Hospital Level (Adult) 2019 - v2.0

Standard Treatment Guidelines
and Essential Medicines List

for South Africa
Hospital Level, Adults

2019 Edition
Electronic copies are available on National Department of Health Website:
http://www.health.gov.za/edp.php
Mobile versions can be downloaded as “EML Clinical Guide” smartphone app from
the relevant app stores - available for iOS and Android.
Print copies may be obtained from:

The Directorate: Affordable Medicines
Private Bag X828
Pretoria
0001
First printed 1998

Second edition 2006
Third edition 2012
Fourth edition 2015
Fifth edition 2019
ISBN: 978-1-990938-49-8
NOTE:
The information presented in these guidelines conforms to the current medical,
nursing and pharmaceutical practice. Contributors and editors cannot be held
responsible for errors, individual responses to medicines and other consequences.
© Copyright 2019, The National Department of Health.

Any part of this material may be reproduced, copied or adapted to meet local
needs, without permission from the Committee or the Department of Health,
provided that the parts reproduced are distributed free of charge or at no cost – not
for profit.
Suggested citation:
National Department of Health, South Africa. Essential Drugs Programme.
Hospital level (Adults) Standard Treatment Guidelines and Essential
Medicines List. 5th ed. 2019.
Published and funded by:

The National Department of Health, Pretoria, Republic of South Africa.
ACKNOWLEDGEMENTS
This edition of the Adult Hospital Level Standard Treatment Guidelines is
evidence of the dedication, technical expertise, skills, and considerable time
offered up by the Adult Hospital Level Expert Review Committee. The
Committee has enthusiastically evolved with the review process, embracing
Health Technology Assessment principles as South Africa journeys towards
Universal Health Coverage. Collaboration with various stakeholders was
strengthened and we thank all for your constructive engagement. We
recommend continuous participation in the peer review consultative process
and encourage the dissemination and implementation of these guidelines.
In particular, we would like to thank each Committee Member for their
valuable contributions, and the Chairpersons of the Adult Hospital Level
Expert Review Committee, Dr Black and Dr Dawood, for their unwavering
commitment and support during this review process.
NATIONAL ESSENTIAL MEDICINES LIST COMMITTEE (2017 - present)

Prof A Parrish (Chairperson) Mr K Mahlako
Dr G Reubenson (Vice Chairperson) Mrs N Makalima
Prof L Bamford Ms E Maramba
Dr A Black (resigned) Ms T Matsitse
Prof S Boschmans (resigned) Ms N Mazibuko
Dr RC Chundu Prof M Mendelson (resigned)
Dr K Cohen Ms N Mokoape (resigned)
Dr D Dawood (2019-current) Ms N Mpanza
Dr R de Waal Dr L Mvusi
Mr M Dheda Mr R Naidoo
Dr N Dlamini (resigned) Dr N Ndjeka
Ms D du Plessis Dr N Ndwamato (resigned)
Ms S Dube Dr L Padayachee
Prof M Freeman (resigned) Dr Z Pinini
Ms T Furumele (2019-current) Mr W Ramkrishna (resigned)
Mr A Gray Ms S Ramroop (resigned)
Dr G Grobler Ms R Reddy
Ms N Gumede Ms Z Rhemtula (2019-current)
Dr P Holele (resigned) Dr A Robinson (resigned)
Prof B Hoek (2020-current) Prof P Ruff
Ms Y Johnson Mr G Steel (resigned)
Brig Gen T Kgasago (resigned) Prof M Tshifularo (resigned)
Dr T Kredo (2019-current) Mr G Tshitaudzi
Ms F Loonat Dr K Vilakazi-Nhlapo (2019-current)
Dr J Lotter (resigned) Mr R Wiseman
Prof G Maartens Ms C Zeelie (resigned)
iii

ACKNOWLEDGEMENTS
ADULT HOSPITAL LEVEL EXPERT REVIEW COMMITTEE (2017-2020)

Dr A Black - Chair (resigned 2019) Dr H Dawood - Chair (2019-2020)
Dr E Bera - Vice Chair Prof PJC Commerford
Dr A Sherriff Dr RP Kaswa
Dr S Takuva Dr AS Rossouw
Dr GA Timothy Prof GS Gebhardt
Prof R Coetzee Dr L Robertson
Mr JM Nabyoma Dr R Griesel (resigned 2018)
Dr Y Hookamchand (resigned 2018) Dr V Mpongoshe (resigned 2019)
TECHNICAL AD HOC SUPPORT TO THE ADULT HOSPITAL LEVEL

COMMITTEE (2017-2020)
Dr K Balme Dr J Nel
Dr H Gunter Dr MFP van Jaarsveld
Prof S Honikman Prof L Wallis
Dr R Kularatne Dr L Weich
Ms J Mueller
MEDICINE REVIEW AUTHORS/PEER REVIEWERS

Dr K Balme Dr H Gunter Prof AG Parrish
Prof L Bamford Dr RP Kaswa Ms J Patterson
Dr E Bera Dr SR Krause Dr G Reubenson
Dr A Black Dr T Kredo Dr L Robertson
Prof R Coetzee Ms TD Leong Dr AS Rossouw
Prof K Cohen Ms P Letsoane Dr S Takuva
Prof PJC Commerford Prof A Moodley Dr GA Timothy
Dr H Dawood Dr MA Moorhouse Dr MFP van Jaarsveld
Dr R de Waal Ms L Mopelo Ms M Wilkinson
Prof GS Gebhardt Dr V Mpongoshe Mr R Wiseman
Mr A Gray Mr JM Nabyoma
Dr R Griessel Dr J Nel
Evidence reviews (78) developed during this review cycle are accessible at:
http://www.health.gov.za/index.php/standard-treatment-guidelines-and-essential-medicines-list/category/286-
hospital-level-adults
COSTINGS/ ECONOMIC ANALYSES

Dr E Bera Ms V Mutyambizi (UCT)
Ms E Chanikira (UCT) Dr J Miot (HE2RO)
Prof GS Gebhardt Ms R Rapiti (Priceless-SA)
Miss TD Leong Ms M Wilkinson (Cochrane-SA)
Dr L Chola (Priceless-SA) Mr T Wilkinson (Priceless-SA/ UCT)
Ms K Macquilkan (Priceless SA) Mr A Winch (Priceless SA)
Costing/ economic analyses (12) developed during this review cycle are accessible at:
http://www.health.gov.za/index.php/standard-treatment-guidelines-and-essential-medicines-list/category/286-
hospital-level-adults
iv

ACKNOWLEDGEMENTS
COMMENTS AND CONTRIBUTIONS

Dr K Balme Prof L Jenkins Dr V Pillay-Fuentes Lorente
Dr T Boltina Ms Y Johnson Dr F Pirie
Dr M Braithwaite Dr W Jooste Dr P Raubenheimer
Dr N Brey Dr T Kalk Dr G Reubenson
Dr K Brouard Dr J Kanku Prof B Rayner
Prof A Bryer Dr T Kemp Ms R Reddy
Prof J Carr Dr D Kettles Dr M Redelinghuys
Dr A Chin Ms B Koopman Prof G Richards
Dr Chundu Ms S Kirsten Prof P Ruff
Dr A Coetzee Dr L Lai King Dr A Scheibe
Dr R Coetzee Dr R Krause Prof A Schutte
Prof K Cohen Dr R Kularatne Mr R Setshedi
Dr M Conradie Prof G Lamacraft Dr S Singh
Dr T Crede Dr N Lister Prof M Sonderup
Dr J Cunningham Prof V Louw Prof W Spearman
Dr J Dave Prof D Lubbe Dr J Stanford
Dr H Dawood Ms E Maramba Dr D Stanton
Dr A de Villiers Dr K Mawson Dr C Stephen
Prof K Dheda Dr S Meiring Dr J Taljaard
Dr P Douglas-Jones Prof K Mlisana Dr A Thornton
Prof A Doubell Dr S Mohangi Ms N Thipe
Ms A du Toit Dr L Molife Dr N Tsabedze
Dr R du Toit Prof J Moodley Dr IS Ukpe
Prof S Dyer Dr MA Moorhouse Dr A Vachiat
Dr R Freercks Prof A Motala Dr E van Duuren
Ms M Gijzelaar Dr F Moti Dr MFP van Jaarsveld
Prof AGS Gous Ms L Muller Dr R van Rensburg
Prof N Govender Dr N Ndjeka Prof R van Zyl-Smit
Dr T Hardcastle Dr SC Nyoka-Mokgalong Ms C Vedalanker
Ms H Hayes Prof AP Parrish Dr L Visser
Dr E Hodgson Dr I Paruk Mr F Vorster
Dr B Hodkinson Dr M Patel Dr S Walaza
Ms H Hoffman Dr AJK Pecararo Prof L Wallis
Dr N Horn Dr L Pein Dr L Weich
Dr N Ismail Dr Petro Ms L Whitelaw
Allergan Pharmaceuticals South Africa (Pty) Ltd
National Committee on Confidential Enquiries into Maternal Deaths
Novartis South Africa
Pfizer Laboratories (Pty) Ltd
Private Healthcare Information Standards Committee (PHISC)
Psychological Society of South Africa: Sexuality & Gender Division
South African HIV Clinicians Society
Society for Endocrinology, Metabolism and Diabetes in South Africa
South African Rheumatism Arthritis Association
South African Gastroenterology Society
v

ACKNOWLEDGEMENTS
South African Medical Association

South African Society of Anaesthesiologists
South African Society of Clinical Pharmacy
South African Society of Ophthalmology
CLINICAL EDITORS
Prof PJC Commerford Dr R de Waal
Prof GS Gebhardt Prof G Maartens
EDITORIAL
Ms TD Leong Dr J Jugathpal
Ms G Mngola Ms A Brewer
Ms S Putter
SECRETERIATE
Ms TD Leong Dr J Jugathpal
Dr J Riddin Dr R Lancaster
Ms S Govender
LOGISTICS
Ms P Ngobese Mr M Molewa
DIRECTOR: AFFORDABLE MEDICINES

Ms K Jamaloodien
vi

TABLE OF CONTENTS
Foreword i
Introduction ii
Acknowledgements iii
Table of contents vii
The Essential Medicines Concept xxiii
How to use these guidelines xxiv
A guide to patient education in chronic diseases xxxiii
CHAPTER 1: ALIMENTARY TRACT 1.1

1.1 Gastrointestinal disorders 1.1
1.1.1 Bowel preparations 1.1
1.1.2 Diverticulosis 1.1
1.1.3 Gastro-oesophageal reflux disease (GORD) 1.2
1.1.4 Hiatus hernia 1.4
1.1.5 Inflammatory bowel disease 1.4
1.1.6 Pancreatitis, acute 1.4
1.1.7 Pancreatitis, chronic 1.5
1.1.8 Peptic ulcer 1.6
1.2 Hepatic disorders 1.7
1.2.1 Hepatitis, non-viral 1.8
1.2.2 Liver failure, acute 1.9
1.2.3 Portal hypertension and cirrhosis 1.10
1.2.4 Hepatitis, viral 1.11
1.2.4.1 Hepatitis B, acute 1.12
1.2.4.2 Hepatitis B, chronic (non-HIV coinfection) 1.13
1.2.4.3 Hepatitis B, chronic (HIV coinfection) 1.15
1.2.5 Liver abscess, pyogenic 1.15
1.2.6 Liver abscess, amoebic 1.15
1.2.7 Cholecystitis, acute and cholangitis, acute 1.16
1.3 Diarrhoea 1.16
1.3.1 Cholera 1.16
1.3.2 Dysentery (acute inflammatory diarrhoea) 1.17
1.3.3 Diarrhoea, acute non-inflammatory 1.17
1.3.4 Clostridum difficle diarrhoea 1.18
1.3.5 Amoebic dysentery 1.19
1.3.6 Giardiasis 1.20
1.3.7 Typhoid 1.20
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1.3.8 Bacterial peritonitis 1.20
CHAPTER 2: BLOOD AND BLOOD FORMING ORGANS 2.1

2.1 Anaemia 2.1
2.1.1 Anaemia, iron deficiency 2.1
2.1.2 Anaemia, megaloblastic 2.3
2.1.3 Anaemia, chronic disorder 2.5
2.1.4 Anaemia, haemolytic 2.5
2.1.5 Anaemia, aplastic 2.7
2.1.6 Anaemia, sickle cell 2.7
2.2 Febrile neutropenia 2.9
2.3 Myelodysplastic syndromes 2.10
2.4 Bleeding disorders 2.11
2.4.1 Haemophilia A and B, von willebrand’s disease 2.11
2.5 Immune thrombocytopenia (ITP) 2.15
2.6 Thrombotic thrombocytopenic purpura-haemolytic uraemic syndrome (TTP-HUS) 2.16
2.7 Acquired coagulation defects 2.17
2.7.1 Disseminated intravascular coagulation (DIC) 2.17
2.8 Venous thrombo-embolism 2.18
CHAPTER 3: CARDIOVASCULAR SYSTEM 3.1

3.1 Ischaemic heart disease and atherosclerosis, prevention 3.1
3.2 Acute coronary syndromes 3.5
3.2.1 ST elevation myocardial infarction (STEMI) 3.5
Non-ST elevation myocardial infarction (NSTEMI) and Unstable
3.2.2 angina (UA) 3.9
3.2.3 Chronic management of STEMI / NSTEMI / UA 3.11
3.2.4 Angina pectoris, stable 3.12
3.2.5 Atherosclerotic peripheral arterial disease 3.13
3.3 Cardiac dysrhythmias 3.14
3.3.1 Narrow QRS complex (supraventricular) tachydysrhythmias 3.14
3.3.1.1 Atrial fibrillation 3.15
3.3.1.2 Atrial flutter 3.18
3.3.1.3 AV junctional re-entry tachycardias 3.18
3.3.2 Wide QRS (ventricular) tachyarrhythmias 3.20
3.3.2.1 Regular wide QRS tachycardias 3.20
Sustained (>30 seconds) irregular wide QRS
3.3.2.2 tachycardias 3.21
Non-sustained (<30 seconds) irregular wide QRS
3.3.2.3 tachycardias 3.21
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3.3.2.4 Torsades de pointes ventricular tachycardia (VT) 3.22

3.3.3 Heart block (second or third degree) 3.23
3.3.4 Sinus bradycardia 3.24
3.3.5 Sinus arrest 3.24
3.4 Congestive cardiac failure (CCF) 3.24
3.5 Endocarditis, infective 3.27
3.6 Hypertension 3.31
3.6.1 Hypertension, asymptomatic severe 3.37
3.6.2 Hypertensive urgency 3.37
3.6.3 Hypertensive crisis, hypertensive emergency 3.38
3.7 Rheumatic heart disease 3.39
CHAPTER 4: DERMATOLOGY 4.1

4.1 Acne 4.1
4.2 Cellulitis and erysipelas 4.2
4.3 Impetigo 4.3
4.4 Furuncles and abscesses 4.4
4.5 Atopic eczema/ dermatitis 4.5
4.6 Erythema multiforme, stevens johnson syndrome, toxic epidermal necrolysis 4.7
4.7 Leg ulcers, complicated 4.9
4.8 Psoriasis 4.10
4.9 Urticaria 4.11
4.9.1 Papular urticaria 4.12
4.10 Fungal infections 4.12
4.11 Viral infections 4.13
4.11.1 Viral warts/anogenital warts 4.13
4.11.2 Shingles (Herpes zoster) 4.14
CHAPTER 5: GYNAECOLOGY 5.1

5.1 Dysmenorrhoea 5.1
5.2 Uterine bleeding, abnormal 5.1
5.3 Pelvic inflammatory disease (PID) 5.3
5.4 Endometriosis 5.5
5.5 Amenorrhoea 5.6
5.6 Hirsutism and virilisation 5.6
5.7 Infertility 5.7
5.8 Miscarriage 5.7
5.8.1 Silent miscarriage or early fetal death 5.8
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5.8.2 Incomplete miscarriage in the first trimester 5.8

5.8.3 Midtrimester miscarriage (from 13–22 weeks gestation) 5.8
5.8.4 Septic miscarriage 5.9
5.8.5 Trophoblastic neoplasia (‘hydatidiform mole’) 5.10
5.9 Termination of pregnancy (TOP) 5.10
5.9.1 TOP: Management for pregnancies ≤14 weeks of gestation 5.11
5.9.2 TOP: From the thirteenth week (12 weeks and 1 day) up to the
twentieth week (19 weeks and 6 days) 5.13
5.10 Sexual assault 5.14
5.11 Urinary incontinence 5.15
5.11.1 Stress incontinence 5.15
5.11.2 Urgency incontinence (overactive bladder) 5.16
5.12 Menopause and perimenopausal syndrome 5.16
5.13 Medical management of ectopic pregnancy 5.18
5.14 Family planning referrals from primary care 5.19
5.14.1 Intra-uterine contraceptive device 5.19
5.14.2 Implants 5.20
5.14.3 Injectable contraception 5.20
CHAPTER 6: OBSTETRICS 6.1

6.1 Anaemia in pregnancy 6.1
6.2 Diabetes mellitus in pregnancy 6.2
6.3 Heart disease in pregnancy 6.5
6.4 Hypertensive disorders in pregnancy 6.7
6.5 Eclampsia 6.10
6.6 Chronic hypertension 6.11
6.7 HIV in pregnancy 6.12
6.8 Syphilis 6.15
6.9 Hepatitis B in pregnancy 6.16
6.10 Jaundice in pregnancy 6.17
6.11 Hyperemesis gravidarum 6.18
6.12 Preterm labour (PTL) and preterm prelabour rupture of membranes (PPROM) 6.18
6.13 Prevention of preterm labour (singleton pregnancies only) 6.20
6.14 Suppression of labour for fetal distress 6.21
6.15 Labour induction 6.21
6.16 Labour pain, severe 6.23
6.17 Dehydration/Ketosis in labour 6.24
6.18 Postpartum fever 6.24
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6.19 Postpartum haemhorrhage 6.25

6.20 The Rhesus negative woman 6.26
6.21 Urinary tract infection (UTI) in pregnancy 6.27
6.21.1 Cystitis 6.27
6.21.2 Pyelonephritis, acute 6.28
CHAPTER 7: NEPHROLOGY/UROLOGICAL DISORDERS 7.1

7.1 Nephrology disorders 7.1
7.1.1 Chronic Kidney Disease (CKD) 7.1
7.1.2 Glomerular Disease and Nephritic Syndrome 7.6
7.1.3 Nephrotic syndrome 7.7
7.1.4 Acute kidney injury (AKI) 7.8
7.1.5 Renal replacement therapy 7.9
7.2 Major electrolyte abnormalities 7.10
7.2.1 Hyperkalaemia 7.10
7.2.2 Hypokalaemia 7.10
7.2.3 Hypernatraemia 7.11
7.2.4 Hyponatraemia 7.12
7.3 Urological disorders 7.15
7.3.1 Haematuria 7.15
7.3.2 Urinary tract infection (UTI) 7.16
7.3.3 Recurrent UTI 7.18
7.3.4 Prostatitis 7.19
7.3.5 Benign prostatic hyperplasia 7.19
7.3.6 Overactive bladder 7.20
7.3.7 Erectile dysfunction 7.20
7.3.8 Renal calculi 7.21
CHAPTER 8: ENDOCRINE CONDITIONS 8.1

8.1 Acromegaly 8.1
8.2 Adrenal insufficiency (addison disease) 8.1
8.3 Androgen deficiency 8.3
8.4 Cushing syndrome 8.4
8.5 Diabetes mellitus 8.5
8.5.1 Type 2 diabetes mellitus 8.7
8.5.2 Type 1 diabetes mellitus 8.10
8.6 Diabetic emergencies 8.12
8.6.1 Hypoglycaemia 8.12
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8.6.2 Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemic state

(HHS) 8.14
8.7 Complications of diabetes 8.17
8.7.1 Diabetic neuropathies 8.17
8.7.2 Diabetic kidney disease 8.18
8.7.3 Diabetic foot ulcers 8.18
8.8 Dyslipidaemia 8.19
8.9 Hypercalcaemia, including primary hyperparathyroidism 8.21
8.10 Hypocalcaemia 8.22
8.11 Hypothyroidism 8.23
8.12 Osteoporosis 8.24
8.13 Osteomalacia/rickets 8.26
8.14 Paget’s disease 8.26
8.15 Pituitary disorders 8.26
8.15.1 Prolactinoma 8.26
8.15.2 Anterior hypopituitarism 8.27
8.15.3 Diabetes insipidus (posterior hypopituitarism) 8.28
8.16 Phaeochromocytoma 8.30
8.17 Primary aldosteronism 8.31
8.18 Hyperthyroidism 8.32
8.18.1 Graves’ hyperthyroidism 8.32
8.18.2 Toxic multinodular goiter 8.33
8.18.3 Single toxic nodules 8.33
8.18.4 Thyroiditis 8.34
8.18.5 Thyroid crisis 8.34
CHAPTER 9: SYSTEMIC AND HEALTHCARE-ASSOCIATED INFECTIONS 9.1

Antimicrobial stewardship 9.1
9.1 Healthcare-associated and hospital acquired infections 9.1
9.1.1 Intravascular catheter infections 9.2
9.1.2 Surgical wound infections 9.3
9.1.3 Hospital-acquired pneumonia (HAP) 9.4
9.1.4 Urinary tract infections, catheter associated 9.6
9.2 Adult vaccination 9.7
9.2.1 Rabies vaccination 9.7
9.3 Brucellosis 9.7
Emerging respiratory Pathogens, e.g. Covid-19: Coronavirus-19 disease, Middle
9.4 East Respiratory Syndrome CoronaVirus infection: Mers CoV 9.7
9.5 Haemorrhagic fever syndrome 9.9
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9.6 Hydatid disease 9.10

9.7 Malaria 9.10
9.7.1 Malaria, uncomplicated 9.10
9.7.2 Malaria, severe 9.11
9.8 Schistomiasis 9.12
9.9 Tetanus 9.13
9.10 Tick bite fever 9.15
9.11 Typhoid fever (enteric fever) 9.15
9.12 Varicella (chickenpox), complicated 9.16
9.13 Zoster (shingles) 9.17
CHAPTER 10: HIV AND AIDS 10.1

10.1 Antiretroviral therapy 10.1
10.1.1 Management of selected antiretroviral adverse drug reactions 10.9
10.1.2 Immune reconstitution inflammatory syndrome (IRIS) 10.16
10.2 Opportunistic diseases 10.17
10.2.1 Tuberculosis preventive therapy (TPT) 10.17
10.2.2 Opportunistic infection prophylaxis, with cotrimoxazole 10.18
10.2.3 Candidiasis of oesophagus/trachea/bronchi 10.18
10.2.4 Cryptococcosis 10.19
10.2.4.1 Asymptomatic cryptococcosis, CrAg positive 10.19
10.2.4.2 Symptomatic, non-meningeal cryptococcosis 10.21
10.2.4.3 Cryptococcal meningitis 10.21
10.2.5 Cryptosporidiosis diarrhoea 10.22
10.2.6 Cytomegalovirus (CMV) 10.23
10.2.7 Cystoisosporiasis 10.24
10.2.8 Mycobacteriosis – disseminated non-tuberculous 10.24
10.2.9 Pneumocystis pneumonia 10.25
10.2.10 Cerebral toxoplasmosis 10.26
10.3 HIV and kidney disease 10.27
10.4 Kaposi Sarcoma (KS) 10.28
10.5 Post-exposure prophylaxis 10.29
10.5.1 Post-exposure prophylaxis, occupational 10.29
10.5.2 Non occupational post exposure prophylaxis, sexual assault 10.32
10.5.3 Non occupational post exposure prophylaxis, inadvertent non-
occupational 10.33
CHAPTER 11: SURGICAL ANTIBIOTIC PROPHYLAXIS 11.1

General principles 11.1
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Dosage recommendations 11.2

Antibiotic prophylaxis 11.3
Special considerations 11.5
Process measures 11.5
CHAPTER 12: ANAESTHESIOLOGY AND INTENSIVE CARE 12.1

12.1 Premedication 12.1
12.2 General anaesthesia 12.1
12.2.1 Intravenous induction (and/or maintenance) agents 12.1
12.2.2 Inhalation agents 12.2
12.2.2.1 Induction 12.2
12.2.2.2 Maintenance 12.2
12.3 Muscle relaxants 12.3
12.3.1 Depolarising muscle relaxants 12.3
12.3.2 Non-depolarising muscle relaxants (NDMR) 12.3
12.3.3 Muscle relaxation for rapid sequence intubation 12.4
12.3.4 Medicines to reverse muscle relaxation 12.4
12.4 Perioperative analgesia 12.5
12.4.1 Perioperative analgesics 12.5
12.4.1.1 Oral analgesics 12.5
12.4.1.2 Intravenous analgesics 12.6
12.4.2 Postoperative pain in the recovery room 12.6
12.4.3 Postoperative analgesia ward prescriptions 12.7
12.4.3.1 Examples of ward prescriptions for postoperative
analgesia according to anticipated pain severity 12.7
12.5 Intravenous fluids 12.9
12.5.1 Crystalloids 12.9
12.6 Medicines to treat complications of anaesthesia 12.10
12.6.1 Malignant hyperthermia 12.10
12.6.2 Local anaesthetic toxicity 12.10
12.6.3 Anaesthetic-related acute hypotension 12.11
12.6.4 Anaesthetic-related acute hypertension 12.11
12.6.5 Postoperative nausea and vomiting (PONV) 12.11
12.6.5.1 Prevention of PONV 12.11
12.6.5.2 Treatment of PONV 12.12
12.6.6 Acid aspiration prophylaxis 12.13
12.7 Spinal (intrathecal) anaesthesia 12.13
12.7.1 Anticoagulants and spinal or epidural blocks 12.14
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12.8 Epidural anaesthesia 12.15

12.9 Peripheral nerve block or wound infiltration 12.15
12.10 Topical anaesthesia 12.16
12.11 Sedation 12.16
12.12 Pain, chronic 12.16
12.13 Intensive care 12.16
12.13.1 Nutritional support 12.16
CHAPTER 13: MUSCULOSKELETAL CONDITIONS 13.1

13.1 Arthritis, rheumatoid (RA) 13.1
13.2 Arthritis, septic and osteomyelitis, acute 13.4
13.3 Osteoarthritis 13.6
13.4 Gout 13.7
13.5 Seronegative spondylarthritis 13.10
13.5.1 Arthritis, reactive 13.11
13.6 Systemic lupus erythematosus (SLE) 13.11
CHAPTER 14: NEUROLOGICAL DISORDERS 14.1

14.1 Cerebrovascular disease 14.1
14.1.1 Stroke 14.1
14.1.2 Transient ischaemic attack (TIA) 14.3
14.1.3 Spinal cord injury, acute 14.5
14.1.4 Subarachnoid haemorrhage 14.5
14.2 Dementia 14.6
14.3 Delirium 14.7
14.4 Epilepsy 14.7
14.4.1 Status epilepticus 14.12
14.5 Headache and facial pain syndromes 14.14
14.5.1 Migraine 14.14
14.5.2 Cluster headache 14.15
14.5.3 Trigeminal neuralgia 14.15
14.5.4 Tension headache 14.15
14.5.5 Medication overuse headache 14.16
14.5.6 Idiopathic intracranial hypertension (pseudotumour cerebri) 14.16
14.6 Infectious and parasitic conditions 14.17
14.6.1 Meningitis 14.17
14.6.1.1 Tuberculous meningitis 14.19
14.6.1.2 Cryptococcal meningitis 14.20
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14.6.1.2.1 Cryptococcal meningitis, HIV-infected 14.20

14.6.1.2.2 Cryptococcal meningitis, HIV-uninfected 14.20
14.6.2 Viral meningoencephalitis 14.21
14.6.3 Meningovascular syphilis (neurosyphilis) 14.22
14.6.4 Brain abscess 14.23
14.6.5 Antimicrobial use in patients with head injuries 14.23
14.6.6 Neurocysticercosis 14.23
14.7 Movement disorders 14.24
14.7.1 Parkinsonism, primary 14.24
14.7.1.1 Idiopathic parkinson disease 14.24
14.7.2 Parkinsonism, secondary 14.25
14.7.3 Essential tremor 14.26
14.7.4 Chorea 14.26
14.8 Neuropathy 14.26
14.9 Myelopathy, acute 14.27
14.10 Multiple sclerosis 14.27
14.11 Myasthenia gravis 14.27
14.12 Oedema, cerebral 14.27
14.12.1 Brain oedema due to tumours and inflammation 14.28
14.12.2 Brain oedema due to traumatic injury 14.28
CHAPTER 15: MENTAL HEALTH CONDITIONS AND SUBSTANCE MISUSE 15.1

Mental health conditions 15.1
15.1 Aggressive disruptive behaviour in adults 15.1
15.2 Anxiety and obsessive-compulsive disorders 15.6
15.3 Mood disorders 15.11
15.3.1 Depressive disorders 15.11
15.3.2 Bipolar and related disorders 15.14
15.4 Trauma and stress-related disorders 15.20
15.5 Psychotic disorders 15.21
15.5.1 Acute and transient psychotic disorders 15.22
15.5.2 Schizophrenia spectrum disorders 15.22
15.6 Insomnia 15.26
15.7 Discontinuation symptoms of serotonin reuptake inhibitors 15.27
Substance misuse 15.28
15.8 Alcohol 15.29
18.8.1 Alcohol withdrawal delirium (delirium tremens) 15.29
15.9 Opiate (e.g. heroin, unga, whoonga, nyaope) withdrawal 15.31
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Stimulant withdrawal, including cocaine and amphetamine type stimulants (e.g.

15.10 methamphetamine/ tik, methcathinone/cat) 15.34
15.11 Methaqualone (mandrax/whitepipe) withdrawal 15.34
15.13 Cannabis withdrawal 15.34
15.13 Benzodiazepine withdrawal 15.34
CHAPTER 16: RESPIRATORY DISORDERS 16.1

16.1 Asthma, acute 16.1
16.2 Asthma, chronic persistent 16.3
16.3 Bronchiectasis 16.6
16.4 Chronic obstructive pulmonary disease (COPD) 16.7
16.5 Lung abscess 16.12
16.6 Pneumonia, community acquired 16.13
16.7 Pneumonia, aspiration 16.15
16.8 Empyema 16.16
16.9 Tuberculosis, pulmonary 16.17
16.10 Tuberculosis, pleural (TB pleurisy) 16.18
16.11 Drug-resistant TB 16.19
16.11.1 Isoniazid monoresistant TB 16.19
16.11.2 Multidrug-resistant TB 16.20
CHAPTER 17: EAR, NOSE AND THROAT DISORDERS 17.1

17.1 Epiglottitis 17.1
17.2 Rhinitis, Allergic, persistent 17.1
17.3 Sinusitis, bacterial, complicated 17.2
17.4 Otitis media, acute 17.3
17.5 Otitis media, chronic, suppurative 17.4
17.6 Mastoiditis 17.5
17.7 Otitis Externa 17.5
17.8 Abscess, Peritonsillar 17.6
17.9 Vertigo, acute 17.7
CHAPTER 18: EYE DISORDERS 18.1

18.1 Conjunctivitis 18.1
18.1.1 Conjunctivitis, Adenoviral 18.1
18.1.2 Conjunctivitis, Allergic 18.2
18.1.3 Conjunctivitis, Bacterial 18.2
18.2 Endophthalmitis, Bacterial 18.2
18.3 Glaucoma 18.3
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TABLE OF CONTENTS
18.4 Herpes zoster Ophthalmicus 18.5

18.5 Keratitis 18.6
18.5.1 Keratitis, herpes simplex 18.6
18.5.2 Keratitis, suppurative 18.6
18.6 Retinitis, HIV CMV 18.7
18.7 Uveitis 18.7
18.8 Surgical and diagnostic products 18.8
18.9 Dry eye 18.9
18.10 Medical management of eye injury 18.9
18.10.1 Chemical burn 18.9
18.10.2 Eye injury: blunt/penetrating/foreign body 18.9
CHAPTER 19: POISONINGS 19.1

Poisons information centres 19.1
Envenomation 19.1
19.1 Insect bites and stings 19.1
19.2 Snakebites 19.2
19.2.1 Cytotoxic and neurotoxic snakebite 19.3
19.2.2 Boomslang snakebite 19.5
19.2.3 Snake venom in the eye 19.6
19.3 Scorpion envenomation 19.6
19.4 Spider envenomation 19.8
Poisoning 19.10
19.5 Analgesic poisoning 19.14
19.5.1 Paracetamol poisoning 19.14
19.5.2 Salicylate poisoning 19.17
19.5.3 Opioid poisoning 19.18
19.6 Antidepressant poisoning 19.19
19.6.1 Tricyclic antidepressant poisoning 19.19
19.7 Iron poisoning 19.20
19.8 Theophylline poisoning 19.21
19.9 Sedative hypnotic poisoning 19.22
19.9.1 Benzodiazepine poisoning 19.22
19.9.2 Lithium poisoning 19.22
19.10 Isoniazid poisoning 19.23
19.11 Calcium channel blocker and beta blocker poisoning 19.24
19.12 Cotrimoxazole poisoning 19.25
19.13 Antiretroviral agents poisoning 19.26
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TABLE OF CONTENTS
19.14 Illicit drugs 19.26

19.14.1 Cocaine poisoning 19.26
19.14.2 Amphetamine derivatives poisoning 19.27
19.15 Hydrocarbon poisoning 19.28
19.16 Ingestion of caustic substances 19.29
19.17 Alcohols 19.29
19.17.1 Ethanol poisoning 19.29
19.17.2 Ethylene glycol poisoning 19.30
19.17.3 Methanol poisoning 19.31
19.18 Pesticides and rodenticides 19.32
19.18.1 Amitraz poisoning 19.32
19.18.2 Organophosphate poisoning 19.33
19.18.3 Paraquat poisoning 19.35
19.19 Anticoagulant (warfarin and rodenticide superwarfarin) poisoning 19.35
19.20 Carbon monoxide poisoning 19.37
19.21 Heavy metal poisoning 19.38
19.22 Poisoning with substances that cause methaemoglobinaemia 19.39
CHAPTER 20: EMERGENCIES AND INJURIES 20.1

Cardiac arrest - cardiopulmonary resuscitation algorithm 20.1
20.1 Cardiac arrest in adults 20.2
20.2 Post cardiac arrest care 20.4
20.3 Cardiac dysrhythmias 20.6
Medical emergencies 20.7
20.4 Acute coronary syndromes 20.7
20.5 Asthma, acute 20.7
20.6 Angioedema 20.7
20.7 Anaphylaxis/anaphylactic shock 20.8
20.8 Delirium with perceptual disturbances 20.10
20.9 Diabetic emergencies 20.11
20.10 Pulmonary oedema, acute 20.11
20.11 Shock 20.13
20.11.1 Hypovolaemic shock 20.13
20.11.1.1 Non-trauma-related hypovolaemic shock 20.13
20.11.1.2 Trauma-related hypovolaemic shock 20.13
20.11.1.2.1 Massive transfusion 20.14
20.11.2 Distributive shock 20.15
20.11.2.1 Neurogenic shock 20.16
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TABLE OF CONTENTS
20.11.2.2 Septic shock 20.17

20.11.3 Cardiogenic shock 20.18
20.11.4 Obstructive shock 20.18
20.12 Status epilepticus 20.19
Trauma and injuries 20.20
20.13 Acute kidney injury 20.20
20.14 Bites and stings 20.20
20.15 Burns 20.20
20.16 Exposure to poisonous substances 20.24
20.17 Eye injuries 20.24
20.18 Post exposure prophylaxis 20.24
20.19 Soft tissue injuries 20.24
20.20 Sprains and strains 20.24
CHAPTER 21: ONCOLOGIC EMERGENCIES 21.1

21.1 Oncological emergencies 21.1
21.1.1 Metabolic emergencies 21.1
21.1.1 Hypercalcemia of malignancy 21.1
Syndrome of inappropriate antidiuretic hormone
21.1.2 (SIADH) 21.1
21.1.3 Tumour lysis syndrome 21.1
21.1.2 Haematologic emergencies 21.2
21.1.2.1 Febrile neutropaenia 21.2
21.1.2.2 Hyperviscosity and leucostatic syndromes 21.2
21.1.3 Structural emergencies 21.3
21.1.3.1 Epidural spinal cord compression 21.3
21.1.3.2 Malignant pericardial effusion 21.3
21.1.3.3 Superior vena cava syndrome 21.4
21.2 Side effects from oncology treatment agent 21.4
21.2.1 Diarrhoea 21.4
21.2.2 Extravasations 21.5
21.2.3 Constipation 21.5
21.3 Side-effects from radiation and chemotherapy 21.5
21.3.1 Radiation and chemotherapy related mucositis 21.5
21.3.2 Wet desquamation of skin 21.6
21.3.3 Radiation or chemotherapy induced pneumonitis 21.7
21.3.4 Radiation proctitis 21.7
21.3.5 Radiation or chemotherapy induced cystitis 21.8
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TABLE OF CONTENTS
21.4 Side-effects from pain medication 21.8

21.4.2 Nausea and vomiting 21.8
21.4.3 Depression 21.8
CHAPTER 22: MEDICINES USED FOR DIAGNOSIS 22.1

22.1 Diagnostic contrast agents and related substances 22.1
CHAPTER 23: SEDATION 23.1
23.1 Sedation 23.1
23.1.1 Procedural sedation and analgesia 23.1
23.1.2 Sedation in intensive care 23.4
23.1.3 Sedation in palliative care 23.5
CHAPTER 24: MEDICINES FOR PALLIATIVE CARE 24.1

Palliative care 24.1
24.1 Gastrointestinal conditions 24.1
24.1.1 Anorexia and cachexia 24.1
24.1.3 Diarrhoea 24.3
24.1.4 Nausea and vomiting 24.3
24.2 Neuropsychiatric conditions 24.4
24.2.1 Anxiety 24.4
24.2.2 Delirium 24.6
24.2.3 Depression 24.7
24.2.4 Fatigue 24.8
24.3 Pain 24.8
24.3.1 Chronic cancer pain 24.8
24.3.2 Neuropathic pain 24.9
24.4 Respiratory conditions 24.9
24.4.1 Dyspnoea 24.9
24.4.2 Respiratory secretions 24.9
24.5 Sedation in palliative care 24.10
24.6 End of life care 24.11
CHAPTER 25: SEXUALLY TRANSMITTED INFECTIONS 25.1

25.1 Male urethritis syndrome (MUS) 25.1
25.2 Vaginal discharge syndrome (VDS) 25.2
25.3 Genital ulcer syndrome (GUS) 25.3
25.4 Bubo 25.5
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TABLE OF CONTENTS
CHAPTER 26: PAIN 26.1

26.1 Pain, chronic 26.1
26.1.1 Analgesia for chronic non-cancer pain 26.1
26.1.2 Analgesia for chronic cancer pain 26.5
26.1.3 Treatment of adverse effects of chronic opioid use 26.5
26.1.4 Neuropathic pain 26.6
26.2 Analgesia for acute non-surgical pain 26.8
26.2.1 Medical conditions associated with severe pain 26.8
26.2.2 Acute pain due to gastrointestinal colic 26.8
Appendix I: Antimicrobial medicines AI.1
Appendix II: Prescribing information for specific medicines AII.1
Appendix III: Medicines in pregnancy AIII.1
Appendix IV: Extemporaneous preparations AIV.1
Appendix V: Asthma monitoring AV.1
Guideline for the motivation of a new medicine on the National Essential Medicines List xli
Guidelines for adverse drug reaction reporting xlv
Disease notification procedures li
Index of conditions and diseases liv
Index of medicines lxiii
Abbreviations lxxii
Declarations of interest and funding lxxvi
Useful contact numbers and url links lxxix
xxii

THE ESSENTIAL MEDICINES CONCEPT
The WHO describes Essential medicines as those that satisfy the priority
health care needs of the population. Essential medicines are intended to be
available within the context of functioning health systems at all times in
adequate quantities, in the appropriate dosage forms, with assured quality
and adequate information, and at a price the individual and the community
can afford.
The concept of essential medicines is forward-looking. It incorporates the
need to regularly update medicines selections to:
» reflect new therapeutic options and changing therapeutic needs;
» the need to ensure medicine quality; and
» the need for continued development of better medicines, medicines for
emerging diseases, and medicines to meet changing resistance patterns.
Effective health care requires a judicious balance between preventive and
curative services. A crucial and often deficient element in curative services is
an adequate supply of appropriate medicines. In the health objectives of the
National Drug Policy, the government of South Africa clearly outlines its
commitment to ensuring availability and accessibility of medicines for all
people. These are as follows:
» To ensure the availability and accessibility of essential medicines to all
citizens.
» To ensure the safety, efficacy and quality of medicines.
» To ensure good prescribing and dispensing practices.
» To promote the rational use of medicines by prescribers, dispensers and
patients through provision of the necessary training, education and
information.
» To promote the concept of individual responsibility for health, preventive
care and informed decision-making.
Achieving these objectives requires a comprehensive strategy that not only
includes improved supply and distribution, but also appropriate and extensive
human resource development. The implementation of an Essential Drugs
Programme (EDP) forms an integral part of this strategy, with continued
rationalisation of the variety of medicines available in the public sector as a
first priority. The private sector is encouraged to use these guidelines and
medicine list wherever appropriate.
The criteria for the selection of essential medicines for Adult Hospital Level in
South Africa were based on the WHO guidelines for drawing up a national
EML. Essential medicines are selected with due regard to disease prevalence,
evidence on efficacy and safety, and comparative cost.
The implementation of the concept of essential medicines is intended to be
flexible and adaptable to many different situations. It remains a national
responsibility to determine which medicines are regarded as essential.
xxiii
HOW TO USE THESE GUIDELINES
Principles
The National Drug Policy1 makes provision for an Essential Drugs Programme
which is a key component in promoting rational medicines use.
The perspective adopted in the Adult Hospital Level Standard Treatment
Guidelines (STGs) is that of a competent medical officer practicing in a public
sector hospital. The STGs serve as a standard for practice, but do not replace
sound clinical judgment. It is important to remember that the treatments
recommended are guidelines only and are based on the assumption that
prescribers can manage patients with the relevant conditions.
This includes rational prescribing in the elderly and palliative care, as the use
of some medicines, especially as people get older or more ill, can cause more
harm than good. Optimizing medication through targeted de-prescribing is a
vital part of managing chronic conditions, avoiding adverse effects and
improving outcomes. The goal of de-prescribing is to reduce pill burden and
maintain or improve quality of life.
All reasonable steps were taken to align the STGs with Department of Health
guidelines that were available at the time of review. Each treatment guideline
in the Adult Hospital Level STGs and Essential Medicines List (EML) was
designed as a progression in care from the current Primary Health Care (PHC)
STGs and EML. Given that the PHC STGs and EML were reviewed prior to
the Adult Hospital Level STGs, the two STGs are not always perfectly aligned.
Where referral to a tertiary facility is recommended, the relevant medicines
have either been reviewed or included in the tertiary level EML, or are in the
process of being reviewed.
Each medicine was included or removed from the EML using an evidence
based review of safety and effectiveness, followed by considerations of cost
and other relevant practice factors, such as availability and storage
requirements. Some recommendations might not be aligned with the SAHPRA
registered label/package insert; but are guided by health needs assessment
and the best available scientific evidence.
The dosing regimens provide the recommended doses used in usual
circumstances. However, the prescribed dose should take into consideration
drug-drug interactions and co-morbid states, notably renal or hepatic failure,
critical illness, and morbid obesity.
Local formularies
The EML has been developed down to generic or International Non-Propriety
Name (INN) level. Each Province is expected to review the EML and prevailing
tenders and compile a formulary which:
» lists formulations and pack sizes that will facilitate care in alignment with the
STGs and EML;
1 National Drugs Policy, 1996. https://www.gov.za/documents/national-drugs-policy

xxiv
» selects the preferred member of the therapeutic class based on cost;
» implements formulary restrictions consistent with the local environment; and
» provides information on medicine prices.
Therapeutic classes are designated in the “Medicine treatment” sections of the
STGs which provide classes of medicines followed by an example of each class,
such as ‘HMGCoA reductase inhibitors (statins) e.g. simvastatin’. Therapeutic
classes are designated where none of the members of the class offer any
significant benefit over the other registered members of the class. It is
anticipated that by listing a class rather than a specific medicine there is
increased competition and hence an improved chance of obtaining the lowest
possible price in the tender process. The designation of medicines into
therapeutic classes may also assist with remedial actions to mitigate challenges
to security of supply, by providing suggested alternatives which have already
been approved by the ministerially appointed National Essential Medicines List
Committee (NEMLC)2.
Where therapeutic classes are listed in the STGs always consult your local
formulary to identify the specific medicine that has been approved for use in your
facility. A therapeutic interchange database has been developed that lists
evidence-based reviewed medicines that have been grouped into each
therapeutic class for a specific condition, as outlined in the policy for classifying
medicines into therapeutic classes for purposes of therapeutic interchange. The
database and policy are available on the National Department of Health website:
http://www.health.gov.za/edp.php
Navigating the guidelines

It is important that you become familiar with the contents and layout of these
guidelines in order to use the STGs effectively.
The STGs are arranged into chapters according to the organ systems of the
body. Conditions and medicines are cross referenced in two separate indexes
of these guidelines. In some therapeutic areas that are not easily amenable
to the development of a STG, the section is limited to a list of medicines.
This edition of the Adult Hospital Level STG and EML provides additional
information: Appendix III – guidance on the use of certain medicines in
pregnancy; and Appendix IV – guidance on extemporaneous preparation of
certain medicines using a standardised formula.
Revisions to previous recommendations are accompanied by the level of

evidence that is cited and hyperlinked accordingly. All evidence is graded
according to the Strength Of Recommendation Taxonomy (SORT) (a patient-
centered approach to grading evidence in the medical literature), described in
detail on page xli. To further promote transparency of medicine selection
decisions, NEMLC reports, medicine reviews and costing reports are available
2 NEMLC is tasked to formulate and revise the Standard Treatment Guidelines (STGs) and Essential Medicines List
(EML) using a peer review consultative process.
xxv
on the National Department of Health website: http://www.health.gov.za/edp.php
The section on Patient Education in Chronic Conditions aims to assist health
workers to improve patient adherence and health, generally. Information on
the Central Chronic Medicines Dispensing and Distribution (CCMDD)
programme is available at: [email protected]
Diagnosis codes from the International Statistical Classification of Diseases and
Related Health Problems (ICD-10) are included for each condition to facilitate
accurate recording of diagnoses. The primary ICD-10 code may be
accompanied by a secondary code that is bracketed to differentiate a secondary
manifestation from the primary aetiology. (For example, uncomplicated
broncho-pneumonia with severe penicillin allergy would be coded as:
J18.0+(Z88.0)). All the rules and guidelines for the use of ICD-10 must be
applied as per the World Health Organisation (WHO), the agreed South African
Morbidity Coding Standards and Guidelines document, and the South African
Master Industry Table (MIT).
Available at: http://www.health.gov.za/index.php/shortcodes/2015-03-29-10-
42-47/2015-06-10-09-23-36/2015-06-10-09-26-11
Medicines safety
Provincial and local Pharmaceutical and Therapeutics Committees (PTCs)
should develop medicines safety systems to obtain information regarding
medication errors, prevalence and importance of adverse medicine events,
interactions, and medicines quality. These systems should not only support the
regulatory pharmacovigilance plan, but should also provide
pharmacoepidemiology data that will be required to inform future essential
medicines decisions as well as local interventions to improve safety.
In accordance with SAHPRA’s guidance on reporting adverse drug reactions
in South Africa, the medical officer with the support of the PTC should report
the relevant adverse reactions to the National Adverse Drug Event Monitoring
Centre (NADEMC). To facilitate reporting, a copy of the form and guidance on
its use has been provided.
Feedback
Comments that aim to improve these treatment guidelines will be appreciated.
The submission form and guidance for completing the form are included with
these guidelines. Motivations will be accepted from Provincial PTCs only.
THERAPEUTIC DRUG MONITORING (TDM)

Medicines with narrow therapeutic indices and those with variable
pharmacokinetics should be monitored regularly to optimise dosing, obtain
maximum therapeutic effect, limit toxicity, and assess compliance. Appendix
II provides detailed information for specific medicines.
TDM sampling for all drugs is to be done only once steady state has been
reached (i.e. after 4–5 half-lives).
Lithium
Measure serum concentrations at about 12 hours after the last dose – i.e.
xxvi
immediately prior to the next dose. Concentrations should be less than 1
mmol/L and should be monitored 6-monthly while on therapy, with more
frequent monitoring in the elderly (see Appendix II for guidance on prescribing
lithium).
Aminoglycosides
Peak concentrations will generally be adequate if dosing is adequate (e.g.
gentamicin 5 mg/kg/day in a single daily dose) and measuring peak
concentrations is not recommended unless the organism has a high minimum
inhibitory concentration (MIC) or if the patient is critically ill. Trough
concentrations, taken immediately before the next dose, are valuable for
identifying potential toxicity. Toxicity may manifest as deafness or renal
impairment. Aminoglycosides are relatively contraindicated in renal
impairment. Audiology assessment and renal function monitoring is indicated
in all patients who develop aminoglycoside toxicity (see Appendix II for
guidance on prescribing amikacin and gentamicin).
Anti-epileptics
Measuring concentrations may be helpful to confirm poor adherence or to
confirm a clinical suspicion of toxicity. Routine measurement in patients with
well-controlled seizures and no clinical evidence of toxicity, is not appropriate.
Individual concentrations may be difficult to interpret – if in doubt, seek
assistance from a clinical pharmacologist.
PRESCRIPTION WRITING
Prescribers may initiate and/or maintain treatment with medicines as per the
STGs in accordance with their scope of practice.
Medicines should be prescribed only when they are necessary for treatment
following clear diagnosis. Not all patients or conditions need prescriptions for
medication. In certain conditions simple advice and general and supportive
measures may be more suitable.
In all cases carefully consider the expected benefit of a prescribed medication
against potential risks. This is especially important during pregnancy where
the risk to both mother and fetus must be considered.
All prescriptions must:
» be written legibly in ink by the prescriber with the full name, identification
number and address of the patient, and signed with the date on the
prescription form;
» specify the age and, in the case of children, weight of the patient;
» have prescriber details including contact details i.e. name, qualification,
registration number, address and contact telephone number;
» indicate the diagnosis on the prescription, where there patient has
provided consent.
In all prescriptions:
» State the treatment regimen in full:
 medicine name, strength and formulation,
 dose or dosage,
xxvii
 dose frequency,
 dose route
 duration of treatment,
 e.g. amoxicillin 250 mg capsules, 8 hourly orally for 5 days.
» Write the name of the medicine/preparation in full using the generic name.
» Avoid abbreviations to reduce the risk of misinterpretation. Avoid the
Greek mu (ų): write mcg as an abbreviation for micrograms.
» Avoid unnecessary use of decimal points. If necessary, write a zero in
front of the decimal point only, e.g. 2 mg not 2.0 mg; or 0.5 mL not .5 mL.
» Avoid Greek and Roman frequency abbreviations that cause considerable
confusion (qid, qod, tds, tid, etc). Instead either state the frequency in
terms of hours (e.g. ‘8 hourly’) or times per day in numerals (e.g. ‘3x/d’).
» In the case of “as required”, a minimum dose interval should be specified,
e.g. ‘every 4 hours as required’.
» Most monthly outpatient scripts for chronic medication are for 28 days;
check that the patient will be able to access a repeat before the 28 days
are completed.
» Prescriptions for schedules 6 medicines are not repeatable, requiring to
be issued monthly; and the quantity to be issued should be expressed in
words.
After writing a prescription, check that the dose, dose units, route, frequency,
and duration for each item is stated. Consider whether the number of items is
too great to be practical for the patient, and check that there are no redundant
items or potentially important drug interactions. Check that the script is dated,
that the patient’s name, identification number and diagnosis/diagnostic code
are on the prescription form. Only then should you sign the prescription and
provide some other way for the pharmacy staff to identify the signature if there
are problems (print your name, use a stamp, or use a prescriber number from
your institution’s pharmacy).
Notes on specific medicines

ACE-inhibitor Angioedema is a potentially serious complication of ACE-
inhibitor treatment and if it occurs it is a contraindication to
continued therapy or to re-challenge.
ACE-inhibitors ACE-inhibitors and ARBs can cause or exacerbate
and ARBs hyperkalaemia in chronic kidney disease (eGFR < 60
mL/minute). Check the serum potassium before starting these
medicines, and monitor serum potassium on therapy.
ACE-inhibitors and ARBs are contra-indicated in pregnancy.
Allopurinol Contra-indicated in patients with eGFR <30 mL/minute.
Do not stop uric acid lowering drugs during an acute attack.
Amitriptyline + Concomitant use of amitriptyline and citalopram may increase
citalopram the risk of serotonin syndrome or neuroleptic malignant
syndrome. Furthermore, there is a potential risk for QT-
prolongation.
xxviii
Anti-epileptic Phenytoin, phenobarbitone, and carbamazepine are potent
medicines enzyme inducing agents and should be used with caution with
other medicines metabolised by the liver, especially warfarin,
antiretrovirals, progestin subdermal implants, and oral
contraceptives.
Benzodiazepines Benzodiazepines can cause respiratory depression.
Monitor patients closely as benzodiazepines can exacerbate an
abnormal mental state or mask important neurological signs of
deterioration.
Prolonged treatment with benzodiazepines often leads to
tolerance and withdrawal symptoms if the medicine is
discontinued abruptly.
Combination therapy with more than one benzodiazepine is not
indicated.
ß–blockers ß–blockers should not be used in cocaine poisoning.
ß–blockers may cause bronchospasm in asthmatics.
Ciprofloxacin Irrational use of quinolones contributes to the emergence of
XDR-TB and potential masking of active TB.
Clindamycin Clindamycin has good coverage against Gram positive
organisms and anaerobes, so the addition of metronidazole is
unnecessary.
Folic acid + Anaemia megaloblastic: Give vitamin B12 and folic acid
vitamin B12 together until the test results are available as giving folic acid
alone in patients with a B12 deficiency may precipitate
a permanent neurological deficit.
Haloperidol Dosing may vary according to clinical circumstances, e.g. lower
doses in the elderly or where HIV infection or HIV-related
dementia is known or suspected. In frail and elderly patients,
reduce the dose by half.
Lithium Therapeutic drug monitoring is essential when using lithium.
Clinical toxicity may occur even within the therapeutic range.
Concomitant use of many medicines e.g. ACE-inhibitors,
NSAIDs and diuretics may increase the risk of lithium toxicity.
Loperamide Contraindicated in dysentery, acute non-inflammatory
diarrhoea, antibiotic-associated diarrhoea and amoebic
dyssentery; as it may result in toxic megacolon.
Low molecular In morbid obesity dosing of LMWH should be individualised, in
weight heparin discussion with a specialist.
(LMWH) In renal failure (eGFR < 30 mL/minute), the recommended dose
of LMWH is 1 mg/kg/day. Pregnant women with mechanical
prosthetic valves should not receive LMWH unless antifactor Xa
levels can be monitored reliably weekly. Therapeutic range is
pre-dosing level 0.6 units/mL and a 4-hour peak level of 1–1.2
units/mL.
Metformin Metformin should be dose adjusted in renal impairment (eGFR:
30-60 mL/minute).
Metronidazole The addition of metronidazole to amoxicillin/clavulanic acid is
unnecessary as amoxicillin/clavulanic acid has adequate
anaerobic cover.
xxix
Misoprostol (for Misoprostol can cause uterine rupture in women with previous
TOP) Caesarean sections and those of high parity. In these women
use 200 mcg of misoprostol or alternative methods such as
extra-amniotic saline infusion without misoprostol. The dose of
misoprostol, PV, decreases with increasing gestational age
because of the risk of uterine rupture.
NSAIDs Concomitant use of more than one NSAID has no additional
clinical benefit and only increases toxicity. Chronic use of all
NSAIDs is associated with varying degrees of gastrointestinal,
renal, and cardiovascular risks. Long-term use of NSAIDs
should weigh potential benefits against these risks.
Oral diabetic Oral diabetic agents should not be used in type 1 diabetes and
agents used with caution in liver and renal impairment.
Insulin in the Potassium will fall on insulin treatment and patients with DKA
treatment of DKA have potassium depletion even if initial potassium is normal or
high. It is therefore essential to monitor and replace potassium.
Antivenom Never administer antivenom without being fully prepared to
manage acute anaphylaxis.
Sodium chloride Rapid correction of sodium, in hyponatraemia, may lead to
central pontine myelinolysis, which is often irreversible. Sodium
should be frequently monitored and increases should be <9
mmol/L per day.
Spironolactone Monitoring of sodium, potassium and renal function is essential
in patients taking spironolactone. Avoid if eGFR < 30
mL/minute.
SSRIs Adolescents with depression may have an increased risk of
suicidal ideation when initiated on SSRIs.
Streptokinase Do not use heparin if streptokinase is given.
Sulphonylureas Hypoglycaemia caused by a sulphonylurea can be prolonged.
The patient should be hospitalised with an intravenous glucose
infusion, and observed for at least 12 hours after glucose
infusion has stopped.
Tricyclic Avoid in patients with cardiac disease and a high risk of
antidepressants overdose.
Testosterone Screen hypogonadal men for prostate cancer before beginning
testosterone replacement.
Unfractionated Evidence indicates that PTT monitoring is not necessary with
heparin weight based dosing of unfractionated heparin. However, in
patients with morbid obesity and renal failure (eGFR < 30
mL/minute) unfractionated heparin should be used with PTT
monitoring to maintain the PTT at 1.5 to 2.5 times the control.
Blood for measurement of PTT should be taken 4 hours after
SC dose.
Verapamil Never give verapamil or adenosine IV to patients with a wide
QRS tachycardia as this may precipitate ventricular fibrillation.
In atrial flutter, do not use verapamil as it will not convert flutter
to sinus rhythm and may cause serious hypotension.
Warfarin Warfarin use requires regular INR monitoring and dose
adjustment according to measured INR. See appendix II.
xxx
PENICILLIN DESENSITISATION
This has been included for information only.
Perform only in an ICU setting.
Discontinue all ß-adrenergic antagonists. Have an IV line, ECG monitor and
spirometer in place. Once desensitised, treatment must not lapse as risk of
subsequent allergy increases.
A history of Stevens-Johnson’s syndrome, exfoliative dermatitis,
erythroderma are absolute contra-indications to desensitisation (use only as
an approach to IgE sensitivity).
Oral route is preferred. 1/3 of patients develop a transient reaction during
desensitisation or treatment, which is usually mild.
A: Reconstitute phenoxymethylpenicillin 250 mg/ 5mL
Step Medicine mg/mL Amount to administer
(mL)
Strictly every 15 minutes B: To make 0.5 mg/mL solution:
Dilute 0.5 mL of reconstituted phenoxymethylpenicillin
solution in 49.5 mL water.
1 0.1 mL
2 0.2 mL
3 0.5 mg/mL solution 0.4 mL
4 (1000 units/mL) 0.8 mL
5 1.6 mL
6 3.2 mL
7 6.4 mL
C: To make 05 mg/mL solution:
Dilute 1 mL of reconstituted phenoxymethylpenicillin
solution in 9 mL water.
8 1.2 mL
9 5 mg/mL solution 2.4 mL
10 (10000 units/mL) 4.8 mL
D: Reconstituted phenoxymethylpenicillin
250mg/ 5mL = 50 mg/mL
11 1.0 mL
12 50 mg/mL 2.0 mL
13 (80000 units/mL) 4.0 mL
14 8.0 mL
After step 14, observe for 30 minutes, then give 1.0 g IV.
Interval between doses: 15 minutes.
xxxi
Parenteral route
Step Medicine mg/mL Amount to administer (mL)
Strictly every 15 minutes:
1 0.1 mL
2 0.1 mg/mL 0.2 mL
3 0.4 mL
4 0.8 mL
5 0.16 mL
6 1 mg/mL 0.32 mL
7 0.64 mL
8 0.12 mL
9 10 mg/mL 0.24 mL
10 0.48 mL
11 0.1 mL
12 0.2 mL
13 0.4 mL
14 100 mg/mL 0.8 mL
15 0.16 mL
16 0.32 mL
17 0.64 mL
After step 17, observe for 30 minutes, then give 1.0 g IV.
Interval between doses: 15 minutes.
COTRIMOXAZOLE DESENSITISATION
Attempt desensitisation in patients with a history of cotrimoxazole intolerance,
unless this was life-threatening, e.g.: Stevens-Johnson syndrome. (See
section 4.6: Erythema Multiforme, Stevens Johnson Syndrome, Toxic
Epidermal Necrolysis). Unless the rash is severe or associated with systemic
symptoms, continue treatment with careful observation for deterioration.
Desensitisation should be attempted using cotrimoxazole suspension 240
mg/5mL. Dilute the suspension appropriately and consult with your pharmacist
if necessary.
Note: Do not administer antihistamines or steroids with this regimen.
Time (hours) Cotrimoxazole dose (mL of

240mg/5mL suspension
0 0.0005
1 0.005
2 0.05
3 0.5
4 5
5 Two single strength tablets (each tablet
= 80/400 mg) followed by full dose
xxxii
A GUIDE TO PATIENT ADHERENCE IN CHRONIC
CONDITIONS
Achieving health goals for chronic conditions such as asthma, diabetes, HIV
and AIDS, epilepsy, hypertension, mental health disorders and TB requires
attention to:
» Adherence to long term pharmacotherapy – incomplete or non-adherence
can lead to failure of an otherwise sound pharmacotherapeutic regimen.
» Organisation of health care services, which includes consideration of access
to medicines and continuity of care.
Patient Adherence
Adherence is the extent to which a person’s behaviour – taking medication,
following a diet and/or executing lifestyle changes, corresponds with agreed
recommendations from a health care provider.
Poor adherence results in less than optimal management and control of the
illness and is often the primary reason for suboptimal clinical benefit. It can
result in medical and psychosocial complications of disease, reduced quality of
life of patients, and wasted health care resources.
Poor adherence can fall into one of the following patterns where the patient:
» takes the medication very rarely (once a week or once a month);
» alternates between long periods of taking and not taking their medication e.g.
after a seizure or BP reading;
» skips entire days of medication;
» skips doses of the medication;
» skips one type of medication;
» takes the medication several hours late;
» does not stick to the eating or drinking requirements of the medication;
» adheres to a purposely modified regimen; and
» adheres to an unknowingly incorrect regimen.
Adherence should be assessed on a regular basis. Although there is no gold
standard, the current consensus is that a multi method approach that includes
self-report be adopted such as that below.
xxxiii
Barriers that contribute toward poor adherence:
BARRIER RECOMMENDED SUPPORT
Life style
» It is often difficult to take multiple » Create a treatment plan with
medications. information on how and when to
take the medications.
» A busy schedule makes it difficult to » Use reminders such as cues that
remember to take the medication. form part of the daily routine.
Attitudes and beliefs
» The condition is misunderstood or » Remind patients that they have a
denied. long term illness that requires their
involvement.
» Treatment may not seem to be » Use change techniques such as
necessary. motivational interviewing.
» May have low expectations about » Identify goals to demonstrate
treatment. improvement/stabilisation.
Social and economic
» May lack support at home or in the » Encourage participation in treatment
community support programs.
» May not have the economic » Consider down referral or reschedule
resources to attend appointments. appointment to fit in with other
commitments.
Healthcare team related
» Little or no time during the visit to » Encourage patient to ask questions.
provide information.
» Information may be provided in a » Use patient literacy materials in the
way that is not understood. patient’s language of choice.
» Relationship with the patient may » Engage active listening.
not promote understanding and self-
management.
Treatment related
» Complex medication regimens » If possible reduce treatment
(multiple medications and doses) complexity
can be hard to follow.
» May be discouraged if they don’t feel » Help the patient understand the
better right away. condition and the role of their
medication
» May be concerned about adverse » Discuss treatment goals in relation to
effects. potential adverse effects.
Although many of these recommendations require longer consultation time, this
investment is rewarded many times over during the subsequent years of
management.
For a patient to consistently adhere to long term pharmacotherapy requires
integration of the regimen into his or her daily life style. The successful
integration of the regimen is informed by the extent to which the regimen differs
from his or her established daily routine. Where the pharmacological proprieties
xxxiv
of the medication permits it, the pharmacotherapy dosing regimen should be
adapted to the patient’s daily routine. For example, a shift worker may need to
take a sedating medicine in the morning when working night shifts, and at night,
when working day shifts. If the intrusion into life style is too great alternative
agents should be considered if they are available. This would include situations
such as a lunchtime dose in a school-going child who remains at school for
extramural activity and is unlikely to adhere to a three times a regimen but may
very well succeed with a twice daily regimen.
Towards concordance when prescribing

Establish the patient’s:
» occupation,
» daily routine,
» recreational activities,
» past experiences with other medicines, and
» expectations of therapeutic outcome.
Balance these against the therapeutic alternatives identified based on clinical
findings. Any clashes between the established routine and life style with the
chosen therapy should be discussed with the patient in such a manner that the
patient will be motivated to change their lifestyle.
Note: Education that focuses on these identified problems is more likely to
be successful than a generic approach toward the condition/medicine.
Education points to consider
» Focus on the positive aspects of therapy, but be supportive regarding
negative aspects and offer guidance on how to manage this, if present.
» Provide realistic expectations regarding:
 normal progression of the illness - especially important in those
diseases where therapy merely controls the progression and those
that are asymptomatic;
 the improvement that therapy and non-medicinal treatment can add to
the quality of life.
» Establish therapeutic goals and discuss them openly with the patient.
» Any action to be taken with loss of control or when side effects develop.
» In conditions that are asymptomatic or where symptoms have been
controlled, reassure the patient that this reflects therapeutic success, and
not that the condition has resolved.
» Where a patient raises concern regarding anticipated side effects, attempt
to place this in context with respect to incidence, the risks vs. the benefits,
and whether or not the side effects will disappear after continued use.
Note: Some patient’s lifestyles make certain adverse responses acceptable
which others may find intolerable. Sedation is unlikely to be acceptable to a
student, but an older patient with insomnia may welcome this side effect.
This is where concordance plays a vital role.
Notes on prescribing in chronic conditions.
» Do not change doses without good reason.
» Never blame anyone or anything for non-adherence before fully investigating
xxxv
the cause.
» If the clinical outcome is unsatisfactory - investigate adherence (note that side
effects may be an issue).
» Always think about side effects and screen for them from time to time.
» When prescribing a new medicine for an additional health related problem ask
yourself whether or not this medicine is being used to manage a side effect.
» Adherence with a once daily dose is best. Twice daily regimens show
agreeable adherence. However, adherence decreases as the number of
administration interval increases.
» Keep the total number of tablets to an absolute minimum as too many may
lead to medication dosing errors and may influence adherence.
Improving Continuity of Therapy
» Make clear and concise records.
» Involvement the patient in the care plan.
» Every patient on chronic therapy should know:
 his/her diagnosis
 the name of every medicine
 the dose and interval of the regimen
 his/her BP or other readings
Note: The prescriber should reinforce this only once management of the
condition has been established.
» When the patient seeks medical attention for any other complaints such as
a cold or headache he/she must inform that person about any other
condition/disease and its management.
» If a patient indicates that he/she is unable to comply with a prescribed
regimen, consider an alternative - not to treat might be one option, but be
aware of the consequences e.g. ethical.
xxxvi
Patient Adherence Record
Folder No. Date / /
(dd/mm/yyyy)
Self-Reporting
Question Yes No
Do you sometimes find it difficult to remember to take your medicine?
When you feel better, do you sometimes stop taking your medication?
Thinking back over the past four days, have you missed any of your doses?
Sometimes if you feel worse when you take the medicine, do you stop taking it?
Visual Analogue Scale (VAS)
0 1 2 3 4 5 6 7 8 9 10
Score ____%
Pill Identification Test (PIT)

Medication Knows the name Knows the Time the medication is taken Knows any
(Y/N) number of pills Considered additional
Morning Evening
per dose (Y/N) Acceptable instruction
(hour) (hour)
(Y/N)
xxxvii
Pill Count
Did the client return the medication containers?

Yes* No
*If yes, check that the client only used medication from this container since the date of their last visit. If leftover medication
had been used or an emergency prescription obtained, then the calculation will be invalid – skip to adherence assessment.
–
Dispensed – Returned
% Adherence = X 100 = X 100 = %
Expected to be taken
Adherence Assessment
Answered ‘No’ to all Answered ‘Yes’ to 1 Answered ‘Yes’ to 2 or more
Self-reporting
questions question questions
VAS ≥ 95% 75–94% Less than 75%
Dose, Time, and
PIT—Client knows the… Dose and Time Dose only or confused
Instructions
Pill count ≥ 95% 75–94% Less than 75%
Overall Adherence High Moderate Low
xxxviii
CENTRAL CHRONIC MEDICINE DISPENSING AND
DISTRIBUTION (CCMDD)
The Central Chronic Medicines Dispensing and Distribution programme
(CCMDD) has been implemented to improve access to medicines for stable
patients with chronic conditions. It enables patients to collect their repeat
medicines for one or two month`s supply at a pick-up point nearer to home
or place of work and it is thus no longer necessary to wait in long queues at
health facilities just to collect repeat medicines.
Each province provides a list of medicines aligned to the EML and STGs
including prescriber levels that can be utilised for recruitment of patients on
the programme. Prescriptions for patients enrolled on CCMDD not meeting
legal requirements and compliance to EML and STGs are rejected. The
ultimate goal of the CCMDD programme is to improve adherence and better
health outcomes.
CCMDD Benefits:
Improved access to chronic medicines;
Reduced workload for public health facilities and health workers;
Reduced patient waiting times and better time management;
Improved quality of care and service delivery;
Improved patient experience in collection of chronic medication;
Decongestion of health facilities through the use of alternative Pick up Points;
Improved patient satisfaction and knowledge of care.
Improved treatment adherence;
Decreased stigma for HIV patients;
Improved availability of reliable data to inform decision-making at Facilities,
SPs, PuPs;
Improved supply chain processes.
CCMDD is a proven, successful, patient centric approach to service patients

in a manner that is beneficial to patients, Departments of Health, communities
and creates lasting partnerships with the private sector.
Detailed information regarding the CCMDD process can be accessed at:

www.health.gov.za/
xxxix
Central Chronic Medicine
Dispensing and Distribution
(CCMDD)
PROCESS
CRITERIA
1. Stable patient 2. Patients meets
on chronic eligibility criteria
medication
SELECT PuP REGISTER

4. Patient selects
3. Patient agrees to be
approved pick up
point (PuP) registered on CCMDD
CREATE DISPENSE
6. First supply is
5. A 6-month repeat issued to the patient at
prescription is created facilty
RETURN COLLECT
7. Patient collects
8. Patient returns to
subsequent month(s)
facility every 6 months
supply from chosen PuP
ALIMENTARY TRACT
1.1 GASTROINTESTINAL DISORDERS

1.1.1 BOWEL PREPARATIONS
Bowel preparation is essential for colonoscopy.
Split-dose (half the dose the night before and half the dose on the day of
colonoscopy) bowel cleanser and no dietary restriction seems to provide
better quality colon cleansing than single doses with a liquid diet on the day
preceding colonoscopy.
GENERAL MEASURES
Health care professionals should provide both oral and written patient
education instructions and emphasise the importance of adherence to the
bowel preparation.
MEDICINE TREATMENT
Preparations containing ingredients such as polyethylene glycol (PEG), and
sodium sulphate are adequate for bowel cleansing. LoE:IIi
 PEG/sodium sulfate, oral, solution.
o 2 litres the night before the procedure and 2 litres the following
morning within two hours of the procedure. LoE:Iii
Routine use of adjunctive agents (e.g. bisacodyl, senna, prokinetics) for
bowel cleansing before colonoscopy is not recommended. LoE:IIIiii
1.1.2 DIVERTICULOSIS
K57.0-5/K57.8-9
DESCRIPTION
Colonic diverticulosis becomes increasingly common with age. Acute
diverticulitis is suspected in patients with lower abdominal pain (typically in the
left lower quadrant). The pain is usually constant and is often present for
several days prior to presentation. Nausea and vomiting are often present
due to a bowel obstruction or an ileus due to peritoneal irritation. Changes in
bowel habits can be observed.
Diverticulosis can be complicated by haemorrhage or diverticulitis. Acute

diverticulitis is inflammation of diverticulae usually accompanied by
polymicrobial infection. Acute diverticulitis is defined as complicated when
there is bowel obstruction, abscess, fistula, or perforation.
2019 1.1
CHAPTER 1 ALIMENTARY TRACT
GENERAL MEASURES
Increase dietary fibre intake.
MEDICINE TREATMENT
Total duration of antibiotic therapy is 10 days, depending on clinical
response. LoE:III
Uncomplicated diverticulitis:
 Amoxicillin/clavulanic acid, oral, 875/125 mg 12 hourly.
If unable to tolerate oral therapy:
 Amoxicillin/clavulanic acid, IV, 1.2 g 8 hourly.
LoE:IIIiv
REFERRAL
» Acute diverticulitis with clinical deterioration or failure to improve on
medical therapy.
» Peritonitis.
» Complicated diverticulitis (to a centre which can perform colonic surgery).
» Massive haemorrhage.
1.1.3 GASTRO-OESOPHAGEAL REFLUX DISEASE

(GORD)
K21.0/K21.9/K22.7
DESCRIPTION
A disorder which develops as a consequence of the reflux of gastric and
duodenal contents into the oesophagus. It is usually characterised by
heartburn and regurgitation.
Intermittent indigestion, heartburn or dyspepsia may be associated with:

» use of NSAIDs e.g. aspirin, ibuprofen, pain powders
» spicy food, alcohol, carbonated drinks
» smoking
Complications that may develop in severe disease are strictures, ulceration,

Barrett’s oesophagus and adenocarcinoma of the oesophagus. Two thirds of
patients have a normal endoscopy which is termed non-erosive reflux disease
(NERD).
GENERAL MEASURES
» Stop smoking.
» Limit alcohol intake.
» Eat small frequent meals.
» Avoid late night meals.
» Check haemoglobin.
» Stop the use of potential ulcerogenic medicines e.g. NSAIDs.
2019 1.2
All patients with alarm symptoms, i.e. weight loss, haematemesis or melaena,
dysphagia, or anaemia, chest pain or older than 45 years of age should have
an endoscopy.
MEDICINE TREATMENT
Proton pump inhibitors (PPIs)
A trial with a PPI confirms acid-related disease. Only if no alarm symptoms:
 PPI, e.g.:
 Lansoprazole, oral, 30 mg daily for 4 weeks. LoE:Iv
o Ensure adherence to promote healing.
LoE:Ivi
Recurrence of symptoms
After endoscopic confirmation of disease:
 PPI, e.g.:
 Lansoprazole, oral, 30 mg daily.
o Decrease dose of PPI after 4 weeks, e.g: omeprazole, oral, 10 mg
daily.
Barrett’s oesophagus K22.7
Restart PPI:
 PPI, e.g.:
Note:
» These patients usually need maintenance PPI therapy.
» There is no convincing evidence that long-term treatment of Barrett’s
oesophagus with PPIs reduces dysplasia or progression to malignancy.
REFERRAL
Discuss with a specialist:
» young patients who are PPI dependent and will require life-long therapy;
» patients unable to take PPIs;
» patients requiring high doses of PPIs;
» patients with large hiatus hernias and “volume reflux”;
» a rolling hiatus hernia with obstructive symptoms requires surgery;
» Alarm features that may be suggestive of gastrointestinal malignancy:
― New onset dyspepsia in patient >60 years,
― Evidence of gastrointestinal bleeding,
― Iron deficiency anaemia,
― Anorexia,
― Unexplained weight loss,
― Dysphagia,
― Odynophagia (painful swallowing),
― Persistent vomiting,
― Gastrointestinal cancer in a first-degree relative.
2019 1.3
1.1.4 HIATUS HERNIA

K44.0/K44.1/K44.9
Manage GORD. See section 1.1.3: Gastro-Oesophageal Reflux Disease
(GORD).
1.1.5 INFLAMMATORY BOWEL DISEASE

K50.0-1/K50.8-9/K51.0-5/K51.8-9/K52.0-3/K52.8-9
DESCRIPTION
Inflammatory bowel disease is a chronic inflammatory disorder of the
gastrointestinal tract that includes both Crohn’s disease (CD) and ulcerative
colitis. Abdominal pain, rectal bleeding, diarrhoea and weight loss
characterise both CD and ulcerative colitis.
REFERRAL
All patients with a potential diagnosis of Crohn’s disease or ulcerative colitis,
should be discussed with a specialist.
1.1.6 PANCREATITIS, ACUTE

K85.0-3/K85.8-9
DESCRIPTION
Acute inflammatory condition of the pancreas.
Acute pancreatitis is based on the fulfilment of ‘2 out of 3’ of the following
criteria:
» clinical (upper abdominal pain),
» laboratory (serum amylase or lipase >3x upper limit of normal), and/or
» imaging (CT, MRI, ultrasonography) criteria.
Intense local inflammation results in pain and local as well as systemic

complications. DIC, metabolic derangements and shock may occur.
Renal function, electrolytes and calcium, can be used to determine severity.
GENERAL MEASURES
Nasogastric suction when persistent vomiting or ileus occurs.
Parenteral fluid replacement to correct metabolic and electrolyte disturbances.
Parenteral nutrition is associated with adverse outcomes and should only be
considered in patients that cannot receive or tolerate nasogastric or enteral
nutrition.
Drainage of abscess, pseudocyst, if required.
MEDICINE TREATMENT
For pain:
 Morphine, IV, to a total maximum dose of 10 mg (See Appendix II, for
individual dosing and monitoring for response and toxicity).
2019 1.4
Acute symptomatic hypocalcaemia E83.5

 Calcium gluconate 10%, IV infusion, 10 mL as a bolus over 10 minutes.
o Follow with 60–120 mL diluted in 1 L sodium chloride 0.9%,
administered over 12–24 hours.
o Monitor serum calcium at least 12 hourly.
LoE:III
If serum magnesium <0.5 mmol/L:
ADD
 Magnesium sulfate, IV infusion, 25–50 mmol in 12–24 hours.
o 1 mL magnesium sulfate 50% = 2 mmol magnesium.
Antimicrobial therapy
The administration of prophylactic antibiotics are not necessary.
For abscess of the pancreas:

Broad spectrum IV antibiotics:
 Amoxicillin/clavulanic acid, IV, 1.2 g 8 hourly for 10 days,
depending on clinical response. LoE:IIIvii
REFERRAL
Severe complications, e.g. necrosis, haemorrhagic or systemic complications,
infective pancreatitis.
1.1.7 PANCREATITIS, CHRONIC

K86.1
DESCRIPTION
Chronic inflammatory condition of the pancreas with severe abdominal pain,
which results in functional and structural damage. In most patients, this is a
chronic progressive disease leading to exocrine and/or endocrine
insufficiency.
GENERAL MEASURES
Abstinence from alcohol reduces abdominal pain in the early stages of the
disease.
Stop smoking.
Small frequent meals, and restricted fat intake reduces pancreatic secretion
and pain.
Elemental diets (i.e. parenteral or enteral nutrition) in chronically debilitated
patients.
When weight loss is not responding to exogenous enzymes and diet, consider
supplementation with medium chain triglycerides.
There is a risk of developing cancer of the pancreas. This should be
considered in patients who develop worsening pain, new onset diabetes or
deterioration in exocrine function.
Dietary advice by dietician.
2019 1.5
MEDICINE TREATMENT
Treatment is aimed at:
» pain,
» malabsorption, and
» endocrine function. See section 8.5.2: Type 1 Diabetes mellitus.
Analgesia
See Section 26.1: Pain, chronic.
Note: Pancreatic enzymes may reduce pain by negative feedback on
pancreatic secretion.
Malabsorption
Start treatment when >7 g (or 21 mmol) fat in faeces/24 hours while on a 100
g fat/day diet.
Reduce dietary fat to <25 g/meal.
Supplementation of fat-soluble vitamins may be indicated.
 Lipase, oral, equivalent to lipase 30 000 units per day, in divided doses
with meals.
Aim for symptom control and/or 5% of normal faecal fat output.
REFFERAL
Surgical intervention, pseudocyst.
Autoimmune chronic pancreatitis.
1.1.8 PEPTIC ULCER

K25.0-7/K25.9/K26.0-7/K26.9/K27.0-7/K27.9
DESCRIPTION
Ulcer in the stomach mucosa (gastric ulcer: GU) or first few centimetres of the
duodenum (duodenal ulcer: DU), which penetrates into or through the
muscularis mucosa.
Diagnosis is made after endoscopy, as all GUs require biopsy to exclude
malignancy.
Patients with GUs and complicated DUs, those that have bled, perforated or are
recurrent, must be rescoped at appropriate intervals until the ulcer has healed.
H. pylori can be assessed at scope by rapid urease testing (RUT) or biopsy.
GENERAL MEASURES
Advise patient to avoid ulcerogenic medications, e.g. NSAIDs.
Advise patient to stop smoking and drinking alcohol.
Dietary advice by dietician.
MEDICINE TREATMENT
H. pylori +ve
The vast majority of GUs and DUs are associated with H. pylori infection and
eradication therapy is indicated if infection is present. This will greatly reduce
2019 1.6
the rate of recurrent ulceration. Empiric eradication of H. pylori is not

recommended.
Proton pump inhibitors (PPIs)
 PPI, e.g.:
 Lansoprazole, oral, 30 mg 12 hourly.
o Duodenal ulcer: for 7 days.
o Gastric ulcer: for 28 days.
LoE:Iviii
AND
H. PYLORI ERADICATION: K25.0-7/K25.9/K26.0-7/K26.9/K27.0-7/K27.9 + (B96.8)
 Amoxicillin, oral, 1 g 12 hourly for 14 days. LoE:Iix
OR
For severe penicillin allergy: (Z88.0)
 Azithromycin, oral, 500 mg daily for 3 days.
LoE:IIx
AND
 Metronidazole, oral, 400 mg 12 hourly for 14 days.
LoE:Ixi
Failure of H. pylori eradication: Discuss with specialist.
H. pylori –ve
These are usually a consequence of NSAID use.
Stop NSAID until ulcer has healed.
If patient is unable to stop NSAID, refer to specialist.
 PPI, e.g.:
o Duodenal ulcer: for 14 days. LoE:IIxii
o Gastric ulcer: for 28 days.
Resistant disease
Ulcer not healing.
High-risk patients, i.e. poor surgical risk and the elderly or concomitant
disease.
Maintenance therapy:
 PPIs, e.g.:
 Lansoprazole, oral, 30 mg daily. Specialist initiated.
LoE:IIIxiii
1.2 HEPATIC DISORDERS

Hepatitis (inflammation of the liver) may be infectious (caused by viral,
bacterial, fungal, and parasitic organisms) or non-infectious (triggered by
alcohol, drugs, autoimmune diseases, and metabolic diseases).
Causes of hepatitis includes idiosyncratic drug reactions, viral hepatitis (A, B,
C, D, E), alcoholic hepatitis, autoimmune hepatitis, Wilson’s disease,
ischaemic hepatopathy, Budd-Chiari syndrome, veno-occlusive disease,
2019 1.7
acute fatty liver of pregnancy/HELLP syndrome, malignant infiltration, partial

hepatectomy, toxin exposure, including mushroom poisoning, sepsis, heat
stroke or haemophagocytic lymphohistiocytosis.
For management of hepatitis C, consult a specialist.
1.2.1 HEPATITIS, NON-VIRAL

K70.1/K71.0-9/K75.4
* Notifiable medical condition if caused by agricultural chemicals or insecticides.
DESCRIPTION
Any form of hepatitis not caused by the common hepatotropic viruses.
Liver biopsy is indicated if hepatitis persists or diagnosis is unclear.
GENERAL MEASURES
Diet: If no hepatic encephalopathy, then normal protein intake appropriate.
With hepatic encephalopathy, maintain 1 to 1.5mg/kg daily protein intake.
Avoid alcohol and other hepatotoxic agents.
Monitor blood glucose regularly given potential risk of hypoglycaemia.
MEDICINE TREATMENT
If the patient is bleeding, check INR and correct coagulopathy with:
 Lyophilised plasma or FFP LoE:IIxiv
Parenteral Vitamin K should be provided and the INR reassessed.
Hepatitis due to infections

Antibiotic therapy based on culture, serology or suspected aetiology e.g.
leptospirosis.
Alcohol-induced hepatitis
 Thiamine, oral, 300 mg daily. LoE:IIIxv
Other vitamins if indicated.
Drug-induced hepatitis
Stop all potentially hepatotoxic medication immediately, in consultation with a
specialist.
Auto-immune hepatitis K75.4

Patients with persistent hepatitis, negative viral markers and no hepatotoxins.
Biopsy and/or various parameters are required to make the diagnosis.
If autoimmune hepatitis:
 Corticosteroids (intermediate-acting) e.g.:
 Prednisone, oral, 0.5 mg/kg daily.
o Taper dose to a suitable maintenance dose. (Refer to Appendix II for
an example of a dose reduction regimen).
2019 1.8
AND (in consultation with gastroenterologist or hepatologist)

 Azathioprine, oral, 0.5 mg/kg daily, titrated up to 1 mg/kg daily depending
on response and WCC.
REFERRAL
» Where patients cannot be managed locally or biopsy cannot be done, i.e.
diagnosis is unclear.
» Non-resolving hepatitis.
Note: Refer timeously before extensive liver damage occurs.
1.2.2 LIVER FAILURE, ACUTE

K72.0/K72.9
DESCRIPTION
Acute liver failure refers to the development of severe acute liver injury with
encephalopathy and impaired synthetic function (INR of ≥1.5) in a patient
without cirrhosis or pre-existing liver disease. There are many causes, but the
commonest are viral hepatitis, alcohol, drug-induced liver injury, toxins or
ischemic hepatitis.
GENERAL MEASURES
Patient education.
Avoid hepatotoxic drugs and alcohol.
Rest and reduce physical activity.
Protein restriction indicated for encephalopathy. Severe protein restriction
may accentuate catabolism. Use increments of 20 g protein per day as
tolerated.
Monitor blood glucose regularly because hypoglycaemia is common.
Correct electrolyte disturbances.
Exclude GI bleed as precipitant.
Avoid any measure, e.g. medications that may worsen or precipitate functional
deterioration.
Avoid vigorous paracentesis.
Exclude infection as precipitant.
If the patient is bleeding, check INR and correct coagulopathy with FFP or
lyophilised plasma. Routine administration of parenteral vitamin K1 is of
unproven value.
MEDICINE TREATMENT
 Lactulose, oral, 10–30 mL 8 hourly, titrated to attain 2–3 soft stools per
day.
Do not give antibiotics unless there is evidence of bacterial sepsis.
REFERRAL
All cases of severe acute liver failure should be discussed with a specialist.
2019 1.9
1.2.3 PORTAL HYPERTENSION AND CIRRHOSIS

R18/K72.9/K74.6+ + (I98.2*/I98.3*)
DESCRIPTION
The complications of portal hypertension include:
» variceal bleeds
» ascites
» hepatic encephalopathy (HE)
» splenomegaly with hypersplenism
» hepatorenal syndrome
» hepato-pulmonary syndrome or porto-pulmonary hypertension
GENERAL MEASURES
Ascites: sodium restriction, i.e. ≤ 2 g/day or ≤ 88 mmol/day.
Monitor weight regularly.
Encephalopathy: with acute HE, protein restrict otherwise 1–1.5 mg/kg protein
per day.
Exclude infection, high protein load, occult bleed, sedatives and electrolyte
disturbances.
Variceal bleeding: endoscopic variceal ligation and/or immediate referral for
advanced management.
MEDICINE TREATMENT
Ascites R18
 Single morning dose of oral spironolactone, oral 100 mg and furosemide,
oral, 40 mg.
o Increase the dose by 100 mg and 40 mg, respectively, every 3–5 days,
to a maximum dose of 400 mg spironolactone and 160 mg of
furosemide.
o Rapid fluid shifts may precipitate acute liver and/or renal failure.
o Spironolactone may cause hyperkalaemia.
Monitoring of sodium, potassium and renal function is essential in

patients taking spironolactone. Avoid spironolactone if eGFR <30
mL/minute.
LoE:IIIxvi
Measure response to diuretics by weighing patient daily. Aim for maximal
weight loss of:
500 g/day patients without oedema
1 000 g/day patients with oedema
Tense ascites R18

Albumin replacement should be considered if ≥5 L of fluid is removed or pre-
existing renal dysfunction:
2019 1.10
 Albumin, IV, 40 g (20%), as an infusion. LoE:IIxvii

o Refer to specialist unit to consider transjugular
intrahepatic portosystemic (TIP) shunt or potential transplant.
 Introduce diuretics and titrate doses as necessary to prevent recurrence
of ascites (see above).
Note:
» Avoid NSAIDS and ACE-inhibitors.
» Exclude spontaneous bacterial peritonitis in patients with new onset
ascites.
Refractory ascites R18

» No response to optimal diuretic therapy, despite sufficient sodium
restriction (≤2 g/day or ≤88 mmol/day) with avoidance of NSAIDs.
» Ascites recurs rapidly following therapeutic paracentesis.
Perform serial large volume paracentesis, as an outpatient, usually not more
frequently than every 2 weeks.
Haemodynamic collapse is more likely in patients who are intravascularly
volume depleted. Check renal function before paracentesis.
Albumin replacement should be considered if >5 L of fluid is removed:
 Albumin, IV, 40 g (20%), as an infusion. LoE:IIxviii
Encephalopathy
 Lactulose, oral, 10–30 mL 8 hourly, depending on stool number and
consistency (aim for 2 soft stools/day).
Look for precipitating factors: Sepsis, protein load, GIT bleed, over diuresis,
sedation.
Oesophageal varices
To reduce the risk of bleeding:
 Beta-blocker, e.g.:
 Propranolol, oral, 20–40 mg 12 hourly. Titrate to resting pulse rate of 55-
60 beats per minute (bpm). Monitor pulse and BP.
LoE:IIIxix
REFERRAL
Refer to specialist unit to consider TIP shunt or potential transplant.
1.2.4 HEPATITIS, VIRAL

*Notifiable medical condition.
DESCRIPTION
Hepatitis caused by one of the hepatotropic viruses, hepatitis A, B, C and E.
2019 1.11
1.2.4.1 HEPATITIS B, ACUTE

B16.0-2/B16.9
GENERAL MEASURES
Bed-rest until acute phase is over.
Avoid alcohol during the illness and for ≥ 6 months after clinical recovery.
Screen sexual contacts of patients with acute hepatitis B. If they are non-
immune (negative for hepatitis B antibodies) then they should receive hepatitis
B active immunisation.
MEDICINE TREATMENT
For nausea and vomiting: (R11)
 Metoclopramide, IV/oral, 10 mg 8 hourly as required.
Hepatitis B virus: prophylaxis following exposure e.g. needle stick injury
S61.0 + (W46.22+Z20.5+Z29.8)
Persons at risk can be protected by passive immunisation with hyper immune
serum globulin prepared from blood containing anti-HBs.
It is essential that all categories of healthcare workers (HCW) who are at risk
of exposure, including cleaning staff, be fully vaccinated against hepatitis B.
All exposure incidents must be adequately documented for possible
subsequent compensation.
Recommended post-exposure management for HCW exposed to infectious
material from patients with infectious hepatitis B (either surface antigen or e
antigen positive).
Vaccination Source patient status & treatment
status and HBsAg positive HBsAg negative HBsAg unknown
antibody
response status
of HCW
Unvaccinated  HBIG, IM, 500  Initiate Hep B  HBIG, IM, 500
OR units* vaccination units*
vaccination  Hep B vaccine (month 0, 1 and 6)  Hep B vaccine
incomplete (3 doses at monthly (3 doses at monthly
intervals) intervals)
Vaccinated No treatment No treatment No treatment
AND HBsAb
>10 units/mL#
Vaccinated  HBIG, IM, 500 units  Initiate Hep B  HBIG, IM, 500
AND * vaccination units*
HBsAb <10  Repeat Hep B (month 0, 1 and 6)  Repeat Hep B
units/mL vaccine vaccine
(3 doses at monthly (3 doses at monthly
intervals) intervals)
* HBIG and first dose of vaccine to be given simultaneously, but at different sites.
#
If the delay in obtaining HBsAb results is more than 24 hours initiate treatment as for
vaccinated AND HBsAb <10 units/mL.
2019 1.12
1.2.4.2 HEPATITIS B, CHRONIC (NON-HIV COINFECTION)

B18.0-2/B18.8-9
Consult the most recent Hepatitis Guidelines from the National

Department of Health for comprehensive monitoring recommendations.
DESCRIPTION
HBV is most commonly transmitted horizontally, in children <5 years of age.
Vertical mother to child transmission and adult transmission, sexually or
through a parenteral route, can also occur.
Acute infection may be asymptomatic or present as acute hepatitis.
A proportion of patients develop chronic hepatitis (defined as abnormalities
listed in the table below persisting for >6 months), which can result in cirrhosis
and hepatocellular carcinoma.
It is essential to know the HIV status of all patients with chronic hepatitis B
before considering therapy.
Antiviral therapy is not indicated for acute hepatitis B infection.
There are 5 potential phases of chronic hepatitis B infection which determine
the need for treatment:
Phase Serology Viral load ALT Management
(HBV DNA) LoE:IIIxx
IU/mL
1. HBeAg-positive » HBsAg >20000 Normal » Treatment not routinely
chronic HBV positive (usually needed, but should be
infection (Immune » HBeAg >200000) followed up.
Tolerant) positive » Treat only if on
immunosuppressive
therapy to prevent
hepatitis B flares.
2. HBeAg-positive » HBsAg >20000 Elevated » Treatment required.
chronic hepatitis positive
B (Immune » HBeAg
Clearance) positive
3. HBeAg-negative » HBsAg <2000 Normal » Treatment not routinely
chronic HBV positive needed, but should be
infection (Immune » HBeAg followed up.
Control) negative » Treat only if on
immunosuppressive
therapy to prevent
hepatitis B flares.
4. HBeAg-negative » HBsAg >2000 Elevated » Treatment required.
chronic hepatitis positive
B (Immune » HBeAg
Escape) negative
5. Occult hepatitis B » HBsAg <200 - » No follow-up required.
negative » Treat only if on
» HBsAb immunosuppressive
negative therapy to prevent
» HB IgG hepatitis B flares.
core Ab
positive
2019 1.13
HBsAg: hepatitis B surface antigen; HBsAb: hepatitis B surface antibody; HBIG: hepatitis B
immunoglobulin
Treat all patients with cirrhosis regardless of ALT level, HBeAg status and
DNA level, to prevent hepatitis B flares that will lead to decompensation.
MEDICINE TREATMENT
 Tenofovir, oral, 300 mg daily, if estimated CrCl >50 mL/minute.
LoE:IIIxxi
AIMS OF TREATMENT
HBeAg-positive disease
» Sustained HBsAg loss off therapy, with/without the development of anti-
HBs, and
» Suppression of HBV DNA to undetectable or low (<2000 IU/mL) levels,
and
» Normalisation of ALT, and
» Sustained HBeAg loss and seroconversion to anti-HBe.
HBeAg-negative disease
» Sustained HBsAg loss off therapy, with/without the development of anti-
HBs, and
» Suppression of HBV DNA to undetectable or low (<2000 IU/mL), and
» Normalisation of ALT.
MONITORING WHILST ON TENOFOVIR

Baseline FBC+diff, ALT, INR, urine protein,
serum phosphate and serum creatinine
Week 4 and every 12 weeks FBC+diff, ALT
Week 4 INR
Week 4, then at 3, 6 and 12 months after Serum creatinine
initiation and every 12 months thereafter
if on TDF
Every 6 months HBeAg-positive patients:
HbsAg after anti-HBe seroconversion
HBeAg-negative patients: HBsAg with

persistently undetectable HBV DNA
Every 12 months HBeAg-positive patients: HBeAg, anti
HBe
HBeAg-positive patients: 12 months after HBV DNA levels
HBeAg seroconversion
Adapted from: National Department of Health, National guidelines for the management of viral hepatitis, 2018.
Available at www.health.gov.za
DISCONTINUE TREATMENT WITH TENOFOVIR WHEN:

» HBeAg-positive patients: 12 months after HBeAg seroconversion and in
association with persistently normal ALT levels and undetectable HBV
DNA levels.
» HBeAg-negative patients: Long-term therapy unless HBsAg
seroconversion is achieved.
2019 1.14
» Cirrhotic patients: Lifelong treatment.
REFERRAL
Failure of or contraindications to tenofovir.
1.2.4.3 HEPATITIS B, CHRONIC (HIV CO-INFECTION)

See chapter 10: HIV and AIDS.
1.2.5 LIVER ABSCESS, PYOGENIC

K75.0
DESCRIPTION
Focal bacterial infection, usually polymicrobial, of the liver with pus. Multiple
abscesses are not uncommon.
GENERAL MEASURES
Drainage is essential in all cases. This should preferably be done
percutaneously by inserting a catheter under ultrasound guidance.
MEDICINE TREATMENT
Empiric antibiotic therapy
Duration of antibiotic therapy is ill defined, but may need to be for as long as
12 weeks in cases of multiple abscesses. Continue until drainage is complete
and CRP has returned to normal values. Ultrasound resolution is very slow
and is not useful for monitoring response to therapy.
1.2.6 LIVER ABSCESS, AMOEBIC

A06.4
DESCRIPTION
Focal hepatic infection due to E. histolytica. Only about a third of cases have
concomitant amoebic colitis. Diagnosis can be excluded if the serological test is
negative. It is essential to exclude pyogenic infection (a diagnostic aspirate
should be taken under ultrasound guidance in all cases where there is doubt).
GENERAL MEASURES
Drainage is recommended for abscesses that are large, i.e. >10 cm diameter,
involve the left lobe or are near the surface of the liver. Drainage can be
achieved by percutaneous aspiration under ultrasound guidance.
MEDICINE TREATMENT
 Metronidazole, oral, 800 mg 8 hourly for 10 days. LoE:IIIxxii
2019 1.15
1.2.7 CHOLECYSTITIS, ACUTE AND CHOLANGITIS, ACUTE

K81.0/K83.0
GENERAL MEASURES
Surgical drainage/cholecystectomy according to indication and/or patient's
condition.
MEDICINE TREATMENT
Acute cholecystitis
Mild and asymptomatic cases without risk factors may not require antibiotic
treatment. If signs of infection present and/or risk factors for severe disease
are present, such as:
» Elderly patients (>60 years of age)
» Co-morbid conditions
» Immune compromised
Acute cholecystitis and acute cholangitis
REFERRAL
» Clinical deterioration or failure to improve.
» Fistulae or perforation.
» Need for complicated surgery.
1.3 DIARRHOEA
1.3.1 CHOLERA
A00.0-1/A00.9
DESCRIPTION
Diarrhoea due to Vibrio cholerae, often in outbreaks.
GENERAL MEASURES
Rehydration is the cornerstone of management. This should be done with oral
rehydration solution (ORS) unless the patient is vomiting or profoundly
dehydrated.
MEDICINE TREATMENT
 Ciprofloxacin, oral, 500 mg 12 hourly for 3 days.
o Adjust antibiotic choice, according to the sensitivity of the isolate
responsible for the local epidemic.
LoE:IIIxxiii
2019 1.16
1.3.2 DYSENTERY (ACUTE INFLAMMATORY DIARRHOEA)

A03.0-3/A03.8-9/A41.0-5/A41.8-9
DESCRIPTION
Diarrhoea with neutrophils, blood and/or mucus.
GENERAL MEASURES
dehydrated.
Stool culture is advised.
MEDICINE TREATMENT
Loperamide is contraindicated as it may result in toxic megacolon.
Antibiotic therapy
Consider in patients with signs of sepsis and severe cases or significant
underlying disease:
 Ceftriaxone, IV 1g daily.
o Switch to oral therapy when clinically appropriate i.e. ciprofloxacin,
oral, 500 mg 12 hourly.
For uncomplicated dysentery in patients with no co-morbidity:
For uncomplicated dysentery in patients with significant co-morbidity e.g.
immunocompromised patients:
REFERRAL
Persistent diarrhoea with blood and mucus for longer than 2 weeks.
1.3.3 DIARRHOEA, ACUTE NON-INFLAMMATORY

A04.1
DESCRIPTION
Diarrhoea without macroscopic blood or mucus, or neutrophils on microscopy.
Common causes include viruses and enterotoxigenic strains of E. coli.
Note: Neutropenic patients may have inflammatory diarrhoea in the absence
of neutrophils.
GENERAL MEASURES
dehydrated.
2019 1.17
MEDICINE TREATMENT
 Loperamide, oral, 4 mg immediately, followed by 2 mg after each loose
stool.
o Maximum dose: 16 mg daily.
1.3.4 CLOSTRIDUM DIFFICILE DIARRHOEA

A04.7
DESCRIPTION
Diarrhoea caused by altered bowel flora due to antibiotic exposure.
Clostridium difficile infection may result in severe disease and/or the
development of pseudomembranous colitis.
Diagnosis is confirmed in the laboratory on a stool sample. Patients with
unexplained and new-onset diarrhoea of more than 3 unformed stools in 24
hours should be tested. Repeat testing (within 7 days) is not recommended.
GENERAL MEASURES
» The most important aspect of management is discontinuing antibiotics.
» Rehydration may be necessary. This should be done with oral rehydration
solution (ORS) unless the patient is vomiting or profoundly dehydrated.
» Patients with known or suspected Clostridium difficile infection should be
placed on contact precaution according institutional infection control and
prevention measures.
» Contact precautions should be maintained for at least 48 hours after
diarrhoea has resolved.
» Healthcare workers and all close contacts should perform regular
handwashing with soap and water. Alcohol-based hand sanitizer does not
kill spores.
MEDICINE TREATMENT
Mild to moderate infection

Laboratory results confirm toxigenic Clostridium difficile infection, diarrhoea
does not settle on antibiotic withdrawal:
Severe infection
Laboratory results confirm toxigenic Clostridium difficile infection, WCC >15
micromol/L or serum creatinine >132 micromol/L, or other risk predictors of
severity (immunodeficiency, intensive care admission, serious comorbidity,
age >65 years of age).
 Vancomycin, oral, 125 mg 6 hourly (give parenteral formulation orally) for
10 days.
2019 1.18
Fulminant infection
If ileus or toxic megacolon or hypotension/shock:
10 days.
AND
 Metronidazole, IV, 500 mg 8 hourly for 10 days.
Switch to oral metronidazole, if possible, to complete 10 day course.
Recurrence
If metronidazole was used during the first episode:
10 days.
If vancomycin was used during the first episode, consider oral vancomycin as
tapered and pulsed regimen:
10 days, then 12 hourly for 7 days, then once per day for 7 days, and then
every 2nd or 3rd day for 2 to 8 weeks.
LoE:Ixxiv
REFERRAL
» Surgical consult should be obtained in all patients with complicated
Clostridium difficile infection (e.g. bowel perforation, hypotension requiring
vasopressor therapy, clinical signs of sepsis).
» Failure to improve on medical therapy after 5 days.
1.3.5 AMOEBIC DYSENTERY

A06.0-1/A06.7-9
DESCRIPTION
Diarrhoea with blood and/or mucus due to E. histolytica. Organism must be
demonstrated on a warm stool specimen for microscopy.
GENERAL MEASURES
Rehydration may be necessary. This should be done with oral rehydration
solution (ORS) unless the patient is vomiting or profoundly dehydrated.
Surgery for bowel perforation.
MEDICINE TREATMENT
 Metronidazole, oral, 800 mg 8 hourly for 10 days. LoE:IIIxxv
1.3.6 GIARDIASIS
A07.1
DESCRIPTION
Infection with the protozoan parasite, G. lamblia which colonises the proximal
2019 1.19
small intestine. Does not typically presents with acute diarrhoea.
GENERAL MEASURES
Fluid and electrolyte replacement in severe diarrhoea.
MEDICINE TREATMENT
 Metronidazole, oral, 2 g daily for 3 days.
1.3.7 TYPHOID
See section 9.11: Typhoid fever.
1.3.8 BACTERIAL PERITONITIS

K65.0/K65.8-9
DESCRIPTION
Infection of the peritoneum, usually secondary to a surgical cause such as
perforated bowel. In this setting polymicrobial infection with anaerobes, Gram-
positive cocci, and Enterobacteriaceae are usually found.
Primary or spontaneous bacterial peritonitis is much less common and usually
complicates ascites in patients with portal hypertension. This is not usually
polymicrobial but due generally to Enterobacteriaceae such as E. coli.
Spontaneous bacterial peritonitis is often culture-negative but is diagnosed by
ascitic neutrophil count >0.25 x 109/L (250 cells/mm3).
GENERAL MEASURES
Secondary peritonitis
Intravenous fluids and nasogastric suction.
Prompt surgical intervention is essential.
MEDICINE TREATMENT
For surgical causes of peritonitis:
 Amoxicillin/clavulanic acid, IV 1.2 g 8 hourly.
As soon as patient can tolerate oral medication:
For spontaneous bacterial peritonitis:
 Ceftriaxone, IV, 1 g daily.
o Patients not responding to ceftriaxone after 48 hours, consult a
specialist.
Switch to oral therapy when clinically appropriate according to culture or treat with:
 Ciprofloxacin, oral, 500 mg 12 hourly.
o Total duration of therapy: 14 days.
2019 1.20
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volume paracentesis: a meta-analysis of randomized trials. Hepatology. 2012 Apr;55(4):1172-81.
xviii Albumin, IV: AASLD Practice Guidelines Committee. Management of adult patients with ascites due to cirrhosis:
an update. Hepatology. 2009 Jun;49(6):2087-107. http://www.ncbi.nlm.nih.gov/pubmed/19475696

Albumin, IV: Bernardi M, Caraceni P, Navickis RJ, Wilkes MM. Albumin infusion in patients undergoing large-
volume paracentesis: a meta-analysis of randomized trials. Hepatology. 2012 Apr;55(4):1172-81.
xix Propranolol, oral: Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis:
Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study
of liver diseases. Hepatology. 2017 Jan;65(1):310-335. https://www.ncbi.nlm.nih.gov/pubmed/27786365
Propranolol, oral: Tripathi D, Stanley AJ, Hayes PC, Patch D, Millson C, Mehrzad H, Austin A, Ferguson JW,
Olliff SP, Hudson M, Christie JM; Clinical Services and Standards Committee of the British Society of
Gastroenterology. U.K. guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut. 2015
Nov;64(11):1680-704. https://www.ncbi.nlm.nih.gov/pubmed/25887380
xxManagement of chronic hepatitis B infection: European Association for the Study of the Liver. EASL 2017 Clinical
Practice Guidelines on the management of hepatitis B virus infection. J Hepatol. 2017 Aug;67(2):370-398.
https://www.ncbi.nlm.nih.gov/pubmed/28427875
xxi
Tenofovir: Marcellin P, Gane E, Buti M, Afdhal N, Sievert W, Jacobson IM, Washington MK, Germanidis G,
Flaherty JF, Schall RA, Bornstein JD, Kitrinos KM, Subramanian GM, McHutchison JG, Heathcote EJ. Regression
of cirrhosis during treatment with tenofovir disoproxil fumarate for chronic hepatitis B: a 5-year open-label follow up
2019 1.22
study. Lancet.2013;381:468–75.http://www.ncbi.nlm.nih.gov/pubmed/23234725
Tenofovir: World Health Organisation. Guidelines for the prevention, care and treatment of persons with chronic
hepatitis B infection, March 2015. http://www.who.int/hiv/pub/hepatitis/hepatitis-b-guidelines/en/
xxii Metronidazole, oral: Ravdin JI. Amebiasis. Clin Infect Dis. 1995 Jun;20(6):1453-64; quiz 1465-6. Review.
Metronidazole, oral: Wuerz T, Kane JB, Boggild AK, Krajden S, Keystone JS, Fuksa M, Kain KC, Warren R, Kempston
J, Anderson J. A review of amoebic liver abscess for clinicians in a nonendemic setting. Can J Gastroenterol. 2012
Oct;26(10):729-33. http://www.ncbi.nlm.nih.gov/pubmed/23061067
xxiiiCiprofloxacin, oral (extended course for cholera): National Institute for Communicable Diseases. Data on file,
2020.
Ciprofloxacin, oral (extended course for cholera): Communicable Diseases Communiqué, January 2020, Vol. 19
(1). http://www.nicd.ac.za/
xxiv Antibiotic therapy for CDI (metronidazole oral/IV, vancomycin, oral): McDonald LC, Gerding DN, Johnson S, Bakken JS,
Carroll KC, Coffin SE, Dubberke ER, Garey KW, Gould CV, Kelly C, Loo V, Shaklee Sammons J, Sandora TJ, Wilcox MH.
Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases
Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018 Mar
19;66(7):987-994. https://www.ncbi.nlm.nih.gov/pubmed/29562266
Antibiotic therapy for CDI (metronidazole oral/IV, vancomycin, oral): Nelson RL, Suda KJ, Evans CT. Antibiotic treatment
for Clostridium difficile-associated diarrhoea in adults. Cochrane Database Syst Rev. 2017 Mar 3;3:CD004610.
Antibiotic therapy for CDI (metronidazole oral/IV, vancomycin, oral): Stevens VW, Nelson RE, Schwab-Daugherty EM,
Khader K, Jones MM, Brown KA, Greene T, Croft LD, Neuhauser M, Glassman P, Goetz MB, Samore MH, Rubin MA.
Comparative Effectiveness of Vancomycin and Metronidazole for the Prevention of Recurrence and Death in Patients With
Clostridium difficile Infection. JAMA Intern Med. 2017 Apr 1;177(4):546-553.
Antibiotic therapy for CDI (metronidazole oral/IV, vancomycin, oral): National Department of Health: Affordable
Medicines, EDP-Adult Hospital level. Medicine Review: Systemic antibiotics for Enterocolitis due to Clostridium
difficile, August, 2018. http://www.health.gov.za/
xxv Metronidazole, oral: Marie C, Petri WA Jr. Amoebic dysentery. BMJ ClinEvid. 2013 Aug 30;2013. pii:
0918. http://www.ncbi.nlm.nih.gov/pubmed/23991750
Metronidazole, oral: Gonzales ML, Dans LF, Martinez EG. Antiamoebic drugs for treating amoebic colitis.
Cochrane Database Syst Rev. 2009 Apr 15;(2):CD006085. http://www.ncbi.nlm.nih.gov/pubmed/19370624
2019 1.23
CHAPTER 2
BLOOD AND BLOOD FORMING ORGANS
2.1 ANAEMIA
Defined as a reduction in the absolute number of circulating red blood cells
and most commonly diagnosed when the haemoglobin (Hb) concentration is
reduced below the reference range for age and gender. The clinical features
depend on the severity of anaemia, the rate at which it developed and the
oxygen demands of the patient.
Cause
Can be classified according to the mean corpuscular volume (MCV) of the red
blood cell (RBC) into macrocytic anaemia (MCV >100 fL); microcytic anaemia
(MCV <80 fL) or normocytic anaemia (MCV 80–100 fL).
2.1.1 ANAEMIA, IRON DEFICIENCY

D50.0-1/D50.8-9
DESCRIPTION
Anaemia due to iron deficiency. Common causes of iron deficiency are chronic
blood loss, poor iron absorption or poor nutritional intake.
Investigations
» Low MCV and MCH (mean cell Hb – hypochromia) – note that this often
normal in early stages.
» Full blood count (FBC) Smear: Hypochromic microcytic anaemia and
pencil cells often reported.
» Confirm with low ferritin.
» Investigate for cause of iron deficiency.
» Consider upper and lower endoscopies in high risk patients (all males and
postmenopausal female patients) and patients not responding to treatment.
GENERAL MEASURES
Identify and treat the underlying cause.
Dietary adjustment if this is the underlying cause.
MEDICINE TREATMENT
Oral iron supplementation
Treatment
Treat underlying cause.
 Ferrous sulfate compound BPC (dried), oral, 170 mg (± 55 mg elemental
iron) 12 hourly.
LoE:IIIi
OR
2019 2.1
CHAPTER 2 BLOOD AND BLOOD FORMING ORGANS
Ferrous fumarate, oral, 200 mg (± 65 mg elemental iron) 12 hourly.

o Do not ingest with tea, antacids or calcium supplements/milk.
o Doses should be taken on an empty stomach, but if gastrointestinal
side effects occur doses should be taken with meals.
o Continue with treatment for 3 months once Hb has normalised to
replace iron stores.
o If daily iron is poorly tolerated (e.g. epigastric pain, nausea, vomiting
and constipation), administer oral iron on alternate days with meals.
LoE:IIIii
Follow the patient after one month of treatment and Hb should rise by at least 2
g/dl in the adherent patient without ongoing blood loss.
Prophylaxis O99.0/D50.0-1/D50.8-9/Z29.2
For example during pregnancy:
iron) daily.
OR LoE:IIIiii
Ferrous fumarate, oral, 200 mg once daily (± 65 mg
elemental iron).
If daily iron is poorly tolerated (e.g. epigastric pain, nausea, vomiting and
constipation), intermittent iron supplementation may be LoE:Iiv
administered:
 Ferrous sulphate compound BPC (dried), oral, 340 mg per week, (± 110
mg elemental iron), with meals.
OR
Ferrous fumarate, oral, 400 mg per week (± 130 mg elemental iron).
Consider the following if there is failure to respond to iron therapy:
» non-adherence,
» continued blood loss,
» wrong diagnosis,
» malabsorption, or
» mixed deficiency; concurrent folate or vitamin B12 deficiency.
Parenteral iron
Parenteral iron is seldom required and may very rarely be associated with
anaphylaxis.
Parenteral iron is only indicated when oral iron is:
» ineffective, defined as lack of response after three months of oral iron
therapy, or
» iron deficiency anaemia from 36 weeks of pregnancy, or
» expected to be ineffective, e.g. malabsorption, patients on haemodialysis
and erythropoietin therapy, or
» not tolerated.
2019 2.2
In people who require repeated therapy, the intravenous route is preferred.

Minimum required dose is 250 mg of iron per gram of Hb below normal.
Note: Use in consultation with a specialist.
 Iron, IV, e.g.:
 Iron sucrose, IV, 200 mg in 200 mL sodium chloride 0.9%, over 30
minutes, given on alternate days until the total dose has been given.
o Note: Test dose is not required.
o An initial total dose of 600 mg is usually adequate to raise the Hb to
acceptable levels.
OR
 Low molecular weight iron dextran, administered as a single dose.
o Determine total dose of iron required (total dose up to 20 mg/kg body
weight).
o Note: Start with test dose - 25 mg in 100 ml sodium chloride 0.9%,
infused over 15 minutes and observe the patient for 1 hour.
o If there is no adverse drug reaction, administer the remaining dose in
500 mL of sodium chloride 0.9%, 0.9% over 4-6 hours. Observe the
patient for 1 hour after the infusion.
LoE:IIIv
Resuscitation equipment should be ready to manage anaphylaxis.
Red cell concentrate transfusion

Indicated in patients with:
» anaemia leading to cardiac failure or severe dyspnoea;
» active, ongoing bleeding; or
» where correction of anaemia is required prior to performing an urgent
invasive procedure or surgery.
2.1.2 ANAEMIA, MEGALOBLASTIC

D53.1/D58.9/D59.9/D55.0-3/D55.8-9/D56.0-4/D56.8-9/D57.0-3/D57.8/D58.0-2/
D58.89/D47.1/L26
DESCRIPTION
Anaemia caused by a deficiency of folate and/or vitamin B12.
Note that several medicines can cause macrocytic anaemia (e.g.
hydroxyurea, stavudine and zidovudine) without deficiencies of folate and/or
vitamin B12.
Investigations
» Elevated MCV and MCH.
» Pancytopaenia in severe cases.
» FBC smear: oval macrocytes, hypersegmentation of neutrophils,
thrombocytopenia with giant platelets.
2019 2.3
» Decreased serum vitamin B12 or red blood cell folate.

» Intrinsic factor antibodies, and/ or anti-parietal cell antibodies are found in
pernicious anaemia.
GENERAL MEASURES
Dietary modifications to ensure adequate intake of folate and vitamin B12
(important in vegetarians and malnourished patients).
Identify and treat the underlying cause, e.g. antibiotics for intestinal
overgrowth with bacteria.
Metformin use can lead to vitamin B12 deficiency by interfering with absorption.
MEDICINE TREATMENT
After blood samples for RBC folate and vitamin B12 levels have been taken,
start with folic acid and vitamin B12 supplementation.
Monitor serum potassium and replace if necessary.
Adjust management according to results.
Give vitamin B12 and folic acid together until the test results are available
as giving folic acid alone in patients with a B12 deficiency may precipitate
a permanent neurological deficit.
Folic acid deficiency

 Folic acid, oral, 5 mg daily until Hb returns to normal.
Prolonged treatment may be required for malabsorption states.
Vitamin B12 deficiency
 Vitamin B12, IM.
o 1 mg daily for 5 days, then weekly for a further 3 doses
o Follow with 1 mg every second month for life in patients with pernicious
anaemia.
Note:
» Response to treatment is associated with an increase in energy and
strength and improved sense of well-being.
» Reticulocytosis begins 3–5 days after therapy and peaks at about day 7.
» Anaemia normally corrects within 1–2 months. The white cell count and
platelets normalise in 7–10 days. As there is an increase in red blood cell
production, iron and folic acid supplementation is also recommended, until
Hb has normalised. Check for hypokalaemia in the first few days of therapy.
Hypokalaemia: See section 7.2.2: Hypokalaemia.
Consider the following if there is failure to respond:
» Co-existing folate and/or iron deficiency,
» Other causes of macrocytosis:
- Myelodysplasia,
- Hypothyroidism,
- Chronic alcohol use,
» Drug-induced, e.g. hydroxyurea, stavudine and zidovudine.
2019 2.4
Prophylaxis O99.0/Z49.1/Z29.2
Vitamin B12 is indicated for patients after total gastrectomy or ileal resection.
 Vitamin B12, IM, 1 mg every second month for life.
Indications for folic acid:

» Chronic inherited or acquired haemolytic anaemias, e.g. sickle cell
anaemia, thalassaemia.
» Myeloproliferative disorders.
» Exfoliative skin disorders.
» Increased demands, e.g. pregnancy, chronic haemodialysis.
 Folic acid, oral, 5 mg daily.
2.1.3 ANAEMIA, CHRONIC DISORDER

(D63.0/D63.8)
DESCRIPTION
Anaemia due to chronic inflammation. This is characteristically a
normochromic normocytic anaemia. Common causes of anaemia of chronic
disorder include:
» malignancy, e.g. haematological or solid tumours
» autoimmune disorders, e.g. rheumatoid arthritis
» chronic infections, e.g. HIV and TB
» chronic kidney disease
TREATMENT
Treat the underlying condition.
Transfusion is seldom necessary.
Do not treat with iron, folic acid or vitamin B12 unless there is a documented
deficiency (note that diagnosing iron deficiency is difficult in chronic disorders
as ferritin increases and serum iron decreases due to the acute phase
response). A transferrin saturation level less than 20% usually indicates a
combination of iron deficiency anaemia and anaemia of chronic disease.
2.1.4 ANAEMIA, HAEMOLYTIC

D59.0-1
DESCRIPTION
Anaemia due to destruction of red blood cells. Destruction may be due to:
» Extracellular factors such as auto-immunity or mechanical factors, e.g.
disseminated intravascular coagulation (DIC), hypersplenism, mechanical
heart valves.
» Abnormalities of the cell membrane, e.g. hereditary spherocytosis.
» Enzymes, e.g. G6PD deficiency.
» Haemoglobin abnormalities, e.g. sickle cell anaemia, thalassaemia.
» Thrombotic thrombocytopenic purpura is a life-threatening emergency, if
treated early. Immediate referral to specialist unit for plasma infusion or
2019 2.5
exchange is necessary (see section 2.12: Thrombotic thrombocytopenic

purpura-Haemolytic uraemic syndrome).
Investigations
» Evidence of haemolysis: anaemia, reticulocytosis, decreased haptoglobin,
increased lactate dehydrogenase (LDH) and unconjugated
hyperbilirubinaemia.
» FBC smear: Spherocytes often reported
» Coombs’ test (direct antiglobulin) is usually positive with autoimmune
haemolysis.
» HIV status.
GENERAL MEASURES
Treat the underlying cause.
Do not transfuse prior to appropriate investigations, unless anaemia is severe.
In situations of life-threatening anaemia, transfuse the most compatible unit
of red blood cells and get specialist advice urgently. Coombs-positive
haemolytic anaemia may be technically difficult to cross match.
Efficacy of transfusion is limited by the shortened red cell survival due to
haemolysis.
In G6PD deficiency, avoid drugs known to cause haemolysis, including
aspirin, sulphonamides (including cotrimoxazole), dapsone and primaquine.
In patients with cold agglutinins all transfusions must be given through a blood
warmer to avoid cold-induced haemolysis.
MEDICINE TREATMENT
All patients:
Because of high red cell turnover, supplement with:
Autoimmune haemolytic anaemia
Treat under specialist supervision.
 Prednisone, oral.
o Initial dose:1 mg/kg daily, until Hb stable and >10 g/dL.
o Taper slowly and monitor Hb at least once weekly. LoE:IIIvi
(Refer to Appendix II for an example of a dose
reduction regimen).
o Glucocorticoids should be tapered slowly, when there is normalization
of the haemoglobin and LDH. The patient should be monitored for
recurrence following cessation of treatment.
o As these conditions can often be life-threatening, specialist advice
should be sought as early as possible after diagnosis.
REFERRAL/CONSULTATION
If inadequate response:
» haemolysis remains severe for 3 weeks at prednisone doses of 1 mg/kg,
if remission cannot be maintained on low doses of prednisone, or if the
2019 2.6
patient has intolerable adverse effects or contraindications to

glucocorticoids.
Refer to specialist for second-line treatment:
» Splenectomy: vaccination: see chapter 11: Surgical prophylaxis.
Immunosuppresive therapy is needed in some cases, initiated by specialists.
LoE:IIIvii
2.1.5 ANAEMIA, APLASTIC

D60.0-1/D60.8-9/D61.0-3/D61.8-9
DESCRIPTION
Pancytopenia due to a hypoplastic bone marrow.
Clinical features:
» pallor » purpura
» petechiae » bleeding
» frequent or severe infections
Pancytopenia in HIV positive patients B23.2 + (D61.0/D61.9)

Most common causes include:
Direct effect of HIV, medication, secondary opportunistic infections,
malignancies and nutritional deficiencies. Many cases are idiopathic.
Investigations
» FBC smear (FBC indicates different degrees of: anaemia,
thrombocytopaenia and leucopaenia).Vitamin B12 and red cell folate.
» Appropriate investigation to exclude opportunistic infections.
» Bone marrow trephine and aspiration in selected patients (where no other
cause is found, in patients with persistent pancytopaenia) to exclude
infiltration with opportunistic infections, malignancies, etc.
MEDICINE TREATMENT
If neutropenic and febrile, see section 2.8: Febrile neutropenia.
REFERRAL
Discuss all cases of suspected aplastic anaemia with a specialist. (Stabilise
patient, if necessary, with blood products before transport but after
consultation with an expert).
2.1.6 ANAEMIA, SICKLE CELL

D57.0-3/D57.8
DESCRIPTION
Homozygous sickle cell anaemia (HbSS). Individuals with sickle cell trait have
<50% HbS and are generally asymptomatic. Milder sickle cell disease occurs
in individuals with HbSC.
2019 2.7
The disease is characterised by recurrent acute vaso-occlusive episodes

(“sickle crises”) and chronic haemolytic anaemia.
Adults develop hyposplenism, predisposing them to infection with
encapsulated bacteria.
Vaso-occlusive episodes
Vaso-occlusion can involve any part of the body, especially the skeleton.
Episodes may be triggered by dehydration, infection, stress or menstruation.
The most common presentation is with acute episodes of pain, varying in
severity, in the affected areas.
Investigations
The diagnosis is suspected from the history, peripheral blood examination,
and/or screening tests for sickling.
Diagnosis is confirmed on haemoglobin electrophoresis.
GENERAL MEASURES (SEVERE VASO-OCCLUSIVE EPISODES)

Keep well hydrated with intravenous fluids.
Transfusion is only indicated for severe episodes with severe anaemia –
discuss with a specialist.
Pain must be controlled.
MEDICINE TREATMENT (SEVERE VASO-OCCLUSIVE EPISODES)

 Use of Oxygen to maintain adequate saturation.
To prevent venous thromboembolism:
 Low molecular weight heparin, e.g.:
 Enoxaparin, SC, 40 mg daily.
In morbid obesity dosing of LMWH should be individualised, in discussion

with a specialist. LoE:IIIviii
In renal failure (eGFR <30 mL/minute), the recommended dose of

LMWH is 1 mg/kg daily. LoE:IIIix
OR
 Unfractionated heparin, SC, 5 000 units 12 hourly. LoE:IIIx
Analgesia
Refer to chapter 12: Anaesthesiology, pain and intensive care.
MEDICINE TREATMENT (CHRONIC MANAGEMENT)

All patients:
 Vaccination against infections due to pneumococci and haemophilus

(see section 9.2: Adult vaccination).
2019 2.8
Hydroxyurea (specialist-initiated) is the mainstay of therapy in severe disease.

