Zimbabue Standard Guidelines Essential Medicines PDF

EDLIZ 2006
5th Essential Drugs List

and
Standard Treatment Guidelines
for
Zimbabwe
EDLIZ 5TH EDITION 2006
PUBLISHED BY:
The National Drug and Therapeutics Policy
Advisory Committee [NDTPAC]
Ministry of Health & Child Welfare
Republic of Zimbabwe
Further copies may be obtained through

the relevant
Provincial Medical Directorate, Health Authority, the
NDTPAC, Ministry of Health & Child Welfare, PO Box CY
1122, Causeway, Harare, Zimbabwe,
or
ndtpac@healthnet.org.zw. Copies of the text may be
obtained on diskette if required for teaching purposes.
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 drug 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
Coverredesign & Layout: Kim Hoppenworth
© Copyright May 2006, Ministry of Health & Child Welfare
EDLIZ REVIEW COMMITTEE
Basopo Victor Mwaramba Charles

Borok Margaret Nathoo Kusum
Chakanyuka Christine Ndhlovu Chiratidzo
Kasule Jonathan Sifeku Flora
Kumire Celestine Simoyi Tendayi
Mahomva Agnes Wellington Maureen
Mashaire S Wilson Eunice
Mujuru Hilda Mudzure Emma
Mupanomunda Maria
ACKNOWLEDGEMENTS
We would like to thank all the individuals who made contributions
through colleagues or discussion forums or by communicating
through mails. 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. Dr K Tisocki and Prof
Mielke spearheaded the revision of our Specialist Drug List revision
which became the basis of our current SEDLIZ. Prof Latif is
recognised for editing the HAQOCI guidelines which formed the
basis of our revisison of the HIV chapter.
The following attended our review workshops as well as being
instrumental in current chapter reviews:
Allain T Dr Maponga CC Dr
Andifasi Dr Masanganise R Mr
Basopo V Mr Mason P Prof
Borok M Dr Matenga JA Prof
Bwakura Dr Mielke J Prof
Chakanyuka C Dr Mujuru H Dr
Chidzonga Prof Mungofa Dr
Chifamba N Dr Mupanomunda M Dr
Chingono A Mr Nathoo K Prof
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EDUZ2006
Dhliwayo P Dr Ndhlovu CE Dr
Dixon M Dr Ndlovu N Dr Nhachi C
Glavintcheva Dr Prof Nyathi M Dr
Gwanzura L Prof Pazvakavambwa I Dr
Hakim JG Prof Pfumojena JW Dr
Hove R Mrs Reid A Dr Sebit Dr
Hoppenworth K Mr Shumbairerwa Dr
Jonsson K Prof Sibanda EN Dr
Kambarami R Prof Sifeku F Mrs
Kasule Prof Simoyi T Ms
Kumire C Mr Tagwireyi D Dr
Lutalo S Dr Trap B Dr
Mabaera B Dr Tumushime-Buturo Mr
Mahomva A Dr Wellington M Dr Euro
Malaba L Dr Health Group
Manase Dr
Mandisodza A Mr
Thank you!
Ms. T. Simoyi Dr. C. E. Ndhlovu

Director of Pharmacy Services NDTPAC Chairperson
4
FOREWORD
FOREWORD
It is the national objective that the health needs of
Zimbabweans are provided for through the provision and
proper use of essential drugs. Sometimes we do not need
to give drugs i.e there is not always a “pill for every ill”.
Thus, there is need to use drugs and 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 our Burden of Disease as reflected by the
inclusion of antiretroviral drugs and treatment of other
opportunistic infections other than 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 new guidelines, to prescribe within the bounds of
this book, and to recognise the critical importance of
providing a quality service to all health care recipients
through the rational use of drugs.
EDLIZ is good medicine! Use it.
Hon. Dr. D P Parirenyatwa Minister of

Health & Child Welfare in Zimbabwe
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EDLIZ2006
THE ESSENTIAL DRUGS LIST FOR

ZIMBABWE - 5TH EDITION
This 5th essential drugs list and standard treatment
guidelines for the most common health conditions in
Zimbabwe has been endorsed by the National Drug &
Therapeutics Policy Advisory Committee [NDTPAC]. 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 result of its widespread use by our healthcare
workers. We continue to revise and take into account drug
developments and new healthcare problems such as HIV
related diseases. Thus this latest edition has included extra
essential drugs. The specialist drugs list has been brought
back into this edition.
The essential drug list is based on the need to have drugs
that cover the majority of our needs. Many other countries,
both industrialised and developing have moved towards
using essential drugs lists. For example Australia. Drugs 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 drugs for inclusion
Selection of drugs for inclusion in EDLIZ have been based on the
following criteria, with special emphasis on proven evidence for
their use in the Zimbabwean setting:
relevance to prevalent diseases Safe
proven efficacy and safety Efficacious
Quality
adequate scientific data in a variety of settings Available
adequate quality Affordable
Accessible
favourable cost-benefit ratio Rationally used
desirable pharmacokinetics
possibilities for local manufacture
available as single ingredient items
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THE ESSENTIAL DRUGS LIST FOR ZIMBABWE - 5TH EDITION
GENERIC DRUGS
Every drug has a chemical name [for example,
N-(4-Hydroxyphenol) acetamide] and an international
non-proprietary name (INN) or generic name
[paracetamol]. The INN is the drug's official name
regardless of who manufactures or markets it. An
additional brand name is chosen by the manufacturer
to facilitate recognition and association of the product
with a particular firm for marketing purposes.
For most common drugs there are several branded
products that all contain the same active ingredient
and therefore share the same INN. For example, the
African Monthly Index of Medical Specialties (MIMS)
lists over fifteen different brand names of paracetamol.
There are 12 different preparations containing aspirin,
13 different brands of amoxycillin, 12 different brands
of ampicillin, 8 different brands of chloroquine….
The use of generic names for drug purchasing as well
as prescribing carries considerations of clarity, quality,
and price. Proponents of generic drug purchasing 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 drug products are often
cheaper than products sold by brand name; this is
shown very clearly when it comes to antiretroviral
drugs . generic prescribing also
facilitates product
substitution, whenever appropriate. Opponents
argue that the quality of generic drugs is inferior to that
of brand-name products. Quality control and naming of
drugs are completely separate issues.
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Generic drugs from reliable suppliers are as safe,

effective, and high in quality as drugs with well-known
brand names. At the same time, brand-name drugs
from a manufacturer with inadequate procedures for
quality control can be of poor quality, despite the
brand name. Also, although any drug can be
counterfeited, there are more incentives for
counterfeiting brand-name drugs. In countries with
strong drug regulatory systems, drug products sold by
generic name have the same low rate of recall as
brand-name products. 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
drugs, 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 drugs (and includes frusemide,
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).
8
ADVANTAGES OF EDLIZ
The benefits of the selection and use of a limited number of
essential drugs are:
Improved drug supply
More rational prescribing
Lower costs
Improved patient use
IMPROVED DRUG SUPPLY

The regular supply of drugs is difficult in many countries, and the
consequent health implications are many. Improved
drug
availability should lead to improved clinical outcomes.
With fewer essential drugs being
purchased, the mechanisms and • easier procurement,
logistics for procurement, storage & storage & distribution
distribution will clearly be easier. It is • lower holding stocks
not practical for each clinic • lower losses
in • better quality assurance
Zimbabwe to attempt to procure,
transport and store all the hundreds
of items in EDLIZ. Conversely, limiting the number of drugs
available at the primary level makes a regular supply of drugs
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 drugs expiring or being damaged during storage.
Quality assurance can be better managed when the number of
drugs is limited, and quality checks can be performed more
frequently.
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EDLIZ2006
M ORE RATIONAL PRESCRIBING

In the absence of limited lists the large variety of
available on the market contributes products to inconsistent
prescribing and
consequently, variation in • focused, more effective training
clinical practice even within • more experience with fewer drugs
the same health • no irrational treatment alternatives
care available
facility. Irrational • focused drug information
better recognition of adverse drug
prescribing leads to •
reactions
therapeutic hazards and
increased costs.
When the number of drugs 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 drugs they use, and better able to recognise adverse effects.
The use of EDLIZ also eliminates irrational products from being
available for prescribing, and allows for more focused drug
information to be provided on suitable essential drugs.
LOWER COSTS
Improved effectiveness and efficiency in
patient treatment leads to lower health • more competition
• lower prices
care costs. The essential drugs concept
is increasingly being accepted as a universal tool to
promote both quality of care and cost control.
Essential drugs are usually available from multiple suppliers. With
increased competition, more favourable prices can be negotiated.
By limiting the number of different drugs that can be used to treat
a particular clinical problem, larger quantities of the selected drug
will be needed, with potential opportunities to achieve economies
of scale.
10
IMPROVED PATIENT USE

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

DRUG AND THERAPEUTICS COMMITTEES
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 drugs 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 drug and
therapeutic committees(HDTC) have to be taken to ensure
cost-effective prescribing and patient care. It is therefore
necessary for each and every hospital to have a forum where
drug issues can be discussed. Ideally, a separate hospital drug
and therapeutics committee(HDTC) should be formed. Given our
current manpower constraints, we encourage hospitals to use
whatever regular meetings they have e.g Division meetings in
Central Hospitals to discuss and address drug related problems.
The NDTPAC will be available to help those hospitals that are
ready to set up an HDTC. There is a Zimbabwean draft
manual(plus a WHO manual) on how to do this.
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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 drug recommendations have
occurred. This , for instance, occurred when the first line treatment for
malaria was changed in the recent past.
All drugs 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, prednisolone is available at District (B) level and is
ranked vital (V).
Drug Codes Adult dose Frequency
Duration
prednisolone po B V 30mg once a day 14
days
LEVEL OF AVAILABILITY
C drugs are those required at primary health care level and should
be available at all levels of care.
B drugs are found at district hospital level or secondary and higher
levels of care. Some B drugs 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 drugs are prescribed at provincial or central hospital levels.
S drugs (specialist only) have been brought back into this
edition.These are drugs that require special expertise and /or diagnostic
tests before being prescribed.
VEN CLASSIFICATION
All drugs are also classified according to their priority. This is mostly a
tool to assist in giving priority to drugs based on economic considerations.
Thus V drugs (vital) are considered life saving or unavailability would
cause serious harm and efforts should always be aimed at making them
100% available.
E drugs are essential, and are given second priority. Without E
drugs there would be major discomfort or irreversible harm. And N
drugs are still necessary but are lower in priority than V and E drugs.
12
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 NDTPAC 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 NDTPAC through
Directorate of Pharmacy Services on
dps@healthnet.org.zw with your comments.
DR E TMABI2A
Permanent Secretary
Ministry of Health & Child Welfare
Republic of Zimbabwe
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EDUZ2006
MAJOR HIGHLIGHTS IN THE

LATEST EDLIZ
Need for Hospital formularies and Hospital Therapeutics

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 drug management or
supply issues. Ideally each hospital should create its own
local drug formulary which shows which drugs are
considered very useful in that setting so that you do not
have to order drugs that your nurse or doctors will not
prescribe use. For instance you should not keep specialist
drugs if there is no specialist to prescribe them. Hospital
Drug and Therapeutics Committees should select drugs for
use in their hospital using the EDLIZ.
New chapters:
There are 3 new chapters – Common Oral Conditions, Ear,
Nose and Throat Disorders as well as a chapter on
Antineoplastic drugs. The latter has been included to remind
healthcare workers that administering chemotherapy agents
requires them to be trained in their use.
HIV and AIDS care:

One of the major changes that has happened since the last
edition of EDLIZ is the revolutionisation of HIV and AIDS
care and management. In particular, we can now offer
treatment to those presenting with Cryptococcal meningitis
whereas before we could not afford to do so. Inclusion of
antiretroviral drugs has obviously improved HIV and AIDS
care. Although we have included a chapter on ART here,
you should use this together with the latest national
Guidelines for Antiretroviral Therapy in Zimbabwe. These
ARV guidelines will be reviewed more often than the EDLIZ.
Be certain that you are using the most recent
recommendation given the rapidly changing therapies in this
field. Due to the use of Fixed Dose Combination(FDC) drugs
in ART, you will come across some brand names where
ART is involved. Generic prescribing is still the norm. Further
management of HIV and AIDs related conditions can
14
MAJOR HIGHLIGHTS IN THE LATEST EDLIZ
be found in greater detail in the HIV and AIDS Quality of

Care Initiative(HAQOCI) Guidelines.
Other Antiviral agents:

Apart from the inclusion of ARVs, antiviral agents such as
acyclovir are now available in generic form and hence have
also been included for use in e.g. disseminated or recurrent
herpes simplex infections or severe cases of herpes zoster.
Antifungal Agents:
Fluconazole is available as a generic formulation as well as
though the DIFLUCAN PARTNERSHIP PROGRAMME
which most hospitals should have access to. In view of the
wider usage of ARVs, you will need to be aware of the
interaction between Ketoconazole and Nevirapine. Thus we
would recommend that Ketoconazole be used sparingly for
instance for Histoplasmosis whereas the oesophageal
candidiasis is treated with fluconazole.
Antibacterial Agents:
Amoxycillin has been recategorised to C level for first line
treatment of moderate pneumonia especially as it is
anticipated that patients may already have been on
Cotrimoxazole prophylaxis.
You will need to be aware of the revised recommendations

for the treatment of bloody dysentery which now includes
the use of Ciprofloxacin but Nalidixic acid is still first line
therapy. These guidelines are based on the latest studies
conducted in this country which showed a growing
resistance by shigella dysentery to nalidixic acid.
Antimalarials:
A lot has occurred with malaria treatment and you will need
to be aware of the latest guidelines as produced via the
National Malaria Subcommittee. Although Zimbabwe has
embraced the use of Artemisinin Combined Therapies(ACT)
such as Coartem which is a combination of Artemisinin and
Lumefantrine, the first line treatment remains as chloroquine
together with Sulphadiazine- Pyridoxine(SP). The latter was
down graded to a household remedy(HR) and hence should
be available to patients without the need for a prescription.
You will need to familiarise yourselves with Intermittent
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EDUZ2006
Presumptive Treatment (IPT) guidelines for malaria in

pregnancy.
Tuberculosis Treatment:
The new TB manual should soon be available and the use
of combined TB drugs will become routine once the drugs
become available.
Paediatric Management:
There have been extensive changes in the paediatrics
chapter and you will need to read it carefully. Please note
the change in the formulation of the Oral Rehydration
Solution (ORS). 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. Give Zinc sulphate 20mg/day for 14days with every
bout of diarrhoea. Give 10mg/day in infants below 6 months.
Gastrointestinal disease
You will now be able to use a proton pump inhibitor as part
of your anti helicobacter therapy. Ranitidine has replaced
Cimetidine and hence should be used as part of the H. pylori
therapy.
Diabetes Mellitus
Watch out for the new algorithm for the treatment of Type II
diabetes. For the type II diabetics who are not well
controlled, one can change to insulin therapy totally or add
insulin to the oral hypoglycaemics.
Specialist Drugs List:

You may not be aware that there was a Specialist Drug
List(SEDLIZ) that was compiled in 2002. Confusion arose
among the healthcare workers due to not knowing what was
on this list and hence the list is now available for you to see
within this new EDLIZ. Specialist drugs are those drugs that
require special expertise or diagnosis and hence their
prescription will be restricted. Each hospital will therefore
have to consider whether or not to include these drugs in
their local formulary. Thus we will encourage the use of
hospital formularies that are commensurate with the
expertise available at a given healthcare delivery centre.
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TABLE OF CONTENT
TABLE OF CONTENT
ANTIMICROBIAL TREATMENT AND PROPHYLAXIS 18
PAEDIATRIC CONDITIONS 24
IMMUNISATION 64
OBSTETRIC AND GYNAECOLOGICAL CONDITIONS 68
SEXUALLY TRANSMITTED INFECTIONS 91
HIV RELATED DISEASE 105
ANTIRETROVIRALTHERAPHY 114
TUBERCULOSIS 121
TROPICAL DISEASES 132
MALARIA 143
RESPIRATORY CONDITIONS 153
CARDIOVASCULAR DISEASE 165
GASTROINTESTINAL CONDITIONS 184
RENAL TRACT CONDITIONS 197
RHEUMATOLOGICAL AND JOINT CONDITIONS 206
METABOLIC & ENDOCRINE CONDITIONS 213
NEUROLOGICAL CONDITIONS 231
PSYCHIATRIC CONDITIONS 245
COMMON EYE CONDITIONS 251
COMMON ORAL CONDITIONS 259
EAR NOSE AND THROAT DISORDERS 264
SKIN CONDITIONS 269
BURNS 280
PAIN & CARE OF THE TERMINALLY ILL 290
DRUGS AND THE ELDERLY 297
HAEMATOLOGY AND BLOOD PRODUCTS 300
INTRAVENOUS FLUID REPLACEMENT 316
ANAPHYLAXIS 324
POISONING 326
DRUGS USED IN ANAESTHESIA 343
ANTINEOPLASTIC AGENTS 355
REPORTING ADVERSE DRUG REACTIONS 364
DRUG INTERACTIONS & INCOMPATIBILITIES 373
INDEX BY MEDICINE NAME 395
INDEX BY CONDITION 404
NOTES 420
NOTES 421
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GUIDELINES ON ANTIMICROBIAL
TREATMENT AND PROPHYLAXIS
GENERAL GUIDELINES
Antimicrobials are the most over-used class of drugs
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 drugs will initially be given “blind”, 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 drug 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
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CHAPTER 1 ANTIMICROBIAL TREATMENT AND PROPHYLAXIS
and sensitivity testing should be obtained before commencing

antimicrobial therapy.
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 i.e. 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, e.g. eye infections
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 e.g. in empirical therapy or
in mixed infections,
to achieve a more rapid and complete bactericidal effect
e.g. in enterococcal endocarditis,
to prevent the emergence of resistant micro-organisms e.g.
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 should be
half the recommended adult dose (see chapter on Drugs 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 amoxycillin 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
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EDUZ2006
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.
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 (i.e. a pruritic rash occurring
within 48 hours or angioedema or anaphylaxis) must not be given
penicillin. Rashes occurring after 48 hours are rarely due to allergy
and are not a contraindication to further use. Erythromycin is a
suitable alternative although the intravenous route is very poorly
tolerated.
If there is a history of cotrimoxazole allergy, and it was not
Stevens-Johnson type, it is likely that the person can be
desensitised (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 e.g. of hepatitis)
Malaria
Typhoid
Urinary tract infection
Bacteraemia
If HIV infection is suspected see guidelines in the chapter on HIV Related
Diseases.
20
If the patient’s general condition is satisfactory, it is reasonable

to withhold antibiotics while carrying out a few basic
investigations: i.e. 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).
Recommended ‘blind’ therapy for septicaemia with no

identifiable source is as follows:
Drug Codes Adult dose Frequency Duration
ampicillin iv B E 2g 4 times a day review
And gentamicin iv B V 4-5mg /kg once a day
max 2 weeks
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EDUZ2006
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 drug (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:
chloramphenicol iv B V 1g single dose
Hysterectomy, Caesarean section, or Colorectal surgery e.g.

appendicectomy:
benzylpenicillin iv C V 5MU single dose
and chloramphenicol iv B V 1g single dose
If signs of infection after operation, give:

amoxycillin po C V 500mg 3 times a day 7 days
and metronidazole po C V 400mg 3 times a day 7 days
Urinary tract surgery e.g. prostatectomy:

Drug Codes Adult dose
Frequency
22
Other prophylaxis
Skull base fracture with liquorrhoea (rhino/otorrhoea):

Subacute bacterial endocarditis See Cardiovascular Chapter
Chemoprophylaxis for meningococcal meningitis contacts. Give

as soon as diagnosis is made in the index case:
Duration
rifampicin po B V 600mg 2 times a
day 2 days
<1yr = 2.5mg/kg
>1yr = 5mg/kg
or ciprofloxacin po B V 500mg once only single
dose
Note: Weigh the benefits against the risks when using ciprofloxacin in
pregnancy.
• Cotrimoxazole Prophylaxis( see HIV chapter):
cotrimoxazole* po C V 960mg every day for life or until
CD4>200 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.
23
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PAEDIATRIC CONDITIONS
Neonatal Conditions 25
Routine Management at Birth 26
Resuscitation of the newborn 26
Feeding and Fluids 28
Neonatal Infections 29
Jaundice 31
Convulsions 31
Vitamins and Iron 32
Paediatric Conditions 35
General guidelines on the use of antibiotics 35
General Danger Signs 35
Acute Respiratory Infections 35
Diarrhoea in Children 47
Protein/Energy Malnutrition 53
Paediatric HIV infection 58
Paediatric Drug Doses 61
24
CHAPTER 2 PAEDIATRIC CONDITIONS
General Notes:
The content of this chapter reflects the major causes of
infant mortality and morbidity in Zimbabwe - perinatal
asphyxia, acute respiratory infections, diarrhoeal diseases,
neonatal sepsis, malnutrition and, immunisable diseases.
Many 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
Drug Dosage for Infants Under 1 Month (see pp)
During the first month of life absorption, metabolism and excretion
in a baby are not yet fully developed. For this reason the frequency
of drug dosing is based on gestational age and not on the
characteristics of the drug.
The table below gives the frequency of dosing for all drugs and is
referred to in the therapies that follow in the text.
Table 2.1 Frequency of dosage by gestational age
Gestational age > 37 weeks (term baby)
First two days 2 doses per 24 hours NB: Not for
3 days to 2 weeks 3 doses per 24 hours gentamicin –
> 2 weeks 4 doses per 24 hours see Table 2.2
Gestational age < 37 weeks (pre-term baby)
First week 2 doses per 24 hours
1-4 weeks 3 doses per 24 hours
> 4 weeks 4 doses per 24 hours
For example: Chloramphenicol dose = 12.5mg/kg. Thus a 2kg

pre-term baby 5 days old would receive 25mg chloramphenicol every
12hours, whilst a 2kg term baby 5 days old would receive 25mg every
8 hours.
25
EDUZ2006
Routine Management at Birth

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.
To prevent neonatal ophthalmia, instil into both eyes:
Drug Codes Paed dose Frequency
Duration
tetracycline eye oint. C V instil into both once only
at birth
1% eyes
To prevent haemorrhagic disease of the newborn, give:
Duration
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

See algorithm on next page:
26
Clear of meconium ?
Breathing or crying ?
Good muscle tone?
Colour pink ? Term
gestation ?
Ventilate with bag and mask *

Administer cardiac massage
* consider
HR < 60 intubation
Give adrenaline1 ml//kg 1:10 000
Consider hypovolaemia and acidosis
27
EDUZ2006
Ensuring adequate warmth and ventilation (either by mask or

intubation) is much more important than administering any drugs.
The following may be useful:
For respiratory depression, but only if the mother was given pethidine in
labour:
Drug Codes Paed dose Freq.
Duration
naloxone neonatal BV <1kg 10mcg =0.5ml repeat as
20mcg/ml im 1-2kg 20mcg =1ml necessary
NB: Note strength. 2-3kg 30mcg =1.5ml
>3kg 40mcg =2ml
Adrenaline dilute to 1:10 CV 10mcg 1ml/kg
000
Only if the baby has no spontaneous breathing after 5 minutes of

ventilation, give a slow intravenous injection directly into
the umbilical vein:
Duratio
n
sodium bicarbonate B N 4-6ml/kg
slow iv 4.2%
or 2-3 ml/kg of 8.4% solution diluted with equal quantity of water for
injection, if only strength available.
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].
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.
28
Day 1
Drug Codes Paed Freq. Duratio n
dose
dextrose 10% iv BN 60ml/kg/24hrs
infusion
Days 2-4 or when otherwise required:

Drug Codes Duratio
n
Paed dose Freq. Same as for oral fluids up to a max. of
150ml/kg/24hrs – inclusive of all fluids
Darrows half strength / dextrose administered – oral, nasogastric and
2.5% iv with 10% dextrose intravenous.
infusion*
or neonatalyte iv infusion B N
*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 2.2 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
There are usually few localising signs in infants, and

accurate diagnosis may not be possible. The following
regimens are recommended for suspected sepsis.
Suspected sepsis in first 48hrs:

2.5mg/kg
Drug Codes Paed
dose
benzylpenicillin im/iv C V
0.1MU/kg
and gentamicin im/iv B V

5 days
Table
Freq.
2.2
Duratio n
Table 5 days
2.1
Suspected sepsis after 48hrs:
29
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Drug Codes Paed Freq. Duratio

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

unavailable
Meningitis:
Drug Codes Paed dose Freq. Duratio
n
benzylpenicillin im/iv
Table 14-21
2.1 days
C V 0.1MU/kg Table
2.2
And gentamicin im/iv B V Table
2.1
2.5mg/kg
And chloramphenicol iv B V
12.5mg/kg
Necrotising enterocolitis
Nil by mouth. Supportive care is vital: oxygen, intravenous
fluids, warmth, nasogastric suctioning. Anticipate
complications such as bleeding, vomiting, perforation,
seizures. Refer for specialist diagnosis and care.
n
Table
benzylpenicillin im/iv C V 0.1MU/kg 10 days
2.1
Table
And gentamicin im/iv B V 2.5mg/kg 2.2 10 days
Table
And metronidazole iv A N 7.5mg/kg 2.1 10 days
Neonatal tetanus
The important principle in treating these babies
is minimal
handling. Give:
n
benzylpenicillin im/iv C V 0.05MU per kg 12 hrly
5-7days
Or Procaine penicillin im C V 50mg/kg Once a 5 -7
day days
And tetanus B E 500 - 1000 units Once
single
immunoglobulin im only dose
30
Control of muscle spasms:

Duratio
n
diazepam iv CV 0.25-1mg/kg
according to [toof
a 10mg]
max total 4-8hrly, titrated
response dose
Or chlorpromazine CV 2mg/kg/24hrs in 4-6 divided doses

iv/im/nasogastric
And phenobarbitone BE 2.5-5mg/kg 12hrly for as
iv/im/nasogastric long as necessary
Congenital syphilis
Drug Codes Paed dose Freq. Duration
Procaine penicillin C V 50mg/kg Once a 10 days
day
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.
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
, then give:
Dextrose 10% iv B N 4ml/kg per hour
infusion
• recheck blood sugar (dextrostix) in 30 minutes

If intravenous route impossible give breast milk
through
nasogastric route -10-20ml/kg initially and continue normal
31
EDUZ2006
requirement two hourly. Dextrose should ??not?? be given by

nasogastric tube.
Anticonvulsants:
Duratio n
phenobarbitone iv B E 10mg per kg over 5-10mins
repeat in 30
minutes if still
convulsing
or paraldehyde deep im A N 0.1ml per kg once
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:
Drug Paed dose Freq. Duratio n
Codes
vitamin D po 800units 5mg once a to age of
day 3mths
B V And folic acid po weekly
Freq.
and, starting from the age of month: Paed Duratio n
one Drug dose

Codes
And ferrous sulphate po C 3-6 mg/kg once a to age
E (60mg/5mls = 12mg elemental iron elemental iron day 3mths
/5mls)
32
Table 2.3 Dosages for infants under one month:

Drug Route Dosage Freq.
(per
day)
Adrenaline 1:1000 iv/sc 0.01mg/kg (=10mcg/kg) -
1mg/ml injection
Aminophylline iv/ infuse Loading: 6mg/kg over 30mins -
25mg/ml injection Maintenance: 0.16mg/kg/hr
Amoxycillin 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
(dihydrate) injection dose
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 0.5mg/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
0.25mg/ml total 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
33
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Table 2.3 Dosages for infants under one month: [contd.]

Drug Route Dosage Freq.
(per
day)
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
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 OOOu/dose 4
100 OOOunits/ml
Paraldehyde deep im 0,1 ml/kg -
10ml injection pr 0.3 ml/kg -
Penicillin procaine im 50 mg/kg/24hrs once
300mg/ml injection
[=50 OOOu/kg/day]
Phenobarbitone iv 10 to 20mg stat over 10mins -
200mg/ml injection im/po maintenance = 3 to 5mg/kg/24 hrs 1 to 2
15mg/5ml syrup
Phenytoin po 4mg/kg/dose 2
30mg/5ml syrup
iv Loading: 15-20mg/kg slow (0.5mg/kg/min)
50mg/ml injection
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 <2500g -
(phytomenadione)
2mg/ml inj.
34
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: e.g. 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.
35
EDUZ2006
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.
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.
Management:
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 disease > Treat to prevent low blood
chest indrawing sugar (see below)
or > Keep the child warm
stridor in a calm child > Treat wheeze if present
> 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
36
> Follow-up in 7 days if not

improving
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 IMCI. For babies 1-2 months
see neonatal doses.
Well nourished children over 6 months with severe pneumonia
can be managed with benzylpenicillin only.
Give first dose of intramuscular benzylpenicillin and kanamycin
and refer child urgently to hospital.
If referral not possible repeat the benzylpenicillin 6 hourly and
kanamycin 12 hourly.
n
Benzylpenicillin im C V 0.05 -0.1MU/kg 6 hourly
10 days
and kanamycin im C V 7.5mg/kg 12
hourly
OR Gentamicin B V 5-7mg/kg Once 10 days
daily
Note: change to oral when possible
If less than 6 months add high dose cotrimoxazole FOR 21

days and check HIV status
COTRIMOXAZOLE TABLE
Age or adult Paediatric Syrup
weight tablet tablet
2-6 months ¼ 1 2.5mls
(4-<6kg)
6m-3yrs ½ 2 5mls
(6-<14kg)
3-5yrs 1 3 ls
(14-19kg)
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If benzylpenicillin is not available, substitute with:

Duration
<1yr ½ ml (= 150mg)
procaine penicillin C V once a
5 days
im day
1-3yrs 1ml (= 300mg)
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
> 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.
Oxygen.
Management of moderate pneumonia

First line:
n
cotrimoxazole po CV 4-<6kg = 2 times 5 days
Codes 120mg 6 - <14kg = a day
240mg 14-19kg = Freq.
Second line: 360mg Duratio n
Drug Paed dose
amoxycillin po* C V 4-<14kg = 125mg 3 times 5 days

14-19kg = 250mg a day
or procaine penicillin im C V <1yr = 150mg once a 5 days
1-3yrs = 300mg day
3-5yrs = 450mg
*Use amoxycillin as first line in children on cotrimoxazole

prophylaxis
Reassess after 2 days of antibiotic treatment.
38
Treat fever, if present with:

n
paracetamol po C E 10mg/kg 6hrly as req’d.
Note: Do not give paracetamol to children under 2 months of age.
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.
Advise mother to return with the child in 2 days for reassessment, 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
Monitoring the child with moderate 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
39
EDUZ2006
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:

Drug Codes Paed dose Freq. Duratio n
paracetamol po C E 6hrly as req’d.
10mg/kg
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.
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 antibiotic, and refer urgently
to any danger sign; or if hospital fast breathing
> If no fast Treat as “no pneumonia, cough/ cold”. Follow up after 2
breathing days
Children with first episode of wheezing

child 1 year and over
> If chest indrawing; or Give rapid-acting bronchodilator, oral prednisolone and
any danger sign 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 Give oral bronchodilator;
breathing Send home on treatment as “no pneumonia, cough/
40
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.
> 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.
41
EDUZ2006
Prednisolone dose in wheezing:

n
prednisolone po B V <1yr = 10mg once repeat in
>1yr = 20mg 6hrs if
reqd.
If a rapid acting bronchodilator is required:
n
salbutamol nebulised B V <1yr = 2.5mg as required
5mg/ml in 2ml sterile >1yr = 5mg
water
or salbutamol po B V 2-12mnths = 1 mg 3 times
1-5yrs = 2mg a day
or adrenaline C V 0.01ml/kg up to a repeat after
20mins
subcutaneously 1:1000 max of 0.25ml if required
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.
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!
If referral not possible or there is a delay give chloramphenicol
and cloxacillin:
n
chloramphenicol iv B V 12.5mg/kg 6hourly 7 days
and cloxacillin iv B V 12.5-25mg/kg 6hourly 7 days
Watch carefully for signs of obstruction. Intubation or
a
tracheostomy may be required (poor air entry; severe chest
indrawing, restlessness, pallor).
42
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
Antibiotics if there is fast breathing (secondary infection.)
Retropharyngeal Abscess
Surgical drainage is required. Give:
Drug Codes Paed Freq.
dose Duratio
C V n
benzylpenicillin im And 0.05-0.1MU/kg B V 6 hourly 7
Gentamicin im/iv days
24 7 days
hourly
Empyema / lung abscess

Duratio
Cloxacillin iv/im/po B V n
And Gentamicin im/iv 12.5-25mg/kg B V 6hrly 6 weeks
5-7mg/kg 24 14 days
Or Kanamycin im hourly
C V 7.5mg/kg 12hrly 14 days
Empyema –should also insert a chest drain
Diphtheria
Give antitoxin and:
Durati
Benzyl penicillin im C V on
100 000 unit/kg per 6hrly 7 days
dose
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EDUZ2006
Pertussis
Drug Codes Paed Freq. Duratio n
dose
erythromycin po CV 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.
n
benzylpenicillin im And C V 6 hourly
kanamycin im 0.05-0.1MU/kg CV 10days
or gentamycin i.m And 7.5mg/kg 5-7mg/kg C 12 hrly
paracetamol po E 10mg/kg 24hrly
6hrly as req’d.
Acute ear infection
Pus is seen draining from the ear and discharge is reported for less
than 14 days; or ear pain.
Give antibiotics and analgesia:
cotrimoxazole po
C V 4-<6kg =120mg 6 12 5 days
- =240mg hourly
<14kg
And paracetamol po =360mg
C E 10mg/kg 6hrly 14-19kg
as req’d.
Use amoxycillin as first line in children on
cotrimoxazole prophylaxis
Dry the ear by wicking
Follow-up for 5 days
44
Chronic ear infection

Pus is seen draining from the ear and discharge is reported for 14
days or more.
Dry the ear by wicking
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:
Drug Code Paed dose Freq. Duratio
s n
procaine penicillin CV < 1yr 1/2mls(=150mg) once a 5 days
im 1 to 3yrs 1ml(= 300mg) 3 to then
5yrs 11 /2mls( 450mg) penicillin
V for 5
day 4 days
or penicillin V po C E <3yrs = 125mg 10 days
>3yrs = 250mg a day
>12yrs = 500mg
Give paracetamol for pain.

