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Page 1 / 409
Exported on: 30/01/2025
Clinical guidelines - Diagnosis and treatmentmanual
For curative programmes in hospitals and dispensariesGuidance for prescribing
 
 
© Médecins Sans Frontières
All rights reserved for all countries. No reproduction, translation and adaptation may be done without the prior
permission of the Copyright owner.
We're working to ﬁx some technical issues in the MSF Guidelines app affecting ofﬂine access ×


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ISBN
 
Médecins Sans Frontières. Clinical guidelines - Diagnosis and treatment manual.
December 2024
978-2-37585-276-7


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Table of contents
Authors/Contributors
Preface
Abbreviations and acronyms
Chapter 1: A few symptoms and syndromes
Chapter 2: Respiratory diseases
Chapter 3: Gastrointestinal disorders
Chapter 4: Skin diseases
Chapter 5: Eye diseases
Chapter 6: Parasitic diseases
Chapter 7: Bacterial diseases
Chapter 8: Viral diseases
Chapter 9: Genito-urinary diseases
Chapter 10: Medical and minor surgical procedures
Chapter 11: Mental disorders in adults
Chapter 12: Other conditions
Appendices
Main references


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Authors/Contributors
 
 
The Clinical guidelines  has been developed by Médecins Sans Frontières.
 
MSF would like to express its sincere gratitude to everyone who has contributed to developing these guidelines. Co-authors: Grace Dubois, Blandine Vasseur-Binachon, Cedric Yoshimoto Contributors: Gabriel Alcoba, Beatriz Alonso, Mohana Amirtharajah, Haydar Alwash, Catherine Bachy, Roberta
Caboclo, Severine Caluwaerts, Cristina Carreno, Arlene Chua, Kate Clezy, Anne-Sophie Coutin, Marcio da Fonseca,
Martin De Smet, Eva Deplecker, Carolina Echeverri, Sylvie Fagard-Sultan, Roopan Gill, Sonia Guinovart, Jarred Halton,
Kerstin Hanson, Christian Heck, Caroline Henry-Ostian, Cathy Hewison, Yves-Laurent Jackson, Carolina Jimenez, John


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Kerstin Hanson, Christian Heck, Caroline Henry-Ostian, Cathy Hewison, Yves-Laurent Jackson, Carolina Jimenez, John
Johnson, Rupa Kanapathipillai, Mohamad Khalife, Nadia Lafferty, Amin Lamrous, James Lee, Helen McColl, Natasha
Mlakar, Juno Min, Miguel Palma, Isabella Panunzi, Roberta Petrucci, Nicolas Peyraud, Ernestina Repetto, Jean Rigal,
Koert Ritmeijer, Julia Sander, Raghda Sleit, Erin Stratta, Alex Telnov, Malcolm Townsend, Clara Van Gulik. Speciﬁc support has been given by the International Guidelines Publication team:
Editor: Véronique Grouzard
Language editors: Mohamed Elsonbaty Ramadan, Carolina López, Anna Romero
Lay-out designer: Evelyne Laissu


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Preface
 
 
This guide is designed for use by medical professionals involved in curative care at the dispensary and primary hospital. We have tried to respond in the simplest and most practical way possible to the questions and problems faced by ﬁeld
medical staff, using the accumulated ﬁeld experience of Médecins Sans Frontières, the recommendations of reference
organizations such as the World Health Organization (WHO) and specialized works in each ﬁeld. This edition touches on the curative and, to a lesser extent, the preventive aspects of the main diseases encountered
in the ﬁeld. The list is incomplete, but covers the essential needs. This guide is used not only in programmes supported by Médecins Sans Frontières, but also in other programmes and in


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other contexts. It is notably an integral part of the WHO Emergency Health Kit.
Médecins Sans Frontières has also issued French, Spanish and Arabic editions. Editions in other languages have also
been produced in the ﬁeld. This guide is a collaborative effort of medical professionals from many disciplines, all with ﬁeld experience. Despite all efforts, it is possible that certain errors may have been overlooked in this guide. Please inform the authors
of any errors detected. It is important to remember, that if in doubt, it is the responsibility of the prescribing medical


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of any errors detected. It is important to remember, that if in doubt, it is the responsibility of the prescribing medical
professional to ensure that the doses indicated in this manual conform to the manufacturer ’s speciﬁcations. To ensure that this guide continues to evolve while remaining adapted to ﬁeld realities, please send any comments or
suggestions.  As treatment protocols are regularly revised, please check the monthly updates.


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ACE angiotensin converting enzyme
ACT  artemisinin-based combination therapy 
AFB acid-fast bacillus
ALT alanine aminotransferase
ARV antiretroviral
AST aspartate aminotransferase
BCG  bacillus Calmette-Guérin 
BMI body mass index
BP  blood pressure 
°C  degree Celsius 
co-amoxiclav amoxicillin + clavulanic acid
co-trimoxazole sulfamethoxazole + trimethoprim
CRT capillary reﬁll time
CSF cerebrospinal ﬂuid
CMV cytomegalovirus
D1 (D2, D3, etc.)  Day 1 or ﬁrst day (Day 2 or 2  day, Day 3 or 3  day, etc.)nd rd
dl  decilitre 
(e)FAST (extended) focused assessment with sonography for trauma
FBC full blood count
g  gram 
HBP high blood pressure (hypertension)
HF heart failure
HIV  human immunodeﬁciency virus 
HR heart rate


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Ig immunoglobulin
IM  intramuscular 
IO intraosseous
IU  international unit 
IV  intravenous
kcal kilocalorie
kg  kilogram 
LP lumbar puncture
mg  milligram 
MIU million international units
ml  millilitre 
mmHg  millimetre of mercury 
mmol  millimole 
MSF Médecins Sans Frontières
NSAID nonsteroidal anti-inﬂammatory drug
ORS oral rehydration solution or salts
PCP pneumocystosis
PCR polymerase chain reaction
PO  per os – oral administration 
POCUS point-of-care ultrasound
PRBC packed-red blood cells
RR respiratory rate
SAM severe acute malnutrition
SC  subcutaneous
SMX sulfamethoxazole


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SMX + TMP sulfamethoxazole + trimethoprim = co-trimoxazole
SpO2 arterial blood oxygen saturation measured by pulse oximetry
tab  tablet 
TB  tuberculosis 
TMP trimethoprim
WHO  World Health Organization


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Page 10 / 409
Chapter 1: A few symptoms and syndromes
Shock
Generalised tonic-clonic seizures and convulsive status epilepticus
Hypoglycaemia
Fever
Pain
Anaemia
Dehydration
Severe acute malnutrition


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Shock
Last updated: September 2023
 
Shock is a condition of widespread reduced tissue perfusion and inadequate oxygen delivery. Prolonged shock can
result in cellular dysfunction and irreversible organ failure. Mortality is high without early diagnosis and treatment.
Clinical features
Shock should be suspected in patients with:
 In children, accurate BP measurement is difﬁcult, and hypotension is a very late sign of shock. Therefore, critically ill
children should be treated for shock if they present at least one of the following signs: lower limb temperature
gradient , CRT ≥ 3 seconds, weak radial pulse or severe tachycardia . Clinical features may vary according to the type of shock :


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gradient , CRT ≥ 3 seconds, weak radial pulse or severe tachycardia . Clinical features may vary according to the type of shock : 
Sign(s) of hypotension: weak pulse, low or declining blood pressure (BP) , narrow pulse pressure a 
Acute onset of signs of tissue hypoperfusion:
Skin: pallor, mottled skin, sweating, cold extremities or lower limb temperature gradient , capillary reﬁll time
(CRT) ≥ 3 seconds
 b 
Lungs: tachypnea, dyspnoea
Heart: tachycardia, which often occurs before BP decreases
Kidney: oliguria (urine output < 0.5 to 1 ml/kg/hour) or anuria
Brain: thirst, anxiety, agitation, confusional state, apathy, altered mental status
 c 
 b  d [1] 
 [2]


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Type Speciﬁc clinical features Risk factors
Distributive
Severe vasodilation
and increased capillary
permeability resulting
in maldistribution of
blood ﬂow
Anaphylaxis: likely when either of the following 2
criteria develop within minutes to hours : [3] 
Involvement of skin and/or mucous membranes (e.g.
generalised urticaria, itching, ﬂushing, swollen
lips/tongue/uvula) AND ≥ 1 of the following:
respiratory symptoms (wheeze, dyspnoea);
low BP or symptoms of end-organ dysfunction
(hypotonia, incontinence);
severe gastrointestinal symptoms (abdominal
pain, repetitive vomiting).
Hypotension, bronchospasm or laryngeal
involvement (stridor, vocal changes, odynophagia)
after exposure to known or probable allergen for
that patient.
Recent exposure to an allergen


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involvement (stridor, vocal changes, odynophagia)
after exposure to known or probable allergen for
that patient.
Recent exposure to an allergen
(e.g. food, sting, medicine) or
history of anaphylaxis
 
 
Septic shock: signs of infection, fever or
hypothermia, altered mental status, dyspnoea,
persisting hypotension despite ﬂuid resuscitation [4]
Infection, recent surgery,
immunodeﬁciency
Cardiogenic
Cardiac pump failure
Ischaemia: chest pain, dyspnoea
Arrhythmia
Murmur of valvular heart disease
History of cardiac disease,
advanced age
Acute heart failure: see Heart failure in adults, Chapter
12.
History of cardiac disease, viral
illness, immunodeﬁciency
Hypovolaemic
Direct blood/ﬂuid loss
or ﬂuid sequestration
into the extravascular
space resulting in
decreased
intravascular volume


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Hypovolaemic
Direct blood/ﬂuid loss
or ﬂuid sequestration
into the extravascular
space resulting in
decreased
intravascular volume
Haemorrhagic: external bleeding, signs and symptoms
of internal bleeding, hypotension (a)
Trauma, recent surgery, obstetric
haemorrhage
Non-haemorrhagic: dry mouth, absence of tears,
sunken eyes/fontanelle, low jugular venous pressure
(JVP), altered mental status
Profuse diarrhoea and/or
vomiting, intestinal obstruction
Obstructive
Obstruction to blood
ﬂow to, or from, the
heart or great vessels
Pulmonary embolism (PE): chest pain, tachycardia,
tachypnoea, hypoxia 
Deep vein thrombosis (DVT): leg pain, swelling, warmth
Recent surgery or immobilisation,
cancer, history of PE or DVT
Tension pneumothorax: decreased breath sounds,


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Recent surgery or immobilisation,
cancer, history of PE or DVT
Tension pneumothorax: decreased breath sounds,
raised JVP, weak radial pulse, tracheal deviation
Trauma, invasive medical
procedure
Cardiac tamponade: pulsus paradoxus , raised JVP,
narrow pulse pressure, mufﬂed heart sounds
 (b) Trauma, immunodeﬁciency
(a) In children and young adults with hypovolaemic shock, BP may be maintained initially, but subsequently declines rapidly ifﬂuid loss is not replaced.


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Management
 Primary objective of shock management is to restore adequate tissue perfusion, demonstrated by:
 After initial management:
 On-going care:
Basic Life Support
1) Manage airways and breathing
(b) Pulsus paradoxus is measured by taking the patient's BP during both expiration and inspiration. It is deﬁned as a decreaseof > 10 mmHg in the SBP during inspiration compared with expiration.
Attend to the patient immediately even if the type of shock is not known. Call for help. Move to critical care unit if
possible.
Assess and manage A (airway), B (breathing), and C (circulation) according to Basic Life Support (see below). If
anaphylaxis is suspected, immediately go to speciﬁc management.  
Take a rapid history to try to determine underlying cause.
Monitor:


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anaphylaxis is suspected, immediately go to speciﬁc management.  
Take a rapid history to try to determine underlying cause.
Monitor:
urine output hourly (insert a urinary catheter)
HR, RR, BP, temperature, CRT, SpO, and level of consciousness2
Perform the following tests:
haemoglobin and blood glucose level
malaria rapid diagnostic test in endemic area: see Malaria, Chapter 6
blood culture (if available) and blood group
In children, administer ceftriaxone IV : one dose of 80 mg/kg. Reassess need for further antibiotic treatment
according to underlying cause.
 e 
Treat pain: see Pain, Chapter 1.
Returning vital signs, CRT, SpO, mental status, etc. to normal.2
Maintaining mean arterial pressure (MAP) > 65 mmHg in adults (or higher if patient has pre-existing hypertension). f


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Maintaining mean arterial pressure (MAP) > 65 mmHg in adults (or higher if patient has pre-existing hypertension). f 
Maintaining urine output > 0.5 to 1 ml/kg/hour.
Take a more detailed history.
Perform a comprehensive physical examination.
In case of dehydration: see Dehydration, Chapter 1.
In case of blunt thoracic or abdominal trauma, perform POCUS : (e)FAST exam to evaluate for pneumothorax or
free ﬂuid in pleural, pericardial and/or peritoneal spaces. Refer to surgeon as required.
 g 
Re-evaluate patient’s condition and response to treatment every 10 minutes until patient is stable.
Perform a second comprehensive physical examination.
Initiate nutritional support adapted to patient's needs as soon as possible and reassess regularly. Patients have high


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Initiate nutritional support adapted to patient's needs as soon as possible and reassess regularly. Patients have high
protein and energy requirements. Enteral route is preferred. 
Lay the patient on their back. However:
if spinal trauma is suspected, do not move the patient;
in case of anaphylaxis, the patient may prefer a sitting position.
In case of altered mental status:
be prepared with mask and bag if needed for ventilation;
remove any airway obstruction (e.g. secretions, foreign body);
open airway: stand at head of bed, place one hand on the forehead and gently tilt the head back.
Simultaneously, place the ﬁngertips of the other hand under the chin and lift the chin. If suspicion of spinal


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Simultaneously, place the ﬁngertips of the other hand under the chin and lift the chin. If suspicion of spinal
trauma, do not move the neck. Instead, place heels of both hands on patient’s parietal areas, and use index and
middle ﬁngers of both hands to push the angle of mandible anteriorly (jaw thrust)


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 2) Maintain circulation
Anaphylaxis
Repeat after 5 minutes if no or poor clinical improvement (up to a total of 3 IM injections). 
Repeat bolus once if signs of poor perfusion persist after 15 minutes.
Septic shock
Look for source of infection. If possible, take specimens for culture before starting antibiotic treatment.
if needed, insert an oropharyngeal airway.
Auscultate lungs to assess ventilation.
Administer 10 to 15 litres/minute of oxygen with mask to maintain SpO > 94%.2
If SpOremains ≤ 94% with oxygen, see If resources allow.2 
Control bleeding:
apply direct manual pressure and/or compression/haemostatic dressing to the wound;
in case of massive life-threatening bleeding from an extremity (e.g. leg) not controlled by direct pressure: apply a


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in case of massive life-threatening bleeding from an extremity (e.g. leg) not controlled by direct pressure: apply a
windlass tourniquet . h [5] 
Insert 2 peripheral IV lines (catheters 20-22G in children and 14-18G in adults) or an intraosseous (IO) needle.
Administer Ringer lactate (RL) , glucose 5%-Ringer lactate (G5%-RL) , and/or blood, following speciﬁc
management described below. Reassess before giving additional ﬂuid therapy. Monitor for ﬂuid overload ,
especially in patients at risk, e.g. severely malnourished children; patients with severe malaria, heart disease, severe
anaemia; older patients.  
 i  j 
 k 
Maintain normal body temperature.
If unable to maintain BP, see If resources allow.
Remove exposure to causal agent.


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i  j 
 k 
Maintain normal body temperature.
If unable to maintain BP, see If resources allow.
Remove exposure to causal agent.
Administer epinephrine (adrenaline) IM into the mid-anterolateral thigh. Use undiluted solution and a 1 ml syringe
graduated in 0.01 ml : [6] 
Children under 6 months: 0.1 to 0.15 ml
Children 6 months to 5 years: 0.15 ml
Children 6 to 12 years: 0.3 ml
Children over 12 yearsand adults: 0.5 ml l 
Monitor HR, BP, CRT and clinical response.
In case of stridor, administer nebulized epinephrine: 0.5 mg/kg/dose (max. 5 mg) in 5 ml of 0.9% sodium chloride
over 10 to 15 minutes
If SpO is < 94%, ventilate with bag mask.2
Administer a bolus of RL:
Children: 10 ml/kg as quickly as possible
Adults: 500 ml as quickly as possible


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If SpO is < 94%, ventilate with bag mask.2
Administer a bolus of RL:
Children: 10 ml/kg as quickly as possible
Adults: 500 ml as quickly as possible
If shock persists after 3 IM injections of epinephrine, in particular if unable to maintain BP, see If ressources allow.
After initial treatment with epinephrine and IV ﬂuids, some patients (e.g. patients requiring continuing treatment after
2 doses of epinephrine IM or patients with ongoing asthma or shock) may beneﬁt from a short course of
corticosteroid therapy. When the patient is stable, prednisolone PO : 1 to 2 mg/kg (max. 50 mg) once daily in the
morning for 3 to 5 days. Use an IV corticosteroid only if the patient cannot take oral treatment.
Fluid therapy:


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morning for 3 to 5 days. Use an IV corticosteroid only if the patient cannot take oral treatment.
Fluid therapy:
Children and adolescents under 15 years: G5%-RL solution as maintenance ﬂuids (see Appendix 1)
Adolescents 15 years and over and adults: one bolus of 250 to 500 ml of RL as quickly as possible
Antibiotic treatment:
Start antibiotics according to the suspected origin of infection within 1 hour of presentation (see tables
below).
 [7]


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Page 15 / 409
 
If source is unknown, administer a broad-spectrum antibiotic to cover gram-positive, gram-negative, and
anaerobic bacteria. If possible, take into account local epidemiology (rates and types of resistance).
Differentiate community acquired sepsis and nosocomial sepsis as pathogens and rates of resistance may be
different. Simplify the antibiotic treatment (to narrower spectrum) whenever possible.
Reassess treatment daily:
If culture results are available: adapt treatment accordingly.
If improvement after 24 to 48 hours: change to oral route, however some foci (e.g. meningitis) require
prolonged IV treatment.
If no improvement after 48 to 96 hours: consider resistant pathogen , in particular in patients with


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prolonged IV treatment.
If no improvement after 48 to 96 hours: consider resistant pathogen , in particular in patients with
immunodeﬁciency or recent (in the last month) hospitalisation or antibiotic use and adapt treatment
accordingly.
 m 
Other measures to control infection:
If suspected catheter-related infection, insert a new catheter in another site and remove the suspected
catheter.
Drain soft-tissue abscess (see Cutaneous abscess, Chapter 10); irrigate and debride traumatic wounds. Refer to
surgeon if needed for debridement, drainage, relieving obstruction, etc.
Treatment of fever: see Fever, Chapter 1.


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Page 16 / 409
Origin  Antibiotics Alternatives (c)
Cutaneous
staphylococci, streptococci (d)
cloxacillin
(+ vancomycin if risk factors
for MRSA ) (e) 
cefazolin
(or vancomycin if risk factors for
MRSA )
 (f)
 (e) 
Pulmonary
pneumococci, H. inﬂuenzae
ceftriaxone + azithromycin
(+ gentamicin if risk factors
for MDR gram negative
bacteria ) (g) 
clindamycin + ciproﬂoxacin +
doxycyline
Intestinal or biliary
enterobacteria, anaerobic bacteria,
enterococci
ceftriaxone +
metronidazole
(+ gentamicin if risk factors
for MDR gram negative
bacteria )
(+ ampicillin if biliary source)
 (g) 
clindamycin + ciproﬂoxacin
Gynaecological 
streptococci, gonococci, anaerobic
bacteria, E. coli
ceftriaxone +
metronidazole +
azithromycin
clindamycin + gentamicin +
azithromycin
Urinary
enterobacteria, enterococci


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bacteria, E. coli
ceftriaxone +
metronidazole +
azithromycin
clindamycin + gentamicin +
azithromycin
Urinary
enterobacteria, enterococci
ceftriaxone
(+ amikacin if risk factors
for pseudomonas ) (h) 
meropenem
(+ amikacin if risk factors for
pseudomonas ) (h) 
Central nervous system See Bacterial meningitis, Chapter 7.
Other or undetermined
ampicillin + gentamicin in
children
ceftriaxone
or cloxacillin + amikacin in children
ceftriaxone
(+ amikacin if risk factors
for pseudomonas ) in
adults
 (h) 
clindamycin + ciproﬂoxacin in adults
(c) Only if ﬁrst-line antibiotic is not available or in allergic patients.
(d) For necrotising infections, see Necrotising infection of skin and soft tissues, Chapter 10.


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(d) For necrotising infections, see Necrotising infection of skin and soft tissues, Chapter 10.
(e) Risk factors for MRSA: prior MRSA infection, recent hospitalisation or antibiotic use, recurrent skin infection, chronicwounds, invasive device, settings with high rates of MRSA.
(f) Do not administer if severe beta-lactam allergy
(g) Risk factors for multiresistant (MDR) gram negative bacteria: recent hospitalisation in intensive care unit or antibiotic use.
(h) Risk factors for pseudomonas: immunodeﬁciency, recent hospitalisation or antibiotic use, burns or presence of invasivedevice.


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Antibiotics Children over 1 month Adults
amikacin IM or slow IV injection
over 3 minutes
15 mg/kg (max. 1.5 g) once daily 15 mg/kg once daily
ampicillin IV infusion over
30 minutes
50 mg/kg (max. 2 g) every 8 hours 2 g every 6 to 8 hours
(2 g every 4 hours for meningitis)
azithromycin PO (by NGT)
                       
10 to 20 mg/kg (max. 500 mg) once
daily
500 mg to 1 g once daily
cefazolin slow IV injection over 3
minutes or IV infusion over 30
minutes
25 mg/kg (max. 3 g) every 12 hours 2 g every 8 hours
ceftriaxone slow IV injection
over 3 minutes or IV infusion over
30 minutes
80 mg/kg (max. 4 g) once daily (100
mg/kg, max. 4 g, once daily for
meningitis)
2 g once daily (2 g every 12 hours for
meningitis)
ciproﬂoxacin PO (by NGT) 15 to 20 mg/kg (max. 750 mg) every


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meningitis)
2 g once daily (2 g every 12 hours for
meningitis)
ciproﬂoxacin PO (by NGT) 15 to 20 mg/kg (max. 750 mg) every
12 hours
500 to 750 mg every 12 hours
ciproﬂoxacin IV infusion over
60 minutes
10 mg/kg (max. 400 mg) every 8
hours
400 mg every 8 to 12 hours
 
clindamycin IV infusion over
30 minutes
10 mg/kg (max. 600 mg) every 8
hours
600 to 900 mg every 8 hours
cloxacillin IV infusion over
60 minutes
25 to 50 mg/kg (max. 2 g) every 6
hours
2 g every 6 hours
doxycycline PO (by NGT) 4.4 mg/kg (max. 200 mg) on D1 then
2.2 mg/kg (max. 100 mg) every 12
hours
200 mg on D1 then 100 mg every 12
hours
gentamicin IM or slow IV
injection over 3 minutes
7.5 mg/kg once daily
 
5 mg/kg once daily
meropenem IV infusion over
15 or 30 minutes
20 mg/kg (max. 2 g) every 8 hours 2 g every 8 hours


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7.5 mg/kg once daily
 
5 mg/kg once daily
meropenem IV infusion over
15 or 30 minutes
20 mg/kg (max. 2 g) every 8 hours 2 g every 8 hours
metronidazole PO (by NGT) 10 mg/kg (max. 500 mg) every 8
hours
500 mg every 8 hours
metronidazole IV infusion
over 30 minutes
10 mg/kg (max. 500 mg) every 8
hours
500 mg every 8 hours
vancomycin IV infusion over 15 mg/kg (max. 500 mg) every 6 15 to 20 mg/kg (max. 2 g) every 12 hours


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Page 18 / 409
 
Cardiogenic shock
Hypovolemic non-haemorrhagic shock
Hypovolaemic haemorrhagic shock
In order to prevent the “lethal trauma triad” of hypothermia, acidosis and coagulopathy:
Repeat if needed.
When blood is available, stop RL and administer blood only.
Then immediately start a second dose, administered by IV infusion over 8 hours.
Obstructive shock
The management described up to this point will provide only temporary stabilization. Treat the cause or refer for
aetiological treatment:
 
 
 f
60 to 240 minutes hours 
Administer RL with extreme caution and monitor closely for signs of ﬂuid overload:
Adults: 100 to 250 ml over 30 minutes
Subsequent ﬂuid administration should be based on thorough patient assessment, including urinary output,
mental status and SpO.2


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Subsequent ﬂuid administration should be based on thorough patient assessment, including urinary output,
mental status and SpO.2
Vasopressors are often required to maintain BP, see If resources allow.
In case of acute heart failure, see Heart failure in adults, Chapter 12.
Arrhythmias should be managed according to Advanced Life Support techniques as appropriate and where
available.
Administer RL:
Children under 1 year: 30 ml/kg over 1 hour then 70 ml/kg over 5 hours
Children/adolescents 1 to 14 years: 30 ml/kg over 30 minutes then 70 ml/kg over 2.5 hours
Adolescents 15 years and over and adults: 250 to 500 ml as quickly as possible (to be repeated once if required)
then adjusted to patient’s condition, providing up to 70 ml/kg over 2.5 hours


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then adjusted to patient’s condition, providing up to 70 ml/kg over 2.5 hours
Determine blood group and if needed transfuse, as quickly as possible:
Children under 20 kg: 20 ml/kg of whole blood
Children 20 kg and over and adults: an adult unit of whole blood
If blood is not immediately available, administer a bolus of RL with caution (i.e. minimize the use of RL) while waiting
for blood:
Children: 20 ml/kg as quickly as possible
Adults: 250 to 500 ml as quickly as possible
Warm the patient (blankets, warm room, warm IV ﬂuids).
In case of trauma presenting within 3 hours, administer tranexamic acid slow IV (over 10 minutes):
Children: 15 mg/kg (max. 1 g)
Adults: 1 g
In case of postpartum haemorrhage, refer to the guide Essential obstetric and newborn care, MSF.
Refer to surgery if needed.


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Adults: 1 g
In case of postpartum haemorrhage, refer to the guide Essential obstetric and newborn care, MSF.
Refer to surgery if needed.
Pulmonary embolism: anticoagulation +/- thrombolysis.
Tension pneumothorax: needle decompression/ﬁnger thoracostomy, followed by insertion of chest tube.
Cardiac tamponade: pericardial tap.


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Page 19 / 409
If resources allow:
 These protocols are for peripheral IV administration. Titrate according to patient's clinical situation. Refer to
management objectives (including BP) under Management. 
Manage airways and breathing:
complete airway obstruction: endotracheal intubation or cricothyroidotomy
respiratory failure: non-invasive or invasive mechanical ventilation
Maintain circulation:
If unable to achieve management objectives (in particular BP) using ﬂuid therapy (and no signs of ﬂuid
overload are present) or, in the case of anaphylaxis, if shock persists after 3 IM epinephrine injections,
vasopressors-inotropes (see below) can be used in the following conditions:
close monitoring in a critical care unit;


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vasopressors-inotropes (see below) can be used in the following conditions:
close monitoring in a critical care unit;
a large peripheral IV catheter (proximal forearm or above), a central venous catheter or an IO line
dedicated to the infusion;
 n 
use of an electric syringe or pump to control ﬂow rate ; o 
intensive monitoring of drug administration, particularly during syringe changes.
All infused volumes must be accounted for when recording ﬂuid balance.
  Norepinephrine (NEP) tartrate (i) Epinephrine (EPN) (adrenaline)
Indication Children: 2 choice 
Adults: 1  choice
nd 
st
Children: 1  choice 
Adults: 2  choice
st
nd
Preparation
of
diluted
solution (j)
Children:
Add 1 ml (2 mg) of NEP tartrateto 39 ml
of 0.9% NaCl to obtain a 0.05 mg/ml (50
micrograms/ml) solution.
  
Children:


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diluted
solution (j)
Children:
Add 1 ml (2 mg) of NEP tartrateto 39 ml
of 0.9% NaCl to obtain a 0.05 mg/ml (50
micrograms/ml) solution.
  
Children:
Add 2 ml (2 mg) of EPN to 38 ml of 0.9% NaCl
to obtain a 0.05 mg/ml (50 micrograms/ml)
solution.
Adults:
Add 2 ml (4 mg) of NEP tartrateto 38 ml
of 0.9% NaCl to obtain a 0.1 mg/ml (100
micrograms/ml) solution.
  
Adults:
Add 4 ml (4 mg) of EPN to 36 ml of 0.9% NaCl
to obtain a 0.1 mg/ml (100 micrograms/ml)
solution.
Starting
rate (k)
0.1 microgram/kg/minute
Rate for
increasing   (k) 
Increase by 0.05 micrograms/kg/minute every 10 minutes for the ﬁrst hour, then every hour.
Max. 1 microgram/kg/minute.
Rate for
decreasing   (k) 
Taper down doses when management objectives are attained. Do not stop abruptly.


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Max. 1 microgram/kg/minute.
Rate for
decreasing   (k) 
Taper down doses when management objectives are attained. Do not stop abruptly.
Decrease by 0.05 micrograms/kg/minute every hour.
(i) 2 mg of NEP tartrate = 1 mg of NEP base.
(j) 0.9% sodium chloride or 5% glucose or RL can be used for dilution.
(k) The infusion rate is calculated as follows: [desired dose (microgram/kg/min) x weight (kg) x 60 min] ÷ concentration(microgram/ml).
Ongoing care: measure serum potassium, magnesium, calcium and phosphate levels and correct any
abnormalities. Additional investigations (e.g. X-rays, other laboratory tests) may be indicated, depending on
aetiology suspected.


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References
Footnotes
(a) Hypotension is based on systolic blood pressure (SBP) in adults: SBP < 90 mmHg or decrease in SBP ≥ 40 mmHg frombaseline or mean arterial pressure MAP < 65 mmHg. Shock is often accompanied by hypotension but may also occur withnormal or elevated BP.
(b) Run the back of the hand from the toe to the knee. A notable temperature change from the cold foot to the warm knee is apositive temperature gradient, indicating distal hypoperfusion.
(c) Critically ill-appearing child: weak grunting or crying, drowsy and difﬁcult to arouse, does not smile, disconjugate or anxiousgaze, pallor or cyanosis, general hypotonia.
(d) Children under 1 year: > 180 bpm; Children 1 to 5 years: > 160 bpm; Children 5 years and over: > 140 bpm.


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(d) Children under 1 year: > 180 bpm; Children 1 to 5 years: > 160 bpm; Children 5 years and over: > 140 bpm.
(e) For IV administration of ceftriaxone, dissolve only in water for injection.
(f) MAP = diastolic BP (DBP) + 1/3 (SBP-DBP). A patient with BP 90/60 has a MAP = 60 + 1/3 (90-60) = 70.
(g) POCUS should only be performed and interpreted by trained clinicians.
(h) The patient should receive surgery within 1 hour of the application of a windlass tourniquet. After 1 hour, there is a risk ofischaemic injury of the limb. If surgery is not possible and the tourniquet is required to save the patient’s life, it should beleft in place. Any tourniquet that has been applied for more than 6 hours should be left in place until arrival at a facilitycapable of providing deﬁnitive surgical care.


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(i) Crystalloids should be used. Colloids (e.g. modiﬁed ﬂuid gelatin, albumin) are not recommended.
(j) Remove 50 ml of RL from a 500 ml RL bottle or bag, then add 50 ml of 50% glucose to the remaining 450 ml of RL to obtain500 ml of 5% glucose-RL solution.
(k) In case of ﬂuid overload: sit the patient up, reduce the infusion rate to a minimum and administer furosemide IV (0.5 mg/kg inchildren; 40 mg in adults). Monitor the patient closely over 30 minutes and assess for underlying cardiorespiratory or renaldisease. Once the patient is stabilised, reassess the necessity of continuing IV ﬂuids. If IV ﬂuids are still required, re-start athalf the previous infusion rate and monitor closely.
(l) If small or prepubertal children, administer 0.3 ml of epinephrine.


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(l) If small or prepubertal children, administer 0.3 ml of epinephrine.
(m)For example: methicillin-resistant Staphylococcus aureus (MRSA), pseudomonas species, and gram-negative bacteria withextended-spectrum beta-lactamase (ESBL) activity.
(n) When using a peripheral vein, monitor infusion site closely for signs of extravasation, in particular in young children.


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(n) When using a peripheral vein, monitor infusion site closely for signs of extravasation, in particular in young children.
(o) If no system to control volume delivery and ﬂow rate (e.g. syringe pump), an infusion using an infusion bag and standardpaediatric giving set can be considered in extreme situations as a temporary measure. However, it is important to considerthe risks related to this type of administration (accidental bolus or insufﬁcient dose). The infusion must be constantlymonitored to prevent any, even small, change from the prescribed rate. 
1. Houston KA, George EC, Maitland K. Implications for paediatric shock management in resource-limited settings: aperspective from the FEAST trial. Crit Care. 2018;22(1):119.https://doi.org/10.1186/s13054-018-1966-4


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2. Cecconi M, De Backer D, Antonelli M, et al. Consensus on circulatory shock and hemodynamic monitoring. Task force of theEuropean Society of Intensive Care Medicine. Intensive Care Med. 2014;40(12):1795-1815. https://doi.org/10.1007/s00134-014-3525-z
3. Cardona V, Ansotegui IJ, Ebisawa M, et al. World allergy organization anaphylaxis guidance 2020. World Allergy Organ J.


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2020;13(10):100472. Published 2020 Oct 30.https://doi.org/10.1016/j.waojou.2020.100472
4. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Deﬁnitions for Sepsis and Septic Shock(Sepsis-3). JAMA. 2016;315(8):801-810.https://doi.org/10.1001/jama.2016.0288
5. Richey SL. Tourniquets for the control of traumatic hemorrhage: a review of the literature. World J Emerg Surg. 2007;2:28.Published 2007 Oct 24.  https://doi.org/10.1186/1749-7922-2-28
6. Emergency treatment of anaphylaxis. Guidelines for healthcare providers. Rescuscitation Council UK. Updated 2021[Accessed May 31 2023].https://www.resus.org.uk/sites/default/ﬁles/2021-05/Emergency%20Treatment%20of%20Anaphylaxis%20May%202021_0.pdf


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7. Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis andseptic shock 2021. Intensive Care Med. 2021;47(11):1181-1247. https://doi.org/10.1007/s00134-021-06506-y


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Generalised tonic-clonic seizures andconvulsive status epilepticus
Last updated: October 2024
 
Generalised tonic-clonic seizures are involuntary movements of both sides of the body associated with impaired or
loss of consciousness. They result from abnormal brain activity. Most seizures are brief (less than 5 minutes) and resolve spontaneously. They may occur once or may recur. In young children, seizures frequently occur in the context of fever, with no underlying causes. These are deﬁned as
"febrile seizures". A seizure lasting longer than 5 minutes or 2 or more seizures in 5 minutes without complete restoration of baseline
consciousness between seizures is deﬁned as "status epilepticus" . Status epilepticus is a medical emergency


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consciousness between seizures is deﬁned as "status epilepticus" . Status epilepticus is a medical emergency
requiring immediate management. The longer a seizure lasts, the more difﬁcult it is to stop, and the greater the risk
for permanent brain damage and death. In pregnancy and the postpartum period, seizures may be a manifestation of eclampsia. Refer to Essential obstetric
and newborn care, MSF. 
Clinical features
During a seizure
and
These signs may be associated with loss of urine, breathing difﬁculty, and cyanosis. Immediately after a seizure (postictal phase)
The patient experiences fatigue and temporary symptoms such as confusional state, headache, memory loss, focal
deﬁcits. Recovery usually occurs within 30 to 60 minutes but may be delayed.
First aid during a seizure


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deﬁcits. Recovery usually occurs within 30 to 60 minutes but may be delayed.
First aid during a seizure
Febrile seizures
 [1] [2] 
contraction of muscles, including respiratory muscles (tonic phase), followed by rhythmic jerking of the arms and
legs (clonic phase)
loss of consciousness
 [3] 
Note the time. Call for help.
Protect from falls and trauma, loosen clothing.
Maintain airway, place patient in recovery position to avoid aspiration, do not put anything in the mouth.
Treat hypoglycaemia if present or administer glucose if unable to measure capillary blood glucose
immediately (see Hypoglycaemia, Chapter 1).
Depending on the context:
Administer oxygen if available.
If febrile seizures are likely, see Febrile seizures.


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Depending on the context:
Administer oxygen if available.
If febrile seizures are likely, see Febrile seizures.
In adults, thiamine (100 mg by IV infusion in 100 ml 0.9% NaCl over 30 minutes) may be administered at the
same time as glucose if vitamin B deﬁciency is suspected (e.g. in case of alcohol-related seizures) .1  a 
If seizures stop spontaneously in 5 minutes or less, see Postictal management.


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Febrile seizures frequently occur in children aged 6 months to 5 years with fever (usually due to viral infection) and no
signs of central nervous system (CNS) infection, metabolic disturbances, or history of afebrile seizures . They may be
either "simple" or "complex".  
 
 
Status epilepticus
In case of status epilepticus, start antiseizure medication (ASM).
 
Step 1 - First-line ASM treatment
Status epilepticus in pre-hospital setting
Status epilepticus in hospital setting
 [4] 
A simple febrile seizure is deﬁned as a single generalised seizure, without focal signs, that lasts less than 15 minutes,
and does not recur within a 24-hour period . Most of these seizures last less than 5 minutes and if so,


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and does not recur within a 24-hour period . Most of these seizures last less than 5 minutes and if so,
no antiseizure treatment is required. The risk of subsequent epilepsy is low after this type of seizure. Observe the
child at least until full recovery, and discharge when child returns to neurological baseline. Give instructions for
home-based management: symptomatic treatment of fever to make the child more comfortable (see Fever,
Chapter 1) and of underlying viral infection if relevant.
 [4] 
A complex febrile seizure is a seizure meeting at least one the following criteria: presence of focal signs, a duration
more than 15 minutes, or multiple seizures within a 24-hour period .  [4] 
In all cases:
Provide ﬁrst aid during a seizure.
After a seizure, see Postictal management.


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In all cases:
Provide ﬁrst aid during a seizure.
After a seizure, see Postictal management.
If a seizure lasts more than 5 minutes or recurs within 5 minutes, start treatment for status epilepticus.
 
 
ASMs may cause respiratory depression, bradycardia, and hypotension, especially in children
and older patients. 
During and after ASM administration:
have ventilation equipment (Ambu and mask) and solutions for ﬂuid replacement ready for use,
monitor RR, SpO, HR, and BP at least every 15 minutes until stable.2
Never administer ASMs by rapid IV injection. Reduce the administration rate in the event of drop in RR,
HR, or BP.
Administer one of the following benzodiazepines (BZD). The choice depends on the situation, i.e. if seizures occur
in pre-hospital or hospital setting.


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in pre-hospital or hospital setting.
In any case, do not administer more than 2 doses of BZD.
Administer midazolam (5 mg/ml solution) by buccal or intranasalroute or diazepam (5 mg/ml solution) by rectal
route. For doses to be administered, see Table 1.
 
If seizures do not stop 5 minutes after the ﬁrst dose of BZD, readminister the same dose. 
If seizures do not stop after the second dose of BZD, refer urgently to hospital for treatment with second-line
ASM(s).
If seizures stop after 1 or 2 doses of BZD, refer to hospital for further management (aetiologic treatment and
potential maintenance treatment).
While awaiting transfer, monitor vital signs, administer oxygen if available to maintain SpO > 94%. If seizures stop,
see Postictal management.
2


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Check whether a BZD has been administered before arrival at the hospital and the number of doses. If one dose was
administered, give a second dose. If 2 doses were administered, start Step 2 - Second-line ASM treatment. If no pre-hospital dose of BZD was administered:
 Table 1 - Dosage of benzodiazepines 
If IV or IO access: diazepam (5 mg/ml solution) by slow IV injection (over 3 to 5 minutes). For doses to be
administered, see Table 1.
If no IV or IO access: midazolam (5 mg/ml solution) by buccal or intranasalroute or midazolam (1 mg/ml solution)
by IM route or diazepam (5 mg/ml solution) by rectal route. For doses to be administered, see Table 1.
 
If seizures do not stop 5 minutes after the ﬁrst dose of BZD, readminister the same dose.


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If seizures do not stop 5 minutes after the ﬁrst dose of BZD, readminister the same dose. 
If seizures do not stop after the second dose of BZD, start Step 2 - Second-line ASM treatment.
If seizures recur: 
6 hours or more after seizures stop, restart treatment from Step 1 - First-line ASM treatment as for a new
seizure,
Less than 6 hours after seizures stop, continue treatment at the last point, e.g.:
if seizures recur < 6 hours after a ﬁrst dose of BZD, readminister the same dose,
if seizures recur < 6 hours after 2 doses of BZD, start Step 2 - Second-line ASM treatment.
If seizures stop after 1 or 2 doses of BZD and do not recur, see Postictal management and evaluate the need for
maintenance ASM treatment.


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If seizures stop after 1 or 2 doses of BZD and do not recur, see Postictal management and evaluate the need for
maintenance ASM treatment.
Age 1 to < 4months 4 to < 12months 1 to < 3years 3 to < 5years 5 to < 9 years  9  to < 12years ≥ 12 years adults
Weight 3 to < 6kg 6 to < 10kg 10 to < 15kg 15 to < 20kg 20 to < 30 kg 30 to < 40 kg ≥ 40 kg
midazolam buccal  or intranasal route , dose in ml (5 mg/ml solution)   (a)  (b) 
  0.25 ml 0.4 ml 0.6 ml 1 ml 1.2 ml 2 ml 2 ml
midazolam IM route, dose in ml (1 mg/ml solution)   
  0.6 ml 1.2 ml 2 ml 3 ml 4 ml 6 ml 10 ml
diazepam rectal route , dose in ml (5 mg/ml solution)    (c) 
  0.4 ml 0.7 ml 1.2 ml 1.5 ml 2 ml 2 ml 2 to 4 ml (d)
diazepam slow IV route, dose in ml (5 mg/ml solution)  
  0.25 ml 0.4 ml 0.6 ml 1 ml 1.2 ml 2 ml 2 ml (d)


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diazepam slow IV route, dose in ml (5 mg/ml solution)  
  0.25 ml 0.4 ml 0.6 ml 1 ml 1.2 ml 2 ml 2 ml (d)
(a) Midazolam buccal route: lay the patient on their side. Withdraw the required dose using a 1 ml or 2 ml syringe. Remove theneedle. Insert the tip of the syringe into the space between the gum and cheek. Administer the dose by slowly pushing thesyringe plunger.


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(b) Midazolam intranasal route: lay the patient on their back or side. Withdraw the required dose using a 1 ml or 2 ml syringe(add an additional 0.1 ml to the calculated dose to account for the remaining liquid in the atomising device). Remove theneedle. Attach the intranasal atomisation device to the syringe. Briskly push the syringe plunger to spray the dose into thenostril. The dose can be split in both nostrils to reduce irritation.


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(c) Diazepam rectal route: lay the patient on their side. For volumes up to 1 ml, use a 1 ml syringe. Withdraw the required dose.Remove the needle. Insert the syringe into the rectum for a length of 1 to 3 cm (depending on age) to administer the dose.For volumes greater than 1 ml, use a 2 ml syringe and attach to the tip of the syringe a nasogastric tube n°8 cut to a lengthof 2 to 3 cm to administer the dose. After administration, hold the buttocks together for at least one minute.


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Step 2 - Second-line ASM treatment
Patients with no known epilepsy
Second-line ASMs are indicated for:
The choice of the ASM depends on the patient’s characteristics: age, sex, pregnancy or breastfeeding status, and
comorbidities. See Table 2. 
For doses to be administered, see Table 3 Table 2 - Choice of a second-line antiseizure medication 
Patients with known epilepsy
(d) In patients ≥ 65 years: for diazepam rectal, do not exceed 2 ml (= 10 mg) per dose; for diazepam IV, reduce the dose by half(1 ml = 5 mg per dose).
Children, if seizures do not stop within 5 minutes of second dose of BZD.
All adults, even if seizures stop after 1 or 2 doses of BZD, unless a reversible cause of seizure can be quickly
treated (e.g. hypoglycaemia, electrolyte disturbances).


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treated (e.g. hypoglycaemia, electrolyte disturbances).
  Children 1 month to < 2 years
Girls ≥ 10 years and women
Girls 2 to < 10 years
Boys ≥ 2 years and men
 
First choice levetiracetam (LEV) (e) levetiracetam (LEV) or
valproic acid (VPA)
 (e) 
 (f)
Second choice phenobarbital (PB) (g) phenobarbital (PB) (g)
Third choice phenytoin (PHT) (h) phenytoin (PHT) (h)
(e) LEV can be used in all patients but with caution in patients with renal impairment or heart disorders.


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(e) LEV can be used in all patients but with caution in patients with renal impairment or heart disorders.
(f) VPA is contraindicated:• in children under 2 years and patients with hepatic disease;• in women and girls who are or may become pregnant. Every effort should be made to ﬁnd a safer alternative to VPA inpregnant women and girls. However, prolonged status epilepticus is a life-threatening condition both for the mother andthe unborn child. If VPA is the only ASM available, use the lowest possible dose. 
(g) PB is contraindicated in patients with severe impairment of respiratory, renal or hepatic function. It should be administeredwith caution in children, older patients and patients with mild to moderate impairment of respiratory, renal or hepaticfunction.


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(h) PHT is contraindicated in patients with bradycardia, atrioventricular block. It should be administered with caution inpatients with hepatic impairment, heart failure, cardiac rhythm disorders, hypotension.
If seizures do not stop after second-line ASM, change to another second-line ASM.
If seizures do not stop or recur in < 6 hours despite 2 second-line ASMs, transfer the patient to an intensive care
unit for treatment of refractory status epilepticus.
If seizures stop after 1 or 2 second-line ASM(s), see Postictal management and Maintenance ASM treatment.
History taking:
ASM and dose taken, effectiveness.
Missed doses if any, and reason (e.g. forgetting, interruption due to adverse effects, shortage of medication).
Management:


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Missed doses if any, and reason (e.g. forgetting, interruption due to adverse effects, shortage of medication).
Management:
Administer the IV loading dose of the medication that the patient should usually take or see Table 2.


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Step 3 - Maintenance ASM treatment 
Some patients may require maintenance treatment after the loading dose. 
Unless the child has already received a loading dose, start with a loading dose, see Table 3. 
 
Postictal management
Frequent causes of seizures
If seizures do not stop, continue treatment as for patients with no known epilepsy.
If seizures stop after 1 or 2 second-line ASM(s), see Postictal management and Maintenance ASM treatment.
In children, maintenance treatment is indicated when:
a second-line ASM has been used to control seizures, unless a reversible cause of seizure can be quickly
treated (e.g. hypoglycaemia, electrolyte disturbances),
3 or more seizures occur within a 24-hour period,


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treated (e.g. hypoglycaemia, electrolyte disturbances),
3 or more seizures occur within a 24-hour period,
focal signs and/or impaired consciousness persist beyond expected postictal period,
there is known or presumed traumatic brain injury (within 24 hours of injury),
there is known or presumed epilepsy.
In adults, maintenance treatment is indicated for all patients, unless a reversible cause of seizure can be quickly
treated (e.g. hypoglycaemia, electrolyte disturbances).
If seizures do not recur, administer maintenance treatment for 48 to 72 hours and then reassess. Use oral route (or
nasogastric tube). For maintenance doses to be administered, see Table 3.
For seizures in the context of head trauma, maintenance treatment should last 7 days.