Typical indications include:
 frequent painful vaso-occlusive episodes,
 severe vaso-occlusive episodes (e.g. acute chest syndrome, stroke), and
 severe symptomatic anemia.
REFERRAL
» All patients, for chronic management in a specialised centre.
» Vaso-occlusive episodes should be managed in consultation with a
specialist.
2.2 FEBRILE NEUTROPENIA

D70
DESCRIPTION
Febrile neutropenia is conventionally defined as an absolute neutrophil count
of <0.5 x 109/L with a temperature of greater than 38°C for >1 hour or a single
temperature of 38.3°C, but any neutropaenic patient showing clinical signs of
sepsis should be investigated.
Note:
» This is a medical emergency as a minor infection may become very
serious, these patients can rapidly develop features of severe sepsis
(multi-organ failure and/or hypotension). It is crucial to monitor and treat
patients for signs and symptoms of infection.
» Cultures should be obtained for appropriate microbiological testing
prior to empirical antimicrobial therapy. It is critical to recognise
neutropenic fever early and to initiate empiric systemic antibacterial
therapy promptly in order to avoid progression to a sepsis syndrome and
possibly death.
LoE:IIIxi
GENERAL MEASURES
Treat the underlying cause of neutropenia, if applicable.
Withdraw any medication that may cause neutropenia.
Consider removing central IV line. Once culture results are available, adjust
treatment to the most appropriate narrow spectrum agent.
MEDICINE TREATMENT
For patients with febrile neutropenia within 48 hours of admission:
AND
 Gentamicin, IV, 6 mg/kg daily (see Appendix II for guidance on
prescribing).
2019 2.9
If IV line, skin infection is suspected as the cause::

ADD:
 Vancomycin, IV, 30 mg/kg as a loading dose. Follow with 20 mg/kg/dose
12 hourly. (See Appendix II for guidance on prescribing and monitoring).
If fever develops after 48 hours of admission:

(Choice of antibiotic will depend on local susceptibility patterns).
 Carbapenem with activity against Pseudomonas, e.g.:
 Meropenem, IV, 1 g 8 hourly
OR
Imipenem/cilastan, IV, 500/500 mg 6 hourly.
Note: Ertapenem is not recommended because it is not effective for
Pseudomonas species, which are important pathogens in this setting.
OR
 Piperacillin/tazobactam, IV, 4.5 g 8 hourly
AND
Amikacin, IV, 15 mg/kg daily. (See Appendix II, for LoE:IIIxii
individual dosing and monitoring for response and
toxicity).
OR
 Cefepime, IV, 2 g 12 hourly. LoE:IIIxiii
If no response after 5–7 days: (In discussion with a Clinical Haematologist or

Infectious Disease specialist).
ADD
 Amphotericin B, IV, 1 mg/kg daily in dextrose 5 % over 4 hours.
o Ensure adequate hydration to minimise nephrotoxicity. (See Appendix
II for preventing, monitoring and management of toxicity).
Duration of therapy:
» If neutrophil count increases to >0.5  109/L, continue for 2 days after
fever has settled.
» If neutrophil count remains 0.5  109/L, continue for 7 days after fever
has settled.
All cases – consult with haematologist/oncologist.
2.3 MYELODYSPLASTIC SYNDROMES

D46.0-2/D46.4-7/D46.9
DESCRIPTION
A group of disorders characterised by refractory cytopaenias due to bone
marrow failure. Tthere is a risk of disease progression to acute leukaemia.
2019 2.10
Investigations
» Evidence of cytopenia, with normal B12 and folate levels, and often
substantial morphological dysplasia on the blood smear.
» Bone marrow examination confirms dysplasia of the blood elements and
the presence of cytogenetic abnormalities.
TREATMENT
Transfusion should ideally be with leucodepleted red cells to delay
immunisation, as these patients require frequent transfusions.
Bone marrow transplantation can be curative in selected patients.
If neutropenic and febrile, see section 2.8: Febrile neutropenia.
REFERRAL
All patients for further investigation and management.
2.4 BLEEDING DISORDERS
GENERAL PRINCIPLES
A bleeding tendency may result from:
» a coagulation defect (congenital/acquired),
» a vessel wall defect, or
» a platelet defect (quantitative/qualitative).
A careful and detailed history, thorough examination and review of relevant
laboratory investigations will allow differentiation between these three
categories, as the management of each of these groups differs significantly.
Screening tests include: FBC, prothrombin time (PT) and activated partial
thromboplastin time (aPTT) (if prolonged, mixing studies are required).
Patients with a chronic bleeding tendency should be advised to wear a medic
alert bracelet which clearly mentions the type of disorder he/she suffers from,
e.g. severe Haemophilia A, Factor VIII <1%, no inhibitors.
2.4.1 HAEMOPHILIA A AND B, VON WILLEBRAND’S

DISEASE
D66/D67/D68.0
DESCRIPTION
Haemophilia A, haemophilia B and von Willebrand's disease are chronic
bleeding disorders caused, respectively, by a lack of clotting factor VIII, clotting
factor IX and von Willebrand factor (VWF, a carrier protein for factor VIII).
Presentation depends on severity of the condition (see classification below).
2019 2.11
Complications include haemarthrosis with later chronic arthropathy,

intracranial haemorrhage, soft tissue and muscle haematomas. Pain/tingling
in a joint suggests bleeding into the joint in a known haemophiliac.
Early consultation with a haematologist or a clinician with expertise in the
handling of such patients is advisable. Clinicians should make contact with
their local haemophilia centre which may be identified at:
http://www.haemophilia.org.za/treatment-centres/
All patients diagnosed with haemophilia should at least annually attend a
specialised Haemophilia Treatment Centre with a dedicated multi-disciplinary
health care team as guided by the local Haemophilia Treatment Centre.
Subclassification (factor VIII and IX deficiency):

CLOTTING
CLASS % OF NORMAL SIGNS
FACTOR
Mild VIII or IX >5–<40% Occasional bleeds
Moderate VIII or IX 1–5% Less frequent
bleeding associated
with trauma, surgery
or dental work
Severe VIII or IX <1% Traumatic or
spontaneous bleeds
Investigations
Prolonged partial thromboplastin time (PTT).
Factor VIII or factor IX concentration and inhibitor screen.
TREATMENT GUIDELINES
Treatment approaches are divided into two main categories: prophylaxis and
on demand.
Prophylaxis
Secondary prophylaxis is sometimes needed in patients presenting with a
target joint in consultation with a Haemophilia Treatment Centre.
The aim is to reduce the number of bleeds and prevent or delay development
of joint arthropathy.
Treatment on Demand
Episodic treatment for bleeding episodes is referred to as on-demand therapy
(i.e. the use of factor replacement therapy after bleeding occurs).
GENERAL MEASURES
» Patient and family education.
» Enroll on the Haemophilia registry.
» Alert bracelet.
» Dental care (discuss management of tooth extraction with local
haemophilia centre).
» Avoid contact sport.
2019 2.12
Acute bleeds into joints

Patients with severe haemophilia should be trained to self-administer their
clotting factor concentrate.
Adjunctive management
» Protection (splint but no circumferential casting).
» Rest the affected limb until pain free and no weight bearing.
» Ice packs may be applied immediately (apply ice, 5 minutes on and 10
minutes off).
» Elevation of the affected limb.
MEDICINE TREATMENT
For pain: Refer to chapter 12: Anaesthesiology, pain and intensive care.
Exercise great caution when taking blood specimens.
Taking blood from femoral veins is absolutely contra-indicated.
Do not use central lines for transfusions. Do not do joint aspirations
Avoid IM injections.
Avoid aspirin and NSAIDS.
HAEMOPHILIA WITH NO INHIBITORS

The dose of the factor VIII and IX is individualised as it is dependent on body
mass, severity of the condition, and the nature and site of the bleeding.
Factor VIII deficiency (with no inhibitor present)

Minor bleeds:
Bleeds into the muscle or soft tissue, mouth or gums, epistaxis, painless
haematuria and early joint bleeds.
Treatment:
 Factor VIII, intravenous, 25 IU/kg IV, immediately as a single dose.
o If there is evidence of ongoing bleeding after 12 hours, consult with
local haemophilia treatment centre.
Major bleeds:
Advanced muscle or joint bleeds, bleeds resulting from severe injury, or
bleeds that affect the central nervous system; gastrointestinal system; neck or
throat; hip or iliopsoas; or forearm compartment.
Treatment:
 Factor VIII, intravenous, 50 IU/kg, immediately as a single dose.
o All of these patients need hospitalisation.
o Discuss all patients promptly with local haemophilia treatment centre.
LoE:IIIxiv
Factor IX deficiency (with no inhibitor present)
Minor bleeds:
Bleeds into the muscle or soft tissue, mouth or gums, epistaxis, painless
haematuria and early joint bleeds.
2019 2.13
Treatment:
 Factor IX, intravenous, 40 IU/kg immediately as a single dose.
o If there is evidence of ongoing bleeding after 12 hours, consult with
local haemophilia treatment centre.
Major bleeds:
Major muscle or joint bleeds, bleeds resulting from severe injury, or bleeds
that affect the central nervous system; gastrointestinal system; neck or throat;
hip or iliopsoas; or forearm compartment.
Treatment:
 Factor IX, intravenous, 60 IU/kg immediately as a single dose.
o All of these patients need hospitalisation.
Discuss all patients promptly with local haemophilia treatment centre to plan
ongoing treatment and factor replacement.
LoE:IIIxv
Mucous membrane bleeds in haemophilia A and B:
 Tranexamic acid, oral, 1 g, 6 hourly.
Ideally elective surgery should be perfomed at a tertiary centre with a
consultation with a haematologist.
In emergencies, treat as major bleed and consult the local Haemophilia
Treatment Centre as soon as feasible.
If serious bleeding with known haemophilia, and no factor VIII available:

 Lyophilised plasma, IV, 15 mL/kg.
OR
FFP, IV, 15 mL/kg.
LoE:IIxvi
HAEMOPHILIA WITH INHIBITORS
Refer for assessment and planning with a haematologist.
VON WILLEBRAND’S DISEASE

Mild bleeding
Such as epistaxis and menorrhagia.
Antifibrinolytics, e.g.:
 Tranexamic acid, oral, 1 g 6 hourly.
Recurrent menorrhagia can also be treated effectively with oral contraceptives.
See section 5.2: Uterine bleeding, abnormal.
More severe mucous membrane bleeding

Consult a local haemophilia treatment centre.
During surgery or after major trauma, patients should receive:
 Von Willebrand factor VIII concentrate, IV, 30 units/kg/dose given every
12 hours.
o Continue for 48–72 hours to ensure optimal haemostasis.
o For major surgical procedures, use for 7–10 days. LoE:III
2019 2.14
REFERRAL
» All cases with suspected haemophilia (prolonged PTT and normal INR)
to a haemophilia treatment centre, for assessment, genetic counselling
and planning of management.
» Patients with proven antibodies (inhibitors) against factor VIII or IX.
» For further replacement, complex situations and complications in
consultation with a haematologist.
2.5 IMMUNE THROMBOCYTOPENIA (ITP)

D69.3
DESCRIPTION
A common bleeding disorder due to immune-mediated destruction of platelets.
Clinically apparent associated conditions, drugs (e.g. penicillins,
cephalosporins, quinine, rifampicin and heparin), or other agents that may
cause thrombocytopenia are NOT present. Patients with suspected ITP
should be tested for SLE and for HIV infection.
Investigations
» Thrombocytopenia with normal white cell count and red cell indices
(however, anaemia may be present due to blood loss).
» Peripheral blood smear to exclude RBC fragments. Smear may show large
platelets.
» Do INR and aPTT, both of which should be normal in ITP.
» If there is a poor response to treatment do a bone marrow aspirate and
biopsy.
GENERAL MEASURES
Avoid:
» medication that affects platelet function, e.g. NSAIDs and aspirin,
» platelet transfusions, unless there are life-threatening bleeds,
» dental procedures in acute phase, and
» IM injections.
Reassure the patient that resolution usually occurs in acute ITP.
Medic alert bracelet.
Platelet transfusions may be given if surgery is required or in life-threatening
bleeding, discuss with haematologist.
Goal of treatment: reduce the risk of bleeding, not normalise the platelet count.
Avoid unnecessary treatment of asymptomatic patients with mild to moderate
thrombocytopenia (platelet count >30 x 109/L).
MEDICINE TREATMENT
Acute ITP
 Prednisone, oral, 1 mg/kg daily, until platelet count has normalised.
o Taper slowly and monitor platelet count. (Refer to Appendix II for an
example of a dose reduction regimen).
2019 2.15
o Although prednisone is also indicated for HIV-associated immune

thrombocytopenia it is important that all these patients should be fast-
tracked for ART.
LoE:IIIxvii
Second line therapy
Patients with persistent thrombocytopenia not responding to treatment with
glucocorticoids.
Treatment with specialist supervision
There are other multiple treatments available but are dependent on
specialist opinion.
REFERRAL
» All cases not responding to steroids and, in the case of HIV-infected
patients, not responding to ART – discuss with haematologist.
» Refer for second line treatment.
Acute active life-threatening bleeding and surgery

 Platelet transfusions.
Platelet transfusions are only indicated in acute active bleeding uncontrolled
by other means or before procedures. In an adult, 1 unit of platelets, preferably
single donor, leucocyte depleted platelets, is usually sufficient to control the
bleeding initially. Platelet transfusions have limited benefit in this condition as
platelets are rapidly destroyed by the immune system.
 Methylprednisolone acetate 1 g, IV, daily for 3 days. LoE:IIIxviii
If the bleeding cannot be controlled, consult with a specialist.
2.6 THROMBOTIC THROMBOCYTOPENIC PURPURA-

HAEMOLYTIC URAEMIC SYNDROME (TTP-HUS)
D59.3 + (M31.1)
DESCRIPTION
This is a medical emergency.
Acute syndromes with abnormalities in multiple organ systems with evidence of
micro-angiopathic haemolytic anaemia and thrombocytopenia.
This condition presents with varying combinations of the following (only some of
which may be present):
» Microangiopathic haemolytic anaemia thrombocytopenia, often with
purpura but not usually severe bleeding,
» acute renal insufficiency,
» neurologic abnormalities, and
» fever.
Note: The presence of fragments and low platelets is enough to consider the
diagnosis.
2019 2.16
Microangiopathic haemolytic anaemia is defined as nonimmune haemolysis

with prominent RBC fragmentation (schistocytes) observed on the peripheral
blood smear along with thrombocytopaenia.
TTP-HUS is often associated with HIV infection and all patients should be
tested for HIV.
TTP-HUS should be distinguished from disseminated intravascular
coagulation (DIC) and severe pre-eclampsia where, in the latter, the
coagulation profile (PT/PTT) is also deranged.
TREATMENT
 In HIV-associated thrombotic thrombocytopenia, start combination
antiretroviral therapy urgently.
 Lyophilised plasma, IV infusion, 30 mL/kg/day in 3–4 divided doses.
OR
FFP, IV infusion, 30 mL/kg/day in 3–4 divided doses.
LoE:IIxix
Use of platelet transfusions should be discussed with a
specialist.
REFERRAL
All patients – discuss with a haematologist urgently.
2.7 ACQUIRED COAGULATION DEFECTS

2.7.1 DISSEMINATED INTRAVASCULAR COAGULATION
(DIC)
D65/D68.2/D68.8
DIC is a complication of an underlying condition and is characterised by

widespread activation of clotting cascade leading to consumption of clotting
factors and platelets with generalized bleeding. No single diagnostic test, but
the combination of a prolonged INR and PTT, thrombocytopenia, decreased
fibrinogen and increased D-dimer is highly suggestive of the diagnosis.
MANAGEMENT
Identify and treat the underlying cause.
If the patient is bleeding, replace haemostatic factors with cryoprecipitate or
FFP/lyophilised plasma.
If the patient is not actively bleeding and platelet count >20 x 109/L, then
platelet transfusion is not necessary.
Replacement therapy for thrombocytopenia should consist of 1 apheresis
single donor unit or 1 pooled random donor unit. In chronic DIC, or in the
2019 2.17
absence of bleeding, platelet transfusions should not be given merely to

correct the thrombocytopenia.
For hypofibrinogenaemia:
 Cryoprecipitate, IV, 1 unit/10 kg.
For depletion of other coagulation factors:

 Lyophilised plasma, IV, 15 mL/kg as initial dose.
o Volume: ±200 mL/unit.
OR
FFP, IV, 15 mL/kg as initial dose.
o Volume: ±280 mL/unit. LoE:IIxx
Repeat replacement therapy 8 hourly or less frequently, with adjustment
according to the clinical picture and laboratory parameters.
Monitor response with frequent estimation of the platelet count and
coagulation screening tests.
2.8 VENOUS THROMBO-EMBOLISM

I80.0-3/I80.8-9/I81/I82.0-3/I8.8-9/I26.0/I26.9
DESCRIPTION
Venous thromboembolism (VTE) should be seen as a spectrum from calf
deep venous thrombosis (DVT) to pulmonary thrombo-embolism. All patients
should be seen as potentially high risk.
Differential diagnosis includes:
» cellulitis » ruptured popliteal (Baker’s) cyst
» superficial thrombophlebitis » calf muscle pull or tear
» lymphoedema » internal derangement of the knee
» chronic venous insufficiency
Diagnosis is primarily clinical and confirmed with imaging studies, e.g. Duplex
Doppler.
GENERAL MEASURES
Strategies for prevention include: lifestyle modifications like avoiding obesity
and inactivity, avoiding dehydration, avoiding cigarette smoking, maintaining
normal blood pressure, and mechanical measures like vascular compression
stockings and intermittent pneumatic compression boots.
LoE:IIIxxi
Acute management
Thrombolytic therapy may be indicated in patients with confirmed early
pulmonary embolism where haemodynamic stability cannot be achieved.
Discuss with a specialist.
2019 2.18
MEDICINE TREATMENT
PROPHYLAXIS
Risk Assesement
Risk assessment is essential, and treatment needs to be individualised. Risk
factors for VTE can be divided into predisposing factors (i.e. patient
characteristics) and exposing factors (i.e. underlying medical conditions,
nature of surgical intervention, etc.).
SUBCATEGORIES OF VTE RISK IN SURGICAL AND NON-SURGICAL PATIENTS

Surgical patients Medical patients
Low VTE risk » Surgery lasting <30 minutes » Infection or acute inflammatory
» Injuries without or with only diseases without bed rest
minor soft-tissue trauma » Central venous catheters
» No or only minor additional » No or only minor additional
predisposing risk factors predisposing risk factors
Moderate VTE » Surgical procedures of longer » Acute cardiac insufficiency
risk duration (NYHA III/IV)
» Immobilisation of lower limb with » Acute decompensated COPD
plaster cast without ventilation
» Lower limb arthroscopic » Infection or acute inflammatory
procedures. diseases with bed rest
» No or only minor additional » Malignant disease
predisposing risk factors » No or only minor additional
predisposing risk factors
High VTE risk » Major surgical procedures for » Stroke with paralysis
malignancy » Acute decompensated COPD
» Multiple trauma or severe trauma with ventilation
of the spine, vertebra or » Sepsis
» lower limbs » ICU patients
» Major orthopaedic surgery, e.g.
hip or knee replacement
» Major surgical procedure of
cardiothoracic and pelvic region
Source: Jacobson BF, Louw S, Büller H, Mer M, de Jong PR, Rowji P, Schapkaitz E, Adler D, Beeton A, Hsu HC,
Wessels P, Haas S; South African Society of Thrombosis and Haemostasis. Venous thromboembolism: prophylactic
and therapeutic practice guideline. S Afr Med J. 2013 Feb 15;103(4 Pt 2):261-7.
Some risk assesement models for assessing VTE risk:

Model Url link to tool
Padua Prediction Scorexxii https://www.mdcalc.com/padua-prediction-score-
risk-vte
IMPROVE VTE risk scorexxiii https://www.outcomes-
umassmed.org/IMPROVE/risk_score/vte/index.html
Geneva risk scorexxiv https://www.mdcalc.com/geneva-risk-score-
venous-thromboembolism-vte-prophylaxis
Prophylactic treatment
Prophylaxis is indicated for medical patients with moderate to high risk of VTE
(see table above), with restricted mobility during acute illness/ surgical patients.
 Low molecular weight heparin, e.g.: LoE:Ixxv
 Enoxaparin, SC, 40 mg daily.
2019 2.19

with a specialist. LoE:IIIxxvi

LMWH is 1 mg/kg daily. LoE:IIIxxvii
OR
 Unfractionated heparin, SC, 5 000 units 12 hourly. LoE:IIIxxviii
Although the risk of bleeding is small, in the following patients prophylaxis

should only be used under exceptional circumstances:
» active bleeding
» intraocular, intracranial or spinal surgery
» lumbar puncture or spinal/epidural anaesthesia within 12 hours after
prophylactic dose or 24 hours of full therapeutic dose, [Timing of
anticoagulants for patients receiving anaesthesia: See section 12.8: Spinal
(intrathecal) anaesthesia]
» renal insufficiency
» coagulopathy
» uncontrolled hypertension
ACUTE TREATMENT
Unfractionated or low molecular weight heparin started simultaneously with
warfarin. After 5 days, heparin may be stopped if a therapeutic INR level has
been reached and maintained for at least 24 hours.
Note: Heparin and warfarin therapy should overlap for at least 5 days.
For proximal deep venous thrombosis and/or pulmonary embolism: LoE:Ixxix

 Enoxaparin, SC, 1.5 mg/kg daily, LoE:Ixxx
or
1 mg/kg 12 hourly.

with a specialist. LoE:IIIxxxi

LMWH is 1 mg/kg daily. LoE:IIIxxxii
OR
 Unfractionated heparin, SC, 333 units/kg as an initial dose.

o Follow 12 hours later by 250 units/kg/dose 12 hourly.
2019 2.20
Units of unfractionated heparin Volume of heparin in mL

(25 000 units/mL)
Weight (kg) Loading dose 12 hourly Loading dose 12 hourly
(units) dose (units) (mL) dose
(mL)
35 kg 11 000 units 8 750 units 0.44 mL 0.35 mL
75 kg 25 000 units 18 750 units 1 mL 0.75 mL
Evidence indicates that PTT monitoring is not necessary with weight-

based dosing of unfractionated heparin. However, in patients with morbid
obesity and renal failure (eGFR <30 mL/minute) unfractionated heparin
should be used with PTT monitoring to maintain the PTT at 1.5 to 2.5
times the control.
PTT should be taken 4 hours after SC dose.
LoE:III
Follow with:
 Warfarin, oral, 5 mg daily.
o INR should be done after 48 hours, then every 1 to 2 days until within
the therapeutic range of 2 to 3 (refer to Initiation dosing tables in the
Appendix II).
o Adjust dose to keep INR within therapeutic range (refer to Maintenance
dosing tables in the Appendix II).
o Continue warfarin for 3 months with regular INR monitoring if there was
a precipitating cause that has resolved.
o In patients with a first unprovoked DVT, discuss duration of therapy
with a specialist.
o Contraindications for warfarin: first trimester and the last month of
pregnancy. In these instances, replace with heparin.
o For all major elective surgery and other elective procedures with a
significant bleeding risk, such as neuraxial anaesthesia and lumbar
punctures, the INR should be <1.5.
Heparin induced thrombocytopenia

A severe immune-mediated drug reaction occurring in 1–5% of patients
receiving heparin (more common with unfractionated heparin, but may also
occur with low molecular weight heparin) therapy. It presents with
2019 2.21
thrombocytopenia and thrombosis. Diagnosis needs a high index of suspicion

and should be considered if a patient has a 50% drop in platelet count within
5–10 days after initiating heparin therapy. Confirmation is done by positive
antibody testing.
Stop heparin and discuss all patients with a specialist.
Heparin-induced thrombocytopenia.
2019 2.22
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Low molecular weight heparin (first line option - prophylaxis): National Department of Health: Affordable Medicines, EDP-
Adult Hospital Level. Cost-effectiveness and budget impact analyses: Fondaparinux for prophylaxis of venous
thromboembolism in medical and surgical patients in hospitalised patients in the South African public health system, April
2018. http://www.health.gov.za/
Low molecular weight heparin (first line option - treatment): National Department of Health: Affordable Medicines, EDP-
Adult Hospital Level. Cost-effectiveness and budget impact analyses: Fondaparinux for the treatment of venous
thromboembolism in hospitalised patients in the South African public health system, April 2018. http://www.health.gov.za/
xxvi Low molecular weight heparin (morbid obesity): Lalama JT, Feeney ME, Vandiver JW, Beavers KD, Walter LN, McClintic
JR. Assessing an enoxaparin dosing protocol in morbidly obese patients. J Thromb

Thrombolysis. 2015 May;39(4):516-21. http://www.ncbi.nlm.nih.gov/pubmed/25087072
Low molecular weight heparin (morbid obesity): Spinler SA, Inverso SM, Cohen M, Goodman SG, Stringer KA, Antman
EM; ESSENCE and TIMI 11B Investigators. Safety and efficacy of unfractionated heparin versus enoxaparin in patients who
are obese and patients with severe renal impairment: analysis from the ESSENCE and TIMI 11B studies. Am Heart J. 2003
Low molecular weight heparin (morbid obesity): Thompson-Moore NR, Wanat MA, Putney DR, Liebl PH, Chandler WL,
Muntz JE. Evaluation and Pharmacokinetics of Treatment Dose Enoxaparin in Hospitalized
Patients With Morbid Obesity. Clin Appl Thromb Hemost. 2015 Sep;21(6):513-20.
Low molecular weight heparin (morbid obesity): Freeman A, Horner T, Pendleton RC, Rondina MT. Prospective
comparison of three enoxaparin dosing regimens to achieve target anti-factor Xa levels in hospitalized, medically ill patients
with extreme obesity. Am J Hematol. 2012 Jul;87(7):740-3. http://www.ncbi.nlm.nih.gov/pubmed/22565589
xxvii Low molecular weight heparin (renal impairment): South African Medicines Formulary. 12th Edition. Division of Clinical

xxviii Heparin, SC: Collins R, Scrimgeour A, Yusuf S, Peto R. Reduction in fatal pulmonary embolism and venous thrombosis
by perioperative administration of subcutaneous heparin. Overview of results of randomized trials in general, orthopedic, and
urologic surgery. N Engl J Med. 1988 May 5;318(18):1162-73. https://www.ncbi.nlm.nih.gov/pubmed/3283548
2019 2.25
CHAPTER 3
CARDIOVASCULAR SYSTEM
3.1 ISCHAEMIC HEART DISEASE AND

ATHEROSCLEROSIS, PREVENTION
I20-I25
Major risk factors for ischaemic cardio- and cerebrovascular disease:

» Diabetes mellitus.
» Hypertension.
» Central obesity (waist circumference): men ≥102 cm, women ≥88 cm.
» Smoking.
» Dyslipidaemia:
- Total cholesterol >5.0 mmol/L, or
- LDL >3 mmol/L, or
- HDL <1 mmol/L in men and <1.2 mmol/L in women.
» Family history of premature cardiovascular disease in first degree male
relatives <55 years and in first degree female relatives <65 years.
» Age: men >55 years, women >65 years.
» Psychological stress. LoE:IIi
GENERAL MEASURES
Lifestyle modification, especially smoking cessation, is essential and
often has greater beneficial impact on prognosis than vascular
interventions and medications.
All persons should be encouraged to make the following lifestyle changes as

appropriate:
» Smoking cessation.
» Weight reduction in overweight patients, i.e. BMI >25 kg/m2.
» Maintain ideal weight, i.e. BMI <25 kg/m2.
» Reduce alcohol intake to no more than 2 standard drinks/day
» Follow a prudent eating plan i.e. low saturated fat, high fibre and unrefined
carbohydrates, with adequate fresh fruit and vegetables.
» Moderate aerobic exercise, e.g. 40 minutes brisk walking at least 3 times
a week.
2019 3.1
CHAPTER 3 CARDIOVASCULAR SYSTEM
Calculation of risk of developing cardiovascular disease over 10

years (in the absence of cardiovascular disease)
To derive the absolute risk as the percentage of patients who will have a
myocardial infarction over 10 years, add the points for each risk category
(Section A). The risk associated with the total points is then derived from
Section B.
SECTION A
Age MEN WOMEN
(years)
30–34 0 0
35–39 2 2
40–44 5 4
45–49 6 5
50–54 8 7
55–59 10 8
60–64 11 9
65–69 12 10
70–74 14 11
75–79 15 12
Total cholesterol MEN WOMEN

(mmol/L)
<4.1 0 0
4.1–5.1 1 1
5–6.2 2 3
6.2–7.2 3 4
>7.2 4 5
HDL cholesterol MEN WOMEN
(mmol/L)
>1.6 –2 –2
1.3–1.5 1 –1
1.2–1.3 0 0
0.9–1.1 1 1
<0.9 2 2
MEN WOMEN
Smoker 4 3
Diabetic* 3 4
*Type 2 diabetics >40 years, qualify for statin therapy irrespective of risk score.
MEN WOMEN
Systolic BP Untreated Treated Untreated Treated
(mmHg)
<120 –2 0 –3 –1
120–129 0 2 0 2
130–139 1 3 1 3
140–149 2 4 2 5
150–159 2 4 4 6
≥160 3 5 5 7
2019 3.2
SECTION B
Total points
10-year risk % MEN 10-year risk % WOMEN
<1 ≤–3 <1 ≤–2
1.1 –2 1.0 –1
1.4 –1 1.2 0
1.6 0 1.5 1
1.9 1 1.7 2
2.3 2 2.0 3
2.8 3 2.4 4
3.3 4 2.8 5
3.9 5 3.3 6
4.7 6 3.9 7
5.6 7 4.5 8
6.7 8 5.3 9
7.9 9 6.3 10
9.4 10 7.3 11
11.2 11 8.6 12
13.2 12 10.0 13
15.6 13 11.7 14
18.4 14 13.7 15
21.6 15 15.9 16
25.3 16 18.5 17
29.4 17 21.5 18
>30 ≥18 24.8 19
28.5 20
>30 21+
MEDICINE TREATMENT
Indications for lipid lowering medicine therapy
Patients with any of the following factors are at a relatively high risk for a
cardiovascular event and should receive lipid lowering therapy:
» Established atherosclerotic disease:
 ischaemic heart disease
 peripheral vascular disease
 atherothrombotic stroke
» Type 2 diabetes with age >40 years.
» Diabetes for >10 years.
» Diabetes with chronic kidney disease (eGFR <60 mL/minute).
LoE:Iii
Patients with any of the following factors are also potentially at risk for
cardiovascular disease (other than the categories above):
» diabetes mellitus
» hypertension
» central obesity: waist circumference ≥94 cm (men) and ≥80 cm (women)
» smoking
» age: men >55 years of age, women >65 years of age
2019 3.3
These patients should be managed according to their 10–year risk of a

cardiovascular event as calculated using either:
A. BMI–based risk assessment – see PHC STGs and EML, section 4.1:
Prevention of ischaemic heart disease and atherosclerosis, or
B. Framingham risk score (cholesterol-based assessment) – see tables above.
Management is based on the patient’s 10-year risk of a cardiovascular event:
 <10% risk: lifestyle modification and risk assess patient every 5 years
 10–20% risk: lifestyle modification and risk assess patient annually
 ≥20% risk: lifestyle modification and start statin treatment
Note:
» Lipid lowering medicines should be given to those with a high risk of CVD
even if cholesterol is within the desirable range.
 HMGCoA reductase inhibitors (statins), according to table below:
INDICATION HMGCOA REDUCTASE INHIBITOR
(STATIN) DOSE
A: Primary prevention - no existing CVD
» Type 2 diabetes with age >40 years.  HMGCoA reductase inhibitors
» Diabetes for >10 years. (statins), e.g.:
» Diabetes with chronic kidney disease.  Simvastatin, oral, 10 mg at night.
» ≥ 20% 10-year risk of cardiovascular
event.
» Patients on protease inhibitors.  Atorvastatin, oral, 10 mg at night.
(Risks as above, after switching to
atazanavir – see section below).
B: Secondary prevention – existing CVD
» Ischaemic heart disease.  HMGCoA reductase inhibitors

» Atherothrombotic stroke. (statins), e.g.:
» Peripheral vascular disease.  Simvastatin, oral, 40 mg at night
LoE:Iiii

LoE:Iiv
» Patients on amlodipine (and not on  Simvastatin, oral, 10–20 mg at night.

protease inhibitor). LoE:IIIv
» If patient complains of muscle pain. Reduce dose:

 HMGCoA reductase inhibitors
(statins), e.g.:
 Simvastatin, oral, 10 mg at night.
OR
Consult specialist for further
management.
LoE:IIIvi
Note: Lipid-lowering medicines must always be used in conjunction with ongoing
lifestyle modification.
2019 3.4
Protease inhibitor-induced dyslipidaemia:

» Certain antiretroviral medication, particularly protease inhibitors, can
cause dyslipidaemia. Fasting lipid levels should be done 3 months after
starting lopinavir/ritonavir. Lopinavir/ritonavir is associated with a higher
risk of dyslipidaemia (specifically hypertriglyceraemia) than atazanavir/
ritonavir.
» Patients at high risk (>20% risk of developing a CVD event in 10 years)
should switch to atazanavir/ritonavir and repeat the fasting lipid profile in 3
months.
» Patients with persistent dyslipidaemia despite switching, qualify for lipid
lowering therapy. Criteria for initiating lipid lowering therapy are the same
as for HIV-uninfected patients. Many statins (including simvastatin) cannot
be used with protease inhibitors, as protease inhibitors inhibit the
metabolism of the statin resulting in extremely high blood levels.
» Patients who fail to respond to lifestyle modification and have
dyslipidaemia treat with:
 Atorvastatin, oral, 10 mg at night.
REFERRAL
» Random cholesterol >7.5 mmol/L.
» Fasting (14 hours) triglycerides >10 mmol/L.
3.2 ACUTE CORONARY SYNDROMES

These conditions should be managed in a high care setting with continuous
ECG and frequent BP monitoring.
Reference guide for ECG analysis: “ECG APPtitude” smartphone app can be
downloaded from the relevant app stores - available for iOS and Android.
3.2.1 ST ELEVATION MYOCARDIAL INFARCTION (STEMI)

I21.0-I21.4/I21.9/I22.0-1/I22.8-9
DESCRIPTION
Ischaemic chest pain that is prolonged, or associated with nausea, sweating
and syncope or associated with persistent ST elevation or new or presumed
new left bundle branch block (LBBB). Repeat ECG at 20-30 minute intervals
if the initial ECG is not diagnostic.
MEDICINE TREATMENT LoE:Ivii

 Oxygen if saturation <94%.
LoE:Iviii
 Clopidogrel, oral, 75 mg daily for one month.
AND
 Aspirin, oral, 150 mg immediately as a single dose (chewed or dissolved).
2019 3.5
o Followed with 150 mg daily (continued indefinitely in absence of

contraindications).
LoE:Iix
AND
Thrombolytic therapy
 Streptokinase, IV 1.5 million units diluted in 100 mL sodium chloride 0.9%,
infused over 30–60 minutes. Do not use heparin if streptokinase is
given.
o Hypotension may occur. If it does, reduce the rate of infusion but
strive to complete it in <60 minutes.
o Streptokinase is antigenic and should not be re-administered in the
period of 5 days to 2 years after 1st administration.
o Severe allergic reactions are uncommon but antibodies which may
render it ineffective may persist for years.
Indications Contra-indications
» For acute myocardial infarction » Absolute:
with ST elevation or left bundle -streptokinase used within the last year,
branch block: -previous allergy,
-CVA within the last 3 months,
- maximal chest pain is ≤6 hours -history of recent major trauma,
- beyond 6 hours and chest -bleeding within the last month,
pain, consult a specialist -aneurysms,
- >6 hours and no chest pain, -brain or spinal surgery or head injury within
manage with anticoagulants the preceding month, or recent (<3 weeks)
(see section 3.2.2: NSTEMI) major surgery,
- if on-going ischaemic pain - active bleeding or known bleeding disorder,
LoE:Ix - aortic dissection.
» Relative (consult specialist):
- refractory hypertension,
- warfarin therapy,
- recent retinal laser treatment,
- subclavian central venous catheter,
- pregnancy,
- TIA in the preceding 6 months,
- traumatic resuscitation.
OR
If streptokinase is unavailable:
 Alteplase, IV infusion:
o Do not exceed 100 mg. LoE:Ixi
o if history of onset is less than 6 hours (beyond 6 hours
consult a specialist or treat as NSTEMI (see below):
Bolus Next 30 Next 60
minutes minutes
>67 kg 15 mg 50 mg 35 mg
≤67 kg 15 mg 0.75 mg/kg 0.5 mg/kg
o Indications and contraindications are similar to those for streptokinase
as above (except that prior use of streptokinase is not a
contraindication).
2019 3.6
Monitor the following, continuously and also during transfer:

» pulse
» BP
» respiration depth and rate (count for a full minute)
» ECG
Note: Defibrillator should be readily available at all times including during
transport.
Adjunctive treatment
 Enoxaparin (after alteplase, do not use heparins after streptokinase).
o Loading dose: IV, 30 mg as a bolus, followed by SC, 1 mg/kg as a
single dose (total cumulative dose not to exceed 100 mg).
o Maintenance dose: SC, 1.5 mg/kg daily or 1 mg/kg 12 hourly.
LoE:Ixii
In the elderly (>75 years of age), omit IV loading dose and reduce SC dose:
o Loading dose: SC, 0.75 mg/kg as a single dose.
o Maintenance dose: SC, 1.5 mg/kg daily or 1 mg/kg LoE:Ixiii
12 hourly.
Pain not responsive to thrombolytics may suggest ongoing unresolved

ischaemia.
 Nitrates, e.g.: LoE:IIIxiv
 Isosorbide dinitrate, SL, 5 mg immediately as a single
dose.
o May be repeated at 5-minute intervals for 3 or 4 doses.
For ongoing chest pain, to control hypertension or treat pulmonary oedema:

 Glyceryl trinitrate, IV, 5–200 mcg/minute, titrated to response.
o Start with 5 mcg/minute and increase by 5 mcg/minute every 5 minutes
until response or until the rate is 20 mcg/minute.
o No response after 20 mcg/minute, increase by 20 mcg/minute every 5
minutes until a pain response or medicine is no longer tolerated.
o Flush the PVC tube before administering the medicine to patient.
o Monitor BP carefully.
Dilution of Glyceryl trinitrate:
Volume of diluent Glyceryl trinitrate Concentration of
5mg/mL dilution
5 mL (25 mg) 100 mcg/mL
250 mL 10 mL (50 mg) 200 mcg/mL
20 mL (100 mg) 400 mcg/mL
10 mL (50 mg) 100 mcg/mL
500 mL 20 mL (100 mg) 200 mcg/mL
40 mL (200 mg) 400 mcg/mL
Solution 100 mcg/mL 200 mcg/mL 400 mcg/mL
Concentration solution solution solution
(mcg/mL)
2019 3.7
Dose (mcg/min) Flow rate (microdrops/min = mL/hour)

5 3 — —
10 6 3 —
15 9 — —
20 12 6 3
30 18 9 —
40 24 12 6
60 36 18 9
80 48 24 12
100 60 30 15
120 72 36 18
160 96 48 24
200 – 60 30
For severe pain unresponsive to nitrates:

o Ongoing severe pain despite all appropriate treatment above is an
indication for urgent referral.
When clinically stable without signs of heart failure, hypotension,
bradydysrhythmias or history of asthma:
 Cardio-selective -blocker, e.g.:
 Atenolol, oral, 50 mg daily.
 HMGCoA reductase inhibitors (statins), e.g.:
LoE:Ixv
Patients on protease inhibitor:
LoE:Ixvi
Patients on amlodipine (and not on a protease inhibitor):
LoE:IIIxvii
If patient complains of muscle pain:
Reduce dose:
 Simvastatin, oral, 10–20 mg at night.
OR
Consult specialist for further management. LoE:IIIxviii
For LV dysfunction following myocardial infarction, heart failure or ejection

fraction <40%:
 ACE-inhibitor, e.g.:
 Enalapril, oral, target dose, 10 mg 12 hourly.
o Institute other therapy for heart failure and LV dysfunction as
described below – see section 3.4: Congestive cardiac failure.
2019 3.8
If ACE-inhibitor intolerant, i.e. intractable cough:

 Angiotensin receptor blocker (ARB), e.g.:
 Losartan, oral, 50–100 mg daily. Specialist initiated.
» Angioedema is a potentially serious complication of ACE-inhibitor/

angiotensin receptor blocker treatment and if it occurs stop the
medication and do not re-challenge.
» Concomitant use of fluoroquinolones with ACE-inhibitor/angiotensin
receptor blocker is contraindicated in moderate to severe renal
impairment (CrCl ≤30 mL/minute) and in the elderly. Assess renal
function before initiating treatment and monitor during treatment.
LoE:IIIxix
REFERRAL
» Refractory cardiogenic shock.
» Refractory pulmonary oedema.
» Haemodynamically compromising ventricular dysrhythmia.
» Patients with the combination of new right bundle and posterior fascicular
block post MI should be referred for permanent pacemaker consideration
as they are at high risk for progression to complete heart block.
» Myocardial infarction-related mitral regurgitation or ventricular septal
defect (VSD).
» Contraindication to thrombolytic therapy provided PCI facility available
(confirm with cardiologist).
» Ongoing ischaemic chest pain.
» Failed reperfusion (<50% reduction in ST elevation at 90 minutes in leads
showing greatest ST elevation, especially in anterior infarct or inferior
infarct with right ventricular involvement).
3.2.2 NON-ST ELEVATION MYOCARDIAL INFARCTION

(NSTEMI) AND UNSTABLE ANGINA (UA)
I21.4/I21.9/I20.0
DESCRIPTION
Non-ST elevation MI: Chest pain that is increasing in frequency and/or
severity, or occurring at rest. The chest pain is associated with elevated
cardiac biomarkers and ST segment depression or T wave inversion on ECG.
Biomarker elevation in the absence of diagnostic ECG changes or symptoms
compatible with myocardial ischemia should prompt consideration of
alternative diagnoses (e.g. heart failure, pulmonary embolism, chronic kidney
disease, sepsis, myopericarditis).
Unstable angina pectoris: Chest pain that is increasing in frequency and or

severity, or occurring at rest. It also encompasses post-infarct angina. The
chest pain may be associated with ST segment depression or T wave
inversion on ECG. There is no rise in cardiac biomarkers.
2019 3.9
MEDICINE TREATMENT
 Oxygen, if saturation <94%. LoE:Ixx
 Clopidogrel, oral, 300 mg. LoE:Ixxi

Followed by 75 mg daily for 3 months.
AND
contraindications). LoE:Ixxii
AND
Anticoagulation:
For NSTEMI and UA (also for STEMI not given thrombolytic therapy):
 Enoxaparin, SC, 1 mg/kg 12 hourly for minimum of 2 days.
OR
 Unfractionated heparin, IV bolus, 5 000 units.
o Follow with 1 000–1 200 units hourly monitored by aPTT.
o Continue infusion for minimum of 2 days.
LoE:Ixxiii
To relieve possible coronary spasm and pain and to reduce
preload:
 Nitrates, e.g.:
 Isosorbide dinitrate SL, 5 mg immediately as a single dose.
o May be repeated at 5-minute intervals for 3 or 4 doses.
For persistent pain and if oral therapy is insufficient:

o If no response after 20 mcg/minute, increase by 20 mcg/minute every
5 minutes until pain response or medicine no longer tolerated.
o Flush the PVC tube before administering the medicine to patient.
o Monitor BP carefully.
For dilution of glyceryl trinitrate refer to section 3.2.1: ST elevation myocardial
infarction (STEMI).
For severe pain unresponsive to nitrates:

o Ongoing severe pain despite all appropriate treatment above is an
indication for urgent referral
When clinically stable without signs of heart failure, hypotension,

bradydysrhythmias or asthma:
2019 3.10

Patients on protease inhibitor: LoE:Ixxiv
Patients on amlodipine (and not on a protease inhibitor): LoE:Ixxv
If patient complains of muscle pain: LoE:IIIxxvi
Reduce dose:
OR
Consult specialist for further management. LoE:IIIxxvii
If there is cardiac failure or LV dysfunction (see section 3.4: Congestive

cardiac failure):
(I50.0)
 Enalapril, oral, target dose 10 mg 12 hourly. LoE:IIIxxviii

3.2.3 CHRONIC MANAGEMENT OF STEMI / NSTEMI / UA

I25.2/I20.0
GENERAL MEASURES
Lifestyle modification. See section 3.1: Ischaemic heart disease and
atherosclerosis, prevention.
MEDICINE TREATMENT
Continue oral therapy as above.
If heart failure develops, replace atenolol with carvedilol. See section 3.4:
Congestive cardiac failure.
REFERRAL
» Patients with a diagnosis of acute coronary syndrome should be risk
stratified at presentation to estimate their likelihood of developing a major
adverse cardiac event (acute MI, heart failure, death or readmission for
UA) over the subsequent 4-6 weeks. High risk patients (including those
with positive troponins) should be discussed with a cardiology service for
consideration for angiography and revascularization therapy. , Two widely
used and well validated risk stratification scores are TIMI
(http://www.mdcalc.com/timi-risk-score-for-uanstemi/) and Grace Risk
2019 3.11
Scores (http://www.mdcalc.com/grace-acs-risk-and-mortality-calculator).
The patient’s co-morbidities and willingness to undergo revascularisation,
which may involve coronary surgery, should be taken into account when
advising such referral.
» Other important indications for referral include ongoing chest pain, post-
infarct angina, sustained dysrhythmias or refractory heart failure.
3.2.4 ANGINA PECTORIS, STABLE

I20.0-I/I20.8-9
DESCRIPTION
Characteristic chest pain due to myocardial ischaemia usually occurring on
exercise and relieved by rest. Discomfort may occasionally be experienced in
a site of referral (shoulder, jaw) but the characteristic provocation by exercise
and relief by rest is a valuable clue.
GENERAL MEASURES
Lifestyle modification. See section 3.1: Ischaemic heart disease and
atherosclerosis, prevention.
MEDICINE TREATMENT
Long-term prophylaxis for thrombosis:
contraindications).
xxix
AND LoE:I
Relief of angina:
 Nitrates, short acting e.g.:
 Isosorbide dinitrate, SL, 5 mg.
o May be repeated if required at 5-minute intervals for 3 or 4 doses.
o Instruct patients to keep the tablets in the airtight and lightproof
container in which they are supplied.
o Instruct patients that nitrates are not addictive.
o Instruct patients to use prophylactically, before activities which may
provoke angina.
AND
Step 1
 Atenolol, oral, 50–100 mg daily.
o Titrate to resting heart rate of approximately 60 bpm.
If ß-blocker cannot be tolerated or is contraindicated, use a long acting calcium
channel blocker.
Step 2
ADD
 Long-acting calcium channel blocker, e.g.:
2019 3.12
 Amlodipine, oral, 5mg daily.

o Increase to 10 mg daily if required.
Step 3
ADD
 Organic nitrates, e.g.:
 Isosorbide mononitrate: 10–20 mg twice daily.
OR
Isosorbide dinitrate: 20–30 mg twice daily
o Taken at 8:00 and 14:00 as this provides a nitrate-free period to
prevent tolerance.
o Modify for night shift workers.
LoE:IIIxxx
ADD
LoE:Ixxxi
LoE:Ixxxii
LoE:IIIxxxiii
Reduce dose:
OR
Consult specialist for further management. LoE:IIIxxxiv
REFERRAL
» When diagnosis is in doubt, despite exercise stress testing.
» Failed medical therapy. A common reason for “failed” therapy is that the
patient has an alternative diagnosis. Therefore, this conclusion should be
reached after reasonable effort for non-invasive diagnosis including
exercise stress test.
3.2.5 ATHEROSCLEROTIC PERIPHERAL ARTERIAL

DISEASE
I70.90-1
DESCRIPTION
History and palpation of pulses confirms diagnosis.
GENERAL MEASURES
Smoking cessation is essential and is the single most important intervention
to prevent progression.
2019 3.13
Exercise within exercise tolerance and other lifestyle modifications.

See section 3.1: Ischaemic heart disease and atherosclerosis, prevention.
MEDICINE TREATMENT
Long-term prophylaxis for thrombosis:
 Aspirin, oral, 150 mg daily.

LoE:Ixxxv
LoE:Ixxxvi
LoE:IIIxxxvii
Reduce dose:
OR
Consult specialist for further management. LoE:IIIxxxviii
Therapy should be initiated together with appropriate lifestyle modification.
See section 3.1: Ischaemic heart disease and atherosclerosis, prevention.
REFERRAL
Ongoing vascular insufficiency, which may be surgically reversible.
3.3 CARDIAC DYSRHYTHMIAS

Exclude underlying structural cardiac disease in all patients with cardiac
dysrhythmias.
3.3.1 NARROW QRS COMPLEX (SUPRAVENTRICULAR)

TACHYDYSRHYTHMIAS
I47.0-2/I47.9
DESCRIPTION
Sustained (>30 seconds) or non-sustained narrow QRS (≤0.1 seconds)
tachycardias.
REFERRAL
» Poor rate control.
» Frequent or severe symptoms for curative radiofrequency catheter ablation.
» All symptomatic Wolf-Parkinson-White (WPW) syndrome patients (sinus
rhythm ECG shows delta waves) for radiofrequency catheter ablation.
2019 3.14
» Asymptomatic patients in whom the WPW pattern is detected on ECG do

not need referral.
3.3.1.1 ATRIAL FIBRILLATION

I48.0-I48.4/I48.9
Acute onset (<48 hours)

Assess clinically, e.g. heart failure, mitral stenosis, thyrotoxicosis, hypertension,
age and other medical conditions.
Consider anticoagulation with warfarin (see table below on CHA2DS2-VASc
Score).
Synchronised direct current (DC) cardioversion is occasionally necessary in
haemodynamic instability.
Non-acute/chronic (>48 hours)
As above, but not immediate DC cardioversion, unless there is haemodynamic
instability.
MEDICINE TREATMENT
The main aims of therapy for patients with atrial fibrillation should be:
1. Reduction of stroke and systemic embolic risk.
2. Rate control.
3. Relief of symptoms attributed to the atrial fibrillation.
Patients <65 years of age with no heart diseases or other risk factors may be
managed with aspirin alone.
A simple scoring system allows calculation of risk of stroke in patients with
non-valvar atrial fibrillation.
CHA2DS2-VASc Score:
Risk Factor Score
Congestive heart failure/LV dysfunction 1
Hypertension 1
Age ≥ 75 years of age 2
Diabetes mellitus 1
Stroke/TIA/Thromboembolism 2
Vascular disease 1
Age 65–74 years of age 1
Sex (female gender) 1
Source: Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke
and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial
fibrillation.Chest. 2010 Feb;137(2):263-72. http://www.ncbi.nlm.nih.gov/pubmed/19762550
» When the score is ≥2, use warfarin or equivalent. The higher the score the
greater the risk of stroke and therefore the more compelling the use of
effective anticoagulation.
» Note: This score has been developed on patients with non-valvular atrial
fibrillation and may not be applicable to patients with atrial fibrillation and
rheumatic mitral valve disease. Anticoagulation has not been tested in this
population but most authorities favour anticoagulation.
2019 3.15
Initial therapy aimed at stroke reduction

Anticoagulate with warfarin:
the therapeutic range of 2 to 3 (refer to initiation dosing tables in
Appendix II).
o Adjust dose to keep INR within therapeutic range (refer to Maintenance
dosing tables in Appendix II).
For therapy aimed at rate control

o Contraindicated in asthmatics, heart failure.
OR
If in CCF: (I50.0)
 Carvedilol, oral. See section 3.4: Congestive cardiac failure.
AND
If control not adequate add:
 Digoxin, oral, 0.125 mg daily, adjust according to rate response and trough
plasma level
o Digoxin trough plasma levels (before the morning dose) should be
maintained between 0.6-1 nmol/L.
o Patients at high risk of digoxin toxicity: the elderly, patients with renal
dysfunction, hypokalaemia, and patients with lean body mass.
LoE:IIxxxix
If -blockers are contra-indicated, e.g. asthma or severe
peripheral vascular disease:
 Verapamil, oral, 40–120 mg 8 hourly.
o Titrate against ventricular rate (verapamil is negatively inotropic,
therefore avoid in heart failure due to LV dysfunction).
LoE:IIIxl
If not controlled on these agents, refer to specialist for consideration of
alternative therapy, e.g. amiodarone or atrioventricular node ablation and
pacemaker insertion.
DC cardioversion in selected cases, after 4 weeks effective warfarin
anticoagulation.
Long-term therapy
Continue warfarin anticoagulation long-term, unless contra-indicated:
o Control with INR to therapeutic range:
 INR between 2–3 and patient stable: monitor every 3 months.
 INR <1.5 or >3.5: monitor monthly.
2019 3.16
Caution
Warfarin use requires regular INR monitoring and dose adjustment
according to measured INR.
For rate control:

o Contraindicated in asthmatics, heart failure.
If in CCF: (I50.0)
 Carvedilol, oral. See section 3.4: Congestive cardiac failure.
AND
If control not adequate add:

 Digoxin, oral, start at 0.125 mg daily and adjust according to rate response
and trough plasma level.
o In patients with impaired renal function (eGFR <60 mL/minute),
consider 0.125 mg daily and adjust according to trough level
monitoring.
o In all patients, digoxin trough level monitoring is required at all doses.
LoE:IIxli
If -blockers are contra-indicated, e.g. asthma or severe peripheral vascular
disease:
o Titrate against ventricular rate (verapamil is negatively inotropic,
avoid in heart failure due to left ventricular LoE:IIIxlii
dysfunction).
If not controlled on these agents, refer to specialist for consideration of
alternative therapy.
Prevention of recurrent paroxysmal atrial fibrillation:

Note: The risk of thromboembolic complications and stroke is similar
to that of patients with persistent or paroxysmal atrial fibrillation and
similar recommendations as to anticoagulation apply.
Only in patients with severe symptoms despite the above measures:

 Amiodarone, oral, 200 mg 8 hourly for 1 week. Specialist initiated.
o Followed by 200 mg 12 hourly for one week.
o Thereafter, 200 mg daily.
xliii
Precautions: LoE:I
o If on warfarin, halve the dose of warfarin and monitor INR closely, until
INR is stable.
o Avoid concomitant digoxin.
o Monitor thyroid function every 6 months as thyroid abnormalities may
develop.
2019 3.17
o Ophthalmological examination every 6 months.
For management of pregnant women with valvular disease and atrial

fibrillation, see section 6.3: Heart disease in pregnancy.
3.3.1.2 ATRIAL FLUTTER

I48.0-4/I48.9
Atrial rate >250 bpm with no flat baseline.

Can be difficult to recognise if 2:1 atrioventricular (AV) block, as the first of the
two p waves preceding each QRS complex might be confused with the T-wave
of the preceding beat. Vagal stimulation might slow the ventricular rate (usually
approximately 150 bpm) and make the dysrhythmia more obvious.
Synchronised direct current (DC) cardioversion is occasionally necessary in
haemodynamic instability.
MEDICINE TREATMENT
 Midazolam IV, 1–2.5 mg, administered over 2-3 minutes.
o Monitor and repeat dose after 2-3 minutes, as necessary.
LoE:III
If flutter has been present longer than 48 hours, defer
cardioversion until after 4 weeks’ anticoagulation with warfarin, unless severe
symptoms or heart failure require urgent cardioversion.
DC cardioversion is the most effective therapy.

Do not use verapamil as it will not convert flutter to sinus rhythm and
may cause serious hypotension.
Anticoagulants if sustained. (See section 3.3.1.1 Atrial fibrillation). Most
consider that the thromboembolic risks in atrial flutter and atrial fibrillation are
similar). LoE:III
Long-term therapy
Recurrent atrial flutter is an indication for referral as many may be relatively
simply cured by radio-frequency catheter ablation.
3.3.1.3 AV JUNCTIONAL RE-ENTRY TACHYCARDIAS

I47.1
Usually paroxysmal.
Often young patients with normal hearts.
AV nodal re-entry or atrioventricular re-entry (WPW syndrome).
P waves usually not visible (hidden by QRS complexes).
GENERAL MEASURES
Vagal manoeuvres: The modified Valsalva manoeuvre is the most effective – it
should be done semi-recumbent with 15 seconds of strain, followed immediately
2019 3.18
by supine positioning and passive leg raising.

Carotid sinus massage.
Should be done with the patient supine and as relaxed as possible.
MEDICINE TREATMENT
Initial therapy
If vagal manoeuvres fail:
 Adenosine, rapid IV bolus, 6 mg.
o Follow by a bolus of 10 mL sodium chloride 0.9% to ensure that it
reaches the heart before it is broken down.
o Half life: ± 10 seconds.
o Run the ECG for 1 minute after the injection as a recording of method
of cessation may be helpful diagnostically.
o If 6 mg fails, repeat with 12 mg.
o If this fails, repeat with another 12 mg.
» If the medicine reaches the central circulation before it is broken down the
patient will experience flushing, sometimes chest pain, wheezing and anxiety.
» If the tachycardia fails to terminate without the patient experiencing those
symptoms, the medicine did not reach the heart.
If none of the above is effective or if the patient is hypotensive, consider
synchronised cardioversion.
Note: Adenosine is contraindicated when atrial flutter is the obvious diagnosis,
administration of adenosine can precipitate 1:1 conduction at ventricular rates
250–360 bpm and should be avoided.
LoE:III
Long term therapy
Teach the patient to perform vagal manoeuvres. Valsalva is the most effective.
For infrequent, non-incapacitating symptoms:

 Cardio-selective ß–blocker, e.g.:
If asthmatic, without heart failure: LoE:IIIxliv

Verapamil and digoxin are contraindicated in WPW syndrome.
REFERRAL
If the patient continues to experience debilitating symptoms refer for
radiofrequency ablation.
3.3.2 WIDE QRS (VENTRICULAR) TACHYARRHYTHMIAS

DESCRIPTION
Sustained (>30 seconds) or non-sustained wide QRS (>0.12 seconds)
2019 3.19
tachycardias.
3.3.2.1 REGULAR WIDE QRS TACHYCARDIAS

I47.0-2/I47.9
Regular wide QRS tachycardias are ventricular until proved otherwise.

Regular wide QRS supraventricular tachycardias are uncommon.
Refer all cases after resuscitation and stabilisation.
Emergency DC cardioversion is mandatory with a full protocol of Cardio-
pulmonary resuscitation (CPR) if there is haemodynamic compromise.
GENERAL MEASURES
CPR if necessary.
If no cardiac arrest:
DC cardioversion, 200 J, after sedation with:
 Midazolam, IV, 1–2.5 mg, administered over 2-3 minutes.
o If 200 J fails, use 360 J. LoE:III
If cardiac arrest:
Defibrillate (not synchronised).
MEDICINE TREATMENT
Caution LoE:IIIxlv
Never give verapamil or adenosine IV to patients with
wide QRS tachycardia as this may precipitate ventricular fibrillation.
DC cardioversion is preferred and safest first line therapy for regular wide
QRS tachycardias. Medicines are needed if ventricular tachycardia (VT)
recurs after cardioversion, or spontaneous termination.
LoE:III
If in doubt as to the nature of a tachycardia, and in all patients with

haemodynamic compromise, DC cardioversion under IV sedation is the
safest option.
 Amiodarone, IV, 5 mg/kg infused over 30 minutes.

Follow with:
 Amiodarone, oral, 200 mg 8 hourly for 7 days.
o Then, 200 mg 12 hourly for 7 days.
o Maintenance dose: 200 mg daily for the minimum time required to
control the arrhythmia
2019 3.20
o Consult specialist before instituting long-term (>1 week) therapy.

xlvi
Precautions: LoE:III
INR is stable.
o Monitor thyroid function every 6 months for thyroid abnormalities.
3.3.2.2 SUSTAINED (>30 SECONDS) IRREGULAR WIDE QRS

TACHYCARDIAS
I47.0-2/I47.9
These tachycardias are usually due to atrial fibrillation with bundle branch
block, or pre-excitation (WPW syndrome).
If the QRS complexes have a pattern of typical right or left bundle branch block,
with a rate <170 bpm, treat as for atrial fibrillation. See section 3.3.1: Narrow QRS
complex (supraventricular) tachycardias.
If the rate is >170 bpm, and/or the complexes are atypical or variable, the likely
diagnosis is WPW syndrome with atrial fibrillation, conducting via the bypass
tract. Treat with DC conversion.
Do not treat with medication.
Verapamil and digoxin may precipitate ventricular fibrillation by increasing the
ventricular rate.
If in doubt as to the nature of a tachycardia, and in all patients with

haemodynamic compromise, DC cardioversion under IV sedation is the
safest option.
3.3.2.3 NON-SUSTAINED (<30 SECONDS) IRREGULAR

WIDE QRS TACHYCARDIAS
I47.0-2/I47.9
These tachycardias are usually ventricular. They are common in acute

myocardial infarction. Check serum potassium level and correct if low.
MEDICINE TREATMENT
 Amiodarone, IV, 5 mg/kg infused over 30 minutes.
Follow with:
 Amiodarone, oral, 800 mg daily for 7 days.
o Then 600 mg daily for 3 days.
o Follow with a maintenance dose of 200–400 mg daily, depending upon
2019 3.21
clinical judgement. Consult specialist before instituting long-term (>1

week) therapy.
Precautions:
INR is stable.
o Monitor thyroid function every 6months as thyroid abnormalities may
develop.
OR
Only in haemodynamically stable patients:
 Lidocaine (lignocaine), IV, 50–100 mg (1–2 mg/kg) initially and at 5 minute
intervals if required to a total of 200–300 mg.
Thereafter, for recurrent ventricular tachycardia only:
 Lidocaine (lignocaine), IV infusion, 1–3 mg/minute for 24–30 hours.
» Lidocaine will only terminate ± 30% of sustained ventricular tachycardias,
and may cause hypotension, heart block or convulsions.
» For emergency treatment of ventricular tachycardia, DC cardioversion is
first line therapy, even if stable.
In the absence of acute ischaemia or infarction, consider torsades de pointes,
due to QT prolonging medicines.
3.3.2.4 TORSADES DE POINTES VENTRICULAR

TACHYCARDIA (VT)
I47.0-2/I47.9
Torsades de pointes Ventricular Tachycardia (VT) has a twisting pattern to the

QRS complexes and a prolonged QT interval in sinus rhythm. It is usually due
to a QT-prolonging medication, active myocardial ischaemia and/or
hypokalaemia and/or a history of alcohol abuse/malnutrition.
GENERAL MEASURES
Defibrillation, as necessary.
Torsades complicating bradycardia: temporary pacing.
MEDICINE TREATMENT
Stop all QT-prolonging medicines (a list of medicines that cause QT
prolongation can be viewed at https://www.sads.org.uk/drugs-to-
avoid/?doing_wp_cron=1585301751.3996679782867431640625
Correct serum potassium.
 Magnesium sulphate, IV, 2 g administered over 5–10 minutes.
If recurrent episodes after initial dose of magnesium sulphate:
 Magnesium sulphate, IV, 2 g administered over 24 hours. LoE:III
2019 3.22
Torsades complicating bradycardia:

 Adrenaline (epinephrine) infusion to raise heart rate to >100 bpm (if
temporary pacing unavailable).
REFERRAL
All cases of wide QRS tachycardia, after resuscitation and stabilization.
3.3.3 HEART BLOCK (SECOND OR THIRD DEGREE)

I44.1/I44.2
DESCRIPTION
The majority of cases occur in patients >60 years of age and are idiopathic,
with an excellent long-term prognosis, provided a permanent pacemaker is
implanted. Acute, reversible AV block commonly complicates inferior
myocardial infarction. Heart block may also be induced by metabolic and
electrolyte disturbances, as well as by certain medicines.
GENERAL MEASURES
Emergency cardio-pulmonary resuscitation (if necessary).
External pacemaker should be available in all secondary hospitals and must
be preceded by appropriate analgesia.
MEDICINE TREATMENT
Analgesia if external pacemaker:
 Morphine, IM, 10–15 mg 3–6 hourly.
Apply relevant precautions as indicated in Appendix II (i.e. monitoring for
response and toxicity).
AV nodal block with narrow QRS complex escape rhythm only:
 Atropine, IV bolus, 0.6–1.2 mg.
o May be repeated as needed until a pacemaker is inserted.
o Use in patients with inferior myocardial infarct and hypotension and
second degree AV block, if symptomatic.
o It is temporary treatment of complete AV block before referral
(urgently) for pacemaker.
OR
For resuscitation of asystole in combination with CPR:
I46.0-1/I46.9+(I44.1-2)
 Adrenaline (epinephrine) 1:10 000, slow IV, 5 mL (0.5 mg).
o Used as temporary treatment of complete heart block when other
medicines are not effective.
REFERRAL
» All cases with a heart rate <40 bpm after resuscitation and stabilisation.
» All cases of 2nd or 3rd degree AV block, whether or not myocardial infarct
or other reversible cause is suspected, and whether or not the patient is
thought to be symptomatic.
2019 3.23
A permanent pacemaker is the definitive form of treatment. These are only

available in tertiary institutions. Refer all symptomatic patients with significant
bradyarrhthmias for evaluation.
3.3.4 SINUS BRADYCARDIA

R00.1
DESCRIPTION
This rhythm does not require treatment, unless it is causing symptoms, i.e.
syncope, dizziness, tiredness and poor effort tolerance.
Sinus bradycardia <50 bpm or sinus arrest with slow escape rhythm,
accompanied by hypotension, strongly suggest a treatable underlying cause
such as:
» acute inferior myocardial infarct,
» hyperkalaemia, especially if wide QRS and/or peaked T waves,
» medicines, especially combination of verapamil and ß-blocker or digoxin,
» hypothermia,
» hypoxia, or
» hypothyroidism.
Treat the cause. Consider atropine if inferior myocardial infarct.
3.3.5 SINUS ARREST

I49.5
Refer all urgently to a cardiologist.
3.4 CONGESTIVE CARDIAC FAILURE (CCF)

I50.0
DESCRIPTION
CCF is a clinical syndrome and has several causes. The cause and immediate
precipitating factor(s) of the CCF must be identified and treated to prevent
further harm.
Potentially reversible causes include:
» hypertension » thiamine deficiency
» thyroid disease » ischaemic heart disease
» valvular heart disease » haemochromatosis
» constrictive pericarditis » tachycardia
GENERAL MEASURES
Patient and family education.
Monitor body weight to assess changes in fluid balance.
Limit fluid intake to 1–1.5 L/day if fluid overloaded despite diuretic therapy.
Limit alcohol intake to a maximum 2 drinks per day if at all.
Salt restriction (dietician guided when possible).
Regular exercise within limits of symptoms.
2019 3.24
Avoid NSAIDs as these may exacerbate fluid retention.

Counsel that pregnancy may exacerbate heart failure and some medicines
used in treatment of heart failure are contraindicated in pregnancy e.g. ACE-
inhibitors, angiotensin-receptor blockers, spironolactone. LoE:IIIxlvii
Advise on contraception or refer for such advice.
MEDICINE TREATMENT
Where heart failure is due to left ventricular systolic dysfunction, mortality is
significantly reduced by the use of ACE-inhibitors, ß-blockers and
spironolactone and every effort should be made to ensure eligible patients
receive all these agents in appropriate doses.
Note: All the guideline evidence presented here relates to treatment
of patients in whom the heart failure syndrome is due to left
ventricular systolic dysfunction and cannot necessarily be
extrapolated to patients in whom heart failure is due to other causes
of the syndrome.
Digoxin has only been shown to improve symptoms and reduce

hospitalisation.
LoE:Ixlviii
Diuretic
Mild volume overload (mild CCF) and normal renal function, thiazide diuretic:
 Hydrochlorothiazide, oral, 25–50 mg daily.
o Caution in patients with gout.
o Less effective in impaired renal function.
o Caution in patients with a history or family history of skin cancer; and
counsel all patients on sun avoidance and sun protection.
LoE:IIIxlix
Significant volume overload or abnormal renal or hepatic function, loop diuretic:
 Furosemide, oral, daily.
o Initial dose: 40 mg/day.
o Higher dosages may be needed, especially if comorbid renal failure.
o Advise patients to weigh themselves daily and adjust the dose if
necessary. LoE:III
Note:
» Unless patient is clinically fluid overloaded, reduce the dose of diuretics
before adding an ACE-inhibitor. After introduction of an ACE-inhibitor, try
to reduce diuretic dose and consider a change to hydrochlorothiazide.
» Routine use of potassium supplements with diuretics is not recommended.
They should be used short-term only, to correct documented low serum
potassium level.
LoE:Il
Renin-angiotensin-aldosterone system (RAAS) blockers
 Enalapril, oral, 2.5 mg 12 hourly, titrated to 10 mg 12 hourly.
o In the absence of significant side-effects always try to increase the
2019 3.25
dose to the level shown to improve prognosis LoE:Ili

(i.e.10 mg 12 hourly).
Spironolactone
Use with an ACE-inhibitor and furosemide in patients presenting with Class III
or IV heart failure.
Do not use if eGFR <30 mL/minute.
Monitoring of potassium levels is essential if spironolactone is used with an
ACE-inhibitor or other potassium sparing agent or in the elderly.
 Spironolactone, oral, 25–50 mg once daily.
LoE:IIIlii
ß-blockers
For all stable patients with heart failure who tolerate it:
Note: Patients should not be fluid overloaded or have a low BP before
initiation of therapy.
 Carvedilol, oral.
o Initial dose: 3.125 mg 12 hourly.
o Increase at 2-weekly intervals by doubling the daily dose until a
maximum of 25 mg 12 hourly, if tolerated.
o If not tolerated, i.e. worsening of cardiac failure symptoms, reduce the
dose to the previously tolerated dose.
o Up-titration should take several weeks or months. LoE:Iliii
Digoxin
Patients in sinus rhythm remaining symptomatic despite the above-mentioned
agents (Specialist consultation):
 Digoxin, oral, 0.125 mg daily, adjust according to response and trough
plasma level.
maintained between 0.6-1 nmol/L.
o Patients at high risk of digoxin toxicity: the elderly, patients with renal
dysfunction, hypokalaemia and patients with lean body mass.
LoE:IIliv
Anticoagulants
Heparin: for DVT prophylaxis for patients admitted to hospital, unless
contraindicated: See section 2.14: Venous thrombo-embolism.
Warfarin: See section 3.3.1: Narrow QRS complex (supraventricular)
tachydysrhythmias.
Anti-dysrhythmic medicines
Only for potentially life-threatening ventricular dysrhythmias. See section 3.3:
Cardiac Dysrhythmias.
Always exclude electrolyte abnormalities and medicine toxicity first.
2019 3.26
Thiamine
Consider as a trial of therapy in all unexplained heart failure:
 Thiamine, oral/IM, 100 mg daily for 4 weeks.
Prophylaxis (Z29.2)
 Annual influenza vaccine. See section 9.2: Adult vaccination.
REFERRAL
» Where specialised treatment and diagnostic work-up is needed and to
identify treatable and reversible causes.
» All patients with audible cardiac murmurs should undergo specialist
evaluation, as should all patients with potentially reversible causes of the
heart failure syndrome and those with persistent and severe symptoms and
signs of fluid overload despite adequate doses of diuretic.
» Patients who have LBBB on the ECG are potential candidates for cardiac
resynchronization therapy. An ECG should be recorded at baseline and
repeated at 6-monthly intervals.
» Patients with LBBB should be referred for consideration for
resynchronsation therapy, discussed with a specialist.
3.5 ENDOCARDITIS, INFECTIVE

I33.0
GENERAL MEASURES
Bed rest.
Early surgical intervention in acute fulminant and prosthetic valve endocarditis
is often indicated. Consider surgery if there is heart failure, embolism, large
vegetations on echocardiography, heart block, evidence of persistent infection
despite antibiotics or renal impairment. Refer these patients promptly.
LoE:III
MEDICINE TREATMENT
Treat accompanying complications, e.g. cardiac failure. Such treatment
should not delay referral.
Antibiotic therapy
It is essential to do at least 3 blood cultures, taken by separate venipunctures,
before starting antibiotics.
In patients with subacute presentation and no haemodynamic compromise,
wait for the results of blood culture before starting antibiotics.
Empiric treatment is indicated in patients with a rapidly fulminant course or
with severe disease only.
Aminoglycoside therapy should be monitored with trough levels for safety.
Duration of therapy given is the minimum and may be extended based on the
response (clinical and laboratory).
2019 3.27
Severe penicillin-allergic patients, or methicillin resistant staphylococcal

infections: (Z88.0)
 Vancomycin, IV, 20 mg/kg 12 hourly, is the antibiotic of choice. It is
essential to monitor trough concentrations of vancomycin regularly and
adjust doses accordingly, starting after the third dose.
LoE:IIIlv
Empiric therapy
 Benzylpenicillin (penicillin G), IV, 5 MU 6 hourly for 4 weeks
Native AND
valve  Gentamicin, IV, 1.5 mg/kg 12 hourly for 2 weeks. (See Appendix
II, for guidance on prescribing).
If staphylococcal infection is suspected (acute onset):

ADD
 Cefazolin, IV, 2 g, 8 hourly.
 Vancomycin, IV, 20 mg/kg 12 hourly for 6 weeks.
Prosthetic AND
valve*  Rifampicin, oral, 7.5 mg/kg 12 hourly for 6 weeks.
AND
 Gentamicin, IV, 1.5 mg/kg 12 hourly for 2 weeks. (See Appendix
II for guidance on prescribing).
* All cases of prosthetic valve endocarditis should be referred.
2019 3.28
Directed therapy (native valve)

Streptococcal
Fully susceptible to  Benzylpenicillin (penicillin G), IV, 5 MU 6 hourly for 4
penicillin weeks.
MIC: <0.2 mg/L
Moderately  Benzylpenicillin (penicillin G), IV, 5 MU 6 hourly for 4
susceptible weeks.
MIC: 0.12–0.5 mg/L AND
 Gentamicin, IV, 1.5 mg/kg 12 hourly for 2 weeks (see
Appendix II for guidance on prescribing).
Moderately resistant  Benzylpenicillin (penicillin G), IV, 5 MU 6 hourly for 4
MIC: 0.5–4 mg/L weeks.
Enterococci and AND
Abiotrophia spp.  Gentamicin, IV, 1.5 mg/kg 12 hourly for 4 weeks.
(nutritionally variant o 6 weeks of therapy may be required in cases with a
streptococci) history of >3 months, or mitral or prosthetic valve
involvement (see Appendix II for guidance on
prescribing).
Fully resistant  Vancomycin, IV, 20 mg/kg 12 hourly for 6 weeks.
MIC: >4 mg/L AND
 Gentamicin, IV, 1.5 mg/kg 12 hourly for 6 weeks (see
Enterococcal
Fully susceptible to  Benzylpenicillin (penicillin G), IV, 5 MU 6 hourly for 4
penicillin weeks.
MIC: <4 mg/L
Moderately resistant  Benzylpenicillin (penicillin G), IV, 5 MU 6 hourly for 4
MIC: 0.5–4 mg/L weeks.
Enterococci and AND
Abiotrophia spp.  Gentamicin, IV, 1 mg/kg 8 hourly for 2 weeks.
(nutritionally variant o 6 weeks of therapy may be required in cases with a
streptococci) history of >3 months, or mitral or prosthetic valve
involvement (see Appendix II for guidance on
prescribing).
LoE:IIIlvi
Penicillin-resistant Refer.
MIC ≥ 4 mg/L or
significant -lactam
allergy
and
Sensitive to
vancomycin MIC: ≤4
mg/L
2019 3.29
Staphylococcal (cloxacillin/methicillin sensitive)

S. aureus  Cefazolin, IV, 2g 8 hourly for 4 weeks.
If necessary, add:
 Gentamicin, IV, 6 mg/kg daily for the first 3–5 days (see
» The benefit of adding an aminoglycoside has not been
established.
Coagulase-negative Consult expert opinion on correct diagnosis in this setting.
staphylococci
Staphylococcal (cloxacillin/methicillin resistant) or methicillin sensitive

with significant beta-lactam allergy
S. aureus  Vancomycin, IV, 20 mg/kg 12 hourly for 4 weeks.

Coagulase-negative Consult expert on correct on antibiotic choice.
staphylococci
Directed therapy for prosthetic valve endocarditis

Duration of therapy is usually a minimum of at least 6 weeks.
Seek expert opinion on antibiotic choice and the need for referral for repeat
cardiac surgery early in the course of treatment.
Endocarditis prophylaxis
Cardiac conditions
Patients with the following cardiac conditions are at high risk of developing
infective endocarditis:
» Acquired valvular heart disease with stenosis or regurgitation.
» Patients with prosthetic heart valves.
» Structural congenital heart disease, including surgically corrected or
palliated structural conditions, but excluding isolated atrial septal defect,
fully repaired ventricular septal defect or fully repaired patent ductus
arteriosus.
» Patients who have suffered previous endocarditis.
Procedures requiring prophylaxis

Antibiotic prophylaxis is recommended for all dental procedures that involve
manipulation of either the gingival tissue or the peri-apical region of the teeth.
Antibiotic prophylaxis is not recommended for patients who undergo a gastro-
intestinal or genito-urinary procedure.
Prophylaxis (Z29.2)
Maintain good dental health.
This is the most important aspect of prophylaxis.
Refer all patients to a dental clinic/dental therapist for assessment and on-
going dental care.
 Amoxicillin, oral, 2 g one hour before the procedure.
2019 3.30
If patient cannot take oral:

 Ampicillin, IV/IM, 2 g one hour before the procedure.
Severe penicillin allergy: (Z88.0)

 Clindamycin, oral, 600 mg one hour before the procedure.
If patient cannot take oral:

 Clindamycin IV, 600 mg one hour before the procedure.
The NICE review noted the lack of a consistent association between
interventional procedures and development of infective endocarditis,
and that the efficacy of antibiotic prophylaxis is unproven. It further
commented that because the antibiotic is not without risk, there is a
potential for a greater mortality from severe hypersensitivity than from
withholding antibiotics.
It is very difficult to extrapolate from these guidelines to a South African
situation where good dental hygiene may be lacking and valvular heart
disease is common. Practitioners need to weigh the risk of the
underlying heart disease (particularly previous successfully treated
endocarditis) and the essential need for ongoing antibiotic stewardship.
LoE:IIIlvii
3.6 HYPERTENSION
I10
KEY POINTS
Hypertension control has significant benefit for patients.
Detect and treat co-existent risk factors.
Assess cardiovascular risk.
Lifestyle modification and patient education is essential for all patients.
Medicine treatment is needed for SBP ≥140 mmHg and DBP ≥90 mmHg
despite lifestyle modification. See medicine treatment choices below.
Immediate medicine treatment is needed for DBP ≥110 mmHg and/or SBP
≥180 mmHg (defined as severe hypertension - see sections 3.6.1, 3.6.2 and
3.6.3) or for patients with 3 or more risk factors, target organ damage and/or
associated clinical conditions.
Patients should be evaluated for cardiovascular risk factors, target
organ damage and associated clinical conditions.
Other major risk factors for ischaemic cardio- and cerebrovascular disease
(see section 3.1: Ischaemic heart disease and atherosclerosis, prevention).
Target organ damage:
» left ventricular hypertrophy,
» hypertensive retinopathy,
» microalbuminuria, or positive dipsticks for albuminuria or elevated
albumin/creatinine ratio, or
» elevated creatinine level (or eGFR <60 mL/minute).
2019 3.31
Associated clinical conditions:

» ischaemic heart disease,
» heart failure,
» stroke or transient ischaemic attack,
» chronic kidney disease,
» peripheral arterial disease.
Investigations
If overweight, record body weight and waist circumference at each visit when
BP is measured. Central obesity is defined as waist circumference:
» 102 cm in men, and
» 88 cm in women.
Do urine test strip analysis for protein, blood and glucose at presentation.
» If normal, repeat urine test strip every 6 months.
» If abnormal, do spot urine ACR. Repeat yearly.
» If haematuria >1+, investigate further.
» If glycosuria, exclude diabetes mellitus.
» If known diabetic, HbA1c.
» Random total cholesterol.
» Perform a resting ECG to exclude left ventricular hypertrophy or ischaemia.
» Assess renal function (serum creatinine and eGFR).
Goals of treatment
Aim for SBP <140 mmHg and DBP <90 mmHg.
GENERAL MEASURES
Lifestyle modification
All persons with hypertension should be encouraged to make the following
lifestyle changes as appropriate.
» Smoking cessation.
» Maintain ideal weight, i.e. BMI <25 kg/m2. Weight reduction in the overweight
patient.
» Salt restriction with increased potassium intake from fresh fruits and
vegetables (e.g. remove the salt from the table, gradually reduce added salt
in food preparation and avoid processed foods). Dietician’s advice
recommended.
» Reduce alcohol intake to no more than 2 standard drinks per day for males
and 1 for females.
» Follow a prudent eating plan i.e. low fat, high fibre and unrefined
carbohydrates, with adequate fresh fruit and vegetables. Dietician’s advice
recommended.
» Regular moderate aerobic exercise, e.g. 40 minutes brisk walking at least 3
times a week.
MEDICINE TREATMENT
Initial medicine choice in patients qualifying for treatment is dependent on the
presence of compelling indications (see table on page 3.31); the severity of
2019 3.32
the BP; and the presence of target organ damage, cardiovascular risk factors,
and associated clinical conditions.
Advise patient to take medication regularly, including on the day of the
clinic visit, but a single missed dose does not account for severe
elevations in BP.
Note:
» Check adherence to antihypertensive therapy by doing pill counts and
questioning family members.
» The use of fixed dose combination medication for control of hypertension
provides greater adherence and such agents should be used when they
are available. LoE:IIIlviii
» There is emerging evidence that taking the total daily dose of
antihypertensive medication at bedtime rather than on awaking provides
both better control of hypertension and a significant reduction in
important cardiovascular events. LoE:IIIlix
» Monitor patients monthly and adjust therapy if necessary until the BP is
controlled.
» After target BP is achieved, patients can be seen at 3–6 monthly intervals.
2019 3.33
MEDICINE TREATMENT CHOICES WITHOUT COMPELLING INDICATIONS

Stepped-care approach to BP treatment
Note:
» If lifestyle modification failed to achieve BP control: Counsel patient on the
risk of major cardiovascular events associated with elevated BP; and
initiate monotherapy.
» If BP control is suboptimal: Up titrate treatment (maximise dose of current
antihypertensive and/or add additional medicine). Evidence suggests that
2019 3.34
treatment inertia contributes to suboptimal BP control with patients

remaining on monotherapy and/or suboptimal doses. LoE:IIIlx
» Initiate combination medicine therapy in cases of severe hypertension
(see section 3.6.1) and hypertension urgency (see section 3.6.2).
BP 140-159/90-99 mmHg:
» < 3 risk factors, no target organ damage or associated clinical conditions:
 Lifestyle modification for 3–6 months.
 Start antihypertensive therapy with a single medicine if target BP
not achieved.
» ≥ 3 risk factors, target organ damage and/or associated clinical
conditions:
 Start antihypertensive therapy immediately (together with
lifestyle modification).
BP 160-179/100-109 mmHg:
» Even in absence of risk factors, or target organ damage or associated
clinical conditions:
 Start antihypertensive therapy (together with lifestyle modifications)
with a combination of two medicines.
BP ≥180/100 mmHg: this is severe hypertension: see sections 3.6.1, 3.6.2

and 3.6.3.
Initial antihypertensive medicine:

 Hydrochlorothiazide, oral, 12.5 mg daily.
o Caution in patients with gout.
o Less effective in impaired renal function.
o Caution in patients with a history or family history of skin cancer; and
counsel all patients on sun avoidance and sun protection.
LoE:IIIlxi
If target BP is not reached after one month despite adequate
adherence (or immediately in patients with BP160-179/100-109 mmHg), add one
of the following: ACE-inhibitor or calcium channel blocker.

 Amlodipine, oral, 5 mg at night. LoE:Ilxii
OR
 Enalapril, oral, 10 mg at night. LoE:Ilxiii

 Losartan, oral, 50 mg daily. Specialist initiated.
If target BP is not reached after one month despite adequate adherence on
2019 3.35
two medicines, add one of ACE-inhibitor or calcium channel blocker,

whichever has not already been used.
If target BP is still not achieved after one month despite adequate adherence,
increase the dose of medication, one medicine every month, to their maximal
levels: amlodipine 10 mg daily, enalapril 20 mg daily (losartan 100 mg daily)
hydrochlorothiazide 25 mg daily.
If target BP is not reached after one month despite adequate adherence:

ADD
 Spironolactone, oral 25–50 mg daily. LoE:Ilxiv
For refractory hypertension:

ADD
 β-blocker , e.g.: LoE:Ilxv
 Atenolol, oral, 50 mg at night.
Note: In 60–80% of patients a combination of the above antihypertensive

therapy is needed. Combination therapy, i.e. hydrochlorothiazide plus a
calcium channel blocker or ACE-inhibitor should be considered at the outset
in patients with BP >160/100 mmHg.
Medicine treatment choices with compelling indications

Compelling indications Medicine class
Angina ß-blocker
Calcium channel blocker
Post myocardial infarction ß-blocker
ACE-inhibitor
Heart failure ACE-inhibitor
Carvedilol
Spironolactone
Hydrochlorothiazide or furosemide
Left ventricular hypertrophy ACE-inhibitor
Stroke Hydrochlorothiazide
Diabetes type 1 or 2 ACE-inhibitor, usually in combination with a
with/without evidence of diuretic
microalbuminuria or
proteinuria
Chronic kidney disease ACE-inhibitor, usually in combination with a
diuretic
2019 3.36
Isolated systolic hypertension Hydrochlorothiazide

Pregnancy See Chapter 6: Obstetrics.
Caution
Lower BP over a few days.
A sudden drop in BP can be dangerous, especially in the elderly.
BP should be controlled within 1–6 months.
Assess for risk of ischaemic disease. See section 3.1: Ischaemic heart
disease and atherosclerosis, prevention.
REFERRAL
Referrals or consultation with a specialist are indicated when:
» Patients are adherent to therapy, and BP is refractory, i.e. >140/90 mmHg,
while on medicines from 3-4 different classes at appropriate dose, one of
which is a diuretic.
» All cases where secondary hypertension is suspected.
» Complicated hypertensive urgency e.g. malignant/accelerated hypertension,
severe heart failure with hypertension and hypertensive emergency.
3.6.1 HYPERTENSION, ASYMPTOMATIC SEVERE

I10
DESCRIPTION
These patients have severe hypertension (DBP ≥110 mmHg and/or SBP ≥180
mmHg), are asymptomatic and have no evidence of progressive target organ
damage.
Keep the patient in the care setting and repeat BP measurement after resting
for 1 hour.
If the second measurement is still elevated at the same level, start oral therapy
using two medicines together, one of which should be low dose
hydrochlorothiazide. The second medicine is either a long-acting calcium
channel blocker, e.g. amlodipine, or an ACE-inhibitor, e.g. enalapril.
Follow up carefully and refer as needed.
3.6.2 HYPERTENSIVE URGENCY

I10
DESCRIPTION
Severe hypertension (DBP ≥110 mmHg and/or SBP ≥180 mmHg) which is
symptomatic and/or with evidence of progressive target organ damage.
There are no immediate life threatening neurological or cardiac complications
such as are seen in the hypertensive emergencies.
2019 3.37
Do not lower BP in acute stroke or use antihypertensive medication

unless SBP >220 mmHg or the DBP >120 mmHg, as a rapid fall in BP
may aggravate cerebral ischaemia and worsen the stroke – see section
14.1.1: Stroke.
Treatment may be given orally but in patients unable to swallow, use

parenteral medicines.
MEDICINE TREATMENT
Ideally, all patients with hypertensive urgency should be treated in hospital.
Commence treatment with two oral agents and aim to lower the DBP to 100
mmHg slowly over 48–72 hours.
This BP lowering can be achieved by:
 Long-acting calcium channel blocker.
 ACE-inhibitor.
Note: Avoid if there is severe hyponatraemia, i.e. serum Na <130 mmol/L.
 Spironolactone.
 -blocker.
Diuretics may potentiate the effects of the other classes of medicines when
added. Furosemide should be used if there is renal insufficiency or signs of
pulmonary congestion.
3.6.3 HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY

I10
DESCRIPTION
This is a life-threatening situation that requires immediate lowering of BP
usually with parenteral therapy. Grade 3-4 hypertensive retinopathy is usually
present, together with impaired renal function and proteinuria.
The true emergency situation should preferably be treated by a specialist.
Life-threatening complications include:
» Hypertensive encephalopathy, i.e. severe headache, visual disturbances,
confusion, seizures and coma that may result in cerebral haemorrhage.
» Unstable angina or myocardial infarction.
» Acute left ventricular failure with severe pulmonary oedema (extreme
breathlessness at rest).
» Eclampsia and severe pre-eclampsia.
» Acute kidney failure with encephalopathy.
» Acute aortic dissection.
2019 3.38
MEDICINE TREATMENT
Admit the patient to a high-care setting for intravenous therapy and close
monitoring. Do not lower the BP by >25% within 30 minutes to 2 hours.
In the next 2–6 hours, aim to decrease the BP to 160/100 mmHg.
This may be achieved by the use of intravenous or oral medicines.
Intravenous therapy
 Labetalol, IV, 2 mg/minute to a total dose of 1–2 mg/kg, while trying to
achieve control with other agents.
o Caution in acute pulmonary oedema.
OR
If myocardial ischaemia and CCF:

 Glyceryl trinitrate, IV, 5–10 mcg/minute.
Refer to dosing table in section 3.2.1: ST elevation myocardial infarction
(STEMI).
AND
 Furosemide, IV, 40–80 mg.
o Duration of action: 6 hours.
o Potentiates all of the above medicines.
Oral therapy
 Enalapril, oral, 2.5 mg as a test dose.
o Increase according to response, to a maximum of 20 mg daily.
o Monitor renal function.

3.7 RHEUMATIC HEART DISEASE

I09.0-2/I09.9/I01.0-2/I01.8-9
DESCRIPTION
These are chronic sequelae of rheumatic fever consisting of valvular damage,
usually involving left heart valves, with progression and complications.
GENERAL MEASURES
Acute stage of rheumatic fever: bed rest and supportive care.
MEDICINE TREATMENT
Acute rheumatic fever
For eradication of streptococci in throat:
 Benzathine benzylpenicillin (depot formulation), IM, 1.2 MU as a single
dose.
2019 3.39
o For benzathine benzylpenicillin, IM injection, dissolve benzathine

benzylpenicillin 1.2 MU in 3.2 mL lidocaine 1% without
adrenaline (epinephrine) or 3 mL water for LoE:IIIlxvi
injection.
OR
Phenoxymethylpenicillin, oral, 500 mg 12 hourly for 10 days.

 Macrolide, e.g.:
 Azithromycin, oral, 500 mg daily for 3 days. LoE:Ilxvii
For arthritis and fever:

 NSAID, e.g.:
 Ibuprofen, oral, 400 mg 8 hourly with meals. LoE:III
Prevention of recurrent rheumatic fever

All patients with confirmed rheumatic fever and no persistent rheumatic
valvular disease:
» Treat for 10 years or until the age of 21 years, whichever is longer.
All patients with confirmed rheumatic fever and persistent rheumatic valvular
disease:
» Treat lifelong. LoE:IIIlxviii
 Benzathine benzylpenicillin (depot formulation), IM, 1.2
MU every 3–4 weeks (preferred treatment).
o For benzathine benzylpenicillin, IM injection, dissolve benzathine
benzylpenicillin 1.2 MU in 3.2 mL lidocaine 1% without adrenaline
(epinephrine) or 3 mL water for injection.
OR LoE:IIIlxix
Phenoxymethylpenicillin, oral, 250 mg 12 hourly.

 Azithromycin, oral, 250 mg daily. LoE:III
Prophylaxis for infective endocarditis

See section 3.5: Endocarditis, infective.
REFERRAL
» Any patient with rheumatic valvular heart disease who requires a
significant dose of diuretic to control fluid overload or who has had an
episode of pulmonary oedema should be discussed with a specialist and
referred for possible valve surgery.
» Pregnancy poses a particular problem in women with symptomatic
rheumatic valvular heart disease and all should be referred for specialist
consultation.
2019 3.40
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Town. 2016.
xlii Verapamil: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of Cape
Town. 2016.
xliii Amiodarone, oral (after cardioversion of atrial fibrillation): Lafuente-Lafuente C, Valembois L, Bergmann JF, Belmin
J. Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation. Cochrane Database Syst Rev.
2015 Mar 28;(3):CD005049. https://www.ncbi.nlm.nih.gov/pubmed/25820938
xliv Verapamil: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of Cape
Town. 2016.
xlv Adenosine: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of
Cape Town. 2016.

Verapamil: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of Cape
Town. 2016.
xlvi Amiodarone, oral (dosing): British National Formulary, 78th edition (September 2019-March 2020).
xlvii Pregnancy – medicines contraindicated: South African Medicines Formulary. 12th Edition. Division of Clinical
Pharmacology. University of Cape Town. 2016.

xlviii Digoxin: Digitalis Investigation Group. The effect of digoxin on mortality and morbidity in patients with heart failure. N
Engl J Med. 1997 Feb 20;336(8):525-33. http://www.ncbi.nlm.nih.gov/pubmed/9036306

xlix Hydrochlorothiazide, oral (skin cancer risk): Pedersen SA, Gaist D, Schmidt SAJ, Hölmich LR, Friis S, Pottegård A.
Hydrochlorothiazide use and risk of nonmelanoma skin cancer: A nationwide case-control study from Denmark. J Am
Acad Dermatol. 2018 Apr;78(4):673-681.e9. https://www.ncbi.nlm.nih.gov/pubmed/29217346
Hydrochlorothiazide, oral (skin cancer risk): Pottegård A, Hallas J, Olesen M, Svendsen MT, Habel LA, Friedman
GD, Friis S. Hydrochlorothiazide use is strongly associated with risk of lip cancer. J Intern Med. 2017 Oct;282(4):322-
2019 3.45
Hydrochlorothiazide, oral (skin cancer risk): National Department of Health, Essential Drugs Programme: Updated
Notice: Risk of skin cancer associated with hydrochlorothiazide, 6 March 2019. http://www.health.gov.za/
lACE-inhibtors (first-line option for CCF): Tai C, Gan T, Zou L, Sun Y, Zhang Y, Chen W, Li J, Zhang J, Xu Y, Lu H, Xu
D. Effect of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers on cardiovascular events in
patients with heart failure: a meta-analysis of randomized controlled trials. BMC Cardiovasc Disord. 2017 Oct
5;17(1):257. https://www.ncbi.nlm.nih.gov/pubmed/28982370
li Enalapril target dose: Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and
congestive heart failure. The SOLVD Investigators. N EnglJ Med. 1991 Aug 1;325(5):293-302.
Enalapril target dose: Effect of enalapril on mortality and the development of heart failure in asymptomatic patients
with reduced left ventricular ejection fractions. The SOLVD Investigators. N Engl J Med. 1992 Sep 3;327(10):685-91.
Erratum in: N Engl J Med 1992 Dec 10;327(24):1768. http://www.ncbi.nlm.nih.gov/pubmed/1463530
Enalapril target dose: CONSENSUS Trial Study Group. Effects of enalapril on mortality in severe congestive heart
failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). N Engl J Med. 1987
Jun 4;316(23):1429-35. https://www.ncbi.nlm.nih.gov/pubmed/2883575
lii Spironolactone: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of
Cape Town. 2016.
liii Carvedilol: Packer M, Coats AJ, Fowler MB, Katus HA, Krum H, Mohacsi P, Rouleau JL, Tendera M, Castaigne A,
Roecker EB, Schultz MK, DeMets DL; Carvedilol Prospective Randomized Cumulative Survival Study Group. Effect of
carvedilol on survival in severe chronic heart failure. N Engl J Med. 2001 May 31;344(22):1651-8.
liv Digoxin: Fauchier L, Laborie G, Clementy N, Bernard A, Angoulvant D, Lip GHY, Babuty D. Effect of digoxin on all-
cause mortality in patients with atrial fibrillation in a population-based cohort study. Heart Failure Congress; May 24,
2015; Seville, Spain.Presentation 539.https://www.escardio.org/
Digoxin:Rathore SS, Curtis JP, Wang Y, Bristow MR, Krumholz HM. Association of serum digoxin concentration and
outcomes in patients with heart failure. JAMA. 2003 Feb 19;289(7):871-8.
Digoxin: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of Cape
Town. 2016.
lv Vancomycin, IV: Groote Schuur Hospital’s vancomycin protocol.
lvi Gentamicin, IV (Enterococcal infective endocarditis): Baddour LM, Wilson WR, Bayer AS, Fowler VG Jr, Tleyjeh IM,
Rybak MJ, Barsic B, Lockhart PB, Gewitz MH, Levison ME, Bolger AF, Steckelberg JM, Baltimore RS, Fink AM, O'Gara
P, Taubert KA; American Heart Association Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of
the Council on Cardiovascular Disease in the Young, Council on Clinical Cardiology, Council on Cardiovascular Surgery
and Anesthesia, and Stroke Council. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and
Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart
Association. Circulation. 2015 Oct 13;132(15):1435-86. https://www.ncbi.nlm.nih.gov/pubmed/26373316
Gentamicin, IV (Enterococcal infective endocarditis): Horstkotte D, Follath F, Gutschik E, et al. Guidelines on
prevention, diagnosis and treatment of infective endocarditis executive summary; the task force on infective
endocarditis of the European society of cardiology. Eur Heart J 2004; 25:267–76.
Gentamicin, IV (Enterococcal infective endocarditis): Elliott TS, Foweraker J, Gould FK, Perry JD, Sandoe JA.
Guidelines for the antibiotic treatment of endocarditis in adults: report of the Working Party of the British Society for
Antimicrobial Chemotherapy. J Antimicrob Chemother 2004; 54:971–81.
lvii Antibiotics for prophylaxis (infective endocardtis): NICE, Clinical guideline 64 Prophylaxis against infective
endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional
procedures, March 2008. www.nice.org.uk/CG064
lviii Antihypertensives – fixed dose combinations: Gupta P, Patel P, Štrauch B, Lai FY, Akbarov A, Marešová V, White
CMJ, Petrák O, Gulsin GS, Patel V, Rosa J, Cole R, Zelinka T, Holaj R, Kinnell A, Smith PR, Thompson JR, Squire I,
Widimský J Jr, Samani NJ, Williams B, Tomaszewski M. Risk Factors for Nonadherence to Antihypertensive
Treatment. Hypertension. 2017 Jun;69(6):1113-1120. https://www.ncbi.nlm.nih.gov/pubmed/28461599
lix Antihypertensives – dosing at bedtime: : Hermida RC, Crespo JJ, Domínguez-Sardiña M, Otero A, Moyá A, Ríos MT,
Sineiro E, Castiñeira MC, Callejas PA, Pousa L, Salgado JL, Durán C, Sánchez JJ, Fernández JR, Mojón A, Ayala DE;
Hygia Project Investigators. Bedtime hypertension treatment improves cardiovascular risk reduction: the Hygia
Chronotherapy Trial. Eur Heart J. 2019 Oct 22. pii: ehz754. https://www.ncbi.nlm.nih.gov/pubmed/31641769
lx Suboptimal BP control – treatment inertia: Tiffe T, Wagner M, Rucker V, Morbach C, Gelbrich G, Stork S,
Heuschmann PU. Control of cardiovascular risk factors and its determinants in the general population- findings from the
STAAB cohort study. BMC Cardiovasc Disord 2017;17:276. https://www.ncbi.nlm.nih.gov/pubmed/29096615
Suboptimal BP control – treatment inertia: Berry KM, Parker WA, Mchiza ZJ, Sewpaul R, Labadarios D, Rosen S,
Stokes A. Quantifying unmet need for hypertension care in South Africa through a care cascade: evidence from the
SANHANES, 2011-2012. BMJ Glob Health. 2017 Aug 16;2(3):e000348.
lxi Hydrochlorothiazide, oral (skin cancer risk): Pedersen SA, Gaist D, Schmidt SAJ, Hölmich LR, Friis S, Pottegård A.
Hydrochlorothiazide use and risk of nonmelanoma skin cancer: A nationwide case-control study from Denmark. J Am
Acad Dermatol. 2018 Apr;78(4):673-681.e9. https://www.ncbi.nlm.nih.gov/pubmed/29217346
Hydrochlorothiazide, oral (skin cancer risk): Pottegård A, Hallas J, Olesen M, Svendsen MT, Habel LA, Friedman
GD, Friis S. Hydrochlorothiazide use is strongly associated with risk of lip cancer. J Intern Med. 2017 Oct;282(4):322-
2019 3.46
Hydrochlorothiazide, oral (skin cancer risk): National Department of Health, Essential Drugs Programme: Updated
Notice: Risk of skin cancer associated with hydrochlorothiazide, 6 March 2019. http://www.health.gov.za/
lxii Calcium channel blocker (place in treatment protocol): Brewster LM, van Montfrans GA, Oehlers GP, Seedat YK.
Systematic review:antihypertensive drug therapy in patients of African and South Asian ethnicity. Intern Emerg Med.
2016 Apr;11(3):355-74. https://www.ncbi.nlm.nih.gov/pubmed/27026378
Calcium channel blocker (dosing at bedtime): Hermida RC, Crespo JJ, Domínguez-Sardiña M, Otero A, Moyá A,
Ríos MT, Sineiro E, Castiñeira MC, Callejas PA, Pousa L, Salgado JL, Durán C, Sánchez JJ, Fernández JR, Mojón A,
Ayala DE; Hygia Project Investigators. Bedtime hypertension treatment improves cardiovascular risk reduction: the
Hygia Chronotherapy Trial. Eur Heart J. 2019 Oct 22. pii: ehz754. https://www.ncbi.nlm.nih.gov/pubmed/31641769
lxiii Enalapril, oral (daily dosing): Girvin B, McDermott BJ, Johnston GD. A comparison of enalapril 20 mg once daily
versus 10 mg twice daily in terms of blood pressure lowering and patient compliance. J Hypertens. 1999
Nov;17(11):1627-31. https://www.ncbi.nlm.nih.gov/pubmed/10608477
Enalapril, oral (daily dosing): Davies RO, Gomez HJ, Irvin JD, Walker JF. An overview of the clinical pharmacology of
enalapril. Br J Clin Pharmacol. 1984;18 Suppl 2:215S-229S. https://www.ncbi.nlm.nih.gov/pubmed/6099737
Enalapril, oral (dosing at bedtime): Hermida RC, Crespo JJ, Domínguez-Sardiña M, Otero A, Moyá A, Ríos MT,
lxivSpironolactone, oral:Williams B, MacDonald TM, Morant S, Webb DJ, Sever P, McInnes G, Ford I, Cruickshank JK,
Caulfield MJ, Salsbury J, Mackenzie I, Padmanabhan S, Brown MJ; British Hypertension Society's PATHWAY Studies
Group. Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant
hypertension (PATHWAY-2): a randomised, double-blind, crossover trial. Lancet. 2015 Nov 21;386(10008):2059-68.
lxvBeta-blocker, oral (dosing at bedtime): Hermida RC, Crespo JJ, Domínguez-Sardiña M, Otero A, Moyá A, Ríos MT,
lxviLidocaine 1%: Amir J, Ginat S, Cohen YH, Marcus TE, Keller N, Varsano I. Lidocaine as a diluent for administration
of benzathine penicillin G. Pediatr Infect Dis J. 1998 Oct;17(10):890-3. http://www.ncbi.nlm.nih.gov/pubmed/9802630

lxviiAzithromycin: van Driel ML, De Sutter AI, Keber N, Habraken H, Christiaens T. Different antibiotic treatments for
group A streptococcal pharyngitis. Cochrane Database Syst Rev. 2013 Apr 30;4:CD004406.
Azithromycin: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of
Cape Town. 2016.
Azithromycin: Guo D, Cai Y, Chai D, Liang B, Bai N, Wang R. The cardiotoxicity of macrolides: a systematic
review.Pharmazie. 2010 Sep;65(9):631-40. Review.http://www.ncbi.nlm.nih.gov/pubmed/21038838
Azithromycin: Contract circular HP02-2013AI, to 31July2015.http://www.health.gov.za/
lxviiiPeriod of antibiotic prophylaxis therapy:Begs S, Petrson G, Thompson A. Report for the 2nd meeting of the World
Health Organization’s subcommittee of the Expert Committee of the selection and use of essential medicines: Antibiotic
use for the prevention and treatment of rheumatic fever and treatment of rheumatic fever and rheumatic heart disease
in children. 30 June 2008.
http://www.who.int/selection_medicines/committees/subcommittee/2/RheumaticFever_review.pdf
Period of antibiotic prophylaxis therapy: Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST,
Taubert KA. Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific
statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of
the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and
Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the
American Academy of Pediatrics. Circulation. 2009 Mar 24;119(11):1541-51.
lxixLidocaine 1%: Amir J, Ginat S, Cohen YH, Marcus TE, Keller N, Varsano I. Lidocaine as a diluent for administration
of benzathine penicillin G. Pediatr Infect Dis J. 1998 Oct;17(10):890-3. http://www.ncbi.nlm.nih.gov/pubmed/9802630
2019 3.47
CHAPTER 4
DERMATOLOGY
Extemporaneous compounding of some of the preparations listed should

only take place at institutions where the competencies and equipment are
available.
4.1 ACNE
L70.0-5/L70.8-9
DESCRIPTION
Acne is an inflammatory condition of the pilosebaceous unit. Secondary
changes can lead to scarring and inflammation.
Mild acne:
Predominantly consists of non-inflammatory comedones.
Moderate acne:
Consists of a mixture of non-inflammatory comedones and inflammatory
papules and pustules.
Severe acne
It is characterised by the presence of widespread nodules and cysts, as well
as a preponderance of inflammatory papules and pustules.
GENERAL MEASURES
Do not squeeze lesions.
Avoid greasy or oily topical products such as moisturisers that block the hair
follicle openings.
Discourage excessive facial washing.
MEDICINE TREATMENT
Primary management: See Primary Health Care Standard Treatment
Guidelines and Essential Medicine List, section 5.3: Acne vulgaris.
Women who need oral contraception and have inflammatory acne can be
initiated on a cyproterone acetate-containing combined oral contraceptive pill,
provided that they have no personal or family history of breast cancer or
thrombosis.
 Cyproterone acetate 2 mg plus ethinyl estradiol 35 mcg, oral.
LoE:Ii
Discuss all severe cases with a dermatologist.
2019 4.1
CHAPTER 4 DERMATOLOGY
4.2 CELLULITIS AND ERYSIPELAS

L03.0-3/L03.8-9 + (L04.0-3/L04.8-9/B95.0-8) and A46
DESCRIPTION
Skin and subcutaneous infections with pain, swelling, and erythema, usually
caused by streptococci and staphylococci, and occasionally other
organisms. Regional lymphadenitis may be present. Erysipelas has a raised
demarcated border, whilst the border is indistinct in cellulitis.
The presence of areas of necrosis, haemorrhage, or pain out of proportion to

the physical signs should raise suspicion of necrotising fasciitis which
requires aggressive surgical debridement and broad spectrum antibiotics
(e.g. amoxicillin/clavulanic acid) as these infections are often polymicrobial.
GENERAL MEASURES
Elevate the affected limb to reduce swelling and pain.
Hydrate.
MEDICINE TREATMENT
For pain: LoE:Iii
 NSAID, oral: e.g.
 Ibuprofen, oral, 400 mg 8 hourly with meals.
OR
 Paracetamol, oral, 1 g 4–6 hourly when required.
o Maximum dose: 15 mg/kg/dose.
o Maximum daily dose: 4 g in 24 hours.
Antibiotic therapy
 Cefalexin, oral, 500 mg 6 hourly for 5 days.
OR
Flucloxacillin, oral, 500 mg 6 hourly for 5 days.
Macrolide:
Severe cases may require parenteral antibiotics.
Severe infection
If intravenous antibiotics are given initially, patients should be switched to
oral agents as soon as there is clinical improvement.
If there is a rapid progression of erythema, intravenous antibiotics are
preferred.
The recommended duration of antimicrobial therapy is 5 days, but treatment
should be extended if the infection has not improved within this time period.
LoE:IIIiii
 Cefazolin, IV, 1 g 8 hourly.
2019 4.2
When there is clinical improvement, change to: LoE:IIiv

 Flucloxacillin, oral, 500 mg 6 hourly.

 Clindamycin, IV, 600 mg 8 hourly.
When there is clinical improvement, change to:
 Clindamycin, oral, 450 mg 8 hourly.
If patient is admitted and bed-bound with lower limb cellulitis, consider deep
venous thrombosis prophylaxis. See section 2.14 Venous thrombo-embolism.
If Taenia pedis is suspected to be the pre-disposing cause, treat accordingly.

See section 4.10: Fungal infections.
REFERRAL
Urgent
» For debridement if necrotising fasciitis is suspected, i.e. gangrene, gas in
the tissues or haemorrhagic bullae.
Non-urgent
» To surgeon for non-response.
» Cellulitis involving wounds in aquatic environment, (salt or brackish water),
fresh water or lack of response to treatment, refer for further investigation
with an option for a biopsy.
4.3 IMPETIGO
L01.0 + (B95.0-8)
DESCRIPTION
Superficial skin infection, starting as vesicles with an inflammatory halo. Later a
characteristic honey-coloured crust on erythematous base develops which heals
without scarring. Usually caused by group A streptococci or staphylococci. Post-
streptococcal glomerulonephritis is a potential complication.
GENERAL MEASURES
Good personal and household hygiene to avoid spreading the infection and
to reduce carriage of organisms.
Wash and soak lesions in soapy water to soften and remove crusts.
MEDICINE TREATMENT
Antibiotic therapy
 Flucloxacillin, oral, 500 mg 6 hourly for 5 days.
Macrolide:
2019 4.3
4.4 FURUNCLES AND ABSCESSES

L02.0-4/L02.8-9/H00.0/H60.0/N76.4/J34.0 + (B95.6)
DESCRIPTION
Localised bacterial skin infection of hair follicles (furuncle/boil) or dermis
(abscess), usually with S. aureus.
The surrounding skin becomes:
» swollen, » red,
» hot , and » tender to touch.
Note: Boils in diabetic, malnourished, or other immunocompromised patients
are more likely to develop complications.Check blood glucose levels and HIV
status, if the boils are recurrent.
GENERAL MEASURES
Drainage of the abscess is the treatment of choice. Perform surgical incision
only if the lesion is fluctuant.
Note: Needle aspiration is insufficient for adequate abscess drainage.
The treatment of choice for small furuncles is moist warm compress to
infected area, several times per day to promote drainage.
Large fluctuant lesions should be treated with incision and drainage.
The following sites should be drained by a surgeon:
» Peri-rectal abscess
» Anterior and lateral neck abscess
» Abscess adjacent to nerves or blood vessels e.g carotid artery, facial
nerve, central triangle of face (formed by the corners of the mouth and
the nasal bridge).
Systemic antibiotics are used only as indicated below.
MEDICINE TREATMENT
Antibiotic therapy
Systemic antibiotics are seldom necessary, except for facial abscesses, or
abscesses associated with tender draining lymph nodes, fever, or extensive
surrounding cellulitis.
Antibiotics should usually be given for 5–10 days, depending on clinical
response.
 Cefazolin, IV, 1g 8 hourly.
When there is clinical improvement, change to: LoE:IIv
When there is clinical improvement, change to:
2019 4.4
4.5 ATOPIC ECZEMA/ DERMATITIS

L20.0/L20.8-9
DESCRIPTION
Eczema is an pruritic, inflammatory skin condition recognised by vesicles,
weeping, and crusting in the acute phase; and thickened, scaly skin with
increased skin markings known as lichenification in the chronic phase.
Assessing severity
1% of body surface is equal to the size of one hand (including the fingers) of
the patient.
Mild
» Less than 5% body surface involved.
» No acute changes.
» No significant impact on quality of life.
Moderate
» 5–30% body surface involved.
» Mild dermatitis with acute changes.
» Mild dermatitis with significant impact on quality of life.
Severe
» More than 30% body surface involved.
» Moderate dermatitis with acute changes.
» Moderate dermatitis with significant impact on quality of life.
GENERAL MEASURES
» Avoid exposure to trigger or precipitating factors, where applicable.
» Avoid irritants such as strong detergents, antiseptics, foam (especially
hot) baths, soaps and rough occlusive clothing (silk is better than cotton,
which is better than nylon, which is better than wool).
» Good personal hygiene with once daily washing to remove crusts and
accretions and avoid secondary infection.
» Keep fingernails short to minimise trauma from scratching.
» Respect patient preference for cream or ointment topical treatment.
» Wet wraps may help control eczema and pruritus but should not be used
for infected eczema.
» Diet modification has no role in atopic eczema treatment unless double
blind challenge testing proves food sensitivity.
» Avoid smoking.
MEDICINE TREATMENT
To relieve skin dryness:
 Aqueous cream topical, to wash or bath.
 Emulsifying ointment (UE), topical, applied daily to dry areas as a
2019 4.5
moisturiser. LoE:IIIvi
Moisturising soap, creams and ointments, as described above, should
continue permanently as maintenance, even if the dermatitis is controlled.
To control dermatitis:
Creams are preferred to ointments on open or oozing lesions and in
intertriginous folds.
Mild eczema
 Hydrocortisone 1%, topical, applied 12 hourly to body and face until
control is achieved.
o Can be used on face and in skin folds.
o Apply sparingly to the face.
o Use with caution around the eyes.
Moderate and severe eczema

 Potent topical corticosteroids, e.g.:
 Betamethasone 0.1%, topical, applied daily for 7 days to the affected areas.
o Apply sparingly to face, neck and flexures.
Note: There is no clear benefit for more than once daily application.
LoE:Ivii
If non-responsive:
Refer for dermatologist opinion.
 Prednisone, oral, 0.5 mg/kg daily, for ≤ 2 weeks. Specialist initiated.
Maintenance therapy
Once eczema is controlled, wean to the lowest potency topical corticosteroid
that maintains remission, applied twice a week.
Apply moisturiser as needed.
 Emulsifying ointment (UE), topical, applied daily.
Infected eczema
This is usually due to staphylococcal infection.
Antibiotic therapy
 Flucloxacillin, oral, 500 mg 6 hourly for 5 days.
 Clindamycin, oral, 450 mg 8 hourly for 5 days.
For sedation and relief of itch:

 Chlorphenamine, oral, 4 mg at night as needed.
Eczema herpeticum B00.0

Therapy should be initiated without delay:
 Aciclovir 400 mg, oral, 8 hourly for 7 days.
LoE:IIIviii
If patient is unable to swallow due to odynophagia:
2019 4.6
 Aciclovir,IV, 5 mg/kg/dose, 8 hourly for 7 days.

o Infuse over 1 hour.
LoE:IIIix
REFERRAL
Severe, non-responsive, or complicated cases or cases with uncertain
diagnosis (e.g. severe infection including disseminated herpes simplex).
4.6 ERYTHEMA MULTIFORME, STEVENS JOHNSON

SYNDROME, TOXIC EPIDERMAL NECROLYSIS
L51.0-2/L51.8-9
DESCRIPTION
Erythema multiforme
An acute, self-limiting, and commonly recurrent inflammatory skin eruption
with variable involvement of the mucous membranes and without systemic
symptoms.
Symmetrically distributed crops of target lesions (dark centre, an inner, pale
ring surrounded by an outer red ring) often involving palms and soles are
characteristic. This condition is usually due to an infection, commonly herpes
simplex or mycoplasma.
Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN)
Life-threatening acute hypersensitivity reactions with systemic upset,
epidermal necrosis, and mucous membrane involvement. TEN and SJS are
different ends of the same spectrum: in TEN epidermal necrosis involves
>30% of body surface area, while in SJS the involvement is <10%. Non-
specific prodromal symptoms, often mistaken as an upper respiratory tract
infection, may occur before skin lesions are apparent.
Cutaneous lesions may start as a dusky red macular rash, progressing to
confluence with epidermal necrosis and large flaccid blisters which rupture,
leaving large areas of denuded skin. Mucous membrane erosions are
common and multi-organ involvement may be present.
This condition is usually due to medication, e.g. sulfonamides, non-
nucleoside reverse transcriptase inhibitors (especially nevirapine), anti-
epileptics (phenytoin, phenobarbitone, carbamazepine, lamotrigine),
allopurinol, laxatives (phenolphthalein).
Complications include:
» Dehydration,electrolyte disturbances, and shock,
» hypoalbuminaemia,
» hypo- and more commonly hyperthermia,
» high output cardiac failure,
» secondary infection and sepsis, and
» adhesions and scarring.
2019 4.7
Stop all medicines, where safely possible, including complementary,

alternative, and self medication.
GENERAL MEASURES
Principles of management
Immediate in hospital evaluation
The foundation of management is supportive, good nursing, and the
prevention of dehydration and sepsis.
Management is similar to that of burns.
Stop/substitute all medicines.
Patients usually require care in a high or intensive care unit with dedicated
nursing.
Attempt to identify causative agent as early withdrawal of agent improves
prognosis.
Monitoring
Monitor vital organ function.
Examine daily for infection and swab infected lesions. Do blood cultures if
fever persists or suspicion of infection.
Dressings
Skin hygiene; daily cleansing and bland, non-adherent dressings as needed.
Do not use silver sulfadiazine if SJS/TEN is thought to be due to

cotrimoxazole or other sulfonamides.
Mucous membranes:
Regular supervised oral, genital and eye care to prevent adhesions and scarring.
Two-hourly mouth washes with bland mouth wash, e.g. glycothymol.
Examine daily for ocular lesions and treat 2-hourly with eye care and
lubricants (see section 18.9: Dry eye) and break down adhesions.
Treat genitalia 6-hourly with Sitz baths and encourage movement of
opposing eroded surfaces to prevent adhesions.
Fluids:
Oral rehydration is preferred but intravenous fluid therapy may be required to
treat significant dehydration.
Encourage oral fluids to prevent pharyngeal adhesions.
Provide soft, lukewarm food. Restrict nasogastric feeds to those patients that
are unable to eat, as they may lead to additional trauma with bleeding,
secondary infection, and adhesions.
Note: All patients should receive a notification bracelet/necklace on
discharge.
2019 4.8
MEDICINE TREATMENT
Corticosteroids
The practice of using systemic corticosteroids is not supported by evidence
and is therefore not recommended.
Antibiotic therapy
Systemic antibiotics may be indicated, depending on results of appropriate
cultures. They should not be administered routinely, nor be given
prophylactically. Organisms identified on skin swabs are not a good indicator
of systemic infection.
Analgesia
Appropriate and adequate analgesia for the pain associated with dressing
changes, given at least half an hour before dressing change (See section
12.4.1: Perioperative analgesics).
Discuss with a specialist, if considering re-initiation of medicine treatment.
Where there is ocular involvement, consult a specialist immediately.
4.7 LEG ULCERS, COMPLICATED

L97
DESCRIPTION
A chronic relapsing disorder of the lower limbs. It has many causes and is
often associated with lipodermatosclerosis (bound-down, fibrosed skin) and
eczema. It is mainly associated with vascular, predominantly venous,
insufficiency and immobility. It is also associated with neuropathy and,
occasionally, with infections, neoplasia, trauma, or other rare conditions.
GENERAL MEASURES
The aim of management should be to:
» Treat underlying conditions, e.g. heart failure, diabetes mellitus and
venous stasis.
» Limit the extent of damage.
» Encourage rapid healing to minimise scarring and fibrosis.
» Prevent recurrences.
Avoid all topical irritants and allergens, e.g. lanolin, neomycin, bacitracin,
parabens, fusidic acid, clioquinol, antihistamine creams, etc.
If the ulcer is oedema- or stasis-related, rest the leg in an elevated position.
In venous insufficiency, compression (bandages or stockings) is essential to
achieve and maintain healing, provided the arterial supply is normal.
In patients with arterial insufficiency, avoid pressure elevation and
compression bandages or stockings on bony prominences and the toes.
Stress meticulous foot care and avoidance of minor trauma.
2019 4.9
Walking and exercises are recommended.

Encourage patients with neuropathy not to walk barefoot, to check their
shoes for foreign objects, examine their feet daily for trauma, and to test bath
water before bathing to prevent getting burnt.
Avoid excessive local heat.
Indications for surgical procedures include:
» slough removal » arterial insufficiency
» surgery for varicose veins » skin grafting
MEDICINE TREATMENT
Antibiotic therapy
Systemic antibiotics are seldom required for ulcers, and should be
considered only if there is surrounding cellulitis. These infections are
typically polymicrobial and broad-spectrum antibiotics are recommended.
 Amoxicillin/clavulanic acid, oral, 875/125 mg 12 hourly for 7 days.
Local wound care

Topical cleansing
Use bland, non-toxic products to clean the ulcer and surrounding skin.
For clean uninfected wounds:
 Sodium chloride 0.9% or sterile water.
Dressed frequently with:
 Moistened dressing e.g. gauze with sodium chloride 0.9%.
LoE:Ix
For exudative, infected wounds:
 Povidone-iodine 5% cream, topical apply daily.
4.8 PSORIASIS
L40.0-5/L40.8-9
DESCRIPTION
This is an inflammatory condition of the skin and joints of unknown aetiology.
Scaly red, papules and plaques over extensor surfaces and on the scalp are
common. The nails and skin folds are often involved. In exceptional cases, it
is localised to palms and soles and pustular skin lesions are seen, especially
following rapid treatment withdrawal, e.g. steroids or systemic agents.
GENERAL MEASURES
Counselling regarding precipitating factors and chronicity.
Encourage sun exposure as tolerated.
MEDICINE TREATMENT
Note:
» Systemic steroids should be avoided.
2019 4.10
» Patient adherence is the greatest barrier to treatment success with

topical therapies.
Local plaques
For maintenance:
 Coal tar 6% ointment, topical, apply at night.
o Avoid use on the face, flexures and genitalia.
For flares:
 Potent topical corticosteroids, e.g.: LoE:IIIxi
 Betamethasone 0.1%, topical, apply 12 hourly.
o Decrease according to severity, reduce to hydrocortisone 1%, then stop.
Scalp psoriasis
For maintenance:
 Wash with coal tar containing shampoo.
OR
Coal tar 1% ointment, topical, apply at night, under occlusion and wash
out the next morning.
For flares:
 Potent topical corticosteroids, e.g.: LoE:IIIxii
 Betamethasone 0.1% lotion, topical, apply once daily.
REFERRAL
» Indequate response to topical treatment.
» Severe disease, especially if joint involvement.
4.9 URTICARIA
L50.0-6/L50.8-9
DESCRIPTION
A transient itchy inflammatory skin and mucosal condition recognised by a
wheal and flare reaction. There are many causes. In most chronic cases the
precipitant for the urticaria is never found. Lesions due to insect bites are
often grouped, show a central bite mark, are on exposed areas of the body,
and are often associated excoriations, vesicles, pigmentary changes, and
secondary infection.
GENERAL MEASURES
Limit exposure to triggers such as non-immune mast cell degranulators,
which aggravate and prolong urticaria, e.g. opioids (such as codeine),
NSAIDs, salicylates, alcohol, etc.
MEDICINE TREATMENT
Antihistamines
Regular use is recommended until the urticaria is quiescent.
2019 4.11
For chronic urticaria less sedating antihistamines are preferable:

 Cetirizine, oral, 10 mg daily.
Avoid oral corticosteroids.
REFERRAL
All patients with urticarial lesions where the individual lesions remain for
longer than 48 hours to a specialist to exclude urticarial vasculitis.
4.9.1 PAPULAR URTICARIA

L50.8
DESCRIPTION
Papular urticaria is a hypersensitivity disorder to insect bites, resulting in
recurrent and sometimes chronic itchy papules on exposed areas of the body.
Initial lesion is a red papule, which may blister, become excoriated, and then
heal with hyperpigmentation.
Usually occur in crops over several months.
Chronic, severe, persistent reactions may be seen in immunocompromised
patients, e.g. HIV infection, immunosuppressive therapy, and malnutrition.
GENERAL MEASURES
Reduce exposure to insects by treating pets, using mosquito nets and
fumigating household regularly.
Use of insect repellents may be helpful.
Examine carefully for burrows to rule out scabies.
MEDICINE TREATMENT
New inflamed lesions:
 Potent topical corticosteroids, e.g.: LoE:IIIxiii
 Betamethasone 0.1%, topical apply daily for 5 days.
For relief of itch and sedation:
 Chlorphenamine, oral, 4 mg at night as needed in severe cases.
REFERRAL
Non-responsive and chronic cases.
4.10 FUNGAL INFECTIONS

B35.0-6/B35.8-9/B36.0-3/B36.8-9/B40.3/B45.2/B46.3
DESCRIPTION
The skin may be infected by fungi and the clinical presentation varies with
organism, body site infected, and the body’s response to the infection.
2019 4.12
GENERAL MEASURES
Manage predisposing factors, i.e. occlusion, maceration, and underlying
conditions such as diabetes mellitus, eczema, immunocompromising
conditions, etc.
Advise patient regarding spread of infection and exposure in communal,
shared facilities (dermatophytes).
MEDICINE TREATMENT
Yeast and dermatophytes (fungal infection of the skin):
 Imidazole, e.g.:
 Clotrimazole 1%, topical, apply 8 hourly until clear of disease (i.e. for at
least 2 weeks after the lesions have cleared).
Pityriasis versicolor: B36.0

 Selenium sulfide 2.5% suspension, applied once weekly to all affected
areas.
o Allow to dry and leave overnight before rinsing off.
o Repeat for 3 weeks.
Systemic antifungal therapy

Topical treatment is generally ineffective for dermatophyte hair and nail
infections.
Systemic therapy may be indicated for immunocompromised individuals with
extensive skin infection
Recurrent infections are not uncommon if repeat exposure is not prevented.
 Fluconazole, oral, 200 mg weekly for 6 weeks.
o For onychomycosis, 200 mg weekly for 6 months.
LoE:Ixiv
REFERRAL
» Non-responsive infections.
» Systemic infections.
4.11 VIRAL INFECTIONS

4.11.1 VIRAL WARTS/ANOGENITAL WARTS
B07/A63.0
DESCRIPTION
Superficial muco-cutaneous infection caused by the human papilloma virus.
GENERAL MEASURES
Patients with anogenital warts are at an increased risk of other STIs.
Anogenital warts:
» Pap smear should be done in women.
» Screen for other STIs.
2019 4.13
MEDICINE TREATMENT
Cutaneous warts
Treatment seldom indicated.
Anogenital warts
 Podophyllotoxin 0.5% solution.
o Apply 12 hourly for 3 consecutive days until lesions disappear
(patient application).
o Apply petroleum jelly to surrounding skin and mucous membrane for
protection.
o Treatment may be repeated at weekly intervals if necessary for a total
of four 3-day treatment courses.
OR
 Podophyllin 20% in Tinct. Benz. Co., topical.
o Apply at weekly intervals to lesions until lesions disappear (health
care professional application).
o Apply petroleum jelly to surrounding skin and mucous membrane for
protection.
o Wash the solution off after 4 hours.
Note: LoE:IIxv
» Podophyllin is a cytotoxic agent.
» Avoid systemic absorption.
» Contraindicated in pregnancy.
REFERRAL
Extensive or recurrent anogenital warts.
4.11.2 SHINGLES (HERPES ZOSTER)

See section 9.11: Zoster (shingles).
2019 4.14
References:
i Cyproterone acetate 2 mg plus Ethinyl Estradiol 35 µg, oral: Arowojolu AO, Gallo MF, Lopez LM, Grimes DA. Combined
oral contraceptive pills for treatment of acne. Cochrane Database Syst Rev. 2012 Jul 11;7:CD004425.
Cyproterone acetate 2 mg plus Ethinyl Estradiol 35 µg, oral: South African Medicines Formulary. 12th Edition. Division
of Clinical Pharmacology. University of Cape Town, 2016.
ii
NSAIDs as a therapeutic class (diclofenac, naproxen, ibuprofen): Affordable Medicines, EDP-Adult Hospital
level. NSAIDs – comparative review of efficacy and safety, 15 January 2018. http://www.health.gov.za
NSAIDs as a therapeutic class (diclofenac, naproxen, ibuprofen): Van Walsem A, Pandhi S, Nixon RM, Guyot P,
Karabis A, Moore RA. Relative benefit-risk comparing diclofenac to other traditional non-steroidal anti-inflammatory
drugs and cyclooxygenase-2 inhibitors in patients with osteoarthritis or rheumatoid arthritis: a network meta-
analysis. Arthritis Research & Therapy 2015;17:66. https://www.ncbi.nlm.nih.gov/pubmed/25879879
NSAIDs as a therapeutic class (diclofenac, naproxen, ibuprofen): Nissen SE, Yeomans ND, Solomon DH,
Lüscher TF, et al. Cardiovascular Safety of Celecoxib, Naproxen, or Ibuprofen for Arthritis. N Engl J Med
2016;375:2519-29. https://www.ncbi.nlm.nih.gov/pubmed/28379793
NSAIDs as a therapeutic class (diclofenac, naproxen, ibuprofen): Coxib and traditional NSAID Trialists’ (CNT)
Collaboration. Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses
of individual participant data from randomised trials. Lancet 2013; 382: 769–79.
NSAIDs as a therapeutic class (diclofenac, naproxen, ibuprofen): Trelle S, Reichenbach S, Wandel S,
Hildebrand P, Tschannen B, et al. Cardiovascular safety of non-steroidal anti-inflammatory drugs: network meta-
analysis. BMJ 2011;342:c7086. https://www.ncbi.nlm.nih.gov/pubmed/21224324
NSAIDs as a therapeutic class (diclofenac, naproxen, ibuprofen): Ong CKS, Lirk P, Tan Ch, Seymour RA. An
evidence-based update on nonsteroidal anti-inflammatory drugs. Clinical Medicine and Research 2007; 5(1):19-34.
NSAIDs as a therapeutic class (diclofenac, naproxen, ibuprofen): Stam WB, Jansen JP, Taylor SD. Efficacy of
etoricoxib, lumiracoxib, non-selective NSAIDs, and acetaminophen in osteoarthritis: a mixed treatment comparison.
The Open Rheumatology Journal 2012; 6:6-20. https://www.ncbi.nlm.nih.gov/pubmed/22582102
NSAIDs as a therapeutic class (diclofenac, naproxen, ibuprofen): Bello AE, Holt RJ. Cardiovascular risk with
non-steroidal anti-inflammatory drugs: clinical implications. Drug Saf. 2014 Nov;37(11):897-902.
NSAIDs as a therapeutic class (diclofenac, naproxen, ibuprofen): South African Medicines Formulary. 12th
Edition. Division of Clinical Pharmacology. University of Cape Town, 2016.
iii Intravenous antibiotics (severe cellulitis and erysipelas): Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein
EJ, Gorbach SL, Hirschmann JV, Kaplan SL, Montoya JG, Wade JC; Infectious Diseases Society of America. Practice
guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases
Society of America. Clin Infect Dis. 2014 Jul 15;59(2):e10-52. https://www.ncbi.nlm.nih.gov/pubmed/24973422
iv Cefazolin, IV: Loubet P, Burdet C, Vindrios W, Grall N, Wolff M, Yazdanpanah Y, AndremontA, Duval X, Lescure FX.
Cefazolin versus anti-staphylococcal penicillins for treatment of methicillin-susceptible Staphylococcus aureus bacteraemia:
a narrative review. ClinMicrobiol Infect. 2017 Jul 8.pii: S1198-743X(17)30358-
Cefazolin, IV: Bai AD, Showler A, Burry L, Steinberg M, Ricciuto DR, Fernandes T, Chiu A, Raybardhan S, Science M,
Fernando E, Tomlinson G, Bell CM, Morris AM. Comparative effectiveness of cefazolin versus cloxacillin as definitive
antibiotic therapy for MSSA bacteraemia: results from a large multicentre cohort study. J Antimicrob Chemother. 2015
May;70(5):1539-46. https://www.ncbi.nlm.nih.gov/pubmed/25614044
Cefazolin, IV: Perovic O, Singh-Moodley A, Govender NP, Kularatne R, Whitelaw A, Chibabhai V, Naicker P, Mbelle N,
Lekalakala R, Quan V, Samuel C, Van Schalkwyk E; for GERMS-SA. A small proportion of community-associated
methicillin-resistant Staphylococcus aureus bacteraemia, compared to healthcare-associated cases, in two South African
provinces. Eur J Clin Microbiol Infect Dis. 2017 Dec;36(12):2519-2532. https://www.ncbi.nlm.nih.gov/pubmed/28849285
Cefazolin, IV: Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, Hirschmann JV, Kaplan
SL, Montoya JG, Wade JC; Infectious Diseases Society of America. Practice guidelines for the diagnosis and management
of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014 Jul
15;59(2):e10-52. https://www.ncbi.nlm.nih.gov/pubmed/24973422
v Cefazolin, IV: Loubet P, Burdet C, Vindrios W, Grall N, Wolff M, Yazdanpanah Y, AndremontA, Duval X, Lescure FX.
2019 4.15
vi Aqueous cream and emollients: Tsang M, Guy RH. Effect of aqueous cream BP on human stratum corneum in vivo. Br J
Dermatol 2010; 163:954–8.http://www.ncbi.nlm.nih.gov/pubmed/20649794
Aqueous cream and emollients: Mohammed D, Matts PJ, Hadgraft J, Lane ME. Influence of aqueous cream BP on
corneocyte size, maturity, skin protease activity, protein content and transepidermal water loss. Br J Dermatol 2011;
164:1304–10.http://www.ncbi.nlm.nih.gov/pubmed/21443526
Aqueous cream and emollients: Danby S, Cork MJ. A new understanding of atopic dermatitis: the role of epidermal
barrier dysfunction and subclinical inflammation. J ClinDermatol 2010; 1:33–46.
Aqueous cream and emollients: Hoare C, Li Wan Po A,Williams H. Systematic review of treatments of atopic eczema.
Health Technol Assess 2000;4(37).http://www.ncbi.nlm.nih.gov/pubmed/11134919
Aqueous cream and emollients: Lewis-Jones S, Cork MJ, Clark C et al. Atopic Eczema in Children – Guideline
Consultation: A Systematic Review of the Treatments for Atopic Eczema and Guideline for its Management. London:
National Institute for Clinical Excellence (NICE), 2007.https://www.nice.org.uk/guidance/cg57
vii Potent and very potent corticosteroids, topical: Green C, Colquitt JL, Kirby J, Davidson P, Payne E. Clinical and
cost-effectiveness of once-daily versus more frequent use of same potency topical corticosteroids for atopic eczema: a
systematic review and economic evaluation. Health Technol Assess. 2004 Nov;8(47):iii,iv, 1-120.
viiiAciclovir, oral: Workowski KA, Bolan GA: Centers for Disease Control and Prevention (CDC). Sexually transmitted
diseases treatment guidelines, 2015.MMWR Recomm Rep. 2015;64; RR-3):1-140. http://www.cdc.gov/std/tg2015/tg-2015-

print.pdf
ix Aciclovir, IV: Cernik C, Gallina K, Brodell RT. The treatment of herpes simplex infections:an evidence-based review. Arch
Intern Med. 2008 Jun 9;168(11):1137-44.http://www.ncbi.nlm.nih.gov/pubmed/18541820

Aciclovir, IV: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of
Cape Town, 2016.
x Dressing: Palfreyman SJ, Nelson EA, Lochiel R, Michaels JA. Dressings for healing venous leg ulcers. Cochrane
Database Syst Rev. 2006 Jul 19;(3):CD001103. Review.Update in: Cochrane Database Syst Rev. 2014;5:CD001103.
xi Potent topical corticosteroids (therapeutic class): South African Medicines Formulary. 12th Edition. Division of

xii Potent topical corticosteroids (therapeutic class): South African Medicines Formulary. 12th Edition. Division of

xiii Potent topical corticosteroids (therapeutic class): South African Medicines Formulary. 12th Edition. Division of

xiv Fluconazole, oral:Gupta AK, Ryder JE, Johnson AM. Cumulative meta-analysis of systemic antifungal agents for the
treatment of onychomycosis.Br J Dermatol. 2004 Mar;150(3):537-44. http://www.ncbi.nlm.nih.gov/pubmed/15030339

Fluconazole:Nozickova M, Koudelkova V, Kulikova Z, Malina L, Urbanowski S, Silny W. Acomparison of the efficacy of
oral fluconazole, 150 mg/week versus 50 mg/day, in the treatment of tinea corporis, tinea cruris, tinea pedis, and cutaneous
candidosis.Int J Dermatol. 1998 Sep;37(9):703-5.http://www.ncbi.nlm.nih.gov/pubmed/9762826
Fluconazole: Faergemann J, Mörk NJ, Haglund A, Odegård T. A multicentre (double-blind)
comparative study to assess the safety and efficacy of fluconazole andgriseofulvin in the treatment of tinea corporis and
tinea cruris. Br J Dermatol.1997 Apr;136(4):575-7.http://www.ncbi.nlm.nih.gov/pubmed/91559
xv Podophyllotoxin 0.5%, topical: National Department of Health: Affordable Medicines, EDP-Adult Hospital level. Medicine
Review: Ano-genital warts, May 2018. http://www.health.gov.za/

Podophyllotoxin 0.5%, topical: Thurgar E, Barton S, Karner C, Edwards SJ. Clinical effectiveness and cost-effectiveness
of interventions for the treatment of anogenital warts: systematic review and economic evaluation. Health Technol Assess.
2016 Mar;20(24):v-vi, 1-486. https://www.ncbi.nlm.nih.gov/pubmed/27034016
Podophyllin 20% in compound tincture benzoin BP, topical: Thurgar E, Barton S, Karner C, Edwards SJ. Clinical
effectiveness and cost-effectiveness of interventions for the treatment of anogenital warts: systematic review and economic
evaluation. Health Technol Assess. 2016 Mar;20(24):v-vi, 1-486. https://www.ncbi.nlm.nih.gov/pubmed/27034016
2019 4.16
CHAPTER 5
GYNAECOLOGY
5.1 DYSMENORRHOEA
N94.4-6
DESCRIPTION
Lower abdominal pain that starts with the onset of menstruation and subsides after
menses have ended. This may be associated with headaches, nausea and vomiting. It
may be primary or secondary. Primary dysmenorrhoea is menstrual pain without
organic disease. Secondary dysmenorrhoea is associated with identifiable disease, e.g.
chronic pelvic infection, fibroids, endometriosis, adenomyosis and use of intrauterine
contraceptive device.
GENERAL MEASURES
For secondary dysmenorrhoea, investigate and treat the underlying condition.
MEDICINE TREATMENT
Symptomatic relief:
 NSAID, e.g.:
 Ibuprofen, oral, 400 mg 8 hourly with or after a meal.
OR LoE:IIIi
LoE:III
For dysmenorrhoea caused by endometriosis:
ADD
 Combined oral contraceptive and review after 3 months.
OR LoE:Iii
Medroxyprogesterone acetate (long-acting), IM, 150 mg, 12
weekly.
o Review after 3 months. LoE:IIiii
REFERRAL
» If there is uncertainty about the diagnosis.
» Young women with pain not responding to conventional treatment.
» Older (>40 years of age) women with persistent pain.
5.2 UTERINE BLEEDING, ABNORMAL (AUB)

N92.0–1
GENERAL MEASURES
All women >45 years of age with AUB should have a transvaginal ultrasound and
endometrial sampling to exclude pathology.
2019 5.1
CHAPTER 5 GYNAECOLOGY
Actively exclude organic causes, e.g. fibroids, for abnormal uterine bleeding. All women
should receive a speculum examination to rule out cervical pathology. A cervical
cytology smear should be performed if the cervix appears abnormal or if indicated
according to the national screening program.
MEDICINE TREATMENT
Dysfunctional uterine bleeding implies that no organic cause is present.
Arrest of acute haemorrhage

Progestin, e.g.:
 Norethisterone, oral, 5 mg 4 hourly until bleeding stops up to a LoE:IIIiv
maximum 48 hours.
OR
Tranexamic acid, oral, 1g 6 hourly on days 1–4 of the cycle.
LoE:Iv
After bleeding has stopped, continue with:
 Combined oral contraceptive, oral, 1 tablet 8 hourly for 7 days.
o Follow with 1 tablet once daily for 3 months.
For restoring cyclicity N92.6

For women in the reproductive years: (Z30.2)
 Combined oral contraceptive, oral, 1 tablet daily for 6 months.
OR
Alternative to combined oral contraceptives:
Progestin only: (Z30.2)
 Medroxyprogesterone acetate, oral, 30 mg daily from day 5 to LoE:IIIvi
day 26 of the cycle.
o Use for 3–6 cycles.
OR
 Norethisterone, oral, 15 mg daily from day 5 to day 26 of the cycle.
OR
 Ibuprofen, oral, 400 mg 8 hourly with or after a meal. LoE:Ivii
o Begin trial of NSAID starting on 1st day of menses until menses
cease.
OR
 Tranexamic acid, oral, 1 g 6 hourly on days 1–4 of the cycle.
LoE:Iviii
For perimenopausal women, hormone therapy (HT): N92.4
 Conjugated estrogens, oral, 0.625 mg daily for 21 days with the addition of
medroxyprogesterone acetate, oral 10 mg daily from day 11 to day 21.
o Day 22– 28 no treatment.
ADD
2019 5.2
For dysmenorrhoea and abnormal bleeding:

 Ibuprofen, oral, 400 mg 8 hourly for 2–3 days with or after a meal, depending on
severity of pain.
REFERRAL
Treatment failure - refer for consideration of levonorgestrel intrauterine system or
surgical procedures as dictated by the diagnosis.
5.3 PELVIC INFLAMMATORY DISEASE (PID)

N73.0-1/N73.9
DESCRIPTION
PID includes salpingitis with or without oophoritis and, as precise clinical localisation
is often difficult, denotes the spectrum of conditions resulting from infection of the
upper genital tract.
Sequelae include:
» recurrent infections if inadequately treated,
» infertility,
» increased probability of ectopic pregnancy, and
» chronic pelvic pain.
Stage Manifestations
Stage I » cervical motion tenderness and/or uterine
tenderness and/or adnexal tenderness
Stage II » as stage I, plus pelvic peritonitis
Stage III » as stage II, plus
» tubo-ovarian complex or abscess
Stage IV » generalised peritonitis
» ruptured tubo-ovarian complex
» septicaemia
GENERAL MEASURES
Hospitalise all patients with stage II–IV PID for parenteral antibiotic therapy.
Frequent monitoring of general abdominal and pelvic signs is essential.
Admission for parenteral therapy, observation, further investigation and/or possible
surgical intervention should also be considered in the following situations:
» a surgical emergency cannot be excluded
» lack of response to oral therapy
» clinically severe disease
» presence of a tubo-ovarian abscess
» intolerance to oral therapy
» pregnancy
2019 5.3
Further Investigation
All sexually active patients should be offered:
» a pregnancy test
» screening for sexually transmitted infections including HIV
Perform a pregnancy test, as an ectopic pregnancy forms part of the differential
diagnosis.
Note: Remove IUCDs and provide alternative contraception.
In stage III, surgery is indicated if:
» the diagnosis is uncertain,
» there is no adequate response after 48 hours of appropriate therapy,
» the patient deteriorates on treatment, or
» there is a large or symptomatic pelvic mass after 6 weeks.
MEDICINE TREATMENT
Stage I
 Azithromycin, oral, 1 g as a single dose
AND LoE:IIix
 Ceftriaxone, IM, 250 mg as a single dose.
o Dissolve ceftriaxone, IM, 250 mg in 0.9 mL lidocaine 1% without adrenaline
(epinephrine).
AND LoE:IIIx
LoE:IIIxi
 Azithromycin, oral, 2 g as a single dose
AND LoE:Ixii
Stage II–IV
 Ceftriaxone, IV, 1 g daily
AND
 Metronidazole, IV, 500 mg 8 hourly.
Continue intravenous therapy until there is definite clinical improvement (within 24-48
hours). Thereafter, change to:
 Amoxicillin/clavulanic acid, oral, 875/125 mg 12 hourly to complete 10 days
therapy.
AND LoE:IIIxiii
To treat chlamydia: A56.1+(N74.4*)
 Azithromycin, oral, 1 g, as a single dose.
Note: The addition of metronidazole to amoxicillin/clavulanic acid is unnecessary as
amoxicillin/clavulanic acid has adequate anaerobic cover.

