Sandbox mona cor

• Chlamydia trachomatis Return to Top

• 1 Chlaymydial infections

• 1.1 Chlamydial Infections in Adolescents and Adults

• Preferred regimen(1): Doxycycline 100 mg PO bid for 7 days
• Preferred regimen(2): Azithromycin 1 g PO in a single dose
• Alternative regimen (1): Erythromycin base 500 mg PO qid for 7 days
• Alternative regimen (2): Erythromycin ethylsuccinate 800 mg PO qid for 7 days
• Alternative regimen (3): Levofloxacin 500 mg PO qd for 7 days
• Alternative regimen (4): Ofloxacin 300 mg PO bid for 7 days.
• Note: Patients should be instructed to refer their sex partners for evaluation, testing, and treatment if they had sexual contact with the patient during the 60 days preceding onset of the patient's symptoms or chlamydia diagnosis.

• 1.2 Chlamydial Infections in patients with HIV Infection

• Preferred regimen(1): Doxycycline 100 mg PO bid for 7 days
• Preferred regimen(2): Azithromycin 1 g PO in a single dose
• Preferred regimen(3): Azithromycin 1 g PO in a single dose
• Alternative regimen (1): Erythromycin base 500 mg PO qid for 7 days
• Alternative regimen (2): Erythromycin ethylsuccinate 800 mg PO qid for 7 days
• Alternative regimen (3): Levofloxacin 500 mg PO qd for 7 days
• Alternative regimen (4): Ofloxacin 300 mg PO bid for 7 days.

• 1.3 Pregancy

• Preferred regimen: Azithromycin 1 g PO in a single dose
• Alternative regimen (1): Amoxicillin 500 mg PO tid for 7 days
• Alternative regimen (2): Erythromycin base 500 mg PO qid for 7 days
• Alternative regimen (3): Erythromycin base 250 mg PO qid for 14 days
• Alternative regimen (4): Erythromycin ethylsuccinate 800 mg PO qid for 7 days
• Alternative regimen (5): Erythromycin ethylsuccinate 400 mg PO qid for 14 days
• Note:Doxycycline, Ofloxacin, and Levofloxacin are contraindicated in pregnant women

• 1.4 Management of sex partners

• Preferred regimen (1): Doxycycline 100 mg PO bid for 7 days
• Preferred regimen (2): Azithromycin 1 g PO in a single dose
• Alternative regimen (1): Erythromycin base 500 mg PO qid for 7 days
• Alternative regimen (2): Erythromycin ethylsuccinate 800 mg PO qid for 7 days
• Alternative regimen (3): Levofloxacin 500 mg PO qd for 7 days
• Alternative regimen (4): Ofloxacin 300 mg PO bid for 7 days.
• Note (1): Recent sex partners (i.e., persons having sexual contact with the infected patient within the 60 days preceding onset of symptoms or Chlamydia diagnosis) should be referred for evaluation, testing, and presumptive dual treatment.
• Note (2): If the patient’s last potential sexual exposure was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated.
• Note (3): To avoid reinfection, sex partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sexual partner(s) have completed treatment and after resolution of symptoms, if present

• 2 Chlamydial infection among neonates

• 2.1 Ophthalmia Neonatorumcaused by C. trachomatis

• Preferred regimen: Erythromycin base or ethylsuccinate 50 mg/kg/ day divided into 4 doses PO daily for 14 days
• Alternative regimen: Azithromycin suspension 20 mg/kg /day PO qd for 3 days
• Note: The mothers of infants who have chlamydial infection and the sex partners of these women should be evaluated and treated.