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For seizures in the context of head trauma, maintenance treatment should last 7 days.
In case of epilepsy, start or resume long-term treatment. See Epilepsy, Chapter 12.
Note time of end of seizure; keep patient in recovery position; maintain airway.
Administer oxygen to all patients if available and especially to patients who received ASM(s). Maintain SpO > 94%.2
Monitor vital signs and SpO every 15 minutes until stable, then every hour.2
Closely monitor RR if the patient received BZD, PB or PHT; HR and BP (and ECG if available) if the patient
received PHT.
Observe for further seizures.
As soon as possible, try to identify the underlying cause and treat it, even in patients with known epilepsy (see
Frequent causes of seizures):


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As soon as possible, try to identify the underlying cause and treat it, even in patients with known epilepsy (see
Frequent causes of seizures):
Take a detailed history and perform a full clinical examination, looking particularly for general status and focal
signs.
Depending on assessment, perform the following tests if available:
capillary blood glucose, especially if not done during the seizure. Check regularly blood glucose if necessary.
rapid diagnostic test for malaria in endemic areas
CSF examination (lumbar puncture) and culture
white blood cell count, serum electrolytes and creatinine, liver enzymes and coagulation tests, blood culture
Note if patient does not return to baseline status within 30 to 60 minutes of end of seizure.


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Note if patient does not return to baseline status within 30 to 60 minutes of end of seizure.
Febrile seizures: in young children with fever, usually in a context of a respiratory or gastrointestinal viral infection.
CNS infections: e.g. any meningitis (for Bacterial meningitis, see Chapter 7); severe malaria, neurocysticercosis,
trypanosomiasis (see Chapter 6); cerebral toxoplasmosis, cryptococcal meningitis (see HIV infection and AIDS,
Chapter 8).
Metabolic abnormalities: e.g. hypoglycaemia (Chapter 1), electrolyte disorders (hyponatremia, hypocalcaemia).
Intoxications: e.g. psychoactive drugs and alcohol, methanol, medications, neurotoxic pesticides and venoms,
carbon monoxide.


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Dosage of second-line antiseizure medications
Table 3 - Second-line antiseizure medications (loading doses and maintenance doses) 
Withdrawal from CNS depressants: e.g. alcohol (see Agitation and Acute confusional state, Chapter 11), opioids,
benzodiazepines, barbiturates.
Use of seizure-provoking drugs: many drugs may be involved, e.g. antidepressants, antipsychotics, some
antimicrobials.
Vitamin B deﬁciencies (thiamine and pyridoxine), particularly in patients with chronic alcohol consumption.
Epilepsy: undiagnosed epilepsy, poor adherence to treatment, ineffective treatment or abrupt stop of ASM.
Head trauma, CNS tumour, stroke, sepsis, encephalopathy (e.g. hypertensive, hypoxic).


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ASMs Loading dose Maintenance dose
levetiracetam
= LEV
500 mg in 5 ml vial (100 mg/ml)
Children ≥ 1 month:
Use diluted solution: add 3 ml
(300 mg) of LEV to 17 ml of 0.9%
NaCl to obtain 20 ml of
solution containing 15 mg of LEV
per ml.
Administer 40 mg/kg (max. 3
g) over 10 minutes by IV infusion
using a syringe pump or by very
slow IV injection. 
If seizures do not stop after the
end of the ﬁrst dose,
readminister half-dose: 20 mg/kg
(max. 1.5 g) as above.
Do not exceed the total dose of
60 mg/kg or 4.5 g.
Do not exceed an infusion rate of
5 mg/kg/minute.
12 hours after the loading dose:
7 mg/kg every 12 hours PO
10 mg/kg every 12 hours PO
Children 1 to 5 months: 
Children 6 months to 15 years:
Adults  : (i) 
60 mg/kg (max. 4.5 g) single dose
over 15 minutes


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10 mg/kg every 12 hours PO
Children 1 to 5 months: 
Children 6 months to 15 years:
Adults  : (i) 
60 mg/kg (max. 4.5 g) single dose
over 15 minutes 
Use diluted solution as above (15
mg/ml) if administered by IV
infusion using a syringe pump.
Use undiluted solution if
administered by IV infusion in a bag
of 100 ml of 0.9% NaCl.
Do not exceed an infusion rate of
5 mg/kg/minute
12 hours after the loading dose:
Adults: 1 to 1.5 g every 12
hours PO
phenobarbital
= PB
200 mg in 1 ml ampoule (200
mg/ml)
Children ≥ 1 month:
Use diluted solution: add 1 ml (200
mg) of PB to 9 ml of 0.9% NaCl
to obtain 10 ml of
solution containing 20 mg of PB
per ml.
Administer 20 mg/kg (max. 1 g)
over 20 minutes by IV infusion
using a syringe pump (or only if not
available, using a pediatric infusion
set).


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Administer 20 mg/kg (max. 1 g)
over 20 minutes by IV infusion
using a syringe pump (or only if not
available, using a pediatric infusion
set).
If seizures do not stop after the
end of the ﬁrst dose, readminister
half-dose: 10 mg/kg as above.
Do not exceed an infusion rate of
1 mg/kg/minute.
12 hours after the loading dose:
Children 1 to 11 months: 5 to 6
mg/kg once daily PO
Children 1 to 5 years: 6 to 8
mg/kg once daily PO
Children 6 to 12 years: 4 to 6
mg/kg once daily PO
Children > 12 years: 1 to 3
mg/kg once daily PO


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Adults:
15 mg/kg (max. 1 g) single dose
over 15 minutes 
Use diluted solution as above (20
mg/ml) if administered by IV
infusion using a syringe pump.
Use undiluted solution if
administered by IV infusion in a bag
of 100 ml of 0.9% NaCl. 
Do not exceed an infusion rate of
100 mg/minute.
12 hours after the loading dose:
Adults: 60 to 180 mg once
daily PO
phenytoin
= PHT
250 mg in 5 ml
ampoule or vial (50 mg/ml)
 
 
 
    
 
Use a large central or
peripheral vein.
Use a infusion set or line with
a 0.2 micron ﬁlter.
Before and after infusion,
ﬂush the catheter with 0.9%
NaCl to limit venous irritation
and potential incompatibility
with other drugs.
DO NOT DILUTE IN
GLUCOSE. 
Do not use a line used for
glucose solution.
Children ≥ 1 month and ≤ 25 kg


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with other drugs.
DO NOT DILUTE IN
GLUCOSE. 
Do not use a line used for
glucose solution.
Children ≥ 1 month and ≤ 25 kg
Use diluted solution: add 1 ml (50
mg) of PHT to 9 ml of 0.9% NaCl
to obtain 10 ml of
solution containing 5 mg of PHT
per ml. 
Administer 20 mg/kg (max. 2
g) single dose over 20 minutes by
IV infusion using a syringe pump.
Only if syringe pump is not
available, use a paediatric infusion
set.
Do not exceed an infusion rate of
1 mg/kg/minute.
12 hours after the loading dose:
Children: 2.5 mg/kg every 12 hours
PO
Children > 25 kg and adults (j)
Add undiluted solution to a 100 ml
bag of 0.9% NaCl. 
Administer 20 mg/kg (max. 2 g)
single dose by IV infusion at the
following rate:
≤ 1 g or ≤ 50 kg: 20 minutes
> 1 g and ≤ 1.5 g or > 50 kg
and ≤ 75 kg: 30 minutes


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single dose by IV infusion at the
following rate:
≤ 1 g or ≤ 50 kg: 20 minutes
> 1 g and ≤ 1.5 g or > 50 kg
and ≤ 75 kg: 30 minutes
> 1.5 g and ≤ 2 g or > 75 kg
and ≤ 100 kg: 40 minutes
Do not exceed an infusion rate of
50 mg/minute.
 
 
 
 
 
 
 
 
 
 
 
 
 
12 hours after the loading dose:
 
Adults: 3 to 4 mg/kg once daily
PO
Older patients (≥ 65 years)
and adults with cardiac disorders
Add undiluted solution to a 100 ml
bag of 0.9% NaCl. 
Administer 20 mg/kg (max. 2 g)
single dose by IV infusion at the
following rate:
≤ 1 g or ≤ 50 kg: 40 minutes


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> 1 g and ≤ 1.5 g or > 50 kg
and ≤ 75 kg: 60 minutes
> 1.5 g and ≤ 2 g or > 75 kg
and ≤ 100 kg: 80 minutes
Do not exceed an infusion rate of
25 mg/minute.
valproic acid
= VPA (or sodium valproate)
400 mg in 4 ml ampoule (100
mg/ml)
 (k)
Children ≥ 2 years: 
Use diluted solution: add 4 ml (400
mg) of VPA to 6 ml of 0.9% NaCl
to obtain 10 ml
of solution containing 40 mg of
VPA per ml.
Administer 20 mg/kg (max. 1.5 g)
over 5 minutes by IV infusion using
a syringe pump or by slow IV
injection.
If seizures do not stop after the
end of the ﬁrst dose, readminister
the same dose: 20 mg/kg (max.
1.5 g) as above. 
Do not exceed the total dose
of 40 mg/kg or 3 g. 
Do not exceed an infusion rate of
6 mg/kg/minute
6 to 8 hours after the loading dose:


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Do not exceed the total dose
of 40 mg/kg or 3 g. 
Do not exceed an infusion rate of
6 mg/kg/minute
6 to 8 hours after the loading dose:
5 to 7.5 mg/kg (max. 600 mg) 2 times
daily PO
Children ≥ 2 years:
Adults : (i) 
40 mg/kg (max. 3 g) single dose
over 10 minutes 
Use diluted solution as above (40
mg/ml) if administered by IV
infusion using a syringe pump.
Use undiluted solution if
administered by IV infusion in a bag
of 100 ml of 0.9% NaCl. 
Do not exceed an infusion rate of
6 mg/kg/minute.
12 hours after the loading dose:
Adults: 1 g 2 times daily PO 
(i) Reduce dosage in patients with renal impairment.
(j) Reduce dosage in patients with hepatic impairment.


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Adults: 1 g 2 times daily PO 
(i) Reduce dosage in patients with renal impairment.
(j) Reduce dosage in patients with hepatic impairment.
(k) For a pregnant woman, if VPA is the only ASM available, use the lowest possible loading dose (an option could be toadminister 20 mg/kg over 5 minutes, then repeat the same dose only if seizures do not stop by the end of the ﬁrst dose).


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References
Footnotes
(a) Thiamine should be administered at the same time as glucose because glucose may precipitate Wernicke's encephalopathyin patients with chronic alcohol consumption. Treatment should be continued for 3 to 5 days with thiamine PO (100 to 200mg once daily) or IM (100 mg once daily).
1. Lowenstein DH, Bleck T, Macdonald RL. It’s Time to Revise the Deﬁnition of Status Epilepticus. Epilepsia. 1999;40(1):120-122. https://doi.org/10.1111/j.1528-1157.1999.tb02000.x
2. Brophy GM, Bell R, Claassen J, et al. Guidelines for the Evaluation and Management of Status Epilepticus. Neurocrit Care.2012;17:3-23.https://higherlogicdownload.s3.amazonaws.com/NEUROCRITICALCARE/b8b3b384-bfb9-42af-bb55-45973d5054a4/UploadedImages/Documents/Guidelines/SE_Guidelines_NCS_0412.pdf


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3. Pottkämper JCM, Hofmeijer J, Van Waarde JA, Van Putten MJAM. The postictal state — What do we know? Epilepsia.2020;61(6):1045-1061.https://doi.org/10.1111/epi.16519
4. Steering Committee on Quality Improvement and Management, Subcommittee on Febrile Seizures. Febrile Seizures: ClinicalPractice Guideline for the Long-term Management of the Child With Simple Febrile Seizures. Pediatrics. 2008;121(6):1281-1286.https://doi.org/10.1542/peds.2008-0939


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Hypoglycaemia
Last update: November 2023
 
Hypoglycaemia is an abnormally low concentration of blood glucose. Severe hypoglycaemia can be fatal or lead to
irreversible neurological damage.
Blood glucose levels should be measured whenever possible in patients presenting symptoms of hypoglycaemia. If
hypoglycaemia is suspected but blood glucose measurement is not available, glucose (or another available sugar)
should be given empirically.
Always consider hypoglycaemia in patients presenting impaired consciousness (lethargy, coma) or seizures.
For diagnosis and treatment of hypoglycaemia in neonates, refer to the guide Essential obstetric and newborn care,
MSF.
Clinical features


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For diagnosis and treatment of hypoglycaemia in neonates, refer to the guide Essential obstetric and newborn care,
MSF.
Clinical features
Rapid onset of non-speciﬁc signs, mild to severe depending on the degree of the hypoglycaemia: sensation of hunger
and fatigue, tremors, tachycardia, pallor, sweats, anxiety, blurred vision, difﬁculty speaking, confusion, convulsions,
lethargy, coma.
Diagnosis
Capillary blood glucose concentration (reagent strip test):
 If blood glucose measurement is not available, diagnosis is conﬁrmed when symptoms resolve after the administration
of sugar or glucose.
Symptomatic treatment
Symptoms improve approximately 15 minutes after taking sugar by oral route.


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of sugar or glucose.
Symptomatic treatment
Symptoms improve approximately 15 minutes after taking sugar by oral route. 
Neurological symptoms improve a few minutes after the injection. Check blood glucose after 15 minutes. If it is still low, re-administer glucose by IV route or sugar by oral route according
to the patient’s clinical condition.
If there is no clinical improvement, differential diagnoses should be considered: e.g. serious infection (severe malaria,
meningitis, etc.), epilepsy, unintentional alcohol intoxication or adrenal insufﬁciency in children.
In all cases, after stabilisation, give a meal or snack rich in complex carbohydrates and monitor the patients for a few
hours.
Non-diabetic patients:
Hypoglycaemia: < 3.3 mmol/litre (< 60 mg/dl)


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hours.
Non-diabetic patients:
Hypoglycaemia: < 3.3 mmol/litre (< 60 mg/dl)
Severe hypoglycaemia: < 2.2 mmol/litre (< 40 mg/dl)
Diabetic patients on home treatment: < 3.9 mmol/litre (< 70 mg/dl) [1]
Conscious patients:
Children: a teaspoon of powdered sugar in a few ml of water or 50 ml of fruit juice, maternal or therapeutic milk
or 10 ml/kg of 10% glucose by oral route or nasogastric tube.
Adults: 15 to 20 g of sugar (3 or 4 cubes) or sugar water, fruit juice, soda, etc.
Patients with impaired consciousness or prolonged convulsions:
Children: 2 ml/kg of 10% glucose by slow IV (2 to 3 minutes)   a 
Adults: 1 ml/kg of 50% glucose by slow IV (3 to 5 minutes)


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If patient does not return to full alertness after an episode of severe hypoglycaemia, monitor blood glucose levels
regularly.
Aetiological treatment
 
References
Other than diabetes:
Treat severe acute malnutrition, neonatal sepsis, severe malaria, acute alcohol intoxication, etc.
End prolonged fast.
Replace drugs inducing hypoglycaemia (e.g. quinine IV, pentamidine, ciproﬂoxacin, enalapril, beta-blockers, high-
dose aspirin, tramadol), or anticipate hypoglycaemia (e.g. administer quinine IV in a glucose infusion).
In diabetic patients:
Avoid missing meals, increase intake of carbohydrates if necessary.
Adjust dosage of insulin according to blood glucose levels and physical activity.
Adjust dosage of oral antidiabetics, taking into account possible drug interactions.


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Adjust dosage of oral antidiabetics, taking into account possible drug interactions.
Footnotes
(a) If ready-made 10% glucose solution is not available: remove 100 ml of 5% glucose from a 500 ml bottle or bag, then add 50ml of 50% glucose to the remaining 400 ml of 5% glucose to obtain 450 ml of 10% glucose solution.
1. American Diabetes Association. Standards of Care in Diabetes—2023 Abridged for Primary Care Providers. Clinical Diabetes.2022;41(1):4-31.https://doi.org/10.2337/cd23-as01


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Fever
Last updated: December 2023
 
Fever is deﬁned as an axillary temperature higher than 37.5 °C.
Fever is frequently due to infection. In a febrile patient, ﬁrst look for signs of serious illness then, try to establish a
diagnosis.
Signs of severity
Infectious causes of fever according to signs and symptoms
Petechial or purpuric rash, meningeal signs, heart murmur, severe abdominal pain, dehydration.
Signs of severe bacterial infection or sepsis: critically ill appearance , hypothermia, altered level of consciousness,
severe tachycardia, hypotension, tachypnoea, respiratory distress, seizures; a bulging fontanel in young children.
 a 
Signs of circulatory impairment or shock: see Shock, Chapter 1.


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Laboratory and other examinations
Signs or symptoms Possible aetiology
Meningeal signs, seizures Meningitis/meningoencephalitis/severe malaria
Abdominal pain or peritoneal signs Appendicitis/peritonitis/enteric fevers/amaebic liver abscess
Diarrhoea, vomiting Gastroenteritis/enteric fevers
Jaundice, enlarged liver Viral hepatitis
Cough Pneumonia/measles/tuberculosis if persistent
Eyelid erythema, eye pain and oedema Orbital cellulitis
Ear pain, red tympanic membrane Otitis media
Tender swelling behind the ear Mastoiditis
Sore throat, enlarged lymph nodes Streptococcal pharyngitis/diphtheria/retropharyngeal or tonsillar
abscess/epiglotittis
Multiple vesicles on the oral mucosa and lips Oral herpes
Dysuria, urinary frequency, back pain Urinary tract infection


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abscess/epiglotittis
Multiple vesicles on the oral mucosa and lips Oral herpes
Dysuria, urinary frequency, back pain Urinary tract infection
Red, warm, painful skin Erysipelas/cellulitis/necrotising infections of the skin and soft
tissues/abscess
Limp, difﬁculty walking Osteomyelitis/septic arthritis
Rash Measles/dengue/viral haemorrhagic fevers/chikungunya
Bleeding (petechiae, epistaxis, etc.) Dengue/viral haemorrhagic fevers/severe malaria
Joint pain Rheumatic fever/chikungunya/dengue
If the patient is ill appearing and has a persistent fever, consider HIV infection and tuberculosis, according to
clinical presentation.
 a 
Malaria rapid diagnostic test in endemic areas.
In case of circulatory impairment or shock: see Shock, Chapter 1. 
Children 1 to 3 months with fever without a focus:


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In case of circulatory impairment or shock: see Shock, Chapter 1. 
Children 1 to 3 months with fever without a focus:
urine dipstick and urine culture, if available;
blood culture, if available;
full blood count (FBC), if available;


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Aetiological treatment
Symptomatic treatment
paracetamol PO 
Children 1 month and over: 15 mg/kg 3 to 4 times daily (max. 60 mg/kg daily)
Adults: 1 g 3 to 4 times daily (max. 4 g daily)
or
ibuprofen PO
Children over 3 months and < 12 years: 5 to 10 mg/kg 3 to 4 times daily (max. 30 mg/kg daily)
Children 12 years and over and adults: 200 to 400 mg 3 to 4 times daily (max. 1200 mg daily)
or
acetylsalicylic acid (ASA) PO
Children over 16 years and adults: 500 mg to 1 g 3 to 4 times daily (max. 4 g daily)
lumbar puncture (LP) if meningeal signs or signs of severe bacterial infection or sepsis, or failure of prior
antibiotic treatment;
chest x-ray, if available, in case of signs of respiratory disease or severe infection or sepsis.


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antibiotic treatment;
chest x-ray, if available, in case of signs of respiratory disease or severe infection or sepsis.
Children > 3 months to 2 years with fever without a focus:
urine dipstick and urine culture, if available;
LP if meningeal signs or signs of severe bacterial infection or sepsis;
chest x-ray, if available, if fever > 72 hours or signs of severe bacterial infection or sepsis;
blood culture, if available, if fever > 72 hours or signs of severe bacterial infection or sepsis;
FBC, if available, if fever > 72 hours or signs of severe bacterial infection or sepsis;
other: according to clinical presentation.
Children over 2 years with fever without a focus:
urine dipstick and urine culture, if available, if history of urinary tract infection or fever > 72 hours or signs of


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urine dipstick and urine culture, if available, if history of urinary tract infection or fever > 72 hours or signs of
severe bacterial infection or sepsis;
LP if meningeal signs or signs of severe bacterial infection or sepsis;
chest x-ray, if available, if fever > 72 hours or signs of severe bacterial infection or sepsis;
blood culture, if available, if fever > 72 hours or signs of severe bacterial infection or sepsis;
FBC, if available, if fever > 72 hours or signs of severe bacterial infection or sepsis;
other: according to clinical presentation.
Adults: according to clinical presentation.
Treat patients with a positive malaria test: see Malaria, Chapter 6.
If the source of infection has been found: administer antibiotic treatment accordingly.


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If the source of infection has been found: administer antibiotic treatment accordingly.
If severe infection, sepsis, circulatory impairment or shock: hospitalise and immediately administer an empiric
antibiotic treatment (see Shock, Chapter 1). Continue this treatment until the source of infection is found and adapt
antibiotic treatment accordingly.
If no source of infection is found, and there are no signs of severe infection, sepsis, circulatory impairment or
shock, hospitalise for further investigations and monitoring:
Children 1 to 3 months;
Children > 3 months to < 2 years with negative urine dipstick (and negative urine culture if available).
For malnourished children, see Severe acute malnutrition, Chapter 1.


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For malnourished children, see Severe acute malnutrition, Chapter 1.
For patients with sickle cell disease, see Sickle cell disease, Chapter 12.
Undress the patient. Do not wrap children in wet towels or cloths (not effective, increases discomfort, risk of
hypothermia).
Antipyretics may increase the patient’s comfort but they do not prevent febrile convulsions. Do not treat for more
than 3 days with antipyretics.


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Prevention of complications
 Notes:
 
Encourage oral hydration. Continue frequent breastfeeding in infants.
Look for signs of dehydration.
Monitor urine output.
In pregnant or breast-feeding women use paracetamol only.
In case of viral haemorrhagic fevers and dengue: acetylsalicylic acid and ibuprofen are contraindicated; use
paracetamol with caution in the presence of hepatic dysfunction.
Footnotes
(a) Critically ill appearing child: weak grunting or crying, drowsiness, difﬁcult to arrouse, does not smile, disconjugate or anxiousgaze, pallor or cyanosis, general hypotonia.


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Pain
Pain results from a variety of pathological processes. It is expressed differently by each patient depending on cultural
background, age, etc. It is a subjective experience meaning that only the individual is able to assess his/her level of pain.
Regular assessment of the intensity of pain is indispensable in establishing effective treatment.
Clinical features
Pain assessment
Clinical examination
Synthesis
The synthesis of information gathered during history taking and clinical examination allows aetiological diagnosis and
orients treatment. It is important to distinguish:
Pain evaluation scales
Self-evaluation scale - Children over 5 years and adults
Simple verbal scale (SVS)


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Pain evaluation scales
Self-evaluation scale - Children over 5 years and adults
Simple verbal scale (SVS)
Intensity: use a simple verbal scale in children over 5 years and adults, and NFCS or FLACC scales in children less
than 5 years (see Pain evaluation scales).
Pattern: sudden, intermittent, chronic; at rest, at night, on movement, during care procedures, etc.
Character: burning, cramping, spasmodic, radiating, etc.
Aggravating or relieving factors, etc.
Of the organ or area where the pain is located.
Speciﬁc signs of underlying disease (e.g. bone or osteoarticular pain may be caused by a vitamin C deﬁciency) and
review of all systems.
Associated signs (fever, weight loss, etc.).


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review of all systems.
Associated signs (fever, weight loss, etc.).
Nociceptive pain: it presents most often as acute pain and the cause-effect relationship is usually obvious (e.g.
acute post-operative pain, burns, trauma, renal colic, etc.). The pain may be present in different forms, but
neurological exam is normal. Treatment is relatively well standardized.
Neuropathic pain, due to a nerve lesion (section, stretching, ischaemia): most often chronic pain. On a background
of constant, more or less localized pain, such as paraesthesia or burning, there are recurrent acute attacks such as
electric shock-like pain, frequently associated with disordered sensation (anaesthesia, hypo or hyperaesthesia).


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electric shock-like pain, frequently associated with disordered sensation (anaesthesia, hypo or hyperaesthesia).
This type of pain is linked to viral infections directly affecting the CNS (herpes simplex, herpes zoster), neural
compression by tumors, post- amputation pain, paraplegia, etc.
Mixed pain (cancer, HIV) for which management requires a broader approach.
Intensity
of pain
No 
pain
Mild
pain
Moderate
pain Severe pain
Scoring 0 1 2 3
Write down 0 + ++ +++


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Observational evaluation scale - Children 2 months-5 years
FLACC scale (Face Limb Activity Cry Consolability)
 Each category is scored from 0 to 2, giving a ﬁnal score between 0 and 10.
0 to 3: mild pain, 4 to 7: moderate pain, 7 to 10: severe pain
Observational evaluation scale - Children under 2 months
NFCS scale (Neonatal Facial Coding System)
 A score of 2 or more signiﬁes signiﬁcant pain, requiring analgesic treatment.
Treatment
Treatment depends on the type and intensity of the pain. It may be both aetiological and symptomatic if a treatable
cause is identiﬁed. Treatment is symptomatic only in other cases (no cause found, non-curable disease).
 
Items
Scoring
0 1 2
Face No particular
expression or smile
Occasional grimace or frown, withdrawn,
disinterested


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Items
Scoring
0 1 2
Face No particular
expression or smile
Occasional grimace or frown, withdrawn,
disinterested
Frequent to constant frown,
clenched jaw, quivering chin
Legs Normal position or
relaxed
Uneasy, restless, tense Kicking, or legs drawn up
Activity Lying quietly, normal
position, moves easily
Squirming, shifting back and forth, tense Arched, rigid or jerking
Cry No cry (awake or
asleep)
Moans or whimpers, occasional
complaint
Crying steadily, screams or
sobs, frequent complaints
Consolability Content, relaxed Reassured by occasional touching,
hugging or being talked to, distractible
Difﬁcult to console or comfort
 
Items
Scoring
0 1
Brow bulge no yes
Eye squeeze no yes
Nasolabial furrow no yes
Open lips no yes


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Nociceptive pain
The WHO classiﬁes analgesics used for this type of pain on a three-step ladder:
 The treatment of pain is based on a few fundamental concepts:
Treatment of acute pain
 
Step 1: non-opioid analgesics such as paracetamol and nonsteroidal anti-inﬂammatory drugs (NSAIDs).
Step 2: weak opioid analgesics such as codeine and tramadol. Their combination with one or two Step 1 analgesics
is recommended.
Step 3: strong opioid analgesics, ﬁrst and foremost morphine. Their combination with one or two Step 1 analgesics
is recommended.
Pain can only be treated correctly if it is correctly evaluated. The only person who can evaluate the intensity of pain
is the patient himself. The use of pain assessment scales is invaluable.


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is the patient himself. The use of pain assessment scales is invaluable.
The pain evaluation observations should be recorded in the patient chart in the same fashion as other vital signs.
Treatment of pain should be as prompt as possible.
It is recommended to administer analgesics in advance when appropriate (e.g. before painful care procedures).
Analgesics should be prescribed and administered at ﬁxed time intervals (not on demand).
Oral forms should be used whenever possible.
The combination of different analgesic drugs (multimodal analgesia) is advantageous.
Start with an analgesic from the level presumed most effective: e.g., in the event of a fractured femur, start with a
Step 3 analgesic.


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Start with an analgesic from the level presumed most effective: e.g., in the event of a fractured femur, start with a
Step 3 analgesic.
The treatment and dose chosen are guided by the assessment of pain intensity, but also by the patient’s response
which may vary signiﬁcantly from one person to another.
Mild pain Paracetamol + /- NSAID
Moderate pain Paracetamol + /- NSAID + tramadol or codeine
Severe pain Paracetamol + /- NSAID + morphine


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Analgesics Children
Adults (except
pregnant/breast-feeding
women)
Remarks
Level
1
paracetamol
PO
< 1 month: 10 mg/kg
every 6 to 8 hours (max.
40 mg/kg daily)
≥ 1 month: 15 mg/kg
every 6 to 8 hours (max.
60 mg/kg daily)
 
1 g every 6 to 8 hours (max.
4 g daily)
The efﬁcacy of IV paracetamol
is not superior to the efﬁcacy of
oral paracetamol; the IV route is
restricted to situations where
oral administration is impossible.
paracetamol
IV
< 1 month: 7.5 mg/kg
every 6 hours (max. 30
mg/kg daily)
≥ 1 month and < 10 kg: 10
mg/kg every 6 hours (max.
30 mg/kg daily)
≥ 10 kg: 15 mg/kg every 6
hours (max. 60 mg/kg
daily)
< 50 kg: 15 mg/kg every 6
hours (max. 60 mg/kg daily)
≥ 50 kg: 1 g every 6 hours
(max. 4 g daily)
acetylsalicylic
acid (aspirin)
PO
– 300 mg to 1 g every 4 to 6


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hours (max. 60 mg/kg daily)
≥ 50 kg: 1 g every 6 hours
(max. 4 g daily)
acetylsalicylic
acid (aspirin)
PO
– 300 mg to 1 g every 4 to 6
hours (max. 4 g daily)
Avoid in children less than 16
years.
diclofenac IM – 75 mg once daily Treatment must be as short as
possible.
Respect contra-indications.ibuprofen PO > 3 months: 5 to 10 mg/kg
every 6 to 8 hours (max.
30 mg/kg daily)
> 12 years: as for adults
200 to 400 mg every 6 to 8
hours (max. 1200 mg daily)
Level
2
 
 
codeine PO > 12 years: 30 to 60 mg
every 4 to 6 hours (max.
240 mg daily)
30 to 60 mg every 4 to 6
hours (max. 240 mg daily)
Add a laxative if treatment > 48
hours.
tramadol PO > 12 years: 50 to 100 mg
every 4 to 6 hours (max.
400 mg daily)
50 to 100 mg every 4 to 6
hours (max. 400 mg daily)
 
25 to 50 mg every 12 hours in


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every 4 to 6 hours (max.
400 mg daily)
50 to 100 mg every 4 to 6
hours (max. 400 mg daily)
 
25 to 50 mg every 12 hours in
elderly patients and in patients
with severe renal or hepatic
impairment.
 
tramadol IM,
slow IV or
infusion
> 12 years: 50 to 100 mg
every 4 to 6 hours (max.
600 mg daily)
50 to 100 mg every 4 to 6
hours (max. 600 mg daily)
Level
3
morphine PO
immediate
release (MIR)
> 6 months: 0.15 mg/kg
every 4 hours, to be
ajusted in relation to pain
intensity
10 mg every 4 hours, to be
ajusted in relation to pain
intensity
• Reduce the dose by half in
elderly patients and patients
with renal or hepatic impairment.


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 Notes on the use of morphine and derivatives:
The RR should remain equal to or greater than the thresholds indicated below:
  Respiratory depression must be identiﬁed and treated quickly: verbal and physical stimulation of the patient;
administration of oxygen; respiratory support (bag and mask) if necessary. If no improvement, administer naloxone
(antagonist of morphine) in bolus to be repeated every minute until RR normalises and the excessive drowsiness
resolves: 5 micrograms/kg in children and 1 to 3 micrograms/kg in adults.
• Add a laxative if treatment >
48 hours.
morphine PO
sustained
release (MSR)
The daily dose is
determined during the
initial treatment with
immediate release
morphine (MIR).
If treatment is initiated
directly with MSR:
> 6 months: 0.5 mg/kg


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determined during the
initial treatment with
immediate release
morphine (MIR).
If treatment is initiated
directly with MSR:
> 6 months: 0.5 mg/kg
every 12 hours, to be
ajusted in relation to pain
intensity
The daily dose is
determined during the initial
treatment with immediate
release morphine (MIR).
If treatment is initiated
directly with MSR:
30 mg every 12 hours, to
be ajusted in relation to
pain intensity
• Do not initiate treatment with
the MSR in elderly patients and
patients with renal or hepatic
impairment. Begin treatment
with MIR.
• Add a laxative if treatment >
48 hours.
morphine SC,
IM
> 6 months: 0.1 to 0.2
mg/kg every 4 hours
0.1 to 0.2 mg/kg every 4
hours
• Reduce doses by half and
administer less frequently,
according to clinical response, in
elderly patients and patients


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hours
• Reduce doses by half and
administer less frequently,
according to clinical response, in
elderly patients and patients
with severe renal or hepatic
impairment.
• Add a laxative if treatment >
48 hours.
morphine IV > 6 months: 0.1 mg/kg
administered in
fractionated doses (0.05
mg/kg every 10 minutes)
every 4 hours if necessary
0.1 mg/kg administered in
fractionated doses (0.05
mg/kg every 10 minutes)
every 4 hours if necessary
Morphine is an effective treatment for many types of severe pain. Its analgesic effect is dosedependent. Its
adverse effects have often been exaggerated and should not be an obstacle to its use.
The most serious adverse effect of morphine is respiratory depression, which may be fatal. This adverse effect


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The most serious adverse effect of morphine is respiratory depression, which may be fatal. This adverse effect
results from overdose. It is, therefore, important to increase doses gradually. Respiratory depression is preceded by
drowsiness, which is a warning to monitor respiratory rate (RR). 
Children 1 to 12 months RR ≥ 25 respirations/minute
Children 1 to 2 years RR ≥ 20 respirations/minute
Children 2 to 5 years RR ≥ 15 respirations/minute
Children > 5 years and adults RR ≥ 10 respirations/minute
Morphine and codeine always cause constipation. A laxative should be prescribed if the opioid treatment continues
more than 48 hours. Lactulose PO is the drug of choice: children < 1 year: 5 ml daily; children 1-6 years: 5 to 10 ml


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more than 48 hours. Lactulose PO is the drug of choice: children < 1 year: 5 ml daily; children 1-6 years: 5 to 10 ml
daily; children 7-14 years: 10 to 15 ml daily; adults: 15 to 45 ml daily.


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If the patient’s stools are soft, a stimulant laxative (bisacodyl PO: children > 3 years: 5 to 10 mg once daily; adults:
10 to 15 mg once daily) is preferred.
Children:
ondansetron PO: 0.15 mg/kg (max. 4 mg per dose) up to 3 times daily
Do not use metoclopramide in children.
Adults:
haloperidol PO (2 mg/ml oral solution): 1 to 2 mg up to 6 times daily or metoclopramide PO: 5 to 10 mg 3 times
daily with an interval of at least 6 hours between each dose
Do not combine haloperidol and metoclopramide.
Treatment of nociceptive pain in pregnant and breast-feeding women
Neuropathic pain
Nausea and vomiting are common at the beginning of treatment.
For chronic pain in late stage disease (cancer, AIDS etc.), morphine PO is the drug of choice. It may be necessary to


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For chronic pain in late stage disease (cancer, AIDS etc.), morphine PO is the drug of choice. It may be necessary to
increase doses over time according to pain assessment. Do not hesitate to give sufﬁcient and effective doses.
Morphine, tramadol and codeine have similar modes of action and should not be combined.
Buprenorphine, nalbuphine and pentazocine must not be combined with morphine, pethidine, tramadol or codeine
because they have competitive action.
Analgesics
Pregnancy
Breast-feeding0-5
months
From 6  monthth
 
Level
1
paracetamol ﬁrst
choice
ﬁrst choice ﬁrst choice
aspirin avoid contra-indicated avoid
ibuprofen avoid contra-indicated possible
 
 
 
Level
2
codeine possible The neonate may develop withdrawal
symptoms, respiratory depression and


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ibuprofen avoid contra-indicated possible
 
 
 
Level
2
codeine possible The neonate may develop withdrawal
symptoms, respiratory depression and
drowsiness in the event of prolonged
administration of large doses at the
end of the thirdtrimester. Closely
monitor the neonate.
Use with caution, for a short period
(2-3 days), at the lowest effective
dose. Monitor the mother and the
child: in the event of excessive
drowsiness, stop treatment.
tramadol possible The child may develop drowsiness when the mother receives tramadol at the
end of the thirdtrimester and during breast-feeding. Administer with caution, for
a short period, at the lowest effective dose, and monitor the child.
 
Level
3
morphine possible The child may develop withdrawal symptoms, respiratory depression and


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Level
3
morphine possible The child may develop withdrawal symptoms, respiratory depression and
drowsiness when the mother receives morphine at the end of the third trimester
and during breast-feeding.
Administer with caution, for a short period, at the lowest effective dose, and
monitor the child.


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Commonly used analgesics are often ineffective in treating this type of pain.
Treatment of neuropathic pain is based on a combination of two centrally acting drugs:
amitriptyline PO
Adults: 25 mg once daily at bedtime (Week 1); 50 mg once daily at bedtime (Week 2); 75 mg once daily at bedtime (as
of Week 3); max.150 mg daily. Reduce the dose by half in elderly patients.
carbamazepine PO
Adults: 200 mg once daily at bedtime (Week 1); 200 mg 2 times daily (Week 2); 200 mg 3 times daily (as of Week 3)
Given its teratogenic risk, carbamazepine should only be used in women of childbearing age when covered
by effective contraception (intrauterine device or injectable progestogen). It is not recommended in pregnant women.
Mixed pain


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by effective contraception (intrauterine device or injectable progestogen). It is not recommended in pregnant women.
Mixed pain
In mixed pain with a signiﬁcant component of nociceptive pain, such as in cancer or AIDS, morphine is combined with
antidepressants and antiepileptics.
Chronic pain
In contrast to acute pain, medical treatment alone is not always sufﬁcient in controlling chronic pain. A multidisciplinary
approach including medical treatment, physiotherapy, psychotherapy and nursing is often necessary to allow good pain
relief and encourage patient selfmanagement.
Co-analgesics
The combination of certain drugs may be useful or even essential in the treatment of pain: antispasmodics, muscle
relaxants, anxiolytics, corticosteroids, local anaesthesia, etc.


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Anaemia
Last updated: January 2024
 
Anaemia is deﬁned as a haemoglobin (Hb) level below reference values , which vary depending on age, sex, and
pregnancy status (see Table 2). Anaemia may be caused by:
 The causes of anaemia are often interlinked.
Clinical features
Laboratory
 Table 1 - Possible diagnoses with FBC 
 [1] [2] 
Decreased production of red blood cells: iron deﬁciency, nutritional deﬁciencies (folic acid, vitamin B , vitamin A),
depressed bone marrow function, certain infections (HIV, visceral leishmaniasis), renal failure;
12
Loss of red blood cells: acute or chronic haemorrhage (gastrointestinal ulcer, ancylostomiasis, schistosomiasis,
etc.);
Increased destruction of red blood cells (haemolysis): parasitic (malaria), bacterial and viral (HIV) infections;


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etc.);
Increased destruction of red blood cells (haemolysis): parasitic (malaria), bacterial and viral (HIV) infections;
haemoglobinopathies (sickle cell disease, thalassaemia); intolerance to certain drugs (primaquine, dapsone, co-
trimoxazole, nitrofurantoin, etc.) in patients with G6PD deﬁciency.
Common signs: pallor of the conjunctivae, mucous membranes, palms of hands and soles of feet; fatigue,
dizziness, dyspnoea, tachycardia, heart murmur.
Signs of decompensation: cold extremities, altered mental status, oedema in the lower limbs, respiratory distress,
elevated jugular venous pressure, cardiac/coronary failure, shock.
Signiﬁcant signs: cheilosis and glossitis (nutritional deﬁciency), jaundice, hepatosplenomegaly, dark coloured urine


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Signiﬁcant signs: cheilosis and glossitis (nutritional deﬁciency), jaundice, hepatosplenomegaly, dark coloured urine
(haemolysis), bleeding (maelena, haematuria, etc.), signs of malaria (Chapter 6), etc.
Hb levels
Rapid diagnostic test or thick and thin blood ﬁlms in areas where malaria is endemic.
Urinary dipstick: check for haemoglobinuria or haematuria.
If sickle cell disease is suspected (to be done before blood transfusion): rapid diagnostic test (Sickle SCAN®) or, if
not available, Emmel test.
Full blood count (FBC) if available to guide diagnosis.


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Aetiological treatment
Anaemia in itself is not an indication for transfusion. Most anaemias are well tolerated and can be corrected with simple
aetiological treatment.
Aetiological treatment may be given alone or together with transfusion.
ferrous salts/folic acid PO, or if not available, ferrous salts PO, for 3 months
Doses are expressed in elemental iron :
 
 
folic acid PO for 4 months:
Characteristics Main diagnoses
Macrocytic  Deﬁciency (folic acid, vitamin B ), chronic alcoholism12
Microcytic Iron deﬁciency (malnutrition, chronic haemorrhage), chronic inﬂammation (HIV
infection, cancer), thalassaemia
Normocytic  Acute haemorrhage, renal failure, haemolysis
Reduced number of
reticulocytes
Deﬁciency (iron, folic acid, vitamin B ), spinal tumour, renal failure12


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Reduced number of
reticulocytes
Deﬁciency (iron, folic acid, vitamin B ), spinal tumour, renal failure12
Increased or normal number of
reticulocytes
Haemolysis, sickle cell disease, thalassaemia
Eosinophilia Ancylostomiasis, trichuriasis, schistosomiasis, HIV infection, malignant
haemopathies
Iron deﬁciency
 a 
Children 1 month to < 6 years: 1.5 to 3 mg/kg 2 times daily
Children 6 to < 12 years: 65 mg 2 times daily
Children ≥ 12 years and adults: 65 mg 2 to 3 times daily
Age Weight
Treatment
45 mg/5 ml syrup 60 or 65 mg tablet
1 month to < 1 year 4 to < 10 kg 1.5 ml x 2 –
1 to < 6 years 10 to < 20 kg 2.5 ml x 2 –
6 to < 12 years 20 to < 40 kg – 1 tab x 2
≥ 12 years and adults  ≥ 40 kg   1 tab x 2 or 3
Helminthic infections: see Schistosomiasis and Nematode infections (Chapter 6).


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≥ 12 years and adults  ≥ 40 kg   1 tab x 2 or 3
Helminthic infections: see Schistosomiasis and Nematode infections (Chapter 6).
Folic acid deﬁciency (rarely isolated)
Children under 1 year: 0.5 mg/kg once daily
Children 1 year and over and adults: 5 mg once daily


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Blood transfusion
Indications
To decide whether to transfuse, several parameters should be taken into account:
If transfusion is indicated, it should be carried out without delay . For transfusion thresholds, see Table 2.
Volume to be transfused
If presence of haemorrhagic shock: see Shock, Chapter 1. Otherwise: 
Transfusion volume is based on presence or absence of fever at any point from the time of ordering blood to the
time of transfusion: 
 
 Repeat if necessary, depending on clinical condition.
Monitoring
Repeat the injection (same dose) after 2 hours if necessary.
Malaria: see Malaria (Chapter 6). In the event of associated iron deﬁciency, wait 4 weeks after malaria treatment
before prescribing iron supplements.


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before prescribing iron supplements.
Suspected haemolytic anaemia: stop any drug that causes haemolysis in patients with (or that may possibly have)
G6PD deﬁciency.
Clinical tolerance of anaemia
Underlying conditions (cardiovascular disease, infection, etc.)
Rate at which anaemia develops.
Hb levels
 b 
Children : [3] 
If no fever (axillary temperature ≤ 37.5 °C) : administer either 15 ml/kg of packed red blood cells (PRBC) over 3
hours or 30 ml/kg of whole blood over 4 hours
 c 
If fever (axillary temperature > 37.5 °C) : administer either 10 ml/kg of PRBC over 3 hours or 20 ml/kg of whole
blood over 4 hours
 c 
Adolescents and adults: start with an adult unit of PRBC or whole blood; do not exceed a transfusion rate of 5
ml/kg/hour.


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blood over 4 hours
 c 
Adolescents and adults: start with an adult unit of PRBC or whole blood; do not exceed a transfusion rate of 5
ml/kg/hour.
Monitor the patient’s condition and vital signs (heart rate, blood pressure, respiratory rate, temperature):
During the transfusion: 5 minutes after the start of transfusion, then every 15 minutes during the ﬁrst hour, then
every 30 minutes until the end of the transfusion.
After the transfusion: 4 to 6 hours after the end of the transfusion.
Pay attention to signs of transfusion reaction, ﬂuid overload, decompensation or continuing blood loss.
For children: measure Hb once between 8 and 24 hours after the end of the transfusion or if signs of
decompensation or continuing blood loss.
If signs of circulatory overload appear:


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decompensation or continuing blood loss.
If signs of circulatory overload appear:
Stop temporarily the transfusion.
Sit the patient in an upright position.
Administer oxygen.
Administer furosemide by slow IV injection:
Children: 0.5 to 1 mg/kg
Adults: 20 to 40 mg
Once the patient has been stabilised, start the transfusion again after 30 minutes.


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Prevention
ferrous salts/folic acid PO, or if not available, ferrous salts PO, as long as the risk of deﬁciency persists (e.g.
pregnancy , malnutrition).
Doses are expressed in elemental iron :
 
 
 
Table 2 - Deﬁnition of anaemia and transfusion thresholds 
Iron (and folic acid) deﬁciency:
Drug supplements:
 [4] 
 a 
Children 1 month to < 12 years: 1 to 2 mg/kg once daily (max. 65 mg daily)
Children ≥ 12 years and adults: 65 mg once daily
Age Weight
Prevention
45 mg/5 ml syrup 60 or 65 mg tablet
1 month to < 1 year 4 to < 10 kg 1 ml –
1 to < 6 years 10 to < 20 kg 2.5 ml –
6 to < 12 years 20 to < 40 kg 5 ml –
≥ 12 years and adults ≥ 40 kg – 1 tab
Nutritional supplements (if the basic diet is insufﬁcient).


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6 to < 12 years 20 to < 40 kg 5 ml –
≥ 12 years and adults ≥ 40 kg – 1 tab
Nutritional supplements (if the basic diet is insufﬁcient).
In the event of sickle cell anaemia: see Sickle cell disease (Chapter 12).
Early treatment of malaria, helminthic infections, etc.