2019 5.4
AND
 Gentamicin, IV, 6 mg/kg daily (see Appendix II for guidance on prescribing).
Continue intravenous therapy until there is definite clinical improvement (within 24-48
hours). Thereafter, change to:
AND
 Ciprofloxacin, oral, 500 mg 12 hourly to complete 10 days therapy.
To treat chlamydia: A56.1+(N74.4*) LoE:IIIxiv

Note: The addition of metronidazole to clindamycin is unnecessary as clindamycin has
adequate anaerobic cover.
REFERRAL
Stages III and IV should be managed in consultation with a gynaecologist.
5.4 ENDOMETRIOSIS
N80.0-5/N80.6/N80.9
DESCRIPTION
The presence and proliferation of endometrial tissue outside the uterine cavity, usually
within the pelvis. It may manifest as dysmenorrhoea, dyspareunia and chronic pelvic
pain. Diagnosis is made by laparoscopy.
MEDICINE TREATMENT
For pain:
 Ibuprofen, oral, 400 mg 8 hourly with or after a meal. LoE:III
AND
 Combined oral contraceptives for 6 months.
OR
 Medroxyprogesterone acetate, oral, 30 mg daily for at least 3 months.
Note: The recurrence of symptoms is common following cessation of treatment.
REFERRAL
» Women with infertility.
» No response to treatment after 3 months.
2019 5.5
5.5 AMENORRHOEA
N91.0-2
DESCRIPTION
Primary amenorrhoea: no menstruation by 16 years of age in the presence of
secondary sexual characteristics.
Secondary amenorrhoea: amenorrhoea for at least 3 months in women with previous
regular menses, or for at least 6 months in women with irregular cycles.
Investigations
» Body mass index.
» Urine pregnancy test.
» Pelvic ultrasound.
» Serum for TSH, FSH, LH, prolactin.
 FSH>15 units/L in a woman <40 years of age suggests premature ovarian
failure.
 LH/FSH ratio of >2:1 suggests polycystic ovarian syndrome.
MEDICINE TREATMENT
For treatment of hyperprolactinaemia, hypo- or hyperthyroidism, see Chapter 8:
Endocrine System.
Progestin challenge test:
If no cause for secondary amenorrhoea is found:
 Medroxyprogesterone acetate, oral, 10 mg daily for 10 days.
o Anticipate a withdrawal bleed 5–7 days following conclusion of treatment.
REFERRAL
» All cases of primary amenorrhoea.
» Secondary amenorrhoea not responding to medroxyprogesterone acetate.
» Polycystic ovarian syndrome and premature ovarian failure, for further evaluation.
5.6 HIRSUTISM AND VIRILISATION

L68.0/E25.0/E25.9
DESCRIPTION
Hirsutism refers to terminal hair growth in amounts that are socially undesirable,
typically following a male pattern of distribution. Virilisation refers to the development of
male secondary sexual characteristics in a woman.
Refer to a tertiary hospital for investigation and management.
REFERRAL
All cases.
2019 5.6
5.7 INFERTILITY
N97.9
DESCRIPTION
Inability to conceive after a year of regular sexual intercourse without contraception.
GENERAL MEASURES
Counselling.
Lifestyle modification, e.g. weight optimisation, smoking cessation and regular sexual
intercourse.
Investigations
» Partner semen analysis.
» Anti-mullerian hormone (AMH) levels to evaluate ovarian reserve (>1.1 ng/ml
suggests good ovarian reserve)
» If AMH is unavailable - Mid-luteal (day 21) progesterone assay: >30 nmol/L suggests
adequate ovulation (Specialist indication).
» Laparoscopy and/or hysterosalpingography (Specialist supervision).
MEDICINE TREATMENT
Treat the underlying disease.
For induction of ovulation, in women with confirmed anovulation:
There are two options available: letrozole or clomifene.
Note: Women should be counselled on the risk of multiple births with medicines
inducing ovulation.
Letrozole is likely to result in more pregnancies and sooner pregnancies but both
agents are effective.
Administer letrozole following a spontaneous menses or a medroxyprogesterone
acetate withdrawal bleed.
 Letrozole 2.5mg daily on days 3-7 of the cycle (Specialist only).

o Letrozole for ovulation induction is an off-label indication. Counsel patient and
obtain patient consent.
LoE:IIxv
If letrozole cannot be used:
 Clomifene, oral, 50 mg daily on days 5–9 of the cycle (Specialist only).
o Monitor the progress of ovulation.
LoE:IIxvi
For hyperprolactinaemia after further investigation:
See section 8.15.1: Prolactinoma.
2019 5.7
5.8 MISCARRIAGE
Both Manual Vacuum Aspiration (MVA) and medical evacuation are equally effective
for miscarriage. However, in the follow settings, MVA is preferred:
» septic miscarriage
» anaemia
» haemodynamic instability
» second trimester miscarriage
5.8.1 SILENT MISCARRIAGE OR EARLY FETAL DEATH

O02.1
GENERAL MEASURES
Counselling.
Evacuation of the uterus.
MEDICINE TREATMENT
Before MVA, to ripen the cervix:
 Misoprostol, PV, 400 mcg as a single dose.
Medical evacuation: (004.9)
 Misoprostol, oral/PV, 600 mcg as a single dose.
o Repeat after 24 hours if necessary.
5.8.2 INCOMPLETE MISCARRIAGE IN THE FIRST TRIMESTER

O02.1
GENERAL MEASURES
Counselling.
Evacuation of the uterus after ripening the cervix.
MEDICINE TREATMENT
Before MVA, to ripen the cervix:
 Misoprostol, oral/PV, 400 mcg as a single dose.
Medical evacuation: (004.9)
 Misoprostol, PV, 800 mcg every 3 hours for 2 doses.
OR
 Misoprostol, SL, 600 mcg every 3 hours for 2 doses LoE:IIIxvii
2019 5.8
5.8.3 MIDTRIMESTER MISCARRIAGE (FROM 13–22 WEEKS

GESTATION)
O03.4/O.03.9
GENERAL MEASURES
Counselling.
Evacuation of the uterus after the fetus has been expelled.
MEDICINE TREATMENT
If no cervical dilatation:
 Misoprostol, PV/SL/buccal, 200 mcg every 4–6 hours until expulsion of the
products of conception.
o Duration of treatment must not exceed 5 doses over 24 hours.

LoE:IIIxviii
Previous Caesarean delivery:
 Misoprostol, PV/SL/buccal 100 mcg every 4–6 hours until expulsion of the
products of conception.
o Duration of treatment must not exceed 5 doses over 24 hours.
LoE:IIxix
If cervical dilatation already present:
 Oxytocin, IV.
o Dilute 20 units in 1 L sodium chloride 0.9%, i.e. 20 milliunits/mL solution, and
infuse at 125 mL/hour.
o Reduce rate if strong contractions are experienced.
Note: Check serum sodium if used for more than 24 hours because of the danger
of dilutional hyponatraemia.
For analgesia:
 Morphine, IV, to a maximum dose of 10 mg (See Appendix II, for individual
dosing and monitoring for response and toxicity).
If Rh-negative: (O36.0)
 Anti-D immunoglobulin, IM, 100 mcg as a single dose.
REFERRAL
» Uterine abnormalities.
» Recurrent miscarriages (3 consecutive spontaneous miscarriages).
» Suspected cervical weakness: mid-trimester miscarriage(s) with minimal pain
and bleeding.
» Diabetes mellitus.
» Parental genetic defects and SLE or other causes of autoimmune disease.
5.8.4 SEPTIC MISCARRIAGE

O03.0/O08.0 + (A41.9/N71.0/R57.2)
2019 5.9
GENERAL MEASURES
Counselling.
Urgent evacuation of uterus (under general anaesthesia and not a MVA) and surgical
management of complications.
MEDICINE TREATMENT
 Oxytocin, IV.
o Dilute 20 units in 1 L sodium chloride 0.9%, i.e. 20 milliunits/mL solution
administered at a rate of 125 mL/hour.
o Reduce rate if strong contractions are experienced.
Antibiotic therapy
 Amoxicillin/clavulanic acid, IV, 1.2 g, 8 hourly.
Change to oral treatment after clinical improvement:
 Amoxicillin/clavulanic acid, oral, 875/125 mg 12 hourly for 7–10 days.
Note: The addition of metronidazole to amoxicillin/clavulanic acid is unnecessary as
amoxicillin/clavulanic acid has adequate anaerobic cover.
Severe penicillin allergy: (Z88.0) LoE:III
AND
 Gentamicin, IV, 6 mg/kg daily (see Appendix II for guidance on prescribing).
Change to oral treatment after improvement:
AND
Note: The addition of metronidazole to clindamycin is unnecessary as clindamycin has
adequate anaerobic cover.
If patient has severe sepsis, consider urgent hysterectomy.
REFERRAL
» Evidence of trauma.
» No response to treatment within 48 hours.
5.8.5 TROPHOBLASTIC NEOPLASIA (‘HYDATIDIFORM MOLE’)

O01.9
Misoprostol is not indicated in this condition because of risk of dissemination.

Send products of conception for histology.
REFERRAL
All patients.
2019 5.10
5.9 TERMINATION OF PREGNANCY (TOP)

Early ultrasound examination is more accurate than last normal menstrual period at
determining gestational age, and also of value in identifying ectopic pregnancy, molar
pregnancy or twins.
The legal criteria for TOP follow below. The clinical management for pregnancies up
to 14 weeks is the same (outpatient procedures). From 14 weeks onwards, TOP
should be done in a medical facility. Note that the gestational ages used for clinical
management differs from the legal cut-offs, e.g. a patient at 12 weeks and 1 day will
meet the legal requirements as described in the act for TOP after 12 weeks, but the
clinical management is the same as for a pregnancy from day one up to 14 weeks
(see below).
Summary of Choice of Termination of Pregnancy Act
Women eligibility
Up to 12 weeks and 0 days: On request.
From the thirteenth week (12 weeks and 1 day) up to the twentieth week (19 weeks
and 6 days): If doctor is satisfied that pregnancy was from rape or incest, or there is
risk of fetal abnormality or risk to mother’s physical or mental health or social or
economic circumstances.
More than 20 weeks (≥ 20 weeks 1 day): Doctor and second doctor or registered
midwives are satisfied that there is danger to the mother’s life, a lethal or severe fetal
malformation or fetal death.
Venue
An accredited facility with staff trained in performing TOP, designated by the Member
of Executive Council at provincial level.
Practitioner
Up to 12 weeks and 0 days: Doctor, midwife or registered nurse with appropriate
training.
From the thirteenth week (12 weeks and 1 day) up to the twentieth week (19 weeks
and 6 days): Doctor responsible for decision and prescription of medication;
registered nurse/midwife may administer medication according to prescription.
» Pre-and post-termination counselling and contraceptive counselling is essential.
» Consent of spouse/partner is not necessary.
» Consent for TOP and related procedures e.g. laparotomy may be given by minors.
Minors are encouraged to consult parents or others, but consent is not mandatory.
2019 5.11
5.9.1 TOP: MANAGEMENT OF PREGNANCIES ≤14 WEEKS OF

GESTATION
O04.9
GENERAL MEASURES
Counselling.
Outpatient procedure by nursing staff with specific training.
Discuss TOP options with patient: Manual vacuum aspiration of the uterus or
medical TOP. LoE:IIIxx
MEDICINE TREATMENT
Manual vacuum aspiration:
 Misoprostol, PV, 400 mcg 3 hours before routine vacuum aspiration of the uterus.
Routine analgesia for vacuum aspiration:
 Morphine, IM, 0.1 mg/kg 30 minutes before aspiration procedure, to a
maximum of 10 mg. LoE:IIIxxi
Do not give intravenous benzodiazepines and parenteral opioid analgesics

concurrently.
Conscious sedation - see chapter 23: Sedation.

Alternatively, consider a paracervical block:
 Use Lidocaine 1%.
o Draw up lidocaine 1% in a 20 mL syringe.
o Attach a 20-gauge spinal needle. Inject 2 mL superficially in the cervix at 12h00
and immediately grab the cervix with a tenaculum at 12h00 to stabilise cervix.
o Inject remaining 18 mL slowly over 60 seconds into the cervicovaginal junction
in four equal doses of 4–5mL at 2, 4, 8, and 10 o’clock (see diagram below).
o This injection is continuous from superficial to deep (a depth of 3 cm) and again
to superficial (injecting with insertion and withdrawal).
o Manual vacuum aspiration can start after 3 minutes.
Left
Right
Anterior view of the cervix

2019 5.12
LoE:Ixxii
Oral analgesia as required for 48 hours:
AND
 NSAID, e.g.:
Medical TOP:
Up to 12 weeks and 0 days:
 Mifepristone, oral, 200 mg, immediately as a single dose.
xxiii
Followed 1-2 days later by: LoE:I
 Misoprostol, PV/SL 800 mcg or buccal by self-administration
o If expulsion has not occurred 4 hours after misoprostol administration, a
second dose of misoprostol 400 mcg may be given.
Note: Bleeding may persist for up to 1 week. If there is no bleeding after the second
dose of misoprostol, the woman must return to the facility as soon as possible as
there is a possibility of an incomplete procedure or ectopic pregnancy.
LoE:IIIxxiv
For pain:
ADD
After expulsion is complete:
 NSAID, e.g.:
5.9.2 TOP: FROM THE THIRTEENTH WEEK (12 WEEKS AND 1

DAY) UP TO THE TWENTIETH WEEK (19 WEEKS AND 6
DAYS)
O04.9
Medical TOP: From 12 weeks onwards, inpatient care in facilities with 24-hour service
and facilities for general anaesthesia, as there is a greater risk for bleeding or a need
for surgical completion of the procedure. LoE:IIIxxv
Manual vacuum aspiration (up to 14 weeks). Misoprostol 400 mcg
administered sublingually or vaginally, 2 to 3 hours prior to the procedure for cervical
priming.
Surgical TOP (Dilatation and Evacuation procedure after cervical preparation) can be
done by specially trained providers as a day theatre procedure after 14 weeks.
GENERAL MEASURES
2019 5.13
Manual vacuum aspiration of the uterus, if expulsion of products of conception is not

complete after medical termination.
MEDICINE TREATMENT for Medical TOP

 Mifepristone, oral, 200 mg, oral, immediately as a single dose.
LoE:Ixxvi
Follow 1-2 days later with:
 Misoprostol, PV/SL/buccal, 400 mcg, every 3 hours until LoEIIxxvii
abortion occurs.
LoE:IIIxxviii
Analgesia:
 Morphine, IM, 0.1 mg/kg 4 hourly as needed, to a maximum of 10 mg.
If Rh-negative: O36.0
 Anti-D immunoglobulin, IM, 100 mcg as a single dose.
Contraception:
Counsel all women on effective contraception, especially long-acting reversible methods.
All methods can be given at the time of the procedure, with the exception of the IUCD
at a medical TOP.
REFERRAL
» Complicating medical conditions, e.g. cardiac failure, etc.
» Failed procedure.
» Ectopic pregnancy.
5.10 SEXUAL ASSAULT

T74.2 + (Y05.99)
INVESTIGATIONS
Urine pregnancy test.
Blood for:
» Syphilis serology,
» HIV, and
» Hepatitis B if no history of previous Hep B immunisation.
GENERAL MEASURES
Trauma counselling and completion of J88 forms.
Examination under anaesthesia may be required for adequate forensic sample
collection, or repair of genital tract trauma.
MEDICINE TREATMENT
Emergency contraception: (Z29.8)
 Levonorgestrel 1.5 mg, oral, preferably within 24 hours of event.
2019 5.14
Note: Emergency contraception (EC) can be given up to 5 days following an episode

of unprotected intercourse.
LoE:Ixxix
CAUTION
Emergency contraceptive tablets must be taken as soon as possible, preferably
within 72 hours of unprotected intercourse, and not later than 5 days.
Enzyme inducers (including efavirenz, carbamazepine) cause a significant
reduction in LNG concentrations. Women on these medicines should preferably
have copper IUCD EC inserted or alternatively double the dose of levonorgestrel,
because of significant reduction of LNG EC.
Women >80 kg or BMI ≥30 should be given twice the standard dose.
OR LoE:IIIxxx
 Copper IUCD, e.g.:
 Cu T 380A, within 5 days of unprotected intercourse.
An anti-emetic: (Z29.8) LoE:Ixxxi
 Metoclopramide oral, 10 mg 8 hourly as needed.
LoE:III
STI prophylaxis (Z29.8)
o For ceftriaxone IM injection: Dissolve ceftriaxone 250 mg in 0.9 mL
lidocaine1% without adrenaline (epinephrine).
AND
 Azithromycin, oral, 1 g, as a single dose. LoE:IIIxxxii
AND
 Metronidazole, oral, 2 g immediately as a single dose.
HIV post-exposure prophylaxis (PEP) (Z20.6+Z29.8)

See section10.4.2: Non-occupational post exposure prophylaxis, sexual assault and
inadvertent exposure.
5.11 URINARY INCONTINENCE
DESCRIPTION
The involuntary leak of urine. Occurs in 10-17% of all women.
Risk factors include: Age (prevalence and severity increase with age), increased parity,
obesity, smoking, caffeine intake, diabetes and menopausal vaginal atrophy.
Most common types are stress incontinence, urgency incontinence (overactive bladder)
or a mixed incontinence (features of both stress and urgency).
5.11.1 STRESS INCONTINENCE

N39.3
2019 5.15
DESCRIPTION
Incontinence that occurs with increased abdominal pressure (e.g. cough, sneeze or
laugh) in the absence of a bladder contraction.
GENERAL MEASURES
Exclude urinary tract infection or diabetes.
Pelvic examination to exclude pelvic masses, pelvic organ prolapse or menopausal
vaginal atrophy.
Stop smoking.
Manage obesity.
Reduce or avoid caffeine.
Reduce alcohol intake
Manage constipation and avoid excessive fluid intake.
Keep a bladder diary.
Pelvic floor exercises (see section 7.3.6: Overactive bladder).
MEDICINE TREATMENT
There are no pharmacological interventions to manage stress incontinence.
REFERRAL
» If any pelvic pathology, immediate referral to specialist
» If no underlying pathology, refer for bladder stress testing if no improvement with
conservative measures after 3-6 months.

5.11.2 URGENCY INCONTINENCE (OVERACTIVE BLADDER)
See section: 7.3.6: Overactive bladder.
5.12 MENOPAUSE AND PERIMENOPAUSAL SYNDROME

N95.9
GENERAL MEASURES
Counselling:
» Stop smoking.
» Maintain a balanced diet.
» Regular exercise
MEDICINE TREATMENT
Hormone therapy (HT)
Not indicated in all postmenopausal women. Women with significant menopausal
symptoms and those with osteoporosis risk factors will benefit most.
The benefits of HT need to be weighed against the potential harm (e.g. breast cancer,
venous thrombo-embolism).
Long-term follow up studies from the Women’s Health Initiative Randomised Trials
have shown that hormone replacement therapy in post-menopausal women was not
associated with an increased risk of all-cause, cardiovascular or cancer mortality.
2019 5.16
However, long-term use of hormone therapy has safety issues and stopping
treatment will result in return of menopausal symptoms.
Note: Contraindications to HT: LoE:IIIxxxiii
» Current, past or suspected breast cancer.
» Known or suspected oestrogen-dependent malignant tumours.
» Undiagnosed genital bleeding.
» Untreated endometrial hyperplasia.
» Previous idiopathic or current venous thrombo-embolism.
» Known arterial CHD.
» Active liver disease.
» Porphyria.
» Thrombophilia.
Intact uterus (no hysterectomy)

HT can be offered as sequentially opposed or continuous combined preparations.
Continuous combined preparations have the advantage of less breakthrough bleeding,
but should only be commenced once the woman has been stable on sequentially
opposed therapy for a year. Treatment should be planned for 5 years but reviewed
annually.
CONTINUOUS COMBINED THERAPY
 Estradiol/norethisterone acetate, oral, 1 mg/0.5 mg for 28 days.
OR
 Estradiol/norethisterone acetate, oral, 2 mg/1 mg for 28 days.
OR
 Conjugated estrogens, oral, 0.3–0.625 mg for 28 days.
AND
 Medroxyprogesterone acetate, oral, 2.5–5 mg daily for 28 days.
OR
SEQUENTIALLY OPPOSED THERAPY
Estradiol valerate/cyproterone acetate, oral:
 Estradiol valerate, oral, 1–2 mg for 11 days.
 Estradiol valerate/cyproterone acetate, 1–2 mg/1 mg for 10 days.
 Placebo, oral, for 7 days.
OR
 Estradiol valerate, oral, 1–2 mg daily for 21 days.
ADD
 Medroxyprogesterone acetate, oral, 5–10 mg daily from day 12–21.
o Followed by no therapy from day 22–28.
OR
 Conjugated oestrogens, oral, 0.3–0.625 mg daily for 21 days.
ADD
 Medroxyprogesterone acetate, oral, 5–10 mg daily from day 12–21.
o Followed by no therapy from day 22–28.
2019 5.17
Note:
» Start at the lowest possible dose to alleviate symptoms. The need to continue HT
should be reviewed annually. Abnormal vaginal bleeding requires specialist
consultation/referral.
» Any unexpected vaginal bleeding is an indication for excluding endometrial
carcinoma. The use of transvaginal ultrasound to measure endometrial thickness
plus the taking of an endometrial biopsy is recommended.
Uterus absent (post hysterectomy): (Z90.7)

HT is given as estrogen only:
 Estradiol valerate, oral, 1–2 mg daily.
OR
 Conjugated equine estrogens, oral, 0.3 mg daily or 0.625 mg on alternative days
up to a maximum of 1.25 mg daily.
HT is contra-indicated, poorly tolerated or ineffective:

 Fluoxetine, oral LoE:IIIxxxiv
o Initiate at 20 mg on alternate days.
o If there is no response after 12 weeks, increase the dose to 20 mg daily.
If on tamoxifen: LoE:IIIxxxv
 Citalopram, oral, 10 mg daily.
o If there is no response after 12 weeks, increase the dose to 20 mg daily.
Note:
Start at the lowest possible dose to alleviate symptoms. The need to continue therapy
should be reviewed annually.
REFERRAL
» Premature menopause, i.e. <40 years of age.
» Severe osteoporosis.
» Post-menopausal bleeding.
» Hormone-dependent cancers, thrombo-embolism, liver disease; and
unacceptable side-effects to hormone replacement therapy e.g. exacerbation of
depression, enlargement of uterine fibroids, exacerbation of endometrioses (see
section 5.4: Endometriosis).
5.13 MEDICAL MANAGEMENT OF ECTOPIC PREGNANCY

O0.0-2/O0.8-9
GENERAL MEASURES
Ruptured or suspected rupture of an ectopic pregnancy should be managed with urgent
resuscitation and surgery.
There must be certainty that there is no viable intra-uterine pregnancy.
If the initial β-hCG level is below the discriminatory zone (<1500 IU/L) to diagnose a
pregnancy on ultrasound, and transvaginal ultrasound cannot definitively identify an
2019 5.18
intrauterine or extra-uterine gestation, then serial β-hCG measurements are necessary

to document either a growing, potentially viable, or a nonviable pregnancy.
Repeat the β-hCG in 48 hours. If the level has dropped, conservative management may
be appropriate.
The minimum rise in β-hCG for a potentially viable pregnancy in women who present
with symptoms of pain and/or vaginal bleeding is 53% every 2 days.
If the level has increased by >50% or is now above the discriminatory zone, do a repeat
scan to exclude an intra-uterine pregnancy before methotrexate is administered.
LoE:IIIxxxvi
MEDICINE TREATMENT
Methotrexate should be the first-line management for women who are able to return for
follow-up and who have the following characteristics:
» haemodynamic stability and no significant pain
» an unruptured ectopic pregnancy with a mass <35 mm with no visible heartbeat
» low serum β-hCG, ideally less than 1500 IU/L but can be up to 5000 IU/L
» certainty that there is no intrauterine pregnancy
» willingness to attend for follow-up
There are single dose or multiple dose methotrexate protocols available. The single
dose protocol is less expensive, requires less intensive monitoring and does not require
folinic acid rescue. The single dose protocol is recommended for the medical
management of ectopic pregnancy. LoE:Ixxxvii
Protocol:
Day 1: Do urea, creatinine, AST and FBC to exclude abnormalities.
 Methotrexate, IM, 50 mg/m2 of body surface area (BSA).
o BSA may be calculated based upon height and weight on the day of
treatment using the formula BSA = square root ([cm X kg]/3600)
Day 4: Repeat β-hCG.

If the decrease from day 4 to day 7 is ≥15%:
» Continue with weekly β -hCG until undetectable.
If decrease <15% and patient still fulfil the criteria for medical management:
 Methotrexate, IM, 50 mg/m2 BSA.
LoE:IIIxxxviii
REFERRAL
After two doses of methotrexate, if the decline in β-hCG is still <15% on day 14, refer
for specialist care.
2019 5.19
5.14 FAMILY PLANNING REFERRALS FROM PRIMARY

CARE
5.14.1 INTRA-UTERINE CONTRACEPTIVE DEVICE

N92.1/T83.3 + (Z30.4/8/9)
GENERAL MEASURES
Where there is excessive bleeding after insertion:
» Exclude perforation of the uterus.
Abnormal bleeding for >3 months:

» Exclude cervical or pelvic infection, partial expulsion, intrauterine or ectopic
pregnancy (rare) or other pathology.
If no pathology is detected:
» Counsel.
MEDICINE TREATMENT
If no pathology is detected:
 NSAID, e.g.:
 Ibuprofen, oral, 400 mg 8 hourly with or after a meal for 5 days. LoE:Ixxxix
o Follow up and if bleeding is unacceptable, offer alternative
contraception and remove IUCD.
5.14.2 IMPLANTS
Z30.4/8/9
Failure to locate an implant (in the arm) by palpation:

» Ultrasound guided removal of deep implants must be done by specially trained
providers at regional hospitals.
5.14.3 INJECTABLE CONTRACEPTION

N92.1 + (Z30.4/8/9)
GENERAL MEASURES
Heavy or prolonged bleeding despite adequate treatment with combined oral
contraceptives:
» Do thorough gynaecological examination to exclude other pathology.
» Check haemoglobin and prescribe iron if needed. See section 2.2 Anaemia, iron
deficiency.
MEDICINE TREATMENT
 Ethinylestradiol, oral, 50 mcg daily for 3 months. LoE:III
2019 5.20
OR
Combined oral contraceptive, containing 50 mcg ethinylestradiol, oral, for 3
months.
If no response to high dose ethinylestradiol, replace with:

 NSAID, e.g.:
 Ibuprofen, oral, 400 mg 8 hourly with or after a meal for 5 days. LoE:IIIxl
If no response to NSAID, replace with:

 Tranexamic acid, oral, 500 mg 8 hourly for 4 days.
LoE:Ixli
If there is no response to above-mentioned treatment:
» Change to another method of contraception. See Primary Health Care Standard
Treatment Guidelines - Chapter 7: Family planning.
2019 5.21
References:
i Ibuprofen (ceiling effect): Laska EM, Sunshine A, Marrero I, Olson N, Siegel C, McCormick N. The correlation between blood
levels of ibuprofen and clinical analgesic response. ClinPharmacolTher. 1986 Jul;40(1):1-
7..http://www.ncbi.nlm.nih.gov/pubmed/3522030
ii Combined oral contraceptive (dysmenorrhea caused by endometriosis): Wong CL, Farquhar C, Roberts H, Proctor M. Oral
contraceptive pill for primary dysmenorrhoea. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD002120.
Combined oral contraceptive (dysmenorrhea caused by endometriosis): American College of Obstetricians and
Gynecologists. ACOG practice bulletin no. 110: noncontraceptive uses of hormonal contraceptives. Obstet Gynecol.
2010;115(1):206-218.http://www.ncbi.nlm.nih.gov/pubmed/20027071
Combined oral (dysmenorrhea caused by endometriosis): Davis L, Kennedy SS, Moore J, Prentice A. Modern combined
oral contraceptives for pain associated with endometriosis. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD001019.
iii Medroxyprogesterone acetate, IM:SchlaffWD, Carson SA, Luciano A, Ross D, Bergqvist A. Subcutaneous injection of depot
medroxyprogesterone acetate compared with leuprolide acetate in the treatment of endometriosis-associated pain. FertilSteril.
2006 Feb;85(2):314-25. http://www.ncbi.nlm.nih.gov/pubmed/16595206
Medroxyprogesterone acetate, IM:Crosignani PG, Luciano A, Ray A, Bergqvist A. Subcutaneous depot
medroxyprogesterone acetate versus leuprolide acetate in the treatment of endometriosis-associated pain. Hum Reprod 2006;
iv Progestin, oral (therapeutic class – arrest of acute haemmhorhage): James AH, Kouides PA, Abdul-Kadir R, Dietrich JE,
Edlund M, Federici AB, Halimeh S, Kamphuisen PW, Lee CA, Martínez-Perez O, McLintock C, Peyvandi F, Philipp C,
Wilkinson J, Winikoff R. Evaluation and management of acute menorrhagia in women with and without underlying bleeding
disorders: consensus from an international expert panel. Eur J ObstetGynecolReprod Biol. 2011 Oct;158(2):124-34.
v Tranexamic acid: Lethaby A, Farquhar C, Cooke I. Antifibrinolytics for heavy menstrual bleeding. Cochrane Database Syst
Rev. 2000;(4):CD000249. http://www.ncbi.nlm.nih.gov/pubmed/11034679

Tranexamic acid: Leminen H, Hurskainen R. Tranexamic acid for the treatment of heavy menstrual bleeding: efficacy and
safety. Int J Womens Health. 2012;4:413-21. http://www.ncbi.nlm.nih.gov/pubmed/22956886
Tranexamic acid: Sundström A, Seaman H, Kieler H, Alfredsson L. The risk of venous thromboembolism associated with
the use of tranexamic acid and other drugs used to treat menorrhagia: a case-control study using the General Practice
Research Database. BJOG. 2009 Jan;116(1):91-7. http://www.ncbi.nlm.nih.gov/pubmed/19016686
vi Progestin,oral (therapeutic class – restoring cyclicity): Singh S, Best C, Dunn S, Leyland N, Wolfman WL; Clinical Practice
– Gynaecology Committee, Leyland N, Wolfman W, Allaire C, Awadalla A, Best C, Dunn S, Heywood M, Lemyre M, Marcoux
V, Menard C, Potestio F, Rittenberg D, Singh S; Society of Obstetricians and Gynaecologists of Canada. Abnormal uterine
bleeding in pre-menopausal women. J ObstetGynaecol Can. 2013 May;35(5):473-9.
Progestin,oral (therapeutic class – restoring cyclicity):Sweet MG, Schmidt-Dalton TA, Weiss PM, Madsen KP. Evaluation
and management of abnormal uterine bleeding in premenopausal women. Am Fam Physician. 2012 Jan 1;85(1):35-43.
vii NSAID:Serrant-Green L. Review: non-steroidal anti-inflammatory drugs reduce menstrual pain and heavy bleeding
associated with an intrauterine device. Evid Based Nurs. 2007 Apr;10(2):48. http://www.ncbi.nlm.nih.gov/pubmed/17384100
viii Tranexamic acid, oral: Lethaby A, Farquhar C, Cooke I. Antifibrinolytics for heavy menstrual bleeding. Cochrane Database
Syst Rev. 2000;(4):CD000249. http://www.ncbi.nlm.nih.gov/pubmed/11034679

Tranexamic acid, oral: Callender ST, Warner GT, Cope E. Treatment of menorrhagia with tranexamic acid. A double-blind
trial. Br Med J. 1970 Oct 24;4(5729):214-6. http://www.ncbi.nlm.nih.gov/pubmed/4919554
ix Azithromycin: Savaris RF, Teixeira LM, Torres TG, Edelweiss MI, Moncada J, Schachter J. Comparing ceftriaxone plus
azithromycin or doxycycline for pelvic inflammatory disease: a randomized controlled trial. ObstetGynecol.2007Jul;110(1):53-
Azithromycin (LAP/ SSW/ BUBO): AmsdenGW, Gray CL. Serum and WBC pharmacokinetics of 1500 mg of azithromycin
when given either as a single dose or over a 3 day period in healthy volunteers. J AntimicrobChemother.2001Jan;47(1):61-6.
Azithromycin (LAP/ SSW/ BUBO): Sampson MR, DumitrescuTP, Brouwer KL, Schmith VD. Population pharmacokinetics
of azithromycin in whole blood, peripheral blood mononuclear cells, and polymorphonuclear cells in healthy
adults.CPTPharmacometricsSystPharmacol.2014 Mar 5;3:e103. http://www.ncbi.nlm.nih.gov/pubmed/24599342
x Lidocaine 1% without adrenaline (epinephrine): MCC registered package inserts of Kocef® 250 mg, 500 mg, 1 g; Rociject®
500 mg, 1 g; Oframax® 250 mg, 1 g.
xi Metronidazole, oral Bignell C, Fitzgerald M; Guideline Development Group; British Association for Sexual Health and HIV UK.
UK national guideline for the management of gonorrhoea in adults, 2011.Int J STD AIDS. 2011 Oct;22(10):541-7.
Metronidazole, oral: Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually transmitted
diseases treatment guidelines, 2010.MMWRRecomm Rep. 2010 Dec 17;59(RR-12):1-110. Erratum in: MMWRRecomm Rep.
2011 Jan 14;60(1):18. Dosage error in article text. http://www.cdc.gov/std/treatment/2010/
xiiAzitromycin, oral, 2 g (Severe penicillin allergy): Azithromycin: Pitsouni E, Iavazzo C, Athanasiou S, Falagas ME. Single-dose
azithromycin versus erythromycin or amoxicillin for Chlamydia trachomatis infection during pregnancy: a meta-analysis of
randomised controlled trials. Int J AntimicrobAgents.2007Sep;30(3):213-21. http://www.ncbi.nlm.nih.gov/pubmed/17596917
xiii Antibiotic therapy for stage II-IV PID: Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment
Guidelines, 2015. MMWRRecomm Rep 2015;64(No. RR-3): 1-137.

xiv Antibiotic therapy for stage II-IV PID (Severe pencillin allergy): Centers for Disease Control and Prevention. Sexually
Transmitted Diseases Treatment Guidelines, 2015. MMWRRecomm Rep 2015;64(No. RR-3): 1-137.
2019 5.22
xv Letrozole, oral: National Department of Health: Affordable Medicines, EDP-Adult Hospital level. Medicine Review:
Letrozole for infertility associated with anovulation, April 2020. http://www.health.gov.za/

Letrozole, oral: Franik S, Eltrop SM, Kremer JA, Kiesel L, Farquhar C. Aromatase inhibitors (letrozole) for subfertile
women with polycystic ovary syndrome. Cochrane Database Syst Rev. 2018;5(5):CD010287.
xvi Clomifene, oral: Franik S, Eltrop SM, Kremer JA, Kiesel L, Farquhar C. Aromatase inhibitors (letrozole) for subfertile
women with polycystic ovary syndrome. Cochrane Database Syst Rev. 2018;5(5):CD010287.
Clomifene, oral: National Department of Health: Affordable Medicines, EDP-Adult Hospital level. Medicine Review:
Letrozole for infertility associated with anovulation, April 2020. http://www.health.gov.za/
xvii Misoprostol - doses (1st trimester: incomplete miscarriage): Morris JL, Winikoff B, Dabash R, Weeks A, Faundes A, Gemzell-
Danielsson K, Kapp N, Castleman L, Kim C, Ho PC, Visser GHA. FIGO's updated recommendations for misoprostol used alone in
gynecology and obstetrics. Int J Gynaecol Obstet. 2017 Sep;138(3):363-366. https://www.ncbi.nlm.nih.gov/pubmed/28643396
xviii Misoprostol - doses (2nd trimester: incomplete miscarriage): Morris JL, Winikoff B, Dabash R, Weeks A, Faundes A, Gemzell-
xix Misoprostol - doses (2nd trimester: previous Caeserean section): Dodd JM, Crowther CA. Misoprostol for induction of labour to
terminate pregnancy in the second or third trimester for women with a fetal anomaly or after intrauterine fetal death. Cochrane Database
Syst Rev. 2010 Apr 14;(4):CD004901. https://www.ncbi.nlm.nih.gov/pubmed/20393941
Misoprostol - doses (2nd trimester: previous Caeserean section): Morris JL, Winikoff B, Dabash R, Weeks A, Faundes A, Gemzell-
xxTOP option (MVA or medical TOP): Blanchard K, Lince-Deroche N, Fetters T, Devjee J, de Menezes ID, Trueman K,
Sudhinaraset M, Nkonko E, Moodley J. Introducing medication abortion into public sector facilities in KwaZulu-Natal, South
Africa: an operations research study. Contraception. 2015 Oct;92(4):330-8. http://www.ncbi.nlm.nih.gov/pubmed/26162575
xxiMorphine, IM: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of Cape Town.
2016.
xxiiLidocaine 1% (paracervical block): Renner RM, Nichols MD, Jensen JT, Li H, Edelman AB. Paracervical block for pain control
in first-trimester surgical abortion: a randomized controlled trial. Obstet Gynecol. 2012 May;119(5):1030-7.
xxiii Mifepristone, oral (TOP - Up to 12 weeks and 0 days): Kulier R, Kapp N, Gülmezoglu AM, Hofmeyr GJ, Cheng L, Campana
A. Medical methods for first trimester abortion. Cochrane Database Syst Rev. 2011 Nov 9;(11):CD002855.
Mifepristone, oral (TOP - Up to 12 weeks and 0 days): National Department of Health: Affordable Medicines, EDP-Adult
Hospital level. Medicine Review Update: Mifepristone for medical termination of pregnancy, 20 October 2017.
Mifepristone, oral (TOP - Up to 12 weeks and 0 days): The Royal College of Obstetricians and Gynaecologist. Best practice
in comprehensive abortion care, June 2015. https://www.rcog.org.uk/globalassets/documents/guidelines/best-practice-
papers/best-practice-paper-2.pdf
xxiv Misoprostol, oral/PV (TOP - Up to 12 weeks and 0 days): World Health Organisation. Medical management of abortion,
2018. http://www.who.int/reproductivehealth/publications/medical-management-abortion/en/
xxv Medical TOP (12-20 weeks): World Health Organisation. Safe abortion: technical and policy guidance for health systems,
2012. http://www.who.int/reproductivehealth/publications/unsafe_abortion/9789241548434/en/
xxvi Mifepristone, oral (TOP - 2nd trimester): Wildschut H, Both MI, Medema S, Thomee E, Wildhagen MF, Kapp N. Medical
methods for mid-trimester termination of pregnancy. Cochrane Database Syst Rev. 2011 Jan 19;(1):CD005216.
Mifepristone, oral (TOP - 2nd trimester): National Department of Health: Affordable Medicines, EDP-Adult Hospital level.
Medicine Review Update: Mifepristone for medical termination of pregnancy, 20 October 2017. http://www.health.gov.za/
Mifepristone, oral (TOP – 2nd trimester): The Royal College of Obstetricians and Gynaecologist. Best practice in
comprehensive abortion care, June 2015. https://www.rcog.org.uk/globalassets/documents/guidelines/best-practice-
papers/best-practice-paper-2.pdf
xxvii Interval between mifepristone-misoprostol (12-24 hours for 2nd trimester TOP): Shaw KA, Topp NJ, Shaw JG, Blumenthal
PD. Mifepristone-misoprostol dosing interval and effect on induction abortion times: a systematic review. Obstet Gynecol.
2013 Jun;121(6):1335-47. https://www.ncbi.nlm.nih.gov/pubmed/23812471
xxviii Misoprostol, PV/SL/buccal (2nd trimester TOP): World Health Organisation. Medical management of abortion, 2018.
http://www.who.int/reproductivehealth/publications/medical-management-abortion/en/
xxix Levonorgestrol, oral, 1.5 mg – emergency contraception: Cheng L, Che Y, Gülmezoglu AM. Interventions for emergency
contraception. Cochrane Database Syst Rev. 2012 Aug 15;8:CD001324. http://www.ncbi.nlm.nih.gov/pubmed/22895920

xxxLevonorgesterol, oral - emergency contraception (double dose): Carten ML, Kiser JJ, Kwara A, Mawhinney S, Cu-Uvin S.
Pharmacokinetic interactions between the hormonal emergency contraception, levonorgestrel (Plan B), and Efavirenz. Infect
Dis Obstet Gynecol. 2012;2012:137192. http://www.ncbi.nlm.nih.gov/pubmed/22536010
Levonorgesterol, oral - emergency contraception (double dose): Tittle V, Bull L, Boffito M, Nwokolo N. Pharmacokinetic and
pharmacodynamic drug interactions between antiretrovirals and oral contraceptives. ClinPharmacokinet. 2015 Jan;54(1):23-34.
Levonorgesterol, oral - emergency contraception (double dose): Jatlaoui TC and Curtis KM. Safety and effectiveness data
for emergency contraceptive pills among women with obesity: a systematic review. Contraception 94 (2016) 605–611.
xxxi Copper IUD – emergency contraception: Cheng L, Che Y, Gülmezoglu AM. Interventions for emergency contraception.
Cochrane Database Syst Rev. 2012 Aug 15;8:CD001324. http://www.ncbi.nlm.nih.gov/pubmed/22895920
2019 5.23
xxxii STI prophylaxis (Ceftriaxone, IM; lidocaine 1% without adrenaline (epinephrine); azithromycin, oral; metronidazole, oral):
National Department of Health, Essential Drugs Programme: PHC STGs and EML, 2014. http://health.gov.za/
STI prophylaxis (Ceftriaxone, IM; lidocaine 1% without adrenaline (epinephrine); azithromycin, oral; metronidazole, oral):
National Department of Health. STI Guidelines, 2014. http://health.gov.za/
xxxiii Hormone therapy: Manson JE, Aragaki AK, Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Chlebowski RT, Howard BV,
Thomson CA, Margolis KL, Lewis CE, Stefanick ML, Jackson RD, Johnson KC, Martin LW, Shumaker SA, Espeland MA,
Wactawski-Wende J; WHI Investigators. Menopausal Hormone Therapy and Long-term All-Cause and Cause-Specific Mortality:
The Women's Health Initiative Randomized Trials. JAMA. 2017 Sep 12;318(10):927-938.
xxxiv Fluoxetine, oral: National Department of Health: Affordable Medicines, EDP-Adult Hospital level. Medicine Review: SSRIs
for control of menopausal symptoms in women where hormone therapy is contra-indicated, July 2018.
Fluoxetine, oral: Grant MD, Marbella A, Wang AT, Pines E, Hoag J, Bonnell C, et al. Menopausal Symptoms: Comparative
Effectiveness of Therapies [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2015 [cited 2018 Aug 30].
(AHRQ Comparative Effectiveness Reviews). Available from: http://www.ncbi.nlm.nih.gov/books/NBK285463/
xxxv Citalopram, oral (concomitant tamoxifen): National Department of Health: Affordable Medicines, EDP-Adult Hospital level.
Medicine Review: SSRIs for control of menopausal symptoms in women where hormone therapy is contra-indicated, July
Citalopram, oral (concomitant tamoxifen): Grant MD, Marbella A, Wang AT, Pines E, Hoag J, Bonnell C, et al. Menopausal
Symptoms: Comparative Effectiveness of Therapies [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US);
2015 [cited 2018 Aug 30]. (AHRQ Comparative Effectiveness Reviews). Available from:
http://www.ncbi.nlm.nih.gov/books/NBK285463/
Citalopram, oral (concomitant tamoxifen): Davari-Tanha F, Soleymani-Farsani M, Asadi M, Shariat M, Shirazi M, Hadizadeh H.
Comparison of citalopram and venlafaxine’s role in treating sleep disturbances in menopausal women, a randomized, double-blind,
placebo-controlled trial. Arch Gynecol Obstet. 2016 May;293(5):1007–13. https://www.ncbi.nlm.nih.gov/pubmed/26437957
xxxvi Management of ectopic pregnancy and miscarriage: Practice Committee of American Society for Reproductive Medicine.
Medical treatment of ectopic pregnancy: a committee opinion. Fertil Steril. 2013 Sep;100(3):638-44.
xxxvii Methotrexate, IM (Single dose protocol for ectopic pregnancy): Hajenius PJ, Mol F, Mol BW, Bossuyt PM, Ankum WM, van
der Veen F. Interventions for tubal ectopic pregnancy. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD000324.
xxxviii Methotrexate, IM: Ectopic pregnancy and miscarriage: diagnosis and initial management in early pregnancy of ectopic
pregnancy and miscarriage. National Guideline Clearinghouse [Internet]. [cited 2017 Jun 8]. Available from:
https://guideline.gov/summaries/summary/39274/ectopic-pregnancy-and-miscarriage-diagnosis-and-initial-management-in-early-
pregnancy-of-ectopic-pregnancy-and-miscarriage?q=ectopic+pregnancy.
Methotrexate, IM: Diagnosis and Management of Ectopic Pregnancy [Internet]. Royal College of Obstetricians &
Gynaecologists. [cited 2017 Jun 8]. Available from: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg21/
Renner R-M, Nichols MD, Jensen JT, Li H, Edelman AB. Paracervical block for pain control in first-trimester surgical abortion: a
randomized controlled trial. Obstet Gynecol. 2012 May;119(5):1030–7. https://www.ncbi.nlm.nih.gov/pubmed/22525915
xxxix NSAIDs (bleeding associated with IUCDs): Grimes DA, Hubacher D, Lopez LM, Schulz KF. Non-steroidal anti-inflammatory
drugs for heavy bleeding or pain associated with intrauterine-device use. Cochrane Database Syst Rev. 2006 Oct
18;(4):CD006034. https://www.ncbi.nlm.nih.gov/pubmed/17054271
xl NSAIDs (bleeding associated with injectable progestins): National Department of Health. National Contraception and Fertility
Planning and Service Delivery Guidelines, 2012. http://www.health.gov.za/

xli Tranexamic acid, oral (bleeding associated with injectable progestins): Lethaby A, Farquhar C, Cooke I. Antifibrinolytics for
heavy menstrual bleeding. Cochrane Database Syst Rev. 2000;(4):CD000249. https://www.ncbi.nlm.nih.gov/pubmed/11034679
2019 5.24
CHAPTER 6
OBSTETRICS
Note: For medical complications during pregnancy, refer to the relevant
chapters. Only common conditions specific to pregnancy, or requiring special
management in pregnancy are included in this chapter.
6.1 ANAEMIA IN PREGNANCY

O99.0 + (D50.9/D64.9)
DESCRIPTION
Haemoglobin (Hb) <11 g/dL. Anaemia in pregnancy is most commonly due to
iron deficiency. Hb levels in pregnancy should be routinely checked on-site at
the first antenatal visit, and again at 30 weeks and 38 weeks. If Hb falls below
10g/dL, commence treatment with iron and do a FBC.
LoE:IIIi
GENERAL MEASURES
A balanced diet to prevent nutritional deficiency.
Advise against eating soil, clay, charcoal, and excessive consumption of tea
and coffee.
MEDICINE TREATMENT
Prophylaxis Z34.9 + (Z29.9)
iron) daily.
OR LoE:IIIii
Ferrous fumarate, oral, 200 mg (± 65 mg elemental iron)
daily.
(For folic acid supplementation guidance to prevent neural tube defects, see
Primary Health Care STGs and EML, section 6.4.1: Antenatal supplements).
Iron deficiency (Hb <10g/dL)

 Ferrous sulfate compound BPC, oral (dried), 170 mg (± 55 mg elemental
iron) 12 hourly.
OR LoE:Iiii
Ferrous fumarate, oral, 200 mg (± 65 mg elemental iron)
12 hourly.
LoE:IIIiv
o Continue for 3–6 months after the Hb reaches normal to replenish iron
stores.
o Hb is expected to rise by at least 1.5 g/dL in two weeks.
o When using iron together with calcium supplementation, ensure that
iron and calcium are taken at least 4 hours apart from one another.
o If Hb has not increased after 4 weeks of therapy, do a FBC to confirm
hypochromic microcytic anaemia.
2019 6.1
CHAPTER 6 OBSTETRICS
Parenteral iron - See section: 2.1.1 Anaemia, iron deficiency.

If there is no response to oral iron, and iron deficiency is confirmed, review
adherence to oral iron, and consider:
 Iron, IV, e.g.:
 Iron sucrose, IV, 200 mg in 200 mL sodium chloride 0.9%, over 30
minutes, given on alternate days until the total dose has been given.
o Note: Test dose is not required, but only administer where personnel
and therapies are readily available to manage anaphylactic-type
reactions.
o An initial total dose of 600 mg is usually adequate to raise the Hb to
acceptable levels.
o For markedly anaemic or very obese women, consult the package
insert on the total dose of iron infusion.
LoE:III
No response to management.
6.2 DIABETES MELLITUS IN PREGNANCY

O24.0-4/O24.9
This condition should ideally be managed in consultation with a specialist.
DESCRIPTION
Established diabetes: Diabetes (type 1 or 2) predating pregnancy.
Gestational diabetes (GDM): carbohydrate intolerance first recognised during
pregnancy. It does not exclude the possibility that diabetes preceded the
antecedent pregnancy.
Diagnostic criteria for GDM

Either a fasting plasma glucose ≥ 5.6 mmol/L OR a plasma glucose of ≥7.8
mmol/L two hours after a 75 g oral glucose tolerance test.
The following women should be screened for GDM, between 24 and 28 weeks
of gestation:
» Women of Indian ethnic origin.
» BMI >35kg/m2.
» Age >40 years of age.
» GDM in previous pregnancy.
» Family history (first degree relative) of diabetes.
» Previous unexplained third trimester fetal death.
» Previous baby with birthweight >4 kg.
» Polyhydramnios in index pregnancy.
» Glycosuria (≥1+ glucose in urine).
» A fetus that is large for gestational age.
GENERAL MEASURES
» Stop smoking.
2019 6.2
» Moderate exercise.
» Dietary advice.
Elective delivery at about 38 weeks’ gestation.
MEDICINE TREATMENT
The mainstay of therapy is insulin. An initial trial of metformin has a role in the
following patients:
» obese women, and
» women with mild type 2 diabetes.
Even with careful selection, approximately half of patients will require addition
of insulin for adequate glucose control. LoE:Iv
 Metformin, oral, 500 mg daily.

o Increase dose to 500 mg 12 hourly after 7 days.
o Titrate dose to a maximum of 850 mg 8 hourly according to glucose
control.
o Contra-indications to metformin: liver or renal impairment.
o If not tolerated, change to insulin.
Do capillary glucose profiles, i.e. pre-prandial and 1-hour and 2-hour post-
prandial for breakfast, lunch and supper.
Aim for:
» preprandial values <5.3 mmol/L
» 1-hour postprandial <7.8 mmol/L
» 2-hour postprandial <6.4 mmol/L
LoE:Ivi
Abnormal profiles
Diabetic women should be admitted for poor glucose control, despite
metformin therapy.
Start insulin.
Insulin requirements may increase with increasing gestation and later
readmission may be necessary.
Preferred insulin regimen
 Insulin, short-acting with all 3 meals to maintain the postprandial levels.
AND
 Insulin, intermediate-acting at bedtime (with a bedtime snack) to maintain
preprandial levels.
Insulin dosing:
o Total daily dose: 0.5 units/kg/day.
o One third of the total dose: intermediate acting insulin at bedtime.
o The remaining two thirds divided into three equal doses are given
before each meal (breakfast, lunch and supper).
Adjust insulin dosage daily according to blood glucose profiles, until control is
adequate.
Where the above recommended regimen is not feasible
Twice-daily regimen with biphasic insulin.
2019 6.3
 Insulin, biphasic.
o Daily dose: 0.5 units/kg/day, two thirds, 30 minutes before breakfast and
one third 30 minutes before supper.
o Titrate to achieve target blood glucose as above. LoE:Ivii
Delivery
Consider induction of labour at 38 weeks gestation, provided glucose control is
adequate, or earlier with maternal co-morbid conditions, or if glycaemic control
is poor. If the estimated fetal weight (EFW) on ultrasound is >4 kg, offer elective
Caesarean delivery.
During labour:
Monitor serum glucose hourly.
Stop subcutaneous insulin.
Administer short-acting insulin to maintain physiological blood glucose levels.
 Insulin, short-acting, continuous IV infusion, 20 units plus 20 mmol
potassium chloride in 1 L dextrose 5% at an infusion rate of 50 mL/hour, i.e.
1 unit of insulin/hour.
o If blood glucose <4 mmol/L, discontinue insulin.
o If >7 mmol/L, increase infusion rate to 100 mL/hour.
Postpartum insulin requirements decrease rapidly.
During the first 48 hours give insulin 4-hourly according to blood glucose levels.
Resume pre-pregnancy insulin or oral hypoglycaemic regimen once eating a
full diet.
The newborn is at risk of:
» hypoglycaemia » hyperbilirubinaemia
» respiratory distress syndrome » congenital abnormalities
Postpartum management
Contraception Z30.0 + (O24.3-4/O24.9)
Tubal ligation should be considered.
Consider:
 Low-dose combined contraceptive in well-controlled cases.
 Progestin-only preparation or intra-uterine contraceptive device if planning
to breastfeed.
See Primary Health Care chapter 7: Family planning.
Need for ongoing anti-diabetic therapy
Offer women diagnosed with GDM during the index pregnancy an oral glucose
tolerance test after 6 weeks postpartum to assess whether they have diabetes
needing ongoing therapy.
» Obese women.
» Excessive fetal growth despite adequate diabetes control.
» Poor glucose control despite adequate insulin.
2019 6.4
6.3 HEART DISEASE IN PREGNANCY

O99.4 + (S151.9)
All women with heart disease require referral for specialist evaluation and risk
assessment. The risk is particularly high in women with mechanical valves,
Eisenmenger’s syndrome or pulmonary hypertension. Termination of
pregnancy (TOP) is an option for women with severe heart disease if
recommended by a specialist.
GENERAL MEASURES
All pregnant women with haemodynamically significant heart disease require
multidisciplinary management in consultation with both obstetrician and
physician/cardiologist.
Consider thyrotoxicosis, anaemia and infection, which may precipitate cardiac
failure.
Spontaneous delivery is usually preferable to Caesarean delivery, unless there
are obstetric reasons for surgery.
Women with prosthetic heart valves should be counselled about the risks of
pregnancy to themselves and fetus; and offered effective contraception.
During labour:
» Nurse in semi-Fowler’s position.
» Avoid unnecessary intravenous fluids.
» Give adequate analgesia.
» Antibiotic prophylaxis for infective endocarditis, guided by the nature of the
heart lesion (for cardiac indications and antibiotic recommendations see
section 3.5: Endocarditis, Infective). Procedures for which endocarditis
prophylaxis is indicated include:
 Vaginal delivery in the presence of suspected infection.
 Caesarean delivery.
 Assisted vaginal delivery.
 Prelabour rupture of membranes.
» Avoid a prolonged second stage of labour by means of assisted delivery
with forceps (preferably) or ventouse.
» Avoid ergometrine after delivery of the newborn.
» Observe in a high care area for 24 hours post-delivery, as the risk of
pulmonary oedema is highest in this period.
Contraception, including the option of tubal ligation should be discussed
during the antenatal period and after delivery in all women with significant
heart disease.
Women who had life-threatening complications during pregnancy should be
advised not to become pregnant again.
Anticoagulation during pregnancy:

Indications for full anticoagulation during pregnancy (high risk):
» Valvular disease with atrial fibrillation: Women with valvular heart disease
should be guided to consider completing their family early and then consider
2019 6.5
family planning including tubal ligation, before progressing to requiring

mechanical valves.
» Mechanical prosthetic heart valves: Women with mechanical prosthetic
heart valves should be offered contraception (preferably a LARC not
containing estrogen); see PHC STGs and EML, chapter 7: Family planning.
If they conceive, offer the option of TOP or refer to tertiary centre for
anticoagulation management by a multi-disciplinary team.
MEDICINE TREATMENT
For pregnant women with valvular disease and atrial fibrillation:
First trimester
 Enoxaparin SC, 1 mg/kg 12 hourly.
OR
 Unfractionated heparin, IV, 5 000 units as a bolus.
o Followed by 1 000–1 200 units/hour as an infusion.
OR
 Unfractionated heparin, SC, 15 000 units 12 hourly.
o Adjust the dose to achieve a mid-target PTT at 2–3 x control.
Practise strict infection control if using multi-dose vials, with one vial per patient
and use of needle-free adaptor.
Second trimester until 36 weeks

o Adjust dose to keep INR within the therapeutic range of 2–3.
After 36 weeks until delivery

 Enoxaparin SC, 1 mg/kg 12 hourly.
OR
 Unfractionated heparin, IV, 5 000 units as a bolus.
o Followed by 1 000–1 200 units/hour as an infusion.
OR
o Adjust dose with aPTT to keep it 2–3 x control.
Delivery
Stop heparin on the morning of elective Caesarean delivery (6 hours before
scheduled surgery) or when in established labour, and re-start 6 hours after
vaginal delivery or 12 hours after Caesarean delivery, as long as there is no
concern that the patient is bleeding.
Secondary prophylaxis for venous thromboembolism Z29.9

» More than one previous episode of venous thromboembolism.
» One previous episode without a predisposing factor, or evidence of
thrombophilia.
2019 6.6
 Enoxaparin, SC, 40 mg daily. LoE:Iviii

OR
LoE:Iix
Cardiac failure O99.4 + (I50.9)
See section 3.4: Congestive Cardiac Failure.
Treatment is as for non-pregnant women, except that ACE-inhibitors, ARBs
and spironolactone are contra-indicated. LoE:IIIx
If a vasodilator is needed:
 Hydralazine, oral, 25 mg 8 hourly.
AND
 Isosorbide dinitrate, oral, 20 mg 12 hourly.
Delivery O99.4 + (I50.0)

Contraction and retraction of the uterus after delivery increases the total
peripheral resistance, and causes a relative increase in circulating volume. This
may precipitate pulmonary oedema.
In women with NYHA grade II dyspnoea or more, consider the use of
furosemide:
 Furosemide, IV, 40 mg with delivery of the baby.
o Monitor for 48 hours thereafter for pulmonary oedema.
REFERRAL
» All pregnant women with mechanical prosthetic heart valves requiring
anticoagulation.
Pregnant women with mechanical prosthetic valves should not receive
LMWH unless antifactor Xa levels can be monitored reliably weekly.
Therapeutic range is pre-dosing level 0.6 units/mL and a 4-hour peak
level of 1–1.2 units/mL
6.4 HYPERTENSIVE DISORDERS IN PREGNANCY

O10.0/O11/O14.0-2/O14.9
DESCRIPTION
Hypertensive disorders are one of the most common direct causes of maternal
mortality and are responsible for significant perinatal and maternal morbidity.
These disorders include chronic hypertension, pre-eclampsia, eclampsia and
HELLP Syndrome. Early detection and timely intervention is essential to prevent
maternal and perinatal complications.
Preeclampsia
Preeclampsia is hypertension with significant proteinuria developing for the
2019 6.7
first time after 20 weeks of gestation, and can also be superimposed on

chronic hypertension - evidenced by the new onset (after 20 weeks’ gestation)
of persistent proteinuria in a woman who had an initial diagnosis of chronic
hypertension.
Pre-eclampsia without severe features:
A diastolic BP of 90-109 mmHg and/or systolic BP of 140-159 mmHg; but no
symptoms or organ dysfunction.
Maternal features of severe disease:
» Acute severe hypertension (diastolic BP of 110 mmHg and/or systolic >160
mmHg).
» Thrombocytopenia (platelet <100 000/μL).
» Impaired liver function (ALT or AST >40 IU/L).
» Severe persistent right upper quadrant or epigastric pain.
» HELLP syndrome (platelets <100 000 and AST >70 µl and LDH >600 µl).
» Serum creatinine ≥120 micromol/L.
» Pulmonary oedema.
» New-onset severe headache unresponsive to medication.
» Visual disturbances.
GENERAL MEASURES
Bed rest, preferably in hospital.
Lifestyle adjustment and diet.
Monitor BP, urine output, renal and liver function tests, platelet count, proteinuria
and fetal condition.
Consider delivery when risks to mother outweigh risks of prematurity to baby.
MEDICINE TREATMENT
Treatment
Antihypertensives
Medicine treatment will be dictated by blood pressure response.
Monitor progress until a stable result is achieved.
In general, diuretics are contra-indicated for hypertension in pregnant women.
When needed, combine drugs using lower doses when BP >160/100 mmHg,
before increasing single medication doses to a maximum.
LoE:IIIxi
 Methyldopa, oral, 250 mg 8 hourly as a starting dose.
o Increase to a maximum of 750 mg 8 hourly, according to response.
AND/OR LoE:IIIxii
 Amlodipine, oral, 5 mg daily.
o Increase to 10 mg daily.
Hypertensive emergency O10.0

SBP ≥160 mmHg and/or DBP ≥110 mmHg. Admit to a high-care setting for close
monitoring.
 Nifedipine, oral, 10 mg.
2019 6.8
o Repeat after 30 minutes if needed, until systolic blood pressure <160

mmHg and diastolic blood pressure <110 mmHg.
o Swallow whole. Do not chew, bite or give sublingually.
LoE:IIIxiii
If unable to take oral or inadequate response:
 Labetalol, IV infusion, 2 mg/minute to a total of 1–2 mg/kg.
o Reconstitute solution as follows:
- Discard 40mL of sodium chloride 0.9% from a 200mL container.
- Add 2 vials (2 x 100 mg) of labetalol (5 mg/mL) to the remaining 160
mL of sodium chloride 0.9% to create a solution of 1 mg/mL.
- Start at 40mL/hour to a maximum of 160 mL/hour.
- Titrate against BP – aim for BP of 140/100 mmHg.
o Once hypertensive crisis has been resolved, switch to an oral preparation.
LoE:Ixiv
Delivery
 Oxytocin, IM, 10 units as a single bolus after delivery of the baby.
LoE:IIIxv
Ergot-containing medicines are contraindicated in hypertensive women,
including pre-eclampsia, following delivery of the baby.
Pre-eclamptic and eclamptic women are often hypovolaemic, particularly
when the haematocrit exceeds 40%, but are also susceptible to pulmonary
oedema. Consequently, hypotension is a risk during anaesthesia. Careful
infusion of IV fluids is important. Limit blood-loss at Caesarean section.
Prevention of pre-eclampsia O10.0/O24.0-3/O99.1/O99.8 + (D68.6/M32.9)

For women at high risk of pre-eclampsia, e.g. pre-eclampsia in a previous
pregnancy, chronic hypertension, diabetes, antiphospholipid syndrome or SLE.
From 6 weeks’ gestation onwards, preferably before 16 weeks gestation:

 Aspirin, oral, 150 mg daily. LoE:Ixvi
At confirmation of pregnancy
 Calcium, oral.
o For high-risk patients: Calcium carbonate, oral, 500 mg 12 hourly
(equivalent to 1 g elemental calcium daily).
o Although the benefit is greatest in high-risk women, consider use of this
agent in all pregnant women.
o When using iron together with calcium supplementation, ensure that iron
and calcium are taken at least 4 hours apart from one another.
LoE:Ixvii
Prevention of eclampsia
To prevent eclamptic seizures, magnesium sulfate is recommended for patients
with severe features. In some cases this allows for delivery to be delayed to
improve neonatal outcome. When used for prevention of eclampsia, magnesium
sulfate is administered for 24 hours, and then stopped. The same dose regimens
are used as for eclampsia. Women with severe features should be managed
2019 6.9
under specialist care.
6.5 ECLAMPSIA
O11/O14.0-2/O14.9/O15.0-2/O15.9
DESCRIPTION
Generalised tonic-clonic seizures after 20 weeks of pregnancy and within 7 days
after delivery associated with hypertension and proteinuria. Exclude any other
obvious cause of the seizure before making the diagnosis. Management will
include preventing further seizures, controlling the blood pressure, referral to a
high-care unit and delivery of the baby if not already post-delivery.
GENERAL MEASURES
Place patient in left-lateral position.
Clear airway. If necessary, insert oropharyngeal airway.
Abort seizures with magnesium sulfate.
MEDICINE TREATMENT
If necessary:
 Oxygen via nasal prongs or face mask to maintain a saturation of >90%.
Treatment
Where infusion pumps are not available:
 Magnesium sulfate, IV, 4 g in 200 mL sodium chloride 0.9% over 20 minutes.
Follow with:
 Magnesium sulfate, IM, 5 g every 4 hours administered at different sites,
until 24 hours after delivery or following the last convulsion.
In high-care setting:
 Magnesium sulfate, IV, 4 g in 200 mL sodium chloride 0.9% over 20 minutes
(loading dose).
Follow with:
 Magnesium sulfate, IV infusion, 1 g every hour, until 24 hours after delivery,
or after the last convulsion (maintenance dose).
STOP MAGNESIUM SULFATE IF KNEE REFLEXES BECOME ABSENT OR
IF URINE OUTPUT <100 ML/ 4 HOURS OR RESPIRATORY RATE <16
BREATHS/MINUTE.
IF RESPIRATORY DEPRESSION OCCURS:

 Calcium gluconate 10%, IV, 10 mL given slowly at a rate not exceeding
5 mL/minute.
Recurrent eclamptic seizure despite magnesium sulfate loading dose
administration:
 Magnesium sulfate, IV, 2 g over 10 minutes.
2019 6.10
For agitated and restless women with eclampsia:

 Lorazepam, IV/IM, 4 mg.
o Maximum dose: 8 mg.
OR
Clonazepam, IV, 2 mg.
o May be repeated after 5 minutes.
o Maximum dose: 4 mg.
OR
If above not available:
Diazepam, IV, 10–20 mg, not faster than 2 mg/minute.
Notify the person who will resuscitate the newborn that a

benzodiazepine and/or magnesium has been given to the mother.
REFERRAL
Refer all eclampsia cases to a high or intensive care facility.
6.6 CHRONIC HYPERTENSION

O10.0-4/O10.9
GENERAL MEASURES
No alcohol should be taken.
Regular moderate exercise, e.g. 30 minutes brisk walking at least 3 times a
week.
Smoking cessation.
Aim to keep BP <140/90 mmHg.
Screen for end-organ damage.
Fetal surveillance by symphysis-fundus height (SFH) growth.
Ask mother about fetal movements at each antenatal visit.
Consider labour induction if:

» BP persistently 160/110 mmHg, or
» pregnancy of ≥38 weeks duration, or
» in the presence of maternal or fetal compromise, e.g. poor SFH growth and
oligohydramnios, etc.
MEDICINE TREATMENT
See prevention and treatment of pre-eclampsia.
Switch ACE-inhibitors and diuretics to methyldopa and/or amlodipine. Women
should be advised that there is an increased risk of congenital abnormalities if
ACE-inhibitors were taken during pregnancy.
2019 6.11
6.7 HIV IN PREGNANCY

O98.7 + (Z21/B24)
Consult the most recent National Department of Health Guideline for the
Prevention of Mother to Child Transmission of Communicable Infections
https://www.knowledgehub.org.za/elibrary/guideline-prevention-mother-child-
transmission-communicable-infections
All pregnant women should receive routine counselling and voluntary HIV
testing at their very first antenatal visit.
All women who test negative should be offered repeat HIV testing at every
routine visit throughout pregnancy (8 visits in all), at labour/delivery, at the 6-
week EPI visit and three monthly throughout breastfeeding.
HIV-infected pregnant women upon diagnosis, should be clinically staged, and
have a blood sample taken for CD4 cell count and serum creatinine taken on
the same day. The result must be obtained within a week.
Postpartum contraceptive use should be discussed in the antenatal period.
All women should be educated during the antenatal period about the benefits of
exclusive breastfeeding for the first 6 months and breastfeeding with
complimentary feeding from 6 months until at least 2 years after delivery (Only
in circumstance where the mother has confirmed 2nd or 3rd line ART regimen
failure (VL >1000 copies/mL), advise not to breastfeed and prescribe
replacement feeds).
All pregnant women should have a TB symptom screen at each visit, with further
TB investigations if any of the answers to the screening questions are positive.
A TB geneXpert test must be done for all pregnant women with a new diagnosis
of HIV disease, or known HIV positive women with a new pregnancy diagnosis.
Patients should be screened and treated for syphilis and other STIs, in line with
basic antenatal care.
Initiate lifelong ART in all pregnant or breastfeeding women on the same day of
diagnosis regardless of CD4 count or infant feeding practice.
Provide adequate support and counselling, particularly addressing ART
adherence.
Assist women with unwanted pregnancies <20 weeks’ gestation with access to
TOP services.
MEDICINE TREATMENT
» Patients should receive ART at the first antenatal visit, whether newly
diagnosed or known to be living with HIV but not on ART.
» Perform a baseline ALT and serum creatinine at commencement of ART.
» Tenofovir should not be used in pregnant women with a calculated creatinine
clearance <60 mL/minute or a serum creatinine ≥85 micromol/L (the latter is
a more sensitive measure of renal impairment in pregnancy).
2019 6.12
» Pregnant women may be initiated on/switched to dolutegravir-containing

regimen after 6 weeks gestational age. Counsel appropriately on the risk of
NTDs in subsequent pregnancies and effective postpartum contraception to
enable patient to make an informed choice of ART-regimen. Switching
between TEE and TLD regimens with a VL <50 copies/mL in the last 6
months. See section 10.1: Antiretroviral therapy.
» Initiate antenatal supplementation (see PHC STGs and EML, section 6.4.1:
Antenatal supplements), noting that calcium and DTG should not be taken
together on an empty stomach, but can be taken together with food.
» Test partner for HIV and perform routine cervical cancer screening.
1st ANC visit

Pregnant women >6 weeks gestation - not on  TDF, oral, 300 mg daily.
ART, with normal renal function, without TB, AND
with no desire for more children and who  3TC, oral, 300 mg daily.
chooses to use DTG after understanding the risk
AND
and benefits.
 DTG, oral, 50 mg daily.
(DTG associated with NTDs, ≤6 weeks gestation) Provided as a fixed dose
combination (FDC).
Pregnant women >6 weeks gestation - not on  TDF, oral, 300 mg daily.
ART, with normal renal function, with TB, with no AND
desire for more children and who chooses to use  3TC, oral, 300 mg daily.
DTG after understanding the risk and benefits.
AND
(DTG requires boosting with TB treatment)  DTG, oral, 50 mg daily.
Provided as a fixed dose
combination (FDC).
WITH
DTG, oral 50 mg 12 hours later.
Pregnant women ≤6 weeks gestation, or  TDF, oral, 300 mg daily.
planning a pregnancy after this one. AND
 FTC, oral, 200 mg daily.
AND
 EFV, oral, 600 mg at night.
Provided as a fixed dose
combination (FDC).
Pregnant woman already on TDF+3TC+DTG Chooses to remain on
and understands the risk and benefits of DTG. TDF+3TC+DTG:
Enter in antiretroviral pregnancy
(Document in the antiretroviral pregnancy
register
register http://www.APRegistry.com/)
http://www.APRegistry.com/
Pregnant woman (>6 weeks gestation) already Chooses to switch to
on TDF + FTC + EFV and understands the risk TDF+3TC+DTG:
and benefits of DTG. » Switch only if VL is <50
Obtain consent for DTG use (Document in copies/mL in the last 6 months
patient’s clinical notes, sign notes and provide
patient with medicine information leaflet)xviii
2019 6.13
Pregnant woman already on ART with a VL See section 10.1: Antiretroviral

between 50-1000 copies/ml Therapy
2nd ANC visit ( 1 week later)

Creatinine ≤85 micromol/L Continue ART as a FDC
Creatinine >85 micromol/L Stop FDC:
(TDF is contraindicated) TDF+FTC/3TC+EFV/DTG
Replace TDF with ABC:
 ABC, oral, 600 mg daily
Active psychiatric illness Replace EFV with DTG
(EFV may be contraindicated; consult an HIV
specialist and/or psychiatrist, if required) If DTG not suitable:
Replace EFV with LPV/r, oral,
400/100 mg 12 hourly
O98.7 + (Z21/B24 + 099.3 +F-ICD10 code)
LoE:IIIxix
Caesarean Delivery (CD):
Provide antibiotic prophylaxis to all pregnant women, including HIV-infected
pregnant women prior to surgery (See chapter 11: Surgical antibiotic prophylaxis).
Women with the following risk factors may be at higher risk of infection post
Caesarean delivery:
» Advanced immunosuppression.
» Prolonged rupture of membranes (>18 hours).
» Multiple vaginal examinations during labour (>5 PVs).
» Second stage CD.
Monitor carefully and treat infection appropriately.
HIV-infected pregnant women not on ART undergoing elective Caesarean
delivery/or in labour:
 NVP, oral, 200 mg as a single dose.
WITH
 TDF, oral, 300 mg as a single dose.
AND
 3TC, oral, 300 mg as a single dose.
AND
 DTG, oral 50 mg as a single dose (as a FDC 4 hours before Caesarean delivery).
Followed by lifelong:
 TDF+3TC+DTG (provided as a FDC), provided the mother has been
adequately counselled on the risk of NTDs in subsequent pregnancies and
effective postpartum contraception.
If the mother chooses not to use effective contraception and is of child-bearing
potential or has fertility intentions:
 TDF+ FTC+EFV (provided as a FDC). LoE:IIIxx
For management of the HIV-exposed infant, see PHC STG and EML, section 11.5.
For more information on HIV management, see section 10.1: Antiretroviral Therapy.
2019 6.14
6.8 SYPHILIS
O98.1
DIAGNOSTIC CRITERIA
Most pregnant women are asymptomatic.
See Primary Health Care STGs and EML, section 12.8: Syphilis serology and
treatment.
GENERAL MEASURES
Inform contact(s).
MEDICINE TREATMENT
Mother (treat as either early or late latent/unknown or early stage of syphilis):
For late latent syphilis or syphilis of unknown duration
 Benzathine benzylpenicillin (depot formulation), IM, 2.4 million units diluted
in 6 mL 1% lidocaine without adrenaline (epinephrine), weekly for 3 doses.
Note: If the mother has received <3 doses, treat the baby for congenital syphilis.
xxi
For early syphilis LoE:III
 Benzathine benzylpenicillin (depot formulation), IM, 2.4 million units diluted
in 6 mL 1% lidocaine without adrenaline (epinephrine), immediately as a
single dose.
Severe penicillin allergy (Z88.0)
For penicillin sensitive pregnant women: penicillin desensitisation.
(See page xxxi for detailed information).
Oral penicillin desensitisation regimen.
A: Reconstitute phenoxymethylpenicillin 250mg/ 5mL
Step Medicine mg/mL Amount to administer (mL)
Strictly B: To make 0.5 mg/mL solution
every 15 Dilute 0.5 mL of reconstituted phenoxymethylpenicillin solution in 49.5 mL
minutes water.
1 0.1 mL
2 0.2 mL
3 0.5 mg/mL solution 0.4 mL
4 (1000 units/mL) 0.8 mL
5 1.6 mL
6 3.2 mL
7 6.4 mL
C: To make 0.5 mg/mL solution
Dilute 1 mL of reconstituted phenoxymethylpenicillin solution in 9 mL water.
8 1.2 mL
9 5 mg/mL solution 2.4 mL
10 (10000 units/mL) 4.8 mL
D: Reconstituted phenoxymethylpenicillin 250 mg/5 mL = 50 mg/mL
11 1.0 mL
12 50 mg/mL 2.0 mL
13 (80000 units/mL) 4.0 mL
14 8.0 mL
2019 6.15
After step 14, observe for 30 minutes, then 1.0 g IV; Interval between doses: 15 minutes.
Asymptomatic, well baby:
Mother has syphilis and has not been treated, or was only partially treated:
 Benzathine benzylpenicillin (depot formulation), IM, 50 000 units/kg as a
single dose into the antero-lateral thigh.
Symptomatic baby
 Procaine penicillin, IM, 50 000 units/kg daily for 10 days. (Not for IV use).
OR
Benzylpenicillin (Penicillin G), IV, 50 000 units/kg, 12 hourly for 10 days.
6.9 HEPATITIS B IN PREGNANCY

O98.0
DESCRIPTION
Hepatitis B virus (HBV) is transmitted sexually or by percutaneous exposure
to infectious body fluids, i.e. blood, saliva, vaginal fluid & semen. Diagnosis is
confirmed serologically by a positive hepatitis B surface antigen (HBsAg).
Screening in pregnancy for HBsAg should ideally be performed in the first
trimester. HBeAg positive pregnant women are more infectious than HBsAg
positive women, as they have higher rates of HBV replication and perinatal
transmission.
GENERAL MEASURES
Screen sexual contact(s); if they are sero-negative, give hepatitis B vaccination.
All infected patients should be counselled with regard to lifestyle modifications
to reduce hepatotoxicity, including alcohol, substance abuse, and co-
prescription of herbal and traditional medicines.
MEDICINE TREATMENT
Indications for medical therapy in HIV-uninfected pregnant women are the
same as for non-pregnant adults.
» For management of chronic hepatitis B, without chronic HIV infection, see
section 1.2.4.2 Hepatitis B, chronic (non-HIV coinfection).
» For management of chronic hepatitis B with chronic HIV infection, see chapter
10: HIV and AIDS. (ART should include ARV active against hepatitis B).
Note:
» Ensure normal renal function before starting treatment with tenofovir
(serum creatinine <85 micromol/L or creatinine clearance >60 mL/minute).
» Monitor ALT and HBV DNA viral load at 6 months after commencing
treatment.
» An adequate virological response is an HBV DNA VL<2000 IU/mL.
Prevention of perinatal transmission
» Caesarean delivery is reserved for obstetric indications only.
2019 6.16
» Babies born to mothers with acute hepatitis B infection at the time of delivery
or to mothers who are HBsAg-positive or HBeAg-positive, see Primary
Health Care STGs and EML, section 6.6.5: Hepatitis B exposed infant.
REFERRAL
» Cirrhosis.
» Liver failure.
» Renal dysfunction (eGFR <60 mL/minute).
» Treatment failure.
» Refer all infected babies to a specialist paediatrician for further
management.
6.10 JAUNDICE IN PREGNANCY

O26.6
DESCRIPTION
The most common causes of jaundice in pregnancy are not pregnancy-
specific. They include viral hepatitis, and adverse drug reactions.
Pregnancy-specific causes include:
» intrahepatic cholestasis of pregnancy,
» acute fatty liver of pregnancy (acute yellow atrophy of the liver),
» severe pre-eclampsia or eclampsia, and
» hyperemesis gravidarum.
REFERRAL
All, as certain causes of jaundice in pregnancy have a high mortality.
6.11 HYPEREMESIS GRAVIDARUM

O21.0/1/9
DESCRIPTION
Recurrent vomiting leading to ketosis, generally in the first trimester.
Exclude:
» medical causes, e.g. thyrotoxicosis, and
» molar pregnancy.
GENERAL MEASURES
Counselling.
Frequent small, dry meals.
Avoid fatty and spicy foods.
Restrict oral intake for 24–48 hours, but ensure adequate intravenous hydration.
MEDICINE TREATMENT
Correct electrolyte imbalance with IV fluids.
 Pyridoxine, oral, 25 mg 8 hourly.
2019 6.17
AND
 Metoclopramide, oral/IV, 10–20 mg 6 hourly as needed.
AND
 Vitamin B complex, IV, 10 mL.
In refractory cases:
Administer daily until hyperemesis is controlled:
 Dexamethasone, IM/IV, 4–8 mg daily.
AND
 Ondansetron, IV, 4–8 mg over 5 minutes, daily.
o Note: There is uncertainty regarding the safety of ondansetron in the first
trimester. Use with caution and only when necessary. LoE:IIIxxii
6.12 PRETERM LABOUR (PTL) AND PRETERM

PRELABOUR RUPTURE OF MEMBRANES (PPROM)
O60.0/O42.2/O60.0
DESCRIPTION
Preterm: <37 weeks’ gestation.
Most problems occur at <34 weeks’ gestation.
Confirm ruptured membranes by sterile vaginal speculum.
Preterm labour confirmed by regular uterine contractions with progressive
cervical changes.
GENERAL MEASURES
Assess fetal wellbeing.
Estimate fetal weight.
Deliver if chorio-amnionitis suspected.
MEDICINE TREATMENT
If gestation <34 weeks:
Pre-hydrate before administration of nifedipine:
 Sodium chloride 0.9%, IV, 200 mL.
AND
 Nifedipine, oral, 20 mg.
o If contractions persist, follow with 10 mg after 30 minutes then 10 mg 4
hourly for up to 48 hours.
If gestation <32 weeks and where nifedipine contra-indicated:
 Indomethacin, oral, 50 mg immediately then 25 mg 4 hourly for up to 48 hours.
Note: Indomethacin may cause oligohydramnios, and its LoE:Ixxiii
use is associated with a risk of premature closure of the
ductus arteriosus. Use only if there is intolerance to nifedipine.
To improve fetal lung maturity at 26–34 weeks: (Z29.2)
 Betamethasone, IM, 12 mg, 2 doses 12–24 hours apart. LoE:Ixxiv
2019 6.18
If betamethasone is not available:

 Dexamethasone, IM, 8 mg, 3 doses 8 hours apart. LoE:IIIxxv
Note: Corticosteroids are maximally effective about 24 hours after
administration of the first dose. Therefore, give as soon as possible following
diagnosis of PTL or PPROM.
Antibiotic therapy (Z29.2)
Indicated routinely for PPROM only:
 Amoxicillin, oral, 500 mg 8 hourly for 5 days.
AND
LoE:Ixxvi
 Azithromycin, oral, 500 mg daily for 3–5 days
AND LoE:IIIxxvii
Prepare for appropriate care of preterm infant.
REFERRAL
» Fetus that may require neonatal intensive care, e.g. estimated weight <1.5
kg or gestation <32 weeks.
» Fetus requiring specialised treatment after birth, e.g. surgery.
» Severely ill mother.
6.13 PREVENTION OF PRETERM LABOUR (SINGLETON

PREGNANCIES ONLY)
Z35.2
DESCRIPTION
Women with a previous spontaneous preterm delivery are at higher risk for
preterm delivery in the next pregnancy. In certain high-risk cases, pregnancy
may be prolonged by the careful consideration of either cervical cerclage or
vaginal progesterone therapy.
The following high-risk women should undergo cervical screening and offered
a choice of cerclage or progesterone:
» A history of 2nd trimester miscarriage (between 16 and 26 weeks) suggestive
of cervical incompetence: (Painless dilatation with a quick labour, and birth
of a live baby or fresh stillbirth) after excluding other causes of mid-trimester
losses, e.g. intra-uterine death that required induction, abruptio placentae,
fetal abnormalities, polyhydramnios, and medical terminations.
» Previous history of spontaneous preterm birth between 27 and 34 weeks
(exclude non-spontaneous causes e.g. iatrogenic delivery for pre-
2019 6.19
eclampsia, or syphilis). No need to refer previous late preterm deliveries (34-

37 weeks).
Do not screen low-risk women routinely, as it is not cost-effective.
GENERAL MEASURES
Cervical length must be measured by a skilled operator using transvaginal
ultrasound.
Cervical measurement can be done between 16 and 24 weeks.
A cervical length of ≤25 mm indicates a higher risk for recurrent preterm labour.
Discuss the risks and benefits of both options with the patient to make an
informed shared decision of the most appropriate treatment.
MEDICINE TREATMENT
Women should be counselled that 20 cerclage procedures will prevent one
preterm delivery (NNT 17 to 20) and that progesterone is successful in 1 out of
every 8 cases (NNT 6 to 8), to assist them in making an LoE:Ixxviii
informed decision.
Consider prophylactic vaginal progesterone or cervical cerclage (MacDonald

suture) for women with:
» history of spontaneous preterm birth (27-34 weeks) or mid-trimester loss
(16-24 weeks), and
» cervical length ≤ 25 mm confirmed on ultrasound (16-24 weeks).
 Progesterone, PV, 200 mg daily. LoE:Ixxix
o Stop treatment at 34 weeks and refer to antenatal
services at primary level of care for further management.
(Note: Vaginal progesterone may be considered for high-risk women with a
normal cervix length on ultrasound).
Consider prophylactic cervical cerclage (MacDonald suture) only for women with:
» cervical length ≤ 25 mm confirmed on ultrasound (16-24 weeks),
AND
» history of preterm prelabour rupture of membranes (PPROM), or
» history of cervical trauma.
Rescue cerclage:
» If the cervix is already open and the membranes exposed, but unruptured,
consider a rescue cervical cerclage (16-27 weeks).
» Do not insert a rescue cerclage if there are contractions, active vaginal
bleeding or signs of infection.
Cerclage should be removed at 36 weeks, and thereafter the patient can
be referred to antenatal services at primary level of care. LoE:Ixxx
REFERRAL
Women with recurrent losses and previous cerclage that torn out (severe
cervical trauma), as they may require an abdominal cerclage.
2019 6.20
6.14 SUPPRESSION OF LABOUR FOR FETAL DISTRESS

O68.9 + (Z51.2)
DESCRIPTION
Tocolysis is useful to treat fetal distress in labour and to suppress labour in
women needing transfer or awaiting Caesarean delivery. Also used prior to
external cephalic version.
MEDICINE TREATMENT
 Salbutamol bolus, 250 mcg IV, slowly over 2 minutes.
o Reconstitute the solution as follows:
– Add 1 mL (i.e. 0.5 mg/mL) salbutamol to 9 mL sodium chloride 0.9%
to make a solution of 50 mcg/mL. Administer 5 mL (250 mcg) of this
solution.
– Monitor pulse. Do not administer if mother has cardiac disease.
– Place the mother in the left lateral position.
– If pulse increases >120 bpm, discontinue salbutamol.
LoE:Ixxxi
6.15 LABOUR INDUCTION

Z35.9/Z51.2
If induction of labour is indicated, for medical reasons, for example pre-

eclampsia, diabetes, or post-term pregnancy.
GENERAL MEASURES
Counsel the woman about the risks: failed induction or uterine hyperstimulation
syndrome, which may require emergency Caesarean delivery.
Cervix favourable and confirmed HIV-uninfected mother

Artificial rupture of the membranes.
Cervix unfavourable (Bishop score <7)

Extra-amniotic Foley catheter with/without saline infusion:
Pass a Foley catheter with 30 mL bulb through cervix with sterile technique.
Inflate bulb with 50 mL water or sodium chloride 0.9%.
Tape catheter to thigh with light traction.
Alternatively, attach sodium chloride 0.9% 1 L with giving set to catheter, and
infuse sodium chloride 0.9% at 50 mL/hour. Remove after 24 hours.
LoE:III
MEDICINE TREATMENT
Cervix unfavourable (Bishop score <7)
Extra-amniotic Foley catheter (as above) PLUS one of the options below:
LoE:Ixxxii
Prostaglandins, e.g.:
2019 6.21
 Dinoprostone gel, intravaginally, 1 mg.

o Repeat after 6 hours.
o Do not exceed 4 mg.
OR
 Dinoprostone tablets, intravaginally, 1 mg.
o Repeat after 6 hours.
o Do not exceed 4 mg. LoE:IIIxxxiii
OR
 Misoprostol, oral, 20 mcg 2 hourly until in labour, or up to 24 hours.
o Oral misoprostol may be given as freshly made-up solution of one 200
mcg tablet in 200 mL water, i.e. 1 mcg/mL solution. Give 20 mL of this
solution 2 hourly.
o Stop misoprostol administration when in established labour.
o Maximum 24 hours.
o Never use oxytocin and misoprostol simultaneously.
o Misoprostol and other prostaglandins are contraindicated in women with
previous Caesarean sections and in grand multiparous women.
Note:
» Misoprostol in larger doses than indicated here for labour induction at term,
may cause uterine rupture.
» Only to be prescribed by a doctor experienced in Maternal Health.
Non-stress test and cardiotocography:

Note: Perform a non-stress test (NST), before starting the induction, and
cardiotocography (CTG) within an hour of each dinoprostone insertion, to
evaluate the fetal condition during labour induction.
When using oral misoprostol, do a baseline NST before commencing IOL,
followed by CTG 4-hourly (prior to every alternate dose).
Repeat CTG once contractions have started, or more frequently only if
clinically indicated. LoE:III
Cervix favourable (Bishop score ≥7)

Amniotomy followed 2 hours later by:
 Oxytocin, IV, 2 units in 200 mL sodium chloride 0.9%. LoE:IIIxxxiv
o Start at an infusion rate of 12 mL/hour (i.e. 2
milliunits/minute). If absent or inadequate contractions, increase infusion
rate according to the table below:
2019 6.22
Time after starting Oxytocin dose Dilution: 2 units in 200

(minutes) (milliunits/minute) mL sodium chloride
0.9% (mL/hour)
0 2 12
30 4 24
60 6 36
90 8 48
120 10 60
150 12 72
180 14 84
210 16 96
240 18 108
270 20 120
Note:
» It is safe to perform amniotomy in pregnant women with HIV on ART who
have an undetectable plasma VL at delivery. LoE:IIxxxv
» Avoid oxytocin in women with previous Caesarean section
or parity ≥5.
» Continuous electronic fetal heart rate monitoring is essential.
» Aim for adequate uterine contractions (3–5 contractions in 10 minutes).
Once adequate contractions achieved, do not increase rate further.
» Most women will experience adequate contractions at a dose of 12
milliunits/minute.
» If tachsystole develops (>5 contractions in 10 minutes), reduce or stop the
oxytocin infusion to achieve 3-5 contractions in 10 minutes. If there are fetal
heart rate abnormalities which persist despite stopping the oxytocin,
administer salbutamol as above.
6.16 LABOUR PAIN, SEVERE

O62.9 +(Z51.2)
GENERAL MEASURES
Antenatal counselling.
Psychological support from family member, friend or volunteer ‘doula’.
The need for analgesics may be reduced by keeping the woman informed
about the progress of labour, providing reassurance and carefully explaining
the procedures performed.
Anticipate the need for analgesia rather than waiting for severe distress.
MEDICINE TREATMENT
 Pethidine, IM, 1 mg/kg 4 hourly as needed, to a maximum of 100 mg.
OR
LoE:IIIxxxvi
Titrate dose and dose frequency according to pain.
Supplement with premixed nitrous oxide 50%/ oxygen 50% in late first stage.
2019 6.23
Epidural anaesthesia
Offer this service only at hospitals with anaesthetic expertise, monitoring,
capacity and equipment for epidural. (See chapter 12: Anaesthesiology, pain
and intensive care).
Perineal analgesia: R10.2

 Lidocaine, 1 or 2%, infiltration, locally or by a pudendal block.
Postpartum and post-episiotomy pain O90.9 + (R10.2 + Z51.2)

OR
 NSAID, e.g.:
OR
 Pethidine, IM, 1 mg/kg 4 hourly as needed, to a maximum of 100 mg.
OR
LoE:IIIxxxvii
6.17 DEHYDRATION/KETOSIS IN LABOUR

O99.2 + (E86)
DESCRIPTION
Subclinical dehydration is often missed in labour.
GENERAL MEASURES
Encourage adequate oral fluid intake.
MEDICINE TREATMENT
Mild dehydration
Give oral fluids.
Moderate/severe dehydration
Administer intravenous fluids, e.g.:
 Sodium chloride 0.9%, IV, 250 mL/hour.
Re-evaluate hydration hourly.
6.18 POSTPARTUM FEVER

O85/O86.0-4/O86.8
DESCRIPTION
During delivery the woman's protective barrier against infections is temporarily
reduced and this may lead to infections.
2019 6.24
The cause of fever may be a serious complication.

Consider excessive use of misoprostol for PPH (doses >600 mcg) as a
possible non-infectious cause of postpartum fever.
GENERAL MEASURES
Prevent deep vein thrombosis.
Complete evacuation of uterine contents.
Hysterectomy may be indicated in severe uterine sepsis.
Attention to breast engorgement.
MEDICINE TREATMENT
Antibiotic treatment, where appropriate, should be guided by the presumed
source of infection.
 Amoxicillin/clavulanic acid, IV, 1.2 g 8 hourly, until patient apyrexial for 24
hours.
Follow with: LoE:III
REFERRAL
» No clinical response in 48 hours of antibiotic treatment.
» Septic shock.
6.19 POSTPARTUM HAEMORRHAGE

O72.1-3 + (Z51.2)
DESCRIPTION
Blood loss >500 mL after birth of the baby or any blood loss which results in
haemodynamic instability (tachycardia and/or hypotension).
GENERAL MEASURES
Bimanual compression of the uterus.
Ensure delivery of placenta is complete.
Check for local causes of bleeding.
Balloon tamponade of the uterine cavity should be considered if the patient is to
be transferred to another facility.
MEDICINE TREATMENT
Prevention Z29.2
Active management of the 3rd stage of labour:
 Oxytocin, IM, 10 units.
Note:
» Delay cord clamping and cutting (after 1 minute)
» Deliver the placenta by controlled cord traction.
2019 6.25
Treatment
Resuscitate.
Put up two IV lines of crystalloid, one of which should contain oxytocin 20 IU.
Cross match and hold blood for transfusion.
Monitor BP and pulse, and response to uterotonics every 15 minutes.
 Oxytocin, IV, 20 units in 1 L sodium chloride 0.9% at 250 mL/hour.

If uterus remains atonic (palpable above the umbilicus):
ADD
 Ergometrine, IM, 0.5 mg.
OR
 Oxytocin, IM, 5 units.
AND
 Ergometrine, IM, 0.5 mg.
o Avoid ergometrine in women with hypertension or cardiac disease,
except in severe cases where the benefit is considered to outweigh the
risk (discuss with a specialist).
o Repeat ergometrine 0.5 mg IM after 15 minutes if no response
If still no response after 15 minutes:

 Tranexamic acid 1 g, IV, slowly over 10 minutes. LoE:Ixxxviii
o Repeat after 30 minutes if there is ongoing vaginal
bleeding.
In settings where oxytocin had NOT been administered as prophylaxis at birth:
 Misoprostol, sublingual, or rectal, 600 mcg as a single dose.
LoE:Ixxxix
6.20 THE RHESUS NEGATIVE WOMAN

O36.0 + (Z29.1)
GENERAL MEASURES
Maternal serum antibodies absent
Prevention
Test for maternal serum antibodies at ‘booking’, 28 and 34 weeks’ gestation.
During pregnancy, give prophylactic anti-D immunoglobulin to the mother within
72 hours of a potentially sensitising event.
MEDICINE TREATMENT
After a termination of pregnancy (TOP), miscarriage, ectopic pregnancy or
amniocentesis <20 weeks:
 Anti-D immunoglobulin, IM, 50 mcg. LoE:IIIxl
After external cephalic version or potentially sensitizing event ≥20 weeks:

 Anti-D immunoglobulin, IM, 100 mcg.
2019 6.26
At birth, determine the Rh status of the cord blood and request a Coomb’s test:
Cord blood Rh negative - no treatment.
Cord blood Rh positive, Coomb’s negative:
 Anti-D immunoglobulin, IM, 100 mcg.
If a large feto-maternal haemorrhage is suspected:

 Anti-D immunoglobulin, IM, 300 mcg for every 30 mL haemorrhage.
o Maximum dose: 1 200 mcg.
AND
Do a maternal blood Kleihauer test (consult a specialist).
Rh positive, Coomb’s positive:

In these cases, the mother will also have antibodies.
Do not administer anti-D immunoglobulin.
Maternal serum antibodies present.

Consult a specialist.
6.21 URINARY TRACT INFECTION (UTI) IN PREGNANCY

6.21.1 CYSTITIS
O23.1
DESCRIPTION
This condition usually presents with lower abdominal pain, frequency of
micturition, and/or dysuria. There are no features of sepsis, e.g. fever. Urine
dipstick testing usually shows nitrites, with/without leukocytes; and/or blood.
GENERAL MEASURES
Encourage oral fluid intake.
Midstream urine for microscopy, culture and sensitivity.
MEDICINE TREATMENT
Empiric treatment (symptoms present with nitrites positive AND leukocytes
positive on dipstick):
 Fosfomycin, oral, 3 g as a single dose LoE:IIIxli
OR LoE:Ixlii
 Nitrofurantoin, oral, 100 mg, 6 hourly for 5 days.
LoE:Ixliii
REFFERAL/CONSULTATION
No response to treatment, or resistant organism on culture.
2019 6.27
6.21.2 PYELONEPHRITIS, ACUTE

O23.0
DESCRIPTION
This condition is more serious and may result in preterm labour.
Features of pyelonephritis include:
temperature ≥ 38ºC
renal angle tenderness (often bilateral)
other features of sepsis, i.e. vomiting, tachypnoea, tachycardia, confusion and
hypotension.
GENERAL MEASURES
Admit to hospital.
Ensure adequate hydration with intravenous fluids, up to 3 L of sodium
chloride 0.9% over 24 hours.
Midstream urine for microscopy, culture and sensitivity.
MEDICINE TREATMENT
Empiric therapy:
 Ceftriaxone, IV, 1 g, daily for 48 hours, or until fever subsides.
OR
 Gentamicin, IV, 6 mg/kg, daily (ensure normal renal function).
Switch to oral therapy as soon as the patient is able to take oral fluids:
Change antibiotics according to culture and sensitivity results.

After treatment, ensure that two urine specimens are negative to confirm
eradication.
2019 6.28
References:
i National Department of Health. Guidelines for maternity in South Africa, 2018. http://www.health.gov.za/
ii Ferrous sulfate compound BPC South African Medicines Formulary. 12th Edition. Division of Clinical
iii Ferrous sulfate compound BPC: Reveiz L, Gyte GM, Cuervo LG, Casasbuenas A. Treatments for iron-deficiency
anaemia in pregnancy. Cochrane Database Syst Rev. 2011 Oct

5;(10):CD003094.http://www.ncbi.nlm.nih.gov/pubmed/21975735
iv Ferrous fumarate, oral: National Department of Health, Essential Drugs Programme: Primary Health Care STGs
and EML, 2018. http://www.health.gov.za/

v Insulin (supplemental to metformin): Rowan JA, Hague WM, Gao W, Battin MR, Moore MP; MiG Trial
Investigators. Metformin versus insulin for the treatment of gestational diabetes. N Engl J Med.
2008 May 8;358(19):2003-15.http://www.ncbi.nlm.nih.gov/pubmed/18463376
vi Thresholds for diagnosing gestational diabetes: Farrar D, Duley L, Dowswell T, Lawlor DA. Different strategies
for diagnosing gestational diabetes to improve maternal and infant health. Cochrane Database Syst Rev. 2017 Aug
23;8:CD007122. https://www.ncbi.nlm.nih.gov/pubmed/28832911
Thresholds for diagnosing gestational diabetes: National Collaborating Centre for Women's and Children's
Health (UK). Diabetes in Pregnancy: Management of Diabetes and Its Complications from Preconception to the
Postnatal Period. London: National Institute for Health and Care Excellence (UK); 2015 Feb.
https://www.nice.org.uk/guidance/ng3/resources/diabetes-in-pregnancy-management-from-preconception-to-the-
postnatal-period-51038446021
viiInsulin dosing (pregnancy): Nachum Z, Ben-Shlomo I, Weiner E, Shalev E. Twice daily versus four times daily
insulin dose regimens for diabetes in pregnancy: randomised controlled trial. BMJ. 1999 Nov 6;319(7219):1223-
viii Enoxaparin:Wein L, Wein S, Haas SJ, Shaw J, Krum H. Pharmacological venous thromboembolism prophylaxis
in hospitalized medical patients: a meta-analysis of randomized controlled trials. Arch Intern Med. 2007 Jul
ix Unfractionated heparin: Phung OJ, Kahn SR, Cook DJ, Murad MH. Dosing frequency of unfractionated heparin
thromboprophylaxis: a meta-analysis. Chest. 2011 Aug;140(2):374-
x Spironolactone, oral (contra-indicated in pregnancy): South African Medicines Formulary. 12th Edition. Division
of Clinical Pharmacology. University of Cape Town. 2016.

xi Antihypertensive combination therapy: Hypertension guideline working group, Seedat YK, Rayner BL, Veriava
Y. South African hypertension practice guideline 2014. Cardiovasc J Afr. 2014 Nov-Dec;25(6):288-
xii Methyldopa, oral (dosing): South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.

Methyldopa, oral (dosing): Wright JM, Orozco-Gonzalez M, Polak G, Dollery CT. Duration of effect of single
daily dose methyldopa therapy. Br J Clin Pharmacol. 1982 Jun;13(6):847-54.
xiii Nifedipine (dosing interval): Prevost RR, Akl SA, Whybrew WD, Sibai BM. Oral nifedipine pharmacokinetics in
pregnancy-induced hypertension. Pharmacotherapy. 1992;12(3):174-7.

Nifedipine (dosing interval): Committee on Obstetric Practice. Committee Opinion No. 623: Emergent therapy
for acute-onset, severe hypertension during pregnancy and the postpartum period. Obstet Gynecol. 2015
Feb;125(2):521-5. http://www.ncbi.nlm.nih.gov/pubmed/25611642
Nifedipine (dosing interval): Mol BW, Roberts CT, Thangaratinam S, Magee LA, de Groot CJ, Hofmeyr GJ.
Pre-eclampsia. Lancet. 2015 Sep 2. pii: S0140-6736(15)00070-7. http://www.ncbi.nlm.nih.gov/pubmed/26342729
xiv Labetalol, IV infusion: Raheem IA, Saaid R, Omar SZ, Tan PC. Oral nifedipine versus intravenous labetalol for
acute blood pressure control in hypertensive emergencies of pregnancy: a randomised trial. BJOG. 2012
Jan;119(1):78-85. http://www.ncbi.nlm.nih.gov/pubmed/21985500
xv Oxytocin, IM: National Department of Health. Guidelines for maternity in South Africa, 2015.
http://www.health.gov.za
xvi Aspirin, dose - prevention of preeclampsia: Duley L, Henderson-Smart DJ, Meher S, King JF. Antiplatelet
agents for preventing pre-eclampsia and its complications. Cochrane Database Syst Rev. 2007 Apr
Aspirin, oral - prevention of preeclampsia (safety from 6 weeks’ gestation): Hoffman MK, Goudar SS, Kodkany
BS, Metgud M, Somannavar M, Okitawutshu J et al; ASPIRIN Study Group. Low-dose aspirin for the prevention of
preterm delivery in nulliparous women with a singleton pregnancy (ASPIRIN): a randomised, double-blind, placebo-
controlled trial. Lancet. 2020 Jan 25;395(10220):285-293. https://www.ncbi.nlm.nih.gov/pubmed/31982074
Aspirin, oral - prevention of preeclampsia (safety from 6 weeks’ gestation): National Department of Health:
Affordable Medicines, EDP-Adult Hospital level. Review: Safety of aspirin in pregnancy, February 2020.
xvii Calcium: Hofmeyr GJ, Lawrie TA, Atallah AN, Duley L, Torloni MR. Calcium supplementation during pregnancy for
preventing hypertensive disorders and related problems. Cochrane Database Syst Rev. 2014 Jun
Calcium: WHO. WHO recommendations for prevention and treatment of pre-eclampsia and eclampsia, 2011.
http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/9789241548335/en/
xviii Dolutegravir, oral (risk acknowledgement): National Department of Health. Circular no.1 of 2020: Introduction of
Dolutegravir in the ARV Programme, 24 February 2020. http://www.health.gov.za

xix ART regimens (pregnancy): South African National Department of Health South Africa. Guideline for the
2019 6.29
Prevention of Mother to Child Transmission of Communicable Infections, October 2019.

https://www.knowledgehub.org.za/elibrary/guideline-prevention-mother-child-transmission-communicable-infections
xx ART regimens (Caesarean delivery): South African National Department of Health South Africa. Guideline for the
Prevention of Mother to Child Transmission of Communicable Infections, October 2019.

https://www.knowledgehub.org.za/elibrary/guideline-prevention-mother-child-transmission-communicable-infections
xxi Benzathine benzylpenicillin (late latent syphilis/of unknown duration): Workowski KA, Bolan GA. Workowski KA,
Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015
[published correction appears in MMWR Recomm Rep. 2015 Aug 28;64(33):924] MMWR Recomm Rep.
2015;64(RR-03):1-137. https://pubmed.ncbi.nlm.nih.gov/26042815/
Benzathine benzylpenicillin (late latent syphilis/of unknown duration): World Health Organization: WHO
Guidelines for the treatment of Treponema palladum (syphilis), 2016.
https://www.who.int/reproductivehealth/publications/rtis/syphilis-treatment-guidelines/en/
xxii Ondansetron, parenteral (in pregnancy): Kaplan YC, Richardson JL, Keskin-Arslan E, Erol-Coskun H, Kennedy
D. Use of ondansetron during pregnancy and the risk of major congenital malformations: A systematic review and
meta-analysis. Reprod Toxicol. 2019;86:1-13. https://pubmed.ncbi.nlm.nih.gov/30849498/
Ondansetron, parenteral (in pregnancy): Huybrechts KF, Hernández-Díaz S, Straub L, et al. Association of
Maternal First-Trimester Ondansetron Use With Cardiac Malformations and Oral Clefts in Offspring. JAMA.
2018;320(23):2429-2437. https://pubmed.ncbi.nlm.nih.gov/30561479/
Ondansetron, parenteral (in pregnancy): Huybrechts KF, Hernandez-Diaz S, Straub L, et al. Intravenous
Ondansetron in Pregnancy and Risk of Congenital Malformations [published online ahead of print, 2019 Nov 15].
JAMA. 2019;323(4):372-374. https://pubmed.ncbi.nlm.nih.gov/31730152/
xxiii Indomethacin: Reinebrant HE, Pileggi-Castro C, Romero CL, Dos Santos RA, Kumar S, Souza JP, Flenady V.
Cyclo-oxygenase (COX) inhibitors for treating preterm labour. Cochrane Database Syst Rev. 2015 Jun
5;6:CD001992.http://www.ncbi.nlm.nih.gov/pubmed/26042617
xxiv Betamethasone, IM: Roberts D, Dalziel S. Antenatal corticosteroids for accelerating fetal lung maturation for
women at risk of preterm birth. Cochrane Database Syst Rev. 2006 Jul
Betamethasone, IM: Royal College of Obstetricians and Gynaecologists. Green-top Guideline No.7: Antenatal
corticosteroids to reduce neonatal morbidity and mortality. October 2010. Available at:
https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_7.pdf
xxv Dexamethasone, IM: Brownfoot FC, Gagliardi DI, Bain E, Middleton P, Crowther CA. Different corticosteroids
and regimens for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database Syst
Rev. 2013 Aug 29;8:CD006764. http://www.ncbi.nlm.nih.gov/pubmed/123990333
Dexamethasone, IM: Royal College of Obstetricians and Gynaecologists. Green-top Guideline No.7: Antenatal
corticosteroids to reduce neonatal morbidity and mortality. October 2010. Available at:
https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_7.pdf
xxvi Amoxicillin, oral: Pattinson RC, Makin JD, Funk M, Delport SD, Macdonald AP, Norman K, Kirsten G,Stewart C,
Woods D, Moller G, Coetzee E, Smith P, Anthony J, Schoon M, Grobler S. The use of dexamethasone in women
with preterm premature rupture of membranes--a multicentre, double-blind, placebo-controlled, randomised trial.
Dexiprom StudyGroup. S Afr Med J. 1999 Aug;89(8):865-70.http://www.ncbi.nlm.nih.gov/pubmed/10488363
Metronidazole, oral: Pattinson RC, Makin JD, Funk M, Delport SD, Macdonald AP, Norman K, Kirsten G,Stewart
C, Woods D, Moller G, Coetzee E, Smith P, Anthony J, Schoon M, Grobler S. The use of dexamethasone in
women with preterm premature rupture of membranes--a multicentre, double-blind, placebo-controlled,
randomised trial. Dexiprom StudyGroup. S Afr Med J. 1999 Aug;89(8):865-
xxvii Azithromycin: Contract circular HP02-2015AI. http://www.health.gov.za/
xxviii Prevention of preterm labour: Alfirevic Z, Stampalija T, Medley N. Cervical stitch (cerclage) for preventing
preterm birth in singleton pregnancy. Cochrane Database Syst Rev. 2017 Jun 6;6:CD008991.
Prevention of preterm labour: Jarde A, Lutsiv O, Beyene J, McDonald SD. Vaginal progesterone, oral
progesterone, 17-OHPC, cerclage, and pessary for preventing preterm birth in at-risk singleton pregnancies: an
updated systematic review and network meta-analysis. BJOG 2019; 126: 556–567.
Prevention of preterm labour: NICE Guidelines: Preterm Labour and Birth, August 2019
https://www.nice.org.uk/guidance/ng25
xxix Progesterone, PV: Jarde A, Lutsiv O, Beyene J, McDonald SD. Vaginal progesterone, oral progesterone, 17-
OHPC, cerclage, and pessary for preventing preterm birth in at-risk singleton pregnancies: an updated systematic
review and network meta-analysis. BJOG 2019; 126: 556–567. https://www.ncbi.nlm.nih.gov/pubmed/30480871
Progesterone, PV: National Department of Health: Affordable Medicines, EDP-Adult Hospital level. Medicine
Review: Progesterone, vaginal for prevention of preterm labour, October 2019. http://www.health.gov.za/
xxx Cerclage: Alfirevic Z, Stampalija T, Medley N. Cervical stitch (cerclage) for preventing preterm birth in singleton
pregnancy. Cochrane Database Syst Rev. 2017 Jun 6;6:CD008991.

Cerclage: NICE Guidelines: Preterm Labour and Birth, August 2019 https://www.nice.org.uk/guidance/ng25
xxxi Salbutamol, IV: Neilson JP, West HM, Dowswell T. Betamimetics for inhibiting preterm labour.
Cochrane Database Syst Rev. 2014 Feb 5;2:CD004352. http://www.ncbi.nlm.nih.gov/pubmed/24500892

Salbutamol, IV: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.
xxxii Extra-amniotic Foley catheter: PLUS prostaglandin protocol: Al-Ibraheemi Z, Brustman L, Bimson BE, Porat N,
Rosenn B. Misoprostol With Foley Bulb Compared With Misoprostol Alone for Cervical Ripening: A Randomized
2019 6.30
Controlled Trial. Obstet Gynecol. 2018 Jan;131(1):23-29. https://www.ncbi.nlm.nih.gov/pubmed/29215514

Extra-amniotic Foley catheter: PLUS prostaglandin protocol: Osoti A, Kibii DK, Tong TMK, Maranga I. Effect of
extra-amniotic Foley's catheter and vaginal misoprostol versus vaginal misoprostol alone on cervical ripening and
induction of labor in Kenya, a randomized controlled trial. BMC Pregnancy Childbirth. 2018 Jul 12;18(1):300.
Extra-amniotic Foley catheter: PLUS prostaglandin protocol: World Health Organisation. WHO
recommendations for induction of labour, Clinical Practice Guideline, 2011.
https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/9789241501156/en/
xxxiii Dinoprostone: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University
of Cape Town. 2016.

xxxiv Oxytocin, IV (Cervix favourable (Bishop score ≥7): NICE Clinical Guideline: 70 - Induction of labour, 2008.
https://www.nice.org.uk/guidance/cg70/evidence/cg70-induction-of-labour-full-guideline2
xxxv Amniotomy in HIV-infected pregnant women: Peters H, Byrne L, De Ruiter A, Francis K, Harding K, Taylor GP,
Tookey PA, Townsend CL. Duration of ruptured membranes and mother-to-child HIV transmission: a prospective
population-based surveillance study. BJOG. 2016 May;123(6):975-81.
xxxvi Pethidine, IM: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University
of Cape Town. 2016.

Morphine, IM: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University
of Cape Town. 2016.
xxxvii Pethidine, IM: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.
Morphine, IM: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University
of Cape Town. 2016.
xxxviii Tranexamic acid, IV: WOMAN Trial Collaborators. Effect of early tranexamic acid administration on
mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an
international, randomised, double-blind, placebo-controlled trial. Lancet 2017; 6736(17)30638-4.
Tranexamic acid, IV: National Department of Health: Affordable Medicines, EDP-Adult Hospital level. Medicine
Review: Tranexamic acid, IV, for management of post partum haemmhorhage in pregnant women, 11 October
xxxix Misoprostol: Essential Steps in Managing Obstetric Emergencies (ESMOE), facilitator’s guide.
Misoprostol: Hofmeyr GJ, Gülmezoglu AM, Novikova N, Linder V, Ferreira S, Piaggio G. Misoprostol to prevent
and treat postpartum haemorrhage: a systematic review and meta-analysis of maternal deaths and dose-related
effects. Bull World Health Organ. 2009 Sep;87(9):666-77. http://www.ncbi.nlm.nih.gov/pubmed/19784446
Misoprostol: Department of Health, Republic of South Africa. 2015. Guidelines for Maternity care in South
Africa, 5thedition. http://www.health.gov.za/
Misoprostol: International Federation Of Gynecology And Obstetrics. Treatment of postpartum hemorrhage with
misoprostol. Int J Gynaecol Obstet. 2012 Dec;119(3):215-6. http://www.ncbi.nlm.nih.gov/pubmed/23036964
xlAnti-D Immunoglobulin, iM ( 20 weeks): NICE Clinical Guideline: 156 - Routine antenatal anti-D prophylaxis for
women who are rhesus D negative, 2008. https://www.nice.org.uk/guidance/ta156/resources/routine-antenatal-

antid-prophylaxis-for-women-who-are-rhesus-d-negative-pdf-82598318102725
xliDipsticks (positive nitrites or leukocytes): Mambatta AK, Jayarajan J, Rashme VL, Harini S, Menon S, Kuppusamy
J. Reliability of dipstick assay in predicting urinary tract infection. J Family Med Prim Care. 2015 Apr-Jun;4(2):265-
Dipsticks (positive nitrites or leukocytes): Demilie T, Beyene G, Melaku S, Tsegaye W. Diagnostic accuracy of
rapid urine dipstick test to predict urinary tract infection among pregnant women in Felege Hiwot Referral Hospital,
Bahir Dar, North West Ethiopia. BMC Res Notes. 2014 Jul 29;7:481.
xlii Fosfomycin, oral: Falagas ME, Vouloumanou EK, Togias AG, Karadima M, Kapaskelis AM, Rafailidis PI,
Athanasiou S. Fosfomycin versus other antibiotics for the treatment of cystitis: a meta-analysis of randomized
controlled trials. J Antimicrob Chemother. 2010 Sep;65(9):1862-77. http://www.ncbi.nlm.nih.gov/pubmed/20587612
Fosfomycin, oral: Lewis DA, Gumede LY, van der Hoven LA, de Gita GN, de Kock EJ, de Lange T, Maseko V,
Kekana V, Smuts FP, Perovic O. Antimicrobial susceptibility of organisms causing community-acquired urinary tract
infections in Gauteng Province, South Africa. S Afr Med J. 2013 Mar 15;103(6):377-81.
xliiiNitrofurantoin: Zalmanovici Trestioreanu A, Green H, Paul M, Yaphe J, Leibovici L. Antimicrobial agents for treating
uncomplicated urinary tract infection in women. Cochrane Database Syst Rev. 2010 Oct 6;(10):CD007182.
Nitrofurantoin: Lewis DA, Gumede LY, van der Hoven LA, de Gita GN, de Kock EJ, de Lange T, Maseko V, Kekana
V, Smuts FP, Perovic O. Antimicrobial susceptibility of organisms causing community-acquired urinary tract infections in
Gauteng Province, South Africa. S Afr Med J. 2013 Mar 15;103(6):377-81.http://www.ncbi.nlm.nih.gov/pubmed/23725955
Nitrofurantoin: Nordeng H, Lupattelli A, Romøren M, Koren G. Neonatal outcomes after gestational exposure to
nitrofurantoin. Obstet Gynecol. 2013 Feb;121(2 Pt 1):306-13. http://www.ncbi.nlm.nih.gov/pubmed/23344280
2019 6.31
CHAPTER 7
NEPHROLOGY/UROLOGICAL DISORDERS
7.1 NEPHROLOGY DISORDERS
CAUTION
Check all medicines for possible dose adjustment based on eGFR/CrCl.
The doses of many medicines need to be adjusted in renal impairment.
Recommendations for medicines that require dose adjustment in renal
impairment can be found in the SAMF, package insert, and from many online
resources e.g.: http://www.globalrph.com/index_renal.htm
7.1.1 CHRONIC KIDNEY DISEASE (CKD)

N18.1-5/N18.9
DESCRIPTION
Structural or functional kidney damage present for >3 months, with or without
a decreased estimated glomerular filtration rate (eGFR).
Markers of kidney damage include:
- proteinuria; ACR-urine (albumin creatinine ratio) ≥30 mg/g or ≥3 mg/mmol;
PCR-urine (protein creatinine ratio) >0.05 g/mmol
- urine dipstick positive for blood and/or protein (for females with
haematuria: exclude current menstrual cycle)
- increased serum creatinine or low eGFR
- abnormal kidneys on ultrasound, e.g. polycystic, small in size, scarring
- abnormalities on renal biopsy
- electrolyte abnormalities due to tubular disorders
- history of kidney transplant
eGFR calculator online access:
https://www.kidney.org/apps/professionals/egfr-calculator
Common causes of CKD include:
Category Example
Vascular Hypertension, vasculitis etc.
Glomerular Diabetes, autoimmune diseases, systemic infections,
diseases drugs, neoplasia
Tubulointerstitial UTI, drug induced interstitial nephritis (e.g. rifampicin,
diseases allopurinol, fluoroquinolones, sulphonamides)
Structural Polycystic kidney/s, renal artery stenosis, small or
enlarged kidneys, renal masses, obstruction (stones,
strictures)
Others Congenital
2019 7.1
CHAPTER 7 NEPHROLOGICAL/UROLOGICAL DISORDERS
Chronic kidney disease can be entirely asymptomatic

until over 75% of kidney function is lost.
TREATMENT AND PREVENTION STRATEGIES ACCORDING TO STAGES

Adverse outcomes of CKD can often be prevented or delayed through early
detection and treatment of risk factors for CKD.
In patients with CKD, the stage of disease should be assigned based on the
level of kidney function according to the classification below, irrespective of
diagnosis.
Adults with early CKD i.e. stages 0–3 can all be managed at primary care level
once the cause and plan for care has been established.
All stage 4 and 5 patients require referral/consultation with a specialist. If the
patient is a candidate for long-term dialysis nephrological referral is advised.
Prognosis of CKD by GFR and albuminuria categories: KDIGO 2012
Persistent albuminuria categories
Description and range
A1 A2 A3
Normal to
Moderately Severely
mildly
increased increased
increased
ACR* ACR* ACR*

<30 mg/g 30–300 mg/g >300 mg/g
<3 mg/mmol 3–30 mg/mmol >30 mg/mmol
G1 Normal or high ≥90
1.73m2) - description and range
G2 Mildly decreased 60 –89

eGFR categories (ml/min per
G3a Mildly to moderately 45–59 Refer

decreased
G3b Moderately to 30–44 Refer Refer
severely
decreased
G4 Severely 15–29 Refer Refer Refer
decreased
G5 Kidney failure <15 Refer Refer Refer
ACR: albumin to creatinine ratio in urine specimen.

Green: low risk (if no other markers of kidney disease, no CKD); yellow: moderately increased risk; orange: high
risk; red: very high risk; A1, A2, A3 = categories of albuminuria; G1, G2, G3a, G3b, G4, G5 = categories of eGFR
Adapted from: Levin A, Stevens PE. Summary of KDIGO 2012 CKD Guideline: behind the scenes, need for guidance,
and a framework for moving forward. Kidney Int. 2014 Jan;85(1):49-61.
GENERAL MEASURES
» Address cardiovascular disease risk factors. See section 3.1 Ischaemic
heart disease and atherosclerosis, prevention.
2019 7.2
» Limit salt intake unless salt wasting kidney disease.

» Limit dietary protein intake to 0.8 g/kg/day.
» Avoid nephrotoxic medicines like NSAIDs.
» Regular exercise, target BMI according to South African calculations.
» Screen for proteinuria.
- If urine dipstick 1+ or greater, repeat on a properly collected midstream
urine specimen on another occasion.
- If proteinuria persists, quantify protein with a spot urine protein
creatinine ratio. Significant proteinuria = spot urine PCR of >0.1
g/mmol.
- If urine dipstick < 1+, ACR.
Patients differ in their ability to excrete a salt and water load and therefore
fluid balance should be individualised.
MEDICINE TREATMENT
The following interventions may delay progression of renal disease.
Proteinuria reduction
Ideal targets are: PCR <0.03 g/mmol or ACR <3 mg/mmol.
Most benefit is achieved by reducing protein creatinine ratio to <0.1 g/mmol
or ACR <100 mg/mmol.
 Start treatment with a low dose of ACE-inhibitor and titrate up to the

maximum tolerated dose, e.g.
 Enalapril, oral.
o Start with 5 mg 12 hourly and titrate to 20 mg 12 LoE:IIIi
hourly, if tolerated.
o Monitor creatinine and potassium after 2 weeks if eGFR <60
mL/minute and after 4 weeks if eGFR >60 mL/minute.
o If creatinine increases by >20% from the baseline, stop ACE-inhibitor
and consult a specialist.
LoE:IIIii
ACE-inhibitor not tolerated due to intractable cough
(specialist initiated):
 Consider an angiotensin II receptor blocker (ARB), e.g.:
 Losartan, oral, LoE:IIIiii
o Start with 50 mg daily and titrate to 100 mg daily, if
tolerated.
o Replacing ACE-inhibitor with ARB does not preclude the risk of
angioedema. LoE:IIiv
CAUTION
ACE-inhibitors and ARBs can cause or exacerbate hyperkalaemia in
CKD. Check the serum potassium before starting these medicines, and
monitor serum potassium on therapy.
2019 7.3
Hypertension
Optimise BP control with additional antihypertensive agents. BP control
results in a lowering of proteinuria and slower decline in eGFR.
Target BP for patients with hypertension: <140/90 mmHg.
Target BP for patients with hypertension and confirmed CKD and/or diabetes:
<130/80 mmHg.
See section 3.6: Hypertension.
Hyperlipidaemia
If hyperlipidaemia is a co-existent cardiovascular risk factor, manage
according to section 3.1 Ischaemic heart disease and atherosclerosis,
prevention.
Diabetes mellitus
In diabetics, optimise control according to section 8.5: Diabetes mellitus.
In diabetics with kidney disease there is an increased risk of hypoglycaemia.
Insulin is the safer option to control blood glucose in patients with eGFR<60
mL/minute.
Note:
» Insulin requirements will decrease as renal disease progresses.
» Stop glibenclamide when eGFR <60 mL/minute because of an increased
risk of hypoglycaemia.
» Reduce metformin dose when eGFR <60 mL/minute (maximum dose 500 mg
12 hourly).
» Discontinue metformin when eGFR <30 mL/minute because of the risk of
lactic acidosis.
LoE:IIIv
Fluid overload and oedema
 Furosemide, oral, 40 mg 12 hourly.
When fluid overloaded and eGFR <60 mL/minute, start:
o Titrate to a maximum of 500 mg 12 hourly.
o Furosemide is ineffective when patients are on dialysis and anuric.
Hypocalcaemia and hyperphosphataemia

The aim is to lower phosphate levels and maintain normal calcium levels to
ensure calcium phosphate product (i.e. Ca x PO4) <4.4 mmol2/L2, to prevent
calcium deposition in vessels and tissue which aggravates vascular disease.
Restrict dietary phosphate intake. (Dietitian consultation)
https://www.kidney.org/
2019 7.4
Patients with CKD stage 3–5, not on dialysis:

Hyperphosphataemia and/or hypocalcaemia:
 Calcium carbonate, oral, equivalent to elemental calcium, approximately
500 mg 8 hourly with meals.
o Increase to approximately 1 g 8 hourly with meals, if
hyperphosphatemia persists.
Hypocalcaemia and low or normal serum phosphate:

 Calcium carbonate, oral, equivalent to elemental calcium, approximately
500 mg 8 hourly between meals, increase to approximately 1 g 8 hourly
between meals.
In patients with CKD stage 5 who are not candidates for renal replacement
therapy, the benefits of phosphate binding are unclear, and regular PTH
(parathyroid hormone) monitoring is not necessary.
Patients considered suitable candidates for renal replacement therapy:
Monitor Ca++, PO4 and PTH levels, as per table: Staging of kidney disease.
For hyperphosphataemia uncontrolled on calcium carbonate:
 Aluminium hydroxide BP (300 mg/5 mL), oral, 10 mL 8 hourly. Specialist
initiated.
o To prevent dementia-associated aluminium toxicity, do not use for
longer than 3 months.
For hyperparathyroidism, initiate when PTH levels >2 times upper limit of
normal range: (Specialist initiated)
(N25.8)
 Calciferol, oral, 50 000 IU once weekly. LoE:IIIvi
OR
Calcitriol, oral, 0.25–4 mcg daily.
Anaemia associated with CKD in patients on dialysis programmes N18.1-

5†/N18.9† + (D63.8*/Z49.1-2)
Patients on chronic haemodialysis or peritoneal dialysis are often anaemic
due to iron deficiency and deficiency of erythropoietin (EPO).
Simultaneous administration of iron and EPO is recommend, as EPO should
be administered in a patient with normal iron stores. Adequate iron stores
are required to assist with red blood cell production immediately after EPO
administration (see section 2.2: Anaemia, iron deficiency).
LoE:Ivii
 Iron, elemental, oral. See section 2.2 Anaemia, iron
deficiency.
o If no response, consider parenteral iron.
AND
 Erythropoietin, 40–50 IU/kg/dose, IV/SC 2–3 times weekly and assessed
at 4 weekly intervals.
o Administer IV dose over 1–5 minutes.
2019 7.5
o If necessary, dose may be increased by 25 IU/kg.

o Note: There is an increased risk of cardiovascular events with
haemoglobin levels >12 g/dL.
LoE:IIIviii
Definitive treatment, e.g. transplantation, usually improves
anaemia. It is important to identify factors likely to aggravate anaemia, e.g.
iron deficiency and infection.
Acidosis and hyperkalaemia

Specialist consultation for possible renal replacement therapy.
Check all medicines for possible dose adjustments.

http://www.globalrph.com/index_renal.htm
CONSULT WITH A SPECIALIST AT THE LOCAL REFERRAL

CENTRE
» Unknown cause of kidney failure.
» Rapid deterioration in renal function.
» Resistant hypertension despite appropriate medication and adherence.
» All patients with persistent proteinuria: on urine dipstick ≥ 1+ or proteinuria
>1 g/24 hours (PCR >0.1 g/mmol).
REFERRAL
» All ESRD patients who may qualify for long term dialysis programs. See
section 7.1.5: Renal replacement therapy.
» CKD stage 3 and above (see prognosis table).
7.1.2 GLOMERULAR DISEASE AND NEPHRITIC

SYNDROME
N04.9/N05.9
DESCRIPTION
Acute glomerulonephritis presents with one or more of the following:
haematuria, proteinuria, an acute decrease in eGFR, fluid retention, or
hypertension.
GENERAL MEASURES
» Give oxygen, and place patient in semi-Fowler’s position if patient has
respiratory distress.
» Early consultation with a specialist.
» Regulate fluid and electrolyte balance. Monitor weight closely.
» Dietary modification if severe kidney dysfunction, e.g. restrict salt, protein,
potassium and phosphate intake.
» Avoid potential nephrotoxins: e.g. NSAIDs, aminoglycosides.
2019 7.6
MEDICINE TREATMENT
Fluid overload
 Furosemide, as a slow IV bolus, 80 mg.
o Avoid unnecessary intravenous fluids.
If hypertension present: I12.0/I12.9

Diastolic BP >100 mmHg or systolic BP >150 mmHg:
 Amlodipine, oral, 5 mg as a single dose.
AND
 Hydrochlorothiazide, oral, 25 mg (if eGFR ≥30 mL/minute).
OR
Furosemide, oral, 40–80 mg (if eGFR <30 mL/minute).
Check all medicines for possible dose adjustments.

http://www.globalrph.com/index_renal.htm
CONSULTATION/REFERRAL
The management of glomerular disease is individualised and management of
all patients should be discussed with a specialist.
7.1.3 NEPHROTIC SYNDROME

N04.9
DESCRIPTION
Glomerular disease characterised by:
» severe proteinuria, i.e.: PCR >0.25 g/mmol
and
- oedema,
- hypoalbuminaemia, and
- hyperlipidaemia.
The cause cannot be determined accurately without a biopsy.
GENERAL MEASURES
Regulate salt and fluid intake.
Weigh regularly to assess fluid retention.
Check for postural hypotension to identify excessive diuresis.
Evaluate proteinuria with PCR:
» initially – weekly
» when discharged – monthly, until stable
Monitor potassium frequently for patients on ACE-inhibitors and/or diuretics.
MEDICINE TREATMENT
Management should be guided by a specialist.
CONSULTATION/REFERRAL
All patients.
2019 7.7
7.1.4 ACUTE KIDNEY INJURY

N17.9
DESCRIPTION
Kidney injury may be due to a combination of factors.
Acute kidney injury (AKI) is defined as any of the following:
» Increase in serum creatinine by ≥26.5 μmol/L within 48 hours; or
» Increase in serum creatinine to ≥1.5 times baseline, which is known or
presumed to have occurred within the prior 7 days; or
» Urine volume <0.5 mL/kg/hour for 6 hours.
GENERAL MEASURES
A detailed history and good clinical examination is necessary to identify
potentially reversible causes. Ensure volume status, perfusion and
oxygenation. Monitor serum creatinine, potassium and urine output.
If radiocontrast diagnostic procedures are required, see section 22.1:
Diagnostic contrast agents and related substances.
Avoid any nephrotoxic medicines e.g. NSAIDs, aminoglycosides. Check all
medicines for possible dose adjustments.
MEDICINE TREATMENT
Fluid overload
In patients with fluid overload where dialysis is not immediately available, a
short trial of high dose furosemide in consultation with a specialist may be
appropriate.
LoE:III
Acute dialysis
Discuss all cases with the referral centre.
Common indications for acute dialysis include:
» Pulmonary oedema and anuria.
» Intractable metabolic acidosis (pH < 7.2) and severe hyperkalaemia (>7
mmol/L).
» Uraemic complications, e.g. pericarditis, encephalopathy and bleeding.
» Medication overdose if due to dialysable toxin. See section 19: Exposure
to poisonous substances.
Note: HIV infection is not a contra-indication for acute dialysis.
Both haemodialysis and peritoneal dialysis are acceptable modalities of
therapy in the acute setting.
Peritoneal dialysis fluid is potentially infectious for HIV and viral hepatitis.
Hyperkalaemia
Serum K+ >6.5 mmol/L.
2019 7.8
Emergency measures
 Calcium gluconate 10%, slow IV bolus, 10 mL over 10 minutes.
o Maximum dose: 40 mL.
 Dextrose 50%, continuous IV infusion, 100 mL with soluble insulin, 10
units administered over 15–30 minutes.
o Monitor blood glucose levels hourly.
AND
 Salbutamol nebulisation, 5 mg.
o Dilute in 4 mL of sodium chloride 0.9%.
These are short-term measures - patients should be dialysed or if this is not

feasible:
 Sodium polystyrene sulfonate, oral, 15 g with 15 mL lactulose, 6 hourly.
OR
 Sodium polystyrene sulfonate, rectal, 30–60 g as an enema.
o After 8 hours, wash out with phosphate enema.
o Note: Rectal administration is less effective.
LoE:III
Glycaemic control
Close glycaemic control can reduce the incidence and severity of AKI.
See section 8.5: Diabetes mellitus.
Some patients do not recover kidney function and should be treated as CKD.
7.1.5 RENAL REPLACEMENT THERAPY

Z99.2
Refer to the current National Department of Health Guidelines for renal

dialysis.
PATIENT SELECTION
The final decision for selection of patients for renal replacement therapy
should be made by a multidisciplinary team using standardised selection
criteria.
The ideal patient for renal replacement therapy has uncomplicated CKD stage
5 (ESRD), and is a suitable candidate for renal transplantation.
Individual renal units have their own criteria for acceptance and these may include:
» presence of systemic illnesses,
» age,
» BMI, and
» psychosocial factors.
Obtain these guidelines from the referral centre.
2019 7.9
7.2 MAJOR ELECTROLYTE ABNORMALITIES

Guidance provided on potassium and sodium electrolyte imbalances.
7.2.1 HYPERKALAEMIA
E87.5
See section 7.1.4: Acute kidney injury.
7.2.2 HYPOKALAEMIA
E87.6
DESCRIPTION
A serum potassium level <3.5 mmol/L.
Mild to moderate symptoms: muscle weakness (respiratory, as well as, GIT
muscles) and cramps.
Severe symptoms: rhabdomyolysis, paralysis, dysrhythmias, diaphragmatic
weakness.
Signs of hypokalaemia: cardiac arrhythmias as well as ECG abnormalities (ST
–segment changes).
It is usually due to gastro-intestinal losses (vomiting, diarrhoea) or renal losses
(diuretic therapy, hyperaldosteronism).
MEDICINE TREATMENT
For chronic asymptomatic hypokalaemia, look for and manage the cause:
 Potassium chloride, oral, 600 mg, 1–2 tablets 8 hourly.
o Each 600 mg potassium chloride tablet contains 8 mmol of
potassium chloride. LoE:IIIix
o Titrate according to response to therapy.
o Maximum daily dose: 6 g (i.e.10 tablets per day in divided doses).
o Review potassium levels after 4 weeks.
Note: Routine supplementation with potassium chloride in patients who are on
diuretics is usually inappropriate. Co-administration of ACE-inhibitors and/or
spironolactone counteracts the hypokalaemia from furosemide or thiazides.
For mild to moderate hypokalaemia in a non-vomiting patient (potassium level

usually 3–3.4 mmol/L):
 Each 600 mg potassium chloride tablet contains 8 mmol of potassium
chloride.
o Titrate according to response to therapy.
o Maximum daily dose: 6 g.
o Continue treatment until the serum potassium concentration is
persistently above 3.5 mmol/L and symptoms or signs have resolved.
LoE:IIIx
For severe symptomatic hypokalaemia:
 Potassium chloride, IV by peripheral line, 40 mmol in 1 L of 0.9% or 0.45%
sodium chloride, mixed thoroughly.
2019 7.10
o Administer at a maximum rate of 20 mmol per hour over 3 hours.

