MTI ACUTE TREATMENT GUIDELINES (Somalia) 2011
SYSTEMIC ILLNESSES
Disease
Criteria
Fever
Malaria
Periodic evening fevers Q 1-3 days
Headache, body ache
Splenomegaly
Pale conjunctiva
+ Malaria smear or RDT
Severe= AMS, sz, NPO, vomit,
hemoglobinuria, bleeding, anuria,
SOB/resp failure, jaundice, T>39,
SBP<80, Rx failure after 2-3d.
Rx
Alternative/Comments
Paracetamol 10-15 mg/kg/dose qid prn
Tepid sponging
Ibuprofen 10/mg/kg/dose qid prn
ACT (artesunate 50mg; sulfadoxine-pyrimethamine 500/25mg) Day1
Day2
Day3
Age
Weight SP + AS
AS
AS
<1yr
5-10kg ½ + ½
½
½
1 to <3yr
10-14kg 1 + 1
1
1
3 to <5yr
15-19kg 1 + 2
2
2
5-11yr
20-35kg 2 + 3
3
3
12+ yr
36+kg 3 + 4
4
4
Coartem (x pregnancy: use quinine )
Quinine 10 mg/kg TD 7d po/IV/IM
4mo-3y 5-14 kg “Yellow” = 1 BD 3d
Dose : 122mg/5ml or 300mg tab
3-7y
15-24kg “Blue” = 2 BD 3d
4-6 kg
2ml
7-12y 25-34kg “Brown”= 3 BD 3d
7-10 kg
3ml or ¼ tab
>12y
> 35 kg “Green” = 4 BD 3d
11-18 kg
½ tab
Severe/Cerebral:
19-24 kg
¾ tab
Quinine 20mg/kg (max 600 mg) IV in 10 ml/kg D5W over 4hr,
25-30 kg
1 tab
repeat (10mg/kg) Q8h, at least 3 doses, then PO if better.
31-40 kg
1¼ tab
Add D50 1cc/kg IV x1 then D5LR gtt; see Dehydration below.
41-50 kg
1¾ tab
Alt: Artemeter 3.2 mg/kg IM day 1; 1.6 mg/kg IM days 2-7
>50kg
2 tabs
Alt2: Artesunate 2.4mg/kg IV/IM x1; at 12h give 1.2mg/kg IV/IM; then qd x ≥3d or switch to PO.
Seizures
See chronic disease protocol.
Diazepam: 0.5 mg/kg PR (max 10 mg adult, 5mg if <3y/o) q10min prn, or 0.2 mg/kg IV
Phenobarbital IV 20mg/kg/dose
Typhoid Fever
Malaise, headache, sore throat,
cough, abd pain (2nd wk)
#1: Chloramphenicol: Peds (<2yr) 8mg/kg, (>2yr) 25mg/kg q6h; Adults 500mg po qid; x 14d
#2: TMP-SMX; Peds 24mg/kg bid; Adults 960mg bid; x 14d
Alt: Cipro, Cefixime, Azithro
Late: bowel perforation
Diarrhea or constipation
Relative bradycardia
Negative UA & malaria
Peds, severe: Ceftriaxone 75 mg/kg/d
Adults, severe (shock, altered mental status):
Dexamethasone 3 mg/kg IV then 1 mg/kg IV Q 6 hr x 8 doses
plus: Ceftriaxone 2 Gm IV QD x 5 d
HA, stiff neck, fever, AMS
Also treat for malaria if not r/o.
Chloramphenicol IM/IV q6h: adults 1 gm; children >1yr 25mg/kg; <1 yr 12.5mg/kg; neonates 6.25mg/kg
PLUS Benzylpenicillin 100,000u (60mg)/kg IV/IM q6h) (or Ampicillin 50mg/kg IV/IM q6h)
Older child/adult may add ceftriaxone 50-100 mg/kg qd IV/IM
Sepsis/Meningitis
MTI ACUTE TREATMENT GUIDELINES (Somalia) 1
Parasites
(Pinworm,roundworm
ascaris, hookworm)
Distended abdomen/abd pain,
wheeze, chr cough, urticaria,
reflux, chest pain, malnutrition,
visible worms skin/stool
Mebendazole 500mg x1 (250mg if <6mo)
Alt: (peds) 6mo - 2 yrs: Albendazole 200mg PO x1
> 2yrs: Albendazole 400 mg PO x1
Onchocerciasis
SubQ itchy hyperpigmented
papules/nodules/ocular lesions.
Add: Doxy 100mg BID x6wk reduces rickettsiae x12mos.
Ivermectin 150mcg/kg single dose every 6-12 months
Ivermectin 3mg tab: #1, 2, 3, or 4 for height > 90, 120, 140, or 160 cm (safe in preg, not in <5y/o)
Schistosomiasis
1)itchy pap rash/edema 2)Katayama
Praziquantel 40mg/kg x 1 (>50 kg = 4 x 600mg tabs), OK in pregnancy/lactation
Prednisone first for Katayama fever and neuro symptoms.
Caution: check TB status prior to steroids.
3)chronic multisystem dz.
Rx all >6mo if not Rx'd in last 6mo.
Avoid albendazole in 1st trimester pregnancy
Cysticercosis
Echinococcus
Peds: praziquantel 5-10mg/kg x 1
Adults: praziquantel 600mg x 1, or mebendazole 1gm qd x 5
>4yr: praziquantel 15mg/kg tid x 14 dy + prednisone 1 mg/kg/d x 5d then rapid taper. (Caution: check TB status prior to steroids .)
Albendazole 5mg/kg (max 400) bid x 4wk, 2wk rest, 3 cycles
(elephantiasis or transient
recurrent fever, inguinal LAD,
edema)
1) Doxy 200mg/d x6wk, then
2) Ivermectin 150mcg/kg x 1 (or DEC- see right) and
3) Add albendazole 400mg x 1 to step 2
Criteria
Redness/discharge
WHO Grading; vision loss.
Night blindness, corneal lesions
Rx
Tetracycline ointment TID x7d
Tetracycline ointment TID x6wks
<6mo: 50k IU; 6-12mo: 100k IU; >12mo: 200k IU
Without xerophthalmia:
With measles: dose day 1&2. With other illness: dose x1.
Prophylaxis:
Dose q6mo. Pregnancy: 10k qd (mixed evidence). Postpartum: 200k IU within 8wk.
Disease
Pneumonia
Criteria
Cough, Fever, Fast breathing
RR: (<2mo=60/min) (<1yr =50/min)
(1y-5y =40/min)
Evidence of lung consolidation
Possible pleural pain
Rx
Alternative/Comments
Peds: TMP-SMX 24 mg/kg/dose bid x 5d or Amoxicillin 40 mg/kg/dose bid x 5d
Adults: Amox 500 tid x 5d (double in severe infx)
Amox dosing: 125mg/ml liquid or 250mg tab
or TMP-SMX (960mg) bid x5d
2mo-1yr(4-10kg): 7.5ml liquid TID or .75tab TID
[If atypicals possible, add: Doxycycline 100mg bid
1yr-5yr(10-19kg): 15ml liquid TID or 1.5tab TID
Adults: TMP/SMX, ceph.
or erythromycin 500mg qid]
Severe: ceftriax 100mg/kg/d IV/IM or [benzylPCN 50k u/kg IV q6h + gent 2.5mg/kg IV q8h] or [chloramphenicol 25mg/kg IV q6h]
Acute Otitis Media
Dull, red eardrum
Bulge/retract/no reflex
Peds: Amox 25mg/kg TID x 5-10 d (Max 2 g/d)
Adults: Amox 500 mg TID x 5-10 d
Otitis Externa
Swollen ext auditory canal
Drainage
Peds/Adults: Vinegar, cortisporin, wicking
Gentamicin gtt 3drops TID x7d or gentian violet 0.5% swab qd x3-5d
Asthma
Cough/wheeze, +/- exercise/cold
induced, nocturnal, allergic.
Severe acute attack: Salbutamol MDI w/spacer 8 puffs, repeat x2 Q10 min prn or continuous.
Epinephrine 1:1000 0.01 mg/kg IM q 30min max x 3 prn
Prednisone 2 mg/kg up to 60 mg x1, then ≤40 mg qd x 4 days or Dexamethasone 0.6 mg/kg ≤16 mg x1 then ≤16 mg daily x 4d
Uncomplicated: salbutamol 4 mg tab (adults 0.3 mg/kg/d; 1-9yr ¼ tab; >10yr 2 tabs) TID x 5d then taper ( but risk SE at useful doses )
Tapeworm
Lymphatic filariasis
OPHTHALMOLOGIC
Disease
Conjunctivitis
Trachoma
Vit A deficiency
Intestinal
Alt to 2) Peds >15kg and Adults: DEC 6mg/kg x1 dose.
Caution: Do not use DEC if coinfected with onchocerciasis.
Alternative/Comments
Refer for surgery.
Doses on days 1, 2, 14
RESPIRATORY
Alt1:(If >2mo/old) TMP/SMX 6/30 mg/kg (up to 160/800mg) BID x5d
Alt2: PenV 250mg: 0-1y (5-10kg) ¼ tab qid,1-5y (10-30kg) ½ tab qid,
6-12y(>30kg) 1 tab qid; adults 2 tabs qid x 10d
MTI ACUTE TREATMENT GUIDELINES (Somalia) 2
GASTROINTESTINAL
Disease
Criteria
Diarrhea
Watery
(Shigella) Blood and/or fever
>14d consider HIV
Zinc for all types
(Giardia ) Main finding = foul belch
Only 50% have diarrhea (mucus)
(Amebiasis ) Mucus/blood
Dehydration
GERD / Gastritis
Mild-Moderate
Severe
H. pylori
DERMATOLOGIC
Disease
Tinea:
Corporis
Rx
Alternative/Comments
ORS (see below) + zinc 20mg/d x10d (10mg if <6mo old).
If <9mo, nurse both breasts before ORS.
Adults: (>30kg): Cipro 500 mg BD x5d; pregnancy 1 gm x1
Alt: Adults: Cotrim 960mg bid; Peds (SMX) 25 mg/kg bid; x 5 days
Peds: Cipro (15 mg/kg/dose BD x3d): <6m 125 mg/dose, >6m 250mg/dose
Peds: Metronidazole 15mg/kg/d divided TID x5d
Adults: Metronidazole 2g QD x2d
Adults: Metronidazole (200mg tabs) 4 TIDx 5d or Tinidazole (not preg or BF) 2gm QD 3d
Peds: Metronidazole 10 mg/kg TD 5d
Some (moderate) : ≥2 of sunken
eyes, no tears, dry mouth, thirsty,
skin tenting, restless.
Severe : lethargic, unable to drink,
weak pulse, fast HR, low BP.
Shock with severe malnutrition :
ORS: in first 4 hours: <6kg (<4mo) 200-400ml. 6-10kg (4-12mo) 400-700ml.
10-12kg (12mo-2y) 700-900ml, 11-16 kg (2-5y) 900ml-1.4L. 16-30kg (>5y) 1.2 - 2.2L, >30kg 2.2 - 4L.
Use NGT if unable to swallow or no IV available.
IVF: Start 100ml/kg over 3hrs (6hrs if peds <1yr). (30ml/kg over 30min, then 70ml/kg).
After 3 hrs of IVF, reassess and recategorize dehydration, then follow protocol for that category. Monitor x 6hrs.
15ml/kg IV LR or D5LR over 1hr, then ORS by NG/PO 10mg/kg/hr x10hr.
Occasional heartburn
Heartburn >1wk
Daily or nightly persistent heartburn
Adults: Antacids 2 QID prn
Adults: Ranitidine 150 mg PO BID prn
Adults: Omeprazole 20 mg PO QD prn
Lifestyle: elevate HOB, no caffeine
Epigastric burning, relieved w/ food
N/V, GIB, wt loss, anorexia
PPI + amox + flagyl (or clarithro if available) x 7 days
Many alternates (PPI/bismuth/flagyl/tetracycline)
Amox: 500 tid. Flagyl 500 tid. Clarithro 500 bid.
TCN 500 qid. Omeprazole 20 bid. Pepto 2tab qid.
High prevalence, but if no dx test available treating is controversial.
Focus on severity of symptoms and likelihood of PUD.
Literature says NNT 7-14 for Rx of dyspepsia.
Criteria
Rx
Alternative/Comments
Raised, scaly annular
lesions with central clearing
Gentian violet or Whitfield's or Clotrimazole (BID x14d)
Peds: Fluconazole 8 mg/kg Qwk x2wk
Adults: Fluconazole 150 mg Qwk x2wk
Topical treatment of capitis is temporary.
Gentian Violet: 1tsp/L QD x1wk (inexpensive alternate)
Patches demarc/discolored skin
Peds: Griseofulvin microsize 10 mg/kg/d x6wks
Adults: Griseofulvin 500 mg/d x 4 wks
Alt: Fluconazole 6mg/kg/d x6wk (if available)
Adults: Fluconazole 150mg x1
Scabies
Multiple small lesions in different
stages
Pruritic
Peds & Adults: Benzoyl benzoate (BBT) 1.25% qwk x2
(or if available) Elimite (permethrin 5% topical)
Apply to entire body, wash in 12hrs if <2y/o, 72hrs if >2y.
1st treat bacterial superinfx. Temporary rx (likely to recur).
For peds, dilute BBT 1:1 with water.
If >15kg: Ivermectin 200mcg/kg x1, repeat in 2wk
Lice
Parasitic arthropods in scalp,
pubic hair
Peds & Adults: Elimite (permethrin 5% topical)
apply to all affected areas, then wash (remove) in 24 hrs.
If >15kg: Ivermectin 200mcg/kg x1,
repeat in 2wk
Impetigo/Cellulitis
Multiple crusts or 'buttons'
Streaking redness
Peds: Cloxacillin 12mg/kg QID x 5-10d.
(250mg tab): 3-5kg = 1/2 tab
6-13kg = 1 tab
>14kg = 2 tabs
Adults: Cloxacillin 500mg QID x 5-10d
Peds: Erythromycin 7.5 mg/kg/dose (up to 250 mg) QID x 5-10d
Adults: Erythromycin 250 mg PO QID
Alt: Cephalexin, TMP/SMX.
(For chronic wounds, trauma, DM, or H2O contact add cipro/flagyl)
Capitis
Versicolor
Adults: Whitfield's or selenium sulfide x5d
MTI ACUTE TREATMENT GUIDELINES (Somalia) 3
GENITOURINARY / OB
Disease
Criteria
Rx
Mastitis/abscess
Doxycycline 200mg x1, then 100mg qd x 6d.
Alternative/Comments
Vaginal Candidiasis
Severe pruritis, dyspareunia
Thick white cheesy discharge
Clotrimazole 200mg supp PV QHS x 3d
Alt: nystatin 100k IU supp PV QHS x10d
Vaginitis, Trich
or Bacterial (BV)
Copious, foamy, fishy
or malodorous discharge
Adults: Metronidazole 2g x1 or 500 mg PO BID x 7 d
Urethritis/
Cervicitis
Purulent urethral discharge
Purulent cervical drainage
Ciprofloxacin 500 mg PO x 1 plus Doxy 100 mg PO BID x7d
For all women add: Flagyl 500mg TID x7d
For non-response, add 7 days of doxy and treat partners.
Herpes
Multiple vesicles, painful ulcers
Acyclovir 200mg q5hr x5-7d
For HIV +ve, increase dose to 400mg.
Syphilis
Primary chancre
Benzathine PCN 2.4 million units IM x1
PID
Low abd/pelvic tenderness
Cipro 500mg BD x3d plus doxy 100mg BD x10d plus Flagyl 400mg x10d
Preg: ceftriax 250mg IM QD plus Metro 400mg BD x14d plus EES 500mg QID x7d
1st Trimester: Cotrimox 2.4g BD x3d plus EES 500mg QID x7d
UTI
Adults: TMP/SMX DS 1 BID x3d
Dysuria, frequency
Alternate: cephalosporins (ceftriax 250mg IM QD)
Moderate (outpatient) Ceftriax 1g x1, then cipro 500mg BID x7d
Severe (hospitalized) IV amp 2g q6hr plus gentamicin 5mg/kg (IBW) q24hr
Pyelo/urosepsis
PP Hemorrhage
MALNUTRITION
See IMCI protocol.
Adults: Fluconozole 150 mg x1
Most discharge is physiologic.
Alt: Cipro 500mg BID x3d
Extend length of rx for men/pregnant women; Rx men as STI.
TMP-SMX ds BID x14d (requires longer course than cipro).
Change to PO when clinically improved, for 2wk total Rx.
Oxytocin 10u IM or ergometrine 0.2mg (1ml) IM
<12 mo: Severe = W/H <85% and unable to BF/drink
12-59 mo: Severe = MUAC <110mm or W/H <Z -3 or Bilat LEE
12-59 mo (or >6mo if H >65cm ): Moderate = MUAC 110 - 125 mm (Z -2)
Mild = MUAC 125 - 135 mm (Z -1)
New WHO cutoff for SAM is <115mm; check the arm band.
Give glucose, antimalarial, vit A, ABX (see below), mebendazole. ORS/warming prn.
Outpt (Plumpynut) if no complications, +appetite, 0-2+ edema.
ABX: TMP-SMX x 5d if no complic. If low Glu/temp/mentation: add amp+gent x7d.
If not improved in 48h, add chloramphenicol x5d.
MTI ACUTE TREATMENT GUIDELINES (Somalia) 4
Meds in pregnancy/lactation/peds:
Antibiotics
Ciprofloxacin:
Chloramphenicol
Cotrimoxizole
Doxycycline
Erythro estolate
Naladixic acid
Rifampin
Tetracycline
Pregnancy?
no (unless vital)
no
rd
no 3 tm
no
no (other macrolides fine)
no
avoid
no
Anti-protozoans
Albendazole
Artesunate
DEC
Fansidar (S-P)
Fluconazole
Griseofulvin
Ketokonazole
Mebendazole
Mefloquine
Metronidazole
Praziquantel
no 1 tm
avoid 1st tm
avoid
no 1st tm
avoid
no
no
st
no 1 tm
no 1st tm
OK
avoid
Weight estimate:
1-11 mo: (age in mos +9)/2 = kg
1-6 yr: (age in yrs x 2) +8 = kg
7-12 yr: (age in yrs x 7) - 5 / 2 = kg
Height estimate:
Birth average = 50 cm
1 yr average = 75 cm
2-12 yrs: (age in yrs x 6) + 77 = cm
Anthropometrics
st
Lactation?
no
no
no
no
no (other macrolides fine)
no
avoid
no
yes
yes
avoid
no
avoid
no
no
yes
yes
yes
avoid
Peds?
(no < 8yr)
(no < 8yr)
(no < 2yr)
(no < 2mo)
©Medical Teams International. Permission granted to share with other organizations if attribution retained. Email for questions or feedback: Steve Sethi, [email protected]
Credits: Based on data/guidelines from R Jacobs, S Boyer, I Shenk, et al., WHO Somalia Standard Treatment Guidelines 2nd ed.
Please note: this guide is not intended to be comprehensive, inerrant, or a substitute for clinical judgement. Clinicians are responsible to ensure conformity with the standard of care.
MTI ACUTE TREATMENT GUIDELINES (Somalia) 5
(no <2yr)