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References
Patients Hb levels deﬁning
anaemia Transfusion thresholds
Children 2-6 months < 9.5 g/dl Hb < 4 g/dl, even if there are no signs of
decompensation
Hb ≥ 4 g/dl and < 6 g/dl if there are signs of
decompensation or ongoing blood loss or severe
malaria or serious bacterial infection or pre-existing
heart disease (a)
Children 6 months-4 years < 11 g/dl
Children 5-11 years < 11.5 g/dl
Children 12-14 years < 12 g/dl
Men (≥ 15 years) < 13 g/dl Hb < 7 g/dl if there are signs of decompensation or
ongoing blood loss or severe malaria or serious bacterial
infection or pre-existing heart diseaseWomen (≥ 15 years) < 12 g/dl
Pregnant women
 
< 11 g/dl
(1  and 3  trimester) < 10.5 g/dl
(2  trimester)
 
st rd
nd
< 36 weeks
Hb ≤ 5 g/dl, even if there are no signs of
decompensation


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< 11 g/dl
(1  and 3  trimester) < 10.5 g/dl
(2  trimester)
 
st rd
nd
< 36 weeks
Hb ≤ 5 g/dl, even if there are no signs of
decompensation
Hb > 5 g/dl and < 7 g/dl if there are signs of
decompensation or sickle cell disease or severe
malaria or serious bacterial infection or pre-existing
heart disease
≥ 36 weeks
Hb ≤ 6 g/dl, even if there are no signs of
decompensation
Hb > 6 g/dl and < 8 g/dl if there are signs of
decompensation or sickle cell disease or severe
malaria or serious bacterial infection or pre-existing
heart disease


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decompensation or sickle cell disease or severe
malaria or serious bacterial infection or pre-existing
heart disease
(a) Immediate transfusion is not required in children 2 months to 12 years with Hb ≥ 4 g/dl and < 6 g/dl and no sign ofdecompensation or ongoing blood loss, provided that:• they are closely monitored (including Hb measurements at 8, 24 and 48 hours), and• transfusion preparation (blood grouping, etc.) is carried out without delay in case the child needs to be transfused lateron.
Footnotes


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Footnotes
(a) A coformulated tablet of ferrous salts/folic acid contains 185 mg of ferrous fumarate or sulfate (equivalent to 60 mg ofelemental iron) and 400 micrograms of folic acid.A 200 mg tablet of ferrous fumarate or sulfate contains 65 mg of elemental iron.A 140 mg/5 ml syrup of ferrous fumarate contains 45 mg/5 ml of elemental iron.
(b) Before transfusing: determine the recipient’s and potential donors’ blood groups/rhesus and carry out screening tests onthe donor’s blood for HIV-1 and 2, hepatitis B and C, syphilis and, in endemic areas, malaria and Chagas disease.
(c) Axillary temperature should be taken at the time of ordering blood and immediately prior to transfusion.


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1. World Health Organization. Haemoglobin Concentrations for the Diagnosis of Anaemia and Assessment of Severity. WorldHealth Organization; 2011. [Accessed June 26, 2023]https://apps.who.int/iris/handle/10665/85839
2. World Health Organization. Educational Modules on Clinical Use of Blood. World Health Organization; 2021. [Accessed June26, 2023]https://apps.who.int/iris/handle/10665/350246
3. Maitland K, Olupot-Olupot P, Kiguli S, et al. Transfusion Volume for Children with Severe Anemia in Africa. N Engl J Med.2019;381(5):420-431.https://doi.org/10.1056/NEJMoa1900100
4. Word Health Organization. Daily iron and folic acid supplementation in pregnant women. Word Health Organization. Geneva,2012. [Accessed June 26, 2023]https://apps.who.int/iris/handle/10665/77770


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Dehydration
Dehydration results from excessive loss of water and electrolytes from the body. If prolonged, dehydration can
compromise organ perfusion, resulting in shock.
It is principally caused by diarrhoea, vomiting and severe burns.
Children are particularly susceptible to dehydration due to frequent episodes of gastroenteritis, high surface area to
volume ratio and inability to fully communicate, or independently meet their ﬂuid needs. The protocols below are focused on treatment of dehydration caused by diarrhoea and vomiting. Alternative treatment
protocols should be used for children with malnutrition (see Severe acute malnutrition, Chapter 1) or in patients with
severe burns (see Burns, Chapter 10).
Clinical features and assessment


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severe burns (see Burns, Chapter 10).
Clinical features and assessment
 
Classiﬁcation of degree of dehydration (adapted from the WHO) 
Treatment of dehydration
History of diarrhoea and/or vomiting and concomitant reduced urine output.
Clinical features depend on the degree of dehydration (see table below). Features such as dry mouth, absence of
tears may also be noted.
Patients with severe dehydration should be assessed for shock (tachycardia, low blood pressure and delayed
capillary reﬁll time etc.).
Electrolyte disorders may cause tachypnoea, muscle cramps or weakness, cardiac arrhythmia (irregular heart rate,
palpitation), confusion and/or seizures.
 [1] [2]
 
 
Severe dehydration
At least 2 of the
following signs:
Some dehydration
At least 2 
of the following signs:
No dehydration


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[1] [2]
 
 
Severe dehydration
At least 2 of the
following signs:
Some dehydration
At least 2 
of the following signs:
No dehydration
No signs of "severe"
or "some" dehydration.
Mental status Lethargic or
unconscious Restless or irritable Normal
Radial pulse Weak or absent Palpable Easily palpable
Eyes (a) Sunken Sunken Normal
Skin pinch (b) Goes back very slowly 
(> 2 seconds)
Goes back slowly
(< 2 seconds)
Goes back quickly
(< 1 second)
Thirst Drinks poorly
or not able to drink
Thirst, 
drinks quickly
No thirst,
drinks normally
(a) Sunken eyes may be a normal feature in some children. Ask the mother if the child's eyes are the same as usual or if they aremore sunken than usual.


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(b) Skin pinch is assessed by pinching the skin of the abdomen between the thumb and foreﬁnger without twisting. In olderpeople this sign is not reliable as normal aging diminishes skin elasticity.


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Severe dehydration
 
WHO Treatment Plan C 
 
 
Some dehydration
 
WHO Treatment Plan B
Treat shock if present (see Shock, Chapter 1).
If able to drink, administer oral rehydration solution (ORS) PO whilst obtaining IV access.
 according to WHO Treatment Plan C, monitoring infusion rate closely:
Insert peripheral IV line using large caliber catheter (22-24G in children or 18G in adults) or intraosseous needle.
Administer Ringer lactate (RL) a
 [1] [2]
Age First, give 30 ml/kg over : (c) Then, give 70 ml/kg over:
Children < 1 year 1 hour 5 hours
Children ≥ 1 year and adults 30 minutes 2 ½ hours
(c) Repeat once if radial pulse remains weak or absent after ﬁrst bolus.
In case of suspected severe anaemia, measure haemoglobin and treat accordingly (see Anaemia, Chapter 1). b


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In case of suspected severe anaemia, measure haemoglobin and treat accordingly (see Anaemia, Chapter 1). b
As soon as the patient is able to drink safely (often within 2 hours), provide ORS as the patient tolerates. ORS
contains glucose and electrolytes which prevent development of complications.
Monitor ongoing losses closely. Assess clinical condition and degree of dehydration at regular intervals to ensure
continuation of appropriate treatment.
If over the course of treatment the patient:
remains or becomes lethargic: measure blood glucose level and/or treat hypoglycaemia (see Hypoglycaemia,
Chapter 1).
develops muscle cramps/weakness and abdominal distention: treat for moderate hypokalaemia with 7.5%
potassium chloride syrup (1 mmol of K/ml) PO for 2 days:


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potassium chloride syrup (1 mmol of K/ml) PO for 2 days:
Children under 45 kg: 2 mmol/kg (2 ml/kg) daily (according to weight, the daily dose is divided into 2 or 3 doses)
Children 45 kg and over and adults: 30 mmol (30 ml) 3 times daily
This treatment should only be given as an inpatient .
+
 c 
develops peri-orbital or peripheral oedema: reduce the infusion rate to a minimum, auscultate the lungs, re-
evaluate the stage of dehydration and the necessity of continuing IV rehydration. If IV rehydration is still required,
continue the infusion at a slower rate and observe the patient closely. If IV rehydration is no longer required,
change to oral treatment with ORS.
develops dyspnoea, cough and bibasal crepitations are heard on auscultation of the lungs: sit the patient up,


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change to oral treatment with ORS.
develops dyspnoea, cough and bibasal crepitations are heard on auscultation of the lungs: sit the patient up,
reduce the infusion rate to a minimum and administer one dose of furosemide IV (1 mg/kg in children; 40 mg in
adults). Monitor the patient closely over 30 minutes and assess for underlying cardiorespiratory or renal disease.
Once the patient is stabilised, reassess the degree of dehydration and the necessity of continuing IV rehydration.
If IV rehydration is still required, re-start at half the previous infusion rate and monitor closely. If IV rehydration is
no longer required, change to oral treatment with ORS.
Administer ORS according to WHO Treatment Plan B which equates to 75 ml/kg ORS given over 4 hours.
 [1] d


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No dehydration
Prevent dehydration:
 
WHO Treatment Plan A 
 
Treatment of diarrhoea
In addition to the WHO treatment plan corresponding to patient's degree of dehydration:
 
Age < 4
months
4 to
11 months
12 to
23 months 2 to 4 years 5 to
14 years ≥ 15 years
Weight < 5 kg 5 to 
7.9 kg
8 to 
10.9 kg
11 to 15.9
kg
16 to 29.9
kg ≥ 30 kg
Quantity of ORS over
4 hours
200 to 400
ml
400 to 
600 ml
600 to 
800 ml
800 to 1200
ml
1200 to
2200 ml
2200 to
4000 ml
Encourage additional age-appropriate ﬂuid intake, including breastfeeding in young children. Give additional ORS
after each loose stool (see below).
Monitor ongoing losses closely. Assess clinical condition and degree of dehydration at regular intervals to ensure
continuation of appropriate treatment.


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continuation of appropriate treatment.
Encourage age-appropriate ﬂuid intake, including breastfeeding in young children.
Administer ORS according to WHO Treatment Plan A after any loose stool.
 [1] [2]
Age Quantity of ORS
Children < 2 years 50 to 100 ml (10 to 20 teaspoons)
Children 2 to 10 years 100 to 200 ml (½ to 1 glass)
Children > 10 years and adults at least 250 ml (at least 1 glass)
Administer aetiologic treatment if required.
Administer zinc sulfate to children under 5 years (see Acute diarrhoea, Chapter 3).
Footnotes
(a) If RL not available, 0.9% sodium chloride can be used.
(b) If transfusion is required, it should be provided in parallel to IV ﬂuids, using a separate IV line. The blood volume administeredshould be deducted from the total volume of Plan C.


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(c) If available, take blood tests to monitor urea and electrolyte levels.
(d) For more detailed information on ORS recommendations by age and weight, refer to the guide Management of a choleraepidemic, MSF.


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References
1. World Health Organization. The treatment of diarrhoea : a manual for physicians and other senior health workers, 4threv. World Health Organization. 2005. https://apps.who.int/iris/handle/10665/43209
2. World Health Organization. Pocket book of Hospital Care for children. Guidelines for the Management of CommonChildhood Illnesses. 2013.https://apps.who.int/iris/bitstream/handle/10665/81170/9789241548373_eng.pdf?sequence=1


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Severe acute malnutrition
Last updated: February 2024
 
Severe acute malnutrition (SAM) results from insufﬁcient energy (kilocalories), fat, protein and/or other nutrients
(vitamins and minerals, etc.) to cover individual needs. SAM is frequently associated with medical complications due to metabolic disturbances and compromised immunity. It
is a major cause of morbidity and mortality in children globally. The protocols below are focused on the diagnosis and management of SAM in children 6 to 59 months only. For
further details regarding this age group, and guidance for other age groups, refer to national recommendations and/or
specialised protocols. 
Clinical assessment
Characteristic physical signs
Diagnostic and admission criteria


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specialised protocols. 
Clinical assessment
Characteristic physical signs
Diagnostic and admission criteria
Diagnostic criteria for SAM are both anthropometric and clinical:
 Admission criteria for SAM treatment programmes vary with context. Refer to national recommendations.
Medical complications
Nutritional treatment
In marasmus: skeletal appearance resulting from signiﬁcant loss of muscle mass and subcutaneous fat.
In kwashiorkor:
Bilateral oedema of the lower limbs sometimes extending to other parts of the body (e.g. arms and hands, face).
Discoloured, brittle hair; shiny skin which may crack, weep, and become infected.
Mid-upper arm circumference (MUAC) measures the degree of muscle wasting. MUAC < 115 mm indicates
SAM and signiﬁcant mortality risk.
 a


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Mid-upper arm circumference (MUAC) measures the degree of muscle wasting. MUAC < 115 mm indicates
SAM and signiﬁcant mortality risk.
 a 
Weight-for-height z-score (WHZ) indicates the degree of weight loss by comparing the weight of the child with the
median weight of non-malnourished children of the same height and sex. SAM is deﬁned as WHZ < –3 with
reference to the WHO Child Growth Standards . b 
The presence of bilateral pitting oedema of the lower limbs (when other causes of oedema have been ruled out)
indicates SAM, regardless of MUAC and WHZ.
Children with any of the following severe medical conditions should receive hospital-based medical management:
Pitting oedema extending from the lower limbs up to the face;
Anorexia (observed during appetite test);


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Pitting oedema extending from the lower limbs up to the face;
Anorexia (observed during appetite test);
Other severe complications: persistent vomiting, shock, altered mental status, seizures, severe anaemia
(clinically suspected or conﬁrmed), persistent hypoglycaemia, eye lesions due to vitamin A deﬁciency, frequent
or abundant diarrhoea, dysentery, dehydration, severe malaria, pneumonia, meningitis, sepsis, severe cutaneous
infection, fever of unknown origin, etc.
In the absence of these conditions, children should be treated as outpatients with regular follow-up.
All children with SAM should receive nutritional treatment.


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Routine medical management 
The following should be provided to all inpatients and outpatients with SAM: 
 
Nutritional treatment is based on the use of specialised nutritious foods enriched with vitamins and minerals: F-75
and F-100 therapeutic milks, and ready-to-use therapeutic food (RUTF).
Nutritional treatment is organised into phases:
Phase 1 (inpatient) intends to restore metabolic functions and treat or stabilize medical complications. Children
receive F-75 therapeutic milk. This phase may last 1 to 7 days, after which children usually enter transition
phase. Children with medical complications generally begin with phase 1.
Transition phase (inpatient) intends to ensure tolerance of increased food intake and continued improvement of


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Transition phase (inpatient) intends to ensure tolerance of increased food intake and continued improvement of
clinical condition. Children receive F-100 therapeutic milk and/or RUTF. This phase usually lasts 1 to 3 days, after
which children enter phase 2.
Phase 2 (outpatient or inpatient) intends to promote rapid weight gain and catch-up growth. Children receive
RUTF. This phase usually lasts 1 to 3 days when inpatient, after which children are discharged for outpatient
care. Children without medical complications enter directly into this phase as outpatients. The outpatient
component usually lasts several weeks.
Breastfeeding should be continued in breastfed children.
Drinking water should be given in addition to meals, especially if the ambient temperature is high, or the child has a


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Drinking water should be given in addition to meals, especially if the ambient temperature is high, or the child has a
fever or is receiving RUTF.
Antibiotic
treatment
From D1, unless speciﬁc signs of infection are present:
amoxicillin PO: 50 mg/kg (max. 1 g) 2 times daily for 5 to 7 days
Malaria On D1, rapid diagnostic test in endemic areas and treatment for malaria according to results or if
testing is not available (see Malaria, Chapter 6).
Intestinal
parasites
In transition phase or upon outpatient admission, albendazole PO:
Children 12 to 23 months: 200 mg single dose
Children 24 months and over: 400 mg single dose
Vaccination
Children vaccinated between 6 and 8 months should be re-vaccinated as above (i.e. with 2


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Children 24 months and over: 400 mg single dose
Vaccination
Children vaccinated between 6 and 8 months should be re-vaccinated as above (i.e. with 2
doses) once they reach 9 months of age, provided that an interval of 4 weeks from the ﬁrst dose
is respected.
In transition phase or upon outpatient admission, measles vaccine for children 6 months to 5
years, unless a document shows that the child received 2 doses of vaccine administered as
follows: one dose at or after 9 months and one dose at least 4 weeks after the ﬁrst dose. 
Other vaccines included in the EPI: check vaccination status and refer the child to vaccination
services at discharge.
Tuberculosis
(TB)
 
At D1 then regularly during treatment, screen for TB. For a child screening positive, perform
complete diagnostic evaluation.


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Tuberculosis
(TB)
 
At D1 then regularly during treatment, screen for TB. For a child screening positive, perform
complete diagnostic evaluation.
For more information, refer to the guide Tuberculosis, MSF.
HIV infection
 
Perform HIV counselling and testing (unless the mother explicitly declines testing).
Children under 18 months: test the mother with rapid diagnostic tests. For a mother testing
positive, request PCR test for the child.
Children 18 months and over: test the child with rapid diagnostic tests.


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Management of complications
Infections
Severe anaemia
Diarrhoea and dehydration
 
Respiratory, cutaneous and urinary infections are common. However, classic signs of infection, such as fever, may
be absent . [1] 
Severe infection or sepsis should be suspected in children that are lethargic or apathetic or suffering from an acute
complication such as hypothermia, hypoglycaemia, seizures, difﬁculty breathing, or shock. Immediately
administer ampicillin IV 50 mg/kg every 8 hours + gentamicin IV 7.5 mg/kg once daily. Continue this treatment
unless the source of infection is identiﬁed and different antibiotic treatment is required.
If circulatory impairment or shock, immediately administer ceftriaxone IV, one dose of 80 mg/kg, then assess the


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If circulatory impairment or shock, immediately administer ceftriaxone IV, one dose of 80 mg/kg, then assess the
source of infection to determine further antibiotic treatment. See also Shock, Chapter 1. Transfuse urgently as for
severe anaemia (see below) if haemoglobin (Hb)  is < 6 g/dl. 
In less severe infections, assess the source of infection (see Fever, Chapter 1) and treat accordingly.
If fever is present and causes discomfort, undress the child. If insufﬁcient, administer paracetamol PO in low dose:
10 mg/kg, up to 3 times maximum per 24 hours. Encourage oral ﬂuids (including breast milk).
If hypothermia is present, place the child skin-to-skin against the mother's body and cover with a warm blanket.


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If hypothermia is present, place the child skin-to-skin against the mother's body and cover with a warm blanket.
Treat for infection as above. Check blood glucose level and treat for hypoglycaemia if necessary (see
Hypoglycaemia, Chapter 1).
In children with kwashiorkor, infection of cutaneous lesions is common and may progress to soft tissue or systemic
infection. If cutaneous infection is present, stop amoxicillin and start amoxicillin/clavulanic acid PO. Use
formulations in a ratio of 8:1 or 7:1. The dose is expressed in amoxicillin: 50 mg/kg 2 times daily for 7 days.
Children with Hb < 4 or < 6 with signs of decompensation (such as respiratory distress) or ongoing blood loss require


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Children with Hb < 4 or < 6 with signs of decompensation (such as respiratory distress) or ongoing blood loss require
transfusion within the ﬁrst 24 hours. See Anaemia (Chapter 1) for volume to be transfused and patient monitoring
during and after transfusion.
Preferably use packed red blood cells (PRBC), if available. Monitor closely for signs of ﬂuid overload (see box
below). 
Diarrhoea is common. Therapeutic foods facilitate the recovery of physiological function of the gastrointestinal
tract. Amoxicillin administered as part of routine treatment reduces intestinal bacterial overgrowth. Diarrhoea
generally resolves without additional treatment. If an aetiological treatment is necessary, see Acute diarrhoea,
Chapter 3.


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generally resolves without additional treatment. If an aetiological treatment is necessary, see Acute diarrhoea,
Chapter 3.
Zinc supplementation is not needed if children consume recommended amounts of therapeutic foods.
The diagnosis of dehydration is based on history and clinical features.
Clinical assessment is difﬁcult in children with SAM as delayed skin pinch test and sunken eyes are often present
even in the absence of dehydration.
For classiﬁcation of degree of dehydration adapted for children with SAM, see table below:


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Acute diarrhoea with no dehydration (Plan A SAM)
Acute diarrhoea with some dehydration (Plan B SAM)
Acute diarrhoea with severe dehydration (Plan C SAM)
Clinical features
(2 or more of the following signs)
No
dehydration
Some
dehydration
Severe
dehydration
Mental status Normal Restless, irritability Lethargic or
unconscious
Thirst No thirst, drinks
normally Thirsty, drinks eagerly Unable to drink or drinks
poorly
Urine output Normal Reduced Absent for
several hours
Recent frequent watery
diarrhoea and/or vomiting Yes Yes Yes
Recent obvious rapid weight
loss No Yes Yes
Stools are neither frequent nor abundant (outpatient): oral rehydration solution (ORS) PO: 5 ml/kg after each loose
stool to prevent dehydration.


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Stools are neither frequent nor abundant (outpatient): oral rehydration solution (ORS) PO: 5 ml/kg after each loose
stool to prevent dehydration.
Stools are frequent and/or abundant (inpatient): ReSoMal PO or by nasogastric tube (NGT): 5 ml/kg after each
loose stool to prevent dehydration.
 c 
In all cases, continue feeding and breastfeeding, encourage oral ﬂuids.
Determine the target weight (weight before the onset of diarrhoea) before starting rehydration. If not feasible (e.g.
new admission), estimate target weight as current weight x 1.06.
ReSoMal PO or by NGT: 20 ml/kg/hour for 2 hours. In addition, administer 5 ml/kg of ReSoMal after each loose
stool if tolerated.
 c 
Assess after 2 hours (clinical evaluation and weight):
If improvement (diarrhoea and signs of dehydration regress):


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stool if tolerated.
 c 
Assess after 2 hours (clinical evaluation and weight):
If improvement (diarrhoea and signs of dehydration regress):
Reduce ReSoMal to 10 ml/kg/hour until the signs of dehydration and/or weight loss (known or estimated)
have been corrected.
Assess every 2 hours.
Once there are no signs of dehydration and/or the target weight is reached, change to Plan A SAM to
prevent dehydration.
If no improvement after 2 to 4 hours or if oral rehydration cannot compensate for losses: change to Plan C SAM
"with circulatory impairment".
Continue feeding including breastfeeding.
Monitor for signs of ﬂuid overload (see box below). Regardless of the target weight, stop rehydration if signs
of ﬂuid overload appear.
In all patients:


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of ﬂuid overload appear.
In all patients:
Assess for circulatory impairment (see Shock, Chapter 1).
Estimate target weight as current weight x 1.1.


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Signs of ﬂuid overload include:
Plus any one of the following:
 
Other complications
For other complications (to be treated as inpatient), see:
Measure blood glucose level and treat hypoglycaemia (Chapter 1) if necessary.
Monitor vital signs and signs of dehydration every 15 to 30 minutes.
Monitor urine output.
Monitor for signs of ﬂuid overload (see box below).
If there is no circulatory impairment:
ReSoMal PO or by NGT: 20 ml/kg over 1 hour
If the child is alert, continue feeding including breastfeeding.
Assess after 1 hour:
If improvement: change to Plan B SAM, but keep the same target weight.
If rehydration PO/NGT not tolerated (e. g. vomiting):
Stop ReSoMal. Administer glucose 5%-Ringer lactate (G5%-RL) IV infusion: 10 ml/kg/hour for 2 hours. d


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Stop ReSoMal. Administer glucose 5%-Ringer lactate (G5%-RL) IV infusion: 10 ml/kg/hour for 2 hours. d 
Assess after 2 hours of IV ﬂuids:
If improvement and/or not vomiting, stop G5%-RL IV infusion and change to Plan B SAM.
If no improvement or still vomiting, continue G5%-RL IV infusion: 10 ml/kg/hour for 2 hours.
If deterioration with circulatory impairment: see below.
If there is circulatory impairment:
Administer ceftriaxone IV, one dose of 80 mg/kg. Subsequent antibiotic treatment depends on assessment of
underlying cause.
Administer G5%-RL IV infusion: 10 ml/kg/hour for 2 hours. Stop ReSoMal if the child was taking it.
Assess after 1 hour of IV ﬂuids:
If improvement and no vomiting: stop IV ﬂuid and change to Plan B SAM, but keep the same target weight.
If no improvement:


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If improvement and no vomiting: stop IV ﬂuid and change to Plan B SAM, but keep the same target weight.
If no improvement:
Continue G5%-RL IV infusion: 10 ml/kg/hour.
Prepare for blood transfusion.
Assess after 2 hours of IV ﬂuids:
If improvement: change to Plan B SAM, but keep the same target weight.
If no improvement or deterioration:
Check Hb as baseline and administer blood transfusion using a separate IV line. See Anaemia (Chapter 1)
for volume to be transfused and patient monitoring during and after transfusion.
While transfusing, continue G5%-RL IV infusion 10 ml/kg/hour for another 2 hours.
RR ≥ 10 breaths/minute compared to initial RR, or
HR ≥ 20 beats/minute compared to initial HR
New or worsening hypoxia (decrease in SpO by > 5%)2


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RR ≥ 10 breaths/minute compared to initial RR, or
HR ≥ 20 beats/minute compared to initial HR
New or worsening hypoxia (decrease in SpO by > 5%)2
New onset of rales and/or ﬁne crackles in lung ﬁelds
New galloping heart rhythm
Increased liver size (must have marked liver border with pen before rehydration)
New peripheral or eyelid oedema
Hypoglycaemia, seizures, Chapter 1.
Acute pneumonia, Chapter 2.
Stomatitis, Chapter 3.
Xerophthalmia (vitamin A deﬁciency), Chapter 5.


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Discharge criteria
In general:
 Discharge criteria vary with context. Refer to national recommendations.
 
References
Children can be discharged from hospital and be treated as outpatients if the following criteria are met:
clinically well;
medical complications controlled; 
able to eat RUTF (observed during appetite test);
reduction or absence of oedema;
caregiver feels able to provide care as outpatient;
vaccinations up to date or referral to vaccination service organised.
Children can be discharged from nutritional treatment if the following criteria are met:
co-existing medical conditions stable and outpatient treatment organised if necessary (e.g. dressing changes,
follow-up for chronic diseases);
vaccinations up to date or referral to vaccination service organised;


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follow-up for chronic diseases);
vaccinations up to date or referral to vaccination service organised;
absence of oedema and WHZ > –2 or MUAC > 125 mm for at least 2 weeks.
Footnotes
(a) MUAC is measured at the mid-point of the left upper arm. The arm should be relaxed. The measuring tape should be incontact with the skin all around the arm, without exerting pressure.
(b) For WHZ, see WHO simpliﬁed ﬁeld tables in z-scores for girls and for boys:https://www.who.int/tools/child-growth-standards/standards/weight-for-length-height
(c) ReSoMal is a speciﬁc oral rehydration solution for malnourished children, containing less sodium and more potassium thanstandard ORS. It should be administered under medical supervision to avoid overdosing and hyponatremia.


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(d) Remove 50 ml of Ringer lactate (RL) from a 500 ml RL bottle or bag, then add 50 ml of 50% glucose to the remaining 450 mlof RL to obtain 500 ml of 5% glucose-RL solution.
1. Jones KDJ, Berkley JA. Severe acute malnutrition and infection. Paediatrics and International Child Health 2014; 34(sup1):S1-S29.https://www.tandfonline.com/doi/full/10.1179/2046904714Z.000000000218 [Accessed 24 August 2022]


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Chapter 2: Respiratory diseases
Acute upper airway obstruction
Rhinitis and rhinopharyngitis (common cold)
Acute sinusitis
Acute pharyngitis
Diphtheria
Other upper respiratory tract infections
Croup (laryngotracheitis and laryngotracheobronchitis)
Epiglottitis
Bacterial tracheitis
Otitis
Acute otitis externa
Acute otitis media (AOM)
Chronic suppurative otitis media (CSOM)
Pertussis (whooping cough)
Bronchitis
Acute bronchitis
Chronic bronchitis
Bronchiolitis
Acute pneumonia
Pneumonia in children under 5 years of age
Pneumonia in children over 5 years and adults
Persistent pneumonia
Staphylococcal pneumonia
Asthma
Acute asthma (asthma attack)
Chronic asthma
Pulmonary tuberculosis


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Acute upper airway obstruction
Acute upper airway obstruction can be caused by foreign body aspiration, viral or bacterial infections (croup,
epiglottitis, tracheitis), anaphylaxis, burns or trauma.
Initially stable and partial obstruction may worsen and develop into a life-threatening emergency, especially in young
children.
Clinical features
Clinical signs of the severity of obstruction: 
 
Management in all cases
Obstruction Signs Danger
signs
Complete Respiratory distress followed by cardiac arrest
Yes
Imminent
complete
Severe respiratory distress with cyanosis or SpO < 90%2
Agitation or lethargy
Tachycardia, capillary reﬁll time > 3 seconds
Severe Stridor (abnormal high pitched sound on inspiration) at rest
Severe respiratory distress:


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Tachycardia, capillary reﬁll time > 3 seconds
Severe Stridor (abnormal high pitched sound on inspiration) at rest
Severe respiratory distress:
Severe intercostal and subcostal retractions
Nasal ﬂaring
Substernal retractions (inward movement of the breastbone during
inspiration)
Severe tachypnoea
Moderate Stridor with agitation
Moderate respiratory distress:
Mild intercostal and subcostal retractions
Moderate tachypnoea No
Mild Cough, hoarse voice, no respiratory distress
Examine children in the position in which they are the most comfortable.
Evaluate the severity of the obstruction according to the table above.
Monitor SpO, except in mild obstruction.2
Administer oxygen continuously:


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Evaluate the severity of the obstruction according to the table above.
Monitor SpO, except in mild obstruction.2
Administer oxygen continuously:
to maintain the SpO between 94 and 98% if it is ≤ 90%or if the patient has cyanosis or respiratory distress;2  a 
if pulse oxymeter is not available: at least 5 litres/minute or to relieve the hypoxia and improve respiration.
Hospitalize (except if obstruction is mild), in intensive care if danger signs.
Monitor mental status, heart and respiratory rate, SpO and severity of obstruction.2
Maintain adequate hydration by mouth if possible, by IV if patient unable to drink.


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Management of foreign body aspiration
Acute airway obstruction (the foreign body either completely obstructs the pharynx or acts as a valve on the laryngeal
inlet), no warning signs, most frequently in a child 6 months-5 years playing with a small object or eating. Conscience is
initially maintained. Perform maneuvers to relieve obstruction only if the patient cannot speak or cough or emit any sound:
Heimlich manoeuvre: stand behind the patient. Place a closed ﬁst in the pit of the stomach, above the navel and
below the ribs. Place the other hand over ﬁst and press hard into the abdomen with a quick, upward thrust. Perform
one to ﬁve abdominal thrusts in order to compress the lungs from the below and dislodge the foreign body.


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one to ﬁve abdominal thrusts in order to compress the lungs from the below and dislodge the foreign body.
Place the infant face down across the forearm (resting the forearm on the leg) and support the infant’s head with
the hand. With the heel of the other hand, perform one to ﬁve slaps on the back, between shoulder plates.
If unsuccessful, turn the infant on their back. Perform ﬁve forceful sternal compressions as in cardiopulmonary
resuscitation: use 2 or 3 ﬁngers in the center of the chest just below the nipples. Press down approximately one-
third the depth of the chest (about 3 to 4 cm). Repeat until the foreign body is expelled and the patient resumes spontaneous breathing (coughing, crying, talking). If


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the patient loses consciousness ventilate and perform cardiopulmonary rescucitation. Tracheostomy if unable to
ventilate.
Differential diagnosis and management of airway obstructions ofinfectious origin
 
Management of other causes
 
Children over 1 year and adults:
Children under 1 year:
Infections Symptoms Appearance Timing of
symptoms
Viral croup Stridor, cough and moderate respiratory
difﬁculty
Prefers to sit Progressive
Epiglottitis Stridor, high fever and severe respiratory
distress
Prefers to sit, drooling (cannot
swallow their own saliva)
Rapid
Bacterial tracheitis Stridor, fever, purulent secretions and severe
respiratory distress
Prefers to lie ﬂat Progressive
Retropharyngeal or
tonsillar abscess
Fever, sore throat and painful swallowing,
earache, trismus and hot potato voice


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Prefers to lie ﬂat Progressive
Retropharyngeal or
tonsillar abscess
Fever, sore throat and painful swallowing,
earache, trismus and hot potato voice
Prefers to sit, drooling Progressive
Croup, epiglottitis, and tracheitis: see Other upper respiratory tract infections.
Abscess: refer for surgical drainage.
Anaphylactic reaction (angioedema): see Anaphylactic shock (Chapter 1)
Burns to the face or neck, smoke inhalation with airway oedema: see Burns (Chapter 10).


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Footnotes
(a) If possible it is better to treat all patients with a SpO < 95% with oxygen.2


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Rhinitis and rhinopharyngitis (common cold)
Rhinitis (inﬂammation of the nasal mucosa) and rhinopharyngitis (inﬂammation of the nasal and pharyngeal mucosa) are
generally benign, self-limited and most often of viral origin. However, they may be an early sign of another infection (e.g.
measles or inﬂuenza) or may be complicated by a bacterial infection (e.g. otitis media or sinusitis).
Clinical features
Treatment
 
Nasal discharge or obstruction, which may be accompanied by sore throat, fever, cough, lacrimation, and diarrhoea
in infants. Purulent nasal discharge is not indicative of a secondary bacterial infection.
In children under 5 years, routinely check the tympanic membranes to look for an associated otitis media.


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In children under 5 years, routinely check the tympanic membranes to look for an associated otitis media.
Antibiotherapy is not recommended: it does not promote recovery nor prevent complications.
Treatment is symptomatic:
Clear the nose with 0.9% sodium chloride . a 
Fever, throat soreness: paracetamol PO for 2 to 3 days (Fever, Chapter 1).
Footnotes
(a) For a child: place him on his back, head turned to the side, and instil 0.9% sodium chloride into each nostril.


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Acute sinusitis
Acute sinusitis is an inﬂammation of one or more of the sinus cavities, caused by an infection or allergy.
Most acute sinus infections are viral and resolve spontaneously in less than 10 days. Treatment is symptomatic.
Acute bacterial sinusitis may be a primary infection, a complication of viral sinusitis or of dental origin. The principal
causative organisms are Streptococcus pneumoniae, Haemophilus inﬂuenzae and Moraxella catarrhalis.
It is essential to distinguish between bacterial sinusitis and common rhinopharyngitis (see Rhinitis and rhinopharyngitis).
Antibiotic therapy is required in case of bacterial sinusitis only.
Without treatment, severe sinusitis in children may cause serious complications due to the spread of infection to the


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Without treatment, severe sinusitis in children may cause serious complications due to the spread of infection to the
neighbouring bony structures, orbits or the meninges.
Clinical features
Sinusitis in adults
 Sinusitis is likely if symptoms persist for longer than 10 to 14 days or worsen after 5 to 7 days or are severe (severe
pain, high fever, deterioration of the general condition).
Sinusitis in children
Treatment
Symptomatic treatment
Antibiotherapy
 
Purulent unilateral or bilateral discharge, nasal obstruction
and
Facial unilateral or bilateral pain that increases when bending over; painful pressure in maxillary area or behind the
forehead.
Fever is usually mild or absent.
Same symptoms; in addition, irritability or lethargy or cough or vomiting may be present.


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forehead.
Fever is usually mild or absent.
Same symptoms; in addition, irritability or lethargy or cough or vomiting may be present.
In the event of severe infection: deterioration of the general condition, fever over 39 °C, periorbital or facial
oedema.
Fever and pain (Chapter 1).
Clear the nose with 0.9% sodium chloride . a 
In adults:
Antibiotherapy is indicated if the patient meets the criteria of duration or severity of symptoms. Oral amoxicillin is
the ﬁrst-line treatment.
If the diagnosis is uncertain (moderate symptoms < 10 days) and the patient can be reexamined in the next few
days, start with a symptomatic treatment, as for rhinopharyngitis or viral sinusitis.
In children:


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days, start with a symptomatic treatment, as for rhinopharyngitis or viral sinusitis.
In children:
Antibiotic therapy is indicated if the child has severe symptoms or mild symptoms associated with risk factors (e.g.
immunosuppression, sickle cell disease, asthma).
Oral amoxicillin is the ﬁrst-line treatment.
amoxicillin PO for 7 to 10 days:


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Other treatments
 
Children: 30 mg/kg 3 times daily (max. 3 g daily)
Adults: 1 g 3 times daily
In the event of failure to respond within 48 hours of therapy:
amoxicillin/clavulanic acid PO for 7 to 10 days. Use formulations in a ratio of 8:1 or 7:1 exclusively. The dose
is expressed in amoxicillin:
Children < 40 kg: 25 mg/kg 2 times daily
Children ≥ 40 kg and adults:
Ratio 8:1: 2000 mg daily (2 tablets of 500/62.5 mg 2 times daily)
Ratio 7:1: 1750 mg daily (1 tablet of 875/125 mg 2 times daily)
In penicillin-allergic patients:
erythromycin PO for 7 to 10 days:
Children: 30 to 50 mg/kg daily
Adults: 1 g 2 to 3 times daily
 b 
In infants with ethmoiditis, see Periorbital and orbital cellulitis (Chapter 5).


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Children: 30 to 50 mg/kg daily
Adults: 1 g 2 to 3 times daily
 b 
In infants with ethmoiditis, see Periorbital and orbital cellulitis (Chapter 5).
For sinusitis secondary to dental infection: dental extraction while under antibiotic treatment.
In the event of ophthalmologic complications (ophthalmoplegia, mydriasis, reduced visual acuity, corneal
anesthesia), refer for surgical drainage.
Footnotes
(a) For a child: place him on his back, head turned to the side, and instil 0.9% sodium chloride into each nostril.
(b) For dosage according to age or weight, see erythromycin in the guide Essential drugs, MSF.


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Acute pharyngitis
Last updated: November 2020
 
Acute inﬂammation of the tonsils and pharynx. The majority of cases are of viral origin and do not require antibiotic
treatment. Group A streptococcus (GAS) is the main bacterial cause, and mainly affects children aged 3 to 14 years.
Acute rheumatic fever (ARF), a serious late complication of GAS pharyngitis, can be prevented with antibiotic
treatment.
One of the main objectives of assessing acute pharyngitis is to identify patients requiring antibiotic treatment.
Clinical features
 
 Common forms:
Centor criteria
 In patients over 14 years, the probability of GAS pharyngitis is low. Infectious mononucleosis (IM) due to the
Epstein-Barr virus should be suspected in adolescents and young adults with extreme fatigue, generalized


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Epstein-Barr virus should be suspected in adolescents and young adults with extreme fatigue, generalized
adenopathy and often splenomegaly.
Erythematous or exudative pharyngitis may also be associated with gonococcal or primary HIV infection. In
these cases, the diagnosis is mainly prompted by the patient's history.
  Other forms of pharyngitis:
Features common to all types of pharyngitis: throat pain, dysphagia (difﬁculty swallowing), inﬂammation of the
tonsils and pharynx, tender anterior cervical lymph nodes, with or without fever.
Speciﬁc features, depending on the cause:
Erythematous (red throat) or exudative (red throat and whitish exudate) pharyngitis: this appearance is
common to both viral and GAS pharyngitis. Centor criteria help assessment and decrease the empirical use of


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common to both viral and GAS pharyngitis. Centor criteria help assessment and decrease the empirical use of
antibiotics in settings where rapid testing for GAS is not available. A Centor score of less than 2 rules out GAS
infection . Nevertheless, in patients with risk factors (immunosuppression, personal or family history of ARF)
for poststreptococcal complications, or for local or general complications, do not use Centor score and
prescribe empirical antibiotic treatment.
 [1] [2] 
Criteria Score
Temperature > 38 °C 1
Absence of cough 1
Tender anterior cervical lymph node(s) 1
Tonsillar swelling or exudate 1
Pseudomembranous pharyngitis (red tonsils/pharynx covered with an adherent greyish white false membrane):
see Diphtheria, Chapter 2.


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Pseudomembranous pharyngitis (red tonsils/pharynx covered with an adherent greyish white false membrane):
see Diphtheria, Chapter 2.
Vesicular pharyngitis (clusters of tiny blisters or ulcers on the tonsils): always viral (coxsackie virus or primary
herpetic infection).
Ulcero-necrotic pharyngitis: hard and painless syphilitic chancre of the tonsil; tonsillar ulcer soft on palpation in
a patient with poor oral hygiene and malodorous breath (Vincent tonsillitis).


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Peritonsillar, retropharyngeal or lateral pharyngeal abscess: fever, intense pain, dysphagia, hoarse voice, trismus
(limitation of mouth opening), unilateral deviation of the uvula. 
 
Treatment
 
 
 
 
 
 
 
Spots on oral mucosa (Koplik’s spots) accompanied by conjunctivitis and skin rash (see Measles, Chapter 8).
“Strawberry” (red and bumpy) tongue accompanied by a skin rash: scarlet fever caused by GAS.
Local complications:
General complications:
Complications due to the toxin: diphtheria (see Diphtheria, Chapter 2).
Poststreptococcal complications: ARF, acute glomerulonephritis.
Signs of serious illness in children: severe dehydration, severe difﬁculty swallowing, upper airway compromise,
deterioration of general condition.


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Signs of serious illness in children: severe dehydration, severe difﬁculty swallowing, upper airway compromise,
deterioration of general condition.
Differential diagnosis: epiglottitis (see Epiglottitis, Chapter 2).
Symptomatic treatment (fever and pain): paracetamol or ibuprofen PO (Fever, Chapter 1).
Centor score ≤ 1: viral pharyngitis, which typically resolves within a few days (or weeks, for IM): no antibiotic
treatment.
Centor score ≥ 2 or scarlet fever: antibiotic treatment for GAS infections : [3] 
If single-use injection equipment is available, benzathine benzylpenicillin is the drug of choice as streptococcus
A resistance to penicillin remains rare; it is the only antibiotic proven effective in reducing the incidence of


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A resistance to penicillin remains rare; it is the only antibiotic proven effective in reducing the incidence of
rheumatic fever; and the treatment is administered as a single dose.
benzathine benzylpenicillin IM
Children under 30 kg (or under 10 years): 600 000 IU single dose
Children 30 kg and over (or 10 years and over) and adults: 1.2 MIU single dose
Penicillin V is the oral reference treatment, but poor adherence is predictable due to the length of treatment.
phenoxymethylpenicillin (penicillin V) PO for 10 days
Children 1 to < 6 years: 250 mg 2 times daily
Children 6 to < 12 years: 500 mg 2 times daily
Children 12 years and over and adults: 1 g 2 times daily
Children under 1 year: 125 mg 2 times daily


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Children 6 to < 12 years: 500 mg 2 times daily
Children 12 years and over and adults: 1 g 2 times daily
Children under 1 year: 125 mg 2 times daily
Amoxicillin is an alternative and the treatment has the advantage of being relatively short. However, it can
cause adverse skin reactions in patients with undiagnosed IM and thus should be avoided when IM has not been
excluded
amoxicillin PO for 6 days
Children: 25 mg/kg 2 times daily
Adults: 1 g 2 times daily
Macrolides should be reserved for penicillin allergic patients as resistance to macrolides is frequent and their
efﬁcacy in the prevention of rheumatic fever has not been studied. 
azithromycin PO for 3 days
Children: 20 mg/kg once daily (max. 500 mg daily)
Adults: 500 mg once daily


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azithromycin PO for 3 days
Children: 20 mg/kg once daily (max. 500 mg daily)
Adults: 500 mg once daily
Gonococcal or syphilitic pharyngitis: as for genital gonorrhoea (Chapter 9) and syphilis (Chapter 9).
Diphtherial pharyngitis: see Diphtheria (Chapter 2).
Vincent tonsillitis: metronidazole or amoxicillin.
Peritonsillar retropharyngeal or lateral pharyngeal abscess: refer for surgical drainage.


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References
If signs of serious illness or epiglottitis are present in children: hospitalise.
1. Fine AM, Nizet V, Mandl KD. Large-scale validation of the Centor and McIsaac scores to predict group A streptococcalpharyngitis. Arch Intern Med. 2012;172(11):847-852.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3627733/ [Accessed 20 October 2020]
2. National Institute for Health and Care Excellence. Sore throat (acute): antimicrobial prescribing. 2018.http://www.nice.org.uk/ng84 [Accessed 20 October 2020]
3. Group A Streptococcal Disease, Centers for Disease Control and Prevention. Atlanta (GA): CDC; 2020. https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html [Accessed 20 October 2020]


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Diphtheria
Last updated: October 2022
 
 
Diphtheria is a bacterial infection due to Corynebacterium diphtheriae, spread from person to person through
inhalation of infected respiratory droplets of symptomatic or asymptomatic individuals, or direct contact with
contaminated objects or diphtheria skin lesions .
After infection, C. diphtheriae has an incubation period of 1 to 5 days (max. 10 days) during which time it multiplies in
the upper respiratory tract. The bacteria secretes a toxin which causes severe local as well as systemic effects. Death
can occur from airway obstruction or as a result of systemic complications, including damage to the myocardium and
nervous system, caused by the toxin.


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nervous system, caused by the toxin. 
Cases can remain infectious up to 8 weeks after initial infection . Antibiotic treatment can reduce infectiousness to 6
days .
Vaccination is the key to prevention and control of diphtheria. It protects individuals from severe disease (fewer and
less severe symptoms) but does not prevent the spread of C. diphtheriae. Clinical disease does not confer protective
immunity and vaccination is an integral part of case management.
Clinical features
Laboratory
Treatment
 [1] [2] a 
 [1] 
 [2] 
 [3] 
During clinical examination respect standard, contact, and droplet precautions (handwashing, gloves, gown, mask,
etc.). Conduct a careful examination of the throat.
Signs of respiratory diphtheria : a


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etc.). Conduct a careful examination of the throat.
Signs of respiratory diphtheria : a 
pharyngitis, rhinopharyngitis, tonsillitis or laryngitis with tough, greyish, ﬁrmly adherent pseudo-membranes of the
pharynx, nasopharynx, tonsils, or larynx;
dysphagia and cervical adenitis, at times progressing to massive swelling of the neck;
airway obstruction and possible suffocation when the infection extends to the nasal passages, larynx, trachea
and bronchi;
fever is generally low-grade . [2] 
Generalised signs due to effects of the toxin:
cardiac dysfunction (tachycardia, arrhythmias), severe myocarditis with heart failure and possibly cardiogenic
shock (see Shock, Chapter 1) 3 to 7 days or 2 to 3 weeks after onset of the disease;


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shock (see Shock, Chapter 1) 3 to 7 days or 2 to 3 weeks after onset of the disease;
neuropathies in 2 to 8 weeks after the onset of disease leading to nasal voice and difﬁculty with swallowing
(paralysis of the soft palate), vision (ocular motor paralysis), breathing (paralysis of respiratory muscles) and
ambulation (limb paralysis);
oliguria, anuria and acute renal failure.
Differential diagnoses: Epiglottitis and Acute pharyngitis, Chapter 2, Stomatitis, Chapter 3.
Diagnosis is conﬁrmed by isolation of toxigenic C. diphtheriae by culture (and antibiotic susceptibility test) of swab
specimens collected from the affected areas: throat (tonsils, pharyngeal mucosa, soft palate, exudate, ulcer, etc.),
nasopharynx.


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specimens collected from the affected areas: throat (tonsils, pharyngeal mucosa, soft palate, exudate, ulcer, etc.),
nasopharynx.
The presence of the toxin is conﬁrmed by PCR testing (detection of diphtheria toxin gene).
Isolation of patients; standard, droplet, and contact precautions for medical staff.