Beware of volume overload (See Appendix II, for individual dosing and
monitoring for response and toxicity).
o Repeat as required, monitoring potassium serum levels after each
replacement dose.
o Potassium chloride 15% 10 mL ampoule contains 20 mmol potassium.
o Maximum allowed daily dose of K+ is 3 mmol/kg/day (or 400 mmol/day).
LoE:IIIxi
CAUTION
Potassium chloride ampoules must always be diluted before
infusion.
Reduce the rate of intravenous potassium repletion or change to oral therapy

once the hypokalaemia is no longer severe. Continue treatment until the
serum potassium concentration is persistently above 3.5 mmol/L and
symptoms or signs have resolved.
Online calculator for calculating potassium deficit:
http://www.medicinehack.com/2011/07/hypokalemia-potassium-
replacement.html
If not responding to therapy, check for hypomagnesaemia as low serum

magnesium may potentiate potassium loss.
7.2.3 HYPERNATRAEMIA
E87.0
DESCRIPTION
A serum sodium level >145mmol/L.
» Mild to moderate symptoms: Lethargy, weakness, irritability
» Severe symptoms: Convulsions, coma
It is usually due to inadequate water intake (decreased thirst sensation or
inability to drink water) or due to gastro-intestinal losses (vomiting, diarrhoea)
or renal losses (diabetes insipidus, osmotic diuresis, furosemide).
GENERAL MEASURES
Treat the cause.
Calculate the water deficit:
Water deficit = (total body water)*(1-(140/Na))
Total body water = correction factor * weight.
(The correction factor is 0.6 for men, 0.5 for women and elderly men, and
0.45 for elderly women).
Online calculator: http://www.nephromatic.com/water_deficit.php
2019 7.11
MEDICINE TREATMENT
Correction fluid:
 Oral fluids or via NGT.
 Dextrose 5%, IV infusion.
o Monitor for hyperglycaemia. Rate of correction of hypernatraemia should
be slower than 10 mmol/L over 24 hours to prevent cerebral oedema.
o Ongoing obligatory water loss through skin and stool (estimated at 30
mL/hour) must also be replaced.
LoE:IIIxii
Desired water replacement in the first 24 hours =
Water deficit x 10 mmol/L ÷ (Serum [Na] – 140)
Hourly infusion rate =
Desired water replacement in the first day ÷ 24 hours + 30 mL/hour.
7.2.4 HYPONATRAEMIA
E87.1
DESCRIPTION
A serum sodium level <135mmol/L.
Mild to moderate symptoms: Headache, nausea, vomiting, fatigue,
gait disturbances, and confusion.
Severe symptoms: Seizures, obtundation, coma, and

respiratory arrest.
Acute hyponatraemia develops within hours due to self-inflicted water-

intoxication.
\
Rapid correction may lead to central pontine myelinolysis, which is often

irreversible. Sodium should be frequently monitored and increases should
be <9 mmol/L per day.
2019 7.12
APPROACH
MEDICINE TREATMENT
In the presence of fluid overload:
o Increase dose to control signs of fluid overload and to improve
hyponatraemia. LoE:IIIxiii
In the absence of fluid overload:

Consult with a specialist before administering sodium chloride, IV
infusion.
 Sodium chloride, IV infusion.
CAUTION
Hypertonic sodium chloride should be reserved for severe acute
hyponatraemia (sodium level <120 mmol/L with severe symptoms) and
exceptional circumstances.
2019 7.13
One litre of Total Na Indication Fluid Aim

NaCl infusate (mmol/l)
5% NaCl 855 » Sodium level  Hypertonic » Symptom relief
<120 mmol/L sodium » Correct
Expect an and chloride, 5%, 60 hypona-
increase of 2-3 mL as an IV
mmol/L for » Severe traemia:
symptoms (see bolus over 15 - 4-6 mmol/L
every 60 mL min
above) immediately
or AND
o If symptoms - Maximum 8
» Acute persist/
hyponatraemia mmol/L in 1st
worsens or 24 hrs
due to water sodium is not
intoxication improving,
consult a
specialist
5% NaCl 855 » Sodium level  Hypertonic » Symptomatic

<120 mmol/L with sodium chloride, relief.
Expect an mild to moderate 5%, 30 mL as
increase of 2-3
» Correct
symptoms an IV bolus over hypona-
mmol/L for or 15 min traemia:
every 60 mL
» Chronic - Maximum 8
hyponatraemia mmol/L in 1st
24 hrs
0.9% NaCl 154 » Sodium level  Sodium » Rehydration
>120 mmol/L chloride, 0.9%,
» Dehydrated. IV infusion, 1L
8 hourly
» Asymptomatic or
mild symptoms

LoE:IIIxiv
To calculate the infusion rate, consult a specialist.
https://reference.medscape.com/calculator/hyponatremia-correction-
infusate-rate
2019 7.14
7.3 UROLOGICAL DISORDERS

Disorders of the genitourinary system.
7.3.1 HAEMATURIA
R31/ B65.0-3/B65.8-9
DESCRIPTION
Bleeding from the urinary tract, which can be from the kidneys, collecting
system, bladder, prostate and urethra.
LoE:III
2019 7.15
REFERRAL
Suspected glomerular disease. LoE:IIIxv
7.3.2 URINARY TRACT INFECTION (UTI)

N30.9/O23.4/N10
DESCRIPTION
UTIs include cystitis (infection of the bladder/lower urinary tract) and
pyelonephritis (infection of the kidney/upper urinary tract). Pyelonephritis
develops when pathogens ascend to the kidneys via the ureters.
Uncomplicated UTIs involve either the lower urinary tract (bladder) and/or the
upper urinary tract (kidney) in non-pregnant, pre-menopausal woman with no
known relevant anatomical and/or functional abnormalities within the urinary
tract or any comorbidities. UTIs in other groups of patients are complicated by
definition.
Features of upper UTI include:

» flank pain/tenderness,
» temperature >38ºC,
» other features of sepsis, i.e. tachypnoea, tachycardia, confusion and
hypotension, or
» nausea and vomiting.
In complicated, recurrent or upper UTIs, mid-stream urine should be sent for
microscopy, culture and sensitivity.
MEDICINE TREATMENT
Women with recurrent UTIs should be advised to:
» void bladder after intercourse and before retiring at night
» not postpone voiding when urge to micturate occurs
» change from use of diaphragm to an alternative type of contraception
Empirical treatment is indicated only if:
» positive leucocytes and nitrites on urine test strips on freshly passed urine,
or
» leucocytes or nitrites with symptoms of UTI, or
» systemic signs and symptoms indicating an upper UTI and/or urosepsis.
Alkalinising agents are not recommended, as many antibiotics require a lower

urinary pH.
Uncomplicated community acquired cystitis N30.9
 Fosfomycin, oral, 3 g as a single dose. LoE:Ixvi
OR
Gentamicin, IM, 5 mg/kg as a single dose.
o Note: Gentamicin should not be used in renal impairment or
LoE:Ixvii
2019 7.16
pregnancy (see Appendix II for guidance on prescribing).

OR
Nitrofurantoin, oral, 100 mg 6 hourly for 5 days.
Complicated community acquired cystitis N30.9
 Ciprofloxacin, oral, 500 mg 12 hourly for 7–10 days.
LoE:IIIxviii
CAUTION
Concomitant use of fluoroquinolones with ACE-inhibitor/angiotensin
receptor blocker is contraindicated in moderate to severe renal impairment
(Creatinine Clearance ≤ 30 ml/minute) and in the elderly. Assess renal
function before initiating treatment and monitor during treatment.
Evidence suggests a risk of developing acute kidney injury with
concomitant use of fluoroquinolones and renin-angiotensin receptor
blockers.
LoE:IIIxix
For pregnant women: O23.4

 Nitrofurantoin, oral, 100 mg 6 hourly for 5 days. LoE:Ixx
OR
Fosfomycin, oral, 3 g as a single dose. LoE:Ixxi
Acute pyelonephritis N10

Admit all patients with vomiting, sepsis, diabetes or impaired/worsened renal
function (eGFR <60 mL/minute).
Ensure adequate hydration with intravenous fluids.
If there is a poor response, perform an ultrasound on all hospitalised patients
urgently as in-patients.
Adjust antibiotic according to sensitivity.
Duration of antibiotic therapy in uncomplicated pyelonephritis:
» fluoroquinolones 7 days
» other antibiotics 14 days.
Longer courses of therapy, 2–3 weeks, should be given for complicated
pyelonephritis.
Patients who have features of severe sepsis or who are vomiting, initiate IV
therapy and switch to oral therapy as soon as clinical condition improves:
If normal renal function:

prescribing).
Switch to oral therapy as soon as the patient is able to take oral fluids,
according to microscopy culture and sensitivity results:
 Ciprofloxacin, oral, 500 mg 12 hourly for 7–10 days.
2019 7.17
If impaired renal function:

Switch to oral therapy as soon as the patient is able to take oral fluids,
according to microscopy culture and sensitivity results:
o CrCl: <10 mL/minute: 50% of normal dose.
REFFERAL/CONSULTATION
Urgent
» Acute pyelonephritis in pregnant women.
» Acute pyelonephritis with:
- vomiting
- sepsis
- diabetes mellitus
- urinary tract obstruction on ultrasound
Non-urgent
» Failure to improve within 72 hours.
» Women beyond reproductive age.
» >3 uncomplicated UTIs within a one-year period.
» >1 complicated UTI within a one-year period.
7.3.3 RECURRENT UTI

N39.0
DESCRIPTION
Recurrence of a UTI >3 times within a one-year period.
Send urine for microscopy, culture and sensitivity as treatment is determined
by the results.
GENERAL MEASURES
Women should void soon after intercourse.
Identify and treat hormone-deficient atrophic vulvo-vaginitis in the elderly.
MEDICINE TREATMENT
Prophylaxis (Z29.9)
To reduce risk of recurrence in patients with >3 infections/year requires
continuous prophylaxis for 6 months:
 Cotrimoxazole 80/400 mg, oral, 1 tablet at night.
Treatment
Treat according to microscopy, culture and sensitivity.
» Failure to respond to prophylactic treatment.
» Uncertain diagnosis.
2019 7.18
» Recurrent infections where no facilities exist for adequate culture of urine.

» All complicated recurrent UTIs.
» STI pathogens.
7.3.4 PROSTATITIS
N41.1/N41.9 + (N34.2)
DESCRIPTION
Clinical features include:
» pyrexia,
» acute pain in the pelvis and perineum,
» dysuria and frequency,
» urinary retention or difficulty, and
» acutely tender prostate on rectal examination.
Chronic non-bacterial prostatitis

This is a diagnosis of exclusion, i.e. failure to respond to antibiotics. It is
associated with perineal, suprapubic, penile and testicular pain.
MEDICINE TREATMENT
Acute bacterial prostatitis
If there are features of associated urethritis (STI regimen):
AND LoE:IIIxxii
 Azithromycin, oral, 1 g as a single dose.
LoE:Ixxiii
If there are no features of associated urethritis:
LoE:III
Chronic/relapse/persistent infection: N41.1
LoE:III
REFERRAL
To urologist if:
» No response to treatment.
» Urinary retention present.
» Chronic/relapsing prostatitis.
7.3.5 BENIGN PROSTATIC HYPERPLASIA

N40
DESCRIPTION
Benign prostatic hyperplasia is a noncancerous (benign) growth of the
prostate gland. It usually occurs in men over 50 years of age.
2019 7.19
May be associated with both obstructive (weak, intermittent stream and

urinary hesitancy) and irritative (frequency, nocturia and urgency) voiding
symptoms.
Digital rectal examination reveals a uniform enlargement of the prostate.
Urinary retention with a distended bladder may be present in the absence of
severe symptoms, therefore it is important to palpate for an enlarged bladder
during examination.
GENERAL MEASURES
Consult with an urologist.
Annual follow-up.
For patients presenting with urinary retention, insert a urethral catheter.
Stop medication that may aggravate urinary retention e.g. anticholinergics.
MEDICINE TREATMENT
 Alpha blocker, e.g.:
 Tamsulosin, oral, 0.4 mg daily. LoE:Ixxiv
7.3.6 OVERACTIVE BLADDER

N32.8
DESCRIPTION
A clinical syndrome consisting of urinary frequency (both day-and night time)
and urgency, with or without urgency incontinence,
GENERAL MEASURES
Urine dipstick to exclude an UTI.
Health education.
Avoid caffeine containing, alcoholic and carbonated beverages.
Pelvic floor muscle training: three sets of 8-12 contractions sustained for 8-10
seconds each, performed three times a day. Patients should continue for at
least 15-20 weeks.
MEDICINE TREATMENT
For detrusor hyperactivity:
 Oxybutynin, oral, 2.5–5 mg 8 hourly. Specialist initiated.
LoE:IIIxxv
REFERRAL
» For confirmation of diagnosis.
» Complications.
» Not responding to medical therapy.
2019 7.20
7.3.7 ERECTILE DYSFUNCTION

F52.2/N48.4 + (E29.1)
DESCRIPTION
The inability to attain and maintain an erect penis with sufficient rigidity for
sexual intercourse.
Many cases are psychogenic.
Organic causes include neurogenic, vasculogenic or endocrinological
disorders; many systemic diseases; pelvic trauma/surgery; and certain
medicines.
GENERAL MEASURES
Thorough medical and psychosexual history.
Examination should exclude gynaecomastia, testicular atrophy or penile
abnormalities.
Review all medicines and, if possible, withdraw medicines that may be
associated with erectile dysfunction.
Identify and treat cardiovascular risk factors e.g. obesity, hypertension, and
dyslipidaemia.
Advise on lifestyle modification e.g. cessation of smoking and excessive
alcohol use, physical activity, and weight loss.
MEDICINE TREATMENT
Treat the underlying condition.
In patients with proven testosterone deficiency: (E29.1)

 Testosterone. Specialist initiated.
See section 8.3: Androgen deficiency.
REFERRAL
To an urologist or appropriate specialist if surgical intervention is needed, e.g.
penile prostheses, vascular surgery and pelvic fractures.
7.3.8 RENAL CALCULI

N20.0
DESCRIPTION
A kidney stone or calculus which has formed in the renal tract, i.e. pelvis,
ureters or bladder, as a result of urine which is supersaturated with a stone-
forming salt.
Clinical features of obstructing urinary stones may include:
» sudden onset of acute colic, localized to the flank, causing the patient to
move constantly,
» nausea and vomiting,
» referred pain to the scrotum or labium as the stone moves down the ureter.
2019 7.21
Urinalysis usually reveals microscopic or macroscopic haematuria.

Stones may be passed spontaneously, or after medical or invasive treatment.
If available, collect the stones and send to the laboratory for analysis.
GENERAL MEASURES
Acute stage:
Oral fluids administered liberally.
Intravenous fluids to ensure adequate hydration and urine flow.
To prevent recurrence:
Avoid dehydration.
If recurrences occur, consult a specialist.
MEDICINE TREATMENT
Analgesia for renal colic:
 NSAID, oral: e.g. LoE:Ixxvi
Note: Avoid NSAIDs if renal impairment is present or suspected.
If patient is vomiting:
 Diclofenac, IM, 75 mg as a single dose.
LoE:III
AND/OR
 Tramadol, IM, 50–100 mg, 4–6 hourly.

LoE:III
OR

Currently, there is no convincing evidence to support the use of hyoscine in

this setting.
For vomiting:
 Metoclopramide, IM, 10 mg 8 hourly.
LoE:III
REFERRAL
» In acute setting for suspected or diagnosed obstruction and/or ongoing
pain.
» Complicating urinary tract sepsis.
» Recurrent calculi.
2019 7.22
References:
i Enalapril, oral (maximum daily dose of 40 mg): Joint Formulary Committee. British National Formulary. London:
BMJ Group and Pharmaceutical Press; 2018.
ii ACE-inhibitor (e.g. enalapril): South African Renal Society Recommendations for the early detection and
management of CKD in South Africa. http://www.sa-renalsociety.org/guidelines
ACE-inhibitor (e.g. enalapril): The National Kidney Foundation Kidney Disease Outcomes Quality Initiative
(KDOQI) Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification
PART 9. Approach to chronic kidney disease using these guidelines.
https://www.kidney.org/professionals/guidelines
ACE-inhibitor (e.g. enalapril): South African Renal Society Guidelines for the Optimal Care of Patients on
Chronic Dialysis in South Africa, revised 2011. http://www.sa-renalsociety.org/guidelines
iii Angiotensin II receptor blocker (e.g. Losartan): South African Renal Society Recommendations for the Early
detection and management of CKDin South Africa. http://www.sa-renalsociety.org/guidelines
Angiotensin II receptor blocker (e.g. Losartan): The National Kidney Foundation Kidney Disease Outcomes
Quality Initiative (KDOQI) Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and
Stratification PART 9. Approach to chronic kidney disease using these guidelines.
https://www.kidney.org/professionals/guidelines
Angiotensin II receptor blocker (e.g. Losartan): South African Renal Society Guidelines for the Optimal Care of
Patients on Chronic Dialysis in South Africa, revised 2011. http://www.sa-renalsociety.org/guidelines
iv Angiotensin II receptor blocker (angioedema): Caldeira D, David C, Sampaio C. Tolerability of angiotensin-
receptor blockers in patients with intolerance to angiotensin-converting enzyme inhibitors: a systematic review and
meta-analysis. Am J Cardiovasc Drugs. 2012 Aug1;12(4):263-77. https://www.ncbi.nlm.nih.gov/pubmed/22587776
Angiotensin II receptor blocker (angioedema): Haymore BR, Yoon J, Mikita CP, Klote MM, DeZee KJ. Risk of
angioedema with angiotensin receptor blockers in patients with prior angioedema associated with angiotensin-
converting enzyme inhibitors: a meta-analysis. Ann Allergy Asthma Immunol. 2008 Nov;101(5):495-9.
Angiotensin II receptor blocker (angioedema): Makani H, Messerli FH, Romero J, Wever-Pinzon O,
Korniyenko A, Berrios RS, Bangalore S. Meta-analysis of randomized trials of angioedema as an adverse event of
renin-angiotensin system inhibitors. Am J Cardiol. 2012 Aug 1;110(3):383-91.
v Metformin: National Department of Health, Essential Drugs Programme: Primary Health Care STGs and EML,
Metformin: Amod A, Ascott-Evans BH, Berg GI, Blom DJ, Brown SL, Carrihill MM, Dave JA, Distiller LA, Ganie YN,
Grobler N, Heilbrunn AG, Huddle KRL, Janse van Rensburg G, Jivan D, Joshi P, Khutsoane DT, Levitt NS, May WM,
Mollentze WF, Motala AA, Paruk IM, Pirie FJ, Raal FJ, Rauff S, Raubenheimer PJ, Randeree HAR, Rheeder P,
Tudhope L, Van Zyl DJ, Young M; Guideline Committee. The 2012 SEMDSA Guideline for the Management of Type 2
Diabetes (Revised) JEMDSA 2012;17(2)(Supplement 1): S1-S95.
http://www.semdsa.org.za/images/2012_SEMDSA_Guideline_July_FINAL.pdf
Metformin: Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes
Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J
Diabetes 2013;37(suppl 1):S1-S212. http://www.ncbi.nlm.nih.gov/pubmed/24070961
Metformin: NICE Clinical Guideline 87: Type 2 diabetes - The management of type 2 diabetes, 2009, 2014.
www.nice.org.uk/Guidance/CG87
Metformin: Aronoff, Bennett et al. Drug Prescribing in Renal Failure: Dosing Guidelines for Adults and Children,
5th Edition. American College of Physicians. United States of America, 2007.
Metformin: Lipska KJ, Bailey CJ, Inzucchi SE. Use of metformin in the setting of mild-to-moderate renal
insufficiency. Diabetes Care. 2011 Jun;34(6):1431-7. http://www.ncbi.nlm.nih.gov/pubmed/21617112
vi Calciferol, oral: Malabanan et al. Redefining Vit D deficiency. Lancet 1998, 351: 805-806.
vii Erythropoetin, parenteral (simulataneous administration with iron in CKD): Palmer SC, Saglimbene V, Mavridis D,
Salanti G, Craig JC, Tonelli M, Wiebe N, Strippoli GF. Erythropoiesis-stimulating agents for anaemia in adults with
chronic kidney disease: a network meta-analysis. Cochrane Database Syst Rev. 2014 Dec 8;(12):CD010590.
Erythropoetin, parenteral (simultaneous administration with iron in CKD): Macdougall IC, White C, Anker SD,
Bhandari S, Farrington K, Kalra PA, McMurray JJV, Murray H, Tomson CRV, Wheeler DC, Winearls CG, Ford I;
PIVOTAL Investigators and Committees. Intravenous Iron in Patients Undergoing Maintenance Hemodialysis. N Engl
J Med. 2019 Jan 31;380(5):447-458. https://www.ncbi.nlm.nih.gov/pubmed/30365356
Erythropoetin, parenteral (simultaneous administration with iron in CKD): Kidney disease: improving global outcomes
(KDIGO) anemia work group. KDIGO clinical practice guideline for anemia in chronic kidney disease. Kidney Int
Suppl. 2012;2:279–335. https://kdigo.org/wp-content/uploads/2016/10/KDIGO-2012-Anemia-Guideline-English.pdf
viii Erythropoetin, parenteral: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.

ix Potassium chloride, oral: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.
x Potassium chloride, oral: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.
Potassium chloride, oral: Rastegar A, Soleimani M. Hypokalaemia and hyperkalaemia. Postgrad Med J. 2001
Dec;77(914):759-64. Review. Erratum in: Postgrad Med J 2002 Feb;78(916):126. Rastergar A [corrected to
Rastegar A]. http://www.ncbi.nlm.nih.gov/pubmed/8250319
Potassium chloride, oral: Wong KC, Schafer PG, Schultz JR. Hypokalemia and anesthetic implications.
2019 7.23
AnesthAnalg. 1993 Dec;77(6):1238-60. Review. Erratum in: AnesthAnalg 1994 May;78(5):1035.

xi Potassium chloride, IV: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.
Potassium chloride, IV (monitoring): Tsuji H, Venditti FJ Jr, Evans JC, Larson MG, Levy D. The associations of
levels of serum potassium and magnesium with ventricular premature complexes (the Framingham Heart Study).
Am J Cardiol. 1994 Aug 1;74(3):232-5. https://www.ncbi.nlm.nih.gov/pubmed/7518645
Potassium chloride, IV (monitoring): Hoes AW, Grobbee DE, Peet TM, Lubsen J. Do non-potassium-sparing
diuretics increase the risk of sudden cardiac death in hypertensive patients? Recent evidence. Drugs. 1994
xii Dextrose 5%, IV: Adrogué HJ, Madias NE. Hypernatremia. N Engl J Med. 2000 May 18;342(20):1493-9.
Review. http://www.ncbi.nlm.nih.gov/pubmed/10816188
Dextrose 5%, IV: Lindner G, Funk GC. Hypernatremia in critically ill patients. J Crit Care. 2013
Apr;28(2):216.e11-20. http://www.ncbi.nlm.nih.gov/pubmed/22762930
xiii Furosemide, oral: Adrogué HJ, Madias NE. Hyponatremia. N Engl J Med. 2000 May 25;342(21):1581-9.
Review. http://www.ncbi.nlm.nih.gov/pubmed/10824078
xiv Sodium chloride, 0.9%, IV: Adrogué HJ, Madias NE. Hyponatremia. N Engl J Med. 2000 May 25;342(21):1581-
9. Review. http://www.ncbi.nlm.nih.gov/pubmed/10824078
xv Praziquantel: National Department of Health, Essential Drugs Programme: Primary Health Care STGs and
EML, 2018. http://www.health.gov.za/

xvi Fosfomycin, oral: Falagas ME, Vouloumanou EK, Togias AG, Karadima M, Kapaskelis AM, Rafailidis PI,
Kekana V, Smuts FP, Perovic O. Antimicrobial susceptibility of organisms causing community-acquired urinary
tract infections in Gauteng Province, South Africa. S Afr Med J. 2013 Mar 15;103(6):377-81.
xvii Gentamicin, parenteral: National Department of Health: Affordable Medicines, EDP-Adult Hospital level.
Medicine Review: Gentamicin for uncomplicated UTI, November 2019. http://www.health.gov.za/

Gentamicin, parenteral:Goodlet KJ, Benhalima FZ, Nailor MD. A Systematic Review of Single-Dose
Aminoglycoside Therapy for Urinary Tract Infection: Is It Time To Resurrect an Old Strategy? Antimicrob Agents
Chemother. 2018 Dec 21;63(1). pii: e02165-18. https://www.ncbi.nlm.nih.gov/pubmed/30397061
xviii Ciprofloxacin, oral: Lewis DA, Gumede LY, van der Hoven LA, de Gita GN, de Kock EJ, de Lange T, Maseko V,
tract infections in Gauteng Province, South Africa. S Afr Med J. 2013 Mar 15;103(6):377-
xix Ciprofloxacin, oral (caution - concomitant use with ACE-inhibitor/ARB): Savage R. Ciprofloxacin, enalapril and
acute kidney injury: Strengthening of a drug Interaction signal. WHO Pharmaceuticals Newsletter : 16-21, No. 1,
201. http://www.who.int/medicines/publications/WHO-Pharmaceuticals_Newsletter_No1-2018.pdf?ua=1
Ciprofloxacin, oral (caution - concomitant use with ACE-inhibitor/ARB): Bird ST, Etminan M, Brophy JM,
Hartzema AG, Delaney JA. Risk of acute kidney injury associated with the use of fluoroquinolones. CMAJ. 2013 Jul
9;185(10):E475-82. https://www.ncbi.nlm.nih.gov/pubmed/23734036
xx Huttner A, Verhaegh EM, Harbarth S, Muller AE, Theuretzbacher U, Mouton JW. Nitrofurantoin revisited: a
systematic review and meta-analysis of controlled trials. J Antimicrob Chemother. 2015 Sep;70(9):2456-64.
Nitrofurantoin, oral: Zalmanovici Trestioreanu A, Green H, Paul M, Yaphe J, Leibovici L. Antimicrobial agents
for treating uncomplicated urinary tract infection in women. Cochrane Database Syst Rev. 2010 Oct
Nitrofurantoin, oral: Lewis DA, Gumede LY, van der Hoven LA, de Gita GN, de Kock EJ, de Lange T, Maseko
V, Kekana V, Smuts FP, Perovic O. Antimicrobial susceptibility of organisms causing community-acquired urinary
Nitrofurantoin, oral: Nordeng H, Lupattelli A, Romøren M, Koren G. Neonatal outcomes after gestational
exposure to nitrofurantoin. Obstet Gynecol. 2013 Feb;121(2 Pt 1):306-13.
xxi Fosfomycin, oral: Falagas ME, Vouloumanou EK, Togias AG, Karadima M, Kapaskelis AM, Rafailidis PI,
xxii Ceftriaxone, IM: National Department of Health, Essential Drugs Programme: Primary Health Care STGs and

Ceftriaxone, IM: Newman LM, Moran JS, Workowski KA. Update on the management of gonorrhea in adults in
the United States. Clin Infect Dis. 2007 Apr 1;44Suppl 3:S84-101.Review.
2019 7.24
Ceftriaxone, IM: Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually
transmitted diseasestreatment guidelines, 2010.MMWR Recomm Rep. 2010 Dec 17;59(RR-12):1-110. Erratum in:
MMWR Recomm Rep. 2011 Jan14;60(1):18. Dosage error in article text. http://www.cdc.gov/std/treatment/2010/
xxiii Azithromycin, oral: National Department of Health, Essential Drugs Programme: Primary Health Care STGs and

Azithromycin, oral: Azithromycin: Lau CY, Qureshi AK. Azithromycin versus doxycycline for genital chlamydial
infections: a meta-analysis of randomized clinical trials. Sex Transm Dis. 2002 Sep;29(9):497-502.
xxiv Alpha-blocker (e.g. tamsulosin): Djavan B, Marberger M. A meta-analysis on the efficacy and tolerability of
alpha1-adrenoceptor antagonists in patients with lower urinary tract symptoms suggestive of benign prostatic
obstruction. Eur Urol. 1999;36(1):1-13.http://www.ncbi.nlm.nih.gov/pubmed/10364649
xxv Oxybutynin, oral: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University
of Cape Town, 2016.

xxvi NSAID, oral: Afshar K, Jafari S, Marks AJ, Eftekhari A, MacNeily AE. Nonsteroidal anti-inflammatory drugs
(NSAIDs) and non-opioids for acute renal colic. Cochrane DatabaseSyst Rev. 2015 Jun 29;6:CD006027.
2019 7.25
CHAPTER 8
ENDOCRINE DISORDERS
8.1 ACROMEGALY
E22.0
DESCRIPTION
Acromegaly is a disorder caused by growth hormone (GH) hypersecretion
usually due to a pituitary adenoma, with associated morbidities, and increased
mortality.
This condition should be managed at a tertiary centre.
Transsphenoidal adenomectomy is the accepted form of primary therapy.
Radiotherapy post operatively may be required. In addition, adjunctive
medical therapy may be required in specific circumstances.

Investigations
If the diagnosis is suspected, screening should be done in consultation with a
specialist.
REFERRAL
All patients with suspected acromegaly to a hospital with endocrine and
neurosurgery facilities.
8.2 ADRENAL INSUFFICIENCY (ADDISON DISEASE)

E27.1/E27.2
DESCRIPTION
Primary adrenocortical insufficiency.
Clinical presentation
Acute crisis: (not all symptoms and signs may occur in a particular patient, so
a high index of suspicion is needed).
» hypotension » depressed mentation
» fever » hypoglycaemia
» GIT disturbances » hyponatraemia
» dehydration » hyperkalaemia
» weakness » acidosis
Chronic:
» hyperpigmentation » GIT disturbances
» weakness and fatigue » hypotension
» loss of weight » hypoglycaemia
» postural dizziness » hyponatraemia
» arthralgia » hyperkalaemia
2019 8.1
CHAPTER 8 ENDOCRINE DISORDERS
Always consider this diagnosis in a thin, hypotensive, hypoglycaemic patient,

or during stress e.g. sepsis. The combination of hyponatraemia and
hyperkalaemia should suggest possible primary adrenal insufficiency.
Note: Treatment of suspected acute adrenal failure should never be delayed
to obtain results of diagnostic procedures.
Investigations
08h00 serum cortisol level (or at time of presentation in acute crisis):
 >500 nmol/L: virtually excludes the diagnosis
 with newer assays cortisol concentrations >450 nmol/L are acceptable to
exclude hypoadrenalism
 100–450 nmol/L is indeterminate and may require an adrenocorticotropic
hormone (ACTH) stimulation test:
 ACTH depot, IM, 1 mg with blood sampling at 60 minutes.

o Post ACTH, serum cortisol level normal value: >550 nmol/L or
double the pre-test level.
LoE:IIIi
GENERAL MEASURES
All patients with confirmed hypoadrenalism.
Investigate for other causes such as sepsis and treat accordingly.
MEDICINE TREATMENT
Acute crisis
E27.2
Before administering hydrocortisone, ensure blood samples are taken for
serum cortisol and plasma ACTH, if feasible.
 Hydrocortisone, IV, 100 mg 6 hourly.
o Change to oral maintenance therapy once stable. LoE:IIIii
To maintain adequate intravascular volume guided by blood pressure:

 Sodium chloride 0.9%, IV with regular glucose monitoring, and 50%
dextrose boluses if required.
o Beware of fluid overload if the combination of sodium chloride
0.9%/dextrose 5% is utilised.
o The fluid deficit is often several litres. LoE:IIIiii
Monitor glucose levels closely and treat hypoglycaemia if present.

Note: All suspected cases should be referred for full evaluation, prior to
chronic maintenance therapy.
Chronic
As maintenance therapy:
 Hydrocortisone, oral.
o Start with 10 mg in the morning and 5 mg at night.
2019 8.2
o Increase the dose according to clinical response up to 20 mg in the

morning and 10 mg at night.
o In patients requiring a midday dose, a suggested regimen is 10 mg in
the morning, 5 mg at midday and 5 mg in the early evening.
o
OR LoE:III
 Prednisone, oral.
o Start with 5 mg daily.
o Increase to maximum of 7.5 mg daily, if necessary. LoE:IIIiv
For patients who have symptoms of mineralocorticoid deficiency:

 Fludrocortisone, oral, 50–100 mcg daily may be required to normalise the
potassium and to reduce postural hypotension in primary
hypoadrenalism.
o Titrate dose of fludrocortisone in consultation with a specialist.
LoE:IIIv
Monitor response to therapy with:
» Symptoms: improvement in fatigue and GIT disturbances.
» Blood pressure: normotensive and no postural drop.
» Electrolytes: normal Na+ and K+.
During times of severe “stress” i.e. acute illness, surgery, trauma, etc.:
 Hydrocortisone, IV, 100 mg 6 hourly. LoE:IIIvi
Minor stressors e.g.: Influenza, diarrhoeal illness, chest infections and dental
procedures warrant doubling of the doses of hydrocortisone for the duration of
illness and gradual tapering back to usual dose.
REFERRAL
All suspected cases, for full evaluation.
8.3 ANDROGEN DEFICIENCY

E29.1
DESCRIPTION
Reduced testosterone due to hypothalamic/pituitary hypofunction or primary
testicular failure.
Investigations
» Morning (08h00–09h00) serum total testosterone.
» LH and FSH
2019 8.3
Serum testosterone LH and FSH

Primary testicular failure Below normal Above normal
Secondary Below normal Normal or below
(hypothalamic/pituitary) normal
hypogonadism
Note: If the serum total testosterone concentration is borderline low repeat the
test before replacement therapy is initiated. Don’t test during serious illness.
» Measure serum prolactin
» Sperm count, if infertility is a consideration.
» Further investigations to determine cause to be undertaken after referral;
consult a specialist.
MEDICINE TREATMENT
Screen hypogonadal men for prostate cancer before beginning
testosterone replacement. Testosterone therapy can induce prostatic
hypertrophy, polycythaemia, liver dysfunction, sleep apnoea and
hyperlipidaemia. Baseline investigations for these are required prior to
initiation of therapy and long-term surveillance is required.
Individualise dosage and review doses based on clinical response.
 Testosterone cypionate, deep IM, 200–300 mg every 2–4 weeks.
o Monitor patients for prostate cancer during treatment.
o Monitor haematocrit. If haematocrit ≥ 54%, stop testosterone therapy.
LoE:Ivii
8.4 CUSHING SYNDROME

E24.0-4/E24.8-9
DESCRIPTION
Cushing syndrome is an illness resulting from excess cortisol secretion or
exogenous glucocorticoid administration. Cushing disease is hypercortisolism
secondary to an ACTH-secreting pituitary tumour.
Investigations
Low dose overnight dexamethasone suppression test (or when unavailable,
betamethasone 1 mg equivalent to dexamethasone 1 mg).
 Dexamethasone, oral, 1 mg.
o Administer at 23:00.
o Measure plasma cortisol at 8:00, the next morning after breakfast.
o In people with normal pituitary and adrenal function morning cortisol
will be suppressed to <50 nmol/L.
o Refer if cortisol levels >50 nmol/L.
LoE:IIIviii
GENERAL MEASURES
Check for hypertension and diabetes and treat accordingly.
Check potassium.
2019 8.4
REFERRAL
All cases for investigation of aetiology and appropriate management.
8.5 DIABETES MELLITUS

DESCRIPTION
Types of diabetes:
» Type 1.
» Type 2.
» Other specific types, including pancreatic diabetes mellitus.
» Gestational diabetes mellitus: See section 6.2: Diabetes mellitus in
pregnancy.
GENERAL MEASURES
All patients require lifestyle modification.
Type 2 diabetes mellitus patients: weight loss if weight exceeds ideal weight.
Correct meal/energy distribution.
Moderate or no alcohol intake.
Encourage smoking cessation.
Increase physical activity, aim for 30 minutes per day 5 times a week.
Education about foot care is essential.
Manage comorbid depression. See section 15.3.1: Depressive disorders.
Diagnosis
» In patients with symptoms of hyperglycaemia and any one of the following
criteria:
- Random plasma glucose ≥11.1 mmol/l; or
- Fasting plasma glucose ≥7.0 mmol/l; or
- 2-hour plasma glucose in a 75 g oral glucose tolerance test ≥11.1 mmol/l.
» In asymptomatic patients any one of the following criteria, confirmed by a
repeat test on a separate day within 2 weeks:
- Fasting plasma glucose ≥7.0 mmol/l; or
- 2-hour plasma glucose in a 75 g oral glucose tolerance test ≥11.1
mmol/l.
LoE:IIIix
Classification:
After diabetes mellitus has been diagnosed, attempts must be made to
classify the patient as type 1, type 2 or one of the other specific types
(including pancreatic diabetes, genetic syndromes, infection and other
causes). For management of gestational diabetes, see section 6.2: Diabetes
mellitus in pregnancy.
2019 8.5
Monitoring
At every visit: LoE:IIIx
» Finger-prick blood glucose.
» Weight and calculation of body mass index.
» Waist circumference.
» Blood pressure.
Baseline:
» Serum creatinine concentration (and calculate estimated glomerular
filtration rate (eGFR)).
» Serum potassium concentration, if on ACE-inhibitor or eGFR <30 mL/minute.
» Urine protein by dipstick.
 If dipstick negative, request ACR, unless already on an ACE-inhibitor -
microalbuminuria is defined as 2.5 to 25 mg/mmol in men, and 3.5 to
35 mg/mmol in women (see section 8.7.2: Diabetic kidney disease).
 If dipstick positive, see section 8.7.2: Diabetic kidney disease.
» Blood lipids (fasting total cholesterol, triglycerides, HDL and LDL
cholesterol).
» Foot examination.
» Eye examination to look for retinopathy.
» Waist circumference.
Measure HbA1c:
» 6-monthly in patients who meet treatment goals, and
» 3-monthly in patients whose control is sub-optimal or if therapy has
changed, until stable.
Note: Monitoring of HbA1c implies that active clinical management will be
implemented if the level is sub-optimal.
Annually:
» Serum creatinine concentration (and calculate eGFR).
» Serum potassium concentration (if on ACE-inhibitor/ eGFR <30 mL/minute).
» Urine protein by dipstick. LoE:IIIxi
 If dipstick negative, request ACR, unless already on
an ACE-inhibitor - microalbuminuria is defined as 2.5 to 25 mg/mmol
in men, and 3.5 to 35 mg/mmol in women (see section 8.7.2: Diabetic
kidney disease).
 If dipstick positive, see section 8.7.2: Diabetic kidney disease.
» Eye examination to look for retinopathy.
» Foot examination.
» Assessment for peripheral neuropathy.
» Oral and dental examination.
» Assessment for macrovascular disease.
» Resting ECG.
2019 8.6
TARGETS FOR CONTROL

Glycaemic targets for control:
Patient type Target Target FPG* Target PPG*
HbA1c
 Young, low risk
 Newly diagnosed <6.5% 4.0–7.0 mmol/L 4.4–7.8 mmol/L
 No CVS disease
 Majority of patients <7.0% 4.0–7.0 mmol/L 5.0–10.0 mmol/L
 Elderly
 High risk <7.5% 4.0–7.0 mmol/L <12.0 mmol/L
 Hypoglycaemic
unawareness
 Poor short-term
prognosis
*FPG: fasting plasma glucose; PPG: post prandial plasma glucose.
Non-glycaemic targets:
» BMI ≤25 kg/m2.
» BP ≤140/90 mmHg and ≥120/70 mmHg.
In the elderly, the increased risk of hypoglycaemia must be weighed against
the potential benefit of reducing microvascular and macrovascular
complications.
In patients with severe target organ damage, therapy should be tailored on an
individual patient basis and should focus on avoiding hypoglycaemia.
REFERRAL
» Inability to achieve optimal metabolic control.
» Complications that cannot be managed on site, especially ophthalmic, e.g.
cataracts and proliferative retinopathy.
» Recurrent severe hypoglycaemia.
8.5.1 TYPE 2 DIABETES MELLITUS

E11.0-9/E12.0-9/E13.0-9/E14.0-9
Management includes:
» Treatment of hyperglycaemia.
» Treatment of hypertension and dyslipidaemia after risk-assessment. See
section 3.6: Hypertension.
» Prevention and treatment of microvascular complications.
» Prevention and treatment of macrovascular complications.
2019 8.7
MEDICINE TREATMENT
Oral blood glucose lowering drugs
Metformin is the preferred initial medicine and is added to the combination of
dietary modifications and physical activity/exercise. If metformin, in maximal
dose, with diet and exercise fails to lower HbA1c to target, a second agent
should be added. This second agent may be either a sulphonylurea, or basal
insulin. The specific indication is dependent on individual circumstances.
If a combination of two agents fails to lower HbA1c to target, a third agent is
added. The preferential sequence of agents to use is metformin, followed by
the addition of sulphonylurea, followed by the addition of basal insulin.
If the combination of two oral agents and basal insulin fails to lower HbA1c to
target, or if other reasons to adjust therapy exist (such as nocturnal
hypoglycaemia), then intensified insulin therapy in consultation with a
specialist is required (either twice daily pre-mix, or basal-bolus therapy) and
sulphonylureas are discontinued.
Note: Secondary failure of oral agents occurs in about 5–10% of patients
annually.
Metformin
 Metformin, oral, 500 mg twice daily with meals.
o Adjust dose based on fasting blood glucose levels and/or HbA1c to a
maximum dose of 850 mg 8 hourly.
o Monitor renal function. LoE:Ixii
o Dose-adjust in renal impairment as follows:
eGFR Metformin dose
» eGFR >60 mL/min: Normal daily dose (see above).
» eGFR 45–60 mL/min: Standard dose, measure eGFR 3–6 monthly.
» eGFR 30–45 mL/min: Maximum dose 1 g per day; measure eGFR 3–6
monthly.
» eGFR <30 mL/min: Stop metformin.
o Contra-indicated in:
- renal impairment i.e. eGFR <30 mL/minute, LoE:IIIxiii
- uncontrolled congestive cardiac failure,
- severe liver disease,
- patients with significant respiratory compromise, or
- peri-operative cases.
Sulphonylurea derivatives: glimepiride or glibenclamide.
 Glimepiride, oral, 1 mg daily.
o Titrate the dose by 1 mg at weekly intervals up to 6 LoE:IIIxiv
mg daily (according to blood glucose levels).
o Usual dose: 4 mg daily.
OR
 Glibenclamide, oral, 2.5 mg daily 30 minutes before breakfast.
2019 8.8
o Titrate dose slowly depending on HbA1c and/or fasting blood glucose

levels to 15 mg daily.
o When ≥7.5 mg per day is needed, divide the total daily dose into 2, with
the larger dose in the morning.
o Avoid in the elderly and patients with renal impairment (i.e. eGFR <60
mL/minute).
LoE:IIIxv
Oral agents should not be used in type 1 diabetes and should be used
with caution in liver and renal impairment.
Metformin should be dose adjusted in renal impairment.
Monitor patients on sulphonylurea derivatives and concomitant rifampicin
and dose-adjust sulphonylurea as required. When rifampicin is
discontinued, monitor for risk of hypoglycaemia and dose adjustment is
required, particularly in the elderly.
Monitor serum creatinine and estimated eGFR three monthly in patients with
kidney disease.
Insulin therapy in type 2 diabetes

Indications for insulin therapy:
» Inability to control blood glucose pharmacologically, i.e.
combination/substitution insulin therapy.
» Temporary use for major stress, e.g. surgery, medical illness.
» Severe kidney or liver disease.
» Pregnancy.
Note:
» At initiation of insulin therapy, give appropriate advice on self-blood
glucose monitoring (SBGM) and diet.
» It is advisable to maintain all patients on metformin once therapy with
insulin has been initiated.
Insulin type Starting dose Increment Max. daily dose
Add on therapy: 10 units, (or 0.3 If the starting dose Refer if recurrent
 Intermediate to units/kg/day), in the is not effective hypoglycaemia
long-acting evening before increase by 2-4 occurs and targets
insulin bedtime, but not after units per dose every for control are not
22h00. 3 to 7 days until met.
fasting glucose is in
the target range.
Substitution Total daily dose: 0.3 4 units weekly. Refer if recurrent
therapy: units/kg/day divided as hypoglycaemia
 Biphasic follows: First increment is occurs and targets
insulin (30/70  2/3 of total daily added to dose for control are not
mix) dose 30 minutes before breakfast. met.
before breakfast.
 1/3 of total daily
dose 30 minutes
2019 8.9
Insulin type Starting dose Increment Max. daily dose

before supper. Second increment
LoE:IIIxvi is added to dose
before supper.
Basal bolus Start with 0.4 to 0.6 Basal insulin is Refer if recurrent
insulin therapy units/kg and divide this adjusted according hypoglycaemia
total daily dose into to fasting glucose occurs and targets
50% basal and 50% levels and bolus for control are not
bolus, using equal pre- insulin is adjusted met.
meal doses according to pre-
and post-meal
glucose, using the
patient’s home
glucose record as a
guide.
Also see insulin protocols as in section 8.5.2: Type 1 diabetes mellitus.
LoE:IIIxvii
Note: Insulin requirements decrease in patients with chronic renal impairment.
In these situations, blood glucose monitoring must be done regularly (at least
daily) in order to reduce the dose appropriately, reducing the risk of
hypoglycaemia.
To reduce cardiovascular risk

See section 8.8: Dyslipidaemia.
Renal impairment
If urine ACR >2.5 mg/mmoL (men) or >3.5 mg/mmoL (women):
Start treatment with a low dose of ACE-inhibitor and titrate up to the maximum
tolerated dose.
ADD LoE:Ixviii
 Enalapril, oral.
o Start with 5 mg 12 hourly and titrate to 20 mg 12 LoE:IIIxix
hourly, if tolerated (depending on BP and ACR).
See section 7.1.1: Chronic Kidney Disease.
If an ACE-inhibitor is not tolerated due to intractable cough, consider an

angiotensin II receptor blocker. See section 7.1.1: Chronic Kidney Disease.
8.5.2 TYPE 1 DIABETES MELLITUS

E10.0-9/ E12.0-9/E13.0-9/E14.0-9
Management includes:
» Maintenance of glycaemic control within acceptable limits.
» Prevention of chronic complications.
» Prevention of acute complications, e.g. hyperglycaemic and hypoglycaemic
coma.
2019 8.10
Insulin preparations
 Insulin, short acting SC, three times daily, 30 minutes before meals:
Regular human insulin.
Onset of action: 30 minutes.
Peak action: 2–5 hours.
Duration of action: 5–8 hours.
 Insulin, intermediate acting, SC, once or twice daily, usually at night, not
later than 22h00.
Onset of action: 1–3 hours.
 Insulin, biphasic, SC, once or twice daily.
Mixtures of regular human insulin and NPH insulin in different
proportions, e.g. 30/70.
Onset of action: 30 minutes.
Selection of insulin regimen

Basal bolus regimen
All type 1 diabetics should preferentially be managed with combined
intermediate-acting (basal) and short-acting insulin (bolus), the so-called
basal bolus regimen. This consists of pre-meal short-acting insulin and
bedtime intermediate-acting insulin not later than 22h00.
Insulin doses
The initial total daily insulin dose:
o 0.6 units/kg body weight.
The total dose is divided into:

o 40–50% basal insulin
o The rest of the total daily dose (TDD) is given as bolus insulin split equally
before each meal.
Adjust dose on an individual basis.
Alternative regimen where blood glucose cannot be measured frequently by

the patient or caregiver: Twice daily insulin
Twice daily pre-mixed insulin, i.e. a mixture of intermediate- or short- acting
insulin provides adequate control, when used with at least daily blood glucose
monitoring.
Note: Optimal glycaemic control is seldom achieved with this regimen.
LoE:III
Insulin delivery devices
In visually impaired patients prefilled syringes should be used.
2019 8.11
Home glucose monitoring

Patients on basal/bolus insulin should measure glucose 3-4 LoE:III
times daily. This may be individualised depending on the
clinical need of the patient.
All patients with type 2 diabetes, on insulin, should be given test strips for
home glucose monitoring appropriate for their care plan.
It is important to maximise the value of home glucose monitoring by careful
review of home glucose records at each visit and appropriate patient
education in terms of self-dose adjustment.
LoE:Ixx
Glucagon
Type 1 diabetics, who are found to be at high risk of hypoglycaemia because
of recurrent episodes, should have a glucagon hypoglycaemia kit and both the
patient and their family should be trained to use this emergency therapy.
Repeat prescriptions of glucagon hypoglycaemia kit should only be given if
the kit has expired or been utilised.
LoE:III
8.6 DIABETIC EMERGENCIES

Diabetic emergencies includes hypyoglycaemia, diabetic ketoacidosis (DKA)
and hyperglycaemic hyperosmolar syndrome (HHS).
8.6.1 HYPOGLYCAEMIA
E10.0-1/E10.6/E11.0-1/E11.6/E12.0-1/E12.0-1/E12.6/E13.0-1/E13.6/E14.0-1/E14.6
Diagnosis: Clinical
Symptoms:
» Anxiety » Sweating
» Palpitations » Hunger
» Headaches » Behavioural changes
Signs:
» Sweating » Tremor
» Tachycardia » Confusion
» Bizarre neurological signs » Seizures
» Coma
Biochemical
Act on finger prick blood glucose. Confirm with laboratory measurements if
uncertain.
TREATMENT
Start immediately.
2019 8.12
 Dextrose 50%, rapid IV injection, 50 mL.

Assess clinical status and finger prick glucose level over the next 5–10 minutes.
LoE:IIIxxi
Establish a large bore intravenous line and keep open with:
 Dextrose 10%, IV.
If no clinical response, give a second injection of:
 Dextrose 50%, IV, 50 mL.
To prevent recurrent hypoglycaemia, continue infusion with:
 Dextrose 10%, IV infusion, at a rate of ± 1 L 6 hourly.
Once blood glucose is normal or elevated, and the patient is awake, check blood
glucose hourly for several hours, and check serum potassium for hypokalaemia.
If the patient has not regained consciousness after 30 minutes with normal or
elevated blood glucose, look for other causes of coma.
Once the patient is awake, give a snack if possible, and admit for observation
and education etc., to prevent further hypoglycaemic episodes.
If hypoglycaemia was caused by a sulphonylurea, the patient will require

hospitalisation and a prolonged intravenous glucose infusion.
Observe patient for at least 12 hours after glucose infusion has stopped.
Recurrent hypoglycaemia
In cases of recurrent hypoglycaemia consider:
» inappropriate management, e.g. too much insulin or too high dose of
sulphonylurea,
» poor meal adherence,
» poor adherence,
» alcohol abuse,
» physical exercise,
» factitious administration of insulin,
» the “honeymoon” period of type 1 diabetes,
» the advent of renal failure,
» hypoglycaemic unawareness, or
» pancreatic diabetes/malabsorption.
Other causes of hypoglycaemia should also be considered e.g. associated
Addison’s disease or hypopituitarism.
Recurrent hypoglycaemia may be the cause of hypoglycaemic unawareness,
which may occur in patients with type 1 diabetes. The loss of warning symptoms
can lead to severe hypoglycaemia. In some cases, this situation can be restored
to normal with avoidance of any hypoglycaemia for at least 2–4 weeks.
2019 8.13
8.6.2 DIABETIC KETOACIDOSIS (DKA) AND

HYPEROSMOLAR HYPERGLYCAEMIC STATE (HHS)
E10.0-1/E11.0-1/E12.0-1/E13.0-1/E14.0-1
Diabetic comas – recognition and clinical profiles

DKA often occurs in younger patients and develops over hours to days. There
may be vomiting, abdominal pain and acidotic breathing.
» blood glucose usually <40 mmol/L
» blood ketones are positive
» serum osmolality <350 mOsm/L
Hyperosmolar hyperglycaemic state (HHS) is a syndrome characterised by
impaired consciousness, sometimes accompanied by seizures, extreme
dehydration and severe hyperglycaemia, that is not accompanied by severe
ketoacidosis (pH usually >7.2). It usually occurs in elderly type 2 diabetic
patients and develops over days to weeks.
» Blood glucose usually >40 mmol/L.
» Blood ketones usually negative to moderately elevated.
» Urine ketones may be positive.
» Serum osmolality is >320 mOsm/L.
Anion gap = Na – (CI + HCO3) (Normal = ± 12: DKA >20).
Calculated serum osmolarity = 2 (Na + K) + glucose + urea.
GENERAL MEASURES
All patients:
» Set up an intravenous line.
» Protect airway and insert a nasogastric tube, if unconscious.
» Monitor urine output.
» Monitor plasma glucose, ketones, urine, electrolytes and venous blood gas.
» Look for precipitating causes, e.g. infection or MI.
MEDICINE TREATMENT
Fluids
Average deficit 6 L, may be as much as 12 L.
If renal or cardiac disease is present, monitor with central venous pressure.
In the absence of renal or cardiac compromise:
 Sodium chloride 0.9%, IV, 15–20 mL/kg in the first hour.
o Patients <20 years of age: initial volume of 10–20 mL/kg in the 1st hour.
o Subsequent infusion rate varies from 5–15 mL/kg/hour depending on
the clinical condition.
o Correction of estimated deficits should take place over 24 hours.
o The volume infused in the first 4 hours should not exceed 50 mL/kg.
o Fluid therapy thereafter is calculated to replace the estimated deficit in
48 hours, ± 5 mL/kg/hour.
o Reduction in serum osmolality should not exceed 3 mOsm/kg/hour.
2019 8.14
Correct plasma sodium value for blood glucose.

[Rough guide: divide glucose by 3 and add to sodium value.]
If plasma Na+ >140 mmol/L:

 Sodium chloride 0.45%, IV.
If plasma Na+ ≤140 mmol/L:
If plasma glucose <15 mmol/L, but ketones still present:

 Dextrose 5% or dextrose 10% in sodium chloride 0.9%, IV.
Note: LoE:IIIxxii
» Adjust fluid volumes according to clinical criteria.
» Cerebral oedema may occur with over-aggressive fluid replacement or
rapid sodium change.
Potassium
Potassium will fall on insulin treatment and patients with DKA have
potassium depletion even if initial potassium is normal or high.
It is therefore essential to monitor and replace potassium.
Total body deficit 300–1 000 mmol.

(1 ampoule = 20 mmol = 10 mL)
 Potassium chloride, IV, added to 1 L of fluid.

o potassium <3.5 mmol/L: add 40 mmol (2 ampoules).
o potassium 3.5–5.5 mmol/L: add 20 mmol (1 ampoule).
o potassium >5.5 mmol/L: do not add any potassium.
Maximum potassium dose: 40 mmol/hour.
Monitor potassium hourly initially, then 2 hourly when stabilised.
LoE:III
If serum potassium results are not readily available:
 Potassium chloride, IV, 20 mmol (1 ampoule) added to 1 L of fluid as soon
as the patient has established adequate urinary output.
Bicarbonate
There is no proven role for the use of intravenous sodium bicarbonate and it
could potentially cause harm.
Insulin therapy
Patients should be preferentially managed with continuous intravenous
infusions or hourly intramuscular injections (see below) in a high care ward,
with appropriate monitoring.
2019 8.15
Note:
» Ketonaemia takes longer to clear than hyperglycaemia and combined
insulin and glucose (and K+) are needed to ensure clearance of
ketonaemia.
» Avoid focusing on glucose control alone!
» Continue insulin until acidosis and ketosis have resolved.
Continuous intravenous infusion:

 Insulin, short-acting, IV infusion, 50 units in 200 mL sodium chloride 0.9%.
o 4 mL solution = 1 unit insulin.
o Initial infusion: 0.1 unit/kg/hour.
o Usually 5–7 units/hour: 20–28 mL/hour.
o If plasma glucose does not fall by 3 mmol/L in the 1st hour, double the
insulin infusion (hourly) until a steady reduction of plasma glucose is
achieved, i.e. at least 3–4 mmol/L per hour.
o If plasma glucose <14 mmol/L, reduce insulin infusion rate to 1–2
units/hour and adjust subsequently according to hourly bedside
capillary glucose level measured with glucose test strips.
Hourly intramuscular bolus injections:

Where intravenous infusion cannot be safely administered:
 Insulin, short-acting
o Dilute 100 units with sodium chloride 0.9% to 10 mL i.e. 10 units/mL.
o Loading dose: 0.5 units/kg body weight.
o Administer half the dose as an intravenous bolus injection and the
other half IM. Do not administer with an insulin syringe and needle.
o Subsequent hourly doses: ± 5–10 units IM every hour (i.e. 0.1
units/kg/hour) and titrated against the bedside capillary glucose level.
Progress management
Continue insulin therapy until the acidosis has resolved and:
o the patient is able to eat, and
o subcutaneous insulin therapy is instituted either at previous doses or, for
newly diagnosed diabetes at 0.5–1 unit/kg total daily dose divided into at
least 2 doses with mixed short- and long-acting insulin (biphasic insulin
2/ in the morning and 1/ at night).
3 3
Infusion must overlap with subcutaneous regimen for 1–2 hour to avoid
reversion to keto-acidosis.
Heparin.
For all patients:
 Enoxaparin, SC, 40 mg daily. LoE:Ixxiii
2019 8.16
OR
8.7 COMPLICATIONS OF DIABETES

Macrovascular complications
Diabetic patients with a history of myocardial infarction, vascular bypass,
stroke or transient ischemic attack, peripheral vascular disease, claudication,
or angina need secondary prevention with aspirin and a statin – see section
3.1: Ischaemic heart disease and atherosclerosis, prevention.
Hypertension
See section 3.6: Hypertension.
Dyslipidaemia
See section 8.8: Dyslipidaemia.
8.7.1 DIABETIC NEUROPATHIES

E10.4 / E11.4† + (G63.2*/G99.0*/G59.0*)
†
DESCRIPTION
Neuropathies are a common complication of diabetes. They play an important
role in the morbidity and mortality suffered by people with diabetes.
There are three major categories:
» peripheral neuropathy,
» autonomic neuropathy, and
» acute onset neuropathies.
MEDICINE TREATMENT
Ensure appropriate glycaemic control.
Exclude or treat other contributory factors e.g.:
» alcohol excess,
» vitamin B12 deficiency, if suspected,
» uraemia, and
» HIV infection.
Pain
See section 26.1.4: Management of neuropathic pain.
Gastroparesis
 Metoclopramide, oral, 10 mg 8 hourly, 30 minutes before meals.
If ineffective, consult a specialist.
2019 8.17
8.7.2 DIABETIC KIDNEY DISEASE

E10.0/E11.2/E12.2/E13.2/E14.2 + (N18.1-5/N18.9)
See section 7.1.1: Chronic Kidney Disease.
8.7.3 DIABETIC FOOT ULCERS

L97/L08.8 + (E10.5/E11.5/E12.5/E13.5/E14.5)
GENERAL MEASURES
Metabolic control.
Treat underlying comorbidity (e.g.: corns, alcohol misuse, ingrown toenails).
Relieve pressure: non-weight bearing is essential.
Smoking cessation is essential.
Deep (limb-threatening) infection

X-ray of affected limb.
Surgical drainage as soon as possible with removal of necrotic or poorly
vascularised tissue, including infected bone – refer urgently.
Revascularisation, if necessary.
Local wound care

Frequent wound debridement with scalpel, e.g. once a week.
Frequent wound inspection.
Absorbent, non-adhesive, non-occlusive dressings.
Superficial ulcer with extensive infection

Debridement with removal of all necrotic tissue.
MEDICINE TREATMENT
Superficial ulcer with extensive infection
Antibiotic therapy
For polymicrobial infection:
Topical antibiotics are not indicated.
o Longer course of therapy may be necessary.
Severe infection
Severe penicillin allergy (Z88.0)

 Clindamycin, oral, 150–450 mg 8 hourly.
AND
prescribing).
2019 8.18
REFERRAL
Arterial revascularisation procedures.
8.8 DYSLIPIDAEMIA
E78.0-9/E78.8-9
DESCRIPTION
Non-pharmacological therapy plays a vital role in the management of
dyslipidaemia. Many patients with mild or moderate dyslipidaemia will be able
to achieve optimum lipid levels with lifestyle modification alone and may not
require lifelong lipid modifying therapy.
Accompanying modifiable risk factors for coronary artery disease (CAD) e.g.
hypertension, smoking, diabetes, must be sought and treated.
Underlying causes of secondary dyslipidaemia, e.g. excess alcohol intake,
hypothyroidism, should be identified and corrected.
The goal of treatment should be explained clearly to the patient and the risks
of untreated dyslipidaemia should be emphasised.
GENERAL MEASURES
Dietary strategies are effective.
» Replace saturated fats with unsaturated fats (mono-and polyunsaturated
fats) without increasing calories from fats.
» Consume a diet high in fruits, vegetables, nuts and whole unrefined grains.
Smoking cessation.
Increase physical activity.
Maintain ideal body weight.
MEDICINE TREATMENT
Indication for medicine therapy
Cardiovascular
The main indication for lipid-modifying medication is to reduce the risk of a
cardiovascular event. Medicine therapy should be considered when non-
pharmacological means have failed to reduce the lipid levels to within the target
range. When lipid-lowering medicines are used, this is always in conjunction
with ongoing lifestyle modification.
Patients with any of the following factors are at a relatively high risk for a
cardiovascular event and would benefit from lipid lowering therapy:
» established atherosclerotic disease
- confirmed ischaemic heart disease
- peripheral vascular disease
- atherothrombotic stroke
» type 2 diabetics with age >40 years of age
2019 8.19
» type 1 diabetes with microalbuminuria

» diabetes with chronic kidney disease (eGFR <60 LoE:Ixxiv
mL/minute).
Patients without established vascular disease, with a risk of MI ≥20% in 10

years: lifestyle modification and start statin treatment - see section 3.1:
Ischaemic heart disease and atherosclerosis, prevention.
Non-cardiovascular
The most serious non-cardiovascular complication of dyslipidaemia is the
development of acute pancreatitis. This is seen in patients with severe
hypertriglyceridaemia (fasting triglycerides >10 mmol/L). Ideally such patients
should be discussed with a lipid specialist.
Fibrates are the medicines of choice for severe hypertriglyceridaemia not due
to secondary causes.
Choice of medication
Depends on the type of lipid disturbance:
» predominant hypercholesterolaemia: statin
» mixed hyperlipidaemia: statin or fibrate
» predominant hypertriglyceridaemia: fibrate
 HMGCoA reductase inhibitors (statins), according to table below:

INDICATION HMGCOA REDUCTASE INHIBITOR
(STATIN) DOSE
A: Primary prevention - no existing CVD

» Type 2 diabetes with age >40 years.  HMGCoA reductase inhibitors
» Diabetes for >10 years. (statins), e.g.:
» Diabetes with chronic kidney  Simvastatin, oral, 10 mg at night.
disease.
» ≥20% 10-year risk of cardiovascular
event.
(Risks as above, after switching to
atazanavir – see section below).
B: Secondary prevention – existing CVD
» Ischaemic heart disease.  HMGCoA reductase inhibitors

» Atherothrombotic stroke. (statins), e.g.:
» Peripheral vascular disease.  Simvastatin, oral, 40 mg at night
LoE:Ixxv
LoE:Ixxvi
» Patients on amlodipine (and not on  Simvastatin, oral, 10–20 mg at night.

protease inhibitor). LoE:IIIxxvii
2019 8.20
» If patient complains of muscle pain. Reduce dose:

 HMGCoA reductase inhibitors
(statins), e.g.:
OR
Consult specialist for further
management.
LoE:IIIxxviii
Note: Lipid-lowering medicines must always be used in conjunction with

ongoing lifestyle modification.
For patients with moderate to severe fasting hypertriglyceridaemia and for

patients on antiretroviral therapy i.e. triglycerides >10 mmol/L:
 Fibrates, e.g.:
 Bezafibrate, slow release, oral, 400 mg daily.
Aspirin therapy:
Use in adult patients with diabetes who have a history of cardiovascular disease
i.e.
- ischaemic heart disease
- peripheral vascular disease
- previous thrombotic stroke
 Aspirin, oral, 150 mg daily. LoE:Ixxix
Dyslipidaemia in HIV-infected patients: See section 10.1.2: Management of
selected antiretroviral adverse drug reactions.
REFERRAL
» Patients with possible familial hypercholesterolaemia (FH) i.e. random
cholesterol >7.5 mmol/L or with tendon xanthomata (See section 3.1:
Ischaemic heart disease and atherosclerosis).
» Suspected severe familial dyslipidaemias.
8.9 HYPERCALCAEMIA, INCLUDING PRIMARY

HYPERPARATHYROIDISM
E83.5 + (E21.0/D71)
DESCRIPTION
When serum calcium (corrected for albumin) concentrations exceed the upper
limit of normal.
Aetiology
» Ambulatory patients: most common cause is hyperparathyroidism (>90%
of cases).
» Hospitalised patients: malignancies are the most common cause (65% of
cases). Hyperparathyroidism accounts for another 25%.
» Granulomatous disease (e.g. sarcoid).
2019 8.21
» Immobilisation in those with high bone turnover.
Investigations
Draw blood for parathyroid hormone (PTH) and simultaneous calcium,
phosphate, magnesium, albumin, creatinine and sodium and potassium, and
25 hydroxy-vitamin D concentrations.
A detectable PTH in the presence of hypercalcaemia indicates PTH-
dependent hyperparathyroidism.
MEDICINE TREATMENT
Hypercalcaemia
Patients with moderate/severe hypercalcaemia should be kept well hydrated
and may need several litres of fluid.
Avoid thiazide diuretics in the acute setting as they increase serum calcium
concentration.
The addition of furosemide has not been shown to be of benefit.
For symptomatic hypercalcaemia:
 Sodium chloride solution 0.9%, IV infusion, 4–6 L in 24 hours.
o Monitor urine output.
If still symptomatic after 24 hours and adequate hydration, or if initial serum
calcium is >3 mmol/L:
ADD
 Bisphosphonates, e.g.:
 Zoledronic acid, IV infusion, 4 mg over 15 minutes (specialist initiated).
o eGFR 35 to 60 mL/minute, adjust dose in consultation with specialist.
o Note: Do not use if eGFR <35 mL/minute. LoE:Ixxx
In patients with granulomatous disease and haematological malignancies:

 Prednisone, oral, 40 mg depending on response, daily.
LoE:IIIxxxi
REFERRAL
When a diagnosis of hyperparathyroidism is confirmed or other cause is not
obvious.
8.10 HYPOCALCAEMIA
E83.5 + (E20.0-1/E20.8-9)
DESCRIPTION
Serum calcium (corrected for albumin) below the lower limit of normal.
Causes
» Renal failure.
» Hypoparathyroidism:
2019 8.22
― post neck surgery,

― radiotherapy, or
― idiopathic.
» Vitamin D-related, (deficient intake, activation or action).
» Hypomagnesaemia.
» Malabsorption syndrome.
MEDICINE TREATMENT
Therapy is aimed at treating the underlying cause.
For acute hypocalcaemia with neurological problems and prolonged QT time

on ECG:
 Calcium gluconate 10%, infusion, 20 mL in 100 mL dextrose 5% given
over 20 minutes, with ECG monitoring.
AND
 Calcium gluconate 10%, infusion, 15 mg/kg (= wt [kg] x 1.7 mL) in 1000
mL sodium chloride 0.9% over 4 hours.
LoE:IIIxxxii
For hypoparathyroidism:
 Alfacalcidol, oral, 1–3 mcg daily.
AND
 Calcium, elemental, oral, 500–1 500 mg daily in divided doses.
Correct magnesium deficiency if present.
Renal failure:
See Section: 7.1.1 Chronic Kidney Disease (CKD).
REFERRAL
» If cause is uncertain.
» If hypoparathyroidism suspected and PTH analysis required as above.
8.11 HYPOTHYROIDISM
E03.0-5/E03.8-9
DESCRIPTION
Causes
Common causes of primary hypothyroidism are:
» chronic autoimmune thyroiditis,
» post-surgery, and
» post radio-active iodine.
Secondary hypothyroidism (less than 1% of cases) may be due to any cause
of anterior hypopituitarism.
2019 8.23
Investigations
Thyroid stimulating hormone (TSH) and thyroxine (T4) initially. In primary
hypothyroidism TSH is elevated and T4 is low. If TSH is normal or slightly
elevated and T4 is low this suggests hypopituitarism: take blood for cortisol
and ACTH, give hydrocortisone replacement before starting levothyroxine and
investigate for causes of hypopituitarism.
MEDICINE TREATMENT
 Levothyroxine, oral, 100 mcg daily.
o If there is a risk of ischaemic heart disease, start at 25 mcg daily and
increase by 25 mcg every 4 weeks.
Check TSH and T4 after 2–3 months and adjust dose if required.
TSH levels will take several weeks to stabilise. Once stable check T4 and TSH
annually.
Hypothyroidism in pregnancy
About 60% of hypothyroid pregnant women need an increase in levothyroxine
therapy in the second and third trimesters. Because T4 takes a long time to
reach steady state and 1st trimester hypothyroidism is undesirable for the
fetus, for patients with borderline control (TSH>1.2mU/L) it is advisable to
increase the pre-pregnancy dose by 30%. Check TSH monthly and increase
levothyroxine doses to keep serum TSH levels low normal and free T4 levels
in the high-normal range. After delivery, revert to pre-conception doses.
Note: TSH and T4 reference range is trimester-specific.
LoE:IIxxxiii
8.12 OSTEOPOROSIS
M80.00-59/M80.80-99/M81.00-69/M81.80-99/M82.00-19/M82.80-89
DESCRIPTION
A disease characterised by low bone mass and micro-architectural bone
deterioration leading to bone fragility and increase in fracture risk.
GENERAL MEASURES
Prevention
Adequate energy and protein intake.
Adequate dietary calcium intake (>1 g/day) particularly in the young, in
breastfeeding mothers and in the elderly. This is preferably obtained from a
dietary source.
Weight bearing exercises, e.g. brisk 30-minute walk 3 times a week.
Smoking cessation.
Avoid excessive alcohol intake - >2 units daily has a 40% increased risk of
sustaining any osteoporotic fracture, compared to people with moderate or no
alcohol intake.
Avoid falls. LoE:IIIxxxiv
2019 8.24
MEDICINE TREATMENT
Primary prevention
In institutionalised frail elderly patients, supplementation with calcium and
vitamin D may reduce the incidence of hip fractures:
 Calcium, elemental, oral, 1 000 mg daily. LoE:IIIxxxv
AND
 Vitamin D (Calciferol), oral, 800 units daily or 50 000 units weekly.
Note: Routine supplementation with calcium and vitamin D marginally
increases the risk of myocardial infarction and stroke and is of unclear
benefit in other populations. LoE:Ixxxvi
For glucocorticoid-induced osteoporosis, i.e. patient on long-term (>3 months)

corticosteroids at doses ≥5 mg/day: M81.80-M81.89 LoE:Ixxxvii
 Alendronic acid, oral, 70 mg weekly, for a maximum duration of 5 years.
o Taken with a full glass of water, 30 minutes before breakfast – do not
lie down.
Secondary prevention
Secondary prevention of osteoporotic fracture:
In severe osteoporosis, i.e. patients who have a T-score of –2.5 (severe
osteoporosis) plus an osteoporotic fracture: LoE:Ixxxviii
 Alendronic acid, oral, 70 mg weekly, for a maximum duration of 5 years.
o Taken with a full glass of water, 30 minutes before breakfast – do not
lie down.
Supplement bisphosphonate therapy with:

 Calcium, elemental, oral, 1 000mg daily.
AND
 Vitamin D (Calciferol), oral, 800 units daily.
Hormone replacement therapy
See Section 5.12: Menopause and Perimenopausal Syndrome.
Only indicated early in menopause, if vasomotor symptoms are significant.
Review contra-indications before initiating therapy.
REFERRAL
» Initial assessment.Initiation of, and monitoring response to, therapy, and 18–
24 monthly bone mineral density (BMD), where required.
» Fractures suspected to be due to osteoporosis for consideration for
bisphosphonates.
» Patients not tolerating oral bisphosphonate.
» Patients with e-GFR < 30 mL/minute.
2019 8.25
8.13 OSTEOMALACIA/RICKETS
M83.00-59/M83.80-99/E55.0
DESCRIPTION
A disorder of mineralisation of newly synthesised bone matrix.
REFERRAL
All patients.
8.14 PAGET’S DISEASE

M88.08/M88.80-99
DESCRIPTION
Bone disease characterised by localised uncontrolled formation of highly
active osteoclasts leading to an increase in bone resorption followed by
chaotic increase in bone formation.
GENERAL MEASURES
Most cases are mild and asymptomatic and no treatment is required. The
diagnosis is supported by isolated high alkaline phosphatase and typical CXR
radiological changes.
Avoid high calcium diet when immobile as hypercalcaemia may occur with
immobilisation.
Differentiate bone pain of Paget’s, especially at night, from arthritic pain in
joints near deformed bone, e.g. hip and knee joints, as well as pain resulting
from fracture or complicating osteosarcoma.
MEDICINE TREATMENT
For arthritic pain:
 NSAID, e.g.:
REFERRAL
All patients.
8.15 PITUITARY DISORDERS

Includes prolactinoma, anterior hypothyroid hypopituitarism and diabetes
insipidus.
8.15.1 PROLACTINOMA
D35.2 + (M8271/0)
DESCRIPTION
Prolactinoma is the most common functioning pituitary tumour.
2019 8.26
Investigations
Serum prolactin, β-hCG.
Note:
» There are numerous causes of hyperprolactinaemia other than a
prolactinoma, so secondary causes must be excluded e.g. pregnancy,
medicines, physiological, hypothyroidism, chronic renal failure and
tumours.
» In patients with prolactinoma, serum prolactin levels are usually elevated
≥4 times the upper limit of the normal reference range for the laboratory
method used. Lesser degree of elevation of serum prolactin may also be
found in patients with other pituitary tumours associated with pituitary stalk
compression.
MEDICINE TREATMENT
Dopamine agonist therapy is the treatment of choice.
 Bromocriptine, oral, 1.25 mg at bedtime with a snack.
o Initial maintenance dose: increase dose to 2.5 mg 12 hourly with food
and check prolactin 4 weeks later.
o Higher doses may be needed.
o GIT side effects are minimised by giving doses with food.
o If total dose of 10 mg does not normalise prolactin, refer.
REFERRAL
» All tumours, once causes of secondary hyperprolactinaemia have been
sought and excluded.
» Intolerance to bromocriptine.
» Unexplained hyperprolactinemia.
Urgent
» Any visual disturbances, especially those suggesting compression of
optic chiasm.
» Pituitary apoplexy.
8.15.2 ANTERIOR HYPOPITUITARISM

E23.0-3/E28.3/E29.1
DESCRIPTION
Absent or diminished secretion of one or more anterior pituitary hormones due
to primary damage of the anterior pituitary gland, or secondary to
hypothalamic dysfunction, which may result in hypothyroidism and/or
hypoadrenalism and/or hypogonadism or growth retardation in children.
GENERAL MEASURES
Surgery is required for large tumours, pituitary apoplexy, and hormone
secreting tumours (except for most patients with prolactinomas, who generally
2019 8.27
respond well to medical therapy).

Radiotherapy may be required in selected patients.
A notification bracelet is needed.
MEDICINE TREATMENT
Acute crisis
Treat as for acute crisis in section 8.2: Adrenal Insufficiency (Addison’s
Disease).
Chronic
See section 8.2: Adrenal Insufficiency (Addison’s Disease).
Hypoadrenalism
See section 8.2: Adrenal Insufficiency (Addison’s disease) and 8.11:
Hypothyroidism.
Hypothyroidism
See section 8.11: Hypothyroidism.
Hypogonadism
Individualise dosage and need for replacement according to age, symptoms, etc.
Women:
As for postmenopausal HT, see section 5.12: Menopause and
perimenopausal syndrome.
Men:
 Testosterone cypionate, IM, 200–300 mg every 3–4 weeks.
See section 8.3: Androgen deficiency.
REFERRAL
All diagnosed patients for initial assessment.
8.15.3 DIABETES INSIPIDUS (POSTERIOR HYPOPITUITA-

RISM)
E23.2
DESCRIPTION
Damage to the posterior pituitary leading to deficient production of antidiuretic
hormone. Characterised by the passage of large amounts of dilute urine,
usually >2.5 litres daily.
Causes include head trauma and neurosurgery but most cases are idiopathic.
Consultation with a specialist is recommended.
GENERAL MEASURES
Rehydration with water or hypotonic fluids.
2019 8.28
MEDICINE TREATMENT
Postoperative or acutely ill patients:
 Desmopressin, IV/SC, 2–4 mcg daily, either as a single dose or in 2
divided doses.
OR
 Desmopressin, nasal spray, 10–40 mcg daily, either as a single dose or in
2–3 divided doses.
OR
 Desmopressin, oral, 0.05 mg, 8–12 hourly.
o Optimal dose: 0.1–0.8 mg daily.
o Adjust dose according to response to a maximum of 1.2 mg daily in
divided doses.
If patient has a normal thirst mechanism, and does not receive IV fluids for
other purposes:
» oral, intranasal, or IV/SC dosing can be used; and
» keep urine osmolality at 450–600 mOsm/kg.
If patient requires IV fluids and/or is unable to regulate total fluid intake by

thirst mechanism:
» IV dosing is preferred; and
» continually adjust the level of antidiuresis to maintain hydration and plasma
sodium within the normal.
Replacement therapy:
 Desmopressin, nasal spray, 10–40 mcg daily, either as a single dose or in
2–3 divided doses.
o Adjust morning and evening doses separately for appropriate diurnal
rhythm of water turnover.
OR
 Desmopressin, oral, 0.05 mg, either as a single dose or in 2–3 divided
doses.
o Optimal dose: 0.1–0.8 mg daily.
o Adjust dose according to response to a maximum of 1.2 mg daily in
divided doses.
LoE:IIIxxxix
REFERRAL
All patients diagnosed or suspected.
Water deprivation may be necessary to confirm the diagnosis. Careful
monitoring of electrolytes and exclusion of fluid overload while on therapy is
essential to determine the appropriate dose.
2019 8.29
8.16 PHAEOCHROMOCYTOMA
C74.0-1/C74.9/C79.7/D09.3/D35.0/D44.1 + (M8700/0/3/6)
Description
Catecholamine-secreting tumour of the adrenal medulla.
Clinical presentation
Always consider in hypertensive patients who have paroxysmal symptoms:
» headaches, » tremor,
» GIT symptoms, » recurrent chest discomfort,
» palpitations, » sweating, and
» anxiety.
There is marked inter-individual variation in symptoms.
Patients may also have orthostatic changes in BP.
Diagnosis
24-hour urine acidified with HCl: normetanephrine (NMA), vanillylmandelic
acid (VMA), should be ≥ twice normal for a definite diagnosis. Test is best
done during a paroxysm, if possible, using at least 2 samples.
There are many drugs, foods and diseases that can falsely elevate or lower
NMA/VMA levels; therefore, the clinician must interpret the results in the light
of the clinical context and after having taken an accurate history.
Screen:
» young hypertensive patients;
» hypertensive patients with paroxysmal symptoms; and
» patients with:
― The classic triad of headache, sweating, and tachycardia, whether or
not they have hypertension
― a family history of a phaeochromocytoma,
― A familial syndrome that predisposes to catecholamine-secreting
tumours (e.g., multiple endocrine neoplasia type 2 [MEN2],
neurofibromatosis type 1 [NF1], or von Hippel-Lindau [VHL]). or
― radiologic evidence of an adrenal mass (adrenal incidentaloma) with
or without hypertension.
GENERAL MEASURES
Surgical removal of the tumour.
MEDICINE TREATMENT
Once diagnosis is confirmed, initiate medication with immediate referral.
 Alpha blockers, e.g.:
 Doxazosin, oral, 4 mg daily.
o Dose increase above 8 mg daily to control blood pressure may be
required.
LoE:IIIxl
 Calcium channel blockers may be added, e.g.:
2019 8.30
 Amlodipine, oral, 5–10 mg daily.

Note:
» Do not give patients diuretic therapy unless pulmonary oedema is present.
» β-blockers must be used with extreme caution in the management of
phaeochromocytoma, and only after adequate alpha blockade.
LoE:IIIxli
REFERRAL
All patients.
8.17 PRIMARY ALDOSTERONISM

E26.0
DESCRIPTION
Increased aldosterone production usually due to an adrenal adenoma (Conn's
syndrome) or idiopathic bilateral adrenal hyperplasia (the majority of cases).
Clinical
Suspect in a patient with resistant hypertension or hypertension with
hypokalaemia.
Diagnosis
Elevated serum aldosterone with a suppressed renin level and elevated
aldosterone/renin ratio.
ACE-inhibitors, angiotensin receptor blockers (ARBs), and diuretics can give
falsely elevated or lowered results. Stop all these drugs for a minimum of 2
weeks before testing. Stop spironolactone for 6 weeks before testing.
Because of limited specificity, a positive screening test result should be
followed by a confirmatory test. A negative random ratio test does not
necessarily exclude the diagnosis.
MEDICINE TREATMENT
Adrenal adenoma
A surgical resection/removal of adenoma.
Bilateral hyperplasia
Standard anti-hypertensive therapy, including spironolactone.
 Spironolactone, oral, 100–200 mg daily.
REFERRAL
All patients to an endocrinologist or a hypertension centre for confirmation of
the diagnosis and further treatment.
2019 8.31
8.18 HYPERTHYROIDISM
E05.0-5/E05.8-9
DESCRIPTION
Most common cause of hyperthyroidism is Graves’ disease, which is an
autoimmune condition resulting from the presence of thyroid stimulating
autoantibodies. Other common causes are toxic single or multinodular goitre
and sub-acute thyroiditis. Thyrotoxicosis in the setting of any other acute life-
threatening condition such as cardiac failure etc. should be managed as
thyroid crisis – see section 8.18.5: Thyroid crisis.
Investigation
TSH and free T4.
If TSH suppressed and free T4 normal, request free T3.
The usual biochemical abnormalities are: low TSH, elevated free T4/3.
TSH receptor antibodies should be measured in all patients.
Once thyrotoxicosis is confirmed, if cause is uncertain request thyroid uptake
scan. If uptake is:
» Elevated or diffuse: Grave’s disease.
» Markedly decreased: Thyroiditis.
» Patchy uptake with areas of increased uptake: Toxic multinodular goitre.
REFERRAL
» Consultation with a specialist is recommended in all cases.
» For thyroid scan if necessary.
» Thyroid-associated ophthalmopathy.
» When radioactive iodine or surgery is contemplated.
» If patient is pregnant.
8.18.1 GRAVES’ HYPERTHYROIDISM

E05.0
MEDICINE TREATMENT
 Carbimazole, oral, 20–40 mg daily.
o Titrate dose according to thyroid hormone levels (T4).
o Duration of therapy: 12–18 months.
o Durations of therapy longer than 12 months must be in consultation
with a specialist.
ß–blockers
» Used to counteract excessive sympathetic symptoms, e.g. palpitations.
» Dose is titrated according to the heart rate.
» Give for 2–6 weeks, together with carbimazole until T4 levels normalise.
 ß–blocker, e.g.:
2019 8.32
o Titrate according to symptom control up to 100 mg daily. LoE:IIIxlii
Radioactive iodine
In the setting of Graves’ disease radioactive iodine may be administered for
failed medical therapy and may be indicated for patients with coexistent heart
disease. Refer patient if radioactive treatment is contemplated.
Surgery
Seldom indicated, but to consider in the following situations: large thyroid
causing obstructive symptoms, failure of anti-thyroid medicine therapy, allergy
to anti-thyroid therapy, 2nd trimester of pregnancy, and not responding to or
allergic to anti-thyroid medication.
Monitoring
Patients with Graves’ disease who are treated with anti-thyroid drugs should
be monitored every 6–8 weeks using a serum T4. TSH may remain suppressed
for months. Once in remission, patients may be monitored less frequently to
determine signs and symptoms of recrudescence of thyrotoxicosis.
Because there is a risk of neutropenia or agranulocytosis with carbimazole,
therapy should be temporarily stopped and a white cell count (with differential)
must be done in patients presenting with an infection or sore throat.
Post-radio-active iodine TSH and free T4 should be checked at 6 weeks, 3, 6,
9 and 12 months and annually thereafter until either hypothyroidism occurs or
patient remains euthyroid for ± 3–4 years. Although uncommon, new onset
hypothyroidism can occur years later.
8.18.2 TOXIC MULTINODULAR GOITER

E05.2
MEDICINE TREATMENT
Radio-active iodine
Radioactive iodine is the treatment of choice. Medical therapy is indicated initially
for patients with underlying heart disease to achieve euthyroidism before radio-
active iodine. Surgery is restricted to patients with obstructive symptoms.
8.18.3 SINGLE TOXIC NODULES

E05.1
MEDICINE TREATMENT
Radioactive iodine
Smaller nodules are best managed with radio-active iodine while larger
nodules may require surgery.
ß–blockers
» Used to counteract excessive sympathetic symptoms, e.g. palpitations.
» Dose is titrated according to the heart rate.
» Give for 2–4 weeks.
2019 8.33
o Titrate according to symptom control up to 100 mg daily.
8.18.4 THYROIDITIS
E06.0-5/E06.9
Toxic phase lasts up to 3 months.
MEDICINE TREATMENT
ß–blockers
Used to counteract excessive sympathetic symptoms, e.g. palpitations.
Dose is titrated according to the heart rate.
Give for 2–4 weeks.
 Atenolol, oral, 50 mg daily
For painful subacute thyroiditis (De Quervain’s): E06.1
 NSAID, e.g.:
AND
 Prednisone, oral, 40 mg daily (Specialist consultation). LoE:IIIxliii
8.18.5 THYROID CRISIS

E05.5
MEDICINE TREATMENT
IV fluids as indicated.
 Carbimazole, oral, 40–60 mg 6 hourly until crisis is controlled.

30 minutes after the first dose of carbimazole: LoE:IIIxliv
 Lugol’s iodine, oral, 10 drops in milk, 8 hourly.
AND
 Atenolol, oral, 50 mg daily
If life-threatening:
ADD
2019 8.34
Actively manage precipitating illness and infection. ICU admission is

desirable.
REFFERRAL
All patients once stabilised.
2019 8.35
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subclinical hypothyroidism complicating pregnancy. Thyroid. 2002 Jan;12(1):63-8.
xxxiv Limited alcohol intake (osteoporosis): Kanis JA, Johansson H, Johnell O, Oden A, De Laet C, Eisman JA, Pols
H, Tenenhouse A. Alcohol intake as a risk factor for fracture. Osteoporos Int. 2005 Jul;16(7):737-42.
xxxv Vitamin D, oral (dosing): South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.

xxxvi Calcium: Bolland MJ, Leung W, Tai V, Bastin S, Gamble GD, Grey A, Reid IR. Calcium intake and risk of fracture:
2019 8.38
systematic review. BMJ. 2015 Sep 29;351:h4580. http://www.ncbi.nlm.nih.gov/pubmed/26420387

Vitamin D: Bolland MJ, Leung W, Tai V, Bastin S, Gamble GD, Grey A, Reid IR. Calcium intake and risk of
fracture: systematic review. BMJ. 2015 Sep 29;351:h4580. http://www.ncbi.nlm.nih.gov/pubmed/26420387
xxxviiBisphosphonates, oral (therapeutic class): Davis S, Martyn-St James M, Sanderson J, Stevens J, Goka E,
Rawdin A, et al. A systematic review and economic evaluation of bisphosphonates for the prevention of fragility
fractures. Health Technol Assess 2016;20(78). https://www.ncbi.nlm.nih.gov/pubmed/27801641
Bisphosphonates, oral (therapeutic class): National Department of Health: Affordable Medicines, EDP-Adult
Hospital level. Medicine Review: Bisphosphonates, oral therapeutic class for secondary prevention of fragility
fractures, 31 October 2017. http://www.health.gov.za/
Bisphosphonates, oral (primary prevention of glucocorticoid-induced bone loss): Allen CS, Yeung JH,
Vandermeer B, Homik J. Bisphosphonates for steroid-induced osteoporosis. Cochrane Database Syst Rev. 2016
Oct 5;10:CD001347. https://www.ncbi.nlm.nih.gov/pubmed/27706804
xxxviiiBisphosphonates, oral (therapeutic class): Davis S, Martyn-St James M, Sanderson J, Stevens J, Goka E,
Rawdin A, et al. A systematic review and economic evaluation of bisphosphonates for the prevention of fragility
fractures. Health Technol Assess 2016;20(78). https://www.ncbi.nlm.nih.gov/pubmed/27801641
Bisphosphonates, oral (therapeutic class): National Department of Health: Affordable Medicines, EDP-Adult
Hospital level. Medicine Review: Bisphosphonates, oral therapeutic class for secondary prevention of fragility
fractures, 31 October 2017. http://www.health.gov.za/
xxxixDesmopressin, oral/IV/SC/nasal spray: Oiso Y, Robertson GL, Nørgaard JP, and Juul KV. Treatment of
Neurohypophyseal Diabetes Insipidus. J Clin Endocrinol Metab 98: 3958–3967, 2013.

Desmopressin, oral/IV/SC/nasal spray: British National Formulary, March 2017-September 2018.
https://www.bnf.org/
xlDoxazosin: van der Zee PA, de Boer A. Pheochromocytoma: a review on preoperative treatment with
phenoxybenzamine or doxazosin. Neth J Med. 2014 May;72(4):190-201.

xliβ-blockers (after adequate α-blockade): Lenders JW, Duh QY, Eisenhofer G, Gimenez-Roqueplo AP, Grebe SK,
Murad MH, Naruse M, Pacak K, Young WF Jr, Endocrine Society. Pheochromocytoma and paraganglioma: an
endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2014 Jun;99(6):1915-
xlii Atenolol, oral: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of
Cape Town. 2016.

xliii Corticosteroids, oral (intermediate-acting therapeutic class): South African Medicines Formulary. 12th Edition.

xliv Carbimazole: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of
Cape Town. 2016.
2019 8.39
CHAPTER 9
SYSTEMIC AND HEALTHCARE-ASSOCIATED
INFECTIONS
ANTIMICROBIAL STEWARDSHIP
Antimicrobial stewardship refers to a systematic approach to optimising the
appropriate use of an antibiotic to improve patient outcome(s) and limit
emergence of resistant pathogens, whilst ensuring patient safety. It is one
arm of the national and international response to the increasing public health
crisis of antibiotic resistance. A critical component is adequate infection
control. Antibiotics should only be used for the treatment and prevention of
bacterial infections. The following checklist will help optimize prescribing:
Checklist for optimal antibiotic prescribing
1. Medicine – which is the narrowest-spectrum antibiotic that I can use to
treat this bacterial infection?
2. Dose – many antibiotics require weight-based dosing and their dosing
depends on renal and/or hepatic function
3. Dose frequency – dependent on the half-life of the drug and whether
the action of the antibiotic depends on the time above the MIC or the
area under the concentration/time curve. Guidance for dosing
frequency may require therapeutic drug monitoring, e.g. vancomycin
and aminoglycosides.
4. Duration – should be dictated by evidence from randomised controlled
trials whenever possible. Expert opinion from national and international
guidelines should be consulted where evidence is weak.
5. Route – most antibiotics have good oral bioavailability, but some
infections will require intravenous therapy either for the whole or part of
the course.
6. De-escalation – applies to the spectrum of antibiotic use and route of
administration. All attempts to convert early from parenteral to oral use
should be made.
MIC = minimum inhibitory concentration.
9.1 HEALTHCARE-ASSOCIATED AND HOSPITAL

ACQUIRED INFECTIONS
DEFINITION AND PRINCIPLES
Patients with healthcare associated and hospital acquired infections are at
increased risk of being infected with drug resistant organisms. A hospital
acquired infection is a new infection that develops after at least 48 hours of
hospitalisation without evidence that the infection was present or incubating
at the time of admission. Healthcare-associated infections should also be
2019 9.1
CHAPTER 9 SYSTEMIC AND HEALTHCARE-ASSOCIATED INFECTIONS
considered in persons with extensive healthcare contact such as: residence

in a nursing home or other long-term care facility, hospitalisation in an acute
care hospital for >2 days during the prior 90 days, or attendance at a
hospital or haemodialysis clinic during the prior 30 days.
It is essential to obtain specimens for culture and sensitivity testing in
all cases before starting antibiotics.
Empiric therapy suggestions below are only rough guidelines due to
heterogenity of resistance patterns between facilities and over time. Close
liaison with regional microbiologists and regular review of hospital antibiotic
policy based on local resistance patterns are essential.
9.1.1 INTRAVASCULAR CATHETER INFECTIONS

L53.9/T80.2 + (B95.8/Y84.8/B37.8)
PERIPHERAL LINE INFECTION:

Common organisms:
» coagulase negative staphylococci, particularly S. epidermis
» S. aureus
The intravascular line should always be removed.
Microbiologic specimens: peripheral blood culture, blood culture from central
catheter prior to removal, and culture of the catheter tip.
Small localised area of erythema at the catheter insertion site will usually
resolve without antibiotic therapy.
In patients with larger areas of erythema and tenderness extending beyond
the insertion site who are systemically well:
 Clindamycin, oral, 450 mg 8 hourly for 5 days. LoE:IIIi
If patients with peripheral or central venous catheter infections are
systemically unwell they should be treated as a venous catheter related
systemic blood infection.
MEDICINE TREATMENT
Duration of antibiotic therapy should generally be for 48–72 hours after
resolution of fever except for:
» confirmed S. aureus infection, and LoE:IIIii
» candidaemia,
where treatment should be continued for 2 weeks after the 1st negative
blood culture. LoE:IIIiii
Note: For candidaemia and S. aureus infection, perform blood cultures
every 2-3 days after therapy has been initiated until 2 consecutive cultures
are negative, and 2 weeks after the 1st negative blood culture.
2019 9.2
S. aureus infection (B95.8/Y84.8)

 Vancomycin, IV, 30 mg/kg, empirically as a loading dose.
o Follow with 20 mg/kg/dose 12 hourly. (See Appendix II for guidance
on prescribing and therapeutic drug monitoring).
o Tailor therapy to drug-susceptibility results. LoE:IIIiv
Candidaemia (B37.8/Y84.8)
Note: Candida isolated from blood culture should always be treated, even if the
fever has settled after line removal because of a high risk of late complications.
Candidaemia with species other than Candida albicans is becoming increasingly
common – these species are often resistant to azoles.
Treatment duration should be 2 weeks after 1st negative blood culture:
 Amphotericin B, IV, 0.7 mg/kg daily. LoE:IIIv
o Ensure adequate hydration to minimise nephrotoxicity.
(See Appendix II for preventing, monitoring and
management of toxicity). LoE:Ivi
Follow up susceptibility:
- Once improved, if sensitive complete course with:
 Fluconazole, oral, 800 mg daily. LoE:IIIvii
Intolerance to amphotericin B:
 Fluconazole, oral, 800 mg daily, if sensitive.
o Dose adjust in renal impariment.
Invasive candidiasis (resistant to fluconazole/amphotericin B or renal

impairment is present and amphotericin B cannot be used):
 Echinocandins. (Specialist motivation).
S. aureus endocarditis.
9.1.2 SURGICAL WOUND INFECTIONS

T81.4 + (Y83.6/Y83.8-9/B95.6/U82.1)
DESCRIPTION
Common organisms: Gram positive bacteria, especially S. aureus, are the
commonest cause. Gram negative and anaerobic bacteria are important
causes following gynaecological and intestinal surgery.
Microbiologic specimen: deep wound swab or aspirate of pus, and blood culture.
Suture removal plus incision and drainage is essential. Antibiotics are not
usually necessary except if there is marked surrounding cellulitis or features
of systemic infection.
2019 9.3
MEDICINE TREATMENT
Empiric antibiotic therapy: Total duration of therapy should not exceed 7 days.
If surrounding cellulitis or systemic sepsis not involving the gastro-
intestinal (GI) or female genital tract:
Follow with oral therapy as soon as patient can swallow and LoE:IIviii
the temperature is <37.8oC for 24 hours:
 Flucloxacillin, oral, 500 mg 6 hourly. LoE:IIIix
Check Gram stain of exudate. If Gram negative organism:

ADD
 Piperacillin/tazobactam, IV, 4.5 g 8 hourly.
LoE:III
Follow with oral therapy as soon as patient can swallow and the temperature
is <37.8oC for 24 hours, based on culture results:
 Clindamycin, oral, 450 mg 8 hourly, and LoE:IIIx
Check Gram stain of exudate. If Gram negative organism:

ADD
 Ertapenem, IV, 1g daily. LoE:Ixi
Methicillin (cloxacillin) reistant S. aureus (MRSA)

T81.4+ (B95.6+U82.1+Y83.9)
12 hourly. (See Appendix II for guidance on prescribing and monitoring).
o Drain wound and obtain cultures to verify MRSA.
If female uro-genital tract surgery or open GIT surgery:

T81.4 +(Y83.6/Y83.8)
AND
 Metronidazole, IV, 500 mg 8 hourly. LoE:IIIxii
9.1.3 HOSPITAL-ACQUIRED PNEUMONIA (HAP)

J12.0-3/J12.8-9/J13/J14/J15.0-9/J16.0/J16.8/J18.0-2/J18.8-9 + (Y95)
DESCRIPTION
HAP is defined as a new lung infiltrate (not present on admission) plus
clinical evidence that the infiltrate is an infection (e.g. new onset of fever,
purulent sputum, leukocytosis) occurring >48 hours after admission to
hospital. HAP has a high morbidity and mortality and early appropriate
antibiotic therapy is essential.
Infection may be due to multi-drug resistant organisms, particularly in
2019 9.4
patients with prior intravenous antibiotic use within 90 days. LoE:Ixiii

Ventilator-associated pneumonia (VAP) ocurs >48 hours after intubation. VAP
is more often due to multi-drug resistant organisms than HAP.
Microbiologic specimens: blood culture and sputum/tracheal aspirate bacterial
culture. Therapy should be adjusted according to culture result. A good quality
Gram stain may be useful in guiding the choice of initial therapy.
MEDICINE TREATMENT
Duration: 10 days.
HAP with no prior intravenous antibiotic use within 90 days:

and
 Amikacin, IV, 15 mg/kg daily.
Severe Penicillin allergy: (Z88.0)
 Moxifloxacin, oral/IV, 400 mg daily.
and
 Amikacin, IV, 15 mg/kg daily. (See Appendix II, for individual dosing and
HAP with prior intravenous antibiotic use within 90 days and VAP.
Antibiotic choice will depend on local susceptibility patterns. One or more of
the following antibiotics/classes must be available, dependant on local
susceptibility patterns:
and
 Amikacin, IV, 15 mg/kg daily. (See Appendix II, for individual dosing and
LoE:IIIxiv
OR
 Cefepime, IV, 2 g 12 hourly. (See Appendix II for guidance on dosing in
renal impairment).
OR LoE:IIIxv
Instead of piperacillin/tazobactam + amikacin OR cefepime:
Carbapenem with activity against Pseudomonas:
 Imipenem/cilastan, IV, 1000/1000 mg 8 hourly (except CNS infections or
known epileptics).
LoE:IIIxvi
OR
Instead of piperacillin/tazobactam + amikacin OR cefepime OR imipenem:

 Meropenem, IV, 2 g 8 hourly (CNS infections or known epileptics).
Note: De-escalate as soon as the culture is available.
2019 9.5
9.1.4 URINARY TRACT INFECTIONS, CATHETER

ASSOCIATED
T83.5 + (Y84.6+N39.0)
DESCRIPTION
Common organisms: resistant aerobic Gram negative bacteria.
Microbiologic specimen: blood culture and MSU/CSU for microscopy and
bacterial culture.
In most patients with long-term catheters bacteria cultured on CSU represent
colonisation rather than infection – only treat with antibiotics if there are
features of sepsis or pyelonephritis.
GENERAL MEASURES
Remove catheter.
MEDICINE TREATMENT
Empiric antibiotic therapy (Duration of therapy 7–14 days):
OR
If local resistance patterns show low level resistance to ciprofloxacin or
culture shows sensitivity:
 Ciprofloxacin, oral, 500 mg 12 hourly. LoE:IIIxvii
9.2 ADULT VACCINATION

Vaccine Indications Comments
» Pregnant women o Contraindication: severe
» Elderly patients >65 years. egg allergy, <6 months of
» HIV-infected patients. age.
 Influenza vaccine » Patients with chronic o Dose: IM, 0.5 mL.
Z25.1 pulmonary, cardiac, and o Repeat annually.
renal conditions.
» Healthcare workers with
direct patient contact.**
o Contraindication:
 Pneumococcal » Asplenic patients. pregnancy.
vaccine (23 » Chronic cerebrospinal fluid o Dose: IM, 0.5 mL.
valent (CSF) leak. Booster: after 5 years
polysaccharide) and at 65 years of age.
Z23.8
LoE:IIIxviii
o Dose: IM, 1 mL
» High risk groups, e.g. immediately then 1 mL
 Hepatitis B hospital personnel or sexual after 1 month and 1 mL 6
vaccine* contacts of infected patients. months after 1stdose.
Z24.6
» Sexual assault. o Administer deep IM in
deltoid muscle.
2019 9.6
Booster when there is a high

 Tetanus toxoid risk for tetanus e.g.
vaccine contaminated wound or o Dose: IM, 40 iu (0.5 mL).
Z23.5 pregnant women to prevent
neonatal tetanus.
* Not to be given to patients who have already been immunised.
**Healthcare workers are not routinely offered immunisation during the annual campaign. Although it
is recommended that healthcare workers are vaccinated against influenza, they will not be provided
with publicly funded vaccines unless they fall within any of the designated high risk groups.
NOTE: Prioritisation strategies may vary in a pandemic.
9.2.1 RABIES VACCINATION

Z24.2
See the Primary Health Care STGs and EML - Section 21.3.1.1: Animal bites.
9.3 BRUCELLOSIS
A23.0-3/A23.8-9
DESCRIPTION
Zoonotic infection, usually due to B. abortus in South Africa. Infection is
usually acquired from unpasteurised milk products or handling raw meat.
MEDICINE TREATMENT
Exclude TB before starting therapy.
 Doxycycline, oral, 100 mg 12 hourly for 6 weeks.
AND
 Gentamicin, IV, 6 mg/kg daily for 3 weeks (see Appendix LoE:IIIxix
II for guidance on prescribing).
- Preferred regimen for osteo-articular or cardiac involvement.
OR
AND
 Rifampicin, oral, 7.5 mg/kg 12 hourly for 6 weeks.
9.4 EMERGING RESPIRATORY PATHOGENS, e.g. COVID-19:

CORONAVIRUS DISEASE-19; MIDDLE EAST
RESPIRATORY SYNDROME CORONAVIRUS INFECTION:
MERS COV
B34.2/U07.1
Note: Consult most recent guidelines from National Department of Health/ NICD.
2019 9.7
DESCRIPTION
Middle East Respiratory Syndrome (MERS) is a viral respiratory illness
caused by Middle East Respiratory Syndrome Coronavirus (MERS-CoV).
Individuals with MERS-CoV present with a wide spectrum of clinical
presentation ranging from asymptomatic infection to acute upper respiratory
illness, and rapidly progressing lower respiratory illness; respiratory failure,
septic shock and multi-organ failure resulting in death.
A typical presentation of MERS includes:
» fever (>38°C), chills or rigors, cough, shortness of breath
Presentation may include:
» hemoptysis, sore throat, myalgias, diarrhoea, vomiting, abdominal pain
Complications:
» severe pneumonia » acute renal failure
» ARDS » refractory hypoxaemia
GENERAL MEASURES
All suspected, probable cases and contacts must be discussed and
managed in consultation with the regional virologist or infectious diseases
specialist at the referral centre.
In addition cases should be discussed with the Centre for Respiratory
Diseases of the National Institute for Communicable Diseases (NICD).
Tel: 011 386 6392/ 011 3866390 , Outbreak hotline: 082 883 9920
COVID-19 HOTLINE NUMBERS
Clinicians: 080011131
Public: 080002999
http://www.nicd.ac.za/ ; https://sacoronavirus.co.za/
Transfer of patients will only occur once all relevant arrangements have
been made to limit further exposure to a potential contagious and life
threatening agent.
Droplet precautions should be added to the standard precautions. Airborne
precautions should be applied when performing aerosol-generating
procedures.
ISOLATE SUSPECTED SYMPTOMATIC CASES AT ALL TIMES.
If MERS coronavirus is suspected, isolate patient to limit further exposure.
MANAGEMENT
Treatment
Treatment is supportive.
No antiviral agents or vaccines are currently available.
Management of contact: consult with NICD and isolate contact.
Record and follow-up all patient contacts.
Prevention
Handwashing and the careful disposal of materials infected with nasal
2019 9.8
secretions. Antiseptic/disinfectant solutions:choroxylenol, benzalkonium

chloride, and cetrimide. Chlorhexidine has been shown to be ineffective.
REFERRAL
All cases after consultation with infectious diseases and NICD.
9.5 HAEMORRHAGIC FEVER SYNDROME

A98.0-4/A98.8/A99
* Notifiable medical condition.
Severe bacterial infections can mimic the features of haemorrhagic fever

syndrome, and broad spectrum antibiotics, e.g. ceftriaxone, IV, 2 g daily, are
indicated in every case until the diagnosis is confirmed.
DESCRIPTION
High fever, together with disseminated intravascular coagulation (DIC) and
bleeding tendency. Other symptoms and organ involvement vary according
to the causative virus.
Some important causes other than viral haemorrhagic fevers (VHF) are:
» severe bacterial infections, particularly N. meningitidis,
» severe tick bite fever,
» severe falciparum malaria,
» fulminant hepatitis,
» leptospirosis, and
» other causes for DIC or bleeding tendency.
Endemic causes of VHF in South Africa are Crimean-Congo fever and Rift
Valley Fever, both of which may be transmitted between humans by means of
blood and body fluids.
REFERRAL
All suspected VHF cases need to be discussed and managed in consultation
with the Regional Virologist or Infectious Diseases Consultant at the referral
centre.
Cases may also be discussed with the Special Pathogens Unit of the
National Institute for Communicable Diseases (NICD):
Tel: 011 386 6000, Outbreak hotline: 082 883 9920
Transfer of patients will only occur once all relevant arrangements have
been made to limit further exposure to a potentially contagious and life
threatening virus.
MANAGEMENT
A detailed travel and clinical history is crucial. If VHF is still considered,
isolate patient in a single room and take proper precautions to limit further
exposure. These include:
2019 9.9
» long sleeved disposable gown,

» vinyl or rubber apron if the patient is bleeding,
» two pairs of latex gloves, one below the gown and one over the gown,
» disposable face mask preferably with a visor,
» goggles if a mask without the visor is used, and
» waterproof boots or 2 pairs of overshoes, one over the other.
Exclude alternate diseases by means of appropriate laboratory testing.
Support patients with packed red cells and fresh frozen plasma, as required.
Testing for VHF may be required, both to confirm or exclude the possibility of
VHF - this must be arranged with the NICD (see above), before sending the
specimens, as specific precautions apply.
Record and follow up all patient contacts.
9.6 HYDATID DISEASE

B67.0-9
DESCRIPTION
Cysts of E. granulosus, acquired from ingestion of helminth ova passed out
in dog faeces, particularly in sheep-farming areas. Cysts may occur in any
organ, but are most commonly found in the liver and lungs.
Note: Definitive treatment with surgery or PAIR (percutaneous aspiration
injection of helminthicidal agent and re-aspiration) is preferred for all
accessible lesions.
With medical therapy as below, cure is achieved in about half, improvement
in about a quarter and no response in about a quarter of cases.
MEDICINE TREATMENT
 Albendazole, oral, 15 mg/kg/day up to maximum of 400 mg 12 hourly
with a fatty meal (e.g. a glass of full cream milk). LoE:IIIxx
o Duration is 3–6 months according to response on
imaging for inoperable cysts or 14–28 days before and 28 days after
PAIR or surgery. LoE:Ixxi
o Monitor liver function tests and FBCs monthly.
REFERRAL
All cases to a centre with experience in surgery and PAIR.
9.7 MALARIA
See the Primary Health Care STGs and EML - Section 10.7: Malaria.
9.7.1 MALARIA, UNCOMPLICATED

B54/B51.9/B52.9/B53.0
See the Primary Health Care STGs and EML - Section 10.7.1: Malaria, non-
2019 9.10
severe/uncomplicated.
9.7.2 MALARIA, SEVERE

B50.0/B50.8
See the Primary Health Care STGs and EML - Section 10.7.2: Malaria,
severe/complicated.
DESCRIPTION
P. falciparum malaria with one or more of the following features:
» severe general body weakness » abnormal bleeding (e.g
(prostration) epistaxis)
» impaired consciousness » convulsions
» renal dysfunction » heavy parasitaemia (5%)
» repeated vomiting » ARDS
» severe diarrhoea » shock
» severe anaemia (Hb <6 g/dL) » hypoglycaemia
» haemoglobinuria » clinical jaundice
» acidosis (plasma bicarb <15 mmol/L)
GENERAL MEASURES
Maintain hydration but avoid excessive fluid administration as this could
contribute to the development of ARDS (especially in pregnancy).
Transfuse if haemoglobin <6 g/dL.
There is no convincing evidence of benefit for the use of exchange
transfusion.
MEDICINE TREATMENT
Intravenous therapy:
The preferred agent is parenteral artesunate:
 Artesunate IV, 2.4 mg/kg at 0, 12 and 24 hours; then daily until patient is
able to tolerate oral therapy.
o Administer at least 3 IV doses before switching to oral
artemether/lumefantrine.
LoE:Ixxii
If parenteral artesunate is not available:
 Quinine, IV (1 mL = 300 mg quinine salt).
o Loading dose: 20 mg/kg in dextrose 5% administered over 4 hours.
o Maintenance dose: 8 hours after start of the loading dose, give 10
mg/kg in dextrose 5% over 4 hours repeated every 8 hours until there
is clinical improvement and the patient can take oral therapy.
o Monitor for hypoglycaemia and dysrhythmias at least 4 hourly.
o If there is significant renal failure increase dose interval to 12 hourly
after 48 hours.
Follow intravenous therapy with oral therapy:
 Artemether/lumefantrine 20/120 mg, oral, 4 tablets/dose with fat-
containing food or full cream milk to ensure adequate absorption.
2019 9.11
o Give the first dose immediately.

o Give the second dose 8 hours later.
o Then 12 hourly for another 2 days. (Total number of doses in 3 days
= 6; i.e. 24 tablets).
Monitor treatment response with regular blood smears.
An increase in parasitaemia may occur within 24 hours due to release of
sequestrated parasites, but a reduction should be seen after 48 hours.
Note: Gametocytes may appear after this stage – this does NOT mean
failure of therapy as gametocytes may persist for up to 2 weeks after
successful therapy.
Only the reappearance of or failure to clear trophozoites means failure.
Consider concomitant bacteraemia in patients with severe malaria,

especially if they have neutrophilia.
REFERRAL
Patient in need of ventilation or dialysis if these are unavailable on site.
9.8 SCHISTOMIASIS
B65.0-3/B65.8-9
DESCRIPTION
A parasitic infestation with:
» Schistosoma haematobium: primarily involves the bladder and renal
tract, or
» Schistosoma mansoni: primarily involves the intestinal tract.
DIAGNOSIS
Acute schistosomiasis syndrome
» Typically occurs in travellers to endemic areas with freshwater exposure
3-7 weeks before onset.
» Clinical features include fever, rigors/chills, urticaria,angioedema,
myalgias, arthralgias, dry cough, diarrhea, abdominal pain, and
headache. Symptoms are usually relatively mild and resolve
spontaneously over a period of a few days to a few weeks.
» The eosinophil count is almost invariably markedly elevated.
» Diagnosis is confirmed serologically – eggs are seldom seen in stool or
urine.
» Differential diagnosis includess urinary tract infection,
glomerulonephritis, HIV, gastroenteritis (Salmonella), hepatitis A, B and
C, malaria.
2019 9.12
Chronic schistosomiasis
» Most individuals with schistosomiasis infection are asymptomatic.
» S. haematobium may present with macroscopic haematuria and urinary
symptoms. Chronic bladder involvement and urinary tract involvement
may cause urinary incontinence and obstructive uropathy.
» S. mansoni may present with chronic or intermittent dysentery. Periportal
fibrosis and portal hypertension may occur.
» Pulmonary hypertension and central nervous system involvement
(particularly myelopathy) are uncommon complications.
» Definitive diagnosis is by finding eggs in urine (S. haematobium), stool
(S. mansoni), or on biopsy. Serology is usually positive.
MEDICINE TREATMENT
Acute schistosomiasis syndrome
 Prednisone, oral, 40 mg daily for 5 days.
LoE:IIIxxiii
4-6 weeks later, after symptoms have resolved:
 Praziquantel, oral, 40 mg/kg as a single dose.
AND LoE:IIIxxiv
 Corticosteroids (intermediate-acting)e.g.:
Optimum time for administration of praziquantel is uncertain but sufficient
time is required for the worms to mature.
If in 4-6 weeks, eosinoplilia present and high antibody titres, repeat

praziquantel treatment:
 Praziquantel, oral, 40 mg/kg as a single dose.
LoE:IIIxxv
Chronic schistosomiasis
Manage as recommended in PHC STGs and EML, section 10.12:
Schistosomiasis (bilharzia).
9.9 TETANUS
A35
DESCRIPTION
Painful muscle spasms and rigidity following inoculation by trauma of
Clostridium tetani spores, which germinate and produce toxins. The wound
may be trivial and healing may have occurred before presentation.
Incubation period is 3-21 days. Tetanus may be localised, with muscle
spasms near the site of inoculation, or generalised, with spasm of the jaw
muscles being a common presenting sign.
2019 9.13
GENERAL MEASURES
These patients need to be managed in a high care setting where ventilation
is available.
Maintain and protect airway.
Monitor ECG and blood pressure.
Maintain and replace IV fluids.
Wound management is essential with debridement and removal of any
foreign bodies.
Alleviate fever with mechanical cooling methods.
MEDICINE TREATMENT
For rigidity, spasms: (R25.2)
 Diazepam, IV, 10 mg 4 hourly, for 24 hours, then consider oral route as
high doses of parentral diazepam can cause an acidosis.
o Titrate to effect. LoE:Ixxvi
o Doses as high as 50–100 mg 2 hourly are sometimes required.
o Higher doses require monitoring for respiratory depression.
Use muscle relaxants sparingly as these may exacerbate autonomic instability.
Antibiotic treatment:
 Metronidazole, IV, 500 mg 8 hourly for 10 days. LoE:IIIxxvii
For passive immunisation: (Z23.5)

 Tetanus immunoglobulin, IM, 3 000 units as a single dose.
For active immunisation of all patients:(as clinical tetanus does not always
confer immunity) (Z23.5)
 Tetanus toxoid vaccine, IM, 0.5 mL, total of 3 doses:
o on admission,
o at 4 weeks, and
o at 6 months.
o Administer at a different site to that used for administering tetanus
immunoglobulin.
For pain:
o Maximum daily dose: 4 g in 24 hours. LoE:Ixxviii

For shock, dehydration, maintenance of hydration: R57.9+ (A35)
 IV fluids.
For prophylaxis for deep vein thrombosis: (Z29.2)
See section 2.14: Venous thrombo-embolism.
2019 9.14
REFERRAL
All cases to a facility with resources for artificial mechanical ventilation.
9.10 TICK BITE FEVER

A93.8
DESCRIPTION
Tick-borne infection due to R. conorii, acquired from dogs, or R. africae,
acquired from cattle and game. The hallmark of tick bite fever is the eschar,
a round black lesion ± 5 mm in diameter with an inflammatory halo, occurs in
about two thirds of patients with R. conorii and in most cases of R. africae
infection, where multiple eschars are common. A rash develops on about the
third day of illness in about two thirds of patients with R. conorii and in fewer
cases of R. africae infection. In R. conorii infection the rash is maculopapular
and involves the palms and soles. In R. africae infection the rash is sparse
and may be vesicular. Headache is a prominent symptom.
MEDICINE TREATMENT
 Doxycycline, oral, 100 mg 12 hourly, for at least 3 days after the fever
subsides with clinical improvement.
o Total duration of treatment is 7 days.
LoE:IIIxxix
In pregnancy: O98.5+(A93.8)
 Azithromycin, oral, 500 mg 12 hourly for 3 days.
o In severe cases, initiate therapy with 1–2 days of doxycycline.
LoE:IIIxxx
For the rare patient unable to take oral therapy:
Total duration of therapy: 7 days.
 Ciprofloxacin, IV, 400 mg 8 hourly. LoE:IIIxxxi
Note:This is inferior to doxycycline and oral doxycyclineshould be commenced
as soon as possible.
REFERRAL
Tick bite fever responds rapidly to treatment and fever persisting for >48
hours after initiation of treatment should prompt consideration of an
alternative or additional diagnosis.
LoE:IIIxxxii
9.11 TYPHOID FEVER (ENTERIC FEVER)

A01.0-4
*Notifiable medical condition (Typhoid fever).
DESCRIPTION
Systemic infection due to S. enteritica serotype Typhi or related organisms
(e.g. S. paratyphi, S. choleraesuis). Initial symptoms are abdominal pain,
headache, cough and fever, with diarrhoea developing after a few days.
2019 9.15
Bacteraemia is common in the first week of illness, subsequently stool

culture has the highest yield.
GENERAL MEASURES
Transfusion is indicated for severe haemorrhage.
Replace fluid and electrolytes.
Contact isolation during acute phase of illness.
MEDICINE TREATMENT
Antibiotic therapy
There is increasing resistance to ciprofloxacin in South Africa and it
is important to send specimens for culture and sensitivity prior to
commencing antibiotic therapy.
Total duration of antibiotic therapy: 10 days.

 Ceftriaxone, IV, 2 g 12 hourly. LoE:IIxxxiii
Follow with oral therapy as soon as patient can swallow and the
temperature is <37.8oC for 24 hours, based on culture sensitivity results:
 Ciprofloxacin, oral, 500 mg 12 hourly. LoE:III
Stool cultures must be repeated at weekly intervals after convalescence to

ensure that a carrier state has not developed. Two consecutive negative stool
cultures are required to exclude carrier state. This is of vital importance in food
handlers, who must not be permitted to return to work until stools are negative.
Chronic carriers: (Z22.0)

 Ciprofloxacin, oral, 500 mg 12 hourly for 6 weeks (if sensitive to
ciprofloxacin).
o Advise strict hand washing.
o Avoid food preparation for others during severe illness.
REFERRAL
Surgical consultation for complications such as intestinal haemorrhage,
threatening bowel perforation or localisation with metastatic infection with or
without abscess formation, and peritonitis.
Drug resistant organism: consult microbiology/infectious diseases services.
9.12 VARICELLA (CHICKENPOX), COMPLICATED

B01.1† + (G02.0*/G05.1*+J17.1*)/B01.8
GENERAL MEASURES
Cool, wet compresses or tepid water baths.
Body hygiene to prevent secondary infection.
Advise against scratching.
2019 9.16
MEDICINE TREATMENT
Antiviral therapy is required in complicated cases, e.g.:
» chickenpox pneumonia,
» pregnancy,
» neurological involvement, and
» chickenpox in immunocompromised patients.
 Aciclovir, IV, 10 mg/kg administrerd over one hour 8 hourly for 7 days.
The course can be completed with:
 Antiviral, (active against varicella zoster), e.g: LoE:Ixxxiv
 Aciclovir, oral, 800 mg five times daily.
Treat secondary bacterial infection if suspected.
For patients who are severely immunologically compromised and are not
immune: (Z29.1)
 Varicella-zoster immunoglobulin (VZIG), IM, 125 units/10 kg.
o Maximum dose: 625 units.
o Administer within 96 hours after significant exposure.
9.13 ZOSTER (SHINGLES)

B02.9
DESCRIPTION
Dermatomal eruption of vesicles on an erythematous base due to varicella-
zoster virus (lies dormant in nerve ganglia following chickenpox).
GENERAL MEASURES
Isolate from immunocompromised or pregnant non-immune individuals (who
may develop severe chickenpox).
Offer HIV test, especially in patients <50 years of age.
MEDICINE TREATMENT
Antiviral therapy, for:
» zoster in immunocompromised patients, provided that active lesions are
still being formed, and
» in immunocompetent individuals provided they present within 72 hours of
onset of clinical symptoms.
 Antiviral (active against herpes zoster) e.g.:
 Aciclovir, oral, 800 mg five times daily for 7 days (4 hourly LoE:Ixxxv
missing the middle of the night dose).
For zoster with secondary dissemination or neurological/ eye involvement:

B02.7/B02.0-2†+(G02.0*/G05.1*/G53.0*/G63.0*)/ B02.3†+(H03.1*/H13.1*/H22.0*/H19.2*/
H19.0*)
 Aciclovir, IV, 10 mg/kg administred over one hour 8 hourly for 7 days.
2019 9.17
o The course can be completed with aciclovir, oral, 800 mg five times
daily.
o Dose adjustment based on renal clearance (See Appendix IIfor
guidance on prescribing and monitoring).
LoE:IIIxxxvi
Secondary infection
B02.8
This is seldom present and is over-diagnosed. The vesicles in shingles often
contain purulent material, and erythema is a cardinal feature of shingles. If
there is suspected associated bacterial cellulitis:
 Flucloxacillin, oral, 500 mg 6 hourly for 5 days.
For pain:
Pain is often very severe and requires active control. Combination of
different classes of analgesics is often necessary.
Recommended therapy for acute phase of infection, e.g.:
 Paracetamol, oral, 1 g 4–6 hourly when required.
AND/OR
If pain is not adequately controlled:
 Tramadol, oral, 50–100 mg 4–6 hourly.
See chapter 26: Pain.
Post-herpetic neuralgia: B02.2+(G53.0*)

Initiate treatment with adjuvant therapy early.
 Amitriptyline, oral, 25 mg at night.
o Titrate as necessary to a maximum of 75 mg.
See section 26.1.4: Neuropathic pain.
REFERRAL
Refer to an ophthalmologist if there is ocular involvement with ophthalmic
zoster (if the tip of the nose is involved then ocular involvement is much
more likely). See section 18.4: Herpes zoster ophthalmicus.
Patients who develop complications e.g. myelitis.
2019 9.18
References:
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Project. Management bundles for candidaemia: the impact of compliance on clinical outcomes. J
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vii Fluconazole, oral: Rex JH, Pappas PG, Karchmer AW. A randomized and blinded multicenter trial of high-dose
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Fluconazole, oral: Edwards JE Jr, Bodey GP, Bowden RA, Büchner T, de Pauw BE, Filler SG, GhannoumMA,
Glauser M, Herbrecht R, Kauffman CA, Kohno S, Martino P, Meunier F, Mori T, Pfaller MA, Rex JH, Rogers TR,
Rubin RH, Solomkin J, Viscoli C, Walsh TJ, White M. International Conference for the Development of a
Consensus on the Management and Prevention of Severe Candidal Infections. Clin Infect Dis. 1997 Jul;25(1):43-
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2019 9.19
Fluconazole, oral: Andes D, van Ogtrop H. Characterization and quantitation of the pharmacodynamics of
fluconazole in a neutropenic murine disseminated candidiasis infection model. Antimicrob Agents Chemother 1999;
viii Cefazolin, IV: McDanel JS, Perencevich EN, Diekema DJ, Herwaldt LA, Smith TC, ChrischillesEA, Dawson JD,
Jiang L, Goto M, Schweizer ML. Comparative effectiveness of beta-lactams versus vancomycin for treatment of
methicillin-susceptible Staphylococcus aureus bloodstream infections among 122 hospitals. Clin Infect Dis. 2015
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ix Flucloxacillin, oral (dose): South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.
x Empiric antibiotic therapy (surgical wound infections): Stevens DL, Bisno AL, Chambers HF, Dellinger EP,
Goldstein EJ, Gorbach SL, Hirschmann JV, Kaplan SL, Montoya JG, Wade JC. Practice guidelines for the
diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of
America. Clin Infect Dis. 2014 Jul 15;59(2):e10-52. Erratum in: Clin Infect Dis. 2015 May 1;60(9):1448. Dosage
error in article text.http://www.ncbi.nlm.nih.gov/pubmed/24973422
xi Ertapenem, IV (severe penicillin allergy & confirmed Gram negative culture): An MM, Zou Z, Shen H, Zhang JD,
Chen ML, Liu P, Wang R, Jiang YY. Ertapenem versus piperacillin/tazobactam for the treatment of complicated
infections: a meta-analysis of randomized controlled trials. BMC Infect Dis. 2009 Dec 2;9:193.
Ertapenem (severe penicillin allergy & confirmed Gram negative culture): NICD AMR surveillance for ESKAPE,
1 January 2016 to 31 December 2016.
xii Empiric antibiotic therapy (surgical wound infections): Stevens DL, Bisno AL, Chambers HF, Dellinger EP,
Goldstein EJ, Gorbach SL, Hirschmann JV, Kaplan SL, Montoya JG, Wade JC. Practice guidelines for the
diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of
America. Clin Infect Dis. 2014 Jul 15;59(2):e10-52. Erratum in: Clin Infect Dis. 2015 May 1;60(9):1448. Dosage
error in article text.http://www.ncbi.nlm.nih.gov/pubmed/24973422
Ceftriaxone, IV (Surgery on female uro-genital tract/ open GIT surgery): Stevens DL, Bisno AL, Chambers HF,
Dellinger EP, Goldstein EJ, Gorbach SL, Hirschmann JV, Kaplan SL, Montoya JG, Wade JC. Practice guidelines
for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases
Society of America. Clin Infect Dis. 2014 Jul 15;59(2):e10-52. Erratum in: Clin Infect Dis. 2015 May 1;60(9):1448.
Dosage error in article text.http://www.ncbi.nlm.nih.gov/pubmed/24973422
Metronidazole, IV (Surgery on female uro-genital tract/ open GIT surgery): Stevens DL, Bisno AL, Chambers
HF, Dellinger EP, Goldstein EJ, Gorbach SL, Hirschmann JV, Kaplan SL, Montoya JG, Wade JC. Practice
guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious
Diseases Society of America. Clin Infect Dis. 2014 Jul 15;59(2):e10-52. Erratum in: Clin Infect Dis. 2015 May
1;60(9):1448. Dosage error in article text.http://www.ncbi.nlm.nih.gov/pubmed/24973422
xiii Criterion for empiric antibiotic therapy for MDR-HAP and MDR-VAP: Meta-analysis in guideline - Kalil AC,
Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB et al. Management of Adults With Hospital-
acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases
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C, Kolenda H, Prange HW. Kinetics of piperacillin and tazobactam in ventricular cerebrospinal fluid of
hydrocephalic patients.Antimicrob Agents Chemother. 1997 May;41(5):987-
xv Cefepime, IV (2 g): NICD AMR surveillance for ESKAPE, 1 January 2016 to 31 December 2016.
Cefepime, IV (2 g): South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.
xvi Imipenem, IV: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University
of Cape Town. 2016.

