Standard Treatment Guidelines

and Essential Medicines List

for South Africa

Primary Healthcare Level

2018 Edition

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 FOREWORD

Strengthening Primary Healthcare services is a priority of the Department of

Health and a critical component of this process is to ensure equitable access
to effective and safe medicines at all Primary Health Care facilities. I am,
therefore, proud to present this sixth edition of the Primary Health Care
Level Standard Treatment Guidelines and Essential Medicines List.

Primary Healthcare facilities are the foundation of our health system. In order
to improve the health and quality of life of our patients, they must provide
essential services to prevent and treat a wide range of acute and chronic
conditions, and appropriately refer patients who should be treated at higher
levels of care. The Standard Treatment Guidelines and Essential Medicines
List aim to provide clear guidance to health care workers regarding the
management of all patients at primary care level; ensuring equitable access
to services for individual patients across all stages of life, and the efficient
and cost-effective promotion of health for all - essential components for
achieving universal health care.

To achieve the aim of improving health for all, it is my sincere hope that the
Primary Healthcare Standard Treatment Guidelines and Essential Medicines
List are implemented as widely and as swiftly as possible, through
leveraging of innovative electronic tools.

I express my sincere gratitude to the Primary Health Care Expert Review

Committee for their commitment to the principles of evidence-based
medicine selection, diligence, enthusiasm and dedication. Special thanks to
all stakeholders involved, including healthcare workers from all disciplines,
Professional Societies and Organisations and representatives from
Department of Health Programmes. I strongly encourage continuous active
participation by all those involved in the healthcare sector.

DR A MOTSOALEDI, MP
MINISTER OF HEALTH
DATE: 5 SEPTEMBER 2018

i

 INTRODUCTION

The sixth edition of the Primary Health Care Standard Treatment Guidelines
and Essential Medicines List comprises evidence-based standardised
guidance for healthcare workers, in order to promote equitable access to
safe, effective, and affordable health services.

These treatment guidelines are aimed at healthcare workers at Primary

Health Care facilities. However, the availability of the Essential Medicines
List Clinical Guide mobile application encourages improved access to
Standard Treatment Guidelines at all levels of care. This allows for
consistency in patient management, and for the provision of services
according to the level of expertise of healthcare workers and the capacity of
each individual facility.

The Primary Health Care Standard Treatment Guidelines and Essential

Medicines List have always covered conditions relevant to infants, children,
and adults. New to this edition is the inclusion of guidance for medicine use in
palliative care. In this way healthcare workers are further empowered to
provide care across the life cycle of all their patients.

This edition also includes updated and comprehensive lists of ICD10 codes for
all conditions, to ensure best practice in the categorisation of each disorder.

The Primary Health Care Standard Treatment Guidelines and Essential

Medicines List are the culmination of an intensive evidence-based review.
The revisions, accompanied by the level of evidence provides transparency
and informs users of the guideline on the quality of the evidence. This
enables a more informed decision when treating patients.

I thank the Primary Health Care Expert Review Committee and the
stakeholders for their involvement in the review process, sharing of their
expertise and commitment to improve healthcare provision in South Africa.

I strongly encourage all stakeholders including Provincial Departments of

Health, Pharmaceutical and Therapeutics Committees, Health Care
Managers, Supply Chain Managers, and every health care professional in
South Africa to provide input into, use and promote the implementation of
the sixth edition of the Primary Health Care Standard Treatment Guidelines
and Essential Medicines List.

MS MP MATSOSO
DIRECTOR-GENERAL: HEALTH
DATE: 28 AUGUST 2018
ii

 ACKNOWLEDGEMENTS
The publication of this exceptional edition of the Primary Health Care
Standard Treatment Guidelines and Essential Medicines List is testament of
the enthusiasm, commitment, technical expertise and time given by the
Primary Health Care Review Committee. Extensive constructive
collaboration with various stakeholders further contributed to the quality of
this edition. We welcome continuous engagement and thank all for the
willingness to participate in this peer review consultative process.
In particular, we would like to thank the Chairperson of the Primary Health
Care Expert Review Committee, Dr R de Waal, for her dedication, passion
and continuous support of this process.

NATIONAL ESSENTIAL DRUGS LIST COMMITTEE (2015 – 2016)

Prof G Maartens (Chairperson) Dr S Joubert
Prof L Bamford Prof P Mntla
Dr E Bera Mr HT Mphaka
Dr F Benson Dr L Mvusi
Prof M Blockman Ms M Ndwandwe
Prof H Brits Ms B Ngxowa
Dr C Clark Ms MNM Ntshangase
Mr M Dheda Prof AG Parrish
Dr N Dlamini Dr L Pein
Ms D Du Plessis Dr Z Pinini
Prof M Freeman Ms R Reddy
Mr A Gray Dr G Reubenson
Dr G Grobler Dr C Scott
Dr P Holele Dr W Seaketso
Prof PM Jeena Ms N Thipa
Ms Y Johnson

NATIONAL ESSENTIAL MEDICINES LIST COMMITTEE (2017 – )

Prof AG Parrish (Chairperson) Mr K Mahlako
Dr G Reubenson (Vice Chairperson) Mrs N Makalima
Prof L Bamford Ms E Maramba
Dr A Black Ms T Matsitse
Prof S Boschmans Ms N Mazibuko
Dr RC Chundu Prof M Mendelson
Dr K Cohen Ms N Mokoape
Dr R de Waal Ms N Mpanza
Mr M Dheda Dr L Mvusi
Dr N Dlamini Mr R Naidoo
Ms D du Plessis Dr N Ndjeka
Ms S Dube Dr N Ndwamato
Prof M Freeman (resigned) Dr L Padayachee (resigned)
Mr A Gray Dr Z Pinini
Dr G Grobler Mr W Ramkrishna (resigned)
Ms N Gumede Ms S Ramroop
Dr P Holele (resigned) Ms R Reddy
Ms Y Johnson Prof A Robinson (resigned)
Brig Gen T Kgasago (resigned) Prof P Ruff
iii
Dr T Kredo Mr GS Steel
Dr J Lotter (resigned) Prof M Tshifularo
Prof G Maartens Mr G Tshitaudzi

PRIMARY HEALTHCARE EXPERT COMMITTEE (2016 – 2018)

Dr R de Waal (Chairperson) Dr MA Moorhouse
Prof L Bamford (Vice Chairperson) Ms M Mubayiwa (resigned)
Dr K Cohen Mrs S Olivera (resigned)
Dr TN Gengiah Dr L Pein
Dr C Ifebuzor Dr SC Picken
Ms PP Lentsoane Dr TM Pinkoane (resigned)
Mr J Mangane (resigned) Prof MN Sibiya (resigned)
Dr M Mokhonoana (resigned)

CONSULTANTS (co-opted experts)

Dr E Bera Dr A Sothlingham
Dr J Nuttall Prof LA Wallis
Dr R Kularatne Dr M Namane
Dr L Robertson

COMMENTS AND CONTRIBUTIONS

Dr K Balme Dr N Moran
Dr C Bamford Ms H Moropoyane
Dr E Bera Prof A Mosam
Dr TC Boyles Prof DJJ Muckart
Dr E Carcreek Dr V Mudaly
Prof JA Carr Prof SBA Mutambirwa
Dr AV Chateau Ms C Naested
Dr R Coetzee Dr P Naidoo
Dr GJ Copley Dr K Narsi
Dr H Dawood Dr C Neumüller
Ms M de Hoop Prof M Ntsekhe
Dr E de Vries Dr J Nuttall
Dr E Decloedt Prof Y Osman
Mr D den Hollander Dr M Panday
Prof N Dlova Prof AG Parrish
Dr L Fairall Dr M Patel
Ms MA February Prof F Raal
Prof R Freercks Dr M Ramavhuya
Dr K Govender Prof B Rayner
Prof TC Hardcastle Red Cross Childrens Hospital - PIC
Mr J Hattingh Dr G Reubenson
Ms H Hayes Prof P Rheeder
Dr EH Hodgson Prof AKL Robinson
Ms S Jaftha Dr L Robertson
Dr SJ Jessop Dr L Rogers
Ms Y Johnson Dr S Rossouw
Dr T Kerry Dr S Salojee
Ms ES Kgabo Prof H Simmonds
Dr R Krause Dr C Stephen
Dr M Levine Prof C Szabo
Dr N Mabatane Ms G Turner

iv
Prof J Mahlangu Dr IS Ukpe
Dr M Makua Ms J Voget
Prof AD Marais Dr K von Pressentin
Ms E Marumo Prof A Whitelaw
Dr K Mawson Ms L Whitelaw
Dr N Mbatani Prof JM Wilmshurst
Prof M Mendelson Prof E Zöllner
Prof J Moodley
Merck Pharmaceuticals Pfizer Laboratories
National Advisory Group on Immunisation
National Committee for Confidential Enquiry into Maternal Deaths
National Department of Health: Dental Therapy Directorate
National Department of Health: EPI programme
National Department of Health: HIV/AIDS Programme
National Department of Health: HIV & AIDS and STIs: Prevention strategies
National Department of Health: Women’s Health and genetics
National Department of Health: Nutrition Directorate
Palliative Care Drug Availability Technical Working Group
Pharmaceutical Society of South Africa
Private Healthcare Industry Standards Committee
South African Medical Association
Society for Endocrinology, Metabolism and Diabetes of South Africa
South African Society of Clinical Pharmacists
The Paediatric Neurology and Development Association of South Africa
Western Cape Pharmaceutics and Therapeutics Committee

EDITORIAL
Dr R de Waal Dr L Pein
Ms TD Leong Dr J Munsamy
Ms A Roos Ms MC Jones

SECRETARIATE
Ms TD Leong Dr J Munsamy
Dr J Riddin Dr R Lancaster

LOGISTICS
Mr M Molewa Ms P Ngobese

DIRECTOR: AFFORDABLE MEDICINES

Ms K Jamaloodien

CLUSTER MANAGER: SECTOR WIDE PROCUREMENT

Mr GS Steel

v
 TABLE OF CONTENTS
Foreword i
Introduction ii
Acknowledgements iii
Table of contents vi
The Essential Medicines Concept xvii
How to use this book xviii
A guide to patient education in chronic diseases xxiii
CHAPTER 1: DENTAL AND ORAL CONDITIONS 1.1
1.1 Abscess and caries, dental 1.2
1.1.1 Dental abscess 1.2
1.1.2 Dental caries 1.3
1.2 Candidiasis, oral (thrush) 1.3
1.3 Gingivitis and periodontitis 1.4
1.3.1 Uncomplicated gingivitis 1.4
1.3.2 Periodontitis 1.5
1.3.3 Necrotising periodontitis 1.5
1.4 Herpes simplex infections of the mouth and lips 1.6
1.5 Aphthous ulcers 1.7
1.6 Teething, infant 1.8
CHAPTER 2: GASTRO-INTESTINAL CONDITIONS 2.1
2.1 Abdominal pain 2.2
2.2 Dyspepsia, heartburn and indigestion, in adults 2.3
2.3 Gastro-oesophageal reflux/ disease, in infants 2.4
2.4 Nausea and vomiting, non-specific 2.4
2.5 Anal conditions 2.5
2.5.1 Anal fissures 2.5
2.5.2 Haemorrhoids 2.6
2.5.3 Perianal abscesses 2.6
2.6 Appendicitis 2.7
2.7 Cholera 2.7
2.8 Constipation 2.9
2.9 Diarrhoea 2.10
2.9.1 Diarrhoea, acute in children 2.10
2.9.2 Diarrhoea, persistent in children 2.14
2.9.3 Diarrhoea, acute, without blood in adults 2.15
2.9.4 Diarrhoea, chronic in adults 2.15
2.10 Dysentery 2.16
2.10.1 Dysentery, bacillary 2.16
2.11 Helminthic infestation 2.18
2.11.1 Helminthic infestation, tapeworm 2.18
2.11.2 Helminthic infestation, excluding tapeworm 2.19
2.12 Irritable bowel syndrome 2.20
2.13 Typhoid fever 2.21
CHAPTER 3: NUTRITION AND ANAEMIA 3.1
3.1 Anaemia 3.2
3.1.1 Anaemia, iron deficiency 3.3
3.1.2 Anaemia, macrocytic or megaloblastic 3.5

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 TABLE OF CONTENTS

3.2 Childhood malnutrition, including not growing well 3.6

3.2.1 Severe acute malnutrition (SAM) 3.6
3.2.1.1 Complicated SAM 3.6
3.2.1.2 Uncomplicated SAM 3.8
3.2.2 Moderate acute malnutrition (MAM) 3.9
3.2.3 Not growing well (including failure to thrive/growth faltering) 3.10
3.3 Overweight and obesity 3.13
3.4 Vitamin A deficiency 3.13
3.5 Vitamin B deficiencies 3.15
3.5.1 Vitamin B3/Nicotinic acid deficiency 3.15
(Pellagra)
3.5.2 Vitamin B6/Pyridoxine deficiency 3.16
3.5.3 Vitamin B1/Thiamine deficiency (Wernicke 3.17
encephalopathy and beriberi)

CHAPTER 4: CARDIOVASCULAR CONDITIONS 4.1

4.1 Prevention of ischaemic heart disease and atherosclerosis 4.2
4.2 Angina pectoris, stable 4.7
4.3 Angina pectoris, unstable/ Non ST elevation 4.8
myocardial infarction (NSTEMI)
4.4 Myocardial Infarction, acute (AMI)/ ST elevation 4.10
myocardial infarction (STEMI)
4.5 Cardiac arrest, cardiopulmonary resuscitation 4.12
4.6 Cardiac failure, congestive (CCF) 4.12
4.6.1 Cardiac failure, congestive (CCF), adults 4.12
4.6.2 Cardiac failure, congestive (CCF), children 4.15
4.7 Hypertension 4.16
4.7.1 Hypertension in adults 4.16
4.7.2 Hypertensive emergency 4.24
4.7.3 Hypertension in children 4.24
4.8 Pulmonary oedema, acute 4.25
4.9 Rheumatic fever, acute 4.25
4.10 Valvular heart disease and congenital structural heart disease 4.27
CHAPTER 5: SKIN CONDITIONS 5.1
5.1 Dry skin 5.3
5.2 Itching (pruritus) 5.3
5.3 Acne vulgaris 5.4
5.4 Bacterial infections of the skin 5.5
5.4.1 Boil, abscess 5.5
5.4.2 Impetigo 5.7
5.4.3 Cellulitis 5.8
5.4.4 Chronic lower limb ulcers 5.9
5.5 Fungal infections of the skin 5.10
5.5.1 Candidiasis, skin 5.10
5.5.2 Ringworm and other tineas 5.10
5.5.2.1 Ringworm – Tinea corporis 5.10
5.5.2.2 Athlete’s foot – Tinea pedis 5.11
5.5.2.3 Scalp infections – Tinea capitis 5.12
5.5.2.4 Pityriasis versicolor – Tinea versicolor 5.12
5.5.2.5 Nail infections – Tinea unguium 5.12
5.6 Nail and nailfold infections 5.13

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 TABLE OF CONTENTS

5.6.1 Paronychia – chronic 5.13

5.6.2 Paronychia – acute 5.13
5.6.3 Nail infections – Tinea unguium 5.13
5.7 Parasitic infestations of the skin 5.14
5.7.1 Lice (pediculosis) 5.14
5.7.1.1 Head lice 5.14
5.7.1.2 Body lice 5.15
5.7.1.3 Pubic lice 5.15
5.7.2 Scabies 5.16
5.7.3 Sandworm 5.17
5.8 Eczema and dermatitis 5.17
5.8.1 Eczema, atopic 5.17
5.8.2 Eczema, acute, moist or weeping 5.19
5.8.3 Dermatitis, seborrhoeic 5.20
5.9 Nappy rash 5.21
5.10 Allergies 5.22
5.10.1 Urticaria 5.22
5.10.2 Angioedema 5.22
5.10.3 Fixed drug eruptions 5.23
5.10.4 Papular urticaria 5.24
5.10.5 Erythema multiforme 5.25
5.10.6 Severe cutaneous adverse drug reactions 5.25
5.10.6.1 Stevens-Johnson syndrome (SJS)/Toxic 5.25
Epidermal Necrolysis (TEN)
5.10.6.2 Drug Reaction with Eosinophilia and Systemic 5.26
Symptoms (DRESS)
5.11 Pityriasis rosea 5.26
5.12 Molluscum contagiosum 5.27
5.13 Herpes simplex 5.28
5.14 Herpes Zoster 5.28
5.15 Warts 5.28
5.15.1 Common warts 5.28
5.15.2 Plane warts 5.29
5.15.3 Plantar warts 5.29
5.15.4 Genital warts: Condylomata accuminata 5.30
5.16 Psoriasis 5.30
5.17 Hidradenitis suppurativa 5.30
5.18 Hypopigmentory disorders 5.31
5.18.1 Albinism 5.31
5.18.2 Vitiligo 5.32
5.19 Pressure ulcers/sores 5.32
CHAPTER 6: OBSTETRICS & GYNAECOLOGY 6.1
Obstetrics 6.3
6.1 Bleeding in pregnancy 6.3
6.1.1 Ectopic pregnancy 6.3
6.2 Miscarriage 6.3
6.2.1 Management of incomplete miscarriage in the 1st trimester, 6.4
at primary health care level
6.2.2 Antepartum haemorrhage 6.5
6.3 Termination of pregnancy (TOP) 6.6
6.3.1 Management of termination of pregnancy at primary health care 6.7

viii

 TABLE OF CONTENTS

level: gestation ”12 weeks (& 0 days)

6.4 Antenatal care 6.8
6.4.1 Antenatal supplements 6.8
6.4.2 Hypertensive disorders in pregnancy 6.10
6.4.2.1 Chronic hypertension 6.11
6.4.2.2 Gestational hypertension: mild to 6.11
6.4.2.3 Gestational hypertension: severe 6.11
6.4.2.4 Pre-eclampsia 6.12
6.4.2.5 Eclampsia 6.13
6.4.3 Anaemia in pregnancy 6.14
6.4.4 Syphilis in pregnancy 6.15
6.4.5 Urinary tract infection, in pregnancy 6.16
6.4.5.1 Cystitis 6.16
6.4.5.2 Pyelonephritis 6.17
6.4.6 Listeriosis 6.17
6.4.7 Preterm labour (PTL) and preterm prelabour rupture of 6.18
membranes (PPROM)
6.4.7.1 Preterm labour (PTL) 6.18
6.4.7.2 Preterm prelabour rupture of membranes (PPROM) 6.19
6.4.7.3 Prelabour rupture of membranes at term (PROM) 6.19
6.5 Intrapartum care 6.20
6.6 Care of the neonate 6.22
6.6.1 Routine care of the neonate 6.22
6.6.2 Neonatal resuscitation 6.23
6.6.3 Care of sick and small neonates 6.27
6.6.4 Care of the HIV-exposed infant 6.28
6.6.5 Perinatal transmission of hepatitis B 6.28
6.7 Postpartum care 6.29
6.7.1 Postpartum haemorrhage (PPH) 6.29
6.7.2 Puerperal sepsis 6.30
6.7.3 Cracked nipples during breastfeeding 6.30
6.7.4 Mastitis 6.31
6.8 HIV in pregnancy 6.31
6.9 Maternal mental health 6.36
6.9.1 Antepartum depression 6.36
6.9.2 Postpartum depression 6.37
6.9.3 Postpartum psychosis 6.37
Gynaecology 6.39
6.10 Ectopic pregnancy 6.39
6.11 Vaginal bleeding 6.39
6.11.1 Abnormal vaginal bleeding during fertile years 6.39
6.11.2 Post–menopausal bleeding 6.40
6.12 Dysmenorrhoea 6.40
6.13 Hormone therapy (HT) 6.41
6.14 Vaginal ulcers 6.43
6.15 Vaginal discharge/lower abdominal pain in women 6.43

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 TABLE OF CONTENTS

CHAPTER 7: FAMILY PLANNING 7.1

Introduction to contraception 7.2
7.1 Intrauterine device/contraception (IUCD) 7.4
7.2 Contraception, hormonal 7.5
7.2.1 Subdermal implant 7.5
7.2.2 Injectable 7.9
7.2.3 Oral 7.10
7.2.4 Missed pills 7.11
7.3 Contraception, barrier methods 7.12
7.4 Contraception, emergency 7.12
7.5 Voluntary sterilisation, male and female 7.13
7.6 Breakthrough bleeding with contraceptive use 7.13
CHAPTER 8: KIDNEY AND UROLOGICAL DISORDERS 8.1
Kidney 8.2
8.1 Chronic kidney disease 8.2
8.2 Acute kidney injury 8.5
8.3 Glomerular disease (GN) 8.6
8.3.1 Nephritic syndrome 8.7
8.3.2 Nephrotic syndrome 8.7
8.4 Urinary tract infection 8.8
8.5 Prostatitis 8.11
Urology 8.12
8.6 Haematuria 8.12
8.7 Benign prostatic hyperplasia 8.12
8.8 Prostate cancer 8.13
8.9 Enuresis 8.13
8.10 Impotence/ Erectile dysfunction 8.14
8.11 Renal calculi 8.14
CHAPTER 9: ENDOCRINE CONDITIONS 9.1
9.1 Type 1 Diabetes mellitus 9.2
9.1.1 Type 1 Diabetes mellitus, in children & adolescents 9.2
9.1.2 Type 1 Diabetes mellitus, in adults 9.3
9.2 Type 2 Diabetes mellitus 9.5
9.2.1 Type 2 Diabetes mellitus, in adolescents 9.5
9.2.2 Type 2 Diabetes mellitus, in adults 9.6
9.3 Diabetic emergencies 9.13
9.3.1 Hypoglycaemia in diabetics 9.13
9.3.2 Severe hyperglycaemia (diabetic ketoacidosis (DKA) & 9.16
hyperosmolar hyperglycaemic state (HHS)
9.4 Microvascular complications of diabetes 9.17
9.4.1 Diabetic neuropathy 9.17
9.4.2 Diabetic foot ulcers 9.18
9.4.3 Diabetic nephropathy 9.19
9.5 Cardiovascular risk in diabetes 9.20
9.5.1 Obesity in diabetes 9.20
9.5.2 Dyslipidaemia in diabetes 9.20
9.5.3 Hypertension in diabetes 9.21
9.6 Hypothyroidism 9.21
9.6.1 Hypothyroidism in neonates 9.21
9.6.2 Hypothyroidism children & adolescents 9.22
9.6.3 Hypothyroidism in adults 9.22
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 TABLE OF CONTENTS

9.7 Hyperthyroidism 9.23

9.7.1 Hyperthyroidism in children & adolescents 9.23
9.7.2 Hyperthyroidism in adults 9.23
CHAPTER 10: INFECTIONS AND RELATED CONDITIONS 10.1
10.1 Antiseptics and disinfectants 10.2
10.2 Chickenpox 10.3
10.3 Cholera 10.5
10.4 Dysentery, bacillary 10.5
10.5 Fever 10.5
10.6 Giardiasis 10.7
10.7 Malaria 10.7
10.7.1 Malaria, uncomplicated 10.9
10.7.2 Malaria, severe (complicated) 10.9
10.7.3 Malaria, prophylaxis (self-provided care) 10.10
10.8 Measles 10.11
10.9 Meningitis 10.13
10.10 Mumps 10.13
10.11 Rubella (German measles) 10.14
10.12 Schistosomiasis (bilharzia) 10.15
10.13 Shingles (Herpes zoster) 10.16
10.14 Tick bite fever 10.17
10.15 Typhoid fever 10.19
10.16 Tuberculosis 10.19
10.17 Tuberculosis, extrapulmonary 10.19
10.18 Viral haemorrhagic fever (VHF) 10.20
CHAPTER 11: HUMAN IMMUNODEFICIENCY VIRUS AND ACQUIRED 11.1
IMMUNODEFICIENCY SYNDROME (HIV AND AIDS)
HIV infection in adults 11.3
11.1 Antiretroviral therapy, adults 11.5
11.2 Opportunistic infections, prophylaxis in adults 11.12
11.2.1 Cotrimoxazole prophylaxis 11.12
11.2.2 Isoniazid preventive therapy (IPT) 11.13
11.3 Opportunistic infections, treatment in adults 11.13
11.3.1 Aphthous ulcers in HIV infection 11.13
11.3.2 Candidiasis, oral 11.14
11.3.3 Candida, oesophageal 11.14
11.3.4 Cryptococcosis 11.15
11.3.4.1 Cryptococcal infection pre-emptive therapy 11.16
11.3.4.2 Cryptococcal meningitis 11.16
11.3.5 Diarrhoea, HIV associated 11.17
11.3.6 Eczema, seborrhoeic 11.17
11.3.7 Fungal nail infections 11.17
11.3.8 Fungal skin infections 11.17
11.3.9 Gingivitis, acute, necrotising, ulcerative 11.18
11.3.10 Herpes simplex ulcers, chronic 11.18
11.3.11 Herpes zoster (Shingles) 11.18
11.3.12 Papular pruritic eruption 11.19
11.3.13 Pneumonia, bacterial 11.19
11.3.14 Pneumonia, pneumocystis 11.19
11.3.15 Toxoplasmosis 11.19
11.3.16 Tuberculosis (TB) 11.20
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11.4 HIV and kidney disease 11.20

HIV infection in children 11.21
11.5 The HIV exposed infant 11.24
11.6 Management of HIV infected children 11.28
11.7 Opportunistic infections, prophylaxis in children 11.38
11.8 Opportunistic infections, treatment in children 11.38
11.8.1 Candidiasis, oral (thrush), recurrent 11.38
11.8.2 Candidiasis, oesophageal 11.39
11.8.3 Diarrhoea. HIV associated 11.39
11.8.4 Pneumonia 11.39
11.8.5 Measles and chickenpox 11.39
11.8.6 Skin conditions 11.39
11.8.7 Tuberculosis (TB) 11.39
11.9 Developmental delay or deterioration 11.40
11.10 Anaemia 11.40
HIV prevention 11.41
11.11 Pre-exposure prophylaxis (PrEP) 11.41
11.12 Post exposure prophylaxis 11.44
Side effects and complications of ART 11.45
11.13 Immune Reconstitution Inflammatory Syndrome (IRIS) 11.45
11.14 Lactic acidosis 11.45
CHAPTER 12: SEXUALLY TRANSMITTED INFECTIONS 12.1
12.1 Vaginal discharge syndrome (VDS) 12.4
12.1.1 Sexually non-active women 12.4
12.1.2 Sexually active women 12.5
12.2 Lower abdominal pain (LAP) 12.6
12.3 Male urethritis syndrome (MUS) 12.7
12.4 Scrotal swelling (SSW) 12.8
12.5 Genital ulcer syndrome (GUS) 12.9
12.6 Bubo 12.10
12.7 Balanitis/balanoposthitis (BAL) 12.11
12.8 Syphilis serology and treatment 12.12
12.9 Treatment of more than one STI syndrome 12.14
12.10 Treatment of partners 12.15
12.11 Genital molluscum contagiosum (MC) 12.17
12.12 Genital warts (GW) Condylomata Accuminata 12.17
12.13 Pubic lice (PL) 12.17
CHAPTER 13: IMMUNISATION 13.1
13.1 Immunisation schedule 13.2
13.2 Childhood immunisation schedule 13.3
13.3 Vaccines for routine administration 13.5
13.4 The cold chain 13.9
13.5 Open multi-dose vial policy 13.10
13.6 Adverse Events Following Immunisation (AEFI) 13.11
13.7 Other vaccines 13.11
CHAPTER 14: MUSCULOSKELETAL CONDITIONS 14.1
14.1 Arthralgia 14.2
14.2 Arthritis, rheumatoid 14.3
14.3 Arthritis, septic 14.4
14.4 Gout 14.5
xii

 TABLE OF CONTENTS

14.4.1 Gout, acute 14.5

14.4.2 Gout, chronic 14.6
14.5 Osteoarthrosis (osteoarthritis) 14.7
CHAPTER 15: CENTRAL NERVOUS SYSTEM CONDITIONS 15.1
15.1 Stroke 15.2
15.2 Dementia 15.3
15.3 Seizures (convulsions/fits) 15.4
15.3.1 Status epilepticus 15.5
15.3.2 Epilepsy 15.5
15.3.3 Febrile Seizures 15.10
15.4 Meningitis 15.11
15.4.1 Meningitis, acute 15.11
15.4.2 Meningitis, meningococcal, prophylaxis 15.13
15.4.3 Cryptococcal meningitis 15.14
15.5 Headache, mild, nonspecific 15.14
15.6 Neuropathy 15.15
15.6.1 Post-herpes zoster neuropathy (Post herpetic neuralgia) 15.15
15.6.2 Bells palsy 15.16
15.6.3 Peripheral neuropathy 15.16
CHAPTER 16: MENTAL HEALTH CONDITIONS 16.1
16.1 Aggressive disruptive behaviour 16.2
16.1.1 Acute confusion – Delirium 16.2
16.1.2 Aggressive disruptive behaviour in adults 16.2
16.1.3 Aggressive disruptive behaviour in children 16.5
16.2 Antipsychotic adverse drug reactions 16.6
16.2.1 Extra-pyramidal side effects 16.6
16.2.2 Neuroleptic malignant syndrome 16.7
16.3 Anxiety disorders 16.8
16.4 Mood disorders 16.10
16.4.1 Depressive disorders 16.11
16.4.2 Bipolar disorder 16.13
16.5 Psychosis 16.14
16.5.1 Acute psychosis 16.14
16.5.2 Chronic psychosis (Schizophrenia) 16.15
16.6 Psychiatric patients - general monitoring and care 16.17
16.7 Suicide risk assessment 16.18
16.8 Special considerations 16.19
16.8.1 Intellectual disability 16.19
16.8.2 Older patients (• 45 years) 16.20
16.8.3 Sexual health and sexuality 16.20
16.8.4 Maternal mental health 16.20
16.9 Substance misuse 16.20
16.9.1 Substance use disorders 16.20
16.9.2 Substance-induced mood disorder 16.21
16.9.3 Substance-induced psychosis 16.22
16.9.4 Alcohol withdrawal (uncomplicated) 16.23

xiii

 TABLE OF CONTENTS

CHAPTER 17: RESPIRATORY CONDITIONS 17.1

17.1 Conditions with predominant wheeze 17.3
17.1.1 Acute asthma and acute exacerbation of chronic 17.3
obstructive pulmonary disease (COPD)
17.1.2 Chronic asthma 17.7
17.1.3 Acute bronchiolitis in children 17.13
17.1.4 Chronic obstructive pulmonary disease (COPD) 17.14
17.2 Stridor (upper airway obstruction) 17.16
17.2.1 Croup (laryngotracheobronchitis) in children 17.16
17.3 Respiratory tract infections 17.18
17.3.1 Influenza 17.18
17.3.2 Acute bronchitis in adults or adolescents 17.19
17.3.3 Acute exacerbation of chronic obstructive pulmonary 17.19
disease (COPD)
17.3.4 Pneumonia 17.19
17.3.4.1 Pneumonia in children 17.20
17.3.4.2 Pneumonia in adults 17.21
17.3.4.2.1 Uncomplicated pneumonia 17.21
17.3.4.2.2 Pneumonia in adults with underlying 17.22
medical conditions or >65 years of age
17.3.4.2.3 Severe pneumonia 17.22
17.3.4.2.4 Pneumocystis pneumonia 17.23
17.4 Pulmonary tuberculosis 17.24
17.4.1 Pulmonary tuberculosis, in adults 17.24
17.4.1.1 TB chemoprophylaxis/ isoniazid preventive 17.25
therapy (IPT), in adults
17.4.1.2 TB control programme: medicine regimens, in adults 17.26
17.4.2 Pulmonary tuberculosis, in children 17.26
17.4.2.1 TB chemoprophylaxis/ isoniazid preventive 17.27
therapy (IPT), in children
17.4.2.2 TB control programme: medicine regimens, in 17.28
children
17.4.3 TB, HIV and AIDS 17.31
17.4.4 Multi-drug-resistant tuberculosis (MDR TB) 17.32
17.4.4.1 Multi-drug-resistant tuberculosis (MDR TB), in adults 17.32
17.4.4.2 Multi-drug-resistant tuberculosis (MDR TB), in 17.32
children
CHAPTER 18: EYE CONDITIONS 18.1
18.1 Conjunctivitis 18.2
18.1.1 Conjunctivitis, allergic 18.2
18.1.2 Conjunctivitis, bacterial (excluding conjunctivitis of the 18.3
newborn)
18.1.3 Conjunctivitis of the newborn 18.4
18.1.4 Conjunctivitis, viral (pink eye) 18.6
18.2 Corneal ulcer 18.7
18.3 Eye injuries 18.7
18.3.1 Eye injury, chemical burn 18.7
18.3.2 Eye injury/foreign bodies 18.8
18.3.3 Eye injury (blunt or penetrating) 18.9
18.4 Glaucoma, acute and closed angle 18.10
18.5 Painful red eye 18.11

xiv

 TABLE OF CONTENTS

18.6 Structural abnormalities of the eye 18.11

18.7 Visual problems 18.12
CHAPTER 19: EAR, NOSE AND THROAT CONDITIONS 19.1
19.1 Allergic rhinitis 19.2
19.2 Common cold (viral rhinitis) 19.3
19.3 Epistaxis 19.4
19.4 Otitis 19.4
19.4.1 Otitis externa 19.4
19.4.2 Otitis media, acute 19.5
19.4.3 Otitis media, chronic, suppurative 19.7
19.5 Sinusitis, acute, bacterial 19.8
19.6 Tonsillitis and pharyngitis 19.9
CHAPTER 20: PAIN 20.1
20.1 Pain control 20.2
20.2 Acute pain 20.3
20.3 Chronic non-cancer pain 20.5
20.4 Chronic cancer pain 20.7
CHAPTER 21: EMERGENCIES AND INJURIES 21.1
21.1 Cardiopulmonary arrest– cardiopulmonary resuscitation 21.3
21.1.1 Cardiac arrest, adults 21.3
21.1.2 Cardiopulmonary arrest, children 21.6
21.1.3 Bradycardia 21.9
21.1.4 Tachydysrhythmias 21.11
21.1.5 Management of suspected choking/foreign body aspiration 21.12
in children
21.2 Medical emergencies 21.15
21.2.1 Paediatric emergencies 21.15
21.2.1.1 Rapid triage of the child presenting with acute 21.15
conditions in clinics and CHCs
21.2.2 Angina pectoris, unstable 21.18
21.2.3 Myocardial infarction, acute (AMI) 21.18
21.2.4 Delirium with acute confusion and aggression in adults 21.18
21.2.5 Hyperglycaemia and ketoacidosis 21.19
21.2.6 Hypoglycaemia and hypoglycaemic coma 21.20
21.2.7 Nose bleeds (epistaxis) 21.22
21.2.8 Pulmonary oedema, acute 21.22
21.2.9 Shock 21.23
21.2.10 Anaphylaxis 21.25
21.2.11 Seizures and status epilepticus 21.27
21.3 Trauma and injuries 21.29
21.3.1 Bites and stings 21.29
21.3.1.1 Animal bites 21.29
21.3.1.2 Human bites 21.32
21.3.1.3 Insect stings and spider bites 21.34
21.3.1.4 Snakebites 21.35
21.3.2 Burns 21.38
21.3.3 Exposure to poisonous substances 21.43
21.3.4 Eye injury, chemical burns 21.46
21.3.5 Eye injury, foreign body 21.46
21.3.6 Post exposure Prophylaxis (PEP) 21.46

xv

 TABLE OF CONTENTS

21.3.6.1 Post exposure Prophylaxis, occupational 21.46

21.3.6.2 Post exposure Prophylaxis, rape and sexual assault 21.50
21.3.6.3 Post exposure Prophylaxis, inadvertent non- 21.56
occupational)
21.3.7 Soft tissue injuries 21.56
21.3.8 Sprains and strains 21.60
CHAPTER 22: MEDICINES USED IN PALLIATIVE CARE 22.1
22.1 Gastrointestinal conditions 22.2
22.1.1 Constipation 22.2
22.1.2 Diarrhoea 22.3
22.1.3 Nausea and vomiting 22.4
22.2 Neuropsychiatric conditions 22.4
22.2.1 Anxiety 22.4
22.2.2 Delirium 22.6
22.2.3 Depression 22.7
22.3 Pain 22.8
22.3.1 Chronic cancer pain 22.8
22.4 Respiratory conditions 22.8
22.4.1 Dyspnoea 22.8
22.5 Pressure ulcers/sores 22.9
22.6 End of life care 22.9
Standard paediatric weight-band dosing tables 23.1
Guideline for the motivation of a new medicine on the National Essential xxxii
Medicines List
Guidelines for adverse drug reaction reporting xxxvi
Disease notification procedures xli
Using the Road to Health booklet & Ideal Body Weight xliv
Peak expiratory flow rates xlviii
Index of conditions and diseases li
Index of medicines lviii
Abbreviations lxiii
Declarations of interest lxvi
Useful contact numbers and url links lxvii

xvi

 +2:7286(7+,6%22.

3ULQFLSOHV
The National Drug Policy provides for an Essential Drugs Programme (EDP)
- a key component of promoting rational medicines use. Medicines are
included or removed from the Essential Medicines List (EML) based on an
evidence-based review of safety and effectiveness, followed by
consideration of cost and other relevant practice factors. All reasonable
steps are taken to align the Standard Treatment Guidelines (STGs) with
Department of Health guidelines that are available at the time of review.
Some recommendations might not be aligned with the SAHPRA/MCC
registered label/package insert; but are guided by health needs assessment
and the best available scientific evidence. The perspective of the STGs is
that of a competent prescriber practicing in a public sector facility. As such,
the STGs serve as a standard for practice but do not replace sound clinical
judgment.

The Primary Healthcare (PHC) EML and STGs allow for the management of
patients with relatively common conditions at the PHC level. They also guide
referral of patients with more complex or uncommon conditions to facilities
with the skills and resources to provide further investigation and
management. As such, they serve as a progression to Adult and Paediatric
hospital level EMLs and STGs.

The PHC STGs and EML should be used by healthcare workers providing
care at clinics, community health centres, and gateway clinics at hospitals.
Pharmaceutical and Therapeutics Committees (PTCs) are responsible for
ensuring the availability of medicines listed in the PHC EML at those
facilities, as well as at higher levels of care.

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DFFRUGLQJ WR ORFDO FLUFXPVWDQFHV DQG DYDLODEOH H[SHUWLVH DQG WR
IDFLOLWDWH DQG FRQWURO DFFHVV WR PHGLFLQHV OLVWHG RQ WKH $GXOW DQG
3DHGLDWULFKRVSLWDOOHYHO(0/VDWVSHFLILF3+&IDFLOLWLHV

Provincial PTCs are also responsible for facilitating access to medicines at
PHC level for specific patients through down-referral from higher levels of
care. This flexible approach aims to promote better utilisation of resources
while providing access to healthcare that is more convenient for patients.

Given that the STGs and EMLs for the various levels of care are reviewed at
different times, there may be periods when they are not perfectly aligned.
Likewise, updated STGs and EMLs will not always be synchronised with
public sector pharmaceutical tenders, and PTCs should facilitate the phase
in/out of the relevant essential medicines.
xviii
/RFDOIRUPXODULHV
The EML has been developed down to generic or International Non-
Propriety Name (INN) level. Each Province is expected to review the EML
and prevailing tenders and compile a formulary which:
» lists formulations and pack sizes that will facilitate care in alignment with
the STGs and EML;
» selects the preferred member of the therapeutic class based on cost;
» implements formulary restrictions consistent with the local environment;
and
» provides information on medicine prices.
Therapeutic classes are designated in the “Medicine treatment” sections of
the STGs which provide classes of medicines followed by an example of
each class, such as ‘HMGCoA reductase inhibitors (statins) e.g. simvastatin’.
Therapeutic classes are designated where none of the members of the class
offer any significant benefit over the other registered members of the class. It
is anticipated that by listing a class rather than a specific medicine there is
increased competition and hence an improved chance of obtaining the
lowest possible price in the tender process. Where therapeutic classes are
listed in the STGs always consult your local formulary to identify the specific
medicine that has been approved for use in your facility.

1DYLJDWLQJWKHERRN
Each chapter covers a broad organ system, with cross-referral to other
chapters where necessary. Within each chapter, conditions are usually listed
alphabetically. Conditions and medicines are cross referenced in two
separate indexes of the book.

ICD10 codes
Diagnosis codes from the International Statistical Classification of Diseases
and Related Health Problems (ICD-10) are included for each condition to
facilitate accurate recording of diagnoses. The primary ICD-10 code may be
accompanied by a secondary code that is bracketed to differentiate a
secondary manifestation from the primary aetiology. (For example,
uncomplicated broncho-pneumonia with severe penicillin allergy would be
coded as: J18.0+(Z88.0)). All the rules and guidelines for the use of ICD-10
must be applied as per the World Health Organisation (WHO), the agreed
South African Morbidity Coding Standards and Guidelines document, and the
South African Master Industry Table (MIT).
Available at: http://www.health.gov.za/index.php/shortcodes/2015-03-29-10-
42-47/2015-06-10-09-23-36/2015-06-10-09-26-11

xix
Diagnosis
A brief description and diagnostic criteria for each condition are included to
assist healthcare workers to make a diagnosis.

Medicine treatment
The dosing regimens provide the recommended doses for usual
circumstances. The final dose should take into consideration capacity to
eliminate the medicine, interactions and co-morbid states.

Paediatric dose calculation

Paediatric doses are usually provided in the form of weight-band dosing
tables according to age. Doses should be calculated by weight, described as
mg/kg. If this is not possible, choose a dose from the weight-band tables.
Only use the dose according to age as a last resort. In particular, do not use
age bands if the child appears small for his/her age or is malnourished.
Different conditions may require different doses of medicine. ‘Standard’
paediatric weight-band dosing tables for medicines are contained in an
appendix. Where a specific condition is not listed in the appendix, refer to
the STG in the main text of the book for the dose specific to that condition.

EML Clinical Guide tools

The mobile application also provides tools to assist healthcare workers.
These include calculators for BMI, Cardiovascular Event Risk (cholesterol-
and BMI-based), eGFR, and Paediatric dose.

3UHVFULSWLRQZULWLQJ
Medicines should be prescribed only when they are necessary for treatment
following clear diagnosis. Not all patients or conditions need prescriptions for
medication. In certain conditions simple advice and general and supportive
measures may be more suitable.
In all cases carefully consider the expected benefit of a prescribed
medication against potential risks. This is especially important during
pregnancy where the risk to both mother and fetus must be considered.
All prescriptions must:
» be written legibly in ink by the prescriber with the full name,
identification number and address of the patient, and signed with the
date on the prescription form;
» specify the age and, in the case of children, weight of the patient;
» have contact details of the prescriber e.g. name and telephone number.

xx
In all prescriptions:

x medicine name and strength,

» State the treatment regimen in full:

x dose or dosage,
x dose frequency,
x duration of treatment,
x e.g. amoxicillin 250 mg 8 hourly for 5 days.
» Write the name of the medicine or preparation in full using the generic
name.
» Avoid abbreviations to reduce the risk of misinterpretation. Avoid the
Greek mu (ǐ): write mcg as an abbreviation for micrograms.
» Avoid unnecessary use of decimal points. If necessary, write a zero in
front of the decimal point only, e.g. 2 mg not 2.0 mg; or 0.5 mL not .5
mL.
» Avoid Greek and Roman frequency abbreviations that cause
considerable confusion – qid, qod, tds, tid, etc. Instead either state the
frequency in terms of hours (e.g. ‘8 hourly’) or times per day in
numerals (e.g. ‘3x/d’).
» In the case of “as required”, a minimum dose interval should be
specified, e.g. ‘every 4 hours as required’.
» Most monthly outpatient scripts for chronic medication are for 28 days;
check that the patient will be able to access a repeat before the 28
days are completed.

After writing a prescription, check that the dose, dose units, route, frequency,
and duration for each item is stated. Consider whether the number of items
is too great to be practical for the patient, and check that there are no
redundant items or potentially important drug interactions. Check that the
script is dated, that the patient’s name, identification number and
diagnosis/diagnostic code are on the prescription form. Only then should you
sign the prescription and provide some other way for the pharmacy staff to
identify the signature if there are problems (print your name, use a stamp, or
use a prescriber number from your institution’s pharmacy).

1(0/&UHSRUWV
To promote transparency of medicine selection decisions, NEMLC reports,
summary slide decks, medicine reviews and costing reports are available on
the National Department of Health website:
http://www.health.gov.za/edp.php

2WKHULQLWLDWLYHV
The PHC STGs and EML supports the Ideal Clinic Framework
(https://www.idealclinic.org.za/) and the Central Chronic Medicines
Dispensing and Distribution (CCMDD) programme (See page xxiii).

xxi
0HGLFLQHV6DIHW\
Provincial and local PTCs should develop medicines safety systems to
obtain information regarding medication errors, prevalence and severity of
adverse medicine events, interactions, and medication quality. These
systems should not only support the regulatory pharmacovigilance plan but
should also provide pharmacoepidemiology data to inform future essential
medicines decisions as well as local interventions to improve safety.
In accordance with the SAHPRA’s guidance on reporting adverse drug
reactions in South Africa, healthcare workers (with the support of PTCs)
should report all relevant adverse reactions to the National Adverse Drug
Event Monitoring Centre (NADEMC). To facilitate reporting, a copy of the
Adverse Drug Reaction form and guidance on its use has been provided at
the back of the book.

)HHGEDFN
Comments that aim to improve these treatment guidelines are appreciated.
The submission form and guidelines for completing the form are included in
the book. Motivations will only be accepted via Provincial PTCs.
These guidelines are also reviewed on a regular basis. During the review
process, comments are requested and should be forwarded directly to the
EML Secretariat.


xxii
 $*8,'(723$7,(17$'+(5(1&(,1&+521,&
&21',7,216

Achieving health goals for chronic conditions such as asthma, diabetes, HIV
and AIDS, epilepsy, hypertension, mental health disorders and TB requires
attention to:
» Adherence to long term pharmacotherapy – incomplete or non-adherence
can lead to failure of an otherwise sound pharmacotherapeutic regimen.
» Organisation of health care services, which includes consideration of access
to medicines and continuity of care.

3DWLHQW$GKHUHQFH
Adherence is the extent to which a person’s behaviour – taking medication,
following a diet and/or executing lifestyle changes, corresponds with agreed
recommendations from a health care provider.
Poor adherence results in less than optimal management and control of the
illness and is often the primary reason for suboptimal clinical benefit. It can
result in medical and psychosocial complications of disease, reduced quality of
life of patients, and wasted health care resources.
Poor adherence can fall into one of the following patterns where the patient:
» takes the medication very rarely (once a week or once a month);
» alternates between long periods of taking and not taking their medication e.g.
after a seizure or BP reading;
» skips entire days of medication;
» skips doses of the medication;
» skips one type of medication;
» takes the medication several hours late;
» does not stick to the eating or drinking requirements of the medication;
» adheres to a purposely modified regimen; and
» adheres to an unknowingly incorrect regimen.
Adherence should be assessed on a regular basis. Although there is no gold
standard, the current consensus is that a multi method approach that includes
self-report be adopted such as that below.

xxiii
Barriers that contribute toward poor adherence:
%$55,(5 5(&200(1'('6833257
/LIHVW\OH
» It is often difficult to take multiple » Create a treatment plan with
medications. information on how and when to
take the medications.
» A busy schedule makes it difficult to » Use reminders such as cues that
remember to take the medication. form part of the daily routine.
$WWLWXGHVDQGEHOLHIV
» The condition is misunderstood or » Remind patients that they have a
denied. long term illness that requires their
involvement.
» Treatment may not seem to be » Use change techniques such as
necessary. motivational interviewing.
» May have low expectations about » Identify goals to demonstrate
treatment. improvement/stabilisation.
6RFLDODQGHFRQRPLF
» May lack support at home or in the » Encourage participation in treatment
community support programs.
» May not have the economic » Consider down referral or reschedule
resources to attend appointments. appointment to fit in with other
commitments.
+HDOWKFDUHWHDPUHODWHG
» Little or no time during the visit to » Encourage patient to ask questions.
provide information.
» Information may be provided in a » Use patient literacy materials in the
way that is not understood. patient’s language of choice.
» Relationship with the patient may » Engage active listening.
not promote understanding and self-
management.
7UHDWPHQWUHODWHG
» Complex medication regimens » If possible reduce treatment
(multiple medications and doses) complexity
can be hard to follow.
» May be discouraged if they don’t feel » Help the patient understand the
better right away. condition and the role of their
medication
» May be concerned about adverse » Discuss treatment goals in relation to
effects. potential adverse effects.
Although many of these recommendations require longer consultation time, this
investment is rewarded many times over during the subsequent years of
management.
For a patient to consistently adhere to long term pharmacotherapy requires
integration of the regimen into his or her daily life style. The successful
integration of the regimen is informed by the extent to which the regimen differs

xxiv
from his or her established daily routine. Where the pharmacological proprieties
of the medication permits it, the pharmacotherapy dosing regimen should be
adapted to the patient’s daily routine. For example, a shift worker may need to
take a sedating medicine in the morning when working night shifts, and at night,
when working day shifts. If the intrusion into life style is too great alternative
agents should be considered if they are available. This would include situations
such as a lunchtime dose in a school-going child who remains at school for
extramural activity and is unlikely to adhere to a three times a regimen but may
very well succeed with a twice daily regimen.

7RZDUGVFRQFRUGDQFHZKHQSUHVFULELQJ
Establish the patient’s:
» occupation,
» daily routine,
» recreational activities,
» past experiences with other medicines, and
» expectations of therapeutic outcome.
Balance these against the therapeutic alternatives identified based on clinical
findings. Any clashes between the established routine and life style with the
chosen therapy should be discussed with the patient in such a manner that the
patient will be motivated to change their lifestyle.
1RWHEducation that focuses on these identified problems is more likely to
be successful than a generic approach toward the condition/medicine.
(GXFDWLRQSRLQWVWRFRQVLGHU
» Focus on the positive aspects of therapy, but be supportive regarding
negative aspects and offer guidance on how to manage this, if present.

 normal progression of the illness - especially important in those

» Provide realistic expectations regarding:

diseases where therapy merely controls the progression and those

 the improvement that therapy and non-medicinal treatment can add to

that are asymptomatic;

the quality of life.

» Establish therapeutic goals and discuss them openly with the patient.
» Any action to be taken with loss of control or when side effects develop.
» In conditions that are asymptomatic or where symptoms have been
controlled, reassure the patient that this reflects therapeutic success, and
not that the condition has resolved.
» Where a patient raises concern regarding anticipated side effects, attempt
to place this in context with respect to incidence, the risks vs. the benefits,
and whether or not the side effects will disappear after continued use.
1RWH: Some patient’s lifestyles make certain adverse responses acceptable
which others may find intolerable. Sedation is unlikely to be acceptable to a
student, but an older patient with insomnia may welcome this side effect.
This is where concordance plays a vital role.
1RWHVRQSUHVFULELQJLQFKURQLFFRQGLWLRQV
» Do not change doses without good reason.
xxv
» Never blame anyone or anything for non-adherence before fully investigating
the cause.
» If the clinical outcome is unsatisfactory - investigate adherence (note that side
effects may be an issue).
» Always think about side effects and screen for them from time to time.
» When prescribing a new medicine for an additional health related problem ask
yourself whether or not this medicine is being used to manage a side effect.
» Adherence with a once daily dose is best. Twice daily regimens show
agreeable adherence. However, adherence decreases as the number of
administration interval increases.
» Keep the total number of tablets to an absolute minimum as too many may
lead to medication dosing errors and may influence adherence.
,PSURYLQJ&RQWLQXLW\RI7KHUDS\
» Make clear and concise records.
» Involvement the patient in the care plan.

 his/her diagnosis
» Every patient on chronic therapy should know:

 the name of every medicine

 the dose and interval of the regimen
 his/her BP or other readings
1RWH: The prescriber should reinforce this only once management of the
condition has been established.
» When the patient seeks medical attention for any other complaints such as
a cold or headache he/she must inform that person about any other
condition/disease and its management.
» If a patient indicates that he/she is unable to comply with a prescribed
regimen, consider an alternative - not to treat might be one option, but be
aware of the consequences e.g. ethical.

xxvi
 3DWLHQW$GKHUHQFH5HFRUG
Folder No. Date / /
(dd/mm/yyyy)
6HOI5HSRUWLQJ
4XHVWLRQ <HV 1R
Do you sometimes find it difficult to remember to take your medicine?
When you feel better, do you sometimes stop taking your medication?
Thinking back over the past four days, have you missed any of your doses?
Sometimes if you feel worse when you take the medicine, do you stop taking it?
9LVXDO$QDORJXH6FDOH9$6
          
Score ____%

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Medication Knows the name Knows the Time the medication is taken Knows any
(Y/N) number of pills Considered additional
Morning Evening
per dose (Y/N) Acceptable instruction
(hour) (hour)
(Y/N)


xxvii
3LOO&RXQW

Did the client return the medication containers?

Yes* No

,I\HVcheck that the client only used medication from this container since the date of their last visit. If leftover medication
had been used or an emergency prescription obtained, then the calculation will be invalid – skip to adherence assessment.

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Answered ‘No’ to all Answered ‘Yes’ to 1 Answered ‘Yes’ to 2 or more
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questions question questions
9$6 • 95% 75–94% Less than 75%
Dose, Time, and
3,7²Client knows the… Dose and Time Dose only or confused
Instructions
3LOOFRXQW • 95% 75–94% Less than 75%
2YHUDOO$GKHUHQFH High Moderate Low

xxviii
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[[L[

 Central Chronic Medicine
Dispensing and Distribution
(CCMDD)

PROCESS
CRITERIA
1. Stable patient 2. Patients meets
on chronic eligibility criteria
medication

SELECT PuP REGISTER

4. Patient selects
3. Patient agrees to be
approved pick up
point (PuP) registered on CCMDD

CREATE DISPENSE
6. First supply is
5. A 6-month repeat issued to the patient at
prescription is created facilty

RETURN COLLECT
7. Patient collects
8. Patient returns to
subsequent month(s)
facility every 6 months
supply from chosen PuP
PHC Chapter 1: Dental and oral
Conditions
1.1 Abscess and caries, dental
1.1.1 Dental abscess
1.1.2 Dental caries
1.2 Candidiasis, oral (thrush)
1.3 Gingivitis and periodontitis
1.3.1 Uncomplicated gingivitis
1.3.2 Periodontitis
1.3.3 Necrotising periodontitis
1.4 Herpes simplex infections of the mouth and lips
1.5 Aphthous ulcers
1.6 Teething, infant




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'(17$/$%6&(66
K04.7

'(6&5,37,21
Acute or chronic suppuration related to teeth, due to infection. It is characterised by:
» acute, severe, throbbing pain
» swelling adjacent to the tooth, or on the face
» pain worsened by tapping on affected teeth
» restricted mouth opening or difficulty chewing
» pus collection located around the tooth or at the apex of the root

0(',&,1(75($70(17
,QLWLDWHWUHDWPHQWEHIRUHUHIHUUDO

x Amoxicillin, oral, 10–20 mg/kg 8 hourly for 5 days.

Children

8VHRQHRIWKHIROORZLQJ
:HLJKW 'RVH 6XVS &DSVXOH $JH
kg mg 125mg 250mg 250 500 Months/years
/5mL /5mL mg mg
‫ޓ‬18 months–7
‫ޓ‬11–25 kg 250 mg 10 mL 5 mL 1 cap –
years
‫ޓ‬25 kg 500 mg – – 2 caps 1 cap ‫ޓ‬7 years
$1'
x Metronidazole, oral, 7.5 mg/kg/dose 8 hourly for 5 days. See dosing table, pg
23.7.

x Amoxicillin, oral, 500 mg 8 hourly for 5 days.

Adults

$1'
x Metronidazole, oral, 400 mg, 8 hourly for 5 days.
6HYHUHSHQLFLOOLQDOOHUJ\(Z88.0)
Children < 18 kg
ƒ Macrolide, e.g.:
x Azithromycin, oral, 10 mg/kg/dose, daily for 3 days. See dosing table, pg 23.2.
Children > 35 kg and adults
ƒ Macrolide, e.g.:
x Azithromycin, oral, 500 mg daily for 3 days.
3DLQ

x Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See dosing table,
Children

pg 23.8

2018 1.2
&+$37(5 '(17$/$1'25$/&21',7,216

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per 24

Adults

hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.

5()(55$/
All cases.

'(17$/&$5,(6
K02.0-5/K02.8-9

To be managed by a dentist or dental therapist.

x Lidocaine (Dentist and dental therapist).

For local anaesthesia for dental procedures:

x Lidocaine with adrenaline (epinephrine) (Dentist and dental LoE: IIIi

therapist).

 &$1',',$6,625$/7+586+

B37.0

'(6&5,37,21
A candida infection of the mouth and sometimes of the pharynx.
Commonly presents as painful creamy white patches that can be scraped off the
tongue and buccal mucosa.
Often occurs in healthy babies up to one month of age.
Risk factors for candidiasis include:
» poor oral hygiene
» immunosuppression (may be responsible for severe cases of oral thrush)
» prolonged use of broad spectrum antibiotics or corticosteroids (including
inhaled)
» certain chronic diseases, e.g. diabetes mellitus
» trauma e.g. from poorly fitting dentures or dentures worn whilst sleeping

*(1(5$/0($685(6
» Identify underlying causes, based on risk factors.
» Improve oral hygiene.
» Feed infants using cup instead of a bottle.
» Ensure proper fitting dentures.

0(',&,1(75($70(17
x Nystatin suspension, oral, 100 000 IU/mL, 1 mL 6 hourly after each meal/feed
for 7 days.
o Keep in contact with the affected area for as long as possible prior to swallowing.
o In older children, ask the child to swirl in the mouth, prior to swallowing.

2018 1.3
&+$37(5 '(17$/$1'25$/&21',7,216

o In infants, advise mothers to apply to front of the mouth and spread over the
oral mucosa with a clean finger.
o Continue for 48 hours after cure.
1RWHIn HIV-infected patients, candidiasis may involve the oesophagus as well as
the mouth. Pain and difficulty in swallowing in an HIV-infected patient with oral
candidiasis suggest oesophageal involvement, which requires systemic treatment
with fluconazole. See Section 11.3.3: Candidiasis, oesophageal.

5()(55$/
No improvement.

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81&203/,&$7('*,1*,9,7,6
K05.0/K05.1

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An inflammation of the gum margin causing the gums to separate from the teeth.
Pockets (recesses) form between the gums and the teeth.
Pus and bacteria can collect in these pockets, eventually causing periodontitis. See
section 1.3.2: Periodontitis.
Characteristics of uncomplicated gingivitis:
» may be painful » redness
» bleeding » swollen gums
» gum recession may occur

3523+</$;,6$1'*(1(5$/0($685(6
Oral hygiene is usually adequate to prevent superficial mouth and gum infection:
» Oral hygiene after each meal to remove plaque and food debris.
» Brush teeth twice daily.
» Floss teeth at least once daily.
» Rinse mouth with homemade salt mouthwash for one minute twice daily (i.e.
½ medicine measure of table salt in a glass of lukewarm water).

0(',&,1(75($70(17
Brush, floss, rinse mouth with water and then rinse with:
x Chlorhexidine 0.2%, 15 mL as a mouthwash, twice daily, after brushing teeth,
for 5 days.
o Do not swallow.
1RWH: Do not eat or drink immediately after this.
3DLQ

x Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See dosing table,
Children

pg 23.8.

2018 1.4
&+$37(5 '(17$/$1'25$/&21',7,216

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per 24

Adults

hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.

3(5,2'217,7,6
K05.2/K05.3

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Progressive gingivitis to the point where the underlying bone is eroded. It is
characterised by loose teeth and is a cause of tooth loss in adults.

*(1(5$/0($685(6
» Provide advice on improving and maintaining oral hygiene.
» Brush teeth frequently, at least twice daily.

0(',&,1(75($70(17
Brush, floss, rinse mouth with water and then rinse with:
x Chlorhexidine 0.2%, 15 mL as a mouthwash, twice daily, for 5 days.
o Do not swallow.
1RWH: Do not eat or drink immediately after this.
3DLQ

x Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See dosing table,
Children

pg 23.8

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per 24

Adults

hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.

5()(55$/
All cases for dental treatment.

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K05.2

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An acute, very painful infection of the gingival margin. It is characterised by:
» foul smelling breath
» necrosis and sloughing of the gum margin, especially of the interdental papillae
» loss of gingiva and supporting bone around teeth
May be associated with underlying disease, e.g. HIV.
May lead to disease of surrounding lips and cheeks if not adequately treated.

2018 1.5
&+$37(5 '(17$/$1'25$/&21',7,216

*(1(5$/0($685(6
» Relieve pain.
» Improve oral hygiene.
» Exclude underlying disease e.g. HIV.

0(',&,1(75($70(17

x Metronidazole, oral, 7.5 mg/kg/dose 8 hourly for 5 days. See dosing table, pg 23.7.
Children

x Metronidazole, oral, 400 mg, 8 hourly for 5 days.

Adults

Brush, floss, rinse mouth with water and then rinse with:
x Chlorhexidine 0.2%, 15 mL as a mouthwash, twice daily, for 5 days.
o Do not swallow.
1RWH: Do not eat or drink immediately after this.
3DLQ

x Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See dosing table,
Children

pg 23.8.

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per 24

Adults

hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.

5()(55$/
All cases for dental treatment.

+(53(66,03/(;,1)(&7,2162)7+(0287+$1'/,36
B00.1-2

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Acute, painful vesicular eruptions of the lips or ulcerations of the lips and mouth
caused by Herpes simplex virus and characterised by:
» shallow painful ulcers on the lips, gingiva, tongue and pharynx
» pain exacerbated by eating
It is a self-limiting infection with symptoms subsiding within 10 days.

*(1(5$/0($685(6
» Rinse mouth with homemade salt mouthwash for one minute twice daily (i.e.
½ medicine measure of table salt in a glass of lukewarm water).
» Ensure adequate hydration.
» Fluid diet for children.
» Avoid acidic drinks, e.g. orange juice or soft drinks as they may cause pain.

2018 1.6
&+$37(5 '(17$/$1'25$/&21',7,216

0(',&,1(75($70(17
x Cover lesions on the lips with petroleum jelly.
3DLQ

x Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See dosing table,
Children

pg 23.8.

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per 24

Adults

hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.
([WHQVLYHRUDOKHUSHV

x Tetracaine 0.5 %, topical, applied every 6 hours.

For children > 6 years and adults

o Apply a thin layer on the affected areas only (may be used inside mouth).
1RWHSafety in children < 6 years of age has not been established.
7KHIROORZLQJSDWLHQWVVKRXOGEHWUHDWHGZLWKDFLFORYLU
ª Children with extensive oral herpes SURYLGHGWUHDWPHQWFDQEHVWDUWHGZLWKLQ
KRXUVRIRQVHWRIV\PSWRPV
» HIV-infected patients with herpes infections of the lips or mouth.

x Aciclovir, oral, 250 mg/m2/dose, 8 hourly for 7 days. See dosing table, pg 23.1
Children < 15 years of age

Children • 15 years of age and adults

x Aciclovir, oral, 400 mg, 8 hourly for 7 days.

5()(55$/
» Severe condition.
» Dehydrated patients.
» No improvement after 1 week of treatment.

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K12.0

'(6&5,37,21
Painful ulcers in the mouth, except the gums, hard palate and dorsum of the tongue.
Minor ulcers (< 1 cm diameter) usually heal within 10 days. Major ulcers (> 1 cm
diameter) are very painful, often very deep and persist. Major ulcers usually indicate
advanced HIV infection.

0(',&,1(75($70(17
0LQRUDSKWKRXVXOFHUV

x Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See dosing table,
Children < 6 years of age

2018 1.7
&+$37(5 '(17$/$1'25$/&21',7,216

pg 23.8.

x Tetracaine 0.5 %, topical, applied every 6 hours.

Children > 6 years of age and adults

o Apply a thin layer on the affected areas only (may be used inside mouth).
1RWHSafety in children < 6 years of age has not been established.

5()(55$/
» Major ulcers for further diagnostic evaluation.
» Ulcers that are not healing within 10 days.

7((7+,1*,1)$17
K00.7

'(6&5,37,21
Teething is the appearance of teeth through the gums in the mouth of infants and
young children.
Symptoms often associated with teething include:
» fretfulness
» biting or chewing on hard objects
» drooling, which may often begin before teething starts
» gum swelling and tenderness
» refusing food
» sleeping problems
Teething is not a cause of severe or systemic symptoms, such as high fever or
diarrhoea. Exclude conditions other than teething in infants who are systemically
unwell or in distress.
Advise caregivers to seek medical advice if the infant becomes systemically unwell.

*(1(5$/0($685(6
Teething is a normal physiological process; simple self-care measures are
recommended.
» Gentle massage to the gum or biting on objects (such as teething rings) may
produce relief by producing counter-pressure against the gums (beware of
choking risks).
» Cold objects may help to ease symptoms.

Do not use local oral anaesthetic preparations in infants, as these have been
associated with severe adverse events.

5()(55$/
All children with systemic symptoms (e.g. high fever or diarrhoea) that cannot be
managed at primary healthcare level.
5HIHUHQFHV
i Lidocaine:NationalDepartmentofHealth.GovernmentGazette:No.36827:MedicinesandrelatedsubstancesAct,1965;Schedules

(Regulation674),13September2013.http://www.sabinetlaw.co.za/health
 Lidocaine with epinephrine (adrenaline): National Department of Health. Government Gazette: No. 36827: Medicines and related
substancesAct,1965;Schedules(Regulation674),13September2013.http://www.sabinetlaw.co.za/health

2018 1.8
PHC Chapter 2: Gastro-intestinal
conditions

2.1 Abdominal pain
2.2 Dyspepsia, heartburn and indigestion, in adults
2.3 Gastro-oesophageal reflux/disease, in infants
2.4 Nausea and vomiting, non-specific
2.5 Anal conditions
2.5.1 Anal fissures
2.5.2 Haemorrhoids
2.5.3 Perianal abscesses
2.6 Appendicitis
2.7 Cholera
2.8 Constipation
2.9 Diarrhoea
2.9.1 Diarrhoea, acute in children
2.9.2 Diarrhoea, persistent in children
2.9.3 Diarrhoea, acute, without blood in adults
2.9.4 Diarrhoea, chronic in adults
2.10 Dysentery
2.10.1 Dysentery, bacillary
2.11 Helminthic infestation
2.11.1 Helminthic infestation, tapeworm
2.11.2 Helminthic infestation, excluding
tapeworm
2.12 Irritable bowel syndrome
2.13 Typhoid fever
&+$37(5 *$6752,17(67,1$/&21',7,216

$%'20,1$/3$,1
R10.0-4

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Abdominal pain is a common symptom, which may be non-specific. It is frequently
benign, but may indicate a serious acute pathology. A thorough evaluation is
necessary to exclude a surgical abdomen or other serious conditions.
The history should include:
» duration, location, type, radiation and severity of pain
» relieving or aggravating factors e.g. food, antacids, exertion
» associated symptoms e.g. fever or chills, weight loss or gain, nausea, vomiting,
diarrhoea, cramps, fresh blood per rectum, melaena stools, jaundice, change in
stool or urine colour, vaginal discharge
» past medical and surgical history
» medication history
» alcohol intake or intake of other recreational substances
» family history of bowel disorders
» menstrual and contraceptive history in women
» associated vaginal discharge in women with lower abdominal pain
Examination should emphasise detection of:
» tachycardia
» fever
» jaundice or pallor
» abdominal masses, distension, tenderness
» signs of peritonitis (rebound tenderness and guarding)
» features of possible associated diseases (e.g. HIV)

0(',&,1(75($70(17
8ULQDU\WUDFWLQIHFWLRQ
See Chapter 8: Kidney and urological disorders.
'\VSHSVLD
See Section 2.2: Dyspepsia, heartburn and indigestion, in adults.

&DQFHUSDLQHJSDQFUHDWLFJDVWULFFDQFHU
See Section 20.4: Chronic cancer pain.
5HQDODQGELOLDU\FROLFRUDFXWHVXUJLFDODEGRPHQ
x Morphine, IM/IV, 10 mg as a single dose and refer (Doctor prescribed).
o For IV morphine: dilute in 10 mL sodium chloride 0.9%.
o Administer slowly over 5 minutes.
Symptomatic treatment if no specific cause or indication for referral is found:
3DLQUHOLHIDGXOWV
Analgesia as appropriate. See Section 20.1: Pain control.

2018 2.2
&+$37(5 *$6752,17(67,1$/&21',7,216

$EGRPLQDOFUDPSOLNHSDLQVDGXOWV
x Hyoscine butylbromide, oral, 10 mg 6 hourly for a maximum of 3 days.

5()(55$/
» Severe pain that cannot be managed at primary level of care.
» Signs of acute abdomen.
» Associated bloody non-diarrhoeal stools. (Red currant jelly stools in children).
» Associated abdominal mass.

 '<63(36,$+($57%851$1',1',*(67,21,1$'8/76
K30/R12

'(6&5,37,21
Dyspepsia, heartburn and indigestion are common conditions and may be caused
by gastro-oesophageal reflux.
These conditions often present with epigastric discomfort and minimal change in
bowel habits.
Intermittent indigestion, heartburn or dyspepsia may be associated with:
» use of NSAIDs e.g. aspirin, ibuprofen, pain powders
» spicy food, alcohol, carbonated drinks
» smoking
1RWHDyspeptic symptoms may possibly be due to acute coronary syndrome.

*(1(5$/0($685(6
» Stop smoking.
» Limit alcohol intake.
» Eat small frequent meals.
» Avoid late night meals.
» Check haemoglobin.
» Stop the use of potential ulcerogenic medicines e.g. NSAIDs.

0(',&,1(75($70(17
Initiate medicine therapy with:
ƒ Proton-pump inhibitor e.g.:
x Lansoprazole 30 mg, oral, daily for a maximum of 14 days.
o Also indicated for short-term use in pregnancy.
o Refer if symptoms recur after 14-day course of therapy.

5()(55$/
» Presence of warning signs:
– weight loss – anaemia
– persistent vomiting – haematemesis
– dysphagia – palpable abdominal mass
» No response within 7 days of starting proton-pump inhibitor therapy treatment.
» Recurrence of symptoms, especially:

2018 2.3
&+$37(5 *$6752,17(67,1$/&21',7,216

– > 50 years of age – previous gastric surgery

– family history of gastric carcinoma

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P78.8-9

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Gastro-oesophageal reflux (GOR) is the passive regurgitation of gastric content into
the oesophagus. It may be a normal physiological phenomenon in infants, children
and adults. Gastro-oesophageal reflux disease (GORD) is when GOR results in
abnormal or pathological complications.
6\PSWRPV
Frequent positing/regurgitation of small amounts of milk/food.

*(1(5$/0($685(6
In the absence of referral criteria (features of GORD), no medicine treatment is
required. Counselling and non-medicinal measures are suggested:
» Explain that GOR is common and resolves in the majority of children by the age
of 12–18 months.
» Upright positioning after feeds.

5()(55$/
» Failure to thrive (growth faltering).
» Abnormal posturing with opisthotonus or torticollis (Sandifer’s syndrome).
» Respiratory symptoms, i.e. recurrent wheeze or cough, chronic obstructive
airway disease, recurrent aspiration/pneumonia, stridor, apnoea and apparent
life-threatening events.

 1$86($$1'920,7,1*12163(&,),&
R11

'(6&5,37,21
There are many possible causes of nausea and vomiting.
Some important causes to H[FOXGH are:
» gastro-intestinal disease » alcohol abuse
» liver disease » early pregnancy
» renal failure » medicines
Establish if the vomiting is associated with:
» abdominal pain » headache
» diarrhoea » constipation

*(1(5$/0($685(6
» Maintain adequate hydration with clear fluids. See Section 2.9: Diarrhoea.

2018 2.4
&+$37(5 *$6752,17(67,1$/&21',7,216

» In children, do not stop feeds for more than 1 hour. Restart feeds in smaller and
more frequent amounts.
» Exclude pregnancy in women of child bearing age.

0(',&,1(75($70(17
Children
Do not use anti-emetics. Give small volumes of fluids more frequently.

x Metoclopramide, IM/IV/oral, 10 mg 8 hourly.

Adults

5()(55$/
8UJHQW
» Severe dehydration. » Severe pain.
» Shock. » Wasting.
» Diabetes. » Jaundice.
» Clinical features of sepsis.
» Associated abdominal tenderness with guarding and rebound tenderness.
» Signs of intestinal obstruction i.e. no stool or flatus passed.
» Infants with projectile vomiting or vomiting everything.
» Vomiting with digested or fresh blood present.

 $1$/&21',7,216

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K60.0-2

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Painful small cracks just inside the anal margin, sometimes a linear ulcer.
It is often seen together with a sentinel pile or external haemorrhoids.
May cause spasm of the anal sphincter.
May cause bleeding on defaecation.

*(1(5$/0($685(6
Dietary advice to promote soft stools.

0(',&,1(75($70(17

x Lactulose, oral, 0.5 mL/kg/dose once daily. See dosing tables, pg 23.6.
Children

o If poor response, increase frequency to 12 hourly.

x Lactulose, oral, 10–20 mL once daily.

Adult

o If poor response, increase frequency to 12 hourly.

x Bismuth subgallate compound, ointment, topical, applied 2–4 times daily.

2018 2.5
&+$37(5 *$6752,17(67,1$/&21',7,216

25
Lidocaine 2%, cream, topical, applied before and after each bowel action.

5()(55$/
» Severe pain.
» Recurrent episodes.
» Poor response to symptomatic treatment.
» Persistent anal bleeding.

 +$(0255+2,'6
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'(6&5,37,21
Varicose veins of the ano-rectal area.
Is usually accompanied by a history of constipation.
In older patients consider a diagnosis of underlying carcinoma.

*(1(5$/0($685(6
» High-fibre diet.
» Counsel against chronic use of laxatives.
» Avoid straining at stool.

0(',&,1(75($70(17

x Bismuth subgallate compound, ointment, topical, applied 2–4 times daily

Symptomatic treatment for painful haemorrhoids:

25
Bismuth subgallate compound suppositories, insert one into the rectum 3 times
daily.
25
Lidocaine 2%, cream, topical, applied before and after each bowel action.
&RQVWLSDWLRQ
See Section 2.8: Constipation.

5()(55$/
» For surgical intervention if necessary:
– if the haemorrhoid cannot be reduced
– if the haemorrhoid is thrombosed
– poor response to conservative treatment
» Children.
» Persistent anal bleeding.

 3(5,$1$/$%6&(66(6
K61.0-4

An abscess adjacent to the anus.

2018 2.6
&+$37(5 *$6752,17(67,1$/&21',7,216

Caused by organisms spreading through the wall of the anus into peri-anal soft tissues.
Treatment is by surgical drainage.
Presents as an indurated or tender area adjacent to the anus.

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K35.0-3/K35.8-9/K37

'(6&5,37,21
This is characterised by inflammation of the appendix, and usually requires urgent
surgical intervention.
Clinical features
» Sudden peri-umbilical pain often migrating to the right iliac fossa.
» Nausea and vomiting.
» Loss of appetite.
» Fever.
» Constipation or occasionally diarrhoea.
» Bloated abdomen.
» Rebound tenderness, guarding and rigidity.
» Right iliac fossa tenderness.
» Right iliac fossa rebound pain.
» Severe persistent abdominal pain.

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Keep nil per mouth.

0(',&,1(75($70(17

x Sodium chloride, 0.9%, IV.

Hydrate if required:

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All patients.

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Very acute severe watery diarrhoea due to infection with Vibrio cholerae.
Clinical features include:
» rice water appearance of stools:
– no blood in stools
– no pus in stools
– no faecal odour
» possible vomiting

2018 2.7
&+$37(5 *$6752,17(67,1$/&21',7,216

» rapid severe dehydration

*(1(5$/0($685(6
Rehydrate aggressively with oral rehydration solution (ORS).

0(',&,1(75($70(17
7UHDWGHK\GUDWLRQ
Children
Treat dehydration. See Section 2.9.1: Diarrhoea, acute in children.
Adults

x ORS.
Oral treatment:

25
Homemade sugar and salt solution. See Section 2.9: Diarrhoea.
The volume of fluid required for oral rehydration depends on the severity of the
dehydration.
Oral rehydration is preferred. In stuporose patients administer IV fluids or ORS by
nasogastric tube.

x Sodium chloride 0.9%, IV.

IV treatment:

$1'

$QWLELRWLFWUHDWPHQW

x Ciprofloxacin, oral, 20 mg/kg as a single dose immediately. (Ciprofloxacin is

Children

specifically used for this indication in children).

8VHRQHRIWKHIROORZLQJ
:HLJKW 'RVH 6XVS 7DEOHW $JH
kg mg 250 mg / Months / years
5 mL 250 mg 500 mg
‫ޓ‬3.5–5 kg 75 mg 1.5 mL – – ‫ޓ‬1–3 months
‫ޓ‬5–7 kg 100 mg 2 mL – – ‫ޓ‬3–6 months
‫ޓ‬7–9 kg 150 mg 3 mL – – ‫ޓ‬6–12 months
‫ޓ‬9–11 kg 200 mg 4 mL – – ‫ޓ‬12–18 months
‫ޓ‬11–14 kg 250 mg 5 mL 1 tablet – ‫ޓ‬18 months–3 years
‫ޓ‬14–17.5 kg 300 mg 6 mL – – ‫ޓ‬3–5 years
‫ޓ‬17.5–25 kg 400 mg 8 mL – – ‫ޓ‬5–7 years
‫ޓ‬25–35 kg 500 mg 10 mL 2 tablets 1 tablet ‫ޓ‬7–11 years
‫ޓ‬35–55 kg 750 mg 3 tablets – ‫ޓ‬11–15 years

x Ciprofloxacin, oral, 1 g as a single dose immediately.

Adults

$1'

2018 2.8
&+$37(5 *$6752,17(67,1$/&21',7,216

1XWULWLRQDOVXSSOHPHQWDWLRQ
In all children who are able to take oral medication
x Zinc (elemental), oral for 14 days.
o If < 10 kg give 10 mg/day.
o If > 10 kg give 20 mg/day.

5()(55$/
» Severely ill patients.
» According to provincial and local policy.

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K59.0

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A condition characterised by a change in usual bowel habits and dry, hard stools.
There is a decreased frequency of bowel action. Patients should be assessed
individually.
Constipation may have many causes, including:
» incorrect diet (insufficient fibre and fluid) » lack of exercise
» pregnancy » old age
» medicines, e.g. opiates and anticholinergics » ignoring the urge
» hypothyroidism » neurogenic
» lower bowel abnormalities » psychogenic disorders
» chronic use of enemas and laxatives » cancer of the bowel
» behavioural problems in children
&$87,21
In adults be especially suspicious of a change in bowel habits, as this may indicate
cancer of the large bowel.

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» Encourage exercise.
» Increase intake of fibre-rich food, e.g. vegetables, coarse maize meal, bran and
cooked dried prunes.
» Ensure adequate hydration.
» Encourage regular bowel habits.
» Discourage continuous use of laxatives.

0(',&,1(75($70(17

x Lactulose, oral, 0.5 mL/kg/dose once daily. See dosing tables, pg 23.6.
Children >12 months of age

o If poor response, increase frequency to 12 hourly.

x Sennosides A and B, oral, 13.5 mg, 1 tablet at night.

Adults and children >15 years of age

o In resistant cases increase to 4 tablets.

2018 2.9
&+$37(5 *$6752,17(67,1$/&21',7,216

25
Lactulose 10–20 mL once or twice daily.


&$87,21
Prolonged severe constipation may present with overflow “diarrhoea”.
Rectal examination should be done in all adults.

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» Recent change in bowel habits.
» Faecal impaction.
» Poor response to treatment.
» Uncertain cause of constipation.

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&$87,21
There is no place for antidiarrhoeal preparations in the treatment of acute
diarrhoea in children or in dysentery.

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A sudden onset of increased frequency of stools that are looser than normal, with or
without vomiting. Commonly caused by a virus, but may be caused by bacteria or
parasites. The cause of acute diarrhoea cannot be diagnosed without laboratory
investigation. It may be an epidemic if many patients are infected at the same time.
Assess and manage dehydration according to the table below.
Children with severe dehydration require referral. Begin management for
dehydration immediately whilst awaiting referral (see below).
All children should be assessed and treated for associated conditions e.g.
hypothermia, convulsions, altered level of consciousness, respiratory distress,
surgical abdomen.
6SHFLDOW\SHVRIGLDUUKRHD
» Bloody diarrhoea: consider dysentery. See Section 2.10: Dysentery.
» Diarrhoea with high fever or very ill: consider typhoid. See Section 2.13: Typhoid
fever.
» Persistent diarrhoea: See section 2.9.2: Diarrhoea, persistent in children.
» Diarrhoea in children in the context of an adult epidemic: consider cholera. See
Section 2.7: Cholera.

2018 2.10
Treatment according to hydration classification
Assess hydration and begin hydration (Plan A, B and C) based on this assessment

Plan C Plan B Plan A

Severe dehydration Some dehydration No visible dehydration

Classification 2 of the signs below: 2 of the signs below, but not Only one or none of the signs of
» lethargic or unconscious severe dehydration: dehydration.
» eyes sunken » restless or irritable
» drinks poorly or not able to drink » eyes sunken
» severe decrease in skin turgor (skin pinch » thirsty, drinks eagerly
returning• 2 seconds) » moderate decrease in skin
turgor - by slow skin pinch,
returning in < 2 seconds
Plan C Plan B Plan A
Severe dehydration Some dehydration No visible dehydration

Treatment Give rapidly: Give: » Show the caregiver how to

‡ Sodium chloride 0.9%, IV, 20 mL/kg. ‡ ORS, oral, give ORS with a cup and
o If signs of acute severe malnutrition 80 mL/kg over 4 hours, e.g. spoon using frequent small
decrease the bolus to 10 mL/kg over 10 5 mL/kg every 15 minutes. sips.
minutes. » Encourage caregiver to give:
o Repeat up to twice if radial pulse is » Give more if the child wants
weak or undetectable. more.
‡ ORS, oral,
10 mL/kg after each diarrhoeal
o Continue with 20 mL/kg every hour for
stool until diarrhoea stops.
the next 5 hours. » Show the caregiver how to
ż Child” 2 years of age: 50–
give ORS with a cup and
Then: 100 mL.
spoon using frequent small
o Refer urgently for further management, sips. ż Child ‫ޓ‬2 years of age: 100–
continuing with 20 mL/kg every hour for 200 mL.
the next 5 hours unless the child is

2018 2.11
&+$37(5 *$6752,17(67,1$/&21',7,216

reclassified as B: Some dehydration. » If child vomits wait 10 » Continue at home.

o Reassess every 2 hours while awaiting minutes and then continue
transfer. more slowly. » Encourage the caregiver to
o If hydration status does not improve, continue feeding the child,
give IV fluids more rapidly. » Encourage the caregiver to especially breastfeeding.
continue feeding the child,
» As soon as the child can drink, usually » Instruct the caregiver how to
especially breastfeeding.
after 3–4 hours in infants and 1–2 hours in make ORS/SSS at home and
to continue treatment.
x ORS, oral, 5 mL/kg/hour.
children, also give: If after 4 hours there are:
ª No signs of dehydration –
o If IV administration is not possible, insert treat as$1RYLVLEOH
a nasogastric tube. GHK\GUDWLRQ
» Still some dehydration signs
» While awaiting, and during urgent transfer,
– continue as above. (Refer if
x ORS, NG, 20 mL/kg/hour over the next 6
give:
dehydration still present after
8 hours of treatment).
hours.
» Signs of severe dehydration
» If only oral administration is possible, or – treat as C: Severe
the condition is not improving, transfer the dehydration.
child urgently.
While awaiting, and during urgent transfer,
give:
x ORS, oral, 20 mL/kg/hour.
» Reassess and reclassify the child every 
KRXUV
If improves reclassify as
B: Some dehydration and treat accordingly.

2018 2.12
Child should return immediately if:
» condition does not improve » fever develops
» condition deteriorates » eyes sunken
» poor drinking or feeding » slow skin pinch
» blood in stool

MEDICINE TREATMENT
The following children should receive ceftriaxone prior to referral:
- Neonates with severe dehydration.
Children with Severe Acute Malnutrition (SAM) AND severe dehydration or shock.
‡ Ceftriaxone, IM, 80 mg/kg/dose immediately as a single dose. See dosing
table, pg 23.3.
o Do not inject more than 1 g at one injection site.
CAUTION: USE OF CEFTRIAXONE IN NEONATES AND CHILDREN
» If SUSPECTING SERIOUS BACTERIAL INFECTION in neonate, give ceftriaxone,
even if jaundiced.
» Avoid giving calcium-containing IV fluids (e.g. Ringer Lactate) together with ceftriaxone:
‡ If ” 28 days old, avoid calcium-containing IV fluids for 48 hours after ceftriaxone
administered.
‡ If > 28 days old, ceftriaxone and calcium-containing IV fluids may be given
sequentially provided the giving set is flushed thoroughly with sodium chloride 0.9%
before and after.
‡ Preferably administer IV fluids without calcium contents.
» Always include the dose and route of administration of ceftriaxone in the referral letter.

In all children who are able to take oral medication

‡ Zinc (elemental), oral for 14 days:
o If < 10 kg give 10 mg/day.
o If > 10 kg give 20 mg/day.
Homemade sugar and salt solution is recommended for home use and to prevent
dehydration.

Homemade sugar and salt solution (SSS)

½ level medicine measure of table salt
plus
8 level medicine measures of sugar
dissolved in 1 litre of boiled (if possible) then cooled water
(1 level medicine measure = approximately 1 level 5 mL teaspoon)

REFERRAL
» Severe dehydration. Failure to maintain hydration on oral fluids/feeds (failed
Plan B).
» Children with general danger signs, e.g.:
– convulsions
– altered level of consciousness
– intractable vomiting

2018 2.13
&+$37(5 *$6752,17(67,1$/&21',7,216

– inability to feed or drink

» Children with dysentery if:
– < 12 months of age
– signs of dehydration
» Malnourished children.
» Suspected acute abdomen or other surgical problem.

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A09.0/A09.9/ K52.2/K52.8/K52.9

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Diarrhoea for 7–14 days.

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» Assess for possible HIV infection, and manage appropriately.
» Prevent dehydration using homemade sugar and salt solution.
» Counsel mother regarding feeding.
– If breastfeeding, give more frequent, longer feeds.
– If replacement feeding, replace milk with breast milk or with fermented milk
products such as amasi (maas) or yoghurt, if available.
– Continue with solids: give small, frequent meals at least 6 times a day.
» Follow-up 5 days later. If diarrhoea persists, refer to doctor.

0(',&,1(75($70(17
Give an additional dose of Vitamin A:
x Vitamin A (retinol), oral.
$JHUDQJH 'RVH &DSVXOH &DSVXOH
IU 100 000 IU 200 000 IU
Infants 6–11 months old 100 000 1 capsule –
Children 12 months to 5 years 200 000 2 capsules 1 capsule
Administration of a vitamin A capsule
o Cut the narrow end of the capsule with scissors.
o Open the child’s mouth by gently squeezing the cheeks.
o Squeeze the drops from the capsule directly into the back of the child’s
mouth. If a child spits up most of the vitamin A liquid immediately, give one
more dose.
o Do 127 give the capsule to the mother or the caregiver to take home.
x Zinc (elemental), oral for 14 days:
o If < 10 kg give 10 mg/day.
o If • 10 kg give 20 mg/day.

5()(55$/
» Child < 2 months of age.
» Signs of dehydration. See Section 2.9.1: Diarrhoea, acute in children.

2018 2.14
&+$37(5 *$6752,17(67,1$/&21',7,216

» Malnutrition or weight loss.

» Diarrhoea still present at 5-day follow-up

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Acute diarrhoea is usually self-limiting and is managed by fluid replacement.

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x Oral rehydration solution (ORS).

Treat dehydration vigorously.

25
Homemade sugar and salt solution (SSS).

+RPHPDGHVXJDUDQGVDOWVROXWLRQ666
½ level medicine measure of table salt
SOXV
8 level medicine measures of sugar
dissolved in 1 litre of boiled (if possible) then cooled water
(1 level medicine measure = approximately 1 level 5 mL teaspoon)

x Loperamide, oral, 4 mg immediately and 2 mg as required after each loose stool

up to 6 hourly.
o Not more than 12 mg daily.

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» Suspected acute surgical abdomen.
» Dehydration not corrected with rehydration.

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Diarrhoea lasting > 2 weeks.
The majority of cases may be HIV related. Encourage HIV testing.
Send a stool sample for microscopy for ova, cysts and parasites.
1RWH Do not request culture and sensitivity of the stool sample. Giardiasis is a
common cause of chronic diarrhoea in adults, and may be difficult to diagnose on
stools. Therefore, empiric treatment for giardiasis is recommended before referring
such patients.

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x Metronidazole, oral, 2 g daily for 3 days.
o Avoid alcohol.


2018 2.15
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&KURQLFGLDUUKRHDLQ+,9$,'6
See Section 11.3.5: Diarrhoea, HIV-associated.

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All HIV negative cases with no pathogen identified and significant diarrhoea.

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A06.0

Dysentery, or diarrhoeal stool with blood or mucus, is usually due to bacteria and
should be treated as bacillary dysentery. If there is no clinical response within three
days manage as amoebic dysentery or refer for formal assessment. Exclude
surgical conditions, e.g. intussusception in children.
Commonly encountered infectious conditions include Shigella, Salmonella, E. Coli,
Entamoeba histolytica and Campylobacter.

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» No response to treatment.
» Abdominal distension.
» Intussusception.

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Acute infection of the bowel usually caused by Shigella, Salmonella or Campylobacter.
There is sudden onset diarrhoea with:
» blood (not due to haemorrhoids or anal fissure) or mucous in the stools
» convulsions (in children)
» fever
» tenesmus

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» Prevent spread of micro-organism by:
– good sanitation to prevent contamination of food and water
– washing hands thoroughly before handling food
– washing soiled garments and bed clothes

0(',&,1(75($70(17
7UHDWGHK\GUDWLRQYLJRURXVO\
Children
Treat dehydration according to Section 2.9.1: Diarrhoea, acute in children.
Adults

x Oral rehydration solution (ORS).

Oral treatment:

2018 2.16
&+$37(5 *$6752,17(67,1$/&21',7,216

25
Homemade sugar and salt solution.

+RPHPDGHVXJDUDQGVDOWVROXWLRQ666
½ level medicine measure of table salt
SOXV
8 level medicine measures of sugar
dissolved in 1 litre of boiled (if possible) then cooled water
(1 level medicine measure = approximately 1 level 5 mL teaspoon)

Oral rehydration volume will depend on the severity of the dehydration.

x Sodium chloride 0.9%, IV.

IV treatment:

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Indicated for:
» Children > 1 year of age and adults with blood in the stools.
» HIV-infected patients.
» Children < 12 months of age.

x Ciprofloxacin, oral, 15 mg/kg/dose 12 hourly for 3 days. See dosing tables,

Children

pg 23.4.

x Ceftriaxone, IM, 80 mg/kg/dose immediately as a VLQJOH GRVH DQG UHIHU See

Children < 12 months of age

dosing table, pg 23.3.

o Do not inject more than 1 g at one injection site.
&$87,2186(2)&()75,$;21(,11(21$7(6$1'&+,/'5(1
» If SUSPECTING SERIOUS BACTERIAL INFECTION in neonate, give ceftriaxone,
even if jaundiced.

 If ” 28 days old, avoid calcium-containing IV fluids for 48 hours after ceftriaxone

» Avoid giving calcium-containing IV fluids (e.g. Ringer Lactate) together with ceftriaxone:

 If > 28 days old, ceftriaxone and calcium-containing IV fluids may be given

administered.

sequentially provided the giving set is flushed thoroughly with sodium chloride 0.9%

 Preferably administer IV fluids without calcium contents.

before and after.

» Always include the dose and route of administration of ceftriaxone in the referral letter.

x Ciprofloxacin, oral, 500 mg 12 hourly for 3 days.

Adults

1RWH
» Check for complications such as intestinal perforation or peritonitis.
» Ensure adequate urine output to exclude haemolytic uraemic syndrome.

2018 2.17
&+$37(5 *$6752,17(67,1$/&21',7,216

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» Severe illness.
» Persistent blood in urine on dipstix or macroscopically.
» Acute abdominal signs (severe pain, acute tenderness, persistent or bilious
vomiting).
» Bloody mucous passed in absence of diarrhoea.
» Failure to respond within 3 days.
» Malnutrition in children.
» Dehydration in children.
» Children < 12 months of age.

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Infestation with tapeworm occurs after eating infected, undercooked or raw meat
like beef or pork.
Infestation may be caused by:
» beef tapeworm – Taenia saginata
» pork tapeworm – Taenia solium
Signs and symptoms include:
» vague abdominal pain » weight loss
» diarrhoea » anal (nocturnal) itch
» flat white worm segments seen in the stool
(blunt ended)

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Health education about adequate preparation and cooking of meat.

0(',&,1(75($70(17

x Albendazole, oral, daily for 3 days.

If the patient has diarrhoea, wait for it to settle.

o Children 1–2 years: 200 mg as a single dose.

o Children • 2 years and adults: 400 mg as a single dose.

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» Abdominal tenderness or pain.
» Abdominal masses.
» Vomiting.

2018 2.18
&+$37(5 *$6752,17(67,1$/&21',7,216

+(/0,17+,&,1)(67$7,21(;&/8',1*7$3(:250
B76.1/B76.9/B77.0/B77.8/B77.9/B79/B80/B81.4/B82.0
1RWH6RLOWUDQVPLWWHGKHOPLQWKLQIHFWLRQVDUHQRWLILDEOHFRQGLWLRQV

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Types of worm infestation and the characteristics are shown in the table below. Check
for anaemia and failure to thrive (growth faltering). Infestations are often
asymptomatic.
7\SHRIZRUP 'HVFULSWLRQ 6LJQVDQGV\PSWRPV
Common Roundworm » Long pink/white worms with » Cough.
Ascaris lumbricoides sharp ends. » If there is vomiting consider
» Up to 25–30cm long. intestinal obstruction.
» Often seen in the stools
and vomitus.
Pinworm  » White and thread-like. » Anal itching; worse at night.
Enterobius vermicularis » Up to 10 mm long. » Sleeplessness.
» Often seen in the stools.
» Self-infection common.
Hookworm » Up to 8 mm long. » No symptoms or pain.
Necator americanus » Anaemia.
Whipworm » Up to 5 cm long. » No symptoms.
Trichuris trichiura » Anterior half thinner than » Abdominal pain.
posterior half. » Diarrhoea.
» Possible anaemia and
rectal prolapse.
» Abdominal discomfort.
» Weight loss.

*(1(5$/0($685(6
» Patient counselling and education.
» Wash hands with soap and water, especially:
– after passing stool(s)
– before working with food or eating
» Keep fingernails short.
» Wash fruit and vegetables well before eating or cooking.
» Keep toilet seats clean.
» Teach children how to use toilets and wash hands.
» Do not pollute the soil with sewage or sludge.
» Dispose of faeces properly.

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x Mebendazole, oral, 12 hourly for three days.
o Children 1–2 years: 100 mg 12 hourly for 3 days.
o Children • 2 years and adults: 500 mg as a single dose.
25
Albendazole oral, single dose. LoE:IIi
o Children 1–2 years: 200 mg as a single dose.
o Children • 2 years and adults: 400 mg as a single dose.

2018 2.19
&+$37(5 *$6752,17(67,1$/&21',7,216

Many children with worms who have pica may have iron deficiency (See Section
3.1.1: Anaemia, iron deficiency).

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» Signs of intestinal obstruction.
» Abdominal tenderness.
» Pain.
» Persistent vomiting.

 ,55,7$%/(%2:(/6<1'520(,%6

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6\QRQ\PVVSDVWLFFRORQLUULWDEOHFRORQ

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» Irritable bowel syndrome consists of a triad of:
1. abdominal pain and discomfort,
2. variations in bowel habits from constipation to diarrhoea, and
3. the passage of small stools at the time abdominal pain is at its worst.
» The diagnosis is suggested by a protracted and intermittent history of these
symptoms which are frequently more pronounced when there is also stress.
» It is a functional disorder, most often seen in women 15–45 years old.

*(1(5$/0($685(6
For patients with an established diagnosis:
» Reassure patient that there is no serious organic disorder.
» High fibre/bran diets may be tried for patients with constipation.
– warn about temporary increased flatus and abdominal distension.
– High fibre/bran diets are not effective for Global IBS (i.e. all symptoms).
» Dietary advice by dietician.

0(',&,1(75($70(17
» Not specifically indicated.
» Based on patients’ predominant symptoms.
» Short-term symptomatic treatment for diarrhoea and/or constipation.
x Laxatives only for constipation-specific IBS. See Section 2.8: Constipation.

x Anti-diarrhoeals only for diarrhoea-specific IBS. See Section 2.9: Diarrhoea.

5()(55$/
» Blood or mucous in the stool.
» Weight loss.
» Age > 50 years of age.

2018 2.20
&+$37(5 *$6752,17(67,1$/&21',7,216

7<3+2,')(9(5
A01.0
1RWHQRWLILDEOHFRQGLWLRQ.

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A septicaemic illness with fever caused by the micro-organism Salmonella typhi.
The cause of the fever is difficult to diagnose except in an epidemic.
It may present with:
» acute abdomen. See Section 2.1: Abdominal pain
» prolonged or high fever in a previously healthy individual
» fever with a slower pulse rate than expected
» headache and convulsions
» constipation during the first week
» diarrhoea may occur later in the illness and may be accompanied by frank bleeding
» diagnosis is confirmed only by stool culture or blood tests

0(',&,1(75($70(17
Treat dehydration if present and refer.

5()(55$/
8UJHQW
All cases or suspected cases.
5HIHUHQFHV
i Albendazole, oral: Steinmann P, Utzinger J, Du ZW, Jiang JY, Chen JX, Hattendorf J, Zhou H, Zhou XN. Efficacy of single-
dose and triple-dose albendazole and mebendazole against soil-transmitted helminths and Taenia spp.: a randomized
controlled trial. PLoSOne. 2011;6(9):e25003. https://www.ncbi.nlm.nih.gov/pubmed/21980373
Albendazole, oral: Mabaso ML, Appleton CC, Hughes JC, Gouws E. Hookworm (Necator americanus) transmission in
inland areas of sandy soils in KwaZulu-Natal, South Africa. Trop Med Int Health. 2004 Apr;9(4):471-6.
https://www.ncbi.nlm.nih.gov/pubmed/15078265
Albendazole, oral: Montresor A, Awasthi S, Crompton DW. Use of benzimidazoles in children younger than 24 months for
the treatment of soil-transmitted helminthiasis. Acta Trop. 2003 May;86(2-3):223-32.
https://www.ncbi.nlm.nih.gov/pubmed/12745139
Albendazole, oral: American Academy of Pediatrics. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book:
2012 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2012:241.
https://redbook.solutions.aap.org/DocumentLibrary/RB12_interior.pdf
Albendazole, oral: National Department of Health: Affordable Medicines, EDP-PHC. Medicine Review: Benzimidazoles for
soil-transmitted helminths, 31Jan2017http://www.health.gov.za/

2018 2.21
PHC Chapter 3: Nutrition and anaemia
3.1 Anaemia
3.1.1 Anaemia, iron deficiency
3.1.2 Anaemia, macrocytic or megaloblastic
3.2 Childhood malnutrition, including not growing well
3.2.1 Severe acute malnutrition (SAM)
3.2.1.1 Complicated SAM
3.2.1.2 Uncomplicated SAM
3.2.2 Moderate acute malnutrition (MAM)
3.2.3 Not growing well (including failure to
thrive/growth faltering)
3.3 Overweight and obesity
3.4 Vitamin A deficiency
3.5 Vitamin B deficiencies
3.5.1 Vitamin B3/Nicotinic acid deficiency
(Pellagra)
3.5.2 Vitamin B6/Pyridoxine deficiency
3.5.3 Vitamin B1/Thiamine deficiency (Wernicke
encephalopathy and beriberi)













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A condition characterised by low haemoglobin (Hb), clinically recognised by pallor,
tiredness, shortness of breath.
It is commonly caused by:
» Nutritional deficiency of iron or folate or vitamin B12.
» Chronic systemic diseases such as HIV, TB, malignancy.
» Blood loss (bleeding/haemorrhage) e.g. caused by parasites, ulcers, tumours,
abnormal menstruation.
Other causes include:
» Infiltration or replacement of the bone marrow.
» Abnormal Hb or red cells.
» Haemolysis.
',$*126,6
+EOHVVWKDQ
» women 12 g/dL;11 g/dL in pregnancy
» men 13 g/dL
» children 1–5 years of age 10 g/dL
» children >5 years of age 11 g/dL
Children < 5 years of age
Anaemia is most often due to iron deficiency. See Section 3.1.1: Anaemia, iron
deficiency.
Children > 5 years of age and adults
Request a full blood count.
» If MCV is normal (normocytic):
– then systemic disease or haemolysis are likely causes.
» If MCV is low (microcytic):
– then iron deficiency is the most likely cause.
» If MCV is high (macrocytic):
– then folate and/or vitamin B12 deficiency is the most likely cause.
Pregnant women
See Section 6.4.3: Anaemia in pregnancy.

5()(55$/
» Unknown cause.
» Symptomatic anaemia e.g. palpitations and shortness of breath.
» Evidence of cardiac failure.
» Signs of chronic disease (investigate for HIV and TB before referral).
» Anaemia associated with enlargement of the liver, spleen or lymph nodes.
» Evidence of acute blood loss or bleeding disorder.
» Menorrhagia or dysfunctional uterine bleeding.
» Blood in stool, or melaena.
» Pregnant women > 34 weeks of gestation and Hb < 7 g/dL.

2018 3.2
&+$37(5 1875,7,21$1'$1$(0,$

» Children with Hb ” 7 g/dL (If Hb cannot be done, look for severe palmar pallor).
» Anaemia associated with other abnormalities on FBC or smear.
» No improvement despite correct treatment.

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D50.0/D50.8/D50.9

'(6&5,37,21
A common cause of anaemia in young children and women of childbearing age.
A full blood count showing a low MCV suggests the diagnosis of iron deficiency
anaemia. A full blood count is not required for children, unless referral criteria above
are present.
1RWH Iron deficiency anaemia in children > 5 years of age, adult males and non-
menstruating women, is generally due to occult or overt blood loss. Refer all cases
for investigation and treatment of the underlying cause.

*(1(5$/0($685(6
» Identify and treat the cause.
» Exclude other causes. See referral criteria in Section 3.1: Anaemia.

 Avoid drinking tea/coffee with meals.

» Dietary advice:

 Increase vitamin C intake (e.g. citrus fruit, orange juice, broccoli, cauliflower,

 Increase dietary intake of iron. Foods rich in iron include: liver, kidney, beef, dried
guavas, strawberries) with meals to increase iron absorption from the diet.

beans and peas, green leafy vegetables, fortified wholegrain breads, cereals.

0(',&,1(75($70(17
7UHDWPHQW

x Iron, oral, 1–2 mg/kg/dose of elemental iron 8 hourly with meals.

Children< 5 years of age

o Follow up Hb after 14 days.

o Hb lower than before: refer.
o Hb the same/higher: continue treatment and repeat after another 28 days.
o Continue treatment for 3 months after Hb normalises.
(PSLULFWUHDWPHQWIRUZRUPVWKLVZLOOQRWWUHDWWDSHZRUP
x Mebendazole, oral.
o Children 1–2 years: 100 mg 12 hourly for 3 days.
o Children > 2–5 years: 500 mg as a single dose.
25
Albendazole oral, single dose.
o Children 1–2 years: 200 mg as a single dose.
o Children • 2 years and adults: 400 mg as a single dose.
LoE:IIi

x Ferrous sulfate compound BPC (dried), oral, 170 mg (± 55 mg elemental iron) 12

Adults

hourly with meals.

2018 3.3
&+$37(5 1875,7,21$1'$1$(0,$

25
Ferrous fumarate, oral, 200 mg (± 65 mg elemental iron) 12 hourly.
o Follow up at monthly intervals.
o Continue for 3–6 months after the Hb normalises in order to replenish body
iron stores. The expected response is an increase in Hb of • 2 g/dL in 4
weeks.
o Taking iron tablets with meals decreases iron absorption, but improves
tolerability (1RWH Do not take iron tablets with milk or calcium tablets).
LoE:IIIii
Pregnant women
See Section 6.4.3: Anaemia in pregnancy.
3URSK\OD[LV
Infants from 6 weeks (Z29.2)

x Ferrous lactate, oral, 0.6 mL daily (provides ± 15 mg elemental iron) until 6

If < 2.5 kg at birth:

months of age.
25
Ferrous gluconate syrup, oral, 2.5 mL daily (provides ± 15 mg elemental
iron) until 6 months of age.
LoE: IIIiii
(OHPHQWDOLURQSHUSUHSDUDWLRQ
350 mg/5 mL 40 mg elemental iron 8 mg elemental iron
Ferrous gluconate elixir
per 5 mL per mL
Ferrous gluconate 30 mg elemental iron 6 mg elemental iron
250 mg/5 mL
syrup per 5 mL per mL
25 mg elemental iron 1 mg elemental iron
Ferrous lactate drops 25 mg/mL
per mL per 0.04 mL
Ferrous sulfate
170 mg
compound BPC (dried) ± 55 mg elemental iron per tablet
tablets
Ferrous fumarate 200 mg ± 65 mg elemental iron per tablet
LoE:IIIiv


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Iron is extremely toxic in overdose, particularly in children.
Store all medication out of reach of children.

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» As in Section 3.1: Anaemia.
» Children > 5 years of age, men and non-menstruating women.
» No or inadequate response to treatment.

2018 3.4
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Anaemia with large red blood cells is commonly due to folate or vitamin B12 deficiency.
Folate deficiency is common in pregnant women and in the postpartum period, and in
alcoholics. Macrocytic anaemia in these patients can be assumed to be due to folate
deficiency and does not require further investigation. See Section 6.4.3: Anaemia in
pregnancy.
Vitamin B12 deficiency occurs mainly in middle-aged or older adults, and can cause
neurological damage if not treated.
Macrocytic anaemia outside of pregnancy or the postpartum period requires further
investigations to establish the cause.

,19(67,*$7,216
FBC will confirm macrocytic anaemia.
» MCV will be elevated.
» White cell count and/or platelet count may also be reduced.
If there is a poor response to folate, measure serum vitamin B12.
1RWH Zidovudine and stavudine cause elevated MCV. Zidovudine often causes
anaemia and/or decreased white cell count. It is not necessary to measure folate
and B12 if the patient is not anaemic.

*(1(5$/0($685(6

 Liver, eggs, fortified breakfast cereals, citrus fruit, spinach and other green
» Dietary advice: Increase intake of folic acid rich foods such as:

 Reduce alcohol intake.

vegetables, lentils, dry beans, peanuts.

 High protein diet is recommended (1.5g/kg/day).

» Vitamin B12 deficiency anaemia:

 Increase intake of dietary vitamin B12 sources, including meat (especially

liver), eggs and dairy products.

0(',&,1(75($70(17

x Folic acid, oral, 5 mg daily until Hb is normal.

Folic acid deficiency:

o Check Hb monthly.

Folic acid given to patients with vitamin B12 deficiency can mask vitamin B12
deficiency and lead to neurological damage, unless vitamin B12 is also given.

5()(55$/
» Patients with suspected B12 deficiency.
» Chronic diarrhoea.
» Poor response within a month of treatment.
» Macrocytic anaemia of unknown cause.

2018 3.5
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In all children, check for malnutrition and anaemia:

» Plot the weight on the Road to Health chart/booklet.
» Look at the shape of the weight curve:
Ͳ Is the weight curve rising parallel to the reference lines?
25
Ͳ is it flattening?
25
Ͳ is there weight loss?
» Look for visible wasting.
» Look and feel for oedema of both feet.
» Look for palmar pallor.
» Check Hb if anaemia is suspected.

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Diagnostic criteria for SAM in children aged 6–60 months (any one of the following):
,QGLFDWRU 0HDVXUH &XWRII
Severe wasting Weight-for-Height z-score (WHZ) < -3
Mid Upper Arm Circumference (MUAC) < 11.5 cm
Bilateral nutritional oedema Clinical signs of nutritional oedema*
:KHUHDVXLWDEOHPHDVXULQJGHYLFHLVQRWDYDLODEOHWKHIROORZLQJOHVVVHQVLWLYH
ILQGLQJVZRXOGDOVRLQGLFDWHWKHQHHGWRPDQDJHDVVHYHUHDFXWHPDOQXWULWLRQ
» 6HYHUHXQGHUZHLJKW
 WHZ < -3 (usually clinically reflective of marasmus) where no other

 clinically severe wasting (usually clinically reflective of marasmus – thin

explanation is present, and/or

arms, thin legs, “old man” appearance, baggy pants folds around buttocks,
wasted buttocks).
» 1XWULWLRQDO RHGHPD* supported by findings of skin changes, fine pale sparse
hair, enlarged smooth soft liver, moon face.
([FHSWLRQ
Babies who were premature and are growing parallel to or better than the z-score
lines, should not be classified as failure to thrive or not growing well.

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Any child with SAM who has any 21( of the following features:

2018 3.6
&+$37(5 1875,7,21$1'$1$(0,$

» < 6 months of age or weighs < 4 kg.

» Pitting oedema.
» Refusing feeds or is not eating well.
» Any of the danger signs listed below.
'DQJHU6LJQV
 dehydration 
 vomiting 
hypoglycaemia

 respiratory distress (including fast breathing) 

hypothermia

 not able to feed 

convulsions

 lethargy (not alert) 

shock

 weeping skin lesions 

jaundice
bleeding
All children with complicated SAM are at risk of complications or death.
Refer urgently!
Stabilise before referral.
Initiate treatment while waiting for transport to hospital.

*(1(5$/0($685(6
» Keep the child warm.
» Test for and prevent hypoglycaemia in all children.
,IWKHFKLOGLVDEOHWRVZDOORZ
 If breastfed: ask the mother to breastfeed the child, or give expressed breastmilk.
 If not breastfed give a 30–50 mL of a stabilising feed (F-75) or a breastmilk

 If no F-75 or breastmilk substitute is available, give 30–50 mL of sugar water.

substitute before the child is referred.

To make sugar water: Dissolve 4 level teaspoons of sugar (20 g) in a 200 mL

 Repeat 2 hourly until the child reaches hospital.

cup of clean water.

,IWKHFKLOGLVQRWDEOHWRVZDOORZ
 Insert a nasogastric tube and check the position of the tube.
 Give 50 mL of breastmilk, F-75, breastmilk substitute or sugar water by
nasogastric tube (as above).
Repeat 2 hourly until the child reaches hospital.
,IEORRGVXJDUPPRO/WUHDWZLWK
x 10% Glucose:
o Nasogastric tube: 10 mL/kg.
o Intravenous line: 2 mL/kg.
&$87,21
In malnutrition, if IV fluids are required for severe dehydration/shock, give sodium
chloride 0.9%, 10 mL/kg/hour and monitor for volume overload. Once stable
continue with ORS orally or by nasogastric tube.

2018 3.7
&+$37(5 1875,7,21$1'$1$(0,$

0(',&,1(75($70(17
1RWH Signs of infection such as fever are usually absent. Treat infection while
awaiting transfer.

x Amoxicillin, oral, 30 mg/kg as a single dose. See dosing table, pg 23.1.

If there are no danger signs, give1st dose while arranging referral to hospital:

x Ceftriaxone, IM, 80 mg/kg/dose immediately as a VLQJOH GRVH and refer. See

If the child has any danger signs:

dosing table, pg 23.3.

o Do not inject more than 1 g at one injection site.
&$87,2186(2)&()75,$;21(,11(21$7(6$1'&+,/'5(1


» If SUSPECTING SERIOUS BACTERIAL INFECTION in neonate, give ceftriaxone, even

if jaundiced.

 If ” 28 days old, avoid calcium-containing IV fluids for 48 hours after ceftriaxone

» Avoid giving calcium-containing IV fluids (e.g. Ringer Lactate) together with ceftriaxone:

 If >28 days old, ceftriaxone and calcium-containing IV fluids may be given sequentially
administered.

 Preferably administer IV fluids without calcium contents.

provided the giving set is flushed thoroughly with sodium chloride 0.9% before and after.

» Always include the dose and route of administration of ceftriaxone in the referral letter.

Give an additional dose of Vitamin A:

x Vitamin A (retinol), oral.
$JHUDQJH 'RVH &DSVXOH &DSVXOH
Units 100 000 IU 200 000 IU
Infants 6–11 months 100 000 1 capsule –
Children 12 months–5 years 200 000 2 capsules 1 capsule

81&203/,&$7('6$0
E43

'(6&5,37,21

 The child is > 6 months of age and weight > 4 kg, and
Children with SAM who meet the following criteria:

 There is no pitting oedema, and

 The child is alert (not lethargic), and
 The child has a good appetite and is feeding well, and
 The child does not have any danger signs or severe classification (and does
not require referral for another reason).
All cases require careful assessment for possible TB or HIV.

*(1(5$/0($685(6
» Provide RTUF and/or other nutritional supplements according to supplementation
guidelines.
» Counsel according to IMCI guidelines.

2018 3.8
&+$37(5 1875,7,21$1'$1$(0,$

» Regular follow-up to ensure that the child gains weight and remains well.

 WHZ (weight-for-height z-score): > -2 WHZ for two consecutive visits at

» Discharge with supplementation, once the following criteria are met:

 MUAC: > 11.5cm (preferably at 12 cm, if MUAC used alone).

least one month apart and/or

» Follow patients for at least 6 months to ensure sustained growth.

0(',&,1(75($70(17
Do not repeat if child has received these during inpatient stay:
Give an additional dose of Vitamin A:
x Vitamin A (retinol), oral.
$JHUDQJH 'RVH &DSVXOH &DSVXOH
Units 100 000 IU 200 000 IU
Infants 6–11 months 100 000 1 capsule –
Children 12 months–5 years 200 000 2 capsules 1 capsule
x Multivitamin, oral, daily.

x Mebendazole, oral.
Empiric treatment for worms:

o Children 1–2 years: 100 mg 12 hourly for 3 days.

o Children > 2–5 years: 500 mg as a single dose.
25
Albendazole oral, single dose.
o Children 1–2 years: 200 mg as a single dose.
o Children • 2 years and adults: 400 mg as a single dose.
LoE:IIv
5()(55$/
» When regular nutritional supplements (e.g. RTUF) cannot be provided and
follow-up on an ambulatory (outpatient) basis is not possible.
» The child develops pitting oedema or any of the danger signs (see above).
» Failure to gain weight despite provision of nutritional supplements.

 02'(5$7($&87(0$/1875,7,210$0

E44.0

'(6&5,37,21
Children and infants older than 6 months who have either:
» A WHZ-score between -2 and -3.
» MUAC between 11.5 cm and 12.5 cm.
» No pitting oedema or SAM danger signs (see above).
» Good appetite.
All cases require careful assessment for possible TB or HIV.

*(1(5$/0($685(6
» Provide ready to use therapeutic food (RTUF) and/or other nutritional supplements

2018 3.9
&+$37(5 1875,7,21$1'$1$(0,$

according to supplementation guidelines.

» Counsel according to IMCI guidelines.
» Follow-up frequently to ensure that the child gains weight and remains well.

 WHZ (weight-for-height z-score): > -2 WHZ for two consecutive visits at

» Discharge with supplementation, once the following criteria are met:

 MUAC: > 11.5 cm (preferably at 12 cm, if MUAC used alone).

least one month apart and/or

» Follow patients for at least 6 months to ensure sustained growth.

0(',&,1(75($70(17
Do not repeat if child has received these during inpatient stay:
Give an additional dose of Vitamin A:
x Vitamin A (retinol), oral.
$JHUDQJH 'RVH &DSVXOH &DSVXOH
Units 100 000 IU 200 000 IU
Infants 6–11 months 100 000 1 capsule –
Children 12 months–5 years 200 000 2 capsules 1 capsule

x
LoE: IIIvi
Multivitamin, oral, daily.
LoE:IIIvii
x Mebendazole, oral.
Empiric treatment for worms:

o Children 1–2 years: 100 mg 12 hourly for 3 days.

o Children > 2–5 years: 500 mg as a single dose.
25 LoE:IIIviii
Albendazole oral, single dose.
o Children 1–2 years: 200 mg as a single dose.
o Children • 2 years and adults: 400 mg as a single dose.
LoE:IIix
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» No response to treatment.
» All children other than those with insufficient food intake (If there is inadequate
food intake, refer to a social worker, if available).
» Severe malnutrition.

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Children and infants who have either:
» Unsatisfactory weight gain (growth curve flattening or weight loss) on the Road
to Health chart/ booklet.
25
» Low weight for age (but WHZ > -2)

2018 3.10
&+$37(5 1875,7,21$1'$1$(0,$

1RWHBabies who were premature and are growing parallel to or better than the z-
score line, should not be classified as having failure to thrive or not growing well.
Not growing well may be due to:
» Insufficient food intake due to anorexia and illness or poor availability of food.
» Insufficient uptake of nutrients, e.g. malabsorption.
» Insufficient use of nutrients for growth due to chronic disease.
» Increased demand for nutrients due to illness such as TB and HIV/ AIDS.
Conduct a feeding and clinical assessment to determine the cause. Exclude anaemia.

*(1(5$/0($685(6
» Counselling on nutrition (see below).
» Nutritional supplementation should be supplied unless there is a correctable cause.
» Assess the general condition of the child.
» Assess the child for possible HIV and TB, and manage appropriately.
» Assess for other long-term health conditions, and manage appropriately.
» Assess the child’s feeding and recommend actions as outlined below.
» Provide supplements according to the child’s age to meet specific nutritional
needs.
» Provide adequate micronutrients.
» Ensure that immunisations are up to date. Record the dose given on the Road
to Health chart/booklet.
» Follow up monthly. If responding, review the child every two months.
» Refer for social assistance if needed.
)HHGLQJUHFRPPHQGDWLRQVIRUDOOFKLOGUHQ
0–6 months of age
Breastfeed exclusively- feed at least 8 times in 24 hours.
If formula is medically indicated (refer below) or if the mother has chosen to formula-feed
the child, discuss safe preparation and use with the mother.
6–12 months of age
Continue breastfeeding (breastfeed before giving foods).
Introduce complementary foods at six months of age. Start by giving 2–3 teaspoons
of iron-rich food such as mashed vegetables or cooked dried beans.
Children 6–8 months should be given two meals daily, gradually increasing the
number of meals so that at 12 months the child is receiving 5 small meals.
For children who are not growing well, mix margarine, fat, or oil with their porridge.
12 months to 2 years of age
Continue breastfeeding. If the child is not breastfed, give 2 cups of full cream cow’s
milk every day. Make starchy foods the basis of the child’s meal. Give locally
available protein at least once a day, and fresh fruit or vegetables twice every day.
2–5 years of age
Give the child his/her own serving of family foods 3 times a day. In addition, give 2
nutritious snacks e.g. bread with peanut butter, full cream milk or fresh fruit between
meals.

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2018 3.11
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Infants with a small number of metabolic diseases qualify to receive specialised

infant formula. These infants should be managed in tertiary centres.
Maternal medical condition that may justify temporary or permanent avoidance of
breastfeeding:
» Severe illness that prevents a mother from caring for her infant, e.g.: sepsis,
renal failure.
» Herpes simplex virus type 1 (HSV-1): direct contact between lesions on the
mother’s breasts and the infant’s mouth should be avoided until all active lesions
have resolved.
» Maternal medications: sedating psychotherapeutic medicines, anti-epileptic
medicines and opioids (may cause drowsiness and respiratory depression in the
infant), radioactive iodine-131, excessive use of topical iodine or iodophors
(especially on open wounds or mucous membranes), cytotoxic chemotherapy.
Infants who qualify to receive infant formula as part of the supplementation scheme:
» The mother has died or infant has been abandoned.
» Other individual circumstances deemed necessary by a multidisciplinary team.
» Infants of mothers who are failing second or third line ARV treatment (VL >1000
copies/ml) should be advised not to breastfeed.
LoE:IIIx
0(',&,1(75($70(17
x Multivitamin, oral, daily.
(PSLULFWUHDWPHQWIRUZRUPVWKLVZLOOQRWWUHDWWDSHZRUP
x Mebendazole, oral.
o Children 1–2 years: 100 mg 12 hourly for 3 days.
o Children > 2–5 years: 500 mg as a single dose.
25
Albendazole oral, single dose.
o Children 1–2 years: 200 mg as a single dose.
o Children • 2 years and adults: 400 mg as a single dose.
x
LoE:IIxi
Vitamin A (retinol), oral, 6 monthly.
$JHUDQJH 'RVH &DSVXOH &DSVXOH
Units 100 000 IU 200 000 IU
Infants 6–11 months 100 000 1 capsule –
Children 12 months–5 years 200 000 2 capsules 1 capsule
$QDHPLD
See Section 3.1: Anaemia.

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» No response to treatment.
» All children other than those with insufficient food intake (If there is inadequate
food intake, refer to a social worker, if available).
» Severe malnutrition.

2018 3.12
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29(5:(,*+7$1'2%(6,7<
E66.0/E66.8/E66.9

'(6&5,37,21
Overweight and obesity are abnormal or excessive fat accumulation that may impair
health.
Body mass index (BMI) is a simple index of weight-for-height that is commonly used
to classify overweight and obesity in adults (> 19 years). It is defined as a person's
weight in kilograms divided by the square of his height in meters (kg/m2).
)RUDGXOWV
» overweight is a BMI •25; and
» obesity is a BMI •30.
&KLOGUHQDJHGEHWZHHQ±\HDUV
» overweight is BMI-for-age > 1 standard deviation above the WHO Growth
Reference median; and
» obesity is > 2 standard deviations above the WHO Growth Reference median.
)RUFKLOGUHQ\HDUVRIDJH
» overweight is weight-for-height > 2 standard deviations above WHO Child
Growth Standards median; and
» obesity is weight-for-height > 3 standard deviations above the WHO Child
Growth Standards median.

*(1(5$/0($685(6
» maintain ideal weight, i.e. BMI ” 25 kg/m2
» weight reduction, i.e. if BMI > 25 kg/m2
» follow a prudent eating plan i.e. low fat, high fibre and unrefined carbohydrates,
with fresh fruit and vegetables
» regular moderate aerobic exercise, e.g. 30 minutes brisk walking 3–5
times/week (150 minutes/week)
» screen for hypertension, diabetes and hyperlipidaemia, and manage
appropriately (See Sections: 4.7: Hypertension, 9.2 Type 2 Diabetes mellitus,
4.1: Prevention of ischaemic heart disease and atherosclerosis).
» calculate risk of developing cardiovascular events and manage appropriately
(See Section: 4.1: Prevention of ischaemic heart disease and atherosclerosis).

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Dietician and support group, where available.

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'(6&5,37,21
A condition predominantly affecting the skin, mucous membranes and the eyes.
It is most common in children of 1–5 years of age.

2018 3.13
&+$37(5 1875,7,21$1'$1$(0,$

If associated with measles and diarrhoea there is an increased risk of illness and death.
If not identified and treated early, it can cause blindness.
Clinical features include:
» night blindness or inability to see in the dark
» white foamy patches on the eye (Bitot’s spot) or conjunctival and corneal dryness
» keratomalacia or wrinkling and cloudiness of cornea
» corneal ulceration or the cornea becomes soft and bulges

*(1(5$/0($685(6

 fortified maize meal and/or bread,

Increase dietary intake of vitamin A rich food including:

 carrots, sweet potato, mangoes and pawpaw, broccoli, sprouts,

 dark green leafy vegetables e.g. morogo/imifino and spinach,
 apricots, melon, pumpkin, and
 liver, eggs, full cream milk and fish

0(',&,1(75($70(17
3URSK\OD[LV
x Vitamin A (retinol), oral, every 6 months up to the age of 5 years.
$JHUDQJH 'RVH &DSVXOH &DSVXOH
Units 100 000 IU 200 000 IU
Infants 6–11 months 100 000 1 capsule –
Children 12 months–5 years 200 000 2 capsules 1 capsule
Children with the following conditions should be given an additional dose:
» Severe Acute Malnutrition
» persistent diarrhoea
» measles
x Vitamin A (retinol), oral.
$JHUDQJH 'RVH &DSVXOH &DSVXOH
Units 100 000 IU 200 000 IU
Infant < 6 months 50 000 ½ capsule –
Infants 6–11 months 100 000 1 capsule –
Children 12 months–5 years 200 000 2 capsule 1 capsule
Administration of a vitamin A capsule
o Cut the narrow end of the capsule with scissors.
o Open the child’s mouth by gently squeezing the cheeks.
o Squeeze the drops from the capsule directly into the back of the child’s
mouth. If a child spits up most of the vitamin A liquid immediately, give one
more dose.
o Do 127 give the capsule to the mother or the caretaker to take home.

2018 3.14
&+$37(5 1875,7,21$1'$1$(0,$

7UHDWPHQW
If any clinical eye signs of vitamin A deficiency are present (see clinical features

x Vitamin A (retinol), oral, as a pre-referral dose.

above), give a pre-referral dose:

$JHUDQJH 'RVH &DSVXOH &DSVXOH

Units (IU) 100 000 IU 200 000 IU
Infant < 6 months 50 000 ½ capsule –
Infants 6–11 months 100 000 1 capsule –
Children > 12 months and adults 200 000 2 capsule 1 capsule
1RWH
» Children (6 months to 5 years of age) who received a routine prophylactic dose
within the previous month should not receive any additional doses of vitamin A.
» If a child is scheduled to receive a routine prophylactic dose of vitamin A and
has received a treatment dose within the past month, postpone the routine dose
for approximately one month.
» Wait at least one month between doses.
» Children receiving routine multivitamin syrup can still receive vitamin A
supplements.

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All cases with clinical signs.

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E52

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Pellagra is a condition associated with nicotinic acid deficiency. It is usually
accompanied by other vitamin deficiencies.
Clinical features include:
» diarrhoea
» dementia
» dermatitis with darkening of sun-exposed skin

*(1(5$/0($685(6
» Lifestyle adjustment including discouraging of alcohol abuse.


» Dietary advice. Increase intake of:


liver, kidneys, other meats, poultry and fish


milk


marmite and Brewer’s yeast
peanuts, pulses, whole meal wheat and bran

2018 3.15
&+$37(5 1875,7,21$1'$1$(0,$

0(',&,1(75($70(17
)RUVHYHUHGHILFLHQF\

x Nicotinamide, oral, 50 mg 8 hourly until resolution of major signs and symptoms.

Children

x Nicotinamide, oral, 100 mg 8 hourly until skin lesions heal

Adults

LoE:IIIxii
)RUPLOGGHILFLHQF\

x Nicotinamide, oral, 50 mg daily for one week.

Children

x Nicotinamide, oral, 100 mg daily for one week.

Adults

5()(55$/
Failure to respond.

9,7$0,1%3<5,'2;,1('(),&,(1&<
E53.1

'(6&5,37,21
Commonly presents as signs of peripheral neuropathy including:
» tingling sensation
» burning pain or numbness of the feet
Pyridoxine deficiency is related to:
» malnutrition
» alcoholism
» isoniazid or combination TB therapy

*(1(5$/0($685(6
Dietary advice: Increase intake of pyridoxine rich foods such as:
» Liver, meat, fish and offal,
» Wholegrain cereals, fortified breakfast cereals,
» Peanuts, bananas, raw vegetables,
» Walnuts and seeds, avocados, dried fruits,
» Potatoes and baked beans.

0(',&,1(75($70(17
)RUGHILFLHQF\

x Pyridoxine, oral, 12.5 mg daily for 3 weeks.

Children

x Pyridoxine, oral, 25 mg daily for 3 weeks.

Adults

2018 3.16
&+$37(5 1875,7,21$1'$1$(0,$

)RUPHGLFLQHLQGXFHGQHXURSDWK\

x Pyridoxine, oral, daily for 6 months.

Children

o < 5 years of age: 12.5 mg daily.

o • 5 years of age: 25 mg.
LoE:IIIxiii

x Pyridoxine, oral, 200 mg daily for 3 weeks.

Adults

x Pyridoxine, oral, 25 mg daily as maintenance dose (for patients on TB

Then follow with:

therapy/isoniazid).

5()(55$/
» Failure to respond.
» Children.

 9,7$0,1 %7+,$0,1( '(),&,(1&< :(51,&.(

 (1&(3+$/23$7+<$1'%(5,%(5,
E51.1-2/E51.8-9

'(6&5,37,21
Clinical features include:
» confusion
» short-term memory loss
» paralysis of one or more of the ocular muscles or ophthalmoplegia
» nystagmus
» ataxia
» peripheral neuropathy
» cardiac failure
Alcoholics may present with Wernicke encephalopathy, neuropathies or cardiac
failure associated with multiple vitamin deficiencies.

*(1(5$/0($685(6
» Lifestyle adjustment including discouraging alcohol abuse.

 wholewheat breads, oatmeal

» Dietary advice to increase intake of thiamine rich foods such as:

 pulses, nuts, yeast

 fortified cereals
 pork, bacon and marmite
 potatoes and peas

0(',&,1(75($70(17
3HULSKHUDOQHXURSDWK\DQGFDUGLDFIDLOXUH
x Thiamine, oral, 100 mg daily.

2018 3.17
&+$37(5 1875,7,21$1'$1$(0,$

In susceptible patients, administration of intravenous glucose precipitates Wernicke

encephalopathy if administered before thiamine supplementation. Thiamine should
be given first in all patients treated with intravenous glucose who are at risk of
thiamine deficiency, e.g. alcoholics.

5()(55$/
All patients with encephalopathy, eye muscle paralysis or cardiac failure.

5HIHUHQFHV
i Albendazole, oral: Steinmann P, Utzinger J, Du ZW, Jiang JY, Chen JX, Hattendorf J, Zhou H, Zhou XN. Efficacy of single-
dose and triple-dose albendazole and mebendazole against soil-transmitted helminths and Taenia spp.: a randomized
controlled trial. PLoSOne. 2011;6(9):e25003. https://www.ncbi.nlm.nih.gov/pubmed/21980373
Albendazole, oral:Mabaso ML, Appleton CC, Hughes JC, Gouws E. Hookworm (Necatoramericanus) transmission in inland
areas of sandy soils in KwaZulu-Natal, South Africa. Trop MedInt Health. 2004 Apr;9(4):471-6.
https://www.ncbi.nlm.nih.gov/pubmed/15078265
Albendazole, oral: Montresor A, Awasthi S, Crompton DW. Use of benzimidazoles in children younger than 24 months for
the treatment of soil-transmitted helminthiasis. Acta Trop. 2003 May;86(2-3):223-
32.https://www.ncbi.nlm.nih.gov/pubmed/12745139
Albendazole, oral: American Academy of Pediatrics. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book:
2012 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2012:241.
https://redbook.solutions.aap.org/DocumentLibrary/RB12_interior.pdf
Albendazole, oral: National Department of Health: Affordable Medicines, EDP-PHC. Medicine Review: Benzimidazoles for
soil-transmitted helminths, 31Jan2017http://www.health.gov.za/
ii Ferrous sulfate, oral: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of

Cape Town, 2016.

Ferrous sulfate, oral: Reveiz L, Gyte GM, Cuervo LG, Casasbuenas A. Treatments for iron-deficiency anaemia in
pregnancy. Cochrane Database Syst Rev. 2011 Oct 5;(10):CD003094. https://www.ncbi.nlm.nih.gov/pubmed/21975735
Ferrous sulfate, oral : Rimon E, Kagansky N, Kagansky M, Mechnick L, Mashiah T, Namir M, Levy S. Are
we giving too much iron? Low-dose iron therapy is effective in octogenarians. Am J Med. 2005 Oct;118(10):1142-7.
https://www.ncbi.nlm.nih.gov/pubmed/16194646
Ferrous sulfate, oral: National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML,
2015. http://www.health.gov.za/ Ferrous fumarate, oral: South African Medicines Formulary. 12th Edition. Division of
Clinical Pharmacology. University of Cape Town, 2016.
iii Iron prophylaxis - preterm infants: National Department of Health, Essential Drugs Programme: Paediatric Hospital Level

STGs and EML, 2017. http://www.health.gov.za/

Iron prophylaxis - preterm infants: Baker RD, Greer FR; Committee on Nutrition American Academy of Pediatrics.Diagnosis
and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age). Pediatrics. 2010
Nov;126(5):1040-50.https://www.ncbi.nlm.nih.gov/pubmed/20923825
Iron prophylaxis - preterm infants: National Department of Health: Newborn care charts, 2014. http://www.health.gov.za/
iv Iron preparations: National Department of Health, Essential Drugs Programme: Paediatric Hospital Level STGs and EML,

2017. http://www.health.gov.za/
Iron preparations: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of Cape
Town, 2016.
v Albendazole, oral: Steinmann P, Utzinger J, Du ZW, Jiang JY, Chen JX, Hattendorf J, Zhou H, Zhou XN. Efficacy of single-

dose and triple-dose albendazole and mebendazole against soil-transmitted helminths and Taenia spp.: a randomized
controlled trial. PLoSOne. 2011;6(9):e25003. https://www.ncbi.nlm.nih.gov/pubmed/21980373
Albendazole, oral:Mabaso ML, Appleton CC, Hughes JC, Gouws E. Hookworm (Necatoramericanus) transmission in inland
areas of sandy soils in KwaZulu-Natal, South Africa. Trop MedInt Health. 2004 Apr;9(4):471-6.
https://www.ncbi.nlm.nih.gov/pubmed/15078265
Albendazole, oral:Montresor A, Awasthi S, Crompton DW. Use of benzimidazoles in children younger than 24 months for
the treatment of soil-transmitted helminthiasis. Acta Trop. 2003 May;86(2-3):223-
32.https://www.ncbi.nlm.nih.gov/pubmed/12745139
Albendazole, oral:American Academy of Pediatrics. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book:
2012 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2012:241.
https://redbook.solutions.aap.org/DocumentLibrary/RB12_interior.pdf
Albendazole, oral: National Department of Health: Affordable Medicines, EDP-PHC. Medicine Review: Benzimidazoles for
soil-transmitted helminths, 31Jan2017http://www.health.gov.za/
vi Vitamin A, oral (MAM): National Department of Health. Integrated management of children with acute malnutrition in South

Africa: Operational Guidelines, 2015.http://www.health.gov.za/

vii Multivitamin, oral (MAM): National Department of Health. Integrated management of children with acute malnutrition in

South Africa: Operational Guidelines, 2015.http://www.health.gov.za/

viii Mebendazole, oral (MAM): National Department of Health. Integrated management of children with acute malnutrition in

South Africa: Operational Guidelines, 2015.http://www.health.gov.za/

2018 3.18
&+$37(5 1875,7,21$1'$1$(0,$
ix Albendazole, oral: Steinmann P, Utzinger J, Du ZW, Jiang JY, Chen JX, Hattendorf J, Zhou H, Zhou XN. Efficacy of single-

dose and triple-dose albendazole and mebendazole against soil-transmitted helminths and Taenia spp.: a randomized
controlled trial. PLoSOne. 2011;6(9):e25003. https://www.ncbi.nlm.nih.gov/pubmed/21980373
Albendazole, oral:Mabaso ML, Appleton CC, Hughes JC, Gouws E. Hookworm (Necatoramericanus) transmission in inland
areas of sandy soils in KwaZulu-Natal, South Africa. Trop MedInt Health. 2004 Apr;9(4):471-6.
https://www.ncbi.nlm.nih.gov/pubmed/15078265
Albendazole, oral: Montresor A, Awasthi S, Crompton DW. Use of benzimidazoles in children younger than 24 months for
the treatment of soil-transmitted helminthiasis. Acta Trop. 2003 May;86(2-3):223-32.
https://www.ncbi.nlm.nih.gov/pubmed/12745139
Albendazole, oral:American Academy of Pediatrics. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book:
2012 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2012:241.
https://redbook.solutions.aap.org/DocumentLibrary/RB12_interior.pdf
Albendazole, oral:National Department of Health: Affordable Medicines, EDP-PHC. Medicine Review: Benzimidazoles for
soil-transmitted helminths, 31Jan2017http://www.health.gov.za/
x Supplementary infant feeding (Mothers failing 2nd or 3rd line ART): National Department of Health, Essential Drugs

Programme: Paediatric Hospital Level STGs and EML, 2017. http://www.health.gov.za/

xi Albendazole, oral: Steinmann P, Utzinger J, Du ZW, Jiang JY, Chen JX, Hattendorf J, Zhou H, Zhou XN. Efficacy of single-

dose and triple-dose albendazole and mebendazole against soil-transmitted helminths and Taenia spp.: a randomized
controlled trial. PLoSOne. 2011;6(9):e25003. https://www.ncbi.nlm.nih.gov/pubmed/21980373
Albendazole, oral:Mabaso ML, Appleton CC, Hughes JC, Gouws E. Hookworm (Necatoramericanus) transmission in inland
areas of sandy soils in KwaZulu-Natal, South Africa. Trop MedInt Health. 2004 Apr;9(4):471-6.
https://www.ncbi.nlm.nih.gov/pubmed/15078265
Albendazole, oral:Montresor A, Awasthi S, Crompton DW. Use of benzimidazoles in children younger than 24 months for
the treatment of soil-transmitted helminthiasis. Acta Trop. 2003 May;86(2-3):223-
32.https://www.ncbi.nlm.nih.gov/pubmed/12745139
Albendazole, oral:American Academy of Pediatrics. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book:
2012 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2012:241.
https://redbook.solutions.aap.org/DocumentLibrary/RB12_interior.pdf
Albendazole, oral: National Department of Health: Affordable Medicines, EDP-PHC. Medicine Review: Benzimidazoles for
soil-transmitted helminths, 31Jan2017http://www.health.gov.za/
xii Nicotinamide, oral (duration of therapy): South African Medicines Formulary. 12th Edition. Division of Clinical

Pharmacology. University of Cape Town, 2016.

xiii Pyridoxine, oral (children – medicine induced neuropathy): National Department of Health, Essential Drugs Programme:

Paediatric Hospital Level STGs and EML, 2017. http://www.health.gov.za/

2018 3.19
PHC Chapter 4: Cardiovascular
conditions

4.1 Prevention of ischaemic heart disease and

atherosclerosis
4.2 Angina pectoris, stable
4.3 Angina pectoris, unstable/ Non ST elevation
myocardial infarction (NSTEMI)
4.4 Myocardial infarction, acute (AMI)/ ST elevation
myocardial infarction (STEMI)
4.5 Cardiac arrest, cardiopulmonary resuscitation
4.6 Cardiac failure, congestive (CCF)
4.6.1 Cardiac failure, congestive (CCF), adults
4.6.2 Cardiac failure, congestive (CCF), children
4.7 Hypertension
4.7.1 Hypertension in adults
4.7.2 Hypertensive emergency
4.7.3 Hypertension in children
4.8 Pulmonary oedema, acute
4.9 Rheumatic fever, acute
4.10 Valvular heart disease and congenital structural
heart disease
CHAPTER 4 CARDIOVASCULAR CONDITIONS

4.1 PREVENTION OF ISCHAEMIC HEART DISEASE AND

ATHEROSCLEROSIS
I20.0-1/I20.8-9/I21.0-4/I21.9/I22.0-1/I22.8-9/I24.0-1/I24.8-9/I25.0-6/I25.8-9/I63.0-6/I63.8-
9/I64/I65.0-3/I65.8-9/I73.8-9/G45.0-2/G45.8-9

Patients at risk for cardiovascular diseases (such as stroke or myocardial infarction)

may benefit from lifestyle modification and lipid-lowering medicine therapy. Patients
should be managed according to their level of risk, and lipid lowering medicines
should be given to those with a high risk of CVD even if cholesterol is within the
desirable range.
Indications for lipid lowering medicine therapy
Patients with any of the following factors are at a relatively high risk for a
cardiovascular event and should receive lipid lowering therapy:

 ischaemic heart disease

» Established atherosclerotic disease:

 peripheral vascular disease

 atherothrombotic stroke
» Type 2 diabetes with age > 40 years.
» Diabetes for > 10 years.
» Diabetes with chronic kidney disease (eGFR < 60 mL/min).
Patients with any of the following factors are also potentially at risk for
cardiovascular disease (other than the categories above)
» diabetes mellitus
» hypertension
» central obesity: waist circumference • 94 cm (men) and • 80 cm (women)
» smoking
» age: men > 55 years of age, women > 65 years of age
These patients should be managed according to their 10-year risk of a
cardiovascular event as calculated using either:
A. BMI - based risk assessment, or
B. Framingham risk score (cholesterol-based assessment).

 < 10% risk: lifestyle modification and risk assess patient every 5 years
Management is based on the patient’s 10-year risk of a cardiovascular event as follows:

 10–20% risk: lifestyle modification and risk assess patient annually

 • 20% risk: lifestyle modification and start statin treatment
Cardiovascular disease risk assessment
A: BMI-based risk assessment:
1. Measure body mass index (BMI): BMI=weight (kg)/[height (m) x height (m)]
2. Measure blood pressure. LoE:IIIi
3. Calculate 10-year risk of a cardiovascular event using the
BMI-based CVD risk tool.
(BMI and BMI-based CVD risk tools are available on the EML Clinical Guide
mobile application or at: https://www.framinghamheartstudy.org/fhs-risk-
functions/cardiovascular-disease-10-year-risk/#).

2018 4.2
CHAPTER 4 CARDIOVASCULAR CONDITIONS

B: Framingham risk score (cholesterol-based):

Calculation of risk of developing cardiovascular events over 10 years
(in the absence of cardiovascular disease or genetic disorders such as
familial hypercholesterolaemia)

To derive the absolute risk as a percentage of patients who will have a

cardiovascular event (i.e. death, myocardial infarction or stroke) over 10 years, add
the points for each risk category (Section A). The risk associated with the total
points is then derived from Section B.
SECTION A
Age MEN WOMEN
(years)
30–34 0 0
35–39 2 2
40–44 5 4
45–49 6 5
50–54 8 7
55–59 10 8
60–64 11 9
65–69 12 10
70–74 14 11
75–79 15 12

Total cholesterol MEN WOMEN

(mmol/L)
<4.1 0 0
4.1–5.19 1 1
5.2 – 6.19 2 3
6.2–7.2 3 4
>7.2 4 5

HDL cholesterol MEN WOMEN

(mmol/L)
>1.5 –2 –2
1.3–1.49 –1 –1
1.2–1.29 0 0
0.9–1.119 1 1
<0.9 2 2

MEN WOMEN
Smoker 4 3
Diabetic* 3 4

*Type 2 diabetics > 40 years of age qualify for statin therapy irrespective of risk score.

