck stiffness, fever, focal
neurologic signs, confusion, and altered mental status. All those who
screen positive should be referred for further diagnostic work up for
meningitis. Screening of asymptomatic ART naïve individuals with CD4
count <100cells/mm3 is recommended and should be done with a
Cryptococcal neoformans antigen test (CrAg) using latex agglutination
tests (LA) or lateral flow assays (LFA) on serum, plasma or CSF. A
lumbar puncture should be offered to individuals who screen positive
for cryptococcal antigen, as a positive cryptococcal antigen may
precede the onset of clinical cryptococcal meningitis by many weeks.
Individuals who are screened for cryptococcal disease should be
managed as indicated in Table 8.2.
Table 8.2: Treatment decisions for asymptomatic cryptococcal disease
Serum No LP necessary. No fluconazole required. Initiate ART.
CrAg
negative
Serum If available recommend LP:
CrAg
positive
If CSF CrAg positive, manage for cryptococcal meningitis
If CSF CrAg negative treat with Fluconazole 800mg orally once
daily for 2 weeks, then Fluconazole 400mg orally daily for 8
weeks, followed by maintenance therapy with Fluconazole 200mg
orally daily until CD4>200 cells/mm3 for 6 months
Timing of ART for individuals with asymptomatic cryptococcal

antigenemia is unknown. We recommend initiation of ART 2-4 weeks
after initiation of antifungal therapy in individuals who screen positive
for serum CrAg without any evidence of disseminated cryptococcal
meningitis.
Timing of ART in cryptococcal meningitis
The timing of the initiation of ART in patients with cryptococcal
meningitis is still uncertain. Early initiation of ART is recommended for
all OIs except for intracranial OIs such as TB meningitis and
cryptococcal meningitis. In cryptococcal meningitis ART can be
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initiated 2- 4 weeks after initiation of antifungal therapy with

amphotericin B based regimens. In patients who are predominately
treated with fluconazole monotherapy ART should be initiated at least
4 weeks after initiation of antifungal therapy.
ART should not be commenced at the same time that amphotericin B
and/or fluconazole therapy is commenced for cryptococcal meningitis.
Use of ARVs in Children
More than 90% of HIV-infected children acquire their infection through

mother to child transmission of HIV (vertical transmission). Thus,
elimination of new HIV infections among children through
effective PMTCT interventions should be prioritized. HIV disease
progression occurs very rapidly in the first few months of life in infants
acquiring HIV in utero, often leading to death. The importance of early
infant diagnosis (EID) of HIV infection and early initiation of ART can
therefore not be overemphasised.
Early infant diagnosis

All infants should have their HIV-exposure status established at their
first contact with the health system, ideally before six weeks of age.
Check for HIV exposure status on the child health card, or inquire from
the mother or caregiver. Where the mother is available and was not
tested during pregnancy, perform a rapid HIV test on the mother and if
she is positive, then her infant is HIV exposed and needs to have a
DBS collected for HIV DNA PCR.
At 9 months of age, most infants (93%) no longer possess maternally

transferred antibodies. Prior to the age of 18 months, a DNA
polymerase chain reaction (PCR) test for HIV is more reliable. A DNA
PCR test should be offered to all exposed infants from six weeks of
age. If the DNA PCR test is negative before the age of 18 months, the
infant does not have HIV infection but is at risk of infection if
breastfeeding is continued.
In an infant, outside the window period (three months after last

exposure - labour/delivery, or breastfeeding) and rapid HIV test is
negative, then the infant has not been infected with HIV and can be
considered definitively negative.
If an infant is still within the window period, and rapid HIV test is
negative then the infant is still considered to be HIV exposed and may
be infected and should be managed as an HIV-exposed infant.
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Where virological testing is not available for children less than 18
months, a presumptive diagnosis of severe HIV disease should be
made if the infant is confirmed HIV antibody positive and:
1. Diagnosis of any AIDS-defining condition(s) can be made, or
2. The infant is symptomatic with two or more of the following:
1. Oral thrush
2. Severe pneumonia
3. Severe sepsis
Infants under 18 months of age with clinically diagnosed presumptive

severe HIV should be started on ART. Confirmation of HIV diagnosis
should be obtained as soon as possible.
Recommendations for antibody testing in infants

Antibody tests (rapid and laboratory-based ELISA) are the preferred
method of diagnosis for HIV infection for children over 18 months of
age.
In a child under 18 months who has never been breastfed and HIV
antibody tests are negative, this child is uninfected and virological
testing is indicated only if clinical signs or subsequent events suggest
HIV infection.
In a child under 18 months who has not breastfed for more than six
weeks, HIV antibody tests that are negative mean the child is
uninfected.
HIV antibody tests that are positive at any age under 18 months
identify those infants who need virological tests (i.e., the child is HIV
exposed but needs definitive test with HIV DNA PCR to confirm HIV
infection).
Care of an HIV-exposed infant

Initial care
Care for HIV-exposed infants should include the following:
 Make sure HIV-exposed infants are entered into the “HIV exposed
follow-up register”
 All HIV-exposed infants should have HIV DNA PCR testing

performed from six weeks of age or at the earliest possible time
thereafter if 6 weeks testing is missed.
 Cotrimoxazole prophylaxis should be given from six weeks of age

until the HIV status of the infant is known. If the HIV infection is
confirmed, continue cotrimoxazole and commence on ART.
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 Monthly follow up visits are recommended, but more

frequent visits may be needed if problems are detected.
During these visits the following services should be provided:
 Growth monitoring and promotion
 Developmental assessment
Counselling on infant and young child feeding:

 Counselling and support for the HIV infected mother to adhere to
ART is crucial.
 Weaning should not be abrupt, but rather should be gradual over

a one month period.
 HIV-infected infants diagnosed by virological testing or infants

with symptoms suggestive of HIV should continue breastfeeding
for as long as possible.
 Immunisations should be given according to the national

guidelines. The BCG vaccination should still be given at birth, but
BCG should not be given to children with symptomatic HIV
infection.
 Always look for and treat opportunistic infections.
Management of an HIV-infected child using ARVs
Infants and young children have an exceptionally high risk of poor

outcomes from HIV infection.
The goal of ART for children is to increase survival and decrease HIV-
related morbidity and mortality.
Criteria to initiate ART in children

1. All children below 5 years of age MUST be commenced on ART
irrespective of their CD4 count.
2. All children 5 years and above with paediatric WHO clinical stage
3 or 4 disease MUST be commenced on ART irrespective of CD4
percentage.
3. Children≥5 years with WHO clinical stage 1 or 2 and a CD4 count
less than 500 should be commenced on ART (see Appendix II for
clinical staging)
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Table 8.3: Recommendations on when to start ART in children
(Adopted from WHO 2013 HIV guidelines)
Age When to start

Infants (<1yr) Treat all individuals
1 year to less than 5 years Treat all individuals
(children ≤2 years or with WHO stage
3 or 4 or CD4 count ≤750 or CD4
%<25% as a priority)
5 years and above WHO stage 3 or 4 or CD4 ≤500 (CD4

≤350 as a priority)
Issues to consider in initiating ART in children
Psychosocial factors: It is important to identify and counsel at least

one dedicated caregiver who can supervise and/or give medicines.
Disclosure: The process of disclosure to the child should be initiated as
early as possible, usually from as early as 5 – 7 years of age.
Adherence is good in children who know their status and are supported
to adhere to medicines.
Table 8.4: Recommended first-line treatment for children
First line treatment Alternative first line

treatment
Children < 3years AZT + 3TC + LPV/r AZT + 3TC + NVP
ABC + 3TC + LPV/r
ABC + 3TC + NVP
Children 3 - <10 years and AZT + 3TC + NVP ABC + 3TC + EFV
adolescents <35kg
Special circumstances* d4T+ 3TC + LPV/r
d4T+ 3TC + NVP
* use d4T for children with anaemia or other contraindication to use

AZT
Monitoring children on ART

 Check haemoglobin if on Zidovudine after at least 6-8 weeks
 Urine dipsticks for glycosuria and estimated glomerular filtration

rate (eGFR) and/or serum creatinine when on Tenofovir
 Alanine aminotransferase (ALT) for Nevirapine
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 CD4 count every 6 months
 Viral load once every year or when clinical signs are suggestive of
treatment failure
Recommended second-line treatment for children
Definition of treatment failure in children
Clinical Failure:
New or recurrent clinical event indicating advanced or
severe immunodeficiency (WHO clinical stage 3 and 4
or clinical condition with exception of TB) after 6 months of
effective treatment
Immunological failure:
Younger than 5 years - Persistent CD4 levels below 200 cells/mm3 or
CD4 percentage <10%
Older than 5 years - Persistent CD4 levels below 100 cells/mm3
Virological failure:
Plasma viral load above 1000 copies/ ml based on two consecutive
viral load measurements after 3 months, with adherence support.
OR If using dry blood spot technology, a viral load above 3000

copies/ml based on two consecutive viral load measurements after 3
months, with adherence support.
Table 8.5: Recommended second line ART regimens
Second line ART Preferred Alternative

If AZT used for 1st line ABC+3TC+LPV/r
Children then use ABC
containing 2nd line, if
ABC is used then use
AZT
If PI <3yrs No change from ABC +3TC + NVP
based first line regimen
first line used
regimen 3yrs to ABC +3TC + EFV TDF+ 3TC NVP
used <10yrs ABC+3TC+NVP
Discuss the child with your mentor IF NOT SURE OF

SECOND LINE TREATMENT
Starting ART in children using FDCs
132
Refer to dosing table. Keep the following factors in mind with regard to
dosing:
 Medicine doses must be adjusted as the child grows.
 Dosing is by weight.
 Overdosing up to 10% is acceptable.
 Scored tablets may be divided into two equal halves
 Tablets may be crushed and mixed with a small amount food
or water and administered immediately.
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Table 8.5: Recommended Paediatric ARV medicines (adopted from WHO 2013)
Strength of tablet No. of tablets or sprinkle capsule/sachets by weight band
or sprinkle
sachet or 3-5.9kg 6 -9.9kg 10-13.9kg 14-19.9kg 20-24.9kg 25-34.9kg
capsule
AM PM AM PM AM PM AM PM AM P AM
M
PABC/3TC/NVP 60mg/30mg/50mg 1 1 1.5 1.5 2 2 2.5 2.5 3 3 4 4

LPV/r sprinkles 40mg/10mg 2 2 3 3 4 4 5 5 6 6
ABC/3TC/LPV/r 30mg/15mg/ 2 2 3 3 4 4 5 5 6 6
40mg/10mg
AZT/3TC/LPV/r 30mg/15mg/ 2 2 3 3 4 4 5 5 6 6
40mg/10mg
DRV/r 240/40mg - - - - 1 1 1 1 2 1
ATV/r 100/33mg - 1 1 2
ABC/3TC 120/60mg 1 1.5 2 2.5 3
TDF/3TC 75mg/75mg 1.5 2 2.5 3-3.5
TDF/3TC/EFV 75mg/75mg/1 1.5 2 2.5 3-3.5
50mg
TDF/3TC adult 300mg/300mg One third One half Two thirds 1
double scored
TDF/3TC/EFV 300mg/300mg/ One third One half Two thirds 1
adult double 600mg
scored
3 tablets for 25-29.9kg and 3.5 tablets for 30-34.9kg
TDF tablets are scored to break into half or third.
134
USE OF ARVS FOR PREVENTION OF
MOTHER-TO-CHILD TRANSMISSION OF HIV
(PMTCT)
GENERAL NOTES 136
INFANT AND YOUNG CHILD FEEDING RECOMMENDATIONS
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General Notes
Mother-to-child transmission is responsible for more than 90% of HIV infection

in children and at least two thirds of such infections occur during pregnancy
and delivery whilst the remainder occur during breastfeeding. It is therefore
critical to identify HIV-positive pregnant and lactating women and manage
them appropriately.
When to start ART in HIV positive pregnant and breastfeeding women
 All HIV infected pregnant and breastfeeding women should initiate

lifelong antiretroviral treatment (ART) irrespective of their CD4 count or
WHO clinical stage (Option B+).
 Women who are not yet ready for lifelong ART should be initiated on
triple ARVs (ART), which should be continued at least for the duration of
breastfeeding to prevent further risk of mother-to-child transmission of
HIV through breast milk.
 HIV infected lactating women meeting treatment eligibility criteria (CD4
500 or less) should continue lifelong ART according to criteria for adult
non-pregnant populations as it would be inappropriate for them to
discontinue ART after the breastfeeding period.
N.B. Pregnant and breastfeeding women who were initiated on Zidovudine

prophylaxis should be discontinued and commenced on lifelong ART (Option
B+).
Being on lifelong ART will necessitate ongoing counselling of HIV

positive pregnant and breastfeeding women to support retention and
adherence and to minimize loss to follow-up.
 Emphasise modes of HIV transmission and prevention, PMTCT,

and access to care and treatment.
 Encourage partner HIV testing and counselling
 Encourage the importance of skilled birth attendance, clean and

safe delivery, and newborn care.
 Counsel on infant and young child feeding and maternal nutrition.
 Counsel on sexual and reproductive health including family planning

and the need for dual contraception (reliable hormonal
contraceptive plus barrier method like male or female condoms)
 Make an appointment for family planning at six weeks postpartum.
136
 Stress the need for condom use for prevention of STIs and HIV
during pregnancy and in the postpartum period.
 Retest previously negative women in 3rd trimester of pregnancy and/

or at delivery, 6 weeks post natally and 6 monthly thereafter.
 Stress the importance of follow-up for the HIV exposed infant

o Commence cotrimoxazole prophylaxis from 6 weeks of
age
o Collect Dried Blood Spot (DBS) for HIV DNA PCR test at
6 weeks of age i.e.Early Infant Diagnosis (EID).
o Infants should be re-tested at the end of the breast-
feeding period
Table 9.1: Timing of Initiation of ART for Mother and ARV Prophylaxis for
Infant (PMTCT)
Pregnancy Labour Post delivery (breastfeeding and

non breastfeeding)
Maternal Infant (Birth to six weeks)
Preferred first line
Tenofovir + Lamivudine +Efavirenz BW<2500: NVP 10mg daily

BW ≥2500: NVP 15mg daily
Alternative First line
Zidovudine +Lamivudine + Efavirenz BW<2500: NVP 10mg daily

BW≥2500: NVP 15mg daily
When using ARVs in pregnant women, certain precautions should be kept in

mind:
Efavirenz (EFV)
Previously there was a recommendation not to use Efavirenz during the first
trimester and in women at risk of becoming pregnant. However, WHO issued
evidence based update on Efavirenz safety in pregnancy in 2011 which
recommends it to be safe for use even in the first trimester.
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Infant and young child feeding

recommendations
All mothers whether known to be infected with HIV or not should exclusively
breastfeed their infants (no mixed feeding) for the first 6 months of life,
introducing safe, adequate and nutritious complementary foods thereafter,
with continued breastfeeding up to 24 months and beyond.
ARV prophylaxis in an HIV-exposed infant
HIV-exposed infants whose mothers are on lifelong ART should be
commenced on Nevirapine prophylaxis for six weeks.
Table 9.2: Infant Nevirapine prophylaxis
Age Nevirapine dosage

Birth to six weeks BW <2500*: 10mg once daily
BW ≥ 2500: 15mg once daily
 Always remember to change the dose when baby gains weight.

 *For very low birth weight babies below 2000g dose of NVP is 2
mg/kg once daily for 6 weeks
 If any contraindications to NVP use 3TC 4mg per kg 12hourly for 6
weeks
 For non-breastfeeding infants NVP as above or AZT 4mg/kg 12
hourly for 6 weeks
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TUBERCULOSIS
GENERAL NOTES 140
CONTROL OF TUBERCULOSIS - TB POLICY 140
PREVENTION 141
CASE MANAGEMENT 142
MEDICINE REGIMENS FOR TUBERCULOSIS 143
TREATMENT OF NEW CASES OF TB 144
ALL PREVIOUSLY TREATED CASES OF ANY FORM OF TB 145
DRUG RESISTANT TB (DR-TB) 146
FIXED DOSE COMBINATION OF ANTI-TB MEDICINES 146
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General Notes
Tuberculosis is a chronic, infectious, debilitating disease, caused by
Mycobacterium tuberculosis. It is a public health problem and all cases must
be notified to the Provincial/City Medical Director in terms of the Public Health
Act. Due to the association between TB and HIV infection, the prevalence of
TB is increasing, and patients are often more seriously ill than before.
Control of Tuberculosis - TB Policy

For more information on National Policy and the organisation of the TB services refer to the
Ministry of Health & Child Care’s ZIMBABWE TUBERCULOSIS CONTROL PROGRAMME
MANUAL.
The essential points of the TB policy are:

 Sputum microscopy for diagnosis and follow up provided free of charge
in the public health sector
 Short-course chemotherapy provided free of charge in the public health
sector
 Treatment of Drug Resistant TB(DRTB) provided for free of charge in the
public sector
 TB services available at all levels of the health delivery system,
being integrated into the primary health care system to ensure
efficient case finding, particularly for sputum smear positive
patients
 Collaborative TB/HIV activities at all levels
An important emphasis of the TB programme is the direct observation of

treatment (DOTS), which means that a treatment supervisor watches the
patient actually swallowing the tablets. A supervisor can either be a healthcare
worker or a trained member of the community.
TB control is administered in a standardised way from the Central level to

Health Centre level. Within this system notification, registration, record
keeping and contact tracing activities in addition to treatment are carried out. It
is essential that all patients requiring TB treatment be referred for
management in the National TB Programme.
TB fixed dose combinations are to be available at all levels from C
through to A. Single formulations’ level of availability is B level
medicines. TB medicines are accorded V level of priority.
140
Prevention
Primary prevention
 BCG vaccination is given at birth or at first contact with the child after birth
(except in babies with clinical signs of HIV infection and/or in infants born
to a mother with sputum positive TB).
 BCG vaccine should be given to all babies, even those born to mothers
known to be HIV positive.
 BCG is given intradermally on the right upper arm, above the insertion of
the deltoid muscle.
 No booster dose should be given.
The batch number of the vaccine and the date must be recorded on the child’s
health card. Dosage is as recommended by EPI Programme (see the chapter on
Immunisation).
Problems associated with BCG vaccination remain uncommon and are mainly
due to faulty technique.
Abscesses or ulcers should be treated with local hygienic care. Abscesses
should be aspirated not incised. Secondary infections can be treated with
antibiotics. Non-healing ulcers, (ulcers of duration > 8 weeks) or regional
lymphadenopathy can be treated with:
Medicine Codes Dose Frequency Duration
isoniazid po B V 10mg/kg once a day 2 months
Secondary prevention
An infant born to a mother with sputum positive TB should not be given BCG
at birth
 Give the child isoniazid 10mg/kg day prophylaxis for two months
 After two months perform a mantoux test.
 If the Mantoux test is positive give full TB treatment.
 If the Mantoux test is negative continue with isoniazid prophylaxis for
four more months.
 Follow with BCG vaccination if not HIV infected
If parents are found to be sputum positive and the child has no signs of active
TB, check the child’s BCG status and vaccinate if not already done.
In addition give isoniazid prophylaxis for 6 months to children less than three
years of age:
Medicine Codes Paed Dose Frequency Duration

isoniazid po B V 10mg/kg once a day 6 months
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Note: For prophylaxis and treatment in neonates give isoniazid 5mg/kg/day

Prevent further transmission of tuberculosis by health education and
counselling on the importance of completing TB treatment, contact tracing,
case finding and prevention of HIV infection.
IPT for HIV positive patients in whom active TB has been excluded, refer to
IPT under HIV related diseases and National TB Guidelines
Case Management
Diagnosis
Clinical Diagnosis of TB
The presence of pulmonary tuberculosis should be suspected in individuals
presenting with one or more of the following complaints:
 Cough for 2 weeks or longer
 Production of sputum, which may be bloodstained
 Loss of appetite
 Night sweats
 Fever
 Loss of weight
 Shortness of breath
Sputum
The diagnosis of TB is made by demonstrating alcohol acid-fast bacilli (AAFB)
in the sputum by direct smear microscopy (DSM). DSM is repeated at the end
of the intensive and continuation phases to confirm sputum conversion and
cure.
Due to the concerns of medicine resistance the following patients MUST
submit sputum specimens for Gene Xpert test, culture and medicine sensitivity
testing to the TB Reference Laboratory
 All relapses
 Patients on category 1 treatment who are sputum positive at 3/5 months
 Patients on category 2 treatment who are sputum positive at 3/4 months (at end of
prolonged intensive phase).
 Patients on category 2 treatment who are sputum positive at the end of treatment
 Patients who are sputum-smear positive and have been in contact with MDR-TB
case.
 Gene-Xpert screening for all HIV positive patients
 Residence in DRTB high burden zones
 Return after treatment default
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Chest X-Rays
Indications for chest x-rays
 A child suspected of TB
 HIV positive patient who is sputum negative
 Non-response to broad-spectrum antibiotics for correct duration in sputum negative
and HIV negative patient
 Non-response to broad spectrum antibiotics in a sputum negative patient.
 When suspecting complications, e.g., pneumothorax, or pleural effusion
 When frequent and severe haemoptysis occurs
 When other lung diseases are suspected by the medical officer
 Pericardial effusion
Chest x-rays should NOT be routinely used for diagnosing pulmonary TB. In sputum
positive patients a chest x-ray is not necessary.
Note: In the presence of clinical improvement, it is not necessary to monitor the response of
pulmonary TB to treatment by chest x-rays
Tuberculin Testing
Use Mantoux test only:
tuberculin, purified B E 0.1ml - -
(PPD) 1:1000 intradermal (=5TU)
Examine induration at 48-72 hours.

 A positive Mantoux (person with normal immunity: induration > 10 mm,
person with defective immunity: induration > 6 mm) may indicate active
infection (especially if strongly positive), previous infection or previous
BCG.
 Absence of a response does not exclude TB because individuals with HIV
may not have sufficient immunity for a positive skin test despite active TB.
 If a child under 3 years of age has not had BCG, the Mantoux test may be
useful.
 All TB suspects should be offered HIV counselling and testing (Provider
initiated testing and counselling i.e. PITC) at the same facility where the
sputum is examined.
Medicine Regimens for Tuberculosis

Two main treatment categories, Category 1 and Category II are now used in
Zimbabwe for medicine sensitive TB. The regimens consist of a combination
of five first line medicines. These medicines are available as oral Fixed Dose
Combination (FDC) and an injectable, streptomycin.
The intention of these combination tablets is to improve compliance by
reducing the number of tablets a patient has to take, and to reduce the
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possibility of medicine resistance developing. The number of FDC

tablets is determined by a weight range for each patient at the start of
treatment
 Treatment is the same for HIV infected people as for non-HIV infected.
 There are specific differences between regimes for adults and children in
each category.
NOTE: If any signs of a reaction occur, the treatment should be stopped
immediately and the patient seen by a doctor.
Key to Medicine Abbreviations

H= isoniazid Z/PZA= pyrazinamide
R= rifampicin S= streptomycin
E= ethambutol
No streptomycin should be given to children less than 12 years old
except for meningitis, or to pregnant women, or those whose body
weight is below 30kgs). Recent evidence has shown that it is safe to use
ethambutol in children as it has less ocular toxicity in children of all ages than
previously thought. Thus ethambutol has been reintroduced in paediatric
regimens.WHO (2006). Ethambutol efficacy and toxicity: literature review and recommendations
for daily and intermittent dosage in children,
Treatment of new cases of TB

(Category I)
All new cases of TB regardless of site, bacteriology or severity
Adults:
. Intensive phase: 2 months HRZE (DOT)
Continuation phase: 4 months HR (DOTS) OR (6 months HR in TB of
meninges, bone, joint, pericardium, disseminated spinal disease)
2HRZE/4HR (DOT)
The use of the combination of isoniazid and ethambutol (HE) in the

continuation phase has been phased out in Zimbabwe.
Children:
 Intensive phase: Two months HRZE (DOT)
 Continuation phase: Four months HR (DOT) ( or 10HR for patients with
TB of the meninges, bone joint, pericardium, military TB or TB spine)
In children under 12 years, no streptomycin should be given except for TB
meningitis.
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General notes: Category I
 In smear positive cases, repeat sputum smear exam at end of two
months. If the sputum is still positive at the end of two months the
extension of the intensive phase is no longer necessary. Start
continuation phase irrespective of sputum results at end of two months.
 If the sputum is still smear positive at the end of two months repeat
sputum smear exam at the end of month three. Sputum smear should be
sent to the National TB Laboratory for culture and sensitivity testing if still
smear positive after three months of treatment. A sputum sample should
be collected for Gene Xpert test at the local laboratory.
 Sputum testing should be collected for Gene Xpert testing and another
one sent to the National TB Laboratory for culture and sensitivity testing if
still smear positive after five or six months of treatment. If the patient’s
sputum remains smear positive after five months of treatment (treatment
failure) Category II treatment should be commenced.
 Children weighing less than 11kg receive paediatric FDC HRZ plus
additional isoniazid and ethambutol.
 Children weighing 11kg and above receive adult formulations and
additional isoniazid.
 The total duration of treatment is six months.
 Children with tuberculous meningitis or pericarditis, disseminated or spinal
disease with neurological complications should be given 10HR
(continuous phase) i.e. 10 months of isoniazid and rifampicin under direct
observation.
 Adults with TB of meninges, bone, joint, pericardium, disseminated, or
spinal disease should be given 6 HR (continuous phase) i.e. 6 months of
isoniazid and rifampicin under direct observation.
All previously treated cases of any form of TB

(Category II)
Adults:
 Intensive phase: 2 SHRZE daily for two months followed by HRZE daily
for one month
 Continuation phase: 5 HRE daily for 5 months [DOT]
Children:
 Intensive phase: 3 months RHZE daily
 Continuation phase: 5 months of HRZ daily
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General notes: Category II

 Duration of TB Course: 8 months
 If at the end of the initial 3 months the sputum is smear negative or
positive the continuation phase is started.
 If the sputum is smear positive at three months (12 weeks), take sputum
for Gene Xpert,and for culture and DST. Start the continuation phase.
Consult the District/Local MDR TB Team when DST results available.
Further extension of the continuation phase will not increase the chances
of cure.
 If a patient is still smear positive at the end of 4 months, all
medicines should be stopped for 3 days and a sputum specimen
sent for Gene Xpert testing and another sputum specimen sent to
the National TB Reference Laboratory(NTBRL) in Bulawayo or
National Microbiology Reference Laboratory in Harare(NMRL) for
culture and susceptibility. The patient should then be started on the
continuation phase.
 Patients who remain smear positive after the end of the fully supervised
continuation phase will derive no benefit from another re-treatment
regimen. They are termed chronic TB cases and are at high risk for
medicine resistant TB. Collect sputum for Gene Xpert as well as for
culture and sensitivity. Refer to DR-TB guidelines
Drug Resistant TB (DR-TB)

Drug resistant TB (DR-TB) is the presence of bacilli resistant to one or more
anti-tuberculosis medicines and includes multidrug-resistant tuberculosis
(MDR-TB) and extensively drug-resistant TB (XDR-TB).
These are patients who remain (or again become smear positive) after
completing a fully supervised re-treatment regimen. The management of
MDR or XDRTB cases is problematic; health workers should consult the MDR
TB team.
Note: Although smear negative PTB and extra-pulmonary cases may also
be treatment failures, relapses and DR-TB, this is a rare event and should
be supported by pathological and /or bacteriological evidence.
MDR TB: Following preliminary results of rifampicin resistance by gene-
xpert, patients must be put on standardised Category 4 treatment of
MDR-TB whilst waiting for full DST results.
Fixed Dose Combination of Anti-TB Medicines

The essential anti-TB medicines now come in fixed dose combinations
(FDCs) such that each tablet has 2 (2-FDC), 3 (3-FDC), or 4 (4-FDC)
medicines.
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Fixed dose combination tablets
Fixed dose combination tablets improve compliance by reducing the number
of tablets a patient has to take, and reduce the possibility of medicine
resistance developing. The FDCs available in Zimbabwe are:
 Rifampicin, Isoniazid, Pyrazinamide and Ethambutol: (RHZE)
 Rifampicin, Isoniazid and Ethambutol: (RHE)
 Rifampicin and Isoniazid: (RH)
The number of FDC tablets is determined by a weight range for each patient
at the start of treatment and this is shown in the Table 10.1 to Table 10.8.
Adverse Medicine Reaction

Stop all TB medicines and assess. If necessary evaluate the liver function.
Then reintroduce one medicine at a time, and build up gradually. Start with
isoniazid at 25mg – the least likely to cause a reaction. When the required
dose has been achieved without any reaction, another medicine should be re-
introduced in a similar manner – slowly, increasing the dose daily.
e.g Day 1 Isoniazid 25mg
Day 2 Isoniazid 50mg
Day 5 Isoniazid 300mg + Rifampicin 150mg
Day 6 Isoniazid 300mg + Rifampicin 300mg
Day 7 Isoniazid 300mg + Rifampicin 450mg, etc(Refer to the National
TB Guidelines)
TB and HIV Co-infection
Refer to the current national ARV guidelines as well as the TB guidelines.
Also refer to the ARV chapter in this EDLIZ
Recommended doses of TB medicines in Children
 Rifampicin: 15 mg/kg/day (10 to 20 mg/kg/day)
• Isoniazid: 10 mg/kg/day (10 to 15 mg/kg/day)
• Pyrazinamide: 35 mg/kg/day (30 to 40 mg/kg/day)
 Ethambutol: 20 mg/kg/day (15 mg to 25 mg/kg/d).
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Daily doses by weight – Category I
Table 10.1: Paediatric Intensive Phase weight band (2 months RHZE)

Weight Rifampicin Additional Ethambutol
bands Isoniazid (H) INH 100mg tabs 100mg
in kg Pyrazinamide (Z) tab
60/30/150mg
3 - 5.9 1 ½ tabs ¼ tab 1 tab
6 - 10.9 2 tabs ½ tab 2 tabs
Table 10.2: For children in the 11-30.9 kg weight band use adult kits with
additional INH
Weight Rifampicin Isoniazid (H) Additional
bands in kg Pyrazinamide (Z INH 100mg
Ethambutol tabs tab
150mg:75mg:400mg:275mg
11 - 15.9 1 tab 1 tab
16 - 20.9 2 tabs 1 tab
21 - 30.9 2 tabs 2 tabs
Table 10.3: Paediatric Continuation Phase (RH) 4 months daily

Weight Rifampicin Additional
bands Isoniazid INH 100mg
in kg 60mg/30mg tab
3 - 5.9 1 ½ tabs ¼ tab
6 - 10.9 2 tabs ½ tab
Table 10.4: Continuation phase (RH) 4 months daily (except TB meningitis,

TB spine where (RH) 10 months
Weight Rifampicin Isoniazid Additional INH
bands in 150mg:75mg 100mg tab
kg
11 - 15.9 1 tab 1 tab
16 - 20.9 2 tabs 1 tab
21 - 30.9 2 tabs 2 tabs
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Table 10.5: New adult Number of FDC tablets per day for each Weight band
(2RHZE/4HR)
Regimen Initial phase (2 Continuation
months) Phase (4 months)
2(RHZE) daily 4(HR) daily
(Isoniazid 75mg+ (Isoniazid 75mg +
Rifampicin 150mg + Rifampicin
Patient’s
Pyrazinamide 400mg + 150mg)
Weight
Ethambutol 275mg)
30 - 39 kg 2 1.5
40 - 54 kg 3 2
55 - 70 kg 4 3
70 kg + 5 3
Daily doses by weight – Category II
Table 10.6: Paediatric Intensive Phase 3 months (RHZE)

Weight Rifampicin (R) Addition Ethambutol (E)
bands Isoniazid (H) al INH tabs 100mg
in kg Pyrazinamide (Z) 100mg
60/30/150mg tab
3 - 5.9 1 ½ tabs ¼ tab 1 tab
6 - 10.9 2 tabs ½ tab 2 tabs
Weight Rifampicin (R) Isoniazid Additional

bands in kg (H) Pyrazinamide (Z) INH 100mg
Ethambutol (E) tabs tab
150mg:75mg
:400mg:275mg
11 -15.9 1 tab 1 tab
16 - 20-.9 2 tabs 1 tab
21 - 30.9 2 tabs 2 tabs
Table 10.7: Paediatric Continuation Phase 5 months (RHE)

Weight Rifampicin(R) Ethambutol
bands Isoniazid (H) (E) tabs
in kg 60:30mg 400mg
3 - 5.9 1 tab 1/4 tab
6 - 10.9 2 tabs 1/2 tab
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Weight Rifampicin(R) Isoniazid Additional INH

bands in (H) Ethambutol(E) tabs 100mg tab
kg 150mg:75mg:275mg
11 - 15.9 1 tab 1 tab
16 - 20.9 2 tabs 1 tab
21 - 30.9 2 tabs 2 tabs
Table 10.8: Category II : Retreatment in Previously treated adult

Regimen Initial Phase (3 months) Continuation Phase
(5 months)
Patient’s 2(RHZE)S / 1(RHZE) daily 5HRE
Weight
(Isoniazid 75 mg + 5(HRE) daily (Isoniazid 75 mg +
Rifampicin 150mg + Rifampicin 150 mg +
Pyrazinamide Streptomycin Ethambutol 275mg)
400mg + Ethambutol (IM) 2 months
275mg)
30 - 39 kg 2 0.50 g 2
40 - 54 kg 3 0.75 g 3
55 - 69 kg 4 1 g* 4
70 kg + 5 1 g* 5
 * 0.75 g if 60 years or over.
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TROPICAL DISEASES
ANTHRAX (CUTANEOUS) 152
TICK TYPHUS (AFRICAN) 152
RABIES 152
GENERAL GUIDELINES FOR NTDS 154
KATAYAMA SYNDROME 155
HELMINTHIASIS 155
LYMPHATIC FILARIASIS (ELEPHANTIASIS) 156
PLAGUE (BUBONIC) 157
LEPROSY 158
HUMAN AFRICAN TRYPANOSOMIASIS: 161
TYPHOID FEVER 162
NOTIFIABLE DISEASES AND EVENTS OF PUBLIC HEALTH
IMPORTANCE 165
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Anthrax (Cutaneous)
Case definition: an acute bacterial disease caused by Bacillus anthracis
(Gram-positive). It is manifested at first by itching of an exposed skin
surface, followed by a painful lesion which becomes papular, then
vesiculated and eventually develops into a depressed black eschar in 2-6 days
NB Do not take any laboratory specimens, treat on clinical and
epidemiological basis.
Initial treatment, in severe cases:
benzylpenicillin im/iv C V 1-2 MU 4 times a day initially, then
then procaine penicillin im C V 3gm once daily 7-10 days
Less severe cases:

Doxycycline* po C V 200mg first dose, then
100mg once daily 7 days
*avoid use of doxycycline in pregnant women and children

NB: Pulmonary form of Anthrax- refer to designated Infectious
Disease Hospital
Tick Typhus (African)

Case definition: a rickettsial disease (spread usually by tick bites) that has a
variable onset but most often marked by sudden headache, chills, prostration,
fever and general pains. A maculopapular eruption appears on the 5 th – 7th
day, initially on the upper trunk followed by a spread to the entire body but
usually not to the face, palms or soles. Chancre, local erythema on bite site
with local lymphadenopathy.
doxycycline po C V 200mg first dose, then
100mg once daily 7 days
If no improvement - refer
Rabies
Prevention of Rabies in Humans
 Pre-exposure immunisation
Individual pre-exposure immunisation should be offered to persons at high
risk of exposure, such as animal handlers, veterinarians, National Parks
and Wild Life personnel.
152
 Pre-exposure immunisation schedule:
rabies vaccine, human B V 0.5ml single doses on Day 0, 7
diploid cell im and 28 only
Give a booster every 2-3 years.
Post-exposure Treatment
In dog and other animal bites, the wound should be thoroughly cleaned
with povidone-iodine or soap and water as soon as possible.
Treatment: High Risk
In a previously unvaccinated or incompletely vaccinated individual, where
there is a high risk of rabies, i.e.:
 broken skin
 uncertain animal history or strong suspicion of rabid animal give:
human rabies B V 10 IU/kg once only -
immunoglobulin
(instilled and infiltrated locally around the wound)
and human rabies B V 10 IU/kg once only -
immunoglobulin im
(gluteal)
Vaccinate using the abbreviated multi-site regimen:

2-1-1 vaccination schedule:
rabies vaccine (human B V 0.5ml in one dose on Day 0
diploid cell) im each arm
(upper arm site) Then 0.5ml in one dose on Days 7
one arm and 21
Use a separate syringe and needle for each dose; store vials at 4-8oC after
reconstitution and use as soon as possible.
Low Risk
Where the risk of rabies is low, i.e.:
 skin not broken or other contact (e.g. with infected meat)
 bite from domestic animal WITH LAPSED immunisation against rabies
Follow the 2-1-1 vaccination schedule, but without giving immunoglobulin.
Minimal – no risk
 Bite from a domestic animal FULLY immunised against rabies
 In previously vaccinated individuals give a single booster dose of
rabies vaccine.
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General guidelines for NTDs

Neglected Tropical Diseases (NTDs) include Bilharzia, intestinal worms,
lymphatic filariasis and blinding trachoma
Zimbabwe is instituting Mass Drug (Medicine) Administration (MDA) for

bilharzia, intestinal worms, lymphatic filariasis and blinding trachoma to
children aged 5 to 15 years in endemic districts annually using WHO
guidelines for preventative chemotherapy.
Bilharzia (Schistosoma mansoni & haematobium)

Proper diagnosis can only be made by microscopy of urine and stools.
Antibody tests alone are insufficient basis for treatment.
Clinics without microscopes can treat Schistosoma haematobium infection
on the basis of visible haematuria or positive urine strip test for blood and
or protein in children and adolescents. Refer all suspected cases of
Schistosoma mansoni for further investigations, particularly in the older
patient.
NB. In female patients exclude haematuria caused by menstruation
S. Mansoni
Most patients with S. Mansoni infection have minimal or no symptoms
unless there is heavy infestation. Infection should be suspected in young
patients with unexplained iron deficiency anaemia, hepatosplenomegaly or
non-resolving chronic salmonella infections.
Occasionally patients may present with dysentery like symptoms when
colonic polyps due to S. Mansoni ulcerate and bleed.
Treatment:
S. Haematobium
Medicine Codes Children Frequency Duration
and Adult
dose
praziquantel po C E 40mg/kg one dose only
S. Mansoni:
praziquantel po C E 60 mg/kg once a day 3 Days
General notes:
 Do not give praziquantel in pregnancy. Treat after delivery.
 Praziquantel is generally available as a double-scored 600mg tablets.
Using a 40mg/kg body weight dose, the patient should be given a
dose to the nearest quarter tablet (150mg).
154
Example: The dose for a 70 kg person is 2800 mg (70kg x 40mg).
The patient should be given four and three quarter tablets (2850
mg, the closest convenient dose).
Treatment with praziquantel will also have eliminated any roundworm
infestation.
In Mass drug/medicine administration (MDA) campaigns, a dose pole is
used for administration of praziquantel.
Katayama Syndrome
This is a severe immunological reaction to recent heavy infection with
Schistosoma mansoni or haematobium causing fever and acute serum
sickness. Treat with:
Medicine Codes Adult and Frequency Duration
children
dose
praziquantel po C E 40mg/kg one dose repeat after 2 weeks
and prednisolone po B V 50mg, once a day, reducing by 5mg per day
according to response.
Helminthiasis
General Notes
Prevention: transmission of helminths can be reduced by measures such
as thorough cooking of meat and fish, use of latrines, wearing shoes,
washing hands. Attention to the hands and nails is particularly important in
the case of pinworm. Education to prevent re-infection is very important.
The diagnosis should be confirmed by examination of stool for helminths
and stool microscopy for eggs; peri-anal swab placed in saline for
pinworm.
In the case of pinworm, threadworms (enterobius), the whole family should
be treated. The first choice treatment for all of the above infestations is
albendazole, a broad-spectrum anthelmintic. Note also that treatment of
bilharzia with praziquantel would also have eliminated roundworms.
Caution: Safety in pregnancy has not been established for albendazole; do
NOT use in the first trimester of pregnancy. In most cases, treatment can be
given AFTER delivery.
 All Roundworms except Strongyloides
albendazole po C E 400mg one dose only
<2yrs = 200mg
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 Tapeworm and Strongyloides

albendazole po C E 400mg once a day 3 days*
<2yrs = 200mg
*Note: If not cured after 3 weeks, repeat the course.
 Cutaneous larva migrans (“sandworm”)
albendazole po C E 400mg once a day 7 days
<2yrs=200mg
 Cysticercosis and Neurocysticercosis

Specialist inpatient treatment is required.
praziquantel po C E 17mg/kg 3 times a day 15 days
and prednisolone po B V 15mg 2 times a day 18 days*
* Note: prednisolone therapy must start 2-3 days before praziquantel.
 Hydatid Disease
Refer to central hospital. Serological confirmation is required before
treatment commenced.
Do not aspirate the cysts. Surgery is the treatment of choice. If
inoperable:
albendazole po C E 3mg/kg 3 times a day 30 days, then
wait 15 days (medicine free). Then repeat the cycle 4 times.
Monitor progress with ultrasound.
Lymphatic Filariasis (Elephantiasis)

Case Definition: Hydrocoele, lymphoedema, elephantiasis or chyluria in a
resident of an endemic area for which other causes of these findings have
been excluded.
Causative organisms:
Lymphatic filariasis is caused by the following nematodes
1. Wuchereria Bancrofti (most common)
2. Brugia Malayi
3. Brugia Timori
The infection is transmitted by mosquitoes of the anopheles and culicine

species. The disease is prevalent in 39 of 63 districts in Zimbabwe which
will require MDA.
Clinical Manifestations:
There are three stages of the disease:
156
Early stage:
Due to infective larvae comprising a triad of eosinophilia,
lymphadenopathy and a positive intradermal test. Some patients may be
asymptomatic.
Acute Filarial Manifestation: patients have fever, lymphangitis,

lymphadenitis and relapsing lymphoedema of various body parts e.g.
epididymo-orchitis in males.
Chronic stage: gross persistent lymphoedema of limbs, scrotum, breast

or vulva in females.
Diagnosis: this is based on a combination of a clinico-epidemiological

information and sometimes demonstration of microfilariae in a blood or
fluid smear.
Treatment of the acute phase involves use of Diethylcarbamazine (DEC).
Patients should be referred for specialist management.

Drug therapy for chronic elephantiasis does not alter the eventual clinical
outcome. Surgery for hydrocoele is indicated with local care of the limbs
through daily cleaning/hygiene, elevation, exercise and use of foot ware.
BLINDING TRACHOMA
Refer to Common Eye condition chapter
Plague (Bubonic)
Case definition: Any person with rapid onset of fever, chills, headache,
severe malaise, prostration with extremely painful swelling of lymph nodes,
or cough with blood-stained sputum, chest pain and difficulty in breathing in
an area known to have plague.
 Treat with:
streptomycin im B V 1g first dose Then
0.5g 6 hourly 10 days
Paed = 5-10mg/kg
or chloramphenicol im/iv B V 12.5-25mg/kg
6 hourly 10 days
Paed = 6.25-12.5mg/kg
 Prophylaxis whilst nursing & contacts:

doxycycline po C V 100mg 2 times a day 10 days
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Leprosy
All patients should be referred to the Provincial TB/Leprosy Co-ordinator
(PTBLCO) or specialist for confirmation of diagnosis. Notification is
mandatory.
Classification of Leprosy
Knowledge of the classification of leprosy is important for choosing the
appropriate Multi Drug Therapy (MDT) regimen. The classification can be
based on clinical manifestations and/ or skin smear results. In the
classification based on skin smear results, patients showing negative
smears at all sites are grouped as paucibacillary leprosy (PB), while those
showing positive smears at any site are grouped as having multibacillary
leprosy (MB).
The clinical system of classification for the purpose of treatment includes
the use of the number of lesions and nerves involved as the basis for
grouping leprosy patients into MB and PB. The clinical classification is
shown below:
Classification of leprosy
SITE PAUCIBACILLARY LEPROSY MULTIBACILLARY LEPROSY
Skin Lesions 1-5 lesions asymmetrically More than 5 lesions. Distributed
distributed with definite loss of more symmetrically. With or
sensation without loss of sensation
Nerve enlargement Only one nerve trunk involved Many nerve trunks involved
Any patient showing a positive skin smear should be treated with the MDT
regimen for multibacillary (MB) leprosy, irrespective of the clinical
classification. When classification is in doubt, the patient should be
treated as MB leprosy.
Primary Prevention
Screening of family contacts should be performed.
BCG vaccine C V see section on Immunisation
Treatment of Paucibacillary Patients

dapsone po B V 100mg once a day 6 months
Paed = 1-2mg/kg
and rifampicin po - B V 600mg once a 6 months
supervised dose Paed = 10-15mg/ kg* month
* but not less than 150 mg of rifampicin
158
Treatment of Multibacillary Patients
Duration of therapy is now reduced to 12 months, with adequate education
and follow up.
 It is important to educate the patients at the time of stopping treatment
about the signs and symptoms of relapse and reaction, and request
them to come back immediately.
 Lepromatous or borderline lepromatous patients who return not
showing any improvement or with evidence of deterioration will need
an additional 12 months of MDT for multibacillary leprosy.
 Review patients regularly for 12months to diagnose deterioration as
early as possible.
Treat with:
dapsone po B V 100mg once a day 12 months
Paed =1-2mg/kg
and clofazimine po A N 50mg once a day 12 months

Paed = 0.5 –1mg/kg
and clofazimine po – A N 300mg once a 12 months

supervised dose Paed = 5-10mg/kg month
and rifampicin po B V 600mg once a 12 months

Paed =10-15mg/kg* month
*Not less than 150 mg of rifampicin.
MDT should be supplied in 28-day blister packs for ease of ordering and to
avoid medicine wastage. Specific blister packs are available for children.
Reversal Reaction (Type I Reaction)

This is a cell-mediated immune reaction to mycobacterium leprae. It is
characterised by swelling of skin lesions that become oedematous, red
and tender. New lesions may appear. Peripheral nerves may become
swollen and tender, with loss of sensation and paralysis in the distribution
of the nerves involved. The reactions can occur before MDT is
commenced or after completion of MDT but they are commonest during
the first 3 months of MDT. The full dose of antileprosy medicines must be
continued in addition to treatment of the reaction.
Mild Reversal Reaction
A reaction in which only the skin, not the nerves, are involved:
aspirin po C V 600mg 4 times a day 1-2 weeks
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If there is no improvement consider treatment with corticosteroids. If

there is evidence of neuritis (tender nerves, nerve deficit) use
corticosteriods as below. Do not wait for nerve damage to appear as it
may be too late for function to return.
Severe Reversal Reaction
A reaction in which there is also new nerve damage with loss of sensation
and /or motor function in hands, feet or eyes.
‘New’ implies additional to what the patient already had at registration or
developed within the last 6 months.
Admit to hospital. Treat with corticosteroid:
prednisolone po B V 40mg (or once a day -
1mg/kg)
Then reduce slowly by 5mg each week, once
nerve tenderness subsides
then maintain at 20mg once a day 2-3 months
Then reduce slowly over 1-2 total 6
months months
Patients can be discharged at the dosage of 20 mg daily for subsequent
outpatient review.
Erythema Nodosum Leprosum (ENL) Type II reaction

In this reaction immune complex formation and deposition occurs with the
activation of complement. This type of reaction is characterised by crops
of tender subcutaneous nodules on the face, trunk and extensor surfaces
of the limbs. It may include systemic features such as fever,
lymphadenitis, orchitis, arthritis, nephritis, iridocyclitis and peripheral
neuritis. Severe ENL may also present with ulcerating and pustular
lesions. The full dose of antileprosy medicines should be continued in
addition to the treatment of the reaction.
Mild Type II Reaction

aspirin po C V 600mg 4 times a day 1-2 weeks
If there is no improvement or the patient develops nerve damage,
corticosteroids are indicated.
160
Severe Type II Reaction
Admit for corticosteroid therapy and refer to specialist urgently:
prednisolone po B V 40-60mg once a day 1-2 weeks
then reduce slowly by 5mg-10mg each
week, over a period of 4-6 weeks;
*total duration = 6-10weeks
Recurrent Type II Reaction

Use clofazimine in anti-inflammatory dosage in addition to prednisolone.
Attempt to taper prednisolone while maintaining clofazimine as below:
clofazimine po A N 100mg 3 times a day 3 months
then 100mg 2 times a day 3 months
then 100mg once a day 6 months
Refer all patients developing abdominal complaints (pain, constipation,

distension).
It may take 4 to 6 weeks for clofazime to take effect in controlling ENL.
Steroid side-effects
 Be on the alert for new onset of diabetes or exacerbation of known
diabetes. Diabetes will need careful monitoring – ideally as an
inpatient.
 Blood pressure should also be monitored.
 Also watch for tuberculosis or gastrointestinal parasitic infections that
might be revealed by the use of steroids.
 If difficulties arise in balancing treatment of reactions and side effects,
refer for specialist care.
All patients should be managed at primary care level under the guidance of
District and Provincial TB/Leprosy Co-ordinators. Complicated cases should be
referred to the Tropical Diseases Unit at Harare Central Hospital. Advice can be
obtained from the Leprosy Mission on telephone Harare +263( 4) 251647.
Human African Trypanosomiasis:

General notes
Human African Trypanosomiasis (HAT) is caused by the protozoa of the
genus trypanosoma that is transmitted by the bite of tsetse fly in sub-
Saharan Africa. The disease is also known as sleeping sickness and has
been reported from remote areas mainly from the game parks in
Mashonaland Central, Mashonaland West and Matebeland North.
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There are two forms of HAT:

 Trypanosoma brucei rhodisiense – found in East and Southern Africa
 Trypanosoma brucei gambiense – found mainly in Central and West
Africa.
Clinical Presentation has 2 phases:

 Acute haemolymphatic phase: presentation is with episodic bouts
of fever, headache, joint pains, pruritis and anorexia. An eschar, “bite
site” may be present together with local lymphadenopathy.
 Delayed Neurological phase: when the parasite crosses the blood
brain barrier it causes neurological signs and symptoms of sleep
cycle disturbance, confusion, behavioural changes and poor
coordination.
Refer all cases of Human African trypanosomiasis for specialist care.

Suramin is the medicine of choice for the acute haemolyphatic phase.
Melarsoprol is required if the patient progresses to the neurological phase.
Typhoid Fever
Typhoid fever is caused by Salmonella typhi, a Gram-negative bacterium.
A very similar but often less severe disease is caused by the Salmonella
serotype paratyphi A in 10% of cases.
Humans are the only natural host and reservoir. The infection is
transmitted by ingestion of faecally contaminated food or water and
through direct contact with infected persons and formites (contaminated
items).
Case Definition:
Any person with gradual onset of steadily increasing and then persistently
high fever, chills, malaise, headache, sore throat, cough, and sometimes
abdominal pain and constipation or diarrhoea.
Clinical features
The clinical presentation of typhoid fever varies from a mild illness with low
grade fever, malaise and dry cough to a severe clinical picture with
abdominal discomfort, altered mental status and multiple complications.
Clinical diagnosis is difficult to make as it is confused with many similar
conditions. In the absence of laboratory confirmation, any case of fever of
at least 38 °C for 3 or more days is considered suspect if the
epidemiological context is suggestive.
Depending on the clinical setting and quality of available medical care,
some 5–10% of typhoid patients may develop serious complications, the
most frequent being intestinal haemorrhage or peritonitis due to intestinal
perforation.
162
Laboratory testing
In Zimbabwe, blood culture samples, stool/rectal swab and bone marrow
aspirate have been used to culture for isolation of S typhi. Blood culture is
the usual diagnostic test locally with a sensitivity of up to 90% in the first
week of onset of fever. Stool and rectal swab cultures yield positive results
in up to 40% of the cases.
Case Management
More than 90% of patients can be managed at home with oral
antimicrobial, minimal nursing care, and close medical follow-up for
complications or failure to respond to therapy.
Antimicrobial therapy for treatment of Typhoid fever
i) Susceptibility: Fully Sensitive

ciprofloxacin po B V 500mg Twice a day 5-7days
Alternative Medicines
chloramphenicol po B V 1g 4 times a day 14–21days
or amoxicillin po C V 2g 3 times a day 14days
ii)Susceptibility: Multidrug Resistant

ciprofloxacin po B V 500mg Twice a day 7-14days
or cefixime po B V 500- Twice a day 7days
750mg
azithromycin po C V 1gm Once a day 5
Cefixime po B V 500- Twice a day 7-14
750mg
iii) Susceptibility: Quinoline Resistant

azithromycin po C V 250- once a day 7
500mg
or ceftriaxone iv C V 2gm once a day 10-14
Cefixime po C V 600mg Twice a day 7-14
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SEVERE TYPHOID DISEASE

i) Susceptibility: Fully Sensitive
dose
ciprofloxacin po B V 500mg Twice a day 7-10
dose
chloramphenicol po B V 500mg 4 times a day 14
or amoxicillin po C V 500mg 3 times a day 14
ii) Susceptibility: Multidrug Resistant

ciprofloxacin po B V 500mg Twice a day 10-14
or Cefixime C V 600mg Twice a day 10-14
dose
ceftriaxone iv C V 2gm once a day 7-14
iii) Susceptibility: Quinolone Resistance

dose
ceftriaxone iv C V 2gm once a day 7-14
or azithromycin po C V Igm once a day 5
Dehydration is uncommon in Typhoid fever; however, electrolyte

imbalance, e.g. hypoglycaemia, hypokalaemia and hyponatremia
frequently occur and need to be corrected using appropriate electrolyte
solutions. In cases where intestinal perforation is suspected surgery and
parenteral nutrition may be required. In cases of moderate to severe
dehydration, follow the guideline for treatment of dehydration.
A. Treatment of Carriers
An individual is considered to be a chronic carrier if he or she is
asymptomatic and continues to have positive stool or rectal swab cultures
for S. typhi a year following recovery from acute illness:

Ciprofloxacin po B V 500mg Twice a day 4 weeks
Ciprofloxacin can be used in children if the benefits outweigh the

potential harms.
164
And/or:
 Cholecystectomy if lithiasis is present
 Treat schistosomiasis if present
 Vi (virulence) antibody test useful to screen carriers
Notifiable diseases and events of Public Health

importance
According to the Public Health Act (PHA) Chapter 15:09, there are
infectious diseases that have to be immediately notified to health authority
in an area by either District Medical Officer, or Provincial Medical Director,
or City Health Director. These diseases can spread rapidly and cause
outbreaks. They need closer monitoring if they are to be controlled. It is
important that the health authority knows what action has been taken to
control the spreading of the diseases. It is also a requirement that
Zimbabwe reports cases and deaths from these diseases to the WHO
(World Health Organization). While there is a longer list of diseases in the
PHA, health workers are encouraged to notify the following using the
T1/T2 forms:
1. Acute flaccid paralysis (AFP/polio)

2. Anthrax
3. Brucellosis
4. Cholera
5. Diphtheria
6. Hepatitis (all forms)
7. Human Influenza A caused by a new subtype ( e.g. H1N1, H1N5)
8. Meningococcal Meningitis
9. Noma
10. Plague
11. Rabies
12. SARS
13. TB (Tuberculosis) and Leprosy are also notifiable, but they continue
to be notified on TB Form A and TB Form B for TB, and the Leprosy
form for leprosy.
14. Trypanosomiasis
15. Typhoid
16. Typhus
17. Viral Haemorrhagic fever (e.g. Ebola, Marburg, Crimean Congo)
18. Yellow fever
19. All such other infectious/ communicable diseases and events of
public health importance as the Minster of Health & Child Care may
declare by statutory instrument, to be infectious diseases
throughout or in any part of Zimbabwe. These events of public
health importance include maternal deaths, disasters such as
chemical spillage, floods and others.
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How to notify: Any health worker, including those in private sector, who
comes into contact with any of the notifiable diseases. All suspected and
laboratory confirmed cases of the above should be notified immediately to
the District Medical Officer or City Health Director by the fastest means
possible (telephone if available). The notifying health worker should then
complete a T1 form in triplicate. These forms can be obtained from the
offices of District Medical Officer or City Health Director upon request.
166
MALARIA
GENERAL NOTES: 168
MALARIA PREVENTION 168
MEDICINE PROPHYLAXIS 168
TREATMENT OF MALARIA 169
UNCOMPLICATED MALARIA 169
TREATMENT FAILURE 171
SEVERE MALARIA 173
TREATMENT AT COMMUNITY LEVEL 181
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General Notes:
 The pattern of malaria varies geographically. Plasmodium falciparum
causes almost all the malaria in Zimbabwe. A few cases of malaria
due to P.vivax, P.ovale and P.malariae may be seen.
 Complications occur mainly with P.falciparum and usually in young
children, pregnant women, adults in epidemic prone areas and
people moving from areas of no malaria to areas with malaria
including immune compromised patients and sicklers.
 Malaria usually occurs 1-6 weeks after a bite by an infected female
anopheles mosquito. So it is important to take a good history and to
always ask about travel and self-medication.
Malaria Prevention
Social and behaviour change communication on non-pharmacological
means of prevention is extremely important e.g. indoor residual spraying,
use of mosquito coils, repellents, long lasting insecticide-treated mosquito
nets, appropriate protective clothing.
Medicine Prophylaxis
Due to lack of evidence of efficacy on antimalarial prophylaxis in
Zimbabwe coupled with suspected poor performance of the previously
used medicines, personal protection is highly recommended. This is to
avoid providing false sense of protection to those visiting malarious areas.
Personal protection can be achieved by sleeping under a net, use of
repellents when visiting a malarious area, putting on long sleeved clothes
at dusk or dawn and getting indoors early. Where medicines are used, it is
important to note that no medicine gives 100% protection against malaria,
but medicines do reduce the risk. However, chemoprophylaxis is
recommended in pregnant women as indicated below:
Malaria prophylaxis for:
Intermittent Preventive Treatment (IPTp)
 Pregnant women in regions of moderate to high transmission.

