THE REPUBLIC OF UGANDA MINISTRY OF HEALTH UGANDA CLINICAL GUIDELINES 2016 National Guidelines for Management of Common Conditions Published by the Ministry of Health Uganda First edition: January 2003 (reprint: July 2004, May 2005) Revised: January 2010, November 2012, December 2016 Any part of these guidelines may be reproduced in any form without the prior permission of the publisher, provided that this is not for profit and that due acknowledgement is given. Any reproduction for profit must be given prior permission from the Ministry of Health. Copies may be obtained from the: Pharmacy Department, Ministry of Health Plot 6 Lourdel Road, P.O.Box 7272 Kampala, Uganda Tel: +256-417-771330 Email: [email protected] Website: www.health.go.ug Disclaimer Every effort has been made to ensure that the information in this book is accurate, complete, and conforms to the current therapeutic practice. However, the publisher, editor, and contributors cannot be held responsible for any errors, omissions, individual patient responses to recommended therapies, or other consequences that may arise from its use. Contents Foreword ......................................................1 Preface.........................................................3 Acknowledgements ...........................................5 Abbreviations ................................................16 Introduction to Uganda Clinical Guidelines 2016 ..........29 1. Emergencies and Trauma . 51 1.1 Common Emergencies...............................51 1.1.1 Anaphylactic Shock ..............................51 1.1.2 Hypovolaemic Shock.............................53 1.1.2.1 Hypovolaemic Shock in Children...........56 1.1.3 Dehydration ......................................58 1.1.3.1 Dehydration in Children under 5 years.....58 1.1.3.2 Dehydration in Older Children and Adults.......................................63 1.1.4 Fluids and Electrolytes Imbalances .............66 1.1.4.1 IV Fluids in Children........................69 1.1.5 Febrile Convulsions ..............................74 1.1.6 Hypoglycaemia ...................................75 1.2 Trauma and Injuries..................................78 1.2.1 Bites and Stings ..................................78 1.2.1.1 Snakebites...................................79 1.2.1.2 Insect Bites & Stings........................81 1.2.1.3 Animal and Human Bites ...................83 1.2.1.4 Rabies Post Exposure Prophylaxis .........84 1.2.2 Fractures ........................................ 90 1.2.3 Burns .............................................92 1.2.4 Wounds...........................................99 1.2.5 Head Injuries...................................102 1.2.6 Sexual Assault/Rape........................... 107 UGANDA CLINICAL GUIDELINES 2016 iii Contents 1.3 Poisoning ............................................112 1.3.1 General Management of Poisoning . .112 1.3.1.1 Supportive Treatment in Poisoning .......113 1.3.1.2 Removal and Elimination of Ingested Poison ................................115 1.3.2 Acute Organophosphate Poisoning.............117 1.3.3 Paraffin and Other Petroleum Products Poisoning ..........................................119 1.3.4 Acetylsalicylic Acid (Aspirin) Poisoning......120 1.3.5 Paracetamol Poisoning .........................121 1.3.6 Iron Poisoning.................................. 123 1.3.7 Carbon Monoxide Poisoning................... 124 1.3.8 Barbiturate Poisoning.......................... 125 1.3.9 Opioid Poisoning............................... 126 1.3.10 Warfarin Poisoning ........................... 126 1.3.11 Methyl Alcohol (Methanol) Poisoning ....... 127 1.3.12 Alcohol (Ethanol) Poisoning ................. 128 1.3.12.1 Acute Alcohol Poisoning................. 128 1.3.12.2 Chronic Alcohol Poisoning.............. 130 1.3.13 Food Poisoning................................ 132 2. Infectious Diseases ..................................... 134 2.1 Bacterial Infections . 134 2.1.1 Anthrax......................................... 134 2.1.2 Brucellosis ..................................... 136 2.1.3 Diphtheria...................................... 138 2.1.4 Leprosy.........................................140 2.1.5 Meningitis...................................... 143 2.1.5.1 Neonatal Meningitis . 147 2.1.5.2 Cryptococcal Meningitis ................. 148 2.1.5.3 TB Meningitis............................. 148 2.1.6 Plague .......................................... 149 2.1.7 Septicaemia .....................................151 2.1.7.1 Neonatal Septicaemia..................... 153 iv UGANDA CLINICAL GUIDELINES 2016 Contents 2.1.8 Tetanus......................................... 154 2.1.8.1 Neonatal Tetanus ......................... 157 2.1.9 Typhoid Fever (Enteric Fever) ................ 158 2.1.10 Typhus Fever ................................. 160 2.2 Fungal Infections....................................161 2.2.1 Candidiasis......................................161 2.3 Viral Infections . 163 2.3.1 Avian Influenza ................................ 163 2.3.2 Chickenpox .................................... 166 2.3.3 Measles ........................................ 167 2.3.4 Poliomyelitis . 169 2.3.5 Rabies ...........................................171 2.3.6 Viral Haemorrhagic Fevers.................... 172 2.3.6.1 Ebola and Marburg ....................... 172 2.3.6.2 Yellow Fever ...............................175 2.4 Helminthes Parasites .............................. 177 2.4.1 Intestinal Worms .............................. 177 2.4.1.1 Taeniasis (Tapeworm).................... 179 2.4.2 Echinococcosis (Hydatid Disease).............181 2.4.3 Dracunculiasis (Guinea Worm) . 182 2.4.4 Lymphatic Filariasis........................... 184 2.4.5 Onchocerciasis (River Blindness)............. 185 2.4.6 Schistosomiasis (Bilharziasis) ................ 187 2.5 Protozoal Parasites ................................ 189 2.5.1 Leishmaniasis.................................. 189 2.5.2 Malaria..........................................191 2.5.2.1 Clinical Features of Malaria...............191 2.5.2.2 Investigations for Malaria................ 194 2.5.2.3 Management of Malaria.................. 195 2.5.2.4 Management of Complications of Severe Malaria ................................201 2.5.2.5 Management of RDT/Blood Smear Negative Patients .............................205 2.5.2.6 Malaria Prophylaxis ......................207 UGANDA CLINICAL GUIDELINES 2016 v Contents 2.5.2.7 Malaria Prevention and Control .........208 2.5.3 Human African Trypanosomiasis (Sleeping Sickness) ..............................209 3. HIV/AIDS and Sexually Transmitted Infections....... 213 3.1 HIV Infection and Acquired Immunodeficiency Syndrome (AIDS).................................... 213 3.1.1 Clinical Features of HIV ....................... 214 3.1.2 Diagnosis and Investigations of HIV .......... 219 3.1.3 Management of HIV Infection.................224 3.1.3.1 Measures before ARV Treatment ........224 3.1.3.2 General Principles of Antiretroviral Treatment (ART) .............................225 3.1.3.3 Recommended First Line Regimens in Adults, Adolescents, Pregnant Women and Children ..................................232 3.1.3.4 Monitoring of ART........................235 3.1.3.5 ARV Toxicity..............................238 3.1.3.6 Recommended Second Line Regimens in Adults, Adolescents, Pregnant Women and Children ..................................242 3.1.4 Mother-to-Child Transmission of HIV .......247 3.1.4.1 Management of HIV Positive Pregnant Mother ........................................248 3.1.4.2 Care of HIV Exposed Infant ..............249 3.1.5 Opportunistic Infections in HIV ..............253 3.1.5.1 Tuberculosis and HIV Co-Infection......253 3.1.5.2 Cryptococcal Meningitis .................256 3.1.5.3 Hepatitis B and HIV Co-Infection........ 261 3.1.5.4 Pneumocystis Pneumonia................262 3.1.5.5 Other Diseases ............................264 3.1.6 Prevention of HIV..............................264 3.1.6.1 Post-Exposure Prophylaxis...............265 vi UGANDA CLINICAL GUIDELINES 2016 Contents 3.1.7 Psychosocial Support for HIV Positive Persons ...........................................268 3.2 Sexually Transmitted Infections (STI).............269 3.2.1 Urethral Discharge Syndrome (Male).........269 3.2.2 Abnormal Vaginal Discharge Syndrome ......272 3.2.3 Pelvic Inflammatory Disease (PID) ...........276 3.2.4 Genital Ulcer Disease (GUD) Syndrome......276 3.2.5 Inguinal Swelling (Bubo) ......................279 3.2.6 Genital Warts .................................. 281 3.2.7 Syphilis.........................................283 3.2.8 Other Genital Infections.......................285 3.2.8.1 Balanitis...................................285 3.2.8.2 Painful Scrotal Swelling..................285 3.2.9 Congenital STI Syndromes....................286 3.2.9.1 Neonatal Conjunctivitis (Ophthalmia Neonatorum) .................................286 3.2.9.2 Congenital Syphilis.......................288 4. Cardiovascular Diseases . .290 4.1.1 Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE).............................290 4.1.2 Infective Endocarditis.........................292 4.1.3 Heart Failure...................................294 4.1.4 Pulmonary Oedema............................298 4.1.5 Atrial Fibrillation ..............................300 4.1.6 Hypertension .................................. 301 4.1.6.1 Hypertensive Emergencies and Urgency .......................................305 4.1.7 Ischaemic Heart Disease