Other

For patients with:

• At least 3 doses of tetanus toxoid vaccine AND
• Last vaccine was given within 5 years

No prophylaxis required

For patients with:

• Unknown vaccination status OR
• Less than 3 doses of vaccine OR
• Last vaccine over 5 years ago

Give Tetanus toxoid vaccine

For patients who present with anything other than a minor, clean wound AND with:

• Unknown vaccination status OR
• Less than 3 doses of vaccine

Give tetanus immunoglobulin 250 IU if <24 hours since injury, 500 IU if >24 hours since injury (if this is available), IN ADDITION to tetanus toxoid vaccine.

For treatment see Tetanus in Special Infections.

Benzathine Penicillin 1.2 million IU (900mg) (child <20kg 0.6 million IU (450mg)) IM for 1 dose every 28 days.

In patients with severe RHD PLUS severe pulmonary hypertension or uncontrolled heart failure use:

Penicillin V 250mg (child 15mg/kg) PO BID

OR

Amoxicillin 500mg for >20kg, 250mg <250mg PO OD

Alternative:

Erythromycin 250mg PO BID

(Oral therapy can also be used in patients where IM therapy is not possible, however this is not the preferred route).

See also Timor-Leste Guidelines for the Prevention and Management of Acute Rheumatic Fever (ARF) and Rheumatic Heart Disease (RHD) 2021

Duration:

No cardiac valve involvement: Treat for a minimum of 5 years or until age 21 (whichever is longer).

Mild cardiac valve involvement: Treat for a minimum of 10 years or until age 25 (whichever is longer).

Moderate cardiac valve involvement: Treat for a minimum of 10 years or until age 40 (whichever is longer).

Severe cardiac valve involvement: Continue prophylaxis for life.

See Pharyngitis / Tonsilitis in ENT/Respiratory Infections for treatment of Streptoccocus pyogenes sore throat (primary prevention of ARF).

When infective endocarditis prophylaxis is indicated, it should be given in addition to usual recommended surgical prophylaxis.

For dental procedures:

Amoxicillin 2g (child 50mg/kg) PO, 1 hour before procedure.

For other procedures:

Ampicillin 2g (child 50mg/kg) IV within the 60 minutes prior to procedure.

Alternative:

Cefazolin 2 g (child 30mg/kg) IV

OR

Clindamycin 600mg (child 20mg/kg) IV

OR

Vancomycin 15mg/kg

High risk procedures include:

• Dental procedures involving manipulation of gingival or periapical tissue, or perforation of the oral mucosa (e.g. Extraction, implant placement, biopsy, removal of soft tissue or bone, subgingival scaling, and root planing, replanting avulsed teeth)
• Skin and musculoskeletal procedures involving infected skin, skin structures or musculoskeletal tissue.
• Respiratory tract and ENT procedures tonsillectomy, adenoidectomy; invasive respiratory tract or ENT procedures to treat an established infection (e.g. abscess drainage)
• GIT and GUT procedures if usual surgical prophylaxis is indicated for patients with an established infection.

High risk cardiac conditions include:

• Rheumatic heart disease
• Prosthetic heart valve or other prosthetic cardiac material
• Previous infective endocarditis

Unrepaired cyanotic congenital heart disease

See Cardiovascular Infections for treatment of infective endocarditis

Variceal bleeding:

Ceftriaxone 1g IV OD

Alternative:

Ciprofloxacin 400mg PO BID

Spontaneous Bacterial Peritonitis (after first episode of SBP):

Cotrimoxazole 160/800mg PO OD

Duration:

Variceal bleeding: Treat for 3-7 days
Spontaneous Bacterial Peritonitis: Continue lifelong if tolerated.

See Spontaneous bacterial peritonitis in Gastrointestinal infections for treatment.

Amoxicillin 250mg (child: 15mg/kg) PO OD

All patients should have an emergency supply of antibiotics to begin taking immediately at home when they become unwell with fever, and be reviewed as soon as possible by a doctor.

In the event of a sudden onset of unexplained fever use:

Adult:

Amoxicillin 3g PO for 1 dose then 1g TID until review.

Child:

Amoxicillin/Clavulanic acid 25/6.25 mg/kg (max 500/125mg) PO TID until review.

Duration:

Children with congenital haemoglobinopathies (e.g. thalassaemia) should remain on prophylaxis at least until the age of 5.
Post splenectomy patients should receive prophylaxis for at least 3 years. Consider lifelong prophylaxis in the following:

• Immunocompromised patients
• Patients with haematological malignancy

Patients who have experienced significant post-splenectomy infection (particularly with Streptococcus pneumoniae).

Ciprofloxacin 500mg (child 10mg/kg) PO BID

PLUS

Fluconazole 200 mg (child 6-12mg/kg) PO OD

Duration:

Continue for duration of expected neutropaenia.

Indications in Timor-Leste:

• ≥ 20mg prednisone (or equivalent corticosteroid) for more than 4 weeks
• Acute lymphocytic leukaemia
• HIV with CD4 count <350 cells/microlitre or CD4 percentage <14%.

Co-trimoxazole 160 / 800mg (child 3-5kg 20/100mg, 6-13kg 40/200mg, 14-30kg 80/400mg) PO OD daily or BID three times a week

Duration:

Corticosteroids: Continue for 6 weeks after steroid dose is reduced below 20mg of prednisone (or equivalent), then cease.
HIV: Stop when on ART AND CD4 count >350 cells/microlitre for 6 months.

See Pneumocystis jirovecii (PJP) in Special Infections for treatment.

Start when CD4 count is <100 cells/microlitre.

Co-trimoxazole 160 / 800mg (child 3-5kg 20/100mg, 6-13kg 40/200mg, 14-30kg 80/400mg) PO OD daily or BID three times a week