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thoroughly
collective:
slaughterhouse
monitoring
Diphyllobothriasis
Diphyllobothrium latum
(temperate or cold lake
areas)
Often asymptomatic
In the event of heavy
infection: mild
gastrointestinal
disturbances, anaemia due
to vitamin B deﬁciency
associated with (rare)
neurological sequelae
Laboratory: eggs in stools
12 
praziquantel PO
Children 4 years and
over and adults:
5 to 10 mg/kg single
dose
If anaemia: vitamin B
+ folic acid
 (a) 
12
Transmission by eating
raw or under- cooked
freshwater ﬁsh
Prevention:
individual: cook ﬁsh
thoroughly
Hymenolepiasis
Hymenolepis nana
(worldwide)
Often asymptomatic
In the event of heavy
infection: gastrointestinal
disturbances (epigastric
pain)
Laboratory: eggs in stools
praziquantel PO
Children 4 years and
over and adults:
15 to 25 mg/kg single
dose


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disturbances (epigastric
pain)
Laboratory: eggs in stools
praziquantel PO
Children 4 years and
over and adults:
15 to 25 mg/kg single
dose
 (a) Transmission by faecal-
oral route or auto-infection
Prevention:
individual: hand washing,
nail cutting
collective: hygiene and
sanitation (water,
latrines, etc.)
(a) Praziquantel may be administered to pregnant women with T. solium taeniasis. For the other indications, treatment canusually be deferred until after delivery.


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Parasites Clinical features/Laboratory Treatment Transmission/Prevention
Cysticercosis
Taenia solium
(worldwide)
Laboratory: hypereosinophilia in
blood and cerebrospinal ﬂuid
Muscular: asymptomatic or
myalgia
Subcutaneous: nodules
Neurological
(neurocysticercosis): headache,
convulsions, coma, etc.
Ocular: exophthalmia,
strabismus, iritis, etc.
Neurological and ocular
cysticercosis should be
managed in specialized
facilities.
Antiparasitic treatment
without diagnosis of
location by
computerirsed
tomography and/or
magnetic resonance
imaging can worsen the
symptoms even threat
the life. Neurosurgical
treatment can be
required.
Transmission by eating
food contaminated with T.
solium eggs or auto-
infection
Prevention:
individual: treat T. solium
carriers, hygiene, cook


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Transmission by eating
food contaminated with T.
solium eggs or auto-
infection
Prevention:
individual: treat T. solium
carriers, hygiene, cook
meat thoroughly
Hydatid cyst
Echinococcus
granulosus
(South America,
North, East and South
Africa, Western
Europe)
Cysts located in the liver (60% of
cases); lungs (30% of cases), and,
less frequently, in other sites
including the brain.
Long asymptomatic period. The
cyst becomes symptomatic when
complications develop (biliary
obstruction; anaphylactic shock in
the event of rupture into peritoneal
cavity, vessels or an organ; febrile
painful jaundice in the event of
rupture into the biliary tree, etc.).
First-line treatment:
surgical excision
albendazole PO  is
useful in addition to, or
instead of, surgery:
Children over 2 years


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First-line treatment:
surgical excision
albendazole PO  is
useful in addition to, or
instead of, surgery:
Children over 2 years
and adults under 60 kg:
7.5 mg/kg 2 times daily
Adults over 60 kg:
400 mg 2 times daily
Treatment duration:
In addition to surgery
(pre-operatively or
post- operatively):
continuous course of
minimum 2 months or at
least two 28-day
courses with a drug-
free interval of 14 days.
Inoperable cases: 28-
day courses with drug-
free intervals of 14
days, for 3 to 6 months
(on average), possibly
up to 1 year.
 (b) 
Transmission:
Prevention:
direct: contact with
dogs
indirect: water and food
contaminated by dog
faeces
individual: avoid contact
with dogs
collective: eliminate
stray dogs, monitor
slaughterhouses


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indirect: water and food
contaminated by dog
faeces
individual: avoid contact
with dogs
collective: eliminate
stray dogs, monitor
slaughterhouses
(b) Albendazole is contra-indicated during the ﬁrst trimester of pregnancy.


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Infection/Epidemiology Clinical features/Diagnosis Treatment
Ascariasis (roundworms)
Ascaris lumbricoides
Distribution: worldwide,
mainly in tropical and
subtropical
Transmission: ingestion of
ascaris eggs
(a) During larval migration
Loefﬂer ’s syndrome: transient pulmonary
symptoms (dry cough, dyspnoea, wheezing) and
mild fever.
Once adult worms are present in the intestine
Abdominal pain and distension. In general, the
diagnosis is made when adult worms are
expelled from the anus (or occasionally from the
mouth). Ascaris are large (15-30 cm), cylindrical
worms, pinkish-white, with slightly tapered ends.
Complications
Ascariasis is usually benign, but massive
infestation may cause intestinal obstruction
(abdominal pain, vomiting, constipation),


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Complications
Ascariasis is usually benign, but massive
infestation may cause intestinal obstruction
(abdominal pain, vomiting, constipation),
especially in children < 5 years. Worms may
accidentally migrate to gall bladder, liver or
peritoneum, causing jaundice, liver abscess, or
peritonitis.
Ascaris eggs may be detected through
parasitological examination of stools.
albendazole PO single dose
Children > 6 months and adults:
400 mg
(200 mg in children > 6 months
but < 10 kg)
or
mebendazole PO for 3 days
Children > 6 months and adults:
100 mg 2 times daily
(50 mg 2 times daily in children
> 6 months but < 10 kg)
Trichuriasis (whipworms)
Trichuris trichiura
Distribution and
transmission:
as for A. lumbricoides
(a) In heavy infection: abdominal pain and diarrhoea.


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Trichuris trichiura
Distribution and
transmission:
as for A. lumbricoides
(a) In heavy infection: abdominal pain and diarrhoea.
In massive infection: chronic bloody diarrhea,
tenesmus, rectal prolapse due to frequent
attempts to defecate, especially in children.
Worms may sometimes be seen on the rectal
mucosa when prolapsed: these are grayish-
white, 3-5 cm in length, in the shape of a whip,
with a thickened body and a long, threadlike
extremity.
Trichuris eggs may be detected through
parasitological examination of stools.
albendazole PO for 3 days
Children > 6 months and adults:
400 mg once daily
(200 mg once daily in children >
6 months but < 10 kg)
or
mebendazole PO for 3 days,
as for ascariasis.
A single dose of albendazole
or mebendazole is often
insufﬁcient.
Ankylostomiase


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or
mebendazole PO for 3 days,
as for ascariasis.
A single dose of albendazole
or mebendazole is often
insufﬁcient.
Ankylostomiase
Ancylostoma duodenale
Necator americanus
Distribution: tropical and
subtropical regions
Transmission: larval skin
penetration following
contact (feet, hands) with
contaminated soil
(a) During larval penetration/migration
Cutaneous signs (pruritic papulo-vesicular rash
at the site of penetration, usually the feet) and
pulmonary symptoms (similar to ascariasis).
Once adult worms are present in the intestine
Mild abdominal pain. Attachment of the parasite
to the mucosa leads to chronic blood loss and
anaemia (in endemic areas, antihelminthic
treatment is recommended for patients with
iron-deﬁciency anaemia).
Hookworm eggs may be detected through


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anaemia (in endemic areas, antihelminthic
treatment is recommended for patients with
iron-deﬁciency anaemia).
Hookworm eggs may be detected through
parasitological examination of stools.
albendazole single dose (as
for ascariasis) is much more
effective than mebendazole
single dose.
When using mebendazole, a 3-
day treatment (as for
ascariasis) is recommended.
Treatment of anaemia
(Chapter 1).
Strongyloidiasis Acute strongyloidiasis First line treatment is:


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Strongyloides stercoralis
Distribution: humid tropical
regions
Transmission: larval skin
penetration and auto-
infection
During larval penetration/migration:
cutaneous signs (erythema and pruritus at the
site of penetration, which may persist several
weeks) and pulmonary symptoms (similar to
ascariasis).
Once larvae are present in the intestine:
gastrointestinal symptoms (bloating,
abdominal and epigastric pain, vomiting,
diarrhoea).
Chronic strongyloidiasis
Intestinal larvae may re-infect their host (auto-
infection) by penetrating through the intestinal
wall or by migrating transcutaneously from
perianal skin. Chronic infections result in
prolonged or recurrent pulmonary and
gastrointestinal symptoms. Transcutaneous
migration of intestinal larvae gives rise to a


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prolonged or recurrent pulmonary and
gastrointestinal symptoms. Transcutaneous
migration of intestinal larvae gives rise to a
typical rash (larva currens), mainly in the anal
region and on the trunk: sinuous, raised, linear,
migrating lesion, intensely pruritic, moving rapidly
(5 to 10 cm/hour) and lasting several hours or
days.
Complications
Hyperinfection (massive infestation) results in
exacerbation of pulmonary and gastrointestinal
symptoms, and possible dissemination of larvae
to atypical locations, (CNS, heart, etc.). This
form occurs mainly in patients receiving
immunosuppressive therapy (e.g.
corticosteroids).
Strongyloides larvae may be detected through
parasitological examination of stools.
ivermectin PO  single dose
Children > 15 kg and adults:
200 micrograms/kg, on an


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parasitological examination of stools.
ivermectin PO  single dose
Children > 15 kg and adults:
200 micrograms/kg, on an
empty stomach
While less effective, a 3-day
treatment with albendazole
PO (as for trichuriasis) may be
an alternative.
Hyperinfections are refractory
to conventional therapy.
Prolonged or intermittent
multiple-dose regimens are
required.
(b)
Enterobiasis (pinworms)
Enterobius vermicularis
Distribution: worldwide
Transmission: faecal-oral
route or auto-infection
Anal pruritus, more intense at night, vulvovaginitis
in girls (rare). In practice, the diagnosis is most
often made when worms are seen on the
perianal skin (or in the stool in heavy infestation).
Pinworms are small (1 cm), mobile, white,
cylindrical worms with slightly tapered ends.


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perianal skin (or in the stool in heavy infestation).
Pinworms are small (1 cm), mobile, white,
cylindrical worms with slightly tapered ends.
Pinworm eggs may be collected from the anal
area (scotch tape method) and detected under
the microscope.
albendazole PO single dose,
as for ascariasis
or
mebendazole PO single dose
Children > 6 months and adults:
100 mg
(50 mg in children > 6 months
but < 10 kg)
A second dose may be given
after 2 to 4 weeks.
Trichinellosis
Trichinella sp
Distribution: worldwide,
particularly frequent in Asia
(Thailand, Laos, China, etc.)
Enteric phase (1 to 2 days after ingestion of
infected meat)
Self-limited episode of diarrhoea and abdominal
pain lasting several days.
albendazole PO for 10 to 15
days
Children > 2 years:
5 mg/kg 2 times daily
Adults:


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 Roundworms, whipworms and hookworms frequently co-infect the same host. This should be taken into account
when prescribing antihelminthic treatment.   The migrating larvae of Ancylostoma braziliense and caninum (hookworms of cats and dogs) also present as a
pruritic, inﬂammatory, creeping eruption in humans (cutaneous larva migrans) but with a slower rate of progression and a
longer duration (several weeks or months). Treatment is with albendazole (400 mg single dose or once daily for 3 days
in children > 6 months and adults; 200 mg in children > 6 months but < 10 kg) or ivermectin (200 micrograms/kg single
dose).
Transmission: consumption
of raw or undercooked
meat containing trichinella
larvae (pork, wart-hog, bear,
dog, etc.)


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dose).
Transmission: consumption
of raw or undercooked
meat containing trichinella
larvae (pork, wart-hog, bear,
dog, etc.)
Muscular phase (about 1 week after ingestion)
High fever; muscular pain (ocular [pain on eye
movement], masseters [limitation of mouth
opening], throat and neck [pain with swallowing
and speech], trunk and limbs); facial or bilateral
peri-orbital oedema; conjunctival haemorrhage,
subungual haemorrhage; headache. Typical
features are not always present and the patient
may present with a non-speciﬁc ﬂu-like
syndrome.
Other features, such as dietary habits
(consuming pork/raw meat), suggestive
symptoms (fever > 39 °C and myalgia and facial
oedema) in several individuals who have shared
the same meal (e.g. ceremony) or
hypereosinophilia > 1000/mm, reinforce the


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oedema) in several individuals who have shared
the same meal (e.g. ceremony) or
hypereosinophilia > 1000/mm, reinforce the
clinical suspicion.
3
Deﬁnitive diagnosis: muscle biopsy; serology
(ELISA, Western Blot).
400 mg 2 times daily
or
mebendazole PO for 10 to 15
days
Children > 2 years:
2.5 mg/kg 2 times daily
Adults:
200 mg 2 times daily
plus, regardless of which anti-
helminthic is chosen:
prednisolone PO
0.5 to 1 mg/kg once daily for
the duration of treatment
(a)
(b)


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Filariasis
 
 
 
 
Filariases are helminthiases due to tissue-dwelling nematode worms (ﬁlariae). Human to human transmission takes
place through the bite of an insect vector. The most important pathogens are outlined in the table below. Mixed infections are common in co-endemic regions. Each ﬁlarial species is found in 2 principal developmental stages: macroﬁlariae (adult worms) and microﬁlariae (larval
offspring). The treatment depends on the pathogenic stage of the species considered and targets microﬁlariae for O.
volvulus and macroﬁlariae for the other species. 
Classical antiﬁlarial agents include diethylcarbamazine (DEC), ivermectin and albendazole. Doxycycline is used solely in


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Classical antiﬁlarial agents include diethylcarbamazine (DEC), ivermectin and albendazole. Doxycycline is used solely in
the treatment of O. volvulus and lymphatic ﬁlarial worms, which harbour an endosymbiotic bacterium (Wolbachia)
sensitive to doxycycline.
Onchocerciasis (river blindness)
Loiasis.
Lymphatic ﬁlariasis (LF)
 
Species/Infections Location of
macroﬁlariae
Location of 
microﬁlariae
Pathogenic 
stage
Presence
of Wolbachia
Onchocerca volvulus
(onchocerciasis)
Subcutaneous
nodules Skin and eye Microﬁlariae Yes
Loa loa
(loiasis)
Subcutaneous
tissue Blood Macroﬁlariae No
Wuchereria bancrofti, Brugia
malayi and Brugia timori
(lymphatic ﬁlariasis)
Lymph vessels Blood Macroﬁlariae Yes


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Onchocerciasis (river blindness)
The distribution of onchocerciasis is linked to that of its vector (Simulium), which reproduces near rapidly ﬂowing rivers
in intertropical Africa (99% of cases), Latin America (Guatemala, Mexico, Ecuador, Colombia, Venezuela, Brazil) and
Yemen.
Clinical features
In endemic areas, the following signs, alone or in combination, are suggestive of onchocerciasis:
Laboratory
Treatment
Antiparasitic treatment
Onchocercomas: painless subcutaneous nodules containing adult worms, usually found over a bony prominence
(iliac crest, trochanters, sacrum, rib cage, skull, etc.), measuring several mm or cm in size, ﬁrm, smooth, round or
oval, mobile or adherent to underlying tissue; single, or multiple and clustered.


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oval, mobile or adherent to underlying tissue; single, or multiple and clustered.
Acute papular onchodermatitis: papular rash, sometimes diffuse but often conﬁned to the buttocks or lower
extremities, intensely itchy, associated with scratch marks, often superinfected (“ﬁlarial scabies”) . This arises from
dermal invasion by microﬁlariae.
 a 
Late chronic skin lesions: patchy depigmentation on the shins (“leopard skin”), skin atrophy or areas of dry,
thickened, peeling skin (licheniﬁcation; “lizard skin”).
Visual disturbances and ocular lesions: see Onchocerciasis, Chapter 5.
Detection of the microﬁlariae in the skin (skin snip biopsy, iliac crest).
If the skin biopsy is positive, look for loiasis in regions where loiasis is co-endemic (mainly in Central Africa).


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If the skin biopsy is positive, look for loiasis in regions where loiasis is co-endemic (mainly in Central Africa).
Diethylcarbamazine is contra-indicated (risk of severe ocular lesions).
Doxycycline PO (200 mg once daily for 4 weeks; if possible 6 weeks) kills a signiﬁcant percentage of adult worms
and progressively reduces the number of O. volvulus microﬁlariae . It is contraindicated in children < 8 years and
pregnant or breast-feeding women.
 b 
Ivermectin PO is the drug of choice: 150 micrograms/kg single dose; a 2  dose should be administered after 3
months if clinical signs persist. Repeat the treatment every 6 or 12 months to maintain the parasite load below the
threshold at which clinical signs appear . Ivermectin is not recommended in children < 5 years or < 15 kg and


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threshold at which clinical signs appear . Ivermectin is not recommended in children < 5 years or < 15 kg and
pregnant women.
nd
 c 
In case of co-infection with Loa loa or in regions where loiasis is co-endemic, ivermectin should be administered
with caution (risk of severe adverse reactions in patients with high L. loa microﬁlarial load):
If it is possible to test for Loa loa (thick blood ﬁlm):
Conﬁrm and quantify the microﬁlaraemia. Administer the appropriate treatment according to the microﬁlarial
load (see Loiasis).
If it is not possible to perform a thick ﬁlm examination, take a history from the patient:
If the patient has received a previous treatment with ivermectin without developing serious adverse reactions
(see Loiasis), administer the treatment.


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(see Loiasis), administer the treatment.
If the patient has never received ivermectin nor developed signs of loiasis (migration of an adult worm under the
conjunctiva, or « Calabar » swellings), administer the treatment.
If the patient already has developed signs of loiaisis and if onchocerciasis has a signiﬁcant clinical impact,
administer ivermectin under close supervision (see Loiasis) or use an alternative (doxycycline, as above).


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Nodulectomy (surgical removal of onchocercomas)
Nodules are benign, often deep, and their ablation does not treat onchocerciasis. Thus, nodulectomy is reserved for
cranial nodules (their proximity to the eye is a risk factor for visual compromise) or nodules which are cosmetically
unacceptable. In other cases, refrain from nodulectomy. Nodulectomy is performed under local anaesthesia, in an
appropriately equipped facility.
 
In the case of concomitant lymphatic ﬁlariasis: administer ivermectin ﬁrst then start treatment for lymphatic
ﬁlariasis with doxycycline PO (see Lymphatic ﬁlariasis) one week later.
Footnotes
(a) Differential diagnosis is sarcoptic scabies (Scabies, Chapter 4).


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Footnotes
(a) Differential diagnosis is sarcoptic scabies (Scabies, Chapter 4).
(b) Elimination of Wolbachia reduces the longevity and fertility of the macroﬁlariae, and thus the production of new microﬁlariaewithin the organism.
(c) Ivermectin kills microﬁlariae and disrupts production of microﬁlariae by adult worms. However the treatment must beadministered at regular intervals since it does not kill adult worms.


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Loiasis
The distribution of loiasis is linked to that of its vector (Chrysops) in forests or savannah with gallery forests in West or
Central Africa (limits West: Benin; East: Uganda; North: Sudan and South: Angola).
Clinical features
Laboratory
Treatment
Antiparasitic treatment
 
 
 
 1)  L. loa microﬁlaraemia is < 1,000-2,000 mf/ml
A 28-day treatment of DEC may be started using a small dose: 6 mg on D1, i.e. 1/8 of a 50 mg tablet 2 times
daily.
Double the dose every day up to 200 mg 2 times daily in adults (1.5 mg/kg 2 times daily in children).
If microﬁlaraemia or symptoms persist, a second treatment is given 4 weeks later.
If DEC is contra-indicated due to possible or conﬁrmed co-infection with O. volvulus, ivermectin (150


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If DEC is contra-indicated due to possible or conﬁrmed co-infection with O. volvulus, ivermectin (150
microgams/kg single dose) treats onchocerciasis, and reduces pruritus and frequency of Calabar swellings.
The treatment may be repeated every month or every 3 months. 
The subconjunctival migration of an adult worm is pathognomonic of Loa loa infection. 
Localised subcutaneous swellings, allergic in origin, transient (several hours or days), painless, non-pitting, appearing
anywhere on the body, frequently the upper extremities and face, often associated with localised or generalised
pruritus (« Calabar swellings »).
Onset of pruritus, in the absence of other signs.
Subcutaneous migration of an adult worm: pruritic, palpable red cord-like linear lesion, sinuous, advancing (1


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Subcutaneous migration of an adult worm: pruritic, palpable red cord-like linear lesion, sinuous, advancing (1
cm/hour), disappearing rapidly with no trace . Such migration generally arises following treatment with
diethylcarbamazine, rarely spontaneously.
 a 
Detection of microﬁlariae in the peripheral blood (thick ﬁlm, stained with Giemsa). Blood specimens should be
collected between 10 am and 5 pm. Quantify microﬁlaraemia even if the diagnosis is certain, since treatment is
determined by the intensity of the parasite load.
If the thick ﬁlm is positive, look for onchocerciasis in regions where onchocerciasis is coendemic (mainly in Central
Africa).
Diethylcarbamazine (DEC) is the only macroﬁlaricide available but is contra-indicated in:


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Africa).
Diethylcarbamazine (DEC) is the only macroﬁlaricide available but is contra-indicated in:
Patients with microﬁlaraemia > 2000 mf/ml (risk of severe encephalopathy, with poor prognosis).
Patients co-infected with O. volvulus (risk of severe eye lesions).
Pregnant women, infants, and patients in poor general condition.
Ivermectin (and possibly albendazole) is used to reduce microﬁlaraemia before administration of DEC; however,
ivermectin administration may trigger encephalopathy in patients with very high Loa loa microﬁlaraemia (> 30 000
mf/ml).
Doxycycline is not indicated since Loa loa does not harbour Wolbachia.
Management:


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2)  L. loa microﬁlaraemia is between 2,000 and 8,000 mf/ml
Reduce microﬁlaraemia with ivermectin (150 micrograms/kg single dose); repeat the treatment every month if
necessary; administer DEC when the microﬁlaraemia is < 2000 mf/ml. 3)  L. loa microﬁlaraemia is between 8,000 and 30,000 mf/ml
Treatment with ivermectin (150 micrograms/kg single dose) may cause marked functional impairment for
several days. Close supervision and support from family member(s) are necessary . Prescribe paracetamol as
well for 7 days. 4)  L. loa microﬁlaraemia is > 30,000 mf/ml
Extraction of macroﬁlariae
Subcutaneous migration of a microﬁlaria usually results from treatment with DEC; the worm will die beneath the skin


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Extraction of macroﬁlariae
Subcutaneous migration of a microﬁlaria usually results from treatment with DEC; the worm will die beneath the skin
and extracting it serves no purpose. Removal of an adult worm from the conjunctiva: see Loasis, Chapter 5.
 
 b 
If the loiasis is well tolerated, it is preferable to refrain from treatment: the disease is benign and treatment
with ivermectin may cause very severe adverse reactions (encephalopathy), albeit rarely.
If loiasis has a signiﬁcant clinical impact and/or the patient presents with symptomatic onchocerciasis
requiring treatment, ivermectin (150 micrograms/kg single dose) is administered for 5 days under supervision
in hospital . An attempt to ﬁrst reduce L. loa microﬁlaraemia using albendazole (200 mg 2 times daily for 3


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in hospital . An attempt to ﬁrst reduce L. loa microﬁlaraemia using albendazole (200 mg 2 times daily for 3
weeks) is an option. When L. loa microﬁlaraemia is < 30 000 mf/ml, treat with ivermectin under close
supervision and support, then DEC when the microﬁlaraemia is < 2000 mf/ml.
 c 
Footnotes
(a) For differential diagnosis, see cutaneous larva migrans.
(b) Patients may present with various pain syndromes, be unable to move without help or unable to move at all. Monitoring isnecessary to determine whether the patient can manage activities of daily living, and provide assistance if necessary. If thepatient remains bedridden for several days, ensure pressure sores do not develop (mobilisation, repositioning).


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(c) A severe reaction may occur on D2-D3. It is usually preceded by haemorrhages of the palpebral conjunctiva on D1-D2.Routinely check for this sign by turning back the eyelids. Symptoms of post ivermectin encephalopathy are reversible andthe prognosis favourable, if the patient is correctly managed; the treatment is symptomatic until symptoms resolve. Avoidthe use of steroids due to adverse effects.


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Lymphatic ﬁlariasis (LF)
The distribution of LF is linked to that of its mosquito vectors (Anopheles, Culex, Aedes, etc.):
90% of LF is due to W. bancrofti and 10% to Brugia spp.
Clinical features
 
Laboratory
Treatment
Antiparasitic treatment
W. bancrofti: sub-Saharan Africa, Madagascar, Egypt, India, South East Asia, Paciﬁc region, South America, The
Caribbean
B. malayi: South East Asia, China, India, Sri Lanka
B. timori: Timor
Acute recurrent inﬂammatory manifestations
Adenolymphangitis: lymph node(s) and red, warm, tender oedema along the length of a lymphatic channel, with or
without systemic signs (e.g. fever, nausea, vomiting). The inﬂammation may involve the lower limbs, external
genitalia and breast.


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without systemic signs (e.g. fever, nausea, vomiting). The inﬂammation may involve the lower limbs, external
genitalia and breast.
 In men: acute inﬂammation of the spermatic cord (funiculitis), epididymis and testicle (epididymo-orchitis).
Attacks resolve spontaneously within a week and recur regularly in patients with chronic disease.
Chronic manifestations
Lymphoedema: oedema of the lower extremity or external genitalia or breast, secondary to obstruction of the
lymphatics by macroﬁlariae. The oedema is reversible initially but then becomes chronic and increasingly severe:
hypertrophy of the area affected, progressive thickening of the skin (ﬁbrous thickening with formation of
creases, initially superﬁcial, but then deep, and verrucous lesions). The ﬁnal stage of lymphoedema is


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creases, initially superﬁcial, but then deep, and verrucous lesions). The ﬁnal stage of lymphoedema is
elephantiasis.
In men: increase in volume of ﬂuid due to accumulation within the tunica vaginalis (hydrocoele, lymphocoele,
chylocoele); chronic epididymo-orchitis.
Chyluria: milky or rice-water urine (disruption of a lymphatic vessel in the urinary tract).
In patients parasitized by Brugia spp, genital lesions and chyluria are rare: lymphoedema is usually conﬁned to
below the knee.
Detection of microﬁlariae in the peripheral blood (thick ﬁlm) ; blood specimens should be collected between 9 pm
and 3 am.
 a 
In regions where loiasis and/or onchocerciasis are co-endemic, check for co-infection if the LF diagnosis is
positive.
Treatment is not administered during an acute attack.


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positive.
Treatment is not administered during an acute attack.
Doxycycline PO, when administered as a prolonged treatment, eliminates the majority of macroﬁlariae and reduces
lymphoedema: 200 mg once daily for 4 weeks minimum. It is contraindicated in children < 8 years and pregnant or
breast-feeding women.
Diethylcarbamazine PO single dose (400 mg in adults; 3 mg/kg in children) may be an alternative but eliminates a
variable proportion of adult worms (up to 40%) and does not relieve symptoms; a prolonged treatment is no more
effective than single dose therapy. In addition, DEC is contra-indicated in patients with onchocerciasis or Loa
loa microﬁlarial load > 2000 mf/ml and in pregnant and breast-feeding women.


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Control/prevention of inﬂammatory manifestations and infectious complications
Surgery
May be indicated in the treatment of chronic manifestations: advanced lymphoedema (diversion-reconstruction),
hydrocoele and its complications, chyluria.
 
Ivermectin (weak or absent macroﬁlaricidal effect) and albendazole should not be used for the treatment of
individual cases (no effect on symptoms).
In the case of conﬁrmed or probable co-infection with O. volvulus: treat onchocerciasis ﬁrst, then administer
doxycycline.
Acute attacks: bed rest, elevation of the affected limb without bandaging, cooling of the affected limb (wet cloth,
cold bath) and analgesics; antibacterial or antifungal cream if necessary; antipyretics if fever (paracetamol) and
hydration.


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cold bath) and analgesics; antibacterial or antifungal cream if necessary; antipyretics if fever (paracetamol) and
hydration.
Prevention of episodes of lymphangitis and lymphoedema: hygiene of the affected extremity , comfortable
footwear, immediate attention to secondary bacterial/fungal infections and wounds.
 b 
Established lymphoedema: bandaging of the affected limb by day, elevation of the affected extremity (after
removal of the bandage) when at rest, simple exercises (ﬂexion-extension of the feet when recumbent or upright,
rotation of the ankles); skin hygiene, as above.
Footnotes
(a) When test results are negative in a clinically suspect case, consider detection of antigens (ICT rapid test) and/or ultrasoundof the inguinal area in search of the « ﬁlarial dance sign ».


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(b) Wash at least once daily (soap and water at room temperature), paying special attention to folds and interdigital areas;rinse thoroughly and dry with a clean cloth; nail care.


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Chapter 7: Bacterial diseases
Bacterial meningitis
Tetanus
Enteric (typhoid and paratyphoid) fevers
Brucellosis
Plague
Leptospirosis
Relapsing fever (borreliosis)
Louse-borne relapsing fever (LBRF)
Tick-borne relapsing fever (TBRF)
Eruptive rickettsioses


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Bacterial meningitis
Meningitis is an acute bacterial infection of the meninges, which may affect the brain and lead to irreversible
neurological damage and auditory impairment.
Bacterial meningitis is a medical emergency. The treatment is based on early parenteral administration of antibiotics
that penetrates well into the cerebrospinal ﬂuid (CSF). Empiric antibiotic therapy is administered if the pathogen cannot
be identiﬁed or while waiting for laboratory results.
The main bacteria responsible vary depending on age and/or context:
Meningitis in a non-epidemic context
L. monocytogenes is occasionally responsible for meningitis during this period.
 Special conditions:
Meningitis in an epidemic context


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L. monocytogenes is occasionally responsible for meningitis during this period.
 Special conditions:
Meningitis in an epidemic context
In the Sahelian region (but not exclusively, e.g. Rwanda, Angola, Brazil), during the dry season, epidemics of
meningococcal meningitis (Neisseria meningitidis A or C or W135) affect children from 6 months of age, adolescents
and adults. In these regions, whether during epidemics or not, all the above pathogens can be found, especially in young
children.
Clinical features
The clinical presentation depends on the patient's age.
Children over 1 year and adults
Children under 1 year
The classic signs of meningitis are usually absent.
Children 0 to 3 months:
Children ≤ 7 days: Gram-negative bacilli (Klebsiella spp, E. coli, S.


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The classic signs of meningitis are usually absent.
Children 0 to 3 months:
Children ≤ 7 days: Gram-negative bacilli (Klebsiella spp, E. coli, S.
marcescens, Pseudomona spp, Salmonella spp) and group B streptococcus
Children > 7 days: S. pneumoniae accounts for 50% of all bacterial meningitis
Children 3 months-5 years: S. pneumoniae, H. inﬂuenza B and N. meningitidis
Children > 5 years and adults: S. pneumoniae and N. meningitidis
Immunodepressed patients (HIV, malnourished): high percentage of Gram- negative bacilli (specially Salmonella spp)
and also M. tuberculosis.
Sickle cell anaemia: Salmonella spp and Staphylococcus aureus are frequent causes.
Meningitis may be related to S. aureus when associated with skin infection or skull fracture.


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Meningitis may be related to S. aureus when associated with skin infection or skull fracture.
Fever, severe headache, photophobia, neck stiffness
Brudzinski's sign (neck ﬂexion in a supine patient results in involuntary ﬂexion of the knees) and Kernig's sign
(attempts to extend the knee from the ﬂexed-thigh position are met with strong passive resistance).
Petechial or ecchymotic purpura (usually in meningococcal infections)
In severe forms: coma, seizures, focal signs, purpura fulminans
The child is irritable, appears sick with fever or hypothermia, poor feeding or vomiting.
Other features include: seizures, apnoea, altered consciousness, bulging fontanelle (when not crying); occasionally,
neck stiffness and purpuric rash.


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Laboratory
 
 Note: in an endemic area, it is essential to test for severe malaria (rapid test or thin/thick ﬁlms).
Treatment in a non-epidemic context
Antibiotic therapy
For the choice of antibiotic therapy and dosages according to age, see table below. 
Lumbar puncture (LP):
Macroscopic examination of CSF: antibiotic therapy should be initiated immediately if the LP yields a turbid CSF.
Microscopic examination: Gram stain (but a negative examination does not exclude the diagnosis) and white
blood cell count (WBC).
In an epidemic context, once the meningococcal aetiology has been conﬁrmed, there is no need for routine LP
for new cases.
  Pressure Aspect WBC
(leucocytes/mm)3 Protein Other
tests
Normal CSF   Clear < 5 Pandy–
< 40 mg/dl –


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for new cases.
  Pressure Aspect WBC
(leucocytes/mm)3 Protein Other
tests
Normal CSF   Clear < 5 Pandy–
< 40 mg/dl –
Bacterial meningitis ++++ Cloudy, turbid
100-20 000 
mainly neutrophiles
In neonates: 
> 20
In
immunocompromised, 
the WBC may be < 100
Pandy+
100-500
mg/dl
Gram stain +
Viral meningitis Normal to
+ Clear 10-700
mainly lymphocytes Pandy– –
TB meningitis +++ Clear or
yellowish
< 500 
mainly lymphocytes Pandy+ AFB
Cryptococcal
meningitis ++++ Clear < 800 
mainly lymphocytes Pandy– India ink
Rapid test for detection of bacterial antigens.


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  No associated skin infection Associated skin infection (including umbilical
cord infection)
  First line Alternative First line Alternative
0 to 7
days
< 2 kg
ampicillin IV
100 mg/kg every 12 hours
+
cefotaxime IV
50 mg/kg every 12 hours
ampicillin IV
100 mg/kg
every 12
hours
+
gentamicin
IV
3 mg/kg
once daily
cloxacillin IV
50 mg/kg every 12 hours
+
cefotaxime IV
50 mg/kg every 12 hours
cloxacillin
IV
50 mg/kg
every 12
hours
+
gentamicin
IV
3 mg/kg
once daily
0 to 7
days
≥ 2 kg
ampicillin IV
100 mg/kg every 8 hours
+
cefotaxime IV
50 mg/kg every 8 hours
ampicillin IV
100 mg/kg
every 8
hours
+
gentamicin
IV
5 mg/kg
once daily
cloxacillin IV
50 mg/kg every 8 hours
+
cefotaxime IV
50 mg/kg every 8 hours
cloxacillin
IV
50 mg/kg
every 8
hours
+
gentamicin
IV
5 mg/kg
once daily


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cloxacillin IV
50 mg/kg every 8 hours
+
cefotaxime IV
50 mg/kg every 8 hours
cloxacillin
IV
50 mg/kg
every 8
hours
+
gentamicin
IV
5 mg/kg
once daily
8 days
to
< 1
month
≥ 2 kg
ampicillin IV
100 mg/kg every 8 hours
+
cefotaxime IV
50 mg/kg every 8 hours
ampicillin IV
100 mg/kg
every 8
hours
+
gentamicin
IV
5 mg/kg
once daily
cloxacillin IV
50 mg/kg every 6 hours
+
cefotaxime IV
50 mg/kg every 8 hours
cloxacillin
IV
50 mg/kg
every 6
hours
+
gentamicin
IV
5 mg/kg
once daily
1 to 3
months
ampicillin IV
100 mg/kg every 8 hours
+
ceftriaxone IV 100 mg/kg on D1
then starting on D2: 100 mg/kg once
daily or 50 mg/kg every 12 hours
ampicillin IV
100 mg/kg
every 8
hours
+
gentamicin
IV
2.5 mg/kg
every 8
hours
cloxacillin IV
50 mg/kg every 6 hours
+
ceftriaxone IV 100 mg/kg on D1


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ampicillin IV
100 mg/kg
every 8
hours
+
gentamicin
IV
2.5 mg/kg
every 8
hours
cloxacillin IV
50 mg/kg every 6 hours
+
ceftriaxone IV 100 mg/kg on D1
then starting on D2: 100 mg/kg once
daily or 50 mg/kg every 12 hours
cloxacillin
IV
50 mg/kg
every 6
hours
+
gentamicin
IV
2.5 mg/kg
every 8
hours


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Duration of antibiotherapy: 1) According to the pathogen:
 2) If the pathogen is unknown:
Additional treatment
Treatment in an epidemic context
Antibiotic therapy
In this context, N. meningitidis is the most likely pathogen. 
> 3
months
ceftriaxone IV
Children: 100 mg/kg on D1 then starting on D2: 100
mg/kg once daily or 50 mg/kg every 12 hours (max.
4 g daily)
cloxacillin IV
Children < 40 kg: 50 mg/kg every 6 hours
Children ≥ 40 kg: 2 g every 6 hours
+
ceftriaxone IV
Children: 100 mg/kg on D1 then starting on D2: 100
mg/kg once daily or 50 mg/kg every 12 hours (max.
4 g daily)
Adults ceftriaxone IV: 4 g once daily or 2 g every 12 hours cloxacillin IV: 2 g every 6 hours
+
ceftriaxone IV: 4 g once daily or 2 g every 12 hours
Haemophilus inﬂuenzae: 7 days


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+
ceftriaxone IV: 4 g once daily or 2 g every 12 hours
Haemophilus inﬂuenzae: 7 days
Streptococcus pneumonia: 10-14 days
Group B streptococcus and Listeria: 14-21 days
Gram-negative bacilli: 21 days
Neisseria meningitidis: see antibiotherapy in an epidemic context
Children < 3 months: 2 weeks beyond the ﬁrst sterile CSF culture or 21 days
Children > 3 months and adults: 10 days. Consider extending treatment or alternative diagnoses if fever persists
beyond 10 days. On the other hand, a 7-day course of ceftriaxone is sufﬁcient in patients who are making an
uncomplicated recovery.
Dexamethasone reduces the risk of hearing loss in patients with H. inﬂuenzae or S. pneumoniae.
Early administration is indicated in meningitis caused by these pathogens or when the pathogen is unknown, except


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Early administration is indicated in meningitis caused by these pathogens or when the pathogen is unknown, except
in neonates (and in presumed meningococcal meningitis in an epidemic context).
dexamethasone IV
Children > 1 month: 0.15 mg/kg (max. 10 mg) every 6 hours for 2 to 4 days
Adults: 10 mg every 6 hours for 2 to 4 days
The treatment should be started before or with the ﬁrst dose of antibiotic, otherwise, the treatment offers no
beneﬁt.
 [1] [2] 
Ensure that the patient is well fed and well hydrated (infusions or nasogastric tube if necessary).
Seizures (Chapter 1).
Coma: prevention of bed sores, care of the mouth and eyes, etc.


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Note:
A short treatment with a single dose of ceftriaxone IM can be used in children 2 years and older and in adults during a
meningococcal meningitis epidemic if 1) conﬁrmed by a reliable laboratory 2) the number of cases exceeds
management capacities with the 5-day treatment. Check national recommendations. Nevertheless, it is essential to
ensure a monitoring of cases after 24 hours.
ceftriaxone IM
Children 2 to < 12 years: 100 mg/kg single dose
Children ≥ 12 years and adults: 4 g single dose
If there is no clinical improvement (fever > 38.5 °C, repeated seizures, appearance or aggravation of a reduced level of
consciousness or of neurological signs) 24 hours after the injection, continue the treatment with ceftriaxone for 5 days.
Additional treatment
 
References


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Additional treatment
 
References
Age Treatment [3]
Children
< 2 months
ceftriaxone IV or IM  for 7 days
100 mg/kg once daily 
 (a)    (b) 
Children ≥ 2 months
and adults
ceftriaxone IV or IM  or 5 days
Children 2 months to < 5 years: 100 mg/kg once daily (max. 2 g daily)
Children ≥ 5 years and adults: 2 g once daily
 (a)    (b) 
(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) For IM administration, divide the dose into 2 injections if needed, half-dose in each buttock.
 a 
Ensure that the patient is well fed and well hydrated (infusions or nasogastric tube if necessary).
Seizures (Chapter 1).


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a 
Ensure that the patient is well fed and well hydrated (infusions or nasogastric tube if necessary).
Seizures (Chapter 1).
Coma: prevention of bed sores, care of the mouth and eyes, etc.
Dexamethasone in not indicated.
Footnotes
(a) For IM administration, divide the dose into 2 injections if needed, half-dose in each buttock.
1. D. van de Beek, C. Cabellos, O. Dzupova, S. Esposito, M. Klein, A. T. Kloek, S. L. Leib, B. Mourvillier, C. Ostergaard, P. Pagliano,H.W. Pﬁster, R. C. Read, O. Resat Sipahi, M.C. Brouwer. ESCMID guideline: diagnosis and treatment of acute bacterialmeningitis, 2016.https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(16)00020-3/pdf


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2. Sheldon L Kaplan, MD. Bacterial meningitis in children: Dexamethasone and other measures to prevent neurologiccomplications. UpToDate [Accessed 25 February 2019].
3. World Health Organization. Managing meningitis epidemics in Africa. A quick reference guide for health authorities andhealth-care workers. 2015.https://apps.who.int/iris/bitstream/handle/10665/154595/WHO_HSE_GAR_ERI_2010.4_Rev1_eng.pdf?sequence=1


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Tetanus
Last updated: August 2022
 
Tetanus is a severe infection due to the bacillus Clostridium tetani, found in soil, and human and animal waste. The
infection is noncontagious.
Clostridium tetani is introduced into the body through a wound and produces a toxin whose action on the central
nervous system is responsible for the symptoms of tetanus.
Tetanus is entirely preventable by vaccination. It occurs in people who have not been fully vaccinated before exposure
or have not received adequate post-exposure prophylaxis. In these individuals, most breaks in the skin or mucous
membranes carry a risk of tetanus, but the wounds with the greatest risk are: the stump of the umbilical cord in


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membranes carry a risk of tetanus, but the wounds with the greatest risk are: the stump of the umbilical cord in
neonates, puncture wounds, wounds with tissue loss or contamination with foreign material or soil, avulsion and crush
injuries, sites of non-sterile injections, chronic wounds (e.g. lower extremity ulcers), burns and bites. Surgical or
obstetrical procedures performed under non-sterile conditions also carry a risk of tetanus.
Clinical features
Generalised tetanus is the most frequent and severe form of the infection. It presents as muscular rigidity, which
progresses rapidly to involve the entire body, and muscle spasms, which are very painful. Level of consciousness is not
altered.
Children and adults
Neonates
Treatment


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altered.
Children and adults
Neonates
Treatment
Hospitalisation is needed and usually lasts 3 to 4 weeks. Correct management can reduce mortality even in hospitals
with limited resources.
General measures
Average time from exposure to onset of symptoms is 7 days (3 to 21 days).
Muscular rigidity begins in the jaw muscles (difﬁculty with then inability to open mouth [trismus] preventing the patient
from speaking, eating), spreading to the face (ﬁxed smile), neck (difﬁculty with swallowing), to the trunk (restriction
of respiratory muscles; hyperextension of spine [opisthotonus]), to the abdomen (guarding) and to the limbs (ﬂexion
of the upper limbs and extension of the lower limbs).


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of the upper limbs and extension of the lower limbs).
Muscle spasms, which are very painful, appear at the onset or when muscular rigidity becomes generalised. They
are triggered by stimuli (noise, light, touch) or arise spontaneously. Spasms of the thoracic and laryngeal muscles
may cause respiratory distress or aspiration.
In 90% of cases, initial symptoms appear within 3 to 14 days of birth.
The ﬁrst signs are signiﬁcant irritability and difﬁculty sucking (rigidity of the lips, trismus) then rigidity becomes
generalised, as in adults. Any neonate, who initially sucked and cried normally, presenting with irritability and difﬁculty
sucking 3 to 28 days after birth and demonstrating rigidity and muscle spasms should be assumed to have neonatal
tetanus.
Ensure intensive nursing care.


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tetanus.
Ensure intensive nursing care.
The patient should be in a dark, quiet room. Blindfold neonates with a cloth bandage.


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Neutralisation of toxin
human tetanus immunoglobulin IM
Neonates, children and adults: 500 IU single dose, injected into 2 separate sites
Inhibition of toxin production
metronidazole IV infusion (30 minutes; 60 minutes in neonates) for 7 days
Control of rigidity and spasms, and sedation of the patient
Diazepam should decrease the frequency and intensity of spams without causing respiratory depression. The dose and
frequency of administration depend on the patient’s clinical response and tolerance. 
 
Handle the patient carefully, while sedated and as little as possible; change position every 3 to 4 hours to avoid
bedsores.
Teach family the danger signs and instruct them to call the nurse for the slightest respiratory symptom (cough,


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bedsores.
Teach family the danger signs and instruct them to call the nurse for the slightest respiratory symptom (cough,
difﬁculty breathing, apnoea, excessive secretions, cyanosis, etc.).
Establish IV access for hydration, IV injections.
Gentle suction of secretions (mouth, oropharynx).
Insert a nasogastric tube for hydration, feeding and administration of oral medications.
Provide hydration and nutrition in feeds divided over 24 hours. In neonates, give expressed breast milk every 3 hours
(risk of hypoglycaemia).
  a 
Neonates:
0 to 7 days: 15 mg/kg on D1 then, after 24 hours, 7.5 mg/kg every 12 hours
8 days to < 1 month (< 2 kg): same doses
8 days to < 1 month (≥ 2 kg): 15 mg/kg every 12 hours
Children 1 month and over: 10 mg/kg every 8 hours (max. 1500 mg daily)


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8 days to < 1 month (≥ 2 kg): 15 mg/kg every 12 hours
Children 1 month and over: 10 mg/kg every 8 hours (max. 1500 mg daily)
Adults: 500 mg every 8 hours
 
 
There is a high risk of respiratory depression and hypotension when using diazepam, especially in children and
elderly patients. Constant and close monitoring of the patient‘s respiratory rate (RR) and oxygen saturation
(SpO) is essential, with immediate availability of equipment for manual ventilation (Ambu bag, face mask) and
intubation, suction (electric if possible) and Ringer lactate.
2
A continuous IV infusion of diazepam requires the use of a dedicated vein (no other infusion/injection in this
vein); avoid the antecubital fossa if possible.
Do not stop treatment abruptly; an abrupt stop can cause spasms.