• 2.2 Infant Pneumonia

• Preferred regimen: Erythromycin base or ethylsuccinate 50 mg/kg/ day divided into 4 doses PO daily for 14 days
• Alternative regimen: Azithromycin suspension 20 mg/kg /day PO qd for 3 days

• 3.Chlamydial infection among infants and childern

• 3.1 Infants and childern who weigh < 45 kg

• Preferred regimen: Erythromycin base or ethylsuccinate 50 mg/kg/ day divided into 4 doses PO daily for 14 days

• 3.2 Infants and childern who weigh ≥45 kg but who are aged <8 years

• Preferred regimen: Azithromycin 1 g PO in a single dose

• 3.3 Infants and childern aged ≥8 years

• Preferred regimen(1): Azithromycin 1 g PO in a single dose
• Preferred regimen(2): Doxycycline 100 mg PO bid for 7 days

• 4. Lymphogranuloma venereum (LGV)
• Lymphogranuloma venereum (LGV) is caused by C. trachomatis serovars L1, L2, or L3 '

• Preferred regimen: Doxycycline 100 mg PO bid for 21 days
• Alternative regimen: Erythromycin base 500 mg PO qid for 21 days
• Note (1): Azithromycin 1 g PO once weekly for 3 weeks is probably effective based on its chlamydial antimicrobial activity. Fluoroquinolone-based treatments might also be effective, but extended treatment intervals are likely required.
• Note (2): Pregnant and lactating women should be treated with Erythromycin. Azithromycin might prove useful for treatment of LGV in pregnancy, but no published data are available regarding its safety and efficacy. Doxycycline is contraindicated in pregnant women.
• Note (3): Persons with both LGV and HIV infection should receive the same regimens as those who are HIV negative. Prolonged therapy might be required, and delay in resolution of symptoms might occur.
• Note(4): Persons who have had sexual contact with a patient who has LGV within the 60 days before onset of the patient’s symptoms should be examined and tested for urethral, cervical, or rectal chlamydial infection depending on anatomic site of exposure. They should be presumptively treated with a chlamydia regimen ( Azithromycin 1 g PO single dose OR Doxycycline 100 mg PO bid for 7 days).

• Neisseria gonorrhoeae, treatment

• 1. Gonococcal infections in adolescents and adults

• 1.1 Uncomplicated gonococcal infections of the cervix, urethra, and rectum

• Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1 g PO in a single dose
• Alternative regimen: Cefixime 400 mg PO in a single dose AND Azithromycin 1 g PO in a single dose (if ceftriaxone is not available)

• 1.2 Uncomplicated gonococcal infections of the pharynx

• Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1 g PO in a single dose

• 1.2.1 Management of sex partners

• Expedited partner therapy: Cefixime 400 mg PO in a single dose AND Azithromycin 1 g PO in a single dose
• Note (1): Recent sex partners (i.e., persons having sexual contact with the infected patient within the 60 days preceding onset of symptoms or gonorrhea diagnosis) should be referred for evaluation, testing, and presumptive dual treatment.
• Note (2): If the patient’s last potential sexual exposure was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated.
• Note (3): To avoid reinfection, sex partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sexual partner(s) have completed treatment and after resolution of symptoms, if present.

• 1.2.2 Allergy, intolerance, and adverse reactions

• Preferred regimen (1): Gemifloxacin 320 mg PO in a single dose AND Azithromycin 2 g PO in a single dose
• Preferred regimen (2): Gentamicin 240 mg IM in a single dose AND Azithromycin 2 g PO in a single dose
• Note: Use of ceftriaxone or cefixime is contraindicated in persons with a history of an IgE-mediated penicillin allergy (e.g., anaphylaxis, Stevens Johnson syndrome, and toxic epidermal necrolysis).

• 1.2.3 Pregnancy

• Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1 g PO in a single dose

• 1.2.4 Suspected cephalosporin treatment failure

• Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1 g PO in a single dose
• Alternative regimen (1): Gemifloxacin 320 mg PO single dose AND Azithromycin 2 g PO single dose (when isolates have elevated cephalosporin MICs)
• Alternative regimen (2): Gentamicin 240 mg IM single dose AND Azithromycin 2 g PO single dose (when isolates have elevated cephalosporin MICs)
• Alternative regimen (3): Ceftriaxone 250 mg IM as a single dose AND Azithromycin 2 g PO as a single dose (failure after treatment with cefixime and azithromycin)
• Note: Treatment failure should be considered in: (1) persons whose symptoms do not resolve within 3–5 days after appropriate treatment and report no sexual contact during the post-treatment follow-up period; (2) persons with a positive test-of-cure (i.e., positive culture ≥ 72 hours or positive NAAT ≥ 7 days after receiving recommended treatment) when no sexual contact is reported during the post-treatment follow-up period; (3) persons who have a positive culture on test-of-cure (if obtained) if there is evidence of decreased susceptibility to cephalosporins on antimicrobial susceptibility testing, regardless of whether sexual contact is reported during the post-treatment follow-up period.