2018 4.3
CHAPTER 4 CARDIOVASCULAR CONDITIONS

MEN WOMEN
Systolic BP Untreated Treated Untreated Treated
(mmHg)
<120 –2 0 –3 –1
120–129 0 2 0 2
130–139 1 3 1 3
140–149 2 4 2 5
150–159 2 4 4 6
•160 3 5 5 7
SECTION B
Total points
MEN 10-year risk % WOMEN 10-year risk %
”–3 <1 ”–2 <1
–2 1.1 –1 1.0
–1 1.4 0 1.2
0 1.6 1 1.5
1 1.9 2 1.7
2 2.3 3 2.0
3 2.8 4 2.4
4 3.3 5 2.8
5 3.9 6 3.3
6 4.7 7 3.9
7 5.6 8 4.5
8 6.7 9 5.3
9 7.9 10 6.3
10 9.4 11 7.3
11 11.2 12 8.6
12 13.2 13 10.0
13 15.6 14 11.7
14 18.4 15 13.7
15 21.6 16 15.9
16 25.3 17 18.5
17 29.4 18 21.5
•18 >30 19 24.8
Calculation of CVS risk using the table:
A risk of MI > 20% in 10 years equates to • 15 points for men, and • 18 points for
women. It is important to score each patient individually, as there are many
combinations of risk factors that can add up to those total points.
For example:
» A male patient > 60 years old with systolic BP > 140 mmHg on treatment would

 11 points for his sex and age

score:

 4 points for his on-treatment BP

 Total: 15 points

2018 4.4
CHAPTER 4 CARDIOVASCULAR CONDITIONS

» A male patient > 50 years old with systolic BP > 130 mmHg on treatment who is

 8 points for his sex and age

a smoker would score:

 3 points for his on-treatment BP

 4 points for his smoking status
 Total: 15 points

» A female patient > 70 years old with systolic BP > 160 mmHg on treatment

 11 points for her sex and age

would score:

 7 points for her on-treatment BP

 Total: 18 points

Screening for familial hypercholestareamia:

In addition to the above cardiovascular risk assessment, measure random total
cholesterol in patients with the following features (suggestive of familial
hypercholesterolaemia or other heritable dyslipidaemias), regardless of their
cardiovascular risk:
» cardiovascular event < 55 years in men or < 65 years in women
» family history of early onset cardiovascular disease in male relatives < 55 years
of age and in female relatives < 65 years of age
» skin or tendon xanthomata in patient or first degree relative
» family history of familial hyperlipidaemia
Refer patients with random total cholesterol > 7.5 mmol/L for further investigation.

GENERAL MEASURES
All people with any risk factors for cardiovascular disease should be encouraged to
make the following lifestyle changes as appropriate.
» maintain ideal weight, i.e. BMI < 25 kg/m2
» weight reduction in the overweight patient, i.e. BMI > 25 kg/m2
» reduce alcohol intake to ” 2 standard drinks/day for men and ” 1 for women on
no more than 5 out of 7 days per week (1 standard drink is equivalent to 25 mL
of spirits, 125 mL of wine, 340 mL of beer or sorghum beer, or 60 mL of sherry)
» follow a prudent eating plan i.e. low fat, high fibre and unrefined carbohydrates,
with fresh fruit and vegetables
» regular moderate aerobic exercise, e.g. 30 minutes brisk walking 3–5
times/week (150 minutes/week)
» stop smoking

MEDICINE TREATMENT
Note:
» Lipid lowering medicines should be given to those with a high risk of CVD even
if cholesterol is within the desirable range.
» When lipid-lowering medicines are used, this is ALWAYS in conjunction with
ongoing lifestyle modification.

2018 4.5
CHAPTER 4 CARDIOVASCULAR CONDITIONS

ƒ HMGCoA reductase inhibitors (statins), according to table below:

INDICATION HMGCOA REDUCTASE INHIBITOR
(STATIN) DOSE
A: Primary prevention - no existing CVD
» Type 2 diabetes with age > 40 years. x Simvastatin, oral, 10 mg at night.
» Diabetes for > 10 years.
» Diabetes with chronic kidney disease.
» • 20% 10-year risk of cardiovascular

x Atorvastatin, oral, 10 mg at night.

event.
» Patients on protease inhibitors.
(Risks as above, after switching to
atazanavir – see section below).
B: Secondary prevention – existing CVD
» Ischaemic heart disease. x Simvastatin, oral, 40 mg at night
» Atherothrombotic stroke. LoE:Iii

x Atorvastatin, oral, 10 mg at night.

» Peripheral vascular disease.
» Patients on protease inhibitors.

x Simvastatin, oral, 10 mg at night.

LoE:Iiii

» Patients on amlodipine (and not on

protease inhibitor). LoE:IIIiv

x Simvastatin, oral, 10 mg at night.

» If patient complains of muscle pain. Reduce dose to:

OR
Refer for further management.
LoE:IIIv

Protease inhibitor-induced dyslipidaemia:

» Certain antiretroviral medication, particularly protease inhibitors, can cause
dyslipidaemia. Fasting lipid levels should be done 3 months after starting
lopinavir/ritonavir. Lopinavir/ritonavir is associated with a higher risk of
dyslipidaemia (specifically hypertriglyceraemia) than atazanavir/ritonavir.
» Patients at high risk (> 20% risk of developing a CVS event in 10 years) should
switch to atazanavir/ritonavir and repeat the fasting lipid profile in 3 months.
» Patients with persistent dyslipidaemia despite switching, qualify for lipid lowering
therapy. Criteria for initiating lipid lowering therapy are the same as for HIV-
uninfected patients. Many statins (including simvastatin) cannot be used with
protease inhibitors, as protease inhibitors inhibit the metabolism of the statin
resulting in extremely high blood levels.
» Patients who fail to respond to lifestyle modification and have dyslipidaemia

x Atorvastatin, oral, 10 mg at night.

treat with:

2018 4.6
CHAPTER 4 CARDIOVASCULAR CONDITIONS

REFERRAL
» Random cholesterol > 7.5 mmol/L (to be evaluated for genetic disorders), after
excluding secondary causes such as uncontrolled diabetes, hypothyroidism, or
protease inhibitor use.
» Tendon or skin xanthomata (except xanthelasma around the eyes).
» Statins not tolerated by patients, despite lower dose (for consideration of
alternative treatment).

4.2 ANGINA PECTORIS, STABLE

I20.9

DESCRIPTION
Characteristic chest pain (burning or heavy discomfort behind the sternum), of
duration < 15 minutes, due to myocardial ischaemia, usually occurring on exercise
and relieved by rest.

GENERAL MEASURES
Life style modification. See Section 4.1: Prevention of ischaemic heart disease and
atherosclerosis.

MEDICINE TREATMENT (Doctor initiated)

x Aspirin, oral, 75–100 mg daily.

Long-term prophylaxis for thrombosis:

x Aspirin, oral, 150 mg daily.

If unavailable: LoE:Ivi

AND
ƒ Nitrates, short acting e.g.:
x Isosorbide dinitrate, sublingual, 5 mg.
o May be repeated if required at 5–10 minute intervals for 3 doses.
AND

x Atenolol, oral, 50–100 mg daily.

Step 1

o Titrate to resting heart rate of approximately 60 beats/minute.

If ß-blocker cannot be tolerated or is contraindicated, consider long-acting calcium
channel blocker.

Step 2
ADD
ƒ Long-acting calcium channel blocker e.g.:
x Amlodipine, oral, 5 mg daily.

Step 3
ADD
x Isosorbide mononitrate, oral, 10–30 mg twice daily. LoE:IIIvii
OR

2018 4.7
CHAPTER 4 CARDIOVASCULAR CONDITIONS

Isosorbide dinitrate, oral, 20–30 mg twice daily.

o At 8:00 and 14:00 hours for both medicines in order to provide a nitrate free
period to prevent tolerance.
o Modify for night shift workers.

Angina is a high-risk condition for cardiovascular disease and an indication for a statin.
ƒ HMGCoA reductase inhibitors (statins), e.g.:
x Simvastatin, oral, 40 mg at night.
LoE:Iviii

x Atorvastatin, oral, 10 mg at night.

Patients on protease inhibitor:

LoE:Iix

x Simvastatin, oral, 10 mg at night.

Patients on amlodipine (and not on a protease inhibitor):

LoE:IIIx
If patient complains of muscle pain:

x Simvastatin, oral, 10 mg at night.

Reduce dose to:

OR
Refer for further management.
LoE:IIIxi
REFERRAL
» When diagnosis is in doubt.
» Failed medical therapy.

4.3 ANGINA PECTORIS, UNSTABLE / NON ST ELEVATION

MYOCARDIAL INFARCTION (NSTEMI)
I20.0/I21.0-4/I21.9/I22.0-1/I22.8-9/I24.8-9/I25.6/I25.8-9

DESCRIPTION
Unstable angina is a medical emergency and if untreated can progress to NSTEMI.
Presents as chest pain or discomfort similar to stable angina but with the following
additional characteristics:
» angina at rest or minimal effort
» angina occurring for the first time, particularly if it occurs at rest
» prolonged angina > 10 minutes, not relieved by sublingual nitrates
» the pattern of angina accelerates and gets worse

DIAGNOSIS
» Made from good history.
» ECG may show ST segment depression or transient ST segment elevation.
» Normal ECG does not exclude the diagnosis.

x
MEDICINE TREATMENT LoE:Ixii
Oxygen 40% via facemask, if saturation < 94% or if in distress.

2018 4.8
CHAPTER 4 CARDIOVASCULAR CONDITIONS

x Aspirin, oral, 75–100 mg as a single dose (chewed or dissolved) as soon as

possible.

x Aspirin, oral, 150 mg as a single dose.

If unavailable:

LoE:Ixiii

x Isosorbide dinitrate, sublingual, 5 mg immediately and then repeat once if

ADD

necessary for pain relief.

x Morphine 10 mg diluted with 10 mL of water for injection or sodium chloride

ADD

0.9%, slow IV (Doctor initiated).

o Start with 5 mg; thereafter slowly increase by 1 mg/minute up to 10 mg.
o Can be repeated after 4–6 hours if necessary, for pain relief.
o Beware of hypotension.

Continuation of aftercare treatment initiated at higher level of care:

Continue therapy with appropriate lifestyle modification and adherence support.
x Aspirin, oral, 75–100 mg daily (continued indefinitely in absence of
contraindications). LoE:Ixiv

x Aspirin, oral, 150 mg daily.

If unavailable:

When clinically stable without signs of heart failure, hypotension,

ƒ Cardio-selective E-blocker, e.g.:(Doctor prescribed)

bradydysrhythmias or asthma:

x Atenolol, oral, 50 mg daily.

AND
ƒ
x
HMGCoA reductase inhibitors (statins), e.g.:
Simvastatin, oral, 40 mg at night. LoE:Ixv

x Atorvastatin, oral, 10 mg at night.

Patients on protease inhibitor:
LoE:Ixvi

x Simvastatin, oral, 10 mg at night.

Patients on amlodipine (and not on a protease inhibitor):

LoE:IIIxvii
If patient complains of muscle pain:

x Simvastatin, oral, 10 mg at night.

Reduce dose to:

OR
Refer for further management.
LoE:IIIxviii
AND
If there is cardiac failure or LV dysfunction (Doctor prescribed):
ƒ ACE-inhibitor, e.g.:
x Enalapril, oral, target dose 10 mg 12 hourly (usually titrated from LoE:IIIxix

2018 4.9
CHAPTER 4 CARDIOVASCULAR CONDITIONS

2.5 mg 12 hourly).

Angioedema is a potentially serious complication of ACE-inhibitor treatment and if it

occurs it is a contraindication to continued therapy or to re-challenge.

REFERRAL
Urgent
All suspected or diagnosed cases.

4.4 MYOCARDIAL INFARCTION, ACUTE (AMI)/ ST

ELEVATION MYOCARDIAL INFARCTION (STEMI)
I21.0-4/I21.9/I22.0-1/I22.8-9/I24.8-9/I25.6/I25.8-9

DESCRIPTION
AMI/STEMI is caused by the complete or partial occlusion of a coronary artery and
requires prompt hospitalisation and intensive care management.
The major clinical feature is severe chest pain with the following characteristics:
» site: retrosternal or epigastric
» quality: crushing, constricting, or burning pain or discomfort
» radiation: to the neck and/or down the inner part of the left arm
» duration: at least 20 minutes and often not responding to sublingual nitrates
» occurrence: at rest
May be associated with:
» pallor » pulmonary oedema
» sweating » a decrease in blood pressure
» arrhythmias
Note: Not all features have to be present.

EMERGENCY TREATMENT
Before transfer
Cardio-pulmonary resuscitation if necessary (See Section 21.1: Cardiac arrest –
cardiopulmonary resuscitation).
x Oxygen 40% via facemask, if saturation < 94% or if in distress. LoE:Ixx

x Aspirin, oral, 75–100 mg as a single dose (chewed or dissolved) as soon as

AND

possible.

x Aspirin, oral, 150 mg as a single dose.

If unavailable:
LoE:Ixxi

x Isosorbide dinitrate, sublingual, 5 mg, every 5–10 minutes as needed for relief of
AND

pain to a maximum of three tablets.

2018 4.10
CHAPTER 4 CARDIOVASCULAR CONDITIONS

x Morphine 10 mg diluted with 10 mL of water for injection or sodium chloride

AND

0.9%, slow IV (Doctor initiated).

o Start with 5 mg; thereafter slowly increase by 1 mg/minute up to 10 mg.
o Can be repeated after 4–6 hours if necessary, for pain relief.
o Beware of hypotension.
AND
ƒ Thrombolytic, e.g.:(see table for time window below):
x Streptokinase, IV 1.5 million units diluted in 100 mL sodium LoE:Ixxii
chloride 0.9%, infused over 30–60 minutes. Do not use heparin
if streptokinase is given. LoE:Ixxiii
o Hypotension may occur. If it does, reduce the rate of infusion
but strive to complete it in < 60 minutes.
o Streptokinase is antigenic and should not be re-administered in the period of
5 days to 2 years after 1st administration.
o Severe allergic reactions are uncommon but antibodies which may render it
ineffective may persist for years.
Indications Contra-indications
» For acute myocardial infarction with » Absolute:
ST elevation or left bundle branch Ͳ streptokinase used within the last year,
block: Ͳ previous allergy,
- if history of onset < 6 hours Ͳ CVA within the last 3 months,
(Beyond 6 hours treat as NSTEMI Ͳ history of recent major trauma,
(see below) Ͳ bleeding within the last month,
- if on-going ischaemic pain Ͳ aneurysms,
LoE:Ixxiv Ͳ brain or spinal surgery or head injury within the
preceding month, or
Ͳ active bleeding or known bleeding disorder.
» Relative:
Ͳ refractory hypertension,
Ͳ warfarin therapy,
Ͳ recent retinal laser treatment,
Ͳ subclavian central venous catheter,
Ͳ pregnancy,
Ͳ TIA in the preceding 6 months,
Ͳ traumatic resuscitation.
Continuation of aftercare treatment initiated at higher level of care:
Continue therapy with appropriate lifestyle modification and adherence support.
x Aspirin, oral, 75–100 mg daily (continued indefinitely in absence of
contraindications). LoE:Ixxv

x Aspirin, oral, 150 mg daily.

If unavailable:

When clinically stable without signs of heart failure, hypotension,

ƒ Cardio-selective E-blocker, e.g.:(Doctor prescribed)

bradydysrhythmias or asthma:

x Atenolol, oral, 50 mg daily.

2018 4.11
CHAPTER 4 CARDIOVASCULAR CONDITIONS

ƒ
x
HMGCoA reductase inhibitors (statins), e.g.:
Simvastatin, oral, 40 mg at night.
LoE:Ixxvi
x Atorvastatin, oral, 10 mg at night.
Patients on protease inhibitor:

LoE:Ixxvii
x Simvastatin, oral, 10 mg at night.
Patients on amlodipine (and not on a protease inhibitor):

LoE:IIIxxviii
If patient complains of muscle pain:

x Simvastatin, oral, 10 mg at night.

Reduce dose to:

OR LoE:IIIxxix
Refer for further management.

AND
If there is cardiac failure or LV dysfunction (Doctor prescribed):
ƒ ACE-inhibitor, e.g.:
x Enalapril, oral, target dose 10 mg 12 hourly (usually titrated from LoE:IIIxxx
2.5 mg 12 hourly).

Angioedema is a potentially serious complication of ACE-inhibitor treatment and if it

occurs it is a contraindication to continued therapy or to re-challenge.

REFERRAL
Urgent
All suspected or diagnosed cases.

4.5 CARDIAC ARREST, CARDIO-PULMONARYRESUSCITATION

See Chapter 21: Emergencies and injuries.

4.6 CARDIAC FAILURE, CONGESTIVE (CCF)

4.6.1 CARDIAC FAILURE, CONGESTIVE (CCF), ADULTS

I50.0-1/I50.9

DESCRIPTION
CCF is a clinical syndrome and has several causes. The cause and immediate
precipitating factor(s) must be identified and treated to prevent further damage to
the heart.
Signs and symptoms include:
» dyspnoea (breathlessness) » tachypnoea
» ankle swelling with pitting – men: breathing rate > 18 breaths/minute
oedema – women: breathing rate > 20 breaths/minute
» fatigue » inspiratory basal crackles or wheezing on

2018 4.12
CHAPTER 4 CARDIOVASCULAR CONDITIONS

» tachycardia auscultation of the lungs

» orthopnoea » enlarged liver, often tender
» raised jugular venous pressure

GENERAL MEASURES
» Monitor body weight to assess changes in fluid balance.
» Salt (sodium chloride) restriction to less than 2–3 g/day.
» Regular exercise within limits of symptoms.

MEDICINE TREATMENT
All patients should be assessed by a doctor for initiation or change of treatment.
» Many of the medicines used can affect renal function and electrolytes.
» Monitor sodium, potassium and serum creatinine.

S T E P 1 : Diuretic plus ACE-inhibitor

x Hydrochlorothiazide, oral, 25–50 mg daily.

Mild volume overload (mild CCF) and normal renal function – thiazide diuretic

x Furosemide, oral, daily (Doctor initiated).

Significant volume overload or abnormal renal function – loop diuretic

o Initial dose: 40 mg.

o If dose > 80 mg/day is required, change dose interval to 12 hourly.
o Higher doses may be needed if co-morbid kidney impairment is present.
o Once CCF has improved, consider switching to hydrochlorothiazide.
o Monitor electrolytes and creatinine.

x Furosemide, IV. See Section 21.2.8: Pulmonary oedema, acute.

Acute pulmonary oedema

Note:
» Use a lower diuretic dose when given in combination with an ACE-inhibitor.
» Routine use of potassium supplements with diuretics is not recommended. They
should only be used short-term to correct documented low serum potassium level.
All patients with CCF, unless contraindicated or poorly tolerated
ƒ ACE-inhibitor, e.g.:
x Enalapril, oral, 2.5 mg 12 hourly, up to maximum of 10 mg twice daily.
o Titrate dosages gradually upwards until an optimal dose is achieved
o Absolute contraindications include: (refer to package insert)
- cardiogenic shock
- bilateral renal artery stenosis, or stenosis of an artery to a dominant/single
kidney
- aortic valve stenosis and hypertrophic obstructive cardiomyopathy
- pregnancy
- history of angioedema associated with previous ACE-inhibitor or
angiotensin II receptor blocker (ARB) therapy

2018 4.13
CHAPTER 4 CARDIOVASCULAR CONDITIONS

ƒ S T E P 2 : After titration of ACE-inhibitor, add carvedilol (alpha 1 and

non-selective beta blocker) unless contra-indicated (Refer to package insert
for full prescribing information).
x Carvedilol, oral (Doctor initiated).
o Starting dose: 3.125 mg twice daily.
o Increase dose at two-weekly intervals by doubling the daily dose until a
maximum of 25 mg twice daily, if tolerated.
o If not tolerated, i.e. worsening of cardiac failure manifestations, reduce the
dose to the previously tolerated dose.
o Up-titration can take several months.
o Should treatment be discontinued for >14 days, reinstate therapy as above.
o Absolute contraindications include: (Refer to package insert)
- cardiogenic shock, bradycardia, various forms of heart block
- severe fluid overload
- hypotension
- asthma
Note: Do not use atenolol for cardiac failure.
OR
Spironolactone, oral, 25 mg daily (Doctor initiated).

CAUTION
Spironolactone can cause severe hyperkalemia and should only be used when
serum potassium can be monitored.
Do not use together with potassium supplements.
Do not use in kidney failure (Do not use if eGFR < 30 mL/min).

S T E P 3 : Add spironolactone, if patient remains symptomatic despite

x Spironolactone, oral, 25mg daily (Doctor initiated).

optimal therapy AND if serum potassium can be monitored.

CAUTION
Spironolactone can cause severe hyperkalemia and should only be used when
serum potassium can be monitored.
Do not use together with potassium supplements.
Do not use in kidney failure (Do not use if eGFR < 30 mL/min).

x Carvedilol, oral (Doctor initiated).

OR

o Starting dose: 3.125 mg twice daily.

o Increase dose at two-weekly intervals by doubling the daily dose until a
maximum of 25 mg twice daily, if tolerated.
o If not tolerated, i.e. worsening of cardiac failure manifestations, reduce the
dose to the previously tolerated dose.
o Up-titration can take several months.
o Should treatment be discontinued for > 14 days, reinstate therapy as above.

2018 4.14
CHAPTER 4 CARDIOVASCULAR CONDITIONS

o Absolute contraindications include: (Refer to package insert)

- cardiogenic shock, bradycardia, various forms of heart block
- severe fluid overload
- hypotension
- asthma

STEP 4:
Symptomatic CCF despite above-mentioned therapy:
Refer to hospital for step up therapy with digoxin.

CAUTION
Patients with CCF on diuretics may become hypokalaemic.
Digoxin therapy should not be initiated if the patient is hypokalaemic.

REFERRAL
Urgent
» Patients with prosthetic heart valve.
» Suspected infective endocarditis.
» Fainting spells.
Non urgent
» Initial assessment and initiation of treatment.
» Poor response to treatment.

4.6.2 CARDIAC FAILURE, CONGESTIVE (CCF), CHILDREN

I50.0/I50.1-9

DESCRIPTION
The congestion of the systemic or pulmonary venous systems due to cardiac
dysfunction of various different causes; including congenital heart disease and
acquired cardiac and lung conditions (e.g. cor-pulmonale due to bronchiectasis in
HIV-infected children).
Often mistaken for respiratory infection.
Signs and symptoms
Infants
» rapid breathing » chest indrawing
» rapid heart rate » crackles or wheezing in lungs
» cardiomegaly » active cardiac impulse
» enlarged tender liver
Often presents primarily with shortness of breath, difficulty in feeding and sweating
during feeds. Oedema is usually not an obvious feature.
Children
» rapid breathing » chest indrawing
» rapid heart rate » crackles or wheezing in lungs
» cardiomegaly » active and displaced cardiac impulse
» enlarged tender liver » oedema of the lower limbs or lower back

2018 4.15
CHAPTER 4 CARDIOVASCULAR CONDITIONS

GENERAL MEASURES

x Oxygen, using nasal cannula at 2–3 L per minute.

While arranging transfer:

OR
Oxygen 40%, using face mask at 2–3 L per minute.
» Semi-Fowlers position.
Note: If hypertensive, consider glomerulonephritis in children.

MEDICINE TREATMENT
While arranging transfer:

x Furosemide, IV, 1 mg/kg, over 5 minutes. See dosing tables, pg 23.5.

If CCF is strongly suspected

o Do not put up a drip or run in any IV fluids.

REFERRAL
All children with suspected congestive cardiac failure.

4.7 HYPERTENSION
4.7.1 HYPERTENSION IN ADULTS
I10

DESCRIPTION
A condition characterised by an elevated BP measured on 3 separate occasions, a
minimum of 2 days apart.
However, when BP is severely elevated (refer to the table below), a minimum of 3
BP readings must be taken at the 1st visit to confirm hypertension. Ensure that the
correct cuff size is used in obese patients.
» Systolic BP • 140 mmHg
and/or
» Diastolic BP • 90 mmHg.
LEVELS OF HYPERTENSION IN ADULTS
Level of hypertension Systolic mmHg Diastolic mmHg
mild 140–159 90–99
moderate 160–179 100–109
severe • 180 • 110
Achieve and maintain target BP: Systolic < 140 mmHg and diastolic < 90 mmHg.

MONITORING
At every visit:
» Weight
» Blood pressure
Baseline:

 If dipstix positive send blood for serum creatinine concentration (and eGFR)
» Urine protein by dipstix.

2018 4.16
CHAPTER 4 CARDIOVASCULAR CONDITIONS

(See Section 8.2: Acute kidney injury).

» BMI for cardiovascular risk assessment (See Section 4.1: Prevention of
ischaemic heart disease and atherosclerosis).
» Abdominal circumference.
» Serum potassium concentration, if on ACE-inhibitor or eGFR < 30 mL/min. (See
Section 9.2.2: Type 2 Diabetes Mellitus, Adults).
Six monthly:
» Serum potassium concentration in patients on spironolactone or eGFR < 30
mL/min.
Annually:
» Fingerprick blood glucose (see Section 9.2.2: Type 2 Diabetes Mellitus, Adults).
» Urine protein by dipstix (see Section 8.1: Chronic Kidney Disease (CKD)).

 proteinuria 1+ or more
» Serum creatinine concentration (and eGFR) in patients who have:

 existing cardiovascular disease

 hypertension present for 10 years or more (annually if uncontrolled)
 chronic kidney disease (eGFR < 60 mL/min)

GENERAL MEASURES
Screen all patients for cardiovascular disease risk factors (see Section 4.1:
Prevention of ischaemic heart disease and atherosclerosis) and prescribe a statin if
required.
Screen for presence of compelling indications (see table below) and manage
patients accordingly.
All patients with hypertension require lifestyle modification:
weight loss if overweight » regular physical exercise (150 minutes/week)
» stop smoking » avoid excessive alcohol intake
» restrict salt intake » restrict fat intake

MEDICINE TREATMENT
Initial medicine choices are dependent on the presence or absence of compelling
indications.
Medicine treatment without compelling indications (see table below for a
list of compelling indications and recommendations for treatment).
Mild hypertension
When there are no cardiovascular risk factors, initiate lifestyle modification
measures. If there is poor response to lifestyle modification measures after 3
months, initiate medicine therapy.
Presence of risk factors (see Section 4.1: Prevention of ischaemic heart disease
and atherosclerosis).
Initiate medicine therapy as well as lifestyle modification (Step 2).
Moderate hypertension
Confirm diagnosis within 2 weeks. Initiate treatment after confirmation of diagnosis

2018 4.17
CHAPTER 4 CARDIOVASCULAR CONDITIONS

(medicine and lifestyle modification) at Step 2.

Severe hypertension
Confirm diagnosis within 1 hour.
» In patients who are not symptomatic, initiate treatment (medicine and lifestyle
modification) at Step 3.
Patients with symptoms of progressive target organ damage or associated clinical
conditions: See hypertensive urgency, below and Section 4.7.2: Hypertensive
emergency.

Special cases
Pregnancy-induced hypertension
See Section 6.4.2: Hypertensive disorders of pregnancy.
Asymptomatic severe hypertension
» These patients have severe hypertension, are asymptomatic and have no
evidence of progressive target organ damage.
» Observe the patient in the health care setting and repeat BP measurement after
the patient has rested for 1 hour.
» If the second measurement is still elevated at the same level, start oral
treatment with 2 agents (Step 3), one of which should be low dose
hydrochlorothiazide and the second medicine is usually a calcium channel
blocker, e.g. amlodipine.
» Patient should be followed up within a week.
» Refer to doctor if BP >160/100 mmHg after 4 weeks.
Hypertensive urgency
» Most affected adults have a systolic BP > 220 mmHg and/or diastolic BP > 120
mmHg.
» Patients are symptomatic, usually with severe headache, shortness of breath
and oedema.
» Treatment should be commenced with 2 oral agents (Step 3) with the aim to
lower diastolic BP to 100 mmHg slowly, over 48–72 hours.
» Amlodipine and furosemide or hydrochlorothiazide should be used, if there is
renal insufficiency or evidence of pulmonary congestion (See Section 4.6.1:
Cardiac failure, congestive (CCF), adults).
» All patients with hypertensive urgency should be referred to a hospital.
Stroke
BP is often elevated in acute stroke. Do not treat elevated BP at PHC, but refer
patient urgently.
Elderly
In patients without co-existing disease, initiate medicine treatment only when the
BP > 160/90 mmHg.
Note:
» Check adherence to medication before escalating therapy.
» Monitor patients monthly and adjust therapy if necessary until the BP is stable.
» After target BP is achieved, patients may be seen at 3–6 monthly intervals.

2018 4.18
CHAPTER 4 CARDIOVASCULAR CONDITIONS

CAUTION
Lower BP over a few days.
A sudden decrease in BP can be dangerous, especially in the elderly.

STEPWISE TREATMENT WITHOUT COMPELLING INDICATIONS

STEP 1: Lifestyle modification.
Entry to Step 1 Treatment Target
» Diastolic BP 9099 mmHg » Lifestyle modification. » BP control within
and/or systolic BP 140159 3 months to
mmHg without any existing <140/90 mmHg.
disease.
AND
» No major risk factors.
STEP 2: Add hydrochlorothiazide.
Entry to Step 2 Treatment Target
» Diastolic BP 9099 mmHg » Lifestyle modification » BP control within

x Hydrochlorothiazide,
and systolic BP 140159 AND 1 month to <
mmHg without any existing 140/90 mmHg.
disease. oral, 12.5 mg daily.
AND LoE:Ixxxi

» No major risk factors.

AND
» Failure of lifestyle
modification alone to reduce
BP after 3 months.
OR
Mild hypertension with major
risk factors or existing
disease.
OR
Moderate hypertension at
diagnosis.
STEP3: Add a second antihypertensive medicine.
Entry to Step 3 Treatment Target
» Failure to achieve targets in » Lifestyle modification » BP control within

x Hydrochlorothiazide, oral,
Step 2 after 1 month AND 1 month to
despite adherence to <140/90 mmHg.
therapy. 12.5 mg daily.
OR ADD
Severe hypertension (See ƒ Long-acting calcium
table). channel blocker, e.g.:
ƒ Amlodipine, oral, 5 mg
daily.

2018 4.19
CHAPTER 4 CARDIOVASCULAR CONDITIONS

OR
ƒ ACE-inhibitor. e.g.:
x Enalapril, oral, 10 mg
x daily. LoE:IIIxxxii

STEP 4: Increase the dose of the second antihypertensive medicine.

Entry to Step 4 Treatment Target
» Failure of step 3 after 1 » Lifestyle modification » BP control within

x Hydrochlorothiazide, oral,
month of adherence. AND 1month to
<140/90 mmHg,
12.5 mg daily. with no adverse
AND reactions.
Increase dose of
antihypertensive started in
Step 3:
ƒ Long-acting calcium
channel blocker, e.g.:
ƒ Amlodipine, oral, increase
to 10 mg daily.
OR
ƒ ACE-inhibitor, e.g.:
x Enalapril, increase to 20
mg daily.
STEP 5: Add a third antihypertensive medicine
Entry to Step 5 Treatment Target
» Failure of step 4 after 1 » Lifestyle modification » BP control within

x Hydrochlorothiazide, oral,
month of adherence. AND 1 month to
<140/90 mmHg
12.5 mg daily. with no adverse
AND medicine
ƒ ACE-inhibitor, e.g.:
x Enalapril, oral: continue
reactions.

Step 4 dose, or if not

started previously start at
10 mg daily.
AND
ƒ Long-acting calcium

x Amlodipine, oral: continue

channel blocker, e.g.:

Step 4 dose, or if not

started previously start at
5 mg daily.

2018 4.20
CHAPTER 4 CARDIOVASCULAR CONDITIONS

STEP 6: Increase the dose of the third antihypertensive medicine

Entry to Step 6 Treatment Target
» Failure of step 5 after 1 » Lifestyle modification » BP control within 1

x Hydrochlorothiazide, oral,
month of adherence. AND month to <140/90
mmHg with no
12.5 mg daily adverse medicine
AND reactions.
ƒ ACE-inhibitor, e.g.:
x Enalapril, oral, 20 mg
daily
AND
ƒ Long-acting calcium

x Amlodipine 10 mg daily.
channel blocker, e.g.:

STEP 7: Increase the dose of HCTZ and add a fourth antihypertensive medicine
Entry to Step 7 Treatment Target
» Failure of step 7 after 1 » Lifestyle modification » BP control within

x Hydrochlorothiazide, oral,
month of adherence. AND 1 month to
<140/90 mmHg,
25 mg daily. with no adverse
AND medicine
ƒ ACE-inhibitor, e.g.:
x Enalapril, 20 mg daily.
reactions.

AND
ƒ Long-acting calcium

x Amlodipine, oral 10 mg
channel blocker, e.g.:

daily.

x Spironolactone, oral, 25
AND ADD

mg daily (Doctor initiated).

LoE:Ixxxiii

CAUTION
Spironolactone can cause severe hyperkalemia and should only be used when
serum potassium can be monitored.
Do not use together with potassium supplements.
Do not use in kidney failure (Do not use if eGFR < 30 mL/min).

If not controlled on step 7– refer.

2018 4.21
CHAPTER 4 CARDIOVASCULAR CONDITIONS

Hypertension treatment algorithm for stepwise treatment

without compelling indications

Compelling indications for specific Medicine therapeutic class

x
medicines
Angina ß-blocker
OR

x ß-blocker
Long-acting calcium channel blocker
Prior myocardial infarction

x ACE-inhibitor
AND

Heart failure x ACE-inhibitor

2018 4.22
CHAPTER 4 CARDIOVASCULAR CONDITIONS

x Carvedilol
AND

OR
Spironolactone

x Loop diuretic
For significant volume overload:

Left ventricular hypertrophy(confirmed by x ACE-inhibitor

x Hydrochlorothiazide
ECG)
Stroke: secondary prevention

x ACE-inhibitor
AND

Diabetes type 1 and 2 with/without x ACE-inhibitor, usually in combination

evidence of microalbuminuria/proteinuria
x ACE-inhibitor, usually in combination
with diuretic
Chronic kidney disease

x Hydrochlorothiazide
with diuretic
Isolated systolic hypertension
OR

x Methyldopa
Long-acting calcium channel blocker
Pregnancy
Contraindications to individual medicines
Hydrochlorothiazide
» gout
» pregnancy
» severe liver impairment
» kidney impairment (eGFR < 30 mL/min)
Spironolactone
» kidney impairment (eGFR < 30 mL/min) LoE:IIIxxxiv
» pregnancy
ACE-inhibitors
» pregnancy
» bilateral renal artery stenosis or stenosis of an artery to a dominant/single kidney
» aortic valve stenosis
» history of angioedema
» hyperkalemia
» severe renal impairment (eGFR < 30 mL/min)
CAUTION
Advise all patients receiving ACE-inhibitors about the symptoms of ACE-induced
angioedema.

Calcium channel blockers

» untreated heart failure

REFERRAL
» Young adults (< 30 years of age).

2018 4.23
CHAPTER 4 CARDIOVASCULAR CONDITIONS

» BP not controlled by 4 medicines and where there is no doctor available.

» Pregnancy.
» Signs of target organ damage e.g. oedema, dyspnoea, proteinuria, angina etc.
» If severe adverse drug reactions develop.
» Hypertensive urgency and hypertensive emergency.

4.7.2 HYPERTENSIVE EMERGENCY

I10

DESCRIPTION
A markedly elevated BP: systolic BP > 180 mmHg and/or a diastolic BP > 130 mmHg
associated with • one of the following:
» unstable angina/chest pain
» neurological signs, e.g. severe headache, visual disturbances, confusion, coma
or seizures
» pulmonary oedema
» renal failure

x
MEDICINE TREATMENT
Amlodipine, oral, 10 mg immediately as a single dose.

x Furosemide, IV, 40 mg as a single dose (See Section 21.2.8: Pulmonary

If pulmonary oedema:

oedema, acute).

CAUTION
A hypertensive emergency needs immediate referral to hospital.

REFERRAL
Urgent
All patients.

4.7.3 HYPERTENSION IN CHILDREN

I10

Hypertension is defined as systolic and/or diastolic blood pressure t the 95th

DESCRIPTION

percentile for gender, age, and height percentile on at least 3 consecutive

occasions. Refer to table below.
The use of appropriate cuff size is important. Too small a cuff for the arm leads to
false high BP. The cuff bladder must encircle at least 80% of the upper arm and
should cover at least 75% of the distance between the acromion and the olecranon.
It is better to use a cuff that is slightly too large than one that is too small. Large
cuffs, if covered with linen-like material, can be folded to the appropriate size in
smaller infants as long as the bladder encompasses the arm.

2018 4.24
CHAPTER 4 CARDIOVASCULAR CONDITIONS

Infants and preschool-aged children are almost never diagnosed with essential
hypertension and are most likely to have secondary forms of hypertension.
With age, the prevalence of essential hypertension increases, and after 10 years of
age, it becomes the leading cause of elevated BP. Obesity currently is emerging as
a common comorbidity of essential hypertension in paediatric patients, often
manifesting during early childhood.

DIAGNOSIS
Age 95th BP percentiles for boys 95th BP percentiles for girls
years mmHg mmHg
1 103/56 104/58
3 109/65 107/67
5 112/72 110/72
6 114/74 111/74
8 116/78 115/76
9 118/79 117/77
10 119/80 119/78
11 121/80 121/79
12 123/81 123/80
Adapted from U.S Department of Health and Human Services.National Institutes of Health (National Heart, Lung,
and Blood Institute): The 4th report on the diagnosis, evaluation, and treatment of high blood pressure in children
and adolescents, May 2005 (using the 50th height percentile).

REFERRAL
All cases with BP above the 95th percentile.

4.8 PULMONARY OEDEMA, ACUTE

See Section 21.2.8: Pulmonary oedema, acute.

4.9 RHEUMATIC FEVER, ACUTE

I00/I01.0-2/I01.8-9
Note: notifiable condition.

DESCRIPTION
A condition in which the body develops antibodies against its own tissues, following
a streptococcal throat infection. Effective treatment of streptococcal pharyngitis can
markedly reduce the occurrence of this disease.
Commonly occurs in children, 3–15 years of age.
Recurrences are frequent.
Clinical signs and symptoms include:
» arthralgia or arthritis that may shift from one joint to another
» carditis including cardiac failure
» heart murmurs
» subcutaneous nodules
» erythema marginatum
» chorea (involuntary movements of limbs or face)

2018 4.25
CHAPTER 4 CARDIOVASCULAR CONDITIONS

» other complaints indicating a systemic illness e.g. fever

MEDICINE TREATMENT
Eradication of streptococci in throat:

x Phenoxymethylpenicillin, oral, 250 mg 12 hourly for 10 days.

Children: 18 months–11 years of age

x Phenoxymethylpenicillin, oral, 500 mg 12 hourly for 10 days.

Children > 11 years of age and adults

OR
Children
x Amoxicillin, oral, 50 mg/kg daily for 10 days.
Weight Dose Use one of the following Age
kg mg Susp Capsule Months/years
125 250 250 500
mg/5mL mg/5mL mg mg
>2–2.5 kg 100 mg 4 mL 2 mL – – >34–36 weeks
>2.5–3.5 kg 150 mg 6 mL 3 mL – – >36 weeks–1 month
>3.5–5 kg 200 mg 8 mL 4 mL – – >1–3 months
>5–7 kg 275 mg 11 mL 5.5 mL – – >3–6 months
>7–11 kg 400 mg – 8 mL – – >6–18 months
>11–17.5 kg 575 mg – 11.5 mL – – >18 months–5 years
>17.5–25 kg 750 mg – 15 mL 3 – >5–7 years
>25–35 kg 1000 mg – 20 mL 4 2 >7–11 years
>35 kg 2000 mg – – 4 >11years
xxxv
LoE:I
x Amoxicillin, oral, 1 000 mg 12 hourly for 10 days.
Adults

OR LoE:IIIxxxvi
Benzathine benzylpenicillin, IM, single dose.
o Children < 30 kg: 600 000 IU.
o Children • 30 kg and adults: 1.2 MU.
o Dissolve benzathine benzylpenicillin 1.2 MU in 3.2 mL lidocaine 1% without
adrenaline (epinephrine) or 3 mL water for injection.
Severe penicillin allergy: (Z88.0)
Children
ƒ Macrolide, e.g.:
x Azithromycin, oral, 10 mg/kg daily for 3 days. See dosing table pg 23.2.
Children > 35 kg and adults
ƒ Macrolide, e.g.:
x Azithromycin, oral, 500 mg daily for 3 days.

Prophylaxis for rheumatic fever: (Z29.2)

All patients with confirmed rheumatic fever and no persistent rheumatic valvular
disease
» Treat for 10 years or until the age of 21 years, whichever is longer.

2018 4.26
CHAPTER 4 CARDIOVASCULAR CONDITIONS

x Phenoxymethylpenicillin, oral, 12 hourly.

All patients with confirmed rheumatic fever and persistent rheumatic valvular disease

o Children: 125 mg
o Adults: 250 mg
OR
Amoxicillin, oral, daily.
o Children <30 kg: 125 mg LoE:III
o Children •30 kg and adults: 250 mg
OR
Benzathine benzylpenicillin, IM, every 21–28 days (3–4 weeks).
o Children < 30 kg: 600 000 IU
o Children • 30 kg and adults: 1.2 MU
o For benzathine benzylpenicillin, IM injection, dissolve benzathine
benzylpenicillin 1.2 MU in 3.2 mL lidocaine 1% without adrenaline
(epinephrine).

CAUTION
Avoid IM injections if patients are on warfarin.

Severe penicillin allergy: (Z88.0)

Children < 11 years
ƒ Macrolide, e.g.:
x Azithromycin, oral, 10mg/kg/day, 3 times weekly. See dosing table, pg 23.2.
LoE:IIIxxxvii
Children • 11 years and adults
ƒ Macrolide, e.g.:
x Azithromycin, oral, 250 mg daily.
LoE:IIIxxxviii
REFERRAL
All patients for diagnosis and management.

4.10 VALVULAR HEART DISEASE AND CONGENITAL

STRUCTURAL HEART DISEASE
I05.0-2/I05.8-9/I06.0-2/I06.8-9/I07.0-2/I07.8-9/I08.0-3/I08.8-9/I34.0-2/I34.8-9/I35.0-2/I35.8-
9/I36.0-2/I36.8-9/I37.0-2/I37.8-9/Q22.0-6/Q22.8-9/Q23.0-4/Q23.8-9

DESCRIPTION
Damage to heart valves, chamber or vessel wall anomalies caused by rheumatic
fever or other causes, e.g. congenital heart defects and ischaemic heart disease.
May be complicated by:
» heart failure » atrial fibrillation
» infective endocarditis » systemic embolism

GENERAL MEASURES
» Advise all patients with a heart murmur regarding the need for prophylactic
treatment prior to undergoing certain medical and dental procedures.

2018 4.27
CHAPTER 4 CARDIOVASCULAR CONDITIONS

» Advise patients to inform health care providers of the presence of the heart
murmur when reporting for medical or dental treatment.

MEDICINE TREATMENT
Prophylactic antibiotic treatment for infective endocarditis:
» Should be given prior to certain invasive diagnostic and therapeutic procedures
e.g. tooth extraction, to prevent infective endocarditis.
» Is essential for all children with congenital or rheumatic heart lesions needing
dental extraction.

x Amoxicillin, oral, 50 mg/kg (maximum dose: 2 g), 1 hour before the procedure.
Dental extraction, if no anaesthetic is required: (Z29.2)

o Repeat dose 6 hours later.

Age Dose
< 5 years 750 mg
5–10 years 1 500 mg
• 10 years 2g

Severe penicillin allergy: (Z88.0)

Refer.

If anaesthetic is required:
Refer.

Prophylaxis for rheumatic fever:

See Section 4.9: Rheumatic fever, acute.

REFERRAL
» All patients with pathological heart murmurs for assessment.
» All patients with heart murmurs not on a chronic management plan.
» Development of cardiac signs and symptoms.
» Worsening of clinical signs and symptoms of heart disease.
» Any newly developing medical condition, e.g. persistent fever.
» All patients with valvular heart disease for advice on prophylactic antibiotic
treatment prior to any invasive diagnostic or therapeutic procedure.
References:
i BMI-based CVD risk assessment: D'Agostino RB Sr, Vasan RS, Pencina MJ, Wolf PA, Cobain M, Massaro JM, Kannel

WB. General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation. 2008 Feb
12;117(6):743-53. https://www.ncbi.nlm.nih.gov/pubmed/18212285
ii Simvastatin 40 mg, oral (secondary prevention of ischaemic events): National Department of Health. Affordable Medicines,

EDP-Primary Health Care. Cost-effectiveness analysis of high, intermediate, and low dose statins for the secondary
prevention of cardiovascular disease, 31 January 2018. www.health.gov.za/
Simvastatin 40 mg, oral (secondary prevention of ischaemic events): Cholesterol Treatment Trialists' (CTT) Collaboration.
Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170 000 participants in 26
randomised trials. The Lancet 2010; 376(9753): 1670-81. https://www.ncbi.nlm.nih.gov/pubmed/21067804
Simvastatin 40 mg, oral (secondary prevention of ischaemic events): Naci H, Brugts JJ, Fleurence R, Ades A. Dose-
comparative effects of different statins on serum lipid levels: a network meta-analysis of 256,827 individuals in 181
randomized controlled trials. European journal of preventive cardiology 2013; 20(4): 658-70.
https://www.ncbi.nlm.nih.gov/pubmed/23529608

2018 4.28
CHAPTER 4 CARDIOVASCULAR CONDITIONS

Simvastatin 40 mg, oral (secondary prevention of ischaemic events): Contract circular HP09-2016SD.
http://www.health.gov.za/
iii Atorvastatin 10 mg, oral (secondary prevention of ischaemic events – patients on protease inhibitors): Chastain DB, Stover

KR, Riche DM. Evidence-based review of statin use in patients with HIV on antiretroviral therapy. J Clin Transl Endocrinol.
2017 Feb 22;8:6-14. https://www.ncbi.nlm.nih.gov/pubmed/29067253
Atorvastatin 10 mg, oral (secondary prevention of ischaemic events – patients on protease inhibitors): National Department
of Health. Affordable Medicines, EDP-Primary Health Care. Cost-effectiveness analysis of high, intermediate, and low dose
statins for the secondary prevention of cardiovascular disease, 31 January 2018. www.health.gov.za/
Atorvastatin 10 mg, oral (secondary prevention of ischaemic events – patients on protease inhibitors): Cholesterol
Treatment Trialists' (CTT) Collaboration. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of
data from 170 000 participants in 26 randomised trials. The Lancet 2010; 376(9753): 1670-81.
https://www.ncbi.nlm.nih.gov/pubmed/21067804
Atorvastatin 10 mg, oral (secondary prevention of ischaemic events – patients on protease inhibitors): Naci H, Brugts JJ,
Fleurence R, Ades A. Dose-comparative effects of different statins on serum lipid levels: a network meta-analysis of 256,827
individuals in 181 randomized controlled trials. European journal of preventive cardiology 2013; 20(4): 658-70.
https://www.ncbi.nlm.nih.gov/pubmed/23529608
Atorvastatin 10 mg, oral (secondary prevention of ischaemic events – patients on protease inhibitors): Contract circular
HP09-2016SD. http://www.health.gov.za/
Atorvastatin, oral (drug-drug interaction with protease inhibitors): University of Liverpool. HIV drug interaction database.
https://www.hiv-druginteractions.org/
iv Simvastatin 40 mg, oral (amlodipine drug interaction): Lexicomp: Drug Interactions database. [Accessed 7 February 2018]

Available at: https://www.uptodate.com/drug-interactions

v High dose statins (management of adverse drug reactions): NICE: Cardiovascular disease: risk assessment and reduction,

including lipid modification. Clinical guideline, 18 July 2014. www.nice.org.uk/guidance/cg181

vi Aspirin, oral (stable angina): Antithrombotic Trialists' Collaboration. Collaborative meta-analysis of randomised trials of

antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients.BMJ. 2002 Jan
12;324(7329):71-86. Erratum in: BMJ 2002 Jan 19;324(7330):141. https://www.ncbi.nlm.nih.gov/pubmed/11786451
vii Isosorbide mononitrate, oral: National Department of Health: Essential Drugs Programme. Adult Hospital level STGs and

EML, 2015. http://www.health.gov.za/

Isosorbide mononitrate, oral: Thadani U, Lipicky RJ. Short and long-acting oral nitrates for stable angina pectoris.
Cardiovasc Drugs Ther. 1994 Aug;8(4):611-23. https://www.ncbi.nlm.nih.gov/pubmed/7848896
Isosorbide mononitrate, oral: Parker JO. Eccentric dosing with isosorbide-5-mononitrate in angina pectoris. Am J Cardiol.
1993 Oct 15;72(12):871-6. https://www.ncbi.nlm.nih.gov/pubmed/8213541
Isosorbide mononitrate, oral: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.
University of Cape Town. 2016.
viii Simvastatin 40 mg, oral (secondary prevention of ischaemic events): National Department of Health. Affordable Medicines,

EDP-Primary Health Care. Cost-effectiveness analysis of high, intermediate, and low dose statins for the secondary
prevention of cardiovascular disease, 31 January 2018. www.health.gov.za/
Simvastatin 40 mg, oral (secondary prevention of ischaemic events): Cholesterol Treatment Trialists' (CTT) Collaboration.
Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170 000 participants in 26
randomised trials. The Lancet 2010; 376(9753): 1670-81. https://www.ncbi.nlm.nih.gov/pubmed/21067804
Simvastatin 40 mg, oral (secondary prevention of ischaemic events): Naci H, Brugts JJ, Fleurence R, Ades A. Dose-
comparative effects of different statins on serum lipid levels: a network meta-analysis of 256,827 individuals in 181
randomized controlled trials. European journal of preventive cardiology 2013; 20(4): 658-70.
https://www.ncbi.nlm.nih.gov/pubmed/23529608
Simvastatin 40 mg, oral (secondary prevention of ischaemic events): Contract circular HP09-2016SD.
http://www.health.gov.za/
ix Atorvastatin 10 mg, oral (secondary prevention of ischaemic events – patients on protease inhibitors): Chastain DB, Stover

KR, Riche DM. Evidence-based review of statin use in patients with HIV on antiretroviral therapy. J Clin Transl Endocrinol.
2017 Feb 22;8:6-14. https://www.ncbi.nlm.nih.gov/pubmed/29067253
Atorvastatin 10 mg, oral (secondary prevention of ischaemic events – patients on protease inhibitors): National Department
of Health. Affordable Medicines, EDP-Primary Health Care. Cost-effectiveness analysis of high, intermediate, and low dose
statins for the secondary prevention of cardiovascular disease, 31 January 2018. www.health.gov.za/
Atorvastatin 10 mg, oral (secondary prevention of ischaemic events – patients on protease inhibitors): Cholesterol
Treatment Trialists' (CTT) Collaboration. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of
data from 170 000 participants in 26 randomised trials. The Lancet 2010; 376(9753): 1670-81.
https://www.ncbi.nlm.nih.gov/pubmed/21067804
Atorvastatin 10 mg, oral (secondary prevention of ischaemic events – patients on protease inhibitors): Naci H, Brugts JJ,
Fleurence R, Ades A. Dose-comparative effects of different statins on serum lipid levels: a network meta-analysis of 256,827
individuals in 181 randomized controlled trials. European journal of preventive cardiology 2013; 20(4): 658-70.
https://www.ncbi.nlm.nih.gov/pubmed/23529608
Atorvastatin 10 mg, oral (secondary prevention of ischaemic events – patients on protease inhibitors): Contract circular
HP09-2016SD. http://www.health.gov.za/
Atorvastatin, oral (drug-drug interaction with protease inhibitors): University of Liverpool. HIV drug interaction database.
https://www.hiv-druginteractions.org/
x Simvastatin 40 mg, oral (amlodipine drug interaction): Lexicomp: Drug Interactions database. [Accessed 7 February 2018]

Available at: https://www.uptodate.com/drug-interactions

2018 4.29
CHAPTER 4 CARDIOVASCULAR CONDITIONS

xi High dose statins (management of adverse drug reactions): NICE: Cardiovascular disease: risk assessment and reduction,

including lipid modification. Clinical guideline, 18 July 2014. www.nice.org.uk/guidance/cg181

xii Oxygen (unstable angina/ NSTEMI): Chu DK, Kim LH, Young PJ, Zamiri N, Almenawer SA, Jaeschke R, Szczeklik W,

Schünemann HJ, Neary JD, Alhazzani W. Mortality and morbidity in acutely ill adults treated with liberal versus conservative
oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet. 2018 Apr 28;391(10131):1693-1705.
https://www.ncbi.nlm.nih.gov/pubmed/29726345
xiiiAspirin, oral (NSTEMI): Peters RJ, Mehta SR, Fox KA, Zhao F, Lewis BS, Kopecky SL, Diaz R, Commerford PJ, Valentin V,

Yusuf S; Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) Trial Investigators. Effects of aspirin dose when
used alone or in combination with clopidogrel in patients with acute coronary syndromes: observations from the Clopidogrel in
Unstable angina to prevent Recurrent Events (CURE) study. Circulation. 2003 Oct 7;108(14):1682-7.
https://www.ncbi.nlm.nih.gov/pubmed/14504182
xiv Aspirin, oral (NSTEMI): Peters RJ, Mehta SR, Fox KA, Zhao F, Lewis BS, Kopecky SL, Diaz R, Commerford PJ, Valentin

V, Yusuf S; Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) Trial Investigators. Effects of aspirin dose
when used alone or in combination with clopidogrel in patients with acute coronary syndromes: observations from the
Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) study. Circulation. 2003 Oct 7;108(14):1682-7.
https://www.ncbi.nlm.nih.gov/pubmed/14504182
xv Simvastatin 40 mg, oral (secondary prevention of ischaemic events): National Department of Health. Affordable Medicines,

EDP-Primary Health Care. Cost-effectiveness analysis of high, intermediate, and low dose statins for the secondary
prevention of cardiovascular disease, 31 January 2018. www.health.gov.za/
Simvastatin 40 mg, oral (secondary prevention of ischaemic events): Cholesterol Treatment Trialists' (CTT) Collaboration.
Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170 000 participants in 26
randomised trials. The Lancet 2010; 376(9753): 1670-81. https://www.ncbi.nlm.nih.gov/pubmed/21067804
Simvastatin 40 mg, oral (secondary prevention of ischaemic events): Naci H, Brugts JJ, Fleurence R, Ades A. Dose-
comparative effects of different statins on serum lipid levels: a network meta-analysis of 256,827 individuals in 181
randomized controlled trials. European journal of preventive cardiology 2013; 20(4): 658-70.
https://www.ncbi.nlm.nih.gov/pubmed/23529608
Simvastatin 40 mg, oral (secondary prevention of ischaemic events): Contract circular HP09-2016SD.
http://www.health.gov.za/
xvi Atorvastatin 10 mg, oral (secondary prevention of ischaemic events – patients on protease inhibitors): Chastain DB, Stover

KR, Riche DM. Evidence-based review of statin use in patients with HIV on antiretroviral therapy. J Clin Transl Endocrinol.
2017 Feb 22;8:6-14. https://www.ncbi.nlm.nih.gov/pubmed/29067253
Atorvastatin 10 mg, oral (secondary prevention of ischaemic events – patients on protease inhibitors): National Department
of Health. Affordable Medicines, EDP-Primary Health Care. Cost-effectiveness analysis of high, intermediate, and low dose
statins for the secondary prevention of cardiovascular disease, 31 January 2018. www.health.gov.za/
Atorvastatin 10 mg, oral (secondary prevention of ischaemic events – patients on protease inhibitors): Cholesterol
Treatment Trialists' (CTT) Collaboration. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of
data from 170 000 participants in 26 randomised trials. The Lancet 2010; 376(9753): 1670-81.
https://www.ncbi.nlm.nih.gov/pubmed/21067804
Atorvastatin 10 mg, oral (secondary prevention of ischaemic events – patients on protease inhibitors): Naci H, Brugts JJ,
Fleurence R, Ades A. Dose-comparative effects of different statins on serum lipid levels: a network meta-analysis of 256,827
individuals in 181 randomized controlled trials. European journal of preventive cardiology 2013; 20(4): 658-70.
https://www.ncbi.nlm.nih.gov/pubmed/23529608
Atorvastatin 10 mg, oral (secondary prevention of ischaemic events – patients on protease inhibitors): Contract circular
HP09-2016SD. http://www.health.gov.za/
Atorvastatin, oral (drug-drug interaction with protease inhibitors): University of Liverpool. HIV drug interaction database.
https://www.hiv-druginteractions.org/
xvii Simvastatin 40 mg, oral (amlodipine drug interaction): Lexicomp: Drug Interactions database. [Accessed 7 February 2018]

Available at: https://www.uptodate.com/drug-interactions

xviii High dose statins (management of adverse drug reactions): NICE: Cardiovascular disease: risk assessment and reduction,

including lipid modification. Clinical guideline, 18 July 2014. www.nice.org.uk/guidance/cg181

xix Enalapril (cardiac failure/ LV dysfunction): South African Medicines Formulary. 12th Edition. Division of Clinical

Pharmacology. University of Cape Town. 2016.

xx Oxygen (AMI/STEMI): Chu DK, Kim LH, Young PJ, Zamiri N, Almenawer SA, Jaeschke R, Szczeklik W, Schünemann HJ,

Neary JD, Alhazzani W. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy
(IOTA): a systematic review and meta-analysis. Lancet. 2018 Apr 28;391(10131):1693-1705.
https://www.ncbi.nlm.nih.gov/pubmed/29726345
xxi Aspirin, oral (STEMI): Berger JS, Stebbins A, Granger CB, Ohman EM, Armstrong PW, Van de Werf F, White HD, Simes

RJ, Harrington RA, Califf RM, Peterson ED. Initial aspirin dose and outcome among ST-elevation myocardial infarction
patients treated with fibrinolytic therapy. Circulation. 2008 Jan 15;117(2):192-9.
https://www.ncbi.nlm.nih.gov/pubmed/18086929
Aspirin, oral (STEMI): CURRENT-OASIS 7 Investigators, Mehta SR, Bassand JP, Chrolavicius S, Diaz R,
Eikelboom JW, Fox KA, Granger CB, Jolly S, Joyner CD, Rupprecht HJ, Widimsky P, Afzal R, Pogue J, Yusuf S. Dose
comparisons of clopidogrel and aspirin in acute coronary syndromes. N Engl J Med. 2010 Sep 2;363(10):930-42.
https://www.ncbi.nlm.nih.gov/pubmed/20818903
xxii Thrombolytics (Therapeutic class): Dundar Y, Hill R, Dickson R, Walley T. Comparative efficacy of thrombolytics in acute

myocardial infarction: A systematic review. QJM - Monthly Journal of the Association of Physicians. 2003;96(2):103-
13.http://www.ncbi.nlm.nih.gov/pubmed/12589008

2018 4.30
CHAPTER 4 CARDIOVASCULAR CONDITIONS

Thrombolytics (Therapeutic class): National Department of Health: Affordable Medicines, EDP-Adult Hospital level.
Medicine Review: Thrombolytics, therapeutic class for STEMI, July 2015.
http://www.health.gov.za/
xxiii Do not use heparin if streptokinase is given: Jinatongthai P, Kongwatcharapong J, Foo CY, Phrommintikul A, Nathisuwan

S, Thakkinstian A, Reid CM, Chaiyakunapruk N. Comparative efficacy and safety of reperfusion therapy with fibrinolytic
agents in patients with ST-segment elevation myocardial infarction: a systematic review and network meta-analysis. Lancet.
2017 Aug 19;390(10096):747-759. https://www.ncbi.nlm.nih.gov/pubmed/28831992
Do not use heparin if streptokinase is given: Eikelboom JW, Quinlan DJ, Mehta SR, Turpie AG, Menown IB, Yusuf S.
Unfractionated and low-molecular-weight heparin as adjuncts to thrombolysis in aspirin-treated patients with ST-elevation
acute myocardial infarction: a meta-analysis of the randomized trials. Circulation. 2005 Dec 20;112(25):3855-67.
https://www.ncbi.nlm.nih.gov/pubmed/16344381
xxiv Streptokinase: Squire IB, Lawley W, Fletcher S, Holme E, Hillis WS, Hewitt C, Woods KL. Humoral and cellular immune

responses up to 7.5 years after administration of streptokinase for acute myocardial infarction.Eur Heart J. 1999
Sep;20(17):1245-52. http://www.ncbi.nlm.nih.gov/pubmed/10454976
Streptokinase: Boersma E, Maas AC, Deckers JW, Simoons ML. Early thrombolytic treatment in acute myocardial
infarction: reappraisal of the golden hour. Lancet. 1996 Sep 21;348(9030):771-5.
http://www.ncbi.nlm.nih.gov/pubmed/8813982
xxv Aspirin, oral (STEMI): Berger JS, Stebbins A, Granger CB, Ohman EM, Armstrong PW, Van de Werf F, White HD, Simes

RJ, Harrington RA, Califf RM, Peterson ED. Initial aspirin dose and outcome among ST-elevation myocardial infarction
patients treated with fibrinolytic therapy. Circulation. 2008 Jan 15;117(2):192-9.
https://www.ncbi.nlm.nih.gov/pubmed/18086929
Aspirin, oral (STEMI): CURRENT-OASIS 7 Investigators, Mehta SR, Bassand JP, Chrolavicius S, Diaz R,
Eikelboom JW, Fox KA, Granger CB, Jolly S, Joyner CD, Rupprecht HJ, Widimsky P, Afzal R, Pogue J, Yusuf S. Dose
comparisons of clopidogrel and aspirin in acute coronary syndromes. N Engl J Med. 2010 Sep 2;363(10):930-42.
https://www.ncbi.nlm.nih.gov/pubmed/20818903
xxvi Simvastatin 40 mg, oral (secondary prevention of ischaemic events): National Department of Health. Affordable

Medicines, EDP-Primary Health Care. Cost-effectiveness analysis of high, intermediate, and low dose statins for the
secondary prevention of cardiovascular disease, 31 January 2018. www.health.gov.za
Simvastatin 40 mg, oral (secondary prevention of ischaemic events): Cholesterol Treatment Trialists' (CTT) Collaboration.
Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170 000 participants in 26
randomised trials. The Lancet 2010; 376(9753): 1670-81. https://www.ncbi.nlm.nih.gov/pubmed/21067804
Simvastatin 40 mg, oral (secondary prevention of ischaemic events): Naci H, Brugts JJ, Fleurence R, Ades A. Dose-
comparative effects of different statins on serum lipid levels: a network meta-analysis of 256,827 individuals in 181
randomized controlled trials. European journal of preventive cardiology 2013; 20(4): 658-70.
https://www.ncbi.nlm.nih.gov/pubmed/23529608
Simvastatin 40 mg, oral (secondary prevention of ischaemic events): Contract circular HP09-2016SD.
http://www.health.gov.za/
xxvii Atorvastatin 10 mg, oral (secondary prevention of ischaemic events – patients on protease inhibitors): Chastain DB,

Stover KR, Riche DM. Evidence-based review of statin use in patients with HIV on antiretroviral therapy. J Clin Transl
Endocrinol. 2017 Feb 22;8:6-14. https://www.ncbi.nlm.nih.gov/pubmed/29067253
Atorvastatin 10 mg, oral (secondary prevention of ischaemic events – patients on protease inhibitors): National Department
of Health. Affordable Medicines, EDP-Primary Health Care. Cost-effectiveness analysis of high, intermediate, and low dose
statins for the secondary prevention of cardiovascular disease, 31 January 2018. www.health.gov.za/
Atorvastatin 10 mg, oral (secondary prevention of ischaemic events – patients on protease inhibitors): Cholesterol
Treatment Trialists' (CTT) Collaboration. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of
data from 170 000 participants in 26 randomised trials. The Lancet 2010; 376(9753): 1670-81.
https://www.ncbi.nlm.nih.gov/pubmed/21067804
Atorvastatin 10 mg, oral (secondary prevention of ischaemic events – patients on protease inhibitors): Naci H, Brugts JJ,
Fleurence R, Ades A. Dose-comparative effects of different statins on serum lipid levels: a network meta-analysis of 256,827
individuals in 181 randomized controlled trials. European journal of preventive cardiology 2013; 20(4): 658-70.
https://www.ncbi.nlm.nih.gov/pubmed/23529608
Atorvastatin 10 mg, oral (secondary prevention of ischaemic events – patients on protease inhibitors): Contract circular
HP09-2016SD. http://www.health.gov.za/
Atorvastatin, oral (drug-drug interaction with protease inhibitors): University of Liverpool. HIV drug interaction database.
https://www.hiv-druginteractions.org/
xxviii Simvastatin 40 mg, oral (amlodipine drug interaction): Lexicomp: Drug Interactions database. [Accessed 7 February 2018]

Available at: https://www.uptodate.com/drug-interactions

xxix High dose statins (management of adverse drug reactions): NICE: Cardiovascular disease: risk assessment and reduction,

including lipid modification. Clinical guideline, 18 July 2014. www.nice.org.uk/guidance/cg181

xxxEnalapril (cardiac failure/ LV dysfunction): South African Medicines Formulary. 12th Edition. Division of Clinical

Pharmacology. University of Cape Town. 2016.

xxxi Hydrochlorothiazide, oral (1st line treatment - hypertension without compelling indications): ALLHAT officers and co-

ordinators for the ALLHAT collaborative research group. The antihypertensive and lipid lowering treatment to prevent heart
attack trial. Major outcomes in moderately hypercholesterolemic, hypertensive patients randomized to pravastatin vs usual
care: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT-LLT). JAMA 2002;
288:2998–3007. https://www.ncbi.nlm.nih.gov/pubmed/12479764
Hydrochlorothiazide, oral (1st line treatment - hypertension without compelling indications): de Leeuw PW, Ruilope LM,
Palmer CR, Brown MJ, Castaigne A, Mancia G, Rosenthal T, Wagener G. Clinical significance of renal function in

2018 4.31
CHAPTER 4 CARDIOVASCULAR CONDITIONS

hypertensive patients at high risk: results from the INSIGHT trial. Arch Intern Med. 2004 Dec 13-27;164(22):2459-64.
https://www.ncbi.nlm.nih.gov/pubmed/15596636
Hydrochlorothiazide, oral (1st line treatment - hypertension without compelling indications): Black HR, Elliott WJ, Grandits
G, Grambsch P, Lucente T, White WB, Neaton JD, Grimm RH Jr, Hansson L, Lacourciere Y, Muller J, Sleight P, Weber MA,
Williams G, Wittes J, Zanchetti A, Anders RJ; CONVINCE Research Group. Principal results of the Controlled Onset
Verapamil Investigation of Cardiovascular End Points (CONVINCE) trial. JAMA. 2003 Apr 23-30;289(16):2073-82.
https://www.ncbi.nlm.nih.gov/pubmed/12709465
Hydrochlorothiazide, oral (1st line treatment - hypertension without compelling indications): Task Force for the
management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of
Cardiology (ESC). 2013 ESH/ESC Guidelines for the management of arterial hypertension Journal of Hypertension. 2013,
31:1281–1357. https://www.ncbi.nlm.nih.gov/pubmed/24107724
Hydrochlorothiazide, oral (1st line treatment - hypertension without compelling indications): Eighth Joint National
Committee (JNC 8) 2014 Evidence-Based Guidelines for the Management of High Blood Pressure in Adults, 2014.
http://www.aafp.org/patient-care/clinical-recommendations/all/highbloodpressure.html
xxxiiEnalapril, oral (daily dosing): Girvin B, McDermott BJ, Johnston GD. A comparison of enalapril 20 mg once daily versus 10

mg twice daily in terms of blood pressure lowering and patient compliance. J Hypertens. 1999 Nov;17(11):1627-31.
https://www.ncbi.nlm.nih.gov/pubmed/10608477
Enalapril, oral (daily dosing): Davies RO, Gomez HJ, Irvin JD, Walker JF. An overview of the clinical pharmacology of
enalapril. Br J Clin Pharmacol. 1984;18 Suppl 2:215S-229S. https://www.ncbi.nlm.nih.gov/pubmed/6099737
Enalapril, oral (daily dosing): Contract circular HP09-2016SD. http://www.health.gov.za/
xxxiiiSpironolactone (hypertension):Williams B, MacDonald TM, Morant S, Webb DJ, Sever P, McInnes G, Ford I, Cruickshank

JK, Caulfield MJ, Salsbury J, Mackenzie I, Padmanabhan S, Brown MJ; British Hypertension Society's PATHWAY Studies
Group. Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant
hypertension (PATHWAY-2): a randomised, double-blind, crossover trial. Lancet. 2015 Nov 21;386(10008):2059-68.
http://www.ncbi.nlm.nih.gov/pubmed/26414968
xxxiv Spironolactone, oral (contra-indications): South African Medicines Formulary. 12th Edition. Division of Clinical

Pharmacology. University of Cape Town. 2016.

xxxv Amoxicillin, oral (children): Clegg HW, Ryan AG, Dallas SD, Kaplan EL, Johnson DR, Norton HJ, Roddey OF, Martin ES,

Swetenburg RL, Koonce EW, Felkner MM, Giftos PM. Treatment of streptococcal pharyngitis with once-daily compared with
twice-daily amoxicillin: a noninferiority trial. Pediatr Infect Dis J. 2006 Sep;25(9):761-7.
https://www.ncbi.nlm.nih.gov/pubmed/16940830
Amoxicillin, oral (children): Lennon DR, Farrell E, Martin DR, Stewart JM. Once-daily amoxicillin versus twice-daily penicillin
V in group A beta-haemolytic streptococcal pharyngitis. Arch Dis Child. 2008 Jun;93(6):474-8.
https://www.ncbi.nlm.nih.gov/pubmed/18337284
xxxviAmoxicillin, oral (adults): Brink AJ, Cotton M, Feldman C, Finlayson H, Friedman R, Green R, Hendson W, Hockman M,

Maartens G, Madhi S, Reubenson G, Silverbauer E, Zietsman I. Updated recommendations for the management of upper
respiratory tract infections in South Africa. S Afr Med J. 2015 Apr 6;105(5):344-52.
http://www.ncbi.nlm.nih.gov/pubmed/26242659
Amoxicillin, oral (adults): National Department of Health: Affordable Medicines, EDP-Primary Health Care level. Medicine
Review: Phenoxymethylpenicillin vs amoxicillin for tonsilitis_pharyngitis, October 2016. http://www.health.gov.za/
xxxviiAzithromycin: National Department of Health: Essential Drugs Programme. Paediatric Hospital level STGs and EML,

2017. http://www.health.gov.za/
xxxviiiAzithromycin: National Department of Health: Essential Drugs Programme. Adult Hospital level STGs and EML, 2015.

http://www.health.gov.za/

2018 4.32
PHC Chapter 5: Skin Conditions
5.1 Dry skin
5.2 Itching (pruritus)
5.3 Acne vulgaris
5.4 Bacterial infections of the skin
5.4.1 Boil, abscess
5.4.2 Impetigo
5.4.3 Cellulitis
5.4.4 Chronic lower limb ulcers
5.5 Fungal infections of the skin
5.5.1 Candidiasis, skin
5.5.2 Ringworm and other tineas
5.5.2.1 Ringworm – tinea corporis
5.5.2.2 Athlete’s foot – tinea pedis
5.5.2.3 Scalp infections – tinea capitis
5.5.2.4 Pityriasis versicolor – tinea
versicolor
5.5.2.5 Nail infections – tinea unguium
5.6 Nail and nailfold infections
5.6.1 Paronychia – chronic
5.6.2 Paronychia – acute
5.6.3 Nail infections – tinea unguium
5.7 Parasitic infestations of the skin
5.7.1 Lice (pediculosis)
5.7.1.1 Head lice
5.7.1.2 Body lice
5.7.1.3 Pubic lice
5.7.2 Scabies
5.7.3 Sandworm
5.8 Eczema and dermatitis
5.8.1 Eczema, atopic
5.8.2 Eczema, acute, moist or weeping
5.8.3 Dermatitis, seborrhoeic
CHAPTER 5 SKIN CONDITIONS

5.9 Nappy rash

5.10 Allergies
5.10.1 Urticaria
5.10.2 Angioedema
5.10.3 Fixed drug eruptions
5.10.4 Papular urticaria
5.10.5 Erythema multiforme
5.10.6 Severe cutaneous adverse drug reactions
5.10.6.1 Stevens-Johnson syndrome (SJS)/
Toxic Epidermal Necrolysis (TEN)
5.10.6.2 Drug Reaction with Eosinophilia
and Systemic Symptoms(DRESS)
5.11 Pityriasis rosea
5.12 Molluscum contagiosum
5.13 Herpes simplex
5.14 Herpes Zoster
5.15 Warts
5.15.1 Common warts
5.15.2 Plane warts
5.15.3 Plantar warts
5.15.4 Genital warts: Condylomata accuminata
5.16 Psoriasis
5.17 Hidradenitis suppurativa
5.18 Hypopigmentory disorders
5.18.1 Albinism
5.18.2 Vitiligo
5.19 Pressure ulcers/sores

2018 5.2
CHAPTER 5 SKIN CONDITIONS

5.1 DRY SKIN

L85.3

DESCRIPTION
The skin is dry and rough, together with varying degrees of scaling.
Severe forms are mainly inherited, e.g. ichthyosis.
Milder forms (xeroderma), seen as dryness with only slight scaling are common in the
elderly and some chronic conditions, e.g. HIV disease, malignancies and atopic
eczema.

MEDICINE TREATMENT
ƒ
x
Avoid soap, use soap substitutes e.g.
Aqueous cream (UEA).
o Rub on skin, before rinsing off completely.
o Aqueous cream should not be used as an emollient.
ƒ
x
Emollient, e.g.:
Emulsifying ointment (UE).

5.2 ITCHING (PRURITUS)

L29.0-3/L29.8-9

DESCRIPTION
Itching may be:
» localised or generalised
» accompanied by obvious skin lesions or skin conditions e.g. chicken pox
» accompanied by many systemic diseases, e.g. hepatitis
» caused by scabies and insect bites

GENERAL MEASURES
» Trim fingernails.
» Avoid scratching.

MEDICINE TREATMENT

x Calamine lotion, apply when needed.

Diagnose and treat the underlying condition.

For pruritis associated with dry skin:

ƒ Emollient, e.g.:
x Emulsifying ointment (UE).
Severe pruritus:
For short term use

x Chlorphenamine, oral, 0.1 mg/kg/dose 6–8 hourly. See dosing table, pg 23.3.
Children

2018 5.3
CHAPTER 5 SKIN CONDITIONS

x Chlorphenamine, oral, 4 mg, 6–8 hourly.

Adults

Note: Chlorphenamine is sedating and in mild cases may be used only at night.
For long term use e.g. for chronic pruritus:

x Cetirizine, oral, 5 mg once daily. See dosing table, pg 23.3.

Children: 2–6 years of age

x Cetirizine, oral, 10 mg once daily.

Children > 6 years of age and adults

CAUTION
Do not give an antihistamine to children < 2 years of age.

REFERRAL
» No improvement after 2 weeks.
» Underlying malignancy or systemic disease suspected.

5.3 ACNE VULGARIS

L70.0-5/L70.8-9

DESCRIPTION
Acne is an inflammatory condition of the hair follicle.
It is caused by hormones and sebum gland keratinisation, leading to follicular
plugging producing comedomes and proliferation of Propioni bacterium acnes.
Distributed on face, chest and back.
Occurs more commonly in adolescence, but may also occur in adulthood.
May also occur as a result of the inappropriate use of topical steroids or as a side
effect of medicine e.g. INH therapy.
Mild acne:
Predominantly consists of non-inflammatory comedones.
Moderate acne:
Consists of a mixture of non-inflammatory comedones and inflammatory papules
and pustules.
Severe acne
It is characterised by the presence of widespread nodules and cysts, as well as a
preponderance of inflammatory papules and pustules.

GENERAL MEASURES
» Do not squeeze lesions.
» Avoid greasy or oily cosmetics and hair grooming products that block the
hair follicle openings.
» Avoid excessive facial washing.

2018 5.4
CHAPTER 5 SKIN CONDITIONS

MEDICINE TREATMENT

x Benzoyl peroxide 5%, gel, apply in the morning to affected areas as tolerated.
Mild inflammatory acne:

o Wash off in the evening.

o If ineffective and tolerated, increase application to 12 hourly.
o Avoid contact with eyes, mouth, angles of the nose and mucous membranes.
LoE:IIIi
For non-inflammatory acne:
Topical retinoids
The main action is to control comedone formation.
Introduce topical retinoids gradually as a night-time application to limit skin irritant
effects, as they are not photo-stable and degrade when exposed to sunlight.
CAUTION
Do not use if pregnant or planning pregnancy.
Limit exposure to sunlight. If sunburn occurs, discontinue therapy LoE:Iii
until the skin has recovered.
x Tretinoin, topical, apply at night to affected areas for at least 6 weeks.
o Review patient after 6 weeks’ treatment.
o Minimise exposure to sunlight. If sunburn occurs, discontinue therapy until
the skin has recovered
o Acne may worsen during the first few weeks.

x Benzoyl peroxide 5%, gel, apply in the morning to affected areas as tolerated.
Moderate inflammatory acne:

o Wash off in the evening.

o If ineffective and tolerated, increase application to 12 hourly.
o Avoid contact with eyes, mouth, angles of the nose and mucous membranes.

x Doxycycline, oral, 100 mg daily for 3 months.

AND LoE:IIIiii

o Review patient after 3 months of treatment.

o It should be taken with meals.
o Do not take it together with iron preparations and antacids.
LoE:IIIiv
REFERRRAL
» All severe cases.
» Poor response to treatment.

5.4 BACTERIAL INFECTIONS OF THE SKIN

5.4.1 BOIL, ABSCESS
L02.0-4/L02.8-9/H00.0/H60.0/N76.4/J34.0 + (B95.6)

DESCRIPTION
Localised bacterial skin infection of hair follicles or dermis, usually with S. aureus.
The surrounding skin becomes:

2018 5.5
CHAPTER 5 SKIN CONDITIONS

» swollen » hot
» red » tender to touch
Note:
» Check blood glucose level if diabetes suspected or if the boils are recurrent.
Boils in diabetic or immunocompromised patients require careful management.
» Axillary abscesses and pustules (See Section 5.17: Hidradenitis suppurativa).

GENERAL MEASURES
» Encourage general hygiene e.g.: frequent showering, keeping nails short.
» Drainage of abscess is the treatment of choice.
» Perform surgical incision only when the lesion is fluctuant.

MEDICINE TREATMENT
Systemic antibiotics are seldom necessary, except if there are:
» Swollen tender lymph nodes in the area » extensive surrounding cellulitis
» fever » boils on the face
Antibiotics are also indicated in immunocompromised patients, diabetic
patients and neonates:
Children ” 7 years of age
x Cephalexin, oral, 12–25 mg/kg/dose 6 hourly for 5 days See dosing table, pg 23.3.
OR
Flucloxacillin, oral, 12–25 mg/kg/dose 6 hourly for 5 days. See dosing table,
pg 23.5.

x Cephalexin, oral, 500 mg 6 hourly for 5 days.

Children > 7 years of age and adults

OR
Flucloxacillin, oral, 500 mg 6 hourly for 5 days.
Severe penicillin allergy: (Z88.0)
Children:
ƒ Macrolide, e.g.:
x Azithromycin, oral, 10 mg /kg/dose daily for 3 days. See dosing table, pg 23.2.
Adults
ƒ Macrolide, e.g.:
x Azithromycin, oral, 500 mg daily for 3 days.

REFERRAL
» Poor response to treatment.
» Abscesses of the palm of the hand and pulp space abscess of the fingers.
» Features of severe sepsis requiring intravenous antibiotics.
» Deep abscess e.g. ischiorectal and breast abscess.

2018 5.6
CHAPTER 5 SKIN CONDITIONS

5.4.2 IMPETIGO
L01.0-1

DESCRIPTION
A common contagious skin infection caused by streptococci or staphylococci.
Predominantly occurs in children.
Often secondary to scabies, insect bite, eczema or tinea capitis.
Clinical features:
» starts as blisters containing pus
» subsequently becomes eroded producing honey-coloured crusts
» commonly starts on the face or buttocks
» spreading to neck, hands, arms and legs
Note:
» Post-streptococcal glomerulonephritis is a potential complication.
» Check urine for blood if the sores have been present for more than a week.

GENERAL MEASURES
» Good personal and household hygiene to avoid spread of the infection and to
reduce carriage of organisms.
» Trim finger nails.
» Wash and soak sores in soapy water to soften and remove crusts.
» Continue with general measures until the sores are completely healed.

x
MEDICINE TREATMENT
Povidone iodine 5%, cream or 10% ointment apply 8 hourly.
AND
Children ” 7 years of age
x Cephalexin, oral, 12–25 mg/kg/dose 6 hourly for 5 days. See dosing table, pg 23.3.
OR
Flucloxacillin, oral, 12–25mg/kg/dose 6 hourly for 5 days. See dosing table,
pg 23.5.

x Cephalexin, oral, 500 mg 6 hourly for 5 days.

Children > 7 years of age and adults

OR
Flucloxacillin, oral, 500 mg 6 hourly for 5 days.
Severe penicillin allergy: (Z88.0)
Children
ƒ Macrolide, e.g.:
x Azithromycin, oral, 10 mg /kg/dose daily for 3 days. See dosing table, pg 23.2.
Adults
ƒ Macrolide, e.g.:
x Azithromycin, oral, 500 mg daily for 3 days.
If impetigo has improved, but has not completely cured, give a 2nd 5-day course of
antibiotics.

2018 5.7
CHAPTER 5 SKIN CONDITIONS

REFERRAL
» No improvement after second course of antibiotics.
» Presence of blood on urine test strip for longer than 5-7 days.
» Clinical features of glomerulonephritis. See Section 8.3.1: Nephritic syndrome.

5.4.3 CELLULITIS
L03.0-3/L03.8-9

DESCRIPTION
A diffuse, spreading, acute infection within skin and soft tissues, commonly caused
by streptococci and staphylococci.
Characterised by:
» oedema » redness
» increased local temperature » no suppuration
Frequently associated with lymphangitis and regional lymph node involvement.
Commonly occurs on the lower legs, but may occur elsewhere.
May follow minor trauma.
There may be significant systemic manifestations of infection:
» fever » tachycardia » hypotension
» chills » delirium/altered mental state
May present as an acute fulminant or chronic condition.

GENERAL MEASURES
Elevate the affected limb to reduce swelling and discomfort.

MEDICINE TREATMENT
Children ” 7 years of age
x Cephalexin, oral, 12–25 mg/kg/dose 6 hourly for 5 days. See dosing table, pg 23.3.
OR
Flucloxacillin, oral, 12–25 mg/kg/dose 6 hourly for 5 days. See dosing table,
pg 23.5.

x Cephalexin, oral, 500 mg 6 hourly for 5 days.

Children > 7 years of age and adults

OR
Flucloxacillin, oral, 500 mg 6 hourly for 5 days.
Severe penicillin allergy: (Z88.0)
Children:
ƒ Macrolide, e.g.:
x Azithromycin, oral, 10 mg /kg/dose daily for 3 days. See dosing table, pg 23.2.
Adults
ƒ Macrolide, e.g.:
x Azithromycin, oral, 500 mg daily for 3 days.
Severe cases:
Refer for parenteral antibiotics.

2018 5.8
CHAPTER 5 SKIN CONDITIONS

REFERRAL
Urgent
» Children who have significant pain, swelling or loss of function (to exclude
osteomyelitis).
» Haemorrhagic bullae, gas in the tissues or gangrene.
» Extensive cellulitis.
» Recurrent cellulitis associated with underlying conditions, e.g. lymphoedema.
» Cellulitis with systemic manifestations, e.g. confusion, hypotension.
» Poorly controlled diabetic patients.
» Involvement of the hand, face and scalp.
Non-urgent
» Inadequate response to initial antibiotic treatment.

5.4.4 CHRONIC LOWER LIMB ULCERS

L97

DESCRIPTION
A chronic relapsing disorder of the lower limbs.
Associated with vascular insufficiency (predominantly venous insufficiency) and
patient immobility.
Commonly associated with neuropathy, infections, neoplasia, trauma or other rare
conditions.

GENERAL MEASURES
» If the ulcer is oedema- or stasis-related, rest the leg in an elevated position.
» In venous insufficiency, compression (bandages or stockings) are essential to
achieve and maintain healing, provided the arterial supply is normal.
» In patients with arterial insufficiency, avoid pressure on bony prominences and
the toes.
» In patients with neuropathy, relieve pressure from the area.
» Exclude diabetes with finger prick blood glucose test.
» Avoid topical application of home remedies.
» Stress meticulous foot care and avoidance of minor trauma. Encourage patients
with neuropathy not to walk barefoot, check their shoes for foreign objects,
examine their feet daily for trauma and to test bath water before bathing to
prevent getting burnt.
» Avoid excessive local heat.
» Walking and exercises are recommended.

MEDICINE TREATMENT
Refer for assessment and initiation of treatment.
Local wound care:

x Sodium chloride 0.9%.

Use bland, non-toxic products to clean the ulcer and surrounding skin.

2018 5.9
CHAPTER 5 SKIN CONDITIONS

x
For venous ulcers:
Paraffin gauze dressing.

REFERRAL
» No improvement after 1 month.
» All foot ulcers.
» Ulcers with atypical appearance.
» Venous ulcers that are persistently infected, or have offensive odour.

5.5 FUNGAL INFECTIONS OF THE SKIN

5.5.1 CANDIDIASIS, SKIN
B37.2
Vaginal candidiasis: See Section 12.1: Vaginal discharge syndrome (VDS).

DESCRIPTION
A skin infection caused by C. albicans.
Most common sites for infection are skin folds such as:
» under the breasts » natal cleft
» axillae » groins
» nail folds » neck folds, peri-anal, perineum and groins in infants
The skin lesions or sores:
» are red raw-looking patches
» appear moist (weeping)
» have peripheral outlying white pustules, red scaly lesions which become confluent

GENERAL MEASURES
Exclude diabetes.

MEDICINE TREATMENT
ƒ
x
Imidazole, e.g.:
Clotrimazole 1% cream, apply three times daily for 14 days.

5.5.2 RINGWORM AND OTHER TINEAS

Fungal infections affecting the skin (tinea corporis; tinea versicolor), feet (tinea pedis),
scalp (tinea capitis) and nails (tinea unguium). These infections may be contagious.

5.5.2.1 RINGWORM – TINEA CORPORIS

B35.4

DESCRIPTION
Clinical features include:
» itchy ring-like patches » raised borders
» patches slowly grow bigger
As the patch extends a clear area develops in the center which may become hyper-

2018 5.10
CHAPTER 5 SKIN CONDITIONS

pigmented in dark skin.

Extensive disease is common in HIV, often with no evidence of the patches
developing clear centres.

GENERAL MEASURES
» Prevent spreading the infection to others.

 clothes
» Do not share:

 towels
 toiletries, especially combs and hair brushes
» Wash skin well and dry before applying medicine treatment.

MEDICINE TREATMENT
Treat any secondary skin infection with antibiotics. See Section 5.4.2: Impetigo.
ƒ Imidazole, e.g.:
x Clotrimazole 1% cream, topical, apply 3 times daily.
o Continue using cream for at least 2 weeks after lesions have cleared.

REFERRAL
Extensive disease.

5.5.2.2 ATHLETE'S FOOT – TINEA PEDIS

B35.3

DESCRIPTION
A common contagious fungal infection of the foot, characterised by itching, burning
and stinging between the toes or the sole.
The skin between the toes is moist and white (maceration) and may become
fissured. There is also associated erythema, scaling and peeling.
Secondary eczema of the hands may be an associated condition. See Section
5.8.1: Eczema, atopic.
Vesicles may occur in inflammatory cases.
Pain and tenderness in the web spaces may indicate secondary bacterial infection.
Re-infection is common.

GENERAL MEASURES
» Discourage the use of shared bathing or swimming areas, whilst infected.

 wear open sandals

» Keep feet dry:

 do not wear socks of synthetic material

 dry between toes after washing the feet or walking in water
 wash and dry feet twice daily before applying medicine treatment

x
MEDICINE TREATMENT

x
Imidazole cream, e.g.:
Clotrimazole 1%, apply twice daily for 4 weeks.

2018 5.11
CHAPTER 5 SKIN CONDITIONS

REFERRAL
No improvement after 4 weeks.

5.5.2.3 SCALP INFECTIONS – TINEA CAPITIS

B35.0

DESCRIPTION
Round or patchy bald areas with scales and stumps of broken off hair.

GENERAL MEASURES
Avoid shaving head in children.
Do not share toiletries such as combs and hair brushes.

MEDICINE TREATMENT
For scalp infections:

x Fluconazole, oral, 6 mg/kg once daily, for 28 days. See dosing table, pg 23.5.
Children

LoE:Iv
Adults
x Fluconazole, oral, 200 mg weekly, for 6 weeks. LoE:Ivi
Note: Do not give to women of child-bearing age unless they are using an effective
contraceptive.

5.5.2.4 PITYRIASIS VERSICOLOR – TINEA VERSICOLOR

B36.0

DESCRIPTION
Mostly found on the upper chest and back and less commonly on the neck, face,
abdomen and upper limbs. Round macules which are usually lighter than normal
skin (but may be darker). On the chest and back the more central macules join
together and the condition spreads with the formation of new macules on the
periphery. After treatment, the pigmentation may take months to return to normal.
Recurrences are common, especially in hot weather.

GENERAL MEASURES
Avoid wearing heavy clothing in hot weather to reduce perspiration.

MEDICINE TREATMENT

x Selenium sulphide, 2.5% suspension

Oral antifungal therapy is not indicated.

o Lather shampoo on affected parts.

o Apply daily for 3 successive days and leave on for 30 minutes, then wash off;
o or leave on overnight once a week for 3 weeks. LoE:IIIvii

5.5.2.5 NAIL INFECTIONS – TINEA UNGUIUM

See Section 5.6.3: Nail infections – tinea unguium.

2018 5.12
CHAPTER 5 SKIN CONDITIONS

5.6 NAILFOLD AND NAIL INFECTIONS

5.6.1 PARONYCHIA, ACUTE
L03.0

DESCRIPTION
Small subcutaneous collection of pus under the nailfold.
Often associated with cutting nails too short, or nail biting.

GENERAL MEASURES
» Avoid cutting finger nails too short.
» Avoid nail biting.

MEDICINE TREATMENT
Drain abscess by puncture or incision.

x Flucloxacillin 500 mg 6 hourly for 5 days.

Adults

5.6.2 PARONYCHIA, CHRONIC

L03.0

DESCRIPTION
» Chronic, red, swollen nailfold, lifted off the nail plate with whitish pus.
» Commonly caused by working in water and contact with household detergents.

GENERAL MEASURES
» Avoid hand contact with household detergents, washing powders and fabric
softeners.
» Patients to wear rubber gloves when washing clothes, linen and kitchen utensils in
order to keeping hands clean and dry as far as possible, during day.

MEDICINE TREATMENT
ƒ
x
Corticosteroid, potent, topical, e.g.:
Betametasone 0.1% cream, apply at night until lesions have cleared.
o After washing hands, massage cream into the nailfold.
If secondary infection is present, indicated by pain and tenderness in the nail fold,
treat with antibiotics. See Section 5.4.2: Impetigo.
LoE:IIIviii
REFERRAL
No response to treatment.

5.6.3 NAIL INFECTIONS – TINEA UNGUIUM

B35.1

DESCRIPTION
Nails are lifted, distorted, crumbling and discoloured. One or more nails may be affected.

2018 5.13
CHAPTER 5 SKIN CONDITIONS

GENERAL MEASURES
Topical treatment is generally ineffective for fungal nail infections.
Systemic treatment is often unsuccessful and recurrent infections are common if
repeat exposure is not prevented.

REFERRAL
Only patients that are distressed by cosmetic appearance.

5.7 PARASITIC INFESTATIONS OF THE SKIN

5.7.1 LICE (PEDICULOSIS)
DESCRIPTION
An infestation of the body with parasitic lice.
Clinical features include:
» itching
» bite marks
» presence of secondary eczema and secondary infection

CAUTION
Do not use commercial insect sprays as they are toxic.
Lotions used for the treatment of lice are toxic when swallowed.

Treat secondary infection with antibiotics. See Section 5.4.2: Impetigo.

5.7.1.1 HEAD LICE

B85.0

DESCRIPTION
Head lice are common in children. The eggs (nits) appear as fixed white specks on
the hair.

GENERAL MEASURES
» Use a fine comb to comb out the nits after washing hair.
» Shaving of the head may expedite treatment, where socially acceptable.
» Prevent spread by treating other contacts.
» Remove nits from eyelashes by applications of white soft paraffin.

x
MEDICINE TREATMENT
Permethrin 5% lotion.
o Apply permethrin 5% lotion to towel-dried or dry hair. Comb into hair
repeatedly with a normal comb until scalp is covered completely.
o Remove lice and nymphs with fine lice comb, by dividing scalp into sections
and combing away from scalp.
o Rinse lice comb in a white bowl filled with hot water between hair strokes to
identify removed lice, or detach on white tissue paper. Paralysed and dead lice

2018 5.14
CHAPTER 5 SKIN CONDITIONS

will present as dark spots (like ground pepper).

o Take note of the physical size of removed lice and nymphs, as the size should
get smaller with consecutive treatments.
o Keep on combing with fine lice comb, rinsing or wiping comb frequently.
o Permethrin 5% lotion is safe and can be left in the hair for up to one hour.
o After combing, rinse hair with lukewarm water and wash permethrin 5% lotion
out with normal shampoo (more than one foaming might be needed).
o Repeat this procedure every 5days for 3weeks.
o Thereafter, carry out frequent inspections to detect new infestations early.
Note:
o Do not apply to broken skin or sores. LoE:IIIix
o Avoid contact with eyes.

5.7.1.2 BODY LICE

B85.1/B85.4
Body lice live in the seams of clothing and only come to the skin to feed.
Note: Body lice may carry typhus fever.

GENERAL MEASURES
Regularly wash bed linen and underclothes in hot water and expose to sunlight.

MEDICINE TREATMENT

x Benzyl benzoate 25% lotion, undiluted, applied over the whole body.
Adults and adolescent children

o Leave on overnight and wash off the next day.

o Repeat once a week for up to 3 weeks.
Note:
o Do not apply to neck and face.
o Avoid contact with eyes and broken skin or sores.
o The lotion is toxic if swallowed.
o Do not continue if a rash or swelling develops.
o Itching may continue for 2–3 weeks after treatment.
LoE:IIx

5.7.1.3 PUBIC LICE

B85.3/B85.4
Pubic lice are acquired as STIs and nits are found on pubic hair and eyelashes.

GENERAL MEASURES
Prevent spread by treating other contacts.

MEDICINE TREATMENT
Benzyl benzoate 25%
o Apply to affected area.
o Leave on for 24 hours, then wash thoroughly.
o Repeat in 7 days.

2018 5.15
CHAPTER 5 SKIN CONDITIONS

Pediculosis of the eyelashes or eyebrows

Yellow petroleum jelly (Note: Do not use white petroleum jelly near the eyes).
o Apply to the eyelid margins (cover the eyelashes) daily for 10 days to
smother lice and nits.
o Do not apply to eyes.
LoE:III
REFERRAL
Lice infestation of eyelashes in children to exclude suspected sexual abuse.

5.7.2 SCABIES
B86

DESCRIPTION
An infestation with the parasite Sarcoptes scabei.
Commonly occurs in the skin folds. The infestation spreads easily, usually affecting
more than one person in the household.
Clinical features include:
» intense itching, which is more severe at night
» small burrows between fingers, toes, elbow areas and buttocks where the
parasite has burrowed under the skin
» secondary infection which may occur due to scratching with dirty nails
» in small babies, there are often vesicles and pustules on the palms and soles
and sometimes on the scalp

GENERAL MEASURES
All close contacts must be treated simultaneously even if they are not itchy –
see medicinal treatment below.
» Cut finger nails and keep them clean.
» Wash all linen and underclothes in hot water.
» Expose all bedding to direct sunlight.
» Put on clean, washed clothes after medicine treatment.

MEDICINE TREATMENT

x Benzyl benzoate 25% lotion, applied undiluted to the whole body from neck to
Adults and children > 6 years of age

feet and rub in well.

o Allow the lotion to remain on the body for 24 hours, then wash off using soap
and water.
o For severe infestation treatment may be repeated after 24 hours or once
within 5 days.
o All infected persons living in the household, or likely to contract the infection,
should be treated at the same time.

x Permethrin 5% lotion, applied undiluted to the whole body from neck to feet.
If benzyl benzoate is unsuccessful:

o Leave on overnight (8–12 hours) and wash off the following morning.
LoE:Ixi

2018 5.16
CHAPTER 5 SKIN CONDITIONS

x Permethrin 5% lotion, applied undiluted to the whole body from neck to feet
Children < 6 years of age

o Leave on overnight (8–12 hours) and wash off the following morning.
Note: LoE:IIIxii
o Benzyl benzoate and permethrin are toxic if swallowed.
o Avoid contact with eyes and broken skin or sores.
o Do not continue if rash or swelling develops.
o Itching may continue for 2–3 weeks after treatment.
Treatment may need to be repeated after one week.
Treat secondary infection with antibiotics. See Section 5.4.2: Impetigo.

5.7.3 SANDWORM
B76.0

DESCRIPTION
Creeping eruption (cutaneous larva migrans) caused by Ancylostoma braziliense, a
hookworm of dog or cat. Larvae of ova in soil penetrate skin commonly through the
feet, legs, buttocks or back and cause a winding thread-like trail of inflammation
with itching, scratching dermatitis and bacterial infection.

x
MEDICINE TREATMENT
Albendazole, oral, daily for 3 days.
o Children < 2 years of age: 200 mg
o Children • 2 years of age and adults: 400 mg

x Chlorphenamine, oral, 0.1 mg/kg/dose 6–8 hourly. See dosing table, pg 23.3.
Children

x Chlorphenamine, oral, 4 mg, 6–8 hourly.

Adults

Note: Chlorphenamine is sedating and in mild cases may be used only at night.
CAUTION
Do not give an antihistamine to children < 2 years of age.

5.8 ECZEMA AND DERMATITIS

5.8.1 ECZEMA, ATOPIC
L20.0/L20.8-9

DESCRIPTION
An allergic disorder with an itchy red rash or dry rough skin.
In babies it appears at approximately 3 months.
Family history of asthma, hay fever or atopic dermatitis is common.
Clinical features:
» occurs on the inner (flexural) surfaces of elbows and knees, the face and neck
» can become chronic with thickened scaly skin (lichenification)

2018 5.17
CHAPTER 5 SKIN CONDITIONS

» secondary bacterial infection may occur with impetigo or pustules

» can be extensive in infants
» very itchy at night
Eczema is usually a chronic condition and requires long-term care.
Sufferers of atopic eczema are particularly susceptible to herpes simplex and may
present with large areas of involvement with numerous vesicles and crusting
surrounded by erythema (eczema herpeticum). See Section 5.13: Herpes simplex.

GENERAL MEASURES
» Avoid direct skin contact with woollen or rough clothes.
» Avoid overheating by blankets at night.
» Trim fingernails to prevent scratching.
» Good personal hygiene with regular washing to remove crusts and accretions
and to avoid secondary infection.
» Diet modification may have no role in atopic eczema treatment.
» Avoid soap on affected areas.

MEDICINE TREATMENT
(For management of severe eczema, start at step 3).

x Avoid soap, use soap substitutes such as aqueous cream (UEA).

STEP 1

o Rub on skin, before rinsing off completely.

o Aqueous cream should not be used as an emollient.
ƒ Emollient, e.g.:
x Emulsifying ointment (UE).
STEP 2

x Hydrocortisone 1% cream, applied twice daily for 7 days.

If no response within seven days; or more severe eczema:

o Apply sparingly to the face.

o Do not apply around the eyes.
If there is a response:
Reduce the use of the hydrocortisone cream to once daily for a further few days,

x Aqueous cream (UEA) as a soap.

then stop and maintain treatment with:

AND
ƒ Emollient, e.g.:
x Emulsifying ointment (UE).
STEP 3
If no response within seven days or more severe eczema:
ƒ Corticosteroid, potent, topical, e.g.:
x Betamethasone 0.1% ointment applied once daily for 7 days (Doctor initiated).
o Do not apply to face, neck and flexures.
LoE:Ixiii

2018 5.18
CHAPTER 5 SKIN CONDITIONS

If there is a response:
Reduce use of corticosteroid ointment to once daily for a further few days, then stop

x Aqueous cream (UEA) as a soap.

and maintain treatment with:

AND
ƒ Emollient, e.g.:
x Emulsifying ointment (UE).
For itching

x Chlorphenamine, oral, 0.1 mg/kg/dose at night for a maximum of 2 weeks. See

Children

dosing table, pg 23.3.

Adults
x Chlorphenamine, oral, 4 mg, at night for a maximum of 2 weeks. LoE:III
o Note: Chlorphenamine is sedating.
If itch not controlled or more severe daytime itch, switch to:

x Cetirizine, oral, 5 mg once daily. See dosing table, pg 23.3.

Children: 2–6 years of age

Children > 6 years of age and adults

x Cetirizine, oral, 10 mg once daily. LoE:III

CAUTION
Do not give an antihistamine to children < 2 years of age.

REFERRAL
» No improvement in 2 weeks.
» Infants and children requiring more than 1% hydrocortisone cream.
» Extensive involvement.
» Eczema herpeticum.

5.8.2 ECZEMA, ACUTE, MOIST OR WEEPING

L20.0/L20.8-9

DESCRIPTION
A form of eczema with small or large vesicles, associated with oozing and eventual
crusting and scaling. Yellow pustules which crust indicate sepsis.

GENERAL MEASURES
» Sodium chloride 0.9% dressings, applied daily or twice daily.
» Avoid use of soap on affected areas.

MEDICINE TREATMENT

x Hydrocortisone 1% cream, applied 12 hourly, until improved.

Topical steroids, e.g.:

o Topical steroids should be applied to both moist and dry inflamed areas.

2018 5.19
CHAPTER 5 SKIN CONDITIONS

Antibiotic treatment if secondary infection is present:

Children ” 7 years of age
x Cephalexin, oral, 12–25 mg/kg/dose 6 hourly for 5 days. See dosing table, pg 23.3.
OR
Flucloxacillin, oral, 12–25 mg/kg/dose 6 hourly for 5 days. See dosing table,
pg 23.4.

x Cephalexin, oral, 500 mg 6 hourly for 5 days.

Children > 7 years of age and adults

OR
Flucloxacillin, oral, 500 mg 6 hourly for 5 days.
Severe penicillin allergy: (Z88.0)
Children:
ƒ Macrolide, e.g.:
x Azithromycin, oral, 10 mg /kg/dose daily for 3 days. See dosing table, pg 23.4.
Adults
ƒ Macrolide, e.g.:
x Azithromycin, oral, 500 mg daily for 3 days.
For itching:

x Chlorphenamine, oral, 0.1 mg/kg/dose.at night See dosing table, pg 23.3.

Children

Adults
x Chlorphenamine, oral, 4 mg, at night. LoE:III
Note: Chlorphenamine is sedating.
CAUTION
Do not give an antihistamine to children < 2 years of age.

If itch not controlled or more severe daytime itch, switch to:

x Cetirizine, oral, 5 mg once daily. See dosing table, pg 23.3.

Children: 2–6 years of age

Children > 6 years of age and adults

x Cetirizine, oral, 10 mg once daily. LoE:III

x Calamine lotion, applied on the skin.

For itching in children < 2 years of age:

REFERRAL
» No improvement after a week.
» Severe acute moist or weeping eczema.

5.8.3 DERMATITIS, SEBORRHOEIC

L21.0-1/L21.8-9

DESCRIPTION
Dandruff is an uninflamed form of seborrhoeic dermatitis.

2018 5.20
CHAPTER 5 SKIN CONDITIONS

Pruritus may or may not be present in seborrhoeic dermatitis.

The scalp, face, ears and skin folds e.g. axillae, groins, under the breasts are
commonly affected.
May become very extensive, particularly in infants and HIV infected patients.

GENERAL MEASURES
» Trim nails.
» Avoid scratching.
» Avoid perfumed soap.

x
MEDICINE TREATMENT
Hydrocortisone 1% cream, apply twice daily until improved.
o Then apply once or twice weekly for maintenance as needed.
For severe dermatitis:
ƒ Corticosteroid, potent, topical, e.g.:
x Betamethasone 0.1% ointment, applied once daily for 5–7 days. (Doctor
initiated).
o Do not apply to face neck and flexures.
LoE:Ixiv

x Selenium sulphide, 2.5% suspension, apply weekly.

For itching scalp, scaling and dandruff:

o Lather on the scalp.

o Rinse off after 10 minutes.
o Apply weekly, until improved and every second week to maintain control.

5.9 NAPPY RASH

L22

DESCRIPTION
A diffuse reddish eruption in the nappy area, usually caused by irritation from:
» persistent moisture and irregular cleaning and drying of the nappy area,
» diarrhoeal stools,
» underlying skin conditions in some cases, or
» improper rinsing of nappies to remove urine and stool breakdown products.
Rash is predominantly on areas in contact with the nappy, and spares the flexures.

GENERAL MEASURES
» Prompt changing of soiled nappies.
» Avoid waterproof pants. Expose nappy area to air if possible especially with
severe nappy dermatitis.

 washing, rinsing and drying of the nappy when soiled.

» Educate caregiver on:

x
MEDICINE TREATMENT
Zinc and castor oil ointment, applied after each nappy change.

2018 5.21
CHAPTER 5 SKIN CONDITIONS

If rash involves the flexures, suspect candida:

ƒ Imidazole, e.g.:
x Clotrimazole 1% cream applied beneath zinc and castor oil ointment after each
nappy change until symptoms are resolved.

REFERRAL
No improvement after 3 days of treatment.

5.10 ALLERGIES
5.10.1 URTICARIA
L50.0-6/L50.8-9

DESCRIPTION
Urticaria is a skin disorder characterised by itchy wheals (hives). There are many
causes, including allergic, toxic or physical. Allergic urticaria may be caused by
drugs, plant pollen, insect bites or foodstuffs, e.g. fish, eggs, fruit, milk and meat.
Note: Commonly caused by medicines e.g. aspirin, NSAIDs and codeine.

GENERAL MEASURES
» Take detailed history to determine trigger factors.
» Lifestyle adjustment.

MEDICINE TREATMENT

x Chlorphenamine, oral, 0.1 mg/kg/dose 6–8 hourly. See dosing table, pg 23.3.
Children

x Chlorphenamine, oral, 4 mg, 6–8 hourly.

Adults

CAUTION
Do not give an antihistamine to children < 2 years of age.

x Calamine lotion, applied on the skin.

o The use of oral corticosteroids should be avoided.
LoE:III
REFERRAL
No improvement or response after 24 hours.

5.10.2 ANGIOEDEMA
T78.3 + (Y14.99/Y34.99/Y57.9)

DESCRIPTION
Localised oedema of the subcutaneous tissue affecting particular parts of the face
i.e. lips, eyes and tongue. May also affect the larynx, causing life threatening airway
obstruction and anaphylaxis.
ACE-inhibitors are the most common cause in adults.

2018 5.22
CHAPTER 5 SKIN CONDITIONS

Other causes include other medicines and allergies.

GENERAL MEASURES
» Stop all suspected agents e.g. ACE-inhibitor.
» In the case of airway obstruction, a definitive airway must be established if
oedema is extensive or progressing.

MEDICINE TREATMENT
In severe cases where airway obstruction is present:

x Adrenaline (epinephrine), 1: 1000 solution, 0.5 mL into the lateral thigh,

Adults

administered immediately and repeated every 5 to 15 minutes as needed.

x Adrenaline (epinephrine), IM, 0.01 mL/kg of 1:1000 solution, administered

Children

immediately.
o Maximum dose of 0.3 mL

x Hydrocortisone, IV, 100 mg as a single dose.

In all cases

AND

x Chlorphenamine, oral, 4 mg immediately.

If the angioedema is not due to an ACE-inhibitor

OR
Promethazine, IM, 25–50 mg immediately.

CAUTION
Do not give an antihistamine to children < 2 years of age.

Observe all cases until resolution.

REFERRAL
» Failure to respond.
» No obvious cause found.

5.10.3 FIXED DRUG ERUPTIONS

L27.0-1

DESCRIPTION
Dark coloured round macules that can occur anywhere on the body following the
ingestion of a medicine to which the patient has become allergic.
They recur on the same spot and increase in number with each successive attack.
In the acute stage they are itchy, red around the edge or even bullous.

GENERAL MEASURES (all patients)

Stop the offending medicine.

2018 5.23
CHAPTER 5 SKIN CONDITIONS

MEDICINE TREATMENT (all patients)

x Hydrocortisone 1%, topical, apply daily for 5 days.

Acute/active stage

LoE:III
REFERRAL
Widespread eruptions.

5.10.4 PAPULAR URTICARIA

L50.8

DESCRIPTION
Hypersensitivity response to insect bites.
Initial lesion is a red papule, which may blister, become excoriated, and then heal
with hyperpigmentation. Usually occur in crops over several months.
Common and often severe in HIV infections (Papular pruritic eruption, PPE).

GENERAL MEASURES
Reduce exposure to insects by treating pets, using mosquito nets and fumigating
houses regularly. Use of insect repellents may be helpful.

MEDICINE TREATMENT

x Hydrocortisone 1%, topical, apply daily for 5 days.

New, inflamed lesions:

For relief of itch:

x Chlorphenamine, oral, 0.1 mg/kg/dose 6–8 hourly. See dosing table, pg 23.3.
Children

x Chlorphenamine, oral, 4 mg, 6–8 hourly.

Adults

Note: Chlorphenamine is sedating and in mild cases may be used only at night.
For long term use in adults and school going children:

x Cetirizine, oral, 5 mg once daily. See dosing table, pg 23.3.

Children: 2–6 years of age

x Cetirizine, oral, 10 mg once daily.

Children > 6 years of age and adults

CAUTION
Do not give an antihistamine to children < 2 years of age.

REFERRAL
Non-responsive and chronic cases.

2018 5.24
CHAPTER 5 SKIN CONDITIONS

5.10.5 ERYTHEMA MULTIFORME

L51.9

DESCRIPTION
A self-limiting and commonly recurrent inflammatory eruption of the skin. Sometimes
involves mucous membrane (but not more than one surface) and without systemic
symptoms. Usually lasts for 10–14 days before complete recovery occurs.
Symmetrically distributed crops of target lesions (dark centre, an inner, pale ring
surrounded by an outer red ring) occur on the extremities and in particular on the
backs of the hands and forearms, palms and soles. This condition is usually due to
an infection, commonly herpes simplex or mycoplasma.

REFERRAL
» All patients with systemic symptoms or mucosal involvement.
» Unsure of the diagnosis.

5.10.6 SEVERE CUTANEOUS ADVERSE DRUG REACTIONS

5.10.6.1 STEVENS-JOHNSON SYNDROME (SJS)/TOXIC
EPIDERMAL NECROLYSIS (TEN)
L51.1/ L51.2

DESCRIPTION
An acute, systemic condition with vesico-bullous lesions involving the skin and
mucous membranes (• 2 mucosal surfaces), but occasionally only the mucous
membranes.
The eruption may start as widespread red irregular macules and patches. There
may be a vesicle or bulla in the central area of the lesion. The blisters rupture
leaving denuded areas of skin. Mucous membrane erosions often with slough
covering the surface are frequently seen.
Toxic epidermal necrolysis (TEN) is a more severe form of the condition and is
suggested if the skin lesions cover > 30% of the body surface area. The mucous
membranes such as the mouth, eyes and vagina are also more severely affected.
The condition is usually caused by medicines e.g. sulphonamides, anti-retrovirals
(nevirapine), anti-epileptics (phenytoin, phenobarbitone, carbamazepine, lamotrigine).
Systemic involvement with multi-organ dysfunction is common.

GENERAL MEASURES
Immediate withdrawal of offending medicine.
Patients usually require care in a high or intensive care unit with dedicated nursing.

REFERRAL
All patients.

2018 5.25
CHAPTER 5 SKIN CONDITIONS

5.10.6.2 DRUG REACTION WITH EOSINOPHILIA AND

SYSTEMIC SYMPTOMS (DRESS)
L27.0 + (D72.0)

DESCRIPTION
Severe hypersensitivity reaction to a medicine.
Typically occurs within 3 months of starting the offending medicine.
Clinical symptoms include:
» maculopapular rash
» fever > 38o C
» lymphadenopathy
» hepatitis or other organ involvement
» blood count abnormalities especially eosinophilia
Medicines that commonly induce the DRESS syndrome include phenobarbital,
carbamazepine, phenytoin, lamotrigine, allopurinol, sulphonamides, abacavir,
nevirapine.

REFERRAL
All patients.

5.11 PITYRIASIS ROSEA

L42

DESCRIPTION
A common disease of unknown cause, probably due to a viral infection as it occurs
in minor epidemics. Most common in young adults but any age may be affected.
The rash involves the trunk, neck and mainly proximal parts of the limbs.
Presents as pink papules and macules. The macules are oval, and have a thin collar
of scale towards, but not at the periphery of the lesions. The eruption is usually
preceded by a few days by one larger, oval, slightly scaly area (“herald patch”),
commonly found in the scapular area or abdomen. The macules on the thorax
characteristically lie parallel to the long axis of the ribs (“Christmas tree” distribution).
The itch is usually mild and there are few or no constitutional symptoms. It is self-
limiting within about 6–8 weeks.

GENERAL MEASURES
Explain about the benign but prolonged nature of the condition.

MEDICINE TREATMENT

x Chlorphenamine, oral, 0.1 mg/kg/dose at night. See dosing table, pg 23.3.

Children

x Chlorphenamine, oral, 4 mg at night.

Adults

Note: Chlorphenamine is sedating.

2018 5.26
CHAPTER 5 SKIN CONDITIONS

If itch not controlled or more severe daytime itch, switch to:

x Cetirizine, oral, 5 mg once daily. See dosing table, pg 23.3.

Children: 2–6 years of age

Children > 6 years of age and adults

x Cetirizine, oral, 10 mg once daily. LoE:III

CAUTION
Do not give an antihistamine to children < 2 years of age.

x Aqueous cream, applied 3 times daily.

5.12 MOLLUSCUM CONTAGIOSUM

B08.1

DESCRIPTION
Infectious disease caused by a poxvirus. Presents with dome-shaped papules with a
central depression (umbilication). Varies from occasional lesions to large crops of
lesions particularly in immunocompromised or HIV-infected patients.
Papules are commonly seen on the face in children, but may be found at any skin
site, except on the palms and soles. They may also occur on the genitalia as an STI.
Most infections resolve spontaneously except in the immunocompromised.

GENERAL MEASURES
In non-genital molluscum contagiosum:
» Allow lesions to heal spontaneously if the lesions are few in number and the
patient not immunocompromised.
» In adults, contents can be expressed manually remembering it is contagious.
In genital molluscum contagiosum:
» Counsel on risk reduction for transmission of STIs.
» Notify that the partner(s) must be examined and treated.

x Tincture of iodine BP, applied to core of individual lesions using an applicator.

MEDICINE TREATMENT

CAUTION
Beware of hypersensitivity to iodine.

REFERRAL
» Extensive disease.
» Those failing to respond to simple measures.
» Peri-ocular lesions to an ophthalmologist.

2018 5.27
CHAPTER 5 SKIN CONDITIONS

5.13 HERPES SIMPLEX

B00.0-4/B00.7-9

DESCRIPTION
Infection caused by herpes simplex virus type 1 or 2.
Primary herpes infection involving gingivostomatitis (usually type 1) or the genital
area (usually type 2) may be extensive, but may occur at other sites, e.g. the face.
It is characterised by grouped crusted vesicles surrounded by erythema. The
vesicles rupture soon producing discrete ulcers.
Recurrences are usually mild and last a few days, except in immunosuppressed
patients. Recurrences of oral herpes may be triggered by other respiratory tract
infections or exposure to ultraviolet light.
Sufferers of atopic eczema are particularly susceptible to the virus and may present
with large areas of involvement with numerous vesicles and crusting surrounded by
erythema (eczema herpeticum).
Herpes simplex mucocutaneous ulceration that persists for > 1 month is an AIDS–
defining illness. See Section 11.3.10: Herpes simplex ulcers, chronic. Herpes simplex
infection may be the precipitating event in many cases of erythema multiforme.

GENERAL MEASURES
Keep the skin lesions clean and dry.

MEDICINE TREATMENT

x Aciclovir, oral, 400 mg 8 hourly for 10 days.

Extensive herpes, eczema herpeticum or chronic mucocutaneous ulcerations:

o Children dose: 250 mg/m2/dose. See dosing table, pg 23.1.

5.14 HERPES ZOSTER

See Section 11.3.11: Herpes zoster (Shingles).

5.15 WARTS
DESCRIPTION
A common, infectious, self-limiting condition of the skin or mucous membrane
caused by papilloma virus.

5.15.1 COMMON WARTS

B07

DESCRIPTION
Seen most often on the hands and fingers, but can be found anywhere on the body.
Raised nodules with a rough ‘warty’ surface.

GENERAL MEASURES
In most cases they should be left alone, as they will spontaneously resolve.

2018 5.28
CHAPTER 5 SKIN CONDITIONS

x
MEDICINE TREATMENT
Salicylic acid, 15 to 30% topical liquid application.
o Protect surrounding skin with petroleum jelly.
o Apply daily to wart and allow to dry.
o Occlude for 24 hours.
o Soften lesions by soaking in warm water and remove loosened keratin by
light abrasion.
o Wash well, dry, reapply the wart paint and occlude.
o Repeat process daily until the wart disappears.
LoE:IIIxv
REFERRAL
Extensive warts.

5.15.2 PLANE WARTS

B07

DESCRIPTION
Very small warts that are just slightly raised.
Present as smooth, flat, skin-coloured or slightly pigmented surface.
They occur particularly on the face, backs of the hands and knees.
Commonly seen in the immunocompromised.

MEDICINE TREATMENT

x Salicylic acid, 2%, topical.

These warts are notoriously difficult to treat with a poor response.

LoE:IIIxvi
REFERRAL
» Failure to respond.
» Extensive cases involving the face.

5.15.3 PLANTAR WARTS

B07

DESCRIPTION
Appear commonly on the pressure-bearing areas of the soles and can be painful
and interfere with walking. Because pressure forces them deep into the dermis they
are flat, almost circular lesions, with a rough surface and are often thick and hard
due to increased keratin formation. They are contagious and walking barefoot in
communal areas should be discouraged.

x
MEDICINE TREATMENT
Salicylic acid, 15 to 30% topical liquid application.
o Protect surrounding skin with petroleum jelly.
o Apply daily to wart and allow to dry.
o Occlude for 24 hours.

2018 5.29
CHAPTER 5 SKIN CONDITIONS

o Soften lesions by soaking in warm water and remove loosened keratin by

light abrasion.
o Wash well, dry, reapply the wart paint and occlude.
o Repeat process daily until the wart disappears.
LoE:IIIxvii
REFERRAL
» No response to treatment.
» Diabetic patients.

5.15.4 GENITAL WARTS: CONDYLOMATA ACCUMINATA

See Section 12.12: Genital warts (GW): condylomata accuminata.

5.16 PSORIASIS
L40.0-5/L40.8-9

DESCRIPTION
Inflammatory condition of the skin and joints of unknown aetiology.
Scaly itchy plaques occur especially on the extensor surfaces of the knees, elbows,
sacrum and scalp.
Psoriasis may spread to involve any other sites, although the face is usually spared.
The nails and skin folds are often involved.
Often aggravated by stress and may be provoked by HIV disease.

GENERAL MEASURES
» Counselling regarding precipitating factors and chronicity.
» HIV test, if acute onset and risk factors present.
» Encourage sun exposure as tolerated.

MEDICINE TREATMENT

x Coal tar (Liquor picis carbonis (LPC) BP 5%, topical.

For flares (if delay experienced in obtaining a dermatological consultation):

OR
ƒ Corticosteroid, potent, topical, e.g.:
x Betamethasone 0.1%, topical, apply 12 hourly (Doctor initiated).
o Decrease according to severity, reduce to hydrocortisone 1%, topical, and
then stop.

REFERRAL
All patients, if diagnosis is not already confirmed.
Complications such as pustular psoriasis, acute flares, chronic local plaques.

5.17 HIDRADENITIS SUPPURATIVA

L73.2

DESCRIPTION
A chronic disorder of the apocrine glands involving the formation of abscesses and

2018 5.30
CHAPTER 5 SKIN CONDITIONS

cysts, often accompanied by scarring and sinus tract formation.

Commonly found in axillae, groin, between the thighs, perianal and perineal areas.
Flare-ups may be triggered by perspiration, hormonal changes (such as menstrual
cycles), humidity and heat, and friction from clothing.

GENERAL MEASURES
Avoid tight clothing and clothing made of heavy non-breathable material.

REFERRAL
Refer all patients with abscesses, infected cysts or sinuses and suspicion of the
diagnoses.

5.18 HYPOPIGMENTORY DISORDERS

5.18.1 ALBINISM
E70.3

DESCRIPTION
Congenital disorder characterised by the complete or partial absence of pigment in
the skin, hair and eyes.
Albinism is associated with a number of vision defects such as photophobia,
nystagmus, squint and amblyopia.
Lack of skin pigmentation increases a person’s susceptibility to sunburn and skin
cancers.

GENERAL MEASURES
To avoid sunburn and skin damage:
» Avoid going out when the sun is at its strongest (between 10 am and 3 pm).
» When out in the sun to wear a wide-brimmed hat and long-sleeved top.
» To wear sunscreens with a high sun protection factor (SPF); a SPF of between
20 and 30 will provide adequate protection. The product should also provide
protection against both UVA and UVB rays.

 Wear sunglasses that preferably have UV filters

» To reduce photophobia and prevent retinal damage:

 Check skin regularly for signs of skin cancer such as a new spot or growth
on their skin.

x
MEDICINE TREATMENT
Zinc oxide ointment.
o Apply evenly to all sun exposed areas at least 15 minutes before going out
into the sun. LoE:IIIxviii
OR
Titanium dioxide ointment/cream (UV block).
o Apply evenly to all sun exposed areas at least 15 minutes before going out
into the sun.
LoE:IIIxix

2018 5.31
CHAPTER 5 SKIN CONDITIONS

REFERRAL
» To dermatologist for regular skin checks.
» To ophthalmologist for visual rehabilitation and regular eye checks.

5.18.2 VITILIGO
L80

Autoimmune disease characterised by patches of the skin losing their pigment.

Often the patches begin in areas of skin that are exposed to the sun.
New patches appear over time and can occur over large portions of the body or
located to a particular area.
Presents as pale patchy areas of depigmented skin which tend to occur on the
extremities. They are most prominent on the face, hands and wrists. The loss of
pigmentation is particularly noticeable around body orifices such as the mouth,
eyes, nostrils genitalia and umbilicus.

GENERAL MEASURES
Avoid sun exposure when the sun is at its strongest particularly between 10:00 and
15:00. As moderate sun exposure is beneficial, sunscreen is not needed at other
times.

x
MEDICINE TREATMENT
Titanium dioxide ointment/cream (UV block),
o Only use when sun is at it is strongest i.e. between 10:00 and 15:00.
o Apply evenly to all sun exposed areas at least 15 minutes before going out
into the sun during this time.
LoE:Ixx
REFERRAL
All patients.

5.19. PRESSURE ULCERS/SORES

L89.0-3/L89.9

DESCRIPTION
Localised damage to the skin and underlying tissue that usually occurs over bony
prominences as a result of pressure, or pressure in combination with sheer and/or
friction. The most common sites are the skin overlying the sacrum, coccyx, heels or
the hips but other sites can be affected.
Pressure ulcers most commonly develop in individuals who are immobile, such as
being bedridden or confined to a wheelchair.
Other factors increasing the risk of pressure ulcer development are:
» Skin wetness e.g. incontinence.
» Reduced blood flow e.g. arteriosclerosis.
» Reduced skin sensation e.g. paralysis or neuropathy.

2018 5.32
CHAPTER 5 SKIN CONDITIONS

GENERAL MEASURES
Skin care
The skin should be kept clean and dry. Ensure that the skin folds are dried
thoroughly.
Wound odour
Regular cleansing, debridement and management of infection.
Activated charcoal dressings may be used.
Pressure redistribution
» Repositioning and turning at regular intervals, every 2-4 hours. For individual
receiving palliative care they should be repositioned in accordance with the
Individual’s wishes, comfort and tolerance.
» If erythema is present avoid positioning the individual on the area.

MEDICINE TREATMENT

x Zinc and castor oil ointment.

Cleanse the skin prior to application of a barrier product.

LoE:IIxxi
For pain:
See chapter 20: Pain.
References
i Benzoyl peroxide 5% gel, topical: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.
University of Cape Town, 2016.
ii Topical retinoids (caution in pregnancy): Kaplan YC, Ozsarfati J, Etwel F, Nickel C, Nulman I, Koren G. Pregnancy outcomes

following first-trimester exposure to topical retinoids: a systematic review and meta-analysis. Br J Dermatol. 2015 Nov;173(5):1132-
41. https://www.ncbi.nlm.nih.gov/pubmed/26215715
Topical retinoids (caution in pregnancy): Panchaud A, Csajka C, Merlob P, Schaefer C, Berlin M, De Santis M, Vial T, Ieri A,
Malm H, Eleftheriou G, Stahl B, Rousso P, Winterfeld U, Rothuizen LE, Buclin T. Pregnancy outcome following exposure to topical
retinoids: a multicenter prospective study. J Clin Pharmacol. 2012 Dec;52(12):1844-51.
https://www.ncbi.nlm.nih.gov/pubmed/22174426
Topical retinoids (caution in pregnancy): Browne H, Mason G, Tang T. Retinoids and pregnancy: an update. The Obstetrician &
Gynaecologist 2014;16:7–11. http://onlinelibrary.wiley.com/doi/10.1111/tog.12075/pdf
iii Benzoyl peroxide 5% gel, topical: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.

University of Cape Town, 2016.

iv Doxycycline, oral: National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML, 2015.

http://www.health.gov.za/
v Fluconazole, oral (children): Chen X, Jiang X, Yang M, González U, Lin X, Hua X, Xue S, Zhang M, Bennett C. Systemic

antifungal therapy for tinea capitis in children. Cochrane Database Syst Rev. 2016 May 12;(5):CD004685.
https://www.ncbi.nlm.nih.gov/pubmed/27169520
vi Fluconazole, oral (adults): National Department of Health, Essential Drugs Programme: Adult Hospital level STGs and

EML, 2015. http://www.health.gov.za/

Fluconazole, oral (adults): Contract circular RT301-2017. http://www.health.gov.za/
Fluconazole, oral (adults): Nozickova M, Koudelkova V, Kulikova Z, Malina L, Urbanowski S, Silny W. A comparison of the
efficacy of oral fluconazole, 150 mg/week versus 50 mg/day, in the treatment of tinea corporis, tinea cruris, tinea pedis, and
cutaneous candidosis. Int J Dermatol. 1998 Sep;37(9):703-5. http://www.ncbi.nlm.nih.gov/pubmed/9762826
Fluconazole, oral (adults): Faergemann J, Mörk NJ, Haglund A, Odegård T. A multicentre (double-blind) comparative study
to assess the safety and efficacy of fluconazole and griseofulvin in the treatment of tinea corporis and tinea cruris. Br J
Dermatol. 1997 Apr;136(4):575-7. http://www.ncbi.nlm.nih.gov/pubmed/91559
vii Selenium sulfide, topical: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of

Cape Town, 2016.

viii Hydrocortisone 0.1%, topical (chronic paronychia): Tosti A, Piraccini BM, Ghetti E, Colombo MD. Topical steroids versus

systemic antifungals in the treatment of chronic paronychia: an open, randomized double-blind and double dummy study. J Am
Acad Dermatol. 2002 Jul;47(1):73-6. https://www.ncbi.nlm.nih.gov/pubmed/12077585
ix Permethrin 5% lotion:Meinking TL, Vicaria M, Eyerdam DH, Villar ME, Reyna S, Suarez G. Efficacy of a reduced application

time of Ovide lotion (0.5% malathion) compared to Nix crème rinse (1% permethrin) for the treatment of head lice.
PediatrDermatol. 2004 Nov-Dec;21(6):670-4.http://www.ncbi.nlm.nih.gov/pubmed/15575855
Permethrin 5% lotion:Frankowski BL, Bocchini Jr. JA and Council on School Health and Committee on Infectious Diseases.
Head lice.Pediatrics2010;126:392-403.http://www.ncbi.nlm.nih.gov/pubmed/20660553

2018 5.33
CHAPTER 5 SKIN CONDITIONS

Permethrin 5% lotion:MarkLebwohl, Lily Clark and Jacob Levitt. Therapy for Head Lice Based on Life Cycle, Resistance, and
Safety Considerations. Pediatrics2007;119(5):965-974. http://www.ncbi.nlm.nih.gov/pubmed/17473098
Permethrin 5% lotion:Nova Scotia District health authority public health services and the department of health promotion and
protection. Guidelines for treatment of pediculosiscapitis (head lice). August 2008. [Online 2008][Cited 2013] Available at:
https://novascotia.ca/dhw/publications/Public-Health-Education/Head_Lice_Guidelines_for_Treatment.pdf
Permethrin 5% lotion: Roberts RJ. Head lice. N Engl J Med 2002;346(21):1645-1650.
https://www.ncbi.nlm.nih.gov/pubmed/12023998
Permethrin 5% lotion: MCC registered package insert for Skabi-rid®.
Permethrin 5% lotion: Diamantis SA, Morrell DS, Burkhart CN.Treatment of head lice. Dermatologic Therapy 2009;22:273–
278.http://www.ncbi.nlm.nih.gov/pubmed/19580574
Permethrin 5% lotion: Jones KN, English III JC. Review of Common Therapeutic Options in the United States for the Treatment
of Pediculosis Capitis.Clinical Infectious Diseases 2003; 36:1355–61. http://www.ncbi.nlm.nih.gov/pubmed/12766828
Permethrin 5% lotion: Madke B, Khopkar U. Pediculosis capitis: An update. Indian J Dermatol Venereol Leprol 2012;78:429-38.
http://www.ncbi.nlm.nih.gov/pubmed/22772612
Permethrin 5% lotion: British National Formulary for children 2016-2017. (2016). 1st ed. London: BMJ Group, Pharmaceutical
Press and RCPCH Publications Ltd.
x Benzyl benzoate lotion: Bachewar NP, Thawani VR, Mali SN, Gharpure KJ, Shingade VP, Dakhale GN. Comparison of safety,

efficacy, and cost effectiveness of benzyl benzoate, permethrin, and ivermectin in patients of scabies.Indian J Pharmacol. 2009
Feb;41(1):9-14.http://www.ncbi.nlm.nih.gov/pubmed/20177574
Benzyl benzoate lotion: Strong M, Johnstone P. Interventions for treating scabies. Cochrane Database Syst Rev. 2007 Jul
18;(3):CD000320.http://www.ncbi.nlm.nih.gov/pubmed/17636630
Benzyl benzoate lotion: Pharmachem. Package insert: Benzyl Benzoate BP emulsion.
xi Permethrin 5% lotion: Strong M, Johnstone P. Interventions for treating scabies. Cochrane Database Syst Rev. 2007 Jul

18;(3):CD000320.http://www.ncbi.nlm.nih.gov/pubmed/17636630
xii Permethrin 5% lotion: British National Formulary for children 2016-2017. (2016). 1st ed. London: BMJ Group, Pharmaceutical

Press and RCPCH Publications Ltd.

xiii Potent and very potent corticosteroids, topical: Green C, Colquitt JL, Kirby J, Davidson P, Payne E. Clinical and

cost-effectiveness of once-daily versus more frequent use of same potency topical corticosteroids for atopic eczema: a
systematic review and economic evaluation. Health Technol Assess. 2004 Nov;8(47):iii,iv, 1-120.
https://www.ncbi.nlm.nih.gov/pubmed/15527669
xiv Potent and very potent corticosteroids, topical: Green C, Colquitt JL, Kirby J, Davidson P, Payne E. Clinical and

cost-effectiveness of once-daily versus more frequent use of same potency topical corticosteroids for atopic eczema: a
systematic review and economic evaluation. Health Technol Assess. 2004 Nov;8(47):iii,iv, 1-120.
https://www.ncbi.nlm.nih.gov/pubmed/15527669
xv Salicylic acid, 15 to 30% topical liquid application: Kwok CS, Gibbs S, Bennett C, Holland R, Abbott R. Topical treatments for

cutaneous warts. Cochrane Database Syst Rev. 2012 Sep 12;9:CD001781. http://www.ncbi.nlm.nih.gov/pubmed/22972052
xvi Salicylic acid, 2%, topical: Kwok CS, Gibbs S, Bennett C, Holland R, Abbott R. Topical treatments for cutaneous warts.

Cochrane Database Syst Rev. 2012 Sep 12;9:CD001781.http://www.ncbi.nlm.nih.gov/pubmed/22972052

Salicylic acid, 2%, topical: Dall'oglio F, D'Amico V, Nasca MR, Micali G. Treatment of cutaneous warts: an evidence-based
review. Am J ClinDermatol. 2012 Apr 1;13(2):73-96.http://www.ncbi.nlm.nih.gov/pubmed/22292461
Salicylic acid, 2%, topical: Sterling JC, Handfield-Jones S, Hudson PM; British Association of Dermatologists. Guidelines for the
management of cutaneous warts.Br J Dermatol. 2001 Jan;144(1):4-11.http://www.ncbi.nlm.nih.gov/pubmed/11167676
xvii Salicylic acid, 15 to 30% topical liquid application: Kwok CS, Gibbs S, Bennett C, Holland R, Abbott R. Topical treatments for

cutaneous warts. Cochrane Database Syst Rev. 2012 Sep 12;9:CD001781. http://www.ncbi.nlm.nih.gov/pubmed/22972052
xviii Zinc oxide ointment (albinism): South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University

of Cape Town, 2016.

xix Titanium dioxide ointment/cream (albinism): South African Medicines Formulary. 12th Edition. Division of Clinical

Pharmacology. University of Cape Town, 2016.

xx Titanium dioxide ointment/cream (vitiligo): Whitton ME, Pinart M, Batchelor J, Leonardi-Bee J, González U, Jiyad Z,

Eleftheriadou V, Ezzedine K. Interventions for vitiligo. Cochrane Database Syst Rev. 2015 Feb 24;(2):CD003263.
https://www.ncbi.nlm.nih.gov/pubmed/25710794
xxi Zinc and castor oil ointment: Health Quality Ontario. Pressure ulcer prevention: an evidence-based analysis.

Ont Health Technol Assess Ser. 2009;9(2):1-104. https://www.ncbi.nlm.nih.gov/pubmed/23074524

Zinc and castor oil ointment: Langemo D, Haesler E, Naylor W, Tippett A, Young T. Evidence-based guidelines
for pressure ulcer management at the end of life. Int J Palliat Nurs. 2015 May;21(5):225-32.
https://www.ncbi.nlm.nih.gov/pubmed/26107544

2018 5.34
PHC Chapter 6: Obstetrics &
gynaecology
Obstetrics
6.1 Bleeding in pregnancy
6.1.1 Ectopic pregnancy
6.2 Miscarriage
6.2.1 Management of incomplete miscarriage in the 1st
trimester, at primary health care level
6.2.2 Antepartum haemorrhage
6.3 Termination of pregnancy (TOP)
6.3.1 Management of termination of pregnancy at
primary health care level: gestation ”12 weeks
(and 0 days)
6.4 Antenatal care
6.4.1 Antenatal supplements
6.4.2 Hypertensive disorders in pregnancy
6.4.2.1 Chronic hypertension
6.4.2.2 Gestational hypertension: mild to
moderate
6.4.2.3 Gestational hypertension: severe
6.4.2.4 Pre-eclampsia
6.4.2.5 Eclampsia
6.4.3 Anaemia in pregnancy
6.4.4 Syphilis in pregnancy
6.4.5 Urinary tract infection, in pregnancy
6.4.5.1 Cystitis
6.4.5.2 Pyelonephritis
6.4.6 Listeriosis
6.4.7 Preterm labour (PTL) and preterm prelabour
rupture of membranes (PPROM)
6.4.7.1 Preterm labour (PTL)
6.4.7.2 Preterm prelabour rupture of
membranes (PPROM)
6.4.7.3 Prelabour rupture of membranes at term
(PROM)
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

6.5 Intrapartum care

6.6 Care of the neonate
6.6.1 Routine care of the neonate
6.6.2 Neonatal resuscitation
6.6.3 Care of sick and small neonates
6.6.4 Care of the HIV-exposed infant
6.6.5 Perinatal transmission of hepatitis B
6.7 Postpartum care
6.7.1 Postpartum haemorrhage (PPH)
6.7.2 Puerperal sepsis
6.7.3 Cracked nipples during breastfeeding
6.7.4 Mastitis
6.8 HIV in pregnancy
6.9 Maternal mental health
6.9.1 Antepartum depression
6.9.2 Postpartum depression
6.9.3 Postpartum psychosis

Gynaecology
6.10 Ectopic pregnancy
6.11 Vaginal bleeding
6.11.1 Abnormal vaginal bleeding during fertile years
6.11.2 Post–menopausal bleeding
6.12 Dysmenorrhoea
6.13 Hormone therapy (HT)
6.14 Vaginal ulcers
6.15 Vaginal discharge/lower abdominal pain in women

2018 6.2
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

OBSTETRICS

6.1 BLEEDING IN PREGNANCY

6.1.1 PREGNANCY, ECTOPIC

See Section 6.10: Pregnancy, ectopic.

6.2 MISCARRIAGE
O02.1/O03.4/O03.9

DESCRIPTION
Bleeding from the genital tract < 22 weeks’ gestation, which may or may not be
associated with lower abdominal pain (LAP).
» Miscarriage is classified as follows:
Cervix closed on digital examination Cervix dilated on digital examination
» Threatened miscarriage: » Inevitable miscarriage:
– mild vaginal bleeding, usually no – moderate vaginal bleeding with
associated LAP associated LAP
– cervix closed on digital examination – cervix dilated on digital examination
– fetus is still in the uterus – fetus is still in the uterus
» Complete miscarriage: » Incomplete miscarriage:
– complete passage of all products of – vaginal bleeding often with clots
conception – partial expulsion of products of
– bleeding and pain have settled conception
– usually still requires referral for – cervix remains open to a varying
confirmation degree

» Miscarriage is considered to be safe or unsafe (septic) miscarriage:

Safe miscarriage Unsafe (septic) miscarriage
– Normal vital signs: pulse, BP, – History of interference
temperature, respiratory rate, Hb – Abnormal vital signs: tachycardia,
– No clinical signs of infection, e.g. chills, hypotension, pyrexia, tachypnoea, Hb
malaise < 10 g/dL
– Uterus < 12 weeks in size – Clinical signs of infections, e.g. chills,
– No offensive products of conception malaise
– No purulent vaginal discharge – Uterus palpable abdominally (• 12
weeks in size)
– Offensive vaginal discharge/ products
of conception
For perinatal mortality audit and statistics (DHIS or PPIP), all fetuses • 500 g are
included.

GENERAL MEASURES
» Monitor vital parameters, e.g. Hb, pulse, BP, temperature.
» Treat for shock if indicated.
» Counselling and support.
» There is no specific treatment for threatened miscarriages: reassure the patient
that bleeding usually stops spontaneously. Advise to return if bleeding worsens
or persists or abdominal pain develops.
2018 6.3
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

MEDICINE TREATMENT

x Oxytocin 20 units, IV, diluted in 1000 mL sodium chloride 0.9% and infused at 125
For inevitable/incomplete miscarriages:

mL/hour (avoid where threatened miscarriage is suspected).

x Anti-D immunoglobulin, IM, 50–100 mcg preferably within 72 hours but may be
For all miscarriages in Rh-negative, non-sensitised women: (O36.0)

given up to 7 days following management of miscarriage.

LoE:IIi
If unsafe (septic) miscarriage is suspected, also give before referral:

x
O03.0/O08.0 + (A41.9/R57.2)
Ceftriaxone, IV, 1 g as a single dose
CAUTION: USE OF CEFTRIAXONE
Do not administer calcium-containing fluids, e.g. Ringer-Lactate, concurrently
with ceftriaxone.

x
AND
Metronidazole, oral, 400 mg as a single dose.

REFERRAL
Urgent
» All patients with unsafe miscarriage
» Suspected ectopic pregnancy.
» Previous miscarriage or previously diagnosed incompetent cervix.
Note: For patients with safe miscarriage the need for referral is determined by skills
and facilities at the primary health care level. A local referral policy should be in
place. Ideally, midwife obstetric units and community health centres should be able
to manage safe miscarriage using manual vacuum aspiration or medical
management.

6.2.1 MANAGEMENT OF INCOMPLETE MISCARRIAGE IN THE

1ST TRIMESTER, AT PRIMARY HEALTH CARE LEVEL
O02.1

Both Manual Vacuum Aspiration (MVA) and medical evacuation are equally effective
for miscarriage.

GENERAL MEASURES
» Counselling.
» Evacuation of the uterus.

MEDICINE TREATMENT

x Misoprostol, oral/vaginal, 600 mcg as a single dose.

Medical evacuation: (O04.9)

o Repeat after 24 hours if necessary.

2018 6.4
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

Manual vacuum aspiration:

x Morphine, IM, 0.1 mg/kg 30 minutes before aspiration procedure, to a

Routine analgesia for vacuum aspiration:

maximum of 10 mg (Doctor prescribed). LoE:IIIii

Alternatively, consider paracervical block if trained in technique.

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per 24

Oral analgesia as required for 48 hours:

hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.

x Ibuprofen, oral, 400 mg 8 hourly with or after a meal.

AND LoE:IIIiii

LoE:IIIiv
Follow up after one week to ensure that bleeding has stopped.

REFERRAL
» Unsafe miscarriage.
» Miscarriage • 13 weeks’ gestation.
» Anaemia.
» Haemodynamic instability.
» Failed medical evacuation.

6.2.2 ANTEPARTUM HAEMORRHAGE

O46.0/O46.8-9

DESCRIPTION
Vaginal bleeding in pregnancy from 22 weeks’ gestation.
Important causes include the following:
» abruptio placentae
» placenta praevia
» uterine rupture (particularly when misoprostol was used to attempt an unlawful TOP).

GENERAL MEASURES
» Monitor vital parameters, e.g. Hb, pulse, BP, temperature.
» Treat for shock if indicated.
Avoid vaginal examination, unless placenta praevia excluded with ultrasound.

x
MEDICINE TREATMENT
Sodium chloride 0.9%, IV.
LoE:III
REFERRAL
Urgent
All patients.