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Count the volume of the infusion of diazepam as part of the patient’s daily ﬂuid intake. 
Neonates diazepam emulsion for injection (10 mg ampoule, 5 mg/ml, 2 ml)
 Example:
Neonate weighing 3 kg (administration by electric syringe)
0.1 mg/kg/hour x 3 kg = 0.3 mg/hour
Dilute one 10 mg ampoule of diazepam emulsion for injection in 50 ml of 10% glucose to obtain a
solution containing 0.2 mg of diazepam per ml.
Administer 1.5 ml/hour [dose (in mg/hour) ÷ dilution (in mg/ml) = dose in ml/hour i.e. 0.3 (mg/hour) ÷ 0.2
(mg/ml) = 1.5 ml/hour]. If an electric syringe is not available, diluting the diazepam emulsion in an infusion bag for continuous
infusion may be considered. Weigh the risks associated with this mode of administration (accidental


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infusion may be considered. Weigh the risks associated with this mode of administration (accidental
bolus or insufﬁcient dose). The infusion should be monitored closely to avoid any change, however
small, of the prescribed rate.
0.1 to 0.3 mg/kg by slow IV injection (3 to 5 minutes) every 1 to 4 hours depending on the severity
and the persistence of the spasms as long as the RR is ≥ 30.
If despite hourly diazepam the spasms persist, start a continuous infusion of diazepam with an
electric syringe: 0.1 to 0.5 mg/kg/hour (2.4 to 12 mg/kg every 24 hours). Start with 0.1 mg/kg/hour
and if symptoms persist, increase by 0.1 mg/kg/hour as long as RR is ≥ 30.
If in spite of 0.5 mg/kg/hour symptoms persist, the dose can be increased up to 0.8 mg/kg/hour as
long as the RR ≥ 30.


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If in spite of 0.5 mg/kg/hour symptoms persist, the dose can be increased up to 0.8 mg/kg/hour as
long as the RR ≥ 30.
Diluted diazepam emulsion does not keep for more than 6 hours.
Children
> 1
month
and
adults
Same doses and protocol as in neonates but:
 Examples:
Use diazepam solution for injection 5 mg/ml: (10 mg ampoule, 5 mg/ml, 2 ml). (a)
These doses can be administered as long as the RR is:
≥ 30 in children under 1 year
≥ 25 in children 1 to 4 years
≥ 20 in children 5 to 12 years
≥ 14 in children over 12 years
≥ 12 in adults
Child weighing 6 kg (continuous IV infusion using a pediatric infusion set; 1 ml = 60 drops)
0.1 mg/kg/hour x 6 kg = 0.6 mg/hour
Dilute one 10 mg ampoule of diazepam solution for injection in 50 ml of 5% glucose (10%


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0.1 mg/kg/hour x 6 kg = 0.6 mg/hour
Dilute one 10 mg ampoule of diazepam solution for injection in 50 ml of 5% glucose (10%
glucose if child < 3 months) to obtain a solution containing 0.2 mg of diazepam per ml.
Administer 3 ml/hour [dose (in mg/hour) ÷ dilution (in mg/ml) = dose in ml/hour i.e. 0.6 (mg/hour) ÷ 0.2
(mg/ml) = 3 ml/hour] or 3 drops/minute (in a paediatric infusion set ml/hour = drops/minute).
Adult weighing 60 kg (standard adult infusion set, 1 ml = 20 drops)
0.1 mg/kg/hour x 60 kg = 6 mg/hour
Dilute 5 ampoules of 10 mg of diazepam solution (50 mg) in 250 ml of 0.9% sodium chloride or
5% glucose to obtain a solution containing 0.2 mg of diazepam per ml.
Administer 30 ml/hour [dose (in mg/hour) ÷ dilution (in mg/ml) = dose in ml/hour e.g. 6 (mg/hour) ÷ 0.5


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Administer 30 ml/hour [dose (in mg/hour) ÷ dilution (in mg/ml) = dose in ml/hour e.g. 6 (mg/hour) ÷ 0.5
(mg/ml) = 30 ml/hour] or 10 drops/minute.
(a) Administer the ﬁrst dose rectally if an IV cannot be placed immediately.


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When the frequency and severity of the spasms have decreased, start weaning the diazepam (gradually decrease the
rate of infusion):
 Notes:
Treatment of pain
morphine PO (via nasogastric tube) if necessary (see Pain, Chapter 1).
When morphine is administered with diazepam the risk of respiratory depression is increased, thus closer monitoring is
required. When morphine is no longer required, wean the same way as diazepam.
Treatment of the entry point and associated infections
Tetanus vaccination
As tetanus does not confer immunity, vaccination against tetanus must be administered once the patient has
recovered.
In case of neonatal tetanus, initiate the vaccination of the mother.
Prevention
Of critical importance, given the difﬁculty of treating tetanus once established.


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Prevention
Of critical importance, given the difﬁculty of treating tetanus once established.
1) Post-exposure prophylaxis
Calculate the total daily dose of IV diazepam and administer it orally in 4 divided doses, 6 hours apart, via
nasogastric (NG) tube. b  
Give ﬁrst NG dose and decrease rate of IV infusion by 50%.
Give second NG dose and stop IV diazepam infusion.
If withdrawal signs appear, wean more slowly. c 
Once on diazepam PO, wean by 10 to 20% of the original dose daily, until at a dose of 0.05 mg/kg every 6 hours.
Then increase the interval from every 6 hours to every 8 hours for 24 hours as tolerated (wean more slowly if
withdrawal signs appear).
Continue to increase the interval between the doses from every 8 hours to every 12 hours and then to every 24


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withdrawal signs appear).
Continue to increase the interval between the doses from every 8 hours to every 12 hours and then to every 24
hours before stopping the diazepam.
Each step should be for 24 hours or more if withdrawal signs appear.
It is often at these smaller doses that it is difﬁcult to wean diazepam. If this is the case, slow the wean further:
dropping the % wean (e.g. 5% wean every 24 hours instead of 10% wean) or increasing the interval between weans
(e.g. going from every 24 hours to every 48 hours).
If the patient is also receiving morphine, wean diazepam ﬁrst then, wean morphine.
Non-pharmacological measures to reduce withdrawal: reduce environmental stimuli; swaddle infants, frequent
feedings.


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Non-pharmacological measures to reduce withdrawal: reduce environmental stimuli; swaddle infants, frequent
feedings.
Infants who have had tetanus remain hypertonic, even when they are no longer having spams.
Search systematically the entry wound. Provide local treatment under sedation: cleansing and for deep wounds,
irrigation and debridement.
Cord infection: do not excise or debride; treat bacterial omphalitis and sepsis, add to metronidazole IV: cloxacillin IV
+ cefotaxime IV or cloxacillin IV + gentamicin IV (for doses, see Bacterial meningitis).
In all cases:
Cleansing and disinfection of the wound, and removal of any foreign body.
Antibiotics are not prescribed routinely for prophylaxis. The decision to administer an antibiotic (metronidazole


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Antibiotics are not prescribed routinely for prophylaxis. The decision to administer an antibiotic (metronidazole
or penicillin) is made on a case-by-case basis, according to the patient’s clinical status.


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 tetanus vaccine IM
Children and adults: 0.5 ml per dose
If no vaccination or unknown vaccination status: administer at least 2 doses at an interval of 4 weeks.
If incomplete vaccination: administer one dose.
Then, to ensure long-lasting protection, administer additional doses to complete a total of 5 doses, as indicated in
the table below. human anti-tetanus immunoglobulin IM
Children and adults: 250 IU single dose; 500 IU for wounds more than 24 hours old.
Inject the vaccine and the immunoglobulin in 2 different sites, using a separate syringe for each.
2) Routine vaccination (pre-exposure prophylaxis)
Depending on pre-exposure vaccination status:
Tetanus vaccine (TV)  and immunoglobulin: see indications below. d 
Type of wound
Complete vaccination (3 or more doses)


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Tetanus vaccine (TV)  and immunoglobulin: see indications below. d 
Type of wound
Complete vaccination (3 or more doses) 
Time since administration of last dose:
Incomplete vaccination 
(less than 3 doses) 
or no vaccination
or unknown status< 5 years 5-10 years > 10 years
Minor, clean None None
TV
1 booster
dose
Initiate or complete TV
Other None TV 
1 booster dose
TV
1 booster
dose
Initiate or complete TV
and administer tetanus immunoglobulin
Children: 6 doses in total: a ﬁrst series of 3 doses of DTP or DTP + HepB or DTP + HepB + Hib before the age of
1 year, administered at an interval of 1 month (e.g. at the age of 6, 10 and 14 weeks), then a dose of a vaccine
containing tetanus toxoid between the age of 12 and 23 months, a dose between the age of 4 to 7 years, then a


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containing tetanus toxoid between the age of 12 and 23 months, a dose between the age of 4 to 7 years, then a
dose between the age of 12 and 15 years.
Women of childbearing age: 5 doses during the reproductive years: a series of 3 doses of Td with an interval of at
least one month between the ﬁrst and second dose and an interval of at least 6 months between the second and
third dose, then two other doses, each at minimum interval of one year, e.g. during pregnancies (see table below).
Pregnant women: if a woman has never been vaccinated or if her vaccination status is unknown: 2 doses of
Tdduring the pregnancy to reduce the risk of tetanus in mother and  neonate: the ﬁrst as soon as possible during


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Tdduring the pregnancy to reduce the risk of tetanus in mother and  neonate: the ﬁrst as soon as possible during
the pregnancy and the second at least 4 weeks later and at least 2 weeks before delivery. This vaccination
schedule protects more than 80% of neonates from tetanus. A single dose offers no protection


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Dose Vaccination schedule in adults Degree and duration of protection
TV1 On ﬁrst contact with the health care system
or as soon as possible during pregnancy No protection
TV2 At least 4 weeks after TV1 80% 
1 to 3 years
TV3 6 months to 1 year after TV2
or during the following pregnancy
95% 
5 years
TV4 1 to 5 years after TV3
or during the following pregnancy
99% 
10 years
TV5 1 to 10 years after TV4
or during the following pregnancy
99% 
Throughout the reproductive years
Footnotes
(a) Clindamycin IV for 7 days is an alternative (for doses, see Periorbital and orbital cellulitis, Chapter 5).


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Footnotes
(a) Clindamycin IV for 7 days is an alternative (for doses, see Periorbital and orbital cellulitis, Chapter 5).
(b) Administration of oral diazepam tablets to infants: calculate the exact dose of diazepam, e.g. to obtain 0.5 mg of diazepam,cut a scored diazepam 2 mg tablet in half along scoring then split in half again. Crush quarter tablet and dissolve inexpressed breast milk or infant formula.
(c) Withdrawal signs: excessive irritability, tremors, increased muscle tone, frequent yawning, poor feeding, watery stools andsweating.
(d) Tetanus-containing vaccine, such as Td or DTP or DTP + HepB or DTP + HepB + Hib according to availability and patient’sage.


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Enteric (typhoid and paratyphoid) fevers
Last updated: March 2024
 
 
Enteric fevers include typhoid fever, due to Salmonella enterica serotype Typhi (S. Typhi) and paratyphoid fever, due
to Salmonella enterica serotype Paratyphi A, B or C (S. Paratyphi).
Enteric fevers are acquired by the ingestion of water or food contaminated with excreta of symptomatic or
asymptomatic carriers or by direct contact (dirty hands).
Enteric fevers are endemic in South, Central and Southeast Asia, sub-saharan Africa, Oceania and, to a lesser extent, in
Latin America.
Effective treatment signiﬁcantly reduces the risk of complications and death.
Clinical features
Clinical manifestations of typhoid and paratyphoid fevers are the same. Enteric fevers have insidious onset and vary


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Clinical features
Clinical manifestations of typhoid and paratyphoid fevers are the same. Enteric fevers have insidious onset and vary
from mild to severe. 
 Clinical diagnosis is difﬁcult as enteric fevers resembles other infections present in regions where they are
endemic. The main differential diagnoses are: malaria, brucellosis, leptospirosis, typhus, rickettsiosis,
sepsis and dengue.
Laboratory
Treatment
In all cases
The characteristic sign is prolonged fever, which gradually increases during the ﬁrst week, plateaus the second
week then decreases between the third and fourth week.  
Non-speciﬁc signs and symptoms are frequently associated: gastrointestinal disturbances (abdominal pain,


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Non-speciﬁc signs and symptoms are frequently associated: gastrointestinal disturbances (abdominal pain,
constipation or diarrhoea, vomiting), headache, malaise, chills, fatigue, non productive cough and/or
hepatosplenomegaly. 
Erythematous maculopapular rash on the trunk extreme fatigue and/or relative bradycardia (heart rate-temperature
dissociation) may be present.
Serious complications affect about 27% of hospitalised patients and usually occur during the second or third
week of illness. These may incude decreased level of consciousness, intestinal haemorrhage or perforation
or peritonitis, shock, or nephritis. In pregnant women, severe infection may lead to foetal complications
(miscarriage, preterm delivery, intrauterine death).
 [1]


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(miscarriage, preterm delivery, intrauterine death).
 [1] 
Relapse may occur 2 to 3 weeks after recovery. It is usually not due to antibiotic resistance, and re-treatment is
required.
Culture of S. Typhi or Paratyphi and drug susceptibility test (blood and stool specimens).
In all cases, rapid test for malaria in endemic regions (and antimalarial treatment if needed, see Malaria, Chapter 6). 
Widal agglutination test, other serologic tests, and rapid diagnostic tests are not recommended (low sensitivity and
speciﬁcity). 
Hydrate and treat fever (Chapter 1). Fever usually resolves 4 to 5 days after starting effective antibiotic treatment.
Choice of antibiotic treatment depends on the susceptibility of the strain, or when susceptibility is unknown, on


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Choice of antibiotic treatment depends on the susceptibility of the strain, or when susceptibility is unknown, on
recent data on susceptibility of strains in the region. Check national recommendations. For information:


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Uncomplicated cases (outpatients)
Uncomplicated cases (the vast majority of cases) can be treated with an oral antibiotic treatment.
Severe cases (inpatients)
These cases should be treated under close monitoring. Antibiotic treatment is initially parenteral, then oral when
there is decreasing fever, clinical improvement and the patient can tolerate oral treatment.
Additional measures
Prevention
Strains resistant to chloramphenicol, ampicillin/amoxicillin and co-trimoxazole (multidrug-resistant, MDR
strains) are present in most parts of the world. 
Ciproﬂoxacin is used as ﬁrst-line treatment in some countries, however ﬂuoroquinolone resistance is endemic in
Asia and is increasing in several parts of the world . [2]


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Asia and is increasing in several parts of the world . [2] 
Ceftriaxone resistance has been identiﬁed in several regions . [2] 
MDR strains also resistant to ﬂuoroquinolones and third-generation cephalosporins (extensively drug-resistant,
XDR strains) have developed .    [3] 
First-line antibiotics:
azithromycin PO for 7 days (including for MDR and XDR cases, and pregnant women)
Children: 10 to 20 mg/kg (max. 1 g) once daily 
Adults: 500 mg to 1 g once daily or 1 g on D1 then 500 mg once daily
or
ceﬁxime PO for 10 to 14 days (except for third-generation cephalosporin resistance and XDR cases)
Children: 10 mg/kg (max. 200 mg) 2 times daily
Adults: 200 mg 2 times daily
Alternatives include, only if recent data show susceptibility of strains to these antibiotics in the region:


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Adults: 200 mg 2 times daily
Alternatives include, only if recent data show susceptibility of strains to these antibiotics in the region:
amoxicillin PO for 14 days
Children: 30 mg/kg (max. 1 g) 3 times daily 
Adults: 1 g 3 times daily 
or
co-trimoxazole PO for 14 days
Children: 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
Severe cases include:
toxic appearance or decreased level of consciousness or medical or surgical complication;
oral administration not possible due to persistent vomiting.
Start with ceftriaxone IV (including for pregnant women)
Children: 50 to 100 mg/kg (max. 4 g) once daily
Adults: 2 g once daily or 2 times daily
Then change to azithromycin PO (as above) to complete at least 7 days of treatment.


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Adults: 2 g once daily or 2 times daily
Then change to azithromycin PO (as above) to complete at least 7 days of treatment.
 a 
For suspected or conﬁrmed ceftriaxone resistance or XDR stains, use meropenem IV, including for pregnant
women, then change to azithromycin PO to complete at least 7 days of treatment.
In case of decreased level of consciousness or shock, dexamethasone IV: a loading dose of 1 mg/kg followed by
0.25 mg/kg every 6 hours for 48 hours (total of 8 doses).
Treat in intensive care unit patients with shock, signiﬁcant intestinal haemorrhage or suspected
perforation/peritonitis. If suspected perforation/peritonitis, get urgent surgical review and add metronidazole to
ceftriaxone for anaerobic bacterial coverage . b


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References
Hygiene measures common to all diarrhoeas: handwashing; consumption of treated water (chlorinated, boiled,
bottled, etc.); washing/cooking of food, etc.
In hospitals: for patients with watery diarrhoea, consider disinfection of excreta with chlorinated solution, if stools
are collected in buckets.
Vaccination with the typhoid conjugate vaccine in endemic regions . This vaccine can be used to control typhoid
outbreaks. It does not protect against paratyphoid fever.
 c 
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) Do not add metronidazole if the patient receives meropenem (meropenem already covers anaerobic bacteria).
(c) For more information, see Typhoid vaccines: WHO position paper:http://apps.who.int/iris/bitstream/handle/10665/272272/WER9313.pdf?ua=1
1. Cruz Espinoza LM, McCreedy E, Holm M, et al. Occurrence of typhoid fever complications and their relation to duration ofillness preceding hospitalization: a systematic literature review and meta-analysis. Clin Infect Dis 2019;69(Suppl 6):S435-48.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6821330/ [Accessed 28 June 2022]


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2. Browne AJ, Hamadani BHK, Kumaran EAP, Rao P, et al. Drug-resistant enteric fever worldwide, 1990 to 2018: a systematicreview and meta-analysis. BMC Medicine 2020;18:1+22.https://doi.org/10.1186/s12916-019-1443-1 [Accessed 23 February 2022]
3. Klemm EJ, Shakoor S, Page AJ, Qamar FN, et al. Emergence of an Extensively Drug-Resistant Salmonella enterica SerovarTyphi Clone Harboring a Promiscuous Plasmid Encoding Resistance to Fluoroquinolones and Third-GenerationCephalosporins. mBio. 2018 Jan-Feb; 9(1): e00105-18. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5821095/ [Accessed 26June 2022]


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Brucellosis
Last updated: September 2022
 
Brucellosis is a zoonosis that mainly affects livestock animals.  The main routes of transmission to humans are: 
 Brucellosis is caused by bacteria of the genus Brucella, particularly B. melitensis (sheep and goats), B.
abortus (cattle), B. suis (pigs). The disease is found worldwide and mainly in rural areas. 
After primary infection relapses may occur (5 to 15% of cases, even months after end of initial treatment) or the
infection may become chronic.
Clinical features
Acute form (primary infection)
 Diagnosis is difﬁcult because of the broad spectrum of ﬂuctuating and non-speciﬁc clinical manifestations. In patients


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Diagnosis is difﬁcult because of the broad spectrum of ﬂuctuating and non-speciﬁc clinical manifestations. In patients
with unexplained fever, brucellosis should be considered when risk factors are present: consumption of unpasteurized
milk products; exposure to livestock (e.g. livestock farmers, veterinarians, butchers, slaughterhouse workers).
Localised form 
Primary infection may progress to localised infection (even several months or years later), mainly:
Paraclinical investigations
Laboratory
digestive, by ingestion of unpasteurized milk (or unpasteurized milk products) from an infected animal;
cutaneous, by direct contact with infected animals or carcasses of infected animals.


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cutaneous, by direct contact with infected animals or carcasses of infected animals. 
Remittent or intermittent fever (39-40 °C), associated with several signs or symptoms: chills, night sweats, joint and
muscle pain, weight loss, fatigue, malaise, headache; adenopathies (particularly in children).
May be associated with: non-speciﬁc gastrointestinal disorders, cough, hepato and/or splenomegaly, arthritis
(knee), orchitis.
osteoarticular: sacroiliac joint and often particularly lower limbs joints;  spine (intervertebral disk infection, vertebral
osteomyelitis)
genito-urinary: orchitis, epididymitis 
pulmonary: bronchitis, pneumonia, pleurisy 
neurological : meningitis, encephalitis, polyneuritis


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genito-urinary: orchitis, epididymitis 
pulmonary: bronchitis, pneumonia, pleurisy 
neurological : meningitis, encephalitis, polyneuritis
Blood culture is the gold standard for diagnosis. It is positive only in the acute phase. The bacteria grow slowly (7 to
21 days).
Serological tests (Rose Bengal, Wright agglutination test, indirect immunoﬂuorescence, ELISA, etc.) provide
presumptive diagnoses.
In the event of neurological signs or meningitis, lumbar puncture shows clear cerebrospinal ﬂuid (CSF) that may
contain high white blood cell count; high protein concentration in CSF; low CSF glucose.
Rule out malaria in endemic regions (rapid test).
Exclude tuberculosis if cough > 2 weeks (sputum smear microscopy).


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Radiography 
Treatment
Check national recommendations on antibiotic therapy. For information: 
co-trimoxazole PO for 6 weeks
Children < 8 years: 20 mg SMX + 4 mg TMP/kg (max. 800 mg SMX + 160 mg TMP) 2 times daily doxycycline PO for 6 weeks 
Children ≥ 8 years and < 45 kg: 2 to 2.2 mg/kg (max. 100 mg) 2 times daily
Children ≥ 45 kg and adults: 100 mg 2 times daily  rifampicin PO for 6 weeks
Children: 15 to 20 mg/kg (max. 600 mg) once daily
Adults: 600 to 900 mg once daily gentamicin IM for 2 weeks
Children and adults: 5 mg/kg once daily streptomycin IM for 2 weeks
Adults: 1 g once daily For localised forms of the infection, same treatment but for a period of 6 weeks to 4 months depending on the focus.
Prevention


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Prevention
Joint pain (hips, knees, ankles, vertebrae, sacroiliac joint): small erosions or destruction or joint space narrowing.
Often involves the spine, particularly the lumbar spine, causing spondylodiskitis.
Pulmonary signs: chest x-ray often normal. There may be consolidation, nodules, lymphadenopathy, or pleural
effusion.
 
Children under 8 years co-trimoxazole + rifampicin
or co-trimoxazole + gentamicin
Children 8 years and over doxycycline + rifampicin
or doxycycline + gentamicin
Adults doxycycline + rifampicin
or doxycycline + streptomycin or gentamicin
Pregnant/breast-feeding women rifampicin
Washing of hands and clothing if in contact with animals.
Boil milk, avoid ingestion of unpasteurized milk products, cook offal thoroughly.


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Plague
Last updated: September 2022
 
 
Plague is a zoonosis caused by the Gram-negative bacillus Yersinia pestis that affects many wild and domestic
mammals, particularly rodents.
Plague is transmitted to man by infected animals (direct contact or inhalation of their respiratory secretions), the bite
of a ﬂea of infected animals, or inhalation of respiratory secretions of individuals with pneumonic plague.
Natural foci of infection include Africa, Asia, North and South America, and parts of Europe. Bubonic plague is the most common form, usually resulting from the bite of an infected ﬂea. Without prompt
treatment, the bacteria may be disseminated by haematogenous route, producing a more severe form (see below) with
a high mortality rate.


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treatment, the bacteria may be disseminated by haematogenous route, producing a more severe form (see below) with
a high mortality rate.
The following forms of plague may be primary or secondary to bubonic plague:
Clinical features 
See table below. Main differential diagnoses include:
Laboratory
Management
Pneumonic plague can rapidly progress to respiratory distress, shock, and death without prompt treatment.
Septicaemic plague is a fulminant illness that can progress to disseminated intravascular coagulation, respiratory
distress, shock, and death.
Plague meningitis is a rare but very severe form of plague.
Other causes of lymphadenitis (e.g. some bacterial skin infections, tularemia, lymphogranuloma
venereum, chancroid)
Acute pneumonia (Chapter 2)


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Other causes of lymphadenitis (e.g. some bacterial skin infections, tularemia, lymphogranuloma
venereum, chancroid)
Acute pneumonia (Chapter 2)
Other causes of septicaemia (see Shock, Chapter 1) or meningitis (see Bacterial meningitis, Chapter 7)
Collect pre-treatment specimens: lymph node aspirate (bubonic plague), sputum (pneumonic plague), blood
(septicaemic plague), or cerebrospinal ﬂuid (plague meningitis).
Send specimens to reference laboratory for: a 
Rapid diagnostic test for detection of F1 capsular antigen of Y. pestis
PCR 
Culture of Y. pestis and drug suceptibility test
In all cases, rapid test for malaria in endemic regions (and antimalarial treatment if needed, see Malaria, Chapter 6).


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In all cases, rapid test for malaria in endemic regions (and antimalarial treatment if needed, see Malaria, Chapter 6).
Start empiric antibiotic treatment for 10 to 14 days as soon as plague is suspected, before results of diagnosis
tests are available. 
A combination of 2 antibiotics from different classes is recommended in severe disease, plague meningitis, and
pregnant women.
Follow national recommendations according to antibiotic resistance patterns if known. For information: see table
below.


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Forms of plague Clinical features Antibiotic treatment [1]
Bubonic
AND 
Fever, chills, malaise,
headache 
Lymph node (bubo), painful,
usually inguinal, (one or
more) 
Children (including < 8 years) and adults:
doxycycline PO:
or
gentamicin IM or IV:
or
ciproﬂoxacin PO:
Under 45 kg: 4.4 mg/kg (max. 200 mg) on D1, then
2.2 mg/kg (max. 100 mg) 2 times daily
45 kg and over: 200 mg on D1, then 100 mg 2 times
daily
 (a)
Children: 4.5 to 7.5 mg/kg once daily
Adults: 5 mg/kg once daily
Children: 15 mg/kg 2 to 3 times daily (max. 750 mg 2
times daily or 500 mg 3 times daily)
Adults: 750 mg 2 times daily
Pneumonic
AND  
Fever, chills, malaise,
headache 
Dyspnea, chest pain,
productive cough with
purulent or blood-stained
sputum 
Respiratory distress or
failure and sepsis in severe


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headache 
Dyspnea, chest pain,
productive cough with
purulent or blood-stained
sputum 
Respiratory distress or
failure and sepsis in severe
or advanced, untreated
disease
Children and adults: If mild disease:
gentamicin IM or IV (as above)
or
ciproﬂoxacin PO (as above) or IV If severe disease:
gentamicin + ciproﬂoxacin (as above)
or, if not available, gentamicin + doxycycline (as
above) After clinical improvement, change to ciproﬂoxacin or
doxycycline PO (as above).
 (a) 
 (b)
Septicaemic Frequently no localizing
symptoms or signs
Gastrointestinal
disturbances (abdominal
pain, vomiting, diarrhoea,
etc.) often present
As severe pneumonic plague
Meningitis (c) Signs of meningitis. Children and adults:
chloramphenicol IV:
+ ciproﬂoxacin PO or IV (as above)
or, if not available,


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Meningitis (c) Signs of meningitis. Children and adults:
chloramphenicol IV:
+ ciproﬂoxacin PO or IV (as above)
or, if not available,
gentamicin + ciproﬂoxacin (as above)
Children 1 to 12 years: 25 mg/kg (max. 1 g) every 8
hours  
Children 13 years and over and adults: 1 g every 8
hours


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Treatment in pregnant women
Infection prevention and control (in hospitals)
Post-exposure prophylaxis of contacts
In the event of contact (distance less than 2 meters without appropriate personal protective equipment) with a
pneumonic plague patient or direct contact with infected body ﬂuids or tissues of any plague patient and within one
week after the end of exposure:
doxycycline PO for 7 days
Children: 2.2 mg/kg (max. 100 mg) 2 times daily
Adults (including pregnant women): 100 mg 2 times daily
or
ciproﬂoxacin PO for 7 days
Children: 20 mg/kg (max. 750 mg) 2 times daily
Adults: 500 to 750 mg 2 times daily 
Pregnant women: 500 mg 3 times daily
Prevention


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Children: 20 mg/kg (max. 750 mg) 2 times daily
Adults: 500 to 750 mg 2 times daily 
Pregnant women: 500 mg 3 times daily
Prevention
 
(a) Streptomycin IM may be an alternative to gentamicin (except in pregnant women):Children: 15 mg/kg (max. 1 g) every 12 hoursAdults: 1 g every 12 hours
(b) Use ciproﬂoxacin IV when oral route is not possible:Children: 10 mg/kg (max. 400 mg) every 8 or 12 hoursAdults: 400 mg every 8 hours
(c) If plague meningitis develops, add chloramphenicol to the existing regimen, and continue the combined regimen for anadditional 10 days.
Bubonic, pneumonic, and septicaemic plague: gentamicin IM or IV (as above) + ciproﬂoxacin PO (500 mg 3 times
daily) or IV (as above)
Plague meningitis: chloramphenicol IV + ciproﬂoxacin PO (500 mg 3 times daily) or IV (as above)


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daily) or IV (as above)
Plague meningitis: chloramphenicol IV + ciproﬂoxacin PO (500 mg 3 times daily) or IV (as above)  
Bubonic plague: no isolation, standard precautions (handwashing, gowns, gloves, eye protection, etc.) with respect
to lymph node aspiration or discharge and other body ﬂuids.
Pneumonic plague: isolation (in single room if possible), standard precautions, plus, for 48 hours after the start of
antibiotic treatment, droplet precautions (medical mask for healthcare workers and for patients during
contact). Only for aerosol-generating procedures, airborne precautions (FFP2 or N95 respirators) for health
workers exposed to aerosols.
Elimination of ﬂeas (e.g. bedding, clothing, corpse): refer to the guide Public health engineering, MSF.


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workers exposed to aerosols.
Elimination of ﬂeas (e.g. bedding, clothing, corpse): refer to the guide Public health engineering, MSF.
Flea vector control, sanitation and rodent reservoir control, refer to the guide Public health engineering, MSF.
Vaccination against plague is indicated for laboratory technicians handling rodents or working with Y. pestis and is
not a method for controlling an epidemic.
Footnotes
(a) Transportation of specimens in 0.9% sodium chloride requires a cold chain (failing that, a temperature below 30 °C), triplepackaging and UN3373 label.


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References
1. Nelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, et al. Antimicrobial treatment and prophylaxis of plague:recommendations for naturally acquired infection and bioterrorism response. MMWR Recomm Rep 2021;70(No. RR-3):1-27.https://www.cdc.gov/mmwr/volumes/70/rr/rr7003a1.htm?s_cid=rr7003a1_w [Accessed 25 January 2022]


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Leptospirosis
Last update: October 2022
 
 
Leptospirosis is a zoonosis that affects many domestic and wild animals, mainly rodents (particularly rats) but also
dogs and cattle, etc. It is transmitted to humans by contact through skin lesions or mucous membranes (e.g. eyes, mouth) with:
 It is caused by bacteria (spirochetes) of the genus Leptospira. Leptospirosis occurs worldwide, particularly in tropical and subtropical regions. There are often outbreaks after heavy
rainfall or ﬂooding.
Clinical features
Approximately 90% of cases are asymptomatic or mild with a favourable outcome. 5 to 15% of cases present a
severe form with multiple organ dysfunction and a high mortality rate without prompt treatment.
Mild form 
Severe or ictero-haemorrhagic form


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severe form with multiple organ dysfunction and a high mortality rate without prompt treatment.
Mild form 
Severe or ictero-haemorrhagic form 
The onset is the same but a few days later the symptoms worsen: renal disorders (oliguria or polyuria), hepatic disorder
(jaundice), widespread haemorrhages (purpura, ecchymoses, epistaxis, haemoptysis, etc.), pulmonary signs (chest pain)
or cardiac signs (myocarditis, pericarditis). 
 Other conditions to consider include a wide range of acute febrile illnesses, e.g.:  
freshwater or moist soil contaminated with urine of an infected animal (indirect contact);
urine, blood and other body ﬂuids or tissues of an infected animal (direct contact).
Acute phase (septicaemic):


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urine, blood and other body ﬂuids or tissues of an infected animal (direct contact).
Acute phase (septicaemic): 
Sudden onset of high fever with chills, headache, myalgia (especially calf and lumbar pain), photophobia, ocular
pain. Bilateral conjunctival suffusion affecting the bulbar conjunctiva (redness without discharge) is a
characteristic sign, but not always present.
May be associated with: gastrointestinal symptoms (anorexia, abdominal pain, nausea, vomiting), non-
productive cough, lymphadenopathy, hepatomegaly, and sometimes, skin rash.
Immune phase:
The signs of the acute phase regress after 5 to 7 days then reappear for a few days usually in a milder form
(milder fever, less severe myalgia) then disappear.


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(milder fever, less severe myalgia) then disappear. 
Signs of meningitis (thought to be of immune origin) are however very common during this phase.
Diagnosis is difﬁcult because of the broad spectrum of clinical manifestations. Patients that present the following
should be considered as suspected cases of leptospirosis :
and
 [1] 
abrupt onset of fever, chills, conjunctival suffusion, headache, myalgia and jaundice
one or more risk factors for infection: exposure to contaminated freshwater (e.g. swimming, ﬁshing, rice ﬁelds,
ﬂooding) or infected animals (e.g. crop and livestock farmers, veterinarians, butchers and slaughterhouse
workers).
Viral haemorrhagic fevers, dengue, chikungunya, Zika, inﬂuenza, measles, viral hepatitis, other causes of meningitis


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Laboratory
Diagnosis
Other investigations
(if available)
Treatment
Start empiric antibiotic treatment as soon as leptospirosis suspected, before results of diagnosis tests are available.
Mild form (outpatients)
Symptomatic treatment
 Antibiotic treatment
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
or, particularly in pregnant women:
Children: 10 mg/kg (max. 500 mg) on D1 then 5 mg/kg (max. 250 mg) once daily on D2 and D3
Adults : 1 g on D1 then 500 mg once daily on D2 and D3 
or, if not available,
Children: 25 mg/kg (max. 1 g) 2 times daily 
Adults: 1 g 2 times daily  Antibiotic treatment can trigger a Jarisch-Herxheimer reaction (high fever, chills, fall in blood pressure and


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Adults: 1 g 2 times daily  Antibiotic treatment can trigger a Jarisch-Herxheimer reaction (high fever, chills, fall in blood pressure and
sometimes shock). It is recommended to monitor the patient for 2 hours after the ﬁrst dose of antibiotic for
occurrence and management of severe Jarisch-Herxheimer reaction (symptomatic treatment of shock).
 
Severe form (inpatients)
Symptomatic treatment
Malaria
Typhoid fever, brucellosis, rickettsioses
Collect pre-treatment specimens and send them to reference laboratory:
Acute phase (ﬁrst week of illness): blood and/or serum for IgM screening, PCR, and acute specimen for
microscopic agglutination test (MAT);
Immune phase (second week of illness): serum for IgM screening and convalescent specimen for MAT, and urine
for PCR.


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Immune phase (second week of illness): serum for IgM screening and convalescent specimen for MAT, and urine
for PCR.
In all cases, rapid test for malaria in endemic regions (and antimalarial treatment if needed, see Malaria, Chapter 6).
Serum creatinine: elevated if renal dysfunction.
Full blood count: possible neutrophilia and thrombocytopenia (acute phase), or anaemia secondary to haemorrhage
(immune phase).
Cerebrospinal ﬂuid (immune phase): features of aseptic meningitis in CSF (see viral meningitis, Chapter 7).
Urine: mild proteinuria, leukocyturia, possible microscopic haematuria (acute phase).
Rest and treatment of pain and fever: paracetamol PO (Chapter 1).
Acetylsalicylic acid (aspirin) is contra-indicated (risk of haemorrhage).
doxycycline PO for 7 days


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Acetylsalicylic acid (aspirin) is contra-indicated (risk of haemorrhage).
doxycycline PO for 7 days
azithromycin PO for 3 days
amoxicillin PO for 7 days


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 Antibiotic treatment
Children: 80 to 100 mg/kg (max. 2 g) once daily
Adults: 2 g once daily
or
Children: 50 000 IU (30 mg)/kg (max. 2 MIU or 1200 mg) every 6 hours
Adults: 1 to 2 MIU (600 to 1200 mg) every 6 hours
Prevention
 
References
Speciﬁc management according to organs affected. Oliguria generally responds to correction of hypovolaemia.
Rest and treatment of pain and fever: paracetamol PO (Chapter 1). Avoid or use paracetamol with caution in
patients with hepatic involvement.
ceftriaxone IV for 7 days a
benzylpenicillin IV for 7 days
Avoid bathing in freshwater in endemic areas.
Disinfect laundry and objects soiled by urine of infected animal or patient. 
Vaccination and protective clothing (only for professionals at risk of exposure).
Footnotes


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Vaccination and protective clothing (only for professionals at risk of exposure).
Footnotes
(a) For IV administration of ceftriaxone, dilute with water for injection only.
1. World Health Organization. Human leptospirosis: guidance for diagnosis, surveillance and control. World Health Organization,2003.https://apps.who.int/iris/bitstream/handle/10665/42667/WHO_CDS_CSR_EPH_2002.23.pdf?%20sequence=1&isAllowed=y[Accessed 5 September 2022]


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Relapsing fever (borreliosis)
 
 
 
 
Relapsing fever (FR) is caused by spirochetes of the genus Borrelia, transmitted to humans by arthropod vectors.
Louse-borne relapsing fever (LBRF)
Tick-borne relapsing fever (TBRF)


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Louse-borne relapsing fever (LBRF)
Last updated: October 2022
 
 
LBRF is caused by Borrelia recurrentis. It occurs in epidemic waves when conditions favourable to the transmission of
body lice are met: cold climate/season, overcrowding and very poor sanitation (e.g. refugee camps, prisons). Endemic
foci of LBRF are mainly the Sudan and the Horn of Africa (especially Ethiopia). LBRF can be associated with louse-
borne typhus (see Eruptive rickettsioses). The mortality rate for untreated LBRF ranges from 15 to 40%.
Clinical features
 In practice, in an applicable epidemiological setting (see above), a suspect case of LBRF is, according to WHO, a
patient with high fever and two of the following symptoms: severe joint pain, chills, jaundice or signs of bleeding (nose


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patient with high fever and two of the following symptoms: severe joint pain, chills, jaundice or signs of bleeding (nose
or other bleeding) or a patient with high fever who is responding poorly to antimalarial drugs. Clothing should be
checked for the presence of body lice and nits.
Laboratory
The diagnosis is conﬁrmed by detection of Borrelia in thick or thin blood ﬁlms (Giemsa stain). Blood samples must be
collected during febrile periods. Spirochetes are not found in the  peripheral blood during afebrile periods. In addition,
the number of circulating spirochetes tends to decrease with each febrile episode.
Treatment
Relapsing fever is characterized by febrile episodes separated by afebrile periods of approximately 7 days (4 to 14
days).
The initial febrile episode lasts up to 6 days:


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days).
The initial febrile episode lasts up to 6 days:
Sudden onset of high fever (axillary temperature > 39 °C), severe headache and asthenia, diffuse pain (muscle,
joint, back pain), often associated with gastrointestinal disturbances (anorexia, abdominal pain, vomiting,
diarrhoea).
Splenomegaly is common; bleeding signs (e.g. petechiae, subconjunctival haemorrhage, epistaxis, bleeding
gums), jaundice or neurological symptoms may be observed.
The febrile episode terminates in a crisis with an elevation in temperature, heart rate and blood pressure,
followed by a fall in temperature and blood pressure, which may last for several hours.
Following the initial febrile episode, the cycle usually reccurs; each episode is less severe than the previous one and


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Following the initial febrile episode, the cycle usually reccurs; each episode is less severe than the previous one and
the patient develops temporary immunity.
Complications:
collapse during defervescence, myocarditis, cerebral haemorrhage;
during pregnancy: abortion, preterm delivery, in utero foetal death, neonatal death.
Antibiotic treatment (suspect or conﬁrmed cases and close contacts):
doxycycline PO
Children: 4 mg/kg (max. 100 mg) single dose 
Adults: 200 mg single dose
or
erythromycin PO
Children under 5 years: 250 mg single dose
Children 5 years and over and adults: 500 mg single dose


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or
azithromycin PO
Children: 10 mg/kg (max. 500 mg) single dose
Adults: 500 mg single dose
Treatment of pain and fever (paracetamol PO) and prevention or treatment of dehydration in the event of
associated diarrhoea.
Elimination of body lice is essential in control of epidemics (see Pediculosis, Chapter 4).


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Tick-borne relapsing fever (TBRF)
Last update: October 2022
 
 
TBRFs are caused by different Borrelia species. They are endemic in temperate and warm regions of the word,
especially in Africa (Tanzania, DRC, Senegal, Mauritania, Mali, the Horn of Africa) and mainly in rural areas. TBRF is a
major cause of morbidity and mortality in children and pregnant women. The mortality rate for untreated TBRF ranges
from 2 to 15%.
Clinical features
The clinical manifestations and complications of TBRF are similar to those of LBRF but central nervous system (CNS)


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from 2 to 15%.
Clinical features
The clinical manifestations and complications of TBRF are similar to those of LBRF but central nervous system (CNS)
involvement (particularly lymphocytic meningitis) is more frequent than in LBRF and the number of relapses is higher. The clinical diagnosis is difﬁcult, especially during the ﬁrst episode: cases occur sporadically rather than in outbreaks;
the tick bite is painless and usually unnoticed by the patient; symptoms are very similar to those of malaria, typhoid
fever, leptospirosis, certain arbovirosis (yellow fever, dengue) or rickettsiosis, and meningitis.
Laboratory
Treatment
Children under 45 kg: 2.2 mg/kg (max. 100 mg) 2 times daily 
Children 45 kg and over and adults: 100 mg 2 times daily 
or


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Laboratory
Treatment
Children under 45 kg: 2.2 mg/kg (max. 100 mg) 2 times daily 
Children 45 kg and over and adults: 100 mg 2 times daily 
or
azithromycin PO for 7 to 10 days (if doxycycline is contra-indicated or not available)
Children: 10 mg/kg (max. 500 mg) once daily
Adults: 500 mg once daily
or
ceftriaxone IV for 10 to 14 days (for pregnant women or in case of CNS involvement)
Children: 50 to 75 mg/kg (max. 2 g) once daily
Adults: 2 g once daily 
   Antibiotic treatment can trigger a Jarisch-Herxheimer reaction with high fever, chills, fall in blood pressure and
sometimes shock. It is recommended to monitor the patient for 2 hours after the ﬁrst dose of antibiotic, for
occurrence and management of severe Jarisch-Herxheimer reaction (symptomatic treatment of shock).


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occurrence and management of severe Jarisch-Herxheimer reaction (symptomatic treatment of shock).
Jarisch-Herxheimer reaction appears to occur more frequently in LBRF than in TBRF.
 
As for LBRF, the diagnosis is conﬁrmed by detection of Borrelia in the patient’s blood.
Repeat the examination if the ﬁrst smear is negative despite strong clinical suspicion.
In all cases, rapid test for malaria in endemic regions (and antimalarial treatment if needed, see Malaria, Chapter 6).
Antibiotic treatment:
doxycycline PO for 7 to 10 days
 a 
Treatment of pain and fever (paracetamol PO) and prevention or treatment of dehydration in the event of
associated diarrhoea.


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Footnotes
(a) For IV administration of ceftriaxone, dilute with water for injection only.


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Eruptive rickettsioses
Last update: October 2022
 
 
Rickettsioses are eruptive fevers caused by bacteria of the genus Rickettsia and transmitted to man by an arthropod
vector. Three main groups are distinguished: typhus group, spotted fever group and scrub typhus group.
Clinical features
 
Common to all forms:
Sudden onset of fever (temperature of over 39 °C) with severe headache and myalgias.
3 to 5 days later; onset of generalised cutaneous eruption (see below).
Hypotension; non-dissociated rapid heart rate (variable).
Typhoid state: prostration, obnubilation, confusion and extreme asthenia, particularly marked in typhus forms.
Inoculation eschar: painless, black crusted lesion surrounded by a erythematous halo at the site of the bite.


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Inoculation eschar: painless, black crusted lesion surrounded by a erythematous halo at the site of the bite.
Always check for this signiﬁcant sign.
Non-cutaneous signs vary from one form to another, and are atypical and variable (see below).


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Laboratory
Detection of speciﬁc IgM of each group by indirect immunoﬂuorescence. The diagnosis is conﬁrmed by 2 serological
tests at an interval of 10 days. In practice, clinical signs and the epidemiological context are sufﬁcient to suggest the
diagnosis and start treatment.
Group Typhus Spotted fever Scrub
typhus
Form Epidemic typhus Murine typhus Mediterranean 
spotted fever
Rocky
Mountain
spotted fever
Other Old-
World tick-
borne fevers
Scrub typhus
Pathogen R. prowasekii R. typhi R. conorii R. rickettsii R. sibirica, R.
australis
O.
tsutsugamushi
Vector body lice rat ﬂeas ticks ticks ticks mites
Reservoir man rats dogs rodents rodents, dogs,
etc.
rodents
Occurence epidemic endemic endemic endemic endemic sporadic
Geographical
distribution
worldwide,
conﬂicts; main


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etc.
rodents
Occurence epidemic endemic endemic endemic endemic sporadic
Geographical
distribution
worldwide,
conﬂicts; main
sites:
Burundi/Rwanda,
Ethiopia
worldwide around the
mediterranean,
Sub-Saharan
Africa
North America, 
Central
America,
Columbia,
Brazil
Southern
Africa,
Australia,
Siberia
Far East, India,
South Paciﬁc
Area
Rash maculopapular maculopapular maculopapular purpural maculopapular macular
Eschar 0 0 black
necrotic area
rare black
necrotic area
black
necrotic area
Typhoid
state
+++ +++ +/- +/- +/- +++
Extra-
cutaneous
signs
cough, myalgia,
meningeal signs
gastrointestinal
signs
meningeal
signs
gastrointestinal
and
neurological
signs,
hypotension
variables meningeal
signs
Case fatality
(%)
30 (without
treatment)
5 2 5 1 0-30


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meningeal
signs
gastrointestinal
and
neurological
signs,
hypotension
variables meningeal
signs
Case fatality
(%)
30 (without
treatment)
5 2 5 1 0-30
Complications can be severe, and sometimes fatal: encephalitis, myocarditis, hepatitis, acute renal failure,
haemorrhage etc.