• 1.3 Gonococcal conjunctivitis

• Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1 g PO in a single dose

Note: Consider one-time lavage of the infected eye with saline solution.

• 1.3.1 Management of sex partners

• Patients should be instructed to refer their sex partners for evaluation and treatment.

• 1.4 Disseminated gonococcal infection

• 1.4.1 Arthritis and arthritis-dermatitis syndrome

• Preferred regimen: Ceftriaxone 1 g IM/IV q24h for 7 days AND Azithromycin 1 g PO in a single dose
• Alternative regimen: Cefotaxime 1 g IV q8h for 7 days OR Ceftizoxime 1 g IV q 8 h for 7 days AND Azithromycin 1 g PO in a single dose

• 1.4.2 Gonococcal meningitis and endocarditis

• Preferred regimen : Ceftriaxone 1-2 g IV q 12-24 h for 10-14 days AND Azithromycin 1 g PO in a single dose

• 2. Gonococcal infections among neonates

• 2.1 Ophthalmia neonatorum caused by N. gonorrhoeae

• Preferred regimen: Ceftriaxone 25-50 mg/kg IV or IM in a single dose, not to exceed 125 mg

• 2.1.1 Management of mothers and their sex partners

• Mothers of infants with ophthalmia neonatorum caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).

• 2.2 Disseminated gonococcal infection and gonococcal scalp abscesses in neonates

• Preferred regimen: Ceftriaxone 25-50 mg/kg/day IM/IV qd for 7 days OR Cefotaxime 25 mg/kg IV /IM q12h for 7 days.
• Note (1): The duration of treatment is 10-14 days if meningitis is documented.
• Note (2): Ceftriaxone should be administered cautiously to hyperbilirubinemic infants, especially those born prematurely.

• 2.2.1 Management of mothers and their sex partners

• Mothers of infants who have DGI or scalp abscesses caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).

• 2.3 Neonates born to mothers who have gonococcal infection

• Preferred regimen: Ceftriaxone 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg

• 2.3.1 Management of mothers and their sex partners

• Mothers who have gonorrhea and their sex partners should be evaluated, tested, and presumptively treated for gonorrhea.

• 3. Gonococcal infections among infants and children

• 3.1 Infants and children who weigh ≤ 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis

• Preferred regimen: Ceftriaxone 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg

• 3.2 Children who weigh > 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis

• Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1g PO in a single dose
• Alternative regimen: Cefixime 400 mg PO single dose AND Azithromycin 1 g PO single dose.(If ceftriaxone is not available)

• 3.3 Children who weigh ≤ 45 kg and who have bacteremia or arthritis

• Preferred regimen: Ceftriaxone 50 mg/kg (maximum dose: 1 g) IM/IV q24h for 7 days

• 3.4 Children who weigh > 45 kg and who have bacteremia or arthritis

• Preferred regimen: Ceftriaxone 1 g IM/IV q24h for 7 days

• Klebsiella granulomatis Return to Top

• Klebsiella granulomatis (formly known as Calymmatobacterium granulomatis)

• Granuloma inguinale (donovanosis)

• Preferred regimen: Azithromycin 1 g PO once a week or 500 mg qd for 3 weeks and until all lesions have completely healed
• Alternative regimen (1): Doxycycline 100 mg PO bid for 3 weeks and until all lesions have completely healed
• Alternative regimen (2): Ciprofloxacin 750 mg PO bid for at least 3 weeks and until all lesions have completely healed
• Alternative regimen (3): Erythromycin base 500 mg PO qid for at least 3 weeks and until all lesions have completely healed
• Alternative regimen (4): Trimethoprim-sulfamethoxazole one double-strength (160 mg/800 mg) tablet PO bid for at least 3 weeks and until all lesions have completely healed

