TROPICAL AND OTHER INFECTIONS

Malaria : Refer to National Guidelines (National Malaria Treatment Protocol 2019)

SEXUALLY TRANSMITTED INFECTIONS:

Refer to National Guidelines (National Guidelines on Management of Sexually Transmitted Infections 2022)

TUBERCULOSIS IN ADULTS:

Refer to National Guidelines (National Tuberculosis Management Guidelines 2019)

Typhoid fever

Infection/Condition and Likely Organism	Suggested Treatment				Comments
	Preferred Treatment			Alternative Treatment
Salmonella Typhi and Salmonella Paratyphi
Uncomplicated enteric fever
Empirical antibiotic	Cefixime 20 mg/kg/day PO for 7-14 days			Azithromycin 1g PO stat on D1 followed by 500mg q24h for total of 5-7 days	Send Blood Culture/ Standard sample 10ml
Fully susceptible	Amoxicillin 1g q8h PO for 7-14 days OR Trimethoprim-sulfamethoxazole DS q12h for 7-14 days			Chloramphenicol 500mg PO q6h for 14 days OR Azithromycin 1g PO stat on D1 followed by 500mg q24h for total of 5-7 days OR Cefixime 20mg/kg/day PO for 7-14 days	Based on C/S reports.
*Multidrug resistant	Ciprofloxacin 500mg PO q12h for 7 days (or 400mg IV q12h)			Cefixime 20mg/kg/day PO for 7-14 days or Azithromycin 20mg/kg/day PO for 7 days	Resistant to Chloramphenicol, Amoxicillin and Trimethoprim-sulfamethoxazole
Quinolones resistant	Azithromycin 20 mg/kg/day PO for 7 days
Extensively drug resistant	Azithromycin 20 mg/kg/day PO for 7 days
Complicated/Severe
Empirical antibiotic		Ceftriaxone 50-75 mg/kg/ day IV for 10-14 days			Modify therapy based on C/S data. *Once improvement – switch to oral.
Fully susceptible		Ciprofloxacin 400mg IV q12 for 10-14 days (or 500mg PO q12h)	Ceftriaxone 50-75 mg/kg/day IV for 10-14 days		Modify therapy based on C/S data. *Once improvement – switch to oral.
Multidrug resistant		Ciprofloxacin 400mg IV q12 for 10-14 days (or 500mg PO q12h)	Ceftriaxone 50-75mg/kg/day IV for 10-14 days		Modify therapy based on C/S data. *Once improvement – switch to oral.
Quinolones resistant		Ceftriaxone 50-75mg/kg/ day IV for 10-14 days	Azithromycin 20 mg/kg/day* IV/PO for 10-14 days		Modify therapy based on C/S data. *Once improvement – switch to oral.
Extensively drug resistant		Meropenem 60mg/kg/day IV for 10-14 days	Azithromycin 20 mg/kg/day* IV/PO for 10-14 days		Modify therapy based on C/S data. *Once improvement – switch to oral.
Bowel perforation/ Septic shock/ Mycotic aneurysm		Meropenem 60mg/kg/day IV in 3 divided doses for 10-14 days

Cholera

Infection/Condition and Likely Organism	Suggested Treatment		Comments
	Preferred Treatment	Alternative Treatment
Vibrio cholerae
Tetracycline susceptible	Doxycycline 300mg PO stat	Ciprofloxacin 1gm PO stat	Oral or intravenous hydration is the mainstay of cholera treatment. Antibiotics is recommended for severely ill patients, who are severely or moderately dehydrated and continue to pass a large volume of stool during rehydration treatment, hospitalized patient and moderate to severe cases. *Azithromycin/ Erythromycin: Recommended alternative for pregnant woman.
Tetracycline resistant	*Azithromycin 1gm PO stat	Ciprofloxacin 1gm PO stat

Scrub typhus

Infection/Condition and Likely Organism	Suggested Treatment		Comments
Infection/Condition and Likely Organism	Preferred Treatment	Alternative Treatment	Comments
Orientia tsutsugamushi
Uncomplicated	Doxycycline 100mg PO q12h for 7 days	*Azithromycin 500mg PO stat	*Azithromycin: Recommended for pregnant woman.
Complicated (ARDS, septic shock, myocarditis, meningoencephalitis, hepatitis, renal failure)	*Azithromycin 500mg IV q24h for 5 days (500mg IV q12h on D1 then q24h)	If not responding to Azithromycin: Rifampicin 600mg PO q24h for 5 days	*Recommend for early IV to Oral switch once symptoms improve or stable.

Brucellosis

Infection/Condition and Likely Organism	Suggested Treatment		Comments
Infection/Condition and Likely Organism	Preferred Treatment	Alternative Treatment	Comments
Brucella melitensis, Brucella abortus, Brucella suis, Brucella canis
Non focal disease	Doxycycline 100mg PO q12h for 6 weeks PLUS Gentamicin 5mg/kg/24h IV for 7 days	Doxycycline 100mg PO q12h for 6 weeks PLUS Rifampicin 600-900mg (15mg/kg) PO q24h for 6 weeks
Spondylitis/Sacroiliitis	Doxycycline 100mg PO q12h for ≥ 12 weeks PLUS Gentamicin 5mg/kg/24h IV for 7 days PLUS Rifampicin 600-900mg (15mg/kg) PO q24h for ≥ 12 weeks
Neurobrucellosis	Doxycycline 100mg PO q12h* PLUS Rifampicin 600-900mg (15mg/kg) PO q24h* PLUS Ceftriaxone 2gm IV q12h**		At least 6 weeks. * Until CSF returns to normal.
Endocarditis	Rifampicin 600-900mg PO q24h PLUS Doxycycline 100mg PO q12h PLUS Trimethoprim-sulfamethoxazole 160/800mg PO q12h PLUS Gentamicin 5mg/kg/24h IV for 2-4 weeks		Duration: 45 days to 6 months. Surgery needed.
Pregnancy*	Rifampicin 600-900mg (15mg/kg) PO q24h for 6 weeks	Rifampicin 600-900mg (15mg/kg) PO q24h for 4 weeks PLUS Trimethoprim-sulfamethoxazole 160/800mg PO q12h for 4 weeks	*Not much data.