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Treatment
 
Children under 45 kg: 2.2 mg/kg (max. 100 mg) 2 times daily
Children 45 kg and over and adults: 100 mg 2 times daily
In severe infections, a loading dose of doxycycline is recommended:
Children under 45 kg: 4.4 mg/kg (max. 200 mg) on D1 then 2.2 mg /kg (max. 100 mg) 2 times daily
Children 45 kg and over and adults: 200 mg on D1 then 100 mg 2 times daily 
Prevention
 
Symptomatic treatment:
Hydration (PO or IV if the patient is unable to drink).
Fever: paracetamol PO (Chapter 1). Acetylsalicylic acid (aspirin) is contra-indicated due to the risk of
haemorrhage.
Antibiotic for 5 to 7 days or until 3 days after the fever has disappeared:
doxycycline PO
 a 
In a context of epidemic typhus, doxycycline PO is the choice treatment, but there is a risk of recurrence:


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doxycycline PO
 a 
In a context of epidemic typhus, doxycycline PO is the choice treatment, but there is a risk of recurrence:
Children: 4 mg/kg (max. 100 mg) single dose 
Adults: 200 mg single dose
Epidemic typhus: control of body lice (see Pediculosis, Chapter 4).
Murine typhus: control of ﬂeas and then rats.
Spotted fevers: avoid tick bites by wearing clothing and using repellents.
Scrub typhus: use of repellents, chemoprophylaxis with doxycycline PO (200 mg once weekly in adults).
Footnotes
(a) Unlike borrelioses, antibiotic treatment of rickettsioses does not provoke a Jarisch-Herxheimer reaction. However, thegeographical distribution of borrelioses and rickettsioses may overlap, and thus a reaction may occur due to a possible co-infection (see Borreliosis).


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Chapter 8: Viral diseases
Measles
Poliomyelitis
Rabies
Viral hepatitis
Dengue
Viral haemorrhagic fevers
HIV infection and AIDS


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Measles
Measles is a highly contagious acute viral infection, transmitted by the airborne route (inhalation of respiratory droplets
spread by infected individuals). The disease mainly affects children under 5 years of age and can be prevented by
immunization. For more information, refer to the guide Management of a measles epidemic, MSF.
Clinical features
The average incubation period is 10 days. Prodromal or catarrhal phase (2 to 4 days)
 Eruptive phase (4 to 6 days)
 The eruptive phase is followed by skin desquamation during 1 to 2 weeks, very pronounced on pigmented skin (the skin
develops a striped appearance). In practice, a patient presenting with fever and erythematous maculopapular rash and at least one of the following


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develops a striped appearance). In practice, a patient presenting with fever and erythematous maculopapular rash and at least one of the following
signs: cough or runny nose or conjunctivitis, is a clinical case of measles.
Complications
Most measles cases experience at least one complication:
 Pneumonia and dehydration are the most common immediate causes of death.
Case management
High fever (39-40 °C) with cough, coryza (nasal discharge) and/or conjunctivitis (red and watery eyes).
Koplik’s spots: tiny bluish-white spots on an erythematous base, found on the inside of the cheek. This sign is
speciﬁc of measles infection, but may be absent at the time of examination. Observation of Koplik's spots is not
required for diagnosing measles.


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speciﬁc of measles infection, but may be absent at the time of examination. Observation of Koplik's spots is not
required for diagnosing measles.
On average 3 days after the onset of symptoms: eruption of erythematous, non- pruritic maculopapules, which
blanch with pressure. The rash begins on the forehead then spreads downward to the face, neck, trunk
(second day), abdomen and lower limbs (third and fourth day).
As the rash progresses, prodromal symptoms subside. In the absence of complications, the fever disappears once
the rash reaches the feet.
The rash fades around the ﬁfth day in the same order that it appeared (from the head to the feet).
Respiratory and ENT: pneumonia, otitis media, laryngotracheobronchitis


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Respiratory and ENT: pneumonia, otitis media, laryngotracheobronchitis
Ocular: purulent conjunctivitis, keratitis, xerophthalmia (risk of blindness)
Gastrointestinal: diarrhoea with or without dehydration, benign or severe stomatitis
Neurological: febrile seizures; rarely, encephalitis
Acute malnutrition, provoked or aggravated by measles (post-measles period)
Admit as inpatient children with at least one major complication:
Inability to eat/drink/suck, or vomiting
Altered consciousness or seizures
Dehydration
Severe pneumonia (pneumonia with respiratory distress or cyanosis or SpO < 90%)2
Acute laryngotracheobronchitis (croup) a
Corneal lesions (pain, photophobia, erosion or opacity)


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If in doubt, keep the child under observation for a few hours.
Treatment
Supportive and preventive treatment
Treatment of complications
Severe oral lesions that prevent eating
Acute malnutrition
Treat as outpatient children with no major complications, no complications or minor complications:
Pneumonia without severe signs
Acute otitis media
Purulent conjunctivitis (no corneal lesions)
Diarrhoea without dehydration
Oral candidiasis that does not interfere with eating
Isolation
Isolation of hospitalized patients
Measles cases treated as outpatients should be kept at home during this period.
Treat fever: paracetamol (Fever, Chapter 1).
Make the child drink (high risk of dehydration).
Give smaller, more frequent meals or breastfeed more frequently (every 2 to 3 hours).


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Make the child drink (high risk of dehydration).
Give smaller, more frequent meals or breastfeed more frequently (every 2 to 3 hours).
Clear the nasopharynx (nose-blowing or nasal lavages) to prevent secondary respiratory infection and improve the
child’s comfort.
Clean the eyes with clean water 2 times daily and administer retinol on D1 and D2 (see Xerophthalmia, Chapter 5) to
prevent ocular complications.
In children under 5 years: amoxicillin PO for 5 days as a preventive measure (reduction of respiratory and ocular
infections).
In the event of watery diarrhoea without dehydration: oral rehydration according to WHO Plan A (see Dehydration,
Chapter 1).
Insert a nasogastric tube for a few days if oral lesions prevent the child from drinking.


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Prevention
 
  Treatment of complications
Severe pneumonia ceftriaxone IV or IM + cloxacillin IV then change to amoxicillin/clavulanic acid
PO (see Chapter 2)
+ oxygen if cyanosis or SpO < 90%
+ salbutamol if expiratory wheezing and sibilant rales on auscultation
In all cases, close monitoring.
2
Pneumonia without severe
signs
amoxicillin PO for 5 days
Croup Inpatient monitoring (risk of worsening). Keep the child calm. Agitation and crying
exacerbate the symptoms.
For severe croup:
dexamethasone IM: 0.6 mg/kg single dose
+ nebulized epinephrine (adrenaline, 1 mg/ml ampoule): 0.5 ml/kg (max. 5 ml)
+ oxygen if cyanosis or SpO < 90%
Intensive monitoring until symptoms resolve.
2
Acute otitis media See Otitis, Chapter 2.


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+ oxygen if cyanosis or SpO < 90%
Intensive monitoring until symptoms resolve.
2
Acute otitis media See Otitis, Chapter 2.
Dehydration Per oral route or IV depending on the degree of dehydration.
Oral candidiasis See Stomatitis, Chapter 3.
Purulent conjunctivitis See Conjunctivitis, Chapter 5.
Keratitis/keratoconjunctivitis tetracycline 1% eye ointment 2 times daily for 7 days
+ retinol PO one dose on D1, D2 and D8 (see Xerophthalmia, Chapter 5)
+ eye protection and pain management (see Pain, Chapter 1).
No topical corticosteroids.
Xerophthalmia See Xerophthalmia, Chapter 5.
Febrile seizures See Seizures, Chapter 1.
No chemoprophylaxis for contacts.
Vaccination:
Between 9 and 12 months: one dose of 0.5 ml. The WHO recommends a second dose between 15 and 18


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No chemoprophylaxis for contacts.
Vaccination:
Between 9 and 12 months: one dose of 0.5 ml. The WHO recommends a second dose between 15 and 18
months. Respect an interval of at least 4 weeks between doses.
Where there is high risk of infection (overcrowding, epidemics, malnutrition, infants born to a mother with HIV
infection, etc.), administer a supplementary dose from 6 months of age then continue vaccination schedule.
Children under 15 years who have missed either one or both doses of routine vaccination should be vaccinated
when they come in contact with health services. Check national recommendations.


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Footnotes
(a) Symptoms (hoarse crying or voice, difﬁculty breathing, a high-pitched inspiratory wheeze [inspiratory stridor], characteristic"barking" cough) are caused by inﬂammation and narrowing of the larynx. Croup is considered benign or “moderate” if thestridor occurs when the child is agitated or crying, but disappears when the child is calm. The child should be monitoredduring this period, however, because his general and respiratory status can deteriorate rapidly. Croup is severe when thestridor persists at rest or is associated with signs of respiratory distress.


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Poliomyelitis
Poliomyelitis is an acute viral infection due to a poliovirus (serotypes 1, 2 or 3). Human-to-human transmission is direct
(faecal-oral) or indirect (ingestion of food and water contaminated by stool). Humans are the only reservoir of the virus.
In principle the disease can be eradicated by mass vaccination. In endemic areas, poliomyelitis mainly affect children under 5 years not (or not fully) vaccinated, but the infection can
affect persons of any age, especially in areas where population immunity is low.
Clinical features
Laboratory
Look for the polio virus in stool samples. The virus is excreted for one month after infection, but only intermittently;


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Clinical features
Laboratory
Look for the polio virus in stool samples. The virus is excreted for one month after infection, but only intermittently;
therefore, 2 samples must be collected with an interval of 24-48 hours, and within 14 days of onset of symptoms
. Send the stool samples to a reference laboratory, with a clinical description of the patient. The stool samples must be
stored and transported between 0 °C and 8 °C.
Treatment
Outbreak control in case of acute ﬂaccid paralysis (AFP)
Up to 90% of cases are asymptomatic or present mild symptoms . [1] 
Non-paralytic form: a non-speciﬁc febrile illness with muscle pain, headache, vomiting, backache; no neurological
involvement. As spontaneous recovery usually occurs within 10 days, diagnosis is rarely made outside epidemic
contexts.


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involvement. As spontaneous recovery usually occurs within 10 days, diagnosis is rarely made outside epidemic
contexts.
Paralytic form: in less than 1% of cases, after the non-speciﬁc signs, the patient develops rapid onset (from the
morning to the evening) asymmetrical acute ﬂaccid paralysis, predominantly of the lower limbs, with ascending
progression. The muscles become soft with diminished reﬂexes. Sensation is maintained. The disease is life
threatening if paralysis involves the respiratory muscles or muscles of swallowing. Initial urinary retention is common.
Gastrointestinal disturbances (nausea, vomiting, diarrhoea), muscle pain and meningeal symptoms may also occur.
 [2]


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Gastrointestinal disturbances (nausea, vomiting, diarrhoea), muscle pain and meningeal symptoms may also occur.
 [2]
Hospitalise patients with the paralytic form: rest, prevent bed sores in bedridden patients, give analgesics (do not
give IM injections to patients in the febrile phase), ventilate patients with respiratory paralysis.
Physiotherapy once the lesions are stable to prevent muscle atrophy and contractures.
Care for sequelae: physiotherapy, surgery and prosthetics.
Consider any patient with AFP as a suspected case of poliomyelitis.
Send stool samples to a reference laboratory to conﬁrm the diagnosis.  
Organize vaccination of all children under 5 years living in the area (from the same village or neighbouring villages)


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Organize vaccination of all children under 5 years living in the area (from the same village or neighbouring villages)
irrespective of their vaccination status, within 14 days of laboratory conﬁrmation and with the available vaccine
(round 0) . [3] 
Organize two mass vaccination campaigns within 8 weeks of the laboratory conﬁrmation. The type of vaccine, the
area and the age groups are determined by epidemiological data.
Organize a mop-up (door-to-door) vaccination campaign wherever monitoring suggests that children have been
missed, to ensure interruption of transmission.
Surveillance: for each case of AFP there are between 100 and 200 subclinical cases. Therefore, active surveillance
to detect new cases is essential for epidemic control.


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Prevention
In children who start routine vaccination late (after the age of 3 months), the dose of IPV is administered together with
the ﬁrst dose of bOPV, followed by 2 doses of bOPV alone administered 4 weeks apart.
There is also an ‘IPV only’ schedule: 3 doses administered at least 4 weeks apart (e.g. at 6, 10 and 14 weeks) and a
booster dose at least 6 months later.
IPV should eventually completely replace bOPV.
 
References
3 types of vaccines exist:
a trivalent injectable inactivated poliovirus vaccine (IPV),
a bivalent oral live attenuated poliovirus vaccine (bOPV), containing serotypes 1 and 3,
a monovalent oral type 2 vaccine (mOPV or nOPV) exclusively used for responding to epidemics.
Vaccination schedule: depends on the epidemiology of the virus.


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Vaccination schedule: depends on the epidemiology of the virus.
Protocols vary according to the country, follow national recommendations. For information, the WHO
recommends:
Schedule
Primary vaccination
Endemic or at risk zones (a) Other zones
Birth 1 dose bOPV (b) –
6 weeks 1 dose bOPV 1 dose bOPV
10 weeks 1 dose bOPV 1 dose bOPV
14 weeks 1 dose bOPV + 1 dose IPV 1 dose bOPV + 1 dose IPV
(a) Countries where poliomyelitis is endemic or zones at high risk of importation and subsequent spread of the virus.
(b) The ﬁrst dose of bOPV is administered at birth, or as soon as possible, to optimise seroconversion rates after subsequentdoses and induce mucosal protection.


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1. World Health Organization. Poliomyelitis (polio).https://www.who.int/health-topics/poliomyelitis#tab=tab_1 [Accessed 08 June 2021]
2. Centers for Disease Control and Prevention. Poliomyelitis. 2020.https://www.cdc.gov/vaccines/pubs/pinkbook/polio.html [Accessed 08 June 2021]
3. Global Polio Eradication Initiative. Standard operating procedures: responding to a poliovirus event or outbreak, version 3.1.World Health Organization. 2020.https://www.who.int/publications/i/item/9789240002999 [Accessed 08 June 2021]


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Rabies
Rabies is a viral infection of wild and domestic mammals, transmitted to humans by the saliva of infected animals
through bites, scratches or licks on broken skin or mucous membranes.  In endemic areas (Africa and Asia), 99% of cases are due to dog bites and 40% of cases are children under 15 years of
age . Before symptoms develop, rabies can effectively be prevented by post-exposure prophylaxis.
Once symptoms develop, rabies is fatal. There is no curative treatment; care is palliative. 
Clinical features
 Diagnosis is often difﬁcult: there may be no history of scratch or bite (exposure through licking) or wounds may have
healed; a reliable history may be difﬁcult to obtain.
Post-exposure prophylaxis
Deﬁnitions of exposure categories (WHO)


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healed; a reliable history may be difﬁcult to obtain.
Post-exposure prophylaxis
Deﬁnitions of exposure categories (WHO)
 Post-exposure prophylaxis is carried out for Category II and III exposures.
Treatment of the wound
In all cases
 [1] 
The incubation period averages 20 to 90 days from exposure (75% of patients), but can be shorter (in severe
exposure, e.g. bites to face, head and hands; multiple bites), or longer (20% of patients develop symptoms
between 90 days and 1 year, and 5% more than 1 year after exposure).
Prodromal phase: itching or paraesthesiae or neuropathic pain around the site of exposure, and non-speciﬁc
symptoms (fever, malaise, etc.).
Neurologic phase:
Encephalitic form (furious form): psychomotor agitation or hydrophobia (throat spasms and panic, triggered by


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Neurologic phase:
Encephalitic form (furious form): psychomotor agitation or hydrophobia (throat spasms and panic, triggered by
attempting to drink or sight/sound/touch of water) and aerophobia (similar response to a draft of air); sometimes
seizures. The patient is calm and lucid between episodes. Infection evolves to paralysis and coma.
Paralytic form (less common, 20% of cases): progressive ascending paralysis resembling Guillain-Barré
syndrome; evolves to coma.
Category I Contact with animal, or licks on intact skin No exposure
Category II Nibbles on exposed skin
Minor bite(s) or scratch(es) without bleeding Minor exposure
Category III
Transdermal bite(s) or scratch(es)
Licks on broken skin
Contamination of mucous membranes by animal’s saliva (licks)
Direct contact with bats a


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Transdermal bite(s) or scratch(es)
Licks on broken skin
Contamination of mucous membranes by animal’s saliva (licks)
Direct contact with bats a
Severe exposure


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Prolonged cleansing of the wound or contact site for 15 minutes to eliminate the virus, as soon as possible after
exposure, is of critical importance. For skin: use soap, rinse copiously with running water, remove all foreign material;
application of a disinfectant (povidone iodine 10% or other) is an additional precaution which does not take the place
of thorough wound washing. For mucous membranes (eye, mouth, etc.): rinse thoroughly with water or 0.9% sodium
chloride. Local cleansing is indicated even if the patient presents late.
According to condition/type of wound
In order to avoid inoculating virus deeper into the tissues, wounds are either not sutured at all (e.g. superﬁcial, non-


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In order to avoid inoculating virus deeper into the tissues, wounds are either not sutured at all (e.g. superﬁcial, non-
mutilating or puncture wounds), or are left open and re-evaluated in 48-72 hours, with a view to possible closure. Highly
contaminated wounds, or wounds that may compromise function, require surgical management (exploration, removal
of foreign material, excision of necrotic tissue, copious irrigation with sterile 0.9% sodium chloride or Ringer lactate,
with local or general anaesthesia). When suturing is indicated (face), rabies immunoglobulin should be administered
several hours before wound closure (see below). Infected wounds are not sutured and reassessed daily.
Passive and active immunisation


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several hours before wound closure (see below). Infected wounds are not sutured and reassessed daily.
Passive and active immunisation
Given the duration of incubation, administration of vaccine/immunoglobulin is always a priority, even for patients
exposed several months previously.
Anti-rabies serotherapy
Rabies immunoglobulin is indicated after:
 It is intended to neutralize virus in the exposure site. It is given as a single dose on D0, with the ﬁrst dose of rabies
vaccine.
human rabies immunoglobulin:
Children and adults: 20 IU/kg
or
highly puriﬁed rabies immunoglobulin F(ab')2 fragments:
Children and adults: 40 IU/kg Inﬁltrate rabies immunoglobulin into and around the previously washed wound(s). Ensure it is not injected into a blood
vessel (risk of shock).


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vessel (risk of shock).
For ﬁnger wounds, inﬁltrate very cautiously to avoid increased pressure in the tissue compartment (compartment
syndrome).
In the event of multiple wounds, dilute the dose 2- to 3-fold with sterile 0.9% sodium chloride to obtain a sufﬁcient
quantity to inﬁltrate all the sites exposed.
Inﬁltrate rabies immunoglobulin into the wound even if it has already healed. 
For mucosal exposures with no wound, rinse with rabies immunoglobulin diluted in sterile 0.9% sodium chloride. Monitor the patient during and after the injection (low risk of anaphylactic reaction). If rabies immunoglobulin is not available on D0, the ﬁrst dose of rabies vaccine is administered alone. Administer rabies
immunoglobulin as soon as possible between D0 and D7; from D8, it is not necessary to


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immunoglobulin as soon as possible between D0 and D7; from D8, it is not necessary to
administer rabies immunoglobulin as vaccine-induced antibodies begin to appear.
Post-exposure rabies prophylaxis 
Category III exposures (except in patients who have received a full course of pre-exposure prophylaxis against
rabies, see Prevention); 
Category II and III exposures in immunocompromised patients (even in patients who have received a full course of
pre-exposure prophylaxis against rabies).
 b 
 [1]


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A complete prophylaxis series is indicated for Category II and III exposures. It should be started on D0 and continued to
completion if the risk of rabies has not been excluded . Several different types of rabies vaccines prepared from cell
cultures (CCEEV) exist.  These vaccines must replace nerve tissue vaccines (NTV). 
Prophylaxis schedules may vary from country to country, check national recommendations. The patient must be
administered the full course of doses indicated. 
Main post-exposure prophylaxis regimens
Notes:
Other measures
Antibiotherapy/antibiotic prophylaxis
 c 
 [1]
Date
No pre-exposure prophylaxis or unknown prophylaxis status 
or incomplete pre-exposure prophylaxis or complete pre-exposure prophylaxis with an NTV
IM route


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or incomplete pre-exposure prophylaxis or complete pre-exposure prophylaxis with an NTV
IM route
1 dose = 0.5 or 1 ml depending on the
manufacturer
 (a) ID route
1 dose = 0.1 ml
 (b) 
D0 2 doses
(1 dose in each arm or thigh)
 (c) 1 dose (c) 2 doses
(1 dose in each arm)
 (c) 
D3   1 dose 2 doses 
(1 dose in each arm)
D7 1 dose 1 dose 2 doses 
(1 dose in each arm)
D14   1 dose (d)  
D21 1 dose    
(a) IM route: there are two possible schedules, the Zagreb regimen (2-0-1-0-1) over 21 days or the 4-dose Essen regimen (1-1-1-1-0) over 14 to 28 days. The IM injection is administered into the anterolateral part of the thigh in children < 2 years; intothe deltoid muscle (arm) in children ≥ 2 years and adults; do not administer into the gluteal muscle.


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(b) ID route: inject into the deltoid muscle (or the suprascapular region or the anterolateral part of the thigh). Incorrect IDtechnique results in failure of post-exposure prophylaxis. If correct ID technique cannot be assured, use IM route.
(c) As well as a single dose of rabies immunoglobulin on D0 if indicated.
(d) The last injection can be administered between D14 and D28.
In immunocompromised patients: 1 dose on D0, 1 dose on D7 and 1 dose between D21 and D28. [1]
In patients that have received a full course of pre-exposure prophylaxis (see  Prevention), the post-exposure
regimen is: 1 dose on D0 and 1 dose D3 by IM or ID route or 4 doses by ID route on D0.
 [2]


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 The same dosage is used for both treatment and prophylaxis:
The treatment of choice is 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)
Tetanus vaccination and serotherapy
Check prophylaxis status. If unknown or not up-to-date, see Tetanus, Chapter 7.
Prevention
Pre-exposure prophylaxis with a CCEEV for people at risk (prolonged stay in rabies endemic areas, professionals in
contact with animals susceptible of carrying the virus, etc): 1 dose by IM route or 2 doses by ID route on D0 and D7.


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contact with animals susceptible of carrying the virus, etc): 1 dose by IM route or 2 doses by ID route on D0 and D7.
 
Infection present No infection
and
No infection 
and
local: redness,
oedema, serosanguinous
or purulent drainage
locoregional or general:
lymphangitis, lymphadenopathy,
localised cellulitis, bone or joint
infection, fever
wounds on the face or hands or
genital region
wounds involving joint, tendon,
ligament or fracture
deep puncture wounds
wounds with crush injury
wounds very contaminated or
requiring debridement
wounds where correct debridement
is not possible
immunocompromised patients
no criteria requiring antibiotic
prophylaxis
wounds more than 24-48
hours old
Antibiotherapy PO 7 days in the event
of local non severe infection;
14 days in the event of severe local


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wounds more than 24-48
hours old
Antibiotherapy PO 7 days in the event
of local non severe infection;
14 days in the event of severe local
infection, or widespread generalised
infection.
Antibiotic prophylaxis PO 5 to 7 days No antibiotic prophylaxis
 d 
Footnotes
(a) In the event of direct contact with bats, check national recommendations.
(b) For example, for HIV-infected patients: CD4 ≤ 25% in children < 5 years and < 200 cells/mm³ in children ≥ 5 years and adults.(http://apps.who.int/iris/bitstream/handle/10665/272371/WER9316.pdf?ua=1)


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(c) Either through observation of the captured animal (if domestic) or through laboratory diagnosis of the animal (killed). TheWHO recommends a 10-day observation period of the animal, if captured. If no signs of rabies develop during theobservation period, the risk of rabies is excluded, and post-exposure prophylaxis is discontinued. Laboratory diagnosis ofthe dead animal involves sending the head to a specialised laboratory, which conﬁrms or excludes rabies in the animal. Iflaboratory diagnosis is negative, risk of rabies is excluded, and post-exposure prophylaxis is discontinued.


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References
(d) In penicillin-allergic patients: • Children: co-trimoxazole (30 mg SMX + 6 mg TMP/kg 2 times daily) + clindamycin (10 mg/kg 3 times daily) • Adults: co-trimoxazole (800 mg SMX + 160 mg TMP 2 times daily) or doxycycline (100 mg 2 times daily or 200 mg oncedaily, except in pregnant and lactating women) + metronidazole (500 mg 3 times daily).
1. Weekly epidemiological record/Relevé épidémiologique hebdomadaire, 20 April 2018, 93th year/20 avril 2018, 93e année.No 16, 2018, 93, 201–220.http://apps.who.int/iris/bitstream/handle/10665/272371/WER9316.pdf?ua=1 [Accessed 25 october 2018]
2. Spencer O, Banerjee S. Animal bites. BMJ Best practice 2018 [Accessed 25 october 2018]


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Viral hepatitis
Last updated: October 2021
 
Several viral infections of the liver are grouped under the heading of viral hepatitis: hepatitis A, B, C, D (delta) and E.
The different hepatitis viruses are present throughout the world, but their prevalence varies by country. Hepatitis A and
B are common in developing countries where the vast majority of infections occur during childhood. The clinical characteristics of all ﬁve diseases are similar enough to make differential diagnosis difﬁcult; however, there
are epidemiological, immunological and pathological differences. Patients with hepatitis B, C and D may later develop
chronic liver disease.
The main characteristics of each type of viral hepatitis are summarized in the table below.
Clinical features


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chronic liver disease.
The main characteristics of each type of viral hepatitis are summarized in the table below.
Clinical features
 The various forms of viral hepatitis
Asymptomatic forms
Mild or anicteric forms are the most common, irrespective of the causal virus. 
Icteric forms
Insidious or sudden onset with symptoms of varying intensity: fever, fatigue, nausea, gastrointestinal disturbance,
followed by jaundice, dark coloured urine and more or less claycoloured stool.
Fulminant forms
Hepatocellular failure with severe cytolysis that can be fatal. This form is most frequent in hepatitis B patients with
secondary infection with the D virus, and in the event of pregnant women infected with hepatitis E during their third
trimester.
Chronic hepatitis


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secondary infection with the D virus, and in the event of pregnant women infected with hepatitis E during their third
trimester.
Chronic hepatitis
Hepatitis B, C and D may lead to cirrhosis and/or hepatocellular carcinoma (HCC).


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  Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E
Age group
most at risk
Children Children Young adults Young adults Young adults
Transmission Faecal-oral
Contaminated
food and
water
Transfusion
(rare)
Vertical
Close contact with infected
person (especially intra-
familial).
Exposure to blood
(transfusion; material
contaminated with blood)
Sexual
 (a) Exposure to
blood
(transfusion;
material
contaminated
with blood)
Sexual (low)
Intranasal
(implements
shared by
intranasal drug
users)
Vertical (a)
Exposure to
blood
(transfusion;
material
contaminated
with blood)
Sexual
Possibly
vertical (a)
Faecal-oral
Contaminated
food and water
Incubation
period
2 to 6 weeks 4 to 30 weeks (average 10
weeks)
2 to 25 weeks Co-infection
B/D: as for
hepatitis B
Secondary


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food and water
Incubation
period
2 to 6 weeks 4 to 30 weeks (average 10
weeks)
2 to 25 weeks Co-infection
B/D: as for
hepatitis B
Secondary
infection of
hepatitis B:
approximately
5 weeks
2 to 8 weeks
Fulminant
forms
0.2 to 0.4% 1 to 3% More rare than
in hepatitis B
Much more
common in
patients with
secondary
infection of
hepatitis B
than in patients
with B/D co-
infection
20% mortality
in pregnant
women
Prognosis No chronic
forms
Chronicity: 0.2 to 10% (risk
is inversely related to age,
e.g. up to 90% if infected
before the age of 1 year) of
which 5 to 15% progress to
cirrhosis.
HCC possible
Chronicity: up
to 50%, of
which 10 to
25% progress
to cirrhosis.
HCC possible
Chronicity: <
5% for
patients with
B/D co-
infection; >
90% if
secondary
infection of
hepatitis B
(rapid cirrhosis)


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to cirrhosis.
HCC possible
Chronicity: <
5% for
patients with
B/D co-
infection; >
90% if
secondary
infection of
hepatitis B
(rapid cirrhosis)
No chronic
forms


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Laboratory
Diagnosis
Other tests
Other investigations
Elastography (Fibroscan®): measures the elasticity of the liver to determine stage of liver ﬁbrosis, scored from
F0 (absence of ﬁbrosis) to F4 (cirrhosis).
Treatment
Treatment of chronic active hepatitis B 
The goal of treatment is to reduce the risk of cirrhosis and HCC. 
Individual
prevention
Polyvalent
immunoglobulin
Speciﬁc anti-HBs
immunoglobulin
Safe sex (condoms)
Speciﬁc anti-
HBs
immunoglobulin
may be
effective
As for hepatitis
B (the D virus
can only
develop with
B)
Cook meat
(pork)
Vaccination Anti-hepatitis
A
Anti-hepatitis B Does not exist Anti-hepatitis
B
Does not exist
Collective
prevention
Hygiene,
sanitation
Limit transfusion, screen blood prior to transfusion
Single use of disposable material
Hygiene,


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Collective
prevention
Hygiene,
sanitation
Limit transfusion, screen blood prior to transfusion
Single use of disposable material
Hygiene,
sanitation
(a) Vertical transmission: transmission of the virus from the mother to the child during pregnancy, at the time of delivery, orduring the ﬁrst 28 days after birth.
HAV, HDV and HEV infection: detection of IgM anti-HAV, anti-HDV and anti-HEV antibodies, respectively.
HBV infection: detection of HBsAg; chronic hepatitis B: presence of HBsAG for longer 6 months; chronic active
hepatitis B: detection of HBeAg and/or HBV DNA.
HCV infection: detection of anti-HCV antibodies and HCV RNA; chronic hepatitis C: viraemia persists for longer
than 6 months.


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HCV infection: detection of anti-HCV antibodies and HCV RNA; chronic hepatitis C: viraemia persists for longer
than 6 months.
ALT (or AST) level, platelet count, creatinine, HCV diagnosis and HBV viral load to decide treatment of chronic
active hepatitis B.
APRI score (evaluation of liver ﬁbrosis in chronic hepatitis): [(patient's AST level/normal AST level) x 100]/platelet
count (10 platelets/litre). An APRI score > 1 indicates probable severe ﬁbrosis.9
HIV test.
Rest, hydration, no special diet.
Do not administer drug therapy for symptomatic treatment (analgesics, antipyretics, antidiarrhoeals, antiemetics
etc.) during the acute phase as it may aggravate symptoms and the evolution of hepatitis. Corticosteroids are not
indicated.
Stop or reduce alcohol consumption.


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indicated.
Stop or reduce alcohol consumption.
Patients with HIV co-infection 
Lifelong antiretroviral therapy of HIV that includes tenofovir. Do not administer tenofovir monotherapy or tenofovir


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Treatment of chronic hepatitis C
 In case of decompensated cirrhosis (presence of ascites or jaundice or mental confusion or signs of gastrointestinal
haemorrhage): same treatment but for 24 weeks. Treatment is contra-indicated during pregnancy and breastfeeding.
For women of childbearing age: provide a contraceptive; do not start treatment in women who do not want
contraception.
Vaccination
 
 
dual therapy with lamivudine or emtricitabine (risk of developing HIV drug resistance). 
Patients without HIV co-infection 
Treatment is indicated in the event of cirrhosis or advanced hepatic ﬁbrosis (APRI score > 1.5 or Fibroscan F3-F4 >
10 kPa); HBsAg positive with persistently elevated ALT or AST > 2 times the normal values in 2 samples taken 3 or


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10 kPa); HBsAg positive with persistently elevated ALT or AST > 2 times the normal values in 2 samples taken 3 or
6 months apart; or persistently elevated ALT or AST with a high viral load (> 20 000 IU/ml).
tenofovir PO (300 mg tab, equivalent to 245 mg of tenofovir disoproxil), lifelong therapy:
Children ≥ 12 years and adults, including pregnant women: one tablet once daily taken with a meal
 [1]
Genotypes 1, 2, 3, 4, 5, 6 without cirrhosis
or with compensated cirrhosis
sofosbuvir/velpatasvir PO (400 mg SOF/100 mg VEL tablet)
1 tablet once daily for 12 weeks
Genotypes 1, 2, 4, 5, 6 without cirrhosis
or with compensated cirrhosis
Genotype 3 without cirrhosis
sofosbuvir/daclatasvir PO (400 mg SOF/60 mg DCV tablet) 
1 tablet once daily for 12 weeks


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or with compensated cirrhosis
Genotype 3 without cirrhosis
sofosbuvir/daclatasvir PO (400 mg SOF/60 mg DCV tablet) 
1 tablet once daily for 12 weeks
Genotype 3 with compensated cirrhosis sofosbuvir/daclatasvir PO (400 mg SOF/60 mg DCV tablet)
1 tablet once daily for 24 weeks
Routine vaccination of neonates and infants  (according to national vaccination schedule):  [2] 
3 dose schedule: one dose as soon as possible after birth, preferably within the ﬁrst 24 hours of life, then one
dose at 6 weeks and one dose at 14 weeks a
4 dose schedule: one dose as soon as possible after birth, preferably within the ﬁrst 24 hours of life, then one
dose at 6 weeks, one dose at 10 weeks and one dose at 14 weeks a
Catch-up vaccination (unvaccinated individuals):


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dose at 6 weeks, one dose at 10 weeks and one dose at 14 weeks a
Catch-up vaccination (unvaccinated individuals):
3 dose schedule (0-1-6): 2 doses 4 weeks apart, then a third dose 6 months after the ﬁrst dose
Post-exposure prophylaxis:
One dose on D0, one dose on D7 and one dose between D21 and D30 then a booster dose 12 months after the
ﬁrst dose
Footnotes


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One dose on D0, one dose on D7 and one dose between D21 and D30 then a booster dose 12 months after the
ﬁrst dose
Footnotes
(a) At birth, only the monovalent hepatitis B vaccine can be used.For the following doses, a monovalent or tetravalent (diphtheria, tetanus, pertussis, hepatitis B) or pentavalent (diphtheria,tetanus, pertussis, hepatitis B and Haemophilus inﬂuenzae) vaccine can be used, depending on national recommendations.If an infant was not administered the birth dose, this dose can be administered at anytime during the ﬁrst contact withhealth-care providers, up to the time of the next dose of the primary schedule.


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References
1. World Health Organization. Guidelines for the care and treatment of persons diagnosed with chronic hepatitis C virusinfection. July 2018.http://apps.who.int/iris/bitstream/handle/10665/273174/9789241550345-eng.pdf?ua=1 [Accessed 21 December 2018]
2. Weekly epidemiological record/Relevé épidémiologique hebdomadaire 7 JULY 2017, 92th YEAR / 7 JUILLET 2017, 92e ANNÉENo 27, 2017, 92, 369–392 http://apps.who.int/iris/bitstream/handle/10665/255841/WER9227.pdf?sequence=1 [Accessed 22 November 2018]


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Dengue
Last update: October 2022
 
 
Dengue fever is an arbovirus transmitted to humans by the bite of a mosquito (Aedes). Transmission by transfusion of
contaminated blood and transplacental transmission to the foetus have also been reported.
Four different serotypes of dengue have been described. Infection with one serotype provides a lifelong immunity to
that speciﬁc serotype, but only partial, short-term immunity to other serotypes. There is no speciﬁc antiviral treatment. Dengue is a mainly urban disease, present in tropical and subtropical regions , in particular in Asia, Central and South


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America and the Caribbean. Outbreaks have been described in Eastern Africa. Primary infection may be asymptomatic or present as mild or occasionally severe dengue fever. Subsequent infections
increase the risk of severe dengue.
Clinical features
After the incubation period (4 to 10 days), the illness occurs in 3 phases:
 
 a 
Febrile phase: high fever (39 to 40 °C) lasting 2 to 7 days, often accompanied by generalized aches, a
maculopapular rash and mild haemorrhagic manifestations. 
Critical phase (between the third and seventh day): at the end of the febrile phase, temperature decreases. The
majority of patients will have dengue without warning signs and proceed to the recovery phase. Certain patients will


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majority of patients will have dengue without warning signs and proceed to the recovery phase. Certain patients will
develop dengue with warning sign(s) at this stage. These patients are at higher risk for developing severe dengue.
Recovery phase: patient improves, vital signs normalise, gastrointestinal symptoms subside and appetite returns.
At times, bradycardia and generalized pruritus.


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Major differential diagnoses
Other conditions to consider include a wide range of acute febrile illnesses, e.g.:  
Laboratory
Diagnosis
Symptoms according to severity (adapted from PAHO ) [1] 
Dengue
without warning
signs
Fever + 2 of the following symptoms:
Nausea, vomiting
Rash resembling measles
Generalized aches (headache, retro-orbital pain, myalgias, arthralgias)
Benign mucocutaneous bleeding (petechiae, positive tourniquet test , epistaxis, gingival
bleeding)
 (a) 
Leucopenia
Dengue
with warning signs
Presence of at least one of these symptoms:
Intense abdominal pain
Persistent vomiting
Fluid accumulation (ascites, pleural effusion)
Mucosal bleeding
Hepatomegaly (> 2 cm)
Postural hypotension
Agitation or lethargy
Increasing haematocrit


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Mucosal bleeding
Hepatomegaly (> 2 cm)
Postural hypotension
Agitation or lethargy
Increasing haematocrit
Severe dengue Severe ﬂuid accumulation (ascites, pleural effusion) with respiratory distress and/or shock
Severe mucocutaneous bleeding
Severe organ involvement (e.g.: transaminases > 1000 IU/litre, myocarditis, altered mental
status)
(a) Tourniquet test: inﬂate a blood pressure cuff on the upper arm to a point midway between the systolic and diastolicpressure for 5 min. The test is positive when 20 or more petechiae per 2.5 cm square are observed.
Chikungunya, Zika, inﬂuenza, mononucleosis, measles, rubella, viral haemorrhagic fevers 
Malaria  
Meningococcemia, typhoid fever, leptospirosis, rickettsioses, other causes of sepsis 
Leukaemia


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Malaria  
Meningococcemia, typhoid fever, leptospirosis, rickettsioses, other causes of sepsis 
Leukaemia   
NS-1 antigen detection during febrile phase with rapid diagnostic test or ELISA (serum, plasma or blood). 
Antibody detection (complex interpretation): 
IgM detection 5 to 6 days after onset of illness may support (but does not conﬁrm) a diagnosis of recent
infection;
IgG detection may indicate prior infection by, or vaccination against, dengue virus or a closely related virus (e.g.
chikungunya, Zika, Japanese encephalitis, yellow fever).
PCR may also be available in reference laboratories. 
In all cases, rapid test for malaria in endemic regions (and antimalarial treatment if needed, see Malaria, Chapter 6).


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Monitoring disease course
Treatment
Patients in Group A (outpatients)
Patients with no warning signs, able to drink sufﬁciently and with a normal urine output.
Patients in Group B (inpatients)
Patients with any of the following:
 In all cases:
 If poor oral intake:
 If warning signs:
Haematocrit (Hct) or if available full blood count (FBC) at baseline, then daily if possible.
A progressive increase in Hct is a warning sign. It indicates haemoconcentration due to increased vascular
permeability (plasma leakage). Hct should be monitored frequently (before and after ﬂuid administration) in
patients with warning signs up to the end of the ﬂuid treatment. 
Leukopenia and thrombocytopenia are common and improve as the recovery phase begins. Leukocytosis may


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Leukopenia and thrombocytopenia are common and improve as the recovery phase begins. Leukocytosis may
occur with severe bleeding.
Liver function tests if possible at baseline, then according to results.
Bed rest and good hydration.
Fever and pain: paracetamol PO at the usual doses (see Fever, Chapter 1), maintaining a 6 to 8 hour interval
between doses. Do not prescribe acetylsalicylic acid, ibuprofen or other NSAIDs.
Seek medical attention if: no clinical improvement, persistent vomiting, cold extremities, agitation or lethargy,
breathing difﬁculties or absence of urine output.
If follow-up is impossible or symptoms cannot be monitored at home (patients living far from the health care
facility/living alone), hospitalise for observation.
Warning sign(s)


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facility/living alone), hospitalise for observation.
Warning sign(s) 
Acute (e.g. severe dehydation or malaria) or chronic (e.g. diabetes, cardiovascular, renal or haemolytic disease,
obesity) co-morbidities
Risk factors for bleeding (e.g. anticoagulation, coagulopathy, peptic ulcer or gastritis, treatment with NSAIDs) 
Pregnant women, patients under 1 year or 65 years and over or patients with difﬁculty drinking
Place the patient under a mosquito net; encourage oral ﬂuid intake (including oral rehydration solution (ORS) if
needed).
Avoid invasive procedures (nasogastric tube, IM injections) to minimize the risk of bleeding.
Fever and pain: paracetamol PO  with caution and without exceeding: [2] 
children: 10 mg/kg every 6 to 8 hours
adults: 500 mg every 6 to 8 hours


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Fever and pain: paracetamol PO  with caution and without exceeding: [2] 
children: 10 mg/kg every 6 to 8 hours
adults: 500 mg every 6 to 8 hours
In case of elevated transaminases ≥ 10 times the upper limit of normal, do not administer paracetamol. Use tepid
sponging for reducing fever.
Monitor vital signs, ﬂuid intake (infusion and oral) and urine output every 4 hours . b 
Place an intravenous line and administer:
children: 5% glucose + Ringer lactate solution as maintenance ﬂuids, according to the Holliday-Segar
formula, i.e. 4 ml/kg/hour for ﬁrst 10 kg of body weight + 2 ml/kg/hour for next 10 kg + 1 ml/kg/hour for each
additional kg above 20 kg.
 c 
adults: Ringer lactate, 2 to 3 ml/kg/hour
Encourage oral intake as soon as possible.


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Patients in Group C (intensive care unit)
Patients with severe dengue requiring emergency treatment for managing shock and other complications (e.g. severe
bleeding, acidosis, coagulopathy).
Prevention
 
References
Monitor clinical status (warning signs, general symptoms, vital signs, capillary reﬁll time), IV and oral ﬂuid intake, urine
output, hourly for at least 4 hours, then every 4 hours while the patient is on IV ﬂuid treatment.
Place an intravenous line and administer a bolus of Ringer lactate:
children and adults: 10 ml/kg over one hour
patients 65 years and over or with co-morbidities : 5 ml/kg over one hour
 Re-assess the patient:
If no improvement after ﬁrst bolus: administer a second bolus as above. If necessary, a total of 3 boluses can


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Re-assess the patient:
If no improvement after ﬁrst bolus: administer a second bolus as above. If necessary, a total of 3 boluses can
be administered. If still no improvement after 3 bolus, consider as severe dengue (patients in Group C) and
transfer to intensive care unit.
If improvement after the ﬁrst, second, or third bolus, reduce Ringer lactate:
children and adults: 5 to 7 ml/kg/hour over 2 to 4 hours
patients 65 years and over or with co-morbidities: 5 ml/kg/hour over 2 to 4 hours
If continuing improvement, reduce Ringer lactate (then stop as soon as possible to reduce the risk of ﬂuid
overload):
children and adults: 3 to 5 ml/kg/hour over 2 to 4 hours, then 2 to 4 ml/kg/hour over 24 to 48 hours


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overload):
children and adults: 3 to 5 ml/kg/hour over 2 to 4 hours, then 2 to 4 ml/kg/hour over 24 to 48 hours
patients 65 years and over or with co-morbidities: 3 ml/kg/hour over 2 to 4 hours, then 2 ml/kg/hour over 24
to 48 hours
If the patient deteriorates after initial improvement, resume the bolus therapy with Ringer lactate (up to 3 bolus)
as above.
Individual protection: long sleeves and trousers, repellents, mosquito net (Aedes bites during the day).
Elimination of mosquito breeding sites (small collections of water in discarded tires, ﬂower pots, and other
containers).
Footnotes
(a) For more information:http://gamapserver.who.int/mapLibrary/Files/Maps/Global_DengueTransmission_ITHRiskMap.png?ua=1


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containers).
Footnotes
(a) For more information:http://gamapserver.who.int/mapLibrary/Files/Maps/Global_DengueTransmission_ITHRiskMap.png?ua=1
(b) Adequate urine output: at least 1 ml/kg/hour in children and 0.5 ml/kg/hour in adults. If unavailable, ensure that the patient isurinating at least every 4 hours.
(c) 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. Pan American Health Organization. Dengue: guidelines for patient care in the Region of the Americas, 2nd edition.Washington, D.C.: PAHO, 2016.https://iris.paho.org/bitstream/handle/10665.2/31207/9789275118900-eng.pdf?sequence=1&isAllowed=y [Accessed 23 Aug2022]


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2. Pan American Health Organization. Guidelines for the Clinical Diagnosis and Treatment of Dengue, Chikungunya, and Zika.


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Washington, D.C. : PAHO; 2022.  https://iris.paho.org/handle/10665.2/55867 [Accessed 16 Aug 2022]


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Viral haemorrhagic fevers
Several diseases with different aetiologies and different modes of transmission are grouped under this term as they
present with common clinical signs.
Dengue haemorrhagic fever is a viral haemorrhagic fever that is described in a speciﬁc chapter (see Dengue, Chapter
8).
Clinical features
 
Common syndrome (CS):
Fever higher than 38.5 °C;
Haemorrhagic symptoms (purpura, epistaxis, haematemesis, melaena, etc.).
The clinical signs are often nonspeciﬁc; the severity varies depending on the aetiology.