Chemoprophilaxis in this group in based on an assumption that every
pregnant woman in a malaria-endemic area is infected with malaria and
has malaria parasites in the blood or in the placenta. The medication is
given as treatment doses at prescribed intervals.
168
 Three tablets of SP (each SP tablet contains Sulphadoxine 500
mg and Pyrimethamine 25 mg) are given at booking (after
quickening).
 Give SP to all pregnant women at each scheduled ANC visit up to
time of delivery
 The doses should not be less than 4 weeks apart
 SP should ideally be given as directly observe therapy of three
tablets
 SP can be given on either an empty stomach or with food
 SP should NOT be administered to women receiving Co-
trimoxazole prophylaxis due to a higher risk of adverse effects
 It is recommended that weekly folic acid also be given to pregnant
woman taking IPTp. (This is done in conjuction with the
Reproductive Health Department).
Malaria prophylaxis for:

 visitors from outside the country
May continue with the prophylaxis recommended to them before coming to
Zimbabwe, but personal protection should be emphasized.
Treatment of malaria
All antimalarial medicines should be administered only to confirmed
cases (Confirmation is done by RDT or Malaria Blood Slide). However in
children less than five years treatment may be initiated whilst awaiting
blood results provided other causes of fever have been clinically excluded.
Malaria blood slides MUST be taken in the following cases:
 Patients with severe/ complicated malaria.
 Patients with treatment failure.
 All referrals.
 All cases where Co-artemether has been used in the preceding 2
weeks
Note: Pregnant women diagnosed with malaria must receive medicine
therapy immediately. Although quinine is potentially teratogenic, the benefit
of giving quinine therapy far outweighs any risk.
Uncomplicated malaria
The first line treatment of uncomplicated malaria is the arteminisinin
combined therapy Artemether-lumefantrine (Co-artemether).
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artemether-lumefantrine po C V See table
below
(Co-artemether) Artemether-Lumefantrine (1.5mg/12mg/kg):
To be given as a 6 dose course of tablets twice a day for 3 days as
follows:
Dosage Day 1 Day 2 Day 3
Weight Lts Age (yrs) Start After AM PM AM PM

(kg) Dose 8hrs*
5- 14 <3 1 1 1 1 1 1
15-24 3-8 2 2 2 2 2 2
25-34 9-14 3 3 3 3 3 3
>35 >14 4 4 4 4 4 4
Note:
 *Strictly after 8 hours.
 Parasitological proof of malaria by blood slide or rapid
diagnostic test (RDT) is desirable whenever Arteminisin based
combination is used
 Tablet of Co-artemether- is a fixed dose formulation
of(Artemether 20mg/Lumefantrine120mg)
N.B:
1. If the initial dose of Co-artemether is vomited within 30 minutes
repeat dose.
2. If vomiting is persistent treat as severe/complicated malaria.
3. If no improvement within 48 hours change to oral
Artesunate/amiodiaquine.
4. To ensure compliance it is desirable to give the STAT doses as
Directly Observed Therapy (DOT).
5. Malaria in the 1st trimester of pregnancy should be treated with a 7
day course of oral quinine and clindamycin.
TREATMENT IN SPECIAL GROUPS
Uncomplicated malaria in infants not eligible for treatment with Co-
artemether
170
Treatment of infants under 5kg body weight

quinine po C V 10mg per Kg body Every 8 hours 7 days
weight
Uncomplicated malaria in pregnancy
TRIMESTER/APPROXIMATE GESTATION
st
1 trimester-before 2nd and 3rd trimester –after quickening
quickening
Medicine Medicine DAY1 DAY2 DAY 3

STAT After AM PM AM PM
8 hrs
Quinine tab 600mg Co- 4 4 4 4 4 4
every 8 artemether
hrs for (No. Of
7 days tablets)
Clindamycin 300mg
tab every 8
hours
for 7
days
 Twelve hours apart from day 2 to day 3
Treatment failure
Early treatment failure is formally diagnosed if a patient is still febrile 72hrs
after initial therapy and has more than 25% of initial asexual parasitaemia.
Treatment failure however should be suspected clinically if there is no
response after 48 hours of correct therapy, and a change to second line
therapy made immediately.
Late treatment failure is the recurrence of fever and asexual parasitaemia
7-14 days after initial successful treatment.
Treatment failure may be due to:
 Inadequate therapy, e.g. medicine being vomited within 30 minutes,
under dosing or failure to complete the treatment.
 Presence of undetected severe and complicated malaria.
 Malaria parasite resistance (known or suspected) to the given
medicine.
If a patient returns to the health facility still feeling unwell:
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 Check for other conditions e.g. meningitis, ARI, gastro-enteritis

 Check for signs of severe and complicated malaria
 Take a blood slide
If there are no signs of severe/complicated malaria give the following
treatment immediately:
Second Line Therapy –
Artesunate/Amodiaquine C V As per Once daily 3 days

po table
below
Each tablet of AS-AQ may contain Artesunate 25mg and Amodiaquine

67.5mg, Artesunate 50mg and Amodiaquine 135mg OR Artesunate
100mg and Amodiaquine 270mg
Dosage is 4mg/kg body weight Artesunate and 10mg/kg Amodiaquine
base taken once daily orally for three days.
Weight range
(approximate age Dosage Day 1 Day 2 Day 3
range)
25mg Artesunate +
≥5kg to <9kg
67.5 mg 1 Tablet 1 Tablet 1 Tablet
(2 -11 months)
Amodiaquine
50mg Artesunate +
≥9kg to <18kg
135mg 1 Tablet 1 Tablet 1 Tablet
(1 year- 5 years)
Amodiaquine
100mg Artesunate
≥18kg to 36kg + 270mg 1 Tablet 1 Tablet 1 Tablet
( 6-13 years) Amodiaquine
100mg Artesunate
≥36kg
+ 270mg 2 Tablets 2 Tablets 2 Tablets
(14 years and above)
Amodiaquine
Second line treatment of uncomplicated malaria in adults unable to

tolerate Artesunate-Amodiaquine is Oral Quinine with doxycycline or
clindamycin
Each Quinine tablet contains quinine sulphate 300mg
172
Treatment schedule for second line therapy: Adults

quinine po C V 600mg Every 8 hours 7 days
doxycline po C V 100mg Once daily 30 days
or clindamycin B V 300mg Every 8hrs 7 days
po
7 Day Quinine Course
quinine po B V Adults Every 8 hours 7 days

600 mg
Children 10 mg/kg Every 8 hours 7 days

body weight
Short Course Quinine plus Doxycycline or Clindamycin (Adult)
quinine po B V 600 mg Every 8 5 days

hours
clindamycin B V 300mg Every 8 5 days

po hours
doxycycline C V 100 mg Once daily 7 days

po*
N.B:-
1. Duration of quinine may be shortened to 5 days if doxycycline is
also given.
2. *Doxycycline is contraindicated in children below 10 years and in
pregnancy and these patients should complete the 7 day quinine
course.
Severe malaria
This is a life threatening condition, and the goal of management therefore
is to prevent death. Therapy should be initiated without delay.
Check for signs of:
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 prostration, i.e. if the patient is unable to stand or sit or feed

independently,(children will be unable to breastfeed)
 persistent vomiting,
 the slightest sign of alteration in consciousness which may indicate
cerebral malaria (refer to the Coma Scale).
Complications include any of the following:

 Cerebral malaria
 Bleeding tendencies
 Severe anaemia (Hb≤6g/dl) ; (Hb < 7.5g/dl for Non immune Patients)
 Hyperpyrexia
 Jaundice
 Shock
 Severe haemoglobinuria
 Hyperparasitaemia (>5% in non- immune patients)
 Acute renal failure
 Respiratory distress
 Hypoglycaemia
Treatment of severe/complicated malaria must be parenteral and the
medicine of choice is artesunate while quinine will remain a usable option.
Treatment at Health Centre

Parenteral therapy with artesunate injection must be commenced at
primary level using IM administration or, if it is practical, by IV infusion
before the patient is referred. Treatment is initiated by a loading dose of
artesunate or quinine.
Artesunate 60mg injection (V, C) is used as follows:
Dosage at 2.4 mg /kg (comprehensive dosage schedule).
Weight 5kg-25kg 26kg-50kg 51kg-75kg 76kg-100kg
60mg vial 1 2 3 4
Instructions for dilution of parenteral Artesunate for IV use.

Reconstitute the artesunate powder with the 1ml of sodium bicarbonate
ampoule provided. The solution will initially look cloudy. Wait for 1 minute
for it to clear. Discard the solution if it does not clear. Add 5 mls of 5%
dextrose water or N/saline to the reconstituted solution. The resultant 6ml
solution will contain 10mg per ml of Artesunate. Check the dose to
administer on the table below.
Dosing Schedule
174
 Give a minimum of 3 parenteral doses of Artesunate once
started before changing to oral treament, even if the patient is
able to take oral medication early
 Prepare a fresh solution for each injection
 IV injection is given as slow bolus, about 4 mls per minute.
 Discard any unused solution.
Dosing schedule
Day 1 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Stat 12 hrs 24 hrs Daily Daily Daily Daily Daily

Dose 1 Dose 2 Dose 3 Dose 4 Dose 5 Dose 6 Dose 7 Dose 8
Check the dose to give intravenously on table below:
Weight Dose (mg) Volume (ml)

5-8 kg 20 2
9-12 kg 30 3
13-16 kg 40 4
17-20 kg 50 5
21-25 kg 60 6
26-29 kg 70 7
30-33 kg 80 8
34-37 kg 90 9
38-41 kg 100 10
42-45 kg 110 11
46-50 kg 120 12
51-54 kg 130 13
55-58 kg 140 14
59-62 kg 150 15
63-66 kg 160 16
67-70 kg 170 17
71-75 kg 180 18
76-79 kg 190 19
80-83 kg 200 20
84-87 kg 210 21
88-91 kg 220 22
92-95 kg 230 23
96-100 kg 240 24
 Once the patient is able to take oral medication switch to oral
Co-artemether for a full three day course (see Table for Co-
artemether course).
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 If the patient is unable to take any oral medication continue with

intravenous Artesunate for a total of seven days (see Table
above).
 Continue to evaluate the patient regularly for improvement or

deterioration.
176
 Continue supportive treatment and monitoring as required in all patients with severe malaria.
PREPARING ARTESUNATE FOR IM USE:

1. RECONSTITUTE ( Activate the Artesunate powder by mixing with 1ml of bicarbonate provided)
Inject full contents of Shake until

Artesunate Wait for 1 minute. The
bicarbonate ampoule 1ml dissolved. Solution
powder + solution will clear. Do
into Artesunate vial. will be cloudy.
bicarbonate. not use if not clear.
2. DILUTE ( Add 2mls normal saline solution or 5% dextrose to each vial of Reconstituted Artesunate)
CAUTION ! : Do not use water for injection !
1. Inject 2ml saline

Artesunate Withdraw any air from Artesunate 3ml
solution to vial of
reconstituted (1ml) + the vial before injecting solution ready
reconstitued
saline solution (2ml) 2. saline for dilution for use,
Artesunate
(20mg/ml)
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3. CHECK THE DOSE TO GIVE ON TABLE BELOW:
Weight <5k 5- 9- 13- 17- 21- 26- 30- 34- 38- 42- 46- 51- 55- 59-62kg
g 8k 12k 16k 20k 25k 29k 33k 37k 41k 45k 50k 54k 58k
g g g g g g g g g g g g g
Dose 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150

(mg)
Volume 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8
(ml)
Weight 63-66kg 67-70kg 71-75kg 76-79kg 80-83kg 84-87kg 88-91kg 92-95kg 96-100kg
Dose 160 170 180 190 200 210 220 230 240
(mg)
Volume 8 9 9 10 10 11 11 12 12
(ml)
178
 Administer injection slowly.
 IM Injection volumes greater than 5 mls should be spread

over different injection sites.
OR
 IN ADULTS administer quinine intravenously:
 IV quinine loading dose of 20mg per Kg body weight diluted in

500ml of Normal saline or 5% dextrose water infused over 4
hours. Do not exceed 1200mg of loading dose. After 8 hours
subsequent doses should be administered at 10mg per Kg body
weight diluted in Normal Saline or 5% dextrose water.
Additional Supportive measures for patients with severe malaria

awaiting transfer:
 Maintain airway by appropriately positioning the patient in a left
lateral position with the chin extended if patient is in a coma or
convulsing. Administer oxygen if available. Patients with
pulmonary oedema should be propped up and given IV diuretics.
 Give IV 25% dextrose water for hypoglycaemia in children as 1ml

50% dextrose per Kg body weight diluted 1:1 with water for
injection. This can also be given orally or via nasogastric tube if
IV access is not readily secured. Where the child is still able to;
continue to breastfeed.
 Parenteral anti-emetics can be administered in adults with

persistent vomiting.
 Address hyperpyrexia through physical means such as tepid

sponging and fanning. Antipyretics such as Paracetamol may be
given where appropriate.
 Where available treat convulsions with either intravenous or

rectal diazepam.
A CLEAR LEGIBLE REFERRAL LETTER STATING THE DATE, NAME

OF PATIENT, BRIEF HISTORY, DIAGNOSIS AND THE PRE REFERRAL
TREATMENT GIVEN SHOULD ACCOMPANY THE PATIENT TO THE
NEXT LEVEL OF CARE. COMPLETE THE MALARIA REFERRAL FORM
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If IV Artesunate is unavailable, IV Quinine is the alternative for patients

with severe malaria.
NOTE: Intravenous quinine is the medicine of choice to treat SEVERE

MALARIA in children weighing less than 5kg and pregnant women in
the first trimester.
Note: Do not use a loading dose if the patient has taken quinine in the
preceding 24-48 hours (or mefloquine in the preceding 7 days).
quinine infusion in 5% B V 20mg/kg over 4 hours, monitor
dextrose infusion rate carefully,
(max loading dose = 1200mg)
then after 8hrs: 10mg/kg  over next 4 hours,
then  repeat every 8 hours until
(max maintenance dose = 600mg) able to tolerate oral
therapy.
then reduce to 5mg/kg every 8 hrs *
*Note: Change to oral therapy if the patient can swallow. Give the equivalent
dose of quinine salt orally to complete 7 days of treatment.
Cautions: Quinine may have toxic effects even at this dosage - headache,
confusion, nausea, tinnitus, tremors, abdominal pain, rashes, temporary visual
disturbances and reversible deafness. Hypersensitivity reactions may occur
rarely. Attention should therefore be paid to the dose per body weight, and the
change to oral therapy made as soon as possible.
 Full size adults are generally assumed to weigh 60kg. The loading dose
is therefore 1200mg and maintenance 600mg. Never exceed this dose
even if the patient weighs more than 60kg.
 All efforts should be made to weigh adolescents or “small adults” to
avoid overdosing those who might be far less than 60kg. If weighing is
not possible assume to be 45 kg.
 Hypoglycaemia is an important problem with IV quinine. Monitor blood
glucose 4hrly. If there is any deterioration of consciousness,
hypoglycaemia should be considered. The infusion fluid (Dextrose 5%)
is NOT for the specific correction of hypoglycaemia. Hypoglycaemia
should be treated with the appropriate agents.
When an IV line cannot be established:
quinine im * B V 10mg/kg every 4 hrs for 3 doses,
then
10mg/kg every 8hrs 7 days
180
 Patients referred to the district hospital after receiving a loading dose of
IM quinine should be commenced on IV quinine 8 hours after the last
dose of IM quinine was given.
The duration of the quinine course may be shortened to 5 days if
doxycycline is added to the therapy – see under Treatment Failure previous
pages.
*IM quinine should be diluted as follows:

Dilute the quinine with water for injection. Draw 8ml of water for
injection into a 10ml syringe, and then draw 2ml of quinine injection into
the same syringe. The syringe now contains 10ml of a concentration of
60mg of quinine salt per ml. If the volume to be injected is greater than
3ml then give half into each thigh
General measures
 Coma: maintain airway, nurse on side, and exclude other causes of
coma, 2 hourly turns.
 Convulsions: treat appropriately and check for hypoglycaemia.
 Hypoglycaemia: monitor blood glucose, correct with dextrose 50%
1ml/kg (diluted 1 to 1) in children, 20-50ml in adults followed by
dextrose 10% infusion.
 Severe anaemia: transfusion of packed cells if HB < 6g/dl.
 Acute pulmonary oedema: review fluid balance. Monitor infusion rates
carefully. If over-hydrated give IV frusemide.
 Acute renal failure: exclude pre-renal causes, check fluid balance,
dialyse early.
 Check carefully for meningitis - do a lumbar puncture if necessary.
Treatment at community level
When a patient presents with signs and symptoms of severe malaria as a

referral from the community health worker he/she may have been given
rectal artesunate if they were unable to take any medication orally and time
to get to the referral centre was more than 6 hours.
 Rectal artesunate is given as follows:
The dose of rectal artesunate is 10mg per Kg Body weight.

 Where the weight of the patient is not immediately known use the
table below:
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AGE ARTESUNATE DOSE ROUTE

6 months-1 YEAR 50MG STAT PER RECTUM
>1 -3 YEARS 100MG STAT PER RECTUM
>3 -5 YEARS 200MG STAT PER RECTUM
>5-13 YEARS 300MG STAT PER RECTUM
14-15 YEARS 400MG STAT PER RECTUM
≥16 YEARS 600MG STAT PER RECTUM
The weight of patients above 16yrs and all fully grown up adults has
been assumed to be an average of 60kg. When artesunate is given
according to known body weight do not exceed 1200mg.
 Do not give rectal artesunate to children weighing less than 5kg
(less than 6 months).
 Artesunate suppositories come in doses of 50mg, 100mg, 200mg

and 400mg per suppository.
 To get to the required dose, 1 or more suppositories can be given

in combination to get to the total dose required being considerate
not to exceed three suppositories.
 If the suppository is expelled within 30 minutes, the dose should

be repeated by insertion of another suppository.
 In children the buttocks can be held together for ten minutes to

ensure retention.
 Once the rectal artesunate has been given the patient is

immediately referred to the nearest health centre for further
management without further delay.
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RESPIRATORY CONDITIONS
ACUTE RESPIRATORY INFECTIONS IN ADULTS 184
IN-PATIENT MANAGEMENT 185
LUNG ABSCESS 186
EMPYEMA 187
OTHER COMMON RESPIRATORY INFECTIONS 187
ASTHMA 190
ACUTE ASTHMA ATTACKS – ADULTS 192
ASTHMA IN CHILDREN 194
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Acute respiratory infections in adults

Outpatient management
For acute respiratory infections in children see the paediatrics chapter.
Common cold, influenza and acute bronchitis (‘cough’)
No antibiotics are required. Treat symptomatically.
Other respiratory infections (Including pneumonia and other severe lower
respiratory infections)
 The approach to management may be influenced by the patient’s HIV
status. Always exclude TB and PCP. Loss of weight, productive cough
for > 3 weeks, night sweats and a fever requires TB screening i.e.
sputum tests and/or CXR. Take a history of the duration of symptoms,
sputum production (colour, haemoptysis and volume), constitutional
symptoms of anorexia, weight loss, night sweats, and pyrexia. Ask for
pleuritic chest pains.
 If tuberculosis is unlikely and the patient’s condition does not warrant
admission, treat the infection with:
amoxicillin po C V 1g stat, 3 times a 7 days+review
then day (Return earlier if
500mg symptoms
worsen)
or If sensitive to C V 500mg 4 times a 7 days
penicillin use: day
erythromycin po
 If tuberculosis is likely arrange a sputum examination (2 sputum smear

tests) and plan a review within one week.
On re-assessment, if no clinical improvement refer to district level. The
three commonest diagnoses are:
 Pneumonia - non-responding segmental/lobar(See section on
inpatient management )
 Tuberculosis
Repeat sputum smear tests. Refer to the chapter on tuberculosis for
treatment protocols.
 Pneumocystis Pneumonia (PCP)
Patients are usually breathless, may be only breathless on exertion
early in the illness, may be cyanosed; and may have negligible chest
signs. The chest x-ray typically reveals bilateral fine perihilar mid-zone
reticular-nodular infiltrates (ground grass). There may be cystic change.
Frequently there are other signs of immuno-suppression.
184
 Manage with:
cotrimoxazole po C V 1920mg 3 times a day 21 days
(4 tabs)
 or in sulphonamide allergy:
clindamycin po B V 600mg 3 times a day
21 days
and primaquine po B N 15mg once a day
 If tachypnoea or cyanosis is present, add:

prednisolone po B V 40mg twice a day 5 days
then prednisolone po B V 40mg once a day 5 days
then prednisolone po B V 20mg once a day 11 days
 After PCP has been treated give cotrimoxazole prophylaxis and

refer to the OI/ART clinic. If there is sulpha allergy, cotrimoxazole
desensitization may be considered.
cotrimoxazole po C V 960mg once a day Indefinitely
< 6mths = 120mg
6-12mths = 240mg
>1 year = 480mg
 If no improvement ensures, consider malignancies such as, Kaposi’s

Sarcoma and consider referral to a Specialist.
In-patient management
Consider admission if patient is obviously unwell, or in severe pain.
Admission and close monitoring is mandatory if any of these signs are
present:
 respiratory distress
 cyanosis
 pulse >124/min
 hypotension (systolic < 90mmHg)
 temperature > 40oC or < 35oC
 altered mental state
 if elderly >65 years
 if patient has chronic lung disease ( e.g. chronic obstructive
pulmonary disease), chronic renal failure, chronic cardiac failure,
chronic liver disease
 Scoring for pneumonia severity( CURB-65)( the presence of any of
the following merits admission)
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 C= confusion
 U= urea greater than 7 mmol/L
 R= respiratory rate > or equal to 30
 B = blood pressure less than 90/60
 65= age of 65 or more
 Always try to obtain sputum for MCS to establish the aetiological
pathogen and its sensitivity to guide antibiotic treatment after
empiric therapy.
Pneumonia - segmental/ lobar (usually pneumococcal)
benzylpenicillin iv or im C V 1.5gm 6 hourly 7 days
(=2.5MU)
or ceftriaxone IV C V 1gm Daily or 7 days
twice
+/- erythromycin po C V 500mg 4 times a 7 days
day
A stat dose may be given at primary care level prior to transfer.
Note: Switch to oral amoxicillin to complete the course
 If no improvement 48 hours, review diagnosis (consider tuberculosis or
a complication of pneumonia e.g. lung abscess)
Pneumonia - Staphylococcal
cloxacillin iv* B V 1 - 2 gm 6 hourly 14 days
or clindamycin iv* in B N 600mg 3 – 4 times 14 days
penicillin allergy a day
*iv for at least 7 days, then consider changing to oral route
Pneumonia – Klebsiella, other gram negative

gentamicin iv C V 120mg 12 hourly 10-14 days
and ceftriaxone iv C V 1gm 2 times a 10-14 days
day
or based on culture and sensitivity.
Lung abscess
 Postural drainage and physiotherapy is mandatory. Patients with
very large absesses should lie in the lateral decubitus position
with the absess side down, plus
benzylpenicillin iv C V 1.5gm 6 hourly 4-8weeks*
(=2.5MU)
and metronidazole po C V 400mg 3 times a day 4-8weeks
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Alternatively (alone)
Co-amoxiclavulanic S V 625mg 3 times a
acid po day
*continue until no longer toxic +/- 7 days, then complete treatment as
outpatient for 4-8 weeks with oral amoxicillin 500mg three times a day. Be on
the look out for C. dificille diarrheoa due to long course of antibiotics. Repeat
the CXR at 6 weeks. If no significant resolution/response, refer to a Specialist
to consider possibility of MRSA (if patient was previously hospitalised), TB or
other pathologies such as malignancy.
Empyema
 Institute pleural drainage with a large intercostal tube and
underwater seal.
benzylpenicillin iv C V 2.5MU 6 hourly 10-14 days
and metronidazole po C V 400mg 3 times a day 10-14 days
Alternatively (alone)
Co-amoxiclavulanic S V 625mg 3 times a
acid po day
Also institute thromboprophylaxis with heparin/warfarin (refer to
Haematology section).
Note: If pus still drains after two weeks refer for surgical opinion.
 If preceded by a suspected staphylococcal pneumonia use:
cloxacillin iv B V 1gm 6 hourly 10-14 days
and metronidazole po C V 400mg 3 times a day 10-14 days
 Also consider TB empyema especially in HIV infection
Hospital Acquired Infections (Nosocomial)

 Pneumonia presenting 3 days after admission:
gentamicin iv C V 120mg 12 hourly 7-10 days
and benzylpenicillin iv C V 1.5gm 6 hourly 7-10 days
(=2.5MU)
Other common respiratory infections
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Chronic Obstructive Pulmonary Disease (COPD)

This term has replaced “chronic bronchitis and emphysema”.
There are many aspects of management:
 All patients with a clinical diagnosis of COPD should have spirometric
lung function testing. This is done to assess for obstruction, assess the
severity of the disease and to exclude asthma by demonstrating
reversibility or non-reversibilty of the obstruction.
 Stop smoking and/or remove from hazardous (dusty) environment.
 Prompt treatment of infective exacerbations (or as for pneumonia):
Treatment of COPD exacerbation
Antibiotics if sputum colour has changed to purulent, fever or new chest
Xray infiltrates.

or doxycycline po C V 100mg once a day 7 days
 For airway obstruction and dyspnoea add:

 Mild /Moderate Disease and patient able to use inhaler (check
technique):
salbutamol inhaler C V 100-200mcg 6 hourly review
plus ipratropium inhaler S N 40mcg 6 hourly review
 If dyspnoea is severe:
salbutamol nebulised B V 5mg 6 hourly review
plus ipratropium nebulised S N 500mcg 6 hourly review
and prednisolone po B V 30mg once a day 7 to 14days
 Preferably drive the nebuliser with air rather than oxygen.
 Controlled oxygen therapy - 2 litres/minute by nasal prongs or 28%
ventimask (Avoid higher concentrations of oxygen unless access to
blood gas analyser). if able to monitor oxygen saturation aim for SPO2
88-92%
 Pulmonary rehabilitation to prevent respiratory muscle wasting and
deconditioning.
 Nutritional support.
Management of stable COPD

 Overall management of patients with stable COPD is individualised.
188
 Use of bronchodilators
 If the patient has mild symptoms and infrequent exacerbations (1 or nil
per year) use:
salbutamol Inhaler C V 200mcg PRN
 If no improvement add:
ipratropium inhaler S N 400mcg PRN
 If the patient has frequent to persistent symptoms of breathlessness
and frequent exacerbations (more than 1 per year) refer to a specialist
whilst trying the following:
beclomethasone B V 200mcg twice a day PRN
inhaler
+ salbutamol Inhaler C V 200mcg PRN
 Alternatively adding Theophylline SR 250-500mg PO once daily may
be helpful if patients remain symptomatic.
 Pulmonary rehabilitation
 Nutritional support
 Vaccinations: Influenza and pneumococcal
 Enquire about symptoms of gastroeosophageal reflux disease (GERD)
and treat.
Bronchiectasis (Non cystic fibrosis)

The hallmarks of treatment are:
 Prompt treatment of infective exacerbations with broad spectrum
antibiotics. Exacerbations are characterized by an increase in volume
of sputum, change in sputum colour from white to yellowish or green
plus a fever.
 Referral to physiotherapist for postural drainage and physiotherapy.
 Always send sputum to the laboratory for microscopy, culture and
sensitivity together with ZN stain.
 To prevent exacerbations, patients should get an annual flu vaccine
and a five yearly pneumococcal vaccine.
 Frank haemoptysis warrants referral to a Specialist.
Acute Exacerbations of Bronchiectasis

 Infectious aetiology includes S. pneumonia, H. influenza, P.
aeruginosa, Moraxella, Mycobacteria and sometimes fungi.
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 Antibiotics should be chosen to cover pathogens empirically. Adjust

treatment when microbiology results are available.
 Inhaled bronchodilators
 Good hydration
 Chest physiotherapy and postural drainage
 Persistent haemoptysis requires cardiothoracic surgeon’s attention.
Long Term care for Bronchiectasis
 Improve lung function if patient has proven airway obstruction
salbutamol inhaler C V 200mcg PRN
+/- beclomethasone C V 200mcg PRN
inhaler
 Sputum clearance: nebulise with 0.9% Saline together with chest

physiotherapy
 Pulmonary rehabilitation: inspiratory muscle training, improve
exercise tolerance and endurance.
Asthma
General measures in Asthma
Asthma education should be viewed as a continuous process with regular
re-enforcing during patient visits to the care giver. All patients should be
treated with maintenance inhaled steroids unless the patient has mild
intermittent asthma as evidenced by the odd chest tightness once in every
4 months or so. Any patient with asthma who requires hospital emergency
treatment or admission should be prescribed an inhaled steroid for
maintenance therapy.
Attention should be paid to the following:

 Domestic allergens e.g. house dust mite( carpets), cats, cockroaches
 Environmental aero-allergens
 Allergic rhinitis and sinusitis
 Gastro-eosophageal reflux disease( GERD)
 Emotional problems
 Smoking
 Work related dusts, fumes, vapours and gases
The aims of asthma management are total control of symptoms as

indicated by:
 Normal activities of life ( work, school, sports)
190
 Normal sleep with no waking up at night (i.e. no nocturnal cough)
 Normal lung function
If the above are not achievable, partial control is second best. Uncontrolled
asthma is not acceptable and warrants referral to a Specialist
Two aspects of the management of asthma in adults and children are

considered here:
 maintenance therapy;
 treatment of acute attacks.
The management of asthma in children is similar to that in adults. However,
children under 18 months may not respond well to bronchodilators. Details of
asthma medicine treatment in children are given below.
Inhalers
 All patients with chronic asthma will require inhalers. Therefore, give
careful advice and check inhalation technique. Technique can be
improved in most asthmatics, particularly children, by a spacer device.
 The device can be improvised as follows: cut a hole at the bottom of a
750 –1000ml plastic bottle and insert the open end of the inhaler to
ensure a tight (snug) fit. Deliver one puff into the spacer and allow
normal breathing for 30 seconds through the other end. All healthcare
staff should be instructed in these techniques.
Asthma Score
 The scoring system shown below can help to assess the severity of
asthma. Peak flow meters, when available, must always be used to
assess the progress. Antibiotics are indicated only if there is evidence
of chest infection or a fever.
 Partially controlled asthma:
 Day time symptoms more than twice a week
 Limitation of daily activities
 Nocturnal symptoms
 Peak expiratory flow/FEV1 less than 80% of predicted
 Exacerbations >1 per year
 Use of relieving medicines( e.g. salbutamol inhaler) more than twice
per week
 Uncontrolled asthma:
 Any 3 of the above features under partially controlled asthma
Mild Intermittent Asthma (symptoms once in 3 to 4 months)

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salbutamol inhaler C V 100– as needed, or before

200mcg exercise
Mild Chronic Asthma

beclomethasone inhaler B V 200-400mcg 2 times a day continual
100mcg/puff
and salbutamol inhaler C V 100-200mcg as required Continual
Moderate Chronic Asthma

beclomethasone inhaler B V 200mcg Twice a day -
salbutamol inhaler C V 200mcg As required -
Severe Chronic Asthma

If response is still not adequate and the inhaler technique is adequate:
beclomethasone inhaler B V 400mcg 2- 4 times a day Continual
100mcg/puff
and prednisolone po* B V 2.5 – once a day Continual
10mg* (morning)
and salbutamol inhaler C V 100-200mcg as required as

required
or Salmetarol/Fluticasone S E 50/250mg Once/twice a continual
inhaler day
+/- theophylline slow B E 200mg 2-3 times a day continual
release po
* using the lowest effective dose possible (prednisolone can also be usefully given on an alternative
day regimen of 10mg)
Acute Asthma Attacks – Adults

Acute asthma attacks are features of uncontrolled disease and are
associated with mortality. Careful monitoring of the patient’s condition is
essential to assess severity, and to detect improvement or deterioration. In
the absence of blood gas facilities, this will depend on close assessment of
physical signs such as paradoxical breathing, the use of accessory
muscles, colour, altered mental state, etc.
1. Assess the severity of asthma.
Take a careful history and examine the patient.

 Observe breathing, talking and alertness use of accessory
muscles, colour, and mental status
 Measure the pulse, respiratory rate,
192
 Auscultation of the chest (assess wheezes); Measure lung
function by peak flow or spirometer (PEF or FEV1) and arterial
blood gases if available).
2. Grade the asthma according to severity (mild, moderate, severe
or imminent respiratory arrest)
3. Use medicines and interventions that are appropriate to degree of
severity.
Humidified oxygen by mask at high concentration (6 litres/min) is important.
Give:
salbutamol nebulised B V 5mg repeat at ½ - 1 hr
(in saline or sterile water) intervals, then every 2-4
hours until recovered
+/- Ipratropium inhaler S N 500mcg
and oxygen B V 6 litres/min
or adrenaline 1:1000 sc C V 0.5ml 1-2 hourly as required
useful when no nebuliser available
and prednisolone po B V 40mg once a day 10-14 days
in all but the mildest cases (mornings)
1. Note: There is no need to taper the dose of prednisolone if the

duration is not more than 14 days
2. If poor response to initial nebuliser therapy, SpO2 not improving,
risk of near fatal asthma or attack severe admit to HDU/ICU and
add:
hydrocortisone iv B V 200mg once only (unless oral
dosing not possible)
magnesium sulphate iv S V 1.2-2g Slow iv over 20-30mins
once
Consider ventilation in severe cases.
Criteria for ICU admission:
 Patient getting tired
 Confusion, drowsiness
 Rising pCO2 >45mmHg
 Persistent hypoxia < 60mmHg
 Inability to complete short sentences
 Acidosis
Consider the following management for very severe cases requiring ICU
care:
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 Continuous high flow oxygen.

 Nebulised salbutamol and ipratropium bromide.
 IV Beta 2 agonist.
 IV hydrocortisone or methylprednisolone.
 Possible intubation and mechanical ventilation.
Asthma in Children
Acute Attacks - Children
 The same general measures apply as in adults.
Give:
salbutamol nebulised B V <5yrs = repeat 2 times in the first
(in saline or sterile water) 2.5mg/2ml hour,
- flow rate 6L/min >5yrs = then every 4 hours until
5mg/2ml recovered.
or salbutamol inhaler C V 100-200mcg as required -
through a spacer (1-2 puffs)
Give oxygen between nebulisations.
 If nebulisation facilities are not available, or response is poor:
+/- adrenaline 1:1000 sc C V 0.01ml/kg may be repeated twice at
20 minute intervals
and prednisolone po B V 1-2mg/kg once a day 3-5 days
Severe Acute Attack in Children

 If response to the above is inadequate, give intravenous fluids at 80-
100 ml/kg/day, and:
hydrocortisone iv/im B V 4-8mg/kg once only, then
2-4mg/kg 6 hourly then:
then prednisolone po B V 1-2mg/kg once a day 5 days
 Using an inhaler via a spacing device may be effective. A spacer can

be improvised by using a plastic cup/ tumbler:
salbutamol inhaler C V 200mcg – 400mcg as required
Maintenance Therapy
1. Do not keep children on long term beta-2 stimulant medicines (e.g.
salbutamol) if they are mostly asymptomatic.
194
2. Do not use antibiotics routinely in treating known asthmatics with
wheeze.
The choice of medication depends on the frequency and severity of
symptoms, as well as the cost and availability of medication. Aerosol sprays
in conjunction with a large volume spacing device can be effectively used in
children as young as 3 years old.
Mild asthma - children

Mild or intermittent asthma mainly associated with respiratory infections:
salbutamol inhaler C V 100-200mcg as required intermittent
or theophylline po B E 5mg/kg < 4 times a day intermittent
Moderate asthma - children

These may be triggered by infections, allergies, exercise etc. Treatment is
for mild asthma, but continual therapy may be required. It may also be used
in combination with theophylline.
Severe asthma - children

Severe, persistent asthma, persistent wheeze, and failure to respond to the
above: add to the above
add beclomethasone B V 50-100mcg 3 – 4 times a continual
inhaler day
or prednisolone po* B V 1-2mg/kg once in the until control,
morning then
reducing to the lowest, effective dose on alternate
days
*long term prednisolone should be avoided in children, unless there is no
alternative.
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CARDIOVASCULAR DISEASE
ENDOCARDITIS 197
RHEUMATIC FEVER 199
TREATMENT OF HYPERTENSION 200
MANAGEMENT OF SEVERE HYPERTENSION 202
CARDIAC FAILURE 203
ACUTE PULMONARY OEDEMA: 205
ANGINA PECTORIS 206
ACUTE MYOCARDIAL INFARCTION 207
196
Endocarditis
Consult a microbiologist where possible. Alpha-haemolytic
streptococci are the most common causes of native valve
endocarditis but Staphylococcus aureus is more likely if the disease
is rapidly progressive with high fever, or is related to a prosthetic
valve (Staphylococcus epidermidis). Three sets of blood cultures
should be taken before starting treatment.
Native valve endocarditis
Empirical treatment:
benzylpenicillin iv C V 5MU 6 hourly 2-6 weeks
or ceftriaxone 1g iv B V 1g 12 hourly 2-6 weeks
and gentamicin iv B V 80-120mg 12 hourly 2 weeks
*Total duration of antibiotic therapy should be 4 – 6 weeks if there is

evidence of improvement.
*Treatment can be changed to oral therapy after at least 2 weeks of IV
antibiotics if there is marked improvement.
Prosthetic valve endocarditis
Initially:
cloxacillin iv B V 2g 6 hourly 4-6 weeks
It is important to measure serum gentamicin levels every 3-4 days. One-hour
peak concentration should not exceed 10mg/l and trough concentration (2 hour
pre-dose) should be less than 2mg/l.
Treatment of culture positive endocarditis
Streptococcal infection (e.g. Strep. viridans):
Enterococcal infection (e.g. Enterococcus faecalis):

Max-120mg
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Staphylococcal infection (for example, Staph. aureus & Staph. epidermidis):

cloxacillin iv B V 2g 6 hourly 4-6 weeks
At any stage, treatment may have to be modified according to:

 detailed antibiotic sensitivity tests
 adverse reactions
 allergy
 failure of response
Endocarditis leading to significant cardiac failure or the failure to
respond to antibiotics may well require cardiac surgery.
Prophylaxis against endocarditis – no special risk:
Dental procedures, upper respiratory tract, obstetrics and gynaecological procedures
under local or no anaesthesia (no special risk):
amoxicillin po C V 3g one dose only – one hour
Paed = 50mg/kg before procedure
or clindamycin po in B E 600mg one dose only,
penicillin allergy or recent <5yrs = 150mg one hour before
penicillin administration 5-10yrs = 300mg procedure
(< one month)
Dental procedures, upper respiratory tract, obstetrics and gynaecological procedures

under general anaesthesia (no special risk):
ampicillin iv B E 1g at induction, then 500mg after 6hrs
or amoxicillin po C V 3g 4hrs before anaesthesia, then 1g 6
hours post-op.
If penicillin allergy or recent administration of penicillin within the previous
month see under special risk groups below.
Prophylaxis against endocarditis – special risk:

Prosthetic valve in situ, or previous endocarditis or genitourinary procedures
(special risk groups)
ampicillin iv B E 1g at induction single dose
and gentamicin iv B V 120mg at induction single dose
If penicillin allergy or administration of penicillin in the past month:
clindamycin iv* B N 300mg at induction single dose
198
and gentamicin iv B V 120mg at induction single dose
*Do not use clindamycin for urological/gynaecological procedures because it
will not prevent enterococcal infection. In these cases replace clindamycin with
vancomycin iv [Specialist-only medicine] 1g over at least 100 minutes 1-2 hours
before procedure.
Rheumatic fever
Treatment of acute attack:
benzathine penicillin im C V 0.6MU(0.72
g)
1.44g = 1.2MU Paed: <5 yrs =0 once dose
single dose
.15MU(0.18g) only
5-10 yrs= 0.3MU(0.36g)
>10 yrs=0.6MU( 0.72g)
Or amoxycillin po C V 500mg
Paed: <5 yrs=125mg 3 times a
10 days
5-10 yrs=250mg day
>10 yrs=500mg
Or erythromycin po – in C V 500mg 4 times a 10 days
penicillin allergy day
Treatment of acute arthritis and carditis:

aspirin po C V 25mg/kg* 4 times a day as required
*dose should be reduced if tinnitus or other toxic symptoms develop.
Aspirin should be continued until fever, all signs of joint inflammation and the
ESR have returned to normal, and then tapered gradually over 2 weeks.
If symptoms recur, full doses should be restarted.
In severe carditis with development of increasing heart failure or failure of
response to aspirin, add:
prednisolone po B V 1-2mg/kg once a day 3-4 weeks,
then review
Gradual reduction and discontinuation of prednisolone may be started after 3-4
weeks when there has been a substantial reduction in clinical disease.
Heart failure should be managed in the usual way.
All patients with carditis should be kept on strict bed rest until all evidence of
active carditis has resolved and the ESR has returned to normal.
Activity can then be gradually increased.
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Treatment of chorea:
dose
haloperidol po A N 1.5-3mg 3 times a day as required
Paed =
25-
50mcg/k
g
or B V 200-400 2 divided doses
Sodium
valproate po 1-2 times a day As required
Antibiotic prophylaxis after rheumatic fever:

Prophylaxis should be given to all patients with a history of rheumatic fever
and to those with heart valve lesions thought to be of rheumatic origin.
The optimum duration of prophylaxis is controversial, but should be
continued up to at least 21 years of age. If at that age there are any
significant heart murmurs, prophylaxis should be life-long.
Specific situations requiring prophylaxis for longer periods (can be lifelong):
 definite carditis in previous attacks
 high risk of exposure to streptococcal infection at home or work
(crowded conditions, high exposure to children)

benzathine penicillin im C V 2.4MU(1.44g)
(1.44g =2.4MU) Monthly up to 21-30yrs
<12yrs = 1.2MU(0.72g)
or amoxycillin po C V 250mg
2 times a day up to 21-30yrs
<12yr = 125-250mg
or erythromycin po in C V 250mg
penicillin allergy <12yr=125-250mg 2 times a day up to 21-30yrs
<12yr=125-250mg
Note: The need for continuing prophylaxis should be reviewed at 21-30

years and patients with rheumatic heart disease must take prophylaxis life
long.
Treatment of hypertension
Non medicine treatment:
All patients with hypertension or high normal blood pressure should be given
advice on regular exercise, stopping smoking, reducing obesity and limiting
intake of alcohol, salt and saturated fat.
200
Medicine treatment
Methyldopa and propranolol are no longer recommended for the treatment of
hypertension except in special circumstances.
Guidelines for treatment of hypertension:
 start with first line medicine
 start with the lowest recommended dose
 if ineffective or not tolerated change the medicine or add a medicine from
another class.
First line agents = shown to reduce mortality

 Thiazides
hydrochlorothiazide po C V 12.5 – 25mg once a day long term
(max 25mg)
Unwanted side effects include raised plasma glucose, uric acid, cholesterol and
reduced plasma potassium and magnesium; sinus congestion.
 Calcium channel blockers:

nifedipine slow release B V 10 - 40mg 1-2 times a long term
po day
Or amlodipine po B E 5 – 10mg once a day long term
Unwanted side effects include vasodilator effects such as headache and facial
flushing in up to 20% of patients, peripheral oedema (usually due to a local
action rather than an effect on the heart or kidney).
Second line agents

 ACE inhibitors:
Enalapril B V 5 - 40mg Once a day long term
Or Lisinopril B E 5-40mg Once a day long term
Unwanted side effects include cough in 10-25% of patients, angioedema,
postural hypotension and occasionally syncope, particularly in patients with a
low plasma volume due to diuretic treatment. All ACE inhibitors can cause
excessive hypotension and renal failure.
A useful alternative to ACE inhibitor when cough develops are Angiotensin-
receptor blockers such as Losartan.
Caution: concomitant potassium supplements or potassium retaining medicines
should be avoided, or used only with careful monitoring of serum potassium.
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 Angiotensin receptor-blockers:
losartan po B V 25-100mg 1-2 times a long term
day
 Beta-blockers
Medicine Codes Adult Frequenc Duration
dose y
atenolol po B V 50mg once a long term
day
Unwanted side effects include precipitation or exacerbation of asthma, heart
failure, impaired glucose control, fatigue and peripheral vascular disease.
 Alpha-blockers:
prazosin po B V 0.5-5mg 2-3 times a long term
day
or Doxazocin B V 4-16mg Once a day Long term
Management of severe hypertension

Definition: diastolic blood pressure >120mmHg
Emergency intravenous therapy or sublingual nifedipine is rarely
required and is potentially dangerous (may result in stroke, renal
failure or myocardial infarction).
Indications for emergency treatment:

 Left ventricular failure with pulmonary oedema (also see section on
treatment of acute pulmonary oedema).
 Hypertensive encephalopathy.
 Acute aortic dissection.
 Severe pre-eclampsia (see chapter on Obstetrics & Gynaecology).
 Recent stroke requires caution as rapid lowering of blood pressure may
worsen neurological deficit. Treat if diastolic blood pressure >120mmHg
after 48 hours. Long term treatment indicated if diastolic blood pressure
>100mmHg after 3 months.
 frequent blood pressure monitoring
 Sub-lingual nifedipine should be restricted in its use for hypertension.
The only remaining major indication for it is severe hypertension with
aortic dissection.
202
Medicines
 Beta-blocker, with alpha activity:
labetalol iv S V 20 mg IVI stat over 2 mins, then 10-80
mg IVI every ten minutes until desired
BP level achieved
labetalol continuous S V **2 mg IVI per minute by continuous IV
infusion infusion
* *Total dose should not exceed 300 mg
 Direct acting vasodilator:

dihydralazine iv/im B V 6.25-25mg PRN until desired BP
level achieved
BP should be measured every 5-10 minutes
Parenteral anti-hypertensives should be used under specialist supervision
and where facilities for continuous BP monitoring are available
Cardiac Failure
Usually presents with shortness of breath on exertion or at rest, swelling of
ankles, ascites and easy fatigueability.
General guidelines:
 Precipitating factors should be sought and treated e.g:
 hypertension
 infections such as sub-acute bacterial endocarditis, chest infection
 arrhythmias
 hypokalaemia
 anaemia
 medicines, eg. digoxin overdose,NSAID’s, beta-blockers
 pulmonary embolism
 thyrotoxicosis
 myocardial infarction
 Daily weights and fluid balance (intake/output) should be recorded as a

simple measure of response to treatment. Ideal weight loss should be 1
kg per day.
 Restrict salt in diet.
 Encourage bed rest.
 Check blood pressure daily.
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 Potassium supplements are to be stopped and levels monitored

regularly when using ACE inhibitors (e.g.captopril and enalapril).
 Monitor serum potassium levels.
 Digoxin toxicity may be a problem especially in the elderly and in
patients with hypokalaemia and hypomagnesaemia.
 The role of digoxin in systolic heart failure patient who are in sinus
rhythm (as compared to atrial fibrillation) has diminished over the years.
Digoxin does not improve mortality in such patients, and be harmful in
some patients and should therefore be used with great care
 Low dose aspirin should be considered in most patients with severe
systolic heart failure (very low ejection fraction) who have not had a
stroke
Medicine Management:
Chronic heart failure management (heart failure secondary to
left ventricular systolic dysfunction)
frusemide po1 B V 40-80mg 1-2 times a day long term
and enalapril po B V 5-20mg once daily long term
And Metoprolol Succinate Xl B V 12.5 – 200 Once daily long term
Carvedilol mg
OR B V 3.125 – 25mg Twice daily long term
Bisoprolol
OR B V 1.25 – 10 mg Once daily long term
and Spironolactone B V 25-50 mg Once daily long term

+/- potassium chloride po2 B V 600mg-1.2g 1-2 times a day long term
+/- digoxin po B E 0.25-0.5mg 3 times a day first 24hrs
then 0.125-0.25mg once a day long term
Paed = 0.01mg/kg
+/- Spironolactone po B E 25-50mg Once daily Long term
1
give intravenous treatment for severely oedematous patients
2
if using ACE inhibitors, losartan or spironolactone discontinue or use
cautiously
*ACE inhibitors are of benefit in all stages of heart failure
Selected beta blockers such as carvedilol, metoprolol succinate XL or bisoprolol
are of benefit in all stages of heart failure
For oedematous and bed-ridden patients:

Enoxaparin B V 40 mg Once daily As required
add heparin sc B V 5000 units 3 times a day as required
204
Acute pulmonary oedema:
 Prop up in bed.
 40% oxygen by mask (2 – 4L/min)
 and:
morphine iv B E 5-10mg slowly over 1-2 mins;
repeat every 15mins if
required.
plus prochlorperazine iv B E 12.5mg when required for
vomiting
Plus frusemide iv B V 40-80mg repeat as required
 Subsequent treatment includes ACE inhibitors as for heart failure.
 Beta blockers should not be introduced in patients with acute heart
failure which has not been stabilized (in contrast, patients with acutely
decompensated heart heart who are already taking a beta blocker
should be continued on their current dose – dose escalation should be
deferred until the acute episode has been controlled)
Resistant cardiac failure

Exclude advanced renal failure as a cause of resistant heart
failure.
A progressive increase of frusemide is valuable. A single daily dose, at first,
up to 160mg.Then hydrochlorothiazide 50mg may be added to advantage.
After which the frusemide can be further increased up to 240mg. A second
dose of frusemide before 4.00pm may be useful for nocturnal
breathlessness.
The use of IV frusemide confers little advantage over the oral preparation.
If still unsatisfactory consider referral for further management under
specialist care.
Aim to optimize medical therapy, i.e. maximum tolerated doses of ACE

inibitors (or ARBs), spironolactone or beta blockers in addition to diuretic
therapy titrated to severity of symptoms
Refractory cardiac failure due to documented systolic heart failure, may

represent ‘end stage’disease – medical therapy is only palliative, with a goal
of relieving symptoms and quality of life rather than prolonging life
Heart failure due to specific causes such as rheumatic heart disease needs
to be considered separately, and patients should be referred for surgical
intervention as early as possible
Cor Pulmonale
Treat as above but ACE inhibitors are not recommended.
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Care should be taken with higher doses of diuretics as patients with cor
pulmonale are prone to overdiuresis and subsequent pre-renal azotaemia
Anticoagulation should be considered in patients with cor pulmonale,
pulmonary venous thromboembolic disease should be sought if the cause of
the cor pulmonale is not obvious
Angina Pectoris
Change in lifestyle measures. Minimise risk factors with particular attention
to:
 cessation of smoking;
 weight reduction if obese;
 control of hypertension.
 control of hypercholesterolaemia
 control of diabetes
 encouragement of exercise
 minimise stressful life style
Stable angina/ infrequent attacks:

aspirin po1 C V 75-150mg Once a day long term
and glyceryl trinitrate sub- A E 500mcg not more than 3 tablets
lingual2 every 15 mins
1
aspirin is contraindicated in bleeding peptic ulcers
2
glyceryl trinitrate deteriorates on storage - tablets should be kept in original
container and discarded 3 months after opening.
Frequent attacks of angina:

aspirin po C V 75-150mg once a day long term
and isosorbide dinitrate po A E 10-40mg 3 times a day long term
 If no response, add:
atenolol po B V 50-100mg once a day long term
+/- nifedipine slow release B V 10-20mg 2 times a day long term
po
 If pain continues in spite of above treatment, refer for further
investigation and treatment.
206
Unstable Angina:
Angina of new onset or brought on by minimum exertion. Admit to hospital
for:
aspirin po C V 75-150mg once a day long term
and isosorbide dinitrate po A E 10-40mg 3 times a day as required
or glyceryl trinitrate iv A E 10-20mcg /min infusion as required
and heparin iv B V 5000iu 6 hourly as required
and atenolol po B V 25-100mg once a day as required
and nifedipine slow release B V 10-20mg twice a day as required
po
Acute Myocardial Infarction

General Measures
 Bed rest
 Oxygen administration
 Set up an intravenous line (dextrose 5% or sodium chloride 0.9%)
Avoid intramuscular injections where possible as this interferes with
the measurement of cardiac enzymes and results in haematomas
with thrombolytic agents.
Management of Acute Myocardial Infarction:
aspirin po C V 300mg once only as a single dose,
then
75-150mg once a day long term
Clopidogrel B E 300mg Once only
75mg Once daily
and morphine iv B E 2-5mg every 10– as required
15min
and isosorbide dinitrate po A E 10-40mg 3 times a day as required
and low molecular
weight heparins
and streptokinase (or A N 1.5MU in 100ml sodium chloride 0.9%
preferably urokinase) iv or dextrose 5% run over one hour,
Useful for MI with ST once only
segment elevation
and atenolol po B V 50-100mg once a day long term
and captopril po B E 12.5-25mg 2 times a day long term
 Thrombolytic agents should be administered early preferably in infarcts of

less than 12 hours duration.
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 CAUTIONS: DO not give digoxin in acute infarction unless there is a supra-

ventricular arrhythmia that requires it.
 DO not use inotropic agents such as isoprenaline or adrenaline as they may
be counter-productive and cause an extension of the infarction.
Arrhythmias after myocardial infarction:

Ectopic beats
Give reassurance about the condition, but if troublesome:
atenolol po B V 50-100mg once a day as required
Atrial fibrillation and atrial flutter

add atenolol po B V 25-50mg once to twice review
a day
or *verapamil po A V 40-120mg 3 times a day review
*Verapamil is contraindicated in heart failure patients.
If poor control of ventricular response, cautiously add:

dose
digoxin po B V 0.25- 3 times a first
0.5mg day 24hrs
then 0.125-0.25mg once long
a day term
For chronic atrial fibrillation:
dose
warfarin po B V 10mg once a day for 3 days
then adjust according to INR
For atrial flutter, synchronised D.C. cardioversion (50-200 joules) can be

tried.
208
Paroxysmal supraventricular tachycardia
Carotid sinus massage/valsalva manoeuvre or prompt squatting. Consider
synchronized D.C. cardioversion (50-200 joules) if patient distressed.
verapamil iv A V 5-10mg bolus, can be repeated
after 10 min
For long term therapy:

verapamil po A V 40-120mg 3 times a day long term
Caution: avoid intravenous verapamil in patients treated with beta-blockers.
If poor response, refer for specialist management.
Ventricular tachycardia
 Consider D.C. cardioversion if patient distressed.
lignocaine iv A E 75-100mg stat, then
4mg/min for 30 mins, then
1-2mg/min for 12-24 hours
 If ventricular arrhythmias are troublesome disopyramide (specialist-only)
may be used – refer.
 High degree and symptomatic heart block (Stokes Adams attack)
refer to specialist for pacemaker insertion.
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GASTROINTESTINAL CONDITIONS
ACID RELATED CONDITIONS 211
ACUTE DIARRHOEA & ASSOCIATED CONDITIONS IN
ADULTS 214
ACUTE GASTRO-ENTERITIS (FOOD POISONING) 214
CHOLERA 215
ACUTE INTESTINAL DISEASE - AMOEBIC DYSENTERY
217
LIVER ABSCESS 218
CHRONIC BOWEL DISORDERS 218
OTHER GASTROINTESTINAL PROBLEMS 220
LIVER DISEASE 220
BLEEDING OESOPHAGEAL VARICES 221
210
Acid Related Conditions
Gastroeosophageal disease (GERD)
Presenting as heartburn, acid regurgitation and sometimes difficulty or
pain on swallowing, also as asthma and with a hoarse voice.
General measures:
 Life style modifications are important: weight reduction, elevation of
head of bed, avoidance of tight clothes, stooping, large meals, and
food triggers that patient suspects (chocolate, colas, coffee). No meals
or drink for 3 hours preceding bedtime.
Mild symptoms:
magnesium trisilicate & C N 20ml or 2 at least 4 as required
aluminium hydroxide tablets times a day
po
Moderate symptoms:
add *omeprazole po B E 20mg twice daily 2 months
* Omeprazole to be taken 30 minutes BEFORE meals.
Severe symptoms: If no response to above, give:

ranitidine po B E 150mg Twice a day 6-8 weeks
Note: Heartburn or pain on swallowing unresponsive to treatment,

presence of dysphagia, weight loss should be referred to specialist.
Odynophagia: (Pain on swallowing)