Imipenem, IV: NICD AMR surveillance for ESKAPE, 1 January 2016 to 31 December 2016.
xvii Ciprofloxacin, oral: NHLS/NICD Communicable Diseases Surveillance Bulletin, April 2015 (Volume 13. No 1).
http://www.nicd.ac.za/
xviii Pneumococcal vaccine (23 valent polysaccharide): ACIP Practice Guidelines - CDC. Morbidity and Mortality
Weekly Report, October 12, 2012, Vol 61, No

40.http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6140a4.htm?s_cid=mm6140a4_w
xix Gentamicin: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of
Cape Town. 2016..

xx Albendazole: Rigter IM, Schipper HG, Koopmans RP, van Kan HJ, Frijlink HW, Kager PA, Guchelaar HJ.
Relative bioavailability of three newly developed albendazole formulations: a randomized crossover study with
healthy volunteers. Antimicrob Agents Chemother. 2004 Mar;48(3):1051-
xxi Albendazole plus PAIR surgery: Smego RA Jr, Bhatti S, Khaliq AA, Beg MA. Percutaneous aspiration-injection-
reaspiration drainage plus albendazole or mebendazole for hepatic cystic echinococcosis: a meta-analysis. Clin
Infect Dis. 2003 Oct 15;37(8):1073-83. http://www.ncbi.nlm.nih.gov/pubmed/14523772
xxii Artesunate, IV: Artesunate, parenteral: Sinclair D, Donegan S, Isba R, Lalloo DG. Artesunate versus quinine for
treating severe malaria. Cochrane Database Syst Rev. 2012 Jun

2019 9.20
xxiii Prednisone, oral: Grandière-Pérez L, Ansart S, Paris L, Faussart A, Jaureguiberry S, Grivois JP,Klement E,
Bricaire F, Danis M, Caumes E. Efficacy of praziquantel during the incubation and invasive phase of Schistosoma
haematobium schistosomiasis in 18 travelers. Am J Trop Med Hyg. 2006 May;74(5):814-8.
xxiv Praziquantel, oral: Grandière-Pérez L, Ansart S, Paris L, Faussart A, Jaureguiberry S, Grivois JP,Klement E,
Bricaire F, Danis M, Caumes E. Efficacy of praziquantel during the incubation and invasive phase of Schistosoma
haematobium schistosomiasis in 18 travelers. Am J Trop Med Hyg. 2006 May;74(5):814-8.
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JP,Klement E, Bricaire F, Danis M, Caumes E. Efficacy of praziquantel during the incubation and invasive phase of
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xxvi Diazepam, IV: Vassa NT, Doshi HV, Yajnik VH, Shah SS, Joshi KR, Patel SH. Comparative clinical trial of
diazepam with other conventional drugs in tetanus. Postgrad Med J. 1974 Dec;50(590):755-
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xxvii Metronidazole, IV: World Health Organisation. Technical note: Current recommendations for treatment of
tetanus during humanitarian emergencies, January 2010.

https://www.who.int/diseasecontrol_emergencies/who_hse_gar_dce_2010_en.pdf
xxviii Paracetamol (fever in tetanus): Lee BH, Inui D, Suh GY, Kim JY, Kwon JY, Park J, et al: Fever and Antipyretic
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xxix Doxycycline, oral: Chapman AS, Bakken JS, Folk SM, Paddock CD, Bloch KC, Krusell A, et al: Tickborne
Rickettsial Diseases Working Group; CDC. Diagnosis and management of tickborne rickettsial diseases: Rocky
Mountain spotted fever, ehrlichioses, and anaplasmosis--United States: a practical guide for physicians and other
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Dis. 2002 Jan 15;34(2):154-8. http://www.ncbi.nlm.nih.gov/pubmed/11740701
xxxi Ciprofloxacin, IV: Raoult D, Drancourt M. Antimicrobial therapy of rickettsial diseases. Antimicrob Agents
Chemother. 1991 Dec;35(12):2457-62. http://www.ncbi.nlm.nih.gov/pubmed/1810178

xxxii Treatment failure > 48 hours requiring referral: Chapman AS, Bakken JS, Folk SM, Paddock CD, Bloch KC,
Krusell A, et al: Tickborne Rickettsial Diseases Working Group; CDC. Diagnosis and management of tickborne
rickettsial diseases: Rocky Mountain spotted fever, ehrlichioses, and anaplasmosis--United States: a practical
guide for physicians and other health-care and public health professionals. MMWR Recomm Rep. 2006 Mar
31;55(RR-4):1-27. https://www.ncbi.nlm.nih.gov/pubmed/16572105
xxxiii Ceftriaxone, IV: Acharya G, Butler T, Ho M, Sharma PR, Tiwari M, Adhikari RK, Khagda JB, Pokhrel B, Pathak
UN. Treatment of typhoid fever: randomized trial of a three-day course of ceftriaxone versus a fourteen-day course
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Ceftriaxone, IV: Wallace MR, Yousif AA, Mahroos GA, Mapes T, Threlfall EJ, Rowe B, Hyams KC. Ciprofloxacin
versus ceftriaxone in the treatment of multiresistant typhoid fever. Eur J ClinMicrobiol Infect Dis. 1993
Dec;12(12):907-10. http://www.ncbi.nlm.nih.gov/pubmed/8187784
Ceftriaxone, IV: Islam A, Butler T, Kabir I, Alam NH. Treatment of typhoid fever with ceftriaxone for 5 days or
chloramphenicol for 14 days: a randomized clinical trial. Antimicrob Agents Chemother. 1993 Aug;37(8):1572-5.
Ceftriaxone, IV: Lasserre R, Sangalang RP, Santiago L. Three-day treatment of typhoid fever with two different
doses of ceftriaxone, compared to 14-day therapy with chloramphenicol: a randomized trial. J
AntimicrobChemother. 1991 Nov;28(5):765-72. http://www.ncbi.nlm.nih.gov/pubmed/1778879
Ceftriaxone, IV: Islam A, Butler T, Nath SK, Alam NH, Stoeckel K, Houser HB, Smith AL. Randomized treatment
of patients with typhoid fever by using ceftriaxone or chloramphenicol. J Infect Dis. 1988 Oct;158(4):742-7.
xxxiv Antiviral, oral (active against herpes zoster) therapeutic class: McDonald EM, De Kock J, Ram FS. Antivirals for
management of herpes zoster including ophthalmicus: a systematic review of high-quality randomized controlled
trials. Antiviral Therapy 2012; 17(2): 255-264. https://www.ncbi.nlm.nih.gov/pubmed/22300753
xxxvAntivirals to treat herpes zoster (therapeutic class): McDonald EM, De Kock J, Ram FS. Antivirals for
management of herpes zoster including ophthalmicus: a systematic review of high-quality randomized controlled
trials. Antiviral Therapy 2012; 17(2): 255-264.https://www.ncbi.nlm.nih.gov/pubmed/22300753
xxxvi Aciclovir, IV - dose adjustment in renal impairment:: South African Medicines Formulary. 12th Edition. Division
2019 9.21
CHAPTER 10
HIV AND AIDS
Consult the most recent HIV Guidelines from the
National Department of Health.
https://www.knowledgehub.org.za/elibrary/2019-art-clinical-guidelines-
management-hiv-adults-pregnancy-adolescents-children-infants
10.1 ANTIRETROVIRAL THERAPY

B24
Antiretroviral therapy (ART) consists of combinations of antiretroviral medicines

that are capable of suppressing HIV replication (defined as an undetectable viral
load). Continued use of ART with a detectable viral load results in the
development of resistance to some or all of the medicines in the regimen. High
levels of adherence are essential for long-term success with ART.
The current recommended first-line ART regimen contains two nucleoside
reverse transcriptase inhibitors (NRTIs) together with an integrase inhibitor
(InSTI) dolutegravir. Previously a non-nucleoside reverse transcriptase inhibitor
(NNRTI), efavirenz or nevirapine, together with two NRTIs, were recommended
for first-line ART. Dolutegravir is better tolerated than the NNRTIs and has a
much higher barrier to the development of resistance.
Dolutegravir, together with two NRTIs, is also recommended in second-line ART
after failing an NNRTI-based first-line regimen. Previously a protease inhibitor
(PI), together with two NRTIs, was recommended for second-line ART, but
dolutegravir is better tolerated than PIs. Switching people, established on ART
to the newer dolutegravir-based ART regimens needs to be carefully done to
reduce the risk of the emergence of resistance (refer to National Department of
Health HIV Guidelines).
ELIGIBILITY FOR ART

Eligibility to start ART:
All adults with confirmed HIV infection, irrespective of CD4 count or WHO clinical
stage. Where a patient is willing and ready, ART should be initiated on the same
day as HIV diagnosis, except in patients with TB or cryptococcal meningitis (see
Timing of ART initiation below).
LoE: Ii
Immediate initiation:
ART should be initiated immediately in pregnancy and during breastfeeding.
LoE:IIIii
Fast tracking (within 7 days):
Patients with CD4 <200 cells/mm3.
OR LoE:IIIiii
Patients with WHO stage 4.
2019 10.1
CHAPTER10 HIV AND AIDS
Timing of ART initiation:

» ART should be started as soon as the patient is ready. However, with
some opportunistic diseases early ART initiation can cause harm by
increasing the risk of the immune reconstitution inflammatory syndrome
(IRIS) - see section 10.1.2: Management of selected antiretroviral
adverse drug reactions).
» In TB co-infection, start with TB treatment first, followed by ART initiation

according to CD4 count (except TB meningitis – see below):
- CD4 <50 cells/mm3: initiate ART within 2 weeks of starting TB treatment.
- CD4 ≥50 cells/mm3: defer ART until 8 weeks after starting TB treatment,
which has shown to be safe and reduces the risk of deterioration due to
IRIS.
LoE:Iiv
» In patients with TB meningitis (irrespective of CD4
count), defer ART until 8 weeks after initiating TB treatment.
LoE:Iv
» In patients with cryptococcal meningitis, defer ART until
4–6 weeks after starting antifungal treatment (earlier initiation has been
shown to increase the risk of death). LoE:Ivi
PSYCHOSOCIAL INDICATORS OF READINESS FOR ART

It is essential that patients have good insight into the need for long-term
therapy and high levels of adherence. Give careful attention to adherence
planning. Encourage patients to disclose their HIV status to somebody who
should act as a treatment supporter. If this is not possible then the patient
should join a support group.
Manage depression.
Active substance abuse/alcoholism is an impediment to adherence and, if
possible, should be addressed prior to initiating ART.
Women of childbearing potential (WOCP) should be given all necessary
information on the benefits and potential risks of neural tube defects (NTDs)
with dolutegravir use periconception.
LoE:IIIvii
ART REGIMENS
1ST LINE ART
Treatment-naïve patients » Men ≥35kg and ≥10 years of age
» WOCP not actively wishing to
conceive
» Pregnant women ≥6 weeks
gestation, and those who make an
informed choice to use DTG
TDF + 3TC + DTG
Patients with TB:

TDF + FTC + EFV
2019 10.2
Pregnant women <6 weeks gestation or

actively wanting to conceive:
TDF + FTC + EFV
(Also see section 6.7: HIV in
pregnancy)
LoE:Iviii
Contraindications and intolerance to TDF + 3TC + DTG
EFV » WOCP actively wanting to conceive
and pregnant women <6 weeks
gestation require adequate
counselling to make an informed
choice to use DTG.
Contraindications to EFV and DTG Start protease inhibitor-based regimen:
TDF + 3TC/FTC + LPV/r
Contraindication to TDF Replace TDF + 3TC/FTC with either
» eGFR <50 mL/minute. ABC+ 3TC or AZT + 3TC
» Use of additional nephrotoxic drug LoE:Iix
e.g. aminoglycoside.
Contraindication to TDF and ABC AZT+ 3TC with DTG or EFV

intolerance
» eGFR <50 mL/minute.
» Use of additional nephrotoxic agent
e.g. aminoglycoside.
» Hypersensitivity.
Note: In the unlikely scenario where there is intolerance/contraindication to all currently
available NRTIs, an alternative dual-therapy regimen may be used, e.g. DTG + 3TC (if
no resistance/intolerance to 3TC and VL <500 000 copies/mL) or EFV + LPV/r or DTG
+ LPV/r may be used. Consult a specialist.
LoE:Ix
2ND LINE ART
Management of viraemia on 1st line If plasma VL between 50–999
ART copies/mL:
» Address adherence, tolerability,
medicine interactions & psychosocial
factors.
» Repeat VL test 3 months later.
If plasma VL > 1000 copies/mL:

» Assess adherence, tolerability,
medicine interactions & psychosocial
factors.
Repeat VL test 3 months later
If plasma VL 50-999 copies/mL:
» Continue enhanced adherence
support.
2019 10.3
» Repeat VL test 6 months later.
If plasma VL remains at 50-999

copies/mL i.e. persistent low grade
viraemia:
» Manage as virological failure below.
Management of virological failure on If plasma VL confirmed ≥1000
1st line ART copies/mL (on 2 tests), and adherence
issues addressed:
Note: Always check hepatitis B surface » Change regimen to 2nd line therapy.
antigen (HBsAg) before stopping TDF:
» If patient has chronic hepatitis B,
stopping TDF may lead to a fatal
hepatitis flare.
» If hepatitis B positive, TDF should be
continued in the 2ndline regimen.
Failing a NNRTI-based 1st line AZT + 3TC + DTG.
regimen (TDF+3TC/FTC+EFV/NVP)
If HBsAg positive:
TDF + 3TC + DTG
If DTG contraindicated/ not tolerated:
AZT + 3TC +LPV/r
(PLUS TDF, if HBsAg positive).
If AZT and TDF contraindicated/ not
tolerated (e.g. anaemia and renal
impairment):
ABC + 3TC + LPV/r
Failing a DTG- based 1st line regimen AZT + 3TC +LPV/r
for >2 years (TDF+3TC+DTG)
» Resistance testing for adults and If HBsAg positive:
adolescents failing a DTG-based TDF + 3TC/FTC +LPV/r
regimen and who meet the definition of
confirmed virological failure may be
authorized by an expert on a case-by-
case basis.
Dyslipidaemia requiring lipid- Switch LPV/r to ATV/r
lowering therapy or diarrhoea
associated with LPV/r
3RD LINE ART

Failing any 2nd line regimen Refer to a specialist.
Resistance to LPV/r or ATV/r and/or DTG
must be shown on genotype antiretroviral
resistance test in order to qualify for 3rd
line – this test is expensive and should
only be done in patients with at least 2
years exposure to a PI and objective
evidence of good adherence.
Application for 3rd line using the standard
motivation form is required (available
2019 10.4
from [email protected]) –the

regimen will be determined by an Expert
Committee based on the pattern of
resistant mutations and the prior history of
antiretroviral exposure.
ABC= Abacavir, 3TC= Lamivudine, TDF = Tenofovir disoproxyl fumarate, AZT=Zidovudine, FTC =
Emtricitabine, LPV/r=Lopinavir/ritonavir, DTG= Dolutegravir, EFV= Efavirenz
Currently available ARV FDC preparations on contract circular:

 ABC 600 mg + 3TC 300 mg
 TDF 300 mg + FTC 200 mg
 AZT 300 mg + 3TC 150 mg
 LPV 800 mg + ritonavir 200 mg
 TDF 300 mg + FTC 200 mg + EFV 600 mg LoE:IIIxi
 TDF 300mg + DTG 50 mg + 3TC 300 mg
ART: DOSING AND IMPORTANT ADVERSE EFFECTS

Generic Clas Usual dose Renal adjusted Important adverse drug
name s dose reactions and timing
Tenofovir NRTI 300 mg Avoid in renal » Acute kidney injury (rare - weeks
(TDF) daily impairment (eGFR to months).
<50 mL/min) » Decline in eGFR (months to
years) LoE:IIIxii
» Fanconi
syndrome (rare – months to
years)
» Reduced bone mineral density
(months to years).
» Hyperlactataemia/
steatohepatitis (very low risk -
months).
Abacavir NRTI 600 mg Dose adjustment » Hypersensitivity reaction (1 to 6
(ABC) daily not required weeks) fever, rash,
constitutional symptoms,
gastrointestinal symptoms and
respiratory symptoms.
» Hyperlactataemia/
steatohepatitis (very low risk -
months).
Zidovudine NRTI 300 mg CrCl <10 mL/min: » Anaemia, neutropenia (weeks
(AZT) 12 hourly 300 mg daily to months).
» Gastro-intestinal upset.
» Headache.
» Myopathy (rare).
» Hyperlactataemia /
steatohepatitis (medium risk -
months).
» Lipoatrophy (months to years).
Lamivudine NRTI 300 mg daily CrCl 10-50 » Anaemia due to pure red cell
(3TC) (or mL/min: aplasia (rare).
150 mg 12 150 mg daily » Hyperlactataemia /
hourly) steatohepatitis (very low risk -
CrCl <10 mL/min: months).
50 mg daily
2019 10.5
Emtricitabine NRTI 200 mg CrCl 30-50 » Palmar hyperpigmentation.
(FTC) daily mL/min: » Hyperlactataemia /
200 mg every 2 steatohepatitis (very low risk -
days months).
» Anaemia due to pure red cell
CrCl 15-29 aplasia (rare).
mL/min:
LoE:IIIxiii
200 mg every 3
days
CrCl <15 mL/min:
200 mg every 4
days
Nevirapine NNR 200 mg Dose adjustment » Rash and/or Hepatitis (1 week
(NVP) TI daily for 14 not required to 3 months).
days *Avoid in women with a CD4
then count >250 cells/mm3 and men
200 mg with a CD4 count >400
12-hourly cells/mm3 initiating ART due to
increased risk of rash
associated hepatitis.
Efavirenz NNR 600 mg Dose adjustment » Central nervous system
(EFV) TI at night not required symptoms: vivid dreams,
problems with concentration,
confusion, mood disturbance,
psychosis (days to weeks).
» Encephalopathy, often with
cerebellar features (uncommon
– months to years).
LoE:IIIxiv
» Rash (1 to 6 weeks).
» Hepatitis (weeks to months)
» Gynaecomastia.
Lopinavir/ Boost 400/100 mg Dose adjustment » Gastrointestinal upset.
ritonavir ed PI 12-hourly not required » Dyslipidaemia (weeks).
(LPV/r) OR » Rash and/or Hepatitis (1 to 6
800/200 mg weeks).
daily (only if
PI-naïve)
Atazanavir/ Boost 300 mg Dose adjustment » Unconjugated
ritonavir ed PI with not required hyperbilirubinaemia (common,
(ATV/r) ritonavir but benign)).
100 mg » Dyslipidaemia (low risk).
daily » Hepatitis (rare - 1 to 6 weeks).
» Renal stones (not common).
Dolutegravir InSTIs 50 mg once Dose adjustment » Hypersensitivity (rare, weeks)
(DTG) daily not required » Insomnia (common)
» Headache (common)
» Other neuropsychiatric
symptoms
» Nausea, diarrhea (common)
» Hepatitis (uncommon)
» Weight gain
» Increase in serum creatinine
due to inhibition of creatinine
secretion by DTG; this is
clinically insignificant as
glomerular filtration rate is not
reduced but will modestly
2019 10.6
affect eGFR which is
determined using serum
creatinine.
Raltegravir 400mg 12 Dose adjustment » Decreased appetite;
(RAL) hourly not required headache; nausea; insomnia;
dizziness (common)
» Anaemia, mental disorders,
liver failure, herpes infection,
warts, visual disturbance,
anxiety, hepatic steatosis,
neutropenia (uncommon).
The time-onset information with respect to adverse drug reactions (ADRs) serves as an
estimate. Patients may present with ADRs with the onset deviating from that indicated
in the table.
LoE:IIIxv
ART: DRUG-DRUG INTERACTIONS
Information can be accessed from:
https://www.hiv-druginteractionslite.org/checker
http://www.mic.uct.ac.za/ and download the ARV/EML interaction checker.
Package inserts.
ART INTERACTIONS WITH RIFAMPICIN AND RECOMMENDATIONS

FOR ADMINISTRATION
Class ARV Interaction with Dose of ARV with
rifampicin rifampicin
NRTI 3TC/FTC/ No clinically significant No dose adjustment required.
TDF/AZT/ pharmacokinetic interactions
ABC
NNRTI EFV Non-significant change No dose adjustment required
(EFV concentrations may (600 mg at night).
increase in patients who are
genetic slow metabolisers of
EFV due to inhibition by
isoniazid)
NVP NVP concentrations are NVP (200 mg 12 hourly) can be
modestly reduced. used without lead-in dose.
PI LPV/r LPV plasma concentrations Double the dose of LPV/r to
significantly decreased 800/200 mg 12-hourly.
Note: There is an increased risk
of ALT/AST elevations and
gastrointestinal disorders. Dose
adjustments should be gradually
titrated upward over 1-2 weeks.*
All other Marked reduction in PI Do not prescribe concomitantly –
PIs concentrations replace rifampicin with rifabutin
150 mg daily (see monitoring
instructions below).
InSTI DTG Significant reduction in Dosing frequency increased to 50
concentration of DTG mg 12 hourly.*
RAL Significant reduction in RAL Dosing frequency to be increased
concentration to 400 mg 12 hourly.
*Dose adjustments should be continued for 2 weeks after rifampicin is stopped.
LoE:IIIxvi
2019 10.7
In patients on atazanavir or darunavir, or if double dose LPV/r is not tolerated,

replace rifampicin with:
 Rifabutin, oral, 150 mg daily.
o Monitor FBC monthly for anaemia, and neutropenia.
o Monitor clinically for symptoms of uveitis (e.g. pain, photophobia,
variable loss of vision, circumcilliary injection, a miotic pupil) –
immediately stop rifabutin pending ophthalmology opinion.
LoE:IIIxvii
DRUG INTERACTIONS WITH DOLUTEGRAVIR
Interacting medicine Effect of co- Recommendation
administration
Preparations containing Significant reduction in Magnesium- and aluminum-containing
polyvalent cations (Mg2+, concentration of DTG preparations should be taken 6 hours
Ca2+, Fe2+, Al3+, Zn2+) before or 2 hours after DTG.
Antacids
Sucralfate Calcium- and iron- containing
Multivitamins preparations can be taken with DTG
Nutritional supplements together with food.
Note: Iron and calcium should be taken
at least 4 hours apart from one another.
Anticonvulsants: Significant reduction in Avoid co-administration if possible.
Carbamazepine concentration of DTG Consider valproate or lamotrigine.
Phenobarbital
Phenytoin For carbamazepine:
Double DTG dose to 50 mg 12 hourly.
Metformin Significant increase Administer metformin to a maximum of
in metformin levels 500 mg 12 hourly.
Rifampicin Significant reduction in Double DTG dose to 50 mg 12 hourly.
concentration of DTG
LoE:IIIxviii
DRUG INTERACTIONS WITH BOOSTED PIs
Interacting medicine Effect of co- Recommendation
administration
Substrates of cytochrome Significant increase Avoid co-administration or use lower
P450 3A4 (e.g. most statins, in levels of doses of CYP3A4 substrates (always
calcium channel blockers, CYP3A4 substrates consult interaction resources)
most SSRIs, most
benzodiazepines)
Anticonvulsants: Significant Avoid co-administration.
Carbamazepine reduction in Consider valproate or lamotrigine.
Phenobarbital concentration of PI
Phenytoin
Proton pump inhibitors Significant Avoid co-administration.

reduction in ATV LoE:IIIxix
levels
Rifampicin Significant Double LPV/r dose. Avoid co-administration
reduction in levels of other PIs (replace rifampicin with
of PI rifabutin)
2019 10.8
MONITORING ON ART
At HIV » Confirm HIV positive result with antibody test.

Diagnosis » WHO staging.
» Check CD4 count.
- CD4 <100 cells/mm3: Check cryptococcal antigen (If
symptomatic, perform LP).
- CD4 <200 cells/mm3: Fast track for ART initiation, initiate
cotrimoxazole prophylaxis.
- CD4 <350 cells/mm3: Prioritise for ART.
» Screen for pregnancy or ask if planning to conceive.
» Screen for mental health, STIs and NCDs.
» Screen for TB using the WHO screening questionnaire (any one
of cough, fever, night sweats, or weight loss) – in pregnancy do
sputum XpertMTB/RIF Ultra® in all.
» Do urine LAM testing if patients are seriously ill or CD4 ≤100
cells/mm3 and there are signs and symptoms of tuberculosis.
Urine dipstick for proteinuria and haematuria LoE:IIIxx
Prior to » Check creatinine (avoid TDF if eGFR <50 mL/minute).
initiating » Check FBC (avoid AZT if Hb <8 g/dl).
ART » Check HBsAg (if positive, TDF should form part of the regimen).
On ART » VL at 6 and 12 months after initiating ART and every 12 months
thereafter, if virologically suppressed.
» CD4 at 12 months after initiating ART*.
» Creatinine at 3, 6 and 12 months after initiation, and every 12
months thereafter if on TDF.
» FBC and differential count at 3 and 6 months after initiating AZT,
then every 12 months.
» ALT if symptoms of hepatitis develop.
» Fasting cholesterol and triglycerides at 3 months after initiating
LPV/r.
*Stop CD4 count monitoring when >200 cells/mm3 and
virologically suppressed. However, if virological or clinical failure
occurs, then a CD4 count should be done as cotrimoxazole may
need to be commenced/recommenced. Repeat CD4 count every
6 months if VL remains > 1000 copies/mL
LoE:IIIxxi
10.1.1 MANAGEMENT OF SELECTED ANTIRETROVIRAL

ADVERSE DRUG REACTIONS
E78.4/K71.9 + (Y41.5 + B24)
Dyslipidaemia E78.4 + (Y41.5 + B24)

Certain antiretroviral medication, particularly the protease inhibitors, can cause
dyslipidaemia. Fasting lipid levels should be done 3 months after starting
protease inhibitors. LPV/r is associated with a higher risk of dyslipidaemia
(especially hypertriglyceridaemia) than ATV/r.
2019 10.9
Patients on LPV/r who:

» develop triglycerides >10 mmol/L;or
» have a total cholesterol >6 mmol/L with a high risk (>20% risk of
developing a CVD event in 10 years)
» should switch to ATV/r and repeat the fasting lipid profile in three months.
Patients with persistent dyslipidaemia despite switching to ATV/r, qualify for
lipid lowering therapy. Criteria for initiating lipid lowering therapy are the same
as for HIV seronegative patients. (See section3.1: Ischaemic heart disease
and atherosclerosis, prevention).
Many statins (including simvastatin) cannot be used with protease inhibitors,
as protease inhibitors inhibit the metabolism of the statin resulting in extremely
high blood levels.
Patients, who fail to respond to lifestyle modification and have
hypertriglyceridemia, treat with a fibric acid derivative, e.g.:
 Bezafibrate, oral, 400 mg at night.
OR
If LDL cholesterol is raised (See section 3.1: Ischaemic heart disease and
atherosclerosis, prevention):
 Atorvastatin, oral, 10 mg daily (do not exceed this dose due to a drug
interaction with PIs).
Anaemia and neutropenia

AZT causes macrocytosis and can cause anaemia and neutropenia (but note
that it does not cause thrombocytopenia). AZT does not need to be stopped
with mild anaemia and/or neutropenia, but must be stopped and replaced with
an alternative medication if:
» anaemia is symptomatic,
» anaemia is severe (Hb <8.0 g/dL), or
» the neutrophil count is below 0.75 × 109/L.
Lamivudine and emtricitabine can cause pure red cell aplasia, but this is rare.
Hypersensitivity
Note that pre-existing dermatological conditions (especially papulopruritic
eruptions and acne) may worsen after commencing ART due to immune
reconstitution inflammatory syndrome (see section 10.1.2: Management of
selected antiretroviral adverse drug reactions) – this is not a hypersensitivity
reaction and ART should be continued.
Other medicines, notably cotrimoxazole, can also cause hypersensitivity.
Hypersensitivity rashes occur commonly in the 8-week period after starting

NVP or EFV. NNRTI-associated rashes can be severe and life-threatening,
especially with nevirapine. If a rash develops on NVP an ALT should be
requested urgently.
2019 10.10
If any of the following features occur, then NVP or EFV must be permanently
discontinued:
» Blistering – if more than 30% of the skin surface is involved this is called
Toxic Epidermal Necrolysis, and requires admission.
» Lesions affecting mucous membranes (mouth, eyes, or genitals) – this is
called Stevens-Johnson Syndrome, and requires admission
» Fever.
» Features of hepatitis (with nevirapine) – either ALT > 5 times the upper limit
of normal or symptomatic hepatitis with deranged liver function tests. Note
that the hepatitis usually starts a week or two after the onset of the rash.
With mild rashes NVP and EFV can be continued with careful observation and
the rash will often subside. If mild rashes occur on NVP during the dose lead-
in phase (200 mg daily) do not increase the dose to 200 mg 12 hourly until the
rash improves.
If rash worsens or does not improve within a week discontinue EFV or NVP.
If NVP has been stopped due to cutaneous hypersensitivity, then EFV can be
substituted provided that the rash has settled, and that the reaction was not
life-threatening (either Stevens-Johnson Syndrome or Toxic Epidermal
Necrolysis). If the reaction was life-threatening then a protease inhibitor, e.g.
LPV/r, should be substituted.
DTG can cause systemic hypersensitivity syndrome with rash, but this is very
uncommon. DTG should be permanently discontinued if this occurs.
ABC can cause a rash as part of a systemic hypersensitivity reaction, which

is confined to people who are HLA-B*5701 positive. ABC should be
permanently discontinued if this occurs.
LoE:IIIxxii
Hyperlactataemia
Symptomatic hyperlactataemia occurs due to mitochondrial toxicity of NRTIs.
Check for acidosis in such patients.
The estimated risk of lactate elevation differs among the NRTIs, with
zidovudine having moderate risk and the other NRTIs low risk.
Risk factors for hyperlactataemia include:
» females,
» obesity,
» prolonged use of NRTIs (> 3 months), or
» development of NRTI-induced peripheral neuropathy or fatty liver.
Clinical symptoms of hyperlactataemia are non-specific and may include:
» nausea » vomiting
» abdominal pain » weight loss
» malaise » tachycardia
» liver dysfunction (due to steatosis)
2019 10.11
A high index of suspicion is necessary. Send blood for lactate levels (check with
your local laboratory for specimen requirements for lactate). Alternatively, point
of care finger prick lactate monitoring can be done. Check the serum
bicarbonate level.
Patients with mild hyperlactataemia (lactate 2.5–5 mmol/L):

Therapy should be altered by selecting NRTIs that are less associated with
hyperlactataemia.
Monitor serial lactate measurements until the lactate has returned to within
the normal range.
Note: The resolution of hyperlactataemia may take a few months.
Patients with lactate levels > 5 mmol/L:

Stop the NRTIs.
If the patient is on a 1st line regimen, continue the EFV or DTG and add LPV/r.
If the patient is on the 2nd line regimen, consult with an HIV specialist.
If there is acidosis, then admission to a high care unit is recommended.
Lactic acidosis carries a poor prognosis. Treatment is largely supportive. It is
essential to exclude other causes of lactic acidosis, especially sepsis. High dose
vitamin B, especially riboflavin and thiamine, may have a role in therapy.
Hepatotoxicity K71.9 + (Y41.5 + B24)

All currently available antiretrovirals are potentially hepatotoxic. EFV has the
highest risk. NRTIs uncommonly cause acute hepatitis, but may result in
steatohepatitis after prolonged use, which manifests with mildly elevated liver
enzymes, affecting GGT and alkaline phosphatase more than the
transaminases, and ALT more than AST. Patients on atazanavir may develop
jaundice due an unconjugated hyperbilirubinaemia, which is not accompanied
by liver injury. This is a cosmetic issue and the atazanavir can be substituted
if the patient is unable to tolerate the jaundice. However, all protease inhibitors
can rarely cause hepatitis, so it is important to exclude this in patients
developing jaundice on ATV/r.
Other potentially hepatotoxic medicines prescribed to in HIV-infected patients
include anti-tuberculous therapy, fluconazole and cotrimoxazole.
Cotrimoxazole, amoxicllin/clavulanate and macrolides tend to cause
cholestatic hepatitis that may take months to resolve.
The exclusion of viral hepatitis is important in the work-up of drug-induced liver
injury (DILI). Testing for hepatitis A, B and C should be undertaken. Hepatitis
B is common, and flares of viral hepatitis may occur after ART initiation.
Furthermore, life threatening flares may occur when antiretrovirals that are
also active against hepatitis B (TDF, 3TC and FTC) are withdrawn.
Other potential causes include disseminated TB, IRIS, alcohol, alternative
remedies, fatty liver, sepsis and HIV cholangiopathy.
2019 10.12
Investigations:
» Request an ALT.
» Request viral hepatitis screen, full liver function tests and INR in patients
if ALT >5 x upper limit of normal (ULN) and/or jaundice and/or symptoms
of hepatitis are present.
» Perform a liver ultrasound if GGT or ALP are significantly elevated or if
conjugated bilirubin is elevated, to exclude:
- Extrahepatic biliary obstruction.
- Fatty liver due to NRTIs.
- Disseminated TB.
Management:
Upper Limit of <2.5 x 2.5 – 5 x >5x
Normal (ULN) ULN ULN ULN
ALT Repeat in Repeat in Stop
2 weeks 1 week ART
Isolated Repeat in 1 Stop ART Stop
Hyperbilirubinaemia week ART
*Stop the relevant medicines at lower levels if symptoms of hepatitis (right
upper quadrant pain, nausea / vomiting) or jaundice are present.
If ART is considered to be the cause substitute ART as follows:
» If the hepatitis occurred on efavirenz, substitute with DTG or a boosted PI.
» If hepatitis occurred on PI, substitute with DTG.
» NRTI fatty liver – discontinue AZT (if relevant) and replace with safer NRTI
(TDF or ABC) – if not on AZT and hepatitis is severe switch to NRTI-
sparing regimen.
Hepatitis in patients on ART and anti-tuberculosis therapy
Drug-induced liver injury (DILI) is a known adverse effect of anti-tuberculosis
therapy and ART and is a common problem in HIV/TB co-infected patients.
First-line TB medicines associated with DILI include isoniazid (INH), rifampicin
(RIF) and pyrazinamide (PZA). Anti-tuberculosis therapy commonly causes
transient, mild, asymptomatic elevations in serum aminotransferase levels not
requiring discontinuation of therapy.
If hepatitis develops, as defined above, stop all antiretrovirals, cotrimoxazole
and all potentially hepatotoxic TB medicines (isoniazid, rifampicin and
pyrazinamide).
TB immune reconstitution inflammatory syndrome (TB-IRIS) should be
considered in the differential diagnosis (see section 10.1.2: Management of
selected antiretroviral adverse drug reactions). This condition presents shortly
after ART initiation in patients with TB. The GGT and ALP are elevated to a
greater degree than the transaminases. Mild jaundice with a conjugated
hyperbilirubinaemia and tender hepatosplenomegaly may be present.
Investigations:
» Request an ALT.
2019 10.13
» Request viral hepatitis screen, full liver function tests and INR in patients
if ALT >5 x ULN and/or jaundice and/or symptoms of hepatitis are present.
» Perform a liver ultrasound if GGT or ALP are significantly elevated or if
conjugated bilirubin is elevated, to exclude extrahepatic biliary obstruction.
» Reassess the grounds for TB diagnosis.
» Check if patient is on intensive or continuation phase of TB treatment.
Management:
» Stop TB therapy and initiate background TB therapy and continue
throughout rechallenge:
 Moxifloxacin, oral, 400 mg daily or levofloxacin 750–1000 mg daily.
 Ethambutol, oral, 800–1200 mg daily.
» Stop cotrimoxazole prophylaxis and do not rechallenge.
» Stop ART as described above.
» Repeat ALT and bilirubin in 2 days (inpatient) or 7 days (outpatient).
» When ALT is <100 IU/L and total bilirubin is less than twice the upper limit
of normal, start TB medicine rechallenge as follows:
Day 1:  Rifampicin, oral 600 mg daily.
o If <60 kg: rifampicin, oral 450 mg daily.
Day 3: » Check ALT.
Day 4–6: ADD

 Isoniazid, oral 300 mg daily.
Day 8: » Stop moxifloxacin/levofloxacin and amikacin. Consider a

pyrazinamide rechallenge (in cases of TB meningitis or
intolerance/resistance to other medicines).
 Pyrazinamide, oral 25 mg/kg daily.
» Thereafter, monitor ALT twice weekly for the first 3 weeks,
then every two weeks for a month, then monthly until 3
months.
 Restart ART 2 weeks after completing rechallenge of TB
therapy.
o Monitor ALT every 2 weeks for 2 months after ART
rechallenge.
2019 10.14
LoE:Ixxiii
2019 10.15
10.1.2 IMMUNE RECONSTITUTION INFLAMMATORY

SYNDROME (IRIS)
D89.3 + (Y41.5 + B24)
DESCRIPTION
IRIS occurs when improving immune function unmasks a previously occult
opportunistic disease, which has an unusual inflammatory presentation
(“unmasking IRIS”) or causes paradoxical deterioration of an existing
opportunistic disease (“paradoxical IRIS”). IRIS is more common in patients with
advanced HIV disease, particularly those with a CD4 count <100 cells/mm3.
IRIS nearly always presents during the first 3 months of ART, with the median
time of onset being about two weeks. The diagnosis of paradoxical IRIS is often
difficult as new opportunistic diseases or drug resistance of the organism
causing the opportunistic infection need to be excluded.
TB is the commonest opportunistic disease involved in IRIS reactions in South
Africa. Paradoxical TB IRIS presents as recurrence of TB symptoms/signs, or
worsening, or new manifestations. The commonest presentation is with
enlarging lymph nodes, often with extensive caseous necrosis. Lung infiltrates
or effusions may worsen or develop. It is important to exclude multi-drug
resistance in all patients suspected with paradoxical TB IRIS.
Other common IRIS manifestations include:
» Inflammatory reactions to skin diseases, especially acne and Kaposi’s
sarcoma.
» Worsening cryptococcal meningitis.
» Flares of hepatitis B or C.
GENERAL MEASURES
Counseling is important to ensure that the patient understands that IRIS does
not mean failure of ART.
Management of IRIS is mainly symptomatic, e.g. aspiration of TB lymph nodes
or effusions.
Continue ART and therapy for the opportunistic infection.
MEDICINE TREATMENT
For pain and fever:
OR
 NSAID, e.g.:
Treating severe IRIS manifestations (e.g. compression of major structures by

enlarging lymph nodes, expanding CNS tuberculomata, worsening meningitis):
2019 10.16
 Prednisone, oral, 1.5 mg/kg daily for 2 weeks.

o Then 0.75 mg/kg daily for 2 weeks.
Preventing severe IRIS in high risk patients (CD4 ≤100 cells/mm3) and had
antituberculosis treatment for <30 days before initiating ART:
 Prednisone, oral, 40 mg daily for 2 weeks.
o Then 20 mg daily for 2 weeks. LoE:Ixxiv
Note: Do not use steroids in patients with Kaposi sarcoma.
10.2 OPPORTUNISTIC DISEASES

10.2.1 TUBERCULOSIS PREVENTIVE THERAPY (TPT)
Z29.2 + (B24)
Patients with HIV infection are more susceptible to TB infection than HIV-
uninfected patients at any CD4 count. TPT is an effective intervention for
reducing the incidence of TB in HIV-infected patients
Eligibility
All HIV-infected patients, irrespective of CD4 count and ART status.
Exclusions
» Suspected or confirmed TB » Painful peripheral neuropathy
» Liver Disease » Alcohol abusers
» Previous MDR- or XDR-TB
Note:
» TB must be excluded prior to initiating TPT by screening for the following:
- Cough (any duration) - Weight loss
- Fever - Night sweats
» TPT should not be initiated in patients if any of the above is present.
These patients require further investigation for active TB.
Start TPT together with ARVs:

 Isoniazid, oral, 300 mg daily for 12 months.
AND
 Pyridoxine, oral, 25 mg once daily for 12 months.
o Educate patients on the symptoms of hepatotoxicity (nausea, vomiting,
yellow eyes, brown urine, and pain in right upper quadrant).
o Instruct patient to present early if any of these symptoms arise.
o Patients should be followed up monthly for the first 3 months.
In pregnant women, starting ART: LoE:Ixxv
» If CD4 >350 cells/mm3. » If CD4 ≤350 cells/mm3.
 Defer TPT until after delivery.  Exclude active TB with symptom
screen and TB Xpert MTB/RIF Ultra ®,
then give TPT. LoE:IIxxvi
2019 10.17
10.2.2 OPPURTUNISTIC INFECTION PROPHYLAXIS, WITH

COTRIMOXAZOLE
Z29.2 + (B24)
DESCRIPTION
Primary prophylaxis reduces the probability of developing many infections,
e.g.:
» Pneumocystis pneumonia » bacteraemia
» toxoplasmosis » cystoisosporiasis
» bacterial pneumonia
Indications for primary prophylaxis: LoE:IIIxxvii

» WHO Clinical stage II, III or IV.
» CD4 count <200 cells/mm3.
MEDICINE TREATMENT
Prophylaxis
 Cotrimoxazole, oral, 160/800 daily. LoE:Ixxviii
Note:
Once the CD4 >200 cells/mm3 (as measured at the routine CD4 count done
at 1 year on ART), discontinue prophylaxis. If the CD4 count was >200
cells/mm3 when cotrimoxazole was commenced (e.g. patients with TB)
continue for 6 months.
10.2.3 CANDIDIASIS OF OESOPHAGUS/TRACHEA/BRONCHI

B20.4
DESCRIPTION
Mucosal candidiasis involving the oesophagus/trachea/bronchi is AIDS-
defining (WHO clinical stage 4). Oesophagitis is by far the commonest
manifestation.
Clinical features: symptoms of pain or difficulty on swallowing. Oral thrush is
present in most patients.
GENERAL MEASURES
Maintain adequate hydration.
MEDICINE TREATMENT
 Fluconazole, IV/oral, 200 mg daily for 14 days.
o The usual route is oral but give IV if patient unable to swallow or is
vomiting.
o An early relapse should be treated with a 4-week course of
fluconazole as above.
Note: Primary or secondary fluconazole prophylaxis for mucosal candidiasis
is not recommended.
2019 10.18
10.2.4 CRYPTOCOCCOSIS
10.2.4.1 ASYMPTOMATIC CRYPTOCOCCOSIS, CRAG POSITIVE
B20.5
DESCRIPTION
All ART-naïve patients with CD4 <100 cells/mm3 should have cryptococcal
antigen (CrAg) test done on serum, plasma or whole blood (unless they had
a diagnosis of cryptococcal infection). The treatment of patients who are CrAg
positive and with no signs or symptoms of meningitis and CSF crag negative
is outlined below. Refer to algorithm
LoE:IIIxxix
MEDICINE TREATMENT
Induction phase
 Fluconazole, oral 1200 mg daily for 14 days. LoE:IIIxxx
Consolidation phase
Follow with:
 Fluconazole, oral, 800 mg daily for 8 weeks.
Maintenance phase
 Fluconazole, oral, 200 mg daily.
o Continue for at least 1 year provided that the CD4 count increases to
>200 cells/mm3 on ART. If the CD4 count does not increase continue
treatment indefinitely.
LoE:IIIxxxi
 Commence ART after completion of the induction
phase i.e. at 2 weeks. See section 10.1: Antiretroviral therapy.
LoE:IIIxxxii
CAUTION
» Fluconazole should be avoided in the 1st trimester, but pregnant women
should be counselled that the benefits of fluconazole may outweigh the
risks in the management of cryptococcosis.
» All pregnant women <20 weeks gestation exposed to fluconazole should
have an ultrasound scan to detect congenital LoE:IIIxxxiii
abnormalities.
» For management of breastfeeding mothers, consult a specialist; as
fluconazole is present at concentrations similar to maternal plasma
concentrations in breast milk that will be transmitted to the breastfed
infant.
LoE:IIIxxxiv
2019 10.19
Adapted from: Govender NP, Meintjes G (Chairpersons), Bicanic T, Dawood H, Harrison TS, Jarvis JN, Karstaedt
AS, Maartens G, McCarthy KM, Rabie H, Variava E, Venter WDF (Expert panel members), Boulware DR, Chiller T,
Meya DB, Scriven J (Reviewers). Guideline for the prevention, diagnosis and management of cryptococcal meningitis
among HIV-infected persons: 2013 update. S Afr J HIV Med 2013;14(2):76-86.
http://www.sajhivmed.org.za/index.php/hivmed/article/view/82/128
2019 10.20
10.2.4.2 SYMPTOMATIC, NON-MENINGEAL CRYPTOCOCCOSIS

B20.5
DESCRIPTION
Cryptococcal infection confirmed on culture or serum CrAg positive with non-
meningeal disease. Any anatomical site may be involved, but the lungs are
the commonest site.
MEDICINE TREATMENT
Induction phase
 Fluconazole, oral 1200 mg daily for 14 days.
AND
 Amphotericin B, slow IV infusion, 1 mg/kg daily in dextrose 5 % over 4
hours for 14 days.
o Ensure adequate hydration to minimise nephrotoxicity. (See Appendix
II for preventing, monitoring and management of toxicity).
Consolidation phase
Follow with:
Maintenance phase
LoE:IIIxxxv
 Commence ART 4–6 weeks after starting antifungal
therapy. See section 10.1: Antiretroviral therapy.
10.2.4.3. CRYPTOCOCCAL MENINGITIS

B20.5 + (B45.1 + G02.1*)
DESCRIPTION
Cryptococcal meningitis is the commonest manifestation of disseminated
cryptococcosis in patients with advanced HIV. Severe headache is common
due to raised intracranial pressure.
Diagnosis
Confirmed on lumbar puncture.
GENERAL MEASURES
Therapeutic lumbar puncture is indicated to lower pressure in symptomatic
patients and should be done with pressure monitoring. Remove sufficient CSF
(maximum 30 mL) to lower pressure to 50% of the opening pressure but not
less than 20 cm H2O.
2019 10.21
Therapeutic lumbar puncture should be done daily until there is clinical

improvement.
MEDICINE TREATMENT
Induction phase
 Fluconazole, oral 1200 mg daily for 14 days.
AND
 Amphotericin B, slow IV infusion, 1 mg/kg daily in dextrose 5 % over 4
hours for 14 days.
 Ensure adequate hydration to minimise nephrotoxicity. (See Appendix II
for preventing, monitoring and management of toxicity).
Consolidation phase
Follow with:
Maintenance phase
LoE:IIIxxxvi
 Commence ART 4–6 weeks after starting antifungal
therapy. See section 10.1: Antiretroviral therapy.
LoE:IIIxxxvii
Note: Adjunctive corticosteroids have been shown to be
detrimental.
LoE:Ixxxviii
REFERRAL
» Focal neurological signs – CT scan required to exclude other pathology
e.g. toxoplasmosis.
» Persistent raised intracranial pressure despite daily therapeutic lumbar
puncture.
10.2.5 CRYPTOSPORIDIOSIS DIARRHOEA

B20.8 + (A07.2)
DESCRIPTION
Chronic diarrhoea due to Cryptosporidium parvum. Disease lasting >4 weeks
is AIDS-defining (WHO clinical stage 4).
GENERAL MEASURES
Rehydration with oral rehydration solution (ORS).
2019 10.22
MEDICINE TREATMENT
There is no specific antimicrobial therapy for cryptosporidiosis. As with other
opportunistic diseases it responds well to ART.
Antimotility agents are partially effective, e.g.:
 Loperamide, oral, 4 mg initially, followed by 2 mg as required up to four
times daily.
10.2.6 CYTOMEGALOVIRUS (CMV)

B20.2
DESCRIPTION
CMV disease outside the reticulo-endothelial system is an AIDS-defining
illness (WHO clinical stage 4).
CMV disease is seen in patients with CD4 counts <100 cells/mm3.
The commonest manifestations are:
» retinitis,
» gitulceration,
» pneumonitis, and
» polyradiculitis.
GIT and other organ involvement must be diagnosed on biopsy.
CNS disease must be diagnosed by PCR of CSF.
The diagnosis of CMV retinitis should be confirmed by an ophthalmologist
Note: CMV serology (IgM and IgG), antigenaemia (pp65), or PCR on blood
are not helpful in the diagnosis of CMV disease in HIV-infected adults.
MEDICINE TREATMENT
Valganciclovir is the treatment of choice, but this agent is toxic and expensive;
and should only be used by a specialist familiar with its use.
To prevent recurrent disease commence patients on ART as soon as possible
after initiating valganciclovir (see section 10.1: Antiretroviral therapy).
Maintenance therapy is only applicable to CNS disease and retinitis.
Monitor FBC regularly during therapy. Avoid other medicines associated with
bone marrow suppression, particularly zidovudine.
Biopsy-proven GIT disease and pneumonitis

 Valganciclovir, oral, 900 mg 12 hourly for the first 3 weeks, if available.
Specialist initiated.
OR
If unable to tolerate oral medication:
 Ganciclovir, IV, 5 mg/kg 12 hourly for 14 days, if available. Specialist initiated.
Maintenance treatment is not indicated unless there has been a relapse.
2019 10.23
CNS disease
Initial treatment:
 Valganciclovir, oral, 900 mg 12 hourly for the first 3 weeks, if available.
Specialist initiated.
OR
 Ganciclovir, IV, 5 mg/kg 12 hourly for 14 days. Specialist initiated.
Maintenance treatment:
Only patients with a good clinical response should be considered for
maintenance.
 Valganciclovir, oral, 900 mg daily until CD4 count rises to >100 cells/mm3
on ART, if available.Specialist initiated.
OR LoE:IIIxxxix
 Ganciclovir, IV, 5 mg/kg daily until CD4 count rises to >100 cells/mm3 on
ART. Specialist initiated.
Specialist or tertiary
All patients.
10.2.7 CYSTOISOSPORIASIS
A07.3/B20.8
DESCRIPTION
Diarrhoea due to Cystoisospora belli. Disease lasting >4 weeks is AIDS-
defining (WHO clinical stage 4).
GENERAL MEASURES
Rehydration with oral rehydration solution (ORS).
MEDICINE TREATMENT
 Cotrimoxazole 160/800 mg, oral, 2 tablets 12 hourly for 10 days.
OR
If allergic to cotrimoxazole:
Secondary prophylaxis:
Continue for at least 6 months and until CD4 count increases to >200
cells/mm3 on ART.
 Cotrimoxazole 160/800 mg, oral daily.
2019 10.24
10.2.8 MYCOBACTERIOSIS – DISSEMINATED NON-

TUBERCULOUS
B20.0
DESCRIPTION
Disseminated infection due to non-tuberculous mycobacteria, usually
Mycobacterium avium complex.
Diagnosis must be by culture from sterile sources, e.g. blood, tissue or bone
marrow. Note that culture from a single sputum specimen is not adequate to
make the diagnosis as this often reflects colonisation rather than disease.
Non-tuberculous mycobacteria can cause limited pulmonary disease, which is
diagnosed if the sputum culture is positive repeatedly and there is a worsening
pulmonary infiltrate.
Disseminated disease is AIDS-defining (WHO clinical stage 4).
MEDICINE TREATMENT
 Azithromycin, oral, 500 mg daily.
AND LoE:IIxl
 Ethambutol, oral, 15–20 mg/kg daily.
Treatment can be stopped when treatment has been continued for at least 12
months AND the CD4 count has increased to >100 cells/mm3 on ART.
10.2.9 PNEUMOCYSTIS PNEUMONIA

B20.6
DESCRIPTION
Interstitial pneumonitis due to Pneumocystis jirovecii (formerly carinii). AIDS-
defining illness (WHO clinical stage 4).
MEDICINE TREATMENT
All patients:
 Cotrimoxazole 80/400 mg, oral, 6 hourly for 21 days.
o <60 kg three tablets
o ≥60 kg four tablets
Monitor FBC and potassium when on high dose therapy.
OR
If vomiting:
 Cotrimoxazole, IV, 6 hourly for 21 days.
o <60 kg 240/1200 mg
o ≥60 kg 320/1600 mg
For hypoxic patients:

 Oxygen by face mask or CPAP as necessary.
AND
2019 10.25

 Prednisone, oral, 80 mg daily for 5 days, then taper over 14 days.(Refer
to Appendix II for an example of a dose reduction regimen).
Cotrimoxazole intolerance and desensitisation
Attempt desensitisation in patients with a history of cotrimoxazole intolerance,
unless this was life-threatening, e.g. Stevens-Johnson syndrome. See section
4.6: Erythema Multiforme, Stevens Johnson Syndrome, Toxic Epidermal
Necrolysis. Unless rash is severe or associated with systemic symptoms,
continue treatment with careful observation for deterioration.
Desensitisation should be attempted using cotrimoxazole suspension 240
mg/5ml. Dilute the suspension appropriately and consult with your pharmacist
if necessary. DO NOT administer antihistamines or steroids.
Time (hours) Cotrimoxazole dose (mL of
240mg/5mL suspension
0 0.0005
1 0.005
2 0.05
3 0.5
4 5
5 Two single strength tablets (each tablet
= 80/400 mg) followed by full dose
Alternatively, in case of intolerance and unsuccessful desensitisation:

AND
 Primaquine, oral, 15 mg daily for 21 days.
o Exclude G6PD deficiency before initiating therapy.
OR
If primaquine is not available, consider:

AND
 Dapsone, oral, 100 mg daily for 21 days.
Secondary prophylaxis
Continue for at least 6 months and until CD4 count increases to >200
cells/mm3 on ART.
 Cotrimoxazole 160/800 mg, oral daily.
Alternatively, in case of intolerance to cotrimoxazole:
 Dapsone, oral, 100 mg daily.
Intolerance to second line regimen.
2019 10.26
10.2.10 CEREBRAL TOXOPLASMOSIS

B20.8
DESCRIPTION
Intracranial space-occupying lesions, with contrast enhancement on imaging,
due to Toxoplasma gondii. AIDS-defining illness (WHO clinical stage 4).
The diagnosis of toxoplasmosis is very unlikely if either the serum toxoplasma
IgG is negative or the CD4 count is > 200 cells/mm3.
Diagnosis is confirmed by a clinical response to therapy, which occurs in 7–14
days. CT scan improvement usually occurs within 14–21 days. Interpreting the
response to therapy may be difficult if steroids have been given concomitantly.
Steroid therapy should only be given for life-threatening peri-lesionaloedema.
MEDICINE TREATMENT
 Cotrimoxazole 160/800, oral, 2 tablets 12 hourly for 28 days, followed by
1 tablet 12 hourly for 3 months.
Secondary prophylaxis
Continue for at least 6 months and until CD4 count increases to > 200 cells/mm3
on ART.
 Cotrimoxazole 160/800 mg, oral, 2 tablets daily.
See cotrimoxazole desensitisation: Page 10.23.
Intolerance to cotrimoxazole.
Note: Attempt desensitisation first (see section 10.2.9: Pneumocystis
pneumonia).
10.3 HIV AND KIDNEY DISEASE

B23.8 + (N28.9)
DESCRIPTION
A number of kidney disorders are associated with HIV infection.
Acute kidney injury due to sepsis, dehydration or nephrotoxicity from medicines
occurs commonly.
The commonest chronic kidney disorder is HIV-associated nephropathy (HIVAN).
Typical features of HIVAN are:
» Heavy proteinuria.
» Rapidly progressive chronic kidney disease with preserved kidney size on
imaging.
» ART slows progression of chronic kidney disease.
Early detection of kidney disease is important in order to implement
interventions that may slow kidney disease progression, and for adjusting the
2019 10.27
dose of relevant medicines.

Risk factors for HIV renal disease:
» CD4 count <200 cells/mm3.
» Use of nephrotoxic medications.
» Comorbidity such as diabetes mellitus, hypertension, or hepatitis C virus co-
infection.
Screening for renal disease in HIV

» Tests should include:
 Urine dipstick for haematuria and proteinuria (request urine
protein:creatinine ratio if proteinuria is detected; if this is >0.15 g/mmol
discuss with a specialist).
 Serum creatinine and eGFR.
Dose adjustment of ART in renal impairment: Refer to table: Dosing of ART
for renal adjusted doses in section 10.1: Antiretroviral therapy.
10.4 KAPOSI SARCOMA (KS)

B21.0
DESCRIPTION
Kaposi Sarcoma (KS) is a malignancy of lymphatic endothelial origin associated
with Human Herpes Virus-8, also known as KS Herpes Virus, infection.
KS may involve the skin, oral cavity, lymph nodes or viscera (especially lung
and GIT).
Most patients have multiple lesions.
Lymphoedema is a common complication.
10–20% of cases of visceral KS will have no oral or skin involvement.
KS is an AIDS-defining illness (WHO clinical stage 4).
Although most cases are diagnosed on the typical macroscopic appearance
of skin and oral lesions, biopsy confirmation is necessary for atypical lesions
and if chemotherapy is considered. One important differential diagnosis is
bacillary angiomatosis, which develops more rapidly.
MEDICINE TREATMENT
All patients with KS should be commenced on ART (see section 10.1:
Antiretroviral therapy) and cotrimoxazole prophylaxis (see section 10.2.2:
Opportunistic infection prophylaxis, with cotrimoxazole) regardless of CD4 count.
Many patients with limited mucocutaneous KS will have complete resolution
or substantial regression on ART alone.
REFERRAL
Prior to referral, all patients must be started on ART.
» Radiotherapy/intralesional chemotherapy for symptomatic local lesions.
» Systemic chemotherapy is indicated in patients with poor prognostic factors:
- more than 25 skin lesions,
2019 10.28
- rapidly progressive disease,

- visceral involvement,
- extensive oedema, or
- “B” symptoms, i.e. fever, night sweats, significant constitutional symptoms.
» Failure of KS to respond to ART.
10.5 POST-EXPOSURE PROPHYLAXIS

National HIV Health Care Worker Hotline: 0800 212 506 or 021 406 6782.
10.5.1 POST-EXPOSURE PROPHYLAXIS, OCCUPATIONAL

S61.0 + (W46.22 + Z20.6 + Z29.8)
DESCRIPTION
Antiretroviral therapy may prevent the risk of acquiring HIV following a
significant occupational exposure.
It is essential to document occupational exposures adequately for possible
subsequent compensation.
Other blood borne infections (hepatitis B and C) should also be tested for in
the source patient and appropriate prophylaxis instituted in the case of
hepatitis B.
Assessing the risk of occupational exposures
The risk of acquiring HIV following occupational exposure is determined by the
nature of the exposure and the infectiousness of the source patient. High-risk
exposures involve exposure to a larger quantity of viruses from the source patient,
either due to exposure to larger quantity of blood or because the amount of virus
in the blood is high.
Any one of the following associated with an increased risk of HIV transmission:
» deep percutaneous sharps injuries
» percutaneous exposure involving a hollow needle that was used in a vein or
artery
» visible blood on the sharp instrument involved in a percutaneous injury
» the source patient has terminal AIDS or is known to have a high viral load,
i.e. >100 000 copies/mL
In instances when the risk of infection is extremely low or non-existent, post-
exposure prophylaxis (PEP) is not indicated, as the risks of PEP will far
outweigh the benefits. PEP is NOT indicated when:
» The material the healthcare worker was exposed to is not infectious for
HIV in the occupational setting, e.g. vomitus, urine, faeces or saliva,
unless these are visibly blood stained.
» The exposure was on intact skin.
» The source patient is HIV negative, unless there are clinical features to
suggest seroconversion illness, in which case PEP should be commenced
until further tests are done – consult with a virologist or infectious diseases
2019 10.29
specialist.
» The healthcare worker is HIV infected, as this person should be assessed
for ART initiation.
PEP REGIMENS
PEP should be commenced as soon as possible after the injury. Do not delay
initiating PEP while awaiting confirmatory test results on the source patient
and health care worker. PEP should be considered up to 72 hours after
exposure and, in exceptional circumstances involving high-risk exposures,
PEP may be considered up to 7 days after exposure.
When PEP is indicated:

 Tenofovir, oral, 300 mg daily for 4 weeks (provided baseline eGFR is >50
mL/minute).
and
 Lamivudine, oral, 200 mg daily for 4 weeks
and
 Dolutegravir, oral 50 mg once daily for 4 weeks. LoE:IIIxli
In WOCP, pregnant women <6 weeks gestation, or where DTG is not

tolerated:
 Tenofovir, oral, 300 mg daily for 4 weeks (provided baseline eGFR is >50
mL/minute).
and
 Emtricitabine, oral, 200 mg daily for 4 weeks.
and LoE:IIIxlii
 Atazanavir/ritonavir 300/100 mg daily for 4 weeks.
Or
 Lopinavir/ritonavir 200/50 mg, oral, 2 tablets 12 hourly for 4 weeks.
If tenofovir is contraindicated or if source patient is known to be failing a

tenofovir based regimen, replace tenofovir and emtricitabine with:
 Zidovudine, oral, 300 mg 12 hourly for 4 weeks.
and
 Lamivudine, oral, 150 mg 12 hourly for 4 weeks.
PEP is generally not well tolerated. Adverse effects occur in about half of
cases and therapy is discontinued in about a third. Efavirenz is not
recommended as it is very poorly tolerated in PEP.
Zidovudine often causes nausea and headache. If zidovudine is not tolerated,
switch to tenofovir (check baseline eGFR as above).
Lopinavir/ritonavir often causes diarrhoea. If lopinavir/ritonavir is not tolerated
switch to atazanavir/ritonavir. Atazanavir/ritonavir often causes unconjugated
jaundice, which is benign but may not be tolerated, in which case switch to
lopinavir/ritonavir.
2019 10.30
Recommendations for post exposure prophylaxis (PEP) after occupational

exposure to infectious material (includes blood, CSF, semen, vaginal
secretions and synovial/pleural/ pericardial/ peritoneal/amniotic fluid) from HIV
seropositive patients are given in the table, below.
PEP for healthcare worker following occupational HIV exposure:

Exposure HIV Status of source patient
Negative Unknown or Positive
Intact skin no PEP no PEP
Mucosal splash no PEP 3-drug regimen (PI-based)
or
non-intact skin
or
percutaneous injury
When the source patient is known to be failing ART, modify the PEP regimen:
» If the patient is on zidovudine , use tenofovir.
» If the patient is on tenofovir then use zidovudine.
Patients failing 2nd line ART usually have no resistance to protease inhibitors,
so lopinavir/ritonavir should still be effective, but consultation with a virologist
or infectious diseases physician is recommended for advice on which ARVs
to use for PEP in this setting.
PEP for healthcare workers following hepatitis B exposure

Source patient
HBsAg positive HbsAg HBsAg
negative unknown
Unvaccinated  HBIG, IM, 500  Initiate Hep B  HBIG, IM, 500
or units* vaccination units*
vaccination  Hep B vaccine (month 0, 1  Hep B vaccine
Vaccination incomplete (3 doses at and 6) (3 doses at
status monthly intervals) monthly
and intervals)
antibody Vaccinated AND No treatment No treatment No treatment
response known to have
status of HBsAb
HCW >10 units/mL#
Vaccinated AND  HBIG, IM, 500 No treatment  HBIG, IM, 500
HBsAb units * units*
<10 units/mL  Repeat Hep B  Repeat Hep B
or vaccine vaccine
level unknown (3 doses at (3 doses at
monthly intervals) monthly
intervals)
* HBIG and first dose of vaccine to be given simultaneously, but at different sites.
#
If the delay in obtaining HBsAb results is more than 24 hours initiate treatment as for vaccinated
AND HBsAb < 10 units/mL.
After vaccination ensure the health care worker has a HBsAb > 10 units/mL 1 – 2 months after the
last vaccine dose.
2019 10.31
Monitoring in occupational exposures

Source Exposed health care worker
patient
Baseline Baseline 2 weeks 6 weeks 4 months
HIV Rapid test Rapid test ELISA ELISA
PLUS PLUS
ELISA ELISA
Hepatitis B Surface Surface
antigen antibody*
Hepatitis C HCV HCV antibody* HCV PCR*
antibody
Syphilis RPR/ RPR/TP RPR/TP
TP antibody antibody* antibody*
Creatinine If TDF part of If TDF
PEP part of
PEP
FBC If AZT part of If AZT
PEP part of
PEP
*Only if source patient was positive.
10.5.2 NON OCCUPATIONAL POST EXPOSURE

PROPHYLAXIS, SEXUAL ASSAULT
Z29.8
PEP should be offered to rape survivors who present within 72 hours

(management is the same as for occupational HIV exposure. See section
10.4.1 Post-exposure prophylaxis, occupational).
A patient presenting ≥72 hours since the alleged incident should not be given
PEP, but should be counselled about the possible risk of transmission, with
HIV testing provided at the time of presentation and 4 months later. Rape
survivors who test HIV seropositive should be initiated on ART– see section
10.1: Antiretroviral therapy.
Other important aspects of care for the rape survivor should not be forgotten,
i.e. contraception, treatment for sexually transmitted infections, counseling
and forensic specimens.
Emergency contraception after pregnancy is excluded
Do a pregnancy test in all women and female adolescents. Children must be
tested and given Emergency contraception from Breast Tanner Stage III, if
unsure of staging, give Emergency contraception when you detect any breast
development (DO NOT REGARD MENARCHE AS AN INDICATION).
 Levonorgestrel 1.5 mg, oral, as a single dose as soon as possible after
unprotected intercourse. LoE:IIIxliii
o Repeat the dose, if woman vomits within 2 hours.
2019 10.32
CAUTION
Emergency contraceptive tablets must be taken as soon as possible, preferably
within 72 hours of unprotected intercourse, and not later than 5 days.
Enzyme inducers (including efavirenz, carbamazepine) cause a significant
reduction in levonorgestrel concentrations. Women on these medicines should
double the dose of levonorgestrel, because of significant reduction of
levonorgestrel. Women > 80 kg or BMI ≥ 30 should also be given twice the
standard dose.
LoE:IIIxliv
An anti-emetic:
 Metoclopramide oral, 10 mg 8 hourly as needed.
LoE:IIIxlv
STI prophylaxis
lidocaine 1% without epinephrine (adrenaline).
AND
AND
 Metronidazole, oral, 2 g immediately as a single dose.
LoE:IIIxlvi
Inadvertent (non-occupational) exposure to infectious material from HIV sero-
positive persons often requires clinical judgement and includes:
» human bites (requires hepatitis B, but not HIV prophylaxis)
» sharing of needles during recreational drug use
» consensual sexual exposure, burst condoms
» contact sports with blood exposure LoE:IIIxlvii
10.5.3 NON OCCUPATIONAL POST EXPOSURE

PROPHYLAXIS, INADVERTENT NON-
OCCUPATIONAL
Z29.8
Management of inadvertent (non-occupational) HIV exposure is the same as

for occupational HIV exposure. See section 10.4.1 Post-exposure
prophylaxis, occupational.
2019 10.33
References:
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xix Atazanavir-PPI/H2-anatagonist interaction: University of Liverpool HIV Drug Interaction online tool. https://www.hiv-
druginteractions.org/checker
2019 10.35
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xxiiAbacavir: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of Cape
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xxiiiManagement of drug-induced liver injury: Jong E, Conradie F, Berhanu R, Black A, John MA, Meintjes G, Menezes
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art-clinical-guidelines-management-hiv-adults-pregnancy-adolescents-children-infants
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xxixFluconazole (CD4 < 100 cells/mm3): Meya DB, Manabe YC, Castelnuovo B, Cook BA, Elbireer AM, Kambugu A,
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xxx Fluconazole, oral (cryptococcosis): WHO. Guidelines for the diagnosis, prevention and management of
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https://www.who.int/hiv/pub/guidelines/cryptococcal-disease/en/
Fluconazole, oral (cryptococcosis): Govender NP, Meintjes G (Chairpersons), Bicanic T, Dawood H, Harrison
TS, Jarvis JN, Karstaedt AS, Maartens G, McCarthy KM, Rabie H, Variava E, Venter WDF(Expert panel members),
2019 10.36
Boulware DR, Chiller T, Meya DB, Scriven J (Reviewers). Guideline for the prevention, diagnosis and management
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Fluconazole, oral (cryptococcosis): NICD data on file
xxxiFluconazole, oral (cryptococcosis): WHO. Guidelines for the diagnosis, prevention and management of
Fluconazole, oral (cryptococcosis): NICD data on file.
xxxii ART: Makadzange AT, Ndhlovu CE, Takarinda K, Reid M, Kurangwa M, Gona P, Hakim JG. Early versus delayed
initiation of antiretroviral therapy for concurrent HIV infection and cryptococcal meningitis in sub-saharan Africa. Clin
Infect Dis. 2010 Jun 1;50(11):1532-8.http://www.ncbi.nlm.nih.gov/pubmed/20415574
ART: WHO. Guidelines for the diagnosis, prevention and management of cryptococcal disease in HIV-infected
adults, adolescents and children supplement to the 2016 consolidated guidelines on the use of antiretroviral drugs
for treating and preventing HIV infection, March 2018. https://www.who.int/hiv/pub/guidelines/cryptococcal-
disease/en/
ART: Govender NP, Meintjes G (Chairpersons), Bicanic T, Dawood H, Harrison TS, Jarvis JN, Karstaedt AS,
Maartens G, McCarthy KM, Rabie H, Variava E, Venter WDF(Expert panel members), Boulware DR, Chiller T,
Meya DB, Scriven J (Reviewers). Guideline for the prevention, diagnosis and management of cryptococcal
meningitis among HIV-infected persons: 2013 update. S Afr J HIV Med 2013;14(2):76-86.
xxxiii Fluconazole, oral (pregnancy): Mølgaard-Nielsen D, Pasternak B, Hviid A. Use of oral fluconazole during pregnancy
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Between Use of Oral Fluconazole During Pregnancy and Risk of Spontaneous Abortion and Stillbirth. JAMA. 2016 Jan
Fluconazole, oral (pregnancy): Govender NP, Meintjes G (Chairpersons), Bicanic T, Dawood H, Harrison TS,
Jarvis JN, Karstaedt AS, Maartens G, McCarthy KM, Rabie H, Variava E, Venter WDF(Expert panel members),
xxxiv Fluconazole, oral (breastfeeding): South African Medicines Formulary. 12th Edition. Division of Clinical

Fluconazole, oral (breastfeeding): Govender NP, Meintjes G (Chairpersons), Bicanic T, Dawood H, Harrison TS,
Jarvis JN, Karstaedt AS, Maartens G, McCarthy KM, Rabie H, Variava E, Venter WDF(Expert panel members),
xxxvFluconazole, oral (cryptococcosis): WHO. Guidelines for the diagnosis, prevention and management of
xxxviFluconazole, oral (cryptococcosis): WHO. Guidelines for the diagnosis, prevention and management of
xxxvii ART: Makadzange AT, Ndhlovu CE, Takarinda K, Reid M, Kurangwa M, Gona P, Hakim JG. Early versus delayed
initiation of antiretroviral therapy for concurrent HIV infection and cryptococcal meningitis in sub-saharan Africa. Clin
Infect Dis. 2010 Jun 1;50(11):1532-8.http://www.ncbi.nlm.nih.gov/pubmed/20415574
ART: WHO. Guidelines for the diagnosis, prevention and management of cryptococcal disease in HIV-infected
adults, adolescents and children supplement to the 2016 consolidated guidelines on the use of antiretroviral drugs
for treating and preventing HIV infection, March 2018. https://www.who.int/hiv/pub/guidelines/cryptococcal-
disease/en/
2019 10.37
ART: Govender NP, Meintjes G (Chairpersons), Bicanic T, Dawood H, Harrison TS, Jarvis JN, Karstaedt AS,
Maartens G, McCarthy KM, Rabie H, Variava E, Venter WDF(Expert panel members), Boulware DR, Chiller T,
Meya DB, Scriven J (Reviewers). Guideline for the prevention, diagnosis and management of cryptococcal
meningitis among HIV-infected persons: 2013 update. S Afr J HIV Med 2013;14(2):76-86.
xxxviiiSteroids and HIV-associated Cryptococcal Meningitis Treatment: Beardsley J, Wolbers M, Kibengo FM, Ggayi
AB, Kamali A, Cuc NT, et al. Adjunctive dexamethasone in HIV-associated cryptococcal meningitis. N Engl J Med
xxxixValganciclovir, oral: 1. Martin DF, Sierra-Madero J, Walmsley S, Wolitz RA, Macey K, Georgiou P, Robinson CA,
Stempien MJ; Valganciclovir Study Group. A controlled trial of valganciclovir as induction therapy for cytomegalovirus
retinitis. N Engl J Med. 2002 Apr 11;346(15):1119-26. http://www.ncbi.nlm.nih.gov/pubmed/11948271
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1999 Aug;37(2):167-76. http://www.ncbi.nlm.nih.gov/pubmed/10496303
xlAzithromycin: Dunne M, Fessel J, Kumar P, Dickenson G, Keiser P, Boulos M, Mogyros M, White Jr AC, Cahn P,
O'Connor M, Lewi D, Green S, Tilles J, Hicks C, Bissett J, Schneider MM, Benner R. A randomized, double-blind trial
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bacteremia in patients with human immunodeficiency virus infection. Veterans Affairs HIV Research Consortium.
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xli Dolutegravir-based PEP regimen: Ford N, Shubber Z, Calmy A, Irvine C, Rapparini C, Ajose O, et al. Choice of
antiretroviral drugs for postexposure prophylaxis for adults and adolescents: A systematic review. Clinical
Infectious Diseases. 2015;60 Suppl 3:S170–6. https://www.ncbi.nlm.nih.gov/pubmed/25972499
Dolutegravir-based PEP regimen: McAllister JW, Towns JM, McNulty A, Pierce AB, Foster R, Richardson R, et
al. Dolutegravir with tenofovir disoproxil fumarate-emtricitabine as HIV postexposure prophylaxis in gay and
bisexual men. AIDS. 2017;31(9):1291–5. https://www.ncbi.nlm.nih.gov/pubmed/28301425
Dolutegravir-based PEP regimen: Goldschmidt RH. CDC Releases Updated Guidelines for Postexposure
Prophylaxis After Sexual, Injection Drug, or Other Nonoccupational Exposures to HIV. Am Fam Physician. 2016
Sep 1;94(5):392-3. https://www.ncbi.nlm.nih.gov/pubmed/27583430
Dolutegravir-based PEP regimen: Canadian guideline on HIV pre-exposure prophylaxis and nonoccupational
postexposure prophylaxis. CMAJ. 2018 Jun 25;190(25):E782. https://www.ncbi.nlm.nih.gov/pubmed/29941442
xliiProtease-inhibitor- based PEP regimen: Ford N, Shubber Z, Calmy A, Irvine C, Rapparini C, Ajose O, et al.
Choice of antiretroviral drugs for postexposure prophylaxis for adults and adolescents: A systematic review. Clinical
Infectious Diseases. 2015;60 Suppl 3:S170–6. https://www.ncbi.nlm.nih.gov/pubmed/25972499
Protease-inhibitor- based PEP regimen: Zash R, Holmes L, Diseko M, Jacobson DL, Brummel S, Mayondi G,
Isaacson A, Davey S, Mabuta J, Mmalane M, Gaolathe T, Essex M, Lockman S, Makhema J, Shapiro RL. Neural-
Tube Defects and Antiretroviral Treatment Regimens in Botswana. N Engl J Med. 2019 Aug 29;381(9):827-840.
Protease-inhibitor- based PEP regimen: Goldschmidt RH. CDC Releases Updated Guidelines for Postexposure
Prophylaxis After Sexual, Injection Drug, or Other Nonoccupational Exposures to HIV. Am Fam Physician. 2016
Sep 1;94(5):392-3. https://www.ncbi.nlm.nih.gov/pubmed/27583430
Protease-inhibitor- based PEP regimen: Canadian guideline on HIV pre-exposure prophylaxis and
nonoccupational postexposure prophylaxis. CMAJ. 2018 Jun 25;190(25):E782.
xliiiLevonorgestrel 1.5 mg: National Department of Health, Essential Drugs Programme: Primary Health Care STGs and

xliv Levonorgesterol, oral - emergency contraception (double dose): Carten ML, Kiser JJ, Kwara A, Mawhinney S,
Cu-Uvin S. Pharmacokinetic interactions between the hormonal emergency contraception, levonorgestrel (Plan B),
and Efavirenz. Infect Dis Obstet Gynecol. 2012;2012:137192. http://www.ncbi.nlm.nih.gov/pubmed/22536010
Levonorgesterol, oral - emergency contraception (double dose): Tittle V, Bull L, Boffito M, Nwokolo N.
Pharmacokinetic and pharmacodynamic drug interactions between antiretrovirals and oral contraceptives.
ClinPharmacokinet. 2015 Jan;54(1):23-34. http://www.ncbi.nlm.nih.gov/pubmed/25331712
Levonorgesterol, oral - emergency contraception (double dose): Jatlaoui TC and Curtis KM. Safety and
effectiveness data for emergency contraceptive pills among women with obesity: a systematic review.
Contraception 94 (2016) 605–611. https://www.ncbi.nlm.nih.gov/pubmed/27234874
xlv Metoclopramide, oral: National Department of Health, Essential Drugs Programme: Primary Health Care STGs and

xlviSTI prophylaxis:National Department of Health, Essential Drugs Programme: Primary Health Care STGs and EML,
xlviiNon-occupational PEP: South African HIV Clinician Society. Post-exposure prophylaxis guidelines. The S A Jr of HIV
Med, Winter 2008.[Online] Available at:http://www.sahivsoc.org/upload/documents/guidelines_nov_2008.pdf
2019 10.38
CHAPTER 11
SURGICAL ANTIBIOTIC PROPHYLAXIS
GENERAL PRINCIPLES
» Prophylactic antibiotic therapy reduces the risk of surgical site infection.
» The need for surgical antibiotic prophylaxis depends on the nature of the
expected wound from the procedure.
» Wounds that are expected to be clean (defined as no inflammation
encountered; and the respiratory, alimentary, genital, or uninfected urinary
tracts were not entered) generally do not require antibiotic prophylaxis,
except where the consequences of surgical site infection could be severe
(e.g. joint replacement in orthopaedic surgery).
» Antibiotic prophylaxis is indicated for procedures with clean-contaminated
wounds (defined as entering the respiratory, alimentary, genital, or urinary
tracts under controlled conditions; and
without unusual contamination). LoE:IIIi
» A course of antibiotic treatment, not antibiotic prophylaxis, is required for
procedures with contaminated wounds (defined as fresh open accidental
wounds, or operations with major breaks in sterile technique), or dirty or
infected wounds (defined as old traumatic wounds with retained
devitalized tissue; and those that involve existing clinical
infection or perforated viscera). LoE:IIIii
(See chapter 20: Emergencies and injuries for antibiotic
treatment).
» The antibiotic of choice should be active against Gram positive organisms,
notably Staphylococcus aureus, which is the commonest cause of surgical
site infections, with additional cover for other common pathogens
according to the surgical site (e.g. anaerobic bacteria for GIT surgery).
» Give prophylaxis at induction. LoE:IIIiii
» If a tourniquet is used at the site of surgery, administer
the entire
antibiotic dose before the tourniquet is inflated. LoE:IIIiv
» Implement perioperative glycaemic control and use blood
glucose target levels less than 11.1 mmol/L in patients with and without
diabetes. LoE:IIIv
» Maintain perioperative normothermia.
vi
» Antibiotic prophylaxis should be used in conjunction with LoE:III
good pre-, intra-, and post-operative infection prevention strategies.
» Advise patient to shower or bathe with soap or antiseptic agent on at
least the night before the procedure. LoE:IIIvii
2019 11.1
CHAPTER 11 SURGICAL ANTIBIOTIC PROPHYLAXIS
» Do not remove hair preoperatively unless the hair at or around the incision
site will interfere with the operation. If hair removal is necessary, remove
immediately before the operation, with clippers.
LoE:Iviii
DOSAGE RECOMMENDATIONS:
 Cefazolin, IV.
o <60 kg: 1g
o 60–120 kg and BMI ≤35: 2g
o ≥120 kg or BMI >35: 3g
LoE:IIIix
Pregnant women:
o <60 kg: 1g
o 60–100 kg: 2g
o >100 kg: 3g
LoE:IIIx
 Metronidazole, IV, 500 mg.
 Azithromycin, IV, 500 mg.
 Gentamicin, IV, 6 mg/kg (See Appendix II, for guidance on prescribing).
 Clindamycin, IV, 600 mg.
In most instances a single antibiotic dose prior to the procedure is

sufficient for prophylaxis. Postoperative antimicrobial administration
is not recommended for most surgeries as this selects for
antimicrobial resistance.
LoE:Ixi
» Additional intra-operative doses should be
administered in circumstances of significant blood loss (>1500 mL) in
order to ensure an adequate antimicrobial level until wound closure.
LoE:IIIxii
» With prolonged procedures, antibiotics are required to
be re-dosed (i.e. >4 hours for cefazolin; >8 hours for metronidazole; >
6 hours for clindamycin and gentamicin).
LoE:IIIxiii
2019 11.2
ANTIBIOTIC PROPHYLAXIS
TYPE OF SURGERY ANTIBIOTIC RECOMMENDED
 Cefazolin, IV  Cefazolin, IV
PLUS
Orthopaedic surgery Primary total hip/ total
knee replacement;
internal fixation of hip;
spinal procedures;
open reduction and
internal fixation of
fractures; insertion of
prostheses, screws,
plates, lower limb
amputation, etc.
Gastrointestinal surgery Gastric/ duodenal/ Biliary, colorectal,
oesophageal hernia manipulation of viscera,
repair. appendicectomy, division
of adhesions,
exploratory laparotomy:
ADD
 Metronidazole, IV.
Thoracic Pneumonectomy/
surgery(specialist) lobectomy:
ADD
Cardiac surgery Coronary artery bypass
(specialist) surgery/ routine cardiac
valve surgery (continue
cefazolin, IV, 8 hourly
for 24 hours); cardiac
device insertion
(pacemaker
implantation).
Vascular surgery Vascular Lower limb amputation:
(specialist) reconstruction: ADD
(Prophylaxis is not abdominal aorta, groin  Metronidazole, IV.
recommended for other incision (continue 8
clean procedures). hourly for 24 hours);
AV fistula formation;
and ligation of varicose
veins.
Urology Clean procedures Clean-contaminated
procedures:
ADD
2019 11.3
Plastic and Craniotomy

reconstructive surgery procedures.
(Prophylaxis is not
recommended for
clean bone or soft
tissue surgery).
Otorhinolaryngology/ No incision through the With incision through the
head and neck surgery oropharyngeal oropharyngeal mucosa:
(Prophylaxisis not mucosa. ADD
recommended for other  Metronidazole, IV.
procedures such as
tonsillectomy, sinus
procedures, etc.).
Hysterectomy,
Obstetrics/ laparotomy procedures,
gynaecology vaginal repair:
(Prophylaxis is not ADD
recommended for early  Metronidazole, IV.
suction termination). Caesarean delivery:
ADD
 Azithromycin, IV.
Neurosurgery Craniotomy; CSF
(Prophylaxis is not shunt/drain;
recommended for other laminectomy.
minor clean
procedures).
Endoscopic Percutaneous
gastrointestinal endoscopic
procedures gastrostomy
(Prophylaxis is not insertion/revision.
recommended for all
other procedures, with
or without biopsy).
General Surgery Clean contaminated
(Prophylaxis is not procedures
recommended for (mastectomy, node
uncomplicated clean biopsy, etc.),
procedures or clean splenectomy.
excision procedures i.e.
wound revision,
excision of scar tissue,
etc.).
LoE:Ixiv
Beta lactam allergies: Avoid beta-lactam antimicrobials in
patients with a history of anaphylaxis, bronchospasm, urticaria, or angioedema
after exposure to one of these agents.
2019 11.4
 Clindamycin, IV.
ADD
 Gentamicin, IV for the procedures listed below: (See Appendix II, for
guidance on prescribing).
» Gastrointestinal surgery, urology procedures (clean-contaminated), and
obstetric/gynaecological surgery (hysterectomy, laparotomy procedures,
vaginal repair).
Note: Clindamycin has good coverage against Gram positive organisms and
anaerobes, so the addition of metronidazole is unnecessary.
LoE:IIIxv
Ophthalmic surgery:
 Chloramphenicol 0.5% ophthalmic drops, instil 1 drop 2–4 hourly for 24
hours prior to surgery.
SPECIAL CONSIDERATIONS
» Elective splenectomy patients should be vaccinated at least 14 days prior
to surgery. If splenectomy was urgent, or if vaccination was omitted before
elective splenectomy, vaccinate at least 14 days post-splenectomy.
» The following vaccines should be administered: LoE:IIxvi
VACCINE SCHEDULE
 Polyvalent pneumococcal vaccine, 0.5 o PCV13, SC, 2 weeks before surgery.
mL, SC. o PPS23, SC, 8 weeks later.
o Revaccinate with PPS23 after 5 years
and then at 65 years.
LoE:IIxvii
 Haemophilus influenza type B, 0.5 mL, –
intramuscular.
 Meningococcal polysaccharide vaccine Revaccinate every 5 years.
(ACW135Y), 0.5 mL, SC
 Influenza vaccine, 0.5 mL, IM. Revaccinate annually.
LoE:IIIxviii
PROCESS MEASURES
Measure the percentage of procedures in which antimicrobial prophylaxis was
appropriately provided.
These include:
» Correct type of antibiotic.
» Correct dose.
» Administration of the antibiotic(s) within 1 hour before incision.
» Not continuing the antibiotic(s) after surgery (except for 24 hours for
cardiac and selected vascular procedures).
2019 11.5
References:
i Surgical antibiotic prophylaxis: Centers for Disease Control and Prevention. Procedure-associated Module.
Surgical Site Infection (SSI) Event. [Online] [Published April 2015; accessed December 2015]
http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf
ii Surgical antibiotic prophylaxis: Centers for Disease Control and Prevention. Procedure-associated Module.
Surgical Site Infection (SSI) Event. [Online] [Published April 2015; accessed December 2015]
http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf
iii Surgical antibiotic prophylaxis (timing): Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon
MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA; American Society of Health-
System Pharmacists; Infectious Disease Society of America; Surgical Infection Society; Society for Healthcare
Epidemiology of America. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst
Pharm. 2013 Feb 1;70(3):195-283. https://www.ncbi.nlm.nih.gov/pubmed/23327981
Surgical antibiotic prophylaxis (timing):Burke JP. Maximizing appropriate antibiotic prophylaxis for surgical
patients:an update from LDS Hospital, Salt Lake City. ClinInfect Dis. 2001 Sep 1;33Suppl2:S78-83.
Surgical antibiotic prophylaxis (timing): Bratzler DW, Houck PM, Richards C, Steele L, Dellinger EP, Fry DE,
Wright C, Ma A, Carr K, Red L. Use of antimicrobial prophylaxis for major surgery: baseline results from the
National Surgical Infection Prevention Project. Arch Surg. 2005 Feb;140(2):174-82.
Surgical antibiotic prophylaxis (timing): van Kasteren ME, Manniën J, Ott A, Kullberg BJ, de Boer AS, Gyssens
IC. Antibiotic prophylaxis and the risk of surgical site infections following total hip arthroplasty: timely administration
is the most important factor. Clin Infect Dis. 2007 Apr 1;44(7):921-7. http://www.ncbi.nlm.nih.gov/pubmed/17342642
Surgical antibiotic prophylaxis (timing): Koch CG, Li L, Hixson E, Tang A, Gordon S, Longworth D, Phillips S,
Blackstone E, Henderson JM. Is it time to refine? An exploration and simulation of optimal antibiotic timing in
general surgery. J Am Coll Surg. 2013 Oct;217(4):628-35.http://www.ncbi.nlm.nih.gov/pubmed/23849901
iv Surgical antibiotic prophylaxis (tourniquet): Bratzler DW, Houck PM; Surgical Infection Prevention Guidelines
Writers Workgroup; American Academy of Orthopaedic Surgeons; American Association of Critical Care Nurses;
American Association of Nurse Anesthetists; American College of Surgeons; American College of Osteopathic
Surgeons; American Geriatrics Society; American Society of Anesthesiologists; American Society of Colon and
Rectal Surgeons; American Society of Health-System Pharmacists; American Society of PeriAnesthesia Nurses;
Ascension Health; Association of periOperative Registered Nurses; Association for Professionals in Infection
Control and Epidemiology; Infectious Diseases Society of America; Medical Letter; Premier; Society for Healthcare
Epidemiology of America; Society of Thoracic Surgeons; Surgical Infection Society. Antimicrobial prophylaxis for
surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis. 2004 Jun
v Surgical antibiotic prophylaxis (glycaemic control): Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone
EC, Kelz RR, Reinke CE, Morgan S, Solomkin JS, Mazuski JE, Dellinger EP, Itani KMF, Berbari EF, Segreti J,
Parvizi J, Blanchard J, Allen G, Kluytmans JAJW, Donlan R, Schecter WP; Healthcare Infection Control Practices
Advisory Committee. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site
Infection, 2017. JAMA Surg. 2017 Aug 1;152(8):784-791. https://www.ncbi.nlm.nih.gov/pubmed/28467526
vi Surgical antibiotic prophylaxis (normothermia): Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone
EC, Kelz RR, Reinke CE, Morgan S, Solomkin JS, Mazuski JE, Dellinger EP, Itani KMF, Berbari EF, Segreti J,
Parvizi J, Blanchard J, Allen G, Kluytmans JAJW, Donlan R, Schecter WP; Healthcare Infection Control Practices
Advisory Committee. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site
Infection, 2017. JAMA Surg. 2017 Aug 1;152(8):784-791. https://www.ncbi.nlm.nih.gov/pubmed/28467526
vii Surgical antibiotic prophylaxis (washing): Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC,
Kelz RR, Reinke CE, Morgan S, Solomkin JS, Mazuski JE, Dellinger EP, Itani KMF, Berbari EF, Segreti J, Parvizi
J, Blanchard J, Allen G, Kluytmans JAJW, Donlan R, Schecter WP; Healthcare Infection Control Practices Advisory
Committee. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection,
2017. JAMA Surg. 2017 Aug 1;152(8):784-791. https://www.ncbi.nlm.nih.gov/pubmed/28467526
viii Preoperative hair removal: Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site
infection. Cochrane Database Syst Rev. 2011 Nov 9;(11):CD004122.

ix Cefaxolin (dose): Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, Reinke CE,
Morgan S, Solomkin JS, Mazuski JE, Dellinger EP, Itani KMF, Berbari EF, Segreti J, Parvizi J, Blanchard J, Allen
G, Kluytmans JAJW, Donlan R, Schecter WP; Healthcare Infection Control Practices Advisory Committee. Centers
for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017
Aug 1;152(8):784-791. https://www.ncbi.nlm.nih.gov/pubmed/28467526
Cefaxolin (dose): Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN,
Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA; American Society of Health-System
Pharmacists; Infectious Disease Society of America; Surgical Infection Society; Society for Healthcare
Pharm. 2013 Feb 1;70(3):195-283. https://www.ncbi.nlm.nih.gov/pubmed/23327981
x Cefaxolin (dose) – pregnant women: Swank ML, Wing DA, Nicolau DP, McNulty JA. Increased 3-gram cefazolin
dosing for cesarean delivery prophylaxis in obese women. Am J Obstet Gynecol. 2015 Sep;213(3):415.e1-8.
Cefaxolin (dose) – pregnant women: Elkomy MH, Sultan P, Drover DR, Epshtein E, Galinkin JL, Carvalho B.
Pharmacokinetics of prophylactic cefazolin in parturients undergoing cesarean delivery. Antimicrob Agents
Chemother. 2014 Jun;58(6):3504-13. https://www.ncbi.nlm.nih.gov/pubmed/24733461
2019 11.6
xi Surgical antibiotic prophylaxis (single dose): McDonald M, Grabsch E, Marshall C, Forbes A. Single- versus
multiple-dose antimicrobial prophylaxis for major surgery: a systematic review. Aust N Z J Surg. 1998
Jun;68(6):388-96.http://www.ncbi.nlm.nih.gov/pubmed/9623456
Surgical antibiotic prophylaxis (single dose): Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG,
Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA; American Society of Health-
System Pharmacists; Infectious Disease Society of America; Surgical Infection Society; Society for Healthcare
Pharm. 2013 Feb 1;70(3):195-283.http://www.ncbi.nlm.nih.gov/pubmed/23327981
xii Surgical antibiotic prophylaxis (blood loss > 1500 mL): Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B,
Stone EC, Kelz RR, Reinke CE, Morgan S, Solomkin JS, Mazuski JE, Dellinger EP, Itani KMF, Berbari EF, Segreti
J, Parvizi J, Blanchard J, Allen G, Kluytmans JAJW, Donlan R, Schecter WP; Healthcare Infection Control
Practices Advisory Committee. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical
Site Infection, 2017. JAMA Surg. 2017 Aug 1;152(8):784-791. https://www.ncbi.nlm.nih.gov/pubmed/28467526
xiii Surgical antibiotic prophylaxis (re-dosing):Ohge H, Takesue Y, Yokoyama T, Murakami Y, Hiyama E,
Yokoyama Y, Kanehiro T, Itaha H, Matsuura Y. An additional dose of cefazolin for intraoperative prophylaxis. Surg
Today. 1999;29(12):1233-6.http://www.ncbi.nlm.nih.gov/pubmed/16039702
Surgical antibiotic prophylaxis (re-dosing): National Institute for Health and Care Excellence. Surgical site
infections: prevention and treatment clincal guideline, 22 October 2008. https://www.nice.org.uk/guidance/cg74
xiv Azithromycin, IV (with cefazolin, IV for emergency caesarean delivery): Tita ATN, Boggess K, Saade G.
Adjunctive Azithromycin Prophylaxis for Cesarean Delivery. N Engl J Med. 2017 Jan 12;376(2):182.
Azithromycin, IV (with cefazolin, IV for emergency caesarean delivery): Farmer N, Hodgetts-Morton V, Morris
RK. Are prophylactic adjunctive macrolides efficacious against caesarean section surgical site infection: A
systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2020 Jan;244:163-171.
xv Clindamycin: Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano
LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA; American Society of Health-System Pharmacists; Infectious
Disease Society of America; Surgical Infection Society; Society for Healthcare Epidemiology of America. Clinical
practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013 Feb 1;70(3):195-283.
xvi Immunisation –splenectomy (timing): Shatz DV, Schinsky MF, Pais LB, Romero-Steiner S, Kirton OC, Carlone
GM. Immune responses of splenectomized trauma patients to the 23-valent pneumococcal polysaccharide vaccine
at 1 versus 7 versus 14 days after splenectomy. J Trauma.
1998 May;44(5):760-5; discussion 765-6. http://www.ncbi.nlm.nih.gov/pubmed/9603075
Immunisation –splenectomy (timing):Konradsen HB, Rasmussen C, Ejstrud P, Hansen JB. Antibody levels
against Streptococcus pneumoniae and Haemophilus influenzae type b in a population of splenectomized
individuals with varying vaccination status. Epidemiol Infect. 1997 Oct;119(2):167-74.
xvii Polyvalent pneumococcal vaccine revaccination – splenectomy: Rutherford EJ, Livengood J, Higginbotham M,
Miles WS, Koestner J, Edwards KM, Sharp KW, Morris JA Jr. Efficacy and safety of pneumococcal revaccination
after splenectomy for trauma. J Trauma. 1995 Sep;39(3):448-52. http://www.ncbi.nlm.nih.gov/pubmed/7473907
Polyvalent pneumococcal vaccine revaccination – splenectomy (dosing schedule): ACIP Practice Guidelines -
CDC. Morbidity and Mortality Weekly Report, October 12, 2012, Vol 61, No 40.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6140a4.htm?s_cid=mm6140a4_w
xviii Vaccines – splenectomy: Davies JM, Lewis MP, Wimperis J, Rafi I, Ladhani S, Bolton-Maggs PH; British
Committee for Standards in Haematology. Review of guidelines for the prevention and treatment of infection in
patients with an absent or dysfunctional spleen: prepared on behalf of the British Committee for Standards in
Haematology by a working party of the Haemato-Oncology task force. Br J Haematol. 2011 Nov;155(3):308-17.
Vaccines – splenectomy: Rubin LG, Levin MJ, Ljungman P, Davies EG, Avery R, Tomblyn M, Bousvaros A,
Dhanireddy S, Sung L, Keyserling H, Kang I, Infectious Diseases Society of America. 2013 IDSA clinical practice
guideline for vaccination of the immunocompromised host. Clin Infect Dis. 2014 Feb;58(3):e44-100.
Vaccines – splenectomy: Davidson RN, Wall RA. Prevention and management of infections in patients
without a spleen. ClinMicrobiol Infect. 2001 Dec;7(12):657-60. http://www.ncbi.nlm.nih.gov/pubmed/11843905
Vaccines – splenectomy:Bisharat N, Omari H, Lavi I, Raz R. Risk of infection and death among
post-splenectomy patients. J Infect. 2001 Oct;43(3):182-6. http://www.ncbi.nlm.nih.gov/pubmed/11798256
2019 11.7
CHAPTER 12
ANAESTHESIOLOGY AND INTENSIVE CARE
Anaesthetic and sedative medication may only be administered by medical
practitioners trained and experienced in their use.
Sound theoretical and practical training followed by several years of supervised
experience in the administration of anaesthetics is essential to develop the skills
of the anaesthetist. Even within the recommended dosage range, anaesthetic
agents can cause death when inappropriately used and only as a last resort
should they be administered by non-specialised personnel. LoE:IIIi
Medicines and equipment for resuscitation should be functional and
immediately available whenever general anaesthesia, regional anaesthesia
or sedation is administered.
The following is a list of medicines required for anaesthesia that should be
available at district and regional hospitals.
The doses of the medicines given are those recommended for healthy
adults. Patients who are acutely or chronically sick, and or elderly, may
require substantial reductions in the doses given otherwise life-
threatening adverse effects may ensue.
12.1 PREMEDICATION
 Lorazepam, 1–2 mg, oral, the night before surgery and 1–2 hours
preoperatively
o Use half the dose in the elderly.
o Duration of action (10–20 hours).
o Unsuitable for day case surgery.
LoE:IIIii
 Midazolam, 5–7.5 mg, oral, one hour preoperatively.
o Use only in healthy adults <65 years of age.
o Duration of action 1–4 hours.
o Suitable for day case surgery. LoE:IIIiii
12.2 ANAESTHESIA, GENERAL

12.2.1 INTRAVENOUS INDUCTION (AND/OR
MAINTENANCE) AGENTS
Inject intravenous induction agents over 30 seconds (>60 seconds in the
elderly).
Titrate the dose to effect.
2019 12.1
CHAPTER 12 ANAESTHESIOLOGY AND INTENSIVE CARE
Respiratory depression occurs following induction of anaesthesia and

ventilation should be supported as required.
Administer at appropriate doses, after consideration of patient factors, surgical
factors and contraindications:
» Propofol is the most widely used IV induction agent but can produce
hypotension.
» Etomidate or ketamine is preferred in haemodynamically unstable patients.
» Thiopental has a rapid onset, is contraindicated in porphyria and may be
preferred for Caesarean deliveries. LoE:IIIiv
 Propofol, IV, 1.5–2.5 mg/kg.

o 6–12 mg/kg/hour IV infusion for maintenance, if volatile agent use
contraindicated.
 Etomidate, IV, 0.3 mg/kg (0.2–0.6 mg/kg)
 Ketamine, IV, 1–2 mg/kg.
 Thiopental, IV, 3–5 mg/kg.
12.2.2 INHALATION AGENTS
12.2.2.1 INDUCTION
In adults, intravenous induction is preferable.
Inhalational induction is reserved for patients with difficult airways or severe
needle phobia.
Use only halothane or sevoflurane (isoflurane is too irritant). Halothane can
cause hepatitis after repeated exposure within 3 months. Halothane sensitises
the heart to catecholamines and may cause cardiac dysrhythmias, particularly
if anaesthesia is too light or the patient hypercarbic.
Sevoflurane is not associated with these problems, has a faster onset and
emergence time.
 Halothane, titrated to effect.
OR
 Sevoflurane, titrated to effect. LoE:IIIv
12.2.2.2 MAINTENANCE
In spontaneously breathing patients, the dose of a volatile agent is titrated to
clinical effect. If a neuromuscular blocking agent has been used, the dose of the
volatile agents must be adequate to prevent awareness. This is about 1
minimum alveolar concentration (MAC), but must be titrated according to clinical
signs of awareness (e.g. tachycardia, hypertension, sweating, lacrimation).
 Isoflurane (MAC = 1.2%).
2019 12.2
12.3 MUSCLE RELAXANTS

Used to facilitate intubation and to provide intraoperative muscle relaxation for
surgery. It must not be used if difficult intubation anticipated.
12.3.1 DEPOLARISING MUSCLE RELAXANTS

 Suxamethonium, IV, 1–1.5 mg/kg.
o Onset 30–60 seconds.
o Duration 5 minutes.
o Repeated doses associated with bradycardia and prolonged
neuromuscular block.
o Contraindicated in patients at risk for developing suxamethonium-
induced hyperkalaemia, e.g. upper or lower motor neuron defect,
prolonged chemical denervation (ICU >3 days), direct muscle trauma,
tumour or inflammation, burns, disuse atrophy, severe infection, pre-
existing hyperkalaemia.
LoE:IIIvi
12.3.2 NON-DEPOLARISING MUSCLE RELAXANTS

(NDMR)
Use a nerve stimulator to monitor effect and determine when subsequent
doses (about a fifth of the intubating dose) are required.
Higher doses result in shorter onset times but longer duration of action.
 Intermediate-acting neuromuscular blocking agents, e.g.:

 Cisatracurium (shorter-acting) LoE:IIIvii
o Intubation dose 0.1–0.15 mg/kg.
o Onset 3–5 minutes.
o Duration of action 45–55 minutes.
o Eliminated by Hoffman degradation, therefore can be used in renal or
liver impairment.
 Vecuronium
o Intubation dose 0.08–0.1 mg/kg.
o Intubate after 2 minutes. LoE:IIIviii
o Duration 20–30 minutes.
o Eliminated by liver and kidney: avoid in renal and liver impairment.
2019 12.3
12.3.3 MUSCLE RELAXATION FOR RAPID SEQUENCE

INTUBATION
Patients at risk of aspiration (e.g. emergency surgery, incomplete gastric
emptying) require a rapid sequence intubation.
An IV induction agent is given through an IV line with fast running fluids,
immediately followed by a rapidly acting muscle relaxant.
Cricoid pressure is applied and then intubation proceeds.
The rapid onset of action enables the time to intubation to be short enough to
avoid mask ventilation, as this can result in gastric insufflation and aspiration
of gastric contents.
 Suxamethonium, 1–1.5 mg/kg, IV. (See section 12.3.1: Depolarising
muscle relaxants).
o Preferred agent as, in the event of a failed intubation, it wears off
quickly enabling spontaneous respiration to resume.
o Contraindications to suxamethonium
- Congenital and acquired medical conditions associated with
severe, potentially lethal suxamethonium-induced hyperkalaemia.
- Malignant hyperthermia. LoE:Iix
If suxamethonium is contra-indicated, consider:

 Rocuronium, 0.9 mg/kg, IV.
o Duration +/- 60 minutes. LoE:IIIx
Sub-optimal conditions for intubating and prolonged effect
can be problematic in the event of a difficult or failed intubation and if the
procedure is short.
12.3.4 MEDICINES TO REVERSE MUSCLE RELAXATION

Only administer when the clinical signs of NDMR are wearing off or at least 2
twitches occur using train-of-four on nerve stimulator.
Neostigmine has profound cholinergic effects and, to counteract resultant
profound bradycardia, is administered mixed with an anticholinergic agent,
atropine or glycopyrrolate.
Whilst atropine is effective and can be used for this purpose in otherwise
healthy patients, the onset of neostigmine and duration of action more closely
matches that of glycopyrrolate, so this is the preferred combination agent for
patients who poorly tolerate tachycardia or bradycardia.
 Neostigmine, IV, 50 mcg/kg.

LoE:IIIxi
WITH EITHER:
 Atropine, IV, 20 mcg/kg (maximum 1.2 mg).
OR LoE:IIIxii
2019 12.4
Glycopyrrolate, IV, 10 mcg/kg.

LoE:IIIxiii
12.4 PERIOPERATIVE ANALGESIA

R52.9
» The perioperative period includes the preoperative, intraoperative and

post-operative stages of surgery.
» Perioperative analgesia should be multi-modal, i.e. use analgesics, where
possible, from different classes to reduce side effects from high doses of a
single agent (e.g. paracetamol, NSAID and a weak/strong opioid) with either
a regional block or wound infiltration with local anaesthetic.
» Patients with pain before surgery should be given analgesia
preoperatively.
» Paracetamol may be given orally with premedication to prophylactically
reduce perioperative pain.
» Intraoperatively, analgesics are given intravenously and/or a central
neuraxial or regional local anaesthetic block may be used. The analgesic
effect of these may extend into the early postoperative period.
» Postoperatively analgesics are given IV, IM and/or rectally, until the patient
is able to take oral medication. Patients with a functioning block may not
require analgesia until the block wears off but analgesics should be
prescribed in anticipation of this.
» Pain severity should be assessed frequently post-operatively (see Section
12.5.3: Postoperative analgesia ward prescriptions).
12.4.1 PERIOPERATIVE ANALGESICS
12.4.1.1 ORAL ANALGESICS

AND LoE:Ixiv
 Tramadol, oral, 50–100 mg 4–6 hourly.
o Avoid in head injury and epilepsy.
o Improved effect when given with paracetamol.
AND LoE:IIIxv
 NSAID, e.g.:
Note: Do not administer NSAIDs to patients at risk of hypovolaemia, renal
impairment or gastrointestinal bleeding. Avoid in patients with asthma who
experience bronchospasm with NSAIDs. LoE:IIIxvi
2019 12.5
12.4.1.2 INTRAVENOUS ANALGESICS

 Fentanyl, IV, 1–2 mcg/kg
o Onset ± 3 minutes, duration of action 30–60 minutes. Higher doses
last longer. LoE:IIIxvii
 Morphine, IV/IM, 3–5 mg as a single dose then further boluses at intervals

of 5–10 minutes and monitor all vitals closely. LoE:IIIxviii
o Dilute 10 mg up to 10 mL with sodium chloride 0.9%.
o Total maximum dose: 10 mg.
o Monitor response to pain and effects on respiration and BP.
o Onset 5-10 minutes. Duration of action ± 3 hours.
o Histamine release may cause intraoperative hypotension.
 Ketamine, IV, 0.1–0.3 mg/kg – a subanaesthetic dose given pre-incision

may reduce persistent post-surgical pain. LoE:Ixix
12.4.2 POSTOPERATIVE PAIN IN THE RECOVERY

ROOM
R52.0
Pain should be assessed on arrival in the recovery room and at regular

intervals postoperatively. Pain Scores should be recorded with other routine
postoperative observations.
A Numeric Rating Scale (NRS) can be used to score pain:
Source: Breivik H, Borchgrevink PC, Allen SM, Rosseland LA, Romundstad L, Hals EK, Kvarstein G,
Stubhaug A. Assessment of pain. Br J Anaesth. 2008 Jul;101(1):17-24.
2019 12.6
The patient is asked to indicate on the scale the numeric value that best
indicates their pain intensity or verbally if they cannot visualise the scale.
Severe pain (use lower doses if pain less):
o Monitor conscious level and pulse oximetry continuously. Also monitor
respiration, heart rate and BP at 5 minute intervals and for at least 20
minutes after the last IV morphine bolus.
In patients at high risk for respiratory depression, tramadol may be used
instead of morphine as it causes less respiratory depression (although
respiratory depression may still occur with tramadol).
Tramadol is a weak opioid agonist and increases spinal cord levels of

serotonin and noradrenaline.
 Tramadol, IV, 50–100 mg over 3 minutes to reduce side-effects of nausea
and vomiting (Specialist prescribed).
o Ceiling effect i.e. higher doses do not improve pain LoE:IIIxx
relief.
In addition to morphine or tramadol, diclofenac may also be given to
supplement analgesia and reduce opioid requirements:
 Diclofenac, deep IM, 75 mg 12 hourly.
o Administer for a maximum of 2 days.
o Avoid the same injection site.
o Counsel patient prior to injection of adverse events (scarring) at inject
site, if applicable. LoE:IIIxxi
12.4.3 POSTOPERATIVE ANALGESIA WARD

PRESCRIPTIONS
Analgesia should be prescribed according to the severity of pain anticipated
from the surgery and the anticipated, appropriate, postoperative route of
administration.
Pain should be assessed at regular intervals on the ward postoperatively. Pain
scores should be recorded with other routine postoperative observations.
Respiratory rate should be monitored for opioid-induced respiratory depression.
12.4.3.1 EXAMPLES OF WARD PRESCRIPTIONS FOR

POSTOPERATIVE ANALGESIA ACCORDING TO
ANTICIPATED PAIN SEVERITY
R52.9
MILD PAIN:
2019 12.7

AND
 NSAID, oral, e.g.:

 Ibuprofen, oral, 400 mg 8 hourly after meals.
CAUTION
Concomitant use of more than one oral NSAID has no additional clinical
benefit and only increases toxicity.
Use of all NSAIDs is associated with increased risks of gastrointestinal
bleeding, renal dysfunction, and cardiovascular events (stroke and
myocardial infarction).
NSAIDs should be used judiciously at the lowest effective dose for the
shortest duration. Explore and manage exacerbating factors for pain. See
section 26.1: Chronic pain.
Do not use NSAID in pregnancy or while breastfeeding.
AND

MODERATE PAIN:
AND
 NSAID, oral, e.g.:

CAUTION
AND
2019 12.8

OR
Morphine, IM, 0.1–0.2 mg/kg 4 hourly or IV via a patientcontrolled
analgesia device (see below).
SEVERE PAIN:
 Morphine, IM, 0.1–0.2 mg/kg 4 hourly or IV via a PCA device.
AND

AND
 NSAID, e.g.:
LoE:IIIxxii
Note:
Patient controlled analgesia
If a device is available that will administer patient controlled analgesia:
 Morphine, IV, in boluses of 1 mg every 6-10 minutes, with a maximum
dose of 0.1–0.2 mg/kg 4 hourly.
o In the elderly and frail, the dose of morphine should be reduced and
the dosage interval increased.
LoE:Ixxiii
If unable to take oral medication, stop oral ibuprofen and use:
 Diclofenac, deep IM, 75 mg 12 hourly, to upper, outer quadrant of buttock.
o Administer for a maximum of 2 days.
o Avoid the same injection site.
o Counsel patient prior to injection of adverse events (scarring) at
injection site if applicable.
LoE:IIIxxiv
12.5 INTRAVENOUS FLUIDS

The following IV fluids should be available for perioperative fluid replacement
and maintenance therapy.
12.5.1 CRYSTALLOIDS
Most commonly used crystalloid for perioperative fluid maintenance:
2019 12.9
Higher sodium content than indicated if there is a perioperative risk of

hyponatraemia e.g. transurethral resection of prostate.
Balanced solutions may be appropriate in some patients (i.e. presentation
with hyponatraemia, previous renal placement therapy):
 Balanced solution, e.g.:
 Ringer Lactate, IV.  LoE:Ixxv
12.6 MEDICINES TO TREAT COMPLICATIONS OF

ANAESTHESIA
12.6.1 MALIGNANT HYPERTHERMIA

T88.3
 Dantrolene IV, 2.5 mg/kg as a single dose (preferably through large bore
cannula).
o Reconstitute with 60 mL water for injection. For a 70 kg patient, 175 mg
(9 vials) is required.
o Administer subsequent doses to clinical effect (cardiac and respiratory
symptoms stabilise, muscle tone and body temperature reduced).
o Doses higher than 10 mg/kg is uncommon and the clinician should
question the diagnosis.
o Although, high doses of 10 mg/kg may be required in muscular males.
LoE:IIIxxvi
12.6.2 LOCAL ANAESTHETIC TOXICITY

T41.3
Airway management:
 Ventilate with 100% oxygen.
Seizure suppression:
 Diazepam, IV, 10 mg.
Cardiopulmonary resuscitation may be required:
 Reduce individual adrenaline (epinephrine) doses to <1 mcg/kg.
LoE:IIIxxvii
 Lipid emulsion (20%), IV, 1.5 mL/kg over 1 minute, then continuous
infusion 0.25 mL/kg/minute.
o Repeat bolus 1–2 times for persistent cardiovascular collapse.
o Double infusion rate to 0.5 mL/kg/minute if BP remains low.
o Continue infusion for at least 10 minutes after cardiovascular stability
attained.
o Recommended upper limit: approximately 10 mL/kg lipid emulsion over
the first 30 minutes.
LoE:IIIxxviii
2019 12.10
12.6.3 ANAESTHETIC-RELATED ACUTE HYPOTENSION

I95.81
Treat the cause of hypotension.

Ensure appropriate fluids are given to correct hypovolaemia.
The medicines given below all require significant dilution before administration.
 Adrenergic and dopaminergic agents, e.g.:
 Ephedrine IV, 3–5 mg as a single dose and then further boluses as
required to a maximum of 30 mg.
o Increases heart rate and contractility, and vasoconstrictor.
o Repeated administration can result in tolerance and tachyphylaxis.
o Alternative vasopressor infusion (e.g. adrenaline (epinephrine)) may
be needed to mitigate unresponsiveness to treatment.
LoE:IIIxxix
OR
Phenylephrine IV, 50–100 mcg as a single dose and then infuse at 60–
180 mcg/minute.
o Vasoconstrictor. LoE:IIIxxx
o High doses may cause significant reflex.
bradycardia: treat this by discontinuing the phenylephrine only.
12.6.4 ANAESTHETIC-RELATED ACUTE HYPERTENSION

I97.3
To obtund the hypertensive response to intubation e.g. pre-eclampsia:

 Alfentanil, IV, 7.5 mcg/kg (with magnesium sulfate, IV 30 mg/kg).
LoE:III
During anaesthesia or post-operatively, establish the cause
(e.g. light anaesthesia or inadequate pain relief) and treat as appropriate.
 Labetalol IV, 5–10mg IV over 2 minutes.

o Repeated at intervals of at least 5 minutes to maximum 200 mg.
o Duration of action 50 minutes.
o Vasodilates and slows heart rate. LoE:IIIxxxi
12.6.5 POSTOPERATIVE NAUSEA AND VOMITING (PONV)
12.6.5.1 PREVENTION OF PONV

R11.2
Patients identified preoperatively as medium or high risk for PONV should be

considered for prophylactic antiemetics.
Prophylactic antiemetics also required if postoperative vomiting is potentially
dangerous, e.g. after jaws wired, open eye surgery, oesophageal surgery.
2019 12.11
High risk patients should receive anti-emetics from ≥ 1 class.

Adequate IV hydration associated with less PONV.
Risk factors for PONV Points
Female Gender 1
Non-Smoker 1
History of PONV and/or motion 1
sickness
Postoperative opioids 1
Sum 0–4
Points Risk for PONV (%) Risk category
0 10 Low
1 20 Low
2 40 Medium
3 60 High
4 80 High
Class Anti-emetic Prophylactic Notes

Dose and
timing
Corticosteroid e.g.: Dexamethasone 4-8 mg, IV, on Increases blood
(glucorticoids) induction. glucose in
LoE:IIxxxii
diabetics.
Only used for
prophylaxis, not
established
PONV.
5-HT3 receptor e.g.: Ondansetron 4–8 mg, slow Prolongs QTc
antagonist IV/IM, on interval
induction.
LoE:IIIxxxiii
Phenothiazine Promethazine 6.25–12.5 mg, Intra-arterial
IV (large bore injection causes
cannula) gangrene.
diluted to 20 Extravasation or
mL over 10-20 subcutaneous
minutes, or injection
deep IM, at end associated with
of surgery. skin necrosis.
Anticholinergic
side effects and
sedation.
12.6.5.2 TREATMENT OF PONV

R11.2
Ensure adequate hydration and correct hypotension if present.

Give an emetic from a different class than the prophylactic agent given (except
dexamethasone, which is only used for prophylaxis).
2019 12.12
 Metoclopramide, IM/IV
o If <60 kg: 5 mg IM or IV (over 2 minutes).
o If ≥60 kg: 10 mg IM or IV (over 2 minutes).
o Repeat 8 hourly if required.
Note: Metoclopramide can cause extrapyramidal side effects.
Treat acute dystonic reactions with:
 Anticholinergic agent, e.g.:
 Biperiden, IM/IV, 2 mg.
o Repeat as necessary.
If an anticholinergic agent is not available:
 Promethazine, deep IM, 25–50 mg.
o In the elderly 25 mg.
If an anticholinergic agent or promethazine is not available:
 Diazepam, IV, 5–10 mg for symptom relief. LoE:III
12.6.6 ACID ASPIRATION PROPHYLAXIS

O74.0
The use of a non-particulate, non-effervescent antacid reduces the risk of

pneumonitis if gastric fluid is aspirated. Give to patients at risk of aspiration,
e.g. pregnant women before Caesarean delivery.
 Sodium citrate, 0.3M, oral, 30 mL.
o Not more than 30 minutes pre-induction of anaesthesia.
LoE:Ixxxiv
12.7 ANAESTHESIA, SPINAL (INTRATHECAL)

Only preservative free medicines may be used.
Larger doses cause block to spread higher, with risks of respiratory
depression, hypotension and loss of consciousness.
 Bupivacaine 0.5% (Spinal use)

o Give up to 3 mL according to desired level of block.
o Becomes hypobaric (light) within CSF so block may spread higher than
anticipated.
 Bupivacaine 0.5% with dextrose (Spinal use)

o Give up to 3 mL according to desired level of block.
o Hyperbaric (heavy) so block spreads according to patient position.
To increase duration of analgesia:

ADD
 Fentanyl, 10–25 mcg (i.e. small amounts).
2019 12.13
Caesarean deliveries
Lower doses are required due to physiologic changes of pregnancy:
 Bupivacaine 0,5% with dextrose, 1.8 mL (9 mg).
AND
 Fentanyl, 10 mcg (0.2 mL).
12.7.1 ANTICOAGULANTS AND SPINAL OR EPIDURAL

BLOCKS
Patients on anticoagulants are at risk of developing a spinal haematoma with
subsequent paralysis after a spinal or epidural block. These anticoagulants
should be stopped before the spinal or epidural is performed according to the
guidelines given below. In order to encourage safe and quality care of
patients, please consult a specialist prior to attempting blocks on
patients on anticoagulants. There are a range of oral anticoagulation, with
each having specific recommendations with regard to neuraxial blocks.
Timing of anticoagulants in patients receiving neuraxial anaesthesia:

Anticoagulant Before Neuraxial After Neuraxial block
Block
Consult with specialist Restart after neuraxial
Warfarin, oral to stop warfarin. block performed (do not
delay) and epidural
catheter removed.
Monitor INR daily with
indwelling catheter.
Unfractionated Heparin, Neuraxial techniques may be performed if total daily
SC dose is <10 000U. Check PTT if higher doses are
used.
Unfractionated Heparin, Stop heparin 4-6 hours Wait 1 hour before next
IV and check PTT<40 bolus/infusion restarted.
Prophylactic LMWH, SC 12 hours after last dose 4 hours after neuraxial
block performed and
epidural catheter removed
Therapeutic LMWH, SC 24 hours after last dose >24 hours and consult a
specialist (bleeding risk of
surgery should be
assessed).
LoE:IIxxxv
Note. After neuraxial block or epidural catheter removal, patients should be
observed closely for new or progressive neurological symptoms. A spinal
haematoma can result in permanent paralysis unless decompressive surgery
is performed within 8 hours of paralysis onset.
Clopidogrel and platelet GPIIb/IIIa inhibitors have variable durations of effects
on clotting after stopping these medications. Specialist advice should be
2019 12.14
sought before performing neuraxial blocks on patients receiving these

medications.
For patients on warfarin the use of bridging anticoagulation (giving heparin
after warfarin is stopped in preparation for surgery or invasive procedures)
remains unsettled. Practitioners should exercise careful judgment of
competing risks in individual patients. Heparin may increase the risk of
bleeding. Whatever practice is adopted the most important consideration is to
ensure that adequate anticoagulation with warfarin is re-instituted once the
risk of bleeding is past.
12.8 ANAESTHESIA, EPIDURAL

Only preservative free medicines may be used.
Local anaesthetics are administered through a catheter inserted into the
epidural space at a spinal level appropriate for the surgery.
Aspiration and a test dose (2–3 mL) of local anaesthetic should be given to
confirm catheter not intravascular or intrathecal. Subsequent doses should be
fractionated (3–5 mL boluses).
 Bupivacaine 0.5%.
o Onset ±10 minutes. LoE:IIIxxxvi
o Duration ±4 hours.
o Motor block is less with lower concentrations.
o Maximum dose 2 mg/kg.
12.9 PERIPHERAL NERVE BLOCK OR WOUND

INFILTRATION
Only preservative free medicines may be used for nerve blocks.
Lidocaine has a faster onset of action than bupivacaine, but a shorter duration
of action.
 Lidocaine 1% or 2%.
o Higher concentrations cause more pain on injection.
o Maximum dose: 3 mg/kg.
 Lidocaine 2% plus adrenaline.
o Not to be used in areas supplied by an end-artery e.g. finger, ear,
penis.
 Bupivacaine 0.5%
o Not be used in mucosal areas as risk of systemic toxicity.
LoE:IIIxxxvii
2019 12.15
12.10 ANAESTHESIA, TOPICAL

 Lidocaine jelly, topical, 2 g/100mL.
o For urethral catheterisation: female 5–7 mL, male 10–15 mL.
LoE:IIIxxxviii
 Lidocaine topical spray, 4%.
o Maximum dose 160 mg.
o To assist with awake intubation or reduce haemodynamic response
to intubation. LoE:IIIxxxix
For venepuncture analgesia in adults or oncology patients requiring repeated

invasive procedures (e.g. lumbar punctures, venepuncture):
 Lidocaine/prilocaine, topical cream, 2.5/2.5%.
o Apply at least 1 hour before and cover with occlusive dressing.
LoE:IIIxl
12.11 SEDATION
See chapter 23: Sedation.
12.12 PAIN, CHRONIC

12.13 INTENSIVE CARE
12.13.1 NUTRITIONAL SUPPORT

E63.9
Establish a multidisciplinary nutrition support team to assess and address the

nutritional requirements of patients. This team should include a dietician.
Nutrition support should be considered in patients at risk, defined as those
who have a poor absorptive capacity and/or high nutrient losses and/or
increased nutritional needs from causes such as catabolism.
Oral feeding, if feasible, is preferred.
Enteral tube feeding is the next best option.
Total parenteral nutrition (TPN) is indicated in exceptional circumstances.
For short-term care (≤ two weeks), the current standard formulas in multi-
chamber bags that have a long shelf-life are considered to provide
adequate nutritional support. Clinicians should be aware of the possibility
of clinically important hypovitaminosis in individual patients, and replace
selected vitamins where appropriate.
2019 12.16
Refer to the most current version of the National Department of Health Parenteral
Nutrition Practice Guidelines for Adults, available at: www.health.gov.za
In selecting the treatment modality, the team should consider:

» The likely duration of nutrition support.
» Patient activity levels and the underlying clinical condition, e.g. catabolism.
» Gastrointestinal tolerance, potential metabolic instability and risks of re-
feeding.
Potential complications harms of nutritional support include:
» Re-feeding syndrome: Hypophosphataemia occurs when patients are re-
fed too quickly with high carbohydrate feeds. The syndrome usually begins
within 4 days of re-feeding. A multitude of life-threatening complications
involving multiple organs may occur, causing: respiratory failure, cardiac
failure, cardiac dyshythmias, rhabdomyolysis, seizures, coma, red cell and
leukocyte dysfunction. The most effective way to prevent re-feeding
syndrome is that feeds should be started slowly with aggressive
supplementation of magnesium, phosphate and potassium.
» Diarrhoea.
» Lactose intolerance.
Regularly review the need for ongoing therapeutic nutritional support.
Vitamin and mineral supplementation should be considered on a case-by-
case basis.
Enteral tube feeding

Enteral tube feeding should be used in patients who cannot swallow or who
are at risk of aspiration.
Patients should be fed via a nasogastric tube unless this is contra-indicated.
Patients with upper gastro-intestinal dysfunction (or an inaccessible upper gastro-
intestinal tract) should receive post-pyloric (duodenal or jejunal) feeding.
Percutaneous endoscopic gastrostomy feeding should be used in patients
likely to need long-term (≥4 weeks) enteral tube feeding.
Parenteral feeding
The team should consider parenteral nutrition in patients who are
malnourished or at risk of malnutrition and fit the following criteria:
» inadequate or unsafe oral and enteral tube nutritional intake, or
» a non-functional, inaccessible or perforated (leaking) gastrointestinal tract.
Note: For short-term care, the current standard formulas in multi-chamber
bags that have a long shelf-life are considered to provide adequate nutritional
support.
The addition of glutamine does not confer any clear clinical benefits
and is thus not recommended.
2019 12.17
Parenteral nutrition can be withdrawn once adequate oral or enteral nutrition

is tolerated and nutritional status is stable. Withdrawal should be planned and
done in a stepwise way with a daily review of the patient’s progress.
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anaesthesia, 1994. https://apps.who.int/medicinedocs/en/d/Jh2929e/2.html
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Midazloma, IV: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University
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xiii Glycopyrrolate: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.

xiv Paracetamol, oral: The South African Society of Anaesthesiologists. South African Acute Pain Guidelines.
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Ketamine, IV: Brinck EC, Tiippana E, Heesen M, Bell RF, Straube S, Moore RA, Kontinen V. Perioperative
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Tramadol, IV: National Department of Health, Essential Drugs Programme. Medicine review: Tramadolol, IV
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http://www.sasaweb.com/content/images/SASA_Pain_Guidelines.pdf
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18;(4):CD003348. Review. Update in: Cochrane Database Syst Rev. 2015;6:CD003348..
xxiv Diclofenac, IM (potential for scarring): Tarloff D, Lamacraft G, Joubert G. The prevalence of skin scars in
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Hospital, Bloemfontein, South Africa. S Afr Med J. 2017 Jan 30;107(2):101-105.
xxv Ringer Lactate, IV: National Department of Health: Affordable Medicines, EDP-Adult Hospital level. Medicine
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Ringer Lactate, IV: Antequera Martin AM, Barea Mendoza JA, Muriel A, Saez I, Chico-Fernandez M, Estrada-
Lorenzo JM, et al. Buffered solutions versus 0.9% saline for resuscitation in critically ill adults and children.
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Ringer Lactate, IV: Liu C, Lu G, Wang D, Lei Y, Mao Z, Hu P, Hu J, Liu R, Han D, Zhou F. Balanced crystalloids
versus normal saline for fluid resuscitation in critically ill patients: A systematic review and meta-analysis with trial
sequential analysis. Am J Emerg Med. 2019 Mar 1. pii: S0735-6757(19)30149-4.
Ringer Lactate, IV: Brown RM, Wang L, Coston TD, Krishnan NI, Casey JD, Wanderer JP, et al. Balanced
Crystalloids Versus Saline in Sepsis: A Secondary Analysis of the SMART Trial. Am J Respir Crit Care Med. 2019
Aug 27. doi: 10.1164/rccm.201903-0557OC. [Epub ahead of print]
Ringer Lactate, IV: Rochwerg B, Alhazzani W, Sindi A, Heels-Ansdell D, Thabane L, Fox-Robichaud A, et al. Fluid
resuscitation in sepsis: A systematic review and network meta-analysis. Ann Intern Med. 2014;161(5):347–55.

xxvi Dantrolene, IV: Kolb ME, Horne ML, Martz R. Dantrolene in human malignant hyperthermia.
Anesthesiology. 1982 Apr;56(4):254-62. https://www.ncbi.nlm.nih.gov/pubmed/7039419

Dantrolene, IV: Flewellen EH, Nelson TE, Jones WP, Arens JF, Wagner DL. Dantrolene dose response in
awake man: implications for management of malignant hyperthermia. Anesthesiology. 1983 Oct;59(4):275-80.
Dantrolene, IV: Larach MG, Brandom BW, Allen GC, Gronert GA, Lehman EB. Cardiac arrests and deaths
associated with malignant hyperthermia in north america from 1987 to 2006: a report from the north American
malignant hyperthermia registry of the malignant hyperthermia association of the United States. Anesthesiology.
2008 Apr;108(4):603-11. https://www.ncbi.nlm.nih.gov/pubmed/18362591
Dantrolene, IV: Chapin et al. Medscape: Malignant Hyperthermia Treatment & Management, 28 November
2018. [Internet][Accessed 2 December 2019] https://emedicine.medscape.com/article/2231150-treatment#d11
Dantrolene, IV: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University
of Cape Town, 2016.
xxvii Oxygen: Neal JM, Mulroy MF, Weinberg GL; American Society of Regional Anesthesia and Pain Medicine.
American Society of Regional Anesthesia and Pain Medicine checklist for managing local anesthetic systemic
toxicity: 2012 version. Reg Anesth Pain Med. 2012 Jan-Feb;37(1):16-8.
Diazepam, IV: Neal JM, Mulroy MF, Weinberg GL; American Society of Regional Anesthesia and Pain
Medicine. American Society of Regional Anesthesia and Pain Medicine checklist for managing local anesthetic
systemic toxicity: 2012 version. Reg Anesth Pain Med. 2012 Jan-Feb;37(1):16-8.
Adrenaline (epinephrine): Neal JM, Mulroy MF, Weinberg GL; American Society of Regional Anesthesia and
Pain Medicine. American Society of Regional Anesthesia and Pain Medicine checklist for managing local
anesthetic systemic toxicity: 2012 version. Reg Anesth Pain Med. 2012 Jan-Feb;37(1):16-8.
xxviii Lipid emulsion (20%), IV: Jamaty C, Bailey B, Larocque A, Notebaert E, Sanogo K, Chauny JM. Lipid
emulsions in the treatment of acute poisoning: a systematic review of human and animal studies. Clin Toxicol
(Phila). 2010 Jan;48(1):1-27. http://www.ncbi.nlm.nih.gov/pubmed/20095812
Lipid emulsion (20%), IV: Neal JM, Mulroy MF, Weinberg GL; American Society of Regional Anesthesia and
Pain Medicine. American Society of Regional Anesthesia and Pain Medicine checklist for managing local
anesthetic systemic toxicity: 2012 version. Reg Anesth Pain Med. 2012 Jan-Feb;37(1):16-8.
Lipid emulsion (20%), IV: National Department of Health, Essential Drugs Programme. Cost analysis report for
intralipid 20% emulsion for local anesthetic systemic toxicity, 8 October 2015. http://health.gov.za/
xxix Ephedrine, IV: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University
of Cape Town, 2016.

xxx Phenylephrine, IV: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.

2019 12.19
xxxi Labetalol, Scott DB. The use of labetalol in anaesthesia. Br J Clin Pharmacol. 1982 Jun;13(1 Suppl):133S-
135S. http://www.ncbi.nlm.nih.gov/pubmed/7093097
Labetalol, IV: Varon J, Marik PE. Perioperative hypertension management. Vascular Health and Risk
Management. 2008;4(3):615-627. http://www.ncbi.nlm.nih.gov/pubmed/18827911
xxxii Dexamethasone, IV: Carlisle JB, Stevenson CA. Drugs for preventing postoperative nausea and vomiting.
Cochrane Database Syst Rev. 2006 Jul 19;(3):CD004125. http://www.ncbi.nlm.nih.gov/pubmed/16856030

Ondansetron, IV: Carlisle JB, Stevenson CA. Drugs for preventing postoperative nausea and vomiting. Cochrane
Database Syst Rev. 2006 Jul 19;(3):CD004125. http://www.ncbi.nlm.nih.gov/pubmed/16856030
Promethazine, IV: Carlisle JB, Stevenson CA. Drugs for preventing postoperative nausea and vomiting. Cochrane
Database Syst Rev. 2006 Jul 19;(3):CD004125. http://www.ncbi.nlm.nih.gov/pubmed/16856030
xxxiii Ondansetron, IV/IM (PONV): Zhang D, Shen Z, You J, Zhu X, Tang QF. Effect of ondansetron in preventing
postoperative nausea and vomiting under different conditions of general anesthesia: a preliminary, randomized,
controlled study. Ups J Med Sci. 2013 May;118(2):87-90. https://www.ncbi.nlm.nih.gov/pubmed/23441598
Ondansetron, IV/IM (PONV): South African Medicines Formulary. 12th Edition. Division of Clinical
xxxiv Sodium citrate, solution: Paranjothy S, Griffiths JD, Broughton HK, Gyte GM, Brown HC, Thomas J.
Interventions at caesarean section for reducing the risk of aspiration pneumonitis. Cochrane Database Syst Rev.
2014 Feb 5;2:CD004943. http://www.ncbi.nlm.nih.gov/pubmed/24497372
Sodium citrate solution: National Department of Health, Essential Drugs Programme. Medicine review: Sodium
citrate solution to reduce the risk of aspiration pneumonitis in patients undergoing Caeserean section. September
2015. http://health.gov.za/
xxxv Timing of anticoagulants: The BRIDGE Study Investigators .Bridging Anticoagulation: Is it Needed When
Warfarin Is Interrupted Around the Time of Surgery or a Procedure? Circulation 2012;125:e496-e498.

Timing of anticoagulants: Horlocker TT, Vandermeuelen E, Kopp SL, Gogarten W, Leffert LR, Benzon HT.
Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of
Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Fourth Edition). Reg Anesth Pain Med. 2018
Apr;43(3):263-309. https://www.ncbi.nlm.nih.gov/pubmed/29561531
xxxvi Bupivicaine, 0.5%: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.

xxxviiLidocaine 1% or 2%: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.

Lidocaine 2% plus adrenaline: South African Medicines Formulary. 12th Edition. Division of Clinical
Bupivicaine 0.5%: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.
xxxviii Lidocaine topical jelly: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.

xxxix Lidocaine topical spray: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.

xl Lidocaine/prilocaine, topical cream, 2.5/2.5%.: Sharma SK, Gajraj NM, Sidawi JE, Lowe K. EMLA cream
effectively reduces the pain of spinal needle insertion. Regional anesthesia. 1996 Nov-Dec;21(6):561-4.
2019 12.20
CHAPTER 13
MUSCULOSKELETAL CONDITIONS
13.1 ARTHRITIS, RHEUMATOID (RA)

M05.80-89/M05.90-99/M06.00-09/M06.80-09/M06.90-99/M08.30-39/M08.40-49/
M08.80-89/M08.90-99
DESCRIPTION
A chronic, inflammatory, systemic condition with a fluctuating course. It may
affect many organs, but the joints are predominantly affected. Characteristic
joint manifestations are:
» Swelling or fluid, affecting at least three joint areas simultaneously.
» Pain.
» Limited movement with morning stiffness >1 hour, which improves with
activity. This helps distinguish osteoarthritis from rheumatoid arthritis.
» Destruction and deformity of affected joints.
» The small joints of the fingers and hands, with the exception of the distal
interphalangeal joints, are usually involved, although any joint can be
involved.
» Arthritis is typically symmetrical.
GENERAL MEASURES
Manage by co-ordinated multidisciplinary care.
The primary objective is to improve and maintain functional status.
Early use of non-drug measures, especially nursing, physiotherapy and
occupational therapy, is essential.
Acute flare-ups: rest affected joints and consider the use of day and/or night
splints.
Obtain a baseline complete blood count, serum creatinine, alanine
aminotransferase (ALT), and erythrocyte sedimentation rate (ESR) or C-
reactive protein (CRP) in all patients.
Obtain X-rays of the hands and wrists, as well as both forefeet to include the
metatarsophalangeal joints as a baseline for evaluating change in the joints
during treatment.
MEDICINE TREATMENT
All patients with suspected RA should be seen by a specialist. Evaluate all
patients with suspected RA for disease-modifying anti-rheumatic drug
(DMARD):
 Methotrexate (preferred initial therapy)
 Chloroquine sulphate
 Sulfasalazine
2019 13.1
CHAPTER 13 MUSCULOSKELETAL CONDITIONS
Monitoring response to DMARDs:

» Assess response to DMARD therapy by monitoring the number of swollen
and tender joints, restricted to 28 joints (shoulders, elbows, wrists, 5
metacarpophalangeal joints, 5 proximal interphalangeal joints and knees
bilaterally) together with ESR or CRP.
» If there is poor response to one DMARD, after 3 months, add another
DMARD. LoE:IIi
» Patients on DMARDs must be monitored regularly for toxicity, as outlined
below:
 Methotrexate, oral, 7.5 mg once per week. Specialist consultation.

o Increase dose gradually to a maximum of 25 mg per week.
o Monitor: ALT and FBC before and 12 weekly during treatment.
AND
 Folic acid, oral, 5 mg per week at least 24 hours after the methotrexate
dose.
LoE:IIii
AND/OR
 Chloroquine sulphate, oral, 150 mg (as base) daily for 5 days of each
week.
o Do ophthalmic examination at baseline within the first year of treatment
and annually thereafter, to monitor for ocular damage.
AND/OR
 Sulfasalazine, oral, 500 mg 12 hourly with meals.
o Gradually increase over one month from 500 mg to 1 g 12 hourly.
o FBC and ALT monthly for first 3 months then every 3–6 months.
LoE:IIIiii
Oral corticosteroids
Systemic corticosteroids are effective at relieving symptoms in RA and have
been shown to modify the course of the disease, but long-term use is
discouraged because this is associated with considerable toxicity, notably
osteoporosis, which is very common in patients with RA.
Indications:
» As bridging therapy while waiting for DMARDs to take effect.
» Acute disease flares.
» Severe extra-articular manifestations, e.g. scleritis.

 Prednisone, oral, 40 mg daily for 2 weeks.
o Thereafter gradually reduce the dose to 7.5 mg daily. (Refer to
Appendix II for an example of a dose reduction regimen).
o Discontinue at 3–6 months.
o If disease flares after stopping corticosteroids LoE:IIiv
DMARD therapy should be optimised.
2019 13.2
Patients requiring corticosteroids for longer than 3 months should be educated

to take in enough calcium in their diet.
For pain:
NSAIDs
NSAIDs are used for symptomatic relief in patients with active inflammation
and pain. They have no long-term disease modifying effects.
NSAID dose should be reduced and then stopped once the DMARDs have taken
effect.
Reduce NSAID doses in the elderly.
NSAIDs are relatively contra-indicated in patients with significantly impaired
renal function, i.e. eGFR <60 mL/minute.
CAUTION
 NSAID, e.g.:
 Ibuprofen, oral, 400 mg 8 hourly with meals. LoE:Iv
An extra night-time dose of an NSAID may be added in some patients with
severe nocturnal pain/morning stiffness.
Note: When an additional night-time dose is added to the patient’s regimen,
the risk of NSAID toxicity increases. A reduction in the daytime dose of
NSAIDs is recommended as the night-time dose will often exceed the
recommended total daily NSAID dose.
If a reduction in daytime dose causes increased pain, then the use of the night-
time dose must be for the shortest period possible.
In high-risk patients: >65 years of age; history of peptic ulcer disease; on
concomitant warfarin, aspirin, or corticosteroids:
ADD LoE:IIvi
 PPI, e.g.:
 Lansoprazole, oral, 30 mg daily while on an NSAID.
Adjunct for pain control:
 Amitriptyline, oral, 10–25 mg at night.
2019 13.3
o Titrate dose according to response.

o Initial dose in the elderly: 10 mg at night.
o Maximum dose: 75 mg at night.
o Use with caution in patients with angle closure glaucoma, prostatic
hypertrophy and the elderly.
Intra-articular corticosteroids
Consider only in cases where a few joints are very actively inflamed.
To be prescribed by a specialist.
Not more than 2–3 injections per year per joint are recommended.
 Intra-articular corticosteroid, e.g.:
 Methylprednisolone acetate, 20–80 mg depending on joint size.
LoE:IIIvii
REFERRAL
» At initial diagnosis.
» Disease activity cannot be controlled with the measures as mentioned.
» Compression neuropathy.
» For joint replacement.
Urgent
» Rupture of tendons.
» Scleritis.
» Unstable upper cervical spine.
» Vasculitis.
» Cricoarytenoid joint involvement with hoarseness and inspiratory stridor.
13.2 ARTHRITIS, SEPTIC AND OSTEOMYELITIS, ACUTE

M00.90-99/M86.10-19
DESCRIPTION
Septic arthritis is typically an acute infective condition involving one or more
joints. The joint is hot, swollen, very painful on movement, and with restricted
movements.
Acute osteomyelitis typically involves the long bones or the vertebrae.
Signs of systemic infection are usually present. The infection is usually
bloodborne, but may follow trauma. The course may be acute or protracted. The
commonest causative organism is Staphylococcus aureus. N. gonorrhoeae is
an important cause of septic arthritis.
Note: Acute gout and haemophiliacs with bleeding into joints may mimic
septic arthritis.
GENERAL MEASURES
Baseline X-ray.
Rest and immobilisation.
Septic arthritis: Drainage is important. Discuss with a specialist.
2019 13.4
MEDICINE TREATMENT
Therapy is directed against S. aureus unless there is evidence of urethritis or
PID, in which case gonococcal infection should be covered.
It is crucial to obtain cultures of blood, joint or aspirate of osteomyelitis focus
before administering antibiotics.
 Cefazolin, IV, 2 g 8 hourly for 4 weeks. LoE:IIviii
After 2 weeks of IV therapy, a change to oral therapy may be considered in
patients with a good clinical response:
 Flucloxacillin, oral, 1 g 6 hourly to complete the 4 weeks’ treatment.