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Laboratory
 
Reservoir/ Vector
Geographical
distribution
Isolation
of
patients
Clinical features
Estimated
case
fatality
rate
Ebola Marburg (a) Bats (?)
Africa
Strict
isolation
CS + sudden onset general malaise,
vomiting and diarrhoea 60-80%
Lassa (a) Rodents 
West Africa (b)
Strict
isolation
CS + general malaise, headache, muscle
pain, facial oedema, pharyngitis, proteinuria
on reagent strip
15-20%
Junin and
Machupo (a)
Rodents 
South America Isolation CS + vomiting, erythema of the face and,
depending on the aetiology:
periorbital oedema, cervical
adenopathy, pharyngitis
pharyngitis, reddened conjunctivae
oedema of the soft palate, generalised
petechial rash
proteinuria on reagent strip
15-30%
Omsk Ticks 
Europe, Asia None 2-5%
Crimean
Congo (a)
Livestock/Ticks


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petechial rash
proteinuria on reagent strip
15-30%
Omsk Ticks 
Europe, Asia None 2-5%
Crimean
Congo (a)
Livestock/Ticks
Africa, Asia
Strict
isolation 5-20%
FHSR
(hantavirus) (a)
Rodents 
Asia and Europe None < 1%
Kyasanur Small mammals/Ticks 
India None CS + headache, muscle pain, prostration 2-10%
Rift Valley (a) Livestock/Mosquitoes
Africa
Mosquito
nets
Clinical signs:
isolated fever
SC
encephalitis
retinitis and blindness
30-50%
Yellow fever (a) Primates/Mosquitoes
Africa, South America
Mosquito
nets
CS + jaundice, proteinuria on reagent strip,
oliguria, headache 10-30%
(a) Viral haemorrhagic fever with epidemic potential.
(b) For more information on geographic distribution of Lassa fever: https://www.who.int/emergencies/diseases/lassa-fever/geographic-distribution.png?ua=1


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A sample of whole blood must be send to a reference laboratory for serological diagnosis, with a clinical description
of the patient. The sample may also be sent on ﬁlter paper. It is easier to transport, but the small volume of blood
only allows a limited number of aetiologies to be tested.
Protective clothing must be worn while taking or handling the sample (gown, gloves, glasses, mask, etc.).
The sample must be sent in a triple packaging system for Category A infectious substances.


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Management
Suspicion of haemorrhagic fever
Isolated case of fever with haemorrhagic symptoms in an endemic area 
Conﬁrmed cases of Ebola, Marburg, Lassa, Crimean-Congo fevers or epidemics of unknown origin
PLUS
Conﬁrmed cases of Yellow fever or Rift Valley fever
For all patients
Report to the Ministry of Health of the country.
Treatment
Isolation: isolation room (or if not available, use screens/partitions); restrict visitors (if a carer is strictly necessary,
s/he must be protected with gown, gloves, mask).
Standard precautions:
The majority of hospital-acquired infections have occurred due to a lack of respect for these precautions:
Hand washing;
Gloves for patient examination and when touching blood, body ﬂuids, secretions, excretions, mucous
membranes, non-intact skin;


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Hand washing;
Gloves for patient examination and when touching blood, body ﬂuids, secretions, excretions, mucous
membranes, non-intact skin;
Gowns to protect skin and prevent soiling of clothing during consultations and activities that are likely to
generate splashes or sprays of blood, body ﬂuids, secretions, or excretions;
Surgical mask and goggles, or face shield, to protect mucous membranes of the eyes, nose, and mouth during
activities that may generate splashes of blood, body ﬂuids, secretions, and excretions;
Adequate procedures for the routine cleaning and disinfection of objects and surfaces;
Rubber gloves to handle soiled laundry;
Safe waste management;
Safe injection practices.


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Rubber gloves to handle soiled laundry;
Safe waste management;
Safe injection practices.
Strict isolation in a reserved area separate from other patient areas, with a deﬁned circuit for entrance/exit and
changing room at the entrance/exit; dedicated staff and equipment/supplies; use of disposable material if possible.
Standard precautions (as above)
Droplet precautions AND contact precautions including personal protective equipment (PPE).
The PPE is to be worn systematically prior to entry into isolation area, regardless the tasks to be performed (care,
cleaning, distribution of meals, etc.) and to be removed before leaving the isolation area:
two pairs of gloves,
double gown or coverall suit,
surgical cap or hood, mask, protective glasses,
impermeable apron,
rubber boots.


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two pairs of gloves,
double gown or coverall suit,
surgical cap or hood, mask, protective glasses,
impermeable apron,
rubber boots.
Disinfection of surfaces, objects, clothing and bedding with chlorine solution; safe handling and on site disposal of
waste and excreta, etc.
In the event of a death, do not wash the body. Prompt and safe burial of the dead as quickly as possible, using a
body bag.
Standard precautions.
Patient under a mosquito net to prevent transmission.


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Prevention
 
References
Aetiological treatment: ribavirine for Lassa fever and Crimean-Congo fever.
Symptomatic treatment:
Fever: paracetamol (Chapter 1). Acetylsalicylic acid (aspirin) is contra-indicated.
Pain: mild (paracetamol), moderate (tramadol), severe (sublingual morphine): see Pain, Chapter 1.
Dehydration: oral rehydration salts and/or IV rehydration with Ringer lactate, see Dehydration, Chapter 1.
Seizures (Chapter 1).
Vomiting: ondansetron PO
Children 6 months to < 2 years: 2 mg once daily
Children 2 to < 4 years: 2 mg 2 times daily
Children 4 to < 12 years: 4 mg 2 times daily
Children ≥ 12 years and adults: 4 to 8 mg 2 times daily
 [1] 
For Ebola and Marburg haemorrhagic fevers: invasive procedures must be strictly limited. Health care staff is at risk


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[1] 
For Ebola and Marburg haemorrhagic fevers: invasive procedures must be strictly limited. Health care staff is at risk
of contamination when inserting and maintaining IV lines. An IV line must be well secured so that the patient, often
confused, cannot pull it out.
Vaccination against yellow fever :
Children and adults: 0.5 ml single dose 
 [2] 
Routine vaccination : children from 9 months of age, along with the measles vaccine.
Mass vaccination campaign during an epidemic: children from 6 months and adults ; for pregnant women, only
administer during an epidemic.
Vaccination against Rift Valley fever: only during an epidemic.
Vector control programmes for known vectors.
Infection control measures are essential in all cases.


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Vector control programmes for known vectors.
Infection control measures are essential in all cases.
1. World Health Organization. Clinical management of patients with viral haemorrhagic fever. A pocket guide for front-linehealth workers. Interim emergency guidance for country adaptation, February 2016.http://apps.who.int/iris/bitstream/handle/10665/205570/9789241549608_eng.pdf;jsessionid=15E17DE39631519C2051413DDCBBC8A7?sequence=1 [Accessed 11 January 2019]
2. Weekly epidemiological record-Relevé épidémiologique hebdomadaire 5 july 2013, 88th year / 5 juillet 2013, 88e année No. 27,2013, 88, 269–284.https://www.who.int/wer/2013/wer8827.pdf?ua=1 [Accessed 10 december 2018]


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HIV infection and AIDS
Last updated: January 2024
 
Acquired immune deﬁciency syndrome (AIDS) is the most advanced stage of infection with human immunodeﬁciency
virus (HIV).
Two subtypes of HIV have been identiﬁed. HIV-1 is more widespread than HIV-2, the latter mainly being found in West
Africa. HIV-2 is less virulent and less transmissible than HIV-1.
HIV weakens the immune system by causing a deﬁcit in CD4 T lymphocytes.
Evolution of the disease
 The World Health Organization (WHO) has proposed a clinical classiﬁcation of HIV infection in 4 stages of severity for
adults and adolescents and for children.
Laboratory
Diagnosis of HIV infection
CD4 lymphocyte counts


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adults and adolescents and for children.
Laboratory
Diagnosis of HIV infection
CD4 lymphocyte counts
CD4 cell depletion is a marker of the progression of immune depression. The level of the CD4 cell count is a predictor
of the development of opportunistic infections or neoplasms and can be used to orient their diagnosis, e.g. cerebral
toxoplasmosis or cryptococcal meningitis appear when the CD4 count is below 100 cells/mm in adults. If clinical
symptoms/signs are present suggesting one of these infections, but the CD4 count is greater than or equal to 200
cells/mm, it is unlikely that that particular infection is present.
Opportunistic infections
Primary infection or acute retroviral syndrome: 50 to 70% of newly infected individuals develop during


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Opportunistic infections
Primary infection or acute retroviral syndrome: 50 to 70% of newly infected individuals develop during
seroconversion (from 15 days to 3 months post exposure), a viral syndrome with fever, malaise, and
lymphadenopathy.
Asymptomatic HIV infection (after seroconversion): a period of clinical latency, but not viral latency. The time
period for progression from HIV infection to the development of severe immune deﬁciency in western countries is
approximately 10 years. This period appears to be shorter in developing countries.
Symptomatic HIV infection: with progressive destruction of the immune system, common and more severe
diseases occur more frequently, and with higher mortality, in seropositive individuals.


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diseases occur more frequently, and with higher mortality, in seropositive individuals.
AIDS: this stage corresponds to the development of severe opportunistic infections and neoplasms. From a
biological point of view, AIDS is deﬁned as a CD4 count < 200 cells/mm. Without treatment the disease
progresses rapidly towards death.
3
 [1]
The diagnosis is made with serological (detection of antibodies against the virus) or virological (especially in infants)
testing.
Testing should always be done voluntarily with informed consent.
All HIV test results must be strictly conﬁdential in order to avoid discrimination.
The individual should have access to services offering pre-test and post-test counselling, treatment and support.


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The individual should have access to services offering pre-test and post-test counselling, treatment and support.
A diagnosis of HIV infection can be made only after at least 2 different test results (2 different brands) are clearly
positive: the positive result of an initial (highly sensitive) test must be conﬁrmed through use of a second (highly
speciﬁc) test. In areas where HIV prevalence is low, diagnosis is conﬁrmed after 3 positive test results.
3
3


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It is important to screen for serious opportunistic infections in those at risk (e.g. testing for cryptococcal antigen for all
adults with a CD4 count < 100 cells/mm regardless of symptoms).
Treatment of HIV infection
Antiretroviral (ARV) treatment
A multi-drug (at least 3) antiretroviral therapy (ART) is the reference treatment. It does not eradicate the virus, but
slows the progression of the disease and improves the patient’s clinical state by reducing viral replication and
consequently increasing the CD4 cell count to levels beyond the threshold of opportunistic infections.
Therapeutic classes
Four major classes ARV are used:
Principles of ARV treatment
Other possible combinations exist which are less commonly used or more difﬁcult to manage.
Criteria for ARV treatment


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Principles of ARV treatment
Other possible combinations exist which are less commonly used or more difﬁcult to manage.
Criteria for ARV treatment
As a priority ART should be initiated in all patients with WHO clinical stage 3 or 4 and patients with CD4 < 350 /mm.
However, those with higher CD4 counts can initiate ART.
Monitoring of ARV treatment
HIV viral load is an essential tool for monitoring the effectiveness of ARV. CD4 count is useful for identifying severely
immunosuppressed. Other tests such as blood count, tests for liver (ALAT) and renal function (creatinine clearance) are
not essential, but can be useful in detecting adverse effects.
Treatment of opportunistic and other infections


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not essential, but can be useful in detecting adverse effects.
Treatment of opportunistic and other infections
With progressive immunosuppression, HIV-infected patients who are not receiving triple therapy (or patients on ART
but with poor adherence) become increasingly susceptible to infections. For conditions of clinical stages 2 and 3,
standard treatments are usually effective. Patients may beneﬁt from primary prophylaxis against opportunistic
infections (see Primary prophylaxis). Tuberculosis (TB) is the most common serious opportunistic infection. It can be
difﬁcult to diagnose in HIV-infected patients however.
Treatment of pain
Treat all patients for associated pain (see Pain, Chapter 1).
Prevention of HIV infection
3
 a


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Treatment of pain
Treat all patients for associated pain (see Pain, Chapter 1).
Prevention of HIV infection
3
 a
NRTI (nucleoside/nucleotide reverse transcriptase inhibitors): zidovudine (AZT), lamivudine (3TC), abacavir (ABC),
tenofovir (TDF), emtricitabine (FTC).
NNRTI (non-nucleoside reverse transcriptase inhibitors): efavirenz (EFV), nevirapine (NVP), etravirine (ETR). HIV-2 is
naturally resistant to NNRTIs.
PI (protease inhibitors): atazanavir (ATV), lopinavir (LPV), ritonavir (RTV), darunavir (DRV).
INI (integrase inhibitors): dolutegravir, raltegravir.
Daily triple therapy must be taken for life to prevent the rapid development of resistance. It is important that the
patient understands this and that adherence to treatment is optimal.


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patient understands this and that adherence to treatment is optimal.
Follow the ART protocols recommended by national HIV program.
The most widely used and easiest regimens to administer are 2 NRTI + 1 NNRTI: e.g. TDF/3TC/EFV.
In the event of treatment failure, all 3 drugs should be replaced with a second-line regimen: 2 other NRTIs + 1 PI.
3


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Sexual transmission
The most reliable method of prevention is the use of male or female condoms.
Male circumcision decreases signiﬁcantly the risk of HIV transmission.
Early diagnosis and treatment of sexually transmitted infections is essential as they increase the transmission of HIV
(see Chapter 9).
ART to HIV positive and adherent partner does protect the negative partner from HIV infection.
Occupational transmission
(accidental needle stick injuries or injuries with contaminated objects, contact between a patient’s blood and
unprotected broken skin or mucous membranes)
Prevention is based on use of standard precautions to avoid contamination with soiled material or potentially infected
body ﬂuids.


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Prevention is based on use of standard precautions to avoid contamination with soiled material or potentially infected
body ﬂuids.
Post-exposure prophylaxis (PEP): e.g. in the event of rape or occupational accidental exposure to blood, ARV
treatment initiated as soon as possible within 72 hours of exposure for a duration of 1 month may reduce the risk of
infection.
Nosocomial transmission
Prevention of nosocomial HIV infection is based on the rational use of injections and strict respect for hygiene and
sterilization and disinfection procedures for medical material.
For transfusion: strict respect of indications for transfusion and systematic serological screening of the donor’s blood
are the two indispensable precautions in the prevention of HIV transmission through transfusions.


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are the two indispensable precautions in the prevention of HIV transmission through transfusions.
Transmission in injection drug users
Needle and syringe exchange programs with disposable needles and syringes for users can reduce the risk.
Mother-to-child transmission (MTCT)
The global rate of vertical transmission varies from 20 to 40%. The risk of transmission through breast-feeding is
evaluated at approximately 12% and persists for the duration of breast-feeding.
Prevention of opportunistic infections
In the absence of ARV treatment, all HIV-infected individuals become symptomatic and evolve towards AIDS.
However, some opportunistic infections can be prevented.
Primary prophylaxis


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However, some opportunistic infections can be prevented.
Primary prophylaxis
For HIV infected patients who have not previously contracted an opportunistic infection, in order to prevent the
development of some opportunistic infections. 
In pregnant women: HIV transmission from mother-to-child may be reduced by ART. The protocol called Option
B+ is the internationally preferred protocol. All HIV-infected pregnant women receive lifelong triple-drug therapy,
regardless of the CD4 count or clinical stage, both for their own health and to prevent transmission to the child. The
most commonly recommended ART is TDF/3TC/EFV or TDF/FTC/EFV. Check national recommendations. In
addition, ARVs are administered to the newborn.


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most commonly recommended ART is TDF/3TC/EFV or TDF/FTC/EFV. Check national recommendations. In
addition, ARVs are administered to the newborn.
Programs targeting pregnant women also include other preventive measures such as avoiding artiﬁcial rupture of
the membranes and systematic episiotomy.
In breast-feeding women: exclusive breast-feeding for the ﬁrst 6 months of life, introduction of complementary
(solid) foods at 6 months, gradual cessation of breast-feeding to the age of 12 months.


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Secondary prophylaxis
For patients who develop a speciﬁc opportunistic infection, in order to prevent recurrence once treatment for the
infection is completed. 
 
Infections Primary prophylaxis
Pneumocystosis
Cerebral toxoplasmosis
Isosporiasis
Various bacterial infections
Malaria
co-trimoxazole PO
Children: 50 mg SMX + 10 mg TMP/kg once daily
Adults: 800 mg SMX + 160 mg TMP once daily
Infections Secondary prophylaxis Comments
Pneumocystosis
co-trimoxazole PO
Children: 50 mg SMX + 10 mg TMP/kg once
daily
Adults: 800 mg SMX + 160 mg TMP once
daily
Alternative
dapsone PO
Children: 2 mg/kg once daily (max. 100 mg
daily)
Adults: 100 mg once daily
Toxoplasmosis Alternative
Adults:
dapsone PO: 200 mg once weekly or 50
mg once daily
+ pyrimethamine PO: 75 mg once weekly


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Adults: 100 mg once daily
Toxoplasmosis Alternative
Adults:
dapsone PO: 200 mg once weekly or 50
mg once daily
+ pyrimethamine PO: 75 mg once weekly
+ folinic acid PO: 25 to 30 mg once
weekly
Isosporiasis –
Penicilliosis
Histoplasmosis
itraconazole PO
Adults: 200 mg once daily –
Cryptococcal meningitis ﬂuconazole PO
Children: 6 mg/kg once daily
Adults: 200 mg once daily
–
Oral or oesophageal
candidiasis
ﬂuconazole PO
Children: 3 to 6 mg/kg once daily
Adults: 100 to 200 mg once daily
Only for frequent and severe recurrences
Herpes simplex aciclovir PO
Children under 2 years: 200 mg 2 times daily
Children 2 years and over and adults: 400 mg
2 times daily
Only for frequent and severe recurrences


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Symptoms Deﬁnitions and
aetiologies Diagnosis Treatment
Diarrhoea
with or without blood
(also see
Chapter 3)
Diarrhoea is deﬁned as at
least 3 liquid stools per
day.
Aetiologies:
Parasitic infections
• Isospora belli
• Cryptosporidium
• Microsporidium
• Giardia lamblia
• Entamoeba histolytica
Bacterial infections
• Shigella
• Salmonella enteritis
• Campylobacter
enteritis
Mycobacterial
infections
• Mycobacterium
tuberculosis
(gastrointestinal TB)
• Mycobacterium avium
complex
Helminthiasis
• Strongyloides
stercoralis
Viral infections
• Cytomegalovirus (CMV)
Other causes
• Kaposi sarcoma
• Lymphoma
• Idiopathic (HIV
infection)
• Antiretrovirals
(especially lopinavir and
ritonavir)
1. History and clinical
examination
2. Microscopic
examination of stool for


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infection)
• Antiretrovirals
(especially lopinavir and
ritonavir)
1. History and clinical
examination
2. Microscopic
examination of stool for
ova and parasites (2 to 3
samples)
Note:
I. belli, Cryptosporidium,
Microsporidium, MAC
and CMV are unlikely if
CD4 count > 200 cells.
• Persistent (> 2 weeks) or chronic (>
4 weeks) diarrhoea is often
associated with weight loss and
dehydration.
• Prevention or treatment of
dehydration is critical (Dehydration,
Chapter 1).
• Depending on the results of the
stool examinations: give appropriate
treatment.
• If there is no laboratory support:
Acute bloody diarrhoea
• First-line treatment:
Children: azithromycin PO: 20 mg/kg
once daily for 5 days or
ciproﬂoxacin PO: 15 mg/kg 2 times
daily for 7 days
Adults: ciproﬂoxacin PO: 500 mg 2


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Children: azithromycin PO: 20 mg/kg
once daily for 5 days or
ciproﬂoxacin PO: 15 mg/kg 2 times
daily for 7 days
Adults: ciproﬂoxacin PO: 500 mg 2
times daily for 7 days
• If amoebiasis suspected:
tinidazole or metronidazole PO (
Amoebiasis, Chapter 3).


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Non-bloody persistent or chronic
diarrhea
Persistent or chronic diarrhoea
suggests advanced
immunocompromised state. For
patients who qualify for ARVs by
CD4 count (or unknown CD4 count),
ARV initiation is urgent and will
usually resolve symptoms in 14 to 28
days.
• Isospora belli: co-trimoxazole PO
Children: 40 mg SMX + 8 mg TMP/kg
2 times daily for 10 days then 25 mg
SMX + 5 mg TMP/kg 2 times daily
for 3 weeks
Adults: 800 mg SMX + 160 mg TMP
2 times daily for 7 to 10 days then
400 mg SMX + 80 mg TMP 2 times
daily for 3 weeks
• Cryptosporidium: no speciﬁc
treatment in HIV-infected patients
• Microsporidium: albendazole PO
(limited efﬁcacy)
Children: 10 mg/kg 2 times daily
(max. 800 mg daily) for 7 days
Adults: 400 mg 2 times daily for 2 to
4 weeks


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(limited efﬁcacy)
Children: 10 mg/kg 2 times daily
(max. 800 mg daily) for 7 days
Adults: 400 mg 2 times daily for 2 to
4 weeks
• Helminthiasis: albendazole PO for
3 days
Children > 6 months but ≤ 10 kg: 200
mg once daily
Children > 6 months and adults: 400
mg once daily
• Giardiasis: tinidazole or
metronidazole (
Intestinal protozoan infections,
Chapter 6).
• If no improvement (and no contra-
indications such as bloody
diarrhoea), symptomatic treatment
with loperamide PO:
Adults: initial dose 4 mg then 2 mg
after each liquid stool (max. 16 mg
daily)


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Nutrition ++++
Children: continue to breastfeed;
increase daily calorie intake:
6-11 months: add 150 kcal daily
12-23 months: add 200 kcal daily
2-5 years: add 250 kcal daily
6-9 years: add 350 kcal daily
10-14 years: add 400 kcal daily
Eliminate fresh milk, give porridge
prepared with rice water or soup or
yoghurts. Give 2.5 ml of oil per meal.
Any child 0-5 years should receive
zinc sulfate (Acute diarrhoea,
Chapter 3).
Adults: increase the calorie and
protein intake (at least 2 g protein/kg
daily). No food is excluded but avoid
raw food, fresh milk and foods high
in ﬁbre. Encourage small, frequent
meals.
Oral and
oesophageal
lesions
Fungal infections
• Oral candidiasis: see 
Stomatitis, Chapter 3.
• Oesophageal
candidiasis: pain on
swallowing, dysphagia.


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oesophageal
lesions
Fungal infections
• Oral candidiasis: see 
Stomatitis, Chapter 3.
• Oesophageal
candidiasis: pain on
swallowing, dysphagia.
May result in weight loss.
Viral infections
• Oral hairy leukoplakia
(keratosis on the lateral
sides of the tongue due
to the Epstein-Barr virus)
• Oral and oesophageal
herpes
Aphthous ulcers
Clinical examination is
enough to make a
diagnosis.
Consider all severe oral
candidiasis (if the
pharynx is involved) as
oesophageal candidiasis
even in the absence of
dysphagia.
• Mild oral candidiasis
nystatin PO
Children and adults: 100 000 IU (= 1
ml) 4 times daily
or miconazole oral gel
Children 6 months-2 years: 1.25 ml 4
times daily
Children over 2 years and adults: 2.5
ml 4 times daily
The treatment lasts 7 to 14 days.
• Moderate to severe oral


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times daily
Children over 2 years and adults: 2.5
ml 4 times daily
The treatment lasts 7 to 14 days.
• Moderate to severe oral
candidiasis and oesophageal
candidiasis
ﬂuconazole PO
Children: 3 to 6 mg/kg once daily
Adults: 50 to 200 mg once daily
up to 400 mg daily if necessary
The treatment lasts 7 to 14 days for
oral candidiasis and 14 to 21 days
for oesophageal candidiasis.
Candidiasis is an indication for
prophylaxis with co-trimoxazole.
• Oral hairy leukoplakia: no treatment


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• Oral herpes:
Analgesics (paracetamol, ibuprofen).
For recurrent or extensive forms
affecting the oesophagus, add:
aciclovir PO for 7 days
Children under 2 years: 200 mg 5
times daily
Children 2 years and over and adults:
400 mg 5 times daily
Secondary prophylaxis only for
patients with frequent recurrences.
Respiratory
problems
(also see
Chapter 2)
Cough and/or thoracic
pain and/or dyspnoea in a
symptomatic HIV
infected patient.
Aetiologies:
Bacterial infections
• Streptococcus
pneumoniae
• Haemophilus
inﬂuenzae
• Staphylococcus aureus
Mycobacterial
infections
• M. tuberculosis, MAC
Protozoal infections
• Pneumocystis jiroveci
(PCP)
Fungal infections
• Cryptococcus
neoformans
• Histoplasma
capsulatum
• Coccidioides immitis
• Aspergillus spp
• Penicillium marneffei


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(PCP)
Fungal infections
• Cryptococcus
neoformans
• Histoplasma
capsulatum
• Coccidioides immitis
• Aspergillus spp
• Penicillium marneffei
Viral infections
• CMV
Neoplasms
• Kaposi sarcoma
• Non-Hodgkin’s
lymphoma
1. History and clinical
examination:
Blood in the sputum?
If fever < 7 days,
dyspnoea: unlikely TB.
If cough > 21 days,
weight loss, thoracic pain
> 15 days, no dyspnoea:
likely TB.
Pulmonary auscultation:
bilateral lobar
pneumonia?
2. If possible:
a) Look for AFB in
sputum
b) Chest x-ray
• PCP: bilateral interstitial
inﬁltrates
• TB: miliary shadowing,
large heart, pleural
effusion, enlarged lymph
nodes inside the chest.
Notes
• MAC, PCP, CMV and
fungal infections are
unlikely in patients with a
CD4 count > 200
cells/mm.
• Staphylococcal
pneumonia is often
associated with a


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• MAC, PCP, CMV and
fungal infections are
unlikely in patients with a
CD4 count > 200
cells/mm.
• Staphylococcal
pneumonia is often
associated with a
pyomyositis or an
abscess.
3
• For the diagnosis and treatment of
upper respiratory tract infections,
particularly pneumonia: see 
Chapter 2.
• If the chest x-ray is consistent with
staphylococcal pneumonia:
Children: see 
Staphylococcal pneumonia, Chapter
2.
Adults: ceftriaxone IM or slow IV 1 g
once daily + cloxacillin IV 2 g every
6 hours
• If the sputum examination is AFB+,
treat for TB.


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Others
• Lymphoid interstitial
pneumonia
• Pleural effusion (often
TB)
• Pericardial effusion
(often TB)
• Pneumothorax (may be
due to PCP)
• If the sputum examination is
negative and the chest x-ray is
consistent with PCP:
co-trimoxazole PO for 21 days
Children: 50 mg SMX + 10 mg
TMP/kg 2 times daily
Adults: 1600 SMX + 320 TMP 3
times daily
Note: the symptoms may become
worse during the ﬁrst phase of
treatment, effectiveness can only be
evaluated after one week of
treatment.
Add prednisolone PO for patients
with severe PCP with hypoxia:
Children: start with 2 mg/kg daily
then decrease the dose following
the adult example
Adults: 40 mg 2 times daily for 5
days, then 40 mg once daily for 5
days then 20 mg once daily for 10
days
Secondary prophylaxis is
recommended.


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Adults: 40 mg 2 times daily for 5
days, then 40 mg once daily for 5
days then 20 mg once daily for 10
days
Secondary prophylaxis is
recommended.
• Fungal infections (cryptococcosis,
penicilliosis, histoplasmosis):
Adults: amphotericin B IV: 0.7 to 1
mg/kg once daily for 2 weeks
(cryptococcosis, penicilliosis) or 1 to
2 weeks (histoplasmosis), then:
ﬂuconazole PO: 400 mg daily for 8
weeks (cryptococcosis)
itraconazole PO: 200 mg 2 times
daily for 10 weeks (penicilliosis)
itraconazole PO: 200 mg 3 times
daily for 3 days then 200 to 400 mg
daily for 12 weeks (histoplasmosis)
Secondary prophylaxis is
recommended.
Lymphadenopathy Enlarged lymph nodes in
a symptomatic HIV-
infected patient
1. Clinical examination:
look for a local cause
(skin or dental infection
etc.); TB or syphilis.


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a symptomatic HIV-
infected patient
1. Clinical examination:
look for a local cause
(skin or dental infection
etc.); TB or syphilis.
• Treat according to the aetiology or
empirical treatment with, for
example doxycycline PO.
• TB: see the guide Tuberculosis,
MSF.


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Persistent generalised
lymphadenopathy (PGL):
• 2 or more extra-inguinal
sites
• lymph nodes > 1.5 cm
• enlarged for 3 or more
months PGL is usually
due to HIV infection.
Aetiologies:
HIV infection
Infections
• TB
• Syphilis
• Histoplasmosis
• Toxoplasmosis
• CMV
Neoplasms
• Kaposi sarcoma
• Lymphoma
2. Suspected TB: lymph
node aspiration, look for
AFB, chest x-ray
Note: in HIV infected
patients, TB is often
extrapulmonary.
3. Suspected syphilis:
serology
4. If all examinations are
negative: biopsy is useful
to exclude lymphoma,
Kaposi’s sarcoma and
fungal or mycobacterial
infections (see notes for
patients in stage 1).
• Early syphilis:
benzathine benzylpenicillin IM
Adults: 2.4 MIU single dose (1.2 MIU
in each buttock)
or, if not available:
azithromycin PO


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• Early syphilis:
benzathine benzylpenicillin IM
Adults: 2.4 MIU single dose (1.2 MIU
in each buttock)
or, if not available:
azithromycin PO
Adults: 2 g single dose
Note: in patients in stage 1, no
further investigation (other than 1, 2
and 3 in this table) or treatment are
required.
Skin lesions
(also see
Chapter 4)
Bacterial infections
• Furunculosis
• Impetigo and pyoderma
• Axillary hidradenitis
• Pyomyositis
• Syphilis
Viral infections
• Herpes zoster
• Herpes simplex
• Genital warts
• Molluscum
contagiosum
Fungal infections
• Candidiasis,
dermatophytoses and
deep mycoses
(penicilliosis,
cryptococcosis,
histoplasmosis, etc.)
Neoplasms
• Kaposi sarcoma
  Bacterial infections
• Furunculosis, impetigo, chronic
folliculitis: see 
Bacterial skin infections, Chapter 4.


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Neoplasms
• Kaposi sarcoma
  Bacterial infections
• Furunculosis, impetigo, chronic
folliculitis: see 
Bacterial skin infections, Chapter 4.
• Suppurative axillary hidradenitis:
local treatment + doxycycline PO:
200 mg once daily for 6 weeks (in
adults)
• Pyomyositis: antibiotics and
surgical drainage, see Pyomyositis,
Chapter 10.
• Primary and secondary syphilis: see
Genital ulcers, Chapter 9.


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Other skin infections
• Chronic prurigo or
urticaria
• Severe seborrhoeic
dermatitis
• Psoriasis
• Scabies
• Diffuse cutaneous
xerosis
Rash caused by
medication
Bed sores
Viral infections
• Herpes zoster: see 
Herpes simplex and herpes zoster,
Chapter 4.
For necrotic, extensive forms,
eruption on the face, ophthalmic
zoster, add aciclovir within 48 hours
of the onset of lesions:
Children (IV route): 5 to 10 mg/kg
every 8 hours for 7 days
Adults (oral route): 800 mg 5 times
daily for 7 days
• Herpes simplex: see 
Herpes simplex and herpes zoster,
Chapter 4.
• Genital warts: see Venereal warts,
Chapter 9.
Fungal infections
• Candidiasis: 2% miconazole
cream, one application 2 times daily
• Dermatophytoses: see 
Superﬁcial fungal infections, Chapter
4.


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Fungal infections
• Candidiasis: 2% miconazole
cream, one application 2 times daily
• Dermatophytoses: see 
Superﬁcial fungal infections, Chapter
4.
Treatment of Kaposi sarcoma (KS)
• Start promptly ART.
• KS tumours with oedema or
ulceration or presence of extensive
oral or gastrointestinal or pulmonary
KS +/- systemic illness:
chemotherapy
Other skin infections
• Prurigo, urticaria: see 
Other skin disorders, Chapter 4.
• Seborrhoeic dermatitis: Whitﬁeld’s
ointment or 2% miconazole, one
application 2 times daily. For severe
inﬂammation, use a topical
corticosteroid in combination with
miconazole.
• Xerosis: zinc oxide ointment or
calamine lotion
• Psoriasis: corticosteroids and
zinc oxide ointment
• Scabies: local treatment. For
crusted or profuse scabies, add


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calamine lotion
• Psoriasis: corticosteroids and
zinc oxide ointment
• Scabies: local treatment. For
crusted or profuse scabies, add
ivermectin PO (see Scabies,
Chapter 4).
Neurological Aetiologies: History and clinical Positive malaria test: see Malaria,


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disorders in adults Infections
• TB meningitis
• Cryptococcal meningitis
• Cerebral toxoplasmosis
• Neurosyphilis
• CMV encephalitis
• HIV encephalopathy
• Progressive multifocal
leuko- encephalopathy
• Cerebral malaria
Neoplasms
• Primary CNS lymphoma
Common causes of
headache unrelated to
HIV infection:
sometimes more
frequent in HIV infected
patients (sinusitis,
problems with
accommodation etc.)
Adverse effects of
ARVs
examination:
• Change in mental state
• Focal deﬁcits
• Seizures
• Signs of meningeal
irritation
• Raised intercranial
pressure
• Motor problems, ataxia
In settings where
cryptococcal infection is
common, screen all
adults with CD4 < 100
prior to initiation of ART,
using a rapid CrAg test
on serum or plasma.
In endemic areas: check
for malaria (if febrile).


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adults with CD4 < 100
prior to initiation of ART,
using a rapid CrAg test
on serum or plasma.
In endemic areas: check
for malaria (if febrile).
Lumbar puncture (LP) if
not contra-indicated.
Elements in favour of
neurosyphilis:
• VDRL positive in blood
and/or CSF
• cells in the CSF
• high protein in the CSF
Chapter 6.
If focal signs, treat for
toxoplasmosis:
co-trimoxazole PO: 25 mg SMX + 5
mg TMP/kg 2 times daily for 4 to 6
weeks
or
pyrimethamine PO: 100 mg morning
and evening on D1, then 75 to 100
mg daily + sulfadiazine PO: 2 g 2 to
3 times daily + folinic acid PO: 15
mg once daily, for 6 weeks
A secondary prophylaxis is
recommended.


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If the LP is positive:
• Bacterial meningitis: see Chapter 7.
• TB meningitis: see the guide 
Tuberculosis, MSF.
• Cryptococcal meningitis :
amphotericin B IV: 1 mg/kg once
daily + ﬂucytosine PO: 25 mg/kg 4
times daily for 1 week
then ﬂuconazole PO: 1200 mg once
daily for 1 week then 800 mg once
daily for 8 weeks
or, if not available
amphotericin B IV: 1 mg/kg once
daily + ﬂuconazole PO: 1200 mg
once daily for 2 weeks
then ﬂuconazole PO alone: 800 mg
once daily for 8 weeks
or
ﬂuconazole PO: 1200 mg once daily
+ ﬂucytosine PO: 25 mg/kg 4 times
daily for 2 weeks
then ﬂuconazole PO alone: 800 mg
once daily for 8 weeks
During the induction phase: give
ﬂuconazole IV (same doses) if the
patient cannot take oral treatment;
liposomal amphotericin B (3 mg/kg


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During the induction phase: give
ﬂuconazole IV (same doses) if the
patient cannot take oral treatment;
liposomal amphotericin B (3 mg/kg
daily 2 weeks) may be used instead
of conventional amphotericin B in
case of renal impairment.
A secondary prophylaxis is
recommended.
Note: intracranial pressure (ICP) is
often raised in cryptococcal
meningitis. To lower ICP, repeated
‘therapeutic’ punctures to drain CSF
may be necessary at the beginning
of treatment.
Neurosyphilis:
benzylpenicillin IV: 2 to 4 MIU (1.2
to 2.4 g) every 4 hours for 14 days
or ceftriaxone IV or IM: 2 g once
daily for 10 to 14 days
Headache of unknown origin:
symptomatic treatment starting with
a step 1 analgesic (see Pain,
Chapter 1).
 [2]


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daily for 10 to 14 days
Headache of unknown origin:
symptomatic treatment starting with
a step 1 analgesic (see Pain,
Chapter 1).
 [2] 
Neurological Aetiologies: Good history taking as Positive malaria test: see Malaria,


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disorders in
children
• Bacterial meningitis
• TB meningitis
• Cryptococcal meningitis
• Cerebral toxoplasmosis
• CMV meningo-
encephalitis
• Cerebral malaria
only patients with acute
episodes beneﬁt from
speciﬁc aetiological
treatment (seizures,
meningeal syndrome,
focal signs).
In endemic areas, check
for malaria (if febrile).
Lumbar puncture (LP) if
not contra-indicated.
Chapter 6.
If LP is not possible:
• Treat for bacterial meningitis if
patient febrile and/or meningeal
syndrome (see Chapter 7).
• If focal signs, treat for
toxoplasmosis:
co-trimoxazole PO: 25 mg SMX + 5
mg TMP/kg 2 times daily for 4 to 6
weeks
or 
pyrimethamine PO: 1 mg/kg 2 times
daily for 2 days then 1 mg/kg once
daily + sulfadiazine PO: 40 mg/kg 2
times daily + folinic acid PO: 10 mg


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or 
pyrimethamine PO: 1 mg/kg 2 times
daily for 2 days then 1 mg/kg once
daily + sulfadiazine PO: 40 mg/kg 2
times daily + folinic acid PO: 10 mg
once daily, for 8 weeks
A secondary prophylaxis is
recommended.


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If the LP is positive:
• Bacterial meningitis: see Chapter 7.
• TB meningitis: see the guide 
Tuberculosis, MSF.
• Cryptococcal meningitis (in order of
preference) :
amphotericin B IV: 1 mg/kg once
daily + ﬂucytosine PO: 25 mg/kg 4
times daily for 1 week then
ﬂuconazole PO: 12 mg/kg once
daily (max. 800 mg daily) for 1 week
then 6-12 mg/kg once daily (max.
800 mg daily) for 8 weeks
or, if not available
amphotericin B IV: 1 mg/kg once
daily + ﬂuconazole PO: 12 mg/kg
once daily (max. 800 mg daily) for 2
weeks then ﬂuconazole PO alone:
6-12 mg/kg once daily for 8 weeks
(max. 800 mg daily)
or
ﬂuconazole PO: 12 mg/kg once
daily (max. 800 mg daily) +
ﬂucytosine PO: 25 mg/kg 4 times
daily for 2 weeks then ﬂuconazole
PO alone: 6-12 mg/kg once daily
(max. 800 mg daily) for 8 weeks


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ﬂucytosine PO: 25 mg/kg 4 times
daily for 2 weeks then ﬂuconazole
PO alone: 6-12 mg/kg once daily
(max. 800 mg daily) for 8 weeks
During the induction phase: give
ﬂuconazole IV (same doses) if the
child cannot take oral treatment;
liposomal amphotericin B (3 mg/kg
daily, 2 weeks) may be used instead
of conventional amphotericin B in
case of renal impairment.
A secondary prophylaxis is
recommended.
 [2] 
Persistent or
recurrent fever
Temperature > 38 °C,
chronic (lasting more than
5 days) or recurrent
(multiple episodes in a
period of more than 5
days)
Aetiologies:
1. History and clinical
examination: look for a
ENT or urinary infection,
TB, skin infection,
enlarged lymph nodes
etc.
2. In endemic areas,
check for malaria.
3. Suspected TB: look
for AFB.
Positive malaria test: see Malaria,


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enlarged lymph nodes
etc.
2. In endemic areas,
check for malaria.
3. Suspected TB: look
for AFB.
Positive malaria test: see Malaria,
Chapter 6.
If testing is not available: in endemic
areas, treat malaria.
Suspected meningitis: treat
according to the results of the LP.
If LP is not available, treat for 
bacterial meningitis, see Chapter 7.


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References
Infections
• Common childhood
diseases
• Severe bacterial
infections (TB,
pneumonia, typhoid fever,
septicaemia, meningitis,
endocarditis, etc.)
• Occult bacterial
infections (sinusitis, otitis,
urinary tract infections)
• Opportunistic infections
(TB, mycosis,
toxoplasmosis)
• Malaria
Neoplasms
• Non-Hodgkin’s
lymphoma
HIV infection
Fever caused by
medication
4. Chest x-ray, CBC,
blood cultures, urinalysis,
stool culture, serology,
lumbar puncture (LP).
If the child is under
treatment, consider
adverse effects of
medication.
Identiﬁed or suspected focus of
infection:
• ENT: see Chapter 2; urinary: see 
Chapter 9, etc.
• TB: see the guide Tuberculosis,
MSF.
Footnotes


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Identiﬁed or suspected focus of
infection:
• ENT: see Chapter 2; urinary: see 
Chapter 9, etc.
• TB: see the guide Tuberculosis,
MSF.
Footnotes
(a) For more information: The use of antiretroviral drugs for treating and preventing HIV infection. Recommendations for apublic health approach. World Health Organization, second edition, 2016.http://apps.who.int/iris/bitstream/10665/208825/1/9789241549684_eng.pdf?ua=1
1. World Health Organization. WHO case deﬁnitions of HIV for surveillance and revised clinical staging and immunologicalclassiﬁcation de HIV-related disease in adults and children, 2007.http://www.who.int/hiv/pub/guidelines/HIVstaging150307.pdf [Accessed 17 May 2018]


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2. Word Health Organization. Guidelines for the diagnosis, prevention, and management of cryptococcal disease in HIV-infected adults, adolescents and children, Geneva, 2018.http://apps.who.int/iris/bitstream/handle/10665/260399/9789241550277-eng.pdf?sequence=1 [Accessed 17 May 2018]


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Chapter 9: Genito-urinary diseases
Nephrotic syndrome in children
Urolithiasis
Acute cystitis
Acute pyelonephritis
Acute prostatitis
Genital infections
Urethral discharge
Abnormal vaginal discharge
Genital ulcers
Lower abdominal pain in women
Upper genital tract infections (UGTI)
Venereal warts
Major genital infections (summary)
Abnormal uterine bleeding (in the absence of pregnancy)


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Nephrotic syndrome in children
Nephrotic syndrome (NS) is characterized by the presence of oedema, heavy proteinuria, hypoalbuminemia, and
hyperlipidaemia.
Primary or idiopathic NS is the most common cause of NS in children between 1 and 10 years. It usually responds to
corticosteroids.
Secondary NS is associated with infectious diseases (e.g. post-infectious glomerulonephritis, endocarditis, hepatitis B
and C, HIV infection, malaria, and schistosomiasis) and may respond to treatment of the underlying cause. Children with NS are at increased risk of thromboembolism, severe bacterial infections (in particular, due to S.
pneumoniae) and malnutrition. Untreated NS may progress to renal failure.
Clinical features


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pneumoniae) and malnutrition. Untreated NS may progress to renal failure.
Clinical features
As oedema worsens, it may localize to the back or genitals, or become generalized with ascites and pleural
effusions. 
 
Laboratory
Treatment
 
 
Typically, the child presents with soft, pitting and painless oedema, which varies in location based on position and
activity. Upon awaking, the child has periorbital or facial oedema, which over the day decreases as oedema of the
legs increases.
This oedema should be differentiated from the oedema of severe acute malnutrition (SAM): in SAM, the child
presents with bilateral pitting oedema of the feet and lower legs that does not vary with position. Oedema extends


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presents with bilateral pitting oedema of the feet and lower legs that does not vary with position. Oedema extends
upwards to hands and face in severe cases. It is usually associated with typical skin and hair changes (see
Kwashiorkor: Severe acute malnutrition, Chapter 1).
Once SAM is excluded, the following two criteria must be met to make a clinical diagnosis of primary NS:
Presence of heavy proteinuria,
and
Absence of associated infections: see Hepatitis B and C and HIV infection (Chapter 8), Malaria and
Schistosomiases (Chapter 6).
Urine
Measure protein with urinary dipstick on three separate voided urine samples (ﬁrst voided urine if possible). In NS,
proteinuria is equal or greater than +++ or equal or greater than 300 mg/dl or 30 g/litre . NS is excluded if heavy


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proteinuria is equal or greater than +++ or equal or greater than 300 mg/dl or 30 g/litre . NS is excluded if heavy
proteinuria is not consistently present.
 a 
In case of macroscopic haematuria, or microscopic haematuria ≥ +, consider glomerulonephritis.
Blood tests (if available)
Serum albumin concentration less than 30 g/litre and hyperlipidaemia.
Blood urea nitrogen (BUN) and creatinine most often in the normal range.
Perform all necessary laboratory tests to exclude secondary NS.
Hospitalize the child for initial therapy.
Corticosteroids (prednisolone or prednisone) are indicated in primary NS.
Before starting corticosteroid treatment:
Treat any concomitant acute infections such as pneumonia, peritonitis, sepsis, pharyngitis, or cellulitis.


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See algorithm below. Total length of initial treatment is 2 to 4 months.
 
 
Treat infections as soon as they appear but do not routinely give prophylactic antibiotics. 
Management of complications
Exclude active tuberculosis and/or start antituberculous treatment.
Corticosteroid treatment
Nutrition, ﬂuid intake, nursing and follow-up
No salt-added diet.
Do not restrict ﬂuids (risk of thrombosis due to hypercoagulability). If oedema is very severe, ﬂuids may initially
be restricted (e.g. 75% of usual intake) while monitoring urine output.
Encourage child to walk and play to prevent thromboembolism.
Discharge child when stable, follow-up at least monthly, more frequently if indicated, weight and urine dipstick at
each visit.


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Discharge child when stable, follow-up at least monthly, more frequently if indicated, weight and urine dipstick at
each visit.
Instruct the parent to continue no salt-added diet and to seek medical advice in case of fever, abdominal pain,
respiratory distress or signs of thromboembolism.
Management of infections
Immunization
Children under 5 years: check that the child has received all EPI vaccines including Haemophilus inﬂuenzae type
B, conjugated pneumococcal vaccine and (if in an endemic area) meningococcal A conjugate vaccine. If not,
administer catch-up vaccines.
Children over 5 years: check that the child has received tetanus, measles, pneumococcal conjugate and (if in an
endemic area) meningococcal A conjugate vaccine. If not, administer catch-up vaccines.


