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Suspect in patients with headache, fevers, elevated transaminases, thrombocytopaenia and leukocytosis. Examine for eschar, painful lymphadenopathy, and rash.
Antimicrobial
Doxycycline 100mg (child 2mg/kg) PO BID
Alternative:
Azithromycin 500mg (child 10mg/kg) on day 1, then 250mg (child 5 mg/kg) for a further 4 days
Comments and Duration of Therapy
Duration:
Treat with doxycycline for 7 days
Caused by Plasmodium parasites and spread by the female Anopheles mosquito. Usually presents as a febrile illness and can range from a mild illness to severe disease with cerebral involvement or multiorgan failure.
Treat as severe malaria if any of the following features:
Antimicrobial
Mild to Moderate:
Artemether/Lumefantrine (Coartem) 20/120mg PO
5-14kg: 1 tablet per dose
15-24kg: 2 tablets per dose
25-34kg: 3 tablets per dose
>34kg: 4 tablets per dose
Give at 0, 8, 24, 36, 48 and 60 hours for a total of 6 doses
Severe:
Artesunate 2.4mg/kg IV/IM 12 hourly for 3 doses then 24 hourly for 2 more doses.
Alternative:
Quinine 20mg/kg in IV fluid infused over 4hrs. Then 8 hours after initial dose was started give 10mg/kg Quinine in IV fluid over 2hrs and repeat 8 hourly for a total of 7 days antibiotic therapy.
Comments and Duration of Therapy
Send blood for antigen testing, PCR, and thick and thin films to confirm diagnosis.
Refer to the Timor-Leste Malaria Guidelines for further advice.
See Neonatal Malaria in Chapter 11: Paediatric Infections (Neonates, Infants and Children)
Clostridium tetani inoculation of a dirty wound causes disease by toxin production. After infection of a wound the incubation period of Tetanus is usually around 1 week but ranges from 1 day to 2 months. Many patients may not remember the wound, so this should not put clinicians off the diagnosis.
Generalised tetanospasm is the most common presentation; symptoms usually begin with trismus and progresses to involve the rest of the muscles of the body. Disease may take weeks to resolve.
Antimicrobial
Clean and debride all contaminated wounds early and thoroughly.
To halt further production of toxin use antibiotics to treat C. tetani:
Metronidazole 500mg (child 12.5mg/kg) IV/PO BID
Alternative:
Benzylpenicillin 3 million IU (1.8g) (child 80 000 IU (50mg)/kg) IV QID
OR
Ampicillin 2g (child 50mg/kg) IV Q4H
To neutralise toxin already in circulation use:
Human antitoxin 500-3000U IM if available
To reduce muscle spasm and distress:
Diazepam 5-20 mg PO/IV TID (doses up to 20mg Q2H may be required) (neonates 2 mg IV TID). At high doses (80 mg/24h) monitor for respiratory suppression
To reduce autonomic dysfunction and muscle spasm:
Magnesium sulphate 5g (child 75mg/kg) IV loading dose, then 2-3g/hr IV infusion until spasm controlled. Monitor patellar reflexes and if areflexia occurs decrease dose.
Comments and Duration of Therapy
All patients will need vaccination against Tetanus. Tetanus infection does NOT confer immunity.
Nurse patients in a calm, dim, quiet environment (movement, wind, bright lights, or emotional distress can all trigger spasms).
The anxiolytic activity of Diazepam is useful in this very distressing disease, but its antispasmodic activity is even more important.
Only use Magnesium sulphate IV and Diazepam IV in a controlled hospital environment with access to respiratory support if required.
Duration:
Treat with antibiotics for 7-10 days.
See Tetanus prophylaxis in Chapter 1: Antibiotic Prophylaxis
Caused by primary infection with the Varicella Zoster virus. Most commonly contracted in childhood but can occur in adulthood when it is more likely to cause severe disease. Usually presents with a pruritic, vesicular rash which later crusts. Most patients do not require treatment.