General / home care & feed child as above.
45
EDUZ2006
Treatment of oral candidiasis (thrush)

Duratio
n
Aqueous gentian violet C V apply after
feeds 0.5%
3- 6 times
or nystatin po B E 250 000u after 5 days
a day
feeds
or miconazole 2% gel po B N 2.5ml after feeds
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.
46
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) 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 MOHCW Chart and IMCI 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 drugs.
Zinc sulphate 20mg/day for 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?
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 2.4
NB: If temperature is 38.5oC or higher look for other causes of fever

and treat.
47
Table 2.4 Classification of Dehydration:
Signs Dehydration Management
Two or more of the following signs: Severe dehydration > Initiate treatment for severe dehydration (Plan C),
> or if another severe classification* - refer urgently to hospital with
Lethargic or unconscious
caregiver giving frequent sips of oral rehydration fluid or by nasogastric
Sunken eyes tube on the way. Advise mother to continue breastfeeding.
Not able to drink or drinking > If the child is 2 years or older and there is cholera in your area, give
poorly antibiotic for cholera.
Skin pinch goes back very slowly
Two or more of the following signs: Some dehydration > Give fluid and food for some dehydration (Plan B).
> *If child also has a severe classification from another main symptom
Restless or irritable
refer urgently to hospital with caregiver giving frequent sips of oral
Sunken eyes rehydration fluid on the way. Advise mother to continue breastfeeding.
Drinks eagerly or thirsty > Advise mother when to return urgently
Skin pinch goes back slowly > Follow -up in 2 days if not improving.
Not enough signs to classify as No dehydration > Give fluid and food to treat diarrhoea at home (Plan A)
‘some’ or severe 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 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.
Explain to mother the reason for giving Oral Rehydration Therapy and
what it does.
Show the mother how much Sugar Salt Solution to give.
Continue to give as much of the normal feeds as the child will take AND
give Sugar Salt Solution.
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
49
EDLIZ2006
Plan B: Treat Some Dehydration with Oral Rehydration

Therapy
In the health facility give the recommended amount of oral rehydration
therapy:
Determine amount of oral rehydration therapy to give every hour for the
first 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
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
50
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 Ringer lactate iv r
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.
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 5 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._____________________________
51
EDUZ2006
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 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, breastmilk, or vitamin supplements.
INDICATIONS FOR ANTIBIOTICS IN DIARRHOEA:

Bloody diarrhoea, cramps and fever (dysentery):
First line:
Drug Codes Paed dose Fre
nalidixic acid po or B V 4-<10kg =

125mg
>10kg = 250mg
Ciprofloxacin po 5 -12yrs = 375mg
B V 5-17yrs 20mg/kg
n
(max
4
times 5 days a
day
Twice a 3 days
day
Follow up after 2 days.

amoebiasis):
Second line (intestinal
Codes Paed
Drug
dose
Freq. Duratio
n
metronidazole po C V 10mg/kg 3 times a 5 days
day
Cholera:
In suspected cases notify the Provincial Medical Director immediately,
and obtain current cholera guidelines. See also the chapter on
gastrointestinal conditions.
m Rehydration is most important.
52
Start antibiotics after the patient is rehydrated and vomiting has

stopped - usually after 4-6hrs.
n
cotrimoxazole po C V 24mg/kg Twice a 3
days
day
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
750ml of clean water measured in any 750ml 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 14days with every bout of
diarrhoea. Give 10mg/day in infants below 6 months.
53
EDUZ2006
PROTEIN /ENERGY MALNUTRITION

(Underweight, Marasmus, Kwashiorkor)
Growth monitoring
Regular growth monitoring is a very important tool 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 on 3rd centile on child health card.
m 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.
Classification
Weight* No Oedema Oedema
60-80% expected weight for age Underweight Kwashiorkor
< 60% expected weight for age Marasmus Marasmic-kwashiorkor
Table 2.5(a) Classification of nutritional status:

Visible severe SEVERE > Give first dose of appropriate antibiotic
wasting or MALNUTRITION
> Give Vitamin A
Oedema of both feet
> Treat to prevent low blood sugar
> Keep child warm
> Refer urgently to hospital
Low weight for age or LOW WEIGHT > Assess the child’s feeding and counsel the
Growth faltering mother on feeding
or > If feeding problem, follow-up in 5 days
GROWTH > Positive T.B contact - refer for assessment
FALTERING > If Low weight or growth faltering give
Vitamin A
> Advise caregiver when to return
immediately
> If low weight for age, follow-up in 1 month
> If growth faltering for 3/12 refer to hospital
No low weight for age NOT LOW > If the child is less than 2 years old assess
and WEIGHT the child’s feeding
No other signs of > If feeding problem follow-up in 5 days
malnutrition
> If positive T.B contact, follow-up in 1 month
> Advise mother when to return immediately
54
Table 2.5(b) Classification of anaemia:

Severe palmar pallor SEVERE > Start anti-malarial if indicated
ANAEMIA
> Treat to prevent low blood sugar
> Keep child warm
> Refer urgently to hospital
Some palmar pallor ANAEMIA > Assess the child’s feeding and counsel the
mother on feeding
> Give Iron and folate
> Give oral anti-malarial if indicated
> Advise caregiver when to return
immediately
> Follow up in 14days
No pallor NO ANAEMIA > If the child is less than 2 years old assess
the child’s feeding
> If feeding problem follow-up in 5 days
> Advise mother when to return immediately
Home management
Encourage:
exclusive breastfeeding up to 6 months (no additional
fluids/foods),
breastfeeding up to two years,
introducing other foods in addition to breast milk at 6 months,
frequent high-energy meals,
hygienic food handling and preparation,
regular weight and growth checks: <1yr – monthly; >1 yr - every
2 months.
Drug therapy in malnutrition:

Duratio
vitamin A po C V <6mnths n
50,000iu 6- 12mths once at the clinic
100,000i and one dose at
u home -2 doses
1-5yr only
And ferrous sulphate 200,000
po iu day
once a
C E 14 days
4-<6kg 6mg Fe
6 - <10kg 12mg
1-3yrs 18mg
3-5yrs 24mg
and folic acid CE <6kg once a 14
po 2.5mg days day
>6kg 5mg
55
EDUZ2006
Nutritional rehabilitation at the referral level

General guidelines:
Try not to separate the caregiver from the child; they should share a
bed where possible.
Keep the child in a warm environment;
Attempt to incorporate an educational message into
each
intervention.
Treat any infection present:
Treat any specific infection (e.g. TB). If seriously unwell give benzylpenicillin
and gentamicin or kanamycin. If condition less severe, consider oral
broad-spectrum antibiotics (cotrimoxazole or amoxycillin).
If copious watery diarrhoea consider lactose intolerance
After rehydration with oral rehydration solution give half-strength
fresh milk or half strength high-energy milk until able to tolerate
full-strength high-energy milk.
Correct dehydration, if present, slowly with ORS 80-100ml/kg/day
(lower than the usual rate).
Provide a high calorie diet with adequate protein.
The therapeutic diet consists of high-energy milk (HEM) every three

hours (starting early in the morning until late at night). If the child has
watery diarrhoea, give half strength HEM (half HEM, half ORS).
In persistent diarrhoea give:
n
metronidazole po C V 10mg/kg 3 times a 5 days
day
Recommended Formula for High Energy Milk (HEM)

Boiled fresh cows’ milk 900 g
sugar 60 g
vegetable oil 50 g
As soon as the child gets better, introduce the fortified, family type diet.
If therapeutic feeding regimens available - Use F75 and F100 as

recommended.
F75 for initial phase
F100 for transition and maintenance phase
56
Vitamins and Electrolytes

Drug Codes Paed dose Freq. Duratio n
multivitamin syrup po BE 5-10ml daily 1 month
<6mths 50,000
iu 6- 12mths
C V
And folic acid po C E 5mg weekly 3 months
And vitamin A po
once at the clinic
and one dose at home -2
u
1-5yr 200,000i
doses only
In all kwashiorkor and marasmic-kwashiorkor children give:

Duratio
n
electrolyte mixture po* 1ml/kg
B 4 times until
B- 1-2mmol/ kg no a day
Or potassium chloride
mixture po oedema
*Kwashiorkor electrolyte mixture(KEM) formula:

Made in hospital pharmacies as follows:
Ingredient weight
potassium chloride 75g
magnesium chloride 25g
zinc sulphate 1.125g
Water to 1 litre
KEM - Not necessary if using F75 or F100
Anaemia:
Test and treat for Hookworm (see Tropical Diseases) After
recovery from the acute state treat with ferrous sulphate.
n
<2yrs 200mg
albendazole po CE one dose only
>2yrs 400mg
C E
And ferrous sulphate once a 30
po 6 - <10kg 12mg 1-3yrs days day
18mg 3-5yrs
2 4mg
57
EDUZ2006
PAEDIATRIC HIV INFECTION

See national Guidelines on Antiretroviral Therapy. Paediatric HIV
infection can be significantly reduced by implementing an effective
PPTCT 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.
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.
58
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:
Duratio
n
< 6mths = 120mg
cotrimoxazole po C V 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.
59
Table 2.6 Dose by age and weight for commonly used drugs:
Age Weight benzylpenicillin kanamycin cotrimoxazole paracetamol amoxycillin procaine
12hourly penicillin
0.05-0.1MU/kg 6 7.5mg/kg 10mg/kg 16mg/kg 8
50mg/kg
hourly 12hourly 6hourly hourly oncedaily
5MU (3gm) vial of 1gm vial of syrup of syrup of syrup of 300mg/ml
500mg/ml [add 6ml 250mg/ml [add 4ml 200mg+40mg 120mg/5ml *use 125mg/5ml injection
water to 5MU vial] water to 1gm vial] per 5ml nearest 2.5ml vol -use nearest
2.5ml vol
2-4 months 4 - <6kg 0.3M (0.4ml) 40mg (0.16ml) 100/20mg 50mg (2.5ml) 62.5m (2.5ml)
U (2.5ml) g
4-9 months 6 - <10kg 0.4M (0.5ml) 50mg (0.2ml) 200/40mg (5ml) 100mg (3-5ml) 125m (5ml)
U g
9-12months 10 <12kg - 0.5M (0.6ml) 75mg (0.3ml) 200/40mg (5ml) 120mg (5ml) 125m (5ml) 150m
U g (0.5ml) g
1-3 years 12 <14kg - 0.7M (0.8ml) 100m (0.4ml) 300/60mg 120mg (5-7ml) 300m
U g (7.5ml) (1.0ml) g
3-5 years 0.8M (1.0ml) 125m (0.5ml) 300/60mg 250mg (10ml) 250m (10ml) 450m
U g (7.5ml) g (1.5ml) g
5-12 years 1MU (1.2ml) 200m (0.8ml) 400/80mg (10ml) 375mg (15ml) 375m (15ml) 600m
g g (2.0ml) g
PAEDIATRIC DRUG DOSES

Notes on Paediatric Drug Doses:
m for infants under one month see Tables 2.1, 2.2 and 2.3;
m read the “dosage” column carefully in conjunction
with the
“doses/day” column; m do not exceed the adult dose: the
dosage per kg is not applicable for
children > 40kg;
Table 2.7 Dosages for Children and Infants Over 2

Months
For antibiotics where “Doses/Day” give a range (e.g. 2-4) 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.
Drug Route Dose Frequ
ency
Acetylcysteine iv 150mg/kg over 15mins then -
200mg/ml injection 50mg/kg over 4hours then
100mg/kg over 16hours
Adrenaline 1:1000 sc 0.01ml/kg, repeat after 20mins -
1 mg/ml injection 0.3 to 0.5ml IM
im
Aminophylline iv Loading: 6mg/kg over 30mins -
25mg/ml injection
po
Amoxycillin 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 OOOu/kg 6hrly

3 g injection = 5MU
(0.05 -0.1MU/kg)
Chloramphenicol iv/ mild 12.5mg 6hrly
1g injection; 125mg/5ml syr severe (meningitis) 25mg/kg
im/po
Chlorpromazine iv/ 0.75mg /kg 4 times
25mg/ml injection 50mg/5ml im/po a day
syrup
Cimetidine po 5 to 10mg/kg 4 times

400mg tab a day
Clindamycin po /im mild 4mg/kg 6hrly
75mg/5ml syrup; 250mg
capsule; 1g injection severe 10mg/kg
Cloxacillin iv/ 12.5 to 25mg/kg 6hrly

125mg/5ml syrup; 250mg im/po
capsule; 0.5g injection
61
EDUZ2006
Table 2.7 Dosages for Children and Infants Over 2 Months:

[contd.]
ency
Codeine Phosphate 0 0.4mg/kg 6hrly
30mg tab (>1yr = 0.75mg/kg)
Cotrimoxazole po normal dose 30mg/kg 12hrly
120mg tab; 480mg
tab; 240mg/5ml syrup high dose 60mg/kg 8hrly
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 1 once a
10mg/ml injection; 40 mg tab day
po to 3mg/kg
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 hrly
25mg tablet
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 8hrly
200mg tab / 1gm suppository po intestinal amoebiasis 10mg /kg
5mg/ml inj po giardiasis 5mg/kg
Morphine Sulphate im/o Up to 0.25mg/kg per dose -
15mg/ml injection;
5mg/5ml syrup
62
Table 2.7 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
Paraldehyde im 0.1ml/kg once

10ml injection
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 1 mg/kg 3 times

40mg tab a day
Rifampicin po 10 to 20mg/kg daily
300mg cap, 100mg/5ml
syrup
Salbutamol neb po/ nebulised 2.5mg in 2mls saline -

4mg tab; 2m/5ml syrup; 3 times
5mg/ml solution; 100mcg inh. maintenance 0.1mg/kg
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
Trimeprazine po Pre-operatively 2 to 4mg/kg once
30mg/5 ml syrup
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IMMUNISATION
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.
GENERAL NOTES
Adverse events
All adverse events should be reported using the ‘Adverse
Events Following Immunisation’ AEFI form.
Diseases Preventable by Immunisation
Diphtheria
Measles
Hepatitis B
Pertussis (whooping cough)
Poliomyelitis
Rabies
Tetanus
Tuberculosis
Open vial policy

Open vials of DPT, DPT+HB, DT, TT and HB may be used
through the following day if they have been kept under cold
chain and sterile conditions, and not taken on outreach.
Opened reconstituted measles and BCG must be discarded.
Opened polio vials which have vaccine vial monitors can be
used if there is no colour change.
If in any doubt - discard.
Use of Vaccinations in HIV Infected Individuals

In general, live vaccines are not given to immune compromised
individuals. However, the risk of measles and polio in infants
not immunised is high, and the risk from these vaccines
appears to be low, even in the presence of symptomatic HIV
infection.
Therefore only the use of BCG in an infant with clinical HIV is
contra-indicated.
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CHAPTER 3 IMMUNISATION
IMMUNISATION SCHEDULE FOR CHILDREN

See Table 3.1. 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.
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 drugs.
Table 3.1: Immunisation schedule by age
Minimum Age Vaccination
* not for immune compromised / HIV patients
a
At birth *BCG 1 [PC]
3 months DPT+HB 1
[PC] OPV 1
b
4 months DPT+HB 2
[PC] OPV 2
b
5 months DPT+HB 3
[PC] OPV 3
9 months Measles [PC]
18 months DPT4 Booster 1
OPV4 Booster 1
5 years DT Booster OPV5
Booster 2
Note [PC]: Primary course is considered complete if the child has all
eight vaccinations marked [PC].
Note a: Revaccinate for BCG in the absence of a scar 6 weeks after
the vaccination, or next contact after 6 weeks.
Note b: The minimum interval between the consecutive doses of
DPT+HB and of OPV is 28 days (check day as well as month).
Catch-Up Schedule
Immunise a child who is behind schedule according to the
following guidelines (Table 3.2).
Ensure that the child’s age is above the mentioned minimum
ages for each vaccination type.
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Table 3.2 Catch-up schedule

Minimum interval / when to Vaccination Type
give
a b
First contact BCG , DPT-HB 1 , OPV 1, Measles
b
After 28 days or more DPT-HB 2 , OPV 2,
b
After 28 days or more DPT-HB 3 , OPV 3
Note a: For a child who has not previously had BCG vaccination, a
single dose may be given (maximum to 10 years). Note b: A child over
24months is given DT 1 and DT 2 instead of DPT-HB1 and DPT-HB2.
DPT-HB3 is not given.
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 3.3 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 3.4.
Table 3.4 Catch up – tetanus

Doses received as a child Doses needed as an adult
No DPT immunisation 5 dose according to schedule (table 3.3)
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)
Immunisation details for available vaccines

Always check the dosage instructions in the manufacturer’s
information supplied with the vaccine as strengths may vary.
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CHAPTER 3 IMMUNISATION
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.
The minimum interval for HB2 and HB3 is 5 months, if given as
a mono dose.
Table 3.5 Details for available vaccines:

Vaccine Min. age Min. Site Route Dosage
first dose interval
BCG Birth [max. age is 10 Right upper arm intra-der 0.05ml or
years for first dose] mal 0.1ml
DPT-HB 3 months 28 days Antero-lateral aspect im 0.5ml
of the thigh
OPV 3 months 28 days Oral oral 2–3
drops
HB1 /2 3 months 28 days Antero-lateral aspect of im 0.5ml
the thigh
HB3/ 4 same 5mnths im 0.5ml
Measles 9 months Left upper arm im 0.5ml
DT 2 years 28 days Antero-lateral aspect of im 0.5ml
the thigh
See table 3.3 See table Upper arm, deltoid im 0.5ml
TT 3.3 muscle
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OBSTETRIC AND GYNAECOLOGICAL

CONDITIONS
HORMONAL CONTRACEPTION 69
ORAL CONTRACEPTIVES 70
DRUG INTERACTIONS WITH ORAL CONTRACEPTIVES 71
LONG TERM HORMONAL CONTRACEPTIVES 72
INFECTIONS, GENITO-URINARY TRACT DURING PREGNANCY 73
POST ABORTAL SEPSIS 74
ACUTE PELVIC INFLAMMATORY DISEASE (PID) 74
PROLONGED RUPTURE OF MEMBRANES 75
PROPHYLAXIS FOR CAESAREAN SECTION 76
NAUSEA AND VOMITING IN PREGNANCY 76
ANAEMIA DURING PREGNANCY 77
CARDIAC DISEASE IN PREGNANCY 77
DIABETES IN PREGNANCY 81
ANAESTHESIA, ANALGESIA, ANTACIDS 82
STEROIDS IN RESPIRATORY DISTRESS SYNDROME 82
CERVICAL RIPENERS/ LABOUR INITIATORS (PROSTAGLANDINS) 83
MYOMETRIAL STIMULANTS (OXYTOCICS) 84
MYOMETRIAL RELAXANTS (BETA-STIMULANTS) 85
TERMINATION OF PREGNANCY 86
DRUGS IN PREGNANCY AND LACTATION 88
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CHAPTER 4 OBSTETRIC AND GYNAECOLOGICAL CONDITIONS
General Note:
Drugs should be avoided if at all possible throughout pregnancy, and
especially during the first trimester. However, drugs may be required
for a number of conditions commonly encountered during pregnancy;
drugs which are appropriate and safe are covered in the sections that
follow. At the end of the chapter is a list of those drugs 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, 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?
Normal delivery within 6 weeks?
Previous treatment for high blood pressure?
History of epilepsy?
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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 or women with mild or moderate hypertension.
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
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CHAPTER 4 OBSTETRIC ANDGYNAECOLOGICAL CONDITIONS
suspected or known carcinoma of the breast

known liver tumour
unexplained chest pain or shortness of breath
severe leg pains;
development of any of the absolute
contra-indications
mentioned in the manufacturers information sheet.
Drug Interactions with Oral Contraceptives

Drugs reducing the effect of oral contraceptives
Caution is needed when prescribing any of the following drugs 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 drug 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, e.g.
condoms or abstinence from intercourse). If the drug is to be used
on a long-term basis the woman should be advised to use another
suitable method of contraception.
Drugs which are made less effective by oral contraceptives

Doses of particular drugs 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
Duration
medroxyprogesterone C V 150mg once every 3 months
acetate im
or Norethisterone B N 200mg once every 2 months
enanthate im
CAUTION: In severe 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 Contraceptive
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.
Duration
levonorgestrel implant B N 2 rods once only once
in
5yrs
CONTRAINDICATIONS: Severe 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.
EMERGENCY CONTRACEPTION
• Combined OC -Within 72 hours of unprotected intercourse,

give:
Duration
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
Note: Advise to return if menstruation does not occur within 3 weeks.

Give appropriate contraceptive advice.
72
• Progesterone only Pill- 1 tablet 750ugm of levonogesterol oral

within 72 hours of unprotected intercourse. Take one more tablet
in 12 hoursIf no menses within 3 weeks - the client should
consult the service provider
• 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, white blood cells, culture and
sensitivity where possible.
First line:
Duration
Amoxycillin po C V 500mg 3 times a day *7 days
Second line:
Norflocaxin B N 400mg 3 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.
m Third line: as per culture and sensitivity.
Positive RPR or Syphilis during pregnancy

Both partners to be counselled and treated with:
Duration
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

Often polymicrobial and requires a combination of drugs
Drug Codes Adult doseFrequency
Duration
erythromycin po C V 500mg4 times a day
7 days
And metronidazole po C V 400mg3 times a day
7days
And miconazole vag C N Oneonce a day
3 days
Caution: Avoid metronidazole in 1st trimester.
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Post Abortal Sepsis

Pyrexia in a woman who has delivered or miscarried in the previous
6 weeks may be due to puerperal or abortal sepsis and should be
managed actively. Abdominal pain in addition to pyrexia is strongly
suggestive. The uterus may need evacuation.
Note: Every year a few women die because what is thought to be
post-abortal sepsis is in reality fever from malaria causing abortion.
Post-abortal sepsis will need a laparotomy if the patient does not respond
to antibiotic therapy and evacuation of uterus.
m Mild/moderate sepsis:
amoxycillin po C V 500mg 3 times a day 10 days
And metronidazole po C V 400mg 3 times a day 10 days
And doxycycline po C V 100mg 2 times a day 10 days
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:
kanamycin im C V 2g [1g per buttock] once single dose
And Doxycycline po C V 100mg 2 times a day 7 days
And metronidazole po C V 400mg 3 times a day 7 days
Second line:
Substitute norfloxacin for kanamycin in above therapy
Drug Codes Adult dose FrequencyDuration
norfloxacin po C E 800mg once a day single dose
And Doxycycline po C V 100mg 2 times a day 7 days
Alternative in doxycycline allergic patients

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

Temperature greater than 38 C with marked abdominal
tenderness. Patients need IV fluids and IV drugs.
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 B 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.
PROLONGED RUPTURE OF MEMBRANES

(PROM)
Duration
Oxytocin infusion Then C V 1 unit initially
4 units in 1L sodium chloride 0.9% at
(see induction of labour)
15, 30, 60 drops per minute until
regular contractions
or dinoprostone in B V 3mg 6hrly
posterior fornix
or misoprostol po A N Depending on the urgency of the
situation, the parity of the patient
decides on a dose and location.
Note: Failed termination of early pregnancy with prostaglandin and
termination not pressured with other means might result in congenital
abnormalities.
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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
Switch to oral antibiotics for 7 days after delivery:
amoxycillin po B V 500mg 3 times a day 7 days
PROPHYLAXIS FOR CAESAREAN SECTION

As the patient is put on theatre trolley:
benzylpenicillin iv C V 5MU 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:
Duration
amoxycillin po B V 500mg 3 times a day 7 days
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 pregnancy. Give:
Duration
promethazine po B N 25mg once at night* as required
or chlorpheniramine po C E 4mgonce at night* 5 days
*Note: If severe, the dose may be given two to three times a day.
Hyperemesis Gravidarum (Vomiting and Dehydration)

Admit for intravenous fluids and give:
Duration
prochlorperazine im B E 12.5mg twice a day as
needed
or promethazine im B V 25mg twice a day as
needed
76
ANAEMIA DURING PREGNANCY

Prophylaxis in Antenatal Care
ferrous sulphate po C E 200-400mg once a day 5 months
and folic acid po C E 5mg once a week 5
months
* Start at 12 weeks or from booking for antenatal care. Continue
prophylaxis for 6 weeks after delivery. Also give dietary advice.
Treatment of Microcytic Anaemia

Before 36 weeks gestation:
ferrous sulphate po C E 200-400mg 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). Parenteral iron preparations can be
used if Hb is <7g/dl.
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
normal.
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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 for the first 13 weeks, and change back to
warfarin between weeks 13 - 37. After 37 weeks change to heparin
again until after delivery. Warfarin can be commenced 24hrs after
delivery.
Labour in cardiac patients

Cardiac disease patients should not be induced - they usually have
easy vaginal delivery, which can be assisted by forceps delivery to
avoid stress.
Give a single dose of ampicillin at the onset of labour:
Duration
ampicillin iv B E 1g once only single
dose
Keep the resuscitation trolley at hand.
Nurse in a propped up position
Do not give ergometrine. Use oxytocin:
Duration
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, use the progesterone only oral contraceptive or
medroxyprogesterone.
Hypertension in Pregnancy
Women who develop hypertension during pregnancy (later than 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.
78
Methyldopa is the recommended

anti-hypertensive throughout pregnancy.
CAUTION: Avoid diuretic drugs during pregnancy.
Essential Hypertension
Monitor for development of proteinuria.
Duration
Methyldopa po B V 250-500mg 3-4 times a day
review
If not responding refer to district level, where a combination of

methyldopa and prazosin can be used:
Duration
Methyldopa po B V 250-500mg 3-4 times a day
review
and Prazosin po B E 2 – 4mg 3 times a day
review
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.
In moderate pregnancy induced hypertension, the above blood
pressure is far more significant in a nullipara under 25 than in a
woman of 37 with four earlier pregnancies without problems.
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:
Duration
methyldopa po B V 250-500mg 3-4 times a day
review
and Prazosin po B E 2 - 4mg 3 times a day
review
At gestation > 37 weeks, plan immediate 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.
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Manage as for moderate pregnancy induced hypertension. If not

controlled add Nifedipine as follows:
methyldopa po B V 250-500mg 3-4 times a day review
and prazosin po B E 2 – 4mg 3 times a day
plus nifedipine sublingual B V review
10mg, repeat after 1 hour
If more than 2 – 3 doses are required –
urgent delivery is required
Pre-Eclamptic Toxaemia (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 imminent eclampsia.
If diastolic > 110 mmHg check blood pressure hourly and give:
hydralazine iv B V 12.5mg intermittently
Or nifedipine sublingual B V 10mg, repeat after 1 hour
If more than 2 - 3 doses are required in one
day - urgent delivery is required
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:
diazepam iv infusion C V 40mg in 1l sodium chloride 0.9%, over
6 hours
Check blood pressure at least hourly. If diastolic pressure > 110

mmHg give anti-hypertensives as for pre-eclamptic toxaemia
(above).
Eclampsia
This is pregnancy-induced hypertension with epileptiform fits.
Ensure clear airway.
Stop convulsions with:
diazepam iv C V 10mg as a single dose- then
[infusion] 40-80mg in 1l sodium chloride 0.9%,
over 6 hours - to prevent further
convulsions
80
Plan urgent delivery, within 6 hours.

Monitor carefully:
Patellar reflex
Respiration
or
Urine output > 100mls in 4 hours
Check blood pressure at least hourly. If diastolic pressure

>110mmHg give:
hydralazine iv B V 12.5mg once
magnesium sulphate* B V 5g in each buttock, once only, then:
im 4g iv slowly (over 2mins), once only,
*arrests and prevents then:
convulsions without 4g in each buttock if at least 30cc/hr
producing central nervous urine output, knee-patella reflex
system depression present and 15 chest excursions per
minute.
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.
Good blood sugar control with insulin and diet is essential since
oral hypoglycaemics are contraindicated in pregnancy and
hypergly-caemia itself may be teratogenic. All known diabetics
should be advised to start insulin 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 125 ml per hour.
Labour should not be prolonged. After labour, manage the
patient on a sliding scale of insulin.
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ANAESTHESIA, ANALGESIA, ANTACIDS

For indigestion
Duration
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:
Duration
magnesium trisilicate po C N 20ml once only -
sodium citrate po B N 15ml once only -
or
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
and promethazine im B V 25mg once a day
To reduce vomiting, give intramuscular anti-emetics
(see
‘Nausea and Vomiting in Pregnancy’) at the same time as
pethidine.
Note: To avoid respiratory depression in the neonate the last
dose should be longer than 2 hours before delivery and no more
than two doses given during labour.
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
Duration
lignocaine 1% local C V Up to max once
infiltration of 10ml
CAUTION: Avoid injecting into a vein! Draw back several times during
infiltration.
Steroids in Respiratory Distress Syndrome

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.
82
Give the mother: Codes Adult dose Frequency Duration
Drug
hydrocortisone iv B V 250mg once, then repeat

after 24hrs
or dexamethasone im B E 12mg for 2 doses (12hrly) Repeat after
1 week
CAUTION: Anaemic patients who are receiving beta stimulants and
steroids are prone to congestive cardiac failure.
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 already ripe.
Cervical ripeners: Prostaglandins are powerful drugs, although

classed as cervical ripeners they are better called labour initiators,
only to be used on a good indication. The higher the parity, the
more chance of uterine rupture.
The safest and simplest method of ripening the cervix:
Duration
dinoprostone po A E 1-2mg once only
or dinoprostone vag tab in A E 3mg once only
posterior fornix
If the contractions are too strong, the tablet might be retrieved from
the vagina.
Where dinoprostone [PG E2] oral tablets or vaginal tablets are
not available and the foetus is alive, use:
Duration
dinoprost extra-amniotic A E 5mg / 10ml
once gel [PG F2a]
Instructions: 5 mg (1 ampoule of dinoprost 5mg/ml) is mixed with 10
ml of sterile gel [KY jelly®] and delivered through a Foley catheter
inserted under clean conditions through the cervical os, and the
balloon inflated with 40 ml water.
If the foetus is dead, use:
Duration
dinoprost intra-amniotic A E 5mg once
Note: with appropriate sterile precautions - only at tertiary level.
Where no drugs are available, the catheter can be inserted through

the cervix under clean conditions, then inflated with
83
EDUZ2006
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 :
Duration
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 unit in
the litre of sodium chloride 0.9% - each time increasing the delivery rate
through 15,30 and 60 drops per minute.
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.
84
Uterine stimulation after delivery

Duration
Ergometrine im C V 0.5mg after delivery to cause
myometrial contraction and prevent
post-partum haemorrhage.
CAUTION: ergometrine may cause a sharp rise in blood pressure and
should therefore be avoided in all hypertensives and patients with
heart disease.
Alternative:
Duration
oxytocin im C V 5 units after delivery of the infant.
If the uterus remains relaxed in spite of above measures and
manual stimulation, give:
Duration
oxytocin iv infusion C V 20 units in 1L of sodium chloride
0.9%
running in at 10 – 60 drops per minute.
Uncontrollable post partum haemorrhage

Post partum haemorrhage is caused by relaxation of the uterus
and should be controlled with high doses of oxytocin or
external rubbing.
If not use prostaglandin injected slowly into the uterine muscle:
Duration
dinoprostone inj A E 5mg slowly intra-myometrial
The uterus should become as hard as stone, if not and still bleeding do
total abdominal hysterectomy.
In cases where there is just trickling,
Duration
Misoprostol po A N 400mcg once only
MYOMETRIAL RELAXANTS
(BETA-STIMULANTS)
Beta-stimulants are used to relax the uterus in order to:
perform external cephalic version
relieve fetal distress immediately prior to LSCS
stop uterine contractions in premature labour
prevent uterine rupture. For
immediate relaxation:
Duration
85
EDUZ2006
hexaprenaline iv B N 12.5mcg over 2minutes,

followed by
infusion of 25mcg in 200ml sodium
chloride over 1 hour
The pulse rate must be monitored and drip rate titrated to keep pulse
rate less than 125 per minute.
For mild contractions or to maintain
cessation of contractions after intravenous beta-stimulant
therapy:
Duration
salbutamol po B V 4mg 8 hourly review
Beta-stimulants should NOT be used if the patient has had an
ante-partum haemorrhage, because uterine relaxation may exacerbate
an abruptio placenta. In patients with cardiac disease or severe
anaemia in pregnancy, parenteral beta-stimulants are
contraindicated.
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 condition, or her mental
state is seriously affected by the pregnancy);
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
Up to 7 weeks since last period: routine dilatation and curettage
can be performed safely.
7-12 weeks since last period: suction termination can
be
performed safely.
After 12 weeks since last period: prostaglandin termination is
indicated.
Prostaglandins in the Termination of Pregnancy
Take blood for haemoglobin and grouping and retain serum.
Start prophylactic antibiotics:
Duration
chloramphenicol iv B V 1g once only
And metronidazole pr B V 1g twice a day
86
Antiseptic cleansing of introitus; pass sterile Cusco speculum;

antiseptic cleansing of cervix; pass sterile Foley catheter
through os; inflate catheter balloon.
Use specially prepared dinoprost gel mixture:
dinoprost [PGF2<x] A E 10ml of gel into catheter.
(special) gel Inject further 2ml special gel every 2
5mg in 10ml gel + 10ml hours until the catheter drops out
sodium chloride 0.9% (ideally)
or repeat 10mls special gel mixture after 12 hours.
Give analgesia and anti-emetics as necessary.

Once catheter has been passed, start infusing:
oxytocin iv C V 20units in 1L dextrose 5%
Once foetus has been passed, arrange early evacuation of

uterus under general anaesthesia.
Send home on oral antibiotics and oral iron if haemoglobin <
10g/dl.
Counsel for family planning and supply contraceptives.
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
Note: Advise to return if menstruation does not occur within 3 weeks.
Give appropriate contraceptive advice.
87
EDUZ2006
For rape victims:

Rape victims should also be given antibiotic STD prophylaxis:
doxycycline po C V 100mg twice a day 7 days
Offer counselling and HIV test at the time of the rape and three
months later.
DRUGS IN PREGNANCY AND LACTATION

Note: the tables below include commonly used drugs, but the absence
of a drug from these tables does not necessarily imply no risk. Always
check if unsure.
General principles
Drugs should be prescribed during pregnancy and lactation only
if the expected benefit to the mother outweighs the risk to the
foetus or neonate;
all drugs should be avoided if possible during the first trimester;
well known drugs, which have been extensively used during
pregnancy or lactation, should be used in preference to new
drugs;
Table 4.1 Drugs to be avoided/ used with caution during

breastfeeding
Drug 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
Doxycyline 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.
88
Table 4.1: Drugs to be used with caution or avoided

in pregnancy
Drug 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 drug if possible.
See individually listed drugs.
Aspirin 3 Avoid Low dose aspirin in PIH is safe in 2 and 3.
1&2 Caution
Atenolol 3 Caution Neonatal hypoglycaemia, bradycardia, intrauterine
Propranolol 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.
Doxycyline 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-sti all Caution
mulant
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
Praziqantel 1 Avoid Wait.
89
EDUZ2006
Table 4.1: Drugs to be used with caution or avoided in

pregnancy (contd.)
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 pregnancy in
2&3 Caution those with prosthetic heart valves, deep vein
thrombosis and pulmonary embolism.
PMTCT
Follow the current national guidelines.
90
CHAPTER 5 SEXUALLY TRANSMITTED INFECTIONS
SEXUALLY TRANSMITTED INFECTIONS

GENERAL GUIDELINES 92
URETHRAL DISCHARGE IN MEN 92
VAGINAL DISCHARGE IN WOMEN 94
GENITAL ULCERS IN MEN & WOMEN (+/-BUBOES) 96
RECURRENT OR VESICULAR GENITAL LESIONS 98
GRANULATING ULCERS WITHOUT BUBOES 100
BUBOES WITHOUT ULCERS 100
ACUTE EPIDIDYMO-ORCHITIS 101
SYPHILIS 101
PELVIC INFLAMMATORY DISEASE 103
GENITAL WARTS (CONDYLOMATA ACUMINATE) 103
MOLLUSCUM CONTAGIOSUM 103
PEDICULOSIS PUBIS (PUBIC LICE) 104
OPHTHALMIA NEONATORUM 104
91
EDUZ2006
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 gonorrhoea and chlamydia
trachomatis. The two co-exist. Rarely, Trichomonas vaginalis
causes a urethral discharge in men. All males with urethritis 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. Treat all contacts.
First Line:
Duration
kanamycin im C V 2g [1g into each buttock] one
dose
only
and doxycycline po C V 100mg twice a day 7 days
Alternative:
Duration
norfloxacin po C E 800mg one dose only
92
CHAPTER 5 SEXUALLYTRANSMITTED INFECTIONS
If the patient still has a urethral discharge, or evidence of

urethritis 7 days after start of treatment, suspect re-infection or
poor treatment compliance. If this is the case, re-start first line
treatment. Otherwise refer the patient for investigations and
appropriate treatment.
Second Line:
Drug Codes Adult
kanamycin im And dose Frequency Duration
CV 2g [1g into each buttock] one dose
metronidazole po only
CV 2g one
If these drugs are not available locally, refer to the next level.
Third Line
ciprofloxacin po C V one dose only
500mg
Flowchart: First line Management of Urethral Discharge in Men

Take history & examine client
Urethral discharge present?
YES
kanamycin 2g single dose Signs of other STI’s present?

plus doxycycline Treat
100mg 2 times a day for 7 days, with accordingly
food.
Give health education on treatment,

compliance, risk reduction, use of
condoms.
Ask patient to have partner(s)
treated Reassure:
Advise on risk
reduction, use of
condoms
Advise to return if
symptoms persist
YES
Reinfection likely ?
Compliance with treatment poor?
Arrange for follow-up after 7 days
REFER
Restart treatment
93
EDUZ2006
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 with vaginal discharge should be treated for both

gonococcal and chlamydial infection. In addition, depending on the
type of discharge, they should be treated for either candidiasis or
trichomoniasis.
CAUTION IN PREGNANCY: See chapter Obstetric and
Gynaecological Conditions. Doxycycline, norfloxacin and
ciprofloxacin should not be used during pregnancy, or in lactating
women. In pregnant women chlamydial infection is best treated with
erythromycin while kanamycin should be used for gonococcal
infection.
First line treatment vaginal discharge

Profuse/ purulent/ frothy vaginal discharge : treat for
gonococcal, chlamydial, trichomonial and/or bacterial vaginosis
infections:
Duration
kanamycin im C V 2g [1g into each buttock] one dose
only
alternative to kanamycin is: (in addition doxycycline and metronidazole)
or norfloxacin po to one dose only
White or curd-like CE 800mg vaginal patient should be
treated for gonococcal, chlamydial and candidial infections:

kanamycin im C V 2g [1g into each buttock] one dose
only
and Miconazole pv C V 200mg every night 3 days
or Clotrimazole pv B E 100mg Once a day 7 days
alternative to kanamycin is:
norfloxacin po C E 800mg one dose only
94
Flow chart: First line management of vaginal discharge using a

speculum
Take history and examine client
including speculum examination.
Vaginal discharge present?
YES NO
Decide on the type of discharge ? V

Signs of other STI?
f
1 ir
Smells?and/ White NO T
or profuse? and/or
and/or curd like?
•Reassure. Treat
frothy? • Give health appropriately
education
f
95
EDUZ2006
Second line treatment vaginal discharge:

Check for compliance and re-infection. A
speculum examination is necessary, treat accordingly – see
flow chart.
Third line treatment vaginal discharge:

Duration
Ciprofloxacin po C V 500mg One dose only
Itchy white, flaky vaginal discharge:

This is due to Candida albicans (thrush). Treat with:
Duration
Miconazole C V apply every night 3
nights
cream/pessary
or nystatin pessary B E 100,000U every night
7 nights
or Clotrimazole pv BE 100mg every night 7
nights
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 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 become secondarily infected.
Hence it is important to bear in mind all these three
diagnoses whenever managing persons with genital ulcers
syndromically.
96
First Line treatment of genital ulcers:

• Advice on local hygiene such as washing twice
a day with soap and water and give the
following:
Duration
Erthromycin po C V 500mg 4 times a 14
days
day
or Benzathine Penicillin IM C V 2.4Megauni Once only
ts(1.44gm) night
Note: Erythromycin will cover chancroid, syphilis and
secondary bacterial infection whereas Benzathine Penicillin
covers syphilis only.
Recurrent or vesicular genital lesions
Treat as herpes simplex virus infection as follows:.

