© 2008 Federal Ministry of Health, Nigeria ACKNOWLEDGEMENTS

The first edition of the Nigerian Standard Treatment Guidelines is a product of the support, All rights reserved. No part of this publication may be reproduced, stored in retrieval recommendations and contributions of the following: system or transmitted in any form or by any means, electronic, mechanical, Federal Ministry Of Health photocopying, recording and/or otherwise, without prior written permission of the Prof. Federal Ministry of Health, Nigeria. Prof. Adenike Grange Mr. R.K. Omotayo mni Mr. J.E. B. Adagadzu

World Health Organization European Commission For all enquiries or comments, write to the publishers: Dr Peter Eriki For funding the programme Dr Mohammed Belhocine Dr. Olaokun Soyinka Dr Ogori Taylor The Honourable Minister, Federal Ministry of Health, Federal Secretariat Complex, Expert Committee Members International Network for Rational Use of Shehu Shagari Way, Prof. Abdu-Aguye, I. Drugs (INRUD) - Nigerian Core Group P.M.B. 080 Garki, Prof. Adelowo, F. Prof. Abdu-Aguye, I. . Prof. Bayeroju-Agbeja, A. Prof. Isah, A.O. Prof. Mabadeje, A.F.B. Prof. Borodo, M. Nigeria Dr. Abosede, O.A. Prof. Danbauchi, S.S Dr. Aina, B.A. Prof. Gureje, O. Dr. Akinyede, A. Printed in Nigeria. Prof. Idoko, J. Dr. Akoria, O.A. Prof. Isah, A.O. Dr. Asalu, A.F. Dr. Akinlekan, J. Prof. Mabadeje, A.F.B. Mr. Obiaga, G. Prof. Mbonu, O. Dr. Obodo, J.O. Prof. Ogisi, F. Mr. Okoko, O.O. Prof. Ohwovoriole, A. Dr. Oparah, A. Prof. Olumide, M. Dr. Olayemi, S.O. Dr. Oreagba, I. Prof. Ojogwu, L.I. Mr. Otahabru, B. Prof. Okonofua, F. Dr. Mero-Asagba, G. Prof. Oruamabo, R. Dr. Taylor, O. Prof. Oviawe, O Dr. Ameh, E. Editorial Team Prof. Abdu-Aguye, I. Dr. Abosede, Y. Prof. Isah, A.O. Dr. Akoria, O. Dr. Akoria, O.A. Dr. Irhibhogbe, P. Dr. Mero-Asagba, G. Dr. Kehinde, M. Mr. Obiaga, G.O. Dr. Mero-Asagba, G. Mrs. Okpeseyi, M.I. Mr. Fagbemiro, L.O. Dr. Okpapi, J.U. Mr. Otahabru, B. Dr. Savage, S. Dr. Olaokun Soyinka Dr. Taylor, O. Dr. Taylor, O. Mr. Obiaga, G.O. FOREWORD

I am indeed very pleased to write the foreword to this maiden edition of the Standard Treatment Guidelines (STG) for the Nigerian health care system. I am aware that the process of its production began in 2005 involving contributions and recommendations of various experts and stakeholders in the health care sector.

The STG is an important tool for the attainment of comprehensive and effective health care delivery services thereby achieving the goals of the National Drug Policy, which inter alia are: the availability of safe, efficacious and affordable medicines to satisfy the healthcare needs of the majority of the population and ensure the rational use of drugs. The fulfillment of the above mentioned goals is part of the strategic thrust of the Health Sector Reform Programme aimed at the reduction of disease burden and the improvement of access to quality health services. It is expected that the STG will become a major reference document for all health workers both in the public and private sectors.

It is instructive to note that the development of the STG followed due process with wide consultations and meetings involving various stakeholders and interest groups. The document that has come out of this process is a reflection of the quality of the inputs that went into its development. In my opinion, this maiden edition of the STG has been produced and serialized in such a way as to assist health care providers especially doctors in the effective discharge of their duties as prescribers. It will also ensure discipline as only those medicines recommended will be prescribed for patients within a given health facility.

I commend all those who worked tirelessly towards the completion of this maiden edition STG. Special mention and gratitude must go to the World Health Organization (WHO) for sponsoring and providing sustained technical support to the committee. Without this support, this STG would not have seen the light of the day.