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There is a risk of anaphylactic reaction, especially in patients with asthma. Close monitoring of the patient is
essential, with immediate availability of equipment for manual ventilation (Ambu bag, face mask) and
intubation, Ringer lactate and epinephrine (see Shock, Chapter 1).
Besredka method: inject 0.1 ml SC and wait 15 minutes. If there is no allergic reaction (no erythema at the injection
site or a ﬂat erythema of less than 0.5 cm in diameter), inject a further 0.25 ml SC. If there is no reaction after 15
minutes, inject the rest of the product IM or IV depending on the volume to be administered.
Doses are given as a function of the severity of illness, and the delay in treatment:
 
Never administer procaine benzylpenicillin by IV injection or infusion.


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Never administer procaine benzylpenicillin by IV injection or infusion.
In penicillin-allergic patients, use erythromycin IV .
Diphtheria antitoxin (DAT) derived from horse serum: 
Administer DAT as soon as possible after disease onset. Do not wait for bacteriological conﬁrmation ; administer
DAT under close monitoring in a hospital setting, according to the Besredka method to assess possibility of allergy.
Any delay can diminish efﬁcacy.
 b 
 [1] 
 
 
Clinical signs Dose in units Administration route
Laryngitis or pharyngitis
or duration < 48 hours 20 to 40 000
IM or IV infusion in 250 ml of 0.9% sodium
chloride in 2 to 4 hours for doses of more
than 20 000 units.
Rhinopharyngitis 40 to 60 000
Severe disease (respiratory distress,
shock), cervical oedema or duration ≥ 48
hours


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than 20 000 units.
Rhinopharyngitis 40 to 60 000
Severe disease (respiratory distress,
shock), cervical oedema or duration ≥ 48
hours
80 to 100 000
Antibiotic treatment (as soon as possible without waiting for bacteriological conﬁrmation ) for 14 days or according
to length of treatment recommended by the national protocol:
if the patient can swallow:
azithromycin PO (ﬁrst-line)
Children: 10 to 12 mg/kg once daily (max. 500 mg daily)
Adults: 500 mg once daily
or
erythromycin PO
Children under 40 kg: 10 to 15 mg/kg (max. 500 mg) 4 times daily
Children 40 kg and over and adults: 500 mg 4 times daily
or
phenoxymethylpenicillin (penicillin V) PO
Children under 40 kg: 10 to 15 mg/kg (max. 500 mg) 4 times daily
Children 40 kg and over and adults: 500 mg 4 times daily


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Children under 40 kg: 10 to 15 mg/kg (max. 500 mg) 4 times daily
Children 40 kg and over and adults: 500 mg 4 times daily
If the patient cannot swallow, start with one of the treatments below and change as soon as possible to oral
route with one of the oral treatments above to complete 14 days of treatment:
procaine benzylpenicillin IM
Children under 25 kg: 50 000 IU/kg (= 50 mg/kg) once daily (max. 1.2 MIU = 1.2 g daily)
Children 25 kg and over and adults: 1.2 MIU (= 1.2 g) once daily
 
 
 c 
Intubation/tracheotomy if necessary (airway obstruction, respiratory failure, etc.).
If the event of shock, see Shock, Chapter 1, for complementary treatment.
Update every patient's vaccination status before hospital discharge (or during ﬁrst visit, if receiving home-based


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Update every patient's vaccination status before hospital discharge (or during ﬁrst visit, if receiving home-based
care). If the patient has been administered DAT and can receive adequate home-based follow up after hospital
discharge, wait 3 weeks after administration of DAT before vaccination.


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Management of close contacts 
Close contacts include household members living under the same roof and people who were directly exposed (less than
one metre) to nasopharyngeal secretions of the patient on a regular basis (e.g. family or close friends, children in the
same class, medical personnel) during the 5 days or nights prior to onset of symptoms of the case .
Benzathine benzylpenicillin should never be administered by IV route.
or azithromycin PO or erythromycin PO as above for 7 days.
Outbreak surveillance measures
AND 
Prevention 
Administer 2 subsequent booster doses containing d at least 4 weeks apart .       
 
 [4] 
Collect nasal and pharyngeal swabs for culture before starting antibiotic prophylaxis; temperature and throat


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[4] 
Collect nasal and pharyngeal swabs for culture before starting antibiotic prophylaxis; temperature and throat
examination daily (10 days); exclusion from school or work until 48 hours after starting antibiotic prophylaxis. If
symptoms of respiratory infection appear: treat immediately as a case of diphtheria.
Antibiotic prophylaxis:
benzathine benzylpenicillin IM
Children under 30 kg: 600 000 IU single dose
Children 30 kg and over and adults: 1.2 MIU single dose
 
 
Check vaccination status:
if less than 3 injections received: complete vaccination schedule (see Prevention below);
if 3 injections received, with the last injection over one year ago: administer a booster dose immediately;


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if 3 injections received, with the last injection over one year ago: administer a booster dose immediately;
if 3 injections received, with the last injection less than one year ago: a booster dose is not immediately
necessary.
A suspected case of diphtheria is deﬁned as a person with:
pharyngitis, rhinopharyngitis, tonsillitis and/or laryngitis
an adherent pseudo-membrane of the pharynx, nose, tonsils and/or larynx . [1] 
Isolate and treat suspect cases without delay. Collect swab samples before starting antibiotic treatment. Submit
case notiﬁcation to the public health authorities within 24 hours . [1] 
Routine vaccination (EPI), for information: 3 doses of conjugate vaccine containing the higher potency (D)


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Routine vaccination (EPI), for information: 3 doses of conjugate vaccine containing the higher potency (D)
formulation of diphtheria toxoid as soon as possible as of 6 weeks of age and at 4 week intervals; D booster
between 12 and 23 months, then between 4 and 7 years; booster with a vaccine containing a reduced dose (d) of
diphtheria toxoid between 9 and 15 years . [5] 
Catch-up vaccination (individuals who have not received routine vaccination), for information:
children 1 to 6 years: 3 doses of conjugate vaccine containing the higher potency (D) formulation of diphtheria
toxoid at least 4 weeks apart;
children 7 years and over and adults (including medical staff): 3 doses of conjugate vaccine containing a reduced


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toxoid at least 4 weeks apart;
children 7 years and over and adults (including medical staff): 3 doses of conjugate vaccine containing a reduced
dose (d) of diphtheria toxoid. Administer with a minimum interval of 4 weeks between ﬁrst and second dose and
an interval of at least 6 months between second and third dose (in the event of an outbreak this interval may be
reduced to 4 weeks to achieve protection quicker).
 [5] 
Footnotes
(a) This guide focuses on respiratory diphtheria and signs due to the toxin. It should be noted that cutaneous diphtheria is stilla signiﬁcant reservoir of C. diphtheriae.


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References
(b) DAT reduces mortality and should be given to all diphtheria patients. However, as supply is very limited, it may be necessaryto deﬁne criteria and reserve DAT for the treatment of patients who will beneﬁt the most from it. DAT can be administeredto pregnant women.
(c) erythromycin IV infusion (60 minutes)Children: 12.5 mg/kg every 6 hours (max. 2 g daily); adults: 500 mg every 6 hoursErythromycin powder (1 g) should be reconstituted in 20 ml of water for injection only. Then, dilute each dose oferythromycin in 10 ml/kg of 0.9% sodium chloride in children less than 20 kg and in a bag of 250 ml of 0.9% sodium chloridein children 20 kg and over and in adults. Do not dilute in glucose.


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1. World Health Organization. Diphtheria. Vaccine-Preventable Diseases Surveillance Standards. 2018.https://www.who.int/immunization/monitoring_surveillance/burden/vpd/WHO_SurveillanceVaccinePreventable_04_Diphtheria_R2.pdf?ua=1 [Accessed 11 August 2020]
2. Tiwari TSP, Wharton M. Chapter 19: Diphtheria Toxoid. In: Plotkin SA, Orenstein WA, Ofﬁt PA, editors. Vaccines. 7th ed.Philadelphia, PA: Elsevier; 2018. p. 261–275.
3. Truelove SA, Keegan LT, Moss WJ, Chaisson LH, Macher E, Azman AS, Lessler J. Clinical and Epidemiological Aspects ofDiphtheria: A Systematic Review and Pooled Analysis. Clin Infect Dis. 2020 Jun 24;71(1):89-97. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7312233/ [Accessed 24 November 2020]


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4. Pan American Health Organization, World Health Organization. Diphtheria in the Americas - Summary of the situation 2018.Epidemiological Update Diphtheria. 16 April 2018.https://www.paho.org/hq/index.php?option=com_docman&view=download&category_slug=diphtheria-%098968&alias=44497-16-april-2018-diphtheria-epidemiological-update-497&Itemid=270&lang=en [Accessed 11 August2020]
5. World Health Organization. Diphtheria vaccine: WHO position paper - August 2017. Weekly epidemiological record 2017;92/(31):417–436.https://www.who.int/immunization/policy/position_papers/wer_31_diphtheria_updated_position_paper.pdf?ua=1 [Accessed11 August 2020]


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Other upper respiratory tract infections
 
 
 
Croup (laryngotracheitis and laryngotracheobronchitis)
Epiglottitis
Bacterial tracheitis


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Croup (laryngotracheitis andlaryngotracheobronchitis)
Last updated: October 2024
 
Common viral respiratory infection with peak incidence amongst children between 6 months and 3 years.
Clinical features
Treatment
 
 
Typical barking cough, hoarse voice or cry.
Inspiratory stridor (abnormal high pitched sound on inspiration):
Croup is considered mild if the stridor only occurs with agitation;
Croup is considered severe if there is stridor at rest, especially when it is accompanied by respiratory distress.
Wheezing may also be present if the bronchi are involved.
In the absence of inspiratory stridor or intercostal, subcostal or sternal retractions, treat symptomatically: ensure


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In the absence of inspiratory stridor or intercostal, subcostal or sternal retractions, treat symptomatically: ensure
adequate hydration, seek medical attention if symptoms worsen (e.g. respiratory difﬁculty, noisy breathing, inability
to tolerate oral ﬂuids).
If stridor is only present with agitation (mild croup) : [1] 
Assure adequate hydration.
Corticosteroids:
dexamethasone PO: 0.15 to 0.6 mg/kg (max. 16 mg) single dose a 
or, if not available, prednisolone PO: 1 mg/kg single dose
Keep the child under observation at least 30 minutes after oral corticosteroid. Consider hospitalisation or longer
observation (> 4 hours) if the child is less than 6 months old, or is dehydrated, or lives far from health facility.


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observation (> 4 hours) if the child is less than 6 months old, or is dehydrated, or lives far from health facility.
If danger signs are present (stridor at rest, respiratory distress, hypoxia) or the child is unable to drink, admit
to hospital : [1] 
Administer oxygen continuously if respiratory distress or SpO < 92%: maintain SpO between 94 and 98% (or if
SpO cannot be determined, at least 5 litres/minute).
2 2
2
Insert a peripheral IV line and provide IV hydration.
Epinephrine (adrenaline) via nebulizer : 0.5 mg/kg (max. 5 mg) to be repeated every 20 minutes if danger
signs persist (see table below).
Monitor heart rate during nebulization (if heart rate greater than 200, stop the nebulization).
 [2] b 
Weight 6 kg 7 kg 8 kg 9 kg 10-17 kg
Dose in mg 3 mg 3.5 mg 4 mg 4.5 mg 5 mg


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[2] b 
Weight 6 kg 7 kg 8 kg 9 kg 10-17 kg
Dose in mg 3 mg 3.5 mg 4 mg 4.5 mg 5 mg
Dose in ml (1 mg/ml, 1 ml ampoule) 3 ml 3.5 ml 4 ml 4.5 ml 5 ml
NaCl 0.9% (a) 1 ml 1 ml – – –
(a) Add sufﬁcient NaCl 0.9% to obtain a total volume of 4 to 4.5 ml in the nebulizing chamber.


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Epinephrine is intended exclusively for nebulized administration and should not be given IV or IM in croup.
 
 
  
 
References
 
 
Corticosteroids:
dexamethasone  PO (or IM or IV if the child is vomiting): 0.6 mg/kg (max. 16 mg) single dose (see table
below)
 c 
or, if not available, prednisolone PO: 1 mg/kg single dose
Weight 6-8 kg 9-11 kg 12-14 kg 15-17 kg
Dose in mg 4 mg 6 mg 8 mg 10 mg
Dose in 2 mg tablet 2 tab 3 tab 4 tab 5 tab
Dose in ml (4 mg/ml, 1 ml ampoule) 1 ml 1.5 ml 2 ml 2.5 ml
Suspect bacterial tracheitis in a critically ill appearing child with croup who does not improve with the above
treatment.
 d 
If the patient has a complete airway obstruction, intubation if possible or emergency tracheotomy.
Footnotes


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treatment.
 d 
If the patient has a complete airway obstruction, intubation if possible or emergency tracheotomy.
Footnotes
(a) If children can easily return to hospital in case of deterioration or return of symptoms, administer 0.15 mg/kg ofdexamethasone. Otherwise, the dose of 0.6 mg/kg should be used. 
(b) Although not licensed for this indication, epinephrine 1:1000 (1 mg/ml) should be used for nebulisation.
(c) Administer orally if possible in order to avoid causing agitation in the child as this may worsen symptoms.
(d) Critically ill appearing child: weak grunting or crying, drowsiness, difﬁcult to arouse, does not smile, disconjugate or anxiousgaze, pallor or cyanosis, general hypotonia.


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1. Pocket book of primary health care for children and adolescents: guidelines for health promotion, disease prevention andmanagement from the newborn period to adolescence. Copenhagen: WHO Regional Ofﬁce for Europe; 2022. Licence: CCBY-NCSA 3.0 IGO.https://www.who.int/europe/publications/i/item/9789289057622
2. Bjornson C, Russell K, Vandermeer B, Klassen TP, Johnson DW. Nebulized epinephrine for croup in children. Cochrane AcuteRespiratory Infections Group, ed. Cochrane Database Syst Rev. Published online October 10, 2013.https://doi.org/10.1002/14651858.CD006619.pub3


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Epiglottitis
Bacterial infection of the epiglottis in young children caused by Haemophilus inﬂuenzae (Hib), it is rare when Hib
vaccine coverage is high. It can be caused by other bacteria and occur in adults.
Clinical features
  Allow the child to sit in a comfortable position or on the parent’s lap. Do not force them to lie down (may
precipitate airway obstruction). Avoid any examination that will upset the child including examination of the
mouth and throat.
Treatment
 
Rapid (less than 12-24 hours) onset of high fever.
Typical “tripod or snifﬁng” position, preferring to sit, leaning forward with an open mouth, anxious appearing.
Difﬁculty swallowing, drooling, and respiratory distress.


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Difﬁculty swallowing, drooling, and respiratory distress.
Stridor may be present (as opposed to croup, hoarse voice and cough are usually absent).
Critically ill appearing . a 
 
 
In case of imminent airway obstruction, emergency intubation or tracheotomy is indicated. The intubation is
technically difﬁcult and should be performed under anaesthesia by a physician familiar with the procedure. Be
prepared to perform a tracheotomy if intubation is unsuccessful.
In all cases:
Insert a peripheral IV line and provide IV hydration.
Antibiotherapy:
ceftriaxone slow IV (3 minutes) or IV infusion (30 minutes) . Avoid IM route (may agitate the child and precipitate
a respiratory arrest).
Children: 50 mg/kg once daily
Adults: 1 g once daily


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a respiratory arrest).
Children: 50 mg/kg once daily
Adults: 1 g once daily
The IV treatment is administered for at least 5 days then, if the clinical condition has improved and oral
treatment can be tolerated, change to:
amoxicillin/clavulanic acid (co-amoxiclav) PO to complete a total of 7 to 10 days of treatment. Use
formulations in a ratio of 8:1 or 7:1 exclusively. The dose is expressed in amoxicillin:
Children < 40 kg: 50 mg/kg 2 times daily
Children ≥ 40 kg and adult:
Ratio 8:1: 3000 mg daily (2 tablets of 500/62.5 mg 3 times daily)
Ratio 7:1: 2625 mg daily (1 tablet of 875/125 mg 3 times daily)
 b 
 c 
Footnotes


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Ratio 8:1: 3000 mg daily (2 tablets of 500/62.5 mg 3 times daily)
Ratio 7:1: 2625 mg daily (1 tablet of 875/125 mg 3 times daily)
 b 
 c 
Footnotes
(a) Critically ill appearing child: weak grunting or crying, drowsiness, difﬁcult to arrouse, does not smile, unconjugate or anxiousgaze, pallor or cyanosis, general hypotonia.
(b) For administration by IV route, ceftriaxone powder should to be reconstituted in water for injection only. For administrationby IV infusion, dilute each dose of ceftriaxone in 5 ml/kg of 0.9% sodium chloride or 5% glucose in children less than 20 kgand in a bag of 100 ml of 0.9% sodium chloride or 5% glucose in children over 20 kg and in adults.


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(c) Improvement criteria include: fever reduction, diminished respiratory distress, improved SpO, improved appetite and/oractivity.
2


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Bacterial tracheitis
Bacterial infection of the trachea in children, occurring as a complication of a previous viral infection (croup, inﬂuenza,
measles, etc.).
Clinical features
Treatment
 
Fever in a critically ill appearing child . a 
Stridor, cough and respiratory distress.
Copious purulent secretions.
As opposed to epiglottitis the onset of symptoms is gradual and the child prefers to lie ﬂat.
In severe cases there is a risk of complete airway obstruction, especially in very young children.
Suction purulent secretions.
Insert a peripheral IV line and provide IV hydration.
Antibiotherapy:
ceftriaxone slow IV (3 minutes) or IV infusion (30 minutes). Do not administer by IM route (may agitate the child and
precipitate a respiratory arrest).
Children: 50 mg/kg once daily


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precipitate a respiratory arrest).
Children: 50 mg/kg once daily
Adults: 1 g once daily
+
cloxacillin IV infusion (60 minutes)
Children less than 12 years: 25 to 50 mg/kg every 6 hours
Children 12 years and over and adults: 2 g every 6 hours
The IV treatment is administered for at least 5 days then, if the clinical condition has improved and oral treatment
can be tolerated, change to :
amoxicillin/clavulanic acid (co-amoxiclav) PO to complete 7 to 10 days of treatment, as in epiglottitis.
 b 
 c 
If the event of complete airway obstruction, intubation if possible or emergency tracheotomy.
Footnotes
(a) Critically ill appearing child: weak grunting or crying, drowsiness, difﬁcult to arrouse, does not smile, unconjugate or anxiousgaze, pallor or cyanosis, general hypotonia.


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(b) For administration by IV route, ceftriaxone powder should to be reconstituted in water for injection only. For administrationby IV infusion, dilute each dose of ceftriaxone in 5 ml/kg of 0.9% sodium chloride or 5% glucose in children less than 20 kgand in a bag of 100 ml of 0.9% sodium chloride or 5% glucose in children over 20 kg and in adults.
(c) Improvement criteria include: fever reduction, diminished respiratory distress, improved SpO, improved appetite and/oractivity.
2


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Otitis
 
 
 
Acute otitis externa
Acute otitis media (AOM)
Chronic suppurative otitis media (CSOM)


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Acute otitis externa
Diffuse inﬂammation of the external ear canal, due to bacterial or fungal infection. Common precipitants of otitis
externa are maceration, trauma of the ear canal or presence of a foreign body or dermatologic diseases (such as
eczema, psoriasis). 
Clinical features
Treatment
Ear canal pruritus or ear pain, often severe and exacerbated by motion of the pinna; feeling of fullness in the ear;
clear or purulent ear discharge or no discharge
Otoscopy (remove skin debris and secretions from the auditory canal by gentle dry mopping (use a dry cotton bud
or a small piece of dry cotton wool):
diffuse erythema and edema, or infected eczema, of the ear canal
look for a foreign body


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or a small piece of dry cotton wool):
diffuse erythema and edema, or infected eczema, of the ear canal
look for a foreign body
if visible, the tympanic membrane is normal (swelling and pain very often prevent adequate visualization of the
tympanic membrane)
Remove a foreign body, if present.
Treatment of pain: paracetamol PO (Chapter 1, Pain).
Local treatment:
Remove secretions from the auditory canal by gentle dry mopping (use a dry cotton bud or a small piece of dry
cotton wool). Consider ear irrigation (0.9% sodium chloride, using a syringe) only if the tympanic membrane can
be fully visualised and is intact (no perforation). Otherwise, ear irrigation is contra-indicated.
Apply ciproﬂoxacin ear drops in the affected ear(s) for 7 days:
Children ≥ 1 year: 3 drops 2 times daily


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Apply ciproﬂoxacin ear drops in the affected ear(s) for 7 days:
Children ≥ 1 year: 3 drops 2 times daily
Adults: 4 drops 2 times daily


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Acute otitis media (AOM)
Acute inﬂammation of the middle ear, due to viral or bacterial infection, very common in children under 3 years, but
uncommon in adults.
The principal causative organisms of bacterial otitis media are Streptococcus pneumoniae, Haemophilus inﬂuenzae,
Moraxella catarrhalis and in older children, Streptococcus pyogenes.
Clinical features
Treatment
 
 
amoxicillin PO for 5 days
Children: 30 mg/kg 3 times daily (max. 3 g daily)
Adults: 1 g 3 times daily
Rapid onset of ear pain (in infants: crying, irritability, sleeplessness, reluctance to nurse) and ear discharge
(otorrhoea) or fever.
Other signs such as rhinorrhoea, cough, diarrhoea or vomiting are frequently associated, and may confuse the


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(otorrhoea) or fever.
Other signs such as rhinorrhoea, cough, diarrhoea or vomiting are frequently associated, and may confuse the
diagnosis, hence the necessity of examining the tympanic membranes.
Otoscopy: bright red tympanic membrane (or yellowish if rupture is imminent) and presence of pus, either
externalised (drainage in ear canal if the tympanic membrane is ruptured) or internalised (opaque or bulging tympanic
membrane). The combination of these signs with ear pain or fever conﬁrms the diagnosis of AOM.
Note:
The following otoscopic ﬁndings are not sufﬁcient to make the diagnosis of AOM:
A red tympanic membrane alone, with no evidence of bulging or perforation, is suggestive of viral otitis in a


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A red tympanic membrane alone, with no evidence of bulging or perforation, is suggestive of viral otitis in a
context of upper respiratory tract infection, or may be due to prolonged crying in children or high fever.
The presence of air bubbles or ﬂuid behind an intact tympanic membrane, in the absence of signs and symptoms
of acute infection, is suggestive of otitis media with effusion (OME).
Complications, particularly in high-risk children (malnutrition, immunodeﬁciency, ear malformation) include chronic
suppurative otitis media, and rarely, mastoiditis, brain abscess or meningitis.
In all cases:
Treatment of fever and pain: paracetamol PO (Chapter 1).
Ear irrigation is contra-indicated if the tympanic membrane is ruptured, or when the tympanic membrane cannot


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Ear irrigation is contra-indicated if the tympanic membrane is ruptured, or when the tympanic membrane cannot
be fully visualised. Ear drops are not indicated.
Indications for antibiotic therapy:
Antibiotics are prescribed in children less than 2 years, children whose assessment suggests severe infection
(vomiting, fever > 39 °C, severe pain) and children at risk of unfavourable outcome (malnutrition,
immunodeﬁciency, ear malformation).
For other children:
If the child can be re-examined within 48 to 72 hours: it is preferable to delay antibiotic prescription.
Spontaneous resolution is probable and a short symptomatic treatment of fever and pain may be sufﬁcient.
Antibiotics are prescribed if there is no improvement or worsening of symptoms after 48 to 72 hours.


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Antibiotics are prescribed if there is no improvement or worsening of symptoms after 48 to 72 hours.
If the child cannot be re-examined: antibiotics are prescribed.
For children treated with antibiotics: advise the mother to bring the child back if fever and pain persist after 48
hours.
Choice of antibiotherapy:
Amoxicillin is the ﬁrst-line treatment:


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amoxicillin/clavulanic acid (co-amoxiclav) PO for 5 days
Use formulations in a ratio of 8:1 or 7:1. The dose is expressed in amoxicillin:
Children < 40 kg: 25 mg/kg 2 times daily
Children ≥ 40 kg and adult:
Ratio 8:1: 2000 mg daily (2 tablets of 500/62.5 mg 2 times daily)
Ratio 7:1: 1750 mg daily (1 tablet of 875/125 mg 2 times daily)
Persistence of a ear drainage alone, without fever and pain, in a child who has otherwise improved (reduction in
systemic symptoms and local inﬂammation) does not warrant a change in antibiotic therapy. Clean ear canal by
gentle dry mopping until no more drainage is obtained.
azithromycin PO
Children over 6 months: 10 mg/kg once daily for 3 days


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gentle dry mopping until no more drainage is obtained.
azithromycin PO
Children over 6 months: 10 mg/kg once daily for 3 days
Amoxicillin/clavulanic acid is used as second-line treatment, in the case of treatment failure. Treatment failure is
deﬁned as persistence of fever and/or ear pain after 48 hours of antibiotic treatment.
Macrolides should be reserved for very rare penicillin-allergic patients, as treatment failure (resistance to
macrolides) is frequent.


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Chronic suppurative otitis media (CSOM)
Chronic bacterial infection of the middle ear with persistent purulent discharge through a perforated tympanic
membrane.
The principal causative organisms are Pseudomonas aeruginosa, Proteus sp, staphylococcus, other Gram negative
and anaerobic bacteria.
Clinical features
Treatment
Children 1 year and over: 3 drops 2 times daily
Adults: 4 drops 2 times daily
Purulent discharge for more than 2 weeks, often associated with hearing loss or even deafness; absence of pain
and fever
Otoscopy: perforation of the tympanic membrane and purulent exudate
Complications:
Consider a superinfection (AOM) in the case of new onset of fever with ear pain, and treat accordingly.


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Complications:
Consider a superinfection (AOM) in the case of new onset of fever with ear pain, and treat accordingly.
Consider mastoiditis in the case of new onset of high fever, severe ear pain and/or tender swelling behind the
ear, in a patient who appears signiﬁcantly unwell.
Consider brain abscess or meningitis in the case of impaired consciousness, neck stiffness and focal
neurological signs (e.g. facial nerve paralysis).
Remove secretions from the auditory canal by gentle dry mopping (use a dry cotton bud or a small piece of dry
cotton wool).
Apply ciproﬂoxacin ear drops until no more drainage is obtained (approximately 2 weeks, max. 4 weeks):
Complications:
Chronic mastoiditis is a medical emergency that requires prompt hospitalisation, prolonged antibiotherapy that


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Complications:
Chronic mastoiditis is a medical emergency that requires prompt hospitalisation, prolonged antibiotherapy that
covers the causative organisms of CSOM (ceftriaxone IM for 10 days + ciproﬂoxacin PO for 14 days),
atraumatic cleaning of the ear canal; surgical treatment may be required. Before transfer to hospital, if the
patient needs to be transferred, administer the ﬁrst dose of antibiotics.
Meningitis (Chapter 7).


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Pertussis (whooping cough)
Last updated: December 2024
 
Pertussis is a highly contagious infection of the respiratory tract caused by the bacterium Bordetella pertussis.
It is transmitted via airborne droplets spread by infected people (by coughing and/or sneezing), particularly within 3
weeks of the onset of cough . Despite the development of effective vaccines, it remains an important cause of
morbidity and mortality, particularly in infants. This disease is endemic worldwide and outbreaks are common.  It most commonly affects children < 5 years, but can
affect any age group. Reported incidence in adolescents and adults has been increasing in some regions . Pertussis is a notiﬁable disease in many countries, and cases should be reported to local or national public health


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authorities. Pertussis immunization is part of all vaccination schedules and is included in the Expanded Programme on
Immunization (EPI).
Clinical features
After an incubation period of 7 to 10 days (up to 21 days), the illness evolves in 3 stages : 
 
 Complications may include secondary bacterial pneumonia (new-onset fever can be an indicator), dehydration and
malnutrition triggered by feeding difﬁculty due to cough and vomiting, seizures, encephalopathy, sudden death,
intracranial bleeding, petechiae, rib fracture, hernia, rectal prolapse. 
 The disease is most severe, with a high risk of death, in infants. Adolescents and adults commonly have milder
symptoms, but older adults, immunocompromised persons, and people with underlying respiratory conditions are at risk


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symptoms, but older adults, immunocompromised persons, and people with underlying respiratory conditions are at risk
of severe disease and hospitalisation . Pertussis is most contagious and antibiotic treatment is most beneﬁcial during the catarrhal stage of the illness. Since
this is also the period during which clinical symptoms and signs are non-speciﬁc, it is necessary to maintain a high index
of suspicion with clues from the context. These include patients with any compatible symptoms and close contact with
a suspected case or in a pertussis outbreak setting.
Management
Suspected cases
Antibiotic treatment
 [1] 
 [2] 
 [3] 
Catarrhal stage (1 to 2 weeks, but may be shorter in infants < 6 months):
Runny nose, mild cough, no or low-grade fever.


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[1] 
 [2] 
 [3] 
Catarrhal stage (1 to 2 weeks, but may be shorter in infants < 6 months):
Runny nose, mild cough, no or low-grade fever.
During this stage, the disease is indistinguishable from other non-speciﬁc respiratory infections.
Paroxysmal stage (1 to 6 weeks):
Cough of increasing severity, occuring in characteristic bouts (paroxysms) of a series of coughs during one
exhalation, followed by a laboured inspiration causing a distinctive gasping sound (whoop), and/or post-tussive
vomiting. 
No or low-grade fever. 
Apnoea and cyanosis (in infants).
Prolonged cough, sometimes without paroxysms or whoop (particularly in older children and adults).
Convalescent stage (weeks to months):
Paroxysms of cough gradually decrease in frequency and severity.
 [4]


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Antibiotic treatment is indicated for the following patients and should be started as soon as pertussis is suspected:
 
 Admit the following patients to hospital
 Infection prevention and control measures
Patients with pertussis are considered infectious until they have completed 5 days of appropriate antibiotics, or if not
treated, until 21 days after the start of the paroxysmal cough . During this infectious period, these measures should
be followed:
 
 [5] 
All patients 1 year of age and older, within 3 weeks of the onset of cough.
Infants and pregnant women, within 6 weeks of the onset of cough.
First line
azithromycin PO
for 5 days
Children < 6 months: 10 mg/kg once daily
Children ≥ 6 months: 10 mg/kg (max. 500 mg) on D1 then 5 mg/kg (max.


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First line
azithromycin PO
for 5 days
Children < 6 months: 10 mg/kg once daily
Children ≥ 6 months: 10 mg/kg (max. 500 mg) on D1 then 5 mg/kg (max.
250 mg) once daily from D2 to D5
Adults: 500 mg on D1 then 250 mg once daily from D2 to D5
Alternatives
erythromycin PO
for 7 days
 (a) Children: 15 mg/kg 3 times daily
Adults: 1 g 3 times daily
co-trimoxazole PO
for 14 days
 (b) Children ≥ 6 weeks: 20 mg SMX/4 mg TMP/kg (max. 800 mg SMX/160
mg TMP) 2 times daily
Adults: 800 mg SMX/160 mg TMP 2 times daily
(a) Erythromycin is an alternative, but azithromycin is better tolerated and simpler to administer (shorter treatment duration,fewer daily doses).


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(a) Erythromycin is an alternative, but azithromycin is better tolerated and simpler to administer (shorter treatment duration,fewer daily doses).
(b) Use co-trimoxazole only if macrolides are contra-indicated, not tolerated, or not available.Avoid:- during the ﬁrst trimester of pregnancy (risk of congenital malformations),- after 36 weeks of pregnancy and in women breastfeeding neonates (0 to 4 weeks), or breastfeeding infants that arepremature, low birth weight, jaundiced, or ill (risk of haemolysis and jaundice in the child).Advise patients to seek immediate medical attention if there are signs of anaemia or jaundice, especially in regions with highprevalence of G6PD deﬁciency.
Patients with severe illness (e.g. respiratory distress, apnoea, cyanosis, pneumonia, seizures or impaired


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Patients with severe illness (e.g. respiratory distress, apnoea, cyanosis, pneumonia, seizures or impaired
consciousness)
Infants up to 3 months of age (with monitoring 24 hours per day due to the risk of apnoea)
Patients with difﬁculty in feeding or drinking
 [1] 
In hospital: single room if possible, or grouping pertussis cases together away from other patients
(cohorting); standard precautions and droplet precautions (including, for the patient, cough etiquette and wearing a
surgical mask if outside the room) [6]
All patients: avoid contact with young children and pregnant women; avoid congregate settings including childcare,
school, and work


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Supportive care
Hydration and nutrition: if child is breastfeeding, continue; ensure adequate ﬂuid and calorie intake, give frequent small
feedings including after coughing bouts and post-tussive vomiting; some patients may require nasogastric tube feeding
or IV maintenance ﬂuids; be aware that NG tube placement might provoke paroxysmal coughing, so it should be
inserted by experienced medical staff with minimal manipulation. If weight loss occurred during illness, consider food
supplements for several weeks during convalescent stage when child is able to eat comfortably. Respiratory measures
 For children treated as outpatients, teach the parents about signs that require immediate medical attention (e.g.


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For children treated as outpatients, teach the parents about signs that require immediate medical attention (e.g.
respiratory difﬁculty, apnoea, cyanosis, increasing fever, seizures or impaired consciousness, dehydration, feeding
difﬁculty).
Contacts 
Prevention
 
 
Place the patient in a semi-reclining position (± 30°).
In case of apnoea, stimulate the patient, but be prepared to ventilate if necessary (keep bag and mask accessible).
Administer oxygen if SpO < 92%, for severe respiratory distress, or for recurrent apnoea. Perform gentle
oropharyngeal suctioning if required but avoid deep suctioning (may provoke paroxysmal coughing).
2
Post-exposure prophylaxis (same antibiotic treatment as for suspect cases) is recommended, regardless of
vaccination status, for:


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2
Post-exposure prophylaxis (same antibiotic treatment as for suspect cases) is recommended, regardless of
vaccination status, for:
Asymptomatic close contacts (having face-to-face exposure or direct contact with oral, nasal, or other
respiratory secretions ) of a person with suspected pertussis within 3 weeks of onset of paroxysmal cough [7] 
Asymptomatic exposed people at high risk of complications or who will come into contact with people at high
risk : [4] [8] 
pregnant women in the third trimester (risk to neonate),
infants under 1 year,
people with immunodepression, moderate to severe asthma, and consider for people with other underlying
respiratory conditions and adults ≥ 65 years.
Isolation of asymptomatic contacts is not necessary.


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respiratory conditions and adults ≥ 65 years.
Isolation of asymptomatic contacts is not necessary.
Symptomatic contacts should be treated as suspected pertussis.
Assess whether the person is up-to-date with pertussis vaccination according to national protocol (see
Prevention).
Pertussis vaccination provides substantial immunity that wanes over time . [1] 
In all cases (suspected cases and contacts) who are not up-to-date with pertussis vaccination, begin or refer for
vaccination.
Routine vaccination with a 3-dose primary series of polyvalent vaccine containing pertussis antigen(s) from the age
of 6 weeks or according to national protocol. A booster dose is recommended, preferably during the second year


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of 6 weeks or according to national protocol. A booster dose is recommended, preferably during the second year
of life . Based on local epidemiology, further booster doses may be required later in life to reinforce immunity and
reduce the risk of developing pertussis.
 [1] 
If the pertussis primary vaccination series has been interrupted, it should be completed rather than restarted from
the beginning.
In general, vaccinations are deferred for patients with moderate to severe illness, but the vaccine should be
administered as soon as the patient's condition has improved. 
Vaccination will probably not prevent disease in a person who is already infected by B. pertussis. It is not a
substitute for post-exposure prophylaxis . [7] [9]


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References
1. Pertussis vaccines: WHO position paper – August 2015. Wkly Epidemiol Rec. 2015;(35):433-458.https://iris.who.int/bitstream/handle/10665/242413/WER9035_433-458.PDF [Accessed May 17, 2024].
2. Güris D, Strebel PM, Bardenheier B, et al. Changing Epidemiology of Pertussis in the United States: Increasing ReportedIncidence Among Adolescents and Adults, 1990‐1996. Clin Infect Dis. 1999;28(6):1230-1237.https://doi.org/10.1086/514776 [Accessed September 10, 2024].
3. Daniels HL, Sabella C. Bordetella pertussis (Pertussis). Pediatr Rev. 2018;39(5):247-257.https://doi.org/10.1542/pir.2017-0229 [Accessed September 11, 2024].


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4. Mbayei SA, Faulkner A, Miner C, et al. Severe Pertussis Infections in the United States, 2011–2015. Clin Infect Dis.2019;69(2):218-226.https://doi.org/10.1093/cid/ciy889 [Accessed September 13, 2024]
5. Centers for Disease Control and Prevention. For Clinicians: Pertussis Treatment. Published online August 4, 2022.https://www.cdc.gov/pertussis/clinical/treatment.html [Accessed April 28, 2024].
6. Siegel J, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee. 2007Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Published onlineJuly 2023.https://www.cdc.gov/infection-control/media/pdfs/Guideline-Isolation-H.pdf [Accessed April 28,2024].


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7. World Health Organization. Pertussis: Vaccine-Preventable Diseases Surveillance Standards. Published online September 5,2018.https://www.who.int/publications/m/item/vaccine-preventable-diseases-surveillance-standards-pertussis [Accessed May 19,2024].
8. Centers for Disease Control and Prevention. Pertussis and Postexposure Antimicrobial Prophylaxis (PEP). Published onlineAugust 4, 2022.https://www.cdc.gov/pertussis/php/postexposure-prophylaxis/index.html [Accessed April 29, 2024].
9. Blain A, Skoff T, Cassiday P, Tondella ML, Acosta A. Pertussis. In: Manual for the Surveillance of Vaccine-Preventable Diseases.Centers for Disease Control and Prevention; 2020:Chapter 10.https://www.cdc.gov/surv-manual/php/table-of-contents/chapter-10-pertussis.html [Accessed May 19, 2024].


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Acute bronchitis
An acute inﬂammation of the bronchial mucosa, most commonly of viral origin. In older children it can be caused
by Mycoplasma pneumoniae. In children over 2 years of age with repetitive acute bronchitis or ‘wheezing’ bronchitis,
consider asthma (see Asthma). In children under 2 years of age, consider bronchiolitis (see Bronchiolitis).
Clinical features
Often begins with a rhinopharyngitis that descends progressively: pharyngitis, laryngitis, tracheitis.
Treatment
amoxicillin PO
Children: 30 mg/kg 3 times daily (max. 3 g daily) for 5 days
Adults: 1 g 3 times daily for 5 days
Heavy cough, dry at the beginning then becoming productive
Low-grade fever
No tachypnoea, no dyspnoea
On pulmonary auscultation: bronchial wheezing
Fever: paracetamol PO (Chapter 1).


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Low-grade fever
No tachypnoea, no dyspnoea
On pulmonary auscultation: bronchial wheezing
Fever: paracetamol PO (Chapter 1).
Keep the patient hydrated, humidify air (with a bowl of water or a wet towel).
Children: nasal irrigation with 0.9% sodium chloride or Ringer lactate, 4 to 6 times daily to clear the airway.
Antibiotherapy is not useful for patients in good overall condition with rhinopharyngitis or inﬂuenza.
Antibiotherapy is indicated only if:
the patient is in poor general condition: malnutrition, measles, rickets, severe anaemia, cardiac disease, elderly
patient etc.
if the patient has dyspnoea, fever greater than 38.5 °C and purulent expectorations: a secondary infection
with Haemophilus inﬂuenzae or with pneumococcus is probable.


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Chronic bronchitis
A chronic inﬂammation of the bronchial mucosa due to irritation (tobacco, pollution), allergy (asthma) or infection
(repetitive acute bronchitis). It may develop into chronic obstructive pulmonary disease.
Clinical features
 A patient with an acute exacerbation of chronic bronchitis presents with:
Treatment
Productive cough for 3 consecutive months per year for 2 successive years.
No dyspnoea at onset. Dyspnoea develops after several years, ﬁrst on exertion, then becoming persistent.
On pulmonary auscultation: bronchial wheeze (always exclude tuberculosis).
Onset or increase of dyspnoea.
Increased volume of sputum.
Purulent sputum.
Antibiotic treatment is not useful in treating simple chronic bronchitis.


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Onset or increase of dyspnoea.
Increased volume of sputum.
Purulent sputum.
Antibiotic treatment is not useful in treating simple chronic bronchitis.
Antibiotic treatment may be useful, for patients in a poor general condition only, for acute exacerbations of chronic
bronchitis (see Acute bronchitis).
Discourage smoking and other irritating factors.


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Bronchiolitis
Last updated: October 2023
 
Bronchiolitis is an epidemic and seasonal viral infection of the lower respiratory tract in children less than 2 years of
age, characterised by bronchiolar obstruction.
Respiratory syncytial virus (RSV) is responsible for 70% of cases of bronchiolitis. Transmission of RSV is direct,
through inhalation of droplets (coughing, sneezing), and indirect, through contact with hands or materials contaminated
by infected secretions.
In the majority of cases, bronchiolitis is benign, resolves spontaneously (relapses are possible), and can be treated on
an outpatient basis.
Severe cases may occur, which put the child at risk due to exhaustion or secondary bacterial infection. Hospitalisation


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an outpatient basis.
Severe cases may occur, which put the child at risk due to exhaustion or secondary bacterial infection. Hospitalisation
is necessary when signs/criteria of severity are present (10 to 20% of cases).
Clinical features
Rhinopharyngitis, with dry cough, precedes these features by 24 to 72 hours; fever is absent or moderate. 
Treatment
Treatment is symptomatic. Obstructive signs and symptoms last for about 10 days; cough may persist for 2 weeks or
longer. Hospitalise children with one of the following criteria:
 Consider hospitalisation on a case-by-case basis in the following situations:
 In all other cases, the child may be treated at home, provided the parents are taught how to carry out treatment, and
what signs of severity should lead to re-consultation.


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what signs of severity should lead to re-consultation.
Tachypnoea, dyspnoea, wheezing, cough; profuse, frothy, obstructive secretions.
On auscultation: prolonged expiration with diffuse, bilateral wheezes; sometimes diffuse ﬁne, end-inspiratory
crackles.
Signs of severity:
Signiﬁcant deterioration in general condition, toxic appearance (pallor, greyish colouration)
Apnoea, cyanosis (check lips, buccal mucosa, ﬁngernails)
Respiratory distress (nasal ﬂaring, sternal and chest wall indrawing)
Anxiety and agitation (hypoxia), altered level of consciousness
Respiratory rate > 60/minute
Decreased signs of respiratory distress (exhaustion) and decline of respiratory rate (< 30/minute below the age


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Respiratory rate > 60/minute
Decreased signs of respiratory distress (exhaustion) and decline of respiratory rate (< 30/minute below the age
of 1 year and < 20/minute below the age of 3 years). Exercise caution in interpreting these signs as indicators of
clinical improvement.
SpO persistently < 92%2
Sweats, tachycardia at rest and in the absence of fever
Silence on auscultation (severe bronchospasm)
Difﬁculty drinking or sucking (reduced tolerance for exertion)
Presence of any sign of severity
Pre-existing pathology (cardiac or pulmonary disease, malnutrition, HIV infection, etc.)
Associated acute pathology (viral gastro-enteritis, bacterial infection, etc.)
Age less than 3 months


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Outpatient treatment
Hospitalisation
 
Prevention and control
The risk of transmission of the virus is increased in hospital settings:
 
Nasal irrigation with 0.9% NaCl before each feeding (demonstrate the technique to the mother) . a 
Small, frequent feedings to reduce vomiting triggered by bouts of coughing.
Increased ﬂuids if fever and/or signiﬁcant secretions are present.
Treat fever (Chapter 1).
Handle the patient the patient as little as possible and avoid unnecessary procedures.
In all cases:
Place the infant in a semi-reclining position (± 30°).
Nasal irrigation, small, frequent feeds, treatment of fever: as for outpatient treatment.
Gentle oro-pharyngeal suction if needed.


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Nasal irrigation, small, frequent feeds, treatment of fever: as for outpatient treatment.
Gentle oro-pharyngeal suction if needed.
Monitor ﬂuid intake: normal requirements are 80 to 100 ml/kg/day + 20 to 25 ml/kg/day with high fever or very
profuse secretions.
According to symptoms:
Humidiﬁed nasal oxygen if respiratory distress or SpO < 92%.2
When there is vomiting or signiﬁcant fatigue when sucking, ﬂuid requirements may be administered by
nasogastric tube (small volumes on a frequent basis) or the IV route, for the shortest possible time. Avoid
breastfeeding or oral feeds in children with severe tachypnoea, but do not prolong NG feeds (respiratory
compromise) or IV infusions any longer than necessary.


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compromise) or IV infusions any longer than necessary.
Bronchodilator therapy is not indicated but a trial treatment may be given in case of severe respiratory distress
(salbutamol metered-dose inhaler, 100 micrograms/puff: 2 to 3 puffs with spacer, repeated 2 times at an
interval of 30 minutes). If inhaled salbutamol appears effective in relieving symptoms, the treatment is continued
(2 to 3 puffs every 6 hours in the acute phase, then gradual reduction as recovery takes place). If the trial is
ineffective, the treatment is discontinued.
Antibiotics are not indicated unless there is concern about complications such as secondary bacterial
pneumonia.
Children with bronchiolitis should be grouped together, away from other children (cohorting).


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pneumonia.
Children with bronchiolitis should be grouped together, away from other children (cohorting).
As infection is most commonly transmitted by the hands, the most important prevention measure is hand-washing
after any contact with patients, and objects or surfaces in contact with patients on which the virus may survive for
several hours.
In addition, staff should wear gowns, gloves and surgical masks when in contact with patients.
Footnotes
(a) Lie the child on his back, head turned to the side and instil 0.9% NaCl into the nose, one nostril at a time.