Duration
Acyclovir po B V 400mg Three times 7 days
a day
97
EDLIZ2006
Flowchart: Management of Genital Ulcers: First Line
Patient complains of Educate and counsel Promote and

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

examine patient
NO
< '
|
'^^
Sore/Ulcer/Vesi
cle present?
^^^ ^
^
NO
^r
V
Any other STI

^L
'
present?
^S. YES
Jr
V
YES
.' N ------- / ±~$
Treat according to
Vesicles or small YES appropriate flowchart
ulcers with history
HERPES SIMPLEX MANAGEMENT:
I
of recurrent
for risk reduction

- Local hygiene
- Educate and counsel
- Counsel on living with genital herpes

NO - Promote and provide
condoms
- Offer HIV counselling and testing
<
Ulcer \
NO
present? v^"
Educate and counsel Promote
and provide condoms Offer HIV
counselling and testing
YES
TREAT FOR CHANCROID /

SECONDARY BACTERIAL INFECTION
WITH ERYTHROMYCIN 500mg PO QID
FOR 7 DAYS
Local hygiene
Educate and counsel on risk reduction
Promote and provide condoms CONTINUE MANAGE AS
Offer HIV counselling and testing ERYTHROMYCIN PERSISTENT
Partner management 500mg PO QID FOR 7 GENITAL
Advise to return in 7 days MORE DAYS ULCER
98
Flowchart for the Management of persistent genital

ulcers(Men and Women):
Patient complains of
persistent genital
ulcer Educate and counsel
Promote and provide condoms
Offer HIV counselling and testing if available
Review if symptoms persist
Take a history
and examine
patient I
I
NO
X
Ulcer NO< Any other STI YES
present?
present?
YES
I
TREAT FOR HERPES / SECONDARY
Treat according to
appropriate
flowchart
Educate and counsel REFER
BACTERIAL INFECTION WITH Promote and provide
ACICLOVIR 400mg PO TID FOR 7 DAYS
AND ERYTHROMYCIN 500mg PO QID
FOR 7 MORE DAYS
Educate
Counsel on risk reduction
Promote and provide condoms
Offer HIV counselling and
testing
Partner management
Advise to return in 7 days
Refer if necessary condoms
Offer HIV counselling
and testing
99
EDUZ2006
Second line: Check for compliance and re-infection.
Third Line:
Duration
ciprofloxacin po C V 500mg twice a day 5 days
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:
Duration
2.4MU one dose only
benzathine penicillin im C V (1.44g) 4 times a 10 days
500mg day
and erythromycin po C V
or, in penicillin allergy Codes Adult dose Frequency Duration
Drug
erythromycin po CV 14 days
Codes Duration
Second line:
Drug 500mg 4 times a day
doxycycline po C V 100mg twice a day 10 days
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.
100
First Line: C V twice a day 14

doxycycline po Duration
100mg days
Second line, or in pregnant women:

Duration
erythromycin po CV 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 Duration
and doxycycline CV 2g [1g in each buttock] one dose only
po CV 100mg twice a day 10
days
alternative to kanamycin is:
norfloxacin po C E once only single
800mg dose
Second Line: C V twice a day 5

ciprofloxacin po Duration
250mg days
SYPHILIS
Early Syphilis
Includes primary, secondary and latent syphilis of less than 2 years
duration:
Duration
benzathine penicillin im C V 1.44g [2.4 MU] one dose
or only doxycycline po (in CV 100mg 2 times a 14
penicillin allergy) days day
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EDLIZ2006
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:
Duration
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) day
or erythromycin po (in C V 500mg 4 times a 30
days
pregnancy) day
RPR diagnosed in pregnant women at clinic level should be

referred. 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:
Duration
benzathine penicillin im C V 30mg/kg one dose only
[=50 000u/kg]
Congenital Syphilis (babies clinically infected):

or
Duration
procaine penicillin im C V 50mg/kg once a day
10 days
[=50 000u/kg]
erythromycin po (in C V 12.5mg/kg 4 times a day 10
days
penicillin allergy)
Neurosyphilis:
Duration
procaine penicillin im C V 600mg [=1ml once a day
21 days
in each buttock]
102
CHAPTER 5 SEXUALLYTRANSMITTED INFECTIONS
PELVIC INFLAMMATORY DISEASE

See chapter Obstetrics & Gynaecology
GENITAL WARTS (CONDYLOMATA

ACUMINATA)
External, Genital, Perianal:
Duration
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.
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PEDICULOSIS PUBIS (PUBIC LICE)

Patients with pediculosis pubis and their sexual partners should
be treated as follows:
Duration
gamma benzene C V Wash off Reapply 7 to 10
days
hexachloride 1% lotion after 24hrs later to kill hatched lice.
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.
m Alternative in pregnancy, lactating mothers or children < 6
months:
Frequency Duration
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. ___
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:
Duration
kanamycin im C V 25mg/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.
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CHAPTER 6 HIV RELATED DISEASE
HIV RELATED DISEASE

GENERAL GUIDELINES 106
CLINICAL PRESENTATION 106
GENERAL NOTES 106
COTRIMOXAZOLE PROPHYLAXIS: 107
PERSISTENT GENERALISED LYMPHADENOPATHY 107
ORAL AND OESOPHAGEAL CANDIDIASIS (THRUSH) 108
DIARRHOEA - ACUTE 108
DIARRHOEA - CHRONIC 109
WASTING SYNDROME (SLIM DISEASE) 109
RESPIRATORY CONDITIONS 110
HEADACHE & PROBLEMS OF THE NERVOUS SYSTEM 111
HEADACHE AND MENINGITIS 111
AIDS DEMENTIA COMPLEX 111
HIV RELATED SKIN CONDITIONS 111
HERPES ZOSTER (SHINGLES) 112
POST-HERPETIC NEURALGIA 112
FOLLICULITIS 112
HERPES SIMPLEX 112
SEBORRHEIC DERMATITIS 113
PRURIGO OR PAPULAR PRURITIC DERMATOSES 113
DRUG REACTIONS 113
KAPOSI’S SARCOMA 113
PALLIATIVE CARE IN HIV 113
ANTIRETROVIRAL DRUGS 113
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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 HAQOCI
standard treatment guidelines as well as in the national Guidelines for the
use of Antiretroviral drugs for Zimbabwe. Use the latest guidelines.
Clinical presentation
Presentation 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
The diagnosis of HIV infection should be established beyond doubt by an
ELISA test or two rapid tests, wherever possible.
For notes on the management of HIV infection and related conditions in
children, see also “Paediatric Infections”.
Although no cure is available, it is inappropriate for health
care personnel to respond to the epidemic of HIV related
diseases with helplessness and hopelessness.
The goal should be 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, by
helping to delay, prevent and treat (as early as possible)
particular life-threatening infections to which people with
HIV/AIDS are vulnerable. Antiretroviral(ARV) drugs are now
available. Please refer to the HIV/AIDS Quality of
Care(HAQOCI) standard treatment guidelines and the
national ARV guidelines 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 infected
persons continue to lead a normal and productive life. 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 and
HAQOCI
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CHAPTER 6 HIV RELATEDDISEASE
management guidelines 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 Clinic is.
The following are fundamental to the management of HIV related

illness, but cannot be covered fully here(Refer to the HAQOCI
guidelines):
counselling: pre-testing, post-test, crisis/support;
health education for prevention of further transmission of HIV,
positive living;
maintenance of good nutrition, vitamin/iron supplements.
Diagnosis and treatment of OIs
Use of antiretroviral drugs
Cotrimoxazole prophylaxis:
Cotrimoxazole has been shown to prolong life and reduce hospital
admissions in those with symptomatic HIV or AIDS. Prophylaxis
should be given to all patients with symptomatic HIV, or who have
had an attack of PCP, and to all patients who have had any AIDS
defining condition (or have a CD4 count <200), unless allergic.
Drug Codes Adult Frequency Duration
dose
cotrimoxazole* po C V 960mg every day for life
or
until
CD4>200 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.
HIV Related 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.
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HIV Related 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 occur exclusively in patients
with HIV infection. For example, oral thrush may follow treatment
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:
Duration
metronidazole po C V 400mg 3 times a day
7 days
If no improvement OR very ill/toxic:
Duration
metronidazole po C V 400mg 3 times a day 7 days
and chloramphenicol po B V 500mg 4 times a day 7 days
108
If bloody diarrhoea:
Duration
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
acute diarrhoea, symptomatic anti-diarrhoeal treatment may be
appropriate:
Duration
codeine phosphate po B V 30 - 60mg < 4 times a day
7 days
Note: codeine phosphate is not considered to be a narcotic, and can
be ordered on a regular prescription.
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.
HIV Related Wasting Syndrome (Slim Disease)
DEFINITION: Severe emaciation with recurrent episodes of diarrhoea

usually associated with persistent or intermittent fever and positive
HIV test. This places the patient in WHO Stage 4 HIV disease and
hence patient should be considered for ARVs.
It is important to exclude treatable conditions, especially TB,
and to treat them appropriately.
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Emaciation: encourage a high calorie and protein diet. Add

vitamin supplementation:
Duration
nicotinamide po BE 50mg once a day
review
and pyridoxine po BE 25-50mg once a day
review
and thiamine po AN 50mg once a day
review
alternative:
Duration
vitamins, multi po C E 2 tablets once a day
continual
Further Management
Treat according to results of investigations. Consider trial of TB
therapy if clinical suspicion high. Keep referrals to a minimum
and only refer if alternative diagnosis is suspected.
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.
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:
Duration
amoxycillin po C V 3 times a day 7 days
or benzylpenicillin iv/im * CV 500mg
2.5MU 6 hourly 7 days
(for severe cases)
or doxycycline po (in CV 100mg 2 times a day 7 days
penicillin allergy)
* Note: May complete course with amoxycillin.
If there is no response, get a chest x-ray and follow
management guidelines in the chapter on respiratory
conditions.
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CHAPTER 6 HIV RELATED DISEASE
Then start on prophylactic cotrimoxazole:

Duration
cotrimoxazole po C V 960mg every day for life
or
until CD4
>200
HIV Related Headache and Problems of the

Nervous System
The symptom of headache is commonly encountered in
patients with HIV infection. The cause of this is not clear.
Careful evaluation and follow up is required to exclude
meningitis and other CNS infections.
Other commonly encountered neurological conditions in HIV
infection include AIDS dementia complex, peripheral
neuropathy, Guillan-Barré syndrome, facial nerve palsy and
stroke.
Headache and meningitis

See the section in Neurological Conditions
AIDS dementia complex

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
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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.
Herpes Zoster (Shingles)

Give analgesia:
Duration
indomethacin po B E 25mg 3 times a day review
and skin care:
Duration
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.
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:
Duration
amitriptyline po B E 25 mg-75mg every as required
night increased to
150mg if required.
or carbamazepine po B E 100 - 200mg every
night increased over 10
days to a max of 400mg (dose divided
in 3).
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.
112
In very severe cases acyc/ov/r should be considered.(See STI

chapter)
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 eg chlorpheniramine or promethazine.
Calamine lotion.
Drug Reactions
These are frequently caused by pyrazinamide, streptomycin,
cotrimoxazole and many others.
Withdraw drug.
Decide on alternative drug if needed.
If reaction is severe, give:

Duration
prednisolone po B V 60mg once a day review,
then
Reduce slowly as reaction subsides
Kaposi’s Sarcoma
Antiretroviral drugs are indicated here but chemotherapy
may also be required. Hence KS patients (good general
condition, early Kaposi Sarcoma, single lesions) may be
referred to central hospital level. Get a tissue diagnosis
before referral.
Palliative Care in HIV

See the chapter on Pain Management & Care of the Terminally Ill.
Antiretroviral drugs( Refer to ARV

chapter)
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ANTIRETROVIRAL THERAPY
REFER TO THE NATIONAL ARV GUIDELINES 115
GOALS OF ART 115
MEDICAL CRITERIA FOR INITIATING ART IN ADULTS/ADOL. 116
REASONS FOR DEFERRING ART 116
RECOMMENDED TREATMENT REGIMENS 116
USE OF ARVS IN PATIENTS WITH TB 120
PATIENTS WITH TB WHO ARE NOT YET ON ART: 120
PATIENTS WHO DEVELOP TB WHEN ALREADY ON ART: 120
ART IN PAEDIATRICS 120
ART IN PREGNANCY 120
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CHAPTER 7 ANTIRETROVIRAL THERAPY
REFER TO THE NATIONAL ARV GUIDELINES

Appropriate and effective provision of ARVs is complex and
needs to be provided by those who have received training in
the management of opportunistic infections as well as trained
in the use of the antiretroviral drugs. Further details on the use
of these drugs is available in the national ARV guidelines.
Please refer to those guidelines. Attempts should be made to
send healthcare workers to the national OI/ARV training
sessions or similar training courses.
In general, it is envisaged that the delivery of ARVs at any

hospital will be via their designated OI/ARV clinic or focal
person. Comprehensive HIV/AIDS care requires that there be
provision of counselling (VCT), laboratory capacity to monitor
at least for anaemia, total lymphocyte count (TLC) and liver
dysfunction, laboratory capacity to diagnose commonly
encountered opportunistic infections such as TB or
cryptococcal meningitis. The pharmacy person should also
have received the OI/ARV training as they will be required to
ensure rational prescribing and proper dispensing of the
antiretroviral drugs, taking into account the importance of
making certain that their hospital/clinic has adequate ARV
drug supplies and that patients receive the appropriate
combination of drugs.
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, and
• Improvement of quality of life. Both medical and
psychosocial issues need to be addressed prior to starting
antiretroviral therapy. Patients should be adequately
counseled about appropriate life style measures such as safe
sex practices and no alcohol problem, nutrition and adherence
prior to commencing
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therapy. It has to be clear to the patient that ART is for life

and that strict adherence to treatment is necessary for the
success of ART.
Medical Criteria for initiating ART in adults/adolescents

The patient should have had a documented positive HIV
test and one of the following:
• Patients with WHO clinical stages 3 and 4

• CD4+ lymphocyte count of less than 200
• Patients with a Total Lymphocyte Count (TLC) of less
than 1200.
Psychosocial criteria for initiating ART
• demonstration of reliability e.g. compliance with

cotrimoxazole prophylaxis, keeping appointments etc
• completion of adherence counselling session(s)
• availability of treatment partner/disclosure to treatment
partner
• ease of follow up of the patient
Reasons for deferring ART

Patients may be deferred from starting therapy if:
• They have an intercurrent opportunistic infection e.g.
TB
• Patient needs further psychosocial counseling e.g.
alcohol problems, needs further information on HIV and
AIDS
• First trimester pregnancy
• If they are WHO clinical stages 1 and 2 and have a
CD4 count above 200
• Terminal illness
These patients should be offered continued monitoring as
well as counseling.
Recommended treatment regimens for adults and

adolescents
116
A large number of drugs and drug combinations have been

used in the treatment of persons with HIV infection. The choice
of drug regimen has been based on drug availability, cost of
medications, side effects and the potential for development of
resistance. In the national programme, the following drug
combinations are available:
Dual combinations e.g. Stavudine/lamivudine (e.g Coviro 30

/Coviro 40 /Lamista) Triple or 3-in-1 combination e.g.
stavudine/lamivudine/nevirapine e.g. Stalanev 30/40 and Triviro
30/40
First Line Treatment:
For the first 2 weeks:

Drug Codes Adult Frequen
Duration
dose cy
Stavudine po B V 30 - Twice a
2 weeks
40mg* day And
Lamivudine po B V 150mg Twice a 2
weeks
day
and Nevirapine po B V 200mg Once a 2
weeks
day#
and Cotrimoxazole** C V 960mg daily 2 weeks
*Stavudine 40 mg orally twice daily if body weight is

more than 60 kg or 30 mg orally twice daily if body
weight is less than 60 kg
# Do not ever start Nevirapine without the gradual
introduction. Patients are more likely to develop adverse
drug reactions such as Steven Johnson Syndrome or
hepatitis if started on the full drug regimen which includes
Nevirapine twice a day.
** Cotrimoxazole prophylaxis should be offered to all
starting ART unless they are allergic to it. Ideally it
should be started prior to prescribing ART.
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The above should be prescribed as a “starter pack” as

follows:
Starter Pack:
Drug Codes Adult Frequency
Duration
dose
Dual Stavudine BV One Morning 2 weeks
30 or 40 tablet
/Lamivudine po
and Triple Stavudine B V One
Evening
30 or 40 tablet
/Lamivudine/Nevir
apine po
and Cotrimoxazole C V 960mg daily
2 weeks
After the first 2 weeks, step up as follows (if drugs have

been tolerated with no rashes or other adverse effects): Review
Step-up:
Drug Codes Adult Frequen Duration
dose cy
Triple Stavudine B V 30 Twice a 2 weeks
-30 or 40 day
40mg* /Lamivudine/Nevir apine po
and Cotrimoxazole po B V Once a Until

960mg day CD4
above
200
In the event of drug toxicity:

If the patient has drug toxicity, therapy may be altered as
follows:
• Change of a single drug in a multi-drug regimen is

permitted, i.e., the offending drug may be replaced
with an alternative drug of the same class.
If a patient has an adverse reaction to stavudine,
then this can be replaced with zidovudine and vice
versa.
118
If a patient reacts to nevirapine, then they can be given

Efavirenz 600mg orally once daily at night.
For patients with severe peripheral neuropathy:

Consider initiating therapy with zidovudine in place of
stavudine.
Second Line Treatment Recommendation for

Adults/Adolescents
Treatment failure:
This diagnosis should not be made lightly. Patients that fail to
respond to first line treatment should be treated with a different
regimen that contains drugs that were not included in the first
regimen. The second line regimen should only be initiated after
consultation with an HIV specialist, as the recommendation
will be based on what the patient has already been taking.
Following our current first line therapy, the regimen below is

currently recommended
• Zidovudine 300mg orally twice daily Plus

• Didanosine 200mg orally twice daily, Plus
• Lopinavir/ritonavir three capsules twice daily
General Notes about some of the antiretroviral drugs:
1. Zidovudine and stavudine must not be used

together
2. Didanosine must be taken on an empty stomach;
the patient should not take food two hours before
and one hour after taking the medication
3. Rifampicin should not be used together with
Nevirapine or a protease inhibitor
4. Combination products can enhance adherence by
reducing the pill burden .
5. Women on Efavirenz should avoid pregnancy by
using effective contraception.
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Use of ARVs in patients with TB

Tuberculosis is the commonest opportunistic infection
encountered among persons with HIV infection in
Zimbabwe. Rifampicin interacts adversely with some
antiretroviral agents such as protease inhibitors and
non-nucleoside reverse transcriptase inhibitors such as
Nevirapine.
Patients with TB who are not yet on ART:

In patients with HIV-related TB and who are not yet on ART,
TB treatment takes priority. Antiretroviral drug therapy
should be deferred until the intensive phase is completed. If
the CD4 count is very low (<50), ART should be
commenced using an Efavirenz based regimen if rifampicin
is being used.
Patients who develop TB when already on ART:

Treat TB in the standard way. Change Nevirapine to
Efavirenz during the intensive phase. Switch back to the
Nevirapine during the continuation phase.
ART In Paediatrics
Our current fixed drug combinations are not suitable for
children as splitting the doses results in inadequate dosing
of some of the components. Thus ART in children needs to
be carefully thought out and the individual drug component
dosages i.e. the stavudine/ lamivudine and nevirapine need
to be calculated carefully (See national ARV guidelines).
ART in Pregnancy
Pregnant women should be assessed for ART using the
same criteria as for non-pregnant women. If the mother
needs therapy herself, she should be treated as per national
ARV guidelines. Those who are not yet to be started on
ART should undergo the PMTCT programme.
PPTCT
Refer to national guidelines
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CHAPTER 8 TUBERCULOSIS
TUBERCULOSIS
CONTROL OF TUBERCULOSIS - TB POLICY 122
PREVENTION 123
PRIMARY PREVENTION 123
SECONDARY PREVENTION 123
CASE MANAGEMENT 124
DRUG REGIMENS FOR TUBERCULOSIS 125
CATEGORY I 126
CATEGORY II 127
DAILY DOSES BY WEIGHT – CATEGORY I 129
DAILY DOSES BY WEIGHT – CATEGORY II 130
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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 Welfare’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
• 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
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 Health Care Worker or a trained member
of the community.
DOTS = Directly Observed Treatment Short Course
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.
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CHAPTER 8 TUBERCULOSI
S
PREVENTION
Primary prevention
BCG vaccination is given at birth or at first contact with the child
after birth.
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). BCG vaccine should be given to
all babies, even those born to mothers known to be HIV positive
unless babies have clinical signs of HIV infection.
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:
Drug Codes Dose Frequency
Duration
isoniazid po B V 10mg/kg once a day 2
months
Secondary prevention
If parents are found to be sputum positive, 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:
Drug Codes Paed Dose Frequency
Duration
isoniazid po B V 10mg/kg once a day 6
months
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.
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CASE MANAGEMENT
Diagnosis
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.
The sputum of smear positive PTB patients MUST be sent to the

TB Reference Laboratory if:
there is concern that during treatment drug resistance has
developed, or
there is a history of previous treatment, or
sputum conversion has not occurred after 4
months of
treatment for category 1 patients and 5 months of treatment for
category II patients.
Chest X-Rays
Indications for chest x-rays
• 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
Chest x-rays should NOT be routinely used for diagnosing pulmonary

TB. In sputum positive patients a chest x-ray is not necessary.
Tuberculin Testing
Use Mantoux test only:
Drug Codes Dose Frequency
Duration
tuberculin, purified B N 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.
124
S
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.
DRUG REGIMENS FOR TUBERCULOSIS

Two main treatment categories are now used in Zimbabwe, each
with its own regimen. The regimens consist of a combination of five
first line drugs.
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 Drug Abbreviations

H= isoniazid Z= pyrazinamide
R= rifampicin S= streptomycin
E= ethambutol
No ethambutol or streptomycin should be given to children less than

10 years old, or to pregnant women.
Trial of TB treatment
Trial of TB treatment is discouraged as a first intervention. A definitive
diagnosis must be made on the basis of history taking and examination.
See the TB Manual for more information on trial of therapy, but note
that monotherapy (use of only one TB drug) should always be avoided,
and trial of TB treatment should only be initiated after treatment with
an antibiotic has been given and other tests undertaken.
Adverse Drug Reaction:

Stop all TB drugs and assess. If necessary evaluate the liver
function. Then reintroduce one drug 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 drug should be re-
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introduced in a similar manner - slowly, increasing the dose daily.

e.g Day 1 Isoniazid 25mg
Day 2 Isoniazid 50mg Day
3 Isoniazid 100mg Day 4
Isoniazid 200mg Day 5
Isoniazid 300mg
Day 6 Isoniazid 300mg + Streptomycin 125mg
Day 7 Isoniazid 300mg + Streptomycin 250mg etc
CATEGORY I
All new cases of TB regardless of site, bacteriology or severity
Adults:
Intensive phase: 2HRZE
Continuation phase: 4HR if DOTS OR ( 6HE For patients on a
nevirapine-based ARV regimen who cannot wait until the end of treatment)
Children <10 years:

Intensive phase: 2HRZ
Continuation phase: 4HR ( or 6HE for patients on nevirapine-
based ARVs
In children under 10 years, no streptomycin should be given except for TB

meningitis. Ethambutol is now recommended for children of all ages on
retreatment.
Streptomycin can replace ethambutol in the intensive phase.
General notes: Category I

In smear positive cases, if the sputum is still smear positive at
the end of two months, the intensive phase is extended for a
maximum of one more month.
The continuation phase can be started when the
sputum
becomes negative before the end of the 4-week period.
Commence the continuation phase after four months
regardless of sputum status.
Sputum testing should be sent to the National TB Laboratory for
culture and sensitivity testing if still smear positive after five
months of treatment. If the patient’s sputum remains smear
positive after five months of treatment (treatment failure)
Category II treatment should be commenced.
126
S
Patients with tuberculous meningitis or

pericarditis,
disseminated or spinal disease with neurological complications
should be given 6HR (continuous phase) i.e. 6 months of
isoniazid and rifampicin under direct observation.
CATEGORY II
All re-treatment of any form of TB.
Adults:
Intensive phase: 2SHRZE + 1HRZE (DOTS)
Continuation phase: 5HRE [DOTS]
Children:
Intensive phase: 3HRZ (DOTS)
• Continuation phase: 5HR [DOTS]
General notes: Category II

These patients must be suspected of having drug-resistant
strains. The re-treatment regimen is the last opportunity for
the patient to be cured. It is advisable to admit the patient for
supervised treatment at a designated centre (Harare or
Bulawayo) A pre-treatment sputum specimen must be
submitted for culture and drug susceptibility testing.
Because of the increased risk of
multi-drug-resistance
(resistance to at least isoniazid (H) and rifampicin(R)),
treatment must be fully supervised for the full course. Duration
of course: 8 months.
Take monthly sputum specimens for monitoring purposes up to
the end of treatment (8 months).
If the sputum is smear positive at three months (12 weeks), the
four oral drugs are continued daily for another month.
If the patient is still smear positive at the end of four months, all
drugs should be stopped for three days and a sputum
specimen sent to the National Reference Laboratory in
Bulawayo for culture and susceptibility testing. The patient
should then be started on the continuation phase. Further
extension of the continuation phase will not increase the
chances of cure.
Patients who remain smear positive after the end of the fully
supervised continuation phase will derive no benefit from
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another re-treatment regimen, and should be classified as

chronic cases.
Chronic cases
These are patients who remain (or again become smear
positive) after completing a fully supervised re-treatment
regimen.
No standard regimen exists for these patients. There is
every likelihood of multi-drug resistant tuberculosis
(MDR-TB). In the best of situations, cure rates for MDR-TB
cases are between 40-60%, the same as for untreated
sputum positive PTB. So-called second line drugs are very
expensive, generally more toxic, and are not as effective as
first line drugs. Because their management is so
problematic, chronic cases should be referred to designated
specialist centres such as Beatrice Road Infectious disease
Hospital, Harare or Thorngrove Hospital, Bulawayo.
Note: Although smear negative PTB and extra-pulmonary cases may
also be treatment failures, relapses and chronic cases , this is a rare
event and should be supported by pathological and /or bacteriological
evidence.
128
DAILY DOSES BY WEIGHT – CATEGORY I

Table 8.1 Intensive phase (2 months)
(pre-treatme Ethambutol (E) Isoniazid (H) Rifampicin (R) Pyrazinamide (Z)
nt) weight 400mg tab 100mg tab or 150mg tab or 500mg tab or
suspension 100mg/5ml suspension
syrup
5-1 Okg n/a 50mg 75 mg 250mg
11-20kg n/a 100mg 150mg 500mg
21-30kg n/a 200mg 300mg 10OOmg
31-<33kg 800mg 200mg 300mg 10OOmg
33-50kg 800mg 300mgs 450mg 1500mg
> 50kg 1200mg 300mg 600mg 2000mg
Table 8.2 Continuation phase – DOTS assured

(4months)
(pre-treatme Isoniazid (H) Rifampicin (R)
nt) weight 100mg tab or 150mg cap or
suspension 100mg/5ml syrup
5-1 Okg 50mg 75 mg
11-20kg 100mg 150mg
21-30kg 200mg 300mg
31-<33kg 200mg 300mg
33-50kg 300mg 450mg
> 50kg 300mg 600mg
Table 8.3 Continuation phase - DOTS not assured (6

months)
(pre-treatme Isoniazid (H) Ethambutol (E)
nt) weight 100mg tab 400mg tab
31-<33kg 200mg 800mg

33-50kg 300mg 800mg
> 50kg 300mg 1200mg
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DAILY DOSES BY WEIGHT – CATEGORY II

Table 8.4 -Adult Intensive Phase (4 months)
Month 1 only Months 1, 2, 3 and 4
Streptomycin * Isoniazid Rifampicin Pyrazinamide Ethambutol
(S) 1gm (H) 100mg (R) 150mg (Z) 500mg (E) 400mg
injection tabs caps tabs tabs
31-<33kg 500 mg 200mg 300mg 10OOmg 800mg
33-50kg 750 mg 300mg 450mg 1500mg 800mg
>50kg 750mg 300mg 600mg 2000mg 1200mg
*Do not exceed 750mg streptomycin in pt’s over 50years.
Table 8.5 – Paediatric Intensive Phase (3 months)

Isoniazid (H) Rifampicin (R) Pyrazinamide (Z)
100mg tabs 150mg caps 500mg tabs
5-1 Okg 50mg 75mg 250mg
11-20kg 100mg 150mg 500mg
21-30kg 200mg 300mg 10OOmg
Table 8.6 - Continuation Phase (5 months)

Isoniazid (H) Rifampicin (R) Ethambutol (E)
100mg tabs 150mg caps 400mg tabs
5-1 Okg 50 mg 75mg n/a
11-20kg 100mg 150mg n/a
21-30kg 200mg 300mg n/a
31-<33kg 200mg 300mg 800mg
35-50kg 300mg 450mg 800mg
>50kg 300mg 600mg 1200mg
130
Intermittent therapy
It is intended in the future to introduce intermittent therapy
for TB. Isoniazid, rifampicin, pyrazinamide and streptomycin
are all as efficacious when given intermittently (2-3 times a
week) as when given daily. There are however certain
precautions that must be ensured before this is
implemented, and the TB Control Programme / MoHCW will
advise on this change.
Fixed dose combination tablets

Fixed dose combination tablets may soon be available. 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 possibility of drug resistance
developing.
Doses using these tablets are the same as for separate
tablets, but care must always be taken and the labels
carefully read. Again, the TB Control Programme will give
more advice when these tablets are available, and
information is in the TB Manual .
TB and HIV Co-infection
Refer to the current national ARV guidelines as well as the
TB manual. Also refer to the ARV chapter in this EDLIZ.
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TROPICAL DISEASES
ANTHRAX (CUTANEOUS) 133
TICK TYPHUS (AFRICAN) 133
RABIES 133
BILHARZIA (SCHISTOSOMA MANSONI & HAEMATOBIUM)
135
HELMINTHIASIS 136
PLAGUE (BUBONIC) 137
LEPROSY 137
NOTIFIABLE DISEASES 142
132
CHAPTER 9 TROPICAL DISEASES
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.
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:

Duration
doxycycline po C V 200mg first dose, then
100mg once daily 7 days
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 5th – 6th day, initially on the upper trunk followed by a
spread to the entire body but usually not to the face, palms or soles.
Duration
doxycycline po C V 200mg first dose, then
100mg once daily 7 days
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.
Pre-exposure immunisation schedule:

Duration
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.
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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, ie:
broken skin
uncertain animal history or strong suspicion of rabid animal
give:
Duration
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:
Duration
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, ie:
skin not broken or other contact (eg. with infected meat)
bite from domestic animal immunised against rabies
Follow the 2-1-1 vaccination schedule, but without giving
immunoglobulin.
Minimal - no risk
In previously vaccinated individuals give a single booster
dose of rabies vaccine.
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BlLHARZIA (SCHISTOSOMA MANSONI &

HAEMATOBIUM)
General Guidelines
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.
Treatment:
Duration
praziquantel po C E 40mg/kg one dose only
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).
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.
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:
Duration
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.
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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
Duration
albendazole po C E 400mg one dose only
<2yrs = 200mg
Tapeworm and Strongyloides

Duration
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”)
Duration
albendazole po C E 400mg one dose only
Cysticercosis and Neurocysticercosis

Specialist inpatient treatment is required.
Duration
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.
136
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:
Duration
albendazole po C E 3mg/kg 3 times a day 30
days, then
wait 15 days (drug free). Then repeat the cycle 4 times.
Monitor progress with ultrasound and/or X-ray.
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:
Duration
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:
Duration
doxycycline po C V 100mg 2 times a day 10
days
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
A 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
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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.
Duration
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
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 or relapse and
reaction, and request them to come back immediately.
138
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 month
*Not less than 150 mg o rifampic =10-15mg/kg* n.

MDT should be suppliedf in 28-day
i blister packs for ease of ordering
and to avoid drug 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 drugs 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
If there is no improvement consider treatment

with corticosteroids. If there is evidence of neuritis
(tender
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EDUZ2006
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:
Duration
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. The full dose of antileprosy
drugs should be continued in addition to the treatment of the
reaction.
Mild Type II Reaction

Duration
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.
140
Severe Type II Reaction

Admit for corticosteroid therapy and refer to specialist urgently:
Duration
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 2 months
then 100mg 2 times a day 2 months
then 100mg once a day 6 months
Refer all patients developing abdominal complaints (pain,

constipation, distension).
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 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 251647.
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NOTIFIABLE DISEASES
Chicken pox
Diptheria
Erysipelas
Pyaemia and septicaemia (puerperal)
Scalatina (scarlet fever)
Typhus fever
Plague
Cholera
Typhoid or enteric fever (including para-typhoid fever)
Undulant or Malta fever
Epidemic cerebrospinal meningitis (or cerebrospinal fever or
spotted fever)
Acute poliomyelitis (or infantile paralysis)
Leprosy
Anthrax
Glanders
Rabies
Trypanosomiasis (sleeping sickness)
All forms of Tuberculosis
Ebola or any haemmorhagic fever diseases
Measles
All such other infectious or communicable diseases as the Minster
of Health & Child Welfare may declare by statutory instrument,
to be infectious diseases throughout or in any part of
Zimbabwe.
142
CHAPTER 10 MALARIA
MALARIA
GENERAL NOTES 144
DRUG PROPHYLAXIS 144
TREATMENT OF MALARIA 146
UNCOMPLICATED MALARIA 147
TREATMENT FAILURE 152
SEVERE/COMPLICATED MALARIA 150
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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 only with F'.falciparum and usually in
young children, pregnant women, debilitated persons, adults in
epidemic prone areas and people moving from areas of no
malaria to areas with malaria including immune-suppressed
patients.
Malaria usually occurs 1-6 weeks after a bite by an infected
anopheles mosquito. So it is important to take a good history
and to always ask about travel and self-medication.
General notes on drug dosages:

All chloroquine doses are expressed as chloroquine base. 150mg of
chloroquine base is equivalent to 200mg of chloroquine sulphate and
is equivalent to 250mg chloroquine phosphate.
All quinine doses are expressed as quinine salt (this is different from
chloroquine). Quinine sulphate, quinine dihydrochloride, quinine
hydrochloride all contain practically the same amount of quinine- i.e.
600mg of quinine dihydrochloride is equivalent to 600mg of quinine
sulphate.
DRUG PROPHYLAXIS
No drug gives 100% protection against malaria, but drugs do
reduce the risk. Health education on non-pharmacological means of
prevention is extremely important e.g. selective spraying, use of
mosquito coils, repellents, insecticide-treated mosquito nets,
appropriate protective clothing.
Drug prophylaxis is recommended for the following categories of

people:
All persons travelling from a non-malaria area to a malaria
area. (e.g. people from cities or the highveld visiting low-lying
areas).
Persons with sickle cell anaemia or splenectomy living in or
visiting a malaria area.
Pregnant women in regions of potentially year round malaria
and essentially seasonal malaria.
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CHAPTER 10 MALARIA
Malaria drug prophylaxis should be commenced 1-7 days before

entering the malarial area and be continued for 4 weeks after leaving
the malarial area, and should be taken same day of the week.
Malaria prophylaxis for:

• persons travelling from a non-malaria area to a
malarial area, and
• persons with sickle cell anaemia / splenectomy
living in or visiting a malarial area:
Pyrimethamine and dapsone remains the drug combination
of choice for malaria prophylaxis in Zimbabwe.
Duration
pyrimethamine /dapsone CE one tablet once a week
12.5mg/100mg po 1 week
Children* before
6 weeks - 1 year 2.5ml syrup once a week entering, +
duration of
1- 5 years ¼ tablet once a week stay + 4
6 - 11 years ½ tablet once a week weeks after
leaving the
*Note: not recommended in infants under 6 weeks. area.
Available tablets = 12.5mg pyrimethamine + 100mg dapsone
tablet and the syrup = 3.125mg pyrimethamine + 25mg dapsone per
5ml. per
Those intolerant to pyrimethamine and dapsone should take:
proguanil po and B N 200mg once a
*C
chloroquine po V 300mg base once a week
*1-7 days before entering, + duration of
NB: must be given together stay + 4 weeks after leaving the area, on
same day of the week.
Table 10.1: Age specific doses for

proguanil/ chloroquine regimen:
Dose of Chloroquine base per Dose of Proguanil per day
week (150mg base tablets and (100mg tablets)
50mg base/5ml syrup)
Under 1 year 50mg(1/3 tablet or 5ml) 25mg (1/4 tablet)
1-4 years 75mg (½ tablet or 7.5ml) 50mg (½ tablet)
5-8 years 150mg (1 tablet or 15ml) 100mg (1 tablet)
9-12 years 225mg (1 ½ tablets or 20ml) 150mg (1½ tablets)
over 12 years 300mg (2 tablets) 200mg (2 tablets)
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• pregnant women in regions of potentially year round
and essentially seasonal endemicity
Chemoprophylaxis in Pregnancy -
Intermittent Presumptive Therapy (IPT)
Timing
At ANC 26-28 Weeks 34-36 Weeks
Booking
Drugs 3 tablets 3 tablets 3 tablets
sulphadoxine- sulphadoxine- sulphadoxine-

pyrimethamine pyrimethamine pyrimethamine
and a and a and a
chloroquine chloroquine chloroquine
course course course
N.B: 1. The doses of IPT should be at least 4 WEEKS

apart.
2. Use of Pyrimethamine
Pyrimethamine/Dapsone (Malasone) is not
recommended in pregnant women

visitors from outside the country
May continue with the prophylaxis recommended to them
before coming to Zimbabwe.
TREATMENT OF MALARIA
Malaria blood slides MUST be taken in the following cases:
Patients with severe/ complicated malaria.
Patients with treatment failure.
All referrals.
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CHAPTER 10 MALARIA
Note: Pregnant women diagnosed with malaria must receive drug

therapy immediately. Although quinine is potentially teratogenic, the
benefit of giving quinine therapy far out weighs any risk.
Uncomplicated malaria
Recent national annual malaria reports in Zimbabwe show
that there has been some decrease in the effectiveness of
chloroquine. Therefore the recommended initial treatment
for uncomplicated malaria is the “free combination” therapy
chloroquine(CQ) and sulphadoxine-pyrimethamine
(SP).
This is an interim treatment policy. The proposed and
preferred long term first line treatment of uncomplicated
malaria is the arteminisinin combined therapies such as
Artemether-lumefantrine.
Give the following treatment immediately:
First Line Therapy – “Free Combination” Therapy
Age Stat Doses After Day 2 Day 3
6 hours
SP CQ CQ only CQ only CQ only