2018 6.5
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

6.3 TERMINATION OF PREGNANCY (TOP)

DESCRIPTION
Under the Choice of Termination of Pregnancy Act, 1996, as amended, a TOP may
be carried out in the following circumstances:
Women eligibility
If gestation ” 12 weeks and 0 days:
» On request.
If gestation 12 weeks and 1 day to 20 weeks and 0 days:
If doctor is satisfied that:
» Pregnancy was from rape or incest, or
» There is a substantial risk that the fetus would suffer from a severe mental or
physical abnormality, or
» The continued pregnancy would pose a risk to mother’s physical or mental health,
or
» Continued pregnancy will significantly affect the social or economic
circumstances of the woman.
If gestation • 20 weeks and 1 day:
» If the doctor after consulting with a second doctor or registered midwife or
registered nurse is satisfied that continuing the pregnancy would endanger the
mothers’ life, pose a risk of injury to the fetus, or result in a severe fetal
malformation.
Venue
An accredited facility with staff trained in performing TOP, designated by the
Member of Executive Council at provincial level.
Practitioner
If gestation ” 12 weeks and 0 days:
» Doctor, midwife or registered nurse with appropriate training.
If gestation • 12 weeks and 1 day:
» Doctor is responsible for decision and prescription of medication. Registered
nurse/midwife may administer medication according to prescription.

GENERAL MEASURES
» Pre- and post-termination counselling is essential.
» Consent for TOP and related procedures (e.g. laparotomy) may be given by
minors. Minors are encouraged to consult parents or others, but parental consent
is not mandatory.
» Consent of spouse/partner is not necessary.
» Offer contraception post TOP.

REFERRAL
» If service not available (facility not accredited), refer to designated district or
regional facility as soon as possible (within 2 weeks).
» If gestation • 12 weeks and 1 day.
2018 6.6
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

6.3.1 MANAGEMENT OF TERMINATION OF PREGNANCY AT

PRIMARY HEALTH CARE LEVEL: GESTATION ” 12
WEEKS AND 0 DAYS
O04.9

GENERAL MEASURES
» Confirm pregnancy with urine pregnancy test.
» Determine gestational age with ultrasound. If ultrasound is unavailable, use dates
(LMP) and bimanual (pelvic) examination.
» If unsure of dates, or examination disagrees with dates, or uterus palpable
abdominally, or the woman is obese or difficult to examine, arrange pre-procedure
ultrasound.
» Ultrasound is mandatory if suspected ectopic pregnancy – refer if uncertain.
» Counselling.
» Outpatient procedure by nursing staff with specific training.
» Screen for STIs (if treatment needed, do not delay TOP).
» Arrange Pap smear if needed.
» Check HIV status, Hb and blood group (Rh).
» Counsel and start contraception post TOP, before leaving facility. Arrange
contraception follow-up.

MEDICINE TREATMENT
Medical TOP - if gestation ” 9 weeks and 0 days:
x Mifepristone, oral, 200 mg, immediately as a single dose.
LoE:IIIv
x Misoprostol, PV, 800 mcg.
Followed 24–48 hours later by:

o If expulsion does not occur within 4 hours of misoprostol administration, a

second dose of misoprostol 400 mcg, oral/PV may be given.
LoE:IIIvi
For pain:

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per 24

After administration of mifepristone, start:

hours.
o Maximum dose: 15 mg/kg/dose. LoE:IIIvii
o Maximum dose: 4 g in 24 hours.
ADD

x Ibuprofen, oral, 400 mg 8 hourly with or after a meal.

After expulsion is complete:

LoE:IIIviii
OR

TOP using manual vacuum aspiration (MVA) - if gestation ” 12 weeks and 0

x Misoprostol, PV, 400 mcg 3 hours before vacuum aspiration of the uterus.
days:

LoE:IIIix

2018 6.7
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

x Morphine, IM, 0.1 mg/kg 30 minutes before aspiration procedure, to a maximum

Routine analgesia for vacuum aspiration:

of 10 mg (Doctor prescribed).
LoE:IIIx
Alternatively, consider paracervical block if trained in technique.

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per 24

Oral analgesia as required for 48 hours:

hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.

x Ibuprofen, oral, 400 mg 8 hourly with or after a meal.

AND LoE:IIIxi

LoE:IIIxii
For both medical and surgical TOPs (MVA):

x Anti-D immunoglobulin, IM, 50–100 mcg preferably within 72 hours but may be
In Rh-negative, non-sensitised women: (O36.0)

given up to 7 days following TOP. LoE:IIIxiii

Review all patients after 7 days: if bleeding persists, arrange urgent ultrasound.

REFERRAL
» If gestation •12 weeks and 1 day.
» If gestation uncertain.
» If any signs or symptoms of ectopic pregnancy or other early pregnancy
complications.
» Co-morbid conditions (heart disease, asthma, diabetes, anaemia, clotting
disorder, seizure disorder, substance abuse, hypertension).
» Large fibroids (may interfere with determining gestation age and/or MVA).
» Any signs of sepsis (tachycardia, hypotension, pyrexia, tachypnoea, offensive
vaginal discharge).
» If gestation • 9 weeks and 1 day and MVA not available or declined, refer.

6.4 ANTENATAL CARE

6.4.1 ANTENATAL SUPPLEMENTS
Z36.9 + (Z29.9)

DESCRIPTION
Supplements before and during pregnancy and lactation can help to prevent, or
lessen the effect of, a number of conditions or complications associated with
pregnancy. Specifically:
» Folic acid, given for at least one month before conception and during pregnancy
(particularly the first 12 weeks) can help to prevent neural tube defects (abnormal
development of spinal cord/brain).
» Iron can help to prevent anaemia.
» Calcium can help to prevent pre-eclampsia.

2018 6.8
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

GENERAL MEASURES
» Eat a balanced diet to prevent nutritional deficiency.
» Avoid unpasteurised milk, soft cheeses, raw or undercooked meat, poultry, raw
eggs and shellfish.
» Cut down on caffeine. Reduce intake of tea. Do not drink tea within 2 hours of
taking iron tablets.

MEDICINE TREATMENT

x Folic acid, oral, 5 mg daily:

Prevention of Neural Tube Defects (NTD)

o All women intending to become pregnant or pregnant women (first trimester

of pregnancy).

 on anticonvulsants - especially valproic acid and carbamazepine,

o If high risk, throughout pregnancy, i.e.:

 previous child with NTD; or

 family history of NTD.
LoE:Ixiv

CAUTION
Children born to women taking valproic acid are at significant risk of birth
defects (10%) and persistent developmental disorders (40%).
Valproic acid is contra-indicated and should be avoided in pregnancy and
women of child-bearing potential. LoE:IIIxv

Prevention of anaemia:

x Ferrous sulfate compound BPC (dried), oral, 170 mg (± 55 mg elemental iron) 12

During pregnancy, after delivery and during lactation:

hourly with meals.

OR LoE:IIIxvi
Ferrous fumarate, oral, 200 mg once daily (± 65 mg elemental
iron).
o Taking iron tablets with meals decreases iron absorption, but improves
tolerability. (Note: Do not take iron tablets with milk).
If daily iron is poorly tolerated (e.g. epigastric pain, nausea, vomiting and

x Ferrous sulIate compound BPC (dried), oral, 340 mg per week, (± 110 mg
constipation), intermittent iron supplementation may be administered:

elemental iron), with meals.

OR
Ferrous fumarate, oral, 400 mg per week (± 130 mg elemental iron).
o Taking iron tablets with meals decreases iron absorption, but improves
tolerability (Note: Do not take iron tablets with milk).
Note: Established anaemia i.e. Hb < 10 g/dL, see Section 3.1: LoE:Ixvii
Anaemia.
Prevention of pre-eclampsia:

x Calcium, elemental, 1 g daily (given as calcium carbonate), oral 12 hourly.

From confirmation of pregnancy:

2018 6.9
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

o Although the benefit is greatest in high-risk women, consider use of this agent
in all pregnant women. See Section 6.4.2.4: Pre-eclampsia.
o Calcium reduces iron absorption from the gastro-intestinal tract. Take
supplements 4 hours apart from each other. LoE:Ixviii

6.4.2 HYPERTENSIVE DISORDERS IN PREGNANCY

DESCRIPTION
Hypertension in pregnancy, pre-eclampsia and eclampsia may have very serious and
fatal consequences for both the mother and the baby.
Hypertension is defined by:
» A systolic BP • 140 and/or a diastolic BP • 90 mmHg measured on 2 occasions,
4 hours apart.
OR
» A systolic BP • 160 and/or a diastolic BP • 110 mmHg measured on a single
occasion.
(Always measure BP in the left lateral, and not supine position).
Hypertensive disorders of pregnancy can be classified as:
» Chronic hypertension:
– Hypertension diagnosed before pregnancy or < 20 weeks of pregnancy.
» Gestational hypertension:
– Hypertension without proteinuria, diagnosed • 20 weeks of pregnancy.
» Pre-eclampsia:
– Hypertension with proteinuria, diagnosed • 20 weeks of pregnancy (high risk
patients include: nulliparity, obesity, multiple pregnancy, chronic hypertension,
kidney disease, diabetes, pre-eclampsia in a previous pregnancy, advanced
maternal age or adolescent pregnancy).
» Eclampsia:
– Generalised tonic-clonic seizures in women with pre-eclampsia.
» Chronic kidney disease:
– Proteinuria with/without hypertension, diagnosed at < 20 weeks of pregnancy.
LEVELS OF SEVERITY OF HYPERTENSION
BP Level mmHg
Level of hypertension
Systolic Diastolic
mild 140–149 or 90–99
moderate 150–159 or 100–109
severe •160 or • 110

REFERRAL
» Chronic hypertension.
» Severe gestational hypertension.
» Pre-eclampsia (all levels of severity).
» Chronic kidney disease.

2018 6.10
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

6.4.2.1 CHRONIC HYPERTENSION

O10.0

Stop ACE-inhibitors when pregnancy is planned or as soon as pregnancy is

diagnosed, change to methyldopa and refer for assessment and management.

x
MEDICINE TREATMENT
Methyldopa, oral, 250 mg 8 hourly.
o Maximum dose: 750 mg 8 hourly.

REFERRAL
Urgent
All cases. LoE:III

6.4.2.2 GESTATIONAL HYPERTENSION: MILD TO MODERATE

O13

DESCRIPTION
Hypertension occurring for the first time at • 20 weeks’ gestation with no proteinuria.

GENERAL MEASURES
» May be managed without admission before 38 weeks’ gestation, provided no
proteinuria.
» Review the following on a weekly basis:
– BP – height of fundus
– weight – fetal heart rate and movements
– urine analysis
» Educate on signs requiring urgent follow-up (headache, epigastric pain, visual
disturbances, vaginal bleeding etc.).

x
MEDICINE TREATMENT
Methyldopa, oral, 250 mg 8 hourly.
o Titrate to a maximum dose: 750 mg 8 hourly.
o When using iron together with methyldopa, ensure that iron and methyldopa
are not taken concurrently.
LoE:IIIxix
REFERRAL
» All patients with gestational hypertension at 38 weeks for delivery.
» Pre-eclampsia (all levels of severity).
» Poor control of hypertension.
» Severe hypertension.

6.4.2.3 GESTATIONAL HYPERTENSION: SEVERE

O13

DESCRIPTION
A systolic BP • 160 and/or a diastolic BP • 110 mmHg, with no proteinuria.
2018 6.11
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

(Always measure BP in the left lateral and not supine position).

MEDICINE TREATMENT

x Nifedipine, oral, 10 mg (not sublingual) as a single dose.

Aim to reduce BP to 140/100 mmHg.

o May be repeated after 30 minutes if diastolic BP remains • 110 mmHg.

REFERRAL
Urgent
All cases.

6.4.2.4 PRE-ECLAMPSIA
O11/O14.0-2/O14.9

DESCRIPTION
» A systolic BP • 140 and/or diastolic BP • 90 mmHg with proteinuria, after 20
weeks of pregnancy (significant proteinuria defined as • 1+ proteinuria).
» Severe pre-eclampsia is acute severe hypertension (systolic BP • 160 and/or diastolic
BP • 110) with • 1+ proteinuria, or any level of hypertension with 3+ proteinuria.
» Imminent eclampsia is pre-eclampsia with severe persistent headache, visual
disturbances, epigastric pain (not discomfort), hyper-reflexia or clonus.
» The following indicate a higher risk of developing pre-eclampsia: nulliparity,
obesity, multiple pregnancy, chronic hypertension, kidney disease, diabetes, pre-
eclampsia in a previous pregnancy, advanced maternal age or adolescent
pregnancy.

GENERAL MEASURES
» Advise all pregnant patients to urgently visit the clinic if severe persistent
headache, visual disturbances, epigastric pain (not discomfort).
» If severe pre-eclampsia or imminent eclampsia:
- Insert a Foley’s catheter and monitor urine output hourly.
- Monitor BP and check reflexes every 30 minutes.

MEDICINE TREATMENT
Prevention of pre-eclampsia

x Calcium carbonate, oral 12 hourly (equivalent to 1 g elemental calcium daily).

From confirmation of pregnancy:

o Although the benefit is greatest in high-risk women, consider use of this

agent in all pregnant women.
o Calcium reduces iron absorption from the gastro-intestinal tract. Take
supplements 4 hours apart from each other.
LoE:Ixx
Treatment

x Magnesium sulfate, IV, 4 g as a loading dose diluted with 200 mL sodium

If severe pre-eclampsia or imminent eclampsia:

chloride 0.9% and infused over 20 minutes.

x Magnesium sulfate, IM, 10 g given as 5 g in each buttock.

AND

o Then IM, 5 g every 4 hours in alternate buttocks.

2018 6.12
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

CAUTION: USE OF MAGNESIUM SULFATE

Stop magnesium sulfate if knee reflexes become absent or if urine output
< 100 mL/4 hours or respiratory rate < 16 breaths/minute.

x Calcium gluconate 10%, IV, 10 mL given slowly at a rate not > 5 mL/minute.
If respiratory depression occurs:

AND
If systolic BP • 160 and/or a diastolic BP • 110 mmHg:
x Nifedipine, oral, 10 mg (not sublingual) as a single dose.
o May be repeated after 30 minutes if diastolic BP remains • 110 mmHg.
LoE:IIIxxi
REFERRAL
Urgent
Severe pre-eclampsia and imminent eclampsia
Non urgent
All women with pre-eclampsia (within 24 hours).

6.4.2.5 ECLAMPSIA
O15.0-2/O15.9

GENERAL MEASURES
» Stabilise prior to urgent referral.
» Ensure safe airway.
» Place patient in left lateral position.
» Insert a Foley’s catheter and monitor urine output hourly.
» Monitor BP and check reflexes every 30 minutes.

x
MEDICINE TREATMENT

x
Administer oxygen.
Magnesium sulfate, IV, 4 g as a loading dose diluted with 200 mL sodium
chloride 0.9% and infused over 20 minutes.

x Magnesium sulfate, IM, 10 g given as 5 g in each buttock

AND

o Then IM, 5 g every 4 hours in alternate buttocks.

CAUTION: USE OF MAGNESIUM SULFATE
Stop magnesium sulfate if knee reflexes become absent or if urine output< 100
ml/4 hours or respiratory rate <16 breaths/minute.

x Calcium gluconate 10%, IV, 10 mL given slowly at a rate not >5 mL/minute.
If respiratory depression occurs:

LoE:IIIxxii

If recurrent eclamptic seizures despite magnesium sulfate loading dose

x Magnesium sulfate, IV, 2 g over 10 minutes.

administration:
LoE:IIIxxiii

2018 6.13
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

If seizures still persist and are continuous, there may be another cause of the
seizures: treat as for status epilepticus (see Section 21.2.11: Seizures and status
epilepticus).
AND
If systolic BP • 160 and/or a diastolic BP • 110 mmHg and patient becomes alert:
x Nifedipine, oral, 10 mg (not sublingual) as a single dose.
o May be repeated after 30 minutes if diastolic BP remains • 110 mmHg.
LoE:III
REFERRAL
Urgent
All cases.

6.4.3 ANAEMIA IN PREGNANCY

O99.0 + (D64.9)

DESCRIPTION
Anaemia in pregnancy is a Hb < 11 g/dL, most commonly due to iron deficiency. Hb
levels should be checked at the booking visit, repeated again between 28 and 32
weeks, and at ± 36 weeks.
Treatment is recommended when the Hb falls below 10g/dL.
Women with iron deficiency often have ‘pica’, e.g. eating substances such as soil,
charcoal, ice, etc.

GENERAL MEASURES
» A balanced diet to prevent nutritional deficiency.
» Reduce intake of tea.
» Do not drink tea within 2 hours of taking iron tablets.

MEDICINE TREATMENT

x Ferrous sulfate compound BPC (dried), oral, 170 mg (± 55 mg elemental iron) 12

Established anaemia with Hb < 10 g/dL:

hourly with meals.

o Taking iron tablets with meals decreases iron absorption, but improves
tolerability (Note: Do not take iron tablets with milk).
OR
Ferrous fumarate, oral, 200 mg (± 65 mg elemental iron) 12 hourly.
o Continue for 3 months after the Hb normalises in order to replenish body iron
stores. Hb is expected to rise by at least 1.5 g/dL in two weeks.
o Taking iron tablets with meals decreases iron absorption, but improves
tolerability. (Note: Do not take iron tablets with milk).
LoE:Ixxiv
REFERRAL
Urgent (same day)
» Hb < 6 g/dL.
» Hb = 6-7.9 g/dL with symptoms (dizziness, tachycardia, shortness of breath at
rest).
Non-urgent (within 1 week)

2018 6.14
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

» Hb = 6-7.9 g/dL without symptoms (high-risk clinic if available).

» Hb = 8-9.9 g/dL and no improvement after one month of treatment (high-risk clinic,
if available).
» Hb < 10 g/dL at 36 weeks’ gestation or more: transfer to hospital for further
antenatal care and delivery.

6.4.4 SYPHILIS IN PREGNANCY

O98.1

DESCRIPTION
A sexually transmitted infection with many manifestations that has a latent phase and
may be asymptomatic in pregnant women. It is caused by the spirochaete, T pallidum.
Vertical transmission to the fetus occurs in up to 80% of cases in untreated mothers.
Untreated maternal syphilis may lead to miscarriage, stillbirth, non-immune hydrops
fetalis, or congenital syphilis in the newborn.

DIAGNOSIS
» All pregnant women should have a syphilis test at the first booking visit.
» Women who booked in the first trimester and tested negative should have a
repeat test done around 32 weeks’ gestation.
» Diagnosis is made by positive serology. There are 2 types of tests used in syphilis
diagnosis:
Specific treponemal test Non-treponemal test
(e.g. TPAb//TPHA/FTA-ABS): (e.g. RPR):
- Specifically picks up syphilis. The RPR can be used:
- Available as a rapid on-site specific » To determine if the patient’s syphilis disease
finger-prick syphilis test. is active or not,
- Once positive, specific treponemal test » To measure a successful response to
generally remains positive for life, and therapy (at least a fourfold reduction in titre,
therefore the presence of specific e.g. 1:256 improving to 1:64), or
treponemal antibodies cannot » To determine a new re-infection.
differentiate between current and past Note:
infections. - False RPR positive reactions may occur,
- A person with previously successfully notably in patients with connective tissue
treated syphilis will retain lifelong disorders (these are usually low titre < 1:8).
positive specific treponemal test For this reason, positive RPR results should
results. be confirmed as due to syphilis by further
testing of the serum with a specific
treponemal test.
- If specific treponemal test e.g. TPAb is
performed first and gives a positive result,
serum can be further tested for RPR to
determine the presence of active syphilis
(reverse testing algorithm).
- Some patients, even with successful
treatment for syphilis, may retain life-long
positive RPR results at low titres (” 1:8),
which does not change by more than one
dilution difference over time (so-called
serofast patients).
2018 6.15
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

GENERAL MEASURES
» Encourage partner notification and treatment.
» Provide counselling and promote HIV testing.
» Educate on treatment adherence.
» Promote condom use.

MEDICINE TREATMENT

x Benzathine benzylpenicillin, IM, 2.4 MU weekly for 3 weeks.

Pregnant woman

o Reconstitute with 6 mL of lidocaine1% without adrenaline (epinephrine).

o Follow up at 3 months after the last injection to confirm a fourfold (i.e. 2
dilution) reduction in RPR titres, provided the initial titre was • 1:8. If initial titre
< 1:8, further reductions may not occur (serofast reaction).
LoE:IIIxxv
Severe penicillin allergy: (Z88.0)
Refer for in-patient penicillin desensitisation.
Newborn baby

x
If baby asymptomatic, well and mother not fully treated > 1 month before delivery, give:
Benzathine benzylpenicillin (depot formulation), IM, 50 000 units/kg as a single
dose into the lateral thigh.
CAUTION
Benzathine benzylpenicillin (depot formulation) must never be given intravenously.

REFERRAL (baby)
» Mother was not treated.
» Mother has received < 3 doses of benzathine benzylpenicillin.
» Mother delivered within 4 weeks of commencing treatment.
» Baby has any of the following:
– Hepatosplenomegaly – Pseudoparesis
– Snuffles – Oedema
– Jaundice – Anaemia
– Purpura – Desquamative rash (especially involving palms
and soles)

6.4.5 URINARY TRACT INFECTION, IN PREGNANCY

6.4.5.1 CYSTITIS
O23.1

DESCRIPTION
This condition usually presents with lower abdominal pain, frequency of micturition
and/or dysuria. There are no features of sepsis, e.g. fever.
Urine dipstick testing usually shows nitrites and/or leukocytes; protein and/or blood
may also be detected.

GENERAL MEASURES
2018 6.16
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

» Encourage oral fluid intake

» Midstream urine for microscopy, culture and sensitivity

MEDICINE TREATMENT
Empiric treatment (nitrites positive OR leukocytes positive on dipstick):
x Nitrofurantoin, oral, 100 mg 6 hourly for 7 days.
LoE:Ixxvi

REFERRAL
» No response to treatment, or resistant organism on culture.
» Features of pyelonephritis (See Section 6.4.5.2: Pyelonephritis, acute, in
pregnancy).

6.4.5.2 PYELONEPHRITIS
O23.0

DESCRIPTION
Features of pyelonephritis include: temperature •38°C, renal angle tenderness,
vomiting, tachypnoea, tachycardia, hypotension, confusion.
This condition is more serious and may result in preterm labour.

GENERAL MEASURES
» Midstream urine for microscopy and culture and sensitivity.
» Ensure adequate hydration with IV fluids while awaiting transfer.

MEDICINE TREATMENT

x Ceftriaxone, IV, 1 g as a single dose.

Empiric therapy:

CAUTION: USE OF CEFTRIAXONE

Do not administer calcium-containing fluids, e.g. Ringer-Lactate, concurrently
with ceftriaxone.

LoE:III
REFERRAL
All cases.

6.4.6 LISTERIOSIS
A32.0-1/A32.7-9
Note: If you have any questions or concerns, visit www.nicd.ac.za or call the NCID
hotline on 082 883 9920.

DESCRIPTION
Listeriosis is a preventable and treatable bacterial disease spread through food. Most
listerial infections are sporadic but outbreaks do occur. Pregnancy is a predisposing
factor for developing serious Listeriosis.

2018 6.17
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

Patients present with a flu-like illness (with fever). They may also have sore joints,
backache, diarrhoea and vomiting, and/or signs of meningitis (headache, neck
stiffness, confusion).
Listeriosis has been added to the national list of notifiable diseases.

GENERAL MEASURES
Educate your patients on how to prevent it: wash hands, knives, and cutting boards
after handling uncooked food, avoid luncheon meats/delicatessen meats, wash raw
vegetables thoroughly, avoid unpasteurised milk, thoroughly cook raw food from
animal sources.

MEDICINE TREATMENT
During outbreaks, if signs of meningitis are present, give pre-referral treatment (see
Section 15.4.2: Meningitis, acute).
LoE:IIIxxvii
REFERRAL
All cases.

6.4.7 PRETERM LABOUR (PTL) AND PRETERM PRELABOUR

RUPTURE OF MEMBRANES (PPROM)
6.4.7.1 PRETERM LABOUR (PTL)
O60.0

DESCRIPTION
Regular painful contractions: 3 per 10 minutes, occurring < 37 weeks of gestation.

GENERAL MEASURES
<26 weeks:
» Refer without tocolysis (medicines to inhibit uterine contractions).
26–34 weeks of gestation:
» Refer with initial tocolysis and corticosteroids.
‫ޓ‬34 weeks of gestation:
» Allow labour to continue at midwife obstetric unit.

MEDICINE TREATMENT

x Betamethasone, IM, 12 mg, 2 doses 12 hours apart.

To improve fetal lung maturity at 26–34 weeks:(Z29.2)

Tocolysis: (Z29.2) LoE:Ixxviii

x Sodium chloride 0.9%, IV, 200 mL.

Preload with:

x Nifedipine, oral, 20 mg as a single dose.

THEN

o Follow with 10 mg after 30 minutes, if contractions persist.

o Then 10 mg every 4 hours until patient is transferred.
o Maximum duration: 24 hours.
2018 6.18
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

REFERRAL
All cases before 34 weeks.

6.4.7.2 PRETERM PRELABOUR RUPTURE OF MEMBRANES

(PPROM)
O42.0-1/O42.9

DESCRIPTION
Rupture of the membranes before 37 weeks’ gestation.
Confirmed with a sterile speculum examination demonstrating leakage of amniotic fluid.
If there is clinical uncertainty test for pH – liquor is alkaline.
Avoid digital vaginal examination.

MEDICINE TREATMENT

x Betamethasone, IM, 12 mg, 2 doses 12 hours apart.

To improve fetal lung maturity at 26–34 weeks:(Z29.2)

LoE:Ixxix

x Amoxicillin, oral, 500 mg 8 hourly, until referral.

Initiate antibiotic therapy:(Z29.2)

LoE:IIIxxx
x Metronidazole, oral, 400 mg 8 hourly, until referral.
AND

LoE:IIIxxxi

x Azithromycin, oral, 500 mg daily, until referral.

Severe penicillin allergy:(Z88.0)

x Metronidazole, oral, 400 mg 8 hourly, until referral.

AND LoE:III

REFERRAL
All cases, but refer urgently if PPROM < 34 weeks.

6.4.7.3 PRELABOUR RUPTURE OF MEMBRANES AT TERM

(PROM)
O42.0-1/O42.9

DESCRIPTION
Rupture of membranes before the onset of labour at term (>37 weeks).
A sterile speculum examination is required to visually confirm amniotic fluid draining
through the cervical os.

GENERAL MEASURES
» If PROM is followed by uterine contractions at >34 weeks’ gestation, allow labour
to proceed.
» If the woman does not develop uterine contractions within 12 hours of PROM,
commence antibiotics and transfer for induction of labour.

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 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

MEDICINE TREATMENT
Prolonged rupture of membranes >12 hours/ suspected chorio-amnionitis:

x Ampicillin, IV, 1 g as a single dose.

Initiate antibiotic therapy:(O41.1)

x Metronidazole, oral, 400 mg as a single dose and refer.

AND

x Azithromycin, oral, 500 mg as a single dose.

Severe penicillin allergy: (Z88.0)

x Metronidazole, oral, 400 mg as a single dose and refer.

AND

LoE:III
REFERRAL
Urgent
» Suspected chorio-amnionitis (refer after starting antibiotics).
» Prolonged rupture of membranes (>12 hours).
» Meconium stained liquor.

6.5 INTRAPARTUM CARE

O80.0-1/O80.8-9

For the comprehensive management of women in labour refer to the most recent
National Maternity Care Guidelines.

DESCRIPTION
Labour is divided into 4 stages:
» First stage
– onset of regular painful uterine contractions at term to full dilatation of cervix.
» Second stage
– full dilatation to delivery of the baby.
» Third stage
– delivery of the baby to delivery of the placenta.
» Fourth stage
– 1 hour post-delivery of the placenta.

GENERAL MEASURES
» Encourage companion support.
» Ensure that the mother is adequately hydrated (can be done orally).
» Monitor progress of labour on partogram.

MEDICINE TREATMENT
First stage with cervical dilatation <10 cm:

x Morphine, IM, 0.1 mg/kg to a maximum of 10 mg, 4 hourly.

Analgesia: O62.9 + (Z51.2)

OR LoE:IIIxxxii

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 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

Especially in advanced first stage of labour:

Nitrous oxide 50% mixed with oxygen 50%, given by mask.
AND

x Promethazine, IM, 25 mg 4 hourly.

For nausea and sedation, if needed:

Second stage

x Lidocaine 1%.
If episiotomy is needed, local anaesthetic: O62.9 +(R10.2+Z51.2)

o Do not exceed 20 mL.

Fetal distress during labour (O75.9)
Place the woman in the left lateral position.
x Salbutamol 0.5 mg/mL, IV, 250 mcg administered slowly over 2 minutes and refer.

 Salbutamol 1 mL (0.5 mg/mL) added to 9 mL of water for injection, to make

o Reconstitute the tocolytic as follows:

 Inject 5 mL (250 mcg) over at least 2 minutes. Monitor pulse.

a 50 mcg/mL solution. Monitor pulse.

 If pulse increases > 120 beats/minute, discontinue the injection.

 Do not administer if mother has cardiac disease.
Third stage
Prevention of post-partum haemorrhage (PPH): (Z29.2)
» Check for twins.
x Oxytocin, IM, 10 units.
» Clamp and cut cord after 1 minute.
» Controlled cord traction of the placenta.
If > 500 mL blood loss, manage as postpartum haemorrhage (see Section 6.7.1:
Postpartum haemorrhage (PPH)).
Rh-negative mother (O36.0)

x Anti-D immunoglobulin, IM, 100 mcg, preferably within 72 hours but can be given
Administer to Rh-negative mother, if baby is Rh-positive or baby’s Rh group is unknown:

up to 7 days after delivery.

Care of the newborn baby
If baby not crying/breathing well, see Section 6.6.2: Neonatal Resuscitation.
For routine care of the neonate, see Section 6.6.1: Routine care of the neonate.
Observe mother and neonate for 1–2 hours before transfer to the postnatal ward.

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per 24

For pain after delivery

hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.

x Ibuprofen, oral, 400 mg 8 hourly with or after a meal as needed for up to 5 days.
OR

LoE:III

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 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

REFERRAL
» Prolonged labour according to charting on partogram.
» Post-partum haemorrhage.
» Retained placenta.
» Other complications of mother or baby.

6.6 CARE OF THE NEONATE

6.6.1 ROUTINE CARE OF THE NEONATE
Z76.2

For the comprehensive management of the newborn refer to the most recent
Newborn Care Charts.

GENERAL MEASURES
Routine care for baby after delivery
» Dry the baby thoroughly at birth.
» If there is meconium, clear the airway first.
» If baby is not crying
Ͳ Clear airway, stimulate.
Ͳ If baby not breathing well, clamp and cut the cord and start resuscitation
(see Section 6.6.2: Neonatal Resuscitation).
» If the baby is crying and breathing well
Ͳ Place on mother’s chest, keep warm and check breathing.
Ͳ Clamp and cut cord after 1 minute.
Ͳ Monitor with mother and initiate breastfeeding.
Check and record the Apgar score:
Apgar score 0 1 2
Heart rate Absent < 100/min > 100/min
Respiration Absent Slow or irregular Good, crying
Muscle tone Limp Slight flexion Active, moves
Response to stimulation No response Grimace Vigorous cry
Colour Blue or pale Body pink, limbs blue Pink all over

Check baby from head to toe including baby’s back

» Check weight and head circumference.
» If any of the following, provide immediate management (see Section 6.6.3: Care of

 Grunting or chest indrawing  Less than normal movements

sick and small neonates) and refer to a neonatal unit:

 Central cyanosis  Major congenital abnormality

 Fast breathing  Head circumference > 39cm
 Abnormal tone (floppy/stiff)  Birth weight < 2.5 kg
Identify the infant at risk or needing special treatment
» Birth weight < 2.5 kg. » Mother diabetic.
» Suspected chorio-amnionitis » Mother syphilis positive (partially
(membranes ruptured for > 18 hours, treated or untreated or treated < 1

2018 6.22
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

offensive liquor at birth). month before delivery).

» Neurological or congenital problem. » Mother HIV-infected.
» Hospital stay > 3 days after delivery. » Infant not breastfed.
» Mother blood group O and/or Rh –ve. » Mother on TB treatment.
» Possible social problem (mother has died or is ill, teenage caregiver, social
deprivation).
Initiate bonding and feeding
» Place the baby skin-to-skin with mother and initiate breastfeeding immediately.
Identify and record
» Formally identify the baby with the mother.
» Place a label with the mother’s name and folder number, baby’s sex, time and
date of birth on the baby’s wrist and ankle.
» After giving vitamin K and chloramphenicol eye ointment, give the baby back to the
mother, unless there is a reason for the baby to be transferred to a neonatal unit.

MEDICINE TREATMENT

x Vitamin K, IM, 1 mg immediately after birth routinely.

Bleeding prophylaxis (Z29.2)

o Administer in the antero lateral aspect of the mid-thigh.

x Chloramphenicol ophthalmic ointment 1%, applied routinely to each eye after birth.
Neonatal conjunctivitis prophylaxis (Z29.2)

x BCG vaccination, intradermal, once neonate is stable. (Z32.2)

Routine EPI immunisation:

x bOPV (polio vaccine), oral, once neonate is stable. (Z24.0)

No baby must be sent home without immunisation.

REFERRAL
Refer to a neonatal unit if:
» Baby needed resuscitation.
» Apgar score < 8 at 5 minutes.

6.6.2 NEONATAL RESUSCITATION

P29.8

Be prepared
Be at the delivery
Check the equipment and emergency medicines
» Follow the algorithm at the end of the section.
» Check that each step has been effectively applied before proceeding to the next
step. The algorithm follows the assumption that the previous step was
unsuccessful and the baby is deteriorating.
» Use oxygen concentration that alleviates central cyanosis, obtains target pulse
oximetry readings (if pulse oximeter is available), and restores a heart rate >100
beats/minute. Bag and mask ventilation should be initially done with room air.

2018 6.23
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

(There is evidence that routine resuscitation with 100% oxygen is potentially

harmful to the baby).

An unsatisfactory response to resuscitation includes:

» A sustained slow heart rate, usually ” 60 beats/minute or a progressive decrease in
heart rate until cardiac arrest occurs.
» Episodes of cardiac arrest, with a progressively weaker response to chest
compressions, positive pressure ventilation and medicines.
» A decreasing blood pressure, increasing acidosis, severe hypotonia with central
cyanosis or intense pallor.
» Apnoea or weak, irregular and inefficient respiratory efforts.

MEDICINE TREATMENT
If baby’s response to resuscitation is inadequate once ventilation and circulation are
adequately supported the following steps should be carried out:
If the mother is known or suspected to have had narcotic pain relief and the baby has
normal heart rate and colour response to bag-mask ventilation, but has not initiated

x Naloxone, IV, 0.1 mg/kg.

sustained regular respiratory effort:

Check the blood glucose of the baby.

x Dextrose 10%, IV, 2.5–5 mL/kg.

If hypoglycaemia is present: (E16.0-2)

Medicines used during neonatal resuscitation

x Adrenaline (epinephrine).
Medicine and dose Indications Effect
» Asystole. » ĹHeart rate.
o 0.1 mL/kg of a 1:10 000 dilution IV, » Heart rate < 60 » ĹMyocardial
(0.01 mg/kg/dose). beats/minute. contractility.
» ĹArterial pressure.
o ET, up to 1 mL/kg of a 1:10 000

x Naloxone, IV/IM, 0.1 mg/kg

dilution (0.1 mg/kg/dose).
» Maternal » Corrects apnoea
o May need repeating after 2 hours. administration of and/or
opiates with apnoeic hypoventilation.

x Dextrose, IV.
infant.
» Hypoglycaemia » Corrects
o 2.5–5 mL/kg of 10% dextrose (250– (usually only occurs hypoglycaemia.
500 mg/kg). after acute
o 10% solution: draw up 4 mL of 50% resuscitation).
dextrose into a 20 mL syringe then
draw up 16 mL water for injection –
mix by agitating the syringe.
» ĹBlood Pressure
x Sodium chloride 0.9%, IV, 10–20
Fluid for volume expansion: » Hypovolaemia
(usually history of and improve tissue
mL/kg, slow IV (5–10 minutes). blood loss, child pale perfusion.
shocked with poor
pulses and
perfusion).

2018 6.24
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

If no adequate response has occurred by this stage, a person skilled in neonatal

resuscitation should be consulted and the baby transferred with ongoing resuscitation
to a higher level of care:
» Discontinue resuscitation if the unsatisfactory response to resuscitation persists
for > 20 minutes and underlying conditions e.g. pneumothorax, diaphragmatic
hernia has been excluded or > 10 minutes of unresponsive cardiac arrest
(asystole) and/or > 20 minutes of unsustained respiration.
» Babies requiring minimal resuscitation with prompt and complete response may
be watched with their mothers. 
» Babies with a favourable response to resuscitation should be referred to a
neonatal high or intensive care unit, if available, for post resuscitation care.
» Babies, who, after resuscitation, are not completely normal, should be referred to
a higher level for care using transport with necessary support, e.g. oxygen,
temperature control.

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 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

2018 6.26
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

6.6.3 CARE OF SICK AND SMALL NEONATES

Z76.2

DESCRIPTION
Neonates can become ill very rapidly and signs of disease are often not readily
appreciated unless specifically looked for. Neonates should be referred urgently.
Neonates < 2.5 kg are at higher risk of feeding and growth problems and need careful
follow-up.
Urgently manage and refer neonates with a possible serious bacterial infection
and jaundice:
» Convulsions » Passing blood per rectum
» Lethargic/ unconscious » Pallor
» Bulging fontanelle » Jaundice in 1st 24 hours of life
» Apnoea (< 30 breaths/min) » Diarrhoea
» Severe chest indrawing » Many or severe skin pustules
» Nasal flaring or grunting » Fast breathing (> 60 breaths/min)
» Swollen eyes; pus draining from » Vomiting everything/bile-stained
eye vomitus
» Low or high temperature » Only moves when stimulated
» Not able to feed » Umbilical redness extending to the
skin and draining pus
GENERAL MEASURES
» Keep the neonate warm (skin-to-skin/kangaroo mother care or in an incubator),
the axillary temperature should be 36.5–37oC.
» Check blood glucose and treat if low (< 2.6 mmol/L). Repeat glucose in 15
minutes. If normal, feed 2-3 hourly. If still low, treat as severe hypoglycaemia.
» Check mother able to successfully establish breastfeeding in the small neonate
and check health and weight gain more frequently.

MEDICINE TREATMENT

x Oxygen, using nasal catheter at 1 L/minute.

If grunting or severe chest indrawing (P22.0-1/P22.8-9)

x Ceftriaxone, IM, 80 mg/kg/dose immediately as a single dose.

If infection is suspected and jaundice has been excluded (Z29.2)

o Administer into the lateral thigh.

o Do not inject more than 1 g at one injection site.
CAUTION: USE OF CEFTRIAXONE IN NEONATES AND CHILDREN
» If SUSPECTING SERIOUS BACTERIAL INFECTION in neonate, give ceftriaxone,
even if jaundiced.

 If ” 28 days old, avoid calcium-containing IV fluids for 48 hours after ceftriaxone

» Avoid giving calcium-containing IV fluids (e.g. Ringer Lactate) together with ceftriaxone:

 If > 28 days old, ceftriaxone and calcium-containing IV fluids may be given

administered.

sequentially provided the giving set is flushed thoroughly with sodium chloride

 Preferably administer IV fluids without calcium contents.

0.9% before and after.

» Always include the dose and route of administration of ceftriaxone in the referral letter.

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 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

If blood glucose < 2.6 mmol/L and baby able to suckle or take orally:
» Breastfeed or give expressed breastmilk (only if breastfeeding is not possible,
give replacement milk feed 10 mL/kg)
» If unable to take orally consider nasogastric tube feeding. Repeat glucose in 15
minutes. If still < 2.6 mmol/L, manage as below.

x Dextrose 10% IV, 2 mL/kg as a bolus.

If blood glucose < 1.4 mmol/L or remains < 2.6 mmol/L after an oral feed:

AND
x Dextrose 10% IV, 3 mL/kg/hour. LoE:IIIxxxiii
o Repeat in 15 minutes.
o If blood glucose still low, repeat dextrose bolus.

REFERRAL
Urgent
» All neonates with a possible serious bacterial infection.
» All neonates with jaundice on the first day of life, with pallor or with poor feeding.
» All other neonates with increasing, deep or persistent (> 10 days) jaundice should
be referred as soon as possible.
» All small neonates (< 2.5 kg) not able to feed.
» Persistent hypoglycaemia despite treatment.
(If possible, always send mother with the neonate as well as any clinical notes).

6.6.4 CARE OF THE HIV-EXPOSED INFANT

See Section 11.5: The HIV-exposed infant.

6.6.5 PERINATAL TRANSMISSION OF HEPATITIS B

P00.2

DESCRIPTION
Babies born to mothers with acute hepatitis B infection at the time of delivery or to
mothers who are HBsAg-positive or HBeAg-positive.

x
MEDICINE TREATMENT
Hepatitis B immunoglobulin, IM, 0.5 mL within 12 hours of LoE:IIIxxxiv
delivery.

x Hepatitis B vaccine, IM, 0.5 mL, first dose within 12 hours of delivery.
AND

o Continue hepatitis B immunisation according to the LoE:IIIxxxv

recommended immunisation schedule.
» Check the baby’s hepatitis B surface antigen (HBsAg) and hepatitis B surface

 If HBsAg positive: baby has hepatitis B infection – refer.

antibody (HBsAb) at 9 months:

 If HBsAg negative and HBsAb negative: repeat vaccination with hepatitis B

containing vaccine, with a repeat dose in 1 month. Repeat HBsAb one month
after the second dose; if still HBsAb negative then refer.

2018 6.28
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

 If HBsAb positive: baby is immune to hepatitis B. Reassure parents, no further

testing required.
Note: Do not check hepatitis B serology before 9 months of age as antibodies from
the birth dose of immunoglobulin might still be present. Refer if hepatitis B serology
is not available.

6.7 POSTPARTUM CARE

6.7.1 POSTPARTUM HAEMORRHAGE (PPH)
O72.0-3

DESCRIPTION
Primary postpartum haemorrhage (PPH) is blood loss >500 mL that occurs within 24
hours of birth.
Secondary PPH occurs 24 hours to 12 weeks after delivery (late or delayed PPH).
The most common cause is an atonic uterus.

GENERAL MEASURES
» Massage fundus and expel clots from vagina.
» Empty the bladder.
» Two intravenous lines (wide bore if possible).
» Bimanually compress the uterus to stop the bleeding.
» If no response to medicine treatment, insert a condom catheter (an open condom
slipped over a large Foley’s catheter and secured at its base with string to provide
a makeshift balloon catheter) into uterus, inflate with 400-500mL of saline and
clamp. Pack vagina with swabs to prevent expulsion and refer urgently.

MEDICINE TREATMENT

x Sodium chloride 0.9%, IV, infused as fast as possible in one IV line.

Replace fluids:

x Oxytocin, IV, 20 units in 1 000 mL sodium chloride 0.9% infused at 250 mL/hour
AND

in 2nd IV line.
LoE:Ixxxvi
x Ergometrine, IM, 0.5 mg.
If no response:

OR LoE:III
Oxytocin/ergometrine, IM, 5 units/0.5 mg.
o Avoid ergometrine in hypertensive women and those with heart disease,
unless haemorrhage is life threatening (women haemodynamically unstable).
o Repeat after 10–15 minutes if no response to 1st dose, while arranging referral.

x Misoprostol, sublingual/rectal, 600 mcg as a single dose.

Only in settings where oxytocin is not available:

LoE:Ixxxvii
REFERRAL
All cases.
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 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

6.7.2 PUERPERAL SEPSIS

O86.0-4/O86.8

DESCRIPTION
Clinical features include a temperature • 38°C (usually • 2 days), often accompanied
by offensive vaginal discharge (lochia) and/or abdominal pain within the first 10 days
postpartum.

GENERAL MEASURES
» Monitor vital parameters, e.g. Hb, pulse, BP, temperature.
» Treat for shock if indicated.

x
MEDICINE TREATMENT
Ceftriaxone, IV, 1 g as a single dose.

CAUTION: USE OF CEFTRIAXONE

Do not administer calcium-containing fluids, e.g. Ringer-Lactate, concurrently
with ceftriaxone.

x Metronidazole, oral, 400 mg as a single dose.

AND

REFERRAL
All cases.

6.7.3 CRACKED NIPPLES DURING BREASTFEEDING

O92.1

DESCRIPTION
The areola and nipple are protected by the secretion of a lubricant from Montgomery’s
glands. Cracked nipples may lead to infection and mastitis.
Causes of cracked nipples include:
» poor positioning of the baby and incorrect attachment to the breast
» removing the baby from the breast before suction is broken
» the four signs of good attachment are:
– chin touching breast (or very close)
– mouth wide open
– lower lip turned outward
– more areola visible above than below the mouth

GENERAL MEASURES
» Apply expressed breast milk to the nipples between feeds and air dry.
» If too painful, express the milk and nurse the baby on the other breast until
improvement.
» Keep areola and nipple clean and dry.
» Avoid use of soap, creams and lotions on the nipples.

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 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

x
MEDICINE TREATMENT
Zinc and castor oil ointment.
o Apply between feeds.

x Nystatin solution. See Section 1.2: Candidiasis, oral (thrush).

If oral thrush is present, treat neonate with:

REFERRAL
No improvement after 2 days.

6.7.4 MASTITIS
O91.2

DESCRIPTION
Inflammation of the breast tissue surrounding the milk ducts.
Risk factor includes retrograde infection from a fissured nipple and milk stasis.
Commonly isolated pathogens include S. aureus and S. epidermidis. Presentation
includes painful breast(s), fever, erythema and malaise.

GENERAL MEASURES
Compresses.
Regular expressing of breast milk.
Do not stop breastfeeding, unless a breast abscess has developed.
If breast abscess present, refer for incision and drainage.

x
MEDICINE TREATMENT
Flucloxacillin, oral, 500mg 6hourly for 5 days.
Severe penicillin allergy: (Z88.0)
ƒ Macrolide, e.g.:
x Azithromycin, oral, 500mg daily for 3 days.

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per

Pain:

24 hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4g in 24 hours.

REFERRAL
» Breast abscess.
» No improvement after 2 days.

6.8 HIV IN PREGNANCY

O98.7

DESCRIPTION
HIV is currently the commonest cause of maternal deaths in South Africa.
Transmission of HIV from mother to infant may occur during pregnancy, delivery
2018 6.31
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

and/or breastfeeding. Without intervention, 25–40% of infants born to HIV-infected

women may become infected. With appropriate interventions, maternal mortality as
well as perinatal transmission of HIV can be substantially reduced. In South Africa,
4% of women who were initially HIV-negative become positive later during
pregnancy. Repeat HIV testing is essential.
For comprehensive information on the care of HIV-infected pregnant women refer to
the current National Consolidated Guidelines for the Prevention of Mother-to-Child
Transmission of HIV (PMTCT) and the management of HIV in Children, Adolescents
and Adults as well as the current Guidelines for Maternity Care in South Africa.

GENERAL MEASURES
HCT in all pregnant and breastfeeding women
» Provide routine counselling and voluntary HIV testing to all pregnant women at their
very first antenatal visit, and treat other STIs if necessary.
» All women who test negative must be offered repeat HIV testing every 3 months
throughout pregnancy, at labour/delivery, at the 6-week EPI visit and 3 monthly
throughout breastfeeding.
Women who choose not to be tested
» Provide with individual ‘post-refusal’ counselling and offer HIV testing at every
subsequent visit.
» Perform a TB symptom screen at each visit.
» Counsel on risks of MTCT to unborn baby, HIV risk reduction behaviour and offer
HIV prevention services.
Pregnant women who test HIV positive
» Confirm result with a 2nd rapid HIV test of another type in compliance with current
HCT policy.
» If results are discordant, repeat both first and confirmatory rapid HIV tests and if
still discordant, send blood for a laboratory HIV ELISA.
» All confirmed HIV-infected women must be fast-tracked for ART regardless of
CD4 count.
» Perform clinical staging and TB symptom screen, and take a blood sample for
CD4 cell count and creatinine, on the day of testing. Obtain results within a week.
– If CD4 < 100 cells/mm3, do a serum cryptococcal antigen (CrAg) test.
» Start ART on the day of diagnosis (unless there are symptoms of TB).
» Investigate all those with TB symptoms before ART initiation. If TB treatment is
started, defer ART for 2 weeks.
» HIV-infected women must return 1 week after their initial ANC visit to get their
creatinine and CD4 cell count results and be managed accordingly.
» Refer women with unwanted pregnancies < 20 weeks’ gestation for termination
of pregnancy (TOP) services.
Pregnant women already known to be HIV-infected
» If not on ART, do clinical staging; take blood for CD4 count (to determine eligibility
for cotrimoxazole prophylaxis) and creatinine. If CD4< 100 cells/mm3, do a serum
cryptococcal antigen (CrAg) test.
Ͳ Start ART the same day if no contraindication.

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 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

» If already on ART for > 3 months, take blood for viral load irrespective of when it
was last done.
Antenatal support
» Counsel about the importance of adherence and virological suppression for
PMTCT.
» Counsel on infant feeding, safer sex, family planning, postnatal contraception,
partner testing, routine cervical cancer screening.
» Perform TB symptom screening at each visit.
» Provide appropriate nutritional care and support including iron, folate and calcium
supplementation and Hb testing.
Postpartum support
» Provide adequate support and counselling, particularly addressing ART
adherence during breastfeeding.
» Educate mothers about the benefits of breastfeeding. Only in circumstance where
the mother has confirmed 2nd or 3rd line ART regimen failure, advise not to
breastfeed and prescribe replacement feeds.
» Refer mother to appropriate services to continue lifelong ART as part of the
general adult ART population.

MEDICINE TREATMENT
Opportunistic infection treatment and prophylaxis for HIV-infected pregnant
women:
Pregnant women diagnosed with pulmonary TB:
» First line TB treatment is safe and effective in pregnant women.
» See Section 17.4.1: Pulmonary tuberculosis (TB) in adults.
Pregnant women on ART with no symptoms of TB:
» See Section 11.2.2: Isoniazid preventive therapy (IPT).
Women with CD4 ” 200 cells/mm3 or WHO clinical stage 2, 3 or 4:
x Cotrimoxazole, oral, 160/800 mg daily, until CD4 > 200 cells/mm3.
If CrAg-positive, asymptomatic and > 13 weeks of gestation (in the 2nd

x If not previously treated, start fluconazole, oral, 800 mg daily for 2 weeks, then
trimester):

400 mg daily for 8 weeks, then 200 mg daily until CD4 > 200 cells/mm3.
Note:
» If there is uncertainty about gestational age, refer for ultrasound scan before
commencing fluconazole. LoE:IIIxxxviii
» If CrAg-positive and symptomatic (e.g. headache, vomiting,
confusion, fever), refer immediately for lumbar puncture and further management.

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 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

FIRST-LINE ART REGIMENS

1ST ANC VISIT
All pregnant women x TDF, oral, 300 mg daily. » Contraindication to TDF: renal

x FTC, oral, 200 mg daily

not on ART (any AND insufficiency, other nephrotoxic
gestational age). medicines e.g.

x EFV, oral, 600 mg at night.

AND AND aminoglycosides.
» Contraindication to EFV: active
All breastfeeding Note: Provide as a fixed dose psychiatric illness.
women not on ART. combination (FDC).
If active psychiatric x TDF, oral, 300 mg daily. » High-risk pregnancy: doctor

x FTC, oral, 200 mg daily

illness (EFV may be AND consult or refer immediately if
contraindicated). acute psychiatric illness.

x NVP, oral, 200 mg daily for 2

AND » CD4 ‫ ޒ‬250 cells/mm3
x Replace EFV with NVP:
weeks, then 200 mg 12 hourly. o Do an ALT test before

x LPV/r 400/100 mg 12
OR starting NVP. Avoid NVP
if ALT elevated. If ALT
hourly). (Doctor consult). elevated, replace EFV
with LPV/r.
» CD4 • 250 cells/mm3
x Replace EFV with LPV/r.
If renal insufficiency Start alternative regimen

x ABC, oral, 600 mg, daily.

or other nephrotoxic (Doctor consult):
medicines e.g.

x 3TC, oral, 300 mg, daily.

aminoglycosides AND
(TDF may be

x EFV, oral, 600 mg daily.

contraindicated) AND

LoE:IIIxxxix
Pregnant women x Continue current ART » Do a VL as soon as pregnancy
currently on ART regimen. is confirmed.
» Pregnant women with
confirmed 2nd or 3rd line ART
regimen failures should not
breastfeed their infants, if they
can safely formula feed.
2ND ANC VISIT (1 WEEK LATER)
Creatinine ” 85 x Continue FDC:
mmol/L TDF+FTC+EFV
Creatinine > 85 x Stop FDC: TDF+FTC+EFV. » High-risk pregnancy: change to
mmol/L alternate triple therapy within 2
(TDF is contra- Start alternative regimen weeks (doctor consult) and

x ABC, oral, 600 mg, daily.

indicated) (Doctor consult): refer for renal dysfunction
investigation.

x 3TC, oral, 300 mg, daily

AND

x EFV, oral, 600 mg daily.

AND

LoE:IIIxl

2018 6.34
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

WOMEN DIAGNOSED HIV POSITIVE IN LABOUR

All unbooked x NVP, oral, 200 mg single Before discharge:
women who test dose as early as possible in » Start on lifelong ART the day
positive during labour. after delivery, if there are no

x AZT, oral, 300 mg

labour should be AND contraindications, regardless
given prophylactic
x FDC (TDF+FTC+EFV)
of CD4:
ART during labour intrapartum, every 3 hours
and initiated on until delivery.
lifelong ART before
x TDF, oral, 300 mg, as a
AND
being discharged.
single dose

x FTC, oral, 200 mg, as a

AND

single dose.

Start lifelong ART next day

x FDC (TDF+FTC+EFV)
regardless of CD4:

POST-DELIVERY
The mother should Start lifelong ART regardless

x FDC (TDF+FTC+EFV)
start ART within 24 of CD4:
hours of delivery to
protect the baby
during breastfeeding.
BABY
See Section 11.5: The HIV-exposed infant to decide whether infant is low risk or high risk
and what HIV prophylactic management is needed.
Note:
» eGFR and creatinine clearance are not reliable for diagnosing renal impairment in pregnancy.
» Monitor response to ART within 3 months of ART initiation with a plasma VL. If VL is not
suppressed, refer for expert advice.
Viral load monitoring for 1st line regimen in pregnant and breastfeeding women:
Viral Load (VL) Response
Lower than » Perform 6 monthly VL monitoring and provide routine adherence
detectable level* support.

 If VL ” 1000 copies/mL, continue on current ART regimen.

Detectable but » Assess adherence carefully (>95% of doses must be taken)
”1000
copies/mL  If concerns about adherence consider doing another VL within 3
months. Repeat VL at 6 months on ART, if suppressed, do 6 monthly
VL testing.
>1000 » If VL > 1000 copies/mL, provide adherence counselling, repeat the
copies/mL VL in 1 month.
» If 2nd VL result is undetectable or has shown a reduction in VL of 1
log (10-fold) or greater, continue with the existing regimen.
» If the VL result is unchanged or has not shown a 1 log (10-fold)
reduction or has increased, the woman should be switched to
second-line therapy urgently.
» Any woman who requires a switch to second-line therapy must
receive intensive adherence counselling and support to ensure high-
level adherence and rapid viral load suppression.

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 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY
* Note that the limit of detection varies between laboratories. Use the cut-off in the laboratory report.
REFERRAL
» Refer mothers suspected of non-adherence early.
Urgent
» Creatinine > 85 mmol/L.
» ALT > 100 IU/L.

 symptomatic (headache, confusion), or

» Pregnant women who are CrAg+, and

 asymptomatic, but in the 1st trimester.

6.9 MATERNAL MENTAL HEALTH

Conditions affecting a pregnant and postpartum woman need to be recognised and
managed because of the significant negative impact this has on the mother’s ability
to carry the pregnancy to term and to care for her baby. This has consequences for
the health and development of the child.
The unique hormonal changes, changes to sleep wake cycles, and the stress of
caring for a newborn make the peri-partum period high risk for any psychiatric
disorder to manifest.
Sufferers of peri-partum psychiatric conditions are at high risk for similar episodes in
future pregnancies and the need for family planning should be emphasised.

6.9.1 ANTEPARTUM DEPRESSION

O28.8-9 + (F32.0-3/F32.8-9/ F33.0-4/F33.8-9/F34.1/F53.0-1/F53.8-9)

DESCRIPTION
Symptoms can mimic those of pregnancy itself and the diagnosis can therefore be
missed. See Section 16.4.1: Depressive disorders, for symptoms and management.
Untreated depression in pregnancy can lead to intrauterine growth problems, low
birth weight, preterm delivery or pregnancy loss, poor adherence to antenatal care
and can lead to postpartum depression.

GENERAL MEASURES
Identification of risk factors for the development of depression, e.g.:
» poor social support,
» absent, abusive or unsupportive partner,
» past history of depression or anxiety,
» recent traumatic life event(s),
» precious pregnancy or unplanned pregnancy.
Provide supportive counselling and mobilise available support systems.
Screen for suicide risk.

REFERRAL
All patients.

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 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

6.9.2 POSTPARTUM DEPRESSION

O90.8-9/P96.8-9 + (F32.0-3/F32.8-9/ F33.0-4/F33.8-9/F34.1/F53.0-1/F53.8-9)

DESCRIPTION
Postpartum "blues":
» Presents with irritability, tearfulness, anxiety;
» Begins by day 3 to 5 postpartum;
» Usually resolves spontaneously within 48 to 72 hours of onset;
If these symptoms persist for longer than a week, screen for postpartum depression.
Postpartum depression:
» Usually begins within a month of delivery, but can be evident up to a year after
delivery.
See Section 16.4.1: Depressive disorders, for symptoms and management.

GENERAL MEASURES
» Mobilise patient's support system.
» Reassure and advise on practical aspects of childcare and adjusting to new lifestyle.
» Organisations such as Postnatal Depression South Africa (PNDSA) are a useful
resource. http://www.pndsa.org.za/
» Edinburgh Postnatal Depression Scale can be a useful screening tool.
https://psychology-tools.com/epds/

 Suicide risk.
» Identify risk factors requiring urgent admission and invoke the MHCA if necessary

 Risk to infant.
 Psychotic features including command auditory hallucinations.

REFERRAL
All patients with postpartum depression.

6.9.3 POSTPARTUM PSYCHOSIS

O90.8/9 + (F28/F29/F53.0-1/F53.8-9)

Is a medical emergency and requires urgent hospitalisation.

DESCRIPTION
Development of bizarre behaviour and/or delusions and/or hallucinations in the
month postpartum.
Can be due to primary psychotic disorder or delirium, but most commonly due to a
severe postpartum mood episode.

GENERAL MEASURES
» Ensure safety of staff, patient and infant.
» De-escalation techniques and non-threatening approach.
» Risk assessment.
» Exclude delirium or general medical condition, if possible.
» Invoke the MHCA and sedate if necessary (see Section 16.1: Aggressive

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 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

disruptive behaviour management).

» Social worker involvement.

REFERRAL
Refer all cases urgently.

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 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

GYNAECOLOGY
6.10 ECTOPIC PREGNANCY
O00.0-2/O00.8-9

DESCRIPTION
Pregnancy outside the uterus, usually presenting with the combination of:
» amenorrhoea (missed menstrual period)
» sudden lower abdominal pain/ pelvic pain
» vaginal bleeding (os closed)
» dizziness
» shock
» anaemia
» urine pregnancy test usually positive
» shoulder tip pain
Note: Consider ectopic pregnancy in young women who complain of lower abdominal
pain.

GENERAL MEASURES
» Monitor vital parameters, e.g. Hb, pulse, BP, temperature.
» Treat for shock if indicated.

x
MEDICINE TREATMENT
Sodium chloride 0.9%, IV.

REFERRAL
Urgent
All suspected cases of ectopic pregnancy.

6.11 VAGINAL BLEEDING

Note: Women should receive regular screening for cervical cancer after the age of
30 years. Any opportunity to perform screening should be taken; this includes taking
pap smears during pregnancy.

6.11.1 ABNORMAL VAGINAL BLEEDING DURING

REPRODUCTIVE YEARS
N92.0-2

DESCRIPTION
Increased vaginal blood flow in either volume, duration, and/or frequency, including
menorrhagia or dysfunctional uterine bleeding.

GENERAL MEASURES
» Assess current contraceptives used.
» Exclude pregnancy complication or organic disease e.g. cervical cancer, fibroids.
2018 6.39
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

x
MEDICINE TREATMENT

x
Combined oral contraceptive pill (ethinylestradiol/levonorgestrel) for 3–6 months.
Ibuprofen, oral, 400 mg 8 hourly with or after a meal as needed for 2–3 days.
o Ibuprofen may reduce blood loss in menorrhagia associated with intrauterine
contraceptive device (IUCD) or chronic salpingitis (See Chapter 12: Sexually
transmitted infections).

x Ferrous sulfate compound BPC (dried), oral, 170 mg (± 55 mg elemental iron) 12

If blood loss has been severe or there are signs of anaemia:

hourly with meals.

OR
Ferrous fumarate, oral, 200 mg (± 65 mg elemental iron) 12 hourly.
o Continue for 3 months after Hb normalises - to replenish body iron stores.
o Taking iron tablets with meals decreases iron absorption, but improves
tolerability (Note: Do not take iron tablets with milk).
LoE:IIIxli
REFERRAL
» No improvement.
» Girls < 12 years of age with vaginal bleeding before the development of their
secondary sexual characteristics.
» For investigation of other causes such as:
– sexual abuse
– foreign bodies
– tumours of the genital tract
» Severe anaemia.

6.11.2 POST-MENOPAUSAL BLEEDING

N95.0

DESCRIPTION
Vaginal bleeding six months following the complete cessation of menstruation.
Note: If bleeding is profuse, stabilise before referral.

REFERRAL
All cases, to exclude underlying malignancy and other pathology.

6.12 DYSMENORRHOEA
N94.4-6

DESCRIPTION
Pain associated with menstrual cycles. In primary dysmenorrhoea there is no known
cause. Secondary dysmenorrhoea usually has an organic cause.

GENERAL MEASURES
» Advise and reassure women with primary dysmenorrhoea about the nature of the
condition.
2018 6.40
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

» Encourage patient to carry on with normal everyday activities.

x Ibuprofen, oral, 400 mg 8 hourly with or after a meal as needed for 2–3 days.
MEDICINE TREATMENT

x Combined oral contraceptive pill, if symptoms still problematic, and if pregnancy

ADD

is not planned.
Treat for pelvic infection when present.

REFERRAL
» Poor response to treatment.
» If an organic cause is suspected, e.g. fibroids.

6.13 HORMONE THERAPY (HT)

N95.1-2/N95.8-9

Indications:
Short-term symptomatic relief for severe menopausal symptoms.
For menopausal women, treatment should be ” 5 years.
Risk-benefit assessment should be individualised in all patients.
Contra-indications include:
» Known or suspected estrogen-dependent malignant tumours (such as
endometrial cancer).
» Coronary heart disease.
» Active liver disease.
» Women • 60 years of age.
» Current, past or suspected breast cancer.
» Thrombophilia.
» Undiagnosed genital bleeding.
» Previous idiopathic or current venous thromboembolism.
» Untreated endometrial hyperplasia.
» Porphyria cutanea tarda.

GENERAL MEASURES
Prior to starting HT:
» Do breast and gynaecological examination.
» Cervical screening.
» Where the facility is available, arrange mammography before starting HT.
However, lack of access to mammography should not delay HT if indicated for
severe menopausal symptoms if the woman has no other special risk factors for
breast cancer (e.g.: family history of breast cancer in first degree relative).
LoE:Ixlii
MEDICINE TREATMENT (Doctor initiated)
Uterus present (no hysterectomy)
HT can be offered as sequentially opposed or continuous combined preparations.
Continuous combined preparations are often preferred if the woman had her last
2018 6.41
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

menstrual period (menopause) over a year ago, as they will not usually cause bleeding
then. For women who are still menstruating or have recently stopped, sequentially
opposed preparations are preferred and will result in regular menstrual periods,
whereas continuous combined may result in irregular bleeding.
CONTINUOUS COMBINED THERAPY
x Estradiol/norethisterone acetate, oral, 1mg/0.5mg for 28 days.
OR
x Estradiol/norethisterone acetate, oral, 2mg/1mg for 28 days.

x Conjugated estrogens, oral, 0.3–0.625 mg for 28 days.

OR

AND
Medroxyprogesterone acetate, oral, 2.5–5mg daily for 28 days.
OR
SEQUENTIALLY OPPOSED THERAPY

x Estradiol valerate, oral, 2 mg for 11 days.

Estradiol valerate/cyproterone acetate, oral:

x Estradiol valerate/cyproterone acetate, 2mg/1mg for 10 days.

x Placebo, oral, for 7 days.

x Estradiol valerate, oral, 1–2 mg daily for 21 days.

OR

x Medroxyprogesterone acetate, oral, 5 -10 mg daily from day 12–21.

ADD

o Followed by no therapy from day 22–28.

x Conjugated oestrogens, oral, 0.3–0.625 mg daily for 21 days.

OR

x Medroxyprogesterone acetate, oral, 5–10 mg daily from day 12–21.

ADD

o Followed by no therapy from day 22–28.

 LoE:IIIxliii
Note: Where a dose range is provided start at the lowest possible
dose to alleviate symptoms. The need to continue HT should be reviewed annually.
Women with no uterus (post-hysterectomy)

x Estradiol valerate, oral, 1–2 mg daily.

HT is given as estrogen only.

OR
Conjugated estrogens, oral, 0.3 mg daily to a maximum of 1.25 mg daily.

REFERRAL
» Premature menopause, i.e. < 40 years of age.
» Severe osteoporosis
» Management difficulties, e.g. where a contra-indication to oestrogen replacement
therapy exists.
» Post-menopausal bleeding.
» If HT needed (symptoms persist) after 5 years of HT or woman • 65 years.
2018 6.42
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

6.14 VAGINAL ULCERS

See Section 12.5: Genital ulcer syndrome (GUS).

6.15 VAGINAL DISCHARGE/LOWER ABDOMINAL PAIN IN

WOMEN
See Sections 12.1: Vaginal discharge syndrome (VDS) and 12.2: Lower abdominal
pain (LAP).
References
i Anti-D immunoglobulin, IM : Karanth L, JaafarSH, Kanagasabai S, Nair NS, Barua A. Anti-D administration after spontaneous
miscarriage for preventing Rhesus alloimmunisation. The Cochrane database of systematic
reviews.2013(3):Cd009617.https://www.ncbi.nlm.nih.gov/pubmed/23543581
ii Morphine, IM (Incomplete 1st trimester miscarriage): National Department of Health, Essential Drugs Programme: Adult Hospital

Level STGs and EML, 2015. http://www.health.gov.za/

iii Paracetamol, oral (Incomplete 1st trimester miscarriage): National Department of Health, Essential Drugs Programme: Adult Hospital

Level STGs and EML, 2015. http://www.health.gov.za/

iv Ibuprofen, oral (Incomplete 1st trimester miscarriage): National Department of Health, Essential Drugs Programme: Adult Hospital

Level STGs and EML, 2015. http://www.health.gov.za/

v Mifepristone (Medical TOP): Royal College of Obstetrics and Gynaecology Guidelines.The Care of Women Requesting Induced

Abortion (Evidence-based Clinical Guideline No. 7), 2011.https://www.rcog.org.uk/en/guidelines-research-services/guidelines/the-care-

of-women-requesting-induced-abortion/
Mifepristone (Medical TOP): WHO.Safe abortion: technical and policy guidance for health systems,
2014.http://www.who.int/reproductivehealth/publications/unsafe_abortion/en/
Mifepristone (Medical TOP): The American College of Obstetricians and Gynaecologists: Best practice in comprehensive abortion
care, 2014. http://www.acog.org/~/media/Practice%20Bulletins/Committee%20on%20Practice%20Bulletins%20--
%20Gynecology/Public/pb143.pdf?dmc=1&ts=20140703T1932230602
Mifepristone (Medical TOP): National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML,
2015. http://www.health.gov.za/
Mifepristone (Medical TOP): Republic of South Africa.Choice on Termination of Pregnancy Act Amendment 1 of
2008.http://www.gov.za/documents/choice-termination-pregnancy-amendment-act
Mifepristone (Medical TOP): National Department of Health: Affordable Medicines, EDP- Primary Health Care. Medicine Review:
Can TOPs be accomplished safely and effectively without ultrasound, July 2016. http://www.health.gov.za/
vi Misoprostol (Medical TOP): Royal College of Obstetrics and Gynaecology Guidelines. The Care of Women Requesting Induced

Abortion (Evidence-based Clinical Guideline No. 7), 2011.https://www.rcog.org.uk/en/guidelines-research-services/guidelines/the-care-

of-women-requesting-induced-abortion/
Misoprostol (Medical TOP): WHO.Safe abortion: technical and policy guidance for health systems,
2014.http://www.who.int/reproductivehealth/publications/unsafe_abortion/en/
Misoprostol (Medical TOP): The American College of Obstetricians and Gynaecologists: Best practice in comprehensive abortion
care, 2014. http://www.acog.org/~/media/Practice%20Bulletins/Committee%20on%20Practice%20Bulletins%20--
%20Gynecology/Public/pb143.pdf?dmc=1&ts=20140703T1932230602
Misoprostol (Medical TOP): National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML, 2015.
http://www.health.gov.za/
Misoprostol (Medical TOP): Republic of South Africa.Choice on Termination of Pregnancy Act Amendment 1 of
2008.http://www.gov.za/documents/choice-termination-pregnancy-amendment-act
Misoprostol (Medical TOP): National Department of Health: Affordable Medicines, EDP- Primary Health Care. Medicine Review: Can
TOPs be accomplished safely and effectively without ultrasound, July 2016. http://www.health.gov.za/
vii Paracetamol, oral (Medical TOP): National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML,

2015. http://www.health.gov.za/
viii Ibuprofen, oral (Medical TOP): National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML,

2015. http://www.health.gov.za/
ix Misoprostol (MVA TOP): National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML, 2015.

http://www.health.gov.za/
x Morphine, IM (MVA TOP): National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML, 2015.

http://www.health.gov.za/
xi Paracetamol, oral (MVA TOP): National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML,

2015. http://www.health.gov.za/
xii Ibuprofen, oral (MVA TOP): National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML, 2015.

http://www.health.gov.za/
xiii Anti-D immunoglobulin, IM (TOP): National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML,

2015. http://www.health.gov.za/
xivFolic acid, oral: De-Regil LM, Peña-Rosas JP, Fernández-Gaxiola AC, Rayco-Solon P. Effects and safety of periconceptional oral

folate supplementation for preventing birth defects. Cochrane Database Syst Rev. 2015 Dec 14;(12):CD007950.
https://www.ncbi.nlm.nih.gov/pubmed/26662928

2018 6.43
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

Folic acid, oral: Atta CA, Fiest KM, Frolkis AD, Jette N, Pringsheim T, St Germaine-Smith C, Rajapakse T, Kaplan GG, Metcalfe A.
Global Birth Prevalence of Spina Bifida by Folic Acid Fortification Status: A Systematic Review and Meta-Analysis. Am J Public Health.
2016 Jan;106(1):e24-34. https://www.ncbi.nlm.nih.gov/pubmed/26562127
Folic acid, oral: Viswanathan M, Treiman KA, Kish-Doto J, Middleton JC, Coker-SchwimmerEJ, Nicholson WK. Folic Acid
Supplementation for the Prevention of Neural Tube Defects: An Updated Evidence Report and Systematic Review for the US
Preventive Services Task Force. JAMA. 2017 Jan 10;317(2):190-203.https://www.ncbi.nlm.nih.gov/pubmed/28097361
Folic acid, oral: RCOG. Nutrition in Pregnancy: Scientific Impact Paper No. 18. https://www.rcog.org.uk/en/guidelines
Folic acid, oral: ACOG Committee on Practice Bulletins. ACOG practice bulletin. Clinical management guidelines for obstetrician-
gynecologists. Number 44, July 2003. (Replaces Committee Opinion Number 252, March 2001) Obstet. Gynecol. 2003;102(1):203–
213. https://www.ncbi.nlm.nih.gov/pubmed/12850637
Folic acid, oral: U.S. Preventive Services Task Force.Folic acid for the prevention of neural tube defects: U.S. Preventive Services
Task Force recommendation statement. Ann Intern Med. 2009 May 5;150(9):626-31. https://www.ncbi.nlm.nih.gov/pubmed/19414842
Folic acid, oral: Wilson RD; Genetics Committee, Wilson RD, Audibert F, Brock JA, Carroll J, Cartier L, Gagnon A, Johnson JA,
Langlois S, Murphy-Kaulbeck L, Okun N, Pastuck M; Special Contributors, Deb-Rinker P, Dodds L, Leon JA, Lowel HL, Luo W,
MacFarlane A, McMillan R, Moore A, Mundle W, O'Connor D, Ray J, Van den Hof M. Pre-conception Folic Acid and Multivitamin
Supplementation for the Primary and Secondary Prevention of Neural Tube Defects and Other Folic Acid-Sensitive Congenital
Anomalies. J ObstetGynaecol Can. 2015 Jun;37(6):534-52.https://www.ncbi.nlm.nih.gov/pubmed/26334606
xv Valproic acid – caution in pregnancy: European Medicines Agency - Pharmacovigilance Risk Assessment Committee. Assessment

report EMA/198940/2018 - valproate exposure in pregnancy, 8 February 2018.

http://www.ema.europa.eu/docs/en_GB/document_library/Referrals_document/Valproate_2017_31/Position_provided_by_CMDh/WC5
00250221.pdf
Valproic acid – caution in pregnancy: Meador K, Reynolds MW, Crean S, Fahrbach K, Probst C. Pregnancy outcomes in
women with epilepsy: a systematic review and meta-analysis of published pregnancy registries and cohorts. Epilepsy Res. 2008
Sep;81(1):1-13. https://www.ncbi.nlm.nih.gov/pubmed/18565732
xvi Ferrous sulfate, oral: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of Cape Town, 2016.

Ferrous sulfate, oral: National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML, 2015.
http://www.health.gov.za/
xvii Ferrous (Iron) supplements, oral - intermittent dosing: National Department of Health: Affordable Medicines, EDP-Primary Health

Care level. Medicine Review: Intermittent iron supplementation in pregnancy, 6 November 2017.http://www.health.gov.za/
Ferrous (Iron) supplements, oral - intermittent dosing:Peña-Rosas JP, De-Regil LM, Gomez Malave H, Flores-Urrutia MC, Dowswell
T. Intermittent oral iron supplementation during pregnancy. Cochrane Database Syst Rev. 2015 Oct
19;(10):CD009997.https://www.ncbi.nlm.nih.gov/pubmed/26482110
Ferrous sulfate, oral: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of Cape Town, 2016.
Ferrous fumarate, oral: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of Cape
Town, 2016.
xviiiCalcium: National Department of Health, Essential Drugs Programme. Adult Hospital level STG, 2015. http://www.health.gov.za/

Calcium: Hofmeyr GJ, Lawrie TA, Atallah AN, Duley L, Torloni MR. Calcium supplementation during pregnancy for
preventing hypertensive disorders and related problems. Cochrane Database Syst Rev. 2014 Jun 24;6:CD001059.
http://www.ncbi.nlm.nih.gov/pubmed/24960615
Calcium: WHO. WHO recommendations for prevention and treatment of pre-eclampsia and eclampsia, 2011.
http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/9789241548335/en/
xixMethyldopa, oral (drug interaction with iron):Campbell N, Paddock V, and Sundaram R. Alteration of Methyldopa Absorption,

Metabolism, and Blood Pressure Control Caused by Ferrous Sulphate and Ferrous Gluconate. ClinPharmacolTher, 1988, 43:381-
6.https://www.ncbi.nlm.nih.gov/pubmed/3356082
xxCalcium: National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML, 2015.

http://www.health.gov.za/
Calcium: Hofmeyr GJ, Lawrie TA, Atallah AN, Duley L, Torloni MR. Calcium supplementation during pregnancy for
preventing hypertensive disorders and related problems. Cochrane Database Syst Rev. 2014 Jun
24;6:CD001059.http://www.ncbi.nlm.nih.gov/pubmed/24960615
Calcium: WHO. WHO recommendations for prevention and treatment of pre-eclampsia and eclampsia, 2011.
http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/9789241548335/en/
xxi Nifedipine: National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML, 2015.

http://www.health.gov.za/
xxii Calcium gluconate 10%, IV: National Department of Health, Essential Drugs Programme: Adult Hospital level STG,

2015.http://www.health.gov.za/
xxiii Magnesium sulfate, IV: National Department of Health, Essential Drugs Programme: Adult Hospital level STG,

2015.http://www.health.gov.za/
xxivFerrous (Iron) supplements: Reveiz L, Gyte GM, Cuervo LG, Casasbuenas A. Treatments for iron-deficiency anaemia in pregnancy.

Cochrane Database Syst Rev. 2011 Oct 5;(10):CD003094. http://www.ncbi.nlm.nih.gov/pubmed/21975735

Ferrous sulfate, oral: National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML, 2015.
http://www.health.gov.za/
Ferrous sulfate, oral: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of Cape Town, 2016.
Ferrous fumarate, oral: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of Cape
Town, 2016.
xxvLidocaine 1% without adrenaline (epinephrine) - diluent:Kingston M, French P, Higgins S, McQuillanO,Sukthankar A, Stott C,

McBrienB, Tipple C, Turner A, Sullivan AK; Members of the Syphilis guidelines revision group 2015, Radcliffe K, Cousins D, FitzGerald
M, Fisher M, Grover D, Higgins S, Kingston M, Rayment M, Sullivan A. UK national guidelines on the management of syphilis 2015.Int
J STD AIDS. 2016 May;27(6):421-46.https://www.ncbi.nlm.nih.gov/pubmed/26721608
xxviNitrofurantoin: ZalmanoviciTrestioreanu A, Green H, Paul M, Yaphe J, Leibovici L. Antimicrobial agents for treating uncomplicated

urinary tract infection in women. Cochrane Database Syst Rev. 2010 Oct
6;(10):CD007182.https://www.ncbi.nlm.nih.gov/pubmed/20927755
2018 6.44
 CHAPTER 6 OBSTETRICS AND GYNAECOLOGY

Nitrofurantoin: Lewis DA, Gumede LY, van der Hoven LA, de Gita GN, de Kock EJ, de Lange T, Maseko V, Kekana V, Smuts FP,
Perovic O. Antimicrobial susceptibility of organisms causing community-acquired urinary tract infections in Gauteng Province, South
Africa. S Afr Med J. 2013 Mar 15;103(6):377-81.http://www.ncbi.nlm.nih.gov/pubmed/23725955
Nitrofurantoin: Nordeng H, Lupattelli A, Romøren M, Koren G. Neonatal outcomes after gestational exposure to nitrofurantoin. Obstet
Gynecol. 2013 Feb;121(2 Pt 1):306-13. http://www.ncbi.nlm.nih.gov/pubmed/23344280
xxvii Listeriosis: National Institute of Communicable Diseases. Listeriosis: Clinical recommendations for diagnosis and treatment, 5

December 2017. http://www.nicd.ac.za/

xxviii Betamethasone, IM: Roberts D, Dalziel S. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of

preterm birth. Cochrane Database Syst Rev. 2006 Jul 19;(3):CD004454.http://www.ncbi.nlm.nih.gov/pubmed/16856047

Betamethasone, IM: Royal College of Obstetricians and Gynaecologists.Green-top Guideline No.7: Antenatal corticosteroids to
reduce neonatal morbidity and mortality. October 2010. Available at:
https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_7.pdf
xxix Betamethasone, IM: Roberts D, Dalziel S. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of

preterm birth. Cochrane Database Syst Rev. 2006 Jul 19;(3):CD004454.http://www.ncbi.nlm.nih.gov/pubmed/16856047

Betamethasone, IM: Royal College of Obstetricians and Gynaecologists.Green-top Guideline No.7: Antenatal corticosteroids to
reduce neonatal morbidity and mortality. October 2010. Available at:
https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_7.pdf
xxxAmoxicillin, oral: National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML, 2015.

http://www.health.gov.za/
xxxiMetronidazole, oral: National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML, 2015.

http://www.health.gov.za/
xxxiiMorphine, IM (intrapartum care): South African Medicines Formulary.12th Edition. Division of Clinical Pharmacology.University of

Cape Town. 2016.

xxxiiiDextrose, 10%, IV: National Department of Health: Integrated Management of Childhood Illness (IMCI) Guidelines,

2014.http://www.health.gov.za/
Dextrose, 10%, IV: National Department of Health: Guidelines for the care of all newborns in District Hospitals, Health Centres and
Midwife Obstetric Units in South Africa: Neonate care charts, March 2014.http://www.health.gov.za/
xxxivHepatitis B immuniglobulin, neonatal transmission: National Department of Health, Essential Drugs Programme: Paediatric Hospital

Level STGs and EML, 2017. http://www.health.gov.za/

xxxvHepatitis B vaccine, neonatal transmission: National Department of Health, Essential Drugs Programme: Paediatric Hospital Level

STGs and EML, 2017. http://www.health.gov.za/

xxxviOxytocin, IV: HofmeyrGJ, Gülmezoglu AM, Novikova N, Linder V, Ferreira S, Piaggio G. Misoprostol to prevent and treat postpartum

haemorrhage: a systematic review and meta-analysis of maternal deaths and dose-related effects. Bull World Health Organ. 2009
Sep;87(9):666-77. http://www.ncbi.nlm.nih.gov/pubmed/19784446
Oxytocin IV:Gülmezoglu AM, Villar J, Ngoc NT, Piaggio G, Carroli G, Adetoro L, Abdel-Aleem H, Cheng L, Hofmeyr G, Lumbiganon
P, Unger C, Prendiville W, Pinol A, Elbourne D, El-Refaey H, Schulz K; WHO Collaborative Group To Evaluate Misoprostol in the
Management of the Third Stage of Labour. WHO multicentre randomised trial of misoprostol in the management of the third stage of
labour.Lancet. 2001 Sep 1;358(9283):689-95. http://www.ncbi.nlm.nih.gov/pubmed/11551574
xxxviiMisoprostol: Widmer M, Blum J, HofmeyrGJ, Carroli G, Abdel-Aleem H, Lumbiganon P, Nguyen TN, Wojdyla D, Thinkhamrop J,

Singata M, Mignini LE, Abdel-Aleem MA, Tran ST, Winikoff B. Misoprostol as an adjunct to standard uterotonics for treatment of post-
partum haemorrhage: a multicentre, double-blind randomised trial. Lancet. 2010 May 22;375(9728):1808-13.
http://www.ncbi.nlm.nih.gov/pubmed/20494730
Misoprostol: World Health Organisation.WHO recommendations for the prevention and treatment of postpartum haemorrhage,
2012.http://apps.who.int/iris/bitstream/10665/75411/1/9789241548502_eng.pdf
xxxviiiFluconazole (from 2nd trimester): Mølgaard-Nielsen D, Pasternak B, Hviid A. Use of oral fluconazole during pregnancy and the risk

of birth defects. N Engl J Med. 2013 Aug 29;369(9):830-9. http://www.ncbi.nlm.nih.gov/pubmed/23984730

Fluconazole (from 2nd trimester):Mølgaard-Nielsen D, Svanström H, Melbye M, Hviid A, Pasternak B. Association Between Use of
Oral Fluconazole During Pregnancy and Risk of Spontaneous Abortion and Stillbirth. JAMA. 2016 Jan 5;315(1):58-67.
http://www.ncbi.nlm.nih.gov/pubmed/26746458
xxxixAbacavir: National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML, 2015.

http://www.health.gov.za/
xlAbacavir: National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML, 2015.

http://www.health.gov.za/
xli Ferrous sulfate, oral: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of Cape Town, 2016.

Ferrous sulfate, oral: Reveiz L, Gyte GM, Cuervo LG, Casasbuenas A. Treatments for iron-deficiency anaemia in pregnancy.
Cochrane Database Syst Rev. 2011 Oct 5;(10):CD003094. https://www.ncbi.nlm.nih.gov/pubmed/21975735
Ferrous sulfate, oral : Rimon E, Kagansky N, Kagansky M, Mechnick L, Mashiah T, Namir M, Levy S. Are
we giving too much iron? Low-dose iron therapy is effective in octogenarians. Am J Med. 2005 Oct;118(10):1142-7.
https://www.ncbi.nlm.nih.gov/pubmed/16194646
Ferrous sulfate, oral: National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML, 2015.
http://www.health.gov.za/
Ferrous fumarate, oral: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of Cape
Town, 2016.
xliiHormone therapy (risk factors)l: Manson JE, Aragaki AK, Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Chlebowski RT,

Howard BV, Thomson CA, Margolis KL, Lewis CE, Stefanick ML, Jackson RD, Johnson KC, Martin LW, Shumaker SA, Espeland MA,
Wactawski-Wende J; WHI Investigators. Menopausal Hormone Therapy and Long-term All-Cause and Cause-Specific Mortality: The
Women's Health Initiative Randomized Trials. JAMA.2017 Sep 12;318(10):927-938.https://www.ncbi.nlm.nih.gov/pubmed/28898378
xliiiHormone therapy (HT): National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML, 2015.

http://www.health.gov.za/

2018 6.45
PHC Chapter 7: Family planning

7.1 Intrauterine device/contraception (IUCD)

7.2 Contraception, hormonal
7.2.1 Subdermal implant
7.2.2 Injectable
7.2.3 Oral
7.2.4 Missed pills
7.3 Contraception, barrier methods
7.4 Contraception, emergency
7.5 Voluntary sterilisation, male and female
7.6 Breakthrough bleeding with contraceptive use












 &+$37(5 )$0,/<3/$11,1*

,1752'8&7,2172&2175$&(37,21
Consult the most recent National Contraception Clinical Guidelines
(especially in women with medical conditions).
The appropriate choice of family planning method should be decided on by
the woman in consultation with the health care professional taking into
consideration safety, efficacy, acceptability and access. A complete medical
and sexual history must be obtained and an appropriate physical examination
performed in order to ensure that there are no contra-indications to using a
particular method. Always exclude pregnancy before commencing
contraception.
Contraceptive methods


Hormonal contraception and IUCDs do not prevent sexually transmitted

infections (STIs), including HIV. Dual protection i.e. the use of a condom
in combination with another contraceptive method is recommended to
reduce the risk of STIs, including HIV.

&RQWUDFHSWLYH $GYDQWDJHV 'LVDGYDQWDJHV

PHWKRG LQFOXGH LQFOXGH
Copper IUCD » Suitable for most women, » Some discomfort or
(see Section 7.1) including nulliparous cramping during and
women. following insertion.
» Provides long-term » IUCD must be inserted
protection i.e. 5years or removed by a trained
» Convenient, does not health care professional.
require regular follow up. » Should not be used in
» Works immediately on women with
insertion. menorrhagia, active
» Non-hormonal therefore pelvic inflammatory
no interaction with other disease (PID), purulent
medication and no cervicitis, unexplained
hormonal side effects. uterine bleeding, cervical
» Fertility returns on and endometrial cancers
removal of IUCD in or other uterine
women of child-bearing abnormalities.
age.
Hormonal subdermal: » Provides long-term » Frequent bleeding
progestin-only protection i.e. 3 years irregularities.
implant (see Section (etonogestrel) or 5 years » Implant must be inserted
7.2.1) (levonorgestrel). or removed by a trained
» Convenient, does not health care professional
require regular follow up. under aseptic conditions
» Can be used in women >35 to prevent infection.
years who are obese, who » Incorrect insertion and
smoke, have diabetes, removal technique may
hypertension, or a history of result in complications.
venous thromboembolism.

2018 7.2
 &+$37(5 )$0,/<3/$11,1*

» Fertility returns on removal

of implant in women of
child-bearing age.
Hormonal injectable: » Daily adherence is not » Delayed return to fertility
progestin-only (see required. of up to • 9 months, after
Section 7.2.2) » Long-acting i.e. given last injection.
every 8 or 12 weeks. » Frequent bleeding
» Interactions with other irregularities (irregular,
medicines do not lower prolonged and/or heavy
contraceptive effect. bleeding, or
» Can be used postpartum. amenorrhoea).
» Can be used in women LoE:IIIi
>35 years who are obese,
who smoke, has diabetes,
hypertension, or a history
of venous
thromboembolism.
Hormonal oral: » Fertility returns within 3 » Daily adherence is
progestin-only (see months of discontinuing required.
Section 7.2.3) the pill. » Interactions with other
» Can be used postpartum. medicines can lower
» Can be used in women contraceptive effect.
>35 years who are obese, » Lower efficacy compared
who smoke, has diabetes, with COC.
hypertension, or a history » Frequent bleeding
of venous irregularities.
thromboembolism.
Hormonal oral: » Non-contraceptive » Daily adherence is
combined oral benefits, e.g.: alleviation required.
contraceptive (COC) of dysmenorrhoea, » Interactions with other
(see Sections 7.2.3 premenstrual syndrome medicines can lower
and 7.2.4) and menorrhagia. contraceptive effect.
» Fertility returns within 3 » Cannot be used in
months of discontinuing women with heart
COC. disease, stroke and a
history of active venous
thromboembolism.
» Cannot be used
immediately postpartum.
Barrier: male and » Protects against STIs, » Possibility of breakage or
female condoms including HIV. slipping off.
(see Section 7.3) » Possible allergic reaction
to latex.
» Lower efficacy than other
contraceptive methods
therefore advised as dual
contraception.
(Refer to the most recent MCC/SAHPRA registered package inserts for detailed information).

2018 7.3
 &+$37(5 )$0,/<3/$11,1*

Effectiveness of family planning methods

Rates of unintended pregnancies per 100 women:
&RQWUDFHSWLYHPHWKRG )DLOXUHUDWHLQVW\HDU
Consistent and As typically
correct use used
Copper IUCD 0.6 0.8
Progestin-only subdermal implant 0.05 0.05
Progestin-only injectable 0.3 3
Progestin-only oral pill (not 0.3 8
breastfeeding)
Progestin-only oral pill (during 0.5 1
breast feeding)
Combined oral contraceptive 0.3 3
(COC) pill
Barrier: female condoms 5 21
Barrier: male condoms 2 15
Sterilisation: male – vasectomy 0.1 0.15
Sterilisation: female - tubal ligation 0.5 0.5
No method 85 85
Key: 0-0.9: very effective 10-25: moderately effective
1-9: effective 26-32: less effective

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Dual protection with barrier methods is recommended to reduce the risk of

STIs including HIV.
The IUCD is an effective, safe, reversible long-term contraceptive method
requiring no patient effort to adhere to the method, has no hormonal adverse
effects and is not prone to drug interactions.

+,9LQIHFWLRQLV127DFRQWUDLQGLFDWLRQWRWKHXVHRIDQ,8&'
,8&'VDUHRIWHQWKHPRVWVXLWDEOHFRQWUDFHSWLYHIRUZRPHQRQ$59V
DQGRWKHUHQ]\PHLQGXFLQJPHGLFLQHVEHFDXVHRIWKHDEVHQFHRI
GUXJLQWHUDFWLRQV
ƒ Copper IUCD, e.g.:
x Cu T380A, 380mm² copper device.
Devices with lower copper surface area are not recommended.
The IUCD can be inserted any time during the menstrual cycle once
pregnancy has been excluded (by clinical history or with a pregnancy test if
required). Insertion at menstruation may be easier for the patient resulting in
less discomfort and spotting.

2018 7.4
 &+$37(5 )$0,/<3/$11,1*

Copper IUCDs may be inserted immediately postpartum or post miscarriage

(within 48 hours) by specially trained heath care professionals, providing that
no contra-indications are present (chorioamnionitis, ruptured membranes for
more than 18 hours and postpartum haemorrhage).
Women should be counselled to return if they experience complications
(excessive bleeding, excessive pain, fever or foul smelling discharge).
Alternatively, an IUCD may be inserted at least 4 weeks postpartum.
Advise the patient when to return: LoE:Iii
» Expulsion of IUCD or if strings of the IUCD protrude.
» Complications (see below).
» Routine follow-up after 3–6 weeks.
LoE:IIIiii
Copper IUCD is not recommended for women with
menorrhagia, active pelvic inflammatory disease (PID), purulent cervicitis,
unexplained uterine bleeding, cervical and endometrial cancers or other uterine
abnormalities.

x Ibuprofen, oral, 400 mg 8 hourly with or after a meal as needed for up to

For mild pain and discomfort after insertion:

3 days.

5()(55$/
» Excessive pain or bleeding after insertion.
» Signs of infection within 7 days of insertion (e.g. fever, abdominal pain
and/or foul-smelling discharge).
» Abnormal bleeding for > 3 months.

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Dual protection with barrier methods is recommended to reduce the risk of

STIs, including HIV.
The subdermal implant is an effective, safe, reversible and convenient long-term
contraceptive method requiring no patient effort once inserted and no regular
follow-up.
ƒ
x
Progestin-only subdermal implant contraceptive, e.g.:
Etonogestrel, subdermal, 68 mg, single-rod implant.
The progestin-only subdermal implant can be inserted any time during the
menstrual cycle, RQFH SUHJQDQF\ KDV EHHQ H[FOXGHG If the implant is
inserted within 7 days of the onset of the menstrual cycle the contraceptive
effect is achieved on the day of insertion.

2018 7.5
 &+$37(5 )$0,/<3/$11,1*

The main reason for discontinuation of the implant is irregular bleeding. This is
often overcome by good counselling before the implant is inserted so that
women know that this side effect can occur and that they can get treatment
should it occur. See Section 7.6: Breakthrough bleeding with contraceptive use.
Progestin-only hormonal contraceptives are contraindicated in certain
conditions e.g. unexplained vaginal bleeding, active liver disease. Consult the
package insert in this regard.

&$87,21
Medicines that induce the metabolism of progestins could reduce
contraceptive efficacy. These medicines include efavirenz, rifampicin,
phenytoin, carbamazepine and phenobarbital.
Women on these medicines should be advised to use alternate
contraceptive methods such as the copper IUCD or DMPA.
If the client chooses to use the implant, then she should be advised to
use dual contraception.
LoE:IIIiv
,QVHUWLRQDQGUHPRYDOSURFHGXUHV
» Participation in a training session is strongly recommended to become
familiar with the use of the subdermal implants and techniques for insertion
and removal.
» Only health care professionals familiar with these procedures should insert
and remove subdermal implants under aseptic conditions.
» Insert the implant VXEGHUPDOO\MXVWXQGHUWKHVNLQRIWKHXSSHUQRQ
GRPLQDQWDUP
» ,PSRUWDQW5HIHUWRWKHSDFNDJHLQVHUWVIRUGHWDLOHGLQIRUPDWLRQ
Insertion of etonogestrel 68 mg implant:
» Insertion should only be performed with the preloaded applicator.
» Have the women lie on her back on the examination table with her non-
dominant arm flexed at the elbow and externally rotated so that her wrist
is parallel to her ear and her hand is positioned next to her head:
» Identify anatomical surface markings to establish area of insertion which
is the inner side of the non-dominant upper arm about 8–10 cm above the
medial epicondyle of the humerus, avoiding the sulcus (groove) between
the biceps and triceps muscle and the large blood vessels and nerves
situated in the neurovascular bundle deeper in the subcutaneous tissue.
» Clean the insertion site with an antiseptic solution.
» Anaesthetise the insertion area.
» Mark the insertion site with a marker.
» Insert subdermally at inner side of the non-dominant upper arm about 8–
10 cm above the medial epicondyle of the humerus.
» Remove the transparent protection cap by sliding it horizontally in the
direction of the arrow away from the needle.
» Puncture the skin with the tip of the needle slightly angled less than 30q.

2018 7.6
 &+$37(5 )$0,/<3/$11,1*

» Lower the applicator to a horizontal position. While lifting the skin with the
tip of the needle, slide the needle to its full length. You should be able to
see the applicator just below the skin. Be seated, looking at the applicator
from the side and NOT from above to clearly see the insertion and
positioning of the needle just under the skin.
» While keeping the applicator in the same position and the needle inserted
to its full length, unlock the purple slider by pushing it slightly down. Move
the slider fully back until it stops.
» The implant is now in its final subdermal position. Remove the applicator.
» Always verify the presence of the implant in the patients arm immediately
after insertion by palpation and allow the patient to feel the implant as well.
» Apply sterile gauze with a pressure bandage to minimise bruising. The
patient may remove the pressure bandage in 24 hours and the small
bandage over the insertion site after 3–5 days.
Insertion of levonorgestrel 2 x 75 mg implants:
» Clean the patient‘s upper arm with an antiseptic solution.
» The optimal insertion area is in the medial aspect of the upper arm about
6-8 cm above the fold of the elbow.
» The implants will be inserted subdermally through a small 2 mm incision,
in the shape of a narrow V, opening towards the armpit.
» Anaesthetise the insertion area.
» Mark the insertion site with a marker.
» Open the implant pouch by pulling apart the film of the pouch and let the
two implants drop on a sterile cloth. Note: Always use sterile gloves or
forceps when handling the implants. If an implant is contaminated, e.g.
falls on the floor leave it for later disposal. Open a new package and
continue with the procedure.
» The implant is provided with a disposable trocar that is sharp enough to
penetrate the skin directly. Thus the disposable trocar can be used to
puncture the skin and insert the rods, without the need for an incision.
» The trocar has two marks. One mark is close to the handle and one close
to the tip. When inserting the implants, the mark closest to the handle
indicates, how far the trocar should be introduced under the skin before
the loading of each implant. The mark closest to the tip indicates how
much of the trocar should be left under the skin after the insertion of the
first implant. When inserting the trocar, avoid touching the part of the trocar
that will go under the skin.
» Once the tip of the trocar is beneath the skin it should be directed along
the skin horizontally by pointing slightly up-wards toward the raising the
skin (tenting) to keep the implant in the subdermal plane. Throughout the
insertion procedure, the trocar should be oriented with the bevel up.
» lt is important to keep the trocar subdermal by tenting the skin with the trocar,
as failure to do so may result in deep placement of the implants causing a
more difficult removal. Advance the trocar beneath the skin about 5.5 cm
from the incision to the mark closest to the handle of the trocar. Do not force
the trocar, and if you feel any resistance, try another direction.

2018 7.7
 &+$37(5 )$0,/<3/$11,1*

» Remove the plunger when the trocar is advanced to the correct mark.
» Load the first implant into the trocar either with tweezers or fingers.
» Push the implant gently with the plunger to the tip of the trocar until you
feel resistance. Never force the plunger.
» Hold the plunger steady and pull the trocar back along it until it touches
the handle of the plunger. lt is important to keep the plunger steady and
not to push the implant into the tissue.
» Do not completely remove the trocar until both implants have been placed.
The trocar is withdrawn only to the mark closest to its tip.
» When you can see the mark near the tip of the trocar in the incision, the
implant has been released and will remain in place beneath the skin. You
can check this by palpation.
» Insert the second implant next to the first one, to form a V shape. Fix the
position of the first implant with the left fore-finger and advance the trocar
along the side of the finger. This will ensure a suitable distance between
implants. To prevent expulsions, leave a distance of about 5 mm between
the incision and the ends of the implants. You can check their correct
position by cautious palpation of the insertion area.
» After inserting the second implant, the edges of the incision are pressed
together, closed with a skin closure and dressed.
» Advise the patient to keep the insertion area dry for 3 days.
» The gauze and the bandage may be removed as soon as the incision has
healed, usually after 3–5 days.

x Ibuprofen, oral, 400 mg 8 hourly with or after a meal as needed for up to

For pain after insertion:

5 days.
Removal of progestin-only subdermal implants:
Remove etonogestrel implants at the end of 3 years and levonorgestrel
implants at the end of 5 years.
» Locate the implant by palpation. If impalpable refer for ultrasound removal.
» Clean the removal site with an antiseptic solution.
» Anaesthetise the removal area.
» Push down the proximal end of the implant and a bulge may appear to
indicate the distal end of the implant.
» Make a 2-4 mm vertical incision with the scalpel close to the distal end of
the implant, towards the elbow.
» Remove the implant very gently, using a small forceps (preferably curved
mosquito forceps). Where an implant is encapsulated, dissect the tissue
sheath to remove the implant with the forceps.
» Confirm that the complete implant has been removed by measuring the
length (etonogestrel rod: 40 mm; levonorgestrel rods: 43 mm). Close the
incision with a steristrip or plaster and dress.
» Advise the patient to keep the arm dry for a few days.
» Confirm that the entire implant has been removed by measuring its length.

2018 7.8
 &+$37(5 )$0,/<3/$11,1*

5()(55$/
» Heavy or prolonged bleeding, despite treatment with COCs.
» Infection at insertion site, inadequately responding to initial course of
antibiotic treatment. See Section 5.4.3: Cellulitis.
» Failure to locate an implant (in the arm) by palpation.

,1-(&7$%/(
Z30.0/Z30.4

Dual protection with barrier methods is recommended to reduce the risk of

STIs, including HIV.
ƒ Progestin-only injectable contraceptive, e.g.:
x Medroxyprogesterone (long-acting), IM, 150 mg, 12 weekly.
LoE:Iv
Progestin-only hormonal contraceptives are contraindicated in
certain conditions e.g. unexplained vaginal bleeding. Consult the package insert
in this regard.
When to start the injection
» The injection can be started anytime within the menstrual cycle, provided
pregnancy has been excluded. If the first injection is given within 7 days
of the onset of the menstrual cycle the contraceptive effect is achieved on
the day of the first injection.
» If started after day 7, abstinence from intercourse or use condoms for the
next 7 days.
» Can be used postpartum.
LoE:IIIvi
Late injection
» If it has been < 2 weeks since the missed injection, the next injection
can be given without loss of protection. Continue with dual contraceptive
method, i.e. condom in combination with the injection.
» If it has been > 2 weeks since the missed injection, exclude pregnancy:
3UHJQDQF\WHVWSRVLWLYH 3UHJQDQF\WHVWQHJDWLYHRUXQDYDLODEOH
» Refer for ante-natal care (See » Provide emergency contraception, if
Section 6.4: Antenatal care). indicated (see Section: 7.4
or Contraception, emergency).
» TOP, see Section 6.3: Termination » Administer the next injection.
of pregnancy (TOP). » Abstain from intercourse or use condoms
to prevent pregnancy for the next 7 days.
LoE:IIIvii
There is uncertainty of the risk of HIV acquisition associated with progestin
injectable contraceptives (Refer to the WHO MEC 2017 guidelinesviii). Dual
protection is recommended.

5()(55$/
Heavy or prolonged bleeding, despite adequate treatment with combined oral
contraceptives. See Section 7.6: Breakthrough bleeding with contraceptive use.

2018 7.9
 &+$37(5 )$0,/<3/$11,1*

25$/
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Dual contraception with barrier methods, are preferred to reduce the risk of
STIs, including HIV.
0RQRSKDVLFSUHSDUDWLRQV
ƒ Progestin only pills, e.g.:
x Levonorgestrel, oral, 30mcg daily.
ƒ
ix
LoE:III

x
Progestins and estrogen, fixed combinations, e.g.:
Ethinylestradiol/ levonorgestrel, oral, 30 mcg/150 mcg:
o 21 tablets ethinylestradiol/levonorgestrel, 30 mcg/150 mcg and
o 7 tablets placebo.
x
7ULSKDVLFSUHSDUDWLRQV LoE:III
ƒ Progestins and estrogen, sequential preparations, e.g.:
x Ethinylestradiol/levonorgestrel, oral:
o 6 tablets ethinylestradiol/levonorgestrel,30 mcg/50 mcg
o 5 tablets ethinylestradiol/levonorgestrel, 40 mcg/75 mcg and
o 10 tablets ethinylestradiol/levonorgestrel,30 mcg/125 mcg and
o 7 tablets placebo.
Patient counselling: LoE:IIIxi
» Hormonal oral pills must be taken at the same time every day without
interruption.
» Taking the hormonal oral pill with food or at bedtime may alleviate nausea.
» If the patient is not using dual contraception with hormonal oral
contraceptives and vomits within 2 hours, or has severe diarrhoea within 12
hours of taking the hormonal oral pill, repeat the dose as soon as possible.
Recommend condom use.
» Women who have persistent vomiting or severe diarrhoea resulting in two
or more missed pills follow instructions for missed pills. See section 7.2.4,
Recommend the use of condoms.
&RQWUDLQGLFDWLRQVDQGJXLGDQFHWRVWDUWLQJWKHRUDOSLOO
3URJHVWLQRQO\ &RPELQHGHVWURJHQSURJHVWLQ
Contraindications Progestin only preparations Combination preparations
are contraindicated in certain contraindicated in certain
conditions (Consult the conditions (Consult the
package insert in this regard). package insert in this regard).
Contraindications include: Contraindications include:
» Abnormal uterine bleeding » Women >35 years of age
of unknown cause. who smoke • 15 cigarettes
» Myocardial infarction/stroke. a day or have risk factors
» Liver disease. for cardiovascular disease:
» Cancer of the breast/ - heart disease
genital tract. - liver disease
» Known or suspected - thromboembolism
pregnancy. - certain cancers
LoE:IIIxii

2018 7.10
 &+$37(5 )$0,/<3/$11,1*

When to start the » Start anytime within the menstrual cycle, but it is advisable
pill to start during menses.
» If the first pill is given between days 1 and 5 of the menstrual
cycle the contraceptive effect is achieved immediately.
» Dual contraception use is recommended irrespective of
when the pill is started in the menstrual cycle.

0HGLFLQHLQWHUDFWLRQV
(Q]\PHLQGXFLQJPHGLFLQHVLQWHUDFWLQJZLWKRUDO 5HFRPPHQGDWLRQ
FRQWUDFHSWLYHV
7KHUDSHXWLFFODVV ([DPSOHV 
Anti-tuberculosis Rifampicin Use IUCD or
Anti-epileptics Phenobarbital alternatively use
Phenytoin dual contraception
Carbamazepine e.g. condoms in
Antiretrovirals Nevirapine combination with
Lopinavir/ritonavir COCs.
Efavirenz

Non-liver enzyme inducing medicines

Lamotrigine:
» Lowering of contraceptive effect not expected.
» Oral contraceptives may reduce lamotrigine concentration by 50%,
increasing the risk of seizures. Consider alternative dual contraception
method.
Breastfeeding
» Women who are intending to breastfeed should delay initiation of COCs until
cessation of breastfeeding or at 6 months postpartum, whichever occurs
earlier.

5()(55$/
Abnormal vaginal bleeding for > 3 months.

0,66('3,//6
3URJHVWLQRQO\SLOOV
Efficacy is rapidly lost if one pill is forgotten or taken > 3 hours late.
Recommend dual contraception for all scenarios.
6FHQDULR $FWLRQ
One pill forgotten or if pill taken >3 hours Take pill as soon as remembered and
late and unprotected sexual intercourse continue taking one pill daily at the
has not occurred in the past 5 days. same hour.
One pill forgotten or if taken > 3 hours Give emergency contraception (see
late and unprotected sexual intercourse Section 7.4).
has occurred in the past 5 days. Take one pill the next day and continue
taking one pill daily at the same hour.

2018 7.11
 &+$37(5 )$0,/<3/$11,1*

&RPELQDWLRQRISURJHVWLQDQGHVWURJHQLQHDFKSLOO
Missing active pills and extending hormone free interval leads LoE:IIIxiii
to decreased contraceptive efficacy. Recommend dual contraception for all
scenarios.

6FHQDULR $FWLRQ
One active pill forgotten. Take pill as soon as remembered and
take next one at usual time.
• Two pills forgotten during the first 7 Give emergency contraception (see
active pills of the pack and sexual Section 7.4).
intercourse has occurred in the past 5 Restart active pills 12 hours later.
days.
• Two pills forgotten during the middle Take the most recent missed pill
7 active pills of the pack. immediately (discard the others).
Continue taking remaining pills as usual.
No emergency contraception required.
• Two pills forgotten in the last 7 active Continue active pills of current pack.
pills of the pack and sexual intercourse Omit the inactive pills and immediately
has occurred in past 5 days. start the active pills of the next pack.

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Condoms (male and female) alone are not the most effective contraceptive
method and should be used in combination with other contraceptive methods
(e.g. copper IUCD). Condoms are recommended to reduce the risk of the
acquisition of STIs and HIV infection.
Condoms (male and female) or other barrier methods may be an option for
contraception where other methods are contraindicated.

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Emergency contraception is the use of a contraceptive method following an

episode of unprotected sexual intercourse to reduce the risk of pregnancy.
Women should be told that their period should be on time, very rarely it is
delayed but it will not be more than 7 days late. If this occurs, they should
come back for a pregnancy test.
Emergency contraception is indicated to prevent pregnancy after unprotected
intercourse in women not using contraception or where contraception is likely
to be ineffective:
» forgotten tablets (See Section 7.2.4: Missed pills)
» slipped or broken condom
» injection given > 2 weeks late
» sexual assault

2018 7.12
 &+$37(5 )$0,/<3/$11,1*

x Levonorgestrel 1.5 mg, oral, as a single dose as soon as possible after

unprotected intercourse, and not later than 5 days.
o Repeat the dose, if woman vomits within 2 hours.
25 
ƒ Copper IUCD, e.g.:
x Cu T380A, inserted as soon as possible after unprotected intercourse
and not later than 5 days.
&$87,21
Emergency contraceptive tablets must be taken as soon as possible, preferably
within 72 hours of unprotected intercourse, and not later than 5 days.
Enzyme inducers (including efavirenz, carbamazepine) cause a significant
reduction in levonorgestrel concentrations. Women on these medicines should
preferably have copper IUCD inserted or alternatively double the dose of
levonorgestrel, because of significant reduction of levonorgestrel. Women > 80 kg
or BMI • 30 should also be given twice the standard dose.
LoE:IIIxiv

5()(55$/
Patients in need of emergency contraception must be referred for HIV
counselling and testing and PEP.

92/817$5<67(5,/,6$7,210$/($1')(0$/(
Z30.2

)HPDOHVWHULOLVDWLRQ
Also known as tubal occlusion or tubal ligation. This is a permanent, surgical
contraceptive method for women who do not intend to have more children.
Women who opt for sterilisation should be adequately counselled and referred.
0DOHVWHULOLVDWLRQ
Also known as vasectomy. This is a permanent surgical contraceptive method
for men who do not want more any children.
Men who opt for this method should be adequately counselled and referred.

&$87,21
Sterilisation does not protect against sexually transmitted infections
(STIs), including HIV. If there is a risk of STI/HIV, the correct and
consistent use of condoms is recommended.
LoE:IIIxv

 %5($.7+528*+%/((',1*:,7+&2175$&(37,9(
 86(
N92.0/N92.1/N92.4

'(6&5,37,21
Breakthrough bleeding refers to unscheduled or irregular vaginal bleeding

2018 7.13
 &+$37(5 )$0,/<3/$11,1*

which often presents as spotting, prolonged or frequent bleeding in women

using hormonal contraception. The pattern and duration of these unscheduled
bleedings vary with the contraceptive method used.

*(1(5$/0($685(6
Counselling prior to commencement of hormonal contraception must be
offered to women regarding possible bleeding patterns, both initially and in
the longer term.
Clinical assessment:
» Current method of contraception and duration of use. 
» Drug interactions.
» Cervical screening history. 
» Risk of sexual transmitted infections (e.g. Chlamydia trachomatis).
» Menstrual and break though bleeding history prior to current method being
initiated.
» Exclude pregnancy.

0(',&,1(75($70(17
&$87,21
Before starting hormonal contraception, women should be advised about
the expected bleeding patterns, both initially and in the longer term.

+RUPRQDOFRQWUDFHSWLYHV 7UHDWPHQW
FDXVLQJEUHDNWKURXJKEOHHGLQJ
Progestin-only injectables x COC containing 30 mcg ethinylestradiol,
oral, for 14 days.
LoE:IIIxvi
Progestin subdermal implants x Ethinylestradiol/levonorgestrel, oral,

x Change COC to a COC containing the

30/150 mcg, daily for 20 days.
Combined oral contraceptive pill
» Unscheduled bleeding with COC lowest dose of ethinylestradiol, oral, daily.

x Change COC to a COC containing 35

usually settles with time. If bleeding persists:
» Changing to another COC in the
first 3 months is not mcg ethinylestradiol, oral, daily.
recommended. LoE:III

5()(55$/
» Pelvic pain.
» Pelvic mass.
» Heavy bleeding.
» Abnormal cervix on speculum examination (e.g. polyps).
» Bleeding not controlled by treatment above.

2018 7.14
 &+$37(5 )$0,/<3/$11,1*
5HIHUHQFHV
i Hormonal injectable: progestin-only (menstrual irregularities): South African Medicines Formulary. 12th Edition.
Division of Clinical Pharmacology. University of Cape Town. 2016.
Hormonal injectable: progestin-only (menstrual irregularities): Faculty of Sexual & Reproductive Healthcare
Clinical Guidance: Problematic Bleeding with Hormonal Contraception Clinical Effectiveness Unit, July 2015.
https://www.fsrh.org/standards-and guidance/documents/ceuguidanceproblematicbleedinghormonalcontraception/
Hormonal injectable: progestin-only (menstrual irregularities): World Health Organisation. Medical eligibility
criteria for contraceptive use, Fifth edition, 2015.
http://www.who.int/reproductivehealth/publications/family_planning/MEC-5/en/
ii Copper IUCD insertion: Lopez LM, Bernholc A, Hubacher D, Stuart G, Van Vliet HA. Immediate postpartum

insertion of intrauterine device for contraception. Cochrane Database Syst Rev. 2015 Jun
26;(6):CD003036.https://www.ncbi.nlm.nih.gov/pubmed/26115018
iii Copper IUCD (patient to return): National Contraception and Fertility Planning and Service Delivery Guidelines,

2012. http://www.health.gov.za/
iv Subdermal implant: Scarsi KK, Darin KM, Nakalema S, Back DJ, Byakika-Kibwika P, Else LJ, PenchalaSD, Buzibye

A, Cohn SE, Merry C, Lamorde M. Unintended Pregnancies Observed With Combined Use of the Levonorgestrel
Contraceptive Implant and Efavirenz-based Antiretroviral Therapy: A Three-Arm Pharmacokinetic Evaluation Over 48
Weeks. Clin Infect Dis. 2016 Mar 15;62(6):675-82.http://www.ncbi.nlm.nih.gov/pubmed/26646680
Subdermal implant: Perry SH, Swamy P, Preidis GA, Mwanyumba A, Motsa N, Sarero HN. Implementing the
Jadelle implant for women living with HIV in a resource-limited setting: concerns for drug interactions leading to
unintended pregnancies. AIDS. 2014 Mar 13;28(5):791-3. http://www.ncbi.nlm.nih.gov/pubmed/24401645
Subdermal implant: Vieira CS, Bahamondes MV, de Souza RM, Brito MB, Rocha Prandini TR, Amaral E,
Bahamondes L, Duarte G, Quintana SM, Scaranari C, Ferriani RA. Effect of antiretroviral therapy including
lopinavir/ritonavir or efavirenz on etonogestrel-releasing implant pharmacokinetics in HIV-positive women. J Acquir
Immune Defic Syndr. 2014 Aug 1;66(4):378-85.http://www.ncbi.nlm.nih.gov/pubmed/24798768
Subdermal implant: World Health Organisation. Medical eligibility criteria for contraceptive use
Fifth edition, 2015. http://www.who.int/reproductivehealth/publications/family_planning/MEC-5/en/
v Progestin-only injectables: Draper BH, Morroni C, Hoffman M, Smit J, Beksinska M, Hapgood J, Van der Merwe L.

Depot medroxyprogesterone versus norethisteroneoenanthate for long-acting progestogenic contraception. Cochrane

Database Syst Rev. 2006 Jul 19;(3):CD005214. http://www.ncbi.nlm.nih.gov/pubmed/16856087
Progestin-only injectables: Contract circular HP03-2015CHM. http://www.health.gov.za/
vi Progestin-only injectables (postpartum): National Contraception and Fertility Planning and Service Delivery

Guidelines, 2012. http://www.health.gov.za/

vii Progestin-only injectables (late injection): National Contraception and Fertility Planning and Service Delivery

Guidelines, 2012. http://www.health.gov.za/

viii World Health Organisation. Guidance statement: Hormonal contraceptive eligibility for women at high risk of HIV,

2017. http://www.who.int/reproductivehealth/publications/family_planning/HC-and-HIV-2017/en/
ix Monophasic-progestin only pills (therapeutic class): van Hylckama Vlieg A, Helmerhorst FM, Vandenbroucke JP,

Doggen CJ, Rosendaal FR. The venous thrombotic risk of oral contraceptives, effects of oestrogen dose and
progestogen type: results of the MEGA case-control study. BMJ. 2009 Aug 13;339:b2921.
https://www.ncbi.nlm.nih.gov/pubmed/19679614
Monophasic-progestin only pills (therapeutic class): Lidegaard Ø, Nielsen LH, Skovlund CW, Skjeldestad FE,
Løkkegaard E. Risk of venous thromboembolism from use of oral contraceptives containing different progestogens and
oestrogen doses: Danish cohort study, 2001-9. BMJ. 2011 Oct 25;343:d6423.
https://www.ncbi.nlm.nih.gov/pubmed/22027398
x Monophasic-progestin/estrogen combination pills (therapeutic class): van Hylckama Vlieg A, Helmerhorst FM,

Vandenbroucke JP, Doggen CJ, Rosendaal FR. The venous thrombotic risk of oral contraceptives, effects of oestrogen
dose and progestogen type: results of the MEGA case-control study. BMJ. 2009 Aug 13;339:b2921.
https://www.ncbi.nlm.nih.gov/pubmed/19679614
Monophasic-progestin/estrogen combination pills (therapeutic class): Lidegaard Ø, Nielsen LH, Skovlund CW,
Skjeldestad FE, Løkkegaard E. Risk of venous thromboembolism from use of oral contraceptives containing different
progestogens and oestrogen doses: Danish cohort study, 2001-9. BMJ. 2011 Oct 25;343:d6423.
https://www.ncbi.nlm.nih.gov/pubmed/22027398
xi Triphasic- progestin/estrogen combination pills (therapeutic class): van Hylckama Vlieg A, Helmerhorst FM,

Vandenbroucke JP, Doggen CJ, Rosendaal FR. The venous thrombotic risk of oral contraceptives, effects of oestrogen
dose and progestogen type: results of the MEGA case-control study. BMJ. 2009 Aug 13;339:b2921.
https://www.ncbi.nlm.nih.gov/pubmed/19679614
Triphasic- progestin/estrogen combination pills (therapeutic class): Lidegaard Ø, Nielsen LH, Skovlund CW,
Skjeldestad FE, Løkkegaard E. Risk of venous thromboembolism from use of oral contraceptives containing different
progestogens and oestrogen doses: Danish cohort study, 2001-9. BMJ. 2011 Oct 25;343:d6423.
https://www.ncbi.nlm.nih.gov/pubmed/22027398
xii Progestin-only pill (contra-indication: myocardial infarction): South African Medicines Formulary. 12th Edition.

Division of Clinical Pharmacology. University of Cape Town. 2016

xiii Combined oral contraceptives (missing pills): National Contraception and Fertility Planning and Service Delivery

Guidelines, 2012. http://www.health.gov.za/

xiv Levonorgesterol, oral - emergency contraception (double dose): Carten ML, Kiser JJ, Kwara A, Mawhinney S,

Cu-Uvin S. Pharmacokinetic interactions between the hormonal emergency contraception, levonorgestrel (Plan B),
and Efavirenz. Infect Dis Obstet Gynecol. 2012;2012:137192. http://www.ncbi.nlm.nih.gov/pubmed/22536010

2018 7.15
 &+$37(5 )$0,/<3/$11,1*

Levonorgesterol, oral - emergency contraception (double dose): Tittle V, Bull L, Boffito M, Nwokolo N.
Pharmacokinetic and pharmacodynamic drug interactions between antiretrovirals and oral contraceptives.
ClinPharmacokinet. 2015 Jan;54(1):23-34. http://www.ncbi.nlm.nih.gov/pubmed/25331712
Levonorgesterol, oral - emergency contraception (double dose): Jatlaoui TC and Curtis KM. Safety and
effectiveness data for emergency contraceptive pills among women with obesity: a systematic review.
Contraception 94 (2016) 605–611. https://www.ncbi.nlm.nih.gov/pubmed/27234874
xv Voluntary sterilisation: World Health Organisation. Medical eligibility criteria for contraceptive use Fifth edition,

2015. http://www.who.int/reproductivehealth/publications/family_planning/MEC-5/en/
xvi Combined oral contraceptive (containing ethinylestradiol 30-35 mcg) for breakthrough bleeding on progestin-

only injectable contraceptives: Faculty of Sexual & Reproductive Healthcare Clinical Guidance: Problematic
Bleeding with Hormonal Contraception Clinical Effectiveness Unit, July 2015. https://www.fsrh.org/standards-and
guidance/documents/ceuguidanceproblematicbleedinghormonalcontraception/

2018 7.16
PHC Chapter 8: Kidney and urological
disorders

Kidney disorders
8.1 Chronic kidney disease
8.2 Acute kidney injury
8.3 Glomerular disease (GN)
8.3.1 Nephritic syndrome
8.3.2 Nephrotic syndrome
8.4 Urinary tract infection
8.5 Prostatitis

Urology disorders
8.6 Haematuria
8.7 Benign prostatic hyperplasia
8.8 Prostate cancer
8.9 Enuresis
8.10 Impotence/ Erectile dysfunction
8.11 Renal calculi














 CHAPTER 8 KIDNEY AND UROLOGICAL DISORDERS

KIDNEY SECTION
8.1 CHRONIC KIDNEY DISEASE (CKD)
N18.1-5/N18.9

CAUTION
Check all medicines for possible dose adjustment based on eGFR/CrCl.

The doses of many medicines need to be adjusted in renal impairment.

Recommendations for medicines that require dose adjustment in renal impairment
can be found in the SAMF, package insert, and from many online resources e.g.:
http://www.globalrph.com/index_renal.htm
LoE:IIIi
DESCRIPTION
Structural or functional kidney damage present for > 3 months, with or without a
decreased glomerular filtration rate (eGFR).
Markers of kidney damage include:
» abnormalities in urine e.g. proteinuria or haematuria
» abnormalities in blood e.g. serum creatinine or low eGFR
» abnormalities in imaging tests e.g. small kidneys or cysts on ultrasound
» abnormalities on pathological specimens e.g. glomerular disease on renal biopsy
Common causes of chronic kidney disease include:
» hypertension » polycystic kidney disease
» diabetes mellitus » HIV/AIDS
» glomerular diseases

Chronic kidney disease can be entirely asymptomatic, BUT early detection and
management can improve the outcome of this condition.

Treatment and prevention strategies according to prognostic category

Estimation of the degree of kidney damage is important to guide management to
prevent adverse outcomes of chronic kidney disease.
Use eGFR and albumin creatinine ratio to put patient into prognostic category - see
table below.
Note:
» Adults with mild to moderate decline in eGFR and no albuminuria can all be
managed at primary care level once the cause and plan for care has been
established.
» All children should be referred for investigation and initial management.

2018 8.2
 CHAPTER 8 KIDNEY AND UROLOGICAL DISORDERS

Prognosis of CKD by GFR and albuminuria categories: KDIGO 2012

Persistent albuminuria categories

Description and range

A1 A2 A3

Normal to
Moderately Severely
mildly increased increased
increased
ACR* ACR* ACR*
<30 mg/g 30–300 mg/g >300 mg/g
<3mg/mmol 3–30 mg/mmol >30 mg/mmol

G1 Normal or high •90 Refer Refer

eGFR categories (ml/min per 1.73m )
2

G2 Mildly decreased 60 –89 Refer Refer

description and range

Mildly to moderately
G3a 45–59 Refer Refer
decreased
Moderately to
G3b 30–44 Refer Refer Refer
severely decreased

G4 Severely decreased 15–29 Refer Refer Refer

G5 Kidney failure <15 Refer Refer Refer

*ACR: albumin to creatinine ratio in urine specimen.

Green: low risk (if no other markers of kidney disease, no CKD); yellow: moderately increased risk; orange: high risk; red:
very high risk; A1, A2, A3 = categories of albuminuria; G1, G2, G3a, G3b, G4, G5 = categories of eGFR
Adapted from: Levin A, Stevens PE. Summary of KDIGO 2012 CKD Guideline: behind the scenes, need for guidance, and a
framework for moving forward. Kidney Int. 2014 Jan;85(1):49-61. https://www.ncbi.nlm.nih.gov/pubmed/24284513

Send blood annually for measurement of creatinine in all patients at increased risk.
(eGFR will be calculated by the laboratory, based on the serum creatinine).

GENERAL MEASURES
» Reduce salt intake.
» Low protein diet is indicated in the presence of CKD stage 4 and 5.
» Reduce cardiovascular disease risk factors. See Section 4.1: Prevention of
ischaemic heart disease and atherosclerosis.
» Avoid nephrotoxic drugs e.g. NSAIDs, tenofovir.

 If urine dipstick 1+ or greater, repeat on a properly collected midstream urine

» Screen for proteinuria.

specimen on another occasion. If proteinuria persists, quantify protein with a

spot urine protein creatinine ratio. Significant proteinuria = spot urine protein

 Note: Proteinuria is screened for differently in diabetics. See Section 9.4.3:

creatinine ratio of > 0.1 g/mmol. This is equivalent to 1g per 24 hours.

Diabetic nephropathy.

2018 8.3
 CHAPTER 8 KIDNEY AND UROLOGICAL DISORDERS

MEDICINE TREATMENT
Treat underlying conditions.
Proteinuria
Measure serum potassium at baseline.
Adults
ƒ ACE-inhibitor, e.g.:
x Enalapril, oral, start with 5 mg 12 hourly.
o Titrate up to 10 mg 12 hourly, if tolerated.
o Start with low dosage of ACE-inhibitor and titrate up to the maximum dose or
until the proteinuria disappears – whichever comes first. Ensure BP remains
in normal range and no side effects are present.

 1–2 weeks after treatment initiation, if eGFR < 60 mL/min and after 4
o Monitor creatinine and potassium:

 If creatinine increases by > 20% from the baseline, stop ACE-inhibitor and
weeks, if eGFR > 60 mL/min.

 If stable, monitor thereafter at regular clinic visits.

refer.

LoE:III
 hyperkalaemia
» ACE-inhibitors are contraindicated in, amongst others:

 known hypersensitivity to an ACE-inhibitor or an ARB

 bilateral renal artery stenosis
 pregnancy
 severe renal impairment (eGFR < 30 mL/min)

Hyperlipidaemia
If hyperlipidaemia is a co-existent risk factor, manage according to Section 4.1:
Prevention of ischaemic heart disease and atherosclerosis.
Diabetes mellitus
» In diabetics, optimise control according to Section 9.1.2: Diabetes mellitus type 2,
in adults.
» Replace oral sulphonylureas with insulin when eGFR < 60 mL/min, because of an
increased risk of hypoglycaemia.
» Replace metformin with insulin when eGFR < 30 mL/min, because of the potential
risk of lactic acidosis.
» Insulin is preferred to control blood glucose in patients with eGFR < 30 mL/min.
Hypertension
Treat if present. See Section 4.7: Hypertension.
Fluid overload
Treat fluid overload if present and refer.

x Furosemide, slow IV or oral, 40–80 mg, 12 hourly.

Adults

o If poor response, repeat after 1 hour.

o Do not give IV fluids – use heparin lock or similar IV access.

2018 8.4
 CHAPTER 8 KIDNEY AND UROLOGICAL DISORDERS

x Furosemide, IV, 1 mg/kg, over 5 minutes. See doing table, pg 23.5.

Children

o Do not put up a drip or run in any IV fluids.

Note: Exclude heart failure in patients with persistent pedal oedema.

REFERRAL
» All cases of suspected chronic kidney disease stages 3–5 for assessment and
planning.
» All children.

 haematuria
» All cases of CKD with:

 significant proteinuria with urine protein creatinine ratio of > 0.1 g/mmol
 eGFR < 60 mL/min for initial assessment and planning
 eGFR < 30 mL/min
» Uncontrolled hypertension/fluid overload.
» CKD associated with hyperlipidaemia.
» No reduction of proteinuria with ACE-inhibitor therapy.
» If ACE-inhibitors are contra-indicated.
» If ACE-inhibitors are not tolerated.

Patients who might qualify for dialysis and transplantation or who have
complications should be referred early to ensure improved outcome and survival on
dialysis, i.e. as soon as eGFR drops < 30 mL/min, or as soon as diagnosis is
made/suspected.

8.2 ACUTE KIDNEY INJURY

N17.9

DESCRIPTION
This is (potentially) reversible kidney failure, commonly as a result of:
» hypovolaemia and fluid loss » acute tubular necrosis
» medicines/toxins » acute glomerulonephritis
» urinary tract obstruction
It is often recognised by:
» fluid overload (e.g. pulmonary oedema)
» decreased or no urine output
» abnormalities of serum urea, creatinine and/or electrolytes
» convulsions in children

GENERAL MEASURES
» Give oxygen, and nurse in Semi-Fowlers position if patient has respiratory
distress. Early referral is essential.

 stop all IV fluids

» If fluid overloaded:

» If dehydrated or shocked:

2018 8.5
 CHAPTER 8 KIDNEY AND UROLOGICAL DISORDERS

 treat immediately as shock. See Section 21.2.9: Shock.

» Stop and avoid any nephrotoxic medicines e.g. NSAIDs, aminoglycosides.

MEDICINE TREATMENT
Children

x Furosemide, IV, 1 mg/kg, over 5 minutes. See dosing table, pg 23.5.

If fluid overloaded (rapid respiration, chest indrawing):

o Do not put up a drip or run in any IV fluids.

If hypertension present:
< 6 years of age: > 120 mmHg systolic BP or > 90 mmHg diastolic BP
6–15 years: > 130 mmHg systolic BP or > 95 mmHg diastolic BP
x Nifedipine, oral, 0.25–0.5 mg/kg squirted into mouth.
o Withdraw contents of 5 mg capsule with a 1 mL syringe:
10–25 kg: 2.5 mg
25–50 kg: 5 mg
>50 kg: 10 mg
Adults

x Furosemide, as an IV bolus, 80 mg.

If fluid overloaded/respiratory distress:

o Do not put up a drip and do not give a fluid infusion.

If hypertension present:

x Amlodipine, oral, 5 mg as a pre-referral dose.

Diastolic BP > 100 mmHg or systolic BP > 150 mmHg:

x Furosemide, oral, 40–80 mg as a pre-referral dose (if current eGFR unknown or

AND

< 30 mL/min).
LoE:IIIii
REFERRAL
All cases.

8.3 GLOMERULAR DISEASES (GN)

DESCRIPTION
Glomerular disease may be a result of a primary condition of the kidney, or may be
secondary to a systemic disorder. Can present with any, or a combination of the following:
» proteinuria
» reduced eGFR
» haematuria
» hypertension and oedema
Approach to care is outlined under the syndromes which follow.
Diabetic nephropathy
See Section 9.4.3 Diabetic nephropathy.

2018 8.6
 CHAPTER 8 KIDNEY AND UROLOGICAL DISORDERS

REFERRAL
» Unexplained haematuria on two to three consecutive visits.
» Proteinuria > 1 g/24 hours or PCR > 0.1 g/mmol
» Elevated or rising creatinine.
» Nephritic syndrome.
» Nephrotic syndrome.
» Chronic Kidney Disease.
Note: Where facilities are available, investigation should be done e.g. creatinine to
calculate the eGFR or PCR.

8.3.1 NEPHRITIC SYNDROME

N05.9

DESCRIPTION
Presents with a varied combination of:
» painless macroscopic turbid, bloody or brownish urine
» peripheral and periorbital oedema
» pulmonary oedema (circulatory overload)
» hypertension or hypertensive encephalopathy with impaired level of
consciousness or convulsions
» little or no urine excretion
In children, this is commonly due to acute post streptococcal glomerulonephritis.

GENERAL MEASURES
» Give oxygen, and nurse in Semi-Fowlers position if patient has respiratory distress.
» Early referral essential, especially if patient had a hypertensive episode or fluid
overload.
» If dehydrated or shocked: Treat immediately. (See Section 21.2.9: Shock).

MEDICINE TREATMENT
For management see Section 8.2: Acute kidney injury.

REFERRAL
All cases.
The definitive treatment of nephritis depends on the cause – an assumption of
acute post streptococcal nephritis or any other disease cannot be made
without specific investigation which may include renal biopsy.

8.3.2 NEPHROTIC SYNDROME

N04.9

DESCRIPTION
Glomerular disease characterised by:

 children: t 3 + proteinuria on dipstick test, or urine protein: creatinine ratio

» severe proteinuria defined as:

(PCR) t 0.2 g/mmol on spot urine sample

2018 8.7
 CHAPTER 8 KIDNEY AND UROLOGICAL DISORDERS

 adults: • 2.5 g/day, as determined by a spot urine protein measurement, i.e.

PCR > 0.25 g/mmol

 oedema,  hypoalbuminaemia,
» and resultant ‘classic’ clinical picture (not always present) which includes:

 hyperlipidaemia.
Accurate diagnosis requires a renal biopsy.

MEDICINE TREATMENT
The management of glomerular disease depends on the type/cause of the disease
and is individualised, guided by a specialist according to the biopsy result.

REFERRAL
All cases.

8.4 URINARY TRACT INFECTION (UTI)

N30.9/N39.0/O23.4

DESCRIPTION
Urinary tract infections may involve the upper or lower urinary tract. Infections may
be complicated or uncomplicated. Uncomplicated UTI is a lower UTI in a non-
pregnant woman of reproductive age and who has a normal urinary tract. All other
UTIs should be regarded as complicated.
Differentiation of upper from lower urinary tract infection in young children is
not possible on clinical grounds.
Upper UTI is a more serious condition and requires longer and sometimes
intravenous treatment.
Features of upper UTI (pyelonephritis) that may be detected in adults and
adolescents include:
» flank pain/tenderness
» temperature 38oC or higher

 tachypnoea,  confusion
» other features of sepsis, i.e.:

 tachycardia,  hypotension
» vomiting
In complicated, recurrent or upper UTIs, urine should be sent for microscopy, culture
and sensitivity.
Features of urinary tract infections in children
Signs and symptoms are related to the age of the child and are often non-specific.
Uncomplicated urinary tract infections may cause very few signs and symptoms.
Complicated infections may present with a wide range of signs and symptoms.
Neonates may present with:
» fever » hypothermia
» poor feeding » sepsis
» vomiting » prolonged jaundice

2018 8.8
 CHAPTER 8 KIDNEY AND UROLOGICAL DISORDERS

» failure to thrive » renal failure

Infants and children may present with:
» failure to thrive » frequency
» persisting fever » dysuria
» abdominal pain » enuresis or urgency
» diarrhoea
In any child with fever of unknown origin, the urine must be examined, to
assess whether a urinary tract infection is present.
Perform a dipstix test on a fresh bag urine specimen.
DIPSTIX RESULT ACTION
No leukocytes/ nitrites UTI unlikely
Leukocytes only Repeat dipstix on a second specimen. If leucocytes on second
specimen, suspect UTI and treat empirically. Collect urine
aseptically if possible for urine MC&S.
Leukocytes or nitrites with Treat empirically for UTI.
symptoms of UTI Collect urine aseptically if possible for urine MC&S.
Leukocytes and nitrites Collect urine aseptically if possible for urine MC&S. Treat
empirically for UTI.

GENERAL MEASURES

 void bladder after intercourse and before retiring at night

» Women with recurrent UTIs should be advised to:

 not postpone voiding when urge to micturate occurs

 change from use of diaphragm to an alternative type of contraception

MEDICINE TREATMENT
Empirical treatment is indicated only if:
» positive leukocytes and nitrites on freshly passed urine, or
» leucocytes or nitrites with symptoms of UTI, or
» systemic signs and symptoms.
Alkalinising agents are not advised.

Uncomplicated cystitis

x Ciprofloxacin, oral, 500 mg 12 hourly for 3 days.

Adults

LoE:Iiii
Complicated cystitis

x Ciprofloxacin, oral, 500 mg 12 hourly for 7 days.

Adults

For pregnant women and adolescents:

x Nitrofurantoin, oral, 100 mg 6 hourly for 7 days.
LoE:IIIiv
Children ” 35 kg who do not meet criteria for urgent referral:
x Amoxicillin/clavulanic acid oral, 15–25 mg/kg/dose of amoxicillin component, 8
hourly for 7 days.

2018 8.9
 CHAPTER 8 KIDNEY AND UROLOGICAL DISORDERS

Weight Dose Use one of the following Age

kg mg Susp Susp Tablet months/years
(amoxicillin 125/31.5 250/62.5 250/125
component) mg/5 mL mg/5 mL
mg/tab
>5–7 kg 100 mg 4 mL 2mL – >3–6 months
>7–9 kg 150 mg 6 mL 3 mL – >6–12 months
>9–11 kg 200 mg 8 mL 4 mL – >12–18 months
>11–14 kg 250 mg 10 mL 5 mL 1 tablet >18 months–3
years
>14–17.5 kg 300 mg 12 mL 6 mL – >3–5 years
>17.5–25 375 mg 15 mL 7.5 mL – >5–7 years
>25–35 kg 500 mg 20 mL 10 mL 2 tablets >7–11 years
LoE:IIIv
Acute pyelonephritis
N10
Outpatient therapy is only indicated for women of reproductive age, who do not have
any of the manifestations requiring referral (see referral criteria below). All other patients

x Ciprofloxacin, oral, 500 mg 12 hourly for 7–10 days.

should be referred.

o It is essential to give at least a 7-day course of therapy.

REFERRAL
Urgent

 vomiting
» Acute pyelonephritis with:

 sepsis
 diabetes mellitus

 pregnant women
» Acute pyelonephritis in:

 women beyond reproductive age

 men
» Children >3 months of age who appear ill.
» Children < 3 months of age with any UTI.
Ill patients awaiting transfer

x Ceftriaxone, IM, 80 mg/kg/dose immediately as a single dose. See dosing tables,

» Ensure adequate hydration with intravenous fluids.

pg 23.3.
o Do not inject more than 1 g at one injection site.

2018 8.10
 CHAPTER 8 KIDNEY AND UROLOGICAL DISORDERS

CAUTION: USE OF CEFTRIAXONE IN NEONATES AND CHILDREN

» If SUSPECTING SERIOUS BACTERIAL INFECTION in neonate, give ceftriaxone, even if
jaundiced.

 If ” 28 days old, avoid calcium-containing IV fluids for 48 hours after ceftriaxone

» Avoid giving calcium-containing IV fluids (e.g. Ringer Lactate) together with ceftriaxone:

 If > 28 days old, ceftriaxone and calcium-containing IV fluids may be given sequentially
administered.

provided the giving set is flushed thoroughly with sodium chloride 0.9% before and

 Preferably administer IV fluids without calcium contents.

after.

» Always include the dose and route of administration of ceftriaxone in the referral letter.

Non-urgent
» All proven UTIs (positive culture) in children after completion of treatment.
» No response to treatment.
» UTI > 3 times within a one-year period in women, and more than once in men.
» Recurrent UTI in children for assessment and consideration of prophylaxis.

8.5 PROSTATITIS
N41.0/N41.9 + (N34.2)

DESCRIPTION
Infection of the prostate caused by urinary or STI pathogens.
Clinical features include:
» perineal, sacral or suprapubic pain
» dysuria and frequency
» varying degrees of obstructive symptoms which may lead to urinary retention
» sometimes fever
» acutely tender prostate on rectal examination
The condition may be chronic, bacterial or non-bacterial, the latter usually being
assessed when there is failure to respond to antibiotics.

MEDICINE TREATMENT
Acute bacterial prostatitis
In men ” 35 years of age or if there are features of associated urethritis (STI regimen):
x Ceftriaxone, IM, 250 mg as a single dose.

x Azithromycin, oral, 1 g as a single dose.

AND

x Ciprofloxacin, oral, 500 mg 12 hourly for 14 days.

In men > 35 years of age or if there is associated cystitis:

LoE:IIIvi
REFERRAL
» No response to treatment.
» Urinary retention.
» High fever.
» Chronic/relapsing prostatitis.

2018 8.11
 CHAPTER 8 KIDNEY AND UROLOGICAL DISORDERS

UROLOGY SECTION
8.6 HAEMATURIA
R31

DESCRIPTION
Bleeding from the urinary tract, which can be from the kidneys, collecting system,
bladder, prostate and urethra.
Glomerular disease is suggested if proteinuria, red blood cell casts and/or
dysmorphic red blood cells are present on microscopy.
Exclude schistosomiasis (bilharzia), a common cause of haematuria.
When haematuria is accompanied by colicky pain a kidney stone should be excluded.
Note: The presence of blood on the urine test strips does not indicate infection and
should be investigated as above.

MEDICINE TREATMENT
If evidence of schistosomiasis, treat as in Section 10.12: Schistosomiasis.
If symptoms of UTI; leucocytes and/or nitrite test positive in urine, treat as UTI.
If haematuria does not resolve rapidly after treatment referral for formal investigation
will be required, i.e. next 48 hours.

REFERRAL
» All cases not associated with schistosomiasis or UTI.
» All cases not responding to specific medicine treatment.
» When glomerular disease is suspected.

8.7 BENIGN PROSTATIC HYPERPLASIA (BPH)

N40

DESCRIPTION
BPH is a noncancerous (benign) growth of the prostate gland.
May be associated with both obstructive (weak, intermittent stream and urinary
hesitancy) and irritative (frequency, nocturia and urgency) voiding symptoms.
Digital rectal examination reveals a uniform enlargement of the prostate.
Urinary retention with a distended bladder may be present in the absence of severe
symptoms, therefore it is important to palpate for an enlarged bladder during
examination.

GENERAL MEASURES
Annual follow-up with digital rectal examination.
For patients presenting with urinary retention, insert a urethral catheter as a
temporary measure while patient is transferred to hospital.
Remove medicines that prevent urinary outflow e.g. tricyclic antidepressants,
neuroleptics.

2018 8.12
 CHAPTER 8 KIDNEY AND UROLOGICAL DISORDERS

REFERRAL
All patients with suspected BPH.

