Gastrointestinal Infections

Nystatin oral suspension 100,000U (1mL) PO QID after food. Place under the tongue or in the buccal cavity then swallow.

Duration:

Treat for 7-14 days or until several days after symptoms have resolved.

See Candida Oesophagitis in Chapter 9: Gastrointestinal infections, Cutaneous Candidiasis in Chapter 13: Skin and Soft Tissue Infection and Vulvovaginal Candidiasis in Chapter 17: Women’s Health

For asymptomatic patients who are not immunocompromised:

Nystatin tablet 500,000U PO QID

OR

Nystatin oral suspension 100,000U (1mL) PO QID

For symptomatic or immunocompromised patients:

Fluconazole 200mg for first dose (child 6mg/kg), followed by 100mg daily (child 3mg/kg)

Duration:

For asymptomatic patients who are not immunocompromised: Treat for 10-14 days
For symptomatic or immunocompromised patients: Treat for 14-21 days. For refractory infection: Extend treatment to 28 days

See Oral thrush (Candidiasis) in Chapter 9: Gastrointestinal infections, Cutaneous Candidiasis in Chapter 13: Skin and Soft Tissue Infection, and Vulvovaginal Candidiasis in Chapter 17: Women’s Health

Most diarrhoeal disease does not require antibiotic therapy.

The major concern with diarrhoea is a rapid loss of fluid and risk of dehydration. Oral and/ or intravenous rehydration is usually all that is required.

In acute diarrhea send stool for rotavirus testing. Stool cultures should be reserved for grossly bloody stool, severe dehydration, signs of inflammatory disease, symptoms lasting more than 3-7 days, immunosuppression, and suspected nosocomial infections. Blood cultures should be obtained from infants <3 months of age, people of any age with signs of septicemia or when enteric fever is suspected, people with systemic manifestations of infection, and in people who are immunocompromised.

Ceftriaxone 2g (child: 50mg/kg) IV OD

PLUS

Metronidazole 500mg (child: 10mg/kg) PO/ IV TID

Change to oral antibiotics when improving according to susceptibility testing. If no susceptibilities available use:

Co-trimoxazole 160/800mg (child: 4+20mg/ kg) PO BID

PLUS

Metronidazole 500mg (child: 10mg/kg) PO TID

Alternative:

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

Send stool for microscopy (including ova, cysts and parasites), culture and susceptibility testing.

Rehydration and electrolyte replacement are the most important component of treatment.

Duration:

Treat for 3-5 days

If enteric fever is suspected or confirmed See Typhoid (enteric fever) in Chapter 9: Gastrointestinal Infections.
If intestinal amoebiasis is suspected see Intestinal Amoebiasis in Chapter 9: Gastrointestinal Infections.

Metronidazole 500mg (child: 10mg/kg) PO TID

Currently luminal amoebicides to eliminate cysts in the colon are not available on the Timor-Leste essential drugs list (e.g. Paromomycin, Diloxanide). The risk of relapse is increased without their use.

Duration:

Metronidazole: Treat for 7-10 days

Amoebic:

Metronidazole 500mg (child: 10mg/kg) PO/ IV TID

Bacterial:

Ceftriaxone 2g (child: 50mg/kg) IV OD

PLUS

Metronidazole 500mg (child: 10mg/kg) PO/ IV TID

Change to oral antibiotics after 2 weeks. If susceptibilities are not available use: Amoxicillin/Clavulanic acid 500/125mg (child 25/6.25 mg/kg) PO TID

Blood cultures should be collected in all patients with liver abscess, prior to antibiotics where possible. If abscess is drained, send pus for culture. Ultrasound or CT is required for diagnosis.

Duration:

Amoebic: Treat for 7-10 days
Bacterial: Change to oral antibiotics after 2 weeks if patient is well. Treat for a total of 6 weeks.

Currently luminal amoebicides to eliminate cysts in the colon (e.g. paromomycin) are not on the Timor-Leste essential drugs list. The risk of relapse is increased without their use.

Metronidazole 500mg (child: 10mg/kg) PO TID

Duration:

Metronidazole: Treat for 5-7 days.

For immunocompetent patients:

Albendazole 400mg (child ≤10kg 200mg) PO BID for 3 days. Repeat after 7 days

Alternative (for adult or child >15kg):

Ivermectin 200mcg/kg PO with fatty food for 1 dose. Repeat 7 days later.

For immunocompromised patients with uncomplicated disease:

Ivermectin (adult and child >15kg) 200mcg/kg PO with fatty food on days 1, 2, 15 and 16.

For patients with disseminated Strongyloidiasis:

Ivermectin (adult and child >15kg) 200mcg/kg PO with fatty food daily until symptoms resolve and stool or sputum microscopy demonstrates clearance of larvae.

Followed by:

Ivermectin on days 7 and 8 after completion of daily therapy.

Diagnosis of Strongyloides depends on microscopic identification of larvae in the stool, or in sputum in disseminated infection. The diagnosis may be supported by the presence of eosinophilia in the blood.

Disseminated Strongyloidiasis occurs when patients with chronic Strongyloidiasis become immunosuppressed. This can be rapidly fatal. For patients with disseminated Strongyloidiasis reduce immunosuppression if possible.

Ivermectin should not be given to children <15kg and should not be used in pregnancy. Round up doses to the nearest 1.5mg.

Cease other antibiotics if possible.

If Clostridium difficile is confirmed or strongly suspected use:

Metronidazole 500mg (child: 10mg/kg) PO BID

For recurrent or refractory Clostridium difficile:

Vancomycin 125mg (child 10mg/kg) PO, QID (IV formulations of vancomycin can be given orally for this indication)

Send stool for culture and specifically request Clostridium difficile testing.

Duration:

Treat Clostridium difficile infections for 10 days.

Ceftriaxone 2g (child: 50mg/kg) IV OD

Alternative:

Azithromycin 1g (child 20mg/kg) PO OD

Step down to oral antibiotics when well according to susceptibilities. If susceptibility results are not available use:

Azithromycin 1g (child 20mg/kg) PO OD

OR

Ciprofloxacin 500mg (child 12.5mg/kg) PO BID

Send blood cultures prior to antibiotics. Send stool culture.

Duration:

Change to oral antibiotics when improving. Treat for a total of 7-10 days.

Optimum therapy if available:

Omeprazole 20mg PO BID

PLUS

Amoxicillin 1g PO BID

PLUS

Clarithromycin 500mg PO BID

Alternative:

Omeprazole 20mg PO BID

PLUS

Amoxicillin 1gram PO BID

PLUS

Metronidazole 500mg PO BID

All patient with a duodenal ulcer, proven H. pylori peptic ulcers or with MALT should be treated.

Duration:

Treat for 10-14 days

Tenofovir dipovoxil fumarate (TDF) 300 mg PO OD

Perform creatinine clearance at baseline.
Perform creatinine clearance, serum phosphate, urine glucose, and protein at least annually.

Test all patients for HIV.
Patients with concurrent HIV should be treated with an anti-retroviral regime with activity against HBV.

Ceftriaxone 2g (child 50mg/kg) IV OD

Alternative:

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

Take blood cultures. Perform ascitic tap and send fluid for chemistry, cell count and culture (fluid for culture should be injected into blood culture bottles to increase yield). Request AFB and GeneXpert if TB peritonitis is suspected.

Change antibiotics according to culture and susceptibility results.

Duration:

If there is rapid clinical improvement stop antibiotics after 5 days.

See Cirrhosis, antibiotic prophylaxis in Chapter 1: Antibiotic prophylaxis for prophylaxis following first episode of SBP in patients with cirrhosis.