Adult 3 tabs 600 mg 300mg(2 300mg(2 300mg
(4 tab) tab) tab) (2 tab)
10+yrs 3 tabs 600 mg 300 mg (2 300 mg (2 300 mg (2

&>60k g (4 tab) tab) tab) tab)
10 2 tabs 450 mg 150 mg (1 150 mg (1 150 mg (1

+yrs & (3 tab) tab) tab) tab)
<60 kg
7 - 10 1½ 450 150 mg (1 150 mg (1 150 mg (1

tabs tab tab) tab) tab)
(tab)
4-6 1 tab 300 mg 150 mg (1 150 mg (1 150 mg (1

(2 tab) tab) tab) tab)
1-3 ½ tab 150 mg 75 mg (1/2 75 mg (1/2 75 mg

(1 tab) tab) or 7.5 tab) or 7.5 (1/2 tab)
or ml ml or
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15 ml 7.5 ml
< 1 ½ tab 75 mg 37.5 mg 37.5 mg 37.5 mg
year (1/2 tab) (1/4 tab) 0r (1/4 tab) (1/4
or 7.5 ml 3.75 ml 0r 3.75 ml tab) 0r
3.75 ml
*Caution: Known to cause serious adverse effects, (although rare)
Stevens-Johnson syndrome, in those patients sensitive to
sulphur drugs.
N.B:
1. If the stat dose of SP and CQ 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 quinine.
4. To ensure compliance it is desirable to give the STAT
doses as Directly Observed Therapy (DOT).
st
5. Malaria in the 1 trimester of pregnancy should be treated
with a 7 day course of oral quinine.
Coartem -Artemether-Lumefantrine(1.5mg/12mg/kg):
To be given as a 6 dose course twice a day for 3 days as follows:
Dosage Day 1 Day 2 Day 3
Weight Start After AM AM

Dose PM PM
8hrs*
5- 14 kgs 1 1 1 1 1 1
15 - 24kgs 2 2 2 2 2 2
25- 34kgs 3 3 3 3 3 3
35kgs 4 4 4 4 4 4
and adults
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.
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CHAPTER 10 MALARIA
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. drug being vomited within 1/2 hour or
failure to complete the treatment.
Presence of undetected severe and complicated malaria.
Malaria parasite resistance (known or suspected) to the given
drug.
If a patient returns to the health facility still feeling unwell:

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 – Oral Quinine + Doxycycline
7 Day Quinine Course
Drug Codes Dose Frequency Duration

Quinine B V Adults – Every 7 days
tablets 600 mg 8 hours
Children – Every 7 days
10 mg/kg 8 hours
body
weight
Short Course Quinine plus Doxycycline (Adult)

Quinine B V 600 mg Every 5 days
8 hours
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Doxycycline* C V 100 mg Once daily 7

days
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. In children a single dose of S/P is
given immediately after completing 5 days of quinine.
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:

prostration, i.e. if the patient is unable to stand or sit or feed
independently,
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<or=6g/dl)
Hyperpyrexia
Jaundice
Shock
Severe haemoglobinuria
Hyperparasitaemia (>5% in non- immune patients)
Acute renal failure
Respiratory distress
Hypoglycaemia
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CHAPTER 10 MALARIA
Treatment of severe/complicated malaria must be parenteral

and the drug of choice is quinine.
Parenteral therapy must be commenced at primary level
either by IM administration or, if it is practical, by IV infusion
before the patient is referred. In both cases treatment is
initiated by a loading dose.
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).
Duration
quinine infusion in 5% BV 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) total of 48 hours of
then reduce to 5mg/kg therapy
every from start.
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.
Or give a full course of e.g Coartem.
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 that
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.
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When an IV line cannot be established:

Duration
quinine im * B V 10mg/kg every 4 hrs for
3 doses,
then
10mg/kg every 8hrs 7
days
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. (An alternative to using doxycycline is
to add sulphadoxine /pyrimethamine at the end of the
treatment).
*IM quinine should be diluted as follows:
Dilute the quinine with water for injection. Draw 8ml of
water for injection into a 10ml syringe, 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
Alternative dose regimen:
Quinine 20mg salt/kg on admission( IV infusion over 4 hours or IM)
and then 10mg/kg 12 hourly.
General measures
Coma: maintain airway, nurse on side, 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.
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CHAPTER 11 RESPIRATORY CONDITIONS
RESPIRATORY CONDITIONS
Acute Respiratory Infections in Adults 154

Outpatient management 154
Common cold, influenza and acute bronchitis 154
Other respiratory infections 154
Inpatient management 155
Pneumonia - segmental/ lobar 155
Pneumonia - bilateral ‘patchy’ 162
Pneumonia - Staphylococcal 156
Pneumonia - Klebsiella, other gram negative 156
Lung abscess 156
Empyema 156
Hospital Acquired Infections (Nosocomial) 157
Other common respiratory infections 157

Chronic Bronchitis and/ Emphysema 157
Bronchiectasis 157
Asthma 158
Management Guidelines 158
Maintenance Therapy - Adults 159
Acute Asthma Attacks - Adults 161
Asthma in Children 162

Acute Attacks - Children 162
Maintenance Therapy 163
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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 does not depend on HIV status.
Take a history of the duration of symptoms, sputum production
(colour, blood, volume) night sweats, pyrexia, etc. Consider
tuberculosis in the diagnosis if symptoms for more than three
weeks. A chest x-ray may be required.
If tuberculosis is unlikely and the patient’s condition does not
warrant admission, treat the infection with:
Amoxycillin C V 500mg Three times 7 days +
a day review
If sensitive to Penicillin C V 500mg Four times a
use day
Erythromycin
If tuberculosis likely arrange a sputum examination and plan

a review in one week.
On re-assessment with no clinical improvement refer to district

level. The three commonest diagnoses will be:
Pneumonia - non-responding segmental / lobar(See section
on inpatient management )
Tuberculosis
Repeat sputum 3 times if necessary. Refer to the chapter on
tuberculosis for treatment protocols.
Pneumocystis Pneumonia (PCP)
Patients are breathless and possibly cyanosed with few or no
chest signs. Their x-ray typically reveals bilateral fine mid-zone
infiltrates. Frequently there are other signs of
immuno-suppression.
154
Manage with:
Duration
cotrimoxazole po C V 1920mg 3 times a day
21 days
(4 tabs)
or in sulphonamide allergy:
Duration
clindamycin po B V 600mg 4 times a day
21 days
And primaquine po B N 15mg once a day
If any tachypnoea or cyanosis is present, add:

Duration
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

for life or CD4 count >200 with ART. This also applies to
any other patients with AIDS defining disease. If they are
allergic, try cotrimoxazole desensitisation
Duration
cotrimoxazole po C V 960mg once a day for life
< 6mths = 120mg
6-12mths = 240mg >1
year = 480mg
If still no response, consider malignancy e.g.Kaposi’s sarcoma.
Inpatient management
Consider admission if patient is obviously unwell, or in severe pain.
Admission and close monitoring is mandatory if:
respiratory distress
cyanosed
pulse >125/min
hypotensive (systolic < 90mmHg)
temperature > 40oC or < 35oC
altered mental state
Pneumonia - segmental/ lobar (usually pneumococcal)

Duration
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.
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Note: Switch to oral amoxycillin to complete the course
m If not improved in 48 hours review diagnosis (consider

tuberculosis or a complication of pneumonia e.g. lung
abscess) and change to:
Duration
erythromycin po C V 500mg 4 times a day 7
days
Pneumonia - Staphylococcal
Duration
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 B V 120mg 12 hourly 10-14 days
And chloramphenicol iv B V 500mg 6 hourly 10-14 days
or based on culture and sensitivity.
Lung abscess
Postural drainage is mandatory, plus
Duration
benzylpenicillin iv C V 1 5gm 6 hourly 4-6weeks*
(=2.5MU)
And metronidazole po C V 400mg 3 times a day
4-6weeks
*continue until no longer toxic +/- 7 days, then complete treatment as
out patient for 4-6 weeks with oral amoxycillin 500mg three times a
day.
Empyema
Drain pleural space with a large intercostal tube
and
underwater seal.
Duration
benzylpenicillin iv C V 2.5MU 6 hourly 10-14 days
10-14 days
Note: If still draining pus after two weeks refer for surgical opinion.
m If preceeded by a suspected staphylococcal pneumonia use:
156

Duration
cloxacillin iv B V 1gm 6 hourly 10-14 days
10-14 days
Hospital Acquired Infections (Nosocomial)

Pneumonia presenting 7 or more days after admission:
Duration
gentamicin iv B V 120mg 12 hourly 7-10 days
and benzylpenicillin iv C V 1.5gm 6 hourly 7-10 days
(=2.5MU)
or based on culture & sensitivity.
OTHER COMMON RESPIRATORY INFECTIONS

Chronic Bronchitis and/ Emphysema
There are many aspects of management:
Stop smoking and/or remove from hazardous
(dusty)
environment.
Prompt treatment of infective exacerbations:
Duration
amoxycillin po C V 500mg 3 times a day 7
days
or doxycycline po C V 100mg once a day 7 days
For airway obstruction and dyspnoea add:

Duration
salbutamol inhaler B E 100-200mcg as needed check
technique
If dyspnoea is severe:
salbutamol nebulised B V 5mg 6 hourly
and prednisolone po B V 30mg once a day up to
14days
controlled oxygen therapy - 2 litres/minute by nasal prongs or
28% ventimask (Avoid higher concentrations of oxygen unless
access to blood gas analyser),
physiotherapy.
Bronchiectasis
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Treat as above. Refer to physiotherapist for postural drainage.

Severe and or persistent infections may need gentamycin
intravenously and other antibiotics.
Haemoptysis usually responds to antibiotics.
ASTHMA
Management Guidelines
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.
Infants under 18 months, however, may not respond well to
bronchodilators. Details of asthma drug treatment in children are
given after that of adults below.
The aim of maintenance therapy is to minimise symptoms and to
prevent acute attacks. If frequent severe attacks continue to occur,
then the maintenance therapy is inadequate. Some patients may
have infrequent symptoms. Patients requiring permanent or
frequent intermittent therapy with bronchodilators need steroids.
They must always have a supply of prednisolone tablets available
to restart treatment at the first sign of symptoms returning.
Inhalers
Some patients with chronic asthma will require inhalers. They
are expensive. 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 inhaler
making sure it fits tightly. Give one puff into the spacer and
allow normal breathing for 30 seconds through the other end.
All medical 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.
158
The asthma score is obtained by adding the ‘symptoms score’

(A) to the ‘frequency of use of bronchodilator’ score (B) in the
table below. The maximum score that can be obtained is 8.
Degree of severity Score (A+B):
Mild asthma 0-3
Moderate asthma 4-6
Severe asthma 7-8
Table 11.1: Asthma Score Chart

Score A Symptoms (Frequency of attacks of tight chest, cough
or wheezing)
4 Waking up at night more than twice a week
3 Daily, but not at night
2 Not daily but more than once a week
1 Less than once a week, or on exercise
0 None for 3 months
Score B Frequency of use of bronchodilator
4 More than 4 times a day
3 1-4 times daily
2 Less than once a day
1 Less than once a week
0 None for 3 months
Maintenance Therapy - Adults

Mild Asthma
A bronchodilator is the drug of choice. It may be used
intermittently as needed or on a regular basis. Salbutamol is
generally better than theophylline.
Mild chest tightness occurring no more than once a day or only
with exercise may be relieved by use of a bronchodilator.
May require prednisolone to be added following ‘colds’ etc.
which may precipitate acute attacks.
salbutamol inhaler Duration
BE 100–200mcg as needed, or before
exercise
or salbutamol po B V 4mg up to 4 see notes
times a day
or theophylline po CE 100-200mg 2-3 times a see
notes
base day
1
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Moderate Asthma
The ideal treatment should always include inhaled steroids
(beclomethasone) with courses of oral steroids (prednisolone)
for exacerbations.
Associated bronchospasm is treated by salbutamol (inhaled
and/or oral). If salbutamol is required more than twice a day or
there is frequent night-time waking, an increased dose of
inhaled steroids is required.
Combined use of salbutamol and theophylline may be effective
in some patients, although side effects sometimes may be
troublesome.
Always check inhaler technique.
Duration
beclomethasone B E 200-400mcg 2 times a day
continual
inhaler 10Omcg/puff
And salbutamol Inhaler B E 100-200mcg as required
continual
+/- salbutamol po B V 4mg 3 times a day continual
+/- theophylline po C E 200mg 2-3 times a continual
day
Add a course of prednisolone if required:

Duration
And prednisolone po B V 30mg once a day one
week,
(morning) or at least
until chest
clears*
*If the course is needed for more than a week, tail off the dose over 10
days.
m If beclomethasone is used and is not controlling the asthma

add:
Duration
prednisolone po B V 2.5 - 10mg once, in the
continuous
morning
160
Severe Asthma
If response is still not adequate and the inhaler technique is good:
Duration
beclomethasone B E 400mcg 2- 4 times a
continual
inhaler 100mcg/puff day
and prednisolone po B V 2.5 - 10mg once a day
continual
using the lowest effective dose possible (morning)
and salbutamol inhaler B E 100-200mcg as required as
required
+/- salbutamol po B V 4mg 3 times a day -
+/- theophylline po C E 200mg 2-3 times a continual
day
Nocturnal Asthma
Patients whose sleep is regularly broken should be advised to
take their medication on going to bed.
If oral theophylline has not been used its addition may be highly
beneficial.
Repeated Attacks of Asthma Requiring Hospital Treatment

These patients should already be on prednisolone. They should
also be given a 5-day course of prednisolone 30-40 mg daily to be
started at home as soon as the onset of an attack is felt.
Acute Asthma Attacks – Adults

1. Careful monitoring of the patient’s condition is essential to
assess severity, and to detect improvement or deterioration. In
the absence of blood gas facilities, this will depend on close
assessment of physical signs such as paradox, use of
accessory muscles, colour, mental state, etc.
2. Humidified oxygen by mask at high concentration (6 litres/min)
is important.
3. Give:
Duration
salbutamol nebulised B V 5mg repeat at ½ - 1 hr
(in saline or sterile water) O2 at 6 intervals,
hours untilthen every 2-4
recovered
litres/min
or adrenaline 1:1000 sc C V 0.5ml 1-2 hourly
as required
useful when no nebuliser available
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and prednisolone po B V 40mg once a day 7 days

in all but the mildest cases (mornings)
4. If poor response to initial nebuliser therapy, or attack severe add:
Duration
hydrocortisone iv B V 200mg once only (unless oral
dosing not possible)
And aminophylline iv slow B V 6mg/kg over 20 minutes,
(unless the
bolus dose patient has taken aminophylline in the
past 8 hours)
The aminophylline iv in B V 12mg/kg/24 hours in 1-2
litres
n dextrose 5% slow
infusion
5. Consider ventilation in severe cases. A short period (5-10
minutes) of ventilation with halothane may end the attack.
6. If chest is clear at 7 days steroids can be stopped without
tapering off the dose; otherwise reduce by 5mg/day
to maintenance of 5mg daily until next review.
7. After an acute attack all patients should continue with broncho-
dilators, and after a severe attack all patients should be on inhaled
beclomethasone.
8. Except in mild cases follow up is essential.
Use of peak flow meter in acute asthma attack:

If peak flow meter is available, measure the peak flow hourly:
If <50l/min give ½ hourly salbutamol until peak >50l/min, then
1 hourly salbutamol until >100l/min, then 2-4hourly salbutamol.
ASTHMA IN CHILDREN
Acute Attacks - Children

The same general measures apply as in adults.
Give:
Duration
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 B E 100-200mcg as required
through a spacer (1-2 puffs)
162
Give oxygen between nebulisations.

If nebulisation facilities are not available, or poor response:
Duration
+/- adrenaline 1:1000 sc C V 0.01ml/kg may be
repeated twice at
20 minute intervals
or aminophylline slow iv B V 4mg/kg over 20-30mins -
not if
theophylline given in the last 8 hours
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:
Duration
aminophylline iv B V 1mg / kg / hour
infusion 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:
Duration
salbutamol inhaler B E 200mcg - 400mcg as required
Maintenance Therapy
1. Advise the parents to avoid combination drugs like Franol ®
and Status ®.
2. Do not keep children on long term beta-2 stimulant drugs (e.g.
salbutamol) if they are mostly asymptomatic.
3. 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:
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salbutamol inhaler B E 100-200mcg as required
or salbutamol po B V 0.1 – 4 times a day
0.15mg/kg
or theophylline po C E 5mg/kg < 4 times a
day intermittent
Moderate asthma - children

Triggered by infection, allergy, exercise etc. As for mild
asthma, but continual therapy may be required. Inhaled
salbutamol is the most effective option of therapy, but if
unavailable oral salbutamol may be used. 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
Duration
Add beclomethasone B E 50-100mcg 3 – 4 times continual
inhaler a 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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CHAPTER 12 CARDIOVASCULAR DISEASE
CARDIOVASCULAR DISEASE
Endocarditis 166
Rheumatic fever 168
Hypertension 170
Treatment of hypertension 171
Hypertension in the elderly 173
Hypertension in diabetics 174
Hypertension in black people 174
Resistant hypertension 174
Management of severe hypertension 174
Cardiac Failure 176
Angina Pectoris 178
Myocardial Infarction 180
Arrhythmia 181
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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:
Duration
benzylpenicillin iv C V 5MU 6 hourly 4-6 weeks
and gentamicin iv B V 1-1.5mg/kg 12 hourly 2
weeks
Prosthetic valve endocarditis

Initially:
Duration
cloxacillin iv B V 2g 6 hourly 4-6 weeks
weeks
It is important to assay 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 (eg. Strep. viridans):
Duration
weeks
Enterococcal infection (eg. Enterococcus faecalis):
Duration

weeks
Max-120mg
166
Staphylococcal infection (eg. Staph. aureus &

Staph. epidermidis):
Duration
cloxacillin iv B V 2g 6 hourly 4-6 weeks
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 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):
Duration
amoxycillin po C V 3g Paed one dose only – one hour
before procedure
= 50mg/kg
or clindamycin po in B E 600mg one dose only,
penicillin allergy or recent one hour before
<5yrs = 150mg
penicillin administration (< one procedure
month) 5-10yrs = 300mg
Dental procedures, upper respiratory tract, obstetrics and gynaecological
procedures under general anaesthesia (no special risk):
Duration
ampicillin iv B E 1g at induction, then 500mg after 6hrs
or amoxycillin 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.
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Prophylaxis against endocarditis

-special risk:
Prosthetic valve in situ, or previous endocarditis or
genitourinary
procedures (special risk groups)
Duration
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:
Duration
clindamycin iv* B N 300mg at induction single
dose
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 drug] 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) once dose
1.44g = 1.2MU Paed: <5 yrs =0 single dose
only
.15(0.18g)
5-10 yrs= 0.3MU(0.36g)
>10 yrs=0.6MU( 0.72g)
or penicillin V po C E 500mg 4 times a
Paed: <5 yrs=125mg day 10 days
5-10 yrs=250mg
>10 yrs=500mg
or erythromycin po - in C V 500mg 4 times a
10 days
______penicillin allergy ___________________________ day ______________
168
Treatment of acute arthritis and carditis:

Duration
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, 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:
Duration
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.
Treatment of chorea:
Duration
haloperidol po A N 1.5-3mg 3 times a day as required
Paed = 25- 2 divided
50mcg/kg doses
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.
Specific situations requiring prophylaxis for longer periods (up
to 30 years as a guide):
definite carditis in previous attacks
high risk of exposure to streptococcal infection at home or work
(crowded conditions, high exposure to children)
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Duration
benzathine penicillin im C V
2.4MU(1.44g monthly up to 21-30yrs
(1.44g =2.4MU) <12yrs = 1.2MU(0.72g)
or penicillin V po C V 250mg
2 times a day up to
<12yr = 125-250mg
21-30yrs
or erythromycin C V 250mg
po in penicillin 2 times a day up to
<12yr=125-250mg
allergy 21-30yrs
HYPERTENSION
Hypertension should not be treated until elevated blood pressure has
been confirmed with three consecutive readings.
Figure 13.1: Interventions in hypertension
* Examples of target organ damage: left ventricular hypertrophy;

nephropathy, retinopathy
170
Drugs that might increase blood

pressure:
Sodium-retaining drugs: mineralocorticoids or glucocorcoticoids,
non-steroidal anti-inflammatory drugs
Sympathomimetics: amphetamines, monoamine
oxidase
inhibitors, aminophylline, cold cures
Oral contraceptives
Treatment of hypertension
Non drug 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.
Drug treatment
Methyldopa and propranolol are no longer recommended for the
treatment of hypertension except in special circumstances.
However, some patients are currently well controlled on these
agents and tolerate them well. For these patients these drugs can
be continued, but newly diagnosed patients should be commenced
on other drugs listed below.
Guidelines for treatment of hypertension:

start with first line drug
start with the lowest recommended dose
if ineffective or not tolerated change the drug or add a drug from
another class.
First line agents = shown to reduce mortality

Thiazides
Duration
hydrochlorthiazide 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.
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Beta-blockers
Duration
atenolol po B V 50mg once a day long
term
Unwanted side effects include precipitation or exacerbation of asthma,
heart failure, impaired glucose control, fatigue and peripheral
vascular disease.
Second line agents

ACE inhibitors:
Enalapril B V 5 - 40mg Once a day long term
Or Lisinopril B V 5 - 40mg Once a day
long term
Or Captopril B E 12.5 - 50mg 2-3 times a long
term
day
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.
Caution: concomitant potassium supplements or potassium retaining
drugs should be avoided, or used only with careful monitoring of
serum potassium.
m Calcium channel blockers:

Duration
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).
m Alpha-blockers:
Duration
prazosin po B V 0.5-5mg 2-3 times a long
term
day
Unwanted side effects include first dose hypotension, and postural
hypotension may also be a problem; this is particularly relevant in the
elderly, in patients with sodium or volume depletion and patients
receiving other antihypertensive treatment.
Ill
Logical combinations:
Diuretic Beta-blo Calcium ACE Alpha
cker antagonist inhibitor blocker
Diuretic Yes Yes Yes
(hydrochlorthiazide)
Beta-blocker Yes Yes* Yes
(atenolol)
Calcium antagonist Yes* Yes Yes
(nifedipine SR)
ACE Inhibitor Yes Yes Yes
(enalapril)
Alpha-blocker Yes Yes Yes Yes
(prazosin)
* Important: verapamil (a calcium channel blocker) and beta-
blockers are absolutely contraindicated.
Follow up
When blood pressure has stabilised, monitor every 1-3
months
Referral
When patients are young (<30 years) or blood pressure is
severe or refractory to treatment, referral to a specialist
centre should be considered.
Hypertension in the elderly

Treat if blood pressure >160mmHg systolic or >90mmHg
diastolic. This includes isolated systolic hypertension.
Therapy reduces the incidence of cardiovascular
complications substantially.
Give aspirin150mg/day in elderly patients (>60years) unless
contraindicated.
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Hypertension in diabetics
Thiazide diuretics can impair glucose tolerance and in
diabetics can exacerbate hyperglycaemia and
hyperlipidaemia. However, these effects appear unlikely
with the low doses now given to reduce blood pressure.
Beta-blockers can interfere with awareness of, and recovery
from, hypoglycaemia in insulin dependent diabetics.
However, this is less likely with the more selective beta1
blockers (e.g. atenolol). Beta blockers can also exacerbate
dyslipidaemia in diabetics.
Recommendations: Low dose

thiazide diuretic and/or
Beta-blocker (e.g. atenolol)
If this fails or if unwanted effects occur, an ACE inhibitor,
calcium channel blocker or alpha blocker can be tried.
In hypertensive patients with diabetic nephropathy ACE
inhibitors have been found to be more effective in
slowing the decline in renal function and are the agent
of first choice.
Hypertension in black people

Black people respond poorly to beta blockers and ACE
inhibitors when used as single agents. However, these
drugs are effective when combined with a diuretic.
Resistant hypertension
Poor compliance should always be considered in all treatment-
resistant patients. Minimise the pill burden.
Drug interactions should be considered (such as concurrent use
of non-steroidal anti-inflammatories, aminophylline, cold cures
etc)
If control remains poor, refer to a specialist.
Management of severe hypertension

Definition: diastolic blood pressure >120mmHg
174
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
start nifedipine 10mg sublingually, repeat after two hours if
diastolic >110 mmHg.
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CARDIAC FAILURE
Usually presents with shortness of breath on exertion or at rest,
swelling of ankles, ascites and easy fatigability.
General guidelines:
Precipitating factors should be sought and treated e.g:
hypertension
infections eg. sub-acute bacterial endocarditis, chest
infection
arrhythmias
hypokalaemia
anaemia
drugs, 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.
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.
176
Drug Management:
Duration
1
frusemide po BV 40-80mg 1-2 times a day long
term
and captopril* po BV 6.25-25mg 2 –3 times a long
term day
BV 5-20mg once daily long term
Or enalapril po BV 5 – 20mg once daily long term
BV 5000 units 3 times a day as
or Lisinopril
po BV 600mg-1.2g 1-2 times a day long term
+/- potassium chloride BE 0.25-0.5mg 3 times a day first 24hrs
2
po +/- digoxin po then 0.125-0.25mg once a day long term
Paed = 0.01mg/kg
B E 25-50mg Once daily
1
give intravenous treatment for severely oedematous patients Long term
2
if using ACE inhibitors discontinue or use cautiously
*ACE inhibitors (captopril) are of benefit in all stages of heart failure
For oedematous and bed-ridden patients:
Duration
required
+/- Spironolactone po
add heparin sc
Acute pulmonary oedema:

Prop up in bed.
40% oxygen by mask (2 – 4L/min)
and:
Duration
BE 5-10mg slowly over 1-2 mins;
repeat every 15mins if
required.
BE 12.5mg when required for
morphine iv vomiting
BV 40-80mg repeat as required
plus prochlorperazine
iv
Plus frusemide iv
Subsequent treatment includes ACE inhibitors as for heart
failure.
Resistant cardiac failure

Exclude advanced renal failure as a cause of resistant heart
failure.
Increase dose of frusemide up to 240mg daily (in divided doses).
Addition of another diuretic eg. hydrochlorthiazide
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may be advantageous. If still unsatisfactory

consider referral for further management under specialist care.
Duration
Spironolactone B E 25mg once a day long term
And Propranolol B V 20mg 3 times a day long
term
or atenolol B V 25-50 mg once daily long term
Cor Pulmonale
Treat as above but ACE inhibitors are not recommended.
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:

Duration
1
aspirin po C V 75-150mg Once a day long
term
and glyceryl trinitrate sub- A E 500mcg not more
than 3 tablets
2
lingual 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:
Duration
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:
Duration
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
178
If pain continues in spite of above treatment, refer for further

investigation and treatment.
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
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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 Myocardial Infarction:

Duration
aspirin po C V 300mg once only as a single
dose,
then
75-150mg once a day long term
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 streptokinase iv A N 1.5MU in 100ml sodium chloride
0.9%
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
Thrombolytic agents should be administered early preferably in

infarcts of less than 12 hours duration.
• 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:

Sinus bradycardia
term Duration
atropine iv B V 0.6-1.2mg as required
Heart block
If symptomatic requires temporary pacemaker insertion.
180
Atrial fibrillation
In acute atrial fibrillation D.C. cardioversion. Digoxin may be used
with caution.
Supraventricular tachycardia
Try vagal manoeuvres e.g. carotid sinus massage. Consider D.C.
cardioversion if patient distressed.
Frequency Duration
_____ verapamil iv __________ A N 5-10mg _ as required __________
Ventricular tachycardia
Consider D.C. cardioversion if patient distressed.
Duration
lignocaine iv A E 75-100mg stat, then
(no adrenaline) 4mg/min for 30 mins, then
1-2mg/min for 12-24 hours
Caution: for all arrhythmias correct low serum potassium and

hypoxia
Major Complications of myocardial infarction

Post infarction angina - treat as for angina pectoris
Left ventricular pump failure
Arrhythmias after myocardial infarction
Rehabilitation
The period of bed rest, rehabilitation, and management varies in
individual cases. Risk factors should be avoided, such as smoking,
high cholesterol diet, stress, and thrombogenic agents such as
oestrogens. Patients with hypercholesterolaemia should be referred
for specialist management.
ARRHYTHMIA
Ectopic beats
Give reassurance about the condition, but if troublesome:
Duration
atenolol po B V 50-100mg once a day as
required
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Atrial fibrillation and atrial flutter

Duration
digoxin po B V 0.25-0.5mg 3 times a day first
24hrs
then 0.125-0.25mg once a day long term
If poor control of ventricular response, cautiously add:

Duration
add atenolol po B V 25-50mg once a day
review
or verapamil po A V 40-120mg 3 times a day
review
For chronic atrial fibrillation:

Duration
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.
Paroxysmal supraventricular tachycardia

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

Duration
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.
182
Ventricular tachycardia
Consider D.C. cardioversion if patient distressed.
Duration
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
Ulcers and Related Conditions 185
Reflux Oesophagitis 185

Peptic Ulcer - General Measures 185
Oesophageal Ulcer 186
Gastric Ulcer 186
Duodenal Ulcer 187
Uncomplicated duodenal ulcer 188
Complicated duodenal ulcer 187
For H. pylori eradication 189
Non-Ulcer Dyspepsia 187
Acute Gastritis 189
Acute Diarrhoea & Associated Conditions in
Adults 188
Gastro-Enteritis (Food Poisoning/ viral) 188
Bacillary Dysentery (bloody diarrhoea) 188
Cholera 189
Dehydration 189
Acute Intestinal Disease - Amoebic Dysentery 190
Amoebic Liver Abscess 190
Chronic Diarrhoea 191
Giardiasis 191
Irritable Bowel Syndrome 191
Malabsorption Syndromes 192
Pernicious Anaemia 192
Chronic Pancreatitis 192
Lactose intolerance 193
Other Gastrointestinal Problems 193
Peritonitis 193
Constipation 193
Haemorrhoids 193
Liver Disease 194
184
CHAPTER 13 GASTROINTESTINAL CONDITIONS
ULCERS AND RELATED CONDITIONS

Gastroeosophageal disease(GERD)
(Reflux Oesophagitis)
General measures: Life style and dietary modifications such as
weight reduction, elevation of head of bed, avoidance of tight
clothes/belts, stooping, large meals (particularly before bedtime).
Mild symptoms:
magnesium trisilicate C N 20ml or 2 at least 4 as
required
po tablets times a day
Moderate symptoms:
Duration
add metoclopramide po A V 10mg 3 times Review
Severe symptoms: If no response to above, give:

Duration
ranitidine po B E 150 Twice a day 6-8 weeks
Or Omeprazole A E 20mg Twice a day two weeks
Note: Maintenance therapy with acid secretaion blockers may be

required.
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Peptic Ulcer - General Measures

Treatment of peptic ulcer disease begins with eradication of
Helicobacter pylori as well as acid suppression therapy.
Precipitating causes such as NSAIDs, cigarettes and alcohol should
be withdrawn. "Ulcer diets" are unnecessary. Avoid foods that
exacerbate pain in individual patients.
Stop smoking and avoid alcohol.
Drugs to be avoided: all non-steroidal anti-inflammatory
agents, aspirin/aspirin compounds, and steroids.
Antacids will alleviate symptoms in most cases
Patients with persistent symptoms or recurrent ulcers should
be referred to a specialist.

Duration
magnesium trisilicate C N 20ml or 2 at least 4
as required
po tablets times a day
For H. pylori eradication:

Duration
amoxycillin po* B V 500mg 3 times a day 2 weeks
and Metronidazole po B E 400mg 3 times a day 2 weeks
And Ranitidine po B E 150mg Twice a day 2 weeks
Or Omeprazole po* A E 20mg Twice a day 1 week
* doxycycline po as an C V 100mg 2 times a day 2 weeks

alternative to amoxycillin
Note: If using Omeprazole, the antibiotic course can be

reduced to 1 week.
Oesophageal Ulcer
Treat as for severe reflux oesophagitis
Gastric Ulcer
Referral to a specialist is recommended for endoscopic biopsy
to exclude malignancy in ALL cases whenever possible.
186
General measures are important.

Treat for H pylori as above
If inadequate response or any evidence of malignancy, refer to

specialist.
Duodenal Ulcer
General measures are important.
Treat for H. pylori
If symptoms persist, endoscopy or barium meal is necessary.
Complicated duodenal ulcer:

This usually involves bleeding and/or perforation. This requires
emergency referral to the Specialists.
Need maintenance antisecretory therapy
For recurrent ulcers on endoscopy, repeat course at same
dose. Also consider referral to a specialist
For persistent (non-healing) ulcers on endoscopy, repeat
course at following doses:
Duration
Ranitidine po B E 150mg Once nocte
indefinitely
Or Omeprazole po A E 20mg Once daily
Non-Ulcer Dyspepsia
Pain or discomfort in the upper abdomen but with normal
endoscopy or barium meal. Could be due to gall stones and these
can be diagnosed by ultrasound. If pain is not relieved by bowel
movement or associated with a change in stool frequency or form,
irritable bowel syndrome may be a possibility.
Explanation and reassurance are important.

May need to treat as “ulcer” dyspepsia.
Try milk-free diet for possible lactose intolerance.
Try an antidepressant
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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/ viral)

Rehydrate - oral fluids in mild cases, IV fluids in more severe
cases.
If anti-emetics are necessary (adults only):
Duration
prochlorperazine im B E 12.5mg one dose
Review
Or Metoclopramide iv B V 10mg
Then prochlorperazine po B E 5mg po 3 times Review
or
Metoclopramide po/iv B E 10mg po 3 times Review
NB: Antibiotics are not required except in the special

circumstances given below. Anti-diarrhoeals should be
avoided.
Bacillary Dysentery (bloody diarrhoea)

Always send stool for microscopy and culture to guide your
antibiotic choice.
Rehydration as for gastro-enteritis above.

Duration
Nalidixic acid po B V 1gm 4 times a day 5
or days
Ciprofloxacin B V 500mg Twice a day
188
Cholera
CASE DEFINITION: Rice water diarrhoea with or without vomiting,
causing severe dehydration or death.
In suspected cases, notify Provincial Medical Director immediately.
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.
Moderate Dehydration
Give oral rehydration:
Duration
oral rehydration - - 75-100ml/ in the first 4 hours,
then
kg reassess:
oral rehydration - - 10-20ml/kg or corresponding
to
losses
If not improved, treat as severe.
Severe Dehydration
Give IV fluids immediately:
Duration
Ringers Lactate iv C V 100ml/kg over 6hrs
review after
4 hrs
Rate for paeds 30ml/kg in first hour then reassess.
[see also section Good response: 10ml/ kg/ hr for 5 hrs
in paediatric Poor response: repeat 30ml/kg in one
chapter] hour, then 10ml/kg for 4hrs
Monitor frequently; give ORS in addition to IV fluids as soon as able
to drink.
Reassess after 4 hours: if improved treat as moderate
dehydration; if still severe, continue IV fluids.
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Further Management
• Avoid further contamination /reinfection
Start antibiotics (see below) after the patient is rehydrated and
vomiting has stopped, usually after 4-6 hours. Although the
disease is self-limiting, an effective antibiotic will reduce the
volume of diarrhoea and shorten the period during which Vibrio
cholera is excreted. Antibiotic prophylaxis may be given to all
close contacts in the same dosage as for treatment:
Duration
cotrimoxazole po C V 24mg/kg twice a day
3 days
[in <12yrs]
or erythromycin po C V 500mg 4 times a day
3 days
[in pregnancy]
Or Ciprofloxacin B V 500mg Twice a day 3 days
Note: Erythromycin may be used in cases of resistance to the above
antibiotics, upon the advice of the Provincial Medical Director.
Start feeding 3-4 hours after oral rehydration begun.