When pain on swallowing is recent in onset and with no heartburn
consider oesophagitis from pill ingestion, HIV complicated by candidiasis,
viral oesophagitis and malignancy. Empirical anti-fungal agent when
appropriate. Early referral for intractable cases.
Dyspepsia:
Includes chronic pain in upper abdomen, fullness, bloating and nausea.
Peptic ulceration accounts for about 10% of uninvestigated dyspepsia,
and gastric cancer is a concern. The majority of patients have functional
dyspepsia. Uninvestigated patient are best managed according to the
algorithm below:
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Dyspeptic Symptoms
Heartburn and/or
regurgitation are Dyspepsia without
predominant or GERD or NSAID use
frequent
NSAID/COX2
Inhibitor use
Manage as GERD
Consider stopping NSAID,

use other agent or add PPI
Age >45 years or

presence of alarm
symptoms
Age < 45 years and

no alarm symptoms
Refer for endoscopy
Test for H. pylori
H. pylori test
not available
positive negative
Treat for H. Pylori PPI trial for 6 weeks
fails fails
Refer to specialist
212
General measures for established peptic ulcer
Treatment of peptic ulcer disease begins with exclusion of aetiologic
factors such as NSAIDs and eradication of Helicobacter pylori. Acid
suppression therapy is also required. Cigarette smoking must be
avoided. "Ulcer diets" are unnecessary. Avoid foods that exacerbate pain
in individual patients. Antacid may give temporary relief of symptoms.
Alarm features: The presence of alarm features are an indication for
immediate referral to a specialist i.e. patient of any age with overt
bleeding, iron deficiency anaemia, progressive unintentional weight loss,
progressive difficulty swallowing, persistent vomiting, epigastric mass or
suspicious barium meal. Gastric ulcer at barium meal requires referral for
endoscopic biopsy.
For H. pylori eradication:

amoxicillin po* C V 1g 2 times a day 2 weeks
and clarithromycin po C V 400mg 2 times a day 2 weeks
and omeprazole po* C V 20mg Twice a day 2 weeks
* metronidazole po for C V 400mg 2 times a day 2 weeks

penicillin allergic patient
ALTERNATIVELY
amoxicillin po* C V 500mg 3 times a day 2 weeks
and metronidazole po C V 400mg 3 times a day 2 weeks
and omeprazole po C V 20mg 2 times a day 2 weeks
* This regime may be more poorly tolerated, affecting compliance
Note: Omeprazole must be taken half hour before meals. Incomplete or

abbreviated courses risk development of antibiotic resistance.
Persistence of H. pylori infection is indication for referral to a specialist.
Preferred test for H. pylori is stool antigen test; antibody test is unreliable
unless locally validated, Endoscopy-based tests are unsuitable for
routine use.
NSAIDs-associated ulcers
When an ulcer develops, NSAID should be withdrawn wherever possible.
Omeprazole at 20 mg b.d. or ranitidine 300 mg b.d. for 4 weeks. If
continued use of NSAID is necessary, refer to specialist.
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Non-Ulcer (functional) dyspepsia

Symptoms suggestive of ulceration but in absence of organic, metabolic
or systemic disease and with negative findings on endoscopy. Symptoms
typically present for 6 months presenting either as post-prandial distress
syndrome, irritable bowel syndrome or epigastric pain syndrome. If
symptoms persist despite treatment as per algorithm, refer for specialist
evaluation.
hyoscine po* C V 10mg 3 times a day 4 weeks
metoclopramide po C V 10mg 3 times a day 4 weeks
*Contraindicated in angle closure glaucoma, prostatic hypertrophy, paralytic ileus
Acute Diarrhoea & Associated Conditions in

Adults
See also the sections on HIV-related diarrhoea and diarrhoea in children.
Stools should be examined microscopically and cultured. Pus cells
suggest an infective cause.
Acute Gastro-Enteritis (Food Poisoning)

Acute diarrhoea +/- vomiting: rehydration and correction of electrolyte
disturbance is primary intervention, especially in infants, elderly and the
very sick. Oral fluids in mild cases. IV fluids in more severe cases or
when vomiting is pronounced. Give anti-emetics when necessary (adults
only):
prochlorperazine im B E 12.5mg one dose Review
or metoclopramide iv B V 10mg one dose Review
then prochlorperazine po B E 5mg 3 times Review
or metoclopramide po/iv B E 10mg 3 times Review
Antibiotics are not required except in the special circumstances given
below. Anti-diarrhoeals (codeine and loperamide) may be used for
uncomplicated acute diarrhoea, but NOT recommended in children.
Antispasmodics (hyoscine) may be useful for abdominal cramps.

codeine phosphate po C V 30 mg 3 times Review
or loperamide po C V 2mg <8mg/day Review
214
Bacillary Dysentery (bloody diarrhoea)
Always send stool for microscopy and culture to guide your antibiotic
choice and to exclude amoebiasis. Empirical choice of antibiotic as
below:
Rehydration as for gastro-enteritis above.

nalidixic acid po B V 1gm 4 times a day 5 days
or ciprofloxacin B V 500mg Twice a day 5 days
or ceftriaxone iv C E 1g Twice a day 5 days
Avoid antimotility drugs. Persistent culture negative bloody

diarrhoea beyond 6 weeks must be referred for evaluation for
inflammatory bowel disease.
Cholera
CASE DEFINITION: Rice water diarrhoea with or without vomiting,
causing severe dehydration or death.
In suspected cases, notify Provincial Medical Director immediately.
• In the area, where cholera is not known to be present – a patient
aged 5 and above develops severe dehydration or dies from acute
watery diarrhoea
• In the area where cholera epidemic is present a patient aged 2
years or more develops acute watery diarrhoea with or without
vomiting
• Every child in cholera affected area who presents with acute watery
diarrhoea with/without vomiting and has signs of some/severe
dehydration – Collect stool samples for confirmation
For confirmation at the beginning of an outbreak, take rectal swab or
stool specimen, handle properly and transport carefully to laboratory.
Treat on site without referral wherever possible.
 Incubation period: commonly 2-4 days (range 1-7 days).
 Management: Rehydration is the most important step- orally in
moderate cases, IV (using Ringer lactate) in more severe cases.
Quick Identification of Cholera Cases Using Standard Case
Definition
A patient who is suffering from acute watery or rice watery diarrhoea with
or without vomiting and with signs of dehydration and is above 2 years of
age should be suspected as a case of cholera during an outbreak. (In an
Epidemic children below 2 years can also be affected). Acute watery
diarrhoea – passage of watery or liquid stools ≥ 3 times in last 24 hours.
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Management of patients presenting with acute watery

diarrhoea
Patient with acute watery diarrhoea
Look for other associated symptoms e.g.,

swelling of legs, respiratory difficulty, anemia
etc.
Urgently Inform Doctor
Assessment for dehydration- Dhaka Method

Condition* Normal Irritable/Less active* Lethargic /
Comatose*
Eyes Normal Sunken
Tongue Normal Dry
Assess Thirst* Normal Thirsty (drinks Unable to drink*
eagerly)
Skin Normal Goes back slowly* Goes back very
pinch* slowly*
Radial Normal Reduced* Uncountable or
pulse* absent*
No sign of If at least 2 signs If some
Diagnosis dehydrati including one (*) sign dehydration plus
on is present, diagnose one of the (*) signs
Some Dehydration are present,
diagnose
Severe
Dehydration
Management A B C
A. No sign of dehydration – ORS

 50 ml ORS per kg body weight over 6 hours plus
ongoing losses
 Send patient to home with 4 packets of ORS
 Feeding should be continued
 Return if condition does not improve or deteriorates
B. Some dehydration – ORS

 80 ml ORS per kg body weight over 4 – 6 hours plus ongoing losses
 Patient should be kept under observation for 6 - 12 hours
 Feeding should be continued
 Reassess the dehydration status frequently - hourly.
 In case of frequent vomiting (>3 times in 1 hour): Treat with I/V fluid
C. Severe dehydration – I/V Ringer’s lactate

 Start I/V fluid immediately (100 ml / kg)
Children < 1 year
30 ml / kg in first 1 hour
70 ml / kg in next 5 hours
Adult and Children > 1 year
30 ml / kg in first 1/2 hour
70 ml / kg in next 21/2 hours
 Encourage the patient to take ORS solution as soon as he/she is able to
216 drink
 Antibiotic after initial rehydration (4-6 hours)
Antibiotics in a Cholera Epidemic
 Antibiotics should be given to all cases of severe dehydration
 The choice of antibiotics depends on local sensitivity pattern
First line medicine (except in pregnancy)

For adults
ciprofloxacin po B V 1g Single dose after correction of
severe dehydration
For children
Medicine Codes Paed Dose Frequency Duration
ciprofloxacin po B V 20mg/kg Single dose after cessation of
vomiting (if any)
Second line medicine

For adults:
azithromycin po C V 1g Single dose after correction of
severe dehydration
For children:
azithromycin po C V 20mg/kg Single dose after cessation of
vomiting (if any)
Alternative medicine
doxycycline po C V 300mg single dose after food
except in pregnancy

erythromycin po C V 500mg 6 hrly 3 days
for all only if sensitive
erythromycin po C V 12.5mg/kg 6 hrly 3 days
Acute Intestinal Disease - Amoebic Dysentery

(Paed = 10mg/kg)
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Liver Abscess
Consider when there is right upper quadrant pain, fever and
hepatomegaly. Could be a pyogenic liver abscess or amoebic abscess.
Surgical or percutaneous drainage should be part of treatment, together
with antibiotics. If use of antibiotics without drainage is unavoidable, long
course of antibiotics with serial scans and close supervision will be
required.
 For abscesses threatening to rupture through lobe of liver, skin or
diaphragm, aspirate in conjunction with medicine therapy.
Pyogenic Abscess:
dose
metronidazole iv A N 500mg 3 times a day 4 – 6 weeks
plus ampicillin iv B E 1g 4 times a day 4 - 6 weeks

or ceftriaxone iv C V 1g once a day
or ciprofloxacin po B V 500mg twice a day
Amoebic Abscess:
metronidazole po C V 400mg 3 times a day 7-10 days
Chronic Bowel Disorders

Investigations to establish cause are essential. See also chapters on HIV
Related Disease and Paediatrics.
General Measures
It is necessary to exclude malignancy. Individual symptoms require
treatment. Adequate hydration appropriate diet and drugs are indicated.
Irritable Bowel Syndrome

Presents with abdominal pain, diarrhoea and or constipation. There is no
weight loss or abnormal laboratory results. Reassurance and anti-
depressants may be effective. Laxative for constipation, and anti-motility
drugs for diarrhoea (loperamide) may be used. Antispasmodic agents are
used for pain. Codeine and related centrally-acting opiods risk
dependency and should be avoided.
loperamide B V 2-8mg 2 times a day Review
218
In refractory cases use:
morphine po B V 5mg every 4 hrs Review
increase to 50mg
Constipation
Encourage high fibre diet and adequate fluid intake.
Give laxatives as required but avoid chronic use.
Rectal stimulant:
glycerine suppository C N one as required -
rectal suppository
or liquid paraffin po B N 10-30ml as needed -
[faecal softener]
or bisacodyl po [only if no C N 5 – 10mg at night -
abdominal tenderness]
Pernicious Anaemia
 Suspect diagnosis in macrocytic anaemia. Need to confirm the
deficiency. Folic acid supplementation is not required.
 Give life-long vitamin B12 every 3 months.
 See section in chapter on blood.
Giardiasis
Malabsorption Syndromes
Correction of electrolyte and nutritional deficiencies is important.
Individual conditions require specific treatment: lactase deficiency,
coeliac disease, pancreatic insufficiency and pernicious anaemia have
specific management. Specialist referral recommended.
Chronic Pancreatitis
 Exclude gallstones, hypercalcaemia, hypertriglyceridaemia and
alcohol as causes
 Pain control must be tailored to each patient and often requires
opiates.
 Treat diabetes as necessary. Give enzyme supplements and acid
suppression for malabsorption.
 Cessation of alcohol intake is imperative.
 Referral to a specialist is recommended.
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Other Gastrointestinal Problems

Peritonitis
Get a definitive diagnosis. Always exclude the need for surgical
intervention. Manage with:
ampicillin iv B E 1g 4 times a day 5-10 days
and gentamicin iv C V 4mg/kg once a day 5-10 days
and metronidazole iv A N 400mg 3 times a day 5-10 days
Haemorrhoids (and other painful peri-anal conditions)

 Encourage high fibre diet and adequate fluid intake.
 Avoid constipation.
 Careful anal hygiene plus saline baths.
 Compound preparations with steroids are suitable for short term use
after exclusion of infection.
benzyl benzoate with B N one twice a day as required
0,25% hydrocortisone application
ointment rectally
Liver Disease
Acute Liver Failure/ Hepatic Encephalopathy
 Identify and eliminate precipitating causes (electrolyte
derangements, toxins, septicaemia, alcohol, upper GI bleeding).
 Stop all unnecessary medicines including diuretics and sedatives.
 Intensive support, including fluid management, assessment for
infection and metabolic parameters and detect bleeding.
 Give high calorie diet (2000 kcal/day), and low protein diet.
 Manage with:
doxycycline po C V 100mg twice a day until recovery
or neomycin po A N 1g every 6 hrs until recovery
 Give sufficient laxatives to induce diarrhoea:

magnesium trisilicate po C N 40ml every 6 hours, until
diarrhoea is induced
or lactulose po A N 30 -50ml 3 times a day
or high bowel washout performed once
dextrose 10% iv A N 3litres/day added to every litre bag if
with potassium chloride iv B V 2g (26mmol) renal function is satisfactory
220
 Screen for infection (urine, chest, blood), and treat vigorously.
 If bleeding is evident or invasive procedure is planned, give:
vitamin K iv C V 10mg once review
and fresh frozen plasma B V 3 bags initially -
and platelets* A E 6 packs - -
*if count <20 x 109/L and patient actively bleeding.
If ethanol aetiology is suspected, give:

thiamine iv slow A N 250mg before dextrose infusion
and daily for 3 days
Bleeding Oesophageal Varices

Commence treatment immediately, before confirmation of diagnosis by
endoscopy/barium meal. Resuscitate completely, and only refer when
patient is stable:
 Insert large IV cannula to transfuse and to replenish blood volume.
Avoid saline unless no alternative.
 Correct raised INR/PT with fresh frozen plasma and vitamin K
 Routinely give 3rd generation cephalosporin (ceftriaxone) during
acute bleeding.
 Sedate [avoid opiates]:
diazepam iv C V 5-15mg as necessary
ceftriaxone iv C V 1g Twice daily 5 days
 Treat concurrent encephalopathy as above.

 Aspirate nasogastric tube hourly.
 If bleeding persists refer: Sengstaken tube should be inserted to
arrest bleeding. Refer to specialist.
 Give Propranolol prophylactically indefinitely:
propranolol po B E 40mg 2-3 times a Indefinitely
day
Ascites of Chronic Liver Failure
Perform diagnostic paracentesis if possible. Check for serum ascitic-
albumin gradient (SAAG), white cell count.
 Restrict salt intake and fluid intake to 1 litre/day. Give potassium
supplements if hypokalaemic. This regimen plus bed rest is enough
to induce a diuresis in some patients.
 Aim for weight loss of 0.5 kg per day. Any more could lead to
hypovolaemia and precipitate liver failure.
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 Polymorph cell count in ascitic tap >500 cells/µL defines

spontaneous bacterial peritonitis irrespective of other results of
microscopy and culture. IV ceftriaxone is indicated. Alternatively,
oral ciprofloxacillin may be given in absence of vomiting, shock and
prior exposure to quinolones
 Resistant patients:

spironolactone po A N 100-400mg once a day Review
Note: Do not give potassium supplements with these diuretics.
 Only if above fail, add:
frusemide po B V Start at once a day increase
40mg gradually
Stop if encephalopathy or uraemia develop.
Massive intractable ascites

Consider possible decompensation of liver function. ?development of
hepatoma; Refer. Perform large volume paracentesis.
222
RENAL TRACT CONDITIONS
ACUTE NEPHRITIC SYNDROME 228
NEPHROTIC SYNDROME 228
PRESCRIBING IN RENAL IMPAIRMENT / RENAL FAILURE 229
MEDICINES AND DIALYSIS 231
END STAGE RENAL DISEASE/CHRONIC DIALYSIS 231
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Urinary Tract Infections (UTI)

Cystitis
Usually presents with dysuria, frequency, urgency and suprapubic pain but
note that in men dysuria more commonly indicates a sexually transmitted
infection (STI). Always exclude an STI. With UTI, urine is often cloudy and
smelly. Where possible diagnosis, should be made with leucocyte dipstick,
microscopy or culture.
 Treat with:
norfloxacin* po C V 400mg 2 times a day 3 days
or amoxicillin po C V 500mg 3 times a day 3 days
 If still symptomatic after 3 days, refer.
Acute pyelonephritis
Diagnosed when a UTI is accompanied by nausea, vomiting, fever, rigors
and loin pain. Dysuria may be absent. Treat for 2 weeks.
 Mild acute pyelonephritis
norfloxacin po C V 400mg 2 times a day 2 weeks
 Acutely ill patients: use IV antibiotics until apyrexial, and then change to
oral therapy.
ceftriaxone iv C V 1g Once a day review
or gentamicin* iv C V 4-7mg/kg once a day review
*Remember gentamicin toxicity is manifested after 7-10 days of use. Check
gentamicin levels where possible. Avoid nephrotoxic medicines such as
gentamicin and nitrofurantoin in renal dysfunction.
Acute Kidney Injury

What is causing the kidney injury? Try and classify by cause. The majority
of cases of acute renal failure (or acute kidney injury) are due to ischaemic
or toxic injury to the kidney and are reversible if treatment is instituted
promptly i.e. within hours not days.
Pre-Renal Cases
Most common cause of acute kidney injury and most amenable to therapy.
Usually have a history of hypovolaemia or hypotension e.g. bleeding,
vomiting, diarrhoea and are usually oliguric. Rapid recovery of renal failure
is to be expected with prompt treatment.
224
Acute Renal Failure
Consider sepsis, malaria, acute glomerulonephritis, acute tubular necrosis,
myeloma, nephrotoxic medicines such as gentamicin and NSAID’s, and
other causes such as acute -on-chronic renal failure. As a minimum, get
urine microscopy and an ultrasound of the kidneys for size. Are the kidneys
normal sized, small, enlarged or obstructed?
Obstructive Uropathy
Continuous bladder catheterisation is required until the obstruction is
relieved. Relief of obstruction can result in polyuria. Therefore, rehydrate
with IV fluids. Aim to keep up with the urine output. Sodium and potassium
supplements may be required. Scan kidneys to exclude hydronephrosis.
Refer to a urologist for definitive management.
Exclude prostatic enlargement in males and cancer of the cervix in women.
Management of Renal Failure

 First line: Exclude dehydration in all cases. Give adequate
rehydration. Try fluid challenge with sodium chloride 0.9%. Should
show response within hours (not days). Aim for a visible jugular
venous pressure (JVP) first and then consider giving IV frusemide to
encourage diuresis.
 Second line: If the patient fails to respond to adequate rehydration

and fluid challenge with sodium chloride 0.9% [not dextrose 5%] within
24 hours and condition is deteriorating, referral for dialysis is indicated.
If this is not possible, then aim to support patient until the kidneys
recover [may take up to 6-8 weeks or more]. Monitor fluid (input and
output charting) carefully. Check electrolytes regularly and maintain
nutrition. Watch for infections.
 Third line: Start dialysis or consult dialysis team sooner rather than
later so that they can help monitor the patient. Late referrals contribute
to the mortality of acute kidney injury (acute renal failure) and end-
stage renal disease. Selection criteria are applied for the chronic
dialysis programme and hence, each individual patient should be
discussed with the dialysis team.
Fluid balance: Daily weights before breakfast. Aim for no weight gain.
Previous day’s losses (urine, vomit etc) +500mls =day’s fluid intake.
Electrolytes: Ideally measure urea and electrolytes at least on alternate
days. Monitor potassium levels.
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To lower potassium levels in acute hyperkalaemia, give:

calcium gluconate (or B V 10mls Once
chloride) 10% IV
insulin with glucose
plus B V 50mls of 50% over 10 min
glucose + 10
units of short
acting insulins
10mg
/or salbutamol nebulised B V 10mg 2 times a day Review
plus insulin with dextrose B V 50mls of 50% dextrose + 10 units of
short acting insulin
or Calcium Resonium® A N 45gm as enema. Leave enema in for
as long as possible
General measures in the management of acute renal failure

 Catheter: Insert a urinary catheter but remove it once sustained
diuresis has occurred or if oliguria persists and the patient is started on
dialysis or conservative treatment. Avoid long catheterisation periods.
 Urine: Ward urinalysis test - check for haematuria, proteinuria and
glycosuria. Send urine for microscopy (for cells, casts), culture and
sensitivity.
 Diet: High calorie and normal or high protein diet with low sodium and
low potassium. Ask for dietician’s help. For low potassium diet, avoid
e.g. oranges, bananas, mangoes.
 Anaemia: If oliguric do not transfuse unless there is significant
bleeding, as there is a high risk of fluid overload. Wait to transfuse until
patient is on dialysis.
 Monitor BP regularly( e.g. 4 hourly)
 Monitor fluid input/output strictly.
 Avoid nephrotoxic medicines such as gentamicin and NSAIDs
 Watch for and treat underlying infections.
 Check weight daily.
226
Management of Pre-renal failure
Check Yes Continue fluids,

Fluid challenge. Is urine output one litre every
(500 -1000ml > 40 ml/hr? 6 hours
saline/hr) until recovery.
No
Check Yes Continue fluids,

If JVP remains
Is urine output one litre every
low/dehydrated/oliguric
> 40 ml/hr? 6 hours
repeat fluid challenge.
until recovery.
No
Give one litre every

If oliguria persists despite
Check Yes 8 hours plus
elevated JVP/adequate Does diuresis
Frusemide stat dose
hydration, stop fluids. Give occur, output
(if output falls below
Frusemide (slow IV) > 40 ml/hr?
40 ml/hr) until
120 mg.
recovery.
No
Give one litre every

If no diuresis 8 hours plus
Check Does diuresis Yes
(output < 40 ml/hr). Give Frusemide stat dose
occur, output
Frusemide (slow IV) (if output falls below
> 40 ml/hr?
100 to 400 mg. 40 ml/hr) until
recovery.
No
If no diuresis, refer for dialysis

or manage as established
renal failure
Note:
Make sure that patient has been fully hydrated before starting on dialysis. If dehydrated,
do not give frusemide until patient is rehydrated (until JVP is clearly visible or central
venous pressure is at least 10 to 12 cm).
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Acute Nephritic Syndrome

Usually presents with facial or generalised oedema plus oliguria and
hypertension. There may be a recent history of tonsillitis, arthralgia, skin
rashes/ infection.
 Promote a diuresis with small doses of oral frusemide (40-80mg once
daily). If response obtained put on a regular dose.
 If post-streptococcal aetiology is suspected give:
amoxicillin po C V 500mg 3 times a 10 days
day
 Do not give steroids.
 Treat hypertension conventionally. Children need early intervention for
elevated blood pressure.
 Restrict fluid if oliguric and carefully maintain fluid balance.
 If no diuresis within one week, and renal function is deteriorating, refer
to nephrologist /specialist physician or paediatrician for dialysis.
Nephrotic Syndrome
Diagnosed where there is generalised oedema, hypoalbuminaemia and
proteinuria (>3gm/day). Dipstick should show at least protein ++. To
quantify the proteinuria, you can request a urine albumin: creatinine ratio.
Estimate the GFR (creatinine clearance). See section on ART for
calculation of GFR.. Check urine microscopy and U&Es. Weigh patient at
each review. Exclude SLE, HIV and Hepatitis B or C or even diabetes.
 Promote diuresis using:
frusemide po B V 40 – 80mg once a day, 5 days
then refer if no response:
frusemide po or iv B V 40 – 200mg twice a day until
resolution
Caution: Excessive use of frusemide may precipitate renal failure and large
doses of frusemide may cause hearing loss. Therefore, check U&Es regularly.
Measure urea and electrolytes. Restrict fluid to 1 litre per day until
diuresis occurs. If oedema is gross and no response, consider adding:
prednisolone as a trial particularly if the urine sediment is benign (i.e. no red
cells or casts).
228
prednisolone po B V 1mg/kg once a day 2 months
[mornings]
Plus enalapril po B V 5-10mg Once a day review
rd
 Aim to tail off dose to zero during the 3 month. Stopping early may
result in a relapse.
 Give an ACEI for the proteinuria even if BP is normal e.g. a small dose
of enalapril early unless contraindicated.This may be increased as the
condiction allows.
 Refer if there is failure to reduce oedema within two weeks on high
dose steroids.
 Anticoagulate if immobile:
heparin sc B V 5000 units 3 times a day until mobile
 Search for underlying cause -e.g. Diabetes, SLE, Hepatitis B/C, HIV,
syphilis.
 Restrict dietary salt intake, but leave on normal protein intake.
 If oedema is not resolving after 2 weeks of treatment, refer to Central
Hospital/Specialist.
Prescribing in Renal Impairment / Renal Failure

Avoid medicines that are eliminated via the kidneys or reduce the dose of
the medicine if no alternative available. In most cases reducing the dose by
half should be adequate.
Table 16.2 Medicines in Renal Impairment

Medicine Comments
Analgesics
aspirin
Avoid, use paracetamol
indomethacin
codeine phosphate
Reduce dose by 25-50%
pethidine
Anti-TB Medicines
ethambutol
Avoid
streptomycin
pyrazinamide Reduce dose by 50%
isoniazid Maximum daily dose 200mg
Table continued overleaf…/
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Table 16.2 Medicines in Renal Impairment [contd.]

Antibiotics
penicillins /cephalosporins Reduce doses by 50% in advanced failure
aminoglycosides Use with extreme caution if no alternative. Use loading dose of
(gentamicin) 1mg/kg gentamicin, then use maintenance dose of 1mg/kg as well,
once daily in moderate renal failure and once on alternate days for
advanced renal failure.
nitrofurantoin
nalidixic acid
trimethoprim
Avoid
sulphonamides
cotrimoxazole
tetracycline
doxycycline May be used safely
Cardiovascular
atenolol Reduce dose by 50% [propranolol = safe]
captopril /enalapril Reduce dose by 50%, but if creatinine is >300mol/L avoid
digoxin Use smaller loading/maintenance doses (125micrograms daily).
Consider alternate day dosing. Measure digoxin levels.
Diuretics
spironolactone Avoid
Thiazides Ineffective – avoid
frusemide High doses usually required (250mg – 400mg) if renal failure is
severe
potassium supplement Avoid
Hypoglycaemics
Insulin Requirements tend to fall with worsening renal function, therefore
use smaller doses of insulin
Metformin Avoid. Risk of lactic acidosis
Glibenclamide Use with caution.
Other
allopurinol Reduce dose (maximum 200mg daily)
phenobarbitone Use 25% of normal dose or avoid if possible
benzodiazepines Use 25% of normal dose or avoid
Antiretroviral Medicines
Abacavir Use usual dose
Zidovudine Reduce dose especially if on dialysis
Lamivudine Reduce dose ( maximum of 150mg daily)
Nevirapine Usually no dose adjustment but an additional 200mg is
recommended after haemodialysis
Efavirenz No need to adjust doses
Tenofovir 300mg following dialysis once a week
Stavudine Reduce dose or increase dosing interval
Lopinavir/Ritonavir Use usual dose
230
Medicines and Dialysis
Dialysis may remove significant quantities of some medicines e.g.
penicillins, aminoglycosides, cephalosporins, chloramphenicol,
metronidazole, methyldopa, anti-TB therapy, quinine. Therefore, give
supplementary doses following a haemodialysis session. The dialysis team
will advise on supplementary doses.
End Stage Renal Disease/Chronic Dialysis

End Stage Renal Disease: This is said to have occurred if a patient needs
dialysis for at least 3 months and thus the need for chronic dialysis may be
more likely.
Chronic dialysis clients have to be selected carefully as renal replacement

therapy is expensive. Clinical and psychosocial selection criteria for the
chronic dialysis programme are applied and each individual patient should
be discussed with the dialysis team. Psychosocial issues may exclude the
patient from the chronic dialysis programme. The goals of providing this
therapy should be addressed adequately with patient and relatives.
Currently dialysis entails out of pocket expenses for the patient and family.
Thus ensure there has been precounselling prior to starting patient on
chronic dialysis.
Chronic peritoneal dialysis and haemodialysis may be available in the
nearest city or town but discuss with the specialist before transferring
patient.
Renal transplantation
There is currently no renal transplantation in Zimbabwe but some patients
have had living related donor kidney transplantation outside this country at
their own expense or that of their medical aid society.
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RHEUMATOLOGICAL AND JOINT

CONDITIONS
INFECTIONS 233
BACK AND NECK PAIN 233
GOUT (URATE CRYSTAL SYNOVITIS) 234
RHEUMATOLOGICAL CONDITIONS 235
232
Infections
Septic arthritis, and Acute osteomyelitis
Surgical drainage is recommended in all cases presenting with a greater than
24 hours history.
cloxacillin iv B V 1-2g 4 times a day 4-6 weeks
or clindamycin iv B V 600mg 3 times a day 4-6 weeks
Culture and sensitivity should guide antibiotic choice where available.

Erythrocyte Sedimentation Rate (ESR) is useful in monitoring response.
Duration of therapy may be reduced if fever and toxicity have resolved, and if
X-ray is normal. Switch to oral therapy when a good response is achieved.
Chronic osteomyelitis
Surgery is recommended. Antibiotics alone are not generally recommended.
Compound fractures
General management as for simple fractures below. Careful debridement of
the site is required.
cloxacillin iv B V 1-2g 4 times a day 5 days
or clindamycin iv B V 600mg 3 times a day 5 days
Simple fracture
Pain relief. Splinting and reduction. Consider circulation to areas beyond the
fracture site. Nil by mouth at appropriate point in referral chain prior to
manipulation under anaesthetic.
Tuberculosis of bones - see chapter on Tuberculosis
Metastatic Bone Disease - see chapter on Pain
Back and neck pain

Exclude serious pathology (fractures, neurological complications, infection)
Acute pain:
aspirin po C V 600mg 4 times a day Review
Or paracetamol po C V 1gm 3 times a day Review
Or ibuprofen po C N 200 -400mg 3 times a day Review
Or diclofenac po B E 25-50mg 3 times a day Review
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Chronic pain:
Use the lowest effective dose analgesia with increased dosages for flare-ups.
Gout (urate crystal synovitis)

Acute gout
The possibility of septic arthritis should always be considered. Allopurinol
should not be given during or within three weeks following an acute attack
unless if patient is currently on it. Aspirin should be avoided. Use:
indomethacin po B E 50mg 4 times a day first 24 hrs
then reduce by 25mg daily to 25mg 3 times a day review
Or colchicine po S N 0.5-1mg Up to 6 times a 2 days
day
Chronic gout
Treat acute attacks as they occur. Stop thiazide diuretics, avoid dehydration.
allopurinol po B E 300mg once a day continual
Note: 300 mg allopurinol orally once daily is the average dose but some patients
need more to reduce the serum uric acid to normal levels.
 In the elderly patients, those on diuretics, or those with impaired renal
function, allopurinol should be started at the lower daily dose of 100 mg
and increased cautiously if necessary.
 Allopurinol should not be introduced during or immediately after an acute
attack.
 During the period when allopurinol is being introduced an active drug for
acute gout, like colchicine or NSAIDs, should be used until a normal level
of uric acid is attained:

colchicine po S N 0.5mg 2 times a day 7 days
Or indomethacin po B E 25mg 3 times a day 7 days
 Concurrent anti-inflammatory therapy should be given for the first 3
months of allopurinol therapy:
indomethacin po B E 25-50mg 3 times a day 3 months
Dietary management of gout

Choice of foods aims to control the amount of purine in the diet.
 Reduce weight (limit fats and refined carbohydrates).
 Alcohol should be avoided or reduced drastically
234
 Avoid dehydration.
These foods should be avoided:
 offals, red meat especially goat meat.
These foods are permissible:
 eggs, milk products, carbohydrates, fruit, vegetables, chicken and fish.
Rheumatological Conditions
General Guidelines
 The first line treatment for most of these conditions is a non-steroidal
anti-inflammatory drug (NSAID). This group includes aspirin,
indomethacin, diclofenac and ibuprofen, but does NOT include
paracetamol.
 NSAID’s should be used cautiously in pregnancy, the elderly, and in
patients with asthma
 NSAID’s should be avoided in patients with a history of peptic ulcer
disease.
 Refer patients with serious rheumatic disease and peptic ulceration for
specialist help.
 Indomethacin, used as a bed time suppository, may be very useful to
alleviate morning stiffness.
 NSAIDS should be taken with food.
 If dyspeptic symptoms develop in a patient on NSAIDs, try adding
magnesium trisilicate mixture. If dyspepsia persists and NSAID use is
considered essential, refer for specialist help. Addition of paracetamol
for control of pain especially in the elderly is useful.
 Physiotherapy or occupational therapy is a useful adjunct treatment
especially after acute inflammation has subsided.
Systemic Connective Tissue Diseases

All cases of chronic polyarthritis should be referred for a definitive diagnosis.
This group shares a number of pathogenic and aetiological factors related to
autoimmunity.
Rheumatoid Arthritis and Juvenile Chronic Arthritis

(Juvenile Rheumatoid Arthritis)
To avert the erosive damage of progressive rheumatoid arthritis, early
diagnosis and initiation of treatment with NSAIDs, Disease Modifying Anti-
Rheumatic Medicines (DMARDs) (chloroquine, methotrexate and
sulphasalazine), and low dose steroids in the presence of severe inflammation
or vasculitis is necessary. Disease modifying medicines are the mainstay of
treatment to minimise erosions and deformities
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EDLIZ 2015
 Manage with:
aspirin po C E 600mg 4 times a day Review
(Paed 12.5mg – 25mg/kg)
or indomethacin po B E 25-50mg 3 times a day Review
+/- an additional night time dose of 75mg at night
or ibuprofen po C N 200-400mg 3 times a day Review
(Paed 7-14mg/kg)
or diclofenac po B E 25 -50mg 3 times a day Review
Notes: A high dose of aspirin may cause tinnitus in an adult and Reye’s Syndrome
in children. Maximum daily dose for indomethacin = 200mg, for ibuprofen = 2.4g
 Disease modifying anti-rheumatic medicines should be started early:
methotrexate po S E 5- 25mg Once a week Review
or chloroquine po S N 150mg base once a day continual/
review
Referral to an ophthalmologist is strongly advised after 9 months of continuous
treatment with chloroquine. Such continuous treatment should never exceed 2
years. Treatment should be discontinued if a patient complains of visual
disturbance on chloroquine. Methotrexate should be monitored with FBC and
LFTs at 3 monthly intervals.
 Oral, low maintenance dose prednisolone can be added where indicated
for a limited period:
prednisolone po B V 2.5 – 10mg once a day limited period
Note: Best results are achieved with combination of medicines.
Systemic Lupus Erythematosus (SLE)

Refer to a higher level for diagnosis and initial treatment. Sun-exposure
should be avoided as much as possible particularly with the use of broad-
brimmed hats and umbrellas.
Manage with aspirin or indomethacin as for Rheumatoid arthritis as above.
 If severe skin or joint lesions, add:
chloroquine po S N 150mg base once a day continual/ review
 In severe disease with complications e.g. renal, neurological, vascular or

haematological add prednisolone in high doses as well as
immunosuppressive medicines:

prednisolone po B V 1mg/kg once a day review, then reduce
236
 Reduce dose after crisis is over to smaller maintenance dose, enough to
suppress activity. Steroids should be started early and closely monitored
for side effects.
 Additionally azathioprine can be used to spare the high dose of
prednisolone. It requires specialist monitoring for side effects, especially
haematological ones. Refer for specialist care.
Degenerative Osteoarthritis & Spinal Spondylosis
Manage with:
aspirin po C E 300-600mg 4 hourly review
or indomethacin po B E 25-50mg 3 times a day review
or ibuprofen po C N 200-400mg 3 times a day review
or diclofenac po B E 25 -50mg 3 times a day Review
Rheumatoid factor negative spondyloarthropathies

Reiter’s disease and Post Infective Arthritis
Treat as for osteoarthritis as above. Exclude UTI/ bowel infection and HIV
infection.
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METABOLIC & ENDOCRINE CONDITIONS
DIABETES MELLITUS 239

ORAL ANTI-DIABETIC AGENTS 241
DIABETIC DIET 246
SPECIAL PROBLEMS IN DIABETICS 248
HYPOGLYCAEMIA AND HYPOGLYCAEMIC COMA 248
SURGERY 249
HYPERGLYCAEMIC COMA & PRE-COMA (ADULTS)250
HYPERGLYCAEMIC COMA AND PRE-COMA (CHILDREN) 252
THYROID DISEASE 254
GOITRE 254
HYPERTHYROIDISM 254
GRAVES’ DISEASE 255
HYPOTHYROIDISM 256
HYPOADRENALISM 256
238
Diabetes Mellitus
There are two main types of diabetes mellitus:
Type 1
 Usually under 30 years but can present at any age, present acutely,
with weight loss and ketonuria: treated with diet and insulin.
Type 2
 Usually over 30 years, insidious onset, frequently obese: treated with
diet and oral anti-diabetic agents. 40% will eventually require insulin
treatment. Weight reduction is crucial.
Dietary control and weight loss plays an important part in the

management of diabetes mellitus. Many type 2 diabetics are
overweight. Reducing body weight through careful control of
energy intake and physical activity like walking helps to control the
symptoms of diabetes.
Most people with diabetes who are properly informed and managed soon
become experts in their own care.
Types of Insulin(Table adapted from www.uptodate.com)

Insulin type Onset Peak Duration Type of
activity [hrs] insulin e.g.
[hrs]
Bolus Insulin 5-15 1-1.5 2-4 Aspat, Lispro
(Rapid and Short Rapid Acting mins Glulisine
acting insulins) Short acting 30mins 2–4 5-8 Actrapid
Basal Insulin Isophane Insulin 2-4 hrs 4 – 12 12- 24 Protaphane
(Intermediate
Human Insulin 2 hrs 3-9 6-24 Detemir
and long-acting
Analogue
insulins)
Human Insulin 2hrs None 20->24 Glargine
Analogue
Biphasic 2-12 + 24 Soluble(30%)/
Isophane(70%)
e.g. Actraphane
General Insulin dosage guidance and monitoring:

 In Type I diabetes, when initiating treatment the starting dose of
insulin is 0.5-1.0units /kg/day. In most patients this was being as a
combination of soluble and isophane insulin given twice daily, giving
2/3 of the total daily dose in the morning and 1/3 in the evening. 2/3 of
the insulin dose should be isophane and 1/3 soluble. Doses should be
given about 30 minutes before meals.
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 Ideally a “basal/bolus” regimen should be used where basal

(intermediate acting) insulin is taken at bedtime and 6-8u of soluble
insulin (bolus) taken 3 times a day before meals. This regimen allows
more flexibility with meals as the soluble insulin dose can be varied
according to what is to be eaten and can be given at different times.
 Self monitoring of blood glucose is recommended and the patient can
be taught to adjust doses appropriately based on results.
 A physiologic insulin regimen can be conceptualized as having 3
separate components: basal insulin, nutritional (or
prandial/meal/bolus) insulin and a correctional dose or
supplementary insulin. A patient’s total daily dose (TDD) of insulin is
a sum of these, and represents the sum of insulin a patient needs.
Roughly 50% of TDD is made up of Basal Insulin and the other 50%
makes up Prandial or Bolus insulin. If the nutritional intake is
interrupted, or severely reduced, this portion of insulin
(prandial/meal/bolus) must be proportionately reduced. The
correctional dose or supplementary dose is what needs to be added to
the patient’s calculated pre-meal insulin boluses based on the glucose
readings(see Correction doses Table below)
Basal Insulin (50% of TDDI):

 Long acting insulin subcutaneously once at bedtime or morning
 Or Intermediate acting insulin subcutaneously twice a day (50%/50%
or 2/3 am and 1/3 pm)
Nutritional Insulin (Prandial/Meal/Bolus): (50% of TDDI)
Can use the rapid acting or regular type insulins:

 Rapid acting insulin before breakfast, lunch and dinner
 Regular insulin 30- 45 mins before breakfast and dinner +/- lunch
correctional doses as per table below:
CORRECTIONAL DOSE SCALES:

Having calculated the total daily dose of insulin, classify your patient
into the following categories i.e. low/medium/high dose. What is the
pre-meal glucose and how much extra insulin should be added to the
calculated pre-meal given the recorded glucose?
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LOW DOSE <40 MEDIUM DOSE HIGH DOSE
units/day 41-80 units/day >80 units/day
Premeal BG Rapid or Short
Acting Insulin
8.5-11.1 1 2 3
11.2-14 2 4 6
14.1-17 3 6 9
17.1-22 4 8 12
>22 5 10 15
 In insulin treated type II diabetes, the total daily dose of insulin is

0.2units/kg/day. In the elderly, this is usually given as a once daily
dose of an intermediate acting insulin.
 Biphasic [pre-mixed] insulin is available. It is simple to give and is
recommended for most type 1 diabetic patients. These preparations
contain a fixed mixture of soluble and isophane insulin.
Additional management guides:
 Insulin treatment often leads to weight gain.
 Combined treatment of insulin + metformin can improve glycemic
control in type 2 diabetes.
 Do not change dietary and medicine regimens simultaneously.
 Select an insulin schedule best suited to the individual patient’s eating
pattern, physical activity and general lifestyle.
 Insulin doses should be adjusted according to blood glucose levels
(where available), and to avoid recurrent episodes of symptomatic
hypoglycaemia.
 Ideally, blood sugar should be maintained in the range 5-7mmol/litre.
 Where blood glucose measurements are not available, urinary sugar
levels give a guide to overall glycaemic control.
 When stable, review at a minimum every 3 months.
Oral anti-diabetic agents

See flow chart below for treatment approach. Apparent treatment failure is
frequently due to poor compliance with diet: Monitor as for Type I diabetes
but less strict glycaemic control is expected, especially in the elderly.
Caution:
 Oral anti-diabetics must not be used in pregnancy.
 Glibenclamide can accumulate in the elderly and cause prolonged
hypoglycaemia
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 Do not use metformin if renal failure, severe heart failure or liver failure
(increased risk of lactic acidosis)
Obese Type 2 diabetic:
metformin po B V 500mg to 2 times a gradual
1000mg day increase
[max 2g/ day]
 if poorly controlled with strict adherence to diet, add:
add glibenclamide po B V 5mg-10mg Once to -
twice a day
or Gliclazide po B E 80-160 Once to
twice daily
*if poorly controlled despite diet: change to insulin or add a daily dose
of intermediate acting insulin to the oral hypoglycaemics. Please
discontinue sulphonylureas (glibenclamide and gliclazide) before
adding insulin.
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Continues on next page!
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Continues on next page!
244
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Normal weight Type 2 diabetes:

metformin po B V 500-850mg 2-3 times a indefinitely
days
glibenclamide po B V 2.5mg once to Indefinitely
twice a day
increase to a max of 10mg twice a day
 if poorly controlled despite diet and oral hypoglycaemics, change to
insulin or add insulin to current therapy.
Diabetic Diet
Ideally a dietician should calculate dietary requirements for individual
patients.
Aim of diet: to reduce the blood sugar to normal and to maintain a constant
blood sugar level.
 45-50% of energy intake should be in the form of carbohydrates; the
amount of carbohydrates should be consistent from day to day.
 Complex carbohydrates are preferable to simple sugars.
 Carbohydrates and calories should be evenly distributed through the
day. Meals must not be missed. A diabetic on insulin may have snacks
between meals.
 An adequate intake of fibre is important.
 Alcohol is NOT RECOMMENDED in Diabetics.
 Sugar and sugar-containing food/drinks should be totally avoided. The
only exceptions are when a patient feels faint, or is ill and cannot eat
normally.
 Exercise should be encouraged. A snack should be taken before and
after playing sport.
 Unrefined carbohydrate, e.g. Roller Meal, wholemeal flour, is
preferable to refined starches.
 Special preparations for diabetics are safe but not “diet” drinks. 100%
fruit juices and diet sodas should be totally avoided in Diabetics.
General Advice for Diabetics
All diabetic patients should have a "medic-alert" bracelet or necklace, and
should be advised to join the Zimbabwe Diabetic Association.
Syringes / Insulin Storage:
 Reuse 1ml disposable syringes for 2-3 weeks.
 Store syringes dry.
 Sterilisation is not necessary.
 Change the needle when blunt.
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 Insulin should be stored in a cool place.
Injection technique
 Clean and dry skin. Inject subcutaneously not intradermally.
 The site of injection should be varied (abdomen and thighs are the
most suitable sites).
Foot Care for Diabetics:
 Advice about foot care is important: keep feet clean and dry, wear
well-fitting shoes, and take care to avoid burns. Healthcare service
provider to screen for diabetic foot at each review visit.
Ophthalmological Examinations:
 At least annually from time of diagnosis; monitor and record acuities
(each eye separately). If acuity drops, look for cataracts. Refer to eye
hospital.
Blood pressure control:
 Good BP control is essential and is more effective at preventing
complications than good glycaemic control. Use combinations of
medicines, preferably including an ACEI, target BP <140/80
Aspirin and diabetes
 To all diabetics with hypertension and any with documented vascular
disease, add:

Aspirin po C E 75mg Once a day
For those that are allergic to Aspirin or have an intolerance:

Clopidogrel po B E 75mg Once a day
Lipid control
 Early and aggressive management of hyperlipidemia is desirable. For
primary prevention treat if 10 year risk >30%. For secondary
prevention following any vascular event aim for total cholesterol <4.8
mmol/l.
Smoking:
 Patients with diabetes should stop smoking.
Sexual Dysfunction:
 Patients (Males and Females) MUST always be asked about sexual
dysfunction and referred accordingly, since it is a marker of vascular
disease.
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Oral Care:
 Good oral Hygiene should always be encouraged and patients should
have annual dental check ups.
Gastrointestinal upset:
 e.g. vomiting diarrhoea or constipation must be sought as they are an
indicator of complications.
Diabetic Clinics
 Are useful to focus care even at District Hospital level. Six monthly
reviews should include eye checks, checking for peripheral
neuropathy, checking for foot problems, oral care, sexual dysfunction
and BP.
Special Problems in Diabetics

Pregnancy
 Oral anti-diabetic agents should not be used and very strict glycaemic
control is necessary. See the chapter on Obstetric and Gynaecological
conditions.
Infections and Other Major Illnesses
 Both types of diabetics (Type I and Type II) may need to be given an
increased dose of infusion or Basal Bolus Insulin (see insulin therapy
in adults). In Type 1 diabetes NEVER stop insulin, even if the patient is
unable to eat.
 Insulin is the anti-hyperglycaemic agent of choice in patients admitted
to Hospital. Insulin acts rapidly, responds in a timely fashion to dose
titrations, & can be used effectively in all patients and clinical
situations. However clinically stable patients with normal nutritional
intake; normal blood glucose and stable renal and cardiac function
may continue oral antidiabetic medications.
Hypoglycaemia and Hypoglycaemic Coma

 Educate patients about hypoglycaemic symptoms (hunger, sweating,
irritability, etc).
Clinical presentation:
Adrenergic features:
 Sweating, pallor, palpitations and tachycardia, hunger
Neuroglycopaenic features
 Confusion, Seizures & Coma
 Patients on oral hypoglycaemic agents and insulin must carry sweets
or glucose tablets. The patient’s close relatives must also be
instructed in management of hypoglycaemic attacks. Metformin cannot
cause hypoglycamia.
Definition of hypoglycaemia
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Venous plasma glucose < 3.0 mmol/L
Management of hypoglycaemia:
50% dextrose: if normal awake, give 25 mL by bolus intravenous injection

(preferably through a large bore cannula). If level of consciousness is
depressed, give 50 mL of 50% dextrose by bolus intravenous injection.
Check blood glucose every 20 minutes. Repeat 25 mL of 50% dextrose
intravenously, every 20 minutes until blood glucose is > 3.3 mmol/L.
5% dextrose: infused slowly (50-60 mL per hour) after injection of 50%

dextrose and titrated according to capillary plasma glucose levels.
Sulphonylurea-induced hypoglycaemia may be prolonged and glucose
infusions may be needed for 2-3 days. The patient should take oral
carbohydrate as soon as possible after the initial management with 20%
dextrose.
 In the event of confusion or coma in a diabetic on treatment and in the
absence of reliable blood sugar readings, there should be no
hesitation in administering a trial injection of intravenous dextrose.
 If the above are unavailable, small quantities of sugar or preferably
glucose, may be placed inside the cheeks and will be eventually
swallowed or absorbed through the buccal mucosa.
Surgery
Diabetic patients requiring surgery SHOULD ALWAYS BE THE FIRST
ONES ON THE SURGERY LIST and are best cared for by specialists.
Refer wherever possible.
In the case of diabetic patients on oral agents, stop the oral medicines and
commence Basal Bolus Regimen.
If NIL BY MOUTH
 Basal: 50% of TDDI
 Long acting insulin at bedtime or morning
 Or Intermediate insulin twice a day (50/50 or 2/3 am
and 1/3 pm)
 Or Insulin INFUSION (preferred if prolonged NPO, ICU
or ketosis prone)
 Prandial/Nutritional: N/A
 Correction
 Rapid acting insulin sc every 4 hours
 Or Regular insulin sc every 6 hours
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 check blood sugar - if less than 5 mmol/L set up 5% dextrose infusion

to run slowly,
 check blood sugar post-operatively and if nil per mouth administer
Basal and Correction Insulin only. Do not give Prandial/Nutritional
Insulin.
Hyperglycaemic Coma & Pre-coma (Adults)

Pass a nasogastric tube and allow free drainage in the unconscious or
semiconscious patient. Search for and treat infections promptly.
Fluid Replacement (Adults)
 Sodium chloride 0.9% is the recommended fluid; as much as 8 litres
may be required in 24 hours:
Medicine Codes Adult dose– fluid rate
sodium chloride 0.9% iv C V first litre over 1 hour
infusion second litre over 2 hours
The schedule given is a third litre over 4 hours
guide. Be flexible. fourth litre over 6 hours
fifth litre over 8 hours
Give subsequent litres of sodium chloride 0.9% every 8 hours. Monitor

closely during the period of infusion and modify accordingly, e.g. take into
account skin turgor, peripheral perfusion and urine output.
CAUTION: Fluid overload is dangerous in elderly patients.
 The above regimen may need to be modified depending on the state
of hydration or the cardiovascular status of the patient.
 Beware of hypernatraemia by monitoring electrolytes and be prepared
to change to a hypotonic solution, e.g. 5% dextrose if appropriate, or
half sodium chloride 0, 9% (prepared by diluting normal saline by 50%
with water for injection).
 When blood sugar falls to 13mmol/L change to dextrose 5% (or if
urinary ketones can be measured), set up 5% dextrose infusion if
ketones moderate or strong and blood sugars <13mmol/L.
Potassium Replacement
 In conditions where blood potassium levels cannot be determined,
add to intravenous fluid:
Medicine Codes Adult dose
add potassium chloride iv B V 20mmol with every litre after the first
infusion litre. Increase to 40mmol / litre given
over 8hrs.
 Where serum potassium levels are available start replacement:
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Medicine Codes Adult dose
potassium chloride iv B V 20mmol / litre as soon as insulin has
infusion been started.
 Assess serum potassium regularly and adjust replacement as needed
to maintain potassium at 4.0-5.0mmol/per litre.
 Continue with oral replacement for one week if not in renal failure:
potassium chloride po B V 600 – twice a day 7 days
1200mg
Insulin Therapy (Adults)

Patients preferentially to be managed with protocol 1 in a High Care ward,
with appropriate monitoring.
PROTOCOL 1:- continuous intravenous infusion:
 Give a bolus intravenous injection of 0.15 units/kg rapid acting or short
acting (regular) insulin followed by a continuous intravenous infusion.
This initial bolus should not be given to patients < 20 years of age
 Mix 50 units rapid or short acting (regular) insulin in 200 mL isotonic
saline - thus 4 mL solution contains 1 unit of insulin
 Initial infusion: 0.1 unit/kg/hr (usually 5-7 units per hour: 20-28 mL/hr)
 If plasma glucose does not fall by 3 mmol/L in the first hour, the insulin
infusion may be doubled (hourly) until a steady reduction of plasma
glucose (at 3.0 to 4.0 mmol/L per hour), is achieved
 When plasma glucose < 14 mmol/L, reduce the insulin infusion rate to
0.05 units/kg/hr and adjust subsequently according to hourly bedside
capillary glucose level (Glucometer)
NOTE: Ketonaemia takes longer to clear than hyperglycaemia and
combined insulin and glucose (and K+) are needed to ensure clearance of
ketonaemia. Avoid focusing on glycaemia alone!
PROTOCOL 2 :- hourly intramuscular or subcutaneous bolus injections:
 Loading dose: 0.4 – 0.6 units rapid or short acting insulin/kg (half the
dose is given as an intravenous bolus injection and half is given
intramuscularly)
 Subsequent hourly doses: 0.1 unit/kg either by intramuscular or
subcutaneous injection and titrated against the bedside capillary
glucose level
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PROTOCOL 3:
 Initially give by intramuscular injection (be careful not to inject into
subcutaneous fat, use intramuscular needles and in very obese
patients use the deltoid region), see below:
soluble insulin im B V 10units immediately, then
5units hourly until blood sugar
down to 14mmol/L
 When the blood sugar is 14mmol/L or less and the clinical condition
shows clear improvement, change to subcutaneous administration but
continue to monitor blood sugar hourly until the level ceases to fall (the
intramuscular injection may continue to act for some hours through a
depot effect).Then give insulin according to Basal Bolus and
correctional dose regimen.
Common problems with using the Sliding Scale Only:

1- Is reactive rather than proactive
2- Often mismatched with changes in patient’s insulin sensitivity
3- It does not meet the physiologic needs of the patient
4- Leads to insulin stacking
 Blood Sugar Soluble Insulin Use blood sugar
[mmol/L] reagent strips or
glucometer readings. Do
>16 12 units not rely totally on these
>12-16 8 units readings- also use
>8-12 4 units clinical judgement.
<8 0.5 units
Sliding scales using URINE glucose tests are unreliable - avoid.
Hyperglycaemic Coma and Pre-coma (Children)

Priorities:
Fluid replacement
Electrolyte / acid-base monitoring
Insulin therapy
Blood glucose monitoring
Fluid Replacement
 Approximately 200 ml/kg in 24 hours is required for rehydration.
 Start with rapid infusion of:
252
Medicine Codes Rate
sodium chloride 0.9% iv C V 20ml/kg fast, then
infusion ½ the remaining volume in 8hrs, then
Total volume = 200ml/kg ½ the remaining volume in 16hrs.
in 24 hours
and potassium chloride B V add 20mmol/L after the initial 20mg/kg
infusion fast infusion.
 Monitor glucose levels hourly: when the blood sugar is less than
15mmol/l change to:
Medicine Codes Rate
half strength Darrows C V see section on iv fluid replacement
with 5% dextrose iv
infusion *
and potassium chloride iv B V 20mmol per litre of the ½ Darrows/
dextrose solution
* Made up by adding 50mls of 50% dextrose to 1 litre ½ Darrows with 2.5%
dextrose.
 Monitor U/E 2-4 hourly watching the potassium levels.
Insulin Therapy (Children)

Medicine Codes Dose Rate
soluble insulin iv B V 0.1units/ kg/ hr until blood sugar
(initial – continuous falls below
infusion)* 15mmol/L, then
(*e.g. make up infusion of 0.05units/ kg/ hr until condition
insulin in normal saline) stabilises, then
soluble insulin sc B V 0.75 – 1unit/kg/day in 3 divided doses
(maintenance) before meals for one day, then
soluble + isophane sc B V apply the rule of thirds, (2/3 of the total
daily dose in the morning and 1/3 in the
evening).
e.g. 30kg child

Initial fluid requirement = (20 x 200mls) = 6Litres
 initial bolus of 600mls normal saline fast
 followed by (5.4L / 2) = 2.7L in next 8hrs and 2.7L in next 16hrs
Initial insulin = (30 x 0.1) = 3units iv continuous infusion,
 slowing to (30 x 0.05) = 1.5units/hr when glucose < 15mmol/L
 when stable (+ 0.75 – 1 unit x 30kg / day) e.g. 24 units per day
(24/3) = 8 units 3 times a day before meals
 then after 24hrs, 24 units isophane and soluble insulin/day:
2/3 isophane: 10units am;6units am
1/3 soluble: 6 units am; 4 units am
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Honeymoon period
In the months after initial diagnosis insulin requirements may decline to less
than 0.5 unit/kg/day as the pancreas continues to produce some
endogenous insulin. Requirements invariably revert to higher doses as
endogenous insulin levels decline. Explain the concept to the patient or
relatives.
Note: Diet is important in children but attempts at too rigid control may prove
to be counter-productive. The diabetic child should be allowed to indulge in
normal activities at school. Teachers need to be informed about the condition.
Thyroid Disease
Goitre
Compulsory iodisation of all salt for human consumption was commenced
in 1995. As a result the iodine intake of the population has increased
tenfold or more and iodine deficiency has been eliminated in Zimbabwe.
Goitre is much less common than in the past, and can no longer be
assumed to be due to iodine deficiency, although long standing cases will
only resolve slowly if at all. Iodine therapy is now rarely indicated.
Points in Management
 Exclude hyper/hypo-thyroidism by careful clinical examination and
thyroid function testing if necessary.
 Thyroid cancer should be considered in patients with nodular goitre, or
a single thyroid nodule, if there are suspicious features. (Rapid growth,
fixation, unusual firmness, enlarged lymph nodes, hoarse voice: refer)
 Otherwise treatment is not necessary, but if the goitre causes
cosmetic embarrassment or pressure symptoms, thyroxine 100mcg
daily should be given for an initial period of at least 6 months and
response observed. In severe or unresponsive cases, consider
surgery.
 After subtotal thyroidectomy, thyroxine 100mcg should be
administered indefinitely. The dose should be adjusted according to
tests of thyroid function.
 Iodine is unlikely to be of benefit unless the subject does not have
access to iodised salt. Supplemental iodine is contra-indicated in
those with nodular goitre due to the risk of hyperthyroidism.
Hyperthyroidism
 Accurate diagnosis and identification of the underlying cause is
essential; if not possible, refer. In clinically obvious cases either refer
or start treatment while awaiting laboratory results.
254
 In severe cases refer early for possible radio-iodine. In all cases
hyperthyroid symptoms may be relieved by propranolol unless
contraindicated (e.g. by asthma):
propranolol po B E 40 – 240mg 3 times a day -
Graves’ disease
 Treat initially with anti-thyroid medicines:
carbimazole po B E 20 -60mg daily until euthyroid, then
[0.5 mg/kg] reduce to 5-20mg [0.125-
0.5mg/kg] daily.
CAUTION: May induce bone marrow suppression; advise patient to report
sore throat or other signs of infection. Stop medicine immediately if
neutropenic. Minor rashes are not an indication to stop treatment.
Check thyroid function at 5-6 weeks and if normalised, gradually reduce the
dose to the lowest that will maintain euthyroidism. Continue carbimazole for
one year from time of stabilisation. If poor response, relapse or clinically
very severe, refer for radio-iodine or surgery.
NB: after radio-iodine therapy for Graves disease, long-term follow up is
essential to detect late hypothyroidism that might otherwise remain
neglected and untreated.
Toxic Nodular Goitre [including toxic adenoma]

 Carbimazole should normally be given only for short-term treatment
prior to surgery or radioiodine. Give as for Graves’ Disease, but higher
doses may be needed.
 Radioiodine is recommended, particularly in older patients and those
with other medical problems. Radio-iodine (I-131) treatment is
available at the Radiotherapy Centres at Parirenyatwa and Mpilo
Central Hospitals.
 Surgery is particularly suitable for those with a large goitre. As
radioiodine may take three months or longer to produce a clinical
effect, propranolol may be continued uninterrupted and carbimazole
may be restarted. Patients must be rendered euthyroid prior to
thyroidectomy by use of anti-thyroid medicines
 Aqueous iodine oral solution may be administered for 10-14 days
before thyroidectomy:
Aq. iodine solution A N 0.1 – 0.3ml 3 times a 10-14 days
(Lugol’s iodine) diluted in day before
130mg iodine/ml water surgery
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Hypothyroidism
Except in iodine deficient areas, this is treated by thyroid hormone
replacement whatever the cause:
thyroxine po B V 50 -100mcg once a day 4 weeks,
initially then
increase by 25 - 50mcg every four weeks as necessary until euthyroid
 Start at 25mcg/day in the elderly or those with heart disease.