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endemic area) meningococcal A conjugate vaccine. If not, administer catch-up vaccines.
Intravascular volume depletion potentially leading to shock, present despite oedematous appearance


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Signs include decreased urine output with any one of the following: capillary reﬁll ≥ 3 seconds, poor skin
perfusion/mottling, cold extremities, low blood pressure.
If signs are present, administer human albumin 5% IV: 1 g/kg. If albumin is not available, administer Ringer
lactate or 0.9% sodium chloride: 10 ml/kg over 30 minutes.
If signs of shock are present, see Shock, Chapter 1. 
This is the only situation in which diuretics should be used and only if there are no signs of intravascular volume
depletion or after hypovolaemia has been corrected:
furosemide PO: 0.5 mg/kg 2 times daily
If not effective, discontinue furosemide. If creatinine is normal, administer spironolactone PO: 1 mg/kg 2 times


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If not effective, discontinue furosemide. If creatinine is normal, administer spironolactone PO: 1 mg/kg 2 times
daily. The dose can be increased to 9 mg/kg daily in resistant cases of ascites.
While on diuretics, monitor for dehydration, thromboembolism and hypokalaemia. Specialized advice and management (including further investigations such as renal biopsy) are required:
 In case of steroid-resistant NS, when referral is impossible and as a last resort, the following palliative measure may
reduce proteinuria and delay renal failure:
enalapril PO: 0.1 to 0.3 mg/kg 2 times daily (start with the lowest dose and increase gradually if necessary until
reduction of proteinuria). If available, monitor for hyperkalaemia.


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reduction of proteinuria). If available, monitor for hyperkalaemia.
This is a palliative measure and the prognosis for steroid-resistant NS is poor in the absence of specialized treatment.
 
Respiratory distress due to severe oedema (rare)
In children less than 1 year or more than 10 years,
In case of steroid resistant NS,
 In case of mixed nephrotic and nephritic clinical picture.
Footnotes
(a) Nephrotic range proteinuria in children is deﬁned as urinary protein excretion greater than 50 mg/kg daily. Quantitativemeasurement of protein excretion is normally based on a timed 24-hour urine collection. However, if this test cannot beperformed, urine dipstick measurements can be substituted.


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Urolithiasis
Last updated: December 2020
 
Urolithiasis is the formation and passage of calculi (stones) in the urinary tract.
Clinical features
 Note: if available, ultrasound may demonstrate calculi and hydronephrosis.
Treatment
 Note: the majority of calculi pass spontaneously. If there are signs of signiﬁcant renal dysfunction or secondary
infection that does not improve with antibiotic treatment, consider surgical referral.
Many calculi do not cause symptoms; they may be found incidentally through radiology exams.
Symptoms arise when calculi cause partial or complete obstruction and/or infection:
Intermittent, acute ﬂank to pelvic pain (renal colic). Pain can be severe and typically causes nausea and vomiting.


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Intermittent, acute ﬂank to pelvic pain (renal colic). Pain can be severe and typically causes nausea and vomiting.
Abdomen/ﬂank may be tender to palpation. Patients are typically restless, ﬁnding no comfortable position.
Haematuria and/or gravel (calculi) passed in urine.
Fever and signs of pyelonephritis if secondary infection develops (see Acute pyelonephritis, Chapter 9).
Encourage the patient to drink ﬂuids.
Administer analgesics according to the intensity of pain (see Pain, Chapter 1).
In case of secondary infection: antibiotic treatment as for pyelonephritis. The effectiveness will depend on the
passage of calculi.


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Acute cystitis
Last updated: July 2021
 
Cystitis is an infection of the bladder and urethra that affects mainly women and girls from 2 years of age. Escherichia
coli is the causative pathogen in at least 70% of cases. Other pathogens include Proteus mirabilis, Enterococcus sp,
Klebsiella sp and in young women, Staphylococcus saprophyticus.
Clinical features
AND
 It is essential to rule out pyelonephritis.
The symptom 'burning pain on urination' alone is insufﬁcient to make the diagnosis. See Abnormal vaginal discharge.
Investigations 
Perform dipstick analysis for nitrites (which indicate the presence of enterobacteria) and leukocytes (which indicate
an inﬂammation) in the urine.


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Perform dipstick analysis for nitrites (which indicate the presence of enterobacteria) and leukocytes (which indicate
an inﬂammation) in the urine.
 
When urine microscopy is not feasible, an empirical antibiotherapy should be administered to patients with typical
signs of cystitis and positive dipstick urinalysis (leukocytes and/or nitrites). Note: aside of these results, in areas where urinary schistosomiasis is endemic, consider schistosomiasis in patients
with macroscopic haematuria or microscopic haematuria detected by dipstick test, especially in children from 5 to 15
years, even if the patient may suffer from concomitant bacterial cystitis. 
Treatment
Cystitis in girls ≥ 2 years
ceﬁxime PO: 8 mg/kg once daily for 3 days
or


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Treatment
Cystitis in girls ≥ 2 years
ceﬁxime PO: 8 mg/kg once daily for 3 days
or
amoxicillin/clavulanic acid PO (dose expressed in amoxicillin): 12.5 mg/kg 2 times daily for 3 days
Cystitis in young, nonpregnant women 
fosfomycin-trometamol PO: 3 g single dose
or
nitrofurantoin PO: 100 mg 3 times daily for 5 days  
Burning pain on urination and urinary urgency and frequency; in children: crying when passing urine; involuntary loss of
urine.
No fever (or mild fever), no ﬂank pain; no systemic signs and symptoms in children.
Urine dipstick test:
If dipstick analysis is positive for nitrites and/or leukocytes, a urinary infection is likely. 
In women, if dipstick analysis is negative for both nitrites and leukocytes, a urinary infection is excluded.


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In women, if dipstick analysis is negative for both nitrites and leukocytes, a urinary infection is excluded. 
Microscopy/culture: when a dipstick analysis is positive, it is recommended to carry out urine microscopy/culture in
order to conﬁrm the infection and identify the causative pathogen, particularly in children and pregnant women.
POCUS : in cases of recurrent cystitis, perform FAST views to evaluate for signs of urinary tract pathologies.  a 
If dipstick analysis is positive for both nitrites and leukocytes:


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Cystitis in pregnant or lactating women
fosfomycin-trometamol PO: 3 g single dose
or
nitrofurantoin PO (contraindicated in the last month of pregnancy): 100 mg 3 times daily for 7 days 
or 
ceﬁxime PO: 200 mg 2 times daily for 5 days
 
If dipstick analysis is negative for nitrites but positive for leukocytes, the infection may be due to S. saprophyticus.
Fosfomycin is not active against this pathogen. Use nitrofurantoin as above.
Whatever the antibiotic used, symptoms may persist for 2 to 3 days despite adequate treatment.
In the event of treatment failure (or recurrent cystitis i.e. > 3-4 episodes per year), ciproﬂoxacin PO: 500 mg 2
times daily for 3 days
For patients with recurrent cystitis, consider bladder stones, urinary schistosomiasis, urinary tuberculosis or


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times daily for 3 days
For patients with recurrent cystitis, consider bladder stones, urinary schistosomiasis, urinary tuberculosis or
gonorrhoea (examine the partner).
Footnotes
(a) POCUS should only be performed and interpreted by trained clinicians.


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Acute pyelonephritis
Pyelonephritis is an infection of the renal parenchyma, more common in women than in men.
The pathogens causing pyelonephritis are the same as those causing cystitis (see Acute cystitis, Chapter 9).
Pyelonephritis is potentially severe, especially in pregnant women, neonates and infants.
Management depends on the presence of signs of severity or complications or risk of complications.
Clinical features
Neonates and infant
 In practice, a urinary tract infection should be suspected in children with unexplained fever or septic syndrome with no
obvious focus of infection.
Older children and adults
AND
Laboratory
See Acute cystitis, Chapter 9.
Treatment


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obvious focus of infection.
Older children and adults
AND
Laboratory
See Acute cystitis, Chapter 9.
Treatment
 
 
Symptoms are not speciﬁc: fever, irritability, vomiting, poor oral intake. Palpation of the lower abdomen may show
abdominal tenderness. The absence of fever does not rule out the diagnosis. On the other hand, fever –with no
obvious cause– may be the only manifestation.
Neonates may present with fever or hypothermia, altered general condition, altered conscious state, pale/grey
colour, shock.
Signs of cystitis (burning pain on urination and urinary urgency and frequency, etc.)
Fever > 38 °C and unilateral ﬂank pain or abdominal tenderness
Nausea and/or vomiting are common.
Criteria for hospital admission:


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Fever > 38 °C and unilateral ﬂank pain or abdominal tenderness
Nausea and/or vomiting are common.
Criteria for hospital admission:
Patients at risk of complications: children, pregnant women, men , functional or structural abnormality of the
urinary tract (lithiasis, malformation, etc.), severe immunodeﬁciency; 
 a 
Patients with complicated pyelonephritis: urinary tract obstruction, renal abscess, emphysematous
pyelonephritis in diabetic patients;
Patients with signs of severe infection: sepsis (infection with signs of organ dysfunction) and septic shock,
dehydration or nausea/vomiting preventing hydration and oral treatment;
No clinical improvement 24 hours after the start of oral antibiotherapy in women treated as outpatients. 
Antibiotherapy in children
Children under one month


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Antibiotherapy in children
Children under one month 
ampicillin slow IV (3 minutes) for 7 to 10 days
Children 0 to 7 days (< 2 kg): 50 mg/kg every 12 hours
Children 0 to 7 days (≥ 2 kg): 50 mg/kg every 8 hours
Children 8 days to < 1 month: 50 mg/kg every 8 hours
+ gentamicin slow IV (3 minutes) for 5 days
Children 0 to 7 days (< 2 kg): 3 mg/kg once daily


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 Preferably use the combination ampicillin + gentamicin to cover enterococci. 
Pyelonephritis with abscess formation or emphysematous pyelonephritis may require longer antibiotherapy. 
 
Children 0 to 7 days (≥ 2 kg): 5 mg/kg once daily
Children 8 days to < 1 month: 5 mg/kg once daily
or
cefotaxime slow IV (3 minutes) for 7 to 10 days
Children 0 to 7 days (< 2 kg): 50 mg/kg every 12 hours
Children 0 to 7 days (≥ 2 kg): 50 mg/kg every 8 hours
Children 8 days to < 1 month: 50 mg/kg every 8 hours
Children one month and over
ceftriaxone IM or slow IV (3 minutes): 50 mg/kg once daily until the child's condition improves (at least 3 days)
then change to oral route to complete 10 days of treatment with:
amoxicillin/clavulanic acid PO (dose expressed in amoxicillin)


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then change to oral route to complete 10 days of treatment with:
amoxicillin/clavulanic acid PO (dose expressed in amoxicillin)
Children < 40 kg: 25 mg/kg 2 times daily 
Children ≥ 40 kg:
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) 
 b  
Antibiotherapy in adults [1]
Uncomplicated pyelonephritis 
ceftriaxone IM: 1 g single dose or gentamicin IM: 5 mg/kg single dose
+
ciproﬂoxacin PO: 500 mg 2 times daily for 7 days
or
amoxicillin/clavulanic acid PO (dose expressed in amoxicillin) for 10 to 14 days
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) 
or
ceﬁxime PO: 200 mg 2 times daily or 400 mg once daily for 10 to 14 days


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Ratio 7:1: 1750 mg daily (1 tablet of 875/125 mg 2 times daily) 
or
ceﬁxime PO: 200 mg 2 times daily or 400 mg once daily for 10 to 14 days
Pyelonephritis with criteria for hospital admission
ampicillin slow IV (3 minutes): 2 g every 6 hours for at least 3 days + gentamicin IM: 5 mg/kg once daily for 3
days
then change to amoxicillin/clavulanic acid PO (or another antibiotic depending on the antibiotic susceptibility
test) to complete 10 to 14 days of treatment
or
ceftriaxone IV : 1 g once daily for at least 3 days + gentamicin IM: 5 mg/kg once daily for 3 days in the event
of sepsis then change to amoxicillin/clavulanic acid PO (or another antibiotic depending on the antibiotic
susceptibility test) to complete 10 to 14 days of treatment
 b


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susceptibility test) to complete 10 to 14 days of treatment
 b  
Treatment of fever and pain: do not administer NSAID (Fever, Chapter 1).
Maintain proper hydration (1.5 litres daily in adults), especially in children (risk of dehydration); treat dehydration if
present (see Dehydration, Chapter 1).
Management of septic shock if needed.
Footnotes
(a) Pyelonephritis is rare in men; bacterial prostatitis should be suspected in the event of febrile urinary tract infection.


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References
(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.


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1. Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG, Moran GJ, Nicolle LE, Raz R, Schaeffer AJ, Soper DE, InfectiousDiseases Society of America, European Society for Microbiology and Infectious Diseases. International clinical practiceguidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the InfectiousDiseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis.2011;52(5):e103. https://academic.oup.com/cid/article/52/5/e103/388285 [Accessed 17 December 2018]


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Acute prostatitis
Prostatitis is an acute bacterial infection of the prostate.
The most common causative pathogen is Escherichia coli. Other pathogens include Proteus
mirabilis, Klebsiella sp, Pseudomonas aeruginosa and Enterococcus sp.
Progression to chronic prostatitis is possible.
Clinical features
 On examination:
Treatment
 
References
Fever (often high) and chills.
Signs of cystitis (burning on urination and urinary frequency).
Perineal, urethral, penile or rectal pain.
Urinary retention.
Very painful digital rectal examination. Fluctuant mass in case of prostatic abscess.
Leukocyturia, pyuria, possible macroscopic haematuria.
Antibiotic therapy:
ciproﬂoxacin PO: 500 mg 2 times daily for 14 days then review the patient. Stop treatment if signs and symptoms


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Antibiotic therapy:
ciproﬂoxacin PO: 500 mg 2 times daily for 14 days then review the patient. Stop treatment if signs and symptoms
have completely resolved. If signs and symptoms are ongoing continue the same treatment for a further 14 days. [1]
Symptomatic treatment:
Ensure adequate hydration (1.5 litres daily).
Treat fever (Chapter 1) and pain (Chapter 1).
Refer to a surgeon in case of suspected prostatic abscess.
1. National Institute for Health and Care Excellence. NICE guideline [NG110] Prostatitis (acute): antimicrobial prescribing, 2018.https://www.nice.org.uk/guidance/ng110/resources/visual-summary-pdf-6544018477 [Accessed 4 March 2020]


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Genital infections
Last updated: August 2021
 
The diagnosis and treatment of genital infections (GI) present several difﬁculties: clinical features are not speciﬁc;
many infections are asymptomatic; laboratory tests available in the ﬁeld are not always reliable; mixed infections are
common; sexual partners need to be treated simultaneously in case of sexually transmitted infections and the risk of
recurrence or treatment failure is increased in HIV-infected patients.
Thus, the WHO has introduced the syndromic management of GI and developed standardised case management
ﬂowcharts: based on the identiﬁcation of consistent groups of signs and symptoms (syndromes), patients are treated
for the pathogens/infections that may cause each syndrome.


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for the pathogens/infections that may cause each syndrome. 
 
Basic principles of GI management
Special situation: sexual violence
 a  
 b  
Look for a GI if a patient complains of: See
Urethral discharge
Painful or difﬁcult urination (dysuria)
Urethral discharge
Abnormal vaginal discharge
Vulvar itching/burning
Pain with intercourse (dyspareunia)
Painful or difﬁcult urination (dysuria)
Abnormal vaginal discharge
Genital blisters or sores
Burning sensation in the vulva or perineum
Genital ulcers
Skin growths in the genital (or anal) area Venereal warts
Lower abdominal pain (in women) Lower abdominal pain
Upper genital tract infections
The patient can be effectively treated without laboratory testing. Some tests may help in diagnosing vaginal and


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Upper genital tract infections
The patient can be effectively treated without laboratory testing. Some tests may help in diagnosing vaginal and
urethral discharge, but they should never delay treatment (results should be available within one hour).
The patient should be treated at his/her ﬁrst encounter with the health care provider (no patient should be sent
home without treatment, e.g. while waiting for laboratory results).
Single dose regimens are preferred when indicated.
In the case of urethral discharge, abnormal vaginal discharge (except candidiasis), genital ulcers (except herpes) and
sexually transmitted upper genital tract infection, the sexual partner should receive a treatment. In the case of


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sexually transmitted upper genital tract infection, the sexual partner should receive a treatment. In the case of
candidiasis, genital herpes and venereal warts, the partner is treated only if symptomatic.
Patients with sexually transmitted infections should receive information on their disease(s) and treatment and be
counselled on risk reduction and HIV testing. Condoms should be provided for the duration of treatment.


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Taking into consideration the physical, psychological, legal and social consequences of sexual violence, medical
care is not limited to the diagnosis and treatment of genital lesions or infections.
Care includes listening to the victim’s story, a complete physical examination, laboratory tests if available, and
completion of a medical certiﬁcate.
During the consultation, prophylactic or curative treatments must be proposed to the patient. 
 
 Mental health care is necessary irrespective of any delay between the event and the patient arriving for a consultation.
Care is based on immediate attention (one-on-one reception and listening) and if necessary, follow-up care with a view


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Care is based on immediate attention (one-on-one reception and listening) and if necessary, follow-up care with a view
to detecting and treating any psychological and/or psychiatric sequelae (anxiety, depression, post-traumatic stress
disorder, etc.). See Chapter 11.
 
Prophylactic treatment:
priority is given to:
a) the risk of HIV transmission. Start antiretroviral therapy as early as possible if the patient is seen within 48-
72 hours after exposure (see HIV infection and AIDS, Chapter 8);
b) the risk of pregnancy resulting from rape. Administer emergency contraception as soon as possible, ideally
within 72 hours after the rape :
levonorgestrel PO, one 1.5 mg tablet single dose (including in women receiving HIV post-exposure


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within 72 hours after the rape :
levonorgestrel PO, one 1.5 mg tablet single dose (including in women receiving HIV post-exposure
prophylaxis); double the dose (3 mg) only if the patient was already taking an enzyme-inducing drug (e.g.
rifampicin, carbamazepine, certain antiretrovirals) before the rape;
or ulipristal PO, one 30 mg tablet single dose;
or a copper intrauterine device (except in case of active genital infection);
 c  
prevention of sexually transmitted infections: a single dose of azithromycin PO 2 g + ceftriaxone IM 500 mg
(or, if ceftriaxone is not available, ceﬁxime PO 400 mg). If necessary, treatment of trichomoniasis may be
started later than the other treatments (tinidazole or metronidazole PO, 2 g single dose);


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started later than the other treatments (tinidazole or metronidazole PO, 2 g single dose);
tetanus prophylaxis and/or vaccination (see Tetanus, Chapter 7) if there are any wounds;
vaccination against hepatitis B (accelerated vaccination schedule, see Viral hepatitis, Chapter 8).
Curative treatment:
of any related pathologies/infections if the assault is not recent.
of wounds,
Footnotes
(a) GI may be sexually transmitted (e.g. gonorrhoea, chlamydia) or not (e.g. most cases of candidiasis).
(b) Keep in mind that in Schistosoma haematobium endemic areas, genital symptoms may also be due to, or associated with,genitourinary schistosomiasis (see Schistosomiasis, Chapter 6).


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(c) Nevertheless, between 72 and 120 hours (5 days) after the rape, emergency contraception is still sufﬁciently effective to beadministered.


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Urethral discharge
Last updated: August 2022
 
Urethral discharge is seen almost exclusively in men. The principal causative organisms are Neisseria gonorrhoeae
(gonorrhoea) and Chlamydia trachomatis (chlamydia).
Abnormal discharge should be conﬁrmed by performing a clinical examination . In males, the urethra should be milked
gently if no discharge is visible. Furthermore, speciﬁcally check for urethral discharge in patients complaining of painful
or difﬁcult urination (dysuria).
Case management
Laboratory
Treatment of the patient
 a 
C. trachomatis cannot easily be identiﬁed in a ﬁeld laboratory. In the absence of validated rapid diagnostic tests,
the treatment is empiric.


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a 
C. trachomatis cannot easily be identiﬁed in a ﬁeld laboratory. In the absence of validated rapid diagnostic tests,
the treatment is empiric.
In men, a methylene blue or Gram stained smear from a urethral swab may be used to detect gonococci (Gram
negative intracellular diplococci).
In women: same treatment as cervicitis.
In men:
If microscopy of a urethral smear has been performed: in the absence of gonococci, treat for chlamydia alone;
in the presence of gonococci, treat for chlamydia AND gonorrhoea.
When no laboratory is available, treat for chlamydia AND gonorrhoea as below:


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Page 308 / 409
 If urethral discharge persists or reappears after 7 days:
Treatment of the partner
The sexual partner receives the same treatment as the patient, whether or not symptoms are present.
 
Treatment for chlamydia   Treatment for gonorrhoea
azithromycin PO: 1 g single dose
or
doxycycline PO: 100 mg 2 times daily for
7 days
PLUS ceftriaxone IM: 500 mg single dose
or, if ceftriaxone is not available,
ceﬁxime PO: 400 mg single dose
Verify that the patient has received an effective treatment (i.e. one of the combinations above).
Gonococcal resistance is a possibility if another treatment (e.g. co-trimoxazole or kanamycin) has been
administered: re-treat for gonorrhoea as above (chlamydia is rarely resistant).


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administered: re-treat for gonorrhoea as above (chlamydia is rarely resistant).
If an effective antibiotic therapy has been given, consider trichomoniasis (tinidazole or metronidazole PO, 2 g
single dose); also consider reinfection.
Footnotes
(a) In areas where lymphatic ﬁlariasis is endemic, be careful not to confuse purulent urethral discharge with milky or rice-waterurine (chyluria) suggestive of lymphatic ﬁlariasis.


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Page 309 / 409
Abnormal vaginal discharge
Last updated: August 2022
 
Abnormal vaginal discharge is deﬁned as discharge that is different from usual with respect to
colour/odour/consistency (e.g. discoloured or purulent or malodorous). Abnormal discharge is often associated with vulvar pruritus or pain with intercourse (dyspareunia), or painful or difﬁcult
urination (dysuria) or lower abdominal pain. Routinely check for abnormal vaginal discharge in women presenting with
these symptoms. Abnormal vaginal discharge may be a sign of infection of the vagina (vaginitis) and/or the cervix (cervicitis) or upper
genital tract infection.
Abnormal discharge must be clinically conﬁrmed: inspection of the vulva, speculum exam checking for cervical/vaginal
inﬂammation or discharge.


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Abnormal discharge must be clinically conﬁrmed: inspection of the vulva, speculum exam checking for cervical/vaginal
inﬂammation or discharge.
Abdominal and bimanual pelvic examinations should be performed routinely in all women presenting with vaginal
discharge to rule out upper genital tract infection (lower abdominal pain and cervical motion tenderness). The principal causative organisms are:
Case management
In vaginitis: Gardnerella vaginalis and other bacteria (bacterial vaginosis), Trichomonas vaginalis (trichomoniasis)
and Candida albicans (candidiasis).
In cervicitis: Neisseria gonorrhoeae (gonorrhoea) and Chlamydia trachomatis (chlamydia).
In upper genital tract infections: see Upper genital tract infections.


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Cervicitis may be difﬁcult to diagnose. When in doubt, administer treatment for cervicitis to women with abnormal
vaginal discharge and any of the following risk factors:
Laboratory
Treatment of the patient
Cervicitis
Treat for both chlamydia AND gonorrhoea. 
Urethral discharge in the partner
Context of sexual violence or prostitution
New partner or more than one partner in the preceding 3 months
Xpert molecular (PCR) tests are recommended for the detection of C. trachomatis and N. gonorrhoea. 
Microscopic examination of a fresh wet smear may show mobile T. vaginalis, yeast cells and hyphae in candidiasis,
and “clue cells” in bacterial vaginosis. 
Identiﬁcation of N. gonorrhoeae by Gram-stained smear is not sensitive in women and is not recommended.


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Bacterial vaginosis and trichomoniasis
tinidazole PO: 2 g single dose
or metronidazole PO: 2 g single dose In the case of treatment failure:
tinidazole PO: 500 mg 2 times daily for 5 days
or metronidazole PO: 400 to 500 mg 2 times daily for 7 days
Vulvovaginal candidiasis
clotrimazole (500 mg vaginal tab): 1 tablet inserted deep into the vagina at bedtime, single dose If the patient has extensive vulvar involvement, miconazole 2% cream (one application to the vulva 2 times daily for 7
days) may be used in combination with the intravaginal treatment above. Miconazole cream may complement, but
does not replace, treatment with clotrimazole.
Treatment of the partner


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does not replace, treatment with clotrimazole.
Treatment of the partner
When the patient is treated for vaginitis or cervicitis, the partner receives the same treatment as the patient, whether
or not symptoms are present. In the case of vulvovaginal candidiasis, the partner is treated only if symptomatic (itching and redness of the
glans/prepuce): miconazole 2% cream, one application 2 times daily for 7 days.
Treatment for chlamydia   Treatment for gonorrhoea
Non-pregnant women
azithromycin PO: 1 g single dose
or
doxycycline PO: 100 mg 2 times daily
for 7 days
PLUS ceftriaxone IM: 500 mg single dose 
or, if not available,
ceﬁxime PO: 400 mg single dose
Pregnant women
azithromycin PO: 1 g single dose
or
erythromycin PO: 1 g 2 times daily
or 500 mg 4 times daily for 7 days


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Pregnant women
azithromycin PO: 1 g single dose
or
erythromycin PO: 1 g 2 times daily
or 500 mg 4 times daily for 7 days
PLUS ceftriaxone IM: 500 mg single dose
or, if not available,
ceﬁxime PO: 400 mg single dose


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Genital ulcers
Genital ulcers, deﬁned as single or multiple vesicular, ulcerative or erosive lesions of the genital tract, with or without
inguinal lymphadenopathy, should lead to consideration of sexually transmitted infection.
The principal causative organisms are Treponema pallidum (syphilis), Haemophilus ducreyi (chancroid) and Herpes
simplex (genital herpes). Chlamydia trachomatis (lymphogranuloma venereum) and Calymmatobacterium
granulomatis (donovanosis) are less frequent.
Case management
Laboratory
Laboratory testing available in the ﬁeld is of little value: e.g., in syphilis, a negative RPR or VDRL result does not
exclude primary syphilis in early stage, and a positive test may reﬂect previous infection in a successfully treated
patient.
Treatment of the patient


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patient.
Treatment of the patient
Genital herpes
 a  
Local treatment: clean the area with soap and water.
Antiviral treatment: aciclovir PO


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In patients with a ﬁrst episode, treatment may reduce the duration of symptoms when given within 5 days after the
onset of symptoms: 400 mg 3 times daily for 7 days.
In patients with recurrence, give the same dose for 5 days, but treatment is only effective if initiated during the
prodromal phase or within 24 hours after the onset of symptoms.
In patients with frequent recurrences (more than 6 episodes par year), see HIV infection and AIDS, Chapter 8.
Syphilis
benzathine benzylpenicillin IM: 2.4 MUI per injection (half the dose in each buttock) .
Early syphilis (primary, secondary, or early latent infection of less than 12 months duration): single dose
Late latent syphilis (infection of more than 12 months duration or of unknown duration): one injection weekly for 3
weeks


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Late latent syphilis (infection of more than 12 months duration or of unknown duration): one injection weekly for 3
weeks
or, for penicillin-allergic patients or if penicillin is not available:
erythromycin PO: 1 g 2 times daily or 500 mg 4 times daily for 14 days (early syphilis) or 30 days (late latent syphilis)
or
doxycycline PO: 100 mg 2 times daily for 14 days (early syphilis) or 30 days (late latent syphilis)
or 
azithromycin PO: 2 g single dose (only in cases of early syphilis and only if the strain is sensitive)
Chancroid
azithromycin PO: 1 g single dose
or
ceftriaxone IM: 250 mg single dose
or


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Chancroid
azithromycin PO: 1 g single dose
or
ceftriaxone IM: 250 mg single dose
or
erythromycin PO: 1 g 2 times daily or 500 mg 4 times daily for 7 days Fluctuant lymph nodes may be aspirated through healthy skin as required. Do not incise and drain lymph nodes. Note: treat simultaneously for syphilis AND chancroid as both are frequent, and cannot be correctly distinguished on
clinical grounds.
Lymphogranuloma venereum
erythromycin PO: 1 g 2 times daily or 500 mg 4 times daily for 14 days
or
doxycycline PO: 100 mg 2 times daily for 14 days Fluctuant lymph nodes may be aspirated through healthy skin as required. Do not incise and drain lymph nodes.
Donovanosis
Treatment is given until the complete disappearance of the lesions (usually, several weeks; otherwise risk of
recurrence):


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Donovanosis
Treatment is given until the complete disappearance of the lesions (usually, several weeks; otherwise risk of
recurrence):
azithromycin PO: 1 g on D1 then 500 mg once daily
or
erythromycin PO: 1 g 2 times daily or 500 mg 4 times daily
or
doxycycline PO: 100 mg 2 times daily In HIV infected patients, add gentamicin IM: 6 mg/kg once daily.
Treatment of the partner
Treatment of pain: paracetamol PO (Chapter 1).
 [1] 
 b 
 [2]
 b
 b


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The sexual partner receives the same treatment as the patient, whether or not symptoms are present, except in the
case of genital herpes (the partner is treated only if symptomatic).
 
References
Footnotes
(a) Lymphogranuloma venereum is endemic in East and West Africa, India, Southeast Asia, South America and the Caribbean.Donovanosis is endemic in South Africa, Papua New Guinea, India, Brazil and the Caribbean.
(b) Doxycycline is contra-indicated in pregnant and breast-feeding women.
1. Centers for Disease Control and Prevention. Syphilis Pocket Guide for Providers. 2017.https://www.cdc.gov/std/syphilis/Syphilis-Pocket-Guide-FINAL-508.pdf


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2. World Health Organization. WHO guidelines for the treatment of Treponema pallidum (syphilis), Geneva, 2016.http://apps.who.int/iris/bitstream/handle/10665/249572/9789241549806-eng.pdf?sequence=1


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Lower abdominal pain in women
Upper genital tract infection should be suspected in women with lower abdominal pain (see Upper genital tract
infections).
Gynaecological examination should be routinely performed:
 If available, POCUS : perform FAST views to evaluate for free ﬂuid and urological abnormalities. Perform pelvic views
to evaluate for uterine and adnexal pathologies. Consult a gynaecologist (local or via telemedicine services). 
Case management
 
Inspection of the vulva, speculum examination: check for purulent discharge or inﬂammation.
Abdominal exam and bimanual pelvic exam: check for pain on mobilising the cervix. 
 a 
Footnotes
(a) POCUS should only be performed and interpreted by trained clinicians.


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Upper genital tract infections (UGTI)
Last update: March 2023
 
Upper genital tract infections are bacterial infections of the uterus (endometritis) and/or the fallopian tubes (salpingitis),
which may be complicated by peritonitis, pelvic abscess or septicaemia.
UGTI may be sexually transmitted or arise after childbirth or abortion. Antibiotic choices are directed by the most
common pathogens in each scenario.
If peritonitis or pelvic abscess is suspected, request a surgical opinion while initiating antibiotic therapy.
Clinical features
Sexually transmitted infections
Diagnosis may be difﬁcult, as clinical presentation is variable.
Infections after childbirth or abortion
Treatment
Sexually transmitted infections


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Diagnosis may be difﬁcult, as clinical presentation is variable.
Infections after childbirth or abortion
Treatment
Sexually transmitted infections
Suggestive symptoms are: abdominal pain, abnormal vaginal discharge, fever, dyspareunia, menometrorrhagia,
dysuria.
Infection is probable when one or more of the above symptoms are associated with one or more of the following
signs: cervical motion tenderness, adnexal tenderness, tender abdominal mass.
Most cases present with a typical clinical picture, developing within 2 to 10 days after delivery (caesarean section
or vaginal delivery) or abortion (spontaneous or induced):
Fever, generally high
Abdominal or pelvic pain
Malodorous or purulent lochia
Enlarged, soft and/or tender uterus
Check for retained placenta.


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Fever, generally high
Abdominal or pelvic pain
Malodorous or purulent lochia
Enlarged, soft and/or tender uterus
Check for retained placenta.
In the early stages, fever may be absent or moderate and abdominal pain may be mild.
Criteria for hospitalisation include:
Clinical suspicion of severe or complicated infection (e.g. peritonitis, abscess, septicaemia)
Diagnostic uncertainty (e.g. suspicion of extra-uterine pregnancy, appendicitis)
Signiﬁcant obstacles to ambulatory oral treatment
No improvement after 48 hours, or deterioration within 48 hours, of outpatient treatment
All other patients may be treated on an ambulatory basis. They should be reassessed routinely on the third day of


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All other patients may be treated on an ambulatory basis. They should be reassessed routinely on the third day of
treatment to evaluate clinical improvement (decrease in pain, absence of fever). If it is difﬁcult to organise routine
follow-up, advise patients to return to clinic if there is no improvement after 48 hours of treatment, or sooner if their
condition is worsening.
Antibiotic therapy combines 3 antibiotics to cover the most frequent causative organisms: gonococci, chlamydiae,
and anaerobes.
Ambulatory treatment:
ceﬁxime PO: 400 mg single dose or ceftriaxone IM: 500 mg single dose


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Infections after childbirth or abortion
 
+ doxycycline PO: 100 mg 2 times daily for 14 days
+ metronidazole PO: 500 mg 2 times daily for 14 days
 a 
Treatment in hospital:
ceftriaxone IM or IV : 1 g once daily
+ doxycycline PO: 100 mg 2 times daily for 14 days
+ metronidazole PO or IV infusion: 500 mg 2 times daily for 14 days
Continue triple therapy for 24 to 48 hours after signs and symptoms have improved (resolution of fever,
decrease in pain), then continue doxycycline (or erythromycin) + metronidazole to complete 14 days of
treatment.
 b 
 a 
If an IUD is in place, it should be removed (offer another method of contraception).
Analgesic treatment according to pain intensity.


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b 
 a 
If an IUD is in place, it should be removed (offer another method of contraception).
Analgesic treatment according to pain intensity.
Treatment of the partner: single dose treatment for both gonorrhoea AND chlamydia (as for Urethral discharge),
whether or not symptoms are present.
Antibiotic therapy: treatment must cover the most frequent causative organisms: anaerobes, Gram negatives and
streptococci.
Ambulatory treatment (early stages only):
amoxicillin/clavulanic acid (co-amoxiclav) PO for 7 days
Use formulations in a ratio of 8:1 or 7:1 exclusively. The dose is expressed in amoxicillin:
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)
or


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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)
or
amoxicillin PO: 1 g 3 times daily + metronidazole PO: 500 mg 3 times daily doses for 7 days
Treatment in hospital:
amoxicillin/clavulanic acid (co-amoxiclav) IV (dose expressed in amoxicillin): 1 g every 8 hours
+ gentamicin IM: 5 mg/kg once daily
or
ampicillin IV: 2 g every 8 hours
+ metronidazole IV infusion: 500 mg every 8 hours
+ gentamicin IM: as above
Stop antibiotic therapy 48 hours after resolution of fever and clinical signs and symptoms.
In penicillin-allergic patients, use clindamycin IV (900 mg every 8 hours) + gentamicin (as above).


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In penicillin-allergic patients, use clindamycin IV (900 mg every 8 hours) + gentamicin (as above).
In case of placental retention: perform digital curettage or manual vacuum extraction (refer to the guide Essential
obstetric and newborn care, MSF) 24 hours after initiation of antibiotic therapy.
Analgesic treatment according to pain intensity.
If the patient’s condition deteriorates or if fever persists after 48-72 hours of treatment, consider the possibility of
complication requiring additional treatment (e.g. pelvic abscess drainage), otherwise change the antibiotic to
ceftriaxone + doxycycline + metronidazole as in hospital-based treatment of sexually transmitted UGTI.
Footnotes


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ceftriaxone + doxycycline + metronidazole as in hospital-based treatment of sexually transmitted UGTI.
Footnotes
(a) In pregnant/breastfeeding women: erythromycin PO: 1 g 2 times daily or 500 mg 4 times daily for 14 daysSingle dose azithromycin is not effective against chlamydia in the treatment of sexually transmitted UGTI.
(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.


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Venereal warts
Venereal warts are benign tumours of the skin or mucous membranes due to certain papilloma viruses (HPV).
Clinical features
Treatment
Choice of treatment depends on the size and location of the warts. Treatment may be less effective, and relapses
more frequent, in HIV infected patients.
External warts < 3 cm and vaginal warts
podophyllotoxin 0.5% solution may be self-applied by the patient, but in the event of vaginal warts, the treatment
must be applied by medical staff. Explain the procedure to the patient: apply the solution to the warts using an applicator or cotton bud, sparing the
surrounding healthy skin, allow to air dry. On vaginal warts, the solution should be allowed to dry before the speculum is
withdrawn.


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surrounding healthy skin, allow to air dry. On vaginal warts, the solution should be allowed to dry before the speculum is
withdrawn.
Apply the solution 2 times daily, 3 consecutive days per week, for up to 4 weeks. Podophyllum preparations are contra-indicated in pregnant or breastfeeding women. They should not be applied on
cervical, intra-urethral, rectal, oral or extensive warts. Improper use may result in painful ulceration.
External warts > 3 cm; cervical, intra-urethral, rectal and oral warts; warts in pregnant orbreastfeeding women
Surgical excision or cryotherapy or electrocoagulation.
 
Venereal warts are soft, raised, painless growths, sometimes clustered (cauliﬂower- like appearance) or macules


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Venereal warts are soft, raised, painless growths, sometimes clustered (cauliﬂower- like appearance) or macules
(ﬂat warts), which are more difﬁcult to discern. Warts can be external (vulva, penis, scrotum, perineum, anus) and/or
internal (vagina, cervix, urethra, rectum; oral cavity in HIV infected patients).
In women, the presence of external warts is an indication for a speculum examination to exclude vaginal or cervical
warts. Speculum exam may reveal a friable, fungating tumour on the cervix, suggestive of cancer associated with
papilloma virus . a 
 b  
 c  
Footnotes


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papilloma virus . a 
 b  
 c  
Footnotes
(a) Certain types of HPV may cause cancer. Presence of genital warts in women is an indication to screen for precancerouslesions of the cervix, if feasible in the context (visual inspection with acetic acid, or cervical smear, or other availabletechniques), and to treat any lesions identiﬁed (cryotherapy, conisation, etc., according to diagnosis).
(b) Podophyllum 10%, 15% or 25% resin is another preparation which is much more caustic, and should be applied only bymedical staff. Protect the surrounding skin (vaseline or zinc oxide ointment) before applying the resin. Wash off with soapand water after 1 to 4 hours. Apply once weekly for 4 weeks.


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(c) Treatment of warts is not an emergency and may be deferred if alternatives to podophyllum preparations are not available.Genital warts are not an indication for caesarean section: it is uncommon for warts to interfere with delivery, and the risk ofmother-to-child transmission is very low.


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Pathogens/
Infections Clinical features Investigations Treatment
Neisseria
gonorrhoeae
(gonorrhoea)
In women:
vaginal discharge, cervicitis
(mucopurulent cervical discharge),
dysuria (50% of infections are
asymptomatic);
UGTI (salpingitis, endometritis).
In men: purulent urethral discharge
and sometimes dysuria (5 to 50% of
infections are asymptomatic).
Best method is PCR
(Xpert), if available.
In men (not sensitive
enough in women): Gram
or methylene blue stain:
intracellular diplococci
and polymorphonuclear
leukocytes (more than 4
per ﬁeld).
ceftriaxone IM: 500 mg
single dose
or, if not available,
ceﬁxime PO: 400 mg
single dose
Treat also for
chlamydia.
In case of upper genital
tract infection, see 
UGTI.
Chlamydia
trachomatis
(chlamydia)
In women:


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single dose
Treat also for
chlamydia.
In case of upper genital
tract infection, see 
UGTI.
Chlamydia
trachomatis
(chlamydia)
In women:
vaginal discharge, cervicitis, and
rarely dysuria (> 50% of
infections are asymptomatic);
UGTI (salpingitis, endometritis).
In men: mild urethral discharge and/or
dysuria but up to 90% of infections
are asymptomatic.
The best method is PCR
(Xpert), if available.
azithromycin PO: 1 g
single dose
or doxycycline PO :
200 mg daily for 7 days
Treat also for
gonococcal infection
(except when a Gram
stain in males or PCR
shows no N.
gonorrhoeae).
In case of upper genital
tract infection, see 
UGTI.
 (a) 
Trichomonas
vaginalis
(trichomoniasis)
In women: yellow-green vaginal
discharge, sometimes foul smelling,
vulvar irritation (10 to 50% of


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UGTI.
 (a) 
Trichomonas
vaginalis
(trichomoniasis)
In women: yellow-green vaginal
discharge, sometimes foul smelling,
vulvar irritation (10 to 50% of
infections are asymptomatic).
In men: most infections are
asymptomatic. Can produce
balanitis, urethritis with mild discharge
and sometimes dysuria.
Wet mount of fresh
vaginal ﬂuid shows motile
trichomonas (low
sensitivity).
pH of urethral/vaginal
ﬂuid > 4.5.
tinidazole or
metronidazole PO: 2 g
single dose
Bacterial
vaginosis
(Gardnerella
vaginalis and
other
associated
bacteria)
Diagnosis is made in the presence of 3 of the following 4 signs:
Homogenous grey-white adherent vaginal discharge
pH of vaginal ﬂuid > 4.5
Vaginal ﬂuid has an amine (ﬁshy) odour, especially when mixed with
10% KOH


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Homogenous grey-white adherent vaginal discharge
pH of vaginal ﬂuid > 4.5
Vaginal ﬂuid has an amine (ﬁshy) odour, especially when mixed with
10% KOH
Presence of clue cells in wet mount or Gram stain of vaginal ﬂuid
tinidazole or
metronidazole PO: 2 g
single dose
Candida
albicans
(candidiasis)
Mainly seen in women: pruritus and
vulvovaginitis, frequently creamy-
white vaginal discharge, sometimes
dysuria.
Saline of KOH wet mount
of fresh vaginal ﬂuid
shows budding yeast
cells and pseudohyphae.
In women:
clotrimazole 500
mg: one vaginal
tablet single dose


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In men: balanitis/balanoposthitis
(inﬂammation of the glans/prepuce,
erythema, pruritus, white pustules)
and rarely urethritis
pH of vaginal ﬂuid:
normal
In men:
miconazole 2%
cream: 1 application
2 times daily for 7
days
Herpes
simplex
virus type 2
(genital herpes)
Many asymptomatic carriers. Multiple
vesicles on genitals leading to painful
ulcerations. In women, affects vulva,
vagina and cervix; in males, penis and
sometimes urethra. In primary episodes,
fever (30%) and lymphadenopathy
(50%). Recurrences in 1/3 of infections
with shorter and milder symptoms.
Diagnosis by culture,
serology and PCR done
exclusively at a reference
laboratory.
Analgesics, local
disinfection.
If available, aciclovir
PO:
Primary episode:
1200 mg daily for 7
days, given within 5


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laboratory.
Analgesics, local
disinfection.
If available, aciclovir
PO:
Primary episode:
1200 mg daily for 7
days, given within 5
days after onset of
lesions.
Recurrent
infections: same
dose for 5 days,
given within 24
hours after onset of
lesions.
Treponema
pallidum
(syphilis)
Single ﬁrm painless genital ulcer, often
unnoticed.
RPR/VDRL lack sensitivity
and speciﬁcity, but may be
useful for following
treatment effectiveness
(decrease in titer) or
conﬁrming re-infection (rise
in titer).
Treponemal tests (TPHA,
FTA-ABS, rapid tests such
as SD Bioline®) are more
sensitive and speciﬁc.
benzathine
benzylpenicillin IM:
2.4 MIU per injection,
single dose (syphylis <
12 months) or once
weekly for 3 weeks
(syphilis > 12 months or
unknown duration)
or azithromycin PO: 2
g single dose


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single dose (syphylis <
12 months) or once
weekly for 3 weeks
(syphilis > 12 months or
unknown duration)
or azithromycin PO: 2
g single dose
or erythromycin PO: 2
g daily for 14 days
or doxycycline PO :
200 mg daily for 14
days
Treat also for
chancroid.
 (a) 
Haemophilus
ducreyi
(chancroid)
Painful single (or multiple) genital ulcer
(soft chancre, bleeds easily when
touched).
Painful and voluminous inguinal
lymphadenitis in 50%. Fistulae develop in
25% of cases.
H. ducreyi bacillus is difﬁcult
to identify on microscopy or
by culture.
azithromycin PO: 1 g
single dose
or ceftriaxone IM: 250
mg single dose
or ciproﬂoxacin PO :
1 g daily for 3 days
or erythromycin PO: 2
g daily for 7 days
Treat also for syphillis.
 (b)


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Human
papillomavirus
(venereal
warts)
Soft, raised, painless growths,
sometimes clustered (acuminate
condyloma) or macules (ﬂat warts).
Warts can be external (vulva, penis,
scrotum, perineum, anus) and/or internal
(vagina, cervix, urethra, rectum; oral
cavity in HIV infected patients).
The diagnosis is based on
clinical features.
It feasible in the context, the
presence of genital warts in
women in an indication to
screen for pre-cancerous
lesions of the cervix (visual
inspection with acetic acid,
or cervical smear, or other
available techniques).
External warts < 3
cm and vaginal
warts:
podophyllotoxin
0.5%
External warts > 3
cm; cervical, intra-
urethral, rectal and
oral warts; warts in
pregnant or
breastfeeding
women: surgical
excision or
cryotherapy or


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cm; cervical, intra-
urethral, rectal and
oral warts; warts in
pregnant or
breastfeeding
women: surgical
excision or
cryotherapy or
electrocoagulation.
(a) Doxycycline is contra-indicated in pregnant women. It should not be administered to breast-feeding women if the treatmentexceeds 7 days (use erythromycin).
(b) Ciproﬂoxacin should be avoided in pregnant women.


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Abnormal uterine bleeding (in the absence ofpregnancy)
Last updated: October 2021
 
 For the management of pregnancy-related bleeding, refer to the guide Essential obstetric and newborn care, MSF.
In all events
According to clinical examination
Heavy menstrual bleeding or intermenstrual genital bleeding
In women of childbearing age:
assess if the bleeding is pregnancy-related;
perform a pregnancy test.
Rapidly assess the severity of bleeding.
Perform a pelvic examination:
speculum examination: determine the origin (vagina, cervix, uterine cavity) and cause of the bleeding; appearance
of the cervix; amount and intensity of bleeding;
bimanual examination: look for cervical motion tenderness, uterine enlargement or irregularity.
Assess for recent trauma or surgical history.