• Chlamydophila psittaci Return to Top

• 1. Pneumonia

• 1.1 Adult

• Preferred regimen(1): Doxycycline 100 mg PO bid daily for 10-21 days
• Preferred regimen(2): Tetracycline 500 mg PO qid for 10-21 days
• Alternative regimen:Minocycline

• 1.2 Pediatric

• Preferred regimen: Azithromycin
• Alternative regimen: fluoroquinolones

• 1.3 Pregnant Patients

• Preferred regimen: Azithromycin
• Alternative regimen: fluoroquinolones

• 2.Endocarditis in valve replacement patients

• Preferred regimen: Doxycycline
• Alternative regimen: fluoroquinolones.

• Legionella Return to Top

• Atypical bacterial pneumonia caused by Legionella

• Preferred Regimen (1): Levofloxacin 750 mg IV q24h
• Preferred Regimen (2): Moxifloxacin 400 mg IV q24h
• Preferred Regimen (3): Azithromycin 500 mg PO on day 1 followed by 250 mg q24h
• Alternate Regimen: Doxycycline 100 mg PO/IV q12h

• Mycoplasma pneumoniae Return to Top

• Atypical pneumonia caused by Mycoplasma pneumoniae

• Preferred regimen (1): Azithromycin 500 mg PO day 1 and 250 mg day 2 to 5
• Preferred regimen (2): Doxycycline 100 mg PO bid for 14 days
• Preferred regimen (3): Moxifloxacin 400 mg PO qd for 14 days

• Mycoplasma genitalium Return to Top

• 1. Urethritis and cervicitis

• Preferred regimen (macrolide-susceptible strains) (1): Azithromycin 1 g PO as a single dose
• Preferred regimen (macrolide-susceptible strains) (2): Azithromycin 500 mg PO as a dose followed by 250 mg PO qd for 4 days
• Preferred regimen (for patients with previous treatment failures): Moxifloxacin 400 mg PO qd for 7–14 days

• 2. Pelvic inflammatory disease (PID)

• Preferred regimen: Moxifloxacin 400 mg PO qd for 14 days

• 3. Specific considerations

• 3.1 Management of sex partners
• Sex partners should be managed according to guidelines for patients with nongonococcal urethritis, cervicitis, and pelvic inflammatory disease.

• 3.2 HIV infection
• Persons who have an M. genitalium infection and HIV infection should receive the same treatment regimen as those who are HIV negative.

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• Plasmodium Return to Top
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• 1. Plasmodium falciparum

• 1.1 Treatment of uncomplicated P. falciparum malaria

• 1.1.1 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- Artemether 20 (mg) AND Lumefantrine 120(mg) given bid for 3 days;
• Body weight (kg)-15 to < 25- Artemether 40 (mg) AND Lumefantrine 240(mg) given bid for 3 days;
• Body weight (kg)-25 to < 35- Artemether 60 (mg) AND Lumefantrine 360(mg) given bid for 3 days;
• Body weight (kg) ≥ 35- 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- Artesunate 25 (mg) AND Amodiaquine 67.5 (mg) given bid for 3 days;
• Body weight (kg)-9 to < 18 - Artesunate 50 (mg) AND Amodiaquine 135 (mg) given bid for 3 days;
• Body weight (kg)-18 to < 36- Artesunate 100 (mg) AND Amodiaquine 270(mg) given bid for 3 days;
• Body weight (kg) ≥ 36 - 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- Artesunate 25 (mg) AND Mefloquine 55 (mg) given bid for 3 days;
• Body weight (kg)-9to < 18- Artesunate 50 (mg) AND Mefloquine 110 (mg) given bid for 3 days;
• Body weight (kg)-18 to < 36- Artesunate 100 (mg) AND Mefloquine 220 (mg) given bid for 3 days;
• Body weight (kg)- ≥ 36 - 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- Artesunate 25 (mg) AND Sulfadoxine-Pyrimethamine 250/12(mg) given bid for 3 days;
• Body weight (kg)-10 to < 25- Artesunate 50 (mg) AND Sulfadoxine-Pyrimethamine 500 / 25 (mg) given bid for 3 days;
• Body weight (kg)-25 to < 50- Artesunate 100 (mg) AND Sulfadoxine-Pyrimethamine 1000 / 50 (mg) given bid for 3 days;
• Body weight (kg)- ≥50- 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