 Typical adult replacement dose is 2mcg/kg/day [i.e. 150mcg daily].
 Larger doses are needed in infancy [10 - 15mcg/kg/day] and childhood
[4mcg/kg/day].
 Close monitoring of clinical response and thyroid function tests (T4,
TSH) is essential.
Hypoadrenalism
May be primary (Addison’s disease) or secondary to pituitary failure, e.g. as
a result of surgical or irradiation ablation of the pituitary gland.
Requires specialist investigation and advice on how to treat the patient..
Surgery or illness necessitates an increase in corticosteroid cover generally
in the form of hydrocortisone parenterally in the acute phase, followed by
oral prednisolone in a higher than usual dosage as the condition improves.
Patients on long term corticosteroid who develop infection or are subjected
to surgery also require additional steroid cover as above.
256
NEUROLOGICAL CONDITIONS
INFECTIONS OF THE NERVOUS SYSTEM 258

MENINGITIS 258
NEUROCYSTICERCOSIS 260
HEADACHE 260
EPILEPSY 262
STATUS EPILEPTICUS 263
ACUTE CONFUSIONAL STATES 265
STROKE 265
PROGRESSIVE GENERALIZED WEAKNESS 266
PERIPHERAL SENSORY SYMPTOMS 267
INVOLUNTARY MOVEMENTS 267
ESSENTIAL TREMOR 268
PARKINSONISM 268
CEREBELLAR TREMOR 268
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Infections of the nervous system

The usual presentation is with:
 headache and fever
 and/or altered level of consciousness
 and/or neck stiffness
 and/or focal neurological signs
 and/or seizures.
In infants lethargy and failure to suck are important signs. Neck
stiffness is an unreliable sign under one year of age, but the detection of a
bulging fontanelle supports the diagnosis.
Differential diagnosis
Headache and fever only: look for cause of fever in other systems (for
example, chest, respiratory tract; urinary tract, etc.). Always do malaria
slides.
If altered level of consciousness, neck stiffness, focal signs or seizures in
the presence of fever, or fever with lethargy and failure to suck in infants:
 Give:
benzylpenicillin iv/im C V 3g (5MU) one dose refer
Note: for dose in children see chapter on Paediatric conditions
 Transfer urgently to a secondary care centre.
Meningitis
Management of suspected meningitis (fever +headache+ neck stiffness) at
District level (or higher):
 Urgent lumbar puncture (18G cannula adequate in adults if spinal
needle unavailable) , measure opening pressure using an IV giving set
if manometer unavailable. If pressure greater than 20cm, remove CSF
until less than 15cm.
 Blood slide for malaria parasites.
 If diagnosis is in doubt DO NOT perform a lumbar puncture. Refer
to a higher level.
 Contraindications to lumbar puncture: deeply unconscious + focal
signs; one pupil large and unresponsive; papilloedema (if fundoscopy
available); rapidly falling level of consciousness. These are indications
for referral to a tertiary care centre.
 Lumbar puncture should be considered mandatory, and, preferably,
when the condition is first suspected since Cryptococcal meningitis
must always be excluded.
 Tuberculous meningitis should always be remembered. It may have no
special distinguishing features, and can present acutely.
258
 If symptoms present less than one week:
benzylpenicillin iv C V 3g (5MU) 6-hourly Until CSF
chloramphenicol iv B V 500mg 6-hourly results out
 Spinal fluid microscopy, (protein, glucose; Gram stain India ink stain,
Ziehl-Neelsen stain and cultures if possible) and blood glucose.
Treatment for bacterial meningitis:

benzylpenicillin iv C V 3g (5MU) 6 hourly 14 days
and chloramphenicol iv B V 500mg 6 hourly 14 days
or ceftriaxone iv C V 1g 12 hourly 14 days
Note: for paediatric doses see chapter on Paediatric conditions
In patients who can swallow, and are fully cooperative, chloramphenicol can
be given orally after 5 days, and amoxicillin 750mg 8 hourly can replace
benzylpenicillin
Chemoprophylaxis for close contacts (meningococcal meningitis
only):
 Give as soon as diagnosis made in index case.
ceftriaxone im C V 500mg once only single dose
Further management
The combination of fever and focal neurological signs is an indication for
referral to a central hospital and CT scan of the head.
The differential diagnosis includes cerebral abscess, cryptococcal
meningitis tuberculoma, toxoplasma encephalitis, and other parasitic
infection.
If a focal contrast-enhancing lesion or multiple lesions are present on scan
and the patient is known to be HIV infected or is suspected to be infected
on clinical grounds, start treatment for toxoplasmosis:
sulphadiazine po S E 2g 4 times a day 6 weeks
and pyrimethamine po S E 200mg once a day 6 weeks
loading
dose and
then 50mg
or clindamycin po B E 600mg 4 times a day 6 weeks
and pyrimethamine po S E 200mg once a day 6 weeks
loading
dose and
then 50mg
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or co-trimoxazole po C V 1920mg 3 times a day 6 weeks

*alternative to sulphadiazine
If there is no response (clinically and on CT scan), in two weeks, or if lesion

appears atypical, consider antituberculous treatment and neurosurgical
intervention. (May need biopsy)
Neurocysticercosis
Focal seizures without fever may be caused by neuro-cysticercosis (typical
CT scan appearance).
albendazole po C E 800mg Twice a day 14 days
and/ praziquantel po C E 40mg/kg once a day 14 days
or
add* prednisolone po B V 1mg/kg once a day review
*If drowsiness, seizures or focal signs develop.
Headache
This may be primary or secondary:
 In secondary headache or facial pain treat specifically for the underlying
cause (e.g. meningitis, sinusitis, malaria) and use aspirin 600mg every
4 hours as analgesic.
 Primary headache is either of tension type (muscle contraction
headache), migraine, or a combination or atypical.
Treatment of primary headache
Tension
 Bilateral; dull; band-like, worse as the day wears on; no nausea; frontal
or occipital in site; often daily; can continue activities.
aspirin po C V 600mg 4 hourly prn no longer than one week
continuously (risk of
analgesic rebound
headache)
 Social circumstances may precipitate these headaches; counselling in

relaxation therapy (muscle relaxation) will help. Lifestyle changes may
help (lunchtime rest, more sleep), and physiotherapy if local muscle
spasm and tenderness.
 Avoid opiates (e.g. codeine compounds) and benzodiazepines as they
particularly can cause rebound headache and habituation.
 If headache persists for more than six weeks, add
260
amitriptyline po B E 25-150mg at night 3 months
Migraine
 Unilateral; (occasionally bilateral); throbbing attacks; last hours to days;
with nausea ± vomiting; photophobia, sometimes preceeded by visual
aura; often have to lie down.
aspirin po C V 600mg 4 hourly as required
or paracetamol po C V 1g 6 hourly as required
and metoclopramide po B V 10mg at onset one dose
 If ineffective:
metoclopramide po B V 10mg at onset -
and ergotamine po A N 1mg at onset. Repeat once
only after 1hr if needed.
Ergotamine is contraindicated in complicated migraines (these include
hemiplegia as an aura symptom).
 Look for and avoid precipitating factors: Not enough sleep, alcohol,
cheese, chocolate, menarche, menstrual cycle, oral contraceptive pills
may all influence migraine frequency.
 If two or more disabling migraines a month (leave work, off school);

propranolol po B N 20mg 3 times a day minimum 3
months
If ineffective increase gradually to a
max of 120mg 3 times a day, if side
effects allow.
or amitriptyline po B E 25mg at night minimum 3
months
Note: propranolol contraindicated in asthma – use amitriptyline.
Cluster Headaches
This is a sub-group of migraine with characteristic features of
hemicrania, and periodicity (occurring about the same time for days or
weeks). It shows a predilection for males.
Combination
A variable mixture of above two types of headache is common. Treat both.
As prophylaxis, amitriptyline 25mg at night may be a good choice.
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General Notes
 Ergotamine should not be taken more than twice in 24 hours, with a
minimum of two days before the next dose, and not as a prophylactic
treatment (excess ergotamine causes ergotism – severe headache,
vomiting, gangrene of extremities and rebound headache). It should
be avoided in pregnancy.
 Patients commonly abuse analgesics: headache diaries with a record of
the daily number of tablets consumed will reveal this.
 Paracetamol 5OOmg 4-hourly should be used in children aged 7-12
years instead of aspirin.
 Ergotamine should not be used in children under 12 years
 Propranolol doses in children should be half of adult doses.
Epilepsy
This is defined as a tendency to recurrent (unprovoked) seizures. A single
seizure is NOT epilepsy. One or more seizures in the presence of fever,
brain infection, medicine intoxication (including alcohol), at the time of
trauma and during an episode of metabolic derangement (hypoglycaemia,
uraemia, liver failure) is not epilepsy, although the brain damage caused by
some of the above may lead to epilepsy. Look for provoking factors like the
ones listed above when faced with a patient with a first seizure.
Seizures are distinguished from other transient neurological episodes by
the history, especially the description provided by an eyewitness. Do not
start anticonvulsant treatment without an eyewitness description of a
seizure.
A typical generalised seizure has a sudden onset with abrupt loss of
consciousness. There are often involuntary movements of the limbs, urinary
incontinence or tongue biting. Afterwards the patient is often confused,
sleepy and complains of headache. Partial seizures do not involve loss of
consciousness but present as recurrent twitching or abnormal sensations in
one body part. Complex partial seizures include reduced awareness,
aimless movements and memory loss for the event afterwards.
First line treatment

Health workers who have undergone training in the recognition and
management of epilepsy may initiate treatment at primary care (C) level.
Otherwise refer to District level.
 If two or more typical seizures in the past 12 months in a patient over 2
years
plus
 normal physical examination, no neurological signs, start:
phenobarbitone po C V 120mg once a day, 2 weeks
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Paed = 5mg/ kg at night until review
Review after 2 weeks. Check compliance and side effects (very sleepy, loss
of balance, rash, poor concentration, hyperactive). If side-effects, reduce
phenobarbitone dose by 30mg. Review again after 4 weeks.
Second line treatment

For the patient with persistent seizures despite phenobarbitone check the
diagnosis, compliance, medicine interactions, and intercurrent illness.
 Increase:
phenobarbitone po C V 120mg every night 4 weeks
then review
 If seizures persist (one or more in four weeks):

add phenytoin po B V 300mg bedtime
 If seizures persist, increase:

carbamazepine po B V 400mg twice a day 4 weeks,
Paed = 10mg/kg then review
 Review in 4 weeks
 If seizures persist, intolerable side effects, patient maintained on more
than one anticonvulsant: refer for tertiary level care or specialist
care.
 Other indications for referral to tertiary level / specialist care: neonatal
epilepsy, progressive neurological deficit, absence seizures
(momentary loss of consciousness without involuntary movements)
Tertiary/Specialist care
Decisions will include whether further investigations (EEG, CT scan) are
indicated, and the use of phenytoin sodium, sodium valproate,
ethosuximide, diazepam or clonazepam.
Status epilepticus
A seizure or a series of seizures continuing for more than 30 minutes, or
recurrent seizures without regaining consciousness in-between, for more
than 30 minutes. Many cases do not occur in known epileptic patients –
always consider possible underlying causes such as stroke or brain
abscess.
The above description should be strictly adhered to. The practice of
prescribing diazepam 10mg i.v. every time a seizure occurs should be
resisted. It is preferable to use a regular anti-convulsant during the in-
patient stay.
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Adults:
Management at primary level:
 Protect the airway and give oxygen if available,
 Give 50ml bolus of dextrose 50% intravenously (children: 10-20ml)
 While making arrangements to transfer the patient to a hospital, give:
Medicine Codes Adult dose Rate
diazepam slow iv (or pr) C V 10mg Given over 2-3 minutes.
(not im) May be repeated once after 5mins.
Management at district level:

 Diazepam as above may be repeated twice (max dose 40 mg) if
seizures persist, but watch for respiratory depression (ambu-bag must
be available).
 If seizures persist after 30 minutes, give:
phenobarbitone iv/im B E 10-15mg/kg 30-50mg per minute
infusion( iv over 10 mins)
 Commence oral medicines as soon as fully conscious: by naso-gastric
tube if unrousable for more than 6hrs.
 If seizures persist, transfer to provincial or central level for:
phenytoin sodium iv A E 15-20 At a rate of 50mg/min,
mg/kg 6 hourly
then 100mg
 If seizures still persist after 30 minutes, and ICU facilities and

anaesthetist available, give:
thiopentone sodium iv B V 7mg/kg assess/review
and suxamethonium B V 100mg assess/review
chloride iv
 intubate and ventilate; consider thiopentone infusion.
Children:
 Protect the airway and give oxygen if available.
 At primary level (C) give:
dextrose 50% iv C V 10-20ml once only -
and diazepam pr * C V 5mg may be repeated once
*use a syringe without a needle
264
 Further management at district (B) level:
diazepam iv slow C V 1mg/year of May be repeated once
age
Febrile convulsions should be treated with tepid sponging, paracetamol and
diazepam as above if necessary. They do not require long-term
anticonvulsants unless recurrent and with neurological deficit.
Acute confusional states

(including delirium)
Cardinal features are disorientation, short-term memory loss and fluctuating
lowered level of consciousness. In delirium there are also hallucinations 
illusions. This indicates organic brain dysfunction and NOT a psychiatric
condition.
 Possible causes include: meningitis, encephalitis, malaria, pneumonia,
septicaemia. Less commonly: HIV (seroconversion), typhoid,
intracranial bleeding, metabolic disorder, liver or other organ
(especially renal) failure and medicine abuse (e.g. alcohol withdrawal).
 Management should focus on identification and treatment of the
underlying cause, usually by looking for infections e.g. malaria and
treating empirically (see section on antibiotics).
 If sedation is required give:
chlorpromazine im C V 25-50 mg 4 hourly as required
Stroke
Acute management in Zimbabwe focuses on prevention of complications.
Fibrinolysis is not practical.
Prevent complications such as:
 chest infection (especially aspiration of vomitus or food because of
dysphagia)
 urinary tract infection
 deep venous thrombosis and pulmonary embolus
 pressure sores
Rehabilitation:
 physiotherapy from the day of admission.
 occupational therapy and speech therapy (if available) is required
 vocational training
Manage precipitating causes:
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 treat hypertension, but only start 2 weeks after the stroke, or if

diastolic BP is >120. Use small doses of hydrochlorothiazide
(avoid ).
 stop smoking
 treat arrhythmias, e.g. atrial fibrillation
 treat cardiac failure
 treatment of cerebral oedema may at times be necessary. Use
mannitol (if available), 20mg IV frusemide, and 30 degree head tilt.
Prevention of stroke recurrence:
Thromboembolic stroke is difficult to differentiate from intracranial
haemorrhage clinically without a CT scan.
For thromboembolic stroke shown on scan, or if no CT scan but stable
stroke, start after 2-4 weeks:
aspirin po C V 150mg once daily long term
For patients with atrial fibrillation who have access to facilities for regular
blood monitoring (weekly INR for 1month, then monthly):
warfarin po B V 10mg 2 times a day 2 days, then
adjust
Usual maintenance dose INR range 1.5 and 2; 2.5 – 5mg once a day
Refer the following patients to tertiary level:

 aged under 50 years
 diagnosis in doubt
 progressive deterioration
Progressive generalized weakness

Patients who become weak without other signs of illness may have a
neurological disease. This is usually at spinal cord, root, peripheral nerve,
neuromuscular junction or muscle level.
Rapid onset of weakness of the lower limbs with urinary retention or
incontinence and sensory loss in the legs and trunk - patient may have a
compressive lesion of the spinal cord and requires URGENT transfer to a
central hospital level.
Ascending weakness of the legs and later arms with paraesthesia in the
feet and hands – patient may have acute post infectious polyneuropathy
(Guillain-Barre syndrome) and need to be hospitalized. If unable to lift the
arms and head off the bed transfer urgently to tertiary care for ventilation.
Treatment does NOT include steroids (can worsen outcome) but may
266
involve plasma exchange or intravenous immunoglobulins (0.4g/kg daily for
5 days) for severe cases.
Gradual onset of weakness with double vision, ptosis or difficulties with
speech and/or swallowing suggests myasthenia gravis and referral to
tertiary care for diagnosis is required.
Peripheral sensory symptoms

(burning or numb hands and feet)
Pain and/or numbness in a glove and stocking or just a stocking distribution
is likely to be due to peripheral neuropathy. Treatment involves:
 recognizing (and eliminating if possible) likely causes: vitamin B12
deficiency, alcohol, diabetes, HIV infection, chronic renal disease and
medicines including ARVs, isoniazid, anticonvulsants, and allopurinol.
 For pain give:
amitriptyline po B E 25-75mg* at night review
*the lower dose is usually sufficient
 If ineffective or intolerable side effects, add:

carbamazepine po B V 100mg 2 times a day 2 days
increasing to 200mg 2 times a day 2 days
increasing to 400mg 2 times a day review
 A small proportion of patients require opiates:

codeine phosphate po B E 30-60mg 6 hourly as required
If codeine morphine sulphate po B V 10-100mg 4hourly As required
ineffective
Pain in the hands only may be due to carpal tunnel syndrome or cervical
root compression: refer to secondary/ tertiary level care for diagnosis.
Involuntary movements
The commonest is tremor, (which is usually essential, (familial) tremor,
Parkinsonism or cerebellar), and the tremor of heavy metal poisoning like
mercury. Is it a resting, postural or action (intention) tremor?
Tremor of the elderly – older people can develop a tremor consisting of

titubation or nodding of the head, it may strongly simulate a tic. NO
TREATMENT is usually required beyond assurance of their benign nature.
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Essential tremor
Fine, bilateral, postural (occurs on maintaining posture) (stops when the
hand is held), there is no increase in muscle tone. Treat with:
propranolol po B E 20mg 3 times a day review, then
increase by 20mg per dose until satisfactory response
or unacceptable side effects, up to 120 mg tds.
Parkinsonism
Coarse resting tremor with increased muscle tone. Treatment is
complicated and the diagnosis should be confirmed at a tertiary care centre.
Exclude medicine-induced Parkinsonism( antipsychotics, methyldopa)
Once motor symptoms interfere with normal household chores, treatment
should be commenced.
Initial treatment of tremor usually consists of:
benzhexol po B E 2-5mg 3 times a day review
Note: Avoid in over 60yrs. Side effects = warn about dry mouth, urinary symptoms,
sedation, and confusion.
Patients usually require treatment with levodopa at some time:

levodopa 250mg + A N ¼ tablet* 3 times a review,
carbidopa 25mg po day then
(levocarb 275) increase to ½ tablet after one week
*Note: Increase number of doses and decrease interval to 3 or even 2 hours if necessary
Cerebellar tremor
An intention tremor often associated with gait ataxia and sometimes
nystagmus. Patients should be referred to central hospital level for CT or
MRI scanning.
268
MENTAL HEALTH
PSYCHOSES 270
MOOD (AFFECTIVE) DISORDERS 274
DEPRESSION 276
ANXIETY DISORDERS 278
TREATMENT OF ALCOHOL DEPENDENCE 278
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General guidelines
Treatment of the mentally ill person does not always require medicines.
Other forms of treatment, that is, social [identification and removal of
precipitating factors] and psychological [counselling, psychotherapy and
behaviour therapy] are important in all cases, and rehabilitation is frequently
required.
 Whenever possible involve the relatives in understanding the nature of
illness and the importance of medicine compliance.
 Do a thorough physical examination, laboratory work, or any other
necessary investigation to exclude other cause of mental illness.
 Emphasise the importance of adhering to the prescriber’s instructions.
 Patients on psychotropic medication should be reviewed frequently.
CAUTION is required when prescribing psychotropic medicines during
pregnancy and lactation, children, HIV/AIDS patients and the elderly.
Psychoses
People with psychoses may present with hallucinations, delusions, loss of
contact with reality. They may be violent; some may be withdrawn and mute.
Medicine Potency Relationships
Potency Relationship
Medicine Dose equivalent 100mg Chlorpromazine

Haloperidol 2 - 3 mg
Olanzapine 5mg
Risperidone 2mg
Sulpiride 200mg
Trifluoperazine 10mg
Non-organic psychosis
 This refers to conditions where there are problems in functioning of the
brain. Major psychiatry conditions that may present with psychoses
include schizophrenia group of disorders such as brief psychotic
disorders, schizophreniform disorders and schizophrenia, mood disorders
such as bipolar affective disorder and major depression, substance
induced psychoses from substances such as cannabis, Zed, cough mixtures
such as bronchleer, heroine, cocaince, inhalants and alcohol related
disorders.Keep the patient in a safe place: prevent harm to self or others. If
uncooperative or difficult to manage, refer to a psychiatric institution.
 Give anti-psychotic medicines: In all cases start at lower dose and
increase gradually.
270
 For a first episode of psychosis the first line medicines should be used.
For a patient who has previously been stabilised on an alternative
medicine may be continued on the same.
Rapid Tranquillisation
For the violent or agitated patient there may be a need for rapid
tranquillisation. The following is recommended:

chlorpromazine C V 50-100mg IMI Initially then Until calm
inj can be and/or can be
repeated after given oral
6 hours medication
or haloperidol inj C V 2-6mg IMI (Total Initially, then Until calm
max 18mg daily) can be and/or can be
repeated after given oral
6 hours medication
or Diazepam inj C V 5-10mg IMI/IVI Initially then Until
can be calmand/or
repeated after can be given
6hrs oral medication
or lorazepam inj C V 1-2 mg IMI Initially then Until calm
(diluted with equal can be and/or can be
amount of water repeated after given oral
of injection or 6hpurs medication
normal saline)
When giving Lorazepam, or any other Benzodiazepine, by IMI or IVI,
resuscitation equipment and facilities for cardio-respiratory support should be
available
NB: Chlorpromanize should not be given IVI under what ever circumistance.
First line medicines
Medicine Codes Adult Dose Frequency Duration
Chlopromazine po C V 50-200 mg 2-3 times daily Continual
or haloperidol po B V 1.25-5 mg 2-3 times daily Continual
or sulpiride po C V 50-200 mg 2-3 times daily Continual
Second Line therapy

trifluoperazine po B E 5 – 10mg 2 times a day continual
or olanzopine po B E 5-10 mg 2 times a day continual
or Risperidone po B E 1-3 mg 2 times a day continual
or clonapine po S E 50-100mg 1-2 times a day continual
Note: The First Line Medicines, chlorpromazine may cause postural
hypotension. Use of Chlorpromazine should be avoided in Epilepsy. Olanzapine
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is associated with metabolic syndrome and Clonapine is associated with

reduction in white cell count, so FBC should be done regularly.
In general poly-pharmacy i.e. the use of two or more antipsychotics should

be avoided. However there may be a place for an additional sedative
medicine at night.
Caution: Use chlorpromazine with caution as it lowers seizure threshold in
organic pyschosis.
Organic Psychosis
HIV/AIDS
 Psychosis in HIV/AIDS may be caused by virus, ART and OIs.
 Patients who are HIV infected are more susceptible to antipsychotic
side effects therefore, use lower doses and observe for the side
effects.
Other causes of organic psychosis
 Infections such as malaria, syphilis,tuberculosis and others
 Traumatic Brain Injury and tumours.
 Systemic, Endocrine and Metabolic Conditions such as kidney
diseases, thyroid disease, diabetes mellitus, electrolyte imbalance
and others.
HIV infected patient preferably require use of atypical antipsychotic
medicines such as risperidone.
Identify the cause and treat whenever possible. Use lower doses of
antipsychotics as patients with organic psychosis are generally more
prone to side effects
Depot Medications
Adequate health education should be given to the patient on the importance
of compliance and adherence. Where patients have difficulty in adherence,
they should be offered the choice of depot preparations.
Risperidone po B V 5mg As a test dose then after
monthly
or fluphenazine decanoate B V 12.5mg as a test dose*, followed
im after 2 weeks by
adjust dose according to response 25 – 50mg once every 4 weeks,
continual
or flupentixol decanoate im B E 20mg as a test dose*, then after
at least 1 week
20 – 40mg Every 2 – 4 weeks
depending on response
Duration of therapy:
First or single psychotic episode
272
Most patients have to be maintained on a reduced dose of medication for 12
months after disappearance of psychotic symptoms. Then the medicine
should be gradually tapered off. The patient must be reviewed regularly by
medical staff and relatives for signs of relapse such as social withdrawal or
strange behaviour.
Repeated relapses of psychoses
These patients require long term maintenance medication to prevent future
relapses. Search for the cause of relapses [for example, continuing stress or
non-compliance] and remedy if possible.
Side effects and adverse reactions of anti-psychotic medicines
Early side effects:
 Chlorpromazine and sulpiride may cause drowsiness, dizziness,
postural hypotension, dry mouth, blurred vision and galactoria: usually
in early stages of treatment and may be self-limiting. These should be
discussed with patients and a change to a first line medicine considered
if such side effects are limiting compliance and adherence.
 Extra pyramidial side effects which include acute dystonia [common
features are body stiffness, tongue protrusion, grimacing, writhing,
twisting of neck or body, torticollis, and oculogyric crisis], Parkinsonism
and akathesia.
Treat with:
Orphenadrine po C V 50mg Once a day 1 week
or benzhexol po C V 5mg 1-2 times a day 1 week
or diazepam po C V 5-10mg 1-2 times a day 1 week
If severe give:
biperiden im/ iv A N 2 – 4mg once only
And then continue with benzhexol as above. Reduce the dose of the anti-
psychotic therapy.
Medium term side effects:
Medicine-induced Parkinsonism, stiffness of arms and legs, muscle cramps,
internal restlessness [akathisia] require addition of:
Orphenadrine po C V 50mg Once a day review
benzhexol po C V 5mg 1-2 times a day Review
and/ diazepam po C V 5mg 1 – 2 times daily Review
or
Note: Avoid long-term use of benzhexol because there is a risk of developing
dependence.
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Avoid benzhexol in the elderly, use orphenadrine.

Hypothermia: keep the patient warm; refer to next level as medical
emergency if body temperature cannot be raised.
Photosensitivity i.e. being more prone to skin damage from sunlight is
common. Advice should be given on hats and sun block creams.
Appetite increase and weight gain are common. Consider regular monitoring
of blood glucose to detect early diabetes
Long term side effects:
Tardive dyskinesia: reduce medicine gradually and eventually stop and
refer for specialist opinion. Use benzodiazepine and switch to atypical
antipsychotics.
Clonazepam po A V 0.25-0.5mg In divided Continual
doses upto
1mg per day
Neuroleptic Malignant Syndrome is characterized by hyperthermia,

fluctuating level of consciousness, muscle rigidity and autonomic dysfunction
with pallor, tachycardia, labile blood pressure, sweating and urinary
incontinence.
This is a rare but potentially fatal side effect. Discontinuation of the
antipsychotic is essential and an emergency referral made to a physician at a
central hospital. During the transferring of patient, there is need to take care
of rehydration of the patient, nutritional and fever control. Renal failure,
hypoxia and acidosis should be managed at a referral centre. Bromocriptine
may be use in doses of 2-3mg/kg body weight maximum 40mg/day and not
for more than 10days.
Mood (Affective) Disorders

Bipolar Disorders
It is a condition characterised by elation (mania) and low mood
(depression).
Treatment is as for other psychoses i.e. with antipsychotics but add mood
stabilisers.
Use:
carbamazepine po B E 100-400mg 3 times daily continual
or Sodium valproate B V 200-500mg 2 times daily continual
lithium carbonate po B V 250mg-1g At night continual
or Lamotrigine po B E 50-200mg 2 times a day continual
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For HIV/AIDS patients use:
sodium valproate po B E 200 – 500mg 2 times daily Continual
or Lamotrigine po B E 50-200mg 2 times daily continual
Note: Avoid carbamazepine in HIV and AIDS patients.
In manic patients with psychoses,

olanzapine po S E 2.5 – 5mg 2 times a day Continual
Quietiapine po S E 50-200mg Once a day Continual
HIV Induced Mood Disorders

For rapid tranquilisation, avoid chlorpromazine, use benzodiazepines

Diazepam IM/IV C V 5-10mg Intially then can
be repeated
after 6hours Till Calm
lorazepam IM B V 1 – 2mg Initially then Till calm
can be repeated
After 6 hours
Blood tests for FBC, U&E, Thyroid function and Pregnancy test are essential
before commencing mood stabilizers. These medicines should be used with
caution during pregnancy especially within the first trimester. Lithium levels
are mandatory for pregnant patients.
Carbamazepine may induce liver enzymes and hence causing more rapid
metabolism, and therefore reduced efficiency of co-administered medicines
e.g. ARV’s and Oral Contraceptives.
Lamotrigine is associated with skin rashes- discontinue treatment if this

occurs.
Lithium toxicity can occur with dehydration, diarrhoea and vomiting. Hence
the need to discontinue. At toxic levels this may cause tremor, in-
coordination, ataxia, coma and death. If toxicity occurs Lithium should be
stopped immediately and a saline drip started – 1 litre fast then 4 hourly -
and the patient should be referred to a central hospital.
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Depression
Assess severity and duration, identify stressoers, and carry out risk
assessment for suicide.
 Depressive Episode (Mild)
Counsel, follow up and help individual to deal with stressors. Commence
on antidepressants preferably with Selective Serotonin Re-uptake
Inhibitors (SSRIs).
 Major Depression
As for depressive episodeUse of anti-depressants and admission very
important to allow monitoring of the patient.
First Line Medicines:

amitriptyline po C V Start at 50mg Once at night 1 Assess
and increase hour before progress after
by 25mg sleep 2 weeeks
every 2 nights
up to 150mg
imipramine po C V Start at 50mg Once at night Assess

and increase by 1 hour before progress after
25mg every 2 sleep 2weeks
nights up to
150mg
Second line Medicines

fluoxetine po A V 20-80mg Once daily in
Assess response
morning with
after 2 weeks
food
or Citalopram po B V 10-40mg Once daily Assess
morning response after 2
weeks
Third Line Medicines:

Venlafaxine po S E 75mg Once daily in the continual
morning with food
or Duloxetine po S E 30mg Once daily in the continual
morning with food
or Mianserin po S E 15-40mg Once at bedtime continual
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Caution: History of Epilepsy, history of Mania, cardiac disease, Diabetes
Mellitus, close angle glaucoma, bleeding tendency or anticoagulant therapy,
hepatic or renal impairment and breast feeding.
Side Effects: “First flood effect” with increased restlessness or agitation
(This may be managed by reduced dosage or with short term usage of a
Benzodiazepine.
Gastro-intestinal upsets and appetite reduction. Reduced Libido. Some
patients may have a hypersensitivity reaction with skin rash and, in general,
medicine should be stopped if this occurs.
“Serotonin Syndrome” is a toxic over-activity of serotonin which may rarely
occur with therapeutic dosage of an SSRI but occurs more commonly as a
result of usage of more than one medicine acting on the serotonin system.
Symptoms of varying severity include:
Autonomic effects – shivering, sweating, raised temperature, high blood
pressure, tachycardia, nausea and diarrhoea.
Motor effects – myoclonus or muscle twitching, brisk tendon reflexes and
tremor.
Cognitive effects – restlessness, hypomania, agitation, headache and coma.
Management involves immediate cessation of the offending medicine/s,
usage of a Benzodiazepine for agitation and supportive care.
Medicines may cause reduced libido.
SSRIs cause insomnia - always take the dose in the morning; where
there is sleep disturbance, limited use of benzodiazepines like
clonazepam 1- 2mg at night or lorazepam 0.5 – 1mg can be given at
night for a maximum of 2 weeks.
Patients with Bipolar Affective Disorder in the depressive phase may

need both an antidepressant and a mood stabiliser (Refer to section
under mania above)
For depression with psychomotor agitation give:
amitriptyline po B E 50 –75mg once at night *14- 21days
or imipramine po A E 50 –75mg once at night then review
*It may take up to 14 - 21 days before therapeutic effect occurs.
For depression with psychomotor retardation use:
fluoxetine po A E 20 – 60mg once only Continual
Do not issue large quantities of antidepressant medicines; tricyclic
antidepressants can be fatal in overdose!
CAUTIONS: Avoid both amitriptyline and imipramine in patients with

history of heart disease, urinary retention; glaucoma and epilepsy [refer
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EDLIZ 2015
such patients to a specialist]. In elderly patients, start with 25-50 mg/day.

Imipramine is less sedating than amitriptyline.
Side effects: Common side effects include dry mouth, blurring

of vision, postural hypotension, appetite increase and
constipation.
With Venlafaxine usage an EEG is recommended prior to
initiating the medicine and blood pressure needs careful
monitoring.
Anxiety Disorders
 Mild
Psychotherapy; identify cause and treat.
 Severe
In addition to counselling, give:
diazepam po C V 5mg [up to once a day Max 2
10-15mg] weeks
clonazepam po S E 0.5mg Up to 3 Max 2
times a day weeks
Caution: Do not prescribe for more than two weeks. If severe anxiety persists
refer to specialist or consider trial of an antidepressant.
Treatment of Alcohol Dependence

Mild to Moderate
Counsel; involve family or others as appropriate. The person must
stop alcohol use OR reduce consumption to not more than 21 units
per week [men] or not more than 14 units per week [women].
1 unit of alcohol = 200ml of beer (5% weight/volume), or one glass of wine,
or one tot of any spirit.
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Severe Alcohol Dependence
Treat physical and social complications. Counsel, with family
involvement. Alcohol use must be stopped: refer to a support
organisation. If severe withdrawal symptoms occur e.g. severe
tremors, insomnia, confusion, hallucinations, give:
diazepam iv C V 10mg once only then
diazepam po C V 20-40mg once a day discontinue
[reduce by 5mg every other day] within 7 –
14days
and multivitamins po C N 2 tablets once a day review
or thiamine po A N 50mg once a day review
and Vit B Complex im C V 1ml Daily for 3
days
These vitamin replacements protect against the development of Wernicke’s
encephalopathy (ophthalmoplegia, ataxia, confusion and altered level of
consciousness)
Attention Deficit Hyperactivity Disorder

methylphenidate po S E 10-60mg Daily in 2 – Continuous
3 divided with regular
doses reviews
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COMMON EYE CONDITIONS

PREVENTION OF BLINDNESS 281
MANAGEMENT OF EYE CONDITIONS 281
ATRAUMATIC EYE CONDITIONS 282
CONJUNCTIVITIS OF THE NEWBORN 285
TRAUMATIC EYE CONDITIONS 286
GLAUCOMA (CHRONIC OPEN ANGLE) 287
CATARACT 288
EYE CONSUMABLES: 290
280
Prevention of Blindness
80% of blindness can be prevented by:
 proper diet (Vitamin A and proteins)
 personal and environmental hygiene
 measles immunisation
 early treatment of eye diseases by qualified health personnel
including cataract surgery and early diagnosis and treatment of
glaucoma.
 appropriate management of STIs in pregnant mothers and
their sexual partners.
 early referral of serious eye diseases and injuries
 tetracycline eye ointment in the new-born child’s eyes (Crede
Prophylaxis)
 early detection and appropriate management of diabetes –
stringent control of blood sugar
 early detection and appropriate management of hypertension
 creation of community awareness on the dangers of using
herbal medicines in the eye
“Healthy bodies, healthy eyes!”
Organic headaches such as migraine and cluster headaches do NOT occur
because of eyestrain. See the chapter on Nervous System Conditions for
management of these conditions.
Excessive use of eyes does NOT harm them, and “bad eyes” do NOT result
from overuse.
Management of Eye Conditions

Diagnose and refer urgently most of the following conditions:
 unexplained vision loss; or visual disturbance.
 glaucoma: high pressure in the eye.
 any perforating eye injury.
 any white pupil in children (retinopblastoma or retinopathy of
prematurity or congenital cataract).
 eye burns.
 orbital cellulitis.
 red eye.
 retinal detachment.
 congenital or developmental squint.
 conjunctivitis persisting after one week of treatment.
 trachoma if eyelashes touching cornea.
 proptosis : (protrusion of the eye ball)
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Important: Avoid the use of steroid eye preparations; conditions requiring

them need confirmation by a specialist - refer. Steroids may lead to
worsening of infective processes like trachoma, increased intra-ocular
pressure, cataracts, delayed healing and worsening of corneal ulcers of viral
origin. Never use local anaesthetic drops for painful corneal conditions. Only
specialists should prescribe atropine eye drops/ointment.
Diagnosis of Eye Conditions

Testing vision is the single most important test and every health
worker must know how to use an eyesight-testing chart e.g. Snellen
Chart or LOGMARChart for both adults and children.
With a simple torch, most of the external eye diseases can be
diagnosed.
Atraumatic Eye Conditions

See table 19.1 for differential diagnosis
Acute Glaucoma
 Refer immediately to hospital (delay increases risk of visual
loss).
 At hospital: Patient suspected of having acute angle closure
glaucoma must be started on pilocarpine 2% or 4% drops in
both eyes four times a day.
and acetazolamide po A N 250-500mg stat, then review
8 hourly
 Refer to eye specialist within 24 hours.
Xerophthalmia/ Vitamin A deficiency

Preventive measures include promotion of breast-feeding, measles
immunisation, Vitamin A supplementation, foods rich in Vitamin A
[carrot, mango, pumpkin, and paw-paw].To all children with signs
and symptoms of xerophthalmia and/or measles, give and refer:
vitamin A po C V 200,000 iu single dose Day 1, Day
[<1yr = 2 and
100, 000iu] repeat after
2 weeks
 Nutritional rehabilitation is indicated.
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CHAPTER 19
Table 21.1 Differential Diagnosis of a Red Eye (Atraumatic)
Condition Redness Pain Blurred vision Discharge Pupil size/ shape/ Visual acuity Refer
reaction to light
Acute Yes Yes. Severe + Yes. Severe + No Dilated. Decreased Yes
glaucoma Max. around limbus headaches + haloes around Fixed.
one or both eyes nausea + lights
vomiting.
Conjunctivitis Yes Yes No Yes. Maybe Normal Normal Only if no
Generalised both Gritty copious. response
eyes usually Photophobia Or copious
discharge
Corneal ulcer Yes Yes. Pricking. Yes Yes, in Normal Decreased. Refer
Max. around limbus Photophobia. bacterial Depends on
more near site of Stains with /fungal ulcers the site / size
ulcer, usually one fluorescein strips. No, in viral / of the ulcer
eye. traumatic
COMMON EYE CONDITIONS

ulcers
Iritis/uveitis Yes Yes. Deep pain Yes No Irregular, small, Decreased Yes
Max. around limbus, worse on moving sluggish reaction
one or both eyes eye. Photophobia to light
3
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Conjunctivitis (including trachoma)

Table 21.2: Differential Diagnosis: Causes of
conjunctivitis
Signs/ Acute bacterial Viral Allergic Chronic,
symptoms endemic
trachoma
Discharge? Purulent Watery / Mucoid None / purulent
none
Itching? None None Marked None
One or both One or both One or both Both Usually both
eyes?
Recurrences? Unusual Unusual Usually Chronic
Note: Bold lettering indicates distinguishing feature.
Treatment of conjunctivitis:
 Acute bacterial conjunctivitis:
tetracycline 1% eye C V apply 3 times a day one week
ointment
Chloramphenicol 1% C V Apply 4 times a day One week
eye ointment
 Viral conjunctivitis:
No medicine treatment as this is a self-resolving infection. If in doubt treat as for
acute bacterial and refer.
 Allergic conjunctivitis:
Educate/ reassure. Apply cold compresses and wear a sun hat whenever
outdoors. If no relief of symptoms refer. A night-time dose of an antihistamine
may relieve symptoms.
NB: Steroids are contraindicated in allergic conjunctivitis

Olopatadine (patanol) C V Apply 2 times a day 2 weeks
1%) eye drops
If no improvement in the three conjunctivitis - refer
Trachoma:
 If left untreated, the cornea becomes permanently and
irreversibly damaged. Apply:

tetracycline 1% eye C V apply 4 times a day for 6 weeks
ointment
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 If inturned eye lashes (trichiasis, entropion) present, perform
epilation (pull out the lashes) and refer the patient to the eye
hospital.
 Provide education in personal and environmental hygiene for
prevention of trachoma, with emphasis on face washing, not
sharing towels, hand washing, provision of safe water supplies
and basic sanitation.
Conjunctivitis of the Newborn

(Ophthalmia Neonatorum)
See also the section on Sexually Transmitted Diseases and the
STI Module.
This is defined as conjunctivitis with discharge occurring in a
neonate within the first month of life. The condition is commonly
caused by gonococcal, chlamydial and bacterial infection and
the new born acquires this infection from an infected birth canal
during delivery. The condition is preventable by detecting and
treating maternal and partner gonococcal and chlamydial
infection during pregnancy and by swabbing with normal saline
wet cotton swab both eyes as soon as the baby’s head is out
followed by instilling 1% tetracycline eye ointment (Crede
Prophylaxis) carefully into the conjunctival sacs of every new
born baby as soon as possible after birth.
Ophthalmia Neonatorum is treated as follows:
 Collect pus swab for culture and sensitive before
initiation of antibiotic treatment
 Eye(s) Irrigation with with warm Normal Saline until all
the pus is removed and intermittently as long as pus is
still present.
Instilling Antibiotic Eye Drops ( Ofloxacillin / Fortified
Gentamicin 0.3% ) hourly as long as the eye are still
discharging and red during the day and 1% Tetracycline eye
ointment at night until infection is cleared.
Treatment:
kanamycin im C V 25mg/kg once single dose
and erythromycin po C V 16mg/kg 6 hourly 14 days
Treat the parents and the baby for gonococcal and chlamydial
infection as described above. Also provide healtheducation and
counselling to the parents.
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Traumatic eye conditions

Penetrating Injury
Treatment: Put on eye shield and ensure NO pressure. Refer
urgently to an eye hospital.
Administer the following medicines before referral:

tetanus toxoid im C V 0.5mls once single dose
and paracetamol po C E 500mg 4 times a day if required
and amoxicillin po C V 500mg 3 times a day 5 days
Corneal Foreign Bodies

Gently attempt removal of foreign body with cotton wool tipped
orange stick.If unsuccessful – refer to eye hospital.
If successful:
tetracycline 1% eye C V apply under 3 times a 1 d
ointment an eye pad day a
for 24hrs, y
then s
Chloramphenicol 1% eye ointment may be used instead of
tetracycline eye ointment above.
If worse after 24 hours – refer to eye hospital.
Corneal Abrasion
Apply an eye pad with tetracycline eye ointment or chloramphenicol
1% eye ointment stat and advise bed rest for 24 hours, then
review.If worse, refer to eye hospital
If improving, continue with:
tetracycline 1% eye C V apply 3 times a day 4 days
ointment
or Chloramphenicol 1% C V Apply 4 times a day 5 days
eye ointment
Chemical Burns
Refer after doing the following:
Consider this to be a medical emergency - prompt action can save
vision.
286
Irrigate the eye and surrounding areas thoroughly using tap water
and a 10ml syringe (without the needle) for 30 minutes. Remove
any debris or foreign bodies from the eye if present.
Then:
tetracycline 1% eye C V apply under an eye pad for 24hrs, then
ointment review
Chloramphenicol 1% eye C V Apply, pad eye and refer
ointment
Iritis/ Uveitis
Refer to eye specialist.
Corneal Ulcers
(Refer) NB: corneal sensation must always be tested with a cotton
tip to exclude herpetic cause of corneal ulcer which would be
treated with antiviral drugs like acyclovir
Treatment:
tetracycline 1% eye C V apply 3 times a day 5-7 days
ointment
or Chloramphenicol 1% eye C V Apply 4 times a day 5 days
ointment
Glaucoma (Chronic Open Angle)

A specialist must first confirm the diagnosis of glaucoma. The
treatment can then be repeated according to the specialist’s
prescription, provided the patient is referred back to the specialist
every 3 months for review. Chronic Glaucoma
At hospital: Chronic open angle glaucoma:
pilocarpine 4% eye B V 1 drop in 6 hourly Continual
drops each eye
Timolol maleate 0.5% B V 1 drop in Twice a day Continual
eye drops each eye as per
recommend
ation by
specialist
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If intra-ocular pressure is more than 40mmHg:

Timolol Maleate B V 1 drop 12 hourly Continual
or Xalatan eye drops B V 1 drop Daily continual
or Xalacom (latanoprost A V 1 drop Daily continual
5micrograms, timolol
maleate 5mg/ml)
or Levobunolol A V 1 drop 12 hourly Continual
hydrochloride 0.5% eye
drops
and *Acetazolamide po A V 0.25-1g Divided Few weeks
doses/day
*NOTE: This medicine should NOT be used for more than 3
continuous months without review by a specialist and potassium
chloride 600mg/day orally should be given when patient is on
acetazolamide.
Timolol should not be prescribed in Asthma and other Chronic
Obstructive Airway Diseases (COAD)
Cataract
Cataract is defined as opacity of the lens. Causes may be
classified as acquired and congenital. Aging, trauma,
inflammation, drugs and metabolic disorders like diabetes
mellitus are the leading acquired causes while intrauterine
infections, inheritance and congenital abnormalities are the
leading congenital causes of cataracts. Treatment for cataract is
surgical except for galactocaemic cataract which reverses when
the neonate is given lactose free diet. Cataract present with a
white pupil in children, loss of vision of various degrees, squint
and rarely painful blind eye if neglected and complicated with
glaucoma and lens induced uveitis.
Mydriatic Drugs:
Tropicamide 0.5% B V 1-3 drops stat Pre-op
or 1% eye drops
Or Cyclopentolate B V 1-3 drops stat Pre-op
0.5% or 1% eye
drops
And Phenylepherine B V 1-3drops stat Pre-op
2.5% eye drops
Atropine 0.5% or B V 1-2 drops 2-3 times/day 1 week
1%
288
Corticosteroid drugs used post cataract surgery:
Dexamethasone B V 1 drop 6 hourly 6 weeks
0.1% neomycin
0.35%, polymyxin
B sulphate
6000units/L and
ointment
Or Dexamethasone B V 1 drop 6 hourly 6 weeks
0.1%, neomycin
0.35% eye drops
and ointment
Or Dexamethasone B V 1 drop 6 hourly 6 weeks
0.1% eye drops
Or Betamethasone B V 1 drop 6 hourly 6 weeks
0.1% eye drops
Or Prednisolone A E 1 drop 1-2 hourly 2-3 weeks
acetate 1% eye
drops
Antibacterial drugs for eye infections
Gentamicin C V 1 drop 2-6 hourly 14 days
0.3% eye drops
or Ciprofloxacin B V 1 drop 1-2 hourly 2 days then
0.3% eye drops reduce dose to
4 hourly for 12
days
or Ofloxacin 0.3% A V 1 drop 2-4hourly 2 days then
eye drops reduce to 4
hourly for 10
days
Antivirals agents for eyes
Acyclovir eye A V 1 cm 5 times a day 14 days
ointment (For ointment
corneal ulcers)
Acyclovir 200mg A V 800mg 5 times a day 7 days
tablet (For herpes
zoster
ophthalmicus)
Or Famcivlovir 250mg A V 500mg 3 times/day 7 days
tablet (For herpes
zoster
ophthalmicus)
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Treatment for Cytomegalovirus retinitis:

Ganciclovir 500mg A V 5mg/kg 12 hourly 14-21
vial infusion days
And Forscanet 24mg/ml A V 90mg/kg 12 hourly 2-3 weeks
IVI infusion
Topical anaesthetics and diagnostic preparations:

Oxybuprocaine B V 1 drop Stat Repeat if
hydrochloride 0.4% eye necessary
drops
Or Tetracaine hydrochloride B V 1 drop Stat Repeat if
0.5% eye drops necessary
Diagnostic preparations
Fluorescein strips
Fluorescein strips C V 1 strip Single use Single use
Fluorescein solution 1% or 2% A V 1 Vial Single use Single use
Eye consumables:
Medicine / item Codes Adult dose Frequency Duration
Intra-ocular lenses B V N/A Single use N/A
(various powers)
Eye pads C V N/A Single use N/A
Methylene Blue A V N/A Single use N/A
Arrow swabs / spears B V N/A Single use N/A
eye swabs
Eye shields C V N/A Single use N/A
Viscoelastic B V N/A Single use N/A
BSS (Balance salt B V N/A Single use N/A
solution vacolitres) for
cataract surgery
Fluid giving sets B V N/A Single use N/A
Micropore C V N/A Single use N/A
Surgical gloves (sterile) C V N/A Single use N/A
290
Suture materials B V N/A Single use N/A
(10.0, 11.0, 9.0 nylon,
8,0 vircyl, 4.0 nylon or
silk)
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COMMON ORAL CONDITIONS

ORAL PROBLEMS 293
MANAGEMENT OF ORAL THRUSH/ORAL CANDIDIASIS
293
OESOPHAGEAL CANDIDIASIS 294
HERPES SIMPLEX LABIALIS 294
KAPOSI SARCOMA 294
GUM INFECTIONS 294
DENTAL CARIES 295
PERSISTENT GENERALIZED LYMPHADENOPATHY
(PGL) 295
ORAL ULCERS 295
HISTOPLASMOSIS 295
292
Oral problems
Oral lesions are quite common especially amongst HIV positive
patients. At any encounter with a healthcare worker, the patient
should have their mouth examined for various lesions such as the
following:
 Oral thrush or candidiaisis/angular cheiltis
 Herpes simplex labialis
 Kaposi’s sarcoma
 Gum infections
 Salivary gland disorders e.g. parotid gland enlargement
 Dental caries
 Cancrum oris
 Enlarged nodes such as submandibular, submental and
cervical lymphadenopathy
 Ranula- bluish sublingual swelling especially in children
 Oral hairy leucoplakia
Some of these lesions will need referral to a dentist for biopsy if one
is worried about malignancy e.g. with Kaposi sarcoma and
lymphoma or infections such as histoplasmosis.
Management of Oral thrush/Oral candidiasis

This will be one of the commonest abnormalities found in the
mouth. Diagnosed when whitish patches or reddening of the oral
mucosa is noted. The condition may be associated with a feeling of
not tasting food well plus odynophagia (pain in the chest on
swallowing). Angular cheilitis is ulceration and occasional bleeding
at the corner of the mouth. Apart from suspecting HIV related
disease, exclude the current use of antibiotics, steroids or the
presence of diabetes mellitus. Offer HIV testing and counselling
(HTC).
Treat with topical therapy such as:
nystatin suspension B E 200 000 5 times a day 7- 14days
units
nystatin lozenges B E Sucked 5 times a day 7- 14 days
or miconazole oral gel C V Topically 4 times a day 7 – 14days-
2%
If there is odynophagia, treat as oesophageal candidiaisis as
follows:
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Oesophageal Candidiasis
This is an AIDS defining illness (WHO Stage 4 disease) and hence
the patient would need to be worked up for referral to the OI Clinic
for ARV therapy. Offer HTC and consider giving Cotrimoxazole
prophylaxis.
Treat oesophageal candidiaisis with systemic medicines such as:

fluconazole po C V 200mg Twice a day 7 – 14days
 Nutritional rehabilitation is indicated.