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Acute pneumonia
 
 
 
 
Acute pneumonia is a viral, bacterial (pneumococcus, Haemophilus inﬂuenzae, staphylococcus, atypical bacteria) or
parasitic (pneumocystosis) infection of the pulmonary alveoli.
Pneumonia in children under 5 years of age
Pneumonia in children over 5 years and adults
Persistent pneumonia


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Page 95 / 409
Pneumonia in children under 5 years of age
The most common causes are viruses, pneumococcus and Haemophilus inﬂuenzae.
Clinical features
 Clinical examination must be done on a calm child in order to correctly count the respiratory rate and look for signs of
severity. 
RR ≥ 60 breaths/minute in children under 1 months
RR ≥ 50 breaths/minute in children from 1 to 11 months
RR ≥ 40 breaths/minute in children from 12 months to 5 years
 Notes:
 Consider also:
Treatment
Severe pneumonia (inpatient treatment)
Cough or difﬁculty breathing
Fever often high (> 39 °C), but the child may present with low-grade fever or may have no fever (often a sign of
serious illness)
A child has tachypnoea (increased respiratory rate) if:


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serious illness)
A child has tachypnoea (increased respiratory rate) if:
On pulmonary auscultation: dullness with diminished vesicular breath sounds, crepitations and sometimes bronchial
breathing or normal pulmonary auscultation.
Signs of severity (severe pneumonia):
Chest indrawing: the inferior thoracic wall depresses on inspiration as the superior abdomen expands
Cyanosis (lips, oral mucosa, ﬁngernails) or SpO < 90%2
Nasal ﬂaring
Altered consciousness (child is abnormally sleepy or difﬁcult to wake)
Stridor (hoarse noise on inspiration)
Grunting (a short repetitive noise produced by a partial closure of the vocal cords) on expiration
Refusal to drink or feed
Children under 2 months
Severe malnutrition


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Refusal to drink or feed
Children under 2 months
Severe malnutrition
In malnourished children, the RR thresholds should be decreased by 5 breaths/minute from those listed above.
Chest indrawing is signiﬁcant if it is clearly visible and present at all times. If it is observed when a child is upset or
feeding and is not visible when the child is resting, there is no chest indrawing.
In children under 2 months of age, moderate chest indrawing is normal as the thoracic wall is ﬂexible.
If only the soft tissues between the ribs or above the clavicles depress, there is no chest indrawing.
Malaria in endemic areas, as it may also cause cough and tachypnoea.
Staphylococcal pneumonia in patients with empyema or painful abdominal swelling and diarrhoea.


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Staphylococcal pneumonia in patients with empyema or painful abdominal swelling and diarrhoea.
Pneumocystosis in children with conﬁrmed or suspected HIV infection (see HIV infection and AIDS, Chapter 8).
Tuberculosis:
in a child with cough, fever and poor weight gain and a history of close contact with a tuberculous patient . For
the diagnosis, refer to the MSF handbook, Tuberculosis.
 a  
in the event of pneumonia complicated with empyema (pus in the pleural space).


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Children under 2 months 
The ﬁrst line treatment is the combination ampicillin slow IV (3 minutes) for 10 days + gentamicin slow IV (3 minutes)
or IM for 5 days: 
 For ampicillin, IV route is preferred but IM route may be an alternative. If ampicillin is not available, alternatives may be cefotaxime slow IV (3 minutes) or infusion (20 minutes) or IM for 10
days (for doses, see Meningitis, Chapter 7), or, as a last resort: ceftriaxone slow IV (3 minutes) or infusion (30 minutes;
60 minutes in neonates) or IM: 50 mg/kg once daily for 10 days. If the child's condition does not improveafter 48 hours of well administered treatment, add cloxacillin IV for 10 to 14
days: 
 
Children from 2 months to 5 years
The ﬁrst line treatment is:


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days: 
 
Children from 2 months to 5 years
The ﬁrst line treatment is:
ceftriaxone IM or slow IV (3 minutes): 50 mg/kg once daily
or
ampicillin slow IV (3 minutes) or IM: 50 mg/kg every 6 hours
+ gentamicin slow IV (3 minutes) or IM: 6 mg/kg once daily
Ampicillin is preferably administered in 4 divided doses. If the context does not permit it, the daily dose must be divided
in at least 3 doses. The treatment is administered by parenteral route for at least 3 days then, if the clinical condition has improved and
oral treatment can be tolerated, switch to amoxicillin PO: 30 mg/kg 3 times daily to complete 10 days of treatment. If the child's condition deteriorates or does not improve after 48 hours of correct administration, add cloxacillin IV: 25


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to 50 mg/kg every 6 hours. After clinical improvement and 3 days with no fever, switch to amoxicillin/clavulanic
acid (co-amoxiclav) PO to complete 10 to 14 days of treatment. Use formulations in a ratio of 8:1 or 7:1
exclusively. The dose is expressed in amoxicillin: 50 mg/kg 2 times daily.
 
Children
0 - 7 days
 
< 2 kg ampicillin 50 mg/kg every 12 hours
+ gentamicin 3 mg/kg once daily
≥ 2 kg ampicillin 50 mg/kg every 8 hours
+ gentamicin 5 mg/kg once daily
Children
8 days - < 1 month
ampicillin 50 mg/kg every 8 hours
+ gentamicin 5 mg/kg once daily
Children
1 month - < 2 months
ampicillin 50 mg/kg every 6 hours
+ gentamicin 6 mg/kg once daily
 b 
 c 
Children 0 - 7 days
< 2 kg cloxacillin 50 mg/kg every 12 hours
≥ 2 kg cloxacillin 50 mg/kg every 8 hours
Children > 7 days


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b 
 c 
Children 0 - 7 days
< 2 kg cloxacillin 50 mg/kg every 12 hours
≥ 2 kg cloxacillin 50 mg/kg every 8 hours
Children > 7 days
< 2 kg cloxacillin 50 mg/kg every 8 hours
≥ 2 kg cloxacillin 50 mg/kg every 6 hours
 b 
 c


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 If the child's condition does not improve after 48 hours with ceftriaxone + cloxacillin, consider tuberculosis. For the
diagnosis, refer to the guide Tuberculosis, MSF.
If tuberculosis is unlikely, continue with ceftriaxone + cloxacillin and add azithromycin (see Atypical pneumonia).
Notes:
Adjuvant therapy
Use a nasogastric tube only if an IV line cannot be established: children under 12 months: 5 ml/kg/hour; children
over 12 months: 3 to 4 ml/kg/hour; alternate milk and water. Resume normal oral feeding as soon as possible.
Pneumonia with no signs of severity
Children under 2 months
Admit the child for inpatient care and treat for severe pneumonia.
Children from 2 months to 5 years
Treat as outpatient, except infants.


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Admit the child for inpatient care and treat for severe pneumonia.
Children from 2 months to 5 years
Treat as outpatient, except infants.
amoxicillin PO: 30 mg/kg 3 times daily for 5 days Follow-up in 48 to 72 hours or sooner if the child’s condition deteriorates:
 
For malnourished children, refer to speciﬁc protocol.
In the event of moderate-large empyema, assess if drainage is required. Administer antibiotics active against
pneumococci and staphylococci (see Staphylococcal pneumonia).
Fever: paracetamol PO (Chapter 1).
Infants: keep warm.
Install on an incline (head elevated) or in semi-sitting position.
Clear the airway (nasal irrigation with 0.9% sodium chloride if needed).
Oxygen at the ﬂow rate required to maintain SpO ≥ 90% or, if pulse oxymeter is not available, minimum 1


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Oxygen at the ﬂow rate required to maintain SpO ≥ 90% or, if pulse oxymeter is not available, minimum 1
litre/minute.
2
Maintain adequate hydration and nutrition:
In children with severe respiratory difﬁculty: place an IV line and give 70% of normal maintenance ﬂuids. Resume
oral feeding as soon as possible (no severe respiratory difﬁculty, ability to eat normally).
In the absence of severe respiratory difﬁculty: breastfeed on demand; milk/food and water by spoon on
demand.
ORS when required (Dehydration, Chapter 1).
If the condition is improving : continue with the same antibiotic to complete treatment. c 
If there is no improvement after 3 days of correct administration: add azithromycin (see Atypical pneumonia).


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If there is no improvement after 3 days of correct administration: add azithromycin (see Atypical pneumonia).
If the condition is deteriorating: hospitalise and treat as severe pneumonia.
Footnotes
(a) Contact is deﬁned as living in the same household, or in close and regular contact with any known or suspected tuberculouscase within the last 12 months.
(b) The solvent of ceftriaxone for IM injection contains lidocaine. Ceftriaxone reconstituted using this solvent must never beadministered by IV route. For IV administration, water for injection must always be used. 
(c) Improvement criteria include: fever reduction, diminished respiratory distress, improved SpO, improved appetite and/oractivity. 
2


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Pneumonia in children over 5 years and adults
The most common causes are viruses, pneumococcus, and Mycoplasma pneumoniae.
Clinical features
 Sudden onset with high fever (higher than 39 °C), thoracic pain and oral herpes are suggestive of pneumococcal
infection. Symptoms may be confusing, particularly in children with abdominal pain, meningeal syndrome, etc. Signs of severity (severe pneumonia) include:
 Patients at risk include the older patients, patients with heart failure, sickle cell disease or severe chronic bronchitis;
immunocompromised patients (severe malnutrition, HIV infection with CD4 < 200).
Treatment
Severe pneumonia (inpatient treatment)
ceftriaxone IM or slow IV (3 minutes)
Children: 50 mg/kg once daily
Adults: 1 g once daily


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Treatment
Severe pneumonia (inpatient treatment)
ceftriaxone IM or slow IV (3 minutes)
Children: 50 mg/kg once daily
Adults: 1 g once daily
The treatment is given by parenteral route for at least 3 days then, if the clinical condition has improved and oral
treatment can be tolerated, switch to amoxicillin PO to complete 7 to 10 days of treatment:
Children: 30 mg/kg 3 times daily (max. 3 g daily)
Adults: 1 g 3 times daily
or
ampicillin slow IV (3 minutes) or IM
Children: 50 mg/kg every 6 hours
Adults: 1 g every 6 to 8 hours
Ampicillin is preferably administered in 4 divided doses. If the context does not permit it, the daily dose must be divided
in at least 3 doses.
The treatment is given by parenteral route for at least 3 days then, if the clinical condition has improved and oral


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in at least 3 doses.
The treatment is given by parenteral route for at least 3 days then, if the clinical condition has improved and oral
treatment can be tolerated, switch to the oral route with amoxicillin PO as above, to complete 7 to 10 days of
treatment. 
Cough, with or without purulent sputum, fever, thoracic pain, tachypnoea
On pulmonary auscultation: decreased vesicular breath sounds, dullness, localised foci of crepitations, sometimes
bronchial wheeze.
Cyanosis (lips, oral mucosa, ﬁngernails)
Nasal ﬂaring
Intercostal or subclavial indrawing
RR > 30 breaths/minute
Heart rate > 125 beats/minute
Altered level of consciousness (drowsiness, confusion)
 a 
 b 
 b


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If the clinical condition deteriorates or does not improve after 48 hours of correct administration, administer
ceftriaxone as above + cloxacillin IV infusion:
Children: 25 to 50 mg/kg every 6 hours
Adults: 2 g every 6 hours
After clinical improvement and 3 days with no fever, switch to amoxicillin/clavulanic acid (co-amoxiclav) PO to
complete 10 to 14 days of treatment. Use formulations in a ratio of 8:1 or 7:1 exclusively. The dose is expressed in
amoxicillin:
Children < 40 kg: 50 mg/kg 2 times daily
Children ≥ 40 kg and adults:
Ratio 8:1: 3000 mg daily (2 tablets of 500/62.5 mg 3 times daily)


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amoxicillin:
Children < 40 kg: 50 mg/kg 2 times daily
Children ≥ 40 kg and adults:
Ratio 8:1: 3000 mg daily (2 tablets of 500/62.5 mg 3 times daily)
Ratio 7:1: 2625 mg daily (1 tablet of 875/125 mg 3 times daily) If the clinical condition does not improve after 48 hours with ceftriaxone + cloxacillin, consider tuberculosis. For the
diagnosis, refer to the guide Tuberculosis, MSF. If tuberculosis is unlikely, continue with ceftriaxone + cloxacillin and add azithromycin (see Atypical pneumonia).
Adjuvant therapy
Pneumonia without signs of severity (outpatient treatment)
amoxicillin PO
Children: 30 mg/kg 3 times daily (max. 3 g daily) for 5 days
Adults: 1 g 3 times daily for 5 days Follow-up in 48 to 72 hours or sooner if the patient's condition deteriorates:


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Adults: 1 g 3 times daily for 5 days Follow-up in 48 to 72 hours or sooner if the patient's condition deteriorates:
 
Fever: paracetamol PO (Chapter 1).
Clear the airway (nasal irrigation with 0.9% sodium chloride if needed).
Oxygen at the ﬂow rate required to maintain SpO ≥ 90% or, if pulse oxymeter is not available, minimum 1
litre/minute.
2
Maintain adequate hydration and nutrition.
If the condition is improving : continue with the same antibiotic to complete treatment. b 
If there is no improvement after 3 days of correct administration: add azithromycin (see Atypical pneumonia).
If the condition is deteriorating: hospitalise and treat as severe pneumonia.
Footnotes


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If the condition is deteriorating: hospitalise and treat as severe pneumonia.
Footnotes
(a) The solvent of ceftriaxone for IM injection contains lidocaine. Ceftriaxone reconstituted using this solvent must never beadministered by IV route. For IV administration, water for injection must always be used.
(b) Improvement criteria include: fever reduction, diminished respiratory distress, improved SpO, improved appetite and/oractivity. 
2


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Page 100 / 409
Persistent pneumonia
 
 
Last update: November 2022
 
In patients not responding to therapy, consider atypical pneumonia, tuberculosis, pneumocystosis (HIV infection and
AIDS, Chapter 8). Bacteria responsible for atypical pneumonia are mainly Mycoplasma pneumoniae and Chlamydophila pneumoniae. If
suspected, one of the following antibiotics may be used: First choice, azithromycin PO
Children: 10 mg/kg (max. 500 mg) once daily for 5 days
Adults: 500 mg on D1 then, 250 mg once daily from D2 to D5 If not available,
erythromycin PO
Children: 10 mg/kg (max. 500 mg) 4 times daily for 10 to 14 days
Adults: 500 mg 4 times daily for 10 to 14 days
or
doxycycline PO (except in pregnant or breastfeeding women)


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Adults: 500 mg 4 times daily for 10 to 14 days
or
doxycycline PO (except in pregnant or breastfeeding women)
Children under 45 kg: 2 to 2.2 mg/kg (max. 100 mg) 2 times daily for 10 to 14 days
Children 45 kg and over and adults: 100 mg 2 times daily for 10 to 14 days


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Staphylococcal pneumonia
Pneumonia due to Staphylococcus aureus affecting young children, often those in a poor general condition
(malnutrition, skin lesions, etc.). Staphylococcal pneumonia is a classic complication of measles.
Clinical features
Paraclinical investigations
Treatment
Treatment is urgent as patients deteriorate quickly: hospitalise. 
ceftriaxone IM or slow IV (at least 3 minutes): 50 mg/kg once daily
+ cloxacillin IV infusion (60 minutes)
Neonates 0 to 7 days (< 2 kg): 50 mg/kg every 12 hours
Neonates 0 to 7 days (≥ 2 kg): 50 mg/kg every 8 hours
Neonates 8 days to < 1 month (< 2 kg): 50 mg/kg every 8 hours
Neonates 8 days to < 1 month (≥ 2 kg): 50 mg/kg every 6 hours


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Neonates 8 days to < 1 month (< 2 kg): 50 mg/kg every 8 hours
Neonates 8 days to < 1 month (≥ 2 kg): 50 mg/kg every 6 hours
Children 1 month and over: 25 to 50 mg/kg every 6 hours (max. 8 g daily) After clinical improvement , 3 days with no fever, and drain removal if any, switch to amoxicillin/clavulanic
acid PO to complete 10 to 14 days. Use formulations in a ratio of 8:1 or 7:1 exclusively. The dose is expressed in
amoxicillin: 50 mg/kg 2 times daily In the event of large empyema: same treatment but switch to the oral route after 7 days with no fever and treat for
3 weeks. Clindamycin IV may be an alternative to cloxacillin: 10 mg/kg every 8 hours then switch to clindamycin PO at the
same dose, according to the criteria above.


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same dose, according to the criteria above. 
 
 
 
 
General signs: change in overall condition, pallor, high fever or hypothermia, frequently signs of shock; presence of
skin lesions (point of bacterial entry), however, skin lesions may be absent.
Gastrointestinal signs: nausea, vomiting, diarrhoea, painful abdominal distention.
Respiratory signs: dry cough, tachypnoea, signs of distress (nasal ﬂaring, chest indrawing). Pulmonary auscultation is
often normal; sometimes dullness indicating pleural effusion.
Chest x-ray (if available): may show multilobar consolidation, cavitation, pneumatoceles, spontaneous
pneumothorax.
Antibiotic treatment: if staphylococcal aetiology cannot be conﬁrmed or while waiting for conﬁrmation, a broad
spectrum antibiotic therapy is recommended:
 a 
 b 
 c


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spectrum antibiotic therapy is recommended:
 a 
 b 
 c 
Fever: paracetamol (Chapter 1).
Hydration by oral route or infusion or nasogastric tube depending on clinical condition.
Oxygen at the ﬂow rate required to maintain SpO ≥ 90% or, if pulse oxymeter is not available, minimum 1
litre/minute.
2
Local disinfection of skin lesions.


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Clinical evolution
 
If there is signiﬁcant pleural effusion: pleural tap with drainage (for pyopneumothorax; insert 2 drains, one anterior
and one posterior) or without drainage (for suppurative pleurisy, make repetitive taps with an IV catheter).
There is a serious risk of decompensation from pneumothorax or suppurative pleurisy or pyopneumothorax.
On a paediatric ward, adequate equipment for urgent pleural drainage should always be available.
Footnotes
(a) The solvent of ceftriaxone for IM injection contains lidocaine. Ceftriaxone reconstituted using this solvent must never beadministered by IV route. For IV administration, water for injection must always be used.


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(b) Cloxacillin powder for injection should be reconstituted in 4 ml of water for injection. Then dilute each dose of cloxacillin in5 ml/kg of 0.9% sodium chloride or 5 % glucose in children less than 20 kg and in a bag of 100 ml of 0.9% sodium chloride or5% glucose in children 20 kg and over and in adults.
(c) Improvement criteria include: fever reduction, diminished respiratory distress, improved SpO2, improved appetite and/oractivity.


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Page 103 / 409
Asthma
 
Last updated: June 2023
 
 
 
Asthma is a chronic inﬂammatory disorder of the airways associated with airway hyperresponsiveness that leads to
recurrent episodes of wheezing, breathlessness, chest tightness and coughing. These episodes are usually associated
with airﬂow obstruction within the lung, often reversible, either spontaneously or with treatment. Factors that precipitate/aggravate asthma include: allergens, infection, exercise, drugs (aspirin), tobacco,
etc. Symptoms are sometimes worse at night. In children up to 5 years, most initial episodes of asthma-like symptoms are associated with a respiratory tract
infection, with no symptoms between infections. Wheezing episodes usually become less frequent with time; most of
these children do not develop asthma.


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Acute asthma (asthma attack)
Last updated: June 2023
 
Asthma attack is a substantial worsening of asthma symptoms. The severity and duration of attacks are variable and
unpredictable.
Assessment of the severity of asthma attack
The severity of the asthma attack must be rapidly evaluated by the following clinical criteria. Not all signs are
necessarily present. 
Assessment of severity in children over 2 years and adults 
 
Treatment
Reassure the patient. Treatment and follow-up depend on the severity of the attack and the patient’s response:
Mild to moderate attack
 [1] [2] [3]
Mild or moderate attack Severe or life-threatening attack
Able to talk in sentences Cannot complete sentences in one breath
or
Too breathless to talk or feed
Mild or moderate increase of


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Able to talk in sentences Cannot complete sentences in one breath
or
Too breathless to talk or feed
Mild or moderate increase of
respiratory rate (RR)
Very high RR
Children 2-5 years: > 40/minute
Children > 5 years and adults: > 30/minute
Normal or mild increase of heart rate (HR)
Children 2-3 years: ≤ 180/minute
Children 4-5 years: ≤ 150/minute
Children > 5 years and adults: ≤ 120/minute 
Very high HR
Children 2-3 years: > 180/minute
Children 4-5 years: > 150/minute
Children > 5 years and adults: > 120/minute
SpO ≥ 90% (≥ 92% for children 2-5 years)2 SpO < 90% (< 92% for children 2-5 years)2
and
No criteria of severe or life-threatening attack
 
Signs of life-threatening attack:
Altered level of consciousness (drowsiness, confusion, coma)
Exhaustion
Silent chest
Cyanosis


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Signs of life-threatening attack:
Altered level of consciousness (drowsiness, confusion, coma)
Exhaustion
Silent chest
Cyanosis
Arrhythmia or hypotension in adults
Place the patient in a 1/2 sitting position.
Administer:


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Severe attack
The two solutions should be mixed in the drug reservoir of the nebuliser. Assess symptoms at the end of each
nebulisation.
If there is no nebuliser, use salbutamol MDI (same dose as for mild to moderate attack) and ipratropium MDI
20 micrograms/puff, 4 to 8 puffs every 20 minutes for the ﬁrst hour.
salbutamol metered-dose inhaler (MDI) 100 micrograms/puff: 2 to 10 puffs every 20 minutes during the ﬁrst
hour. In children, use a spacer  (use face mask in children under 3 years). Single puffs should be given one at a
time, let the child breathe 4 to 5 times from the spacer before repeating the procedure. A spacer can also be
used in adults to increase effectiveness.
 a 
prednisolone PO: one dose of 1 to 2 mg/kg (max. 50 mg) for children over 5 years and adults


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used in adults to increase effectiveness.
 a 
prednisolone PO: one dose of 1 to 2 mg/kg (max. 50 mg) for children over 5 years and adults
oxygen if SpO < 94%.2  b 
If the attack is completely resolved:
Observe the patient for 1 hour (4 hours if they live far from the health centre) then give outpatient
treatment: salbutamol MDI for 24 to 48 hours (2 to 4 puffs every 4 to 6 hours depending on clinical evolution)
and prednisolone PO (same dose as above once daily) to complete 5 days of treatment. 
Reassess after 1 to 2 days: address any identiﬁed risk factor, reassess need for salbutamol and long-term
treatment. If the patient is already receiving long-term treatment, reevaluate the severity of the asthma (see


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treatment. If the patient is already receiving long-term treatment, reevaluate the severity of the asthma (see
Chronic asthma), review compliance and correct use of medications and adjust treatment if necessary.
If the attack is only partially resolved, continue with salbutamol MDI (2 to 10 puffs every 1 to 4 hours) until
symptoms subside. For children up to 5 years, administer one dose of prednisolone PO as above if symptoms
recur within 3 to 4 hours. When the attack is completely resolved, proceed as above.
If symptoms worsen or do not improve, treat as severe attack.
Hospitalise; place the patient in a 1/2 sitting position. c 
Administer:
oxygen to maintain SpO between 94 and 98%.2  b


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Hospitalise; place the patient in a 1/2 sitting position. c 
Administer:
oxygen to maintain SpO between 94 and 98%.2  b 
salbutamol + ipratropium nebuliser solutions using a nebuliser (continue oxygen via nasal cannula during
nebulisation):
Children < 5 years salbutamol 2.5 mg (1.25 ml) + ipratropium 0.25 mg (1 ml) every 20 minutes for the
ﬁrst hour
Children 5 to 11 years salbutamol 2.5 to 5 mg (1.25 to 2.5 ml) + ipratropium 0.5 mg (2 ml) every 20
minutes for the ﬁrst hour
Children 12 years and over
and adults
salbutamol 5 mg (2.5 ml) + ipratropium 0.5 mg (2 ml) every 20 minutes for the ﬁrst
hour
prednisolone PO: one dose of 1 to 2 mg/kg (max. 50 mg)
If prednisolone is not available, or if the patient cannot take oral treatment, administer:


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prednisolone PO: one dose of 1 to 2 mg/kg (max. 50 mg)
If prednisolone is not available, or if the patient cannot take oral treatment, administer:
Children: dexamethasone PO/IV/IM, one dose of 0.15 to 0.6 mg/kg (max. 16 mg)
Adults: hydrocortisone IV, 4 mg/kg (max. 100 mg) every 6 hours for 24 hours
If symptoms do not improve after one hour:
transfer to intensive care unit
insert an IV line
oxygen to maintain SpO between 94 and 98%2  b
continue salbutamol (solution for nebuliser) without ipratropium, and corticosteroids as above.
administer one dose of magnesium sulfate by IV infusion in 0.9% sodium chloride over 20 minutes, monitoring
blood pressure:


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Page 106 / 409
 
Notes:
 
References
Children: 40 mg/kg (max. 2 g)
Adults: 2 g
If symptoms improve: continue salbutamol (solution for nebuliser) every 1 to 4 hours (depending on symptoms) and
oxygen as above. Assess symptoms at the end of each nebulisation. When possible, switch to salbutamol MDI
and continue as for mild to moderate attack.
If the attack is completely resolved, observe the patient for at least 4 hours. Continue the treatment with
salbutamol (MDI) and prednisolone PO and reassess as for a mild to moderate attack.
In pregnant women, treatment is the same as for adults. In mild or moderate asthma attacks, administering oxygen
reduces the risk of foetal hypoxia.
For all patients, irrespective of the severity of the asthma attack, look for underlying lung infection and treat


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reduces the risk of foetal hypoxia.
For all patients, irrespective of the severity of the asthma attack, look for underlying lung infection and treat
accordingly.
Footnotes
(a) If a conventional spacer is not available, use a 500 ml plastic bottle: insert the mouthpiece of the inhaler into a hole made inthe bottom of the bottle (the seal should be as tight as possible). The patient breathes from the mouth of the bottle in thesame way as they would with a spacer. The use of a plastic cup instead of a spacer is not recommended (ineffective).
(b) If pulse oxymetry is not available, administer oxygen continuously in case of moderate, severe or life-threatening attack.
(c) If signs of life-threatening attack, transfer to intensive care unit as soon as possible.


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(c) If signs of life-threatening attack, transfer to intensive care unit as soon as possible.
1. British guideline on the management of asthma. A national clinical guideline First published 2003. Revised edition publishedJuly 2019.https://www.sign.ac.uk/our-guidelines/british-guideline-on-the-management-of-asthma/ [Accessed 12 January 2023]
2. Global INitiative for Asthma. Global Strategy for Asthma Management and Prevention. 2022 update.https://ginasthma.org/gina-reports/ [Accessed 12 January 2023]


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3. WHO Pocket book of primary health care for children and adolescents: guidelines for health promotion, disease preventionand management from the newborn period to adolescence. WHO Regional Ofﬁce for Europe; 2022.https://www.who.int/europe/publications/i/item/9789289057622 [Accessed 12 January 2023]


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Chronic asthma
Last updated: June 2023
Clinical features
Treatment
The mainstay of long-term treatment are inhaled corticosteroids (ICS) and long-acting beta-2 agonists (LABA). LABAs
should never be used alone but always in combination with an ICS. Combination inhalers are preferred, when available.
In addition to long-term treatment, salbutamol (short-acting beta-2 agonist, SABA) and combination inhalers can be
used to reduce bronchoconstriction if the patient is symptomatic.
Treatment is started at the step most appropriate to initial severity then, re-evaluated and adjusted according to
clinical response. An intervening severe asthma attack or loss of control necessitates treatment reassessment.


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clinical response. An intervening severe asthma attack or loss of control necessitates treatment reassessment.
The inhaler is chosen according to age. In children, a spacer should be used. Instructions on inhaler technique and
information on asthma attack symptoms should be provided. 
Long-term treatment of asthma according to severity in children 6 years and over and adults 
Asthma should be suspected in patients with recurrent respiratory symptoms (wheezing, chest tightness, shortness
of breath and/or cough) of variable frequency, severity and duration, disturbing sleep, and causing the patient to sit
up to breathe. These symptoms may appear during or after exercise.
Chest auscultation may be normal or demonstrate diffuse sibilant wheezes.


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up to breathe. These symptoms may appear during or after exercise.
Chest auscultation may be normal or demonstrate diffuse sibilant wheezes.
A personal or family history of atopy (eczema, allergic rhinitis/conjunctivitis) or a family history of asthma increases
probability of asthma but their absence does not exclude asthma.
Patients with typical symptoms of asthma and a history of disease that is characteristic of asthma should be
considered as having asthma after exclusion of other diagnoses.
Any identiﬁed asthma risk factor (e.g. allergen, pollution, tobacco smoke exposure) should be eliminated where
possible. The assessment of the frequency of symptoms and limitations of daily activities determines the
treatment.
 [1] [2]


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Symptoms Children 6 to 11 years Children ≥ 12 years and adults
Intermittent asthma
Daytime symptoms < 2
times monthly
Normal daily activities
salbutamol when symptomatic beclometasone/formoterol when
symptomatic
  OR
beclometasone + salbutamol when
symptomatic (a)
Mild persistent asthma
Daytime symptoms ≥ 2
times monthly
Symptoms may affect
daily activities
beclometasone (low dose) daily
AND
salbutamol when symptomatic
beclometasone/formoterol when
symptomatic
  OR
beclometasone (low dose) daily 
AND
salbutamol when symptomatic
Moderate persistent
asthma
Daytime symptoms most
days OR nighttime
symptoms ≥ once weekly
Symptoms affect daily
activities
beclometasone (low dose)
+ salmeterol daily
AND
salbutamol when symptomatic
 (b)
beclometasone/formoterol (low dose)
daily
AND


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activities
beclometasone (low dose)
+ salmeterol daily
AND
salbutamol when symptomatic
 (b)
beclometasone/formoterol (low dose)
daily
AND
beclometasone/formoterol when
symptomatic
OR
budesonide/formoterol (very low
dose) daily
AND
budesonide/formoterol when
symptomatic
OR
beclometasone (low dose)
+ salmeterol daily
AND
salbutamol when symptomatic
 (b)
Severe persistent asthma
Daily daytime symptoms
OR very frequent
nighttime symptoms
Daily activities very
limited by symptoms
beclometasone (medium dose)
+ salmeterol daily
AND
salbutamol when symptomatic
beclometasone/formoterol (medium
dose) daily
AND
beclometasone/formoterol when
symptomatic
OR
budesonide/formoterol (low dose)
daily
AND
budesonide/formoterol when
symptomatic
OR
beclometasone (medium dose)
+ salmeterol daily
AND


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OR
budesonide/formoterol (low dose)
daily
AND
budesonide/formoterol when
symptomatic
OR
beclometasone (medium dose)
+ salmeterol daily
AND
salbutamol when symptomatic
 
 (c)
(a) Salbutamol should be taken just before beclometasone, or together if a combination inhaler is available.
(b) If salmeterol is not available, use beclometasone medium-dose.
(c) If salmeterol is not available, use beclometasone high-dose.


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The doses vary according to the severity of asthma. Find the lowest possible effective dose necessary to both
relieve symptoms and avoid local and systemic adverse effects. beclometasone MDI (ICS): 
 In all cases, do not exceed 2000 micrograms daily.  The number of puffs of beclometasone depends on its concentration in the inhaled aerosol: 50, 100 or 250
micrograms per puff.
 
salbutamol MDI 100 micrograms/puff (SABA):
 salmeterol MDI 25 micrograms/puff (LABA):
 budesonide/formoterol MDI 80/4.5 micrograms/puff (ICS/LABA combination):
In all cases, do not exceed 8 puffs daily. beclometasone/formoterol MDI 100/6 micrograms/puff (ICS/LABA combination):
In all cases, do not exceed 8 puffs daily.


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In all cases, do not exceed 8 puffs daily.
 
Do not restrict exercise. If exercise is a trigger for asthma attacks, administer 1 or 2 puffs of salbutamol or
beclometasone/formoterol 10 minutes beforehand. In pregnant women, poorly controlled asthma increases the risk of pre-eclampsia, eclampsia, haemorrhage, in utero
growth retardation, premature delivery, neonatal hypoxia and perinatal mortality. Long-term treatment should be
continued under close monitoring.
  Children 6 to 11 years Children ≥ 12 years and adults
When symptomatic – 200 to 500 micrograms
Long-term treatment
Low dose 50 to 100 micrograms
2 times daily
100 to 250 micrograms
2 times daily
Medium dose  150 to 200 micrograms
2 times daily
300 to 500 micrograms
2 times daily
High dose – > 500 micrograms
2 times daily


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2 times daily
Medium dose  150 to 200 micrograms
2 times daily
300 to 500 micrograms
2 times daily
High dose – > 500 micrograms
2 times daily
 
 
Children and adults: 2 to 4 puffs up to 4 times daily if necessary
Children 6 to 11 years: 2 puffs 2 times daily (max. 4 puffs daily)
Children 12 years and over and adults: 2 to 4 puffs 2 times daily (max. 8 puffs daily)
Children 6 to 11 years:
when symptomatic: 1 puff
long-term treatment, very low-dose: 1 puff once daily
long-term treatment, low-dose: 1 puff 2 times daily
Children 12 years and over and adults:
when symptomatic: 1 puff
long-term treatment, low-dose: 1 puff 2 times daily
long-term treatment, medium-dose: 2 puffs 2 times daily


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 If symptoms have not been well controlled for a period of 2 to 3 months, check inhalation technique and adherence
before changing to a stronger treatment. If symptoms have been well controlled for a period of at least 3 months (the patient is asymptomatic or the asthma
attacks are well controlled): try a step-wise reduction in medication.
 
References
1. Global INitiative for Asthma. Global Strategy for Asthma Management and Prevention. 2022 update.https://ginasthma.org/gina-reports/ [Accessed 23 January 2023]


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2. WHO Pocket book of primary health care for children and adolescents: guidelines for health promotion, disease preventionand management from the newborn period to adolescence. WHO Regional Ofﬁce for Europe; 2022.https://www.who.int/europe/publications/i/item/9789289057622 [Accessed 23 January 2023]


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Pulmonary tuberculosis
Pulmonary tuberculosis is a bacterial infection due to Mycobacterium tuberculosis, spread from person to person
through inhalation of infected respiratory droplets.
After infection, M. tuberculosis multiplies slowly in the lungs and is usually eliminated spontaneously or lies dormant.
Only 10% of cases develop active tuberculosis. The risk of progressing to active tuberculosis is higher in
immunocompromised patients. In certain countries, half of newly diagnosed tuberculosis patients are co-infected with
HIV . For more information on tuberculosis, refer to the guide Tuberculosis, MSF.
Clinical features
 In an endemic area, the diagnosis of tuberculosis is to be considered, in any patient consulting for respiratory


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Clinical features
 In an endemic area, the diagnosis of tuberculosis is to be considered, in any patient consulting for respiratory
symptoms for over 2 weeks who does not respond to non-speciﬁc antibacterial treatment.
Laboratory
Treatment
For pulmonary tuberculosis, the standard treatment is a combination of four antituberculosis drugs (isoniazid,
rifampicin, pyrazinamide, ethambutol). The regimen is organised into 2 phases (initial phase and continuation phase) and
lasts 6 months. If the strain is drug-resistant, the treatment is longer and different drug combinations are used. It takes signiﬁcant investment to cure tuberculosis, both from the patient and the medical team. Only uninterrupted


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treatment will lead to cure and prevent the development of resistance. It is essential that the patient understands the
importance of treatment adherence and has access to correct case management until treatment is completed.
Prevention
 
References
 [1] 
Prolonged cough (> 2 weeks) with or without sputum production and/or haemoptysis, prolonged fever, night sweats,
anorexia, weight loss, chest pain and fatigue.
Differential diagnosis includes pneumonia, chronic obstructive pulmonary disease (COPD), lung cancer, pulmonary
distomatosis (Flukes, Chapter 6) and melioidosis (Southeast Asia).
In the general population: Xpert® MTB/RIF test which simultaneously detects M. tuberculosis (MTB) in sputum and
resistance to rifampicin (RIF). If not available perform sputum smear microscopy . [2]


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resistance to rifampicin (RIF). If not available perform sputum smear microscopy . [2] 
If HIV co-infection suspected or diagnosed: Xpert® MTB/RIF test and point-of-care, urine LF-LAM (lateral ﬂow
urine lipoarabinomannan assay) . [2] 
BCG vaccination in neonates: provides 59% protection against pulmonary tuberculosis . [3] 
Infection control in healthcare settings: standard precautions and airborne precautions for conﬁrmed or suspected
cases.
Close contacts: isoniazid preventive therapy for 6 months.


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1. World Health Organization. Global tuberculosis report 2018. https://apps.who.int/iris/handle/10665/274453 [Accessed 21 October 2019]
2. Global Laboratory Initiative. GLI model TB diagnostic algorithms. 2018. http://www.stoptb.org/wg/gli/assets/documents/GLI_algorithms.pdf [Accessed 21 October 2019]
3. World Health Organization. Weekly epidemiological record/Relevé épidémiologique hebdomadaire 23rd February 2018,93rd year/23 Février 2018, 93e année. No 8, 2018, 93, 73–96.https://www.who.int/immunization/policy/position_papers/bcg/en/ [Accessed 21 October 2019]


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Chapter 3: Gastrointestinal disorders
Acute diarrhoea
Shigellosis
Amoebiasis
Disorders of the stomach and duodenum
Gastro-oesophageal reﬂux
Gastric and duodenal ulcers in adults
Dyspepsia
Stomatitis
Oral and oropharyngeal candidiasis
Oral herpes
Other infectious causes
Stomatitis from scurvy (vitamin C deﬁciency)
Other lesions resulting from a nutritional deﬁciency


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Acute diarrhoea
Acute diarrhoea is deﬁned as at least 3 liquid stools per day for less than 2 weeks.
Clinical features
Treatment
General principles:
Prevention and treatment of dehydration 
See Dehydration, Chapter 1.
Adapted treatment protocols are recommended for children with malnutrition (see Severe acute malnutrition, Chapter
1).
Prevention of malnutrition
Continue unrestricted normal diet. In breastfed children, increase the frequency of feeds. Breast milk does not replace
ORS. ORS should be given between feeds.
Zinc supplementation
There are 2 clinical types of acute diarrhoea:
Diarrhoea without blood, caused by viruses in 60% of cases (rotavirus, enterovirus), bacteria (Vibrio cholerae,


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Diarrhoea without blood, caused by viruses in 60% of cases (rotavirus, enterovirus), bacteria (Vibrio cholerae,
enterotoxigenic Escherichia coli, non Typhi Salmonella, Yersinia enterocolitica) or parasites (giardiasis).
Diseases, such as malaria, acute otitis media, respiratory tract infections, etc. can be accompanied by this type
of diarrhoea.
Diarrhoea with blood, caused by bacteria (Shigella in 50% of cases, Campylobacter jejuni, enteroinvasive or
enterohaemorrhagic Escherichia coli, Salmonella) or parasites (intestinal amoebiasis).
Infectious diarrhoeas are transmitted by direct (dirty hands) or indirect (ingestion of contaminated water or food)
contact.
The high mortality rate from diarrhoeal diseases, even benign, is due to acute dehydration and malnutrition. This can


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contact.
The high mortality rate from diarrhoeal diseases, even benign, is due to acute dehydration and malnutrition. This can
be prevented by adequate rehydration and nutrition.
First assess for signs of dehydration (see Dehydration, Chapter 1).
Then look for other signs:
profuse watery diarrhoea (cholera, enterotoxigenic E. coli),
repeated vomiting (cholera),
fever (salmonellosis, viral diarrhoea),
presence of red blood in stools: see also Shigellosis and Amoebiasis (Chapter 3).
In a patient over 5 years with severe and rapid onset of dehydration, suspect cholera.
Prevent or treat dehydration: rehydration consists of prompt replacement of ﬂuid and electrolyte losses as
required, until the diarrhoea stops.
Administer zinc sulfate to children under 5 years.
Prevent malnutrition.


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required, until the diarrhoea stops.
Administer zinc sulfate to children under 5 years.
Prevent malnutrition.
Do not systematically administer antimicrobials: only certain diarrhoeas require antibiotics (see Antimicrobial
treatment).
Do not administer anti-diarrhoeal drugs or antiemetics.
Treat the underlying condition if any (malaria, otitis, respiratory infection, etc.).


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Zinc sulfate is given in combination with oral rehydration solution in order to reduce the duration and severity of
diarrhoea, as well as to prevent further occurrences in the 2 to 3 months after treatment:
zinc sulfate PO
Children under 6 months: 10 mg (½ tablet) once daily for 10 days
Children from 6 months to 5 years: 20 mg (1 tablet) once daily for 10 days Place the half-tablet or full tablet in a teaspoon, add a bit of water to dissolve it, and give the entire spoonful to the
child.
Antimicrobial treatment
Diarrhoea without blood
Most acute diarrhoeas are caused by viruses unresponsive to antimicrobials. Antimicrobials can be beneﬁcial in the
event of cholera or giardiasis.
Diarrhoea with blood
Prevention
 
 
References


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event of cholera or giardiasis.
Diarrhoea with blood
Prevention
 
 
References
Cholera: the most important part of treatment is rehydration. In the absence of resistance (perform antibiotic-
sensitivity testing at the beginning of an outbreak), antibiotic treatment shortens the duration of diarrhoea. See the
guide Management of a cholera epidemic, MSF.
Giardiasis: see Intestinal protozoan infections, Chapter 6.
Shigellosis is the most frequent cause of bloody diarrhoea (amoebiasis is much less common). If there is no
laboratory diagnosis to conﬁrm the presence of amoebae, ﬁrst line treatment is for shigellosis (Chapter 3).
Amoebiasis: antiparasitic treatment only if motile Entamoeba histolytica amoebae are found in stools or if a


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Amoebiasis: antiparasitic treatment only if motile Entamoeba histolytica amoebae are found in stools or if a
correct shigellosis treatment has been ineffective (see Amoebiasis, Chapter 3).
Breastfeeding reduces infant morbidity and mortality from diarrhoea and the severity of diarrhoea episodes.
When the child is weaned preparation and storage of food are associated with the risk of contamination by faecal
micro-organisms: discourage bottle-feeding; food must be cooked well; milk or porridge must never be stored at
room temperature.
Access to sufﬁcient amounts of clean water and personal hygiene (washing hands with soap and water before food
preparation and before eating, after defecation etc.) are effective methods of reducing the spread of diarrhoea.


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preparation and before eating, after defecation etc.) are effective methods of reducing the spread of diarrhoea.
In countries with a high rotavirus diarrhoea fatality rate, the WHO recommends routine rotavirus vaccination in
children between 6 weeks and 24 months of age . [1] 
1. Weekly epidemiological record/Relevé épidémiologique hebdomadaire 1st February 2013, 88th year/1er Février 2013, 88eannée No. 5, 2013, 88, 49–64.https://www.who.int/wer/2013/wer8805.pdf [Accessed 02 January 2019]


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Shigellosis
Shigellosis is a highly contagious bacterial infection resulting in bloody diarrhoea. There are 4 serogroups of shigella: S.
dysenteriae, S. sonnei, S. ﬂexneri, S. boydii.
S. dysenteriae type 1 (Sd1) is the only strain that causes large scale outbreaks. It has the highest case fatality rate (up
to 10%). 
Patients at risk of death are children under 5 years, malnourished patients, children after measles, adults over 50 years.
Clinical features
Laboratory
Shigellosis in an epidemic context:
Treatment
 
 
  If resistance or contra-indication to ciproﬂoxacin or if no improvement within 48 hours of starting ﬁrst-line
treatment:
Diarrhoea with bright red blood visible in stool , with or without fever  a 
Abdominal and rectal pain frequent


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treatment:
Diarrhoea with bright red blood visible in stool , with or without fever  a 
Abdominal and rectal pain frequent
Signs of serious illness: fever above 39 °C; severe dehydration; seizures, altered mental status
Complications (more frequent with Sd1): febrile seizures (5 to 30% of children), rectal prolapse (3%), septicaemia,
intestinal obstruction or perforation, moderate to severe haemolytic uraemic syndrome
Conﬁrm the causal agent (stool culture) and perform antibiotic sensitivity tests.
Perform monthly culture and sensitivity tests (antibiotic resistance can develop rapidly, sometimes during the course
of an outbreak).
Patients with signs of serious illness or with life-threatening risk factors must be admitted as inpatients.


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of an outbreak).
Patients with signs of serious illness or with life-threatening risk factors must be admitted as inpatients.
Treat patients with neither signs of serious illness nor risk factors as outpatients.
Antibiotherapy:
First-line treatment
ciproﬂoxacin PO for 3 days
Children: 15 mg/kg 2 times daily
(max. 1 g daily)
Adults: 500 mg 2 times daily
if the strain is sensitive
if there is no antibiotic sensitivity test
if oral administration is possible
ceftriaxone IM for 3 days
Children: 50 to 100 mg/kg once daily
(max. 1 g daily)
Adults: 1 to 2 g once daily
in patients with severe infection and/or oral
administration is not possible
in pregnant women b


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azithromycin PO for 5 days
Children: one dose of 12 mg/kg on D1 then 6 mg/kg once daily from D2 to D5
Adults: one dose of 500 mg on D1 then 250 mg once daily from D2 to D5
or
ceﬁxime PO for 5 days
Children: 8 mg/kg once daily (max. 400 mg daily)
Adults: 400 mg once daily If there is no improvement 48 hours after starting second-line treatment, treat for amoebiasis . 
 
 
 
Shigellosis in an epidemic context 
 
References
 [1] [2] 
For pain and/or fever:
paracetamol PO (see Pain, Chapter 1). All opioid analgesics are contra-indicated as they slow peristalsis.
Supportive therapy:
nutrition: nutritional supplement with frequent meals 
+ 2500 kcal daily during hospitalisation 
+ 1000 kcal daily as outpatients


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nutrition: nutritional supplement with frequent meals 
+ 2500 kcal daily during hospitalisation 
+ 1000 kcal daily as outpatients 
rehydration: administration of ORS according to WHO protocols (see Dehydration, Chapter 1).
zinc supplement in children under 5 years (see Acute diarrhoea, Chapitre 3).
Never give loperamide or any other antidiarrhoeal.
Management of complications: rectal prolapse reduction, septicaemia (see Septic shock, Chapter 1), etc.
Isolation of hospitalised patients; school exclusion of children treated as outpatients.
Hygiene (handwashing, hygienic preparation and storage of food, home hygiene, etc.).
Management if signs worsen or bloody diarrhoea in entourage (seek medical attention).
Footnotes


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Management if signs worsen or bloody diarrhoea in entourage (seek medical attention).
Footnotes
(a) This deﬁnition excludes: blood detected on microscope examination; stool containing digested blood (melaena); streaks ofblood on the surface of normal stool (haemorrhoids, anal or rectal lesion, etc.).
(b) Ciproﬂoxacin should be avoided in pregnant women. Nevertheless, if ceftriaxone is not available, the other antibiotics canbe used, including ciproﬂoxacin if necessary. 
1. Karen L. Kotloff et al. Seminar: Shigellosis. The Lancet, Volume 391, ISSUE 10122, P801-812, February 24, 2018.