• Dosage regimen based on Body weight (kg)
• Body weight (kg)-5 to < 8- Dihydroartemisinin 20(mg) AND Piperaquine 160 (mg) given bid for 3 days;
• Body weight (kg)-8 to < 11- Dihydroartemisinin30 (mg) AND Piperaquine 240 (mg) given bid for 3 days;
• Body weight (kg)-11 to < 17 - Dihydroartemisinin 40 (mg) AND Piperaquine 320 (mg) given bid for 3 days;
• Body weight (kg)-17 to < 25- Dihydroartemisinin 60 (mg) AND Piperaquine 480 (mg) given bid for 3 days;
• Body weight (kg)-25 to < 36- Dihydroartemisinin 80 (mg) AND Piperaquine 640 (mg) given bid for 3 days;
• Body weight (kg)-36 to < 60- Dihydroartemisinin 120 (mg) AND Piperaquine 960 (mg) given bid for 3 days;
• Body weight (kg)-60 < 80 - 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;

• 1.1.2 Reducing the transmissibility of treated P. falciparum infections In low-transmission areas in patients with P. falciparum malaria (except pregnant women, infants aged < 6 months and women breastfeeding infants aged < 6 months)

• Preferred regimen: single dose of 0.25 mg/kg bw Primaquine with ACT

• 1.2 Recurrent Falciparum Malaria

• 1.2.1 Failure within 28 days

• Note: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.

• 1.2.2 Failure after 28 days

• Note: 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

• 1.3 Reducing the transmissibility of treated P. falciparum infections In low-transmission areas in patients with P. falciparum malaria (except pregnant women, infants aged < 6 months and women breastfeeding infants aged < 6 months)

• Note: a single dose of 0.25 mg/kg bw Primaquine with ACT

• 1.4 Treating uncomplicated P. falciparum malaria in special risk groups

• 1.4.1 Pregnancy

• First trimester of pregnancy :Quinine AND Clindamycin 10mg/kg bw PO bid for 7 days
• Second and third trimesters : Mefloquine is considered safe for the treatment of malaria during the second and third trimesters; however, it should be given only in combination with an artemisinin derivative.
• Note(1): Quinine is associated with an increased risk for hypoglycaemia in late pregnancy, and it should be used (with clindamycin) only if effective alternatives are not available.
• Note(2): Primaquine and tetracyclines should not be used in pregnancy.

• 1.4.2 Infants less than 5kg body weight : with an ACT at the same mg/kg bw target dose as for children weighing 5 kg.
• 1.4.3 Patients co-infected with HIV: should avoid Artesunate + SP if they are also receiving Co-trimoxazole, and avoid Artesunate AND Amodiaquine if they are also receiving efavirenz or zidovudine.
• 1.4.4 Large and Obese adults: For obese patients, less drug is often distributed to fat than to other tissues; therefore, they should be dosed on the basis of an estimate of lean body weight, ideal body weight. Patients who are heavy but not obese require the same mg/kg bw doses as lighter patients.
• 1.4.5 Patients co-infected with TB: Rifamycins, in particular rifampicin, are potent CYP3A4 inducers with weak antimalarial activity. Concomitant administration of rifampicin during quinine treatment of adults with malaria was associated with a significant decrease in exposure to quinine and a five-fold higher recrudescence rate
• 1.4.6 Non-immune travellers : Treat travellers with uncomplicated P. falciparum malaria returning to nonendemic settings with an ACT.
• 1.4.7 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

• 2. Treatment of uncomplicated malaria caused by P. vivax, P. ovale, P. malariae or P. knowlesi

• 2.1 Blood Stage infection

• 2.1.1. Uncomplicated malaria caused by P. vivax

• 2.1.1.1 In areas with chloroquine-sensitive P. vivax

• Preferred regimen: Chloroquine total dose of 25 mg base/kg bw PO. 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.

• 2.1.1.2 In areas with chloroquine-resistant P. vivax

• Note: 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.