 Exclude other OIs such as TB/KS
 Refer to OI Clinic.
Herpes Simplex labialis

Usually the lesions are found on the lips, buccal mucosa and hard
palate. They may prevent the patient from eating or swallowing well.
If lesions are extensive e.g. covering all the lip areas, consider the
following:
acyclovir po C E 400mg 3 times a day 5 days
Kaposi Sarcoma
The purple coloured lesions or nodules should be easy to see
especially when they are on the palate but may be more difficult to
diagnose if they are underneath the tongue. Check for similar lesions
elsewhere. The patient should be offered HTC. Assess for
Cotrimoxazole prophylaxis and refer to your nearest OI clinic.
Gum infections
These are most common in those who do not brush their teeth
regularly. Oral hygiene should be emphasised.
Necrotizing gingivitis/periodontitis/stomatitis There may be
spontaneous bleeding of the gums as well as loosening of the
teeth
plus amoxicillin po C V 500mg 3 times a day 5 days
294
Dental Caries
The teeth will have multiple decays. Oral hygiene is needed and
brushing twice a day with fluoride toothpaste should be
encouraged. Limit sweet foods. Regular dental examination is
required.
Persistent Generalized Lymphadenopathy (PGL)

The commonest cause of generalized enlarged lymph nodes (>
1cm) is underlying HIV. Thus the patient should be considered for
HTC.
Oral Ulcers
These are painful ulcers that may occur anywhere in the buccal
mucosa. They may prevent the patient from eating properly. Apart
from herpes simplex, most are treated symptomatically by using
simple analgesics. Large ulcers may need biopsy to exclude
malignancy.
The following applied to the mouth area may help:
0.2% chlorhexidine C E 2 – 4 times a day
mouth rinse
or 1% povidone iodine C E 4 times a day
or triamcinolone A N
acetonide in orabase 3 times a day
Histoplasmosis
This may present as a nodule on the palate and sometime a
penetrating lesion i.e. a hole in the palate. Biopsy should confirm
the diagnosis.

ketoconazole po A N 200mg Twice a day Months
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EAR NOSE AND THROAT

DISORDERS
ORAL PROBLEMS 293
MANAGEMENT OF ORAL THRUSH/ORAL CANDIDIASIS
293
OESOPHAGEAL CANDIDIASIS 294
HERPES SIMPLEX LABIALIS 294
KAPOSI SARCOMA 294
GUM INFECTIONS 294
DENTAL CARIES 295
PERSISTENT GENERALIZED LYMPHADENOPATHY
(PGL) 295
ORAL ULCERS 295
HISTOPLASMOSIS 295
296
Acute Otitis Media (AOM)
Patient presents with fever, chills and irritability. Most common
under 2 years of age. Examination shows irritable child, tympanic
membrane inflamed and bulging.
Natural history
 60% resolve in 24hrs
 80% by 48hrs
 88% 4-7 days
 OME 63% resolve after 2 weeks 40% remaining after
one month
 20% remaining by 3 months
Organisms that are involved in Acute Otitis Media
Streptococcus pneumonia (35%), Haemophilus influenza (23%),

Moraxella catarrhalis (14%) form the majority.
Treatment
 Avoid risk factors-breastfeed more than 6 months; prevent
parental smoking, encourage vaccination, provide good
nutrition and encourage early attendance to day care.
 Analgesia and supportive care
Indications for giving antibiotics

 AOM under 6 months
 Severe AOM-temperature (axillary) > 39.5ºC
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 Associated comorbidity-malnutrition, HIV

 Failure of resolution of symptoms in 48-72 hrs.
 Patients who might not return to hospital
First line medicine

amoxicillin po C V 500mg 3 times a 2 a
40mg /kg in paeds day y
s
Caution: Use erythromycin in patients with penicillin allergy,

patients who received amoxicillin in the last thirty days (move to
second line as the risk of resistance is high)
Second line medicine

Amoxicillin and B V 80mg/kg; 6.4mg/kg 2 times a 10 days
clavulinic acid po day (severe &
<6mnths)
5-7 days
(less severe)
Recurrent Acute Otitis Media

More than four episodes per year –REFER
Acute Mastoiditis
Patient presents with fever, chills. Examination reveals tenderness
over mastoid and retroauricular swelling. Anterior displacement of
auricle. Bulging and unhealthy tympanic membrane.
 Initiate intravenous antibiotics and REFER

Benzyl penicillin iv/im C V 0.1MU/kg stat
Ceftriaxone iv/im C V 80mg/kg stat
Otitis Media with Effusion

 Follows AOM or can present without any history of AOM
 Hearing loss most common presentation and aural fullness
 5-7 years most common age group affected
298
 Otoscopy reveals brownish fluid behind intact tympanic
membrane. Retraction of bulging of tympanic membrane with
no signs of acute inflammation.
Otitis media with effusion in an adult needs referral to an ENT

specialist for exclusion of nasopharyngeal carcinoma.
Organisms that are involved in Otitis Media Effusion
For management REFER to Specialist
Chronic suppurative otitis media

Presentation
 Otorrhoea for more than 14 days, hearing loss, usually no
otalgia
 Otoscopy -mucopurulent discharge, ossicular chain erosion,
Hearing loss
 Organisms-Staphylococcus aureus, Proteus spp, Klebsiella,
Enterobacteriacie
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Treatment
Ear syringing with saline or acidifying agent such as 1% boric acid,
acetic acid and continued aural toilet
If ear is clear of discharge prescribe the following:

Ciprofloxacin ear drops B V 3 drops Twice daily 7 days
 Keep ears dry
 Avoid swimming
 REFER immediately to Ear Nose throat surgeon
Cholesteatoma
Presentation
 Keratin debris in the middle ear.
REFER immediately
Otitis Externa
 Presentations vary depending on cause
 Itchiness of canal, ulcers on the externa auditory canal,
inflamed canal, occasional discharge from canal
 Otoscopy to assess the canal and tympanic membrane.
Inflamed external ear (auricle and external auditory canal)
Bacterial otitis externa

Aural toilet with boric acid and acetic acid

Ciprofloxacin and B V 3 drops Twice daily 7 days
dexamethasone ear
drops
or Chloramphenicol and B V 3 drops Twice daily 7 days
dexamethasone ear
drops
or Boric acid 1% ear drops B E 3 drops Twice daily 7 days
or Acetic Acid ear drops B N 3 drops Twice daily 7 days
Systemic Antibiotics are indicated for severe Otitis Externa

Amoxicillin po C V 500mg 3 times a day 7-10 days
300
Ciprofloxacin po B V 500mg Twice daily 7-10 days
Malignant Otitis Externa

This is a necrotising infection of the ear canal in patients who are
immunosuppressed. Often the first presentation and should alert
the physician of immunosuppression from any cause e.g. diabetes,
HIV etc.
Initiate IV antibiotics with a penicillin as above

Ciprofloxacin po B V 500mg 2 times a day 12 weeks
Add: Intravenous fluids
Debridement
REFER immediately
Fungal otitis externa

After routine ear toilet as above

Clotrimazole ear drops B V 3 drops Once daily 7 days
Acidifying agents like boric acid and acetic acid can be used as well
Keratosis Obliterans
 Clear the ear canal of all debris
 Inspect the canal and tympanic membrane
Allergic Otitis Externa

1% hydrocortisone cream C V Apply Once daily 7 days
Inner Ear
Vertigo-
 Viral Labyrinthitis
 Benign Paroxysmal Positional Vertigo
 Meniere Syndrome
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REFER
Sensorineural Hearing Loss-REFER
Cerebrospinal Fluid Otorrhoea-REFER
Rhinology
Acute Rhinosinusitis
Clinical presentation
 Nasal blockage, rhinorrhoea, anosmia facial pressure/pain are

common symptoms
 Examination reveals clear nasal discharge initially and
discharge turns mucopurulent when bacterial superinfection
occurs.
 Majority are caused by viral infections such as rhinovirus,
Adenovirus, respiratory syncytial virus, Para influenza virus
Treatment
 Observation and supportive care

 Analgesia and plenty of oral fluids
Indications of antibiotics
 Failure of resolution of symptoms in 48-72 hrs.

 Discharge turns mucopurulent
 Patients with comorbidities e.g. malnutrition,
immunosuppression

Chronic Rhinosinusitis
If above symptoms persist for 90 days.
REFER
Allergic Rhinosinusitis
Presentation
302
 Acute rhinorrhoea- clear nasal discharge, Nasal obstruction,
and anosmia
Treatment
 Avoid allergens
First line

Fluticasone diproprionate B V One puff 1-2 times a 1 month
nasal spray day
Fluticasone furoate spray A E One puff Once a day 1 month
 Duration of treatment varies according to response. Minimum
one month of spray.
 Nasal sprays are efficacious as they control nasal symptoms
and are less systemically absorbed hence have low side effect
profile
Second line
Oral antihistamines

Chlopheniramine po C V 4mg 3 times a day 7 days
 Cause sedation, prostatism and should be used with caution in
patients with glaucoma. They cause dryness of secretions and
tachyphylaxis. Medications should not be taken for more than
seven days without referral
Second generation antihistamines

Cetirizine po B V 10mg Once at 7 days
bedtime
NB: They do not have CNS penetration hence do not cause
sedation and tachyphylaxis.
Patients with persistent symptoms despite nasal steroids need

referral for further investigations
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Fungal Rhinosinusitis-Invasive
 Invasive fungal sinusitis-common in immunosuppressed such
as diabetic (uncontrolled, Ketoacidosis).
 This is an aggressive soft tissue infection with high mortality
rate and needs a high index of suspicion. Early referral to Ear
Nose and Throat Surgeon is required
 Presentation- nasal blockage, necrosis of mucosa of nasal
cavity. Orbital signs include proptosis and opthalmoplegia.
Patients also present with intracranial extension
Management-Refer for:
 Correct underlying cause
 Aggressive surgical debridement
 Microscopy and culture to identify the fungal
 Systemic antifungal treatment
Non Invasive fungal Rhinosinusitis

Refer
Obstructive sleep apnoea from adenotonsillar

hypertrophy
 Children present with snoring, stertor (a respiratory sound
characterized by heavy snoring or gasping caused by partial
obstruction of airway), mouth breathing
 Treatment depends on severity of symptoms.
Refer for persistent symptoms
Tonsillitis-Acute
 Patients present with fever, chills, odynophagia and dysphagia
 On examination the tonsils are inflamed and often have
exudates. Unilateral exudate and tonsillar asymmetry indicate
a peritonsillar abscess
Management
Analgesia and antibiotics
First line
Second line
Amoxicillin/clavulinic A V 80mg/kg;7m 2 times a day 7 days
acid po g/kg
304
Third line
Cephalosporin under specialist care
Recurrent Tonsillitis - Refer
Chronic tonsillitis - Refer
Peritonsillar abscess-Initiate antibiotics as above and refer
Epistaxis
Predisposing factors include upper respiratory tract infection,
habitual nose picking, nasal sprays, haematological malignancies
and patients on anticoagulants,
Patients with hypertension often have severe epistaxis
Management
Expel clots and examine nose with good light
Identify the bleeding points
Children-bleeding on Little’s area is common
Adults –may have a posterior bleed
Anterior epistaxis- Pack anteriorly bilaterally with ribbon gauze
soaked in oily antiseptic solution such as Proflavin gel or glycerine
and icthymol.
Posterior packing. Use Foley’s catheter with 5cc of saline to pack
posteriorly
Reinforce with anterior packing bilaterally
Refer as soon as pack is in situ
The use of adrenaline is discouraged as it may cause severe
rebound epistaxis.
Initiate Amoxicillin if pack is to last for more than 48 hrs.
Indications for referral in epistaxis
Patients with posterior bleed
Patients with comorbidities-hypertension, anticoagulation use,
elderly, severe anterior epistaxis
Anterior epistaxis not responding to initial management
Deranged blood chemistry or deranged full blood count
Suspicion of malignancy
CSF rhinorrhoea
CSF rhinorrhoea should be suspected in a patient who presents
with clear rhinorrhoea after head injury or nasal surgery. It can also
be spontaneous
Patient’s reports worsening of rhinorrhoea on leaning forward. They
have a headache post draining.
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This can be mistaken as allergic Rhinosinusitis with lethal

consequences.
If there is suspicion of CSF leak, refer
Croup
Low grade fever, backing cough, stridor.
Management
Grade the upper airway obstruction
Grade 1 Inspiratory stridor
Grade 2 Inspiratory/expiratory stridor
Grade 3 Inspiratory/expiratory stridor with pulsus paradoxus
Grade 4 Silent chest
Always beware of a silent chest in airway obstruction as this
indicates impending respiratory failure. Reduction in the loudness of
stridor should be regarded as a dangerous sign and needs urgent
securing of airway.
Management
Grade 1 and 2:
Racemic adrenaline C V Every 2hrs PRN
nebulizer
Dexamethasone IV B V 0.1-0.6mg/kg 6 hourly
Strict monitoring with continuous pulse oximetry. Of note is that
pulse oximetry might give a false sense of security as it is a late
marker of hypoxia and is affected by cold extremities and
vasoconstriction.
Refer if no change or as soon as poor response is noted.
Grade 3 and 4:
Need airway to be secured. Treat as above and refer
Acute cervical lymphadenitis

Painful neck mass. Usually follows a history of upper respiratory
infection.
Treatment
Paracetamol po C E 500mg 3 times a day 5-7 days
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SKIN CONDITIONS
BACTERIAL INFECTIONS 308

FUNGAL INFECTIONS 310
SCABIES 311
VIRAL INFECTIONS 312
OTHER DERMATOLOGICAL CONDITIONS 313
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Bacterial Infections
Impetigo
A superficial bacterial infection causing rapidly spreading blisters and
pustules. It occurs commonly in children, usually starting on the face,
especially around the mouth or nose. Often due to Staphylococcus aureus.
Keep infected areas clean and prevent spread to others (care with towels,
clothes, bedding; change frequently and wash clothes separately).
Bathe affected parts/soak off the crusts with soap and water,
If severe, or systemic symptoms present use:
erythromycin po C V 250-500mg 4 times a day 7-10days
[Paed = 125-150mg]
or cloxacillin po B V 250-500mg 4 times a day 7-10days
[Paed = 125-150mg]
Folliculitis
Superficial infection causing small pustules, each localised around a hair.
Deep follicular inflammation often occurs in hairy areas.
Bath and remove crusts using soap and water,
Treat as for impetigo, above.
Furunculosis
These are painful boils, most frequently caused by Staphylococcus
aureus.Usually resolves on its own, but improved by placing frequent hot
compresses over the boil until it breaks.
Review after 2 days; if not improving, consider surgical incision and
drainage. If the boil causes swollen lymph nodes and fever, consider
systemic antibiotics:
cloxacillin po B V 250-500mg 4 times a day 5-7 days
[Paed = 125-250mg]
Erysipelas
A superficial cellulitis with lymphatic vessel involvement, due to streptococcal
infection.
Begins at a small break in the skin or umbilical stump (children). Area
affected has a growing area of redness and swelling, accompanied by high
fever and pains.
Treat with:
erythromycin po C E 250-500mg 4 times a day 7 days
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[Paed = 125-250mg]
Erysipelas has a tendency to recur in the same area. If recurrent episode,
increase duration of antibiotic to 10-14 days.
Acute Cellulitis
Inflammation of the deeper, subcutaneous tissue most commonly caused by
Streptococci or Staphylococci.
Acute cellulitis [indistinct borders] should be differentiated from erysipelas
[raised, sharply demarcated margins from uninvolved skin]. Give antibiotics:
[Paed = 125-250mg]
Paronychia
Painful red swellings of the nailfolds which may be due to bacteria or yeast.
Acute Paronychia
Tenderness and presence of pus indicates systemic treatment with
antibiotics is required:
erythromycin po C E 250-500mg 4 times a day 5 days
[Paed = 125-250mg]
If ineffective:
[Paed = 125-250mg]
Chronic Paronychia
Often fungal - due to candida. Avoid excessive contact with water, protect
from trauma and apply:
Treat secondary infection with antibiotics as above.
For both acute and chronic, incision and drainage may be needed.
Acne
Comedones, papulopustules and eventually nodular lesions on the face, chest
and back.
Seek underlying cause if any e.g. overuse of oils on skin, stress,
anticonvulsant medicines, and use of topical steroids. Topical
hydrocortisone or betamethasone must not be used.
Use ordinary soap and water 2-3 times a day. In cases with many pustules,
use:
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benzoyl peroxide 5%gel C N apply every night Review
In severe cases of nodular acne, treat with oral antibiotic:
doxycycline po C V 100mg once a day 2-4 months
Patients should be encouraged to persist with treatment. If not improved
refer.
Fungal Infections
Body Ringworm (Tinea Corporis)
Round, expanding lesions with white, dust-like scales and distinct borders; on
the body or face.
 Responds to any of the topical antifungal agents.

miconazole cream 2% C V topically 2-3 times a for 7 more days
day after resolved
or clotrimazole cream 1% C E Topically 2-3 times a for 7 more days
day after resolved
First line:
Tinea Pedis (Fungal / Athlete's Foot)

This is a very common fungal infection and is often the source of infection
at other sites. Keep the feet as dry as possible, and as far as possible
avoid wearing socks / closed-in shoes.
Treat any bacterial superinfection first:
miconazole cream 2% C V Topical 2-3 times a for 7 more
day days after
resolved
or clotrimazole cream 1% C V topical 2-3 times a for 7 more
day days after
resolved
 In severe infections use griseofulvin:
griseofulvin po B N 500mg once a day 8 weeks
[Paed = 10mg/kg]
Or terbinafine cream B N apply Twice a day 6-8 weeks
Take with food or milk. Do not crush tablet tablets.
Pityriasis Versicolor (Tinea Versicolor)
310
Common fungal infection caused by a yeast. Hypopigmented patches of
varying size on the chest, back, arms and occasionally neck and face.
Griseofulvin is not effective. Apply:
Selenium sulphide 2,5% B N apply daily 5 days
Scalp Ringworm (Tinea Capitis)

In this case the fungus has grown down into the hair follicle.
Topical antifungal therapy may work but if ineffective; treat with:
griseofulvin po B N 500mg once a day 14 days
[Paed = 10mg/kg]
Take with food or milk. Do not crush tablet tablets.
Scabies
Caused by mites, transmitted by skin-to-skin contact. The lesion is a “burrow”
(a whitish ziz-zag channel), the resting place of the female mite.
Main sites: between the fingers, on the wrists, in the axilla, around the
navel, genitals and inner sides of feet.
Treat all close contacts, especially children in the same household. Wash
clothing and bedding and leave in the sun to dry.
After normal bathing, apply:
Permethrin 5% cream C N apply from once and once only
neck down wash off
after 8-
12hrs*
or gamma benzene C N apply from once and once only
hexachloride 1% lotion neck down wash off
after 24hrs
*CAUTION: In prepubertal children the gamma benzene hexachloride is washed off after
12 hours. Hot baths and scrubbing should be avoided to prevent systemic absorption.
Alternative in pregnancy, lactating mothers or children < 6 months:

benzyl benzoate 25% B N apply from once at night for 3 nights,
emulsion * neck down wash off next repeat if
[irritant] morning necessary
*Dilute with one part water (1:1) for children. within 10
*Dilute with three parts water (1:3) for children. days
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or sulphur ointment 5-10% B N apply 2 times a 1-2 weeks

[in children] day
If there is secondary bacterial infection (“septic sores”), treat as for impetigo
for 4-5 days. Only apply scabicide once lesions are closed.
Advise that the itch may continue for several weeks. This can be relieved by
applying:
calamine lotion C N apply as needed as required
and chlorpheniramine po C E 4mg 3 times a day 3 days
[Paed = 0.1mg/kg]
Cutaneous Larva Migrans

[‘Creeping Eruption, Sandworm’] see chapter on Tropical Diseases
Viral infections
Herpes Simplex
Virus causing vesicles, usually around the lips or around the mouth (but also
occurring elsewhere e.g. genitals).
May recur often during times of decreased well-being (incubation time of
infectious diseases, menses, mental stress). No specific medication; keep
the lesions dry.
Chickenpox
Caused by the varicella-zoster virus. The virus often persists and may later
cause Herpes Zoster (Shingles).
Incubation period is 12-21 days. Patches appear first on the trunk, then
spread to the face and scalp. Within a few days there are papules, vesicles
and crusts.
Keep the lesions dry with saline baths or zinc oxide preparation.
For itching:
calamine lotion C N apply as needed as required
and chlorpheniramine po C E 4mg 3 times a day 3 days
[Paed = 0.1mg/kg]
Herpes Zoster
See the chapter on HIV Related Diseases.
312
Other Dermatological Conditions
Eczema
An inflammatory condition of the skin whose feature include redness,
itching weeping (oozing) vesicular lessions which become scaly,crusted or
hardened and may sometimes become secondarily infected.
Allergic Contact Dermatitis

Results from an acquired allergy after skin contact with particular chemicals
(dyes, perfumes, rubber, chromium, nickel) or medicines (skin preparations
containing lanolin, iodine, antihistamines, neomycin, vioform etc).
Atopic Dermatitis / Eczema
Often a personal or family history of atopic disease (asthma, hay fever or
atopic dermatitis). Cause not known. These persons are also more susceptible
to herpes simplex and vaccinia (but not varicella-zoster).
The clinical form may differ according to age.
Infantile eczema / cradle cap
Usually appears at 3 months with oozing and crusting affecting the cheeks,
forehead and scalp.
IMPORTANT: If generalised exfoliative dermatitis develops, refer to a
specialist at once.
Flexural eczema
Affects the flexor surfaces of elbows, knees and nape of neck. In adults any
part or the whole of the skin may be affected with intense itching, particularly
at night.
Management of Eczema
Remove any obvious cause e.g. skin irritants or allergens.
As a soap substitute use:
emulsifying ointment B N as a soap substitute
or aqueous cream** B N as a soap substitute
**1% Hydrocortisone in an ointment for dry eczema and as a cream for ‘weepy’
eczema
Second Line
Use soap substitute as above and add Betamethasone) 0.1% in an
ointment base for dry eczema and a s a cream for weepy eczema. If this
fails refer for specialist management.
Treat itching with an oral antihistamine. Never use topical antihistamines:
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chlorpheniramine po C E 4mg 3 times a day 3 days
[Paed = 0.1mg/kg]
or promethazine po* B N 25-50mg at night as needed
* Not to be used in children under the age of 2 yrs. Promethazine causes
drownsiness which may be aggravated by simultaneous intake of alcohol
Treat any infection. Choice of skin preparations depends on whether
lesions are wet (use cream) or dry (use ointment)
Where large areas are involved give a course of systemic antibiotics

erythromycin po C V 250-500mg 4 times a day 7-10days
[Paed = 125-150mg]
or cloxacillin po B V 250-500mg 4 times a day 7-10days
[Paed = 125-150mg]
After the lesions have healed, apply a bland preparation such as aqueous
cream or emulsifying ointment to moisturise the skin.
CAUTIONS: Never use corticosteroid preparations stronger than 1%
hydrocortisone on the face. Systemic Steroids should be avoided except in
severe conditions under specialist supervision.
Urticaria
Urticaria is the result of leakage of plasma from the dermal vasculature,
presenting with itchy raised patches of skin (wheals) due to dermal oedema.
These wheals are sometimes known as ‘hives’, and are usually a sign of an
allergic reaction. Hives can be rounded or flat-topped but are always elevated
above the surrounding skin.
Allergic urticaria may be caused by: medicines (e.g. penicillin) infection,
contact with plants, pollen, insect bites, or foodstuffs (e.g. fish, eggs, citrus
fruits, nuts, strawberries, tomatoes.)
Physical urticaria may be caused by mechanical irritation, cold, heat,
sweating.
Exclude medicine reaction (e.g. penicillin), or infection (bacterial, viral or
fungal).
Give antihistamine by mouth [never use topical antihistamines]:
chlorpheniramine po C E 4mg 3 times a day as required
[Paed = 0.1mg/kg]
or promethazine po* C E 25mg once at night as required
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or Cetirizine po B E 10mg Once a day As required
* Not to be used in children under the age of 2 yrs. Promethazine causes
drownsiness which may be aggravated by simultaneous intake of alcohol
If no improvement after 1 month or chronic problem, refer.
Psoriasis
A condition of the skin characterised by thickening and scaling; usually
symmetrical.
Exclude precipitating factors e.g. alcohol, deficiencies of B12 or folate,
stress, infections.
Avoid using steroids.
To reduce scaling use a keratolytic:
salicylic acid 2% oint. B N apply once at night as needed
Sun exposure to the lesions for half an hour or one hour daily may be of
benefit.
In resistant cases add:
coal tar ointment 5% in B N apply twice a day as needed
salicylic acid 2%
or zinc oxide ointment B N apply twice a day as needed
If not responding, refer.
Pellagra
Syndrome caused by deficiency of a variety of specific factors, nicotinic acid
being the most important. Cardinal signs: diarrhoea, dermatitis (sites
exposed to sun and pressure) and dementia.
Treat both adult and child with:
nicotinamide po B E 100mg once a day 2 weeks or
review
Advise on diet: should be rich in protein (meat, groundnuts, beans.)
Albinism/ Vitiligo
Albinism is generalised loss of pigmentation (congenital). Vitiligo is patchy
loss of pigmentation (acquired in later life).
There is no causal therapy for albinism and vitiligo. Advise yearly
examination for skin cancer and protective clothing (long/sleeved garments,
wide-brimmed hat, long skirts /trousers, sunglasses)
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Use a sunscreen and sun blocker on lips. An effective and cheap

preparation with a sun protection factor of 15 (SPF=15) is “PABA”:
para-amino-benzoic C V apply daily in the as required
acid cream / lotion morning
Warts
Warts should usually be left to resolve spontaneously. If extensive, refer.
Plantar warts - are self-limiting and should not be excised or treated with
podophyllin.
Molluscum contagiosum and Genital Warts -

Refer to the chapter n Sexually Transmitted Diseases
316
BURNS
ASSESSMENT 318
GENERAL MANAGEMENT GUIDELINES 320
MANAGEMENT OF MODERATE BURNS 321
SMALL SURFACE AREA BURNS 321
LARGE SURFACE AREA BURNS 322
RESUSCITATION OF LARGE SURFACE AREA BURNS: ADULTS 322
RESUSCITATION OF LARGE SURFACE AREA BURNS: CHILDREN 323
GENERAL NOTES: 323
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Assessment
Burns caused by heat
Immediate cooling by immersion in water at approximately 25°C for
15mins to 30mins; then apply simple dry dressings (remove clothing if not
adherent to burn and wrap in a clean cloth).
Chemical Burns
If there is dry powder present brush off the excess and then wash
preferably with running water in large amounts for at least 20 minutes.
Seal with soft paraffin (Vaseline) only what cannot be extracted with
water.
Remove contaminated clothing, shoes, socks, and jewellery as the wash
is applied. Avoid contaminating skin that has not been in contact with the
chemical.
For burns due to sulphur or phosphorus a copper sulphate solution can
be used to neutralise the chemicals.
Electrical Burns
Cool burns as above. A patient unconscious from electrical or lightning
burns will need urgent cardiac assessment and resuscitation. Defibrillation
or external cardiac massage may be lifesaving.
Smoke Inhalation Burns

If occurred in an enclosed area - may need 100 % oxygen.
Resuscitation takes first precedence over any other management. This is

followed by a quick history of the burn and then an estimation of the extent
of the burn. Obtain information as to time of occurrence and circumstances
of the burn. Other injuries are often seen with burns and may need
management.
Evaluation of Burnt Surface Area

Resuscitation is initially based on surface area burned.
 In children use the Lund & Browder chart (Figure 25.1).
 In adults use the rule of nine’s (Fig 25.2).
In children the head, thigh and legs account for different percentages
according to the age of the child. Use the table below.
318
Figure 25.1 Estimating the Body Surface Area for Burns in Children
(modified Lund & Browder)
Age < 1yr 1 year 5 years 10 years

Head (A or D) 10% 9% 7% 6%
Thigh (B or E) 3% 3% 4% 5%
Leg (C or F) 2% 3% 3% 3%
Note:
The Wallace Rule of Nines (fig. 25.2) is inaccurate in children.
Children compensate for shock very well, but then collapse rapidly – beware
the restless, irritable child.
Do not over-estimate burn size – this will lead to over-hydration.
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Fig 25.2 Estimating the Body Surface Area of the Burn in Adults:
Rule of 9’s.
Note: In adults, the outstretched palm and fingers approximates to 1% of body

surface area. If the burned area is small, find out how many times the ‘hand’
covers the area. (Hand Rule)
Severity of burn is determined by the area of body surface burned and the
depth of the burn.
Burns are either deep or superficial. Superficial burns (partial skin
thickness) are sensitive all over. With deep burns (full thickness) there is
sensation at the edges only. Depth of burn influences later treatment in
particular.
NB: Pain is a poor guide to burn depth in children.
General Management Guidelines

Depends upon extent and nature of burn. Any burn affecting greater than
10% of the body surface area is considered extensive and serious because
of fluid loss, catabolism, anaemia and the risk of secondary infection.
Hospital admission is required for:
320
 Adults with 10% burns or more
 Children with 8-10% burns or more.
 Burns of special regions: face, neck, hands and feet, perineum and
joints.
 Circumferential burns (right around / both sides of a limb /region)
 Electrical, lightning, and chemical burns
 Lesser burns associated with inhalation injury, concomitant
mechanical trauma, or significant pre-existing medical disorders (e.g.
epilepsy, diabetes, malnutrition).
 Very young/very old patients, psychiatric patients/ para-suicidal,
suspected abuse.
Transferring burns patients
Severe burns will require long term special care and should be managed in
a suitable hospital (burns unit). Always endeavour to transfer the above
cases within 24hrs of the burn. Transfer with the following precautions:
 Short, easy journey - commence resuscitation, make clear summary of
records and send with medical attendant.
 Prolonged or delayed journey - resuscitate and transfer when patient
stable. Keep the patient warm and covered during journey and
continue management already started.
Management of Moderate Burns

Small Surface Area Burns
Reassurance. 1st to 2nd degree burns are the most painful. Give adequate
analgesia – see the section on pain management:
paracetamol po C E 500mg-1gm 4-6hrly as required
Paed = 10mg/kg
+/- codeine phosphate po B E Adults: 15- 4 hourly as required
60mg
 Give an anti-tetanus booster:

tetanus toxoid im C V 0.5ml* one dose only
*check manufacturer’s instructions
 Apply simple dry or non-adherent dressings.
 Elevate the burned part.
Follow up as outpatient. Expect healing within 10-14 days if clean. Any burn
unhealed within 21-28 days needs reassessment.
Antibiotics are indicated for contaminated burns and inhalation burns.
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benzylpenicillin iv C V 0.05MU per every 6hrs reassess
kg after culture
or erythromycin po C V 500mg every 6hrs reassess
Paed = 12.5mg/kg after culture
Change regimen if indicated by culture and sensitivity tests. Gram negative

organisms are usually implicated later on, and a more appropriate blind
therapy before results are obtained.
Large Surface Area Burns

Emergency Measures
Reassurance is an essential part of therapy.
Establish IV line. For all adults with burns greater than 15% and children
with burns greater than 10%, start:
Medicine Codes Rate
ringers lactate iv B V 10mls /kg/ hr for 12hrs, then reduce to
8mls /kg /hr.
Analgesia. Do not use oral or intra-muscular route in first 36hrs unless

peripheral circulation is re-established.
Analgesia in adults:
morphine iv slow B E 2.5 – 5mg every 4hrs review
increasing as required
or pethidine im (or iv in B V 1mg/kg every 4hrs review
small diluted doses)
Analgesia in children:
Medicine Codes Paed dose Rate
morphine iv B E 0.05-0.06 per hour continuous iv
mg/kg infusion
or morphine iv bolus B E 0.1mg every 2 hrs
Use nasogastric tube to empty stomach in large burns; the tube may later
be used for feeding if not possible orally after 48 hours.
Resuscitation of Large Surface Area Burns: Adults

Fluid required in the first 24 hours:
*Total amount (ml) = 4 x weight in kg x area of burn %
Medicine Codes Rate
322
ringers lactate iv B V Give ½ the total amount in the first 8hrs.
or normal saline iv C V Then ¼ the total in the next 8hrs, and
the other ¼ in the remaining 8hrs.
* Parkland Formula
Resuscitation of Large Surface Area Burns: Children

For the child in shock or with large burns:
Medicine Codes Paed dose
ringers lactate iv B V 15-25ml/kg over 1-2 hrs
then calculate:
*Total amount in mls = 3.5 x weight in kg x area of burn %
Medicine Codes Rate
ringers lactate iv B V Give 1/3 the total amount every 8hrs
and darrows half strength C V Normal daily requirement (see section
with dextrose 2.5% on IV fluids)
Example: for a 9 Kg child with 20% burn, initially give 135-225 ml (9 X 15-25
ml) plus the first 24 hour requirement by calculation, using the formula:
3.5 X Weight (kg) x BSA burn (%) = volume required
3.5 X 9 X 20 = 630 ml Ringer Lactate
Plus NDR at 100ml/Kg = 900 ml half DD
Total requirement = 1530 ml
Give 210 ml Ringer Lactate every 8 hours.
Give 900 ml half Darrows/Dextrose continuously over 24 hours.
NOTE: In calculating replacement fluid, do not exceed BSA (burned) of 45% for adults
and 35% for children. However, to prevent over (or under) transfusion the best guide is
“Monitoring” (see below).
General Notes:
If isolation facilities are available, then nurse trunk, face and neck exposed,
reapplying a thin layer of burn cream (see below) as often as needed.
Exposed patients lose heat rapidly, so ensure that the room is kept warm
(above 28°C, preferably 31-32°C); this helps conserve calories and protein.
If forced to use a crowded ward, dress whole burn area. Cover loosely with
a bandage. Do not wrap limbs; allow movement, especially at the flexures,
to prevent contractures. Unless infection ensues, the first dressing should
be left undisturbed for 3 days (review daily).
Preferably never mix “old” and “new” burns cases.
Cleaning - small burns
 Normal saline/ sitz baths
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 Povidone solution
 Sitz baths with Povidone
Cleaning - large burns
depending upon facilities and resources:
 shower
 sitz bath or
 sitz bath and povidone iodine solution
Apply to the burns:

silver sulphadiazine 1% B V Apply daily (not to the face)
topical cream
or povidone-iodine 5% B E Apply daily
topical cream
Give antitetanus booster:

tetanus toxoid im C V 0.5ml one dose only
Give antacids routinely every 6 hours:

magnesium trisilicate po C N 20ml 6 hourly review
Antibiotics are required only if/when wounds contaminated. Gram positive

organisms (notably B-haemolytic streptococcus) predominate early on (first
5 days):
benzylpenicillin iv C V 2.5MU 6 hourly change to
oral *
*then Amoxicillin po C E 500mg 6 hourly review
Change regimen if indicated by culture and sensitivity tests. Gram negative

organisms are usually implicated later on, and a more appropriate blind
therapy before results are obtained is:
benzylpenicillin iv C V 2.5MU 6 hrly review
and gentamicin iv C V 80mg 8 hrly based on c/s
Monitoring
324
 Basic observations and clear records including input/output are
essential.
 Mental responsiveness of patient (confusion can correspond to fluid
imbalance).
 Pulse, BP (if possible), temperature.
 Breathing rate/depth; colour of nail beds and mucous membranes.
 ECG after electric shock or lightning injury
 Urine: colour, volume (should be at least 1ml/minute) and specific
gravity; catheterise only if essential (predisposes to infection).
Later investigations:
 full blood count and haematocrit;
 electrolytes plus serum proteins;
 urine electrolytes;
Nutrition
 High protein, high energy diet, burns drink as per patient’s weight.
 Give vitamin supplementation, high dose (dietary) Vitamin C:
(multi)-vitamins po C N 4 tablets 3 times a day review
NB: This does not apply in first 48 hours for large burns or non-motile GI tract
(start feeding when bowel sounds return).
Physiotherapy
It is very important to prevent disability and disfigurement. Physiotherapy
also serves to prevent hypostatic pneumonia. Start physiotherapy early.
Special regions/problem burns
Area Notes
Circumferential burns of Can constrict when swelling develops. This is
trunk, limbs or digits particularly a feature of deep burns.
Eyes Saline irrigation plus tetracycline or
chloramphenicol eye ointment 4 hourly. Refer to
eye hospital for specialist care.
Lips Apply soft paraffin (Vaseline) three times a day.
Face Apply burn cream daily; SSD not to be used on the
face as it causes damage to the eyes.
Neck Keep neck extended and head up (i.e. nurse half-
seated).
Hands / feet Elevate limbs. Dress with burn cream. Hands may
be nursed free in a plastic bag with burn cream*,
changed daily. Splint wrists.
Perineum Catheterise early using sterile preparation. Apply
burn cream* twice daily.
* burn cream is the term used to denote either silver sulphadiazine or povidone
iodine cream
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PAIN MANAGEMENT & CARE OF THE

TERMINALLY ILL
PAIN MANAGEMENT 327
SPECIAL TYPES OF PAIN 329
MANAGEMENT OF PAIN IN CHILDREN 331
CARE OF THE TERMINALLY ILL 332
326
Pain Management
General Principles
A full assessment of the pain is essential.
 Pain may be either acute (e.g. fractures, post-operative), or chronic
(e.g. malignancy) and in each case should be graded as mild, moderate
or severe.
 Pain may occur at more than one site and the cause at each site may
differ, and therefore may require different treatment.
 The psychological state of the patient should be assessed. Anxiolytic
and anti-depressant medication is seldom needed – the opportunity for
discussion is more effective. If overlooked, underlying conditions –like
anxiety, depression, social and spiritual distress - may aggravate pain,
making control more difficult.
 In acute pain, careful and frequent assessment is needed to determine
the period for which medicines should be given. As the pain lessens,
analgesics should be reduced and ultimately discontinued.
 In chronic pain, long term analgesia is required. Frequent assessment
is needed to establish the correct dose and minimise side effects of the
medicines. Wherever possible analgesics should be given orally.
Analgesics should be given at regular intervals to prevent recurrence of
pain. Most preparations should be given every four hours. They should
never be given on an “as required” basis – except when ‘break through’
doses are added to an existing dose. [See management of severe pain
in this chapter.]
Mild Pain in Adults

The medicine of first choice for analgesic and antipyretic action is
paracetamol. If anti-inflammatory action is required aspirin is the
medicine of choice unless there is a definite contra-indication (peptic
ulceration, coagulation defects, low platelet count, prior to surgery or
breast feeding*.
paracetamol po C V 500mg-1g every 4-6hrs as long as
(< 4g/day) required
or aspirin po C V 300-900mg every 4-6hrs as long as
(<4g/day) required
or ibuprofen po C E 200-400mg (< every 4-6hrs as long as
2.4g/day) required
*Use of aspirin as a regular pain and anti-inflammatory medicine raises

safety issues so must be used with caution.
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Moderate Pain
Treat as for mild pain. If inadequate control:
add codeine phosphate po B E 15-60mg every 4 hrs As long as
effective
or Tramadol po B E 50mg 6 hourly 5-7 days
Severe Pain
 Morphine is the medicine of choice. It should be given orally wherever
possible and only rectally or parenterally (s.c., i.m., i.v.) in patients who
cannot swallow.
 Codeine should be discontinued but a mild analgesic given with
morphine may be useful. (largely because of the anti-inflammatory
effect of WHO Pain Ladder level 1 analgesics
 An anti-inflammatory – or other adjuvant analgesic - may be needed.
 Patients should remain on the level of analgesia that controls pain. If
there is inadequate pain control, treatment should be moved up to a
medicine on the next step of the ladder. Patients with severe pain
should be STARTED at the top level (i.e. morphine)
 Morphine is always given 4 hourly, and a “breakthrough pain” dose may
be added at ANY time, the dose added being 60 – 100% of the current
4-hrly dose.
morphine im* B E 10mg every 4 hrs review
or morphine po B V 5-10mg every 4 hrs review,
then
Increase dosage by approximately 50%
increments until pain control is achieved
*when calculating parenteral dose, use one third of estimated or existing oral
dose.
 Increments should be made quite rapidly i.e. after 24 hours at a
particular level have failed to control the pain.
 Patients may be safely advised to increase the dose of morphine if pain
control is not achieved. Tolerance does not occur. Psychological
addiction does NOT occur, but physical dependence does and so an
opiod analgesic must never be withdrawn abruptly. Respiratory
depression is very unlikely if the dose of morphine is adjusted gradually
to the needs of the individual patient.
 It is unusual for patients to require more than 200 mg per dose although
there is no “ceiling” on the individual dose required, For acute pain
smaller doses are usually adequate.
328
 If pain control is not achieved on morphine, a complex pain syndrome
should be suspected and appropriate adjuvant analgesics added.
Additional psycho-social counselling may also be indicated.
 Long term usage of morphine is usually reserved for cancer patients,
but may be required for non-malignant chronic neuropathic pain
syndromes.
Side-effects of morphine
These are mostly transient and treatable and should not contraindicate the
continued use of morphine. They include:
Nausea and vomiting:
This is usually transient. An antiemetic should be offered, or given
prophylactically for the first three days.
metoclopramide po B V 10-20mg 3 times a day 3-5 days
or prochlorperazine po B N 5-10mg 3 times a day 3 – 5 days
or haloperidol po A N 1.5-4.5mg at night 3 – 5 days
*If vomiting is severe, antiemetics may need to be given parenterally or rectally.
Drowsiness, dizziness, confusion:
Occurs especially in the elderly or dehydrated, but improves within 3 days.
Do not discontinue morphine.
Allergy:
Morphine allergy is very rare. Initial vomiting, or transient pruritis are NOT
signs of allergy. An alternative is pethidine, but it is short-acting and less
potent than morphine. Pethidine is better suited for acute pain than chronic.
pethidine im B V 50-100mg 2-3 hourly As long as
there is
pain
*Not suitable for long term use.
Constipation:
This is an INVARIABLE side-effect of opioid analgesics and all patients
should receive regular laxatives. Encourage high roughage diet and high
fluid intake.
Special Types of Pain

In certain situations other medicines may be useful in controlling pain. These
medicines may be used alone or with an analgesic.
Nerve Compression
dexamethasone po B V 8 mg Once daily see below
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Reduce dose of steroids progressively to minimal maintenance level once

clinical improvement occurs.
Raised Intracranial Pressure

Manage with codeine or morphine analgesia and:
dexamethasone po B N 12-16mg once a day review
or prednisolone po B V 90-120mg once a day review
Reduce dose of steroids progressively to minimal maintenance level once clinical
improvement occurs
Joint / Bone Pain

See also chapter on Bone & Joint Conditions
aspirin po C V 600-900mg every 4-6hrs review
or Ibuprofen* po C E 400mg every 4hrs review
or indomethacin** po B E 25 – 50mg every 4-6hrs review
* consider providing Ibupfrofen for facilities where staff is trained in PC
** if a rectal form of indomethacin or other anti-inflammatory is available it
should be considered for use
Metastatic Bone Pain

Use analgesic as per level of pain assessed . Note: regular long term
addition of a non-steroidal anti-inflammatory medicine is effective and often
allows lower doses of analgesics to be used.
Neuropathic Pain
Trigeminal Neuralgia, Post Herpetic Neuralgia & Peripheral Neuralgia
 ALWAYS start with analgesics and then consider adding
carbamazepine po B V 100mg 1-2 times a day Increasing
every 3
days
to max of 400mg 3 times a day, review
+/- amitriptyline po B E 25mg Not later increasing
than 8pm at
night
to 75mg* Before 8pm review
at night,
*Pain relief is achieved at lower doses than for antidepressant effect
In severe cases specific nerve block may be needed (using local anaesthetic
or neurolytic agents).
Phantom Limb Pain
330
Treat as for neuralgia; if severe, nerve block may be required.
Management of Pain in Children

See also the section in the Cancer module.
 Pain in children needs careful and regular assessment as children may
not complain of pain. Babies also experience pain and may require
analgesics. Parents are good judges of their child’s pain.
 When available/ necessary suppositories should be used.
 If pain is intractable refer for specialist management e.g. regional block
or wound infiltration.
Mild Pain
paracetamol po C V 10-15mg/kg every 4hrs review
Moderate Pain
and codeine* phosphate po B V 0.5-1mg/kg every 4hrs review
*Prevent constipation by increased fluid intake and high fibre diet where
feasible and laxative regimen
Severe Pain
and morphine po B V <6months =
0.02mg/kg
every 4hrs
>6months =
0.04mg/kg
or morphine sc/iv B E 0.025 per 4 hour as continuous
mg/kg sc/iv infusion
or Tilidine hydrochloride B V 1 drop per 6 hourly as drops
drops year age
(max. 5
drops)
Nausea and vomiting

metoclopramide po B V 0.1- 3 times a day review
0.2mg/kg
or promethazine po* B N 0.025- 3 times a day review
0.05mg/kg
*not for use in children under the age of 2yrs
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Care of the Terminally Ill

Good palliative care can greatly relieve the mental and physical suffering of
terminally ill patients.
Psychological support
A full explanation of the illness, the treatment and expected physical
symptoms should be discussed (often on several occasions). It is important
that health workers be available to provide continuing support. Fear and
anxiety about dying, pain and other distressing symptoms are common, and
patients may become depressed.
Management includes:
 Honest answers should be provided to all questions asked about the
illness, and delivered with compassion
 taking time to allow patients and their family to share their problems and
concerns
 proper control of pain and other symptoms
Management of physical symptoms

Pain control – see text above
Nausea and vomiting – see text above
Loss of appetite - may be due to many causes including medications.
Identify and treat cause if possible. Good oral care and adequate
hydration should be ensured, using simple mouthwashes.
Difficulty in swallowing – may be due to pharyngeal or oesophageal
obstruction, or thrush. Identify & treat the cause if possible. A feeding
tube might help. Good oral hygiene and hydration.
Diarrhoea – may be due to constipation with overflow, or excessive use
of laxatives. Use loperamide, codeine or morphine.
Shortness of breath – may be due to infections or pleural effusions.
This is one of the most feared symptoms and every effort should be
made to alleviate it. The cause should be established and treated if
possible. A calming presence of a relative/carer, propping the patient
up, and the use of low-dose morphine (2,5mg 4hrly – or a 25% increase
in dose currently being given for analgesia) and mild sedatives may
help. Oxygen is only indicated if there is cyanosis.
During the last hours of a person’s life, carers should focus on minimising
pain, reducing respiratory secretions (e.g. atropine 0,6mg sc 4hrly) and
observing for urinary problems (retention or incontinence). Medicines should
be rationalised, stopping all but those relevant to terminal symptoms/signs.
IV fluids should be discouraged (or discontinued) as they aggravate terminal
respiratory problems. If symptoms and distress are not easily controlled it
may be appropriate to use terminal sedation. Families should always be
informed about the dying process, and consulted on medicine and fluid
rationalization.
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MEDICINES AND THE ELDERLY
GENERAL NOTES 334

ANTI-HYPERTENSIVES 334
DIURETICS 334
ORAL HYPOGLYCAEMICS 334
MAJOR TRANQUILLISERS 335
ANTIDIARRHOEALS 335
NON-STEROIDAL ANTI-INFLAMMATORY MEDICINES 335
STEROIDS 335
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General Notes
Due to physiological changes and altered pharmacodynamic response of
target organs the elderly are more susceptible to adverse Medicine
reactions.
Elderly patients may require multiple medicine therapies. Therefore
medication should be reviewed frequently (every 3 months).
 Provide simple, once or twice daily regimens wherever possible.
 Give clear instructions on how medicines are to be taken.
 Where possible ask relatives to supervise medicine taking.
 Suppositories or liquid formulations should be prescribed where
swallowing is difficult.
 Use reduced doses
 Avoid nephrotoxic medicines
Anti-hypertensives
Prescribe with caution due to increased risk of postural hypotension, side
effects, cognitive dysfunction and falls. The general treatment guidelines on
hypertension should be followed but it is appropriate to start with lower doses
and build up. Re-evaluate therapy every 6-12 months because blood
pressure may decrease as a result of progression of atherosclerotic disease.
Diuretics
Since the elderly have a decreased plasma volume and lower levels of
aldosterone, aggressive diuretic therapy to reduce BP is not indicated. Even
low doses may precipitate hypotension, falls, hyponatraemia and
hypokalaemia. Gravitational oedema will respond to simple mechanical
measures such as raising legs and does not usually warrant use of diuretics.
Digoxin
Lower maintenance doses e.g. 0.625 to 1.25 mg (paediatric elixir
formulation) should be used owing to reduced renal function and increased
sensitivity. Signs of digoxin toxicity are nausea, vomiting, anorexia, visual
disturbances and headache.
Where there is no evidence of heart failure and if the heart is in normal sinus
rhythm digoxin may be safely withdrawn but the patient should be monitored
for atrial fibrillation if discontinuation is attempted.
Oral hypoglycaemics
(see diabetes section in Metabolic and Endocrine Conditions Chapter)
The elderly are at increased risk of hypoglycamia with glibenclamide.
334
Hypnotic / Sedatives
Benzodiazepines (e.g. diazepam) significantly impair cognitive function and
should not be used. Hypnosis or sedation should be achieved with:
amitriptyline* po B E 12.5mg at night intermittently
*Caution: advise of ‘hangover’ effect in the morning.
Major tranquillisers
It is essential to define and remove the underlying cause of agitation e.g.
infection or hypoxia. Once this is done and if tranquillisation is still
considered necessary, the options are:
haloperidol po A N 0.5-2mg bd review
or haloperidol im A N 1-5mg bd review
Always start with the lower dose if possible. 0.5 mg bd is often enough. Avoid
chlorpromazine and fluphenazine decanoate where possible as major
irreversible side effects may occur.
Antidiarrhoeals
The elderly are prone to spurious, or overflow diarrhoea from chronic faecal
impaction. No diarrhoea in the elderly should be treated with anti-diarrhoeal
medicines before an adequate physical examination has excluded impaction.
In such cases a high fibre diet, regular enemas and a stimulant such as
senna or bisacodyl will relieve the problem.
Non-steroidal Anti-inflammatory medicines

These should be used with caution as the elderly are particularly susceptible
to gastrointestinal complications (erosions and bleeding) and renal
complications (e.g. interstitial nephritis). Paracetamol is a more appropriate
analgesic in older adults.
aspirin po C V 300-600mg < 3 times a day as required
or ibuprofen po C N 200mg < 3 times a day as required
*add magnesium trisilicate as required for gastrointestinal side effects.
Steroids
The known side effects of steroids occur more rapidly and are accentuated in
the elderly. Use with caution and monitor for side effects.
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HAEMATOLOGY AND BLOOD

PRODUCTS
ANAEMIA 337
IRON DEFICIENCY ANAEMIA 337
MEGALOBLASTIC ANAEMIA 337
SICKLE CELL ANAEMIA 338
G6PD DEFICIENCY 339
OTHER ANAEMIAS 340
HEREDITARY BLEEDING DISORDERS 340
ACQUIRED BLEEDING DISORDERS/ PLATELET
DISORDERS 342
ANTICOAGULATION 343
PROPHYLAXIS FOR DEEP VEIN THROMBOSIS (DVT)
344
LIFE THREATENING PULMONARY EMBOLISM/
ARTERIAL EMBOLISM 345
USE OF BLOOD AND BLOOD PRODUCTS 345
SPECIFIC INDICATIONS FOR USE OF BLOOD AND
BLOOD PRODUCTS 346
336
Anaemia
This is defined as a decrease in the concentration of haemoglobin
(<13.5 g/dl in men and <11.5 g /dl in women) and haematocrit
(<0.42 in men and <0.36 in women). Use of red blood cell indices
and careful examination of a peripheral blood smear may indicate
the likely cause of anaemia. If in doubt contact a central hospital
laboratory for assistance (peripheral blood films and where possible
bone marrow films can be sent for comment).
Avoid blood transfusion before knowing the cause of anaemia or at
least taking samples for doing appropriate investigations. Further,
avoid transfusions in cases correctacble by hematinics or other
therapy, unless patient has life threatening symptoms. Avoid poly-
pharmacy (giving multiple haematinics without knowing the cause of
the anaemia).
Iron deficiency anaemia

Note: parenteral iron, which is neither faster acting nor more effective
than oral iron, is rarely indicated. The cause of Iron deficiency
anaemia must be elucidated as much as possibleas correcting the
primary cause should be the most single important objective. The
typical blood picture is that of hypochromia microcytosi (MCV
<75fL).
ferrous sulphate po C E 200mg 3 times a Review
[60mg iron] day
Paed = 12mg iron, <1yr = 6mg iron
Expected response rise is haemoglobin 1g/dl/week. Continue
treatment for 3 months after haemoglobin has normalised to
replenish body iron stores.
Megaloblastic Anaemia
This is due to deficiency of vitamin B12 and/or folic acid. It is
important to establish the cause of the deficiency for appropriate
treatment. The typical blood picture is that of macrocytosis with or
without reduced platelet count (MCV >105 fL). Until or unless blood
levels are available, it is mandatory to give both vitamin B12
(parenteral) and folic acid to prevent precipitation of neuropathy.
Avoid blood transfusion if possible
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Macrocytosis also occurs in liver disease, alcohol excess,

hypothyroidism, some haemolytic anaemias and myelodysplastic
syndromes. In the presence of these conditions vitamin B12 /folate
deficiency must be excluded. Macrocytosis is physiological in the
neonate.
Vitamin B12 Deficiency
Lifelong replacement is mandatory in pernicious anaemia, post-
gastrectomy or illeal resection.
hydroxocobalamin B V 1mg daily 3 days
(vitamin B12) im then weekly for 3 weeks, and monthly
for 3 months and then every 3 month
for a year and then twice a year.
Folic Acid Deficiency

Occurs in most prolonged haemolytic anaemias, pregnancy, and
seasonally in dry areas with no access to fresh vegetables, in
malabsorption up to 15mg daily may be required.
folic acid po C E 5mg once a day 3 months
and review
Sickle Cell Anaemia

Management:
folic acid po C E 5mg once a day for life
penicillin V po C E 250mg once a day for life
For malaria prophylaxis in endemic areas:

pyrimethamine/dapsone C E one tablet once a Continual
po 12.5mg/100mg week
In painful crisis, intravenous rehydration, regular and adequate
analgesia, oxygen by mask where available and possibly in some
cases antibiotics are required.
Morphine is necessary to control severe pain. Weaker opiates
(codeine) or non-steroidal anti-inflammatory medicines (e.g. aspirin)
may be used for less severe pain. See chapter on Pain.
Antibiotic therapy:
Other antibiotics may be required according to site of
infection/causative organism.
Osteomyelitis: see chapter on Bone and Joint Conditions.
338
Other types of crises:
In aplastic and haemolytic crisis, red cell transfusion may be
required to treat anaemic heart failure. Sequestration or splenic
pooling requires splenic massage and less often, blood transfusion.
Note that over transfusion worsens the sickling crisis and may
cause iron overload. Special precautions must be taken during
anaesthetizing sickle cell disease patients. Adequate hydration and
oxygen exposure are essential to avoid red cell sickling.
Avoid debridement of leg ulcers as these are due poor circulation
rather than mere dead tissue.
Treat priapism conservatively with hydration and analgesia before
resorting to surgery.
Patients with frequent crises need to be started on hydroxy urea
where possible, refer to provincial central hospital. The objective is
to increase the HbF to at least 20%, levels which do not lead to
haemolysis.

hydroxyurea po B V 500mg once a day indefinitely
Note: Use hydroxyurea 500 mgs daily indefinitely, titrate against

HbF. Monitor white cell and platelets counts.
Sickle cell trait requires no treatment, and does not cause anaemia.
G6PD deficiency
Glucose-6-phosphate dehydrogenase (G6PD) deficiency is
common in Zimbabwe. All patients should have a "Medic-alert"
bracelet or necklace.
Severe anaemia occurs with intravascular haemolysis and
haemoglobinuria on exposure to oxidant medicines (e.g.
primaquine, dapsone, sulphonamides, quinolones, nitrofurantoin
and in some cases quinine and chloroquine) and be worsened by
acute infections e.g. malaria. Treat these episodes with intravenous
fluids, oral iron and folate supplement; treat or remove the
underlying cause.
Prescribers must always check complete list.
The risk of malaria outweighs the risk of haemolysis, so quinine
should be used if indicated for malaria treatment unless the specific
patient is known to sensitive to the specified anti-malaria in question.
Avoid blood transfusion unless clinically indicated.
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Other Anaemias
HIV anaemia is a common finding with HIV and AIDS patients.
Transfusion is only indicated in treating severe anaemia and
cardiac failure. The causes of the anaemia include medicines
such as zidovudine, and infections.
Other cytopaenias: refer to next section on Blood Products.
Aplastic anaemia presents as pancytopaenia. Diagnosis needs
confirmation by bone marrow examination. Refer to central
hospitals for specialist care after confirmation.
Myelodysplastic syndromes: refer to Central Hospital for
specialist management.
Sideroblastic anaemia may occur in alcoholism, malignancy,
hypothyroidism and particularly during TB treatment. Some
respond to vitamin B6, but refer to central hospital for specialist
care.
Leukaemias: refer to central level.
Hereditary Bleeding Disorders