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bimanual examination: look for cervical motion tenderness, uterine enlargement or irregularity.
Assess for recent trauma or surgical history.
Measure haemoglobin, if possible, to prevent or treat anaemia.
In the event of signs of shock, see Shock, Chapter 1.
In the event of heavy bleeding:
start an IV infusion of Ringer lactate;
monitor vital signs (heart rate, blood pressure);
administer : 
tranexamic acid IV: 10 mg/kg (max. 600 mg) every 8 hours. When bleeding has been reduced, switch to
tranexamic acid PO: 1 g 3 times daily, until bleeding stops (max. 5 days).
 [1] 
if bleeding persists and/or in case or contraindication to tranexamic acid, administer one of the following two
drugs (except if suspicion of cervical or endometrial cancer):


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drugs (except if suspicion of cervical or endometrial cancer):
ethinylestradiol/levonorgestrel PO (0.03 mg/0.15 mg tab): one tablet 3 times daily for 7 days
or medroxyprogesterone acetate PO: 20 mg 3 times daily for 7 days
In case of massive haemorrhage and/or lack of response to medical management: surgical management (dilation
and curettage, intrauterine balloon, and as a last resort, hysterectomy).
In the event of referral to a surgical facility, difﬁcult transport conditions may aggravate the bleeding: the patient
should have an IV line and/or be accompanied by family members who are potential blood donors.
If available, POCUS : perform FAST to evaluate for free ﬂuid and/or urological abnormalities; perform pelvic views
to evaluate for uterine and/or adnexal pathologies.
 a


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to evaluate for uterine and/or adnexal pathologies.
 a 
Friable, hard, ulcerated, hypertrophic mass on the cervix: possible cervical cancer; surgical treatment,
chemotherapy, radiation therapy or palliative care is required depending on the stage of the cancer. While waiting
for appropriate treatment, tranexamic acid PO (1 g 3 times daily for 5 days max.) may be used to reduce bleeding.
Inﬂammation of the cervix, light or moderate bleeding, purulent cervical discharge, pelvic pain: consider cervicitis
(see Abnormal vaginal discharge) or salpingitis (see Upper genital tract infections).


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 Note: rule out other causes of vaginal bleeding before diagnosing functional uterine bleeding. Consider for example
poorly tolerated contraceptive, endometrial cancer in postmenopausal women, genitourinary schistosomiasis in
endemic areas (see Schistosomiasis, Chapter 6).
 
References
Enlarged, irregular uterus: uterine ﬁbroids. In case of failure to respond to medical treatment, surgical management
is required. While waiting for surgery or if surgery is not indicated, treat as for functional uterine bleeding.
Normal uterus and cervix: possible functional uterine bleeding: tranexamic acid PO as above. In case of repeated
bleeding, it can be combined with an NSAID (ibuprofen PO for 3 to 5 days, see Pain, Chapter 1) and/or one of the
following long-term treatments:


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bleeding, it can be combined with an NSAID (ibuprofen PO for 3 to 5 days, see Pain, Chapter 1) and/or one of the
following long-term treatments:
levonorgestrel intrauterine device
or ethinylestradiol/levonorgestrel PO (0.03 mg/0.15 mg tab): one tablet daily
or medroxyprogesterone acetate IM: 150 mg every 3 months
or medroxyprogesterone acetate PO : 10 mg once daily (up to 30 mg once daily if necessary) for 21 days
monthly.
 b 
Footnotes
(a) POCUS should only be performed and interpreted by trained clinicians.
(b) Unlike the other treatments, this drug has no contraceptive effect.


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(a) POCUS should only be performed and interpreted by trained clinicians.
(b) Unlike the other treatments, this drug has no contraceptive effect.
1. American College of Obstetricians and Gynecologists. Management of acute abnormal uterine bleeding in nonpregnantreproductive-aged women. Obstet Gynecol. 2013 Apr;121(4):891-6. https://www.acog.org/-/media/project/acog/acogorg/clinical/ﬁles/committee-opinion/articles/2013/04/management-of-acute-abnormal-uterine-bleeding-in-nonpregnant-reproductive-aged-1.pdf


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Chapter 10: Medical and minor surgicalprocedures
Dressings
Treatment of a simple wound
Burns
Cutaneous abscess
Pyomyositis
Leg ulcers
Necrotising infections of the skin and soft tissues
Venomous bites and stings
Dental infections


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Dressings
The objective of dressing wounds is to promote healing. The procedure includes cleaning, disinfection and protection
of the wound while respecting the rules of hygiene.
Not all wounds need to be covered by a dressing (e.g. a clean wound that has been sutured for several days; a small
dry wound not requiring sutures).
Equipment
Sterile instruments
 Instruments for one dressing for one patient must be wrapped together in paper or fabric (or can be placed in a metallic
box) and sterilised together to limit handling and breaks in asepsis. 5 to 10 compresses may be included in this set.
If there are no sterile instruments, a dressing can be done using sterile gloves.
Renewable supplies
Organisation of care


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If there are no sterile instruments, a dressing can be done using sterile gloves.
Renewable supplies
Organisation of care
Proper organization of care helps maintain the rules of asepsis and decreases the risk of contamination of the wound
or transmission of organisms from one patient to another:
Technique
One Kocher or Pean forceps
One dissecting forceps
One pair of surgical scissors or one scalpel to excise necrotic tissue and to cut gauze or sutures
Sterile compresses
Non-sterile disposable gloves
Adhesive tape and/or crepe or gauze bandage
Sterile 0.9% sodium chloride or sterile water
Depending on the wound: antiseptic (7.5% povidone iodine scrub solution, 10% povidone iodine dermal solution),
parafﬁn compresses, analgesics


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Depending on the wound: antiseptic (7.5% povidone iodine scrub solution, 10% povidone iodine dermal solution),
parafﬁn compresses, analgesics
Assign one room for dressings. It must be cleaned and the waste removed every day. The dressing table must be
disinfected after each patient.
Dressings may be applied at the bedside if the patient’s condition requires. Use a clean, disinfected dressing trolley
with: on the upper tray, sterile and/or clean material (dressing set, extra compresses, etc.) and on the lower tray,
septic material (container for contaminated instruments, sharps disposal container and a container or garbage bag
for waste).
Prepare all the necessary material in a well lit area. If necessary, arrange for an assistant to be present.


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for waste).
Prepare all the necessary material in a well lit area. If necessary, arrange for an assistant to be present.
Wear protective glasses if there is a risk of projection from an oozing wound.
Always proceed from clean to dirty: start with patients with uninfected wounds. If there are multiple dressings for
one patient, start with the cleanest wound.
If the procedure may be painful, give an analgesic and wait the necessary time for the drug to take effect before
starting the procedure.
Settle the patient comfortably in an area where his privacy is respected throughout the procedure.
Explain the procedure to the patient and obtain his co-operation.
Instruments (or sterile gloves) must be changed between patients.


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Removal of an old dressing
Observe the wound
 
 In any case, if local signs of infection are observed, look for general signs of infection (fever, chills, changes in the
overall condition).
Technique for cleaning and dressing of the wound
To prevent drug interactions, use the same antiseptic for all care of one patient.
Wash hands (ordinary soap) or disinfect them with an alcohol-based hand rub.
Put on non-sterile gloves and remove the adhesive tape, bandage and superﬁcial compresses.
Proceed gently with the last compresses. If they stick to the wound, loosen them with 0.9% sodium chloride or
sterile water before removal.
Observe the soiled compresses. If there is signiﬁcant discharge, a greenish colour or a foul odour, a wound infection
is likely.


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Observe the soiled compresses. If there is signiﬁcant discharge, a greenish colour or a foul odour, a wound infection
is likely.
Discard the dressing and the non-sterile gloves in the waste container.
In the case of an open wound, loss of cutaneous tissue or ulcer, the colour is an indicator of the stage in the healing
process:
black area = necrosis, wet or dry infected eschar
yellow or greenish area = infected tissue and presence of pus
red area = granulation, usually a sign of healing (unless there is hypertrophy), however, red edges indicate
inﬂammation or infection
pink area = process of epithelisation, the ﬁnal stage of healing that begins at the edges of the wound
In the case of a sutured wound, the existence of local signs of suppuration and pain requires the removal of one or


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In the case of a sutured wound, the existence of local signs of suppuration and pain requires the removal of one or
more sutures to avoid the infection spreading. Local signs include:
red, indurated and painful edges
drainage of pus between the sutures, either spontaneously or when pressure is applied on either side of the
wound
lymphangitis
sub-cutaneous crepitations around the wound
Wash hands again or disinfect them with an alcohol-based hand rub.
Open the dressing set or box after checking the date of sterilisation and that the wrapping is intact.
Pick up one of the sterile forceps being careful not to touch anything else.
Pick up the second forceps with the help of the ﬁrst one.
Make a swab by folding a compress in 4 using the forceps.


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Pick up the second forceps with the help of the ﬁrst one.
Make a swab by folding a compress in 4 using the forceps.
Clean sutured wound or clean open wound with red granulation:
clean with 0.9% sodium chloride or sterile water to remove any organic residue; work from the cleanest to the
dirtiest area (use a clean swab for each stroke);
dab dry with a sterile compress;
re-cover a sutured wound with sterile compresses or an open wound with parafﬁn compresses; the dressing
should extend a few cm beyond the edges of the wound;
keep the dressing in place with adhesive tape or a bandage.
Necrotic or infected open wounds:
clean with povidone iodine (7.5% scrub solution, 1 part of solution + 4 parts of sterile 0.9% sodium chloride or


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Necrotic or infected open wounds:
clean with povidone iodine (7.5% scrub solution, 1 part of solution + 4 parts of sterile 0.9% sodium chloride or
sterile water). Rinse thoroughly then dab dry with a sterile compress; or if not available, sterile 0.9% sodium
chloride or sterile water and apply an antiseptic (10% povidone iodine dermal solution).
apply sterile vaseline and remove all necrotic tissue at each dressing change until the wound is clean.


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 The principles remain the same if the dressing is done using instruments or sterile gloves.
Subsequent dressings
Discard any sharp materials used in an appropriate sharps container and the rest of the waste in a waste container.
As quickly as possible, soak the instruments in disinfectant.
Wash hands again or disinfect them with an alcohol-based hand rub.
Clean, sutured wound: remove the initial dressing after 5 days if the wound remains painless and odourless, and if
the dressing remains clean. The decision to re-cover or to leave the wound uncovered (if it is dry) often depends on
the context and local practices.
Infected, sutured wound: remove one or more sutures and evacuate the pus. Change the dressing at least once
daily.


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the context and local practices.
Infected, sutured wound: remove one or more sutures and evacuate the pus. Change the dressing at least once
daily.
Open, dirty wound: daily cleaning and dressing change.
Open granulating wound: change the dressing every 2 to 3 days, except if the granulation is hypertrophic (in this
case, apply local corticosteroids).


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Treatment of a simple wound
A simple wound is a break in the continuity of the skin limited in depth at the sub-cutaneous fatty tissue, that does not
affect the underlying structures (muscle, bone, joints, major arteries, nerves, tendons) and without signiﬁcant loss of
tissue. The goal of treatment is to assure rapid healing of the wound without complications or sequelae. Several basic rules
apply:
Equipment
Instruments
(Figures 1a to 1d) 
 Instruments to suture one wound for one patient must be packaged and sterilised together (suture box or set) to limit
handling and breaks in asepsis.
Renewable supplies
Technique
Initial cleaning
rapidly treat wounds, while maintaining the rules of asepsis and the order of the initial procedures: cleaning-
exploration-excision;


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rapidly treat wounds, while maintaining the rules of asepsis and the order of the initial procedures: cleaning-
exploration-excision;
identify wounds that need to be sutured and those for which suturing would be harmful or dangerous;
immediately suture recent, clean, simple wounds (less than 6 hours old) and delay suturing contaminated wounds
and/or those more than 6 hours old;
prevent local (abscess) or general (gas gangrene; tetanus) infections.
One dissecting forceps, one needle-holder, one pair of surgical scissors and one Pean or Kocher forceps are
usually enough.
One or two other artery forceps, a pair of Farabeuf retractors and a scalpel may be useful for a contused or deep
wound.
For local anaesthesia: sterile syringe and needle; 1% lidocaine (without epinephrine)


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wound.
For local anaesthesia: sterile syringe and needle; 1% lidocaine (without epinephrine)
Sterile gloves, fenestrated sterile towel
Sterile absorbable and non-absorbable sutures
Antiseptic and supplies for dressings
For drainage: corrugated rubber drain or equivalent, nylon suture
Settle the patient comfortably in an area with good lighting and ensure all the necessary material is prepared.
Explain the procedure to the patient and ensure his co-operation.
If the patient is a young child, arrange to have an assistant hold the child if necessary.
Wear suitable clothing: sterile gloves for all wounds and a gown and protective glasses if there is a risk of projection
from a bleeding wound.


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Wear suitable clothing: sterile gloves for all wounds and a gown and protective glasses if there is a risk of projection
from a bleeding wound.
Start by washing the wound, prolong the cleaning if the wound is particularly soiled. Use ordinary soap
or 7.5% povidone iodine scrub solution and water and rinse.
If necessary use a sterile brush. Cleaning with running water is preferable to cleaning by immersion.


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Exploration
Wound excision
Immediate suturing of a simple wound
Delayed suturing of a simple wound
Healing by second intention of infected wounds
If the wound is infected and the patient has general signs of infection (fever, chills, changes in the overall condition)
systemic antibiotic therapy may be required. Administer antibiotics at least one hour prior to starting care.
Wash hands and put on sterile gloves.
Disinfect the wound and surrounding area with 10% povidone iodine.
Cover the wound with a fenestrated sterile towel.
Local anaesthetic: inﬁltrate 1% lidocaine into the edges of the wound and wait at least 2 minutes for the
anaesthetic to take effect.
Proceed carefully from the superﬁcial to the deepest parts of the wound to explore the extent of the wound, if


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anaesthetic to take effect.
Proceed carefully from the superﬁcial to the deepest parts of the wound to explore the extent of the wound, if
necessary, aided by an assistant.
Consider the anatomical location of the wound and look for injury to any underlying structures (the clinical
examination of a limb must include evaluation of sensitivity and motor functioning, as well as that of tendons in
order to orient surgical exploration):
a wound that communicates with a fracture is an open fracture,
a wound close to a joint may be a joint wound,
a wound on the hands or feet may affect the nerves and/or tendons,
a wound close to a major artery may be an arterial wound even if it is no longer bleeding.
Look for and remove any foreign bodies.


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a wound close to a major artery may be an arterial wound even if it is no longer bleeding.
Look for and remove any foreign bodies.
In the event of signiﬁcant pain or bleeding, the exploration must be completed in an operating room.
The goal of the excision is to remove non-viable tissue, which favours the proliferation of bacteria and infection.
The wound may require little or no excision if it is clean. The excision is more extensive if the wound is bruised,
irregular or extensive.
Limit excision of the skin around the wound, particularly in facial wounds.
Sub-cutaneous fat and tissue of doubtful viability should be generously excised in order to leave only well
vascularised tissue.


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Sub-cutaneous fat and tissue of doubtful viability should be generously excised in order to leave only well
vascularised tissue.
Immediate suturing may have serious consequences for the patient if precautions to prevent infection and promote
healing are not taken.
The decision to suture immediately can only be taken after the cleaning, exploration and satisfactory excision, and
if the following conditions are met: simple wound, no more than 6 hours old with no devitalised or contused tissue
(the wound may be as long as 24 hours old if on the face, scalp, upper limbs or hands).
Bites (for local treatment see Rabies, Chapter 8) and bullet, shell or mine shrapnel wounds should not be
immediately sutured.
Wounds that do not ﬁll the above conditions should not be immediately sutured.


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immediately sutured.
Wounds that do not ﬁll the above conditions should not be immediately sutured.
After cleaning, exploration and excision a simple dressing is applied to the open wound.
Further cleaning and removal of any remaining necrotic tissue is completed with daily dressing changes.
If after 72 hours there are no signs of local infection, the wound may be sutured.


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If the wound does not meet the conditions of cleanliness described above, the wound cannot be sutured. It will heal
either spontaneously (healing by secondary intention), or will require a skin graft (once the wound is clean) if there is
signiﬁcant loss of tissue. Figures 1 : Basic instruments
Figures 2 : How to hold instruments
Figure 1a
Kocher forceps, 
straight, toothed
Figure 1b
Kelly forceps, 
curved, non-toothed
Figure 1c
Small artery forceps,
curved, non-toothed
 
Figure 1d 
Farabeuf retractors


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Figures 3 : Wound debridement
This should be done sparingly, limited to excision of severely contused or lacerated tissue that is clearly becoming
necrotic.
Figure 2a
Always mount a surgical blade using a needle holder. 
Change the blade for each new procedure.
Figure 2b 
Dissecting forceps should not be held in the palm of the hand,
but rather between the thumb and index ﬁnger. 
Toothed dissecting forceps should only be used on skin.
Figure 2c
Insert the thumb and the ring ﬁnger into the handle of a needle holder (or scissors), and stabilize the instrument using
the index ﬁnger.


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Figures 4 : Practising making knots using forceps
Figure 3a
Debridement of a contused, ragged wound: straightening of the wound edges with a scalpel. Be conservative in
facial wounds.
Figure 3b 
Excision of edges of the aponeurosis to prevent necrosis.
Figure 3c
Excision of contused muscle.


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Figure 4a
Loop the suture around the needle holder in one direction and remember the direction of the loop. Grasp the loose
end with the needle holder
and pull it through the loop to make the ﬁrst knot.
Lower the knot so that it closes the wound.
Figure 4b
The second loop should be in the opposite direction. At least 3 knots are needed to make a suture, alternating form
one direction to the other.
Figure 4c
In principle the ﬁrst knot lies ﬂat. 
 
Figure 4d
Second knot in the opposite direction.
Figure 4e
 Figure 4f


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Figures 5 : Particular problems
Grasp the loose end with the needle holder.
Figure 4g
Fist ﬂat knot.
Slide the knot towards the wound using the hand holding 
the loose end while holding the other end with the needle holder.
Tighten the knot without causing tissue ischaemia.
Figure 4h
 Figure 4i
Second knot in the opposite direction.


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Figure 6 : Closing a corner
Figure 7 : Closure of the skin, simple interrupted sutures with non-absorbable sutures
Figure 5a
 Figure 5b
The suture should be as deep as it is wide.
Figure 5c
 Figure 5d
The suture is too shallow, the edges are invaginated.
Figure 5e 
Poor lining of the edges. 
 
Figure 5f 
Do not make the knot directly over the wound.


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Burns
Last updated: August 2022
 
Burns are cutaneous lesions caused by exposure to heat, electricity, chemicals or radiation. They cause signiﬁcant pain
and may threaten survival and/or compromise function.
Classiﬁcation of burns
Severe burns: one or more of the following parameters:
 Minor burns: involving less than 10% of the BSA in children and 15% in adults, in the absence of other risk factors
Evaluation of burns
Extent of burns
Lund-Browder table – Percentage of body surface area according to age 
Involving more than 10% of the body surface area (BSA) in children and 15% in adults
Inhalation injury (smoke, hot air, particles, toxic gas, etc.)
Major concomitant trauma (fracture, head injury, etc.)


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Inhalation injury (smoke, hot air, particles, toxic gas, etc.)
Major concomitant trauma (fracture, head injury, etc.)
Location: face, hands, neck, genitalia/perineum, joints (risk of functional deﬁcit)
Electrical and chemical burns or burns due to explosions
Age < 3 years or > 60 years or signiﬁcant co-morbidities (e.g. epilepsy, malnutrition)


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 This table helps to accurately calculate the % of BSA involved according to patient’s age: e.g. burn of the face,
anterior trunk, inner surface of the lower arm and circumferential burn of left upper arm in a child 2 years of age: 8.5 +
13 + 1.5 + 4 = 27% BSA.
Depth of burns
Location < 1 year 1-4 years 5-9 years 10-15 years Adults
Head 19 17 13 10 7
Neck 2 2 2 2 2
Anterior trunk 13 13 13 13 13
Posterior trunk 13 13 13 13 13
Right buttock 2.5 2.5 2.5 2.5 2.5
Left buttock 2.5 2.5 2.5 2.5 2.5
Perineum/genitalia 1 1 1 1 1
Right upper arm 4 4 4 4 4
Left upper arm 4 4 4 4 4
Right lower arm 3 3 3 3 3
Left lower arm 3 3 3 3 3
Right hand 2.5 2.5 2.5 2.5 2.5
Left hand 2.5 2.5 2.5 2.5 2.5
Right thigh 5.5 6.5 8.5 8.5 9.5
Left thigh 5.5 6.5 8.5 8.5 9.5
Right leg 5 5 5.5 6 7


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Right hand 2.5 2.5 2.5 2.5 2.5
Left hand 2.5 2.5 2.5 2.5 2.5
Right thigh 5.5 6.5 8.5 8.5 9.5
Left thigh 5.5 6.5 8.5 8.5 9.5
Right leg 5 5 5.5 6 7
Left leg 5 5 5.5 6 7
Right foot 3.5 3.5 3.5 3.5 3.5
Left foot 3.5 3.5 3.5 3.5 3.5


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Apart from ﬁrst-degree burns (painful erythema of the skin and absence of blisters) and very deep burns (third-degree
burns, carbonization), it is not possible, upon initial examination, to determine the depth of burns. Differentiation is
possible after D8-D10. 
 
Evaluation for the presence of inhalation injury
Dyspnoea with chest wall indrawing, bronchospasm, soot in the nares or mouth, productive cough, carbonaceous
sputum, hoarseness, etc.
Treatment of severe burns
I. Initial management
On admission
Once the patient is stabilized
  Superﬁcial burn on D8-D10 Deep burn on D8-D10
Sensation Normal or pain Insensitive or diminished sensation
Colour Pink, blanches with pressure White, red, brown or black
Does not blanch with pressure
Texture Smooth and supple Firm and leathery


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Colour Pink, blanches with pressure White, red, brown or black
Does not blanch with pressure
Texture Smooth and supple Firm and leathery
Appearance Minimal ﬁbrinous exudate
Granulation tissue evident
Bleeds when incised
Covered with ﬁbrinous exudate
Little or no bleeding when incised
Healing Heals spontaneously within 5-
15 days
Very deep burn: always requires surgery (no
spontaneous healing)
Intermediate burn: may heal spontaneously in 3 to 5
weeks; high risk of infection and permanent sequelae
Ensure airway is patent; high-ﬂow oxygen, even when SpO is normal.2
Establish IV access, through unburned skin if possible (intraosseous access if IV access is not possible).
Ringer lactate (RL): 20 ml/kg during the ﬁrst hour, even if the patient is stable.


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Ringer lactate (RL): 20 ml/kg during the ﬁrst hour, even if the patient is stable.
Morphine SC: 0.2 mg/kg (Step 1 and Step 2 analgesics are not effective).
In the event of chemical burns: ﬂush with copious amounts of water for 15 to 30 minutes, avoiding contamination of
healthy skin; do not attempt to neutralize the chemical agent.
Remove clothes if they are not adherent to the burn.
Take history of the burn injury: mechanism, causative agent, time, etc.
Assess the burn injury: extent, depth, carbonization; ocular burns, burns at risk of secondary functional deﬁcits;
circumferential burns of the extremities, chest or neck. Wear face mask and sterile gloves during the examination.
Assess for associated injuries (fractures, etc.).


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Assess for associated injuries (fractures, etc.).
Protect the patient and keep him warm: clean/sterile sheet, survival blanket.
Insert a urinary catheter if burns involve > 15% of BSA, and in the case of electrical burns or burns of the
perineum/genitalia.


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Notes:
II. General measures during the ﬁrst 48 hours
Resuscitative measures
Intravenous replacement ﬂuid to correct hypovolaemia: Fluid and electrolyte requirements during the ﬁrst 48 hours according to age 
Note: increase replacement volumes by 50% (3 ml/kg x % BSA for the ﬁrst 8 hours) in the event of inhalation injury or
electrical burn. For burns > 50% BSA, limit the calculation to 50% BSA.
This formula provides a guide only and should be adjusted according to systolic arterial pressure (SAP) and urine
output. Avoid ﬂuid overload. Reduce replacement ﬂuid volumes if urine output exceeds the upper limit.
Target endpoints for IV replacement ﬂuids
Insert a nasogastric tube if burns involve > 20% of BSA (in the operating room while carrying out dressing
procedure).


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Insert a nasogastric tube if burns involve > 20% of BSA (in the operating room while carrying out dressing
procedure).
Calculate and initiate ﬂuid and electrolyte requirements for the ﬁrst 24 hours.
Intensive monitoring: level of consciousness, heart rate, blood pressure, SpO, respiratory rate (RR) hourly;
temperature and urine output every 4 hours.
2
Additional testing: haemoglobin, blood group, urine dipstick test.
Prepare the patient for the ﬁrst dressing procedure in the operating room.
Burns do not bleed in the initial stage: check for haemorrhage if haemoglobin level is normal or low.
Burns alone do not alter the level of consciousness. In the case if altered consciousness, consider head injury,
intoxication, postictal state in epileptic patients.


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intoxication, postictal state in epileptic patients.
Clinical manifestations of electrical burns vary signiﬁcantly according to the type of current. Look for complications
(arrhythmia, rhabdomyolysis, neurological disorders).
  Children < 12 years Children ≥ 12 years and adults
0 - 8 h 2 ml/kg x % BSA of RL
+ maintenance ﬂuid per hour x 8 h (a) 
2 ml/kg x % BSA of RL
8 - 24 h 2 ml/kg x % BSA of RL
+ maintenance ﬂuid per hour x 16 h (a) 
2 ml/kg x % BSA of RL
24 - 48 h Daily maintenance IV ﬂuid requirements minus oral
ﬂuids such as milk, broth, gavage feeds (do not
include drinking water in the calculation).
 (a) 40 ml/kg RL minus oral ﬂuids (do not include
drinking water in the calculation).


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include drinking water in the calculation).
 (a) 40 ml/kg RL minus oral ﬂuids (do not include
drinking water in the calculation).
(a) Maintenance ﬂuid: alternate RL and 5% glucose: 4 ml/kg/h for ﬁrst 10 kg of body weight + 2 ml/kg/h for next 10 kg + 1ml/kg/h for each additional kg (over 20 kg, up to 30 kg)


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 In patients with oliguria despite adequate ﬂuid replacement:
dopamine IV: 5 to 15 micrograms/kg/minute by IV pump
or
epinephrine IV: 0.1 to 0.5 micrograms/kg/minute by IV pump
Stop the infusion after 48 hours, if ﬂuid requirements can be met by the oral route or gavage.
Respiratory care
Analgesia
See Pain management
Nutrition
Start feeding early, beginning at H8:
Patients at risk of rhabdomyolysis
In the event of deep and extensive burns, electrical burns, crush injuries to the extremities:
Infection control 
 
Non-electrical burns Electrical burns
Children
< 1 year
Children 
1-12 years
Children 
> 12 years/adults All ages
AP (mmHg) SAP ≥ 60 SAP 70 to 90 + (2 x age) SAP ≥ 100 Age appropriate SAP
Urine output 1 to 2 ml/kg/h 1 to 1.5 ml/kg/h 0.5 to 1 ml/kg/h 1 to 2 ml/kg/h


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Urine output 1 to 2 ml/kg/h 1 to 1.5 ml/kg/h 0.5 to 1 ml/kg/h 1 to 2 ml/kg/h
In all cases: continuous inhalation of humidiﬁed oxygen, chest physiotherapy.
Emergency surgical intervention if necessary: tracheotomy, chest escharotomy.
Do not administer corticosteroids (no effect on oedema; predisposition to infection). No speciﬁc treatment for
direct bronchopulmonary lesions.
Daily needs in adults
calories: 25 kcal/kg + 40 kcal/% BSA
proteins: 1.5 to 2 g/kg
High energy foods (NRG5, Plumpy'nut, F100 milk) are necessary if the BSA is > 20% (normal food is inadequate).
Nutritional requirements are administered according to the following distribution: carbohydrates 50%, lipids 30%,
proteins 20%.
Provide 5-10 times the recommended daily intake of vitamins and trace elements.


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proteins 20%.
Provide 5-10 times the recommended daily intake of vitamins and trace elements.
Enteral feeds are preferred: oral route or nasogastric tube (necessary if BSA > 20%).
Start with small quantities on D1, then increase progressively to reach recommended energy requirements within 3
days.
Assess nutritional status regularly (weigh 2 times weekly).
Reduce energy loss: occlusive dressings, warm environment (28-33 °C), early grafting; management of pain,
insomnia and depression.
Monitor for myoglobinuria: dark urine and urine dipstick tests.
If present:  induce alkaline diuresis for 48 hours (20 ml of 8.4% sodium bicarbonate per litre of RL) to obtain an
output of 1 to 2 ml/kg/hour. Do not administer dopamine or furosemide.


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Precautions against infection are of paramount importance until healing is complete. Infection is one of the most
frequent and serious complications of burns:
Other treatments
III. Local treatment
Regular dressing changes prevent infection, decrease heat and ﬂuid losses, reduce energy loss, and promote patient
comfort. Dressings should be occlusive, assist in relieving pain, permit mobilisation, and prevent contractures.
Basic principles
Technique
Hygiene precautions (e.g. sterile gloves when handling patients).
Rigorous wound management (dressing changes, early excision).
Separate “new” patients (< 7 days from burn) from convalescent patients (≥ 7 days from burn).
Do not administer antibiotherapy in the absence of systemic infection.


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Do not administer antibiotherapy in the absence of systemic infection.
Infection is deﬁned by the presence of at least 2 of 4 following signs: temperature > 38.5 °C or < 36 °C,
tachycardia, tachypnoea, elevation of white blood cell count by more than 100% (or substantial decrease in the
number of white blood cells).
In the event of systemic infection, start empiric antibiotherapy:
cefazolin IV
Children > 1 month: 25 mg/kg every 8 hours 
Adults : 2 g every 8 hours
+ ciproﬂoxacin PO
Children > 1 month: 15 mg/kg 2 times daily 
Adults: 500 mg 3 times daily 
Local infection, in the absence of signs of systemic infection, requires topical treatment with silver sulfadiazine. Not
to be applied to children under 2 months.
Omeprazole IV from D1
Children: 1 mg/kg once daily
Adults: 40 mg once daily


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to be applied to children under 2 months.
Omeprazole IV from D1
Children: 1 mg/kg once daily
Adults: 40 mg once daily
Tetanus vaccination (see Tetanus, Chapter 7).
Thromboprophylaxis: low molecular weight heparin SC beginning 48 to 72 hours post-injury.
Physiotherapy from D1 (prevention of contractures), analgesia is necessary.
Intentional burns (suicide attempt, aggression): appropriate psychological follow-up.
 a  
Rigorous adherence to the principles of asepsis.
Dressing changes require morphine administration in the non-anaesthetised patient.
The ﬁrst dressing procedure is performed in the operating room under general anaesthesia, the following in an
operating room under general anaesthesia or at the bedside with morphine.


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operating room under general anaesthesia or at the bedside with morphine.
At the time of the ﬁrst dressing procedure, shave any hairy areas (armpit, groin, pubis) if burns involve the adjacent
tissues; scalp (anteriorly in the case of facial burns, entirely in the case of cranial burns). Cut nails.
Clean the burn with povidone iodine scrub solution (1 volume of 7.5% povidone iodine + 4 volumes of 0.9% sodium
chloride or sterile water). Scrub gently with compresses, taking care to avoid bleeding.
Remove blisters with forceps and scissors.
Rinse with 0.9% sodium chloride or sterile water.
Dry the skin by blotting with sterile compresses.
Apply silver sulfadiazine directly by hand (wear sterile gloves) in a uniform layer of 3-5 mm to all burned areas


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Apply silver sulfadiazine directly by hand (wear sterile gloves) in a uniform layer of 3-5 mm to all burned areas
(except eyelids and lips) to children 2 months and over and adults.


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Frequency
Monitoring
IV. Surgical care
Emergency surgical interventions
Burn surgery
V. Pain management
All burns require analgesic treatment. Pain intensity is not always predictable and regular assessment is paramount: use
a simple verbal scale (SVS) in children > 5 years and adults and NFCS or FLACC scales in children < 5 years (see Pain,
Chapter 1). Morphine is the treatment of choice for moderate to severe pain. Development of tolerance is common in burn
patients and requires dose augmentation. Adjuvant treatment may complement analgesic medication (e.g. massage
therapy, psychotherapy).
Continuous pain (experienced at rest)
Apply a greasy dressing (Jelonet® or petrolatum gauze) using a back and forth motion (do not use a circular
movement).


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Apply a greasy dressing (Jelonet® or petrolatum gauze) using a back and forth motion (do not use a circular
movement).
Cover with a sterile compresses, unfolded into a single layer. Never encircle a limb with a single compress.
Wrap with a crepe bandage, loosely applied.
Elevate extremities to prevent oedema; immobilise in extension.
Routinely: every 48 hours.
Daily in the event of superinfection or in certain areas (e.g. perineum).
Distal ischaemia of the burned limb is the main complication during the ﬁrst 48 hours. Assess for signs of ischaemia:
cyanosis or pallor of the extremity, dysaesthesia, hyperalgia, impaired capillary reﬁll.
Monitor daily: pain, bleeding, progression of healing and infection.


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Monitor daily: pain, bleeding, progression of healing and infection.
Escharotomy: in the case of circumferential burns of arms, legs or ﬁngers, in order to avoid ischaemia, and
circumferential burns of chest or neck that compromise respiratory movements.
Tracheotomy: in the event of airway obstruction due to oedema (e.g. deep cervicofacial burns). Tracheotomy can
be performed through a burned area.
Tarsorrhaphy: in the event of ocular or deep eyelid burns.
Surgery for associated injuries (fractures, visceral lesions, etc.).
Excision-grafting of deep burns, in the operating room, under general anaesthesia, between D5 and D6: excision of
necrotic tissue (eschar) with simultaneous grafting with autografts of thin skin. This intervention entails signiﬁcant


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necrotic tissue (eschar) with simultaneous grafting with autografts of thin skin. This intervention entails signiﬁcant
bleeding risk, do not involve more than 15% of BSA in the same surgery.
If early excision-grafting is not feasible, default to the process of sloughing-granulation-reepithelisation. Sloughing
occurs spontaneously due to the action of sulfadiazine/ petrolatum gauze dressings and, if necessary, by
mechanical surgical debridement of necrotic tissue. This is followed by granulation, which may require surgical
reduction in the case of hypertrophy. The risk of infection is high and the process is prolonged (> 1 month).
Moderate pain:
paracetamol PO + tramadol PO (see Pain, Chapter 1) 
Moderate to severe pain:
paracetamol PO + sustained release morphine PO (see Pain, Chapter 1)


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Acute pain experienced during care
Analgesics are given in addition to those given for continuous pain. 
Note: these doses of morphine are for adults, dosing is the same in children > 1 year, should be halved in children
less than 1 year, and quartered in infants less than 3 months.
Chronic pain (during the rehabilitation period)
Minor burns
 
In patients with severe burns, oral drugs are poorly absorbed in the digestive tract during the ﬁrst 48 hours, morphine
is administered by SC route.
Signiﬁcant medical interventions and extensive burns: general anaesthesia in an operating room.
Limited non-surgical interventions (dressings, painful physiotherapy):
Mild to moderate pain, 60 to 90 minutes before giving care:


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Limited non-surgical interventions (dressings, painful physiotherapy):
Mild to moderate pain, 60 to 90 minutes before giving care: 
tramadol PO (see Pain, Chapter 1) rarely allows treatment to be completed comfortably. In the event of
treatment failure, use morphine.
Moderate or severe pain, 60 to 90 minutes before giving care:
immediate release morphine PO: initial dose of 0.5 to 1 mg/kg; the effective dose is usually around 1 mg/kg,
but there is no maximum dose.
or morphine SC: initial dose of 0.2 to 0.5 mg/kg; the effective dose is usually around 0.5 mg/kg, but there is no
maximum dose.
Pain management using morphine during dressing changes at the bedside requires:
A trained nursing team.
Availability of immediate release oral morphine and naloxone.


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A trained nursing team.
Availability of immediate release oral morphine and naloxone.
Close monitoring: level of consciousness, RR, heart rate, SpO, every 15 min for the ﬁrst hour following dressing
change, then routine monitoring.
2
Assessment of pain intensity and sedation during the intervention and for 1 hour thereafter.
Necessary equipment for ventilation by mask and manual suction.
Gentle handling of the patient at all times.
Adjustment of morphine doses for subsequent dressings:
If pain intensity (SVS) is 0 or 1: continue with the same dose.
If SVS score ≥ 2: increase the dose by 25 to 50%. If pain control remains inadequate, the dressing change
should be carried out in the operating room under anaesthesia.


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should be carried out in the operating room under anaesthesia.
Take advantage of the residual analgesia following dressing changes to carry out physiotherapy.
As a last resort (morphine unavailable and no facilities to give general anaesthesia), in a safe setting (trained staff,
resuscitation equipment, recovery room), adding ketamine IM at analgesic doses (0.5 to 1 mg/kg) reinforces the
analgesic effect of the paracetamol + tramadol combination given before a dressing change.
The treatment is guided by self-evaluation of pain intensity, and utilises paracetamol and/or tramadol. Patients may
develop neuropathic pain (see Pain, Chapter 1).
All other associated pain (physiotherapy, mobilization) should be treated as acute pain.
Treat as outpatients.


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All other associated pain (physiotherapy, mobilization) should be treated as acute pain.
Treat as outpatients.
Wound care: dressings with silver sulfadiazine (to children 2 months and over and adults) or petrolatum gauze
(except for ﬁrst degree superﬁcial burns).
Pain: paracetamol ± tramadol usually effective.


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Footnotes
(a) Open technique « naked burn patient under a mosquito net » and water immersion therapy are obsolete and should nolonger be used.


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Cutaneous abscess
A cutaneous abscess is a collection of pus within the dermis or subcutaneous tissue.
It is most commonly due to Staphylococcus aureus.
Clinical features
Paraclinical investigations
Radiography in case of suspected osteomyelitis or septic arthritis.
Treatment
Equipment
Anaesthesia
 For analgesia, see Pain, Chapter 1.
Technique
Incision
(Figure 8a)
Painful, red, shiny nodule with or without ﬂuctuance; suppuration or surrounding cellulitis (see Erysipelas and cellulitis,
Chapter 4).
Regional adenopathy and fever may be present.
Complications: osteomyelitis, septic arthritis, septic shock (see Shock, Chapter 1).
Treatment is surgical incision and drainage, under aseptic conditions (i.e. sterile consumables and instruments,
antiseptic skin preparation).


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Treatment is surgical incision and drainage, under aseptic conditions (i.e. sterile consumables and instruments,
antiseptic skin preparation).
Refer to a surgeon any cutaneous abscess:
located in anterior and lateral neck, central triangle of the face, hand, perirectal region, breast, or
adjacent to major blood vessels (e.g. femoral artery), or
involving joint and bone.
Antibiotic therapy only if signs of systemic infection, extensive surrounding cellulitis or for individuals with risk
factors e.g. immunosuppression or diabetes (for antibiotic therapy, see Erysipelas and cellulitis, Chapter 4).
Sterile scalpel
Sterile curved, non-toothed artery forceps (Kelly type)
Sterile disposable gloves and compresses
Antiseptic solution and 0.9% sodium chloride
5 or 10 ml syringe


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Sterile disposable gloves and compresses
Antiseptic solution and 0.9% sodium chloride
5 or 10 ml syringe
For small (approximately < 5 cm), well delineated abscess in adults: use local anaesthesia with 1% lidocaine
without epinephrine (10 mg/ml): 15 to 20 ml.
For larger (approximately > 5 cm), deep or poorly delineated abscess in adults or for abscess in children: consider
procedural sedation or general anaesthesia (ketamine IM: 10 mg/kg).


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Digital exploration
(Figure 8b)
Washing
Abundant washing of the cavity using a syringe ﬁlled with 0.9% sodium chloride.
Drainage
(Figure 8c)
Only necessary for deep abscesses.
Insert a drain (or, failing that a gauze wick) into the base of the cavity. If possible, ﬁx it to the edge of the incision with a
single suture. The drain is withdrawn progressively and then, after 3 to 5 days removed completely.
Hold the scalpel between the thumb and middle ﬁnger of the dominant hand, the index ﬁnger presses on the handle.
Hold the abscess between the thumb and index ﬁnger of the other hand. The scalpel blade should be perpendicular
to the skin.
The incision is made in a single stroke along the long axis of the abscess. The incision must be long enough for a
ﬁnger to be inserted.


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to the skin.
The incision is made in a single stroke along the long axis of the abscess. The incision must be long enough for a
ﬁnger to be inserted.
 Figure 8a
Incision with a scalpel
Explore the cavity with the index ﬁnger, breaking down all loculi (a single cavity should remain), evacuate the pus (and
foreign body, if present) and explore to the edges of the cavity.
The exploration also allows an assessment of the extent of the abscess, the depth, and location with respect to
underlying structures (arterial pulsation) or any possible contact with underlying bone. In this last case, seek surgical
advice.
   Figure 8b 
Exploration of the cavity, 
breaking down any loculi


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Pyomyositis
Pyomyositis is an infection of the muscle, almost always due to Staphylococcus aureus. It most commonly affects the
muscles of the limbs and torso. Infections may occur simultaneously in multiple sites.
Risk factors include immunosuppression, concurrent S. aureus infection, malnutrition, trauma and injection drug use.
Risk of mortality is signiﬁcant if treatment is delayed.
Clinical features
Paraclinical investigations
Treatment
Equipment and anaesthesia
As for Cutaneous abscess, Chapter 10.
Technique
Signs and symptoms:
local: exquisite muscle tenderness, oedema giving muscles "woody" texture on palpation.
systemic: regional adenopathy and fever.
pyomyositis of the psoas muscle: patient keeps hip ﬂexed and experiences pain on hip extension. If the abscess


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pyomyositis of the psoas muscle: patient keeps hip ﬂexed and experiences pain on hip extension. If the abscess
is on the right side, the clinical signs are the same as for appendicitis with pain in the right iliac fossa.
Complications: septic emboli, endocarditis and septic arthritis, septic shock (see Shock, Chapter 1).
POCUS : assists in characterisation of abscess; can rule out deep venous thrombosis. a 
Radiography: may demonstrate a foreign body, signs of osteomyelitis or osteosarcoma.
Immobilise the limb.
Systematic antibiotic therapy (see Erysipelas and cellulitis, Chapter 4). 
Adapt analgesics to the pain level (see Pain, Chapter 1).
Apply compresses soaked in 70% alcohol 2 times daily (max. 3 times daily to prevent burns to the skin) until incision
and drainage.


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Apply compresses soaked in 70% alcohol 2 times daily (max. 3 times daily to prevent burns to the skin) until incision
and drainage.
Treatment is surgical incision and drainage, under aseptic conditions (sterile consumables and instruments,
antiseptic skin preparation) following the rules for incision and drainage of abscesses (see Cutaneous abscess,
Chapter 10). Muscle abscesses are often deeper than other abscesses. As a result, aspiration with a large bore
needle may be necessary to locate the abscess. Needle aspiration is insufﬁcient treatment even if pus is evacuated
and should be followed by surgical incision and drainage.
In case of pyomyositis of the psoas muscle, start antibiotics and refer to a surgeon.


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and should be followed by surgical incision and drainage.
In case of pyomyositis of the psoas muscle, start antibiotics and refer to a surgeon.
Generous incision along the axis of the limb, over the site of the abscess and avoiding underlying neurovascular
stuctures; incise the skin, subcutaneous tissues and muscular fascia with a scalpel (Figure 9a).
Dissect the muscle ﬁbres with non-toothed forceps (Kelly type) or round tipped scissors. Insert the instrument or a
ﬁnger into the muscle until the purulent cavity is reached. If an instrument is used, during insertion, keep the
instrument closed and perpendicular to the muscle ﬁbres. Withdraw gently with the scissors or forceps slightly open,


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instrument closed and perpendicular to the muscle ﬁbres. Withdraw gently with the scissors or forceps slightly open,
keeping instrument perpendicular to the ﬁbres (Figure 9b). If abscess is found to be very deep, it may be necessary
to refer to a surgeon.


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Figures 9: Surgical incision-drainage of a pyomyositis
 
Use a foreﬁnger to explore the cavity, break down any loculi and evacuate the pus (Figure 9c).
Wash abundantly with 0.9% sodium chloride.
Insert a large drain.
Fix the drain to the edge of the wound using a single suture. Remove the drain on about the 5  day (Figure 9d).th
 Figure 9a 
Long incision
 
Figure 9b
Dissection of the muscle using Kelly forceps, insert closed
then withdraw  
with the instrument slightly open
 Figure 9c 
Exploration and evacuation of pus with the ﬁnger
Figure 9d
Drain ﬁxed to the skin
Footnotes
(a) POCUS should only be performed and interpreted by trained clinicians.


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Leg ulcers
Daily local treatment
Systemic treatment
Leg ulcers are chronic losses of cutaneous tissue. They are common in tropical regions, resulting from varied
aetiologies:
vascular: venous and/or arterial insufﬁciency,
bacterial: leprosy, Buruli ulcer (Mycobacterium ulcerans), phagedenic ulcer, yaws, syphilis,
parasitic: dracunculiasis (Guinea-worm disease), leishmaniasis,
metabolic: diabetes,
traumatic: trauma is often a precipitating factor combined with another underlying cause.
The history of the disease and a complete clinical examination (paying particular attention to the neurological
examination to determine if there is a peripheral neuropathy caused by leprosy or diabetes) usually leads to an
aetiological diagnosis.