• 2.1.2 Uncomplicated malaria caused by P. ovale, P. malariae or P. knowlesi malaria

• Note: 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.

• 2.1.3 Mixed malaria infections

• Note: ACTs are effective against all malaria species and so are the treatment of choice for mixed infections.

• 2.2 Liver stages (hypnozoites) of P. vivax and P. ovale

• Note: 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.]
• 2.2.1 Primaquine for preventive relapse

• Preferred regimen: Primaquine 0.25–0.5 mg/kg bw per day PO qd for 14 days

• 2.2.2 Primaquine and glucose-6-phosphate dehydrogenase deficiency

• Preferred regimen:Primaquine 0.75 mg base/kg bw PO once a week for 8 weeks.
• Note: The decision to give or withhold Primaquine should depend on the possibility of giving the treatment under close medical supervision, with ready access to health facilities with blood transfusion services.

• 2.2.3 Prevention of relapse in pregnant or lacating women and infants

• Note: Primaquine is contraindicated in pregnant women, infants < 6months of age and in lactating women (unless the infant is known not to be G6PD deficient).

• 3.Treatment of severe malaria

• 3.1 Treatment of severe falciparum infection with Artesunate

• 3.1.1 Adults and children with severe malaria (including infants, pregnant women in all trimesters and lactating women):-

• Preferred regimen: Artesunate IV/IM for at least 24 h and until they can tolerate oral medication. Once a patient has received at least 24 h of parenteral therapy and can tolerate oraltherapy, complete treatment with 3 days of an ACT (add single dose Primaquine in areas of low transmission).

• 3.1.2 Young children weighing < 20 kg

• Preferred regimen:Artesunate (3 mg/kg bw per dose)
• Alternatives regimen: use Artemether in preference to quinine for treating children and adults with severe malaria

• 3.2.Treating cases of suspected severe malaria pending transfer to a higher-level facility (pre-referral treatment)

• 3.2.1 Adults and children

• Preferred regimen: Artesunate IM
• Alternative regimen: Artemether IM OR Quinine IM

• 3.2.2 Children < 6 years

• Preferred regimen: Where intramuscular injections of artesunate are not available , treat with a single rectal dose (10 mg/kg bw) of Artesunate, and refer immediately to an appropriate facility for further care.
• Note: Do not use rectal artesunate in older children and adults.

• 3.3 Pregancy

• Note: Parenteral artesunate is the treatment of choice in all trimesters. Treatment must not be delayed

• 3.4 Treatment of severe P.Vivax infection

• Note: parenteral artesunate, treatment can be completed with a full treatment course of oral ACT or chloroquine (in countries where chloroquine is the treatment of choice). A full course of radical treatment with primaquine should be given after recovery

• 3.5 Additional aspects of management in severe malaria

• Fluid therapy: It is not possible to give general recommendations on fluid replacement; each patient must be assessed individually and fluid resuscitation based on the estimated deficit
• Blood Transfusion :In high-transmission settings, blood transfusion is generally recommended for children with a haemoglobin level of < 5 g/100 mL(haematocrit < 15%). In low-transmission settings, a threshold of 20% (haemoglobin,7 g/100 mL) is recommended
• Exchange blood transfusion: Exchange blood transfusion requires intensive nursing care and a relatively large volume of blood, and it carries significant risks. There is no consensus on the indications, benefits and dangers involved or on practical details such as the volume of blood that should be exchanged. It is, therefore, not possible to make any recommendation regarding the use of exchange blood transfusion.

• Herpes simplex virus Return to Top

• Genital Herpes

• 1.First Clinical Episode of Genital Herpes

• Preferred Regimens(1): Acyclovir 400 mg PO tid for 7–10 days
• Preferred Regimens(2): Acyclovir 200 mg PO five times a day for 7–10 days
• Preferred Regimens(3): Valacyclovir 1 g PO bid for 7–10 days
• Preferred Regimens(4): Famciclovir 250 mg PO tid for 7–10 days
• Note:Treatment can be extended if healing is incomplete after 10 days of therapy.