Never use intramuscular injections and aspirin (paracetamol is
safe). All patients should have a "Medic-alert" bracelet or necklace.
Refer early for specialist management.
All haemophiliac patients should be registered with the Haemophilia
Association/Centre, Department of Haematology, P.O. Box A 178,
Avondale, Harare. Clinics are held at Parirenyatwa Hospital every
month.
For haemarthrosis - do not aspirate joint. Treat by replacement of
specific factor, joint support and analgesia e.g. paracetamol,
codeine, morphine. Rest the joint during the acute period, give
aprpropiate replacement factor and start physiotherapy as soon as
the bleed resolves. Some Haemophilia A and B patients are on a
home therapy programme. They have written instructions on
recommended dosage but may require assistance from health
personnel.
Haemophilia A (factor VIII deficiency)
The amount of factor VIII given depends on assessment of severity
of bleed. Use the table below to determine dosage, for both children
and adults according to body weight.
Ice compression should be applied as soon as possible, as
this reduces the bleed.
Dosage of Factor VIII – Adults – per dose
340
Severity of bleed Required FVIII Cryoprecipitate
FVIII level Concentrate [80 IU/bag]
[500 IU/bottle] (=20mls)
1. Mild bleed (nose, gums 14 IU/kg 1-2 bottles 6 bags
etc.)
2. Moderate bleed joint, 20 IU/kg 2-4 bottles 12 bags
muscle, GIT, minor surgery
3. Major bleed (e..g.. 40 IU/kg 4-6 bottles 12 bags
cerebral)
4. Prophylaxis for major 60 IU/kg 6-10 bottles 18 bags
surgery
Note: For 1 and 2 above, repeat the dose 12 hourly if bleeding persists or
swelling is increasing. With more severe bleeds it is usually necessary to
continue treatment with half of total daily dose 12 hourly for 2 -3 days,
occasionally longer.
Note: For 3 and 4 above, treatment and surgery should be done with
specialist supervision only. Measure levels, (if possible), otherwise give
immediately before surgery. Continue 12 hourly therapy for 48 hours post-
operatively and if no bleeding occurs, scale down gradually over next 3 -5
days.
Note: cryoprecipitate or of fresh frozen plasma should only be used in the
absence of safe treated factor products.
 As adjunct to factor replacement in mucosal or gastro-
intestinal bleeding and surgery, give fibrinolytic inhibitor
[tranexamic acid]. Do not use for haematuria.
 If viral-inactivated treated Factor VIII is unavailable: see
previous table for cryoprecipitate doses.
Haemophilia B (factor IX deficiency)

 Ice compression should be applied as soon as possible, as
this reduces the bleed.
Mild bleed:
factor IX concentrate A V 2 x 500 IU daily Review
or fresh frozen plasma B V 4-6 bags every 24hrs if bleeding
continues
For children use appropriate dosage.
Major bleeding
factor IX concentrate A V 3-6 x 500 IU daily Review
or fresh frozen plasma B V 8 – 12bags every 24hrs if bleeding
continues
For children use appropriate dosage.
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Factor VIII concentrate and cryoprecipitate are not useful for

Haemophilia B, so accurate diagnosis is essential.
von Willebrand Disease (vWD)
The currently available FVIII concentrate from the National Blood
Transfusion Service contains vW factor (but always check the
insert).
Using this FVIII concentrate treat as for mild or moderate bleed of
Haemophilia A. Repeat haemostatic dose every 24-48 hours since
therapeutic response is more sustained in vWD.
If viral inactivated Factor VIII concentrate not available use:
cryoprecipitate A E 6 bags per every 24-48 if bleeding
dose hrs continues
Tranexamic acid (specialist medicine) is very useful in vWD mucosal
and other bleeding.
Acquired Bleeding Disorders/ Platelet Disorders

Disseminated Intravascular Coagulation (DIC)
Monitor prothrombin time (PT), international normalized ratio (INR),
activated partial thromboplastin time (APTT), platelet count and
fibrinogen.
Identify if possible, and treat /remove cause of DIC.
If PT/APTT prolonged and patient is bleeding, give:
fresh frozen plasma B V 4 bags every 12- if bleeding
24hrs continues
 If platelet count <30x109/L and patient is bleeding:

platelet concentrate A E 1 unit/kg
 If fibrinogen is low and/or APTT prolonged give (to supply

fibrinogen and FVIII):
cryoprecipitate A E 6 bags per review Review
dose
 The use of heparin is NOT recommended in bleeding patients
with DIC, except under specialist supervision.
Liver Disease
342
vitamin K iv * C V 10mg** once a day 3 days
*Avoid intra muscular vitamin K.
**The dose is adjusted depending on the INR.
For immediate haemostasis if bleeding and INR>3 give:

fresh frozen plasma B V 4 bags review review
Haemorrhagic disease of the new-born

The policy is to give vitamin K routinely to all new-borns as a
preventive measure. However, if there is active bleeding give FFP
and:
vitamin K im C V 1mg once a day 3 days
Idiopathic Thrombocytopaenic Purpura (ITP)

prednisolone po B V 1mg/kg once a day 2 weeks,
then according to response – see notes
below
or immunoglobin iv S E Img/kg once a day 3 days
Duration of therapy:
No response after 2 weeks - stop.
Complete response - reduce gradually over 8-10 weeks
Partial response; - reduce slowly and refer for alternate management.
Intravenous immunoglobulin given at 1 mg/kg daily for 3 days works
quicker when available. Consider splenectomy for those in whom
steroids fail to achieve adequate control or who relapse after
treatment.
Anticoagulation
Oral
warfarin po B V 10mg once a day 2 days,
(loading dose)
then check the INR on Day 3 and adjust
Note: To be taken at same time each day. Reduce loading dose in
elderly and in-patients with renal/hepatic impairment.
 Monitor INR regularly, initially alternate days then increase
interval gradually to a maximum of 8 weeks. Therapeutic
range: DVT/PE = INR 2-3; Heart valve prosthesis = INR 3-4.5.
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 There is great individual variation in dose required

(average daily dose 2.5-10mg).
 Caution: medicine interactions are common and can be
dangerous. Below are a few examples:
Warfarin Inhibition Warfarin Potentiation
Barbiturates Alcohol
Oral contraceptives Chloramphenicol
Griseofulvin Cimetidine
Rifampicin Erythromycin
Carbamazepine Cotrimoxazole
Vitamin K Aspirin
Warfarin Overdose
 If INR 4.5-7 without haemorrhage - withhold warfarin for 1-2
days then review.
 If INR >7 without haemorrhage - withhold warfarin and check
INR daily. Consider giving:
vitamin K slow iv C V 0.5 – 1mg once a day Review
Note: higher doses vitamin K will prevent adequate anticoagulation
for up to 2 weeks
INR > 7 with haemorrhage give:
fresh frozen plasma B V 4 units - -
and vitamin K iv C V 0.5 – 1mg once a day Review
Parental anticoagulation.
Unfractinated heparin is given subcutaneously or intravenously. The
dose is dependent on the activated partial thromboplastin time ratio
(aPTTR). It has a short half-life and needs laboratory facilities.
Low molecular weight heparin is given subcutaneously with a fixed
dose. No laboratory monitoring facilities are required.
Prophylaxis for Deep Vein Thrombosis (DVT)

This is indicated for all patients who have high risk factors for
thrombosis before and after surgery. These conditions include:
 Obesity
 Prolonged immobility
 Hereditary thrombophilia states (antithrombin III, factor V
Leiden deficiency, protein C & S deficiency etc.)
 Paroxysmal nocturnal haemoglobinuria
 Previous history of DVT
 Various malignances
 Other pro-thrombotic states such as artificial cardiac
valves and atrial fibrillation need lifelong anticoagulation.
344
Methods of prophylaxis available
Physical methods include stockings. Early mobility must be
encouraged in all surgical patients.
Medicine management (targeting an INR of 2 to 2.5):
warfarin po B V 10mg once a day 2 days
then review based on INR level
or heparin sc B V 5000 units 8 hourly Review
(unfractionated)
Treatment of DVT
heparin sc B V 17500 units Twice a day see below*
(unfractionated)
or Low molecular heparin B V 40mg Once daily
*Duration is 4-6 months except in pregnancy, or if there is another reason for

prolonged treatment;
 Pulmonary embolism: 4-6 months.
 Atrial fibrillation: lifelong treatment.
 Heart valve prostheses: lifelong treatment.
Continue heparin until warfarin effective - usually 3-5 days.
Deep Vein Thrombosis in pregnancy

Continue throughout pregnancy, aiming for APTT 2-3 times normal:
Low molecular heparin B V 40mg once a day 1 month
post-partum
or warfarin po B V keep INR in to 37 weeks,
after 12 weeks up to 37 range 2-3 then change
weeks to heparin
CAUTION: Warfarin may harm the foetus and should not be used
under 12 weeks. Monitor closely whichever method is used. Specialist
supervision is recommended.
Heparin may cause thrombocytopaenia, and with prolonged use
osteoporosis.
Life Threatening Pulmonary Embolism/ Arterial
Embolism
See also section in Cardiovascular conditions.
hydrocortisone iv [for B V 100mg once only -
allergic reactions]
and streptokinase iv A N loading dose of 250 000 units over
30minutes, then
100 000 u every hour 24 – 72 hrs
Haematological malignancy: Refer all patients to a Central

Hospital.
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Use of Blood and Blood Products

General Principles
Efforts should be made to avoid transfusions wherever possible
because of:
 The need to conserve scarce and expensive blood products.
 The risk of Transfusion Transmitted Infections e.g. HIV and
Hepatitis C (window period) and other transmissible agents.
 The risk of transfusion reactions.
There are limited and specific indications for transfusion. Use the
appropriate blood fraction to treat specific defects. Transfuse
patients during normal working hours: avoid night-time transfusion
whenever possible.
Note: Anaemia - The correct management of a patient with anaemia is
to identify and treat the cause. Blood transfusion is required only
when the anaemia is life-threatening e.g. cardiac failure or when it
prohibits other necessary treatment e.g. chemotherapy or surgery. A
slow rise of haemoglobin in response to haematinics is not an
indication for transfusion.
Note: The routine use of frusemide is not necessary. When needed,
e.g. in cardiac failure, give small doses (e.g. 20mg). Intra-venous
frusemide is rarely required.
Blood must be kept at appropriate temperature as much as possible
Specific Indications for Use of Blood and Blood

Products
RED CELL CONCENTRATE (PACKED CELLS)
Medicine
Give packed cells in the following situations:
 Acute major haemorrhage.
 Chronic anaemia-when patient has symptoms of cardiac failure
due to low haemoglobin (<5g/dl);
 Anaemic patient (<5g/dl) due to have haemodialysis; (Elderly
patients may require Hb levels higher than 8g/dL)Prior to, and
following aggressive cytotoxic programmes, maintain
haemoglobin at/or above 8g/dl;
 Low haemoglobin (<8g/dl) in presence of severe and persistent
infections and septicaemia;
 Acute haemolysis where patient has symptoms of cardiac failure.
Paediatrics
Small packs (100mls) are available. Indications are as for adults
(see above list). Where transfusion is given on appropriate
346
indication to children with protein-energy malnutrition, they should
be transfused slowly (not more than 2.5 ml/kg body weight/hour).
The presence of anaemia and safety of procedures must be
evaluated on a patient to patient basis. There is no single safe
haemoglobin level, patient haemodynamics must be evaluated
against the procedure to be performed.
Patients are generally haemodynamically stable at haemoglobin
levels above 8 gm/dL for several procedures, but anticipation of
blood loss must be assessed before each procedure.
PLATELET CONCENTRATES
Note: this product is often used inappropriately
This section applies to all disciplines.
Indications for Use of Platelet Concentrates
 Acute bleeding in a patient with a low platelet count less than 30 x
109/L
 Disseminated intravascular coagulation (DIC) with active
generalised bleeding and platelets <20 x 109/L
 Operations with platelets<30 x 109/L
 Cranial operations and eye operations need platelets above 100 x
109/L).
No justification for use of platelets in:
 Low platelet count in patient with no evidence of bleeding, [most
transfused platelets will be eliminated within 24 hrs.]
 Autoimmune thrombocytopenia.
 HIV thrombocytopenia without bleeding.
 Aplastic anaemia without bleeding.
Guidelines for platelet transfusion in surgical patients.
>100x109/L All surgical proceedures including No platelet

eye and brain transfusion required.
>50x109/L All surgical proceedures with the No platelet
exception of eye and brain. transfusion required.
No platelet
>30x109/L Safe for minor procedures such as
non-traumatic lumbar puncture, transfusion required.
bone marrow aspirates, GIT
scopes etc.
* Not to be used in children under the age of 2 yrs.
FRESH FROZEN PLASMA
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Note: Currently this is the most inappropriately used product

in Zimbabwe.
This section applies to all disciplines. The risks of transmission of
infection are no less than with packed red cells or whole blood.
Indications for Use of FFP
 Severe acute disseminated intravascular coagulation (DIC) with active
generalised bleeding
 In presence of bleeding and disturbed coagulation in patients with liver
disease, or following massive transfusion
 In presence of disturbed coagulation in patients requiring liver/renal
biopsy, or surgery
 If immediate reversal of warfarin effect essential (combined with Vitamin
K administration)
 Replacement of single coagulation factor deficiencies where specific
factor concentrate not available e.g. haemophilia B
 Thrombotic thrombocytopaenic purpura
No justification for use of FFP in:
 Hypovolaemia
 Acute haemorrhage with minimal disturbance of coagulation
 As nutritional support
 Obstructive jaundice with disturbed coagulation (vitamin K should be
given).
WHOLE BLOOD
To be used in cases where fractionated blood is not available. The
indication is as for red cell concentrate, and never as source of
plasma.
EXCHANGE TRANSFUSION IN NEONATES STRICTLY USE WHOLE BLOOD.
BLOOD MUST BE LESS THAN 5 DAYS OLD.
Indications:
 Definite clinical jaundice on Day 1 of life
 Clinical signs of kernicterus
 Total Serum Bilirubin levels as shown in the table below [23.3],
depending on gestational and postnatal age of the baby.
Table 26.3 Serum Bilirubin Levels and Exchange Transfusion

Gestational Age Day 1 of Life Day 2 of Life
(Weeks) Serum Bilirubin Serum Bilirubin (umol/l)
(umols/l)
>37 80 350 (300 if sick and/or acidotic)
34 to 37 80 350 (270 if sick and/or acidotic)
31 to 34 70 290(240 if sick and/or acidotic)
29 to 31 70 250 (200 if sick and/or acidotic)
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Birth weight Volume of aliquots
< 1000 – 1490g 5ml
1500 – 2499g 10ml
>2500g 20ml
Withdrawal of blood 1 minute
Injection of blood 4 minutes
LEUKOCYTE-POOR BLOOD
Occasionally required in patients who need regular transfusion over
prolonged periods, in order to prevent febrile reactions due to white
cell antibodies and provision of CMV negative blood from un-
screened blood. Bedside leukocyte reducing filters, supplied by the
Blood Transfusion Service, may be used to attain the same product.
ALBUMIN 4%
Can be used as a volume expander and is HIV free. Must not be
used if solution appears turbid or contains a deposit. Protect from
light and do not freeze.
ANTI-D
To be given post-delivery to Rhesus D negative patients to prevent
immunization.
INTRAVENOUS IMMUNOGLOBULIN.
Can be used in several auto immune diseases to include ITP,
Guillain Barre and in selected infections.
SALT-POOR ALBUMIN
May be indicated for correction of chronic hypoalbuminaemia; in
special circumstances of organ failure and fluid overload e.g. liver
disease and resistant ascites.
FACTOR VIII PREPARATIONS

Products available: (1) freeze dried anti-haemophilic factor (AHF).
(2) cryoprecipitate. To be used in patients with haemophilia A with
mild, moderate or severe bleeds. See notes above.
FACTOR IX CONCENTRATE
For patients with haemophilia B who are bleeding. See notes
above.
CRYOPRECIPITATE
Indications include DIC, von Willebrand Disease, haemophilia, and
bleeding associated with renal failure.
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INTRAVENOUS FLUID REPLACEMENT
SPECIAL NOTES 351

NORMAL DAILY REQUIREMENTS 351
MAINTENANCE 352
REPLACEMENT OF ABNORMAL LOSSES 352
AVAILABLE INTRAVENOUS SOLUTIONS 354
CRYSTALLOIDS 354
COLLOIDS 356
350
NB: Repeated clinical evaluation of patients receiving IV fluid therapy is
necessary in order to avoid the dangers of over-transfusion or
inadequate rehydration. Formulae and biochemical estimations are no
substitute for clinical evaluation.
Special Notes
 Only give intravenous fluids when they are strictly necessary. It is
wasteful and dangerous to give iv fluids to a patient who can drink oral
fluids.
 Small packs of intravenous fluids (e.g. 200 ml) are much more
expensive volume for volume than litre containers.
 For fluid replacement in burns see relevant chapter.
 For use of blood and blood products see relevant chapter.
Electrolyte content of various body fluids
Electrolyte content of various body fluids should be taken into account. For
practical purposes replacement is with Normal Saline or Ringer Lactate with
added potassium, except for diarrhoea, particularly in children, where the
sodium content is proportionately lower and the potassium higher.
FLUID SODIUM POTASSIUM
mmol/litre mmol/litre
Plasma 140 4
Gastric 60 10
Biliary & Pancreatic 140 5
Small Intestine 110 5
Ileal 120 5
Ileostomy 130 15
Diarrhoea 60 40
Sweat 60 10
Normal daily requirements

Substance Weight Dose
Water 0 to 10kg 100ml/kg/24hrs
11 to 20kg 1000ml + 50ml/kg/24hrs
21 kg or more 1500ml + 25ml/kg/24hrs
(for an adult this is 30 – 40ml/kg/day)
Sodium 1 to 1.5mmol/kg/24hrs
Potassium 1mmol/kg/24hrs
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Maintenance
 Adults [and Children > 10 years]:
 The following in combination, adjusted so that total volume is 2-3

litres/24 hours in adults:
sodium chloride 0.9% iv C V 0.5 – 1 litre
or ringer lactate iv C V 0.5 – 1 litre
and dextrose 5% in water iv C V 1.5 – 2 litre
and Potassium chloride iv B V 20 mmol added to each litre
 Children: 1 Month - 10 years( refer to Paediatrics Chapter)

half strength Darrow’s C V 0-10kg = 100ml/kg/24hrs
solution with dextrose 5-10yrs= 75ml/kg/24hrs
2.5% iv
 Infants: (Up to 30 days old)

neonatal multi B N up to 150ml / kg per 24 hours*
electrolyte maintenance
solution (‘neonatalyte’)
*Do not exceed 60 ml/kg/24 hrs in the first 24 hours of life - see section on
neonates in paediatric chapter.
Replacement of Abnormal Losses

Dehydration
 Oral rehydration alone should be carried out wherever possible in
addition to intravenous fluids. In severe cases, IV fluid replacement will
be needed.
Intravenous Rehydration (Adults)
sodium chloride 0.9% iv C V In severe dehydration the first litre may
or ringer lactate iv C V be infused in 15-20 minutes. Thereafter
the drip rate should be progressively
slowed down. Six or more litres may be
required in the first 24 hours, of which
the first 3-4 litres will be a replacement
fluid after which a maintenance
regimen of approximately 3 litres/24
hrs should be used (see “maintenance”
above).
352
Intravenous Infusion Rehydration (Children)
half strength Darrow’s C V Severely dehydrated infants and
with dextrose 2.5% iv children may be rehydrated at a
maximum rate of 30 ml/kg body
weight/hour for the first hour. This rate
should be progressively reduced over
the next few hours to a maintenance
regime (see “maintenance” above)
Rehydration: Infants
See section on Neonatal Conditions.
Rehydration: Paediatrics
See section in Management of Diarrhoea in Children
Nasogastric Suction
 Replace losses with:
sodium chloride 0.9% iv C V replace losses
and potassium chloride iv B V 1g (13mmol) added to each litre
Surgical Losses (not Minor Surgery)

 Trauma to tissues causes shift of extracellular fluid (so-called “third-
space” loss). It is justifiable to replace this with a solution having similar
ionic composition to plasma. A reasonable formula is:
ringer lactate iv C V 10 ml/kg for the first hour of surgery
5 ml/kg during subsequent hours to a
maximum volume of 3 litres (adult) OR
to a maximum equivalent to 40-50
ml/kg in children.
Fever
 For temperature 38oC and above, increase maintenance fluids by 5-10%.
Haemorrhagic Shock
 Use the table below [Table 27.1] to estimate blood loss and replace
total volume lost as shown. A physician should ideally supervise
management of class 3 and 4 haemorrhage.
Septic Shock
 Initial management - see intravenous rehydration of an adult above.
See also section on Blood Transfusion.
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Table 29.1 Clinical estimate of Blood Loss in Haemorrhagic Shock in

Adults
Blood Blood Pulse Blood Resp. Urine Treatment :
loss loss % rate press. rate [per output [replace total
[mls] blood minute] [mls/hr] volume lost] *
volume
Class 1 up to up to < 100 norm 14-20 >30 crystalloid
750 15%
Class 2 1250 20 to 100 – norm 20-30 20-30 crystalloid +
25% 120 colloid
Class 3 1500 to 30 to > 120 decreased 30-40 5-15 crystalloid +
2000 35% <100 colloid +
blood
Class 4 > 2000 > 40% >140 decreased >40 nil crystalloid +
< 60/40 colloid +
blood
*Note: Rules for adequate volume replacement:
crystalloid alone: 2 – 3 times the volume deficit is required
colloid or whole blood: just the volume deficit is required.
Available Intravenous Solutions

These can be divided into two groups: CRYSTALLOIDS and COLLOIDS.
Crystalloids
The composition of the crystalloid solutions is shown in Table 27.2.
Sodium chloride 0.9% (normal saline)

Suitable for fluid replacement in the initial therapy of haemorrhagic shock
and severe dehydration. The sodium content sustains the circulating blood
volume and the absence of potassium allows rapid infusion. Contains no
calories. May be given as part of maintenance regimen.
If normal saline is being given as part of maintenance requirement care must be
taken not to overload the patient particularly in the postoperative period when
sodium and water requirements are decreased - as little as 10mmol of sodium
may be required in 24 hours after major surgery /trauma.
Ringer lactate solution

Suitable for the same purposes as Sodium Chloride 0.9%. In addition to
sodium it contains potassium and calcium in physiological amounts, and
provides bicarbonate. Use with caution in diabetes mellitus and renal failure
and severe diarrhoea with alkalosis.
Maintelyte
Suitable for maintenance, but MUST NOT BE USED FOR RESUSCITATION
as the sodium content is too low to sustain blood volume and the potassium
content is too high for safe rapid infusion. Avoid in renal failure. Since this
354
solution is very hypertonic it may damage vascular endothelium. It should be
avoided in hyperosmolar states. It is currently suggested that
hyperglycaemia is detrimental to patients at risk of cerebral ischaemia (owing
to anaerobic production of lactic acidosis). If maintelyte is used, monitor
blood glucose levels regularly. It cannot be used for replacing potassium
deficits unless more potassium is added as maintelyte contains basic
requirements of potassium only.
Half strength Darrow’s solution with dextrose 2.5%
An all-purpose solution with an electrolyte content intermediate between the
replacement and maintenance solutions; the recommended solution for both
initial (replacement) therapy and subsequent (maintenance) therapy of
dehydrated infants. Use with caution in renal failure. For classes I and II
(mild-moderate) blood loss use normal saline as crystalloid replacement fluid
of choice. Darrow’s contains too little dextrose to maintain the blood sugar
level in neonates. It contains too little sodium to be used in the postoperative
period or replacement of upper gastro-intestinal and small bowel losses. Its
use is mainly confined to rehydrating children with diarrhoea and vomiting.
Dextrose 5% in water
Contains no electrolytes; it may be used:
 as part of maintenance regimen;
 as a replacement fluid where pure water loss predominates (as in
febrile illness, pneumonia and asthma);
 as full maintenance in acute renal failure, where no electrolytes are
being lost in urine;
 as a vehicle for administration of some medicines.
It should not be used in patients with head injuries (cerebral oedema may
result).
Dextrose 10% in water
Used for peri-operative management of diabetic patients (undergoing
surgery) and for patients with hepatitis, hypo-glycaemia.
Dextrose 2.5% and sodium chloride 0.45%
Used as a maintenance solution and as a vehicle for administration of some
medicines.
Dextrose 5% and sodium chloride 0.9%
A special purpose solution useful for certain surgical patients with
hyponatraemia and impaired renal function.
Maintenance solution neonatal multi-electrolyte ‘neonatalyte’
Used as a maintenance solution for neonates. It contains phosphate 3.75
mmol/L (as HPO4). Use with caution in renal failure.
Sodium chloride 0.45% (half normal saline)
Used in cases of sodium overload and in patients with hyperosmolar, non-
ketotic diabetic coma/precoma.
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Colloids
Indication for colloids includes resuscitation in severe hypovolaemia,
treatment of circulatory collapse, and emergency treatment of shock due to
fluid loss or blood loss as a plasma substitute. Colloids should be used when
crystalloids do not improve volume or when crystalloids are not expected to
improve volume. Examples of colloids include albumin, plasma protein
fraction, dextran, gelatin and etherifiedetherified starches (hetastarch,
pentastarch and tetrastarch).
Fresh frozen plasma (FFP) should not be used as a general colloid, but
only when specifically indicated. See section on Blood and Blood related
Products.
Dextran 70
Used to reduce viscosity and prevent venous thrombosis.
Modified gelatin
Used to expand and maintain blood volume in hypovolemic shock.
Table 29.2: Composition of Available IV Solutions
0.45% (half normal

MaintelytbeMaintel
Dextrose 10% in
Sodium chloride
Sodium chloride
Sodium chloride
Dextrose 5% in
Dextrose 2.5%
dextrose 2.5%
Ringer lactate
0.9% (normal
Darrows with
Half strength
Neonatalyte
saline)
saline)
0.45%
water
water
ytbe
Na+
154 131 35 61 0 0 77 20 77
mmol/L
K+
0 5 25 17 0 0 0 15 0
mmol/L
Ca++
0 2 0 0 0 0 0 2.5 0
mmol/L
Mg++
0 0 2.5 0 0 0 0 0.5 0
mmol/L
Cl-
154 111 65 51 0 0 77 21 77
mmol/L
HCO3
0 29 0 0 0 0 0 0 0
mmol/L
Lactate
0 0 0 27 0 0 0 20 0
mmol/L
Dextrose
g/L 0 0 100 25 50 100 25 100 0
Calories
0 0 400 100 200 400 100 400 0
per L
Level C C B C C A B
VEN V V N V V N N
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ANAPHYLAXIS
GENERAL NOTES 358

TRIGGERS 358
CLINICAL PRESENTATION OF ANAPHYLAXIS 358
TREATMENT 359
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General Notes
Severe anaphylaxis is a life threatening immunological response to
a substance to which an individual is sensitised. It is a medical
emergency (life and death situation) in which seconds count.
Prompt treatment is required for acute airway obstruction,
bronchospasm and hypotension.
Triggers
Common triggers of anaphylaxis are medicines, (notably:
antibiotics, non-steroidal anti-inflammatory medicines,
antiarrhythmics, heparin, parenteral iron, desensitising preparations
and vaccines), blood transfusions, bee and other insect stings,
anaesthetic medicines and certain foods. Latex allergy may be
delayed in onset, taking up to 60minutes to manifest. Some
anaesthetic medicines are also associated with anaphylactoid
reactions (urticaria, flushing and mild hypotension). Food allergen
triggers may have a delayed onset. Such as nuts may have a
delayed onset and are commonly associated with urticaria.
Clinical Presentation of Anaphylaxis

Anaphylactoid reactions range from minor to life-threatening. The
major presenting features are commonly cardiovascular. It is
important to recognise and address the following:
Cardiovascular (hypotension, tachycardia, arrhythmias, ECG may
show ischaemic changes even cardiac arrest)
Respiratory system (oedema of the glottis, tongue and airways,
stridor and airway obstruction and bronchospasm)
Gastrointenstinal (abdominal pain, diarrhoea or vomiting)
Cutaneous (flushing, erythema, urticaria)
Note: It is imperative to establish a causative allergen source and it is
essentially that the patient is advised in writing of the allergy and
advised to wear a medic-alert bracelet indicating the sensitivity:
repeat exposure may be fatal.
358
Treatment
Discontinue administration of any suspect agent (for example
medicine, blood, diagnostic agent)
Lay the patient flat and elevate the legs.
Follow the ABC of resuscitation
A- Airway
 Give Adrenaline im 0.5- 1mg (0.5 – 1ml of 1:1000 solution)
repeated each ten minutes as required
 Ensure a clear airway; give 100% oxygen, if available.
B- Breathing
 Ensure adequate breathing (intubate and ventilate as
required)
 Nebulised bronchodilators (for example, 5mg salbutamol) or
iv aminophylline may be required if bronchospasm is
refractory (loading dose of 5mg/kg followed by
0.5mg/kg/hr).
C- Circulation
 Monitor pulse, blood pressure, bronchospasm and general
response/condition every 3-5 minutes.
 Start CPR if cardiac arrest has occurred
Give:
adrenaline 1 in 1000 im C V 0.5 – 1ml Repeat as necessary
[= 10mg/kg] every 10mins until
children >5yrs 0.5ml improvement occurs.
4 years 0.4ml
3 years 0.3ml
2 years 0.2ml
1 year 0.1ml
In severe allergic reaction give:

adrenaline 1 in 10 000 C V 1ml slow repeat until
iv [1-5yr every satisfactory
[Add 9ml normal saline / =0.1ml/kg] minute clinical
water to 1ml of 1in 1000 response
adrenaline]
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Start IV volume expansion with normal saline (or Ringer

lactate) adjusting rate according to blood pressure:
normal saline iv C V First litre run in over 15-20mins, then
review.
 Add:
promethazine slow iv B V 25-50mg 8 hourly up to 48hrs
Paed: 1-5yr = 5mg
or chlorpheniramine iv 6-12yr =12.5mg
(slowly) B V 10mg 6 hourly up to 24hrs
and hydrocortisone iv B V 200mg 6 hourly as required
Paed: < 1yr = 25mg
1-5yrs = 50mg
6-12yrs = 100mg
Monitor pulse, blood pressure, bronchospasm and general

response/condition every two minutes.
If no improvement, the following may be necessary:
aminophylline slow iv - B V 6mg/kg unless the patient has
bolus dose over 20 taken aminophylline in
minutes the past 8 hours
then aminophylline in B V 12mg/ kg in one litre over 24 hours
dextrose 5% slow
infusion
Ventilation and/or tracheostomy
If after 20 minutes of treatment, acidosis is severe (arterial pH<7.2):
sodium bicarbonate B V 50mmol as required (15-30min
8.4% iv intervals)
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POISONING
GENERAL NOTES 362
PREVENTION OF POISONING 362
GENERAL TREATMENT MEASURES 362
FIRST AID 363
CORROSIVE SUBSTANCES 364
INHALED POISONS 365
SKIN CONTAMINATION 365
EYE CONTAMINATION 365
TREATMENT OF SPECIFIC POISONINGS 366
ANTIDEPRESSANTS 366
ASPIRIN / SALICYLATE POISONING 366
CARBON MONOXIDE POISONING 367
CHLOROQUINE POISONING 368
PARACETAMOL POISONING 368
ETHANOL (ALCOHOL) POISONING 369
PESTICIDES 370
ORGANOCHLORINE PESTICIDES 370
PYRETHRUM AND SYNTHETIC PYRETHROIDS 370
ORGANOPHOSPHATE AND CARBAMATE INSECTICIDES 370
PARAQUAT AND RELATED HERBICIDES 372
PARAFFIN, PETROL & OTHER PETROLEUM PRODUCTS 372
OTHER MEDICINES AND CHEMICALS 372
SNAKE BITE 376
SCORPION STING 377
MUSHROOMS 377
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General Notes
Poisons include medicines, plants, traditional medicines, snake and insect
bites, chemicals used in agriculture, industry and at home.
Additional information on the treatment and prevention of poisoning may
be obtained by telephone (24-hour service) or by post from:
The Drug & Toxicology Information Service
University of Zimbabwe, College of Health Sciences
P O Box A178 Avondale, Harare.
Telephone Harare 2933452 direct or 791631 ext 172.
datis@gmail.com
www.datis.co.zw
The following information should be obtained before contacting the poison
information centre:
 Name of product and manufacturer or plant/animal/insect.
 Type of contact with poison (ingestion, inhalation, bite, or absorption
through the skin).
 Age of patient.
 Time lapsed since contact.
 Size of container or estimate of the quantity ingested.
 Any obvious signs or symptoms.
 Any treatment given.
 Existing illnesses and current medication.
Prevention of Poisoning
Continuous education of the community is required to prevent poisoning:
 Store medicines and poisons out of reach of children; do NOT store
in areas or containers used for food storage.
 Do NOT transfer medicines or chemicals from their original
containers (especially hazardous when pesticides are transferred into
containers such as “Coca-cola” or “Mazoe” orange bottles).
 Use the appropriate protective clothing to prevent accidental
poisoning with industrial or agricultural poisons such as pesticides.
General Treatment Measures

In most cases of poisoning there is no specific antidote, but general treatment
measures will minimise the effects.
Aim to slow down, reduce, or prevent further absorption of the poison, and
to counteract the effects of poison already absorbed.
362
First Aid
 Remove patient from further exposure to poison. Remove
contaminated clothing and wash contaminated skin with soap and
large amounts of water. Wear gloves and take necessary precautions
as needed.
 Follow ABC rule
 Maintain respiration; use artificial respiration if necessary.
 Keep the patient warm.
 Maintain blood pressure; place patient lying down with feet elevated
and if required, give fluids.
 Maintain fluid balance (sodium chloride 0.9%); monitor fluid intake and
output (urine, faeces, vomit, etc).
Swallowed Poisons
 Inducing emesis, gastric lavage and use of activated charcoal apply
only if the time since ingestion is 4 hours or less, except for salicylates
and tricyclic antidepressants (8 hours).
Emesis
Emesis is of no clinical benefit unless done within the first few minutes
(maybe 10) after ingestion of a poison)
 CAUTION: It is essential to prevent vomit from entering the lungs. Do
not induce vomiting if the patient is, or may soon become, drowsy, or
unconscious, or convulsive.
 Do not induce vomiting if the patient has swallowed a corrosive (acid,
alkali, bleach) or a petroleum product See "Corrosive Substances",
and "Paraffin, Petrol and Petroleum Products" below.
 Only induce emesis in potentially severe poisoning.
Gastric Lavage
 Should only be performed by personnel familiar with the procedure,
since incorrect use is dangerous.
 CAUTION: Do not attempt gastric lavage in the drowsy or comatose
patient unless there is adequate cough reflex or a cuffed endotracheal
tube is inserted.
 The bore of the lavage tube should be large enough to enable large
particles such as tablets to be removed from the stomach.
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Adults and children over 2 years:

300ml tap water (adult dose) for each washing, and repeat until the
aspirated fluid is clear.
Reduce the amount of water used for each washing in children to 100
– 200 ml.
Children under 2 years:

half strength darrows C V 100 ml for each washing, and repeat
with dextrose 2.5% until aspirated fluid is clear.
IMPORTANT: Sodium chloride solutions and water must not be used as they
are hazardous to children under 2 years.
Activated Charcoal
Binding effect reduces absorption from the gastrointestinal tract; it is
specially prepared for use in poisonings. Ordinary charcoal should not
be used as it does not prevent absorption of poisons.
Do not give charcoal at the same time as ipecacuanha syrup as they
inactivate each other.
Wait for vomiting to occur, and then give:
activated charcoal B E 400ml administration may be
50g added to 400 ml slurry repeated after 4-6 hours
water * children 0.25 –
0.5 g/kg
*Mix well, and administer via the lavage tube (unless patient agrees to drink
the charcoal slurry).
Laxatives
To avoid constipation or impaction following administration of activated
charcoal, give a laxative. This speeds up the removal of toxic
substances from the gastrointestinal tract, thereby reducing absorption.
Corrosive Substances
e.g. battery acid, drain cleaners, oven cleaners, laundry powders, strong
hypochlorite or ammonia solutions, carbolic acid and phenols, pool acids,
dish washing detergent.
 Immediately dilute by the administration of fluid. Water or milk (for
acids) may be used. Avoid excessive oral fluid to prevent vomiting.
 Do not induce vomiting since the corrosive agent will cause further
damage.
 Note: with hydrofluoric acid (HF):t
364
(a) Systemic poisoning may cause circulatory failure associated
with hypocalcaemia, hypomagnesemia and/or hyperkalaemia
(may require rigorous supportive and symptomatic therapy;
monitor CVS especially the heart)
(b) For topical exposure (note that systemic poisoning can occur
after topical exposure to HF), after flushing skin with water, put
calcium gluconate gel on affected area and massage it
continuously until pain goes (about 15 minutes). If calcium
gluconate is not available, soak affected area in solution of
magnesium sulphate (Epsom salts)
 [Immediate use of salts MAY PREVENT deep burns, but once the
acid has gone below the skin they are less effective].
Inhaled Poisons
e.g. liquid polishes, chloramine (produced by mixing hypochlorite and
ammonia), chemical gases, chemical sprays
 Remove patient from further exposure by carrying to fresh air
immediately.
 If breathing is impaired give artificial respiration.
 Follow first aid measures listed above.
Skin Contamination
Many chemicals can be absorbed through skin or cause direct injury to the
skin.
 Wash with large quantities of cold water. Avoid hypothermia.
 Do not delay in removing clothing - this can be done while the skin is
being washed.
 After removal of any contaminated clothing continue thorough
washing with large amount of cold water and soap (including hair if
contaminated).
 Avoid contaminating yourself.
Eye Contamination
See also chapter on Common Eye Conditions.
 The eyelids should be held apart and the eye washed with a gentle
stream of water (e.g. from tap, hose pipe, or jug) for 15 minutes.
 Protect the unaffected eye.
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Treatment of Specific Poisonings

Antidepressants
E.g. amitriptyline and imipramine (tricyclic antidepressants). Signs of
poisoning with these medicines are CNS stimulation and cardiac
arrhythmias.
 Establish airway and maintain respiration. Monitor ECG until the patient is free of
arrhythmia for 24 hours.
 Remove ingested medicine by gastric lavage followed by activated charcoal. Do
not induce emesis since patients may become comatose rapidly.
 Maintain blood pressure by giving intravenous fluid. Avoid vasoconstrictor
agents.
 Control convulsions by giving:
diazepam slow iv C V 0.05 – as required as required
0.1mg/kg
Control arrhythmias appropriately
lignocaine 2% iv B N 500mg over 2-4mins,
preservative free then 1-2mg/min by infusion
For metabolic acidosis, if arterial pH < 7.2:
sodium bicarbonate iv B V continuous infusion
in dextrose 5%
Aspirin / Salicylate Poisoning

Aspirin (acetylsalicylic acid) is present in many analgesic preparations,
and may also be found in herbal medicines. The toxic dose of any
salicylate is estimated to be 0.2-0.5 g/kg.
Emergency Measures
 Delay absorption of the poison by giving activated charcoal. If respiration is
depressed, use airway-protected gastric lavage (lavage is effective up to 8
hours after ingestion).
 If blood pressure is low, treat appropriately.
 Treat respiratory depression by administering oxygen. Artificial ventilation may
be necessary.
 If convulsions occur and hypoglycaemia is not a contributing factor, give
anticonvulsant medicine.
Caution: Central nervous system depressants, such as barbiturates or
diazepam must be administered cautiously.
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General Measures
 Monitor serum bicarbonate, chloride, potassium, sodium, glucose and arterial
pH.
 If there is adequate urine output and no vomiting.
 In severe poisoning, hydration with intravenous fluids must be initiated in the
first hour:
dextrose 5% with sodium B V continuous infusion
bicarbonate 75mmol/L
Alkaline diuresis is an option under specialist guidance.
In the presence of fluid retention, give:
frusemide iv B V 0.25- once review
1mg/kg
Carbon Monoxide Poisoning

Carbon monoxide poisoning commonly occurs as a result of burning coal
or charcoal in a confined space with inadequate ventilation. Signs and
symptoms include headache, weakness, dizziness, tachycardia,
tachypnoea and, in severe cases, respiratory failure and coma.
 Remove patient from further exposure.
 Give 100% oxygen by mask for several hours. If respiration is depressed give
artificial respiration with 100% oxygen.
 Maintain blood pressure and normal body temperature. If hyperthermia is
present reduce body temperature by cooling the skin.
 To reduce cerebral oedema give:
frusemide iv B V 0.25- once Review
1mg/kg
and hydrocortisone iv/ im B V 4mg/kg 4 hourly
Control convulsions or hyperactivity with:
diazepam slow iv C V 0.05- as required as required
[max =30mg] 0.1mg/kg
If recovery occurs, symptoms disappear gradually.
In severe cases tremors, mental deterioration and abnormal behaviour may persist or
reappear after 1-2 weeks. These symptoms of central nervous system damage may
be permanent. Complete recovery is unlikely if symptoms of mental deterioration
persist for 2 weeks.
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Chloroquine Poisoning
(DO NOT induce vomiting as this may trigger cardiac arrhythmias)
Acute chloroquine poisoning occurs following ingestion of as little as 2 g
and may be lethal. Signs and symptoms of acute poisoning include severe
difficulty in breathing, drowsiness, progressive tinnitus, blurring of vision,
fall in blood pressure, cardiac irregularities, respiratory arrest and
convulsions.
Because chloroquine is rapidly absorbed following ingestion:
 Prompt insertion of an orogastric tube followed by
 gastric lavage
 Use activated charcoal
 Extensive supportive therapy, cardiac monitoring and use of mechanical
ventilation is indicated.
 For convulsions and cardioprotective effect give:
diazepam slow iv C V 0.5mg/kg as required as required
[max =30mg]
+/- Adrenaline iv
Paracetamol Poisoning
Liver damage can occur within hours of ingestion of paracetamol
overdose. This may only become evident 3-4 days later.
Emergency Measures
Activated charcoal given within 4 hours of ingestion is the preferred
method of gastric decontamination, with or without gastric lavage.
General Measures
 Keep the patient warm and quiet. Observe for at least 3 to 4 days.
 Monitor liver function tests and prothrombin times as indications of
liver damage and success of therapy.
 Give:
dextrose 5% iv C V continuous infusion first 48 hrs
Antidote
The antidote is effective if given up to 24hrs after ingestion.
If it is suspected that the person has taken in excess of 10 g (20 tablets of
500 mg each) or if the 4 hour plasma paracetamol level exceeds 150
mg/ml administration of antidote is recommended:
368
dose
acetylcysteine iv A V 150mg/kg in 200ml over 15mins, then
infusion in dextrose 5% 50mg/kg in 500ml over 4hrs, then
100mg/kg in 1000ml over 16hrs
Ethanol (Alcohol) Poisoning

 Remove unabsorbed ethanol by gastric lavage (note that activated charcoal
does not absorb alcohol) if performed soon after ingestion
 Maintain adequate airway. Give artificial respiration if necessary.
 If patient is in coma and there is suspicion of co-ingestion with an opiate, give:
naloxone iv B V 0.01mg/kg as required as required
 Maintain normal body temperature.
 Correct acidosis as it arises. For metabolic acidosis, if arterial pH < 7.2:
sodium bicarbonate iv B V continuous infusion
in dextrose 5%
Correct hypoglycaemia if present by:
dextrose 50% iv C V 20ml bolus dose, then
and dextrose 5% iv C V Infusion
Avoid administration of excessive fluids and depressant medicines and give:
thiamine po A N 200mg once a day Review
In acute alcoholic mania (following ethanol withdrawal after chronic ingestion) give:
diazepam slow iv C V 10mg one dose immediately
then 5mg every 5-10mins until
controlled,
then 5-10mg 8 hourly as required
In ethanol withdrawal, patients with a history of seizures give:
diazepam slow iv C V 0.05- as required -
[max = 30mg] 0.1mg/kg
For encephalopathy:
thiamine iv/im A N 250mg once -
then thiamine po A N 200mg one a day 7 days
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Pesticides
Poisoning with insecticides can occur following ingestion, inhalation, or
absorption through the skin.
Solvents: The main hazard of most commercial preparations is the
solvent.
With liquid preparations containing paraffin or petroleum products:
 do not induce vomiting
 do not perform gastric lavage
 activated charcoal may be given.
Organochlorine Pesticides
Common names: aldrin, “Bexadust”, BHC, chlordane, DDT, dicofol,
dieldrin, endosulfan, gammabenzene hexachloride, “Gammatox”, lindane,
toxaphene.
Signs and symptoms of poisoning include CNS excitation, seizures and
respiratory depression.
 Observe general measures for poisoning (activated charcoal and
gastric lavage may be useful).
 CAUTION: Do not give milk, fats or oils as they will increase
absorption of the insecticide if ingested.
 Control of convulsions, hyperactivity, or tremors:
diazepam slow iv C V 0.05- as required -
[max = 30mg] 0.1mg/kg
If convulsions are unresponsive consider:

phenytoin ivi C V 15mg/kg as required -
Pyrethrum and Synthetic Pyrethroids

Common names: alfamethrin, cypermethrin, deltamethrin, fenvalerate,
permethrin.
Generally pyrethroids are of low toxicity and no treatment is required.
(Caution: solvents).
Organophosphate and Carbamate Insecticides

Common names (organophosphates): “Azodrin”, chlorfenviphos, diazinon,
dichlorvos, dimethoate, disulfoton, fenitrothion, malathion, mevinphos,
monocrotophos, parathion, pichloram, “Rogor”, thiometon.
370
Common names (carbamates): aldicarb, carbaryl, carbofuran, EPTC,
methiocarb, pirimicarb, propxur, zineb, ‘rat poison’ (black granules bought
from markets and vendors). May contain carbamates and warfarin.
The effects of organophosphate poisoning are generally more severe, and
last longer than the effects of carbamate poisoning. Signs and symptoms
include increased secretions, contracted pupils, muscle weakness,
sweating, CNS depression, and confusion.
 Remove patient from the source of poisoning and quickly remove any
contaminated clothing.
 Establish airway and start artificial respiration with air or oxygen if
necessary (this may be required at any stage during the first 48 hours
after poisoning). Remove excess bronchial secretions by suction.
 Stomach contents may be decontaminated by administering
activated charcoal (see general notes). Inducing emesis is not
recommended due to the risk of the patient becoming unconscious or
convulsing.
 Wash skin, hair and mucous membranes with large amounts of cold
water and soap. Do NOT rub the skin. If hair is heavily contaminated
shaving may be necessary.
 Rubber gloves should be worn to prevent contamination.
 Give antidote:
atropine iv /im B V 2-4mg every 10 mins [Paed
[Paed=0.02 every 10-15mins], until
-0.05mg/kg signs of atropinisation
appear
repeat to maintain atropinisation* [hot
dry skin, dry mouth, widely dilated
pupils, fast pulse]
*High doses of atropine may be required for many days. The effects of
carbamates are short lived, and atropine may be stopped sooner.
Pralidoxime may be given once the patient is fully atropinised, but is not necessary
in mild cases. It must not be used in carbamate poisoning.
add* pralidoxime iv A N 8-10mg/kg/hr continuous infusion until
recovery [18hrs or more]
Paed: 25mg/kg iv over 15-30mins, then 10-
20mg/kg/hr continuous infusion until recovery.
*Atropine therapy must continue.
If adequate respiration and atropine do not control convulsions, refer.
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Paraquat and Related Herbicides

Common names: “Avenge”, chlormequat, “Cycocel”, difenzoquat, diquat,
“Gramoxone”, mepiquat, morfamquat, “Pix”, “Weedol”.
These compounds cause multiple organ toxicity and pulmonary fibrosis.
Death from paraquat poisoning may occur up to 3 weeks after poisoning,
and is due to lung dysfunction.
CAUTION: Oxygen makes these insecticides more toxic.
If oral poisoning [swallowed]:
 Perform gastric lavage.
 Give Fuller’s Earth (aluminium silicate) if available.
 Activated charcoal may be given as an absorbent
 Monitor and maintain fluid balance, urea and electrolytes.
 If respiratory difficulty occurs, delay the use of oxygen for as long as possible.
NB: Oxygen makes paraquat more toxic.
 In severe cases, especially if the patient is in shock, use of a corticosteroid may
be helpful if started early:
hydrocortisone iv B V 200mg 4 times a early in
day therapy
Paraffin, Petrol & Other Petroleum Products

(including paint thinners, organic solvents, etc)
 These can lead to aspiration pneumonitis where the solvent enters the lungs
and causes tissue damage.
 CAUTION: Do not give ipecacuanha; do not perform gastric lavage.
 Pulmonary oedema and pneumonia will require appropriate therapy.
 Monitor for CNS depression and cardiac arrhythmia.
Other Medicines and Chemicals
see table on next page
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Table 31.1 - Antidotes for Poisoning by other specific medicines and chemicals
Medicine/ poison Antidote Dosage Notes

atropine physostigimine 1-2mg in 1-2ml 0.9% sodium chloride May be repeated every 5mins to a total
iv over 2min dose of 6mg for adults (2mg for
children) every 30mins.
arsenic compounds dimercaprol im 3mg/kg im every 4hrs for 2 days Should be given within 4hrs of
then poisoning
penicillamine po Up to 25mg/kg 4 times a day (max Start after 2 days of dimercaprol
1g/day) for 7 days therapy.
copper salts calcium 15-25mg/kg iv in 250 – 500ml
disodium dextrose 5% over 1-2hrs, twice a day
edetate iv for 5 days, and 12.5mg/kg orally 4
or times a day for 7 days
penicillamine po Up to 25mg/kg 4 times a day (max
1g/day) for 7 days
Cyanides sodium nitrite 10ml iv over 3min Stop if systolic BP drops below 80mm
3% iv and Hg
sodium 25ml of 50% injection (or 50ml of Give after sodium nitrite using same
thiosulphate 25%) over 10min needle and vein.
Repeat BOTH injections at half the SPEED IS ESSENTIAL
initial dose if symptoms reappear.
3
37
4
37
Table 31.1 - Antidotes for Poisoning by other specific medicines and chemicals (cont.)

heparin Protamine 1% iv 0.5ml/min to a total single dose of 5ml. 1mg protamine (0.1ml) will antagonise
May be repeated after 10min. 100units heparin.
hydrogen sulphide sodium nitrite iv 10ml over 3min iv
3%
hypochlorite sodium 5-10g po in 100-200ml water
solutions (‘bleach’) thiosulphate and
magnesium 30-50ml orally
hydroxide
mixture po
iron salts desferrioxamine 10g in 50ml sodium bicarbonate 5% in Only use iv for serious poisoning.
po/ iv water after emesis / lavage, then iv Continue until patient free of symptoms
15mg/kg/hr (max 80mg/kg in each for 24hrs.
12hr period)
Lead dimercaprol im 4mg/kg im every 4hrs for 30 doses
and
calcium 12.5mg/kg im every 4hrs for 30 doses Start 4hr after starting dimercaprol. Use
disodium separate injection sites.
edetate im
Mercury dimercaprol im 3mg/kg im every 4hrs for 2 days, then
or 2mg/kg im every 12hrs for 10 days.
penicillamine po Up to 25mg/kg 4 times a day (max
1g/day) for 7 days
Table 31.1 - Antidotes for Poisoning by other specific medicines and chemicals (cont.)

methanol (methyl ethanol 50% 1.5ml/kg orally then 0.5-1ml/kg iv / po
alcohol) diluted 1:10 with every 2hrs for 4 days
water
opiates e.g. codeine, naloxone iv 0.01mg/kg repeat as necessary
morphine, pethidine
phenothiazines (e.g. biperiden iv or 2-4mg/kg im or iv (adult) Repeat if extrapyramidal symptoms
chlorpromazine, im, and appear.
prochloperazine)
phenytoin slow 1mg/kg slow iv (<50mg/min). Can be To control cardiac arrythmias. Do not
iv repeated every 5min to a total dose of use lignocaine.
10mg/kg
5
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Snake Bite
First Aid for Snake Bite
 Calm and reassure the patient. Get them to lie down.
 If venom has been spat in the eye, wash liberally with water for
at least 15 minutes.
 Apply a pressure bandage (not a tourniquet) firmly around the
limb, starting from the bite site and moving upwards. This
allows blood flow to the limb but prevents lymph return and
absorption of poison.
 Splint the limb to prevent movement that would increase
absorption of poison.
 Get the patient to a hospital with facilities to give antivenom.
Reassure them on the way and be prepared to give artificial
respiration if required.
 Do NOT:
 cut the wound
 use a tourniquet
 give electric shock to the site
 rub or massage the wound site.
In hospital
 Remove the pressure bandage
 Give analgesia and:
tetanus toxoid C V see chapter on immunisation
 If no signs of envenomation, observe for 24 hours (5 days if
boomslang bite) then discharge.
 Only if signs of envenomation (bleeding, signs of
neurotoxicity) give antivenom:
*snake antivenom, B E Test dose of 0.5ml. If no reaction, then
polyvalent iv 40ml [all ages]. Repeat as required.
*Caution: Antivenom wrongly used can be more dangerous than snake bite.
 Polyvalent antivenom covers all the main venomous snakes
found in Zimbabwe except the boomslang, for which specific
antivenom is necessary. Antivenom can prevent tissue
necrosis after adder bites, but only if given early: it will have no
effect once gangrene has set in.
 The decision to use antivenom should be based on the
20WBCT (20 minute Whole Blood Clotting Test. I.e. A few
millilitres of blood taken by venepuncture is placed in a new,
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clean, dry, glass vessel, left undisturbed at room temperature
for 20 minutes; then tipped once to see if the blood has clotted
or not. The vessel must be glass rather plastic in order to
activate blood coagulation via Hageman factor (FX11).
Glass vessels may not activate coagulation if they have
been cleaned with detergent or are wet.
Scorpion Sting
Most scorpions are small and their stings, whilst locally painful, are
not life-threatening. Analgesics and reassurance should suffice,
except in small children and anaphylaxis.
The Parabuthus scorpions are large (8-15cm long), are dark or
yellow in colour, and tend to have small pincers and thick tails. They
are found mostly in the south-eastern lowveld and southern
Zimbabwe.
Systemic signs of a sting include neurotoxic (agitation,
hypersalivation, respiratory distress) and cardiotoxic effects.
Give:
scorpion anti-venom B N Check the manufacturer’s instructions
carefully
 Monitor for cardiac irregularities and manage appropriately.
 If cholinergic signs evident e.g. hypersalivation, excessive
sweating, give atropine (as for organophosphate poisoning).
 Manage symptomatically and refer if poisoning is severe – with
neurological signs.
 Respiratory support may be required.
Mushrooms
 If the patient presents within 4 hours of ingestion, with or
without symptoms induce emesis and/or give activated
charcoal.
 If gastro-intestinal symptoms appear within 1-2 hours after
ingestion: treat symptomatically.
 If gastro-intestinal symptoms appear after 6-12 hours, suspect
Amanita phalloides poisoning. Then:
 Admit to hospital for observation and contact others who may
have eaten the same food.
 Monitor for hepatic damage, acidosis, renal failure and
hypoglycaemia.
 There is no effective antidote.
“Elephant Ear”
 causes a local reaction, not poisonous
 reassure the patient
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MEDICINES USED IN ANAESTHESIA

GENERAL NOTES: 379
GENERAL ANAESTHESIA 379
INTRAVENOUS ANAESTHETICS 380
INHALATIONAL ANAESTHETICS 382
MUSCLE RELAXANTS/CHOLINESTERASE INHIBITORS
383
LOCAL ANAESTHESIA & CONDUCTION ANAESTHESIA
385
OTHER PERI-OPERATIVE MEDICINES 386
ANTACIDS 388
ANTIEMETICS 389
POST-OPERATIVE PAIN 389
MEDICINES USED IN SHOCK 392
ANTIHYPERTENSIVES IN ANAESTHESIA 394
OXYTOCIN GUIDELINES DURING A CAESAREAN
SECTION 395
ACTIVELY HAEMORRHAGING CASES: 396
378
General Notes:
Only persons trained to administer them should use the medicines
in this section and in an institution where there are adequate
facilities for the delivery of safe anaesthesia and resuscitation.
Standards of Anaesthetic Care have been developed by the Zimbabwe
Anaesthetic Association and should be referred to by all persons
practising anaesthesia.
General principles
 All patients should be assessed pre-operatively by the
anaesthetist who will give the anaesthetic, in order to identify
conditions that may influence the outcome of the anaesthesia
and treat them appropriately.
 Before the patient’s arrival in the operating theatre all
equipment must be checked and be in working order. A
protocol is useful here.
 Check of patient identity must be made in every case.
 An adequately trained Anaesthetic Assistant is essential and
should be present on the operating theatre at all times.
Training of such personnel should include the management of
common emergencies.
 The Anaesthetist should be present in the theatre throughout
the duration of the anaesthetic (general, regional or sedation).
 Pre-, intra-, and post-operative records should be made on
every patient. These should be checks of patient’s condition at
appropriate and regular intervals. The records should be part
of the patient’s case file.
 The management of the patient in the Recovery Room is the
responsibility of the Anaesthetist. Continuous individual
observation is required. Transfer of information to the recovery
staff should include the patient’s name, type of anaesthetic,
surgical procedure, patient's condition including significant
disease, airway or circulation problems. The post-operative
orders and analgesia should be detailed and the recovery staff
must be satisfied with the condition of the patient before
accepting responsibility for his/her care.
General Anaesthesia
At least 30% oxygen should be administered to every patient
receiving general anaesthesia.
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Intravenous Anaesthetics
Thiopentone Sodium
A thiobarbiturate (intravenous use only) which produces
anaesthesia, but no analgesia, within one arm-brain circulation
time.
Medicine Codes Dose Onset Duration
thiopentone sodium B V 3-5mg/kg 10-15secs 5-10mins
slow iv repeat if necessary after 20-30secs
Indications
 Induction of general anaesthesia;
 May be used alone to produce anaesthesia for very short,
minor surgical procedures;
 May be used as an anticonvulsant in status epilepticus.
Contraindications
 Porphyria
 Patients in whom maintenance of the airway by the
anaesthetist is in doubt.
Cautions
 Severe tissue damage may occur if thiopentone is given extra-
vascularly or intra-arterially; minimise this risk by always using
a 2.5% solution.
 Use with caution in hypertensive patients, asthmatics and fixed
cardiac output states.
Etomidate
Produces anaesthesia but no analgesia in one arm-brain circulation
time.
etomidate iv B N 0.2 - 0.4mg 30-60sec 3-10min
per kg
Indications
 Anaesthetic induction agent of choice in those with
cardiovascular instability.
Contraindications
 Avoid repeated dosages or infusions as it leads to adrenal
suppression
Caution
 May cause pain on injection, abnormal muscle movement.
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Produces anaesthesia but no analgesia in one arm-brain circulation
time. Recovery is rapid with minimal post-op nausea and vomiting.
propofol iv A V 2-2.5mg/kg 40sec 5-10min
Indications
 Induction of general anaesthesia
 Conscious sedation
 Maintenance of anaesthesia.
Caution
 Store in fridge above freezing temperature
 Reduce dose in the elderly and high risk patients.
 Minimize pain by injecting into large vein and/or mixing with
Lignocaine
 Avoid in children less than one year and epileptic patients
 In patients for Caesarean Section
 Discard unused solutions
 Contraindicated in people allergic to eggs and soyasoya bean
oil
Ketamine
Produces dissociative anaesthesia gradually, in high risk or
hypovolaemic patients.
ketamine iv B V 1-2mg/kg iv 30-90sec 10-20min
4-8mg/kg im
maintenance = serial doses 50% of
induction iv dose or 25% of im dose.
analgesic dose = 0.25 – 0.5mg/kg im
Indications
 Induction and maintenance of anaesthesia;
 Subanaesthetic dosage may be used to provide analgesia for
painful procedures, e.g. dressing of burns.
 Induction agent of choice in shocked patients
Contraindications
 Hypertension,
 Raised intracranial pressure,
 Psychiatric disorders.
Cautions
 Hallucinations may complicate recovery, particularly when
ketamine is given for maintenance; this problem can be
reduced by use of diazepam or midozolam.
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 There may be excessive salivation, so use of atropine should

be considered.
 Respiratory obstruction and depression may occur, though
less commonly than with other anaesthetics.
Inhalational Anaesthetics
Nitrous Oxide
This anaesthetic gas reduces the requirement for more potent
anaesthetics and is also analgesic, given in a concentration of 50-
70% in oxygen.
Medicine Codes Dose
nitrous oxide B V Titrate to effect for analgesia, induction
or maintenance of anaesthesia
Contraindications
 Patient with an air-containing closed space, (e.g.
pneumothorax, middle ear abnormalities, bowel obstruction)
since nitrous oxide will expand such space with deleterious
effect.
Cautions
 The main danger in the use of nitrous oxide is hypoxia; at least
30% oxygen must be used.
Medical Air
Used in conjuction with Oxygen on anaesthetic machines capable
of delivering it.
Halothane
Volatile liquid - always administer via a calibrated vaporiser.
halothane B V Titrate to Dose Dose
effect dependent dependent
Contraindications
 History of malignant hyperthermia.
 Repeated exposure within 3 months is not recommended.
 Not recommended for obstetric anaesthesia, except when
uterine relaxation is required.
Cautions
 Halothane crosses the placental barrier.
382
Isoflurane
A volatile anaesthetic agent for maintenance of general
anaesthesia. Causes less cardiovascular instability compared to
Halothane
Isoflurane B V Titrate to Dose Dose
Contraindications
 In patients with Malignant Hperthermia
Cautions
 Its pungent smell limits its use in inhalational induction
 In patients with coronary artery disease, raised intracranial
pressure, pre-existing liver disease
Sevoflurane
Sevoflurane S V Titrate to Dose Dose
Soda Lime
Used in circle carbon dioxide absorber system with low
fresh gas flow anaesthesia.
Medicine Codes
soda lime B V
Muscle Relaxants/Cholinesterase Inhibitors

 Only personnel who are skilled in managing the patients’
airway through intubation and ventilation must administer
these medicines.
 Ventilation must be mechanically assisted until the medicine
has been inactivated.
 Sedation, analgesia or anaesthesia must be provided when
paralysing patients, as these are not produced by muscle
relaxants.
Suxamethonium Chloride (depolarising)
Given by the iv route, suxamethonium produces fasciculations
followed by flaccid paralysis.

suxamethonium B V 0.5-1.5mg < 30secs up to 5min
chloride iv per kg
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Ave. for intubation: 1mg/kg

Indications
 Laryngoscopy and intubation
 Muscle relaxation of short duration
Contra-indications:
 moderate/severe burns
 crush injuries
 spinal cord transaction e.g. paraplegia or quadriplegia
 division of a major nerve e.g. sciatic, brachial plexus
 tetanus
 history of malignant hyperthermia
 scolene apnoea
Caution
 Repeat doses will cause bradycardia; this can be prevented by
atropine (10-20 micrograms/kg body weight intravenously).
Atracurium Besylate (non-depolarising)

An intermediate acting benzylsoquinolium non-depolarizing muscle
relaxant that undergoes Hofmann elimination and non specific
enzymatic ester hydrolysis. Thus safe to use in patients with
significant renal or hepatic failure.
atracurium besylate iv B V 0.3-0.6 mg per 3-5mins 30-40mins
kg
maintenance dose 0.1-0.2mg/kg As required
infusion 0.3-0.6mg/kg/hr
Caution
 Mild histamine release in higher doses
 Neuromuscular blockade potentiated by aminoglycosides, loop
diuretics, hypokalaemia, hypothermia, acidosis and volatile
anaesthetic agents
Vercuronium
An intermediate acting aminosteroid, with cardiovascular stability
and no histamine release

vecuronium iv B V 0.08-0.1mg/kg 3-5 mins 30-45mins
maintenance 0.02-0.03mg/kg
Caution
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 Neuromuscular blockade potentiated by aminoglycosides,
loop diuretics, hypokalaemia, hypothermia, acidosis and
volatile anaesthetic agents
 hypersensitvity
Neostigmine bromide (Cholinesterase inhibitor)

Provides reversal of non-depolarising neuromuscular blockade.
Medicine Codes Dose
neostigmine bromide B V 2.5-5 mg after/with 1-1.8mg atropine
sulphate.
[Paed =50mcg/kg with/after 20mcg/kg
atropine]
Caution: Neostigmine causes the following if administered
without atropine-
 Bradycardia
 Possible cardiac arrest
 Diarrhoea and vomiting
 Abdominal pain.
Local Anaesthesia & Conduction Anaesthesia

This includes local infiltration, peripheral nerve block, spinal
and epidural anaesthesia and analgesia.
 Equipment for resuscitation should be readily available and
intravenous access must be established before administering
a local anaesthetic
 Factors influencing the safe dosage of local anaesthetics
include patient’s age, weight, physical status, vascularity of the
area to which the medicine is applied.
 Adrenaline should not be added to local anaesthetic applied to
digits and appendages.
 Spinal and epidural blocks should only be attempted by
persons trained in these techniques.
 Spinal and epidural blocks should only be conducted where a
vasopressor medicine (e.g. ephedrine) is available to treat
possible hypotension.
 Preservative-containing solutions should not be used for spinal
anaesthesia.
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Bupivacaine Hydrochloride
bupivacaine A E max = 2mg/kg 10-15 3-6 hours
hydrochloride 5mg/ml min
(plain)
Indications
 Local infiltration
 Epidural anaesthesia
 Epidural analgesia(labour & post-operative)
Bupivacaine Hydrochloride (Heavy)

Intrathecal (spinal) anaesthesia for abdominal surgery expected to
last 45-60mins, or lower limb surgery of 2-3hrs duration
bupivacaine B V 1.5-3ml 10 min 2-3hrs
hydrochloride 5mg/ml
with glucose 80mg/ml
(heavy)
Synonyms-Heavy, Spinal Grade, Hyperbaric Bupivicaine
Contraindications
 Hypersensitivity to the medicine
Contraindications to spinal anaesthesia

 Patient refusal
 Hypovolaemia/hypotension
 Septicaemia/local skin infections
 Coagulation disorders
 Fixed cardiac output states
Lignocaine Hydrochloride
lignocaine HCl 2% plain C V max = 2-10 min 1-2 hours
3mg/kg
lignocaine HCl 2% + B E max = 2-10 min 1-2 hours
adrenaline 1: 200 000 7mg/kg
Other Peri-Operative Medicines

Antimuscarinic Medicines
Atropine Sulphate
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Atropine sulphate iv B V 0.6-1.2mg 2-10 min 1-2 hours
(paeds: 10-
20mcg/kg)
Indications:
 Used with neostigmine for reversal of non-depolarising
neuromuscular block: 0.6-1.2mg iv [Paed=10-20mcg/kg]
 Used in children where a bradycardia may occur when
Halothane and suxamethonium are used.
 Bradycardia; 0.5-0.6mg IV. May repeat to a total dose of 3mg if
necessary.
Glycopyrrolate
Medicine Codes Dose
glycopyrrolate iv S V 200mcg/1mg of
neostigmine
Indications:
 For use with neostigmine for reversal of non-depolarising
neuromuscular blockade
 Causes less tachycardia compared to atropine hence medicine
of choice for the elderly and those with cardiac disease
Sedatives
Diazepam (sedative)
Indications:
 Anxiolysis and sedation with amnesia: 5-10mg orally 1-2hrs
before surgery, or 0.2mg/kg slow iv (adults and over 8yrs)
Diazepam iv/po B V 5-10mg po
0.2mg/kg
slow iv
Caution
 May cause circulatory depression
 May cause respiratory depress
Midazolam
midazolam po B E 7.5 -10mg Less than 10 2 – 6 hours
minutes
or midazolam iv B V 0.025 – 30 -60seconds 15 – 80
0.1mg/kg minutes
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or midazolam B V 1-15mg/hr 30-60 seconds

(ICU sedation)
Indications:
 Premedication
 Adjunct to general anaesthesia
 Conscious sedation and sedation in ICU
Caution:
 Causes respiratory depression when used in conjunction
with opiods and other sedatives
 Contraindicated with acute angle glaucoma or open angle
glaucoma unless patients are receiving appropriate
therapy
 Care in elderly and COAD patients
Promethazine
Antihistamine with sedative, antiemetic and anti-cholinergic
properties. Useful for the pre-operative preparation of the asthmatic
patient.
Indications:
Premedication one hour before surgery:

promethazine B V 25-50mg im
1-5yr = 15-20mg po
>5yrs = 6.25-12.5mg im
Severe anaphylaxis during anaesthesia:
promethazine B V 50mg (Paed 0.4mg/kg)
slow IV
Trimeprazine tartrate
Medicine Codes Dose
trimeprazine tartrate B N 2mg/kg 1-2hrs before surgery
Indications
Pre-operative sedation of children
Cautions
 May cause excessive sedation.
 May cause hyperactivity postoperatively.
Antacids
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Sodium Citrate
Medicine Codes Dose
sodium citrate 0.3molar B N 30ml immediately before induction
solution
Indications
Neutralization of gastric contents to prevent acid aspiration
syndrome where this is a risk, e.g. obstetrics.
Antiemetics
Metoclopramide
Dopamine antagonist; accelerates gastric emptying.
metoclopramide po B V Premedication: 10 mg po/im/iv 1hr
before surgery, then
Further Treatment: 10mg po 8 hourly as required
Indications
Prevention of post-operative nausea and vomiting, reduction of
gastric contents preoperatively.
Cautions
Oculogyric crisis can follow.
Avoid in porphyria.
Prochlorperazine
Indications:
Prophylaxis (Adult 12.5mg po/im) and treatment of post-operative
nausea and vomiting (12.5mg po/im 6hourly) (Paed: 0.1 - 0.2mg/kg
im).
Prochlorperazine po/im B V 12.5mg po/im 2-10 min 1-2 hours
For post-operative nausea and vomiting
12.5mg po/im 6 hourly
(paeds: 0.1-
0.2mg/kg im)
Caution
Extrapyramidal symptoms may occur, particularly in children.
Analgesics
POST-OPERATIVE PAIN
Post operative pain needs to be treated adequately as severe
postoperative pain and stress response to surgery increases
perioperative morbidity and mortality
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Medicine Codes Dose

morphine im B V 5-15mg 4hrly
Indications
 Postoperative pain
 For Patient Controlled Analgesia (PCA) and epidural infusions
refer to local protocols.
 Analgesic effect needs to be reviewed regularly
Caution/Side Effects
 Patient should be closely monitored for side effects mainly
respiratory depression
 Pruritis
 Vomiting
 Constipation
 Urinary retention

Pethidine im B V 1-2mg/kg 3 hourly
Post-operative shivering
10-25mg iv/im
or tramadol im B V 50mg/ml
or tramadol po B V 50-100mg 4 - review
6hrly
Indications
 Post-operative pain 1-2mg/kg IM 3hrly
 Post-operative shivering 10-25mgIV/IM
Caution/Side Effects
Include tramadol SEs
 See under Morphine
A synthetic phenylpiperidine derivative opiod analgesic
fentanyl inj S N 1-10mcg/kg
Indications
 IntraIntra-operative use at a dose of 1 to 10 mcg/kg
 For post-operative pain as an infusion in an ICU or HDU at
1-3mcg/kg/hr
Tilidine Hydrochloride
A synthetic opioid painkiller. Vital for pain management
in paediatrics post-operative
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Tilidine B V 1 drop per year of age. 6 hourly
hydrochloride Max 5 drops
drops
NSAIDS
Used as adjuncts or alternative to opiods in the post op period

diclofenac B E 25-50mg po 3 times a day
25-100mg pr Twice a day
Indomethacin B E 25-100mg po 2 times a day
50-100mg pr Twice a day
Ibuprofen C E 200-400mg po 3 times a day
Indications
 A potent NSAID analgesic for mild to moderate pain
Cautions
 Renal impairment
 Aspirin sensitivity
 Peptic ulceration
 Asthma
LOCAL ANAESTHETIC AGENTS
These are used for local infiltration or regional analgesia
Lignocaine
lignocaine C V 3mg/kg without adrenaline
hydrochloride Inj 7mg/kg with adrenaline
Rapid onset. Duration of action 30-90mins. Action prolonged by

adrenaline
Caution
 use of adrenaline containing solutions should be avoided
for peripheral infiltration of the ear, finger and penis
Bupivicaine
bupivacaine A E 2mg/kg local infiltration 200-400mins
hydrochloride Inj For Epidural infusion follow local protocols
Slower onset than lignocaine.

Caution
 cardiotoxicity
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Medicines Used in Shock

Shock could be caused by the following:
 Acute pump failure – myocardial infarction, arrhythmias,
valve rupture
 Volume loss (hypovolaemia) –haemorrhage, dehydration
 Loss of vascular tone- septic shock, neurogenic shock,
endocrine failure, anaphylactic shock
It is important to make an accurate aetiologic diagnosis for
appropriate treatment. Ideally CVP monitoring is required.
General Principles of Management of Shock
 Treat underlying cause
 Restore adequate perfusion by
o Restoring blood pressure
 Use of fluids, vasoppressors or vasodilators
o Increasing cardiac output
 Use of fluids, inotropes, vasopressors
o Improving oxygenation
 Blood transfusion, Supplemental Oxygen,
Mechanical ventilation as appropriate
 Diligent monitoring (BP, Pulse, Respiration, Pulse
oximetery, Urine output)
Adrenaline 1 in 10 000
Add 9ml normal saline / water to 1ml of 1 in 1000 adrenaline
Severe anaphylaxis in anaesthesia

Medicine Codes Adult dosage
adrenaline 1 in 10 000 C V 1ml slow repeat until
iv [1-5yr every satisfactory
=0.1ml/kg] minute clinical
response
Cardiac arrest during anaesthesia:

adrenaline 1 in 10 000 C V 5ml for fine / low amplitude ventricular
iv fibrillation persisting after defibrillation
[or 10ml of 1 in 1000];
10ml for asystole [or20ml of 1in 1000]
Dopamine
A naturally occurring catecholamine
Medicine Codes Dose

dopamine inj S V 2 to 20mcg/kg/min
392
Caution
 Use via a central line
 Make sure patient is adequately volume filled before
starting dopamine therapy
 Do not mix with Sodium bicarbonate
Noradrenaline/Norepinephrine
A vasoconstrictor sympathomimetic, the first line medicine of
choice for septic shock with infusion via central line
adrenaline iv C V 40mcg/ml base running at initial rate of
0.16-0.33ml/min titrated to effect
Dobutamine
ß1 adrenergic agonist with positive inotropic and chronotropic effects
Indications
Inotrope of choice for patients in Cardiac Failure
Medicine Codes Dose
Dobutamine inj S V 2 to 20mcg/kg/min
Caution
 May cause Tachyarrythmias, fluctuations in Blood
Pressure, Headache, Nausea
 Elderly patients may have a decreased response
Ephedrine sulphate
Indications
This is the medicine of choice in obstetrics
 Hypotension due to spinal or epidural anaesthesia
 acute hypotension secondary to vasodilation
ephedrine sulphate iv B E increments of 5 mg iv until BP has
been restored
If many increments are needed a larger dose may be given
intramuscular or by intravenous infusion.
Phenylephrine hydrochloride
Phenylephrine B E 100 – 500mcg repeated as necessary
hydrochloride iv after every 5 - 15min
(IV Infusion) 180mcg/min reduced to
30-60mcg/min titrating to effect
(sc/im) 2-5mg followed if necessary
after 15 min by doses of 1-10mg
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Hydrocortisone
Peri-operative cover for patients on corticosteroid therapy:
hydrocortisone iv B V 100mg with premedication, then
100mg 6 hourly for 24hrs, then
decrease
Severe anaphylaxis during anaesthesia: refer to Chapter on
Anaphylaxis for comprehensive management
hydrocortisone iv B V 200mg 6 hourly as
[Paed: < 1yr = 25mg required
1-5yrs = 50mg
6-12yrs = 100mg
Lignocaine hydrochloride [preservative-free]

Cardiac arrest as an alternative to amiodaronein in VF/VT
arrest
lignocaine HCl B N 100mg iv [or 200mg endotracheal
preservative-free iv tube], and repeat DC shock 360joules.
If defibrillation is successful, to maintain a stable rhythm:

(stable VT, significant ectopy, wide complex tachycardias)
lignocaine HCl B N 4 mg/minute for 1 hour, then
preservative-free iv 2 mg/minute for 2 hours, and
infusion 1 mg/minute thereafter
Caution
 Prophylactic use in Acute MI contraindicated
 Reduce maintenance dose if there is impaired liver function
 Discontinue if signs and symptoms of toxicity develop
Antihypertensives in anaesthesia
For patients with pregnancy induced hypertension due for
induction of anaesthesia
Medicine codes Dose onset Duration

Magnesium B V 4g in 500 mls normal saline
Sulphate IV run over 10 to 20min titrating
to effect
Reassure if patient develops hot flashes and dizziness. Stop

infusion if patient becomes normotensive or hypotensive
394
Labetalol IV B V 20 mg IVI stat over 2 mins,
then 10-80 mg IVI every ten
Labetalol minutes until desired BP level
continuos achieved
infusion
2 mg IVI per minute by
*Total dose continuous IV infusion
should not
exceed 300
mg
 Direct acting vasodilator:
Hydralazine B V 5-10mg every 20-30 mins
IV/IM
BP should be measured every 5-10 minutes

Parenteral anti-hypertensives should be used under specialist
supervision and where facilities for continuous BP monitoring are
available
Oxytocin guidelines during a caesarean section

All Caesarean section cases:
1) Small dose ivi oxytocin (e.g. 2.5 iu) over 30 seconds after
delivery of the baby and confirming with obstetrician no second
baby present
2) Dose to be repeated at 3 minutes if no adequate contraction
a) Oxytocin induced hypotension can be counteracted with
ivi phenylephrine (50 to 100 mcg) bolus (preceding
oxytocin may be beneficial if initial concerns about effects
of vasodilation)
3) Immediate initiation of an infusion of oxytocin and to continue
for at least eight hours. (20 units of oxytocin/1000 mls over
eight hours)
High risk cases:

 Prolonged augmented labour (oxytocin resistance)
 Preoperative anaemia
 Prolonged labour: esp. long 2nd stage
 Uterine distension: multiple pregnancy, big baby or
polyhydramnios
 Grand-multiparity: >5
 Clotting Dysfunction
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 PPH in the past
Above treatment plus:

a) Increase oxytocin infusion rate (add 40 iu/1000 mls over
eight hours)
b) Add Ergometrine 0.2 mg ivi (repeat per 15 minutes up to
1 mg total ivi)
i) (Beware of Hypertensive complications)
Actively Haemorrhaging Cases:

Above High Risk Management plus:
1) Ensure total misoprostol dose is 600 mcg in the last eight
hours (top up previously administered doses either rectally or
sublingually)
2) Add cyclokapron 1g ivi
a) Repeat 8hrly whilst ongoing haemorrhage
3) Ensure standard resuscitation, transfusion and coagulation
factor management
4) Consider intramyometrial Prostaglandin F2 alpha (250 mcg)
(off label use)
Alternatives for resource constrained environments:

Controlled ivi oxytocin infusion could be replaced with Intramuscular
Syntometrine (5iu/0.5 mcg) (hypertensive diseases must be
excluded) (repeat 6 hrly)
or
Intramuscular Oxytocin 10 iu (repeat 4 hrly)
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SURGICAL CONDITIONS
GENERAL NOTE 398
GENERAL SURGICAL CONDITIONS 398
ACUTE ABDOMEN 398
ACUTE APPENDICITIS 399
INTESTINAL OBSTRUCTION 401
CHOLECYSTITIS 402
PERFORATED DUODENAL ULCER. 403
BREAST CONDITIONS 404
BREAST ABSCESS 405
MASTITIS 405
BREAST ECZEMA 406
THYROID CONDITIONS 406
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General Note
The field of surgery is diverse with many specialties covering
specific clinicopathological areas. The EDLIZ guidelines will attempt
to cover basic essentials of surgical care. Detailed information
should be obtained in literature of the appropriate specialties. The
ability to identify patients needing surgical intervention should be of
paramount importance.
General surgical conditions

1. Acute Abdomen
 Appendicitis
 Intestinal obstruction
 Cholecystitis
 Perforated duodenal ulcer
2. Breast conditions
3. Thyroid condition
4 Ulcers
Acute Abdomen
This is defined as severe sudden onset of pain of less than 7 to 10
days duration. The causes of an acute abdomen can be localized to
the abdomen but sometimes can be from a systemic non-surgical
cause. It is very important to be able to quickly assess and decide
whether it is a surgical acute abdomen or medical acute abdomen.
The usual presentation of a surgical acute abdomen is sudden

abdominal pain (colicky or sharp piercing) associated with vomiting
and/or constipation. Other features might include abdominal
distension and failure to pass flatus. The main causes of a surgical
acute abdomen are acute appendicitis, acute perforated duodenal
ulcers, acute intestinal obstruction, acute cholecystitis, pancreatitis,
ectopic pregnancy and ovarian torsion. Non abdominal causes of
pain that mimic an acute abdomen are numerous and may include
myocardial infarction, pericarditis, pneumonia or pleurisy.
398
EVALUATION
 History and physical examination will help narrow down the

differential diagnoses and also determine whether the patient
requires emergency surgery. Special attention should be paid
to the nature of pain, location, onset, duration, intensity,
recurrent nature, aggravating and alleviating factors.
 Physical exam should note the general state of the patient,
abdominal distension, surgical scars, tenderness, guarding,
rebound tenderness, presence of a mass, rectal, cervical or
adnexal tenderness.
 Initial tests might include an FBC, U&Es, amylase, lipase,
pregnancy test, urinalysis and LFTs.
 Imaging studies may be necessary:
Plain abdominal x-rays may reveal obstruction, perforation (free air

under the diaphragm) and other pathology.
Ultrasound is indicated especially for biliary tract disease, pelvic

and urinary system pathology.
TREATMENT
 Haemodynamically unstable patients might need immediate

resuscitation with Normal saline or Ringers lactate, possible
transfusion, nasogastric tube for obstruction or persistent
vomiting, urinary catheter for monitoring output, broad
spectrum empirical antibiotic for peritonitis, suspected
perforated viscus or intra-abdominal injection.
 Direct treatment towards the specific condition should be
instituted by the specialist after diagnostic workup.
Acute Appendicitis
This is the commonest acute abdominal surgical emergency.
Typical symptoms are shifting abdominal pain (starting as vague
periumbilical pain then shifting to the right iliac fossa) associated
with nausea and occasional vomiting. On evaluation, uncomplicated
appendicitis has right iliac tenderness ellicited maximally at
McBurney’s point with possible positive Rovsing sign. The white
blood count may be elevated. The diagnosis of appendicitis should
be made on clinical grounds but other investigations especially
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ultrasound scan and CT scan might be necessary in females and

where the history is not typical. The other tests are especially useful
to exclude other pathologies that might mimic appendicitis.
Straightforward appendicitis needs emergency surgery as delays
are associated with complications and poor outcome. The treatment
of appendicitis is surgical. Laparascopic appendicectomy is now
popular among surgeons with special interest and is particularly
useful in females where the advantage of visualising pelvic viscera
is important. The cosmetic advantages are additional to the less
pain, reduced hospital stay and earlier recovery noted with
laparascopic surgery.
The use of antibiotics in appendicitis and its complications can be

summarized as below:
CONDITION TREATMENT
 Acute appendicitis: Emergency appendicectomy and

prophylaxis:
Medicine Codes dose Frequency Duration

Ceftriaxone IV C V 1g Once only
and Metronidazole IV B V 500mg Once only
 Appendiceal mass. Clinical assessment of size of mass and

institution of IV antibiotics and analgesia

Benzyl penicillin IV C V 2.5MU 4 times a day
and Gentamicin IV C V 120mg Once a day
and Metronidazole IV B V 500mg 3 times a day
Alternatively:
Ceftriaxone IV C V 1g 2 times a day
This can be done while serial examinations (daily) for clinical
improvement of size of mass. are instituted Serial FBC and
USS monitoring for improvement is also important. Failure to
improve or deterioration in condition might warrant surgical
intervention. If the patient improves elective surgery (six weeks
after initial presentation) is advised as operating early is
fraught with higher risk of complications.
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 Appendiceal abscess. Emergency incision and drainage
(with or without appendicectomy) or USS guided pus drainage
plus antibiotics as follows:

And Gentamicin IV C V 120mg Once a day
Alternatively:
These treatments are continued till clinical improvement is
satisfactory. Interval elective appendicectomy might or might
not be necessary.
 Appendiceal rupture/perforation. Generalised peritonitis is

typical and prognosis is poor. Aggressive fluid resuscitation, IV
antibiotics and urgent laparatomy are all necessary. The IV
antibiotic regime is as for appendiceal abscess above.
Intestinal Obstruction
History and examination is of paramount importance. While the
different causes and types of obstruction are beyond the scope of
the EDLIZ the important symptoms to look for are colicky abdominal
pain, vomiting, abdominal distension and absolute constipation or
obstipation (not passing stool and flatus). These symptoms are
present in different degrees depending on the cause and level of
obstruction. Remember to exclude previous abdominal surgery
which makes adhesions the likely cause of obstruction and assess
the potential hernia sites to exclude obstructed hernia.
Aggressive resuscitation and monitoring is important once intestinal

obstruction is suspected or confirmed. Initial FBC, U+Es and
possible X-match is important. IV fluids in the form of Normal saline
and Ringers lactate are given as guided by degree of dehydration
but aiming to achieve a urine output of 1ml/kg/hr as guided by the
urine output monitoring with a urinary catheter. NGT insertion and
monitoring of the effluent type and amounts is vital. The NGT losses
should be replaced ml per ml with Normal Saline in addition to the
normal daily requirements estimated at 40mls/kg/24hrs.
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Antibiotic use in intestinal obstruction is necessary where bacterial

translocation is suspected especially with longer history of
obstruction or where a closed loop obstruction with possible
gangrene/perforation of bowel is suspected e.g. in sigmoid volvulus
or at surgery where unprepared bowel is opened.
FIRST LINE

Benzyl penicillin IV C V 2.5mg 4 times a day
SECOND LINE

and Metronidazole IV B V 1g 3 times a day
NB. Gentamicin should not be used where renal impairment is likely
or confirmed.
Cholecystitis
Acute cholecystitis is a condition which is becoming more frequent
in our population as major lifestyle changes occur with dietary shifts
towards a western diet. This has increased the incidence of
cholesterol related illness of which gallstone disease is one.
Calculous cholecystitis (gallstone-related cholecystitis) is the
commonest indication for cholecystectomy in Zimbabwe. In young
patients exclusion of haemolytic anaemia especially sickle cell
anaemia is important.
While the definitive treatment for cholecystitis is surgery i.e. open

cholecystectomy or laparascopic cholecystectomy it is necessary to
give antibiotics for acute cholecystitis. While acute cholecystitis
typically presents in a forty year old, fat, fertile, flatulent and fair
female it can also occur in males, in a younger or older age group.
The symptoms are mainly acute right upper quadrant pain usually
at night after a fatty meal with some milder previous episodes of
colicky upper abdominal pains. On examination tender right upper
quadrant is typical with a positive Murphy sign (catch of breath on
inspiration while the palpating hand is advancing up from the right
iliac fossa to the right costal margin).
402
TREAMENT OF ACUTE CHOLECYSTITIS
Antibiotics and analgesia are important.
FIRST LINE

And ampicillin IV C V 500mg 4 times a day
Alternative to ampicillin (if not available):
and Benzyl penicillin IV V 2.5mg 4 times a day
SECOND LINE

Patients are managed as above and if symptoms and signs improve

can be discharged on oral, amoxicillin 500mg tds x for 7 days and
scheduled for elective cholecystectomy after six weeks.
Advances in laparascopic surgery have however made it possible to

do early or “hot” cholecystectomy when certain criteria are met
based on expertise of the surgeon.
Perforated Duodenal Ulcer.

Peptic ulcer disease is generally a medical condition where
advances in diagnosis and treatment have made surgical
intervention only reserved for its complications. Perforated
duodenal ulcers remain a feared and relatively common
complication.
While a reasonable number of patients who present with acute

perforated duodenal ulcer have had a diagnosis of peptic ulcers
before, the majority have no prior diagnosis or investigations done.
Presentation is usually of sudden severe epigastric pain which
rapidly spreads to the whole abdomen associated with fear of
movement. Examination findings are typically those of generalized
tenderness with board-like rigidity of the abdomen and rebound
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tenderness. The erect chest X-ray shows free air under the
diaphragm in 75% of cases.
This is surgical emergency but resuscitation with Normal Saline,

NGT insertion, analgesia and urinary catheterization should be
done. FBC and U+Es are done in preparation for surgery. The
prognosis is poor if surgery is delayed. The adage of “the sun
should not rise and set’ before surgery is done is appropriate for
this condition. IV antibiotics should be given as soon as signs of
peritonitis are picked.
FIRST LINE

NB. Gentamicin should not be used if renal assessment is not satisfactory.
SECOND LINE

or Ceftriaxone IV C V 1g 2 times a day
Breast Conditions
While the breast can be affected by many conditions practitioners
should take all efforts to exclude malignancy. History and
examination is of value in this regard. Common breast conditions
are:
 Breast abscess especially in breastfeeding or pregnant women

 Mastitis
 Breast fibroadenomas especially in young women age (15-
35years).
 Breast cancer especially above the age of 35.
 Ductal papilloma
 Duct ectasia
 Nipple/ breast eczema
 Paget’s disease of the breast
 TB of the breast
404
Breast Abscess
Typically occurs in a young lactating or pregnant women who has
pain and swelling of the breast with an area of maximal tenderness
or fluctuancy. Once the diagnosis is made, incision and drainage in
theatre under general anaesthesia should be done as they are
generally deep abscesses and adequate drainage is advisable
under general anaesthesia. Analgesia and antibiotics should be
instituted once diagnosis is made.
Preferred therapy:

cloxacillin IV B V 500mg 4 times a day 2 days
then cloxacillin po B V 500mg 4times a day 5 days
Alternative therapy:

clindamycin IV B V 300-600mg 3 times a day 2 days
then clindamycin po B V 300-600mg 3times a day 5 days
The wound should be cleaned with saline or povidone iodine and

packed or dressed with glycerin and ichthamol daily until healing
occurs. The mother should be advised to continue breastfeeding or
to express the breast frequently.
Mastitis
This also occurs commonly in breastfeeding or pregnant mothers.
The symptoms are similar to the breast abscess except that there is
no “pointing” area of maximal tenderness or fluctuancy.
If mild symptoms

cloxacillin po B V 500mg 4 times a day 7 days
or clindamycin po B V 450mg 3 times a day 7 days
If severe then admission and IV treatment as in breast abscess
discussed above.
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Breast Eczema
This is a common condition which is usually confused with cracking
nipples in breastfeeding mothers. However, exclusion of breast
cancer is important as in Paget’s disease. Where appropriately
diagnosed, breast eczema can then be managed as per guidelines
in the skin conditions chapter. Where there is doubt of diagnosis a
biopsy of the affected skin is important.
Thyroid Conditions
Patients who present with a goitre need to be assessed properly.
The assessment should focus on assessing their thyroid state
(thyrotoxicosis, euthyroid or hypothyroid) and exclude complications
which might be linked to malignant change e.g upper air ways
compression, hoarse voice in recurrent nerve invasion, retrosternal
extension or superior vena cava compression, rapid growth,
fixation, enlarged lymph nodes.
Treatment for thyrotoxicosis is laid out in the endocrine conditions

chapter.
Surgical intervention is indicated in thyrotoxicosis if
 Not responding to medical therapy.

 Thyrotoxicosis not responding to radioiodine.
 Thyrotoxic patients where antithyroid drugs and
radioiodine are contraindicated.
 Confirmed malignancy.
 Suspected malignancy where confirmation is not possible
before surgery e.g. in follicular carcinoma.
 Goitre causing compressive complications on the airway,
major vessels and nerves.
Patients scheduled for surgical intervention should be rendered
euthyroid before the surgery with oral anti-thyroid drugs.
Emergency cases might need IV propranolol as there is no time to
bring the thyroid hormones down.
406
SKIN ULCERS
Chronic ulcers are a common condition. Unless the cause of the

ulcer is known exclusion of malignancy is important. Exclusion of
malignancy should be done by taking a biopsy for histological
analysis. The common cutaneous malignancies are squamous cell
carcinoma, malignant melanoma and basal cell carcinoma. These
malignancies are more common in albinos who are sun exposed
without ultraviolet protection. Use of sun protective clothes and
sunscreen lotions is important in this group of people. However
everyone is prone to developing skin cancers. Chronic non-healing
ulcers (eg after burns) can develop squamous cell carcinoma,
referred to as a Marjolin ulcer. Malignant melanoma of the acral
lentiginous type is common on the soles of the feet in Zimbabwe
and all suspicious lesions should be biopsied and referred to the
general surgeon for further management.
Where malignancy has been ruled out or is not suspected exclusion

of peripheral vascular disease, diabetes mellitus and venous stasis
(eg in varicose veins) is also important. The management of non-
malignant chronic ulcers involves different disciplines. The guiding
principle, however, is reducing inflammation on the wound by
avoiding irritating substances on the wound and limiting frequent
change of dressings. In this regard simple normal saline or
equivalent salt solution would be preferred for cleaning the wound
and then applying long staying dressings (which can be changed
less often eg once every third day). Wound care products are varied
and the state of the wound would guide the most appropriate
product to use. In the absence of these specialized products
cleaning the wound with simple saline and dressing it with glycerine
and icthamol solution would suffice.
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ANTINEOPLASTIC AGENTS
GENERAL NOTES 409

PRINCIPLES OF COMBINATION CHEMOTHERAPY 409
CHEMORADIATION 410
PALLIATIVE CHEMOTHERAPY 411
SELECTION OF CHEMOTHERAPY AGENTS 411
COMMON SIDE EFFECTS OF CHEMOTHERAPY 413
DOSE MODIFICATION 414
FOLLOW UP 414
408
General Notes
A wide variety of antineoplastic agents are generally available.
These agents should be strictly used under the supervision of a
specialist in oncology, be it for the treatment of malignant or other
conditions.
The role of antineoplastic agents in the management of cancer is
expanding. Chemotherapeutic and other medicines are used during
treatment of most patients with cancer. One of the most important
developments in cancer therapy over the last few decades is the
increased recognition of the role of chemo-radiation in the curative
management of cancer.
Chemotherapy medicines fall into the following classes
 Alkylating medicines,
 Cytotoxic antibiotics,
 Antimetabolites,
 Vinca alkaloids,
 Other medicines.
Recent times have however, seen the development of an array of

other antineoplastic medicines including biological and immune
therapy drugs.
Chemotherapy can be used in a number of ways. The criteria for

use differ for each tumour type, stage morphologic and biologic
characteristics. Combination chemotherapy is more commonly used
than single agent chemotherapy.
Principles of Combination Chemotherapy

1. Only those agents proven effective should be used.
2. Each agent used should have a different mechanism of action
3. Each agent should be used at maximum dose
4. Agents with similar dose – limiting toxicities can be combined
safely only by reducing doses, resulting in decreased effects.
5. Combination chemotherapy should be administered according
to protocol, based on evidence-based medicine with intervals
between therapy cycles allowing for the recovery of normal
tissue.
Guidelines of handling chemotherapy medicines

 Trained personnel should reconstitute the medicines.
 Reconstitution should be done in designated areas,
preferably under lamina air flow.
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 Protective clothing including eye protection should be

worn at all times whilst reconstituting the medicines. This
includes eye protection.
 Gloves should always be worn when administering the
medicines.
 Pregnant health care workers should not handle
chemotherapy medicines.
 Waste disposal should be meticulously handled. All
contaminated disposables should be incinerated.
Adjuvant Chemotherapy
Adjuvant Chemotherapy is use of chemotherapy medicines in
patients who remain at high risk of recurrence after the primary
definitive treatment of the tumour with surgery or by means of
radiation treatment. Cancers effectively treated by adjuvant
chemotherapy includes, Wilm’s tumour, breast cancer,
osteosarcoma and colorectal cancer.
Principles of Adjuvant Chemotherapy

1. Effective chemotherapy must be available
2. Known tumour should have had primary definitive treatment
either surgically or with radiation treatment
3. Chemotherapy should be started as soon as possible after
primary treatment.
4. Chemotherapy should be given in maximally tolerated doses
5. Chemotherapy should continue to the maximum period defined
by the protocol.
Neoadjuvant Chemotherapy
In this instance, chemotherapy is administered before surgery or
radiotherapy. The advantage of this method is that it exposes
potential micrometastases to chemotherapy much earlier. Also
significant regression of the primary tumour may allow easier
management and permit organ and function preservation. Cancers
effectively treated by neoadjuvant chemotherapy include soft tissue
sarcomas, ostesarcoma, anal cancer, bladder cancer, larynx
cancer, oesophageal cancer and locally advanced breast cancer.
Chemoradiation
Chemotherapy is increasingly being administered concurrently with
radiotherapy in most tumours. The result of chemoradiation in these
tumours is superior to that of radiotherapy alone. The improved
outcome outweighs the slightly increased toxicity of the combined
treatment. Cancers effectively treated by chemoradiation include,
410
cervical cancer, oesophangeal cancer, nasopharyngeal cancer and
other head and neck cancers
Maintenance Chemotherapy
In certain specific conditions patients may need to continue on
chemotherapy for a defined period. Examples include tamoxifen for
ER/PR positive breast cancer.
Palliative Chemotherapy
Chemotherapy can be used in advanced disease for palliation
where there is no alternative therapy or where local therapies have
failed. A positive response with acceptable toxicity must be
expected to justify the use of palliative chemotherapy.. Cancers that
may be effectively treated with palliative chemotherapy include
advanced ovarian cancer, germ cell tumours of the testis, small cell
lung cancer and metastatic breast cancer.
Cancers that may be curable with Chemotherapy Alone
Some of the examples of cancers that maybe curable with

chemotherapy alone*
 Gestational choriocarcinoma
 Hodgkin’s disease
 Germ cell cancer of testis
 Acute lymphoid leukemia
 Non-Hodgkin’s lymphoma (some subtypes)
 Hairy cell leukemia (probable)
 Small cell lung cancer
*Depending on stage at presentation
Selection of Chemotherapy Agents

Many chemotherapy regimens for a wide variety of cancers exist.
Patients who are to receive chemotherapy are to be well assessed
prior to prescription and administration of these medicines.
Assessment needs vary according to the medicines that may be
selected for use. The following are to be considered prior to this:
Physiologic Age of the Patient

Whilst age alone is not a valid criterion for excluding patients from
receiving chemotherapy, age related alterations in organ function
may result in unacceptable toxicity. Treatment decisions must
however take into account the likelihood of benefit.
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Performance Status
Patients with poor Karnofsky performance status (KPS) do not
tolerate chemotherapy well. Patients with KPS of 30 percent or less
are not usually candidates for chemotherapy.
Patient Performance Score Using the Karnofsky Scale
Karnofsky (%) Definition
100 Asymptomatic
80 – 90 Symptomatic, fully ambulatory
60 – 70 Symptomatic, in bed < 50% of day
40 – 50 Symptomatic, in bed > 50% of day but not bedridden
20 – 30 Bedridden
Nutritional status
Ingestion of 1500 to 2000 cal/day is necessary to allow for
satisfactory tumour response. This is an important consideration in
the setting of advanced malignancy.
Obesity
Over dosage can occur if dosage is calculated per kilogram rather
than per surface area. Ideal body weight should be used for
palliative therapy rather than actual body weight. For curative cases
if ideal body weight is used, dose escalations should be considered
if treatment well tolerated.
Prior Therapy
The first chemotherapy treatment protocol usually gives best
response and hence the need for optimum timeous management by
knowledgeable team. Failure to respond to first line therapy lessens
the probability to respond to second line therapy. This is most likely
due to the development of multi drug (medicine) resistance.
Organ Function
Altered bone marrow, renal, hepatic, cardiac or pulmonary function
may render it impossible to use some agents or make it necessary
to modify dosage. The oncologist will need to determine baseline
function according to the medicines being administered.
Coexisting Illness
Choice of agents to be used may have to be modified e.g.
adriamycin in congestive cardiac failure and steroids in diabetes
mellitus
412
Requirements for chemotherapy/referral to tertiary level
All patients needing chemotherapy should be referred for treatment
to a referral or tertiary treatment institute, unless there are suitable
facilities and well trained staff in another facility.
All patients suspected of having cancer should also be referred for

further evaluation to institutes with appropriate recourses.
Patients on chemotherapy can be seen at any level of care since

they are just like any other patient and may need basic non-
oncological care for common diseases and pain control. However
the attending practitioners should be very alert since chemotherapy
side effects can mimic or mask signs of other conditions.
Common side effects of chemotherapy

Chemotherapy medicines have a variety of toxicities. Only the
common ones will be highlighted.
Nausea and vomiting; this is one of the most common side effects.
The different medicines have different emetogenic potential.
Treatment of these side effects is therefore tailored to suit the
emetogenic potential of the medicines used. This has to be done
prophylactically. Nausea and vomiting can be acute, delayed or
anticipatory.
Bone marrow suppression; Most medicines will cause bone
marrow suppression, especially neutropenia. This is worst 7 to10
days after administration of the medicine. Check the FBC not more
than a week before the administration of chemotherapy for each
cycle.
Alopecia: This is a distressing side effect that is difficult to prevent
for certain medicines. It is however reversible.
Extravasation reactions: This is a serious side effect resulting
from the medicine leaking out into the soft tissues into extravascular
spaces and causing irritation and tissue necrosis. The damage can
be extensive and permanent. Treatment is prevention. This
emphasizes the need for chemotherapy to be administered by
trained staff within an oncology specialty.
Teratogenicity/effects on the embryo: Chemotherapy is

contraindicated in pregnancy especially the 1st trimester. Should a
pregnant woman need chemotherapy treatment, discussion is
necessary to weigh out possible options of treatment. Contraceptive
advice should be given prior to starting chemotherapy treatment.
Fertility; Permanent sterility with certain medicines is a possibility

for both male and female patients. Germ cell banking should be
considered as appropriate.
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Dose Modification
Dose modification may be necessary if unacceptable toxicity results
e.g. neurotoxicity from vinca alkaloids and mucositis from
methotrexate. Medicine doses are routinely modified for changes in
renal or hepatic functions. The extent of acceptability of
modifications varies according to individual protocols. Modification
for decrease in blood counts is still the norm in resource poor
settings unlike in settings where growth factor support is routinely
available.
Follow up
Adjuvant chemotherapy is usually given for a set number of cycles.
In other situations the patient should be evaluated after two or three
cycles of therapy. If there is a clear response and the treatment is
well tolerated, the treatment can be continued to the set number of
cycles or two cycles beyond complete response.
If disease progression is noted during treatment, therapy must be
discontinued and other treatments evaluated. In the case of stable
disease, treatment can be continued as long as the side effects are
tolerable. In this situation disease progression becomes inevitable
at some stage
414
ANNEX 1
REPORTING ADVERSE MEDICINE

REACTIONS
General Notes
Since the thalidomide disaster, voluntary reporting of adverse drug
reactions (ADRs) has become important in monitoring the safety of
medicines. ADR reporting can also help to identify irrational
presenting, bad batches of a medicine and problems specific to
particular patient groups.
For the purpose of reporting an adverse drug reaction (ADR), a
medicine is defined as:
Any substance administered to man for the prophylaxis, diagnosis or
therapy of disease, or the modification of physiological function.
An adverse reaction to a medicine is defined as:
A reaction which is noxious and unintended, and which occurs at
doses normally used in humans for the prophylaxis, diagnosis, or
therapy of disease, or for the modification of physiological function.
This includes herbal and traditional medicines.
All suspected adverse reactions are of interest, ranging from well-
known ‘side effects’ to dangerous and serious reactions.
Examples include anaphylaxis to penicillin, Steven- Johnson
syndrome in HIV patients given cotrimoxazole, itching due to
chloroquine, etc. Reactions to vaccines specially imported
unregistered medicines, congenital abnormalities and lack of
therapeutic effect should also be reported.
Suspected ADR’s should be reported on the standard form shown
on the next page. TEAR OUT THE PAGE TO SEND.
Additional forms can be obtained from the Medicines Control
Authority of Zimbabwe, 106 Baines Avenue, Harare, Tel +263-4-
708255/2901327-317, Fax +263-4-736980, E-mail:
mcaz@mcaz.co.zw.
The forms can also be downloaded from the MCAZ website:
www.mcaz.co.zw
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Report of a Suspected Adverse Drug Reaction
Identities of Reporter, Patient and Institute will remain confidential
Patient Details (to allow linkage with other reports)
Family Name: OR Patient Clinic/Hospital Number:
Forename(s):
Date of Birth: Weight Sex:
Age: kg M/F
Adverse Reaction
Date of onset:
Duration: Less than one Hours Weeks
hour
Days Months
Description:
Outcome: Recovered Fatal Unknown

Not yet recovered
Suspected Medicine(s)
Medicine: Generic Name:
Brand Name:
Indication medicine was
given for:
Daily dose/route:
Date begun: Date stopped:
Concomitant (Other) Name of Date started: Date
medicines taken & medicine: stopped:
Dates/period taken:
Laboratory test results
Reported by
Family Name:
Forename(s):
Status: Doctor Pharmacist/Pharmacy Nurse
Technician
Address:
Signature: Date:
Send to: 416 The Director-General Medicines Control Authority in Zimbabwe
106 Baines Avenue, P O Box 10559, Harare
Fax:+263-4-736980, email:mcaz@mcaz.co.zw,
ANNEX 1
Adverse Medicine Reaction Report
417
EDLIZ 2015
z
Forename(s):
Age: kg M/F
Adverse Reaction
Date of onset:
hour
Days Months
Description:

Not yet recovered
Brand Name:
given for:
Daily dose/route:
Dates/period taken:
Reported by
Family Name:
Forename(s):
Technician
Address:
Signature: Date:
Send to: The Director-General Medicines Control Authority in Zimbabwe
418 Fax:+263-4-736980, email:mcaz@mcaz.co.zw,
website:www.mcaz.co.zw
ANNEX 1
419
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Forename(s):
Age: kg M/F
Adverse Reaction
Date of onset:
hour
Days Months
Description:

Not yet recovered
Brand Name:
given for:
Daily dose/route:
Dates/period taken:
Reported by
Family Name:
Forename(s):
Technician
Address:
Signature: Date:
Send to: The Director-General Medicines Control Authority in Zimbabwe
420 Fax:+263-4-736980, email:mcaz@mcaz.co.zw,
website:www.mcaz.co.zw
ANNEX 1
421
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Forename(s):
Age: kg M/F
Adverse Reaction
Date of onset:
hour
Days Months
Description:

Not yet recovered
Brand Name:
given for:
Daily dose/route:
Dates/period taken:
Reported by
Family Name:
Forename(s):
Technician
Address:
Signature: Date:
Send to: 422 The Director-General Medicines Control Authority in Zimbabwe
Fax:+263-4-736980, email:mcaz@mcaz.co.zw,
ANNEX 1
423
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424
ANNEX 2
Report on Medicinal (Pharmaceutical) Product Defect or

Problem
425
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426
ANNEX 2

Problem
427
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428
ANNEX 2

Problem
429
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430
ANNEX 2

Problem
431
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MEDICINE INTERACTIONS &

INCOMPATIBILITIES
Additional information on interactions and incompatibilities may be

obtained from your pharmacy department. If further information is
required, it may be obtained by telephone or by post from:
The Drug and Toxicology Information Service
Medical School
P O Box A178, Avondale, Harare
Tel.: +263 4 2933452 or 791631 (ext. 172),
datis@gmail.com
www.datis.co.zw
General notes
When two medicines are administered to a patient they may either
act independently of each other, or interact with each other.
Interaction may increase or decrease the effect of the medicines
concerned, and may cause unexpected toxicity. As newer and more
potent medicines are available to us, the number of serious
medicine interactions occurring is likely to increase.
Remember that interactions may involve non-prescription medicines
and social drugs (such as alcohol, mbanje), plants and traditional
remedies.
Medicine interactions can be the result of interference with another
medicine’s absorption, displacement of the medicine from a plasma
protein binding site, resulting in a similar, or additive effect,
increasing or decreasing the other medicine’s metabolism or
excretion, or interference at receptor sites.
432
ANNEX 2
Potentially hazardous interactions

What follows is not a comprehensive list: refer to the British National
Formulary (BNF) or other reference source for detailed information.
Key:  increased / enhanced effect  decreased effect
Medicine affected Effect Medicines causing effect
enhanced hypotensive Anaesthetics
ACE inhibitors 
effect diuretics
decreased hypotensive non-steroidal anti-inflammatory
ACE inhibitors 
effect medicines
Anaesthetics
antidepressants
enhanced hypotensive
alpha blockers (prazosin)  beta blockers
effect
calcium channel blockers
diuretics
amiloride / spironolactone  raised potassium levels captopril
ototoxic & nephrotoxic high dose frusemide
aminoglycosides 
effects increased
anticoagulants  increased risk of bleeding aspirin
anticoagulants  increased metabolism Carbamazepine
increased anticoagulant Alcohol
anticoagulants /warfarin 
effect imidazole antifungals
Alcohol
antidepressants (tricyclics)  enhanced sedative effect other antidepressants
anti-epileptics
anti-epileptics  lowered threshold antidepressants (tricyclics)
anti-epileptics  inhibited metabolism isoniazid
benzodiazepines  increased action Cimetidine
beta blockers (atenolol/ enhanced hypotensive
Anaesthetics
propranolol)  effect
Phenobarbitone
calcium channel blockers  reduced effect rifampicin
phenytoin
calcium channel blockers  enhanced effect Anaesthetics
calcium channel blockers  increased metabolism rifampicin
erythromycin
increased action of
carbamazepine  isoniazid
carbamazepine
cimetidine
carbamazepine  reduced anti-epileptic effect chloroquine
Alcohol
CNS depressants  increased action sedative medicines
phenobarbitone
corticosteriods  increased metabolism Phenobarbitone
Thiazides
digoxin  enhanced toxicity frusemide
quinine
Potentially hazardous interactions (contd.)

doxycycline  increased metabolism Carbamazepine
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EDLIZ 2015
increased metabolism rifampicin

imidazole antifungals 
reduced plasma conc. phenytoin
indinavir (antiviral)  inhibited metabolism imidazole antifungals
indinavir (antiviral)  enhanced metabolism rifampicin
antacids
ketoconazole  reduced absorption anti-muscarinic medicines
cimetidine
lithium  increased toxicity diuretics
metronidazole  reduced plasma conc. phenytoin
metronidazole  antabuse reaction alcohol
neuromuscular blockers  enhanced effects aminoglycosides
non-steroidal anti-inflammatory increased risk of renal
ACE inhibitors
medicines  damage
rifampicin
‘broad spectrum’ antibiotics
reduced contraceptive
oral contraceptives  phenobarbitone
effect
carbamazepine
phenytoin
increased hypoglycaemic alcohol
oral hypoglycaemic /insulin 
effect
phenytoin  enhanced effect imidazole antifungals
chloramphenicol
cimetidine
phenytoin  action increased cotrimoxazole
isoniazid
metronidazole
chloramphenicol
sulphonylureas  (glibenclamide / cotrimoxazole
increased action
metformin) fluconazole
miconazole
cimetidine
increased theophylline erythromycin
theophylline 
levels oral contraceptives
calcium channel blockers
434
ANNEX 2
Incompatibilities between Medicines and IV Fluids