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1. Karen L. Kotloff et al. Seminar: Shigellosis. The Lancet, Volume 391, ISSUE 10122, P801-812, February 24, 2018.
2. Word Health Organization. Pocket book for hospital care in children: guidelines for the management of common childhoodillnesses, 2013.http://apps.who.int/iris/bitstream/handle/10665/81170/9789241548373_eng.pdf;jsessionid=CE5C46916607EF413AA9FCA89B84163F?sequence=1 [Accessed 20 September 2018]


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Amoebiasis
Amoebiasis is a parasitic infection due to the intestinal protozoa Entamoeba histolytica. Transmission is faecal-oral,
by ingestion of amoebic cysts from food or water contaminated with faeces. Usually, ingested cysts release non-
pathogenic amoebae and 90% of carriers are asymptomatic.
In 10% of infected patients, pathogenic amoebae penetrate the mucous of the colon: this is the intestinal amoebiasis
(amoebic dysentery). The clinical picture is similar to that of shigellosis, which is the principal cause of dysentery.
Occasionally, the pathogenic amoebae migrate via the blood stream and form peripheral abscesses. Amoebic liver
abscess is the most common form of extra-intestinal amoebiasis.
Clinical features
Investigations
Treatment
Amoebic dysentery


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abscess is the most common form of extra-intestinal amoebiasis.
Clinical features
Investigations
Treatment
Amoebic dysentery
diarrhoea containing red blood and mucus
abdominal pain, tenesmus
no fever or moderate fever
possibly signs of dehydration
Amoebic liver abscess
painful hepatomegaly; mild jaundice may be present
anorexia, weight loss, nausea, vomiting
intermittent fever, sweating, chills; change in overall condition
Amoebic dysentery: identiﬁcation of mobile trophozoites (E. histolytica histolytica) in fresh stool samples
Amoebic liver abscess: indirect haemoagglutination and ELISA
POCUS : perform an EFAST (extended focused assessment with sonography for trauma) examination, with


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POCUS : perform an EFAST (extended focused assessment with sonography for trauma) examination, with
additional views of the liver and spleen to evaluate for signs of amoebic lesions. Contact an expert (local or via
telemedicine services) to help interpret the images and differentiate amoebic abscesses from other pathologies
with similar characteristics.
 a 
Amoebic dysentery
The presence of cysts alone should not lead to the treatment of amoebiasis.
Amoebiasis conﬁrmed with a parasitological stool examination: 
tinidazole PO
Children: 50 mg/kg once daily for 3 days (max. 2 g daily)
Adults: 2 g once daily for 3 days
or metronidazole PO
Children: 15 mg/kg 3 times daily for 5 days
Adults: 500 mg 3 times daily for 5 days


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Adults: 2 g once daily for 3 days
or metronidazole PO
Children: 15 mg/kg 3 times daily for 5 days
Adults: 500 mg 3 times daily for 5 days
If there is no laboratory, ﬁrst line treatment for dysentery is for shigellosis. Treat for amoebiasis if correct
treatment for shigellosis has been ineffective.
Oral rehydration salts (ORS) if there is risk of, or if there are signs of dehydration (see Dehydration, Chapter 1).
Amoebic liver abscess
tinidazole PO: same treatment for 5 days
metronidazole PO: same treatment for 5 to 10 days


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Footnotes
(a) POCUS should only be performed and interpreted by trained clinicians.


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Disorders of the stomach and duodenum
 
 
 
 
Gastro-oesophageal reﬂux
Gastric and duodenal ulcers in adults
Dyspepsia


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Gastro-oesophageal reﬂux
Clinical features
Burning stomachache or heartburn, generally relieved by antacids; acid regurgitation (often postural: while sitting
forward or lying down). In the absence of dysphagia (oesophageal stenosis), these signs are benign.
Treatment
First instance: encourage the patient to avoid alcohol and tobacco use.
Give aluminium hydroxide/magnesium hydroxide PO (400 mg/400 mg tablet) : 1 to 2 tablets 3 times daily 20
minutes to one hour after meals, or 1 tablet during painful attacks.
 a 
If antacids are insufﬁcient:
omeprazole PO: 20 mg once daily in the morning for 3 days
In young children: no drug treatment, rest and sleep on an incline (30° to 45°).
Footnotes


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omeprazole PO: 20 mg once daily in the morning for 3 days
In young children: no drug treatment, rest and sleep on an incline (30° to 45°).
Footnotes
(a) Aluminium hydroxide/magnesium hydroxide may decrease intestinal absorption of drugs taken at the same time:•  atazanavir, chloroquine, digoxin, doxycycline, iron  salts, gabapentin, itraconazole, levothyroxine (take at least 2 hoursapart).•  ciproﬂoxacin (take ciproﬂoxacin 2 hours before or 4 hours after antacids), dolutegravir (take dolutegravir 2 hours beforeor 6 hours after antacids), velpatasvir (take 4 hours apart).


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Gastric and duodenal ulcers in adults
Clinical features
Burning epigastric pain or epigastric cramps between meals, that wake the patient at night. Recurrent episodes
characteristically last a few days and are often accompanied by nausea and even vomiting.
The most common complications are perforation and bleeding.
Treatment of non-complicated ulcers
Treatment of complicated ulcers
Perforation
Perforation should be considered in patients presenting with sudden onset intense epigastric pain, particularly if there is
rigidity of the abdominal wall. The risk of peritonitis is increased if the perforation occurs on a full stomach.
Gastrointestinal bleeding
Passing of black stool (maelena) and/or vomiting blood (haematemesis). In 80% of cases the bleeding stops
spontaneously.


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Gastrointestinal bleeding
Passing of black stool (maelena) and/or vomiting blood (haematemesis). In 80% of cases the bleeding stops
spontaneously.
For an isolated episode: 
identify patients taking NSAID or acetylsalicylic acid; stop treatment;
encourage patients to avoid alcohol and tobacco use;
omeprazole PO: 20 mg once daily in the morning for 7 to 10 days. In severe or recurrent cases, dose can be
increased to 40 mg once daily and the treatment can be prolonged for up to 8 weeks.
If the patient has frequent recurrences unrelated to NSAID use, that require repeated treatment with antiulcer drugs:
see eradication of Helicobacter pylori.
To start: 
place the patient on a strict fast (NPO); insert a nasogastric tube and aspirate if possible;


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see eradication of Helicobacter pylori.
To start: 
place the patient on a strict fast (NPO); insert a nasogastric tube and aspirate if possible;
insert an intravenous line and hydrate (Ringer lactate);
treat acute pain (see Pain, Chapter 1);
omeprazole IV infusion: 40 mg once daily over 20 to 30 minutes
Refer to a surgeon.
If referral not possible, risk of mortality is high:
Continue conservative management including maintenance ﬂuid (alternate 5% glucose and Ringer lactate).
Start IV antibiotics (see Shock, Chapter 1).
If after 3 days, the patient's clinical condition has improved, cautiously restart oral feeding, remove the
nasogastric tube and start PO treatment to eradicate Helicobacter pylori (see eradication of Helicobacter
pylori).


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nasogastric tube and start PO treatment to eradicate Helicobacter pylori (see eradication of Helicobacter
pylori).
Insert a nasogastric tube for aspiration and insert an IV line (16G).
If the haemodynamic state is stable (pulse and blood pressure are normal):
Hydrate (Ringer lactate), monitor, keep NPO for 12 hours.
If there is no active haemorrhage, restart oral feeding after 12 hours.
Gastric lavage with cold water is not essential, but may help evaluate persistence of bleeding.
If the haemorrhage continues (haematemesis) and/or if the haemodynamic state deteriorates (pulse increases, BP
drops):


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Eradication of Helicobacter pylori
Most peptic ulcers are caused by Helicobacter pylori infection. If a diagnosis of ulcer is probable, treatment to
eradicate H. pylori should be considered if the patient has frequent attacks requiring repeated and/or prolonged
treatments with antiulcer drugs over 8 weeks or in cases of complicated ulcers (perforation or gastrointestinal
bleeding). Infection should be conﬁrmed with a test where possible. H. pylori resistance to antibiotics varies globally, follow national recommendations where available. If not, for
information, administer a triple therapy for 7 days:
omeprazole PO 20 mg 2 times daily + clarithromycin PO 500 mg 2 times daily + amoxicillin PO 1 g 2 times daily .


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omeprazole PO 20 mg 2 times daily + clarithromycin PO 500 mg 2 times daily + amoxicillin PO 1 g 2 times daily .
 In immunocompromised patients, consider mycobacterium avium complex (MAC) infection or other nontuberculous
mycobacterium (NTM) infection prior to starting a clarithromycin-containing triple therapy. If symptoms continue despite treatment, consider the differential diagnosis of gastric cancer. Refer for investigations
if possible.
 
Notes:
 
Intensive care and transfusion according to the severity of the bleeding (see haemorrhagic shock, Chapter 1).
Emergency surgical intervention.
 a 
Acetylsalicylic acid (aspirin) and NSAID (ibuprofen, diclofenac, etc.) are contra-indicated in patients suffering from
or with a history of ulcers.
Omeprazole is as effective PO as IV.
Footnotes


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or with a history of ulcers.
Omeprazole is as effective PO as IV.
Footnotes
(a) In penicillin-allergic patients, amoxicillin PO can be substituted with metronidazole PO 500 mg 2 times daily.


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Dyspepsia
Last updated: December 2020 
Clinical features
Epigastric pain or discomfort following meals, often accompanied by bloating, sensation of fullness and nausea.
Dyspepsia is most commonly functional. The diagnosis of functional dyspepsia is based on clinical assessment after
ruling out organic causes (Gastro-oesophageal reﬂux, Gastric and duodenal ulcers, drug-induced symptoms, gastric
cancer). If possible, test for Helicobacter pylori.
Treatment
In adults:
  Note: consider and treat possible intestinal parasites (see Intestinal protozoan infections, Cestodes, Nematode
infections, Chapter 6; Amoebiasis, Chapter 3).
 
References
In case of patients who test positive for H. pylori, see Eradication of Helicobacter pylori . [1]


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References
In case of patients who test positive for H. pylori, see Eradication of Helicobacter pylori . [1] 
Omeprazole PO (10 mg once daily) for 4 weeks may help even in H. pylori-negative patients . [2] [3] 
1. Ford AC, Mahadeva S, Carbone MF, Lacy BE, Talley NJ. Functional dyspepsia. Lancet. 2020 Nov 21;396(10263):1689-1702.
2. Moayyedi PM, Lacy BE, Andrews CN, et al. ACG and CAG clinical guideline: management of dyspepsia. Am J Gastroenterol.2017 Jul;112(7):988-1013.http://www.cag-acg.org/images/publications/CAG_CPG_Dyspepsia_AJG_Aug2017.pdf [Accessed 24 November 2020]


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3. National Institute for Health and Care Excellence. Gastro-oesophageal reﬂux disease and dyspepsia in adults: investigationand management. Sept 2014.  https://www.nice.org.uk/guidance/CG184/chapter/1-Recommendations#interventions-for-functional-dyspepsia [Accessed 24 November 2020]


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Stomatitis
 
 
 
 
Stomatitis is an inﬂammation of the mucous membranes of the mouth caused by a fungal, viral or bacterial infection, a
vitamin deﬁciency, an injury, etc.
Prolonged or painful stomatitis may contribute to dehydration or may cause loss of appetite with denutrition,
particularly in children.
In infants, examine routinely the mouth in the event of breast refusal or difﬁculties in sucking.
 
In all cases:
Oral and oropharyngeal candidiasis
Oral herpes
Other infectious causes
Stomatitis from scurvy (vitamin C deﬁciency)
Other lesions resulting from a nutritional deﬁciency
Maintain adequate hydration and feeding; offer foods that will not irritate the mucosa (soft, non-acidic). Use a
nasogastric tube for a few days if pain is preventing the patient from eating.


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nasogastric tube for a few days if pain is preventing the patient from eating.
Keep the mouth clean to prevent complications and recurrence.


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Oral and oropharyngeal candidiasis
Infection due to Candida albicans, common in infants, immunocompromised or diabetic patients. Other risk factors
include treatment with oral antibiotics or high-dose inhaled corticosteroids.
Clinical features
Treatment
nystatin oral suspension for 7 days
Children and adults: 400 000 IU daily, i.e. 1 ml of the oral suspension (100 000 IU) 4 times daily
or 
miconazole oral gel for 7 days
Children 6 months to 2 years: 1.25 ml 4 times daily
Children over 2 years and adults: 2.5 ml 4 times daily Apply the oral suspension of nystatin or the oral gel of miconazole between meals; keep in the mouth for 2 to 3


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minutes, then swallow. In young children, apply to the tongue and inside of each cheek. Show the mother how to treat since, in most cases, candidiasis will be treated at home. In immunocompromised patients: see HIV infection and AIDS, Chapter 8.
White patches on the tongue, inside the cheeks, that may spread to the pharynx.
In patients with frequent recurrences or extensive forms invading the esophagus (swallowing difﬁculty and pain),
consider HIV infection.


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Oral herpes
Infection due to the herpes simplex virus. Primary infection typically occurs in children aged 6 months to 5 years and
may cause acute gingivostomatitis, sometimes severe. After primary infection, the virus remains in the body and
causes in some individuals periodic recurrences which are usually benign (herpes labialis).
Clinical features
Multiple vesicles on the oral mucosa and lips which rupture to form painful, yellowish, at times extensive ulcers.
Local lesions are usually associated with general malaise, regional lymphadenopathy and fever.
Clusters of vesicles at the junction between the lip and the skin. In patients with frequent recurrences or extensive forms, consider HIV infection (see HIV infection and AIDS, Chapter
8).
Treatment


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8).
Treatment
Primary herpetic gingivostomatitis
 In immunocompromised patients: see HIV infection and AIDS, Chapter 8.
Recurrent herpes labialis
Spontaneous resolution within 7 to 10 days. An antiseptic (chlorhexidine or povidone iodine) may be applied;
paracetamol PO if necessary.
 
Both forms of herpes are contagious: do not touch lesions (or wash hands afterwards); avoid oral contact.
Primary herpetic gingivostomatitis
Recurrent herpes labialis
Treat pain: paracetamol or ibuprofen PO (Chapter 1)
In the event of severe lesions, inability to drink and signiﬁcant pain:
Admit the child to hospital (high risk of dehydration).
If the child presents within the ﬁrst 96 hours of symptoms onset, aciclovir PO for 5 to 7 days:
Children under 2 years: 200 mg 5 times daily


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If the child presents within the ﬁrst 96 hours of symptoms onset, aciclovir PO for 5 to 7 days:
Children under 2 years: 200 mg 5 times daily
Children 2 years and over and adults: 400 mg 5 times daily
In the event of secondary bacterial infection: amoxicillin PO 7 days.


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Other infectious causes
 
 
See Pharyngitis (Chapter 2), Diphtheria (Chapter 2), Measles (Chapter 8).


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Stomatitis from scurvy (vitamin C deﬁciency)
Clinical features
Bleeding gums, associated in infants with lower limb pain caused by subperiosteal haemorrhage. It is common in
contexts of poor food quality or in populations completely dependent on food aid (refugee camps).
Treatment
ascorbic acid (vitamin C) PO
The optimal dose has not been established. For information:
Children 1 month to 11 years: 100 mg 3 times daily 
Children 12 years and over and adults: 250 mg 3 times daily 
or
Children 1 month to 3 years: 100 mg 2 times daily
Children 4 to 11 years: 250 mg 2 times daily 
Children 12 years and over and adults: 500 mg 2 times daily  Treatment is administred at least 2 weeks or longer (until symptoms resolve), then preventive treatment is


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Other lesions resulting from a nutritionaldeﬁciency
 
 
Other vitamin deﬁciencies may provoke mouth lesions: angular stomatitis of the lips and glossitis from vitamin
B (riboﬂavin), niacin (see Pellagra, Chapter 4) or vitamin B (pyridoxine) deﬁciencies. Iron deﬁciency may also provoke angular stomatitis (see Anaemia, Chapter 1). Give the corresponding vitamins at curative doses. Multivitamins are insufﬁcient to treat true vitamin deﬁciencies.
2 6


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Chapter 4: Skin diseases
Dermatology
Scabies
Lice (pediculosis)
Superﬁcial fungal infections
Bacterial skin infections
Impetigo
Furuncles and carbuncles
Erysipelas and cellulitis
Cutaneous anthrax
Endemic treponematoses
Leprosy
Herpes simplex and herpes zoster
Herpes simplex
Herpes zoster (shingles)
Other skin disorders
Eczema
Seborrheic dermatitis
Urticaria
Pellagra


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Dermatology
 
 
Skin diseases, particularly infectious skin diseases, are very common. They must be treated individually or collectively,
but must also be considered as indicators of the sanitary condition of a population. A high prevalence of infectious skin
diseases may reﬂect a problem of insufﬁcient water quantity and lack of hygiene in a population.
Dermatological examination
 
Patients with skin disease often present late. At this stage, primary lesions and speciﬁc signs may be masked by
secondary infection. In these cases, it is necessary to re-examine the patient, after treating the secondary infection, in
order to identify and treat the underlying skin disease.
Observe the type of lesion:


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order to identify and treat the underlying skin disease.
Observe the type of lesion:
Macule: ﬂat, non palpable lesion that is different in colour than the surrounding skin
Papule: small (< 1 cm) slightly elevated, circumscribed, solid lesion
Vesicle (< 1 cm), bulla (> 1 cm): clear ﬂuid-ﬁlled blisters
Pustule: vesicle containing pus
Nodule: ﬁrm, elevated palpable lesion (> 1 cm) that extend into the dermis or subcutaneous tissue
Erosion: loss of the epidermis that heals without leaving a scar
Excoriation: erosion caused by scratching
Ulcer: loss of the epidermis and at least part of the dermis that leaves a scar
Scale: ﬂake of epidermis that detaches from the skin surface
Crust: dried serum, blood, or pus on the skin surface
Atrophy: thinning of the skin


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Scale: ﬂake of epidermis that detaches from the skin surface
Crust: dried serum, blood, or pus on the skin surface
Atrophy: thinning of the skin
Licheniﬁcation: thickening of the skin with accentuation of normal skin markings
Look at the distribution of the lesions over the body; observe their arrangement: isolated, clustered, linear, annular
(in a ring). Ask if the lesions are itchy.
Look for a possible cause: insect bites; scabies, lice, other parasitic skin infections; contact with plants, animals,
jewellery, detergents, etc.
Ask about any past or ongoing treatment: topical, oral or parenteral.
Look for local or regional signs (secondary infection, lymphangitis, adenopathy, erysipelas) and/or systemic signs
(fever, septicaemia, secondary focus).


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(fever, septicaemia, secondary focus).
Consider the sanitary conditions of the family, particularly for contagious skin diseases (scabies, scalp ringworm,
lice).
Check tetanus vaccination status.


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Scabies
Scabies is a cutaneous parasitosis due to the presence of the mite Sarcoptes scabiei hominis within the epidermis. It
exists in two forms: ordinary scabies, relatively benign and moderately contagious; and crusted scabies, favoured by
immune deﬁciency, extremely contagious and refractory to conventional treatment.
Person to person transmission takes place chieﬂy through direct skin contact, and sometimes by indirect contact
(sharing clothing, bedding). The challenge in management is that it must include simultaneous treatment of both the
patient and close contacts, and at the same time, decontamination of clothing and bedding of all persons undergoing
treatment, in order to break the transmission cycle.
Clinical features
Ordinary scabies
In older children and adults


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treatment, in order to break the transmission cycle.
Clinical features
Ordinary scabies
In older children and adults
and
and/or
 Typical lesions and secondary lesions may co-exist, or speciﬁc lesions may be entirely masked by secondary lesions.
In infants and young children
Crusted (Norwegian) scabies
Thick, scaly, erythematous plaques, generalised or localised, resembling psoriasis, with or without itching (50% of
cases). Delay in diagnosis may lead to a scabies epidemic.
Treatment
In all cases
Ordinary scabies
Itching, worse at night, very suggestive of scabies if close contacts have the same symptom
Typical skin lesions:
Scabies burrows (common): ﬁne wavy lines of 5 to 15 mm, corresponding to the tunnels made by the parasite


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Typical skin lesions:
Scabies burrows (common): ﬁne wavy lines of 5 to 15 mm, corresponding to the tunnels made by the parasite
within the skin. Burrows are most often seen in the interdigital spaces of the hand and ﬂexor aspect of the wrist,
but may be present on the areolae, buttocks, elbows, axillae. The back and the face are spared. Burrows may
be associated with vesicles, corresponding to the entry point of the parasite in the skin.
Scabies nodules (less common): reddish-brown nodules, measuring 2 to 20 mm, on the genitals in men, persisting
after effective treatment (they are not necessarily indicative of active infection).
Secondary skin lesions: resulting from scratching (excoriations, crusts) or super-infection (impetigo).


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Secondary skin lesions: resulting from scratching (excoriations, crusts) or super-infection (impetigo).
Vesicular eruption; often involving palms and soles, back, face, and limbs. Secondary infection or eczematisation is
frequent. Isolated scabies nodules in the axillae may be the only manifestation.
Examination of the mother’s hands may support the diagnosis. 
Close contacts of the patient are treated simultaneously, even in the absence of symptoms.
Clothing and bedding (including that of contacts) are changed after each treatment. They are washed at ≥ 60 °C
then dried in the sun, or exposed to sunlight for 72 hours, or sealed in a plastic bag for 72 hours.


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Topical treatment
Topical scabicides are applied over the entire body (including the scalp, post-auricular areas, umbilicus, palms and
soles), avoiding mucous membranes and face, and the breasts in breastfeeding women. Particular attention should be
paid to common infestation sites. The recommended contact time should not be shortened or exceeded; the patient
must not wash his hands while the product is in use (or the product should be reapplied if the hands are washed). In
children under 2 years, the hands must be wrapped to prevent accidental ingestion of the product and contact with
eyes. Topical scabicides should not be applied to broken or inﬂamed skin. Treatment of secondary bacterial infection,


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eyes. Topical scabicides should not be applied to broken or inﬂamed skin. Treatment of secondary bacterial infection,
if present, should be initiated 24 to 48 hours before use of topical scabicides (see Impetigo). The preferred treatment is 5% permethrin cream:
Children 2 months and over and adults: one application, with a contact time of 8 hours, then rinse thoroughly. Repeat
the application after 7 days. or, if not available, 25% benzyl benzoate lotion:
See the table below for dilution (depending on age), contact time and number of applications.
 
Oral treatment
Treatment with ivermectin PO (200 micrograms/kg single dose) is an alternative: it is more practical than topical
treatment (e.g. in the case of an epidemic or for treating contacts) and can be started right away in the case of


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treatment (e.g. in the case of an epidemic or for treating contacts) and can be started right away in the case of
secondary infection. A single dose may be sufﬁcient; a second dose 7 days later reduces the risk of treatment failure. Ivermectin is not recommended for children < 15 kg or pregnant women (safety not established) .
Administration of ivermectin to patients with loiasis carries a risk of severe neurological complications when signiﬁcant
Loa loa microﬁlaraemia is present (see Filariasis, Chapter 6) . ivermectin PO single dose:
  Children
< 2 years
Children
2 to 12 years
Children
> 12 years
and adults
Pregnant
women
Dilution
Lotion must be
diluted before use:
1 part 25% lotion +
3 parts water
Lotion must be
diluted before
use:
1 part 25%
lotion + 1 part
water
Use undiluted


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diluted before use:
1 part 25% lotion +
3 parts water
Lotion must be
diluted before
use:
1 part 25%
lotion + 1 part
water
Use undiluted
25% lotion
Use undiluted
25% lotion
Contact time
12 hours (6 hours
for infants
< 6 months)
then rinse
thoroughly
24 hours then
rinse thoroughly
24 hours then
rinse thoroughly
12 hours then
rinse thoroughly
Number of applications One application
Two applications (e.g. 24 hours
apart, with a rinse between the 2
applications; or 2 successive
applications, 10 minutes apart,
when the ﬁrst application has dried
with a rinse after 24 hours) 
One application
 a 
 b


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 Treatment effectiveness is judged on clinical grounds. Itching may persist for 1 to 3 weeks after elimination of the
parasite. Persistence of typical burrows beyond 4 weeks should lead to suspicion of treatment failure (insufﬁcient treatment,
e.g. the scalp was not included in topical treatment or the patient washed his hands during the treatment period), or
early re-infestation (contacts and environment not treated). In these cases, patient and contacts should be retreated. Persistent itching may be due to another condition, initially masked by scabies.
Crusted scabies
Treatment combines simultaneous administration of oral ivermectin and topical scabicide at regular intervals, e.g. every


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Crusted scabies
Treatment combines simultaneous administration of oral ivermectin and topical scabicide at regular intervals, e.g. every
week for 2 to 3 weeks or more, according to severity and clinical response. Crusts should be softened (salicylic acid ointment) and removed before applying local treatment (otherwise, local
treatment is ineffective). As exfoliated skin scales may spread the parasite, the patient should be isolated during the treatment, staff should use
protection (gloves, gowns and hand washing after contact), and environment (bedding, ﬂoors and surfaces) should be
decontaminated.
 
Weight 15 to 24 kg 25 to 35 kg 36 to 50 kg 51 to 65 kg
Ivermectin 3 mg tab 1 tab 2 tab 3 tab 4 tab
Footnotes


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decontaminated.
 
Weight 15 to 24 kg 25 to 35 kg 36 to 50 kg 51 to 65 kg
Ivermectin 3 mg tab 1 tab 2 tab 3 tab 4 tab
Footnotes
(a) Treatment with ivermectin in these patients is reserved for severe cases for which no alternative exists (see Crustedscabies).
(b) In areas where loiasis is endemic, certain precautions are recommended before administering ivermectin: e.g. measure theLoa loa microﬁlaraemia, if possible, or ensure that the patient has no history of loiasis (migration of an adult worm under theconjunctiva or transient « Calabar » swellings), nor history of severe adverse reactions following a previous treatment withivermectin, or if in doubt, use topical treatment in preference to oral.


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Lice (pediculosis)
Pediculosis is a benign contagious parasitic infection due to 3 species of lice speciﬁc to humans: head lice, body lice
and pubic lice. Transmission from person to person occurs through direct or indirect contact.
Body lice are potential vectors of relapsing fever (Chapter 7), typhus (Eruptive rickettsioses, Chapter 7) and trench
fever.
Clinical features
Treatment
Head lice
Body lice
Mass treatment (outbreak)
Apply 30 to 60 g (2 to 4 heaped soup spoons) of 0.5% permethrin powder to the inside of the clothes and
underclothes in contact with the skin (front and back, neck and waistline, sleeves and socks) in a fully clothed patient,
then rub in the powder by hand. Leave for 12 to 24 hours.


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then rub in the powder by hand. Leave for 12 to 24 hours.
Treat other clothing (including headwear) and bedding in a plastic bag with 0.5% permethrin powder. Repeat in 8 to 10
days if the infestation persists.
Head lice mainly affect children: itching and scratch marks (nape of neck and around the ears), which may become
secondarily infected (impetigo) in prolonged infestation; presence of live lice and/or live (shiny, grey) nits attached to
the hair shaft within 5 mm of the scalp.
Body lice mainly affect populations living under poor conditions (refugees, prisoners, the homeless): itching and
scratch marks (back, belt line and armpits), often inﬂamed and infected; presence of lice and nits in the clothing
(parasites are not found on the body).


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(parasites are not found on the body).
Pubic lice are considered to be a sexually transmitted infection (STI): itching and scratch marks (pubic and perianal
area), but other hairy areas may also be affected (armpits, thighs, eyelashes); lice and nits at the base of the hair
shaft, rarely visible.
Examine contacts; check for associated systemic infection (body lice) or STI (pubic lice).
Apply lotion to scalp and dry hair, paying particular attention to the areas behind the ears and around the nape of the
neck. Do not reduce or exceed the recommended duration of application.
4% dimeticone lotion
Children 6 months and over and adults: leave on hair for 8 hours, then rinse thoroughly.


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4% dimeticone lotion
Children 6 months and over and adults: leave on hair for 8 hours, then rinse thoroughly. 
Keep away from ﬂames and/or intense heat sources (including cigarettes) during application and until rinsing (risk of
ignition).
or, if dimeticone is not available or in children 2 to 6 months:
1% permethrin lotion. 
Children 2 months and over and adults: leave on hair for 10 minutes, then rinse thoroughly.
Repeat application of either treatment after 7 days.
Decontaminate combs, headwear and bedding (wash ≥ 60 °C/30 minutes, iron or dry in the sun or, if not feasible,
seal in a plastic bag for 2 weeks).
Treat as above contacts with live lice and/or live nits. Do not treat those with dead nits alone (dull, white, > 1 cm
from scalp).


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Individual treatment
Disinfection of clothing and bedding as above or as for head lice.
Pubic lice
Shave and/or apply 1% permethrin lotion to hairy areas (as for head lice). Treat the partner at the same time.
Decontaminate clothing and bedding (as for head lice). Repeat the application after 7 days.
Treatment of secondary bacterial infection, if present, should begin 24 to 48 hours before local antiparasitic treatment
(see Impetigo); local treatment is applied later when tolerated.


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Superﬁcial fungal infections
Superﬁcial fungal infections are benign infections of the skin, scalp and nails caused by Candida albicans or
dermatophytes.
Clinical features and treatment
Candidiasis
Candidal diaper dermatitis
Erythema of the perianal area with peripheral desquamation and sometimes pustules. Secondary infection may
develop.
Other candidiasis
Dermatophytoses
Dermatophytes cause various clinical lesions, depending on the anatomic site involved: scalp, glabrous (hairless) skin,
folds or nails. 
Buttocks must be kept clean (ordinary soap and water) and dry.
Avoid humidity: according to the context, expose the buttocks to air or change diapers more frequently; remove
plastic pants.
Protect the skin with zinc oxide ointment if diarrhoea is present.


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plastic pants.
Protect the skin with zinc oxide ointment if diarrhoea is present.
If diaper dermatitis is severe and persistent despite these measures, consider an intestinal infection (nystatin PO:
100 000 IU 4 times daily for 20 days).
Candidiasis of skin folds: miconazole 2% cream, one application 2 times daily for 2 to 4 weeks
Oral candidiasis: see Stomatitis, Chapter 3.
Vulvovaginal candidiasis: see Abnormal vaginal discharge, Chapter 9.


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Anatomic
site (a) Clinical features Treatment
Scalp
Scalp ringworm
Tinea capitis
Common in children. Depending on the species:
• One or more round, scaly, erythematous plaques with
the ends of broken hairs.
• Inﬂammation, suppuration, crusting and peripheral
lymphadenopathy (kerion).
• Permanent hair loss (favus).
Some scalp ringworms are contagious:
simultaneously examine (and treat) symptomatic
contacts.
• Shave or cut hair short on and around
the lesions.
• Local treatment: 2 times daily, clean
with soap and water, dry and apply
miconazole 2% cream or Whitﬁeld’s
ointment for 2 weeks or longer if
necessary.
• Administer systemic treatment as
local treatment alone does not cure
scalp ringworm:
griseofulvin PO for 6 weeks minimum
(up to 8 to 12 weeks)


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• Administer systemic treatment as
local treatment alone does not cure
scalp ringworm:
griseofulvin PO for 6 weeks minimum
(up to 8 to 12 weeks)
Children 1 to 12 years: 10 to 20 mg/kg
once daily (max. 500 mg daily)
Children ≥ 12 years and adults: 500 mg
to 1 g once daily, depending on
severity
or itraconazole PO
Children: 3 to 5 mg/kg once daily for 4
to 6 weeks (max. 200 mg daily)
Adults: 200 mg once daily for 2 to 4
weeks
• Suppurative lesions: treat
superinfection (see Impetigo) before
applying local antifungal treatment.
• For painful kerion: paracetamol PO.
In pregnant lactating/breastfeeding
women: oral antifungals are
contraindicated. Apply a topical
treatment (miconazole 2% cream or
Whitﬁeld’s ointment) to limit the
spread of infection until it is possible
to treat orally.


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treatment (miconazole 2% cream or
Whitﬁeld’s ointment) to limit the
spread of infection until it is possible
to treat orally.
Glabrous skin
Ringworm of the
body
Tinea corporis
Erythematous, scaly, pruritic macule with a well-
demarcated, raised, vesicular border and central
healing.
• For non widespread, localised tinea:
Local treatment: 2 times daily, clean
with soap and water, dry and apply
miconazole 2% cream or Whitﬁeld’s
ointment for 2 to 4 weeks or for 2
weeks after clinical resolution.
• Reserve oral antifungals for
particularly extensive lesions:
griseofulvin PO for 4 to 6 weeks or
itraconazole for 2 weeks.
Folds • Interdigital spaces (Tinea pedis): Topical treatment as above. If oozing


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Tinea pedis
(athlete’s foot)
Tinea cruris
Pruritus, ﬁssure and whitish scales in the 3 and/or 4
interdigital spaces .
• Groin (Tinea cruris):
Circumscribed, pruritic, erythematous plaque, with a
pale centre surrounded by vesiculo- pustules, extending
outward from the groin.
rd th
 (b)  
lesions, use miconazole 2% cream
only (do not use Whitﬁeld’s ointment).
(a) Dermatophytosis may affect the nails (Tinea unguium, onychomycosis). Treatment is prolonged (12 to 18 months withgriseofulvin) thus, in practice, difﬁcult. Failures and relapses are frequent.
(b) In candidal intertrigo, lesions are usually located in the 1st and 2nd interdigital spaces.


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Bacterial skin infections
 
 
 
 
Impetigo
Furuncles and carbuncles
Erysipelas and cellulitis


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Impetigo
Impetigo is a benign, contagious infection of the epidermis due to group A ß-haemolytic streptococcus
and Staphylococcus aureus. Co-infection is common. Transmission is by direct contact. Lack of water, and poor
hygiene, increase spread.
Primary infections are most common in children. Secondary infections complicating preexisting pruritic dermatoses
(lice, scabies, eczema, herpes, chickenpox, etc.) are more common in adults.
Clinical features
Treatment
 
 
Non bullous impetigo (classic form): ﬂaccid vesicle on erythematous skin which becomes pustular and forms a
yellowish crust. Different stages o the infection may be present simultaneously. The lesion does not leave a scar.


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yellowish crust. Different stages o the infection may be present simultaneously. The lesion does not leave a scar.
The most common sites of infection are around the nose and mouth, on the limbs or on the scalp.
Bullous impetigo: large ﬂaccid bullae and erosions of the skin in the ano-genital region in newborns and infants.
Ecthyma: an ulcerative form of impetigo that leaves scars. This form is most common in the immunocompromised
(e.g. HIV infection, malnutrition), diabetics and alcoholics.
Regardless of the type of impetigo: absence of fever or systemic signs.
Possible complications:
abscess, pyodermitis, cellulitis, lymphangitis, osteomyelitis, septicaemia;
acute glomerulonephritis (routinely look for signs of glomerulonephritis).


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acute glomerulonephritis (routinely look for signs of glomerulonephritis).
Localised non bullous impetigo (max. 5 lesions in a single skin area):
Clean with soap and water and dry before applying mupirocin.
2% mupirocin ointment: one application 3 times daily for 7 days. Reassess after 3 days. If there is no response,
switch to oral antibiotic therapy (see below).
Keep ﬁngernails short. Avoid touching the lesions, keep them covered with gauze if possible.
Extensive non bullous impetigo (more than 5 lesions or impetigo involving more than one skin area), bullous
impetigo, ecthyma, impetigo with abscess; immunocompromised patient; topical treatment failure:
Clean with soap and water and dry 2 to 3 times daily.


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impetigo, ecthyma, impetigo with abscess; immunocompromised patient; topical treatment failure:
Clean with soap and water and dry 2 to 3 times daily.
Keep ﬁngernails short. Avoid touching the lesions, keep them covered with gauze if possible.
Incise abscesses if present.
Administer oral antibiotic therapy : 
cefalexin PO for 7 days
Neonates under 7 days: 25 mg/kg 2 times daily
Neonates 7 to 28 days: 25 mg/kg 3 times daily
Children 1 month to 12 years: 25 mg/kg 2 times daily
Children 12 years and over and adults: 1 g 2 times daily
or
cloxacillin PO for 7 days
Children over 10 years: 15 mg/kg 3 times daily (max. 3 g daily)
Adults: 1 g 3 times daily
Note: in newborns with lesions located around the umbilicus, administer cloxacilllin IV.
 a 
For all patients:


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Adults: 1 g 3 times daily
Note: in newborns with lesions located around the umbilicus, administer cloxacilllin IV.
 a 
For all patients:
Quarantine from school (children can return to school after 24 to 48 hours of antibiotic therapy).


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Look for and treat any underlying dermatosis: lice, scabies, eczema, herpes, scalp ringworm, or an ENT
infection.
Trace and treat contacts.
Check for proteinuria (use urine dipstick) 3 weeks after the infection.
Footnotes
(a) In penicillin-allergic patients only (resistance to macrolides is common), azithromycin PO for 3 days (children: 10 mg/kg oncedaily; adults: 500 mg once daily).


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Furuncles and carbuncles
Necrotising perifollicular infection, usually due to Staphylococcus aureus. Risk factors include: nasal carriage of S.
aureus, maceration, breaks in the skin, poor hygiene; diabetes mellitus, malnutrition, iron deﬁciency or
immunodeﬁciency.
Clinical features
Treatment
 
 
 
Furuncle: red, warm, painful nodule with a central pustule, usually around a hair follicle. It becomes ﬂuctuant,
discharges a core of purulent exudate, and leaves a depressed scar. It occurs most frequently on the thighs, groin,
buttocks, armpits, neck and back. There is no fever.
Carbuncle: a cluster of interconnected furuncles, sometimes with fever and peripheral lymphadenopathy. It leaves a
depressed scar.
Single furuncle:


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Carbuncle: a cluster of interconnected furuncles, sometimes with fever and peripheral lymphadenopathy. It leaves a
depressed scar.
Single furuncle:
Clean with soap and water 2 times daily and cover with a dry dressing.
Apply warm moist compresses to the furuncle in order to encourage it to drain.
After drainage, clean and apply a dry dressing until the lesion has healed.
Furuncle on the face, multiple furuncles, carbuncles or in immunocompromised patients:
Same local care.
Add systematically an antibiotic for 7 days: 
cefalexin PO
Neonates under 7 days: 25 mg/kg 2 times daily
Neonates 7 to 28 days: 25 mg/kg 3 times daily
Children 1 month to 12 years: 25 mg/kg 2 times daily
Children 12 years and over and adults: 1 g 2 times daily
or


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Children 1 month to 12 years: 25 mg/kg 2 times daily
Children 12 years and over and adults: 1 g 2 times daily
or 
amoxicillin/clavulanic acid (co-amoxiclav) PO. Use formulations in a ratio of 8:1 or 7:1. The dose is expressed
in amoxicillin:
Children < 40 kg: 25 mg/kg 2 times daily
Children ≥ 40 kg and adults: 
Ratio 8:1: 2000 mg daily (2 tablets of 500/62.5 mg 2 times daily)
Ratio 7:1: 1750 mg daily (1 tablet of 875/125 mg 2 times daily)
 a 
In all cases: wash hand frequently, wash bedding.
Footnotes
(a) For penicillin-allergic patients:clindamycin PO (children: 10 mg/kg 3 times daily; adults: 600 mg 3 times daily)


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Erysipelas and cellulitis
Last updated: October 2020
 
 
Acute skin infections, due to bacteria (usually Group A beta-haemolytic streptococcus and sometimes
Staphylococcus aureus, including methicillin resistant S. aureus–MRSA) that enter through a break in the skin.
The main risk factors are: venous insufﬁciency, obesity, oedema or lymphoedema, history of erysipelas or cellulitis,
immunosuppression and cutaneous inﬂammation (e.g. dermatosis, wound).
Erysipelas is a superﬁcial infection (affecting the dermis and superﬁcial lymph vessels), while cellulitis affects the deeper
tissues (deep dermis layers and subcutaneous fat).
Generally, these infections affect the lower extremities and sometimes the face. If the orbital and periorbital tissues


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Generally, these infections affect the lower extremities and sometimes the face. If the orbital and periorbital tissues
are infected, see Periorbital and orbital cellulitis, Chapter 5. If the infection is perifollicular, see Furuncles and
carbuncles, Chapter 4.
Clinical signs
Paraclinical investigations
Treatment
 
Warm, tender, swollen well–demarcated erythematous plaque.
Fever, lymphadenopathy and lymphangitis.
Look for a portal of entry (bite, ulcer, wound, intertrigo, eczema, fungal infection, etc.).
In case of intense pain disproportionate to the skin lesion, hypoesthesia, rapidly progressing local signs, crepitation,
skin necrosis or critically ill appearing patient, consider necrotising fasciitis that is a surgical emergency


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skin necrosis or critically ill appearing patient, consider necrotising fasciitis that is a surgical emergency
(see Necrotising infections of the skin and soft tissues, Chapter 10).
Other complications: septicaemia (see Septic shock, Chapter 1), acute glomerulonephritis, osteomyelitis, septic
arthritis.
The main differential diagnoses include: contact dermatitis, stasis dermatitis due to venous insufﬁciency, venous
thrombosis and erythema migrans characteristic of Lyme disease.
Ultrasound: can detect signs of cellulitis and rule out an underlying abscess, deep vein thrombosis or a foreign body.
Radiography: can detect a foreign body, underlying osteomyelitis (or gas in the subcutaneous tissue in case of a


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Radiography: can detect a foreign body, underlying osteomyelitis (or gas in the subcutaneous tissue in case of a
necrotising infection, nevertheless the absence of gas does not rule out this diagnosis).
Test for proteinuria with urine dipstick 3 weeks after infection to look for glomerulonephritis.
In all cases:
Outline the area of erythema with a pen in order to follow the infection . a 
Bed rest, elevation of affected area (e.g. leg). 
Treatment of pain (Chapter 1). Avoid NSAIDs that may increase the risk of necrotising fasciitis.
Administer antibiotics: either orally or IV depending on severity.
Treat portal of entry and comorbidities.
Check and/or catch up tetanus vaccination (see Tetanus, Chapter 7).


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Treat portal of entry and comorbidities.
Check and/or catch up tetanus vaccination (see Tetanus, Chapter 7).
In case of necrotising fasciitis, septic arthritis or osteomyelitis: urgent transfer to a surgical centre, initiate IV
antibiotic treatment while awaiting transfer.


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  In the event of worsening clinical signs after 48 hours of antibiotic treatment, consider IV route. 
If there is clinical improvement after 48 hours (afebrile and erythema and oedema have improved) switch to
cefalexin or amoxicillin/clavulanic acid PO at the doses indicated above to complete 7 to 10 days of treatment.
After 48 hours, change to clindamycin PO at the doses indicated above to complete 7 to 10 days of treatment.
 
Hospitalize for the following: children younger than 3 months, critically ill appearing patient , local complications,
debilitated patient (chronic conditions, the elderly) or if there is a risk of non-compliance with or failure of outpatient
treatment. Treat other patients as outpatients.
 b 
Outpatient antibiotherapy :


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treatment. Treat other patients as outpatients.
 b 
Outpatient antibiotherapy : 
cefalexin PO for 7 to 10 days
Children 1 month to under 12 years: 25 mg/kg 2 times daily
Children 12 years and over and adults: 1 g 2 times daily
or
amoxicillin/clavulanic acid (co-amoxiclav) PO for 7 to 10 days. 
Use formulations in a ratio of 8:1 or 7:1. The dose is expressed in amoxicillin:
Children < 40 kg: 25 mg/kg 2 times daily
Children ≥ 40 kg and adults:
Ratio 8:1: 2000 mg daily (2 tablets of 500/62.5 mg 2 times daily)
Ratio 7:1: 1750 mg daily (1 tablet of 875/125 mg 2 times daily)
 c  
Inpatient antibiotherapy : d 
First line therapy: 
cloxacillin IV infusion over 60 minutes
Children 1 month to under 12 years: 12.5 to 25 mg/kg every 6 hours
Children 12 years and over and adults: 1 g every 6 hours 
or


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Children 1 month to under 12 years: 12.5 to 25 mg/kg every 6 hours
Children 12 years and over and adults: 1 g every 6 hours 
or
amoxicillin/clavulanic acid (co-amoxiclav) by slow IV injection (3 minutes) or IV infusion (30 minutes). The dose
is expressed in amoxicillin:
Children under 3 months: 30 mg/kg every 12 hours 
Children 3 months and over: 20 to 30 mg/kg every 8 hours (max. 3 g daily)
Adults: 1 g every 8 hours
 e 
If there is no clinical improvement after 48 hours, consider MRSA: 
clindamycin IV infusion over 30 minutes
Children 1 month and over: 10 mg/kg every 8 hours
Adults: 600 mg every 8 hours
 f 
Footnotes
(a) The erythema will regress if the treatment is effective. If the erythema spreads consider a treatment failure (MRSA or anecrotising infection).


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(a) The erythema will regress if the treatment is effective. If the erythema spreads consider a treatment failure (MRSA or anecrotising infection).
(b) Critically ill appearing child: weak grunting or crying, drowsy and difﬁcult to arouse, does not smile, disconjugate or anxiousgaze, pallor or cyanosis, general hypotonia.
(c) For penicillin-allergic patients, clindamycin PO for 7 to 10 days (children: 10 mg/kg 3 times daily; adults: 600 mg 3 times daily).
(d) For penicillin-allergic patients, clindamycin IV infusion (children: 10 mg/kg 3 times daily; adults: 600 mg 3 times daily).


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(d) For penicillin-allergic patients, clindamycin IV infusion (children: 10 mg/kg 3 times daily; adults: 600 mg 3 times daily).
(e) Cloxacillin powder for injection should be reconstituted in 4 ml of water for injection. Then dilute each dose of cloxacillin in5 ml/kg of 0.9% sodium chloride or 5% glucose in children less than 20 kg and in a bag of 100 ml of 0.9% sodium chloride or5% glucose in children 20 kg and over and in adults.


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(f) Dilute each dose of clindamycin in 5 ml/kg of 0.9% sodium chloride or 5% glucose in children less than 20 kg and in a bag of100 ml of 0.9% sodium chloride or 5% glucose in children 20 kg and over and in adults.


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Cutaneous anthrax
Last updated: September 2022
 
 
Anthrax is caused by the bacterium Bacillus anthracis that primarily affects herbivores (sheep, goats, cows, camels,
horses, etc.). Humans may become infected through contact of broken skin with a dead or sick animal. People at risk
include livestock farmers and those that manipulate skins, wool or carcasses of infected animals.
The disease is found in Eastern Europe, Central Asia, the Mediterranean Basin, Africa and South America.
Pulmonary (acquired by inhalation) and intestinal (acquired by eating infected meat) forms also exist.
Clinical features
Laboratory
Treatment
Uncomplicated cutaneous anthrax 
doxycycline PO (except in pregnant or breastfeeding women)
Children under 45 kg: 2 to 2.2 mg/kg (max. 100 mg) 2 times daily


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doxycycline PO (except in pregnant or breastfeeding women)
Children under 45 kg: 2 to 2.2 mg/kg (max. 100 mg) 2 times daily
Children 45 kg and over and adults: 100 mg 2 times daily
clindamycin PO (in patients allergic to ﬁrst-line antibiotics)
Children: 10 mg/kg (max. 600 mg) 3 times daily
Adults: 600 mg 3 times daily
or
Papule, then pruritic vesicle on uncovered skin surfaces (face, neck, arms, legs). The vesicle ulcerates and becomes
a painless black eschar surrounded by oedema, often associated with with lymphangitis and regional
lymphadenopathy.
The following are criteria of severity:
lesion located on the head or neck, or
presence of systemic symptoms (fever, malaise, headache, tachycardia, tachypnoea, hypotension,
hyper/hypothermia), or
presence of extensive oedema, or


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hyper/hypothermia), or
presence of extensive oedema, or
multiple, extensive or bullous lesions.
From vesicular ﬂuid : culture and drug susceptibility testing (rarely available) or Gram stain for microscopic
examination.
 a 
PCR testing (reference laboratory).
Do not excise the eschar; daily dry dressings.
Antibiotic treatment for 7 to 10 days:
First-line antibiotics:
ciproﬂoxacin PO (including in pregnant or breastfeeding women and children)
Children: 15 mg/kg (max. 500 mg) 2 times daily
Adults: 500 mg 2 times daily
or
Alternatives include:


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amoxicillin PO, if penicillins are effective (documented susceptibility)
Children: 30 mg/kg (max. 1 g) 3 times daily
Adults: 1 g 3 times daily
Severe cutaneous anthrax
Do not mix the two antibiotics in the same infusion bag (incompatibility).
ampicillin IV infusion over 30 minutes
Children 1 month and over: 50 mg/kg (max. 3 g) every 6 hours or 65 mg/kg (max. 4 g) every 8 hours 
Adults: 3 g every 6 hours or 4 g every 8 hours
+ clindamycin IV infusion as above.
Change to oral treatment as soon as possible to complete 14 days of treatment with ciproﬂoxacin + clindamycin or
amoxicillin + clindamycin as for uncomplicated cutaneous anthrax.
Prevention
 
Combined antibiotic treatment for 14 days:
 
 
First-line:
ciproﬂoxacin IV infusion over 60 minutes


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Prevention
 
Combined antibiotic treatment for 14 days:
 
 
First-line:
ciproﬂoxacin IV infusion over 60 minutes
Children: 10 mg/kg (max. 400 mg) every 8 hours 
Adults: 400 mg every 8 hours 
+ clindamycin IV infusion over 30 minutes
Children 1 month and over: 10 to 13 mg/kg (max. 900 mg) every 8 hours
Adults: 900 mg every 8 hours
 b 
 b 
Alternative, if penicillins are effective (documented susceptibility):
 b 
Intensive care: symptomatic treatment of shock (see Shock, Chapter 1); tracheostomy and ventilatory support may
be necessary.
Antibiotic prophylaxis in case of known skin exposure: treat for 10 days PO as for uncomplicated cutaneous
anthrax.
Livestock vaccination; burial or burning of animal carcasses.
Footnotes


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anthrax.
Livestock vaccination; burial or burning of animal carcasses.
Footnotes
(a) Samples can be stored (including transport time) for 7 days max. in cold chain (if not available, at a temperature < 30 °C).
(b) Dilute each dose of ciproﬂoxacin, clindamycin or ampicillin in 5 ml/kg of 0.9% sodium chloride or 5% glucose in children lessthan 20 kg and in a bag of 100 ml of 0.9% sodium chloride or 5% glucose in children 20 kg and above and in adults.Administer ciproﬂoxacin more slowly than clindamycin or ampicillin.


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Endemic treponematoses
 Endemic treponematoses are bacterial infections caused by 3 different types of treponema (other than Treponema
pallidum). Human-to-human transmission may be direct or indirect.
The 3 endemic treponematoses result in positive syphilis serology (TPHA-VDRL), but these tests are not necessary as
diagnosis is clinical. There is no laboratory test that can distinguish between the different treponematoses.
For the diagnosis and treatment of syphilis, see Genital infections, Chapter 9.
Clinical features


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  Yaws Pinta Bejel
Pathogen Treponema pertenue Treponema carateum Treponema pallidum type M
Geographic
distribution
Tropical and humid
forests
Tropical zones of Latin America Arid areas, semi-desert of the Middle
East and Africa
Population Children between 4 and
14 years
Children and adults Nomadic populations, particularly
children
First stage Yaws chancre: skin
coloured lesion, non-
indurated, itchy, on the
lower limbs in 95% of
cases, with peripheral
adenopathy.
Spontaneous healing or
development of a large
yaw surrounded by
smaller yaws.
Annular, erythematous, scaly
plaques, usually on uncovered
body parts (face, extremities),
resemble dermatophytes.
Lesions heal sponta- neously
leaving scars.
Discrete chancre: moist papule, most
commonly on the mucous membranes


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resemble dermatophytes.
Lesions heal sponta- neously
leaving scars.
Discrete chancre: moist papule, most
commonly on the mucous membranes
or in dermal folds, with peripheral
adenopathy.
Second
stage
Lesions appear 3
weeks after the initial
chancre, occur in crops
and heal spontaneously:
• Frambesioma
(papillomatous lesion,
vegetal, very
contagious)
• Isolated or associated
with yaws (round,
squamous papules, not
very contagious)
• Osteoperiostitis of the
long bones (phalanges,
nasal process of the
maxilla, tibia)
Pintids: plaques of various
colours (bluish, reddish, whitish).
May occur anywhere on the
body.
• Mucous patches of the mouth
common: very contagious ulcerated,
round in form, indurated, with white
coating, bleed easily, usually occur on
the inside of the lips, cheek and tongue


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round in form, indurated, with white
coating, bleed easily, usually occur on
the inside of the lips, cheek and tongue
or labial folds
• Condyloma in the anogenital region
(rare)
• Cutaneous lesions are rare: vegetal
aspect, in dermal folds
• Bone destruction identical to that of
yaws, in the legs and forearms
Late stage After some years of
latency:
• Periostitis; painful,
debilitating osteitis
• Ulcerating and
disﬁguring
rhinopharyngitis
• Juxta-articular nodules
Symmetrical white patches on
the limbs. The depigmentation is
permanent, remaining after
treatment.
After several years of latency:
• Gummatous lesions of skin and long
bones
• Plantar and palmar keratosis
• Juxta-articular nodules
• Hyper- and hypo-pigmented patches
(as in pinta)


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Treatment
Yaws
azithromycin PO
Children and adults: 30 mg/kg single dose (max. 2 g)
or, if not available,
benzathine benzylpenicillin IM
Children under 10 years: 1.2 MIU single dose
Children 10 years and over and adults: 2.4 MIU single dose
Pinta and bejel
benzathine benzylpenicillin IM.
As for yaws. For patients allergic to penicillin:
doxycycline PO (except in children under 8 years and pregnant or lactating women)
Children 8 years and over: 50 mg 2 times daily for 14 days
Adults: 100 mg 2 times daily for 14 days Notes:
Treatment of contacts and latent cases
The same treatment should be administered to all symptomatic and asymptomatic contacts and to all latent cases
(asymptomatic individuals with positive serologic test for syphilis) in endemic zones. 
 
References
 [1]


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(asymptomatic individuals with positive serologic test for syphilis) in endemic zones. 
 
References
 [1] 
 [2] [3] 
Antibiotic treatment will cure early stage cases and may relieve the pain of osteitis. It may be ineffective for late
stage infections.
Syphilis serology will remain positive despite clinical cure.
1. World Health Organization ( 2012) . Yaws: recognition booklet for communities. Reprinted with changes, 2014. http://www.who.int/iris/handle/10665/75360 [Accessed 15 May 2018]
2. Oriol Mitjà, David Mabey. Yaws, bejel, and pinta (last updated. May 07, 2018). UpToDate [Accessed 15 May 2018].


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2. Oriol Mitjà, David Mabey. Yaws, bejel, and pinta (last updated. May 07, 2018). UpToDate [Accessed 15 May 2018].
3. Michael Marks, Anthony W Solomon, David C Mabey. Endemic treponemal diseases. Transactions of The Royal Society ofTropical Medicine and Hygiene, Volume 108, Issue 10, 1 October 2014, Pages 601–607.https://doi.org/10.1093/trstmh/tru128 [Accessed 15 May 2018]


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Leprosy
Leprosy is a chronic bacterial infection due to Mycobacterium leprae.
It is transmitted by frequent close contact, mainly between household members.
It mainly affects young adults. 94% of reported cases globally were in Bangladesh, Brazil, Democratic Republic of
Congo, Ethiopia, India, Indonesia, Madagascar, Myanmar, Nepal, Nigeria, the Philippines, Sri Lanka and the United
Republic of Tanzania.
Clinical features
Leprosy should be considered in any patient presenting with:
 There are different clinical forms and classiﬁcation systems of leprosy.
Ridley-Jopling classiﬁcation 
This classiﬁcation differentiates 5 forms based on the bacteriological index. These forms correlate with the


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Ridley-Jopling classiﬁcation 
This classiﬁcation differentiates 5 forms based on the bacteriological index. These forms correlate with the
immunological response to  M. leprae. Patients with tuberculoid leprosy (TT) are resistant to the bacillus and infection
is localised. Patients with lepromatous leprosy (LL) are extremely sensitive to the bacillus and the infection is
disseminated. Borderline forms (BT, BB, BL) are between the two ends of the spectrum (TT and LL). 
 
WHO classiﬁcation
In order to simplify diagnosis and to promote rapid implementation of treatment, the WHO has simpliﬁed clinical
classiﬁcation of leprosy and differentiates only 2 forms:
 Multibacillary leprosy includes LL, BL and BB forms and paucibacillary leprosy includes the TT and BT forms of the


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Multibacillary leprosy includes LL, BL and BB forms and paucibacillary leprosy includes the TT and BT forms of the
Ridley-Jopling classiﬁcation system.
Laboratory
 [1]
Hypopigmented or erythematous skin lesion(s) with partial or complete loss of sensation to touch, pain, heat; 
Inﬁltrated pigmented nodules, initially with no sensory loss, on the face, ear lobes and the upper and lower limbs;
Tender, inﬁltrated and hypertrophied peripheral nerve (ulnar, radial, median, popliteal, tibial etc.) with possible
paraesthesia of the extremities, trophic changes (perforating ulcer of the foot) or paralysis (steppage gait,
deformaties of hands and feet, facial nerve paralysis).
Paucibacillary forms 
(least contagious forms)
Multibacillary forms 
(most contagious forms)
Tuberculoid Borderline


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Paucibacillary forms 
(least contagious forms)
Multibacillary forms 
(most contagious forms)
Tuberculoid Borderline
Tuberculoid
Borderline Borderline
Lepromatous
Lepromatous
T.T. B.T. B.B. B.L. L.L.
Multibacillary leprosy: more than 5 skin lesions
Paucibacillary leprosy: 1 to 5 skin lesions
Laboratory diagnosis is based on the detection of acid-fast bacilli in a Ziehl-Neelsen stained nasal smear and skin-
split smear taken from the ear lobe or from a skin lesion. In TT leprosy bacilli are not found.
In practice, in most endemic countries diagnosis is based on the WHO clinical classiﬁcation (number of lesions).


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Treatment
Countries where leprosy is endemic have a control programme. Check national recommendations. First-line treatment regimens recommended by the WHO 
 Note: the monthly doses of rifampicin and clofazimine are administered under direct observation by medical staff
whereas the daily doses of clofazimine and dapsone are taken by the patient at home. Rifampicin should be taken on
an empty stomach to improve absorption. Teach the patient to recognise and quickly report a lepra reaction or relapse in order to modify or restart treatment.
Leprosy reactions
These reactions usually occur during the course of treatment in patients with multibacillary leprosy (BL and LL). They


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Leprosy reactions
These reactions usually occur during the course of treatment in patients with multibacillary leprosy (BL and LL). They
are associated with the immunological response to M. leprae antigens. Urgent treatment is required to avoid
irreversible disability. Do not interrupt ongoing leprosy treatment. 
Clinical features
 
Treatment
 Age Multibacillary leprosy 
(more than 5 skin lesions)
Paucibacillary leprosy  
(1 to 5 skin lesions)
Children 10 to 14 years rifampicin PO: 450 mg once monthly
+ clofazimine PO: 150 mg once monthly
and 50 mg on alternate days
+ dapsone PO: 50 mg once daily
rifampicin PO: 450 mg once monthly
+ clofazimine PO: 150 mg once monthly
and 50 mg on alternate days
+ dapsone PO: 50 mg once daily
Children 15 years and
over and adults


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+ clofazimine PO: 150 mg once monthly
and 50 mg on alternate days
+ dapsone PO: 50 mg once daily
Children 15 years and
over and adults
rifampicin PO: 600 mg once monthly
+ clofazimine PO: 300 mg once monthly
and 50 mg once daily
+ dapsone PO: 100 mg once daily
rifampicin PO: 600 mg once monthly
+ clofazimine PO: 300 mg once monthly
and 50 mg once daily
+ dapsone PO: 100 mg once daily
Duration 12 months 6 months
Reversal reactions: 
Exacerbation of the skin lesions that become erythematous and oedematous and risk or ulceration. Onset or
worsening of numbness of skin lesions; 
Onset of acute painful hypertrophic neuritis.
Erythema nodosum leprosum:
Fever, asthenia, alteration of the general state;
Crops of purplish-red, tender subcutaneous nodules, warmer than the surrounding skin.


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Fever, asthenia, alteration of the general state;
Crops of purplish-red, tender subcutaneous nodules, warmer than the surrounding skin. 
Reversal reactions: 
prednisolone (or prednisone) PO: 0.5 to 1 mg/kg once daily for 2 weeks. Re-examine the patient every 2 weeks
and decrease the dosage if the neurological signs recede. According to clinical response, treatment may last 3 to 6
months.
For example, for an adult:
Week 1 and 2: 40 mg once daily 
 [2] 
 [3]


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References
Week 3 and 4: 30 mg once daily 
Week 5 and 6: 20 mg once daily 
Week 7 and 8: 15 mg once daily 
Week 9 and 10: 10 mg once daily 
Week 11 and 12: 5 mg once daily
Erythema nodosum leprosum:
prednisolone (or prednisone) PO as for reversal reactions, for 3 months.   [2] 
Fever: paracetamol PO (see Fever, Chapter 1)
1. World Health Organization. Global Leprosy Programme. Global leprosy strategy 2016-2020. Accelerating towards a leprosy-free world, 2016.http://apps.who.int/iris/bitstream/handle/10665/208824/9789290225096_en.pdf?sequence=14&isAllowed=y [Accessed 17October 2018]


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2. World Health Organization. WHO Expert Committee on Leprosy. Eighth report. WHO technical report series, n° 968. Geneva,2012.http://www.searo.who.int/entity/global_leprosy_programme/publications/8th_expert_comm_2012.pdf [Accessed 17 October2018]
3. World Health Organization. A guide to eliminating leprosy as a public health problem. Leprosy Elimination Group, 2000.http://apps.who.int/iris/bitstream/handle/10665/66612/WHO_CDS_CPE_CEE_2000.14.pdf?sequence=1 [Accessed 17October 2018]


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Herpes simplex
Recurrent viral infection of the skin and mucous membranes due to the Herpes simplex virus. Recurrent lesions have a
different presentation than primary infection.
Clinical features
Treatment
Recurrent herpes labialis: tingling feeling followed by an eruption of vesicles on an erythematous base, located on
the lips (‘fever blisters’) and around the mouth, they may extend onto the face. Recurrence corresponds to a
reactivation of the latent virus after a primary infection. No associated malaise, adenopathy or fever.
Carefully consider other sites: buccal (Stomatitis, Chapter 3), genital (Genital ulcers, Chapter 9), ophthalmic, and
secondary bacterial infections.
Clean with soap and water 2 times daily until the lesions have healed.


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secondary bacterial infections.
Clean with soap and water 2 times daily until the lesions have healed.
For patients with secondary bacterial infections: antibiotic treatment as for impetigo.


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Herpes zoster (shingles)
Acute viral infection due to the varicella-zoster virus. Chickenpox is the primary infection and herpes zoster the
reactivation of the latent virus.
Clinical features
Treatment
Unilateral neuralgic pain followed by an eruption of vesicles on a erythematous base, that follow the distribution of a
nerve pathway.
Lesions most commonly occur on the thorax, but herpes zoster may also develop on the face with a risk of
ophthalmic complications.
Herpes zoster is more common in adults than in children.
Similar to that of herpes simplex, with the addition of systematic analgesics: paracetamol PO (see Pain, Chapter 1).
Aciclovir PO given within the ﬁrst 48 hours after the eruption of lesions is only indicated for severe forms: necrotic


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Aciclovir PO given within the ﬁrst 48 hours after the eruption of lesions is only indicated for severe forms: necrotic
or extensive lesions or lesion on the face which may spread to the eyes (see HIV infection and AIDS, Chapter 8).


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Eczema
Acute eczema: erythematous plaque, pruritic, vesicular, oozing, with poorly demarcated and crumbly borders.
Chronic eczema: erythematous plaque, scaly, dry, poorly demarcated and pruritic.
Look for a cause (contact allergic dermatitis, fungal or bacterial infection with a distant focus, malnutrition) and ask
about family history.
Treatment
Clean with soap and water 2 times daily.
Then:
for acute eczema: calamine lotion, one application 2 times daily 
for chronic eczema: zinc oxide ointment, one application 2 times daily
Look for and treat any pre-existing condition (scabies, lice etc.).
For patients with secondary infections: treat as impetigo.
For patients with intense pruritus, antihistamines for a few days (see Urticaria).


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Seborrheic dermatitis
Seborrheic dermatitis is an inﬂammatory chronic dermatosis that can be localized on areas rich with sebaceous glands.
This dermatosis is more common in infected patients with HIV.
Clinical features
Treatment
Erythematous plaques covered by greasy yellow scales that can be localized on the scalp, the face (nose wings,
eyebrows, edge of the eyelids), sternum, spine, perineum, and skin folds.
Clean with soap and water 2 times daily; shampooing the scalp.
Hydrocortisone 1% cream: one application once daily or 2 times daily to the affected area only, in thin layer, for 7
days maximum
Do not apply if pre-existing bacterial infection; treat ﬁrst the infection (see Impetigo).


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Urticaria
Last updated: July 2022
 
Papules: transient, erythematous, oedematous, pruritic, resembling nettle stings.
Look for a cause: food or drug (particularly antibiotic) allergy, insect bites; the invasive stage of a bacterial or parasitic
infection (ascariasis, strongylodiasis, ancylostomiasis, schistosomiasis, loiasis), viral infection (hepatitis B or C);
generalised disease (cancer, lupus, dysthyroidism, vasculitis).
Treatment
If the pruritus is intense, antihistamines for a few days:
loratadine PO
Children over 2 years and under 30 kg: 5 mg (5 ml) once daily
Children over 30 kg and adults: 10 mg (1 tab) once daily
In the event of anaphylactic reaction, see Shock (Chapter 1).


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Pellagra
Pellagra is a dermatitis resulting from niacin and/or tryptophane deﬁciency (in persons whose staple food is sorghum;
patients with malabsorption, or during famine).
Clinical features
Classically, disease of the ‘three Ds’: dermatitis, diarrhoea and dementia.
Treatment
Children and adults: 100 mg 3 times daily, give with a diet rich in protein until the patient is fully cured.
 
References
Dark red plaques, well demarcated, symmetric, located on exposed areas of the body (forehead, neck, forearms,
legs). The skin becomes very scaly, pigmented, sometimes with haemorrhagic bullae.
Gastrointestinal (glossitis, stomatitis and diarrhoea) and neuropsychiatric symptoms are seen in more serious forms.
nicotinamide (vitamin PP) PO [1]


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Gastrointestinal (glossitis, stomatitis and diarrhoea) and neuropsychiatric symptoms are seen in more serious forms.
nicotinamide (vitamin PP) PO [1]
In the event of an epidemic of pellagra, for example in a refugee camp, it is vital that the food ration be modiﬁed
(add groundnuts or dry vegetables) in order to meet the daily requirements (approximately 15 mg daily for adults).
1. World Health Organization, United Nations High Commissions for Refugees. Pellagra and its prevention and control in majoremergencies. World Health Organization, 2000.http://www.who.int/nutrition/publications/en/pellagra_prevention_control.pdf [Accessed 23 May 2018]


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Chapter 5: Eye diseases
Xerophthalmia (vitamin A deﬁciency)
Conjunctivitis
Neonatal conjunctivitis
Viral epidemic keratoconjunctivitis
Trachoma
Periorbital and orbital cellulitis
Other pathologies
Onchocerciasis (river blindness)
Loiasis
Pterygium
Cataract


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Xerophthalmia (vitamin A deﬁciency)
The term xerophthalmia covers all the ocular manifestations of vitamin A deﬁciency. Xerophthalmia can progress to
irreversible blindness if left untreated. In endemic areas, vitamin A deﬁciency and xerophthalmia affect mainly children (particularly those suffering from
malnutrition or measles) and pregnant women. Disorders due to vitamin A deﬁciency can be prevented by the routine administration of retinol.
Clinical features
Treatment
Treat early symptoms to avoid the development of severe complications. Vision can be saved provided that
ulcerations affect less than a third of the cornea and the pupil is spared. Even if deﬁciency has already led to


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ulcerations affect less than a third of the cornea and the pupil is spared. Even if deﬁciency has already led to
keratomalacia and irreversible loss of sight, it is imperative to administer treatment, in order to save the other eye and
the life of the patient. retinol (vitamin A) PO:
The ﬁrst sign is hemeralopia (crepuscular blindness): the child cannot see in dim light, may bump into objects and/or
show decreased mobility.
Then, other signs appear gradually:
Conjunctival xerosis: bulbar conjunctiva appears dry, dull, thick, wrinkled and insensitive
Bitot’s spots: greyish foamy patches on the bulbar conjunctiva, usually in both eyes (speciﬁc sign, however not
always present)
Corneal xerosis: cornea appears dry and dull
Corneal ulcerations


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always present)
Corneal xerosis: cornea appears dry and dull
Corneal ulcerations
Keratomalacia (the last and most severe sign of xerophthalmia): softening of the cornea, followed by
perforation of the eyeball and blindness (extreme care must be taken during ophthalmic examination due to risk
of rupturing cornea)
Treatment is the same regardless of the clinical stage, except in pregnant women.
Age 200 000 IU capsule (a)
Children < 6 months (b) 50 000 IU (2 drops) once daily on D1, D2 and D8
Children 6 months to < 1 year 100 000 IU (4 drops) once daily on D1, D2 and D8
Children ≥ 1 year and adults 200 000 IU (one capsule) once daily on D1, D2 and D8
(a) Capsules must not be swallowed whole. Cut the end of the capsule and deliver the dose directly into the mouth.


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(a) Capsules must not be swallowed whole. Cut the end of the capsule and deliver the dose directly into the mouth.
(b) Vitamin A deﬁciency is rare in breastfed infants under 6 months.
In pregnant women, treatment varies according to the stage of illness:
Hemeralopia or Bitot's spots: 10 000 IU once daily or 25 000 IU once weekly for at least 4 weeks. Do not
exceed indicated doses (risk of foetal malformations).


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 Corneal lesions are a medical emergency. In addition to the immediate administration of retinol, treat or prevent
secondary bacterial infections with 1% tetracycline eye ointment, one application 2 times daily (do not apply eye
drops containing corticosteroids) and protect the eye with an eye-pad after each application.
Prevention
To avoid excessive dosage, record any doses administered on the health/immunisation card and do not exceed
indicated doses. Vitamin A overdose may cause raised intracranial pressure (bulging fontanelle in infants; headache,
nausea, vomiting) and, in severe cases, impaired consciousness and convulsions. These adverse effects are transient;
they require medical surveillance and symptomatic treatment if needed.


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they require medical surveillance and symptomatic treatment if needed.
 
If the cornea is affected, risk of blindness outweighs teratogenic risk. Administer 200 000 IU once daily on D1,
D2 and D8.
Systematically administer retinol PO to children suffering from measles (one dose on D1 and D2).
In areas where vitamin A deﬁciency is endemic , routine supplementation of retinol PO: a 
Age 200 000 IU capsule (c)
Children < 6 months 50 000 IU (2 drops) single dose
Children 6 months to < 1 year 100 000 IU (4 drops) every 4 to 6 months
Children 1 to < 5 years 200 000 IU (one capsule) every 4 to 6 months
Women after delivery 200 000 IU (one capsule) single dose
(c) Capsules must not be swallowed whole. Cut the end of the capsule and deliver the dose directly into the mouth.
Footnotes


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(c) Capsules must not be swallowed whole. Cut the end of the capsule and deliver the dose directly into the mouth.
Footnotes
(a) For more information country-speciﬁc prevalence of vitamin A deﬁciency, see:https://www.thelancet.com/action/showPdf?pii=S2214-109X%2815%2900039-X


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Conjunctivitis
 
 
Conjunctivitis is an acute inﬂammation of the conjunctiva due to a bacterial or viral infection, allergy, or irritation.
Conjunctivitis may be associated with measles or rhinopharyngitis in children.
In the absence of hygiene and effective treatment, secondary bacterial infections may develop, affecting the cornea
(keratitis).
Clinical features
Treatment
Bacterial conjunctivitis
Viral conjunctivitis
Allergic conjunctivitis
 
Note: in the event of a foreign body, check tetanus immunisation status.
Neonatal conjunctivitis
Viral epidemic keratoconjunctivitis
Clinical signs of all conjuctivites include: redness of the eye and irritation. Visual acuity is not affected.
Depending on the cause:


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Clinical signs of all conjuctivites include: redness of the eye and irritation. Visual acuity is not affected.
Depending on the cause:
abundant and purulent secretions, eyelids stuck together on waking, unilateral infection at onset: bacterial
conjunctivitis;
watery (serous) secretions, no itching: viral conjunctivitis;
excessive lacrimation, eyelid oedema, intense itching: allergic conjunctivitis.
In endemic areas, turn both upper eyelids up to check for signs of trachoma (see Trachoma).
Suspect keratitis if patient reports intense pain (more than is usually associated with conjunctivitis) and
photophobia. Instill one drop of 0.5% ﬂuorescein to check for possible ulcerations.
Always check for foreign bodies (subconjunctival or corneal) and remove after administering 0.4%


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Always check for foreign bodies (subconjunctival or corneal) and remove after administering 0.4%
oxybuprocaine anaesthetic eye drops. Never give bottle of eye drops to the patient.
Clean eyes 4 times daily with boiled water or 0.9% sodium chloride.
Apply into both eyes 1% tetracycline eye ointment: one application 2 times daily for 7 days
Never use corticosteroid drops or ointment.
Clean eyes 4 times daily with boiled water or 0.9% sodium chloride.
Apply local antibiotics if there is a (risk of) secondary bacterial infection (see above).
Local treatment as for viral conjunctivitis.
Antihistamines PO for one to 3 days (see Urticaria, Chapter 4).


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Neonatal conjunctivitis
Conjunctivitis due to Neisseria gonorrhoeae and/or Chlamydia trachomatis in neonates born to mothers with genital
gonococcal and/or chlamydial infections at the time of delivery.
Neonatal conjunctivitis is a medical emergency. Without prompt treatment, risk of corneal lesions and visual
impairment.
Clinical features
Treatment
 
  If symptoms persist 48 hours after parenteral treatment alone, administer azithromycin PO (or erythromycin PO
as above). Notes:
Prevention
Apply as soon as possible and preferably within one hour after birth:
1% tetracycline eye ointment: application of 1 cm in each eye.
 
References
Unilateral or bilateral purulent conjunctivitis in the ﬁrst 28 days of life.


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References
Unilateral or bilateral purulent conjunctivitis in the ﬁrst 28 days of life.
Clean eyes with isotonic sterile solution (0.9% sodium chloride or Ringer lactate) 4 times daily to remove secretions.
Antibiotic treatment:
for all neonates with conjunctivitis in the ﬁrst 28 days of life
for all neonates born to mothers with a genital infection (purulent cervical discharge) at the time of delivery 
  0 to 7 days 8 to 28 days
First line
 
ceftriaxone IM: 50 mg/kg single dose
(max. 125 mg)
 
ceftriaxone IM: 50 mg/kg single dose
(max. 125 mg)
+
azithromycin PO: 20 mg/kg once daily for
3 days
Alternatives If ceftriaxone contra-indicated:
cefotaxime IM: 100 mg/kg single dose
If azithromycin unavailable:
erythromycin PO: 12.5 mg/kg 4 times daily for
14 days


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cefotaxime IM: 100 mg/kg single dose
If azithromycin unavailable:
erythromycin PO: 12.5 mg/kg 4 times daily for
14 days
When systemic treatment is not immediately available, clean both eyes and apply 1% tetracycline eye
ointment every hour, until systemic treatment is available.
In all cases, treat the genital infection of the mother and partner (see Genital infections, Chapter 9).
Azithromycin and erythromycin are associated with an increased risk of pyloric stenosis in neonates. The risk is
higher with erythromycin . Adverse effects should be monitored. [1] [2] [3]


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1. Lund M et al. Use of macrolides in mother and child and risk of infantile hypertrophic pyloric stenosis: nationwide cohortstudy. BMJ. 2014; 348: g1908.https://www.bmj.com/content/348/bmj.g1908 [Accessed 16 April 2021]
2. Murchison L et al. Post-natal erythromycin exposure and risk of infantile hypertrophic pyloric stenosis: a systematic reviewand meta-analysis. Pediatr Surg Int. 2016 Dec; 32(12): 1147-1152. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5106491/ [Accessed 16 April 2021]


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3. Almaramhy HH et al. The association of prenatal and postnatal macrolide exposure with subsequent development ofinfantile hypertrophic pyloric stenosis: a systematic review and meta-analysis. Ital J Pediatr. 2019 Feb 4; 45(1)20. https://ijponline.biomedcentral.com/articles/10.1186/s13052-019-0613-2 [Accessed 16 April 2021]


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Viral epidemic keratoconjunctivitis
 
Corneal and conjunctival lesions
 
Treat as viral conjunctivitis. If possible, refer to an ophthalmologist.
Protect the eye with a compress as long as photophobia lasts. Remove as soon as possible.
If necessary, administer a preventive dose of vitamin A.


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Trachoma
Trachoma is a highly contagious keratoconjunctivitis due to Chlamydia trachomatis. The disease is endemic in the
poorest rural areas of Africa, Asia, Central and South America and the Middle East.
Infection is usually ﬁrst contracted early in childhood by direct or indirect contact (dirty hands, contaminated towels,
ﬂies). In the absence of hygiene and effective treatment, the inﬂammation intensiﬁes with successive infections,
causing scars and deformities on the upper tarsal conjunctiva. The resulting ingrowing eyelashes (trichiasis) cause
corneal lesions followed by permanent blindness, usually in adulthood.
The WHO classiﬁes trachoma into 5 stages. Early diagnosis and treatment of ﬁrst stages is essential to avoid the


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The WHO classiﬁes trachoma into 5 stages. Early diagnosis and treatment of ﬁrst stages is essential to avoid the
development of trichiasis and associated complications.
Clinical features
Several stages can occur simultaneously : 
 
 
 
 
Treatment
 
 
 [1] [2] 
Stage 1: trachomatous inﬂammation - follicular (TF)
Presence of ﬁve or more follicles in the upper tarsal conjunctiva. Follicles are whitish, grey or yellow elevations,
paler than the surrounding conjunctiva.
Stage 2: trachomatous inﬂammation - intense (TI)
The upper tarsal conjunctiva is red, rough and thickened. The blood vessels, normally visible, are masked by a
diffuse inﬂammatory inﬁltration or follicles.
Stage 3: trachomatous scarring (TS)


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diffuse inﬂammatory inﬁltration or follicles.
Stage 3: trachomatous scarring (TS)
Follicles disappear, leaving scars: scars are white lines, bands or patches in the tarsal conjunctiva.
Stage 4: trachomatous trichiasis (TT)
Due to multiple scars the margin of the eyelid, usually the upper lid, turns inwards (entropion); the eyelashes rub
against the cornea and cause ulcerations and chronic inﬂammation.
Stage 5: corneal opacity (CO)
Cornea gradually loses its transparency, leading to visual impairment and blindness.
Stages 1 and 2:
Clean eyes and face several times per day.
Antibiotic treatment :
The treatment of choice is azithromycin PO:
Children: 20 mg/kg single dose
Adults: 1 g single dose


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Antibiotic treatment :
The treatment of choice is azithromycin PO:
Children: 20 mg/kg single dose
Adults: 1 g single dose
Failing the above, 1% tetracycline eye ointment: one application 2 times daily for 6 weeks, or, as a last resort,
erythromycin PO: 20 mg/kg (max. 1 g) 2 times daily for 14 days.
 [3] 
Stage 3: no treatment
Stage 4: surgical treatment
While waiting for surgery, if regular patient follow-up is possible, taping eyelashes to the eyelid is a palliative
measure that can help protect the cornea. In certain cases, this may lead to permanent correction of the trichiasis
within a few months.
The method consists in sticking the ingrowing eyelashes to the external eyelid with a thin strip of sticking-plaster,


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within a few months.
The method consists in sticking the ingrowing eyelashes to the external eyelid with a thin strip of sticking-plaster,
making sure that the eyelid can open and close perfectly. Replace the plaster when it starts to peel off (usually once
a week); continue treatment for 3 months.


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Prevention
Cleaning of the eyes, face and hands with clean water reduces direct transmission and the development of secondary
bacterial infections.
 
References
Note: epilation of ingrowing eyelashes is not recommended since it offers only temporary relief and regrowing
eyelashes are more abrasive to the cornea.
Stage 5: no treatment
1. Solomon AW et al. The simpliﬁed trachoma grading system, amended. Bull World Health Organ. 2020;98(10):698-705. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7652564/ [Accessed 20 April 2021]
2. Thylefors B et al. A simple system for the assessment of trachoma and its complications. Bull World Health Organ.1987;65(4):477–83.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2491032/ [Accessed 20 April 2021]


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3. Evans JR et al. Antibiotics for trachoma. Cochrane Database Syst Rev. 2019 Sep 26;9:CD001860. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001860.pub4/full [Accessed 20 April 2021]


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Periorbital and orbital cellulitis
Periorbital cellulitis is a common, usually benign, bacterial infection of the eyelids. It arises principally following trauma
to the eyelids (insect bite or abrasion).
Orbital cellulitis is a serious infection involving the contents of the orbit (fat and ocular muscles) that may lead to loss of
vision or a brain abscess. It usually arises secondary to spread from sinusitis (e.g. as a complication of ethmoid
sinusitis).
Periorbital and orbital cellulitis are more common in children than in adults.
The most common organisms causing periorbital and orbital cellulitis are Staphylococcus aureus, Streptococcus
pneumoniae and other streptococci, as well as Haemophilus inﬂuenzae type b (Hib) in children living in countries where


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pneumoniae and other streptococci, as well as Haemophilus inﬂuenzae type b (Hib) in children living in countries where
rates of immunisation with Hib remain low.
Clinical features
Treatment
 
 
Signs common to both periorbital and orbital cellulitis: acute eyelid erythema and oedema; the oedema has a
violaceous hue if secondary to H. inﬂuenzae.
In case of orbital cellulitis only:
Pain with eye movements;
Ophthalmoplegia (paralysis of eye movements) often with diplopia (double vision);
Protrusion of the eye (eye bulges out of the socket);
High fever, systemic signs.
Hospitalize for the following: orbital cellulitis, children younger than 3 months, critically ill appearing patient , local


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Hospitalize for the following: orbital cellulitis, children younger than 3 months, critically ill appearing patient , local
complications, debilitated patient (chronic conditions, the elderly), if there is a risk of non-compliance with or failure
of outpatient treatment. Treat the other patients as outpatients.
 a 
Outpatient antibiotic therapy :
cefalexin PO for 7 to 10 days
Neonates 0 to 7 days: 25 mg/kg 2 times daily 
Neonates 8 days to 1 month: 25 mg/kg 3 times daily 
Children over 1 month: 25 mg/kg 2 times daily (max. 2 g daily)
Children ≥ 40 kg and adults: 1 g 2 times daily
or
amoxicillin/clavulanic acid (co-amoxiclav) PO for 7 to 10 days
Use formulations in a ratio of 8:1 or 7:1 exclusively. The dose is expressed in amoxicillin:
Children < 40 kg: 50 mg/kg 2 times daily


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Use formulations in a ratio of 8:1 or 7:1 exclusively. The dose is expressed in amoxicillin:
Children < 40 kg: 50 mg/kg 2 times daily
Children ≥ 40 kg and adults:
Ratio 8:1: 3000 mg daily (2 tab of 500/62.5 mg 3 times daily)
Ratio 7:1: 2625 mg daily (1 tab of 875/125 mg 3 times daily)
 b 
Inpatient antibiotic therapy :
ceftriaxone slow IV (3 minutes) or IV infusion (30 minutes; 60 minutes in neonates) for at least 5 days
Children: one dose of 100 mg/kg on the ﬁrst day, then 50 mg/kg 2 times daily
Adults: 1 to 2 g once daily
+
cloxacillin IV infusion (60 minutes)
Neonates 0 to 7 days (< 2 kg): 50 mg/kg every 12 hours
 c 
 d 
 e


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  If there is no improvement in the ﬁrst 48 hours (suspicion of methicillin resistant S. aureus), replace cloxacillin with:
clindamycin IV infusion (30 minutes)
Neonates 0 to 7 days (< 2 kg): 5 mg/kg every 12 hours
Neonates 0 to 7 days (≥ 2 kg): 5 mg/kg every 8 hours
Neonates 8 days to < 1 month (< 2 kg): 5 mg/kg every 8 hours
Neonates 8 days to < 1 month (≥ 2 kg): 10 mg/kg every 8 hours
Children 1 month and over: 10 mg/kg every 8 hours (max. 1800 mg daily)
Adults: 600 mg every 8 hours
After 5 days, change to clindamycin PO at the same doses to complete 7 to 10 days of treatment. 
 
Neonates 0 to 7 days (≥ 2 kg): 50 mg/kg every 8 hours
Neonates 8 days to < 1 month (< 2 kg): 50 mg/kg every 8 hours
Neonates 8 days to < 1 month (≥ 2 kg): 50 mg/kg every 6 hours


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Neonates 8 days to < 1 month (< 2 kg): 50 mg/kg every 8 hours
Neonates 8 days to < 1 month (≥ 2 kg): 50 mg/kg every 6 hours
Children 1 month and over: 25 to 50 mg/kg every 6 hours (max. 8 g daily)
Children ≥ 40 kg and adults: 2 g every 6 hours
If there is clinical improvement (patient afebrile and erythema and oedema have improved) after 5 days, change to
amoxicillin/clavulanic acid PO at the doses indicated above to complete 7 to 10 days of treatment.
 f 
If orbital cellulitis is unresponsive to IV antibiotics, consider an abscess. Transfer patient to a surgical centre for
drainage.
Footnotes
(a) Critically ill appearing child: weak grunting or crying, drowsy and difﬁcult to arrouse, does not smile, disconjugate or anxiousgaze, pallor or cyanosis, general hypotonia.


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(b) For penicillin-allergic patients, clindamycin PO for 7 to 10 days:Children: 10 mg/kg 3 times daily; adults: 600 mg 3 times daily
(c) For penicillin-allergic patients, clindamycin IV infusion (doses as above).
(d) For administration by IV route, ceftriaxone powder should to be reconstituted in water for injection only. For administrationby IV infusion, dilute each dose of ceftriaxone in 5 ml/kg of 0.9% sodium chloride or 5% glucose in children less than 20 kgand in a bag of 100 ml of 0.9% sodium chloride or 5% glucose in children over 20 kg and in adults.


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(e) Cloxacillin powder for injection should be reconstituted in 4 ml of water for injection. Then dilute each dose of cloxacillin in5 ml/kg of 0.9% sodium chloride or 5 % glucose in children less than 20 kg and in a bag of 100 ml of 0.9% sodium chloride or5% glucose in children over 20 kg and in adults.
(f) Dilute each dose of clindamycin in 5 ml/kg of 0.9% sodium chloride or 5% glucose in children less than 20 kg and in a bag of100 ml of 0.9% sodium chloride or 5% glucose in children over 20 kg and in adults.


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Onchocerciasis (river blindness)
Ocular lesions result from the invasion of the eye by microﬁlariae. They generally develop in adults and progress to
blindness in the absence of early treatment.
Clinical features and treatment
Ocular lesions are always associated with onchocercal skin lesions (see Onchocerciasis, Chapter 6).
 For treatment, see Onchocerciasis, Chapter 6. Ivermectin treatment may improve anterior segment lesions (sclerosing
keratitis, iridocyclitis) and visual acuity. Severe lesions (chorioretinal lesions, optic atrophy) continue to progress despite
treatment.
Pruritus, hemeralopia (crepuscular blindness), decrease in visual acuity, narrowing of the visual ﬁeld, awareness of


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treatment.
Pruritus, hemeralopia (crepuscular blindness), decrease in visual acuity, narrowing of the visual ﬁeld, awareness of
microﬁlariae in the visual ﬁeld (the patient sees “little wiggling worms before his eyes”).
Lesions of the cornea (punctuate, then sclerosing, keratitis), iris (iridocyclitis) or posterior segment
(chorioretinopathy and optic atrophy); microﬁlariae within the anterior chamber or vitreous humor (slit lamp).


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Loiasis
Clinical features and treatment
Migration of an adult worm under the palpebral or bulbar conjunctiva (white, ﬁliform worm, measuring 4 to 7 cm in
length, mobile) and ocular pruritus, lacrimation, photophobia or eyelid oedema. For treatment, see Loiais, Chapter 6. The migration of the worm is often of very brief duration. Do not attempt to
extract it, or administer anaesthetic drops; simply reassure the patient, the event is harmless. Surgical removal is
likewise futile if the worm is dead/calciﬁed.


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Pterygium
A whitish, triangular growth of ﬁbrovascular tissue extending slowly from the conjunctiva to the cornea. It occurs most
frequently in patients who are exposed to wind, dust, or arid climates and never disappears spontaneously.
Clinical features and treatment
Two stages:
Benign pterygium develops slowly, does not reach the pupil: no treatment.
Progressive vascularized pterygium: red and inﬂamed growth covers the pupil and may impair vision:
Clean eye with sterile water or 0.9% sodium chloride.
Surgical removal if facilities are available.


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Cataract
 
 
Opacity of the lens that causes a progressive loss of visual acuity. Cataract is common in the tropics and can occur at
a younger age than in Europe. The presence of cataract in both eyes leads to blindness. Surgery is the only treatment.


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Chapter 6: Parasitic diseases
Malaria
Human African trypanosomiasis (sleeping sickness)
American trypanosomiasis (Chagas disease)
Leishmaniases
Intestinal protozoan infections (parasitic diarrhoea)
Flukes
Schistosomiases
Cestodes
Nematode infections
Filariasis
Onchocerciasis (river blindness)
Loiasis
Lymphatic ﬁlariasis (LF)


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Malaria
Malaria is a parasitic infection due to protozoa of the genus Plasmodium, transmitted to humans by the bite of
Anopheles mosquitoes. Transmission by transfusion of parasite infected blood and transplacental transmission are
also possible.
5 species of Plasmodium cause malaria in humans: P. falciparum, P. vivax, P. ovale, P. malariae and P. knowlesi. All
species may cause uncomplicated malaria. Severe malaria (deﬁned by the presence of complications) is almost always
due to P. falciparum. and, less frequently, P. vivax and P. knowlesi.
Uncomplicated malaria can rapidly progress to severe malaria, and severe malaria may cause death within a few hours
if left untreated.
Clinical features


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if left untreated.
Clinical features
Malaria should always be considered in patients living in or coming from, an endemic area, who presents with fever (or
history of fever in the previous 48 hours). 
Uncomplicated malaria
Fever is frequently associated with chills, sweating, headache, muscular ache, malaise, anorexia or nausea. In children,
fever may be associated with abdominal pain, diarrhoea and vomiting. Mild to moderate anaemia is frequent in children
and pregnant women.
Severe malaria
In addition to the above, patients presenting with one or more of the following complications  should be hospitalised
immediately:
Laboratory
Parasitological diagnosis
Diagnosis of malaria should be conﬁrmed, whenever possible. If testing is not available, treatment of suspected malaria


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Parasitological diagnosis
Diagnosis of malaria should be conﬁrmed, whenever possible. If testing is not available, treatment of suspected malaria
should not be delayed.  Rapid diagnostic tests (RDTs)
Rapid tests detect parasite antigens. They give only a qualitative result (positive or negative) and may remain positive
several days or weeks following elimination of parasites. 
 [1] 
Impaired consciousness, including coma.
Seizures: more than 2 episodes of generalised or focal (e.g. abnormal eye movements) seizures within 24 hours.
Prostration: extreme weakness; in children: inability to sit or drink/suck.
Respiratory distress: rapid, laboured breathing or slow, deep breathing.
Shock: cold extremities, weak or absent pulse, capillary reﬁll time ≥ 3 seconds, cyanosis.


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Shock: cold extremities, weak or absent pulse, capillary reﬁll time ≥ 3 seconds, cyanosis.
Jaundice: yellow discolouration of mucosal surfaces of the mouth, conjunctivae and palms.
Haemoglobinuria: dark red urine.
Abnormal bleeding: skin (petechiae), conjunctivae, nose, gums; blood in stools.
Acute renal failure: oliguria (urine output < 12 ml/kg/day in children and < 400 ml/day in adults) despite adequate
hydration.
 [2]
 a


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Microscopy
Thin and thick blood ﬁlms enable parasite detection, species identiﬁcation, quantiﬁcation and monitoring of
parasitaemia.
Blood ﬁlms may be negative due to sequestration of the parasitized erythrocytes in peripheral capillaries in severe
malaria, as well as in placental vessels in pregnant women. Note: even with positive diagnostic results, rule out other causes of fever.
Additional examinations
Haemoglobin (Hb) level
To be measured routinely in all patients with clinical anaemia, and in all patients with severe malaria. Blood glucose level
To be measured routinely to detect hypoglycaemia in patients with severe malaria and those with malnutrition (see
Hypoglycaemia, Chapter 1).
Treatment of malaria due to P. vivax, P. ovale, P. malariae, P. knowlesi


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Hypoglycaemia, Chapter 1).
Treatment of malaria due to P. vivax, P. ovale, P. malariae, P. knowlesi
chloroquine (CQ) PO
Children and adults:
Day 1: 10 mg base/kg
Day 2: 10 mg base/kg 
Day 3: 5 mg base/kg In general P. vivax remains sensitive to CQ but resistance is found in several countries. Where such resistance is high
(>10%), or in countries which have de-registered CQ due to P. falciparum resistance, an artemisinin-based combination
therapy (ACT)  should be used instead . For dosing information, see Treatment of uncomplicated falciparum malaria. Relapses can occur with P. vivax and P. ovale due to activation of dormant parasites in the liver. Primaquine PO for 14
days (0.25 to 0.5 mg/kg once daily in children ≥ 15 kg; 15 mg once daily in adults) can be given to eliminate these


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days (0.25 to 0.5 mg/kg once daily in children ≥ 15 kg; 15 mg once daily in adults) can be given to eliminate these
parasites, after the initial treatment with CQ or an ACT. However, this treatment is only recommended for patients living
in areas where reinfection is unlikely, i.e. non-endemic, low transmission areas or in countries aiming for elimination of
malaria. This treatment is contra-indicated in individuals with G6PD deﬁciency. If G6PD deﬁciency cannot be tested
individually, the decision to prescribe primaquine must take into account the prevalence of deﬁciency in the population.
Treatment of uncomplicated falciparum malaria
Antimalarial treatment


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Treatment of uncomplicated falciparum malaria
Antimalarial treatment
During pregnancy, see Antimalarial treatment in pregnant women. Treatment is an artemisinin-based combination therapy (ACT) given by the oral route for 3 days . The ﬁrst-line ACT
is chosen according to therapeutic efﬁcacy in the area where the patient is living. If the ﬁrst line ACT is unavailable,
contra-indicated or has failed despite being correctly administered, use another ACT. For dosing information, see table
below. 
 b 
 c  [1] 
 c    [1]


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Treatment of uncomplicated falciparum malaria
In low malaria endemic areas, in addition to ACT, all individuals (except in children < 30 kg,  pregnant women or
breastfeeding women of infants aged < 6 months) diagnosed with P. falciparum malaria, should be given a single dose
of 0.25 mg/kg primaquine to reduce the risk of transmission . Notes:
 Quinine PO is not recommended as standard treatment, however still remains in some national protocols:
quinine PO for 7 days
Children and adults under 50 kg: 10 mg/kg 3 times daily
Adults 50 kg and over: 600 mg 3 times daily
Symptomatic treatment
Paracetamol PO in the event of high fever only (Fever, Chapter 1).
Treatment of severe malaria
The patient must be hospitalised.
Antimalarial treatment
 b 
 [3]


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Treatment of severe malaria
The patient must be hospitalised.
Antimalarial treatment
 b 
 [3] 
In infants below the age/weight mentioned in the table above, there is little data on efﬁcacy and safety of ACTs.
The combinations AL, AS/AQ and DHA/PPQ can be used. The dose should be calculated so as to correspond to
10-16 mg/kg/dose of lumefantrine; 10 mg/kg daily of amodiaquine; 20 mg/kg daily of piperaquine.
Clinical condition of young children can deteriorate rapidly; it may be preferable to start parenteral treatment
straight away (see below).
 b


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During pregnancy, see Antimalarial treatment in pregnant women.
Pre-referral treatment
If the patient needs to be transferred, administer before transfer:
or
 In either case, provide patients, especially children, with some sugar prior to or during transfer.
Inpatient treatment
The drug of choice is artesunate, preferably IV, or if not possible IM.
For patients in shock: IM route is not appropriate, use artesunate IV only.  artesunate slow IV injection (3 to 5 minutes) or, if not possible, slow IM injection, into the anterior thigh:
Children under 20 kg: 3 mg/kg/dose
Children 20 kg and over and adults: 2.4 mg/kg/dose
Treat parenterally for at least 24 hours (3 doses), then, if the patient can tolerate the oral route, change to a complete


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Treat parenterally for at least 24 hours (3 doses), then, if the patient can tolerate the oral route, change to a complete
3-day course of an ACT. If not, continue parenteral treatment once daily until the patient can change to oral route
(without exceeding 7 days of parenteral treatment). If artesunate is not unavailable, artemether may be an alternative: 
artemether IM into the anterior thigh (never administer by IV route)
Children and adults: 3.2 mg/kg on admission (D1) then 1.6 mg/kg once daily
Treat parenterally for at least 24 hours (2 doses), then, if the patient can tolerate the oral route, change to a complete
3-day course of an ACT. If not, continue parenteral treatment once daily until the patient can change to oral route


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3-day course of an ACT. If not, continue parenteral treatment once daily until the patient can change to oral route
(without exceeding 7 days of parenteral treatment). Note: if patient is still on parenteral treatment on Day 5, continue on the same treatment until Day 7. In this case it is
not necessary to start an ACT.
 
Quinine IV is still recommended in some national protocols. It may be used in treatment of malaria with shock if
artesunate IV is not available. The dose is expressed in quinine salt:
For adults, administer each dose of quinine in 250 ml of glucose. For children under 20 kg, administer each dose of
quinine in a volume of 10 ml/kg of glucose.
Do not administer a loading dose to patients who have received oral quinine, or meﬂoquine within the previous 24


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Do not administer a loading dose to patients who have received oral quinine, or meﬂoquine within the previous 24
hours: start with maintenance dose.
Treat parenterally for at least 24 hours, then, if the patient can tolerate the oral route, change to a complete 3-day
course of an ACT (or if not available, oral quinine to complete 7 days of quinine treatment). If not, continue parenteral
treatment until the patient can change to oral route (without exceeding 7 days of parenteral treatment).
At community level, for children under 6 years: one dose of rectal artesunate  (10 mg/kg) d 
Children 2 months to < 3 years (≤ 10 kg): 1 rectal capsule (100 mg)
Children 3 to < 6 years (≤ 20 kg): 2 rectal capsules (200 mg)


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Children 2 months to < 3 years (≤ 10 kg): 1 rectal capsule (100 mg)
Children 3 to < 6 years (≤ 20 kg): 2 rectal capsules (200 mg)
At dispensary level, for children and adults: the ﬁrst dose of artesunate or, if unavailable, the ﬁrst dose of
artemether. For dosing information, see below.
One dose on admission (H0)
One dose 12 hours after admission (H12)
One dose 24 hours after admission (H24)
Then one dose once daily
Loading dose: 20 mg/kg to be administered over 4 hours, then, keep the vein open with an infusion of 5% glucose
over 4 hours; then
Maintenance dose: 8 hours after the start of the loading dose, 10 mg/kg every 8 hours (alternate quinine over 4
hours and 5% glucose over 4 hours).


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Symptomatic treatment and management of complications
Hydration
Maintain adequate hydration. As a guide, for volume to be administered per 24 hours by oral or IV route, see Appendix
1.
Adjust the volume according to clinical condition in order to avoid dehydration or ﬂuid overload (risk of pulmonary
oedema).
Fever
Paracetamol in the event of high fever only (Fever, Chapter 1).
Severe anaemia
For treatment, see Anaemia, Chapter 1.
Hypoglycaemia
For treatment, see Hypoglycaemia, Chapter 1. Notes: 
Coma
Check/ensure the airway is clear, measure blood glucose level and assess level of consciousness.
In the event of hypoglycaemia or if blood glucose level cannot be measured, administer glucose.


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In the event of hypoglycaemia or if blood glucose level cannot be measured, administer glucose.
If the patient does not respond to administration of glucose, or if hypoglycaemia is not detected:
Seizures
See Seizures, Chapter 1. Address possible causes (e.g. hypoglycaemia; fever in children).
Respiratory distress
 
Oliguria and acute renal failure
In an unconscious or prostrated patient, in case of emergency or when venous access is unavailable or awaited, use
granulated sugar by the sublingual route to correct hypoglycaemia . e 
The risk of hypoglycaemia is higher in patients receiving IV quinine. 
Insert a urinary catheter; place the patient in the recovery position.
Monitor vital signs, blood glucose level, level of consciousness, ﬂuid balance (urine output and ﬂuid input) hourly until


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Monitor vital signs, blood glucose level, level of consciousness, ﬂuid balance (urine output and ﬂuid input) hourly until
stable, then every 4 hours.
Rule out meningitis (lumbar puncture) or proceed directly to administration of an antibiotic (see Meningitis, Chapter
7).
Reposition the patient every 2 hours; ensure eyes and mouth are kept clean and moist, etc.
Rapid laboured breathing:
Check for pulmonary oedema (crepitations on auscultation), which may occur with or without ﬂuid overload: reduce
IV infusion rate if the patient is receiving IV therapy, nurse semi-sitting, oxygen, furosemide IV: 1 mg/kg in children,
40 mg in adults. Repeat after 1 to 2 hours if necessary.
Associated pneumonia should also be considered (see Acute pneumonia, Chapter 2).


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40 mg in adults. Repeat after 1 to 2 hours if necessary.
Associated pneumonia should also be considered (see Acute pneumonia, Chapter 2).
Slow, deep breathing (suspected metabolic acidosis):
Look for dehydration (and correct if present), decompensated anaemia (and transfuse if present).


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Look ﬁrst for dehydration (Dehydration, Chapter 1), especially due to inadequate ﬂuid intake or excessive ﬂuid losses
(high fever, vomiting, diarrhoea). Treat dehydration if present. Be aware of the risk of ﬂuid overload and acute
pulmonary oedema. Monitor for the return of urine output. Acute renal failure (ARF) is found almost exclusively in adults and is more common in Asia than Africa. Insert a urinary
catheter, measure output. Restrict ﬂuids to 1 litre/day (30 ml/kg/day in children), plus additional volume equal to urine
output. Renal dialysis is often necessary.
Antimalarial treatment in pregnant women
Uncomplicated P. vivax, P. ovale, P. malariae, P. knowlesi malaria
As other patients.
Primaquine should not be given in pregnancy.
Uncomplicated falciparum malaria


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As other patients.
Primaquine should not be given in pregnancy.
Uncomplicated falciparum malaria
All ACT included in the table Treatment of uncomplicated falciparum malaria can be used in all trimesters.
If ACTs are not available, quinine PO (for dosing, see Treatment of uncomplicated falciparum malaria)
combined with clindamycin PO if possible (10 mg/kg 2 times daily for 7 days) may be an alternative to ACT.
Primaquine should not be given in pregnancy.
Severe malaria
Artesunate, or if unavailable artemether, is recommended in all trimesters.
Quinine IV is not recommended as standard treatment, however it still remains in some national protocols.
Prevention
 
For pregnant women in areas with high risk of infection with P. falciparum, refer to the guide Essential obstetric and


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Prevention
 
For pregnant women in areas with high risk of infection with P. falciparum, refer to the guide Essential obstetric and
newborn care, MSF.
In areas with seasonal malaria transmission (in particular across the Sahel sub-region), seasonal malaria
chemoprevention in children < 5 years reduces mortality: administer amodiaquine + SP at monthly intervals for 4
months during the transmission period . [4] 
In malaria endemic areas and in epidemic-prone contexts, all in-patient facilities (including HIV treatment centres
and feeding centres), should be furnished with long-lasting insecticidal nets (LLINs). For more information, refer to
the guide Public health engineering, MSF.
See specialised literature for information regarding anti-vector measures and prevention in travellers.


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the guide Public health engineering, MSF.
See specialised literature for information regarding anti-vector measures and prevention in travellers.
Footnotes


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See specialised literature for information regarding anti-vector measures and prevention in travellers.
Footnotes
(a) Most rapid tests detect the following antigens alone or in combination: HRP2 protein speciﬁc to P. falciparum; an enzyme(Pf pLDH) speciﬁc to P. falciparum; an enzyme (pan pLDH) common to all 4 plasmodium species. HRP2 may continue to bedetectable for 6 weeks or more after parasite clearance; pLDH remains detectable for several days (up to 2 weeks) afterparasite clearance.Use pan pLDH tests as ﬁrst choice in hyper and holo-endemic areas, as well as in areas of intense seasonal transmission andduring outbreaks or complex emergencies. In other contexts, HRP2 tests (P. falciparum > 95%) or HRP2 + pLDH combinationtests (P. falciparum < 95%) are preferred.


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(b) If the patient vomits within 30 minutes after administration: re-administer the full dose. If the patient vomits between 30minutes and 1 hour after administration, re-administer half of the dose. If severe vomiting precludes oral therapy, manage assevere malaria, see Treatment of severe malaria.


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References
(c) ACT: a combination of artemisinin or one of its derivatives (e.g. artesunate, artemether) with another antimalarial of adifferent class.
(d) If it is impossible to refer a patient to a center capable of providing parenteral treatment, rectal artesunate should be givenaccording to the same schedule as artesunate slow IV injection (H0, H12, H24, then once daily).
(e) Place a level teaspoon of sugar, moistened with a few drops of water, under the tongue, then place the patient in therecovery position. Repeat after 15 minutes if the patient has not regained consciousness. As with other methods fortreating hypoglycaemia, maintain regular sugar intake, and monitor.


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1. World Health Organization. Guidelines for the treatment of malaria, 3rd ed. World Health Organization. 2015.https://apps.who.int/iris/handle/10665/162441
2. World Health Organization. Compendium of WHO malaria guidance: prevention, diagnosis, treatment, surveillance andelimination. 2019.https://apps.who.int/iris/handle/10665/312082
3. World Health Organization. WHO policy brief on single-dose primaquine as gametocytocide in Plasmodium falciparummalaria. 2015.https://www.who.int/malaria/publications/atoz/who_htm_gmp_2015.1.pdf?ua=1


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4. World Health Organization. WHO Policy Recommendation: Seasonal Malaria Chemoprevention (SMC) for Plasmodiumfalciparum malaria control in highly seasonal transmission areas of the Sahel sub-region in Africa. 2012.https://www.who.int/malaria/publications/atoz/smc_policy_recommendation_en_032012.pdf?ua=1


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Human African trypanosomiasis (sleepingsickness)
Human African trypanosomiasis (HAT) is a zoonosis caused by protozoa (trypanosomes), transmitted to humans
through the bite of a tsetse ﬂy (Glossina). Transmission by contaminated blood transfusion and transplacental
transmission are also possible.
The disease is found only in sub-Saharan Africa. There are two forms: Trypanosoma brucei gambiense HAT in western
and central Africa and Trypanosoma brucei rhodesiense HAT in eastern and southern Africa.
Clinical features
Inoculation may be followed by an immediate local reaction (trypanosomal chancre). This chancre arises in about 50%
of all rhodesiense but rarely in gambiense.
Gambiense HAT
Rhodesiense HAT


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of all rhodesiense but rarely in gambiense.
Gambiense HAT
Rhodesiense HAT
The ﬁrst stage is the same as above, but the incubation period is shorter (< 3 weeks), the disease evolves more rapidly
and symptoms are more severe. Patients often die of myocarditis in 3 to 6 months without having developed signs of
the meningo-encephalitic stage.
In practice, gambiense and rhodesiense HAT can be difﬁcult to differentiate: e.g., there exist cases of acute
gambiense infection and others of chronic rhodesiense infection.
Laboratory
Incubation lasts from a few days to several years.
The ﬁrst stage (haemolymphatic stage) corresponds to the haematogenous and lymphatic dissemination of the
parasite. Signs include intermittent fever, joint pain, lymphadenopathy (ﬁrm, mobile, painless lymph nodes, mainly


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parasite. Signs include intermittent fever, joint pain, lymphadenopathy (ﬁrm, mobile, painless lymph nodes, mainly
cervical), hepatosplenomegaly and skin signs (facial oedema, pruritus).
The second stage (meningoencephalitic stage) corresponds to the invasion of the central nervous system. Signs of
the haemolymphatic stage recede or disappear and varying neurological signs progressively develop: sensory
disturbances (deep hyperaesthesia), psychiatric disorders (apathy or agitation), disturbance of the sleep cycle (with
daytime somnolence alternating with insomnia at night), impaired motor functions (paralysis, seizures, tics) and
neuroendocrine disorders (amenorrhoea, impotence).
In the absence of treatment: cachexia, lethargy, coma and death.


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neuroendocrine disorders (amenorrhoea, impotence).
In the absence of treatment: cachexia, lethargy, coma and death.
Diagnosis involves 3 steps for gambiense HAT (screening test, diagnostic conﬁrmation and stage determination)
and 2 steps for rhodesiense HAT (diagnostic conﬁrmation and stage determination).
The recommended screening test for T.b. gambiense infection is the CATT (Card Agglutination Test for
Trypanosomiasis). It detects the presence of speciﬁc antibodies in the patient’s blood or serum.
Diagnostic conﬁrmation: presence of trypanosomes in lymph node aspirates or in blood using concentration
techniques: capillary tube centrifugation technique (Woo test), quantitative buffy coat (QBC), mini-anion exchange
centrifugation technique (mAEC).


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techniques: capillary tube centrifugation technique (Woo test), quantitative buffy coat (QBC), mini-anion exchange
centrifugation technique (mAEC).
Stage determination: detection of trypanosomes (after centrifugation) and white cell count in the cerebrospinal ﬂuid
(lumbar puncture):
Haemolymphatic stage: no trypanosomes AND ≤ 5 white cells/mm3


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Treatment (except in pregnant women)
Haemolymphatic stage (Stage I)
Gambiense HAT
pentamidine isetionate deep IM
Children and adults: 4 mg/kg once daily for 7 to 10 days
Patients should receive a source of glucose (meal, sweet tea) one hour before injection (risk of hypoglycaemia); they
should remain supine during administration and one hour after injection (risk of hypotension).
Rhodesiense HAT
suramin slow IV
Children and adults:
D1: test dose of 4 to 5 mg/kg
D3, D10, D17, D24, D31: 20 mg/kg (max. 1 g per injection)
Suramin may cause anaphylactic reactions, a test dose is recommended prior to starting treatment. In the event of an
anaphylactic reaction after the test dose, the patients must not be given suramin again.
Meningoencephalitic stage (Stage II)


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anaphylactic reaction after the test dose, the patients must not be given suramin again.
Meningoencephalitic stage (Stage II)
Before administrating trypanocides, the priority is to improve the patient’s general condition (rehydration, treatment of
malaria, intestinal worms, malnutrition, bacterial infections). It is nonetheless recommended not to postpone the
trypanocidal treatment for more than 10 days.
Gambiense HAT
 
Meningoencephalitic stage: evidence of trypanosomes OR > 5 white cells/mm3
Due to the toxicity of trypanocides, detection of the parasite is essential before initiating treatment. In the absence
of parasitological conﬁrmation, treatment may nevertheless be justiﬁed in certain cases: very strong clinical


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of parasitological conﬁrmation, treatment may nevertheless be justiﬁed in certain cases: very strong clinical
suspicion, patients in life-threatening condition, strong serological suspicion (CATT 1:16 positive) in a population
where the disease is highly prevalent (> 2%).
Several treatment regimens exist. Check national recommendations and local resistance levels.
Treatment must be administered under close medical supervision. Patients receiving pentamidine can be treated as
outpatients but those receiving suramin, eﬂornithine (with or without nifurtimox) or melarsoprol should be
hospitalised.
After treatment, patients should be checked every 6 months (clinical examination, lumbar puncture and examination
for trypanosomes) over 24 months, to look for relapse.


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for trypanosomes) over 24 months, to look for relapse.
First choice: nifurtimox-eﬂornithine combination therapy (NECT)
nifurtimox PO
Children and adults: 5 mg/kg 3 times daily for 10 days
+ eﬂornithine IV infusion over 2 hours
Children and adults: 200 mg/kg every 12 hours for 7 days
The catheter must be handled with great attention to avoid local or general bacterial infections: thoroughly disinfect
the insertion site, ensure secure catheter ﬁxation, protect the insertion site with a sterile dressing, systematically
change the catheter every 48 hours or earlier in case of signs of phlebitis.
Second choice:
eﬂornithine IV infusion over 2 hours


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Rhodesiense HAT
melarsoprol slow IV
Children and adults: 2.2 mg/kg once daily for 10 days
Prednisolone PO (1 mg/kg once daily) is frequently combined throughout the duration of treatment.
Treatment in pregnant women
All trypanocides are potentially toxic for the mother and the foetus (risk of miscarriage, malformation, etc.). However,
due to the life-threatening risk for the mother and the risk of mother-to-child transmission, treatment must be initiated
as follows: 
 
Prevention and control
Children under 12 years: 150 mg/kg every 6 hours for 14 days
Children 12 years and over and adults: 100 mg/kg every 6 hours for 14 days
In the event of a relapse after NECT or eﬂornithine:
melarsoprol slow IV
Children and adults: 2.2 mg/kg once daily for 10 days


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In the event of a relapse after NECT or eﬂornithine:
melarsoprol slow IV
Children and adults: 2.2 mg/kg once daily for 10 days
Melarsoprol is highly toxic: reactive encephalopathy (coma, or recurrent or prolonged seizures) in 5 to 10% of
treated patients, fatal in around 50% of cases; peripheral neuropathy, invasive diarrhoea, severe skin rash, phlebitis,
etc.
Prednisolone PO (1 mg/kg once daily) is frequently combined throughout the duration of treatment.
Haemolymphatic stage:
pentamidine for gambiense HAT as of the second trimester and suramin for rhodesiense HAT.
Meningoencephalitic stage: treatment depends on the mother's condition:
If in immediately life-threatening condition: treatment with NECT or eﬂornithine cannot be deferred until after
delivery.


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If in immediately life-threatening condition: treatment with NECT or eﬂornithine cannot be deferred until after
delivery.
If not immediately life-threatening condition: pentamidine for gambiense HAT and suramin for rhodesiense HAT.
Treatment with NECT or eﬂornithine is to be administered after delivery.
Individual protection against tsetse ﬂy bites: long sleeves and trousers, repellents, keeping away from risk areas
(e.g. near rivers).
Disease control: mass screening and treatment of patients (T.b. gambiense), trypanocide treatment of cattle (T.b.
rhodesiense), vector control using tsetse ﬂy traps or insecticides.


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American trypanosomiasis (Chagas disease)
Chagas disease is a zoonosis caused by the protozoa Trypanosoma cruzi. It is transmitted to humans by contact of
triatomine bug faeces with a break in the skin (often caused by a bite from the triatomine bug), or with mucous
membranes. Transmission by contaminated blood transfusion, accidental exposure to blood, mother-to-child (during
pregnancy or childbirth) or consumption of contaminated food and water is also possible. 
Chagas disease has two phases: an acute phase, which lasts approximately 4 to 6 weeks, and a chronic phase, which
is lifelong if left untreated.
The disease is primarily found on the American continent . It is signiﬁcantly underdiagnosed.
Clinical features
Acute phase
Chronic phase
Diagnosis
Laboratory


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Clinical features
Acute phase
Chronic phase
Diagnosis
Laboratory
Other investigations
Treatment
 a  [1]
Most cases are asymptomatic.
If transmitted through a break in the skin: a red swelling on the skin (chagoma) or unilateral painless purplish
periorbital oedema (Romaña's sign) with local lymphadenopathy, headache and fever.
Rarely: multiple lymphadenopathies, hepatosplenomegaly, myocarditis (chest pain, dyspnoea), meningoencephalitis
(seizures, paralysis).
Many cases remain asymptomatic (indeterminate phase).
Up to 30% of cases develop organ damage: [2]
cardiac lesions (conduction disorders, dilated cardiomyopathy): arrhythmia, dyspnoea, chest pain, heart failure;
gastrointestinal lesions (dilation of the oesophagus or colon i.e. megaoesophagus, megacolon): difﬁculty


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gastrointestinal lesions (dilation of the oesophagus or colon i.e. megaoesophagus, megacolon): difﬁculty
swallowing, severe constipation.
Individuals with immunosuppression have a higher risk of developing organ damage than the general population.
 [1]
Acute phase:
Identiﬁcation of Trypanosoma cruzi by direct microscopy of fresh blood or blood concentrated by
microhematocrit method.
In case of strong clinical suspicion despite no deﬁnitive diagnosis from direct microscopy, perform serologic
tests after a delay of approximately 1 month (see "Chronic phase").
Chronic phase:
Identiﬁcation of anti-Trypanosoma cruzi antibodies by serologic tests, e.g. enzyme-linked immunosorbent assay


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Chronic phase:
Identiﬁcation of anti-Trypanosoma cruzi antibodies by serologic tests, e.g. enzyme-linked immunosorbent assay
(ELISA), hemagglutination inhibition assay (HAI), indirect immunoﬂuorescence (IIF) or rapid diagnostic test (RDT).
For a deﬁnitive diagnosis, two different serological tests should be performed simultaneously; in case of
conﬂicting results, a third test is recommended. b
ECG may demonstrate conduction disorders.
Chest or abdominal x-ray may demonstrate cardiomegaly, megaoesophagus or megacolon.


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Aetiologic treatment
For information:
Symptomatic treatment
See Seizures (Chapter 1), Pain (Chapter 1) and Heart failure (Chapter 12).
Prevention
 
References
Acute or chronic Chagas disease can be treated with either benznidazole or nifurtimox. However, treatment is not
recommended if patient has already developed cardiac or digestive complications.
Close clinical monitoring should be provided due to the frequent occurrence of adverse effects. Where available,
blood tests (complete blood count, liver and renal function tests) should be performed before, during and after
treatment.
Protocols vary according to the country, follow national recommendations.
  Age Dose and duration
benznidazole
PO( (a)
2 to 12 years [3] 5 to 8 mg/kg daily in 2 divided doses for 60 days


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Age Dose and duration
benznidazole
PO( (a)
2 to 12 years [3] 5 to 8 mg/kg daily in 2 divided doses for 60 days
> 12 years and adults [4] 5 to 7 mg/kg daily in 2 divided doses for 60 days
nifurtimox
PO (b) [3]
≤ 10 years 15 to 20 mg/kg daily in 3 to 4 divided doses for 90 days
11 to 16 years 12.5 to 15 mg/kg daily in 3 to 4 divided doses for 90 days
≥ 17 years and adults 8 to 10 mg/kg daily in 3 to 4 divided doses for 90 days
(a) Benznidazole is contra-indicated in pregnancy, breastfeeding and in patient with severe hepatic/renal impairment.


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(a) Benznidazole is contra-indicated in pregnancy, breastfeeding and in patient with severe hepatic/renal impairment.
(b) Nifurtimox is contra-indicated in pregnancy, breastfeeding, patients with severe hepatic/renal impairment or history ofsevere mental disorders or seizures. Adverse effects (gastrointestinal disturbances, agitation, sleeping disorders, seizure)are frequent and reversible and should not necessarily result in discontinuation of treatment. Avoid alcohol and fatty mealsduring treatment.
Individual protection against bite from triatomine bugs: use of long-lasting insecticidal net.
In healthcare settings: standard precautions to avoid contamination with soiled materials or potentially infected
body ﬂuids.


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In healthcare settings: standard precautions to avoid contamination with soiled materials or potentially infected
body ﬂuids.
Blood transfusions: advise patients with Chagas disease not to donate blood. In endemic areas, screen donor
blood for Trypanosoma cruzi antibodies. 
Footnotes
(a) For more information on geographical distribution of cases of T. cruzi infection:http://gamapserver.who.int/mapLibrary/Files/Maps/Global_chagas_2009.png
(b) If resources are limited, ELISA alone can be performed. If the result is positive, a second serologic test should then beperformed to conﬁrm the diagnosis before starting treatment.


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1. Pan American Health Organization. Guidelines for diagnosis and treatment of Chagas disease. Washington, D.C. 2019.http://iris.paho.org/xmlui/bitstream/handle/123456789/49653/9789275120439_eng.pdf?sequence=6&isAllowed=y
2. Rassi A, Marin-Neto J. Seminar: Chagas disease. The Lancet, Volume 375, ISSUE 9723, P1388-1402, April 17, 2010.
3. Centers for Disease Control and Prevention. Parasites - American Trypanosomiasis.https://www.cdc.gov/parasites/chagas/ [Accessed 17 February 2020]
4. World Health Organization. WHO Model Prescribing Information: Drugs Used in Parasitic Diseases - Second Edition. Geneva.1995. https://apps.who.int/iris/handle/10665/41765 [Accessed 6 May 2020]


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Leishmaniases
The leishmaniases are a group of parasitic diseases caused by protozoa of the genus Leishmania, transmitted by the
bite of a sandﬂy. Over 20 species cause disease in man.
Clinical features
Cutaneous and mucocutaneous leishmaniasis
Visceral leishmaniasis
Visceral leishmaniasis (kala azar) is a systemic disease, resulting in pancytopenia, immunosuppression, and death if left
untreated.
Post-kala azar dermal leishmaniasis
Macular, nodular or papular skin rash of unknown aetiology, particularly on the face, and typically occurring after
apparent cure of visceral leishmaniasis.
Laboratory
Cutaneous and mucocutaneous leishmaniasis
Visceral leishmaniasis
Cutaneous leishmaniasis is endemic in more than 70 countries in South and Central America, Middle East, Central


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Visceral leishmaniasis
Cutaneous leishmaniasis is endemic in more than 70 countries in South and Central America, Middle East, Central
Asia, and Africa.
Mucocutaneous leishmaniasis occurs in Latin America and, more rarely, in Africa (Ethiopia, Sudan).
Visceral leishmaniasis occurs in more than 60 countries in East and North Africa, South and Central Asia, Southern
Europe, and South and Central America.
Single or multiple lesions on the uncovered parts of the body: an erythematous papule begins at the sandﬂy bite,
enlarges to a nodule and extends in surface and depth to form a scabbed ulcer. Ulcers are painless, unless there is
secondary bacterial or fungal infection.
Usually, lesions heal spontaneously, leaving a scar, and result in lifelong protection from disease.


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secondary bacterial or fungal infection.
Usually, lesions heal spontaneously, leaving a scar, and result in lifelong protection from disease.
Lesions may also spread to the mucosa (mouth, nose, conjunctiva) giving rise to the mucocutaneous form, which
may cause severe disﬁgurement.
Prolonged (> 2 weeks) irregular fever, splenomegaly, and weight loss are the main signs.
Other signs include: anaemia, diarrhoea, epistaxis, lymphadenopathy, moderate hepatomegaly.
Bacterial diarrhoea, pneumonia, and tuberculosis may develop due to immunosuppression.
Parasitological diagnosis: identiﬁcation of Giemsa-stained parasites in smears of tissue biopsy from the edge of
the ulcer.
No useful serological tests.


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the ulcer.
No useful serological tests.
Parasitological diagnosis: identiﬁcation of Giemsa-stained parasites in smears of splenic, bone marrow, or lymph
node aspiration-biopsy. Splenic aspiration is the most sensitive technique but carries a theoretical risk of potentially
fatal haemorrhage.
Serological diagnosis: rK39 dipstick test and direct agglutination test (DAT) can be used for diagnosis of primary
visceral leishmaniasis in clinically suspect cases. Diagnosis of relapse is only by parasitological conﬁrmation.


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Treatment
The various species of Leishmania respond differently to drugs. Follow national recommendations.
For information:
Cutaneous and mucocutaneous leishmaniasis
Visceral leishmaniasis
Visceral leishmaniasis in East Africa
 
 
Visceral leishmaniasis in South Asia
 
 For all patients with visceral leishmaniasis, hydration, nutritional support and treatment of intercurrent infections
(malaria, dysentery, pneumonia, etc.) are essential.
Tuberculosis and/or HIV infection may also be present and should be suspected if relapse occurs more than once or in
the event of treatment failure.
Cutaneous lesions generally heal spontaneously in 3 to 6 months. Treatment is only indicated if lesions are
persistent (> 6 months), disﬁguring, ulcerating, or disseminated.


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persistent (> 6 months), disﬁguring, ulcerating, or disseminated.
Forms with a single lesion or few lesions: start with local treatment with a pentavalent antimonial: sodium
stibogluconate or meglumine antimoniate, 1 to 2 ml inﬁltrated into the lesion if it is a nodule and into the edges
and base around the crust if it is an ulcer.
It should be repeated every 3 to 7 days for 2 to 4 weeks. Once healing begins, the treatment can be stopped and
healing will continue.
IM treatment with a pentavalant antimonial (20 mg/kg daily for 10 to 20 days) is restricted to severe cases and must
be administered under close medical supervision.
Miltefosine PO (as for visceral leishmaniasis) for 28 days is effective in many forms of cutaneous leishmaniasis.


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Miltefosine PO (as for visceral leishmaniasis) for 28 days is effective in many forms of cutaneous leishmaniasis.
Ulcers are often secondarily infected with streptococci and staphylococci: administer suitable antibiotics.
Mucocutaneous forms: as for visceral leishmaniasis.
First-line treatment:
a pentavalent antimonial IM or slow IV: 20 mg/kg daily for 17 days
+ paromomycin IM: 15 mg (11 mg base)/kg daily for 17 days
Second-line treatment for relapse and for speciﬁc vulnerable groups: severe disease, pregnant women, patients
over 45 years:
liposomal amphotericin B IV infusion: 3 to 5 mg/kg once daily for 6 to 10 days up to a total dose of 30 mg/kg
Treatment in HIV co-infected patients:


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liposomal amphotericin B IV infusion: 3 to 5 mg/kg once daily for 6 to 10 days up to a total dose of 30 mg/kg
Treatment in HIV co-infected patients:
liposomal amphotericin B IV infusion: 3 to 5 mg/kg once daily for 6 to 10 days up to a total dose of 30 mg/kg
+ miltefosine PO for 28 days:
Children 2 to 11 years: 2.5 mg/kg once daily
Children ≥ 12 years and < 25 kg: 50 mg once daily
Children ≥ 12 years and adults 25 to 50 kg: 50 mg 2 times daily
Adults > 50 kg: 50 mg 3 times daily
First-line treatment:
liposomal amphotericin B IV infusion: 3 to 5 mg/kg once daily for 3 to 5 days up to a total dose of 15 mg/kg
or
liposomal amphotericin B IV infusion: 10 mg/kg single dose
Second-line treatment for relapse:


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or
liposomal amphotericin B IV infusion: 10 mg/kg single dose
Second-line treatment for relapse:
liposomal amphotericin B IV infusion: 3 to 5 mg/kg once daily for 5 to 8 days up to a total dose of 25 mg/kg


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Post-kala azar dermal leishmaniasis (PKDL)
Only patients with severe or disﬁguring disease or with lesions remaining for > 6 months, and young children with oral
lesions that interfere with feeding, are treated.
PKDL in East Africa
a pentavalent antimonial IM or slow IV: 20 mg/kg daily for 17 to 60 days
+ paromomycin IM: 15 mg (11 mg base)/kg daily for 17 days
or
liposomal amphotericin B IV infusion: 2.5 mg/kg once daily for 20 days
or
miltefosine PO for 28 days (as for visceral leishmaniasis) may be beneﬁcial in HIV co-infected patients
PKDL in South Asia
liposomal amphotericin B IV infusion: 5 mg/kg 2 times weekly up to a total dose of 30 mg/kg
Prevention
Insecticide-treated mosquito nets.
Vector control and elimination of animal reservoir hosts.


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Intestinal protozoan infections (parasiticdiarrhoea)
The most important intestinal protozoan infections are amoebiasis (Entamoeba histolytica), giardiasis (Giardia
lamblia), cryptosporidiosis (Cryptosporidium sp), cyclosporiasis (Cyclospora cayetanensis) and isosporiasis (Isospora
belli). Intestinal protozoa are transmitted by the faecal-oral route (soiled hands, ingestion of food or water contaminated
with faeces) and may cause both individual cases of diarrhoea and epidemic diarrhoea outbreaks.
Clinical features
 
Laboratory
Deﬁnitive diagnosis relies on parasite identiﬁcation in stool specimens (trophozoites and cysts for giardia; oocysts for
cryptosporidium, cyclospora, isospora). Two to three samples, collected 2 to 3 days apart are necessary, as


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cryptosporidium, cyclospora, isospora). Two to three samples, collected 2 to 3 days apart are necessary, as
pathogens are shed intermittently.
Treatment
 
Amoebiasis gives rise to bloody diarrhoea (see Amoebiasis, Chapter 3).
Clinical presentation of giardiasis, cryptosporidiosis, cyclosporiasis and isosporiasis is very similar:
Diarrhoea is usually mild and self-limiting, except in children and patients with advanced HIV disease (CD4 < 200).
These patients are likely to develop severe, intermittent or chronic diarrhoea that may be complicated by
malabsorption with signiﬁcant wasting (or failure to gain weight in children) or severe dehydration.
Stools are usually watery, but steatorrhoea (pale, bulky, fatty stools) may be found in the event of secondary fat


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Stools are usually watery, but steatorrhoea (pale, bulky, fatty stools) may be found in the event of secondary fat
malabsorption; stools may contain mucus.
Diarrhoea is usually associated with non-speciﬁc gastrointestinal symptoms (abdominal distension and cramps,
ﬂatulence, nausea, anorexia), but patients have low-grade fever or no fever.
Correct dehydration if present (for clinical features and management, see Dehydration, Chapter 1).
If the causal agent has been identiﬁed in the stool:


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Giardiasis tinidazole PO single dose
Children: 50 mg/kg (max. 2 g) 
Adults: 2 g
or
metronidazole PO for 3 days
Children: 30 mg/kg once daily
Adults: 2 g once daily
Cryptosporidiosis In immunocompetent patients, no aetiological treatment; spontaneous
resolution in 1 to 2 weeks.
Cyclosporiasis co-trimoxazole PO for 7 days
Children: 25 mg SMX + 5 mg TMP/kg 2 times daily
Adults: 800 mg SMX + 160 mg TMP 2 times daily
In immunocompetent patients, symptoms usually resolve spontaneous in 1 to 3
weeks. Treatment is given in case of severe or prolonged symptoms.
Isoporiasis co-trimoxazole PO for 7 to 10 days
Adults: 800 mg SMX + 160 mg TMP 2 times daily
In immunocompetent patients, symptoms usually resolve spontaneous in 2 to 3


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Adults: 800 mg SMX + 160 mg TMP 2 times daily
In immunocompetent patients, symptoms usually resolve spontaneous in 2 to 3
weeks. Treatment is given in case of severe or prolonged symptoms.
If reliable stool examination cannot be carried out: parasitic diarrhoeas cannot be differentiated on clinical grounds,
nor is it possible to distinguish these from non- parasitic diarrhoeas. An empirical treatment (using tinidazole or
metronidazole and co-trimoxazole as above, together or in succession) may be tried in the case of prolonged
diarrhoea or steatorrhoea. In patients with HIV infection, see empirical treatment (HIV infections and AIDS, Chapter
8).
In patients with advanced HIV disease, cryptosporidiosis, cyclosporiasis and isosporiasis are opportunistic


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8).
In patients with advanced HIV disease, cryptosporidiosis, cyclosporiasis and isosporiasis are opportunistic
infections; the most effective intervention is the treatment of the underlying HIV infection with antiretrovirals.
Patients remain at high risk for dehydration/death until immunity is restored.


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Infection/Epidemiology Clinical features/Diagnosis Treatment
Lung ﬂukes
Paragonimus sp
Distribution: South-East
Asia, China, parts of
Cameroon, Nigeria,
Gabon, Congo, Colombia,
Peru
Transmission: eating raw
freshwater crustaceans
The two most prominent symptoms are prolonged (> 2 weeks)
productive cough and intermittent haemoptysis (rusty-brown sputum).
In endemic areas, paragonimosis should be considered whenever
pulmonary tuberculosis is suspected as the clinical and radiological
features overlap. Paragonimosis is conﬁrmed when eggs are
detected in sputum (or possibly in stools).
praziquantel
PO
Children 4 years
and over and
adults:
25 mg/kg 3
times daily for 2
days
Hepatobiliary ﬂukes
Fasciola hepatica and
gigantica
Distribution: worldwide, in
areas where sheep and


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adults:
25 mg/kg 3
times daily for 2
days
Hepatobiliary ﬂukes
Fasciola hepatica and
gigantica
Distribution: worldwide, in
areas where sheep and
cattle are raised
Transmission: eating
uncooked aquatic plants
 
During migration phase: asthenia, prolonged fever, myalgia, right
upper quadrant pain, mild hepatomegaly; sometimes, allergic signs
(e.g. pruritus). At this stage, the diagnosis is rarely considered and can
only be conﬁrmed through serology; parasitological examination of
stools is always negative.
Once adult ﬂukes are present in the biliary tract: presentation
resembles cholelithiasis: right upper quadrant pain, recurrent episodes
of obstructive jaundice/ febrile cholangitis. The diagnosis is
conﬁrmed when parasite eggs are detected in stools (or ﬂukes are


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of obstructive jaundice/ febrile cholangitis. The diagnosis is
conﬁrmed when parasite eggs are detected in stools (or ﬂukes are
seen in the biliary tract with sonography).
 
triclabendazole
PO
Children and
adults:
10 mg/kg single
dose
May repeat in
24 hours in the
event of severe
infection
Opisthorchis felineus
(Asia, Eastern Europe)
Opisthorchis viverrini
(Cambodia, Laos,
Vietnam, Thailand)
Clonorchis sinensis
(China, Koera, Vietnam)
Transmission: eating
raw/undercooked
freshwater ﬁsh
Abdominal pain and diarrhoea. With heavy infection, hepatobiliary
symptoms: hepatomegaly, right upper quadrant pain, jaundice or
episodes of febrile cholangitis. The diagnosis is conﬁrmed when
parasite eggs are detected in stools.
praziquantel
PO
Children 4 years
and over and
adults:
25 mg/kg 3


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parasite eggs are detected in stools.
praziquantel
PO
Children 4 years
and over and
adults:
25 mg/kg 3
times daily for 2
days
Intestinal ﬂukes
Fasciolopsis buski
(India, Bangladesh,
South-East Asia)
Heterophyes
heterophyes
(South-East Asia, Nile
delta)
Metagonimus yokogawai
(Siberia, China, Korea)
Transmission: eating
uncooked aquatic plants
(F. buski),
Symptoms are limited to diarrhoea and epigastric or abdominal pain.
With massive infection, F. buski can cause oedematous allergic
reactions (including ascites, anasarca).
The diagnosis is conﬁrmed when parasite eggs are detected in
stools.
praziquantel
PO
Children 4 years
and over and
adults:
25 mg/kg 3
times daily, 1
day


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Schistosomiases
Schistosomiases are acute or chronic visceral parasitic diseases due to 5 species of trematodes (schistosomes). The
three main species infecting humans are Schistosoma haematobium, Schistosoma mansoni and Schistosoma
japonicum. Schistosoma mekongi and Schistosoma intercalatum have a more limited distribution. Humans are infected while wading/bathing in fresh water infested with schistosome larvae. Symptoms occurring during
the phases of parasite invasion (transient localized itching as larvae penetrate the skin) and migration (allergic
manifestations and gastrointestinal symptoms during migration of schistosomules) are frequently overlooked. In
general, schistosomiasis is suspected when symptoms of established infection become evident. Each species gives


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general, schistosomiasis is suspected when symptoms of established infection become evident. Each species gives
rise to a speciﬁc clinical form: genito-urinary schistosomiasis due to S. haematobium, intestinal schistosomiasis due S.
mansoni, S. japonicum, S. mekongi and S. intercalatum. The severity of the disease depends on the parasite load. Heavily infected patients are prone to visceral lesions with
potentially irreversible sequelae. Children aged 5 to 15 years are particularly at risk: prevalence and parasite load are
highest in this age group. An antiparasitic treatment should be administered to reduce the risk of severe lesions, even if there is a likelihood of re-
infection.
Clinical features


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  Parasite/Epidemiology a Clinical features/Diagnosis
(established infection)
Genito-urinary
schistosomiasis
S. haematobium
Distribution: Africa,
Madagascar and the
Arabian peninsula
Urinary manifestations:
In endemic areas, urinary schistosomiasis should be
suspected in any patients who complain of macroscopic
haematuria (red coloured urine throughout, or at the end of,
micturition). Haematuria is frequently associated with
polyuria/dysuria (frequent and painful micturition).
In patients, especially children and adolescents, with urinary
symptoms, visual inspection of the urine (and dipstick test
for microscopic haematuria if the urine appears grossly
normal) is indispensible.
Presumptive treatment is recommended in the presence of


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for microscopic haematuria if the urine appears grossly
normal) is indispensible.
Presumptive treatment is recommended in the presence of
macro- or microscopic haematuria, when parasitological
conﬁrmation (parasite eggs detected in urine) cannot be
obtained.
Genital manifestations:
In women, symptoms of genital infection (white-yellow or
bloody vaginal discharge, itching, lower abdominal pain,
dyspareunia) or vaginal lesions resembling genital warts or
ulcerative lesions on the cervix; in men, haematospermia
(blood in the semen).
If left untreated: risk of recurrent urinary tract infections,
ﬁbrosis/calciﬁcation of the bladder and ureters, bladder
cancer; increased susceptibility to sexually transmitted
infections and risk of infertility.


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ﬁbrosis/calciﬁcation of the bladder and ureters, bladder
cancer; increased susceptibility to sexually transmitted
infections and risk of infertility.
In endemic areas, genito-urinary schistosomiasis may be a
differential diagnosis to the genito-urinary tuberculosis, and in
women, to the sexually transmitted infections (especially in
women with an history of haematuria).
Intestinal
schistosomiasis
S. mansoni
Distribution: tropical
Africa, Madagascar, the
Arabian peninsula, South
America (especially Brazil)
S. japonicum
Distribution: China,
Indonesia, the Philippines
S. mekongi
Distribution: parts of Lao
PDR, Cambodia (along the
Mekong River)
S. intercalatum
Distribution: parts of DRC,
Congo, Gabon, Cameroon,
Chad
Non-speciﬁc digestive symptoms (abdominal pain; diarrhoea,


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Mekong River)
S. intercalatum
Distribution: parts of DRC,
Congo, Gabon, Cameroon,
Chad
Non-speciﬁc digestive symptoms (abdominal pain; diarrhoea,
intermittent or chronic, with or without blood) and
hepatomegaly.
For S. intercalatum: digestive symptoms only (rectal pain,
tenesmus, rectal prolapse, bloody diarrhoea).
If left untreated: risk of hepatic ﬁbrosis, portal hypertension,
cirrhosis, gastrointestinal haemorrhage (hematemesis, melena,
etc.), except with S. intercalatum (less pathogenic than other
intestinal schistosomes, no severe hepatic lesions).
The diagnosis is conﬁrmed when parasite eggs are detected
in stools.
In the absence of reliable parasitological diagnosis: in areas
where intestinal schistosomiasis is common, diarrhoea


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in stools.
In the absence of reliable parasitological diagnosis: in areas
where intestinal schistosomiasis is common, diarrhoea
(especially bloody diarrhoea) with abdominal pain and/or
hepatomegaly may be a basis for presumptive diagnosis and
treatment.


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Page 204 / 409
 
Treatment
praziquantel PO
Children 4 years and over and adults :
 
References
 [1] [2] 
 b  
S. haematobium, S. mansoni, S. intercalatum: 40 mg/kg single dose or 2 doses of 20 mg/kg administered 4 hours
apart
S. japonicum, S. mekongi: 2 doses of 30 mg/kg or 3 doses of 20 mg/kg administered 4 hours apart
Footnotes
(a) For more information on geographic distribution of schistosomiasis:https://www.who.int/schistosomiasis/Schistosomiasis_2012-01.png?ua=1
(b) For the treatment of schistosomiasis, praziquantel may me administered to pregnant women.
1. Treatment Guidelines from The Medical Letter. Vol. 11 (Suppl). Drugs for Parasitic Infections. 2013.https://www.uab.edu/medicine/gorgas/images/docs/syllabus/2015/03_Parasites/RxParasitesMedicalLetter2013.pdf [Accessed 25 May 2020]


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2. Centers for Disease Control and Prevention (CDC). Schistosomiasis. Resources for Health Professionals. 2018.https://www.cdc.gov/parasites/schistosomiasis/health_professionals/index.html#tx [Accessed 25 May 2020]


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Page 205 / 409
Cestodes
Cestodes (adult forms)
Cestodes (larvae)
Parasites Clinical
features/Laboratory Treatment Transmission/Prevention
Taeniasis
Taenia saginata
Taenia solium
(worldwide)
Often asymptomatic
Segments expelled in the
stools, sometimes
gastrointestinal disturbances
(epigastric or abdominal
pain, nausea, diarrhoea)
Laboratory: eggs in stools
or collected from perianal
skin (scotch tape method),
segments in stools
praziquantel PO
Children 4 years and
over and adults:
5 to 10 mg/kg single
dose
 (a) Transmission by eating
raw or under-cooked meat:
Prevention:
beef for T. saginata
pork for T. solium
individual: cook meat
thoroughly
collective:
slaughterhouse
monitoring
Diphyllobothriasis
Diphyllobothrium latum
(temperate or cold lake
areas)
Often asymptomatic