• 2.Established HSV-2 Infection

• 2.1 Suppressive Therapy for Recurrent Genital Herpes

• Preferred Regimen(1): Acyclovir 400 mg PO bid
• Preferred Regimen(2): Valacyclovir 500 mg PO qd
• Preferred Regimen(3): Valacyclovir 1 g PO qd
• Preferred Regimen(4): Famciclovir 250 mg PO bid
• Note(1):Daily therapy with Acyclovir for as long as 6 years and with Valacyclovir or Famciclovir for 1 year
• Note(2):Valacyclovir 500 mg qd might be less effective than other Valacyclovir or Acyclovir dosing regimens in persons who have very frequent recurrences (i.e., ≥10 episodes per year).

• 2.2 Episodic Therapy for Recurrent Genital Herpes

• Preferred Regimen: Acyclovir 400 mg PO tid for 5 days
• Preferred Regimen: Acyclovir 800 mg PO bid for 5 days
• Preferred Regimen: Acyclovir 800 mg PO tid for 2 days
• Preferred Regimen: Valacyclovir 500 mg PO bid for 3 days
• Preferred Regimen: Valacyclovir 1 g PO qd for 5 days
• Preferred Regimen: Famciclovir 125 mg PO bid for 5 days
• Preferred Regimen: Famciclovir 1 gram PO bid for 1 day
• Preferred Regimen: Famciclovir 500 mg once, followed by 250 mg PO bid for 2 days

• 3. Severe Disease (disseminated infection, pneumonitis, or hepatitis) or CNS complications (e.g., meningoencephalitis).

• Preferred Regimens: Acyclovir 5–10 mg/kg IV q8h for 2–7 days or until clinical improvement is observed, followed by oral antiviral therapy to complete at least 10 days of total therapy. HSV encephalitis requires 21 days of intravenous therapy. Impaired renal function warrants an adjustment in acyclovir dosage.

• 4. Special Considerations

• 4.1HIV Infection

• 4.1.1 Daily Suppressive Therapy in Persons with HIV
• Preferred Regimens: Acyclovir 400–800 mg PO bid /tid OR Valacyclovir 500 mg PO bid OR Famciclovir 500 mg PO bid
• 4.1.2 Episodic Infection in Persons with HIV
• Preferred Regimens: Acyclovir 400 mg PO tid for 5–10 days OR Valacyclovir 1 g PO bid for 5–10 days OR Famciclovir 500 mg PO bid for 5–10 days
• Note:For severe HSV disease, initiating therapy with Acyclovir 5–10 mg/kg IV every 8 hours might be necessary.

• 4.2.Genital Herpes in Pregnancy

• suppressive therapy of pregnant women with recurrent genital herpes *
• Preferred Regimens: Acyclovir 400–800 mg PO bid /tid OR Valacyclovir 500 mg PO bid
• Note:Treatment recommended starting at 36 weeks of gestation.

• 4.3Neonatal Herpes

• known or suspected neonatal herpes: Acyclovir 20 mg/kg IV q 8 h
• Note(1):treatment for 14 days if disease is limited to the skin and mucous membranes, or
• Note(2):treatment for 21 days for disseminated disease and that involving the central nervous system.

• 4.4 Acyclovir-resistant genital herpes

• Preferred Regimens: Foscarnet 40–80 mg/kg IV q8 h until clinical resolution is attained
• Alternative Regimens: Cidofovir 5 mg/kg IV once weekly might also be effective.
• Alternative Regimens:Imiquimod topical preparations should be applied to the lesions qd for 5 consecutive days.

• 4.5Management of Sex Partners

• Preferred Regimens: Acyclovir 400 mg PO tid for 7–10 days OR Acyclovir 200 mg PO five times a day for 7–10 daysOR Valacyclovir 1 g PO bid for 7–10 daysOR Famciclovir 250 mg PO tid for 7–10 days
• Note:The sex partners of persons who have genital herpes can benefit from evaluation and counseling. Symptomatic sex partners should be evaluated and treated

• 4.6 Allergy, Intolerance, and Adverse Reactions

• Allergic and other adverse reactions to oral Acyclovir, Valacyclovir, and Famciclovir are rare. Desensitization to acyclovir has been described.