Finally, let me quickly add that this STG must be widely circulated and disseminated. Everything possible must be done to ensure that practitioners maximize the benefit of such a useful document. If it has worked in other parts of the world, it should also work in Nigeria. It must also be subjected to regular reviews in view of the dynamic nature of health care management.

Dr. Hassan Muhammed Lawal, CON Supervising Minister of Health

PREFACE Standard Treatment Guidelines for Nigeria 2008

This first edition of Standard Treatment Guidelines (STG) for the Nigerian health TABLE OF CONTENTS practitioner is coming relatively later than those of many other countries. It is indeed a welcome development. SECTION A The standard of medical practice and the wage bill of health services are usually Chapter 1: Alimentary Tract remarkably improved by health personnel putting to use STG. This among other Gastrointestinal Disorders ...... 1 Chapter 4: Central Nervous System benefits can only lead to improved health of the community. Amoebiasis ...... 1 Non-psychiatric Disorders ...... 34 Bacillary Dysentry ...... 1 Dizziness ...... 34 In Nigeria our health indices are among the worst in the world. Our country Nigeria ...... 2 Headaches...... 35 Constipation ...... 2 Meningitis ...... 36 does not lack the manpower or the necessary infrastructure to turn things around. What Diarrhoea (acute) ...... 3 Migraine ...... 37 appears to be lacking is the organization of health services required to put both to Gastritis ...... 4 Parkinsonism...... 38 optimal use. Efforts such as the actualization of our own national STG and the various Giardiasis ...... 4 Seizures/epilepsies ...... 39 health reforms currently in progress will definitely improve our situation. Haemorrhoids ...... 5 Stroke ...... 41 Pancreatitis ...... 5 Syncope ...... 42 ...... 6 The Unconscious Patient ...... 42 It is therefore my pleasure and privilege to write the preface to this maiden edition of Upper Gastrointestinal Bleedin ...... 6 Psychiatric Disorders ...... 43 the STG. This is the outcome of a long journey that started several years ago. The Hepatic And Biliary Disorders ...... 7 Alcoholism (alcohol Dependence) ...... 43 previous chairmen of the National Formulary and Essential Drugs Review Committees Hepatitis...... 7 Anxiety Disorder ...... 44 made efforts to start the project but were unsuccessful due to lack of funds. Hepatic Encephalopathy ...... 8 Bipolar Disorders ...... 44 Jaundice ...... 9 Delirium...... 45 Liver Cirrhosis ...... 9 Depression ...... 46 The current committee had the luck of being assisted by the country office of the World Nutritional Disorders ...... 10 Insomnia...... 47 Health Organization (WHO) in not only this endeavor but in the preparation and Kwashiokor And Marasmus ...... 10 Panic Disorder...... 47 printing of the last edition of the Nigerian Essential Medicines List. The desk officer, Micronutrient Deficiencies ...... 10 Schizophrenia...... 48 Obesity...... 11 Dr Ogori Taylor showed great commitment to the project and the country owes a debt Chapter 5: Dental And Oral Disorders of gratitude to WHO. Chapter 2: Blood And Blood-forming Organs Acute Necrotizing Ulcerative Gingivitis...... 49 Anaemias ...... 13 Acute Periapical ...... 49 In preparing this document every effort was made to ensure that the stakeholders own Blood Transfusion ...... 14 Alveolar Osteitis ...... 50 Haemostasis And Bleeding Disorders ...... 16 Cellulitis...... 50 the project so that it is not seen as an imposition. Accordingly, the major contributions Leukaemias ...... 16 Dental Caries ...... 50 came from various practitioners and their associations as well as from many Lymphomas ...... 19 Gingivitis ...... 51 practitioners whose input were judged crucial to the success of the project. We also Sickle Cell Disease...... 20 Neoplasms Of The Oral Cavity ...... 51 adopted the acceptable practices in the field that were in use by special health projects Oral Thrush (candidiasis) ...... 51 Chapter 3: Cardiovascular System Pericoronitis ...... 52 such as HIV/AIDS, Malaria, TB/Leprosy programmes etc. The academia was also Pectoris...... 23 Periodontitis...... 52 involved. There were several fora where the contributions were discussed openly with Cardiac ...... 23 Pulpitis ...... 53 the stakeholders and consensus arrived at. Congenital Heart Disease ...... 24 Salivary Gland Diseases ...... 54 Deep Venous Thrombosis ...... 24 Temporo-mandibular Joint Disorders...... 54 ...... 25 It is my hope therefore that this document will be widely used by Nigerian health Hyperlipidaemia ...... 26 Chapter 6: Dermatology practitioners. I salute the contributors and those that helped in one way or the other. Hypertension ...... 26 Bacterial Infections ...... 56 The committee of course accepts responsibility for any lapses but also hopes that these Infective ...... 27 Cellulitis ...... 56 ...... 29 would be brought to our attention for correction in subsequent editions. Furunculosis (boils) ...... 56 ...... 30 Impetigo Contagiosa ...... 57 Paediatric Cardiac Disorders...... 30 Dermatitis And Eczema ...... 58 ...... 30 Atopic Dermatitis (atopic Eczema)...... 58 Pulmonary Embolism ...... 31 Contact Dermatitis ...... 59 Pulmonary Oedema ...... 32 Professor Ibrahim Abdu-Aguye,MBBS; FMCP;SFIAM; FIICA;D. Sc (Hon) Exfoliative Dermatitis (erythroderma)...... 59 ...... 32 Chairman, National Formulary and Essential Drugs Review Committee. Parasitic Dermatoses ...... 60 Rheumatic Heart Disease ...... 33 Cutaneous Larva Migrans (creeping Eruption)...... 61