8.8 PROSTATE CANCER

C61/D07.5/D29.1/D40.0

DESCRIPTION
Usually occurs in men >50 years of age and is most often asymptomatic.
Systemic symptoms, i.e. weight loss, bone pain, etc. occurs in 20% of patients.
Obstructive voiding symptoms and urinary retention are uncommon.
The prostate gland is hard and may be nodular on digital rectal examination.
As the axial skeleton is the most common site of metastases, patients may present
with back pain or pathological spinal fractures.
Lymph node metastases can lead to lower limb lymphoedema.

REFERRAL
All patients with suspected cancer.

8.9 ENURESIS
F98.0

DESCRIPTION
Enuresis is bedwetting that occurs in children > 5 years of age.
It is a benign condition which mostly resolves spontaneously.
It is important, however, to differentiate between nocturnal enuresis and daytime
wetting with associated bladder dysfunction.
Secondary causes of enuresis include:
» diabetes mellitus » urinary tract infection
» physical or emotional trauma
Note:
» Clinical evaluation should attempt to exclude the above conditions.
» Urine examination should be done on all patients.

GENERAL MEASURES
» Motivate, counsel and reassure child and parents.
» Advise against punishment and scolding.
» Spread fluid intake throughout the day.
» Diapers are not advised, as this will lower the child’s self-esteem.

REFERRAL
» Suspected underlying systemic illness or chronic kidney disease.
» Persistent enuresis in a child.
» Diurnal enuresis.

2018 8.13
 CHAPTER 8 KIDNEY AND UROLOGICAL DISORDERS

8.10 IMPOTENCE/ERECTILE DYSFUNCTION

N48.4/F52.2

DESCRIPTION
The inability to attain and maintain an erect penis with sufficient rigidity for
penetration. Organic causes include neurogenic, vasculogenic, endocrinological (e.g.
diabetes mellitus) as well as many systemic diseases and medications.

GENERAL MEASURES
» Thorough medical and psychosexual history.
» Physical examination should rule out gynaecomastia, testicular atrophy or penile
abnormalities.
» Consider the removal of medicines (e.g. beta-blockers) that may be associated
with the problem.
» A change in lifestyle or medications may resolve the problem, e.g. advise
cessation of smoking and alcohol use.

TREATMENT
Treat the underlying condition.

8.11 RENAL CALCULI

N20.0

DESCRIPTION
This is a kidney stone or calculus which has formed in the renal tract i.e. pelvis,
ureters or bladder as a result of urine which is supersaturated with respect to a stone-
forming salt.
Clinical features of obstructing urinary stones may include:
» sudden onset of acute colic, localised to the flank, causing the patient to move
constantly,
» nausea and vomiting,
» referred pain to the scrotum or labium on the same side as the stone moves down
the ureter.
Urinalysis usually reveals microscopic or macroscopic haematuria.

GENERAL MEASURES
Ensure adequate hydration.

MEDICINE TREATMENT
Adults:

x Morphine, IM, 0.1 mg/kg 30 minutes before aspiration procedure, to a

Analgesia for pain, if needed:

maximum of 10 mg (Doctor initiated). LoE:III

2018 8.14
 CHAPTER 8 KIDNEY AND UROLOGICAL DISORDERS

REFERRAL
All patients.

References
i Dose adjustment of medicines in renal impairment: National Department of Health. Adult Hospital level STG, 2015.
http://www.health.gov.za/
ii Furosemide, oral (eGFR cut-off): Levin A, Stevens PE. Summary of KDIGO 2012 CKD Guideline: behind the scenes, need

for guidance, and a framework for moving forward. Kidney Int. 2014 Jan;85(1):49-61.
https://www.ncbi.nlm.nih.gov/pubmed/24284513
Furosemide, oral (eGFR cut-off): South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.
University of Cape Town, 2016.
iii Ciprofloxacin-uncomplicated cystitis: Zalmanovici Trestioreanu A, Green H, Paul M, Yaphe J, Leibovici L. Antimicrobial

agents for treating uncomplicated urinary tract infection in women. Cochrane Database Syst Rev. 2010 Oct 6;(10):CD007182.
http://www.ncbi.nlm.nih.gov/pubmed/20927755
Ciprofloxacin-uncomplicated cystitis Lewis DA, Gumede LY, van der Hoven LA, de Gita GN, de Kock EJ, de Lange T,
Maseko V, Kekana V, Smuts FP, Perovic O. Antimicrobial susceptibility of organisms causing community-acquired urinary
tract infections in Gauteng Province, South Africa. S Afr Med J. 2013 Mar 15;103(6):377-81.
http://www.ncbi.nlm.nih.gov/pubmed/23725955
ivNitrofurantoin: Lewis DA, Gumede LY, van der Hoven LA, de Gita GN, de Kock EJ, de Lange T, Maseko V, Kekana V,

Smuts FP, Perovic O. Antimicrobial susceptibility of organisms causing community-acquired urinary tract infections in
Gauteng Province, South Africa. S Afr Med J. 2013 Mar 15;103(6):377-81. http://www.ncbi.nlm.nih.gov/pubmed/23725955
Nitrofurantoin: Nordeng H, Lupattelli A, Romøren M, Koren G. Neonatal outcomes after gestational exposure to nitrofurantoin.
Obstet Gynecol. 2013 Feb;121(2 Pt 1):306-13. http://www.ncbi.nlm.nih.gov/pubmed/23344280
v Amoxicillin/clavulanic acid – Children ” 35 kg: Bosch FJ, van Vuuren C, Joubert G. Antimicrobial resistance patterns in

outpatient urinary tract infections--the constant need to revise prescribing habits. S Afr Med J. 2011 May;101(5):328-31.
http://www.ncbi.nlm.nih.gov/pubmed/21837876
Amoxicillin/clavulanic acid – Children ” 35 kg: Zorc JJ, Kiddoo DA, Shaw KN. Diagnosis and management of pediatric
urinary tract infections. ClinMicrobiol Rev. 2005 Apr;18(2):417-22. http://www.ncbi.nlm.nih.gov/pubmed/15831830
Amoxicillin/clavulanic acid – Children ” 35 kg: Bamford C, Bonorchis K, Ryan A, Hoffmann R, Naicker P, Maloba M, Nana T,
Zietsman I, Govind C. Antimicrobial susceptibility patterns of Escherichia coli strains isolated from urine samples in South
Africa from 2007-2011. South Afr J Epidemiol Infect 2012;27(2):46-52.http://www.sajei.co.za/index.php/SAJEI/article/view/483
Amoxicillin/clavulanic acid – Children ” 35 kg: Lewis DA, Gumede LY, van der Hoven LA, de Gita GN, de Kock EJ, de
Lange T, Maseko V, Kekana V, Smuts FP, Perovic O. Antimicrobial susceptibility of organisms causing community-acquired
urinary tract infections in Gauteng Province, South Africa. S Afr Med J. 2013 Mar 15;103(6):377-
81.http://www.ncbi.nlm.nih.gov/pubmed/23725955
Amoxicillin/clavulanic acid – Children ” 35 kg: Fitzgerald A, Mori R, Lakhanpaul M, Tullus K. Antibiotics for treating lower
urinary tract infection in children. Cochrane Database Syst Rev. 2012 Aug 15;8:CD006857.
http://www.ncbi.nlm.nih.gov/pubmed/22895956
Amoxicillin/clavulanic acid – Children ” 35 kg: Keren R, Chan E. A meta-analysis of randomized, controlled trials comparing
short- and long-course antibiotic therapy for urinary tract infections in children. Pediatrics. 2002 May;109(5):E70-0.
http://www.ncbi.nlm.nih.gov/pubmed/11986476
Amoxicillin/clavulanic acid – Children ” 35 kg: Downs SM. Technical report: urinary tract infections in febrile infants and
young children. The Urinary Tract Subcommittee of the American Academy of Pediatrics Committee on Quality Improvement.
Pediatrics. 1999 Apr;103(4):e54.http://www.ncbi.nlm.nih.gov/pubmed/10103346
Amoxicillin/clavulanic acid – Children ” 35 kg: American Academy of Pediatrics. Committee on Quality Improvement.
Subcommittee on Urinary Tract Infection. Pediatrics. 1999 Apr;103(4 Pt 1):843-52. Erratum in: Pediatrics1999 May;103(5 Pt
1):1052, 1999 Jul;104(1 Pt 1):118. 2000 Jan;105(1 Pt 1):141. http://www.ncbi.nlm.nih.gov/pubmed/10103321
Amoxicillin/clavulanic acid – Children ” 35 kg: Kennedy KM, Glynn LG, Dineen B. A survey of the management of urinary
tract infection in children in primary care and comparison with the NICE guidelines. BMC Fam Pract. 2010 Jan 26;11:6.
http://www.ncbi.nlm.nih.gov/pubmed/20102638
Amoxicillin/clavulanic acid – Children ” 35 kg: Shann F. Drug doses, 15th edition, 2010. Intensive Care Unit,Royal
Children’s Hospital, Parkville, Victoria 3052, Australia.
Amoxicillin/clavulanic acid – Children ” 35 kg: Triomed, RSA. Package insert for Augmaxcil®S, SF (Powder for suspension,
suspension forte). 1997.
Amoxicillin/clavulanic acid – Children ” 35 kg: Montini G, Toffolo A, Zucchetta P, Dall'Amico R, Gobber D, Calderan A,
Maschio F, Pavanello L, Molinari PP, Scorrano D, Zanchetta S, Cassar W, Brisotto P, Corsini A, Sartori S, Da Dalt L, Murer L,
Zacchello G. Antibiotic treatment for pyelonephritis in children: multicentre randomised controlled non-inferiority trial. BMJ.
2007 Aug 25;335(7616):386.http://www.ncbi.nlm.nih.gov/pubmed/17611232
vi Ciprofloxacin – cystitis associated with prostatitis: Lewis DA, Gumede LY, van der Hoven LA, de Gita GN, de Kock EJ, de

Lange T, Maseko V, Kekana V, Smuts FP, Perovic O. Antimicrobial susceptibility of organisms causing community-acquired
urinary tract infections in Gauteng Province, South Africa. S Afr Med J. 2013 Mar 15;103(6):377-81.
http://www.ncbi.nlm.nih.gov/pubmed/23725955

2018 8.15
PHC Chapter 9: Endocrine conditions
9.1 Type 1 Diabetes mellitus
9.1.1 Type 1 Diabetes mellitus, in children &
adolescents
9.1.2 Type 1 Diabetes mellitus, in adults
9.2 Type 2 Diabetes mellitus
9.2.1 Type 2 Diabetes mellitus, in adolescents
9.2.2 Type 2 Diabetes mellitus, in adults
9.3 Diabetes mellitus emergencies
9.3.1 Hypoglycaemia in diabetics
9.3.2 Severe hyperglycaemia (Diabetic
ketoacidosis (DKA) & hyperosmolar
hyperglycaemic state (HHS))
9.4 Microvascular complications of diabetes
9.4.1 Diabetic neuropathy
9.4.2 Diabetic foot ulcers
9.4.3 Diabetic nephropathy
9.5 Cardiovascular risk in diabetics
9.5.1 Obesity in diabetes
9.5.2 Dyslipidaemia in diabetes
9.5.3 Hypertension in diabetes
9.6 Hypothyroidism
9.6.1 Hypothyroidism in neonates
9.6.2 Hypothyroidism children & adolescents
9.6.3 Hypothyroidism in adults
9.7 Hyperthyroidism
9.7.1 Hyperthyroidism in children & adolescents
9.7.2 Hyperthyroidism in adults
 CHAPTER 9 ENDOCRINE SYSTEM

9.1 TYPE 1 DIABETES MELLITUS

DESCRIPTION
Type 1 diabetes mellitus, previously known as juvenile onset diabetes mellitus and
as insulin-dependent diabetes mellitus (IDDM), occurs because of a lack of insulin.
The result is an increase in blood glucose concentration.

CLINICAL PRESENTATION
» hunger » thirst
» polyuria » unexplained weight loss
» ketoacidosis » tiredness

DIAGNOSIS
Type 1 diabetes mellitus is diagnosed when the classic symptoms of polyuria and
polydipsia are associated with hyperglycaemia:
» Random blood glucose • 11.1 mmol/L.
» Random is defined as any time of day without regard to time since last meal.
OR
» Fasting blood glucose • 7.0 mmol/L.
» Fasting is defined as no caloric intake for • 8 hours.

GENERAL MEASURES
» Education regarding diabetes and its complications.
» Even and regular meal consumption.
» Dietary emphasis should be on regulating carbohydrate, fibre and fat intake (See
Section 9.2.2: Type 2 Diabetes mellitus, in adults for recommended diet plan).
» Increased physical activity: aim for 30 minutes 5 times a week.
» Appropriate weight loss if body mass index > 25 kg/m2.
» Education about foot care.
» Monitor for development of depression.
» All patients should wear a notification bracelet.

REFERRAL
All patients.

9.1.1 TYPE 1 DIABETES MELLITUS, IN CHILDREN AND

ADOLESCENTS
E10.9

MEDICINE TREATMENT
Oral anti-diabetic medicines should not be used to treat children with type 1 diabetes
mellitus.

REFERRAL
All children with confirmed or suspected type 1 diabetes mellitus must be referred to a
hospital immediately for management.

2018 9.2
 CHAPTER 9 ENDOCRINE SYSTEM

9.1.2 TYPE 1 DIABETES MELLITUS, IN ADULTS

E10.9

Type 1 diabetes mellitus is a rare condition and should be diagnosed and monitored
at hospital level. Only stable patients may be down referred for chronic medicines.

MONITORING FOLLOWING DOWN REFERRAL

At every visit:
» Finger-prick blood glucose.
» Weight.
» Blood pressure.
Annually:
» HbA1c, one month before next hospital appointment.

TARGETS FOR CONTROL

Glycaemic targets for control:
Patient type Target HbA1c Target FBG* Target PPG*
» Young, low risk
» Newly diagnosed < 6.5% 4.0–7.0 mmol/L 4.4–7.8 mmol/L
» No CVS disease
» Majority of patients < 7.0% 4.0–7.0 mmol/L 5.0–10.0 mmol/L
» Elderly
» High risk < 7.5% 4.0–7.0 mmol/L < 12.0 mmol/L
» Hypoglycaemic
unawareness
» Poor short-term
prognosis
*FBG: fasting blood glucose; PPG: post-prandial blood glucose.
Non-glycaemic targets:
» Body mass index ” 25 kg/m2.
» BP < 140/90 mmHg.
The increased risk of hypoglycaemia must always be weighed against the potential
benefit of reducing microvascular and macrovascular complications.

MEDICINE TREATMENT
As type 1 diabetes mellitus usually presents with diabetic ketoacidosis, treatment is
usually initiated with insulin and the patient is stabilised at hospital level. Oral anti-
diabetic medicines should not be used to treat type 1 diabetics.
Insulin dose requirements will decrease as kidney disease progresses.

x Insulin, short acting, SC, three times daily, 30 minutes before meals.
Types of insulin

o Regular human insulin.

o Onset of action: 30 minutes.
o Peak action: 2–5 hours.
o Duration of action: 5–8 hours.

2018 9.3
 CHAPTER 9 ENDOCRINE SYSTEM

x Insulin, intermediate acting, SC, once or twice daily usually at night at bedtime,
approximately 8 hours before breakfast.
o Intermediate acting insulin.
o Onset of action: 1–3 hours.
o Peak action: 6–12 hours.
o Duration of action: 16–24 hours.

x Insulin, biphasic, SC, once or twice daily.

o Mixtures of regular human insulin and intermediate acting insulin in different
proportions, e.g. 30/70 (30% regular insulin and 70% intermediate acting
insulin).
o Onset of action: 30 minutes.
o Peak action: 2–12 hours.
o Duration of action: 16–24 hours.

Insulin regimens
Basal bolus regimen
All type 1 diabetics should preferentially be managed with the “basal bolus regimen” i.e.
combined intermediate acting (basal) and short acting insulin (bolus). This consists of
pre-meal, short acting insulin and bedtime intermediate acting insulin not later than
22h00.
The initial total daily insulin dose:
o 0.6 units/kg body weight.
The total dose is divided into:
o 40–50% basal insulin
o The rest as bolus insulin, split equally before each meal.
Adjust dose on an individual basis.
Pre-mixed insulin
Twice daily pre-mixed insulin, i.e. a mixture of intermediate- or short acting insulin provides
adequate control, when used with at least daily blood glucose monitoring. It is a practical
option for patients who cannot monitor blood glucose frequently.
Education related to insulin therapy
» Types of insulin.
» Injection technique and sites of injection.
» Insulin storage.
» Recognition and treatment of acute complications, e.g. hypoglycaemia and
hyperglycaemia.

 Meal frequency, as this varies according to the type and frequency of insulin, e.g.
» Diet:

 Consistent carbohydrate intake for patient receiving fixed mealtime doses of

patients may need a snack at night, about 3–4 hours after the evening meal.

insulin.
» Self-monitoring of blood glucose and how to self-adjust insulin doses.

2018 9.4
 CHAPTER 9 ENDOCRINE SYSTEM

Drawing up insulin from vials

» Clean the top of the insulin bottle with an antiseptic swab.
» Draw air into the syringe to the number of marks of insulin required and inject this
into the bottle; then draw the required dose of insulin into the syringe.
» Before withdrawing the needle from the insulin bottle, expel the air bubble if one
has formed.
Injection technique
» The skin need not be specially cleaned.
» Repeated application of antiseptics hardens the skin.
» Stretching the skin at the injection site is the best way to obtain a painless
injection. In thin people it may be necessary to pinch the skin between thumb and
forefinger of one hand.
» The needle should be inserted briskly at almost 90 to the skin to almost its whole
length (needles are usually 0.6–1.2 cm long).
» Inject the insulin.
» To avoid insulin leakage, wait 5–10 seconds before withdrawing the needle.
» Injection sites must be rotated to avoid lipohypertrophy.
Prefilled pens and cartridges
In visually impaired patients and arthritic patients, prefilled pens and cartridges may
be used.
Home blood glucose monitoring
Patients on basal/bolus insulin should initially measure glucose at least twice daily.
Once patient is stable, reduce the frequency of monitoring.

REFERRAL
All patients.

9.2 TYPE 2 DIABETES MELLITUS

9.2.1 TYPE 2 DIABETES MELLITUS, IN ADOLESCENTS
E11.9

DESCRIPTION
The majority of adolescent diabetics are of type 1. However, an increasing number
of adolescents are being diagnosed with type 2 diabetes mellitus.
Criteria for screening for diabetes in children
» Body mass index > 85th percentile for age and sex.
» Family history of type 2 diabetes mellitus.
» Presence of hyperlipidaemia, hypertension or polycystic ovarian syndrome.
AND
» Physical signs of puberty or age > 10 years of age.

DIAGNOSIS
» Symptoms of diabetes plus a random blood glucose • 11.1 mmol/L.

2018 9.5
 CHAPTER 9 ENDOCRINE SYSTEM

 Random is defined as any time of day without regard to time since last meal.
 Classic symptoms of diabetes mellitus include: polyphagia, polyuria, polydipsia.
Fasting blood glucose • 7.0 mmol/L.
 Fasting is defined as no caloric intake for • 8 hours.
»

It is difficult to distinguish type 2 from type 1 diabetes mellitus, as many type 1

diabetics may be overweight, or have a family history of type 2 diabetes mellitus,
given the increasing prevalence of both obesity and type 2 diabetes mellitus. The
diagnosis of type 2 diabetes mellitus in adolescents should be made in consultation
with a specialist.

REFERRAL
All patients.

9.2.2 TYPE 2 DIABETES MELLITUS, ADULTS

E11.9

DESCRIPTION
Type 2 diabetes mellitus is a chronic debilitating metabolic disease characterised by
hyperglycaemia with serious acute and chronic complications. It is an important
component of the metabolic syndrome (see Section 9.5.1: Obesity in diabetes).
Most type 2 diabetes mellitus adults are overweight with a high waist to hip ratio.
In adults the condition might be diagnosed when presenting with complications, e.g.:
» ischaemic heart disease » deteriorating eyesight
» peripheral artery disease » foot ulcers
» stroke » erectile dysfunction

CLINICAL PRESENTATION
Symptoms of hyperglycaemia are:
» thirst, especially noticed at night
» polyuria
» tiredness
» periodic changes in vision due to fluctuations in blood glucose concentration
» susceptibility to infections, especially of the urinary tract, respiratory tract and skin
Note: It is important to distinguish type 2 diabetes mellitus from type 1diabetes mellitus.
Suspect type 1 diabetes mellitus among younger patients with excessive weight loss
and/or ketoacidosis.

DIAGNOSIS
Symptoms of diabetes plus a random blood glucose • 11.1 mmol/L.
 Random is defined as any time of day without regard to time since last meal.
»

Fasting blood glucose • 7.0 mmol/L.

 Fasting is defined as no caloric intake for • 8 hours.
»

» If screening and not symptomatic: 2 positive tests done on separate days are
required for diagnosis.

2018 9.6
 CHAPTER 9 ENDOCRINE SYSTEM

MONITORING
At every visit:
» Finger-prick blood glucose.
» Weight.
» Blood pressure.
Baseline:
» Serum creatinine concentration (and calculate eGFR).
» Serum potassium concentration, if on ACE-inhibitor or eGFR < 30 mL/min.

 If dipstix negative, send urine to laboratory for albumin: creatinine ratio, unless
» Urine protein by dipstix.

 If dipstix positive, see Section 9.4.3: Diabetic nephropathy.

already on an ACE-inhibitor. (See Section 9.4.3: Diabetic nephropathy).

» BMI for cardiovascular risk assessment if appropriate (See Section 4.1:

Prevention of ischaemic heart disease and atherosclerosis).
» Blood lipids (fasting total cholesterol, triglycerides, HDL and LDL cholesterol).
» Foot examination.
» Eye examination to look for retinopathy.
» Abdominal circumference.
Annually:
» Serum creatinine concentration (and calculate eGFR).
» Serum potassium concentration, if on ACE-inhibitor or eGFR < 30 mL/min.

 If dipstix negative, send urine to laboratory for albumin: creatinine ratio, unless
» Urine protein by dipstix.

already on an ACE-inhibitor. (See Section 9.4.3: Diabetic nephropathy.)

» HbA1c, in patients who meet treatment goals (3–6 monthly in patients whose
therapy has changed, until stable).
» Eye examination to look for retinopathy.
» Foot examination.
TARGETS FOR CONTROL
Glycaemic targets for control:
Patient type Target HbA1c Target FBG* Target PPG*
»
Young, low risk
»
Newly diagnosed < 6.5% 4.0–7.0 mmol/L 4.4–7.8 mmol/L
»
No CVS disease
»
Majority of patients < 7.0% 4.0–7.0 mmol/L 5.0–10.0 mmol/L
»
Elderly
»
High risk < 7.5% 4.0–7.0 mmol/L < 12.0 mmol/L
»
Hypoglycaemic
unawareness
» Poor short-term
prognosis
*FBG: fasting blood glucose; PPG: post-prandial plasma glucose.
» In the elderly, the increased risk of hypoglycaemia must be weighed against the
potential benefit of reducing microvascular and macrovascular complications.
» Prevent acute complications, e.g. hyperglycaemic and hypoglycaemic coma.

2018 9.7
 CHAPTER 9 ENDOCRINE SYSTEM

Non-glycaemic targets:
» Body mass index ” 25 kg/m2.
» BP ” 140/90 mmHg and • 120/70 mmHg.
Management of type 2 diabetes mellitus includes:
» Treatment of hyperglycaemia.
» Management of chronic conditions associated with diabetes. For treatment of
hypertension and dyslipidaemia after risk-assessment, see Section 4.7:
Hypertension and Section 4.1: Prevention of Ischaemic heart disease and
atherosclerosis.
» Prevention and treatment of microvascular complications. See Section 9.4:
Microvascular complications of diabetes.
» Prevention and treatment of macrovascular complications. See Section 9.5:
Cardiovascular risk in diabetes.

GENERAL MEASURES
» Lifestyle modification, including self-care practices.
» Refer to a dietician if available for annual follow-up.
» Refer to a support group if available.
» Education about diabetes and its complications.
» Increased regular physical activity, aim for 30 minutes 5 times a week.
» Appropriate weight loss if weight exceeds ideal weight.
» Discourage smoking.
» Moderate or no alcohol intake (” 2 standard drinks per day for males and ” 1 for
females).
» Education about foot care.
» All patients should wear a notification bracelet.
Diet
Encourage: LoE: IIIi
» regular, evenly-spaced meals, with small portions
» nutritionally balanced meals, with a variety of healthy foods
» meals that consist of one meat dish option with an option of vegetarian for those
who are vegetarian, one starch option, two vegetable options, one fruit option and
water

Carbohydrates

 encourage small portions of healthy carbohydrates, such as vegetables, fruits,

» Strict control of carbohydrate intake:

whole grains (e.g. whole wheat bread, oats, brown rice, pearled wheat, maize
meal porridge, sorghum porridge, samp, wheat rice), legumes (lentils, beans),

 discourage intake of less healthy, highly processed/refined carbohydrate foods,

and dairy products

especially those with added fats, sugars, or salt (e.g. takeaways, deep-fried
foods, pies, doughnuts, cakes, biscuits, white bread, sugary drinks)
Fruit and vegetables
» Aim for 5 servings of fruit or vegetables per day (e.g. vegetables: spinach, morogo,
cabbage, tomato, imifino (amadumbe, amaranth, cowpea, pumpkin and sweet

2018 9.8
 CHAPTER 9 ENDOCRINE SYSTEM

potato leaves); fruit: apple, orange, naartjie, banana, mango, pear, peach)
» Limit fruit to 2 servings per day, preferably in small portions throughout the day
rather than all at one meal
» Limit intake of starchy vegetables like potatoes, sweet potatoes, mielies,
butternut, and pumpkin
» Limit intake of concentrated fruit sources such as dried or tinned fruit, or juices.

Legumes
» Soy beans, dry beans, chickpeas, lentils, and split peas are an economical source
of protein and fibre
» They do contain starch, so contribute to total carbohydrate intake (see portion
sizes below)
Dairy
» Advise fat-free or lower fat options.
Meat, fish, and eggs
» Encourage less fatty cuts of meat if possible.
» Encourage low fat cooking methods such as baking, grilling, or steaming. Trim
excess fat from meat and remove skin from chicken before cooking.
» Encourage patients to eat oily fish e.g. sardines and pilchards 2-3 times a week.
» Limit eggs to 1 per day.
» Avoid processed meats such as polony and viennas.
Fats
» Replace unhealthy animal fats (fatty beef, pork, lamb and chicken) and tropical oils
(e.g. coconut and palm kernel oil) with healthier fats (e.g. avocado pear, fatty fish
such as pilchards and plant oils such as canola, olive, sunflower, or peanut butter).
» Do not reheat oil, and use softer margarines where possible.
» Limit intake of takeaway foods, and rather prepare food at home most of the time.

Sugar
» Avoid sugar and sugary foods and drinks, such as: table sugar, honey, sugary
drinks (fizzy drinks, fruit juices, energy drinks, sport drinks, sweetened flavoured
milk/drinking yoghurt, flavoured water), sweets, desserts and baked goods.
» If eaten on special occasions, advise in very small portions.

Salt
» Do not exceed a half teaspoon of salt per day. This includes hidden salt in
processed foods (e.g. stock cubes, gravy and soup powders, deli meats like
polony and viennas, take-away foods, chips/crisps).
» Avoid adding salt to food.
» Use less salt when preparing food. Use herbs and spices to enhance the flavour
of foods instead of salt.
Portion control guide
A portion is the amount of food that a person eats at one time, for a meal or snack.
Advise the following portion sizes:
» Make protein (e.g. fish, chicken, or meat) food portions the size of the palm of

2018 9.9
 CHAPTER 9 ENDOCRINE SYSTEM

your hand (about 90 g or 1/2 cup).

» Make fruit, vegetables and starchy food (such as rice, pasta and potatoes)
portions no greater than the size of your clenched fist (1 cup).
» Make healthy fat portions the size of the tip of your thumb (1 teaspoon).
» Make hard cheese or peanut butter portions the length of your thumb (1
tablespoon).

MEDICINE TREATMENT
Oral blood glucose lowering agents
Stepwise approach:
» Add metformin to the combination of dietary modifications and physical
activity/exercise.
» Combination therapy with metformin plus a sulphonylurea is indicated if therapy
with metformin alone (together with dietary modifications and physical
activity/exercise) has not achieved the HbA1c target.
» For persisting HbA1c above acceptable levels and despite adequate adherence
to oral hypoglycaemic agents: add insulin and withdraw sulphonylurea.
» Ensure patient is adherent at each step.
» Oral agents should not be used in type 1 diabetes mellitus, renal impairment or
clinical liver failure.

STEP 1
Lifestyle modification plus metformin
Entry to Step 1 Treatment and duration Target

» Typical symptoms - » Lifestyle modification » 2-hour post-prandial

thirst, tiredness, for life. finger-prick blood
polyuria. glucose: 8–10 mmol/L.
AND » Appropriate diet. OR
» Random blood glucose fasting finger-prick
>11.1mmol/L. » Weight loss until at blood glucose: 6–8
OR ideal weight. mmol/L.
» Fasting blood glucose • AND/OR

x Metformin.
7 mmol/L. Initiate drug therapy with: » HbA1c:7–8%.

x
» Assess monthly.
Metformin, oral, 500 mg daily with meals.
o Titrate dose slowly depending on HbA1c and/or fasting blood glucose
concentrations to a maximum dose of 850 mg 8 hourly.

 uncontrolled congestive cardiac failure

o Contraindicated in:

 severe liver disease

 patients with significant respiratory compromise

2018 9.10
 CHAPTER 9 ENDOCRINE SYSTEM

In patients with renal impairment, adjust dose according to table:

eGFR Action
> 30–60 mL/minute » Continue use.
» 50% of dose (maximum 500 mg 12 hourly).
» Increase frequency of renal function monitoring (3–6
monthly).
< 30 mL/minute Stop metformin.

STEP 2
Add sulphonylurea:
Entry to Step 2 Treatment and duration Target
» Failed step 1: HbA1c > » Lifestyle modification. » 2-hour post-prandial
8 % or fasting finger- AND finger prick blood
prick blood glucose >8 » Combination oral glucose < 8–10
mmol/L despite hypoglycaemic mmol/L.

x Metformin.
adherence to treatment agents, i.e.: OR
plan in step 1 and » fasting finger prick

x Sulphonylurea.
maximal dose of AND blood glucose: 6–8
metformin for 2–3 mmol/L.
months. AND/OR
OR » HbA1c:7–8%.
» 2-hour post-prandial
finger-prick blood
glucose >10 mmol/L
despite adherence to
treatment plan in
step 1 and maximal
dose of metformin for
2–3 months.
ƒ
x
Sulphonylurea derivatives
Glimepiride, oral with breakfast.
o Initially 1 mg daily, adjusted according to response in 1 mg increments at 1 to
2 week intervals.
o Maximum dose of 4 mg daily.
o Preferred in the elderly.
OR
Glibenclamide, oral, 2.5 mg daily 30 minutes with breakfast.
o Titrate dose slowly depending on HbA1c and/or fasting blood glucose levels
to a maximum of 15 mg daily.
o When • 7.5 mg per day is needed, divide the total daily dose into 2, with the
larger dose in the morning.
o Avoid in the elderly and patients with renal impairment.
All sulphonylureas should be avoided in patients with renal impairment i.e.
eGFR < 60 mL/minute.

2018 9.11
 CHAPTER 9 ENDOCRINE SYSTEM

Sulphonylureas are contraindicated in:

» severe hepatic impairment
» pregnancy

Missing meals while taking sulphonylureas may lead to hypoglycaemia.

STEP 3
Insulin therapy: See Section 9.1.2: Type 1 diabetes mellitus, in adults.
» Insulin is indicated when oral combination therapy fails.
» Continue lifestyle modification.
» Insulin therapy must be initiated and titrated by a doctor, until stabilised.
» Stop sulphonylurea once insulin therapy is initiated but continue metformin.
LoE: IIIii
Education for patients on insulin therapy:
» Types of insulin.
» Injection technique and sites of injection.
» Insulin storage.
» Self-monitoring of blood glucose and how to self-adjust insulin doses.

 Meal frequency, this varies according to the type and frequency of insulin, e.g.
» Diet:

 Consistent carbohydrate intake for patients receiving fixed mealtime doses of

patients may need a snack at night about 3–4 hours after the evening meal.

insulin.
» Recognition and treatment of acute complications, e.g. hypoglycaemia and
hyperglycaemia.
Insulin type Starting dose Increment

x Intermediate to
Add on therapy: 10 units in the evening before If 10 units not effective: increase
bedtime, but not after 22h00. gradually to 20 units (2–4 units
long acting increase each week).
Substitution Twice daily. 4 units weekly.

x Biphasic
therapy:
Total daily dose: First increment is added to dose
Start with 0.3 units/kg/day* before breakfast.
divided as LoE: IIIiii

follows: Second increment is added to

o 2/3 of total daily dose, 30 dose before supper.
minutes before breakfast.
o 1/3 of total daily dose, 30
minutes before supper.
*Example of a dose calculation:
- For a 70 kg adult: 0.3 units x 70 kg = 21 units per day; divided as 14 units 30 minutes
before breakfast and 7 units 30 minutes before breakfast.

REFERRAL
Urgent (same day)
» Acidotic breathing.
» Dehydration and hypotension.

2018 9.12
 CHAPTER 9 ENDOCRINE SYSTEM

» Nausea, vomiting and abdominal pain.

» Ketonuria (more than 1+).
» Hyperglycaemia >25 mmol/L.
» Gangrene.
» Sudden deterioration of vision.
» Serious infections.
Note: Consider IV infusion with sodium chloride 0.9%, before transferring very ill
patients.

Non-urgent
» Pregnancy.
» Failure of step 3 to control diabetes.
» eGFR< 30 mL/minute.
» Ischaemic heart disease.
» Cerebrovascular disease.
» Refractory hypertension.
» Progressive loss of vision.

9.3 DIABETIC EMERGENCIES

DESCRIPTION
Diabetics may present with a decreased level of consciousness owing to:
» hyperglycaemia diabetic ketoacidosis (DKA) or hyperosmolar hyperglycaemic
state (HHS), or
» hypoglycaemia.

DIAGNOSIS
Check blood glucose concentration and test urine for ketones, immediately.
Hyperglycaemia Hypoglycaemia
DKA HHS
Blood glucose • 11.1 mmol/L Usually > 40 < 4 mmol/L
mmol/L
Urine test for Usually positive Usually negative Usually negative
ketones and > 1+
If a diagnosis cannot be made, treat as hypoglycaemia and refer urgently.
Low blood glucose presents the most immediate danger to life.

9.3.1 HYPOGLYCAEMIA IN DIABETICS

E10.0/E11.0/E12.0/E13.0/E14.0

DESCRIPTION
Diabetic patients on therapy may experience hypoglycaemia for reasons such as
intercurrent illness (e.g. diarrhoea); missed meals; inadvertent intramuscular
injections of insulin or miscalculated doses of insulin or progressive renal failure
leading to decreased insulin clearance; alcohol ingestion; and exercise without

2018 9.13
 CHAPTER 9 ENDOCRINE SYSTEM

appropriate dietary preparation.

Risk factors include age < 6 years of age, low HbA1c, and longer duration of diabetes.
Hypoglycaemia in diabetic patients can be graded according to the table below:
Mild/moderate hypoglycaemia Severe hypoglycaemia
» Capable of self-treatment*. » Semi-conscious
or
» Unconscious/comatose.
» Conscious, but requires help from someone else. » Requires medical help.
*Except children < 6 years of age.
Autonomic symptoms/signs Neurological symptoms/signs
» Tremors » Headache
» Palpitations » Mood changes
» Sweating » Low attentiveness
» Hunger » Slurred speech
» Fatigue » Dizziness
» Pallor » Unsteady gait
» Depressed level of consciousness/ convulsions
*Note:
» Children, particularly < 6 years of age, generally are not capable of self-
management and are reliant on supervision from an adult.
» Patients may fail to recognise that they are hypoglycaemic when neuroglycopenia
(impaired thinking, mood changes, irritability, dizziness, tiredness) occurs before
autonomic activation.

DIAGNOSIS
» Blood glucose < 4mmol/L with symptoms in a known diabetic patient.
» Blood glucose concentrations should be measured with a glucometer to confirm
hypoglycaemia.

Hypoglycaemia must be managed as an emergency.

If a diabetic patient presents with an altered level of consciousness and a
glucometer is not available, treat as hypoglycaemia.

EMERGENCY TREATMENT
» Measure blood glucose concentration with glucometer/testing strip, immediately.
Conscious patient, able to feed

 give breast milk

Breastfeeding child

 a formula feed of 5 mL/kg

Older children

 oral sugar solution

OR

o dissolve 3 teaspoons of sugar (15 g) in 200 mL cup of water, administer 5 mL/kg

2018 9.14
 CHAPTER 9 ENDOCRINE SYSTEM

 sweets, sugar, glucose by mouth

OR

 sweets, sugar, glucose by mouth

Adults

 oral sugar solution

OR

o dissolve 3 teaspoons of sugar (15 g) in 200 mL cup of water, administer 5 mL/kg

Conscious patient, not able to feed without danger of aspiration

x Dextrose 10%, 5mL/kg

Administer via nasogastric tube:

o Add 1 part 50% dextrose water to 4 parts water to make a 10% solution.

 milk
OR

 sugar solution
OR

o dissolve 3 teaspoons of sugar (15 g) in 200 mL of water; administer 5 mL/kg

Unconscious patient

x Dextrose 10%, IV, 2–5 mL/kg.

Children

IV administration of dextrose in children with hypoglycaemia:

» Establish an IV line. Do not give excessive volumes of fluid: usually can
keep line open with 2mL/kg/hour.
» Take a blood sample for emergency investigations and blood glucose.

 If low, i.e. < 2.5 mmol/L or if testing strips are not available, administer
» Check blood glucose.

2–5 mL/kg of 10% dextrose solution IV rapidly.

In the majority of cases an immediate clinical response can be expected.

 If still low, repeat 2 mL/kg of 10% dextrose solution.

» Recheck the blood glucose after infusion.

» After recovery, maintain with 5–10% dextrose solution until blood glucose is
stabilised.
» Feed the child as soon as conscious.

x Dextrose 10%, solution, IV, 2–5 mL/kg.

Adults

o Do not give unless hypoglycaemic or hypoglycaemia strongly suspected.

o Do not give excessive volumes of fluid.

 re-check blood glucose 10–15 minutes later;

o If hypoglycaemia is treated:

 if still low, give further bolus of dextrose 10%, IV, 2 mL/kg, and
commence dextrose 5 or 10%, infusion, 3–5 mL/kg/hour to prevent
blood glucose dropping again.
Assess continuously until the patient shows signs of recovery.
LoE:IIIiv

2018 9.15
 CHAPTER 9 ENDOCRINE SYSTEM

x Thiamine, IV/IM, 100 mg immediately.

Alcoholics (or where alcohol intake cannot be excluded)

CAUTION
Thiamine should preferably be administered prior to intravenous glucose to
prevent permanent neurological damage.
Do not delay the dextrose administration in a hypoglycaemic patient.

REFERRAL
Urgent
» All hypoglycaemic patients on oral hypoglycaemic agents.
» Hypoglycaemic patients who do not recover completely after treatment.
» All children with documented hypoglycaemia unless the cause is clearly
identified and safe management instituted to prevent recurrence.

9.3.2 SEVERE HYPERGLYCAEMIA (DIABETIC KETOACIDOSIS

(DKA) & HYPEROSMOLAR HYPERGLYCAEMIC STATE
(HHS)
E10.0-1/E11.0-1/E12.0-1/E13.0-1/E14.0-1

DESCRIPTION
Clinical features of severe hyperglycaemia include:
» dehydration » drowsiness, confusion, coma
» abdominal pain » acetone/fruity smelling breath
» vomiting » elevated blood glucose
» deep sighing respiration

MEDICINE TREATMENT
Adults
Average fluid deficit 6 L, and may be as much as 12 L.
Be cautious in renal and cardiac disease.
In the absence of renal or cardiac compromise:
x Sodium chloride 0.9%, IV, 15–20 mL/kg in the first hour.
o Subsequent infusion rate: 10 mL/kg/hour with 20 mL/kg boluses if shocked.
o Do not exceed 50 mL/kg in the first 4 hours.
o Correct estimated deficits over 24 hours.
Refer urgently with drip in place and running at planned rate.
When referral will take more than 2 hours and a diagnosis of diabetes with

x Insulin, short acting, IM, 0.1 unit/kg.

hyperglycaemia is confirmed:

o When giving insulin IM, do not use insulin needle.

2018 9.16
 CHAPTER 9 ENDOCRINE SYSTEM

CAUTION
Do not administer short acting insulin if the serum electrolyte status, especially
potassium is not known.
Continue with fluids but delay giving insulin in these cases in consultation with
referral facility as this delay should not negatively affect the patient, but
hypokalaemia with resultant cardiac dysrhythmias definitely will.

Children

x Sodium chloride 0.9%, IV, 20 mL/kg as a bolus.

If in shock:

o If shock not corrected, repeat the bolus.

o If a 3rd bolus is required, consult with paediatrician.

x Sodium chloride 0.9%, IV.

If no shock or aftershock is corrected:

Fluid rates of sodium chloride 0.9%, IV (if no Check regularly for shock or
shock) in children awaiting transfer. increasing dehydration
Weight range Rate(mL/hr)
kg (2–10 kg: 6 mL/kg/hr)
(>10-–20 kg: 5 mL/kg/hr)
(>20–40 kg: 4 mL/kg/hr)
>4–6 25
>6–10 40
>10–15 60
>15–20 85
>20–30 100
>30–45 150
>45–80 200

Refer urgently with drip in place and running at planned rate.

When referral will take > 2 hours and a diagnosis of diabetes with hyperglycaemia is

x Insulin, short acting, IM, 0.1 units/kg after 1st hour of infusion of saline
confirmed and provided glucose is monitored hourly:

o When giving insulin IM, do not use insulin needle.

9.4 MICROVASCULAR COMPLICATIONS OF DIABETES

9.4.1 DIABETIC NEUROPATHY
E10.4/E11.4 + (G63.2*/G99.0*/G59.0*)

DESCRIPTION
Neuropathies are a common complication of diabetes. They play an important role in
the morbidity and mortality suffered by people with diabetes.
There are three major categories:
» peripheral neuropathy
» autonomic neuropathy
» acute onset neuropathies

2018 9.17
 CHAPTER 9 ENDOCRINE SYSTEM

GENERAL MEASURES
» Educate patient regarding appropriate footwear and good foot care.
» Patients with neuropathy should have their feet examined at every visit.

MEDICINE TREATMENT
Ensure appropriate glycaemic control.
Exclude or treat other contributory factors e.g.:
» alcohol excess » uraemia
» vitamin B12 deficiency, if suspected » HIV infection

x Amitriptyline, oral, 10–25 mg at night increasing to 100 mg, if necessary.

Pain:

x Paracetamol, oral, 1 g 6 hourly as needed.

AND/OR

x Metoclopramide, oral, 10 mg 8 hourly before meals.

Gastroparesis:

REFERRAL
For further treatment if the above measures do not control symptoms adequately.

9.4.2 DIABETIC FOOT ULCERS

L97/L08.8 + (E10.5/E11.5/E12.5/E13.5/E14.5)

DESCRIPTION
Ulcers develop at the tips of the toes and on the plantar surfaces of the metatarsal
heads and are often preceded by callus formation.
If the callus is not removed, then haemorrhage and tissue necrosis occurs below the
plaque of callus, which leads to ulceration. Ulcers can be secondarily infected by
staphylococci, streptococci, coliforms, and anaerobic bacteria which can lead to
cellulitis, abscess formation, gangrene, and osteomyelitis.

DIAGNOSIS
The three main factors that lead to tissue necrosis in the diabetic foot are:
» neuropathy,
» infection, and
» ischaemia.

GENERAL MEASURES
» Metabolic control.
» Treat underlying comorbidity.
» Relieve pressure: non-weight bearing is essential.
» Smoking cessation is essential.
» Frequent (e.g. weekly) removal of excess keratin by a chiropodist with a scalpel
blade to expose the floor of the ulcer and allow efficient drainage of the lesion.
» Cleanse with sodium chloride 0.9% solution daily and apply non-adherent dressing.

2018 9.18
 CHAPTER 9 ENDOCRINE SYSTEM

x
MEDICINE TREATMENT
Amoxicillin/clavulanic acid 875/125 mg oral 12 hourly for 10 days.
Severe penicillin allergy: (Z88.0)
Refer.

REFERRAL
Urgent
Threatened limb, i.e. if the ulcer is associated with:
» cellulitis,
» severe hyperglycaemia,
» abscess,
» discolouration of surrounding skin, or
» crepitus.
Non-urgent
» Claudication.
» Ulcers not responding to adequate treatment.
» Severe penicillin allergy.

9.4.3 DIABETIC NEPHROPATHY

E10.2/E11.2/E12.2/E13.2/E14.2 + (N18.1-5/N18.9)

DESCRIPTION
Screening
» Check annually for proteinuria using dipstix.
» A diagnosis of nephropathy can be made on either a positive dipstix or, if dipstix
negative, send urine to laboratory for albumin:creatinine ratio. If ratio > 30 mg/g
(3 mg/mmol), diagnose nephropathy.
» Measure serum creatinine annually, and estimate eGFR. LoE: IIIv

Diet and lifestyle

» Limit protein intake < 0.8 g/kg daily, if proteinuric.
» Advise smoking cessation.

MEDICINE TREATMENT
Start treatment with an ACE-inhibitor and increase gradually to maximal dose if
tolerated.
ƒ ACE-inhibitor, e.g.:
x Enalapril, oral, initiate with 5 mg 12 hourly.
o Increase to maximum daily dose of 20 mg.
o Monitor potassium, at baseline, within 1 month, and annually.
LoE: Ivi
Persistent proteinuria
See Chapter 9: Kidney and urological disorders.

Hypertension
Target BP: < 140/90 mmHg. See Section 4.7: Hypertension.

2018 9.19
 CHAPTER 9 ENDOCRINE SYSTEM

Diabetes mellitus
Target HbA1c < 7.5%.
Intensify other renal and cardiovascular protection measures (not smoking, aspirin
therapy, lipid-lowering therapy).

REFERRAL
To specialist: When eGFR<30 mL/minute or earlier if symptomatic.

9.5 CARDIOVASCULAR RISK IN DIABETES

E10.5-9/E11.5-9
See section 4.1: Prevention of ischaemic heart disease and atherosclerosis.

9.5.1 OBESITY IN DIABETES

E66.0/E66.8-9 + (E10.5-9/ E11.5-9)

DESCRIPTION
Abdominal obesity is a waist circumference >94 cm in men, and > 80 cm in women.
BMI is determined by weight in kg/height in m2.
BMI (kg/m2)
18.5–24.9 normal
25.0–29.9 overweight
30.0–34.9 mildly obese
35.0–39.9 moderately obese
>40 extremely obese

GENERAL MEASURES
A decrease in food intake together with an increase in physical activity is crucial to
losing weight.

MEDICINE TREATMENT
Treat the metabolic risk factors, i.e. dyslipidaemia, hypertension, and
hyperglycaemia.

9.5.2 DYSLIPIDAEMIA IN DIABETES

E78.0-6/E78.8-9

DESCRIPTION
Dyslipidaemia in type 2 diabetes is usually characterised by increased fasting
plasma triglycerides (> 1.7 mmol/L), decreased HDL cholesterol (< 1.0 mmol/L in
men and < 1.3 mmol/L in women) and to a lesser extent, increased LDL cholesterol.
In those with type 1 diabetes, triglycerides, and to a lesser extent cholesterol
concentration, are usually increased.

2018 9.20
 CHAPTER 9 ENDOCRINE SYSTEM

MONITORING
See Section 9.2.2: Type 2 diabetes mellitus, in adults.

MEDICINE TREATMENT
Dyslipidaemia may successfully be treated through lifestyle modifications alone.

ƒ HMGCoA reductase inhibitor (statin) therapy should be added to lifestyle

modifications, regardless of baseline lipid concentrations, for all type 2 diabetic

 are > 40 years of age;

patients, who:

 have had diabetes for > 10 years;

 have existing cardiovascular disease (for example angina pectoris, previous

 have chronic kidney disease (eGFR < 60 mL/minute);

myocardial infarction, peripheral vascular disease or stroke);

x e.g.: Simvastatin, oral, 10 mg at night.

In patients < 40 years of age, risk assess as for dyslipidaemia; patients on protease
inhibitors or amlodipine, see Section 4.1: Prevention of ischaemic heart disease and
atherosclerosis.

REFERRAL
» Random cholesterol > 7.5 mmol/L.
» Fasting (14 hours) triglycerides > 10 mmol/L.

9.5.3 HYPERTENSION IN DIABETES

I10

BP lowering in hypertensive patients reduces cardiovascular risk. The diagnosis of

hypertension is confirmed if the blood pressure remains > 140/90 mmHg on two
separate days. See Section 4.7: Hypertension.

9.6 HYPOTHYROIDISM

9.6.1 HYPOTHYROIDISM IN NEONATES

E03.0-5/E03.8-9

DESCRIPTION
Congenital deficiency of thyroid hormone due to aplasia/hypoplasia of the thyroid
gland, defects in thyroid hormone biosynthesis or intrauterine exposure to antithyroid
medicines. Congenital hypothyroidism is one of the common treatable causes of
preventable mental retardation in children. Congenital hypothyroidism must be
treated as early as possible to avoid intellectual impairment.

DIAGNOSIS
Clinical
» prolonged jaundice » swollen hands, feet and genitals

2018 9.21
 CHAPTER 9 ENDOCRINE SYSTEM

» feeding difficulties » decreased muscle tone

» lethargy » delayed achievement of milestones
» constipation » enlarged tongue

REFERRAL
All patients for investigation and initiation of therapy.

9.6.2 HYPOTHYROIDISM IN CHILDREN AND ADOLESCENTS

E03.0-5/E03.8-9

DESCRIPTION
Hypothyroidism in children causes decreased growth, lethargy, cold intolerance and
dry skin. Physical signs may include goitre, short stature, bradycardia and delayed
deep tendon reflexes.
Congenital hypothyroidism may present in childhood. Acquired hypothyroidism in
children and adolescents may be caused by:
» chronic lymphocytic thyroiditis » radioactive iodine
» iodine deficiency » infiltrations
» surgery

DIAGNOSIS
Elevated TSH and low T4 concentrations.

x
MEDICINE TREATMENT
Levothyroxine, oral, 100 mcg/m2 once daily, preferably on an empty stomach
(Doctor initiated).

REFERRAL
All cases for investigation and initiation of therapy.

9.6.3 HYPOTHYROIDISM IN ADULTS

E03.0-5/E03.8-9

DESCRIPTION
Hypothyroidism causes general slowing of metabolism, which results in symptoms
that include fatigue, slow movement and speech, hoarse voice, weight gain,
constipation, cold intolerance, depression and impaired memory. Physical signs may
include bradycardia, dry, coarse skin, hair loss and delayed relaxation of deep tendon
reflexes.
Common causes of primary hypothyroidism are:
» thyroiditis » post-surgery
» amiodarone » radio-active iodine
Secondary hypothyroidism (< 1% of cases) may be due to any cause of anterior
hypopituitarism.

2018 9.22
 CHAPTER 9 ENDOCRINE SYSTEM

DIAGNOSIS
» Check TSH concentration. If elevated, check T4 concentration.
» If TSH is elevated, and T4 is low, diagnose hypothyroidism.

x
MEDICINE TREATMENT
Levothyroxine, oral, 100 mcg daily, preferably on an empty stomach.
o If there is a risk of ischaemic heart disease, start at 25 mcg daily and increase
by 25 mcg every 4 weeks.
o In the elderly, start at 50 mcg daily, increased by 25 mcg at 4 week intervals,
according to response.
o Check TSH and T4 after 2–3 months and adjust dose if required.
o Once stable, check TSH andT4 annually.

REFERRAL
» Suspected hypopituitarism.
» Hypothyroidism in pregnancy.

9.7 HYPERTHYROIDISM
9.7.1 HYPERTHYROIDISM IN CHILDREN AND ADOLESCENTS
E05.0-5/E05.8-9

DESCRIPTION
Hyperthyroidism is a pathological syndrome in which tissue is exposed to excessive
amounts of circulating thyroid hormones. The most common cause is Grave’s
disease, although thyroiditis may also present with thyrotoxicosis.

DIAGNOSIS
Clinical
» fatigue » tachycardia
» nervousness or anxiety » warm moist hands
» weight loss » thyromegaly
» palpitations » tremor
» heat insensitivity

REFERRAL
Urgent
All patients.

9.7.2 HYPERTHYROIDISM IN ADULTS

E05.0-5/E05.8-9

DESCRIPTION
Most common cause of hyperthyroidism is Graves’ disease, which is an autoimmune
condition resulting from the presence of thyroid stimulating autoantibodies. Other

2018 9.23
 CHAPTER 9 ENDOCRINE SYSTEM

common causes are toxic single or multinodular goitre and sub-acute thyroiditis.

DIAGNOSIS
Suppressed TSH and elevated T4.
Note: T4 may be normal in hyperthyroidism.

REFERRAL
Urgent
All patients.

References:
i Diet recommendations (diabetes mellitus): Evert AB, Boucher JL, Cypress M, Dunbar SA, Franz MJ, Mayer-Davis EJ,
Neumiller JJ, Nwankwo R, Verdi CL, Urbanski P, Yancy WS Jr. Nutrition therapy recommendations for the management of
adults with diabetes. Diabetes Care. 2014 Jan;37 Suppl 1:S120-43. https://www.ncbi.nlm.nih.gov/pubmed/24357208
Diet recommendations (diabetes mellitus): The Society for Endocrinology, Metabolism and Diabetes of South Africa Type 2
Diabetes Guidelines Expert Committee. The 2017 SEMDSA Guideline for the Management of Type 2 Diabetes Guideline
Committee. JEMDSA 2017; 21(1)(Supplement 1): S1-S196. http://www.jemdsa.co.za/index.php/JEMDSA/article/view/647/937
ii Insulin, SC (stop sulphonylureas): Swinnen SG, Dain MP, Mauricio D, DeVries JH, Hoekstra JB, Holleman F. Continuation

versus discontinuation of insulin secretagogues when initiating insulin in type 2 diabetes. Diabetes ObesMetab. 2010
Oct;12(10):923-5. http://www.ncbi.nlm.nih.gov/pubmed/20920046
iii Insulin, biphasic, SC (starting dose): The Society for Endocrinology, Metabolism and Diabetes of South Africa Type 2

Diabetes Guidelines Expert Committee. The 2017 SEMDSA Guideline for the Management of Type 2 Diabetes Guideline
Committee. JEMDSA 2017; 21(1)(Supplement 1): S1-S196. http://www.jemdsa.co.za/index.php/JEMDSA/article/view/647/937
iv Dextrose 10%, IV:Moore C, Woollard M. Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A

randomised controlled trial.Emerg Med J. 2005 Jul;22(7):512-5.https://www.ncbi.nlm.nih.gov/pubmed/15983093

v Albumin:creatinine ratio (diabetic nephropathy): Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group.

KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease.Kidney inter., Suppl. 2013;
3: 1–150. http://www.kdigo.org/clinical_practice_guidelines/pdf/CKD/KDIGO_2012_CKD_GL.pdf
vi ACE-inhibitor, oral: Lv J, Perkovic V, Foote CV, Craig ME, Craig JC, Strippoli GF. Antihypertensive agents for preventing

diabetic kidney disease. Cochrane Database Syst Rev. 2012 Dec 12;12:CD004136.
https://www.ncbi.nlm.nih.gov/pubmed/23235603
ACE-inhibitor, oral: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of Cape
Town. 2016.
ACE inhibitor, oral: National Department of Health, Essential Drugs Programme: Adult Hospital level STGs and EML, 2015.
http://www.health.gov.za/

2018 9.24
PHC Chapter 10: Infections and related
conditions
10.1 Antiseptics and disinfectants
10.2 Chickenpox
10.3 Cholera
10.4 Dysentery, bacillary
10.5 Fever
10.6 Giardiasis
10.7 Malaria
10.7.1 Malaria, non-severe/uncomplicated
10.7.2 Malaria, severe (complicated)
10.7.3 Malaria, prophylaxis (self-provided care)
10.8 Measles
10.9 Meningitis
10.10 Mumps
10.11 Rubella (German measles)
10.12 Schistosomiasis (bilharzia)
10.13 Shingles (Herpes zoster)
10.14 Tick bite fever
10.15 Typhoid fever
10.16 Tuberculosis
10.17 Tuberculosis, extrapulmonary
10.18 Viral haemorrhagic fever (VHF)
 CHAPTER 10 INFECTIONS AND RELATED CONDITIONS

10.1 ANTISEPTICS AND DISINFECTANTS

DESCRIPTION
Disinfectants are used to kill micro-organisms on working surfaces and instruments,
but cannot be relied on to destroy all micro-organisms.
Antiseptics are used for reducing bacterial load on skin and mucous membranes.
Disinfecting surfaces
Guidelines for the use of disinfectants
» Cleansing (removal of visible soiling) is the first and most important step in
chemical disinfection.
» The disinfectant fluid must entirely cover the object and penetrate all crevices.
» Use the recommended strengths for specific purposes.
» Disinfectants cannot sterilise surgical instruments.
» No chemical agent acts immediately; note the recommended exposure time.
» Equipment must be rinsed with sterile water after immersion in a chemical
disinfectant e.g. chlorhexidine solution, 0.5% in 70% alcohol.
» Avoid recontamination at this stage.
» Make sure that the rinsing water and all other apparatus are sterile.
» Equipment must not be stored in chemical disinfectants.
» The best disinfectant for killing HIV and other pathogens is a chlorinated solution
such as bleach or hypochlorite:
– Solutions must be freshly prepared.
– Discard after 24 hours to disinfect properly.
– Do not use on the skin.

Intact skin
» Use alcohol swabs to clean skin surface before injections are administered.
» Use antiseptics like povidone iodine or chlorhexidine for surgical scrubbing.

x Use chlorhexidine 0.05% aqueous solution to clean dirty wounds.

Wounds and mucous membranes

x Use sodium chloride 0.9% and sterile water on clean wounds.

Disinfectant Indications Directions for application

x Chlorhexidine » Cleaning dirty » Remove all dirt, pus and blood before
solution: wounds. use.
o 0.05% aqueous » Skin disinfection » Clean dirty wounds with 0.05%
solution. before surgery. aqueous solution.
o 0.5% in 70% » Do not use for normal cleaning.
alcohol. » Use the correct concentration for a
specific purpose.
x Povidone iodine: » Skin and wound » Use ointment for skin infection.
o solution 10%. infections » Use solution for cleaning skin and
o ointment 10%. Contraindication: wounds.
o cream 5%. iodine allergy. » Avoid using on large wounds because
of danger of iodine absorption.

2018 10.2
 CHAPTER 10 INFECTIONS AND RELATED CONDITIONS

Articles and instruments

Adhere to the appropriate cleansing and disinfection policy.

10.2 CHICKENPOX
B01.9/B01.8

DESCRIPTION
A mild viral infection that presents 2–3 weeks after exposure, with:
» mild fever preceding the rash
» lesions beginning on the trunk and face, later spreading to the arms and legs
» small, red, itchy spots that turn into blisters and crusts. These stages may all be
present at the same time.
Chickenpox is infective from the start of the fever until 6 days after the lesions have
appeared or until all the lesions have crusted.
The infection is self-limiting, with a duration of about 1 week.
Complications such as secondary bacterial infection, encephalitis, meningitis and
pneumonia may occur (more common in adults and immunocompromised patients).

GENERAL MEASURES
» Isolate from immunocompromised people and pregnant women until all lesions
have crusted.
» Ensure adequate hydration.
» Cut fingernails short and discourage scratching.

MEDICINE TREATMENT
CAUTION
Avoid the use of aspirin in children and adolescents < 16 years of age with acute
febrile illness because of risk of Reye’s syndrome.

x Calamine lotion, applied as needed.

For itch:

In severe cases

x Chlorphenamine, oral, 0.1 mg/kg/dose 6–8 hourly. See dosing table, pg 23.3.
Children

CAUTION
Do not give an antihistamine to children < 2 years of age.

x Chlorphenamine, oral, 4 mg, 6–8 hourly.

Adults

For fever with distress:

x Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See dosing table,
Children

pg 23.8.

2018 10.3
 CHAPTER 10 INFECTIONS AND RELATED CONDITIONS

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per 24

Adults

hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.
If skin infection is present due to scratching, treat as for bacterial skin infection. See
Section 5.4: Bacterial infections of the skin.

Treatments with antiviral agents are recommended for:

» Immunocompromised patients.

 Extensive rash.  Visceral involvement.

» All patients with severe chickenpox (irrespective of duration of rash).

 Haemorrhagic rash.  Presence of complications.

» Adults and adolescents presenting within 48 hours of the onset of the rash.
» Pregnant women.

x Aciclovir, oral, 20 mg/kg/dose6 hourly for 7 days (Doctor prescribed).

Children

Weight Dose Use one of the following: Age

kg mg Susp Tablet months/years
200 mg 200 mg 400 mg
/5 mL
>3.5–5 100 2.5 mL – – >1–3 months
>5–7 140 3.5 mL – – >3–6 months
>7–9 160 4 mL – – >6–12 months
>9–11 200 5 mL 1 tablet ½ tablet >12–18 months
>11–14 240 6 mL – – >18 months–3 years
>14–25 300 7.5 mL 1½ tablet – >3–5 years
>25–35 500 15 mL 2 ½ tablets – >7–11 years
>35–55 700 – 3 ½ tablets – >11–15 years

Adults
ƒ Antiviral, (active against varicella zoster) e.g.:
x Aciclovir, oral, 800 mg 6 hourly for 7 days (Doctor prescribed). LoE:IIIi

REFERRAL

 meningoencephalitis
» Complications such as:

 pneumonia
» Severely ill patients.
» Pregnant women.
» Asymptomatic neonates whose mothers had developed chickenpox during the
period from 7 days before to 7 days after delivery.
» Neonates with clinical chickenpox.

2018 10.4
 CHAPTER 10 INFECTIONS AND RELATED CONDITIONS

10.3 CHOLERA
See Chapter 2: Gastrointestinal conditions.

10.4 DYSENTERY, BACILLARY

See Chapter 2: Gastrointestinal conditions.

10.5 FEVER
R50.0-1/R50.8-9

DESCRIPTION
Fever, i.e. temperature • 38°C, is a natural and sometimes useful response to
infection, inflammation or infarction.
Fever alone is not a diagnosis.
Fever may be associated with convulsions in children < 6 years of age, but is not a
cause of the convulsions.
Note:
» Temperature > 40°C needs urgent lowering in children.
» Fluid losses are increased with fever.
» Malaria must be considered in anyone with fever who lives in a malaria endemic
area, or who has visited a malaria area in the past 12 weeks.

GENERAL MEASURES
Children
» Caregivers should offer the child fluids regularly to keep them well hydrated
(where a baby or child is breastfed the most appropriate fluid is breast milk).
» Dress child appropriately for the weather.
» Ensure the child is rested.
» Following contact with a healthcare professional, parents and carers who are looking
after their feverish child at home should seek further advice if:
– the child has a convulsion
– the child develops a non-blanching rash
– the parent or carer feels that the child is less well than when they previously sought
advice
– the parent or carer is more concerned than when they previously sought advice
– the fever lasts > 2 days
Note: Tepid sponging and evaporative cooling are not recommended, as this causes
the child to shiver which actually increases the core temperature.
Adults
Maintain hydration.

MEDICINE TREATMENT
Consider treatment with paracetamol in adults with associated tachycardia, possibility
of worsening cardiac conditions, and adults and children who are in distress.

2018 10.5
 CHAPTER 10 INFECTIONS AND RELATED CONDITIONS

Antipyretic agents are not indicated with the sole aim of reducing body temperature in
children and adults with fever.

x Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See dosing table,
Children

pg 23.8.

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per 24

Adults

hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.

CAUTION
Do not treat undiagnosed fever with antibiotics, except in children < 2 months of
age who are classified as having
POSSIBLE SERIOUS BACTERIAL INFECTION.
Do not give aspirin to children and adolescents with acute febrile illness.

Children < 2 months of age, fulfilling any criterion of possible serious bacterial

x Ceftriaxone, IM, 80 mg/kg/dose immediately as a single dose. See dosing

infection (see referral criteria):

table, pg 23.3.
o Do not inject more than 1 g at one injection site.
CAUTION: USE OF CEFTRIAXONE IN NEONATES AND CHILDREN
» If SUSPECTING SERIOUS BACTERIAL INFECTION in neonate, give ceftriaxone,
even if jaundiced.

 If ” 28 days old, avoid calcium-containing IV fluids for 48 hours after ceftriaxone

» Avoid giving calcium-containing IV fluids (e.g. Ringer Lactate) together with ceftriaxone:

 If > 28 days old, ceftriaxone and calcium-containing IV fluids may be given

administered.

sequentially provided the giving set is flushed thoroughly with sodium chloride

 Preferably administer IV fluids without calcium contents.

0.9% before and after.

» Always include the dose and route of administration of ceftriaxone in the referral letter.

REFERRAL
» All children < 2 months of age with any one of the following criteria of possible
serious bacterial infection:
– axillary temperature > 37.5°C
– bulging fontanelle
– decreased movement/only moves when stimulated
– convulsions with current illness
– decreased level of consciousness
– breathing difficulties, i.e. respiratory rate > 60, nasal flaring, chest in-drawing
or apnoea

2018 10.6
 CHAPTER 10 INFECTIONS AND RELATED CONDITIONS

– pus forming conditions, i.e. umbilical redness extending to the skin or

draining pus, many or severe skin pustules, pus draining from eye
» All children in whom a definite and easily managed cause is not found.
» Fever that lasts > 2 days without finding a treatable cause.
» Fever that recurs.
» Fever combined with:
– signs of meningitis – coma or confusion
– toxic-looking patient – jaundice
– convulsion – failure to feed

10.6 GIARDIASIS
See Chapter 2: Gastrointestinal conditions.

10.7 MALARIA
Note: notifiable medical conditions.

Refer to the most recent Malaria Treatment Guidelines from the Department of Health
for the most suitable management in the various endemic areas.

Global malaria endemic areas:

https://www.iamat.org/risks/malaria?gclid=CjwKEAiAjIbBBRCitNvJ1o257WESJADp
oUt072u5_X4Wb0fVtkQLiEFrWye263Ef_on8eykkOwLK_hoCFtDw_wcB

Local endemic areas:

https://www.santhnet.co.za/index.php/travel-health-advice/travel-advice/malaria-
advice-for-travellers/item/330-malaria-risk-map-for-south-africa-2017.html

DESCRIPTION
Malaria is an infection of red blood cells by a parasite micro-organism called
Plasmodium. Five species of Plasmodium are known to cause malaria in humans in
Africa. The five species are:
» Plasmodium falciparum (P. falciparum)
» Plasmodium vivax (P. vivax)
» Plasmodium ovale (P. ovale)
» Plasmodium malariae (P. malariae)
» Plasmodium knowlesi (P. knowlesi)
The parasites are usually transmitted to humans by the bite of a vector mosquito. In
South Africa, P. falciparum is the most common and the most dangerous of the
malaria species. Malaria caused by P. falciparum is an acute febrile illness that may
progress rapidly to severe disease if not diagnosed early and treated adequately.
Symptoms and signs of malaria are non-specific.
The most important element in the diagnosis of malaria is a high index of suspicion
in both endemic and non-endemic areas. Any person resident in or returning from a
malaria area and who presents with fever (usually within 3 months of possible

2018 10.7
 CHAPTER 10 INFECTIONS AND RELATED CONDITIONS

exposure to vector mosquito bites) should be tested for malaria. The progression of
P. falciparum malaria to severe disease is rapid and early diagnosis and effective
treatment is crucial. Pregnant women, young children ” 5 years of age and people
living with HIV/AIDS are at particularly high risk of developing severe malaria.
Symptoms and signs of malaria may include:
» severe headache » shivering episodes
» fever > 38qC » nausea and vomiting
» muscle and joint pains » flu-like symptoms
» diarrhoea » dry cough
Severe disease may present with one or more of the following additional
clinical features:
» prostration (severe general body weakness)
» sleepiness, unconsciousness or coma, convulsions
» respiratory distress and/or cyanosis
» jaundice
» renal failure
» shock
» repeated vomiting
» hypoglycaemia
» severe anaemia (Hb < 7 g/dL)
» haemoglobinuria/black urine
» abnormal bleeding

DIAGNOSIS
Microscopic examination of thick and thin blood smears. Thick films are more
sensitive than thin films in the detection of malaria parasites.
Where rapid diagnostic tests, e.g. HRP2 antigen dipsticks are available, these can be
used to diagnose malaria within 10–15 minutes.
Note:
» Rapid tests may remain positive up to 1 month after successful treatment
» One negative malaria test does not exclude the diagnosis of malaria. Request a
second test.

GENERAL MEASURES
» Provide supportive and symptomatic relief.
» Monitor for complications.
» Ensure adequate hydration.
» Carefully observe all patients with P. falciparum malaria for the first 24 hours for
features of severe malaria.

MEDICINE TREATMENT
All first doses of antimalarial medicines must be given under supervision and
patients must be observed for at least an hour as vomiting is common in patients
with malaria. Treatment must be repeated if the patient vomits within the first hour.
Vomiting oral treatment is one of the commonest reasons for treatment failure.

2018 10.8
 CHAPTER 10 INFECTIONS AND RELATED CONDITIONS

In areas with high incidence of malaria (whether locally transmitted or

imported) it should be definitively diagnosed and treated at PHC level. In other
areas, patients should be referred for treatment.

10.7.1 MALARIA, NON-SEVERE/UNCOMPLICATED

B51.9/B52.9/B53.0/B54
Note: notifiable medical condition.

x
MEDICINE TREATMENT
Artemether/lumefantrine 20/120 mg, oral, with fat-containing food/full cream
milk to ensure adequate absorption.
o Give the first dose immediately.
o Follow with second dose 8 hours later.
o Then 12 hourly for another 2 days (total number of doses in 3 days = 6).
Weight Tablet Age
kg Artemether/lumefantrine 20/120 mg months/years
>5–15 1 tablet 6 months–3 years
>15–25 2 tablets >3–8 years
>25–35 3 tablets >8–12 years
>35 4 tablets >12 years and adults

For fever in children < 5 years of age:

x Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See dosing table,
Children

pg 23.8.

REFERRAL
Urgent
» All patients in areas that do not stock antimalarials.
» Vomiting leading to inability to retain medication.
» Patients not responding to oral treatment within 48 hours.

 All patients with any sign of severe (complicated) malaria, see Section
» After 1st dose of artemether/lumefantrine 20/120 mg:

 All children < 2 years of age.

10.7.2: Malaria, severe/complicated.

 Pregnant women.
 Patients with co-morbidities such as HIV, diabetes etc.
 Patients > 65 years of age.

10.7.2 MALARIA, SEVERE/COMPLICATED

B50.0/B50.8
Note: notifiable medical condition.

DESCRIPTION
Any one of the following is a sign of severe (complicated) malaria, is associated

2018 10.9
 CHAPTER 10 INFECTIONS AND RELATED CONDITIONS

with a higher mortality, and requires urgent referral (after initial quinine dose
as below):
» prostration (severe general body weakness)
» sleepiness, confusion, unconsciousness or coma, convulsions
» respiratory distress and/or cyanosis
» jaundice
» renal failure
» shock
» repeated vomiting
» hypoglycaemia
» severe anaemia (Hb<7g/dL)
» haemoglobinuria/black urine
» abnormal bleeding

MEDICINE TREATMENT
Treatment may be commenced before referral in clinics designated by the regional
malaria control programme provided they have facilities to diagnose malaria (either
microscopy or rapid antigen point of care tests) and healthcare workers trained in the
management of severe malaria.
Correct hypoglycaemia immediately, if present.
The preferred agent is parenteral artesunate:
x Artesunate IM, 2.4 mg/kg IM immediately as a single dose and refer urgently.
o If transferral to referral hospital is delayed, administer second dose at 12 hours
and third dose at 24 hours.

x Quinine, IV or IM, 20 mg/kg immediately as a single dose and refer urgently.

If parenteral artesunate is not available:

See dosing table pg 23.9.

o IV: dilute with 5–10 mL/kg of dextrose 5% and administer over 4 hours. If
facilities not available for IV administration then:
o IM: dilute quinine dihydrochloride in sodium chloride 0.9% to between 60 and
100 mg/mL. Inject half the volume immediately as a single dose in each thigh
(anterolateral) to reduce pain and prevent sterile abscess formation.
Note: For all patients requiring referral, the patient must be transferred to reach
the referral hospital within 6 hours of being seen at the PHC facility.
Advise referral hospital that a loading dose has been administered.

REFERRAL
Urgent
All patients.

10.7.3 MALARIA, PROPHYLAXIS (SELF-PROVIDED CARE)

Z29.1

In South Africa, malaria prophylaxis should be used, together with preventive

measures against mosquito bites, from September to May in high-risk areas. State

2018 10.10
 CHAPTER 10 INFECTIONS AND RELATED CONDITIONS

facilities do not provide prophylactic therapy. It is recommended that persons

intending to travel to high-risk areas take the relevant prophylactic therapy.
Preventative measures against mosquito bites between dusk and dawn include:
» Use of di-ethyl 3-methylbenzamid (DEET) insecticide impregnated mosquito nets,
insecticide coils or pads.
» Application of insect repellent to exposed skin and clothing.
» Wearing long sleeves, long trousers and socks, if outside, as mosquitoes are most
active at this time.
» Visiting endemic areas only during the dry season.

CAUTION
Immunocompromised patients, pregnant women and children <5 years of age
should avoid visiting malaria-endemic areas, as they are more prone to the
serious complications of malaria.

Refer to National Department of Health Malaria Guidelines.

10.8 MEASLES
B05.0-4/B05.8-9
Note: notifiable medical condition.

CASE DEFINITION
» Fever.
AND
» Red maculopapular (blotchy) rash.
AND
» Cough or coryza (runny nose) or conjunctivitis.
Inform the local EPI co-ordinator about all cases of suspected measles, (i.e.
which fulfil the case definition criteria). Send clotted blood and throat swabs to
confirm (or exclude) a diagnosis of measles.

DESCRIPTION
A viral infection that is especially dangerous in malnourished children or in children
who have other diseases such as TB or HIV/AIDS.
Initial clinical features, that occur 7–14 days after contact with an infected individual,
include:
» coryza » conjunctivitis which may be purulent
» fever » cough
» diarrhoea
After 2–3 days of the initial clinical features, a few tiny white spots, like salt grains appear
in the mouth (Koplik spots).
The skin rash appears 1–2 days later, lasting about 5 days and:
» usually starts behind the ears and on the neck
» then on the face and body
» thereafter, on the arms and legs
Secondary bacterial infection (bronchitis, bronchopneumonia, and otitis media) may

2018 10.11
 CHAPTER 10 INFECTIONS AND RELATED CONDITIONS

occur, especially in children with poor nutrition or other concomitant conditions.

GENERAL MEASURES
» Isolate the patient in the clinic to prevent spread.
» In the clinic utilise face masks and gloves when examining the patient.
» Counsel the caregiver to isolate the patient in the home (if feasible).
» Reduce exposure of children < 12 months of age and pregnant women to the
index patient.
» Ensure that the caregiver and other close contacts have been previously
immunised.

MEDICINE TREATMENT
All children < 5 years of age with measles should be given an extra dose of
vitamin A, unless the last dose was received within a month:
x Vitamin A (retinol), oral, as a single dose.
Age range Dose Capsule Capsule
units 100 000 IU 200 000 IU
Infants 6–11 months 100 000 1 capsule –
Children 12 months–5 years 200 000 2 capsules 1 capsule
In children < 5 years of age, give the 1st dose immediately. If the child is sent home,
the caregiver should be given a 2nd dose to take home, which should be given the
following day.
Administration of a vitamin A capsule
o Cut the narrow end of the capsule with scissors.
o Open the child’s mouth by gently squeezing the cheeks.
o Squeeze the drops from the capsule directly into the back of the child’s mouth. If
a child spits up most of the vitamin A liquid immediately, give one more dose.
For fever with distress:

x Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See dosing table,
Children

pg 23.8.

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per 24

Adults

hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.
Children with diarrhoea:
Treat according to Section 2.9.1: Acute diarrhoea in children.

x Amoxicillin, oral, 30 mg/kg/dose 8 hourly for 5 days. See dosing table, pg 23.2
Children with pneumonia (1st dose before referral):

2018 10.12
 CHAPTER 10 INFECTIONS AND RELATED CONDITIONS

Children with otitis media:

Children ” 3 years of age
x Amoxicillin, oral, 45 mg/kg/dose 12 hourly for 5 days.
Use one of the following:
Weight Dose Capsule Age
Syrup mg/5mL
kg mg mg Months/years
125 250 250 500
>7–11 375 15 mL 7.5 mL – – >6–18 months
>11–14 500 – 10 mL 2 1 >18 months–3 years

x Amoxicillin, oral, 500 mg, 8 hourly for 5 days.

Children > 3 years of age

Severe penicillin allergy: (Z88.0)

Children
ƒ Macrolide, e.g.:
x Azithromycin, oral, 10 mg/kg/dose daily for 3 days. See dosing table, pg 23.2.
LoE:IIIii

x Chloramphenicol, 1%, ophthalmic ointment 8 hourly into lower conjunctival sac.

Purulent conjunctivitis:

REFERRAL
» All adults.
» Children <6 months of age.
» Children who are malnourished or immunocompromised, or who have TB.
» Where serious complications are present. These include:
– stridor/croup
– pneumonia
– dehydration
– neurological complications
– severe mouth and eye complications
Provide emergency treatment, if needed, before referral.

10.9 MENINGITIS
See Chapter 15: Central nervous system.

10.10 MUMPS
B26.0-3/B26.8-9

DESCRIPTION
Incubation period: 14–21 days.
A viral infection primarily involving the salivary glands.
Signs and symptoms:
» Fever.
» Pain on opening the mouth or eating.

2018 10.13
 CHAPTER 10 INFECTIONS AND RELATED CONDITIONS

» About two days later a tender swelling appears below the ears at the angle of
the jaw, often first on one side and later on the other. The swelling disappears in
about 10 days.

GENERAL MEASURES
» Bed rest during febrile period.
» Advise on oral hygiene.
» Recommend plenty of fluids and soft food during acute stage.
» Patient is infectious from 3 days before parotid swelling to 7 days after it started.
Isolate until swelling subsides.
» Children may return to school 1 week after initial swelling.

MEDICINE TREATMENT

x Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See dosing table,
Children

pg 23.8.

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per 24

Adults

hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.

REFERRAL
» Abdominal pain (to exclude pancreatitis).
» Painful swollen testes (orchitis).
» Suspected meningo-encephalitis.

10.11 RUBELLA (GERMAN MEASLES)

B06.0/B06.8-9

DESCRIPTION
Incubation period: 14–21 days. A viral infection with skin lesions that is less severe
than measles and lasts only 3–4 days.
A maculopapular red rash starts on the face spreading to the trunk, arms and legs. It
usually fades as it spreads.

Note: If cough, coryza or conjunctivitis are also present, it is essential to exclude

measles. See case definition of measles (Section 10.8: Measles).

Clinical features include:

» mild rash
» swollen and tender lymph nodes behind the ears or at the back of the
neck(suboccipital)
» in adults, a small joint arthritis may occur

2018 10.14
 CHAPTER 10 INFECTIONS AND RELATED CONDITIONS

Note: Infection during the first or second trimester of pregnancy may lead to severe
permanent deformities in the baby. All pregnant women should be referred for
confirmation of diagnosis of rubella and counselling.

GENERAL MEASURES
» Bed rest, if needed.
» Isolate from pregnant women for 7 days after onset of the rash.

MEDICINE TREATMENT

x Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See dosing table,
Children

pg 23.8.

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per 24

Adults

hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.

REFERRAL
Urgent
» Pregnant women with rubella.
» Pregnant women who have been in contact with a patient with rubella.

10.12 SCHISTOSOMIASIS (BILHARZIA)

B65.0-3/B65.8-9
Note: notifiable medical condition.

DESCRIPTION
A parasitic infestation with:
» Schistosoma haematobium: primarily involves the bladder and renal tract, or
» Schistosoma mansoni: primarily involves the intestinal tract.
Infestation occurs during washing, bathing or paddling in water harbouring snails
shedding this parasite.
Clinical features vary with the location of the parasite.
Most cases are asymptomatic.
Chronic schistosomiasis may present with local or systemic complications due to
fibrosis, including urinary tract obstruction with ensuing renal failure, portal
hypertension or other organ involvement.
Schistosoma haematobium Schistosoma mansoni
Clinical features » blood in the urine » diarrhoea with blood and
» recurrent cystitis mucus in the stools
» other urinary symptoms » colicky abdominal pain
» enlarged liver and spleen
Diagnosis » eggs in urine or stool on microscopy
» rectal biopsy

2018 10.15
 CHAPTER 10 INFECTIONS AND RELATED CONDITIONS

Acute schistosomiasis occurs several weeks after exposure and may present with non-
specific signs such as fever, cough, headache and urticaria.
Life threatening cardiac and neurological complications may occur.
Refer all suspected cases for diagnosis and further management.
Diagnosis is made by assessing for eosinophilia and conducting serological testing.

GENERAL MEASURES
If bilharzia is endemic, educate the community to avoid contact with contaminated
water:
» Do not urinate or pass stools near water used for drinking, washing or bathing.
» Do not swim in contaminated water.
» Collect water from rivers and dams at sunrise when risk of infestation is lowest.
» Boil all water before use.

MEDICINE TREATMENT
In endemic areas where urine microscopy cannot be done patients should be treated
empirically after first excluding possible glomerulonephritis, i.e. no raised blood
pressure, no oedema, and no shortness of breath. See Section 8.3: Glomerular
diseases (GN).
In non-endemic areas treatment should be given only if eggs of S. haematobium or
S. mansoni are found in the urine/faeces.

x Praziquantel, oral, 40 mg/kg as a single dose. See dosing table pg 23.8.

Children

x Praziquantel, oral, 40 mg/kg as a single dose.

Adults

LoE:Iiii
Note: Praziquantel may cause life-threatening deterioration if given
in acute schistosomiasis. If the acute phase is suspected, consult with a specialist.

REFERRAL
» Children < 2 years of age.
» Ongoing urinary tract symptoms including haematuria persisting for 60 days after
treatment.
» Signs of bleeding disorders or glomerulonephritis.
» Suspected acute schistosomiasis.

10.13 SHINGLES (HERPES ZOSTER)

B02.0-3/B02.7-9

DESCRIPTION
Dermatomal eruption of vesicles on an erythematous base due to varicella zoster
virus (lies dormant in nerve ganglia following chickenpox).

2018 10.16
 CHAPTER 10 INFECTIONS AND RELATED CONDITIONS

GENERAL MEASURES
» Isolate patient from immunocompromised or pregnant non-immune individuals
(who may develop severe chickenpox).
» Offer HIV test, especially to patients.

MEDICINE TREATMENT
Antiviral therapy, indicated for herpes zoster:
» in immunocompetent individuals - only of benefit within 72 hours of onset, and
» in immunocompromised patients - beyond 72 hours, provided that there are
active lesions.
ƒ Antiviral, (active against herpes zoster) e.g.:
x Aciclovir, oral, 800 mg five times daily for 7 days (4 hourly LoE:Iiv
missing the middle of the night dose).
LoE:IIIv
For pain:
Pain is often very severe and requires active control. A combination of different

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per 24

classes of analgesics is often necessary.

hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.
AND/OR LoE:IIIvi
During acute presentation if pain is severe and not adequately

x Tramadol, oral 50mg 6 hourly (Doctor prescribed).

controlled:

o If response not adequate, increase dose to 100mg 6 hourly.

LoE:IIIvii
To treat post-herpetic neuralgia:

x Amitriptyline, oral, 25 mg at night (Doctor prescribed).

Initiate treatment with adjuvant therapy early.

o Titrate as necessary to a maximum of 75 mg.

LoE:IIIviii
REFERRAL
» Herpes zoster with secondary dissemination or neurological involvement.
» Ocular involvement (if the tip of the nose is involved then ocular involvement is
more likely).
» Uncontrolled pain.

10.14 TICK BITE FEVER

A79.8/A79.9

DESCRIPTION
Tick-borne infection due to Rickettsia conorii, acquired from dogs, or Rickettsia africae,
acquired from cattle and game. The hallmark of tick bite fever is the eschar, i.e. round
black lesion ± 5 mm in diameter with an inflammatory halo. A rash develops on about
the third day of illness in about two thirds of patients with R. conorii and in fewer cases

2018 10.17
 CHAPTER 10 INFECTIONS AND RELATED CONDITIONS

of R. africae infection. In R. conorii infection the rash is maculopapular and involves the
palms and soles. In R. africae infection the rash is sparse and may be vesicular. The
classic triad of fever, eschar and rash occurs in 50-75% of patients. Signs of severe tick
bite fever include severe headache, hypotension, shortness of breath and neurological
manifestations.

GENERAL MEASURES
» Application of insect repellent to exposed skin and clothing.
» Wearing long sleeves, long trousers and socks, if outside.
» Inspect clothing for presence of ticks after suspected exposure.
Complications include:
» vasculitis » myocarditis
» encephalitis » pneumonitis
» thrombosis » thrombocytopaenia
» renal failure

MEDICINE TREATMENT
Antibiotic therapy:
Treatment must be started before confirmation of diagnosis by serology.
Although not recommended for children < 8 years of age, doxycycline is still regarded
as the medicine of choice for children with tick bite fever. However, due to the
unavailability of lower dosage forms of doxycycline alternative medicines are
considered in children < 8 years of age or those weighing < 45kg with mild infection.
Mild to moderate infection:

x Azithromycin, oral, 10 mg/kg/dose daily for 3 days. See dosing table pg 23.2.
Children < 45 kg

LoE:IIix
Children • 45 kg and adults
x Doxycycline, oral, 100 mg 12 hourly for 7 days.
LoE:IIIx

x Azithromycin, oral, 500 mg 12 hourly for 3 days.

In pregnancy:

o In severe cases, initiate therapy with 1–2 days of doxycycline.

LoE:IIIxi
For headache and fever:

x Paracetamol, oral, 15 mg/kg/dose, 6 hourly as required. See dosing table, pg

Children

23.8.
LoE:IIIxii

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per 24

Adults

hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours
LoE:IIIxiii
REFERRAL
» Patients unable to take oral therapy.

2018 10.18
 CHAPTER 10 INFECTIONS AND RELATED CONDITIONS

» Patients not responding to adequate therapy.

» Patients with complications.
» Patients with severe tick bite fever.

10.15 TYPHOID FEVER

See Section 2.13: Typhoid fever.

10.16 TUBERCULOSIS
See Chapter 17: Respiratory conditions. Section 17.4: Pulmonary tuberculosis.
Note: notifiable medical condition.

10.17 TUBERCULOSIS, EXTRAPULMONARY

A18.0-9
Note: notifiable medical condition.

DESCRIPTION
Extra-pulmonary tuberculosis is defined as infection of organ systems other than the
lung with Mycobacterium tuberculosis. Extra-pulmonary TB can present with non-
specific symptoms such as unintentional weight loss (> 1.5kg in a month), night
sweats and fever for more than 2 weeks. Other symptoms depend on the organ
affected. The most common types of extra-pulmonary TB are listed below along with
commonly associated signs and symptoms:
Extra-pulmonary TB type Common presenting sign/symptom
TB lymphadenitis » Audible wheeze or typical brassy cough caused by large
mediastinal lymph nodes.
» Peripheral TB lymphadenopathy occurs in neck and
armpits. Typically nodes are large (> 2 cm), tender, non-
symmetrical, matted, firm to fluctuant and rapidly growing.
TB pleural effusion » Non-productive cough.
(usually single-sided) » Chest pain.
» Shortness of breath.
» High temperature.
» Tracheal and mediastinal shift away from the side of the
effusion.
» Decreased chest movement.
» Stony dullness on percussion on the side of the effusion.
TB of spine, bones and » Decreased movement in the joints.
joints » Excessive sweating, especially at night.
» Joint swelling with warm, tender joints.
» Low-grade fever.
» Muscle atrophy and/or spasms.
» Numbness, tingling, or weakness below the infection (if
the spine is involved).
TB pericardium » Chest pain.
» Shortness of breath.

2018 10.19
 CHAPTER 10 INFECTIONS AND RELATED CONDITIONS

» Dizziness and weakness from low cardiac output

» Signs and symptoms of right-sided heart failure
(tachycardia, low BP, peripheral oedema, liver congestion,
ascites).
TB meningitis » During the early phase of TB meningitis, malaise, low-
grade fever, headache and personality change may be
present.

 gradual onset of headache

» With suspected established infection assess for:

 malaise
 confusion
 decreased consciousness
 vomiting
 neck stiffness and positive Kernig’s sign
» In children, TB meningitis may be acute, sub-acute or
chronic and typically presents between 23-49 months of

 altered level of consciousness

age with:

 history of fever
 irritability
 headache
 convulsions
 poor feeding and failure to thrive
 vomiting
 cough
 meningism
Disseminated/miliary TB » Most often seen in children and young adults.
» Fever.
» Cough.
» Generalised lymphadenopathy.
» Hepatomegaly.
» Consider in febrile patients presenting with HIV wasting
syndrome.
TB empyema » Similar to pleural effusion, but aspiration reveals thick pus.
TB peritoneum » Ascites with no signs of portal hypertension.
» Possible palpable abdominal masses.
» Possible bowel obstruction.

REFERRAL
All suspected cases of extra-pulmonary TB should be referred immediately to
secondary or tertiary care for diagnosis and further management.

10.18 VIRAL HAEMORRHAGIC FEVER (VHF)

A98.0/A98.1/A98.2/A98.3/A98.4/A98.4/A98.5/A98.8/A99/A91
Note: notifiable medical conditions.

Consult the most recent Viral Haemorrhagic Fever Guidelines

from the National Department of Health.

2018 10.20
 CHAPTER 10 INFECTIONS AND RELATED CONDITIONS

DESCRIPTION
Viral haemorrhagic fevers (VHF) are uncommon conditions in South Africa. They may
present with non-specific signs (fever, headache, conjunctivitis, pharyngitis, myalgia
(especially lower back pain), diarrhoea, vomiting, abdominal pain) or with signs
strongly suggestive of VHF (petechial rash, ecchymoses, other haemorrhagic signs
e.g. epistaxis, haematemesis and melaena). Other symptoms and organ involvement
may be variable.
More than 90% of suspected cases of VHF in South Africa prove to be severe forms
of common diseases. Many of the diseases mistaken for VHF are treatable if
diagnosed early.
These include:
» Severe tick bite fever. » Fulminant hepatitis.
» Severe falciparum malaria. » Leptospirosis.
» Severe bacterial infections, particularly N.meningitidis.
Endemic causes of VHF in South Africa are Crimean-Congo fever and Rift Valley Fever,
both of which may be transmitted between humans by means of blood and body fluids.
Imported conditions include Lassa, Ebola and Marburg Fever amongst others.
Obtaining a history of possible exposure to infection (including a detailed travel
history) is crucial to diagnosing VHF. Relatives and friends often provide more reliable
information than severely ill patients.

GENERAL MEASURES
All suspected, probable VHF cases and contacts of VHF cases must be discussed
and managed in consultation with the Regional Virologist or Infectious Diseases
Consultant at the referral centre.
Cases should also be discussed with the Special Pathogens Unit of the National
Institute for Communicable Diseases (NICD):
Tel: 011 386 6000, Outbreak hotline: 082 883 9920
Transfer of patients will only occur once all relevant arrangements have been made
to limit further exposure to a potentially contagious and life threatening agent.

Viral haemorrhagic fevers (VHF) are readily transmitted to healthcare workers,

so it is essential to apply strict contact precautions.
ISOLATE ALL SUSPECTED SYMPTOMATIC CASES AT ALL TIMES

If VHF is considered, isolate patient in a single room and take proper precautions to
limit further exposure. These include where available:
» long-sleeved disposable gown,
» waterproof apron if the patient is bleeding,
» two pairs of latex gloves, one underneath the gown and one with the wrist of the
glove pulled over the gown wrist,
» disposable face mask (preferably with a visor),
» goggles if a mask without the visor is used,

2018 10.21
 CHAPTER 10 INFECTIONS AND RELATED CONDITIONS

» waterproof boots or 2 pairs of overshoes, one over the other.

Note: Do not touch your own skin with your gloved hands.

MANAGEMENT
Signs strongly suggesting VHF Non-specific signs that may occur
with VHF
» Petechial rash. » Fever.
» Ecchymoses. » Headache.
» Other haemorrhagic signs (e.g. » Conjuctivitis.
epistaxis, haematemesis, » Pharyngitis.
melaena). » Myalgia (especially lower back pain).
» Non-specific signs of infection. » Vomiting.
» Abdominal pain.
» Diarrhoea.

Management of VHF contact

» Consult clinician, discuss with NICD and isolate patient (See above).
» Record and follow-up all patient contacts.
Management of suspected/possible/probable VHF
» Non-specific signs:
– Consult with clinician, discuss with NICD, isolate patient, initiate ceftriaxone
and record and follow-up all patient contacts.

2018 10.22
 CHAPTER 10 INFECTIONS AND RELATED CONDITIONS

» Signs strongly suggestive of VHF:

– Consult with a clinician, discuss with NICD, isolate patient, initiate ceftriaxone
and arrange transfer with EMS (providing patient’s VHF status, and names,
addresses and telephone numbers of patient contacts).

x Ceftriaxone, IV, 2 g immediately.

Adults

LoE:IIIxiv

x Ceftriaxone, IM, 80 mg/kg/dose immediately as a single dose. See dosing

Children

table, pg 23.3.
o Do not inject more than 1 g at one injection site.
CAUTION: USE OF CEFTRIAXONE IN NEONATES AND CHILDREN
» If SUSPECTING SERIOUS BACTERIAL INFECTION in neonate, give ceftriaxone,
even if jaundiced.

 If ” 28 days old, avoid calcium-containing IV fluids for 48 hours after ceftriaxone

» Avoid giving calcium-containing IV fluids (e.g. Ringer Lactate) together with ceftriaxone:

 If > 28 days old, ceftriaxone and calcium-containing IV fluids may be given

administered.

sequentially provided the giving set is flushed thoroughly with sodium chloride

 Preferably administer IV fluids without calcium contents.

0.9% before and after.

» Always include the dose and route of administration of ceftriaxone in the referral letter.

REFERRAL
» All cases, after consultation with clinician, discussion with NICD, isolation of
patient and management of acute condition.
Manage all contacts of VHF cases according to the current national guidelines.
Ensure that contact details are obtained and that there is a plan to manage
contacts.

2018 10.23
 CHAPTER 10 INFECTIONS AND RELATED CONDITIONS
References:
i Antivirals to treat varicella zoster, oral- adults (therapeutic class):Tunbridge AJ, Breuer J, Jeffery KJ; British Infection
Society. Chickenpox in adults - clinical management. J Infect. 2008 Aug;57(2):95-102.
https://www.ncbi.nlm.nih.gov/pubmed/18555533
ii Azithromycin, oral: National Department of Health, Essential Drugs Programme: Paediatric Hospital Level STGs and EML,

2017. http://www.health.gov.za/
iii Praziquantel, oral (dosing in children and adults): Kramer CV, Zhang F, Sinclair D, Olliaro PL. Drugs for treating urinary

schistosomiasis. Cochrane Database Syst Rev. 2014 Aug 6;(8):CD000053. https://www.ncbi.nlm.nih.gov/pubmed/25099517

Praziquantel, oral (dosing in children and adults): Danso-Appiah A, Olliaro PL, Donegan S, Sinclair D, Utzinger J. Drugs for
treating Schistosoma mansoni infection. Cochrane Database Syst Rev. 2013 Feb 28;(2):CD000528.
https://www.ncbi.nlm.nih.gov/pubmed/23450530
iv Antivirals to treat herpes zoster, oral (therapeutic class): McDonald EM, De Kock J, Ram FS. Antivirals for management of

herpes zoster including ophthalmicus: a systematic review of high-quality randomized controlled trials. Antiviral Therapy 2012;
17(2): 255-264.https://www.ncbi.nlm.nih.gov/pubmed/22300753
v Aciclovir, oral: National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML, 2015.

http://www.health.gov.za/
vi Paracetamol, oral: National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML, 2015.

http://www.health.gov.za/
vii Tramadol, oral: National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML, 2015.

http://www.health.gov.za/
viii Amitriptyline, oral: National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML, 2015.

http://www.health.gov.za/
Amitriptyline, oral: Dworkin RH, Schmader KE. Treatment and prevention of postherpetic neuralgia. Clin Infect Dis. 2003
Apr 1;36(7):877-82. https://www.ncbi.nlm.nih.gov/pubmed/12652389
ix Azithromycin, oral (children < 45 kg): Meloni G, Meloni T. Azithromycin vs. doxycycline for Mediterranean spotted fever. Pediatr

Infect Dis J. 1996;15(11):1042-4. https://www.ncbi.nlm.nih.gov/pubmed/8933556

Azithromycin, oral: Chapman AS, Bakken JS, Folk SM, Paddock CD, Bloch KC, Krusell A, Sexton DJ, Buckingham SC,
Marshall GS, Storch GA, Dasch GA, McQuiston JH, Swerdlow DL, Dumler SJ, Nicholson WL, Walker DH, Eremeeva ME, Ohl CA;
TickborneRickettsial Diseases Working Group.; CDC.. Diagnosis and management of tickbornerickettsial diseases: Rocky
Mountain spotted fever, ehrlichioses, and anaplasmosis--United States: a practical guide for physicians and other health-care and
public health professionals. MMWR Recomm Rep. 2006 Mar 31;55(RR-4):1-27. https://www.ncbi.nlm.nih.gov/pubmed/16572105
x Doxycycline, oral (children > 45 kg and adults): National Department of Health, Essential Drugs Programme: Paediatric

Hospital Level STGs and EML, 2017. http://www.health.gov.za/ ; Adult Hospital level STG, 2015. http://www.health.gov.za/
xi Azithromycin, oral (pregnancy): National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and

EML, 2015. http://www.health.gov.za/

xii Paracetamol, oral (children - headache and fever in tick bite fever): National Department of Health, Essential Drugs

Programme: Paediatric Hospital Level STGs and EML, 2017. http://www.health.gov.za/

xiii Paracetamol, oral (adults - headache and fever in tick bite fever): National Department of Health, Essential Drugs

Programme: Adult Hospital Level STGs and EML, 2015. http://www.health.gov.za/

xiv Ceftriaxone, IM (adults): National Department of Health. National guidelines for recognition & management of viral

haemorrhagic fevers, 2015. http://www.health.gov.za/

2018 10.24
PHC Chapter 11:
Human immunodeficiency virus
and acquired immune deficiency
syndrome (HIV AND AIDS)

HIV infection in adults

11.1 Antiretroviral therapy, adults
11.2 Opportunistic infections, prophylaxis in adults
11.2.1 Cotrimoxazole prophylaxis
11.2.2 Isoniazid preventive therapy (IPT)
11.3 Opportunistic infections, treatment in adults
11.3.1 Aphthous ulcers in HIV infection
11.3.2 Candidiasis, oral
11.3.3 Candidiasis, oesophageal
11.3.4 Cryptococcosis
11.3.4.1 Cryptococcal infection, pre-
emptive therapy
11.3.4.2 Cryptococcal meningitis
11.3.5 Diarrhoea, HIV-associated
11.3.6 Eczema, seborrhoeic
11.3.7 Fungal nail infections
11.3.8 Fungal skin infections
11.3.9 Gingivitis, acute, necrotising, ulcerative
11.3.10 Herpes simplex ulcers, chronic
11.3.11 Herpes zoster (shingles)
11.3.12 Papular pruritic eruption
11.3.13 Pneumonia, bacterial
11.3.14 Pneumonia, pneumocystis
11.3.15 Toxoplasmosis
11.3.16 Tuberculosis (TB)
11.4 HIV and kidney disease
 &+$37(5 +,9$1'$,'6

HIV infection in children

11.5 The HIV-exposed infant
11.6 Management of HIV-infected children
11.7 Opportunistic infections, prophylaxis in
children
11.8 Opportunistic infections, treatment in children
11.8.1 Candidiasis, oral (thrush), recurrent
11.8.2 Candidiasis, oesophageal
11.8.3 Diarrhoea, HIV-associated
11.8.4 Pneumonia
11.8.5 Measles and chickenpox
11.8.6 Skin conditions
11.8.7 Tuberculosis (TB)
11.9 Developmental delay or deterioration
11.10 Anaemia

HIV prevention
11.11 Pre-exposure prophylaxis (PrEP)
11.12 Post exposure prophylaxis

Side effects and complications of ART

11.13 Immune Reconstitution Inflammatory
Syndrome (IRIS)
11.14 Lactic acidosis











2018 11.2
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HIV replicates in CD4 lymphocytes and monocytes, leading to progressive
destruction of CD4 lymphocytes and impaired immunity.
Primary infection is characterised by:
» glandular fevertype illness
» maculopapular rash
» small orogenital ulcers
After primary infection, patients may have generalised lymphadenopathy and are
usually asymptomatic for several years. Subsequently inflammatory skin conditions
and an increased frequency of minor infections occur, followed by more severe
infections (especially tuberculosis), weight loss or chronic diarrhoea. Eventually
severe opportunistic infections, HIV-associated cancers or other severe HIV
manifestations develop, known as the $cquired ,mmune 'eficiency 6yndrome
(AIDS).

',$*126,6
» Adequate pre- and post-test counselling must be provided.
» Ensure patient confidentiality.
» HIV in adults must be confirmed with a 2nd test. This can either be 2 rapid tests,
using kits from different manufacturers, or with 1 rapid test and 1 laboratory test,
usually ELISA.
» HIV antibodies are not detected during the 1st few weeks in primary infection. This
is known as the window period.

352*126,6
Progression of HIV diseases is variable. The CD4 lymphocyte count and clinical
features of immune suppression (see WHO staging below) both provide independent
information on prognosis. Patients may be asymptomatic with very low CD4 counts
or have severe clinical features with well-preserved CD4 counts. CD4 counts < 200
cells/mm3 indicate severe immune suppression. All HIV-infected patients must have
a CD4 count requested and WHO clinical staging done.

Although all HIV-infected patients are eligible for ART, irrespective of CD4 count or
WHO stage, some patients with high CD4 counts may elect to defer ART. The CD4
count should be repeated every 6 months in patients not yet started on ART. Patients
should be counselled about the benefits and risks of early ART initiation.

2018 11.3
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» Asymptomatic.
» Persistent generalised lymphadenopathy.
&OLQLFDOVWDJH
» Unexplained moderate weight loss (< 10% of presumed or measured
body weight).
» Recurrent respiratory tract infections (sinusitis, otitis media and pharyngitis).
» Herpes zoster (shingles).
» Angular stomatitis.
» Recurrent oral ulceration.
» Papular pruritic eruption.
» Seborrhoeic dermatitis.
» Fungal nail infections.
&OLQLFDOVWDJH
» Unexplained severe weight loss (> 10% of presumed or measured body weight).
» Unexplained chronic diarrhoea for > 1 month.
» Unexplained persistent fever (> 37.5ºC intermittent or constant for > 1 month).
» Persistent oral candidiasis (thrush).
» Oral hairy leukoplakia.
» Pulmonary TB.
» Severe bacterial infections (such as pneumonia, empyema, pyomyositis, bone or
joint infection, meningitis or bacteraemia).
» Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis.
» Unexplained anaemia (< 8 g/dL), neutropaenia (< 0.5 × 109/L) and/or chronic
thrombocytopaenia (< 50 × 109/L).
&OLQLFDOVWDJH
» HIV wasting syndrome.
» Extrapulmonary tuberculosis.
» Pneumocystis pneumonia.
» Recurrent severe bacterial pneumonia.
» Chronic herpes simplex infection (orolabial, genital or anorectal of > 1month
duration or visceral at any site).
» Oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs).
» Kaposi’s sarcoma.
» Cytomegalovirus infection (retinitis or infection of other organs).
» Central nervous system toxoplasmosis.
» HIV encephalopathy.
» Extrapulmonary cryptococcosis including meningitis.
» Disseminated non-tuberculous mycobacterial infection.
» Progressive multifocal leukoencephalopathy.
» Chronic cryptosporidiosis.
» Chronic isosporiasis.
» Disseminated mycosis (extrapulmonary histoplasmosis or coccidiomycosis).
2018 11.4
 &+$37(5 +,9$1'$,'6

» Recurrent septicaemia (including non-typhoidal Salmonella).

» Lymphoma (cerebral or B cell non-Hodgkin).
» Invasive cervical carcinoma.
» Atypical disseminated leishmaniasis.
» Symptomatic HIV-associated nephropathy or symptomatic HIV-associated
cardiomyopathy.

*(1(5$/0($685(6
» Patients and their families must be supported and encouraged to join support or
peer groups.
» Counsel patients on preventive methods of reducing the spread of HIV:
Ͳ use condoms during sexual intercourse
Ͳ ART in HIV-infected
Ͳ PrEP where indicated
Ͳ seek early treatment for sexually transmitted infections
Ͳ safe handling of blood spills.

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All adults with confirmed HIV infection, irrespective of CD4 count or WHO clinical stage.
LoE: Ii
7LPLQJRI$57LQLWLDWLRQ
ART may be started on the same day if the patient has no clinical contraindication,
and the patient is willing to start after receiving pre ART counselling. In general, ART
should be started as soon as possible, within 2 weeks of CD4 count result availability.
For clinical indications for deferring ART initiation, see below.

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ART should be initiated immediately in pregnancy and during breastfeeding.
LoE:IIIii
)DVWWUDFNLQJZLWKLQGD\V
Unless contra-indicated (see table below), ART should be initiated within one week
in the following cases:
» CD4 count < 200 cells/mm3 (except TB patients and cryptococcal meningitis).
» WHO stage 4 (except TB meningitis and cryptococcal meningitis).

&OLQLFDOLQGLFDWLRQVIRUGHIHUULQJ$57LQLWLDWLRQ
Early ART initiation increases the risk of the immune reconstitution inflammatory
syndrome (IRIS) (see Section 11.13.1: Immune Reconstitution Inflammatory
Syndrome (IRIS)). Defer ART in patients with cryptococcal meningitis (see Section
11.3.4.2: Cryptococcal meningitis) or TB meningitis (see Section 10.17: Tuberculosis,

2018 11.5
 &+$37(5 +,9$1'$,'6

extrapulmonary) as there is increased risk of mortality due to IRIS with early initiation
(see below for timing).

7%FRLQIHFWLRQ
Initiating ART in patients with TB co-infection
Start with TB treatment first, followed by ART initiation. Start ART as follows:
» In TB patients with CD4 counts < 50 cells/mm3 (except TB meningitis), start ART
within 2 weeks after starting TB treatment.
LoE:Iiii
» In patients with TB meningitis (irrespective of CD4 count), defer
ART until 8 weeks after starting TB treatment.
» In TB patients with CD4 count > 50 cells/mm3, defer ART until 8 LoE:Iiv
weeks after starting TB treatment, which has shown to be safe
and reduces the risk of deterioration due to the immune reconstitution
inflammatory syndrome (IRIS).
LoE:Iv
&U\SWRFRFFDOPHQLQJLWLV
Initiating ART in patients with cryptococcal meningitis
In patients with cryptococcal meningitis, ART should be deferred until 4–6 weeks after
starting antifungal treatment (earlier initiation has been shown to increase the risk of
death).

36<&+262&,$/,1',&$72562)5($',1(66)25$57
It is essential that patients have good insight into the need for long-term therapy and
high levels of adherence. Give careful attention to adherence planning. Encourage
patients to disclose their HIV status to somebody who should act as a treatment
supporter. If this is not possible then the patient should join a support group.
Manage depression.
Active substance abuse/alcohol is an impediment to adherence and, where possible,
should be addressed prior to initiating ART.
LoE:IIIvi

2018 11.6
Antiretroviral medicines: Dose and common adverse drug reactions (life-threatening reactions in bold type)
ART: DOSING AND IMPORTANT ADVERSE EFFECTS
Generic Class Usual dose Renal adjusted dose Important adverse drug reactions and timing
name
Abacavir NRTI 600 mg daily Dose adjustment not required » Hypersensitivity reaction (rare, occurs 1 to 6
(ABC) weeks): Suspect if 2 or more of 1) fever, 2) rash, 3)
gastrointestinal symptoms and 4) other symptoms
(pharyngitis, dyspnoea, cough, musculoskeletal,
malaise, lymphadenopathy, paraesthesia).
» Hyperlactataemia/ steatohepatitis (very low risk;
months).
LoE:IIIvii
Emtricitabine NRTI 200 mg daily CrCl 30-50 mL/min: 200 mg » Palmar hyperpigmentation.
(FTC) every 2 days » Hyperlactataemia / steatohepatitis (low risk;
CrCl 15-29 mL/min: 200 mg months).
every 3 days
CrCl < 15 mL/min: 200 mg
every 4 days

Lamivudine NRTI 300 mg daily (or CrCl 10-50 mL/min: 150 mg daily » Anaemia (pure red cell aplasia; rare).
(3TC) 150 mg 12 » Hyperlactataemia / steatohepatitis (low risk;
hourly) CrCl < 10 mL/min: 50 mg daily months).

Stavudine NRTI 30 mg 12 hourly CrCl 10-50 mL/min: 15 mg 12 » Peripheral neuropathy.

(d4T) hourly » Lipoatrophy.
» Hyperlactataemia / steatohepatitis (high risk,
CrCl < 10 mL/min: 15 mg daily months).
» Pancreatitis.
» Dyslipidaemia.

2018 11.7
CHAPTER 11 HIV AND AIDS

Tenofovir NtRTI 300 mg daily Avoid in renal impairment » Renal failure (weeks to months).
(TDF) » Reduced bone mineral density (months).
» Hyperlactataemia/ steatohepatitis (very low risk -
months).
Zidovudine NRTI 300 mg CrCl < 10 mL/min: 300 mg daily » Bone marrow suppression (anaemia,
(AZT) 12 hourly neutropaenia; weeks to months).
» Gastro-intestinal upset.
» Headache.
» Myopathy.
» Lipoatrophy (6 months).
» Hyperlactataemia / steatohepatitis (medium risk,
months).
Nevirapine NNRTI 200 mg Dose adjustment not required » Rash (high risk), hepatitis (high risk), (1 week to
(NVP) daily for 14 days 3 months).
then *Avoid in women with a CD4 count > 250
200 mg cells/mm3 and men with a CD4 count > 400
12 hourly cells/mm3 initiating ART due to increased risk of
rash associated hepatitis.
Efavirenz NNRTI 600 mg at night Dose adjustment not required » Central nervous system symptoms (vivid dreams,
(EFV) (400 mg if patient problems with concentration, confusion, mood
weighs < 40 kg). disturbance, psychosis).
» Rash (medium risk; 1 to 6 weeks).
» Hepatitis (medium risk; weeks to months)
» Gynaecomastia.
Etravirine NNRTI 200 mg 12 hourly Dose adjustment not required Rash, hepatitis (both uncommon)
(ETR) (2nd
Lopinavir/ generatio
Boosted 400/100 Dose adjustment not required » Gastrointestinal upset.
ritonavir n)
PI mg 12 hourly » Dyslipidaemia (high risk; weeks).
(LPV/r) OR » Rash and/or hepatitis (1 to 6 weeks).
800/200 mg daily
(only if PI- naïve)

2018 11.8
 CHAPTER 11 HIV AND AIDS

Atazanavir/ Boosted 300 mg with ritonavir Dose adjustment not required » Unconjugated hyperbilirubinaemia (common, but
ritonavir PI 100 mg daily benign as there is no associated hepatitis).
(ATV/r) » Dyslipidaemia (low risk).
» Hepatitis (1 to 6 weeks).
» Renal stones (not common).
Darunavir/ Boosted 600 mg 12 hourly with Dose adjustment not required GI upset, rash, dyslipidaemia, hepatitis (uncommon).
ritonavir PI 100 mg ritonavir 12 Contains sulphonamide moiety (use with caution in
(DRV/r) hourly or 800/100 mg patients with sulpha allergy)
daily
(only if PI-naive)
Dolutegravir InSTI 50 mg daily Dose adjustment not required Insomnia, headache and other CNS side effects, GI
(DTG) upset, hepatitis and rash (rare)
Raltegravir InSTI 400 mg 12 hourly Dose adjustment not required Headache and other CNS side effects, GI upset,
(RAL) hepatitis and rash (rare), rhabdomyolysis (rare)

NRTI = nucleoside reverse transcriptase inhibitor; NtRTI = nucleotide reverse transcriptase inhibitor; NNRTI = non-nucleoside reverse transcriptase inhibitor; PI =
protease inhibitor, InSTI = integrase strand transfer inhibitor
LoE:IIIviii

2018 11.9
Standardised national ART regimens for adults and adolescents
First-line
All new patients TDF + FTC (or Replace EFV with NVP* in patients
needing treatment, 3TC) + EFV with significant psychiatric co-
including pregnant morbidity or intolerance to EFV
women FDC preferred and where the neuropsychiatric
Contraindication to TDF + FTC (or toxicity of EFV may impair daily
EFV 3TC) + NVP* functioning, e.g. shift workers.

Contraindication to ABC + 3TC + EFV Renal impairment, i.e.:

TDF** (or NVP) » creatinine clearance < 50
mL/min, or
» eGFR < 60 mL/min/1.73 m2, or
» use of nephrotoxic medicines
e.g. aminoglycosides.
Contraindication to AZT + 3TC + EFV Renal disease or the use of other
TDF and ABC (or NVP) nephrotoxic medicines, e.g.
aminoglycosides and rash.
Currently on Switch to: Contraindication to TDF**:
d4T/AZT 1st line TDF + FTC (or Replace TDF with ABC.
regimen 3TC) + EFV

FDC preferred
Second-line
Management of If plasma HIV RNA >1000
virological failure copies/mL:
Check for adherence, tolerability
and medicine interactions and
assess psychological issues.
Repeat VL test 2 months later.

If plasma VL confirmed > 1000

copies/mL:
Change regimen to 2nd line
therapy.
Failing on a TDF- AZT + 3TC + LPV/r Check hepatitis B surface antigen
based 1st line – if positive continue TDF + 3TC
regimen (or FTC) and add AZT + LPV/r. *
Failing on an ABC - AZT + 3TC (or
based 1st line FTC) + LPV/r
regimen
Failing on a TDF + 3TC (or
d4T/AZT–based 1st FTC) + LPV/r
line regimen LoE:IIIix
Dyslipidaemia or Switch LPV/r to
diarrhoea associated ATV/r
with LPV/r
2018 11.10
 &+$37(5 +,9$1'$,'6

7KLUGOLQH
nd
Failing 2 line Genotype antiretroviral resistance test must be done. Only
regimen for > 1 year patients with resistance to LPV/r (or ATV/r) qualify for 3rd
and good adherence line. Application for 3rd line using the standard motivation
documented (e.g. by form is required (available from [email protected]) –
pharmacy refills on the regimen will be determined by an expert committee
time for the last 6 based on the pattern of resistance mutations and the prior
months). history of antiretroviral exposure.
Nevirapine should not be initiated in women with baseline CD4 count > 250
cells/mm3 or men with baseline CD4 count > 400 cells/mm3.
LoE:IIIx
Always check for hepatitis B co-infection before stopping TDF. If
patient has chronic hepatitis B, stopping TDF may lead to a fatal hepatitis flare. If
hepatitis B positive, TDF should be continued as a fourth medicine in the 2nd line
regimen.
 LoE:IIIxi
1RWHIn patients who have interrupted ART:
ª Recommence previous regimen and 
» Do VL, recommence ART regimen, do VL in 2 months. Target is greater than 1
log (10 fold) decrease. LoE:IIIxii

6WDQGDUGLVHGQDWLRQDOPRQLWRULQJIRUDGXOWVDQGDGROHVFHQWVZLWK+,9
$WLQLWLDOGLDJQRVLVRI+,9 3XUSRVH
Confirm HIV result with rapid antibody test. Ensure that national testing algorithm
has been followed.
If HIV-infected: Do CD4 count and WHO To assess eligibility for OI prophylaxis
clinical staging. and management.
To assess eligibility for fast-tracking.
Screen for pregnancy or ask if planning to See Section: 6.8: HIV in pregnancy.
conceive.
Screen for TB symptoms (See Section To identify TB/HIV co-infected.
17.4: Pulmonary tuberculosis).
If CD4 < 100 cells/mm3: Do cryptococcal To identify asymptomatic patients
antigen test (CrAg). who need pre-emptive fluconazole
treatment.
If AZT required: Do FBC. To detect anaemia or neutropaenia.
If TDF required: Do creatinine. To detect renal insufficiency.
If NVP required: Do ALT. To exclude liver disease.
2Q$57 3XUSRVH
CD4 at 1 year on ART. To monitor immune response to ART
and see if OI prophylaxis is still
necessary.
VL at month 6, 1 year and then every 12 To identify treatment failures and
months. problems with adherence.

2018 11.11
 &+$37(5 +,9$1'$,'6

If on NVP and develops rash or To identify NVP toxicity.

symptoms of hepatitis: Do ALT.
If on AZT: Do FBC at month 1, 2, 3 and 6. To identify AZT toxicity.
If on TDF: Do creatinine at month 3 and To identify TDF toxicity.
6, 1 year and then every 12 months.
If on LPV/r: Do fasting cholesterol and To identify LPV/r toxicity.
triglycerides at month 3.
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RSWLQJWRGHIHU$57
Repeat CD4 count at 6 months. To determine patient eligibility for OI
prophylaxis.
Screen for TB symptoms. To identify TB/HIV co-infection.
If no TB symptoms, consider IPT. See To prevent TB activation.
Section 11.2.2: Isoniazid preventive
therapy (IPT).
Offer advice on secondary prevention of To prevent HIV transmission and re-
HIV. infection and STIs.
In patients treated for TB with rifampicin-containing regimens there are some
important medicine interactions:
» Efavirenz is not significantly affected and no dose adjustment is needed.
» Nevirapine concentrations are modestly reduced. If efavirenz is contra-indicated
nevirapine can be used, but the lead-in dose of nevirapine must be omitted.
» Lopinavir concentrations are markedly reduced. The dose should be doubled
slowly (increase to 3 tablets 12 hourly after 1 week, then 4 tablets 12 hourly after
the 2nd week, with monthly ALT monitoring).
» Rifampicin reduces concentrations of some antiretrovirals (e.g. atazanavir)
including antiretrovirals used for 3rd line therapy (raltegravir, dolutegravir,
darunavir and etravirine). Patients on these medicines require referral for rifabutin
in place of rifampicin, antiretroviral dose-adjustment or change in the antiretroviral
regimen, as appropriate.
LoE:IIIxiii
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Contra-indications to commencing ART.

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Primary prophylaxis with cotrimoxazole prevents many infections, e.g.:

» Pneumocystis pneumonia » bacteraemia
» toxoplasmosis » isosporiasis
» bacterial pneumonia

2018 11.12
 &+$37(5 +,9$1'$,'6

,QGLFDWLRQVIRUSULPDU\SURSK\OD[LV
» WHO Clinical stage 2, 3 or 4.
25
» CD4 count < 200 cells/mm3.
3URSK\OD[LVVKRXOGEHGLVFRQWLQXHGLIWKH&'FRXQWLQFUHDVHVRQ$57WR!
FHOOVPPIRUDWOHDVWPRQWKV
x Cotrimoxazole, oral, 160/800 mg daily.
(See Section 17.3.4.2.4: Pneumocystis pneumonia for secondary prophylaxis).
1RWH Cotrimoxazole hypersensitivity is common and usually presents as a
maculopapular rash. If there are systemic features or mucosal involvement
associated with the use of cotrimoxazole, the medicine must be immediately and
permanently stopped and the patient referred to hospital.

 ,621,$=,'35(9(17,9(7+(5$3<,37

Z29.2 + (B24)

Patients with HIV infection are more susceptible to TB infection than HIV-uninfected
patients at any CD4 count.
It is essential to rule out active TB before IPT is given.
Do not start IPT if the patient has any of the following:
» Active cough (any duration). » Night sweats.
» Fever. » Weight loss.

0(',&,1(75($70(17

x Isoniazid, oral, 300 mg daily for 12 months

Start IPT together with ARVs:

$1'
x Pyridoxine, oral, 25 mg once daily for 12 months
o Educate patients on the symptoms of hepatotoxicity (nausea, vomiting,
yellow eyes, brown urine, pain in right upper quadrant).
o Instruct patient to present early if any of these symptoms arise.
o Patients should be followed up monthly for the first 3 months.
LoE:Ixiv
In pregnant women, starting ART:
» If CD4 •100 cells/microL:
x Defer IPT until after delivery. x Exclude active TB with symptom
» If CD4 <100 cells/microL:

screen, then give IPT.

LoE:IIxv

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Painful ulcers in the mouth, except the gums, hard palate and dorsum of the tongue.
2018 11.13
 &+$37(5 +,9$1'$,'6

Minor ulcers (< 1 cm diameter) usually heal within 2 weeks.

Major ulcers (> 1 cm diameter) are very painful, often very deep and persist. Major
ulcers generally resolve rapidly on ART.
Herpes simplex, histoplasmosis and mycobacteria may also present with major
mucosal ulcers.

0(',&,1(75($70(17

x Tetracaine 0.5 %, oral, topical, applied every 6 hours.

Minor aphthous ulcers:

o Apply a thin layer on the affected areas only.

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Major aphthous ulcers for further diagnostic evaluation.

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x Commence ART.
See Section 1.2: Candidiasis, oral (thrush).

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Infection of the oesophagus with candida, a fungus causing oral thrush.
Patients with oral thrush who have pain or difficulty on swallowing may have
oesophageal candidiasis.
See Section 1.2: Candidiasis, oral (thrush).

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Maintain hydration.

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x
x
Fluconazole, oral, 200 mg daily for 14 days.
Commence ART within 7 days (unless patient has cryptococcal or TB meningitis).
See section: 11.1 Antiretroviral therapy, adults.
LoE:IIIxvi
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» Inability to swallow.
» Frequent relapses.
» Poor response to fluconazole.

2018 11.14
 &+$37(5 +,9$1'$,'6

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1RWH The following CrAg+ patients require XUJHQWUHIHUUDO

» Pregnant women who are symptomatic (headache, confusion).
» Pregnant women who are asymptomatic, but in the 1st trimester.
LoE:IIIxvii
Adapted from: Govender NP, Meintjes G (Chairpersons), Bicanic T, Dawood H, Harrison TS, Jarvis
JN, et al. Guideline for the prevention, diagnosis and management of cryptococcal meningitis among HIV-infected persons:
2013 update. S Afr J HIV Med 2013;14(2):76-86. http://www.sajhivmed.org.za/index.php/hivmed/article/view/82/128

2018 11.15
 &+$37(5 +,9$1'$,'6

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All ART-naïve patients with CD4 < 100 cells/mm3 should have cryptococcal antigen
(CrAg) test done on serum (unless they have had a diagnosis of cryptococcal
infection).

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&U$JSRVLWLYHDQGDQ\V\PSWRPRIPHQLQJLWLV:
Refer patient immediately for lumbar puncture.
&U$JSRVLWLYHDQGQRV\PSWRPVRIPHQLQJLWLV
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x Fluconazole, oral 800 mg daily for 14 days.
&RQVROLGDWLRQSKDVH

x Fluconazole, oral, 400 mg daily for 8 weeks.

Follow with:

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x Fluconazole, oral, 200 mg daily.
o Continue for at least 1 year provided that the CD4 count increases to > 200
cells/mm3 on ART. If the CD4 count does not increase continue treatment
indefinitely.
x Commence ART after completion of the induction phase i.e. at 2 weeks.

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Pregnant women with a positive CrAg test.
All patients with positive CrAg test and symptoms suggestive of meningitis.

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Fungal meningitis occurring in advanced HIV infection.
Presents with headache, often lasting for weeks. Neck stiffness is often absent.
Decreased level of consciousness, confusion and fever are common.

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All patients should be treated for cryptococcal meningitis at hospital level. Patients
may be down referred for secondary prophylaxis.
6HFRQGDU\SURSK\OD[LV

x Fluconazole, oral, 200 mg daily for a minimum of 12 months.

After completion of fluconazole 400 mg daily for 8 weeks:

o Continue with fluconazole if CD4 count does not increase to > 200 cells/mm3

x Commence ART 4–6 weeks after starting antifungal therapy.

on ART.

2018 11.16
 &+$37(5 +,9$1'$,'6

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All patients for initial management in hospital.

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Diarrhoea that persists for > 2 weeks.
Often associated with wasting.
Stool for ova, cysts and parasites should be requested in all cases.

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If stool is negative for parasites or shows Cryptosporidium:
1RWH A negative stool specimen does not exclude Cryptosporidium. If
cryptosporidium infection is suspected, request specific laboratory testing for the
parasite.
x Loperamide, oral, 2 mg as required.

x
o Maximum 8 mg daily.
Commence ART.

x Cotrimoxazole, oral, 320/1600 mg (4 tablets) 12 hourly for 10 days.

If stool shows Isospora belli:

x Commence ART.
o Followed by 160/800 mg (2 tablets) daily until CD4 > 200 cells/mm3 on ART.

Diarrhoea persisting for 4 weeks is a WHO stage 3 condition (if there is weight loss
or fever it is stage 4) and ART should be commenced.

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Stool contains blood or mucus.

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See section 5.8.3: Dermatitis, seborrhoeic.

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This is common in HIV-infected patients and can involve multiple nails. Treatment is
not generally recommended because it is mostly of only cosmetic importance and
therefore the risk of systemic therapy is not warranted. It generally resolves when
patient is on ART.

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See Section 5.5: Fungal infections of the skin.

2018 11.17
 &+$37(5 +,9$1'$,'6

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See Section 1.3.3: Necrotising periodontitis.

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Painful ulcers due to herpes simplex virus, involving the skin around the anogenital
area or in and around the mouth and nostrils in patients with advanced HIV infection.
Ulcers persist for weeks and may be several centimetres in diameter.

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Keep affected areas clean with soap and water or diluted antiseptic solution.

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ƒ Aciclovir, oral, 400 mg 8 hourly for 7 days.
x Commence ART.
3DLQ
x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per
24 hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.

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» No response to therapy.
» Frequent recurrences

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Painful vesicular rash in a dermatomal distribution, usually presenting as a band on
one side of the body, due to recrudescence of the varicella-zoster virus that causes
chickenpox. The surrounding skin is inflamed and the vesicles often contain cloudy
fluid. Secondary bacterial infection is often suspected, but is very uncommon.
The elderly and HIV-infected are most affected.
Severe pain can occur after shingles has healed (post-herpetic neuralgia).
Shingles is less infectious than varicella and isolation is not warranted.

0(',&,1(75($70(17

x Aciclovir, oral, 800 mg five times daily (4 hourly missing the middle of the night
If fresh vesicles are present:

dose) for 7 days.

If secondary infection is present:
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x Flucloxacillin, oral, 500 mg 6 hourly for 5 days.

2018 11.18
 &+$37(5 +,9$1'$,'6

3DLQ
x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per
24 hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.

If inadequate pain relief

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x Amitriptyline, oral, 25 mg at night.
o Increase dose to 50 mg after two weeks if needed.
o Increase further to 75 mg after a further two weeks if needed.

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» Involvement of the eye.
» Disseminated disease (many vesicles extending beyond the main area).
» Features of meningitis (headache and neck stiffness).
» Severe post-herpetic neuralgia not responding to amitriptyline.

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Itchy inflamed papules at different stages of evolution. Healed lesions are often
hyperpigmented. The itch is difficult to manage. May flare after starting ART, but
generally improves as the CD4 count increases. It is essential to exclude scabies.

*(1(5$/0($685(6
Minimise exposure to insect bites, e.g. by regularly dipping pets.

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x
x
Cetirizine 10 mg, oral daily.
Hydrocortisone 1%, topical cream, applied twice daily for 7 days.
o Apply sparingly to the face.

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See Section 17.3: Respiratory infections.

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See Section 17.3.4.2.4: Pneumocystis pneumonia.

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Initial diagnosis can only be made at hospital level.

2018 11.19
 &+$37(5 +,9$1'$,'6

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x Cotrimoxazole, oral, 320/1600 mg 12 hourly for 4 weeks.
o Then 160/800 mg 12 hourly for 12 weeks.
6HFRQGDU\SURSK\OD[LV
x Cotrimoxazole, oral 160/800 mg daily.

x Commence ART.
o Continue until the CD4 count has risen to > 200 cells/mm3 on ART.

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See Section 17.4: Pulmonary tuberculosis (TB).

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Various forms of kidney disorders are described among patients who are HIV-infected.
Early detection of HIV kidney disease may be beneficial in an attempt to protect the
kidney from further disease progression and for adjusting the dose of relevant
medicines (See table: Antiretroviral medicines: Dose and common adverse drug
reactions, section: 11.1 Antiretroviral therapy, adults).
Screen all patients for renal disease at time of HIV diagnosis.
Patients at high risk or susceptible for HIV renal disease include:
» CD4 count < 200 cells/mm3.
» History of nephrotoxic medications.
» Comorbidity such as diabetes mellitus, hypertension, or hepatitis C virus co-
infection.
6FUHHQLQJIRUUHQDOGLVHDVHLQ+,9

 Urine dipstix for haematuria and proteinuria.

» Tests should include:

 Serum creatinine and eGFR.

» If there is no evidence of kidney disease at the initial evaluation, screening
should be repeated annually.
» Monitor creatinine on initiation and at months 3, 6, 12 and then 12 monthly for
patients receiving tenofovir.

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» Patients with persistent significant proteinuria (1+ or more).
» Unexplained haematuria on 2 consecutive visits
» Estimated creatinine clearance < 60 mL/min.

2018 11.20
 &+$37(5 +,9$1'$,'6

+,9,1)(&7,21,1&+,/'5(1
'(6&5,37,21
HIV is a retrovirus affecting immune cells, especially CD4 T-lymphocytes. In
advanced HIV disease the body loses its ability to fight infections and this is
characterised by organ damage, opportunistic infections, malignancies and very low
CD4 counts.
In infants and children, most infection is transmitted from mother to child.
In adolescents and adults sexual spread is the usual cause.
Infants born of HIV-infected mothers may be:
» HIV-infected,
» HIV-exposed uninfected, or
» HIV-exposed, unknown infection status (at risk of becoming HIV-infected).
To exclude HIV infection in HIV-exposed infants/children, an HIV PCR test (if • 18
months of age: an HIV rapid or ELISA test) performed • 6 weeks following cessation
of breastfeeding should be negative and the infant should be • 6 weeks of age.
If an HIV test result is indeterminate, or if the positive HIV status of a child already
initiated on ART is disputed, consult with the closest referral centre for additional HIV
testing.
For the purpose of the ART guidelines:
» Children and Adolescents < 15 years of age: follow the paediatric antiretroviral
therapy (ART) guidelines.
» Late adolescence (15–19 years of age): follow the adult ART guidelines.

',$*126,6,1&+,/'5(1
Testing must be done with counselling of parent/legal guardian/primary caregiver
and, where appropriate, the child. The appropriate consent/assent should be
obtained.

:+(1$1'+2:727(67,1&+,/'5(1
:KLFKWHVW
Child < 18 months of age
HIV PCR test: Always confirm with 2nd HIV PCR test if the first test is positive. This
should not delay ART initiation, which should be done with the first positive result.
Child • 18 months of age
HIV rapid or ELISA test: Always confirm with a 2nd HIV rapid or ELISA test if first test
is positive. This second confirmatory test should be a kit from a different manufacturer
and preferably a different blood specimen.
Ͳ HIV rapid tests may be less reliable in children with advanced disease. If clinical
findings suggest HIV infection but the rapid test is negative, send a further
specimen of blood to the laboratory for HIV ELISA testing.
:KHQWRWHVW+,9H[SRVHGFKLOGUHQ (See section: 11.5 The HIV-exposed infant).
» Birth (HIV PCR).
» Repeat at 10-week visit (HIV PCR).
» Repeat at 18-week visit (HIV PCR) only if:
2018 11.21
 &+$37(5 +,9$1'$,'6

 the child received NVP for 12 weeks (the mother received < 4 weeks of ART in

 the child received dual therapy (due to maternal virological failure)

pregnancy)

» At any time when clinical signs indicate possible HIV infection.

» 6 weeks after breastfeeding has stopped.
» 18 months (ELISA or HIV rapid test), if the exposed infant has not been shown to
be HIV-infected.
$OVRSHUIRUP3&5WHVWLQJ$7%,57+RQ
» Infants born to mothers who were on TB treatment for active TB during their
pregnancy.
» Infants with congenital pneumonia.
» Infants with clinical features suggestive of HIV infection.
» High risk infants requiring urgent HIV diagnosis.
If the HIV PCR result is not available at discharge, the mother should return within 1
week for the result.

 If HIV PCR result at 10–18 weeks, or an age-appropriate test 6 weeks after

» If the HIV PCR result is negative, repeat at 10 weeks:

breastfeeding has stopped, is still negative, perform HIV rapid test at 18 months

 If positive at any time, start infant ART.

of age.

1RWH
» Negative tests do not exclude infection until 10-18 weeks after birth and 6 weeks after
exposure to other risk of HIV infection (including cessation of breastfeeding).
» Children with discordant HIV test results must be discussed with an expert.
» Do not repeat HIV rapid/ELISA tests in children on established ART.
$OVRSHUIRUPDJHDSSURSULDWHWHVWLQJDWDQ\WLPHRQ
» Parental request to test the child.
» HIV-infected father or sibling.
» Death of mother, father or sibling.
» Mother’s HIV status and her whereabouts are unknown.
» Clinical features suggest HIV infection.
» Infant has acute severe illness.
» Breastfed infant of newly diagnosed HIV-infected breastfeeding mother.
» IMCI classification of SUSPECTED SYMPTOMATIC HIV INFECTION or POSSIBLE
HIV INFECTION.
» TB diagnosis, history of TB treatment or new TB exposure.
» Suspicion of sexual assault.
» Wet-nursed/breastfed infant fed by a woman of unknown or HIV-infected status (and
repeat age-appropriate test 6 weeks later).
» Children considered for adoption or fostering.
1HZERUQ FKLOG ZKRVH PRWKHU LV RI XQNQRZQ +,9 VWDWXV KDV GLHG RU LV QRW
DYDLODEOHGXHWRDEDQGRQPHQWRURWKHUUHDVRQV
Perform an infant HIV rapid test and if positive, perform HIV PCR. Initiate PMTCT.
Perform age-appropriate HIV testing in an HIV-uninfected child at any other time if
clinical symptoms suggest HIV infection.

2018 11.22
 &+$37(5 +,9$1'$,'6

&OLQLFDOLQGLFDWLRQVWKDW+,9LQIHFWLRQVKRXOGEHFRQVLGHUHGLQDFKLOGDUH
» If the mother is HIV-infected or if the mother’s HIV status is not known.
» If the child was HIV PCR-negative but was subsequently breastfed.
» If a child has any of the following features:
- Rapid breathing or chest indrawing now (“Pneumonia”).
- Persistent diarrhoea now or in the past.
- Ear discharge now or in the past.
- Low weight for age/height or unsatisfactory weight gain.
- • 2 enlarged glands of: neck, axilla or groin.
- Oral thrush.
- Parotid enlargement.
All infants/children accessing care should have their HIV exposure status (recent
maternal HIV status) and/or HIV status determined.
Women who previously tested HIV-positive should not be retested.
Where mothers tested negative in pregnancy, maternal HIV status should be
determined 3 monthly whilst breastfeeding.
$GDSWHG:+2FOLQLFDOVWDJLQJRI+,9DQG$,'6IRULQIDQWVDQGFKLOGUHQ
For persons ”15 years of age with confirmed laboratory evidence of HIV infection
&OLQLFDO6WDJH
» asymptomatic
» persistent generalised lymphadenopathy (PGL)
&OLQLFDO6WDJH
» unexplained persistent weight loss
» hepatosplenomegaly
» papular pruritic eruptions
» extensive human papilloma virus infection
» extensive molluscum contagiosum
» fungal nail infections
» recurrent oral ulcerations
» lineal gingival erythema (LGE)
» unexplained persistent parotid enlargement
» herpes zoster
» recurrent or chronic RTIs, i.e.
» otitis media
» otorrhoea
» sinusitis
&OLQLFDO6WDJH
» moderate unexplained malnutrition (not adequately responding to standard therapy)
» unexplained persistent diarrhoea (14 days or more)
» unexplained persistent fever (above 37.5°C, intermittent or constant, for longer than
one month)
» persistent oral candidiasis (after first 6-8 weeks of life)
» oral hairy leukoplakia
» acute necrotising ulcerative gingivitis/periodontitis
» lymph node TB
» pulmonary TB
» severe recurrent bacterial pneumonia
» chronic HIV-associated lung disease including bronchiectasis
» symptomatic lymphoid interstitial pneumonitis (LIP)

2018 11.23
 &+$37(5 +,9$1'$,'6

unexplained anaemia ( 8 g/dL), and or neutropaenia (< 500/mm3) and/or

thrombocytopaenia ( 50 000/mm3) for more than one month
»

&OLQLFDO6WDJH
» unexplained severe wasting, stunting or severe malnutrition not adequately responding
to standard therapy
» pneumocystis pneumonia

 empyema
» recurrent severe presumed bacterial infections, e.g.

 pyomyositis
 bone or joint infection
 meningitis
but excluding pneumonia
» chronic herpes simplex infection; (orolabial or cutaneous of more than one month’s
duration or visceral at any site)
» extrapulmonary TB
» Kaposi’s sarcoma
» oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs)
» CNS toxoplasmosis (outside the neonatal period)
» HIV encephalopathy
» CMV infection (CMV retinitis or infections of organs other than liver, spleen or lymph
nodes; onset at age one month of more)
» extrapulmonary cryptococcosis including meningitis
» any disseminated endemic mycosis, e.g.
» extrapulmonary histoplasmosis
» coccidiomycosis
» chronic cryptosporidiosis
» chronic isosporiasis
» disseminated non-tuberculous mycobacteria infection
» HIV associated recto-vaginal fistula
» cerebral or B cell non-Hodgkin lymphoma
» progressive multifocal leukoencephalopathy (PML)
» HIV-associated cardiomyopathy or HIV-associated nephropathy

7+(+,9(;326(',1)$17
Z20.6

'(6&5,37,21
An infant whose mother is HIV-infected, or in whom HIV infection has not been
confirmed or excluded.
Transmission of HIV infection from mother to child may occur during pregnancy, during
delivery or via breastfeeding. Prevention of transmission of infection from mother to
child can be effectively carried out with a very high success rate by means of
suppressing the mother’s VL and giving ARVs to the infant.
Where the mother’s VL cannot be suppressed the risk of breast milk transmission
remains significant.
:KHQWRWHVW+,9H[SRVHGFKLOGUHQ
» Birth (HIV PCR).
» For recommendations on when to perform additional tests, refer to the guidance
on “When to Test” (Section: HIV infection in children).
2018 11.24
 &+$37(5 +,9$1'$,'6

0(',&,1(75($70(17
0RWKHU
The PMTCT plan starts with initiation of ART in the mother (either pre or post
conception). See Section 6.8: HIV in pregnancy.

,QIDQW
Thereafter, the HIV-exposed infant may be classified into one of the following
categories which determines the appropriate infant prophylaxis regimen:
» Low risk.
» High risk.
» Unknown risk. LoE:IIxviii
6LWXDWLRQ )HHGLQJDGYLFH &RPPHQW
/2:5,6.
x 193 at birth and then daily for 6 weeks.
Mother on lifelong ART Encourage breast » Do HIV PCR at birth.
at time of conception. feeding. » Do HIV PCR at 10 weeks.
RU » Do infant HIV testing 6 weeks’ post-
ART started more than 4
cessation of breastfeeding (either HIV
weeks prior to delivery
and VL < 1000 copies/ml PCR or ELISA depending on age).
Encourage maternal ART adherence.
+,*+5,6.
x 193dailyDQG$=7 twice daily, as soon as possible for 6 weeks.
o Followed by an additional 6 weeks of 193 daily. LoE:Ixix
Mother newly diagnosed Encourage breast » Immediate initiation of maternal ART.
HIV-positive and did not feeding » Do infant HIV PCR at birth/
start ART before or immediately, if infant tests HIV PCR+,
during delivery.
do repeat HIV PCR test and initiate
RU
Breastfeeding mother ART immediately.
diagnosed HIV positive > » Do HIV PCR at 10 weeks, and
72 hours after delivery. » Do HIV PCR at 18 weeks.
» Do infant HIV testing 6 weeks’ post-
cessation of breastfeeding (either HIV
PCR or ELISA depending on age).
Encourage maternal ART adherence.
Mother started ART < 4 Encourage breast » Do infant HIV PCR at birth, if infant
weeks prior to delivery. feeding. tests HIV PCR+, do repeat HIV PCR
test and initiate ART immediately**.
» Do HIV PCR at 10 weeks, and
» Do HIV PCR at 18 weeks.
» Do infant HIV testing 6 weeks’ post-
cessation of breastfeeding (either HIV
PCR or ELISA depending on age).
» Encourage maternal ART adherence.

2018 11.25
 &+$37(5 +,9$1'$,'6

6LWXDWLRQ )HHGLQJDGYLFH &RPPHQW

st
Mother on ART with latest Mothers failing on 1 » Do HIV PCR at birth, if infant tests
VL > 1000 copies/ml. line treatment: HIV PCR+, do repeat HIV PCR test
» Encourage breast and initiate ART immediately**.
feeding. » Do HIV PCR at 10 weeks, and
Mothers on 2nd or 3rd » Do HIV PCR at 18 weeks.
line regimens and » Do infant HIV testing 6 weeks’ post-
VL >1000 copies/ml: cessation of breastfeeding (either HIV
» Advise not to PCR or ELISA depending on age).
breast feed. » If repeat maternal VL > 1000
» Refer for copies/ml continue NVP and AZT if
replacement breastfeeding, and refer/discuss.
feeding. » Encourage maternal ART adherence.

Mother on ART with no Encourage breast » Do maternal HIV VL and review

HIV viral load available. feeding. result.
» If VL <1000 copies/mL: change
prophylaxis to low risk protocol.
» If VL •1000 copies/mL: manage as
above (high risk protocol).
81.12:15,6.
x 193daily immediately.
Unknown maternal status » Test infant with rapid HIV test*.
because orphaned or x Positive: If presents within 72 hours of
abandoned. delivery, give NVP daily for 6 weeks.
o Do HIV PCR at 10 weeks of age. If
HIV PCR +, do repeat HIV PCR test

x Negative: Discontinue NVP.

and initiate ART immediately**.