• Varicella-zoster virus Return to Top
• Human papillomavirus Return to Top

• Anogenital Warts

• 1.Preferred regimen for External Anogenital Warts (i.e., penis, groin, scrotum, vulva, perineum, external anus, and perianus)

• 1.1 Patient-Applied:: Imiquimod 3.75% or 5% cream OR Podofilox 0.5% solution or gel OR Sinecatechins 15% ointment
• 1.2 Provider-Administered: Cryotherapy with liquid nitrogen or cryoprobe OR Surgical removal either by tangential scissor excision, tangential shave excision, curettage, laser,or electrosurgery OR Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80%-90% solution
• Note(1): Many persons with external anal warts also have intra-anal warts. Thus, persons with external anal warts might benefit from an inspection of the anal canal by digital examination, standard anoscopy, or high-resolution anoscopy.
• Note(2): Might weaken condoms and vaginal diaphragms.

• 2.Alternative Regimens for External Genital Warts

• 2.1 Urethral Meatus Warts

• Regimens: Cryotherapy with liquid nitrogen OR Surgical removal

• 2.2 Vaginal Warts

• Regimens: Cryotherapy with liquid nitrogen. OR Surgical removal OR TCA or BCA 80%–90% solution
• Note: The use of a cryoprobe in the vagina is not recommended because of the risk for vaginal perforation and fistula formation

• 2.3 Cervical Warts

• Regimen: Cryotherapy with liquid nitrogen OR Surgical removal OR TCA or BCA 80%–90% solution
• Note: Management of cervical warts should include consultation with a specialist.For women who have exophytic cervical warts, a biopsy evaluation to exclude high-grade SIL must be performed before treatment is initiated.

• 2.4 Intra-anal Warts

• Regimens :Cryotherapy with liquid nitrogen OR Surgical removalOR TCA or BCA 80%–90% solution
• Note:Management of intra-anal warts should include consultation with a specialist.

• 3. Specific considerations

• 3.1 Follow-up

• Most anogenital warts respond within 3 months of therapy. Factors that might affect response to therapy include immunosuppression and treatment compliance. In general, warts located on moist surfaces or in intertriginous areas respond best to topical treatment. A new treatment modality should be selected when no substantial improvement is observed after a complete course of treatment or in the event of severe side effects; treatment response and therapy-associated side effects should be evaluated throughout the course of therapy.

• 3.2 Management of sex partners

• Persons should inform current partner(s) about having genital warts because the types of HPV that cause warts can be passed on to partners. Partners should receive counseling messages that partners might already have HPV despite no visible signs of warts, so HPV testing of sex partners of persons with genital warts is not recommended.

• 3.3 Pregnancy

• Podofilox (podophyllotoxin), Podophyllin, and Sinecatechins should not be used during pregnancy. Imiquimod appears to pose low risk but should be avoided until more data are available.
• Cesarean delivery is indicated for women with anogenital warts if the pelvic outlet is obstructed or if vaginal delivery would result in excessive bleeding.
• Pregnant women with anogenital warts should be counseled concerning the low risk for warts on the larynx of their infants or children (recurrent respiratory papillomatosis).

• 3.4 HIV infection
• Data do not support altered approaches to treatment for persons with HIV infection.
• Squamous cell carcinomas arising in or resembling anogenital warts might occur more frequently among immunosuppressed persons, therefore requiring biopsy for confirmation of diagnosis for suspicious cases

• 3.5 High-grade squamous intraepithelial lesions

• Biopsy of an atypical wart might reveal HSIL or cancer of the anogenital tract. In this instance, referral to a specialist for treatment is recommended.

• Influenza A Return to Top
• Influenza B Return to Top
• Avian influenza Return to Top

• 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 (1): Zanamivir10 mg inhaled bid for minimum 5 days
• Preferred regimen (2): Peramivir600 mg IV as a single dose for 1 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.

• Acanthamoeba Return to Top

• 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

• Balamuthia mandrillaris Return to Top

• Chronic granulomatous meningitis

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

• Naegleria fowleri Return to Top

• 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.

• Babesia microti Return to Top

• 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 .
• Preferred regimen: 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

• Leishmaniasis Return to Top

• 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

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