i Standard Treatment Guidelines for Nigeria 2008 Standard Treatment Guidelines for Nigeria 2008

Guinea Worm Disease (dracunculiasis)...... 61 The Red Eye ...... 104 Chapter 13: Obstetrics And Gynaecology Myiasis ...... 62 Trachoma...... 105 Abortion ...... 149 Onchocerciasis (river Blindness) ...... 62 Xerophthalmia ...... 105 Antenatal Care ...... 150 Pediculosis (lice) ...... 63 Anaemia In Pregnancy ...... 152 Section C Scabies ...... 64 Cancer Of The Cervix ...... 153 Papulosquamous Disorders ...... 65 Chapter 10: Genito-urinary System Cardiac Disease In Pregnancy ...... 154 Chapter 18: Emergencies Lichen Planus ...... 65 Nephrology ...... 106 Eclampsia ...... 156 Acute Left Ventricular Failure ...... 195 Pityriasis Rosea ...... 66 Acute Renal Failure...... 106 Ectopic Pregnancy ...... 158 ...... 196 Psoriasis ...... 67 Chronic Kidney Disease ...... 106 Hyperemesis Gravidarum ...... 159 Drowning And Near-drowning ...... 197 Superficial Fungal Infections ...... 69 Nephrotic Syndrome ...... 107 Immunization Schedules ...... 160 Electrolyte Abnormalities ...... 198 Dermatophyte Infections (tinea) ...... 69 Sexually Transmitted Infections ...... 108 Jaundice In Pregnancy ...... 160 Hypertensive Emergencies ...... 200 Pityriasis Versicolor (tinea Versicolor ) ...... 70 Bacterial Vaginosis ...... 108 Pelvic Inflammatory Disease ...... 162 Hypoglycemia ...... 200 Viral Infections ...... 71 (ulcus Molle, Soft Chancre) ...... 109 Rape ...... 163 Myxoedema Coma ...... 201 Herpes Zoster ...... 71 Chlamydial Infection ...... 110 Thyroid Storm (thyrotoxic Crisis) ...... 201 Molluscum Contagiosum ...... 72 Gonorrhoea ...... 111 Chapter 14: Respiratory System Poisoning ...... 202 Varicella (chickenpox) ...... 72 (donovanosis; Acute Epiglottitis ...... 165 Viral Warts (verrucae) ...... 73 Granuloma Venereum)...... 113 Acute Laryngo-tracheo-bronchitis (croup) ...... 165 Chapter 19: Therapeutics Miscellaneous Disorders ...... 74 Lymphogranuloma Venereum ...... 114 Acute Rhinitis (common Cold) ...... 166 Prescription Writing ...... 206 Acne Vulgaris (pimples) ...... 74 Syphilis ...... 115 Bronchial Asthma ...... 166 Adverse Drug Reactions ...... 208 Pruritus ...... 76 Trichomoniasis ...... 116 Bronchiectasis ...... 167 Urticaria And Angioedema ...... 78 Vulvo-vaginal Candidiasis ...... 117 Chest Pain ...... 168 Chapter 20: Notifiable Diseases ...... 209 Vitiligo ...... 80 Urology ...... 118 Chronic Obstructive Airways Disease(coad) ....168 Benign Prostatic Hyperplasia ...... 118 Cough ...... 169 Chapter .7: Ear, Nose And Throat Carcinoma Of The Prostate ...... 118 Dyspnoea ...... 170 Acute ...... 81 Erectile Dysfunction (impotence) ...... 119 Lung Abscess ...... 170 APPENDICES Adenoid Disease ...... 82 Male Infertility ...... 120 ...... 