Leptospirosis

Infection/Condition and Likely Organism	Suggested Treatment		Comments
Infection/Condition and Likely Organism	Preferred Treatment	Alternative Treatment	Comments
Leptospira spp.
Mild to Moderate disease	Doxycycline 100mg PO q12h for 5-7 days	Azithromycin 500mg PO q24h for 3 days
Severe disease (Leptospiral pulmonary syndrome, multiorgan involvement, sepsis)	Ceftriaxone 2gm IV q24h for 7 days (to deescalate to Benzylpenicillin once symptoms improve/ stable) OR Benzylpenicillin 1.5MU IV q6h for 7 days		May consider Methylprednisolone 500-1000mg IV for 3 days if pulmonary hemorrhage present. However, there is insufficient evidence to support the routine use of corticosteroid.

Tetanus

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred Treatment

Alternative Treatment

Causative organism Clostridium tetani

Metronidazole 500mg IV q6-8h for 7-10 days

PLUS

Human Tetanus Immunoglobulin 3000- 6000IU IM stat

PLUS

Tetanus toxoid vaccine IM (initiate age appropriate active immunization at a different site)

Benzylpenicillin 100,000-200,000 unit/kg/24h IV q6h for 7-10 days

PLUS

Human Tetanus Immunoglobulin 3000-6000IU IM stat

PLUS

Anti-toxoid vaccine IM (initiate age appropriate active immunization at a different site)

Human Tetanus

Immunoglobulin 500IU might be as effective as higher doses of 3,000 to 6,000IU and causes less discomfort.

All patients with tetanus should undergo wound debridement to eradicate spores and necrotic tissue.

Melioidosis

Infection/Condition and Likely Organism	Suggested Treatment		Comments
Infection/Condition and Likely Organism	Preferred Treatment	Alternative Treatment	Comments
Bukholderia pseudomallei
Intensive Therapy (Uncomplicated)	Ceftazidime 100-120mg/ kg/24h IV q6-8h (in children) Adults: 2gm IV q6h for 10-14 days PLUS *Trimethoprim-sulfamethoxazole (Dose as per eradication therapy below)		*Add on Trimethoprim-sulfamethoxazole in eye, neurologic, testicular, prostatic, pericardium, bone and joint melioidosis. Drainage of abscesses should be attempted wherever appropriate such as pericardial and prostatic abscess, and empyema. Duration of intensive therapy: Skin, bacteraemia with no foci, mild pneumonia: 2 weeks Complicated pneumonia, prostatic, deep-seated foci, septic arthritis: 4 weeks Osteomyelitis: 6 weeks Neurologic/CNS: 8 weeks To use clinical judgement to guide prolongation of intensive phase if improvement is slow/ persistent bacteraemia.
Intensive Therapy (Complicated) (Severe melioidosis or neuromelioidosis)	Meropenem 75mg/kg/24h IV q8h (usual dose: 1gm IV q8h; if neurologic, 2gm IV q8h) OR Imipenem 50mg/kg/24h IV q6h (usual dose: 500-1000mg q6h) PLUS *Trimethoprim-sulfamethoxazole (Dose as per eradication therapy below)
Eradication/Maintenance Therapy	Trimethoprim-sulfamethoxazole <40 kg: 160/800mg PO q12h 40-60kg: 240/1200mg PO q12h >60kg: 320/1600mg PO q12h	For children < 8 years Amoxicillin-clavulanate <60kg: 1250mg (2 tabs of 625mg) PO q8h >60kg: 1875mg (3 tabs of 625mg) PO q8h	Duration of eradication therapy: Osteomyelitis, Neurologic/CNS: 24 weeks Others: minimum 12 weeks

References

Basnyat B. Qamar FN, Rupali P, Ahmed T. Clinical update. Enteric Fever. BMJ 2021.
Antibiotic Treatment in Cholera. 2015.
Tetanus, Clinical information for clinicians. 2017.
Currie B. Melioidosis: The 2014 Revised RDH Guideline. The Northern Territory Disease Control Bulletin. 2014;21(2): 4-8.
Kim YS et al. A comparative trial of single dose Azithromycin vs Doxycycline for treatment old mild scrub typhus. CID.2004; 39(9):1329-35.
National Antimicrobial Guideline, Third Edition. Petaling Jaya: Ministry of Health, Malaysia; 2019.
National Malaria Treatment Protocol 2019. Epidemiology and Disease Control Division. Department of Health Science. Teku, Kathmandu.
Recommendations for clinical management of cholera. November 2010.
Phimda K, et al. Doxycycline vs Azithromycin for treatment of leptospirosis and scrub typhus. Antimicrob Agents Chemother. 2007;51(9):3259-63.
Rahi M, et al.DHR-ICMR Guidelines for Diagnosis and Management of Rickettsial Diseases in India. Indian J Med Res. 2015;141(4):417-22.
Brucellosis in humans and animals. 2006.
Current recommendations for treatment of tetanus. 2010.
Leptospirosis. 2013.
The diagnosis, treatment and prevention of typhoid fever. 2003.
Currie B. Melioidosis: The 2014 Revised RDH Guideline. The Northern Territory Disease Control Bulletin 2014;21(2).