After 2 weeks of IV therapy, a change to oral therapy may be considered in
patients with a good clinical response:
 Clindamycin, oral, 450mg 8 hourly to complete the 4 weeks’ treatment.
LoE:IIIix
For gonococcal arthritis A54.4+ + (M01.30-39*)
 Ceftriaxone, IV, 1 g daily for 1 week.
AND
 Azithromycin, oral, 1 g, as a single dose. LoE:IIIx

Refer.
Analgesia
 NSAID, e.g.:
 Ibuprofen, oral, 400 mg 8 hourly with meals. LoE:Ixi
AND/OR
REFERRAL
» Acute osteomyelitis/ septic arthritis for early drainage by specialist surgeon.
» If pyrexia persists despite adequate antibiotic therapy, a sub-periosteal
abscess must be sought and drained by a specialist surgeon.
» Chronic osteomyelitis.
» Pathological fractures.
13.3 OSTEOARTHRITIS
M13.00-19/M16.0-9/M17.0-9/M18.0-9/M19.00-09/M19.80-99
DESCRIPTION
A disorder typically affecting weight-bearing joints and the hand (distal and
proximal interphalangeals, and first metacarpophalangeal joints).
2019 13.5
Signs and symptoms include:

» Pain on effort, relieved by rest.
» Morning stiffness, lasting < 30 minutes.
» Limited movement.
» Joint swelling (effusions and/or osteophytes).
GENERAL MEASURES
Weight reduction.
Exercise: postural and non-weight bearing. Quadriceps strengthening for
knee involvement.
Support and alleviate weight bearing of affected joints, i.e. walking stick.
Physiotherapy and/or occupational therapy.
MEDICINE TREATMENT
When only pain relief is required:
If ineffective:
ADD
 NSAID, e.g.:
 Ibuprofen, oral, 400 mg 8 hourly with meals. LoE:Ixii
As many of these patients, particularly the elderly, have concomitant medical

conditions such as cardiovascular, gastrointestinal disease or renal function
impairment, NSAIDs must be used with caution.
Patients on aspirin for cardiovascular risk reduction should take this agent 30
minutes before the 1st dose of NSAID in the morning, as taking aspirin and
NSAID at the same time may reduce aspirin’s efficacy. LoE:IIIxiii
In high-risk patients: >65 years of age; history of peptic ulcer disease; or on
concomitant warfarin, aspirin or corticosteroids:
ADD LoE:IIxiv
 PPI, e.g.:
CAUTION
2019 13.6
If ineffective:
Adjunct for pain control:
o Titrate dose according to response.
o Initial dose in the elderly: 10 mg at night.
o Maximum dose: 75 mg at night.
Intra-articular corticosteroids
Consider in cases where a joint is actively inflamed.
To be prescribed and administered by a specialist only.
Not more than 2–3 injections per year per joint are recommended.
 Intra-articular corticosteroid, e.g.:
 Methylprednisolone acetate, 20–80 mg depending on joint size.
LoE:IIIxv
REFERRAL
» For consideration for joint replacement.
» Intractable pain.
» Neurogenic compression.
13.4 GOUT
M10.90-99
DESCRIPTION
A metabolic disease in which uric acid crystal deposition occurs in joints and
other tissues.
Gout is managed in the following three stages:
i) Treating the acute attacks;
ii) Prevention of acute flares;
iii) Lowering excessive uric acid to prevent flares and tissue deposition of urate
crystals.
LoE:IIIxvi
Acute gout:
Joint involvement is characterised by recurrent attacks of acute arthritis, which
usually affects one joint, and is accompanied by extreme pain and tenderness,
swelling, redness, and local heat.
» The inflammation may extend beyond the joint.
» In many patients the first metatarsophalangeal joint is initially involved.
» The instep, ankle, heel, and knee are also commonly involved.
» Bursae (such as the olecranon) may be involved.
Chronic gout:
Gout with one or more of the following:
» uric acid deposits in and around joints, bursae and cartilages of the
extremities (tophi)
» initial involvement of the first metatarsophalangeal joint in most patients
» involvement of the instep, ankle, heel and knee
2019 13.7
» involvement of bursae (such as the olecranon)

» significant periarticular inflammation
» bone destruction
» prolongation of attacks, often with reduction in pain severity
» incomplete resolution between attacks
GENERAL MEASURES
Acute gout:
Rest and immobilisation.
Chronic gout:
Lifestyle modification, including high fluid intake.
Avoid alcohol intake.
If possible, avoid diuretics, or use the lowest dose possible.
MEDICINE TREATMENT
ACUTE GOUT:
Initiate treatment as early as possible in an acute attack:
 NSAID, e.g.:
 Ibuprofen, oral, 400 mg 8 hourly with meals. LoE:Ixvii
In high-risk patients: > 65 years of age; history of peptic ulcer disease; on

concomitant warfarin, aspirin, or corticosteroids:
ADD LoE:IIxviii
 PPI, e.g.:
 Lansoprazole, oral, 30 mg daily while on an NSAID.
If NSAIDS are contraindicated, e.g. warfarin therapy and renal dysfunction:

CHRONIC GOUT:
If possible, avoid known precipitants and medicines that increase uric acid,
including:
» low dose aspirin,
» ethambutol,
» pyrazinamide, and
» thiazide and loop diuretics.
If diagnosis uncertain, joint aspiration with microscopy for crystal analysis is
recommended.
Investigate for and treat secondary causes (e.g. haematological
malignancies) where clinically indicated.
Measure serum creatinine and urate.
Serum urate may be normal during acute attacks.
Urate lowering therapy
Urate lowering therapy is recommended in the following circumstances:
2019 13.8
» >2 acute attacks per year » urate renal stones

» chronic tophaceous gout » urate nephropathy
When the acute attack has settled, i.e. usually after 2 weeks:
 Allopurinol, oral, 100 mg daily.
o Increase monthly by 100 mg according to serum urate levels.
o Titrate dose to reduce serum urate to <0.35 mmol/L.
o Allopurinol dosage is dependent on severity of LoE:IIIxix
disease and serum urate concentration. Doses in
excess of 300 mg should be administered in divided doses.
o Maximum dose: 900 mg per day.
o Elderly: start with 50 mg daily.
o Renal impairment: Adjust dose according to renal function.
- eGFR 30–60 mL/minute: start with 50 mg daily.
- eGFR <10 mL/minute: consult a specialist. LoE:IIIxx
Caution in prescribing allopurinol to patients with renal impairment as they

have an increased risk of a hypersensitivity reaction. Immediate cessation
of allopurinol if rash or fever occurs.
LoE:IIIxxi
Prophylaxis to prevent breakthrough gout attacks:
An increase incidence of gout flares is associated with initiation of urate
lowering therapy. Thus, colchicine or NSAIDs is recommended as anti-
inflammatory prophylaxis when initiating allopurinol.
Anti-inflammatory prophylaxis should be discontinued at 6 months provided
gout symptoms have resolved.
 NSAID, e.g.: LoE:Ixxii
o Monitor renal function, as clinically indicated.
OR
Colchicine, oral, 0.5 mg 12 hourly for 6 months. LoE:IIIxxiii
o eGFR < 50 mL/minute: consult a specialist
CAUTION
2019 13.9
In high-risk patients: i.e. patients > 65 years of age, or with a history of peptic
ulcer disease, or on concomitant warfarin, aspirin or corticosteroids:
ADD LoE:IIxxiv
 PPI, e.g.:
Do not stop urate lowering drugs during an acute attack.
REFERRAL
» No response to treatment despite adequate adherence.
» Suspected secondary gout.
» Non-resolving tophaceous gout.
13.5 SERONEGATIVE SPONDYLARTHRITIS

M45.X0-X9/M47.9099
DESCRIPTION
A group of diseases in which the rheumatoid factor is usually negative and the
spine is often involved. These disorders have certain similar clinical features
and occur predominantly in individuals with HLA-B27 antigen. The
rheumatological manifestations in these disorders are variable, typically
including asymmetrical lower-limb arthritis, sacro-iliitis, spinal inflammation
(spondylitis), and enthesitis (e.g., Achilles tendonitis). The spondyloarthritides
include ankylosing spondylitis, reactive arthritis, psoriatic arthropathy, and
arthritis associated with inflammatory bowel disease. Extra-articular
manifestations occur, especially uveitis, in about one third of patients.
GENERAL MEASURES
Physiotherapy to prevent spine deformity.
MEDICINE TREATMENT
Initiate treatment with NSAIDs.
 NSAID, e.g.:
 Ibuprofen, oral, 400 mg 8 hourly with meals. LoE:Ixxv
ADD LoE:IIxxvi
 PPI, e.g.:
REFERRAL
» Uveitis, to an ophthalmologist.
» Psoriasis, to dermatologist and rheumatologist
2019 13.10
» Arthritis refractory to NSAIDs, to a rheumatologist.

» Deformity at diagnosis, to a rheumatologist.
13.5.1 ARTHRITIS, REACTIVE

M02.30-39
DESCRIPTION
A spondylarthritis often preceded by enteric or urogenital infections 1–4 weeks
before the arthritis and occurring predominantly in individuals with HLA-B27
antigen.
It is a clinical diagnosis with no laboratory test or radiographic findings.
It occurs more commonly in HIV infection.
It is usually self-limiting.
MEDICINE TREATMENT
 NSAID, e.g.:
 Ibuprofen, oral, 400 mg 8 hourly with meals. LoE:Ixxvii
ADD LoE:IIxxviii
 PPI, e.g.:
If urethritis is present, treatment may prevent further episodes of arthritis:

lidocaine 1% without epinephrine (adrenaline).
AND
LoE:IIIxxix
13.6 SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

M32.9
These patients need to be managed by a specialist.

GENERAL MEASURES
Education regarding the disease and complications.
Avoid cigarette smoking as it is a trigger for lupus.
Sun protective barrier creams are often indicated.
Regularly monitor urine for blood and protein.
Provide advice regarding family planning as pregnancy may cause a lupus
flare.
2019 13.11
MEDICINE TREATMENT
MILD DISEASE
For pain:
AND/OR
 NSAID, e.g.:
 Ibuprofen, oral, 400 mg 8 hourly with meals. LoE:Ixxx
ADD LoE:IIxxxi
 PPI, e.g.:
To suppress disease activity

 Chloroquine sulphate, oral, 150 mg (as base) daily for 5 days of each week.
o Do ophthalmic examination at baseline within the first year of treatment
and annually, to monitor for ocular damage.
LoE:Ixxxii
Corticosteroids
Initiate therapy in patients with life threatening manifestations and organ
involvement.
 Prednisone, oral, 2 mg/kg daily, initial dose.
o Taper to the lowest maintenance dose after a response has been
obtained. Refer to Appendix II for an example of a dose reduction
regimen.
o Usual maintenance dose: 10 mg daily.
Patients requiring corticosteroids for >3 months (long-term) should be
managed for secondary prevention of osteoporotic fractures. See section
8.12: Osteoporosis.
Additional immunosuppressive therapy

Is often required for life-threatening disease, particularly kidney and CNS
involvement. These medicines should be initiated by a specialist and regular
FBC monitoring should be done.
 Azathioprine, oral, 1 mg/kg daily, titrated to a maximum of 3 mg/kg daily.
OR LoE:III
Cyclophosphamide, oral, 100 mg daily, titrated to a
maximum of 200 mg daily (or 1–3 mg/kg daily).
LoE:III
RAYNAUD’S PHENOMENON I73.0
2019 13.12
LoE:IIxxxiii
ANTIPHOSPHOLIPID ANTIBODY SYNDROME
Patients with previous thrombo-embolic episodes should receive lifelong
warfarin (target INR 3 to 4).
LoE:III
Hormonal therapy in women
The use of oral contraceptives is controversial.
Until there is clarity it is advisable to use either progesterone-only, or low dose
oestrogens, or non-hormonal methods.
REFERRAL
» All patients to a specialist for initial assessment.
» Lupus flare.
» Nephritis for renal biopsy.
» Persistent haematological derangements i.e. thrombocytopaenia.
» Neurological manifestations of lupus.
2019 13.13
References:
i DMARDs - 3 month time point: Aletaha D, Alasti F, Smolen JS. Optimisation of a treat-to-target approach in
rheumatoid arthritis: strategies for the 3-month time point. Ann Rheum Dis. 2016 Aug;75(8):1479-85.
DMARDs - 3 month time point: Smolen JS, Landewé R, Bijlsma J, Burmester G, Chatzidionysiou K, Dougados
M, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological
disease-modifying antirheumatic drugs: 2016 update. Ann Rheum Dis. 2017 Jun;76(6):960-977.
DMARDs - 3 month time point: Singh JA, Saag KG, Bridges SL Jr, Akl EA, Bannuru RR, Sullivan MC, et al.
2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Rheumatol.
2016 Jan;68(1):1-26. https://www.ncbi.nlm.nih.gov/pubmed/26545940
ii Folic acid: Shea B, Swinden MV, TanjongGhogomu E, Ortiz Z, Katchamart W, Rader T, Bombardier C, Wells
GA, Tugwell P. Folic acid and folinic acid for reducing side effects in patients receiving methotrexate for
rheumatoid arthritis. Cochrane Database Syst Rev. 2013 May 31;5:CD000951.
iii Sulfasalazine, oral: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.
iv Corticosteroids, oral (3-6 months): Boers M, Verhoeven AC, Markusse HM, van de Laar MA, Westhovens R,
van DenderenJC, van Zeben D, Dijkmans BA, Peeters AJ, Jacobs P, van den Brink HR, Schouten HJ, van der
Heijde DM, Boonen A, van der Linden S. Randomised comparison of combined step-down prednisolone,
methotrexate and sulphasalazine with sulphasalazine alone in early rheumatoid arthritis. Lancet. 1997 Aug
2;350(9074):309-18. Erratum in: Lancet 1998 Jan 17;351(9097):220. http://www.ncbi.nlm.nih.gov/pubmed/9251634
Corticosteroids, oral (3-6 months):Goekoop-Ruiterman YP, de Vries-Bouwstra JK, Allaart CF, van Zeben D,
KerstensPJ, Hazes JM, Zwinderman AH, Ronday HK, Han KH, Westedt ML, Gerards AH, van Groenendael JH,
Lems WF, van KrugtenMV, Breedveld FC, Dijkmans BA. Clinical and radiographic outcomes of four different
treatment strategies in patients with early rheumatoid arthritis (the BeSt study): a randomized, controlled trial.
Arthritis Rheum. 2005 Nov;52(11):3381-90.http://www.ncbi.nlm.nih.gov/pubmed/16258899
Corticosteroids, oral (3-6 months): Singh JA, Saag KG, Bridges SL Jr, Akl EA, Bannuru RR, Sullivan MC,
Vaysbrot E, McNaughton C, Osani M, Shmerling RH, Curtis JR, Furst DE, Parks D, Kavanaugh A, O'Dell J, King C,
Leong A, Matteson EL, Schousboe JT, Drevlow B, Ginsberg S, Grober J, St Clair EW, Tindall E, Miller AS,
McAlindon T. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis.
Arthritis Rheumatol. 2016 Jan;68(1):1-26.http://www.ncbi.nlm.nih.gov/pubmed/26545940
Corticosteroids, oral: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.
v NSAIDs as a therapeutic class (diclofenac, naproxen, ibuprofen): Affordable Medicines, EDP-Adult Hospital
level. NSAIDs – comparative review of efficacy and safety, 15 January2018. http://www.health.gov.za
vi PPI (high risk patients on chronic NSAID therapy): McQuaid KR ,Laine L . Systemic review and meta-analysis of
adverse events of low-dose aspirin and clopidogrel in randomized controlled trials. Am J Med 2006;119:624–38.
PPI (high risk patients on chronic NSAID therapy): Serrano P, Lanas A, Arroyo MT, Ferreira IJ. Risk of upper
gastrointestinal bleeding in patients taking low-dose aspirin for the prevention of cardiovascular diseases. Aliment
PharmacolTher. 2002 Nov;16(11):1945-53. http://www.ncbi.nlm.nih.gov/pubmed/12390104
PPI (high risk patients on chronic NSAID therapy): Lanza FL, Chan FK, Quigley EM; Practice Parameters
Committee of the American College of Gastroenterology. Guidelines for prevention of NSAID-related ulcer
complications. Am J Gastroenterol. 2009 Mar;104(3):728-38. http://www.ncbi.nlm.nih.gov/pubmed/19240698
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PPI (high risk patients on chronic NSAID therapy): Narum S, Westergren T, Klemp M. Corticosteroids and risk of
gastrointestinal bleeding: a systematic review and meta-analysis. BMJ Open. 2014 May15;4(5):e004587.
PPI (high risk patients on chronic NSAID therapy): Scarpignato C, Gatta L, Zullo A, Blandizzi C; SIF-AIGO-FIMMG
Group; Italian Society of Pharmacology, the Italian Association of Hospital Gastroenterologists, and the Italian
Federation of General Practitioners. Effective and safe proton pump inhibitor therapy in acid-related diseases - A
position paper addressing benefits and potential harms of acid suppression. BMC Med. 2016 Nov 9;14(1):179.
vii Intra-articular corticosteroids: South African Medicines Formulary. 12th Edition. Division of Clinical

viii Cefazolin, IV: Loubet P, Burdet C, Vindrios W, Grall N, Wolff M, Yazdanpanah Y, AndremontA, Duval X, Lescure FX.
ix Clindamycin, oral dose: Bouazza N, Pestre V, Jullien V, Curis E, Urien S, Salmon D, Tréluyer JM. Population
pharmacokinetics of clindamycin orally and intravenously administered in patients with osteomyelitis. Br J Clin
Pharmacol. 2012 Dec;74(6):971-7.http://www.ncbi.nlm.nih.gov/pubmed/22486719
Clindamycin, oral dose: Wasserman et al. South African antibiotic stewardship programme (SAASP): A pocket
guide to antibiotic prescribing for adults in South Africa,
2014.http://www.fidssa.co.za/images/SAASP_Antibiotic_Gudidelines_2015.pdf
x Ceftriaxone, IV: Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted
diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015 Jun 5;64(RR-03):1-137. Erratum in: MMWR
Recomm Rep. 2015 Aug 28;64(33):924. https://www.ncbi.nlm.nih.gov/pubmed/26042815
Azithromycin, oral: Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted
xi NSAIDs as a therapeutic class (diclofenac, naproxen, ibuprofen): Affordable Medicines, EDP-Adult Hospital
xii NSAIDs as a therapeutic class (diclofenac, naproxen, ibuprofen): Affordable Medicines, EDP-Adult Hospital

2019 13.15

xiii Ibuprofen-aspirin interaction: Gladding PA, Webster MW, Farrell HB, Zeng IS, Park R, Ruijne N. The antiplatelet
effect of six non-steroidal anti-inflammatory drugs and their pharmacodynamic interaction with aspirin in healthy
volunteers. Am J Cardiol. 2008 Apr 1;101(7).http://www.ncbi.nlm.nih.gov/pubmed/18359332
Ibuprofen-aspirin interaction: Meek IL, Vonkeman HE, Kasemier J, Movig KL, van de Laar MA. Interference of
NSAIDs with the thrombocyte inhibitory effect of aspirin: a placebo-controlled, ex vivo, serial placebo-controlled
serial crossover study. Eur J Clin Pharmacol. 2013 Mar;69(3):365-71.
xiv PPI (high risk patients on chronic NSAID therapy): McQuaid KR ,Laine L . Systemic review and meta-analysis of
xv Intra-articular corticosteroids: South African Medicines Formulary. 12th Edition. Division of Clinical

xvi Management of gout: Dalbeth N, Reid S, Stamp LK, Arroll B. Making the right thing the easy thing to do:
strategies to improve outcomes in gout. Lancet Rheumatology. October 01, 2019. 1:2:PE122-E131. DOI:
https://doi.org/10.1016/S2665-9913(19)30004-9
xvii NSAIDs as a therapeutic class (diclofenac, naproxen, ibuprofen): Affordable Medicines, EDP-Adult Hospital

2019 13.16
xviii PPI (high risk patients on chronic NSAID therapy): McQuaid KR ,Laine L . Systemic review and meta-analysis of
xix Allopurinol, oral – maximum dose: South African Medicines Formulary. 12th Edition. Division of Clinical

xx Allopurinol, oral – renal adjusted dosing: Siu YP, Leung KT, Tong MK, Kwan TH. Use of allopurinol in slowing
the progression of renal disease through its ability to lower serum uric acid level. Am J Kidney Dis. 2006;47(1):51–
Allopurinol, oral – renal adjusted dosing: Goicoechea M, de Vinuesa SG, Verdalles U, Ruiz-Caro C, Ampuero J,
Rincón A, Arroyo D, Luño J. Effect of allopurinol in chronic kidney disease progression and cardiovascular risk. Clin
J Am Soc Nephrol. 2010 Aug;5(8):1388-93. https://www.ncbi.nlm.nih.gov/pubmed/20538833
Allopurinol, oral – renal adjusted dosing: South African Medicines Formulary. 12th Edition. Division of Clinical
Allopurinol, oral – renal adjusted dosing: Bennet et al. Drug Prescribing in Renal Failure. 5th Edition.
Philadelphia: American College of Physicians. 2007;104.
xxi Allopurinol, oral: hypersensitivity caution: Yang CY, Chen CH, Deng ST, Huang CS, Lin YJ, Chen YJ, Wu CY,
Hung SI, Chung WH. Allopurinol Use and Risk of Fatal Hypersensitivity Reactions: A Nationwide Population-Based
Study in Taiwan. JAMA Intern Med. 2015 Sep;175(9):1550-7. https://www.ncbi.nlm.nih.gov/pubmed/26193384
xxii NSAIDs as a therapeutic class (diclofenac, naproxen, ibuprofen): Affordable Medicines, EDP-Adult Hospital

xxiii Colchicine – prophylaxis for breakthrough gout attacks: Wortmann RL, Macdonald PA, Hunt B, Jackson RL.
Effect of prophylaxis on gout flares after the initiation of urate-lowering therapy: analysis of data from three phase
III trials. Clin Ther. 2010 Dec;32(14):2386-97. https://www.ncbi.nlm.nih.gov/pubmed/21353107
2019 13.17
xxiv PPI (high risk patients on chronic NSAID therapy): McQuaid KR ,Laine L . Systemic review and meta-analysis of
xxv NSAIDs as a therapeutic class (diclofenac, naproxen, ibuprofen): Affordable Medicines, EDP-Adult Hospital

xxvi PPI (high risk patients on chronic NSAID therapy): McQuaid KR ,Laine L . Systemic review and meta-analysis of
xxvii NSAIDs as a therapeutic class (diclofenac, naproxen, ibuprofen): Affordable Medicines, EDP-Adult Hospital

2019 13.18
xxviii PPI (high risk patients on chronic NSAID therapy): McQuaid KR ,Laine L . Systemic review and meta-analysis of
xxix Ceftriaxone, IM: National Department of Health STI Guidelines, 2014 and PHC STGs and EML, 2014.
Lidocaine 1% with epinephrine (adrenaline): National Department of Health STI Guidelines, 2014 and PHC STGs
and EML, 2014. http://www.health.gov.za
Azithromycin: National Department of Health STI Guidelines, 2014 and PHC STGs and EML, 2014.
xxx NSAIDs as a therapeutic class (diclofenac, naproxen, ibuprofen): Affordable Medicines, EDP-Adult Hospital

xxxi PPI (high risk patients on chronic NSAID therapy): McQuaid KR ,Laine L . Systemic review and meta-analysis of
2019 13.19
xxxiiChloroquine: Ruiz-Irastorza G, Ramos-Casals M, Brito-Zeron P, Khamashta MA. Clinical efficacy and side
effects of antimalarials in systemic lupus erythematosus: a systematic review. Ann Rheum Dis. 2010 Jan;69(1):20-
xxxiii Amlodipine: Ennis H, Anderson ME, Wilkinson J, Herrick AL. Calcium channel blockers for primary Raynaud's
phenomenon. Cochrane Database Syst Rev. 2014 Jan 30;1:CD002069.

2019 13.20
CHAPTER 14
NEUROLOGICAL DISORDERS
14.1 CEREBROVASCULAR DISEASE
14.1.1 STROKE
I63.0-6/I63.8-9/I64
GENERAL MEASURES
Optimise hydration and nutrition; insert nasogastric tube if patient cannot
swallow. Take precautions to ensure an open airway if patient is
unconscious.
Physiotherapy and good nursing care. Consider rehabilitation for suitable
patients, refer if necessary.
Do an ECG to rule out an acute coronary event or atrial fibrillation as
precipitants.
Do serology to exclude meningovascular syphilis.
Check lipid profile in ischaemic strokes.
Ischaemic stroke in young adults (<45 years of age) may be due to
atherosclerosis, but also consider:
» Embolic: e.g. rheumatic heart disease, atrial fibrillation, cardiomyopathy,
previous myocardial infarction, and, very rarely, patent foramen ovale:
history, careful clinical cardiac examination, ECG/CXR, and
echocardiography.
» Vessel wall disease: e.g. syphilis, HIV infection, collagen-vascular
diseases, TB or bacterial meningitis and extracranial arterial dissection.
Investigate as dictated by clinical presentation, but at least syphilis and HIV
serology, urine dipstix (haematuria and/or proteinuria), and ANF/RF.
ANCA, and cerebral angiography or carotid Doppler may be indicated.
Note that absence of a carotid bruit does not exclude significant carotid
stenosis.
» Hypercoagulable states: e.g. antiphospholipid antibody syndrome,
thrombotic thrombocytopenic purpura. Useful screening investigations are
FBC and, in women, PTT/Anti-phospholipid Ab. Testing for thrombophilias
and their management should only be done in consultation with an expert.
MEDICINE TREATMENT
Hyper-acute management:
Symptom onset ≤ 3 hours:
» Do not give aspirin.
» Refer immediately to hospital that can provide thrombolytic therapy:
 Alteplase, IV, 0.9 mg/kg.
o 10 % of total dose given as a bolus and the remainder continued as
an infusion over an hour.
LoE:Ii
2019 14.1
CHAPTER 14 NEUROLOGICAL DISORDERS
Symptoms >3 hours:

 Aspirin, oral, 300 mg, immediately. LoE:Iii
Followed by:
If patient is unable to swallow, administer through a naso-gastric tube.
Do not administer aspirin if there are symptoms suggestive of a sub-
arachnoid bleed, e.g. headache, stiff neck, etc.
AND
DVT prophylaxis see section: 2.14 Venous thrombo-embolism.
Treat secondary pulmonary and urinary tract infections appropriately.
Secondary prevention:
Measures for secondary prevention may not be appropriate for patients with
severe disability.
All patients with a thrombotic stroke, not on anticoagulation and
irrespective of the LDL level:
 Aspirin, oral, 150 mg daily. LoE:Iiii
AND
LoE:Iiv
LoE:Iv
LoE:IIIvi
Reduce dose:
OR
Consult specialist for further management. LoE:IIIvii
In patients with cardio embolic strokes (e.g. secondary to atrial fibrillation)

with no evidence of haemorrhage on CT scan, the optimal time to start
anticoagulation therapy is likely to vary among individual patients; this can
be from 7 to 14 days and up to 21 days and is dependent on the infarct size
(>1/3 of the hemisphere) and the patient’s risk factors for recurrent events.
viii
Bridging anticoagulation with heparin, or earlier initiation of LoE:III
warfarin, is not recommended because, although it reduces ischaemic stroke
recurrence, it increases symptomatic intracranial haemorrhage.
LoE:III
2019 14.2
Blood pressure management

A transient increase in BP is common after an acute stroke. Do not actively
lower a systolic BP <220 mm Hg or diastolic BP <120 mm Hg in the first few
days after stroke as this may be associated with an increased risk of death.
In patients presenting with stroke and BP >220/120 mmHg, lower BP to about
180/110 mm Hg in the first 24 hours.
Lowering BP during the acute phase of stroke (within 6 hours of onset) may
not improve morbidity. Antihypertensive medicines may be withheld until
patients have suitable oral or enteral access. Cautious incremental
reintroduction of treatment is advised to achieve long-term standard BP
control. See section: 3.6.3 Hypertensive crisis, hypertensive emergency.
LoE:Iix
If BP >220/120 mm Hg:
OR LoE:IIx
If adequate fluid intake can be ensured:
 Hydrochlorothiazide, oral, 12.5 mg daily. LoE:III
Note:
» There is some evidence of harm from BP reduction within 7 days of
acute stroke; after 7 days cautious incremental re-introduction of
treatment is advised to achieve long term standard BP control.
» Antihypertensive medicines should be stopped in acute LoE:Ixi
stroke unless the BP is >220/120 mm Hg (see above).
» The need for re-initiating the patients previous antihypertensive regimen
should be reassesed. See section 3.6: Hypertension.
LoE:IIIxii
REFERRAL
To a facility with a CT scan:
» Patients with atypical clinical presentation.
» Selected patients with suspected ischaemic stroke who may benefit from
thrombolysis with tissue plasminogen activator if initiated within 3 hours
of onset of symptoms.
» Patients with suspected posterior cerebral fossa haemorrhage who may
require surgical decompression.
» If there is a history suggestive of subarachnoid haemorrhage or if there is
neck stiffness.
» Patients with aspirin intolerance.
14.1.2 TRANSIENT ISCHAEMIC ATTACK (TIA)

G45.9
DESCRIPTION
A transient ischaemic attack is an episode of the brain, spinal cord, or retinal
ischaemia causing focal neurological dysfunction usually for less than one
2019 14.3
hour. Risk of subsequent stroke is highest in the week after a TIA. Consider
hypoglycemia, epilepsy and migraine as alternative causes for the symptoms.
The ABCD2 scoring system:
Feature Points
≥60 years of age 1
BP ≥ 140/90 mmHg 1
Clinical features:
speech disturbance without weakness OR 1
unilateral weakness 2
Diabetes 1
Duration: 10 to 59 minutes OR
≥1 hour 1
2
ABCD2 score of ≥4 is regarded as high risk and warrants urgent investigation
and management as the risk of stroke within the next week is ≥4%.
MEDICINE TREATMENT
Cardioembolic disease:
the therapeutic range of 2 to 3 (refer to Initiation dosing tables in the
Appendix II).
o Adjust dose to keep INR within therapeutic range (refer to
Maintenance dosing tables in the Appendix II).
Other patients: LoE:IIIxiii
LoE:Ixiv
AND
LoE:Ixv
LoE:Ixvi
LoE:IIIxvii
Reduce dose:
OR
Consult specialist for further management. LoE:IIIxviii
Manage hypertension – see section 3.6: Hypertension.
2019 14.4
14.1.3 SPINAL CORD INJURY, ACUTE

T09.3
Substantial evidence is lacking for the use of high dose corticosteroids in

this clinical setting.
For symptomatic management of:
» Constipation – see section 24.1.2: Constipation.
» Urinary retention – see section 7.3.6: Overactive bladder.
14.1.4 SUBARACHNOID HAEMORRHAGE

I60.0-9
DESCRIPTION
Bleeding into the subarachnoid space, most commonly due to the rupture of a
vascular aneurysm. Patients typically present with an acute onset of severe
headache and may have additional neurological symptoms and signs.
Diagnosis is confirmed preferably by neurological imaging and, when this is
not available, by demonstrating CSF xanthochromia on lumbar puncture.
GENERAL MEASURES
Maintain normal hydration and electrolyte status.
Control blood pressure.
MEDICINE TREATMENT
Analgesia if level of consciousness is not impaired:
If no response:
Avoid NSAIDs.
In all patients presenting with aneurysmal subarachnoid hemorrhage (SAH)
while waiting for transfer to neurosurgical facility and in consultation with
neurosurgeon:
 Nimodipine, oral, 60 mg 4 hourly for 21 days.
REFERRAL
All patients with minimal impairment of consciousness level for angiography
and appropriate neurosurgical management. Patients initially deemed
unsuitable for further investigation, may be referred at a later stage, should
their condition improve.
2019 14.5
14.2 DEMENTIA
E51.2/E52/E63.9 + (F02.8*)
DESCRIPTION
Progressive loss of cognitive function, usually of insidious onset. Initial
presentation may be with mild personality or memory changes, before more
pronounced defects become evident. Investigate patients for potentially
reversible causes:
» Metabolic
- Hypothyroidism
- Vitamin B12 deficiency
- Pellagra
- Thiamine deficiency (Wernicke’s syndrome)
» Medications and drugs
- Alcohol abuse
- Many medicines with CNS side-effects
» Infections
- Syphilis
- HIV
» Surgical
- Chronic subdural haematoma
- Normal pressure hydrocephalus
» Severe depression (may mimic dementia)
Conditions which may worsen already existing dementia include:
» electrolyte disturbances and dehydration
» infections
» medicine toxicity
GENERAL MEASURES
Appropriate care and support, according to the level of impairment.
Ambulatory care is preferred to hospitalisation, if feasible.
Family counselling and support.
MEDICINE TREATMENT
Management is mainly symptomatic.
To control restless patients:
 Haloperidol, oral, 0.75–1.5 mg 8 hourly with a higher dose at night, if
required.
Note:
» There is uncertainty of benefit versus harm of long-term use of
antipsychotics in dementia, but antipsychotics may be of benefit in
severe behavioural and psychological symptoms.
» Inform the family of a possible elevated risk of mortality with prolonged
use of antipsychotics.
2019 14.6
» If there is no improvement, stop the antipsychotic.

» Initiate treatment at a low dose and titrate to the lowest effective dose
for the shortest possible time. Reassess the person at least every 6
weeks, to check whether they still need medication.
LoE:IIIxix
For pellagra:
 Nicotinamide, oral, 100 mg 8 hourly.
Wernicke’s syndrome: E51.2 + (F02.8*)

 Thiamine, IV, 500 mg 12 hourly for 3 days, followed by 500 mg daily for
3–5 days.
o Follow with oral thiamine 100 mg 8 hourly.
Prophylaxis in patients at risk (alcoholism, malnutrition): Z29.2
 Thiamine, IM/oral, 100 mg 8 hourly for 14 days. LoE:IIIxx
Treat other commonly associated nutritional deficiencies:

If confirmed Vitamin B12 deficiency, manage as section 2.1.2: Anaemia,
megaloblastic.
14.3 DELIRIUM
See section 20.8: Delirium with perceptual disturbances.
14.4 EPILEPSY
G40.0-9
GENERAL MEASURES
Take an adequate history to define the type of epilepsy.
Juvenile myoclonic epilepsy and absence seizures should be specifically
considered and identified, as some standard medicines may be less
efficacious or may even worsen seizure frequency or severity.
Patients with new onset epilepsy should have a CT scan (this is essential in
immunocompromised patients) and other investigations as clinically indicated.
A single unprovoked seizure is not always an indication for treatment,
although 40% of patients may have a subsequent seizure within 2 years.
Such a decision ultimately needs to be made by the patient after discussion
of risks and benefits of anti-epileptic medicines. Anticonvulsants should be
commenced after a single unprovoked seizure in patients at high risk of
subsequent seizures (e.g. abnormal neurological examination, strong family
history, abnormal brain imaging).
Record dates and, if possible, times of seizures in a seizure diary. Present
seizure diary at each consultation for assessment of therapy.
Disease identification bracelet, necklace or card.
Counselling and advice on:
2019 14.7
» the adverse effect of alcohol on seizures,

» sleep hygiene,
» the effect of missing a dose of medication,
» discontinuing the medication without advice of a doctor, and
» family planning is important in women of child-bearing potential as
anticonvulsants, are all potentially teratogenic. Note that there are
important drug-drug interactions between hormonal contraceptives
(except DMPA) and several anticonvulsant medicines (carbamazepine,
phenobarbital, phenytoin).
» patients with uncontrolled seizures should avoid driving and operating
machinery until they have been seizure free for one year.
MEDICINE TREATMENT
The anticonvulsant treatment strategy should be individualised based on the
seizure type, the use of other medicines and co-morbidities.
The choice between therapeutic agents must be made on the acceptability
of side effects and how the number of doses influences lifestyle.
The aim is to use monotherapy, i.e. a single anticonvulsant, and to
progressively increase the dose until the seizures are controlled or clinically
important side effects occur.
Add-on or switching medication:
If the initial medicine fails to achieve satisfactory control with optimal dosages,
or causes unacceptable adverse effects, then a second medicine may be
started. The first medicine should be continued for 2 weeks and then gradually
reduced over 6–8 weeks until stopped, whilst the second medicine is gradually
increased over an appropriate period to therapeutic doses. Failure of second-
line treatment with the exclusion of alcohol use/misuse and poor adherence,
may require combination therapy; this should be done in consultation with a
specialist.
Patients with a history of myoclonic seizures or typical absence seizures
should preferably be treated with valproate (valproic acid), as those seizures
may be aggravated by the use of either phenytoin or carbamazepine (See
other epilepsy types, below).
Therapeutic drug monitoring should not be done routinely, but should be
done in the following situations:
» To confirm toxicity in a symptomatic patient. LoE:IIIxxi
» Poor control.
» To confirm poor adherence despite self-reported good adherence.
Acute management
If convulsing:
» Measure blood glucose and treat hypoglycaemia, if present.
» Ensure an open airway and administer oxygen.
» Place in recovery position to prevent aspiration.
» Obtain intravenous access.
2019 14.8
» Avoid putting anything in the mouth.

Partial seizures (focal seizures) G40.0-2
 Carbamazepine, oral.
o Start with 100 mg 12 hourly.
o Increase by 100–200 mg/day at weekly intervals according to seizure
control and adverse events.
o Usual maximal dose: 600 mg 12 hourly. LoE:IIIxxii
OR
Lamotrigine, oral.
o Refer to the lamotrigine dose-titration table, below.
CAUTION
Phenytoin, phenobarbitone and carbamazepine are potent enzyme inducing
agents and should be used with caution with other medicines metabolised
by the liver, especially warfarin, some ARVs, progestin subdermal implants
and oral contraceptives.
Generalised tonic clonic seizures G40.3

 Lamotrigine, oral.
o Refer to the lamotrigine dose-titration table.
OR
Carbamazepine, oral.
o Start with 100 mg 12 hourly.
o Increase by 100–200 mg/day at weekly intervals according to seizure
control and adverse events.
o Usual maximal dose: 600 mg 12 hourly. LoE:Ixxiii
For patients controlled on phenytoin:

 Phenytoin, oral, 4.5–5 mg/kg (lean body mass) daily.
o Usual starting dose in an adult male: 300 mg once daily.
o Dose changes above 300 mg should be done only in no more than
50 mg increments at intervals no shorter than 2 weeks.
Note: Caution and frequent monitoring of drug levels are obligatory at doses
>300 mg daily as the risk for toxicity is high and could lead to permanent
cerebellar damage. LoE:III
For patients not controlled on or who do not tolerate the above medications:
 Valproate (valproic acid), oral.
o Usual starting dose: 200–300 mg 12 hourly.
o Increase, as required, every 2 weeks to a maximum dose of 1.2 g
12 hourly.
Other epilepsy types G40.4-5/G40.8-9

Manage in consultation with a specialist.
Juvenile myoclonic epilepsy:
Refer all for specialist investigation and initiation of therapy with valproate
(valproic acid). LoE:IIIxxiv
2019 14.9
Absence seizures:
 Valproate (valproic acid), oral (specialist consultation).
o Increase, as required, every 2 weeks to a maximum dose of 1200 mg
12 hourly.
OR LoE:IIIxxv
 Lamotrigine, oral (specialist consultation).
o Refer to dose titration table.
Dose-titration of lamotrigine:
NOT ON VALPROATE (VAPROIC ACID) ON VALPROATE (VALPROIC ACID)
Weeks Dose Weeks Dose
1,2 25 mg daily 1,2 25 mg alternate days
3,4 25 mg 12 hourly 3,4 25 mg daily
5 25 mg in the morning; 50 mg 5 25 mg 12 hourly
at night
6 50 mg 12 hourly 6 25 mg in the morning; 50 mg
at night
7 50 mg 12 hourly
Note: LoE:IIIxxvi
o Further increase by 50 mg every 1–2 weeks,
according to response.
o Usual maintenance dose: 100–200 mg daily, given in two divided
doses with doses up to 500 mg may be required.
Adapted from the Western Cape Department of Health, Lamotrigine dose titration protocol,
2019.
HIV-infected individuals on ARVs (B24)

Phenytoin, phenobarbital and carbamazepine are enzyme inducing anti-
epileptic medicines. Due to potential drug interactions with antiretroviral
medicines, switch these anticonvulsants to lamotrigine.
o Refer to the lamotrigine dose-titration table.
If not on any anti-epileptic medicine:

o Refer to the lamotrigine dose-titration table, above.
OR
Valproate (valproic acid), oral.
o Increase, as required, every 2 weeks to a maximum dose of 1200 mg
12 hourly.
Add on therapy to valproate (valproic acid):

2019 14.10
o Refer to the lamotrigine dose-titration table, above.

CAUTION - LAMOTRIGINE
Lamotrigine may cause Stevens-Johnson Syndrome.
Note:
» Metabolism of lamotrigine is induced by lopinavir/ritonavir and
atazanavir/ritonavir. Dose of lamotrigine may need to be increased when
patients are switched to a lopinavir/ritonavir or atazanavir/ritonavir.
» In the absence of evidence of benefit, using lamotrigine serum levels for
dose titration is discouraged.
LoE:IIIxxvii
Pregnancy
» Optimal control of epilepsy on a single agent is the best management.
» Individualise anti-epileptic treatment.
» Advise women of child-bearing potential (WOCP) to use effective
contraception.
» Risk-assess patients who fall pregnant on valproate (valproic acid), in
consultation with a specialist to determine if switching is required.
» If alternate treatment cannot be recommended and valproate (valproic
acid) required, supplement with:
 Folic acid, oral, 5 mg daily. LoE:IIIxxviii
CAUTION
Children born to women taking valproate (valproic acid) are at significant risk
of birth defects (10%) and persistent developmental disorders (40%).
Valproate (valproic acid) is contra-indicated and should be avoided in
pregnancy and women of child-bearing potential.
LoE:IIIxxix
Prophylaxis in head trauma Z29.2

Duration of anti-epileptic prophylaxis is dependent on the severity of the head
trauma.
Acute management:
 Phenytoin, IV, 20 mg/kg diluted in sodium chloride 0.9% (not dextrose)
administered not faster than 50 mg/minute preferably with cardiac
monitoring.
Patient is awake and able to swallow:
 Phenytoin, oral, 18 mg/kg as a single dose. LoE:IIIxxx
 Phenytoin, IV, 5 mg/kg/day (300 mg daily for most adults) diluted in
sodium chloride 0.9% (not dextrose), at night for 7 days – monitor
clinical response and manage appropriately.
o If arrhythmias occur, interrupt the infusion temporarily and
reintroduce slowly.
2019 14.11
LoE:IIxxxi
Patient is awake and able to swallow:
 Phenytoin, oral, 300 mg at night for 7 days.
REFERRAL
» Epileptics who are poorly controlled on adequate treatment with
therapeutic drug concentrations.
» Epilepsy with unexplained neurological symptoms or signs.
14.4.1 STATUS EPILEPTICUS

G41.0-2/G41.8-9
DESCRIPTION
Status epilepticus is defined as either:
1) two or more sequential seizures, lasting more than 5 minutes without full
recovery of consciousness between seizures or;
2) continuous seizure activity for longer than 5 minutes.
GENERAL MEASURES
Start treatment immediately. Do not wait for results of special investigations.
Place the patient in a lateral (recovery) position.
Stabilise the patient (i.e. secure airway and check breathing and circulation).
Time seizure from its onset.
Assess oxygenation and give oxygen via nasal cannula/face mask if required.
Check serum glucose, and treat if hypoglycaemic.
Secure intravenous access.
Check electrolytes (e.g. sodium, calcium, urea).
Consider poisoning, e.g. isoniazid, theophylline, tricyclic antidepressants and
cocaine poisonings.
MEDICINE TREATMENT
Seizures should be stopped promptly, as prolonged seizures can cause
permanent brain damage. Aim for definitive control within 60 minutes of onset.
Initial treatment:
Benzodiazepine:
 Lorazepam, IV, 4 mg, repeat once after 5–10 minutes, if necessary.
OR LoE:Ixxxii
Midazolam, IM/IV, 10 mg, repeat once after 5–10
minutes if necessary.
OR LoE:Ixxxiii
Midazolam buccal, 10 mg using the parenteral
formulation, repeat once after 5–10 minutes if necessary.
OR LoE:III
Clonazepam, IV, 2 mg, repeat once after 5–10 minutes
if necessary.
2019 14.12
LoE:IIIxxxiv
If none of the above are available, consider:
 Diazepam, IV, 10 mg, not faster than 2 mg/minute, repeat once after 5–10
minutes if necessary.
LoE:Ixxxv
AND
 Phenytoin, IV, 20 mg/kg diluted in 200 ml sodium chloride 0.9% (not
dextrose) administered not faster than 50 mg/minute preferably with
cardiac monitoring.
o Avoid phenytoin if seizures are secondary to poisons with potential
cardio-toxic effects. LoE:IIxxxvi
o If arrhythmias occur, interrupt the infusion temporarily
and reintroduce slowly.
o If further/continued seizures, repeat a second phenytoin dose, IV,
10 mg/kg.
LoE:Ixxxvii
Seizures continuing after 30 minutes:
Intubate and ventilate the patient.
 Thiopental, IV, 2–4 mg/kg, followed by 50 mg bolus every 2–3 minutes to
control seizures.
o Maintenance dose: 1–5 mg/kg/hour, depending on the presence of
epileptogenic activity on EEG.
o Beware of hypotension.
o Once seizures are controlled for 24 hours, wean off thiopental by
decreasing the dose by 1 mg/kg every 12 hours.
OR LoE:IIIxxxviii
Propofol, IV, 1–2 mg/kg/dose as a bolus, followed by 2–
10 mg/kg infusion, titrated to effect
o Maintenance dose: 3–5 mg/kg/hour.
OR LoE:Ixxxix
Midazolam, IV 0.1–0.2 mg/kg bolus, followed by 0.05–0.5
mg/kg/hour infusion, titrated to effect.
LoE:IIIxl
Note:
» Continue anaesthetic for 12−24 hours after the LoE:IIIxli
last clinical or electrographic seizure, then taper the dose.
» Higher initial maintenance doses of phenytoin may be needed in patients
who have had previous thiopental exposure.
» After thiopental has been weaned off, use daily therapeutic drug
monitoring to guide phenytoin doses, until phenytoin levels have
stabilised. LoE:IIIxlii
Maintenance therapy
Once seizures are controlled: LoE:IIIxliii
 Phenytoin, IV/oral, 300 mg daily.
o Adminster the first maintenance dose 12 hours after the loading dose.
2019 14.13
Clinical signs that seizures are controlled include autonomic stability and the
absence of abnormal movement.
For long-term maintenance therapy, see section 14.4: Epilepsy.
14.5 HEADACHE AND FACIAL PAIN SYNDROMES
14.5.1 MIGRAINE
G43.0-3/G43.8-9
DESCRIPTION
A migraine is an episodic headache, usually located unilaterally and
throbbing/ pulsating in nature, which may occur with or without an aura.
Migraines are usually accompanied by nausea and/or vomiting, photophobia
(sensitivity to light) and phonophobia (sensitivity to noise). There are several
variants of migraine.
GENERAL MEASURES
Reassure patient that this is a benign condition.
Attempt to identify any precipitating factors or food triggers from the patient’s
history.
MEDICINE TREATMENT
Acute treatment
Initiate therapy during the migraine attack or at the onset of the headache.
Analgesia:
OR
 NSAID, e.g.:
 Ibuprofen, oral, 400 mg immediately then 8 hourly with meals, if needed.
For nausea:
 Metoclopramide, oral/IM, 10 mg 8 hourly, as required.
Prophylaxis (Z29.2)
Regular, daily, prophylactic therapy is advised if:
» attacks are frequent, i.e. more than 2–3 per month, or
» severe, causing a significant amount of disability, or
» attacks are long lasting, or
» patient poorly tolerates therapy for acute attacks.
LoE:IIIxliv
 Amitriptyline, oral, 10–25 mg at bedtime.
o Up-titrate dose to adequate clinical response.
2019 14.14
o Doses greater than 25–75 mg are seldom required.

OR LoE:Ixlv
Poor response or contraindication to amitriptyline:
 β-blocker, e.g.:
 Propranolol, oral, 40 mg 12 hourly.
o Titrate dose to adequate response
o Maximum dose 120–240 mg daily. LoE:Ixlvi
REFERRAL
Inadequate response to treatment.
14.5.2 CLUSTER HEADACHE

G44.0
DESCRIPTION
Repetitive episodes of excruciating headache typically of short duration (up to
2 hours) in clusters for weeks to months at a time. Typically, the headache is
of sudden onset, unilateral during the specific cluster, and quickly reaches a
climax. Associated redness of the eye with lacrimation and rhinorrhoea occurs.
MEDICINE TREATMENT
 Oxygen inhalation may abort some episodes.
Analgesics are ineffective.

To induce rapid remission in patients with episodic cluster headache:
 Prednisone, oral, 40 mg daily for 5–10 days.
o Tapering is not necessary when the above duration is used.
LoE:IIIxlvii
Prophylaxis
REFERRAL
Inadequate response to treatment.
14.5.3 TRIGEMINAL NEURALGIA

See section 26.1.4 Management of neuropathic pain.
14.5.4 TENSION HEADACHE

G44.2/G93.2
DESCRIPTION
Tension headaches are described as a tight band around the head and is
generally worse in the afternoon. Occurs over the back of the head, but may
extend over the entire head.
2019 14.15
GENERAL MEASURES
Consider use of relaxation techniques.
Exclude medication overuse headache.
MEDICINE TREATMENT
REFERRAL
» Atypical pain and/or focal neurological signs and symptoms, suggestive
of alternate diagnosis.
» Poor response to therapy.
14.5.5 MEDICATION OVERUSE HEADACHE

G44.4
DESCRIPTION
Medication overuse headache generally occurs for ≥15 days per month for
more than 3 months; and develops as a consequence of regular overuse of
analgesics for acute pain-relief. The headache develops or markedly
worsens during medication overuse, and usually, but not invariably, resolves
after the overuse is stopped.
LoE:IIIxlviii
GENERAL MEASURES
Stop all analgesics.
Counsel patient regarding the link between overuse of analgesics and the
development of and/or worsening of the headache syndrome.
The headache usually resolves after the overuse is stopped, but may
transiently worsen.
MEDICINE TREATMENT
 Amitriptyline, oral, 10 mg at night.
o Increase to a maximum of 75 mg at night. LoE:IIxlix
o May be used during withdrawal of acute or
symptomatic headache treatment.
14.5.6 IDIOPATHIC INTRACRANIAL HYPERTENSION

(PSEUDOTUMOUR CEREBRI)
G93.2
DESCRIPTION
Patients present with symptoms (chronic headache, visual disturbance or loss
due to papilloedema and tinnitus) and signs (papilloedema) of raised
intracranial pressure without structural intracranial abnormality and with normal
CSF composition.
2019 14.16
Diagnosis
All patients should have neuro-imaging (CT scan).
» If this is normal, i.e. the absence of structural lesions or hydrocephalus,
perform a lumbar puncture and measure intracranial pressure.
» Diagnosis is confirmed by the presence of raised CSF pressure >20 cm H20.
GENERAL MEASURES
Stop medicines associated with benign intracranial hypertension (e.g.
doxycycline, corticosteroids, combined oral contraceptives).
Regular monitoring of visual fields is crucial.
Weight loss.
Repeated lumbar punctures with measurement of opening pressure (do
lumbar puncture with patient in left lateral position).
Consider surgery if there is progression of visual defects, despite medical
therapy, visual loss at onset or severe papilloedema.
MEDICINE TREATMENT
Discuss all cases with a specialist.
For visual involvement, persistent headaches, or severe papilloedema:
 Acetazolamide, oral, 250 mg 12 hourly, maximum dose 2 g daily
OR LoE:IIl
Furosemide, oral, 40 mg daily.
REFERRAL
» For neuro-imaging, if not available locally.
» Visual symptoms or deterioration of visual fields for opthalmology evaluation.
» Patients not responding to therapy or in need of surgical management.
14.6 INFECTIOUS AND PARASITIC CONDITIONS

14.6.1 MENINGITIS
G00.0-3/G00.8-9/G03.0-2/G03.8-9/A32.1
*N. meningitidis, H. influenzae Type B and listeriosis are notifiable medical conditions.
DIAGNOSIS
Computed tomography should be done before lumbar puncture in patients with:
» focal neurological signs,
» new seizures,
» papilloedema, or
» reduced level of consciousness.
In cases where lumbar puncture is delayed or cannot be done (e.g.
uncontrolled significant bleeding tendency), commence empiric antibiotic
therapy after taking samples for blood cultures. Attempt the lumbar puncture
later, if possible.
2019 14.17
GENERAL MEASURES
Observe patient closely with regular monitoring of vital signs and
neurological state.
Pay close attention to hydration status.
Nurse patients in a quiet, semi-dark surrounding.
Repeated lumbar punctures are of no benefit in uncomplicated bacterial
meningitis.
Prompt initiation of antibiotic therapy is associated with improved outcomes
in patients with bacterial meningitis.
MEDICINE TREATMENT
All patients require sufficient analgesia:
AND/OR
 NSAID, e.g.:
 Ibuprofen, oral, 400 mg then 8 hourly with meals, if needed.
Severe pain:
Antibiotic therapy
Empiric therapy for bacterial meningitis, until sensitivity results are available:
 Ceftriaxone, IV, 2 g 12 hourly for 10 days. LoE:IIIli
Adjunctive corticosteroids are not recommended as trials in low-

middle income countries have not demonstrated benefit.
Meningococcal meningitis A39.0 + (G01*)

For confirmed meningococcal disease only:
 Benzylpenicillin (penicillin G), IV, 20–24 MU daily in 4–6 divided doses
for one week.
Eradicate nasopharyngeal carriage with a single dose of ciprofloxacin 500
mg after completing course of benzylpenicillin. This is not required if the
patient received an initial, pre-referral dose of ceftriaxone.
 Ciprofloxacin, oral, 500 mg immediately as a single dose.
 Meropenem, IV, 2 g 8 hourly for 7 days. LoE:IIIlii
Prophylaxis of contacts:
Only for close household contacts.
Only for healthcare workers who resuscitate patients before they received
appropriate treatment.
2019 14.18
Pneumococcal meningitis G00.1

This organism may be associated with CSF leaks.
If sensitive to penicillin: (Z88.0)
for 10 days.
If resistant to penicillin:
 Ceftriaxone, IV, 2 g 12 hourly for at least 10 days.
 Meropenem, IV, 2 g 8 hourly for 10 days.
Note: Consult a microbiologist/infectious diseases specialist.
Haemophilus influenzae G00.0

 Ceftriaxone, IV, 2 g 12 hourly for 10 days.
 Meropenem, IV, 2 g 8 hourly for 10 days.
Note: Consult a microbiologist/infectious diseases specialist.
Listeria monocytogenes meningitis A32.1

 Ampicillin, IV, 3 g 6 hourly for 21 days. LoE:IIIliii
AND
 Gentamicin, IV, 5 mg/kg daily for 7 days (may be prolonged if response
is poor). See Appendix II for guidance on prescribing.
Consult a specialist.
14.6.1.1 TUBERCULOUS MENINGITIS (TBM)

A17.0 + (G01*)
CSF findings are extremely variable. Generally, lymphocytes predominate,

however, polymorphs predominate initially in about a third of patients.
Protein is usually >1 g/L and glucose is usually low.
In cases where the differential diagnosis between bacterial and tuberculous
meningitis is in doubt, lumbar puncture should be repeated 2–3 days later
while still on ceftriaxone. If the aetiology is bacterial, considerable
improvement in CSF findings may be expected, but with untreated
tuberculous meningitis the cell counts and protein levels will be the same or
higher; and the glucose level will be the same or lower.
Standard combination tuberculosis therapy according to National protocol.
See section 16.9: Tuberculosis, Pulmonary.
Duration of therapy: 9 months.
In HIV non-infected individuals:
Corticosteroid use may be of benefit in reducing neurological deficit in
2019 14.19
patients with grade II to III disease (focal neurological disease, depressed

levels of consciousness Glasgow Coma Scale of 14 or less.
 Dexamethasone, IV,
o 0.3–0.4 mg/kg/day for 2 weeks.
o Followed by 0.2 mg/kg daily during week 3.
o Then 0.1 mg/kg/day during week 4, then 4 mg per day during week
5, and therafter, taper 1 mg off the daily dose each week.
o Total duration approximately 8 weeks.
LoE:Iliv
 Prednisone, oral, 60 mg daily for 2 weeks. LoE:IIIlv
o Then taper gradually over the next 6 weeks (See Appendix II for an
example of a dose reduction regimen).
LoE:Ilvi
In HIV-infected individuals:
Note: There is uncertainty whether the use of corticosteroids is beneficial in
HIV-infected patients with TBM. LoE:Ilvii
14.6.1.2 CRYPTOCOCCAL MENINGITIS

HIV-infected patients (see section 10.2.4: Cryptococcosis)
» In HIV infection the aim is to suppress the infection until immune
restoration occurs with antiretroviral therapy.
HIV-uninfected patients
» In HIV-uninfected patients the aim is to cure the infection.
14.6.1.2.1 CRYPTOCOCCAL MENINGITIS, HIV-INFECTED

See section 10.2.4: Cryptococcosis.
14.6.1.2.2 CRYPTOCOCCAL MENINGITIS, HIV-

UNINFECTED
B45.1 + (G02.1*)
MEDICINE TREATMENT
Initial therapy: LoE:Ilviii
 Amphotericin B, IV, 1 mg/kg daily.
o Ensure adequate hydration to minimise nephrotoxicity. (See
Appendix II for preventing, monitoring and management of toxicity).
o Duration of initial IV therapy:
- Treat intravenously for 4 weeks, provided that there are no
neurological complications and follow up CSF culture at 2 weeks
is negative. In patients with neurological complications or
persistent positive culture: increase the initial phase of therapy to
6 weeks in consultation with a specialist.
2019 14.20
AND LoE:IIIlix
 Fluconazole, oral, 800 mg daily for 2 weeks, followed by 400 mg daily
for 2 months.
 Fluconazole, oral, 200 mg daily for a minimum of 1 year.
Follow all patients closely for relapses.
Therapeutic lumbar puncture: LoE:IIIlx
This should be considered as the intracranial pressure is often elevated with
a communicating hydrocephalus. See section 10.2.4: Cryptococcosis.
14.6.2 VIRAL MENINGOENCEPHALITIS

B00.4 + (G05.1*) / A86
DESCRIPTION
Patients present with headache, neck stiffness, and encephalitic symptoms
which may include fever, personality or behavioural changes, hallucinations
and seizures. Lumbar puncture typically shows mildly elevated protein,
normal glucose and mild pleocytosis (< 500), mainly lymphocytes (early on
polymorphs may predominate). Treatment for herpes simplex encephalitis
should be commenced in all patients until this has been excluded (see
below).
MEDICINE TREATMENT
Analgesia:
AND/OR
 NSAID, e.g.:
 Ibuprofen, oral, 400 mg immediately then 8 hourly with meals, if needed.
OR LoE:IIIlxi
Herpes simplex encephalitis

Clinical features are fever, change in behaviour and seizures, which may be
either focal or generalised.
Evidence of mucocutaneous involvement is usually not present. Lumbar
puncture shows the above features of viral meningoencephalitis. Evidence
of encephalitis involving medial temporal lobe region on MRI/CT neuro-
imaging or on EEG is strongly supportive of the diagnosis and positive HSV
PCR test on CSF is diagnostic.
 Aciclovir, IV, 10 mg/kg 8 hourly for 14 days (21 days in immunocompromised
patients).
2019 14.21
o Start therapy as early as possible, i.e. before results are available.

o A negative herpes PCR usually excludes the diagnosis unless the
specimen was taken within 72 hours of onset of symptoms, when
false negatives have been described.
LoE:IIIlxii
Treat seizures appropriately, see section 14.4: Epilepsy.
All suspected cases of herpes encephalitis should be discussed with a
specialist.
REFERRAL
» For neuro-imaging: patients not responding or worsening in condition, i.e.
decrease in consciousness and cranial nerve palsies, despite
appropriate therapy.
» This is especially urgent in patients with tuberculous meningitis, who may
develop hydrocephalus and require an urgent shunting procedure.
» Patients with shunts.
14.6.3 MENINGOVASCULAR SYPHILIS (NEUROSYPHILIS)

A52.1 + (G01*)
DIAGNOSIS
Lumbar puncture typically shows lymphocytosis with mildly elevated protein
and low/normal glucose.
Serum syphilis serology: a negative TPHA or TPAb excludes the diagnosis;
RPR may be negative in some cases.
CSF syphilis serology: a CSF VDRL positive result is highly specific for
neurosyphilis, but may be negative in approximately 50%; a negative CSF
FTA-ABS excludes the diagnosis of neurosyphilis.
MEDICINE TREATMENT
 Benzylpenicillin (penicillin G), IV, 20 MU daily in 4–6 divided doses for 10
days.
LoE:III
A serum RPR response (4-fold decline in titre) after 6 months is predictive of
treatment success for neurosyphilis.
LoE:IIIlxiii
Refer for consideration of desensitisation and subsequent treatment with
benzylpenicillin at a referral centre.
2019 14.22
14.6.4 BRAIN ABSCESS

G06.0
DIAGNOSIS
Patient may present with focal neurological signs and signs of infection.
Neurological signs may not always be prominent. Neuro-imaging usually
confirms diagnosis. Patients may have concomitant infection of ears,
paranasal sinuses or lower respiratory tract.
MEDICINE TREATMENT
 Ceftriaxone, IV, 2 g 12 hourly.
AND
 Metronidazole, oral, 400 mg 8 hourly or IV, 500 mg 8 hourly.
Adjust according to antimicrobial sensitivity after surgical drainage.
REFERRAL
All, as patients require urgent neurosurgery opinion and treatment.
14.6.5 ANTIMICROBIAL USE IN PATIENTS WITH HEAD

INJURIES
S09.9/S02.10-11/S06.00-01/S06.10-11/S06.20-21/S06.30-31/S06.40-41/S06.50-
51/S06.60-61/S06.70-71/S06.80-81/S06.90-91
MEDICINE TREATMENT
Basal skull fractures
Antibiotic prophylaxis is not indicated.
Penetrating brain injuries
Antibiotics are given for therapy.
 Ceftriaxone, IV, 2 g 12 hourly for 7 days. LoE:III
14.6.6 NEUROCYSTICERCOSIS
B69.0 + (G99.8*)
DIAGNOSIS
Patients may present with seizures and/or focal neurological deficit. Typical
cystic lesions are seen on neuro-imaging. Old calcified lesions are inactive
and do not require treatment.
GENERAL MEASURES
Health education.
Surgery for treatable ventricular blockage or spinal or intraocular cysts.
2019 14.23
MEDICINE TREATMENT
For active or viable cysts only:
 Albendazole, oral, 12 hourly for 8 days.
o ≥ 60 kg: 400 mg.
o < 60 kg: 7.5 mg/kg to a maximum of 800 mg daily.
o Do not use in pregnancy.
AND LoE:IIlxiv
 Prednisone, oral, 60 mg daily for 8 days. LoE:IIIlxv
Anticonvulsants, if required. See section 14.4: Epilepsy. LoE:IIlxvi
REFERRAL
Uncontrolled seizures despite antiparasitic and anticonvulsant therapy.
14.7 MOVEMENT DISORDERS
DESCRIPTION
Abnormalities of movement/initiation of movement, divided into those with
reduction of movement (hypokinesia or bradykinesia), or those with
excessive movements (hyperkinesia).
14.7.1 PARKINSONISM, PRIMARY

14.7.1.1 IDIOPATHIC PARKINSON DISEASE
G20/G21.1
DESCRIPTION
Parkinsonism is a syndrome characterised by tremor, rigidity, bradykinesia
and postural disturbances. It may be primary, i.e. Parkinson’s disease, or
secondary, i.e. drug-induced, or due to uncommon disorders that may
initially resemble Parkinson’s disease.
The objective of treatment is to:
» minimise disabling symptoms
» prevent complications and avoid serious drug-induced side effects
GENERAL MEASURES
General supportive therapy and advice about lifestyle modification,
physiotherapy and occupational therapy.
MEDICINE TREATMENT
Note: Set therapeutic targets so that the patient is functioning as well as
possible.
2019 14.24
Bradykinesia, rigidity and postural disturbance:

 Carbidopa/levodopa, 25/100 mg (1 tablet), oral, 8 hourly, increase
gradually according to clinical response.
o Maximum dose of 200/800 mg daily (8 tablets).
o Increase dose in consultation with a specialist.
REFERRAL
» Alternative diagnosis suspected (e.g. Parkinson’s plus disorders etc.)
» No improvement or poor control with treatment.
» Increasing on/off phenomenon.
» Dyskinesias.
14.7.2 PARKINSONISM, SECONDARY

G21.0-4/G21.8-9
DESCRIPTION
Secondary parkinsonism is caused by certain medicines (typical and atypical
antipsychotics, anti-emetics, anticonvulsants (phenytoin, valproate/ valproic
acid) and SSRIs), a different nervous system disorder, or another illness.
GENERAL MEASURES
Primary approach in drug-induced parkinsonism should be to stop the
offending medicine if possible.
Refer to psychiatric services for review of antipsychotic treatment in patients
requiring treatment for parkinsomism (see section 15.5.2: Schizophrenia
spectrum disorders).
MEDICINE TREATMENT
Anticholinergics have a limited role in this setting and should be used with
caution.
 Orphenadrine, oral, 50 mg 8 hourly, increase gradually according to
clinical response.
o Usual dose: 150–250 mg daily. LoE:IIIlxvii
Note: Anticholinergic side effects are common and may be exacerbated by
antipsychotics.
OR
 Carbidopa/levodopa, 25/100 mg (1 tablet), oral, 8 hourly.
Acute dystonic reaction:
Usually follows administration of dopamine-antagonistic drug, e.g.
metoclopramide and phenothiazines.
 Biperiden, IM/IV, 2 mg.
o Repeat as necessary.
2019 14.25
OR
Promethazine, deep IM, 25–50 mg.
o In the elderly 25 mg. LoE:III
14.7.3 ESSENTIAL TREMOR

G25.0
GENERAL MEASURES
Exclude and manage alternate causes, such as drugs, thyrotoxicosis and
hyperadrenergic states. Occasionally a patient may present with essential
tremor and an additional neurological condition, which may make the
diagnosis difficult.
MEDICINE TREATMENT
If tremor is severe and interfering with normal daily activity:
 Propranolol, oral,
o Start at 20 mg daily and titrate as needed up to 80 mg 8 hourly.
o Monitor BP. LoE:IIIlxviii
14.7.4 CHOREA
G25.5
DESCRIPTION
Involuntary random, irregular movements.
Aetiology is classified as:
» primary – Huntington’s chorea,; or
» secondary – Sydenham’s chorea, hemiballismus secondary to infarction,
diabetes (hyperglycemia)
MEDICINE TREATMENT
Treat the underlying cause, if relevant.
 Haloperidol, oral, 0.75–5 mg 8–12 hourly (Specialist consultation).
14.8 NEUROPATHY
See section 26.1.4: Management of neuropathic pain
14.9 MYELOPATHY, ACUTE

G95.9
DESCRIPTION
Patients present with a sudden onset of paraparesis, with associated
sensory loss, i.e. a sensory level may be found. Incontinence and autonomic
instability may be present.
2019 14.26
Note: Do cervical and thoracic spine films, with chest X-Ray to exclude
obstructive lesions before performing a lumbar puncture.
REFERRAL
All patients for urgent imaging.
14.10 MULTIPLE SCLEROSIS

G35
DESCRIPTION
A demyelinating disease of the central nervous system, characterised by
relapsing and remitting episodes of unifocal or multifocal neurological
dysfunction. Diagnosis is confirmed by imaging. The CSF may show
oligoclonal bands and raised IgG index.
Recovery between acute flares of illness is common, although a general
stepwise deterioration from baseline is usually found.
Consult with neurologist for diagnosis and treatment.
REFERRAL
All patients.
14.11 MYASTHENIA GRAVIS

G70.0
DESCRIPTION
Consider this in patients with new onset weakness and fatiguability.
particularly involving the eyes and the swallowing muscles.
MEDICINE TREATMENT
Discuss both diagnosis and treatment with a specialist.
 Pyridostigmine, oral, 60 mg 5 times daily. LoE:IIIlxix
Corticosteroids and azathioprine should only be used in consultation with a
specialist.
14.12 OEDEMA, CEREBRAL

DESCRIPTION
Swelling of brain parenchymal tissue, due to vasogenic, cytotoxic and
osmotic causes. Only the vasogenic causes, such as brain tumours and
inflammation, respond to corticosteroids.
2019 14.27
14.12.1 BRAIN OEDEMA DUE TO TUMOURS AND

INFLAMMATION
G93.6
GENERAL MEASURES
Supportive management. See section 14.1.1: Stroke.
MEDICINE TREATMENT
Treat the underlying cause. This is especially important where brain oedema
associated with systemic conditions, such as electrolyte disturbances and
organ failure.
Patients with primary brain tumours or brain metastases should be
considered for definitive treatment of the tumour, which includes surgery
and/or radiotherapy.
 Dexamethasone, IV, 4 mg 6 hourly, initially.
OR
Betamethasone, oral/IV, 4 mg 6 hourly.
o Discontinue if no response has occurred after 48 hours.
o Taper dose according to response and duration of therapy.
14.12.2 BRAIN OEDEMA DUE TO TRAUMATIC INJURY

S06.10-11 + External Cause Code (V,W,X,Y)
GENERAL MEASURES
Refer patient for neurosurgical opinion, if indicated.
Supportive management. See section 14.1.1: Stroke.
Note: DVT prophylaxis with heparin may be contraindicated owing to risk of
increased bleeding.
The following measures should be used in patients with raised intracranial
pressure:
» head elevation and position,
» airway and ventilation control,
» sedation and analgesia,
» control of fever,
» control of hypertension, and
» prevention of seizures.
Currently, no evidence supports the use of hyperventilation in this setting.
MEDICINE TREATMENT
For raised intracranial pressure, pending a definitive neurosurgical
procedure only:
 Mannitol 15–25%, IV, 0.25–1 g/kg administered over 30–60 minutes.
o Monitor neurological response and urine output.
2019 14.28
o Beware of hypovolaemia and electrolyte disturbances, especially

hypokalaemia.
Note: Corticosteroids should not be used in this setting as they have a
harmful effect.
References:
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lxvii Orphenadrine: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University of
Cape Town, 2016.

lxviiiPropranolol: Zesiewicz TA, Elble RJ, Louis ED, Gronseth GS, Ondo WG, Dewey RB Jr, Okun MS, Sullivan KL,
Weiner WJ. Evidence-based guideline update: treatment of essential tremor: report of the Quality Standards
subcommittee of the American Academy of Neurology. Neurology. 2011 Nov 8;77(19):1752-5.
Zesiewicz TA, Kuo SH. Essential tremor. BMJ Clin Evid. 2015 Dec 15;2015. pii: 1206.
Propanolol: Jefferson D, Jenner P, Marsden CD. Relationship between plasma propranolol concentration and relief
of essential tremor.J NeurolNeurosurg Psychiatry. 1979 Sep;42(9):831-7. http://www.ncbi.nlm.nih.gov/pubmed/501384
lxix Pyridostigmine: South African Medicines Formulary,12th Edition. Division of Clinical Pharmacology. University of
Cape Town, 2016.
2019 14.34
CHAPTER 15
MENTAL HEALTH CONDITIONS AND
SUBSTANCE MISUSE
MENTAL HEALTH CONDITIONS
Precepts of the Mental Health Care Act No. 17 of 2002 include:
» All patients with mental illness and/or severe to profound intellectual
disability receive mental health care as either Voluntary, Assisted or
Involuntary Mental Health Care Users.
» All registered medical practitioners, professional nurses, psychologists,
occupational therapists (OTs), and social workers whose training includes
mental health are designated Mental Health Care Practitioners.
» Mental health care practitioners and heads of health establishments at
PHC and Hospital Adults level must be familiar with MHCA Forms 01 –
13A, 14, 17, 22, 25, 26, 27, 48.
» The South African Police Service have an obligation to protect, apprehend,
and assist with transfer of people with mental illness to and between health
establishments.
15.1 AGGRESSIVE DISRUPTIVE BEHAVIOUR IN ADULTS

R45.1/R45.4-8 + code(s) for underlying/comorbid condition(s)
DESCRIPTION
Agitation may escalate to overt aggression and often manifests with
restlessness, pacing, and loud or demanding speech. Aggressive behaviour
includes verbally abusive language, specific verbal threats, intimidating
physical behaviour, and/or actual physical violence to self, others or property.
All agitation and aggression must be considered an emergency and violence
prevented wherever possible.
Multiple causes for aggressive, disruptive behaviour include:
» Physical: acute medical illness, delirium and its causes, epilepsy (pre-,
intra-, and post-ictal), intracerebral lesions, traumatic brain injury.
» Psychiatric: psychosis, mania, agitated depression, neurocognitive
disorders (e.g. dementias, old traumatic brain injury), developmental
disorders (e.g. intellectual disability and autistic spectrum disorder),
severe anxiety.
» Substance misuse: alcohol, cannabis, methaqualone (mandrax)
intoxication or withdrawal; stimulant (cocaine, methamphetamine (tik),
methcaninone (cat)) intoxication; benzodiazepine withdrawal.
» Psychological factors: high levels of impulsivity and antagonism,
hypersensitivity to rejection or insult, poor frustration tolerance, and
2019 15.1
CHAPTER 15 MENTAL HEALTH CONDITIONS AND SUBSTANCE MISUSE
maladaptive coping skills all contribute to aggression and rage.

» In pregnant women: labour, obstetric complications, sepsis, organ failure
as well as substances and mental disorders (See Primary Health Care
STGs and EML, Chapter 6.9: Maternal mental health).
CAUTION
» Do not assume that the aggression is due to the mental illness.
» Known psychiatric and intellectually disabled patients often have
medical conditions, trauma, and substance misuse.
GENERAL MEASURES
» Prepare, anticipate and prevent:
Be aware of high risk patients e.g. those with previous violence, substance
misuse, and State Patients on leave of absence. Have:
- A step-wise protocol to ensure safety of all patients and staff.
- Clear roles for all staff members.
- A triage plan for early signs of aggression.
- Available backup – hospital security and SAPS and EMS.
- A designated calming area – suitable for regular monitoring.
» De-escalate and contain:
- Be calm, confident, kind, and reassuring.
- Maintain a submissive posture with open hands.
- Do NOT turn your back on the patient; avoid direct eye contact.
- Do NOT attempt to reason with the patient.
- Do NOT argue, confront delusions, or touch the patient.
- Set clear limits regarding behaviour.
- Take patient to quiet, calm area – do NOT leave unobserved.
» Examine for delirium, medical and other causes while calming the patient
and after sedation.
» Manual restraint may be necessary to administer medication – this must
be respectful, controlled and kept to a minimum. It should be applied by
personnel of the same sex as the patient.
» Mechanical restraint:
- Only if absolutely necessary to protect the patient and others for as
short a time as possible.
- Document the type, sites and duration of any restraints used.
- 15-minute monitoring: vital signs, the mental state, restraint sites, and
reasons for use.
- A MHCA Form 48 (restraint register) must be completed and submitted
to the Mental Health Review Board.
» Pregnant women
- Never leave unattended.
- Use restraint sparingly, with care, if possible, with mother in a
supported semi-seated position (not supine or prone).
2019 15.2
Aggressive and Disruptive Behaviour in Adults

District Hospital Casualty & Ward guideline
(For PHC & CHC Casualty – see Chapter 15.1 in PHC STGs and EML)
Patient brought in by SAPS or family/neighbour/other?
SAPS Family/neighbour/other
Collect Form 22 from SAPS
Complete Form 01 Accompanying person to await results of clinical
Or collect Form 01 if completed by clinic assessment and complete a Form04
staff
Patient is alert, has clear consciousness and is medically stable?
Yes No
De-escalate & Contain Manage as Delirium (Chapter 20)
Admit as medical/surgical patient
Contained & co-operative?
No Yes
Proceed with medicine treatment Manage main complaint, offer oral sedation
Complete Form 48 if restraint needed Remains co-operative?
No Yes – requires Yes –

admission transient
disturbance
Complete Forms 04, 2 x 05, and 07 to admit as Involuntary

for 72 hour observation or as an Assisted user
Conduct medical / surgical / gynae and pyschiatric evaluation
Contact relatives/ caregivers if not present
Continue sedation in the ward while necessary

Monitor vitals & mental state – every 30 minutes if secluded or restrained
Detox from alcohol / other substances
Institute initial treatment for psychiatric &/or medical condition
Severe behaviour Requires further inpatient psychiatric care –

disturbance & complete 2 x Form 06 and Form 08 Psychiatrically and
uncontainable medically stable
Medically stable
Involuntary Assisted or Voluntary User
Discharge with Form 03 &
Consult specialist User
investigation results to
psychiatric hospital Refer to regional or tertiary
appropriate outpatient care
& transfer with hospital psychiatry unit with
&/or
Form11 and Form 11 and investigation
substance use rehab
investigation results. results
2019 15.3
MEDICINE TREATMENT– Rapid Tranquillisation

The goal of rapid tranquilisation is to calm the patient so that risk to self or
others is minimised and the underlying condition may be managed.
CAUTION
» Rapid tranquillisation may cause cardiovascular collapse, respiratory
depression, acute dystonic reactions, and neuroleptic malignant
syndrome.
» Pregnant women, elderly, intellectually disabled and those with comorbid
medical conditions and/or substance use are at highest risk.
» Late pregnancy: neonatal sedation or extra-pyramidal side effects may
occur.
» Write out single prescriptions and review between each prescription
» Allow at least 30 – 60 minutes between prescriptions.
» An emergency trolley, airway, bag, oxygen and intravenous line must
be available.
LoE:IIIi
» In pregnancy, the frail and elderly, or where respiratory depression is a
concern, use a short-acting benzodiazepine at the lowest dose.
» The safest route of administration of benzodiazepines is oral followed by
IM with the IV route having the highest risk of respiratory depression and
arrest. Use the safest route possible.
» Monitor vital signs closely during and after administration. Use haloperidol
instead of benzodiazepines in patients with respiratory insufficiency.
» Where aggression is clearly caused by psychosis, haloperidol and
promethazine may be used as 1st line treatment and not benzodiazepines.
LoE:IIIii
Offer oral benzodiazepine treatment:
 Benzodiazepines: LoE:IIiii
 Lorazepam, oral, 0.5–2 mg, immediately.
OR LoE:IIIiv
Clonazepam, oral, 0.5–2 mg, immediately.
OR LoE:IIIv
Diazepam, oral, 5–10 mg, immediately.
OR LoE:IIIvi
Midazolam, oral or buccal, 7.5–15 mg, immediately.
LoE:IIIvii
Oral treatment refused, administer parenteral benzodiazepine treatment:

 Lorazepam, IM, 0.5–2 mg, immediately. LoE:IIviii
OR LoE:Iix
Midazolam, IM, 7.5–15 mg immediately.
OR LoE:IIIx
Clonazepam, IM, 0.5–2 mg, immediately.
2019 15.4
Note:
» To avoid inappropriate repeat dosing allow at least 30 minutes for the
oral/IM medication to take effect. LoE:IIIxi
» Repeated IM doses of benzodiazepines may result in
toxicity owing to accumulation.
» Lorazepam IM has slower onset of sedation than midazolam IM (32 vs 18
minutes) and longer duration of sedation (217 vs 82 minutes).
» Clonazepam oral or IM may be used if longer duration of sedation is
required. Onset of action may be 30-60 minutes, time to maximum
concentration is 1-4 hours. Long half-life (18-50 hours) increases risk of
accumulation. Allow at least 12 hours between repeat doses.
LoE:IIIxii
Inadequate response to benzodiazepines (after 30-60 minutes):
 Haloperidol, IM, 2.5–5 mg, immediately.
AND
 Promethazine, deep IM, 25–50 mg.
LoE:IIxiii
Repeat after 30–60 minutes if needed.
Under specialist care in psychiatric wards:

 Zuclopenthixol acetate, IM, 50–150 mg every 2–3 days
(specialist/specialist consultation).
o Maximum dose is 400 mg over a two-week period. LoE:IIIxiv
If alcohol use is suspected:

ADD
 Thiamine, oral, 300 mg immediately and daily for 14 days.
LoE:IIIxv
Monitor the patient:
» Nurse in recovery position – prevent aspiration. Nurse pregnant women in
supported semi-seated position if possible or left lateral position, and not
supine.
» Monitor pulse, respiratory rate, blood pressure, temperature every 5–10
minutes for the first hour, and then every 30 minutes until the patient is
ambulatory. Use pulse oximeter if available.
» Pregnant women: monitor fetal heart rate as well as mother’s vital signs.
» Continue observation once ambulatory: for falls and further injury (especially
elderly and frail), re-emergence of aggression, and to prevent abscondment.
» If patient absconds – request assistance from SAPS with a MHCA Form 25.
Manage acute complications:

» Respiratory depression: if respiratory rate drops to .12 breaths/ minute or
oxygen saturation <90% - give oxygen; be prepared to ventilate.
» Circulatory collapse: See section 20.1: Cardiac arrest in adults.
» Acute dystonia: See the PHC STGs and EML, 2018, section 16.2.1: Extra-
pyramidal side effects.
2019 15.5
» Neuroleptic Malignant Syndrome: See the PHC STGs and EML, 2018,
section 16.2.2: Neuroleptic malignant syndrome.
15.2 ANXIETY AND OBSESSIVE-COMPULSIVE

DISORDERS
F40.0-2/F40.8-9/F41.0-3/F41.8-9/F42.0-9 + (F10.0-F19.9/R45.0-8/Z65.0-5/Z65.8-
9/Z81.0-4/ Z81.8)
DESCRIPTION
Anxiety is an emotional response to a perceived or anticipated stress. It is
diagnosed as a disorder when it is excessive or persistent and impacts daily
functioning. Anxiety disorders often present with medically unexplained
symptoms such as non-cardiac chest pain, abdominal discomfort and neck and
back muscle tension. However, anxiety symptoms may be caused by various
medical conditions. In addition, medical conditions are commonly comorbid with
anxiety disorders; they may exacerbate the symptoms and the anxiety disorder
may worsen the outcome of treatment of the medical condition.
Tobacco, alcohol and other substance use are commonly associated with
anxiety disorders. The substance use may be secondary to the disorder or
causative or both. If caused by a substance, then an Anxiety Disorder due to
the specific substance (F10 – F19) should be diagnosed.
In pregnancy and postnatally, anxiety may impact negatively on the mother’s
coping and use of services and is associated with poor psychological and
neurodevelopmental outcomes in the child (See Primary Health Care STGs
and EML, Chapter 6.9: Maternal mental health).
» Psychological manifestations of anxiety include panicky feelings,

excessive worry, mood changes, irritability, tearfulness, distress, and
difficulty concentrating.
» Physical symptoms include muscle tension, headache, abdominal
cramps, nausea, palpitations, sweating, a choking feeling, shortness of
breath, chest pain, dizziness, numbness, and tingling of the hands and
feet.
» People with intellectual disability may present with aggression,
agitation, and demanding behaviour instead of anxiety.
» Panic attacks are abrupt surges of intense anxiety with prominent
physical symptoms. They may occur in anxiety, mood, and psychotic
disorders, and with alcohol and other substance misuse. They are a
marker of increased severity of the primary disorder and may indicate a
heightened risk of suicide.
» Social phobia (social anxiety disorder) is the fear of social interactions; it
usually starts in adolescence. Distorted thoughts are of negative
evaluation by others. Self-medication with alcohol or other substances is
common and substance intoxication may be the presenting feature.
2019 15.6
» Obsessive thoughts and/or compulsive behaviour are a core feature

of Obsessive Compulsive Disorder but may also occur in other disorders,
particularly tic disorders, autistic spectrum, and psychotic disorders.
Themes of the distorted thoughts and compulsions include hygiene
(cleaning), security, symmetry, sexual and taboo topics, fears of causing
harm, perceived physical defects, hair-pulling or hoarding.
GENERAL MEASURES
Most patients can be treated as outpatients, but some may need to be
admitted for diagnostic clarification, containment in extreme distress, or at
high risk of suicide.
» Maintain patience and an empathic attitude
» Screen for and manage:
- Causative and comorbid medical illness, e.g. thyroid disease,
hyperparathyroidism, phaeochromocytoma, vestibular dysfunctions,
epilepsy, and cardiac conditions, hypertension, COPD, asthma,
inflammatory bowel disease, GORD.
- Substance misuse, e.g. caffeine, nicotine, alcohol, analgesics,
amphetamines and cocaine
- Psychosocial stressors, especially in people with intellectual and
other disabilities.
» Psycho-educate the patient and family (with patient’s permission).
» Refer to local support groups. Provide links to self-help literature, web-
sites or groups, e.g. www.sadag.org
MEDICINE TREATMENT
Indicated where symptoms are interfering with normal functions of daily living.
Where there is concomitant drug/alcohol dependence or comorbid major
depressive episode, an antidepressant may be more appropriate.
» Offer a choice of psychotherapy or medication and monitor response.
» Review every 2–4 weeks for 3 months, then 3–6 monthly.
» Partial response: combine medication with psychotherapy.
» If effective, continue for at least 12 months to prevent relapse.
 SSRI, e.g.:
 Fluoxetine, oral.
o Initiate at 20 mg alternate days for 2 weeks.
o Increase to 20 mg daily after 2–4 weeks.
o Delay dosage increase if increased agitation/panicky LoE:Ixvi
feelings occur.
o If partial response, increase to 40 mg daily.
OR
If fluoxetine is poorly tolerated:
 Alternative SSRI e.g.:
 Citalopram, oral.
o Initiate at 10 mg daily for the 1st week.
2019 15.7
o Then increase to 20 mg daily. LoE:Ixvii

o If partial response, increase to 40 mg daily (not in
cardiac disease or >65 years of age).
CAUTION - SSRIs
SSRIs (e.g. fluoxetine, citalopram) may cause agitation initially.
This typically resolves within 2-4 weeks. LoE:IIIxviii
Ask about suicidal ideation in all patients, particularly adolescents and
young adults (PHC STGs and EML, section 16.7: Suicide risk assessment).
If suicidal ideation present, refer before initiating SSRI.
Once started, monitor closely for clinical worsening, suicidality, or unusual
changes in behaviour. Advise families and caregivers of the need for
close observation and refer as required.
Note: Continue treatment for a minimum of 12 months. Consider slowly
tapering and stopping treatment only if patient has had no/minimal symptoms
and has been able to carry out routine daily activities.
Prolong treatment if:
» Previous episode/s of anxiety (extend treatment to at least 3 years).
» Any of: onset in adolescence, severe anxiety, suicidal attempt, sudden
onset of symptoms, family history of bipolar disorder (extend treatment to
at least 3 years).
» If ≥3 episodes of anxiety (advise lifelong treatment). LoE:IIIxix
For short term use only in severe acute distress:

 Benzodiazepines, e.g.: LoE:IIIxx
 Diazepam, oral, 2.5–5 mg as a single dose.
o Repeat 8 hourly, if required to a maximum of 30 mg daily (in divided
doses).
o Half the dose in the elderly or debilitated.
o Duration of therapy: up to 2 weeks, taper off to zero within 6 weeks
o Commence definitive treatment with psychotherapy/SSRI treatment.
CAUTION - BENZODIAZEPINES
» Associated with cognitive impairment – reversible with short-term use
and irreversible with long-term use.
» Elderly are at risk of over-sedation, falls and hip fractures.
» Dependence may occur after only a few weeks of treatment.
» Prescribe for as short a period of time as possible.
» Warn patient not to drive or operate machinery when used short-term.
» Avoid use in people at high risk of addiction: e.g. personality disorders
and those with previous or other substance misuse.
LoE:IIIxxi
2019 15.8
PREGNANCY AND BREASTFEEDING

» SSRI treatment of depression in pregnancy is associated with improved
symptoms in the mother and better emotional and psychological
development of the child. Benefit is greater with increasing illness severity.
Effect of SSRIs on anxiety in pregnancy is less clear.
» Lack of matched case-control studies mean harms of treatment are
unclear.
» If stable on an SSRI, do not stop – discuss risk/benefit with mother.
» Index presentations: offer counselling, psychotherapy; discuss risk/benefit
of SSRIs.
» Avoid fluoxetine due to long half-life and relatively high concentration in
breastmilk. Consider citalopram as alternative
» All antidepressants: possible increased risk of post-partum
haemorrhage, transient neonatal symptoms (jitteriness, irritability), and
persistent pulmonary hypertension of the newborn.
» Avoid benzodiazepines – some association with neurodevelopmental
delay in the child; neonatal sedation if used late in pregnancy.
LoE:IIIxxii
REFERRAL
» High suicide risk
» Severe symptoms with marked functional impairment
» Co-morbid severe psychiatric or medical conditions
» Poor response to treatment.
2019 15.9
Adapted from the MCPAP for Moms Perinatal Depression Toolkit funded by the Massachusetts
Department of Mental Health. Original Authors: Byatt N., Biebel K., Mittal L., Lundquist R., Freeman M., &
Cohen L., Moore Simas T.
2019 15.10
15.3 MOOD DISORDERS
15.3.1 DEPRESSIVE DISORDERS

F32.0-3/F32.8-9/F33.0-4/F33.8-9/F34.1 + (F10.0-F19.9/R45.0-8/Z65.0-5/Z65.8-9/Z81.0-
4/ Z81.8)
DESCRIPTION
Depressive disorders may occur as single or recurrent episodes (Major or
Minor Depression), or as a chronic, persistent low mood (Dysthymia) or a
combination of the two. Depressive episodes may also occur as part of Bipolar
Disorder, which requires a different treatment strategy.
Depressive disorders cause significant impairment in social and occupational
functioning, and may result in unemployment, poor self-care, neglect of
dependent children, and suicide. They may be comorbid with or secondary to
other medical illness or substance use. Depression impacts negatively on
comorbid conditions, with increased pain, disability and poorer treatment
outcomes.
Depression is characterised by a low mood and/or a reduced capacity to enjoy
life. However, it is often not recognised by the sufferer or clinicians. It may be
regarded as a normal emotional state or it may be unacceptable to the sufferer
due to stigma. Thus, associated symptoms may be the presenting complaint
rather than the low mood. Symptoms may also be masked in the interview
setting. It is important to have a high degree of suspicion and to elicit
symptoms, degree of impaired function, and suicide risk with care.
» In general, insomnia and loss of energy are the most common presenting
complaints. In African cultures, somatic symptoms (bodily aches and
pains) and rumination (‘thinking too much’) may predominate.
» The presence of mood, psychological, and cognitive symptoms help to
differentiate between depression and normal sadness following a loss, or
the loss of appetite and energy associated with a medical condition.
» Psychotic symptoms (delusions, hallucinations, or thought disorder) are
usually mood congruent and indicate marked severity and a high risk to
self or others.
In pregnancy and postnatally, depression is associated with preterm delivery,
low-birth weight babies, poor maternal self-care, impaired mother-infant
engagement, and poor psychological and neurodevelopmental outcomes in
the child. Risk of negative impact is increased with increased severity (See
Primary Health Care STGs and EML, Chapter 6.9: Maternal mental health).
GENERAL MEASURES
» Maintain an empathic and concerned attitude.
» Discuss uncertainty with a specialist at any point in the care pathway.
» Assess severity of the condition and suicide risk. See PHC STGs and EML,
2018 – section 16.7: Suicide risk assessment.
2019 15.11
» Exclude and optimise treatment of underlying and/or comorbid medical

conditions (e.g. hypothyroidism, anaemia, HIV/AIDS, TB, cancers,
diabetes).
» Screen for and manage underlying or comorbid substance use, e.g. nicotine,
alcohol, over the counter analgesics, benzodiazepines.
» Screen for bipolar disorder and comorbid psychiatric disorders – refer for
specialist assessment.
» Explore and address psychosocial stressors:
 Stress management/coping skills – refer for counselling.
 Relationship and family issues – refer for counselling
(www.famsa.org.za). Refer to a social worker if abuse is evident.
» Provide self-help literature, where available, and refer to local support
groups (www.sadag.org)
MEDICINE TREATMENT
» Offer choice of psychotherapy (if available) or medication.
» Antidepressants take 4–6 weeks to achieve their maximum effect. There is
little evidence to support combination medicine treatment.
» Tricyclic antidepressants (TCA) and selective serotonin reuptake inhibitors
(SSRIs) are of equal efficacy.
» Electroconvulsive therapy (ECT) (specialist administered) is indicated under
specific circumstances, e.g. severe depression, in pregnancy
» The choice of therapy is guided by comorbid states, risk of overdose, and
patient response.
CAUTION - ANTIDEPRESSANTS
» SSRIs (e.g. fluoxetine, citalopram) may cause agitation and an increased
suicide risk during the first 2–4 weeks.
» Once started, monitor closely for clinical worsening, suicidality, or unusual
changes in behaviour. Advise families and caregivers of the need for close
observation and refer as required.
» TCAs can be fatal in overdose. Prescription requires a risk assessment of
the patient and others in their household, especially adolescents.
» Avoid TCAs in the elderly and patients with heart disease, urinary
retention, glaucoma, and epilepsy.
» Do not prescribe antidepressants to a patient with bipolar disorder without
consultation, as they may precipitate a manic episode.
» Be aware of interactions between antidepressants and other agents (e.g.
other medicines, St John’s Wort or traditional African medicine).
2019 15.12

» SSRI treatment of depression in pregnancy is associated with improved
symptoms in the mother and better emotional and psychological
development of the child. Benefit is greater with increasing illness severity.
Effect of SSRIs in pregnancy on anxiety is less clear.
» Lack of matched case-control studies mean harms of treatment are unclear.
» If stable on an SSRI, do not stop – discuss risk/benefit with mother.
» Index presentations: offer counselling, psychotherapy; discuss risk/benefit
of SSRIs.
» Avoid fluoxetine due to long half-life and relatively high concentration in
breastmilk. Consider citalopram as alternative.
» All antidepressants: possible increased risk of post-partum haemorrhage,
transient neonatal symptoms (jitteriness, irritability), and persistent
pulmonary hypertension of the newborn.
» Avoid benzodiazepines – some association with neurodevelopmental
delay in the child; neonatal sedation if used late in pregnancy.
LoE:IIIxxiii
 Selective serotonin reuptake inhibitor (SSRI), e.g.:
 Fluoxetine, oral.
o Initiate at 20 mg alternate days for 2–4 weeks.
o Thereafter, increase to 20 mg daily. Delay dosage increase if
agitation/panicky feelings occur.
o Reassess response after 4–6 weeks.
o If partial response: increase to 40 mg daily and/or augment with
psychotherapy.
o If no response: consult with specialist (re-evaluate diagnosis, repeat
general measures, prescribe alternative SSRI, psychotherapy, or ECT).
If fluoxetine is poorly tolerated:

 Alternative SSRI e.g.:
o Initiate at 10 mg daily for the 1st week.
o Then increase to 20 mg daily. LoE:Ixxiv
o If partial response: increase to 40 mg daily (except in
cardiac disease and >65 years) and/or augment with psychotherapy.
o If no response: consult with specialist (re-evaluate diagnosis, repeat
If a sedating antidepressant is required:

 Amitriptyline, oral, at bedtime.
o Initial dose: 25 mg per day.
o Increase by 25 mg per day at 3–5 day intervals.
o Maximum dose: 150 mg per day.
o If no response: discuss with specialist (re-evaluate diagnosis, repeat
LoE:IIIxxv
2019 15.13
Treatment duration
Continue for a minimum of 9 months. Consider stopping only if patient has
had no/minimal symptoms and can carry out routine daily activities. Taper
medicine slowly to avoid discontinuation symptoms; reinstitute if there is a
recurrence.
Prolong treatment if:
» Concomitant generalised anxiety disorder (extend treatment to at least 1
year).
» Previous episode/s of depression (extend treatment to at least 3 years).
» Any of: severe depression, suicidal attempt, sudden onset of symptoms,
family history of bipolar disorder (extend treatment to at least 3 years).
» If ≥3 episodes of depression advise lifelong treatment. LoE:IIIxxvi
REFERRAL
» Inadequate response to treatment.
» High suicide risk.
» Psychotic features.
15.3.2 BIPOLAR AND RELATED DISORDERS

F30.0-2/F30.8-9/F31.0-9/F34.0/F34.8-9/F38.0/F39/F06.3 + (F10.0-F19.9/R45.0-
8/Z65.0-5/Z65.8-9/Z81.0-4/ Z81.8)
DESCRIPTION
Bipolar disorder (BD) is a heterogenous illness, with high overlap in genetic risk
with depression and schizophrenia. Usually follows a chronic, relapsing course,
commonly starting in youth. The goal of care is euthymia and optimal
functioning according to the person’s ability.
BD may present with:

» an episode of depression, hypomania, mania or mixed mood symptoms
» psychosis
» treatment resistant depression and/or anxiety
» consequences of disturbed behaviour and/or comorbid substance use
» depression in women; men more likely with disruptive behaviour
Diagnostic requirements include, over the lifetime course:

» Bipolar I disorder (BD I): an episode of mania
» Bipolar II disorder (BD II): an episode of hypomania and of depression.
» Other specified BD (BD OS): symptoms of BD plus clinical distress and/or
functional impairment but full DSM criteria are not met.
» BD due to another medical condition: direct physiological cause for the
bipolar symptoms from another illness, e.g. right-sided cortical or sub-
cortical lesions.
In pregnancy and postnatally, bipolar disorder is associated with pre-

eclampsia, preterm delivery, and low-birth weight babies. Risk of relapse is
2019 15.14
high, especially postpartum. Psychotic episodes may be dangerous to mother,

baby, or others (See Primary Health Care STGs and EML, Chapter 6.9:
Maternal mental health).
GENERAL MEASURES
Assess and manage in consultation with a psychiatrist.
Risk to self and others is high in BD and unpredictable – repeated risk
assessments and a biopsychosocial approach to care is recommended.
Acute management
» Mania, severe depression, and psychosis require urgent hospitalisation in
a psychiatric unit, often as an Assisted or Involuntary MHCU.
» Investigate for causative medical conditions, medications, substances.
» Optimise management of comorbid medical illness and substance use.
» Stabilise the immediate mood; electroconvulsive therapy may be required.
» Commence long-term treatment strategy.
» Avoid premature discharge and ensure continuity of care post-discharge.
Long-term management
» Individualise management according to course of illness, cognitive
functioning, insight and judgement, and social circumstances.
» Assertive nursing with adherence monitoring is required.
» Screen for and manage comorbid medical illness (thyroid disease,
HIV/AIDS, cardiovascular and pulmonary disease, epilepsy, diabetes)
» Screen for and manage substance use.
» Psycho-educate patient, family and carers on the nature of the illness,
need for continued treatment, how to self-monitor, early signs of relapse,
need for structure and routine.
» Refer to support groups e.g. www.SADAG.org and www.SAFMH.org.za
» Delay important decisions until full recovery from an acute episode; a
custodian/ curatorship/ power of attorney may be required.
» Refer to social worker for placement in a residential home, day care or
sheltered employment/workshop as needed.
Women in reproductive age-group (See Primary Health Care STGs and

EML, Chapter 6.9: Maternal mental health).
» Advise family planning – psycho-educate re need to plan pregnancy and
comply with antenatal care.
» Manage pregnancy and postpartum period as high-risk for adverse events.
» Select treatment options which are relatively safe in pregnancy.
MEDICINE TREATMENT
Treatment choice depends on course of illness, gender, comorbid medical,
substance use, and psychiatric conditions, and risk of non-adherence. Acute
treatment should incorporate a long-term strategy. Combinations of medicines
may be required, particularly in depression. See algorithms below.
2019 15.15
Lithium is first-line option for long-term treatment:

» Response takes ± 1 week in mania and 6–8 weeks in depression
» Prevents manic episodes by up to 40-50% and depressive episodes by
up to 20-30% and reduces aggression, self-harm, and suicide.
 Lithium, oral, usual dose range 200–800 mg at night.
o Pre-treatment: check eGFR, TFTs, calcium, and ECG in patients with
cardiovascular risk factors. Proceed if eGFR, ECG normal and any
thyroid or parathyroid disease is treated.
o Start with 400 mg (200 mg in elderly or high risk for renal disease).
o Trough (12 hours after night dose) plasma level after 5 days, then 7
days after each dose change, then at 1 month and 3 months.
o Lithium has a narrow therapeutic window. The therapeutic range is 0.8–
1.0 mmol/L in acute mania, 0.6–0.8 mmol/l for prevention of mania and
0.4–0.8 mmol/l for prevention of depressive relapse.
o Monitor lithium and eGFR 6-monthly (3-monthly in elderly or medical
comorbidity); TSH and calcium annually.
CAUTION - LITHIUM
» Abrupt discontinuation may precipitate mania – taper slowly over 4 weeks.
» Adverse effects include nephrogenic diabetes insipidus, interstitial nephritis,
chronic kidney disease; hypothyroidism; hyperparathyroidism; tremor.
» Toxicity occurs with levels >1.2 mmol/l (results in anorexia, nausea,
diarrhoea, muscle weakness, drowsiness, ataxia, disorientation, seizures,
coma and death. Manage as for lithium poisoning: section 19.9.2.
» Risk of toxicity increased with e.g. change to a low salt diet, dehydration,
drug-drug interactions (diuretics, ACE-inhibitors, NSAIDs).
» Therapeutic drug monitoring is essential when using lithium.
» Clinical toxicity may occur even within the therapeutic range.
2019 15.16

Valproate:
» Contraindicated due to high teratogenic risk and adverse
neurodevelopmental outcomes with any pregnancy exposure.
» If no alternative, the acknowledgment of risk form must be signed
https://www.sahpra.org.za/documents/f150bf3f6.28_Valproate_Annual_R
isk_Acknowledgement_Form_Dec18_v1.pdf
» If already on valproate: cross-titrate to an alternative medication if possible
(consult specialist if required).
» Not recommended in breastfeeding as associated with adverse
neurodevelopmental outcomes. LoE:IIIxxvii
Lithium:
» 1st trimester exposure associated with increased risk of congenital
anomalies.
» Fetal anomaly ultrasound at 18–22 weeks gestation.
» Adjust dose with physiological changes of pregnancy: monitor levels
monthly, then weekly after 36 weeks.
» Neonatal complications: goitre, nephrogenic diabetes insipidus, cardiac
arrhythmias, cardiac failure, hypotonia, and lethargy.
» Excreted in breast milk, risk to the infant is unknown but toxicity may occur:
breastfeeding is not recommended. LoE:IIIxxviii
Lamotrigine: Increased hepatic clearance in pregnancy, returns to normal

post-partum; adjust dose according to clinical response. May cause a rash
in breastfed infant. LoE:IIIxxix
Antipsychotics: Considered safest, particularly quetiapine. Increased risk

of gestational diabetes and obesity (highest risk with olanzapine,
clozapine).
Clozapine is not recommended due to risk of agranulocytosis.
LoE:IIIxxx
Benzodiazepines: Avoid in pregnancy.
Use only very short-term for severe distress. LoE:IIIxxxi
 Quetiapine, oral, usual dose range 100–300 mg at night (specialist

prescribed).
o Titrate to clinical effect, e.g.: Day 1: 50 mg. Day 2: 100 mg. Day 3: 200
mg. Day 4: 400 mg.
o In the elderly and patients with hepatic impairment: Start with 25 mg and
titrate up more slowly according to clinical effect.
LoE:IIIxxxii
2019 15.17
LoE:IIxxxiii
2019 15.18
LoE:IIxxxiv
REFERRAL
All patients to be managed in consultation with a psychiatrist, refer as advised,
particularly if:
» High risk to self or others at any time.
2019 15.19
» Rapid cycling (repeated episodes despite treatment).

» Poor response to treatment with persistent depressive, manic, or mixed
symptoms.
15.4 TRAUMA AND STRESS-RELATED DISORDERS

F43.0/F43.1
DESCRIPTION
Acute stress and post-traumatic stress disorder arise in response to stressful
events. The patient should have experienced the event as life threatening or
as a physical threat to themselves or others, at which time they felt fear and
helplessness.
A range of symptoms are associated with both of these conditions and
include:
» Re-experiencing of the event, e.g. flashbacks, dreams.
» Avoidance of situations associated with the event.
» Features of anxiety or increased arousal, e.g. hypervigilance, heightened
startle response and insomnia.
The conditions are symptomatically similar but differ with regard to the
duration and time of onset of symptoms. The symptoms of acute stress
disorder arise within 4 weeks of the event and last up to 4 weeks, whereas the
symptoms of post-traumatic stress disorder last longer than 4 weeks, and may
arise more than 4 weeks after the traumatic incident.
Child abuse and trauma histories (including traumatic birth experience) and
trauma experiences within pregnancy are associated with gestational and
postnatal PTSD.
GENERAL MEASURES
Reassurance and support of patient and family.
Psychotherapy, usually of a supportive/cognitive-behavioural nature.
Trauma debriefing is not routinely recommended.
MEDICINE TREATMENT
Acute stress disorder:
Benzodiazepines may be useful in the immediate period following the
traumatic event.
Prolonged use >1 week may be detrimental to adaptation, leading to higher
rates of post-traumatic stress disorder.
For acute anxiety or agitation:
 Clonazepam, oral 0.5–2 mg in divided doses. LoE:IIIxxxv
For sleep disturbance: See section 15.13: Insomnia.
2019 15.20
Post-traumatic stress-disorder:
 Selective serotonin reuptake inhibitors, e.g.:
 Citalopram, oral, initial dose 20 mg daily. LoE:IIIxxxvi
OR
Fluoxetine, oral, initial dose 20 mg in the morning.
o A response to SSRI should be expected after 4–6 weeks.

o If there is no or partial response after 4–8 weeks, increase SSRI dose to
40 mg, if well tolerated.
o An adequate trial of treatment is 8–12 weeks, before an alternative
treatment should be considered.
REFERRAL
» Persistent symptoms.
» Inadequate response to treatment.
» Comorbid conditions.
15.5 PSYCHOTIC DISORDERS

DESCRIPTION
Psychosis is characterised by a loss of contact with reality. Psychotic
disorders may present with:
» Delusions: Fixed beliefs, manifest as disturbed speech content with e.g.
persecutory, referential, grandiose, religiose, erotic, bizarre themes.
» Hallucinations: Perceptual disturbances, e.g. auditory hallucinations,
which are heard as voices distinct from the patients’ thoughts.
» Disorganised thinking: Manifests as disordered flow of speech which
impairs communication.
» Grossly disorganised or abnormal motor behavior (including catatonia).
» Negative symptoms: reduced emotional expression, avolition, lack of
speech, anhedonia, lack of social interaction.
Psychotic symptoms may occur in other psychiatric conditions (e.g. bipolar
mania, major depression), medical conditions (e.g. certain types of epilepsy),
or substance use (intoxication or withdrawal).
Psychosis is often accompanied by a lack of insight into the symptoms and
poor judgement. The risk to self and others must always be assessed. It may
be necessary to treat as an Assisted or Involuntary User under the MHCA.
2019 15.21
15.5.1 ACUTE AND TRANSIENT PSYCHOTIC

DISORDERS
F23.0-F23.9 + (F10.0-F19.9/R45.0-8/Z65.0-5/Z65.8-9/Z81.0-4/ Z81.8)
DESCRIPTION
Sudden onset of ≥ 1 psychotic symptom (usually delusions, hallucinations or
disorganised thinking) which resolve spontaneously, usually within 1 month,
with a full return to premorbid social or occupational functioning. Stressful
events may precede the psychotic episode. Within 3 years, 40-50% will have
a recurrent episode or develop schizophrenia or bipolar disorder.
LoE:IIIxxxvii
GENERAL MEASURES
Assess and manage in consultation with a psychiatrist.
» Assess risk to self and others.
» Exclude and treat medical causes of psychotic symptoms (e.g. delirium,
dementia, epilepsy).
» Exclude and manage substance use (e.g. cannabis, alcohol,
amphetamines, and cocaine).
» Assess and treat other mental illness, e.g. anxiety disorders (section 15.2)
and trauma and stress-related disorders (section 15.4).
» Address psycho-social stressors – refer to social worker, psychologist,
counselling services
» Active follow-up is needed: commence treatment for schizophrenia or
bipolar disorder if these become evident. (See sections 15.3.2: Bipolar
Disorder and 15.6.2: Schizophrenia).
MEDICINE TREATMENT
Manage severe aggressive or disruptive behavior (see section 15.1:
Aggressive disruptive behaviour in adults).
Treat according to underlying cause.
15.5.2 SCHIZOPHRENIA SPECTRUM DISORDERS

F20-F20.9; F22.0-22.9; F25.0-25.9 + (F10.0-F19.9/R45.0-8/Z65.0-5/Z65.8-9/Z81.0-4/
Z81.8)
DESCRIPTION
Schizophrenia is characterised by psychotic episodes which are severe,
persistent, and accompanied by a marked deterioration in personal, social,
and occupational functioning.
Whilst the presentation may be acute, typically the illness has a chronic,
relapsing course with progressive cognitive and functional decline. Onset is
usually in youth. Prognosis is worsened with delay in initial treatment,
repeated episodes, and comorbid substance use. Comorbid metabolic
syndrome and cardiovascular disease are common.
2019 15.22
GENERAL MEASURES
Manage all patients in consultation with a psychiatrist.
Diagnostic certainty requires careful observation and re-evaluation over time.
Acute psychosis
» Assess risk to self and others.
» Clarify diagnosis.
» Manage within a multi-disciplinary team.
» Use shared decision-making in treatment process.
» Involve family and carers with patient’s permission unless risk to self/
others necessitates a breach of confidentiality.
» Provide psychoeducation to patient, family, and carers on the nature of the
illness, need for continued treatment, how to self-monitor, early signs of
relapse, and need for structure and routine.
Maintenance treatment
» Antipsychotic maintenance treatment is needed to prevent relapse.
» Community-based nursing with adherence support, repeated risk
assessment, and shared decision-making is required.
» Monitor psychiatric symptoms (use rating scales, e.g. BPRS or PANSS)
» Monitor extra-pyramidal side effects, weight, BP and glucose 6-monthly
» Adjust treatment according to response, adverse effects, and comorbidity.
» Provide lifestyle and dietary education; encourage exercise
» Treat comorbid mood disorders (section 15.6)
» Treat comorbid hypertension (section 3.6), diabetes mellitus (section 8.5),
and other medical conditions as needed
» Manage substance use – refer for rehab (SANCA, Social Development)
» Poor adherence with recurrent episodes:
- Check reasons – illness, medication, patient factors.
- Poor previous response/ tolerability – change to alternative
antipsychotic (olanzapine or clozapine).
- Poor insight - try depot antipsychotic – start with test dose (half initial
dose in algorithm below).
- Address psychosocial factors, substance use.
» Refer to social worker for placement in a residential home, day care or
sheltered employment/workshop as needed.
Women in reproductive age-group (See Primary Health Care STGs and

EML, Chapter 6.9: Maternal mental health).
» Advise family planning – psycho-educate regarding need to plan
pregnancy and comply with antenatal care
» If a parent – support childcare; refer to social worker if impaired.
» Risk of psychotic relapse is high in pregnancy and postpartum including
the first year post-delivery.
» Continue antipsychotic treatment in pregnancy. All are considered safe
except clozapine – only use if benefit outweighs risk.
2019 15.23
MEDICINE TREATMENT
Acute psychotic episode
» Treat severe aggression and disturbed behaviour as in Section 15.1:
Aggressive disruptive behaviour in adults.
» Initiate treatment with a view to long-term management.
» High risk of tardive dyskinesia (age >50 years, female sex, prominent
mood symptoms, cognitive or neurological disturbance e.g. intellectual
disability, autistic spectrum, HIV-positive): avoid haloperidol and
antiparkinsonian medicines; use chlorpromazine, risperidone or
olanzapine at lowest doses possible. LoE:IIIxxxviii
Initiate treatment:
 Haloperidol, oral.
o Initial dose: 0.75–1.5 mg daily, increasing to 5 mg daily. LoE:IIIxxxix
If good response/ tolerability to haloperidol, or patients’ preference:

 Depot antipsychotic, e.g:
 Flupenthixol decanoate, IM, 10–40 mg every 4 weeks.
OR LoE:IIIxl
Zuclopenthixol decanoate, IM, 200–400 mg every 4
weeks.
LoE:IIIxli
If poor response/ poorly tolerated/ high risk of tardive
dyskinesia/ extra-pyramidal side effects:
 Risperidone, oral
o Initial dose: 2–4 mg at night. LoE:Ixlii
o Assess efficacy after 4–6 weeks:
- If a partial response is noted, optimise the dosage.
- If no response is noted, switch treatment.
OR
 Chlorpromazine, oral, 75–300 mg daily in divided doses. LoE:IIIxliii
If poor response/tolerability to haloperidol, risperidone or chlorpromazine:

 Olanzapine, oral (specialist initiated).
o Initial dose: 5 mg at night, increase to 10 mg at night.
o Maximum dose: 20 mg at night. LoE:Ixliv
If poor response/ tolerability to olanzapine:

3
 Clozapine, oral (specialist initiated, preferably as inpatient):

o Initial dose: 12.5–25 mg at night.
o Usual dose: 200–450 mg per day in divided doses.
o Maximum dose: 900 mg/day in divided doses. LoE:IIIxlv
2019 15.24
CAUTION - CLOZAPINE
» May cause neutropenia (3% of cases) and agranulocytosis (0.8% of
cases):
- Pre-treatment: Baseline normal white cell count and absolute neutrophil
count.
- Monitor absolute neutrophil count regularly.
- Withdraw clozapine and review medication if neutrophils <1.0 x109/L
(general population).
» Myocarditis: highest risk in first two months of treatment. Monitor pulse,
blood pressure, temperature; advise patient to report any palpitations,
shortness of breath, chest pain, fever immediately.
» Seizures: risk increased at doses >450 mg/day.
Manage as for epilepsy, section 14.4: Epilepsy. Lamotrigine preferable
as it is weight neutral and does not interfere with clozapine metabolism.
Avoid carbamazepine because of possible myelosuppression and
enzyme induction.
» Constipation: avoid anticholinergics; may require laxatives; prolonged
discomfort may indicate intestinal obstruction.
» Weight gain, diabetes, dyslipidaemia: Manage as per PHC STGs and
EML, section 16.6: Psychiatric patients general monitoring and care;
Prevention of ischaemic heart disease and atherosclerosis (section 3.1),
and Type 2 diabetes mellitus (section 8.5.1).
LoE:IIIxlvi
OR
Refer to tertiary and quaternary level care for amisulpiride if LoE:IIIxlvii
excessive weight gain and/or type 2 diabetes, or persistent
negative symptoms.
LoE:IIIxlviii
ADVERSE EFFECTS
Extrapyramidal adverse effects
Note: Anticholinergic medicines (e.g. orphenadrine) should not be added
prophylactically to antipsychotics to prevent extrapyramidal side effects.
Acute dystonia: See the PHC STGs and EML, section 16.2.1: Extra-
pyramidal side effects.
Parkinsonism:
 Orphenadrine, oral, 50–150 mg daily according to individual response
o Usual dose: 50 mg 8 hourly.
o Use with caution in the elderly as it may cause confusion and urinary
retention.
o Review antipsychotic treatment, and stop orphenadrine if medicine
2019 15.25
changed. LoE:IIIxlix
Akathisia (a subjective unpleasant state of inner restlessness where there is

a strong desire or compulsion to move):
 Propranolol, oral,
o Start at 20 mg daily and titrate as needed up to 80 mg LoE:IIl
8 hourly.
o Monitor pulse and blood pressure.
Neuroleptic Malignant Syndrome:

See the PHC STGs and EML, section 16.2.2: Neuroleptic malignant
syndrome.
REFERRAL
All patients to be managed in consultation with a psychiatrist, refer as
advised, particularly if:
» High risk to self or others at any time.
» If diagnosis is uncertain.
» Poor response to treatment.
15.6 INSOMNIA
G47.0/G47.9
DESCRIPTION
Insomnia may be an independent disorder, or associated with comorbid
conditions. Insomnia may persist despite successful treatment of the
comorbidity, and may necessitate separate treatment.
Patients presenting with insomnia may complain of difficulty falling asleep,
frequent waking during the night, early-morning wakening and daytime
sleepiness.
GENERAL MEASURES
» Treat the medical condition, psychiatric illness, substance use disorder or
sleep disorder that may be precipitating or exacerbating the insomnia, if
present.
» All patients should receive basic behavioural counselling about sleep hygiene
and stimulus control as first step of treatment.
» Cognitive behavioural therapy is the treatment of choice.
MEDICINE TREATMENT
If medication is needed:
» Use the lowest effective dose.
» Use intermittent dosing if possible (alternate night or less).
2019 15.26
Sleep hygiene and stimulus control:

» Maintain a regular sleep cycle (same time wake up in the morning, including
week-ends).
» Stimulus control:
- Keeping the room quiet, dark and at a comfortable temperature.
- Using the bed and bedroom only for sleeping (and sex).
» Limit intake of caffeine, nicotine, and alcohol, especially before bedtime.
» Eating a light snack before bedtime, but not a large meal late at night.
» Sleep restriction: avoiding daytime naps.
» Increasing daily exercise (not late in the evening).
» Using anxiety management or relaxation techniques.
» Go to bed only when tired. Sleep as much as needed to feel refreshed, not
longer.
» If unable to sleep for more than 15–20 minutes, get out of bed and engage
in a non-stimulating activity until tired (e.g. listen to soft music, read).
If medication is needed to treat the insomnia:

 Short-acting benzodiazepines, e.g.:
 Oxazepam, oral 15–30 mg at night.
Short-term use of benzodiazepines of 14 days is recommended, as long-
term use is often associated with dependence.
LoE:Ili
REFERRAL
Patients with chronic insomnia.
15.7 DISCONTINUATION SYMPTOMS OF SEROTONIN

REUPTAKE INHIBITORS
Discontinuation symptoms are experienced due to receptor adaptation or
receptor rebound after stopping of antidepressants. It can be avoided or
reduced by slowly tapering the drug over at least 4 weeks.
Symptoms include flu-like symptoms, ‘shock-like” sensations, dizziness
exacerbated by movement, insomnia, vivid dreaming and irritability, problems
with concentration, and memory or movement disorders.
It is managed by reintroduction of the SSRI and slower tapering of the dose.
Note: Fluoxetine seldom causes discontinuation symptoms because of its
long half-life.
2019 15.27
SUBSTANCE MISUSE
DESCRIPTION
Substance misuse is a general term which encompasses a range of
substance use patterns including:
» Hazardous use – a risk of harmful consequences (social, mental, physical)
to the user or others;
» Harmful use – the substance use causes harm to the user or others, may
be continuous or episodic (e.g. interpersonal violence after an alcohol
binge).
» Dependence - characterised by a loss of self-regulation, repeated use
despite harm, substance-induced mental illness, and withdrawal
syndromes.
People with substance misuse present for related or comorbid health
problems e.g. to emergency rooms, infectious disease services (e.g. TB, HIV,
Hepatitis, etc.), antenatal clinics, STD services, and mental health services.
Early identification and intervention of the substance use is advised to prevent
further harm or dependence.
GENERAL MEASURES
» Screen for substance use disorders as a routine part of patient
assessment, e.g. with WHO ASSISTlii. The outcome of the screen should
determine the level of intervention that is recommended– e.g. brief advice,
a brief intervention (ASSIST linked brief interventionliii) or referral to a local
substance treatment programme (through a social worker or a registered
NGO).
» Elective detoxification: plan in conjunction with a comprehensive
substance treatment plan, co-ordinated by the Department of Social
Development.
» Unplanned withdrawal: may occur during treatment for another medical
condition or may be the presenting complaint. Provide brief intervention
counselling and refer to a substance treatment programme.
» Injection drug use: counsel on harm reduction measures and refer to
needle and syringe programmes, e.g. StepUp projectliv (TB HIV Care),
OUT, Anovalv and COSUPlvi.
REFERRAL
» All patients treated for substance withdrawal should be referred to Social
Services and/or a rehabilitation service for management of their substance
use and aftercare.
» Discuss those with comorbid severe mental disorders services with a
psychiatrist; refer to specialist dual diagnosis services where available.
2019 15.28
15.8 ALCOHOL
F10.3-4
GENERAL MEASURES
The following patients should be admitted for detoxification:
» past history of convulsions
» past history of psychosis
» suicidal ideation
» significant medical comorbidity such as heart failure and liver disease
» inadequate support at home
» history of withdrawal delirium
» >60 years of age
» pregnancy
» cognitive impairment
» previous failed community detoxification attempts
MEDICINE TREATMENT
Alcohol detoxification may be managed on an outpatient basis in most
patients.
 Thiamine, oral, 300 mg daily for 14 days.
AND LoE:IIIlvii
 Diazepam, oral, 10 mg immediately.
o Then 5 mg 6 hourly for 3 days.
o Then 5 mg 12 hourly for 2 days.
o Then stop.
o Higher doses may be needed in individual patients.
15.8.1 ALCOHOL WITHDRAWAL DELIRIUM (DELIRIUM

TREMENS)
F10.4
DESCRIPTION
Delirium typically occurs 2–3 days following cessation of prolonged alcohol
intake, reaching a peak at around 5 days. However, some withdrawal
symptoms, such as tremor, may start within 12 hours.
Typical clinical features include:
» visual hallucinations,
» delusions,
» disorientation, fluctuating level of consciousness,
» agitation,
» tonic-clonic seizures – these do not generally need long term
anticonvulsant therapy,
» tachycardia, and
» hypertension.
2019 15.29
It is important to consider alternative diagnoses, especially true in cases with

an atypical presentation.
Similar symptoms may occur following withdrawal from other sedative-
hypnotic agents.
Mortality varies from 1–5%.
GENERAL MEASURES
» See section 20.8: Delirium with perceptual disturbances.
» Cardiac monitoring and oximetry should be used when administering large
doses of benzodiazepines.
» Assess for infections and other comorbid conditions.
» Ensure adequate hydration. Overhydration is a common error made in this
setting.
» Correct abnormalities of electrolytes.
» Nutritional support.
» Consider referring appropriate patients to a rehabilitation programme after
recovery from delirium tremens.
MEDICINE TREATMENT
Administer medicine doses according to severity of symptoms. These patients
may require high doses of benzodiazepines because of hepatic enzyme
induction.
 Benzodiazepines, e.g.:
 Diazepam, slow IV, 10 mg (Not IM).
o Repeat dose after 5–10 minutes if required.
o If this dose is not sufficient, use 10 mg every 5–10 minutes for another
1–2 doses.
o If patient is not yet sedated, continue with doses of 20 mg until this
occurs. Usual initial dose is 10–20 mg, but up to 60 mg is occasionally
required.
OR
Where intravenous access is not possible:
 Clonazepam, IM, 2 mg as a single dose.
o If no response, repeat dose after 60 minutes until patient is sedated.
o Repeat dose regularly to maintain mild sedation.
LoE:III
OR
Lorazepam, IM, 1–4 mg every 30–60 minutes until patient is sedated.
o Repeat dose regularly to maintain mild sedation. LoE:III
Once patient is sedated, i.e. light somnolence, maintain mild sedation with:
 Diazepam, oral, 5–20 mg.
o Repeat dose regularly to maintain mild sedation. LoE:III
2019 15.30
CAUTION
Benzodiazepines, especially diazepam IV, can cause respiratory depression.
Monitor patients closely as benzodiazepines can exacerbate an abnormal
mental state or mask important neurological signs of deterioration.
See the note regarding benzodiazepines in section 15.2: Confusional
states/delirium.
Neuroleptic medicines, e.g. haloperidol, are associated with a reduced seizure
threshold. Consider only for severe agitation and restlessness persisting
after adequate doses of benzodiazepines.
 Haloperidol, IV/IM, 0.5–5 mg.

o Repeat after 4–8 hours as required to a maximum of 20 mg daily.
Once patient has responded and is able to take oral medication:
 Haloperidol, oral, 0.75–5 mg 4–8 hourly.
LoE:IIIlviii
When administering glucose-containing fluids:
 Thiamine, oral/IM, 300 mg daily.
15.9 OPIATE (E.G. HEROIN, UNGA, WHOONGA, NYAOPE)

WITHDRAWAL
F11.2
DESCRIPTION
Opioid withdrawal is generally poorly tolerated, but not dangerous, except in
very frail debilitated patients or during pregnancy, with an increased risk of
miscarriage in the first trimester and of preterm delivery in the third trimester.
Signs and symptoms of opiate intoxication:
» Pinpoint pupils » Drowsiness
» Clammy skin » Euphoria
» Respiratory depression » Hallucinations
Signs and symptoms of opiate withdrawal:
» Nausea / vomiting » Myalgia
» Gooseflesh » Diarrhoea
» Abdominal cramps » Restlessness / agitation
» Rhinorrhoea and lacrimation
GENERAL MEASURES:
» The identification and evidence-based management of opioid dependence
among patients who are admitted to hospital will increase their likelihood
of completing their primary admission-related treatment. Sub-optimal
management of opioid withdrawal will increase the likelihood of
2019 15.31
absconding from hospital.

» It is extremely important to counsel patients managed for opioid withdrawal
upon discharge. Patients’ opioid tolerance will be reduced after the down-
tapering of methadone (or similar medication) during hospital stay. Upon
discharge, patients should be advised to use opioids with caution due to
their increased risk of accidental overdose. Opioid related overdose
deaths must be prevented.
» Special considerations apply during pregnancy, consult an expert.
» Concomitant withdrawal from opioids and other “downer” drugs, like
benzodiazepines or alcohol may complicate withdrawal, consult an expert.
MEDICINE TREATMENT
Monitor for objective signs of withdrawal using a rating scale like the
objective opioid withdrawal scale (OOWS)
https://medicine.yale.edu/sbirt/OOWS_251773_284_5_v1.pdf
LoE:IIIlix
Mild withdrawal (OOWS <4)
May be managed on an outpatient basis.
Symptomatic treatment
 Diazepam, oral, 5–20 mg/day in divided doses.
o Taper off over 5–7 days.
For stomach cramps:
 Hyoscine butylbromide, oral, 20 mg 8 hourly as required.
For headaches:
o Maximum dose: 15 mg/kg/dose. LoE:III
For muscle pains:
 NSAID, e.g.:
 Ibuprofen, oral 400 mg 8 hourly, with meals, as required.
LoE:III
For diarrhoea:
 Loperamide, oral, 4 mg immediately.
o Then 2 mg after each loose stool.
o Maximum dose: 16 mg in 24 hours.
Moderate to severe withdrawal (OOWS ≥4)

Hospitalise patient.
Opioid assisted withdrawal

» Goal is to safely alleviate withdrawal symptoms without causing intoxication
or overdose.
» Symptomatic medication listed above may be used to reduce methadone
need.
2019 15.32
Day 1:
 Wait for early evidence of withdrawal (OOWS ≥4)
 Methadone, oral, 5–10 mg.
o If symptoms are still present after 2–-4 hours, give another 5–10 mg.
o Repeat until objective withdrawal symptoms are adequately managed
(OOWS <4).
o The total 24-hour dose should not be more than 30 mg. Consult a
person experienced in opioid withdrawal if >30 mg/day is required.
Day 2:
 Methadone, oral.
o Repeat total dose of day 1 as a single or 2 divided doses.
o Monitor for on-going signs and symptoms of withdrawal.
o If the signs and symptoms of withdrawal are still present on day 2, top-
up doses of 5 mg may be given at 2–4 hourly intervals with a total daily
dose of up to 30 mg. Consult a person experienced in opioid withdrawal
if symptoms not controlled on 30 mg/day.
Day 3 onwards:
 Methadone, oral.
o Repeat total dose of day 2 if top-ups were needed and begin reductions
on day 4.
o If no top-ups required on day 2 and withdrawal symptoms are
adequately controlled, begin dose reduction.
o Decrease dose by 10–20% per day over a period of 3–10 days.
o The withdrawal regimen may be shortened, if the patient’s withdrawal
symptoms allow it.
LoE:IIIlx
If methadone is unavailable:
 Tramadol, oral, 200 mg 12 hourly for 14 days may attenuate withdrawal
symptoms.
LoE:IIlxi
Opioid poisoning
See section: 19.5.3. Opioid poisoning.
REFERRAL
» Patients with an opioid use disorder should be offered a referral to access
opioid substitution therapy and/or other evidence-based treatment and
support.
» Patients identified with current/ recent history of injecting drug use should
be provided with sterile injecting equipment (1 ml insulin needles and
alcohol swabs) upon discharge from hospital, as well as a referral to a
community- based needle and syringe programme.
2019 15.33
15.10 STIMULANT WITHDRAWAL, INCLUDING COCAINE

AND AMPHETAMINE TYPE STIMULANTS (E.G.
METHAMPHETAMINE/ TIK, METHCATHINONE/CAT)
F14.2
GENERAL MEASURES
These patients usually do not require admission.
Beware of depression and assess suicide risk.
Assess and monitor for psychosis.
MEDICINE TREATMENT
No substitute medication available for detoxification.
For severe anxiety, irritability and insomnia:
 Benzodiazepines, short-term, e.g.:
 Diazepam, oral, 5–10 mg 8 hourly for 5–7 days.
15.11 METHAQUALONE (MANDRAX/WHITEPIPE)

WITHDRAWAL
F19.4/F19.9
Withdrawal can be dangerous and may lead to seizures or delirium.

If withdrawal is symptomatic:
 Diazepam, oral, 5 mg 8 hourly.
o Reduce over 3–5 days depending on clinical response.
15.12 CANNABIS WITHDRAWAL

F12.2
Withdrawal is rarely dangerous or poorly tolerated.

Assess for other accompanying psychiatric disorders e.g. mood or psychosis.
15.13 BENZODIAZEPINE WITHDRAWAL

F13.2
DESCRIPTION
Benzodiazepine addiction may occur after only a few weeks of use. Withdrawal
symptoms on abrupt dose reduction or cessation includes anxiety,
nervousness, irritability, depersonalisation, delirium and seizures, increased
sweating, sound sensitivity, nausea, difficulty concentrating, myoclonus,
tremor, weakness and fatigue.
Gradual tapering of the benzodiazepine is recommended to facilitate
discontinuation.
2019 15.34
GENERAL MEASURES
» The therapeutic relationship between client and doctor is extremely
important in initiating dose reduction.
» Confirm benzodiazepine dependence – ascertain usage, history of previous
withdrawal symptoms; a urine screen may be necessary
» Establish full dosage of all benzodiazepines being taken, including those
prescribed by other medical practitioners
» Take time to explain negative impact of ongoing benzodiazepine use,
benefits of stopping, and concepts like tolerance and withdrawal
» Encourage the patient not to seek medication from other doctors.
» Evaluate and optimise management of comorbid substance use disorders,
mental illness, and general health conditions.
» Avoid abrupt withdrawal of benzodiazepines; be prepared to take time.
Negotiate each reduction with the patient. Individualise regular monitoring
and motivation.
» Long-term follow-up with repeated motivation may be necessary to prevent
relapse.
LoE:Ilxii
MEDICINE TREATMENT
Replace short-acting benzodiazepine with an equivalent diazepam (long
acting benzodiazepine) dose.
Patients may present with medicines that are unavailable in the public sector.
Approximate equivalent doses to diazepam 5 mg are: LoE:IIIlxiii
» chlordiazepoxide 12.5 mg
» clobazam 10 mg
» clonazepam 0.25–1 mg
» lorazepam 0.5 mg
» alprazolam 0.25 mg
» bromazepam 1.5 mg
» flunitrazepam 0.5 mg
» nitrazepam 5 mg
» oxazepam 15 mg
» temazepam 10 mg
» zopiclone 7.5 mg
» zolpidem 10 mg
Note: Medicines have only been included for comparison of estimated
`
equivalent doses.
Higher doses may be required for patients who are dependent on both alcohol
and benzodiazepines. Inpatient assessment and initiation of benzodiazepine
tapering may be warranted in these patients.
Reduction is done according to clinical response.

 Diazepam, oral.
o Reduce daily dose every 1–2 weeks by 10 mg/day until a daily dose of
50 mg.
2019 15.35
o Then reduce every 1–2 weeks by 5 mg/day until a daily dose of 30 mg.
o Then reduce every 1–2 weeks by 2.5 mg/day until a daily dose of 20 mg.
o Then reduce every 1–2 weeks by 1.25 mg/day until stopped.
o If symptoms reappear, increase the dose a little and reduce dose over
longer intervals.
o No more than one week’s duration of therapy is generally issued at
one time. LoE:IIIlxiv
2019 15.36
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analysis. JAMA Psychiatry. 2016 Mar;73(3):211-20. https://www.ncbi.nlm.nih.gov/pubmed/26764163
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Assessment of Tardive Dyskinesia and Advances in Treatment. J Clin Psychiatry. 2017 Sep/Oct;78(8):1136-1147.
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xl Flupenthixol decanoate, IM: South African Medicines Formulary. 12th Edition. Division of Clinical
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generation antipsychotic drugs for schizophrenia: a meta-analysis. Lancet. 2009 Jan 3;373(9657):31-41.
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Garcia G, Caseiro O, Pelayo-Terán JM, Vázquez-Barquero JL. Effectiveness of haloperidol, risperidone and
olanzapine in the treatment of first-episode non-affective psychosis: results of a randomized, flexible-dose, open-
label 1-year follow-up comparison. J Psychopharmacol.2011 Jun;25(6):744-54.
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xliv Olanzapine, oral: Leucht S, Cipriani A, Spineli L, Mavridis D, Orey D, Richter F, Samara M, Barbui C, Engel RR,
Geddes JR, Kissling W, Stapf MP, Lässig B, Salanti G, Davis JM. Comparative efficacy and tolerability of 15
antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis. Lancet. 2013 Sep 14;382(9896):951-62.
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Antipsychotic drugs for patients with schizophrenia and predominant or prominent negative symptoms: a
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Review: Olanzapine, oral for schizophrenia and related disorders, June 2019. http://www.health.gov.za/
xlv Orphenadrine, oral: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.

xlvi Clozapine, oral (caution): FDA Drug Safety Communication: FDA modifies monitoring for neutropenia associated
with schizophrenia medicine clozapine, 2015. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-

safety-communication-fda-modifies-monitoring-neutropenia-associated-schizophrenia-medicine
Clozapine, oral (caution): Taylor, David; Paton, Carol; Kapur, Shitij. The Maudsley Prescribing Guidelines,
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xlviiClozapine, oral: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology. University
of Cape Town. 2016.

xlviii Amisulpiride, oral: National Department of Health, Essential Drugs Programme: Tertiary and Quaternary EML,
xlix Amisulpiride, oral: National Department of Health, Essential Drugs Programme: Tertiary and Quaternary EML,
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option in the treatment of antipsychotic-induced akathisia. A randomized, double-blind, placebo- and propranolol-
controlled trial. Biol Psychiatry 2006; 59: 1071– 7.http://www.ncbi.nlm.nih.gov/pubmed /16497273
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efficacy and safety of drug treatments for chronic insomnia in adults: a meta-analysis of RCTs. J Gen Intern Med.
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liii Tool for brief intervention for substance use disorders: ASSIST
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BDFF4B1DE1DE097A?sequence=1
liv Needle and syringe programme: https://tbhivcare.org/
lv Needle and syringe programme: https://www.anovahealth.co.za/clinical-interest-areas/prevention/harm-reduction/
lvi Needle and syringe programme: https://www.facebook.com/pages/COSUP-Community-Oriented-Substance-
Use-Programme/480035362389140
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lviii Haloperidol, oral: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.

lix Objective opioid withdrawal scale (OOWS) rating scale: Handelsman L, Cochrane KJ, Aronson MJ, Ness R,
Rubinstein KJ, Kanof PD. Two new rating scales for opiate withdrawal. Am J Drug Alcohol Abuse. 1987;13(3):293-
lx Methadone, oral: National Department of Health. National Policy guidelines on detoxification of psychoactive
substances. http://www.health.gov.za/
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guidelines for the management of opioid dependence. Updated 2013. Pretoria: South African Addiction Medicine
Society; 2013.
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orders_2015.pdf
lxiTramadol, oral: Chattopadhyay S, Singh OP, Bhattacharyya A, Sen S, Roy P, Debnath S. Tramadol versus
clonidine in management of heroin withdrawl. Asian J Psychiatr. 2010 Dec;3(4):237-9.