171 Chronic Otitis Media ...... 82 Posterior Urethral Valves ...... 120 Pulmonary Embolism ...... 172 Epistaxis ...... 83 Priapism ...... 121 Appendix I Foreign Bodies In The Airways ...... 83 Prostatitis ...... 121 WHO clinical staging of HIV for infants and Foreign Bodies In The Ear ...... 84 Scrotal Masses ...... 122 Section B children with established HIV infection...... 211 Foreign Bodies In The Nose And Rhinoliths...... 84 Torsion Of The Testis ...... 122 Chapter 15: Injuries And Acute Trauma Mastoiditis...... 84 Urethral Stricture ...... 123 Bites And Stings ...... 173 Appendix II: Nasal Allergy ...... 85 Urinary Schistosomiasis ...... 123 Burns ...... 175 WHO new antenatal care model classifying Otitis Externa ...... 86 Urinary Tract Calculi ...... 124 Disaster Plan ...... 176 form 2001...... 212 Peritonsillar Abscess (quinsy) ...... 86 Head Injury ...... 177 Pharyngitis (sore Throat) ...... 86 Chapter 11: Infectious Diseases / Multiple Injuries ...... 180 Appendix III Sinusitis ...... 87 infestations Calculation of dosage requirements in Tonsillitis ...... 88 Fevers: Management Approach ...... 125 Chapter 16: Surgical Care And Associated children...... 214 Tracheostomy ...... 89 Food Poisoning ...... 125 Disorders Wax In The Ear ...... 89 Helminthiasis ...... 127 Acute Abdomen ...... 182 Human Immunodeficiency Virus Infection ...... 129 Appendix IV: Chapter 8: Endocrine System Antimicrobial Prophylaxis In Surgery ...... 184 Malaria ...... 135 Medicines with teratogenic potential...... 215 Diabetes Mellitus ...... 90 Intestinal Obstruction ...... 184 Rabies...... 137 Hyperthyroidism (thyrotoxicosis) ...... 97 Preoperative Evaluation and Tetanus ...... 138 Hypothyroidism (myxoedema) ...... 99 Postoperative Care ...... 186 Appendix V: Trypanosomiasis (sleeping Sickness) ...... 140 Use Of Blood Transfusion In Surgery ...... 189 Medicines that could cause harm when Tuberculosis ...... 140 administered to breastfeeding mothers...... 215 Chapter 9: Eye Disorders ...... 142 Chapter 17: Paediatric Perspectives Acute Anterior Uveitis (iritis) ...... 100 Measles (rubeola) ...... 190 Appendix VI: Acute Keratitis ...... 100 Chapter 12: Musculoskeletal System Poliomyelitis ...... 191 NAFDAC Adverse Drug Reaction Reporting Allergic ...... 101 Back Pain ...... 143 Vitamin A Deficiency ...... 193 Eye Injuries ...... 101 Gout ...... 144 form ...... 217 Foreign Bodies In The Eye ...... 102 Osteoarthritis ...... 145 Infective Conjunctivitis ...... 103 Rheumatoid Arthritis ...... 146 Ophthalmia Neonatorum ...... 103 Septic Arthritis ...... 147 Scleritis / Episcelitis ...... 104 Systemic Lupus Erythematosus ...... 148 Stye (hordeolum) ...... 104

ii iii Chapter 3: Cardiovascular System Standard Treatment Guidelines for Nigeria 2008

Echocardiography Chest: with or without crepitations - Warfarin: monitor INR 2 - 2.5 Serum proteins (total and differential) Electrocardiography Abdomen: hepatomegaly - Important in atrial Treatment objectives Venography(pelvic or calf veins) Differential diagnoses Supportive measures Lower lipid levels Treatment objectives Bronchial asthma Pacemakers for arrythmias Prevent complications Lyse the clot Chronic obstructive airways disease (COAD) Ventricularassist devices Treat complications Prevent clot from being dislodged Renal failure Notable adverse drug reactions Non-drug treatment Relieve inflammation Liver failure Digoxin: arrhythmias Stop smoking Non-drug treatment Complications Potassium-sparing drugs: hyperkalaemia Reduce weight Avoid stasis Thrombo-embolic phenomena: stroke, pulmonary ACEIs: hypotension, hyperkalaemia Exercise moderately and regularly Drug treatment embolism Do not combine potassium supplements with potassium- Water soluble fibre: oat, bran AchieveAPTT of 1.5 to 2.5 of control: Pre-renal azotaemia sparing drugs Drug treatment Heparin 5000 - 10,000 units by intravenous injection Arrhythmias Precautions Fluvastatin followed by subcutaneous injection of 15,000 units every Investigations The dose and infusion rate for dopamine are critical - Initially 20 mg orally once daily at bedtime 12 hours or intravenous infusion at 15 - 25 units/kg/hour, Full Blood Count with differentials - Low dose infusion rates will cause excessive - Adjust dose at 4-week intervals as needed and tolerated with close laboratory monitoring Urea, Electrolytes and Creatinine hypotension - Maintenance 20 - 40 mg orally once daily in the Warfarin 1-5mgorally daily for6-12weeks Fasting blood glucose - Higher infusion rates will elevate the blood pressure evening Notable adverse drug reactions Urine micro-analysis The use ofβ blockers, atrial natriuretic peptide - A 40 mg daily dose may be split and taken every 12 Bleeding from heparin, warfarin Chest radiograph analogues and endothelin receptor antagonists should be hours Osteoporosis (heparin) Electrocardiography reserved for specialist care Notable adverse drug reactions, caution and Prevention Echocardiography Prevention contraindications Low molecular weight heparin 5000 units Treatment objectives Adequate treatment of hypertension and diabetes Caution in patients with history of liver disease, high subcutaneously every 12 hours Relieve symptoms mellitus alcohol intake Early mobilization Enhance quality of life Good sanitation and personal hygiene (to prevent Hypothyroidism should be adequately managed before Prevent complications rheumatic fever) starting treatment with a statin Prolong life Liver function tests mandatory before and within 1 - 3 Non-drug treatment months of starting treatment; thereafter at intervals of 6 HEART FAILURE Bed rest months for 1 year Introduction Low salt diet HYPERLIPIDAEMIA Statins may cause reversible myositis, headache, A clinical state (syndrome) in which the heart is unable Exercise (within limits of tolerance) Introduction diarrhoea, nausea, vomiting, constipation, flatulence, to generate enough cardiac output to meet up with the Drug treatment Aclinical syndrome in which there are high lipid levels: abdominal pain; insomnia metabolic demands of the body Digoxin cholesterol, or its fractions, or triglyceridaemia Prevention The commonest cause in Nigeria is hypertension - 125 - 250 micrograms daily (the elderly may require Can be primary (hereditary) or secondary - as a result of Dietary manipulation Other causes include dilated and 62.5 - 125 micrograms daily) other diseases Early identification of individuals at risk rheumatic heart disease Diuretics Incidence in Nigeria is thought to be low but recent Cardiac failure can be classified as: - Furosemide 40 - 80 mg intravenously or orally studies show increasing incidence in association with Left or right-sided Or: diabetes mellitus and hypertension Congestive - Bendroflumethiazide 5 mg orally daily Amajor risk factor for heart disease HYPERTENSION Acute Or: Clinical features Introduction Chronic - Spironolactone 25 - 100 mg once, every 8 - 12 hours Patients present with complications of hypertension, A persistent elevation of the blood pressure above - Chronic cardiac failure is the commonest syndrome daily ischaemic heart disease or the cause of secondary normal values (taken three times on at least two different encountered in our setting Potassium supplements hyperlipideaemia occasions with intervals of at least 24 hours) Clinical features - Potassium chloride 600 mg orally once, every 8 - 12 Signs include xanthomata, xanthelasmata, and corneal Blood pressure³ 140/90 mmHg irrespective of age is Difficulty with breathing on exertion hours daily depending on the serum levels of potassium arcus regarded as hypertension Paroxysmal nocturnal dyspnoea Vasodilators Differential diagnoses The commonest non-communicable disease in Nigeria Orthopnoea - Angiotensin converting enzyme inhibitors (ACEIs) Primary hyperlipidaemia The commonest cause of cardiac failure and stroke Cough productive of frothy sputum Captopril 6.25 - 25 mg every 12 hours Secondary hyperlipidaemia: diabetes mellitus, Hypertension may be: Leg swelling Or: nephrotic syndrome Diastolic and systolic Abdominal swelling Lisinopril 2.5 - 20 mg daily Complications Diastolic alone The prominence of particular symptoms will depend on Venodilators Ischaemic heart disease Isolated systolic which side is affected - Nitrates Peripheral vascular disease Clinical features Signs include: Glyceryl trinitrate 0.3-1mgsublingually and repeated as Stroke, hypertension Largely is asymptomatic until complicated (”silent Oedema required Investigations killer”) (about 100 beats per minute) Ionotropes Urea, Electrolytes and Creatinine Non-specific symptoms: headache, dizziness, Raised jugular venous pressure - Dopamine 2 - 5 microgram/kg/minute by intravenous Fasting blood glucose palpitations etc Displaced apex infusion Lipid profile Other symptoms and signs depending on the target S3 or S4 or both ( With or without murmurs) Anticoagulants Urine proteins organs affected e.g. cardiac or renal failure, stroke etc

25 26 Chapter 3: Cardiovascular System Standard Treatment Guidelines for Nigeria 2008

Differential diagnoses Or: The sub-acute form usually occurs on damaged valves Following bacteriological confirmation institute White coat hypertension Amlodipine 2.5 - 10 mg orally once daily (e.g. rheumatic heart disease, congenital heart disease), appropriate antimicrobial therapy Anxiety/fright/stress Angiotensin converting enzyme inhibitors: shunts, and atherosclerotic lesions Staphylococci: Complications Captopril 6.25 - 50 mg orally once or every 8 - 12 hours Causative organisms include staphylococci, Flucloxacillin Heart: Or: streptococci enterococci; , , - 250 mg - 2 g intravenously every 6 hours for4-6 - Heart failure, ischaemic heart disease Lisinopril 2.5 - 20 mg orally once daily , eikenella, and species weeks Brain: Angiotensin receptor blockers: ('HACEK' organisms) Candida: - Stroke (ischaemic, hemorrhagic) Losartan 50 - 100 mg orally daily Clinical features Systemic antifungals Eye: Other vasodilators: Acute: Notable adverse drug reactions - Hypertensive retinopathy Hydralazine 25 - 100 mg orally once daily or every 12 High fever with rigors : rashes, anaphylaxis Kidney: hours Delirium : nephropathy - Renal failure Or: Shock Prevention Large arteries: Prazosin 0.5-1mgorally daily Development of new murmurs Prophylactic antibiotics for patients at risk who are - Aortic aneurysm Centrally acting drugs: Severe cardiac failure undergoing: Investigations Alpha methyldopa 250 - 500 mg orally twice, three or may form in many parts of the body (e.g. 1. Dental procedures Full Blood Count four times daily brain) Under local or no anaesthesia, for those who have NOT Urinalysis; urine microscopy Fixed combinations: Subacute: had endocarditis, and have NOT received more than a Urea, Electrolytes and Creatinine Reserpine plus dihydroergocristine plus clopamide Low-grade fever single dose of a penicillin in the last one month: Uric acid 0.25/0.5/5 mg one-two tablets orally daily Signs of carditis Amoxicillin Fasting blood glucose Or: Finger clubbing Adult: 3 g orally 1 hour before procedure Lipid profile Lisinopril plus hydrochlorothiazide 20/12.5 mg daily Arthralgia Child under 5 years: 750 mg orally 1 hour before Chest radiograph Hypertensive emergencies Splenonegaly procedure; 5- 10 years: 1.5 g Electrocardiography Treatment should be done by the experts Osler's nodules For penicillin-allergic patients or patients who have Echocardiography (not in all cases) Involves the administration of antihypertensives by the Janeway lesions received more than a single dose of a penicillin in the Abdominal ultrasound parenteral route (usually intravenous hydralazine or Roth spots previous one month: Renal angiography (not in all cases) sodium nitoprusside) Differential diagnoses Azithromycin Treatment objectives Supportive measures Myocarditis Adult: 500 mg orally one hour before procedure Educate patient about disease and need for treatment Patient/care giver education Rheumatic heart disease Child under 5 years: 200 mg orally; 5 - 10 years: 300 mg adherence Notable adverse drug reactions, caution and Complications Patients who have had endocarditis: Reduce blood pressure to acceptable levels contraindications Cardiac failure - Amoxicillin plus gentamicin intravenously as for Prevent complications (primary, secondary, tertiary) All antihypertensive drugs may themselves cause Destruction of heart valves procedures under general anaesthesia (see below) Rehabilitate hypotension Systemic embolism (could be infective) Dental procedures under general anaesthesia, and no Non-drug treatment (lifestyle modification) Angiotensin converting enzyme inhibitors, angiotensin Investigations special risk: Low salt diet receptor blockers: angioedema; cough withACEIs Full Blood Count and differentials; ESR Amoxicillin Achieve/maintain ideal body weight (BMI 18.5 - 24.9 Alpha methyldopa, thiazides (and potentially other anti- Urinalysis; urine microscopy Adult: 1 g intravenously at induction of anaesthesia; 500 kg/m2 ) hypertensive drugs): erectile dysfunction Blood cultures X 3 (the yield is higher at the time of mg orally 6 hours later Stop smoking SLE-like syndrome: hydralazine pyrexia) Child under 5 years: a quarter of adult dose; 5 - 10 years: Reduce alcohol intake Do not useβ blockers in asthmatics Echocardiography half adult dose Regular moderate exercise Prevention Treatment objectives Or: Reduce polysaturated fatty acid intake Weight reduction Stop the infection Adult: 3 g orally 4 hours before induction, then 3 g orally Drug treatment Exercise moderately and regularly Treat cardiac failure as soon as possible after the procedure Diuretics: Public education Prevent coagulation disorders Child under 5 years: a quarter of adult dose; 5 - 10 years: Thiazides Individual approach Non-drug treatment half adult dose - Bendroflumethiazide 2.5 - 10 mg orally daily Population approach Bed rest Special risk, e.g. previous , or Or: Advocacy for the positive lifestyle change Low salt diet patients with prosthetic valves: - Hydrochlorothiazide 12.5 - 50 mg orally daily Drug treatment Amoxicillin plus gentamicin intravenously Or: Initiate therapy with: Adult: 1 g amoxicillin plus 120 mg gentamicin at - Hydrochlorothiazide/amiloride 25/2.5 mg daily Benzylpenicillin 7.2 g daily by slow intravenous induction Loop diuretics INFECTIVE ENDOCARDITIS injection or intravenous infusion in 6 divided doses for 4 - - Then oral amoxicillin 500 mg 6 hours after procedure - Furosemide 40 - 80 mg orally daily Introduction 6 weeks Child under 5 years: a quarter of adult dose of amoxicillin ß-blockers: Amicrobial infection of the and the valves - May be increased up to 14.4 g daily if necessary (e.g. in plus 2 mg/kg gentamicin intravenously at induction Propranolol 40 - 80 mg orally every 8 - 12 hours of the heart endocarditis) 5 - 10 years: half adult dose for amoxicillin; 2 mg/kg Or: May be acute or sub-acute Plus: gentamicin Atenolol 25 - 100 mg orally daily Some acute cases occur in normal valves or may be part Gentamicin 60 - 80 mg intravenously or intramuscularly Patients who are penicillin-allergic or have received more Calcium channel antagonists: of systemic illness every 8 hours for 2 weeks than a single dose of a penicillin in the last one month: Nifedipine retard 20 - 40 mg orally once or twice daily Vancomycin

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