If rapid HIV test can be done ” 2 hours, wait for HIV result before commencing NVP.
** ART initiation in infants - See Section 11.6: Management of HIV-infected children.

1RQEUHDVWIHHGLQJPRWKHUGLDJQRVHG+,9SRVLWLYH!KRXUVDIWHUGHOLYHU\ Do
not start NVP. Perform an HIV test on infant and if positive initiate ART.
,QIDQW307&7GRVDJHV
Premature and low-birth weight newborns (< 2 kg) are treated in hospital.
Daily prophylaxis for 6 or 12 weeks administered to infants, as indicated above:
» Give 1st dose as soon as possible after birth.
» If baby vomits: Repeat dose once only.
» If infant HIV PCR is positive at any time, stop prophylactic ARV, confirm with 2nd
PCR and initiate/refer for ART, while awaiting 2nd PCR result.
» Continue normal breastfeeding and start cotrimoxazole prophylaxis if > 6 weeks
of age.

2018 11.26
 &+$37(5 +,9$1'$,'6

1HYLUDSLQH193GRVHIRULQIDQWRQ307&7

Newborns • 2 kg and infants:
x Nevirapine, oral, daily.
:HLJKW 'RVH 6\UXS $JH
kg mg 10 mg/mL Months
2–2.5 kg 10 mg 1 mL
Birth–6 weeks
> 2.5 kg 15 mg 1.5 mL
> 2.5–7 kg 20 mg 2 mL > 6 weeks–6 months
=LGRYXGLQH$=7GRVHIRULQIDQWRQ307&7
Newborns • 2 kg and infants:
x Zidovudine, oral, 4mg/kg/dose 12 hourly.
:HLJKW 'RVH 6\UXS $JH
kg mg 10 mg/mL Months
2–2.499kg 10mg 1 mL Birth–6 weeks
• 2.5 kg 15 mg 1.5 mL > 6 weeks

)HHGLQJDGYLFH
» Exclusive breastfeeding is strongly recommended for the 1st 6 months, after which
the nutritional needs of the child will require the introduction of complementary
foods, while breastfeeding continues.
» Mothers failing 2nd or 3rd line regimens should not breastfeed. However, a
sustainable supply of formula must be provided.
» If women are switched from 1st to 2nd line therapy during pregnancy or
breastfeeding, consult with a practitioner experienced and knowledgeable of the
factors informing the feeding option decision.
» Mothers on effective ART should be encouraged to breastfeed as the advantages
of breastfeeding exceed the risks of HIV transmission.
» Use of flash pasteurisation or Pretoria pasteurisation to reduce HIV transmission
is supported but may pose significant barriers to successful breast milk feeding
due to the effort involved.
&RWULPR[D]ROHSURSK\OD[LV
Initiation:
» All HIV-exposed or infected infants, starting from 6 weeks of age.
» Any child 1–5 years of age with CD4% < 25%.

x Cotrimoxazole, oral, once daily (everyday). See dosing table, pg 23.4.

» Any child > 5 years of age with CD4 count < 350 cells/mm3.

Discontinuation:
» Child is HIV-uninfected and has not been breastfed for the last 6 weeks.
» HIV-infected child > 1 year of age whose immune system is fully reconstituted on
ART (i.e. 1–5 year: CD4% > 25% or > 5 years: CD4 count > 350 cells/mm3 on two
tests at least 3–6 months apart).
» Child is HIV-infected with PJP infection: after treatment, continue cotrimoxazole
prophylaxis until 5 years of age.

2018 11.27
 &+$37(5 +,9$1'$,'6

5()(55$/
Mother declines infant ARV prophylaxis.

 0$1$*(0(172)+,9,1)(&7('&+,/'5(1
B24

'(6&5,37,21
HIV-infected child: An infant/child in whom HIV infection has been confirmed with
two age-appropriate tests. See Section 11.4. The HIV-exposed infant.

*(1(5$/$1'6833257,9(0($685(6
» Identify a caregiver who can supervise the child’s treatment.
» Link the HIV interventions to the regular well infant visits/nutritional care. Ensure the
road to health booklet is correctly completed and used to reflect and guide care.
Counselling is a vital part of the successful care of children with HIV infection and
their families. Specific matters requiring attention are:
» The implications of the disease to the family.
» Implications of treatment and understanding of the condition and its care.
» The disclosure process within the family and extended family should be
encouraged. Besides the caregiver, help from the family is often useful.

 Find out what the child understands of their illness and what they would like to
» Disclosure to the child appropriate to age and maturity with the parents’ support.

 Disclosure should be child led in terms of information required, language used

know.

 Anticipate the effects of disclosure on the child, family and other contacts such
and educational/emotional readiness.

 Ensure that in disclosure the child is constantly reassured of the

as friends and school colleagues.

parents’/caregivers’ love.
Treatment of mothers, caregivers and other family members:
» Always ask about the caregiver’s health, and the health of other family members.
» Ensure that mothers and other family members have timeous access to medical
care including ART.
» Encourage breastfeeding in all mothers with HIV-infected children, with
introduction of complementary foods from 6 months of age.
» At every visit ask about TB contacts and TB symptoms in children and their
caregivers.
67$1'$5',6('1$7,21$/021,725,1*)25,1)$176 &+,/'5(1:,7++,9
$7,1,7,$/',$*126,62)+,9 385326(
Verify HIV status. To ensure that national testing algorithm has
been followed.
Document weight, height, head circumference To monitor growth and development.
(< 2 years of age) and development.
Screen for TB symptoms. To identify TB and HIV co-infection
Do CD4 count. Children < 5 years: Baseline. Do QRW wait for
CD4 count to start ART.
2018 11.28
 &+$37(5 +,9$1'$,'6

Children • 5 years: To assist in determining

eligibility for OI prophylaxis.
Hb or FBC if available. To detect anaemia or neutropaenia.
$75287,1()2//2:839,6,76,)127 385326(
&855(17/<21$57 
Document weight, height, head circumference To monitor growth and development.
(< 2 years) and development.
If > 5 years: Check that a CD4 count has To determine eligibility for OI prophylaxis.
been done in the last 6 months.
If > 5 years: WHO clinical staging. To determine eligibility for OI prophylaxis and
identify new OIs.
Screen for TB symptoms. To identify TB/HIV co-infection.
$7,1,7,$7,212)$57%$6(/,1( 385326(
Hb or FBC. If < 8 g/dL: Manage appropriately.
CD4 count (if not performed in last 6 Baseline assessment.
months).
If on PI-based regimen: Cholesterol and Baseline assessment.
triglyceride.
If considering TDF-based regimen: Serum If abnormal refer for specialist opinion.
creatinine and urine dipstick test.
If jaundiced or on TB treatment: ALT. To detect liver dysfunction.
21$57 385326(
Height, weight, head circumference (if child < To monitor growth and development.
2 years) and development. Adjust dosing at each visit according to
weight gain.
Clinical assessment including medicine- To monitor response to ART and detect
related adverse events. adverse effects.
CD4: 1 year on ART, and then 12-monthly. To monitor response to ART.
Stop cotrimoxazole prophylaxis if indicated.
Viral load:
» < 5 years: At month 6 and 12 on ART, then To monitor viral response to ART.
12-monthly.
» 5–15 years: At month 6 on ART, and if To identify treatment failure and adherence
suppressed, 12-monthly. problems.
If on AZT: Hb or FBC: At month 1, 2, 3 and To identify AZT-related anaemia.
then 12-monthly.
If on PI-based regimen:
Cholesterol + triglyceride at 1 year of To monitor for PI-related metabolic side
treatment and then 12-monthly.. effects.

0(',&,1(75($70(17
&RWULPR[D]ROHSURSK\OD[LV
Initiation:
» All HIV-exposed or infected infants, starting from 6 weeks of age.
» Any child 1–5 years of age with CD4% < 25%.

x Cotrimoxazole, oral, once daily (everyday). See dosing table, pg 23.4.

» Any child > 5 years of age with CD4 count < 350 cells/mm3.

Discontinuation:
» Child is HIV-uninfected and has not been breastfed for the last 6 weeks.

2018 11.29
 &+$37(5 +,9$1'$,'6

» HIV-infected child > 1 year of age whose immune system is fully reconstituted on
ART (i.e. 1–5 year: CD4% > 25% or > 5 years: CD4 count > 350 cells/mm3 on two
tests at least 3–6 months apart).
» Child is HIV-infected with PJP infection: after treatment, continue cotrimoxazole
prophylaxis until 5 years of age.
,PPXQLVDWLRQGHZRUPLQJDQGYLWDPLQ$SURJUDPPH
» Continue deworming and vitamin A programme as in the HIV-uninfected child.

 Do not give BCG.

» Continue immunisation as in the HIV-uninfected child except:

 See Section 13.3: Vaccines for routine administration.

1XWULWLRQDOVXSSRUW
Specific nutritional conditions should be treated appropriately.
$QWLUHWURYLUDOWKHUDS\
Initiation of ART in well, uncomplicated infants shown to be PCR-positive should be
carried out at PHC level.
The preparation of the child and family to start ART is critical to the success of the
treatment. Failure to achieve adherence and understanding may lead to resistance
and adversely affect the prognosis of the child.

(OLJLELOLW\IRU$57
&OLQLFDOFULWHULD
» Confirmation of diagnosis of HIV infection, irrespective of CD4 count/percentage
or WHO clinical stage.
xx
$1' LoE:III
» No medical contraindication (e.g. major organ dysfunction). If medical
contraindications are present refer to hospital for rapid review and planning.
&KLOGUHQUHTXLULQJIDVWWUDFNLHVWDUW$57ZLWKLQGD\VRULIVDIHWRGRVRZLWK
DWWHQWLRQWRVRFLDOLVVXHVFRXQVHOOLQJDQGDGKHUHQFH
» Children < 1 year of age.
» WHO Clinical stage 4.
» MDR or XDR-TB, except TB meningitis, in which case wait 8 weeks to initiate ART.
» CD4 count < 200 cells/mm3 or CD4 % < 15%. LoE:IIxxi
6RFLDOLVVXHVWKDWPXVWEHDGGUHVVHGWRHQVXUHVXFFHVVIXOWUHDWPHQW
These are extremely important for success and impact on adherence. Social
challenges should be overcome and not be barriers to care. Adherence to treatment
must at least be considered probable. Disclosure to another adult living in the same
house is encouraged so that there is someone else who can assist with the child’s
treatment. However, absence of disclosure should not preclude ART initiation.
» Mandatory component: At least one identifiable caregiver able to supervise the
child and/or administer medication. All efforts should be made to ensure that the
social circumstances of vulnerable children (e.g. orphans) be addressed to
facilitate treatment.

2018 11.30
 &+$37(5 +,9$1'$,'6

 High levels of adherence are required for adequate virological response and
» Adherence:

prevention of viral resistance. This can be achieved with regular education

 All efforts to encourage this level of adherence should be made.

and support.

 Viral load measurements are useful for monitoring adherence.

 Sensitive, age-appropriate disclosure facilitates adherence.
» Mother and other family members should be assessed and treated.
Requirements before ART is initiated:
The child’s family (parents, caregivers) should understand:
» ART is life-long.
» The prognosis of the condition (treated and untreated).
» Medicines’ adverse effects and modes of action, and the risk and implications of
developing resistance, if incorrectly used.
» That all medicines should be given. If more than one antiretroviral is missing from
the medicine regimen, treatment should be stopped until they are all available again.
$57UHJLPHQV
» Are chosen according to age, weight, expected adverse effects, efficacy and prior
antiretroviral exposure.
» Adjust the dosage of ART according to weight, during follow up visits.
» Do not change regimens or move to 2nd line therapy without clear guidance from
a practitioner experienced in child ARV medicine, as unnecessary loss of effective
regimens can shorten life expectancy. Adherence problems need to be addressed
thoroughly before switching to a 2nd or 3rd line regimen.
» Single medicine substitutions may only be made when medicine-specific adverse
effects are encountered, on condition that virological suppression is documented
and the matter is discussed with a practitioner experienced in child ARV medicine.
),567/,1(5(*,0(1
Infants < 3 months or < 3 kg: Seek advice on treatment regimen and dosage.
All infants (> 3 months) and children < ABC + 3TC + LPV/r.
3 years
RU
Older children < 10 kg.
All children > 3 years and > 10 kg. ABC + 3TC + EFV.

Do not exceed maximum adult dosage.

Adolescents > 15 years and > 40 kg. TDF + 3TC/FTC + EFV.

Do not use in patients with significant psychiatric

comorbidity, renal compromise (creatinine
clearance < 80 mL/min/1.73m2), or co-
administration of nephrotoxic medicines.

$'-8670(172)35(9,286),567/,1(5(*,0(16
 If VL is suppressed: Change d4T to ABC.
 If VL is > 1000 copies/mL: Manage as
d4T-containing first-line regimens

virological failure. If VL remains high after

2018 11.31
 &+$37(5 +,9$1'$,'6

enhanced adherence, refer for consideration


of a change in regimen.
If VL is detectable, but < 1000 copies/mL:


Consult or refer.
Change first-line children regimen to If VL is > 1000 copies/mL: Manage as
adult treatment, if > 15 years DQG> 40 virological failure. If VL remains high after
kg. enhanced adherence, refer for consideration


of a change in regimen.
If VL is detectable, but < 1000 copies/mL:


Consult or refer.
If VL is suppressed and on first-line:

x Change to TDF + 3TC/FTC + EFV.

1. ABC + 3TC + EFV.

x Change to TDF + 3TC/FTC + EFV.

2. ABC + 3TC + LPV/r.

Changing from a second-line child regimen

requires consultation or referral.
ddI-containing first-line regimens Change ddI to ABC, irrespective of VL. If
receiving ddI and AZT as a second-line regimen,
stop the ddI and replace with 3TC.
LoE:IIIxxii
,QLWLDWLQJ$57LQFKLOGUHQWKHVWHSV,0&,FKLOG1,0$57
(These steps are taken from the IMCI nursing protocol. Doctors may obtain further
guidance from the Paediatric Hospital Level EML and STG, 2017).
1. Decide if the child has confirmed HIV infection (see testing above).
2. Decide if the caregiver is able to give ART (If not, refer to appropriate level to
ensure ability to take ART effectively and safely).
3. Decide if a nurse should initiate ART (i.e. NIMART suited patient).
a. If any of the following are present refer:
Ͳ Fast breathing.
Ͳ TB.
Ͳ Weight < 3 kg.
Ͳ General danger signs or severe disease evident.
4. Assess and record baseline information.
a. Record the following information:
Ͳ Weight and height.
Ͳ Head circumference in children < 2 years of age.
Ͳ Assess for malnutrition and anaemia.
Ͳ Feeding assessment and feeding problems.
Ͳ Development.
Ͳ Consider and screen for TB.
Ͳ WHO clinical stage.
Ͳ Laboratory results: Hb, CD4 count and percentage.
b. If SEVERE MALNUTRITION, SEVERE ANAEMIA or TB refer to next level of care.
c. If POSSIBLE TB provide appropriate follow up.
d. If Hb < 10 g/dL (but not severe anaemia) treat as per IMCI. Do not delay ART.
Send appropriate laboratory tests but do not wait for results to start ART.

2018 11.32
 &+$37(5 +,9$1'$,'6

5. Start ART:
a. If < 3 years of age 25< 10 kg: ABC + 3TC + LPV/r.
b. If > 3 years of age $1'• 10 kg: ABC + 3TC + EFV.
c. Continue (or start) cotrimoxazole prophylaxis.
d. Follow up after 1 week:
Ͳ To check ability to adhere.
Ͳ To check outstanding laboratory results.
Ͳ To resolve any problems that may have arisen.
7KHQSURFHHGWRORQJWHUPIROORZXSWKHVWHSV,0&,FKLOG1,0$57
(These steps are taken from the IMCI nursing protocol. Doctors may obtain further
guidance from the Paediatric Hospital Level EML and STG, 2017).
1. Assess for problems:
a. Ask if there are any problems.
b. Check for any danger signs.
c. Check for ART danger signs:
Ͳ Severe skin rash.
Ͳ Difficulty breathing or severe abdominal pain.
Ͳ Yellow eyes.
Ͳ Fever, vomiting, rash.
d. Check for any other symptoms.
e. Consider TB/ask if there has been TB contact and examine at each visit.
2. Monitor progress on ART:
a. Record weight (and height every 3 months).
b. Assess development every 6 months.
c. Assess adherence and record (ask mother, self-assessment, record correct
number of pills remain, watch body language).

 yellow eyes  rash

d. Assess for side effects. If present manage according to guidelines or refer:

 nausea and vomiting  diarrhoea

 fever  headache
 sleep disturbances  nightmares
 anxiety  tingling or numbness
 lipoatrophy
e. Assess clinical progress.
f. Monitor blood results.
g. Indications for referral to a doctor include:
Not gaining weight for 3 months.
Regression of milestones.
Failure to attain milestones.
Poor adherence after adherence counselling.
Significant side effects despite appropriate management.
Deterioration of clinical stage.
CD4 count significantly dropping.
Detectable VL, despite adherence counselling.
Fasting total cholesterol > 4.43mmol/L.
Fasting TG > 5.6 mmol/L.
2018 11.33
 &+$37(5 +,9$1'$,'6

3. Provide further ART:

a. Continue treatment if stable and no significant side effects.
1RWH Check dose is correct for current weight and adjust accordingly.
4. Provide other treatments:
a. Continue cotrimoxazole prophylaxis until: 1–5 year: CD4% > 25%; or if > 5
years: CD4 > 350 cells/mm3; on two tests at least 3–6 months apart.
5. Provide routine care:
a. Check immunisations, vitamin A, deworming etc. have all been done.
6. Counsel the mother/caregiver:
a. Use the visit to check mother’s knowledge and need for support.
b. Check if family and mother are receiving own necessary care.
7. Arrange further follow up:
a. Arrange follow up in 1 month (more frequently if other problems are present).
7UHDWPHQWIDLOXUH
» VL is the most sensitive method to detect failure of response to ART.
» Virological failure can be defined as a measurable viral load, despite optimal
adherence and optimal dosing over a 4-month period. Clinical and immunological
deterioration are late features of ART failure.
» The most common cause of treatment failure is poor adherence. Adherence has
to be addressed, before switching to 2nd-line therapy.
9LUDOORDG9/ 5HVSRQVH
Lower than » Praise the patient and caregiver(s) and continue 12-monthly VL
detectable limits monitoring.
Detectable, but » Begin step up adherence package.
< 1 000 copies/mL » Repeat VL in 6 months.
> 1 000 copies/mL » Begin step-up adherence package.
» Repeat VL in 3 months:
 VL lower than detectable limits: Return to routine 6–12
monthly monitoring.
 VL detectable, but ”1000 copies/mL: Continue step up
adherence and repeat VL after 6 months.
 VL > 1000 copies/mL despite stepped up adherence, DQG
child is on NNRTI-based regimen: Consult or refer for switch
to 2nd line therapy after adherence ensured.
 Child is on a PI-based regimen and VL > 1000 copies/mL,
despite stepped up adherence:
 If the child received an unboosted PI (e.g. ritonavir alone) in
the past or received TB treatment while on LPV/r (without
dose adjusting or adding additional ritonavir) and the VL is >
1000 copies/mL, discuss new regimen with an expert.
 Referral for resistance testing is indicated in these situations,
but should only be done if the child has been taking ARVs
reliably in the last month
» VL < 30 000 copies/mL: Continue with same regimen
while monitoring VL 3-monthly. Continue stepping up
adherence and consult an expert.
» VL > 30 000 copies/mL: Refer.


ൈ Note that the limit of detection varies between laboratories. Use the cut-off in the laboratory report.
LoE:III

2018 11.34
 &+$37(5 +,9$1'$,'6

*HQHUDO$57FRPPHQWV
» Switch to tablets or capsules from syrups or solutions as soon as possible.
» Fixed-dose combinations are preferred to single agents.
» If available, use daily dose regimens.

6LGHHIIHFWV
&RQWLQXH$57ZLWK &RQVLGHUVWRSSLQJ
FDUHIXOPRQLWRULQJ WUHDWPHQW85*(17/<
*HWH[SHUWDGYLFH &RQVXOWH[SHUWXUJHQWO\
Symptomatic Lactate: 2–5 mmol/L with Lactate > 5 mmol/L,
hyperlactataemia/lactic no signs or symptoms RU
acidosis acidosis,
RU
signs or symptoms.
Anaemia Hb: 7.0–9.9 g/dL Hb < 7g/dL,
RU
cardiac failure.
Neutropaenia 0.4–1.2 X 109/L < 0.4 X 109/L
Increased liver enzymes and < 9.9 X upper normal limit • 10.0 X upper normal limit
hepatitis
Increased serum triglycerides 1.54–8.46 mmol/L • 8.47 mmol/L
Increased total cholesterol 4.43–12.92 mmol/L • 12.93 mmol/L
Skin reactions Ͳ diffuse maculopapular Vesiculation,
rash, RU RU
Ͳ dry desquamation ulcers,
RU
exfoliative dermatitis,
RU
Stevens-Johnson
syndrome,
RU
erythema multiforme,
RU
moist desquamation,
RU
elevated ALT,
RU
elevated AST.

Lipoatrophy » Look for and respond to Not an indication to stop

(Subcutaneous fat loss of clinical features of ART.
the face, extremities and/or lipoatrophy.
buttocks. Caused by NRTIs, » Change regimen to
in particular ddI, d4T and include NRTIs less likely
sometimes AZT. to cause lipoatrophy e.g.
ABC, TDF, FTC, 3TC are replace d4T or AZT with
less likely to cause ABC or TDF. (FDC
lipoatrophy). preferred, where
possible).

2018 11.35
 &+$37(5 +,9$1'$,'6

» Seek specialist advice

for switching if not
virologically suppressed.
Other side effects: Clinical evaluation.
Ͳ peripheral neuropathy 
Ͳ myopathy 'LVFXVVDOOFDVHVZLWKDQ+,9FOLQLFLDQEHIRUH
Ͳ abdominal pain LQWHUUXSWLQJWKHUDS\
Ͳ nausea and vomiting 
Ͳ pancreatitis 
Ͳ headache 
Ͳ fatigue 
Ͳ sedative effect 
Ͳ sleep disturbance 
Ͳ confusion 
Ͳ abnormal thinking 
Ͳ possible teratogenicity

































2018 11.36
 &+$37(5 +,9$1'$,'6

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 $EDFDYLU /DPLYXGLQH (IDYLUHQ] /RSLQDYLUULWRQDYLU 5LWRQDYLUU
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8 mg/kg 12 hourly 4 mg/kg 12 hourly 21/<DV
Target 25 25 By weight band 300/75mg/m2/dose LPV/r ERRVWHUIRU/39U
dose • 10 kg: • 10 kg: once daily 12 hourly ZKHQRQ
16 mg/kg once daily 8 mg/kg once daily ULIDPSLFLQ
Sol. 20 mg/mL Caps 50,200 mg 12 hourly
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formula- Tab 150 mg (scored),300 mg; Adult Tabs 200/50 mg,
Tab 300 mg (not scored), 600 mg (not 12 hourly)
tions Tab ABC/3TC 600/300 mg Paeds Tabs 100/25 mg
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Weight Kg Currently available tablet formulations of ABC (except 60 mg), EFV, LPV/r must be swallowed whole and QRW chewed, divided or crushed.
<3 Consult with a clinician experienced in paediatric ARV prescribing for neonates (< 28 days of age) and infants weighing < 3 kg
3–4.9 2 mL 12 hourly 2 mL 12 hourly 'RQ¶W8VH 1 mL 12 hourly 1 mL 12 hourly
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12 mL daily at night 12 hourly
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12 hourly
8 mL Choose one option
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25
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2.5x60* tabs
15 mL daily ½x150* tab 15 mL daily tabs 12 hourly
12 hourly
12 hourly 1x200* cap/tab + 12 hourly
20 mL daily 2x50* cap/tab at
1x150* tab 30 mL daily
20–22.9 10 mL 12 hourly 25 night 25
12 hourly 25 (LWKHU 25
25 1x300*+ 1x60* tab daily 2x100/25*
25 1x300* tab daily 3 mL 12 hourly 1x200/50* tab 2.5 mL 12 hourly
3x60* tabs 20 mL daily tabs
15 mL 25 12 hourly
23-24.9 12 hourly 25 12 hourly
12 hourly 2x150* tab daily
1x300*+ 2x60* tabs daily
(LWKHU 25
25–29.9 25
3.5 mL 12 hourly 1x200/50*
2x150* tabs daily 3x100/25*
tab+1x100/25* 3 mL 12 hourly
2x300 tabs daily 25 2x200* caps/tab (LWKHU tabs
tab
30–34.9 1x300* tab 25 1x150 tab 1x300* tab daily at night 4 mL 12 hourly 12 hourly
12 hourly
12 hourly 1 x ABC/3TC 600/300* tab 12 hourly 25
35–39.9 daily 1 x ABC/3TC
(LWKHU 25 2x200/50* tabs
600/300* tab daily 4 mL 12 hourly
5 mL 12 hourly 12 hourly
> 40 600 tab at night

dosage in mg
xxiii
Sol: solution Tab: tablet Cap: capsule LoE:III
For standard dosing of abcavir, see dosing table - pg 23.1; efavirenz - see dosing table pg 23.4; lamivudine - see dosing table pg 23.6; lopinavir/ritonavir -
see dosing table pg 23.7; ritonavir - see dosing table pg 23.9.
2018 11.37
 CHAPTER 11 HIV AND AIDS

11.7 OPPORTUNISTIC INFECTIONS, PROPHYLAXIS IN

CHILDREN
Z29.2 + (B24)

Cotrimoxazole prophylaxis
Indications:
» All HIV-exposed or infected infants, starting from 6 weeks of age.
» Any child 1–5 years of age with CD4% < 25%.
» Any child > 5 years of age with CD4 count < 350 cells/mm3.
‡ Cotrimoxazole, oral, once daily (everyday). See dosing table, pg 23.4.
Discontinuation:
» Child is HIV-uninfected and has not been breastfed for the last six weeks.
» HIV-infected child > 1 year of age whose immune system is fully reconstituted
on ART (i.e. 1– 5 year: CD4% > 25% or > 5 years: CD4 count > 350 cells/mm3
on two tests at least 3–6 months apart).
» Child is HIV-infected with PJP infection: after treatment, continue cotrimoxazole
prophylaxis until 5 years of age.
TB prophylaxis
See Section 17.4.2.1: TB chemoprophylaxis/Isoniazid preventive therapy (IPT) in
children.
Immunisation
Continue immunisation as in the HIV-uninfected child except:
- Do not give BCG.
- See Chapter 13: Immunisation.

11.8 OPPORTUNISTIC INFECTIONS, TREATMENT IN

CHILDREN
11.8.1 CANDIDIASIS, ORAL (THRUSH), RECURRENT
B20.4

MEDICINE TREATMENT
‡ Nystatin suspension, oral, 100 000 IU/mL, 0.5 mL after each feed.
o Keep in contact with the affected area for as long as possible prior to
swallowing.
o In the older child, ask child to swirl in the mouth, prior to swallowing.
o In the infant, advise mom to apply to front of the mouth and spread over the
oral mucosa with a clean finger.
o Continue for 48 hours after resolution of symptoms.

If there is oral candidiasis and the child cannot swallow, this indicates the presence
of oesophageal candidiasis. See Section 11.8.2: Candidiasis, oesophageal.

2018 11.38
 &+$37(5 +,9$1'$,'6

 &$1',',$6,62(623+$*($/
B20.4

0(',&,1(75($70(17
x Fluconazole, oral, 6 mg/kg once daily for 21 days. See dosing table, pg 23.5.

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See Section 2.9: Diarrhoea.

 31(8021,$
See Section 17.2: Respiratory infections.

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Refer all patients.

 6.,1&21',7,216
These are common and include scabies, seborrhoeic eczema and others. See
Chapter 5: Skin conditions.
If no response to care as directed in the chapter, refer.

 78%(5&8/26,67%
A15.0-3/A15.7-8/A16.0-2/A16.7-8/B20.0

'(6&5,37,21
TB and HIV are often comorbid conditions. Exclude TB in all patients before starting
ART. See Section 17.4.2: Pulmonary tuberculosis, in children.
Re-evaluate the risk for TB and TB contact at each visit on history (including contact
history) and clinical examination.
TB should be considered early in non-resolving pneumonias.
Tuberculin tests are often not reliable and a negative test does not exclude TB.
If TB is suspected but cannot be proven, refer early for diagnostic evaluation.

0(',&,1(75($70(17
7%SURSK\OD[LVZ29.2 + (B24)
Give TB prophylaxis to all HIV-infected children in whom no evidence of TB disease
is present and who are:
» Exposed to a close contact with infectious pulmonary TB or
» TST-positive (only the 1st time a positive TST is shown).
x Isoniazid, oral, 10 mg/kg/dose once daily for 6 months.
o Maximum dose 300 mg daily.
o See Section 17.4.2.1: TB chemoprophylaxis/Isoniazid preventive therapy
(IPT) in children.
Repeat course if an HIV-infected patient, irrespective of age, is re-exposed to a TB
contact at any point after completing TB treatment or prophylaxis.

2018 11.39
 &+$37(5 +,9$1'$,'6

If patient has been exposed to a known MDR or XDR-TB source case or the contact
case has failed standard TB treatment, refer.

7%WUHDWPHQW
If the child is not yet on ART:

 2 weeks if CD4 < 50 cells/mm3

» Commence TB treatment first. Follow with ART, usually after 2–8 weeks:

 8 weeks if CD4 > 50 cells/mm3

» Check ALT before commencing ART. If the ALT is raised, discuss this with an
expert as it may not be an absolute contra-indication to treatment.
» Be aware of the possibility of Immune Reconstitution Inflammatory Syndrome (IRIS).
If the child is already on ART:
» Commence TB treatment taking into consideration possible medicine interactions.
If the child needs to take concomitant ART and rifampicin:
» Efavirenz: use the normal recommended dosage as per dosing table on pg 23.4.
» Abacavir and lamivudine: no dose adjustment required.
» Lopinavir/ritonavir: Add additional ritonavir to ensure an equal dose in mg of
lopinavir and ritonavir while on rifampicin. For example, for each mL of LPV/r
solution (80/20 mg/mL), add 0.75 mL of ritonavir solution (80 mg/mL). See dosing
table, pg 23.9.
» Give pyridoxine (vitamin B6) to all children on TB and ART, to avoid development
of peripheral neuropathy.

 '(9(/230(17$/'(/$<25'(7(5,25$7,21
Refer for assessment.

 $1$(0,$
See Section 3.1: Anaemia







2018 11.40
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+,935(9(17,21
35((;32685(3523+</$;,6
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3U(3HOLJLELOLW\FULWHULD
3U(3LVFXUUHQWO\DYDLODEOHDWGHVLJQDWHGVLWHVRQO\

'(6&5,37,21
Pre-exposure prophylaxis (PrEP) is the use of antiretroviral medicines by HIV-
negative individuals before potential exposure to HIV to prevent them from acquiring
HIV infection.
PrEP only protects against HIV infection; it does not offer protection against other
STIs or pregnancy.
PrEP should be used as part of a package including condoms, lubricants for anal sex,
STI management, screening and management of intimate partner violence, sexual
and reproductive health services, medical male circumcision and HIV services,
including counseling and testing, HIV management, ART, PEP, and PrEP.
,QGLYLGXDOVLQLWLDWHGRQ3U(3PXVWEH
» HIV-negative.
» At substantial risk of HIV infection.
» Willing and able to adhere to PrEP.
» Prepared to come for repeat HIV testing every 3 months.
» No contra-indications to tenofovir or emtricitabine.
» No suspicion of acute HIV-infection (see clinical features, below).
&OLQLFDOIHDWXUHVRIDFXWH+,9LQIHFWLRQ
6\PSWRPV 6LJQV
Malaise, anorexia, Fever, sweating, viral meningitis, generalised
myalgia, headache, sore lymphadenopathy, hepatosplenomegaly, pharyngitis, truncal
throat, sore glands, rash rash, orogenital herpetiform ulceration, oral/oesophageal
candidiasis, cervical adenopathy

&2175$,1',&$7,2167235(3
» Pre-existing HIV infection.
» Creatinine clearance or eGFR < 60 mL/min.
» Use of nephrotoxic medicines e.g. aminoglycosides.
» Young women/men < 35 kg or < 15 years of age who are not Tanner stage 3
(sexual maturity) or greater.
» Unwilling or unable to adhere to daily PrEP.
35(35(*,0(1

x Tenofovir, oral, 300 mg daily.

A fixed dose combination formulation of:

$1'
x Emtricitabine, oral, 200 mg daily. LoE:Ixxiv
2018 11.41
 &+$37(5 +,9$1'$,'6

1RWHTo reach adequate protective levels in tissues, 7 days of daily dosing are
required for anal sex and 20 days for vaginal sex.
6FUHHQLQJLQYHVWLJDWLRQVEHIRUHVWDUWLQJ3U(3 LoE:IIIxxv
,QYHVWLJDWLRQ 3XUSRVH $FWLRQ
HIV test Assessment of HIV status. If HIV-negative, consider PrEP
(using If HIV-positive.
algorithm in Link to treatment and care services.
the HTS
guidelines)
Creatinine To identify pre-existing renal Do not initiate PrEP if creatinine
clearance/ disease. clearance/eGFR < 60 mL/min. Repeat
eGFR creatinine clearance after two weeks. If
renal function returns to normal and
other PrEP criteria are met, PrEP may be
initiated. Refer for further investigation if
renal function remains abnormal.
Hepatitis B To diagnose chronic Consider vaccination if available for
surface hepatitis B infection. HBsAg-negative.
antigen To identify those eligible for If HBsAg-positive, do ALT prior to PrEP
(HBsAg) vaccination against hepatitis initiation.
B.
ALT if HBsAg- If ALT persistently elevated or other
positive abnormal liver function tests, refer for
assessment.
Urine To identify if pregnant. Discuss the potential risks of TDF + FTC.
pregnancy test
RPR To diagnose syphilis Manage according to STI guidelines.
infection for treatment.
Syndromic STI To diagnose and treat STI. Manage according to STI guidelines.
screening

1RWH
» If symptoms or signs of acute HIV infection are present, PrEP should be
postponed until symptoms subside and a repeat rapid HIV test after 4 weeks
remains negative.
» TDF + FTC is active against hepatitis B (HBV) infection. HBV infection is not a
contra-indication to PrEP, but will require LFT monitoring. Discontinuation of
TDF + FTC in patients with HBV requires referral to a specialist because of a
risk of a hepatitis flare.
+HSDWLWLV%LPPXQHVWDWXVDQG3U(3HOLJLELOLW\
+HSDWLWLV%VXUIDFH +HSDWLWLV%VXUIDFH $FWLRQ
DQWLJHQ+%V$J DQWLERG\+%V$E
Negative (-) Negative (-) Start PrEP. Vaccinate
concurrently if available
Negative (-) Positive (+) Start PrEP. No vaccine needed
Positive (+) N/A Refer for evaluation, if ALT > 2
times upper limit of normal.
1RWH
» PrEP users with chronic hepatitis B infection who develop abnormal liver

2018 11.42
 &+$37(5 +,9$1'$,'6

function tests should be referred for assessment.

3U(3IROORZXSDQGPRQLWRULQJ
$FWLYLW\ )UHTXHQF\
Confirmation of HIV-negative status At 1 month, then every 3 months
Address side effects Every visit
Adherence counseling Every visit
Creatinine clearance At 1 month, then every 3 months for the
first year, then 12-monthly
STI screening and treatment Every visit
PrEP dispensing 1 month supply, then 3 monthly supply
Behavioural sexual risk reduction counseling Every visit

35(36$)(7<
5HOHYDQWPHGLFLQHLQWHUDFWLRQLQIRUPDWLRQ
0HGLFLQH ,QWHUDFWLRQ $GYLVH
LQIRUPDWLRQ
Standard TB No interaction No need for dose adjustments
medicines
MDR-TB Increase risk of Avoid PrEP. Advise other prevention methods
medicines renal side effects
Hormonal No interaction Hormonal contraception does not affect PrEP
contraception effectiveness, nor does PrEP affect hormonal
contraceptive effectiveness
Nephrotoxic Increase risk of Avoid PrEP. Advise other prevention methods
medicines renal side effects

6LGHHIIHFWVRI7'))7&FRPELQDWLRQ
Major Renal toxicity, decreased bone mineral density, extremely small risk of lactic
acidosis and hepatic steatosis or steatohepatitis
Minor Gastrointestinal symptoms (diarrhoea, nausea, vomiting and flatulence),
unintentional weight loss

1RWH
» Minor side effects are relatively common (approximately 1 in 10 individuals in
the first 1-2 months).
» Mild and self-limiting; do not require discontinuation.
» Renal toxicity and decreased bone mineral density usually reversible upon
stopping PrEP.

67233,1*35(3
PrEP should be stopped if:
» Tests HIV-positive.
» Renal disease develops.
» Non-adherent to PrEP.
» Does not need or want PrEP.
» No longer meets eligibility criteria.
» There are safety concerns where the risks of PrEP use outweigh potential benefit.
Continue PrEP for 28 days after the last potential HIV exposure.
2018 11.43
 &+$37(5 +,9$1'$,'6

1RWH Patients with chronic HBV may experience a hepatitis flare on discontinuation
of PrEP.

35(3,1,7,$7,21$/*25,7+0

5()(55$/
» HBsAg-positive, with abnormal ALT.
» Discontinuation of TDF + FTC in patients with HBV.

3267(;32685(3523+</$;,6
See Section 21.3.6: Post exposure Prophylaxis (PEP).

2018 11.44
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 ,0081(5(&2167,787,21,1)/$00$725<
   6<1'520(,5,6
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Clinical deterioration can occur after starting ART due an improvement in the immune
system response to organisms already causing infection, e.g.
» M.Bovis (BCG)
» M. tuberculosis (MTB)
There are 2 types of IRIS:
1. Unmasking: when a previously unsuspected condition becomes manifest.
2. Paradoxical: known condition on appropriate treatment becomes worse.

',$*1267,&&5,7(5,$
» Exclude other active or inadequately treated diseases (including DR-TB).

 Usually during the first 6 weeks after starting ART.

» Presentation:

 Depends on the causative organism and the organ system involved, e.g. TB
presents with fever, lymphadenopathy, worsening of the original tuberculous
lesion, and/or deteriorating chest radiographic manifestations such as miliary
pattern or pleural effusion.

5()(55$/
All.

 /$&7,&$&,'26,6
E87.2 + (Y41.5 + B24)

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All nucleoside analogues have been associated with lactic acidosis, which is rare but
life-threatening. Initial symptoms vary and occur between 1–20 months (median 4
months) after starting therapy. The risk is highest with stavudine, followed by
didanosine and then zidovudine.

',$*1267,&&5,7(5,$
&OLQLFDO
Clinical prodromal syndrome:
» Generalised fatigue
» Weakness and myalgia

 nausea 
» Gastrointestinal symptoms:

 vomiting 
vague abdominal pain

 diarrhoea 
hepatomegaly

 unexplained weight loss

anorexia

2018 11.45
 &+$37(5 +,9$1'$,'6

» Respiratory symptoms: tachypnoea and dyspnoea.

» Neurologic symptoms, including motor weakness.
,QYHVWLJDWLRQV

 Hyperlactataemia
» Laboratory abnormalities:

Raised: 2.1–5 mmol/L

 Lactic acidosis, defined by:

Severely raised : > 5 mmol/L

Lactate > 5 mmol/L.

Bicarbonate < 20 mmol/L.
Severe acidosis i.e. pH < 7.3.
Increased anion gap i.e. > 15 mEq/L.

5()(55$/
All urgently.

5HIHUHQFHV
iEligibility for ART: INSIGHT START Study Group, Lundgren JD, Babiker AG, Gordin F, Emery S, Grund B, Sharma S, Avihingsanon A,

Cooper DA, Fätkenheuer G, Llibre JM, Molina JM, Munderi P, Schechter M, Wood R, Klingman KL, Collins S, Lane HC, Phillips AN,
Neaton JD. Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection. N Engl J Med. 2015 Aug 27;373(9):795-807.
http://www.ncbi.nlm.nih.gov/pubmed/26192873
Eligibility for ART: TEMPRANO ANRS 12136 Study Group. A Trial of Early Antiretrovirals and Isoniazid Preventive Therapy in Africa.
N Engl J Med. 2015 Aug 27;373(9):808-22. http://www.ncbi.nlm.nih.gov/pubmed/26193126
iiImmediate initiation of ART, pregnant and breastfeeding women:National Department of Health. National consolidated guidelines for

the prevention of mother-to-child transmission of HIV (PMTCT) and the management of HIV in children, adolescents and adults, 2014.
http://www.health.gov.za/
Immediate initiation of ART, pregnant and breastfeeding women: WHO. Consolidated guidelines on the use of antiretroviral drugs for
treating and preventing HIV infection, June 2013.Web annexes: Chapter 7 Clinical guidance across the continuum of care: antiretroviral
therapy guidelines; Section 7.1.2: When to start ART in pregnant and breastfeeding women and GRADE tables.
http://www.who.int/hiv/pub/guidelines/arv2013/annexes/en/index2.html
iii TB patients with CD4 count < 50 cells/mm3: Uthman OA, Okwundu C, Gbenga K, Volmink J, Dowdy D, Zumla A, Nachega JB.

Optimal Timing of Antiretroviral Therapy Initiation for HIV-Infected Adults With Newly Diagnosed Pulmonary Tuberculosis: A Systematic
Review and Meta-analysis. Ann Intern Med. 2015 Jul 7;163(1):32-9. http://www.ncbi.nlm.nih.gov/pubmed/26148280
ivTiming of ART initiation (tuberculous meningitis): Török ME, Yen NT, Chau TT, Mai NT, Phu NH, Mai PP, Dung NT, Chau NV, Bang

ND, Tien NA, Minh NH, Hien NQ, Thai PV, Dong DT, Anh do TT, Thoa NT, Hai NN, Lan NN, Lan NT, Quy HT, Dung NH, Hien TT,
Chinh NT, Simmons CP, de Jong M, Wolbers M, Farrar JJ. Timing of initiation of antiretroviral therapy in human immunodeficiency virus
(HIV)--associated tuberculous meningitis. Clin Infect Dis. 2011 Jun;52(11):1374-83. http://www.ncbi.nlm.nih.gov/pubmed/21596680
v TB patients with CD4 count > 50 cells/mm3: Uthman OA, Okwundu C, Gbenga K, Volmink J, Dowdy D, Zumla A, Nachega JB.

Optimal Timing of Antiretroviral Therapy Initiation for HIV-Infected Adults With Newly Diagnosed Pulmonary Tuberculosis: A Systematic
Review and Meta-analysis. Ann Intern Med. 2015 Jul 7;163(1):32-9. http://www.ncbi.nlm.nih.gov/pubmed/26148280
vi Antiretroviral medicines: WHO. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection,

June 2013; March 2014 and December 2014 supplements.http://www.who.int/hiv/pub/guidelines/arv2013/en/

Criteria for fast track of ART: National Department of Health.National consolidated guidelines for the prevention of mother-to-child
transmission of HIV (PMTCT) and the management of HIV in children, adolescents and adults, 2014.
vii Antiretroviral medicines dosing and common adverse drug reactions- Abacavir: South African Medicines Formulary. 12th Edition.

Division of Clinical Pharmacology. University of Cape Town, 2016.

viii Antiretroviral medicines dosing and common adverse drug reactions: National Department of Health, Essential Drugs Programme:

Adult Hospital Level STGs and EML, 2015. http://www.health.gov.za/http://www.health.gov.za/

Antiretroviral medicines dosing and common adverse drug reactions: Meintjes G, Moorhouse MA, Carmona S, Davies N, Dlamini S,
van Vuuren C, Manzini T, Mathe M, Moosa Y, Nash J, Nel J, Pakade Y, Woods J, Van Zyl G, Conradie F, Venter F. Adult antiretroviral
therapy guidelines 2017. South Afr J HIV Med. 2017 Jul 15;18(1):776. https://www.ncbi.nlm.nih.gov/pubmed/29568644
ix Failing on a d4T/AZT-regimen: National Department of Health. National consolidated guidelines for the prevention of mother-to-child

transmission of HIV (PMTCT) and the management of HIV in children, adolescents and adults, 2014.http://www.health.gov.za/
x Nevirapine initiation (CD4 cut-off): South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of

Cape Town, 2016.

xi TDF, failing regimen and hepatitis B surface antigen positive: National Department of Health, Essential Drugs Programme: Adult

Hospital Level STGs and EML, 2015. http://www.health.gov.za/

xii ART defaulting - VL target: National Department of Health. National consolidated guidelines for the prevention of mother-to-child

transmission of HIV (PMTCT) and the management of HIV in children, adolescents and adults, 2014. http://www.health.gov.za/
xiiiAtazanavir/ 3rd line antiretrovirals (raltegravir, dolutegravir) -rifampicin – drug-drug interactions: South African Medicines Formulary.

12th Edition. Division of Clinical Pharmacology. University of Cape Town, 2016.

2018 11.46
 &+$37(5 +,9$1'$,'6

xivIsoniazid (IPT) - 12-month therapy: Rangaka MX, Wilkinson RJ, Boulle A, Glynn JR, Fielding K, van Cutsem G, Wilkinson KA, Goliath
R, Mathee S, Goemaere E, Maartens G. Isoniazid plus antiretroviral therapy to prevent tuberculosis: a randomised double-blind
placebo-controlled trial. Lancet 2014;384(9944):682-90. http://www.ncbi.nlm.nih.gov/pubmed/24835842
xv Isoniazid (IPT) – Pregnant women: Gupta et al. Randomized trial of safety of isoniazid preventive therapy during or after pregnancy.

CROI Conference Abstract, March 2018.

http://www.croiwebcasts.org/console/player/37314?mediaType=audio&&crd_fl=1&ssmsrq=1521455648187&ctms=5000&csmsrq=989
Isoniazid (IPT) – Pregnant women: Akolo C, Adetifa I, Shepperd S, Volmink J. Treatment of latent tuberculosis infection in HIV
infected persons. Cochrane Database Syst Rev. 2010 Jan20;(1):CD000171. https://www.ncbi.nlm.nih.gov/pubmed/20091503
Isoniazid (IPT) – Pregnant women: Post FA, Szubert AJ, Prendergast AJ, Johnston V, Lyall H, Fitzgerald F, Musiime V, Musoro G,
Chepkorir P, Agutu C, Mallewa J, Rajapakse C, Wilkes H, Hakim J, Mugyenyi P, Walker AS, Gibb DM, Pett SL; Reduction of EArly
mortaLITY in HIV-infected adults and children starting antiretroviral therapy (REALITY) Trial Team . Causes and Timing of Mortality and
Morbidity Among Late Presenters Starting Antiretroviral Therapy in the REALITY Trial. Clin Infect Dis. 2018 Mar 4;66(suppl 2):S132-
S139. https://www.ncbi.nlm.nih.gov/pubmed/29514234
xvi ART - Candidiasis, oesophageal: National Department of Health. National consolidated guidelines for the prevention of mother-to-

child transmission of HIV (PMTCT) and the management of HIV in children, adolescents and adults, 2014.http://www.health.gov.za/
xviiFluconazole (from 2nd trimester): Mølgaard-Nielsen D, Pasternak B, Hviid A. Use of oral fluconazole during pregnancy and the risk of

birth defects. N Engl J Med. 2013 Aug 29;369(9):830-9. http://www.ncbi.nlm.nih.gov/pubmed/23984730

Fluconazole (from 2nd trimester):Mølgaard-Nielsen D, Svanström H, Melbye M, Hviid A, Pasternak B. Association Between Use of
Oral Fluconazole During Pregnancy and Risk of Spontaneous Abortion and Stillbirth. JAMA. 2016 Jan 5;315(1):58-67.
http://www.ncbi.nlm.nih.gov/pubmed/26746458
xviiiPMTCT(risk-stratified): Beste S, Essajee S, Siberry G, Hannaford A, Dara J, Sugandhi N, Penazzato M. Optimal Antiretroviral

Prophylaxis in Infants at High Risk of Acquiring HIV: A Systematic Review. Pediatr Infect Dis J. 2018 Feb;37(2):169-175.
https://www.ncbi.nlm.nih.gov/pubmed/29319636
PMTCT(risk-stratified): National Department of Health, Essential Drugs Programme: Paediatric Hospital Level STGs and EML, 2017.
http://www.health.gov.za/
PMTCT(risk-stratified): World Health Organisation. Consolidated guidelines on the use of antiretroviral drugs for treating and
preventing HIV infection, 2016. https://www.ncbi.nlm.nih.gov/pubmed/29319636
xix Zidovudine, oral (PMTCT- high risk protocol): Nielsen-Saines K, Watts DH, Veloso VG, Bryson YJ, Joao EC, Pilotto JH, Gray G,

Theron G, Santos B, Fonseca R, Kreitchmann R, Pinto J, Mussi-Pinhata MM, Ceriotto M, Machado D, Bethel J, Morgado MG, Dickover
R, Camarca M, Mirochnick M, Siberry G, Grinsztejn B, Moreira RI, Bastos FI, Xu J, Moye J, Mofenson LM; NICHD HPTN 040/PACTG
1043 Protocol Team. Three postpartum antiretroviral regimens to prevent intrapartum HIV infection. N Engl J Med. 2012 Jun
21;366(25):2368-79. https://www.ncbi.nlm.nih.gov/pubmed/22716975
Zidovudine, oral (PMTCT- high risk protocol): Smith C, Forster JE, Levin MJ, Davies J, Pappas J, Kinzie K, Barr E, Paul S,
McFarland EJ, Weinberg A. Serious adverse events are uncommon with combination neonatal antiretroviral prophylaxis: a retrospective
case review. PLoS One. 2015 May 22;10(5):e0127062. https://www.ncbi.nlm.nih.gov/pubmed/26000984
Zidovudine, oral (PMTCT- high risk protocol): Mulenga V, Musiime V, Kekitiinwa A, Cook AD, Abongomera G, Kenny J, Chabala C,
Mirembe G, Asiimwe A, Owen-Powell E, Burger D, McIlleron H, Klein N, Chintu C, Thomason MJ, Kityo C, Walker AS, Gibb DM;
CHAPAS-3 trial team. Abacavir, zidovudine, or stavudine as paediatric tablets for African HIV-infected children (CHAPAS-3): an open-
label, parallel-group, randomised controlled trial. Lancet Infect Dis. 2016 Feb;16(2):169-79.
https://www.ncbi.nlm.nih.gov/pubmed/26481928
xx Eligibility criteria for ART (children): World Health Organisation. Consolidated guidelines on the use of antiretroviral drugs for treating

and preventing hiv infection, 2016. Recommendations for a public health approach. http://www.who.int/hiv/pub/arv/arv-2016/en/
xxiTiming of ART initiation (TB): Uthman OA, Okwundu C, Gbenga K, Volmink J, Dowdy D, Zumla A, Nachega JB. Optimal Timing of

Antiretroviral Therapy Initiation for HIV-Infected Adults With Newly Diagnosed Pulmonary Tuberculosis: A Systematic Review and
Meta-analysis. Ann Intern Med. 2015 Jul 7;163(1):32-9. http://www.ncbi.nlm.nih.gov/pubmed/26148280
Timing of ART initiation (tuberculous meningitis): Török ME, Yen NT, Chau TT, Mai NT, Phu NH, Mai PP, Dung NT, Chau NV, Bang
ND, Tien NA, Minh NH, Hien NQ, Thai PV, Dong DT, Anh do TT, Thoa NT, Hai NN, Lan NN, Lan NT, Quy HT, Dung NH, Hien TT,
Chinh NT, Simmons CP, de Jong M, Wolbers M, Farrar JJ. Timing of initiation of antiretroviral therapy in human immunodeficiency virus
(HIV)--associated tuberculous meningitis. Clin Infect Dis.2011 Jun;52(11):1374-83. http://www.ncbi.nlm.nih.gov/pubmed/21596680
xxii1st line ART regimen (children): National Department of Health. National consolidated guidelines for the prevention of mother-to-child

transmission of HIV (PMTCT) and the management of HIV in children, adolescents and adults, 2014.http://www.health.gov.za/
1st line ART regimen (children): National Department of Health, Essential Drugs Programme: Paediatric Hospital Level STGs and
EML, 2017. http://www.health.gov.za/
1st line ART regimen (children): National Department of Health. Integrated Management of Childhood Illnesses Guidelines, 2014.
http://www.health.gov.za/
xxiii Antiretroviral medicine dosages by weight bands (adapted for primary level of care): Child and Adolescent Committee of the SA HIV

Clinicians Society in collaboration with the Department of Health: Antiretroviral drug dosing chart for children, 2013.
http://www.sahivsoc.org/Files/2013%20ARV%20dosing%20chart%20for%20children%20(Aug%202013).pdf
xxiv PrEP regimen (Tenofovir + emtricitabine): Fonner VA, Dalglish SL, Kennedy CE, Baggaley R, O'reilly KR, Koechlin FM, Rodolph M,

Hodges-Mameletzis I, Grant RM. Effectiveness and safety of oral HIV pre-exposure prophylaxis (PrEP) for all populations: A systematic
review and meta-analysis. AIDS. AIDS. 2016 Jul 31;30(12):1973-83. http://www.ncbi.nlm.nih.gov/pubmed/27149090
PrEP regimen (Tenofovir + emtricitabine): World Health Organisation. Guideline on when to start antiretroviral therapy and on pre-
exposure prophylaxis for HIV, September 2015.http://www.who.int/hiv/pub/guidelines/earlyrelease-arv/en/
xxv PrEP regimen (Tenofovir + emtricitabine: adequate dosing): Patterson KB, Prince HA, Kraft E, Jenkins AJ, Shaheen NJ, Rooney JF,

Cohen MS, Kashuba AD. Penetration of tenofovir and emtricitabine in mucosal tissues: implications for prevention of HIV-1
transmission. Sci Transl Med. 2011 Dec 7;3(112):112re4. https://www.ncbi.nlm.nih.gov/pubmed/22158861

2018 11.47
PHC Chapter 12: Sexually transmitted
infections

12.1 Vaginal discharge syndrome (VDS)

12.1.1 Sexually non-active women
12.1.2 Sexually active women
12.2 Lower abdominal pain (LAP)
12.3 Male urethritis syndrome (MUS)
12.4 Scrotal swelling (SSW)
12.5 Genital ulcer syndrome (GUS)
12.6 Bubo
12.7 Balanitis/balanoposthitis (BAL)
12.8 Syphilis serology and treatment
12.9 Treatment of more than one STI syndrome
12.10 Treatment of partners
12.11 Genital molluscum contagiosum (MC)
12.12 Genital warts (GW) Condylomata Accuminata
12.13 Pubic lice (PL)
 CHAPTER 12 SEXUALLY TRANSMITTED INFECTIONS

The syndromic approach to Sexually Transmitted Infections (STIs) diagnosis and

management is to treat the signs or symptoms (syndrome) of a group of diseases
rather than treating a specific disease. This allows for the treatment of one or more
conditions that often occur at the same time and has been accepted as the
management of choice.
Causative organisms and medicine management for STI syndromes:
ORGANISM SYNDROME/S MEDICINE MANAGEMENT
Neisseria gonorrhoeae VDS, MUS, LAP ceftriaxone + azithromycin
LoE:IIIi
Chlamydia trachomatis VDS, MUS, LAP, azithromycin
GUS, Bubo
Trichomonas vaginalis VDS, LAP metronidazole
Bacterial vaginosis VDS metronidazole
(overgrowth of Gardnerella
vaginalis, lactobacillus,
anaerobes etc.)
Candida albicans VDS clotrimazole
Treponema pallidum GUS doxycycline/ benzathine
benzylpenicillin
Herpes simplex GUS aciclovir
Haemophilus ducreyi GUS, Bubo azithromycin
It is important to take a good sexual history and undertake a thorough ano-genital
examination in order to perform a proper clinical assessment. The history should
include questions concerning symptoms, recent sexual history, sexual orientation, type
of sexual activity (oral, vaginal, anal sex), the possibility of pregnancy (females), use
of contraceptives including condoms, recent antibiotic history, antibiotic allergy, recent
overseas travel and domestic violence. Refer to a social worker, as required.
Note: Standard referral letter for treatment failure must include the following:
» reason for referral: presumptive diagnosis (e.g. persistent cervicitis with suspected
resistant gonorrhoea)
» clinical findings including speculum examination for vaginal discharge
» treatment history (including all medicines with dose and duration)
» details of notification and treatment history of partner(s)

Suspected STI in children should be referred to hospital for further investigation

and management.

GENERAL MEASURES
» Counselling and education, including HIV testing.
» Condom promotion, provision and demonstration to reduce the risk of STIs.
» Compliance/ adherence with treatment.
» Contact treatment/ partner management.
» Circumcision promotion (counselling to continue condom use).
» Cervical cancer screening.
2018 12.2
 CHAPTER 12 SEXUALLY TRANSMITTED INFECTIONS

Promote HIV counselling and testing.

For negative test results repeat test after 6 weeks, because of the window period.

Benzathine benzylpenicillin
Benzathine benzylpenicillin remains the recommended treatment for syphilis.
However, due to global shortage of benzathine benzylpenicillin (limited global supply
of the active pharmaceutical ingredient) the algorithms now recommend doxycycline,
oral except in pregnant women and children. Azithromycin is not recommended for the
treatment of syphilis in pregnancy as azithromycin does not effectively treat syphilis in
the fetus, and resistance develops rapidly to macrolides. Therefore, the limited stock
of benzathine benzylpenicillin must be reserved for use in pregnant women and
children.











2018 12.3
 CHAPTER 12 SEXUALLY TRANSMITTED INFECTIONS

12.1 VAGINAL DISCHARGE SYNDROME (VDS)

B37.3/N76.0/N89.8
12.1.1 SEXUALLY NON-ACTIVE WOMEN

LoE:IIIii
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 CHAPTER 12 SEXUALLY TRANSMITTED INFECTIONS

12.1.2 SEXUALLY ACTIVE WOMEN

LoE:IIIiii

2018 12.5
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12.2 LOWER ABDOMINAL PAIN (LAP)

N73.9

2018 12.6
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12.3 MALE URETHRITIS SYNDROME (MUS)

A64 + N34.1

2018 12.7
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12.4 SCROTAL SWELLING (SSW)

N45.1

2018 12.8
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12.5 GENITAL ULCER SYNDROME (GUS)

A60.9/A51.0 LoE:IIIiv

LoE:IIv

2018 12.9
 CHAPTER 12 SEXUALLY TRANSMITTED INFECTIONS

12.6 BUBO
A58

LoE:IIIvi

2018 12.10
 CHAPTER 12 SEXUALLY TRANSMITTED INFECTIONS

12.7 BALANITIS/BALANOPOSTHITIS (BAL)

N48.1

2018 12.11
 CHAPTER 12 SEXUALLY TRANSMITTED INFECTIONS

12.8 SYPHILIS SEROLOGY AND TREATMENT

A53.9

Syphilis serology
The Rapid Plasmin Reagin (RPR) measures disease activity, but is not specific for
syphilis. False RPR-positive reactions may occur, notably in patients with connective
tissue disorders (false positive reactions are usually low titre <1:8). For this reason,
positive RPR results should be confirmed due to syphilis by further testing of the serum
with a specific treponemal test, e.g.:
» Treponema pallidum haemagglutination (TPHA) assay.
» Treponema pallidum particle agglutination (TPPA) assay.
» Fluorescent Treponemal Antibody (FTA) assay.
» Treponema pallidum ELISA.
» Rapid treponemal antibody test (TPAb)

Screening can also be done the other way around starting with a specific treponemal
test followed by a RPR in patients who have a positive specific treponemal test. This
is sometimes referred to as the “reverse algorithm”.

 Once positive, specific treponemal tests generally remain positive for life and
therefore the presence of specific treponemal antibodies cannot differentiate


between current and past infections
A person with previously successfully treated syphilis will retain lifelong positive
specific treponemal test results.

The RPR can be used:

» To determine if the patient’s syphilis disease is active or not,
» To measure a successful response to therapy (at least a fourfold reduction in
titre, e.g. 1:256 improving to 1:64), or
» To determine a new re-infection.
Some patients, even with successful treatment for syphilis, may retain life-long
positive RPR results at low titres (”1:8), which do not change by more than one dilution
difference (up or down) over time (so-called serofast patients).
Note:
» Up to 30% of early primary syphilis cases, i.e. those with genital ulcers may have
a negative RPR.
» The RPR is always positive in the secondary syphilis stage and remains high
during the first two (infectious) years of syphilis.
LoE:IIvii
For syphilis treatment in pregnancy, see Section 6.4.4: Syphilis in pregnancy.

2018 12.12
 CHAPTER 12 SEXUALLY TRANSMITTED INFECTIONS

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 CHAPTER 12 SEXUALLY TRANSMITTED INFECTIONS

MEDICINE TREATMENT
Early syphilis treatment
Check if treated at initial visit.
x Benzathine benzylpenicillin, IM, 2.4 MU immediately as a single dose.
o Dissolve benzathine benzylpenicillin, IM, 2.4 MU in 6 mL lidocaine 1% without
adrenaline (epinephrine).
In penicillin-allergic patients or if benzathine benzylpenicillin is unavailable: (Z88.0)
x Doxycycline, oral, 100 mg 12 hourly for 14 days.
LoE:IIIviii

x Amoxicillin, oral 1 g 8 hourly for 14 days (Doctor initiated).

If pregnant and benzathine benzylpenicillin is unavailable:

x Probenecid, oral 250 mg, 8 hourly for 14 days (Doctor initiated).

AND

If penicillin-allergic and pregnant: Refer for penicillin desensitisation. LoE:IIIix

Late/ late latent syphilis treatment

Check if treatment was commenced at initial visit.
x Benzathine benzylpenicillin, IM, 2.4 MU once weekly for 3 weeks.
o Dissolve benzathine benzylpenicillin, IM, 2.4 MU in 6 mL lidocaine 1% without
adrenaline (epinephrine).
In penicillin-allergic patients or if benzathine benzylpenicillin is unavailable: (Z88.0)
x Doxycycline, oral, 100 mg 12 hourly for 30 days.
LoE:IIIx

x Amoxicillin, oral 1 g 8 hourly for 28 days (Doctor initiated).

If pregnant and benzathine benzylpenicillin is unavailable:

x Probenecid, oral 250 mg, 8 hourly for 28 days (Doctor initiated).

AND

If penicillin-allergic and pregnant: Refer for penicillin desensitisation. LoE:IIIxi

REFERRAL
» Tertiary syphilis: neurosyphilis, cardiovascular syphilis; gummatous syphilis.
» Clinical congenital syphilis.

12.9 TREATMENT OF MORE THAN ONE STI SYNDROME

STI SYNDROMES TREATMENT (NEW EPISODE)
MUS + SSW Treat according to SSW flow chart.
MUS + BAL Treat according to MUS flow chart.

x Clotrimazole cream, 12 hourly for 7 days.

AND

MUS + GUS x Ceftriaxone, IM, 250 mg immediately as a single dose.

x Azithromycin, oral, 1 g as a single dose.

AND

x Aciclovir, oral, 400 mg 8 hourly for 7 days*.

AND

2018 12.14
 CHAPTER 12 SEXUALLY TRANSMITTED INFECTIONS

Treat according to LAP flow chart.

VDS + LAP AND

x Ceftriaxone, IM, 250 mg immediately as a single dose.

Treat for candidiasis, if required (see VDS flow chart).
VDS + GUS

x Metronidazole, oral, 2 g immediately as a single dose.

AND

x Azithromycin, oral, 1 g as a single dose.

AND

x Aciclovir, oral, 400 mg 8 hourly for 7 days*.

AND

AND

x Ceftriaxone, IM, 250 mg immediately as a single dose.

Treat for candidiasis, if required (see VDS flow chart).
LAP+ GUS

x Metronidazole, oral, 400 mg 12 hourly for 7days.

AND

x Aciclovir, oral, 400 mg 8 hourly for 7 days*.

AND

x Azithromycin, oral, 1 g as a single dose.

AND

SSW+ GUS x Ceftriaxone, IM, 250 mg immediately as a single dose.

x Aciclovir, oral, 400 mg 8 hourly for 7 days*.

AND

x Azithromycin, oral, 1 g as a single dose.

AND

*Treat with aciclovir only if HIV status is positive or unknown.

**Penicillin allergic men and non-pregnant women avoid ceftriaxone and refer to
relevant algorithms.

Penicillin allergic pregnant/breastfeeding women, refer for penicillin desensitisation.

12.10 TREATMENT OF PARTNERS

Syndrome Asymptomatic partner Symptomatic partner
VDS x Ceftriaxone, IM, 250 mg x Ceftriaxone, IM, 250 mg immediately
immediately as a single dose. as a single dose.
AND AND
x Metronidazole, oral, 2 g x Metronidazole, oral, 2 g immediately
immediately as a single dose. as a single dose.
AND AND
x Azithromycin, oral, 1 g as a x Azithromycin, oral, 1 g as a single
single dose. dose.
PLUS treatment for syndrome present if
not included in the above.
LAP x Ceftriaxone, IM, 250 mg x Ceftriaxone, IM, 250 mg immediately
immediately as a single dose. as a single dose.
AND AND

2018 12.15
 CHAPTER 12 SEXUALLY TRANSMITTED INFECTIONS

x Metronidazole, oral, 2 g x Metronidazole, oral, 2 g immediately

immediately as a single dose. as a single dose.
AND AND
x Azithromycin, oral, 1 g as a x Azithromycin, oral, 1 g as a single
single dose. dose.
PLUS treatment for syndrome present if
not included in the above.
MUS x Ceftriaxone, IM, 250 mg x Ceftriaxone, IM, 250 mg immediately
immediately as a single dose. as a single dose.
AND AND
x Azithromycin, oral, 1 g as a x Azithromycin, oral, 1 g as a single
single dose. dose.
x PLUS treatment for syndrome
present if not included in the above
(see VDS flow chart).
Scrotal x Ceftriaxone, IM, 250 mg x Ceftriaxone, IM, 250 mg immediately
swelling immediately as a single dose. as a single dose.
AND AND
x Azithromycin, oral, 1 g as a x Azithromycin, oral, 1 g as a single
single dose. dose.
PLUS treatment for syndrome
present if not included in the above.
GUS x Doxcycyline, oral, 100 mg 12 x Doxcycyline, oral, 100 mg 12 hourly
hourly for 14 days. for 14 days.
Except pregnant women: Except pregnant women:
x Benzathine benzylpenicillin, x Benzathine benzylpenicillin, IM, 2.4
IM, 2.4 MU immediately as a MU immediately as a single dose.
single dose. o Dissolve benzathine
o Dissolve benzathine benzylpenicillin, IM, 2.4 MU in 6
benzylpenicillin, IM, 2.4 MU in mL lidocaine 1% without
6 mL lidocaine 1% without epinephrine (adrenaline).
epinephrine (adrenaline). PLUS treatment for syndrome
(If pregnant and benzathine present if not included in the above.
benzylpenicillin is unavailable, see (If pregnant and benzathine
syphilis flow chart). benzylpenicillin is unavailable, see
syphilis flow chart).
Bubo x Azithromycin, oral, 1 g as a x Azithromycin, oral, 1 g as a single
single dose. dose.
PLUS treatment for syndrome
present if not included in the above.
LoE:IIIxii

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 CHAPTER 12 SEXUALLY TRANSMITTED INFECTIONS

12.11 GENITAL MOLLUSCUM CONTAGIOSUM (MC)

B08.1

DESCRIPTION
This is a viral infection which can be transmitted sexually and non-sexually. It is usually
self-limiting but can be progressive in an advanced stage of immunodeficiency.
Clinical signs include papules at the genitals or other parts of the body.
The papules usually have a central dent (umbilicated papules).

MEDICINE TREATMENT
x Tincture of iodine BP, topical.
o Apply with an applicator to the core of the lesions.

12.12 GENITAL WARTS (GW): CONDYLOMATA ACCUMINATA

A63.0

DESCRIPTION
The clinical signs include:
» Warts on the ano-genital areas, vagina, cervix, meatus or urethra.
» Warts can be soft or hard.
In most cases, warts resolve without treatment after 2 years in non-immunosuppressed
patients.

GENERAL MEASURES
» If warts do not look typical or are fleshy or wet, perform a RPR test to exclude
secondary syphilis, which may present with similar lesions.
» Emphasise HIV testing.

REFERRAL

 warts > 10 mm
» All patients with:

 inaccessible warts, e.g. intra-vaginal or cervical warts

 numerous warts

12.13 PUBIC LICE (PL)

B85.3

DESCRIPTION
Infestation of lice mostly confined to pubic and peri-anal areas, and occasionally
involves eyelashes.
The bites cause intense itching, which often results in scratching with bacterial super-
infection.

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 CHAPTER 12 SEXUALLY TRANSMITTED INFECTIONS

GENERAL MEASURES
Thoroughly wash clothing and bed linen that may have been contaminated by the
patient in the 2 days prior to the start of treatment in hot water and then iron.

MEDICINE TREATMENT
x Benzyl benzoate 25%
o Apply to affected area.
o Leave on for 24 hours, then wash thoroughly.
o Repeat in 7 days.
Pediculosis of the eyelashes or eyebrows
x Yellow petroleum jelly (Note: Do not use white petroleum jelly near the eyes).
o Apply to the eyelid margins (cover the eyelashes) daily for 10 days to smother
lice and nits.
o Do not apply to eyes.
LoE:III
REFERRAL
All children with lice on pubic, perianal area and eyelashes to exclude sexual abuse.

References:
i Ceftriaxone, IM (Neisseria gonorrhoeae): Lewis DA, Sriruttan C, Müller EE, Golparian D, Gumede L, Fick D, de Wet J,Maseko V,
Coetzee J, Unemo M. Phenotypic and genetic characterization of the first two cases of extended-spectrum-cephalosporin-resistant
Neisseria gonorrhoeae infection in South Africa and association with cefixime treatment failure. J Antimicrob Chemother. 2013
Jun;68(6):1267-70. https://www.ncbi.nlm.nih.gov/pubmed/23416957
Ceftriaxone, IM (Neisseria gonorrhoeae): Lewis DA. Gonorrhoea resistance among men who have sex with men: what’s oral sex
got to do with it? South Afr J Epidemiol Infect 2013;28(2):77. https://journals.co.za/content/mp_sajei/28/2/EJC138699
Ceftriaxone, IM (Neisseria gonorrhoeae): Ito M, Yasuda M, Yokoi S, Ito S, Takahashi Y, Ishihara S, Maeda S, Deguchi T.
Remarkable increase in central Japan in 2001-2002 of Neisseria gonorrhoeae isolates with decreased susceptibility to penicillin,
tetracycline, oral cephalosporins, and fluoroquinolones. Antimicrob Agents Chemother. 2004 Aug;48(8):3185-7.
https://www.ncbi.nlm.nih.gov/pubmed/15273147
Ceftriaxone, IM (Neisseria gonorrhoeae): Tanaka M, Nakayama H, Tunoe H, Egashira T, Kanayama A, Saika T, Kobayashi I,
Naito S. A remarkable reduction in the susceptibility of Neisseria gonorrhoeae isolates to cephems and the selection of antibiotic
regimens for the single-dose treatment of gonococcal infection in Japan. J Infect Chemother. 2002 Mar;8(1):81-6.
https://www.ncbi.nlm.nih.gov/pubmed/11957125
Ceftriaxone, IM (Neisseria gonorrhoeae): Yokoi S, Deguchi T, Ozawa T, Yasuda M, Ito S, Kubota Y, Tamaki M, Maeda S. Threat
to cefixime treatment for gonorrhea. Emerg Infect Dis. 2007 Aug;13(8):1275-7. https://www.ncbi.nlm.nih.gov/pubmed/17953118
Ceftriaxone, IM (Neisseria gonorrhoeae): Unemo M, Nicholas RA. Emergence of multidrug-resistant, extensively drug-resistant
and untreatable gonorrhea. Future Microbiol. 2012 Dec;7(12):1401-22. https://www.ncbi.nlm.nih.gov/pubmed/23231489
Ceftriaxone, IM (Neisseria gonorrhoeae): Zhao S, Duncan M, Tomberg J, Davies C, Unemo M, Nicholas RA. Genetics of
chromosomally mediated intermediate resistance to ceftriaxone and cefixime in Neisseria gonorrhoeae. Antimicrob Agents
Chemother. 2009 Sep;53(9):3744-51. https://www.ncbi.nlm.nih.gov/pubmed/19528266
Ceftriaxone, IM (Neisseria gonorrhoeae): Chisholm SA, Mouton JW, Lewis DA, Nichols T, Ison CA, Livermore DM.
Cephalosporin MIC creep among gonococci: time for a pharmacodynamic rethink? J Antimicrob Chemother. 2010 Oct;65(10):2141-
8. https://www.ncbi.nlm.nih.gov/pubmed/20693173
Ceftriaxone, IM (Neisseria gonorrhoeae): Contract circular RT301-2017: Ceftriaxone 250 mg, parenteral formulation.
ii Vaginal discharge syndrome – Sexual activity criterion: Kularatne R, Radebe F, Kufa-Chakezha T, Mbulawa Z, Lewis D.

Sentinel Surveillance of Sexually Transmitted Infection Syndrome aetiologies and HPV genotypes among patients attending
Primary Health Care Facilities in South Africa, April 2014 – September 2015. http://www.nicd.ac.za/wp-
content/uploads/2017/03/3Final-25-April-2017_Revised-NAS_v5_NICD.pdf
Vaginal discharge syndrome – speculum examination: National Department of Health. Comprehensive STI Clinical Management
Guidelines, draft version.
Clotrimazole, topical: Vaginal discharge syndrome – non-sexually active women (monotherapy syndromic directed management –
candidiasis): Kularatne R, Radebe F, Kufa-Chakezha T, Mbulawa Z, Lewis D. Sentinel Surveillance of Sexually Transmitted
Infection Syndrome aetiologies and HPV genotypes among patients attending Primary Health Care Facilities in South Africa,
April 2014 – September 2015. http://www.nicd.ac.za/wp-content/uploads/2017/03/3Final-25-April-2017_Revised-NAS_v5_NICD.pdf
Metronidazole, oral: Vaginal discharge syndrome – non-sexually active women (monotherapy syndromic directed management –
bacterial vaginosis): Kularatne R, Radebe F, Kufa-Chakezha T, Mbulawa Z, Lewis D. Sentinel Surveillance of Sexually
Transmitted Infection Syndrome aetiologies and HPV genotypes among patients attending Primary Health Care Facilities in
South Africa, April 2014 – September 2015. http://www.nicd.ac.za/wp-content/uploads/2017/03/3Final-25-April-2017_Revised-
NAS_v5_NICD.pdf

2018 12.18
 CHAPTER 12 SEXUALLY TRANSMITTED INFECTIONS

iii Vaginal discharge syndrome – Sexual activity criterion: Kularatne R, Radebe F, Kufa-Chakezha T, Mbulawa Z, Lewis D.
Sentinel Surveillance of Sexually Transmitted Infection Syndrome aetiologies and HPV genotypes among patients attending
Primary Health Care Facilities in South Africa, April 2014 – September 2015. http://www.nicd.ac.za/wp-
content/uploads/2017/03/3Final-25-April-2017_Revised-NAS_v5_NICD.pdf
Vaginal discharge syndrome – speculum examination: National Department of Health. Comprehensive STI Clinical Management
Guidelines, draft version.
iv Doxycycline, oral (genital ulcer syndrome): World Health Organization. WHO guidelines for the treatment of Treponema pallidum

(syphilis), 2016.http://apps.who.int/iris/bitstream/10665/249572/1/9789241549806-eng.pdf
v Benzathine benzylpenicillin (genital ulcer syndrome): Liu HY, Han Y, Chen XS, Bai L, Guo SP, Li L, Wu P, Yin YP. Comparison of

efficacy of treatments for early syphilis: A systematic review and network meta-analysis of randomized controlled trials and
observational studies. PLoS One. 2017 Jun 28;12(6):e0180001. https://www.ncbi.nlm.nih.gov/pubmed/28658325
Pregnant women, 1st trimester (genital ulcer syndrome): National Department of Health. Guidelines for Maternity Care in South
Africa, 2016. http://www.health.gov.za
vi Azitromycin, oral (bubo): González-Beiras C, Marks M, Chen CY, Roberts S, Mitjà O. Epidemiology of Haemophilus ducreyi

Infections. Emerg Infect Dis. 2016 Jan;22(1):1-8. https://www.ncbi.nlm.nih.gov/pubmed/26694983

vii Syphilis serology (RPR follow-up test in doxycycline-treated patients not recommended): Liu HY, Han Y, Chen XS, Bai L, Guo SP,

Li L, Wu P, Yin YP. Comparison of efficacy of treatments for early syphilis: A systematic review and network meta-analysis of
randomized controlled trials and observational studies. PLoS One. 2017 Jun 28;12(6):e0180001.
https://www.ncbi.nlm.nih.gov/pubmed/28658325
Syphilis serology (RPR follow-up test in doxycycline-treated patients not recommended): Salado-Rasmussen K, Hoffmann S,
Cowan S, Jensen JS, Benfield T, Gerstoft J, Katzenstein TL. Serological Response to Treatment of Syphilis with Doxycycline
Compared with Penicillin in HIV-infected Individuals. Acta Derm Venereol. 2016 Aug 23;96(6):807-11.
https://www.ncbi.nlm.nih.gov/pubmed/26568359
Syphilis serology (RPR follow-up test in doxycycline-treated patients not recommended): Dai T, Qu R, Liu J, Zhou P, Wang Q.
Efficacy of Doxycycline in the Treatment of Syphilis. Antimicrob Agents Chemother. 2016 Dec 27;61(1). pii: e01092-16.
https://www.ncbi.nlm.nih.gov/pubmed/27795370
viii Doxycycline, oral (Early syphilis treatment - penicillin allergic/benzathine benzylpenicillin unavailable): World Health Organization.

WHO guidelines for the treatment of Treponemapallidum (syphilis), 2016.

http://apps.who.int/iris/bitstream/10665/249572/1/9789241549806-eng.pdf
ix Amoxicillin, oral + probenecid, oral (Early syphilis treatment - pregnant/benzathine benzylpenicillin unavailable): Tanizaki R,

Nishijima T, Aoki T, Teruya K, Kikuchi Y, Oka S, et al. High-dose oral amoxicillin plus probenecid is highly effective for syphilis in
patients with HIV infection. Clin Infect Dis. 2015;61(2):177-83. https://www.ncbi.nlm.nih.gov/pubmed/25829004
Amoxicillin, oral + probenecid, oral (Early syphilis treatment - pregnant/benzathine benzylpenicillin unavailable): National
Department of Health: Affordable Medicines, EDP-Adult Hospital level. Medicine Review: Amoxicllin+probenecid for syphilis in
pregnant women, January 2018. http://www.health.gov.za/
x Doxycycline, oral: Late latent syphilis treatment - penicillin allergic: World Health Organization. WHO guidelines for the treatment

of Treponema pallidum (syphilis), 2016.http://apps.who.int/iris/bitstream/10665/249572/1/9789241549806-eng.pdf

xi Amoxicillin, oral + probenecid, oral (Late latent syphilis treatment - pregnant/benzathine benzylpenicillin unavailable): Tanizaki R,

Nishijima T, Aoki T, Teruya K, Kikuchi Y, Oka S, et al. High-dose oral amoxicillin plus probenecid is highly effective for syphilis in
patients with HIV infection. Clin Infect Dis. 2015;61(2):177-83. https://www.ncbi.nlm.nih.gov/pubmed/25829004
Amoxicillin, oral + probenecid, oral (Late latent syphilis treatment - pregnant/benzathine benzylpenicillin unavailable): National
Department of Health: Affordable Medicines, EDP-Adult Hospital level. Medicine Review: Amoxicllin+probenecid for syphilis in
pregnant women, January 2018. http://www.health.gov.za/
xii STI partner treatment: Centers for Disease Control and Prevention. 2015 Sexually Transmitted Diseases Treatment Guidelines.

https://www.cdc.gov/std/tg2015/

2018 12.19
PHC Chapter 13: Immunisation
13.1 Immunisation schedule
13.2 Childhood immunisation schedule
13.3 Vaccines for routine administration
13.4 The cold chain
13.5 Open multi-dose vial policy
13.6 Adverse Events Following Immunisation (AEFI)
13.7 Other vaccines














&+$37(5 ,0081,6$7,21

7KHFRQWHQWVRIWKLVFKDSWHUDUHEDVHGRQWKHFXUUHQW1DWLRQDO
9DFFLQDWRUV 0DQXDO DQG UHFRPPHQGDWLRQV IURP WKH 1DWLRQDO
$GYLVRU\*URXSRQ,PPXQLVDWLRQ1$*,
,0081,6$7,216&+('8/(
$Q\ PHGLFDO LQFLGHQW WKDW WDNHV SODFH DIWHU LPPXQLVDWLRQ DQG PD\ EH
SRWHQWLDOO\UHODWHGWRLPPXQLVDWLRQVKRXOGEHUHSRUWHG
» Every clinic day is an immunisation day.
» Never miss a chance to immunise – never turn a child away if an immunisation
is needed, even if it means opening a multi-dose vial for just one child.
» Check the Road to Health Booklet every time the child visits the clinic, and give
missed immunisations. These should be given according to the catch-up
schedule which is shown in the Catch-up doses table on page 13.4.
ª Mild illnesses are not a contra-indication to immunisation – most children who
are well enough to be sent home, are well enough to be immunised. Do not
immunise a sick child if the mother seriously objects, but encourage her to bring
the child for immunisation on recovery.
» Give an extra dose if in doubt whether a child has had a certain dose or not, as
extra doses are not harmful.
» The currently used measles vaccine must not be given with other childhood
vaccines. All other vaccine listed in the table below can be given safely at the
same time, but should not be given in the same syringe.
» Serious adverse events following immunisation are uncommon. All adverse
events other than mild systemic symptoms (irritability, fever < 38°C) and minor
local reactions (redness/swelling at infection site) should be reported.

There are very few contra-indications, but many missed opportunities.

$GYHUVHHYHQWVUHTXLULQJUHSRUWLQJ


/RFDOUHDFWLRQV
» Pain, redness and / or swelling of more than 3 days’ duration.
» Swelling more than 5cm from injection site.
» BCG lymphadenitis following immunization.
» Injection site abscesses following immunisation.
6\VWHPLFUHDFWLRQV
» All cases of hospitalisation (thought to be related to immunisation).
» Encephalopathy within 7 days.
» Collapse or shock-like state within 48 hours.
» Fever of more than 38°C within 48 hours.
» Seizures within 3 days.
» All deaths (thought to be related to immunisation).
&RQGLWLRQVWKDWDUHnotFRQWUDLQGLFDWLRQVWRDQ\RIWKHVWDQGDUG(3,YDFFLQHV
» Family history of any adverse reactions following vaccination.
» Family history of convulsions.
» Previous convulsions.

2018 13.2
&+$37(5 ,0081,6$7,21

» Previous measles, mumps, rubella or pertussis-like illness.

» Preterm birth.
» History of jaundice after birth.
» Stable neurological conditions such as cerebral palsy or trisomy 21.
» Contact with an infectious disease.
» Minor illness (without systemic illness and with a temperature below 38.5°C).
» Treatment with antibiotics.
» Asthma, eczema, hay fever or ‘snuffles’.
» Treatment with locally acting (inhaled or low-dose topical) steroids.
» Child’s mother is pregnant.
» Child being breastfed.
» Underweight, but otherwise healthy child.
» Over the age recommended in vaccination schedule but not above the allowable
upper age limit per manufacturer's recommendations.
» Recent or imminent surgery.

&+,/'+22',0081,6$7,216&+('8/(
,PPXQLVDWLRQVFKHGXOH
$JHRIFKLOG 9DFFLQH
At birth OPV0
BCG
6 weeks OPV1
RV1
Hexavalent (DTaP-IPV-HB-Hib)1
PCV 1
10 weeks Hexavalent (DTaP-IPV-HB-Hib)2
14 weeks RV2
Hexavalent (DTaP-IPV-HB-Hib)3
PCV2
6 months Measles1
9 months PCV3
12 months Measles2
18 months Hexavalent (DTaP-IPV-HB-Hib)4
6 years Td
12 years Td
1RWH
» Children with HIV should receive the full schedule of vaccines.
» Exception: patients with primary immune deficiency or known HIV-infection
should not be given BCG vaccine.
 LoE:III







2018 13.3
&+$37(5 ,0081,6$7,21

&DWFKXSGRVHV
Any child who is unimmunised should be given a full schedule of immunisations.
9DFFLQH $JHRIFKLOG )LUVWGRVH ,QWHUYDOIRUVXEVHTXHQWGRVHV
 6HFRQG 7KLUG )RXUWK
Give one
BCG < 1 year
dose
• 1 year Do not give
Give first
<6 months 4 weeks
OPV dose
•6 months Do not give
12 months
Hexavalent
Give first (do not give
(DTaP-IPV- Up to 5 years 4 weeks 4 weeks
dose before child is
HB-Hib)
18 months old)
Give first
< 20 weeks 4 weeks
dose
Rotavirus Give one
20–24 weeks
dose
> 24 weeks Do not give
Give first Give at 9
< 6 months 4 weeks
dose months of age
Give first
6–9 months 4 weeks 8 weeks
dose
PCV
Give first
>912 months 4 weeks 8 weeks
dose
Give one
1–6 years
dose
Give first At 12
< 11 months
dose months
Measles
Give first
• 11 months 4 weeks
dose
Give first At 12
Td > 6 years
dose years

















2018 13.4
&+$37(5 ,0081,6$7,21

9$&&,1(6)255287,1($'0,1,675$7,21
5HFRPPHQGHG
9DFFLQH )RUP 'RVH 5RXWH $JH
VLWH
Right upper arm, at
BCG Powder 0.05 mL Intra-dermal Birth
the deltoid muscle
OPV Liquid 2 drops Oral Oral Birth, 6 weeks
RV Liquid 1.5 mL Oral Oral 6, 14 weeks
< 1 year: lateral
Hexavalent Liquid aspect of the left 6,10,14
(DTaP-IPV- and 0.5 mL IM thigh weeks,
HB-Hib) Powder • 1 year: left upper 18 months
arm
< 1 year: lateral
aspect of the left
Measles Powder 0.5 mL SC thigh 6, 12 months
• 1 year: right
upper arm
Lateral aspect of 6, 14 weeks,
PCV Liquid 0.5 mL IM
the right thigh 9 months

57 years,
Td Liquid 0.5 mL IM Upper arm
• 12 years.

%&*(Bacillus Calmette-Guérin)
Z23.2

x BCG0.05 mL of reconstituted intradermal BCG vaccine.

Protects against TB meningitis and miliary TB in children < 2 years of age.

o Administered into the skin (intradermally) on the right upper arm, overlying
insertion of the deltoid.

 Fridge: In a vaccine fridge at 2–8°C.

o Storage:

 Discard opened vial after 6 hours or at end of immunisation session,

whichever comes first.

 Initial reaction to intradermal vaccination is a papule formation that lasts

o Adverse events:

a maximum of 4–6 weeks. This develops into a scar (visible in 40% of

 In 1–10% there is oozing, ulceration and lymphadenopathy after

vaccinated infants).

vaccination. This is a usual reaction and not a cause for alarm.

 Occasionally the papule becomes a pustule.

Lymphadenopathy < 1.5 cm is not clinically significant.

 Complete AEFI notification and refer all cases with significant

lymphadenopathy or a draining sinus.

 Children with known HIV infection should not get BCG vaccination. Do
o Contraindications:

 Children > 12 months old should not get BCG vaccination.

not delay BCG vaccination if HIV status is unknown. LoE:III

2018 13.5
&+$37(5 ,0081,6$7,21

 Newborn infants: if the mother is on TB chemotherapy, the infant should

be on chemoprophylaxis or treatment, and receive BCG once treatment
is completed.

+H[DYDOHQW'7D3,39+%+LEYDFFLQH
Z27.8
(Diphtheria, tetanus, acellular pertussis, inactivated polio, hepatitis B and
Haemophilus influenzae type b vaccine).
Protects against diphtheria, tetanus, pertussis, poliomyelitis, hepatitis B infection

x Hexavalent (DTaP-IPV-HB-Hib), IM, 0.5 mL.

and invasive infections caused by Haemophilus influenzae type b.

o <1 year of age: administer into outer side of left thigh.

o >1 year of age: administer into upper left arm.
Hexavalent (DTaP-IPV-HB-Hib) vaccine is a fully liquid combination of diphtheria
toxoid, tetanus toxoid, acelluar pertussis vaccine, inactivated polio vaccine, hepatitis B
vaccine and Haemophilus influenzae type b vaccine.

 Fridge: In a vaccine fridge at 2–8°C.

o Storage:

 Hexavalent (DTaP-IPV-HB-Hib) vaccine should never be frozen.

 Irritability.
o Adverse events:

 Fever • 38°C and acute illness.

 Redness and induration at the site of the injection.

 Known hypersensitivity to any component of the vaccine or pertussis

o Contra Indications:

vaccine (acellular or whole cell pertussis) or a life-threatening reaction

after previous administration of the vaccine or a vaccine containing the
same substance.
7G(Tetanus and diphtheria vaccine)
Z27.8

x Td, IM, 0.5 mL in upper arm.

Protects against diphtheria and tetanus.

 Fridge: In a vaccine fridge at 2–8°C.

o Storage:

 Easily damaged by freezing.

 Keep opened vials, record date of opening, for next session if kept at

 Record date of reconstitution.

correct temperature and not contaminated.

 Discard after 30 days.

 Mild fever.  Pain.

o Adverse events:

 Local swelling occasionally.

 Previous anaphylaxis.
o Contraindications:

2018 13.6
&+$37(5 ,0081,6$7,21

 Children < 6 years of age should not get Td.


E239(Oral polio vaccine)
Z24.0

x bOPV, oral, 2 drops given by mouth.

Protects against polio.

o If spat out or vomited, repeat immediately.

o Not affected by feeding (breast or other).

 Fridge: In a vaccine fridge at 2–8°C; or freezer (in pharmacy).

o Storage:

 Not damaged by freezing.

 Easily damaged by temperature > 8qC.
 Record date of opening.
 Discard after 30 days.

 May be associated with a flu-like illness and gastroenteritis.

o Adverse events:

 Mild fever.

 Previous anaphylaxis.
o Contraindications:

 bOPV is not contraindicated in HIV-infected children but should not be

administered to children with primary immune deficiency.
59(Rotavirus Vaccine)
Z25.8

x RV, oral, 1.5 mL given by mouth.

Protects against gastro-enteritis caused by rotavirus.

o Squeeze the entire contents of the tube in the inner cheek.

 Fridge: In a vaccine fridge at 2–8°C.

o Storage:

 Easily damaged by freezing.

 Protect the vaccine from light.

 Mild fever.
o Adverse events:

 Irritability.

 Previous anaphylaxis to rotavirus or any ingredients in the formulation.

o Contra-indications:

 Do not give Rotavirus vaccine if a child has a history of chronic gastro-

intestinal disease or severe diarrhoea including children with any history
of uncorrected congenital malformation of the gastrointestinal tract. Refer

 A history of intussusception (severe abdominal pain, persistent vomiting,

the child for medical opinion.

 Rotavirus vaccine should not be given after 24 weeks of age (see table
bloody stools, abdominal bloating and/or high fever).

on page 13.4 for catch-up schedule).



2018 13.7
&+$37(5 ,0081,6$7,21

3&9(Pneumococcal Conjugated Vaccine)

Z23.8
Protects against invasive pneumococcal disease (meningitis, septicaemia),

x PCV, IM, 0.5 mL

pneumonia and otitis media.

o < 1 year of age: administer into outer side of right thigh.

o > 1 year of age: administer into upper arm in the deltoid muscle.
o PCV and Hexavalent (DTaP-IPV-HB-Hib) can be administered at the same
time, but at different sites.

 Fridge: middle shelf at 2–8qC.

o Storage:

 Do not freeze as the vaccine is easily damaged by freezing.

 Do not mix PCV in the same syringe with other vaccines.
 Shake the vaccine well before use.

 Previous anaphylaxis.
o Contra- indications:

0HDVOHV
Z24.4

x Measles vaccine, SC, 0.5 mL.

o < 1 year of age: administer subcutaneously on lateral aspect of the left thigh.
o • 1 year of age: administer subcutaneously on right upper arm.
o The new guideline is to administer the measles vaccine at 6 (range 7-11
months) and 12 months.
o Do not give the currently available measles vaccine at the same time as
other vaccines. If a child requires measles vaccine and other vaccines at the
same time, give measles vaccine immediately and schedule visit to receive
remaining vaccines 1 month later.

 Fridge: In a vaccine fridge at 2–8°C.

o Storage:

 Discard opened vial after 6 hours or at end of immunisation session

(whichever comes first).

 Burning or stinging at the injection site, fever.

o Adverse events:

 Transient morbilliform rash and mild pyrexia up to 30 days after

vaccination.

 Previous anaphylaxis.
o Contra-indications:

 Uncontrolled convulsions: consult a doctor.

2018 13.8
&+$37(5 ,0081,6$7,21

7+(&2/'&+$,1
Maintaining the cold chain means keeping vaccines at the right temperature
throughout distribution, storage and use. The cold chain can be maintained by:
» Never exposing vaccines to heat or freezing conditions, especially during
transportation from one point to another.
» Always using a cold box to keep the vaccines cold during transport and immunisation.
» All vaccines should be kept in a refrigerator at a temperature of 2–8qC.
» Defrosted OPV should not be kept in the freezer or be allowed to freeze again.
» Use a metal dial thermometer or a fridge-tag for all vaccines (Min-max
thermometer not recommended).
» Do not let Hexavalent (DTaP-IPV-HB-Hib), HPV, PCV, RV, Td and TT vaccines
touch the evaporator at the back of the fridge as they may freeze. Do not freeze
these vaccines. Do not use frozen vaccines. If unsure, do shake test to check
whether vaccines have frozen.
» Monitor and record fridge temperature twice daily.
» Leave space between each tray to allow cold air to circulate.
» Do not keep food in the same fridge as the vaccines.
» If possible do not keep other medications e.g. insulin etc. in the vaccine fridge.
» Do not keep blood and other specimens in the vaccine fridge.
&RUUHFWSDFNLQJRIWKHFROGER[
» )XOO\ conditioned ice packs (the ice should rattle inside the pack) are placed on
the bottom, at the sides and on top.
» If there are not enough ice packs, place available ice packs at the sides and on
top of the vaccines.
» Td, TT, HPV, PCV, RV and Hexavalent vaccines must not be allowed to freeze.
» Keep measles and polio vaccines very cold - place on bottom of the cold box,
closest to the ice packs.
» BCG can be placed anywhere in the box.
» Keep the lid firmly closed and the box out of the sun.
» Keep a thermometer and a freeze tag in the cold box with the vaccines and the
temperature at 2–8qC.
» Live vaccines (BCG, OPV, measles) are very sensitive to heat, sunlight and skin
antiseptics.
+RZWRSDFN\RXUIULGJHFRUUHFWO\
» Vaccines should be stored in a specific vaccine fridge. However, if unavailable
store the vaccines in a domestic fridge, as follows:

 Middle shelf: BCG, Td, Hexavalent (DTaP-IPV-HB-Hib), HPV, RV, PCV and TT
» Top shelf: measles and polio vaccines in the coldest part.

 Do not let Td, Hexavalent (DTaP-IPV-HB-Hib), HPV, RV, PCV and TT

vaccines (do not freeze) with sufficient diluent for the BCG and measles for 2 days.

vaccines touch the evaporator plate at the back of the fridge as they are

 Do not keep vaccines in the fridge door.

destroyed by freezing.

 Store the same kind of vaccines together in one tray.

2018 13.9
&+$37(5 ,0081,6$7,21



Leave about 2cm space between each tray to allow the cold air to move around.
Bottles filled with salt water stored in the bottom of the fridge will keep the

 'RQRWNHHSIRRGLQWKHVDPHIULGJHDVWKHYDFFLQHVWRDYRLGXQQHFHVVDU\
fridge contents cold when the door is opened.

RSHQLQJRIWKHGRRU
» There should be a contingency plan written and posted on every vaccine fridge
of what to do in the event of a power failure.
» Monitor and record temperature twice daily.

&$87,21
Do not use vaccines that have expired, missed the cold chain or that VVM has
reached discard point.
Keep the fridge temperature between 2–8qC.

1RWHAll vaccines with a “T” in the name are sensitive to freezing –TT, Td,
HexavalenT, RoTavirus, HepaTiTis B and even diluents. All diluents (measles and
BCG) should never be frozen.

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2SHQHGYLDOVRI777G+HS%DQG239YDFFLQHV
» May be used in subsequent immunisation sessions IRUDPD[LPXPRIRQH
PRQWKprovided that each of the following conditions have been met:
 the expiry date has not passed
 each vial must be dated when opened
 the vaccines are stored under appropriate cold chain conditions (2–8qC with

 the vaccine vial septum has not been submerged in water

temperature monitoring and recording)

 aseptic technique has been used to withdraw all doses

2SHQHGYLDOVRIPHDVOHV%&*
Check the VVM and expiration date prior to reconstitution. 
Reconstituted vials of measles and BCG vaccines must be discarded at the end of
each immunisation session or at the end of 6 hours, whichever comes first.
Always label the vials with the date and time when opening or reconstituting.
All opened vials must be discarded immediately if:
» sterile procedures have not been fully observed,
» there is even a suspicion that the opened vial has been contaminated,
» there is visible evidence of contamination such as a change in appearance or
floating particles, etc.
,1-(&7,216$)(7<
» Always wash hands before and after giving the vaccine.
» Always keep a fully equipped emergency tray at the immunisation point.
» Use a sterile syringe and sterile needle for each immunisation.
» Clean the skin adequately with cotton wool and water, do not use alcohol swabs.
» Check all vaccines for safety.

2018 13.10
&+$37(5 ,0081,6$7,21

» Return all unsafe vaccines back to the pharmacy.

» Use the same needle for drawing up and administering the vaccine. “One
Needle, One Syringe”.
» Diluents are not interchangeable. Different vaccines have different diluents.
» Always use the same diluent from the same manufacturer as the vaccine.
» Used needles and syringes must be disposed of safely.
» Discard all used empty vaccines in the sharps container.

$'9(56((9(176)2//2:,1*,0081,6$7,21$(),
Report all AEFIs to the local EPI Coordinator.
AEFI form may be accessed at: http://www.health.gov.za/index.php/2014-08-15-12-
57-15/category/268-2016-frms

27+(59$&&,1(6
77 (Tetanus toxoid)
Z23.5

x TT, IM, 0.5 mL into arm

Protects against tetanus (neonatal and after wounds)

 Fridge: middle shelf at 2–8°C.

o Storage:

 Easily damaged by freezing.

 Keep opened vials for next session if kept at correct temperature and not

 Discard after 30 days.

contaminated.

 Record date of reconstitution.

 Previous anaphylaxis.
o Contraindications:

3UHJQDQWZRPHQ
All pregnant women should routinely receive tetanus toxoid.
77RU7G 77RU7G 77RU7G 77RU7G 77RU7G
Pregnant women
At least 6
with no previous As early as At least 4 At least 1 At least 1
months
immunisation (or possible in weeks year later, year later,
later, or in
unreliable 1st later or in next or in next
next
immunisation pregnancy pregnancy pregnancy
pregnancy
information)
Pregnant women As early as At least 4
At least 1
with 3 childhood possible in weeks
year later
DTP, DTP-Hib or 1st later
DTaP-IPV//Hib doses pregnancy
Pregnant women
As early as
with 4 childhood
possible in At least 1
DTP, DTP-Hib or
1st year later
DTaP-IPV//Hib
pregnancy
doses

2018 13.11
&+$37(5 ,0081,6$7,21

7UDXPD
x Give booster dose of TT/Td after each trauma episode (unless given in previous 5
years).
+XPDQ3DSLOORPD9LUXV+399DFFLQH Z25.8
Protects against infection with HPV serotypes 16 and 18.
Persistent HPV infection is associated with the development of a number of
reproductive tract cancers, especially cancer of the cervix.
Two dose schedule (6 months apart) currently offered as part of the ,QWHJUDWHG
6FKRRO+HDOWKSURJUDPPH to Grade 4 girls (• 9 years of age) in public schools.
x HPV, IM, 0.5 mL
o Administered into the deltoid of the non-dominant arm.

 Fridge: middle shelf at 2–8°C.

o Storage:

 Easily damaged by freezing – do not freeze and discard any vaccine

 Store in original package and protect from light.

which has been frozen.

 Use immediately once withdrawn into a syringe.

 Previous anaphylaxis.
o Contraindications:

 Febrile illness (• 38.5°C).

 Should not be administered to girls/women who are known to be
pregnant.

 Injection site pain and swelling in the arm are common.

o Adverse events:

 Itching, rash, redness and urticaria may also occur.

 Nausea, diarrhoea, abdominal pain, headache, myalgia, fever (38ƒC) are

 Syncope, dizziness, lymphadenopathy, and anaphylaxis have been

not uncommon.

reported.
+HSDWLWLV%
Z24.6
$OOSHUVRQQHOZRUNLQJLQDKHDOWKFDUHIDFLOLW\LQFOXGLQJVXSSRUWVWDII
x Hepatitis B, IM, 3 adult doses of 1 mL.
o ILUVWGRVH administered immediately;
o VHFRQGGRVH 1 month after the first dose;
o WKLUGGRVH 6 months after the first dose.
3HULQDWDOWUDQVPLVVLRQ
Babies born to mothers with acute hepatitis B infection at the time of delivery or to
mothers who are HBsAg-positive or HBeAg-positive, see Section 6.6.5: Perinatal
transmission of hepatitis B.

,QIOXHQ]DYDFFLQH

x
Z25.1
Influenza vaccine, IM, 0.5 mL.

2018 13.12
&+$37(5 ,0081,6$7,21

» All women who are pregnant at the time of the annual immunisation campaign
should be immunised.
» People with the following risk factors may be offered immunisation during the

 HIV infection.
annual campaign:

 Chronic cardiac or pulmonary conditions.

 Age > 65 years.
» Healthcare workers are not routinely offered immunisation during the annual
campaign. Although it is recommended that healthcare workers are vaccinated
against influenza, they will not be provided with publically funded vaccines
unless they fall within any of the designated high risk groups.

Recommended dosage of influenza vaccine for patients of different age groups:

$JHJURXS 'RVH 1XPEHURIGRVHV
Adults and children • 9 years 0.5 mL, IM Single dose.
Children:> 3 to < 9 years 0.5 mL, IM 2 doses • 4 weeks apart during
first year of immunisation,
thereafter one dose per annum.
Children: > 6 months to < 3 years 0.25 mL, IM 2 doses • 4 weeks apart during
first year of immunisation,
thereafter one dose per annum.

2018 13.13
PHC Chapter 14: Musculoskeletal
conditions
14.1 Arthralgia
14.2 Arthritis, rheumatoid
14.3 Arthritis, septic
14.4 Gout
14.4.1 Gout, acute
14.4.2 Gout, chronic
14.5 Osteoarthrosis (osteoarthritis)

 
&+$37(5 086&8/26.(/(7$/&21',7,216

$57+5$/*,$
M25.50-59

'(6&5,37,21
Joint pain without swelling, warmth, redness or systemic manifestations such as fever.
It is usually self-limiting. May be an early manifestation of degenerative joint conditions
(osteoarthrosis) or local and systemic diseases. May follow injury to the joint, e.g.
work, play and position during sleep.
Suspect rheumatic fever in children, especially if arthralgia affects several joints in
succession.

*(1(5$/0($685(6
» Advise patient to:
– apply heat locally to the affected joint, taking precautions not to burn
themselves
– exercise once their pain is relieved
– reduce weight, if overweight, to decrease stress on the joint
» Exclude systemic causes.
» Reassure patient.

0(',&,1(75($70(17
Treat for 1 week (maximum 2 weeks) provided no new signs develop.
3DLQ

x Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See dosing table,
Children

pg 23.8.

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per

Adults

24 hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.
x Methyl salicylate ointment, topical, may provide some relief.

5()(55$/
» Pain for 1 week in children, and pain for > 2 weeks in adults.
» Recurrent pain.
» Severe pain.
» Fever.
» Involvement of several joints in succession
» Evidence of systemic illness e.g. e.g. sore throat in children, presence of
jaundice, anaemia.

2018 14.2
&+$37(5 086&8/26.(/(7$/&21',7,216

$57+5,7,65+(80$72,'
M06.90-99

'(6&5,37,21
A chronic inflammatory systemic condition. May affect many organs, but the
musculoskeletal system is predominantly affected with several joints becoming
painful and swollen. There is usually symmetrical involvement of small joints from
early on. The small joints of the fingers and hands with the exception of the distal
interphalangeal joints, are usually involved, although any joint can be involved.

 Stiffness: Early morning stiffness lasting > 30 minutes.

» Four ‘S factors’ are useful to screen for early joint disease:

 Swelling: Persistent swelling of 1 or more joints, particularly hand joints.

 Squeeze test hands: Tenderness on squeezing across all 4 metarcarpo-

 Squeeze test feet: Tenderness on squeezing across all 4 metartarso-

phalangeal joints.

phalangeal joints.
Late disease may have destruction and deformity of affected joints especially of the
fingers e.g. ulnar deviation, buttonhole and swan neck deformities.
LoE:IIIi
*(1(5$/0($685(6
» Advise patient to:
– reduce weight
– stop smoking
» Manage co-morbidities.
» Educate on joint-care (refer for occupational therapy, if available).

0(',&,1(75($70(17
All newly diagnosed patients must be referred for specialist management with
Disease Modifying Anti-rheumatic Drugs (DMARDs).

)RUFRQWURORIDFXWHV\PSWRPVZKLOVWDZDLWLQJUHIHUUDO'RFWRULQLWLDWHG
ƒ NSAIDs, e.g.:
x Ibuprofen, oral, 400 mg 8 hourly with or after a meal.
o Continue for no longer than 3–6 months.

)RU FRQWURO RI DFXWH V\PSWRPV GXULQJ GLVHDVH IODUHV DQG LQ VHYHUH H[WUD
DUWLFXODUPDQLIHVWDWLRQVHJVFOHULWLV'RFWRUSUHVFULEHG
ƒ NSAIDs, e.g.:
x Ibuprofen, oral, 400 mg 8 hourly with or after a meal for 2 weeks.
LoE:IIIii
NSAIDs are used for symptomatic relief in patients with active
inflammation and pain. They have no long-term disease modifying effects.
NSAIDs are relatively contra-indicated in patients with significantly impaired renal
function, i.e. eGFR < 60 mL/minute.

2018 14.3
&+$37(5 086&8/26.(/(7$/&21',7,216

Concomitant use of more than one oral NSAID has no additional clinical benefit and
only increases toxicity.
Chronic use of all NSAIDs is associated with increased risks of gastrointestinal
bleeding, renal failure, and cardiovascular events (stroke and myocardial infarction).

If NSAIDS are contraindicated for acute flares e.g. warfarin therapy, renal dysfunction
(Doctor prescribed):
x Prednisone, oral, 7.5 mg daily for a maximum of 2 weeks.


LoE:IIIiii

In high-risk patients: > 65 years of age; history of peptic ulcer disease; on

concomitant warfarin, aspirin, or corticosteroids:
$'' LoE:IIiv
ƒ Proton pump inhibitor, e.g.
x Lansoprazole, oral, 30 mg daily whilst on an NSAID.
For confirmed rheumatoid arthritis, NSAIDs and corticosteroids will be continued by
a specialist as bridging therapy until DMARDs have taken effect.

5()(55$/
8UJHQWWRDVSHFLDOLVW
» Severe extra-articular articular manifestations.
1RQXUJHQW
» Refer all patients early for confirmation of diagnosis and management.
» Known rheumatoid arthritis patients with acute disease flares.

$57+5,7,66(37,&
M00.90-99

'(6&5,37,21
An acute infective condition involving one or more joints.
The joint is hot, swollen, and very painful, and movement is restricted.
Signs of systemic infection, including fever, are usually present. The infection is
usually blood borne, but may follow trauma to the joint. The course may be acute or
protracted. A wide spectrum of organisms is involved, including staphylococci and N.
gonorrhoea.
1RWH Haemophiliacs may present with an acute arthritis similar to septic arthritis.
This is due to bleeding into a joint and not due to infection.

0(',&,1(75($70(17
» Infants ” 2 months of age, who fulfil the IMCI criteria for “POSSIBLE SERIOUS
BACTERIAL INFECTION” should receive a first dose of ceftriaxone and other
IMCI urgent care while arranging transfer.
x Ceftriaxone, IM, 80 mg/kg/dose immediately as a VLQJOH GRVH See dosing
table, pg 23.3.

2018 14.4
&+$37(5 086&8/26.(/(7$/&21',7,216

o Do not inject more than 1 g at one injection site.

&$87,2186(2)&()75,$;21(,11(21$7(6$1'&+,/'5(1
» If SUSPECTING SERIOUS BACTERIAL INFECTION in neonate, give ceftriaxone,
even if jaundiced.

 If ” 28 days old, avoid calcium-containing IV fluids for 48 hours after ceftriaxone

» Avoid giving calcium-containing IV fluids (e.g. Ringer Lactate) together with ceftriaxone:

 If > 28 days old, ceftriaxone and calcium-containing IV fluids may be given sequentially
administered.

 Preferably administer IV fluids without calcium contents.

provided the giving set is flushed thoroughly with sodium chloride 0.9% before and after.

» Always include the dose and route of administration of ceftriaxone in the referral letter.
Children with suspected septic arthritis should be assessed for evidence of
septicaemia and septicaemic shock, which should be treated accordingly while
awaiting transfer.

5()(55$/
8UJHQW
All patients for confirmation of diagnosis and surgical drainage.

 *287

*287$&87(
M10.00-09/M10.90-99

'(6&5,37,21
A metabolic disease in which uric acid crystals are deposited in joints and other
tissues. Characterised by recurrent attacks of an acute arthritis that often affects
one joint which is very painful, tender, swollen, red and hot to the touch. The
inflammation may extend beyond the joint.
In many patients the 1st metatarso-phalangeal joint is initially involved. The instep,
ankle, heel, and knee are also commonly involved. Bursae (such as the olecranon)
may be involved.
Gout commonly occurs in men > 40 years of age and in postmenopausal women.

,19(67,*$7,216
Increased serum uric acid level.
However, the serum uric acid level may be normal during acute attacks, and therefore
best estimated after the acute symptoms have subsided.

*(1(5$/0($685(6
» Immobilise the affected joint during the acute painful attack.
» Increase (high) fluid intake.
» Avoid alcohol.
» Avoid aspirin.


2018 14.5
&+$37(5 086&8/26.(/(7$/&21',7,216

0(',&,1(75($70(17
Initiate treatment as early as possible in an acute attack.
ƒ NSAIDs, e.g.:
x Ibuprofen, oral, 400 mg,8 hourly with or after a meal for the duration of the attack.
LoE: IIIv
,I16$,'6DUHFRQWUDLQGLFDWHGHJSHSWLFXOFHUDWLRQZDUIDULQWKHUDS\DQGUHQDO
G\VIXQFWLRQRUKHDUWIDLOXUH
x Prednisone, oral, 40 mg daily for 5 days (Doctor initiated). LoE:IIvi

5()(55$/
» No response to treatment.
» For confirmation of diagnosis, if in doubt.
» Patients with chronic kidney disease.
» Patients with suspected secondary gout (e.g. haematological malignancies).
1RWH
» Gout may be secondary to other medical conditions, e.g. haematological
malignancies.
» Gout may co-exist with hypertension, diabetes mellitus (as a risk factor for
degenerative vascular disease) and chronic kidney disease. The
pharmacological treatment of these conditions could precipitate gout.

*287&+521,&
M10.00-09/M10.90-99

'(6&5,37,21
Gout with one or more of the following:
» uric acid deposits in and around the joints and cartilages of the extremities (tophi)
» tophi are most commonly found as hard nodules around the fingers and toes, at
the tips of the elbows (olecranon bursae) or at the pinnae of the ears
» serum uric acid >0.5 mmol/L
» bone and cartilage destruction of the fingers and toes with joint swelling and
deformity
» prolongation of attacks, often with reduction in pain severity
» incomplete resolution between attacks

*(1(5$/0($685(6
» If possible, avoid known precipitants and medicines that may increase uric
acid, e.g. low dose aspirin, ethambutol, pyrazinamide and diuretics, especially
hydrochlorothiazide. LoE:III
» Encourage weight loss, if overweight.
» Avoid alcohol.

0(',&,1(75($70(17
Uric acid lowering therapy is required in all of the following:
» • 2 acute attacks per year » urate renal stones
» chronic tophaceous gout » urate nephropathy

2018 14.6
&+$37(5 086&8/26.(/(7$/&21',7,216

x Allopurinol, oral, 100 mg daily (Doctor initiated).

When the acute attack has settled completely, i.e. usually after 3 weeks:

o Increase monthly by 100 mg according to urate blood levels.

o Titrate dose to reduce serum urate to < 0.35 mmol/L.
o Average dose: 300 mg perday.
o Maximum dose: 400 mg daily.
o The elderly and patients with renal impairment require lower doses.

5()(55$/
» Suspected secondary gout.
» No response to treatment.
» Non-resolving tophaceous gout.

267(2$57+526,6267(2$57+5,7,6
M13.00-19/M13.80-99/M15.0/M15.3/M15.8-9/M16.0-9/M18.0-5/M18.9/M19.00-09/M19.80-99

'(6&5,37,21
A degenerative disorder typically affecting weight-bearing joints.
Signs and symptoms include:
» pain usually with movement » post-rest stiffness
» limited range of movement » joint may be swollen
often with crepitus

*(1(5$/0($685(6
Non-pharmacological/general measures are as important as pharmacological
management.
Educate patient and family on:
» weight reduction
» exercise
» rest during acute painful episodes.
Recommend use of a walking stick or crutch to alleviate stress on weight bearing joint.
Physiotherapy and/or occupational therapy.

0(',&,1(75($70(17
3DLQ
x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per
24 hours.
o Maximum dose: 15 mg/kg/dose.

x Methyl salicylate ointment, topical, may provide some relief.

o Maximum dose: 4 g in 24 hours.

x Paracetamol, oral, 500 mg, 6–8 hourly when required.

If patient responds to paracetamol reduce the dose to:

If no response and inflammation is present:

$''
ƒ NSAID, e.g.:

2018 14.7
&+$37(5 086&8/26.(/(7$/&21',7,216

x Ibuprofen, oral, 400 mg 8 hourly with or after a meal, as needed for 7 days.

As many of these patients, particularly the elderly, have concomitant medical

conditions such as cardiovascular, gastrointestinal disease or renal function
impairment, NSAIDs must be used with caution.
Patients on aspirin for cardiovascular risk reduction should take aspirin 30 minutes
before the 1st dose of ibuprofen in the morning, as taking aspirin and
ibuprofen at the same time may reduce aspirin’s efficacy. LoE:IIIvii

In high-risk patients: > 65 years of age; history of peptic ulcer disease; or on
concomitant warfarin, aspirin or corticosteroids:
$''
ƒ Proton pump inhibitor, e.g.:
x Lansoprazole, oral, 30 mg daily. LoE:IIviii


&$87,21
Chronic use of all NSAIDs is associated with increased risks of gastrointestinal
bleeding, renal failure, and cardiovascular events (stroke and myocardial infarction).
and has adverse effects on joint cartilage.

5()(55$/

 uncertain diagnosis
» All cases with:

 intractable pain
 recurrent episodes of pain with inflammation
 suspected infection
» Consideration of joint replacement.
5HIHUHQFHV
i Rheumatoid arthritis clinical presentation: Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO 3rd, Birnbaum
NS, Burmester GR, Bykerk VP, Cohen MD, Combe B, Costenbader KH, Dougados M, Emery P, Ferraccioli G, Hazes JM, Hobbs
K, Huizinga TW, Kavanaugh A, Kay J, Kvien TK, Laing T, Mease P, Ménard HA, Moreland LW, Naden RL, Pincus T, Smolen JS,
Stanislawska-Biernat E, Symmons D, Tak PP, Upchurch KS, Vencovský J, Wolfe F, Hawker G. 2010 Rheumatoid arthritis
classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative.
Arthritis Rheum. 2010 Sep;62(9):2569-81. https://www.ncbi.nlm.nih.gov/pubmed/20872595
ii NSAIDs: National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML, 2015.
http://www.health.gov.za/
iii Prednisone, oral (acute flares): Smolen JS, Landewé R, Bijlsma J, Burmester G, Chatzidionysiou K, Dougados M, et al.. EULAR

recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs:
2016 update. Ann Rheum Dis. 2017 Jun;76(6):960-977. https://www.ncbi.nlm.nih.gov/pubmed/28264816
Prednisone, oral (acute flares): del Rincón I, Battafarano DF, Restrepo JF, Erikson JM, Escalante A. Glucocorticoid dose
thresholds associated with all-cause and cardiovascular mortality in rheumatoid arthritis. Arthritis Rheumatol. 2014 Feb;66(2):264-
72. https://www.ncbi.nlm.nih.gov/pubmed/24504798
iv Proton pump inhibitor (therapeutic class): National Department of Health: Affordable Medicines, EDP-Adult Hospital level.
Medicine Review: Proton pump inhibitors therapeutic class review, May 2018. http://www.health.gov.za
Proton pump inhibitor (therapeutic class): McDonagh MS, Carson S, Thakurta S. Drug Class Review: Proton Pump Inhibitors:
Final Report Update 5 [Internet]. Portland (OR): Oregon Health & Science University; 2009 May.
http://www.ncbi.nlm.nih.gov/books/NBK47260/
Proton pump inhibitor (therapeutic class): National Institute for Health and Care Excellence: Clinical Guidelines: Gastro-
oesophageal reflflux disease and dyspepsia in adults: investigation and management. https://www.nice.org.uk/guidance/cg184
Proton pump inhibitor: Contract circular HP09-2014SD.http://www.health.gov.za
Proton pump inhibitor (high risk patients on chronic NSAID therapy): McQuaid KR , Laine L . Systemic review and meta-
analysis of adverse events of low-dose aspirin and clopidogrel in randomized controlled trials. Am J Med 2006;119:624–38.
http://www.ncbi.nlm.nih.gov/pubmed/16887404

2018 14.8
&+$37(5 086&8/26.(/(7$/&21',7,216

Proton pump inhibitor (high risk patients on chronic NSAID therapy): Serrano P, Lanas A, Arroyo MT, Ferreira IJ. Risk of upper
gastrointestinal bleeding in patients taking low-dose aspirin for the prevention of cardiovascular diseases. Aliment Pharmacol Ther.
2002 Nov;16(11):1945-53. http://www.ncbi.nlm.nih.gov/pubmed/12390104
Proton pump inhibitor (high risk patients on chronic NSAID therapy): Lanza FL, Chan FK, Quigley EM; Practice Parameters
Committee of the American College of Gastroenterology. Guidelines for prevention of NSAID-related ulcer complications. Am J
Gastroenterol. 2009 Mar;104(3):728-38. http://www.ncbi.nlm.nih.gov/pubmed/19240698
v Ibuprofen (ceiling effect): Laska EM, Sunshine A, Marrero I, Olson N, Siegel C, McCormick N. The correlation between blood

levels of ibuprofen and clinical analgesic response. Clin Pharmacol Ther. 1986 Jul;40(1):1-
7.http://www.ncbi.nlm.nih.gov/pubmed/3522030
Ibuprofen (ceiling effect): National Department of Health, Essential Drugs Programme: Adult Hospital level STGs and EML,
2015. http://www.health.gov.za/
vi NSAIDs and heart failure risk: Arfè A, Scotti L, Varas-Lorenzo C, Nicotra F, Zambon A, Kollhorst B, Schink T, Garbe E, Herings

R, Straatman H, Schade R, Villa M, Lucchi S, Valkhoff V, Romio S, Thiessard F, Schuemie M, Pariente A, Sturkenboom M, Corrao
G; Safety of Non-steroidal Anti-inflammatory Drugs (SOS) Project Consortium.. Non-steroidal anti-inflammatory drugs and risk of
heart failure in four European countries: nested case-control study. BMJ. 2016 Sep 28;354:i4857.
https://www.ncbi.nlm.nih.gov/pubmed/27682515
vii Ibuprofen-aspirin interaction: Gladding PA, Webster MW, Farrell HB, Zeng IS, Park R, Ruijne N. The antiplatelet effect of six

non-steroidal anti-inflammatory drugs and their pharmacodynamic interaction with aspirin in healthy volunteers. Am J Cardiol. 2008
Apr 1;101(7).http://www.ncbi.nlm.nih.gov/pubmed/18359332
Ibuprofen-aspirin interaction: Meek IL, Vonkeman HE, Kasemier J, Movig KL, van de Laar MA. Interference of NSAIDs with the
thrombocyte inhibitory effect of aspirin: a placebo-controlled, ex vivo, serial placebo-controlled serial crossover study. Eur J Clin
Pharmacol. 2013 Mar;69(3):365-71. http://www.ncbi.nlm.nih.gov/pubmed/22890587
viii Proton pump inhibitor (therapeutic class): National Department of Health: Affordable Medicines, EDP-Adult Hospital level.

Medicine Review: Proton pump inhibitor therapeutic class review, May 2018. http://www.health.gov.za
Proton pump inhibitor (therapeutic class): McDonagh MS, Carson S, Thakurta S. Drug Class Review: Proton Pump Inhibitors:
Final Report Update 5 [Internet]. Portland (OR): Oregon Health & Science University; 2009 May.
http://www.ncbi.nlm.nih.gov/books/NBK47260/
Proton pump inhibitor (therapeutic class): National Institute for Health and Care Excellence: Clinical Guidelines: Gastro-
oesophageal reflux disease and dyspepsia in adults: investigation and management. https://www.nice.org.uk/guidance/cg184
Proton pump inhibitor: Contract circular HP09-2014SD.http://www.health.gov.za
Proton pump inhibitor (high risk patients on chronic NSAID therapy): McQuaid KR , Laine L . Systemic review and meta-
analysis of adverse events of low-dose aspirin and clopidogrel in randomized controlled trials. Am J Med 2006;119:624–38.
http://www.ncbi.nlm.nih.gov/pubmed/16887404
Proton pump inhibitor (high risk patients on chronic NSAID therapy): Serrano P, Lanas A, Arroyo MT, Ferreira IJ. Risk of upper
gastrointestinal bleeding in patients taking low-dose aspirin for the prevention of cardiovascular diseases. Aliment Pharmacol Ther.
2002 Nov;16(11):1945-53. http://www.ncbi.nlm.nih.gov/pubmed/12390104
Proton pump inhibitor (high risk patients on chronic NSAID therapy): Lanza FL, Chan FK, Quigley EM; Practice Parameters
Committee of the American College of Gastroenterology. Guidelines for prevention of NSAID-related ulcer complications. Am J
Gastroenterol. 2009 Mar;104(3):728-38. http://www.ncbi.nlm.nih.gov/pubmed/19240698

2018 14.9
PHC Chapter 15: Central nervous
system conditions
15.1 Stroke
15.2 Dementia
15.3 Seizures (convulsions/fits)
15.3.1 Status epilepticus
15.3.2 Epilepsy
15.3.3 Febrile convulsions
15.4 Meningitis
15.4.1 Acute meningitis
15.4.2 Meningococcal meningitis, prophylaxis
15.4.3 Cryptococcal meningitis
15.5 Headache, mild, nonspecific
15.6 Neuropathy
15.6.1 Post-herpes zoster neuropathy (Post
herpetic neuralgia)
15.6.2 Bell’s palsy
15.6.3 Peripheral neuropathy

 
 &+$37(5 &(175$/1(592866<67(0&21',7,216

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Stroke consists of rapidly developing clinical signs of focal (at times global)
disturbance of cerebral function, lasting >24 hours or leading to death. 
Most strokes are ischaemic (embolism or thrombosis) whilst others may be caused
by cerebral haemorrhage.
A transient ischaemic attack (TIA) is defined as stroke symptoms and signs that
resolve within 24 hours. 
The diagnosis of stroke depends on the presentation of sudden onset of neurological
loss, including:
» Weakness, numbness or paralysis of the face or limb/s.
» Sudden onset of blurred or decreased vision in one or both eyes; or double vision.
» Difficulty speaking or understanding.
» Dizziness, loss of balance or any unexplained fall or unsteady gait.
» Headache (severe, abrupt).

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$FXWHPDQDJHPHQW
» Assess airway, breathing, circulation and disability.
» Measure blood glucose and treat hypoglycaemia if present. See Section 21.2.6:
Hypoglycaemia and hypoglycaemic coma.
» BP is often elevated in acute stroke. Do not treat elevated BP at PHC, but refer
patient urgently.
» Patients should be given nil by mouth until swallowing is formally assessed.
/RQJWHUPPDQDJHPHQW
» Optimise treatment for existing medical conditions such as hypertension, diabetes
mellitus, dyslipidaemia and cardiac conditions. 
» Increase regular physical activity, aim for 30 minutes 5 times a week.
» Advise patient regarding appropriate weight loss, if weight exceeds ideal weight.
» Advise patient regarding smoking cessation.
» Refer for physiotherapy, if indicated.

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x Aspirin, oral, 300 mg, as a pre-referral dose. LoE:Ii
1RWH Except if the patient:
» is unconscious
» cannot swallow
» is on long-term anticoagulation therapy
» has signs of a subarachnoid bleed: i.e. neck stiffness, headache
» will be transferred and treated with a thrombolytic within 3 hours
LoE:Iii

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6HFRQGDU\SUHYHQWLRQIRUDGXOWV(i.e. continuation of aftercare treatment initiated

at higher level of care).
Antiplatelet therapy
All patients, if not contraindicated (e.g. haemorrhagic stroke, peptic ulcer, patients

x Aspirin, oral, 75–100 mg daily.

on anticoagulation therapy, etc.):

x Aspirin, oral, 150 mg daily.

If unavailable:

Lipid-lowering medicine therapy, see Section 4.1: Prevention of ischaemic heart

disease and atherosclerosis.
Hypertensive therapy
For blood pressure management, see Section 4.7: Hypertension.
Diabetes mellitus and dietary management information
See Chapter 9: Endocrine system.

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Refer all acute stroke cases for further management (preferably within 3 hours).

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'(6&5,37,21
Progressive loss of cognitive function, usually of insidious onset. Initial presentation
may be with mild personality or memory changes, before more pronounced deficits
become evident.
Common reversible causes of dementia include:
» Metabolic
- Hypothyroidism
- Vitamin B12 deficiency
- Pellagra
» Medications and drugs
- Long-term alcohol abuse
- Many medications have CNS side effects
» Infections
- Neurosyphilis
- HIV dementia
» Surgical
- Normal pressure hydrocephalus
» Severe depression (pseudo-dementia)

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All patients must be seen by a doctor to confirm the diagnosis.

2018 15.3
 &+$37(5 &(175$/1(592866<67(0&21',7,216

People with dementia are vulnerable to delirium and worsening confusion.

Manage conditions that may worsen symptoms, including:
» Electrolyte disturbances and dehydration.
» Infections, usually originating from the respiratory or urinary tract.
» Medication toxicity.
» For confirmed diagnosis of mild to moderate dementia the following supportive

 Disclose the diagnosis to family members /primary care giver.

measure may be taken:

 Explain that the condition is evolving and future planning is necessary

 Advise driving cessation for the patient, if relevant.
 Discuss home safety risks – e.g. potential for patient to leave stove on while

 Ensure that the patient has a caregiver that can supervise medication
cooking or wander if not watched.

 Monitor functional problems and manage as they arise e.g. urinary

taking when the patient is unable to do so themselves.

 Monitor nutritional status and intervene if necessary.

incontinence.

 Provide ongoing medical care.

5()(55$/
» Adults < 60 years of age, adolescents and children, where common reversible
causes of dementia could not be identified.
» When behavioural and/or psychological symptoms pose a risk to patient or carer.

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R56.8

'(6&5,37,21
A seizure is a change in movement, attention or level of awareness that is sustained or
repetitive, and occurs because of abnormal and excessive neuronal discharge within
the brain. Seizures may be secondary (where there is an underlying cause) or idiopathic
(where no underlying cause is evident). When seizures are recurrent or typical of a
specific syndrome, then the term epilepsy is used.
Seizures should be differentiated from:
» syncope
» hyperventilation
» transient ischaemic attack (TIA)
» non-epileptic seizure
» rigors
» febrile convulsions
Important conditions that should be excluded include:
» meningitis
» encephalitis or encephalopathy (including hypertensive encephalopathy)
» metabolic conditions, e.g. hypoglycaemia

2018 15.4
 &+$37(5 &(175$/1(592866<67(0&21',7,216

» brain lesions
» seizure due to alcohol withdrawal

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,IFRQYXOVLQJ
Measure blood glucose and treat hypoglycaemia, if present.
Ensure an open airway and administer oxygen.
» Position to prevent aspiration of vomitus, i.e. recovery position.
» Check glucose during the seizure and blood pressure after the seizure.
» Obtain intravenous access if seizure duration > 5 minutes.
» Avoid putting anything in the mouth.

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See Section 21.2.11: Seizures and status epilepticus.

Always check blood glucose concentrations to exclude hypoglycaemia.

For management of eclamptic convulsions in pregnancy, see Section 6.4.2.5:

Eclampsia.
$IWHUVHL]XUH
» All patients presenting with a first seizure must be investigated to exclude
underlying causes, including meningitis.
» A patient who presents with a first seizure should not automatically be labelled as
an epileptic, or started on treatment.
» When indicated, long term therapy should be initiated by a doctor.

5()(55$/
8UJHQW:
» All patients with status epilepticus or suspected meningitis, see Section 15.4:
Meningitis.
» All patients following a 1st seizure should be examined by a doctor to exclude
underlying causes.
1RWHPersons known to have epilepsy who recover fully following a seizure do not
usually require referral. See criteria for referral under epilepsy.

67$786(3,/(37,&86
See Section 21.2.11: Seizures and status epilepticus.

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Epilepsy is defined as recurrent seizures. Epilepsy is associated with many
psychological, social and legal problems, and cultural misperceptions.

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» Is usually made clinically.

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 &+$37(5 &(175$/1(592866<67(0&21',7,216

» Requires an accurate witness description of the seizure.

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Focal aware (Simple partial) Seizure occurs on one side of the body,
without loss of consciousness. Symptoms
may include sensory, autonomic or psychic
)RFDO effects.
3DUWLDO Focal impaired awareness Complex partial seizures are often
(Complex partial) preceded by a simple partial seizure but is
associated with altered awareness or loss
of consciousness.
Generalised Loss of consciousness preceded by:
tonic-clonic » a brief stiff phase, followed by
Generalised » jerking of all the limbs
motor
Tonic One or more limbs become stiff without
seizure
any jerking.
*HQHUDOLVHG Myoclonic Brief, involuntary, usually generalised
RQVHW jerks, with retained awareness.
Generalised Absence » Occurs in childhood.
non-motor » Sudden cessation of activity
seizure followed by a blank stare.
» Usually no muscle twitching.
» Some children will smack their lips.

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» Educate patient.

 Record the dates and, if possible, the times of the seizures, in a seizure diary.
» Advise patient to:

 Present the seizure diary at each consultation for assessment of therapy.

 Carry a disease identification bracelet, necklace or card.
» Monitor patients for psychiatric disturbances, intellectual disability (limitations in
reasoning, learning and problem solving), anxiety and/or depression, and manage
accordingly.

 the adverse effect of alcohol on seizures

» Counsel and advise patient on:

 the effect of missing a dose of medication

 the risks of discontinuing medicine treatment without advice of the doctor
 the need for family planning
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PDFKLQHU\7KHSDWLHQWVKRXOGVLJQLQWKHQRWHVWKDWWKH\KDYHUHFHLYHGWKLVDGYLFH

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1RWH
» General rule: a single medicine is best.
» Combination therapy should be initiated only by a specialist.

2018 15.6
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Recommended doses are general guides and will be effective in most patients.
Some patients may need much higher or lower doses. Doses should be


increased at 2-weekly intervals only.
In patients receiving any anticonvulsants, therapeutic drug monitoring may be
useful to confirm suspected non-adherence, or diagnose toxicity in a


symptomatic patient.
Therapeutic drug monitoring should be done in patients receiving higher than
usual doses of phenytoin.

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Phenytoin, phenobarbitone and carbamazepine are potent enzyme inducing
agents and should be used with caution with other medicines metabolised by
the liver, especially warfarin, antiretrovirals, progestin subdermal implants and
oral contraceptives.
» Progestin-only injectable contraceptives or IUCDs are the preferred contraceptive
methods for women of child-bearing potential on anti-epileptic medication. See
Chapter 7: Family planning.
LoE:IIIiii
*HQHUDOLVHGWRQLFFORQLFVHL]XUHV
Adults
The aim is to use monotherapy, i.e. a single anticonvulsant, progressively increasing
the dose until the seizures are controlled or clinically important side effects occur.
x Lamotrigine, oral (Doctor initiated).
o 25 mg daily for 2 weeks.
o Then 50 mg daily for 2 weeks.
o Thereafter, increase by 50 mg every 2 weeks according to response.
o Usual maintenance dose: 100–200 mg daily as a single dose or divided doses.
1RWHLamotrigine is the preferred anticonvulsant in women of child-bearing potential.
Avoid valproic acid in women of child-bearing potential. LoE:Iiv

&$87,21
Children born to women taking valproic acid are at significant risk of birth
defects (10%) and persistent developmental disorders (40%).
Valproic acid is contra-indicated and should be avoided in pregnancy and
women of child-bearing potential. LoE:IIIv

25
Carbamazepine, oral (Doctor initiated).
o 100 mg 12 hourly for one week then, 200 mg 12 hourly.
o Titrate upwards by 100–200 mg daily, every week according to response to a
maximum dose of 600 mg 12 hourly.
If the initial medicine fails to achieve satisfactory control with optimal dosages, or
causes unacceptable adverse effects, then a 2nd medicine may be started. The 1st
medicine should be continued for 2 weeks and then gradually reduced over 6–8
weeks until stopped.

2018 15.7
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2QO\LIDOUHDG\ZHOOFRQWUROOHGRQSKHQ\WRLQFRQWLQXHZLWK
x Phenytoin, oral, 4.5–5 mg/kg daily on lean body mass, at night (Doctor initiated).
o Phenytoin is a useful and effective agent. However, doses > 300 mg/day are
potentially toxic, and increased dosages should be monitored carefully, both
clinically and by medicine concentrations.
Children
The decision to initiate long-term therapy is generally made if the child has
experienced • 2 unprovoked convulsions (except febrile convulsions).
» Phenobarbital and carbamazepine are both effective in generalised tonic-clonic
seizures.
» Monitor the behaviour profile and academic performance of children on
phenobarbital. Change treatment if any problems are identified.
x Phenobarbital, oral, 3.5–5 mg/kg at night (< 6 months of age) (Doctor prescribed).
LoE:Ivi
25
x Carbamazepine, oral (Doctor prescribed)
Children ”12 years of age:

 Syrup (100 mg/5mL):

o Initial dose:

 Tablets (200 mg):

5 mg/kg/day, given in divided doses, 8 hourly.
5 mg/kg/day, given in divided doses,12 hourly.
o Depending on UHVSRQVH WR WUHDWPHQW increase slowly by 5 mg/kg/day, if
necessary, at 2 weekly intervals to a maximum of 20 mg/kg/day or 1 g/day.


o Maintenance dose:
Maintenance total daily dose: 10–20 mg/kg/day.
1RWH
» All children not controlled on 20 mg/kg/day should be referred.
» Carbamazepine may exacerbate myoclonic seizures and absence seizures.
 LoE:IIIvii
+,9LQIHFWHGLQGLYLGXDOVRQ$57
Children
For HIV-infected children on ART, valproic acid is preferred because of fewer
medicine interactions. When switching to valproic acid, commence treatment with
maintenance dose of the medicine as below and discontinue the other anticonvulsant
after 7 days. Exclude liver dysfunction prior to initiating therapy (at least ALT), in
children < 2 years or if clinical suspicion of liver dysfunction.
x Valproic acid, oral, 5 mg/kg 12 hourly (Doctor prescribed). LoE:IIIviii
o Titrate according to response over 4 weeks up to 15 mg/kg
12 hourly.
o If poorly tolerated divide total daily dose into 3 equal doses.
o Maximum daily dose 40 mg/kg/day.
o Switch to an alternate anticonvulsant when girls reach child-bearing age.
Adults
For HIV-infected adults on ART, lamotrigine is preferred because of fewer medicine

2018 15.8
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interactions. When switching to lamotrigine, commence treatment as below and

x Lamotrigine, oral (Doctor initiated).

discontinue the other anticonvulsant after 28 days.

o 25 mg daily for 2 weeks.

o Then 50 mg daily for 2 weeks.
o Thereafter, increase by 50 mg every 2 weeks according to response.
o Usual maintenance dose: 100–200 mg/day as a single or divided dose.
1RWHThe dose of lamotrigine will need to be doubled when patients are switched
from efavirenz- or nevirapine-based ART to lopinavir/ritonavir-based ART because
the metabolism of lamotrigine is induced by lopinavir/ritonavir.
3RRUO\FRQWUROOHGHSLOHSV\
Ask the patient, and if possible a family member or primary care giver, about the
following, as these factors can influence decisions regarding medicine therapy:
» Has the patient been adherent in taking the medication regularly for at least 2
weeks or more before the seizure? Ask about medicine dosage and frequency.
» If non-adherence has been established, ask for reasons contributing to non-
adherence and offer guidance.
» Has the patient recently used some other medicine (i.e. look for drug interactions,
substance abuse or traditional medicine use).
» Is there a chance that alcohol is involved?

If • 1 of the above are present, address the problem/s but leave anticonvulsant
therapy unchanged (unless dose adjustment is necessary because of a drug
interaction). Reassess the patient within 2 weeks.

5()(55$/
» All patients with new onset epilepsy for further investigations such as CT scans.
» Patients with seizures other than generalised tonic-clonic seizures, including
absence seizures.
» Increased number of seizures despite attempts to address adherence issues, or
changes in the seizure type.
» Patients who have been seizure free on therapy for • 2 years to review therapy and
consideration for stopping treatment.
» Pregnancy.
» Women of child-bearing potential who are on valproic acid for a switch to a less
teratogenic medicine.
» Development of neurological signs and symptoms.
» Adverse medicine reactions or suspected toxicity in children.
» If uncontrolled on monotherapy, once patient has been shown to be adherent on
monotherapy at the optimal dose.
,QIRUPDWLRQRQWKHVHL]XUHVWKDWVKRXOGDFFRPSDQ\HDFKUHIHUUDOFDVH
» Number and frequency of seizures per month (or year).
» Date and time of most recent seizures.

 aura or warning sign

» Detailed description of the seizures, including:

2018 15.9
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 what happens during the seizure? (give a step-by-step account)

 is the person conscious during the seizure?
 how long do the seizures last on average?
 what does the patient experience after the seizure?
 how long does this experience last?
» Is there a family history of seizures?
» What is the initial date of diagnosis?
» Is there evidence of alcohol use?
» Is there another medical condition, e.g. diabetes, HIV and what medication is used?
» What is the name and dosage of the anti-epileptic medicines used to date?
» Does the person return regularly for repeat of medication?

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R56.0

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A febrile convulsion is a seizure occurring in a child between the ages of 3 months
and 6 years of age in association with a significant fever in the absence of an
intracranial infection. These are the most common type of seizures in children of this
age. However, the diagnosis requires the exclusion of other causes of seizures.
Febrile convulsions can be simple or complex. LoE:IIIix

Simple febrile convulsions:

» are generalised
» occur once per illness
» always last for < 15 minutes (typically lasting 1–2 minutes)
» are not associated with any neurological deficit
» are self-limiting
Complex febrile seizures:
» last > 15 minutes; or
» are recurrent within the same febrile illness; or
» have a focal onset.
Children with febrile convulsions have a good prognosis, and very rarely develop epilepsy.
,IFRQYXOVLQJ

x Midazolam, buccal, 0.5 mg/kg/dose as a single dose. See dosing table, pg 23.7.
Children

o Use midazolam for injection 5 mg in 1 mL undiluted.

o Draw up the required volume in a 5 mL syringe.
o Remove needle then administer midazolam into the buccal cavity (between
gum and cheeks).
o 1RWH: Buccal midazolam should not be used in infants < 6 months of age.
25
x Diazepam, rectal, 0.5 mg/kg/dose as a single dose. See dosing table, pg 23.4.
o Use diazepam for injection 10mg in 2 mL undiluted.
o Draw up the required volume in a 2 mL syringe.

2018 15.10
 &+$37(5 &(175$/1(592866<67(0&21',7,216

o Remove needle then insert the whole barrel of the lubricated syringe into the
rectum and inject the contents.
o Remove syringe and hold buttocks together to minimise leakage.
o Maximum dose: 10 mg in 1 hour.
o May be repeated after 10 minutes if convulsions continue.
o Expect a response within 1–5 minutes.
If no response after two doses of midazolam or diazepam, manage as Status
epilepticus. See Section 21.2.11: Seizures and status epilepticus.
1RWH
» Look for a cause of the fever.
» $OZD\VH[FOXGHPHQLQJLWLVSee Section 15.4: Meningitis.

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Reassure parents and caregivers.

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Treat the underlying cause.

x Paracetamol, oral, 15 mg/kg/dose 6 hourly when required. See dosing table,

For symptomatic relief:

pg 23.8.
o Paracetamol has no effect on seizure prevention.

5()(55$/

 the diagnosis of recurrent simple febrile seizures has been well established
» All febrile convulsions except where:

$1'
 the child regains full consciousness and function immediately after the seizure
$1'
 meningitis has been excluded (See Section 15.4: Meningitis)
» Complex convulsions.

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Infection of the membranes of the brain.
Clinical signs and symptoms include:
» headache » impaired level of consciousness
» neck stiffness » photophobia
» vomiting » bulging fontanelle in infants
» fever
1RWH
» During the early phase of TB meningitis, malaise, low-grade fever, headache and

2018 15.11
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personality change rather than the above-mentioned symptoms may be present.

» Duration of treatment for TB meningitis is 9 months.
1HFNVWLIIQHVVLVUDUHLQ\RXQJFKLOGUHQDQGHVSHFLDOO\QHRQDWHVDQGPD\EH
DEVHQWLQDGXOWVHVSHFLDOO\GHELOLWDWHGSDWLHQWVDQGWKHHOGHUO\.
Young children with fever, vomiting and convulsions or an impaired level of
consciousness must be assumed to have meningitis. Signs may be even more subtle
in newborns.
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» Stabilise before referral.
» Treat for shock, if present.

 maintain airway  give oxygen

» If patient’s level of consciousness is depressed:

» Ensure hydration.