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examination to determine if there is a peripheral neuropathy caused by leprosy or diabetes) usually leads to an
aetiological diagnosis.
All ulcers may become complicated with either local or regional secondary infections (abscess, lymphadenopathy,
adenitis, osteomyelitis, erysipela, pyodermitis), generalised infection (septicaemia), tetanus and after many years of
evolution, skin cancer.
Bathe the leg for 10 to 15 minutes in NaDCC and rinse in boiled water.
Remove any necrotic (black) and ﬁbrinous (yellowish) tissue using compresses or excise the tissue with a scalpel.
Apply:
to a clean ulcer, with little discharge: 10% povidone iodine and vaseline;
to a dirty ulcer, with little discharge: silver sulfadiazine to a limited area (monitor for systemic adverse effects);


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to a dirty ulcer, with little discharge: silver sulfadiazine to a limited area (monitor for systemic adverse effects);
to an oozing ulcer: 10% povidone iodine alone;
to an extensive, oozing ulcer or multiple ulcers: diluted povidone iodine (1/4 of 10% povidone iodine + 3/4 of
0.9% sodium chloride or clean water) for one minute then rinse with 0.9% sodium chloride or clean water to
reduce the risk of transcutaneous iodine absorption.
Cover with a dry sterile dressing.
Treatment with analgesics in the event of pain: adapt the level and dosage to the individual (see Pain, Chapter 1).
Give systemic antibiotics in case of:
Secondary infection (see Bacterial skin infections, Chapter 4).
Phagedenic ulcer (in the early stages, antibiotics may be useful. They are often ineffective in the chronic


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Phagedenic ulcer (in the early stages, antibiotics may be useful. They are often ineffective in the chronic
stages):
doxycycline PO (except in children under 8 years and pregnant or lactating women)
Children 8 years and over: 4 mg/kg once daily
Adults: 200 mg once daily
or
metronidazole PO
Children: 10 mg/kg 3 times daily 
Adults: 500 mg 3 times daily
If after 7 days, antibiotherapy is effective, continue with doxycycline or metronidazole as above. Treatment
duration varies according to the clinical evolution.
Treat the cause.
Complementary therapy:
Elevate the legs in cases of venous and/or lymphatic insufﬁciency.


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Tetanus prophylaxis if appropriate (see Tetanus, Chapter 7).
Skin graft if the ulcer is extensive, clean, red and ﬂat. Skin grafts are often necessary after surgical excision to
heal phagedenic and Buruli ulcers.


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Necrotising infections of the skin and softtissues
Invasive infections of the soft tissues: skin, subcutaneous tissue, superﬁcial or deep fascia, muscles. They include
necrotising cellulitis, necrotising fasciitis, myonecrosis, gas gangrene, etc. Clinical presentation depends on the causative organism and the stage of progression. Group A streptococcus is
frequently isolated, as are Staphylococcus aureus, enterobacteriaceae and anaerobic bacteria including Clostridium
sp. Delay in treatment of a minor wound or certain types of wounds (gunshot wounds or stabbings, open fractures or non-
sterile intramuscular injections/circumcisions) or certain infections (varicella or omphalitis), favours the development of


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sterile intramuscular injections/circumcisions) or certain infections (varicella or omphalitis), favours the development of
a necrotising infection. Patient risk factors include immunosuppression, diabetes, malnutrition and advanced age. A necrotising infection is a surgical emergency and has a high mortality rate.
Clinical features
Laboratory
Paraclinical investigations
Radiography: may demonstrate gas in muscles or along the fascia planes. Can rule out foreign body, osteomyelitis or
osteosarcoma.
Treatment
Prompt surgical management accompanied by IV antibiotic therapy is essential to reduce the high mortality. Refer
immediately to a surgeon. Start resuscitation if necessary (see Shock, Chapter 1).


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immediately to a surgeon. Start resuscitation if necessary (see Shock, Chapter 1). 
 
Initial signs and symptoms include erythema, oedema and pain disproportionate to appearance of infection.
Location depends on the portal of entry. It may be difﬁcult to differentiate necrotising infections from
nonnecrotising infections (see Erysipelas and cellulitis, Chapter 4). Systemic signs of infection (fever, tachycardia
etc.) may be present.
Lesions progress rapidly despite antibiotic therapy, with the development of the typical signs of a necrotizing
infection: haemorrhagic blisters and necrosis (cold bluish or blackish hypoaesthetic macules).
Signs of late infection: crepitus on palpation and fetid odour (gas gangrene) with signs of severe systemic infection
(see Shock, Chapter 1).


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Signs of late infection: crepitus on palpation and fetid odour (gas gangrene) with signs of severe systemic infection
(see Shock, Chapter 1).
If available, the following tests can help identify an early necrotising infection: white blood cell count > 15 000/mm³
or < 4000/mm³; serum creatinine > 141 micromol/litre; serum glucose > 10 mmol/litre (180 mg/dl) or < 3.3 mmol/litre
(60 mg/dl). However, normal results do not exclude a necrotising infection.
Obtain specimens for bacterial culture in the operating room and blood cultures if possible. 
Emergency surgical treatment:
Debridement, drainage, wide excision of necrotic tissue and rapid amputation if necessary.
Surgical re-evaluation within 24 to 36 hours to check for eventual progression of the necrosis and need for
further debridement.


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  cloxacillin IV infusion (60 minutes)
Children < 40 kg: 50 mg/kg every 6 hours
Children ≥ 40 kg and adults: 3 g every 6 hours  ceftriaxone slow IV (3 minutes) or IV infusion (30 minutes)
Children 1 month and over: 100 mg/kg once daily
Adults: 2 g once daily  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 to 13 mg/kg every 8 hours (max. 2700 mg daily)
Adults: 900 mg every 8 hours  amoxicillin/clavulanic acid (co-amoxiclav) slow IV injection (3 minutes) or IV infusion (30 minutes)


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Adults: 900 mg every 8 hours  amoxicillin/clavulanic acid (co-amoxiclav) slow IV injection (3 minutes) or IV infusion (30 minutes)
Children less than 3 months: 50 mg/kg every 12 hours 
Children ≥ 3 months and < 40 kg: 50 mg/kg every 8 hours (max. 6 g daily)
Children ≥ 40 kg and adults: 2 g every 8 hours 
 
IV antibiotic therapy for at least 14 days or more depending on clinical response:
cloxacillin + ceftriaxone + clindamycin or amoxicillin/clavulanic acid + clindamycin. For doses, see below.
 a 
 b 
 c 
 d 
Other treatments:
Deep vein thrombosis prophylaxis;
Appropriate management of pain (see Pain, Chapter 1);
Early nutritional support.
Footnotes


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d 
Other treatments:
Deep vein thrombosis prophylaxis;
Appropriate management of pain (see Pain, Chapter 1);
Early nutritional support.
Footnotes
(a) 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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(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 20 kg and over and in adults.
(c) 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.
(d) Dilute each dose of amoxicillin/clavulanic acid in 5 ml/kg of 0.9% sodium chloride in children less than 20 kg and in a bag of100 ml of 0.9% sodium chloride in children 20 kg and over and in adults. Do not dilute in glucose.


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Venomous bites and stings
Snake bites and envenomation
 
Clinical manifestations and management of bites and envenomations are described in the table below. 
In the event of coagulation abnormalities, continue to monitor once daily until coagulation returns to normal. 
For all patients, be prepared for an anaphylactic reaction, which, despite its potential severity (shock), is
usually more easily controlled than coagulation disorders or serious neurological disorders. 
 
Clinical signs and treatment 
More than 50% of the bites are dry bites, i.e. no envenomation occurred. In the event that venom is injected, the
severity of envenomation depends on the species, the amount of venom injected, the location of the bite (bites on


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severity of envenomation depends on the species, the amount of venom injected, the location of the bite (bites on
the head and neck are the most dangerous) and the weight, general condition and age of the individual (more serious
in children).
It is rare that the snake involved is identiﬁed. However, observation of the clinical signs may orient diagnosis and
management. Two major syndromes are identiﬁed:
neurological disorders that evolve towards respiratory muscle paralysis and coma are common manifestations
of elapid envenomation (cobra, mamba, etc.);
extensive local lesions (intense pain, inﬂammation with oedema and necrosis) and coagulation abnormalities are
common manifestations of viperid or crotalid (rattle snake) envenomation.


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common manifestations of viperid or crotalid (rattle snake) envenomation.
Early diagnosis and monitoring of coagulation abnormalities is based on whole blood clotting tests performed in a
dry tube (at the patient’s arrival and then every 4 to 6 hours for the ﬁrst day).
Take 2 to 5 ml of whole blood, wait 30 minutes and examine the tube:
Complete clotting: no coagulation abnormality
Incomplete clotting or no clotting: coagulation abnormality, susceptibility to bleeding a
Aetiological treatment is based on the administration of snake antivenom serum, only if there are clear clinical
manifestations of envenomation or coagulation abnormalities are observed.
Antivenom sera are effective, but rarely available (verify local availability) and difﬁcult to store. Antivenom serum


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Antivenom sera are effective, but rarely available (verify local availability) and difﬁcult to store. Antivenom serum
should be administered as early as possible: by IV infusion (in 0.9% sodium chloride) if using a poorly puriﬁed serum;
by slow IV in the event of severe envenomation if the serum is known to be well puriﬁed. Repeat antivenom serum
administration after 4 or 6 hours if the symptoms of envenomation persist.
 
 
In asymptomatic patients (bites without signs of envenomation and with normal coagulation), monitoring must
continue for at least 12 hours (24 hours preferred).


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Time
since
bite
Clinical manifestations Possible
aggressor Treatment
Bite
0 Fang marks
Pain at the site of bite
? Strict rest, immobilisation of the limb with a
splint to slow the diffusion of venom .
Wound cleansing.
Tetanus prophylaxis (Tetanus, Chapter 7).
Observe for manifestations of envenomation.
A the dispensary level, prepare patient
evacuation to a referral centre.
 (a) 
Envenomation
10-30
minutes
Hypotension, myosis, excessive
salivation and sweating, dysphagia,
dyspnoea
Local paraesthesia, paresis
Elapids Insert a peripheral IV line.
IV antivenom serum as soon as possible.
Inﬂammatory syndrome: intense pain,
extensive regional oedema
Viperids
Crotalids
Insert a peripheral IV line.
IV antivenom serum as soon as possible.
Analgesics .
IV or PO anti-inﬂammatories.


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Viperids
Crotalids
Insert a peripheral IV line.
IV antivenom serum as soon as possible.
Analgesics .
IV or PO anti-inﬂammatories.
 (b) 
 (b)  
30
minutes-
5 hours
Cobra syndrome: bilateral eyelid drooping,
trismus, respiratory muscle paralysis
Shock
Elapids Intubation and assisted ventilation.
See Shock, Chapter 1.
30
minutes-
48 hours
Haemorrhagic syndome: epistaxis,
purpura, haemolysis or disseminated
intra-vascular coagulation
Shock
Viperids
Crotalids
Monitor coagulation (blood clotting test in a
dry tube).
Transfusion of fresh blood in the event of
severe anaemia.
See Shock, Chapter 1.
6 hours
or more
No signs or changes in coagulation (non-
venomous snakes or snake bite without
envenomation)
? Reassure the patient.
Send him home after 12 hours.


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No signs or changes in coagulation (non-
venomous snakes or snake bite without
envenomation)
? Reassure the patient.
Send him home after 12 hours.
Tissue necrosis   Remove blisters, clean; daily (non occlusive)
dressings.
Surgical intervention for necrosis, depending
on the extent, after the lesions stabilise
(minimum 15 days).
(a) Tourniquets, incision-suction and cauterisation are ineffective and may be dangerous.
(b) Do not use acetylsalicylic acid (aspirin).


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Scorpion stings and envenomation
 
 
 
Spider bites and envenomation
 
 As well as the general measures listed above, treatment includes administration of 10% calcium gluconate by slow IV
in the event of muscle spasms (children: 5 ml per injection, adults: 10 ml per injection, administered over 10 to 20
minutes).
Incision and debridement of necrotic tissue are not recommended (not useful; may impair healing).
Hymenoptera stings (honeybees, wasps and hornets)
In case of clinical evidence of infection only: drainage of any abscess; amoxicillin/clavulanic acid (co-amoxiclav) for
7 to 10 days in case of cellulitis.
Infections are relatively rare, and most often associated with traditional treatment or with nosocomial transmission
after unnecessary or premature surgery.


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after unnecessary or premature surgery.
In most cases, the sting causes local effects including: pain, oedema, erythema. Management includes strict rest,
wound cleansing, analgesics PO, and tetanus prophylaxis (see Tetanus, Chapter 7).
In patients with signiﬁcant pain, inﬁltrate the area around the sting with local anaesthetic (1% lidocaine). Observe
for 12 hours.
General signs appear in the event of severe envenomation: hypertension, excessive salivation and sweating,
hyperthermia, vomiting, diarrhoea, muscle pain, respiratory difﬁculties, seizures; rarely, shock.
Aetiological treatment:
The use of scorpion antivenom sera is controversial (most of them are not very effective; they may be poorly
tolerated due to insufﬁcient puriﬁcation).


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tolerated due to insufﬁcient puriﬁcation).
In practice, in countries where scorpion envenomations are severe (North Africa, the Middle East, Central America
and Amazonia), check local availability of antivenom sera and follow national recommendations.
The criteria for administration are the severity of the envenomation, the age of the patient (more severe in children)
and the time elapsed since the sting. This should not exceed 2 to 3 hours. If the time elapsed is more than 2 or 3
hours, the beneﬁt of antivenom serum is poor in comparison with the risk of anaphylaxis (in contrast to
envenomation by snakes).
Symptomatic treatment:
In the event of vomiting, diarrhoea or excessive sweating: prevention of dehydration (oral rehydration salts),
especially in children.


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In the event of vomiting, diarrhoea or excessive sweating: prevention of dehydration (oral rehydration salts),
especially in children.
In the event of muscle pain: 10% calcium gluconate slow IV (children: 5 ml per injection, adults: 10 ml per
injection, administered over 10 to 20 minutes).
In the event of seizures: diazepam may be used with caution; the risk of respiratory depression is increased in
envenomated patients (see Seizures, Chapter 1).
Treatment is usually limited to wound cleansing, strict rest, analgesics PO and tetanus prophylaxis (see Tetanus,
Chapter 7).
Severe envenomations are rare. There are two main clinical syndromes:
Neurotoxic syndrome (black widow spider): severe muscle pain, tachycardia, hypertension, nausea, vomiting,


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Neurotoxic syndrome (black widow spider): severe muscle pain, tachycardia, hypertension, nausea, vomiting,
headache, excessive sweating. The signs develop for 24 hours and then resolve spontaneously over a few
days.
Necrotic syndrome (recluse spider): local tissue lesions, possible necrosis and ulceration; mild general signs
(fever, chills, malaise and vomiting) which usually resolve over a few days. If present, haemolysis may sometimes
be life threatening.


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For children, if 1 ml syringe is not available, use a diluted solution, i.e. add 1 mg epinephine to 9 ml of 0.9% sodium
chloride to obtain a 0.1 mg/ml solution (1:10 000):
Children under 6 years: 1.5 ml
Children from 6 to 12 years: 3 ml
Repeat after 5 minutes if no clinical improvement.
In patients with circulatory collapse or those who deteriorate despite receiving IM epinephrine, use IV epinephrine
(for doses, see Anaphylactic shock, Chapter 1).
 
Local care: remove the embedded sting (bee); clean with soap and water; calamine lotion if pruriginous (children and
adults: one application 3 to 4 times daily in a thin layer).
Analgesics if necessary (paracetamol PO).
In the event of an anaphylactic reaction:
epinephrine (adrenaline) IM


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Analgesics if necessary (paracetamol PO).
In the event of an anaphylactic reaction:
epinephrine (adrenaline) IM
Use undiluted epinephrine solution (1:1000 = 1 mg/ml) and a 1 ml syringe graduated in 0.01 ml in children:
Children under 6 years: 0.15 ml
Children from 6 to 12 years: 0.3 ml
Children over 12 years and adults: 0.5 ml
Footnotes
(a) There can be a considerable delay between the decrease in coagulation factors (less than 30 minutes after the bite) andthe ﬁrst signs of bleeding (other than bleeding at the site of the bite and/or the development of sero-sanguinous blisters),which may appear only 3 days after the bite. Conversely, bleeding may resolve prior to normalization of coagulationparameters.


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Dental infections
Infection arising as a secondary complication of an inﬂammation of the dental pulp. The severity and the treatment of
dental infections depend on their evolution: localised to the infected tooth, extended to adjacent anatomical
structures or diffuse infections.
Clinical features and treatment
Infection localised to a tooth and its surroundings (acute dental abscess)
Infections extending to adjacent anatomical structures (acute dento-alveolar abscess)
Local spreading of an acute dental abscess into the surrounding bone and tissue.
Notes:
If the dental procedure has to be delayed (local anaesthesia not possible due to inﬂammation, signiﬁcant
trismus), start an antibiotherapy, but the dental procedure must be completed in the following days.


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trismus), start an antibiotherapy, but the dental procedure must be completed in the following days.
If there is no improvement within 48 to 72 hours after the dental procedure, do not change antibiotic, but start a
new procedure on the tooth.
Infections extending into the cervico-facial tissues
Intense and continuous pain.
On examination: swelling limited to the gum surrounding the infected tooth. Purulent exudate may be present
draining either through the root canal, or through the periodontal ligament (loosening the tooth) or through a gingival
ﬁstula. There are no signs of the infection extending to adjacent anatomical structures nor general signs of
infection.
Treatment:


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ﬁstula. There are no signs of the infection extending to adjacent anatomical structures nor general signs of
infection.
Treatment:
Treatment is only surgical (the source of infection is inaccessible to antibiotics): root canal therapy (disinfection
of the root canal) if possible or extraction of the tooth.
Pain: paracetamol or ibuprofen PO (see Pain, Chapter 1).
Painful gingival and buccal swelling with warm and tender skin, developing into a ripe abscess: intense pain, with
trismus, particularly if the infection is in a posterior tooth, presence of general signs (fever, fatigue, cervical
lymphadenopathy).
In patients with acute gangrenous cellulitis (crepitations on palpation), treat as an infection extending into the
cervico-facial tissues (see below).
Treatment:


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cervico-facial tissues (see below).
Treatment:
First surgical: incision and drainage of the pus or extraction of the tooth.
Then antibiotic treatment for 5 days following the procedure: 
amoxicillin PO
Children: 25 mg/kg 2 times daily 
Adults: 1 g 2 times daily
Pain: paracetamol or ibuprofen PO (see Pain, Chapter 1).
Extremely serious cellulitis, with rapidly spreading cervical or facial tissue necrosis and signs of septicaemia.
Treatment:
treatment in an intensive care unit.
high dose antibiotic treatment (see Necrotising infections of the skin and soft tissues).
extraction of the tooth.


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Chapter 11: Mental disorders in adults
Anxiety
Insomnia
Agitation
Acute confusional state (delirium)
Post-traumatic stress disorder
Depression
Psychotic disorders
Acute psychotic episode
Chronic psychoses
Bipolar disorder


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Anxiety
Last updated: November 2021
 
A patient suffering from anxiety has:
 Anxiety is a common feature in depression, post-traumatic stress disorder and psychosis. It can also occur in isolation,
not associated with any other mental disorders. Anxiety symptoms often occur immediately after a difﬁcult life event.
Medically unexplained symptoms are frequent in refugees and people exposed to adversity; in certain cultures they may
be the only expression of psychological distress. 
Management
Try to determine the source of the anxiety and reassure the patient (without minimising the distress or symptoms). If


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Management
Try to determine the source of the anxiety and reassure the patient (without minimising the distress or symptoms). If
necessary, use simple relaxation techniques to alleviate the symptoms . If symptoms are exacerbated (e.g., tachycardia, feeling of suffocation, fear of dying or “going crazy,” agitation, or
conversely, prostration), it may be necessary to administer diazepam: 5 to 10 mg PO or 10 mg IM, to be repeated
after one hour if required. Acute severe anxiety may justify a short course (max. 2 or 3 weeks) of:
diazepam PO: 2.5 to 5 mg 2 times daily; reducing the dose by half in the last few days of treatment Moderate anxiety lasting more than 2 weeks, administer as ﬁrst-line treatment: 
hydroxyzine PO: 25 to 50 mg 2 times daily (max. 100 mg daily)


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hydroxyzine PO: 25 to 50 mg 2 times daily (max. 100 mg daily)
or, only if there is no improvement after 1 week, diazepam PO: 2.5 to 5 mg 2 times daily for max. 2 weeks. If symptoms recur after treatment discontinuation, do not resume diazepam or hydroxyzine. Re-evaluate for possible
depression or post-traumatic stress disorder. For generalised anxiety that lasts more than 2 months, and does not improve with psychosocial interventions, an
antidepressant should be prescribed (ﬂuoxetine or paroxetine PO: 20 mg once daily), to be continued for 2 to 3
months after symptoms resolve then, stop gradually over 2 weeks.
psychological symptoms: pervasive worries, e.g. fear of having a serious illness, fear with no clearly-deﬁned object
or phobias;


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psychological symptoms: pervasive worries, e.g. fear of having a serious illness, fear with no clearly-deﬁned object
or phobias;
behavioural changes: nervousness, avoidance behaviour, self-isolating tendency, irritability;
physical symptoms: e.g. dry mouth, “lump in the throat”; sometimes medically unexplained symptoms (e.g. feeling of
malaise, hot ﬂashes or chills, diffuse pain);
concentration difﬁculties, sleep problems (difﬁculty getting to sleep, recurrent nightmares).
 a 
Footnotes


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concentration difﬁculties, sleep problems (difﬁculty getting to sleep, recurrent nightmares).
 a 
Footnotes
(a) For example, in case of hyperventilation, use a technique that controls the respiratory rate: get the patient in a comfortableposition with his eyes closed. Help him focus on his breathing so that it becomes calmer and more regular, with three-phasebreathing cycles: inhalation (count to three), exhalation (count to three), pause (count to three), etc.


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Insomnia
Last updated: November 2021
 
Complaints may be: difﬁculty falling or remaining asleep, waking up too early in the morning, nightmares, or fatigue.
Symptoms occur at least three times a week for at least one month.
Management
If insomnia is related to an organic cause, treat the cause (e.g. administer analgesics for pain). If insomnia is related to the use of alcohol, drugs or a medication, management depends on the substance involved. If insomnia is related to a particular life event (e.g. bereavement), a short term treatment with a sedative may be useful:
promethazine PO: 25 mg once daily at bedtime for 7 to 10 days
or, if promethazine is not available, hydroxyzine PO: 25 mg once daily at bedtime for 7 to 10 days


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or, if promethazine is not available, hydroxyzine PO: 25 mg once daily at bedtime for 7 to 10 days
or, as a last resort (risk of addiction), diazepam PO: 2 to 5 mg once daily at bedtime for 7 days max. If insomnia persists, re-evaluate the patient. Insomnia is a common feature in depression (Depression), post-traumatic
stress disorder (Post-traumatic stress disorder) and anxiety disorders (Anxiety). In such cases, the underlying disorder
should be addressed.
 
 a 
Footnotes
(a) The main drugs known to cause sleep problems are corticosteroids, beta blockers, levodopa/carbidopa, ﬂuoxetine,levothyroxine, etc.


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Agitation
Last updated: November 2021
 
People who have recently experienced violent events, or with anxiety, depression, psychotic disorders or delirium, may
have periods of psychomotor agitation.
Agitation is common in acute intoxication (alcohol/psychostimulant drugs) and withdrawal syndrome. Certain drugs may
cause agitation (selective serotonin reuptake inhibitors (SSRIs), levodopa, meﬂoquine, efavirenz, etc.).
Agitation may be accompanied by oppositional, violent or ﬂeeing behaviour.
Management
Clinical evaluation is best performed in pairs, in a calm setting, with or without the person’s family/friends, depending on
the situation. It is essential to check for signs of delirium. If present, the priority is to identify the cause and treat it (see Acute


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the situation. It is essential to check for signs of delirium. If present, the priority is to identify the cause and treat it (see Acute
confusional state). It may be necessary to administer diazepam 10 mg PO to reduce the agitation and conduct the clinical exam, without
over-sedating the patient. If the patient is violent or dangerous, urgent sedation is required: diazepam IM 10 mg, to be repeated after 30 to 60
minutes if necessary.
Physical restraint should only be used in certain circumstances, strictly following the procedure in place.  Avoid diazepam if agitation is related to acute alcohol intoxication or in case of delirium (risk of respiratory depression).


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Use haloperidol (see Acute confusional state). Alcoholic patients can experience withdrawal symptoms within 6 to 24 hours after they stop drinking. Withdrawal
syndrome should be taken into consideration in patients who are hospitalised and therefore forced to stop drinking
abruptly. In the early phase (pre-delirium tremens), the symptoms include irritability, a general feeling of malaise, profuse
sweating and shaking. Treatment consists in:
diazepam PO (10 mg every 6 hours for 1 to 3 days, then reduce and stop over 7 days)
+ oral hydration (3 litres of water daily)
+ thiamine IM or very slow IV (100 mg 3 times daily for at least 3 days) If the agitation is associated with anxiety, see Anxiety; if associated with psychotic disorders, see Psychotic disorders.


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Acute confusional state (delirium)
Last updated: July 2022
 
Clinical features
The clinical picture includes:
These symptoms develop rapidly (hours or days), and often ﬂuctuate during the course of the day.
Agitation, delusions, behavioural disorders and hallucinations (often visual) may be associated symptoms.
Management
Delirium almost always has an organic cause:
Also consider the use of drugs which may cause delirium (opioid analgesics, psychotropic drugs, ﬂuoroquinolones, etc.),
use of toxic substances (alcohol/drugs), or withdrawal from these substances. Delirium requires hospitalisation.
 The administration of diazepam may increase delirium. If it is absolutely necessary to sedate an agitated patient, use
low dose haloperidol for a short time (7 days or less):


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low dose haloperidol for a short time (7 days or less):
haloperidol PO: 0.5 to 1 mg 2 times daily
or haloperidol IM: 0.5 to 1 mg, to be repeated if the patient is still agitated 30 to 60 minutes after the ﬁrst injection. 
If necessary, administer additional doses every 4 hours, do not exceed a total dose of 5 mg daily. In case of delirium related to alcohol withdrawal (delirium tremens):
disorientation in time and space;
impaired consciousness;
concentration problems;
memory impairment.
Infectious: meningitis, severe malaria, encephalitis, septicaemia, syphilis, AIDS, etc.
Metabolic: hyper/hypoglycaemia, electrolyte imbalance, niacin (vitamin PP or B) or thiamine (vitamin B)
deﬁciencies, etc.
3 1
Endocrine: thyroid disorders


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deﬁciencies, etc.
3 1
Endocrine: thyroid disorders
Neurological: epilepsy, raised intracranial pressure, head trauma, meningeal haemorrhage, brain tumour, etc.
Treat the underlying cause.
Provide supportive care (i.e. nutrition, ﬂuid, electrolyte balance); ensure bladder function.
Ensure that the patient receives only medications appropriate to their needs.
Treat pain if needed (see Pain, Chapter 1);
Ensure adequate sensory environment: low lightening, limit noise.
Admit the patient to an intensive care unit.
Administer diazepam IV: 10 to 20 mg 4 to 6 times daily, under close supervision with ventilation equipment near at
hand.
The goal is to achieve mild sedation without provoking respiratory depression. The doses and duration of the


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hand.
The goal is to achieve mild sedation without provoking respiratory depression. The doses and duration of the
treatment are adjusted according to the clinical progress.
IV hydration: 2 to 4 litres 0.9% sodium chloride per 24 hours.
Administer thiamine IM or very slow IV (over 30 minutes): 100 mg 3 times daily for 3 to 5 days.
Monitor vital signs and blood glucose levels.


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Post-traumatic stress disorder
Last updated: November 2021
 
An event is “traumatic” when someone has been directly confronted with death, either by seeing another person being
killed or seriously injured as the result of violence, or by experiencing serious harm, such as a threat to his/her life or
physical integrity (e.g. rape, torture). Exposure to one or several of these events causes feelings of helplessness and
horror. Immediate, transitory symptoms (disorientation, anxiety, sadness, ﬂeeing, etc.) are to be distinguished from secondary,
long-lasting problems that appear and/or last several weeks or months after the event: post-traumatic stress, often
associated with depression (Depression), or sometimes acute psychosis (Psychotic disorders), even in people with no


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associated with depression (Depression), or sometimes acute psychosis (Psychotic disorders), even in people with no
history of psychotic symptoms. Post-traumatic stress disorder is characterized by three types of psychological response, generally seen in
combination .
Hypervigilance (constant state of alert), exaggerated startle reaction, anxiety, insomnia, poor
concentration; sometimes somatic symptoms (sweating, shaking, tachycardia, headache, etc.). Re-experiencing is highly distressing and causes disorders that may worsen over time; people isolate themselves,
behave differently, stop fulﬁlling their family/social obligations, and experience diffuse pain and mental exhaustion.
Management


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behave differently, stop fulﬁlling their family/social obligations, and experience diffuse pain and mental exhaustion.
Management
Psychological intervention is essential to reduce the suffering, disabling symptoms and social handicaps resulting from
PTSD. It is important to reassure the patient that their symptoms are a normal response to an abnormal event. Sessions
should be conducted with tact. The patient should be listened to. Avoid intensely questioning the patient about their
emotions: leave it to the patient to decide how far they want to go. Associated symptoms (anxiety or insomnia), if persistent, can be relieved by symptomatic treatment (see Anxiety and


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Insomnia) for no more than two weeks. If the patient has severe symptoms (obsessive thoughts, pronounced hypervigilance, comorbid despression etc.), the
pharmacological treatment is ﬂuoxetine PO (20 mg once daily) or paroxetine PO (10 to 20 mg once daily) or sertraline
PO (50 mg once daily), to be continued for 2 to 3 months after symptoms resolve then, stop gradually.  
 
 [1] 
Persistent re-experiencing
The patient describes:
images, thoughts or perceptions related to the traumatic experience, which intrude despite efforts to block
them out, including at night in the form of distressing dreams;
ﬂashbacks during which the patient “relives” parts of the traumatic scene.
Avoidance 
The patient tries to avoid: 
places, situations and people that might be associated with the trauma;


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Avoidance 
The patient tries to avoid: 
places, situations and people that might be associated with the trauma;
having thoughts or feelings related to the trauma; patients may use alcohol, drugs or any psychotropic agents
for this purpose.
Persistent perceptions of heightened current threat


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References
1. World Health Organization. Post traumatic stress disorder. International Classiﬁcation of Diseases for Mortality andMorbidity Statistics, Eleventh Revision (ICD-11).https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/2070699808 [Accessed 26 January 2021]


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Depression
Last updated: July 2022
 
Depression is characterised by a set of symptoms that have been present at least two weeks and represent a change
from previous functioning. The standard criteria for diagnosis of major depressive disorder are:
 The features of depression can vary according to the patient’s culture . For example, the depressed patient may
express multiple somatic complaints rather than psychological distress. Depression may also manifest itself as an
acute psychotic disorder in a given cultural context.
Management
When faced with symptoms of depression, consider an underlying organic cause (e.g. hypothyroidism or Parkinson’s
disease) or adverse effects from medical treatment (corticosteroids, cycloserine, efavirenz, meﬂoquine, etc.). Look for


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disease) or adverse effects from medical treatment (corticosteroids, cycloserine, efavirenz, meﬂoquine, etc.). Look for
a triggering event (e.g. sexual violence, recent childbirth and post-partum depression). Depressive disorders are the most common mental disorders in patients with severe chronic infectious diseases such
as HIV infection or tuberculosis. These disorders should not be neglected, especially as they have a negative impact on
adherence to treatment. Symptoms of depression are common after a major loss (bereavement, forced displacement, etc.). They gradually
subside, in most cases, with social support. Psychological support may be useful. Pharmacological treatment should always be offered, along with counseling, to patients with severe depression


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(Patient Health Questionnaire-9 (PHQ-9) score > 19; severe functional impairment, psychotic symptoms, and/or
suicidal risk).  In patients with moderately severe depression (PHQ-9 score 15-19), pharmacological treatment should be considered
if there is no improvement after 3 counselling sessions, or from the outset if patients express a personal preference for
it. Before prescribing, make sure that 9-month treatment and follow-up (psychological support, adherence and response)
are possible. 
Pervasive sadness and/or a lack of interest or pleasure in activities normally found pleasurable and
At least four of the following signs:
Signiﬁcant change in appetite or weight
Insomnia, especially early waking (or, more rarely, hypersomnia)
Psychomotor agitation or retardation


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Signiﬁcant change in appetite or weight
Insomnia, especially early waking (or, more rarely, hypersomnia)
Psychomotor agitation or retardation
Signiﬁcant fatigue, making it difﬁcult to carry out daily tasks
Diminished ability to make decisions or concentrate
Feelings of guilt or worthlessness, loss of self-conﬁdence or self-esteem
Feelings of despair
Thoughts of death, suicidal ideation or attempt
 a


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Preferably use a serotonin reuptake inhibitor (SRI), particularly in older patients. Preferably use ﬂuoxetine, except during
pregnancy when sertraline is preferred.
ﬂuoxetine PO: 20 mg on alternate days for one week, then once daily for 3 weeks, then increase the dose if necessary
(max. 40 mg daily); use with caution in patients with severe anxiety disorders or who are immobilised (e.g. wounded)
or
paroxetine PO: 10 mg once daily for 3 days, then 20 mg once daily for 3 weeks, then increase the dose if necessary
(max. 40 mg daily), especially if the depression is accompanied by severe anxiety
or
sertraline PO: 25 mg once daily for 3 days, then 50 mg once daily for 3 weeks, then increase the dose if necessary


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or
sertraline PO: 25 mg once daily for 3 days, then 50 mg once daily for 3 weeks, then increase the dose if necessary
(max. 100 mg daily) Assess tolerance and response every week for 4 weeks. If the response is inadequate after 4 weeks at optimal dose
or if the SRI is poorly tolerated, replace with another SRI (there is no need for a medication-free interval between the
two).
If SRIs are not available, amitriptyline PO may be used as an alternative: start with 25 mg once daily at bedtime and
gradually increase over 8 to 10 days to 75 mg once daily (max. 150 mg daily). The therapeutic dose is close to the
lethal dose; in older patients, reduce the dose by half. There is a delay of 2 to 3 weeks before the antidepressant effect of SRIs occurs, at least 4 weeks for amitriptyline.


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During this period, anxiety may be exacerbated and the risk of suicide may increase, especially with
ﬂuoxetine. Hydroxyzine PO (25 to 50 mg 2 times daily, max 100 mg daily) or promethazine PO (25 to 50 mg once daily
at bedtime) may be given for the ﬁrst 2 weeks of treatment. If there is no improvement after 1 week, change to
diazepam PO (2.5 to 5 mg 2 times daily) for 2 weeks max.  During the ﬁrst 2 to 4 weeks, do not give the patient more tablets than the quantity required for each week or entrust
the treatment to someone in the patient's close entourage that can initially ensure administration of the drug. Severe depression carries the risk of suicide. Talking to patients about this will not increase the risk of suicide attempt.


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On the contrary – depressed people are often anxious and ambivalent about suicide and feel relieved when able to talk
about it. If major symptoms have not improved after a month of treatment, increase to the maximum dose and assess after 2
weeks. If there is no improvement, refer the patient to a psychiatrist, if possible; if not, try a different antidepressant. The treatment should always be stopped gradually over a 4-week period. Inform the patient about problems
associated with abrupt treatment discontinuation (very common with paroxetine).
Special situations: pregnant or breast-feeding women
Re-evaluate the need to continue treatment. If treatment is still necessary, it is best to continue a treatment that


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Re-evaluate the need to continue treatment. If treatment is still necessary, it is best to continue a treatment that
has been effective rather than switching to a different antidepressant. Nevertheless, if the woman plans to
breastfeed and is taking ﬂuoxetine, consider switching to another SRI at least 3 weeks before expected delivery to
reduce adverse effects in the neonate during breastfeeding. Monitor the neonate the ﬁrst few days of life for signs
of toxicity or withdrawal symptoms.
Depression is more frequent in the post-partum (breast-feeding) period than in pregnancy. In case of severe post-
partum depression in a breast-feeding woman: use sertraline as ﬁrst-line option, or if not available, use paroxetine:


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partum depression in a breast-feeding woman: use sertraline as ﬁrst-line option, or if not available, use paroxetine:
do not administer ﬂuoxetine. In case of severe depression during pregnancy: use sertraline, avoid paroxetine.
Pregnancy in a woman under antidepressants:
Depression occurring during pregnancy or during post-partum period:
 
Footnotes


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(a) Hence the importance of working with an “informant” (in the anthropological sense of the word) when dealing withunfamiliar cultural contexts.


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Psychotic disorders
 
 
 
 
Last updated: July 2022
 
Psychoses are characterised by delusions (the patient is convinced of things that are not real and not accounted for by
the person’s cultural background), or hallucinations (the patient hears voices that do not exist) and behavioural
symptoms (e.g. strange behaviour, agitation, mutism, opposition, ﬂeeing).  Management includes psychosocial support and antipsychotic medication.
Treatment efﬁcacy and prognosis depend largely on the quality of the therapeutic relationship established with the
patient and their family.
Keeping the patient at home with outpatient follow-up is preferred if there is no risk of self-harm or harm to others, and


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patient and their family.
Keeping the patient at home with outpatient follow-up is preferred if there is no risk of self-harm or harm to others, and
if the family is capable of managing the disorder. Interpretation of psychotic symptoms vary according to the cultural context . For example, psychotic disorders may
be attributed to charms or to ancestor intervention. Therapeutic approach should take those beliefs into account.
Patients are usually already under “traditional” treatments, this should not be seen as an obstacle to conventional
medical treatment.
 
Acute psychotic episode
Chronic psychoses
Bipolar disorder
 a 
Footnotes
(a) Hence the importance of working with an “informant” (in the anthropological sense of the word) when dealing withunfamiliar cultural contexts.


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Acute psychotic episode
 
 
Last updated: July 2022
 
An acute psychotic episode can be a one-time occurrence, usually of sudden onset, or can occur repeatedly, or it may
be the early phase of chronic psychosis. It can occur following an adverse life event (e.g. loss, acute stress or trauma).
In postpartum psychosis, delusions are frequently related to the mother-child relationship. Before prescribing antipsychotic medication, consider the possibility of an underlying organic cause (see Acute
confusional state (delirium)) or substance use; check and record blood pressure, heart rate, weight. Antipsychotic treatment is the same as for chronic psychoses (haloperidol or risperidone) and should last at least 3


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months. After 3 months, if the patient is stable, stop the treatment gradually over 4 weeks, monitoring for potential
relapse. If the acute episode lasted more than 3 months, continue antipsychotic treatment for at least 2 years.   For severe anxiety or agitation, a short-course anxiolytic or sedative treatment may be added to the antipsychotic
treatment, at the beginning of treatment.


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Chronic psychoses
 
 
Last updated: July 2022
 
Chronic psychoses (schizophrenia, paranoid psychosis, etc.) are deﬁned by speciﬁc clinical characteristics and their
long-term nature.
Schizophrenia is characterized by delusions, disorganized thinking, hallucinations, depersonalisation, loss of motivation,
diminished emotional expression, impaired cognition, abnormal behaviour and neglected hygiene. Such patients are
often very anxious. The goal of treatment is to reduce symptoms and improve social and occupational functioning. It offers real beneﬁts,
even if chronic symptoms persist (tendency toward social isolation, possible relapses and periods of increased


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even if chronic symptoms persist (tendency toward social isolation, possible relapses and periods of increased
behavioural problems, etc.). Before prescribing antipsychotic medication, consider the possibility of an underlying organic cause (see Acute
confusional state (delirium)) and use of substances. Check and record blood pressure, heart rate and weight.  Treatment should last at least one year, possibly for life, particularly in patients with schizophrenia. Uncertainty about
the possibility of follow-up at one year or beyond is no reason not to treat. However, it is better not to start
pharmacological treatment for patients who have no family/social support (e.g. homeless), provided they do not have


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pharmacological treatment for patients who have no family/social support (e.g. homeless), provided they do not have
severe behavioural disorders. Only prescribe one antipsychotic at a time. To limit the risk of adverse effects, start treatment at a low dose and
gradually increase until the minimum effective dose is reached. In older patients, reduce the dose by half, whichever
medication is used.  Haloperidol is the ﬁrst-line antipsychotic. Preferably use oral haloperidol with a view to switching to long-acting
haloperidol (haloperidol decanoate) if the patient is likely to need long-term treatment (e.g. patients with schizophrenia).
haloperidol PO: start with 0.5 mg 2 times daily for 3 days then 1 mg 2 times daily until the end of the ﬁrst week;


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haloperidol PO: start with 0.5 mg 2 times daily for 3 days then 1 mg 2 times daily until the end of the ﬁrst week;
increase to 2.5 mg 2 times daily the second week. After 2 weeks, assess if the treatment is well tolerated and
effective. If it is not effective, check adherence; if necessary increase to 5 mg 2 times daily (max. 15 mg daily). If haloperidol is not available, contraindicated or poorly tolerated, possible alternative are:
risperidone PO: 1 mg 2 times daily for one week, then 2 mg 2 times daily for one week; if necessary, increase to 3 mg
2 times daily as of the third week (max. 10 mg daily).
or
chlorpromazine PO (especially if a sedative effect is required): 
25 to 50 mg once daily in the evening for one week; if necessary, increase to 50 mg in the morning and 100 mg in the


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25 to 50 mg once daily in the evening for one week; if necessary, increase to 50 mg in the morning and 100 mg in the
evening for one week; if necessary, 100 mg 3 times daily as of the third week.
or 
olanzapine PO: 10 mg once daily; if necessary, increase by 5 mg every week (max. 20 mg daily). In case of extrapyramidal symptoms, try reducing the dose of antipsychotic or, if the extrapyramidal symptoms are
severe, add biperiden PO: 2 mg once daily, increase if necessary up to 2 mg 2 to 3 times daily (if biperiden is not
available, use trihexyphenidyl PO at the same dosage).  For severe anxiety, it is possible to add a short-course anxiolytic treatment (for a few days to max. 2 to 3 weeks) to
the antipsychotic treatment:
diazepam PO: 2.5 to 5 mg 2 times daily For major agitation:


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haloperidol PO 5 mg + promethazine PO 25 mg, to be repeated after 60 minutes if necessary. After a further 60
minutes, if necessary administer promethazine IM 50 mg.
In case of hostile or agressive behaviour, use IM route (same dose), to be repeated after 30 minutes if necessary;
after a further 30 minutes, if necessary, administer promethazine IM 50 mg.
High doses of haloperidol can induce extrapyramidal symptoms, add biperiden if necessary.
diazepam PO or IM: 10 mg to be repeated after 60 minutes if necessary
Do not combine two antipsychotics. For long-term treatment (e.g. patients with schizophrenia) a long-acting antipsychotic drug can be used once the
patient has been stabilised on oral treatment. The dosage depends on the oral dose the patient is taking. The switch


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patient has been stabilised on oral treatment. The dosage depends on the oral dose the patient is taking. The switch
from oral to a long-acting antipsychotic should be gradual, according to a speciﬁc protocol. For information, at the
end of the transition period from oral to long-acting antipsychotic, the dose of haloperidol decanoate IM administered
every 3 to 4 weeks is approximately: 
For a patient on risperidone PO: gradually decrease the dose of risperidone by slowly introducing haloperidol PO then,
once the patient is stabilised, change to haloperidol decanoate every 3 to 4 weeks as above.
Special situations: pregnant or breast-feeding women
If the patient is not under antipsychotic treatment:
If the patient is already under antipsychotic treatment:
Daily dose 
of haloperidol PO


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If the patient is not under antipsychotic treatment:
If the patient is already under antipsychotic treatment:
Daily dose 
of haloperidol PO
Monthly dose of
haloperidol decanoate IM (a)
2.5 mg 25 mg
5 mg 50 mg
10 mg 100 mg
15 mg 150 mg
(a) If haloperidol decanoate is not available, ﬂuphenazine IM: 12.5 to 50 mg/injection every 3 to 4 weeks.
In the event of pregnancy in a woman taking antipsychotics: re-evaluate the need to continue the treatment. If
treatment is still necessary, administer the minimal effective dose and avoid combination with an anticholinergic
(biperiden or trihexphenidyl). Monitor the neonate for extrapyramidal symptoms during the ﬁrst few days of life.
First symptoms of psychosis during pregnancy: start with the lowest dose of haloperidol and only increase slowly if


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First symptoms of psychosis during pregnancy: start with the lowest dose of haloperidol and only increase slowly if
necessary. 
Post-partum psychosis: if the woman is breast-feeding, haloperidol should be preferred.
Long-acting antipsychotics should not be administered.


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Bipolar disorder
 
 
Last updated: July 2022
 
Bipolar disorder is characterised by alternating manic and depressive episodes , generally separated by “normal”
periods lasting several months or years. Episodes of mania are characterised by elation, euphoria and hyperactivity accompanied by insomnia, grandiose ideas,
and loss of social inhibitions (sexual, in particular).
Depressive episodes are often severe, with signiﬁcant risk of suicide.
Look for family history of similar symptoms (particularly suicide), very frequent in bipolar patients. Pharmacological treatment:
valproic acid PO: 200 mg 2 times daily (Week 1) then 400 mg 2 times daily (Week 2) then 500 mg 2 times daily


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valproic acid PO: 200 mg 2 times daily (Week 1) then 400 mg 2 times daily (Week 2) then 500 mg 2 times daily
(Week 3). This is usually sufﬁcient to stabilise the patient; if necessary the dose may be increased by 500 mg weekly
(max. 1000 mg 2 times daily).
or
carbamazepine PO: 100 mg 2 times daily (Week 1) then 200 mg 2 times daily (Week 2) then 200 mg 3 times daily
(Week 3). This is usually sufﬁcient to stabilise the patient; if necessary the dose may be increased by 200 mg
weekly (max. 1200 mg daily). 
 Long-term treatment for bipolar disorder is based on continuation of the treatment that led to the remission of the
manic episode: antipsychotic, mood stabilizer, or a combination of both.


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manic episode: antipsychotic, mood stabilizer, or a combination of both.
Treatment can be initiated by a physician trained in mental health, but a consultation should be set up as soon as
possible with a specialist.  
 a 
Episodes of mania are treated with haloperidol PO: 5 mg once daily for 3 days, then 7.5 mg for one week; if
necessary, increase by increments of 2.5 mg per week (max. 15 mg daily). 
Possible alternatives: 
risperidone PO: 2 mg once daily; if necessary, increase in increments of 1 mg per week (max. 6 mg daily). 
or 
olanzapine PO: 10 mg once daily for 3 days; if necessary, increase in increments of 5 mg per week (max. 20 mg
daily). 
If there is improvement after one week of treatment, continue with the same dose for at least 8 weeks after
remission of symptoms.