Tramadol, oral: Lofwall MR, Babalonis S, Nuzzo PA, Siegel A, Campbell C, Walsh SL. Efficacy of extended-
release tramadol for treatment of prescription opioid withdrawal: a two-phase randomized controlled trial. Drug
Alcohol Depend. 2013 Nov 1;133(1):188-97. http://www.ncbi.nlm.nih.gov/pubmed/23755929
Tramadol, oral: Lofwall MR, Walsh SL, Bigelow GE, Strain EC. Modest opioid withdrawal suppression efficacy of
oral tramadol in humans. Psychopharmacology (Berl). 2007 Oct;194(3):381-93.
lxiiBenzodiazepine detoxification (non-pharmacological measures): Darker CD, Sweeney BP, Barry JM, Farrell MF,
Donnelly-Swift E. Psychosocial interventions for benzodiazepine harmful use, abuse or dependence. Cochrane
Database Syst Rev. 2015;(5):CD009652. https://www.ncbi.nlm.nih.gov/pubmed/26106751
lxiiiApproximate equivalent doses of diazepam, oral 5mg: British National Formulary, 78th edition (September 2019-
March 2020).
Approximate equivalent doses of diazepam, oral 5mg: Taylor, David; Paton, Carol; Kapur, Shitij. The Maudsley
Prescribing Guidelines, Twelfth Edition. London: CRC Press; 2015.
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Approximate equivalent doses of diazepam, oral 5mg: South African Medicines Formulary. 12th Edition.
Division of Clinical Pharmacology. University of Cape Town. 2016.
lxivBenzodiazepine detoxification: Taylor, David; Paton, Carol; Kapur, Shitij. The Maudsley Prescribing Guidelines,

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2019 15.43
CHAPTER 16
RESPIRATORY DISORDERS
16.1 ASTHMA, ACUTE

J45.0/1/8/9
GENERAL MEASURES
Ensure adequate hydration.
In patients presenting with asthma without an atopic allergic background, the
diagnosis of pulmonary oedema due to left ventricular heart failure should be
considered.
Patients with severe asthma (characterised by one or more of: unable to
complete sentences in one breath, altered mental status, paradoxical chest
movement, absence of wheezes, peak expiratory flow (PEF) <50% of
predicted/personal best - see PEF charts in Appendix V) should ideally be
closely monitored in a High Care or an Intensive Care Unit.
MEDICINE TREATMENT
If hypoxaemic
 Oxygen, if saturation <94%. LoE:Ii
 Salbutamol, nebulisation, 5 mg.

o Initially nebulise continuously (refill the nebuliser reservoir every 20
minutes) at a flow rate of 6–8 L/minute until PEF >60% of predicted
or >60% of personal best (see PEF charts in Appendix V).
o Once patient reaches 60% of their predicted/personal best PEF,
repeat salbutamol 5 mg 4 hourly.
LoE: Iii
Severe exacerbations:
ADD
 Ipratropium bromide, nebulisation 0.5 mg. LoE: IIiii
o Combination salbutamol/ipratropium UDV, 5/0.5 mg
preferred.
Mild to moderate exacerbations, if response to nebulised salbutamol is poor:
ADD
 Ipratropium bromide, nebulisation 0.5 mg with the 1st and subsequent
refills of the nebuliser reservoir. LoE: IIiv

 Prednisone, oral, 40 mg daily (start 1 hour of presentation) for 7 days.
OR LoE:IIIv
2019 16.1
CHAPTER 16 RESPIRATORY DISORDERS
In patients who cannot use oral therapy, or are vomiting or are suspected of
having gastric atony from a severe asthma exacerbation:
LoE:IIvi
Once oral medication can be taken, switch to:
Continue nebulisations until PEF returns to 80% of predicted/ personal best,

at which point the patient can be converted to:
 Salbutamol, MDI, 200 mcg, as needed.
AND LoE:IIIvii
 Inhaled corticosteroid (ICS), e.g.:
 Budesonide, inhalation, 200 mcg whenever salbutamol is taken.
In patients on protease inhibitors, replace ICS with beclomethasone:
 Beclomethasone, inhalation, 200 mcg whenever salbutamol is taken.
LoE:IIIviii
Monitor response with PEF and clinical signs. Patients who
fail to respond within 1 hour (symptomatic improvement and PEF >60% of
predicted/personal best):
» Exclude upper airway obstruction/stridor, pneumothorax, and
anaphylaxis.
» Discuss management with a specialist.
» Intubation and ventilator support may be required.
» If referral to another facility is required, the patient needs to be stabilised
prior to transfer and transported by the appropriate level of transport -
discuss with the referral centre.
In patients with a poor response:

ADD
 Magnesium sulfate, IV, 2 g in 100mL sodium chloride 0.9%, as a
single dose, administered over 20 minutes. LoE: Iix
Intravenous magnesium, single dose, has been shown to reduce the rate of
hospitalisation.
There is good evidence to recommend against the use of intravenous
aminophylline in acute asthma as its use together with high-dose nebulised
ß2-agonists does not result in significant additional bronchodilation and leads
to a significant increase in toxicity (vomiting and dysrhythmias).
LoE: Ix
Intercurrent bacterial respiratory infections
Bacterial infections are seldom present in acute exacerbations of asthma
and yellow sputum production is usually related to presence of eosinophils.
Antibiotics do not play a role in the management of asthma unless there is
air space consolidation on CXR. See section 16.6: Pneumonia, community
acquired.
2019 16.2
16.2 ASTHMA, CHRONIC PERSISTENT

J45.0/1/8/9
DESCRIPTION
Asthma must be distinguished from chronic obstructive pulmonary disease,
which is often mistaken for asthma. The history is a reliable diagnostic
guideline and may be of value in assessing treatment response.
Asthma COPD
» Young age onset, usually <20 years. » Older age onset, usually >40 years.
» History of hay fever, eczema and/or » Symptoms slowly worsen over a
allergies. long period of time.
» Family history of asthma. » Long history of daily/frequent cough,
» Symptoms are intermittent with periods before the onset of shortness of
of normal breathing in between. breath.
» Symptoms are usually worse at night » Symptoms are persistent and not only
or in the early hours of the morning, at night or during the early morning.
during an upper respiratory tract » History of heavy smoking (>20
infection, when the weather changes cigarettes/day for ≥15 years), heavy
or when upset. cannabis use or previous TB.
» Increase 20% in PEF 10 minutes » Little improvement in PEF with ß2-
after receiving a ß2-agonist. agonist.
LoE:IIxi
GENERAL MEASURES
Patient education: including advice on smoking cessation.
Decrease exposure to triggers, e.g. house dust mite, pollens, grasses, pets,
smoke, fumes, etc.
MEDICINE TREATMENT
Concomitant use of preparations of the same therapeutic class is hazardous
and must be avoided.
Nocturnal symptoms of cough and wheeze, or the need for bronchodilators >
twice a week, or PEF <80% of the patient’s best value, indicates poor asthma
control.
Patients with poorly controlled asthma need to step up their maintenance
therapy as described below.
The Asthma Control Test®, a validated measure of clinical asthma control, can
be completed by the patient (after initial instruction) at each visit to the clinic
prior to consultation. A value of ≥19 suggests adequate asthma control (see
Appendix V).
2019 16.3
A patient with poorly controlled asthma should be assessed for the following and
identified problems addressed prior to stepping up therapy:
1) Correct inhaler technique should be demonstrated and checked regularly, as
many asthmatic patients do not use their inhalers correctly.
2) Adherence to medication, especially the inhaled corticosteroid.
3) Exposure to triggers of bronchospasm.
4) Use of medications that may aggravate asthma e.g. NSAIDS.
5) Other medical conditions such as cardiac disease.
6) Treat allergic rhinitis (see section 17.2: Rhinitis, allergic, persistent) and GORD (see
section 1.1.3: Gastro-oesophageal reflux disease (GORD), if present.
Asthma therapy
Inhaled corticosteroids (ICS) are the mainstay of treatment in asthma.
For patients with infrequent asthma symptoms < twice a month:

As reliever/rescue therapy:
 Short acting ß2-agonists, e.g.:
 Salbutamol, MDI, 200 mcg, as needed.
AND LoE:IIIxii
 ICS, e.g.:
 Budesonide, inhalation, 200 mcg whenever salbutamol is taken.
 Beclomethasone, inhalation, 200 mcg whenever salbutamol taken.
LoE:IIIxiii
For patients with asthma symptoms ≥ twice a month
As controller therapy:
 ICS, low dose, e.g.:
 Budesonide, inhalation, 200 mcg 12 hourly. LoE: Ixiv
o Well and stable after 6 months: can attempt to reduce
budesonide dose to 200 mcg daily.
o Dose adjustments may be required at change of seasons.
 Beclomethasone, inhalation, 200 mcg 12 hourly for 6 months; reduced to
200 mcg daily once well and stable.
LoE:IIIxv
AND
As reliever/rescue therapy:
 Short acting ß2-agonists, e.g.:
 Salbutamol, MDI, 200 mcg, 6 hourly as necessary.
For patients with asthma symptoms almost daily or waking due to

asthma at least once a week:
 Long-acting β2-agonist/corticosteroid combination inhaler, e.g.:
 Salmeterol/fluticasone, inhalation, 50/250 mcg 12 hourly.
o Maximum dose: 50/500 mcg 12 hourly.
2019 16.4
o Well and stable for 6 months: step down to budesonide, inhaled, 200
mcg 12 hourly.
LoE: Ixvi
In patients on protease inhibitors:
 Beclomethasone, inhalation, 400 mcg 12 hourly.
AND LoE:IIIxvii
 Formoterol, inhalation, 12 mcg 12 hourly.
Failure of above therapy:

While awaiting appointment with specialist.
ADD
 Prednisone, oral, 10 mg daily.
Note: Prednisone should not be used as maintenance therapy but only
as a bridging step while awaiting review by specialist.
LoE: III
For short-term exacerbations in patients not responding to the above, while
awaiting review with specialist:
 Prednisone, oral, 40 mg daily for 10 days. LoE: III
PATIENT AND CAREGIVER EDUCATION ON INHALER AND SPACER

TECHNIQUES:
Spacer devices
Patients who are unable to use inhalers correctly after adequate counselling
may benefit from the use of a spacer.
Inhalation therapy without a spacer in adults:
1. Remove the cap from the mouthpiece.
2. Shake the inhaler well.
3. While standing or sitting upright, breathe out as much air as possible.
4. Place the mouth piece of the inhaler between the lips and gently close the
lips around it.
5. While beginning to inhale, press down the canister of the metered dose
inhaler once to release one puff while breathing in as deeply/slowly as
possible.
6. Hold the breath for 5–10 seconds, if possible.
7. Breathe out slowly and rest for a few breaths (30–60 seconds).
8. Repeat steps 2–6 for each puff prescribed.
9. Rinse mouth with water after inhalation of corticosteroids.
Inhalation therapy with a spacer in adults:
1. Remove the caps from the inhaler and the spacer.
2. Shake the inhaler well.
3. Insert the mouthpiece of the metered dose inhaler into the back of the
spacer.
2019 16.5
4. Insert the mouthpiece of the spacer into the mouth and close the lips
around the mouthpiece. Avoid covering any small exhalation holes.
5. Press down the canister of the metered dose inhaler once to release one
puff into the spacer.
6. Immediately take 3–4 slow deep breaths.
7. Repeat steps 4–6 for each puff prescribed, waiting at least 30 seconds
between puffs.
8. Rinse mouth with water after inhalation of corticosteroids.
16.3 BRONCHIECTASIS
J47
GENERAL MEASURES
Patient education.
Advice on early self-referral for suspected acute infections.
Physiotherapy: Regular chest clearance exercises (20 minutes morning and
night) are the mainstay of therapy and must be emphasised and
demonstrated to the patients, including cough and chest drainage
techniques, and must be emphasised repetitively.
MEDICINE TREATMENT
Antibiotic therapy in patients with bronchiectasis should only be used when
there is either systemic evidence of sepsis such as pyrexia or increasing
sputum purulence or volume. Antibiotic choices should be guided by sputum
microscopy, culture and sensitivity. The number and duration of
physiotherapy sessions should be increased.
Treatment may need to be prolonged for two weeks, depending on the
extent of the bronchiectasis and the organisms suspected.
In patients otherwise stable and before culture results:
 Amoxicillin/clavulanic acid, oral, 875/125 mg 12 hourly for 10 days, or
longer depending on the response. LoE:IIIxviii
 Azithromycin, oral, 500 mg daily for 10 days, or longer depending on the
response.
More severely ill patients may require hospitalisation and initiation of
parenteral antibiotic therapy.
Sputum microscopy, culture and sensitivity determination are indicated in all
cases.
 Ceftriaxone 2g, IV, daily, until patient apyrexial for 24 hours.
Follow with: LoE:IIIxix
LoE:IIIxx
2019 16.6
If Pseudomonas infection is confirmed on culture: (B96.5)

ADD
 Moxifloxacin, oral, 400 mg daily for 7 days.
If penicillin allergic and unable to tolerate oral therapy: (Z88.0)
Management of these patients should be discussed with a specialist for
possible referral and alternative parenteral therapy:
 Moxifloxacin, IV, 400 mg daily infused over 60 minutes.
Switch to oral treatment once able to take orally: LoE:IIIxxi
 Moxifloxacin, oral, 400mg daily.
Subsequent antibiotic therapy should be based on results of sputum

investigations. A sputum smear for Acid Fast Bacilli (AFB), followed by
culture if positive, is recommended in patients with a poor response to
antibiotics as patients with bronchiectasis are at increased risk for infection
with Non-tuberculous Mycobacteria which will not be detected by
XpertMTB/RIF® PCR assay.
Inhaled bronchodilators
Bronchodilators may be used as for COPD, if airflow obstruction is present.
There is no indication for inhaled corticosteroids.
Any asthmatic component (i.e. reversible obstruction should be treated in the
usual way, as for asthma).
Prophylaxis (Z25.1)
 Annual influenza vaccine. See section 9.2: Adult vaccination.
For frequent severe exacerbations, consult a specialist.
REFERRAL
» For exclusion of a possible foreign body.
» For assessment for surgical removal of a bronchiectatic segment.
» Major haemoptysis.
16.4 CHRONIC OBSTRUCTIVE PULMONARY DISEASE

(COPD)
J43.0/1/2/8/9/J44.0/1/8/9
DESCRIPTION
COPD is characterised by persistent respiratory symptoms (dyspnoea,
chronic cough and sputum production), and airflow limitation. Spirometry is
required to diagnose COPD, where the post bronchodilator FEV1/FVC ratio
is <0.7. COPD is likely to worsen over time, even with optimal care.
2019 16.7
Regular follow-up is necessary to monitor lung function, symptoms,

exacerbations, co-morbidities, and the need for treatment regimen changes.
COPD can be graded on severity of symptoms and frequency of
exacerbations to assist in treatment selection and to monitor treatment
success:
LoE:IIIxxii
GOLD grade mMRC breathlessness score Exacerbations in past year

A 0–1 <2
B ≥2 <2
C 0–1 ≥2
D ≥2 ≥2
The mMRC scale:
Grade Exacerbations in past year
0 Dyspnea with strenuous exercise
1 Dyspnea when hurrying on level ground or walking up a slight hill
2 Walks slower than people of same age group, due to dyspnea
3 Stops for breath after walking 91m, or after a few minutes on level ground
4 Too breathless to leave the house, or dyspnea when dressing/undressing
Url link to the modified Medical Research Council (mMRC) dyspnea scale LoE:IIIxxiii
calculator:
https://www.mdcalc.com/mmrc-modified-medical-research-council-dyspnea-scale
GENERAL MEASURES
Patients with clinical COPD must undergo spirometry to confirm and grade
the severity of obstruction.
Patients should be screened for ongoing smoking and advised to stop at
each visit. Smoking cessation and avoidance of noxious respiratory particles
should form the mainstay of management.
MEDICINE TREATMENT
Note: Correct inhaler technique should be demonstrated and checked
regularly.
Management of acute exacerbations
Progression of disease (measured by symptoms and deterioration in lung
function) in COPD is variable, but is greater in patients who experience
COPD exacerbations which are defined as:
» worsening of dyspnoea,
» increased cough,
» increased sputum production or purulence or,
» greater than usual day to day variability of symptoms.
Severe exacerbations are defined as being sufficiently severe to prompt use
of an oral corticosteroid course and/or an antibiotic. COPD exacerbations
are not always associated with significant decreases in PEF or FEV1, and
are defined by symptoms and, when severe, measures of respiratory failure.
Most are precipitated by viral and/or bacterial infection, and are more
common in winter.
2019 16.8
Patients should be admitted if there is a marked increase in dyspnoea,

symptoms disturb eating or sleeping, change in mental status or poor social
circumstances. Causes of worsening symptoms other than an acute
exacerbation of COPD such as cardiac failure, pulmonary embolus, or
pneumonia must be considered.
If available, check blood gases for the presence of hypoxaemia and
hypercapnia. In some patients with long-standing lung disease the drive to
respiration switches from hypercapnia (increases in PaCO2) to hypoxaemia
(level of respiratory failure). In such patients, relief of hypoxaemia with
uncontrolled oxygen therapy may result in hypoventilation, with consequent
rise in PaCO2 to dangerous levels and associated respiratory acidosis
leading to coma and death. For this reason, hypoxaemia should be corrected
using controlled use of supplemental oxygen, preferably starting with a nasal
cannula 1-2 litres/minute.
If the patient’s arterial PaCO2 does not rise, the FiO2 may be increased until
a PaO2 of 8 kPa is reached (or oxygen saturation of 90%). The FiO2 must be
reduced or removed if worsening hypercapnia occurs; these patients might
require non-invasive ventilation or intubation for mechanical ventilation.
Where blood gases are not readily available, the patient’s clinical status
should be reviewed regularly to check for increasing drowsiness, headache,
or confusion, which may precede coma.
Where resources for mechanical ventilation are scarce, oxygen saturation
targets for patients with long-standing COPD and limited effort tolerance may
be relaxed if the patient is improving clinically.
 Salbutamol, nebulisation, 5 mg.
o Nebulise continuously (refill the nebuliser reservoir every 20 minutes)
at a flow rate of 6–8 L/minute.
If a poor response to nebulised salbutamol:
ADD
 Ipratropium bromide 0.5 mg (UDV) with the first refill of the nebuliser
reservoir.
o Patients who fail to respond within 1 hour must be discussed with a
specialist. (Patients with COPD have fixed airway disease and unlike
asthmatics, PEF is not a reliable measure of their disease).
Once clinically stabilised, nebulise with:
 Salbutamol, nebulisation 5 mg OR fenoterol 1.25–2.5 mg.
o Repeat 4–6 hourly.
AND
 Prednisone, oral, 40 mg immediately.
Follow with:
 Prednisone, oral, 40 mg daily for 5 days. LoE:Ixxiv
OR
2019 16.9
In patients who cannot use oral therapy:

 Hydrocortisone, IV, 100 mg 6 hourly until patient can take oral medication.
Once oral medication can be taken, follow with:
o Monitor response and clinical signs. LoE:Ixxv
Acute infective exacerbation of chronic bronchitis:

 Doxycycline, oral, 100 mg 12 hourly for 5 days.
Non-responsive to first course of antibiotic therapy or in patients with a

moderate to severe exacerbation and who have increased sputum purulence
plus ≥ 1 of the following symptoms should receive an antibiotic:
» increased dyspnoea,
» increased sputum volume
LoE:IIIxxvi
 Azithromycin, oral, 500 mg daily for 3 days. LoE:IIIxxvii
Chronic therapy
GRADE A
As initial therapy:
 Short acting β2-agonist (SABA) e.g.:
 Salbutamol, MDI, 200 mcg 6 hourly as needed (educate on correct
inhaler use - use a large volume spacer if inhaler technique remains
poor).
If no response in symptoms or GRADE B:
ADD LoE:IIIxxviii
 Long acting β2-agonist (LABA), e.g.:
 Formoterol, inhalation 12 mcg 12 hourly. LoE:Ixxix
GRADE C and D (frequent exacerbations (≥2 per year)):

 Short acting β2-agonist (SABA) e.g.:
 Salbutamol, MDI, 200 mcg 6 hourly as needed using a large volume
spacer.
AND
 LABA/ICS combination, e.g.:
 Salmeterol/fluticasone, inhalation, 50/250 mcg 12 hourly. LoE:Ixxx
AND
Refer COPD patients for additional assessment and management.
2019 16.10
Patients on protease inhibitors:

Replace salmeterol/fluticasone with:
 Beclomethasone, inhalation, 400 mcg 12 hourly.
AND LoE:IIIxxxi
 Formoterol, inhalation, 12 mcg 12 hourly.
If inadequate control with above therapy:

 Theophylline, slow release, oral, 200 mg at night. Specialist consultation.
o Ongoing use of theophylline should be re-evaluated periodically. If
there is no benefit after 12 months discontinue theophylline.
LoE:IIxxxii
Corticosteroids
Oral corticosteroids are not recommended for stable COPD.
For acute exacerbations: J44.1
 Prednisone, oral, 30 mg daily for 5 days. LoE:Ixxxiii
Pre-operative assessment for surgical procedures:

Patients with chronic lung disease are at an increased risk of post-operative
pulmonary complications. Risk is increased with increasing severity of
pulmonary disease, and with upper abdominal or thoracic surgery.
Patients undergoing elective surgery must be optimised pre-operatively by
following the recommended treatment for their disease. Clinical assessment
is sufficient with further investigations such as spirometry, CXR and ABGs
reserved for patients with clinically severe disease/ unstable disease or
where the diagnosis is uncertain. COPD patients should be wheeze free
without dyspnoea on moderate exertion (carrying shopping walking up a
flight of stairs) or a history of frequent exacerbations. As COPD is a disease
characterised by fixed airway obstruction some patients may have
continuous wheezing and will require further pre-operative assessment.
Peri-operative oral corticosteroids may be used to gain optimal control but

are not advocated for routine use:
 Prednisone, oral, 30 mg daily for not longer than 5 days.
AND LoE:III
Inhaled therapy must be continued and may be administered
via nebulisation peri-operatively:
 SABA, e.g.:
 Salbutamol MDI, 200mcg, 30 minutes pre-intubation. LoE:III
Prophylaxis (Z25.1)
 Annual influenza vaccination. See section 9.2: Adult vaccination.
2019 16.11
REFERRAL
» Assessment for long-term home-based oxygen therapy, if COPD with
PaO2 <7.3 kPa and non-smoker for at least 3 months,
» Recent onset of respiratory failure or signs of cor pulmonale.
» Symptoms that appear disproportionate to the level of airflow obstruction,
as judged by spirometry or clinical evaluation (absence of hyperinflation
or unusual pattern of symptoms).
» Onset <40 years of age.
» COPD with a history of little or no smoking.
» Recurrent exacerbations, i.e. ≥2 per year.
» Failure to respond to treatment.
16.5 LUNG ABSCESS

J85.0/J85.1/J85.2/J85.3
GENERAL MEASURES
Physiotherapy and regular emphasis on postural drainage is essential for
management.
Instruct patient to do chest clearance exercises (taught by a physiotherapist
where possible) for at least 20 minutes, 6 hourly.
Nutritional support.
MEDICINE TREATMENT
 Amoxicillin/clavulanic acid, IV, 1.2 g 8 hourly, until patient apyrexial for 24
hours.
Follow with:
 Amoxicillin/clavulanic acid, oral, 875/125 mg 12 hourly. LoE:III

 Moxifloxacin, IV, 400 mg daily, until patient apyrexial for 24 hours.
Follow with:
 Moxifloxacin, oral, 400 mg daily. LoE:IIxxxiv
Duration of therapy
Usually 4-6 weeks - monitor with repeat CXR every 1-2 weeks, which should
show disappearance of air-fluid level and reduction in size of abscess.
REFERRAL
» No response to treatment.
» CXR not resolving or worsening.
» Complications, such as empyema or severe haemoptysis.
2019 16.12
16.6 PNEUMONIA, COMMUNITY ACQUIRED

J13/J14/J15.0-9/J16.0/8/J18.0-2/J18.8-9
Pneumonia is an acute infection of the lung parenchyma. Early appropriate

antibiotic therapy decreases mortality. The decision to hospitalise a patient
and choice of initial antibiotic therapy is guided by age, comorbid diseases
(such as HIV infection, diabetes or chronic respiratory disease), and severity.
Socio-economic circumstances should form part of the clinical assessment
when deciding if a patient is suitable for outpatient treatment.
GENERAL MEASURES
Diagnosis:
Clinical features include cough, fever, tachypnoea, and signs of
consolidation on chest examination.
CXR almost invariably shows a focal area of opacification or consolidation.

However, empiric antibiotic therapy can be considered for severely ill
hospitalised patients with suspected pneumonia and a negative CXR –
pneumonia is excluded if repeat CXR after 24-48 hours still shows no
opacification. Diffuse bilateral interstitial infiltrates in a patient with HIV
infection and hypoxaemia is suggestive of Pneumocystis jirovecii
pneumonia. LoE:IIIxxxv
All patients should be offered HIV testing as HIV infection is associated with
a markedly increased risk of bacterial pneumonia.
Even in typical cases of pneumonia, exclude tuberculosis by sending sputum
for Xpert MTB/RIF Ultra®.
A follow-up CXR 4–6 weeks after completion of therapy should be done in
patients >50 years of age, or if symptoms persist. LoE:IIIxxxvi
Follow-up CXRs are indicated earlier only when complications are
suspected, e.g. empyema, abscess, or pneumothorax.
MEDICINE TREATMENT
 Oxygen, if saturation <94%. LoE:Ixxxvii
Adequate analgesia for pleuritic chest pain, if present. See section 26.2.1:
Medical conditions associated with severe pain.
Duration of antibiotic therapy is guided by clinical response, but should be 5–
7 days, with a minimum of 7 days for MRSA or Pseudomonas.
Longer duration of antibiotic therapy recommended for:
» pathogen identified that was not susceptible to initial empiric therapy
» extrapulmonary infection (e.g. meningitis or endocarditis)
» empyema, lung abscess or necrotizing pneumonia
» unusual organism present LoE:Ixxxviii
2019 16.13
Prolonged fever and clinical signs may be due to unrecognised TB, or of

complications (such as empyema), or the incorrect choice of antibiotic (e.g.
atypical bacteria), or to an underlying bronchus obstruction (foreign body or
carcinoma). These patients should be further investigated.
Community-acquired pneumonia without features of severe pneumonia

(see below for definition) and without co-morbidity and in patients <65
years of age J18.0-2/J18.8-9
 Ampicillin, IV, 1 g 6 hourly.
In haemodynamically stable patients with respiratory rate <25 breaths/min
and the temperature is <37.8oC switch to:
 Amoxicillin, oral, 1 g 8 hourly. LoE:Ixxxix

If poor response after 48 hours, exclude TB and consider atypical bacterial
pneumonia, which requires treatment with a macrolide.
Community-acquired pneumonia without features of severe pneumonia

(see below for definition) in patients >65 years of age or co-morbidity
(e.g. COPD, HIV, cardiac failure, diabetes) J13/J14/J15.0-9/J16.0/J16.8/J18.0-
2/J18.8-9
 Ceftriaxone, IV, 2 g daily. LoE:Ixl
LoE:IIIxli
If poor response after 48 hours, exclude TB and consider atypical bacterial
pneumonia, which requires treatment with a macrolide.
Severe pneumonia (cyanosis, confusion, hypotension or respiratory rate

>30 breaths/min): J13/J14/J15.0-9/J16.0/J16.8/J18.0-2/J18.8-9
» Mechanical ventilation may be required (refer to a centre, if needed).
 Ceftriaxone, IV, 2 g daily:
 Amoxicillin/clavulanic acid, oral, 875/125 mg 12 hourly LoE:IIIxlii
for 5 days.
AND
 Azithromycin, 500 mg, slow IV (over not less than 60 minutes) daily for 3
days. LoE:IIIxliii
2019 16.14

 Moxifloxacin, IV, 400 mg daily.
Note: There is no need to add a macrolide, as moxifloxacin has adequate
cover for the atypical bacteria.
HIV infected with bilateral diffuse interstitial infiltrates on CXR

Clinically may present with a dry cough of <12 weeks’ duration and
significant tachypnoea.
Treat as Pneumocystis jirovecii pneumonia (exclude TB) - see section
10.2.9: Pneumocystis pneumonia.
16.7 PNEUMONIA, ASPIRATION

J69.0-1/J69.8
DESCRIPTION
Following aspiration, a patient may develop pneumonitis or pneumonia.
Aspiration pneumonitis develops within hours of the aspiration event and is
more common in previously healthy people who aspirate gastric acid.
Antibiotics will not benefit these patients unless there is infection present.
Pneumonia following aspiration of gastric contents and/or commensal
organisms from the oropharynx usually occurs in debilitated patients and
presents with symptoms and signs of community-acquired pneumonia, but
may have a more indolent onset and is more frequently complicated by lung
abscess or empyema.
There may be solid (food) particles or other foreign bodies aspirated. The
organisms involved are polymicrobial, i.e. Gram-positive and anaerobes.
Aspiration pneumonia should be suspected in patients with episodic or
prolonged decreased level of consciousness, e.g. in alcoholics, drug
overdoses, epileptics, strokes, or those with swallowing problems.
MEDICINE TREATMENT
Continue therapy until there are no features of sepsis.
 Amoxicillin/clavulanic acid, IV, 1.2 g 8 hourly, until patient is apyrexial
and stable for 24 hours.
Follow with:
Severe penicillin allergy: (Z88.0) LoE:III
 Moxifloxacin, IV, 400 mg daily, until patient is apyrexial for 24 hours.
Follow with:
 Moxifloxacin, oral, 400 mg daily. LoE:IIxliv
2019 16.15
If nosocomial infection present (developed >48 hours post admission), see

section 9.1.3 Hospital-acquired pneumonia.
REFERRAL
» Hypoxaemia non-responsive to facemask oxygen.
» Suspected foreign body aspiration.
» Suspected chemical aspiration pneumonia.
» Non-resolving pneumonia.
16.8 EMPYEMA
J86.0/J86.9
DESCRIPTION
Pus in the pleural cavity and/or bacteria present in a pleural effusion.
An empyema is always secondary to another process, e.g. pneumonia
(especially aspiration pneumonia), lung abscess, tuberculosis, bacteraemia,
or a penetrating chest wall or oesophageal injury.
GENERAL MEASURES
Aspirate and analyse all pleural effusions.
A parapneumonic effusion should be distinguished from an empyema by
biochemical analysis, fluid microscopy and culture – tube drainage is indicated
if the pH is <7.2, or if bacteria are detected, or if pus is aspirated.
The primary management of empyema is early and complete drainage, by
insertion of an intercostal drain, to prevent long-term complications.
MEDICINE TREATMENT
If a complication of pneumonia, antimicrobial therapy as in section 16.6:
Pneumonia, community acquired (but the duration of therapy should be
prolonged until drainage is complete).
If not a complication of pneumonia:
 Amoxicillin/clavulanic acid, IV, 1.2 g 8 hourly, until patient is apyrexial for
24 hours.
Follow with:
Treatment duration is until drainage is complete. LoE:III
Severe penicillin allergy (and not a complication of pneumonia): (Z88.0)

 Moxifloxacin, IV, 400 mg daily, until patient is apyrexial for 24 hours.
Follow with:
 Moxifloxacin, oral, 400 mg daily.
Treatment duration is until drainage is complete. LoE:III
2019 16.16
REFERRAL
» Loculated empyema or inadequate drainage.
» Chronic empyema with pleural thickening and restrictive lung disease,
for consideration for surgical decortication.
16.9 TUBERCULOSIS, PULMONARY

A15.0-3/A15.7-8/A16.0-2/A16.3-4/A16.7-9/B20.0
* Notifiable medical condition.
Tuberculosis (TB) treatment guidelines are updated regularly. The most

recent National Tuberculosis Control Programme Guidelines should be read
in conjunction with recent guidelines.
DESCRIPTION
A chronic, granulomatous infection of the lungs caused by M. tuberculosis.
Pulmonary tuberculosis is a serious health problem in South Africa, which is
exacerbated by HIV and multidrug resistant tuberculosis (MDR-TB).
Note: All patients on TB treatment must be notified.
Diagnosis
Molecular tests are used for the diagnosis of M.tuberculosis and the
identification of drug resistant organisms. The initial diagnostic test for patients
with suspected tuberculosis is the Xpert MTB/RIF Ultra® assay, which also
detects rifampicin resistance. GenoType MTBDRplus® is a line probe assay
(LPA) is used as a confirmatory test for rifampicin resistance detected by Xpert
MTB/RIF Ultra® and also detects isoniazid resistance.
The diagnosis of pulmonary TB in adults is made on a positive
XpertMTB/RIF Ultra® on sputum. In patients with negative sputum smears,
notably HIV-infected patients, XpertMTB/RIF Ultra® is not an adequate ‘rule
out’ test and HIV-infected TB suspects who are XpertMTB/RIF Ultra®
negative require further investigation and may need empiric anti-tuberculosis
therapy while awaiting TB cultures.
Note: XpertMTB/RIF Ultra® may identify DNA from M. tuberculosis in the
absence of active disease in patients who have completed TB treatment,
especially in the past 2 years; TB should be confirmed on culture in this
setting.
All patients who are XpertMTB/RIF Ultra® positive require further sputum to
be sent for AFB to allow for monitoring of treatment. XpertMTB/RIF Ultra®
should not be used for monitoring.
A sputum sample for “DR-TB Reflex” testing should be sent in all patients
with rifampicin resistance detected on XpertMTB/RIF Ultra® .
All TB patients must be screened for HIV. TB HIV co-infected patients are
eligible for cotrimoxazole prophylaxis regardless of CD4 count.
2019 16.17
Sputum induction with nebulised sodium chloride 5% should be attempted

for patients unable to spontaneously produce sputum. A wide needle (e.g.
18G) aspiration for Xpert MTB/RIF Ultra® should be done in patients with
suspected TB lymphadenitis. LoE:IIIxlv
Urine lipoarabinomannan (LAM) is a good “rule-in” diagnostic test for HIV-
infected patients with signs and symptoms of pulmonary and/or
extrapulmonary TB and CD4 ≤100 cells/microL and for HIV-infected patients
who are seriously ill.
LoE:Ixlvi
MEDICINE TREATMENT
All patients with active TB who are Xpert MTB/RIF Ultra® positive and
rifampicin sensitive, should receive 2 months’ intensive phase and 4 months
continuation phase (see table below). Patients who are at risk of having
resistant TB (e.g. previous episode of TB treatment, prisoners, and health
care workers), should have sputum sent for a LPA or culture and sensitivity
to exclude INH mono resistance.
National tuberculosis control programme guidelines

Fixed dose drug combinations available:
RH – 150/75 mg RH – 300/150 mg
RHZE – 150/75/400/275 mg
R – Rifampicin H – Isoniazid (INH)
Z – Pyrazinamide E – Ethambutol
Treatment for known or presumed drug sensitive TB

Pre-treatment Two months initial Four months continuation phase
body weight phase
RHZE RH RH
(150/75/400/275) (150/75) (300/150)
30–37 kg 2 tablets 2 tablets
71 kg and over 5 tablets 2 tablets
The use of INH may result in the development of a peripheral neuropathy
due to drug-induced pyridoxine deficiency.
 Pyridoxine 25 mg daily is recommended prophylactically with INH, in
patients at high risk of peripheral neuropathy (e.g. HIV, diabetes,
alcoholics).
Close contacts (particularly children <5 years of age) of TB patients should
be screened and managed as per National TB Guidelines.
2019 16.18
16.10 TUBERCULOSIS, PLEURAL (TB PLEURISY)

A16.5
DESCRIPTION
TB pleurisy presents with a few weeks of pleuritic pain; often associated with a
dry cough, fever, night sweats, weight loss, and, with large effusions,
progressive shortness of breath.
Diagnosis
It is essential to perform a diagnostic tap of pleural effusions confirmed on CXR.
Although a definite diagnosis can only be made by demonstrating the
organisms on smear or culture, or on histology of a pleural biopsy, the
presence of a lymphocytic exudate on pleural fluid analysis is adequate to
start empiric TB therapy in areas with a high TB burden, particularly if the
patient has HIV infection.
All patients started on empiric TB therapy for pleural TB must be followed up
closely; failure to respond as expected must prompt investigations to exclude
other causes. Once TB therapy is started, signs and symptoms should
resolve within 2 weeks. Radiographic improvement is usually evident by 6
weeks, but complete resorption can take up to 4 months. However, pleural
thickening may persist. A pleural biopsy at initial presentation is strongly
recommended for the following patients: >50 years of age, or suspected
malignancy, or not presenting with typical TB symptoms.
Treatment is as for pulmonary TB (see section 16.9: Tuberculosis, pulmonary).
Note: Total drainage by aspiration or under-water tube is not needed. For
large effusions that cause dyspnoea drain a maximum of 1 litre at a time.
However, note that a TB pleural empyema must be drained by intercostal tube.
REFERRAL
» Non-resolving effusions. Suspect an incorrect diagnosis of TB pleurisy if
the effusion does not improve on the CXR after 3 months of
treatment or if the patient deteriorates.
» Loculated TB empyema, not resolving after intercostal underwater tube
drainage and needing assessment for surgical drainage.
» Bronchopleural fistula, not resolving after 6 weeks.
16.11 DRUG-RESISTANT TB
16.11.1 ISONIAZID MONORESISTANT TB
A15.0-3/A15.7-8/A16.0-2/A16.3-4/A16.7-9/B20.0 + (U50.00-01/U50.10-11)
MEDICINE TREATMENT
Confirmed INH monoresistant TB:
 Rifampicin, oral, 10 mg/kg daily.
AND
2019 16.19
 Ethambutol, oral, 15 mg/kg daily.

AND
 Pyrazinamide, oral, 25 mg/kg daily.
AND
 Levofloxacin, oral, daily.
o 30–50 kg: 750 mg
o >50 kg: 1000 mg LoE:IIIxlvii
Where single medicines are not available or the pill burden is too high a fixed
dose combination of RHZE dosed as per weight may be used, and
levofloxacin added to this.
Treatment should be given for at least 6 months.
16.11.2 MULTIDRUG-RESISTANT TB
A15.0-3/A15.7-8/A16.0-2/A16.3-4/A16.7-9/B20.0 + (U50.00-01)
Never treat for MDR TB without laboratory confirmation, either by

molecular or phenotypic (culture and sensitivity) results.
All cases should be discussed with a designated specialist centre and
MDR TB medicines accessed from the designated centres.
Note: MDR TB guidelines are updated regularly. Consult the most recent
National MDR TB Programme Guidelines.
DESCRIPTION
Multidrug resistant tuberculosis (MDR TB) is diagnosed when there is in vitro
resistance of M. tuberculosis against, at least, rifampicin and isoniazid.
MDR TB is diagnosed exclusively on culture and sensitivity assays or rapid
molecular tests. XpertMTB/RIF Ultra® only tests for rifampicin resistance
and not isoniazid resistance. However, rifampicin resistance detected by
XpertMTB/RIF Ultra® is sufficient to start a patient on MDR treatment
pending confirmation of MDR TB by LPA.
GENERAL MEASURES
Screen all close contacts for signs and symptoms of to detect early disease.
MEDICINE TREATMENT
MDR TB prophylaxis
The effectiveness of preventive therapy in adults exposed to MDR TB
bacteria is not currently known. Consult a specialist for management.
Treatment
Prolonged treatment, for 9–18 months, is required in patients diagnosed with
MDR TB.
2019 16.20
Management of MDR TB should be conducted in dedicated MDR TB clinics

and hospitals with appropriate infection control measures. Patients diagnosed
with MDR TB who are smear positive should be hospitalised for up to eight
weeks or until they become smear negative on two consecutive tests.
Smear negative, culture positive patients should be started on MDR TB
treatment in the community. MDR TB treatment should not be delayed while
waiting for a bed or confirmation of MDR TB by LPA.
XDR TB and Pre-XDR TB
Patients with MDR TB who in addition have resistance to any
fluoroquinolone and at least one of the 2nd line injectables (kanamycin,
amikacin, or capreomycin). Pre-XDR TB is defined as MDR TB plus
resistance to either a fluoroquinolone or an injectable.
Confirmation of XDR TB requires drug susceptibility testing.
Patients with XDR TB need to be referred to a TB hospital. Infection control
to prevent airborne transmission is essential to prevent nosocomial
transmission.
Individualised regimens based on susceptibility tests and treatment history
are recommended to achieve a regimen with a minimum of 4–5 effective
medicines.
References:
i Oxygen: Chu DK, Kim LH, Young PJ, Zamiri N, Almenawer SA, Jaeschke R, Szczeklik W, Schünemann HJ,
Neary JD, Alhazzani W. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen
therapy (IOTA): a systematic review and meta-analysis. Lancet. 2018 Apr 28;391(10131):1693-1705.
ii Salbutamol nebulisation: Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention,
2019. http://www.ginasthma.org/
Salbutamol nebulisation: British Thoracic Society. Scottish Intercollegiate Guidelines Network. British guideline
on the management of asthma, October 2014. Available at: https://www.brit-thoracic.org.uk/document-
library/clinical-information/asthma/btssign-asthma-guideline-2014/
Salbutamol nebulisation: Camargo CA Jr, Spooner CH, Rowe BH. Continuous versus intermittent
beta-agonists in the treatment of acute asthma. Cochrane Database Syst Rev. 2003;(4):CD001115.
Salbutamol nebulisation: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.
iii Ipratropium + salbutamol nebuilsation (severe acute asthma): Kirkland SW, Vandenberghe C, Voaklander B,
Nikel T, Campbell S, Rowe BH. Combined inhaled beta-agonist and anticholinergic agents for emergency management
in adults with asthma. Cochrane Database Syst Rev. 2017 Jan 11;1:CD001284.
iv Ipratropium: Rodrigo GJ, Castro-Rodriguez JA. Anticholinergics in the treatment of children and adults with acute
asthma: a systematic review with meta-analysis. Thorax. 2005 Sep;60(9):740-6. Epub 2005 Jul 29. Review. Erratum in:
Thorax. 2010 Dec;65(12):1118. Thorax. 2008 Nov;63(11):1029. Thorax. 2006 May;61(5):458.Thorax. 2006
Mar;61(3):274. http://www.ncbi.nlm.nih.gov/pubmed/16055613
v Prednisone, oral: Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2019.
http://www.ginasthma.org/
vi Hydrocortisone, IV: Cunnington D, Smith N, Steed K, Rosengarten P, Kelly AM, Teichtahl H. Oral versus
intravenous corticosteroids in adults hospitalised with acute asthma. PulmPharmacol Ther. 2005;18(3):207-
vii Low-dose ICS with SABA MDI (Rescue use): Global Initiative for Asthma. Global Strategy for asthma
management and prevention, 2019. http://www.ginasthma.org/

Low-dose ICS with SABA MDI (Rescue use): Reddel HK, FitzGerald JM, Bateman ED, Bacharier LB, Becker A,
Brusselle G, Buhl R, Cruz AA, Fleming L, Inoue H, Ko FW, Krishnan JA, Levy ML, Lin J, Pedersen SE, Sheikh A,
Yorgancioglu A, Boulet LP. GINA 2019: a fundamental change in asthma management: Treatment of asthma with
2019 16.21
short-acting bronchodilators alone is no longer recommended for adults and adolescents. Eur Respir J. 2019 Jun
27;53(6). https://www.ncbi.nlm.nih.gov/pubmed/31249014
Low-dose ICS with SABA MDI (Rescue use): Papi A, Canonica GW, Maestrelli P, Paggiaro P, Olivieri D, Pozzi
E, Crimi N, Vignola AM, Morelli P, Nicolini G, Fabbri LM; BEST Study Group. Rescue use of beclomethasone and
albuterol in a single inhaler for mild asthma. N Engl J Med. 2007 May 17;356(20):2040-52.
Low-dose ICS with SABA MDI (Rescue use): Suissa S, Ernst P, Benayoun S, Baltzan M, Cai B. Low-dose
inhaled corticosteroids and the prevention of death from asthma. N Engl J Med. 2000 Aug 3;343(5):332-6.
Low-dose ICS with SABA MDI (Rescue use): Suissa S, Ernst P, Kezouh A. Regular use of inhaled
corticosteroids and the long term prevention of hospitalisation for asthma. Thorax. 2002 Oct;57(10):880-4.
Low-dose ICS with SABA MDI (Rescue use):Pauwels RA, Pedersen S, Busse WW, Tan WC, Chen YZ, Ohlsson
SV, Ullman A, Lamm CJ, O'Byrne PM; START Investigators Group. Early intervention with budesonide in mild
persistent asthma: a randomised, double-blind trial. Lancet. 2003 Mar 29;361(9363):1071-6.
Low-dose ICS with SABA MDI (Rescue use): Reddel HK, Busse WW, Pedersen S, Tan WC, Chen YZ, Jorup C,
Lythgoe D, O'Byrne PM. Should recommendations about starting inhaled corticosteroid treatment for mild asthma
be based on symptom frequency: a post-hoc efficacy analysis of the START study. Lancet. 2017 Jan
viii Inhaled corticosteroids (Patients on protease inhibitors): Kedem E, Shahar E, Hassoun G, Pollack S. Iatrogenic
Cushing's syndrome due to coadministration of ritonavir and inhaled budesonide in an asthmatic human
immunodeficiency virus infected patient. J Asthma. 2010 Sep;47(7):830-1.
Inhaled corticosteroids (Patients on protease inhibitors): Frankel JK, Packer CD. Cushing's syndrome due to
antiretroviral-budesonide interaction. Ann Pharmacother. 2011 Jun;45(6):823-4.
Inhaled corticosteroids (Patients on protease inhibitors): Blondin MC, Beauregard H, Serri O. Iatrogenic Cushing
syndrome in patients receiving inhaled budesonide and itraconazole or ritonavir: two cases and literature review.
Endocr Pract. 2013 Nov-Dec;19(6):e138-41. https://www.ncbi.nlm.nih.gov/pubmed/23807527
Inhaled corticosteroids (Patients on protease inhibitors): Yoganathan K, David L, Williams C, Jones K. Cushing's
syndrome with adrenal suppression induced by inhaled budesonide due to a ritonavir drug interaction in a woman with
HIV infection. Int J STD AIDS. 2012 Jul;23(7):520-1. https://www.ncbi.nlm.nih.gov/pubmed/22844010
ix Magnesium sulfate: Kew KM, Kirtchuk L, Michell CI. Intravenous magnesium sulfate for treating adults with
acute asthma in the emergency department. Cochrane Database Syst Rev.2014 May
Magnesium sulfate: Goodacre S, Cohen J, Bradburn M, Gray A, Benger J, Coats T; 3Mg Research Team.
Intravenous or nebulised magnesium sulfate versus standard therapy for severeacute asthma (3Mg trial): a double-
blind, randomised controlled trial. LancetRespir Med. 2013 Jun;1(4):293-
x Aminophylline: Nair P, Milan SJ, Rowe BH. Addition of intravenous aminophylline to inhaled
beta(2)-agonists in adults with acute asthma. Cochrane Database Syst Rev. 2012 Dec
xi Treatment response with SABA: Global Initiative for Asthma. Global Strategy for Asthma Management and
Prevention, 2019. http://www.ginasthma.org/
xii Low-dose ICS with SABA MDI (Rescue use): Global Initiative for Asthma. Global Strategy for asthma
management and prevention, 2019. http://www.ginasthma.org/

Low-dose ICS with SABA MDI (Rescue use): Reddel HK, FitzGerald JM, Bateman ED, Bacharier LB, Becker A,
Brusselle G, Buhl R, Cruz AA, Fleming L, Inoue H, Ko FW, Krishnan JA, Levy ML, Lin J, Pedersen SE, Sheikh A,
Yorgancioglu A, Boulet LP. GINA 2019: a fundamental change in asthma management: Treatment of asthma with
short-acting bronchodilators alone is no longer recommended for adults and adolescents. Eur Respir J. 2019 Jun
27;53(6). https://www.ncbi.nlm.nih.gov/pubmed/31249014
Low-dose ICS with SABA MDI (Rescue use): Papi A, Canonica GW, Maestrelli P, Paggiaro P, Olivieri D, Pozzi
E, Crimi N, Vignola AM, Morelli P, Nicolini G, Fabbri LM; BEST Study Group. Rescue use of beclomethasone and
albuterol in a single inhaler for mild asthma. N Engl J Med. 2007 May 17;356(20):2040-52.
Low-dose ICS with SABA MDI (Rescue use): Suissa S, Ernst P, Benayoun S, Baltzan M, Cai B. Low-dose
inhaled corticosteroids and the prevention of death from asthma. N Engl J Med. 2000 Aug 3;343(5):332-6.
Low-dose ICS with SABA MDI (Rescue use): Suissa S, Ernst P, Kezouh A. Regular use of inhaled
corticosteroids and the long term prevention of hospitalisation for asthma. Thorax. 2002 Oct;57(10):880-4.
Low-dose ICS with SABA MDI (Rescue use):Pauwels RA, Pedersen S, Busse WW, Tan WC, Chen YZ, Ohlsson
SV, Ullman A, Lamm CJ, O'Byrne PM; START Investigators Group. Early intervention with budesonide in mild
persistent asthma: a randomised, double-blind trial. Lancet. 2003 Mar 29;361(9363):1071-6.
2019 16.22
Low-dose ICS with SABA MDI (Rescue use): Reddel HK, Busse WW, Pedersen S, Tan WC, Chen YZ, Jorup C,
Lythgoe D, O'Byrne PM. Should recommendations about starting inhaled corticosteroid treatment for mild asthma
be based on symptom frequency: a post-hoc efficacy analysis of the START study. Lancet. 2017 Jan
xiii Inhaled corticosteroids (Patients on protease inhibitors): Kedem E, Shahar E, Hassoun G, Pollack S. Iatrogenic
syndrome with adrenal suppression induced by inhaled budesonide due to a ritonavir drug interaction in a woman with
HIV infection. Int J STD AIDS. 2012 Jul;23(7):520-1. https://www.ncbi.nlm.nih.gov/pubmed/22844010
xiv Inhaled corticosteroids: Suissa S, Ernst P, Benayoun S, Baltzan M, Cai B. Low-dose inhaled corticosteroids and
the prevention of death from asthma. N Engl J Med. 2000 Aug 3;343(5):332-6.
Inhaled corticosteroids: Busse WW, Pedersen S, Pauwels RA, Tan WC, Chen YZ, Lamm CJ, O'Byrne PM;
START Investigators Group. The Inhaled Steroid Treatment As Regular Therapy in Early Asthma (START) study 5-
year follow-up: effectiveness of early intervention with budesonide in mild persistent asthma. J Allergy ClinImmunol.
2008May;121(5):1167-74.http://www.ncbi.nlm.nih.gov/pubmed/18405951
Inhaled corticosteroids: Reddel HK, Busse WW, Pedersen S, Tan WC, Chen YZ, Jorup C, Lythgoe D, O'Byrne
PM. Should recommendations about starting inhaled corticosteroid treatment for mild asthma be based on
symptom frequency: a post-hoc efficacy analysis of the START study. Lancet. 2017 Jan 14;389(10065):157-166.
Inhaled corticosteroids: Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention,
2019. http://www.ginasthma.org/
xv Inhaled corticosteroids (Patients on protease inhibitors): Kedem E, Shahar E, Hassoun G, Pollack S. Iatrogenic
syndrome with adrenal suppression induced by inhaled budesonide due to a ritonavir drug interaction in a woman
with HIV infection. Int J STD AIDS. 2012 Jul;23(7):520-1. https://www.ncbi.nlm.nih.gov/pubmed/22844010
xviLong-acting β2-agonist/corticosteroid combination inhaler: Walters EH, Gibson PG, Lasserson TJ, Walters JA.
Long-acting beta2-agonists for chronic asthma in adults and children where background therapy contains varied or
no inhaled corticosteroid. Cochrane Database Syst Rev. 2007 Jan24;(1):CD001385.
Long-acting β2-agonist/corticosteroid combination inhaler: Global Initiative for Asthma. Global Strategy for
Asthma Management and Prevention, 2019. http://www.ginasthma.org/
Long-acting β2-agonist/corticosteroid combination inhaler: South African Medicines Formulary. 12th Edition.
Division of Clinical Pharmacology. University of Cape Town. 2016.
xvii Inhaled corticosteroids (Patients on protease inhibitors): Kedem E, Shahar E, Hassoun G, Pollack S. Iatrogenic
xviii Amoxicillin/clavulanic acid, oral: Pasteur MC, Bilton D, Hill AT; British Thoracic Society Bronchiectasis non-CF
Guideline Group. British Thoracic Society guideline for non-CF bronchiectasis.Thorax. 2010 Jul;65Suppl 1:i1-
2019 16.23
xix Ceftriaxone, IV: Pasteur MC, Bilton D, Hill AT; British Thoracic Society Bronchiectasis non-CF Guideline Group.
British Thoracic Society guideline for non-CF bronchiectasis.Thorax. 2010 Jul;65Suppl 1:i1-
xx Amoxicillin/clavulanic acid: Pasteur MC, Bilton D, Hill AT; British Thoracic Society Bronchiectasis non-CF
Amoxicllin/clavulanic acid: NICD pneumococci susceptibility data for amoxicillin for the period 2005-2014 [E-
mail communication]
Amoxicillin/clavulanic acid:Kiffer CR, Pignatari AC. Pharmacodynamic evaluation of commonly prescribed
oral antibiotics against respiratory bacterial pathogens. BMC Infect Dis. 2011 Oct
25;11:286.http://www.ncbi.nlm.nih.gov/pubmed/22026724
xxii Grading of COPD: Vogelmeier CF, Criner GJ, Martinez FJ, Anzueto A, Barnes PJ, Bourbeau J, Celli BR, Chen
R, Decramer M, Fabbri LM, Frith P, Halpin DM, López Varela MV, Nishimura M, Roche N, Rodriguez-Roisin R, Sin
DD, Singh D, Stockley R, Vestbo J, Wedzicha JA, Agustí A. Global Strategy for the Diagnosis, Management, and
Prevention of Chronic Obstructive Lung Disease 2017 Report. GOLD Executive Summary. Am J Respir Crit Care
Med. 2017 Mar 1;195(5):557-582. https://www.ncbi.nlm.nih.gov/pubmed/28128970
xxiii Modified MRC dyspnea scale: Vogelmeier CF, Criner GJ, Martinez FJ, Anzueto A, Barnes PJ, Bourbeau J, Celli
BR, Chen R, Decramer M, Fabbri LM, Frith P, Halpin DM, López Varela MV, Nishimura M, Roche N, Rodriguez-
Roisin R, Sin DD, Singh D, Stockley R, Vestbo J, Wedzicha JA, Agustí A. Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report. GOLD Executive Summary. Am J
Respir Crit Care Med. 2017 Mar 1;195(5):557-582. https://www.ncbi.nlm.nih.gov/pubmed/28128970
Modified MRC dyspnea scale: Williams N. The MRC breathlessness scale. Occup Med (Lond). 2017 Aug
1;67(6):496-497 https://www.ncbi.nlm.nih.gov/pubmed/28898975
xxivPrednisone: Leuppi JD., Schuetz P., Bingisser R., Bodmer M., Briel M., Drescher T., Duerring U., Henzen C.,
Leibbrandt Y., Maier S., Miedinger D., Muller B., Scherr A., Schindler C., Stoeckli R., Viatte S., von Garnier C.,
Tamm J. 2013. Short-term vs Conventional Glucocorticoid Therapy in Acute Exacerbations of Chronic Obstructive
Pulmonary Disease. The REDUCE Randomized Clinical Trial. JAMA. Vol 309(21): 2223-2231
xxvPrednisone: Leuppi JD., Schuetz P., Bingisser R., Bodmer M., Briel M., Drescher T., Duerring U., Henzen C.,
Leibbrandt Y., Maier S., Miedinger D., Muller B., Scherr A., Schindler C., Stoeckli R., Viatte S., von Garnier C.,
Tamm J. 2013. Short-term vs Conventional Glucocorticoid Therapy in Acute Exacerbations of Chronic Obstructive
Pulmonary Disease. The REDUCE Randomized Clinical Trial. JAMA. Vol 309(21): 2223-2231
xxviAmoxicillin/clavulanic acid: GERMSA 2015 susceptibility data. www.nicd.ac.za
Amoxicillin/clavulanic acid, oral:Vollenweider DJ, Jarrett H, Steurer-Stey CA, Garcia-Aymerich J, Puhan MA.
Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane
Database Syst Rev. 2012 Dec 12;12:CD010257.http://www.ncbi.nlm.nih.gov/pubmed/23235687
xxviiMoxifloxacin: NICD susceptibility data. [E-mail communication]
xxviiiLABA added to SABA (Grade B COPD): Vogelmeier CF, Criner GJ, Martinez FJ, Anzueto A, Barnes PJ,
Bourbeau J, Celli BR, Chen R, Decramer M, Fabbri LM, Frith P, Halpin DM, López Varela MV, Nishimura M, Roche
N, Rodriguez-Roisin R, Sin DD, Singh D, Stockley R, Vestbo J, Wedzicha JA, Agustí A. Global Strategy for the
Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report. GOLD Executive
Summary. Am J Respir Crit Care Med. 2017 Mar 1;195(5):557-582.
xxixFormoterol inhaler:Nannini LJ, Lasserson TJ, Poole P. Combined corticosteroid and long-acting beta(2)-agonist
in one inhaler versus long-acting beta(2)-agonists for chronic obstructive pulmonary disease. Cochrane Database
Syst Rev. 2012 Sep12;9:CD006829.http://www.ncbi.nlm.nih.gov/pubmed/22972099
xxxLong-acting β2-agonist/corticosteroid combination inhaler:Nannini LJ, Poole P, Milan SJ, Kesterton A. Combined
corticosteroid and long-acting beta(2)-agonist in one inhaler versus inhaled corticosteroids alone for chronic
obstructive pulmonary disease. Cochrane Database Syst Rev. 2013 Aug
Long-acting β2-agonist/corticosteroid combination inhaler:Kew KM, Dias S, Cates CJ. Long-acting inhaled
therapy (beta-agonists,anticholinergics and steroids) for COPD: a network meta-analysis. CochraneDatabase Syst
Rev. 2014 Mar 26;3:CD010844.http://www.ncbi.nlm.nih.gov/pubmed/24671923
xxxi Inhaled corticosteroids (Patients on protease inhibitors): Kedem E, Shahar E, Hassoun G, Pollack S. Iatrogenic
2019 16.24
xxxii Theophylline:Ford PA, Durham AL, Russell RE, Gordon F, Adcock IM, Barnes PJ. Treatment effects of low-
dose theophylline combined with an inhaled corticosteroid in COPD. Chest. 2010 Jun;137(6):1338-44. doi:
10.1378/chest.09-2363. Epub 2010 Mar 18. http://www.ncbi.nlm.nih.gov/pubmed/20299628
Theophylline: Cosio BG, Iglesias A, Rios A, Noguera A, Sala E, Ito K, Barnes PJ, Agusti A. Low-dose
theophylline enhances the anti-inflammatory effects of steroids during exacerbations of COPD. Thorax. 2009
May;64(5):424-9. http://www.ncbi.nlm.nih.gov/pubmed/19158122
xxxiiiPrednisone: Burge P.S., Calverley P.M.A., Jones P.W., Spencer S., Anderson J.A., on behalf of the ISOLDE
Study Group. 2003. Prednisolone response in patients with chronic obstructive pulmonary disease: results from the
ISOLDE study. Thorax. Vol 58: 654-658 http://www.ncbi.nlm.nih.gov/pubmed/12885977
xxxivMoxifloxacin: Ott SR, Allewelt M, Lorenz J, Reimnitz P, Lode H; German Lung Abscess Study Group.
Moxifloxacin vs ampicillin/sulbactam in aspiration pneumonia and primary lung abscess.Infection. 2008

xxxv Chest x-ray diagnosis (diagnosis of community acquired pneumonia): Boyles TH, Brink A, Calligaro GL, Cohen
C, Dheda K, Maartens G, et al; South African Thoracic Society; Federation of Infectious Diseases Societies of
Southern Africa. South African guideline for the management of community-acquired pneumonia in adults. J Thorac
Dis. 2017 Jun;9(6):1469-1502. https://www.ncbi.nlm.nih.gov/pubmed/28740661
xxxvi Chest x-ray diagnosis (follow-up for community acquired pneumonia): Tang KL, Eurich DT,Minhas-Sandhu
JK,Marrie TJ,Majumdar SR. Incidence, correlates, and chest radiographic yield of new lung cancer diagnosis in
3398 patients with pneumonia. Arch Intern Med 2011;171:1193–1198.
Chest x-ray diagnosis (follow-up for community acquired pneumonia): Mortensen EM, Copeland LA, Pugh MJ,
Fine MJ, Nakashima B, Restrepo MI, de Molina RM, Anzueto A. Diagnosis of pulmonary malignancy after
hospitalization for pneumonia. Am J Med. 2010 Jan;123(1):66-71. https://www.ncbi.nlm.nih.gov/pubmed/20102994
Chest x-ray diagnosis (follow-up for community acquired pneumonia): Metlay JP, Waterer GW, Long AC,
Anzueto A, Brozek J, Crothers K, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia.
An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of
America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67. https://www.ncbi.nlm.nih.gov/pubmed/31573350
Chest x-ray diagnosis (follow-up for community acquired pneumonia): Lim WS, Baudouin SV, George RC, Hill
AT, Jamieson C, Le Jeune I, Macfarlane JT, Read RC, Roberts HJ, Levy ML, Wani M, Woodhead MA; Pneumonia
Guidelines Committee of the BTS Standards of Care Committee. BTS guidelines for the management of
community acquired pneumonia in adults: update 2009. Thorax. 2009 Oct;64 Suppl 3:iii1-55.
Chest x-ray diagnosis (follow-up for community acquired pneumonia):
xxxviiOxygen: Chu DK, Kim LH, Young PJ, Zamiri N, Almenawer SA, Jaeschke R, Szczeklik W, Schünemann HJ,
Neary JD, Alhazzani W. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen
therapy (IOTA): a systematic review and meta-analysis. Lancet. 2018 Apr 28;391(10131):1693-1705.
xxxviiiDuration of antibiotic therapy (community acquired pneumonia): Tansarli GS, Mylonakis E. Systematic Review
and Meta-analysis of the Efficacy of Short-Course Antibiotic Treatments for Community-Acquired Pneumonia in
Adults.Antimicrob Agents Chemother. 2018 Aug 27;62(9). pii: e00635-18.
Duration of antibiotic therapy (community acquired pneumonia): Boyles TH, Brink A, Calligaro GL, Cohen C,
Dheda K, Maartens G, et al; South African Thoracic Society; Federation of Infectious Diseases Societies of
Southern Africa. South African guideline for the management of community-acquired pneumonia in adults. J Thorac
Dis. 2017 Jun;9(6):1469-1502. https://www.ncbi.nlm.nih.gov/pubmed/28740661
Duration of antibiotic therapy (community acquired pneumonia): Metlay JP, Waterer GW, Long AC, Anzueto A,
Brozek J, Crothers K, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official
Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J
Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67. https://www.ncbi.nlm.nih.gov/pubmed/31573350
xxxix Criteria for de-escalation of IV antibiotic therapy (community acquired pneumonia): Oosterheert JJ, Bonten MJ,
Schneider MM, Buskens E, Lammers JW, Hustinx WM, Kramer MH, Prins JM, Slee PH, Kaasjager K, Hoepelman
AI. Effectiveness of early switch from intravenous to oral antibiotics in severe community acquired pneumonia:
multicentre randomised trial. BMJ. 2006 Dec 9;333(7580):1193. https://www.ncbi.nlm.nih.gov/pubmed/17090560
Criteria for de-escalation of IV antibiotic therapy (community acquired pneumonia): Mertz D, Koller M, Haller P,
Lampert ML, Plagge H, Hug B, Koch G, Battegay M, Flückiger U, Bassetti S. Outcomes of early switching from
intravenous to oral antibiotics on medical wards. J Antimicrob Chemother. 2009 Jul;64(1):188-99.
Criteria for de-escalation of IV antibiotic therapy (community acquired pneumonia): Boyles TH, Brink A, Calligaro
GL, Cohen C, Dheda K, Maartens G, et al; South African Thoracic Society; Federation of Infectious Diseases
Societies of Southern Africa. South African guideline for the management of community-acquired pneumonia in
adults. J Thorac Dis. 2017 Jun;9(6):1469-1502. https://www.ncbi.nlm.nih.gov/pubmed/28740661
Criteria for de-escalation of IV antibiotic therapy (community acquired pneumonia): Nathwani D, Lawson W,
Dryden M, Stephens J, Corman S, Solem C, Li J, Charbonneau C, Baillon-Plot N, Haider S, Eckmann C.
Implementing criteria-based early switch/early discharge programmes: a European perspective. Clin Microbiol
Infect. 2015 Sep;21 Suppl 2:S47-55. https://www.ncbi.nlm.nih.gov/pubmed/26198369
xlCeftriaxone: Carratalà J, Garcia-Vidal C, Ortega L, Fernández-Sabé N, Clemente M, Albero G, López M,
Castellsagué X, Dorca J, Verdaguer R, Martínez-Montauti J, Manresa F, Gudiol F. Effect of a 3-step critical
2019 16.25
pathway to reduce duration of intravenous antibiotic therapy and length of stay in community-acquired pneumonia:
a randomized controlled trial. Arch Intern Med. 2012 Jun 25;172(12):922-8.
Ceftriaxone: Oosterheert JJ, Bonten MJ, Schneider MM, Buskens E, Lammers JW, Hustinx WM, Kramer MH,
Prins JM, Slee PH, Kaasjager K, Hoepelman AI. Effectiveness of early switch from intravenous to oral antibiotics in
severe community acquired pneumonia: multicentre randomised trial. BMJ. 2006 Dec 9;333(7580):1193.
Ceftriaxone, IV: Pasteur MC, Bilton D, Hill AT; British Thoracic Society Bronchiectasis non-CF Guideline Group.
British Thoracic Society guideline for non-CF bronchiectasis. Thorax. 2010 Jul;65 Suppl 1:i1-
Ceftriaxone, IV: Perry TR, Schentag JJ. Clinical use of ceftriaxone: a pharmacokinetic-pharmacodynamic
perspective on the impact of minimum inhibitory concentration and serum protein binding. Clin Pharmacokinet.
Ceftriaxone, IV: NICD pneumococci susceptibility data for amoxicillin for the period 2005-2014 [E-mail
communication]
xliAmoxicillin/clavulanic acid: Pasteur MC, Bilton D, Hill AT; British Thoracic Society Bronchiectasis non-CF
Amoxicllin/clavulanic acid: NICD pneumococci susceptibility data for amoxicillin for the period 2005-2014 [E-
mail communication]
Amoxicillin/clavulanic acid: Kiffer CR, Pignatari AC. Pharmacodynamic evaluation of commonly prescribed
oral antibiotics against respiratory bacterial pathogens. BMC Infect Dis. 2011 Oct 25;11:286.
Amoxicillin/clavulanic acid: Allegra L, Blasi F, de Bernardi B, Cosentini R, Tarsia P. Antibiotic treatment and
baseline severity of disease in acute exacerbations of chronic bronchitis: a re-evaluation of previously published
data of a placebo-controlled randomized study. Pulm Pharmacol Ther. 2001;14(2):149-55.
Amoxicillin/clavulanic acid, oral: Vollenweider DJ, Jarrett H, Steurer-Stey CA, Garcia-Aymerich J, Puhan MA.
Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012 Dec
xliiiAzithromycin, oral: Zervos M, Martinez FJ, Amsden GW, Rothermel CD, Treadway G. Efficacy and safety of 3-
day azithromycin versus 5-day moxifloxacin for the treatment of acute bacterial exacerbations of chronic bronchitis.
Int J Antimicrob Agents. 2007 Jan;29(1):56-61. http://www.ncbi.nlm.nih.gov/pubmed/17189096
Azithromycin, oral: Amsden GW, Baird IM, Simon S, Treadway G. Efficacy and safety of azithromycin
vs levofloxacin in the outpatient treatment of acute bacterial exacerbations of chronic bronchitis. Chest. 2003
Mar;123(3):772-7. http://www.ncbi.nlm.nih.gov/pubmed/12628877
Azithromycin, IV: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.
xlivMoxifloxacin: Sun T, Sun L, Wang R, Ren X, Sui DJ, Pu C, Ren Y, Liu Y, Yang Z, Li F. Clinical efficacy and
safety of moxifloxacin versus levofloxacin plus metronidazole for community-acquired pneumonia with aspiration
factors. Chin Med J (Engl). 2014;127(7):1201-5. http://www.ncbi.nlm.nih.gov/pubmed/24709166
Moxifloxacin: Ott SR, Allewelt M, Lorenz J, Reimnitz P, Lode H; German Lung Abscess Study Group.
Moxifloxacin vs ampicillin/sulbactam in aspiration pneumonia and primary lung abscess.Infection. 2008
xlv Sputum induction with nebulised sodium chloride: Antel K, Oosthuizen J, Malherbe F, Louw VJ, Nicol MP,
Maartens G, Verburgh E. Diagnostic accuracy of the Xpert MTB/Rif Ultra for tuberculosis adenitis. BMC Infect Dis.
2020 Jan 13;20(1):33. https://www.ncbi.nlm.nih.gov/pubmed/31931736
xlvi LAM urine testing (DS-TB): National Department of Health. Guidance on the use of the lipoarabinomannan
lateral flow assay (LF-LAM) for the diagnosis of tuberculosis in people living with HIV, July 2017.
LAM urine testing (DS-TB): Bjerrum S, Schiller I, Dendukuri N, Kohli M, Nathavitharana RR, Zwerling AA,
Denkinger CM, Steingart KR, Shah M. Lateral flow urine lipoarabinomannan assay for detecting active tuberculosis
in people living with HIV. Cochrane Database Syst Rev. 2019 Oct 21;10:CD011420.
xlviiLevofloxacin, oral (with rifampicin, ethambutamol, pyrazinamide): National Department of Health: Affordable
Medicines, EDP-Adult Hospital level. Medicine Review: Levofloxacin, oral (in addition to rifampicin, pyrazinamide,
and ethambutol) for isoniazid-resistant tuberculosis, September 2019. http://www.health.gov.za/
Levofloxacin, oral (with rifampicin, ethambutamol, pyrazinamide): Fregonese F, Ahuja SD, Akkerman OW,
Arakaki-Sanchez D, Ayakaka I, Baghaei P, et al. Comparison of different treatments for isoniazid-resistant
tuberculosis: an individual patient data meta-analysis. Lancet Respir Med. 2018;6(4):265-75.
Levofloxacin, oral (with rifampicin, ethambutamol, pyrazinamide): World Health Organization. WHO
Consolidated Guidelines on Drug-resistant Tuberculosis Treatment 2019 [Available from:
https://www.who.int/tb/publications/2019/consolidated-guidelines-drug-resistant-TB-treatment/en/
2019 16.26
CHAPTER 17
EAR, NOSE AND THROAT DISORDERS
17.1 EPIGLOTTITIS
J05.1
DESCRIPTION
Acute epiglottitis can result in severe, sudden or progressive airway obstruction.
Acute epiglottitis can be caused by bacteria (e.g. H. influenzae), viruses (e.g.
herpes simplex) and non-infectious insults (trauma, chemicals, heat).
GENERAL MEASURES
Airway management may require urgent specialist advice.
Adequate hydration.
MEDICINE TREATMENT
Humidified oxygen.
Antibiotic therapy
Follow with oral therapy as soon as patient can swallow and the temperature is
<37.8oC for 24 hours, to complete the 10-day course:
Severe penicillin allergy to amoxicillin/clavulanic acid, oral: (Z88.0)
 Azithromycin, oral, 500mg daily for 3 days.
LoE:IIIi
Acute stage
Imminent airway obstruction:
 Hydrocortisone, IV, 100 mg immediately as a single dose.
AND LoE:IIIii
 Adrenaline (epinephrine) 1:1 000, 1 mL nebulised.
o Dilute to 5 mL with sodium chloride 0.9% and administer 4–6 hourly.
LoE:IIIiii
17.2 RHINITIS, ALLERGIC, PERSISTENT

J30.1-4
DESCRIPTION
Allergic rhinitis is an allergic inflammation of the nasal airways. Signs and
symptoms include rhinorrhoea, itching, sneezing, nasal congestion and obstruction,
conjunctival swelling and erythema, puffy eyes, swollen nasal turbinates, and
middle ear effusion.
2019 17.1
CHAPTER 17 EAR, NOSE AND THROAT DISORDERS
GENERAL MEASURES
Avoid allergens and irritants.
Provide education on the correct technique of administering topical medicines.
Incorrect technique is a common cause of treatment failure.
MEDICINE TREATMENT
 Corticosteroid, topical, nasal spray e.g.:
 Fluticasone topical, aqueous nasal spray, 1 spray of 100 mcg in each nostril
daily.
o Aim the nozzle laterally and upwards (aim for the eye) and not to the back of
the throat.
o Do not sniff vigorously.
LoE:Iiv
Patients on protease inhibitors:
 Beclomethasone, aqueous nasal solution, 1 spray of 100 mcg in each nostril 12
hourly.
o Aim the nozzle laterally and upwards (aim for the eye) and not to the back of
the throat.
o Do not sniff vigorously.
o Review 3 monthly.
LoE:IIIv
If symptoms persist despite an adequate trial of topical corticosteroids administered
with the correct technique:
ADD
 Non-sedating antihistamine, oral e.g.:
 Cetirizine, oral, 10 mg daily.
LoE:Ivi
For relief of nasal blockage:
 Oxymetazoline 0.05%, intranasal, administered 8 hourly for a maximum of 5
days.
Note: Rebound nasal congestion occurs with prolonged use (>5 days) of topical
nasal decongestants.
LoE:IIIvii
Failure of the above:
ADD
 Prednisone, oral, 30 mg daily for 5 days whilst continuing the topical steroid.
17.3 SINUSITIS, BACTERIAL, COMPLICATED

J01.0-4/J01.8-9
DESCRIPTION
Acute bacterial sinusitis complicated by extension to the orbit or intracranially.
Extension to the orbit causes orbital cellulitis or orbital periosteal abscess, both of
which may present with pain on eye movement, partial or complete visual loss
2019 17.2
(which can be irreversible), ophthalmoplegia, and proptosis. Eyelid oedema and

erythema is usually present, but external signs of inflammation may be absent.
Intracranial extension may cause meningitis, subdural empyema, brain abscess, or
thrombosis of cavernous sinus/cortical veins.
In immunosuppressed or diabetic patients presenting with features of sinusitis
consider fungal infections such as mucormycosis. Features suggesting
mucormycosis include necrosis of the nasal or palatal mucosa, and orbital or
cerebral involvement.
MEDICINE TREATMENT
 Ceftriaxone, IV, 2 g 12 hourly and refer.
Pain:
LoE:III
REFERRAL
Urgent
» Proptosis.
» Ophthalmoplegia.
» Suspected mucormycosis, especially in immunocompromised patients.
Non-urgent
» After initiating antimicrobial therapy, refer for a CT scan, to a centre where an
appropriate surgical specialist, i.e. ophthalmologist, ENT specialist or
neurosurgeon, is available.
» Suspected fungal sinusitis (other than mucormycosis).
17.4 OTITIS MEDIA, ACUTE

H66.9
DESCRIPTION
Inflammation of the middle ear of rapid onset.
MEDICINE TREATMENT
In previously untreated patients:
LoE:IIIviii
Patients not responding to amoxicillin:
LoE:IIIix
2019 17.3
For patients with upper respiratory tract congestion, secondary to allergy: (T78.4)
 Non-sedating antihistamine, oral, e.g.:
 Cetirizine, oral, 10 mg daily for 10 days. LoE:IIx
For management of allergic rhinitis, see section 17.2: Rhinitis, allergic, persistent.
For pain:
If pain is not controlled, see chapter 26: Pain. LoE:IIIxi
REFERRAL
» No response to amoxicillin/clavulanic acid.
» No pain relief despite treatment.
» Bulging eardrum, not responding to treatment after 24 hours.
» Swelling and pain on palpation of the mastoid process.
» Recurrent otitis media.
17.5 OTITIS MEDIA, CHRONIC, SUPPURATIVE

H66.1-3
DESCRIPTION
A purulent discharge from the ear for more than 2 weeks.
If the eardrum has been ruptured for 2 weeks or longer, a secondary infection with
multiple organisms usually occurs. Multiple organism infection often makes oral
antibiotic treatment ineffective and patients may need to be referred.
TB is an important cause of a chronically discharging ear in South Africa.
If pain is present, suspect another condition or complications.
Note:
» A chronically draining ear can only heal if it is dry.
» Drying the ear is time consuming but is the most effective treatment.
» HIV status should be established in chronic otitis media.
GENERAL MEASURES
Dry mopping is the most important part of the treatment. It should be demonstrated
to the patient.
» Roll a piece of clean absorbent cloth into a wick.
» Carefully insert the wick into the ear with twisting action.
» Remove the wick and replace with a clean dry wick.
» Repeat this until the wick is dry when removed.
Do not leave anything in the ear.
Avoid getting the inside of the ear wet while swimming and bathing.
Exclude TB as a cause.
2019 17.4
MEDICINE TREATMENT
After cleaning and drying the ear:
 Acetic acid 2% in alcohol, topical, 3–4 drops instilled into the ear every 6 hours
for 5 days.
 Ciprofloxacin, drops, 3 mg/mL, 3–4 drops instilled into the ear every 8 hours for
7 days after mopping.
LoE:Ixii
For pain:
If pain is not controlled, see chapter 26: Pain. LoE:IIIxiii
REFERRAL
» Focal neurological signs such as facial nerve palsy.
» Vomiting or drowsiness.
» Swelling and pain on palpation of the mastoid process.
» No improvement after 4 weeks.
» Any attic perforation.
» Any perforation not progressively improving after 3 months or closed by 6
months, even if dry.
» Moderate or severe hearing loss.
» Effusion.
17.6 MASTOIDITIS
H70.0/H70.9
DESCRIPTION
Infection of the mastoid air cells, usually complicating otitis media. Most patients
have tenderness, erythema, and/or swelling over the mastoid bone. Diagnosis
should be confirmed radiographically, preferably by CT scan.
MEDICINE TREATMENT
REFERRAL
After initiating antimicrobial therapy, refer to a centre for s mastoidectomy.
17.7 OTITIS EXTERNA
17.7.1 OTITIS EXTERNA, NECROTISING

H60.2
DESCRIPTION
Invasive infection of the external auditory canal, which can extend to involve the base of
2019 17.5
the skull with cranial nerve palsies and the temporomandibular joint. Presents with
severe otalgia and otorrhoea, which is unresponsive to topical therapy for otitis externa.
Most common pathogen: P. aeruginosa.
Necrotising otitis externa typically occurs in elderly diabetics or other
immunocompromised patients.
GENERAL MEASURES
Debridement as indicated.
Insert a dry wick such as a dried sponge, into the canal under direct vision. Remove
the wick 2 days later, and replace if necessary.
MEDICINE TREATMENT
 Ciprofloxacin, oral, 750 mg 12 hourly, and refer. LoE:III
REFERRAL
» For surgical debridement of necrotic bone in non-responders.
» All cases to a centre where CT scan of the affected area can be done to assess
the extent of the disease.
» Cranial nerve palsies.
17.8 ABSCESS, PERITONSILLAR

J36
DESCRIPTION
Peritonsillar abscess or quinsy is a collection of pus lateral to the tonsil, i.e.
underneath it pushing it toward the midline. Infections are often polymicrobial. It
typically presents with trismus and sore throat. Other features include:
» unilateral throat pain » muffled voice
» dysphagia » fever
» drooling
SURGICAL MEASURES
Drainage of pus is the most important intervention.
There are 3 main methods:
» needle aspiration of pus
» incision and drainage
» abscess tonsillectomy, either unilateral or bilateral.
MEDICINE TREATMENT
Antibiotic therapy
<37.8oC for 24 hours:
2019 17.6

<37.8oC for 24 hours:
For pain:
REFERRAL
Refer all for ENT and/or anaesthetic review.
Urgent
» Signs of airway compromise (e.g. stridor)).
» Suspicion of infective spread beyond the peritonsillar space.
17.9 VERTIGO, ACUTE

R42/H81.1
DESCRIPTION
An acute syndrome, consisting of vertigo, nystagmus, nausea, vomiting and
postural instability. It is important to differentiate between peripheral and central
causes of vestibular dysfunction.
Peripheral causes
Patients frequently present with vertigo, which is most often rotational, with
nystagmus. The onset is usually sudden and often intermittent. Associated
abnormalities of hearing may be present. Aetiology includes benign paroxysmal
positional vertigo (confirm with a positive Dix-Hallpike test,
https://www.youtube.com/watch?v=8RYB2QlO1N4), aminoglycoside vestibular
toxicity, and vestibular neuritis.
Central causes
It is essential to conduct a thorough neurological examination in patients with
vertigo, looking specifically for signs of brainstem or cerebellar dysfunction.
Aetiology includes cerebellar stroke and space occupying lesions of the posterior
cranial fossa.
GENERAL MEASURES
It is essential to find the cause and treat appropriately. Patients with suspected
central causes should be referred for neuro-imaging and possible neurosurgical
management.
2019 17.7
Benign positional vertigo

H81.1
Good results may be achieved with particle relocation manoeuvres, such as the
Epley manoeuvre. https://www.youtube.com/watch?v=jBzID5nVQjk
In a third of patients, symptoms recur after 1 year and repeat manoeuvres may be
required.
MEDICINE TREATMENT
This is only for symptomatic relief and is determined by the aetiology.
Discontinue all medication as soon as symptoms subside as the medicine itself may
cause vertigo due to involvement of the unaffected side.
 Promethazine, oral, 10 mg 8 hourly.

o May be increased to 20 mg 8 hourly if necessary.
Note: This is sedating and patients should not drive or operate heavy machinery.
LoE:Ixiv
REFERRAL
» If there is no peripheral cause, suspect intracranial mass lesions or cerebellar stroke.
» Patients not responding to therapy for exclusion of alternative aetiology.
2019 17.8
References:
i Azithromycin, oral: Wasserman S, Boyles T, Mendelson M. South African antibiotic stewardship programme (SAASP): A
pocket guide to antibiotic prescribing for adults in South Africa, 2015.
http://www.fidssa.co.za/images/SAASP_Antibiotic_Gudidelines_2015.pdf
ii Hydrocortisone, IV::Riffat F, Jefferson N, Bari N, McGuinness J. Acute supraglottitis in adults. Ann OtolRhinolLaryngol.
2011 May;120(5):296-9. http://www.ncbi.nlm.nih.gov/pubmed/21675584
Hydrocortisone, IV: Mayo-Smith MF, Spinale JW, Donskey CJ, Yukawa M, Li RH, Schiffmann FJ. Acute epiglottitis: an 18-
year old experience in Rhode Island. Chest 1995;108:1640–7. http://www.ncbi.nlm.nih.gov/pubmed/7497775
Hydrocortisone, IV: Bizaki AJ, Numminen J, Vasama JP, Laranne J, Rautiainen M. Acute supraglottitis in adults in Finland:
review and analysis of 308 cases. Laryngoscope. 2011 Oct;121(10):2107-13. http://www.ncbi.nlm.nih.gov/pubmed/21898436
Hydrocortisone, IV: Wick R, Ballmer PE, Haller A. Acute epiglottitis in adults. Swiss Med Wkly 2002; 132: 541–7.
Hydrocortisone, IV: Hafidh MA, Sheahan P, Keogh I, Walsh RM. Acute epiglottitis in adults: a recent experience with 10
cases. J Laryngol Otol. 2006 Apr;120(4):310-3. http://www.ncbi.nlm.nih.gov/pubmed/16623975
iii Adrenaline (epinephrine), nebulisation: Wick R, Ballmer PE, Haller A. Acute epiglottitis in adults. Swiss Med Wkly 2002;
132: 541–7. http://www.ncbi.nlm.nih.gov/pubmed/12557859
iv Corticosteroids, topical nasal (therapeutic class): Chong LY, Head K, Hopkins C, Philpott C, Burton MJ, Schilder AG.
Different types of intranasal steroids for chronic rhinosinusitis. Cochrane Database Syst Rev. 2016 Apr 26;4:CD011993.
Corticosteroids, topical nasal (therapeutic class): South African Medicines Formulary. 12th Edition. Division of Clinical
Corticosteroids, topical nasal (therapeutic class): Herman H. Once-daily administration of intranasal corticosteroids for
allergic rhinitis: a comparative review of efficacy, safety, patient preference, and cost. Am J Rhinol. 2007 Jan-Feb;21(1):70-9.
Fluticasone, topical, aqueous nasal spray: Contract circular HP07-2017DAI.
v Beclomethasone, topical, aqueous nasal spray (drug-drug interaction with protease inhibitors): Foisy MM, Yakiwchuk EM,
Chiu I, Singh AE. Adrenal suppression and Cushing's syndrome secondary to an interaction between ritonavir and fluticasone:
a review of the literature. HIV Med. 2008 Jul;9(6):389-96. https://www.ncbi.nlm.nih.gov/pubmed/18459946
Beclomethasone, topical, aqueous nasal spray (drug-drug interaction with protease inhibitors): University of Liverpool. HIV
drug interaction database. https://www.hiv-druginteractions.org/
Beclomethasone, topical, aqueous nasal spray (drug-drug interaction with protease inhibitors): Frankel JK, Packer CD.
Cushing's syndrome due to antiretroviral-budesonide interaction. Ann Pharmacother. 2011 Jun;45(6):823-4.
Beclomethasone, topical, aqueous nasal spray (drug-drug interaction with protease inhibitors): Yoganathan K, David L,
Williams C, Jones K. Cushing's syndrome with adrenal suppression induced by inhaled budesonide due to a ritonavir drug
interaction in a woman with HIV infection. Int J STD AIDS. 2012 Jul;23(7):520-1.
vi Non-sedating antihistamines, oral: Howarth PH, Stern MA, Roi L, Reynolds R, Bousquet J. Double-blind, placebo-
controlled study comparing the efficacy and safety of fexofenadine hydrochloride (120 and 180 mg once daily) and cetirizine
in seasonal allergic rhinitis. J Allergy ClinImmunol. 1999;104(5):927-933. https://www.ncbi.nlm.nih.gov/pubmed/10550734
Non-sedating antihistamines, oral: Olasińska-Wiśniewska A , Olasiński J, Grajek S. Cardiovascular safety of
antihistamines. Postep Derm Alergol. 2014, 3: 182–186. https://www.ncbi.nlm.nih.gov/pubmed/25097491
Non-sedating antihistamines, oral: National Department of Health: Affordable Medicines, EDP-Adult Hospital level.
Medicine Review: Non-sedating antihistamines for persistent allergic rhinitis, 23 November 2017. http://www.health.gov.za/
Cetirizine, oral: Contract circular HP 09-2016SD.
vii Oxymetazoline intranasal: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.

viii Amoxicillin, oral (acute otitis media): Brink AJ, Cotton M, Feldman C, Finlayson H, Friedman R, Green R, Hendson W,
Hockman M, Maartens G, Madhi S, Reubenson G, Silverbauer E, Zietsman I. Updated recommendations for the management
of upper respiratory tract infections in South Africa. S Afr Med J. 2015 Apr 6;105(5):344-52.
ix Azithromycin, oral: Contract circular RT301-2017
x Antihistamines, oral (Cetirizine): Griffin G, Flynn CA. Antihistamines and/or decongestants for otitis media with effusion
(OME) in children. Cochrane Database Syst Rev. 2011 Sep 7;(9):CD003423. https://www.ncbi.nlm.nih.gov/pubmed/21901683
xi Paracetamol, oral: Sjoukes A, Venekamp RP, van de Pol AC, Hay AD, Little P, Schilder AG,
Damoiseaux RA. Paracetamol (acetaminophen) or non-steroidal anti-inflammatory drugs, alone or combined, for pain relief in
acute otitis media in children. Cochrane Database Syst Rev. 2016 Dec 15;12:CD011534.
Paracetamol, oral: National Department of Health, Essential Drugs Programme: Primary Health Care STGs and EML, 2018.
xii Ciprofloxain, topical: Onali MA, Bareeqa SB, Zia S, Ahmed SI, Owais A, Ahmad AN. Efficacy of Empirical Therapy With
Combined Ciprofloxacin Versus Topical Drops Alone in Patients With Tubotympanic Chronic Suppurative Otitis Media: A
Randomized Double-Blind Controlled Trial. Clin Med Insights Ear Nose Throat. 2018 Jan 11;11:1179550617751907.
xiii Paracetamol, oral: National Department of Health, Essential Drugs Programme: Primary Health Care STGs and EML, 2018.
xivPromethazine, oral: James AL, Burton MJ. Betahistine for Menière's disease or syndrome. Cochrane Database Syst Rev.
2019 17.9
CHAPTER 18
EYE DISORDERS
18.1 CONJUNCTIVITIS
H10.9
DESCRIPTION
Inflammation of the conjunctiva, usually due to allergy or infection (viral or
bacterial).
Conjunctivitis is usually bilateral. Other causes of a red eye are often unilateral.
The condition is self-limiting and usually resolves within 14 days.
GENERAL MEASURES
If it is due to an infection, counsel on the importance of:
» frequent hand washing,
» using separate linen, towels and washcloths, and
» avoiding direct contact with infected material or individuals.
Contact lenses should not be worn if conjunctivitis is present or during a
course of topical therapy. Soft lenses should not be worn within 24 hours of
instilling eye drops containing the preservative benzalkonium chloride.
18.1.1 CONJUNCTIVITIS, ADENOVIRAL

B30.1+ (H13.1*)
DESCRIPTION
Adenovirus is a common cause of infective conjunctivitis. It may be unilateral
but is usually bilateral.
Clinical features:
» Viral conjunctivitis may be associated with an upper respiratory tract
infection.
» A burning, sandy, or gritty feeling in the eyes.
» Morning crusting followed by watery discharge.
» Preauricular lymphadenopathy may be present.
The condition is self-limiting but eye irritation and discharge may get worse
for 3-5 days before getting better and symptoms can persist for 2-3 weeks.
MEDICINE TREATMENT
 Sodium chloride 0.9%, eye washes or irrigation.
If sodium chloride 0.9% is not available, use cooled boiled water/sterile water.
 Oxymetazoline 0.025%, ophthalmic drops, instil 1 drop 6 hourly for 7 days.
2019 18.1
CHAPTER 18 EYE DISORDERS
18.1.2 CONJUNCTIVITIS, ALLERGIC

See Primary Health Care Standard Treatment Guidelines and Essential
Medicine List, 2018; section 18.1.1 Conjunctivitis, allergic.
18.1.3 CONJUNCTIVITIS, BACTERIAL

H10.0
DESCRIPTION
Clinical features:
» It may be either unilateral or bilateral.
» There is matting of lashes in the morning with the eyelids stuck shut.
» There is a mucopurulent discharge throughout the day.
» The eyelids may be swollen.
MEDICINE TREATMENT
During the day:
 Chloramphenicol 1%, ophthalmic ointment 6 hourly for 7 days.
LoE: IIIi
OR
 Fluoroquinolone ophthalmic drops as second-line treatment, e.g.:
 Ciprofloxacin 0.3%, ophthalmic drops, instil 1 drop 2 hourly for 2 days.
o Then reduce frequency to 1 drop 4 hourly during waking hours, for 5
days.
LoE: IIii
REFERRAL
No response to treatment.
18.2 ENDOPHTHALMITIS, BACTERIAL

S05.6 + (Y43.99)
DESCRIPTION
Infection of the ocular cavity is an emergency as it can cause blindness. This
may occur secondary to bacteraemia (endogenous infection) or, more
commonly, after penetrating ocular injury or surgery.
In patients with endogenous endophthalmitis blood cultures should be done
and the source of infection identified and treated.
In patients with endophthalmitis after penetrating injury/surgery culture
should be done on specimens of aqueous or vitreous humour.
MEDICINE TREATMENT
Refer immediately to an ophthalmologist.
Endogenous endophthalmitis
Specialist initiated, vitrectomy often required:
 Ceftriaxone, IV, 2 g daily for 7 days.
Adjust antibiotics according to culture and sensitivity results.
2019 18.2
AND
 Ceftazidime, intravitreal, 2.25 mg.
AND LoE:IIIiii
 Vancomycin, intravitreal, 1 mg.
Administer using separate tuberculin syringes. LoE:IIIiv
Post-surgical endophthalmitis
Specialist initiated, vitrectomy often required:
AND
Administer using separate tuberculin syringes.
In addition, if there is soft tissue involvement or as prophylaxis after a
penetrating eye injury:
18.3 GLAUCOMA
H40.0-6/H40.8-9
DESCRIPTION
Glaucoma is characterised by damage to the optic nerve with associated visual
field loss, for which raised intra-ocular pressure (IOP) is a primary risk factor.
Glaucoma is classified as open-angle or angle-closure. Glaucoma may occur
as a primary condition or secondary to other ocular conditions. The condition
is usually bilateral, but may be unilateral or asymmetrical (especially with
secondary causes).
Clinical features
Open-angle glaucoma:
» Mostly asymptomatic.
» History of gradual loss of vision in the affected eye or loss of visual field.
» Often suspected after seeing cupping of optic disc on routine fundoscopy
or finding elevated intra-ocular pressure on screening.
Angle-closure glaucoma:
» Usually presents acutely with sudden onset of severe eye pain and
redness, associated with nausea, vomiting and hemicranial headache.
» Loss of vision in the affected eye.
» Coloured haloes or bright rings around lights.
» Hazy-looking cornea.
» Fixed, semi-dilated pupil.
» Shallow anterior chamber.
» Severely elevated intra-ocular pressure. When measured with finger
palpation, the affected eye feels hard, compared to the other eye.
» If IOP rises more slowly, patients may be asymptomatic with gradual loss
of vision.
2019 18.3
GENERAL MEASURES
Treatment options for glaucoma include medication (topical or systemic),
laser and surgery.
Choice of treatment modality depends on: intraocular pressure at diagnosis,
optic nerve damage at diagnosis, type of glaucoma, age of the patient, rate
of progression, target intraocular pressure, co-morbidities and adherence
issues and adverse drug reactions.
First line laser treatment or surgery may be indicated. LoE:IIIv
MEDICINE TREATMENT
Refer all patients with suspected glaucoma to an ophthalmology unit for
diagnosis and initiation of treatment.
Open-angle glaucoma
First line
ß-blocker:
 Non-selective -blocker, e.g.:
 Timolol 0.25%, ophthalmic drops, instil 1 drop 12 hourly.
OR LoE:IIvi
Selective -blocker:
 Betaxolol 0.25–0.5%, ophthalmic drops, instil 1 drop 12 hourly.
Poor response despite adequate adherence:
ADD LoE:IIvii
 Prostaglandin analogues, e.g.:
 Bimatoprost 0.01%, ophthalmic drops, instil 1 drop daily. LoE:Iviii
o First line if patient has contra-indication to ß-blocker.
o In place of ß-blocker if patient has intolerable side effects or there is
no significant reduction in IOP with other medicines.
o In combination with ß-blocker if there is no significant reduction in
IOP with ß-blocker.
Intolerance to prostaglandin analogue, or poor response: LoE:IIix
 Alpha-agonist, e.g.:
 Brimonidine 0.15–0.2%, ophthalmic drops, instil 1 drop 12 hourly.
o Second line if patient allergic to prostaglandin analogue.
o In place of prostaglandin analogue if there is no significant further
reduction in IOP when adding prostaglandin analogue to ß-blocker.
o In combination with ß-blocker and prostaglandin analogue if the
patient still has progression of disease or target IOP is not reached.
Failure to respond:
Alternatives in consultation with a specialist:
Parasympathomimetic agent: LoE:III
 Pilocarpine 1%, ophthalmic drops, instil 1 drop 6 hourly.
2019 18.4
In severe cases, as a temporary measure before ocular surgery in consultation

with a specialist:
Carbonic anhydrase inhibitor: LoE:IIx
 Acetazolamide, oral, 250 mg 6 hourly.
Note: Fixed combination therapy, when available, is preferred to two separate
instillations of agents. This improves patient adherence and decreases excess
exposure to preservatives (minimising ocular discomfort).
LoE:IIxi
Angle-closure glaucoma (acute) H40.1
Institute initial therapy and then refer to an ophthalmology unit.
Try to achieve immediate reduction in IOP:
 Acetazolamide, oral, 500 mg immediately as a single dose.
o Followed by 250 mg 6 hourly.
AND
 Timolol 0.25–0.5%, ophthalmic drops, instil 1 drop 12 hourly.
Also treat patient for associated pain and nausea. See sections 12.4.1:
Perioperative analgesics and 12.6.5.2: Treatment of PONV.
Where those measures fail, for short-term use only:
 Mannitol, IV, 1.5–2 g/kg as a 20% solution over 30–60 minutes.
OR
Glycerol, oral, 1 g/kg of 50% solution as a single dose immediately.
REFERRAL
All to an ophthalmology unit.
18.4 HERPES ZOSTER OPHTHALMICUS

B02.2* + (G53.0*)
DESCRIPTION
Herpes zoster ophthalmicus occurs when the varicella-zoster virus reactivates in
the trigeminal ganglion and passes down the ophthalmic division of the
trigeminal nerve. Patients present with a painful vesicular rash in the trigeminal
V1 area – vesicles on the tip of the nose indicate nasociliary branch involvement,
which increases the risk of ocular involvement. A minority of patients may
develop conjunctivitis, keratitis, uveitis, retinitis, and cranial nerve involvement
(oculomotor or optic nerves). Permanent sequelae of ophthalmic zoster infection
may include chronic ocular inflammation, loss of vision, and debilitating post-
herpetic neuralgia. All patients should be offered HIV testing.
MEDICINE TREATMENT
 Aciclovir, oral, 800 mg 4 hourly while awake for 7–10 days.
Note: Treatment should be initiated within the first three days of onset of
symptoms, except in HIV-infected patients who should be treated if there are
active skin lesions. LoE:III
2019 18.5
Post-herpetic neuralgia:
Initiate treatment with adjuvant therapy (i.e. amitriptyline) early. LoE:IIxii
See section 26.1.4: Management of neuropathic pain (Post-
herpetic neuralgia).
REFERRAL
» Vesicles on the tip of the nose.
» Fluorescein staining of cornea shows corneal/ulceration.
» Decreased vision.
» Red eye (uveitis or keratitis).
» Cranial nerve palsies.
18.5 KERATITIS
18.5.1 KERATITIS, HERPES SIMPLEX
B00.5† + (H19.1*)
DESCRIPTION
Acute unilateral painful red eye with visual blurring and decreased corneal
sensation. Characteristic dendritic corneal ulcer seen on staining with
fluorescein.
MEDICINE TREATMENT
 Aciclovir 3%, ophthalmic ointment inserted in the lower conjunctival sac
five times per day at 4 hour intervals.
o Continue for 3 days after ulcer has healed.
If aciclovir 3% ophthalmic ointment is unavailable:
 Aciclovir, oral, 400 mg five times daily for 10–14 days. LoE:IIxiii
Note: Topical corticosteroids are contraindicated for treating
dendritic ulcers.
18.5.2 KERATITIS, SUPPURATIVE

H16.8
DESCRIPTION
Painful red eye with corneal lesion that stains with fluorescein and has
creamy white appearance. Contact lenses are a major risk factor, especially
for fungal infections. Have a high index of suspicion for fungal infection if HIV
positive or there is a history of injury to eye with plant matter.
MEDICINE TREATMENT
Empiric therapy until culture results become available:
Bacterial infection:
 Fluoroquinolone ophthalmic drops, e.g.:
 Ciprofloxacin 0.3%, ophthalmic drops, instil 1 drop hourly for 3 days.
2019 18.6
o Then reduce frequency to 1 drop 3–4 hourly.

LoE: IIIxiv
Fungal infection:
 Natamycin 5%, ophthalmic drops, instil 1 drop 1–2 hourly for 3–4 days.
(Specialist prescribed).
o Then reduce frequency to 1 drop 3–4 hourly.
o Continue for 14–21 days until resolution of infection.
REFERRAL
» Hypopyon (pus in the anterior chamber)
» No facilities for microscopy, culture and sensitivity.
18.6 RETINITIS, HIV CMV

H30.9 + (B20.2)
DESCRIPTION
Cytomegalovirus (CMV) retinitis is seen in advanced HIV infection, with CD4
count <100 cells/mm3. The characteristic retinal appearance is that of
necrosis, i.e. white exudates, and hemorrhages at the edges of the exudates.
Visual loss is irreversible – the goal of therapy is to limit further loss.
MEDICINE TREATMENT
Limited CMV retinitis:
 Valganciclovir, oral, 900 mg 12 hourly for the first 3 weeks, then 900 mg
daily until immune recovery (CD4 >100) and a minimum of 3 months of
therapy with valganciclovir (if available). LoE:Ixv
o Monitor FBC weekly during induction, then monthly as
valganciclovir can cause bone marrow suppression. Avoid concomitant
zidovudine use.
o Initiate ART 2 weeks after starting induction therapy.
If valganciclovir is not available:
 Ganciclovir, intravitreal, 2 mg once a week (specialist)
o Once immune function has been restored with antiretroviral therapy
(CD4 >100) and the features of active retinitis has cleared,
maintenance ganciclovir can be stopped but monitor for recurrence.
REFERRAL
To ophthalmologist for confirmation of diagnosis.
18.7 UVEITIS
H20.0
DESCRIPTION
Inflammation of the uveal tract and adjacent structures. The commonest
2019 18.7
form is acute anterior uveitis, which presents with pain and photophobia,
variable loss of vision, circumcilliary injection, and a miotic pupil. Chronic
uveitis may lead to cystoid macular oedema with decreased central acuity,
cataract formation, and secondary glaucoma. Numerous systemic diseases
can cause uveitis.
MEDICINE TREATMENT
 Cycloplegic agent, e.g.:
 Homatropine 2 %, ophthalmic drops, instil 1–2 drops 3–4 hourly.
OR
Atropine 1%, ophthalmic drops, instil 1 drop 12 hourly.
AND LoE:IIIxvi
 Corticosteroids, e.g.:
 Dexamethasone 0.1%, ophthalmic drops, instil 1–2 drops 4–6 hourly.
LoE:IIIxvii
REFERRAL
All, for management at an ophthalmology unit.
18.8 SURGICAL AND DIAGNOSTIC PRODUCTS

Ocular peri-operative pharmaceutical products
 Sodium hyaluronate 10 mg/mL
 Acetylcholine chloride (for intra-ocular irrigation)
 Sterile intraocular irrigating solution
Ocular diagnostic products

 Fluorescein 2%, ophthalmic drops
 Fluorescein ophthalmic strips
 Tropicamide 1%, ophthalmic drops
 Cyclopentolate 2 mg/mL ophthalmic drops (for cycloplegic refraction)
 Cyclopentolate 2 mg/mL and phenylephrine 10 mg/mL (for fundoscopic
examination)
 Polyacrylic acid 2 mg/g ophthalmic gel (as coupling liquid for diagnostic
contact lenses)
 Local anesthetics used on the eye

 Oxybuprocaine hydrochloride 0.4% LoE:IIIxviii
Preparations for tear deficiency

 Hydroxypropyl methylcellulose 0.3–0.5%
2019 18.8
18.9 DRY EYE

H04.1
DESCRIPTION
Dry eye occurs when there is inadequate tear volume or function.
The common symptoms include feelings of dryness, grittiness, burning and
foreign body sensation, usually worse during the day. A stringy discharge,
redness and transient blurring of vision are also common.
Allergic conjunctivitis should be excluded.
GENERAL MEASURES
The management of dry eye involves controlling the symptoms, since the
disease is generally not curable.
Patients should be educated to avoid over the counter topical medications,
many of which exacerbate dryness, and control their environmental factors
(e.g. encourage frequent blinking during visually attentive tasks, avoid air
conditioners or heating, use humidifiers).
MEDICINE TREATMENT
Tear substitutes:
 Hydroxypropyl methylcellulose, ophthalmic drops, 1 drop, 6 hourly.
OR LoE:IIIxix
Lanolin, anhydrous liquid, ophthalmic ointment, at night.
LoE:IIIxx
18.10 MEDICAL MANAGEMENT OF EYE INJURY
18.10.1 CHEMICAL BURN

This is a medical emergency.
Medicine List, 2018; section 18.3.1: Eye injury, chemical burn.
18.10.2 EYE INJURY: BLUNT/PENETRATING/ FOREIGN

BODY
Medicine List, 2018; sections 18.3.2 Eye injury/foreign bodies and 18.3.3:
Eye injury (blunt or penetrating).
References:
i Chloramphenicol 1%, ophthalmic ointment: South African Medicines Formulary. 12th Edition. Division of
ii Fluoroquinolone ophthalmic drops: Sheikh A, Hurwitz B, van Schayck CP, McLean S, Nurmatov U. Antibiotics
versus placebo for acute bacterial conjunctivitis. Cochrane Database Syst Rev. 2012 Sep 12;(9):CD001211.
2019 18.9
Fluoroquinolone ophthalmic drops: Epling J. Bacterial conjunctivitis. BMJ Clin Evid. 2012 Feb 20;2012. pii: 0704.
Fluoroquinolone ophthalmic drops: Silver LH, Woodside AM, Montgomery DB. Clinical safety of moxifloxacin
ophthalmic solution 0.5% (VIGAMOX) in pediatric and nonpediatric patients with bacterial conjunctivitis. Surv
Ophthalmol. 2005 Nov;50 Suppl 1:S55-63. https://www.ncbi.nlm.nih.gov/pubmed/16257311
Fluoroquinolone ophthalmic drops (ciprofloxacin ophthalmic drops - dosing): South African Medicines
Formulary. 12th Edition. Division of Clinical Pharmacology. University of Cape Town, 2016.
Fluoroquinolone ophthalmic drops (ciprofloxacin ophthalmic drops - dosing): Leibowitz HM. Antibacterial
effectiveness of ciprofloxacin 0.3% ophthalmic solution in the treatment of bacterial conjunctivitis. Am J Ophthalmol.
1991 Oct;112(4 Suppl):29S-33S. https://www.ncbi.nlm.nih.gov/pubmed/1928271
iii Ceftazidime, intravitreal: Yonekawa Y, Chan RV, Reddy AK, Pieroni CG, Lee TC, Lee S. Early intravitreal
treatment of endogenous bacterial endophthalmitis. Clin Experiment Ophthalmol.2011 Nov;39(8):771-8.
Ceftazidime, intravitreal: Okada AA, John RP, Liles WC, D'Amico DJ, Baker AS. Endogenous bacterial
endophthalmitis. Report of a ten-year retrospective study 1994;101(5):832-838.
iv Vancomycin, intravitreal: Yonekawa Y, Chan RV, Reddy AK, Pieroni CG, Lee TC, Lee S. Early intravitreal
treatment of endogenous bacterial endophthalmitis. Clin Experiment Ophthalmol.2011 Nov;39(8):771-8.
Vancomycin, intravitreal: Okada AA, Johnson RP, Liles WC, D'Amico DJ, Baker AS. Endogenous bacterial
endophthalmitis. Report of a ten-year retrospective study. Ophthalmology. 1994 May;101(5):832-8.
v Treatment modalities for glaucoma: van der Valk R, Webers CA, Schouten JS, Zeegers MP, Hendrikse F, Prins
MH. Intraocular pressure-lowering effects of all commonly used glaucoma drugs: a meta-analysis of randomized
clinical trials. Ophthalmology. 2005;112(7):1177-1185. http://pubmed.ncbi.nlm.nih.gov/15921747/
Treatment modalities for glaucoma: European Glaucoma Society Terminology and Guidelines for Glaucoma,
4th Edition - Chapter 3: Treatment principles and options Supported by the EGS Foundation: Part 1: Foreword;
Introduction; Glossary; Chapter 3 Treatment principles and options. Br J Ophthalmol. 2017;101(6):130-195.
vi-blocker (non-selective and selective), ophthalmic drops: van der Valk R, Webers CA, Schouten JS, Zeegers MP,
Hendrikse F, Prins MH. Intraocular pressure-lowering effects of all commonly used glaucoma drugs: a meta-
analysis of randomized clinical trials. Ophthalmology. 2005;112(7):1177-1185.
vii Prostaglandin analogues, ophthalmic drops: van der Valk R, Webers CA, Schouten JS, Zeegers MP, Hendrikse
F, Prins MH. Intraocular pressure-lowering effects of all commonly used glaucoma drugs: a meta-analysis of
randomized clinical trials. Ophthalmology. 2005;112(7):1177-1185. https://pubmed.ncbi.nlm.nih.gov/15921747/
viii Bimatoprost 0.01%, ophthalmic drops: National Department of Health: Affordable Medicines, EDP-Adult Hospital
level. Evidence summary: Bimatoprost 0.01% vs 0.03% for glaucoma, August 2019. http://www.health.gov.za/
Bimatoprost 0.01%, ophthalmic drops: Katz LJ, Cohen JS, Batoosingh AL, Felix C, Shu V, Schiffman RM.
Twelve-month, randomized, controlled trial of bimatoprost 0.01%, 0.0125%, and 0.03% in patients with glaucoma
or ocular hypertension. Am J Ophthalmol. 2010 Apr;149(4):661-671.e1.
ixAlpha-agonist, ophthalmic drops: van der Valk R, Webers CA, Schouten JS, Zeegers MP, Hendrikse F, Prins MH.
Intraocular pressure-lowering effects of all commonly used glaucoma drugs: a meta-analysis of randomized clinical
trials. Ophthalmology. 2005;112(7):1177-1185. https://pubmed.ncbi.nlm.nih.gov/15921747/
Alpha-agonist, ophthalmic drops: South African Medicines Formulary. 12th Edition. Division of Clinical
xAcetazolamide, oral: Maus TL, Larsson LI, McLaren JW, Brubaker RF. Comparison of dorzolamide and
acetazolamide as suppressors of aqueous humor flow in humans. Arch Ophthalmol. 1997 Jan;115(1):45-9.
xiFixed-dose combination therapy: Cox JA, Mollan SP, Bankart J, Robinson R. Efficacy of antiglaucoma fixed
combination therapy versus unfixed components in reducing intraocular pressure: a systematic review. Br J
Ophthalmol. 2008;92(6):729-734. https://pubmed.ncbi.nlm.nih.gov/18460539/
Fixed-dose combination therapy: Olthoff CM, Schouten JS, van de Borne BW, Webers CA. Noncompliance with
ocular hypotensive treatment in patients with glaucoma or ocular hypertension an evidence-based review.
Ophthalmology. 2005;112(6):953-961. https://pubmed.ncbi.nlm.nih.gov/15885795/
Fixed-dose combination therapy: Chrai SS, Makoid MC, Eriksen SP, Robinson JR. Drop size and initial dosing
frequency problems of topically applied ophthalmic drugs. J Pharm Sci. 1974;63(3):333-338.
Fixed-dose combination therapy: Serle JB, Toor A, Fahim MM, Polikoff LA, Ellison J. The Effect of Varying
Dosing Interval on the Efficacy of Intraocular Pressure Lowering Drugs. Invest Ophthalmol Vis Science
2004;45(5):971 https://iovs.arvojournals.org/article.aspx?articleid=2406778
Fixed-dose combination therapy: Pisella PJ, Pouliquen P, Baudouin C. Prevalence of ocular symptoms and
signs with preserved and preservative free glaucoma medication. Br J Ophthalmol. 2002;86(4):418-423.
xii Amitriptyline, oral: Bowsher D. The effects of pre-emptive treatment of postherpetic neuralgia with amitriptyline: a
randomized, double-blind, placebo-controlled trial. J Pain Symptom Manage. 1997 Jun;13(6):327-

2019 18.10
xiii Aciclovir, oral: Wilhelmus KR. Antiviral treatment and other therapeutic interventions for herpes simplex virus
epithelial keratitis. Cochrane Database Syst Rev. 2015 Jan 9;1:CD002898.

xiv Fluoroquinolone ophthalmic drops: Lin A, Rhee MK, Akpek EK, Amescua G, Farid M, Garcia-Ferrer FJ, Varu
DM, Musch DC, Dunn SP, Mah FS; American Academy of Ophthalmology Preferred Practice Pattern Cornea and
External Disease Panel. Bacterial Keratitis Preferred Practice Pattern®. Ophthalmology. 2019 Jan;126(1):P1-P55.
xv Valganciclovir, oral: Roche Products (Pty) Ltd. Valcyte 450 film coated tablet®, South African package insert, 27
July 2012.
Valganciclovir, oral: Martin DF, Sierra-Madero J, Walmsley S, Wolitz RA, Macey K, Georgiou P, Robinson CA,
Stempien MJ; Valganciclovir Study Group. A controlled trial of valganciclovir as induction therapy for
cytomegalovirus retinitis. N Engl J Med. 2002 Apr 11;346(15):1119-26. Erratum in: N Engl J Med 2002 Sep
Valganciclovir, oral (3 months duration): Centers for Disease Control and Prevention. Guidelines for prevention
and treatment of opportunistic infections in HIV-Infected adults and adolescents recommendations from CDC, the
National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America.
MMWR 2009;58(RR-4):1-216. http://www.cdc.gov/mmwr/pdf/rr/rr5804.pdf
xvi Corticosteroids, ophthalmic drops (therapeutic class): McGhee CN, Dean S, Danesh-Meyer H. Locally
administered ocular corticosteroids: benefits and risks. Drug Saf. 2002;25(1):33-55.

Corticosteroids, ophthalmic drops: National Department of Health: Affordable Medicines, EDP-Adult Hospital
level. Medicine Review: Prednisiolone 1% vs Dexamethsone 0.01% ophthalmic drops for uveitis, May 2018.
Corticosteroids, ophthalmic drops: Espinosa G, Muñoz-Fernández S, García Ruiz de Morales JM, Herreras JM,
Cordero-Coma M. Treatment recommendations for non-infectious anterior uveitis. Med Clin (Barc). 2017 Dec
20;149(12):552.e1-552.e12. https://www.ncbi.nlm.nih.gov/pubmed/28911893
xvii Dexamethasone, ophthalmic drops: McGhee CN, Dean S, Danesh-Meyer H. Locally administered ocular
corticosteroids: benefits and risks. Drug Saf. 2002;25(1):33-55. http://www.ncbi.nlm.nih.gov/pubmed/11820911

xviii Local anaesthetics, ophthalmic drops: Lawrenson JG, Edgar DF, Tanna GK, Gudgeon AC. Comparison of the
tolerability and efficacy of unit-dose, preservative-free topical ocular anaesthetics. Ophthalmic Physiol Opt. 1998
Sep;18(5):393-400. https://www.ncbi.nlm.nih.gov/pubmed/10023471
xix Hydroxypropylmethylcellulose, ophthalmic drops: South African Medicines Formulary. 12th Edition. Division of

xx Lanolin, anhydrous liquid, ophthalmic ointment: South African Medicines Formulary. 12th Edition. Division of
2019 18.11
CHAPTER 19
POISONING
POISONS INFORMATION CENTRES

Poisons Information Helpline (national 24 hours/day, 0861 555 777
service) every day for
poisons queries
Red Cross War Memorial Children’s Hospital Office Hours (021) 658 5308
Poisons Information Centre
Email: [email protected]
http://www.paediatrics.uct.ac.za/poisons-
information-centre
Tygerberg Poison Information Centre Office Hours (021) 938 9596

www.sun.ac.za/poisoncentre
University of the Free State Poison Control 24 hours/day 082 491 0160
and Medicine Information Centre
Telephone numbers tested September 2019
Access poison information at: https://www.afritox.co.za/
ENVENOMATION
Envenomation is an instance of poisoning by venom resulting from a bite or
sting from an animal such as a snake, spider, scorpion, insect or marine life.
19.1 INSECT BITES AND STINGS

T63.4 + (X29.99/X23.99) + External Cause Code (V,W,X,Y)
DESCRIPTION
Toxicity due to insect bites and stings usually results in local effects only and
systemic effects are rare. Occasionally, hypersensitivity reactions are
encountered, varying from minor local inflammation to acute anaphylaxis.
Multiple bee stings can result in toxicity and may require ICU care.
GENERAL MEASURES
Allergic reactions may be acutely life threatening.
Patients with multiple stings may develop delayed systemic toxicity. Beware
of premature discharge from the healthcare facility.
2019 19.1
CHAPTER 19 POISONING
MEDICINE TREATMENT
Anaphylaxis: See section 20.1.2: Anaphylaxis/Anaphylactic Shock.
For pain:
LoE:III
19.2 SNAKEBITES
T63.0 + (X20.99/W59.99)
DESCRIPTION
In the majority of snakebite incidents, the offending snake is not identified. The
table below illustrates the three main envenomation syndromes seen in South
Africa: cytotoxic, neurotoxic and haemotoxic.
Venom Cytotoxic Neurotoxic Mixed Haemotoxic

type cytotoxic and
neurotoxic
Snake Puff adder, Black and green Rinkhals, Berg Boomslang,
species Gaboon adder, mamba, non-spitting adder, vine snakes
spitting cobras (Cape, Peringuey’s
cobras(Mozambiq forest, snouted) adder, desert
ue, black-necked, mountain
zebra), stiletto adder, garter
snake, night snakes, shield-
adders, horned nose snake,
adders coral snake
Pain, swelling, Pins and needles, Combined Spontaneous
Clinical bruising, blisters, metallic taste, visual cytotoxic and bleeding
features of necrosis, regional disturbances, ptosis, neurotoxic (can present
envenomat lymphadenopathy, drowsiness, features late >24 hours
ion hypotension, sweating, drooling, after bite),
coagulopathy, dysphagia, headaches,
compartment progressive dizziness,
syndrome weakness, fainting
respiratory paralysis
Polyvalent Polyvalent Polyvalent Boomslang
Antivenom antivenom for Puff antivenom for all antivenom for monovalent
(when adder, Gaboon species rinkhals only antivenom for
indicated) adder and spitting boomslang
cobras only bites only
To view pictures for identification of snakes click on following hyperlink:
http://www.cmej.org.za/index.php/cmej/article/view/2546/2581
2019 19.2
GENERAL MEASURES
Most snake bites will not result in death.
Supportive and symptomatic management with/without antivenom is required.
Mechanical ventilation may be needed in some cases of neurotoxic
envenomation.
Cases of haemotoxic envenomation may require fluid resuscitation including
blood products.
MEDICINE TREATMENT
Cleanse wound:
 Chlorhexidine 0.05% in water.
Antibiotics are seldom needed, except for secondary infection:
T79.3+(X20.99/W59.99)
LoE:IIIi
Immunisation, primary or booster: (Z23.5)
 Tetanus toxoid vaccine, IM, 0.5 mL immediately.
In unimmunised or partially immunised patients:
 Tetanus immunoglobulin, human, IM, 250 units immediately.
Analgesia
For mild pain:
OR
For severe pain:

ADD
o Opioids should be used cautiously in neurotoxic snakebite.
LoE:III
Note: The use of NSAIDs is not recommended due to the antiplatelet effect
and the potential danger of renal failure in a hypotensive patient.
LoE:IIIii
19.2.1 CYTOTOXIC AND NEUROTOXIC SNAKEBITE
T63.0 + (X20.99)
MEDICINE TREATMENT
Polyvalent antivenom
Used in some cytotoxic and neurotoxic envenomations, only when indicated
2019 19.3
Obtainable from South African Vaccine Producers (tel: (011) 386-6063/2/78 or

afterhours 0716809897 or 0828842971). See package insert for full details.
Note: LoE:IIIiii
» In most cases, patients do not need and should not be given antivenom.
» Adverse reactions to antivenom are common and may be severe. Pre-
medication with adrenaline (epinephrine) may reduce the risk of severe
adverse reactions to polyvalent snake antivenom.
» The dose of antivenom is the same for adults and children.
» Monitor for any deterioration in respiratory function as patients may need
ventilation whether or not polyvalent antivenom has been given.
» Antivenom should be given as soon as possible, however administration
may be considered even as late as 48-72 hours after the bite, if there is
continued clinical deterioration indicating ongoing venom activity.
LoE:IIIiv
Indications for polyvalent antivenom:
» Signs of neurotoxicity.
» Positively identified puff adder, Gaboon adder, Mozambique spitting cobra
or rinkhals bites AND evidence of progressive severe cytotoxicity.
» Unidentified snakebites and evidence of progressive severe cytotoxic
envenomation i.e.:
- swelling of whole hand or foot within 1 hour
- swelling to the knee or elbow in less than 6 hours
- swelling of the whole limb in less than 12 hours
- swelling progression >2.5 cm per hour
- a threatened airway due to swelling
- evidence of complication e.g. compartment syndrome
Systemic evidence of severe cytotoxicity includes:
» shock
» haematological abnormalities: INR >1.5, Hb <8 g/dL, thrombocytopaenia
(<100 x 109/L) or leucocytosis (>10 x 109/ L)
» arrhythmias (rare) LoE:IIIv
Note: Polyvalent antivenom is ineffective against the venom
of:
» night adders, berg adders and other smaller adders,
» boomslang, and
» vine/twig snakes.
Caution
Never administer antivenom without being prepared to manage
acute anaphylaxis.
Administration and polyvalent antivenom dose:

 Pre-treat with adrenaline (epinephrine), SC, 0.25 mL of 1:1000 solution.
2019 19.4
(Contraindicated in patients with IHD, stroke, uncontrolled hypertension

and tachyarrhythmia). LoE:Ivi
 Polyvalent snake antivenom, slow IV infusion.

o 1 ampoule contains 10 mL antivenom. LoE:IIIvii
- Cytotoxic snakebite: give 50 mL.
- Neurotoxic snakebite: give 80–100 mL (and up to 200 mL in black
mamba bites).
- Mozambique spitting cobra bite: give 100 mL. LoE:IIIviii
o Dilute in sodium chloride 0.9%, 100–200 mL.
o Administer IV, over 30 minutes.
o Reassess once the infusion is completed. A repeat dose may be given
if there is ongoing progression of neurotoxic or cytotoxic features.
19.2.2 BOOMSLANG SNAKEBITE

T63.0 + (X20.99)
DESCRIPTION
Boomslang venom is haemotoxic. A consumptive coagulopathy usually sets
in within 6–36 hours after the bite with hypofibrinogenaemia and bleeding.
In suspected boomslang bite, a whole blood clotting time is a useful bedside
test, especially in rural areas. Place 5 mL of blood in a dry glass test tube
and leave at room temperature for 20 minutes. Normal clotting time varies
from 5–20 minutes. It is important to repeat these over a few days.
Other investigations include FBC, activated PTT, prothrombin time (INR),
fibrinogen, D-dimer and monomers.
Note: Polyvalent antivenom is not effective in boomslang bite.
Boomslang monovalent antivenom
Indicated for all boomslang bites with evidence of haemotoxicity
Obtainable from South African Vaccine Producers (tel: +2711 386-6063/2/78 or
afterhours 0716809897 or 0828842971). See full details in the package insert.
Caution
Never administer antivenom without being fully prepared to manage acute
anaphylaxis.
 Boomslang monovalent antivenom, slow IV infusion, 20 mL diluted in 50–

100 mL sodium chloride 0.9% or dextrose 5%, administered over 5–10
minutes. LoE:IIIix
o The dose of antivenom is the same for adults and children.
o Spontaneous systemic bleeding should stop within 15–30 minutes
and blood coagulability be restored within 6 hours, after administering
2019 19.5
antivenom.
o Re-evaluate regularly, and if after 6 hours there is ongoing evidence
of coagulopathy, a repeat dose of 10 ml may be considered.
19.2.3 SNAKE VENOM IN THE EYE

S05.9 + (X20.99)
DESCRIPTION
Snake venom in the eye, particularly from various species of spitting cobras and
rinkhals, can cause local cytotoxic effects. Clinical presentation ranges from
periocular swelling and mild conjunctival and corneal inflammation, to frank
corneal ulceration and perforation with eventual blindness.
MEDICINE TREATMENT
Instil local anaesthetic:
 Tetracaine 1%, ophthalmic drops, instill 1 drop into the affected eye(s)
before irrigation.
 Irrigate the eye thoroughly for 15–20 minutes with water or sodium
chloride, 0.9% to dilute or remove the toxin.
 Apply chloramphenicol ointment and cover the affected LoE:III
eye with an eye patch.
Note: Do not instil polyvalent antivenom in the eye or give systemically.
LoE:IIIx
REFERRAL
Refer all patients to an ophthalmologist.
19.3 SCORPION ENVENOMATION

T63.2 + (X22.99)
DESCRIPTION
Medically important scorpions in Southern Africa are of the genus
Parabuthus (P. granulatus and P. transvaalicus). These are large scorpions
measuring 7–15 cm in length. Features useful in their identification are a
relatively large tail and small pincers, so-called thick-tailed scorpions.
Scorpions from the Scorpionidae family (e.g. Hadogenes, Opistophthalmus)
are thin-tailed with large pincers.
To view pictures for identification of scorpions click on following hyperlink:
A sting from thin-tailed scorpions is likely to result in local pain requiring
analgesia only.
2019 19.6
Clinical features of thick-tailed scorpion stings include:

Local effects:
» immediate and excruciating pain
» local paraesthesias and hyperaesthesia
Systemic effects:
» tremors, involuntary movements and fasciculations
» muscle pain, cramps, and weakness
» generalised paraesthesias and hyperaesthesia
» excessive sympathetic stimulation e.g. sweating, tachycardia
» excessive parasympathetic stimulation e.g. hypersalivation, vomiting and
diarrhoea, priapism
» bulbar paralysis (dysphagia, dysarthria)
» respiratory difficulty/failure
GENERAL MEASURES
Observe all cases of thick-tailed scorpion stings for at least 12 hours.
Monitor respiratory function.
Ventilatory support may be required.
MEDICINE TREATMENT
Scorpion antivenom therapy is recommended only in cases presenting with
systemic neurotoxic effects.
Obtainable from South African Vaccine Producers (tel: +2711 386-6063/2/78 or
afterhours 0716809897 or 0828842971). See full details in the package insert.
 Scorpion antivenom, IV infusion, 10 mL diluted in 100 mL sodium
chloride 0.9% or dextrose 5%, administered over 10 minutes.
o Response to antivenom may be slow and a repeat dose may be needed.
LoE:III
CAUTION
Never administer antivenom without being prepared to manage acute
anaphylaxis.

In unimmunised or partially immunised patients: (Z23.5)
Analgesia
For pain:
o Maximum daily dose: 4 g in 24 hours. LoE:IIIxi
2019 19.7
Severe local pain:

 Lidocaine 1–2%, 2 mL: infiltrate affected area as a local anaesthetic.
LoE:IIIxii
Opiates increase the risk of respiratory depression and if required,

should only be used with caution in severe uncontrolled pain.
LoE:IIIxiii
Severe muscle pain and cramps:
 Calcium gluconate 10%, bolus IV infusion, 10 mL over 10 minutes.
o Repeat if needed, only once
Note: Effect may only last for 20–30 minutes and there is a limited amount
that can be given. LoE:IIIxiv
19.4 SPIDER ENVENOMATION

T63.3 + (X21.99)
DESCRIPTION
Local venomous spiders are divided into cytotoxic and neurotoxic groups.
To view pictures for identification of spiders click on following hyperlink:
Cytotoxic spider group

The cytotoxic group includes sac, violin and crab spiders.
Lesions may present with significant bite site necrosis, for which surgical
debridement may be required. Bites can take weeks/months to heal.
Note: Antibiotics are reserved for secondary infection.
Neurotoxic spider group

The neurotoxic group is represented by the button spider (also known as
widow spiders), genus Latrodectus. Black button spiders are more
venomous than brown button spiders.
Features useful in the identification of the black button spider are:
» Black or dark brown colour.
» Variable red markings on the dorsal aspect of the abdomen, which
diminish with age. It has no ventral markings.
Features of brown button spider:
» Light brown to creamy yellow to pitch black in colour
» Typical red-orange hourglass-shaped marking on the ventral surface of
the abdomen.
Envenomation from black button spiders may cause:
» Immediate local burning pain and tender regional lymph nodes within an hour.
2019 19.8
» Severe general muscle pain, cramps and rigidity especially of the large
girdle muscles
- Causes feeling of tightness of the chest and board-like rigidity of a
non-tender abdomen.
- Lasts for days to a week if antivenom is not given.
» Profuse sweating may be prominent.
» Diffuse paraesthesia, especially of the hands and feet.
GENERAL MEASURES
Observe all cases of potential neurotoxic spider bite for at least 24 hours.
MEDICINE TREATMENT
» Spider antivenom is only indicated for systemic symptoms of
neurotoxicity in patients with button spider bites.
» Obtainable from South African Vaccine Producers (tel: +2711 386-
6063/2/78 or afterhours 0716809897 or 0828842971). See full details in
the package insert.
 Spider antivenom, IV infusion, 5–10 mL diluted in 50–100 mL sodium

chloride 0.9% or dextrose 5%, administered over 5–10 minutes.
LoE:IIIxv
Caution
Never administer antivenom without being prepared to manage acute
anaphylaxis.