0(',&,1(75($70(17
Initiate medicine treatment before transfer.

x Ceftriaxone, IM, 80 mg/kg/dose immediately DV D VLQJOH GRVH before referral.

Children

See dosing table, pg 23.3.

o Do not inject more than 1 g at one injection site.
&$87,2186(2)&()75,$;21(,11(21$7(6$1'&+,/'5(1
» If SUSPECTING SERIOUS BACTERIAL INFECTION in neonate, give ceftriaxone,
even if jaundiced.

 If ” 28 days old, avoid calcium-containing IV fluids for 48 hours after ceftriaxone

» Avoid giving calcium-containing IV fluids (e.g. Ringer Lactate) together with ceftriaxone:

 If > 28 days old, ceftriaxone and calcium-containing IV fluids may be given

administered.

sequentially provided the giving set is flushed thoroughly with sodium chloride 0.9%

 Preferably administer IV fluids without calcium contents

before and after.

» Always include the dose and route of administration of ceftriaxone in the referral letter.

x Ceftriaxone, IM, 2 g immediately before referral.

Adults

o Do not inject more than 1 g at one injection site.

'XULQJDOLVWHULDRXWEUHDN$''DVDSUHUHIHUUDOGRVH: A32.0-1/A32.7-9

x Ampicillin, IM/IV 75 mg/kg/dose immediately before referral.

Children

o If referral delayed by 6 hours, administer second dose.

2018 15.12
 &+$37(5 &(175$/1(592866<67(0&21',7,216

:HLJKW 'RVH ,QMHFWLRQ $JH

kg mg 500 mg/mL months/years
(500 mg diluted in 0.9 mL
water for injection (WFI))
>3.5–5.5 kg 300 mg 0.6 mL >1–3 months
>5–7 kg 450 mg 0.9 mL >3–6 months
>7–9 kg 600 mg 1.2 mL >6–12 months
>9–11 kg 750 mg 1.5 mL >12–18 months
>11–17.5 kg 1000 mg 2 mL >18 months–5 years
>17.5–25 kg 1500 mg 3 mL >5–7 years
>25–35 kg 2000 mg 4 mL >7–11 years
‫ޓ‬35 kg 3000 mg 6 mL >11 years

x Ampicillin, IM/IV, 3 g immediately before referral.

Adults

o If referral delayed by 6 hours, administer second dose.

6HYHUHSHQLFLOOLQDOOHUJ\ (Z88.0)

x Cotrimoxazole, oral, 80/400 immediately before referral.

Adults

o If referral delayed by 12 hours, administer second dose.

x
LoE:III
x Co-trimoxazole, oral, immediately before referral. See dosing table, pg 23.4.
Children

R If referral delayed by 12 hours, administer second dose.

If convulsing, see Section 21.2.11: Seizures and status epilepticus.

5()(55$/
All patients with meningitis, or suspected meningitis or suspected listeria meningitis.

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Z29.2

In cases of meningococcal infection, the following close contacts should receive

prophylaxis. Close contacts include:
» household members,
» child-care centre contacts, and
» anyone directly exposed to the patient's oral secretions, e.g. kissing, mouth-to-
mouth resuscitation, endotracheal intubation, or endotracheal tube management.
Chemoprophylaxis is only effective for the current exposure.

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3URSK\OD[LV

x Ceftriaxone, IM 125 mg, as a VLQJOHGRVH

Children < 6 years of age

2018 15.13
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&$87,2186(2)&()75,$;21(,11(21$7(6$1'&+,/'5(1
» If SUSPECTING SERIOUS BACTERIAL INFECTION in neonate, give ceftriaxone,
even if jaundiced.

 If ” 28 days old, avoid calcium-containing IV fluids for 48 hours after ceftriaxone

» Avoid giving calcium-containing IV fluids (e.g. Ringer Lactate) together with ceftriaxone:

 If > 28 days old, ceftriaxone and calcium-containing IV fluids may be given

administered.

sequentially provided the giving set is flushed thoroughly with sodium chloride 0.9%

 Preferably administer IV fluids without calcium contents.

before and after.

» Always include the dose and route of administration of ceftriaxone in the referral letter.

x Ciprofloxacin, oral, 250 mg, as a single dose.

Children 6–12 years of age

x Ciprofloxacin, oral, 500 mg, as a single dose.

Children > 12 years of age and adults

x Ceftriaxone, IM, 250 mg, as a single dose.

Pregnant women

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See Section 11.3.4.2: Cryptococcal Meningitis.

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R51

'(6&5,37,21
Headache can be benign or serious.
Headache can have serious underlying causes including:
» encephalitis » hypertensive emergencies
» meningitis » venous sinus thrombosis
» mastoiditis » stroke
» benign intracranial hypertension » brain tumour
Headache due to a serious disease will often be associated with neurological
symptoms and signs including:
» vomiting » impaired consciousness
» fever » pupillary changes and difference in size
» mood change » focal paralysis
» cranial nerve fall-out » visual disturbances
» convulsions » neck stiffness
» confusion
Tension headache due to muscle spasm:
» May be worse in the afternoon, but often present all day.
» Is normally felt in the neck and the back of the head, but may be felt over the

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entire head.
» Is often associated with dizziness and/or blurring of vision.
» Is often described as a tight band around the head or pressure on the top of the head.
» Does not progress through stages like a migraine (no nausea, no visual symptoms).

*(1(5$/0($685(6
» Teach relaxation techniques where appropriate.
» Reassurance, where applicable.
» Exclude analgesia overuse headache.

0(',&,1(75($70(17

x Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See dosing table,
Children

pg 23.8.

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per 24

Adults

hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.

5()(55$/
» Refer patients with suspected meningitis immediately after initial treatment. See
Section 15.4: Meningitis.
» Headache in children lasting for 3 days.
» Recent headache of increasing severity.
» Headache with neurological manifestations.
» Analgesia overuse headache.
» Newly developed headache persisting for >1 week in an adult.
» Chronic recurrent headaches in an otherwise healthy patient: refer if no
improvement after 1 month of treatment.
» Tension headache due to muscle spasm: refer if no improvement after 1 month
of treatment.

 1(8523$7+<

'(6&5,37,21
Defective functioning of nerves, which may involve peripheral nerves (peripheral
neuropathy) and/or cranial nerves.
Clinical features may be predominantly of a sensory, sensorimotor or motor nature.

3267+(53(6=267(51(8523$7+<3267
   +(53(7,&1(85$/*,$
See Section 10.13: Shingles (Herpes zoster).

2018 15.15
 &+$37(5 &(175$/1(592866<67(0&21',7,216

%(//63$/6<
G51.0

'(6&5,37,21
Unilateral paralysis of all the muscles of facial expression (the corner of the mouth
drops, the forehead is unfurrowed, and the eyelids will not close).
Taste sensation may be lost unilaterally and hyperacusis (painful sensitivity to loud
sounds) may be present.
Most patients recover within a few weeks or months.

*(1(5$/0($685(6
» HIV testing.
» Referral for facial muscle massage and exercises
» Eye patch for protection of the eye during sleep.
0(',&,1(75($70(17

x Prednisone, oral, 60 mg daily for 7 days started within 72 hours, preferably within
Adults

48 hours of onset (Doctor prescribed).

LoE:Ixi

x Prednisone, oral, 2 mg/kg daily for 7 days within 3 days of onset (Doctor prescribed).
Children

:HLJKW 'RVH 7DEOHW $JH

Kg Mg 5mg Months/years
>17.5–25 kg 40 mg 8 tablets >5–7 years
>25–40 kg 55 mg 11 tablets >7–12 years

5()(55$/
» If diagnosis uncertain.
» All cases for physiotherapy, if available.
» Eye irritation requiring lubrication.

3(5,3+(5$/1(8523$7+<
G60.9/G62.9/G62.0-1/E10.6/E11.6

'(6&5,37,21
Initially sensory symptoms consisting of tingling, prickling, burning in the balls of the
feet or tips of the toes or in a general distribution over the soles. The symptoms are
symmetrical and with progression spread proximally.
Later sensory loss over both feet and weakness of dorsiflexion of the toes may be
present. Patients may experience difficulty in walking on their heels and foot drop
becomes apparent.
Common causes include HIV, Diabetes Mellitus, isoniazid, antiretrovirals (stavudine
and didanosine), vitamin B12 deficiency and alcohol.

*(1(5$/0($685(6
» HIV testing.

2018 15.16
 &+$37(5 &(175$/1(592866<67(0&21',7,216

» Screen for diabetes mellitus, syphilis and vitamin B12 deficiency

» Avoid alcohol.
» A balanced diet to prevent nutritional deficiency.

0(',&,1(75($70(17
» Stop the offending medicine or give suitable substitute e.g. substitute stavudine
or didanosine with tenofovir or lamivudine.
» Patients on isoniazid (TB treatment or prophylaxis): increase pyridoxine to 25–

x
50 mg 8 hourly for 3 weeks, followed by 25–50 mg daily.
Amitriptyline, oral, 25 mg at night (Doctor prescribed).
o Titrate at two weekly intervals to a maximum of 75 mg at night.

5()(55$/
» All children.
» Difficulty in walking or foot drop.
» Any limb weakness present.
» Unsteady/ataxic gait.
» Severe sensory loss.
5HIHUHQFHV
i Aspirin, oral (pre-referral dose in acute stroke): Sandercock PA, Counsell C, Tseng MC, Cecconi E. Oral antiplatelet therapy for acute
ischaemic stroke. Cochrane Database Syst Rev. 2014 Mar 26;(3):CD000029. https://www.ncbi.nlm.nih.gov/pubmed/24668137
Aspirin, oral (pre-referral dose in acute stroke): Rothwell PM, Algra A, Chen Z, Diener HC, Norrving B, Mehta Z. Effects of
aspirin on risk and severity of early recurrent stroke after transient ischaemic attack and ischaemic stroke: time-course analysis of
randomised trials. Lancet. 2016 Jul 23;388(10042):365-375. https://www.ncbi.nlm.nih.gov/pubmed/27209146
ii Aspirin, oral (thrombolytic interaction): Luo S, Zhuang M, Zeng W, Tao J. Intravenous Thrombolysis for Acute Ischemic Stroke in

Patients Receiving Antiplatelet Therapy: A Systematic Review and Meta-analysis of 19 Studies. J Am Heart Assoc. 2016 May 20;5(5).
pii: e003242. https://www.ncbi.nlm.nih.gov/pubmed/27207999
Aspirin, oral (thrombolytic interaction): Mousa SA, Forsythe MS, Bozarth JM, Reilly TM. Effect of single oral dose of aspirin on human
platelet functions and plasma plasminogen activator inhibitor-1. Cardiology. 1993;83(5-6):367-73.
https://www.ncbi.nlm.nih.gov/pubmed/8111770
Aspirin, oral (pre-referral dose in acute stroke): National Department of Health: Affordable Medicines, EDP- Primary Health Care
Level. Medicine Review: Aspirin, pre-referral dose for acute stroke, March 2018. http://www.health.gov.za/
iii Anti-epileptic drug-drug interactions: National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and

EML, 2015. http://www.health.gov.za/

iv Anti-epileptics in pregnancy: Weston J, Bromley R, Jackson CF, Adab N, Clayton-Smith J, Greenhalgh J, Hounsome J, McKay AJ,

Tudur Smith C, Marson AG. Monotherapy treatment of epilepsy in pregnancy: congenital malformation outcomes in the child. Cochrane
Database Syst Rev. 2016 Nov 7;11:CD010224. https://www.ncbi.nlm.nih.gov/pubmed/27819746
v Valproic acid – caution in pregnancy: European Medicines Agency - Pharmacovigilance Risk Assessment Committee. Assessment

report EMA/198940/2018 - valproate exposure in pregnancy, 8 February 2018.

http://www.ema.europa.eu/docs/en_GB/document_library/Referrals_document/Valproate_2017_31/Position_provided_by_CMDh/WC5
00250221.pdf
Valproic acid – caution in pregnancy: Meador K, Reynolds MW, Crean S, Fahrbach K, Probst C. Pregnancy outcomes in
women with epilepsy: a systematic review and meta-analysis of published pregnancy registries and cohorts. Epilepsy Res. 2008
Sep;81(1):1-13. https://www.ncbi.nlm.nih.gov/pubmed/18565732
vi Phenobarbital, oral (children): Banu SH, Jahan M, Koli UK, Ferdousi S, Khan NZ, Neville B. Side effects of phenobarbital and

carbamazepine in childhood epilepsy: randomised controlled trial. BMJ. 2007 Jun 9;334(7605):1207.
https://www.ncbi.nlm.nih.gov/pubmed/17145735
vii Carbamazepine, oral (children): National Department of Health, Essential Drugs Programme: Paediatric Hospital Level STGs and

EML, 2017. http://www.health.gov.za/

Carbamazepine, oral (children): Glauser T, Ben-Menachem E, Bourgeois B, Cnaan A, Guerreiro C, Kälviäinen R, Mattson R, French
JA, Perucca E, Tomson T; ILAE Subcommission on AED Guidelines. Updated ILAE evidence review of antiepileptic drug efficacy and
effectiveness as initial monotherapy for epileptic seizures and syndromes. Epilepsia. 2013 Mar;54(3):551-63.
http://www.ncbi.nlm.nih.gov/pubmed/23350722
Carbamazepine, oral (children): Marson AG, Williamson PR, Hutton JL, Clough HE, Chadwick DW. Carbamazepine versus valproate
monotherapy for epilepsy. Cochrane Database Syst Rev. 2000;(3):CD001030. http://www.ncbi.nlm.nih.gov/pubmed/10908558
Carbamazepine, oral (children): British National Formulary for children 2016-2017. (2016). 1st ed. London: BMJ Group,
Pharmaceutical Press and RCPCH Publications Ltd.
viiiChildren: AED-ART - liver dysfunction: National Department of Health, Essential Drugs Programme: Paediatric Hospital Level STGs

and EML, 2017. http://www.health.gov.za/

2018 15.17
 &+$37(5 &(175$/1(592866<67(0&21',7,216

ixFebrile seizures definition: National Department of Health, Essential Drugs Programme: Paediatric Hospital Level STGs and EML,
2017. http://www.health.gov.za/
xAntibiotic pre-referral doses for listeriosis (additional ampicillin/cotrimoxazole): National Institute of Communicable Diseases. Listeriosis:

Clinical recommendations for diagnosis and treatment, 5 December 2017. http://www.nicd.ac.za/

xi Prednisone, oral (adults: within 72 hours): Madhok VB, Gagyor I, Daly F, Somasundara D, Sullivan M, Gammie F, Sullivan F.

Corticosteroids for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2016 Jul 18;7:CD001942.
https://www.ncbi.nlm.nih.gov/pubmed/27428352
Prednisone, oral (adults: within 48 hours): Axelsson S, Berg T, Jonsson L, Engström M, Kanerva M, Pitkäranta A,
Stjernquist-Desatnik A. Prednisolone in Bell's palsy related to treatment start and age. Otol Neurotol. 2011 Jan;32(1):141-6.
https://www.ncbi.nlm.nih.gov/pubmed/21099725

2018 15.18
PHC Chapter 16: Mental health
conditions
16.1 Aggressive disruptive behaviour
16.1.1 Acute confusion – Delirium
16.1.2 Aggressive disruptive behaviour in adults
16.1.3 Aggressive disruptive behaviour in children
and adolescents
16.2 Antipsychotic adverse drug reactions
16.2.1 Extra-pyramidal side effects
16.2.2 Neuroleptic malignant syndrome
16.3 Anxiety disorders
16.4 Mood disorders
16.4.1 Depressive disorders
16.4.2 Bipolar disorder
16.5 Psychosis
16.5.1 Acute psychosis
16.5.2 Chronic psychosis (Schizophrenia)
16.6 Psychiatric patients - general monitoring and care
16.7 Suicide risk assessment
16.8 Special considerations
16.8.1 Intellectual disability
16.8.2 Older patients (• 45 years)
16.8.3 Sexual health and sexuality
16.8.4 Maternal mental health
16.9 Substance misuse
16.9.1 Substance use disorders
16.9.2 Substance-induced mood disorder
16.9.3 Substance-induced psychosis
16.9.4 Alcohol withdrawal (uncomplicated)
 CHAPTER 16 MENTAL HEALTH CONDITIONS

Nurses with authorisation as provided by Section 56(6) of the Nursing Act 33 of

2005 may initiate and/or maintain treatment with medicines as per the STGs and
in accordance with their scope of practice.
Precepts of the Mental Health Care Act (MHCA) No. 17 of 2002 include:
» All mentally ill and intellectually disabled must be managed under the Act and
its regulations as either Voluntary, Assisted or Involuntary Mental Health Care
Users.
» All registered medical practitioners, professional nurses, psychologists,
occupational therapists (OTs) and social workers whose training includes
mental health are designated Mental Health Care Practitioners.
» At PHC level, familiarity with MHCA Forms 01, 02, 04, 05, 07, 11, 13A, 22 and
48. Understanding of the related processes is required by all mental health
practitioners.
» Specific obligations of the South African Police Service to protect, apprehend,
and assist with transfer people with mental illness.
Children presenting with mental health conditions at a primary care setting:
» Manage underlying medical conditions.
» Consider developmental delay and refer for educational interventions.
» Ask about family/psychosocial stressors including abuse and refer to social
worker.

16.1 AGGRESSIVE DISRUPTIVE BEHAVIOUR

16.1.1 ACUTE CONFUSION - DELIRIUM

See Section 21.2.4: Delirium with acute confusion and aggression in adults.

16.1.2 AGGRESSIVE DISRUPTIVE BEHAVIOUR IN ADULTS

R45.1/R45.4-6

DESCRIPTION
Agitation may escalate to overt aggression and often manifests with restlessness,
pacing and loud or demanding speech. Aggressive behaviour includes verbally
abusive language, specific verbal threats, intimidating physical behaviour and/or
actual physical violence to self, others or property. All agitation and aggression
must be considered an emergency and violence prevented wherever possible.
Multiple causes for aggressive, disruptive behaviour include:
» Physical: acute medical illness, delirium and its causes (see Section 21.2.4:
Delirium with acute confusion and aggression in adults), epilepsy (pre-, intra-,
and post-ictal), intracerebral lesions, traumatic brain injury.
» Psychiatric: psychosis, mania, agitated depression, neurocognitive disorders
(e.g. dementias, traumatic brain injury), developmental disorders (e.g.
intellectual disability and autistic spectrum disorder – See Section 16.8.1
Special considerations: Intellectual disability), severe anxiety.
» Substance misuse: alcohol, cannabis, methaqualone (mandrax) intoxication

2018 16.2
 CHAPTER 16 MENTAL HEALTH CONDITIONS

or withdrawal; stimulant (cocaine, methamphetamine (tik), methcaninone (cat)

intoxication; benzodiazepine withdrawal.
» Psychological factors: high levels of impulsivity and antagonism,
hypersensitivity to rejection or insult, poor frustration tolerance and
maladaptive coping skills all contribute to aggression and rage.

CAUTION
» Psychiatric and intellectually disabled patients often have medical conditions,
trauma and substance misuse.
» Do not assume that the aggression is due to the mental illness.

GENERAL MEASURES

 Be aware of high risk patients e.g. those known with previous violence,
» Be prepared:

 Step-wise protocol to ensure safety of the patient and all in the clinic.
substance misuse, State patients.

 Clear roles for all staff members.

 Triage plan for early signs of aggression.
 Available backup – security, SAPS and EMS.
 A designated calming area – suitable for regular monitoring.

 Be calm, confident, kind and reassuring.

» De-escalate and contain:

 Maintain a submissive posture with open hands; do NOT turn your back.
 Do NOT argue, confront delusions or attempt to touch the patient.
» Be vigilant for delirium, medical and other causes while calming the patient.

 Only use when absolutely necessary to protect the patient and others in
» Mechanical restraint:

 Type, sites and duration of any restraints used must be documented, with
an acute setting for as short a period of time as possible.

15-minute monitoring of vital signs, the mental state, restraint sites and
reasons for use. Complete MHCA Form 48 and submit to Mental Health
Review Board if mechanical restraint was used.

2018 16.3
 CHAPTER 16 MENTAL HEALTH CONDITIONS

MEDICINE TREATMENT
Oral treatment:
ƒ Benzodiazepines, e.g.:
x Diazepam, oral, 5 mg, immediately.
OR
Midazolam, buccal, 7.5–15 mg, immediately, using the parenteral formulation.

2018 16.4
 CHAPTER 16 MENTAL HEALTH CONDITIONS

If alcohol use is suspected:

x Thiamine, oral, 300 mg immediately and daily for 14 days.

ADD

If oral treatment fails after 30–60 minutes,

OR
The patient is placing themselves and others at significant risk:
IM treatment (rapid tranquillisation):
ƒ Short-acting benzodiazepines, e.g.:
x Midazolam, IM, 7.5–15 mg immediately.
o Repeat after 30–60 minutes if needed.
OR
Haloperidol, IM, 5 mg, immediately.
o Repeat after 30–60 minutes if needed.
AND
Promethazine, IM, 25–50 mg.
o In the elderly 25 mg.

CAUTION
» Rapid tranquillisation may cause cardiovascular collapse, respiratory
depression, neuroleptic malignant syndrome and acute dystonic reactions.
» The elderly, children, intellectually disabled and those with comorbid medical
conditions and substance users are at highest risk.
» An emergency trolley, airway, bag, oxygen and intravenous line must be
available.
Always monitor vital signs of sedated patient:
» Vital signs: pulse, respiratory rate, blood pressure, temperature, level of
consciousness and hydration.
» Monitor particularly for respiratory depression: if respiratory rate drops to < 12
breaths/minute, call doctor urgently and ventilate with bag-valve mask (1
breath/3-5 seconds) attached to oxygen at 15 L/minute.

REFERRAL
Urgent: All cases.

16.1.3 AGGRESSIVE DISRUPTIVE BEHAVIOUR IN

CHILDREN AND ADOLESCENTS
R45.1/R45.4-6

MEDICINE TREATMENT
Exclude medical causes, e.g. encephalopathy or other intracranial pathology,
infection, seizures, metabolic disease, medication adverse effects and
intoxication.
For children < 6 years of age
Sedation with psychotropic agents should only be considered in extreme cases
and only after consultation with a specialist.
2018 16.5
 CHAPTER 16 MENTAL HEALTH CONDITIONS

For children > 6 years of age

ƒ Benzodiazepines, e.g.:
x Midazolam, IM, 0.1–0.15 mg/kg/dose as a single dose (Doctor initiated).
o Onset of action: within 5 minutes.
CAUTION
» Rapid tranquillisation may cause cardiovascular collapse, respiratory
depression, neuroleptic malignant syndrome (see Section 16.2.2: Neuroleptic
malignant syndrome) and acute dystonic reactions (see Section: 16.2.1: Extra-
pyramidal side effects).
» The elderly, children, intellectually disabled and those with comorbid medical
conditions and substance users are at highest risk.
» An emergency trolley, airway, bag, oxygen and intravenous line must be
available.

x Haloperidol, IM, 0.025–0.05 mg/kg/day in 2–3 divided doses (Doctor initiated).

If sedation is inadequate:

o Maximum daily dose: 0.15 mg/kg/day.

For management of acute dystonic reaction: See Section 16.2.1: Extra-
pyramidal side effects.

CAUTION
Always consult with a doctor, preferably a psychiatrist where possible, when
prescribing antipsychotic medication to children and adolescents.

16.2 ANTIPSYCHOTIC ADVERSE DRUG REACTIONS

16.2.1 EXTRA-PYRAMIDAL SIDE EFFECTS
G21.1/G24.0/G25.8-9 + (T43.0-6/T43.8-9/Y40.0-9/Y59.0-3/Y59.8-9)

DESCRIPTION
Extra-pyramidal side effects (EPSE) may occur with any antipsychotic but are
most commonly due to haloperidol, risperidone and flupenthixol and
zuclopenthixol injections.
» At risk groups include those with underlying medical conditions such as
epilepsy, intellectual disability, dementia and late onset psychosis (more often
associated with a medical condition than psychosis in youth).
» People with Bipolar Disorder are more susceptible to EPSE than those with
schizophrenia.
EPSEs may present as a variety of clinical syndromes:
Early appearing:
» Acute dystonic reaction (sustained muscle contraction that causes twisting
and repetitive movements, abnormal posture or abnormal eye position, or
laryngospasm within a few minutes to days after receiving an antipsychotic
tablet or injection.
2018 16.6
 CHAPTER 16 MENTAL HEALTH CONDITIONS

» Parkinsonism (slow, shuffling gait, delayed responses, masked facies and a

pill rolling tremor).
» Akathisia (a subjective and observed motor restlessness e.g.: pacing,
rocking, marching, crossing and uncrossing legs).
Late appearing:
» Tardive dyskinesia (choreoathetoid involuntary movements that particularly
involve the face, lips and tongue (e.g.: lip smacking or chewing, tongue
protrusion (“catching flies”), but occasionally also arms, legs or trunk. More
common in older women, depression, bipolar disorder, people with cognitive
impairment. Only about 50% of cases are reversible.

MEDICINE TREATMENT
Acute dystonic reaction
Children
ƒ Anticholinergic, e.g.:
x Biperiden, IM/slow IV, 0.05–0.1 mg/kg, to a maximum of:
o 1–6 years: 1–2 mg
o 7–10 years: 3 mg
o > 10 years: 5 mg
OR LoE:IIIi
Promethazine, IM, 0.125–0.5 mg/kg to a maximum of:
o 5–10 years: 12.5 mg
o 10–16 years: 25 mg
Adults LoE:IIIii
ƒ Anticholinergic, e.g.:
x Biperiden, IM, 2.5 mg.
o May be repeated every 30 minutes.
o Maximum of 3 doses within 24 hours. LoE:IIIiii
OR
Promethazine, IM, 50 mg.
Drug-induced parkinsonism
ƒ Anticholinergic, e.g.:
x Orphenadrine, oral, 50 mg 8 hourly, whilst awaiting review.
LoE:IIIiv
REFERRAL
» Refer all children urgently.
» All patients for review of psychotropic medication.

16.2.2. NEUROLEPTIC MALIGNANT SYNDROME

G21.0 + (T43.0-8/ Y40.0-9/Y59.0-3/Y59.8-9)

DESCRIPTION
» Neuroleptic malignant syndrome (NMS) is a rare but potentially fatal syndrome
characterised by a tetrad of fever, muscle rigidity, altered mental state and
autonomic dysfunction.
» An altered mental state with confusion, delirium or stupor may precede other
2018 16.7
 CHAPTER 16 MENTAL HEALTH CONDITIONS

clinical signs of NMS.

» Suspect if exposure to an antipsychotic, fever and sweating, muscle rigidity,
elevated or fluctuating blood pressure.
» Most common after initiation or increase in dose of haloperidol, risperidone or
injectable antipsychotic, but may occur with any antipsychotic at any dose.
» Combinations of antipsychotics with SSRIs or lithium may increase the risk.
» Agitation, dehydration, exhaustion and iron deficiency increase the risk of NMS.
» Other causes of fever must be investigated and treated.
LoE:IIIv
GENERAL MEASURES
Stop all antipsychotics.
Cool patient and hydrate adequately.

REFERRAL
All patients for urgent medical admission and psychiatric review

16.3 ANXIETY DISORDERS

F40.0-2/F40.8-9/F41.0-3/F41.8-9/F42.0-2 + (F10.0-F19.9/R45.0-8/Z65.0-5/Z65.8-9/Z81.0-
4/ Z81.8)

DESCRIPTION
Anxiety is an emotional response to an apparent stress. It is diagnosed as a
disorder when it is excessive or persistent and impacts daily functioning.
Anxiety disorders are associated with an increase in cigarette smoking, alcohol
use and various medical illnesses.
Anxiety may present in various forms:
» Physical symptoms – anxiety may present with medically unexplained
symptoms like: muscle tension, headache, abdominal cramps, nausea,
palpitations, sweating, a choking feeling, shortness of breath, chest pain (non-
cardiac), dizziness, numbness and tingling of the hands and feet.
Ͳ Panic attacks are abrupt surges of intense anxiety with prominent physical
symptoms. They may occur in anxiety, mood, psychotic and substance use
disorders and are a marker of increased severity.
» Psychological symptoms: panicky feelings, excessive worry, mood
changes, irritability, tearfulness, distress, and difficulty concentrating.
Ͳ Phobias are diagnosed when the anxiety is caused by a specific situation or
object. e.g.: social phobia is the fear of social interactions. Thoughts are of
negative evaluation by others and usually start in adolescence. Self-
medication with alcohol or other substances before and during a social event
is common: substance misuse may be the presenting feature.
Ͳ Obsessive thoughts and/or compulsive behaviours are a core feature of
Obsessive Compulsive Disorder but may also occur in other anxiety, mood,
developmental and psychotic disorders.
Ͳ In people with intellectual disability, anxiety may present with aggression,
agitation and demanding behaviour.

2018 16.8
 CHAPTER 16 MENTAL HEALTH CONDITIONS

GENERAL MEASURES
» Assess severity of the condition.
» Maintain an empathic and concerned attitude.
» Educate the patient and family regarding the nature of the anxiety.
» Exclude underlying medical conditions and optimise treatment for comorbid
medical conditions (e.g. heart disease, hypertension, COPD, asthma, GORD,
inflammatory bowel disease, thyroid disease, epilepsy).
» Screen for and manage underlying or co-morbid substance use, e.g. nicotine,
alcohol, over the counter analgesics, benzodiazepines.
» Explore and address psychosocial stressors:
Ͳ Stress management/coping skills – refer to counselling services.
Ͳ Relationship and family issues – refer to counselling services. Refer to a
social worker if abuse is evident.
Ͳ Accommodation and vocational issues – refer to labour/social development.
» Assess social support and refer to a social worker if needed.
» Refer to local support groups and provide self-help literature.

MEDICINE TREATMENT
» Offer a choice of psychotherapy (if available) or medication.
» Review every 2–4 weeks for 3 months, then 3–6 monthly.
» If response only partial, may combine medication with psychotherapy (if available).
» If medication is effective, continue for at least 12 months to prevent relapse.
» Patients with severe conditions should be assessed by a doctor.
x Fluoxetine, oral.
o Initiate at 20 mg alternate days for 2 weeks.
o Increase to 20 mg daily after 2–4 weeks.
o Delay dosage increase if increased agitation/panicky LoE:Ivi
feelings occur.
OR
If fluoxetine is poorly tolerated:
ƒ Alternative SSRI e.g.:
x Citalopram, oral.
o Initiate at 10 mg daily for the 1st week.
o Then increase to 20 mg daily. LoE:Ivii

CAUTION
SSRIs (e.g. fluoxetine, citalopram) may cause agitation initially.
This typically resolves within 2-4 weeks. LoE:IIIviii
Ask about suicidal ideation in all patients, particularly adolescents and young
adults. (See Section 16.7: Suicide risk assessment).
If suicidal ideation present, refer before initiating SSRI.
Once started, monitor closely for clinical worsening, suicidality, or unusual
changes in behaviour. Advise families and caregivers of the need for close
observation and refer as required.
Note: Continue treatment for a minimum of 12 months. Consider stopping only if
patient has had no/minimal symptoms and has been able to carry out routine daily

2018 16.9
 CHAPTER 16 MENTAL HEALTH CONDITIONS

activities. Prolong treatment if:

» Previous episode/s of anxiety (extend treatment to at least 3 years).
» Any of: severe anxiety, suicidal attempt, sudden onset of symptoms, family
history of bipolar disorder (extend treatment to at least 3 years).
» If • 3 episodes of anxiety (advise lifelong treatment).
LoE:IIIix
For severe panic attacks:
ƒ Benzodiazepines, e.g.:
x Diazepam, oral. LoE:IIx
o 2.5–5 mg, immediately.
o Continue with 2.5–5 mg at night, for a maximum of 10 days for severe
anxious distress.
o Start definitive treatment with psychotherapy/SSRI. LoE:Ixi

CAUTION - BENZODIAZEPINES
» Associated with cognitive impairment – reversible with short-term use
and irreversible with long-term use.
» Elderly are at risk of over-sedation, falls and hip fractures.
» Dependence may occur after only a few weeks of treatment.
» Prescribe for as short a period of time as possible.
» Warn patient not to drive or operate machinery when used short-term.
» Long-term use is associated with irreversible cognitive decline.
» Avoid use in people at high risk of addiction: e.g. personality disorders
and those with previous or other substance misuse. LoE:IIIxii

REFERRAL
» High suicide risk.
» Any risk of harm to self or others.
» Comorbid severe mental or physical conditions.
» Poor response to treatment.
» Repeated panic attacks.
» Children and adolescents.

16.4 MOOD DISORDERS

DESCRIPTION
The person’s thoughts and behaviour are driven by their mood, which may be
depressed, sad, angry, happy, elated, manic or any of these in combination.
Mood disorders may be:
» Due to another medical condition, e.g. HIV, TB, anaemia of any cause,
malignancy, hypothyroidism, and chronic pain conditions.
» Comorbid with other medical conditions e.g. epilepsy, diabetes, and
cardiovascular disease.
» Due to substance use, e.g. alcohol, cannabis, benzodiazepine.
» Comorbid with substance use.

2018 16.10
 CHAPTER 16 MENTAL HEALTH CONDITIONS

16.4.1 DEPRESSIVE DISORDERS

F32.0-3/F32.8-9/F33.0-4/F33.8-9/F34.1 + (F10.0-F19.9/R45.0-8/Z65.0-5/Z65.8-9/Z81.0-4/
Z81.8)

DESCRIPTION
» Depressive disorders cause significant impairment in social and occupational
functioning, and may result in unemployment, poor self-care, neglect of
dependent children, and suicide.
» Depression impacts negatively on other medical conditions, with increased
pain, disability and poorer treatment outcomes.
» Depression is characterised by a low mood and/or a reduced capacity to enjoy
life. Depressive episodes may also occur as part of Bipolar Disorder, which
requires a different treatment strategy to the other depressive disorders.
» Depression is often not recognised by the sufferer or clinicians. It may be
regarded as a normal emotional state or it may be unacceptable to the sufferer
due to stigma. Thus, associated symptoms may be the presenting complaint
rather than the low mood. In general, insomnia and loss of energy are the
most common presenting complaints. In African cultures, somatic symptoms
(bodily aches and pains) may predominate. Symptoms may also be masked
in the interview setting. It is important to have a high degree of suspicion and
to elicit symptoms, degree of impaired function, and suicide risk with care.
Depression may present with:
» Mood symptoms: may manifest as depressed, sad, hopeless, discouraged,
feeling empty, having no feelings, irritability, increased anger or frustration,
bodily aches and pains
» Loss of interest or pleasure (anhedonia): ‘not caring any more’, boredom,
social withdrawal, apathy, reduced sexual interest or desire
» Neuro-vegetative symptoms: loss of appetite or an increase in appetite,
sometimes with food cravings; weight loss or gain if appetite changes are
severe; increased or decreased sleep (usually mid- or terminal-insomnia, i.e.
waking during the night or early hours of the morning); psychomotor agitation
(pacing, hand-wringing, rubbing of skin or clothing) or psychomotor retardation
(slowed thoughts, speech and/or movements); tiredness and fatigue – daily
living tasks, e.g. getting dressed, are exhausting
» Psychological symptoms: feelings of worthlessness, unrealistic negative
self-evaluation, self-blame and guilt – may be over minor failings or may be of
delusional proportions
» Cognitive symptoms: diminished ability to think, concentrate or make minor
decisions; may appear to be easily distracted; memory may be impaired (as
in pseudodementia); preoccupation with thoughts of death of loved ones,
others or self (from vague wishes to suicidal ideation or plans)
The presence of mood, psychological and cognitive symptoms help to
differentiate between depression and normal sadness following a loss, or the loss
of appetite and energy associated with a medical condition.

GENERAL MEASURES
» Assess severity of the condition.
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» Maintain an empathic and concerned attitude.

» Exclude underlying medical conditions and optimise treatment for comorbid
conditions (e.g. hypothyroidism, anaemia, HIV/AIDS, TB, cancers, diabetes).
» Screen for and manage underlying or co-morbid substance use, e.g. nicotine,
alcohol, over the counter analgesics, benzodiazepines.
» Explore and address psychosocial stressors:
 Stress management/coping skills – refer to counselling services.
 Relationship and family issues – refer to counselling services. Refer to a
social worker if abuse is evident.
 Accommodation and vocational issues; refer to labour/social development.
 Assess social support and refer to a social worker if financial difficulty.

MEDICINE TREATMENT
Offer choice of psychotherapy (if available) or medication.

x Fluoxetine, oral.
Adults

o Initiate at 20 mg alternate days for 2 weeks.

o Increase to 20 mg daily after 2–4 weeks.
o Delay dosage increase if increased agitation/panicky feelings occur.
o Reassess response after 4 weeks on daily fluoxetine. Symptoms may take
up to 2-4 weeks to resolve. If only a partial or no response after 8 weeks
of treatment refer to doctor.
o See note below for treatment duration.
OR LoE:Ixiii
If fluoxetine is poorly tolerated:
ƒ Alternative SSRI e.g.:
x Citalopram, oral.
o Initiate at 10 mg daily for the 1st week.
o Then increase to 20 mg daily. LoE:Ixiv

CAUTION
SSRIs (e.g. fluoxetine, citalopram) may cause agitation during the first 2–4 weeks.
Ask about suicidal ideation in all patients, particularly adolescents and young
adults. (See Section 16.7: Suicide risk assessment).
If suicidal ideation present, refer before initiating SSRI.
Once started, monitor closely for clinical worsening, suicidality, or unusual
changes in behaviour. Advise families and caregivers of the need for close
observation and refer as required.

If a sedating antidepressant is required:

ƒ Tricyclic antidepressants, e.g.: (Doctor initiated)
x Amitriptyline, oral, at bedtime.
o Initial dose: 25 mg per day.
o Increase by 25 mg per day at 3–5 day intervals.
o Maximum dose: 150 mg per day.

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 CHAPTER 16 MENTAL HEALTH CONDITIONS

CAUTION
» Tricyclic antidepressants can be fatal in overdose.
» Prescription requires a risk assessment of the patient and others in their
household, especially adolescents.
» Avoid tricyclic antidepressants in the elderly and patients with heart
disease, urinary retention, glaucoma and epilepsy.

Note:
Continue treatment for a minimum of 9 months. Consider stopping only if patient
has had no/minimal symptoms and has been able to carry out routine daily
activities. Prolong treatment if:
» Concomitant generalised anxiety disorder (extend treatment to at least 1 year).
» Previous episode/s of depression (extend treatment to at least 3 years).
» Any of: severe depression, suicidal attempt, sudden onset of symptoms,
family history of bipolar disorder (extend treatment to at least 3 years).
» If • 3 episodes of depression (advise lifelong treatment). LoE:IIIxv

CAUTION
» Do not prescribe antidepressants to a patient with bipolar disorder without
consultation, as antidepressants may precipitate a manic episode.
» Be careful of interactions between antidepressants and any other agents
that the patient might be taking (e.g. St John’s Wort or traditional African
medicine).

REFERRAL
» Suicidal ideation.
» Major depression with psychotic features.
» Bipolar disorder.
» Failure to respond to antidepressants.
» Pregnancy and lactation.
» Children and adolescents.

16.4.2 BIPOLAR DISORDER

F31.0-9 + (F10.0-F19.9/R45.0-8/Z65.0-5/Z65.8-9/Z81.0-4/ Z81.8)

DESCRIPTION
A lifelong illness which may have an episodic, variable course with the presenting
episode being manic, hypomanic, mixed or depressive (according to accepted
diagnostic criteria). An episode of mania is typically characterised by an elevated
mood where a patient may experience extreme happiness, lasting days to weeks,
which might also be associated with an underlying irritability. Such mood is associated
with increased energy/activity, talkativeness and a reduction in the need for sleep, and
features may be accompanied by grandiose and/or religious delusions.
The diagnosis of Bipolar Disorder should be confirmed by a specialist. It may present
with any mood state, e.g. with treatment resistant depression. The diagnosis requires
either a current or previous episode of mania (Bipolar I Disorder) or hypomania
2018 16.13
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(Bipolar II Disorder), but this history is not always clear, in which case a trial of
treatment may be indicated. In stable patients with good insight and support, PHC
may continue treatment and management of comorbid medical conditions.
Comorbid substance use is common. It may confuse the clinical presentation and
may cause poor adherence to medication. The ‘dual diagnosis’ of bipolar disorder
and an addiction requires referral to a specialist and ongoing monitoring after
discharge.

GENERAL MEASURES
Reassurance and support of the patient and family.

MEDICINE TREATMENT
For manic, agitated and acutely disturbed patients:
» Stop antidepressants if prescribed.
» Manage as for the aggressive or disruptive patient. See Section 16.1.2:
Aggressive disruptive behaviour in adults.

REFERRAL
All patients.

16.5 PSYCHOSIS
DESCRIPTION
The patient may experience perceptual disturbances, e.g. hallucinations that are
generally auditory, as well as disturbances of thought content, i.e. delusional
thought process. Patients generally have no insight into their symptoms and may
be resistant to intervention. The presentation may be acute (acute psychosis) or
chronic (schizophrenia).

16.5.1 ACUTE PSYCHOSIS

F23.0-3/F23.8-9 + (F10.0-F19.9/R45.0-8/Z65.0-5/Z65.8-9/Z81.0-4/ Z81.8)

DESCRIPTION
Acute psychosis is a clinical state characterised by recent onset of psychotic
symptoms such as: hallucinations, delusions, disorganised or illogical speech,
agitation or bizarre behaviour and extreme and labile emotional states.
These symptoms may be preceded by a period of deteriorating social,
occupational and academic functioning.

GENERAL MEASURES
» Ensure the safety of the patient and those caring for them.
» Minimise stress and stimulation (do not argue with psychotic thinking).
» Avoid confrontation or criticism, unless it is necessary to prevent harmful or
disruptive behaviour.

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 CHAPTER 16 MENTAL HEALTH CONDITIONS

MEDICINE TREATMENT
For agitated and acutely disturbed patients, manage as for the aggressive or
disruptive patient. See Section 16.1.2: Aggressive disruptive behaviour in adults.

REFERRAL
All patients.

16.5.2 CHRONIC PSYCHOSIS (SCHIZOPHRENIA)

F20.0-6/F20.8-9 + (F10.0-F19.9/R45.0-8/Z65.0-5/Z65.8-9/Z81.0-4/Z81.8)

DESCRIPTION
Schizophrenia is the most common chronic psychotic disorder and is
characterised by a loss of contact with reality. It is further characterised by:
» positive symptoms, delusions, hallucinations and thought process disorder
» negative symptoms, blunting of affect, social withdrawal
» mood symptoms such as depression may be present
Clinical features include:
» delusions: fixed, unshakeable false beliefs (not shared by society)
» hallucinations: perceptions without adequate corresponding external stimuli,
e.g. hearing voices
» disorganised thoughts and speech: e.g. derailment or incoherence
» grossly disorganised or catatonic behaviour
» negative symptoms: affective flattening, social withdrawal
» social and/or occupational dysfunction
The diagnosis of schizophrenia should be confirmed by a specialist. In stable
patients with good insight and support, primary care facilities may continue
treatment.

GENERAL MEASURES
» Supportive intervention includes:
 Family counselling and psycho-education for patient and family.
 Supportive group therapy for patients with schizophrenia.
» Rehabilitation may be enhanced by:
 Assertive community programs.
 Occupational therapy.
 Work assessment, and bridging programmes.
 Appropriate placement and supported employment.
» Assessment of risk to self and others and early signs of relapse should be
performed at every review.

MEDICINE TREATMENT
Schizophrenia where a less sedating agent is required:

x Haloperidol, oral. (Doctor prescribed)

Adults

o Initial dose: 1 mg daily, increasing to 5 mg daily.

o Once stabilised, administer as a single dose at bedtime.

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 CHAPTER 16 MENTAL HEALTH CONDITIONS

x Haloperidol, oral. (Doctor prescribed)

Elderly

o Initial dose: 0.5 mg twice daily.

o Increase dose more gradually until symptoms are controlled or until a
maximum of 5 mg daily, if tolerated, is reached.
o Once stabilised, administer as a single dose at bedtime.
See Section 16.8.2: Special considerations: Older patients (• 45 years).
If extrapyramidal side effects: switch to risperidone rather than adding an

x Risperidone, oral (Doctor prescribed).

anticholinergic medicine:

o Initial dose: 2 mg daily.

o Increase to 4 mg daily, if poor response after 4weeks.
Note: Anticholinergic medicines (e.g. orphenadrine) should not routinely be
added prophylactically to antipsychotics to prevent extrapyramidal side effects.

x Chlorpromazine, oral (Doctor initiated).

Patients already stabilised on chlorpromazine:

o Maintenance dose: 75–300 mg at night, but may be as high as 800 mg.

Only for health care workers with advanced psychiatric training:

x Flupenthixol decanoate, IM, 20–80 mg every 4 weeks.

Long-term depot therapy where adherence problem, or patient preference:

o Initial dose: 20 mg.

OR
Zuclopenthixol decanoate, IM, 200–600 mg every 4 weeks.
o Initial dose: 100 mg.
Note: Initially, patients should be stabilised on an oral antipsychotic agent before
changing to a depot preparation. Administer an initial test dose and observe the
patient for 1 week before administering higher doses. Reduce the oral
antipsychotic formulation, stopping once patient is stabilised on the long-term
depot therapy.

x Risperidone, oral 2 mg daily (Doctor prescribed).

For breakthrough episodes, consider short-term therapy of:

» Long-acting antipsychotics are particularly useful in patients unable to adhere

to their oral medication regimens but need to be accompanied by a track and
trace programme to be effective for adherence
» Long-term therapy should always be in consultation with a doctor or, if available,
with a psychiatrist. Patients should be re-assessed every 6 months.
For management of extra-pyramidal adverse drug reactions and acute
dystonic reactions: See Section 16.2.1: Extra-pyramidal side effects.

REFERRAL
» Poor social support.
» High suicidal risk or risk of harm to others.
» Children and adolescents.
» The elderly.
» Pregnant and lactating women.
2018 16.16
 CHAPTER 16 MENTAL HEALTH CONDITIONS

» No response or intolerance to medicine treatment.

» Concurrent medical or other psychiatric illness.
» Epilepsy with psychosis.
» Early sign of relapse.

16.6 PSYCHIATRIC PATIENTS - GENERAL MONITORING

AND CARE
DESCRIPTION
Nursing staff are required to monitor users with serious mental illness between
medical or psychiatric doctor visits.
Regular monitoring with documented nursing notes in the file should occur
monthly to 6-monthly depending on the severity of the illness and the risk of
relapse, aggression, absconding or poor adherence, with referral as required.
Monitoring includes:
» A mental state enquiry and examination.
» A brief psychosocial assessment.
» A risk assessment for harm to self or others with referral if deemed high risk
» Adherence support.
» In women: family planning and pregnancy counselling.
» General health: screen at baseline and annually - weight and BMI, blood
pressure (see Section 4.7: Hypertension), finger-prick blood glucose test for
diabetes (See Section: 9.2.2: Type 2 Diabetes mellitus, adults), HIV (See
chapter 11: HIV and AIDS) and tuberculosis (see Section 17.4: Pulmonary
tuberculosis (TB)).
» Lifestyle advice for obesity, smoking, alcohol, other substances and high- risk
sexual behaviour or victim of abuse.
LoE:IIIxvi
Recommendations for specific medicines include:
» Antipsychotic medicines e.g.: haloperidol, risperidone, flupenthixol
decanoate, zuclopenthixol deconate: If metabolic effects (weight gain/
hyperglycaemia) occur, refer to a dietician and encourage regular exercise.
If needed, manage lipids - See Section: 4.1: Prevention of ischaemic heart
disease and atherosclerosis. LoE:IIIxvii
» Valproic acid and carbamazepine: Avoid in women of childbearing potential.
– If alternate treatment cannot be recommended and these agents are

x Folic acid, oral, 5 mg daily; and ensure reliable contraception.

required, give:
LoE:IIIxviii
CAUTION
Children born to women taking valproic acid are at significant risk of birth
defects (10%) and persistent developmental disorders (40%).
Valproic acid is contra-indicated and should be avoided in pregnancy and
women of child-bearing potential. LoE:IIIxix

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 CHAPTER 16 MENTAL HEALTH CONDITIONS

16.7 SUICIDE RISK ASSESSMENT

R45.8

DESCRIPTION
Suicide is the act of deliberately killing oneself. Self-harm refers to intentionally
self-inflicting injury or poisoning, which may or may not have a fatal intent or
outcome. Suicide risk assessment is a process of estimating probability for a
person to commit suicide.
There are 5 important components when assessing suicide: ideation (thoughts),
intent, plan, access to lethal means, and history of past suicide attempts.
Key risk factors for suicide include previous suicide attempt, current suicidal plan or
ideation, and history of mental illness (most commonly major depressive disorder
and substance abuse), access to lethal means, history of childhood sexual/physical
abuse, family history of suicide and suicidality in males, adolescents, elderly
patients and lesbian, gay, bisexual, and transgender (LGBT) patients (See Section
16.8.3: Special considerations: Sexual health and sexuality).
WARNING
Suicide risk assessment tools and guidelines do not replace clinical judgment.

GENERAL MEASURES
Screen for self-harm/suicide risk if any of the following present:
» Extreme hopelessness and despair.
» Current thoughts/plan/act of self-harm/suicide.
» History of self-harm/suicide.
» Mental health condition: depression, mood disorder, substance use
disorders, psychoses, dementia.
» Chronic condition: chronic pain, disability.
» Extreme emotional distress.
» Key population groups (LGBT) and adolescents.
1. Reduce immediate risk
» Manage the patient who has attempted a medically serious act of
self-harm: see Section 21.3: Trauma and injuries.
» If medically stable, assess for imminent risk of self-harm/suicide:
imminent risk of suicide is likely in a patient who is extremely
agitated, violent, distressed or lacks communication with any the

 Current thoughts or plan of self-harm/suicide or

following:

 History of thoughts or plan of self-harm in the past month or

 Act of self-harm.
2. Manage underlying factors:
» Ensure optimal treatment and support of other conditions like chronic pain and
mental health conditions (depression, mood disorders, substance use
disorders, psychosis, dementia)
» Identify psychosocial stressors like bereavement, intimate partner violence,
bereavement, financial or relationship problems, bullying, divorce, separation.
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3. Monitoring and follow-up:

» For all cases of medically serious acts of self-harm/suicide or where there is

 Do not leave person alone. Place in a secure, supportive environment in

an imminent risk of self-harm/suicide:

 Remove access to means of self-harm/suicide (bleach, pesticides,

health facility while awaiting referral.

firearms, medications) known to be toxic in overdose including

paracetamol, amitriptyline, theophylline).
» Maintain regular contact if possible – suggested weekly contact for the first 2
months. Follow-up for as long as the risk of self-harm/suicide persists. At every
contact, re-assess for suicidal thoughts and plans.

 If one has thoughts of self-harm/suicide, seek help from a trusted family

» Educate patient/carer:

 Talking about suicide does not trigger the act of suicide, and may lower
member, friend or health worker.

the risk of following through on suicidal plans.

» Refer to mental health services, if available or community resources like
religious centres, crisis centres or support groups.
» Try to locate family/friends to care for and support patient during this phase.
Encourage carers to find support for themselves as well.

REFERRAL
» All patients who have attempted a medically serious act of self-harm/suicide.
» All patients where there is an imminent risk of self-harm/suicide.
» All patients with a high index of suspicion.

16.8 SPECIAL CONSIDERATIONS

16.8.1 INTELLECTUAL DISABILITY
F70.0-9/ F71.0-9F72.-9/F73-9/F78.0-9/F79.0-9

» Difficulty with verbal communication in the patient may result in over diagnosis
of psychiatric conditions.
» More time is needed in the consultation and adequate history from family
members.
» High risk of being victims of sexual and physical violence, by the family,
neighbours or strangers.
» Emotional distress, fear, anxiety or depression may present as aggression or
odd behaviour.
» A supportive, caring, secure environment is essential for well-being and
contained behaviour.
» Manage together with social workers, occupational therapists, counsellors and
non-health departments e.g. social development and education.
» Lowest doses of medication should be used; consider anxiety, depression and
epilepsy before psychosis.
» Placement in a residential facility may be necessary. Requires referral to a social
worker and may require completion of a MHCA Form04 and two Form 05s
2018 16.19
 CHAPTER 16 MENTAL HEALTH CONDITIONS

depending on the mental health status of the user.

16.8.2 OLDER PATIENTS (• 45 years)

» New psychiatric diagnoses are rare in the older patient.
» Actively exclude medical causes, e.g. anaemia, pain, dementia, chronic
kidney disease, COPD, malignancy.
» Older patients are very sensitive to the side effects of psychiatric medications
and these are common presentations. Use lowest possible dose.
» Consult with family/carers: educate about the condition and provide support
by explaining how to manage behaviour at home.
» Refer family/carers to social worker/counsellor for further support.

16.8.3 SEXUAL HEALTH AND SEXUALITY

F52.0-9

Sexual problems may be more frequent amongst people with mental illness or
neuropsychiatric conditions:
» Low sex drive, anorgasmia (unable to achieve an orgasm), impotence may
occur as part of the mental illness, as a result of medication side effects (e.g.
fluoxetine), and/or substance use.
» Hyper-sexuality may occur in people with intellectual disability, in manic or
psychotic states, emotional dysregulation, substance use disorders
» Specific sexual disorders, e.g. vaginismus (spasm of vagina) or other sexual
dysfunction, require specialist treatment.
» Refer for assessment and appropriate treatment.
Mental illness is more common amongst people with alternative sexual
orientations or who are transgender.
» Stigma, discrimination and victimisation increase the prevalence of mental
illness amongst this group of people.
» Response to treatment will be poor if underlying issues are not expressed and
managed.
» Disclosure to a staff depends on a non-judgemental, accepting environment.
» Refer to counsellor/social worker.
» Counsel family members/caregivers.
» Refer to psychiatrist depending on clinical presentation/need.

16.8.4 MATERNAL MENTAL HEALTH

See Section 6.9: Maternal mental health.

16.9 SUBSTANCE MISUSE

16.9.1 SUBSTANCE USE DISORDERS
F10.0-F19.9 + (R45.0-8/Z65.0-5/Z65.8-9/Z81.0-4/Z81.8)

Consult National Policy guidelines on detoxification of psychoactive substances.

2018 16.20
 CHAPTER 16 MENTAL HEALTH CONDITIONS

DESCRIPTION
Substance use disorder is mental and physical symptoms caused by the use of
one or more substance despite significant substance-related problems (including
abuse and dependence). Substance-induced disorders include intoxication,
withdrawal and other substance/medication-induced mental disorder.
Alcohol withdrawal
See Section 16.9.4: Alcohol withdrawal (uncomplicated).
Methamphetamines (tik), cocaine (crack), methaqualone (mandrax), cannabis
These patients usually do not require hospitalisation.

GENERAL MEASURES
Reassurance and support of the patient and family.

MEDICINE TREATMENT
For severe anxiety, irritability and insomnia:
ƒ Benzodiazepine, e.g.:
x Diazepam, oral, 5–10 mg as a single dose or 12 hourly for 5–7 days.

x Diazepam, slow IV, 10 mg

For seizure control and /or sedation:

LoE:IIIxx
REFERRAL
» Severe alcohol dependence.
» Past history of withdrawal seizures or a history of epilepsy.
» Past history of Delirium Tremens.
» Younger (< 12 years of age) or older age (> 60 years of age).
» Pregnancy.
» Significant polydrug use.
» Cognitive impairment.
» Lack of support at home or homelessness.
» Previous failed community detoxification attempts.
» Opioid substance use disorder.

16.9.2 SUBSTANCE-INDUCED MOOD DISORDERS

F10.0-F19.9 + (R45.0-8/Z65.0-5/Z65.8-9/Z81.0-4/Z81.8)

DESCRIPTION
Mood disorder secondary to substance use or withdrawal such as abuse of
alcohol, drugs e.g. cannabis.

GENERAL MEASURES
» Generally treated by removal of the causative substance.
» Requires acute detoxification followed by maintenance treatment.
» If symptoms of mood disorder persist after 2 weeks, consider treating the
mood disorder. See Section 16.4: Mood disorders.

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 CHAPTER 16 MENTAL HEALTH CONDITIONS

16.9.3 SUBSTANCE-INDUCED PSYCHOSIS

F10.0-F19.9 + (R45.0-8/Z65.0-5/Z65.8-9/Z81.0-4/Z81.8)

DESCRIPTION
Psychosis secondary to a substance use or withdrawal such as abuse of alcohol,
drugs e.g. cannabis.

GENERAL MEASURES
» Most patients with substance-induced psychosis can be managed without
medication.
» Ensure the safety of the patient and those caring for them.
» Minimise stress and stimulation (do not argue with psychotic thinking).
» Avoid confrontation or criticism, unless it is necessary to prevent harmful or
disruptive behaviour.

MEDICINE TREATMENT
See section 16.1.2: Aggressive disruptive behaviour in adults.
Always use non-pharmacological de-escalation techniques first.
» Calm the patient.
» Manage in a safe environment.
» Ensure the safety of all staff members.
Offer oral treatment:
ƒ Benzodiazepines, e.g.: LoE:IIIxxi
x Diazepam, oral, 5 mg, immediately.
OR LoE:IIxxii
Midazolam, buccal, 7.5–15 mg, immediately.
If oral treatment fails after 30–60 minutes, LoE:IIIxxiii
OR
The patient is placing themselves and others at significant risk: LoE:IIIxxiv
Consider IM treatment:
ƒ Benzodiazepines, e.g.:
x Midazolam, IM, 7.5–15 mg, immediately.
o Repeat after 30–60 minutes if needed.
OR
Haloperidol, IM, 5 mg, immediately.
o Repeat after 30–60 minutes if needed.
AND
Promethazine, IM, 25–50 mg.
o In the elderly 25 mg.
Always monitor vital signs of sedated patient: LoE:IIIxxv
» Vital signs: pulse, respiratory rate, blood pressure, temperature.
» Monitor every 5–10 minutes for the 1st hour, and then every 30 minutes until
the patient is ambulatory.

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 CHAPTER 16 MENTAL HEALTH CONDITIONS

REFERRAL
All patients.

16.9.4 ALCOHOL WITHDRAWAL (UNCOMPLICATED)

F10.3

DESCRIPTION
A syndrome characterised by central nervous system hyperactivity that occurs
when an alcohol dependent individual abruptly stops or significantly reduces alcohol
consumption.
The symptoms of an uncomplicated Alcohol Withdrawal Syndrome include:
» Autonomic (sweating, tachycardia, hypertension, tremors, tonic-clonic
seizures and low grade fever).
» Gastrointestinal (anorexia, nausea, vomiting, dyspepsia and diarrhoea).
» Cognitive and perceptual disturbances (poor concentration, anxiety,
psychomotor agitation, disturbed sleep with vivid dreams, visual hallucinations
and disorientation).
Typical delirium occurs 2–3 days following cessation of prolonged alcohol intake, but
some withdrawal symptoms such as the typical tremor, may start within 12 hours.

GENERAL MEASURES
Assess for comorbid infections.

x Thiamine, oral, 300 mg daily for 14 days.

MEDICINE TREATMENT

x Diazepam, oral, 10 mg immediately.

AND LoE:IIIxxvi

o Then 5 mg 6 hourly for 3 days.

o Then 5 mg 12 hourly for 2 days.
o Then 5 mg daily for 2 days.
o Then stop.
LoE:IIIxxvii
REFERRAL
See referral criteria of Section 16.9.1: Substance use disorders.
References:
i Biperiden, IM/slow IV (children): National Department of Health, Essential Drugs Programme: Paediatric Hospital Level STGs
and EML, 2017. http://www.health.gov.za/
Biperiden, IM/slow IV (children): South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.
University of Cape Town. 2016.
ii Promethazine, IM (children): National Department of Health, Essential Drugs Programme: Paediatric Hospital Level STGs and

EML, 2017. http://www.health.gov.za/

Promethazine, IM (children): South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of
Cape Town. 2016.
iii Biperiden, IM: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of Cape Town. 2016.
iv Orphenadrine, oral (adults): South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of

Cape Town. 2016.

v Neuroleptic malignant syndrome associated with medicines: American Psychiatric Association DSM-5 Task Force. (2013).

Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). Washington, D.C.: American Psychiatric Association.
vi Fluoxetine, oral (anxiety): SSRIs (Therapeutic class): National Department of Health: Affordable Medicines, EDP- PHC and

Adult Hospital level. Medicine Review: SSRIs, therapeutic class for anxiety and depression, October 2017.
http://www.health.gov.za/
Fluoxetine, oral (anxiety): Baldwin D, Woods R, Lawson R, Taylor D. Efficacy of drug treatments for generalised anxiety
disorder: systematic review and meta-analysis. BMJ. 2011;342:d1199. https://www.ncbi.nlm.nih.gov/pubmed/21398351

2018 16.23
 CHAPTER 16 MENTAL HEALTH CONDITIONS
Fluoxetine, oral (anxiety): South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of
Cape Town. 2016.
vii SSRIs, oral (anxiety): SSRIs (Therapeutic class): National Department of Health: Affordable Medicines, EDP- PHC and Adult

Hospital level. Medicine Review: SSRIs, therapeutic class for anxiety and depression, October 2017. http://www.health.gov.za/
SSRIs, oral (anxiety): Bandelow B, Reitt M, Rover C, Michaelis S, Gorlich Y, Wedekind D. Efficacy of treatments for anxiety
disorders: a meta-analysis. Int Clin Psychopharmacol. 2015;30(4):183-92. https://www.ncbi.nlm.nih.gov/pubmed/25932596
SSRIs, oral (anxiety): Mayo-Wilson E, Dias S, Mavranezouli I, Kew K, Clark DM, Ades AE, et al. Psychological and
pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis. Lancet
Psychiatry. 2014;1(5):368-76. https://www.ncbi.nlm.nih.gov/pubmed/26361000
SSRIs, oral (anxiety): Stahl SM, Gergel I, Li D. Escitalopram in the treatment of panic disorder: a randomized, double-blind,
placebo-controlled trial. J Clin Psychiatry. 2003 Nov;64(11):1322-7. https://www.ncbi.nlm.nih.gov/pubmed/14658946
SSRIs, oral (anxiety): Thorlund K, Druyts E, Wu P, Balijepalli C, Keohane D, Mills E. Comparative efficacy and safety of
selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors in older adults: a network meta-analysis. J
Am Geriatr Soc. 2015;63(5):1002-9. https://www.ncbi.nlm.nih.gov/pubmed/25945410
viii SSRIs, oral (resolution of agitation – anxiety disorders): South African Medicines Formulary. 12th Edition. Division of Clinical

Pharmacology. University of Cape Town. 2016.

ix SSRIs, oral (duration of therapy – anxiety disorders): Rickels K, Etemad B, Khalid-Khan S, Lohoff FW, Rynn MA, Gallop RJ.

Time to relapse after 6 and 12 months' treatment of generalized anxiety disorder with venlafaxine extended release. Arch Gen
Psychiatry. 2010 Dec;67(12):1274-81. https://www.ncbi.nlm.nih.gov/pubmed/21135327
SSRIs, oral (duration of therapy – anxiety disorders): World Health Organisation. mhGAP intervention guide for mental,
neurological and substance use disorders in non-specialized health settings: mental health Gap Action Programme (mhGAP),
version 2.0. Geneva, 2016
http://www.who.int/mental_health/mhgap/mhGAP_intervention_guide_02/en/
x Benzodiazepines, oral (anxiety): Bighelli I, Trespidi C, Castellazzi M, Cipriani A, Furukawa TA, Girlanda F, et al.

Antidepressants and benzodiazepines for panic disorder in adults. Cochrane Database Syst Rev. 2016;9:CD011567.
https://www.ncbi.nlm.nih.gov/pubmed/27618521
Benzodiazepines, oral (anxiety): South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.
University of Cape Town. 2016.
xi SSRI/psychotherapy (anxiety): Furukawa TA, Watanabe N, Churchill R. Combined psychotherapy plus antidepressants for

panic disorder with or without agoraphobia. Cochrane Database Syst Rev. 2007(1):CD004364.
https://www.ncbi.nlm.nih.gov/pubmed/17253502
SSRI/psychotherapy (anxiety): Cuijpers P, Cristea IA, Karyotaki E, Reijnders M, Huibers MJ. How effective are cognitive
behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence. World Psychiatry.
2016;15(3):245-58. https://www.ncbi.nlm.nih.gov/pubmed/27717254
SSRI/psychotherapy (anxiety): Bandelow B, Reitt M, Rover C, Michaelis S, Gorlich Y, Wedekind D. Efficacy of treatments for
anxiety disorders: a meta-analysis. IntClinPsychopharmacol. 2015;30(4):183-92. https://www.ncbi.nlm.nih.gov/pubmed/25932596
xii Benzodiazepines (caution): NICE. Generalised anxiety disorder and panicdisorder in adults: management, 26 January 2011.

http://nice.org.uk/guidance/cg113
Benzodiazepines (caution): South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of
Cape Town. 2016.
Benzodiazepines, oral (caution): Picton JD, Marino AB, Nealy KL. Benzodiazepine use and cognitive decline in the elderly. Am
J Health Syst Pharm. 2018 Jan 1;75(1):e6-e12. https://www.ncbi.nlm.nih.gov/pubmed/29273607
Benzodiazepines, oral (caution): Brandt J, Leong C. Benzodiazepines and Z-Drugs: An Updated Review of Major Adverse
Outcomes Reported on in Epidemiologic Research. Drugs R D. 2017 Dec;17(4):493-507.
https://www.ncbi.nlm.nih.gov/pubmed/28865038
Benzodiazepines (caution – long-term use): Picton JD, Marino AB, Nealy KL. Benzodiazepine use and cognitive decline in
the elderly. Am J Health Syst Pharm. 2018 Jan 1;75(1): e6-e12. https://www.ncbi.nlm.nih.gov/pubmed/29273607
Benzodiazepines (caution – long-term use): Brandt J, Leong C. Benzodiazepines and Z-Drugs: An Updated Review of Major
Adverse Outcomes Reported on in Epidemiologic Research. Drugs R D. 2017 Dec;17(4):493-507.
https://www.ncbi.nlm.nih.gov/pubmed/28865038
xiii Fluoxetine, oral (depression): National Department of Health: Affordable Medicines, EDP-PHC and Adult Hospital level.

Medicine Review: SSRIs, therapeutic class for anxiety and depression, October 2017. http://www.health.gov.za/
Fluoxetine, oral (depression): Magni LR, Purgato M, Gastaldon C, Papola D, Furukawa TA, Cipriani A, Barbui C. Fluoxetine
versus other types of pharmacotherapy for depression. Cochrane Database Syst Rev. 2013 Jul 17;(7):CD004185.
https://www.ncbi.nlm.nih.gov/pubmed/24353997
Fluoxetine, oral (depression): South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University
of Cape Town. 2016.
xiv SSRIs, oral (depression): SSRIs (Therapeutic class): National Department of Health: Affordable Medicines, EDP-PHC and

Adult Hospital level. Medicine Review: SSRIs, therapeutic class for anxiety and depression, October 2017.
http://www.health.gov.za/
SSRIs, oral (depression): Cipriani A, Furukawa TA, Salanti G, Chaimani A, Atkinson LZ, Ogawa Y, Leucht S, Ruhe HG, Turner
EH, Higgins JPT, Egger M, Takeshima N, Hayasaka Y, Imai H, Shinohara K, Tajika A, Ioannidis JPA, Geddes JR. Comparative
efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic
review and network meta-analysis. Lancet. 2018 Apr 7;391(10128):1357-1366. https://www.ncbi.nlm.nih.gov/pubmed/29477251
SSRIs, oral (depression): Magni LR, Purgato M, Gastaldon C, Papola D, Furukawa TA, Cipriani A, Barbui C.
Fluoxetine versus other types of pharmacotherapy for depression. Cochrane Database Syst Rev. 2013 Jul 17;(7):CD004185.
https://www.ncbi.nlm.nih.gov/pubmed/24353997
SSRIs, oral (depression): Thorlund K, Druyts E, Wu P, Balijepalli C, Keohane D, Mills E. Comparative efficacy and safety of
selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors in older adults: a network meta-analysis. J
Am Geriatr Soc. 2015;63(5):1002-9. https://www.ncbi.nlm.nih.gov/pubmed/25945410
xv SSRIs, oral (duration of therapy – depression): Bauer M, Severus E, Köhler S, Whybrow PC, Angst J, Möller HJ; Wfsbp

2018 16.24
 CHAPTER 16 MENTAL HEALTH CONDITIONS
Task Force on Treatment Guidelines for Unipolar Depressive Disorders. World Federation of Societies of Biological Psychiatry
(WFSBP) guidelines for biological treatment of unipolar depressive disorders. part 2: maintenance treatment of major depressive
disorder-update 2015. World J Biol Psychiatry. 2015 Feb;16(2):76-95. https://www.ncbi.nlm.nih.gov/pubmed/25677972
SSRIs, oral (duration of therapy – depression): World Health Organisation. mhGAP intervention guide for mental, neurological
and substance use disorders in non-specialized health settings: mental health Gap Action Programme (mhGAP), version 2.0.
Geneva, 2016
http://www.who.int/mental_health/mhgap/mhGAP_intervention_guide_02/en/
SSRIs, oral (duration of therapy – depression): Geddes JR, Carney SM, Davies C, Furukawa TA, Kupfer DJ, Frank E, Goodwin
GM. Relapse prevention with antidepressant drug treatment in depressive disorders: a systematic review. Lancet. 2003 Feb
22;361(9358):653-61. https://www.ncbi.nlm.nih.gov/pubmed/12606176
SSRIs, oral (duration of therapy – depression): El-Mallakh RS, Briscoe B. Studies of long-term use of antidepressants: how
should the data from them be interpreted? CNS Drugs. 2012 Feb 1;26(2):97-109. https://www.ncbi.nlm.nih.gov/pubmed/22296314
xvi Physical health care monitoring (mental illnesses): Tosh G, Clifton AV, Xia J, White MM. Physical health care monitoring for

people with serious mental illness. Cochrane Database Syst Rev. 2014 Jan 17;(1):CD008298.
https://www.ncbi.nlm.nih.gov/pubmed/24442580
xvii Folic acid, oral: Royal College of Obstetricians & Gynaecologists. Green-top Guideline No. 68: Epilepsy in pregnancy, June

2016. https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg68/
xviii Antipsychotics - monitoring: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of

Cape Town. 2016.

xix Valproic acid – caution in pregnancy: European Medicines Agency - Pharmacovigilance Risk Assessment Committee.

Assessment report EMA/198940/2018 - valproate exposure in pregnancy, 8 February 2018.

http://www.ema.europa.eu/docs/en_GB/document_library/Referrals_document/Valproate_2017_31/Position_provided_by_CMDh/
WC500250221.pdf
Valproic acid – caution in pregnancy: Meador K, Reynolds MW, Crean S, Fahrbach K, Probst C. Pregnancy outcomes in
women with epilepsy: a systematic review and meta-analysis of published pregnancy registries and cohorts. Epilepsy Res. 2008
Sep;81(1):1-13. https://www.ncbi.nlm.nih.gov/pubmed/18565732
xx Diazepam: National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML, 2015.

http://www.health.gov.za/
Diazepam: National Department of Health. National Policy guidelines on detoxification of psychoactive substances.
http://www.health.gov.za/
xxiBenzodiazepines, oral: Leucht S, Heres S, Kissling W, Davis JM. Evidence-based pharmacotherapy of schizophrenia.Int J

Neuropsychopharmacol. 2011 Mar;14(2):269-84. http://www.ncbi.nlm.nih.gov/pubmed/21208500

xxiiBenzodiazepines: Gillies D, Sampson S, Beck A, Rathbone J. Benzodiazepines for psychosis-induced aggression or agitation.

Cochrane Database Syst Rev. 2013 Apr 30;4:CD003079. http://www.ncbi.nlm.nih.gov/pubmed/23633309

Benzodiazepines: TREC Collaborative Group. Rapid tranquillisation for agitated patients in emergency psychiatric rooms: a
randomised trial of midazolam versus haloperidol plus promethazine. BMJ. 2003 Sep 27;327(7417):708-13.
http://www.ncbi.nlm.nih.gov/pubmed/14512476
Benzodiazepines: Alexander J, Tharyan P, Adams C, John T, Mol C, Philip J. Rapid tranquillisation of violent or agitated
patients in a psychiatric emergencysetting. Pragmatic randomised trial of intramuscular lorazepam v. haloperidol plus
promethazine. Br J Psychiatry. 2004 Jul;185:63-9.http://www.ncbi.nlm.nih.gov/pubmed/15231557
xxiiiMidazolam, buccal: Taylor D, Okocha C, Paton C, Smith S, Connolly A. Buccal midazolam for agitation on psychiatric intensive

care wards.IntJ Psychiatry ClinPract.2008;12(4):309-11. http://www.ncbi.nlm.nih.gov/pubmed/24937720

xxivSedation algorithm (stepwise approach): NICE. The short-term management of disturbed/violent behaviour in in-patient

psychiatric settings and emergency departments, NICE clinical guideline 25, February 2005. Available at: www.nice.org.uk/cg25
Sedation algorithm (stepwise approach): Wilson MP, Pepper D, Currier GW, Holloman GH Jr, Feifel D. The
psychopharmacology of agitation: consensus statement of the American association for emergency psychiatry project Beta
psychopharmacology workgroup. West J Emerg Med. 2012 Feb;13(1):26-34. http://www.ncbi.nlm.nih.gov/pubmed/22461918
xxvPromethazine, IM: National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML, 2015.

http://www.health.gov.za/
Promethazine, IM: Huf G, Coutinho ES, Adams CE; TREC Collaborative Group. Rapid tranquillisation in psychiatric emergency
settings in Brazil: pragmatic randomised controlled trial of intramuscular haloperidol versus intramuscular haloperidol plus
promethazine. BMJ. 2007 Oct 27;335(7625):869. http://www.ncbi.nlm.nih.gov/pubmed/17954515
xxviThiamine: Day E, Bentham PW, Callaghan R, Kuruvilla T, George S. Thiamine for prevention and treatment of Wernicke-

Korsakoff Syndrome in people who abuse alcohol. Cochrane Database Syst Rev. 2013 Jul 1;7:CD004033.
http://www.ncbi.nlm.nih.gov/pubmed/23818100
Thiamine: Lingford-Hughes AR, Welch S, Peters L, Nutt DJ; British Association for Psychopharmacology, Expert Reviewers
Group. BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful
use, addiction and comorbidity: recommendations from BAP. J Psychopharmacol. 2012 Jul;26(7):899-
952.http://www.ncbi.nlm.nih.gov/pubmed/22628390
Thiamine: Ambrose ML, Bowden SC, Wehan G. Thiamine treatment and working memory function of alcohol dependent
people: preliminary findings. AlcoholClinExpRes 2001; 25: 112–16.http://www.ncbi.nlm.nih.gov/pubmed/11198705
Thiamine: Cook CC. Prevention and treatment of Wernicke-Korsakoff Syndrome. Alcohol AlcoholSuppl 2000; 35: 19–20.
http://www.ncbi.nlm.nih.gov/pubmed/11304070
Thiamine: Thomson AD, Cook CCH, Touquet R, Henry JA. The Royal College of Physicians report on alcohol: guidelines for
managing Wernicke’s encephalopathy in the accident and emergency department. Alcohol AlcoholSuppl 2002; 37: 513–21.
http://www.ncbi.nlm.nih.gov/pubmed/12414541
Thiamne: Cook CCH, Hallwood PM, Thomson AD. B-vitamin deficiency and neuro-psychiatric syndromes in alcohol misuse.
Alcohol AlcoholSuppl 1998; 33: 317–36.http://www.ncbi.nlm.nih.gov/pubmed/9719389
Sechi G, Serra A. Wernicke's encephalopathy: new clinical settings and recent advances in diagnosis and management. Lancet
Neurol. 2007 May;6(5):442-55. Review.http://www.ncbi.nlm.nih.gov/pubmed/17434099
xxviiDiazepam: National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML, 2015.

http://www.health.gov.za/
2018 16.25
PHC Chapter 17: Respiratory
conditions
17.1 Conditions with predominant wheeze
17.1.1 Acute asthma and acute exacerbation of
chronic obstructive pulmonary disease (COPD)
17.1.2 Chronic asthma
17.1.3 Acute bronchiolitis in children
17.1.4 Chronic obstructive pulmonary disease (COPD)
17.2 Stridor (upper airway obstruction)
17.2.1 Croup (laryngotracheo bronchitis) in children
17.3 Respiratory infections
17.3.1 Influenza
17.3.2 Acute bronchitis in adults or adolescents
17.3.3 Acute exacerbation of chronic obstructive
pulmonary disease (COPD)
17.3.4 Pneumonia
17.3.4.1 Pneumonia in children
17.3.4.2 Pneumonia in adults
17.3.4.2.1 Uncomplicated pneumonia
17.3.4.2.2 Pneumonia in adults with
underlying medical conditions
or > 65 years of age
17.3.4.2.3 Severe pneumonia
17.3.4.2.4 Pneumocystis pneumonia
17.4 Pulmonary tuberculosis (TB)
17.4.1 Pulmonary tuberculosis (TB), in adults
17.4.1.1 TB chemoprophylaxis/isoniazid
preventive therapy (IPT), in adults
17.4.1.2 TB control programme: medicine
regimens in adults
17.4.2 Pulmonary tuberculosis, in children
 CHAPTER 17 RESPIRATORY CONDITIONS

17.4.2.1 TB chemoprophylaxis/isoniazid
preventive therapy (IPT), in children
17.4.2.2 TB control programme: medicine
regimens, in children
17.4.3 TB, HIV and AIDS
17.4.4 Multidrug-resistant tuberculosis (MDR TB)
17.4.4.1 Multidrug-resistant tuberculosis (MDR
TB), in adults
17.4.4.2 Multidrug-resistant tuberculosis (MDR
TB) in children

2018 17.2
 CHAPTER 17 RESPIRATORY CONDITIONS

17.1 CONDITIONS WITH PREDOMINANT WHEEZE

17.1.1 ACUTE ASTHMA & ACUTE EXACERBATION OF COPD
J46/J45.0-1/J45.8/J45.9

DESCRIPTION
This is an emergency situation recognised by various combinations of:
» wheeze » breathlessness
» tightness of the chest » respiratory distress
» chest indrawing in children » cough
» use of accessory muscles of respiration
In adults, bronchospasm is usually associated with asthma (where the bronchospasm
is usually completely reversible) or chronic obstructive pulmonary disease (COPD)
(where the bronchospasm is partially reversible).

The clinical picture of pulmonary oedema due to left ventricular heart failure may
be similar to that of asthma. If patients >50 years of age present with asthma for
the first time, consider pulmonary oedema due to left ventricular heart failure.

Bronchospasm in children is usually associated with asthma or with infections such

as bronchiolitis or bronchopneumonia. Consider foreign bodies or obstruction of
airways due to tuberculous nodes or congenital malformation, especially if the
wheeze is unilateral.

All PHC facilities must have peak expiratory flow rate (PEFR) meters, as asthma
cannot be correctly managed without measuring PEFR.

Recognition and assessment of severity of attacks in children

Moderate Severe
Respiratory rate >40 breaths/minute >40 breaths/minute
Chest indrawing/recession present present
PEF (if > 5 years of age) 50–70% of predicted <50% of predicted
Speech normal or difficult unable to speak
Feeding difficulty with feeding unable to feed
Wheeze present absent
Consciousness normal impaired
Recognition and assessment of severity of attacks in adults
Moderate Severe
Talks in phrases words
Alertness usually agitated agitated, drowsy or confused
Respiratory rate 20–30 breaths/minute often >30 breaths/minute
Wheeze loud loud or absent
Heart rate 100–120 beats/minute >120 beats/minute
PEFR after initial ±50–75% <50%; may be too short of
nebulisation breath to blow in PEF meter

2018 17.3
 CHAPTER 17 RESPIRATORY CONDITIONS

Note: PEFR is expressed as a percentage of the predicted normal value for the
individual, or of the patient's personal best value obtained previously when on optimal
treatment.

MEDICINE TREATMENT

x Salbutamol, inhalation using a metered-dose inhaler (MDI), 400–800 mcg (4–8

Adults with mild and moderate attacks

puffs), using a spacer.

o Inhale one puff at a time. Allow for 4 breaths through the spacer between puffs.
o If no relief, repeat every 20–30 minutes in the first hour.
o Thereafter, repeat every 2–4 hours if needed.
Note: Administering salbutamol via a spacer is as effective as, and cheaper than,
using a nebuliser. LoE:IIi
OR
Salbutamol 0.5%, solution, nebulised, preferably delivered at a flow rate of 8 L/min
with oxygen.
o 1 mL (5 mg) salbutamol 0.5% solution, in 4 mL of sodium chloride 0.9%.
o If no relief, repeat every 20–30 minutes in the first hour.
o Thereafter, repeat every 2–4 hours if needed.
LoE:IIIii

x Prednisone, oral, 40 mg immediately if patient known to have asthma/COPD.

AND

o Follow with prednisone, oral, 40 mg daily for 7 days.

x Oxygen, 40% or higher, using highest concentration facemask.

Adults with severe attacks (while awaiting referral)

Note: In COPD:
Give oxygen with care (preferably by 24% or 28% facemask, if available).
Observe patients closely, as a small number of patients’ condition may
deteriorate.

x Salbutamol 0.5%, solution, nebulised, preferably delivered at a flow rate of 8 L/min

AND

with oxygen.
o 1 mL (5 mg) salbutamol 0.5% solution, in 4 mL of sodium chloride 0.9%.
o If no relief, repeat every 20–30 minutes until PEF > 60% of predicted.
o Once PEF > 60% of predicted, repeat every 2–4 hours if needed.
OR LoE:IIIiii
Salbutamol, inhalation using a MDI, 400–800 mcg (4–8 puffs),
up to 20 puffs, using a spacer.
o Inhale 1 puff at a time. Allow for 4 breaths through the spacer between puffs.
o If no relief, repeat every 20–30 minutes until PEF > 60% of predicted.
o Once PEF > 60% of predicted, repeat every 2–4 hours if needed.
LoE:IIIiv

x Prednisone, oral, 40 mg immediately.

AND

o Follow with prednisone, oral, 40 mg daily for 7 days.

2018 17.4
 CHAPTER 17 RESPIRATORY CONDITIONS

OR

x Hydrocortisone IM/slow IV, 100 mg as a single dose.

If oral prednisone cannot be taken:

x Prednisone, oral, 40 mg daily for 7 days.

Follow with:

ADD

x Ipratropium bromide solution, 0.5 mg nebulised, 2 mL (0.5 mg) added to salbutamol

If poor response after first salbutamol nebulisation/inhalation:

solution every 20–30 minutes for 3 doses depending on clinical response.

OR LoE:IIIv
Ipratropium bromide, inhalation using MDI, 80–160 mcg (2–4
puffs), using a spacer every 20–30 minutes as needed for up to 3 hours.
LoE:IIIvi

x Salbutamol, inhalation, using a MDI, 200–400 mcg (2–4 puffs), using a spacer.
Children with mild and moderate attacks

o Inhale 1 puff at a time. Allow for 6 breaths through the spacer between puffs.
o If child < 3 years of age, use a mask attached to the spacer. Apply the mask
to the face to create a seal so that the child breathes through the spacer.
o If no relief, repeat every 20–30 minutes in the first hour.
o Thereafter, repeat every 2–4 hours if needed.
Note: Administering salbutamol via a spacer is as effective as, LoE:IIvii
and cheaper than, using a nebuliser.
OR
Salbutamol 0.5%, solution, nebulised, preferably delivered at a flow rate of 5 L/min
with oxygen.
o 0.5–1 mL (2.5–5 mg) salbutamol 0.5% solution, in 4 mL of sodium chloride
0.9%.
o If no relief, repeat every 20–30 minutes in the first hour.
o Thereafter, repeat every 2–4 hours if needed.
LoE:IIIviii
If reversal of bronchospasm is incomplete after the first
nebulisation/inhalation:

x Prednisone oral, 1–2 mg/kg immediately and follow with same dose for 7 days:
ADD

Weight Dose Tablet Age

kg mg 5 mg months/years
>11–14 kg 20 mg 4 tablets >2–3 years
>14–17.5 kg 30 mg 6 tablets >3–5 years
>17.5 kg 40 mg 8 tablets >5 years and adult

x Oxygen, 100%, at least 4-6 L/minute by facemask or 1-2 L/minute by nasal

Children with severe attacks (while awaiting referral)

cannula.

x Salbutamol 0.5%, solution, nebulised, preferably delivered at a flow rate of 5 L/min

AND

with oxygen.

2018 17.5
 CHAPTER 17 RESPIRATORY CONDITIONS

o 0.5–1 mL (2.5–5 mg) salbutamol 0.5% solution, in 4 mL of sodium chloride 0.9%.

o If no relief, repeat every 20–30 minutes depending on clinical response.
OR LoE:IIIix
Salbutamol, inhalation using a metered-dose inhaler (MDI),
400–600 mcg (4–6 puffs) up to 10 puffs, using a spacer.
o Inhale 1 puff at a time. Allow for 6 breaths through the spacer between
puffs.
o If child < 3 years of age, use a mask attached to the spacer. Apply the mask to
the face to create a seal so that the child breathes through the spacer.
o If no relief, repeat every 20–30 minutes depending on clinical response.
Note: Administering salbutamol via a spacer is as effective as LoE:IIIx
and cheaper than using a nebuliser.

x Ipratropium bromide, 0.25 mg solution, nebulised with salbutamol and sodium

AND

chloride.
o 0.25 mg (2 mL) every 20–30 minutes depending on clinical response for 4
o doses over 2 hours. LoE:IIIxi

x Prednisone oral, 1–2 mg/kg immediately and follow with same dose for 7 days:
AND

Weight Dose Tablet Age

kg mg 5 mg months/years
>11–14 kg 20 mg 4 tablets >2–3 years
>14–17.5 kg 30 mg 6 tablets >3–5 years
>17.5 kg 40 mg 8 tablets >5 years and adult

x Hydrocortisone IM/slow IV, 4–6 mg/kg immediately. See dosing table, pg 23.5.
OR if oral prednisone cannot be taken:

CAUTION
Avoid sedation of any kind.
Note: If poor response to treatment, consider alternate diagnosis and refer urgently.
Assessment of response in children
Response No response
PEFR (if possible) improvement by >20% improvement by <20%
Respiratory rate <40 breaths/ minute >40 breaths/ minute
Chest indrawing or recession absent present
Speech normal impaired
Feeding normal impaired
Assessment of response in adults
Response No response
PEFR (if possible) improvement by >20% improvement by <20%
Respiratory rate <20 breaths/ minute >20 breaths/ minute
Speech normal impaired

2018 17.6
 CHAPTER 17 RESPIRATORY CONDITIONS

Patients responding to treatment:

» Routine prescription of antibiotics is not indicated for acute asthma.
» Review current treatment and possible factors causing acute attack including poor
adherence and poor inhaler technique.
» Advise patient/caregiver on further care at home, danger signs and that follow up is
required.
» Caution patient on the high chance of further wheezing in the week following an
acute attack.
» Patients with a first attack should be fully assessed for maintenance treatment.
» Ask about smoking: if yes, urge patient to stop.
Note: Patients needing repeated courses of oral corticosteroids (more than twice
over 6 months) should be assessed by a doctor for maintenance therapy. (See
Section 17.1.2: Chronic asthma).

REFERRAL
Urgent (after commencing treatment):
» All patients with severe attack.
» Poor response to initial treatment.
» PEFR < 75% of the predicted normal or of personal best value 15–30 minutes
after nebulisation.

 seen in the afternoon or evening, rather than earlier in the day

» A lower threshold to admission is appropriate in patients when:

 recent onset of nocturnal symptoms or aggravation of symptoms

 previous severe attacks, especially if the onset was rapid

17.1.2 CHRONIC ASTHMA

J45.0-1/J45.8-9

DESCRIPTION
A chronic inflammatory disorder with reversible airways obstruction. In susceptible
patients, exposure to various environmental triggers, allergens or viral infections
results in inflammatory changes, bronchospasm, increased bronchial secretions,
mucus plug formation and, if not controlled, eventual bronchial muscle hypertrophy
of the airways’ smooth muscle. All these factors contribute to airways obstruction.
Asthma varies in intensity and is characterised by recurrent attacks of:
» wheezing,
» dyspnoea or shortness of breath,
» cough, especially nocturnal, and
» periods of no airways obstruction between attacks.
Acute attacks may be caused by:
» exposure to allergens,
» respiratory viral infections,
» non-specific irritating substances, and
» exercise.
Asthma must be distinguished from COPD, which is often mistaken for asthma. (See

2018 17.7
 CHAPTER 17 RESPIRATORY CONDITIONS

Section 17.1.4: COPD). The history is a reliable diagnostic guideline and may be of
value in assessing treatment response.
Asthma COPD
» Young age onset, usually < 20 years. » Older age onset, usually > 40 years.
» History of hay fever, eczema and/or » Symptoms slowly worsen over a
allergies. long period of time.
» Family history of asthma. » Long history of daily or frequent
» Symptoms are intermittent with periods cough before the onset of shortness
of normal breathing in between. of breath.
» Symptoms are usually worse at night » Symptoms are persistent rather than
or in the early hours of the morning, only at night or during the early
during an upper respiratory tract morning.
infection, when the weather changes, » History of heavy smoking (> 20
or when upset. cigarettes/day for •15 years), heavy
» Marked improvement with beta2 cannabis use, or previous TB.
agonist. » Little improvement with beta2 agonist.
Asthma cannot be cured, but it can be controlled with regular treatment.
If symptoms suggest TB (e.g. weight loss, night sweats, etc.), investigate and
manage accordingly.
Note: The diagnosis of asthma can be difficult in children < 6 years of age.
If the diagnosis of asthma is uncertain, refer the patient.

ASTHMA DIAGNOSIS AND SEVERITY

Peak Expiratory Flow Rate (PEFR)
See PEF charts on pg lxx.
The PEFR may provide additional information for diagnosis and assessing response to
therapy.

 Instruct the patient to blow forcibly into the device after a deep inspiratory effort.
» PEFR is best assessed in the morning and evening.

 The patient must perform three blows at each testing point.

 Take the highest value as the true value.

 An improvement of 60L/min or •20% of the pre-bronchodilator PEFR, 10–20

» The PEFR can be helpful in confirming a diagnosis of asthma in primary care.

minutes after inhalation of a beta2 agonist e.g. salbutamol, inhalation, 200

 A normal PEFR excludes the possibility of moderate and severe COPD.

mcg, confirms a diagnosis of asthma.

 Any value >80% of the personal best before the use of a bronchodilator is
» PEFR may be useful in assessing response to therapy.

regarded as adequate control. Ensure that pre-bronchodilator values are

measured at follow-up visits.
Note: Initiating and optimising inhalation corticosteroid therapy for moderate and
severe asthma should always be done with the use of a peak flow meter to assess
severity and treatment response of asthma.

2018 17.8
 CHAPTER 17 RESPIRATORY CONDITIONS

Place patient in a severity category based on frequency of daytime symptoms,

frequency of night-time symptoms, PEFR, and history of admission for asthma
exacerbation. Note that an admission in the 12 months’ prior means that the patient
requires treatment for persistent asthma, including inhaled corticosteroids.
Mild Mild persistent Moderate Severe
intermittent asthma persistent persistent
asthma asthma asthma
Daytime ”2 episodes of 2-4 episodes of >4 episodes continuous day
symptoms daytime cough day time of day time time wheeze,
and/or wheeze wheeze, wheeze, tightness or
per week tightness or tightness or cough
cough per week cough per
week
Night-time ”1 night-time 2–4 episodes of >4 episodes frequent night
symptoms cough and/or night time of night time time
wheeze per wheeze or wheeze or awakenings
month cough per cough per
month month
PEFR PEFR •80% PEFR •80% PEFR 60-80% PEFR < 60%
predicted predicted predicted predicted
between between attacks between
attacks attacks
Admissions no admission to - - -
for hospital for
exacerbation asthma within
last 12 months

GENERAL MEASURES
» No smoking by an asthmatic or in the living area of an asthmatic.
» Avoid contact with household pets.
» Avoid exposure to known allergens and stimulants or irritants.
» Education on early recognition and management of acute attacks.

 emphasise the diagnosis and explain the nature and natural course of the
» Patient and caregiver education:

 teach and monitor inhaler technique; and

condition;

 reassure parents and patients of the safety and efficacy of continuous regular
controller therapy.

MEDICINE TREATMENT
Medicine treatment is based on the severity of the asthma and consists of therapy to
prevent the inflammation leading to bronchospasm (controller) and to relieve
bronchospasm (reliever).
Reliever medicines in asthma:
ƒ Short acting Beta2 agonists (SABAs), e.g.:
x Salbutamol (short-acting)
o Indicated for the immediate relief of the symptoms of acute attacks, i.e. cough,

2018 17.9
 CHAPTER 17 RESPIRATORY CONDITIONS

wheeze and shortness of breath.

o Can be used as needed.
o Increasing need for reliever medicine indicates poor asthma control.
Controller medicines in asthma:
ƒ Inhaled corticosteroids, e.g.:
x Budesonide.
o Must be used twice daily every day, even when the patient feels well.
Note: Fluticasone and budesonide interacts with protease inhibitors. Refer all
patients on protease inhibitors requiring inhaled corticosteroids for further
management.
Inhalation therapy: LoE:IIIxii
Inhaled therapy is preferable to oral therapy.
Spacer devices
» Spacers are vital for an adequate therapeutic effect of inhaled therapy.
» Spacer devices should be used for all inhaled medications in all age groups to
improve efficacy of medicine delivery and limit adverse effects.
» Use the spacer appropriate for the age of the patient.
Spacer volume Face mask
Infants 150–250 mL mandatory
Children 500 mL highly recommended
Adolescents and adults 750 mL
» Inhalation spacer devices enable parents to administer inhaled therapy even to
small children.
» Children < 3 years of age should have a spacer with a face mask while older
children and adults can use the spacer with a mouth piece directly.
» Demonstrate steps 2–6 of the relevant inhaler technique more than once to
ensure the correct procedure (see below).
Patient and caregiver education on inhaler and spacer techniques:
» A mask attachment must be used with the spacer for children < 3 years of age.
Inhalation therapy without a spacer in adults:
1. remove the cap from the mouthpiece
2. shake the inhaler well
3. while standing or sitting upright, breathe out as much air as possible
4. place the mouth piece of the inhaler between the lips and gently close the lips
around it
5. while beginning to inhale, press down the canister of the metered dose inhaler once
to release one puff while breathing in as deeply as possible
6. hold breath for 5–10 seconds, if possible
7. breathe out slowly and rest for a few breaths (30–60 seconds)
8. repeat steps 2–6 for each puff prescribed
9. rinse mouth after inhalation of corticosteroids
Inhalation therapy with a spacer in adults and older children:
1. remove the caps from the inhaler and the spacer
2. shake the inhaler well

2018 17.10
 CHAPTER 17 RESPIRATORY CONDITIONS

3. insert the mouthpiece of the metered dose inhaler into the back of the spacer
4. insert the mouthpiece of the spacer into the mouth and close the lips around the
mouthpiece. Avoid covering any small exhalation holes
5. press down the canister of the metered dose inhaler once to release one puff into
the spacer
6. immediately take 3–4 slow deep breaths
7. repeat steps 4–6 for each puff prescribed, waiting at least 30 seconds between puffs
8. rinse mouth after inhalation of corticosteroids
Inhalation therapy with the spacer alone in younger children:
1. allow to breathe slowly in and out of the spacer continuously for 30 seconds
2. while still breathing, release one puff from the inhaler into the spacer
3. continue breathing for 3–4 breaths
4. if breathing through the nose as well as the mouth, pinch the nose gently while
breathing from the spacer
Inhalation therapy with a spacer and mask for infants and small children:
1. remove the caps from the inhaler and the spacer
2. shake the inhaler well
3. infants may be placed on the caregiver’s lap or laid on a bed while administering
the medication
4. apply the mask to the face, ensuring that the mouth and nose are well covered
5. with the mask held firmly onto the face, press down the canister of the metered
dose inhaler once to release one puff into the spacer
6. keep the mask in place for at least six breaths, then remove
7. repeat steps 4–6 for each puff prescribed, waiting at least 30 seconds between puffs

MILD INTERMITTENT ASTHMA

Adults and children
ƒ SABA, e.g.:
x Salbutamol, inhalation, 100–200 mcg (1–2 puffs), 6–8 hourly as needed (until
symptoms are controlled).

PERSISTENT ASTHMA
Children
ƒ Inhaled corticosteroids e.g.:
x Budesonide, inhalation, 100 mcg 12 hourly.
AND
ƒ Beta2 agonist e.g.:
x Salbutamol, inhalation, 100–200 mcg (1–2 puffs), 6–8 hourly as needed (until
symptoms are controlled)

Adults
ƒ Inhaled corticosteroids e.g.:
x Budesonide, inhalation, 200 mcg 12 hourly.
AND
ƒ SABA e.g.:
x Salbutamol, inhalation, 100–200 mcg (1–2 puffs), 6–8 hourly as needed (until

2018 17.11
 CHAPTER 17 RESPIRATORY CONDITIONS

symptoms are controlled).

Note: Fluticasone and budesonide interacts with protease inhibitors. Refer all
patients on protease inhibitors requiring inhaled corticosteroids for further
management.
Review treatment every 3 months. Adequate control is defined as: LoE:IIIxiii
» ” 2 episodes of daytime cough and/or wheeze per week.
» No night-time cough and/or wheeze.
» No recent (within the last year) admission to hospital for asthma.
» PEFR• 80% predicted between attacks.
If control is inadequate:
» check adherence and inhaler technique, and
» exclude on-going exposure to allergens.
After excluding those causes, refer to a doctor to confirm the diagnosis of asthma,
and to exclude TB and heart failure.
Once the diagnosis is confirmed, step-up treatment as follows:

Children
ƒ Inhaled corticosteroids, e.g.:
x Budesonide, inhalation, 200 mcg 12 hourly.
Adults
ƒ Inhaled corticosteroids, e.g.:
x Budesonide, inhalation, 400 mcg 12 hourly.
If control is still inadequate in adults, treat with combination of corticosteroid
and long-acting beta agonist (LABA)
Stop inhaled corticosteroid (e.g. budesonide) and replace with:
ƒ Inhaled long-acting beta agonist (LABA)/corticosteroid combination, e.g.:
x Salmeterol/fluticasone, inhalation, 50/250 mcg (1 puff) 12 hourly (Doctor initiated).
Note: Fluticasone and budesonide interacts with protease inhibitors. LoE:IIIxiv
Refer all patients on protease inhibitors requiring inhaled corticosteroids for further
management.
LoE:IIIxv
Stepping down treatment:
» Attempt a reduction in therapy if the patient has not had any acute exacerbation
of asthma in the preceding 6 months, and day-time and night-time symptoms are
well controlled.
» Gradually reduce the dose of inhaled corticosteroid therapy.
» If the symptoms are seasonal, corticosteroids may be stopped until the next season.
» If symptoms re-appear, increase the therapy to the level on which the patient was
previously controlled.

REFERRAL TO DOCTOR
» All children < 6 years of age for assessment and confirmation of diagnosis.
» Any patient who has received > 2 courses of oral prednisone within 6 months.
» Brittle asthma (very sudden, very severe attacks).

2018 17.12
 CHAPTER 17 RESPIRATORY CONDITIONS

» All patients within adequate control of their symptoms.

» Patients on protease inhibitors, requiring inhaled corticosteroids.

REFERRAL TO HOSPITAL
Uncontrolled asthma.
Note: In patients with new onset of exercise-related symptoms, consider other
diagnoses, particularly if no response to pre-treatment with SABA.

17.1.3 ACUTE BRONCHIOLITIS IN CHILDREN

J21.0-1/J21.8-9

DESCRIPTION
Acute bronchiolitis is a common cause of wheezing and cough in the first two years of life.
It is caused by viral infections and presents with lower airways obstruction due to
inflammation and plugging of the small airways. Recurrent episodes can occur,
usually during winter.
It can be difficult to distinguish between bronchiolitis and asthma. Bronchiolitis does
not respond to salbutamol. If there is a good response to a single dose of salbutamol,
asthma is the likely diagnosis. See Section 17.1.1: Acute asthma and acute
exacerbation of chronic obstructive pulmonary disease (COPD).
Bronchiolitis is extremely rare in children > 2 years of age. Consider other causes of
wheeze in children > 2 years of age. See Section 17.1.1: Acute asthma and acute
exacerbation of chronic obstructive pulmonary disease (COPD) and Section 17.3.4.1:
Pneumonia in children.
Child presents with:
» rapid breathing » decreased breath sounds
» chest indrawing » an audible wheeze
Risk factors for severe bronchiolitis:
» Infants < 3 months of age. » Ex-premature babies.
» Chronic lung disease. » Congenital heart disease.
Signs of severe disease:
» Increased respiratory effort: tachypnoea, nasal flaring, severe lower chest wall
indrawing, accessory muscle use, grunting.
» Central cyanosis or hypoxia (oxygen saturation < 90% in room air)
» Apnoea.
» Inability to feed.
» Lethargy or decreased level of consciousness.

DIAGNOSTIC CRITERIA
» Prodrome of viral infection: irritability and rhinorrhoea.
» A wheeze that is slowly responsive or non-responsive to bronchodilators.
» Tachypnoea: age dependent:
Age Respiratory rate
Birth – 2 months • 60 breaths/minute
2–12 months • 50 breaths/minute
1–5 years • 40 breaths/minute

2018 17.13
 CHAPTER 17 RESPIRATORY CONDITIONS

GENERAL MEASURES
» Minimise contact with other children.
» Avoid routine use of antibiotics and corticosteroids.
» Do not sedate child.

MEDICINE TREATMENT
Mild cases, without risk factors may be managed as an outpatient.

x Oxygen, humidified, using nasal prongs or nasal cannula, at 1–2 L/minute.

Refer severe bronchiolitis or those with risk factors:

REFERRAL
» Signs of severe bronchiolitis (respiratory distress, hypoxia, apnoea, inability to
feed, lethargy/decreased level of consciousness).
» Bronchiolitis with risk factors for severe disease.
» Previous admission for same problem.

17.1.4 CHRONIC OBSTRUCTIVE PULMONARY DISEASE

(COPD)
J44.0-1/J44.8-9/J43.0-2/J43.8-9

DESCRIPTION
Also referred to as chronic obstructive airways disease (COAD), and comprises
chronic bronchitis and emphysema which are characterised by:
» chronic cough with/without sputum production on most days of •3 months for •2
consecutive years;
» dyspnoea or shortness of breath; and
» wheezing.
The onset is very gradual with progressively worsening symptoms. Due to the large
reserve capacity of the lungs, patients often present when there is considerable
permanent damage to the lungs. In addition to the symptoms listed above, patients
may present with symptoms or signs of right heart failure. The airways obstruction is
not fully reversible (in contrast to asthma).
The main causes of COPD are chronic irritation of the airways caused by smoking,
air pollution, previous TB, and previous cannabis (dagga) smoking, although there
are many other causes.
If symptoms suggest TB (e.g. weight loss, night sweats, etc.), investigate and
manage accordingly.

GENERAL MEASURES
» Smoking cessation, including cannabis (dagga), is the mainstay of therapy.
» Chest physiotherapy where available.
» Exercise.

MEDICINE TREATMENT
Acute lower airways obstruction: Treat as for acute asthma.

2018 17.14
 CHAPTER 17 RESPIRATORY CONDITIONS

Chronic management:
» In a stable patient, check PEFR.
» Then give a test dose of salbutamol, i.e. 2 puffs.
» Repeat PEFR 15 minutes later.
» If there is • 20% improvement in peak flow, diagnose asthma and manage
patient accordingly. See Section 17.1.2: Chronic asthma.
» Perform spirometry if available. Diagnose COPD if FEV1/FVC < 70%.
ƒ
x
SABA e.g.:
Salbutamol, inhalation, 100–200 mcg (1–2 puffs), 3–4 times daily as needed for
relief of wheeze.
If not controlled on SABA alone and diagnosis was confirmed by spirometry
(with < 2 exacerbations per year):
ƒ Long-acting ȕ2-agonist (LABA), e.g.:
x Formoterol, inhaled 12 mcg (1 puff) 12 hourly (Doctor initiated).
If not controlled on SABA alone and spirometry not available: LoE:IIIxvi
ƒ
x
Inhaled LABA/corticosteroid combination e.g.:
Salmeterol/fluticasone, inhalation, 50/250 mcg (1 puff) 12 hourly (Doctor
initiated).
If not controlled on a LABA alone or frequent exacerbations (• 2 per year):
Replace with:
ƒ Inhaled LABA/corticosteroid combination e.g.:
x Salmeterol/fluticasone, inhalation, 50/250 mcg (1 puff) 12 hourly (Doctor
initiated).
Note: Fluticasone and budesonide interacts with protease inhibitors. LoE:IIIxvii
Refer all patients on protease inhibitors requiring inhaled corticosteroids for further
management.
LoE:IIIxviii
x Amoxicillin, oral, 500 mg 8 hourly for 5 days.
Acute infective exacerbation of chronic bronchitis:

x Doxycycline, oral, 100 mg 12 hourly for 5 days.

Severe penicillin allergy: (Z88.0)

Note: Oral corticosteroids may be required for acute exacerbations, but these have
severe long-term complications and should only be used long-term if benefit has been
proven by lung function testing.

x Influenza vaccination, annually.

Prophylaxis against respiratory tract infections: Z25.1

REFERRAL
» Poor response to above therapy, for further investigations and adjustment of
treatment.
» Patients on protease inhibitors, requiring inhaled corticosteroids.

2018 17.15
 CHAPTER 17 RESPIRATORY CONDITIONS

17.2 STRIDOR (UPPER AIRWAYS OBSTRUCTION)

17.2.1 CROUP (LARYNGOTRACHEOBRONCHITIS) IN

CHILDREN
J05.0-1

DESCRIPTION
Croup is a common cause of potentially life-threatening airway obstruction in
childhood. It is characterised by inflammation of the larynx, trachea and bronchi. Most
common causative pathogens are viruses, including measles.
A clinical diagnosis of viral croup can be made if a previously healthy child develops
progressive inspiratory airway obstruction with stridor and a barking cough, 1–2 days after
the onset of an upper respiratory tract infection. A mild fever may be present.
Suspect foreign body aspiration if there is a sudden onset of stridor in an otherwise
healthy child.
Suspect epiglottitis if the following are present in addition to stridor:
» very ill child » drooling saliva
» high fever » unable to swallow
» sitting upright with head held erect
Assessment of the severity of airway obstruction and management in croup
Grade 1 x Prednisone, oral, 1–2mg/kg, single dose.
Inspiratory stridor only o Do not give if measles or herpes infection
present.

x
» Refer.
Grade 2 Prednisone, oral, 1–2 mg/kg, immediately as a

x
Inspiratory and expiratory stridor single dose.
Epinephrine, 1:1 000 diluted in sodium chloride
0.9%, nebulised, immediately.
o Dilute 1 mL of 1:1 000 epinephrine with 1 mL
sodium chloride 0.9%.
o Repeat every 15–30 minutes until expiratory
stridor disappears.
» Refer.
Grade 3 » Treat as above.
Inspiratory and expiratory stridor » If no improvement within one hour, refer urgently
with active expiration, using (intubate before referral if possible).
abdominal muscles
Grade 4 » Intubate (if not possible give treatment as above).
Cyanosis, apathy, marked » Refer urgently.
retractions, impending apnoea

GENERAL MEASURES
» Keep child comfortable.
» Continue oral fluids.
» Encourage parent or caregiver to remain with the child.

2018 17.16
 CHAPTER 17 RESPIRATORY CONDITIONS

x
MEDICINE TREATMENT
Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See dosing table,
pg 23.8.

x Adrenaline (epinephrine), 1:1000, nebulised, immediately using a nebuliser.

Children grade 2 or more stridor- while awaiting transfer:

o If there is no improvement, repeat every 15 minutes, until the child is transferred.

o Dilute 1 mL of 1:1000 epinephrine (adrenaline) with 1 mL sodium chloride 0.9%.
o Nebulise the entire volume with oxygen at a flow rate of 6–8 L/minute.
x Prednisone, oral, 1–2 mg/kg immediately as a single dose.
Weight Dose Tablet Age
kg mg 5 mg months/years
>11–14 kg 20 mg 4 tablets >2–3 years
>14–17.5 kg 30 mg 6 tablets >3–5 years

x
If epiglottitis suspected
Ceftriaxone, IM,80 mg/kg/dose immediately as a single dose and refer. See
dosing table, pg 23.3.
o Do not inject more than 1 g at one injection site.
CAUTION: USE OF CEFTRIAXONE IN NEONATES AND CHILDREN
» If SUSPECTING SERIOUS BACTERIAL INFECTION in neonate, give ceftriaxone,
even if jaundiced.

 If ” 28 days old, avoid calcium-containing IV fluids for 48 hours after ceftriaxone

» Avoid giving calcium-containing IV fluids (e.g. Ringer Lactate) together with ceftriaxone:

 If > 28 days old, ceftriaxone and calcium-containing IV fluids may be given

administered.

sequentially provided the giving set is flushed thoroughly with sodium chloride

 Preferably administer IV fluids without calcium contents.

0.9% before and after.

» Always include the dose and route of administration of ceftriaxone in the referral letter.

Management during transfer:

» Give the child oxygen.
» Continue nebulisations with epinephrine (adrenaline).
» If grade 3, contact ambulance or nearest doctor.
» If grade 4, intubate and transfer.

REFERRAL
Urgent

 chest indrawing
» Children with:

 rapid breathing
 altered consciousness
 inability to drink or feed
» For confirmation of diagnosis.
» Suspected foreign body.
» Suspected epiglottitis.

2018 17.17
 CHAPTER 17 RESPIRATORY CONDITIONS

Non Urgent
» All children grade1 or 2 stridor.

17.3 RESPIRATORY INFECTIONS

17.3.1 INFLUENZA
J09/J10.0-1/J10.8/J11.0-1/J11.8

DESCRIPTION
Influenza is a self-limiting viral condition that may last up to 14 days. It presents with
headache, muscular pain and fever, and begins to clear within 7 days.
Malnourished children, the elderly and debilitated patients are at greater risk of
developing complications.
CAUTION
Malaria, measles, and HIV seroconversion may present with flu-like symptoms.

Complications
Secondary bacterial infections, including:
» pneumonia secondary to influenza » sinusitis
» otitis media

GENERAL MEASURES
» Bed rest, if feverish.
» Ensure adequate hydration.
» Advise patient to return to clinic if earache, tenderness or pain over sinuses
develops and/or cough or fever persists for longer than a week.

MEDICINE TREATMENT
Note: Antibiotics are of no value for the treatment of influenza.

x Sodium chloride 0.9%, instilled into each nostril.

Infants

Pain and fever with distress:

x Paracetamol, oral, 10–15 mg/kg/dose 4–6 hourly when required. See dosing
Children

table, pg 23.8.

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses

Adults

per 24 hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.

REFERRAL
Severe complications.

2018 17.18
 CHAPTER 17 RESPIRATORY CONDITIONS

17.3.2 ACUTE BRONCHITIS IN ADULTS OR ADOLESCENTS

J20.9

DESCRIPTION
Acute airways infections, mostly of viral origin, accompanied by cough, sputum
production, and sometimes a burning retrosternal chest pain in patients with
otherwise healthy lungs.
Clinical features:
» initially: non-productive cough
» later: productive cough with yellow or greenish sputum
Viral bronchitis is usually part of an upper respiratory viral infection. It may be
accompanied by other manifestations of viral infections. It is important to exclude
underlying bronchiectasis or an acute exacerbation of chronic bronchitis in adults.
Antibiotics are not indicated in acute bronchitis in the absence of underlying COPD.

17.3.3 ACUTE EXACERBATION OF COPD

See Sections 17.1.1: Acute asthma and acute exacerbation of COPD and 17.1.4:
Chronic COPD.

17.3.4 PNEUMONIA
DESCRIPTION
Acute infection of the lung parenchyma, usually caused by bacteria, especially
Streptococcus pneumonia (pneumococcus).
Management is guided by:
» age » co-morbidity
» severity of the pneumonia
Manifestations include:
» malaise
» fever, often with sudden onset and with rigors
» cough, which becomes productive of rusty brown or yellow-green sputum
» pleuritic type chest pain
» shortness of breath
» in severe cases, shock and respiratory failure
On examination there is:
» fever » crackles or crepitations
» tachypnoea » bronchial breath sounds
There may be a pleural rubbing sound or signs of a pleural effusion.
Predisposing conditions include:
» very young or old age » other concomitant diseases
» malnutrition » HIV infection
Pneumococcal pneumonia often occurs in previously healthy adults.
Adults with mild to moderately severe pneumonia may be managed at PHC level,
depending on the response to initial treatment (see below).

2018 17.19
 CHAPTER 17 RESPIRATORY CONDITIONS

17.3.4.1 PNEUMONIA IN CHILDREN

J18.0-2/J18-9

DESCRIPTION
Pneumonia should be distinguished from viral upper respiratory infections. The most
valuable sign in pneumonia is the presence of rapid breathing.
Assess the child for the severity of the pneumonia
Classify children according to the severity of the illness:
» Pneumonia: fever, cough and rapid breathing, but no chest indrawing (of the
lower chest wall) and no flaring of nostrils.
» Severe pneumonia: fever, cough, rapid breathing, chest indrawing and flaring
nostrils, or grunting.
Note: Children < 2 months of age with rapid breathing should be classified as
having severe pneumonia.
Rapid breathing is defined according to age:
Age Respiratory rate
Birth – 2 months • 60 breaths/minute
2–12 months • 50 breaths/minute
1–5 years • 40 breaths/minute
Danger signs indicating urgent and immediate referral include:
» oxygen saturation of < 90% in room air » cyanosis
» inability to drink » < 2 months of age
» impaired consciousness » grunting

GENERAL MEASURES
» Ensure adequate hydration.
» Continue feeding.

MEDICINE TREATMENT
Pneumonia (non-severe):
x Amoxicillin, oral, 45 mg/kg/dose, 12 hourly for 5 days. LoE:IIIxix
Use one of the following:
Weight Dose Capsule/ tablet Age
Syrup mg/ 5mL
kg mg mg Months/years
125 250 250 500
>3.5–5 kg 200 8 mL 4 mL – – >2–3 months
>5–7 kg 275 11 mL 5.5 mL – – >3–6 months
>7–11 kg 400 8 mL – – >6–18 months
>11–14 kg 500 – 10 mL 2 – >18 months–3 years
‫ޓ‬14–17.5kg 750 – 15 mL 3 – ‫ޓ‬3–5 years
‫ޓ‬17.5–25 kg 1000 – 20 mL* 4 2 ‫ޓ‬5–7 years
‫ޓ‬25–30 kg 1250 – 25mL* 5 – ‫ޓ‬7–10 years
>30 kg 1500 – – 6 3 >10 years
*capsule/tablet preferred

2018 17.20
 CHAPTER 17 RESPIRATORY CONDITIONS

Severe penicillin allergy: (Z88.0)

Children
ƒ Macrolide, e.g.:
x Azithromycin, oral, 10 mg/kg/dose daily for 3 days. See dosing table, pg 23.2.

x Oxygen, using nasal cannula at 1–2 L/minute before and during transfer.
Severe pneumonia:

x Ceftriaxone, IM, 80 mg/kg/dose immediately as a single dose. See dosing table,

page 23.3.
o Do not inject more than 1 g at one injection site.
CAUTION: USE OF CEFTRIAXONE IN NEONATES AND CHILDREN
» If SUSPECTING SERIOUS BACTERIAL INFECTION in neonate, give ceftriaxone,
even if jaundiced.

 If ” 28 days old, avoid calcium-containing IV fluids for 48 hours after ceftriaxone

» Avoid giving calcium-containing IV fluids (e.g. Ringer Lactate) together with ceftriaxone:

 If > 28 days old, ceftriaxone and calcium-containing IV fluids may be given

administered.

sequentially provided the giving set is flushed thoroughly with sodium chloride

 Preferably administer IV fluids without calcium contents.

0.9% before and after.

» Always include the dose and route of administration of ceftriaxone in the referral letter.

REFERRAL
Urgent
» All children with severe pneumonia, i.e. chest indrawing (of the lower chest
wall), flaring nostrils or cyanosis.
» All children < 2 months of age.
Non urgent
» Inadequate response to treatment.
» Children coughing for > 3 weeks to exclude other causes such as TB, foreign
body aspiration or pertussis.

17.3.4.2 PNEUMONIA IN ADULTS

17.3.4.2.1 UNCOMPLICATED PNEUMONIA
J18.0-2/J18-9

DIAGNOSIS
A chest X-ray should ideally be taken in all patients to confirm the diagnosis. Send one
sputum specimen for TB DNA PCR (Xpert MTB/RIF) to exclude pulmonary tuberculosis.

MEDICINE TREATMENT

x Amoxicillin, oral, 1 g 8 hourly for 5 days.

If not severely ill (see referral criteria below):

x Moxifloxacin, oral, 400 mg daily for 5 days.

Severe Penicillin allergy: (Z88.0)

2018 17.21
 CHAPTER 17 RESPIRATORY CONDITIONS

REFERRAL
Any of the following:
» Confusion or decreased level of consciousness.
» Cyanosis.
» Respiratory rate of • 30 breaths/minute.
» Systolic BP < 90 mmHg.
» Diastolic BP < 60 mmHg.
» Deterioration at any point.
» No response to treatment after 48 hours.

 from a poor socio-economic background

» Patients with pneumonia:

 who are unlikely to comply with treatment

 who live a considerable distance from health centres
 who have no access to immediate transport

17.3.4.2.2 PNEUMONIA IN ADULTS WITH UNDERLYING

MEDICAL CONDITIONS OR > 65 YEARS OF AGE
J18.0-2/J18-9

A chest X-ray should ideally be taken in all patients to confirm the diagnosis. Send one
sputum specimen for TB DNA PCR (Xpert MTB/RIF) to exclude pulmonary tuberculosis.
Common underlying conditions include:
» Diabetes mellitus. » Alcoholism.
» HIV infection. » Chronic liver disease.
» Cardiac failure. » Chronic kidney disease.
» COPD.
Most of these patients will require referral to a doctor.

MEDICINE TREATMENT

x Amoxicillin/clavulanic acid 875/125 mg, oral, 12 hourly for 5 days.

Mild pneumonia:

x Moxifloxacin, oral, 400 mg daily for 5 days.

Severe Penicillin allergy: (Z88.0)

17.3.4.2.3 SEVERE PNEUMONIA

J18.0-2/J18.8-9

DESCRIPTION
Severe pneumonia is defined as •2 of the following:
» confusion or decreased level of consciousness
» respiratory rate of •30 breaths/ minute
» systolic BP < 90 mmHg
» diastolic BP < 60 mmHg
» > 65 years of age

2018 17.22
 CHAPTER 17 RESPIRATORY CONDITIONS

MEDICINE TREATMENT

x Oxygen, to achieve a saturation of 92%.

While awaiting transfer:

x Ceftriaxone, IV/IM, 1 g, as a single dose before referral.

CAUTION
Do not administer calcium containing fluids, e.g. Ringer-Lactate, concurrently
with ceftriaxone.

REFERRAL
Urgent
All patients.

17.3.4.2.4 PNEUMOCYSTIS PNEUMONIA

B20.6

DESCRIPTION
Interstitial pneumonia occurring with advanced HIV infection due to Pneumocystis
jiroveci (formerly carinii). Patients usually present with shortness of breath or dry
cough. Chest X-ray may be normal in the early stages, but typically shows bilateral
interstitial or ground glass pattern.

GENERAL MEASURES
Ensure adequate hydration.

MEDICINE TREATMENT

x Cotrimoxazole, oral, 6 hourly for 3 weeks.

Adults

Approx. weight Use one of the following tablets

kg 80/400 mg 160/800 mg
<40 kg 2 tablets 1 tablet
>40–56 kg 3 tablets 1½ tablets
>56 kg 4 tablets 2 tablets

x Cotrimoxazole, oral, daily.

For secondary prophylaxis

Use one of the following tablets

80/400 mg 160/800 mg
2 tablets 1 tablet
Discontinue cotrimoxazole prophylaxis if the CD4 count increases on ART to
> 200 cells/mm3 for at least 6 months.

REFERRAL
» All children.
» Breathing rate > 24 breaths/minute.
» Shortness of breath with mild effort.

2018 17.23
 CHAPTER 17 RESPIRATORY CONDITIONS

» Cyanosed patients.

17.4 PULMONARY TUBERCULOSIS (TB)

Note: TB is a notifiable disease.

TB guidelines are updated regularly. Consult the most recent National

Tuberculosis Control Programme Guidelines.

DESCRIPTION
Tuberculosis is an infection caused by Mycobacterium tuberculosis. It is exacerbated
and complicated by HIV, AIDS, and multi drug-resistant mycobacteria.

17.4.1 PULMONARY TUBERCULOSIS (TB) IN ADULTS

B20.0

DIAGNOSIS
Pulmonary TB is diagnosed on Xpert MTB/RIF testing, sputum smear or culture.

 If Xpert MTB/RIF is positive: treat for TB and send a sputum specimen for
» Send 1 sputum specimen for Xpert MTB/RIF.

 If Xpert MTB/RIF is positive and susceptible to RIF: treat for TB.

smear microscopy. (The smear is used for reporting, not for diagnosis).

 If Xpert MTB/RIF is positive and resistant to RIF: commence MDR treatment and

 If Xpert MTB/RIF is negative and patient is HIV-infected: send sputum for

send sputum for drug susceptibility testing to confirm MDR TB.

 If Xpert MTB/RIF is negative and patient is HIV negative: treat with antibiotics
culture and chest X-ray, if available.

and consider further investigation only if symptoms persist.

Note: If the patient was recently treated for TB, the Xpert MTB/RIF test could be
falsely positive. Send sputum for smear microscopy and culture instead.

 If both smears are negative, send another sputum specimen for culture.
» If Xpert MTB/RIF is not available, send 2 sputum specimens for smear microscopy.

 In all patients who have had TB previously, send a sputum specimen for
culture and sensitivity.

GENERAL MEASURES
» Counsel patients about the disease. Explain the importance of completing treatment.
» Avoid the use of tobacco.
» Avoid excessive alcohol.
» If more than two doses of treatment are missed, extra effort should be made to
identify and manage any problems the patient might have.

MEDICINE TREATMENT
Administer total daily amount of each medicine in one dose and not as divided doses.

2018 17.24
 CHAPTER 17 RESPIRATORY CONDITIONS

Important medicine interactions

Rifampicin may reduce the efficacy of low dose combined oral contraceptives,
resulting in possible unplanned pregnancies (See Chapter 7: Family planning).
» Alter the oral contraceptive to a high dose preparation for the duration of TB
treatment or use an injectable contraception or IUD.
» Use additional contraception in patients using a progestin-only subdermal implant for
the duration of TB therapy. See Section: 11.1 Antiretroviral therapy, adults.
CAUTION
Antiretroviral medicines frequently interact with TB medicines.
Consult the National Department of Health antiretroviral treatment guidelines.

Dose adjustment
Ethambutol should be given on alternative days in patients with impaired renal
function (eGFR < 10 mL/min).
Adverse effects of TB medicines include:

 Taking medicines with meals can minimise nausea.

» Nausea.

» Hepatitis must be excluded, if there is new onset nausea. Request serum alanine
aminotransferase test urgently in these patients.

 Rifampicin, isoniazid and pyrazinamide may cause hepatitis. Cotrimoxazole

» Hepatitis (drug induced liver injury)

and antiretrovirals (efavirenz, nevirapine, lopinavir + ritonavir) can also cause

 Patient may present with jaundice and/or complaining of hepatitis symptoms

hepatitis.

 Refer to hospital for urgent (same day) ALT and further management
(e.g. nausea, malaise, abdominal pain).

 If jaundiced, stop TB treatment and medicines known to cause hepatitis before

referring. See Section: 11.1 Antiretroviral therapy, adults.

 Refer if suspected drug rash.

» New onset skin rash.

 Can be prevented by taking pyridoxine.

» Neuropathy.

 Exclude gout, and treat symptomatically.

» Arthralgia.

17.4.1.1 TB CHEMOPROPHYLAXIS/ISONIAZID PREVENTIVE

THERAPY (IPT) IN ADULTS
See Section 11.2.2: Isoniazid preventive therapy.

2018 17.25
 CHAPTER 17 RESPIRATORY CONDITIONS

17.4.1.2 TB CONTROL PROGRAMME: MEDICINE REGIMENS IN

ADULTS
A15.0-3/A15.7-8/A16.0-2/A16.7-8/B20.0

Treatment should be given once daily seven days per week in both the intensive
and continuation phases.
R – Rifampicin
H – Isoniazid
Z or PZA– Pyrazinamide
E or EMB – Ethambutol
Pre-treatment Two months initial Four months continuation phase
body weight phase
kg RHZE RH RH
(150/75/400/275) (150/75) (300/150)
30–37 kg 2 tablets 2 tablets
38–54 kg 3 tablets 3 tablets
55–70 kg 4 tablets 2 tablets
•71kg 5 tablets 2 tablets
» Keep strictly to the correct dose and the duration of treatment.
» Weigh patient frequently and adjust the dose according to current weight.

17.4.2 PULMONARY TUBERCULOSIS (TB) IN CHILDREN

A15.0-3/A15.7-8/A16.0-2/A16.7-8/B20.0

Most children acquire tuberculosis from infected adults by inhalation. Malnourished,

immunosuppressed (HIV and AIDS) children and children < 5 years of age are at
increased risk for pulmonary tuberculosis.

DIAGNOSIS
Any child presenting with symptoms and signs suggestive of pulmonary TB is
regarded as a case of TB if there is:
» A chest X-ray suggestive of TB,
AND/OR
» History of exposure to an infectious TB case and/or positive tuberculin skin test
(TST) e.g. Mantoux.
A positive Xpert MTB/RIF and/or smear microscopy and/or culture, on early morning
gastric aspirate or induced sputum, confirms TB disease.
Signs and symptoms include:
» unexplained weight loss or failure to thrive,
» unexplained fever for •2 weeks,
» chronic unremitting cough for >14 days,
» lymphadenopathy (especially cervical, often matted),
» hepatosplenomegaly,
» consolidation and pleural effusion.
Tuberculin skin test (TST), e.g. Mantoux.
» A positive test: TST induration •10 mm.

2018 17.26
 CHAPTER 17 RESPIRATORY CONDITIONS

 malnutrition
» A TST may be falsely negative in the presence of:

 immunodeficiency, e.g. HIV and AIDS

 immunosuppression, e.g. steroid therapy, cancer chemotherapy
 following overwhelming viral infection, e.g. measles or post vaccination
In these circumstances a TST induration •5 mm may be regarded as positive.
Frequently, the TST will be non-reactive in these cases. TB treatment should be
considered, despite a negative TST.
The following may be evident on chest X-ray:
» Direct or indirect evidence of hilar or mediastinal adenopathy with or without
parenchymal opacification and/or bronchopneumonia.

GENERAL MEASURES
» Identify and treat the source case.
» Screen all contacts for TB infection.
» Monitor the nutritional status of the child to assess response to treatment.

17.4.2.1 TB CHEMOPROPHYLAXIS/ISONIAZID PREVENTIVE

THERAPY (IPT) IN CHILDREN
Z20.1 + Z29.2

Consider TB chemoprophylaxis/isoniazid preventive therapy (IPT) in all children

exposed to a pulmonary TB contact.

Exclude active TB (i.e. no signs or symptoms suggestive of TB):

» Refer to Section 17.4.2: Pulmonary tuberculosis in children.
» If any signs or symptoms of pulmonary TB are present, refer for chest X-ray.
» Never give IPT to children with active TB.
TB chemoprophylaxis/ IPT is only used in:
» Children < 5 years of age.
OR
» Children of any age, who are HIV-infected.

 Close contact with an infectious pulmonary TB case. If child is re-exposed to

WITH EITHER

a close contact, TB chemoprophylaxis must be repeated (Previous IPT does

 Positive TST (only applicable on the first occasion of a positive TST).

not protect the child against subsequent TB exposure/ infection).

2018 17.27
 CHAPTER 17 RESPIRATORY CONDITIONS

MEDICINE TREATMENT

x Isoniazid, oral, 10 mg/kg daily for 6 months.

Preventive therapy in case of drug-sensitive TB contact:

o Maximum dose: 300 mg daily.

Weight Daily isoniazid (INH)
kg 100 mg tablet
>2–3.4 kg ¼ tablet
>3.5–6.9 kg ½ tablet
>7–9.9 kg 1 tablet
>10–14.9 kg 1½ tablets
>15–19.9 kg 2 tablets
>20–24.9 kg 2½ tablets
>25 kg 3 tablets

Preventive therapy in case of drug-resistant TB contact:

x Rifampicin, oral, 15 mg/kg daily for 4 months.

Isoniazid mono-resistant contact:

o If child unable to swallow tablets.

LoE:IIIxx

x Isoniazid, oral, 10 mg/kg daily for 6 months (see table above).

Rifampicin mono-resistant contact:

LoE:IIIxxi
Children with HIV or malnutrition or existing neuropathy taking
isoniazid:

x Pyridoxine, oral, daily for duration of prophylaxis:

ADD

o Child < 5 years old: 12.5 mg.

o Child • 5 years old: 25 mg.
LoE:IIIxxii
REFERRAL
Children with MDR and XDR TB contacts for expert advice.

17.4.2.2 TB CONTROL PROGRAMME: MEDICINE REGIMENS

IN CHILDREN
A15.0-3/A15.7-8/A16.0-2/A16.7-8/B20.0

Directly observed therapy (DOT), short-course and using fixed medicine

combinations are recommended. Treatment should be given daily in both the
intensive (initial) and the continuation phases.
Recommended dose ranges in mg/kg
Daily(mg/kg) Maximum daily dose
H 10–15 300 mg
R 10–20 600 mg
Z/ PZA 30–40 2g
E 15–25 1200 mg

2018 17.28
 CHAPTER 17 RESPIRATORY CONDITIONS

UNCOMPLICATED PULMONARY TB
Includes smear negative pulmonary TB with no more than mild to moderate lymph node
enlargement and/or lung field opacification, or simple pleural effusion on chest x-ray.
Children ” 8 years of age
4 months
continuation
2 months intensive phase given daily
phase
given daily
Weight RH PZA RH
kg
60/60 150 mg* 500mg 60/60
OR
150mg/3 mL
2–2.9 kg ½ tablet 1.5 mL expert advice ½ tablet
on dose
3–3.9 kg ¾ tablet 2.5 mL ¼ tablet ¾ tablet
4–5.9 kg 1 tablet 3 mL ¼ tablet 1 tablet
6–7.9 kg 1½ tablets ½ tablet 1½ tablets
8–11.9 kg 2 tablets ½ tablet 2 tablets
12–14.9 kg 3 tablets 1 tablet 3 tablets
15–19.9 kg 3½ tablets 1 tablet 3½ tablets
20–24.9 kg 4½ tablets 1½ tablet 4½ tablets
25–29.9 kg 5 tablets 2 tablets 5 tablets
* For each dose, dissolve 150 mg dispersible (1 tablet) in 3 mL of water to prepare a
concentration of 50 mg/mL (150 mg/3 mL)
Note: Give PZA 150 mg or 500 mg, and not both.

x Pyridoxine, oral, daily for 6 months if HIV-infected, malnourished, or have existing

AND

neuropathy:
o Child < 5 years old: 12.5 mg.
o Child • 5 years old: 25 mg.
LoE:IIIxxiii
Children • 8 years and adolescents
Pre-treatment 2 months intensive phase 4 months continuation phase
body weight given daily given daily
kg
RHZE (150,75,400,275) RH (150,75) RH (300,150)
30–37 kg 2 tablets 2 tablets
38–54 kg 3 tablets 3 tablets
55–70 kg 4 tablets 2 tablets
>71 kg 5 tablets 2 tablets
AND

x Pyridoxine, oral, daily for 6 months.

If HIV-infected, malnourished or have existing neuropathy:

o Child < 5 years old: 12.5 mg.

o Child • 5 years old: 25mg.
» Adjust treatment dosages to current body weight. LoE:IIIxxiv
» If calculating dosages, rather give ½ tablet more than ½ tablet less.

2018 17.29
 CHAPTER 17 RESPIRATORY CONDITIONS

COMPLICATED PULMONARY TB
» Includes all other forms of pulmonary TB, such as smear positive TB, cavitating
pulmonary TB, bronchopneumonic TB, large lesion pulmonary TB, tuberculous
empyema.
» Refer all cases of miliary TB for exclusion of TB meningitis.

Children ” 8 years of age

Intensive phase:
» Standard dose 4-drug therapy daily (RHZE) for 2 months.
THEN
Continuation phase:
» Standard dose 2-drug therapy daily (INH+rifampicin) for 4–7 months.
Continuation
Intensive phase: 2 months phase:4–7
months***
Weight RH PZA EMB RH
kg
60/60 150 mg** 500mg 400 mg tablet 60/60
OR OR
150 mg/3 400 mg/8 mL*
mL solution
2–2.9 kg ½ tablet 1.5 mL Expert advice 1 mL ½ tablet
on dose
3–3.9 kg ¾ tablet 2.5 mL ¼ tablet 1.5 mL ¾ tablet
4–5.9 kg 1 tablet 3 mL ¼ tablet 2 mL 1 tablet
6–7.9 kg 1½ tablet ½ tablet 3 mL 1½ tablets
8–11.9 kg 2 tablets ½ tablet ½ tablet 2 tablets
12–14.9 kg 3 tablets 1 tablet ¾ tablet 3 tablets
15–19.9 kg 3½ tablets 1 tablet 1 tablet 3½ tablets
20–24.9 kg 4½ tablets 1½ tablet 1 tablet 4½ tablets
25–29.9 kg 5 tablets 2 tablets 1½ tablets 5 tablets
*EMB: For each dose, crush 400 mg (1 tablet) to a fine powder and dissolve in 8 mL of water to
prepare a concentration of 400mg/8mL. Discard unused solution.
**PZA: For each dose, dissolve 150 mg dispersible (1 tablet) in 3 mL of water to prepare a
concentration of 50 mg/mL (150 mg/3mL)
Note: Give PZA 150 mg or 500 mg, and not both.
***Continuation phase may be prolonged to 7 months in slow responders and children with HIV.
AND

x Pyridoxine, oral, daily for 6–9 months.

If HIV-infected, malnourished or have existing neuropathy:

o Child < 5 years old: 12.5 mg.

o Child • 5 years old: 25 mg.
LoE:IIIxxv

2018 17.30
 CHAPTER 17 RESPIRATORY CONDITIONS

Children • 8 years and adolescents

4 months continuation phase
2 months intensive phase
given daily
given daily

Weight RHZE (150/75/400/275) RH (150/75) RH (300/150)

kg mg mg mg
30–37 kg 2 tablets 2 tablets
38–54 kg 3 tablets 3 tablets
55–70 kg 4 tablets 2 tablets
>71 kg 5 tablets 2 tablets
AND

x Pyridoxine, oral, daily for 6–9 months.

If HIV-infected, malnourished, or have existing neuropathy:
LoE:IIIxxvi
o Child < 5 years old: 12.5 mg.
o Child • 5 years old: 25 mg.
» Weigh at each visit and adjust treatment dosages to body weight. If calculating
dosages, rather give ½ tablet more than ½ tablet less.
» Keep strictly to the correct dose and the duration of treatment.
» The patient should be weighed regularly and the dose adjusted according to the
current weight.

REFERRAL
» Disseminated forms of TB.
» All patients who cannot be managed on an ambulatory basis.
» Children < 12 years of age for a chest X-ray for diagnostic purposes.
» Retreatment cases of children.
» Children who are contacts of patients with open MDR or XDR TB.

17.4.3 TB, HIV AND AIDS

B20.0

HIV and AIDS patients with suspected TB should have one negative sputum TB DNA
PCR test (Xpert MTB/RIF) or two negative sputum smears, before sputum is sent for
culture.
Advise HIV and AIDS patients to present to a clinic if they develop common TB

 active cough (any duration)  night sweats

symptoms:

 fever  loss of weight

HIV-infected patients with TB should be treated according to the standard TB
treatment protocol.
Medicine interactions may occur with ART (See Sections 11.1: Antiretroviral therapy,
adults; 11.7: Opportunistic infections, treatment in children and 11.8.7: Tuberculosis).

2018 17.31
 CHAPTER 17 RESPIRATORY CONDITIONS

17.4.4 MULTIDRUG-RESISTANT TUBERCULOSIS (MDR TB)

MDR TB guidelines are updated regularly.

Consult the most recent National MDR TB Programme Guidelines.

DESCRIPTION
MDR TB is diagnosed when there is resistance to rifampicin and isoniazid.
XDR TB is diagnosed when there is resistance to rifampicin and isoniazid plus
resistance to fluoroquinolones and an injectable medicine e.g. kanamycin.

17.4.4.1 MULTIDRUG-RESISTANT TUBERCULOSIS (MDR TB,

IN ADULTS
A15.0-3/A15.7-8/A16.0-2/A16.7-8/B20.0 + (U50.00-01)

GENERAL MEASURES
Counsel and educate patients about the disease and its treatment, including
treatment duration.
Screen all close contacts for signs and symptoms of MDR TB and by sputum
sampling to detect early disease.
Infection control and cough etiquette is important to limit spread.

REFERRAL
» All MDR patients.
» All XDR patients.

17.4.4.2 MULTIDRUG-RESISTANT TUBERCULOSIS (MDR TB),

IN CHILDREN
A15.0-3/A15.7-8/A16.0-2/A16.7-8/B20.0 + (U50.00-01)

GENERAL MEASURES
Suspect DR-TB when any of the features listed below is present:
» A known source case (or contact) with drug resistant TB or high-risk source case,
e.g. on TB therapy who was recently released from prison.
» A smear positive case after 2 months of TB treatment who failed (or deteriorated
on) 1st line antituberculosis treatment to which they were adherent (treatment
failure or relapse within 6 months of treatment).
» Any severely ill child with TB who failed or got worse on TB treatment.
» Patients who defaulted TB treatment (> 2 months).
» Treatment interruptions (< 1 month) or who relapsed while on TB treatment or at
the end of treatment.
» With recurrent TB disease after completion of TB treatment (retreatment case).
Manage confirmed DR-TB in a dedicated MDR-TB centre with appropriate infection
control measures to prevent nosocomial transmission. Initiate treatment in
consultation with a designated expert while awaiting referral to the designated MDR-

2018 17.32
 CHAPTER 17 RESPIRATORY CONDITIONS

TB centre. An uninterrupted medicine supply, direct supervision with proper

education and counselling is necessary.

REFERRAL
All children.

References:
i Salbutamol MDI (adults): Rodrigo C, Rodrigo G. Salbutamol treatment of acute severe asthma in the ED: MDI versus hand-held
nebulizer. Am J Emerg Med. 1998 Nov16(7):637-42. https://www.ncbi.nlm.nih.gov/pubmed/9827736
Salbutamol MDI (adults): National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML,
2015. http://www.health.gov.za/
ii Salbutamol nebulisation (adults): National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and

EML, 2015. http://www.health.gov.za/

iii Salbutamol nebulisation (adults): National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and

EML, 2015. http://www.health.gov.za/

iv Salbutamol MDI (adults): National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and EML,

2015. http://www.health.gov.za/
v Ipratropium bromide 0.5 mg nebulisation (adults): Global initiative for asthma (GINA) Guidelines, 2018. http://ginasthma.org/
vi Ipratropium bromide MDI (adults ): Global initiative for asthma (GINA) Guidelines, 2018. http://ginasthma.org/
vii Salbutamol MDI (paediatrics): Benito-Fernández J, González-Balenciaga M, Capapé-Zache S, Vázquez-Ronco MA, Mintegi-

Raso S. Salbutamol via metered-dose inhaler with spacer versus nebulization for acute treatment of pediatric asthma in the
emergency department. PediatrEmerg Care. 2004 Oct;20(10):656-9. https://www.ncbi.nlm.nih.gov/pubmed/15454738
Salbutamol MDI (paediatrics): National Department of Health, Essential Drugs Programme:: Paediatric Hospital Level STGs and
EML, 2017. http://www.health.gov.za/
viii Salbutamol nebulisation (paediatrics): National Department of Health, Essential Drugs Programme: Paediatric Hospital Level

STGs and EML, 2017. http://www.health.gov.za/

ix Salbutamol nebulisation (paediatrics): National Department of Health, Essential Drugs Programme: Paediatric Hospital Level

STGs and EML, 2017. http://www.health.gov.za/

x Salbutamol MDI (paediatrics): National Department of Health, Essential Drugs Programme: Paediatric Hospital Level STGs and

EML, 2017. http://www.health.gov.za/

xi Ipratropium bromide 0.5 mg nebulisation (paediatrics): Kling S, Zar HJ, Levin ME, Green RJ, Jeena PM, Risenga SM, Thula SA

,Goussard P, Gie RP, for the South African Childhood Asthma Working Group (SACAWG)S Afr Med J 2013;103(3):199-207.
http://www.samj.org.za/index.php/samj/article/view/6658
xii Inhaled corticosteroids (Patients on protease inhibitors): Kedem E, Shahar E, Hassoun G, Pollack S. Iatrogenic Cushing's

syndrome due to coadministration of ritonavir and inhaled budesonide in an asthmatic human immunodeficiency virus infected
patient. J Asthma. 2010 Sep;47(7):830-1. https://www.ncbi.nlm.nih.gov/pubmed/20653496
Inhaled corticosteroids (Patients on protease inhibitors): Frankel JK, Packer CD. Cushing's syndrome due to antiretroviral-
budesonide interaction. Ann Pharmacother. 2011 Jun;45(6):823-4. https://www.ncbi.nlm.nih.gov/pubmed/21558486
Inhaled corticosteroids (Patients on protease inhibitors): Blondin MC, Beauregard H, Serri O. Iatrogenic Cushing syndrome in
patients receiving inhaled budesonide and itraconazole or ritonavir: two cases and literature review. Endocr Pract. 2013 Nov-
Dec;19(6):e138-41. https://www.ncbi.nlm.nih.gov/pubmed/23807527
Inhaled corticosteroids (Patients on protease inhibitors): Yoganathan K, David L, Williams C, Jones K. Cushing's syndrome with
adrenal suppression induced by inhaled budesonide due to a ritonavir drug interaction in a woman with HIV infection. Int J STD
AIDS. 2012 Jul;23(7):520-1. https://www.ncbi.nlm.nih.gov/pubmed/22844010
xiii Inhaled corticosteroids (Patients on protease inhibitors): Kedem E, Shahar E, Hassoun G, Pollack S. Iatrogenic Cushing's

syndrome due to coadministration of ritonavir and inhaled budesonide in an asthmatic human immunodeficiency virus infected
patient. J Asthma. 2010 Sep;47(7):830-1. https://www.ncbi.nlm.nih.gov/pubmed/20653496
Inhaled corticosteroids (Patients on protease inhibitors): Frankel JK, Packer CD. Cushing's syndrome due to antiretroviral-
budesonide interaction. Ann Pharmacother. 2011 Jun;45(6):823-4. https://www.ncbi.nlm.nih.gov/pubmed/21558486
Inhaled corticosteroids (Patients on protease inhibitors): Blondin MC, Beauregard H, Serri O. Iatrogenic Cushing syndrome in
patients receiving inhaled budesonide and itraconazole or ritonavir: two cases and literature review. Endocr Pract. 2013 Nov-
Dec;19(6):e138-41. https://www.ncbi.nlm.nih.gov/pubmed/23807527
Inhaled corticosteroids (Patients on protease inhibitors): Yoganathan K, David L, Williams C, Jones K. Cushing's syndrome with
adrenal suppression induced by inhaled budesonide due to a ritonavir drug interaction in a woman with HIV infection. Int J STD
AIDS. 2012 Jul;23(7):520-1. https://www.ncbi.nlm.nih.gov/pubmed/22844010
xiv LABA/ICS (Salmeterol/fluticasone) MDI (adults): National Department of Health, Essential Drugs Programme: Adult Hospital

Level STGs and EML, 2015. http://www.health.gov.za/

xv Inhaled corticosteroids (Patients on protease inhibitors): Kedem E, Shahar E, Hassoun G, Pollack S. Iatrogenic Cushing's

syndrome due to coadministration of ritonavir and inhaled budesonide in an asthmatic human immunodeficiency virus infected
patient. J Asthma. 2010 Sep;47(7):830-1. https://www.ncbi.nlm.nih.gov/pubmed/20653496
Inhaled corticosteroids (Patients on protease inhibitors): Frankel JK, Packer CD. Cushing's syndrome due to antiretroviral-
budesonide interaction. Ann Pharmacother. 2011 Jun;45(6):823-4. https://www.ncbi.nlm.nih.gov/pubmed/21558486
Inhaled corticosteroids (Patients on protease inhibitors): Blondin MC, Beauregard H, Serri O. Iatrogenic Cushing syndrome in
patients receiving inhaled budesonide and itraconazole or ritonavir: two cases and literature review. Endocr Pract. 2013 Nov-
Dec;19(6):e138-41. https://www.ncbi.nlm.nih.gov/pubmed/23807527

2018 17.33
 CHAPTER 17 RESPIRATORY CONDITIONS

Inhaled corticosteroids (Patients on protease inhibitors): Yoganathan K, David L, Williams C, Jones K. Cushing's syndrome with
adrenal suppression induced by inhaled budesonide due to a ritonavir drug interaction in a woman with HIV infection. Int J STD
AIDS. 2012 Jul;23(7):520-1. https://www.ncbi.nlm.nih.gov/pubmed/22844010
xvi LABA (Formoterol) MDI (adults): National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs and

EML, 2015. http://www.health.gov.za/

xvii LABA/ICS (Salmeterol/fluticasone) MDI (adults): National Department of Health, Essential Drugs Programme: Adult Hospital

Level STGs and EML, 2015. http://www.health.gov.za/

xviii Inhaled corticosteroids (Patients on protease inhibitors): Kedem E, Shahar E, Hassoun G, Pollack S. Iatrogenic Cushing's

syndrome due to coadministration of ritonavir and inhaled budesonide in an asthmatic human immunodeficiency virus infected
patient. J Asthma. 2010 Sep;47(7):830-1. https://www.ncbi.nlm.nih.gov/pubmed/20653496
Inhaled corticosteroids (Patients on protease inhibitors): Frankel JK, Packer CD. Cushing's syndrome due to antiretroviral-
budesonide interaction. Ann Pharmacother. 2011 Jun;45(6):823-4. https://www.ncbi.nlm.nih.gov/pubmed/21558486
Inhaled corticosteroids (Patients on protease inhibitors): Blondin MC, Beauregard H, Serri O. Iatrogenic Cushing syndrome in
patients receiving inhaled budesonide and itraconazole or ritonavir: two cases and literature review. Endocr Pract. 2013 Nov-
Dec;19(6):e138-41. https://www.ncbi.nlm.nih.gov/pubmed/23807527
Inhaled corticosteroids (Patients on protease inhibitors): Yoganathan K, David L, Williams C, Jones K. Cushing's syndrome with
adrenal suppression induced by inhaled budesonide due to a ritonavir drug interaction in a woman with HIV infection. Int J STD
AIDS. 2012 Jul;23(7):520-1. https://www.ncbi.nlm.nih.gov/pubmed/22844010
xix Amoxicillin: National Department of Health, Essential Drugs Programme: Paediatric Hospital Level STGs and EML, 2017.

http://www.health.gov.za/
xx Rifampicin, oral - Isoniazid mono-resistant contact: National Department of Health, Essential Drugs Programme: Paediatric

Hospital Level STGs and EML, 2017. http://www.health.gov.za/

xxi Isoniazid, oral - Rifampicin mono-resistant contact: National Department of Health, Essential Drugs Programme: Paediatric

Hospital Level STGs and EML, 2017. http://www.health.gov.za/

xxiiPyridoxine, oral: National Department of Health, Essential Drugs Programme: Paediatric Hospital Level STGs and EML, 2017.

http://www.health.gov.za/
xxiiiPyridoxine, oral: National Department of Health, Essential Drugs Programme: Paediatric Hospital Level STGs and EML, 2017.

http://www.health.gov.za/
xxivPyridoxine, oral: National Department of Health, Essential Drugs Programme: Paediatric Hospital Level STGs and EML, 2017.

http://www.health.gov.za/
xxvPyridoxine, oral: National Department of Health, Essential Drugs Programme: Paediatric Hospital Level STGs and EML, 2017.

http://www.health.gov.za/
xxviPyridoxine, oral: National Department of Health, Essential Drugs Programme: Paediatric Hospital Level STGs and EML, 2017.

http://www.health.gov.za/

2018 17.34
PHC Chapter 18: Eye conditions
18.1 Conjunctivitis
18.1.1 Conjunctivitis, allergic
18.1.2 Conjunctivitis, bacterial (excluding
conjunctivitis of the newborn)
18.1.3 Conjunctivitis of the newborn
18.1.4 Conjunctivitis, viral (pink eye)
18.2 Corneal ulcer
18.3 Eye injuries
18.3.1 Eye injury, chemical burn
18.3.2 Eye injury/foreign bodies
18.3.3 Eye injury (blunt or penetrating)
18.4 Glaucoma, acute and closed angle
18.5 Painful red eye
18.6 Structural abnormalities of the eye
18.7 Visual problems
























 &+$37(5 (<(&21',7,216

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An inflammatory condition of the conjunctiva, possibly caused by:
» allergies
» bacterial or viral (pink eye) infections

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H10.1

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An inflammatory condition of the conjunctivae caused by allergy to pollen, grass,
animal fur, medication, cosmetics, etc. Often associated with allergic rhinitis or hay
fever. Common features include:
» itching, watery eyes and photophobia
» slightly red or normal conjunctiva
» conjunctival swelling in severe cases
» normal cornea, iris and pupil
» normal visual acuity
In chronic cases, there may be brown discolouration of the conjunctivae or
cobblestone elevations of the upper tarsal conjunctivae (vernal conjunctivitis).

*(1(5$/0($685(6
Relieve symptoms with cold compresses, i.e. a clean moistened cloth over the eyes
for 10 minutes.

0(',&,1(75($70(17
$GXOWVDQGFKLOGUHQ!\HDUVRIDJH
x Oxymetazoline 0.025%, eye drops, instil 1–2 drops 6 hourly for a maximum of 7 days.
If no response within 7 days or history of recurrent (seasonal)/chronic allergic

x Sodium cromoglycate, 2 % eye drops, instil 1 drop 6 hourly (Doctor initiated).

conjunctivitis, change to:

o Use may be seasonal (1–3 months) or long-term.

LoE:IIi
x Cetirizine, oral, 10 mg once daily.
If symptoms not controlled, add cetirizine/chlorphenamine:

o Use may be seasonal (1–3 months) or long-term.

&KLOGUHQ±\HDUVRIDJH
x Chlorphenamine, oral, 0.1 mg/kg/dose 6–8 hourly. See dosing table, pg 23.3.
If no response within 7 days or history of recurrent (seasonal)/chronic allergic

x Sodium cromoglycate, 2 % eye drops, instil 1 drop 6 hourly (Doctor initiated).

conjunctivitis, change to:

o Use may be seasonal (1–3 months) or long-term.

LoE:IIii
x Cetirizine, oral, 5 mg once daily. See dosing table, pg 23.3.
If symptoms not controlled, add cetirizine:

o Use may be seasonal (1–3 months) or long-term.

2018 18.2
 &+$37(5 (<(&21',7,216

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Do not give an antihistamine to children < 2 years of age.

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» No response to treatment.
» Persons wearing contact lenses.
» Children < 2 years of age.

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An inflammatory purulent condition of the conjunctivae caused by bacterial infection
and characterised by:
» sore, gritty or scratchy eyes and swollen lids
» mucopurulent discharge from one or both eyes
» redness especially of conjunctival angles (fornices)

*(1(5$/0($685(6
» Educate patient on personal hygiene to avoid spread e.g. do not use the same
face-cloth or towels as others.
» Do not use contaminated cosmetics.
» Practise good contact lens hygiene.
» Avoid chronic use topical medications.
» Educate patient on correct application of ophthalmic ointment.

 to wash hands thoroughly before and after applying ophthalmic ointment

» Advise patient:

 not to share ophthalmic ointments or drops

 not to rub eyes
 never to use urine or milk to wash the eyes

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x Chloramphenicol 1%, ophthalmic ointment, applied 6 hourly for 7 days.
3DLQ

x Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See dosing table,
Children

pg 23.8.

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per

Adults

24 hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.

2018 18.3
 &+$37(5 (<(&21',7,216

5()(55$/
» No response after 5 days.
» All cases of unilateral conjunctivitis, as this may be caused by a foreign body.
» Loss of vision.
» Irregularity of pupil.
» Haziness of the cornea.
» Persistent painful eye.

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Inflammation of the conjunctivae in the neonatal period, presenting with a picture that
may range from mildly sticky eyes to an abundant purulent discharge and eyelid
oedema.
Common infectious agents include N. gonorrhoeae, S. aureus, and Chlamydia.
*HQHUDOO\FRQMXQFWLYLWLVRIWKHQHZERUQLVHLWKHUPLOGVPDOODPRXQWRIVWLFN\
H[XGDWHVRUVHYHUHSURIXVHSXVDQGVZROOHQH\HOLGV
7KHODWWHULVRIWHQN. gonorrhoeaeDQGWKUHDWHQVGDPDJHWRWKHFRUQHDZKLOH
WKHIRUPHULVRIWHQS. aureusRUXQGHILQHG

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Treat conjunctivitis with abundant pus immediately to prevent damage to the
cornea that may lead to blindness.
This is often caused by gonorrhoeae.
Treat parents of a neonate with purulent discharge, appropriately.

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» Cleanse or wipe eyes of all newborn babies with a clean cloth, cotton wool or
swab, taking care not to touch or injure the eye.

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5RXWLQHDGPLQLVWUDWLRQIRUHYHU\QHZERUQEDE\
x Chloramphenicol 1%, ophthalmic ointment, applied as soon as possible after birth.
7UHDWPHQW
6WLFN\H\HVZLWKRXWSXUXOHQWGLVFKDUJH
x Chloramphenicol 1%, ophthalmic ointment, applied 6 hourly for 7 days.

3XUXOHQWGLVFKDUJH
LHPLOGGLVFKDUJHZLWKRXWVZROOHQH\HOLGVDQGQRFRUQHDOKD]LQHVV
x Sodium chloride 0.9%, eye washes, immediately then 2–3 hourly, until discharge
clears.
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x Ceftriaxone, IM, 50 mg/kg immediately as a VLQJOHGRVH

2018 18.4
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8VHRQHRIWKHIROORZLQJ
$JH
LQMHFWLRQVPL[HGZLWKZDWHUIRU
Months/years
:HLJKW 'RVH LQMHFWLRQ:),:
kg mg 250 mg/2 mL 500 mg/2 mL
(250 mg diluted (500 mg diluted
in 2 mL WFI) in 2 mL WFI)
‫ޓ‬2–2.5 kg 100 mg 0.8 mL 0.4 mL >34–36 weeks
‫ޓ‬2.5–3.5 kg 150 mg 1.2 mL 0.6 mL >36 weeks–1 month
‫ޓ‬3.5–5.5 kg 200 mg 1.6 mL 0.8 mL ‫ޓ‬1–3 months
Review daily.
$EXQGDQWSXUXOHQWGLVFKDUJHDQGRUVZROOHQH\HOLGVDQGRUFRUQHDOKD]LQHVV
x Sodium chloride 0.9%, eye washes, immediately then hourly until referral.
$1'
x Ceftriaxone, IM, 50 mg/kg immediately as a VLQJOHGRVH and refer
8VHRQHRIWKHIROORZLQJ
$JH
LQMHFWLRQVPL[HGZLWKZDWHUIRU
Months/years
:HLJKW 'RVH LQMHFWLRQ:),:
kg mg 250 mg/2 mL 500 mg/2 mL
(250 mg diluted (500 mg diluted
in 2 mL WFI) in 2 mL WFI)
‫ޓ‬2–2.5 kg 100 mg 0.8 mL 0.4 mL >34–36 weeks
‫ޓ‬2.5–3.5 kg 150 mg 1.2 mL 0.6 mL >36 weeks–1 month
‫ޓ‬3.5–5.5 kg 200 mg 1.6 mL 0.8 mL ‫ޓ‬1–3 months

&$87,2186(2)&()75,$;21(,11(21$7(6$1'&+,/'5(1
» If SUSPECTING SERIOUS BACTERIAL INFECTION in neonate, give ceftriaxone,
even if jaundiced.

 If ” 28 days old, avoid calcium-containing IV fluids for 48 hours after ceftriaxone

» Avoid giving calcium-containing IV fluids (e.g. Ringer Lactate) together with ceftriaxone:

 If > 28 days old, ceftriaxone and calcium-containing IV fluids may be given

administered.

sequentially provided the giving set is flushed thoroughly with sodium chloride 0.9%

 Preferably administer IV fluids without calcium contents.

before and after.

» Always include dose and route of administration of ceftriaxone in the referral letter.

7UHDWERWKSDUHQWVRIQHZERUQEDELHVZKRGHYHORSSXUXOHQWFRQMXQFWLYLWLVDIWHU
KRXUVRIELUWKIRUN. gonorrhoeaeDQGChlamydia.
Parents:
Ɣ Ceftriaxone, IM, 250 mg as a single dose.
o For ceftriaxone IM injection: Dissolve ceftriaxone 250 mg in 0.9 mL lidocaine
1% without epinephrine (adrenaline).
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x Azithromycin, oral, 1 g as a single dose.

2018 18.5
 &+$37(5 (<(&21',7,216

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8UJHQW
» All neonates with abundant purulent discharge and/ or swollen eyelids and/or
corneal haziness.
» Neonate unresponsive to treatment within 2 days.

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B30.1/B30.9 + (H13.1)

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 hands  face cloths

A highly contagious, viral infection, which is spread by contact with:

 towels
It may start in one eye, spreading to the other. More commonly both eyes are infected.
Common symptoms include:
» sore eyes, feeling of itching or burning, often described as being painful
» photophobia
» watery discharge (a yellow discharge indicates a secondary bacterial infection)
» diffuse pink or red conjunctivae, which may become haemorrhagic
» enlarged pre-auricular lymph node
The cornea, iris and pupil are completely normal with normal visual acuity.

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» Advise on correct cleansing or rinsing of eyes with clean water.
» Cold compresses for symptomatic relief.

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x Oxymetazoline 0.025%, eye drops, instil 1–2 drops 6 hourly for a maximum of 7 days.
Children >6 years of age and adults

3DLQ

x Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See dosing table, pg
Children

23.8.

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per

Adults

24 hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.

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» No response after 5 days.
» A unilateral red eye for more than one day.
» Suspected herpes conjunctivitis.
» Loss of vision.

2018 18.6
 &+$37(5 (<(&21',7,216

» Irregularity of pupil.
» Haziness of the cornea.
» Persistent painful eye.

&251($/8/&(5
H16.0

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Corneal ulcers may be caused by an infection a foreign body in the eye, abrasions
on the eye surface, severely dry eye or wearing contact lenses that are left in
overnight.
Presents with:
» Blurring of vision.
» Photophobia.
» Very painful and watery eye.
» White patch/es on the cornea.
» Inflamed conjunctiva.
Herpes virus causes a branching (dendritic) ulcer which can recur and relapse over
the lifetime of an individual.

*(1(5$/0($685(6
» Establish the cause, to determine likelihood of a foreign body.
» Remove any foreign body if visible on sclera or conjunctivae with cotton bud.
» Stain with fluorescein to reveal corneal foreign body or conditions such as abrasion or
dendritic ulcer.
» Cover injured eye with eye pad, provided there is no pressure on the eye.

0(',&,1(75($70(17
If referral is deferred and a culture cannot be done within 12 hours:
x Chloramphenicol 1%, ophthalmic ointment applied 6 hourly.
LoE:IIIiii
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8UJHQWZLWKLQKRXUV
All patients.

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7KLVLVDPHGLFDOHPHUJHQF\

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Damage to one or both eyes caused by contact with irritating chemical substances

2018 18.7
 &+$37(5 (<(&21',7,216

e.g. alkali or acid.

Presents with:
» pain » blurred vision
» inability to open eye » excessive teary and watery eye

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» Irrigate or wash the eye immediately and continuously with clean water or sodium
chloride 0.9% for at least 20 minutes.
» In severe alkaline burn cases, irrigation should be prolonged further.

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/RFDODQDHVWKHWLFLIQHHGHG
x Tetracaine1% eye drops, instil 1drop in the affected eye(s).
o Repeat irrigation of the eye.
o Evert upper eyelid and remove debris with cotton bud.
o Never give anaesthetic drops to the patient to take home as they can cause
blindness if used too often.
x Chloramphenicol 1%, ophthalmic ointment, applied 6 hourly.
3DLQ

x Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See dosing table,
Children

pg 23.8.

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per

Adults

24 hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.

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All cases within 12 hours.

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S05.9+(Y34.99)

Many foreign objects that enter the conjunctiva are the result of mishaps that occur
during everyday activities e.g. eyelashes, dust, dirt, sand.
Foreign objects that enter the eye at high rate of speed pose the highest risk of injury
and may embed in the eye especially the cornea, or may penetrate into the eyeball.
This often follows welding, grinding or hammering metal without wearing a protective
eye visor or spectacles.

'(6&5,37,21
» Disturbance of vision.
» Complaints of foreign body in the eye that may not be visible.
» Pain and lacrimation.

2018 18.8
 &+$37(5 (<(&21',7,216

» Metallic foreign body embedded in the cornea appears as a cloudy spot with a
dark speck (the metal splinter) in the centre.

*(1(5$/0($685(6
» If the foreign body is not embedded, irrigate eye with clean water or sodium
chloride 0.9%.
» Remove any foreign body if visible on sclera or conjunctivae with moist cotton bud.
» Stain with fluorescein to reveal corneal foreign body if it is not obvious.
» Consider X-ray of orbit to exclude intra-ocular metallic foreign body.

0(',&,1(75($70(17
/RFDODQDHVWKHWLFLIQHHGHG
x Tetracaine1% eye drops, instil 1 drop in the affected eye(s), before removal of the
foreign body.
o Apply an eye shield until the anaesthetic effect wears off.
o Never give anaesthetic drops to the patient to take home.
LoE:III
5()(55$/
» Any embedded or penetrating foreign body.
» Failure to remove a visible foreign body.
» Suspected intraocular foreign body.

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S05.9+(Y34.99)

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Eye injuries can be caused by high speed flying objects e.g. pieces of wood, glass,
stone and other materials or by blunt trauma e.g. sporting balls, blow from a fist, facial
trauma in a MVA. Injuries include conjunctival/corneal lacerations, haematoma,
orbital fracture and penetrating open-globe injuries with prolapse of eye contents.
Check for:
» visual loss, hyphema, lacerations
» perforation e.g. teardrop-shaped pupil indicating uveal prolapse
» muscular entrapment associated with a fracture of the orbital bones limiting vision
in one direction

*(1(5$/0($685(6
» Apply an eye shield only. Avoid using pressure patching which increases the risk
of intraocular infection.

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'HHSFRUQHDORUVFOHUDOLQMXULHV
Cover with an eye shield and refer immediately.

x Atropine, 1%, drops, instilled immediately.

If immediate referral is not possible, while awaiting transfer:

x Chloramphenicol 1%, ophthalmic ointment applied immediately.

2018 18.9
 &+$37(5 (<(&21',7,216

3DLQ

x Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See dosing table,
Children

pg 23.8.

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per

Adults

24 hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.
&$87,21
Review the problem daily.
Do not use an eye pad if there is ecchymosis, lid oedema or bleeding.

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,PPHGLDWHO\:
» If the foreign body cannot be removed or an intraocular foreign body is suspected.
» Laceration, perforation or diffuse damage to the cornea or sclera.
» Damage to other structures of the eye, including the eyelid edge.
» Visual abnormalities or limitation of movement of the eye.

 */$8&20$$&87($1'&/26('$1*/(
H40.0-6/H40.8-9

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Acute closed angle glaucoma is damage to the optic nerve caused by raised intra-ocular
pressure. This may result in loss of vision usually in one eye.
Clinical features:
» pupil is moderately dilated and may be oval in shape
» corneal haziness
» pericorneal conjunctival inflammation
» sudden onset of extremely severe, bursting pain and eye redness
» a unilateral, temporal headache, after being exposed to a period of darkness, e.g.
in a cinema
» coloured haloes around lights (bright rings)
» eye feels hard, compared to the other eye, when measured with finger palpation
(this is not an accurate test)
» severe pain in eye (acute)
» nausea and vomiting in severe cases
1RWH The more common chronic open angle glaucoma is usually without symptoms.
(PHUJHQF\PHGLFLQHWUHDWPHQWEHIRUHUHIHUUDO'RFWRUSUHVFULEHG
x Acetazolamide, oral, 500 mg, immediately, followed by 250 mg 6 hourly until
referred.

2018 18.10
 &+$37(5 (<(&21',7,216

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8UJHQW
All patients to an ophthalmologist within 12 hours.

 3$,1)8/5('(<(
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Pain and redness in one eye only, indicates inflammation of the anterior structures of
the eye.
Exclude bacterial or viral conjunctivitis (often bilateral and associated with irritation,
rather than pain).
Consider acute closed angle glaucoma and manage appropriately. See Section 18.4:
Glaucoma, acute and closed angle.

5()(55$/
8UJHQWZLWKLQ±KRXUV:

 Single painful red eye.

» All patients (excluding those with conjunctivitis):

 Corneal ulceration including herpes infection.

 Sudden loss or change in vision, including blurred or reduced vision.
 Sudden onset of visual problems, associated with dizziness, weakness on
either one or both sides, difficulty speaking or swallowing (possible stroke; see

 Foreign body associated with welding or grinding.

Section 15.1: Stroke).

 Chemical burn (see Section 18.3.1: Eye injury, chemical burn).

 Whole eyelid swollen, red and painful (consider orbital cellulitis).
 Coloured haloes around light, dilated oval pupil, headache, nausea, vomiting
(possible glaucoma; see Section 18.4: Glaucoma, acute and closed angle).

 6758&785$/$%1250$/,7,(62)7+((<(
H02.0-1/H02.4/Q10.0-2

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» eyelashes rubbing on the cornea (trichiasis)
» eyelids bent into the eye (entropion)
» eyelids bent out too much (ectropion)
» ptosis (drooping eyelid)

5()(55$/
All patients.

2018 18.11
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H53.0-H53.6/H53.8-9/H54.0-H54.7/H54.9

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Visual problems may be due to refractive errors, damage to the eye or optic nerve.
This may be an indication of underlying disease such as diabetes or hypertension.
$VVHVVPHQW
Look for abnormalities of the eye.
Determine visual acuity accurately in both eyes by using the Snellen chart.
If vision is diminished (less than 6/12) perform the following tests:

 Make a hole of about 1 mm wide in a piece of dark/black paper– you can push
» Pin hole test

 Ask the patient to look through this hole at the Snellen chart.
a hole in paper or card with a pen tip.

 If vision improves, this means that the patient has a refractive error.
» Red reflex test

 With the ophthalmoscope at 0 (zero) the examiner keeps it close to his eye and
The patient looks past the examiner’s head focussing on a distant target.

 The examiner stands about 60 cm away from the patient.

then focuses the beam of light so that it falls on the pupillary area of the cornea.

 In normal individuals, the examiner should be able to see a red or pink colour
(reflex) through the pupil which comes from the retina.
Significance of an absent red reflex.
If there is a history of trauma or diabetes the absence of a red reflex is probably due to:
» retinal detachment
» a vitreous or internal haemorrhage
» mature cataract
If there are cataracts one usually sees:
» black shadows against the red reflex in immature cataracts, or
» absence of red reflex in mature cataracts.
In a patient > 50 years of age with no history of trauma, diabetes or previous eye
disease, an absent red reflex is often due to cataract formation, especially with
decreased visual acuity.
1RWH Associated diabetes or hypertension should be adequately managed with
referral, as surgery can only be considered with appropriately managed disease.

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» Sudden visual loss LQRQHRUERWKH\HV
» Pain or redness LQRQHH\HRQO\especially with visual and pupil abnormalities.
» Recent proptosis of one or both eyes or enlargement of the eye
(buphthalmos/glaucoma) in children.
» Hazy cornea in children.
» Unilateral watery eye.

2018 18.12
 &+$37(5 (<(&21',7,216

:LWKLQGD\V
» Squint of recent onset.
» Suspected or previously diagnosed glaucoma.
» Double vision following recent injury might indicate orbital fracture.
» Leucokoria (white reflex from the pupil).
» Squint at any age if not previously investigated by ophthalmologist.
» Visual loss in patients with systemic disease such as diabetes.

1RQXUJHQWUHIHUUDO
» Cataracts.
» Refractive errors.
» Long-standing blindness – first visit to health facility.

5HIHUHQFHV
i Sodium cromoglycate, 2% eye drops: Castillo M, Scott NW, Mustafa MZ, Mustafa MS, Azuara-Blanco A. Topical
antihistamines and mast cell stabilisers for treating seasonal and perennial allergic conjunctivitis. Cochrane Database Syst
Rev. 2015 Jun 1;(6):CD009566. https://www.ncbi.nlm.nih.gov/pubmed/26028608
ii Sodium cromoglycate, 2% eye drops: Castillo M, Scott NW, Mustafa MZ, Mustafa MS, Azuara-Blanco A. Topical

antihistamines and mast cell stabilisers for treating seasonal and perennial allergic conjunctivitis. Cochrane Database Syst
Rev. 2015 Jun 1;(6):CD009566. https://www.ncbi.nlm.nih.gov/pubmed/26028608
iiiChloramphenicol, ophthalmic ointment: WHO Guidelines for the Management of Corneal Ulcer at Primary, Secondary and

Tertiary Care Health Facilities in the South-East Asia Region, 2004. http://apps.searo.who.int/pds_docs/B3516.pdf

2018 18.13
PHC Chapter 19: Ear, nose and throat
conditions
19.1 Allergic rhinitis
19.2 Common cold (Viral rhinitis)
19.3 Epistaxis
19.4 Otitis
19.4.1 Otitis externa
19.4.2 Otitis media, acute
19.4.3 Otitis media, chronic, suppurative
19.5 Sinusitis, acute, bacterial
19.6 Tonsillitis and pharyngitis





















 &+$37(5 ($5126($1'7+52$7&21',7,216

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Inflammation of the mucous membranes of the nose and paranasal sinuses in
response to an allergen e.g. pollen, house dust, grasses, and animal hair.
Allergic rhinitis is characterised by recurrent episodes of:
» blocked stuffy nose
» watery nasal discharge
» frequent sneezing, often accompanied by nasal itching and irritation
» conjunctival itching and watering
» oedematous pale nasal mucosa
» mouth breathing
» snoring at night
Exclude other causes, such as infections, vasomotor rhinitis, overuse of
decongestant drops, and side effects of antihypertensives and antidepressants.

*(1(5$/0($685(6
Avoid allergens and irritants.

0(',&,1(75($70(17
Adults and children > 6 years of age
ƒ Corticosteroid, e.g.:
x Fluticasone, aqueous nasal solution, 1 spray of 100 mcg in each
LoE:IIIi

nostril 12 hourly.
o Aim the nozzle laterally and upwards (aim for the eye) and not to the back of
the throat.
o Do not sniff vigorously.
o Review 3 monthly. LoE:Iii

1RWH Fluticasone and beclomethasone interacts with protease inhibitors. Refer all
patients on protease inhibitors requiring corticosteroids for further management.
LoE:IIIiii
)RUVKRUWWHUPV\PSWRPDWLFXVH

x Chlorphenamine, oral, 0.1 mg/kg/dose 6–8 hourly. See dosing table, pg 23.3.
Children

x Chlorphenamine, oral, 4 mg, 6–8 hourly.

Adults

)RUUHOLHIRIQRFWXUQDOQDVDOEORFNDJH

x Oxymetazoline 0.05%, intranasal, administered at night for a maximum of 5 days.

Topical nasal decongestant e.g.:

Long-term antihistamines should only be used after an adequate trial of intranasal

corticosteroids and should be added to steroid therapy, if necessary.


2018 19.2
 &+$37(5 ($5126($1'7+52$7&21',7,216

)RUORQJWHUPXVHLQDGXOWVDQGVFKRROJRLQJFKLOGUHQ

x Cetirizine, oral, 5 mg once daily. See dosing table, pg 23.3.

Children: 2–6 years of age

x Cetirizine, oral, 10 mg once daily.

Children > 6 years of age and adults

&$87,21
Do not give an antihistamine to children < 2 years of age.

5()(55$/
» Chronic persistent symptoms.
» Severe symptoms.
» Patients on protease inhibitors, requiring nasal corticosteroids.

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J00

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Colds are self-limiting viral conditions that may last up to 14 days. Colds begin to
clear within 3 days. Colds present with nasal stuffiness and throat irritation.
Malnourished children, the elderly and debilitated patients are at greater risk of
developing complications.
Complications
Secondary bacterial infections, including:
» pneumonia
» otitis media
» sinusitis

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» Limit strenuous activity.
» Ensure adequate hydration.
» Advise patient to return to clinic if earache, tenderness or pain over sinuses
develops or symptoms persist for > 14 days.

0(',&,1(75($70(17
Antibiotics are of no value for the treatment of the common cold.

x Sodium chloride 0.9%, 1–3 drops, instilled into each nostril as required.
Infants

LoE:IIIiv
6\PSWRPDWLFUHOLHIRISDLQDQGIHYHUZLWKGLVFRPIRUW

x Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See dosing table,
Children

pg 23.8.
LoE:IIIv

2018 19.3
 &+$37(5 ($5126($1'7+52$7&21',7,216

5()(55$/
Severe complications.

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See Section 21.2.7: Nose bleeds (epistaxis).

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Inflammation of the external ear may be one of the following:
» Diffuse: An infection of the ear canal, often due to Gram negative bacilli
(especially P. aeruginosa). Pain is increased when chewing and the lining of the
canal may be either inflamed or swollen with dry or moist debris or even a white
or clear discharge.
» Furuncular: Usually caused by Staphylococcus aureus. A painful localised
swelling present at the entrance to the ear canal. May be precipitated by trauma
caused by scratching, e.g. matchsticks, earbuds.

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» Exclude any underlying suppurative otitis media. If suppurative otitis media is
diagnosed, see Section: 19.4.3 Otitis media, chronic, suppurative.
» Most cases recover after thorough cleansing and drying of the ear.
» Keep the ear clean and dry (dry mopping).
» Do not leave pieces of cotton wool, etc. in the ear.
» Do not instil anything into the ear unless prescribed.

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'LIIXVH
» Does not usually require an antibiotic
» Make a wick where possible, using ribbon gauze or other suitable absorbent

x Acetic acid 2% in alcohol, topical, instilled into the ear every 6 hours for 5 days.
cloth, e.g. paper towel to clean and dry the ear.

o Instil 3–4 drops after cleaning and drying the ear.

)XUXQFXODU

x Cephalexin, oral, 12–25 mg/kg/dose 6 hourly for 5 days. See dosing table, pg 23.3.
Children

25
Flucloxacillin, oral, 12–25 mg/kg/dose 6 hourly for 5 days. See dosing table, pg
23.5.

2018 19.4
 &+$37(5 ($5126($1'7+52$7&21',7,216

x Cephalexin, oral, 500 mg 6 hourly for 5 days.

Children > 7 years of age and adults

25
Flucloxacillin, oral, 500 mg 6 hourly for 5 days.
6HYHUHSHQLFLOOLQDOOHUJ\(Z88.0)
Children
ƒ Macrolide, e.g.:
x Azithromycin, oral, 10 mg/kg daily for 3 days. See dosing table pg 23.2.
Children > 35 kg and adults
ƒ Macrolide, e.g.:
x Azithromycin, oral, 500 mg daily for 3 days.

5()(55$/
No response to treatment.

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H66.9

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 pain  drum perforation

Inflammation of the middle ear characterised by:

 loss of hearing  fever in about half of the cases

 red bulging eardrum  loss of the normal light reflex of the eardrum
Mild redness of the eardrum and rubbing the ear are not reliable signs.

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» Do not instil anything into the ear.
» Avoid getting the inside of the ear wet.
» Dry mop ear if discharge is present.
» Do not plug the ear with cotton wool, etc.
» Exclude HIV infection as a contributing factor for recurrent ear infection.

0(',&,1(75($70(17
Children ” 7 years of age
x Amoxicillin, oral, 45 mg/kg/dose 12 hourly for 5 days.
8VHRQHRIWKHIROORZLQJ
:HLJKW 'RVH &DSVXOH $JH
6\UXSmg/ 5mL
kg mg mg Months/years
125 250 250 500
>2–2.5 kg 100 4 mL 2 mL – – 34–36 weeks
>2.5–3.5 kg 125 5 mL 2.5 mL – – Birth–1 month
>3.5–5 kg 175 7 mL 3.5 mL – – >1–3 months
>5–7 kg 250 10 mL 5 mL – – >3–6 months
>7–11 kg 375 15 mL 7.5 mL – – >6–18 months
>11–14 kg 500 – 10 mL 2 1 >18 months–3 years
>14–17.5 kg 750 – 15 mL 3 – >3–5 years
>17.5–25 kg 1000 – – 4 2 >5–7 years

2018 19.5
 &+$37(5 ($5126($1'7+52$7&21',7,216

o Review response after 5 days. LoE:IIIvi

o If pain or discharge persists, consider alternative diagnosis
and continue antibiotics for a further 5 days.
LoE:IIIvii
Children > 7 years of age and adults
x Amoxicillin, oral, 1000 mg 8 hourly for 5 days. LoE:IIIviii

$QWLELRWLFWUHDWPHQWIRUWKRVHZKRKDYHWDNHQDPR[LFLOOLQLQWKHSUHYLRXVGD\V
RUSRRUUHVSRQVHWRGD\FRXUVHRIDPR[LFLOOLQ

x Amoxicillin/clavulanic acid oral, 15–25 mg/kg/dose of amoxicillin component, 8

Children

hourly for 5-10 days.

:HLJKW 'RVH 8VHRQHRIWKHIROORZLQJ $JH
kg mg 6XVS 6XVS 7DEOHW months/years
(amoxicillin 125/31.5 250/62.5 250/125
component) mg/5 mL mg/5 mL
mg/tab
>3.5–5kg 75 mg 3 mL 1.5 mL – >1–3 months
>5–7 kg 100 mg 4 mL 2mL – >3–6 months
>7–9 kg 150 mg 6 mL 3 mL – >6–12 months
>9–11 kg 200 mg 8 mL 4 mL – >12–18 months
>11–14 kg 250 mg 10 mL 5 mL 1 tablet >18 months–3
years
>14–17.5 kg 300 mg 12 mL 6 mL – >3–5 years
>17.5–25 375 mg 15 mL 7.5 mL – >5–7 years
>25–35 kg 500 mg 20 mL 10 mL 2 tablets >7–11 years

x Amoxicillin/clavulanic acid, oral, 875/125 mg 12 hourly for 5 to

Children > 35 kg and adults LoE:IIIix

10 days.
LoE:IIIx
6HYHUHSHQLFLOOLQDOOHUJ\ (Z88.0)
Children
ƒ Macrolide, e.g.:
x Azithromycin, oral, 10 mg/kg daily for 3 days. See dosing table, pg 23.2.
Children > 35 kg and adults
ƒ Macrolide, e.g.:
x Azithromycin, oral, 500 mg daily for 3 days.
3DLQ

x Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See dosing table,
Children

pg 23.8.
xi
LoE:II
x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per 24
Adults

hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.

2018 19.6
 &+$37(5 ($5126($1'7+52$7&21',7,216

5()(55$/
» Severe pain, fever or vomiting, not responding to treatment after 72 hours (if
otoscopy confirmed) or after 24 hours (if otoscopy unconfirmed).
» Recurrent otitis media.
» Painful swelling behind the ear or tenderness on percussion of the mastoid.
» Suspected meningitis.

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A purulent discharge from the ear with perforation for > 2 weeks. If the eardrum has
been ruptured for • 2 weeks, a secondary infection with multiple organisms usually
occurs. Oral antibiotic treatment is generally ineffective.
TB may present with a chronically discharging ear. Consider the diagnosis of TB if
other clinical features suggestive of TB are present (e.g. cough, weight loss, failure
to thrive, etc.). See Section 17.4: Pulmonary tuberculosis (TB).
LoE:IIIxii
*(1(5$/0($685(6
» Do not send pus swabs collected from the external ear canal for routine bacterial
and fungal MC+S (microscopy, culture and sensitivity) or for microscopy and
culture for tuberculosis.
» Explain to patients and caregivers that a chronically draining ear can only heal if
it is dry.
» Dry mopping is the most important part of the treatment. It should be
demonstrated to the child’s caregiver or patient if old enough. Roll a piece of clean
absorbent cloth into a wick.
– Carefully insert the wick into the ear with twisting action.
– Remove the wick and replace with a clean dry wick.
– Repeat this until the wick is dry when removed.
» Do not leave anything in the ear.
» Do not instil anything else in the ear.
» Avoid getting the inside of the ear wet while swimming and bathing.
» Check HIV status if unknown.

5()(55$/
» All sick children, vomiting, drowsy, etc.
» Painful swelling behind the ear.
» Ear discharge still present for • 4 weeks, despite dry mopping.
1RWH These referrals do not all require referral to an ENT. They may be referred to
a hospital outpatient department for consideration of a topical antibiotic eardrops.
» Any attic perforation.
» Any perforation not progressively improving after 3 months or closed by 6 months,
even if dry.
» Moderate or severe hearing loss.

2018 19.7
 &+$37(5 ($5126($1'7+52$7&21',7,216

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J01.0-4/J01.8-9

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Bacterial infection of one or more paranasal sinuses that occurs most often after a
viral nasal infection or allergic rhinitis.
Bacterial sinusitis is characterised by:
» Deterioration of a common cold after 5–7 days.
» Headache.
» Purulent nasal discharge, especially if unilateral.
» Pain and tenderness over one or more sinuses.
» Nasal obstruction.
» Fever.
1RWHSinusitis is uncommon in children < 5 years of age, as sinuses are not fully
developed.

*(1(5$/0($685(6
Consider HIV in recurrent sinusitis.

0(',&,1(75($70(17
Children ” 3 years of age
x Amoxicillin, oral, 45 mg/kg/dose 12 hourly for 5 days.
8VHRQHRIWKHIROORZLQJ
:HLJKW 'RVH &DSVXOH $JH
6\UXSPJP/
kg mg PJ Months/years
125 250 250 500
>2–2.5 kg 100 4 mL 2 mL – – 34–36 weeks
>2.5–3.5 kg 125 5 mL 2.5 mL – – Birth–1 month
>3.5–5 kg 175 7 mL 3.5 mL – – >1–3 months
>5–7 kg 250 10 mL 5 mL – – >3–6 months
>7–11 kg 375 15 mL 7.5 mL – – >6–18 months
>11–14 kg 500 – 10 mL 2 1 >18 months–3 years

Children > 3 years of age

x Amoxicillin, oral, 500 mg 8 hourly for 5 days.

x Amoxicillin, oral, 500 mg 8 hourly for 5 days.

Adults

6HYHUHSHQLFLOOLQDOOHUJ\ (Z88.0)
Children
ƒ Macrolide, e.g.:
x Azithromycin, oral, 10 mg/kg daily for 3 days. See dosing table, pg 23.2.

Children > 35 kg and adults

ƒ Macrolide, e.g.:
x Azithromycin, oral, 500 mg daily for 3 days.
$1'

2018 19.8
 &+$37(5 ($5126($1'7+52$7&21',7,216

x Oxymetazoline, nose drops, 2 drops in each nostril 6–8 hourly for not more than
5 days continuously.
o Children > 5 years of age: 0.025% LoE:IIIxiii
o Adults: 0.05%
$1'25
x Sodium chloride 0.9%, nose drops, use frequently and in fairly large volumes.
3DLQ

x Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See dosing table,
Children

pg 23.8.

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per

Adults

24 hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.

5()(55$/
» Fever lasting > 48 hours.
» Poor response > 5 days.
» Complications, e.g. periorbital cellulitis with periorbital swelling.
» Oedema over a sinus.
» Recurrent sinusitis.
» Meningeal irritation.

7216,//,7,6$1'3+$5<1*,7,6
J03.0/J03.8-9/J35.0/J02.0/J02.8-9/J31.1-2

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A painful red throat and/or enlarged inflamed tonsils. White pus exudates, either spots
or patches, may be present. Tender anterior cervical lymphadenopathy may be present.
Viruses cause the majority of cases. Group A beta haemolytic streptococcus causes
20% of pharyngitis/tonsillitis, and may result in rheumatic fever (which can cause
serious heart disease) as well as local suppurative complications.
Other clinical features that might suggest streptococcal infection may include palatal
petechiae, inflamed tongue mucosal papillae (strawberry tongue), a scarlitiniform
(i.e.: rough, diffuse, fine papular) rash.

*(1(5$/0($685(6
» Homemade salt mouthwash, gargle for 1 minute twice daily:
– 2.5 mL (½ medicine measure) of table salt in 200 mL lukewarm water.
– Do not give to children unable to gargle.
» Advise adequate hydration.
» Avoid irritants e.g. vaporubs inserted into nostrils.

2018 19.9
 &+$37(5 ($5126($1'7+52$7&21',7,216

» For children < 6 years of age: Soothe the throat with, breastmilk. If not exclusively
breastfed, give warm water or weak tea: add sugar or honey and lemon if
available.

0(',&,1(75($70(17
Antibiotics are not required for all patients with a sore throat.
Antibiotics to eradicate streptococci must be given to patients presenting with a sore
throat who are at risk for rheumatic fever (3–21 years of age) if they have:
» Enlarged tonsils;
3/86 at least one of the following criteria:
 Exudates on their tonsils
 No cough
 No runny nose

x
LoE:Ixiv
Benzathine benzylpenicillin, ,0, single dose.
o Children < 30 kg: 600 000 IU.
o Children • 30 kg and adults: 1.2 MU.
o Dissolve benzathine benzylpenicillin 1.2 MU in 3.2 mL lidocaine 1% without
adrenaline (epinephrine) or 3 mL water for injection.
25
Children
x Amoxicillin, oral, 50 mg/kg daily for 10 days.
:HLJKW 'RVH 8VHRQHRIWKHIROORZLQJ $JH
kg mg 6XVS &DSVXOH Months/years
125 250 250 500
mg/5mL mg/5mL mg mg
>2–2.5 kg 100 mg 4 mL 2 mL – – >34–36 weeks
>2.5–3.5 kg 150 mg 6 mL 3 mL – – >36 weeks–1 month
>3.5–5 kg 200 mg 8 mL 4 mL – – >1–3 months
>5–7 kg 275 mg 11 mL 5.5 mL – – >3–6 months
>7–11 kg 400 mg – 8 mL – – >6–18 months
>11–17.5 kg 575 mg – 11.5 mL – – >18 months–5 years
>17.5–25 kg 750 mg – 15 mL 3 – >5–7 years
>25–35 kg 1000 mg – 20 mL 4 2 >7–11 years
>35kg 2000 mg – – 4 >11 years
LoE:Ixv
x Amoxicillin, oral, 1 000 mg 12 hourly for 10 days.
Adults

 LoE:IIIxvi
25

x Phenoxymethylpenicillin, oral, 250 mg 12 hourly for 10 days.

Children: 18 months–11 years of age

x Phenoxymethylpenicillin, oral, 500 mg 12 hourly for 10 days.

Children > 11 years of age and adults

2018 19.10
 &+$37(5 ($5126($1'7+52$7&21',7,216

6HYHUH3HQLFLOOLQDOOHUJ\(Z88.0)
Children > 3 years of age
ƒ Macrolide, e.g.:
x Azithromycin, oral, 10 mg/kg daily for 3 days. See dosing table, pg 23.2.
Children > 35 kg and adults
ƒ Macrolide, e.g.:
x Azithromycin, oral, 500 mg daily for 3 days.
3DLQ

x Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See dosing table,
Children

pg 23.8.

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per

Adults

24 hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.

5()(55$/
» Any suppurative complications, e.g. retropharyngeal or peritonsillar abscess.
» Tonsillitis accompanied by difficulty in opening the mouth (trismus).
» Recurrent tonsillitis (• 6 documented episodes/year) for possible tonsillectomy.
» Suspected acute rheumatic fever.
» Suspected acute glomerulonephritis.
» Heart murmurs not previously diagnosed.

5HIHUHQFHV
i Corticosteroids, topical nasal (children > 6 years of age): South African Medicines Formulary. 12th Edition. Division of
Clinical Pharmacology. University of Cape Town. 2016.
ii Corticosteroids, topical nasal (therapeutic class): Chong LY, Head K, Hopkins C, Philpott C, Burton MJ, Schilder AG.
Different types of intranasal steroids for chronic rhinosinusitis. Cochrane Database Syst Rev. 2016 Apr 26;4:CD011993.
https://www.ncbi.nlm.nih.gov/pubmed/27115215
Corticosteroids, topical nasal (therapeutic class): South African Medicines Formulary. 12th Edition. Division of Clinical
Pharmacology. University of Cape Town. 2016.
Corticosteroids, topical nasal (therapeutic class): Herman H. Once-daily administration of intranasal corticosteroids for
allergic rhinitis: a comparative review of efficacy, safety, patient preference, and cost. Am J Rhinol. 2007 Jan-Feb;21(1):70-9.
https://www.ncbi.nlm.nih.gov/pubmed/17283565
Fluticasone, topical, aqueous nasal spray: Contract circular HP07-2017DAI. http://www.health.gov.za/
iii Beclomethasone, topical, aqueous nasal spray (drug-drug interaction with protease inhibitors): Foisy MM, Yakiwchuk EM,
Chiu I, Singh AE. Adrenal suppression and Cushing's syndrome secondary to an interaction between ritonavir and fluticasone:
a review of the literature. HIV Med. 2008 Jul;9(6):389-96. https://www.ncbi.nlm.nih.gov/pubmed/18459946
Beclomethasone, topical, aqueous nasal spray (drug-drug interaction with protease inhibitors): University of Liverpool. HIV
drug interaction database. https://www.hiv-druginteractions.org/
Beclomethasone, topical, aqueous nasal spray (drug-drug interaction with protease inhibitors): Frankel JK, Packer CD.
Cushing's syndrome due to antiretroviral-budesonide interaction. Ann Pharmacother. 2011 Jun;45(6):823-4.
https://www.ncbi.nlm.nih.gov/pubmed/21558486
Beclomethasone, topical, aqueous nasal spray (drug-drug interaction with protease inhibitors): Yoganathan K, David L,
Williams C, Jones K. Cushing's syndrome with adrenal suppression induced by inhaled budesonide due to a ritonavir drug
interaction in a woman with HIV infection. Int J STD AIDS. 2012 Jul;23(7):520-1.
https://www.ncbi.nlm.nih.gov/pubmed/22844010
ivSodium chloride 0.9% nose drops: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.

University of Cape Town. 2016.

vParacetamol, oral: NICE Clinical Guideline-Feverish illness in children: assessment and initial management in children

younger than 5 years, May 2013. http://www.nice.org.uk/guidance/cg160/chapter/recommendations

viAmoxicillin, oral (AOM – children): Siddiq S, Grainger J. The diagnosis and management of acute otitis media:

2018 19.11
 &+$37(5 ($5126($1'7+52$7&21',7,216

American Academy of Pediatrics Guidelines 2013. Arch Dis Child Educ Pract Ed. 2015 Aug;100(4):193-7.
https://www.ncbi.nlm.nih.gov/pubmed/25395494
Amoxicillin, oral (AOM – children): National Department of Health, Integrated Management of Childhood Illness (IMCI)
Guidelines, 2014. http://www.health.gov.za/
Amoxicillin, oral (AOM – children): Brink AJ, Cotton M, Feldman C, Finlayson H, Friedman R, Green R, Hendson W,
Hockman M, Maartens G, Madhi S, Reubenson G, Silverbauer E, Zietsman I. Updated recommendations for the management
of upper respiratory tract infections in South Africa. S Afr Med J. 2015 Apr 6;105(5):344-52.
https://www.ncbi.nlm.nih.gov/pubmed/26242659
viiAntibiotics, oral (AOM-children): Venekamp RP, Sanders SL, Glasziou PP, Del Mar CB, Rovers MM. Antibiotics for

acute otitis media in children. Cochrane Database Syst Rev. 2015 Jun 23;(6):CD000219.
https://www.ncbi.nlm.nih.gov/pubmed/26099233
Antibiotics, oral (AOM-children): NICE. Otitis media (acute): antimicrobial prescribing. Clinical guideline NG91, March 2018.
https://www.nice.org.uk/guidance/ng91
viiiAmoxicillin, oral (AOM – children > 7 years of age and adults): Brink AJ, Cotton M, Feldman C, Finlayson H, Friedman R,

Green R, Hendson W, Hockman M, Maartens G, Madhi S, Reubenson G, Silverbauer E, Zietsman I. Updated

recommendations for the management of upper respiratory tract infections in South Africa. S Afr Med J. 2015 Apr
6;105(5):344-52. https://www.ncbi.nlm.nih.gov/pubmed/26242659
ixAmoxicillin/clavulanate, oral (AOM – children): Siddiq S, Grainger J. The diagnosis and management of acute otitis media:

American Academy of Pediatrics Guidelines 2013. Arch Dis Child Educ Pract Ed. 2015 Aug;100(4):193-
7.https://www.ncbi.nlm.nih.gov/pubmed/25395494
Amoxicillin/clavulanate, oral (AOM – children): Brink AJ, Cotton M, Feldman C, Finlayson H, Friedman R, Green R,
Hendson W, Hockman M, Maartens G, Madhi S, Reubenson G, Silverbauer E, Zietsman I. Updated recommendations for the
management of upper respiratory tract infections in South Africa. S Afr Med J. 2015 Apr 6;105(5):344-52.
https://www.ncbi.nlm.nih.gov/pubmed/26242659
xAmoxicillin/clavulanate, oral (AOM – adults): Brink AJ, Cotton M, Feldman C, Finlayson H, Friedman R, Green R, Hendson

W, Hockman M, Maartens G, Madhi S, Reubenson G, Silverbauer E, Zietsman I. Updated recommendations for the
management of upper respiratory tract infections in South Africa. S Afr Med J. 2015 Apr 6;105(5):344-52.
https://www.ncbi.nlm.nih.gov/pubmed/26242659
xi Paracetamol, oral (AOM – children): Sjoukes A, Venekamp RP, van de Pol AC, Hay AD, Little P, Schilder AG,

Damoiseaux RA. Paracetamol (acetaminophen) or non-steroidal anti-inflammatory drugs, alone or combined, for pain relief in
acute otitis media in children. Cochrane Database Syst Rev. 2016 Dec 15;12:CD011534.
https://www.ncbi.nlm.nih.gov/pubmed/27977844
xiiTB testing of pus swabs: Baron EJ, Miller JM, Weinstein MP, Richter SS, Gilligan PH, Thomson RB Jr, Bourbeau P, Carroll

KC, Kehl SC, Dunne WM, Robinson-Dunn B, Schwartzman JD, Chapin KC, Snyder JW, Forbes BA, Patel R, Rosenblatt JE,
Pritt BS. A guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2013 recommendations by
the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM)(a). Clin Infect Dis. 2013
Aug;57(4):e22-e121. http://www.ncbi.nlm.nih.gov/pubmed/23845951
xiiiOxymetazoline, nose drops: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.

University of Cape Town. 2016.

xivAntibiotics (Tonsillitis and pharyngitis): Engel MF, Bruns AH, Hulscher ME, Gaillard CA, Sankatsing SU, Teding van

Berkhout F, Emmelot-Vonk MH, Kuck EM, Steeghs MH, den Breeijen JH, Stellato RK, Hoepelman AI, Oosterheert JJ. A
tailored implementation strategy to reduce the duration of intravenous antibiotic treatment in community-acquired pneumonia:
a controlled before-and-after study. Eur J Clin Microbiol Infect Dis. 2014 Nov;33(11):1897-908.
https://www.ncbi.nlm.nih.gov/pubmed/24859925
xv Amoxicillin, oral (children): Clegg HW, Ryan AG, Dallas SD, Kaplan EL, Johnson DR, Norton HJ, Roddey OF, Martin ES,

Swetenburg RL, Koonce EW, Felkner MM, Giftos PM. Treatment of streptococcal pharyngitis with once-daily compared with
twice-daily amoxicillin: a noninferiority trial. Pediatr Infect Dis J. 2006 Sep;25(9):761-7.
https://www.ncbi.nlm.nih.gov/pubmed/16940830
Amoxicillin, oral (children): Lennon DR, Farrell E, Martin DR, Stewart JM. Once-daily amoxicillin versus twice-daily penicillin
V in group A beta-haemolytic streptococcal pharyngitis. Arch Dis Child. 2008 Jun;93(6):474-8.
https://www.ncbi.nlm.nih.gov/pubmed/18337284
xviAmoxicillin, oral (adults): Brink AJ, Cotton M, Feldman C, Finlayson H, Friedman R, Green R, Hendson W, Hockman M,

Maartens G, Madhi S, Reubenson G, Silverbauer E, Zietsman I. Updated recommendations for the management of upper
respiratory tract infections in South Africa. S Afr Med J. 2015 Apr 6;105(5):344-52.
http://www.ncbi.nlm.nih.gov/pubmed/26242659
Amoxicillin, oral (adults): National Department of Health: National Department of Health: Affordable Medicines, EDP-Primary
Health Care level. Medicine Review: Phenoxymethylpenicillin vs amoxicillin for tonsilitis_pharyngitis, October 2016.
http://www.health.gov.za/

2018 19.12
PHC Chapter 20: Pain
20.1 Pain control
20.2 Acute pain
20.3 Chronic non-cancer pain
20.4 Chronic cancer pain




&+$37(5 3$,1

3$,1&21752/
R52.0/R52.9

'(6&5,37,21
Pain is an unpleasant sensation experience associated with actual or potential
tissue injury. It is always subjective. It is affected by the patient's mood, morale
and the meaning the pain has for the patient.
Active pain assessment and self-report is the key to effective pain management.
Different pain assessment scales should be used for different ages and
intellectual categories of patients.
)/$&&6&$/(
For babies and intellectually impaired children and critically ill adults who are
unable to self-report pain the FLACC (face, legs, activity, cry, consolability)
scale is used. Evaluate each item and arrive at a total score ranging from 0
to10.A score of •4 needs active pain management.
,WHP   
)DFH No particular Occasional grimace or Frequent to
expression or frown, withdrawn constant frown,
smile disinterested clenched jaw,
quivering chin
/HJV Normal position Uneasy, restless, Kicking, or legs
or relaxed tense drawn up
$FWLYLW\ Lying quietly, Squirming, shifting Arched, rigid or
normal position, back and forth, tense jerking
moves easily
&U\ No cry Moans or whimpers, Crying steadily,
(awake or occasional complaint screams or sobs,
asleep) frequent complaints
&RQVRODELOLW\ Content, relaxed, Reassured by Difficult to console
no need to occasional touching, or comfort
console hugging or “talking to”,
distractible
5(9,6(')$&(63$,16&$/(
» Use in children > 4 years of age.
» Ask them to point to the face that best depicts their level of pain.




9,68$/$1$/2*8(6&$/(
» Use in children over 7 and adults who can communicate
» Ask: “on a scale of 0 -10, ‘0’ being no pain and to ‘10’being the worst
pain, what number are you feeling right now?”

2018 20.2
&+$37(5 3$,1

Pain should be assessed by:

» duration
» severity, e.g. does the patient wake up because of the pain?
» site
» character, e.g. stabbing, throbbing, crushing, cramp like
» persistent or intermittent
» relieving or aggravating factors
» accompanying symptoms e.g. nausea and vomiting, visual disturbances
» distribution of pain
» referred pain

$&87(3$,1
R52.0/R52.9

'(6&5,37,21
Pain that has been present for less than 4 weeks and usually occurs in
response to tissue damage.

*(1(5$/0($685(6
» Patient counselling.
» Lifestyle adjustment.

0(',&,1(75($70(17
0LOGSDLQ
Non-opioid treatment.
1RQLQIODPPDWRU\RUSRVWWUDXPD

x Paracetamol, oral, 15 mg/kg/dose 6 hourly when required. See

Children

dosing table, pg 23.8.

x Paracetamol, oral, 1 g 4–6 hourly when required

Adults

o Maximum dose: 15 mg/kg/dose.

o Maximum dose: 4 g in 24 hours.
3DLQDVVRFLDWHGZLWKLQIODPPDWLRQ
Adults
ƒ NSAIDs, e.g.:
x Ibuprofen, oral, 400 mg 8 hourly with or after a meal.
If no relief after 2 or 3 doses, combine paracetamol and ibuprofen at the
above dosages.
LoE:IIIi
0RGHUDWHSDLQ
If no relief to paracetamol:
$''


2018 20.3
&+$37(5 3$,1

Children
ƒ NSAIDs, e.g.:
x Ibuprofen, oral, 5–10 mg/kg/dose 8 hourly with or after a meal. See
dosing table, pg 23.6.
o Discontinue if not effective after 2–3 days. LoE:IIIii
If no response to paracetamol and ibuprofen, refer.
Adults
ƒ NSAIDs, e.g.:
x Ibuprofen, oral, 400 mg 8 hourly with or after a meal.
o Discontinue if not effective after 2–3 days.
iii
If still no relief to paracetamol and ibuprofen: LoE:III
$''
x Tramadol, oral, 50 mg, 4–6 hourly as a starting dose. (Doctor prescribed).
o May be increased to a maximum of 400 mg daily.
$FXWHVHYHUHSDLQ
Children
Refer.

x Tramadol, oral, 50 mg, 4–6 hourly as a starting dose.

Adults

o May be increased to a maximum of 400 mg daily.

$1'
x Paracetamol, oral, 1 g 4- 6 hourly when required to a maximum of 4 doses
per 24 hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.

25
Morphine solution, oral.
o Starting dose: 10–15 mg (maximum 0.2 mg/kg) 4 hourly.
o Elderly or frail patients: 2.5–5 mg (maximum 0.1 mg/kg) 4 hourly.

25
Morphine, IM, 10 mg, 4–6 hourly when required.
LoE:IIIiv
25
Morphine, IV, to a total maximum dose of 10 mg.
o Dilute 10 mg up to 10 mL with sodium chloride 0.9%.
o Morphine, IV, 3–5 mg as a single dose then further boluses of 1–2
mg/minute and monitor closely.
o Total maximum dose: 10 mg.
o Repeat after 4 hours if necessary.
o Monitor response to pain and effects on respiration and BP.
LoE:IIIv

2018 20.4
&+$37(5 3$,1

Patients requiring morphine for acute pain of unknown cause or pain not
responding with 1 dose must be referred for definitive treatment.

Precautions and special comments on the use of morphine

» Morphine may cause respiratory depression. This can be reversed with
naloxone. See Section 21.3.3: Exposure to poisonous substances.
'RQRWDGPLQLVWHU morphine in:
– severe head injury
– acute asthma– uncontrolled hypothyroidism
» Morphine can be used for acute abdominal pain without leading to
surgical misdiagnosis.
» 8VHmorphineZLWKH[WUHPHFDUH if there is:
 recent or concurrent alcohol intake or other CNS depressants
 advanced chronic obstructive pulmonary disease, or other respiratory

 hypovolaemia or shock
disease with imminent respiratory failure

 advanced liver disease

 in the elderly
In these circumstances use:

x Morphine, IV, to a total maximum dose of 10 mg.

Adults

o Dilute 10 mg up to 10 mL with sodium chloride 0.9%.

o Morphine, IV, 3–5 mg as a single dose then further boluses of 1–2
mg/minute and monitor closely.
o Total maximum dose: 10 mg.
o Repeat after 4 hours if necessary.
o Monitor response to pain and effects on respiration and BP.
LoE:IIIvi
If morphine has been administered, the time and dose should be clearly
documented on the referral letter as this may alter some of the clinical
features of acute abdomen or head injury.

5()(55$/
» All children with acute severe pain.
» No response to oral pain control and unable to initiate opioid therapy.
» Uncertain diagnosis.
» Management of serious underlying conditions.

&+521,&121&$1&(53$,1
'(6&5,37,21
Pain that is present for more than 4 weeks.
It can arise from:

2018 20.5
&+$37(5 3$,1

» tissue damage (nociceptive pain), e.g. arthritis, lower back pain, pleurisy; or
» injury to nerves (neuropathic pain) e.g. post herpetic neuralgia (pain following
shingles), trigeminal neuralgia, diabetic neuropathy, HIV related peripheral
neuropathy, drug induced peripheral neuropathy or phantom limb; or
» Pain experienced in the absence of tissue damage, inflammation nor
nerve damage (central pain) e.g. fibromyalgia, irritable bowel syndrome.
Assess pain severity, functional status, medication use including self-
medication, co-morbid illnesses, etc.
Actively look for concomitant depression and anxiety/somatoform pain disorders.

*(1(5$/0($685(6
» Lifestyle adjustments.
» Occupational therapy and physiotherapy as appropriate.
» Address psycho-social problems e.g. stress, anxiety, sleep disturbances.

0(',&,1(75($70(17
The principles are the same as with cancer pain relief. Analgesics should be
given by mouth, regularly, in a stepwise manner to ensure adequate relief.
Neuropathic and central pain are best treated with analgesics in addition to
tricyclic antidepressants.
It is useful to combine different classes of analgesics for the additive effects,
depending on pain severity.
0LOGSDLQ
Children
Chronic non-cancer conditions such as genetic conditions, nerve damage

x Paracetamol, oral, 15 mg/kg/dose 6 hourly when required. See

pain, chronic musculoskeletal pain, and chronic abdominal pain:

dosing table, pg 23.8.

LoE:IIIvii
x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses
Adults

per 24 hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.
3DLQDVVRFLDWHGZLWKLQIODPPDWLRQ
Adults
ƒ NSAIDs, e.g.:
x Ibuprofen, oral, 400 mg 8 hourly with or after a meal.
25 LoE:IIIviii
Combine paracetamol and ibuprofen at the above dosages.
0RGHUDWHSDLQ
Adults
If still no relief to simple analgesics (paracetamol and/or ibuprofen), as above
$''
x Tramadol, oral, 50 mg, 4–6 hourly as a starting dose (Doctor initiated).

2018 20.6
&+$37(5 3$,1

o May be increased to a maximum of 400 mg daily.

$GMXYDQWWKHUDS\
Adults

x Amitriptyline, oral, 25 mg at night (Doctor initiated).

In addition to analgesia as above:

o Titrate up to a maximum of 75 mg at night.

8QGHUUHFRJQLWLRQRISDLQDQGXQGHUGRVLQJRIDQDOJHVLFVLV
FRPPRQLQFKURQLFSDLQ
$QDOJHVLFVVKRXOGEHJLYHQUHJXODUO\UDWKHUWKDQRQO\ZKHQ
UHTXLUHGLQSDWLHQWVZLWKRQJRLQJSDLQ

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» Pain requiring strong opioids.
» Pain requiring definitive treatment for the underlying disease.
» All children.

&+521,&&$1&(53$,1
R52.9

'(6&5,37,21
Cancer pain is usually persistent and progressive. Pain assessment requires
training in:
» psycho-social assessment
» assessment of need of type and dose of analgesics
» pain severity assessment
Pain severity and not the presence of pain determine the need for treatment.
Medicinal treatment for pain should never be withheld.
Pain is what the patient says it is.
8QGHUUHFRJQLWLRQRISDLQDQGXQGHUGRVLQJZLWKDQDOJHVLFVLV
FRPPRQLQFKURQLFFDQFHUSDLQ
$QDOJHVLFVVKRXOGEHJLYHQUHJXODUO\UDWKHUWKDQRQO\ZKHQUHTXLUHG
LQSDWLHQWVZLWKRQJRLQJSDLQ

*(1(5$/0($685(6
» Counselling/hospice care.
» Occupational therapy may be required.
» Management of psycho-social factors.
1RWH
» Appropriate care is provided from the time of diagnosis.
» Home palliative care is provided by the family or caregiver with the
support of health care professionals. See Chapter 22: Medicines used in
palliative care.

2018 20.7
&+$37(5 3$,1

0(',&,1(75($70(17
Pain should be controlled as rapidly as possible. If pain is not adequately
controlled within 2 days, proceed to the next step. Cancer pain in children is
managed by the same principles but using lower doses of morphine than adults.

5(&200(1'('67(36,10$1$*(0(172)&$1&(53$,1
$GXOWV
0LOGSDLQ 0RGHUDWHSDLQ 6HYHUHSDLQ
Step 3: strong opioid
e.g. morphine
“non opioid
“ adjuvant therapy

Step 2: weak opioid

e.g. tramadol
 non opioid
“ adjuvant therapy

Step 1: non-opioid,
e.g. paracetamol
and/or ibuprofen where
anti-inflammatory effect
is required


6WHS
1RQRSLRLG
x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses
per 24 hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.
LoE:IIix
$1'25
ƒ NSAIDs, e.g.:
x Ibuprofen, oral, 400 mg 8 hourly with or after a meal.
LoE:IIx
6WHS

x Tramadol, oral, 50 mg, 4–6 hourly as a starting dose (Doctor prescribed).

Add weak opioid to Step 1

o May be increased to a maximum of 400 mg daily.

&$87,21
Use with caution when administered with antidepressants e.g. amitrLptyline
to avoid over sedation.
LoE:IIxi

2018 20.8
&+$37(5 3$,1

6WHS 

x Morphine, oral, 4 hourly (Doctor prescribed).

Paracetamol and/or ibuprofen can be used with morphine in step 3

o Start with5–10 mg.

o Titrate the dose and dose frequency against the effect on pain.
If dosage is established and patient is able to swallow:
x Morphine, long-acting, oral, 8–12 hourly (Doctor prescribed).
o Start with10–20 mg/dose.
o Titrate the dose and dose frequency against the effect on pain.
LoE:IIIxii

x Morphine solution, oral, 4 hourly. (Doctor prescribed)

Elderly adults or severe liver impairment:

o Start with2.5–5 mg.

o Titrate the dose and dose frequency against the effect on pain.
Titrate the dose and dose frequency against the effect on pain.
1RWH
» There is no maximum dose for morphine – dose is titrated upward against
the effect on pain.
» For the management of morphine overdose, see Section 21.3.3:
Exposure to poisonous substances.
&KLOGUHQ
Stepwise approach to pain management is recommended:
0LOGSDLQ 0RGHUDWHWR6HYHUHSDLQ
Step 2: strong opioid
e.g. morphine
“non opioid
“ adjuvant therapy

Step 1: non-opioid,
e.g. paracetamol
and/or ibuprofen where anti-
inflammatory effect is required


LoE:IIIxiii
1RQRSLRLG
x Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See
dosing table, pg 23.8.
ƒ
x
NSAIDs, e.g.:
Ibuprofen, oral, 5–10 mg/kg/dose 8 hourly with or after a meal. See
dosing table, pg 23.6.
o Where anti-inflammatory effect is required.
o Can be used in combination with paracetamol or opioids.
o Discontinue if not effective after 2–3 days.
xiv
2SLRLG LoE:III
x Morphine, oral, 0.2–0.4 mg/kg/dose 4–6 hourly according to severity of

2018 20.9
&+$37(5 3$,1

the pain. See dosing table, pg 23.8 (Doctor prescribed).

LoE:IIIxv
$GMXYDQWWKHUDS\
Adults

x Amitriptyline, oral, 25 mg at night. (Doctor initiated).

In addition to analgesia as above:

o Titrate up to a maximum of 75 mg at night.

6LJQLILFDQWQDXVHDDQGYRPLWLQJ

x Metoclopramide oral, 10 mg, 8 hourly as needed.

Adults

Children
For treatment of nausea and vomiting in the palliative care setting, see
Section: 22.1.3 Nausea and vomiting.
&RQVWLSDWLRQ
A common problem due to long-term use of opioids, which can be prevented
and should always be treated.

x Lactulose, oral, 0.5 mL/kg/dose once daily. See dosing table, pg 23.6.
Children

o If poor response, increase frequency to 12 hourly.

x Lactulose, oral, 10–20 mL once daily.

Adult

o If poor response, increase frequency to 12 hourly.

(See Section: 22.1.1 Constipation for further management of palliative
constipation).
)RUSUXULWXV

x Chlorphenamine, oral, 0.1 mg/kg/dose 6–8 hourly. See dosing table, pg 23.3.
Children

x Chlorphenamine, oral, 4 mg, 6–8 hourly.

Adults

&$87,21
Do not give an antihistamine to children < 2 years of age.

)RUDQ[LHW\

x Diazepam, oral, 0.04 mg/kg/dose 8–12 hourly (Doctor prescribed).

Children

:HLJKW 'RVH 7DEOHW $JH

kg mg 2 mg months/years
>9–17.5 kg 0.5 mg ¼ tablet >12 months–3 years
>17.5–25 kg 1 mg ½ tablet >5–7 years
>25–35 kg 1.5 mg ¾ tablet >7–11 years
>35 kg 2mg 1 tablet >11 years
o May be increased to 0.2 mg/kg/dose 8–12 hourly.
o Beware of respiratory depression if given with morphine.

2018 20.10
&+$37(5 3$,1

x Diazepam, oral, 0.2 mg/kg/dose 8–12 hourly (Doctor initiated).

o Beware of respiratory depression if given with morphine.
:HLJKW 'RVH 8VHRQHRIWKHIROORZLQJ $JH
kg mg WDEOHWV months/years
2 mg 5 mg
>9–11 kg 2 mg 1 tablet – >12–18 months
>11–14 kg 2.5 mg – ½ tablet >18 months–3 years
>14–17.5 kg 3 mg 1½tablets – >5–7 years
>17.5–25 kg 4 mg 2 tablets – >5–7 years
>25 kg 5 mg – 1 tablet >7 years

x Diazepam, oral, 2–5 mg every 12 hours for a maximum of two weeks.

Adults

%UHDNWKURXJKSDLQ
Breakthrough pain is pain that occurs before the next regular dose of
analgesics. This is due to an inadequate regular dose.
It is recommended that an additional dose of morphine (up to the same dose as
the regular 4-hourly dose) be administered for breakthrough pain. The next
regular dose of morphine must still be given at the prescribed time, and not be
delayed because of the additional dose.
The regular 4-hourly dosage should be titrated upward against the effect on
pain in the following way:
» Add up the amount of “breakthrough morphine” needed in 24 hours.
» Divide this amount by 6 (the number of 4 hourly doses in 24 hours).
» The next day increase each dose by that amount.
Example:
Patient gets 10 mg morphine every four hours.
The patient has 3 episodes of breakthrough pain:
3 x 10 mg = 30 mg
30 mg ÷ 6 = 5 mg
The regular 4 hourly dose of 10 mg will be increased by 5 mg
i.e. 10 mg + 5 mg = 15 mg.
The increased morphine dose will be 15 mg 4 hourly.

5()(55$/
» Uncontrolled pain.
» Pain uncontrolled by step 1 if no doctor available.
» Severe emotional or other distress which may aggravate the perception of
pain.
» Nausea and vomiting associated with pain in children.
5HIHUHQFHV
i Ibuprofen, oral (ceiling effect): National Department of Health, Essential Drugs Programme: Adult Hospital Level
STGs and EML, 2015. http://www.health.gov.za/

2018 20.11
&+$37(5 3$,1

Ibuprofen, oral (ceiling effect): Laska EM, Sunshine A, Marrero I, Olson N, Siegel C, McCormick N. The
correlation between blood levels of ibuprofen and clinical analgesic response. Clin Pharmacol Ther. 1986
Jul;40(1):1-7. http://www.ncbi.nlm.nih.gov/pubmed/3522030
ii Ibuprofen, oral: National Department of Health, Essential Drugs Programme: Paediatric Hospital Level STGs

and EML, 2017.http://www.health.gov.za/

iii Ibuprofen (ceiling effect): National Department of Health, Essential Drugs Programme: Adult Hospital Level

STGs and EML, 2015. http://www.health.gov.za/

Ibuprofen, oral (ceiling effect): Laska EM, Sunshine A, Marrero I, Olson N, Siegel C, McCormick N. The
correlation between blood levels of ibuprofen and clinical analgesic response. Clin Pharmacol Ther. 1986
Jul;40(1):1-7. http://www.ncbi.nlm.nih.gov/pubmed/3522030
iv Morphine, IM (adults): South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.

University of Cape Town, 2016.

v Morphine, IV (adults): National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs

and EML, 2015. http://www.health.gov.za/

vi Morphine, IV (adults): National Department of Health, Essential Drugs Programme: Adult Hospital Level STGs

and EML, 2015. http://www.health.gov.za/

vii Paracetamol, oral (Mild chronic non-cancer pain: children): National Department of Health, Essential Drugs

Programme: Paediatric Hospital level STGs and EML, 2017. http://www.health.gov.za/

Paracetamol, oral (Mild chronic non-cancer pain: children): Cooper TE, Fisher E, Anderson B, Wilkinson NM,
Williams DG, Eccleston C. Paracetamol (acetaminophen) for chronic non-cancer pain in children and adolescents.
Cochrane Database Syst Rev. 2017 Aug 2;8:CD012539. https://www.ncbi.nlm.nih.gov/pubmed/28770975
viii Ibuprofen (ceiling effect): National Department of Health, Essential Drugs Programme: Adult Hospital Level

STGs and EML, 2015. http://www.health.gov.za/

Ibuprofen, oral (ceiling effect): Laska EM, Sunshine A, Marrero I, Olson N, Siegel C, McCormick N. The
correlation between blood levels of ibuprofen and clinical analgesic response. Clin Pharmacol Ther. 1986
Jul;40(1):1-7. http://www.ncbi.nlm.nih.gov/pubmed/3522030
ix Paracetamol, oral (adults - chronic cancer pain): Wiffen PJ, Derry S, Moore RA, McNicol ED, Bell RF, Carr DB,

McIntyre M, Wee B. Oral paracetamol (acetaminophen) for cancer pain. Cochrane Database Syst Rev.2017 Jul
12;7:CD012637. https://www.ncbi.nlm.nih.gov/pubmed/28700092
x NSAIDs, oral (adults - chronic cancer pain): Derry S, Wiffen PJ, Moore RA, McNicol ED, Bell RF, Carr DB,

McIntyre M, Wee B. Oral nonsteroidal anti-inflammatory drugs (NSAIDs) for cancer pain in adults. Cochrane
Database Syst Rev. 2017 Jul 12;7:CD012638. https://www.ncbi.nlm.nih.gov/pubmed/28700091
Ibuprofen, oral (ceiling effect): National Department of Health, Essential Drugs Programme: Adult Hospital level
STG, 2015. http://www.health.gov.za/
Ibuprofen (ceiling effect): Laska EM, Sunshine A, Marrero I, Olson N, Siegel C, McCormick N. The correlation
between blood levels of ibuprofen and clinical analgesic response. Clin Pharmacol Ther. 1986 Jul;40(1):1-7.
http://www.ncbi.nlm.nih.gov/pubmed/3522030
xi Tramadol, oral (adults - chronic cancer pain): Wiffen PJ, Wee B, Derry S, Bell RF, Moore RA. Opioids for cancer

pain – an overview of Cochrane reviews. Cochrane Database Syst Rev. 2017 Jul 6;7:CD012592.
https://www.ncbi.nlm.nih.gov/pubmed/28683172
Tramadol, oral (adults - chronic cancer pain: caution): South African Medicines Formulary. 12th Edition.
Division of Clinical Pharmacology. University of Cape Town, 2016.
xii Morphine, long-acting: National Department of Health, Essential Drugs Programme: Adult Hospital level STG,

2015. http://www.health.gov.za/
Morphine, long-acting, oral: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.
University of Cape Town, 2016.
Morphine, long-acting, oral: National Department of Health: Affordable Medicines, EDP-PHC. Medicine Review.
Oxycodone for chronic cancer pain in adults, June 2018. http://www.health.gov.za/
Morphine, long-acting, oral: Schmidt-Hansen M, Bennett MI, Arnold S, Bromham N, Hilgart JS. Oxycodone for
cancer-related pain. Cochrane Database Syst Rev. 2017 Aug 22;8:CD003870.
https://www.ncbi.nlm.nih.gov/pubmed/28829910
xiii Pain ladder (children): World Health Organisation. WHO guidelines on the pharmacological treatment of

persisting pain in children with medical illnesses

http://whqlibdoc.who.int/publications/2012/9789241548120_Guidelines.pdf
xiv NSAIDs, oral (children – chronic cancer pain): Cooper TE, Heathcote LC, Anderson B, Grégoire MC, Ljungman

G, Eccleston C. Non-steroidal anti-inflammatory drugs (NSAIDs) for cancer-related pain in children and
adolescents. Cochrane Database Syst Rev. 2017 Jul 24;7:CD012563.
https://www.ncbi.nlm.nih.gov/pubmed/28737843
xv Paracetamol, oral (children – chronic cancer pain): Wiffen PJ, Cooper TE, Anderson AK, Gray AL, Grégoire MC,

Ljungman G, Zernikow B. Opioids for cancer-related pain in children and adolescents. Cochrane Database Syst
Rev. 2017 Jul 19;7:CD012564. https://www.ncbi.nlm.nih.gov/pubmed/28722116

2018 20.12
PHC Chapter 21: Emergencies and
injuries
21.1 Cardiopulmonary arrest– cardiopulmonary resuscitation
21.1.1 Cardiac arrest, adults
21.1.2 Cardiopulmonary arrest, children
21.1.3 Bradycardia
21.1.4 Tachydysrhythmias
21.1.5 Management of suspected choking/foreign
body aspiration in children
21.2 Medical emergencies
21.2.1 Paediatric emergencies
21.2.1.1 Rapid triage of the child presenting with
acute conditions in clinics and CHCs
21.2.2 Angina pectoris, unstable
21.2.3 Myocardial infarction, acute (AMI)
21.2.4 Delirium with acute confusion and aggression in
adults
21.2.5 Hyperglycaemia and ketoacidosis
21.2.6 Hypoglycaemia and hypoglycaemic coma
21.2.7 Nose bleeds (epistaxis)
21.2.8 Pulmonary oedema, acute
21.2.9 Shock
21.2.10 Anaphylaxis
21.2.11 Seizures and status epilepticus
21.3 Trauma and injuries
21.3.1 Bites and stings
21.3.1.1 Animal bites
21.3.1.2 Human bites
21.3.1.3 Insect stings and spider bites
21.3.1.4 Snakebites
21.3.2 Burns
21.3.3 Exposure to poisonous substances
 CHAPTER 21 EMERGENCIES AND INJURIES

21.3.4 Eye injury, chemical burns

21.3.5 Eye injury, foreign body
21.3.6 Post exposure Prophylaxis (PEP)
21.3.6.1 Post exposure Prophylaxis, occupational
21.3.6.2 Post exposure Prophylaxis, rape and
sexual assault
21.3.6.3 Post exposure Prophylaxis, inadvertent
non-occupational)
21.3.7 Soft tissue injuries
21.3.8 Sprains and strains

The following conditions are emergencies and must be treated as such. Medicines used
for treatment must be properly secured and recorded (time, dosage, route of
administration) on the patient’s notes and on the referral letter.

Determine the priority of patients' treatments based on the severity of their condition,
using a triage system appropriate to your level of care, available resources and staff at
your facility.

2018 21.2
 CHAPTER 21 EMERGENCIES AND INJURIES

21.1 CARDIOPULMONARY ARREST– CARDIOPULMONARY

RESUSCITATION
21.1.1 CARDIAC ARREST, ADULTS
I46.0/I46.9

2018 21.3
 CHAPTER 21 EMERGENCIES AND INJURIES

DESCRIPTION
Described as the loss of a heart beat and a palpable pulse, irrespective of the
electrical activity captured on ECG tracing.
Irreversible brain damage can occur within 2-4 minutes.
Clinical features include:
» sudden loss of consciousness
» absent carotid pulse
» loss of spontaneous respiration

EMERGENCY TREATMENT
» Diagnose rapidly.
» Make a note of the time of starting resuscitation.
» Place the patient on a firm flat surface and commence resuscitation immediately.
» Document medication given and progress after the resuscitation.
» Follow instructions as per algorithm.
HAZARDS, HELLO, HELP
» Assess for any hazards and remove. Make use of personal protective equipment
i.e. gloves, masks.
» Speak to the patient. If they respond, turn into recovery position and continue
management as directed by findings.
» If no response, check for carotid pulse and breathing. Take no longer than 10
seconds.
» Call for skilled help and an automated external defibrillator (AED) or defibrillator.

CARDIOPULMONARY RESUSCITATION (CPR)

» Initiate CAB (Circulation Airway Breathing) sequence of CPR.
Circulation
» If there is no pulse or you are not sure, start with 30 chest compressions at a rate
of 100-120 compressions per minute, and a depth of 5-6 cm.
» Allow full chest recoil between compressions.
» Minimize interruptions during compressions.
Airway and Breathing
» To open the airway, lift the chin forward with the fingers of the one hand and tilt the
head backwards with other hand on the forehead. Do not do this where a neck injury
is suspected.
» If there is no normal breathing, give 2 breaths with bag-valve-mask resuscitator and
face mask.
» The administered breaths must cause visible chest rise.
» If not able to perform breaths, continue compressions (Reposition head and insert
correctly sized oropharyngeal airway and try again after 30 compressions).
Where neck injury is suspected:

 place your fingers behind the jaw on each side

» To open the airway, use a jaw thrust:

 lift the jaw upwards while opening the mouth with your thumbs “Jaw thrust”
» ideally use a 3rd person to provide in-line manual stabilisation of the neck

2018 21.4
 CHAPTER 21 EMERGENCIES AND INJURIES

Repeat the cycle of 30 compressions followed by 2 breaths (30:2) until the AED or
defibrillator arrives.
AED/Defibrillator
Attach leads and analyse rhythm:

 deliver 1 shock
» If shock advised: (ventricular fibrillation or pulseless ventricular tachycardia)

 immediately resume CPR

 continue cycles of 30:2 for 2 minutes, then re-assess for a pulse

 if no pulse or respirations
» If no shock advised: (asystole or pulseless electrical activity)

 immediately resume CPR

 continue cycles of 30:2 for 2 minutes, then re-assess for a pulse
Immediate emergency medicine treatment:
Adrenaline (epinephrine) is the mainstay of treatment. Give immediately, IV or

x Adrenaline (epinephrine), 1:1 000, 1 mL, IV immediately as a single dose.

endotracheal, when there is no response to initial resuscitation or defibrillation.

o Flush with 5–10 mL of sterile water or sodium chloride 0.9%.

o Repeat every 3–5 minutes during resuscitation.

x Adrenaline (epinephrine), intra-osseous (IO), 1:1000, 1 mL, via IO line.

OR

LoE: IIIi
ADDITIONAL GUIDANCE
Connect bag-valve-mask resuscitator to 100% oxygen at 10-15L/min flow.
Check glucose and treat hypoglycaemia.
Continue CPR until spontaneous breathing and/or heart beat returns.
Assess continuously (every 2 minutes) until the patient shows signs of recovery.
Consider stopping resuscitation attempts and pronouncing death if:
» further resuscitation is clearly clinically inappropriate, e.g. incurable underlying
disease, or
» no success after all the above procedures have been carried out for •30 minutes
and no reversible cause detected, or
» no success after all of above procedures have been carried out for •30 minutes
and the rhythm is asystole or pulseless electrical activity.
Consider carrying on for longer especially when:
» hypothermia and drowning
» poisoning or medicine overdose or carbon monoxide poisoning

REFERRAL
All patients: transfer with supportive care and accompanying skilled worker until taken
over by doctor at receiving institution.

2018 21.5
 CHAPTER 21 EMERGENCIES AND INJURIES

21.1.2 CARDIOPULMONARY ARREST, CHILDREN

I46.0/I46.9
The most experienced clinician present should take control of the resuscitation.

2018 21.6
 CHAPTER 21 EMERGENCIES AND INJURIES

DESCRIPTION
Cardiopulmonary arrest is the cessation of respiration or cardiac function and in
children is usually a pre-terminal event as a result of a critical illness.

The effective treatment of cardiorespiratory arrest in children is the

prevention of the arrest by early recognition and management of severe
disease.
Bradycardia in children is a pre-terminal event and needs to be treated with
resuscitation.

Cardiorespiratory arrest in children usually follows poor respiration, poor circulation

or poor respiratory effort (e.g. prolonged seizures, poisoning, neuromuscular
weakness etc.).
The following table outlines signs of serious disease/impending cardiorespiratory
failure in a child. These are an indication that urgent effective management is needed.
Neurological Respiratory Circulatory
Signs of Decreased level of Increased respiratory Increased heart rate:
impending consciousness or rate: > 60 breaths/minute > 160 beats/min in infants
cardio- extreme weakness > 120 beats/min in children
respiratory Abnormal posture Marked chest indrawing Decreased pulse volume
failure/ Pupils – unequal Grunting Capillary refill time > 3
severe or abnormal size seconds
disease Presence of Flaring nostrils, gasping, Poor colour: bluish, grey or
convulsions shallow/irregular breathing marked pallor

EMERGENCY TREATMENT
» Diagnose the need for resuscitation rapidly.
» Make a note of the time of starting.
» Place the patient on a firm flat surface and commence resuscitation immediately.
» Document timings of interventions, medication and any response to these.
(Ideally, during resuscitation, one staff member should act as a ‘scribe’).
» Collect all ampoules used and total them at the end.
HAZARDS, HELLO, HELP
» Assess for any hazards and remove. Make use of personal protective equipment
i.e. gloves, masks.
» Call for skilled help and an automated external defibrillator (AED) or defibrillator.
CARDIOPULMONARY RESUSCITATION (CPR)
Circulation
» Check for signs of life and presence of central pulse for 5–10 seconds. In younger
children (infants) check brachial or femoral pulse, in older children use femoral or
carotid pulse).
» If there is no pulse (or pulse < 60 beats/minute) with no signs of life, give 30 chest
compressions at a rate of 100-120 compressions/minute.
» Compress over lower half of sternum and compress chest by approximately 1/3 of
the anteroposterior diameter of the chest.
» Allow chest to fully recoil before next compression.
» Minimize interruptions in compressions.

2018 21.7
 CHAPTER 21 EMERGENCIES AND INJURIES

Airway
» Manually remove obvious visible obstruction from the mouth.
CAUTION
Do not use blind finger sweeps of the mouth or posterior pharynx as this can
impact any obstruction further down the airway.
» In neonates and infants: position the head in neutral position. In children: position
in the sniffing position.
» Lift the chin forward with the fingers under the bony tip of the jaw.
Breathing

 preferably with bag-valve-mask resuscitator

» If there is no breathing, give breaths:

 mouth-to-nose (covering child’s mouth AND nose with your mouth)

or

 mouth-to-mouth (occluding nose by pinching child’s nostrils)

or

» Give 2 effective breaths at one breath/second.

» Breaths must produce visible chest rise.
Then
» If 2 rescuers are present, carry out cycles of 15 chest compressions followed by
2 breaths (15:2).
» If only 1 rescuer present, carry out cycles of 30 compressions to 2 breaths (30:2).
» Review after 2 minutes or 5 cycles - if pulse is not palpable continue CPR
sequence until help arrives.
x Oxygenate with 100% oxygen, if available.
» Keep patient covered and warm while resuscitating (although the patient should
be fully exposed for short periods during examination).
Immediate emergency medicine treatment:

x Adrenaline (epinephrine), IV, 0.1 mL/kg of 1:10 000 solution.

» If still no pulse or signs of life after cardiac compressions and ventilations:

o To make an 1:10 000 adrenaline (epinephrine) solution, dilute 1 mL ampoule

of adrenaline (epinephrine) (1:1000) with 9 mL of sodium chloride 0.9% to give
10 mL of 1:10000 solution.
o Administer dose according to table below.
o If no IV line is available, the same dose may be given IO.
Weight Dose Volume of diluted Age
kg mg solution months/years
(1: 10 000 solution)
‫ޓ‬2.5–7 kg 0.05 mg 0.5 mL Birth–6 months
‫ޓ‬7–11 kg 0.1 mg 1 mL ‫ޓ‬6–18 months
‫ޓ‬11–17.5 kg 0.15 mg 1.5 mL ‫ޓ‬18 months–5 years
‫ޓ‬17.5–25 kg 0.2 mg 2 mL ‫ޓ‬5–7 years
‫ޓ‬25–35 kg 0.3 mg 3 mL ‫ޓ‬7–11 years
‫ޓ‬35–55 kg 0.5 mg 5 mL ‫ޓ‬11–15 years

2018 21.8
 CHAPTER 21 EMERGENCIES AND INJURIES

x Dextrose 10%, solution, IV, 2–5 mL/kg.

Treat hypoglycaemia

o To make 20 mL of 10% dextrose solution: draw 4 mL of 50% dextrose using

20 mL syringe and add 16 mL of sodium chloride 0.9% or water for injection.
o After dextrose bolus, commence dextrose 5–10% infusion, 3–5 mL/kg/hour to
prevent blood glucose dropping again.
o Re-check the blood glucose after 15 minutes: if blood sugar is still low: give
further bolus of dextrose 10%, IV, 2 mL/kg and continue dextrose infusion.
o Assess continuously until the patient shows signs of recovery.
Consider stopping resuscitation attempts and pronouncing death if:
» No signs of life are present after 30 minutes of active resuscitation. A doctor
must be called before resuscitation is stopped. If no doctor on site, telephonic
consultation should take place.
Always carry on for longer in cases of:
» hypothermia and drowning
» suspected poisoning or medicine overdose or carbon monoxide poisoning

REFERRAL
All patients: transfer with supportive care and accompanying skilled worker until taken
over by doctor at receiving institution.
For guidance on neonatal resuscitation, see Section 6.6.2: Neonatal resuscitation.

21.1.3 BRADYCARDIA
R00.1
Refer to Adult Hospital Level and Paediatric Hospital Level STGs and EML for
relevant guidance.

DESCRIPTION
In adults, bradycardia refers to a pulse rate < 50 beats/ minute.
In children, bradycardia refers to a pulse rate < 60 beats/ minute despite effective
oxygenation and ventilation.

EMERGENCY TREATMENT

 Airway: ensure airway is open and clear.

Assess ABC:

 Breathing: give oxygen to target pulse oximeter saturation of 94–98%.

 Circulation: assess peripheral perfusion, measure pulse and blood pressure.
Attach ECG monitor, pulse oximeter and blood pressure cuff.
Establish IV access.
Print rhythm strip to confirm bradycardia; if possible, do 12 lead ECG.

 Hypotension  Altered mental status

Assess for signs of instability:

 Chest pain  Acute heart failure

 Signs of shock: cold clammy peripheries and weak pulses

2018 21.9
 CHAPTER 21 EMERGENCIES AND INJURIES

Adults

x Atropine, IV, 0.5 mg as a bolus.

If unstable:

o Repeat every 3–5 minutes, if no response.

o Maximum dose: 3 mg.
» Look for and treat contributory causes for bradycardia (see table below).
» If no response to atropine, discuss with referral centre or refer to Adult Hospital
Level STGs and EML for guidance.
If stable:
Look for and treat contributory causes for bradycardia (see table below):
Contributory causes for bradycardia and treatment
Hypoxia Give supplemental oxygen or ventilate.
Hypothermia Warm the patient.
Head injury Give oxygen, elevate head of bed.
Heart block Look for cause of heart block.
Hydrogen ion (acidosis) Look for cause of acidosis.

x Sodium chloride 0.9%, IV, 200 mL.

Hypotension If no signs of heart failure:

Toxins and therapeutic agents Treat as for specific overdose.

Children
If unstable:
Start CPR: 30 compressions: 2 breaths (1 rescuer), or

x
15 compressions: 2 breaths (2 rescuers)
Adrenaline (epinephrine), IV, 0.1 mL/kg of 1:10 000 solution (Doctor prescribed).
o To make 1:10 000 adrenaline (epinephrine) solution: dilute 1 mL ampoule of
adrenaline (epinephrine) (1:1000) with 9 mL of sodium chloride 0.9% to give
10 mL of 1:10000 solution.
o Administer dose every 3–5 minutes, according to table below.
Weight Dose Volume of diluted Age
kg mg solution months/years
(1: 10 000 solution)
‫ޓ‬2.5–7 kg 0.05 mg 0.5 mL Birth–6 months
‫ޓ‬7–11 kg 0.1 mg 1 mL ‫ޓ‬6–18 months
‫ޓ‬11–17.5 kg 0.15 mg 1.5 mL ‫ޓ‬18 months–5 years
‫ޓ‬17.5–25 kg 0.2 mg 2 mL ‫ޓ‬5–7 years
‫ޓ‬25–35 kg 0.3 mg 3 mL ‫ޓ‬7–11 years
‫ޓ‬35–55 kg 0.5 mg 5 mL ‫ޓ‬11–15 years
LoE: IIIii
x Atropine, IV, 0.02 mg/kg/dose as a single dose (Doctor prescribed).
If heart block or increased vagal tone suspected:

o Maximum single dose: 0.5 mg.

o Repeat dose, if no response.
If stable: LoE: IIIiii
Look for and treat contributory causes for bradycardia (see table above).
Close monitoring required.
Ensure adequate oxygenation and ventilation if necessary.

2018 21.10
 CHAPTER 21 EMERGENCIES AND INJURIES

REFERRAL
Urgent
All patients: transfer with supportive care and accompanying skilled worker until taken
over by doctor at receiving institution.

21.1.4 TACHYDYSRHYTHMIAS
R00.0
Refer to Adult and Paediatric Hospital Level STGs and EML for relevant guidance.

DESCRIPTION
Adults: tachydysrhythmias refer to a pulse rate > 150 beats/minute.
Children: tachydysrhythmias refers to a pulse rate > normal range for age (see table).

EMERGENCY TREATMENT
Assess ABC:
» Airway: ensure airway is open and clear
» Breathing: give oxygen to target pulse oximeter saturation of 94-98%
» Circulation: assess peripheral perfusion, measure pulse and blood pressure.
Child heart rate ranges for age
Age Normal heart rate range (beats/minute)
Newborn to 3 months 85–205
3 months to 2 years 100–190
2 years to 10 years 60–140
> 10 years 60–100
» Supraventricular tachycardia is suspected in a child when the pulse rate > 180
beats/minute in a child and > 220 beats/minute in an infant.
Attach ECG monitor, pulse oximeter and blood pressure cuff.
Establish IV access.
Print rhythm strip to confirm tachycardia, if possible do 12 lead ECG.

 Hypotension  Altered mental status

Assess for signs of instability:

 Chest pain  Acute heart failure

 Signs of shock: cold clammy peripheries and weak pulses
Adult
If unstable:
Synchronised cardioversion at 100 J.
Consider analgesia and sedation if time permits.
If stable:
Assess QRS length on rhythm strip or 12 lead ECG:

 Attempt vagal stimulation: Vasalva manoeuvre.

» If QRS < 0.12 = Narrow complex tachycardia (supraventricular tachycardia):

Ice water applied to face.

Cough, breath holding.
Carotid sinus massage (not in elderly or cardiac disease).
» If QRS > 0.12 = Wide complex tachycardia (ventricular tachycardia):

2018 21.11
 CHAPTER 21 EMERGENCIES AND INJURIES

 Correct electrolyte disturbances.

 Consider toxins, overdoses.
Child
If unstable:
Synchronised cardioversion at 0.5-1 J/kg initially (max 4 J/kg).
Consider analgesia and sedation if time permits.
If stable:
Assess QRS length on rhythm strip or 12 lead ECG:

 Attempt vagal stimulation: Ice water applied to face.

» If QRS < 0.08 = Narrow complex tachycardia (supraventricular tachycardia):

 Correct electrolyte disturbances.

» If QRS > 0.08 = Wide complex tachycardia (ventricular tachycardia):

 Consider toxins, poisoning, overdoses.

REFERRAL
Urgent
All patients: transfer with supportive care and accompanying skilled worker until taken
over by doctor at receiving institution.

21.1.5 MANAGEMENT OF SUSPECTED CHOKING/FOREIGN

BODY ASPIRATION IN CHILDREN
T17.2-5/T17.8-9/ T18.0-1

If the child is able to talk and Encourage the child to cough repeatedly while arranging
breathe transfer to hospital urgently with supervision.
If the child is conscious but Give 5 back blows, followed by 5 chest/ abdominal thrusts,
with no effective cough or followed by re-assessment of breathing. and then repeated
breathing as a cycle until recovery or child becomes unconscious.
See differences below for infants and children.
If the child is unconscious Call for assistance.
with no effective breathing Open airway and check for any visible foreign body and
remove.
Start CPR: compressions and breaths (30:2) (check airway
for foreign body each time before giving breaths).
(Infant: < 1 year of age; Child: > 1 year of age until puberty).
Techniques for back blows and chest/abdominal thrusts:
Infants
» Place the baby along one of the rescuer’s arms in a head down position with baby
face down.
» Rescuer to rest his/her arm along own thigh and deliver 5 back blows to the child.
» If this is ineffective turn the baby over (face up) and lay on the rescuer’s thigh in
the head down position.
» Apply 5 chest thrusts – use the lower ½ of the sternum – compress at least 1/3 of
the anteroposterior diameter of the chest. If baby too large to carry out on the
thigh this can be done across the lap.

2018 21.12
 CHAPTER 21 EMERGENCIES AND INJURIES

Children
» In older children, rather lie child across rescuer’s lap to deliver back blows. Use
abdominal thrusts (Heimlich manoeuvre) in place of chest thrust.
» For abdominal thrust in the standing, sitting or kneeling position, rescuer to move
behind the child and pass his/her arms around the child’s body. Then, form a fist
with one hand, and place against the child’s abdomen above the umbilicus and
below the xiphisternum. Then place the other hand over the fist and the thrust
both hands sharply upwards into the abdomen towards the chest.
» In the lying (supine) position, the rescuer to kneel astride the victim and do the
same manoeuvre except use the heel of one hand rather than a fist.

2018 21.13
 CHAPTER 21 EMERGENCIES AND INJURIES

Adapted with permission from the Resuscitation Council of Southern Africa.

www.resuscitationcouncil.co.za

LoE: IIIiv

2018 21.14
 CHAPTER 21 EMERGENCIES AND INJURIES

21.2 MEDICAL EMERGENCIES

21.2.1 PAEDIATRIC EMERGENCIES
Certain emergencies of the airway, breathing, circulation and neurological system are
dealt with in the respiratory, cardiac and nervous system chapters. All doctors should
ensure that they have received appropriate training in at least providing basic (and
preferably advanced) life support to children.

21.2.1.1 RAPID TRIAGE OF CHILDREN PRESENTING WITH

ACUTE CONDITIONS IN CLINICS AND CHCs
Triage is the process of rapidly examining all sick children when they first arrive
at clinics in order to place them in one of three categories (Emergency, Priority,
Non-urgent):

2018 21.15
 CHAPTER 21 EMERGENCIES AND INJURIES

Adapted from Pocketbook of Hospital Care for Children. Management of Common Childhood Illnesses. National Department
of Health, South Africa, 2016.www.health.gov.za/

2018 21.16
 CHAPTER 21 EMERGENCIES AND INJURIES

If any emergency sign is present, give emergency treatment(s), call for help, and
draw blood for emergency laboratory investigations.
(A&B) Airway and Breathing
» Not breathing
or
» Obstructed breathing
or
» Central cyanosis
or
» Severe respiratory distress
(C) Circulation
» Cold hands
and
» Capillary refill •3 seconds
and
» Weak and fast pulse
(C) Coma/convulsing
» Coma
or
» Convulsing (now)
(D) Severe dehydration (e.g. in child with diarrhoea)
» Diarrhoea
plus

 Lethargy
» Any two of:

 Sunken eyes
 Very slow skin pinch
PRIORITY
Priority signs
These children need prompt assessment and treatment
» Tiny baby (< 3 months of age)
» High Temperature
» Trauma or other urgent surgical condition
» Pallor (severe)
» Poisoning (history of)
» Pain (severe)
» Respiratory distress
» Restless, continuously irritable, or lethargic
» Referred for urgent attention
» Malnutrition: visible severe wasting
» Oedema of both feet
» Burns (major)
NON-URGENT (queue)
Proceed with assessment and further treatment according to the child’s priority.

2018 21.17
 CHAPTER 21 EMERGENCIES AND INJURIES

The Emergency Triage Assessment and Treatment (ETAT) tool, presented

above, should be a minimum standard of triage in community health centres.
(Alternative tool P-SATS is available, see the Paediatric Hospital level STGs and EML).

21.2.2 ANGINA PECTORIS, UNSTABLE

See Section 4.3: Angina pectoris, unstable/ Non ST elevation myocardial infarction
(NSTEMI).

21.2.3 MYOCARDIAL INFARCTION, ACUTE (AMI)

See Section 4.4: Myocardial infarction, Acute (AMI)/ ST Elevation Myocardial
Infarction (STEMI).

21.2.4 DELIRIUM WITH ACUTE CONFUSION AND AGGRESSION

IN ADULTS
F05.0-1/F05.8-9/F44.8/R45.1/R45.4-6

DESCRIPTION
Delirium is a medical emergency.
Delirium is a sudden onset state of confusion in which there is impaired awareness and
memory and disorientation.
Delirium should not be mistaken for psychiatric disorders like schizophrenia or a manic
phase of a bipolar disorder. These patients are mostly orientated for time, place and
situation, can in a way make contact and co-operate within the evaluation and are of
clear consciousness.
There are many possible causes including extracranial causes. Organic or physical
illness should also be considered as possible causes.
The elderly are particularly prone to delirium caused by medication, infections,
electrolyte and other metabolic disturbances.
Main clinical features are:
» acute onset (usually hours to days) » confusion
» impaired awareness » disorientation
Other symptoms may also be present:
» restlessness and agitation
» hallucinations
» autonomic symptoms such as sweating, tachycardia and flushing
» patients may be hypo-active, with reduced responsiveness to the environment
» a fluctuating course and disturbances of the sleep-wake cycle are characteristic
» aggressiveness
» violent behaviour alone occurs in exceptional cases only
Risk factors for delirium include
» extremes of age » pre-existing neurological disease e.g. epilepsy
» HIV infection » medicines such as anticholinergics and hypnotics
» pre-existing dementia » substance intoxication and withdrawal
» cerebrovascular disease

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 CHAPTER 21 EMERGENCIES AND INJURIES

Checklist for diagnosis:

D – Drugs (Intoxication and withdrawal. Consider Wernicke’s encephalopathy).
I – Infections, e.g. sepsis, pneumonia, urinary tract infections, peritonitis,
meningitis.
M – Metabolic, e.g. hypoglycaemia, electrolyte abnormalities (e.g.
hyponatraemia); organ failure (e.g. liver failure, renal dysfunction), CO2
narcosis.
T – Trauma, e.g. chronic subdural haematoma.
O – Oxygen deficit (including hypoxia, carbon monoxide poisoning).
P – Psychiatric or physical conditions, e.g. severe stressor pain.

EMERGENCY TREATMENT
» Calm the patient.
» Manage in a safe environment.
» Treat underlying cause first, e.g. hypoglycaemia, hypoxia, pain etc.
If the delirium is caused by seizures or substance withdrawal, or if communication is

x Midazolam, IM, 7.5–15 mg immediately.

difficult

o Repeat after 30–60 minutes if needed.

OR
Diazepam, IV, 10 mg for immediate sedative or hypnotic action.
o If no response, give a 2nd dose.
o Do not administer at a rate over 5 mg/minute.
Switch to oral once containment is achieved.
» Secure airway.
» Exclude hypoglycaemia.
» Monitor for respiratory depression.

x Haloperidol, IM, 5 mg, immediately.

If the most likely cause of delirium is a medical disorder and if very restless:

o In elderly: 2.5 mg, immediately.

o If no response give a second dose.

x Thiamine, IV/IM, 100 mg immediately.

If alcoholic/ Wernicke’s encephalopathy suspected:

REFERRAL
Urgent
All cases.

21.2.5 HYPERGLYCAEMIA AND KETOACIDOSIS

See Section 9.3.2: Severe hyperglycaemia (Diabetic ketoacidosis (DKA) & hyperosmolar
hyperglycaemic state (HHS)).

2018 21.19
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21.2.6 HYPOGLYCAEMIA AND HYPOGLYCAEMIC COMA

E10.0/E10.6/E11.0/E11.6/E12.0/E12.6/E13.0/E13.6/E14.0/E14.6

DESCRIPTION
Hypoglycaemia is a blood sugar < 3 mmol/L (< 2.6 mmol/L in neonate) and may
rapidly cause irreversible brain damage and/or death.
Clinical features include:
» tremor » confusion
» sweating » delirium
» tachycardia » coma
» dizziness » convulsions
» hunger » transient aphasia or speech disorders
» headache » irritability
» impaired concentration
There may be few or no symptoms in the following situations:
» chronically low blood sugar

 the elderly  malnourished

» patients with impaired autonomic nervous system response, e.g.

 very ill  treatment with beta-blockers

 those with long-standing diabetes mellitus
People at risk of hypoglycaemia:
» neonates with low birth weight or ill or not feeding well
» malnourished or sick children
» shocked, unconscious or convulsing patients
» alcohol binge
» liver disease
» diabetics on treatment
Hypoglycaemia may be a marker of deteriorating renal function.

EMERGENCY TREATMENT
» Obtain blood for glucose determination immediately.
» Establish blood glucose level with glucometers or testing strip.
Conscious patient, able to feed

 Sweets, sugar, glucose or milk by mouth.

Adult

 Oral sugar solution.

or

o Dissolve 3 teaspoons of sugar (15 g) in a 200 mL cup of water.

 Administer breast milk.

Breastfeeding child

 A formula feed of 5 mL/kg.

Older children

 Oral sugar solution.

or

2018 21.20
 CHAPTER 21 EMERGENCIES AND INJURIES

o Dissolve 3 teaspoons of sugar (15 g) in a 200 mL cup of water – administer

5 mL/kg.

 Sweets, sugar, glucose by mouth.

or

Conscious patient, not able to feed without danger of aspiration

x Dextrose 10%, 5mL/kg.

Administer via nasogastric tube:

(add 1 part 50% dextrose water to 4 parts water to make 10% solution)
or
 Milk.

 Sugar solution.
or

o Dissolve 3 teaspoons of sugar (15 g) in a 200 mL cup of water – administer

5 mL/kg.
Unconscious patient

x Dextrose 10%, IV, 2–5 mL/kg.

Children

o 10% solution, e.g.: 1 part 50% dextrose water to 4 parts water for injection to
make 10% solution.
o Take a blood sample for emergency investigations and blood glucose.
o After dextrose bolus, commence dextrose 5–10% infusion, 3–5 mL/kg/hour to
prevent blood glucose dropping again.
o Re-check blood glucose after 15 minutes: if blood sugar is still low: give further
bolus of dextrose 10%, IV, 2 mL/kg and continue dextrose infusion.
o Feed the child as soon as conscious.
o Investigate underlying cause e.g. infection.

x Dextrose 10%, IV, 5 mL/kg immediately and reassess.

Adults

o 10% solution, e.g.: 1 part 50% dextrose water to 4 parts water for injection to
make 10% solution.
o Generally, an immediate clinical response can be expected.
o Maintain with 5% dextrose solution until blood glucose is stabilised.
o Investigate underlying cause e.g. infection.
Note: The volume of dextrose has been changed in the above- LoE:IIIv
mentioned protocol.

x Thiamine, IV/IM, 100 mg immediately.

Alcoholics /Malnourished (adults)

CAUTION
Thiamine should preferably be administered prior to intravenous glucose to
prevent permanent neurological damage.
Do not delay the dextrose administration in a hypoglycaemic patient.

2018 21.21
 CHAPTER 21 EMERGENCIES AND INJURIES

REFERRAL
Urgent
» All hypoglycaemic patients on oral hypoglycaemic agents.
» Hypoglycaemic patients who do not recover completely after treatment.
» All children who have had documented hypoglycaemia (unless the cause is
clearly identified and safe management instituted to prevent recurrence).

21.2.7 NOSE BLEED (EPISTAXIS)

R04.0

DESCRIPTION
Nose bleed may be caused by local or systemic diseases, or local trauma, especially
nose picking and occurs from an area anterior and inferior to the nasal septum.
Consider other conditions associated with nosebleeds, especially if recurrent, e.g.
hypertension and bleeding tendency.

MANAGEMENT
Acute episode
Control bleeding by pinching the nasal wings (alae) together for 5–10 minutes.
If this fails, insert nasal tampons or BIPP stripping into bleeding nostril(s), if available.
Identify underlying cause.

REFERRAL
» Recurrent nose bleeds.
» Failure to stop the bleeding.

21.2.8 PULMONARY OEDEMA, ACUTE

J81

DESCRIPTION
A life-threatening condition with abnormal accumulation of fluid in the lungs.
Common causes include acute heart failure and acute renal failure (e.g. acute nephritis).
Persons with pulmonary oedema may present similarly to acute bronchospasm.
It is important to distinguish this condition from an acute attack of asthma.

EMERGENCY TREATMENT
Place the patient in a sitting or Semi-Fowlers position.

x Oxygen, using a 40% face mask or nasal cannula at 2–3 L/minute.

Children

x Furosemide, IV, 1 mg/kg immediately administered slowly over 5 minutes. See

dosing table, pg 23.5.
o Do not put up a drip or run in any IV fluids.
Adults
x Oxygen, using face mask to deliver 40% oxygen at a rate of 6–8 L/minute.

x Furosemide, slow IV, 40 mg.

AND

2018 21.22
 CHAPTER 21 EMERGENCIES AND INJURIES

If response is adequate follow with:

o Furosemide, IV, 40 mg in 2–4 hours.
If no response within 20–30 minutes:
o Furosemide, IV, 80 mg.
AND
x Isosorbide dinitrate, sublingual, 5 mg immediately.
o If needed, repeat every 5–10 minutes. LoE:III
o Do not administer if hypotensive. Monitor BP.

x Morphine, IV, to a total maximum dose of 10 mg (Doctor prescribed).

If patient very anxious or restless, doctor to consider adding morphine:

o Dilute 10 mg up to 10 mL with sodium chloride 0.9%.

o Morphine, IV, 3–5 mg as a single dose then further boluses of 1–2 mg/minute
and monitor closely.
o Total maximum dose: 10 mg.
o Repeat after 4 hours if necessary.
o Monitor response to pain and effects on respiration and BP.
LoE:IIIvi
Pulmonary oedema due to a hypertensive crisis:
ADD
To treat hypertension: (I10)
ƒ ACE-inhibitor, e.g.
x Enalapril 10 mg, oral, as a single dose and refer.

REFERRAL
Urgent
All cases.
(Continue oxygen during transfer).

21.2.9 SHOCK
R57.0-2/R57.8-9/T09.3/T79.4/T78.2 + (Y34.99/Y57.9/Y14.99)

DESCRIPTION
Shock is a life-threatening condition characterised by any evidence of inadequate
organ perfusion.
Signs and symptoms of shock in adults
» Low blood pressure (systolic BP < 80 mmHg) is the key sign of shock.
» Weak and rapid pulse » Restlessness and altered mental state
» Rapid shallow breathing. » Weakness
» Low urine output
Signs and symptoms of shock in children
Shock must be recognised while still in the compensated state to avoid irreversible
deterioration. Therefore, the following are primarily assessed in children:
» Prolonged capillary filling (> 3 seconds).
» Decreased pulse volume (weak thready pulse).
» Increased heart rate (>160 beats/minute in infants, > 120 beats/minute in children).

2018 21.23
 CHAPTER 21 EMERGENCIES AND INJURIES

» Decreased level of consciousness (poor eye contact).

» Rapid breathing.
» The signs mentioned above are more sensitive in detecting shock, before
irreversible. Decreased blood pressure and decreased urine output are late signs
of shock and can be monitored.
Normotensive BP values in children:
Age of child (years)
<1 1-2 2-5 5-12 >12
Respiratory rate (breaths/min) 30–40 25–35 25–30 20–25 15–20
Heart rate (beats/min) 110–160 100–150 95–140 80–120 60–100
Systolic BP (mmHg) 80–90 85–95 85–100 90–110 100–120
Source: The Hands-on Guide to Practical Paediatrics, First Edition. Rebecca Hewitson and Caroline
Fertleman. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd. Companion Website:
www.wileyhandsonguides.com/paediatrics

Types of shock:
– Hypovolaemic shock: Most common type of shock. Primary cause is loss of fluid
from circulation due to haemorrhage, burns, diarrhoea, etc.
– Cardiogenic shock: Caused by the failure of heart to pump effectively e.g. in
myocardial infarction, cardiac failure, etc.
– Septic shock: Caused by an overwhelming infection, leading to vasodilation.
– Anaphylactic shock: Caused by severe allergic reaction to an allergen, or medicine.

EMERGENCY TREATMENT

x
» Maintain open airway. LoE:Ivii
Administer face mask oxygen, if saturation < 94%.
» Consider the need for intubation and seek advice from referral centre.
» Check for and manage hypoglycaemia.
» If anaphylactic shock suspected, see Section 21.2.10: Anaphylaxis.
Intravenous fluid therapy is important in the treatment of all types of shock,
except for cardiogenic shock and septic shock (as fluid-overloaded patients do
not need fluid replacement) – these patients should receive a fluid challenge
as detailed below. Prompt diagnosis of the underlying cause is essential to
ensure optimal treatment.
Fluid replacement (avoid in cardiogenic and septic shock):

x Sodium chloride 0.9%, IV, 1 L as a rapid bolus.

Adults

o Repeat bolus until haemodynamic status is improved.

o Once stable, maintain IV fluids with careful monitoring of haemodynamic
status; adjust infusion rate as needed to maintain stability pending transfer.

x Sodium chloride 0.9%, IV, 20 mL/kg as a rapid bolus.

Children

o Repeat bolus until haemodynamic status is improved.

o Once stable, maintain IV fluids with careful monitoring of haemodynamic
status; adjust infusion rate as needed to maintain stability pending transfer.

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 CHAPTER 21 EMERGENCIES AND INJURIES

Note: If patient develops respiratory distress, recheck airway and breathing and
discontinue fluids.

x Sodium chloride 0.9%, IV, 500 mL over 30 minutes.

In adults with suspected cardiogenic or septic shock: give a fluid challenge:

o Assess blood pressure and pulse rate response. Response is defined by

improvements in blood pressure, pulse rate and mental status (adequate
cerebral perfusion) in addition to a good urine output, rather than an absolute
blood pressure value.
o If response is positive, then continue with intravenous fluid. Monitor the patient
and stop fluids if patient is breathless. Avoid over hydrating as this could
exacerbate hypoxia associated with adult respiratory distress syndrome.
o If no adequate response to fluid challenge (as described above), suspect
septic shock and repeat fluid challenge.
Septicaemia in children:
All children with shock, which is not obviously due to trauma or simple watery
diarrhoea, should in addition to fluid resuscitation, receive antibiotic cover for
probable septicaemia.
x Ceftriaxone, IM, 80 mg/kg/dose immediately as a single dose. See dosing table,
pg 23.3.
o Do not inject more than 1 g at one injection site.

CAUTION: USE OF CEFTRIAXONE IN NEONATES AND CHILDREN

» If SUSPECTING SERIOUS BACTERIAL INFECTION in neonate, give ceftriaxone,
even if jaundiced.

 If ” 28 days old, avoid calcium-containing IV fluids for 48 hours after ceftriaxone

» Avoid giving calcium-containing IV fluids (e.g. Ringer Lactate) together with ceftriaxone:

 If > 28 days old, ceftriaxone and calcium-containing IV fluids may be given

administered.

sequentially provided the giving set is flushed thoroughly with sodium chloride

 Preferably administer IV fluids without calcium contents.

0.9% before and after.

» Always include the dose and route of administration of ceftriaxone in the referral letter.

REFERRAL
Urgent
All patients, after resuscitation.

21.2.10 ANAPHYLAXIS
T78.2 + (Y34.99/Y57.9/Y14.99)

DESCRIPTION
A very severe allergic reaction that usually occurs within seconds or minutes after
exposure to an allergen, but may be delayed for up to 1 hour. The reaction can be
short-lived, protracted or biphasic, i.e. acute with recurrence several hours later.
Immediate reactions are usually the most severe and/or life-threatening.

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 CHAPTER 21 EMERGENCIES AND INJURIES

x
Clinical features include:

x
Acute onset of signs and symptoms.

x
Urticaria (hives) or angioedema.

x
Bronchospasm, wheezing, dyspnoea, chest tightness.

x
Laryngeal oedema with upper airway obstruction or stridor.

x
Gastrointestinal symptoms such as nausea, vomiting, diarrhoea.

x
Hypotension and/or shock.
Dizziness, paraesthesia, syncope, sweating, flushing, dysrhythmias.

EMERGENCY TREATMENT
» Resuscitate (CAB) immediately (See Section 21.1: Cardiopulmonary arrest–
cardiopulmonary resuscitation).
» Place hypotensive or shocked patient in horizontal position. Do NOT sit the
patient up.
» Severe anaphylaxis: administer oxygen by facemask at high flow rate of 15 L/min.
» Remove the trigger if possible.

MEDICINE TREATMENT
First line priority:
Adrenaline (epinephrine) is the mainstay of treatment and should be given

x Adrenaline (epinephrine), 1:1000, IM, 0.01 mL/kg as a single dose.

immediately.

o Children: 1:1000, IM, 0.01 mL/kg as a single dose. See dosing table, pg 23.5.
o Adults: 1:1000, IM, 0.5 mg (0.5 mL) as a single dose, into the lateral thigh.
o Repeat in 5 minutes if no improvement.

x Oxygen, 8-10 L/minute via facemask or up to 100% oxygen, as needed.

Second line priority:

AND LoE: IIIviii

x Sodium chloride 0.9%, IV:

If hypotension not responding promptly to adrenaline (epinephrine), also give:

o Children: 20 mL/kg, over 5 to 10 minutes. Repeat as needed.

o Adults: 1000–2000 mL, at the most rapid flow rate possible in the first minutes
of treatment. Repeat as needed.

CAUTION
Monitor continuously for clinical response and fluid overload.

AND LoE: IIIix

x Salbutamol 0.5%, solution, nebulised, with high flow oxygen.

If wheeze:

o 0.5–1 mL (2.5–5 mg) salbutamol 0.5% solution, in 4 mL of sodium chloride 0.9%.

x Ipratropium bromide, solution, added to salbutamol solution.

AND LoE: IIIx

o Children: 0.5–1 mL (0.125–0.25 mg)

o Adults: 2 mL (0.5 mg) LoE: IIIxi

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 CHAPTER 21 EMERGENCIES AND INJURIES

x Hydrocortisone IM/slow IV, immediately.

AND

o Children: 5 mg/kg immediately. See dosing table, pg 23.5.

o Adults: 200 mg immediately. LoE:IIIxii
AND LoEIIIxiii
x Promethazine IM/slow IV.
o Children > 2 years: 0.25 mg/kg. See dosing table, pg 23.8. LoE: IIIxiv
o Adults: 25–50 mg.

REFERRAL
All patients.
Note: Adrenaline (epinephrine) administration may have to be repeated due to its
short duration of action. Observe closely during transport.

21.2.11 SEIZURES AND STATUS EPILEPTICUS

G41.0-2/G41.8-9
For description and general measures of seizures, see Section 15.3: Seizures.

DESCRIPTION
This is a medical emergency andhas the potential for causing high mortality.
Status epilepticus is a series of seizures follow one another lasting > 30 minutes with
no intervening periods of recovery of consciousness. The seizure may be generalised
or partial, convulsive or non-convulsive.
Do not wait for established status epilepticus to terminate convulsions. Convulsions
lasting > 5 minutes should be terminated.

GENERAL MEASURES
» Place the patient in a lateral (recovery) position.
» Do not place anything (spoon or spatula, etc.) in the patient's mouth.
» Do not try to open the patient’s mouth.
» Maintain airway.
» Assist respiration and give high flow oxygen.
» Prepare for intubation if sufficiently skilled in the procedure and relevant rescue
devices are available.
» Check blood glucose (exclude hypoglycaemia).
» Monitor vital signs every 15 minutes.
» Establish an IV line.

MEDICINE TREATMENT

x Midazolam, buccal, 0.5 mg/kg/dose. See dosing table, pg 23.7.

Children < 12 years of age

o Use midazolam for injection 5 mg in 1 mL undiluted.

o Draw up the required volume in a 5 mL syringe.
o Remove needle then administer midazolam into the buccal cavity (between
gum and cheeks).
o If seizures persist for > 5 minutes, repeat the dose and refer urgently.

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 CHAPTER 21 EMERGENCIES AND INJURIES

o Note: Buccal midazolam should not be used in infants < 6 months of age.
OR LoE:IIxv
Midazolam, IM:
o Child > 13 kg: midazolam, IM, 5 mg, repeat once after 5–10 minutes if still fitting.
OR LoE:IIxvi
Diazepam, rectal, 0.5 mg/kg/dose as a single dose. See dosing
table, pg 23.4.
o Use diazepam for injection 10 mg in 2 mL undiluted.
o Draw up the required volume in a 2 mL syringe.
o Remove needle then insert the whole barrel of the lubricated syringe into the
rectum and inject the contents.
o Remove syringe and hold buttocks together to minimise leakage.
o Maximum dose: 10 mg in 1 hour.
o May be repeated after 10 minutes if convulsions continue.
o Expect a response within 1–5 minutes.

CAUTION
Benzodiazepines, can cause respiratory depression.
Monitor closely for respiratory depression. If this occurs, assist ventilation with
bag-valve mask (1 breath every 3–5 seconds) and refer urgently.
If no response after two consecutive doses of either midazolam or diazepam, and if
the convulsion has lasted more than 20 minutes:

x Phenobarbital, oral, crushed and given by nasogastric tube, 20 mg/kg as a single

ADD

dose. See dosing table, pg 23.8.

LoE: IIIxvii

x Midazolam, IM, 10 mg, immediately.

Adults

o Repeat once after 5–10 minutes if still fitting. LoE: Ixviii

OR
Midazolam, buccal, 10 mg using the parenteral formulation.
o Repeat once after 5–10 minutes if still fitting.
OR LoE: III
Diazepam, slow IV, 10 mg.
o Administer at a rate not exceeding 5mg/minute.
o Repeat within 5 minutes if needed.
o Maximum dose: 20 mg within 1 hour.
o Expect a response within 1–5 minutes. LoE: IIIxix

CAUTION
Benzodiazepines can cause respiratory depression.
Monitor closely for respiratory depression. If this occurs, assist ventilation with
bag-valve mask (1 breath every 3-5 seconds) and refer urgently.
Avoid diazepam IM since absorption is slow and erratic.
Do not mix diazepam with other medicines in same syringe.

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 CHAPTER 21 EMERGENCIES AND INJURIES

REFERRAL
Urgent
Seizures that cannot be controlled.
Non-urgent
All patients once stabilised.
Note: Clinical notes describing medication administered and route of administration
should accompany patients.

21.3 TRAUMA AND INJURIES

21.3.1 BITES AND STINGS
21.3.1.1 ANIMAL BITES
S01.0-9/S11.0-2/S11.7-9/S21.0-2/S21.7-9/S31.0-5/S31.7-8/S41.0-1/S41.7-8/S51.0/S51.7-
9/S61.0-1/S61.7-9/S71.0-1/S71.7-8/S81.0/S81.7-9/S91.0-3/S91.7/T01.0-3/T01.6/T01.8-
9/T09.1/T11.1/T13.1/T14.0-1/A82.0-1/A82.9/Z24.2/Z20.3 + External Cause Code (W,X,Y,Z)
Note: Rabies and tetanus are notifiable medical conditions.

DESCRIPTION
Animal bites may be caused by:
» Domestic animals e.g. horses, cows, dogs, cats.
» Wild animals e.g. jackals, mongooses (meerkats), bats.
Animal bites may result in:
» Wound infection, often due to mixed aerobic and anaerobic infection.
» Puncture wounds.
» Tissue necrosis.
» Transmission of diseases, e.g. tetanus, rabies.
NICD hotline for rabies advice: 0828839920

Suspected rabid bite

Any mammal bite can transmit rabies. Rabies incubation period is at least 9–90 days,
but could be much longer. In suspected rabies exposure of a person by a domestic
animal, attempt to trace source animal to determine likelihood of rabies. Observe the
suspected rabid animal for abnormal behaviour for 10 days. If the animal remains
healthy for 10 days, rabies is unlikely.
Note: If the animal has to be put down, care should be taken to preserve the brain, as
the brain is required by the state veterinarian for confirmation of diagnosis. The animal
must not be killed by shooting it in the head, as this will damage the brain.

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 CHAPTER 21 EMERGENCIES AND INJURIES

Category Type of exposure Management

» Touching/feeding of animal. » No treatment if history is
» Licking of intact skin. reliable.
1
» If history not reliable, treat as
category 2.
» Nibbling of uncovered skin. » Wound management.
2 » Superficial scratch without bleeding. » Administer full course vaccine.
Only stop if animal tested
negative for rabies or is still
healthy after 10 days’
observation.
» Don’t give immunoglobulin,
except in immunocompromised
patients.
» Bites/scratches that penetrate the skin » Wound management.
3 and with any visible blood. » Administer full course vaccine.
» Licking of broken skin or mucous » Only stop if animal tested
membranes e.g. eyes and mouth. negative for rabies or is still
» Bat bites: healthy after 10 days’
– Any close contact with a bat: single observation.
or multiple bites or scratches and » Administer rabies
bruising (even with minor bites or immunoglobulin.
unapparent skin penetration). » Administer tetanus vaccine.
– Direct physical contact with bat » Prescribe antibiotics.
saliva or neural tissue; contact of
mucous membranes with bat saliva,
droppings or urine.

MEDICINE TREATMENT
Emergency management
Wound management:

x Chlorhexidine 0.05%, aqueous solution.

Wash wound thoroughly with soap under running water for 5–10 minutes.

x Povidone-iodine 10%, solution.

Apply disinfectant if available:

CAUTION
Do not suture bite wounds unless on the head/face.
Clean thoroughly, dress (avoid compressive dressings) and review after 48
hours for secondary closure at that time.
The following treatment may be commenced in facilities designated by
Provincial/Regional Pharmaceutical Therapeutics Committees. If access to
rabies vaccine and immunoglobulin is not immediately available refer urgently.
Note: Rabies PEP (post exposure prophylaxis) schedule varies for
immunocompromised patients. The degree to which a patient is immunocompromised
should preferably be verified by a physician and includes congenital immunodeficiency,
HIV infection, leukaemia, lymphoma, generalised malignancy, radiation,
immunosuppressant medicines e.g. long-term therapy of corticosteroids, etc.

2018 21.30
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Rabies immunoglobulin:
» Only indicated for:
– Category 3, immunocompetent patients.
– Category 2 and 3 immunocompromised patients.
– All bat exposures.
» Available from the nearest district hospital.
» If not immediately available, source and give as soon as possible.
x Rabies immunoglobulin 20 IU/kg.
o Infiltrate as much as possible in and around the wound and inject the rest IM
(not buttock, unless the wound is on the buttock).
o Follow with a complete course of vaccine.

Rabies vaccination:
» Only indicated for category 2 and 3 exposure.
» Available from the nearest district hospital.

x Rabies vaccine, 1 amp, IM anterolateral thigh.

Children

Day 0 – single dose

Day 3 – single dose
Day 7 – single dose
Day 14 – single dose
Day 28 – single dose(only if immunocompromised).

x Rabies vaccine, 1 amp, IM deltoid.

Adults

Day 0 – single dose

Day 3 – single dose
Day 7 – single dose
Day 14 – single dose
Day 28 – single dose(only if immunocompromised).

CAUTION
Do not administer rabies vaccine into buttocks (gluteus maximus).

x Tetanus toxoid vaccine (TT), IM, 0.5 mL.

Tetanus prophylaxis if not previously immunised within the last 5 years: Z23.5

Note: In a fully immunised person, tetanus toxoid vaccine or tetanus

immunoglobulin may produce an unpleasant reaction, e.g. redness, itching,
swelling or fever, but in the case of a severe injury the administration is justified.
Antibiotic treatment (only for category 3 exposure, hand wounds):

x Amoxicillin/clavulanic acid oral, 15–25 mg/kg/dose of amoxicillin component, 8

Children

hourly for 5 days.

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 CHAPTER 21 EMERGENCIES AND INJURIES

Weight Dose Use one of the following Age

kg mg Susp Susp Tablet months/years
(amoxicillin 125/31.5 250/62.5 250/125
component) mg/5 mL mg/5 mL mg/tab
>3.5–5kg 75 mg 3 mL 1.5 mL – >1–3 months
>5–7 kg 100 mg 4 mL 2mL – >3–6 months
>7–9 kg 150 mg 6 mL 3 mL – >6–12 months
>9–11 kg 200 mg 8 mL 4 mL – >12–18 months
>11–14 kg 250 mg 10 mL 5 mL 1 tablet >18 months–3 years
>14–17.5 kg 300 mg 12 mL 6 mL – >3–5 years
>17.5–25 375 mg 15 mL 7.5 mL – >5–7 years
>25–35 kg 500 mg 20 mL 10 mL 2 tablets >7–11 years

x Amoxicillin/clavulanic acid, oral, 875/125 mg 12 hourly for 5 days.

Children > 35 kg and adults

Severe penicillin allergy: (Z88.0)

Children
ƒ Macrolide, e.g.:
x Azithromycin, oral, 10 mg/kg daily for 3 days. See dosing table pg 23.2.
Children > 35 kg and adults
ƒ Macrolide, e.g.:
x Azithromycin, oral, 500 mg daily for 3 days.
AND

x Metronidazole, oral, 7.5 mg/kg/dose 8 hourly for 5 days. See dosing table, pg 23.7.
Children

x Metronidazole, oral, 400 mg, 8 hourly for 5 days.

Adults

PREVENTION
» Regular vaccination of domestic cats and dogs.
» Pre-exposure vaccine may be given to those at risk, e.g. occupation, endemic
areas, laboratories.

REFERRAL
» Deep and large wounds requiring suturing.
» Shock and bleeding.
» Possible rabies exposure (for immunoglobulin and vaccination).
» Severe infected wounds or infected wounds not responding to oral antibiotics.
» Hand bites.

21.3.1.2 HUMAN BITES

S01.0-9/S11.0-2/S11.7-9/S21.0-2/S21.7-9/S31.0-5/S31.7-8/S41.0-1/S41.7-8/S51.0/S51.7-
9/S61.0-1/S61.7-9/S71.0-1/S71.7-8/S81.0/S81.7-9/S91.0-3/S91.7/T01.0-3/T01.6/T01.8-
9/T09.1/T11.1/T13.1/T14.0-1 + External Cause Code (W,X,Y,Z)

DESCRIPTION
Human bites may be accidental or intentional (form of assault).

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Human bites may result in:

» Wound infection, often due to mixed aerobic and anaerobic infection.
» Puncture wounds.
» Tissue necrosis.
» Transmission of diseases, e.g. HIV, hepatitis.

MEDICINE TREATMENT
Wound management:

x Chlorhexidine 0.05%, aqueous solution.

Wash wound thoroughly with soap under running water for 5–10 minutes.

x Povidone-iodine 10%, solution.

Apply disinfectant if available:

CAUTION
Do not suture bite wounds unless on the head/face. Clean thoroughly, dress
(avoid compressive dressings). Review after 48 hours for secondary closure at
that time.
Tetanus prophylaxis: Z23.5

x Tetanus toxoid (TT), IM, 0.5 mL.

If not previously immunised within the last 5 years:
LoE: IIIxx
Antibiotic treatment:

x Amoxicillin/clavulanic acid oral, 15–25 mg/kg/dose of amoxicillin component, 8

Children

hourly for 5 days.

Weight Dose Use one of the following Age
kg mg Susp Susp Tablet months/years
(amoxicillin 125/31.5 250/62.5 250/125
component) mg/5 mL mg/5 mL mg/tab
>3.5–5kg 75 mg 3 mL 1.5 mL – >1–3 months
>5–7 kg 100 mg 4 mL 2mL – >3–6 months
>7–9 kg 150 mg 6 mL 3 mL – >6–12 months
>9–11 kg 200 mg 8 mL 4 mL – >12–18 months
>11–14 kg 250 mg 10 mL 5 mL 1 tablet >18 months–3 years
>14–17.5 kg 300 mg 12 mL 6 mL – >3–5 years
>17.5–25 375 mg 15 mL 7.5 mL – >5–7 years
>25–35 kg 500 mg 20 mL 10 mL 2 tablets >7–11 years

x Amoxicillin/clavulanic acid, oral, 875/125 mg 12 hourly for 5 days.

Children > 35 kg and adults

Severe penicillin allergy: (Z88.0)

Children
ƒ Macrolide, e.g.:
x Azithromycin, oral, 10 mg/kg daily for 3 days. See dosing table pg 23.2.

x Metronidazole, oral, 7.5 mg/kg/dose 8 hourly for 5 days. See dosing table, pg 23.7.
AND

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 CHAPTER 21 EMERGENCIES AND INJURIES

Children > 35 kg and adults

ƒ Macrolide, e.g.:
x Azithromycin, oral, 500 mg daily for 3 days.

x Metronidazole, oral, 400 mg, 8 hourly for 5 days.

AND

Hepatitis B prophylaxis (if bite is severe enough to cause bleeding): Z29.8

See section 21.3.6.3: Post exposure prophylaxis, inadvertent (non-occupational).
HIV prophylaxis
The risk of HIV transmission through biting is negligible. Post-exposure prophylaxis is
not indicated after a bite.
LoE: IIxxi
REFERRAL
» Deep and large wounds requiring suturing.
» Shock and bleeding.
» Severe infected wounds or infected wounds not responding to oral antibiotics.
» Hand bites.

21.3.1.3 INSECT STINGS, SCORPION STINGS AND SPIDER

BITES
T63.2/3/4 + External Cause Code (V,W,X,Y)
Poisons Information Helpline:0861555777
See Section 21.3.3: Exposure to poisonous substances.

DESCRIPTION
Injury from spider bites and stings by bees, wasps, scorpions and other insects.
Symptoms are usually local such as pain, redness swelling and itching.
Bees and wasps
» Venom is usually mild but may provoke severe allergic reactions such as
laryngeal oedema or anaphylaxis (see Section 21.2.10: Anaphylaxis).
Spiders and scorpions
» Most are non-venomous or mildly venomous, but some may be extremely
venomous and constitute a medical emergency.

MEDICINE TREATMENT
Emergency treatment:
Treat anaphylaxis (bee/wasp stings). See Section 21.2.10: Anaphylaxis.
Severe local symptoms:

x Chlorphenamine, oral, 0.1 mg/kg/dose 6–8 hourly. See dosing table, pg 23.3.
Children

CAUTION
Do not give an antihistamine to children < 2 years of age.

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 CHAPTER 21 EMERGENCIES AND INJURIES

x Chlorphenamine, oral, 4 mg, 6–8 hourly.

Adults

x Calamine lotion, applied when needed.

AND

If hypersensitivity response to insect bite with inflamed lesion, see Section 5.10.4:
Papular urticaria.
Pain:

x Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See dosing table,
Children

pg 23.8.

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per

Adults

24 hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.
Cytotoxic lesions:
Avoid giving prophylactic antibiotics for bites and stings.
If secondary skin infection (site red, swollen, hot, tender, pus may be present),
manage as cellulitis. See Section 5.4.3: Cellulitis.

x Lidocaine 2%, 2 mL injected around the bite as a local anaesthetic.

Very painful scorpion stings:

Local application of ice, if tolerated.

For spider bites and scorpion stings: Tetanus prophylaxis: Z23.5

x Tetanus toxoid vaccine (TT), IM, 0.5 mL.

If not immunised within the last 5 years:
LoE:IIIxxii

REFERRAL
» For possible antivenom (neurotoxic spider bites or scorpion stings), if applicable,
and intensive care, if necessary.

  double vision
» Presence of systemic manifestations:

  muscle cramps
weakness

  paraesthesia
drooping eyelids

 difficulty in swallowing and speaking  agitation/restlessness in children

hypersalivation

Note: Send the spider or scorpion with the patient, if available.

» If secondary infection of bite/sting this is not responding to first line antibiotics.

21.3.1.4 SNAKEBITES
T63.0 + (X20.99/W59.99)

DESCRIPTION
Of all the species of snakes found in South Africa, about 12% are considered to be
potentially dangerous to humans. However, all snake bites should be considered

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 CHAPTER 21 EMERGENCIES AND INJURIES

dangerous until proven otherwise.

South African poisonous snakes can be broadly divided into 3 groups
according to the action of their venom although there is significant overlap of
toxic effects in some snake venoms.
Cytotoxic venoms
» Venom causes local tissue damage and destruction around the area of bite.
» Bite is painful and symptoms usually start within 10–30 minutes after the bite.
» Examples include:
Ͳ Puff adder Ͳ Mozambique spitting cobra
Ͳ Night adder Ͳ Stiletto snake
Ͳ Gaboon adder Ͳ Rinkhals (cytotoxic as well as
Ͳ Other smaller adders and spitting cobras neurotoxic)
Neurotoxic venoms
» Neurotoxic venom causes weakness, ptosis, drooling and dysphagia, pins and
needles, sweating, blurred vision, hypotension and respiratory difficulty and
paralysis of skeletal muscles and respiratory failure.
» Bite is not as painful as cytotoxic venom bites.
» Symptoms usually start in 15–30 minutes.
» Examples include:
Ͳ Cape cobra Ͳ Green mamba
Ͳ Black mamba Ͳ Rinkhals (cytotoxic as well
Ͳ Berg adder (neurotoxic as well as cytotoxic) as neurotoxic)
Haemotoxic venoms
» Venom affects the clotting of blood causing bleeding tendency which may
present up to a few days after the bite.
Ͳ Boomslang Ͳ Vine snake
Symptoms and signs of snakebite envenomation include:
Local
» Bite marks with or without pain.
» Swelling around the bite, which may be severe with discolouration of skin and/or
blister formation.
» Bleeding or oozing from bite site.
Note: the absence of bite marks does not exclude envenomation.
Systemic
» Nausea, vomiting.
» Sweating and hypersalivation.

 drooping eyelids  difficulty in swallowing

» Skeletal muscle weakness (descending paralysis), which may cause:

 double vision  difficulty in breathing

» Shock.
» Rarely bleeding (epistaxis, haematuria, haematemesis or haemoptysis).

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CAUTION
Do not apply a tourniquet.
Do not apply a restrictive bandage to the head, neck or trunk.
Do not squeeze or incise the wound.
Do not attempt to suck the venom out.

GENERAL MEASURES

x
Emergency treatment
Remove clothing from site of the bite and rings if an extremity bite; and clean the
wound thoroughly with chlorhexidine 0.05%, aqueous solution.
For non-cytotoxic bites only:
» Be prepared to support ventilation in neurotoxic bites as this can be life-saving.
» To prevent spread to vital organs, immediately apply a wide crepe bandage firmly
from just above the bite site up to 10–15 cm proximal to the bite site. Apply no
tighter than for a sprained ankle.
» Immobilise the affected limb with a splint or sling.
» Try to obtain an accurate history e.g. time of the bite, type of snake.
» If no signs and symptoms, observe the patient for 6–8 hours with repeated
examinations.
» Absence of symptoms and signs for 6–8 hours usually indicates a harmless bite.
» Observation for 24 hours is recommended.

MEDICINE TREATMENT
Venom in the eyes: S05.9 + (X20.99)
Irrigate the eye thoroughly for 15–20 minutes with water or sodium chloride, 0.9%.
x Tetracaine 1%, drops (if available), instill 1 drop into the affected LoE:III
eye(s) before irrigation.
Refer patient.

x Non-opioid analgesics according to severity. See Section 20.3: Chronic non-

Pain:

cancer pain.
Shock:
Treat if present. See Section 21.2.9: Shock.

Tetanus prophylaxis: Z23.5

x Tetanus toxoid (TT), IM, 0.5 mL.

If not previously immunised within the last 5 years:

Note:
» The majority of patients do not need and should not be given antivenom.
» The dose of antivenom is the same for adults and children.
» Polyvalent antivenom does NOT include antivenom for Berg adders or Stiletto
snakes. Management for these is symptomatic and supportive only.
Criteria for antivenom administration LoE:IIIxxiii
All patients with systemic signs and symptoms or severe spreading

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 CHAPTER 21 EMERGENCIES AND INJURIES

local tissue damage should receive antivenom.

» Signs of systemic envenomation (see signs, above).

 Swelling of entire hand/foot within 1 hour of bite (80% of bites are on hands/ feet).
» Spreading local damage:

 Swelling extends to elbow or knee within 6 hours, or whole limb within 12

 Upper extremity bite with swelling extending to the chest.

hours, of a bite.

 Lower extremity bite with swelling extending to the groin.

 Bite to chest with severe circumferential swelling resulting in difficulty breathing.
 Significant swelling of head or neck threatening airway.
LoE:IIIxxiv
REFERRAL
» All patients with bites or likely bites even if puncture marks are not seen.
If possible, take the dead snake to the referral centre for identification.
» If the patient presents at the clinic with their own antivenom, contact the
secondary level hospital for advice.
South African Vaccine Producers (SAVP):
Office hours: (011) 386 6062/6063/6078
After hours: (011) 386 6000 or 071 680 9897

21.3.2 BURNS
T30.0-3/T31.0-9 + (Y34.99)

DESCRIPTION
Burns lead to skin and soft tissue injury and may be caused by:
» heat, e.g. open flame, hot liquids, hot steam,
» chemical compounds,
» physical agents, e.g. electrical/lightning) or
» radiation.
The extent and depth may vary from superficial (epidermis) to full-thickness burns
of the skin and underlying tissues.
Initially, burns are usually sterile.
Assessment of burns
Depth of burn Surface /colour Pain sensation/healing
wound
Superficial or Dry, minor blisters, » Painful
epidermal erythema » Heals within 7 days
Partial thickness Blisters, moist » Painful
superficial or » Heals within 10–14 days
superficial dermal
Partial thickness Moist white or yellow » Less painful
deep or deep dermal slough, red mottled » Heals within a month or more Generally
needs surgical debridement and skin graft
Full thickness Dry, charred » Painless, firm to touch
(complete loss of whitish, brown or » Healing by contraction of the margins
skin) black (generally needs surgical debridement
and skin graft)

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 CHAPTER 21 EMERGENCIES AND INJURIES

The figures below are used to calculate body surface area %.1
These diagrams indicate percentages for the whole leg/arm/head (and neck in
adults) not just the front or back.
In children the palm of the hand, including the fingers, is 1%.
Children 8 years and adults

Children < 8 years of age

1
Source: Karpelowsky JS, Wallis L, Madaree A, Rode H; South African Burn Society..South African Burn
Society burn stabilisation protocol. S Afr Med J. 2007
Aug;97(8):574-7.https://www.ncbi.nlm.nih.gov/pubmed/17966146

2018 21.39
 CHAPTER 21 EMERGENCIES AND INJURIES

Child and adult percentages

Age Head + neck Torso Front Torso Leg + foot Front + Arm+ hand
years Front + back Back back Front+ back
<1 18% 18% 18% 14% 9%
1-<2 17% 18% 18% 14.5% 9%
2-<3 16% 18% 18% 15% 9%
3-<4 15% 18% 18% 15.5% 9%
4-<5 14% 18% 18% 16% 9%
5-<6 13% 18% 18% 16.5% 9%
6-<7 12% 18% 18% 17% 9%
7-<8 11% 18% 18% 17.5% 9%
•8 10% 18% 18% 18% 9%

EMERGENCY TREATMENT
Follow the 7C’s:
» Clothing: remove non-sticking clothing especially if hot or smouldering or
constrictive (e.g. rings).
» Cool: with tap water for 30 minutes.
» Clean: with chlorhexidine.
» Cover: with a non-adherent dressing.
» Comfort: provide pain relief.
» Carbon dioxide poisoning: consider if enclosed fire, decreased LOC, disorientation.
» Consider inhalation injury if: carbonaceous (black-coloured) sputum, shortness of
breath, perioral burns, hoarse voice stridor. Discuss with referral centre as early
intubation may be needed.

MEDICINE TREATMENT
Fluid replacement
Burns ” 10% Total Body Surface Area (TBSA):
Oral fluids.

x IV fluid for resuscitation, replacement and maintenance.

Burns > 10% of TBSA:

Calculation of fluid replacement

Fluids in adults:
If shocked, see Section 21.2.9: Shock.
Replacement fluids for burns

x Sodium chloride 0.9%, IV.

First 24 hours:

o Calculate total fluid requirement in 24 hours:

Total % burn x weight (kg) x 4 mL.
o Give half this volume in the first 8 hours.
o Administer remaining fluid volume in next 16 hours.
Note: If urine output is not adequate, increase fluids for the next hour by 50%.
Continue at a higher rate until urine output is adequate, then resume normal
calculated rate.

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 CHAPTER 21 EMERGENCIES AND INJURIES

Fluids in children:
Replacement fluids for burns
» First 8 hours:
Note: Avoid circumferential taping when securing infusion lines, as oedema under the
eschar may decrease the venous return.
Fluid volume (mL per hour) for the 1st 8 hours in burns of > 10% seen in

x 0.9% Sodium Chloride with 100mL of 50% dextrose added to each

PHC clinics while awaiting transfer:
Weight
kg litre or 10mL of 50% dextrose added to each 100mL.
Burns percentage of total body area
10–20% >20–30% >30–40% >40%
>2–2.5 kg 15 19 23 28
>2.5–3.5 kg 20 25 31 36
>3.5–5 kg 28 36 44 51
>5–7 kg 40 50 62 73
>7–9 kg 53 70 84 100
>9–11 kg 67 85 105 120
>11–14 kg 82 105 125 150
>14–17.5 kg 95 125 155 185
>17.5–25 kg 115 155 190 235
>25–35 kg 147 200 250 310
» Next 16 hours:
Fluid volume (mL per hour) for the 2nd (next) 16 hours in burns of >
10% seen in PHC clinics if transfer has not been accomplished in the

x 0.9% Sodium Chloride with 100mL of 50% dextrose added to each

1st 8 hours:
Weight
kg
litre or 10 mL of 50% dextrose added to each 100 mL.
Burns percentage of total body area
10–20% >20–30% >30–40% >40%
>2–2.5 kg 12 14 17 19
>2.5–3.5 kg 16 19 22 25
>3.5–5 kg 23 27 31 35
>5–7 kg 33 38 44 49
>7–9 kg 43 50 58 65
>9–11 kg 54 64 72 82
>11–14 kg 64 76 86 97
>14–17.5 kg 75 91 104 118
>17.5–25 kg 91 110 129 148
>25–35 kg 110 138 165 190

Pain:

x Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See dosing table,
Children

pg 23.8.

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per

Adults

24 hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.

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 CHAPTER 21 EMERGENCIES AND INJURIES

Severe pain:
See Section 20.3: Chronic non-cancer pain.

Wound cleansing:

x Sodium chloride 0.9% or clean water.

Clean the burn wound gently.

Burn dressing:
For patients requiring referral
» If within 12 hours, transfer patient wrapped in clean dry sheet and blankets.
» If delayed by > 12 hours, paraffin gauze dressing and dry gauze on top.
» For full thickness and extensive burns cover with a paraffin gauze occlusive
dressing. Cover the dressing with plastic wrap (e.g. cling film).
For patients not requiring transfer (burns that can be treated at LoE:III
home)
» Paraffin gauze dressing.

x Povidone-iodine 5%, cream, applied daily.

If infected burn

Tetanus prophylaxis: Z23.5

x Tetanus toxoid (TT), IM, 0.5 mL.

If not vaccinated within the last 5 years

See Section 21.3.1.1: Animal bites or 21.3.1.2: Human bites, for detailed indications
and management principles.

REFERRAL
» All children < 1 year of age.
» All burns > 5% in children1–2 years of age.
» Full thickness burns of any size in any age group.
» Partial thickness burns > 10% TBSA.
» Burns of special areas – face, hands, feet, genitalia, perineum and major joints.
» Electrical burns, including lightning injury.
» Chemical burns.
» Inhalation injury – fire or scald injury.
» Circumferential burns of the limbs or chest.
» Burn injury in a patient with pre-existing medical disorders which could complicate
management, prolong recovery or affect mortality.
» Any patient with burns and concomitant trauma.
» Suspected child abuse.
» Burns exceeding the capabilities of the referring centre.
» Septic burn wounds.
Note: IV fluid replacement is very important in large burns. However, if unable to
obtain IV access, give fluids orally or via NGT and transfer urgently.

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 CHAPTER 21 EMERGENCIES AND INJURIES

21.3.3 EXPOSURE TO POISONOUS SUBSTANCES

T36.0-9/T37.0-5/T37.8-9/T38.0-9/T39.0-4/T39.8-9/T40.0-9/T41-0-5/T42.0-8/T43.0-6/T43.8-9/
T44.0-9/T45.0-9/T46.0-9/T47.0-9/T48-0-7/T49.0-9/T50.0-9/T51.0-3/T51.8-9/T52.0-4/T52.8-
9/T53.0-9/T54.0-3/T54.9/T55/T56.0-9/T57.0-3/T57.8-9/T58/T59.0-9/T60.0-4/T60.8-9/T65.0-
6/T65.8-9 + (X44.99/X49.99/X64.99/X69.99/Y14.99/Y19.99)
Note: Poisoning from agricultural stock remedies is notifiable.
POISON INFORMATION CENTRES
Poisons Information Helpline (national
service)
Red Cross War Memorial Children’s
Hospital Poisons Information Centre
Email: [email protected]
http://www.paediatrics.uct.ac.za/poisons- 24 hours/day 0861 555 777
information-centre
Tygerberg Poison Information Centre
Email: [email protected]
www.sun.ac.za/poisoncentre
University of the Free State Poison
Control and Medicine Information Centre 24 hours/day 082 491 0160
Checked on 12 June 2018.
The Afritox database is available free of charge to public hospitals in South Africa:
see www.afritox.co.za for information on how to access the database.
If the above centres cannot be contacted, enquire at the nearest trauma and
emergency unit.

DESCRIPTION
Acute poisoning is a common medical emergency. Poisoning may occur by ingestion,
inhalation or absorption through skin or mucus membranes. Frequently encountered
poisons include:
» analgesics » pesticides
» anti-epileptic agents » volatile hydrocarbons, e.g. paraffin
» antidepressants and sedatives » household cleaning agents
» theophylline » antihypertensive and anti-diabetic agents
» vitamins and minerals, especially iron in children
Signs and symptoms vary according to the nature of poisoning.

GENERAL MEASURES

 If skin contact has occurred, especially pesticides, wash the skin with soap
» Remove the patient from the source of poison:

 For inhalation of poisonous gases, move patient to fresh air.

and water, ensuring carer has protective measures e.g., gloves, gowns, masks, etc.

» Establish and maintain the airway.

» Ensure adequate ventilation and oxygenation.
» Treat shock.

 Obtain collateral information, especially in patients with impaired consciousness.

» Take an accurate history.

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 A special effort should be made to obtain tablets, packets, containers, etc. of

the suspected agent used in order to identify poisons involved.

 pulse rate  level of consciousness

» Document, and respond to, abnormalities of:

 blood pressure  pupillary size and reaction

 respiratory rate  oxygenation

x Activated charcoal.
Ingested poisons

o Only if the patient is fully conscious and able to maintain their airway and if
ingestion was within the previous hour prior to presentation.
o Children: 1 g/kg mixed as a slurry with water. See dosing table, pg 23.1.
o Adults: 50–100 g mixed as a slurry with water.
o Add water to charcoal and not vice versa.
o Do not administer orally if the level of consciousness is reduced.

 volatile hydrocarbon poisoning, e.g. paraffin, petrol

» Activated charcoal should not be given in the case of:

 corrosive poisons, e.g. acids, alkalis, potassium permanganate

 camphor and other convulsants
 metals, e.g. iron, lithium etc.
 all alcohols
 paracetamol overdose where oral acetylcysteine will be given

 Place in lateral position if decreased level of consciousness.

» Protect the airway:

» Identify the poison and keep a sample of the poison or container.

» Contact the nearest hospital or Poisons Information Helpline for advice.

EMERGENCY MANAGEMENT
» Assess patient urgently and perform resuscitation as required. Wear personal
protective equipment. See Section 21.1: Cardiopulmonary – cardiopulmonary
resuscitation.
» Take a history and identify the nature and route of poisoning.
» Remove contaminated clothes in organophosphate poisoning and thoroughly
wash off any poison from the skin with soap and water.
Note: Healthcare workers and relatives should avoid having skin contact with the
poison or the patient’s bodily fluids e.g. vomitus, faeces.
Specific poisons and antidotes:

x Give 100% oxygen by non-rebreather mask.

Hypoxia, especially in carbon monoxide poisoning T58 + (X49.99/X69.99/Y19.99)

Organophosphate and carbamate poisoning T60.0 + (X48.99/X68.99/Y18.99)

 diarrhoea  weakness
» Signs and symptoms of poisoning include:

 vomiting  miosis/mydriasis
 bradycardia  confusion
 muscle twitching  convulsions

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coma


hypersecretions (hypersalivation, sweating, lacrimation, rhinorrhoea)
bronchospasm and bronchorrhoea, causing tightness in the chest,
wheezing, cough and pulmonary oedema
» Protect airway if GCS < 8.
» Intubate and ventilate if hypoxia, hypercarbia or decreased respiratory effort.
» Start atropine antidote immediately:
x Atropine, IV.
o Children: 0.05 mg/kg/dose. See dosing table, pg 23.2.
o Adults: 1 mg
o In both adults and children:

 If no response, give double the initial dose.

Reassess every 3–5 minutes and if necessary give more atropine:

 If some response, repeat the same dose.

Give repeat boluses every 5 minutes until adequate response achieved, i.e.
reduced bronchial secretions, reversal of bronchospasm, no oral secretions,
increasing heart rate and dilating pupils (Note: pupil reversal may be delayed).
o Continue to reassess frequently as additional doses may be required.
Note: Refer all patients urgently but only when stable.
Opioid overdose T40.0-9 + (X42.99/X62.99/Y12.99) LoE:IIIxxv
» Respiratory support is the mainstay of treatment. Give naloxone for severe
poisoning only (i.e. patients requiring ventilatory support) or as a single test

 If respiration adequate, observe the patient in a monitored setting and

dose for uncertain diagnosis.

 If patient is apnoeic or has slow/shallow respirations, assist ventilation with

reassess frequently.

bag-valve mask attached to supplemental oxygen, whilst administering

naloxone below. If GCS < 8, protect airway and consider intubation if
persistent respiratory depression.
x Naloxone, IV (preferable) or IM
Age and Initial dose (IV/IM) Repeat dose: Reassess every 2 minutes. If
weight breathing still inadequate, give further
naloxone every 2–3 minutes.
Children: LoE:IIIxxvi
< 5 years x 0.1 mg/kg immediately Repeat 0.1mg/kg (maximum 2 mg/dose),
or (maximum 2 mg/dose) up to total dose of 10 mg.
” 20 kg
• 5 years x 0.4–2mg immediately Repeat 0.1mg/kg (maximum 2mg/dose),
or up to total dose of 10 mg
> 20 kg
Adults: LoE:III
Adults x 0.4–2 mg immediately Double the dose each time (e.g.: 0.8mg,
2mg, 4 mg), up to total dose of 10 mg.

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o Naloxone has a short duration of action (45 minutes) - continue to monitor

closely as further doses of naloxone may be needed while awaiting and during
transport.
o In patients addicted to opioids, naloxone may precipitate an acute withdrawal
syndrome after several hours. This must not prevent the use of naloxone.
o Refer all patients.

Paracetamol poisoning T39.1 + (X40.99/X60.99/Y10.99)

All symptomatic patients or those with a history of significant single ingestion (• 200
mg/kg or 10 g, whichever is less) should be referred urgently for paracetamol blood
level and consideration of acetylcysteine.

REFERRAL
» All intentional overdoses.
» All symptomatic patients.
» All children in whom toxicity can be expected, e.g. ingestion with:
 paracetamol • 200 mg/kg or 10 g (whichever is less) LoE:IIIxxvii
 anti-epileptics
 warfarin
 tricyclic antidepressants
 sulphonylureas
 paraffin (unless patient has a normal respiratory rate after 6 hours)
 iron tablets
If in doubt, consult the referral hospital or Poisons Information Helpline.
Note: Send the following to hospital with the patient:
» written information
» a sample of the poison or the empty poison container

21.3.4 EYE, CHEMICAL BURNS

(See Chapter 18: Eye conditions).

21.3.5 EYE INJURY, FOREIGN BODY

(See Chapter 18: Eye conditions).

21.3.6 POST EXPOSURE PROPHYLAXIS

21.3.6.1 POST EXPOSURE PROPHYLAXIS, OCCUPATIONAL
Z20.6 + Z20.5 + (Z57.8+X58.92+Z29.8)

DESCRIPTION
This describes post exposure prophylaxis for the health care worker (HCW) exposed
to infectious material from a patient including:
» blood » semen
» body fluids (CSF, synovial, pleural, » vaginal secretions
pericardial, peritoneal, amniotic)

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The risk of acquiring HIV following occupational exposure is estimated at 0.3%. There
is a higher risk when:
» the injury is deep or
» involves a hollow needle or
» if the source patient is more infectious, e.g.: terminal AIDS, seroconversion illness, or
known to have a high viral load.

GENERAL MEASURES
» Where the source patient is on ARVs or has been on ARVs, initiate prophylaxis
and seek expert opinion. An extra blood sample (unclotted, EDTA) of the source
patient should be stored in case of need for further viral testing.
» Other blood borne infections that can be transmitted include hepatitis B, hepatitis
C and syphilis. Test all source patients (see monitoring table).
» Offer comprehensive and confidential pre-test HIV counselling.
» Advise HCW about the need to take precautions, e.g. condom use, to prevent
infection of their own sexual partners.
Monitoring:
Test Source Exposed person
patient *Only if source patient was positive
Baseline Baseline 2 weeks 6 weeks 4 months
HIV Rapid test Rapid test HIV HIV ELISA
PLUS PLUS ELISA (NHLS test)
HIV ELISA HIV ELISA (NHLS
(NHLS test) (NHLS test) test)
Hepatitis B Surface Surface Surface
antigen antibody antigen
Hepatitis C** HCV HCV HCV
antibody antibody* PCR*
Syphilis*** RPR/ RPR/TP RPR/TP
TP antibody antibody* antibody*
Serum If TDF part of If TDF part of
creatinine PEP PEP
FBC If AZT part of If AZT part of
PEP PEP
** If occupational exposure
*** If sexual exposure LoE:IIIxxviii

MEDICINE TREATMENT
1. Prevent HIV: Z20.6 + (Z57.8+X58.92+Z29.8)
» Initiate HIV PEP immediately after the injury - within 72 hours. Do not wait for the
confirmatory test results on the source patient and health care worker.
» If higher risk exposure (defined above) consider initiation of treatment beyond
72 hours, as the risks of prophylaxis in this setting may outweigh the benefits.
Avoid initiating PEP beyond 7 days after exposure.
Note: HIV PEP is not indicated if:
» HCW exposed to body fluids which carry no risk of infection, e.g. vomitus, urine,
faeces or saliva.

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» HCW is HIV-infected. Stop PEP if HIV test of the health care worker is positive at
the time of the injury.
» The source is HIV sero-negative unless there are features suggesting sero-

 Continue prophylaxis until the results of additional tests are available.

conversion illness.

 These cases should be discussed with virologists.

Exposure HIV status of source patient
Negative Unknown or Positive
Intact skin no PEP no PEP
Mucosal splash/ Non-intact skin no PEP PEP
Percutaneous injury no PEP PEP

x Tenofovir (TDF), oral, 300 mg daily for 4 weeks (provided baseline eGFR is > 60
When PEP is indicated, the following regimen is recommended:

mL/min).

x Emtricitabine (FTC), oral, 200 mg daily for 4 weeks.

and

x Atazanavir/ritonavir (ATV/r) 300/100 mg, oral, 1 tablet daily for 4 weeks.

and

OR
Lopinavir/ritonavir (LPV/r) 200/50 mg, oral, 2 tablets 12 hourly for 4 weeks.
Note: Use a FDC wherever possible.

If tenofovir is contraindicated or if source patient is known to be failing a tenofovir

x Zidovudine (AZT), oral, 300 mg 12 hourly for 4 weeks.

based regimen, replace tenofovir and emtricitabine with:

x Lamivudine (3TC), oral, 150 mg 12 hourly for 4 weeks.

and

Note: Adverse effects of PEP:

» PEP is generally not well tolerated. Adverse effects occur in about half of cases
and therapy is discontinued in about a third.
» Nevirapine must never be used for PEP as there is a high risk of severe hepatitis,
when given to people without HIV infection.
» TDF is contra-indicated in renal disease or with concomitant use of nephrotoxic
medicines, e.g. aminoglycosides (check baseline creatinine clearance). Where
TDF is contraindicated, switch to AZT. If AZT is not tolerated, consult or refer for
further management.
» Give ATV/r as first choice as LPV/r frequently causes gastrointestinal side effects.
ATV/r may commonly cause jaundice (i.e. unconjugated hyperbilirubinaemia
without hepatitis) which is harmless.
When the source patient is known to be failing ART, modify the PEP regimen and
seek expert opinion:
» If the patient is on AZT or stavudine then TDF should be used.
» If the patient is on TDF then AZT should be used.
» If the patient is on efavirenz or nevirapine then ATV/r or LPV/r should be used.

2018 21.48
 CHAPTER 21 EMERGENCIES AND INJURIES

Patients failing second line ART almost always have no resistance to protease
inhibitors, so ATV/r or LPV/r should still be effective.
Consultation with a virologist or infectious diseases physician is recommended for
advice on which antiretroviral medicines to use for PEP.
2. Prevent hepatitis B
Decide on what treatment to give the exposed person according to the vaccination
status (and antibody response) of the exposed person, as well as the HBsAg results
of the source patient, if known.
PEP following hepatitis B exposure: Z20.5 + (Z57.8+X58.92+Z29.8)
Vaccination status and Source patient
antibody response of HBsAg positive HbsAg HBsAg
exposed person
x HBIG, IM, 500 units* x Initiate HepB x HBIG, IM, 500
negative unknown

x HepB vaccine
Exposed person
x HepB vaccine
vaccination (month units*
unvaccinated
(3 doses at monthly 0, 1 and 6)
or
intervals) (3 doses at monthly
vaccination
intervals)
incomplete

Exposed person
vaccinated
AND
No treatment No treatment No treatment
known to have
HBsAbtitre• 10
units/mL#

x HBIG, IM, 500 units * x HBIG, IM, 500

x Repeat HepB
No treatment
Exposed person
x Repeat HepB
units*
vaccinated
vaccine
AND
(3 doses at monthly vaccine
HBsAb< 10 units/mL
intervals) (3 doses at monthly
OR
intervals)
level unknown
* Refer to secondary level of care for HBIG, IM. HBIG to be given as soon as possible, preferably
within 24-72 hours after exposure (or within 7 days). LoE:IIIxxix
#
If the delay in obtaining HBsAb results is more than 24 hours, initiate treatment as for
vaccinated AND HBsAb< 10 units/mL.
Note: For health care workers: repeat HBsAb 1 – 2 months after the last vaccine dose, to ensure
adequate immune response (i.e. HBsAb • 10 units/mL). LoE:IIIxxx

REFERRAL
Note: Refer if there are inadequate resources with regard to:
» counselling
» laboratory for testing
» medico-legal examination
» medicine treatment

2018 21.49
 CHAPTER 21 EMERGENCIES AND INJURIES

21.3.6.2 POST EXPOSURE PROPHYLAXIS, RAPE AND SEXUAL

ASSAULT
Z29.8

DESCRIPTION
Sexual offences are of grave concern and in particularly to the most vulnerable
persons including women, children and disabled persons.
The definitions of sexual offences are within the Criminal Law (Sexual Offences and
Related Matters) Amendment Act, No 32 of 2007. Sexual offences are physically and
psychologically damaging to victims, and the ability to consent to a sexual act
depends on the competence of the person to give consent and be knowledgeable of
the consequences of that act - including the risk of contracting sexually transmitted
diseases such as HIV.

GENERAL MEASURES
» Sexual offences victims must be regarded as emergencies but do not displace
life-threatening management of other cases.
» Ensure appropriate management is in place for every case. So called “cold cases”
(> 72 hours after the incident) may be managed medically and given an
appointment for medico-legal investigation.
» If victim wants to open a case, the Family violence, Child protection and Sexual
offences Unit (FCS) must be phoned and requested to come to the hospital.
» Cases must be opened in all cases of suspected or alleged rape/sexual abuse in
children.
Offer 1st dose of antiretroviral PEP in all cases of suspected rape - the following
matters can be resolved in due course:
» Obtain informed consent from the patient and written consent from parent in case
of minors before HIV testing and giving treatment.

 Children who are competent to give consent and are:

» Consent for HIV testing in children can be given by:

(i) • 12 years of age; or

(ii) < 12 years of age and of sufficient maturity to understand the benefits,

 Parents or caregivers of children who are not competent to sign consent (but
risks and social implications of such a test.

the child should have this explained to them so they understand what is

 The clinical head of the institution, where a competent person is not available
happening, appropriate to their age and development).

to give consent for HIV testing and PEP (alleged rape in children is a medical
emergency).

 Prophylaxis given to a previously infected HIV person will have no clinical

» Determine the patient’s HIV status before initiating PEP.

benefit and may lead to the development of viral resistance. Provide

counselling and manage accordingly.

 If the patient declines, give a 3–day starter pack of PEP and encourage the
» It is the patient’s choice to have immediate HIV testing.

patient to reconsider testing within those 3 days.

2018 21.50
 CHAPTER 21 EMERGENCIES AND INJURIES

 No further PEP will be given in the case of continued refusal of HIV

testing in adults, in children where the parent unreasonably refuses PEP

 If in doubt about the indications for HIV PEP, give PEP.

this may be taken further.

» A patient presenting after 72 hours since the alleged incident should not be given

 HIV testing should still be offered at the time of presentation and 4 months later.
PEP, but should be counselled about the possible risk of transmission.

» Perform a pregnancy test in adult and pubertal girls to exclude pregnancy before

 Pregnant rape patients should be referred.

initiating post exposure contraception and STI prophylaxis.

» If the HIV Elisa/Rapid test is positive in sexually abused children <18 months of
age, perform HIV PCR to confirm if HIV infection is truly present.
If HIV-uninfected or if the child has no access to immediate HIV PCR results, they
should receive prophylaxis (until the HIV PCR result is obtained).
Initial Counselling
Counsel all cases of sexual offences patients and caregivers in the case of children
» Explain the side effects of ARVs, e.g. tiredness, nausea and flu-like symptoms.
» Use condoms for 4months.
» Avoid blood or tissue donation for 6 months.
» Emphasise the importance of compliance with ARV PEP.

 Restoring control of the victim by avoiding secondary traumatisation, and give

» Provide psychosocial support pertaining to:

 Medical risks, e.g. transmission of sexually transmitted infections including

choices and participation in treatment decisions.

 Risk of pregnancy.
HIV, syphilis, hepatitis-B and C.

 Psycho-emotional-social effects of the sexual assault according to their level

of understanding and maturity.
Follow-up support
» Discuss issues relating to stress management at subsequent visits.

 general irritability
» Inform the patient of the signs and symptoms of post-traumatic stress, including:

 trembling
 pain in neck and/or lower back
 change in appetite
 change in sleep pattern
 post-traumatic stress syndrome (PTSD), that may eventually cause
exhaustion and illness.
Medico-legal assessment of injuries
» Complete appropriate required forms and registers.

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 CHAPTER 21 EMERGENCIES AND INJURIES

Suspected or alleged sexual assault or

rape

Route to Health System

Police Health System Social Work

Assess urgency
1. Is assault < 72 hours ago
2. Are there surgical / medical urgencies?
e.g. Serious trauma/ bleeding/ pain/ distress.

< 72 hours or
Urgency • 72 hours or
Actions See urgently. Urgency
Don’t displace other life See as soon as possible
threatening emergencies
x Assess life threatening

x If HIV status unknown:

injuries
Immediate

Police and Judicial Parallel Process

st
give 1 dose PEP
- Assess injuries
9 refer appropriately
- Ascertain STD status
9 get consent for tests including HIV
9 determine HIV status, Syphillis status
- Prevent STDs
Medical other 9 give HIV PEP if not HIV positive and < 72 hours
since assault
9 give other STI prophylaxis including Hep B
- Prevent pregnancy
9 confirm not pregnant
9 if not pregnant and if Tanner III or more give
emergency contraception within5 days
- Examine / record J88
- Examine / record
Forensic other - Take specimens
J88
(ensure consent signed)
(ensure consent signed)

Mental Health Appropriate counselling/ psychological support

Social Health Ensure it is safe for victim to return home

Ensure case opened (patient usually brought by

Police
police. If not call the police to the site)
Ensure follow up , safety and support

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 CHAPTER 21 EMERGENCIES AND INJURIES

Investigations
» The patient/parent should sign a consent form for both HIV testing and PEP.
Voluntary rapid HIV testing should be made available and should be done on all
opting for PEP.
» Further baseline blood tests should include creatinine (or FBC, if AZT is part of
PEP), RPR/TP antibody test for syphilis and Hepatitis B serology. Do a pregnancy
test in all women and female adolescents prior to giving treatment.

 2 weeks: creatinine if TDF part of PEP (or FBC if AZT part of PEP).
» Follow up bloods include:

 6 weeks: HIV ELISA.

 4 months: HIV ELISA, RPR test for syphilis, Hepatitis B serology.

MEDICINE TREATMENT
Prevent the following:
1. HIV
2. Hepatitis B
3. Pregnancy
4. STIs
Note:
» Obtain consent for HIV testing from all patients before initiating PEP.
» Offer PEP if the patient presents within 72 hours of being raped and is HIV-
uninfected or HIV status is unknown.
» Initiate therapy as early as possible after the exposure to maximize the chance of
effective prophylaxis. Therapy may be given up to 72 hours after exposure.
» It is important to manage the medical condition before medico-legal examination.
Most of these will require referral.
» In children < 18 months of age: initiate antiretroviral PEP while awaiting transfer
and HIV PCR results.
» If, for practical reasons, a person cannot return for the 3-day follow up, a 28-day
course of ART should be provided.
» Do a pregnancy test in all women and female adolescents prior to post exposure
contraception and STI prophylaxis, to exclude pregnancy.
1. HIV PEP

x Zidovudine, oral, 12 hourly for 28 days.

Children

o Paediatric dose: 180–240 mg/m2. See dosing table, pg 23.9.

o Maximum: 300 mg/dose.

x Lamivudine, oral, 4 mg/kg 12 hourly or 8mg/kg daily for 28 days.

AND

o Maximum: 150 mg/dose if given 12 hourly or 300 mg/dose if given daily. See
dosing table, pg 23.6.

x Lopinavir/ritonavir, oral 12 hourly for 28 days.

AND

o Paediatric dose: 300/75mg/m2. See dosing table, pg 23.7.

o Maximum: 400/100 mg/dose.
Dosages may vary by±1 mg/kg/dose, to allow a convenient volume of medication.

2018 21.53
 CHAPTER 21 EMERGENCIES AND INJURIES

Use the adult dosage regimen if children require more than the maximum dose.
Follow-up visits should be at 2 weeks, 6 weeks, and 4 months after the rape.
Adults
Management for HIV prevention is the same as for occupational HIV exposure. See
section 21.3.6.1 Post-exposure prophylaxis, occupational.

2. Hepatitis B prevention
Management for Hepatitis B prevention is the same as for occupational hepatitis B
exposure. See section 21.3.6.1 Post-exposure prophylaxis, occupational.
LoE:III
3. Emergency contraception (after pregnancy is excluded)
Do a pregnancy test in all women and female adolescents.
Children must be tested and given emergency contraception from Breast Tanner
Stage III, if unsure of staging, give emergency contraception when you detect any

x Levonorgestrel oral, 1.5 mg as a single dose as soon as possible after

breast development (DO NOT REGARD MENARCHE AS AN INDICATION).

unprotected intercourse.
o Repeat the dose, if patient vomits within 2 hours.

CAUTION
Emergency contraceptive tablets must be taken as soon as possible, preferably
within 72 hours of unprotected intercourse, and not later than 5 days.
Women on enzyme inducers (including efavirenz, carbamazepine) cause a
significant reduction in levonorgestrel concentrations. Women on these
medicines should preferably have copper IUCD inserted or alternatively double
the dose of levonorgestrel, because of significant reduction of levonorgestrel.
See Section 7.4: Contraception, emergency. LoE:IIIxxxi

An anti-emetic:

x Metoclopramide oral, 10 mg 8 hourly as needed.

Adults

4. STI prophylaxis

x Ceftriaxone, IM, 250 mg as a single dose.

Adults

o For ceftriaxone IM injection: Dissolve ceftriaxone 250 mg in 0.9 mL lidocaine

1% without adrenaline (epinephrine).

x Azithromycin, oral, 1 g, as a single dose.

AND

x Metronidazole, oral, 2 g immediately as a single dose.

AND

Children
Prior to hospital referral, administer:
Children < 45 kg
ƒ Macrolide, e.g.:
x Azithromycin, oral, 20 mg/kg/dose, as a single dose, and refer.

2018 21.54
 CHAPTER 21 EMERGENCIES AND INJURIES

Use one of the following:

Weight Dose Susp Tablet Age
kg mg 200 Months/years
250 mg 500 mg
mg/5mL
>7–9 kg 160 mg 4 mL >6-12 months
‫ޓ‬9–11 kg 200 mg 5 mL – – ‫ޓ‬12–18 months
‫ޓ‬11–14 kg 240 mg 6 mL – – ‫ޓ‬18 months–3 years
‫ޓ‬14–18 kg 320 mg 8 mL – – ‫ޓ‬3–5 years
>18-25 400 mg 10 mL – – >5-7 years
‫ޓ‬25–35 kg 500 mg – 2 tablets 1 tablet ‫ޓ‬7–11 years
‫ޓ‬35–45 kg 750mg – 3 tablets – ‫ޓ‬11–13 years
> 45 kg 1000 mg – – 2 tablets >13 years

Children • 45 kg
ƒ Macrolide, e.g.:
x Azithromycin, oral, 1g, as a single dose, and refer.

x Metronidazole, oral, as a single dose, and refer.

AND

o 1–3 years: 500 mg

o 3–7 years: 600–800 mg
o 7–10 years 1g
o > 10 years 2g

x Ceftriaxone, IM, 80 mg/kg/dose immediately as a single dose. See dosing

AND

table, pg 23.3.
o Do not inject more than 1 g at one injection site.
CAUTION: USE OF CEFTRIAXONE IN NEONATES AND CHILDREN
» If SUSPECTING SERIOUS BACTERIAL INFECTION in neonate, give ceftriaxone,
even if jaundiced.

 If ” 28 days old, avoid calcium-containing IV fluids for 48 hours after ceftriaxone

» Avoid giving calcium-containing IV fluids (e.g. Ringer Lactate) together with ceftriaxone:

 If > 28 days old, ceftriaxone and calcium-containing IV fluids may be given

administered.

sequentially provided the giving set is flushed thoroughly with sodium chloride 0.9%

 Preferably administer IV fluids without calcium contents.

before and after.

» Always include the dose and route of administration of ceftriaxone in the referral letter.

LoE:IIIxxxii
REFERRAL

 All Children: All for medico legal and general care assessment after
» All patients with severe physical or psychological injuries.

initiation of PEP as outlined above at PHC.

 Adults with:
If uncertain, phone Childline 0800055555

» Active bleeding » Multiple injuries

» Abdominal pain » History of the use of a foreign object
Note: Refer if there are inadequate resources with regards to:

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 CHAPTER 21 EMERGENCIES AND INJURIES

– counselling – medico-legal examination

– laboratory for testing – medicine treatment

21.3.6.3 POST EXPOSURE PROPHYLAXIS, INADVERTENT

(NON-OCCUPATIONAL)
Z29.8

DESCRIPTION
Inadvertent (non-occupational) exposure to infectious material from HIV and hepatitis
B sero-positive persons often requires clinical judgement and includes:
» human bites (requires hepatitis B, but not HIV prophylaxis)
» sharing of needles during recreational drug use
» consensual sexual exposure, burst condoms
» contact sports with blood exposure
Management of inadvertent (non-occupational) HIV and hepatitis B exposure is the
same as for occupational exposure. See Section: 21.3.6.1 Post exposure
prophylaxis, Occupational. LoE:IIIxxxiii

21.3.7 SOFT TISSUE INJURIES

T14.0-1/T14.9

DESCRIPTION
Injuries may be minor, moderate or major:
Major injuries: it is important is to recognise potentially life-threatening injuries.
Indicators of such injuries are:
» Mechanism of injury: motor vehicle collision at speed exceeding 60 km/hour,
ejection from the car, death of other occupant in the same car compartment, roll-
over, pedestrian thrown out of his/her shoes, fall from height of more than 2 stories
(more than thrice the patient’s height in a child), multiple gunshot wounds.
» Physiological status: unable to maintain airway, tachycardia, hypoxia,
hypotension on arrival (even if corrected with crystalloid infusion), tachycardia
(especially in a child) or decreased level of consciousness.
» Anatomical distribution: (suspicion of) injuries to more than one body region (face,
intracranial, chest, abdominal cavity, spine).
» Age: children < 2 years of age require admission.
Moderate injuries (list is not exhaustive):
» Head injuries: moderate head injuries (i.e. any GCS 11-14), facial fractures
(airway maintained).
» Neck injuries: stable patient with a stabbed neck, tenderness over C-spine.
» Chest injuries: pneumothorax, haemothorax, rib fractures (2 or less).
» Abdominal injuries: any suspicion of an intra-abdominal injury in a
haemodynamically stable patient: e.g. abdominal bruising (including seat belt sign
in children), tenderness, distension, loss of bowel sounds, vomiting,
haematemesis or haematuria.

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 CHAPTER 21 EMERGENCIES AND INJURIES

» Extremity injuries: major open wounds, degloving injuries (boggy feel under intact
skin), fractures, dislocations (in children: point tenderness around a major joint), crush
injuries, multiple soft tissue injuries, enlarging or pulsating swelling.
» Suspicion of abuse (child abuse, intimate partner abuse, elderly abuse).
Minor injuries are injuries that can be managed as an outpatient and include bruises,
small lacerations, sprains, concussions etc.
» Human bites (see Section 21.3.1.2: Human bites) and animal bites (see Section
21.3.1.1: Animal bites).
» Sprains or strains (see Section 21.3.8: Sprains and strains).
» Exclude fractures.

EMERGENCY MANAGEMENT
All trauma patients, except for those who only have minor injuries, should undergo
these surveys:
Primary survey
A = Airway: check and maintain airway. If airway obstructed, first perform a jaw
thrust manoeuver, then if able, insert an endotracheal tube. Patients with
maxillofacial fractures may require a tracheostomy.
B = Breathing: assess respiratory rate, use of accessory muscles, symmetry,
oxygen saturation. If needed, support breathing using a Bag-Valve-Mask device
(‘AMBU bag’). Look for signs of pneumothorax (affected site is hyperinflated,
hypertympanic and has decreased breath sounds). If tension pneumothorax
(distended neck veins, deviated trachea, hypoxia and hypotension): perform a
needle thoracostomy.
C = Circulation: look for tachycardia and hypotension. Put up two large bore
peripheral lines, a femoral line or an intraosseous line in the tibia (if no
abdominal injury) or the proximal humerus. In adults: if SBP if < 90 mmHg,
infuse 2 L of sodium chloride 0.9% until SBP • 90 mmHg. If actively bleeding, it
is permissible to maintain SBP• 80 mmHg (or a palpable radial pulse if you do
not have access to a BP machine). In children the SBP should not fall below (70
+ [2 x age]) mmHg.
D = Disability: perform a brief neurologic assessment and classify according to the
Glasgow Coma Score:
Glasgow Coma Score:
Add scores to give a single score out of 15:
Best motor response: Obeys commands 6
Localises to pain 5
Withdraws from pain 4
Abnormal flexion to pain 3
Extends to pain 2
None 1
Best verbal response: Orientated 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
None 1

2018 21.57
 CHAPTER 21 EMERGENCIES AND INJURIES

Eye opening Spontaneous 4

To voice 3
To pain 2
None 1
Total
E = Exposure/environment: expose the patient. If any suspicion of spinal cord
injury (multi-trauma, decreased level of consciousness, neurological deficit,
tenderness over the spine, severe mechanism of injury, anatomic deformity of
the spine or any of the following: intoxication, inability to communicate or a
distracting injury) cut the patient’s clothes off, so as to minimise movement of
the spine, and immobilise neck using a long back board. Use a hard collar and
strapping to the trolley in other patients Prevent hypothermia by covering the
patient with warm blankets, and infusing warm fluids.
When major physiological derangements have been identified and the patient is
stabilised using the ABCDEs of the primary survey, perform an AMPLE history and a
secondary survey:
AMPLE history:
A = allergies
M = the patient’s regular medication (including contraceptives and over-the-counter
medication)
P = past medical history
L = time of last meal (particularly important is the time between the last meal and
the accident)
E = Events leading up to the incident
Secondary survey
The secondary survey is a head-to-toe examination of the patient to identify any
injuries that may have been missed during the primary survey. The secondary survey
is only performed in a stable patient.
First examine patient from the front, then log-roll the patient and examine the back
(include a rectal examination).
All fracture sites must be immobilised by external splints.
Any additional investigations are ordered according to availability of resources:
» Bloods may include FBC, clotting profile, cross-match and U & E’s.
» Consider whether the patient requires transfer for x-rays.

MANAGEMENT OF WOUNDS AND LACERATIONS

» Assess wound: if significant devitalised tissue, especially if due to a crush injury
or a bite, dress with povidone-iodine and refer for surgical debridement.
» Assess surrounding tissues and test function: look for associated fractures,
ligament/tendon damage and nerve or vascular injuries. Document.
» If needed, anaesthetise wound. Remove foreign bodies and irrigate the wound
with sodium chloride 0.9%. If needed, remove any devitalised tissue with a knife
» Wounds may be glued with tissue adhesives if wound < 4 cm, clean and
uncomplicated, especially in children and elderly patients. Avoid in the following
cases: lacerations in areas under tension (hands, feet, joints), oral mucosa,
wounds in moist or hairy areas (axillae/perineum), if needing high level of

2018 21.58
 CHAPTER 21 EMERGENCIES AND INJURIES

precision (hairline or vermilion border of lip), wounds at increased risk of infection

(bite wounds, puncture wounds, wounds with contaminated tissue). Wounds on
the scalp can be glued but surrounding hair needs to be trimmed.
Tissue adhesive (glue):
o Clean wound thoroughly with chlorhexidine 0.05% aqueous solution.
o Ensure good haemostasis before applying glue.
o Appose wound edges (bring wound edges together). Ensure patient positioned
appropriately so that when applied, any excess glue does not run down into areas
not meant to be glued. If this happens, quickly wipe away with dry gauze.
o Crush tissues adhesive vial and invert.
o Gently brush adhesive over laceration (avoid contact with gloves/ instruments and
avoid pushing adhesive into wound).
o Apply three layers of adhesive (maximum bonding strength is achieved within 2.5
minutes of application).
o Do not put on any covering or dressings.
o Advise patients that they may shower but not soak in bath and to pat area dry.
o The bonded adhesives spontaneously slough off within 5 to 10 days.

MEDICINE TREATMENT
If fluid replacement needed, see Section 21.2.9: Shock.

x Sodium chloride 0.9%, IV, 1L as a rapid bolus.

Adults

o Repeat bolus until blood pressure is improved.

x Sodium chloride 0.9%, IV, 20 mL/kg as a rapid bolus.

Children

o Repeat bolus if no adequate response.

Note: If patient develops respiratory distress, discontinue fluids.
Tetanus prophylaxis: Z23.5

x Tetanus toxoid (TT), IM, 0.5 mL.

If not previously immunised within the last 5 years

x Lidocaine 2%, injection.

If sutures needed:

o Infiltrate 7 mg/kg, around the wound as local anaesthetic. LoE:IIIxxxiv

Weight Dose Vial Age

kg mg 2%, 20 mg/mL months/years
‫ޓ‬2.5–3.5 kg 20 mg 1 mL Birth–1 month
‫ޓ‬3.5–5 kg 25 mg 1.25 mL ‫ޓ‬1–3 months
‫ޓ‬5–7 kg 40 mg 2 mL ‫ޓ‬3–6 months
‫ޓ‬7–9 kg 55 mg 2.75 mL ‫ޓ‬6–12 months
‫ޓ‬9–11 kg 70 mg 3.5 mL ‫ޓ‬12–18 months
‫ޓ‬11–14 kg 80 mg 4 mL ‫ޓ‬18 months–3 years
‫ޓ‬14–17.5 kg 100 mg 5 mL >3–5 years
‫ޓ‬17.5–35 kg 150 mg 7.5 mL >5–11 years
‫ޓ‬35–55 kg 300 mg 15 mL >11–15 years

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 CHAPTER 21 EMERGENCIES AND INJURIES

Pain:

x Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See dosing table,
Children

pg 23.8.

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per

Adults

24 hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.
For more severe pain, give analgesia as appropriate. See Section 20.1: Pain control.
Infected wound management:
Manage as for cellulitis. See Section 5.4.3: Cellulitis.

REFERRAL
Urgent
» All major and moderate injuries once stabilised.
» Infected wounds.
Note:
» If uncertain how to stabilize patient, phone for guidance from referral hospital.
» Before transport leaves, ensure endotracheal tube is securely strapped, all lines are
secured, all drips are running well and patient is well covered to prevent hypothermia.
» If transport delayed, ensure patient does not deteriorate while waiting: repeat ABCD
survey at least hourly.

21.3.8 SPRAINS AND STRAINS

S03.4-5/S13.4-6/S23.3-5/S33.5-7/S43.4-7/S53.4/S63.5-7/S73.1/S83.4-6/S93.4-6/T11.2/T13.2/
T14.3

DESCRIPTION
Clinical features include:
» pain, especially on movement » limited movement
» tenderness on touch » history of trauma
May be caused by:
» sport injuries » overuse of muscles
» slips and twists » abnormal posture
Note: In children always bear non-accidental injuries (assault) in mind.
EMERGENCY TREATMENT
Immobilise with firm bandage and/or temporary splinting.

x Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See dosing table,
Children

pg 23.8.

x Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per

Adults

24 hours.
o Maximum dose: 15 mg/kg/dose.
o Maximum dose: 4 g in 24 hours.

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AND
Children >12 years of age and adults
ƒ NSAID, e.g.:
x Ibuprofen, oral, 200–400 mg 8 hourly with or after a meal.

REFERRAL
» Severe progressive pain.
» Progressive swelling.
» Extensive bruising.
» Deformity.
» Joint tenderness on bone.
» No response to treatment.
» Severe limitation of movement.
» Suspected serious injury.
» Recurrence.
» Previous history of bleeding disorder.

References
i Adrenaline/epinephrine, IO (Bradycardia-children): Resuscitation Council of Southern Africa: Basic life support for healthcare

provider, algorithm, 2015. www.resuscitationcouncil.co.za

ii Adrenaline/epinephrine, IV (Bradycardia-children): National Department of Health, Essential Drugs Programme. Paediatric

Hospital Level STGs and EML, 2017. http://www.health.gov.za/

iii Adrenaline/epinephrine, IV (Bradycardia-children): Resuscitation Council of Southern Africa: Basic life support for healthcare

provider, algorithm, 2015. www.resuscitationcouncil.co.za

Atropine, IV (Bradycardia-children): National Department of Health, Essential Drugs Programme. Paediatric Hospital Level
STGs and EML, 2017. http://www.health.gov.za/
iv Management of suspected choking/foreign body aspiration in children: Resuscitation Council of Southern Africa: Choking,

algorithm, 2015. www.resuscitationcouncil.co.za

v Dextrose 10%, IV:Moore C, Woollard M. Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised

controlled trial. Emerg Med J. 2005 Jul;22(7):512-5.https://www.ncbi.nlm.nih.gov/pubmed/15983093

vi Morphine, IV (adults): National Department of Health, Essential Drugs Programme. Adult Hospital Level STGs and EML, 2015.

http://www.health.gov.za/
vii Oxygen (AMI/STEMI): Chu DK, Kim LH, Young PJ, Zamiri N, Almenawer SA, Jaeschke R, Szczeklik W, Schünemann HJ,

Neary JD, Alhazzani W. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA):
a systematic review and meta-analysis. Lancet. 2018 Apr 28;391(10131):1693-1705.
https://www.ncbi.nlm.nih.gov/pubmed/29726345
viii Oxygen (anaphylaxis): Resuscitation Council of Southern Africa: Emergency management of anaphylaxis algorithm, 2015/16.

www.resuscitationcouncil.co.za
ix Sodium chloride 0.9%, IV: Resuscitation Council of Southern Africa: Emergency management of anaphylaxis algorithm,

2015/16. www.resuscitationcouncil.co.za
x Salbutamol nebulisation (anaphylaxis): Resuscitation Council of Southern Africa: Emergency management of anaphylaxis

algorithm, 2015/16. www.resuscitationcouncil.co.za

xi Ipratropium nebulisation (anaphylaxis): Resuscitation Council of Southern Africa: Emergency management of anaphylaxis

algorithm, 2015/16. www.resuscitationcouncil.co.za

xii Hydrocortixone, IV/slow IM: National Department of Health, Essential Drugs Programme. Paediatric Hospital Level STGs and

EML, 2017. http://www.health.gov.za/

xiii Hydrocortisone, IV/slow IM: National Department of Health, Essential Drugs Programme. Adult Hospital Level STGs and EML,

2015. http://www.health.gov.za/
xiv Promethazine IM/IM: National Department of Health, Essential Drugs Programme. Paediatric Hospital Level STGs and EML,

2017. http://www.health.gov.za/
xv MIdazolam, buccal (children-status epilepticus): National Department of Health: Affordable Medicines, EDP-PHC level. Medicine

review: Midazolam, buccal vs diazepam, rectal for the control of seizures in children, 28 May 2014. http://health.gov.za/
MIdazolam, buccal (children-status epilepticus): McMullan J, Sasson C, Pancioli A, Silbergleit R. Midazolam versus diazepam
for the treatment of status epilepticus in children and young adults: a meta-analysis. Acad Emerg Med. 2010 Jun;17(6):575-82.
http://www.ncbi.nlm.nih.gov/pubmed/20624136
Midazolam, buccal (children-status epilepticus): McIntyre J, Robertson S, Norris E, Appleton R, Whitehouse WP, Phillips B,
Martland T, Berry K, Collier J, Smith S, Choonara I. Safety and efficacy of buccal midazolam versus rectal diazepam for
emergency treatment of seizures in children: a randomised controlled trial. Lancet. 2005 Jul 16-22;366(9481):205-10.
http://www.ncbi.nlm.nih.gov/pubmed/16023510

2018 21.61
 CHAPTER 21 EMERGENCIES AND INJURIES

Midazolam, buccal (children-status epilepticus): Mpimbaza A, Ndeezi G, Staedke S, Rosenthal PJ, Byarugaba J. Comparison of
buccal midazolam with rectal diazepam in the treatment of prolonged seizures in Ugandan children: a randomized clinical trial.
Pediatrics. 2008; 121:e58–64. http://www.ncbi.nlm.nih.gov/pubmed/18166545
Midazolam, buccal (children-status epilepticus): Scott RC, Besag FM, Neville BG. Buccal midazolam and rectal diazepam for
treatment of prolonged seizures in childhood and adolescence: a randomised trial. Lancet.1999; 353:623–6.
http://www.ncbi.nlm.nih.gov/pubmed/10030327
MIdazolam, buccal (children-second dose): National Department of Health: Affordable Medicines, EDP-PHC level. Medicine
review: Buccal midazolam (repeat dose) for status epilepticus in children - review update, 25 May 2017. http://health.gov.za/
MIdazolam, buccal (children-second dose): Smith R, Brown J. Midazolam for status epilepticus. Aust Prescr. 2017
Feb;40(1):23-25. https://www.ncbi.nlm.nih.gov/pubmed/28246432
Midazolam, buccal (children-second dose): World Health Organisation. mhGAP Intervention Guide Mental Health Gap Action
Programme for mental, neurological and substance use disorders in non-specialized health settings, version 2.0 Geneva: World
Health Organization; 2016. http://www.who.int/mental_health/mhgap/mhGAP_intervention_guide_02/en/
Midazolam, buccal (children-second dose): National Institute for Health and Care Excellence. Epilepsies: diagnosis and
management Clinical guideline [CG137], 2012. https://www.nice.org.uk/guidance/cg137
xvi MIdazolam, IM (children-status epilepticus): National Department of Health: Affordable Medicines, EDP-PHC level. Medicine

review: Midazolam, IM vs other benzodiazepines (any route of administration), 31 August 2017. http://health.gov.za/
MIdazolam, IM (children-status epilepticus): Jain P, Sharma S, Dua T, Barbui C, Das RR, Aneja S. Efficacy and safety of anti-
epileptic drugs in patients with active convulsive seizures when no IV access is available: Systematic review and meta-analysis.
Epilepsy research. 2016;122:47-55. https://www.ncbi.nlm.nih.gov/pubmed/26922313
Midazolam, IM (children-status epilepticus): Momen AA, Azizi Malamiri R, Nikkhah A, Jafari M, Fayezi A, Riahi K, et al. Efficacy
and safety of intramuscular midazolam versus rectal diazepam in controlling status epilepticus in children. European journal of
paediatric neurology : EJPN : official journal of the European Paediatric Neurology Society. 2015;19(2):149-54.
https://www.ncbi.nlm.nih.gov/pubmed/18166545
xvii Phenobarbital, oral via naso-gastric tube (children-status epilepticus): Wilmshurst JM, van der Walt JS, Ackermann S, Karlsson

MO, Blockman M. Rescue therapy with high-dose oral phenobarbitone loading for refractory status epilepticus. J Paediatr Child
Health. 2010 Jan;46(1-2):17-22. https://www.ncbi.nlm.nih.gov/pubmed/19943867
xviii Midazolam, IM (adults-status epilepticus):Silbergleit R, Durkalski V,Lowenstein D,Conwit R,Pancioli A,Palesch Y,Barsan W;

NETT Investigators. Intramuscular versus intravenous therapy for prehospital status epilepticus. NEnglJMed.
2012Feb16; 366(7):591-600. http://www.ncbi.nlm.nih.gov/pubmed/22335736
xix Diazepam, IV (adults-status epilepticus): Brophy GM, Bell R, Claassen J, Alldredge B, BleckTP, Glauser T, Laroche SM,

RivielloJJ Jr, Shutter L, Sperling MR, Treiman DM, Vespa PM; Neurocritical Care Society Status Epilepticus Guideline Writing
Committee. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care. 2012 Aug;17(1):3-23.
https://www.ncbi.nlm.nih.gov/pubmed/22528274
Diazepam, IV - Adults status epilepticus: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.
University of Cape Town, 2016.
xx Tetanus vaccination (human bites): Muguti GI, Dixon MS. Tetanus following human bite. Br J Plast Surg. 1992 Nov-

Dec;45(8):614-5. https://www.ncbi.nlm.nih.gov/pubmed/1493537
Tetanus vaccination (human bites): Patil PD, Panchabhai TS, Galwankar SC. Managing human bites. J Emerg Trauma
Shock. 2009 Sep;2(3):186-90. https://www.ncbi.nlm.nih.gov/pubmed/20009309
xxi HIV PEP (human bites): Cresswell FV, Ellis J, Hartley J, Sabin CA, Orkin C, Churchill DR. A systematic review of risk of HIV

transmission through biting or spitting: implications for policy. HIV Med. 2018 Apr 23.
https://www.ncbi.nlm.nih.gov/pubmed/29687590
xxii Tetatnus toxoid vaccine (scorpion stings and spider bites): National Department of Health, Essential Drugs Programme. Adult

Hospital Level STGs and EML, 2015. http://www.health.gov.za/

xxiii Snake polyvalent antivenom (indications): South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.

University of Cape Town, 2016.

xxiv Snake antivenom criteria: Wood D, Sartorius B and Hift R. Snakebite in north-eastern South Africa: clinical characteristics and

risks for severity. S Afr Fam Pract 2016; 58(2):62–67. https://www.tandfonline.com/doi/pdf/10.1080/20786190.2015.1120934

xxvAtropine, IV (children): National Department of Health, Essential Drugs Programme. Paediatric Hospital Level STGs and EML,

2017. http://www.health.gov.za/
xxviNaloxone, IV/IM (children): Kleinman ME, Chameides L, Schexnayder SM, Samson RA, Hazinski MF, Atkins DL,

Berg MD, de Caen AR, Fink EL, Freid EB, Hickey RW, Marino BS, Nadkarni VM, Proctor LT, Qureshi FA, Sartorelli K, Topjian A,
van der Jagt EW, Zaritsky AL. Part 14: pediatric advanced life support: 2010 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.Circulation. 2010 Nov 2;122(18 Suppl 3):S876-908.
https://www.ncbi.nlm.nih.gov/pubmed/20956230
xxviiParacetmaol poisoning cut-off (children): National Department of Health, Essential Drugs Programme. Paediatric Hospital Level

STGs and EML, 2017. http://www.health.gov.za/

xxviiiMonitoring (HIV occupational and non-occupational exposure): Moorhouse M, Bekker LG, Black V, Conradie F, Harley B,

Howell P, Maartens G, Papavarnavas T, Rebe K, Sorour G, Venter F, Wallis CL. Guideline on the management of occupational
and non-occupational exposure to the human immunodeficiency virus and recommendations for post-exposure prophylaxis: 2015
Update. South Afr J HIV Med. 2015 Nov 10;16(1):399. https://www.ncbi.nlm.nih.gov/pubmed/29568597
Monitoring (HIV occupational and non-occupational exposure): Centers for Disease Control and Prevention Guidelines: Post
exposure Prophylaxis to Prevent Hepatitis B Virus Infection. MMWR 2006,56(RR-16), Appendix B.
https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5516a3.htm?s_cid=rr5516a3_e
xxixHepatitis B immunoglobulin: (administration within 7 days): Joint Formulary Committee. British National Formulary. London: BMJ

Group and Pharmaceutical Press; 2018.

xxxHepatitis B vaccine and hepatitis B immunoglobulin (HCW-occupational prophylaxis): National Department of Health, Essential

Drugs Programme. Adult Hospital Level STGs and EML, 2015. http://www.health.gov.za/

2018 21.62
 CHAPTER 21 EMERGENCIES AND INJURIES

Hepatitis B vaccine and hepatitis B immunoglobulin (HCW-occupational prophylaxis): Moorhouse M, Bekker LG, Black V,
Conradie F, Harley B, Howell P, Maartens G, Papavarnavas T, Rebe K, Sorour G, Venter F, Wallis CL. Guideline on the
management of occupational and non-occupational exposure to the human immunodeficiency virus and recommendations for
post-exposure prophylaxis: 2015 Update. South Afr J HIV Med. 2015 Nov 10;16(1):399.
https://www.ncbi.nlm.nih.gov/pubmed/29568597
Hepatitis B vaccine and hepatitis B immunoglobulin (HCW-occupational prophylaxis): Centers for Disease Control and
Prevention Guidelines: Post exposure Prophylaxis to Prevent Hepatitis B Virus Infection. MMWR 2006,56(RR-16), Appendix B.
https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5516a3.htm?s_cid=rr5516a3_e
Hepatitis B vaccine and hepatitis B immunoglobulin (HCW-occupational prophylaxis): National Department of Health: Affordable
Medicines, EDP-PHC level. Medicine review: Human Hepatitis B immunoglobulin for hepatitis exposure, March 2018.
http://health.gov.za/
xxxi Levonorgesterol, oral - emergency contraception (double dose): Carten ML, Kiser JJ, Kwara A, Mawhinney S, Cu-Uvin S.

Pharmacokinetic interactions between the hormonal emergency contraception, levonorgestrel (Plan B), and Efavirenz. Infect Dis
Obstet Gynecol. 2012;2012:137192. http://www.ncbi.nlm.nih.gov/pubmed/22536010
Levonorgesterol, oral - emergency contraception (double dose): Tittle V, Bull L, Boffito M, Nwokolo N. Pharmacokinetic and
pharmacodynamic drug interactions between antiretrovirals and oral contraceptives. Clin Pharmacokinet. 2015 Jan;54(1):23-34.
http://www.ncbi.nlm.nih.gov/pubmed/25331712
xxxii Azithromycin, oral (STI prophylaxis for children): Workowski KA, Berman S; Centers for Disease Control and Prevention

(CDC). Sexually transmitted diseases treatment guidelines, 2010.MMWR Recomm Rep. 2010 Dec 17;59(RR-12):1-110. Erratum
in: MMWR Recomm Rep. 2011 Jan 14;60(1):18. Dosage error in article text. http://www.cdc.gov/std/treatment/2010/
Metronidazole, oral (STI prophylaxis for children): Workowski KA, Berman S; Centers for Disease Control and Prevention
(CDC). Sexually transmitted diseases treatment guidelines, 2010.MMWR Recomm Rep. 2010 Dec 17;59(RR-12):1-110. Erratum
in: MMWR Recomm Rep. 2011 Jan 14;60(1):18. Dosage error in article text. http://www.cdc.gov/std/treatment/2010/
Ceftriaxone, IM (STI prophylaxis for children): Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC).
Sexually transmitted diseases treatment guidelines, 2010.MMWR Recomm Rep. 2010 Dec 17;59(RR-12):1-110. Erratum in:
MMWR Recomm Rep. 2011 Jan 14;60(1):18. Dosage error in article text. http://www.cdc.gov/std/treatment/2010/
xxxiiiHepatitis B vaccine and hepatitis B immunoglobulin (HCW-occupational prophylaxis): National Department of Health, Essential

Drugs Programme. Adult Hospital level STGs and EML, 2015. http://www.health.gov.za/
Hepatitis B vaccine and hepatitis B immunoglobulin (HCW-occupational prophylaxis): Moorhouse M, Bekker LG, Black V,
Conradie F, Harley B, Howell P, Maartens G, Papavarnavas T, Rebe K, Sorour G, Venter F, Wallis CL. Guideline on the
management of occupational and non-occupational exposure to the human immunodeficiency virus and recommendations for
post-exposure prophylaxis: 2015 Update. South Afr J HIV Med. 2015 Nov 10;16(1):399.
https://www.ncbi.nlm.nih.gov/pubmed/29568597
Hepatitis B vaccine and hepatitis B immunoglobulin (HCW-occupational prophylaxis): Centers for Disease Control and
Prevention Guidelines: Post exposure Prophylaxis to Prevent Hepatitis B Virus Infection. MMWR 2006,56(RR-16), Appendix B.
https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5516a3.htm?s_cid=rr5516a3_e
Hepatitis B vaccine and hepatitis B immunoglobulin (HCW-occupational prophylaxis): National Department of Health: Affordable
Medicines, EDP-PHC level. Medicine review: Human Hepatitis B immunoglobulin for hepatitis exposure, March 2018.
http://health.gov.za/
xxxivLidocaine 2% injection: National Department of Health, Essential Drugs Programme. Paediatric Hospital Level STGs and EML,

2017. http://www.health.gov.za/

2018 21.63
PHC Chapter 22: Medicines used
in palliative care

22.1 Gastrointestinal conditions

22.1.1 Constipation
22.1.2 Diarrhoea
22.1.3 Nausea and vomiting
22.2 Neuropsychiatric conditions
22.2.1 Anxiety
22.2.2 Delirium
22.2.3 Depression
22.3 Pain
22.3.1 Chronic cancer pain
22.4 Respiratory conditions
22.4.1 Dyspnoea
22.5 Pressure ulcers/sores
22.6 End of life care





















&+$37(5 0(',&,1(686(',13$//,$7,9(&$5(

Palliative care improves the quality of life of patients facing life-threatening

illnesses and their family members, regardless of whether or not they also
receive life-prolonging treatment. It requires a multidisciplinary approach,
and aims to address physical, psychological, spiritual and social problems.
General principles of palliative care include: 
» Treat the underlying causes of symptoms;
» Minimise medicine side effects; and
» Ensure that the patient and caregivers are informed of the nature of the
disease, treatment, side-effects, and likely outcomes.
Palliative care patients who are down-referred from higher levels of care with a
care plan should be managed according to that plan. Palliative care patients
should be assessed by community-based palliative care teams where
available.

Always refer to the latest National Department of Health Guidelines on

Palliative Care.
1RWHThe recommendations in this chapter are primarily directed at end-of-
life care, which is a component of palliative care. 

*$6752,17(67,1$/&21',7,216
&2167,3$7,21
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See section 2.8: Constipation.
'(6&5,37,21
The underlying cause of constipation in palliative care patients may be
functional, disease, or treatment related. Developmental disorders with or
without cognitive deficits, mood and situational circumstances can impact
bowel habits in chronically ill children.

*(1(5$/0($685(6
Ensure privacy and comfort to allow a patient to defecate normally.
Increase fluid intake within the patient’s limits.
Encourage activity and increased mobility within the patient’s limits.
Anticipate the constipating effects of pharmacological agents, such as
opioids, and provide laxatives prophylactically.

0(',&,1(75($70(17

x Sennosides A and B, oral, 13.5 mg, 1 tablet at night.

Adults and children > 15 years of age

o In resistant cases increase to 2 tablets.

$1'25  LoE:IIIi
Lactulose, oral, 10–20 mL 12–24 hourly.
LoE:IIIii

2018 22.2
&+$37(5 0(',&,1(686(',13$//,$7,9(&$5(

x Lactulose, oral, 0.5 mg/kg/dose once daily. See dosing tables, pg 23.6.
Children > 12 months of age

o If poor response, increase frequency to 12 hourly. LoE:IIIiii

1RWHManual removal should only be undertaken if the patient has received
adequate pain relief and if need be sedation as well.
For management of opioid-induced constipation:
See adjuvant therapy in Section 20.4: Chronic cancer pain.

5()(55$/
» All patients with suspected bowel obstruction.
» Patients with severe constipation, not relieved with oral treatment, or who
are unable to swallow.

',$55+2($
A09.0/A09.9/K52.2/K52.9 + (Z51.5)
See Section 2.9: Diarrhoea.
'(6&5,37,21
The commonest cause of diarrhoea in palliative care is laxative use. Other
causes include partial intestinal obstruction, HIV-associated diarrhoea,
pancreatic insufficiency, Clostridium difficile infection, chemotherapeutics,
and radiation enteritis.
Severe constipation and faecal impaction can also cause diarrhoea as backed-
up, liquefied stool may be all that the patient can pass (“overflow diarrhoea").

*(1(5$/0($685(6
Refer to a dietician.
Consider faecal impaction and perform rectal examination if indicated.

0(',&,1(75($70(17
Rehydrate the patient as appropriate if necessary. See Section 2.9.1:
Diarrhoea, acute in children and Section 2.9.3: Diarrhoea, acute, without
blood, in adults.

x Loperamide, oral, 4 mg immediately and 2 mg as required after each

Adults:

loose stool up to 6 hourly.

o Not more than 12 mg daily
o Contraindicated in antibiotic-induced diarrhoea and overflow diarrhoea.

5()(55$/
Persistent diarrhoea (> 2 weeks) in children.

2018 22.3
&+$37(5 0(',&,1(686(',13$//,$7,9(&$5(

1$86($$1'920,7,1*
R11 + (Z51.5)
See Section 2.4: Nausea and vomiting, non-specific.

'(6&5,37,21
Nausea and vomiting may have many causes in palliative care patients e.g.
medication, constipation, anxiety, infection and raised intracranial pressure.

*(1(5$/0($685(6
Refer to a dietician if available.

0(',&,1(75($70(17
Treat the underlying cause and rehydrate the patient if necessary.
Deliver medicines via an appropriate route and regularly.

x Metoclopramide oral, 10 mg, 8 hourly as needed.

Adults:

x Metoclopramide, oral, 0.1 mg/kg/dose, 8–12 hourly.

Children:

:HLJKW 'RVH 6\UXS $JH

kg mg 5 mg/5 mL months/years
‫ޓ‬9–11 kg 1 mg 1 mL ‫ޓ‬12–18 months
‫ޓ‬11–14 kg 1.2 mg 1.2 mL ‫ޓ‬2–3 years
‫ޓ‬14–17.5 kg 1.6 mg 1.6 mL >3–5 years
‫ޓ‬17.5–25 kg 2 mg 2 mL >5–7 years
‫ޓ‬25–35 kg 3 mg 3 mL >7–11 years
‫ޓ‬35–55 kg 4.5 mg 4.5 mL >11–15 years

Use with caution as extrapyramidal side effects may occur (especially at

higher doses).

5()(55$/ LoE:IIIiv
» All patients with a diagnosed or suspected underlying
cause that requires treatment at a higher level of care.
» Consult a palliative care trained doctor if nausea and vomiting persist
despite treatment.

 1(85236<&+,$75,&&21',7,216

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F40.0-2/F40.8-9/F41.0-3/F41.89/F42.0-2/F42.8-9 + (Z51.5)
See Section 16.3: Anxiety disorders.
'(6&5,37,21
Some symptoms of anxiety in palliative care patients may be expected,

2018 22.4
&+$37(5 0(',&,1(686(',13$//,$7,9(&$5(

given the concerns of living with a serious illness. However, if the symptoms
are debilitating, they require treatment.

*(1(5$/0($685(6
Address any contributing factors such as pain and dyspnoea.
Consider other underlying conditions that may mimic anxiety e.g. electrolyte
imbalance, hyperthyroidism, hypoxia, arrhythmias and many adverse drug
reactions.
Assess for depression.
Offer referral for psychotherapy if available.

0(',&,1(75($70(17

x Fluoxetine, oral.
Adult:

o Initiate at 20 mg alternate days for 2 weeks.

o Increase to 20 mg daily after 2–4 weeks.
o Delay dosage increase if increased agitation/panicky feelings occur.
25 LoE:IIv
If fluoxetine is poorly tolerated:
ƒ Alternative SSRI e.g.:
x Citalopram, oral.
o Initiate at 10 mg daily for 2 weeks.
o Then increase to 20 mg daily.
LoE:Ivi
For acute anxiety reactions:
ƒ Benzodiazepine, e.g.:
x Diazepam, oral, 2.5–5 mg.

 For a maximum of 10 days.

LoE:IIIvii

1RWH Benzodiazepines might cause sedation and confusion. Use with

caution.
&$87,21%(1=2',$=(3,1(6
» Associated with cognitive impairment – reversible with short-term use
and irreversible with long-term use.
» Elderly are at risk of over-sedation, falls and hip fractures.
» Dependence may occur after only a few weeks of treatment.
» Prescribe for as short a period of time as possible.
» Warn patient not to drive or operate machinery when used short-term.
» Avoid use in people at high risk of addiction – personality disorders and
those with previous or other substance misuse. LoE:IIIviii

5()(55$/
All children.

2018 22.5
&+$37(5 0(',&,1(686(',13$//,$7,9(&$5(

'(/,5,80
F05.0-1/F05.8-9/F44.8/R45.1/R45.4-6 + (Z51.5)
See Section 21.2.4: Delirium with acute confusion and aggression in adults.

'(6&5,37,21
Delirium (confusion) is common in the terminal stages of advanced disease,
but is rarely seen in children. Supportive measures such as frequent re-
orientation may be useful.

*(1(5$/0($685(6
Assess for underlying causes e.g. infection, electrolyte imbalance.
Remove factors that can agitate patient (full bladders, thirst, pain,
constipation).
Reduce polypharmacy.
Monitor for sensory deficits e.g. hearing impairment.

0(',&,1(75($70(17
&$87,21
» Rapid tranquillisation may cause cardiovascular collapse, respiratory
depression, neuroleptic malignant syndrome and acute dystonic reactions.
» The elderly, children, intellectually disabled and those with comorbid
medical conditions and substance users are at highest risk.
» $QHPHUJHQF\WUROOH\DLUZD\EDJR[\JHQDQGLQWUDYHQRXVOLQHPXVW
EHDYDLODEOH

$GXOWV
For acute agitation
ƒ Benzodiazepine, e.g.:

x
LoE:IIIix
Diazepam, IV, 10 mg
o If no response, give a 2nd dose.
o Do not administer at a rate over 5 mg/minute.

x Diazepam, IV, 5 mg
Elderly or frail patients, or those with liver impairment:

o If no response, give a 2nd dose.

o Do not administer at a rate over 5 mg/minute.
25 LoE:IIIx
Midazolam, IM, 7.5–15 mg immediately.
o Repeat after 30–60 minutes if needed.
o Lower doses are indicated for patients with liver failure.
LoE:IIIxi
Switch to oral benzodiazepine if possible.

2018 22.6
&+$37(5 0(',&,1(686(',13$//,$7,9(&$5(

&$87,21%(1=2',$=(3,1(6
» Associated with cognitive impairment – reversible with short-term use
and irreversible with long-term use.
» Elderly are at risk of over-sedation, falls and hip fractures.
» Dependence may occur after only a few weeks of treatment.
» Prescribe for as short a period of time as possible.
» Warn patient not to drive or operate machinery when used short-term.
» Avoid use in people at high risk of addiction – personality disorders and
those with previous or other substance misuse.
LoE:IIIxii

5()(55$/
All children.

'(35(66,21
F32-3/F32.8-9/F33.0-4/F33.8-9/F34.1 + (Z51.5)
See section 16.4.1: Depressive disorders.
'(6&5,37,21
Depression might be difficult to diagnose in palliative care patients as some
symptoms of depression are similar to disease manifestations such as
anorexia and insomnia. The key indicators of depression in palliative care
patients are persistent feelings of hopelessness and worthlessness and/or
suicidal ideation. Young children may present with somatic complaints e.g.
abdominal pain or headaches, or may have restlessness.

*(1(5$/0($685(6
Refer to a social worker to assist with concerns of future care of patient,
family, and finances.

0(',&,1(75($70(17

x Fluoxetine, oral.
Adults

o Initiate at 20 mg alternate days for 2 weeks.

o Increase to 20 mg daily after 2–4 weeks.
o Delay dosage increase if increased agitation/panicky feelings occur.
25 LoE:Ixiii
If fluoxetine is poorly tolerated:
ƒ Alternative SSRI e.g.:
x Citalopram, oral.
o Initiate at 10 mg daily for 2 weeks.
o Then increase to 20 mg daily.
25 LoE:Ixiv
,IDVHGDWLQJDQWLGHSUHVVDQWLVUHTXLUHG
ƒ Tricyclic antidepressants, e.g.:

2018 22.7
&+$37(5 0(',&,1(686(',13$//,$7,9(&$5(

x Amitriptyline, oral, at bedtime.

o Initial dose: 25 mg per day.
o Increase by 25 mg per day at 3–5 day intervals.
o Maximum dose: 150 mg per day.
1RWH Tricyclic antidepressants may cause dry mouth, constipation, urinary
retention, and confusion, which might be especially problematic in palliative
care patients. Use the lowest dose possible, and titrate slowly.

5()(55$/
»

All children and adolescents.
LoE:IIIxv

» All patients to a psychologist and social worker if available.

 3$,1
See chapter 20: Pain.

 &+521,&&$1&(53$,1
See Section 20.4: Chronic cancer pain.

 5(63,5$725<&21',7,216
 '<6312($
R06.0 + (Z51.5)

'(6&5,37,21
Dyspnoea is the subjective, unpleasant sensation of being unable to breathe
adequately (breathlessness). Dyspnoea is a complex symptom which can be
caused or exacerbated by physical, psychological, and emotional factors.
The intensity of dyspnoea is not related to the oxygen saturation.
The aim should always be to address the cause, however, in end stage
disease symptomatic treatment is indicated.
In children dyspnoea is often evidenced by difficulty talking or feeding, or
restlessness.

*(1(5$/0($685(6
If available refer to a physiotherapist and occupational therapist for
pulmonary rehabilitation, and to teach patients pursed lip breathing, pacing
of activities, relaxation techniques and positioning.
A fan might reduce the sensation of dyspnoea.
Where possible treat the underlying cause e.g. antibiotics for underlying
respiratory infection.

0(',&,1(75($70(17

x Morphine solution, oral. (Doctor initiated)

Adults LoE:IIIxvi

o Starting dose: 2.5–5 mg as required, titrating up slowly.

2018 22.8
&+$37(5 0(',&,1(686(',13$//,$7,9(&$5(

x Morphine solution, oral. (Doctor initiated)

Children

 0–1 month of age:

o Starting dose:

 • 1–12 months of age:

0.05 mg/kg 6 hourly.

 • 12 months of age:
0.1 mg/kg/dose 4 hourly.
0.2–0.4 mg/kg/dose 4 hourly.
LoE:IIIxvii
5()(55$/
Dyspnoea associated with hypoxia for consideration of home-based oxygen.

35(6685(8/&(56625(6
See Section 5.19: Pressure ulcers/sores.

 (1'2)/,)(&$5(
Z51.1

The management of a patient who is imminently terminal (death suspected

to occur within a few days or weeks), should include:
» Communicating honest, direct, compassionate, and culturally sensitive
information regarding the prognosis, and symptoms that might develop.
» Relieving physical, spiritual and emotional distress in the patient and family.
» Treating easily manageable complications that cause suffering.
» Stopping all unnecessary medicines.
» Limiting hospital admissions, if possible.
» Ensuring that parents/caregivers are adequately counselled.
» Decision making as to the preferred place of death (home, hospice, hospital)
and referral to community-based services where available (hospice,
palliative, and home-based care services).
,QGLFDWLRQVIRUUHIHUUDOIRULQSDWLHQWKRVSLWDORUKRVSLFHFDUH
» Hypoxia and respiratory distress where oxygen therapy provides relief. IV/
nasogastric fluid requirements or medication administration needed to relieve
suffering.
» Carer/s unable to cope at home.
)HHGVDQGIOXLGVDWWKHHQGRIOLIH
» Anorexia and refusal of feeds/fluids in dying patients is a normal
phenomenon.
» Encourage the family to ‘feed for comfort only” and reassure them that the
dying patient is not hungry.
,QYHVWLJDWLRQVDWWKHHQGRIOLIH
Investigations should be kept to a minimum and only done if it might
contribute to the patient’s comfort.



2018 22.9
&+$37(5 0(',&,1(686(',13$//,$7,9(&$5(

$QWLELRWLFVDWWKHHQGRIOLIH
» Oral antibiotic therapy might not be indicated. Refer to the patient’s palliative
care plan if available, or consult a palliative care trained doctor.
5HIHUHQFHV
i Sennosides A and B, oral: University of Cape Town,Division of Clinical Pharmacology. South African Medicines
Formulary. 12th Edition. 2016.
Sennosides A and B, oral: Librach SL, Bouvette M, De Angelis C, Farley J, Oneschuk D, Pereira JL, Syme A;
Canadian Consensus Development Group for Constipation in Patients with Advanced Progressive Illness. Consensus
recommendations for the management of constipation in patients with advanced, progressive illness. J Pain Symptom
Manage. 2010 Nov;40(5):761-73. https://www.ncbi.nlm.nih.gov/pubmed/21075273
ii Lactulose, oral: Librach SL, Bouvette M, De Angelis C, Farley J, Oneschuk D, Pereira JL, Syme A; Canadian

Consensus Development Group for Constipation in Patients with Advanced Progressive Illness. Consensus
recommendations for the management of constipation in patients with advanced, progressive illness. J Pain Symptom
Manage. 2010 Nov;40(5):761-73. https://www.ncbi.nlm.nih.gov/pubmed/21075273
iiiSennosides A and B, oral AND lactulose: Librach SL, Bouvette M, De Angelis C, Farley J, Oneschuk D, Pereira JL,

Syme A; Canadian Consensus Development Group for Constipation in Patients with Advanced Progressive Illness.
Consensus recommendations for the management of constipation in patients with advanced, progressive illness. J Pain
Symptom Manage. 2010 Nov;40(5):761-73. https://www.ncbi.nlm.nih.gov/pubmed/21075273
Sennosides A and B, oral AND lactulose: Candy B, Jones L, Larkin PJ, Vickerstaff V, Tookman A, Stone P.
Laxatives for the management of constipation in people receiving palliative care. Cochrane Database Syst Rev. 2015
May 13;(5):CD003448. https://www.ncbi.nlm.nih.gov/pubmed/25967924
ivMetoclopramide, oral (children): National Department of Health. Essential Drugs Programme: Paediatric Hospital Level

STGs and EML, 2017. http://www.health.gov.za/

v Fluoxetine, oral (anxiety): Salt S, Mulvaney CA, Preston NJ. Drug therapy for symptoms associated with anxiety in

adult palliative care patients. Cochrane Database Syst Rev. 2017 May 18;5:CD004596.
https://www.ncbi.nlm.nih.gov/pubmed/28521070
Fluoxetine, oral (anxiety): Baldwin D, Woods R, Lawson R, Taylor D. Efficacy of drug treatments for generalised
anxiety disorder: systematic review and meta-analysis. BMJ. 2011;342:d1199.
https://www.ncbi.nlm.nih.gov/pubmed/21398351
Fluoxetine, oral (anxiety): South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.
University of Cape Town. 2016.
vi SSRIs, oral (anxiety): SSRIs (Therapeutic class): National Department of Health: Affordable Medicines, EDP- PHC

and Adult Hospital level. Medicine Review: SSRIs, therapeutic class for anxiety and depression, October 2017.
http://www.health.gov.za/
SSRIs, oral (anxiety): Bandelow B, Reitt M, Rover C, Michaelis S, Gorlich Y, Wedekind D. Efficacy of treatments for
anxiety disorders: a meta-analysis. Int Clin Psychopharmacol. 2015;30(4):183-92.
https://www.ncbi.nlm.nih.gov/pubmed/25932596
SSRIs, oral (anxiety): Mayo-Wilson E, Dias S, Mavranezouli I, Kew K, Clark DM, Ades AE, et al. Psychological and
pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis.
Lancet Psychiatry. 2014;1(5):368-76. https://www.ncbi.nlm.nih.gov/pubmed/26361000
SSRIs, oral (anxiety): Stahl SM, Gergel I, Li D. Escitalopram in the treatment of panic disorder: a randomized,
double-blind, placebo-controlled trial. J Clin Psychiatry. 2003 Nov;64(11):1322-7.
https://www.ncbi.nlm.nih.gov/pubmed/14658946
SSRIs, oral (anxiety): Thorlund K, Druyts E, Wu P, Balijepalli C, Keohane D, Mills E. Comparative efficacy and safety
of selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors in older adults: a network
meta-analysis. J Am Geriatr Soc. 2015;63(5):1002-9. https://www.ncbi.nlm.nih.gov/pubmed/25945410
vii Benzodiazepines, oral (anxiety): Salt S, Mulvaney CA, Preston NJ. Drug therapy for symptoms associated with

anxiety in adult palliative care patients. Cochrane Database Syst Rev. 2017 May 18;5:CD004596.
https://www.ncbi.nlm.nih.gov/pubmed/28521070
Benzodiazepines, oral (anxiety): Bighelli I, Trespidi C, Castellazzi M, Cipriani A, Furukawa TA, Girlanda F, et al.
Antidepressants and benzodiazepines for panic disorder in adults. Cochrane Database Syst Rev. 2016;9:CD011567.
Benzodiazepines, oral (anxiety): South African Medicines Formulary. 12th Edition. Division of Clinical
Pharmacology. University of Cape Town. 2016.
viii Benzodiazepines (caution): NICE. Generalised anxiety disorder and panic disorder in adults: management, 26

January 2011. http://nice.org.uk/guidance/cg113

Benzodiazepines (caution): South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.
University of Cape Town. 2016.
Benzodiazepines, oral (caution): Picton JD, Marino AB, Nealy KL. Benzodiazepine use and cognitive decline in the
elderly. Am J Health Syst Pharm. 2018 Jan 1;75(1):e6-e12. https://www.ncbi.nlm.nih.gov/pubmed/29273607
Benzodiazepines, oral (caution): Brandt J, Leong C. Benzodiazepines and Z-Drugs: An Updated Review of Major
Adverse Outcomes Reported on in Epidemiologic Research. Drugs R D. 2017 Dec;17(4):493-507.
https://www.ncbi.nlm.nih.gov/pubmed/28865038
Benzodiazepines (caution – long-term use): Picton JD, Marino AB, Nealy KL. Benzodiazepine use and cognitive
decline in the elderly. Am J Health Syst Pharm. 2018 Jan 1;75(1): e6-e12.
https://www.ncbi.nlm.nih.gov/pubmed/29273607

2018 22.10
&+$37(5 0(',&,1(686(',13$//,$7,9(&$5(
Benzodiazepines (caution – long-term use): Brandt J, Leong C. Benzodiazepines and Z-Drugs: An Updated Review
of Major Adverse Outcomes Reported on in Epidemiologic Research. Drugs R D. 2017 Dec;17(4):493-507.
https://www.ncbi.nlm.nih.gov/pubmed/28865038
ix Benzodiazepines (delirium): Grassi L, Caraceni A, Mitchell AJ, Nanni MG, Berardi MA, Caruso R, Riba M.

Management of delirium in palliative care: a review. Curr Psychiatry Rep. 2015 Mar;17(3):550.
https://www.ncbi.nlm.nih.gov/pubmed/25663153
x Diazepam, IV (delirium – elderly, liver failure): South African Medicines Formulary. 12th Edition. Division of Clinical

Pharmacology. University of Cape Town. 2016.

xi Midazolam, oral (delirium – elderly, liver failure): South African Medicines Formulary. 12th Edition. Division of

Clinical Pharmacology. University of Cape Town. 2016.

xii Benzodiazepines (caution): NICE. Generalised anxiety disorder and panicdisorder in adults: management, 26

January 2011. http://nice.org.uk/guidance/cg113

Benzodiazepines (caution): South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.
University of Cape Town. 2016.
Benzodiazepines, oral (caution): Picton JD, Marino AB, Nealy KL. Benzodiazepine use and cognitive decline in the
elderly. Am J Health Syst Pharm. 2018 Jan 1;75(1):e6-e12. https://www.ncbi.nlm.nih.gov/pubmed/29273607
Benzodiazepines, oral (caution): Brandt J, Leong C. Benzodiazepines and Z-Drugs: An Updated Review of Major
Adverse Outcomes Reported on in Epidemiologic Research. Drugs R D. 2017 Dec;17(4):493-507.
https://www.ncbi.nlm.nih.gov/pubmed/28865038
Benzodiazepines (caution – long-term use): Picton JD, Marino AB, Nealy KL. Benzodiazepine use and cognitive
decline in the elderly. Am J Health Syst Pharm. 2018 Jan 1;75(1): e6-e12.
https://www.ncbi.nlm.nih.gov/pubmed/29273607
Benzodiazepines (caution – long-term use): Brandt J, Leong C. Benzodiazepines and Z-Drugs: An Updated Review
of Major Adverse Outcomes Reported on in Epidemiologic Research. Drugs R D. 2017 Dec;17(4):493-507.
https://www.ncbi.nlm.nih.gov/pubmed/28865038
xiii Fluoxetine, oral (depression): Magni LR, Purgato M, Gastaldon C, Papola D, Furukawa TA, Cipriani A, Barbui C.

Fluoxetine versus other types of pharmacotherapy for depression. Cochrane Database Syst Rev. 2013 Jul
17;(7):CD004185. https://www.ncbi.nlm.nih.gov/pubmed/24353997
Fluoxetine, oral (depression): South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.
University of Cape Town. 2016.
xiv SSRIs, oral (depression): SSRIs (Therapeutic class): National Department of Health: Affordable Medicines, EDP-

PHC and Adult Hospital level. Medicine Review: SSRIs, therapeutic class for anxiety and depression, October 2017.
http://www.health.gov.za/
SSRIs, oral (depression): Cipriani A, Furukawa TA, Salanti G, Chaimani A, Atkinson LZ, Ogawa Y, Leucht S, Ruhe
HG, Turner EH, Higgins JPT, Egger M, Takeshima N, Hayasaka Y, Imai H, Shinohara K, Tajika A, Ioannidis JPA,
Geddes JR. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with
major depressive disorder: a systematic review and network meta-analysis. Lancet. 2018 Apr 7;391(10128):1357-1366.
https://www.ncbi.nlm.nih.gov/pubmed/29477251
SSRIs, oral (depression): Magni LR, Purgato M, Gastaldon C, Papola D, Furukawa TA, Cipriani A, Barbui C.
Fluoxetine versus other types of pharmacotherapy for depression. Cochrane Database Syst Rev. 2013 Jul
17;(7):CD004185. https://www.ncbi.nlm.nih.gov/pubmed/24353997
SSRIs, oral (depression): Thorlund K, Druyts E, Wu P, Balijepalli C, Keohane D, Mills E. Comparative efficacy and
safety of selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors in older adults: a
network meta-analysis. J Am Geriatr Soc. 2015;63(5):1002-9. https://www.ncbi.nlm.nih.gov/pubmed/25945410
xvTricyclic antidepressants (note): University of Cape Town ,Division of Clinical Pharmacology. South African Medicines

Formulary. 12th Edition. 2016.

xvi Morphine syrup (Adults: palliative dyspnoea): Barnes H, McDonald J, Smallwood N, Manser R. Opioids for the

palliation of refractory breathlessness in adults with advanced disease and terminal illness. Cochrane Database Syst
Rev. 2016 Mar 31;3:CD011008. https://www.ncbi.nlm.nih.gov/pubmed/27030166
Morphine syrup (Adults: palliative dyspnoea): National Department of Health: Affordable Medicines, EDP- PHC.
Medicine Review: Morphine, oral for palliative dyspnoea in adults and children, September 2017.
http://www.health.gov.za/
xvii Morphine syrup (Children: palliative dyspnoea): Johnston DL, Hentz TA, Friedman DL. Pediatric palliative care. J

Pediatr Pharmacol Ther. 2005 Oct;10(4):200-14. https://www.ncbi.nlm.nih.gov/pubmed/23118638

Morphine syrup (Children: palliative dyspnoea): National Department of Health: Affordable Medicines, EDP- PHC.
Medicine Review: Morphine, oral for palliative dyspnoea in adults and children, September 2017.
http://www.health.gov.za/

2018 22.11
 STANDARD PAEDIATRIC DOSING TABLES
Different conditions require different dosaging of medication. In children most conditions can use
standardised doses. The weight-band dosing tables below are standardised doses of a medicine for
children for specific conditions (indicated above each table). Where a specific condition is not indicated
below, see the main text of the book for the dosing specific to that condition.
ABACAVIR

x
11.6 Management of HIV-infected children
Abacavir, oral, 8 mg/kg 12 hourly or 16 mg/kg daily.
Weight Daily dose Use one of the following Age
kg mg Solution Tablet Tablet Months/years
20 mg/mL 60 mg 300 mg
3–4.9 kg 40 mg 2 mL 12 hourly - - ‫ޓ‬1–3 months
5–6.9 kg 60 mg 3 mL 12 hourly – – ‫ޓ‬3–6 months
7–9.9 kg 80 mg 4 mL 12 hourly – – ‫ޓ‬6 months –1
year
10–13.9 kg 240 mg 6 mL 12 hourly – – ‫ޓ‬1–3 years
OR 12 mL daily
14–19.9 kg 300 mg 7.5 mL 12 2 ½ x 60 mg tablets 1 tablet daily ‫ޓ‬3–4 years
hourly OR 15 12 hourly
mL daily
20–22.9 kg 400 mg 10 mL 12 hourly 3 x 60 mg tablets 12 – ‫ޓ‬4–6 years
OR 20 mL hourly
daily OR 1x 60 mg and 1x 300 mg tablets daily
23–24.9 kg 400 mg 10 mL 12 hourly 2x 60 mg and 1x 300 mg tablets daily >6–7 years
OR 20 mL
daily
>25 kg 600 mg – – 2 tablets daily >7 years
Source: Child and Adolescent Committee of the SA HIV Clinicians Society in collaboration with the Department of Health: Antiretroviral drug dosing
chart for children, 2013. http://www.sahivsoc.org/Files/2013%20ARV%20dosing%20chart%20for%20children%20(Aug%202013).pdf
ACICLOVIR

x
1.4 Herpes simplex infections of the mouth and lips; 5.13 Herpes simplex.
Aciclovir, oral, 250 mg/m2/dose, 8 hourly for 7 days.
Use one of the following:
Weight Dose Age
Susp Tablet
kg mg Months/years
200 mg/5mL 200 mg 400 mg
‫ޓ‬3.5–5 kg 50 mg 1.25 mL – – ‫ޓ‬1–3 months
‫ޓ‬5–7 kg 80 mg 2 mL – – ‫ޓ‬3–6 months
‫ޓ‬7–11 kg 100 mg 2.5 mL ½ tablet – ‫ޓ‬6–18 months
‫ޓ‬11–14 kg 120 mg 3 mL – – ‫ޓ‬18 months–3 years
‫ޓ‬14–25 kg 160 mg 4 mL – ‫ޓ‬3–7 years
‫ޓ‬25–35 kg 200 mg 5 mL 1 tablet ½ tablet ‫ޓ‬7–11 years
‫ޓ‬35 kg–55 kg 300 mg 7.5 mL 1½ tablets – ‫ޓ‬11–15 years
>55 kg 400 mg – – 1 tablet >15 years
ACTIVATED CHARCOAL

x
21.3.3 Exposure to poisonous substances.
Activated charcoal, 1 g/kg mixed as a slurry with water.
Weight Dose Age
kg g Months/years
>3.5–7 kg 5g >1–6 months
>7–11 kg 10 g >6–18 months
>11–17.5 kg 15 g >18 months–5 years
>17.5–35 kg 25 g >5–11 years
>35–55 kg 50 g >11–15 years
>55 kg 50–100 g >15 years

2018 23.1
 STANDARD PAEDIATRIC DOSING TABLES
AMOXICILLIN

x
3.2.1.1 Complicated severe acute malnutrition (SAM); 10.8 Measles (initial dose for measles with pneumonia, then refer).
Amoxicillin, oral, 30 mg/ kg/ dose, 8 hourly for 7 days.
Weight Dose Use one of the following Age
kg mg Susp Capsule Months/years
125 250 250 500
mg/5mL mg/5mL mg mg
‫ޓ‬2–2.5 kg 62.5 mg 2.5 mL 1.25 mL – – ‫ޓ‬34–36 weeks
‫ޓ‬2.5–3.5 kg 75 mg 3 mL 1.5 mL – – ‫ޓ‬36 weeks–1 month
‫ޓ‬3.5–5 kg 125 mg 5 mL 2.5 mL – – ‫ޓ‬1–3 months
>5–7 kg 175 mg 7 mL 3.5 mL – – >3–6 months
>7–11 kg 250 mg 10 mL 5 mL 1 – >6–18 months
>11–17.5 kg 375 mg 15 mL 7.5 mL – – >18 months–5 years
>17.5–25 kg 500 mg – 10 mL 2 1 >5–7 years
>25–35 kg 750 mg – 15 mL 3 >7–11 years
>35 kg 1000 mg – – 4 2 >11years
ATROPINE

x
21.1.3 Bradycardia; 21.3.3 Exposure to poisonous substances.
Atropine, IV, 0.05 mg/kg/dose.
Weight Dose Use one of the following injections Age
kg mg (intravenously) months/years
0.5 mg/mL 1 mg/mL
>3.5–5kg 0.2 mg 0.4 mL 0.2 mL >1–3 months
>5–7 kg 0.3 mg 0.6 mL 0.3 mL >3–6 months
>7–9 kg 0.4 mg 0.8 mL 0.4 mL >6–12 months
>9–11 kg 0.5 mg 1 mL 0.5 mL >12–18 months
>11–14 kg 0.6 mg 1.2 mL 0.6 mL >18 months–3 years
>14–17.5 kg 0.8 mg 1.6 mL 0.8 mL >3–5 years
>17.5 kg 1 mg 2 mL 1 mL >5 years
AZITHROMYCIN
1.1.1 Dental abscess; 4.9 Rheumatic fever, acute; 5.4.1 Boil, abscess; 5.4.2 Impetigo; 5.4.3 Cellulitis; 5.8.2 Eczema,
acute, moist or weeping; 10.8 Measles (children with otitis media); 10.14 Tick bite fever; 17.3.4.1 Pneumonia in children;
19.4.1 Otitis, externa; 19.4.2 Otitis, media, acute; 19.5 Sinusitis, acute, bacterial; 19.6 Tonsillitis and pharyngitis; 21.3.1.1

x
Animal bites; 21.3.1.2 Human bites.
Azithromycin, oral, 10 mg/kg/dose, daily for 3 days.
Use one of the following:
Weight Dose Age
Susp Tablet
kg mg Months/years
200 mg/5mL 250 mg 500 mg
>7–9 kg 80 mg 2 mL >6-12 months
‫ޓ‬9–11 kg 100 mg 2.5 mL – – ‫ޓ‬12–18 months
‫ޓ‬11–14 kg 120 mg 3 mL – – ‫ޓ‬18 months–3 years
‫ޓ‬14–18 kg 160 mg 4 mL – – ‫ޓ‬3–5 years
>18-25 kg 200 mg 5 mL – – >5-7 years
‫ޓ‬25–35 kg 250 mg – 1 tablet – ‫ޓ‬7–11 years
‫ޓ‬35 kg 500 mg – – 1 tablet ‫ޓ‬11 years

2018 23.2
 STANDARD PAEDIATRIC DOSING TABLES
CEFTRIAXONE
2.9.1 Diarrhoea, acute in children; 2.10.1 Dysentery, bacillary; 3.2.1.1 Complicated severe acute malnutrition (SAM); 8.4
Urinary tract infection (UTI); 10.5 Fever; 10.18 Viral haemorrhagic fever; 14.3 Arthritis, septic; 15.4.1 Meningitis, acute; 17.2.1
Croup (laryngotracheobronchitis) in children (epiglottitis suspected);17.3.4.1 Pneumonia in children; 21.2.9 Shock

x
(septicaemia); 21.3.6.2 Post exposure prophylaxis, rape and sexual assault.
Ceftriaxone, IM, 80 mg/kg/dose immediately as a single dose.
Use one of the following injections mixed with
water for injection (WFI):
Weight Dose 1 000 Age
250 mg/2 mL 500 mg/2 mL mg/3.5 mL
kg mg Months/years
(250 mg diluted (500 mg diluted (1 000 mg
in 2 mL WFI) in 2 mL WFI) diluted in
3.5 mL WFI)
‫ޓ‬2–2.5 kg 190 mg 1.5 mL 0.75 mL – >34–36 weeks
‫ޓ‬2.5–3.5 kg 225 mg 1.8 mL 0.9 mL – >36 weeks–1 month
‫ޓ‬3.5–5.5 kg 310 mg – 1.25 mL – ‫ޓ‬1–3 months
‫ޓ‬5.5–7 kg 440 mg – 1.75 mL – ‫ޓ‬3–6 months
‫ޓ‬7–9 kg 625 mg – 2.5 mL – ‫ޓ‬6–12 months
‫ޓ‬9–11 kg 750 mg – 3 mL – ‫ޓ‬12–18 months
‫ޓ‬11–14 kg 810 mg – 3.25 mL – ‫ޓ‬18 months–3 years
‫ޓ‬14–17.5 kg 1 000 mg – 4 mL 3.5 mL ‫ޓ‬3–5 years
>17.5 kg 1 500 mg - - 5.5 mL >5 years
CEPHALEXIN
5.4.1 Boil, abscess; 5.4.2 Impetigo;5.4.3 Cellulitis; 5.8.2 Eczema, acute, moist or weeping; 19.4.1 Otitis, externa,

x
(furuncular).
Cephalexin, oral, 12–25 mg/kg/dose 6 hourly for 5 days.
Weight Dose Syrup Syrup Capsule Age
kg mg 125 mg/ 5mL 250 mg/ 5mL 250 mg Months/years
>2.5–5 kg 62.5 mg 2.5 mL – – Birth–3 months
‫ޓ‬5–11 kg 125 mg 5 mL 2.5 mL – ‫ޓ‬3–18 months
‫ޓ‬11–25 kg 250 mg 10 mL 5 mL 1capsule ‫ޓ‬18 months–7 years
‫ޓ‬25 kg 500 mg – – 2 capsules ‫ޓ‬7 years
CETIRIZINE
5.2 Itching (pruritus); 5.8.1 Eczema, atopic; 5.8.2 Eczema, acute, moist or weeping; 5.10.4 Papular urticaria; 5.11

x
Pityriasis rosea; 18.1.1 Conjunctivitis, allergic; 19.1 Allergic rhinitis.
Cetirizine, oral, once daily
Use one of the following:
Weight Dose Age
kg mg Syrup Tablet years
1 mg/ mL 10 mg
‫ޓ‬12–21 kg 5 mg 5 mL – 2–6 years
‫ޓ‬21 kg 10 mg 10 mL 1 tablet >6 years
CHLORPHENAMINE
5.2 Itching (pruritus); 5.7.3 Sandworm; 5.8.1 Eczema, atopic; 5.8.2 Eczema, acute, moist or weeping; 5.10.1 Urticaria;
5.10.4 Papular urticaria; 5.11 Pityriasis rosea; 10.2 Chicken pox; 18.1.1 Conjunctivitis, allergic; 19.1 Allergic rhinitis;

x
20.4 Chronic cancer pain (pruritis); 21.3.1.3 Insect stings, scorpion stings and spider bites.
Chlorphenamine, oral, 0.1 mg/kg/dose 6–8 hourly.
Use one of the following:
Weight Dose Age
Syrup Tablet
Kg mg years
2 mg/5mL 4 mg
‫ޓ‬12–14 kg 1.2 mg 3 mL – ‫ޓ‬2–3 years
‫ޓ‬14–17.5 kg 1.6 mg 4 mL – >3–5 years
‫ޓ‬17.5–25 kg 2 mg 5 mL – >5–7 years
‫ޓ‬25–35 kg 3 mg 7.5 mL – >7–11 years
‫ޓ‬35 kg 4 mg – 1 tablet >11 years

2018 23.3
 STANDARD PAEDIATRIC DOSING TABLES
CIPROFLOXACIN

x
2.10.1 Dysentery, bacillary.
Ciprofloxacin, oral, 15 mg/kg/dose 12 hourly for 3 days.
Use one of the following:
Weight Dose Age
Susp Tablet
kg mg Months / years
250 mg/5 mL 250 mg 500 mg
‫ޓ‬9–11 kg 150mg 3 mL – – ‫ޓ‬12–18 months
‫ޓ‬11–14 kg 200 mg 4 mL – – ‫ޓ‬18 months–3 years
‫ޓ‬14–17.5 kg 250 mg 5 mL 1 – ‫ޓ‬3–5 years
‫ޓ‬17.5–25 kg 300 mg 6 mL – – ‫ޓ‬5–7 years
‫ޓ‬25 kg 500 mg 10 mL 2 1 ‫ޓ‬7 years
CLARITHROMYCIN.
1.1.1 Dental abscess; 4.9 Rheumatic fever, acute; 5.4.1 Boil, abscess; 5.4.2 Impetigo; 5.4.3 Cellulitis; 5.8.2 Eczema, acute,
moist or weeping; 10.8 Measles (children with otitis media); 17.3.4.1 Pneumonia in children; 19.4.1 Otitis, externa; 19.4.2 Otitis,

x
media, acute; 19.5 Sinusitis, acute, bacterial; 19.6 Tonsillitis and pharyngitis; 21.3.1.1 Animal bites; 21.3.1.2 Human bites.
Clarithromycin, oral, 7.5 mg/kg/dose, 12 hourly for 5 days.
Use one of the following:
Weight Dose Age
Susp Tablet
kg mg Months/years
125mg/5mL 250mg/5mL 250 mg
>3.5–5 kg 30 mg 1.2 – – >1–3 months
>5–7 kg 45 mg 1.8 – – >3–6 months
>7–9 kg 62.5 mg 2.5 – – >6–12 months
>9–11 kg 75 mg 3 – – >12–18 months
>11–14 kg 100 mg 4 – – >18 months–3 years
>14–17.5kg 125 mg 5 2.5 – >3–5 years
>17.5-25kg 150 mg 6 3 – >5–7 years
>25–35 kg 187.5 mg 7.5 3.75 – >7–11 years
>35–55 kg 250 mg – 5 1 tablet >11–15 years
COTRIMOXAZOLE (PROPHYLAXIS)
11.5 The HIV-exposed infant; 11.6 Management of HIV infected children; 11.7 Opportunistic infections, prophylaxis

x
in children; 15.4.1 Meningitis, acute – listeriosis outbreak (pre-referral dose only).
Cotrimoxazole, oral, once daily (everyday).
Recommended daily Dose sulfamethoxazole Susp Single Double
by weight band /trimethoprim 200/40 mg strength tablet strength tablet
per 5 mL 400/80 mg 800/160 mg
3–4.9 kg 100/20 mg 2.5 mL ¼ tablet –
5–13.9 kg 200/40 mg 5 mL ½ tablet –
14–29.9kg 400/80 mg 10 mL 1 tablet ½ tablet
>30 kg 800/160 mg – 2 tablets 1 tablet
DIAZEPAM

x
15.3.3 Febrile convulsions; 21.2.11 Seizures and status epilepticus.
Diazepam, rectal, 0.5 mg/kg/dose for convulsions as a single dose.
Weight Dose Ampoule Age
kg mg 10 mg/2 mL Months/years
>3–6 kg 2 mg 0.4 mL <6 months
>6–10 kg 2.5 mg 0.5 mL >6 months–1 year
>10–18 kg 5 mg 1 mL >1–5 years
>18–25 kg 7.5 mg 1.5 mL >5–7 years
>25–40 kg 10 mg 2 mL >7–12 years
EFAVIRENZ

x
11.6 Management of HIV-infected children
Efavirenz, oral, at night.
Use one of the following:
Weight Dose Age
Capsule/Tablet
kg mg Months/years
50 mg 200 mg 600 mg
10–13.9 kg 200 mg – 1 cap/tab – 3 years
14–24.9 kg 300 mg 2 caps/tabs 1 cap/tab – >3–7 years
25–39.9 kg 400 mg – 2 caps/tabs – >7–12 years
>40 kg 600 mg – – 1 tablet >12 years
Source: Child and Adolescent Committee of the SA HIV Clinicians Society in collaboration with the Department of Health: Antiretroviral drug dosing

2018 23.4
 STANDARD PAEDIATRIC DOSING TABLES
chart for children, 2013. http://www.sahivsoc.org/Files/2013%20ARV%20dosing%20chart%20for%20children%20(Aug%202013).pdf
EPINEPHRINE (ADRENALINE)

x
21.1.1 Cardiac arrest (adults); 21.1.2 Cardiopulmonary arrest, children; 21.1.3 Bradycardia; 21.2.10 Anaphylaxis.
Epinephrine (adrenaline), 1:1000, IM, 0.01 mL/kg as a single dose.
Weight Dose Injection Age
kg mg 1 mg/mL (1:1 000) years
9–12 kg 0.1 mg 0.1 mL 1–2 years
>12–17.5 kg 0.2 mg 0.2 mL >2–5 years
>17.5–40 kg 0.3 mg 0.3 mL >5–12 years
>40 kg 0.5 mg 0.5 mL >12 years
FLUCLOXACILLIN

x
5.4.1 Boil, abscess; 5.4.2 Impetigo; 5.4.3 Cellulitis; 5.8.2 Eczema, acute, moist or weeping; 19.4.1 Otitis, externa (furuncular)
Flucloxacillin, oral, 12–25mg/kg/dose 6 hourly for 5 days.
Weight Dose Syrup Capsule Age
Kg mg 125 mg/ 5mL 250 mg Months / years
‫ޓ‬2.5–5 kg 62.5 mg 2.5 mL – Birth–3 months
‫ޓ‬5–11 kg 125 mg 5 mL – ‫ޓ‬3–18 months
‫ޓ‬11–25 kg 250 mg 10 mL 1 capsule ‫ޓ‬18 months–7 years
‫ޓ‬25 kg 500 mg – 2 capsules ‫ޓ‬7 years
FLUCONAZOLE

x
5.5.2.3 Scalp infections – tinea capitis (for 28 days); 11.8.2 Candidiasis, oesophageal (for 21 days).
Fluconazole, oral, 6 mg/kg once daily.
Use one of the following:
Weight Dose Age
Susp Capsule Capsule
Kg mg Months/years
50 mg/5 mL 50 mg 200 mg
>3.5–5 kg 25 mg 2.5 mL – – >1–3 months
>5–7 kg 30 mg 3 mL – – >3–6 months
>7–9 kg 50 mg 5 mL 1 capsule – >6–12 months
>9–11 kg 60 mg 6 mL >12–18 months
>11–14 kg 70 mg 7mL – – >18 months–3 years
>14–17.5 kg 100 mg 10 mL 2 capsules – >3–5 years
>17.5–25 kg 125 mg 12.5 mL – – >5–7 years
>25–35 kg 150 mg 15 mL 3 capsules – >7–11 years
>35 kg 200 mg – – 1 capsule >11 years
FUROSEMIDE
4.6.2 Cardiac failure, Congestive children (CCF), children; 8.1 Chronic kidney disease (CKD); 8.2 Acute kidney injury;

x
21.2.8 Pulmonary oedema, acute.
Furosemide, IV, 1 mg/kg, over 5 minutes.
Weight Dose Injection Age
Kg mg 10 mg/mL Months/years
>3.5–5 kg 4 mg 0.4 mL >1–3 months
>5–7 kg 6 mg 0.6 mL >3–6 months
>7–9 kg 8 mg 0.8 mL >6–12 months
>9–11 kg 10 mg 1 mL >12–18 months
>11–14 kg 12 mg 1.2 mL >18 months–3 years
>14–17.5 kg 15 mg 1.5 mL >3–5 years
>17.5–25 kg 20 mg 2 mL >5–7 years
>25–35 kg 30 mg 3 mL >7–11 years
>35 kg 40 mg 4 mL >11 years
HYDROCORTISONE

x
17.1.1 Acute asthma & acute exacerbation of COPD; 21.2.10 Anaphylaxis.
Hydrocortisone slow IV, 4–6 mg/kg immediately.
Weight Dose Injection Age
kg mg 100 mg/2 mL months/years
>11–14 kg 50 mg 1 mL >2–3 years
>14–17.5 kg 75 mg 1.5 mL >3–5 years
>17.5 kg 100 mg 2 mL >5 years

2018 23.5
 STANDARD PAEDIATRIC DOSING TABLES
IBUPROFEN

x
20.2 Acute pain; 20.3 Chronic non-cancer pain; 20.4 Chronic cancer pain.
Ibuprofen, oral, 5–10 mg/kg/dose 8 hourly with or after a meal.
Use one of the following:
Weight Dose Age
Syrup Tablet
kg mg Months/years
100 mg/5mL 200 mg
>9–11 kg 80 mg 4 mL – >12–18 months
>11–14 kg 100 mg 5 mL – >18 months–3 years
>14–17.5 kg 120 mg 6 mL – >3–5 years
>17.5–25 kg 150 mg 7.5 mL – >5–7 years
>25–40 kg 200 mg 10 mL 1 tablet >7–12 years
>40 kg 400 mg – 2 tablets >12 years
LACTULOSE
2.5.1 Anal fissures; 2.8 Constipation; 20.4 Chronic cancer pain (constipation); 22.1.1 Constipation (medicines used

x
in palliative care).
Lactulose, oral, 0.5 mL/kg/dose once daily.
o If poor response, increase frequency to 12 hourly.
Weight Syrup Age
kg 3.3 g/5 mL Months/years
‫ޓ‬5–7 kg 3 mL ‫ޓ‬3–6 months
>7–9 kg 4 mL >6–12 months
‫ޓ‬9–11 kg 5 mL ‫ޓ‬12–18 months
‫ޓ‬11–14 kg 6 mL ‫ޓ‬18 months–3 years
>14–17.5 kg 7.5 mL >3–5 years
‫ޓ‬17.5–35 kg 10 mL ‫ޓ‬5–11 years
‫ޓ‬35 kg 15 mL ‫ޓ‬11 years
LAMIVUDINE

x
11.6 Management of HIV-infected children; 21.3.6.2 Post exposure prophylaxis, rape and sexual assault.
Lamivudine, oral, 4 mg/kg 12 hourly or 8 mg/kg daily.
Weight Dose Use one of the following Age
(kg) (mg) Solution Tablet Tablet Months/years
10 mg/mL 150 mg 300 mg
3–4.9 kg 40 mg 2 mL 12 hourly - - ‫ޓ‬1–3 months
5–6.9 kg 60 mg 3 mL 12 hourly – – ‫ޓ‬3–6 months
7–9.9 kg 80 mg 4 mL 12 hourly – – ‫ޓ‬6 months –
1 year
10–13.9 kg 120 mg 6 mL 12 hourly – – ‫ޓ‬1–3 years
OR 12 mL daily
14–19.9 kg 150 mg 7.5 mL 12 hourly ½ tablet 12 hourly – ‫ޓ‬3–4 years
OR 15 mL daily OR 1 tablet daily
20–24.9 kg 300 mg 15 mL 12 hourly 1 tablet 12 hourly 1 tablet ‫ޓ‬4–7 years
OR 30 mL daily OR 2 tablets daily daily
>25 kg 600 mg – 1 tablet 12 hourly 1 tablet ‫ޓ‬7 years
OR 2 tablets daily daily
Source: Child and Adolescent Committee of the SA HIV Clinicians Society in collaboration with the Department of Health: Antiretroviral drug dosing
chart for children, 2013. http://www.sahivsoc.org/Files/2013%20ARV%20dosing%20chart%20for%20children%20(Aug%202013).pdf

2018 23.6
 STANDARD PAEDIATRIC DOSING TABLES

LOPINAVIR/RITONAVIR

x
11.6 Management of HIV-infected children; 21.3.6.2 Post exposure prophylaxis, rape and sexual assault.
Lopinavir/ritonavir, oral 300/75mg/m212 hourly.
Weight Dose Use one of the following Age
(kg) (mg) Solution Tablet Tablet Months/years
80/20 100/25 mg 200/50 mg
mg/mL
3–4.9 kg 80/20 mg 1 mL – – ‫ޓ‬1–3 months
5–9.9 kg 150/15 mg 1.5 mL – – ‫ޓ‬3 months–1
year
10–13.9 kg 160/40 mg 2 mL – – ‫ޓ‬1–3 years
14–19.9 kg 200/50 mg 2.5 mL 2 tablets 1 tablet ‫ޓ‬3–4 years
20–24.9 kg 240/60 mg 3 mL 2 tablets 1 tablet ‫ޓ‬4–7 years
25–29.9 kg 280/70 mg 3.5 mL 3 tablets – >7–9 years
OR 1x100/25 mg tablet and 1x200/50mg
tablet
30–34.9 kg 320/80 mg 4 mL 3 tablets – ‫ޓ‬9–11 years
OR 1x100/25 mg tablet and 1x200/50 mg
tablet
>35 kg 400/100 mg 5 mL – 2 tablets >11 years
Source: Child and Adolescent Committee of the SA HIV Clinicians Society in collaboration with the Department of Health: Antiretroviral drug dosing
chart for children, 2013. http://www.sahivsoc.org/Files/2013%20ARV%20dosing%20chart%20for%20children%20(Aug%202013).pdf
METRONIDAZOLE

x
1.1.1 Abscess, dental; 1.3.3 Necrotising periodontitis; 21.3.1.1 Animal bites; 21.3.1.2 Human bites.
Metronidazole, oral, 7.5 mg/kg/dose 8 hourly for 5 days.
Weight Dose Use one of the following: Age
kg mg Suspension Tabs Tabs Months/years
200 mg/5mL 200mg 400mg
‫ ޓ‬9–11 kg 80 mg 2 mL – – ‫ޓ‬12–18 months
‫ޓ‬11–14 kg 100 mg 2.5 mL ½ tablet – ‫ޓ‬18 months–3 years
‫ޓ‬14–17.5 kg 120 mg 3 mL – – ‫ޓ‬3–5 years
‫ޓ‬17.5–25 kg 160 mg 4 mL – – ‫ޓ‬5–7 years
‫ޓ‬25–35 kg 200 mg 5 mL 1 tablet ½ tablet ‫ޓ‬7–11 years
‫ޓ‬35–55 kg 300 mg 7.5mL 1½ tablets – ‫ޓ‬11–15 years
>55 kg 400 mg – – 2 tablets >15 years
MIDAZOLAM

x
15.3.3 Febrile convulsions; 21.2.11 Seizures and status epilepticus.
Midazolam, buccal, 0.5 mg/kg/dose.
Weight Dose Injection formulation (buccal Age
kg mg administration) 5 mg/mL Months/years
>7–9 kg 4 mg 0.8 mL >6–12 months
>9–11 kg 5 mg 1 mL >12–18 months
>11–14 kg 6 mg 1.2 mL >18 months–3 years
>14–17.5 kg 7.5 mg 1.5 mL >3–5 years
>17.5 kg 10 mg 2 mL >5 years
MORPHINE

x
20.3 Chronic cancer pain
Morphine, oral, 0.2–0.4 mg/kg/dose 4–6 hourly.
Use one of the following:
Weight Dose Age
Syrup Tablet
kg mg Months/years
1 mg/mL 10 mg
>7–9 kg 2 mg 2 mL – >6–12 months
>9–11 kg 2.5 mg 2.5 mL – >12–18 months
>11–14 kg 4 mg 4 mL – >18 months–3 years
>14–17.5 kg 5 mg 5 mL – >3–5 years
>17.5–25 kg 6 mg 6 mL – >5–7 years
>25 kg 10 mg 10 mL 1 tablet >7 years

2018 23.7
 STANDARD PAEDIATRIC DOSING TABLES

PARACETAMOL
1.1.1 Dental abscess; 1.3.3 Necrotising periodontitis; 1.4 Herpes simplex infections of the mouth and lips; 1.5
Aphthous ulcers; 10.2 Chickenpox; 10.5 Fever; 10.7.1 Malaria, uncomplicated (fever in children < 5 years of age);
10.8 Measles; 10.10 Mumps; 10.11 Rubella (German measles); 10.14 Tick bite fever; 14.1 Arthralgia; 15.3.3 Febrile
convulsions; 15.4.1 Meningitis, acute; 15.5 Headache, mild, non-specific; 17.2.1 Croup (laryngotracheobronchitis) in
children; 17.3.1 Influenza; 18.1.2 Conjunctivitis, bacterial (excluding conjunctivitis of the newborn); 18.1.4
Conjunctivitis, viral (pink eye); 18.3.1 Eye injury, chemical burn; 18.3.3 Eye injury (blunt or penetrating); 19.2 Viral
rhinitis (common cold); 19.4.2 Otitis, media, acute; 19.5 Sinusitis, acute, bacterial; 19.6 Tonsillitis and pharyngitis;
20.2 Acute pain; 20.3 Chronic non-cancer pain; 20.4 Chronic cancer pain; 21.3.1.3 Insect stings, scorpion stings and

x
spider bites; 21.3.2 Burns; 21.14 Injuries; 21.3.8 Sprains; 21.3.7 Soft tissue injuries.
Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required.
Weight Dose Use one of the following: Age
kg mg Syrup Tablet Months/years
120 mg/5mL 500 mg
>3.5–5 kg 48 mg 2 mL – >1–3 months
>5–7 kg 72 mg 3 mL – >3–6 months
>7–9 kg 96 mg 4 mL – >6–12 months
>9–11 kg 120 mg 5 mL – >12–18 months
>11–14 kg 144 mg 6 mL >18 months–3 years
>14–17.5 kg 180 mg 7.5 mL >3–5 years
>17.5–25 kg 240 mg 10 mL ½ tablet >5–7 years
>25–35 kg 360 mg 15 mL >7–11 years
>35–55 kg 500 mg – 1 tablet >11–15 years
>55 kg 1 000 mg 2 tablets >15 years
PHENOBARBITAL

x
21.2.11 Seizures and status epilepticus.
Phenobarbitone, oral, crushed and given by nasogastric tube, 20 mg/kg as a single dose.
Weight Dose Tablet Age
kg mg 30 mg Months/ years
>2.5–3.5 kg 60 mg 2 tablets Birth–1 month
>3.5–5 kg 75 mg 2½ tablets >1–3 months
>5–7 kg 120 mg 4 tablets >3–6 months
>7–11 kg 180 mg 6 tablets >6–12 months
>11–14 kg 210 mg 7 tablets >18 months–3 years
>14 kg 240 mg 8 tablets >3 years
PRAZIQUANTEL

x
10.12 Schistosomiasis.
Praziquantel, oral, 40 mg/kg as a single dose.
Weight Dose Tablet Age
kg mg 600 mg years
>12–17.5 kg 600 mg 1tablet >2–5 years
>17.5–25 kg 900 mg 1½ tablet >5–7 years
>25–35 kg 1 200 mg 2 tablets >7–11 years
>35 kg 1 800 mg 3 tablets >11 years
PROMETHAZINE

x
21.2.10 Anaphylaxis.
Promethazine IM/slow IV.
o Children > 2 years: 0.25 mg/kg.
Weight Dose Use one of the following injections: Age
kg mg 25 mg/mL 50 mg/2 mL Months/years
>12–17.5 kg 2.5 mg 0.1 mL 0.1 mL 2–5 years
>17.5–25 kg 5 mg 0.2 mL 0.2 mL >5–7 years
>25–35 kg 7.5 mg 0.3 mL 0.3 mL >7–11 years
>35–55 kg 15 mg 0.6 mL 0.6 mL >11–15 years
>55 kg 25 mg 1 mL 0.51 mL >15 years

2018 23.8
 STANDARD PAEDIATRIC DOSING TABLES

QUININE DIHYDROCHLORIDE

x
10.7.2 Malaria, severe.
Quinine dihydrochloride, IV or IM, 15–20 mg/kg immediately as a single dose and refer urgently.
Weight Dose Injection Use one of the following: Age
kg mg 300 mg IM IV Months/years
/mL volume of Sodium volume of
chloride 0.9% Dextrose 5%
>9–11 kg 180 mg 0.6 mL 2 mL 75 mL >12–18 months
>11–14 kg 210 mg 0.7 mL 2.5 mL 100 mL >18 months–3 years
>14–17.5 kg 300 mg 1 mL 3 mL 125 mL >3–5 years
>17.5–25 kg 360 mg 1.2 mL 4.5 mL 175 mL >5–7 years
>25–35 kg 510 mg 1.7 mL 7.5 mL 250 mL >7–11 years
>35–55 kg 750 mg 2.5 mL 10 mL 350 mL >11–15 years
>55 kg 900 mg 3 mL 10 mL 450 mL >15 years
RITONAVIR

x
11.6 Management of HIV-infected children; 11.8.7 Tuberculosis (concomitant ARVs).
Ritonavir, oral, 12 hourly (ONLY as booster for lopinavir/ritonavir, when on rifampicin).
Weight Dose Solution Age
kg mg 80 mg/mL years
3–4.9 kg 80 mg 1 mL >1–3 months
5–13.9 kg 120 mg 1.5 mL >3 months–3 years
14–19.9 kg 160 mg 2 mL >3–4 years
20–24.9 kg 200 mg 2.5 mL >4–7 years
25–34.9 kg 240 mg 3 mL >7–11 years
>35 kg 320 mg 4 mL >11 years
Source: Child and Adolescent Committee of the SA HIV Clinicians Society in collaboration with the Department of Health: Antiretroviral drug dosing
chart for children, 2013. http://www.sahivsoc.org/Files/2013%20ARV%20dosing%20chart%20for%20children%20(Aug%202013).pdf
ZIDOVUDINE

x
21.3.6.2 Post exposure prophylaxis, rape and sexual assault.
Zidovudine, oral, 180-240 mg/m2 12 hourly.
Weight Dose Use one of the following Age
(kg) (mg) Solution Capsule Tablet years
10 mg/mL 100 mg 300 mg
3–5.9 kg 120 mg 6 mL 12 hourly – – >1–4 months
6–7.9 kg 180 mg 9 mL 12 hourly – – >4–7 months
8–13.9 kg 240 mg 12 mL 12 hourly 1 cap 12 hourly – >7 months–3
years
14–19.9 kg 300 mg 15 mL 12 hourly 2 caps in the morning – >3–4 years
and 1 cap in the
evening
20–24.9 kg 400 mg 20 mL 12 hourly 2 caps 12 hourly – >4–7 years
>25 kg 600 mg – – 1 tab 12 hourly >7 years

2018 23.9
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O


INDEX OF CONDITIONS
Abdominal pain 2.2
Abnormal vaginal bleeding during fertile years 6.39
Abscess and caries, dental 1.2
Acne vulgaris 5.4
Acute asthma & acute exacerbation of chronic obstructive pulmonary disease (COPD) 17.3
Acute bronchiolitis in children 17.13
Acute bronchitis in adults or adolescents 17.19
Acute confusion – Delirium 16.2
Acute exacerbation of chronic obstructive pulmonary disease (COPD) 17.19
Acute kidney injury 8.5
Acute meningitis 15.11
Acute pain 20.3
Acute psychosis 16.14
Adverse events following immunisation (AEFI) 13.11
Aggressive disruptive behaviour 16.2
Aggressive disruptive behaviour in adults 16.2
Aggressive disruptive behaviour in children and adolescents 16.5
Albinism 5.31
Alcohol withdrawal (uncomplicated) 16.23
Allergic rhinitis 19.2
Allergies 5.22
Anaemia 3.2
Anaemia (HIV-associated in children) 11.40
Anaemia in pregnancy 6.14
Anaemia, iron deficiency 3.3
Anaemia, macrocytic or megaloblastic 3.5
Anal conditions 2.5
Anal fissures 2.5
Anaphylaxis 21.25
Angina pectoris, stable 4.7
Angina pectoris, unstable 21.18
Angina pectoris, unstable/Non ST elevation myocardial infarction (NSTEMI) 4.8
Angioedema 5.22
Animal bites 21.29
Antenatal care 6.8
Antenatal supplements 6.8
Antepartum depression 6.36
Antepartum haemorrhage 6.5
Antipsychotic adverse drug reactions 16.6
Antiretroviral therapy, adults 11.5
Antiseptics and disinfectants 10.2
Anxiety (palliative care) 22.4
Anxiety disorders 16.8
Aphthous ulcers 1.7
Aphthous ulcers (HIV-associated in adults) 11.13
Appendictis 2.7
Arthralgia 14.2
Arthritis, rheumatoid 14.3
Arthritis, septic 14.4
Athlete's foot - Tinea pedis 5.11
Bacterial infections of the skin 5.5
Balanitis/balanoposthitis (BAL) 12.11
Bells palsy 15.16
Benign prostatic hyperplasia (BPH) 8.12
Bipolar disorder 16.13
Bites and stings 21.29
Bleeding in pregnancy 6.3
Body lice 5.15
Boil, abscess 5.5
Bradycardia 21.9
Breakthrough bleeding with contraceptive use 7.13
Bubo 12.10
Burns 21.38
Candidiasis, oesophageal (HIV infection in children) 11.39
Candidiasis, oesophageal (HIV-associated in adults) 11.14
Candidiasis, oral (HIV-associated in adults) 11.14

li

 INDEX OF CONDITIONS

Candidiasis, oral (thrush) 1.3
Candidiasis, oral (thrush), recurrent (HIV-associated in children) 11.38
Candidiasis, skin 5.10
Cardiac arrest, adults 21.3
Cardiac arrest, cardiopulmonary resuscitation 4.12
Cardiac failure, congestive (CCF) 4.12
Cardiac failure, congestive (CCF), adults 4.12
Cardiac failure, congestive (CCF), children 4.15
Cardiopulmonary arrest– cardiopulmonary resuscitation 21.3
Cardiopulmonary arrest, children 21.6
Cardiovascular risk in diabetics 9,20
Care of the HIV-exposed infant 6.28
Care of the neonate 6.22
Care of the sick and small neonates 6.27
Caries, dental 1.3
Cellulitis 5.8
Chicken pox 10.3
Childhood immunisation schedule 13.3
Childhood malnutrition, including not frowing well 3.6
Cholera 2.7, 10.5
Chronic asthma 17.7
Chronic cancer pain 20.7, 22.8
Chronic hypertension, in pregnancy 6.11
Chronic kidney disease (CKD) 8.2
Chronic lower limb ulcers 5.9
Chronic non-cancer pain 20.5
Chronic obstructive pulmonary disease (COPD) 17.14
Chronic psychosis (Schizophrenia) 16.15
Common cold (viral rhinitis) 19.3
Common warts 5.28
Complicated SAM 3.6
Conditions with predominant wheeze 17.3
Conjunctivitis 18.2
Conjunctivitis of the newborn 18.4
Conjunctivitis, allergic 18.2
Conjunctivitis, bacterial (excluding conjunctivitis of the newborn) 18.3
Conjunctivitis, viral (pink eye) 18.6
Constipation 2.9
Constipation (palliative care) 22.2
Contraception, barrier methods 7.12
Contraception, emergency 7.12
Contraception, hormonal 7.5
Corneal ulcers 18.7
Cotrimoxazole prophylaxis in adults 11.12
Cracked nipples during breastfeeding 6.30
Croup (laryngotracheobronchitis) in children 17.16
Cryptococcal infection, pre-emptive therapy (HIV-associated in adults) 11.16
Cryptococcal meningitis 15.14
Cryptococcal meningitis (HIV-associated in adults) 11.16
Cryptococcosis (HIV-associated in adults) 11.15
Cystitis (pregnancy) 6.16
Delirium (palliative care) 22.6
Delirium with acute confusion and aggression in adults 21.18
Dementia 15.3
Dental abscess 1.2
Depression (palliative care) 22.7
Depressive disorders 16.11
Dermatitis, seborrhoeic 5.20
Developmental delay or deterioration (HIV-associated in children) 11.40
Diabetec emergencies 9.13
Diabetic foot ulcers 9.18
Diabetic nephropathy 9.19
Diabetic neuropathy 9.17
Diarrhoea 2.10
Diarrhoea (palliative care) 22.3
Diarrhoea, acute in children 2.10
Diarrhoea, acute, without blood, in adults 2.15
Diarrhoea, chronic, in adults 2.15
Diarrhoea, HIV-associated (HIV-associated in adults) 11.17
lii

 INDEX OF CONDITIONS

Diarrhoea, HIV-associated in children 11.39
Diarrhoea, persistent in children 2.14
Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) 5.26
Dry skin 5.3
Dysentery 2.16
Dysentery, bacillary 2.16, 10.5
Dyslipidaemia in diabetes 9.20
Dysmenorrhoea 6.40
Dyspepsia, heartburn and indigestion, in adults 2.3
Dyspnoea (palliative care) 22.8
Eclampsia 6.13
Ectopic pregnancy 6.3, 6.39
Eczema and dermatitis 5.17
Eczema, acute, moist or weeping 5.19
Eczema, atopic 5.17
Eczema, seborrhoeic (HIV-associated in adults) 11.17
End of life care 22.9
Enuresis 8.13
Epilepsy 15.5
Epistaxis 19.4
Erythema multiforme 5.25
Exposure to poisonous substances 21.43
Extra-pyramidal side effects 16.6
Eye injuries 18.7
Eye injury (blunt or penetrating) 18.9
Eye injury, chemical burn 18.7, 21.46
Eye injury, foreign body 18.8, 21.46
Febrile convulsions 15.10
Fever 10.5
Fixed drug eruptions 5.23
Fungal infections of the skin 5.10
Fungal nail infections (HIV-associated in adults) 11.17
Fungal skin infections (HIV-associated in adults) 11.17
Gastrointestinal conditions (palliative care) 22.2
Gastro-oesophageal reflux/disease in infants 2.4
Genital molluscum contagiosum (MC) 12.17
Genital ulcer syndrome (GUS) 12.9
Genital warts (GW) Condylomata Accuminata 5.30, 12.17
Gestational hypertension: mild to moderate 6.11
Gestational hypertension: severe 6.11
Giardiasis 10.7
Gingivitis and peirodontitis 1.4
Gingivitis, acute, necrotising, ulcerative (HIV-associated in adults) 11.18
Glaucoma, acute and closed angle 18.10
Glomerular diseases (GN) 8.6
Gout 14.5
Gout, acute 14.5
Gout, chronic 14.6
Gynaecology 6.39
Haematuria 8.12
Haemorrhoids 2.6
Head lice 5.14
Headache, mild, non-specific 15.14
Helminthic infestation 2.18
Helminthic infestation, excluding tapeworm 2.19
Helminthic infestation, tapeworm 2.18
Herpes simplex 5.28
Herpes simplex infections of the mouth and lips 1.7
Herpes simplex ulcers, chronic (HIV-associated in adults) 11.18
Herpes zoster (shingles) 5.28
Herpes zoster (shingles) (HIV-associated in adults) 11.18
Hidradenitis suppurativa 5.30
HIV and kidney disease (HIV-associated in adults) 11.20
HIV in pregnancy 6.31
HIV infection in adults 11.3
HIV infection in children 11.21
HIV prevention 11.41
Hormone therapy (HT) 6.41
Human bites 21.32
liii

 INDEX OF CONDITIONS

Hyperglycaemia and ketoacidosis 21.19
Hypertension 4.16
Hypertension emergency 4.24
Hypertension in adults 4.16
Hypertension in children 4.24
Hypertension in diabetes 9.21
Hypertensive disorders in pregnancy 6.10
Hyperthyroidism 9.23
Hyperthyroidism in adults 9.23
Hyperthyroidism in children and adolescents 9.23
Hypoglycaemia and hypoglycaemic coma 21.20
Hypoglycaemia in diabetics 9.13
Hypopigmentory disorders 5.31
Hypothyroidism 9.21
Hypothyroidism in adults 9.23
Hypothyroidism in children and adolescents 9.22
Hypothyroidism in neonates 9.21
Immune Reconstitution Inflammatory Syndrome (IRIS) 11.45
Immunisation schedule 13.2
Impetigo 5.7
Impotence/ erectile dysfunction 8.14
Influenza 17.18
Injectable contraception 7.9
Insect stings and spider bites 21.34
Intellectual disability 16.19
Intrapartum care 6.20
Intrauterine device/contraception (IUCD) 7.4
Introduction to contraception 7.2
Irritable bowel syndrome (IBS) 2.20
Isoniazid preventive therapy (IPT) in adults 11.13
Itching (pruritis) 5.3
Kidney disorders 8.2
Lactic acidosis 11.45
Lice (pediculosis) 5.14
Listeriosis 6.17
Lower abdominal pain (LAP) 12.6
Malaria 10.7
Malaria, non-severe/uncomplicated 10.9
Malaria, prophylaxis (self-provided care) 10.10
Malaria, severe (complicated) 10.9
Male urethritis syndrome (MUS) 12.7
Management of HIV-infected children 11.28
Management of incomplete miscarriage in the 1st trimester, at primary health care level 6.4
Management of suspected choking/foreign body aspiration in children 21.12
Management of termination of pregnancy at primary health care level: gestation ”12 6.7
weeks (and 0 days)
Mastitis 6.31
Maternal mental health 6.36, 16.20
Measles 10.11
Measles and chickenpox (HIV-associated in children) 11.39
Medical emergencies 21.15
Meningitis 10.13, 15.11
Meningococcal meningitis, prophylaxis 15.13
Microvascular complications of diabetes 9.17
Miscarriage 6.3
Missed pills 7.11
Moderate acute malnutrition (MAM) 3.9
Molluscum contagiosum 5.27
Mood disorders 16.10
Multidrug-resistant (MDR) TB, in adults 17.32
Multidrug-resistant (MDR) TB, in children 17.32
Multidrug-resistant tuberculosis (MDR TB) 17.32
Mumps 10.13
Myocardial infarction, acute (AMI) 21.18
Myocardial infarction, acute (AMI)/ST elevation myocardial infarction (STEMI) 4.10
Nail infections - Tinea unguium 5.12, 5.13
Nailfold and nail infections 5.13
Nappy rash 5.21
Nausea and vomiting (palliative care) 22.4
liv

 INDEX OF CONDITIONS

Nausea and vomiting, non-specific 2.4
Necrotising periodontitis 1.5
Neonatal resuscitation 6.23
Nephritic syndrome 8.7
Nephrotic syndrome 8.7
Neuroleptic malignant syndrome 16.7
Neuropathy 15.15
Neuropsychiatric conditions (palliative care) 22.4
Nose bleeds (epistaxis) 21.22
Not growing well (including failure to thrive/growth faltering) 3.10
Obesity in diabetes 9.20
Obstetrics 6.3
Older patients (• 45 years) 16.20
Open multi-dose vial policy 13.10
Opportunistic infections, prophylaxis in adults 11.12
Opportunistic infections, prophylaxis in children 11.38
Opportunistic infections, treatment in adults 11.13
Opportunistic infections, treatment in children 11.38
Oral contraception 7.10
Osteoarthrosis (osteoarthritis) 14.7
Other vaccines 13.11
Otitis 19.4
Otitis externa 19.4
Otitis media, acute 19.5
Otitis media, chronic, supparative 19.7
Overweight and obesity 3.13
Paediatric emergencies 21.15
Pain (palliative care) 22.8
Pain control 20.2
Painful red eye 18.11
Papular pruritic eruption (HIV-associated in adults) 11.19
Papular urticaria 5.24
Parasitic infestations of the skin 5.14
Paronychia, acute 5.13
Paronychia, chronic 5.13
Perianal abscesses 2.6
Perinatal transmission of hepatitis B 6.28
Periodontitis 1.5
Peripheral neuropathy 15.16
Pityriasis rosea 5.26
Pityriasis versicolor - Tinea versicolor 5.12
Plane warts 5.29
Plantar warts 5.29
Pneumocystis pneumonia 17.23
Pneumonia 17.19
Pneumonia (HIV-associated in children) 11..39
Pneumonia in adults 17.21
Pneumonia in adults with underlying medical conditions or > 65 years of age 17.22
Pneumonia in children 17.20
Pneumonia, bacterial (HIV-associated in adults) 11.19
Pneumonia, pneumocystis (HIV-associated in adults) 11.19
Post exposure prophylaxis (PEP) 11.44, 21.46
Post exposure prophylaxis, inadvertent non-occupational 21.56
Post exposure prophylaxis, occupational 21.46
Post exposure prophylaxis, rape and sexual assault 21.50
Post-herpes zoster neuropathy (post herpetic neuralgia) 15.15
Post-menopausal bleeding 6.40
Postpartum care 6.29
Postpartum depression 6.37
Postpartum haemorrhage (PPH) 6.29
Postpartum psychosis 6.37
Pre-eclampsia 6.12
Pre-exposure prophylaxis (PrEP) 11.41
Prelabour rupture of membranes at term (PROM) 6.19
Pressure ulcers/sores 5.32, 22.9
Preterm labour (PTL) 6.18
Preterm labour (PTL) and preterm prelabour rupture of membranes (PPROM) 6.18
Preterm prelabour rupture of membranes (PPROM) 6.19
Prevention of ischaemic heart disease and atherosclerosis 4.1
lv

 INDEX OF CONDITIONS

Prostate cancer 8.13
Prostatitis 8.11
Psoriasis 5.30
Psychiatric patients - general monitoring and care 16.17
Psychosis 16.14
Pubic lice 5.15, 12.17
Puerperal sepsis 6.30
Pulmonary oedema, acute 4.25, 21.22
Pulmonary tuberculosis (TB) 17.24
Pulmonary tuberculosis (TB), in adults 17.24
Pulmonary tuberculosis (TB), in children 17.26
Pyelonephritis 6.17
Rapid triage of the child presenting with acute conditions in clinics and CHCs 21.15
Renal calculi 8.14
Respiratory conditions (palliative care) 22.8
Respiratory infections 17.18
Rheumatic fever, acute 4.25
Ringworm - Tinea corporis 5.10
Ringworm and other Tineas 5.10
Routine care of neonate 6.22
Rubella (German measles) 10.14
Sandworm 5.17
Scabies 5.16
Scalp infections - Tinea capitis 5.12
Schistosomiasis (bilharzia) 10.15
Scrotal swelling (SSW) 12.8
Seizures (convulsions/fits) 15.4
Seizures and status epilepticus 21.27
Severe acute malnutrition (SAM) 3.6
Severe cutaneous adverse drug reactions 5.25
Severe hyperglycaemia (Diabetic ketoacidosis (DKA) & hyperosmolar hyperglycaemic 9.17
state (HHS))
Severe pneumonia 17.22
Sexual health and sexuality 16.20
Shingles (Herpes zoster) 10.16
Shock 21.23
Side effects and complications of ART 11.45
Sinusitis, acute, bacterial 19.8
Skin conditions (HIV-associated in children) 11.39
Snakebites 21.35
Soft tissue injuries 21.56
Special considerations 16.19
Sprains and strains 21.60
Status epilepticus 15.5
Stevens-Johnson syndrome (SJS)/ Toxic Epidermal Necrolysis (TEN) 5.25
Stridor 17.16
Stroke 15.2
Structural abnormalities of the eye 18.11
Subdermal implant 7.5
Substance misuse 16.20
Substance use disorders 16.20
Substance-induced mood disorder 16.21
Substance-induced psychosis 16.22
Suicide risk assessment 16.18
Syphilis in pregnancy 6.15
Syphilis serology and treatment 12.12
Tachydysrhythmias 21.11
Teething, infant 1.8
Termination of pregnancy (TOP) 6.6
The cold chain 13.9
The HIV exposed Infant 11.24
Tick Bite Fever 10.17
Tonsillitis and pharyngitis 19.9
Toxoplasmosis (HIV-associated in adults) 11.19
Trauma and injuries 21.29
Treatment of more than one STI Syndrome 12.14
Treatment of partners (STI) 12.15
Tuberculosis (TB) 10.19
Tuberculosis (TB) chemoprophylaxis/Isoniazid preventive therapy (IPT) in adults 17.25
lvi

 INDEX OF CONDITIONS

Tuberculosis (TB) chemoprophylaxis/Isoniazid preventive therapy (IPT) in children 17.27
Tuberculosis (TB) Control Programme: medicine regimens in adults 17.26
Tuberculosis (TB) Control Programme: medicine regimens in children 17.28
Tuberculosis (TB) (HIV-associated in adults) 11.20
Tuberculosis (TB) (HIV-associated in children) 11.39
Tuberculosis (TB), HIV and AIDS 17.31
Tuberculosis, extrapulmonary 10.19
Type 1 Diabetes mellitus 9.2
Type 1 Diabetes mellitus, in adults 9.3
Type 1 Diabetes mellitus, in children & adolescents 9.2
Type 2 Diabetes mellitus 9.5
Type 2 Diabetes mellitus, adults 9.6
Type 2 Diabetes mellitus, in adolescents 9.5
Typhoid fever 2.21, 10.19
Uncompliated SAM 3.8
Uncomplicated gingivitis 1.4
Uncomplicated pneumonia 17.21
Urinary tract infection (UTI) 8.8
Urinary tract infection, in pregnancy 6.16
Urology disorders 8.12
Urticaria 5.22
Vaccines for routine administration 13.5
Vaginal bleeding 6.39
Vaginal discharge syndrome (VDS) 12.4
Vaginal discharge syndrome (VDS): Sexually active women 12.5
Vaginal discharge syndrome (VDS): Sexually non-active women 12.4
Vaginal discharge/ lower abdominal pain in women 6.43
Vaginal ulcers 6.43
Valvular heart disease and congenital structrual heart disease 4.27
Viral haemorrhagic fever (VHF) 10.20
Visual problems 18.12
Vitamin A deficiency 3.13
Vitamin B deficiencies 3.15
Vitamin B1/Thiamine deficiency (Wernicke enchepalopathy and beriberi) 3.17
Vitamin B3/Nicotinic acid deficiency (pellagra) 3.15
Vitamin B6/Pyridoxine deficiency 3.16
Vitiligo 5.32
Voluntary sterilisation, male and female 7.13
Warts 5.28


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19.5 19.5
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2 0 k g 2 0 k g 2 0 k g 18.5 18.5
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7.5 7.5
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7.5 7.5
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