Preferably, give antibiotics with food to minimise vomiting.
Acute Intestinal Disease - Amoebic Dysentery

Duration
metronidazole po C V 800mg 3 times a day
5 days
(Paed = 10mg/kg)
Liver Abscess
Consider when there is right upper quadrant pain,
fever and hepatomegaly. Could be a pyogenic liver
abscess or amoebic abscess.
For abscesses threatening to rupture through lobe of liver,
skin or diaphragm, aspirate in conjunction with drug therapy.
Pyogenic Abscess:
Drug Codes Adult Frequency 3 Duration 4 –
times a day 4 6 weeks 4 -
dose
times a day 6 weeks
metronidazole IV C V 500mg
once a day
plus Ampicillin iv B V 1 gm
twice a day
Or Ceftriaxone iv A V I gram
Or Ciprofloxacin po B V 500mg
190
Amoebic Abscess:
Duration
Metronidazole po C V 400mg 3 times a day 7-10
days
CHRONIC DIARRHOEA
Investigations to establish cause are essential. See also chapters on
HIV Related Disease and Paediatrics. Also refer to the HAQOCI
guidelines.
General Measures
Rehydration is important - orally if appropriate; IV fluids when
there is severe dehydration or concomitant vomiting.
Give potassium and vitamin supplements as indicated on
clinical grounds and after serum potassium measurements.
For persistent diarrhoea after infection has been excluded: Drug
Codes Adult dose Frequency
Duration codeine B V 30-60mg 3 times a day
Review
In refractory cases use:

Duration
morphine po B V 5mg every 4 hrs Review
increase to 50mg
Giardiasis
Duration
metronidazole po C V 400mg 3 times a 5 days
day
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Irritable Bowel Syndrome

May present with pain, chronic diarrhoea or constipation. It is
important to investigate for and exclude organic pathology.
Reassurance and explanation are essential. A high fibre diet is
the mainstay of treatment and treatment of constipation with
sufficient water intake and physical activity.
For relief of pain:
Duration
hyoscine butylbromide B N 20mg 4 times a day review
po
If constipation is prominent:
Duration
magnesium trisilicate C N 20ml or 3 times a day
review
po 2 tablets
Explore psychosocial factors in resistant cases.
Consider referral to clinical psychologist.
Malabsorption Syndromes
Correction of electrolyte and nutritional deficiencies is
important.
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.
Chronic Pancreatitis
• Exclude gallstones and alcohol as causes
Pain control must be tailored to each patient and often requires
opiates.
Treat diabetes as necessary.
Cessation of alcohol intake is imperative.
Referral to a specialist is recommended.
192
Lactose intolerance
Milk and all milk products must be withdrawn.
OTHER GASTROINTESTINAL PROBLEMS

Peritonitis
Get a definitive diagnosis. Always exclude the need for
surgical intervention. Manage with:
Duration
ampicillin iv and B E 1g 4 times a day 5-10 days
gentamicin iv and B V once a day 5-10 days 3
metronidazole iv 4mg/kg times a day 5-10 days
A N
Constipation
Encourage high fibre diet and adequate flui
Give laxatives as required but avoid chronic
Rectal stimulant: Drug Codes Adult dose
glycerine suppository C N one
rectal suppository
or liquid paraffin po B N 10-30ml
[faecal softener]
Constipation
Encourage high fibre diet and adequate fluid intake.
Give laxatives as required but avoid chronic use.
Rectal stimulant: Drug Codes Adult dose Frequency
Duration
glycerine suppository C N one as required -
rectal suppository
or bisacodyl po [only if no C N
5 – 10mg abdominal tenderness]
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]
Haemorrhoids
Haemorrhoids (and other pain (and other
conditions) painful
Encourage high fibre diet and adequate flui
Avoid constipation.
peri-anal
Careful anal hygiene plus saline baths. Drug conditions)
Codes Adult dose Encourage high
bismuth subgallate with B N one fibre diet and adequate
1% hydrocortisone application fluid intake.
ointment rectally Avoid constipation.
Careful anal
hygiene plus saline baths. Drug Codes Adult dose
Frequency Duration
twice a day as required
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LIVER DISEASE
Acute Liver Failure/ Hepatic Encephalopathy
Identify and eliminate precipitating causes (viral hepatitis,
drugs, toxins, septicaemia, alcohol, upper GI bleeding).
Stop all unnecessary drugs including diuretics and sedatives.
Give high calorie diet (2000 kcal/day), and low protein diet.
Manage with:
Duration
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:

Duration
magnesium trisilicate CN 40ml every 6 hours, until
po diarrhoea is induced
or Lactulose po 3 times a day
A N 30 -50ml
or high bowel washout performed once
Duration
dextrose 10% iv B N 3litres/day added to every litre
bag if renal function is
with potassium chloride iv B V 2g satisfactory
(26mmol)
Screen for infection (urine, chest, blood), and treat vigorously.

If bleeding tendency present, give:
Duration
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 10/L and patient actively bleeding.
If ethanol aetiology is suspected, give:

Duration
thiamine iv slow A N 250mg before dextrose infusion
and daily for 3 days
194
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
Sedate [avoid opiates]:
Duration
diazepam iv C V 5-15mg as necessary
Treat concurrent encephalopathy as above.

Aspirate nasogatric tube hourly.
If bleeding persists refer: Sengstaken tube should be inserted to
arrest bleeding. Refer to specialist.
Give Propranolol prophylactically indefinitely:
Duration
Propranolol po B E 40mg 2-3 times a
indefinitely
day
195
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Ascites of Chronic Liver Failure

Perform diagnostic paracentesis if possible.
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.
Resistant patients:
spironolactone po A N 100-400mg once a day
review
or amiloride po A N 10-20mg once a day
review
Note: Do not give potassium supplements with these diuretics.
Only if above fail, add:
Duration
frusemide po B V Start at once a day
increase
40mg gradually
Stop if encephalopathy or uraemia develop.
Massive intractable ascites

Refer. Perform large volume paracentesis.
196
CHAPTER 14 RENAL TRACT CONDITIONS
RENAL TRACT CONDITIONS
Urinary Tract Infections 198

Cystitis 198
Acute pyelonephritis 198
Renal Impairment 198

Acute Renal Failure 198
Management of Renal Failure 199
Acute Nephritic Syndrome 202
Nephrotic Syndrome 202
Prescribing in Renal Impairment / Renal Failure 203

Drugs and Dialysis 204
197
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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:
Duration
norfloxacin* po C E 400mg 2 times a day 3 days
*Do not use norfloxacin in pregnant women or children. For UTI in
pregnancy refer to the Obstetrics & Gynaecology chapter.
m 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
Duration
norfloxacin po C E 400mg 2 times a day 2
weeks
Acutely ill patients: use IV antibiotics until apyrexial, then
change to oral therapy.
Duration
ampicillin iv B E 500mg 6 hourly review
gentamicin* iv B V 4-7mg/kg once a day
review
or
*Remember gentamicin toxicity is manifested after 7-10 days of use.
Check gentamicin levels where possible. Avoid nephrotoxic drugs
such as gentamicin and nitrofurantoin in renal failure.
Acute Renal Failure

Try and classify by cause. The majority of cases of acute
renal failure are due to ischaemic or toxic injury to the
kidney and are reversible if treatment is instituted promptly
i.e. within hours not days.
198
CHAPTER 14 RENALTRACTCONDITIONS
Pre-Renal Cases
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. Management is summarised in Figure 13.1.
Established Acute Renal Failure

Consider sepsis, malaria, acute glomerulonephritis, acute
tubular necrosis, myeloma, nephrotoxic drugs such as
gentamicin and NSAID’s, and other causes such as acute
-on-chronic renal failure. Ultrasound kidneys for size and get
urine microscopy.
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. Ultrasound 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: If you suspect renal failure, refer.
Second line: If the patient fails to respond to
adequate
rehydration and fluid challenge with sodium chloride 0.9% [not
dextrose 5%] within 48 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]. Monitor fluid balance carefully. Check electrolytes
regularly and maintain nutrition. Watch for infections.
Third line: Consult dialysis team sooner rather than later so
that they can help monitor the patient. Selection criteria for the
chronic dialysis programme are applied and each individual
patient should be discussed with the dialysis team.
Late referrals contribute to the mortality of acute renal failure and
end-stage renal failure.
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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.
To lower potassium levels in acute hyperkalaemia, give:
Duration
salbutamol nebulised B V 10mg 2 times a day Review
+/- insulin with dextrose B V 50mls of 50% dextrose +
10 units of
short acting insulin
General measures in the management of acute renal failure

Catheter: Insert a catheter but remove it once
sustained
diuresis has occurred, or if oliguria persists and the patient is
started on dialysis or conservative treatment.
Urine: Ward urinalysis test - high specific gravity
>1.020
suggests dehydration; check for haematuria, proteinuria;
microscopy (for cells, casts), culture and sensitivity are
essential.
Diet: High calorie and normal or high protein diet with low
sodium and low potassium.
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.
IMPORTANT: avoid nephrotoxic drugs; watch for and treat
infections; check weight daily and BP 4 hourly; strict fluid
input/output charting.
200
Fig 14.1: Management Approach in Adult Pre-renal

Cases
Yes Continue
Is urine fluids, one litre
output > 40 every
ml/hr? 6 hours
until recovery.
No
If JVP remains Check Yes Continue

Is urine fluids, one litre
low/dehydrated/oliguric
output > 40 every
repeat fluid challenge.
ml/hr? 6 hours
until recovery.
No
If oliguria persists despite Give one litre every

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

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

or manage as established
renal failure
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).
Note: Large doses of frusemide may cause hearing loss if given too
quickly.
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ACUTE NEPHRITIC SYNDROME

Usually presents with oliguria, hypertension, smokey coloured urine
and generalised oedema. There may be a recent history of
tonsillitis, arthralgia, skin rashes/ infection.
Try to induce 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:
Duration
penicillin V po C E 500mg 6hrly 10 days
Do not give steroids.

Treat hypertension conventionally. Children need
early
intervention for elevated blood pressure. Treat if diastolic BP > 90
mm Hg.
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 for
dialysis.
NEPHROTIC SYNDROME
Diagnosed where there is generalised oedema, hypoalbuminaemia
and proteinuria (>3gm/day). Dipstick should show at least protein
++. Ideally do 24hr urine collection for both creatinine clearance
and proteinuria. Check urine microscopy and U&Es. Weigh patient
at each review. Exclude SLE, HIV and Hepatitis B or C.
Try and induce diuresis:

Duration
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
202
CHAPTER 14 RENALTRACTCONDITIONS
adding: prednisolone as a trial particularly if the urine sediment is

benign (i.e. no red cells or casts).

prednisolone po B V 1mg/kg once a day 2 months
[mornings]
rd
Aim to tail off dose to zero during the 3 month. Stopping early
may result in a relapse. 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,
HIV, syphilis.
Restrict dietary salt intake, but leave on normal protein diet.
If oedema is not reducing after 2 weeks of treatment, refer to
Central Hospital.
PRESCRIBING IN RENAL IMPAIRMENT /

RENAL FAILURE
Avoid drugs that are eliminated via the kidneys or reduce the dose
of the drug if no alternative available. In most cases reducing the
dose by half should be adequate.
Table 14.2 Drugs in Renal Impairment

Drug Comments
Analgesics Avoid, use paracetamol
aspirin
indomethacin
codeine phosphate Reduce dose by 25-50%
pethidine
Anti-TB Drugs Avoid
ethambutol
streptomycin
pyrazinamide Reduce dose by 50%
isoniazid Maximum daily dose 200mg
Table continued overpage…/
203
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Table 14.2 Drugs in Renal Impairment [contd.]

Antibiotics
penicillins /cephalosporins Reduce doses by 50% in advanced failure Use with extreme
caution if no alternative. Use loading dose of 1mg/kg gentamicin,
aminoglycosides
then use maintenance dose of 1 mg/kg as well, once daily in
(gentamicin)
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] Reduce dose by
captopril /enalapril 50%, but if creatinine is >300)j.mol/L avoid Use smaller
loading/maintenance doses (125micrograms daily). Consider
digoxin
alternate day dosing. Measure digoxin levels.
Diuretics
amiloride / 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
chlorpropamide Avoid
glibenclamide Use with caution.
Other
allopurinol Reduce dose (maximum 200mg daily) Use
phenobarbitone 25% of normal dose or avoid if possible Use
benzodiazepines 25% of normal dose or avoid
Drugs and Dialysis

Dialysis may remove significant quantities of some drugs
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.
204
Chronic Dialysis
Chronic peritoneal dialysis and haemodialysis may be
available but discuss with specialist before transferring
patient. Psychosocial issues may exclude the patient from
the chronic dialysis programme.
Current chronic dialysis centres are in Bulawayo and Harare
only.
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RHEUMATOLOGICAL AND JOINT

CONDITIONS
Infections 207
Septic arthritis, and Acute osteomyelitis 207
Chronic osteomyelitis 207
Compound fractures 207
Back and neck pain 208
Gout 208
Rheumatological Conditions 194

General Guidelines 209
Systemic Connective Tissue Diseases 210

Rheumatoid Arthritis & Juvenile Chronic Arthritis 210
Systemic Lupus Erythematosus (SLE) 211
Degenerative Osteoarthritis & Spinal Spondylosis
212
Rheumatoid factor -ve spondyloarthropathies 212
Reiter’s disease and Post Infective Arthritis 212
206
CHAPTER 15 RHEUMATOLOGICAL AND JOINT CONDITIONS
INFECTIONS
Septic arthritis, and Acute osteomyelitis
Surgical drainage is recommended in all cases presenting
with a greater than 24 hours history.
Duration
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.
Duration
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
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BACK AND NECK PAIN

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

Acute gout
Always consider the possibility of septic arthritis. 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:
Duration
indomethacin po BE 50mg 4 times a day first 24 hrs
then reduce by 25mg daily to 25mg 3 times a day review
or colchicine 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.
Duration
allopurinol po BE 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 or patients on diuretics, or with impaired renal
function, allopurinol should be started at 100 mg daily and
cautiously increased if necessary.
Do not start allopurinol during or immediately after an acute
attack.
208
CHAPTER 15 RHEUMATOLOGICAL AND JOINTCONDITIONS
The period of introduction of allopurinol should be covered by

or concurrent colchicine or a regular dose of NSAID until normal
serum uric acid levels have been achieved:
Duration
colchicine po A N 0.5mg 2 times a day 7 days
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:
Duration
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 is forbidden.
Avoid dehydration.
Avoid the following foods:

organ meats, red meat especially goat meat.
Foods allowed:
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 current or past
peptic ulceration. Refer patients with serious rheumatic
disease and peptic ulceration for specialist help. Note that
indomethacin is available in suppository form.
NSAIDS should be taken with food.
If dyspeptic symptoms develop in a patient on NSAIDS, try
adding magnesium trisilicate mixture. If dyspepsia persists and
209
EDUZ2006
NSAID use is considered essential, refer for specialist help.

(See above). 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

Note: Refer chronic cases of polyarthritis for definitive diagnosis
and exclusion of the following conditions. 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 NSAID, disease
modifying anti-rheumatic drugs (e.g. chloroquine, methotrexate and
sulphasalazine), and low dose steroids in the presence of severe
inflammation or vasculitis is necessary. Disease modifying drugs
are the mainstay of treatment to minimise erosions and deformities
Manage with:
Duration
aspirin po C V 4 times a day Review
600mg (Paed 12.5mg - 25mg/kg)
or indomethacin po BE 3 times a day Review
+/- an additional night25-50mg
time dose of 75mg at night
or ibuprofen po A E 3 times a day Review
200-400mg (Paed 7-14mg/kg)
or Diclofenac po B E 25 3 times a day Review
-50mg
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
m Disease modifying anti-rheumatic drugs should be started early:
Duration
chloroquine po C V 150mg base once a day
continual/
review
210
CHAPTER 15 RHEUMATOLOGICAL AND JOINTCONDITIONS
Or Methotrexate po A E 5- 25mg Once a review

week
Eye check is advised after 9 months of chloroquine treatment.
Uninterrupted treatment should not exceed 2 years. Treatment should
be stopped if patient complains of visual disturbance on chloroquine.
.Methotrexate should be monitored with FBC and LFTs at 3 monthly
intervals.
m Oral, low maintenance dose prednisolone can be added where
indicated for a limited period:
Duration
prednisolone po B V 2.5 - 10mg once a day
limited
period
Note: Best results are achieved with combination of drugs.
Systemic Lupus Erythematosus (SLE)

Refer to a higher level for diagnosis and initial treatment. Avoid the
sun and advise the use of a broad brimmed hat. See cautions for
aspirin and indomethacin as above.
Manage with aspirin or indomethacin as for Rheumatoid arthritis
as above.
If severe skin or joint lesions, add:
Duration
chloroquine po C V 150mg once a day continual/
base review
In severe disease with complications e.g. renal, neurological,

vascular or haematological add prednisolone in high doses:
Duration
prednisolone po B V 1mg/kg once a day review,
then reduce
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.
211
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Degenerative Osteoarthritis & Spinal

Spondylosis
Manage with:
Duration
aspirin po CV 300-600mg 4 hourly review
Or indomethacin BE 25-50mg 3 times a day
Or review
AE 200-400mg 3 times a day review
Or
po BE 25 -50mg 3 times a day
ibuprofen po Review
Diclofenac po
Rheumatoid factor negative

spondyloarthropathies
Reiter’s disease and Post Infective Arthritis
Treat as for osteoarthritis as above. Exclude UTI/ bowel
infection and HIV infection.
212
CHAPTER 16 METABOLIC & ENDOCRINE CONDITIONS
METABOLIC & ENDOCRINE

CONDITIONS
Diabetes Mellitus 214
Oral anti-diabetic agents 215

Diabetic Diet 220
Special Problems in Diabetics 221
Surgery 222
Hyperglycaemic Coma & Pre-coma (Adults) 223
Diabetes in Children 225
Hyperglycaemic Coma and Pre-coma (Children) 226
Thyroid Disease 228
Goitre 228
Hyperthyroidism 228
Hypothyroidism 230
Hypoadrenalism 230
213
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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
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 properly informed and managed soon
become experts in their own care.
Insulin dosages
In type I diabetes, when initiating treatment the starting dose
of insulin is 0.6units/kg/day. In most patients this should be
given 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. Alternatively a “basal/bolus” regime can be used
where intermediate acting insulin is taken at bedtime (basal)
and 6-8u of soluble taken 3 times a day before meals (bolus).
This regime allows more flexibility with meals as the soluble
insulin dose can be varied depending on 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.
In insulin treated type II diabetes, the total daily dose of
insulin is 0.3units/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.
214
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 drug 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 as a minimum every 3 months.
Types of Insulin
Duration of Peak Duration Type of Brand names
action activity [hrs] insulin
[hrs]
Short acting 2-5 5-8 soluble Actrapid HM ®
Humulin-R ®
Intermediate 4 - 12 12- 24 isophane Protaphane HM ®
Humulin-N ®
6 - 14 16 - 22 insulin zinc Monotard HM ®
suspension
Humulin-L ®
Long acting 8 - 24 24 - 28 crystalline Ultratard HM ®
insulin zinc
suspension
Biphasic 2-12 + 24hrs soluable/ Actraphane ®
isophane
Humulin 30/70 ®
Note: All of the above are human insulin and are available in U100
strength [100units/ml].
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:
215
EDUZ2006
• Oral anti-diabetics must not be used in pregnancy.
• Glibenclamide can accumulate in the elderly and cause prolonged

hypoglycaemia
• Do not use metformin if renal failure, severe heart failure or liver

failure (increased risk lactic acidosis)
Obese type 2 diabetic:

Duration
metformin po B V 500mg 3 times a
gradual
_________________________________ [max 3g/ day] day _______ increase
if poorly controlled with strict adherence to diet, add:
Duration
Add glibenclamide po B V 5mg once a day -
increase to a max of 10mg twice a day
if poorly controlled despite diet : change to insulin or add a
daily dose of intermediate acting insulin.
216
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217
EDUZ2006
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218
219
EDUZ2006
Normal weight type 2 diabetes:

Duration
glibenclamide po B V 2.5mg once to -
twice a day increase to a
max of 10mg twice a day
if poorly controlled with strict adherence to diet, add:
Duration
Add metformin po B V 500mg 3 times a day review
if poorly controlled despite diet, 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. An insulin
dependent diabetic may have snacks between meals.
An adequate intake of fibre is important.
Alcohol is allowed in moderation only.
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.
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.
220
Syringes / Insulin Storage:

Reuse 1ml disposable syringes for 2-3 weeks.
Store syringes dry.
Sterilisation is not necessary.
Change the needle when blunt.
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, take care to avoid burns.
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
drugs, preferably including an ACEI, target BP 140/80
Aspirin and diabetes
• Add aspirin 75mg/day to all diabetics with hypertension and any
with documented vascular disease.
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.
Diabetic Clinics
Are useful to focus care even at District Hospital level. Six
monthly review should include acuities 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
221
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Both types of diabetics (insulin dependent and non-insulin

dependent) may need to be given an increased dose of
soluble insulin or soluble insulin according to the sliding scale
(see insulin therapy in adults). In type 1 diabetes NEVER stop
insulin, even if the patient is unable to eat.
Hypoglycaemia and Hypoglycaemic Coma

Educate patients about hypoglycaemic symptoms (hunger,
sweating, irritability, etc). 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.
For hypoglycaemic coma give:
Duration
dextrose 50% iv C V 20ml immed. then,
The dextrose 5% infusion C V infusion until taking oral feeds
n
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 are best cared for by specialists:
refer wherever possible.
In the case of diabetic patients on oral agents,

omit the morning dose on morning of preparation,
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 soluble insulin according to a sliding scale (see
below).
In the case of type 1:
give 2/3 of the usual morning dose,
set up infusion of 5% dextrose to run through the period of the
operation,
post-operatively administer soluble insulin according to a
sliding scale.
222
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:
Drug 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:
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:
223
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or 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:
Duration
potassium chloride po B V 600 – twice a day 7 days
1200mg
Insulin Therapy (Adults)

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:
Duration
soluble insulin im B V 10units immediately, then
10units hourly until blood sugar
down to 16mmol/L
When the blood sugar is 16mmol/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), see
below. Give insulin according to a sliding scale (see
overpage).
Sliding scale:
Blood Sugar [mmol/L] Soluble Insulin Use blood sugar
>16 12 units reagent strips or
glucometer readings. Do
>12-16 8 units not rely totally on these
>8-12 4 units readings- also use
clinical judgement.
<8 0.5 units
Sliding scales using URINE glucose tests are unreliable - avoid.
An alternative to the sliding scale is to use an empirical dose
especially when stabilising failed “type II” cases:
Duration
soluble insulin sc B V 6-12units 3 times a day, then
As soon as the patient’s condition is stable, start appropriate
maintenance therapy.
On this regimen, most cases show definite clinical
improvement within 6-10 hours. Clinical and (if available)
biochemical reassessments should be made at
frequent
224
intervals during treatment. Modifications of the fluid

and electrolyte therapy should be made as necessary.
CAUTION: sodium bicarbonate injection should be used ONLY in
cases of extreme acidosis and if complete biochemical data are
available (arterial pH less than 7 or bicarbonate less than 9 mmo1).
DIABETES IN CHILDREN
A significant number of new cases of insulin dependent
diabetes occur in children who usually present with classical
features of diabetic ketoacidosis with polyuria, polydypsia
etc. While the broad principles of management are similar to
those in adult type I diabetes, the different ages and weights
of children and children’s special needs must be taken into
consideration.
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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:
Drug 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:
Drug 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)

Drug 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 before meals for one day, then
(maintenance)
226
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
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.
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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.
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):
Duration
propranolol po B E 40 - 240mg 3 times a day
-
228
Graves’ Disease
Treat initially with anti-thyroid drugs:
Duration
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 drug 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 drugs
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:
Duration
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.
Replacement with Prednisolone 5 mg daily is enough for
most patients but as the mineralocorticoid component is
lacking, this can be supplied by the addition of
fludrocortisone 0.1mg daily if necessary.
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.
230
CHAPTER 17 NEUROLOGICAL CONDITIONS
NEUROLOGICAL CONDITIONS
Infections of the nervous system 232

Meningitis Neurocysticercosis 232
234
Headache 235
Treatment of primary 235
headache Tension Migraine 235
Combination General Notes 235
236
236
Epilepsy 237
Status epilepticus 239
Acute Confusional States 240
Stroke 241
Progressive generalized weakness 242
Peripheral sensory symptoms 243
Involuntary movements 243
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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
(e.g. 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:
Duration
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 + 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.
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.
232
If symptoms present less than one week:

Duration
benzylpenicillin iv C V 3g (5MU) 6-hourlyresults out
BV 500mg 6
Chloramphenicol iv -hourly
Spinal fluid microscopy, (protein and glucose; Gram stain and

India ink stain and Ziehl-Neelsen stain and cultures if possible)
plus blood glucose.
Treat according to lumbar puncture results:
Cerebrospinal fluid Likely diagnosis Treatment
WBC < 10; protein <44mg/dl; Normal. Could be meningism Depends on diagnosis
(neck stiffness in the absence of
glucose > ½ blood glucose meningitis, e.g. malaria, upper
lobe pneumonia).
WBC < 50 (<10 polymorphs), Could be HIV infection only, Symptomatic
protein <100 mg/dl, glucose > without other causes of
½ blood glucose meningitis present.
WBC > 50, > 90% lymphocytes, Viral meningitis. Differential : Symptomatic. Observe in
Partially treated bacterial, hospital.
protein normal or high, glucose >
cryptococcal, syphilis,
½ blood glucose
encephalitis.
WBC >50, > 90% lymphocytes, cryptococcal meningitis likely. Repeat lumbar puncture.
protein normal or high, glucose < Differential: includes bacterial, Serum CRAG
(cryptococcal antigen) if
½ blood glucose , India ink stain TB meningitis.
available. If negative:
negative Start anti-TB drugs and
prednisolone 40 mg daily
for two weeks.
WBC > 50, > 10 polymorphs, Bacterial meningitis. Continue antibacterial
protein normal or high, glucose Differential includes TB, drugs. Add anti-TB drugs
if no better in 48 hours.
normal or low cryptococcal meningitis.
As above plus Gram stain shows Meningococcal meningitis. Treat as for bacterial
Gram negative cocci or N meningitis. NOTIFY.
meningitidis grown on culture Chemoprophlaxis to
close contacts.
India ink stain or CRAG shows Cryptococcal meningitis. Fluconazole 400mg daily
cryptococcal infection orally 14 days, 200mg
daily indefinitely
thereafter*
*Amphotericin B (0.7 mg/kg IV daily for 14 days) is preferred as initial therapy, but is at present not
affordable in the public sector. Essential precautions must be taken when administering this
medication.
Treatment for bacterial meningitis:

Duration
benzylpenicillin iv CV 3g (5MU) 6 hourly
and chloramphenicol BV 500mg 6 hourly
iv or Ceftriaxone iv S V 1g 12 hourly
Note: for paediatric doses see chapter on Paediatric conditions
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Chemoprophylaxis for close contacts (meningococcal

meningitis only):
Give as soon as diagnosis made in index case.
Duration
ciprofloxacin po B V 500mg once only single
dose
or rifampicin po B V 600mg
2 times a day 2 days
Paed =10mg/ kg
Note: Do not use ciprofloxacin in pregnant women.
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,
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:
Duration
* sulphadiazine po S E 2g 4 times a day 6 weeks
and pyrimethamine po S E 50mg once a day 6 weeks
*or clindamycin po B E 600mg 3 times a day 6 weeks
*or Co-trimoxazole C V Four 3 times a day 6 weeks
alternative to sulphadiazine tablets
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).
praziquantel po C E 40mg/kg once a day 14 days
add* prednisolone po B V 1mg/kg once a day review
*If drowsiness, seizures or focal signs develop.
234
HEADACHE
This may be primary or secondary/symptomatic:
In secondary head or facial pain treat the underlying cause (e.g.
sinusitis, malaria) and use aspirin 6OOmg 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 (codeine compounds) and benzodiazepines as
they particularly can cause rebound headache and habituation.
If headache persists for more than six weeks, add
Duration
amitriptyline po B E 25mg at night 3 months
Migraine
Unilateral; (occasionally bilateral); throbbing attacks; last hours to
days; with nausea ± vomiting; photophobia, sometimes
preceded 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:
Duration
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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).
m Look for and avoid precipitating factors: Not enough sleep,
alcohol, cheese, chocolate, menarche, menstrual cycle, oral
contraceptive pill may all influence migraine frequency.
If two or more disabling migraines a month (leave work, off
school);
Duration
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 BE 25mg at night minimum 3
months
Note: propranolol contraindicated in asthma - use amitriptyline.
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.
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.
236
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, drug
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:
Duration
phenobarbitone po C V 60-90mg* once a day, 2
weeks
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EDUZ2006
Paed = 5mg/ kg at night until review

* 90 mg if weight > 70kg
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, drug interactions, intercurrent
illness.
Increase:
Duration
phenobarbitone po C V 150mg every night 4 weeks
then review
If seizures persist (one or more in four weeks):

add carbamazepine po B V 200mg once a day for 3 days,
twice a day for 3 days, then three times Paed = 6mg/kg reduce phenobarbitone
by 30mg each week
If seizures persist, increase:

Duration
carbamazepine po B V 400mg twice a day 4
weeks,
_______________________________ Paed = 10mg/kg ____________then review
If seizures continue to persist:
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)
238
Tertiary / Specialist care

Decisions include whether further investigation (EEG, CT scan) is
indicated, and the use of phenytoin, sodium valproate,
ethosuximide, diazepam or clonazepam.
Status epilepticus
A seizure continuing more than 30 minutes, or recurrent seizures
without regaining consciousness in-between, more than 30 minutes.
Many cases do not occur in known epileptic patients - always
consider possible underlying causes such as stroke or brain
abscess.
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:
Drug 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:
Duration
phenobarbitone iv/im B E 10-15mg/kg 30-50mg per minute
infusion( iv over 10 mins)
or paraldehyde im (deep)* A N 10ml (5ml may be repeated once
each buttock)
*a plastic syringe may be used if the dose is given immediately after

the drug has been drawn up.
m Commence oral drugs 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:
Duration
phenytoin sodium iv A E 15mg/kg over 5 minutes,
then 100mg 6 hourly
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If seizures still persist after 30 minutes, and ICU facilities and

anaesthetist available, give:
Duration
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:
Duration
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
m Further management at district (B) level:
Duration
diazepam iv slow C V 1mg/year of May be repeated
once
__________________________________ age __________________________
or paraldehyde im (deep)* A N 0.1ml/kg May be
repeated once *a plastic syringe may be used if the dose is given immediately
after the drug has been drawn up.
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 conscious level. In delirium there are also
hallucinations + illusions. 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 drug
abuse (e.g. alcohol withdrawal).
240
Management should focus on identification and treatment of the

underlying cause, usually by searching for an infection and
treating empirically (see section on antibiotics) or for malaria.
If sedation is required give:
Duration
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:
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 Day One.
occupational therapy and speech therapy if available /
required
vocational training
Manage precipitating causes:

treat hypertension, but only start 2 weeks after the stroke,
or if diastolic BP is >120. Use small doses of
hydrochlorothiazide (avoid nifedipine).
stop smoking
treat arrhythmias, e.g. atrial fibrillation
treat cardiac failure
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:
Duration
aspirin po C V 150mg once daily long
term
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For patients with atrial fibrillation who have access to

facilities for regular blood monitoring (weekly INR for
1month, then monthly):
Duration
warfarin po B V 10mg 2 times a day 2 days,
then
adjust Usual
maintenance dose 2.5 - 5mg once a day INR range 1.5 and
2
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 require 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 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 / swallowing suggests myasthenia
gravis and referral to tertiary care for diagnosis is required.
242
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: alcohol,
diabetes, HIV infection, chronic renal disease and
drugs including isoniazid, anticonvulsants, and allopurinol.
For pain give:
amitriptyline po BE 25-75mg* at night review
*the lower dose is usually sufficient
If ineffective or intolerable side effects, add:
Drug Codes Frequency Duration

carbamazepine po B E Adult
100mgdose
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:

Duration
Codeine phosphate B E 30-60mg 6 hourly as
required
po
If codeine Morphine sulphate 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
tremor, Parkinsonism or cerebellar).
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Essential tremor
Fine and postural (stops when the hand is held), there is no
increase in muscle tone. Treat with:
Duration
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. Initial treatment of tremor
usually consists of:
Duration
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, confusion.
Patients usually require treatment with levodopa at some
time:
Duration
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.
244
CHAPTER 18 PSYCHIATRIC CONDITIONS
PSYCHIATRIC CONDITIONS
General guidelines 246
Psychoses 246
Mood (Affective) Disorders 248

Mania 248
Depression 248
Anxiety Disorders 249
Treatment of Alcohol Dependence 249
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GENERAL GUIDELINES
Treatment of the mentally ill person does not always require drugs.
Other forms of treatment, i.e. 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 drug compliance.
Emphasise the importance of adhering to the prescriber’s
instructions.
Patients on psychotropic medication should be reviewed
frequently.
Do a thorough physical examination in all psychiatric cases to
identify possible organic causes and to exclude co-existing
physical illness that may influence the person’s response to
psychotropic drugs.
CAUTION is required when prescribing psychotropic medicines to
children, to the elderly and during pregnancy and lactation.
PSYCHOSES
Psychotic persons usually have hallucinations, delusions, loss of
contact with reality. They may be violent; some may be withdrawn and
mute.
Non-organic psychosis
This refers to conditions where there is no physical disease affecting
the brain, e.g. schizophrenia and mania.
Keep the person in a safe place: prevent harm to self or
others.
Give anti-psychotic drugs:
Duration
chlorpromazine po C V 200-300mg 3 times a day see
below
or chlorpromazine im C V 100mg repeat 1- 2hrs if necessary
Note: Use of chlorpromazine should be avoided in patients with
epilepsy. Use of intramuscular chlorpromazine is likely to cause
postural hypotension.
Alternative therapy:
Duration
trifluoperazine po A E 5 - 10mg 3 times a day see
below
246
Trifluoperazine is less sedating than chlorpromazine
Organic Psychosis
May be due to HIV and other infections, head trauma, vitamin
deficiencies, tumours, etc.
Identify the cause and treat whenever possible. Use lower
doses of chlorpromazine.
Maintenance therapy:
chlorpromazine po C V 15 - 200mg 3 times a day continual
or trifluoperazine po A E 1.5 - 6mg 3 times a day continual
or haloperidol po A N 1.5 - 6mg 3 times a day continual
If the patient does not comply with oral medication or would

prefer not to have to take the tablets repeatedly, use:
Duration
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
*Inform patient and relatives of possible dystonic reactions and the
need to report immediately to the nearest health centre with treatment
cards if this occurs.
Fluphenazine decanoate should not be started at clinic level.
However, once a patient has been started on depot injections they may
be continued at clinics, but ensure referral every six months for
specialist review.
Duration of therapy:
First or single psychotic episode
Most persons have to be maintained on a reduced dose of
medication for 3-12 months after disappearance of psychotic
symptoms. Then the drug 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 persons require long term maintenance medication to
prevent future relapses. Search for the cause of relapses [e.g.
continuing stress or non-compliance] and remedy if possible.
Side effects and adverse reactions of anti-psychotic drugs
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Early side effects

Sedation, hypotension, dizziness, dry mouth, blurred vision:
usually occur in early stages of treatment and may be self-limiting.
Acute dystonia [common features are body stiffness, tongue
protrusion, grimacing, writhing, twisting of neck or body,
torticollis, and oculogyric crisis].
Treat with:
Duration
benzhexol po BE 5mg 1-2 times a 1 week
or diazepam po 5mg day
1-2 times a 1 week
BE
If severe give: Codes day Duration
Drug Adult dose Frequency
2 – 4mg once only
biperiden im/ iv AN
and then continue with benzhexol as above. Reduce the dose

of the anti-psychotic therapy.
Medium term side effects
Drug-induced Parkinsonism, stiffness of arms and legs, muscle
cramps, internal restlessness [akathisia] require addition of:
Duration
benzhexol po B E 5mg 1-2 times a day review
Note: Avoid long-term use of benzhexol without specialist
consultation. Some patients become addicted to benzhexol.
Hypothermia: keep the patient warm; refer to hospital as
medical emergency if body temperature cannot be raised.
Long term side effects

Tardive dyskinesia: reduce drug very gradually and refer for
specialist opinion. Do not give benzhexol.
MOOD (AFFECTIVE) DISORDERS

Mania
Treatment as for non-organic psychosis. For poorly controlled
patients and long term maintenance therapy, refer to specialist
level.
Depression
Mild
Counsel; identify and remove possible cause.
248
Severe Depression
In addition to the counselling & identifying and removing the
cause, assess and take precautions for possible suicidal
behaviour;
Duration
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.
Do not issue large quantities of antidepressant drugs;

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 such patients to a specialist]. In elderly patients, start with
25-50 mg/day. Imipramine is less sedating than amitriptyline.
Anxiety Disorders
Mild
Counsel; identify cause and treat.
Severe
In addition to counselling, give:
Duration
diazepam po BE 5mg [up to once a day max 2
10-15mg] weeks
Caution: Do not prescribe for more than two weeks. If severe anxiety
persists refer to specialist.
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.
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
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e.g. severe tremors, insomnia, confusion, hallucinations, give:

diazepam iv Duration
diazepam po CV 10mg once only then
BE 20-40mg once a day
discontinue within 7 –
[reduce by 5mg every other day]
and multivitamins 14days
CN 2 tablets once a day review
or AN 50mg once a day review
po
thiamine po
250
CHAPTER 19 COMMON EYE CONDITIONS
COMMON EYE CONDITIONS
Prevention of Blindness 252

Management of Eye Conditions 252
Diagnosis of Eye Conditions 253
Atraumatic Eye Conditions 253