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daily). 
If there is improvement after one week of treatment, continue with the same dose for at least 8 weeks after
remission of symptoms.
Diazepam PO (5 to 10 mg daily) can be added during the ﬁrst 2 to 3 weeks.
If symptoms do not resolve after 2 weeks of antipsychotic treatment at maximum tolerated dose (and 2 different
antipsychotics have been tried), add a mood stabiliser:
Treatment should be continued until at least 8 weeks after complete remission of symptoms. Assess together with
the patient the beneﬁts and risks of pursuing long-term treatment. 
If is it decided to discontinue antipsychotic treatment, medication should be stopped gradually, monitoring for
possible relapse. 
Depressive episodes are treated as for depression (see Depression).


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possible relapse. 
Depressive episodes are treated as for depression (see Depression). 
If the patient has an episode of mania while on antidepressants, immediately stop antidepressants and treat the
episode of mania as above. An episode of mania while on antidepressants is indicative of bipolar disorder.


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Valproic acid is not recommended in women of childbearing age. If it is necessary to start treatment, use
carbamazepine.
If a woman of childbearing age is already taking valproic acid, switch to carbamazepine by gradually decreasing the
dose of valproic acid over a period of 2 weeks (do not stop treatment abruptly) while gradually starting carbamazepine.
If a woman becomes pregnant or is planning pregnancy it is essential to contact a specialist to re-evaluate whether the
treatment is still necessary and adjust the dose if needed.
 
Footnotes
(a) “Unipolar forms” are characterized by recurring episodes of depression.


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Chapter 12: Other conditions
Sickle cell disease
Epilepsy
Diabetes type 2 in adults
Essential hypertension in adults
Heart failure in adults
Chronic heart failure
Acute heart failure (acute pulmonary oedema)
Endemic goitre and iodine deﬁciency


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Sickle cell disease
Homozygous sickle cell disease (SCD) is a life-threatening genetic disorder of haemoglobin (Hb). The abnormal Hb
(HbS) results in the distortion of red blood cells into a sickle shape leading to increased destruction (haemolysis), an
increase in blood viscosity and obstruction of capillaries (vaso-occlusion).
SCD is common in sub-Saharan Africa (1 to 3% of births), on the American continent, in India and in the Mediterranean
basin.
Clinical features
Major acute manifestations
Painful vaso-occlusive crises (VOC)
Fever
Look for infection: in particular pneumonia, cellulitis, meningitis, osteomyelitis and sepsis (patients are particularly
susceptible to infections especially due to pneumococcus, meningococcus and Haemophilus inﬂuenzae); malaria.


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susceptible to infections especially due to pneumococcus, meningococcus and Haemophilus inﬂuenzae); malaria.
Acute severe anaemia
Stroke
Symptoms generally begin after 6 months of age.
Major signs: recurrent painful crises, chronic anaemia, splenomegaly and frequently, growth retardation and
malnutrition in children.
Serious acute life threatening complications such as stroke, overwhelming infections and acute chest syndrome.
In populations in whom the disease is frequent, diagnosis is suggested by a family history of similar clinical signs.
Children under 2 years present with the hand-foot syndrome or dactylitis (acute pain and swelling in the hands or
feet).
Children older than 2 years and adults present with acute pain affecting the back, chest, abdomen (can resemble an


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feet).
Children older than 2 years and adults present with acute pain affecting the back, chest, abdomen (can resemble an
acute abdomen) and extremities.
Young children may have non-speciﬁc signs of a VOC: refusal to walk, irritability, lack of appetite, crying, whimpering
or moaning when touched, etc.
Look for an associated infection that might have precipitated the VOC.
In case of bony pain in a single location, unresponsive to analgesics (or a persistent limp in a child) associated with
fever and erythema or swelling, consider an osteomyelitis.
The chronic anaemia is often complicated by acute severe anaemia with gradually appearing fatigue, pallor of the
conjunctivae and palms, shortness of breath, tachycardia, syncope or heart failure.
The acute anaemia can be due to:


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conjunctivae and palms, shortness of breath, tachycardia, syncope or heart failure.
The acute anaemia can be due to:
Acute severe haemolysis often secondary to malaria: fever, haemoglobinuria (dark urine) and yellow
conjunctivae.
Splenic sequestration (trapping of blood cells in the spleen), mostly in children 1 to 4 years: sudden enlargement
of the spleen, severe left upper quadrant pain, thrombocytopenia. Can lead to shock.
Aplastic crisis (transient suspension of red blood cell production by the bone marrow): impalpable spleen and
absence of reticulocytes.


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Acute chest syndrome (ACS)
Priapism
Painful prolonged erection in the absence of sexual stimulation, also occurring in young boys. Risk of necrosis and
irreversible erectile dysfunction.
Laboratory and other investigations
Diagnosis
Other examinations
 
Management of major acute manifestations
Most often ischaemic (due to vaso-occlusion in cerebral vessels) but a stroke can also be haemorrhagic.
Sudden loss of motor function or aphasia, in children and in adults.
Signs can resemble meningitis and cerebral malaria: headache, photophobia, vomiting, stiff neck, alteration of
consciousness and neurologic signs or rarely seizures.
Chest pain, tachypnoea, respiratory distress, hypoxia; fever (more frequent in children); pulmonary inﬁltrate on chest
x-ray. Often proceeded by a VOC.


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x-ray. Often proceeded by a VOC.
Complications: multiorgan failure (lung, liver, kidney).
Hb electrophoresis conﬁrms the diagnosis but is often unavailable.
If not available, a positive Emmel test (or sickling test) in the presence of clinical signs of sickle cell disease
supports the diagnosis.
Tests Indications
Haemoglobin • At the time of diagnosis and annually (frequently 7 to 9 g/dl).
• In case of VOC, fever, acute anaemia (≤ 5 g/dl or drop in Hb ≥ 2 g/dl below the
patient’s baseline), stroke, ACS.
• For monitoring of transfused patients.
Platelets • At the time of diagnosis and annually.
• In case of acute anaemia (thrombocytopenia - platelet count ≤ 100 000/mm if
splenic sequestration).
3
Urine dipstick • In case of fever: look for a urinary tract infection.


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splenic sequestration).
3
Urine dipstick • In case of fever: look for a urinary tract infection.
• In case of acute severe anaemia: look for haemoglobinuria.
Malaria test In case of VOC, fever, acute anaemia or stroke.
Lumbar puncture In case of fever with meningeal signs or unexplained coma.
Other
(if available)
• Complete blood count and reticulocyte count.
• Blood culture in case of fever.
• X-ray if suspicion of pneumonia, osteomyelitis, ACS.


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Painful vaso-occlusive crisis (VOC)
 For the treatment of pain according to intensity, see Pain (Chapter 1).
Fever and infection
 
 
 
 
 
ceftriaxone slow IV injection (3 minutes) or IV infusion (30 minutes)
Children < 40 kg: 50 mg/kg every 12 hours
Children ≥ 40 kg and adults: 2 g every 12 hours
+ cloxacillin IV infusion (60 minutes)
Children < 40 kg: 50 mg/kg every 6 hours 
Children ≥ 40 kg and adults: 3 g every 6 hours 
Administer IV therapy for at least 14 days. Then if the patient has improved, change to the oral route for an
additional 14 days of treatment with a combination of:
ciproﬂoxacin PO
Children < 35 kg: 15 mg/kg 2 times daily
Children ≥ 35 kg and adults: 500 mg 2 times daily
+ amoxicillin/clavulanic acid PO (see below)


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Children < 35 kg: 15 mg/kg 2 times daily
Children ≥ 35 kg and adults: 500 mg 2 times daily
+ amoxicillin/clavulanic acid PO (see below)  
ceftriaxone IM or slow IV  injection (3 minutes) or IV infusion (30 minutes)
Children < 20 kg: 50 mg/kg once daily (max. 2 g/day)
Children ≥ 20 kg and adults: 1 to 2 g once daily After 48 hours re-evaluate the patient:
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 
Moderate pain (at home):
Generous oral hydration (water, soup, juice, coconut water): minimum 100 ml/kg daily in children and 50 ml/kg
daily in adults (2.5 to 3 litres daily);
Warm compresses (application of cold is contra-indicated);


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daily in adults (2.5 to 3 litres daily);
Warm compresses (application of cold is contra-indicated);
Level 1 (paracetamol and ibuprofen) and level 2 (tramadol) analgesics;
If pain is not controlled at home within 24 hours, seek medical attention.
Severe pain or pain not controlled at home (in hospital):
PO hydration (as above); if the patient is unable to drink sufﬁciently, IV hydration (Appendix 1); in the event of
dehydration, treat according to the degree of dehydration (see Dehydration, Chapter 1);
Level 3 analgesics (morphine);
Do not give routine antibiotics in the absence of fever; do not transfuse for VOC.
Admit to hospital:
All children less than 2 years;
Children with fever ≥ 38.5 °C and adults with fever ≥ 39.5 °C; patients who are critically ill appearing or have
acute anaemia.


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Children with fever ≥ 38.5 °C and adults with fever ≥ 39.5 °C; patients who are critically ill appearing or have
acute anaemia.
 a  
PO or IV hydration (Appendix 1).
Treat malaria if present.
Treat bacterial infections according to cause.
Treat all patients with respiratory symptoms for pneumonia and ACS.
In case of osteomyelitis:
 b 
 c
If the source of infection is unknown:
 b 
If the patient is improving (afebrile, can drink), change to:


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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)
Patients over 2 years without acute anaemia can continue treatment as outpatients.
Patients under 2 years or with acute anaemia or who cannot be monitored and treated at home by their family
should complete PO antibiotherapy in hospital.
Acute severe haemolysis
Aplastic crisis
Splenic sequestration
 Note: splenectomy is contra-indicated (high operative mortality).
Stroke
If the patient is not improving, continue ceftriaxone until the patient is afebrile, then, change to PO treatment.
Monitor for acute anaemia.
Admit to hospital.
Treat malaria if present.


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Monitor for acute anaemia.
Admit to hospital.
Treat malaria if present.
Transfuse packed red blood cells if Hb < 5 g/dl or drop of 2 g/dl below the patient’s baseline. Target a Hb level of
9 g/dl.
 d e  
Start with 10 to 15 ml/kg in 3 to 4 hours. For information, 10 ml/kg of packed red blood cells usually raise the Hb
by 2.5 g/dl.
Repeat the Hb. If a second transfusion is needed, check for signs of ﬂuid overload before starting the
transfusion.
Measure Hb and perform urine dipstick in the following days. Further transfusions may be necessary if
haemolysis is ongoing.
Admit to hospital.
Treat an associated bacterial infection if present.
Transfuse as for haemolysis. Repeat the Hb every other day. An increasing reticulocyte count and a gradual


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Transfuse as for haemolysis. Repeat the Hb every other day. An increasing reticulocyte count and a gradual
increase of the Hb indicate improvement. Follow patient until they have reached their baseline Hb.
Admit to hospital.
Treat hypovolaemic shock if present.
Monitor the size of the spleen.
Transfuse if Hb < 5 g/dl, target a Hb level of 7 to 8 g/dl maximum.
Administer ceftriaxone as above.
After clinical improvement, monitor for relapse (follow the size of the spleen).
Admit to hospital.
The treatment of choice for ischaemic stroke is an exchange transfusion to lower the concentration of HbS.
Transfer the patient to a specialized facility for further management (including prophylactic therapy to prevent
recurrences with transfusion program, hydroxyurea).


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recurrences with transfusion program, hydroxyurea).
If the patient is awaiting transfer or if transfer is not possible:
Oxygen continuously, at least 5 litres/minute or to maintain the SpO between 94 and 98%.2
Treat seizures if present.
Transfuse if the Hb ≤ 9 g/dl. Target Hb of 10 g/dl.
After the transfusion provide IV hydration (Appendix 1).


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Acute chest syndrome
ceftriaxone slow IV  injection (3 minutes) or IV infusion (30 minutes) for 7 to 10 days
Children < 20 kg: 50 mg/kg once daily (max. 2 g daily)
Children ≥ 20 kg and adults: 1 to 2 g once daily
+ azithromycin PO for 5 days
Children: 10 mg/kg once daily (max. 500 mg daily)
Adults: 500 mg on D1 then 250 mg once daily from D2 to D5
 salbutamol aerosol (100 micrograms/puff)
Children and adults: 2 to 4 puffs with a spacer every 10 to 30 minutes as needed
Priapism
Prevention of complications
Certain complications can be avoided with appropriate health education of patients/families, routine preventive care
and regular follow-up.
Education of patients (including children) and families
Admit to hospital.
Measure SpO and administer oxygen as in stroke.2


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and regular follow-up.
Education of patients (including children) and families
Admit to hospital.
Measure SpO and administer oxygen as in stroke.2
PO hydration as for a VOC; if the patient is unable to drink sufﬁciently, IV hydration (Appendix 1) while monitoring for
ﬂuid overload; in the event of ﬂuid overload, administer one dose of furosemide IV (see Dehydration, Chapter 1).
Antibiotics:
 b 
Transfuse if symptoms are unresponsive to antibiotics and Hb < 9 g/dl.
If wheezing is present treat with:
Encourage deep breathing (incentive spirometry hourly).
Treat pain (see Pain, Chapter 1).
PO hydration as for a VOC; IV hydration if necessary (Appendix 1) and treat dehydration if present (see Dehydration,
Chapter 1).
Encourage urination, apply warm compresses, treat pain.


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Chapter 1).
Encourage urination, apply warm compresses, treat pain.
Erection > 4 hours: consider transfusion and refer to surgery.


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Routine preventive care
phenoxymethylpenicillin (penicillin V) PO until age 15 years (at least until 5 years):
Children < 1 year: 62.5 mg 2 times daily
Children 1 to < 5 years: 125 mg 2 times daily
Children 5 to 15 years: 250 mg 2 times daily 
Ensure that the child’s immunisations are up to date; if not, administer catch up vaccines:
 
folic acid PO(life-long treatment)
Children < 1 year: 2.5 mg once daily
Basic knowledge
Disease
Treatment
Monitoring
Chronic, necessarily transmitted by both parents, non-contagious.
Routine (see below) and symptomatic (pain).
Size of the spleen, temperature, baseline Hb.
Major precipitating factors of a painful crisis and how to prevent them
Cold
Excessive heat
Tight clothing
Dehydration
Excessive effort
Infections


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Major precipitating factors of a painful crisis and how to prevent them
Cold
Excessive heat
Tight clothing
Dehydration
Excessive effort
Infections
Wear warm clothing, avoid bathing in cold water.
For example, avoid going out at mid-day.
Wear wide comfortable clothing without elastics.
Drink plenty of ﬂuids.
Moderate physical activity is beneﬁcial.
Follow routine treatments (including vaccination).
Principal complications requiring the patient to seek urgent medical advice
Pain unresponsive to analgesia after 24 hours or severe from the start.
Any fever (do not treat at home).
Respiratory problems (cough, difﬁculty breathing, chest pain).
Diarrhoea/vomiting and inability to drink.
Dehydration (dark, infrequent urine).
Anaemia (pale or yellow conjunctivae, pale palms, enlarged spleen).


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Diarrhoea/vomiting and inability to drink.
Dehydration (dark, infrequent urine).
Anaemia (pale or yellow conjunctivae, pale palms, enlarged spleen).
Prevention of pneumococcal infections
Immunization
Children 
< 5 years
DTP, hepatitis B, polio, measles, H. inﬂuenzae type B vaccines
Pneumococcal conjugate vaccine (PCV13 or, if not available, PCV10)
Meningococcal conjugate vaccine in endemic areas
At 2 years: pneumococcal 23-valent polysaccharide vaccine, at least 8 weeks after the last
PCV13 or 10
Children 
> 5 years
DTP or Td, hepatitis B, polio, measles, H. inﬂuenzae type B vaccines
Pneumococcal conjugate vaccine PCV13 (or PCV10)
Meningococcal conjugate vaccine in endemic areas
To support red blood cell production
 f


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Children ≥ 1 year and adults: 5 mg once daily 
meﬂoquine PO
Children 6 months to 5 years and > 5 kg: 5 mg base/kg once weekly
Do not use to treat malaria. 
Routine follow-up of patients
Children < 5 years: every 1 to 3 months;
Children ≥ 5 years and adults: every 3 to 6 months.
 
Malaria chemoprophylaxis (if malaria prevalence ≥ 5%)
Provide nutritional support at hospital discharge.
Between crises, for information:
After a crisis: as often as necessary, according to the clinical course.
Footnotes
(a) Critically ill appearing child: weak grunting or crying, drowsy and difﬁcult to arouse, does not smile, disconjugate 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 20 kg and over and in adults.
(c) 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.
(d) Always inquire how many transfusions a patient has previously received (risk of iron overload).


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(d) Always inquire how many transfusions a patient has previously received (risk of iron overload).
(e) Do not transfuse whole blood if possible (risk of ﬂuid overload).
(f) Iron is contraindicated in patients who have received multiple transfusions. Avoid combined preparations of iron and folicacid.


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Epilepsy
Last updated: October 2024
 
Epilepsy is a chronic neurological disorder characterized by recurrent seizures. People with epilepsy frequently face discrimination and stigma as well as social and economic difﬁculties. They are
also at risk of mental, behavioural or cognitive disorders as well as seizure-related injuries. Management of
comorbidities and patient/family education and support are essential. Seizures are usually short episodes. A seizure lasting longer than 5 minutes (or 2 or more seizures in 5 minutes without
complete restoration of baseline consciousness between seizures) is a medical emergency, see Generalised tonic-
clonic seizures and convulsive status epilepticus, Chapter 1.
Clinical features


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clonic seizures and convulsive status epilepticus, Chapter 1.
Clinical features
Manifestations of epilepsy (i.e. seizures) are varied. It is critical to recognize the type of seizure to determine patient
management.
Seizures are classiﬁed as follows : Generalized onset seizures
 Focal onset seizures
 Epilepsy is clinically diagnosed when 2 or more "unprovoked" seizures (i.e. seizures not caused by a temporary
reversible condition) of any type occur more than 24 hours apart .
Treatment principles
Rarely, ASMs may cause a paradoxical increase in seizure frequency, mainly at the start of treatment or after an
increase in dose.
 [1] 
Tonic-clonic seizures: contraction of muscles, including respiratory muscles (tonic phase), followed by rhythmic


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increase in dose.
 [1] 
Tonic-clonic seizures: contraction of muscles, including respiratory muscles (tonic phase), followed by rhythmic
jerking of the arms and legs (clonic phase) and loss of consciousness;
Myoclonic seizures: sudden and brief contractions of a muscle or group of muscles;
Atonic seizures: sudden loss of muscle tone, frequently resulting in falls;
Absence seizures: brief (a few seconds) impairment of consciousness and cessation of activity; most common in
children from 4 years of age.
Start with localised symptoms (e.g. jerking movements of one body part or repetitive lips smacking) and sometimes
spread to the rest of the body, becoming generalised.
 [2] [3]


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spread to the rest of the body, becoming generalised.
 [2] [3] 
Once the diagnosis of epilepsy (or seizures requiring long-term treatment) has been made, an antiseizure medication
(ASM) is prescribed to prevent the occurrence of new seizures.
The treatment prescribed should be a monotherapy (i.e. a single ASM).
For choosing an ASM, see Choice of an antiseizure medication. The likelihood of continued ASM availability should
also be considered when making the choice.
Treatment should be taken daily without interruption for the long term. Abruptly stopping or reducing an ASM dose is
likely to provoke seizures.
Long-term patient follow-up is required, see Patient follow-up. Any change in treatment (dose increments, ASM
substitution or discontinuation) requires close clinical monitoring.


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substitution or discontinuation) requires close clinical monitoring.
If seizures are not controlled, assess adherence to treatment, consider increasing the dose if tolerated, up to the
maximum dose if necessary.


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Choice of an antiseizure medication
An ASM is selected according to:
 
If seizures are still not controlled or treatment is not tolerated, gradually change to another ASM (slowly increase
the dose of the new ASM then slowly decrease the dose of the ﬁrst ASM until complete substitution).
Combination therapy should be considered only if two different ASMs used in monotherapy have failed.
Stopping an antiseizure treatment may be considered when the patient has been seizure-free for at least 2 years
. The beneﬁts/risks of stopping the ASM should be discussed with the patient (seizures may recur after stopping
treatment). The dose should be slowly tapered (e.g. by 10% every 2 weeks) over a period of at least 3 months.


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treatment). The dose should be slowly tapered (e.g. by 10% every 2 weeks) over a period of at least 3 months.
Patients should seek medical attention if seizures recur during or after stopping treatment.
 [4]
Patient and family education is essential.  Provide information about epilepsy as a disease, the beneﬁts of
treatment, ways to maximize control (including adherence to treatment) and ﬁrst aid for seizures. Explain that
people with epilepsy can lead normal lives when certain safety measures are taken (e.g. not swimming alone, not
cooking over open ﬂames) . [4] [5] 
the type of seizure: some ASMs may exacerbate some symptoms, 
the patient’s characteristics: age, sex, pregnancy or breastfeeding status, comorbidities, and related treatments,


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the patient’s characteristics: age, sex, pregnancy or breastfeeding status, comorbidities, and related treatments,
the ASM’s adverse effect proﬁle: in general, newer ASMs (e.g. levetiracetam) are safer, better tolerated, and have
fewer drug interactions than older ASMs (e.g. carbamazepine, phenobarbital, phenytoin, valproic acid).
Age/Type of seizures First choice Second choice Third choice
Children 1 month to < 2 years
Motor, generalised
(tonic-clonic, myoclonic , atonic ) (a)  (b) levetiracetam (LEV) phenobarbital (PB) carbamazepine (CBZ)
or phenytoin (PHT)
Non-motor, generalised (absence) – – –
Focal (partial) LEV or CBZ PB or PHT –
Girls 2 to < 10 years, boys ≥ 2 years and men
Motor, generalised
(tonic-clonic, myoclonic , atonic ) (a)  (b) 
LEV or
valproic acid (VPA)
CBZ or PB


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Girls 2 to < 10 years, boys ≥ 2 years and men
Motor, generalised
(tonic-clonic, myoclonic , atonic ) (a)  (b) 
LEV or
valproic acid (VPA)
CBZ or PB
or PHT –
Non-motor, generalised (absence ) (c) LEV or VPA – –
Focal (partial) LEV or CBZ VPA PB or PHT
Girls ≥ 10 years and women
Motor, generalised
(tonic-clonic, myoclonics , atonic ) (a)  (b) LEV CBZ or PHT PB
Non-motoras, generalised (absence ) (c) LEV – –
Focal (partial) LEV CBZ or PHT PB


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Children
Patients over 65 years
Pregnant women and girls
 In all cases:
Women and girls of childbearing age
(a) For myoclonic seizures: CBZ and PHT are not recommended (risk of worsening symptoms).
(b) For atonic seizures: CBZ is not recommended (risk of worsening symptoms).
(c) For absence seizures: CBZ, PB and PHT are not recommended (risk of worsening symptoms).
VPA is contraindicated in children less than 2 years (increased risk of hepatotoxicity).
LEV is preferred in older patients . [6] 
The risk of major congenital malformations (MCM) is lower with monotherapy than with combined therapy .  [7] 
ASMs that can be used during pregnancy include:
LEV: ﬁrst-line, safest ASM with the lowest risk of MCM .  [7] [8] 
ASMs other than LEV (only if LEV is not available):


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LEV: ﬁrst-line, safest ASM with the lowest risk of MCM .  [7] [8] 
ASMs other than LEV (only if LEV is not available):
CBZ and PHT: associated with an intermediate risk of MCM ;  [7] [8] 
PB: associated with a high risk of MCM  and small for gestational age. [7] [8] 
If taking ASM treatment before pregnancy:
LEV: continue treatment under closer monitoring.
ASMs other than LEV:
The beneﬁts/risks of substitution for a safer ASM should be discussed with patients. 
Substitution may be beneﬁcial for the foetus but may also be a risk for the mother and the foetus if it results
in loss of seizure control. The term of pregnancy should be taken into account. For substitution with a safer
ASM, see Treatment principles. A substitution frequently takes 2 to 3 months.


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ASM, see Treatment principles. A substitution frequently takes 2 to 3 months.
VPA must not be prescribed in pregnant women and girls. It is associated with the highest risk of MCM and
neurodevelopmental disorders in children exposed in utero . In situations where VPA would be the only option,
divide doses over the day to minimize peaks in VPA plasma concentrations.
 [7] [8] 
The parents should be informed of current knowledge in terms of risks for the unborn child, in particular when the risk
of foetotoxicity is high.
Administer the lower effective dose (foetal harms are mainly dose-dependent).
ASM plasma concentrations may decrease during pregnancy. If the dose needs to be increased antepartum, start


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ASM plasma concentrations may decrease during pregnancy. If the dose needs to be increased antepartum, start
reducing it from D3-D4 postpartum to gradually return to the dose effective before pregnancy.
Start taking high dose folic acid to reduce the risk of MCM (5 mg daily for the ﬁrst trimester ). [9] a 
After pregnancy, the beneﬁts of breastfeeding are considered to outweigh the risk of adverse effects of ASMs . [10] 
The choice of an ASM is based on the same criteria as per pregnant women and girls due to the possibility of
undiagnosed or future pregnancies.
Preconception and/or contraception counselling should be offered. 
If considering pregnancy, depending on the ASM currently taken, consider a safer ASM.


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If considering pregnancy, depending on the ASM currently taken, consider a safer ASM. 
When planning pregnancy, start taking folic acid before conception to reduce the risk of MCM.
If no pregnancy is planned, effective contraception should be provided:
Patient taking CBZ, PB or PHT: injectable medroxyprogesterone (DMPA) or levonorgestrel-containing or
copper intrauterine device . [7] 
Patient taking LEV or VPA: as above, but contraceptive implants and oral contraceptives can also be used .  [7]


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Dosage of antiseizure medications
Start with a low dose then increase gradually based on patient's response (seizure control) and tolerance (occurrence
of adverse effects). The following doses are given as a guide and should be ajusted individually. carbamazepine PO:
 levetiracetam PO:
 phenobarbital PO:
 phenytoin PO:
 valproic acid (sodium valproate) PO:
Patient follow-up
In situations where VPA would be the only effective option (i.e. after conﬁrmation that other ASMs are ineffective
or poorly tolerated), a blood pregnancy test should be performed before starting the treatment, then regularly if the
patient is not on effective contraception.
If pregnancy occurs, see Pregnant women and girls.


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patient is not on effective contraception.
If pregnancy occurs, see Pregnant women and girls.
Children 1 month to 11 years: start with 5 mg/kg once daily or 2.5 mg/kg 2 times daily; increase the daily dose by
increments of 2.5 to 5 mg/kg every 3 to 7 days, up to 5 mg/kg 2 or 3 times daily if necessary (max. 20 mg/kg daily).
Children 12 years and over: start with 100 to 200 mg once daily or 50 to 100 mg 2 times daily; increase the daily
dose by increments of 100 to 200 mg every week, up to 200 to 400 mg 2 or 3 times daily if necessary (max. 1800
mg daily).
Adults: start with 100 to 200 mg once daily or 50 to 100 mg 2 times daily; increase the daily dose by
increments of 100 to 200 mg every week, up to 400 mg 2 or 3 times daily if necessary (max. 2 g daily).


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increments of 100 to 200 mg every week, up to 400 mg 2 or 3 times daily if necessary (max. 2 g daily).
Children 1 to 5 months: start with 7 mg/kg once daily; increase to 7 mg/kg 2 times daily after 2 weeks, then by
increments of 7 mg/kg 2 times daily every 2 weeks if necessary (max. 21 mg/kg 2 times daily).
Children 6 months to 17 years (< 50 kg): start with 10 mg/kg once daily; increase to 10 mg/kg 2 times daily after 2
weeks, then by increments of 10 mg/kg 2 times daily every 2 weeks if necessary (max. 30 mg/kg 2 times daily).
Children 50 kg and over and adult: start with 250 mg 2 times daily; increase to 500 mg 2 times daily after 2 to 4
weeks, then by increments of 500 mg 2 times daily every 2 to 4 weeks if necessary (max. 1.5 g 2 times daily).


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weeks, then by increments of 500 mg 2 times daily every 2 to 4 weeks if necessary (max. 1.5 g 2 times daily).
Children 1 month to 11 years: start with 2 to 3 mg/kg once daily at bedtime or 1 to 1.5 mg/kg 2 times daily for 2
weeks; increase the daily dose by increments of 1 to 2 mg/kg every week, up to 2 to 6 mg/kg once daily if
necessary.
Children 12 years and over and adults: start with 1 mg/kg (max. 60 mg) once daily at bedtime for 2 weeks; increase
the daily dose by increments of 15 to 30 mg every week, up to 3 mg/kg once daily if needed (max. 180 mg daily).
Children 1 month to 11 years: start with 1.5 to 2.5 mg/kg 2 times daily; increase the daily dose by increments of 5
mg/kg every 3 to 4 weeks, up to 2.5 to 5 mg/kg 2 times daily if necessary (max. 7.5 mg/kg 2 times daily or 300 mg


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mg/kg every 3 to 4 weeks, up to 2.5 to 5 mg/kg 2 times daily if necessary (max. 7.5 mg/kg 2 times daily or 300 mg
daily).
Children 12 years and over: start with 75 to 150 mg 2 times daily; increase the daily dose by increments of 25 mg
every 3 to 4 weeks, up to 150 to 200 mg 2 times daily if necessary (max. 300 mg 2 times daily).
Adults: start with 150 to 300 mg once daily or 75 to 150 mg 2 times daily; increase the daily dose by increments of
50 mg every 3 to 4 weeks, up to 200 to 400 mg once daily or 100 to 250 mg 2 times daily if necessary (max. 400 mg
once daily or 300 mg 2 times daily).
Children 2 to 11 years: start with 10 to 15 mg/kg once daily or 5 to 7.5 mg/kg 2 times daily; increase the daily dose


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Children 2 to 11 years: start with 10 to 15 mg/kg once daily or 5 to 7.5 mg/kg 2 times daily; increase the daily dose
by increments of 5 to 10 mg/kg every week, up to 12.5 to 15 mg/kg 2 times daily if necessary (max. 600 mg 2 times
daily).
Children 12 years and over and adults: start with 500 to 600 mg once daily; increase the daily dose by increments of
200 mg every 3 days, up to 500 mg to 1 g 2 times daily if necessary (max. 2.5 g daily).


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The initial follow-up schedule is guided by titration of the prescribed ASM.
Once seizures are controlled for at least 1 month, follow-up can be spaced out to 3 months, then every 6 months if the
patient is stable. Encourage maintaining a seizure diary if possible. At each consultation:
 
References
Assess:
Growth and development in children.
Treatment :
response (seizure frequency) and tolerance (adverse effects),
impact on daily life (e.g. time off school or work).
Adherence to treatment.
Co-morbidities, including associated anxiety or depression.
Adjust the dose of the ASM if necessary. In this case, review patient as needed but in any case within one month
following any change in dose.
Provide treatment until the next consultation or the facility’s dispensing schedule.


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following any change in dose.
Provide treatment until the next consultation or the facility’s dispensing schedule.
Answer questions, discuss problems, and try to ﬁnd solutions with the patient.
Footnotes
(a) The optimal dose of folic acid to prevent MCM is not established. After the ﬁrst trimester, the dose should be reduced (usethe ﬁxed-dose combination 60 mg of elemental iron/400 micrograms folic acid).
1. Fisher RS, Cross JH, French JA, et al. Operational classiﬁcation of seizure types by the International League Against Epilepsy:Position Paper of the ILAE Commission for Classiﬁcation and Terminology. Epilepsia. 2017;58(4):522-530. https://doi.org/10.1111/epi.13670


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2. World Health Organization. Pocket book of primary health care for children and adolescents: guidelines for healthpromotion, disease prevention and management from the newborn period to adolescence. Copenhagen: WHO RegionalOfﬁce for Europe; 2022.https://www.who.int/europe/publications/i/item/9789289057622
3. Fisher RS, Acevedo C, Arzimanoglou A, et al. ILAE Ofﬁcial Report: A practical clinical deﬁnition of epilepsy. Epilepsia.2014;55(4):475-482.https://doi.org/10.1111/epi.12550
4. World Health Organization. mhGAP Intervention Guide for Mental, Neurological and Substance Use Disorders in Non-Specialized Health Settings: Mental Health Gap Action Programme (mhGAP). version 2.0. World Health Organization; 2016. https://www.who.int/publications/i/item/9789241549790


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5. NICE. Epilepsies in children, young people and adults. Published online April 27, 2022.https://www.nice.org.uk/guidance/ng217
6. Piccenna L, O’Dwyer R, Leppik I, et al. Management of epilepsy in older adults: A critical review by the ILAE Task Force onEpilepsy in the elderly. Epilepsia. 2023;64(3):567-585. https://doi.org/10.1111/epi.17426
7. American College of Obstetricians and Gynecologists. Gynecologic management of adolescents and young women withseizure disorders. ACOG Committee Opinion No. 806. Obstet Gynecol 2020;135:e213–20.https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2020/05/gynecologic-management-of-adolescents-and-young-women-with-seizure-disorders


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8. Meador KJ. Effects of Maternal Use of Antiseizure Medications on Child Development. Neurol Clin. 2022 Nov;40(4):755-768.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9589915/


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9. Royal College of Obstetricians and Gynaecologists (UK). Epilepsy in Pregnancy. Published online June 2016.https://www.rcog.org.uk/media/rzldnacf/gtg68_epilepsy.pdf
10.Pennell PB. Use of Antiepileptic Drugs During Pregnancy: Evolving Concepts. Neurotherapeutics. 2016 Oct;13(4):811-820.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5081129/


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Diabetes type 2 in adults
Last update: November 2023
 
Diabetes is a metabolic disorder that leads to hyperglycaemia.
Type 2 diabetes usually occurs in adults and accounts for 90 to 95% of diabetes cases worldwide.
Type 2 diabetes can lead to acute complications, as well as chronic complications that result in serious organ damage
(cardiovascular events; diabetic retinopathy, neuropathy, nephropathy).
Clinical features
Diagnosis
 [1] 
Few or no symptoms; symptoms of hyperglycaemia may be present: polyuria (frequent urination) and polydypsia
(excessive thirst and drinking).
In rare cases, patients may present with severe hyperglycaemia (impaired consciousness, coma or acute
dehydration).
Look for diabetes in the event of:
symptoms of hyperglycaemia;


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dehydration).
Look for diabetes in the event of:
symptoms of hyperglycaemia;
cardiovascular disorders: stroke, myocardial infarction, hypertension;
peripheral neuropathies, foot ulcers, absence of tendon reﬂexes or peripheral pulse.
Diagnosis is made on one of the following results : a [1] [2] 
Tests Symptomatic patient Asymptomatic patient
Fasting blood glucose (a) 1 fasting blood glucose
≥ 7 mmol/litre  (≥ 126 mg/dl)
2 fasting blood glucose
≥ 7 mmol/litre (≥ 126 mg/dl)
Random blood glucose (b) 1 random blood glucose
≥ 11 mmol/litre (≥ 200 mg/dl)
See tablenote  (b)
Post-load blood glucose (c) 1 post-load blood glucose: 
on venous blood
≥ 11 mmol/litre (≥ 200 mg/dl)
2 post-load blood glucose:
on venous blood 
≥ 11 mmol/litre (≥ 200 mg/dl)
or
on capillary blood


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on venous blood
≥ 11 mmol/litre (≥ 200 mg/dl)
2 post-load blood glucose:
on venous blood 
≥ 11 mmol/litre (≥ 200 mg/dl)
or
on capillary blood 
≥ 12.2 mmol/litre (≥ 220 mg/dl)
or
on capillary blood  
≥ 12.2 mmol/litre (≥ 220 mg/dl)
Glycated Hb (HbA1c) (d) 1 HbA1c ≥ 6.5% 2 HbA1c ≥ 6.5%
(a) Fasting blood glucose test: performed on patient that has fasted at least 8 hours. Values are the same for venous andcapillary blood.
(b) Random blood glucose test: performed at any moment of the day. Values are for venous blood only. For asymptomatic patients, it is not recommended to perform 2 random blood glucose tests. If the ﬁrst test is a randomblood glucose, the second test should be a fasting blood glucose.


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(c) Post-load blood glucose test: performed 2 hours after oral ingestion of 75 g glucose (one sachet of 75 g anhydrousglucose powder dissolved in 200 to 300 ml of water, to be drunk within 10 minutes).


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or
Treatment 
Glycaemic targets
Fasting blood glucose ≤ 7 mmol/litre (≤ 126 mg/dl) or HbA1c of 7%.
The closer blood glucose levels remain to these values, the more cardiovascular complications are prevented or
delayed.
Depending on the context (healthcare provision) or patient proﬁle (older patient, history of severe hypoglycaemia or
long-standing poorly controlled diabetes), HbA1c ≤ 8%  is acceptable.
Blood glucose should not fall < 4.5 mmol/litre (or < 80 mg/dl) or HbA1c < 6.5%.
Lifestyle and dietary advice
Pharmacological treatment
First-line treatment metformin PO .
The usual dose is 1 to 2 g daily. For information:
Week 1: 500 mg once daily in the morning at breakfast
Week 2: 500 mg 2 times daily (morning and evening) during meals


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Week 1: 500 mg once daily in the morning at breakfast
Week 2: 500 mg 2 times daily (morning and evening) during meals
Increase in increments of 500 mg per week as long as the drug is well tolerated (max. 2 g daily, i.e. 1 g morning and
evening). If glycaemic control is not acheived, administer metformin in combination with a sulfonylurea. 
Sulfonylurea doses are adjusted in increments to avoid the risk of hypoglycaemia, based on blood glucose results.
The usual dose is 5 mg 2 times daily. For information:
Week 1: 2.5 mg once daily in the morning at breakfast
Week 2: 5 mg once daily in the morning at breakfast
Increase in increments of 2.5 mg weekly until fasting blood glucose reaches target levels (max.15 mg daily).
The usual dose is 40 to 80 mg 2 times daily. For information:


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The usual dose is 40 to 80 mg 2 times daily. For information:
Weeks 1 and 2: 40 mg once daily in the morning at breakfast
Increase in increments of 40 mg every 2 weeks (weeks 3 and 4: 80 mg once daily in the morning at breakfast) until
fasting blood glucose reaches target levels (max. 240 mg daily, i.e. 120 mg morning and evening). 
(d) Glycated haemoglobin (HbA1c): reﬂects average glycaemia over around 3 months.
Perform urine dipstick analysis for ketones if:
fasting blood glucose ≥ 15 mmol/litre (≥ 270 mg/dl) and symptoms of hyperglycemia,
fasting or random blood glucose ≥ 18 mmol/litre (≥ 325 mg/dl) even without symptoms.
Refer the patient if acute complications (such as hyperosmolar hyperglycaemia or ketoacidosis) are present.
 [3] 
 [2] 
 b


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Refer the patient if acute complications (such as hyperosmolar hyperglycaemia or ketoacidosis) are present.
 [3] 
 [2] 
 b
Avoid sugared foods and drinks (but no excessive restriction of carbohydrates). 
High ﬁbre intake; limit animal fats and alcohol.
Physical activity.
Weight control. If BMI ≥ 25, try to reduce weight by 5 to 10%.
Stop smoking.
 c 
In patients under 60, glibenclamide PO: 
In patients over 60, gliclazide PO (immediate release tablet):


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If glycaemic control is not acheived with the combination of metformin + a sulfonylurea, continue metformin but
replace the sulfonylurea with intermediate-acting insulin SC: start with 0.2 IU/kg at bedtime. The dose is adjusted
after measuring fasting blood glucose in the morning. Once blood glucose levels have stabilized, test levels once
weekly then after each consultation. Doses of 1 IU/kg/day or more may be necessary to reach glycaemic targets. If
the necessary dose is over 0.5 IU/kg/day, administer in 2 injections daily.
Adjustment of intermediate-acting insulin dosage based on blood glucose levels
 Example for a man weighing 79 kg:
Start with 16 IU per day (79 kg x 0.2 IU).
On D4, blood glucose is 14.6 mmol/litre. Add 4 IU (daily dose of insulin is 20 IU).


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Start with 16 IU per day (79 kg x 0.2 IU).
On D4, blood glucose is 14.6 mmol/litre. Add 4 IU (daily dose of insulin is 20 IU). 
On D8, blood glucose is 10.4 mmol/litre. Add 2 IU (daily dose of insulin is 22 IU). 
On D12, blood glucose is 6.1 mmol/litre. Glycaemic target is reached. 
Surveillance and monitoring
Laboratory surveillance
Morning blood glucose  Action
< 4 mmol/litre
(< 70 mg/dl)
Treat hypoglycaemia (see Hypoglycaemia, Chapter 1).
Reduce daily dose of insulin by 2 to 4 units.
Maintain new dose for 4 days.
Check blood glucose after 4 days, readjust dose if glycaemic target has not
been not reached.
Check blood glucose again after 4 days and repeat the process until
glycaemic target is reached.
≥ 4 and < 7.2 mmol/litre
(≥ 70 and < 130 mg/dl)
Do not change dose.


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glycaemic target is reached.
≥ 4 and < 7.2 mmol/litre
(≥ 70 and < 130 mg/dl)
Do not change dose.
≥ 7.2 and < 11 mmol/litre
(≥ 130 and < 200 mg/dl)
Increase daily dose of insulin by 2 units.
Check blood glucose after 4 days, readjust dose if glycaemic target has not
been not reached.
Check blood glucose again after 4 days and repeat the process until
glycaemic target is reached.
≥ 11 mmol/litre
(≥ 200 mg/dl)
Increase daily dose of insulin by 4 units.
Check blood glucose after 4 days, readjust dose if glycaemic target has not
been not reached.
Check blood glucose again after 4 days and repeat the process until
glycaemic target is reached.
Perform urine dipstick analysis for ketones according to the criteria deﬁned in
the Diagnosis section.


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glycaemic target is reached.
Perform urine dipstick analysis for ketones according to the criteria deﬁned in
the Diagnosis section. 
Patients on oral hypoglycemic agents: blood glucose test once a month to begin with, then during monitoring visits.
Patients on insulin: fasting blood glucose test during the dose adjustment phase then, if possible, once weekly, once
the insulin dose stabilised. 
HbA1c if available: every 3 months, then every 6 months if well stabilised.


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Clinical monitoring
Patient education
 
References
Other necessary tests according to comorbidities and chronic complications.
Routine consultations: check blood pressure (should remain < 140/80 mmHg) and weight, examine feet.
Consultations once a month for the ﬁrst 6 months, then individualised frequency of consultations depending on the
patient's characteristics (e.g. every 6 months if the diabetes is well controlled).
Annual check-up: check for cardiovascular and neurological complications, evaluate renal function (serum creatinine
and proteinuria dipstick test), examination of teeth and gums.
Management of diabetes complications.
 b
Lifestyle and dietary measures (diet, physical activity, etc.).


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Management of diabetes complications.
 b
Lifestyle and dietary measures (diet, physical activity, etc.).
Patients on sulfonylurea or insulin therapy: signs of hypoglycaemia/hyperglycaemia and management.
Patients on insulin therapy: auto-administration (schedule, injection sites and techniques); storage of insulin.
Patients on insulin therapy or presenting hypoglycaemic episodes : self-monitoring of blood glucose and
adjustment of doses at home using a glucometer.
 [3] 
Patients with sensory neuropathy or peripheral arterial disease: autoexamination of feet; prevention of foot lesions.
Footnotes
(a) Even in symptomatic patients, it is preferable to perform a second blood glucose test to conﬁrm the result.


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Footnotes
(a) Even in symptomatic patients, it is preferable to perform a second blood glucose test to conﬁrm the result.
(b) These measures concern all patients regardless of medication prescribed. They can be sufﬁcient alone to normalize bloodglucose levels in certain patients.
(c) If metformin is contraindicated or not tolerated, replace with a sulfonylurea.
1. World Health Organization. Classiﬁcation of Diabetes Mellitus. World Health Organization; 2019 [Accessed October 19, 2023].https://iris.who.int/handle/10665/325182
2. HEARTS D: diagnosis and management of type 2 diabetes [Accessed October 19, 2023].https://www.who.int/publications-detail-redirect/who-ucn-ncd-20.1


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3. Type 2 diabetes in adults: management | Guidance | NICE. Published December 2, 2015 [Accessed October 19, 2023].https://www.nice.org.uk/guidance/ng28


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Essential hypertension in adults
Hypertension (or high blood pressure - HBP) is deﬁned as elevated blood pressure (BP) at rest that persists over time
i.e. measured 3 times during 3 separate consultations over a period of three months.
Essential hypertension is deﬁned as HBP of undetermined cause (the large majority of cases). The global overall prevalence of HBP in adults aged 25 and over is around 40%. Serious complications of HBP can be acute (hypertensive encephalopathy, left-sided heart failure, acute renal failure)
or delayed i.e. occur after a long period during which HBP has not been controlled (stroke, ischaemic heart disease,
peripheral arterial disease, chronic renal impairment). For pregnancy-induced hypertension, see Essential obstetric and newborn care, MSF.


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peripheral arterial disease, chronic renal impairment). For pregnancy-induced hypertension, see Essential obstetric and newborn care, MSF.
Clinical features
 
 
SBP ≥ 180 and/or DBP ≥ 110 and some symptoms (moderate headaches, epistaxis, dizziness, tinnitus, eye
ﬂoaters) but no signs of end-organ damage;
SBP ≥ 180 and/or DBP ≥ 110 and signs of end-organ damage:
Paraclinical investigations
 [1]
HBP thresholds:
HBP classiﬁcation
Blood pressure (BP) in mmHg
Systolic (SBP) Diastolic (DBP)
Mild 140 or over 90 or over
Moderate 160 or over 100 or over
Severe 180 or over 110 or over
Severe HBP is deﬁned more by the presence of serious end-organ damage than the blood pressure reading:
Uncomplicated hypertensive crisis:
Hypertensive emergency:


