Sandbox mona

• Influenza A and B

• Adults

• Preferred regimen:Oseltamivir (Tamiflu)75 mg bid for 5 days OR Zanamivir(Relenza) 10 mg (two 5-mg inhalations)bid for 5 days OR Peramivir(Rapivab) One 600 mg dose, via intravenous infusion for 15-30 minutes for 1 day

• Children

• Preferred regimen:Oseltamivir If younger than 1 yr old: 3 mg/kg/dose bid If 1 yr or older, dose varies by child’s weight: 15 kg or less, the dose is 30 mg bid; >15 to 23 kg, the dose is 45 mg bid ;>23 to 40 kg, the dose is 60 mg bid; >40 kg, the dose is 75 mg bid for 5 days OR

• Zanamivir(Relenza) 10 mg (two 5-mg inhalations)bid
• Note:FDA approved and recommended Peramivir(Rapivab) for use in adults ≥18 yrs

• Dosing in Adult Patients with Renal Impairment
• Oral oseltamivir
• Creatinine clearance 61 to 90 mL/min-75 mg twice a day
• Creatinine clearance 31 to 60 mL/min-30 mg twice a day
• Creatinine clearance 10 to 30 mL/min-30 mg once daily
• ESRD Patients on Hemodialysis
• Creatinine clearance ≤10 mL/min-30 mg after every hemodialysis cycle. Treatment duration not to exceed 5 days
• ESRD Patients on Continuous Ambulatory Peritoneal Dialysis-A single 30 mg dose administered immediately after a dialysis exchange

• Intravenous Peramivir (single dose)
• Creatinine clearance >50 mL/min-600mg
• Creatinine clearance 30 to 49 mL/min-200mg
• Creatinine clearance 10 to 29 mL/min-100mg
• ESRD Patients on Hemodialysis-Dose administered after dialysis at a dose adjusted based on creatinine clearance

• 1.Keratitis

• Preferred regimen: Miltefosine OR Voriconazole.

• 2. Acanthamoeba Granulomatous Amebic Encephalitis and Disseminated Disease

• Preferred regimen: Adults: Success with IV Pentamidine AND Sulfadiazine AND Flucytosine AND (Fluconazole OR Itraconazole )
• Note: 2 children responded to PO rx: TMP-SMX AND Rifampin AND Ketoconazole

• Primary amoebic meningoencephalitis

• Preferred regimen: Amphotericin B 1.5 mg/kg /day bid for 3 days; then 1 mg/kg/day for 6 days AND1.5 mg/day intrathecal x 2 days; then 1 mg/day intrathecal qd for 8 days.
• Note: Investigational drug called miltefosine also available for treatment.

avian flu

• 1.Preferred regimen:Oseltamivir 75 mg PO qd for a minimum 10 days

• Note:Patients with severe disease may have diarrhea and may not absorb oseltamivir efficiently

• 2.Patients with Avian Influenza who have diarrhea and malabsorption

• Preferred regimen:Zanamivir10 mg inhaled bid for minimum 5 days OR Peramivir600 mg IV as a single dose for1 day
• Note(1)Preliminary evidence demonstrates that neuraminidase inhibitor can reduce the duration of viral replication and improve survival among patients with avian influenza. In cases of suspected avian influenza, one of the following 3 neuraminidase inhibitors should be administered as soon possible, preferably within 48 hours of symptom onset.

• Note(2)The use of corticosteroids is not recommended.
• Note(3): Physicians may consider increasing either the recommended daily dose and/or the duration of treatment in cases of severe disease.
• Note(4):The use of amantadine is not recommended as most H5N1 and H7N9 avian influenza viruses are resistant to it.
• Note(5):Supportive care is also an important cornerstone of the care of patients with avian influenza. Considering the severity of the illness and the possible complications, patients may require fluid resuscitation, vasopressors, intubation and ventilation, paracentesis, hemodialysis or hemofiltration, and parentral nutrition.

• Chronic granulomatous meningitis.

• Preferred regimen: Pentamidine AND (Clarithromycin OR Azithromycin) AND Fluconazole AND Sulfadiazine AND Flucytosine

• Chronic granulomatous meningitis.

• Preferred regimen: Pentamidine AND (Clarithromycin OR Azithromycin) AND Fluconazole AND Sulfadiazine AND Flucytosine

Babesia microti; babesiosis

• 1.Mild/moderate disease.

• Preferred regimen: Atovaquone 750 mg po bid AND Azithromycin 600 mg po qd for 7-10 days

• 2.Severe babesiosis:

• Preferred regimen: Clindamycin 600 mg po tid AND Quinine 650 mg po tid for 7–10 days OR Clindamycin 1.2 gm IV bid.
• Note(1) For overwhelming infection in asplenic patients and immunocompromised patients, treat for 6 or more weeks
• Note(2)Consider transfusion if 􀂕10% parasitemia

CL

IM SbV at 20 mg/kg/day for 14 days for the treatment of L. major, the national standard for the treatment of CL

• ===1.Cutaneous Leishmaniasis===

• 1.1Systemic Therapy (Parenteral)

• Preferred Regimen: Sodium stibogluconate 20 mg/kg IV/IM once qd for 10-20 days OR Meglumine antimoniate 20 mg/kg IV/IM once qd for 10-20 days
• Alternative Regimen: Liposomal amphotericin B 3 mg/kg/day IV infusion for 6-10 days OR Pentamidine 2-3 mg/kg/day IV/IM for 4-7 days
• Note: Data supporting the use of amphotericin B for treatment of cutaneous (and mucosal) leishmaniasis are anecdotal; standard dosage regimens have not been established. In the United States, pentamidine isethionate is uncommonly used for treatment of cutaneous leishmaniasis. Its limitations include the potential for irreversible toxicity and variable effectiveness.
• 1.2 Systemic Therapy (Oral)
• Preferred Regimen: In adults and adolescents at least 12 years of age who weigh from 33-44 kg:-Miltefosine 50 mg PO q12h for 28 days
• Patients who weigh >45 kg:-Miltefosine 50 mg PO q8h for 28 days
• Alternative Regimen:Ketoconazole 600 mg qd for 28 days OR Fluconazole 200 mg qd for 6 weeks
• Note:The FDA-approved indications are limited to infection caused by three particular species, all three of which are New World species in the Viannia subgenus—namely, Leishmania (V.) braziliensis, L. (V.) panamensis, and L. (V.) guyanensis. The "azoles" showed modest activity against some Leishmania species in some cases, but are not FDA approved
• 1.3Local Therapy
• List of possible local therapies
• Cryotherapy (with liquid nitrogen OR Thermotherapy (use of localized current field radiofrequency heat) OR Intralesional administration of SbV OR Topical application of paromomycin (such as an ointment containing 15% paromomycin/12% methylbenzethonium chloride in soft white paraffin)

• 2.Visceral Leishmaniasis

• 2.1Systemic Therapy (Parenteral)
• Preferred Regimen: Liposomal amphotericin B 3 mg/kg/day IV for 5 days, then once on day 14 and once on day 21 (Total dose: 21 mg/kg) ORSodium stibogluconate 20 mg/kg IV/IM once daily for 28 days OR Meglumine antimoniate 20 mg/kg IV/IM once daily for 28 days'
• Alternative Regimen:Amphotericin B deoxycholate 0.5-1 mg/kg IV once daily (Total dose: 15-20 mg/kg)
• Note: In immunosuppressed patients, dose is 4 mg/kg/day for 5 days, then once on day 10, 17, 24, 31, and 38 (Total dose: 40 mg/kg)
• 2.2 Systemic Therapy (Oral)
• Preferred Regimen:In adults and adolescents at least 12 years of age, who weigh from 33-44 kg:Miltefosine 50 mg PO q12h for 28 days Patients who weigh >45 kg:Miltefosine 50 mg PO q8h for 28 days

Malaraia

• Treatment of uncomplicated P. falciparum malaria

• Treat children and adults with uncomplicated P. falciparum malaria (except pregnant women in their first trimester) with one of the following recommended ACT (artemisinin-based combination therapy)
• Preferred regimen(1): Artemether 5–24 mg/kg bw PO AND Lumefantrine 29–144 mg/ kg bw PO, Both are given bid for 3 days (total, six doses). The first two doses should, ideally, be given 8 h apart.
• dosage regimen based on Body weight (kg)
• Body weight (kg)-5 to < 15- Dose of Artemether 20 (mg) AND Lumefantrine 120(mg) given bid for 3 days;
• Body weight (kg)-15 to < 25- Dose of Artemether 40 (mg) AND Lumefantrine 240(mg) given bid for 3 days;
• Body weight (kg)-25 to < 35- Dose of Artemether 60 (mg) AND Lumefantrine 360(mg) given bid for 3 days;
• Body weight (kg) ≥ 35- Dose of Artemether 80 (mg) AND Lumefantrine 480(mg) given bid for 3 days.
• Preferred regimen(2):Artesunate (2–10) mg/kg bw per day AND Amodiaquine(7.5–15) mg/kg bw per day ,both are given once a day for 3 days. A total therapeutic dose range of 6–30 mg/kg bw per day artesunate and 22.5–45 mg/kg bw per dose amodiaquine is recommended
• dosage regimen based on Body weight (kg)
• Body weight (kg)-4.5 to < 9- Dose of Artesunate 25 (mg) AND Amodiaquine 67.5 (mg) given bid for 3 days;
• Body weight (kg)-9 to < 18 - Dose of Artesunate 50 (mg) AND Amodiaquine 135 (mg) given bid for 3 days;
• Body weight (kg)-18 to < 36- Dose of Artesunate 100 (mg) AND Amodiaquine 270(mg) given bid for 3 days;
• Body weight (kg) ≥ 36 - Dose of Artesunate 200 (mg) AND Amodiaquine 540 (mg) given bid for 3 days.
• Preferred regimen(3): Artesunate (2–10) mg/kg bw per dayAND Mefloquine (2–10) mg/kg bw per day both are given once a day for 3 days
• dosage regimen based on Body weight (kg)
• Body weight (kg)-5 to < 9- Dose of Artesunate 25 (mg) AND Mefloquine 55 (mg) given bid for 3 days;
• Body weight (kg)-9to < 18- Dose of Artesunate 50 (mg) AND Mefloquine 110 (mg) given bid for 3 days;
• Body weight (kg)-18 to < 36- Dose of Artesunate 100 (mg) AND Mefloquine 220 (mg) given bid for 3 days;
• Body weight (kg)- ≥ 36 - Dose of Artesunate 200 (mg) AND Mefloquine 440 (mg) given bid for 3 days;
• Preferred regimen(4): Artesunate (2–10) mg/kg bw per day given once a day for 3 days AND Sulfadoxine–Pyrimethamine 1.25 (25–70 / 1.25–3.5) mg/kg bw given as a single dose on day 1
• dosage regimen based on Body weight (kg)
• Body weight (kg)-5 to < 10- Dose of Artesunate 25 (mg) AND sulfadoxine–pyrimethamine 250/12(mg) given bid for 3 days;
• Body weight (kg)-10 to < 25- Dose of Artesunate 50 (mg) AND sulfadoxine–pyrimethamine 500 / 25 (mg) given bid for 3 days;
• Body weight (kg)-25 to < 50- Dose of Artesunate 100 (mg) AND sulfadoxine–pyrimethamine 1000 / 50 (mg) given bid for 3 days;
• Body weight (kg)- ≥50- Dose of Artesunate 200 (mg) AND sulfadoxine–pyrimethamine 1500 / 75 (mg) given bid for 3 days;
• Preferred regimen(5):Dihydroartemisinin (2–10) mg/kg bw per day AND Piperaquine(16–27) mg/kg bw per day : A target dose (range) of 4 (2–10) mg/kg bw per day dihydroartemisinin and 18 (16–27) mg/kg bw per day piperaquine given once a day for 3 days for adults and children weighing ≥ 25 kg. The target doses and ranges for children weighing < 25 kg are 4 (2.5–10) mg/kg bw per day dihydroartemisinin and 24 (20–32) mg/kg bw per day piperaquine once a day for 3 days.
• dosage regimen based on Body weight (kg)
• Body weight (kg)-5 to < 8- Dose of Dihydroartemisinin 20(mg) AND Piperaquine 160 (mg) given bid for 3 days;
• Body weight (kg)-8 to < 11- Dose of Dihydroartemisinin30 (mg) AND Piperaquine 240 (mg) given bid for 3 days;
• Body weight (kg)-11 to < 17 - Dose of Dihydroartemisinin 40 (mg) AND Piperaquine 320 (mg) given bid for 3 days;
• Body weight (kg)-17 to < 25- Dose of Dihydroartemisinin 60 (mg) AND Piperaquine 480 (mg) given bid for 3 days;
• Body weight (kg)-25 to < 36- Dose of Dihydroartemisinin 80 (mg) AND Piperaquine 640 (mg) given bid for 3 days;
• Body weight (kg)-36 to < 60- Dose of Dihydroartemisinin]] 120 (mg) AND Piperaquine 960 (mg) given bid for 3 days;
• Body weight (kg)-60 < 80 - Dose of Dihydroartemisinin]] 160 (mg) AND Piperaquine 1280 (mg) given bid for 3 days;
• Body weight (kg)- >80- Dose of Dihydroartemisinin]] 200 (mg) AND Piperaquine 1600 (mg) given bid for 3 days;

'Reducing the transmissibility of treated P. falciparum infections In low-transmission areas, 

give a single dose of 0.25 mg/kg bw primaquine with ACT to patients with P. falciparum malaria (except pregnant women, infants aged < 6 months and women breastfeeding infants aged < 6 months) to reduce transmission. G6PD testing is not required.

RECURRENT FALCIPARUM MALARIA FAILURE WITHIN 28 DAYS The recommended second-line treatment is an alternative ACT known to be effective in the region. Adherence to 7-day treatment regimens (with artesunate or quinine both of which should be co-administered with + tetracycline, or doxycycline or clindamycin) is likely to be poor if treatment is not directly observed; these regimens are no longer generally recommended.

FAILURE AFTER 28 DAYS

all presumed treatment failures after 4 weeks of initial treatment should, from an operational standpoint, be considered new infections and be treated with the first-line ACT. However, reuse of mefloquine within 60 days of first treatment is associated with an increased risk for neuropsychiatric reactions, and an alternative ACT should be used
REDUCING THE TRANSMISSIBILITY OF TREATED P. FALCIPARUM INFECTIONS IN AREAS OF LOW-INTENSITY TRANSMISSION

In low-transmission areas, give a single dose of 0.25 mg/kg bw primaquine with ACT to patients with P. falciparum malaria (except pregnant women, infants aged < 6 months and women breastfeeding infants aged < 6 months) to reduce transmission

Treating uncomplicated P. falciparum malaria in special risk groups First trimester of pregnancy : with 7 days of quinine + clindamycin(10mg/kg bw twice a day). SECOND AND THIRD TRIMESTERS:

Infants less than 5kg body weight : with an ACT at the same mg/kg bw target dose as for children weighing 5 kg.

Patients co-infected with HIV: avoid artesunate + SP if they are also receiving co-trimoxazole, and avoid artesunate + amodiaquine if they are also receiving efavirenz or zidovudine. Non-immune travellers Treat travellers with uncomplicated P. falciparum malaria returning to nonendemic settings with an ACT.

Uncomplicated hyperparasitaemia People with P. falciparum hyperparasitaemia are at increased risk of treatment failure, severe malaria and death so should be closely monitored, in addition to receiving an ACT

TREATMENT OF UNCOMPLICATED MALARIA CAUSED BY P. VIVAX, P. OVALE, P. MALARIAE OR P. KNOWLESI

UNCOMPLICATED P. VIVAX MALARIA In areas with chloroquine-sensitive P. vivax

oral chloroquine at a total dose of 25 mg base/kg bw is effective and well tolerated.  Chloroquine is given at an initial dose of 10 mg base/kg bw, followed by 10 mg/kg bw on the second day and 5 mg/kg bw on the third day.

In areas with chloroquine-resistant P. vivax

ACTs containing piperaquine, mefloquine or lumefantrine are the recommended treatment, although artesunate + amodiaquine may also be effective in some areas. In the systematic review of ACTs for treating P. vivax malaria, dihydroartemisinin + piperaquine provided a longer prophylactic effect than ACTs with shorter half-lives (artemether + lumefantrine, artesunate + amodiaquine), with significantly fewer recurrent parasitaemias during 9 weeks of follow-up (RR, 0.57; 95% CI, 0.40–0.82, three trials, 1066 participants).

UNCOMPLICATED P. OVALE, P. MALARIAE OR P. KNOWLESI MALARIA

Resistance of P. ovale, P. malariae and P. knowlesi to antimalarial drugs is not well characterized, and infections caused by these three species are generally considered to be sensitive to chloroquine. In only one study, conducted in Indonesia, was resistance to chloroquine reported in P. malariae. The blood stages of P. ovale, P. malariae and P. knowlesi should therefore be treated with the standard regimen of ACT or chloroquine, as for vivax malaria.

MIXED MALARIA INFECTIONS
ACTs are effective against all malaria species and so are the treatment of choice for mixed infections.

TREATMENT OF THE LIVER STAGES (HYPNOZOITES) OF P. VIVAX AND P. OVALE

To prevent relapse, treat P. vivax or P. ovale malaria in children and adults (except pregnant women, infants aged < 6 months, women breastfeeding infants < 6 months, women breastfeeding older infants unless they are known not to be G6PD deficient and people with G6PD deficiency) with a 14-day course of primaquine in all transmission settings. Strong recommendation, high-quality evidence In people with G6PD deficiency, consider preventing relapse by giving primaquine base at 0.75 mg base/kg bw once a week for 8 weeks, with close medical supervision for potential primaquine-induced adverse haematological effects.