This section only intended as a general guide. Many other incompatibilities
exist. Always check for compatibility before adding any medicine to an IV fluid
(look at the package insert of the medicine, or ask your local pharmacy
department for advice).
Medicines should not be added to blood, amino acid solutions, or

fat emulsions.
Certain medicines, when added to IV fluids, are inactivated by pH
changes, precipitation, or chemical reaction. Most simple IV fluids
are acidic pH (3.5-6.0).
Medicine Effect Solution/ incompatibility
Benzylpenicillin  lose potency after 6- dextrose solutions – use
Ampicillin 8hrs (due to acidity) within 1 hour
Diazepam  effect due to binding plastic containers, tubing –
Insulin titrate against response
Aminoglycosides incompatible Penicillins
(gentamicin) heparin
Hydrocortisone incompatible heparin
chloramphenicol
tetracycline
Oxytocin at high doses dilute with
dextrose, not normal
saline
Potassium Chloride mix thoroughly to avoid
‘layering’
Ceftriaxone Incompatible Use different IV line from
those of calcium
containing IV fluids
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CATEGORISATION OF MEDICINES ON
THE 7TH ESSENTIAL LIST FOR ZIMBABWE
Medicines used in Anaesthesia
Analgesics and Antipyretics (incl. narcotics & anti-migraine)
Anti-inflammatory Medicines & Medicines for Rheumatism and Gout
Antihistamines (anti-allergic medicines)
Antidotes & Substances used in Poisoning Management
Anti-infective Medicines (antibiotics & other anti-microbials)
Medicines affecting the blood & Blood Products/ Substitutes
Cardiovascular Medicines
Central Nervous System Medicines
Dermatological Agents
Gastrointestinal Medicines
Hormones
Immunological agents (incl. vaccines & sera)
Ophthalmological Medicines
Respiratory System Medicines
Medicines Used in Labour & Delivery
Intravenous (& other) Solutions
Vitamins & Minerals
436
Medicine name Form Level VEN
1. Medicines used in Anaesthesia
Atracurium Inj B V
Bupivacaine hydrochloride Inj A E
Etomidate Inj B N
Halothane Gas B V
Isoflurane Gas B V
Ketamine Inj B V
Lignocaine + adrenaline Inj B E
Lignocaine hydrochloride Inj C V
Lignocaine no preserv 2% Inj B N
Lignocaine spray Top B N
Medical air Gas B V
Neostigmine bromide Inj B V
Nitrous oxide Gas B V
Oxygen Gas C V
Propofol Inj A V
Soda lime - B V
Suxamethonium chloride Inj B V
Thiopentone sodium Inj B V
Trimeprazine tartrate Po B N
Vecuronium Inj B N
2. Analgesics, Antipyretics, Narcotics, Anti-migraine
Aspirin Po C E
Codeine Po B V
Ergotamine Po A N
Morphine Inj B E
Morphine Po B V
Paracetamol Po C E
Paracetamol Syr C E
Pethidine Inj B V
Tramadol Inj B V
Tramadol Po B V
3. Anti-inflammatory, Rheumatism, Gout
Allopurinol Po B E
Colchicine Po A N
Ibuprofen Po C N
Indomethacin Po B E
Diclofenac Po B E
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4. Antihistamines
Chlorpheniramine Po C E
Promethazine Po B N
5. Antidotes, Poisoning
Acetylcysteine Inj A E
Atropine Inj B V
Charcoal activated Po B E
Naloxone neonatal 20mcg/ml Inj B V
Pralidoxime Inj A N
Scorpion antivenom Inj B N
Snake antivenom polyvalent Inj B E
6. Anti-infectives, Antibiotics, Antimicrobials
Acyclovir Po B E
Albendazole Po C E
Amoxicillin Po C V
Amoxicillin Susp C E
Ampicillin Inj B E
Artemether/Lumefantrine 20/120mg Po C V
Artesunate Pr C V
Benzathine penicillin Inj C V
Benzyl benzoate Top B N
Benzylpenicillin Inj C V
Ceftriaxone Inj C V
Chloramphenicol Inj B V
Chloramphenicol Po B V
Chloramphenicol Susp B E
Ciprofloxacin Po B V
Clindamycin Po B V
Clindamycin Inj B N
Clofazimine Po A N
Clotrimazole pess Vag B E
Clotrimazole cream 1% Top B E
Cloxacillin Inj B V
Cloxacillin Po B V
Cloxacillin Susp B E
Cotrimoxazole Po C V
Cotrimoxazole Paed C V
Cotrimoxazole Susp C V
Dapsone Po B V
Doxycycline Po C V
Erythromycin Po C V
438
Erythromycin Susp C V
Ethambutol Po B V
Fluconazole Po B V
Gentamicin Inj C V
6. Anti-infectives (contd.)
Gentian violet Top C V
Griseofulvin Po B N
Isoniazid Po B V
Isoniazid Paed B E
Kanamycin Inj C V
Ketoconazole Po A N
Metronidazole Inj A N
Metronidazole Pr B V
Metronidazole Po C V
Metronidazole Paed B E
Miconazole cream 2% Top C E
Miconazole pess Vag C V
Miconazole oral gel Po C V
Nalidixic acid Po B V
Neomycin Po A N
Nitrofurantoin Po B N
Norfloxacin Po C V
Nystatin Po B N
Nystatin pessaries Vag B E
Penicillin V Po C E
Praziquantel Po C E
Primaquine Po B E
Procaine penicillin Inj C V
Proguanil Po B N
Pyrimethamine + dapsone Po C E
Pyrazinamide Po B V
Quinine Po B V
Quinine infusion Inj B V
Rifampicin Po B V
Rifampicin/Isoniazid/Pyrazinamide Paed C V
60/30/150mg
Rifampicin/Isoniazid 60/30mg Paed C V
Rifampicin/Isoniazid 150/75mg Po C V
Rifampicin/Isoniazid/Ethambutol Po C V
150/75/275mg
Rifampicin/Isoniazid/Pyrazinamide/Eth Po C V
ambutol 150/75/400/275mg
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Rifampicin Paed B E
Streptomycin Inj B V
6. Anti-infectives (contd.)
Selenium sulphide 2% Top C N
Sulphadoxine + pyrimethamine Po B E
7. Medicines affecting the blood, Blood products
Cryoprecipitate Inj A E
Factor IX conc. Inj A V
Factor VIII con. Inj A V
Ferrous sulphate Po C E
Ferrous sulphate Paed B E
Folic acid Po C E
Heparin Inj B V
Plasma - B V
Platelet conc - A E
Red cell conc. - B V
Streptokinase Inj A V
Vitamin B12 (hydroxocobalamin) Inj B V
Vitamin K Po A N
Vitamin K Inj C V
Warfarin Po B V
8. Cardiovascular Medicines
Amiloride Po A N
Amlodipine Po B V
Atenolol Po B V
Captopril Po B E
Digoxin Po B V
Digoxin Inj B E
Ephedrine Inj A V
Enalapril Po B V
Frusemide Po B V
Frusemide Inj B V
Glyceryl trinitrate Inj A E
Hydrochlorothiazide Po C V
Hydralazine Inj B V
Isosorbide Po A E
Lisinopril Po B N
Lorsartan Po A E
Magnesium sulphate Inj C V
Methyldopa Po C E
440
Nifedipine sr Po B E
Potassium chloride Po B V
Potassium chloride Inj B V
8. Cardiovascular Medicines (contd.)
Prazosin Po B E
Propranolol Po B E
Spironolactone Po A N
Verapamil Inj A N
Verapamil Po A N
9. Central Nervous System Medicines
Amitriptylline Po C V
Benzhexol Po C V
Biperiden Inj A E
Carbamazepine Po B V
Carbidopa-levodopa Po A N
Chlorpromazine Po C V
Chlorpromazine Inj C V
Diazepam Po C V
Diazepam Inj C V
Fluexitine Inj B V
Fluphenazine deconoate Inj B V
Flupenthixol decanoate Inj B E
Haloperidol Po C V
Haloperidol Inj C V
Imipramine Po A E
Lorazepam Po B E
Lorazepam Inj C V
Midazolam Inj A E
Olanzapine Po B E
Phenobarbitone Inj B E
Phenobarbitone Po C V
Phenytoin sodium Po B V
Phenytoin sodium Inj A E
Risperidone Po B E
Sertraline Po B E
Sulpiride Po C V
Trifluoperazine Po B E
10. Dermatological Agents
Aqueous cream Top B N
Benzoyl peroxide 5% gel Top A N
Calamine lotion Top C N
441
EDLIZ 2015

Coal tar 5% ointment Top B N
Compound benzoic acid ointment Top C E
Emulsifying ointment Top B N
Gamma benzene hexachloride 1% Top C V
Para aminobenzoic acid Top B E
Podophyllin paint Top B N
Potassium permanganate Top B N
Povidone iodine Top B E
Salicylic acid 2% ointment Top B N
Silver sulphadiazine Top B V
Sulphur 5% - 10% ointment Top B N
Zinc oxide ointment Top B N
11. Gastrointestinal Medicines
Bisacodyl Po C N
Bismuth subgallate with 1% Pr B N
Hydrocortisone
Glycerine suppositories Pr C N
Hyoscine butylbromide Po B N
Liquid paraffin Po B N
Loperamide Po C N
Magnesium trisilicate Po C N
Metoclopramide Po B V
Prochlorperazine Inj B N
Prochlorperazine Po B N
Promethazine Inj B V
Omeprazole Po A E
Raniditine Po B E
12. Hormones
Carbimazole Po B E
Combined oral contraceptive pill Po C V
Dexamethasone Inj B V
Dexamethasone Po B N
Glibenclamide Po B V
Hydrocortisone Inj B V
Insulin Inj B V
Iodine solution Po A N
Levonorgestrel implant Sc B N
Medroxyprogesterone acetate Inj C V
Metformin Po B V
Norethisterone enanthate Po B N
Prednisolone Po B V
442
Progesterone only pill Po C V
Thyroxine Po B V
13. Immunologicals
BCG Vacc C V
DPT Vacc C V
DPT+HBV Vacc C V
DT Vacc C V
HB Vacc C V
Measles Vacc C V
OPV Vacc C V
Rabies immunoglobulin Vacc B V
Rabies Vaccine Vacc B V
Tetanus immunoglobin Inj B E
Tetanus toxoid Inj C V
Tuberculin, purified - B E
14. Ophthalmic Medicines
Acetazolamide Po A N
Pilocarpine eye drops Eye B V
Tetracycline eye ointment 1% Eye C V
15. Respiratory System Medicines
Adrenaline Inj C V
Aminophylline Inj B N
Beclomethasone inhaler Inh B V
Beclomethasone nasal spray Spray A N
Salbutamol Po B N
Salbutamol inhaler Inh B V
Salbutamol nebulised Neb B V
Theophylline slow release Po C N
16. Medicines used in Labour & Delivery
Ergometrine Inj C V
Hexoprenaline Inj B N
Misoprostol Po A N
Oxytocin Inj C V
Sodium citrate Po B N
17. Intravenous solutions
Calcium chloride 10% Inj A E
Calcium gluconate 10% Inj B E
Darrows with dextrose Inj C V
Dextrose 10% Inj A N
Dextrose 5% Inj C V
443
EDLIZ 2015

Dextrose 50% Inj C V
Maintelyte Inj B N
Neonatalyte Inj B V
Ringer lactate Inj C V
Sodium bicarbonate 4.2% Inj B N
Sodium bicarbonate 8.4% Inj B V
Sodium chloride Inj C V
18. Vitamins & Minerals
Nicotinamide Po B E
Pyridoxine Po B E
Thiamine Po A E
Thiamine Inj A N
Vitamin A Po C V
Vitamin B Complex (High Potency) Inj C V
Vitamin D Po B V
Vitamins, multi Po C E
Vitamins, multi Paed B E
19. Antiretrovirals
Single formulations
Abacavir Po B V
Abacavir 20mg/Ml Paed B V
Didanosine 250 Po B V
Didanosine 25mg Paeds B V
Efavirenz Po C V
Efavirenz 50mg Paed C V
Lamivudine Po C V
Nevirapine Po C V
Nevirapine 10mg/mL Paed C V
Stavudine Po C V
Tenofovir Po C V
Zidovudine Po C V
Zidovudine 10mg/Ml Paed C V
Fixed Dose Combinations(FDC)
Abacavir/Lamivudine Po B V
Atazanavir/Ritonavir 300/100mg Po B V
Lopinavir/Ritonavir 100/25mg Paeds B V
Lopinavir/Ritonavir 200/50mg Po B V
Stavudine /Lamivudine 30/150mg Po C V
Stavudine/Lamivudine /Nevirapine Po C V
30/150/200mg
Stavudine/Lamivudine 6/30mg Paeds C V
444
Stavudine/Lamivudine/Nevirapine Paeds C V
6/30/50mg
Tenofovir/Emtricitabine Po B V
Tenofovir/Lamivudine 300/300mg Po C V
Tenofovir/Lamivudine/Efavirenz Po C V
Zidovudine/Lamivudine 300/150mg Po C V
Zidovudine/Lamivudine 30/30mg Paeds C V
Zidovudine/Lamivudine/Nevirapine Po C V
300/150/200mg
Zidovudine/Lamivudine/Nevirapine Paeds C V
60/30/50mg
445
EDLIZ 2015
SPECIALIST ESSENTIAL MEDICINE

LIST IN ZIMBABWE
Medicine Dosage form Strength VEN

1
Medicines Used in
Anaesthesia
1.1 General Anaesthetics/Medical Gases
Sevoflurane Gas E
1.2 Local Anaesthetics
Amethocaine Gel 4% N
Ropivacaine Injection 2mg/ml N
1.3 Muscle Relaxants
Pancuronium Injection 2mg/ml N

1.4 Peri-operative medicines
(a)
2
2.1 Narcotic Analgesics

Alfentanil Injection 500mcg/ml N
Fentanyl Injection 50mcg/ml N
2.2 Nonsteroidal Anti-inflammatory

Medicines (NSAID)
Diclofenac Injection 25mg/ml N
Diclofenac sodium Tablet SR 75mg N
Indomethacin Suppository 100mg N
2.3 Disease Modifying Antirheumatic Medicines

Chloroquine Tablet 150mg N
Methotrexate Tablet 2.5mg N
Sulphasalazine Tablet 500mg N
446
3
Antihistamines
Cetirizine Tablet 10mg N
4
ANTIDOTES AND SUBSTANCES FOR TREATMENT OF
POISONING
Edrophonium Injection 10mg/ml V
Flumazenil Injection 0.1mg/ml V
5
Antiinfective medicines
5.1 Antibacterial Medicines
Azithromycin Capsules 250mg V
Co-amoxiclav Tablets 250/125mg V
acid
Ceftazidime Injection 500mg
Ciprofloxacin Injection 10mg/ml V
5.2 Antitubercular Medicines
Cycloserine Tablet 250mg E
Ethionamide Tablet 250mg E
5.3 Antipneumocystis and
antitoxoplasmosis medicines
Primaquine Tablet 15mg N
Pyrimethamine Tablet 25mg E
Sulphadiazine Tablet 500mg E
5.4 Systemic Antifungal
Medicines
Amphotericin B Injection 50mg E
Fluconazole Injection N
5.5 Systemic Antiviral
Medicines
Acyclovir Injection 250mg E
6
Antimigraine Medicines
Dihydroergotamine Injection 1mg/ml N
mesylate
Sumatriptan Tablet 50 mg N
447
EDLIZ 2015
7
ANTINEOPLASTIC AND
IMMUNOSUPPRESIVE MEDICINES
7.1 Antineoplastic and lmmunosuppresives
Actinomycin D Injection 0.5mg E
Azathioprine Tablet 50mg E
Bleomycin Injection 15mg E
Busulfan Tablet 2mg E
Carboplatin Injection 10mg/ml N
Chlorambucil Tablet scored 3mg, 5mg E
Cisplatin Injection 500ug/ml E
Cyclophosphamide Tablet 50mg E
Cyclophosphamide Injection 200mg, N
500mg
Cytarabine Injection 100mg E
Dacarbazine (DTIC) Injection 200mg E
Daunorubicin Injection 20mg E
Docetaxel Injection 40mg/ml N
Doxorubicin Injection 10mg, E
50mg
Etoposide (VP 16) Tablet 50mg E
Fludarabine phosphate Injection 50mg E
Fluorouracil Injection 25mg/ml E
Fluorouracil Capsule 250mg E
Hydroxyurea Capsule 500mg E
Ifosfamide Injection 1g N
Interferon alpha Injection Million units N
Methotrexate Injection 1g E
Melphalan Tablet 2mg, 5mg E
Mercaptopurine Tablet 50mg E
Mitomycin C Injection 20mg, 40 E
mg
Mustine Injection 10mg E
Procarbazine Capsule 50mg E
Thioguanine Tablet 40mg E
Vinblastine Injection 10mg E
Vincristine Injection 1mg E
448
7.2 Complementary Medicines

Aminoglutethimide Tablet 250mg N
Filgrastim Injection 30million N
units
Folinic acid Tablet 15mg E
Folinic acid Injection 3mg/ml E
Medroxyprogesterone Tablet 100mg N
acetate
Medroxyprogesterone Injection 50mg/ml N
acetate
Mesna Injection 100mg/ml N
Tamoxifen Tablet 10mg N
8
MEDICINES AFFECTING
THE BLOOD
8.1 Anticoagulants and
fibrinolytics
Streptokinase Injection 250 000 IU E
8.2 Antifibrinolytic and Antihaemostatic
Medicines
Tranexamic acid Tablet 500mg N
9
BLOOD PRODUCTS/BLOOD SUBSTITUTES
9.1 Plasma Substitutes (a)
Dextran "70" Infusion 6% in N
glucose
Dextran "70" 5% or in sodium chloride N
0.9%
9.2 Anti-anaemic Medicine
Epoetin alfa and beta Injection 4000units/ N
ml
10 CARDIOVASCULAR
MEDICINES
10.1 Antianginal Medicines
Glyceryl trinitrate Injection 1 mg/ml V
449
EDLIZ 2015
10.2 Antiarrythmic Medicines

Adenosine Injection 3mg/ml N
Amiodorone Injection 50mg/ml E
Propranolol Injection 1mg/ml V
Verapamil Tablet 40mg V
Verapamil Injection 2.5mg/ml V
Sotalol Tablet 10mg N
10.3 Antihypertensive Medicines
Sodium nitroprusside Infusion 10mg/ml N
Minoxidil Tablet 10 mg N
Labetolol Infusion 1mg/ml N
Losartan Tablet 50mg E
Nifedipine Sublingual 10mg N
10.4 Diuretics
10.5 Medicines used in Shock or Anaphylaxis

(c)
Dobutamine Injection 12.5mg/ml V
Dopamine Injection 40mg/ml V
Noradrenaline Injection 2mg/ml V
10.6 Sclerosing Agents
Ethanolamine oleate Injection 5% N
11
CENTRAL NERVOUS SYSTEM MEDICINES
11.1 Anticonvulsants
Sodium valproate Tablet 200mg E
Sodium valproate Suspension 40mg/ml N
Clobazam Tablets 10mg N
Clonazepam Tablet 500ugm E
Lamotrigine Tablet 5, 25mg N
11.2 Psychotherapeutic
Medicines
Methylphenidate Tablet 10mg N
Venlafaxine modified Tablet 75mg E
release
450
11.3 Antiparkinsonian
Medicines
L-dopa Tablet 100/25 N
Orphenadrine Tablet 50mg N
11.4 Medicines used in Spasms and Spastic
Conditions
Baclofen Tablet 10mg N
11.5 Myasthenia Gravis
Edrophonium chloride Injection 10mg/ml V
Pyridostigmine Tablets 60mg V
11.6 Other
Oxybutynin Tablets 2.5mg N
12
DERMATOLOGICAL
AGENTS
12.1 Anti-inflammatory Agents
Betamethasone Cream 0.10% N
12.2 Antibacterial Agents
(Topical)
13
DIAGNOSTIC AGENTS
Tetracosactrin Injection 250ug/ml N
Methylene blue Injection 10mg/ml N
Radiocontrast media
Iohexol Injection “Omnipaque N
300”(or Ultravist)
Iohexol Injection “Omnipaque N
350”(or Ultravist)
Barium EZHD E
Barium EZ-paque N
Pollybar Enema N
Conray 280 N
Urografin 60% N
Meglumine/sodium Injection 100ml “Cardio- N
iothalamate Conray”
Omniscan or Magnavist N
451
EDLIZ 2015
14
GASTROINTESTINAL
MEDICINES
14.1 Antiemetics
Dolasetron Injection 12.5mg E
Ondansetron Tablets 4mg E
Ondansetron Injection 4mg E
14.2 Gastric/Peptic Ulcer
Medicines
14.3 Anti-inflammatory
Medicines
Prednisolone Enema 20mg/100 N
ml
15
HORMONES
15.1 Corticosteroids
Fludrocortisone Tablet 100 N
micrograms
Testosterone Cream 1% N
Methylprednisolone Injection 500mg E
15.2 Androgens
Methyltestosterone Tablets 5mg N
Testosterone Injection 25mg/ml N
Testosterone Injection SR N
15.3 Oestrogens and
Progestogens
Stilboestrol (a) Tablet 1mg N
Oestrogens, conjugated Tablet 0.625 mg N
Oestrogens, conjugated Vaginal cream N
15.4 Sulphonylureas
Gliclazide Tablet 80mg N
Glipizide Tablet 5mg N
452
16
OPHTHALMOLOGICAL
MEDICINES
16.1 Anti-infectives
Ciprofloxacin Eye drops 0.30% E
Neosporin: Eye drops 0.35% E
Bacitracin+neomycin+polym
yxin B
Gentamicin Eye drops 0.30% E
16.2 Corticosteroids/Antiallergics
Dexamethasone Eye drops 0.10% E
Prednisolone-forte Eye drops 1% N
Dexamethasone/neomycin Eye (ear) drops 0. 1 %/0. N
35%
Sodium cromoglycate Eye drops 2% N
16.3 Miotics/ beta-blockers
Levobunolol HCl Eye drops 0.50% E
Timolol maleate Eye drops 0.50% E
16.4 Mydriatics
Homatropine Eye drops 1% N
Tropicamide Eye drops 1% N
16.5 Diagnostics
Fluorescein sodium Eye drops 1% N
16.6 Systemic Treatment of
Glaucoma
Acetazolamide Injection 500mg/ml N
16.7 Miscellaneous
Methylcellulose (artificial tears) N
17
EAR, NOSE AND THROAT
PREPARATIONS
17.1 Ear drops
Clotrimazole Ear drops 1% N
Gentamicin Ear drops 0.30% N
17.2 Inhalers
Ipratropium Inhaler 20mcg N
dose
453
EDLIZ 2015
18
AGENTS CORRECTING WATER AND ELECTROLYTE
DISTURBANCES
18.1 Parenteral Nutrition
Parenteral iron Injection N
Aminoacid Solution N
Aminoacid with electrolytes Solution N
Dextrose 20% Solution N
Lipid-solution Infusion 10% 500ml N
Lipid-solution Infusion 20% 500ml N
Trace elements Injection (additive) N
Vitamins (fat soluble) Injection (additive) N
Vitamins, water soluble Injection (additive) N
Dialysis Solutions
18.2
Intraperitoneal dialysis Solution with 1.5%dextrose V
Intraperitoneal dialysis Solution with 4.5% dextrose V
Haemodialysis conc. Solution E
454
INDEX
INDEX BY MEDICINE NAME
455
EDLIZ 2015
INDEX BY MEDICINE NAME
A
Abacavir ................................................................................... 468
abortion ................................................................................. 71, 83
Acetazolamide ................................................................. 467, 477
acetylcysteine .................................................................... 387, 462
Acne ........................................................................................... 324
Acute Respiratory Infections ............................................... 25, 193
acyclovir............................................................. 117, 118, 462, 471
ADR reporting ............................................................................ 436
Adrenaline ............................................... 18, 23, 55, 404, 411, 467
adrenaline 1 in 10 000 ...................................................... 377, 411
adriamycin................................................................................ 433
Advantages of EDLIZ ................................................................ ix
AIDS
AIDS Dementia Complex ............................................... 113, 116
see also HIV 3, 4, 6, 13, 14, 27, 52, 53, 59, 62, 63, 66, 67, 75, 81,
82, 84, 95, 98, 101, 103, 104, 105, 109, 110, 111, 113, 116,
117, 119, 120, 121, 125, 129, 131, 141, 146, 147, 148, 149,
150, 193, 196, 221, 226, 236, 237, 245, 269, 270, 275, 277,
285, 303, 305, 328, 356, 363, 364, 366, 436
albendazole ......................................................... 51, 163, 164, 462
Albinism ..................................................................................... 331
Alcohol Dependence.................................................................. 289
alcuronium chloride................................... 403, 405, 408, 409, 461
allopurinol ................................................. 238, 242, 243, 277, 461
amiloride ........................................................................... 457, 464
Aminophylline ............................................................... 23, 55, 467
Amitriptyline .............. 118, 271, 272, 277, 286, 288, 346, 350, 384
Amitriptylline ............................................................................ 465
Amoebic Abscess ................................................................. 226
456
amoxicillin .....viii, 2, 5, 23, 34, 45, 54, 55, 70, 71, 73, 82, 111, 112,
195, 196, 197, 220, 296, 305, 309, 310, 312, 313, 314, 315,
316, 318, 320, 321, 355, 462
ampicillin ................................. viii, 2, 4, 72, 76, 228, 232, 459, 462
anaemia 3, 43, 53, 75, 129, 162, 183, 190, 210, 227, 336, 353, 354,
355, 356, 363, 364
Anaemia ....................................................................... 65, 216, 352
analgesia 33, 86, 117, 242, 336, 343, 344, 346, 348, 355, 356, 394,
397, 398, 399, 400, 401, 404, 410
anaphylaxis .............................. 3, 63, 376, 395, 407, 411, 412, 436
Angina Pectoris ......................................................................... 211
Angina unstable ........................................................................ 212
Anthrax ..............................................................................158, 159
Anticoagulation ......................................................................... 360
Antiemetics ................................................................. 86, 407, 476
Antimicrobial Treatment and Prophylaxis .................................... 1
ANTINEOPLASTIC ...............................................................428, 472
Anti-tetanus
booster ..........................................................................336, 339
Anxiety Disorders ...................................................................... 288
aqueous cream ..................................................................329, 465
Artemether-lumefantrine ........................................................ 179
Arthritis ...................................................... 168, 241, 242, 244, 245
aspirin .. viii, 86, 167, 168, 212, 213, 237, 242, 243, 244, 245, 270,
271, 272, 276, 343, 346, 355, 356, 457
asthma . 30, 197, 199, 200, 201, 202, 204, 205, 243, 263, 272, 328,
373
Asthma............................................... xiv, 199, 201, 202, 203, 409
atenolol ............................................. 208, 212, 213, 238, 457, 464
Athlete's Foot............................................................................ 325
Atracurium .........................................................................402, 461
atrial fibrillation ................................................. 214, 276, 350, 361
atrial flutter ........................................................................213, 214
atropine ............................. 292, 389, 390, 391, 395, 400, 402, 403
Aute Confusional States
delirium ................................................................................ 275
Azithromycin .............................................................. 172, 173, 471
457
EDLIZ 2015
B
Back and neck pain .................................................................... 242
BCG .................................................52, 58, 147, 149, 150, 166, 467
beclomethasone inhaler ............................................ 201, 205, 467
beclomethasone nasal spray ................................................ 467
benzathine penicillin ............................... 71, 98, 99, 100, 207, 462
Benzhexol .......................................................... 278, 283, 284, 465
benzoyl peroxide 5% gel ........................................................ 465
benzyl benzoate ........................................................ 102, 327, 462
benzylpenicillin .. 5, 20, 21, 25, 27, 32, 33, 45, 54, 72, 73, 112, 159,
195, 196, 268, 269, 337, 340, 459, 462
Bilharzia ..................................................................................... 161
Biperiden ................................................................... 283, 393, 465
birth asphyxia ........................................................................ 18, 19
Bisacodyl .................................................................................. 466
bismuth subgallate with 1% hydrocortisone ..................... 228, 466
Blindness ................................................................................... 291
Blood Products .......................................... 352, 356, 363, 374, 460
boils ........................................................................................... 323
bowel washout .......................................................................... 228
Buboes ......................................................................................... 98
bupivacaine hydrochloride ........................................ 404, 405, 461
burn cream ........................................................................ 338, 341
Burns ..........................................296, 332, 333, 334, 335, 336, 338
C
Caesarean section ......................................................................... 5
Calamine ................................................................... 117, 327, 328
calamine lotion .................................................................. 327, 465
calcium chloride 10% ............................................................. 467
calcium gluconate 10% .......................................................... 467
candidiasis ............................................35, 52, 53, 71, 92, 302, 303
captopril ............................................................ 210, 213, 238, 457
Carbamate ................................................................................. 389
Carbamazepine .... 68, 118, 273, 277, 285, 346, 360, 457, 458, 465
carbidopa-levodopa ................................................................ 465
Carbimazole ........................................................... 85, 86, 265, 466
458
cardiac failure ............................ 194, 211, 276, 356, 363, 364, 433
Cardiac Failure ...................................................................210, 411
carditis ...................................................................................... 207
Ceftazidime ............................................................................. 471
Cellulitis..................................................................................... 324
Cervical ripeners ......................................................................... 80
CHEMICAL BURNS ..................................................................... 290
Chemotherapy ................................... 428, 429, 430, 431, 433, 434
chest indrawing .................................................... 26, 29, 30, 31, 32
Chickenpox................................................................................ 327
chlamydia ...............................................................................72, 89
chloramphenicol ...... 4, 5, 6, 20, 31, 32, 72, 73, 109, 165, 239, 269,
341, 458, 459, 462
Chlorhexidine ........................................................................... 305
chloroquine ......................... viii, 244, 245, 355, 356, 386, 436, 457
chlorpheniramine .................................. 74, 86, 118, 328, 330, 462
Chlorpheniramine ..................................................... 327, 329, 378
Chlorpromazine ............................. 21, 55, 275, 281, 350, 393, 465
cholera ............................................................. 37, 41, 42, 222, 223
Cholera ......................................................... 41, 174, 222, 223, 225
Chronic Obstructive Pulmonary Disease ................................... 197
Cimetidine ................................................................................. 360
ciprofloxacin......................................................... 99, 270, 462, 471
clindamycin ........................................ 112, 194, 195, 241, 270, 462
clofazimine ................................................................. 167, 169, 462
Clonazepam .......................................................................274, 288
Clotrimazole ............................................................ 71, 92, 93, 325
clotrimazole cream 1% .......................................................... 462
clotrimazole pess.................................................................... 462
cloxacillin ...... 4, 20, 31, 32, 193, 195, 196, 241, 323, 324, 329, 462
Cluster Headaches............................................................... 272
coal tar 5% ointment .............................................................. 465
co-amoxiclavulanic ................................................................... 196
codeine ...... 110, 227, 237, 271, 278, 336, 344, 346, 347, 348, 355,
356, 393, 461
Codeine phosphate .................................................................. 277
colchicine ................................................................... 242, 243, 461
combined oral contraceptive pill ................................... 70, 84, 466
compound benzoic acid ointment ........................................ 466
459
EDLIZ 2015
condoms .......................................................................... 67, 68, 89

Conjunctivitis ............................................................. 293, 294, 295
constipation ................................169, 171, 228, 288, 347, 348, 382
Constipation .............................................................. 227, 345, 408
contraception ........................................................................ 66, 68
Convulsions ................................................................... 21, 86, 190
Corneal Abrasion ....................................................................... 296
Corneal ulcer ............................................................................. 293
cotrimoxazole 6, 27, 28, 33, 34, 42, 45, 53, 54, 105, 112, 113, 118,
194, 238, 458, 462
Cotrimoxazole prophylaxis ........................ 105, 106, 117, 132, 304
cough/cold ................................................................................... 29
Cradle cap.................................................................................. 328
croup ........................................................................................... 31
cryoprecipitate ......................................... 357, 358, 359, 367, 464
Cryptococcal Meningitis ............................................................ 113
Crystalloids ................................................................................ 372
Cystitis ....................................................................................... 232
D
dapsone ..................................................... 166, 167, 354, 355, 462
Darrows with dextrose ...................................................... 375, 467
Deep Vein Thrombosis....................................................... 361, 362
Dehydration ........................................37, 39, 40, 74, 173, 224, 370
Delirium ..................................................................................... 275
Depression ................................................................................. 286
Dexamethasone........................................................... 23, 466, 477
dextrose 10% ....................................................... 19, 190, 229, 467
dextrose 5% . 79, 212, 213, 233, 258, 370, 378, 384, 385, 386, 387,
391, 467
dextrose 50% ............................................. 190, 274, 275, 387, 467
Diabetes............................................... 79, 169, 237, 247, 261, 287
Diabetic Diet .............................................................................. 254
dialysis ............................................... 233, 234, 236, 238, 239, 478
diarrhoea 25, 35, 37, 38, 41, 43, 51, 52, 53, 63, 109, 110, 171, 221,
222, 223, 224, 228, 233, 287, 331, 350, 369, 373, 376
Diarrhoea chronic ...................................................................... 226
Diarrhoea in Children .......................................................... 35, 371
460
Diazepam . 21, 22, 24, 56, 68, 85, 86, 229, 274, 275, 283, 288, 289,
350, 384, 385, 386, 387, 388, 400, 406, 465
diclofenac ................................... 242, 243, 244, 245, 409, 461, 470
Didanosine .............................................................................. 468
digoxin ........................... ix, 210, 211, 213, 214, 238, 349, 457, 464
Disseminated Intravascular Coagulation................................... 358
Dobutamine .......................................................................411, 474
DOTS ..................................................................................146, 151
doxycycline .. 71, 72, 84, 90, 99, 100, 111, 159, 165, 182, 190, 197,
228, 238, 325, 458, 462
DPT ................................................................................. 58, 63, 467
DPT+HBV ................................................................................ 467
DT58, 63, 467
dysentery .............................................................................41, 162
Dyspepsia .............................................................................. 221
E
Ear infection ...........................................................................33, 34
eclampsia .............................................................................77, 209
Eclampsia ...............................................................................77, 78
eczema .................................................................................53, 328
Eczema ...................................................................................... 328
Edrophonium....................................................................471, 475
Efavirenz .................................................................... 238, 468, 469
Embolism .................................................................................. 362
Emergency Contraception .......................................................... 84
EMERGENCY CONTRACEPTION .................................................. 70
Empyema ....................................................................... 32, 33, 196
emulsifying ointment .........................................................329, 466
enalapril ..................................................................... 210, 238, 464
ephedrine................................................................... 404, 412, 464
Epididymo-orchitis ...............................................................99, 164
Epilepsy ...................................................................... 272, 281, 287
Ergometrine............................................................................. 467
ergotamine ................................................................ 271, 272, 461
Erysipelas ...........................................................................323, 324
Erythema Nodosum Leprosum ................................................. 168
461
EDLIZ 2015
erythromycin 33, 72, 93, 98, 99, 100, 102, 207, 295, 323, 329, 337,
457, 458, 462
Essential tremor ........................................................................ 278
ethambutol ................................................................ 150, 237, 463
etomidate .......................................................................... 398, 461
Eye Penetrating Injury ............................................................... 296
F
factor IX conc. ......................................................................... 464
factor VIII con. ......................................................................... 464
ferrous sulphate ...................................22, 47, 51, 74, 75, 353, 464
fluconazole ........................................................................ 458, 463
Fluconazole ............................................................... 114, 115, 304
Flumazenil................................................................................ 471
Fluoxetine ......................................................................... 287, 288
Flupentixol decanoate .............................................................. 282
Fluphenazine decanoate ................................................... 282, 350
fluphenazine deconoate ......................................................... 465
folic acid ................................. 22, 41, 47, 74, 75, 87, 353, 354, 464
Folliculitis ........................................................................... 118, 323
Foreign Body................................................................................ 32
frusemide ...... ix, 190, 210, 211, 230, 236, 238, 363, 385, 457, 464
Furunculosis............................................................................... 323
G
G6PD deficiency......................................................................... 355
Gamma benzene hexachloride ......................................... 102, 327
gamma benzene hexachloride 1% ..................................... 102, 466
Gastroeosophageal disease ....................................................... 217
genital lesions .............................................................................. 96
Genital Ulcers .............................................................................. 95
Genital warts ............................................................................. 101
gentamicin . 3, 4, 20, 45, 72, 86, 195, 196, 228, 232, 233, 238, 340,
459, 463
gentian violet ................................................................... 117, 463
Glaucoma .................................................................. 292, 297, 477
Glibenclamide .................................................................. 250, 466
462
Gloves ................................................................................ 8, 9, 429
glycerine suppositories .......................................................... 466
glyceryl trinitrate ....................................................... 212, 464, 473
Goals of ART ............................................................................. 121
Goitre ........................................................................... 66, 263, 265
Gout ........................................................................... 242, 460, 461
Graves’ Disease ......................................................................... 265
griseofulvin ................................................................ 325, 326, 463
Growth faltering.......................................................................... 43
Gum infections ........................................................... 302, 303, 305
H
H. pylori eradication.................................................................. 220
Haemophilia B ....................................................................357, 358
Haemorrhagic disease of the new-born.................................... 359
Haemorrhoids ........................................................................... 228
Haloperidol ........................................................ 281, 345, 350, 465
halothane ...........................................................................400, 461
Hand Hygiene ............................................................................ 8
HB ................................................................................ 58, 190, 467
Headache ........................................................... 113, 268, 270, 411
Helminthiasis ............................................................................ 163
heparin ............ 76, 87, 211, 212, 237, 359, 361, 362, 376, 392, 459
Herbicides ................................................................................. 390
Herpes Simplex ............................................ 12, 118, 302, 304, 327
Hexoprenaline ......................................................................... 467
Histoplasmosis ...................................................................302, 306
Hormonal Contraception ............................................................ 66
hospital medicine and therapeutics committees .................... xi
Human African Trypanosomiasis .............................................. 170
hydralazine...........................................................................78, 464
hydrochlorothiazide ...........................................................276, 464
hydrocortisone ...118, 203, 204, 266, 325, 362, 378, 385, 390, 412
Hydrocortisone ...................................................... 24, 56, 412, 466
hyoscine butylbromide ........................................................... 466
Hyperglycaemic Coma .......................................................258, 261
hypertension .... 67, 69, 75, 76, 77, 78, 87, 207, 209, 210, 211, 236,
255, 276, 349
463
EDLIZ 2015
Hypertension ................................................................. 76, 77, 399

Hyperthyroidism ........................................................................ 263
Hypoadrenalism ........................................................................ 266
Hypoglycaemic Coma ................................................................ 256
Hypothyroidism ......................................................................... 265
I
ibuprofen ............................ 242, 243, 244, 245, 343, 346, 351, 461
Imipramine .................................................. 68, 286, 288, 384, 465
Immunisation ............................. xiv, 52, 58, 60, 62, 63, 147, 166
Impetigo ............................................................................ 118, 323
Implant Contraceptive ................................................................ 69
indomethacin ............. 117, 118, 237, 242, 243, 244, 245, 346, 461
Infection Prevention and Control Measures ................................. 7
Insulin ........................... 79, 247, 249, 254, 255, 259, 261, 262, 466
iodine solution ................................................................... 265, 466
ipratropium ....................................................................... 197, 477
Iritis ................................................................................... 293, 297
Irritable Bowel Syndrome .......................................................... 226
Isoflurane .......................................................................... 401, 461
isoniazid ......... ix, 147, 148, 150, 152, 154, 237, 277, 457, 458, 463
isosorbide .................................................................. 212, 213, 464
J
Jaundice ............................................................................... 21, 183
K
kanamycin ........ 3, 27, 33, 45, 54, 86, 87, 90, 93, 99, 102, 295, 463
Kaposi’s Sarcoma ....................................... 109, 119, 194, 302, 304
Katayama Syndrome.................................................................. 162
ketamine.................................................................... 399, 400, 461
ketoconazole ..................................................................... 458, 463
Ketoconazole............................................................. 304, 306, 326
Kwashiorkor ..................................................................... 43, 50, 51
464
L
Labour initiators .......................................................................... 80
Lamivudine................................................................. 238, 468, 469
Leprosy............................................................... 165, 166, 169, 174
levonorgestrel implant .........................................................69, 466
Lignocaine .................................................. 399, 405, 410, 412, 461
lignocaine + adrenaline ......................................................... 461
lignocaine hydrochloride ....................................................... 461
lignocaine no preserv 2% ...................................................... 461
liquid paraffin .....................................................................227, 466
lisinopril .................................................................................... 464
Lithium carbonate .................................................................... 285
Liver Abscess ............................................................................. 226
Liver Disease ......................................................................228, 359
Lorazepam ................................................................................ 281
Lund & Browder .................................................................333, 334
M
magnesium sulphate .............................................................. 464
magnesium trisilicate ................... 79, 217, 228, 244, 339, 351, 466
Maintelyte.................................................................. 373, 375, 468
Malabsorption Syndromes ........................................................ 227
Malaria ...................................... xv, 3, 25, 176, 177, 178, 179, 181
Malaria in pregnancy ........................................................... 180
Malnutrition .......... 14, 25, 35, 37, 43, 46, 50, 52, 63, 110, 336, 364
Mania .................................................................................284, 287
Mantoux test ............................................................. 147, 149, 150
Marasmus ........................................................................ 43, 50, 51
Massive intractable ascites ....................................................... 230
Measles ................................................................................58, 467
Medicine Interactions ............................................................... 456
Medicines in Pregnancy and Lactation ....................................... 85
medroxyprogesterone acetate .................................... 69, 466, 473
Meningitis .................................................................... 20, 174, 268
Metformin ..........................................................................256, 466
methyldopa ...................................................... 68, 76, 77, 239, 464
Methylphenidate...................................................................... 289
465
EDLIZ 2015
Metoclopramide ........................217, 222, 271, 345, 347, 407, 466

metronidazole . 5, 20, 41, 71, 72, 73, 82, 90, 92, 93, 109, 196, 225,
226, 227, 228, 239, 458, 463
Metronidazole..................................................... 73, 220, 226, 305
Miconazole cream ............................................................. 118, 325
Miconazole cream 2% ....................................................... 325, 463
miconazole oral gel ................................................................. 463
Miconazole oral gel ................................................................... 304
Miconazole pess ..................................................................... 463
Midazolam ........................................................................ 406, 465
Migraine .................................................................................... 271
Misoprostol .............................................................................. 467
Moderate pneumonia ........................................................... 28, 29
Molluscum Contagiosum ........................................................... 101
Morning-after pill ........................................................................ 84
morphine .... 211, 213, 227, 344, 345, 346, 347, 348, 356, 393, 461
Morphine .......................................24, 56, 344, 345, 355, 408, 409
Mushrooms ............................................................................... 395
Myocardial Infarction ........................................................ 212, 213
Myometrial Stimulants ................................................................ 81
N
nalidixic acid ........................................................................ 41, 238
Nalidixic acid ............................................................... 70, 110, 222
naloxone neonatal 20mcg/ml.............................................. 18, 462
neomycin ........................................................... 228, 328, 463, 477
Neonatal Conditions ...................................................... 14, 80, 371
Neonatal Infections ..................................................................... 19
Neonatalyte ....................................................................... 375, 468
neostigmine bromide ........................................................ 403, 461
Nephritic Syndrome................................................................... 236
Nephrotic Syndrome ................................................................. 236
Neurocysticercosis ............................................................. 163, 270
Neuroleptic Malignant Syndrome ............................................ 284
Nevirapine ................................................ 128, 238, 326, 468, 469
Nicotinamide ............................................................................ 468
Nifedipine ......................................................................... 464, 474
nifedipine sr ............................................................................. 464
466
nitrofurantoin .................................................... 232, 238, 355, 463
nitrous oxide ......................................................................400, 461
NMTPAC .................................................................... iii, v, vii, xi, xiii
Non-organic psychosis .............................................................. 280
norethisterone enanthate ...................................................... 466
norfloxacin ................................................................... 72, 232, 463
Notifiable Diseases.................................................................... 174
Numb hands and feet ............................................................... 277
nystatin ....................................................................................... 35
Nystatin lozenges ..................................................................... 304
Nystatin suspension ................................................................. 304
O
Oesophageal Candidiasis ........................................... 109, 302, 304
Oesophageal Varices, bleeding ................................................. 229
Olanzapine ................................................................................ 281
Omeprazole ............................................................... 217, 220, 466
Ophthalmia Neonatorum .......................................................... 102
OPV .......................................................................................... 467
Oral Contraceptives ....................................................... 67, 68, 286
Oral problems ....................................................................302, 303
Oral thrush ................................................................. 109, 302, 303
Organic Psychosis...................................................................... 282
Organophosphate ..................................................................... 389
Osteoarthritis ............................................................................ 245
Osteomyelitis ............................................................................ 241
Otitis ......................................................................................... 308
oxygen.. 20, 197, 202, 204, 211, 274, 275, 333, 348, 377, 384, 385,
389, 390, 397, 400
Oxygen ......................... 28, 202, 212, 333, 348, 390, 400, 410, 461
Oxytocics ..................................................................................... 81
Oxytocin ................................................................... 73, 76, 81, 467
P
Paediatric Conditions ......................................................... 2, 13, 25
Paediatric Medicines Doses ........................................................ 55
para aminobenzoic acid ........................................................ 466
467
EDLIZ 2015
paracetamol . viii, 28, 29, 33, 34, 54, 237, 242, 243, 244, 271, 275,
296, 336, 343, 347, 356, 386, 461
Paraquat .................................................................................... 390
Parkinsonism ..................................................................... 278, 283
Paronychia ................................................................................. 324
Paroxysmal supraventricular tachycardia .................................. 214
Pediculosis pubis ....................................................................... 102
Pellagra ...................................................................................... 331
Pelvic Inflammatory Disease................................................ 72, 101
Peritonitis .................................................................................. 228
Pernicious Anaemia ................................................................... 227
Persistent Generalized Lymphadenopathy ........................ 302, 305
Personal Protective Equipment ............................................ 8
Pertussis .......................................................................... 33, 58, 63
Pesticides ................................................................................... 388
pethidine .................................. 18, 79, 80, 237, 337, 345, 393, 461
Phenobarbitone ...... 21, 22, 24, 57, 68, 85, 86, 238, 273, 274, 457,
458, 465
Phenytoin ................................ ix, 68, 273, 274, 275, 393, 457, 458
phenytoin sodium.............................................................. 275, 465
pilocarpine eye drops ............................................................. 467
Pityriasis Versicolor .................................................................. 326
Plague ................................................................................ 165, 174
plasma ... 1, 208, 229, 277, 349, 357, 358, 359, 360, 371, 374, 386,
456, 458
platelet conc ...................................................................... 359, 464
PMTCT ......................................................................... 87, 120, 141
Pneumocystis jiroveci pneumonia ............................... 53, 111, 112
Pneumonia .......................................................... 26, 193, 195, 196
podophyllin paint .............................................................. 101, 466
Poisoning ... 221, 379, 380, 384, 385, 386, 387, 388, 391, 392, 393,
460, 462, 471
Post Abortal Sepsis ...................................................................... 71
Post Coital Contraception ............................................................ 84
Post-Herpetic Neuralgia ............................................................ 118
potassium chloride ......... 42, 47, 211, 229, 259, 261, 262, 459, 465
potassium permanganate ...................................................... 466
povidone iodine ......................................... 117, 305, 339, 341, 466
Pralidoxime ........................................................................ 389, 462
468
praziquantel ....................................................... 162, 163, 270, 463
prazosin................................................ 76, 208, 209, 210, 457, 465
Prednisolone .................... 31, 57, 87, 112, 114, 194, 266, 466, 476
primaquine......................................................... 112, 194, 355, 463
Principles of antimicrobial use ...................................................... 1
procaine penicillin ................................ 25, 27, 28, 34, 54, 100, 159
Prochlorperazine ................................................................408, 466
progesterone only pill............................................................. 466
proguanil .................................................................................. 463
Prolonged Rupture of Membranes ............................................. 73
promethazine ............74, 79, 86, 118, 329, 330, 347, 378, 407, 462
propofol .................................................................................... 399
Propofol .............................................................................399, 461
propranolol ........................ 207, 238, 263, 265, 272, 278, 457, 465
Prurigo ...................................................................................... 118
Psoriasis .................................................................................... 330
Psychoses .................................................................................. 280
Pubic lice ................................................................................... 102
pulmonary embolism. ................................................................. 87
pulmonary oedema .................................................... 190, 209, 211
Pyelonephritis ........................................................................... 232
Pyogenic Abscess ............................................................... 226
pyrazinamide ..................................................... 118, 150, 237, 463
Pyridoxine ................................................................................ 468
pyrimethamine + dapsone..................................................... 463
Q
quinine ....... 178, 179, 182, 183, 189, 190, 239, 355, 356, 457, 463
quinine infusion .................................................................189, 463
R
Rabies................................................................... 58, 160, 174, 467
rabies immunoglobulin ......................................................160, 467
rabies vaccine ............................................................ 160, 161, 467
Raniditine................................................................................. 466
Rational prescribing ................................................... ix, x, xi, 121
red cell conc. ........................................................................... 464
469
EDLIZ 2015
Renal Failure ...................................................................... 233, 237

Rheumatoid Arthritis ................................................................. 244
rifampicin ......................... 6, 68, 150, 152, 166, 167, 457, 458, 463
ringer lactate ..................................................................... 370, 468
Ringworm .......................................................................... 325, 326
Risperidone................................................................................ 281
S
Salbutamol........................................................................... 57, 467
salbutamol inhaler ..................................... 197, 201, 202, 204, 467
salbutamol nebulised .......................... 31, 197, 202, 203, 234, 467
Salicylic acid .............................................................................. 330
Scabies ....................................................................................... 326
Schistosoma Haematobilium ..................................................... 162
Schistosoma Mansoni ....................................................... 161, 162
scorpion antivenom ................................................................ 462
Scorpion Sting ............................................................................ 395
Seborrheic Dermatitis ................................................................ 118
Selenium sulphide 2%............................................................ 464
Sertraline................................................................................... 287
Severe pneumonia........................................................... 27, 37, 53
Shock ................................................................. 183, 372, 410, 474
Sickle Cell Anaemia .................................................................... 354
silver sulphadiazine ................................................... 339, 341, 466
Sinusitis.............................................................................. 200, 270
snake antivenom polyvalent .................................................. 462
Snake Bite .................................................................................. 394
soda lime ........................................................................... 401, 461
sodium bicarbonate 4.2% ...................................................... 468
sodium bicarbonate 8.4% ...................................................... 468
sodium bicarbonate slow iv 4.2% ............................................... 18
sodium chloride ... 40, 42, 73, 81, 82, 212, 213, 233, 258, 261, 370,
371, 374, 381, 391, 468, 473
sodium citrate ............................................................. 79, 407, 467
sodium valproate....................................................................... 274
Sodium valproate...................................................................... 285
Soluble insulin ........................................................... 247, 260, 262
Sore Throat .................................................................................. 34
470
Spinal Spondylosis..................................................................... 245
spironolactone ........................................................... 230, 238, 465
Spondyloarthropathies ............................................................. 245
Starter Pack .............................................................................. 128
Status epilepticus ...................................................................... 274
Stavudine ...........................................................................238, 468
streptokinase ............................................................. 213, 362, 464
streptomycin ...................... 3, 86, 87, 118, 150, 151, 165, 237, 464
Stridor ......................................................................................... 31
Stroke ........................................................................................ 276
Sugar Salt Solution ........................................................... 38, 39, 42
Sulphadiazine ........................................................................... 270
sulphadoxine + pyrimethamine ............................................ 464
sulphur 5% - 10% ointment ................................................... 466
Sulphur ointment ..................................................................... 327
Sulpiride.................................................................................... 281
suxamethonium chloride ........................................... 275, 402, 461
Syphilis ..................................................................... 71, 95, 99, 100
Systemic Lupus Erythematosus ................................................. 245
T
Tardive dyskinesia .................................................................... 284
Tenofovir .................................................................... 238, 468, 469
Termination of Pregnancy........................................................... 82
Tetanus Immunisations ............................................................... 62
tetanus immunoglobin ........................................................... 467
tetanus toxoid ...................................... 62, 296, 336, 339, 394, 467
tetracycline eye ointment 1%................................................ 467
theophylline .......................................... ix, 202, 204, 205, 458, 467
thiamine ............................................................. 111, 229, 289, 387
Thiamine .................................................................................. 468
thiopentone sodium .................................................. 275, 398, 461
Thrombocytopaenic Purpura .................................................... 359
thrombo-embolism ................................................................67, 69
Thyroid Disease ......................................................................... 263
Thyroxine ....................................................... 24, 57, 263, 265, 467
Tick Typhus ............................................................................... 159
Tinea Capitis .............................................................................. 326
471
EDLIZ 2015
Tinea Corporis ........................................................................... 325

Tinea Pedis ................................................................................ 325
Triamcinolone acetonide in orabase ........................................ 305
Trifluoperazine .................................................................. 281, 465
trimeprazine tartrate ......................................................... 407, 461
Tuberculin Testing .................................................................... 149
tuberculin, purified ............................................................ 149, 467
tuberculosis ...................... 2, 53, 111, 146, 148, 153, 169, 193, 195
TYPHOID FEVER ......................................................................... 171
U
Ulcer
Peptic Ulcer ................................................................... 220, 476
Ulcers ....................................................... 95, 97, 98, 297, 302, 305
Urethral Discharge................................................................. 89, 91
Urinary Tract Infections ............................................................. 232
Urticaria ..................................................................................... 329
uveitis ........................................................................................ 293
V
Vaginal discharge................................................................... 92, 94
Vaginal Discharge ........................................................................ 92
Vecuronium....................................................................... 402, 461
Ventricular tachycardia ............................................................. 214
verapamil ................................................................... 213, 214, 465
Verapamil ......................................................................... 465, 474
vitamin A ............................................................... 41, 47, 292, 468
Vitamin A deficiency .................................................................. 292
vitamin B12 (hydroxocobalamin) .......................................... 464
vitamin D ............................................................................. 22, 468
vitamin K .........................................15, 86, 229, 359, 360, 365, 464
vitamins, multi ........................................................................... 111
W
warfarin ........................ 75, 214, 276, 360, 361, 362, 365, 389, 457
Warts ......................................................................................... 331
472
Wheezing ...............................................................................29, 30
X
Xerophthalmia .......................................................................... 292
Z
Zidovudine ................................................................. 238, 468, 469
zinc oxide ointment ...........................................................330, 466
473
EDLIZ 2015
NOTES
474
NOTES
475
EDLIZ 2015
This concludes
the EDLIZ 2015
USE IT WELL!
476
For the side cover
477
EDLIZ 2015
478

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F

EDLIZ 7TH EDITION 2015

Further copies may be obtained through the relevant Provincial Medical

No part of this publication may be reproduced by any process without

EDLIZ REVIEW COMMITTEE

Borok Margaret Mujuru Hilda

Chirenje Mike Z., Prof. Musiya N, Dr

Mrs R.F. Hove Prof. C. E. Ndhlovu

EDLIZ REMAINS good medicine! Use it.

Hon. Dr. P.D. Parirenyatwa

THE ESSENTIAL MEDICINES LIST FOR

Selection of medicines for inclusion

 relevance to prevalent diseases

is chosen by the manufacturer to facilitate recognition and association of

IMPROVED MEDICINES SUPPLY

MORE RATIONAL  focused, more effective training

The use of EDLIZ also eliminates irrational products from being

IMPROVED PATIENT USE

IMPLEMENTATION OF EDLIZ AND SETTING UP OF

and therapeutics committee (HMTC) should be formed. Given the

EXPLANATIONS & CHANGES FROM THE PREVIOUS

lifesaving or their unavailability would cause serious harm and efforts

The NMTPAC is a standing committee that reviews the therapeutic

Brigadier General (Dr) G. Gwinji

MAJOR HIGHLIGHTS IN THE LATEST

ART Guidelines (use latest ART guidelines)

Metabolic and Endocrine Conditions

EDLIZ 7TH EDITION 2015 III

MEDICINES AND THE ELDERLY 333

Principles of antimicrobial use

Notes on Specific Antimicrobials

Pyrexia/Fever of unknown origin

Medicine Codes Adult dose Frequency Duration

The use of antimicrobials for prophylaxis of

 Hysterectomy, or Colorectal surgery e.g. appendicectomy:

 If signs of infection after operation, give:

Also refer to Obstetrics and Gynaecology/Surgical

 Urinary tract surgery e.g. prostatectomy:

 Subacute bacterial endocarditis See Cardiovascular Chapter

 For meningococcal meningitis contacts. Give as soon as

 Cotrimoxazole Prophylaxis (see HIV chapter):

Types of Hand Hygiene

1. Hand washing is usually limited to hands and wrists, the hands

Use of Personal Protective Equipment.

Gloves are to be worn when touching the following:

A. Important points to remember when using gloves.

 Re-usable goggles should be washed and decontaminated

Please note: All protective equipment should be removed

G. Needles, sharp instruments and other devices.

All equipment contaminated with blood or other body fluids

 Immediately dispose of all disposable syringes and needles,

B) Transmission based precautions.

For example: Benzyl penicillin dose 100,000u/kg/dose (0.1MU/kg)

Routine Management at Birth

 Do not suction mouth routinely, only if there is something (e.g.

 To prevent haemorrhagic disease of the newborn, give:

Resuscitation of the newborn

check respiration, heart rate and colour

Breathing, pink, HR >100