Antimicrobial
Treat all patients with severe disease, complicated disease (e.g. pneumonitis, encephalitis, or hepatitis) or who are immunocompromised. Treat pregnant women if they present within 72 hours of rash onset.
Acyclovir 800 mg (child: 20 mg/kg) PO 5 times daily
Comments and Duration of Therapy
Patient should stay away from anyone immunocompromised or pregnant while they are infectious.
Duration:
Treat for 7-14 days
See Neonatal Varicella Zoster Virus Prophylaxis / Treatment in Chapter 11: Paediatric Infections (Neonatesm Infants and Children), and Herpes Zoster in Chapter 13: Skin and Soft Tissue Infection
ART is recommended for all patients with HIV. In patients with newly diagnosed HIV exclude other infections before commencing ART to reduce the risk of immune reconstitution inflammatory syndrome (IRIS). For patients without opportunistic infections start ART as soon as possible.
IRIS is an inflammatory reaction to latent or subclinical infection with organisms such as Mycobacterium avium complex, TB, or Cryptococcus. IRIS can occur after starting ART especially when CD4 count < 100 cells / microlitre.
See Timor-Leste Comprehensive ART Guidelines.
Refer all patients to HIV team.
Seek Infectious Diseases review where available.
Antimicrobial
Consider prophylaxis for the following opportunistic infections:
Investigate for active TB in all patients with HIV. Consider treatment for latent TB if there is no evidence of active disease. If CXR and sputum testing are unavailable begin latent TB treatment in patients who DO NOT have fever, night sweats, weight loss, or cough of >2 weeks’ duration. See Timor-Leste Comprehensive TB Guidelines for National Tuberculosis Control Program
In most patients with HIV and active TB, start ART within 2 weeks of commencement of TB treatment. In patients with HIV and TB meningitis delay ART for 8 weeks after commencement of TB treatment.
Comments and Duration of Therapy
Perform the following prior to commencing ART if available:
If patient is symptomatic, consider the following where available:
Screen all patient with HIV for other STIs including syphilis. See Chapter 8: Genital Infection.
See Cryptococcal Meningitis in Chapter 4: Central Nervous System Infections, Tuberculosis (TB) in Chapter 6: ENT / Respiratory Tract Infections, Candida Oesophagitis in Chapter 9: Gastrointestinal Infections, Neonatal HIV prophylaxis in Chapter 11: Paediatric Infections (Neonates, Infants and Children), Pneumocystis jirovecii (PJP) in Chapter 14: Special Infections, Toxoplasma gondii in Chapter 14: Special Infections, Mycobacterium avium complex (MAC) in Chapter 14: Special Infections
Pneumocystis jirovecii usually causes pneumonia in immunocompromised patients. Suspect PJP in immunocompromised patients with fever, dry cough, dyspnoea and hypoxia progressing over days to weeks, who fail to respond to empiric treatment for CAP. Note that CXR may be normal in 50% of cases.
See Timor-Leste Comprehensive ART Guidelines.
Antimicrobial
Co-trimoxazole 5+25mg/kg (adult and child > 1 month) up to 480mg+2400mg, PO TID
In high severity PJP ADD:
Prednisone 40mg (child 1mg/kg) PO BID for 5 days
Followed by:
Prednisone 40mg (child 1mg/kg) OD for 5 days
Followed by:
Prednisone 20mg (child 0.5mg/kg) OD for 11 days
Followed by:
Prednisone wean to cessation.
Comments and Duration of Therapy
PJP is considered high severity if either of the following are present:
For patients with HIV and PJP who have no other opportunistic infections start ART within 2 weeks of diagnosis.
Duration:
Treat for 21 days. After this change to PJP prophylaxis. See Pneumocystis jirovecii (PJP) Prophylaxis in Chapter 1: Antibiotic Prophylaxis.
Toxoplasmosis encephalitis presents as multiple ring-enhancing lesions in immunocompromised patients. It is the most common CNS infection in patients with advanced HIV who are not receiving prophylaxis.
Seek Infectious Diseases review where available.
Antimicrobial
Co-trimoxazole 5+25 mg/kg up to 480 + 2400mg, PO BID for 6 weeks.