Conjunctivitis of the Newborn 256
Traumatic eye conditions 256

Penetrating Injury 256
Corneal Foreign Bodies 256
Corneal Abrasion 257
Chemical Burns 257
Iritis/ Uveitis 257
Corneal Ulcers 257
Glaucoma (Chronic Open Angle) 258
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PREVENTION OF BLINDNESS
75% 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
early referral of serious eye diseases and injuries
tetracycline eye ointment in the new-born child’s eyes
not 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 the following conditions:
unexplained vision loss; or visual disturbance - urgent
glaucoma: high pressure in the eye - urgent
severe perforating injuries with loss of vision - urgent
corneal ulcer - urgent
burns - urgent
orbital cellulitis : urgent
cataract: cloudiness in an otherwise clear lens;
retinoblastoma: (white pupil) cataract / tumour in children
-urgent
severe eye pain
conjuctivitis persisting after one week of treatment
trachoma if eyelashes touching cornea
congenital or developmental squint
proptosis : (protrosion of the eye ball)
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.
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CHAPTER 19 COMMON EYECONDITIONS
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.
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:
pilocarpine eye drops BV 2 drops hourly review
(2 or 4%)
And acetazolamide po A N 500mg stat, then -
250mg 8 hourly
Refer to eye specialist within 24 hours.
Xerophthalmia/ Vitamin A deficiency

Preventive measures include promotion of breast-feeding,
measles immunisation, foods rich in Vitamin A [carrot, mango,
pumpkin, paw-paw] or supplementation.
To all children with signs and symptoms of xerophthalmia and/or
measles, give:
vitamin A po C V 200,000 iu single dose Day 1,
Day
[<1yr = 2 and after
100, 000iu] 1- 4 weeks
Nutritional rehabilitation is indicated.
Refer.
253
Table 19.1 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 copious. response Or
Gritty
eyes usually copious
Photophobia
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
ulcers
Iritis/uveitis Yes Yes. Deep pain Yes No Irregular, small, Decreased Yes
Max. around limbus, worse on moving sluggish reaction to
one or both eyes eye. Photophobia light
Conjunctivitis (including trachoma)

Table 19.2: Differential Diagnosis: Causes of
conjunctivitis
Signs/ Acute Viral Allergic Chronic,
symptoms bacterial endemic
trachoma
Discharge? ^Purulent ^Watery / Mucoid None / purulent
none
Itching? None None ^Marked None
One or both One or both One or both Both Both
eyes?
Recurrences? Unusual Unusual Usually ^Chronic
Note: SBold lettering indicates distinguishing feature.
Treatment of conjunctivitis:
Acute bacterial conjunctivitis:
tetracycline 1% eye CV apply 3 times a day one
ointment week
Viral conjunctivitis:
No drug 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.
Trachoma:
If left untreated, the cornea becomes permanently and
irreversibly damaged. Apply:
tetracycline 1% eye CV apply 4 times a day for 6
ointment weeks
If inturned eye lashes (trichiasis, entropion) present, 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, and
clean hands.
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Conjunctivitis of the Newborn

See also the section in Sexually Transmitted Diseases and the STD
Module.
Prevention:
Duration
tetracycline 1% eye C V one single application to both eyes
ointment within 24 hours of delivery.
Treatment:
Duration
kanamycin im C V 25mg/kg once single dose

and erythromycin po C V 16mg/kg 3 times a day 14
days
Treat the parents of the child.
TRAUMATIC EYE CONDITIONS
Penetrating Injury
Treatment: Put on eye shield and ensure NO pressure. Refer urgently
to an eye hospital.
Duration
tetanus toxoid im C V 0.5mls once single dose
and paracetamol po C E 500mg 4 times a day if
required
and amoxycillin po B 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:
Duration
tetracycline 1% eye C V apply under an eye pad for 24hrs,
then
ointment 3 times a day for 7 days
If worse after 24 hours – refer to eye hospital.
256
Corneal Abrasion
Apply an eye pad with tetracycline eye ointment 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
Chemical Burns
Consider this to be a medical emergency - prompt action can save
vision.
Irrigate the eye and surrounding areas thoroughly using tap

water and a 10ml syringe (without the needle) for 30 minutes.
Then:
tetracycline 1% eye C V apply under an eye pad for 24hrs, then
ointment review
If cornea is involved (ulcer or opacity): refer

If cornea is not involved use, and after 24 hours is improving:
Duration
tetracycline 1% eye C V apply 3 times a day 2
weeks
ointment
Iritis/ Uveitis
Refer to eye specialist.
Corneal Ulcers
Treatment:
tetracycline 1% eye C V apply 3 times a day 5-7 days
ointment
Eye pad is advised only in clean ulcers, with no discharge or
conjunctival oedema.
If no improvement after 4-7 days refer to an eye specialist.
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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.
Duration
pilocarpine 4% eye B V 1 drop in 6 hourly
Continual
drops each eye
If intra-ocular pressure is more than 40mmHg:
Duration
acetazolamide po* A N 250mg 3 times a day until <
and potassium chloride po B V 600mg once a day
40mmHg
*NOTE: This drug should NOT be used for more than 3 continuous
months.
258
CHAPTER 20 COMMON ORAL CONDITIONS
COMMON ORAL CONDITIONS
ORAL PROBLEMS 260

MANAGEMENT OF ORAL THRUSH/ORAL CANDIDIASIS 260
OESOPHAGEAL CANDIDIASIS 261
HERPES SIMPLEX LABIALIS 261
KAPOSI’S SARCOMA 262
GUM INFECTIONS 262
DENTAL CARIES 262
PERSISTENT GENERALIZED LYMPHADENOPATHY(PGL) 262
ORAL ULCERS 262
HISTOPLASMOSIS 263
259
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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 lesion will need referral to a dentist for biopsy

if one is worried about malignancy e.g. with
Kaposi’s
sarcoma and lymphoma or infections
such as
histoplasmosis.
Refer to HAQOCI guidelines.
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 VCT.
260
Treat with topical therapy such as:

Duration
Nystatin suspension B E 200 000 Five times
7- 14days
units a day
Nystatin lozenges B E sucked 5 times a 7- 14
days
day
Or Miconazole oral gel 2% C V topically4 times a 7–
14days-
day
If there is odynophagia, treat as oesophageal candidiaisis
as follows:
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 VCT and consider giving Cotrimoxazole
prophylaxis.
Treat oesophageal candidiaisis with systemic drugs such as:

Duration
Fluconazole po C V 200mg Twice a day 7-
14days
Or Ketoconazole A N 200mg Twice a day 7 - 14
days
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:
Duration
Acyclovir po C E 400mg 3 times a day 5 days
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Kaposi’s 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 VCT. Assess for
Cotrimoxazole prophylaxis and refer to your nearest O I 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
Duration
Metronidazole po C V 200mg 3 times a day 5 days
plus Amoxycillin po C V 500mg 3 times a day 5 days
Dental Caries
The teeth will have multiple decay. 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
VCT.
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:

Duration
262
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
or
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.

Duration
Ketoconazole A N 200mg Twice a day Months
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EAR NOSE AND THROAT

DISORDERS
OTITIS EXTERNA 265

ACUTE OTITIS MEDIA 266
CHRONIC OTITIS MEDIA 266
HEARING LOSS 266
ACUTE SINUSITIS 266
CHRONIC SINUSITIS 267
RHINITIS 267
TONSILLLITIS 267
LARYNGITIS 267
264
CHAPTER 21 EAR NOSE AND THROAT DISORDERS
Ear disorders are common especially in children and HIV

infected patients. See Paediatrics Chapter.
Otitis externa
Otoscopy shows an inflamed and granulating ear canal.
Malignant otitis externa(MOE) is said to have occurred when
there is bone involvement. P.aeruginosa and S. aureus are
usually involved.
• Aural toilet – Just clean the ear canal to remove
debris and also apply acidifying solutions such as
half strength hydrogen peroxide.
Drug Code Adult Frequen

Duration
s dose cy
Gentian violet C V Once Review
after 2
days
Or Half strength C E once Review
hydrogen peroxide in 2 days
• Control pain with simple analgesia
• Avoid getting the ear wet
• Do not put objects in the ear.
• MOE needs surgical intervention
Follow up after 7-14 days.

Duration
s dose cy
Ciprofloxacin po B E 250mg Twice a
6 weeks
day
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Acute Otitis media

Patient presents with throbbing earache, hearing loss with
or without discharge. Antibacterial therapy will shorten the
episode but pain control is also important.
Duration
s dose cy
Amoxycillin C V 500mg 3 times a 10
days
tds day
40mg /kg in
paeds
Chronic suppurative otitis media

Pus is draining from the ear and there is a long history of
ear disease.
• This needs referral to an ENT specialist.
Hearing loss
If there are signs of infection such as meningitis, consider
cryptococcal or TB meningitis and treat accordingly.
Exclude drug toxicity.
Acute sinusitis
Sudden onset nasal congestion, fever, headache or facial
pain. May last up to 1 month.
• Give simple analgesia
Duration
s dose cy
Amoxycillin po C V 500mg 3 times a
3 weeks
day
or Clindamycin po B V 600mg 3 times a
3 weeks
day
Or Ciprofloxacin po B V 500mg Twice a 3
weeks
day
Refer if not resolving after the above.

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CHAPTER 21 EAR NOSE AND THROAT DISORDERS
Chronic sinusitis
Look for facial pain or headache, nasal congestion and post
nasal drip. May last up to 3 months.
Duration
s dose cy
Amoxycillin CV 500mg Twice a 3 weeks
day B V 500mg
Or Twice a 3 weeks
day
Rhinitis
Atrophic and allergic rhinitis- These are quite common and the
identification and control/removal of potential allergens is
helpful. Potential allergens include cat and dog dander, fleas,
cockroaches, pollen and house dust mite. These can be
identified by allergology techniques (see also Chapter 25).

Duration
Beclomethasone s dose cy
nasal spray AN topically Review
Tonsilllitis
In most cases this is a viral infection and does not need
antibiotics. The presence of both fever and tonsillar exudate
may warrant antibiotics.
Duration
s dose cy
Aspirin gargles C V Review
or Paracetamol po C V 500mg 4 times a Review
day
Or Amoxycillin po C V 500mg 3 times a 7 days
day
Laryngitis
Acute laryngitis
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There is a sore throat, painful dry cough and

hoarseness of the voice. Manage with voice rest. plus:
Duration
s dose cy
Amoxycillin po C E 500mg 3 times
7 days
a day
Chronic laryngitis
If the symptoms including hoarseness persist for more than one
month, direct laryngoscopy is required. Refer to an ENT
specialist.
268
CHAPTER 22 SKIN CONDITIONS
SKIN CONDITIONS
Bacterial Infections 270

Impetigo 270
Folliculitis 270
Furunculosis 270
Erysipelas 271
Acute Cellulitis 271
Paronychia 271
Fungal Infections 272

Body Ringworm (Tinea Corporis) 272
Tinea Pedis (Fungal / Athlete's Foot) 273
Pityrias Versicolor (Tinea Versicolor) 273
Scalp Ringworm (Tinea Capitis) 274
Scabies 274
Cutaneous Larva Migrans 275
Viral infections 275
Other Dermatological Conditions 276

Eczema 276
Urticaria 277
Psoriasis 278
Pellagra 278
Albinism/ Vitiligo 279
Warts 279
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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.
m 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, or:
Duration
potassium permanganate B N soak once a day
as needed
1:4000 [0.025%] _________________________________________________
If severe, or systemic symptoms present add:
Duration
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.
m Bathe and remove crusts using soap and water, or:

Frequency Duration
potassium permanganate B N soak once a day
as needed
1:4000 [0.025%]_________________________________________________
Topical treatment is sufficient in mild cases.

If severe treat as for impetigo, above.
Furunculosis
Painful boils, most frequently caused by Staphylococcus aureus.
m Usually resolves itself, 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:
270

Duration
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.
m Begins at a small break in the skin or umbilical stump (infants).

Area affected has a growing area of redness and swelling,
accompanied by high fever and pains.
Treat with:
Duration
Penicillin V po C E 250-500mg 4 times a day 5-7
days
[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.
m Acute cellulitis [indistinct borders] should be differentiated from

erysipelas [raised, sharply demarcated margins from
uninvolved skin]. Give antibiotics:
Duration
cloxacillin po B V 250-500mg 4 times a day
5-7 days
[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:
Duration
Penicillin V po C E 250-500mg 4 times a day
5-7 days
[Paed = 125-250mg]
If ineffective:
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Duration
cloxacillin po B V 250-500mg 4 times a day 5-7
days
[Paed = 125-250mg]
Chronic Paronychia
Often fungal - due to candida. Avoid excessive contact with
water, protect from trauma and apply:
Duration
Miconazole topical C V topical twice a day until
resolved
or Clotrimazole cream C E topical Twice a day Until
resolved
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.
m Seek underlying cause if any e.g. overuse of oils on skin, stress,

anticonvulsant drugs, 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:
Duration
benzoyl peroxide 5%gel A N apply every night Review
In severe cases of nodular acne, treat with oral antibiotic:
Duration
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.
272
m Responds to any of the topical antifungal agents.
First line: Duration
Frequency
benzoic acid compound C E Topical 2-3 4 weeks

times a ointment
Secondday
line: Duration
Frequency
Miconazole cream C V topically 2-3 times a for 7

more
day days after
resolved
or Clotrimazole cream C E Topically 2-3 times a
for 7 more
day days after
resolved
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:
Duration
potassium permanganate B N Soak twice a day as needed
1:4000 [0.025%]
THEN apply:
Duration
Miconazole cream 2% C V topical 2-3 times a for 7 more
day days after
resolved
Or Clotrimazole cream 1% C E topical 2-3 times a
for 7 more
day days after
resolved
In severe infections use griseofulvin:
Duration
griseofulvin po B N 500mg once a day 8 weeks
[Paed = 10mg/kg]
Take with food or milk. Do not crush tablet tablets.
Pityriasis Versicolor (Tinea Versicolor) Common

fungal infection caused by a yeast. Hypopigmented patches of varying
size on the chest, back, arms and occasionally neck and face.
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Griseofulvin is not effective. Apply:

First line:
Duration
Miconazole Cream 2% C V topically Twice a day 2
weeks
or Selenium sulphide 2.5% B N topically once a
day 7 days
(leave of
skin for
10mins)
Second line: If above not effective

Caution: Exclude use of Nevirapine based ART before using
Ketoconazole.
Duration
Ketoconazole po B N 200-400mg daily 5 days
Scalp Ringworm (Tinea Capitis)

In this case the fungus has grown down into the hair follicle.
m Topical antifungal therapy may work but if ineffective; treat with:
Duration
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.
m 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:
Duration
Gamma benzene C V apply from once and
274
onc
e
only
hex
achl
orid
e
1%
loti
on neck down wash off
a
f
t
e
r
2
4
h
r
s
*
CAUTIONS: *In prepubertal children the gamma benzene

hexachloride is washed off after 12 hours. Hot baths and scrubbing
should be avoided to prevent systemic absorption.
m Alternative in pregnancy, lactating mothers or children < 6

months:
Duration
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 infants. days
or sulphur ointment 5-10% B N apply 2 times a 1-2
weeks
[in infants] 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:
Duration
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).
m 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).
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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:
Duration
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.
OTHER DERMATOLOGICAL CONDITIONS

Eczema
Allergic Contact Dermatitis
Results from an acquired allergy after skin contact with particular
chemicals (dyes, perfumes, rubber, chromium, nickel) or drugs (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
276
Remove any obvious cause e.g. skin irritants or allergens.

As a soap substitute use:
Duration
emulsifying ointment B N as a soap
substitute
or aqueous cream B N as a soap
substitute
Treat itching with an oral antihistamine. Never use topical

antihistamines:
Duration
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.
m Treat any infection. Choice of skin preparations depends on

whether lesions are wet (use cream) or dry/ ( use ointment)
If eczema is “weepy”, dry first using saline baths or bathe in:
Duration
potassium permanganate B N soak once a day as
needed
1:4000 [0.025%]
Where large areas are involved give a course of antibiotics for
5-10 days (as for impetigo).
After the lesions have dried, if necessary, apply a bland
preparation such as aqueous cream or zinc oxide preparation for
soothing effect.
CAUTIONS: Never use corticosteroid preparations on the face or in
children unless supervised by a specialist. More potent steroids, e.g.
betamethasone must only be prescribed by specialist. Do not use
corticosteroids on ‘weepy’ skin.
If the skin starts scaling, add a keratolytic preparation such as:

Duration
salicylic acid 2% oint. B N apply twice a day as
needed
or coal tar ointment 5% B N apply twice a day as
needed
[with salicylic acid 2%]
Urticaria
Allergic urticaria may be caused by: drugs (e.g. penicillin) infection,
contact with plants, pollen, insect bites, or foodstuffs (e.g. fish, eggs,
citrus fruits, nuts, strawberries, tomatoes.)
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Physical urticaria may be caused by mechanical irritation, cold,

heat, sweating.
m Exclude drug reaction (e.g. penicillin), or infection (bacterial,

viral or fungal).
Give antihistamine by mouth [never use topical antihistamines]:
Duration
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
m If no improvement after 1 month or chronic problem, refer.
Psoriasis
A condition of the skin characterised by thickening and scaling; usually
symmetrical.
m Exclude precipitating factors e.g. alcohol, deficiencies of B12 or

folate, stress, infections.
Avoid using steriods.
To reduce scaling use a keratolytic:
Duration
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:
Duration
278
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)
Use a sunscreen-and sun blocker on lips An effective and
cheap preparation with a sun protection factor of 15 (SPF=15)
is “PABA”:
Duration
para-amino-benzoic B E 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 on Sexually Transmitted Diseases
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BURNS
Assessment 281
General Management Guidelines 283
Management of Moderate Burns 284
Small Surface Area Burns 284
Large Surface Area Burns 285
Resuscitation of Large Surface Area Burns:

Adults 286
Resuscitation of Large Surface Area Burns:

Child 286
General Notes 287
280
CHAPTER 23 BURNS
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 life saving.
Smoke Inhalation Burns

If occurred in an enclosed area - may need 100 % oxygen.
Assessment
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 23.1).
In adults use the rule of nine’s (Fig 23.2).
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Figure 23.1 Estimating the Body Surface Area for

Burns in Children (modified Lund & Browder)
In children the head, thigh and legs account for different

percentages according to the age of the child. Use the table
below.
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. 23.2) 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.
282
CHAPTER 23 BURNS
Fig 23.2 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
283
EDUZ2006
extensive and serious because of fluid

loss, catabolism, anaemia and the risk of secondary infection.
Hospital admission is required for:
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

SmallSurfaceAreaBurns
Reassurance. 1st to 2nd degree burns are the most painful.
Give adequate analgesia - see the section on pain
management:
Duration
paracetamol po C E as required
500mg-1gm Paed = 4-6hrly 4
+/- codeine phosphate po BE Adults: as required
15-60mg hourly
Give an anti-tetanus booster: Frequency Duration
Drug Codes one dose on
Adult dose
tetanus toxoid im CV 0.5ml* ly
*check manufacturers instructions
Apply simple dry or non-adherent dressings.
284
CHAPTER 23 BURNS
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 ONLY and
should relate to the swab culture. Meanwhile if temperature
greater than 39oC, give:
Duration
benzylpenicillin iv CV 0.05MU per every 6hrs reassess
kg
or erythromycin po C V 500mg every 6hrs reassess
Paed = 12.5mg/kg after culture
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:
Drug Codes Rate
ringers lactate iv BV 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:
Duration
Morphine iv slow B E 2.5 - 5mg every 4hrs
review
increasing as required
every 4hrs review
or pethidine im (or iv in small BV 1mg/kg
diluted doses)
Analgesia in children:
Drug
Codes Paed dose Rate
Morphine iv B E per hour continuous iv
0.05-0.06 infusion
or Morphine iv bolus mg/kg every 2 hrs
B E
0.1mg
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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 %
Drug Codes Rate
ringers lactate iv B V Give ½ the total amount in the first
8hrs.
Then ¼ the total in the next 8hrs, and
or normal saline iv C V
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:
Drug 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 %
Drug 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).
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CHAPTER 23 BURNS
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
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:

Drug Codes Dose Frequency Duration
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
or Cimetidine po B E 400mg once a day review
at night
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EDUZ2006
Antibiotics are required only if/when wounds contaminated.

Gram positive organisms (notably B-haemolytic streptococcus)
predominate early on (first 5 days):
Duration
benzylpenicillin iv C V 2.5MU 6 hourly change to
oral *
*then penicillin V 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:
Duration
benzylpenicillin iv C V 2.5MU 6 hrly review
and gentamicin iv B V 80mg 8 hrly based on c/s
Monitoring
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:
Duration
(multi)-vitamins po C N 4 tablets 3 times a day review
288
CHAPTER 23 BURNS
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 291
SPECIAL TYPES OF PAIN 293
MANAGEMENT OF PAIN IN CHILDREN 295
CARE OF THE TERMINALLY ILL 296
290
CHAPTER 24 PAIN MANAGEMENT & CAREOF THE TERMINALLY ILL
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.
Anxiety, depression and fear should also be assessed and
managed accordingly. Anxiolytic and anti-depressant
medication is seldom needed - the opportunity for discussion
is more effective. If overlooked, these underlying conditions
may aggravate pain, making control more difficult.
In acute pain, careful and frequent assessment is needed to
determine the period for which drugs should be given. As the
pain lessens, analgesics should be reduced and even
discontinued.
In chronic pain, long term analgesia is required. Frequent
assessment is needed to establish the correct dose and
minimise side effects of the drugs. 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

Unless there is a definite contra-indication (peptic ulceration,
coagulation defects, low platelet count, prior to surgery or breast
feeding), the drug of first choice for analgesic and antipyretic action
is paracetamol. If anti-inflammatory action is required aspirin is the
drug of choice*:
Duration
paracetamol po C V 500mg-1g every as required
4-6hrs
(< 4g/day)
or aspirin po CV 300-900mg every as required
4-6hrs
(<4g/day)
or ibuprofen po B E every as required
200-400mg (< 4-6hrs
2.4g/day)
Moderate Pain
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Treat as for mild pain. If inadequate control:

Duration
add codeine phosphate po B E 15-60mg every 4 hrs
as required
Severe Pain
Morphine is the drug 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.
An anti-inflammatory may be needed as an adjuvant.
In most cases patients will have been given drugs for mild and
moderate pain with no success. However, certain patients
have such severe pain that morphine is required straight away.
Morphine is always given 4 hourly.
Duration
morphine im* B E 10mg every 4 hrs review
or morphine po B V 5-10mg every 4 hrs
review,
then
increase by 10mg until 30mg/dose, then
_______________________________ increase by 60mg until pain is controlled.
*when calculating parenteral dose, use one third of estimated or existing
oral dose.
Increments should be made quite rapidly i.e. after 2-3 doses 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, addiction
and respiratory depression are very unlikely if the dose of
morphine is adjusted to the needs of the individual patient.
It is unusual for patients to require more than 200 mg per dose,
and for acute pain smaller doses are usually adequate.
If pain control is not achieved the patient may require an
additional, higher dose to prevent this ‘break through’ pain.
Long term usage of morphine should be restricted to cancer
patients.
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CHAPTER 24 PAIN MANAGEMENT & CAREOF THE TERMINALLY ILL
Side-effects of morphine
These are mostly transient and treatable and should not contraindicate
the continued use of morphine. They include:
Constipation:
This is common and all patients should receive regular laxatives.
Encourage high roughage diet and high fluid intake.
Nausea and vomiting:

This is usually transient. An, antiemetic should be given for the first
three days or longer as needed.
metoclopramide po B V 10-20mg 3 times a day as required
or prochlorperazine po B N 5-10mg 3 times a day as required
or haloperidol po A N 1.5-4.5mg at night as required
*If vomiting is severe, antiemetics may need to be given parenterally or
rectally.
Drowsiness, dizziness, confusion:
Occurs especially in the elderly, but improves in 3-5 days. Do not
discontinue morphine.
Allergy:
Morphine allergy is very rare. An alternative is pethidine, but it is
short-acting and less potent than morphine. Pethidine is better
suited to acute pain than chronic.
Duration
pethidine im B V 50-100mg 3 hourly
as
required*
*Not suitable for long term use.
Special Types of Pain

In certain situations other drugs may be useful in controlling
pain. These drugs may be used alone or with an analgesic
Nerve Compression
Duration
prednisolone po B V 5-10mg 3 times a day see
below
Reduce dose of steroids progressively to minimal maintenance level once
clinical improvement occurs.
Short courses of high dose prednisolone (60-100mg/day) may be
required.
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Raised Intracranial Pressure

Manage with a diuretic, codeine or morphine analgesia and:
Duration
dexamethasone po B N 4mg 3 times a review
or prednisolone po B V 20-30mg day
3 times a day review
Joint / Bone Pain

See also chapter on Bone & Joint Conditions
Duration
aspirin po C V 600-900mg every 4-6hrs review
or ibuprofen po BE 400mg every 4hrs review
or indomethacin* po B E 25 - 50mg every 4-6hrs
review
* if a rectal form of indomethacin or other anti-inflammatory is
available it should be considered for use
Metastatic Bone Pain

Use morphine. Note: regular long term addition of a non-steroidal
anti-inflammatory drug is effective and often allows lower doses of
morphine to be used.
Neuropathic Pain
Trigeminal Neuralgia, Post Herpetic Neuralgia & Peripheral

Neuralgia
Use with or without analgesics:
Duration
Carbamazepine po B E 100mg 1-2 times a day
increasing
slowly
to max of 400mg 3 times a day, review
+/- amitriptyline po BE 25mg at night increasing
to 150mg* at night, review
max
*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

Treat as for neuralgia; if severe, nerve block may be required.
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CHAPTER 24 PAIN MANAGEMENT & CARE OF THE TERMINALLY ILL
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
Duration
paracetamol po CV 10-15mg/kg every 4hrs
review
Moderate Pain
Duration
paracetamol po C V 10-15mg/kg every 4hrs review
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
Severe Pain
paracetamol po Duration
and morphine po CV 10-15mg/kg every 4hrs
or morphine iv review BV <1yr =
or morphine iv bolus
every 4hrs
0.2mg/kg
>1yr =
0.25mg/kg
BE 0.05-0.06 per hour continuous
iv
mg/kg infusion
every 2 hrs
BE 0.1mg
Nausea and vomiting

Duration
metoclopramide po BV 1-2mg/kg 3 times a day
review
or promethazine po* B N 3 times a day
0.25- review
*not for use in children under the age of 2yrs
0.5mg/kg
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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:
a truthful explanation of the illness showing understanding and
concern
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 treateed if possible. A calming presence from
a relative / carer, propping the patient up, oxygen, and the use
of morphine and mild sedatives all help.
During the last hours of a person’s life, carers should focus on

minimising pain, reducing shortness of breath, and reducing the risk
of seizures and choking. If symptoms and distress are not easily
controlled it may be appropriate to use sedation
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CHAPTER 25 DRUGS AND THE ELDERLY
DRUGS AND THE ELDERLY
Due to physiological changes and altered pharmacodynamic

response of target organs the elderly are more susceptible
to adverse drug reactions.
Elderly patients may require multiple drug therapies.
Therefore medication should be reviewed frequently (every
3 months).
Provide simple, once or twice daily regimens wherever possible.
Give clear instructions on how drugs are to be taken.
Where possible ask relatives to supervise drug taking.
Suppositories or liquid formulations should be prescribed where
swallowing is difficult.
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.
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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
Do not use chlorpropamide as impaired renal function may
increase risk of toxicity. Use:
Duration
glibenclamide po B V 2.5mg up to 15mg once a day
But remember - The elderly are also at increased risk of

hypoglycamia with glibenclamide.
If control is not achieved add metformin/refer for further
management (See section on diabetes.)
Hypnotic / Sedatives
Benzodiazepines (e.g. diazepam) significantly impair
cognitive function and should not be used. Hypnosis or
sedation should be achieved with:
Duration
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:
Duration
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.
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CHAPTER 25 DRUGS AND THE ELDERLY
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 drugs before an
adequate physical examination has excluded impaction high
up. In such cases a high fibre diet, regular enemas and a
stimulant such as senna will relieve the problem.
Non-steroidal Anti-inflammatory drugs

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.
Duration
Aspirin po C V 300-600mg < 3 times a day as
required
or ibuprofen po A 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 301
IRON DEFICIENCY ANAEMIA 301
MEGALOBLASTIC ANAEMIA 301
SICKLE CELL ANAEMIA 302
G6PD DEFICIENCY 303
OTHER ANAEMIAS 303
HEREDITARY BLEEDING DISORDERS 304
ACQUIRED BLEEDING DISORDERS/ PLATELET DISORDERS 306
ANTICOAGULATION 307
PROPHYLAXIS FOR DEEP VEIN THROMBOSIS (DVT) 308
PULMONARY EMBOLISM/ ARTERIAL EMBOLISM 309
HAEMATOLOGICAL MALIGNANCY 309
USE OF BLOOD AND BLOOD PRODUCTS 310
SPECIFIC INDICATIONS FOR USE OF BLOOD & BLOOD
PRODUCTS 310
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CHAPTER 26 HAEMATOLOGY AND BLOOD PRODUCTS
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 (< 42% in men and <36% in women). Use
of red blood cell indices and careful examination of a
peripheral blood smear will usually indicate the likely cause
of anaemia. If in doubt contact a central hospital laboratory
for assistance (bone marrow smear and peripheral blood
films can be sent for comment).
Avoid blood transfusion in haematinic deficiency. For other causes,
transfuse only when patient is symptomatic and the cause of anaemia
is not immediately treatable. 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.
Duration
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 normal
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 for appropriate treatment.
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
Macrocytosis also occurs in liver disease, alcohol excess,

hypothyroidism, some haemolytic anaemias and multiple
myeloma. In the presence of these conditions vitamin B12
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/folate deficiency must be excluded. Macrocytosis is

physiological in the neonate.
Vitamin B12 Deficiency

Life long replacement is mandatory in pernicious anaemia,
post-gastrectomy or illeal resection.
Duration
hydroxocobalamin B V 1mg 2 times a week 3
weeks,
(vitamin B12) im then once every 3 months for life
Folic Acid Deficiency

In malabsorption up to 15mg daily may be required.
Duration
folic acid po C E 5mg once a day Review
Sickle Cell Anaemia

Management:
folic acid po C E 5mg once a day for life
and benzathine penicillin im C V 2.4MU
once a month for life
or penicillin V po C E 250mg once a day for life
For malaria prophylaxis in endemic areas:

Duration
pyrimethamine/ dapsone C E one tablet once a Continual
po 12.5mg/100mg week
In painful crisis, intravenous rehydration, regular and adequate
analgesia and antibiotics are required.
Morphine is necessary to control severe pain. Weaker opiates (codeine)
or non-steriodal anti-inflammatory drugs (e.g. aspirin) may be used for
less severe pain. See chapter on Pain.
Antibiotic therapy:
Duration
amoxycillin po C V 500mg 3 times a day
5 days
Other antibiotics may be required according to
site of infection/causative organism.
Osteomyelitis: see chapter on Bone and Joint Conditions.
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CHAPTER 26 HAEMATOLOGY ANDBLOOD PRODUCTS
Other types of crises:

In aplastic, haemolytic or sequestration crisis, red cell
transfusion may be required to treat anaemic heart failure. Note
that over transfusion worsens the sickling crisis and may cause
iron overload.
Sickle cell trait requires no treatment, and does not cause
anaemia.
G6PD deficiency
Glucose-6-phosphate dehydrogenase (G6PD) deficiency is
common in Zimbabwe.
Intravascular haemolysis and haemoglobinuria may occur with

oxidant drugs (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.
The risk of malaria outweighs the risk of haemolysis, so chloroquine and
quinine should be used if indicated for malaria treatment
Avoid blood transfusion unless clinically indicated. Other
Anaemias
HIV anaemia is a common finding with HIV/AIDS patients.
Transfusion is only indicated in treating severe anaemia and
cardiac failure.
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.
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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. Involve the
physiotherapist as soon as the bleed is resolving.
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
Severity of bleed Required FVIII Cryoprecipitate
FVIII level Concentrate [80 IU/bag]
[500 IU/bottle] (=20mls)
1. Mild bleed (nose, gums etc.) 14 IU/kg 1-2 bottles 6 bags
2. Moderate bleed joint, muscle, 20 IU/kg 2-4 bottles 12 bags
GIT, minor surgery
3. Major bleed (e..g.. cerebral) 40 IU/kg 4-6 bottles 12 bags
4. Prophylaxis for major surgery 60 IU/kg 6-10 bottles 18 bags
Note: For 1,2 and 3 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 4 above, 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.
304
Note: For paediatrics give 10ml/kg of cryoprecipitate or of fresh frozen

plasma.
As adjunct to factor replacement in mucosal or gastro-intestinal
bleeding and surgery, give fibrinolytic inhibitor [tranexamic acid].
Do not use for haematuria.
In an emergency, fresh frozen plasma can be used to treat
bleeding in haemophiliacs (give 3 bags initially) if none of the
above are available
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:
Duration
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. Adult dose Frequency Duration
Major bleeding
Drug
Codes
factor IX concentrate A V 3-6 x 500 IU daily Review
or fresh frozen plasma B 8 - 12bags every 24hrs if bleeding
V continues
For children use appropriate dosage.
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:

Duration
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cryoprecipitate A E 6 bags per every 24-48 if

bleeding
dose hrs continues
Tranexamic acid (specialist drug) 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:
Duration
fresh frozen plasma B V 4 bags every 12- if
bleeding
24hrs continues
9
If platelet count <50x10 /L and patient is bleeding:
Duration
platelet concentrate A E 1 unit/kg
If fibrinogen is low and/or APTT prolonged give (to supply

fibrinogen and FVIII):
Duration
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
Duration
vitamin K iv * B 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:

Duration
fresh frozen plasma B V 4 bags review review
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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:
Duration
vitamin K im C V 1mg once a day 3 days
Idiopathic Thrombocytopaenic Purpura (ITP)

Duration
prednisolone po B V 1mg/kg once a day 2 weeks,
then according to response – see
notes below
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.
Consider splenectomy for those in whom steroids fail to achieve
adequate control or who relapse after treatment.
ANTICOAGULATION
Oral Anticoagulation
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 daily/ 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.
There is great individual variation in dose required (average
daily dose 2.5-10mg).
Caution: drug 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
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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:
Duration
vitamin K slow iv B 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:
Duration
fresh frozen plasma B V 4 units
and vitamin K iv B V 0.5 - 1mg once a day
Review
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 (protein C & S deficiency etc.)
Paroxysmal nocturnal haemoglobinuria
Previous history of DVT
Other pro-thrombotic states such as artificial cardiac valves and
atrial fibrillation need life long anticoagulation.
Methods of prophylaxis available

Physical methods include stockings. Early mobility must be
encouraged in all surgical patients.
Drug management (targeting an INR of 2 to 2.5):
Duration
warfarin po BV 10mg once a day 2
days then review based on INR level
or heparin sc BV 5000 units 8 hourly Review
(unfractionated)
Treatment of DVT Codes Adult dose Frequency Duration
Drug
heparin sc BV 17500 units Twice a day see below*
(unfractionated)
308
*Duration is 4-6 months except in pregnancy, or if there is another reason for

prolonged treatment;
Pulmonary embolism: 4-6 months.
Atrial fibrillation: life long treatment.
Heart valve prostheses: life long 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:
Duration
heparin sc B V 17500 units twice a day
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.
Duration
hydrocortisone iv [for B V 100mg once only
allergic reactions]
and streptokinase iv AN 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. Even the process of cross-matching blood is
expensive: for straightforward volume expansion use crystalloids.
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.
cardiac failure, give small doses (e.g. 20mg). Intra-venous frusemide
is rarely required.
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;
Prior to, and following aggressive cytotoxic programmes, maintain
haemoglobin at/or above 8g/dl;
310
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
indication to children with protein-energy malnutrition, they should
be transfused slowly (not more than 2.5 ml/kg body weight/hour).
Surgery
Pre-and peri-operative - Anaesthesia is safe if haemoglobin >8g/dl
in stable individuals (except for the condition being managed
surgically). Where facilities are available major surgical cases can
proceed with group and save. Requests for cross matching should
be done only when blood loss necessitating replacement is
expected. Efforts should be made to encourage autologous
transfusion where appropriate.
Pre-anaesthetic bleeding and transfusion during or at end of operation.
Intra-operative cell salvage and re-transfusion.
Autologous blood donation for elective surgical procedure.
Post Operative - Give packed cells if further treatment of patient

(e.g. further surgery, chemotherapy or radiotherapy) would be
compromised by a low haemoglobin.
For specific indications and operative interventions, see table
below.
Table 26.1 Surgery: Specific Indications and Operative
Interventions
Type of Surgery Operation Blood Requirements
General Surgery Splenectomy Group and save serum
Gastrostomy, ileostomy Cross-match 3 units
Laparotomy for peritonitis Cross-match 2 units
Bowel resection Cross-match 3 units
Abdominal stab and gun-shot wounds Cross-match 3 units
Vascular Surgery Amputation of limb Group and save serum
Cardio-Thoracic Open pleural/lung biopsy Group and save serum
Surgery
Neurosurgery Head injury-extradural haematoma Cross-match 2 units
Orthopaedics Nailing fractured neck of femur Group and save serum
Internal fixation of femur Internal Cross-match 2 units Nil
fixation of tibia or ankle
Urology Nephrectomy Open Cross-match 2 units
prostatectomy Cross-match 2 units
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Obstetrics and Gynaecology

The general principles are the same as for the surgery. For specific
indications and operative interventions, see Table 26.2 below,
where examples of blood requirements (packed cells) are given.
Table 26.2 Obstetrics and Gynaecology: Specific Indications

and Operative Interventions
Procedure Hb<8 Hb 8 - 10 Hb>10
gms/dl gms/dl gms/dl
Dilation and curettage E AA AA
Uterine evacuation E AA AA
Cervical biopsy Tubal E
ligation E
Laparoscopy E B B
Manual removal of placenta G C BC
Vaginal repair G C
Caesarean section for: FF H C
Placenta praevia, abruption E CB CB
Eclampsia Other indications
Laparotomy for: Ruptured EG C C

ectopic Mass, unruptured HH C C
ectopic Ruptured uterus H C
Genital tract malignancy H C
Hysterectomy (abdominal or G C C
vaginal)
Key for table:

Proceed without cross-match or grouping
Group and save serum
Cross-match 2 units.
Cross-match 4 units.
Cross-match and transfuse to 8 gms/dl pre or peri-operatively
Cross-match and transfuse to 10 gms/dl pre or peri-operatively
Transfuse to 8 gms/dl and keep 2 more units.
Transfuse to 10 gms/dl and keep 2 more units.
Note: These modes of management are regarded as safe in usual

circumstances. In situations where less blood is available, it may be
more appropriate to take some risks by proceeding, than taking the
greater risk of transferring a deteriorating patient. Individual clinical
judgement is required. If necessary, telephone the referral centre for
advice.
312
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
Disseminated intravascular coagulation (DIC) with active generalised
9
bleeding and platelets <20 x 10 /L
9
DIC prior to LSCS (or other operation) with platelets<50 x 10 /L
Cranial operations and eye operations need platelets above 100 x
9
10 /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.
FRESH FROZEN PLASMA

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
The sole use is for exchange transfusions.
Blood should be less than 5 days old.
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EXCHANGE TRANSFUSION IN NEONATES

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 Serum
(Weeks) Serum Bilirubin
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)
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.
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.
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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
Normal daily requirements 317
Maintenance 318
Replacement of Abnormal Losses 318
Available Intravenous Solutions 320
Crystalloids 320
Colloids 322
316
CHAPTER 27 INTRAVENOUS FLUID REPLACEMENT
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)
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Sodium 1 to 1.5mmol/kg/24hrs
Potassium 1mmol/kg/24hrs
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)

Drug Codes Paed dose Frequency Duration
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)

Drug Codes Paed dose Frequency Duration
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)

Duration
sodium chloride 0.9% iv C V In severe dehydration the first litre
may
318
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).
Intravenous Infusion Rehydration (Children)

Duration
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:
Duration
Sodium chloride 0.9% C V replace losses iv 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:
Duration
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%.
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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.
Table 27.1 Clinical estimate of Blood

Loss in Haemorrhagic Shock in Adults
Blood Blood Pulse Blood Resp. Urine Treatment :
loss [mls] loss % rate press. rate [per output [replace total
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 +
colloid +
60/40
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.
320
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 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;
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as a vehicle for administration of some drugs.

It should not be used in head injured patients (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 drugs.
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.
Colloids
Indication for colloids: resuscitation in severe hypovolaemia, as a
plasma substitute.
Fresh frozen plasma (FFP) should not be used as a general colloid,
but only when specifically indicated. See section on Blood and Blood
Products.
Dextran 70
Used to reduce viscosity and prevent venous thrombosis.
Modified gelatin
Used to expand and maintain blood volume in hypovolaemic shock.
See table 27.2 on next page.
322
Table 27. 2 Composition of Available IV Solutions
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-m 154 111 65 51 0 0 77 21 77
mol/L
HC03 0 29 0 0 0 0 0 0 0
mmol/L
Lactate 0 0 0 27 0 0 0 20 0
mmol/L
Dextrose 0 0 100 25 50 100 25 100 0
g/L
Calorie 0 0 400 100 200 400 100 400 0
s per L
Level C C B C C A B
VEN V V N V V N N
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ANAPHYLAXIS
Severe anaphylaxis is a medical emergency (life and death
situation) in which seconds count. Prompt treatment is required for
acute airway obstruction, bronchospasm and hypotension.
Common causes of anaphylaxis are drugs, (notably: antibiotics,

non-steroidal anti-inflammatory drugs, antiarrhythmics, heparin,
parenteral iron, desensitising preparations and vaccines), blood
transfusions, bee and other insect stings, and certain foods.
Note: If the allergen can be identified, it is essential 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.
TREATMENT
Discontinue administration of any suspect agent (e.g. drug,
blood)
Lie the patient flat and elevate the legs.
Ensure a clear airway; give 100% oxygen, if available.
Monitor pulse, blood pressure, bronchospasm and general
response/condition every 3-5 minutes.
Give:
Duration
adrenaline 1 in 1000 im C V 0.5 – 1ml Repeat as necessary
children 1-5yrs [= 10mg/kg] every 10mins until
improvement occurs.
0.1-0.2ml
children 6-12yrs 0.2-0.4ml
In severe allergic reaction give:
Drug Adult dose Frequency Duration

Codes
adrenaline 1 in 10 000 C V 1ml slow repeat until
iv [1-5yr every satisfactory
[Add 9ml normal saline / =0.1 ml/kg] minute clinical
water to 1ml of 1in 1000 response
adrenaline]
324
CHAPTER 28 ANAPHYLAXI
S
Start IV volume expansion with normal saline (or Ringer lactate)

adjusting rate according to blood pressure:
Duration
normal saline iv CV First litre run in over 15-20mins, then
review.
Add: Codes Adult dose Frequency

Drug Duration
promethazine slow iv BV 25-50mg 8 hourly up to 48hrs
Paed: 1-5yr = 5mg
6-12yr =12.5mg
and hydrocortisone iv 200mg 12 hourly as
required
B
V
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:
Duration
aminophylline slow iv BV 6mg/kg unless the patient has
-bolus dose over 20 taken aminophylline in
minutes the past 8 hours
then aminophylline in BV 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):
Duration
sodium bicarbonate iv B V 50mmolas required (15-30min
intervals)
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POISONING
Prevention of Poisoning 327
General Treatment Measures 327

First Aid 328
Swallowed Poisons 328
Corrosive Substances 330
Inhaled Poisons 330
Skin Contamination 330
Eye Contamination 330
Treatment of Specific Poisonings 331
Antidepressants 331
Aspirin / Salicylate Poisoning 331
Carbon Monoxide Poisoning 332
Chloroquine Poisoning 333
Paracetamol Poisoning 333
Ethanol (Alcohol) Poisoning 334
Insecticides 339
Organochlorine Insecticides 335
Pyrethrum and Synthetic Pyrethroids 320
Organophosphate and Carbamate Insecticides 320
Paraquat and Related Herbicides 321
Paraffin, Petrol and Other Petroleum Products 337
Other Drugs and Chemicals 322
Snake Bite 326
Scorpion Sting 342
Mushrooms 342
326
CHAPTER 29 POISONING
Poisons include drugs, 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, Medical School
P O Box A178 Avondale, Harare.
Telephone Harare 790233 direct or 791631 ext 172.
datis@healthnet.org.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 drugs and poisons out of reach of children; do NOT store
in areas or containers used for food storage.
Do NOT transfer drugs 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.
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Aim to slow down, reduce, or prevent further absorption of the

poison, and to counteract the effects of poison already absorbed.
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
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.
Induce vomiting with:

ipecacuanha syrup po B N 30ml syrup,If vomiting does not occur
(Ipecac Syrup USP: then half awithin 20 minutes, repea
0.7ml ipecac liq. extract glass of the dose.
in 10ml syrup) water.
6-18months = 10ml
older children = 15ml
328
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.
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:

Duration
D314 C V 100 ml for each washing, and repeat
half strength darrows until aspirated fluid is clear.
with dextrose 2.5%
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, then give:
Duration
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).
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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.
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.
330
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.
TREATMENT OF SPECIFIC POISONINGS
Antidepressants
e.g. amitriptyline and imipramine (tricyclic antidepressants). Signs of
poisoning with these drugs 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 drug 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:
Duration
diazepam slow iv C V 0.05 - as required as
required
0.1mg/kg
Control arrhythmias appropriately
Duration
lignocaine 2% iv A E 500mg over 2-4mins,
preservative free then 1-2mg/min by infusion
For metabolic acidosis, if arterial pH < 7.2:
Duration
sodium bicarbonate iv B V continuous
infusion in dextrose 5%
Aspirin / Salicy l ate 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
Induce emesis with ipecacuanha syrup unless respiration is depressed.
Delay absorption of the remaining poison by giving activated charcoal. If
respiration is depressed, use airway-protected gastric lavage (lavage is
effective up to 8 hours after ingestion).
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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 drug.
Caution: Central nervous system depressants, such as barbiturates or
diazepam must be administered cautiously.
General Measures
Monitor serum bicarbonate, chloride, potassium, sodium, glucose and
arterial pH.
If there is adequate urine output and no vomiting, give milk orally every
hour up to a total of 100ml/kg in the first 24 hours.
In severe poisoning, hydration with intravenous fluids must be initiated in
the first hour:
Duration
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:
Duration
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:
Duration
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:
Duration
332
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.
Chloroquine Poisoning
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:
Duration
diazepam slow iv C V 0.05- as required as
required
[max =30mg] 0.1mg/kg
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:
Duration
dextrose 5% iv C V continuous infusion first 48 hrs
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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:
Duration
acetylcysteine iv AE 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 if performed soon after
ingestion
Maintain adequate airway. Give artificial respiration if necessary.
If patient is in coma, give:
Duration
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:
Duration
sodium bicarbonate iv B V continuous
infusion in dextrose 5%
Correct hypoglycaemia if present by:
Duration
dextrose 50% iv C V 20ml bolus dose, then
and dextrose 5% iv _______ C V infusion______________________
Avoid administration of excessive fluids and depressant drugs and give:
Duration
thiamine po AN 200mg once a day review
In acute alcoholic mania (following ethanol withdrawal after chronic
ingestion) give:
Duration
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 in patients with a history of seizures give:
Duration
diazepam slow iv C V 0.05- as required -
[max = 30mg] 0.1mg/kg
334
For encephalopathy:

thiamine iv/im AN 250mg once -
then thiamine po AN 200mg one a day 7 days
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 and purgative 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 (see notes at the beginning of

this chapter).
CAUTION: Do not give milk, fats or oils as they will increase absorption
of the insecticide if ingested.
Control of convulsions, hyperactivity, or tremors:
Duration
diazepam slow iv C V 0.05- as required -
[max = 30mg] 0.1mg/kg
Pyrethrum and Synthetic Pyrethroids

Common names: alfamethrin, cypermethrin, deltamethrin,
fenvalerate, permethrin.
Generally pyrethroids are of low toxicity and no treatment is
required. (Caution: solvents).
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Organophosphate and Carbarn ate

Insecticides
Common names (organophosphates): “Azodrin”, chlorfenviphos, diazinon,
dichlorvos, dimethoate, disulfoton, fenitrothion, malathion, mevinphos,
monocrotophos, parathion, pichloram, “Rogor”, thiometon
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 emptied by airway protected
gastric
lavage.(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:
Duration
atropine iv /im B V 2mg every 15 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.
Duration
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.
336
If adequate respiration and atropine do not control convulsions, refer.
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]:
Give ipecacuanha syrup if patient not already vomiting.
Perform gastric lavage.
Give Fuller’s Earth (aluminium silicate) if available.
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:
Duration
hydrocortisone iv B V 200mg 4 times a early in
day therapy
Paraffin, Petrol and 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 Drugs and Chemicals
see table on next page

337
Table 29 - Antidotes for Poisoning by other specific drugs and chemicals
Drug/ poison Antidote Dosage Notes
atropine paraldehyde po/ 0.05-0.2ml/kg To control convulsions (do not use
im/ pr 1-2mg in 1-2ml 0.9% sodium chloride diazepam)
physostigimine iv over 2min May be repeated every 5mins to a total
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 Up to 25mg/kg 4 times a day (max poisoning
penicillamine po 1g/day) for 7 days Start after 2 days of dimercaprol
therapy.
copper salts calcium disodium 15-25mg/kg iv in 250 – 500ml dextrose

edetate iv 5% over 1-2hrs, twice a day for 5 days,
or and 12.5mg/kg orally 4 times a day for
penicillamine po 7 days
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 25ml of 50% injection (or 50ml of Hg
sodium 25%) over 10min Give after sodium nitrite using same
thiosulphate Repeat BOTH injections at half the needle and vein.
initial dose if symptoms reappear. SPEED IS ESSENTIAL
Table 29 - Antidotes for Poisoning by other specific drugs 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
solutions (‘bleach’) thiosulphate and 5-10g po in 100-200ml water
magnesium
hydroxide mixture
po 30-50ml orally
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 12hr for 24hrs.
period)
lead dimercaprol im Start 4hr after starting dimercaprol. Use
and 4mg/kg im every 4hrs for 30 doses separate injection sites.
calcium
disodium
edetate im 12.5mg/kg im every 4hrs for 30 doses
mercury dimercaprol im or 3mg/kg im every 4hrs for 2 days, then
penicillamine po 2mg/kg im every 12hrs for 10 days.
Up to 25mg/kg 4 times a day (max
1g/day) for 7 days
Table 29 - Antidotes for Poisoning by other specific drugs 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 1mg/kg slow iv (<50mg/min). Can be appear.
prochloperazine) phenytoin slow repeated every 5min to a total dose of To control cardiac arrythmias. Do not
iv 10mg/kg use lignocaine.
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:
x cut the wound
x use a tourniquet
x give electric shock to the site
x rub or massage the wound site.
In hospital
Remove the pressure bandage
Give analgesia and:
Duration
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:
Duration
*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.
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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:
Duration
scorpion anti-venom B N Check the manufacturers
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
Aminita 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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CHAPTER 30 DRUGS USED IN ANAESTHESIA
DRUGS USED IN ANAESTHESIA
General Notes 344
General principles 344
General Anaesthesia 344
Intravenous Anaesthetics 345

Thiopentone 345
Etomidate 345
Ketamine 346
Inhalational Anaesthetics 347

Nitrous Oxide 347
Halothane 347
Local Anaesthesia & Conduction Anaesthesia 348

Bupivacaine Hydrochloride 348
Lignocaine Hydrochloride 348
Muscle Relaxants/ Cholinesterase Inhibitors 348

Suxamethonium Chloride (depolarising) 349
Alcuronium Chloride (non-depolarising) 349
Pancuronium Bromide (non-depolarising) 349
Neostigmine bromide (Cholinesterase inhibitor) 350
Peri-Operative Drugs 350
Drugs Used in Shock 353
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GENERAL NOTES:
Only persons trained to administer them should use the drugs in
this section and 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 visited 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 personal 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 recovery period is an anaesthetic
responsibility.
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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CHAPTER 30 DRUGS USEDINANAESTHESIA
INTRAVENOUS ANAESTHETICS
Thiopentone
A thiobarbiturate (intravenous use only) which produces
anaesthesia, but no analgesia, within one arm-brain circulation
time.
Drug 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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Propofol
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
Avoin in children less than one year and epileptic patients
In Caesarean Section
Discard unused solutions
Contraindicated in people allergic to eggs and soyabean oil
Ketamine
Produces dissociative anaesthesia gradually.
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.
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.
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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.
Drug 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.
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.
Soda Lime
An adjunct to inhalational anaesthesia. Use in circle carbon dioxide
absorber system with low fresh gas flow anaesthesia.
Drug Codes
soda lime B V
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LOCAL ANAESTHESIA & CONDUCTION

ANAESTHESIA
This includes local infiltration, peripheral nerve block,
spinal anaesthesia and epidural analgesia.
Factors influencing the safe dosage of local anaesthetics
include
patient’s age, weight, physical status, vascularity of the area to which the
drug 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 drug (e.g. ephedrine) is available to treat
possible hypotension.
Preservative-containing solutions should not be used for
spinal
anaesthesia.
Bupivacaine Hydrochloride
bupivacaine A E 10-15 min 3-6 hours
max = hydrochloride
2mg/kg Onset Duration
Lignocaine Hydrochloride
Drug Codes
Dose
lignocaine HCl 2% plain C V max 2-10 min 1-2 hours

=
3mg/kg
lignocaine HCl 2% + B E 2-10 min 1-2 hours
max = adrenaline 1:100 000
7mg/kg
MUSCLE RELAXANTS/ CHOLINESTERASE

INHIBITORS
Only personnel who are skilled in managing the patients’ airway
through intubation and ventilation must administer these drugs.
Ventilation must be mechanically assisted until the drug has
been inactivated.
Sedation, analgesia or anaesthesia must be provided when
paralysing patients, as these are not produced by muscle
relaxants.
348
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
Ave. for intubation: 1mg/kg
Indications
Laryngoscopy and intubation
Muscle relaxation of short duration
Contra-indications:
moderate/severe burns
crush injuries
spinal cord transection
division of a major nerve e.g sciatic, brachial plexus
tetanus
history of malignant hyperthermia
scolene apnoea
Cautions
Repeat doses will cause bradycardia; this can be prevented by atropine (10-20
micrograms/kg intravenously).
Alcuronium Chloride (non-depolarising)

alcuronium chloride iv B V 0.2-0.25 1-2mins
30-40mins
mg per kg
Indications
Muscle relaxation of medium duration.
Cautions
Moderate histamine release may occur.
Hypotension may occur.
Avoid in renal failure.
Pancuronium Bromide (non-depolarising)

Does not cause significant histamine release.
pancuronium bromide A N 0.1mg/kg 1-3mins
40-60mins
iv
top up using 10% of paralysing dose
Indications:
Muscle relaxation of medium to long duration.
Cautions:
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Care is required in hepatic impairment.

Reduce dose in renal failure.
Causes moderate tachycardia and rise in blood pressure.
Neostigmine bromide (Cholinesterase

inhibitor)
Provides reversal of non-depolarising neuromuscular blockade.
Drug 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.
PERI-OPERATIVE DRUGS
Atropine Sulphate (antimuscarinic)
Drug Codes
atropine sulphate B V
Indications:
Drying secretions: 0.3-0.6mg im 30-60mins before induction, or
iv
immediately before induction [Paed = 20mcg/kg]
Reversal of excessive bradycardia: 0.3-1mg iv [Paed =10-30mcg/kg]
Used with neostigmine for reversal of non-depolarising neuromuscular
block: 1-1.8mg iv [Paed=20mcg/kg]
Hyoscine butylbromide (antimuscarinic)

Drug Codes
hysocine butylbromide B N
Indications:
Drying secretions: 0.2-0.6mg oral (or im) 30-60mins before induction
Diazepam (sedative)
Drug Codes
diazepam iv/ po C V
350
CHAPTER 30 DRUGS USED IN ANAESTHESIA
Indications:
Anxiolysis and sedation with amnesia: 5-10mg orally 1-2hrs before
surgery, or 0.2mg/kg slow iv (adults and over 8yrs)
Midazolam
Midazolam po B E 7.5 -10mg Less than 10 minutes 2 – 6 hours
or Midazolam iv B V 0.025 – 30 -60seconds 15 – 80minutes
0.1mg/kg
or midazolam B V 1-15mg/hr 30-60 seconds
• 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 (sedative)
Antihistamine with sedative, antiemetic and anti-cholinergic
properties. Useful for the pre-operative preparation of the asthmatic
patient.
Drug Codes
promethazine B V
Indications:
Premedication one hour before surgery: 25-50mg im
1-5yr = 15-20mg po >5yrs =
6.25-12.5mg im
Severe anaphylaxis during anaesthesia: 50mg (Paed 0.4mg/kg) slow iv.
Trimeprazine tartrate (sedative)

Drug Codes Dose
trimeprazine tartrate B N 2mg/kg 1-2hrs before surgery
Indications
Pre-operative sedation of children
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Cautions
May cause excessive sedation.
May cause hyperactivity postoperatively.
Sodium Citrate (antacid)

Drug 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.
Metoclopramide (antiemetic)
Dopamine antagonist; accelerates gastric emptying.
Duration
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 (antiemetic)
Drug Codes
prochlorperazine B N
Indications:
Prophylaxis (Adult 12.5mg po/im) and treatment of
post-operative
nausea and vomiting (12.5mg po/im 6hourly) (Paed: 0.2mg/kg im).
Cautions
Extrapyramidal symptoms may occur, particularly in children.
Analgesics
See chapter on Pain Management for guidelines on morphine,
pethidine and codeine phosphate.
352
DRUGS USED IN SHOCK

see also chapter on Anaphylaxis
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. CVP monitoring is required.
Adrenaline 1 in 10 000
Add 9ml normal saline / water to 1ml of 1in 1000 adrenaline
Severe anaphylaxis in anaesthesia
Drug Codes Adult dosage
adrenaline 1 in 10 000 C V 1ml slow repeat
until
iv [1-5yr every satisfactory
=0.1 ml/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]
Ephedrine sulphate
This is the drug of choice in obstetrics
Hypotension due to spinal or epidural anaesthesia
ephedrine sulphate iv B E increments of 5 mg iv
If many increments are needed a larger dose may be
given intramuscular or by intravenous infusion.
Hydrocortisone
Peri-operative cover for patients on corticosteroid therapy:
Hydrocortisone B V 100mg with premedication, then
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100mg 6 hourly 24hrs, then

decrease
Severe anaphylaxis during anaesthesia:
hydrocortisone iv B V 200mg 12 hourly as
required
[Paed = 3-
4mg/kg]
Lignocaine hydrochloride [preservative-free]

Cardiac arrest during anaesthesia, with ventricular
fibrillation
persisting after defibrillation:
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:

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
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CHAPTER 31 ANTINEOPLASTIC AGENTS
ANTINEOPLASTIC AGENTS
A wide variety of antineoplastic agents is generally

available. These agents should be used under the
supervision of a specialist in oncology, be it for the
treatment of malignant or other conditions. Chemotherapy
drugs fall into the following classes;
alkylating drugs, cytotoxic antibiotics, antimetabolites, vinca
alkaloids, other drugs.
Chemotherapy can be used in a number of ways. The

criteria for use differ for each tumour type, stage
morphologic and biologic characteristics. Drug combinations
are more commonly used than single agents.
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 drug should be used at maximum dose
4. Each drug should be used at maximum dose.
5. Agents with similar dose – limiting toxicities can be
combined safely only by reducing doses, resulting in
decreased effects.
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6. Drug combination should be administered in shortest

interval between therapy cycles to allow for the
recovery of normal tissue.
GUIDELINES OF HANDLING CHEMOTHERAPY

DRUGS
• The drugs should be reconstituted by trained
personnel.
• Reconstitution should be done in designated
areas, preferably under lamina flow.
• Protective clothing should be worn at all times
whilst reconstituting the drugs. This includes eye
protection.
• Gloves should always be worn when administering
the drugs.
• Pregnant health care workers should not handle
chemotherapy drugs.
• Waste disposal should be meticulously handled. All
contaminated disposables should be incinerated.
ADJUVANT CHEMOTHERAPY
Adjuvant Chemotherapy is use of chemotherapy drugs in
patients who remain at high risk of recurrence after the
primary tumour and all evidence of cancer has been
surgically removed or treated definitely with radiation. These
patients with not be having any evidence of clinical disease.
356
Cancer effectively treated by adjuvant chemotherapy

includes, Wilms tumour, breast cancer, osteosarcoma and
colorectal cancer.
Principles of Adjuvant Chemotherapy

1. Effective chemotherapy must be available
2. Known tumor should be removed by surgery
3. Chemotherapy should be started as soon as possible
postoperatively
4. Chemotherapy should be given in maximally tolerated
doses
5. Chemotherapy should continue for a limited time period
6. Chemotherapy should be intermittent, when possible, to
minimise immunosuppression
NEOADJUVANT CHEMOTHERAPY
Chemotherapy is administered before surgery or
radiotherapy. 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 some tumours. The result
of chemoradiation in these tumours is superior to the use of
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either agent alone or the use of combining chemotherapy

and radiotherapy in any other way. The improved outcome
outweighs the slightly increase incidence of side effects.
Cancers effectively treated by chemoradiation include,
cervical cancer, oesophangeal cancer, nasopharyngeal
cancer and other head and neck cancers
PALLIATIVE CHEMOTHERAPY
Chemotherapy can be used in advanced disease for
palliation where there is no alternative therapy or where
local therapies have failed. Palliative chemotherapy is a very
expensive form of palliation. Complete responses are
achievable in carefully selected patients. 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.
CANCER CURABLE OR OCCASIONALLY

CURABLE WITH CHEMOTHERAPY ALONE
Cancers that are 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)
Cancers occasionally curable with chemotherapy
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Ovarian cancer Small cell

lung cancer
SELECTION OF CHEMOTHERAPY AGENTS

Patients should be assessed adequately prior to prescription
and administration of these drugs or referral to a tertiary
hospital. Consider the following:
PHYSIOLOGIC AGE OF THE PATIENT

Whilst age alone is not a valid criterion for excluding patients
from chemotherapy, age related alterations in organ function
may result in unacceptable toxicity. Treatment decisions
must however take into account the likelihood of benefit .
PERFORMANCE STATUS
Patients with a Karnofsky performance status of 30 percent
or less are not usually candidates for chemotherapy unless
the tumour is previously untreated and especially very likely
to respond.
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
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NUTRITIONAL STATUS
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
Failure to respond to first line therapy lessens the probability
to respond to second line therapy. It is most likely due to the
development of multi drug 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 drugs
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
Requirements for chemotherapy/referral to tertiary level

1. Biopsy – proven, residual or metastatic disease
2. Indicator lesion
360
3. Satisfactory performance score and nutrition

4. Patient capable of informed consent
5. Minimal bone marrow, renal, and hepatic
function (occasionally pulmonary or cardiac function
important)
6. Available monitoring and support functions
Common side effects of chemotherapy Nausea and

vomiting; This is one of the most common side effect. The
different drugs have different emetogenic potential.
Treatment of these side effects is therefore tailored to suit
the emetogenic potential of the drugs used. This has to be
done prophylactically. Nausea and vomiting can be acute,
delayed or anticipatory.
Bone marrow suppression; Most drugs will cause bone
marrow suppression, especially neutropenia. This is worst 7
to10 days after administration of the drug. 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 drugs. It is however reversible.
Extravasation reactions; This is a serious side effect
resulting from the drug 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.
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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 drugs is a possibility for both male and
female patients. Germ cell banking should be considered as
appropriate.
DOSE MODIFICATION
Drug 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
continues to the set number of cycles or two cycles beyond
complete response.
362
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
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REPORTING ADVERSE DRUG

REACTIONS
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 drug 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 thiacetazone, itching due to
chloroquine, etc. Reactions to vaccines specially imported
unregistered drugs, 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 +263-4-736981/5, Fax +263-4-736980, E-mail:
mcaz@africaonline.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:
Forename(s):
Date of Birth: Weight Sex:
Age: kg M/F
Adverse Reaction
Date of onset:
Duration: Less than one hour Hours Weeks
Days Months
Description:
Outcome: Recovered Fatal Unknown

Not yet recovered
Suspected Drug(s)
Drug: Generic Name:
Brand Name:
Condition/indication drug was
givven for:
Daily dose/route:
Date begun:
all other drugs used by patients:
Laboratory test results
Reported by
Family Name:
Forename(s):
Status:
Address:
Signature:
Send this form to: The Director-General Medicines Control Authority in Zimbabwe
106 Baines Avenue, P O Box 10559, Harare Fax:
+263-4-736980, Tel: +263-4-736981/5
E-mail:mcaz@africaonline.co.zw
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Adverse Drug Reaction Report
366
Family Name:
Forename(s):
Age: kg M/F
Adverse Reaction
Date of onset:
Days Months
Description:

Not yet recovered
Suspected Drug(s)
Drug: Generic Name:
Brand Name:
givven for:
Daily dose/route:
Date begun:
Reported by
Family Name:
Forename(s):
Status:
Address:
Signature:
+263-4-736980, Tel: +263-4-736981/5
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368
Family Name:
Forename(s):
Age: kg M/F
Adverse Reaction
Date of onset:
Days Months
Description:

Not yet recovered
Suspected Drug(s)
Drug: Generic Name:
Brand Name:
givven for:
Daily dose/route:
Date begun:
Reported by
Family Name:
Forename(s):
Status:
Address:
Signature:
+263-4-736980, Tel: +263-4-736981/5
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370
Family Name:
Forename(s):
Age: kg M/F
Adverse Reaction
Date of onset:
Days Months
Description:

Not yet recovered
Suspected Drug(s)
Drug: Generic Name:
Brand Name:
givven for:
Daily dose/route:
Date begun:
Reported by
Family Name:
Forename(s):
Status:
Address:
Signature:
+263-4-736980, Tel: +263-4-736981/5
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ANNEX 2 DRUG INTERACTIONS & INCOMPATIBILITIES
DRUG 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.: Harare 790233 or 791631 (ext. 172), or 794411 (ext. 2005)
General notes
When two drugs are administered to a patient they may
either act independently of each other, or interact with each
other. Interaction may increase or decrease the effect of the
drugs concerned, and may cause unexpected toxicity. As
newer and more potent drugs are available to us, the
number of serious drug interactions occurring is likely to
increase.
Remember that interactions may involve non-prescription
drugs and social drugs (such as alcohol, mbanje), plants
and traditional remedies.
Drug interactions can be the result of interference with
another drug’s absorption, displacing the drug from a
plasma protein binding site, having a similar, additive effect,
increasing or decreasing the other drug’s metabolism or
excretion, or interference at receptor sites.
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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: >f> increased / enhanced effect 4> decreased effect
Drug affected Effect Drugs causing effect
ACE inhibitors "f enhanced hypotensive anaesthetics
effect
diuretics
ACE inhibitors 4* decreased hypotensive non-steroidal anti-inflammatory
effect drugs
alpha blockers (prazosin) "f enhanced hypotensive anaesthetics
effect
antidepressants
beta blockers
calcium channel blockers
diuretics
amiloride / spironlactone "f raised potassium levels captopril
aminoglycosides "f ototoxic & nephrotoxic high dose frusemide
effects increased
anticoagulants "f increased risk of bleeding aspirin
anticoagulants 4* increased metabolism carbamazepine
anticoagulants /warfarin "f increased anticoagulant alcohol
effect imidazole antifungals
antidepressants (tricyclics) "f enhanced sedative effect alcohol
other antidepressants
anti-epileptics
anti-epileptics 4* lowered threshold antidepressants (tricyclics)
anti-epileptics 4* inhibited metabolism isoniazid
benzodiazepines "f increased action cimetidine
beta blockers (atenolol/ enhanced hypotensive anaesthetics
propranolol) -f effect
calcium channel blockers 4* reduced effect phenobarbitone
rifampicin
phenytoin
calcium channel blockers "f enhanced effect anaesthetics
calcium channel blockers 4* increased metabolism rifampicin
carbamazepine "f increased action of erythromycin
carbamazepine
isoniazid
cimetidine
carbamazepine 4* reduced anti-epileptic effect chloroquine
CNS depressants "f increased action alcohol
sedative drugs
phenobarbitone
corticosteriods 4* increased metabolism phenobarbitone
digoxin "f enhanced toxicity thiazides
frusemide
quinine
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ANNEX 2 DRUG INTERACTIONS & INCOMPATIBILITIES
Potentially hazardous interactions (contd.)

doxycycline 4* increased metabolism carbamazepine
imidazole antifungals 4* increased metabolism rifampicin
reduced plasma conc. phenytoin
indinavir (antiviral) "f inhibited metabolism imidazole antifungals
indinavir (antiviral) 4* enhanced metabolism rifampicin
ketoconazole 4* reduced absorption antacids
anti-muscarinic drugs
cimetidine
lithium "f increased toxicity diuretics
metronidazole 4* reduced plasma conc. phenytoin
metronidazole antabuse reaction alcohol
neuromuscular blockers "f enhanced effects aminoglycosides
non-steroidal anti-inflammatory increased risk of renal ACE inhibitors
drugs -f damage
oral contraceptives 4* reduced contraceptive rifampicin
effect
‘broad spectrum’ antibiotics
phenobarbitone
carbamazepine
phenytoin
oral hypoglycaemic /insulin "f increased hypoglycaemic alcohol
effect
phenytoin "f enhanced effect imidazole antifungals
phenytoin "f action increased chloramphenicol
cimetidine
cotrimoxazole
isoniazid
metronidazole
sulphonylureas "f (glibenclamide / increased action chloramphenicol
metformin)
cotrimoxazole
fluconazole
miconazole
theophylline "f increased theophylline cimetidine erythromycin
levels
oral contraceptives
calcium channel blockers
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Incompatibilities between Drugs and IV Fluids

This section only intended as a general guide. Many other
incompatibilities exist. Always check for compatibility before adding
any drug to an IV fluid (look at the package insert of the drug, or ask
your local pharmacy department for advice).
Drugs should not be added to blood, amino acid solutions,
or fat emulsions.
Certain drugs, 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).
Drug Effect Solution/ incompatibility
benzylpenicillin lose potency after dextrose solutions – use
6-8hrs (due to acidity) within 1 hour
ampicillin
diazepam effect due to binding plastic containers, tubing –
titrate against response
insulin
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’
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the 5th Essential List for
Zimbabwe
CATEGORISATION OF DRUGS ON
TH
THE 5 ESSENTIAL L IST FOR ZIMBABWE
Drugs used in Anaesthesia

Analgesics and Antipyretics (incl. narcotics & anti-migraine)
Anti-inflammatory Drugs & drugs for Rheumatism and Gout
Antihistamines (anti-allergic drugs)
Antidotes & Substances used in Poisoning Management
Anti-infective Drugs (antibiotics & other anti-microbials)
Drugs affecting the blood & Blood Products/ Substitutes
Cardiovascular Drugs
Central Nervous System Drugs
Dermatological Agents
Gastrointestinal Drugs
Hormones
Immunological agents (incl. vaccines & sera)
Ophthalmological Drugs
Respiratory System Drugs
Drugs Used in Labour & Delivery
Intravenous (& other) Solutions
Vitamins & Minerals
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Drug name Form Level VEN

1. Drugs used in Anaesthesia
alcuronium chloride Inj B V
bupivacaine hydrochloride Inj A E
etomidate Inj B N
halothane Gas B V
ketamine Inj B V
lignocaine + adrenaline Inj B E
lignocaine hydrochloride Inj C V
lignocaine no preserv 2% Inj B N
neostigmine bromide Inj B V
nitrous oxide Gas B V
Oxygen Gas C V
pancuronium bromide Inj A N
Propofol Inj A V
soda lime - B V
suxamethonium chloride Inj B V
thiopentone sodium Inj B V
trimeprazine tartrate Po B N
2. Analgesics, Antipyretics, Narcotics, Anti-migraine
Aspirin Po C V
codeine Po B V
ergotamine Po A N
morphine Inj B E
morphine Po B V
paracetamol Po C V
paracetamol Syr C V
pethidine Inj B V
3. Anti-inflammatory, Rheumatism, Gout
allopurinol Po B E
colchicine Po A N
ibuprofen Po A E
indomethacin Po B E
diclofenac B E
4. Antihistamines
chlorpheniramine Po C E
promethazine Po B N
5. Antidotes, Poisoning
acetylcysteine Inj A E
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Zimbabwe
Drug name Form Level V

Atropine Inj B V
Charcoal activated Po B E
ipecacuanha syrup USP Po B N
naloxone neonatal 20mcg/ml Inj B V
Pralidoxime scorpion Inj A N
antivenom snake antivenom Inj B N
polyvalent Inj B E
6. Anti-infectives, Antibiotics, antivirals
acyclovir
Po B E
albendazole
Po C E
amoxycillin
Po C V
amoxycillin
susp C E
ampicillin
Inj B E
benzathine penicillin
Inj C V
benzyl benzoate
Top B N
benzylpenicillin
Inj C V
chloramphenicol
Inj B V
chloramphenicol
Po B V
chloramphenicol
susp B E
chloroquine
Po C V
ciprofloxacin
Po B V
clindamycin
Po B V
clindamycin
Inj B N
clofazimine
clotrimazole pess po A N
clotrimazole cream 1% vag B E
cloxacillin top B E
inj B V
cloxacillin
cloxacillin po B V
cotrimoxazole susp B E
cotrimoxazole po C V
paed C V
cotrimoxazole
dapsone susp C V
doxycycline po B V
erythromycin po C V
erythromycin po C V
ethambutol susp C V
fluconazole po B V
gentamicin po B V
gentian violet inj B V
griseofulvin top C V
po B N
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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
6. Anti-infectives (contd.)
miconazole oral gel po C V
Nalidixic acid po B V
neomycin po A N
nitrofurantoin po B N
norfloxacin po C V
Ny statin 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 paed B E
streptomycin inj B V
Selenium sulphide 2%
sulphadoxine + pyrimethamine po B E
7. Drugs 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
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Zimbabwe

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 Drugs
amiloride po A N
atenolol po B V
Captopril po B E
digoxin po B V
digoxin inj B E
ephedrine inj A N
enalapril po B V
8. Cardiovascular Drugs (contd.)
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 V
magnesium sulphate inj B V
methyldopa po B E
nifedipine sr po B V
potassium chloride po B V
potassium chloride inj B V
prazosin po B E
propranolol po B E
spironolactone po A N
Verapamil inj A N
verapamil po A N
9. Central Nervous System Drugs
Amitriptylline po B E
Benzhexol po B E
Biperiden inj A N
Carbamazepine po B E
carbidopa-levodopa po A N
Chlorpromazine po C V
Chlorpromazine inj C V
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Diazepam po B E
Diazepam inj C V
fluphenazine deconoate inj B V
Haloperidol po A N
Haloperidol inj A N
Imipramine po A E
Midazolam inj A E
paraldehyde (deep) inj A N
Phenobarbitone inj B E
Phenobarbitone po C V
phenytoin sodium po B V
phenytoin sodium inj A E
sodium valproate po A N
Trifluoperazine po A E
10. Dermatological Agents
aqueous cream top B N
benzoyl peroxide 5% gel top A N
calamine lotion top C N
coal tar 5% ointment top B N
compound benzoic acid ointment top C E
10. Dermatological Agents (contd.)
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 Drugs
Bisacodyl po C N
bismuth subgallate with 1% pr B N
hydrocortisone
Cimetidine po B N
glycerine suppositories pr C N
hyoscine butylbromide po B N
liquid paraffin po B N
magnesium trisilicate po C N
Metoclopramide po B V
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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 E
Dexamethasone po B N
dinoprost (PG F2 alpha) inj A E
dinoprostone (PG E2) po A E
dinoprostone (PG E2) vag A E
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
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 N
14. Ophthalmic Drugs
Acetazolamide po A N
pilocarpine eye drops eye B V
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tetracycline eye ointment 1% eye C V
15. Respiratory System Drugs
Adrenaline Inj C V
Aminophylline Inj B V
beclomethasone inhaler Inh B E
beclomethasone nasal spray Spray A N
Salbutamol po B V
salbutamol inhaler inh B E
salbutamol nebulised neb B V
theophylline po C E
16. Drugs 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
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 N
Thiamine inj A N
vitamin A po C V
vitamin D po B V
Vitamins, multi po C E
Vitamins, multi paed B E
384
Specialist Essential Drug List In
Zimbabwe
SPECIALIST ESSENTIAL DRUG LIST

IN ZIMBABWE
Drug Dosage form Strength VEN
1
Drugs Used in
Anaesthesia
1.1 General Anaesthetics/Medical Gases
Isoflurane Gas E
Sevoflurane Gas E
1.2 Local Anaesthetics
Amethocaine Gel 4% N
Ropivacaine Injection 2mg/ml N
1.3 Muscle Relaxants
Atracurium Injection 10mg/ml N
Vecuronium injection 10mg/vial N
1.4 Peri-operative drugs (a) 2
2.1 Narcotic Analgesics
fentanyl Injection 50mcg/ml N

Alfentanil injection 500mcg/ml N
2.2 Nonsteroidal Anti-inflammatory Drugs
(NSAID)
Diclofenac Injection 25mg/ml N
diclofenac sodium tablet SR 75mg N
Indomethacin Suppository 100mg N
2.3 Disease Modifying Antirheumatic Drugs
Methotrexate Tablet 2.5mg N

sulphasalazine Tablet 500mg N
tablet
3 Antihistamines
Cetirizine 10mg N
385
EDLIZ 2006
4 ANTIDOTES AND SUBSTANCES FOR TREATMENT OF

POISONING
Edrophonium injection 10mg/ml V

Flumazenil injection 0.1mg/ml V
5
Antiinfective drugs
5.1 Antibacterial Drugs
Ceftazidime injection 500mg
ceftriaxone injection 1g V
ciprofloxacin injection 10mg/ml V
5.2 Antitubercular Drugs
Cycloserine tablet 250mg E
Ethionamide tablet 250mg E
5.3 Antipneumocystis and
antitoxoplasmosis drugs
Pyrimethamine lhadiazine tablet 25mg E
Sulphadiazine tablet 500mg E
5.4 Systemic Antifungal
Drugs
amphotericin B injection 50mg E
Fluconazole injection N
5.5 Systemic Antiviral Drugs
acyclovir Injection 250mg E
6 Antimigraine Drugs
Dihydroergotamine Injection 1mg/ml N

mesylate
Sumatriptan Tablet 50 mg N
7 ANTINEOPLASTIC AND
IMMUNOSUPPRESIVE DRUGS 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
386
Zimbabwe
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
7.2 Complementary Drugs
aminoglutethimide Tablet 250mg
Filgrastim Injection 30million
units
folinic acid tablet 15mg
folinic acid Injection 3mg/ml
medroxyprogesterone tablet 100mg
acetate
medroxyprogesterone Injection 50mg/ml
acetate
Mesna Injection 100mg/ml
Tamoxifen Tablet 10mg
387
EDLIZ 2006
8 DRUGS AFFECTING THE

BLOOD
8.1 Anticoagulants and
fibrinolytics
Streptokinase Injection 250 000 IU
E
8.2 Antifibrinolytic and Antihaemostatic
Drugs
tranexamic acid tablet 500mg
N
9 BLOOD PRODUCTS/BLOOD SUBSTITUTES
9.1 Plasma Substitutes (a)
infusion 6% in
dextran "70" N
glucose 5% or in
dextran "70" sodium chloride N 0.9%
9.2 Anti-anaemic drug Injection 4000units/

epoetin alfa and beta N ml
10 CARDIOVASCULAR DRUGS
10.1 Antianginal Drugs
glyceryl trinitrate injection 1 mg/ml V
10.2 Antiarrythmic Drugs
injection 3mg/ml N
Adenosine
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 Drugs
infusion 10mg/ml N
sodium nitroprusside Minoxidil
Amlodipine Labetolol tablet 10 mg N
10.4 Diuretics tablet 5mg E
infusion 1mg/ml N
10.5 Drugs used in Shock or
Anaphylaxis (c)
Dobutamine injection 12.5mg/ml
V
388
Zimbabwe
Dopamine injection 40mg/ml

Noradrenaline injection V 2mg/ml
10.6 Sclerosing Agents V
ethanolamine oleate injection
11
CENTRAL NERVOUS SYSTEM DRUGS 11.1
Anticonvulsants
Sodium valproate tablet 200mg N
Sodium valproate suspension 40mg/ml N
Clobazam tablets 10mg N
Clonazepam tablet 500ugm N
Lamotrigine tablet 5, 25mg N
11.2 Psychotherapeutic Drugs
Fluoxetine tablet 20mg N

Olanzapine tablet 5, 10mg N
Methylphenidate tablet 10mg N
11.3 Antiparkinsonian Drugs
L-dopa tablet 100/25 N
Orphenadrine tablet 50mg N
11.4 Drugs 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)
389
EDLIZ 2006
13
DIAGNOSTIC AGENTS
Tetracosactrin Methylene blue injection 250ug/ml
Radiocontrast media N
injection 10mg/ml
Iohexol
Injection “Omnipaque N
300”(or Ultravist)
lohexol 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
14
GASTROINTESTINAL
DRUGS
14.1 Antiemetics
tablets 4mg E
Ondansetron
14.2 Gastric/Peptic Ulcer Drugs
14.3 Anti-inflammatory Drugs Enema 20mg/100 N ml

Prednisolone
14.4 Antidiarrhoeal Drugs

15
HORMONES
tablet
15.1 Corticosteroids 100 N
Fludrocortisone
micrograms
Testosterone cream 1% N
methylprednisolone Injection 500mg E
15.2 Androgens
tablets 5mg N
methyltestosterone
Injection 25mg/ml N
testosterone
390
Zimbabwe
testosterone Injection SR N
15.3 Oestrogens and
Progestogens
stilboestrol (a) tablet 1mg N
oestrogens, conjugated tablet 0.625 mg
oestrogens, conjugated vaginal cream N
16 N
OPHTHALMOLOGICAL
DRUGS
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/Antiallergi
cs
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 HCI 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
3
91
EDLIZ 2006
Gentamicin ear drops 0.30%

N
18
AGENTS CORRECTING WATER AND ELECTROLYTE
DISTURBANCES
18.1 Parenteral
magnesium sulphate Injection 0.6mg/ml V
18.2 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
18.3
Intraperitoneal dialysis Solution with 1.5%dextrose V
Intraperitoneal dialysis Solution with 4.5% dextrose V
Haemodialysis cone. Solution E
19
ANTIRETROVIRAL
DRUGS
19.1 Nucleoside Reverse Transcriptase Inhibitors
Zidovudine tab300mg N
Zidovudine solution 50mg/5ml
Zidovudine injection 10mg/ml E
Lamivudine tab150mg
Lamivudine solution 50mg/5ml N
Didanosine tab200mg
Didanosine Powder 100mg N
packets
Stavudine tab N
30/40mg
Stavudine powder 5mg/ml E
Abacavir tab
300mg N
Abacavir solution 100mg/5ml
Stavudine/Lamivudine/Nevir tab 30/150/200mg
apine
392
Zimbabwe
Stavudine/Lamivudine/Nevir tab 40/150/200mg

apine V
Stavudine/Lamivudine
tab 30/150mg V
Stavudine/Lamivudine
tab 40/150mg V
Zidovudine/lamivudine
tab 300/150mg V
19.2
Non-nucleoside reverse
Transcriptase Inhibitors
Nevirapine
Nevirapine tab 200mg V
suspension 50mg/ml V
Efavirenz
Efavirenz tab 200mg E
Nelfinavir suspension 150mg/5ml E
19.3 Protease Inhibitors tab 250mg N
Nelfinavir Indinavir
Saquinavir suspensio 50mg/ml N
Ritonavir Ritonavir n
tab 400mg N
Lopinavir/ritonavir capsule 200mg N
capsule 100mg N
Lopinavir/ritonavir solution 400mg/ml N
capsule 133.3mg/33.3m E
g 400mg/1
solution E
OOmg/
5ml
393
EDLIZ 2006
INDEX
INDEX BY MEDICINE NAME 395
INDEX BY CONDITION 404
394
Index by Medicine Name by Medicine Name
INDEX BY MEDICINE NAME
A
Acetazolamide 380 395
acetylcysteine 335 375
acyclovir 15;114;115;376 385
Adrenaline 28;33;62;349;354 380
albendazole 58;138;139 376
alcuronium chloride 350 375
allopurinol 204;208;209;244 375
amiloride 195;204;371 377
Aminophylline 33;62 380
Amitriptylline 378
Amoxacillin
7;19;22;38;45;57;61;75;77;112;158;159;169;187;257;303;
376
Amoxicillin 15;33;62;74;156;263;267;268;269
ampicillin 7;19;21;76;79;169;170;193;198;373;376
Anti-tetanus booster 285;288
aqueous cream 278;378
aspirin
7;90;141;142;170;180;181;186;203;208;209;210;211;212;
222;236;237;242;292;295;303;305;371
atenolol 173;174;175;179;180;181;183;204;371;377
atropine 182;253;337;338;339;343;347;350;351
BCG 59;65;66;67;68;126;127;128;140;380
B beclomethasone inhaler
162;163;166;
380
beclomethasone nasal spray 380
benzathine penicillin 74;102;103;104;170;171;303;376
Benzhexol 378
benzoyl peroxide 5% gel 378
benzyl benzoate 106;376
395
EDLIZ 2006
benzylpenicillin
22;29;30;35;37;38;43;45;57;61;76;77;112;135;157;158;15
9;168;233;234;286;289;373;376
Biperiden 378
Bisacodyl 379
bismuth subgallate with 1% hydrocortisone 194;379
bupivacaine hydrochloride 349;375
c
calamine lotion 276;378
calcium chloride 10% 380
calcium gluconate 10% 380
captopril 177;178;181;204;371
Carbamazepine 295;308;378
carbidopa-levodopa 378
Carbimazole 89;90;230;379
chloramphenicol
21;22;23;25;30;42;76;77;87;110;139;158;204;234;290;37
2;373;376
chloroquine
7;15;146;147;148;149;210;211;304;334;365;371;376
chlorpheniramine 77;90;115;277;279;375
Chlorpromazine 62;378
Cimetidine 16;62;288;308;379
ciprofloxacin 23;94;95;102;103;235;376;384
clindamycin 157;158;169;170;207;235;376
clofazimine 141;143;376
clotrimazole cream 1% 376
clotrimazole pess 376
cloxacillin
21;30;42;158;159;168;169;207;271;272;273;376
coal tar 5% ointment 378
codeine
111;191;203;236;244;285;293;295;296;297;303;305;341;
353;375
colchicine 208;209;375
combined oral contraceptive pill 73;88;379
compound benzoic acid ointment 378
396
cotrimoxazole
20;23;37;38;45;54;57;60;61;109;113;115;118;157;190;20
4;372;376
cryoprecipitate 306;307;316;377
D
dapsone 140;141;147;303;304;376
Darrows with dextrose 324;380
Dexamethasone 33;379;395
dextrose 10% 29;154;194;380
dextrose 5%
82;88;164;181;199;223;224;319;326;332;333;334;335;33
9;380
dextrose 50% 154;223;240;241;335;380
Diazepam 33;63;89;90;240;351;378
diclofenac 208;209;375;383
digoxin 8;177;178;181;183;204;299;371;377
dinoprost (PG F2 alpha) 379
dinoprostone (PG E2) 379
doxycycline
75;88;93;95;102;103;104;112;135;139;152;154;159;187;1
94;204;273;372;376
DPT 65;66;67;68;380
DPT+HBV 380
DT 65;66;67;68;380
E
emulsifying ointment 278;379
enalapril 174;177;178;204;377
ephedrine 349;354;377
Ergometrine 85;380
ergotamine 237;375
erythromycin
44;74;75;95;102;103;104;106;158;170;171;190;257;271;2
86;371;372;376
ethambutol 128;129;203;376
etomidate 346;375
397
EDLIZ 2006
F
factor IX conc. 377
factor VIII con. 377
ferrous sulphate 32;56;58;78;302;377
fluconazole 15;372;376
fluphenazine deconoate 378
folic acid 32;53;56;58;78;91;302;303;377
frusemide
8;154;178;196;201;202;204;311;333;371;378
G
gamma benzene hexachloride 1% 106;379
gentamicin
20;21;29;30;57;76;90;158;159;168;169;170;193;198;199;
204;289;373;376
gentian violet 46;114;376
Glibenclamide 216;379
glycerine suppositories 379
glyceryl trinitrate 180;378;389
griseofulvin 274;275;376
H
Haloperidol 378
halothane 164;348;375
HB 65;66;67;68;154;380
heparin 178;180;203;307;309;310;325;340;373
79;91;
Hexoprenaline 380
hydralazine 81;82;378
hydrochlorothiazide 242;378
Hydrocortisone 34;63;354;379
hyoscine e
butylbromid 192;379
398
I
ibuprofen 208;209;210;212;292;295;300;375
Imipramine 250;378
indomethacin 114;203;208;209;210;211;212;295;375
Insulin 82;214;215;222;225;227;379
iodine solution 230;379
ipecacuanha syrup USP 375
isoniazid 8;126;128;130;203;244;371;372;376
isosorbide 180;181;378
K
kanamycin
20;37;45;57;61;75;90;91;93;94;95;103;106;257;376
ketamine 347;375
ketoconazole 372:376
L
levonorgestrel implant 73;379
lignocaine + adrenaline 375
lignocaine hydrochloride 375
lignocaine no preserv 2% 375
liquid paraffin 193;379
lisinopril 378
M
magnesium sulphate 82;378;396
magnesium trisilicate 83;186;187;192;194;209;288;300;379
Maintelyte 322;324;380
Measles 65;66;67;68;144;380
medroxyprogesterone acetate 73;379;387
Metformin 223;379
methyldopa 72;80;81;204;378
Metoclopramide 189;353;379
399
EDLIZ 2006
metronidazole
22;30;53;57;74;75;76;77;87;94;95;110;158;159;191;192;1
93;204;372;376
Miconazole cream 2% 274;376
miconazole oral gel 377
Miconazole pess 376
Midazolam 352;378
Misoprostol 86;380
morphine
178;181;192;293;294;295;296;297;305;341;353;375
N
nalidixic acid 15;53;204
naloxone neonatal 20mcg/ml 28;375
neomycin 194;277;377;394;395
Neonatalyte 324;380
neostigmine bromide 351;375
Nicotinamide 381
nifedipine sr 378
nitrofurantoin 198;204;304;377
nitrous oxide 348;375
norethisterone enanthate 379
norfloxacin 75;93;95;103;198;377
nystatin 46;97
O
Omeprazole 186;187;188;379
OPV 66;67;68;380
oxygen
30;159;163;165;178;240;241;282;297;325;333;337;338;3
45;348
Oxygen 282
Oxytocin 76;79;85;380
400
P
pancuronium bromide 350;375
para aminobenzoic acid 379
paracetamol
7;39;40;45;46;61;203;208;209;210;236;241;257;285;292;
296;305;334;335;375
paraldehyde (deep) 378
pethidine 28;83;203;286;294;341;353;375
Phenobarbitone 34;64;89;90;378
phenytoin sodium 240;378
pilocarpine eye drops 254;380
plasma
18;173;174;194;195;243;298;306;307;309;320;323;335;3
70;372
platelet conc 307;377
podophyllin paint 105;379
potassium chloride 54;58;178;194;224;225;227;259;373;378
potassium permanganate 271;274;278;379
povidone iodine 114;264;288;290;379
Pralidoxime 337;375
praziquantel 137;138;235;377
prazosin 80;81;174;371;378
Prednisolone 42;64;91;157;231;379;393
primaquine 157;304;377
procaine penicillin 35;38;46;61;104;135
Prochlorperazine 353;379
progesterone only pill 379
proguanil 147;377
promethazine
77;83;90;115;278;279;296;326;352;375
propofol 347
propranolol
173;204;229;230;237;245;371;378
pyrazinamide 115;128;133;203;377
Pyridoxine 15;381
pyrimethamine + dapsone 377
401
Q
quinine 146;149;150;152;153;154;204;304;371;377
quinine infusion 153;377
EDLIZ 2006
R
rabies immunoglobulin 136;380
rabies vaccine 136;380
Raniditine 379
red cell conc. 377
rifampicin 23;72;122;128;130;133;140;141;235;371;372;377
ringer lactate 319;380
s
Salbutamol 64;161;380
salbutamol inhaler ;162;163;164;165;166;38
salbutamol nebulised 42;159;163;164;200;380
scorpion antivenom 376
Selenium sulphide 2% 377
silver sulphadiazine 288;290;379
snake antivenom polyvalent 376
soda lime 348;375
sodium bicarbonate 4.2% 380
sodium bicarbonate 8.4% 380
sodium chloride
52;54;76;81;85;86;87;181;199;224;227;319;323;329;339;
380;388
sodium citrate 83;353;380
sodium valproate 240;378
spironolactone 195;204;378
streptokinase 181;310;377
streptomycin
20;90;91;115;128;129;132;133;139;203;377
sulphadoxine + pyrimethamine 377
sulphur 5% - 10% ointment 379
suxamethonium chloride 241;350;375
T
tetanus immunoglobin 380
tetanus toxoid 67;257;285;288;342;380
tetracycline eye ointment 1% 380
402
theophylline 8;161;162;163;165;166;372;380
thiamine 112;195;251;335;336
Thiamine 381
thiopentone sodium 241;346;375
Thyroxine 34;64;379
Trifluoperazine 248;378
trimeprazine tartrate 352;375
tuberculin, purified 127;380
V
verapamil 175;182;183;378
Verapamil 378;389
vitamin A 53;56;58;254;381
vitamin B12 (hydroxocobalamin)
vitamin D 32;381
vitamin K 26;90;194;195;307;308;309;314;377
vitamins, multi 112
w
warfarin 79;183;243;308;309;310;314;337;371
Z
zinc oxide ointment 279;379
403
EDLIZ 2006
INDEX BY CONDITION
A
Abortion 87
Acne 273
acute arthritis 170
Acute pulmonary oedema 154;178
Acutedelusionalstates
delirium 241
AIDS
see under HIV
14;107;108;109;110;113;116;118;157;262;304
AIDS dementia complex 107;113
albinism 270;280
Allergy
cotrimoxazole
20;23;38;45;54;57;60;61;109;113;115;118;157;190;204
;372;376 morphine
178;181;192;293;294;295;296;297;305;341;353;375
penicillin
20;30;31;35;38;43;46;61;64;74;102;103;104;112;135;1
58;169;170;171;202;278;279;289;303;365;376;377
Anaemia
blood transfusion 302;304;325
folate deficiency 303
liver disease 73;302;314;315
Anaesthesia
epidural 349;354
generalanaesthesia 88;169;345;346;347;352
generalprinciples 313
inhalational 348
musclerelaxants 349
shock 283;287;289;323;338;342;354;355
spinalanaesthesia 349
Analgesia
45;88;90;114;208;266;267;285;292;295;303;305;342;345;
346;347;348;349
Anaphylaxis 20;325;343;352;354;355;365
404
INDEX by Condition
Antimicrobials
cotrimoxazole allergy 20;23;109
Penicillinallergy 20;102;103;104;112;158;169;170;171
surgicalprophylaxis 18
topicalantiseptics 19
Anti-tetanus
booster 285;288
Asthma
asthmascore 161
inhalers 160
inhalertechnique 162;163
managementguidelines 60;109;112
nocturnal 309
spacerdevice 160
Atrial fibrillation 182;183;242;299;309
Atrial flutter 183
B
back/neck
pain 206;208
BCG vaccination 67;126
Birth asphyxia 28
Blood products
Cryoprecipitate 306;307;316;377
Boils
see skin folliculitis 271
Bowel washout 194
burncream
see silversulphadiazine/povid Dneiodin 288;290
Burns e
body surface area children Lund & Browder 282;283
chemical burn 285
dressing 288;347
Lund & Browder chart 282
nutrition 39;109;111 ;117;199;36
physiotherapy 159;236;242;290
special regions 285
405
EDLIZ 2006
c
caesareansection
infection 77;83;85
prophylaxis
15;18;22;23;78;88;107;109;119;126;146;147;148;171;1
90;237;262;263;303;309;365
candidiasis
sexually transmitted disease 15;46;59;60;95;260;261
vaginal discharge 95;96;97
cardiac failure
resistant 18;19;93;130;131;176;178;192;279;315
chemical burn 285
chest indrawing 36;39;40;41;42
chlamydia
urethral discharge men 75;93
cholera 16;49;53;54;190
condoms 71;72;93
conjunctivitis
table differential diagnosis 106;256
constipation 43;192;194;296;297;331
contraception
barrier 70;348
condoms 71;72;93
drug interactions 239;308;370
failure rate 71
levonorgestrel implant 73;379
oestrogen 71;73
progestogen 71
rape 87;88
convulsions
lumbar puncture 32;154;233;234
corneal ulcer 253
cotrimoxazole allergy 20;23;109
cotrimoxazole prophylaxis 38;45;60;118;157
croup
cyanosis 43;157
406
INDEX by Condition
D
death 152;189;325
delirium 241
depression 73;82;292;337;338;347
diabetes mellitus
coma
eyes
foot care 222
hyperglycaemia 175;322
insulin dependent 175;221;223;226
non-insulin dependent 223
oral anti-diabetic agents 214
rule of thirds 228
sliding scale 82;223;225
dialysis 199;200;202;204;205;397
diarrhoea
antibiotics in 53
bloody 110;111;185;189
cholera 16;49;53;54;190
chronic 192
gastro-enteritis 151;189
giardiasis 63
irritable bowel syndrome 188
persistent 48;53;57;59;60;191
shigella 15
difficult breathing 36
disseminated intravascular coagulation 314
DOTS 125;129;130;131;132
duodenal ulcer 185;188
dysentery 15;53
E
eclampsia 80;81;176
eczema 60;277;278
elderly
corticosteroids 141;142;278
digoxin 8;177;178;181;183;204;299;371;377
diuretics 175;194;195;208;298;371;372
407
EDLIZ 2006
non-steroidal anti-inflammatory drugs

172;325;371;372
oral hypoglycaemics 16;82
sedatives
72;194;297;352
tranquillisers 299
embolism
pulmonary
endocarditis 19;23;168;169;177
native valve
prosthetic valve
epilepsy
tertiary care 233;243;245
essential tremor 244
ethanol 194;335;341
eye
bacterial conjunctivitis 256
chemical burn 285
conjunctivitis 106;256
corneal ulcer 253
foreign body 43;47;257
trachoma 253;256
uveitis 255
408
facial
nerve
palsy 113
fast
breathin
g 36;40;41;42;43
folate
deficien
cy 303
G
gastric
lavage 329;330;332;334;335;336;337;338
gastro-e
nteritis 151;189
gastroin
testinal
conditio
ns 53
general
anaesth
esia 88;169;345;346;347;352
general
danger
signs 35
gestatio
nal age 25;62
giardias
is 63
goitre 70;229;230
gonorrh
oea
INDEX by Condition

growth faltering 55
growth monitoring 55
H
haemophilia A 316
factor VIII deficiency 305
haemophilia B 314;316
haemorrhagic disease 26
haemorrhagic shock 321
headache
general notes 337
tension 85;236
headache:
70;113;135;139;153;174;232;233;236;237;238;267;268;2
99;333
helminthiasis
cysticercosis 235
roundworm 137
hepato-splenomegaly 59
herpes simplex 15;97;98;263;277
herpes zoster 15
high dose cotrimoxazole 37;60
HIV
candidiasis 15;46;59;60;95;260;261
cotrimoxazole prophylaxis 38;45;60;118;157
headache
70;113;135;139;153;174;232;233;236;237;238;267;268
;299;333
herpes zoster 15
palliative care 297
peripheral neuropathy 113;120;244
respiratory conditions 112
skin conditions 114
stroke 113;176;240;242
thrush
46;97;110;260;261;297
vertical transmission 85
HIV in children
eczema 60;277;278
409
EDLIZ 2006
high dose cotrimoxazole 37;60

pneumonia
15;19;36;37;38;39;40;41;49;59;60;112;156;158;234;24
1;290;322;338
prophylactic cotrimoxazole 113
hyperglycaemia 175;322
hyperkalaemia 200
ACE inhibitors 173;174;176;177;178;179;371;372
calcium channel blockers 371;372
in black people 167;176
in diabetics 167;175
in elderly 175;224;308;352
resistant 18;19;93;130;131;176;178;192;279;315
thiazides 204;371
hyperthyroidism 229
hypoglycaemia
31;90;153;154;175;215;216;238;333;335;343
hypothyroidism 89;230;302;304
hysterectomy 86
I
immunisation
in HIV
measles
measles epidemic
poliomyelitis
primary course
rabies
tetanus 30;67;257;285;2
tuberculosis
19;60;112;124;125;126;131;143;156;158
impetigo 271;276;278
inhaler technique 162;163
intestinal amoebiasis 53;63
intravenous fluid replacement
haemorrhagic shock 321
septic shock 354
intravenous solutions
colloids 323
crystalloids 311
410
INDEX by Condition
involuntary movement
essential tremor
Parkinsonism
irritable bowel syndrome 188
K
kwashiorkor 55;58
L
labor
augmentation
cardiac patients
prostaglandin
rupture of membranes
uterine rupture
uterine stimulation after
lactation 70;89;106;247
lactose intolerance 57;188
leprosy
multibacillary 140;141
liver disease
bleeding tendency 194
bowel washout 194
ethanol aetiology 194
low birth weight 28
lumbar puncture
32;154;233;234
Lund & Browder chart 282
lung abscess 43;158
lymphadenopathy 59;126;261
malabsorption syndromes
lactose intolerance
M 57;
188
pernicious anaemia 303
411
EDLIZ 2006
malaria
severe/complicated 150;151;153
sickle cell anaemia 146;147
splenectomy 146;147;308
treatment failure 129;131 ;148;151;21
uncomplicated 149
mania 247;335
Mantoux test 127;128
marasmic-kwashiorkor 58
measles
epidemic 68
meningitis
14;28;35;60;62;107;113;117;129;130;144;151;154;233;23
4;241;267
meningococcal meningitis 23;235
methanol 341
molluscum contagiosum 105;114
mood disorder (affective)
depression 73;82;292;337;338;347
mania 247;335
myocardial infarction
complications
30;46;97;112;127;130;175;208;211;222;242;250;300
thrombolytic agents 181
N
nasal discharge 47
neonatal conditions
fluids
29;35;38;39;46;48;50;51;52;54;56;59;76;188;190;191;1
99;287;318;320;329;335;373
gestational age 25;62
muscle spasms 30
pethidine 28;83;203;286;294;341;353;375
respiratory depression
28;83;90;240;293;333;336;352
resuscitation 79;282;285;323;345
special care 28;285
neonates
convulsions 35;81;82;241;332;333;334;336;338;339
412
INDEX by Condition
drug dosages 146

haemorrhagic disease 26
intravenous fluids 29;30;77;165;304;318;319;333
jaundice 31;314;315
low birth weight 28
lumbar puncture 32;154;233;234
meningitis
14;28;35;60;62;107;113;117;129;130;144;151;154;233;
234;241;267
nasogastric feeding 29
oral fluids 29;188;318
sepsis 25;29;30;35;75;199
tetanus 30;67;257;285;288;342;350;380
nervous system infections
toxoplasmosis 235
neurological conditions 113
O
opiates 193;195;236;244;303;341
oral rehydration solution 51;57
oral rehydration therapy 50;51;52
Oxygen 282
oxytocic
uterine stimulation 85
P
packed cells 154;311;312;313
paediatric conditions
anaemia
55;56;60;78;79;87;117;152;154;177;192;285;301;302;3
04;311;314
antibiotics in diarrhoea 53
candidiasis 15;46;59;60;95;260;261
chest indrawing 36;39;40;41;42
cholera 16;49;53;54;190
clubbing 59
413
EDLIZ 2006
cold
31;36;39;40;41;54;65;155;156;172;176;256;278;331;33
7
cough 36;39;40;41;43;65;139;156;161;174;269;330
diarrhoea
16;35;48;49;50;53;54;57;59;60;110;111;188;189;190;1
94;199;279;300;318;322
difficult breathing 36
drug doses
2
dysentery 15;53
electrolytes 111;199;200;202;224;289;322;338;396
fast breathing 36;40;41;42;43
foreign body 43;47;257
general danger signs 35
growth faltering 55
growth monitoring 55
hepato-splenomegaly 59
hypoglycaemia
31;90;153;154;175;215;216;238;333;335;343
intestinal amoebiasis 53;63
lung abscess 43;158
lymphadenopathy 59;126;261
nasal discharge 47
oral rehydration solution 51;57
oral rehydration therapy 50;51;52
oral thrush 110
pneumonia
15;19;36;37;38;39;40;41;49;59;60;112;156;158;234;24
1;290;322;338
respiratory rate 39
rheumatic fever 46;171
sore throat 36;46;230;269
stridor 36;42;43
tonsils 46
vitamins 112;289
wheeze 36;40;43;165;166
pain
general principles 313
palliative care 297
Parkinsonism 244;245;249
pelvic abscess 76
penicillin allergy
20;102;103;104;112;158;169;170;171
414
INDEX by Condition
peptic ulcer 180;186;209;292

peripheral neuropathy 113;120;244
peritonitis 312
pernicious anaemia 303
phototherapy 31
PID 69;75
plague 139
poisoning
activated charcoal 329;330;331;332;334;336;343
alcohol 341;370;371;372
antidepressants 250;329;332;371
arsenic compounds 339
aspirin 371
atropine 337;338;339;343;347;350;351
bleach 329;340
chloroquine 334;365;371;376
copper 74;282;339
ethanol 194;335;341
first aid 331
gastric lavage 329;330;332;334;335;336;337;338
general treatment measures
heparin 325;340;373
hypochlorite solution 340
induce vomiting 329;331;336
insecticides 336;338
iron 302;304;325;340;396
lavage 330;332;340
laxatives 193;194;294;297
lead 338;340
mercury 340
methanol 341
paraffin 336;379
paraquat 338
pethidine 341;353;375
petroleum products 336
phenothiazines 72;341
prevention 328;362
salicylate 332
poliomyelitis 59;144
pregnancy
antacids 83;288;372
cardiac disease 78;87
415
EDLIZ 2006
convulsions 35;81;82;241;332;333;334;336;338;339
diabetes
16;82;87;143;180;193;214;215;221;222;223;226;244;2
61;285;299;322;361
eclampsia 80;81;176
proteinuria 80;200;202
syphilis
termination 31;97;98;103;104;109;203;234
76;87
urinary tract infection 77;80;81;242
pregnancy-induced hypertension 79;81
progesterone 79;379
prophylactic cotrimoxazole 113
prophylaxis
hysterectomy 86
meningococcal meningitis 23;235
prostatectomy 22;312
surgical
18;70;73;105;158;193;231;266;271;309;312;323;345;3
46
prostatectomy 22;312
pyrexia 75;156
R
rabies
abbreviated multi-site regimen 65;136;380
pre-exposure immunisation 135
prevention
109;124;126;146;222;242;256;328;362
reflux oesophagitis 187
renal failure
acute 198;199;200;322
anaemia
55;56;60;78;79;87;117;152;154;177;192;285;301;302;3
04;311;314
established 22;108;138;154;286;297
hyperkalaemia 200
respiratory conditions 112

lung abscess 43;158
416
INDEX by Condition
respiratory distress syndrome

rheumatic fever
acute attack 160;161;164;170;208
carditis
chorea
rheumatoid arthritis 210

rheumatological conditions
rheumatoid arthritis 210
s
scrotal trauma 103
sexually transmitted disease
first line therapy
re-infection
second line therapy
shock 283;287;289;323;338;342;354;355
shortness of breath 70;72;177;297
sickle cell anaemia 146;147

skin
albinism 280
eczema 60;277;278
erysipelas 272
herpes simplex 15;97;98;263;277
herpes zoster 15
impetigo 271;276;278
urticaria 278
vitiligo 280
warts 92;105;280
skin conditions 114
sore throat 36;46;230;269
spacer device 160
spinal anaesthesia 349
splenectomy 146;147;308
STD 88;257
stridor 36;42;43
stroke 113;176;240;242
supraventricular tachycardia 183
417
EDLIZ 2006
T
TB
see tuberculosis
terminally ill
death 152;189;325
diarrhoea
16;35;48;49;50;53;54;57;59;60;110;111;188;189;190;1
94;199;279;300;318;322
management guidelines 60;109;112
shortness of breath 70;72;177;297
tetanus
30;67;257;285;288;342;350;380
thrombolytic agents 181
thrush 46;97;110;260;261;297
thyroid disease
hyperthyroidism 229
hypothyroidism 89;230;302;304
toxoplasmosis 235
trachoma 253;256
trichomonas vaginal discharge 95;96;97
tropical diseases 65
tuberculosis
adverse drug reaction 119;298;365
BCG vaccination 67;126
category I 124;127
category II 124;127
DOTS 125;129;130;131;132
drug regimens 215
intermittent therapy 133;160
Mantoux test 127;128
policy 8;54;65;125;149;308
sputum
125;126;127;129;130;131;139;156
u
ulcers and related conditions
duodenal ulcer
reflux oesophagitis
urticaria 278
uterine rupture 84;86
418
INDEX by Condition
uterine stimulation 85
uveitis 255
V
vitamins & electrolytes
marasmic-kwashiorkor 58
vitiligo 280
w
warts 92;105;280
wheezing 40;42;161
419
EDLIZ 2006
NOTES
420
Notes
NOTES
421
£^S
For the side cover
423

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EDLIZ 2006

5th Essential Drugs List

Further copies may be obtained through

The information presented in these guidelines conforms to

EDLIZ Review Co-ordinator

No part of this publication may be reproduced by any

Basopo Victor Mwaramba Charles

Ms. T. Simoyi Dr. C. E. Ndhlovu

The guidelines in EDLIZ have always reflected the

This new EDLIZ has taken into account the dynamic

EDLIZ is good medicine! Use it.

Hon. Dr. D P Parirenyatwa Minister of

THE ESSENTIAL DRUGS LIST FOR

Generic drugs from reliable suppliers are as safe,

IMPROVED DRUG SUPPLY

M ORE RATIONAL PRESCRIBING

IMPROVED PATIENT USE

IMPLEMENTATION OF EDLIZ / SETTING UP OF HOSPITAL

The advantages presented here however do not just happen.

EXPLANATIONS & CHANGES FROM THE PREVIOUS VERSION

This edition of EDLIZ has been produced as a result of a

MAJOR HIGHLIGHTS IN THE

Need for Hospital formularies and Hospital Therapeutics

HIV and AIDS care:

be found in greater detail in the HIV and AIDS Quality of

Other Antiviral agents:

You will need to be aware of the revised recommendations

Presumptive Treatment (IPT) guidelines for malaria in

Specialist Drugs List:

Principles of antimicrobial use

and sensitivity testing should be obtained before commencing

NOTES ON SPECIFIC ANTIMICROBIALS

brain abscesses and not used indiscriminately in the treatment of

PYREXIA / FEVER OF UNKNOWN ORIGIN

If the patient’s general condition is satisfactory, it is reasonable

Recommended ‘blind’ therapy for septicaemia with no

THE USE OF ANTIMICROBIALS FOR

Hysterectomy, Caesarean section, or Colorectal surgery e.g.

If signs of infection after operation, give:

Urinary tract surgery e.g. prostatectomy:

Skull base fracture with liquorrhoea (rhino/otorrhoea):

Subacute bacterial endocarditis See Cardiovascular Chapter

Chemoprophylaxis for meningococcal meningitis contacts. Give

Acute Respiratory Infections 35

Paediatric HIV infection 58

Paediatric Drug Doses 61

Other paediatric conditions have been described in the relevant

For example: Chloramphenicol dose = 12.5mg/kg. Thus a 2kg

Routine Management at Birth

Resuscitation of the newborn

Ventilate with bag and mask *

Give adrenaline1 ml//kg 1:10 000

Consider hypovolaemia and acidosis

Ensuring adequate warmth and ventilation (either by mask or

Only if the baby has no spontaneous breathing after 5 minutes of

Feeding and Fluids

Days 2-4 or when otherwise required:

Consider transfer to a specialist unit for babies unable to

There are usually few localising signs in infants, and