Followed by:
Co-trimoxazole 160 / 800mg PO BID
Consider corticosteroids if there is mass effect or oedema relating to brain lesions.
Comments and Duration of Therapy
Suspect toxoplasmosis encephalitis in patients with HIV if ALL of the following are present:
Consider alternative diagnosis if there is no clinical or radiological improvement within 10-14 days of commencing treatment.
For patients with HIV and toxoplasmosis who have no other opportunistic infections start ART within 2 weeks of diagnosis. Monitor for symptoms and signs of IRIS.
Duration:
Continue until CD4 > 200 cells/microlitre for at least 6 months.
See Prophylaxis of Toxoplasma gondii in patients with HIV in Chapter 1: Antibiotic Prophylaxis.
MAC infection causes lymphadenitis, pulmonary disease and disseminated infection. Immunocompetent patients who grow MAC from sputum culture do not all need to be treated and must be considered on a case by case basis. Disseminated MAC infection most commonly occurs in immunocompromised patients. Clinical features of this include fever, night sweats, weight loss, fatigue, diarrhoea, abdominal pain, hepatomegaly, splenomegaly, and lymphadenopathy.
Seek Infectious Diseases review where available.
Antimicrobial
Azithromycin 500mg PO OD
(Alternative: Clarithromycin 500mg PO BID)
PLUS
Ethambutol 15mg/kg PO OD
In patients with high mycobacterial burden, very low CD4 counts, or whose viral load does not become suppressed with ART ADD:
Rifampicin 600mg PO OD (OR 300mg PO BID)
AND / OR
Levofloxacin 500mg PO OD
Comments and Duration of Therapy
Perform blood cultures in patients with suspected disseminated disease and request prolonged incubation in BACTEC (cultures are usually positive after 7-10 days). In pulmonary disease send sputum for culture, however note that a positive culture may represent colonization rather than infection. In lymphadenitis send lymph node tissue or aspirate for culture.
For patients with HIV and MAC who have no other opportunistic infections start ART within 2 weeks of diagnosis.
Duration:
Continue for at least 12 months. After this treatment may be stopped if CD4 >100 cells/microlitre for > 6 months
See Mycobacterium avium Complex (MAC) prophylaxis in Patients with HIV in Chapter 1: Antibiotic Prophylaxis.
This is caused by the bacteria Burkholderia pseudomallei. Disease occurs via inhalation and percutaneous inoculation. Patients can present with pneumonia which sometimes mimics TB, sepsis with abscesses in multiple organs, or cutaneous ulcers. Risk factors include diabetes, hazardous alcohol use, renal disease and chronic lung disease, and other forms of immunosuppression.
Seek Infectious Diseases review where available.
Antimicrobial
Intensive therapy:
Meropenem 1g (child 25mg/kg) IV TID
(If there is neurological involvement use 2g (child 50mg/kg) IV TID )
PLUS
In neurological disease, osteomyelitis, septic arthritis, genitourinary infection, and skin and soft tissue infection ADD:
Co-trimoxazole (see below for dose)
Eradication therapy:
Co-trimoxazole 40-60kg 240 / 1200mg, >60kg 320 / 1600mg, child 6/30mg/kg, PO BID
PLUS
Folic acid 5mg (child 0.1 mg/kg) PO OD
Comments and Duration of Therapy
Send blood, urine, sputum, pus and/or wound swab for culture. All patients should have a CXR, and CT or ultrasound of their abdomen and pelvis to detect any abscesses.
Duration:
Skin abscess, bacteraemia without focus: Intensive 2 weeks, Eradication 3 months
Pneumonia: Intensive 3-4 weeks, Eradication 3 months
Deep collection, septic arthritis: Intensive 4 weeks from most recent drainage, Eradication 3 months
Osteomyelitis: Intensive 6 weeks, Eradication 6 months
CNS infection, mycotic aneurysms: Intensive 8 weeks, Eradication 6 months
Monitor electrolytes and creatinine regularly while on co-trimoxazole.