In unimmunised or partially immunised patients: (Z23.5)
Analgesia
For mild pain:
Severe muscle pain and cramps:
 Calcium gluconate 10%, bolus IV infusion, 10 mL over 10 minutes.
o Repeat if needed.
Note: Effect may only last for 20–30 minutes and there is a limited amount
that can be given. LoE:IIIxvi
For secondary infection:
See section 4.2: Cellulitis and Erysipelas.
2019 19.9
POISONING
DESCRIPTION
Frequently encountered poisonings in adults include:
» analgesics » cardiodepressants
» hydrocarbons » anticonvulsants
» pesticides » toxic alcohols e.g. methanol, ethylene glycol
» anti-infectives » sedatives, antidepressants and antipsychotics
» antihistamines » iron
» ethanol/alcohol » irritants and corrosives
Suspect intentional ingestion in adults.
DIAGNOSTIC CRITERIA
Clinical
Can be divided into ‘toxidromes”:
Cholinergic: e.g. organophosphates
» salivation » diarrhoea
» lacrimation » vomiting
» urination » bronchorrhoea
» miosis (pinpoint pupils) » bradycardia
Salicylism: e.g. aspirin
» tachypnoea » agitation
» metabolic acidosis » coma
» seizures
Anticholinergic: e.g. antihistamines, amanita pantherina, atropine
» fever » dry/warm skin
» ileus » blurred vision
» flushing » mydriasis (dilated pupils)
» tachycardia » coma
» urinary retention » hallucinations and seizures
Sedative-hypnotic: e.g. alcohol, benzodiazepines
» obtundation or coma
Opiates: e.g. morphine
» miosis (pinpoint pupils) » decreased bowel sounds
» respiratory depression » hypothermia
» bradycardia » altered (decreased) mental status
» hypotension.
Dystonic reaction: e.g. haloperidol
» torticollis
» opisthotonus
» intermittent spasms and tongue thrusting
Sympathomimetic: e.g. cocaine, amphetamines
» hypertension » agitation
» tachycardia » sweating
» hyperthermia » dilated pupils
2019 19.10
Sympathomimetic toxidrome partly resembles anticholinergic toxidrome, i.e.

fight, flight and fright response, however the sympathomimetic toxic patient is
sweaty as opposed to hot dry skin seen with anticholinergic toxicity.
Toxic alcohols: e.g. ethylene glycol, methanol
» metabolic acidosis » hypoglycaemia
» increased osmolar and anion gap » convulsions
» visual disturbances (methanol) » renal failure (ethylene glycol)
» depressed level of consciousness.
GENERAL MEASURES
It is very important to ascertain if a TOXIC DOSE has been taken BEFORE
instituting any potentially harmful decontamination procedures in an
asymptomatic patient.
Take a complete and accurate history, ascertain all relevant facts and do a
complete clinical examination. A high index of suspicion is important.
Obtain a collateral history, especially for patients with impaired
consciousness. A special effort should be made to obtain tablets, packets,
containers, etc. to identify agents involved.
Stabilise the patient and monitor basic clinical parameters, i.e.:
» blood pressure and heart rate
» hydration
» airway and ventilation
» neurological status
» temperature
» glucose
Persistent or prolonged seizures may require medical management.
Phenytoin should not be used in cases of poisoning due to substances
known to be cardiotoxic e.g. tricyclic antidepressants, or where there is
evidence of clinical cardiotoxicity.
Prevent physical injury in the restless - avoid excessive sedation.
Limit toxicology investigations to those that may influence/alter
management. It is important to note the time after ingestion when blood was
taken in order to correctly interpret results (e.g. paracetamol, iron levels).
LoE:III
DECONTAMINATION
Limit further exposure to poison for the patient and protect healthcare
workers where necessary.
i. Topical exposure
In case of skin exposure, remove clothes and wash the body. Showering
may be useful.
Remove eye contaminants, especially alkalis, acids and other irritants, by
continuous irrigation of the eye with sterile water or normal saline for 15–20
minutes. Analgesic eye drops may be required to perform this adequately.
2019 19.11
ii. Gut decontamination

Methods of gut decontamination include:
 Gastric lavage
 Activated charcoal administration
 Whole bowel irrigation
Gastric lavage
If deemed beneficial, it should only be performed by experienced staff and
within 60 minutes of ingestion. LoE:IIIxvii
Can be considered for cases with:
» potentially life-threatening ingestions AND
» a protected airway i.e. fully awake and cooperative or intubated with a
depressed level of consciousness.
Gastric lavage is contra-indicated after ingestion of corrosive substances
and volatile hydrocarbons such as paraffin.
Technique:
Place patient in left lateral head down position
Insert orogastric tube if possible, with largest bore and rounded tip.
Insert 200ml warmed water or normal saline, and aspirate.
Continue until recovered solution is clear of particulate matter.
Activated charcoal
May reduce systemic absorption of a variety of poisonous substances. The
greatest benefit is achieved if activated charcoal is given within one hour
after ingestion; however where gastric emptying is delayed by certain
substances, there may be a longer period of time in which it is effective.
Activated charcoal must only be given in cases where the airway is
protected; i.e. fully awake and cooperative patient or intubated with a
depressed level of consciousness.
Repeated doses of activated charcoal (i.e. 50 g every 4 hours) are effective
in enhancing elimination of substances that undergo enterohepatic
circulation, e.g. carbamazepine, dapsone, phenobarbitone, quinine or
theophylline overdose.
LoE:IIIxviii
Charcoal may be useful if these Poisons where charcoal is ineffective
poisons are taken in toxic dose and should not be given
» carbamazepine, barbiturates, phenytoin » ethanol, methanol, ethylene glycol
» dapsone, quinine » brake fluid
» theophylline » petroleum products (e.g. petrol or
» salicylates paraffin)
» mushroom poisoning (Amanita » iron salts
phalloides) » lead, mercury, arsenic
» slow release preparations » lithium
» digoxin » strong acids or alkalis
» beta-blockers » other corrosive agents (e.g. household
» NSAIDs detergents)
2019 19.12
 Charcoal, activated, oral, 50 g (equivalent to 36 level medicine

measures) diluted in 100 mL water.
o When mixing, add a small amount of water to charcoal in a container.
o Cap and shake container to make a slurry and then dilute further.
LoE:IIIxix
Whole bowel irrigation
Whole bowel irrigation can be done for potentially toxic ingestions of
substances that are:
» not absorbed by activated charcoal (e.g. iron and lithium)
» sustained-release and enteric-coated products
» or for removal of illicit drugs in body packers
Patients must have a protected airway i.e. fully awake and cooperative or
intubated with a depressed level of consciousness.
 Polyethylene glycol (PEG) balanced electrolyte solution, NGT,
o 1500–2000 mL/hour.
o Continue until rectal effluent is clear.
LoE:IIIxx
OTHER TREATMENT MODALITIES
Urinary alkalinisation (e.g. severe salicylate or tricyclic antidepressant
poisoning)
Caution
This is a high risk procedure and should only be performed in consultation
with a specialist.
Haemodialysis
Patients with symptomatically severe poisoning e.g. due to salicylates, lithium,
ethylene glycol, methanol, ethanol and theophylline, may benefit from dialysis
(http://www.extrip-workgroup.org/).
Refer patient to a hospital with dialysis facilities.
Antidotes
There are a limited number of antidotes for poisoning by certain substances,
e.g. N-acetylcysteine for paracetamol, naloxone for opioids. Each antidote
has specific criteria and indications for use.
Once medically stable:
Assess and manage intentional poisoning – self-harm or harm by others:
» take a history of circumstances around the poisoning, substance use and
mental illness, and examine the mental state
» assess further suicide risk – see Primary Health Care STGs and EML,
section 16.7: Suicide risk assessment.
» refer to social, psychological and/or psychiatric services
Assess and manage a substance use disorder
» quantify the amount of substance used and related harms, e.g. with
2019 19.13
ASSIST (http://www.who.int/substance_abuse/activities/assist/en/) or
DUDIT (https://paihdelinkki.fi/sites/default/files/duditmanual.pdf) rating
scales and discuss with patient
» provide brief intervention with motivational interview
» refer for rehabilitation
REFERRAL
» Severely ill patient for ventilatory/circulatory support.
» Relevant diagnostic testing not available, e.g. paracetamol levels,
acid/base assessment.
» Relevant medication/antidote not available.
» Dialysis/haemoperfusion required.
19.5 ANALGESIC POISONING

19.5.1 PARACETAMOL POISONING
T39.1 + (X40.99/X60.99/Y10.99)
DESCRIPTION
Liver damage, due to the depletion of glutathione and accumulation of toxic
metabolites, can occur in any individual with paracetamol overdose. Patients
with predisposing risk factors for hepatotoxicity (“high risk” patients, see
below) may experience toxicity at lower ingested doses.
Clinical features
Gastrointestinal symptoms (anorexia, nausea, vomiting, malaise)
predominate in the first 0.5-24 hours. Patients with normal or only slightly
raised serum paracetamol levels usually continue to full recovery. In patients
with significantly raised paracetamol levels, hepatic toxicity (right upper
quadrant abdominal pain and tenderness, elevated bilirubin, raised liver
enzymes, coagulation defects, hypoglycaemia, encephalopathy and
metabolic acidosis) may manifest from 20-24 hours, peaking in severity at
about 72-96 hours. Patients may make a full recovery in 5-7 days, or demise
from hepatic failure, or less commonly, renal failure.
“High risk” patients include:
» Chronic alcoholism
» Chronic liver disease
» Use of enzyme-inducing medicines (e.g. carbamazepine, phenytoin,
efavirenz, phenobarbitone, rifampicin etc.)
» Depletion of glutathione resources (e.g. malnutrition, starvation, AIDS,
chronic illness, eating disorders etc.)
» Patients with recent illness, dehydration
2019 19.14
Treatment:
The treatment of paracetamol overdose depends on the dose ingested and
the time of presentation since ingestion. A serum paracetamol level is
plotted on the nomogram to assess the risk for hepatotoxicity. Values which
appear above the treatment line require the antidote N-acetylcysteine (NAC).
Acute single ingestion <8 hours post-ingestion:
Toxic dose defined as >200 mg/kg or 10 g (whichever is less).
Give activated charcoal if the patient presents within 1-2 hours of ingestion
Perform a serum paracetamol level 4 hours post-ingestion
If serum paracetamol level results will not be available before 8 hours post-
ingestion, and the patient has taken a toxic dose, do not delay initiation of
NAC. It can always be stopped if the serum level plotted on the nomogram
does not indicate its continued use.
Acute single ingestion >8 hours post-ingestion:
Toxic dose defined as >200 mg/kg or 10 g (whichever is less).
Start NAC infusion if a toxic dose has been ingested or the patient shows
clinical signs of toxicity.
Perform serum paracetamol level, INR and ALT.
Indications for continuing NAC infusion:
» serum paracetamol level above the treatment line on the nomogram
» serum paracetamol level under the treatment line but abnormal ALT
» more than 24 hours post-ingestion, measurable paracetamol level and/or
abnormal ALT
Acute single ingestion with unknown time of ingestion
Manage as for >8 hours post-ingestion.
2019 19.15
Paracetamol treatment nomogram
Source: Daly FF, Fountain JS, Murray L, Graudins A, Buckley NA; Panel of Australian and New Zealand clinical
toxicologists. Guidelines for the management of paracetamol poisoning in Australia and New Zealand-explanation
and elaboration. A consensus statement from clinical toxicologists consulting to the Australasian poisons
information centres. Med J Aust. 2008 Mar 3;188(5):296-301.
LoE:IIIxxi
(Access the paracetamol nomogram tool on the EML Clinical Guide cellphone application).
Repeated supratherapeutic ingestion (RSTI):

This may occur in patients using repeated high doses of the same product or
concurrent use of multiple paracetamol-containing products such as during
an acute febrile illness or in patients with chronic pain.
RSTI toxic doses are defined as:
» >200 mg/kg or 10 g (whichever is less) over a single 24-hour period.
» >150 mg/kg or 6 g (whichever is less) per 24-hour period for the
preceding 48 hours.
» >100 mg/kg or 4 g/day (whichever is less) per 24-hour period for more
than 48 hours and patients have symptoms suggestive of liver injury.
MEDICINE TREATMENT LoE:IIIxxii

N-acetylcysteine is the antidote of choice and should be
given intravenously. Although it is more effective when given within 8 hours
of ingestion of paracetamol, there may be benefit even if liver failure has
developed.
Histamine may be released, which mimics an allergic reaction. If this occurs
and the patient is stable, infusion may continue at a slower rate under
antihistamine cover. In the presence of bronchospasm, stop the infusion.
 N-acetylcysteine, IV:
o Initial infusion: 200 mg/kg in 500 mL 5% dextrose over 4 hours
2019 19.16
o Second infusion: 100 mg/kg in 1000 mL 5% dextrose over 16 hours.

o Any further N-acetylcysteine is given according to the second infusion
regimen.
LoE:IIIxxiii
If N-acetylcysteine, IV is unavailable:
 N-acetylcysteine, oral, 140 mg/kg, followed by 70 mg/kg 4 hourly for
seventeen doses.
Note: Avoid giving activated charcoal if using oral N-acetylcysteine, as it will
reduce systemic absorption of the antidote.
LoE:IIIxxiv
Further investigations and referral
Blood tests such as renal function, clotting profile, serum glucose and
acid/base status should only be done where clinically indicated.
Patients who develop liver failure must be referred for further management
and/or possible transplant.
19.5.2 SALICYLATE POISONING

T39.0 + (X40.99/X60.99/Y10.99)
DESCRIPTION
Mild to moderate toxicity:
» Nausea, vomiting, tinnitus, fever, tachypnoea and respiratory alkalosis
Severe toxicity:
» Metabolic acidosis, altered mental status, seizures, coma, non-
cardiogenic pulmonary oedema.
Note: Wintergreen oils/ ointments contain 98 % methyl salicylate.
GENERAL MEASURES
» Assess severity with history, clinical examination and salicylate levels if
possible.
» Correct hydration.
» Consider ICU admission for pulmonary and/or cerebral oedema.
MEDICINE TREATMENT
 Salicylates delay gastric emptying, therefore activated charcoal may be
effective for a longer period than usual.
 Whole bowel irrigation maybe useful for enteric-coated or modified-
release preparations.
LoE:IIIxxv
Treat acidosis and enhance renal excretion:
 Sodium bicarbonate, IV and urinary alkalinisation (blood pH 7.45-7.5 and
urine pH 7.5–8.5) in consultation with specialist and arrange for transfer.
LoE:III
2019 19.17
REFERRAL
Where acidosis does not respond to sodium bicarbonate, refer for
haemodialysis. LoE:IIIxxvi
19.5.3. OPIOID POISONING

T40.2 + (X42.99/X62.99/Y12.99)
DESCRIPTION
Patients present with the triad of CNS depression, respiratory depression
and constricted pupils. Non-cardiogenic pulmonary oedema can occur.
GENERAL MEASURES
Supportive management aimed at maintaining cardiorespiratory function.
Body packers/stuffers:
» Patients may ingest packages of heroin, and are at great risk of life-
threatening toxicity in the event of rupture.
» Abdominal X-rays or CT scan may show packages.
» Conservative management is recommended, as any attempt at removal
risks package rupture.
» Activated charcoal and whole bowel irrigation may aid in expelling
packets.
» Surgery is reserved for those who develop obstruction or perforation.
MEDICINE TREATMENT
 Naloxone, IV, 0.4 mg immediately, in patients with significant respiratory
depression.
o Effectiveness is limited by a half-life (± 1 hour) that is shorter than most
opioids; therefore repeated incremental doses may be needed at 2 to
3 minute intervals, followed by a naloxone infusion.
o If there is no response after a maximum of 10 mg of naloxone is
administered, the diagnosis of opioid-induced or partial opioid-
induced toxicity should be questioned.
o Consider intramuscular or subcutaneous administration, if the
intravenous route is not available.
o Note: Clinical response is measured by reversal of respiratory
depression, as the level of CNS depression improves. Continuous
monitoring is required for all patients who received naloxone.
LoE:IIIxxvii
2019 19.18
19.6 ANTIDEPRESSANT POISONING

19.6.1. TRICYCLIC ANTIDEPRESSANT POISONING
T43.0 + (X41.99/X61.99/Y11.99)
DESCRIPTION
Patients can deteriorate rapidly. They may have:
Mild to moderate poisoning:
» Sedation » Tachycardia
» Anticholinergic effects:
- delirium, - urinary retention, or
- dilated pupils, - dry mouth.
Severe Poisoning:
» QRS widening, ventricular dysrhythmias » Seizures
» Coma » Pulmonary oedema
» Hypotension
GENERAL MEASURES
Do a baseline ECG in all patients.
» ICU admission for ventilatory/circulatory support, when indicated. Be
prepared to intubate symptomatic patients early.
» Discharge patients only when
- asymptomatic, or
- mild symptoms/signs of toxicity and ECG has normalised for 24 hours.
MEDICINE TREATMENT
Tricyclic antidepressants delay gastric emptying, therefore activated
charcoal may be effective for a longer period than usual.
Serum alkalinisation for all patients with:

» ventricular dysrhythmias,
» prolonged QRS >100 msec
» hypotension unresponsive to fluids or
» seizures.
 Sodium bicarbonate, IV 1–2 mEq/kg as an 8.4% solution, as bolus doses
to achieve a pH of 7.45–7.55 (Specialist consultation).
o Monitor acid-base status, serum potassium and sodium.
o If sodium bicarbonate is unavailable or fluid restrictions limit intake,
consider hyperventilation of intubated patients.
LoE:IIIxxviii
In severe cases, inotropic support and anti-arrhythmics may be required
(See section 3.3: Cardiac dysrythmias) in addition to serum alkalinisation.
2019 19.19
Hypotension is due to myocardial dysfunction and alpha-adrenergic

vasodilation; be careful not to fluid overload the patient.
LoE:III
For seizures or if sedation is required for restlessness:
Treat with benzodiazepines - see section: 14.4.1 Status epilepticus.
Note: Phenytoin should be avoided (due to potential cardiotoxicity).
LoE:IIIxxix
Note: The use of flumazenil is not recommended in any patient with mixed
overdoses possibly including tricyclic antidepressants as it increases the risk
of convulsions and dysrhythmias.
LoE:Ixxx
19.7 IRON POISONING

T45.4 + (X44.99/X64.99/Y14.99)
DESCRIPTION
Iron is a commonly prescribed drug, especially in pregnancy, and in
overdose causes initial gastrointestinal toxicity.
Patients may have a stage of “apparent recovery” 6–36 hours post-ingestion.
This should not be confused with true recovery as patients may
subsequently deteriorate.
Significant exposure may be associated with:
» severe vomiting and diarrhoea » gastrointestinal haemorrhage
» metabolic acidosis, » hypotension, shock
» CNS depression, » renal failure, and
» hepatitis.
Ferrous salt Amount Elemental iron

Ferrous sulphate 170 mg ±65 mg
Ferrous gluconate 300 mg 35 mg
Ferrous fumarate 200 mg ±65 mg
GENERAL MEASURES
Gastrointestinal decontamination by whole bowel irrigation is recommended:
» if >60 mg/kg elemental iron has been ingested
» if modified-release preparations ingested
» undissolved tablets still visible on abdominal X-ray
Activated charcoal does not bind iron and is not indicated in isolated iron
overdose.
Serum iron concentration should be measured 4–6 hours after ingestion and
repeated every 6 hours until peak. The use of desferrioxamine interferes
with the interpretation of further serum iron levels.
Give intravenous fluids for hypotension.
2019 19.20
MEDICINE TREATMENT
Chelation therapy
Patients with serum iron levels <54 micromol/L and absence of symptoms >6
hours after overdose do not require chelation therapy.
Desferoxamine (deferoxamine) may be used for the following indications. If
in doubt, consult the Poisons Information Helpline):
» Severe symptoms (altered mental status, hemodynamic instability,
metabolic acidosis).
» Serum iron concentration >90 micromol/L.
» Peak serum iron concentration >60 micromol/L, AND persistent
gastrointestinal symptoms.
 Desferoxamine (deferoxamine), IV infusion, 15 mg/kg/hour to a total of
80 mg/kg, i.e. given over about 6 hours. Beware of hypotension.
o Note: Prolonged use >24 hours of high doses is associated with
acute lung injury and should be avoided. However, in LoE:IIIxxxi
severe poisonings, additional doses may be required.
o Desferoxamine can be used in pregnant women.
LoE:IIIxxxii
REFERRAL
Haemodialysis may be needed to remove desferoxamine-iron complexes in
patients with renal insufficiency.
19.8 THEOPHYLLINE POISONING

T48.6 + (X44.99/X64.99/Y14.99)
DESCRIPTION
Patients present with:
» tachycardia and tachyarrhythmias, » hyperventilation
» nausea and vomiting » tremor
» agitation » profound hypokalaemia
» seizures
GENERAL MEASURES
Monitor ECG and treat dysrhythmias.
Monitor and correct fluid status and electrolyte abnormalities.
Monitor theophylline concentrations, if available. Levels may continue to rise
up to 24 hours after ingestion of modified release preparations.
MEDICINE TREATMENT
Vomiting is common: (R11)
 Metoclopramide, IV/oral, 10 mg 8 hourly as required.
LoE:III
 Activated charcoal.
o Multiple doses of activated charcoal enhance LoE:IIIxxxiii
2019 19.21
elimination.
Correct hypokalaemia cautiously:

E87.6 + (T48.6/X44.99/X64.99/Y14.99)
 Potassium chloride, IV, maximal dose 40 mmol/L and maximal rate of 20
mmol/hour. LoE:IIIxxxiv
For seizures: R56.8 + (T48.6/X44.99/X64.99/Y14.99)

LoE:IIIxxxv
REFERRAL
In patients with symptoms of severe overdose (severe hypokalaemia,
seizures, refractory hypotension, dysrhythmias, theophylline level >555
micromol/L (100 mg/L), refer for haemodialysis.
LoE:IIIxxxvi
19.9 SEDATIVE HYPNOTIC POISONING
19.9.1 BENZODIAZEPINE POISONING

T42.4 + (X44.99/X64.99/Y14.99)
DESCRIPTION
Patients present with depressed levels of consciousness, confusion, ataxia
and dysarthria. Benzodiazepines are unlikely to cause significant respiratory
depression unless co-ingested with alcohol or other CNS depressants.
However, in the elderly, the danger of respiratory depression with overdose
exists.
Management is supportive and ventilation may be required.
Note: The use of flumazenil is not recommended in any patient with possible
benzodiazepine poisoning as it increases the risk of convulsions and
dysrhythmias. LoE:Ixxxvii
19.9.2 LITHIUM POISONING

T43.9 + (X44.99/X69.99/Y14.99)
DESCRIPTION
Lithium toxicity mostly occurs with chronic therapy and may be precipitated
by decreased excretion due to renal dysfunction, diuresis, dehydration,
hyponatraemia or drug-drug interactions (e.g. NSAIDs, diuretics, ACE-
inhibitors and ARBs).
2019 19.22
Signs and symptoms include:

» nausea and vomiting » diarrhoea
» nystagmus
» CNS symptoms: tremor, hyperreflexia, choreoathetoid movements,
fasciculations, ataxia, agitation, confusion and lethargy
In severe toxicity:
» coma » seizures
» dysrhythmias » hypotension
GENERAL MEASURES
Whole bowel irrigation may be considered with a potentially toxic ingestion
or ingestion of sustained-release products.
LoE:IIIxxxviii
Monitor:
» Vitals signs, mental status and urine output
» If available, do serial lithium levels 6 hourly until peaked and declining.
» Electrolytes and renal function.
» Fluid status: administer sodium chloride 0.9 % to maintain urine flow of
1–2 mL/kg/hour but prevent hypernatremia.
» Cardiac function and treat dysrhythmias (see chapter 3.3: Cardiovascular
dysrhythmias).
» Thyroid function, in chronic toxicity.
MEDICINE TREATMENT
Correct electrolyte abnormalities: see section: 7.2 Major electrolyte
abnormalities.

LoE:IIIxxxix
REFERRAL
Early referral for haemodialysis is indicated in severe lithium poisoning and
in patients with renal impairment. Discuss with a specialist.
LoE:IIIxl
19.10 ISONIAZID POISONING

T37.1 + (X44.99/X64.99/Y14.99)
DESCRIPTION
Acute toxicity can present with the classic triad of seizures, metabolic
acidosis and coma.
Seizures are generalised tonic-clonic and often refractory to standard
anticonvulsant therapy.
2019 19.23
GENERAL MEASURES
Supportive management aimed at preventing and managing complications.
Treat hyperthermia.
MEDICINE TREATMENT
For seizures:
 Pyridoxine, crushed tablets orally or via NGT in unconscious patient(s).
o 1 g for every gram of isoniazid ingested (maximum of 5 g), or
o 5 g for unknown amount ingested. LoE:IIIxli
Benzodiazepines may be used as an interim measure to control seizures:

 Lorazepam, IV/IM, 4 mg, repeat once after 5–10 minutes, if LoE:IIIxlii
necessary.
OR
Diazepam, IV, 10 mg, not faster than 2 mg/minute, repeat once after 5–
10 minutes if necessary.
OR
Clonazepam, IV, 2 mg, repeat once after 5–10 minutes if necessary.
OR
Midazolam, IM/IV 10 mg, repeat once after 5–10 minutes if necessary.
OR
Midazolam buccal, 10 mg using the parenteral formulation.
Phenytoin should not be used to control seizures in INH poisoning, as

it does not have GABA agonist properties.
LoE:IIIxliii
REFERRAL
Uncontrolled seizures
19.11 CALCIUM CHANNEL BLOCKER AND BETA

BLOCKER POISONING
T46.1
DESCRIPTION
Cardiovascular toxicity results in profound hypotension, bradycardia,
decreased systemic vascular resistance and cardiogenic shock. Depressed
level of consciousness and metabolic acidosis are consequent upon poor
tissue perfusion. Hyperglycaemia and hypokalaemia may occur.
Patients who have co-ingested other cardiac medicines and those with pre-
existing cardiac disease are at increased risk of morbidity.
The treatment of suspected cardiogenic shock in calcium channel blocker

and beta blocker poisoning follows similar therapeutic principles. The
2019 19.24
mainstay of treatment is high-dose insulin euglycaemia therapy and

catecholamine infusions to improve inotropy and chronotropy.
LoE:IIIxliv
GENERAL MEASURES
Monitor vital signs, ECG and blood glucose.
Treat symptomatic patients in consultation with a specialist.
MEDICINE TREATMENT
» Caution is advised for all decontamination procedures as they increase
vagal tone and may exacerbate bradycardia.
» Activated charcoal may be considered before the onset of symptoms.
» Whole bowel irrigation can be considered for ingestion of modified-
release preparations.
LoE:IIIxlv
Treat hypotension: I95.9 + (T46.1/X44.99/X64.99/Y14.99)
 Sodium chloride, IV, 0.9%. LoE:IIIxlvi
If hypotension not effectively controlled add:

 Calcium gluconate 10%, IV, 30–60 mL given over 15–30 minutes, with
ECG monitoring.
o This may be repeated a maximum of 4 times. LoE:IIIxlvii
Treat bradycardia: R00.1 + (T46.1/X44.99/X64.99/Y14.99)

 Atropine, IV 0.5–1 mg every 2–3 minutes to a maximum LoE:IIIxlviii
of 3 mg.
Use vasopressors as needed, e.g. adrenaline (epinephrine) infusion for
persistent hypotension (section 20.1: Cardiac arrest) or dobutamine for
bradycardia (section 20.1.5: Cardiogenic shock).
REFERRAL
Refer for management with high dose insulin for resistant hypotension and
bradycardia, in a high care or ICU setting.
LoE:IIIxlix
If glucose <10 mmol/L:
 Dextrose 50%, IV, 50 mL.
Followed by:
 Insulin, short acting, IV, 1 unit/kg.
o Followed by 0.5 unit/kg/hour.
o Titrate dose up until hypotension is corrected, to maximum 10
units/kg/hour.
Monitor and correct potassium and glucose.
LoE:IIIl
2019 19.25
19.12 COTRIMOXAZOLE POISONING

T37.0
DESCRIPTION
In acute overdose, low toxicity expected. Symptoms include nausea and
vomiting, dizziness, headache and neurological symptoms (such as
drowsiness, confusion and mental depression). Other signs include bone
marrow depression, haematuria and renal insufficiency. Hypersensitivity
reactions may occur.
GENERAL MEASURES
Treatment is symptomatic and supportive.
Monitor FBC, electrolytes, glucose, hepatic and renal function in
symptomatic patients.
19.13 ANTIRETROVIRAL AGENTS POISONING

T37.5
DESCRIPTION
Limited data is available regarding overdose of these medicines.
Toxicological effects are generally extensions of adverse effects.
GENERAL MEASURES
Monitor FBC, serum electrolytes, renal and liver function.
Monitor serum lipase in patients with abdominal pain.
Lactic acid and serum pH should be monitored in acidotic patients.
TREATMENT
There are no specific antidotes.
Treatment is symptomatic and supportive.
19.14 ILLICIT DRUGS
19.14.1 COCAINE POISONING

T40.5 + (X42.99/X65.99/Y12.99)
DESCRIPTION
Cocaine may be absorbed through any mucous membrane, smoked, ingested
or injected intravenously.
Mild toxicity: euphoria, anxiety, altered mental status, tachycardia, mild
hypertension
2019 19.26
Moderate toxicity: agitation, paranoia, hallucinations, cardiac dysrhythmias

Severe toxicity: severe headache, seizure, hyperthermia, rhabdomyolysis,
severe acidosis, vascular incidents (stroke, MI, intestinal ischaemia etc.),
pulmonary oedema.
GENERAL MEASURES
Supportive management aimed at preventing and managing complications.
Cool patients with hyperthermia.
Raised serum creatinine kinase may indicate rhabdomyolysis or myocardial
infarction.
Body packers/stuffers:
» Patients may ingest packages of cocaine, and are at great risk of life-
threatening toxicity in the event of rupture.
» Abdominal X-rays or CT scan may show packages.
» Conservative management is recommended, as any attempt at removal
risks package rupture.
» Activated charcoal and whole bowel irrigation may aid in expelling packets.
» Surgery is reserved for those who develop obstruction or perforation.
MEDICINE TREATMENT
For sedation and seizures: R56.8 + (T40.5/X42.99/X62.99/Y12.99)
LoE:IIIli
Delirium with severe agitation:
Arrhythmias:
See section 3.3: Cardiac dysrhythmias.
ß–blockers should not be used.
Severe hypertension:
See section 3.6.1: Hypertension, severe.
19.14.2 AMPHETAMINE DERIVATIVES POISONING

T43.6 + (X41.99/X61.99/Y11.99)
DESCRIPTION
These include:
» “Ecstasy”: 3,4-methylenedioxymethamphetamine (MDMA).
» “Ice” and “Eve”: 3,4-methylenedioxy-N-ethylamphetamine (MDEA).
» “Tik”: Methamphetamine.
2019 19.27
Drug effects are due to the increased release of noradrenaline, dopamine

and serotonin. Patients present with:
» hyperthermia, especially with MDMA » sweating
» tachycardia » dilated pupils
» hypertension » teeth grinding
» angina pectoris and myocardial infarction » delirium
» stroke » tremors
» hyperactivity » seizures and coma
Additional complications include:

» rhabdomyolysis » hyponatraemia
» hyperkalaemia » dehydration
» acute tubular necrosis
GENERAL MEASURES
Supportive management aims to maintain stable cardiorespiratory function.
Manage hyperthermia, hypoglycaemia, dehydration, and electrolyte
abnormalities.
MEDICINE TREATMENT
LoE:IIIlii
Severe hypertension:
See section 3.6.1: Hypertension, severe.
Haemodialysis may be required for acute renal failure.
19.15 HYDROCARBON POISONING

T52.0
DESCRIPTION
Poisoning due to petroleum products, including paraffin, turpentine, petrol,
mineral spirits. (This section does not include information on aromatic
hydrocarbons (e.g. benzene, toluene, xylene) often used by glue sniffers to
get high).
Clinical signs include:
» chemical pneumonitis, » GIT effects,
» arrhythmias, and » CNS effects.
GENERAL MEASURES
If contaminated, remove clothing and wash skin.
Do not induce emesis or attempt gastric emptying/lavage.
2019 19.28
MEDICINE TREATMENT
Activated charcoal is of no value.
Observe and examine for chemical pneumonitis. Prophylactic antibiotics are
not indicated.
19.16 INGESTION OF CAUSTIC SUBSTANCES

T54.3/T54.2
DESCRIPTION
Alkaline: Toilet bowl cleaners, drain cleaners, oven cleaners.
Acids: Various e.g. domestic descalers.
Depending on the concentration, caustic substances cause necrosis of the gut
mucosa and underlying tissue resulting in possible strictures later.
GENERAL MEASURES
No activated charcoal, forced emesis or gastric lavage.
Rinse mouth with copious amounts of cold water.
Make patient nil by mouth and set up IV access.
If persistent vomiting, drooling or any difficulty in swallowing, patient may
require endoscopic evaluation within 24-48 hours and possible surgical
intervention. (Discuss with a specialist). LoE:IIIliii
19.17 ALCOHOLS
19.17.1 ETHANOL POISONING

T51.0 + (X45.99/X65.99/Y15.99)
DESCRIPTION
Acute poisoning usually presents with:
» nausea and vomiting,
» central nervous system depression,
» hypoglycaemia,
» hypothermia,
» hypokalaemia
» acidosis.
Consider other causes for the patient’s condition, including hypoglycaemia
and head trauma.
GENERAL MEASURES
Supportive management aimed at maintaining stable cardiorespiratory function.
Protect the airway (ventilation may be needed).
Manage hypothermia, hypoglycaemia, and electrolyte abnormalities.
2019 19.29
MEDICINE TREATMENT
 Thiamine, IV, 100 mg in 1 L dextrose 5%.
19.17.2 ETHYLENE GLYCOL POISONING

T52.8 + (X46.99/X66.99/Y16.99)
DESCRIPTION
Ethylene glycol is the main component of motor vehicle radiator
coolant/antifreeze and is occasionally found in brake fluid. It is also found in
homemade toilet and drain cleaners.
Mild to moderate intoxication: Resembles alcohol intoxication, with nausea
and vomiting, nystagmus, ataxia and somnolence.
Severe intoxication:
Associated with more severe CNS depression (coma, hypotonia,
hyporeflexia) and high anion gap metabolic acidosis. Cardiovascular signs
include tachycardia and hypertension. Calcium oxalate crystals cause renal
failure and hypocalcaemia, which may manifest with prolongation of the QT
interval or tetany.
Anion gap calculation = Na – (CI + HCO3) (Normal = 8-16)
GENERAL MEASURES
Immediate consultation with the Poisons Information Helpline is important.
Early treatment with antidote may prevent formation of toxic metabolites.
Monitor blood gases and administer sodium bicarbonate
Early haemodialysis is the treatment of choice for severe poisoning with
profound acidosis.
MEDICINE TREATMENT
Ethanol
Indications:
History of ingestion, plus any two of the following criteria:
» Arterial pH <7.3
» Serum bicarbonate <20 mmol/L
» Presence of urinary oxalate crystals (ethylene glycol only) or visual
disturbances (methanol only) LoE:IIIliv
Dose:
 Ethanol 95% BP, oral,
o Loading dose 1 mL/kg
o Maintenance dose:
 non-drinker: 0.125 mL/kg/hr
 chronic drinker: 0.2 mL/kg/hr
o Dilute the calculated ethanol volume to 20% (1:5) in any suitable liquid.
2019 19.30
OR
 Ethanol 40% (gin, whiskey, vodka), oral
o Loading dose: 2 mL/kg
o Maintenance dose:
 non-drinker: 25 mL/kg/hour
 chronic drinker: 0.5 mL/kg/hour
o Dilute the calculated ethanol volume to 20% (1:2) in LoE:IIIlv
any suitable liquid.
Note:
» If patients are not co-operative, administer ethanol via a nasogastric tube.
» Maintain ethanol levels of 1–1.3 g/L (100–130 mg/dL).
» The dose of ethanol needs to be increased if the patient is receiving
concomitant haemodialysis.
» Several days of ethanol therapy may be required until clinical condition
improves. LoE:IIIlvi
Cofactor therapy:
 Thiamine, oral, 100 mg daily.
 Pyridoxine, oral, 100 mg daily.

LoE:III
Metabolic acidosis E87.2 + (T52.8/X46.99/X66.99/Y16.99)
 Sodium bicarbonate, IV, 50–100 mmol/L administered over 30–45
minutes.
Note:
» Rapid correction of acidosis may precipitate seizures in a hypocalcaemic
patient. Correct severe or clinically evident hypocalcaemia.
» Monitor glucose levels and correct hypoglycaemia, if LoE:IIIlvii
necessary.
REFERRAL
Severe poisoning with profound acidosis for early haemodialysis.
19.17.3 METHANOL POISONING

T51.1
DESCRIPTION
No longer found in methylated spirits as methanol replaced with less toxic
agents 10-20 years ago. Methanol may be found in stove or model fuels, or
in antifreeze and windscreen washes. Methanol may result in an ethanol-like
inebriation in the early phase.
Presentation:
» Ingestion of methanol results in initial mild inebriation (headache,
confusion, nausea and vomiting) followed by an asymptomatic period.
2019 19.31
» Later, toxic metabolite (formic acid) formation results in severe high

anion gap metabolic acidosis, and retinal toxicity (with visual impairment
to total blindness).
Anion gap calculation = Na – (CI + HCO3) (Normal = 8-16)
MEDICINE TREATMENT
If acidotic or visual disturbances;
Start with immediate ethanol antidote therapy (See section 19.15.2: Ethylene
glycol poisoning), and evaluate for urgent dialysis, if available.
LoE:IIIlviii
19.18 PESTICIDES AND RODENTICIDES
19.18.1 AMITRAZ POISONING

T44.6+ (X43.99/X63.99/Y13.99)
* Notifiable condition.
DESCRIPTION
Amitraz is a pesticide/insecticide which is an α2-adrenergic agonist. It is usually
formulated as a tick dip for dogs, cattle and sheep. Commercial formulations
contain up to 20% of amitraz in organic solvents. Poisoning may occur when
amitraz is ingested or absorbed via the skin or by inhalation.
Where the history is of an unspecified rat poison or pesticide ingestion,

consider other active ingredients such as super-warfarin anticoagulants and
organophosphates.
Patients with acute poisoning present with:
» impaired consciousness » bradycardia
» drowsiness » respiratory depression
» vomiting » hypothermia
» hypotension » generalized seizures
» constricted pupils or rarely, dilated pupils
Other complications include:
» hyperglycaemia
» glycosuria
» mild increase in transaminases
Patients usually regain consciousness within 24 hours.
Note: Amitraz poisoning can be confused with organophosphate poisoning;
whilst amitraz causes central nervous system depression, bradycardia,
miosis and respiratory depression, it does not cause excessive sweating and
salivation, urinary and faecal incontinence or muscle fasciculation which are
2019 19.32
seen with organophosphate poisoning. Furthermore, organophosphate

toxicity results in reduced serum pseudocholinesterase levels.
GENERAL MEASURES
Decontamination of skin and clothes where applicable.
Supportive and symptomatic treatment to maintain patent airway, adequate
respiration and circulation.
Mechanical ventilation may be needed in some cases.
Keep patient warm.
MEDICINE TREATMENT
 Activated charcoal, once patient is stabilised.
For severe bradycardia: R00.1 + (T44.6/X43.99/X63.99/Y13.99)
Manage with atropine - see section 3.3.3: Heart block LoE:III
(second or third degree).
LoE:IIIlix
19.18.2 ORGANOPHOSPHATE POISONING
T60.0 + (X48.99/X68.99/Y18.99)
DESCRIPTION
Absorption occurs through the skin, when the agent is taken orally, or by
inhalation.
Patients present with muscarinic and nicotinic manifestations of intoxication.
 Peripheral effects:
- Muscarinic overstimulation: bradycardia, hypotension, salivation,
lacrimation, vomiting, diarrhoea, increased bronchial secretions,
bronchospasm and miosis (pin point pupils).
- Nicotinic overstimulation: muscle weakness and fasciculations,
tachycardia, hypertension, mydriasis (dilated pupils).
 Central effects: coma, confusion, convulsions
Diagnosis is supported by low serum pseudocholinesterase levels.
Intermediate syndrome can occur within 1-4 days after recovery from
cholinergic crisis. Patients develop weakness or paralysis predominantly
affecting the muscles of respiration (including the neck flexors and bulbar
muscles) and proximal limb muscles, sparing the distal muscles. Cranial
nerves may also be affected. Supportive care is the mainstay of therapy.
Refer if ventilatory support is unavailable. LoE:IIIlx
2019 19.33

consider other active ingredients such as super-warfarin anticoagulants and
amitraz.
GENERAL MEASURES
Ensure use of personal protective equipment for staff – gloves, gowns and
eye protection. If staff come into contact with body fluids, wash off
immediately. LoE:IIIlxi
Decontamination procedures for the patient should only be done once the
patient is fully resuscitated.
Remove patient’s clothes and wash the body with soap and water. Place
clothes in closed bags.
Maintain adequate ventilation and circulation. Ventilatory support in ICU may
be required. Suction secretions frequently. If using suxamethonium for
intubation, consider that metabolism may be delayed and prolonged
respiratory support may be required. Use alternative agents if possible (See
section 12.3: Muscle relaxants).
MEDICINE TREATMENT
 Activated charcoal, once patient is stabilised.
For bronchorrhoea, bronchospasm or bradycardia:

 Atropine bolus, IV, 2–5 mg,
o Reassess after 3–5 minutes for evidence of LoE:IIlxii
atropinisation as indicated by reduced bronchial
secretions, dry skin, increasing heart rate and blood pressure, and
dilating pupils (note: pupil dilatation may be delayed)
o Give repeated atropine boluses incrementally doubling the dose until
adequate clinical response achieved, e.g. 2 mg, 4 mg, 8 mg, 16 mg etc.
- If no clinical response, give double the dose.
- If some response, give the same or reduced dose.
o Follow with infusion. Calculate the total dose of atropine given as
boluses (as described above). Give 10–20% of this dose per hour.
o Reassess frequently and adjust atropine infusion as follows:
- Bronchial secretions, bronchospasm or bradycardia recurs:
increase dose.
- Good control of bronchial secretions and signs of atropine overdose
(tachycardia, mydriasis, agitation, pyrexia, reduced bowel sounds
and urinary retention): decrease dose.
- No recurrence of bronchial secretions and no signs of atropine
overdose: reduce dose slowly.
Note: Do not stop atropine infusion abruptly, but wean over LoE:IIIlxiii
2019 19.34
at least 24 hours. Tachycardia and mydriasis are not contraindications for

giving atropine in the acute resuscitation setting.
For severe agitation:

 Diazepam, IV, 5–10 mg, immediately.
o Repeat after 30–60 minutes if needed. LoE:IIIlxiv
REFERRAL
Refer if ventilatory support is unavailable.
19.18.3 PARAQUAT POISONING

T60.3 + (X48.99/X68.99/Y18.99)
DESCRIPTION
Paraquat poisoning causes multi-organ failure and is often fatal. Following
oral ingestion, patients present with oral, oesophageal and gastric erosions
with severe gastroenteritis. Multi-organ failure develops, particularly renal
and respiratory failure, within 1–3 days. Patients surviving the initial phase
usually develop pulmonary fibrosis.
GENERAL MEASURES
Supportive and symptomatic management to maintain patent airway,
adequate respiration and circulation. Mechanical ventilation maybe needed
in some cases. The mainstay of treatment is palliative care.
Note: High inspiratory fraction of inspired oxygen (FiO2) may worsen
pulmonary toxicity. Supplemental oxygen should only be provided if the
patient is confirmed hypoxic.
MEDICINE TREATMENT
 Activated charcoal.
19.19 ANTICOAGULANT (WARFARIN AND RODENTICIDE

SUPERWARFARIN) POISONING
T45.5 + (X44.99/X64.99/Y14.99)
* Notifiable condition – rodenticide superwarfarin poisoning
DESCRIPTION
Poisoning due to ingestion of warfarin and superwarfarins, e.g. rat poison
and other vermin poisons.
Warfarin toxicity can occur with either acute overdose or unintentionally,
during therapeutic use, whereby drug interactions increase warfarin
2019 19.35
bioavailability (e.g. concomitant enzyme inhibitor), or concomitant

anticoagulant drugs are administered (e.g. NSAIDS).
Bleeding is the main clinical presentation e.g. gastrointestinal or intracranial
bleeding; however bleeding may be occult.
Superwarfarins are more potent than warfarin and may have a long duration
of effect; small doses of concentrated formulations may cause significant
anticoagulation.
Measure INR at baseline and 48 hours post ingestion, as the anticoagulant
effect may be delayed by 1–2 days.
consider other active ingredients such as amitraz and organophosphates.
GENERAL MEASURES
Resuscitation.
Stop warfarin in patients on therapy.
MEDICINE TREATMENT
For patients on warfarin therapy
INR 5 to 9 without bleeding:
» Stop warfarin
» Evaluate bleeding risk
- High risk patients: (history of bleeding, stroke, renal insufficiency,
anaemia, hypertension).
 Vitamin K1 oral, 1–2.5 mg, for 1–2 days and monitor INR.
- Low risk patients: Monitor INR.
INR >9 without bleeding:

» Stop warfarin.
 Vitamin K1 oral, 2.5–5 mg, for 1–2 days and monitor INR (response
usually in 24 to 48 hrs).
» Resume warfarin therapy, at a lower dose.
Vitamin K1 is available as a parenteral preparation only, but is safest given
orally in anticoagulant poisoning.
LoE:Ilxv
Elevated INR with significant bleeding: R58 +
(T45.5/X44.99/X64.99/Y14.99)
» Stop warfarin.
 Lyophilised plasma, IV, 15 mL/kg.

OR LoE:IIIlxvi
FFP 15 mL/kg.
LoE:IIlxvii
Followed by:
2019 19.36
 Vitamin K1, IV,10 mg diluted in 100 mL sodium chloride 0.9% over 20

minutes and monitor for prophylaxis.
LoE:IIIlxviii
Note:
» In patients with prosthetic heart valves, high dose vitamin K is
associated with increased resistance to warfarin and increased risk of
thromboembolism. Treat as above, but monitor INR frequently to
prevent overcorrection in consultation with a specialist.
» In all patients on therapeutic warfarin, a major overdose or bleeding
episode should prompt careful review of the need for anticoagulation
» If warfarin is indicated it should be re-instituted, once the INR is in
the therapeutic range.
Rodenticide ingestion - Superwarfarins

Do not given prophylactic vitamin K.
INR >4 or the patient is actively bleeding: LoE:IIIlxix

 Vitamin K1 oral, 10–25 mg, daily may be required.
Vitamin K1 is available as a parenteral preparation only, but is safest given
orally in anticoagulant poisoning.
Treatment with vitamin K1 may need to be prolonged for several months as
superwarfarins are very long acting.
19.20 CARBON MONOXIDE POISONING

T58 + (X47.99/X67.99/Y17.99)
DESCRIPTION
Poisoning caused by accidental or intentional exposure to fires in poorly
ventilated areas, combustion engines, faulty stoves and faulty heating systems.
» dizziness » impaired level of consciousness
» headache » tachycardia
» seizures and other CNS symptoms » chest pain
» nausea and vomiting » retinal haemorrhages
» metabolic acidosis (severe) » respiratory alkalosis (mild)
» high arterial carboxyhaemoglobin levels
Note: There may be a normal arterial PaO2, but low oxygen saturation on
pulse oximetry. Neither are useful in assessing severity of carbon monoxide
poisoning. Ideally, a blood gas sample should be sent for co-oximetry to
specifically detect carboxyhaemoglobin levels.
GENERAL MEASURES
Remove patient from toxic environment.
2019 19.37
Ventilation may be needed in deeply comatose patients.

Monitor ECG and neurological status.
MEDICINE TREATMENT
 Oxygen, 100%, via positive pressure facemask.
For seizures: R56.8 + (T58/X47.99/X67.99/Y17.99)
LoE:IIIlxx
Metabolic acidosis:
Metabolic acidosis shifts the oxygen-dissociation curve to the right and
therefore aids in maintaining tissue oxygenation despite reduced
haemoglobin carrying capacity. Metabolic acidosis should only be treated if
profound and persistent, following standard treatment protocols.
Patients should be followed up after discharge for the persistence of
neurocognitive symptoms.
19.21 HEAVY METAL POISONING

T56.1/T57.0/T56.8/T56.4/T56.0/T56.3
DESCRIPTION
This includes mercury, arsenic, gold, copper, lead poisoning, thallium etc.
Inhalation of metal fumes and particles results in metal fume fever. This may
be confused with an acute viral illness with fever, cough, sweating, myalgia,
headache etc. The course of the illness is usually benign.
The management of heavy metal toxicity depends on the specific metal, route
of exposure and length of time between exposure and clinical presentation of
symptoms. Discuss all potential patients with the Poisons Information Helpline
for further investigation, treatment options and possible referral.
Metal Signs and symptoms
Copper salts GIT irritation, hepatotoxicity and haemolysis.
Arsenic Impairs cellular respiration, resulting in multi-organ
dysfunction.
Mercury Clinical effects depend on the route of exposure and type
of mercury (inorganic versus organic).
Lead Chronic toxicity more common. Affects nervous,
gastrointestinal, renal and haematopoietic systems.
Gold Deposition of immune complexes in kidneys and skin;
mucus membrane inflammation
Thallium Alopecia and painful ascending peripheral neuropathy.
LoE:IIIlxxi
2019 19.38
19.22 POISONING WITH SUBSTANCES THAT CAUSE

METHAEMOGLOBINAEMIA
D74.9 + (T46.3/X44.99/X64.99/Y14.99)
DESCRIPTION
Substances causing methaemoglobinaemia include nitrites, nitroglycerine,
dapsone, mothballs (naphthalene), local anaesthetics, phenazopyridine,
chlorates and anilines.
Nitrites are used to cure meat in the formal and informal butchery sector.
» Deep cyanosis with only mildly reduced oxygen saturation,
» CNS depression, and
» arrhythmias.
Note: Methaemoglobinaemia causes patients to appear cyanosed with

falsely high conventional pulse oximetry readings and normal PaO2. Blood
gas analysis using co-oximetry is required to specifically measure
methaemoglobin levels.
MEDICINE TREATMENT
 Oxygen via facemask.
In symptomatic cases or patients with high methaemoglobin values > 30%:
 Methylene blue (methylthionine chloride) 1% dilute solution, slow IV
infusion, 1–2 mg/kg administered over 5 minutes.
o Repeat in 1 hour and, if necessary, 4 hourly up to total of 7 mg/kg.
o Side effects include precordial pain, restlessness and dyspnoea.
o After administration of methylene blue, oxygen saturation may drop
initially.
In life-threatening cases, not responding to methylene blue or if methylene
blue is not available, exchange transfusion may be considered. Refer to the
Poisons Information Helpline for advice on treatment and possible
alternatives to methylene blue.
2019 19.39
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Cape Town, 2016.

Naloxone: FDA approved package insert – Hospira Inc.: Naloxone Hydrochloride, 2015.
http://medlibrary.org/lib/rx/meds/naloxone-hydrochloride-8/
xxviii Sodium bicarbonate, IV: Bruccoleri RE, Burns MM. A Literature Review of the Use of Sodium Bicarbonate for
the Treatment of QRS Widening. J Med Toxicol. 2016 Mar;12(1):121-9.

xxix Phenytoin (seizures secondary to poisonings): South African Medicines Formulary. 12th Edition. Division of

xxx Flumazenil : Penninga EI, Graudal N, Ladekarl MB, Jürgens G. Adverse Events Associated with Flumazenil
Treatment for the Management of Suspected Benzodiazepine Intoxication - A Systematic Review with Meta-
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Analyses of Randomised Trials. Basic ClinPharmacolToxicol. 2016 Jan;118(1):37-

xxxi Desferrioxamine, IV: Tenenbein M. Benefits of parenteral deferoxamine for acute iron poisoning. J
ToxicolClinToxicol. 1996;34(5):485-9.http://www.ncbi.nlm.nih.gov/pubmed/8800185
Desferrioxamine, IV: Tenenbein M, Kowalski S, Sienko A, Bowden DH, Adamson IY. Pulmonary toxic effects of
continuous desferrioxamine administration in acute iron poisoning. Lancet. 1992 Mar 21;339(8795):699-701.
xxxii Desferrioxamine, IV (pregnancy): Liebelt EL, Kronfol R, Burns MM, Traub SJ, Wiley JF. Acute Iron Poisoning.
UpToDate - Narrative review, August 2015. http://www.uptodate.com/contents/acute-iron-poisoning

xxxiii Activated charcoal (multi-dose): Ghannoum M, Wiegand TJ, Liu KD, Calello DP, Godin M, Lavergne V, Gosselin
S, Nolin TD, Hoffman RS; EXTRIP workgroup. Extracorporeal treatment for theophylline poisoning: systematic
review and recommendations from the EXTRIP workgroup. Clin Toxicol (Phila). 2015 May;53(4):215-29.
xxxiv Potassium chloride, IV: Ghannoum M, Wiegand TJ, Liu KD, Calello DP, Godin M, Lavergne V, Gosselin S,
Nolin TD, Hoffman RS; EXTRIP workgroup. Extracorporeal treatment for theophylline poisoning: systematic review
and recommendations from the EXTRIP workgroup. Clin Toxicol (Phila). 2015 May;53(4):215-29.
xxxv Phenytoin (seizures secondary to poisonings): South African Medicines Formulary. 12th Edition. Division of

xxxvi Haemodialysis: Activated charcoal (multi-dose): Ghannoum M, Wiegand TJ, Liu KD, Calello DP, Godin M,
Lavergne V, Gosselin S, Nolin TD, Hoffman RS; EXTRIP workgroup. Extracorporeal treatment for theophylline
poisoning: systematic review and recommendations from the EXTRIP workgroup. Clin Toxicol (Phila). 2015
xxxvii Flumazenil: Penninga EI, Graudal N, Ladekarl MB, Jürgens G. Adverse Events Associated with Flumazenil
Treatment for the Management of Suspected Benzodiazepine Intoxication - A Systematic Review with Meta-
Analyses of Randomised Trials. Basic ClinPharmacolToxicol. 2016 Jan;118(1):37-
xxxviiiWhole bowel irrigation (with polyethylene glycol): Thanacoody R, Caravati EM, Troutman B, Hojer J, Benson B,
Hoppu K et al. Position paper update: whole bowel irrigation for gastrointestinal decontamination of overdose
patients. Clin Toxicol (Phila) 2015;53:5-12. https://www.ncbi.nlm.nih.gov/pubmed/25511637
Whole bowel irrigation (with polyethylene glycol): National Department of Health, Essential Drugs Programme:
Paediatric Hospital Level STGs and EML, 2017. http://www.health.gov.za/
xxxix Phenytoin (seizures secondary to poisonings): South African Medicines Formulary. 12th Edition. Division of

xl
Haemodialysis (early referral): Decker BS, Goldfarb DS, Dargan PI, Friesen M, Gosselin S, Hoffman RS,
Lavergne V, Nolin TD, Ghannoum M; EXTRIP Workgroup. Extracorporeal Treatment for Lithium Poisoning:
Systematic Review and Recommendations from the EXTRIP Workgroup. Clin J Am Soc Nephrol. 2015 May
xliPyridoxine, oral: Lheureux P, Penaloza A, Gris M. Pyridoxine in clinical toxicology: a review. Eur J Emerg Med.
2005 Apr;12(2):78-85. http://www.ncbi.nlm.nih.gov/pubmed/15756083

Pyridoxine, oral: Dilrukshi M, Ratnayake C, Gnanathasan C. Oral pyridoxine can substitute for intravenous
pyridoxine in managing patients with severe poisoning with isoniazid and rifampicin fixed dose combination tablets:
a case report. BMC Res Notes 2017;10:370. https://www.ncbi.nlm.nih.gov/pubmed/28789699
xlii Benzodiazepines (seizures in INH toxicity): Hoffman RS, Howlands MA, Lewin Na, Nelson LS, Goldfrank LR.
Goldfrank’s Toxicologic Emergencies. 10th ed. China: McGraw-Hill Education; 2015.

xliii Phenytoin (avoid in isoniazid poisoning): Hoffman RS, Howlands MA, Lewin Na, Nelson LS, Goldfrank LR.
Goldfrank’s Toxicologic Emergencies. 10th ed. China: McGraw-Hill Education; 2015.

xlivCalcium channel blocker poisonings and beta-blocker poisonings (similar management): Graudins A, Lee HM, Druda
D. Calcium channel antagonist and beta-blocker overdose: antidotes and adjunct therapies. Br J Clin Pharmacol. 2016
Mar;81(3):453-61. https://www.ncbi.nlm.nih.gov/pubmed/26344579
xlvGut decontamination (Gastric lavage, activated charcoal administration or whole bowel irrigation): St-Onge M,
Anseeuw K, Cantrell FL, Gilchrist IC, Hantson P, Bailey B, Lavergne V, Gosselin S, Kerns W 2nd, Laliberté M,
Lavonas EJ, Juurlink DN, Muscedere J, Yang CC, Sinuff T, Rieder M, Mégarbane B. Experts Consensus
Recommendations for the Management of Calcium Channel Blocker Poisoning in Adults. Crit Care Med. 2017
Mar;45(3):e306-e315. https://www.ncbi.nlm.nih.gov/pubmed/27749343
xlviSodium chloride, 0.9%, IV: Proano L, Chiang WK, Wang RY. Calcium channel blocker overdose. Am J Emerg
Med. 1995 Jul;13(4):444-50.http://www.ncbi.nlm.nih.gov/pubmed/7605536

xlviiCalcium gluconate 10%, IV (calcium channel blocker toxicity): Proano L, Chiang WK, Wang RY. Calcium channel
blocker overdose. Am J Emerg Med. 1995 Jul;13(4):444-50. http://www.ncbi.nlm.nih.gov/pubmed/7605536

Calcium gluconate 10%, IV (calcium channel blocker toxicity): Graudins A, Lee HM, Druda D. Calcium channel
antagonist and beta-blocker overdose: antidotes and adjunct therapies. Br J Clin Pharmacol. 2016 Mar;81(3):453-61.
xlviiiAtropine, IV: Proano L, Chiang WK, Wang RY. Calcium channel blocker overdose. Am J Emerg Med. 1995
xlixDextrose 50%, IV & high dose insulin: Graudins A, Lee HM, Druda D. Calcium channel antagonist and beta-blocker
2019 19.42
overdose: antidotes and adjunct therapies. Br J Clin Pharmacol. 2016 Mar;81(3):453-61.

Dextrose 50%, IV & high dose insulin: Greene SL, Gawarammana I, Wood DM, Jones AL, Dargan PI. Relative
safety of hyperinsulinaemia/euglycaemia therapy in the management of calcium channel blocker overdose: a
prospective observational study. Intensive Care Med. 2007 Nov;33(11):2019-24. Epub 2007 Jul 11.
Dextrose 50%, IV & high dose insulin: Patel NP, Pugh ME, Goldberg S, Eiger G. Hyperinsulinemiceuglycemia
therapy for verapamil poisoning: a review. Am J Crit Care. 2007 Sep;16(5):498-
Dextrose 50%, IV & high dose insulin: Engebretsen KM, Kaczmarek KM, Morgan J, Holger JS. High-dose
insulin therapy in beta-blocker and calcium channel-blocker poisoning. Clin Toxicol (Phila). 2011 Apr;49(4):277-83.
lDextrose 50%, IV: Proano L, Chiang WK, Wang RY. Calcium channel blocker overdose. Am J Emerg Med. 1995
li Phenytoin (seizures secondary to poisonings): South African Medicines Formulary. 12th Edition. Division of

lii Phenytoin (seizures secondary to poisonings): South African Medicines Formulary. 12th Edition. Division of

liii Endoscopic evaluation (within 24-48 hours): Millar AJ, Cox SG. Caustic injury of the oesophagus. Pediatr Surg
Int. 2015 Feb;31(2):111-21. https://www.ncbi.nlm.nih.gov/pubmed/25432099

liv Ethanol (indications for antidote): McMartin K, Jacobsen D, Hovda KE. Antidotes for poisoning by alcohols that
form toxic metabolites. Br J Clin Pharmacol. 2016 Mar;81(3):505-15.

lv Ethanol (dosing of antidote): McMartin K, Jacobsen D, Hovda KE. Antidotes for poisoning by alcohols that form
toxic metabolites. Br J Clin Pharmacol. 2016 Mar;81(3):505-15. https://www.ncbi.nlm.nih.gov/pubmed/26551875

lvi Ethanol (dosing of antidote): McMartin K, Jacobsen D, Hovda KE. Antidotes for poisoning by alcohols that form

lvii Metabolic acidosis cautions: McMartin K, Jacobsen D, Hovda KE. Antidotes for poisoning by alcohols that form

lviii Ethanol antidote and haemodialysis (methanol poisoning): Jacobsen D, McMartin KE. Antidotes for methanol
and ethylene glycol poisoning. J Toxicol Clin Toxicol. 1997;35(2):127-43.

Ethanol antidote and haemodialysis (methanol poisoning): Roberts DM, Yates C, Megarbane B, Winchester JF,
Maclaren R, Gosselin S, Nolin TD, Lavergne V, Hoffman RS, Ghannoum M; EXTRIP Work Group.
Recommendations for the role of extracorporeal treatments in the management of acute methanol poisoning: a
systematic review and consensus statement. Crit Care Med. 2015 Feb;43(2):461-72.
lix Phenytoin (seizures secondary to poisonings): South African Medicines Formulary. 12th Edition. Division of

lx Intermediate syndrome in organophosphate poisoning: Eddleston M, Buckley NA, Eyer P, Dawson AH.
Management of acute organophosphorus pesticide poisoning. Lancet. 2008 Feb 16;371(9612):597-607.

lxi Organophosphate poisoning – healthcare worker protection: Little M, Murray L; Poison Information Centres of
New South Wales, Western Australia, Queensland, New Zealand, and the Australian Capital Territory. Consensus
statement: risk of nosocomial organophosphate poisoning in emergency departments. Emerg Med Australas. 2004
Oct-Dec;16(5-6):456-8. https://www.ncbi.nlm.nih.gov/pubmed/15537409
Organophosphate poisoning – healthcare worker protection: Centers for Disease Control and Prevention (CDC).
Nosocomial poisoning associated with emergency department treatment of organophosphate toxicity--Georgia,
2000. MMWR Morb Mortal Wkly Rep. 2001 Jan 5;49(51-52):1156-8.
Organophosphate poisoning – healthcare worker protection: Stacey R, Morfey D, Payne S. Secondary
contamination in organophosphate poisoning: analysis of an incident. QJM. 2004 Feb;97(2):75-80.
lxii Atropine, IV (bolus dose): Abedin MJ, Sayeed AA, Basher A, Maude RJ, Hoque G, Faiz MA. Open-label
randomized clinical trial of atropine bolus injection versus incremental boluses plus infusion for organophosphate
poisoning in Bangladesh. J Med Toxicol. 2012 Jun;8(2):108-17. http://www.ncbi.nlm.nih.gov/pubmed/22351300
lxiii Atropine, IV (protocol): Eddleston M, Buckley NA, Eyer P, Dawson AH. Management of acute
organophosphorus pesticide poisoning. Lancet. 2008 Feb 16;371(9612):597-607.

Atropine, IV (protocol): Eddleston M, Dawson A, Karalliedde L, Dissanayake W, Hittarage A, Azher S,
Buckley NA. Early management after self-poisoning with an organophosphorus or
carbamate pesticide - a treatment protocol for junior doctors. Crit Care. 2004 Dec;8(6):R391-7.
2019 19.43
lxiv Diazepam, IV (seizures in organophosphate poisoning): Eddleston M, Buckley NA, Eyer P, Dawson AH.
Management of acute organophosphorus pesticide poisoning. Lancet. 2008 Feb 16;371(9612):597-607.
lxvVitamin K , oral:Dezee KJ, Shimeall WT, Douglas KM, Shumway NM, O'malley PG. Treatment of
1
excessive anticoagulation with phytonadione (vitamin K): a meta-analysis. Arch Intern Med. 2006 Feb
Vitamin K1, oral: Crowther MA, Douketis JD, Schnurr T, Steidl L, Mera V, Ultori C, Venco A, Ageno W. Oral vitamin
K lowers the international normalized ratio more rapidly than subcutaneous vitamin K in the treatment of warfarin-
associated coagulopathy. A randomized, controlled trial. Ann Intern Med. 2002 Aug 20;137(4):251-
lxviFreshfrozen plasma: Ansell J, Hirsh J, Hylek E, Jacobson A, Crowther M, Palareti G; American College of Chest
Physicians. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians
Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008 Jun;133(6 Suppl):160S-
198S.http://www.ncbi.nlm.nih.gov/pubmed/18574265
lxviiLyophilised plasma: Lerner RG, Nelson J, Sorcia E, Grima K, Kancherla RR, Zarou-Naimo CM, Pehta JC.
Evaluation of solvent/detergent-treated plasma in patients with a prolonged prothrombin time. Vox Sang.
Lyophilised plasma: Huisman EL, de Silva SU, de Peuter MA. Economic evaluation of pooled solvent/detergent
treated plasma versus single donor fresh-frozen plasma in patients receiving plasma transfusions in the United States.
TransfusApher Sci. 2014 Aug;51(1):17-24. http://www.ncbi.nlm.nih.gov/pubmed/25151097
lxviiiVitamin K , IV: Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ, Svensson PJ, Veenstra DL,
1
Crowther M, Guyatt GH; American College of Chest Physicians. Evidence-based management of anticoagulant
therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians
Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e152S-
84S.http://www.ncbi.nlm.nih.gov/pubmed/22315259
lxix Vitamin K , IV (INR cut-off – rodenticides/superwarfarin poisoning): Watt BE, Proudfoot AT, Bradberry SM, Vale
1
JA. Anticoagulant rodenticides. Toxicol Rev. 2005;24(4):259-69. https://www.ncbi.nlm.nih.gov/pubmed/16499407
lxx Phenytoin (seizures secondary to poisonings): South African Medicines Formulary. 12th Edition. Division of

lxxiHeavy metal poisoning (signs and symptoms): AfriTox 2019. [Accessed September 2019]. www.afritox.co.za
2019 19.44
CHAPTER 20
EMERGENCIES AND INJURIES
CARDIAC ARREST – CARDIOPULMONARY
RESUSCITATION
Abbreviations: CPR = Cardiopulmonary Resuscitation; PEA = Pulseless Electrical Activity; VF =

Ventricular Fibrillation; VT = Ventricular Tachycardia.
2019 20.1
CHAPTER 20 EMERGENCIES AND INJURIES
20.1 CARDIAC ARREST IN ADULTS

I46.0/I46.9
DESCRIPTION
Described as the loss of a heart beat and a palpable pulse, irrespective of the
electrical activity captured on ECG tracing. Irreversible brain damage can occur
within 2–4 minutes.
Clinical features include:
» sudden loss of consciousness, absent carotid pulses
» loss of spontaneous respiration
EMERGENCY TREATMENT
» Diagnose rapidly. After ensuring the safety of the scene, commence
resuscitation as per acute adult cardiac arrest algorithm – as above
» Make a note of the time of starting resuscitation.
» Place the patient on a firm flat surface and commence resuscitation
immediately.
» Call for skilled help and an automated external defibrillator (AED) or
defibrillator.
» Initiate CAB (Circulation Airway Breathing) sequence of CPR
(cardiopulmonary resuscitation).
» Where a defibrillator is not immediately available, a single powerful
precordial thump is recommended for witnessed cardiac arrest.
» Document medication and progress after the resuscitation.
Cardiopulmonary resuscitation (CPR)

Circulation
» Check for carotid pulse for about 5 seconds.
» If there is no pulse or you are not sure, start with chest compressions at a
rate of 100-120 compressions per minute. Push hard and allow full recoil of
chest with minimum interruptions.
Airway and breathing
» To open the airway, lift the chin forward with the fingers of the one hand and
tilt the head backwards with other hand on the forehead.
» Note: Do not do this where a neck injury is suspected – refer below for
management of suspected neck injury.
» Do not do this where a neck injury is suspected – refer below for
management of suspected neck injury
» Ensure airway is open throughout resuscitation.
» If there is no normal breathing, attempt 2 respirations with bag-valve-mask
resuscitator and face mask.
» The administered breaths must cause visible chest rising in patient. If not,
reposition and try again once and proceed to next step.
» Repeat the cycle of 30 compressions followed by 2 respirations for 5 cycles
and then re-assess for a pulse.
2019 20.2
» If advanced airway is placed, administer 1 breath every 6 second. Avoid

excessive ventilation.
 Oxygenate with 100% oxygen.
Where neck injury is suspected:

» To open the airway, place your fingers behind the jaw on each side.
» Lift the jaw upwards while opening the mouth with your thumbs (jaw thrust).
» To open the airway, place your fingers behind the jaw on each side.
» Maintain in line cervical spine immobilisation.
Initiate fluids, IV/IO access

 Sodium chloride 0.9%. LoE:Ii
If pulseless with shockable rhythm (ventricular fibrillation/tachycardia)

» Defibrillate, as indicated per algorithm.
» Immediately resume CPR. Starting with chest compression.
» Continue CPR for 2 minutes.
 Administer adrenaline (epinephrine) as per algorithm.
» Seek reversible cause of arrest.
» Continue CPR until spontaneous breathing and/or heart beat returns.
» For management of
» ventricular fibrillation or pulseless ventricular tachycardia that is
unresponsive to defibrillation:
 Amiodarone, IV bolus, 300 mg, 2 minutes after adrenaline (epinephrine)
dose.
o Follow by a bolus of 10 mL sodium chloride 0.9%
o Patient remains in a shockable rhythm following further 2 minutes of CPR,
a defibrillation shock, another adrenaline (epinephrine) dose, and another
2 minutes of CPR (5 cycles of 30:2): Amiodarone, IV bolus, 150 mg.
LoE:Iii
If pulseless with non-shockable rhythm
» Immediately resume CPR. Starting with chest compression.
» Continue CPR for 2 minutes.
 Administer adrenaline as per algorithm.
» Seek reversible cause of arrest.
» Continue CPR until spontaneous breathing and/or heart beat returns.
Immediate emergency medicine treatment

Adrenaline (epinephrine) is the mainstay of treatment and should be given
immediately, IV or intra-osseous, when there is no response to initial
resuscitation or defibrillation.
 Adrenaline (epinephrine), 1:1 000, 1 mL, IV immediately, as a single
dose. LoE:Iiii
o Flush with 5–10 mL IV of sterile water or sodium
chloride, 0.9%.
o Repeat every 3–5 minutes during resuscitation.
2019 20.3
If no IV line is available:
 Adrenaline (epinephrine), intra-osseous (IO), 1:1000, 1 LoE:IIIiv
mL, via IO line.
o Flush with 5–10 mL of sterile water or sodium chloride 0.9%.
o Repeat every 3–5 minutes during resuscitation.
» Assess continuously until the patient shows signs of recovery.
» Consider stopping resuscitation attempts and pronouncing death if:
 further resuscitation is clearly clinically inappropriate, e.g. incurable
underlying disease, all known reversible factors addressed or
 no success after all the above procedures have been carried out for ≥
30 minutes.
» Consider carrying on for longer especially when:
 hypothermia and drowning, particularly in younger patients
 poisoning or drug overdose or carbon monoxide poisoning
20.2 POST CARDIAC ARREST CARE

I46.0
DESCRIPTION
Post cardiac arrest care starts following successful CPR. During this time the
patient is vulnerable to several processes, including:
» the underlying disease condition or injury causing the cardiac arrest
» post cardiac arrest haemodynamic instability
» post cardiac arrest brain injury
» the sequelae of global ischaemia and reperfusion.
Care should be aimed at reversing or minimising the above processes to
optimise the likelihood of neurologically intact survival.
GENERAL MEASURES
The priorities of management post cardiac arrest include:
Determining the cause of cardiac arrest

» careful history and physical examination
» bedside tests such as 12-lead ECG, blood glucose, Hb, pulse oximetry,
blood gases
» special investigations such as chest x-ray, eFAST, CT of the brain
Treating reversible conditions

This will be specific to the presentation and clinical findings.
Evidence of ST elevation myocardial infarction (STEMI) on ECG should prompt
urgent treatment. See section 3.2.1: ST elevation myocardial infarction (STEMI).
Note: Prolonged CPR may be a contraindication to administration of thrombolytic
or fibrinolytic agents. Consult a specialist to determine whether referral for
2019 20.4
percutaneous intervention is possible.
Supportive care and prevention of complications

Airway
» Ensure that the airway is patent and protected.
» Endotracheal intubation may be required in patients that do not rapidly
regain consciousness following return of spontaneous circulation.
Breathing
» Maintain oxygen saturation above 94%.
» Avoid hyperoxia by weaning the inspired oxygen concentration to the lowest
percentage required to maintain the above saturation.
» Maintain PaCO2 within normal range in ventilated patients where feasible.
Circulation
» Correct hypovolaemia if present, with judicious IV fluids.
» Monitor response to fluids: pulse rate, BP, urine output, skin perfusion,
development of basal crepitations.
» If hypotension persists despite fluid resuscitation, in the absence of ongoing
blood loss, commence inotropes (e.g. adrenaline (epinephrine)).
» Aim to maintain mean arterial blood pressure (MAP) above 65 mmHg.
» If brain or spinal cord injury is suspected, it is reasonable to increase the
target MAP to 80 mmHg.
Neurological care
» Position head up 30 degrees.
» Monitor for seizures. Treat promptly and load with an anti-epileptic agent if
seizures occur.
Blood glucose control
» Maintain blood glucose between 8 and 10 mmol/L and avoid hypoglycaemic
episodes.
LoE:IIIv
Temperature control
» Strictly avoid fever. Aim to control temperature below 36ºC in unconscious
patients in the first 24 hours, using physical cooling methods e.g.: ice packs
and fans, and antipyretics.
Deep vein prophylaxis
» Consider prophylaxis for venous thrombo-embolism, as required. See
section 2.8: Venous thrombo-embolism.
LoE:Ivi
MEDICAL TREATMENT
Hypoglycaemia LoE:IIIvii
 Dextrose 50%, rapid IV injection, up to 50 mL.
Assess clinical status and finger prick glucose level over the next 5–10 minutes.
2019 20.5
Hypovolaemia
 Sodium chloride 0.9%, IV. LoE:Iviii
Hypotension (after volume correction)

 Adrenaline (epinephrine), IV infusion, start at 0.1 mcg/kg/minute titrated
according to the response.
o Dilute 10 mg i.e. 10 ampoules of adrenaline 1:1 000 in 1 L sodium
chloride 0.9%.
o Infuse according to weight and clinical response.
o Infusion rate: mL/hour:
Weight in kg
mcg/kg/minute
50 60 70 80 90 100 110
0.1 30 36 42 48 54 60 66
0.2 60 72 84 96 108 120 132
0.3 90 108 126 144 162 180 198
0.4 120 144 168 192 216 240 264
0.5 150 180 210 240 270 300 330
0.6 180 216 252 288 324 360 396
0.7 210 252 294 336 378 420 462
0.8 240 288 336 384 432 480 528
0.9 270 324 378 432 486 540 594
1 300 360 420 480 540 600 660
LoE:IIIix
Seizures
Treat seizures in post cardiac arrest, similar to management of status
epilepticus. See section 14.4.1: Status epilepticus.
LoE:IIIx
Fever
LoE:IIIxi
REFERRAL
» Following successful resuscitation cases should be discussed with a
hospital with intensive care facilities for transfer.
» If evidence of myocardial infarction is present or if strongly suspected cases
should be discussed with a cardiology service.
20.3 CARDIAC DYSRHYTHMIAS

See section 3.3: Cardiac dysrhythmias.
2019 20.6
MEDICAL EMERGENCIES
Emergency health conditions are those requiring rapid intervention to avert
death or disability, and those for which treatment delays of hours or less make
interventions less effective. Concern that such a condition exists requires
urgent assessment
20.4 ACUTE CORONARY SYNDROMES

See sections 3.2.1: ST elevation myocardial infarction (STEMI) and 3.2.2: Non-
ST elevation myocardial infarction (NSTEMI) and Unstable angina (UA)
20.5 ASTHMA, ACUTE

See section16.1: Asthma, acute for the management of status asthmaticus.
20.6 ANGIOEDEMA
T78.3 + (Y34.99/Y57.9/Y14.99)
DESCRIPTION
Two major groups of angioedema should be differentiated: allergic angioedema
forming part of a systemic reaction to an allergen, and non-allergic angioedema
caused by bradykinin excess.
In allergic angioedema, features of allergy or anaphylaxis will often be present,
including urticaria, bronchospasm, hypotension or gastrointestinal upset.
Anaphylaxis should be treated urgently. See section 20.7:
Anaphylaxis/anaphylactic shock.
Non-allergic angioedema is most commonly caused by ACE-inhibitors in
susceptible individuals. It may also be caused by hereditary angioedema or
acquired C1 esterase deficiency. Associated features of allergy are absent.
Symptoms
Swelling usually occurs around eyes and lips but may occur elsewhere.
Life-threatening airway obstruction can occur with angioedema of upper airways.
GENERAL MEASURES
Stop all suspected agents, e.g. ACE-inhibitor.
In case of angioedema with airway obstruction, early airway management is
essential. If oedema is extensive or progressive, establish a definitive airway. The
most skilled person available must handle airway interventions.
Avoid re-exposure to the offending agent and provide an alert bracelet.
MEDICINE TREATMENT
In severe cases of hypersensitivity where airway obstruction may be imminent:
Note: A definitive airway may be required before patient responds to medical
treatment. Low threshold to surgical airway tracheostomy.
2019 20.7
In cases where angioedema is part of anaphylaxis, treat as anaphylaxis.

See section 20.7: Anaphylaxis/Anaphylactic shock.
If urticaria and/or itch present (no imminent airway compromise):

 Hydrocortisone, IV, 100 mg as a single dose. LoE:III
AND
Promethazine, IV, 25–50 mg as a single dose.
OR
 Cetirizine, oral, 10 mg as a single dose. LoE:III
Severe ACE-inhibitor induced angioedema with threatened airway:

Note: A definitive airway may be required before patient responds to medical
treatment. Low threshold to surgical airway tracheostomy.
 Lyophilised plasma, IV, 2 units.
LoE:III
If lyophilised plasma is unavailable:
 FFP, IV, 2 units. LoE:IIxii
Observe all cases until resolution.
20.7 ANAPHYLAXIS/ANAPHYLACTIC SHOCK

T78.2 + (Y34.99/Y57.9/Y14.99)
DESCRIPTION
An acute, potentially life-threatening hypersensitivity reaction.
The reaction usually starts within seconds to minutes after administration of, or
exposure to a substance to which the individual has been sensitised.
Clinical manifestations range from mild urticaria and angioedema to upper
airway obstruction, bronchospasm, hypotension, shock and death.
The reaction can be short-lived, protracted or biphasic, i.e. acute with
recurrence several hours later.
Immediate reactions are usually the most severe and/or life threatening.
GENERAL MEASURES
Administer adrenaline (epinephrine) immediately (see below)
Cardiopulmonary resuscitation, if required.
Maintain an open airway. Intubate, if necessary.
Monitor all vital parameters (including pulse and blood pressure) closely.
Reassure and comfort the patient.
Patient counselling to prevent recurrence.
An alert bracelet should be worn at all times.
2019 20.8
MEDICINE TREATMENT
 Adrenaline (epinephrine) 1:1000, 0.5 mL, IM, immediately into anterolateral thigh.
o Repeat dose every 5 minutes, as required.
In cases of persistent hypotension or where multiple repeat doses are required:

 Adrenaline (epinephrine), IV infusion, start at 0.05 mcg/kg/minute titrated
according to the response.
o Dilute 10 mg i.e. 10 ampoules of adrenaline 1:1 000 in 1 L sodium
chloride 0.9%.
Weight in kg
mcg/kg/minute
50 60 70 80 90 100 110
0.05 15 18 21 24 27 30 33
0.1 30 36 42 48 54 60 66
0.2 60 72 84 96 108 120 132
0.3 90 108 126 144 162 180 198
0.4 120 144 168 192 216 240 264
0.5 150 180 210 240 270 300 330
0.6 180 216 252 288 324 360 396
0.7 210 252 294 336 378 420 462
0.8 240 288 336 384 432 480 528
0.9 270 324 378 432 486 540 594
1 300 360 420 480 540 600 660
LoE:III
AND
 Hydrocortisone, IV/IM, 200 mg, immediately as a single dose.
AND
Intravenous fluids
Establish an intravenous line:
LoE:Ixiii
If bronchospasm:
 Oxygen if saturation <94%. LoE:Ixiv
AND
Salbutamol, nebulisation, 5 mg.
o Nebulise continuously (refill the nebuliser reservoir every 20 minutes) at
a flow rate of 6–8 L/minute.
AND LoE: IIIxv
 Ipratropium bromide, nebulisation 0.5 mg, added to
salbutamol solution.
LoE: IIIxvi
If urticaria and/or itch present:
 Antihistamine, e.g.:
 Promethazine, IV 25–50 mg as a single dose.
OR
2019 20.9
Cetirizine, oral, 10 mg as a single dose. LoE:IIIxvii
20.8 DELIRIUM WITH PERCEPTUAL DISTURBANCES

F05.0-1/F05.8-9/R45.1/R45.4-6
DESCRIPTION
Confusional states/delirium are characterised by altered consciousness,
accompanied by impairments in orientation to time and place and seldom to
person. Mental status may fluctuate. Disturbed behaviour may be present, e.g.
agitation, hallucinations and paranoid ideation.
Note: Many acute medical emergencies can present as delirium, which may be
misdiagnosed as an acute psychosis.
GENERAL MEASURES
» Investigations need to be done to exclude or diagnose an underlying
medical problem, the treatment of which is the primary management.
» Ensure effective communication, re-orientation and reassurance.
MEDICINE TREATMENT
Treat underlying medical condition.
Acute management
For management for severe aggression and disruptive behaviour: see section
15.1: Aggressive disruptive behaviour in adults.
For agitated and acutely disturbed patient: LoE:IIIxviii

 Haloperidol, IM, 0.5–1 mg
o This can be repeated in 30–60 minutes, if required and then 4 hourly to
a maximum dose of 10 mg within 24 hours.
o Monitor vital signs and beware of acute dystonia and neuroleptic malignant
syndrome.
o Dosing may vary according to clinical circumstances, e.g. lower doses in the
elderly or where HIV infection or HIV-related dementia is known or
suspected.
AND/OR
 Benzodiazepine, repeat as necessary, to achieve containment, e.g.:
 Lorazepam, IM, 1–4 mg.
OR
Clonazepam, IM, 0.5–2 mg.
OR
Diazepam, IV, 10 mg.
o Switch to oral route once containment is achieved.
Note:
2019 20.10
CAUTION
Monitor patients closely.
» In the frail and elderly patient or where respiratory depression is a
concern, reduce the dose by half. LoE:IIIxix
» The safest route of administration is oral followed by IM
with the IV route having the highest risk of respiratory depression and arrest.
Use the safest route wherever possible.
» Monitor vital signs closely during and after administration.
» Use haloperidol instead of benzodiazepines in patients with respiratory
insufficiency.
» In the short-term, benzodiazepines can aggravate delirium.
» To avoid inappropriate repeat dosing allow at least 15–30 minutes for the
medication to take effect. Repeated IM doses of benzodiazepines may
result in toxicity owing to accumulation.
» Physical restraint worsens the outcomes of delirious patients: this is a last
resort when all else has failed and is a short-term measure until chemical
restraint has been achieved.
20.9 DIABETIC EMERGENCIES

See sections 8.6.1: Hypoglycaemia and 8.6.2: Diabetic ketoacidosis (DKA)
and hyperosmolar hyperglycaemic state (HHS).
20.10 PULMONARY OEDEMA, ACUTE

J81
DESCRIPTION
A life-threatening condition with abnormal accumulation of fluid in the lungs.
Common causes include acute decompensation of chronic underlying heart
failure and acute renal failure (e.g. acute nephritis).
The acute decompensated heart failure patient appears extremely ill, restless,
poorly perfused and sweaty, tachypnoeic, tachycardic, hypoxic, increased work
of breathing, frothy sputum.
GENERAL MEASURES
Maintain open airway. Consider non-invasive positive pressure ventilation.
Position in Fowler’s position, unless hypotensive or comatose.
Correct electrolyte disturbances.
Determine and correct any dysrhythmias.
MEDICINE TREATMENT
 Administer oxygen using face mask to deliver 40% oxygen at a rate of 6–8 L
per minute.
2019 20.11
Fluid overload suspected/detected:

 Furosemide, slow IV, 40 mg.
o If response is adequate, follow with 40 mg in 2–4 hours.
o If no response within 20–30 minutes: furosemide, IV, 80 mg.
Followed by:
 Nitrates, e.g.:
 Isosorbide dinitrate, SL, 5 mg repeat every 5–10 minutes, if necessary.
o Monitor blood pressure. Do not administer if hypotensive.
OR LoE:III

o If no response after 20 mcg/minute increase by 20 mcg/minute until
response.
o Flush the PVC tube before administering to patient. LoE:IIIxx
o Monitor blood pressure carefully.
Volume of diluent Glyceryl trinitrate Concentration of
5 mg/mL dilution
5 mL (25 mg) 100 mcg/mL
250 mL 10 mL (50 mg) 200 mcg/mL
20 mL (100 mg) 400 mcg/mL
10 mL (50 mg) 100 mcg/mL
500 mL 20 mL (100 mg) 200 mcg/mL
40 mL (200 mg) 400 mcg/mL
Solution 100 200 400
Concentration mcg/mL mcg/mL mcg/mL
(mcg/mL) solution solution solution
Dose Flow rate (microdrops/min = mL/hr)
(mcg/min)
5 3 – –
10 6 3 –
15 9 – –
20 12 6 3
30 18 9 –
40 24 12 6
60 36 18 9
80 48 24 12
100 60 30 15
120 72 36 18
160 96 48 24
200 – 60 30
No fluid overload present:

Initiate nitrates, followed by furosemide.
2019 20.12
If distressed, consider adding morphine:

 Morphine, IV. (See Appendix II, for individual dosing and monitoring for
response and toxicity).
If hypotensive consider inotropic support, e.g.:

 Dobutamine, IV infusion, 5–20 mcg/kg/minute.
o Dilute 1 vial (250 mg/20 mL) up to 50 mL with sodium chloride 0.9% or
dextrose 5%. (Solution = 5 mg/mL or 5 000 mcg/mL)
o Administer under constant ECG monitoring.
o Rate of infusion in mL/hour: see weight-dose table in section 20.11.3:
Cardiogenic shock.
20.11 SHOCK
20.11.1 HYPOVOLAEMIC SHOCK
20.11.1.1 NON-TRAUMA RELATED HYPOVOLAEMIC

SHOCK
R57.1
DESCRIPTION
This happens when there is loss of intravascular fluid, e.g. severe diarrhoea
and dehydration, haemorrhage or fluid shifts.
GENERAL MEASURES
Control obvious bleeding with direct pressure.
Insert one or two large bore IV catheters; peripheral lines are adequate.
MEDICINE TREATMENT
Non trauma related
 Sodium chloride 0.9%, IV, 1–2 L.
LoE:Ixxi
Monitor blood pressure, pulse and clinical response.
20.11.1.2 TRAUMA-RELATED HYPOVOLAEMIC SHOCK

T79.4 + (R57.1 + Y34.99/Y57.9/Y14.99)
DESCRIPTION
Shock is inadequate perfusion of the vital organs. Clinically this may manifest
with hypotension, tachycardia, weak pulses, clammy skin, pallor, altered mental
state, poor urine output and elevated lactate.
The presence of shock in a patient with bleeding indicates that a significant
volume of blood has already been lost.
The common traumatic sites of blood loss include the chest, abdomen, pelvis,
long bone fractures and vascular injuries.
2019 20.13
Major non-traumatic bleeds include gastrointestinal haemorrhage, ruptured

ectopic pregnancy and obstetric haemorrhage.
GENERAL MEASURES
Control bleeding. Techniques may include:
» Direct, sustained pressure over the bleeding point.
» Use of tourniquets in exsanguinating limb haemorrhage, e.g. manual BP
cuff or specialized tourniquet while awaiting transfer to theatre. (Do not use
for longer than 6 hours).
» Tamponade techniques e.g. inflated Foley catheter in neck, axilla or femoral
wounds.
Obtain large bore IV access, preferably two lines.
Prevent hypothermia.
Send blood sample to blood bank as early as possible for blood type and
screening. Notify blood bank of possible massive transfusion.
MEDICINE TREATMENT
 Oxygen if saturation <94%. LoE:Ixxii
Trauma related
 Sodium chloride 0.9%, IV. LoE:Ixxiii
Consider blood products If more than 1 litre of fluid is needed, consider blood
products:
» In cases of major bleeding, limit fluid volumes to less than 1.5 litres in total
where possible. Replace acute blood loss with blood and blood products.
» Emergency blood should be used in unstable patients and when there will
be significant delay in obtaining cross-matched blood from a blood bank.
» Rh typing is advised when possible.
 Type O Rh negative blood should be reserved for women of childbearing
age that are Rh negative or Rh status unknown.
 Type O Rh positive blood may be given to Rh positive women of
childbearing age, females >50 years of age or males regardless of Rh
status.
» After 2 units of emergency blood, consider activation of massive transfusion
protocol. See section 20.10.1.2.1: Massive transfusion.
20.11.1.2.1 MASSIVE TRANSFUSION

Z51.8
DESCRIPTION
A massive transfusion is the replacement of a patient’s blood volume or 10 units
over a 24-hour period, or replacement of half of that volume over 4 hours.
GENERAL MEASURES
Actively treat and prevent hypothermia.
2019 20.14
When it is anticipated that large volumes of blood will be required, the

replacement of platelets and clotting factors in addition to red blood cells is
needed to prevent coagulopathy.
MEDICINE TREATMENT
Facilities without access to a blood bank:
 Lyophilised plasma, IV.
o 1 unit for each unit of emergency blood transfused.
Arrange urgent transfer to a centre with blood bank and specialist services.
Facilities with access to a blood bank:

» Ensure that the blood bank receives an appropriate specimen as soon as
the possible need for transfusion is identified.
» Notify the blood bank as soon as possible of the need for a massive
transfusion and request a massive transfusion pack.
A massive transfusion pack will typically consist of:
 Red blood cells (RBCs), 6 units.
AND LoE:III
 Lyophilised plasma, IV.
o 1 unit for each unit of emergency blood transfused.
OR
FFP, 6 units - thawed when requested.
AND
 Platelets, 1 mega-unit (normally 6 pooled donor units).
o Aim to transfuse the above products in a 1:1:1 ratio, or as guided by
laboratory parameters.
o Send specimens for FBC and INR and continue to monitor.
LoE:IIIxxiv
Expedite definitive control of bleeding:
 Tranexamic acid, IV, 1 g, infused over 10 minutes.
o Followed with IV infusion, 1 g, over 8 hours. LoE:Ixxv
o Benefit is greatest if initiated in the 1st hour. Initiation of tranexamic acid
more than 3 hours after the initial trauma may be harmful.
If patient responds initially and subsequently deteriorate, there may be an
ongoing occult haemorrhage. If no response occurs, consider:
» Occult exsanguinating haemorrhage: intra-abdominal, retroperitoneal and
intrapleural.
» Non-hypovolaemic shock: tension pneumothorax, myocardial contusion,
cardiac tamponade or myocardial infarct.
20.11.2 DISTRIBUTIVE SHOCK

This happens when the blood vessels are abnormally dilated and presents with
2019 20.15
a low blood pressure, tachycardia and warm peripheries. There are 3 causes
of this type of shock:
» neurogenic shock,
» septic shock, and
» anaphylactic shock (see section: 20.7 Anaphylaxis/anaphylactic shock).
20.11.2.1 NEUROGENIC SHOCK

T09.3 + (Y34.99/R57.8)
DESCRIPTION
Occurs in spinal cord trauma when there is an interruption of the sympathetic
chain causing vasodilatation.
GENERAL MEASURES
Check circulation, airway and breathing.
Spinal cord immobilisation.
Exclude other injuries that could cause low blood pressure.
MEDICINE TREATMENT
 Oxygen if saturation <94%. LoE:Ixxvi
 Sodium chloride 0.9%, IV. LoE:Ixxvii

o Administer crystalloid in titrated boluses up to 1 litre.
LoE:III
 Adrenaline (epinephrine), IV infusion, start at 0.05
mcg/kg/minute titrated according to the response.
o Dilute 10 mg (10 ampoules) of adrenaline 1:1 000 in 1 L sodium chloride
0.9%.
Weight in kg
mcg/kg/minute
50 60 70 80 90 100 110
0.05 15 18 21 24 27 30 33
0.1 30 36 42 48 54 60 66
0.2 60 72 84 96 108 120 132
0.3 90 108 126 144 162 180 198
0.4 120 144 168 192 216 240 264
0.5 150 180 210 240 270 300 330
0.6 180 216 252 288 324 360 396
0.7 210 252 294 336 378 420 462
0.8 240 288 336 384 432 480 528
0.9 270 324 378 432 486 540 594
1 300 360 420 480 540 600 660
2019 20.16
20.11.2.2 SEPTIC SHOCK

R57.2
DESCRIPTION
Shock caused by a confirmed or suspected infection, with vasodilatation,
increased capillary permeability, and decreased contractility of the heart.
GENERAL MEASURES
Check airway, breathing and circulation.
MEDICINE TREATMENT
 Oxygen if saturation <94%. LoE:Ixxviii
Take blood culture (or any other tissue/body fluid), then administer appropriate
parenteral broad spectrum antibiotics urgently, e.g.:
 Ceftriaxone, IV, 2 g daily. LoE:IIxxix
Perform a fluid challenge for hypotension:

 Sodium chloride 0.9%, 500 mL boluses over 30 minutes, whilst monitoring
clinical response until 30 mL/kg has been achieved.
o Assess BP and pulse rate response. Response is defined by a good
urine output (>0.5 mL/kg/hour) and adequate cerebral perfusion rather
than an absolute BP value.

Balanced solutions may be appropriate in some patients (i.e. presentation with
hyponatraemia, previous renal placement therapy): LoE:Ixxx
 Balanced solution, e.g.:
 Ringer lactate, 500 mL boluses over 30 minutes, whilst monitoring clinical
response, until 30 mL/kg has been achieved.
o Assess blood pressure and pulse rate response. Response is defined
by a good urine output (>0.5 mL/kg/hour) and adequate cerebral
perfusion rather than an absolute blood pressure value.
Avoid over-hydrating as this could exacerbate hypoxia associated with adult
respiratory distress syndrome.
If no haemodynamic response to early aggressive fluid resuscitation:

 Adrenaline (epinephrine), IV infusion, 0.05 mcg/kg/minute titrated according
to the response.
o Dilute 10 mg (10 ampoules) of adrenaline 1:1000 in 1 L sodium chloride
0.9%.
o Infuse according to weight and clinical response. (Aim for target MAP 65
mmHg and urine output 0.5 mL/kg/hour).
o See section 20.1.4.1: Neurogenic shock, for the infusion rate.
2019 20.17
20.11.3 CARDIOGENIC SHOCK

R57.0
DESCRIPTION
Patients are hypotensive, cold and clammy and their pulse rate may be variable.
Causes include an acute myocardial infarction, myocardial contusion, myocarditis,
dysrhythmias, valvular heart disease, aortic dissecting aneurysm etc.
Consult with specialist and consider referring patients after initial emergency
measures have been taken.
GENERAL MEASURES
Check circulation, airway and breathing.
ECG.
Treat the underlying cause, e.g.: MI, dysrhythmia, etc.
MEDICINE TREATMENT
 Oxygen if saturation <94%. LoE:Ixxxi
A right ventricular myocardial infarction may respond to a fluid challenge:

 Sodium chloride 0.9%, IV. LoE:Ixxxii
o Administer 250–500 mL as a bolus and assess fluid responsiveness.
 Dobutamine, infusion, 5–10 mcg/kg/minute.
o Dilute 1 vial (250 mg/20 mL) up to 50 mL with sodium chloride 0.9% or
dextrose 5% (5 mg/mL or 5 000 mcg/mL).
o Rate of infusion in mL/hour: LoE:IIIxxxiii
Weight (kg)
Dose mcg/kg/min 30 40 50 60 70 80 90 100 110 120
2 0.9 1.2 1.5 1.8 2.1 2.4 2.7 3 3.3 3.6
5 1.8 2.4 3 3.6 4.2 4.8 5.4 6 6.6 7.2
7.5 2.7 3.6 4.5 5.4 6.3 7.2 8.1 9 9.9 10.8
10 3.6 4.8 6 7.2 8.4 9.6 10.8 12 13.2 14.4
20.11.4 OBSTRUCTIVE SHOCK

R57.8
DESCRIPTION
Occurs when there is an obstruction to the filling of the right ventricle or an
obstruction in blood flow. Clinical signs include hypotension, tachycardia, cold
peripheries and distended neck veins.
2019 20.18
Causes include:
» cardiac tamponade, » tension pneumothorax,
» acute pulmonary embolism, and » severe bronchospasm.
TREATMENT
Treat the cause.
Acute pulmonary embolism and cardiac tamponade require urgent
consultation with a specialist and referral after initial emergency measures
have been taken
20.12 STATUS EPILEPTICUS

See section 14.4.1: Status epilepticus
2019 20.19
TRAUMA AND INJURIES

For trauma-related haemorrhage, presenting within 3 hours of injury, see
section 20.1.3 Hypovolaemic shock.
20.13 ACUTE KIDNEY INJURY

See section 7.1.4: Acute kidney injury.
20.14 BITES AND STINGS

See chapter 19: Poisonings – envenomation.
20.15 BURNS
T30.0-3 + (T31.0-9/Y34.99
DESCRIPTION
Skin and tissue damage caused by:
» exposure to extremes of temperature,
» contact with an electrical current,
» exposure to a chemical agent, and
» radiation.
ASSESSMENT OF BURNS
Depth of burn SURFACE PAIN SENSATION/HEALING
wound /COLOUR
Superficial or Dry, minor » Painful
epidermal blisters, erythema » Heals within 7 days
Partial thickness Blisters, moist » Painful
superficial or » Heals within 10–14 days
superficial dermal
Partial thickness Moist white or » Less painful
deep or deep dermal yellow slough, » Heals within a month or more
red mottled Generally needs surgical debridement
and skin graft
Full thickness Dry, charred » Painless, firm to touch
(complete loss of whitish, brown or » Healing by contraction of the margins
skin) black (generally needs surgical
debridement and skin graft)
2019 20.20
The figures below are used to calculate body surface area %.

These diagrams indicate percentages for the whole leg/arm/head (and
neck in adults) not just the front or back.
Children ≥8 years and adults
Source: Karpelowsky JS, Wallis L, Madaree A, Rode H; South African Burn Society. South African
Burn Society burn stabilisation protocol. S Afr Med J. 2007 Aug;97(8):574-7.
GENERAL MEASURES
» Assess airway, breathing
 Look for signs of inhalational burn- history of hot gas, smoke, steam.
 INTUBATE if significant airway obstruction present or WORSENING
symptoms.
 Intubation is necessary in the case of unconscious patients, hypoxic
patients with severe smoke inhalation, or patients with flame or flash
burns involving the face and neck if there is evidence of compromised
airway patency.
 Intubate early if burns are inhalational, or in the presence of pharyngeal
burns with soft tissue swelling, as these patients frequently tend to
develop respiratory failure.
 Close monitoring is essential during the first 24-48 hours
 If breathing is compromised because of tight circumferential trunk burns,
consult with burn centre surgeons immediately. Urgent escharotomies
may be required to facilitate chest expansion
» Assess circulation
 Establish large-bore intravenous (IV) lines and provide resuscitation
bolus fluid.
 Reminder: IV lines may be placed through the burned area if necessary
(suture to secure).
2019 20.21
» Assess neurological state of the patient

» Assess for associated trauma related injuries
 Secure the C–spine with an inline stabilising collar, when the mechanism
of injury could indicate additional trauma.
 Identify potential sources of internal bleeding.
 Stop any external bleeding.
» Remove any sources of heat or chemicals. Removal constrictive
clothing/accessories.
» Estimate percentage of total body surface area involved.
» Support vital organ function.
» Look for aggravating comorbidities, e.g. seizures, hyperkalaemia, renal
failure.
» Assess need for decompression incisions: escharotomies
» Local wound care: Clean superficial burns can be managed by occlusive
dressings. Deeper wounds may have to be excised and grafted.
» Rehabilitation involving physiotherapy and occupational therapy.
Burn injuries put patients into a hypermetabolic state which requires early and
adequate nutritional support. Seek early guidance from local burns centre. See
section 12.13.1: Nutritional support.
MEDICINE TREATMENT
Fluid replacement
Burns ≤10% Total Body Surface Area (TBSA):
 Oral rehydration solution.
Burns >10% of TBSA:
 Sodium chloride 0.9%, IV fluid for resuscitation, replacement and
maintenance.
Calculation of fluid replacement

Replacement fluids for burns
» First 24 hours:
 Sodium chloride 0.9%, IV. LoE:Ixxxiv
o Calculate total fluid requirement in 24 hours:
Total % burn x weight (kg) x 4 mL.
o Give half this volume in the 1st 8 hours.
o Administer remaining fluid volume in next 16 hours.
Note: If urine output is not adequate, increase fluids for the next hour by 50%.
Continue at a higher rate until urine output is adequate, then resume normal
calculated rate. Aim for urine output 0.5 mL/kg/hr.
Analgesia
Ensure adequate analgesia particularly at change of dressing, i.e.:
2019 20.22
AND
Tetanus prophylaxis Z23.5
Tetanus toxoid vaccine, IM, 0.5 mL immediately.
Local Wound Care
» Melted plastic and tar can be removed with the topical application of liquid
paraffin solution
» Wash burn wounds with soap and water or 1% chlorhexidine.
» Cool burns less than 3 hours old with cold tap water for at least 30 minutes
and then dry the patient.
» Keep the wound clean and dress with sterile dressings.
For chemical burns
» Remove all clothing.
» Brush powdered chemicals off the wound
» Flush chemical burns for a minimum of 30 minutes using copious volumes
of running water.
» Reminder: Never neutralise an acid with a base or vice versa.
» Determine what chemical (and what concentration) caused the injury.
» Ocular burns: T26.4 + (Y34.99)
 Sodium chloride 0.9% gentle eye washes or irrigations as soon as possible.
Follow with an ophthalmology consultation
For electrical burns
» Differentiate between low-voltage (<1 000 v) and high-voltage (>1 000 v)
injuries.
» Attach a cardiac monitor; treat life-threatening dysrhythmias as needed.
» Suspect compartmental syndrome, consider escharotomies.
Stress ulcer prophylaxis
Feeding patients provides protection against gastric ulcer developing and
prophylaxis is not necessary in patients who are tolerating feeds.
Note: Pharmacokinetic parameters are altered in patients with severe burns,
notably an increased volume of distribution. An appropriate loading dose should
be given of certain medicines, e.g. aminoglycosides. Therapeutic drug monitoring
(TDM) may inform dosing and should be requested, if available.
Discuss the following cases with a burns specialist:
» Burns >15% body surface area (BSA) or >10% BSA >50 years of age.
» Burns of face, hands, feet, genitalia, perineum or involving joints.
» Electrical burns, including lightning burns.
» Chemical burns.
» Inhalation injury or burns.
» Burns associated with major trauma.
2019 20.23
» Circumferential burns.
20.16 EXPOSURE TO POISONOUS SUBSTANCES

See chapter 19: Poisoning.
20.17 EYE INJURIES

See section 18.10: Medical management of eye injury.
20.18 POST EXPOSURE PROPHYLAXIS

See section 10.5: Post-exposure prophylaxis.
20.19 SOFT TISSUE INJURIES

See Primary Health Care STGs and EML; section 21.3.7: Soft tissue injuries.
20.20 SPRAINS AND STRAINS

See Primary Health Care STGs and EML; section 21.3.8: Sprains and strains.
2019 20.24
References:
i Sodium chloride, 0.9%: Perel P, Roberts I, Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients.
Sodium chloride, 0.9%: Bunn F, Trivedi D. Colloid solutions for fluid resuscitation. Cochrane
Database Syst Rev. 2012 Jul 11;7:CD001319. http://www.ncbi.nlm.nih.gov/pubmed/22786474
Sodium chloride, 0.9%: Mutter TC, Ruth CA, Dart AB. Hydroxyethyl starch (HES) versus other fluid
therapies: effects on kidney function. Cochrane Database Syst Rev. 2013 Jul 23;7:CD007594.
Sodium Chloride, 0.9%: National Department of Health, Essential Drugs Programme. Medicine review - Hydroxyethyl
Starch (HES) Solutions for acute hypovolaemia due to blood loss (trauma, intraoperative haemorrhage), 6 October 2015.
Sodium chloride 0.9%: National Department of Health: Affordable Medicines, EDP-Adult Hospital level. Medicine
ii Amiodarone, IV: McLeod SL, Brignardello-Petersen R, Worster A, You J, Iansavichene A, Guyatt G, Cheskes S.
Comparative effectiveness of antiarrhythmics for out-of-hospital cardiac arrest: A systematic review and network meta-
analysis. Resuscitation. 2017 Dec;121:90-97. https://www.ncbi.nlm.nih.gov/pubmed/29037886
Amiodarone, IV: Chowdhury A, Fernandes B, Melhuish TM, White LD. Antiarrhythmics in Cardiac Arrest: A Systematic
Review and Meta-Analysis. Heart Lung Circ. 2018 Mar;27(3):280-290. https://www.ncbi.nlm.nih.gov/pubmed/28988724
Amiodarone, IV: Kudenchuk PJ, Cobb LA, Copass MK, Cummins RO, Doherty AM, Fahrenbruch CE, Hallstrom AP,
Murray WA, Olsufka M, Walsh T. Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular
fibrillation. N Engl J Med. 1999 Sep 16;341(12):871-8. https://www.ncbi.nlm.nih.gov/pubmed/10486418
Amiodarone, IV: Morrison LJ, Deakin CD, Morley PT, Callaway CW, Kerber RE, Kronick SL, Lavonas EJ, Link MS,
Neumar RW, Otto CW, Parr M, Shuster M, Sunde K, Peberdy MA, Tang W, Hoek TL, Böttiger BW, Drajer S, Lim SH, Nolan
JP; Advanced Life Support Chapter Collaborators. Part 8: Advanced life support: 2010 International Consensus on
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.
Circulation. 2010 Oct 19;122(16 Suppl 2):S345-421. https://www.ncbi.nlm.nih.gov/pubmed/20956256
iii Sodium chloride, 0.9%: Perel P, Roberts I, Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients.
iv Adrenaline (epinephrine), intra-osseous: Resuscitation Council of Southern Africa: Advanced cardiac arrest algorithm,
2015. www.resuscitationcouncil.co.za
v Blood glucose control: Clifton W. Callaway, Michael W. Donnino, Ericka L. Fink, Romergryko G. Geocadin, Eyal
Golan, Karl B. Kern, Marion Leary, William J. Meurer, Mary Ann Peberdy, Trevonne M. Thompson, Janice L.
Zimmerman. 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Part 8: Post–Cardiac Arrest Care. Circulation. 2015;132:S465-S482.
vi Anticoagulants (deep vein prophylaxis): Dentali F, Douketis JD, Gianni M, Lim W, Crowther MA. Meta-analysis:
anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalized medical patients. Ann
Intern Med. 2007;146(4):278. https://www.ncbi.nlm.nih.gov/pubmed/17310052
vii Dextrose 50%, IV: Moore C, Woollard M. Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital?
A randomised controlled trial. Emerg Med J. 2005 Jul;22(7):512-5.

viii Sodium chloride, 0.9%: Perel P, Roberts I, Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients.

ix Adrenaline (epinephrine): Clifton W. Callaway, Michael W. Donnino, Ericka L. Fink, Romergryko G. Geocadin, Eyal
x Anticonvulsants (seizures): Clifton W. Callaway, Michael W. Donnino, Ericka L. Fink, Romergryko G. Geocadin, Eyal
2019 20.25
xi Paracetamol, oral: Nolan JP, Soar J, Cariou A, Cronberg T, Moulaert VR, Deakin CD, Bottiger BW, Friberg H, Sunde
K, Sandroni C. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines for Post-
resuscitation Care 2015: Section 5 of the European Resuscitation Council Guidelines for Resuscitation 2015.
Resuscitation. 2015 Oct;95:202-222. https://www.ncbi.nlm.nih.gov/pubmed/26477702
Paracetamol, oral: Gebhardt K, Guyette FX, Doshi AA, Callaway CW, Rittenberger JC; Post Cardiac Arrest Service.
Prevalence and effect of fever on outcome following resuscitation from cardiac arrest. Resuscitation. 2013
Aug;84(8):1062-7. https://www.ncbi.nlm.nih.gov/pubmed/23619740
xii Fresh frozen plasma: Prematta M, Gibbs JG, Pratt EL, Stoughton TR, Craig TJ. Fresh frozen plasma for the treatment
of hereditary angioedema. Ann Allergy Asthma Immunol. 2007 Apr;98(4):383-8.

Fresh frozen plasma: Hassen GW, Kalantari H, Parraga M, Chirurgi R, Meletiche C, Chan C, Ciarlo J, Gazi F, Lobaito
C, Tadayon S, Yemane S, Velez C. Fresh frozen plasma for progressive and refractory angiotensin-converting enzyme
inhibitor-induced angioedema. J Emerg Med. 2013 Apr;44(4):764-72. http://www.ncbi.nlm.nih.gov/pubmed/23114109
Fresh frozen plasma: Culley CM, DiBridge JN, Wilson GL Jr. Off-Label Use of Agents for Management of Serious or
Life-threatening Angiotensin Converting Enzyme Inhibitor-Induced Angioedema. Ann Pharmacother. 2016 Jan;50(1):47-
xiii Sodium chloride, 0.9%: Perel P, Roberts I, Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients.

Sodium chloride 0.9%: Clifton W. Callaway, Michael W. Donnino, Ericka L. Fink, Romergryko G. Geocadin, Eyal
Zimmerman. 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care. Part 8: Post–Cardiac Arrest Care. Circulation. 2015;132:S465-S482.
xiv Oxygen: Chu DK, Kim LH, Young PJ, Zamiri N, Almenawer SA, Jaeschke R, Szczeklik W, Schünemann HJ, Neary
xv Salbutamol nebulisation (anaphylaxis): Resuscitation Council of Southern Africa: Emergency management of
anaphylaxis algorithm, 2015/16. www.resuscitationcouncil.co.za
xvi Ipratropium nebulisation (anaphylaxis): Resuscitation Council of Southern Africa: Emergency management of
anaphylaxis algorithm, 2015/16. www.resuscitationcouncil.co.za
xvii Promethazine, IV/ cetirizine, oral: Sheikh A, ten Broek Vm, Brown SG, Simons FE. H1-antihistamines for the
treatment of anaphylaxis with and without shock. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD006160.
Promethazine, IV/ cetirizine, oral: Resuscitation Council of South Africa, Emergency Management of Anaphylaxis
Guidelines, 2015. https://resus.co.za/anaphylaxis/
Promethazine, IV/ cetirizine, oral: Fernando SL, Broadfoot AJ. Ondansetron anaphylaxis: a case report and protocol
for skin testing. Br J Anaesth. 2009 Feb;102(2):285-6. https://www.ncbi.nlm.nih.gov/pubmed/19151059
xviii Haloperidol: Taylor, David; Paton, Carol; Kapur, Shitij. The Maudsley Prescribing Guidelines, Twelfth Edition.
London: CRC Press; 2015

Haloperidol: NICE. Clinical guideline: Delirium: prevention, diagnosis and management, 28 July 2010.
www.nice.org.uk/guidance/cg103
Haloperidol: Taylor, David; Paton, Carol; Kapur, Shitij. The Maudsley Prescribing Guidelines, Twelfth Edition.
London: CRC Press; 2015.
Haloperidol: Burry L, Mehta S, Perreault MM, Luxenberg JS, Siddiqi N, Hutton B, Fergusson DA, Bell C, Rose L.
Antipsychotics for treatment of delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev. 2018 Jun
Haloperidol: Burry L, Hutton B, Williamson DR, Mehta S, Adhikari NK, Cheng W, Ely EW, Egerod I, Fergusson DA,
Rose L. Pharmacological interventions for the treatment of delirium in critically ill adults. Cochrane Database Syst Rev.
2019 Sep 3;9:CD011749. https://www.ncbi.nlm.nih.gov/pubmed/31479532
Haloperidol: Finucane AM, Jones L, Leurent B, Sampson EL, Stone P, Tookman A, Candy B. Drug therapy for
delirium in terminally ill adults. Cochrane Database Syst Rev. 2020 Jan 21;1:CD004770.
xix Benzodiazepines/ Haloperidol (dose in the elderly): South African Medicines Formulary. 12th Edition. Division of

xx Glyceryl trinitrate, IV: MCC registered South African package insert: AHN Pharma,Nitrocine® injection, 1 mg/mL
2019 20.26
xxi Sodium chloride, 0.9%: Perel P, Roberts I, Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients.
Sodium chloride, 0.9%: Mutter TC, Ruth CA, Dart AB. Hydroxyethyl starch (HES) versus other fluid therapies: effects
on kidney function. Cochrane Database Syst Rev. 2013 Jul 23;7:CD007594.
xxii Oxygen: Chu DK, Kim LH, Young PJ, Zamiri N, Almenawer SA, Jaeschke R, Szczeklik W, Schünemann HJ, Neary
xxiii Sodium chloride, 0.9%: Perel P, Roberts I, Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients.

xxiv Massive blood transfusion protocol: Groote Schuur Hospital protocol, current.
xxv Tranexamic acid, IV: CRASH-2 trial collaborators: Shakur H et al. Effects of tranexamic acid on death, vascular occlusive
events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-
controlled trial. Lancet. 2010; 376:23-32. https://www.ncbi.nlm.nih.gov/pubmed/20554319
Tranexamic acid: Roberts I et al. The importance of early treatment with tranexamic acid in bleedingtrauma patients: an
exploratory analysis of the CRASH-2 randomised controlled trial. Lancet. 2011; 377:1096-1101.
Tranexamic acid: Ker K, Roberts I, Shakur H, Coats TJ. Antifibrinolytic drugs for acute traumatic injury. Cochrane
Database Syst Rev. 2015 May 9;(5):CD004896. https://www.ncbi.nlm.nih.gov/pubmed/25956410
xxvi Oxygen: Chu DK, Kim LH, Young PJ, Zamiri N, Almenawer SA, Jaeschke R, Szczeklik W, Schünemann HJ, Neary
xxvii Sodium chloride, 0.9%: Perel P, Roberts I, Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients.

xxviii Oxygen: Chu DK, Kim LH, Young PJ, Zamiri N, Almenawer SA, Jaeschke R, Szczeklik W, Schünemann HJ, Neary
xxix Ceftriaxone, IV: Gaieski DF, Mikkelsen ME, Band RA, Pines JM, Massone R, Furia FF, Shofer FS, Goyal M. Impact of
time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated
in the emergency department. Crit Care Med. 2010 Apr;38(4):1045-53. http://www.ncbi.nlm.nih.gov/pubmed/20048677
Ceftriaxone, IV: Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas
IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado
FR, Rubenfeld GD, Webb SA, Beale RJ, Vincent JL, Moreno R; Surviving Sepsis Campaign Guidelines Committee including
the Pediatric Subgroup. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic
shock: 2012. Crit Care Med. 2013 Feb;41(2):580-637. http://www.ncbi.nlm.nih.gov/pubmed/23353941
xxx Ringer Lactate, IV: National Department of Health: Affordable Medicines, EDP-Adult Hospital level. Medicine
Ringer Lactate, IV: Antequera Martin AM, Barea Mendoza JA, Muriel A, Saez I, Chico-Fernandez M, Estrada-
Lorenzo JM, et al. Buffered solutions versus 0.9% saline for resuscitation in critically ill adults and children. Cochrane
Database Syst Rev. 2019 Jul 19;7:CD012247. https://www.ncbi.nlm.nih.gov/pubmed/31334842
Ringer Lactate, IV: Liu C, Lu G, Wang D, Lei Y, Mao Z, Hu P, Hu J, Liu R, Han D, Zhou F. Balanced crystalloids
2019 20.27
versus normal saline for fluid resuscitation in critically ill patients: A systematic review and meta-analysis with trial
sequential analysis. Am J Emerg Med. 2019 Mar 1. pii: S0735-6757(19)30149-4.
Ringer Lactate, IV: Brown RM, Wang L, Coston TD, Krishnan NI, Casey JD, Wanderer JP, Ehrenfeld JM, Byrne DW,
Stollings JL, Siew ED, Bernard GR, Self WH, Rice
TW, Semler MW; SMART Investigators and the Pragmatic Critical Care Research Group. Balanced Crystalloids Versus
Saline in Sepsis: A Secondary Analysis of the SMART Trial. Am J Respir Crit Care Med. 2019 Aug 27.
Ringer Lactate, IV: Rochwerg B, Alhazzani W, Sindi A, Heels-Ansdell D, Thabane L, Fox-Robichaud A, et al. Fluid
resuscitation in sepsis: A systematic review and network meta-analysis. Ann Intern Med. 2014;161(5):347–55.
xxxi Oxygen: Chu DK, Kim LH, Young PJ, Zamiri N, Almenawer SA, Jaeschke R, Szczeklik W, Schünemann HJ, Neary
xxxii Sodium chloride, 0.9%: Perel P, Roberts I, Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients.

xxxiii Dobutamine: MCC registered South African package insert: Pharmaplan Cardiject® powder for IV infusion, 250 mg/vial.
xxxiv Sodium chloride, 0.9%: Perel P, Roberts I, Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients.

2019 20.28
CHAPTER 21
ONCOLOGIC EMERGENCIES
21.1 ONCOLOGICAL EMERGENCIES
Any acute, potentially morbid or life-threatening event directly or indirectly
related to a patient’s tumour or its treatment. Most oncological emergencies
can be classified as metabolic, haematologic, structural, or side effects of
chemotherapy agents or radiation therapy.
21.1.1 METABOLIC EMERGENCIES
21.1.1.1 HYPERCALCAEMIA OF MALIGNANCY

See section 8.9: Hypercalcaemia, including primary hyperparathyroidism
21.1.1.2 SYNDROME OF INAPPROPRIATE ANTIDIURETIC

HORMONE (SIADH)
E22.2
DESCRIPTION
Patients present with: anorexia, nausea, vomiting, constipation, muscle
weakness, myalgia, polyuria, polydipsia, neurologic symptoms (e.g. seizures,
coma).
For management see section: 7.2.4 Hyponatraemia.
REFERRAL
Refer to Oncology Unit for management of underlying malignancy producing
Antiduretic Hormone (ADH).
21.1.1.3 TUMOUR LYSIS SYNDROME

E88.3
DESCRIPTION
Rapid destruction of malignant cells can result in the release of cellular
breakdown products and intracellular ions, causing potentially lethal metabolic
derangements including acute renal failure.
Commonly seen in cancers with rapidly growing tumours and high tumour
burdens, particularly acute leukaemias, chronic myeloid leukaemia and high-
grade lymphoma, generally following chemotherapy.
Presentation: (Cairo-Bishop definition)
» azotaemia
» acidosis
» hyperphosphataemia >1.45 mmol/L
» hyperkalaemia >6.0 mmol/L
» hypocalcaemia <1.75 mmol/L
2019 21.1
CHAPTER 21 ONCOLOHIC EMERGENCIES
» uric acid >0.476 mmol/L
GENERAL MEASURES
There is an increased risk of arrhythmias.
Monitor urine output.
Monitor urine and electrolytes, creatinine and uric acid levels.
MEDICINE TREATMENT
Fluid resuscitation:
» IV hydration 2–3 L/m2/day. The urine output needs to be monitored and
maintained within 80–100 mL/m2/hour.
» Diuretics are not indicated in patients with normal renal and cardiac
function; and are contraindicated in patients with hypovolemia.
 Sodium chloride 0.9%, IV, 1000 mL 6–8 hourly.
If patient is hypernatraemic or fluid overloaded, consult a specialist.
LoE:IIIi
For control of uric acid:
 Allopurinol, oral, 100 mg 8 hourly.
o Maximum dose: 300 mg 8 hourly.
o Adjust dose to 50 mg 8 hourly, if eGFR <20 mL/minute.
LoE:IIIii
Correct electrolyte imbalances:
» For hyperkalaemia, see section 7.2.1: Hyperkalaemia.
» For hypocalcaemia see section 8.10 Hypocalcaemia.
REFERRAL
Transfer to oncology unit.
21.1.2 HAEMATOLOGIC EMERGENCIES
21.1.2.1 FEBRILE NEUTROPENIA

See section 2.8: Febrile neutropenia.
21.1.2.2 HYPERVISCOSITY AND LEUCOSTATIC

SYNDROMES
D78.9
DESCRIPTION
Hyperviscosity is seen in patients with Waldenström’s macroglobulinemia and
multiple myeloma, while leucostasis may be seen in patients with acute
leukaemias and chronic myeloid leukaemia with high white cell counts.
Sludging and decreased perfusion of the microvasculature and vascular stasis
occur due to increased paraproteins or leucostasis.
Patients present with spontaneous bleeding, visual signs and symptoms, and
2019 21.2
neurologic defects.
GENERAL MEASURES
Perform investigations: FBC, peripheral blood smear, serum protein
electrophoresis (SPEP) and erythrocyte sedimentation rate (ESR).
Monitor urine, electrolytes and creatinine.
REFERRAL
Ensure adequate hydration and refer.
21.1.3 STRUCTURAL EMERGENCIES
21.1.3.1 EPIDURAL SPINAL CORD COMPRESSION

G95.2
DESCRIPTION
Seen in breast, lung, and prostate cancers, as well as multiple myeloma.
Patients present with new back pain that worsens when lying down, late
paraparesis, late incontinence, and loss of sensory function.
GENERAL MEASURES
To evaluate level of neurologic function, perform a spinal x-ray or MRI if
available.
MEDICINE TREATMENT
 Dexamethasone, IV, 16 mg immediately as a single dose.
o Followed by 4 mg 6 hourly, until transfer.
LoE:IIIiii
REFERRAL
Urgent referral to tertiary services with oncology or neurosurgery services.
21.1.3.2 MALIGNANT PERICARDIAL EFFUSION

I31.3
DESCRIPTION
Seen in metastatic lung and breast cancer, melanoma, leukaemia, and
lymphoma.
Patients present with dyspnoea, fatigue, distended neck veins, distant heart
sounds, tachycardia, orthopnoea, narrow pulse pressure, pulsus paradoxus,
or water-bottle heart.
Investigation
Trans-thoracic echocardiography.
2019 21.3
GENERAL MEASURES
Management is dependent on the underlying aetiology and symptom
progression.
Diagnostic and therapeutic pericardiocentesis:
» Immediate pericardiocentesis is mandatory for patients with tamponade.
» Send some of the fluid drained for microbiology and cytology.
REFERRAL
All patients for definitive therapy.
21.1.3.3 SUPERIOR VENA CAVA SYNDROME

I87.1
DESCRIPTION
Superior Vena Cava (SVC) obstruction may be seen in lung cancer, germ cell
tumours, lymphomas, thyroid carcinomas, and metastatic mediastinal
tumours. Indwelling central venous catheters may cause SVC syndrome due
to venous thrombosis.
Patients present with: cough, dyspnea, dysphagia, facial oedema, or upper
extremity swelling or discoloration, with development of collateral venous
circulation.
GENERAL MEASURES
Histological diagnosis is essential for definitive management.
Head elevation and supplementary oxygen.
MEDICINE TREATMENT
Maintain normovolaemia.
 Sodium chloride 0.9%, IV, 1000 mL 8 hourly.
 Corticosteroids may be considered in consultation with a specialist.
REFERRAL
Refer for histological diagnosis, and further management.
21.2 SIDE EFFECTS FROM ONCOLOGY TREATMENT

AGENT
21.2.1 DIARRHOEA
Refer to section 1.3.3: Diarrhoea, acute non-inflammatory.
2019 21.4
21.2.2 EXTRAVASATIONS
T80.8
DESCRIPTION
Chemotherapeutic agents are classified as vesicants (can cause necrosis),
non-vesicants, and irritants.
Patients present with pain and erythema at infusion site, swelling, necrosis,
contractures.
GENERAL MEASURES
Limb elevation.
MEDICINE TREATMENT
Long term
Small localised area of erythema at the catheter insertion site will usually
resolve without antibiotic therapy.
In patients with larger areas of erythema and tenderness extending beyond
the insertion site, where secondary infection is suspected:
 Clindamycin, oral, 450 mg 8 hourly for 5 days. LoE:IIIiv
Catheter related infections

If patients with peripheral or central venous catheter infections are
systemically unwell they should be treated as a venous catheter-related
systemic blood infection.
Microbiologic specimen (for speciation and sensitivity).
REFERRAL
All patients to oncological department where chemotherapy was administered.
21.2.3 CONSTIPATION
See section 24.1.2: Constipation.
21.3 SIDE EFFECTS FROM RADIATION AND

CHEMOTHERAPY
21.3.1 RADIATION AND CHEMOTHERAPY RELATED
MUCOSITIS
K12.3
DESCRIPTION
An inflammatory reaction where shallow ulcerative lesions occur on mucosal
surfaces.
2019 21.5
GENERAL MEASURES
Avoid irritants (e.g.: smoke, alcohol and hot spicy food).
Ensure adequate fluid intake e.g.: 2 L/day.
Modify diet to include soft or pureed foods.
Use lip care e.g. petroleum jelly, as required.
Keep dentures clean and snug fitting. If loose, refer to dentist.
Ensure adequate mouth care:
» Clean teeth with soft toothbrush or clean cloth.
» Avoid dental flossing.
» Rinse and gargle regularly, at a minimum after every meal.
Simple mouth rinse:
- ½ teaspoon salt
- 3 teaspoons sodium bicarbonate
- 1 L of filtered or previously boiled water.
(Discard this mixture after 3 days).
LoE:IIIv
MEDICINE TREATMENT
Adequate pain control. See section 25.2: Analgesia for acute non-surgical pain.
21.3.2 WET DESQUAMATION OF SKIN

R23.4
DESCRIPTION
Acute toxicity of skin that occurs during radiation treatment and up to 2-3
weeks after completion of the radiation.
Few or even no skin care products are effective to prevent or reduce acute
radiotherapy skin reactions.
GENERAL MEASURES
Keep skin clean and apply paraffin gauze dressings daily.
Avoid friction and trauma from clothes, weather, etc.
Prevent infection.
Encourage good nutrition.
Encourage smoking cessation.
MEDICINE TREATMENT
Adequate pain control. See section 25.2: Analgesia for acute non-surgical pain.
2019 21.6
21.3.3 RADIATION- OR CHEMOTHERAPY-INDUCED

PNEUMONITIS
J70.0
DESCRIPTION
Radiation pneumonitis is inflammation of the lung caused by radiation therapy
to the chest. It mostly develops 1–6 months after treatment.
Chemotherapy-induced pneumonitis is inflammation of the lung caused by
various chemotherapy agents. It mostly develops on treatment.
Symptoms include: fever, dry cough, chest congestion, shortness of breath,
and chest pain.
The differential diagnosis includes infectious pneumonitis, pulmonary
embolism, and tumor recurrence.
GENERAL MEASURES
Symptoms generally resolve within 7–10 days following cessation of
treatment.
Maintain hydration.
MEDICINE TREATMENT
For symptomatic subacute pneumonitis:
 Prednisone 1 mg/kg daily for 2–4 weeks at a maximum daily dose of 40–
60 mg, and then taper slowly over 3–12 weeks. Refer to LoE:IIIvi
Appendix II for an example of a dose reduction regimen.
REFERRAL
All patients with symptomatic pneumonitis.

21.3.4 RADIATION PROCTITIS
K62.7
DESCRIPTION
An inflammatory process of the rectal mucosa that can present acutely
(immediately after the initiation of radiation therapy or up to 3 months after) or
chronically (8-12 months after completion of therapy). The acute process is
usually self-limiting.
Symptoms include diarrhoea, nausea, cramps, tenesmus, urgency, mucus
discharge, and minor bleeding.
Severe complications include bleeding, strictures, perforation, fistula, and bowel
obstruction.
2019 21.7
Diagnosis
Suspect radiation proctitis when there has been previous radiation to the
pelvis.
On colonoscopy/sigmoidoscopy, pallor, friability, telangiectasia are seen
localised to the area that was exposed to radiation. Do not biopsy.
Exclude other causes, e.g.: malignancy, infection, or inflammatory bowel disease.
REFERRAL
All patients to a radiation oncology centre.
21.3.5 RADIATION- OR CHEMOTHERAPY-INDUCED

CYSTITIS
N30.4
DESCRIPTION
Symptoms include dysuria, frequency, nocturia, recurrent haematuria, and
recurrent urinary tract infection.
GENERAL MEASURES
Increase fluid intake.
Urine microscopy, culture and sensitivity to exclude/confirm an infection.
High dose cyclophosphamide and ifosfamide may cause severe cystitis due
to excretion of acrolein into bladder.
Acute cystitis is usually self-limiting and resolves in one to two weeks after
completing radiation therapy. If symptoms continue, cystoscopy with biopsy is
indicated.
REFERRAL
All patients.
21.4 SIDE EFFECT FROM CHRONIC PAIN MEDICATION
21.4.1 CONSTIPATION
See section 26.1.3: Treatment of adverse effects of chronic opioid use.
21.4.2 NAUSEA & VOMITING

See section 26.1.3: Treatment of adverse effects of chronic opioid use.
21.4.3 DEPRESSION
See section 24.2.3: Depression.
2019 21.8
References:
i Sodium Chloride 0.9%, IV: Coiffier B, Altman A, Pui CH, Younes A, Cairo MS. Guidelines for the management of
pediatric and adult tumor lysis syndrome: an evidence-based review. J Clin Oncol. 2008 Jun 1;26(16):2767-78.
ii Allopurinol, oral: Krakoff IH. Use of allopurinol in preventing hyperuricemia in leukemia andlymphoma. Cancer.
1966 Nov;19(11):1489-96. https://www.ncbi.nlm.nih.gov/pubmed/5925255

Allopurinol, oral: Coiffier B, Jones GL, Will A, Jackson GH, Webb NJ, Rule S; British Committee for Standards in
Haematology. Guidelines for the management of tumour lysis syndrome in adults and children with haematological
malignancies on behalf of the British Committee for Standards in Haematology. Br J Haematol. 2015
Jun;169(5):661-71. https://www.ncbi.nlm.nih.gov/pubmed/25876990
Allopurinol, oral: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.
Allopurinol, oral: National Department of Health: Affordable Medicines, EDP-Adult Hospital level. Medicine
review: Allopurinol, oral for prevention of tumour lysis syndrome in adults, March 2019. http://www.health.gov.za/
iii Dexamethasone, IV: Kumar A, Weber MH, Gokaslan Z, Wolinsky JP, Schmidt M, Rhines L, Fehlings MG, Laufer
I, Sciubba DM, Clarke MJ, Sundaresan N, Verlaan JJ, Sahgal A, Chou D, Fisher CG. Metastatic Spinal Cord
Compression and Steroid Treatment: A Systematic Review. Clin Spine Surg. 2017 May;30(4):156-163.
Dexamethasone, IV: Greenberg HS, Kim JH, Posner JB. Epidural spinal cord compression from metastatic tumor:
results with a new treatment protocol. Ann Neurol. 1980;8:361-366. https://www.ncbi.nlm.nih.gov/pubmed/7436380
Dexamethasone, IV: Vecht CJ, Haaxma-Reiche H, van Putten WL, de Visser M, Vries EP, Twijnstra A. Initial bolus
of conventional versus high-dose dexamethasone in metastatic spinal cord compression. Neurology. 1989
Sep;39(9):1255-7. https://www.ncbi.nlm.nih.gov/pubmed/2771077
Dexamethasone, IV: National Department of Health: Affordable Medicines, EDP-Adult Hospital level. Historically
accepted use-review: Dexamethasone IV for metastatic spinal cord compression, March 2019.
Dexamethasone, IV (dosing): National Institute for Health and Care Excellence. Clinical Guidelines: Metastatic
spinal cord compression in adults: risk assessment, diagnosis and management, November 2008.
iv Clindamycin, oral: South African Antibiotic Stewardship Programme. A Pocket Guide to Antibiotic Prescribing for
Adults in South Africa, 2015.http://www.fidssa.co.za/images/SAASP_Antibiotic_Gudidelines_2015.pdf

Clindamycin, oral: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.
Clindamycin, oral: Bouazza N, Pestre V, Jullien V, Curis E, Urien S, Salmon D, Tréluyer JM. Population
pharmacokinetics of clindamycin orally and intravenously administered in patients with osteomyelitis. Br J
ClinPharmacol. 2012 Dec;74(6):971-7.http://www.ncbi.nlm.nih.gov/pubmed/22486719
v Saline mouth rinse: Huang BS, Wu SC, Lin CY, Fan KH, Chang JT, Chen SC. The effectiveness of a saline mouth
rinse regimen and education programme on radiation-induced oral mucositis and quality of life in oral cavity cancer
patients: A randomised controlled trial. Eur J Cancer Care (Engl). 2018 Mar;27(2):e12819.
vi Prednisone, oral: Small W Jr, Woloschak G. Radiation toxicity: a practical guide. Introduction. Cancer Treat Res.
Prednisone, oral: Ta V, Aronowitz P. Radiation pneumonitis. J Gen Intern Med. 2011 Oct;26(10):1213-4.
Prednisone, oral: Conway JL, Long K, Ploquin N, Olivotto IA. Unexpected Symptomatic Pneumonitis Following
Breast Tangent Radiation: A Case Report. Cureus. 2015 Oct 22;7(10):e363.
Prednisone, oral: National Department of Health: Affordable Medicines, EDP-Adult Hospital level. Medicine
Review: Prednisone, oral for radiation pneumonitis in Adults, November 2019. http://www.health.gov.za/
2019 21.9
CHAPTER 22
MEDICINES USED FOR DIAGNOSIS
22.1 DIAGNOSTIC CONTRAST AGENTS AND RELATED

SUBSTANCES
Medication used in diagnostic radiology includes:
Barium sulphate suspension.
 Non-ionic contrast media, e.g.:
o iohexol, or
o iopamidol, or
o iopromide, or
o ioversol.
SAFETY
The overall rate of adverse reactions is estimated to be less than 1 in 100i
when using non-ionic contrast media and serious allergic reactions are even
less common (about 1 in 2000ii). Contrast media-associated fatality is rare,
estimated to be 2 per million injections.iii
Management of any reaction depends on it’s severity. Life-threatening acute

cardiopulmonary collapse should be treated according to guidelines for
cardiopulmonary resuscitation. See chapter 20: Emergencies and injuries.
Moderate and severe reactions may be associated with bronchospasm and
wheeze, stridor, hypotension, and loss of consciousness. Stop the infusion of
the contrast agent and start treatment as for anaphylaxis including adrenaline,
oxygen (if indicated), intravenous fluids, and antihistamines. See sections
20.6: Angioedema and 20.7: Anaphylaxis/anaphylactic shock.
Iodine allergy: (Z91.0)

Patients allergic to iodine are at an increased risk of adverse drug reactions
when exposed to iodine-containing contrast media and patients who report
previous allergic reactions to contrast agents should be carefully evaluated as
to the need for the investigation. If the investigation is considered essential, the
patient should be pre-treated with steroids and antihistamines before
proceeding.

 Prednisone, oral, 50 mg given 13 hours, 7 hours, and 1 hour before the
procedure. LoE:IIiv
Contrast-Induced Nephrotoxicity (CIN) is an important consideration; it

may result in permanent renal impairment with significant effects on
longevity. This is particularly important in an environment with limited
access to renal replacement therapy. Before referring any patient for an
2019 22.1
CHAPTER 22 DIAGNOSTICS
investigation involving contrast use, carefully weigh up the individuals’

potential risk of CIN against potential benefits (the likelihood of detecting a
condition for which a significant therapeutic intervention is available).
CIN is variously defined as either a 25% or a 50% rise on pre-contrast
creatinine levels, or an absolute creatinine increase of more than 25
micromol/L. CIN is rare in individuals with normal renal functionv,vi .
Factors that increase the risk of CIN include: diabetes, pre-existing renal
impairment, age >75 years, anaemia, cardiac failure, hypotension and the
volume of contrast media injectedvii,viii.
The probability of developing a 25% rise in creatinine after cardiac
catheterisation in patients given 200 mL of non-ionic contrast media is linked
to co-morbidityvii:
CIN risk None Anaemia >75 yrs CCF or low BP >1 risk factor
No diabetes
eGFR>60 7.5% 7.5% 7.5% 15% 15%
eGFR 40–60 7.5% 15% 15% 15% 15%
eGFR 20–40 7.5% 15% 15% 15% 25%
eGFR<20 15% 15% 25% 25% 25%
Diabetes
eGFR>60 7.5% 15% 15% 15% 25%
eGFR 40–60 15% 15% 15% 25% 25%
eGFR 20–40 15% 25% 25% 25% 25%
eGFR<20 15% 25% 25% 25% 55%
The probability of needing dialysis after cardiac catheterisation is correlated

with the risk of CINvii:
CIN risk 7.5% 15% 25% 55%

Dialysis risk 0.04% 0.12% 1.1% 13%
Reducing the risk of developing CIN

There is no clear evidence that any specific medication is protective against
the development of CIN. However, meticulous attention to fluid balance is
important in patients at higher risk, as dehydration increases the risk of CIN.
Patients on metformin should be monitored for deterioration in renal function
post procedure, as there is a small risk of precipitating lactic acidosis. In high
risk patients it may be advisable to omit metformin for 48 hours after contrast
injection while monitoring serum creatinine.
2019 22.2
CHAPTER 22 DIAGNOSTICS
References:
i Wang CL, Cohan RH, Ellis JH, Caoili EM, Wang G, Francis IR. Frequency, outcome, and appropriateness of
treatment of nonionic iodinated contrast media reactions. AJR2008; 191:409-

ii Katayama H, Yamaguchi K, Kozuka T, Takashima T, Seez P, Matsuura K. Adverse reactions to ionic and
nonionic contrast media. A report from the Japanese Committee on the Safety of Contrast Media. Radiology1990;
175:621-628. http://www.ncbi.nlm.nih.gov/pubmed/2343107
iii Caro JJ, Trindade E, McGregor M. The risks of death and of severe nonfatal reactions with high- vs low-
osmolality contrast media: a meta-analysis. AJR1991;156:825-832. http://www.ncbi.nlm.nih.gov/pubmed/1825900

iv Prednisone, oral (iodine allergy): American College of Radiology. ACR Manual on Contrast Media, 2018,
version 10.3. https://www.acr.org/Clinical-Resources/Contrast-Manual
Prednisone, oral: Tramèr MR, von Elm E, Loubeyre P, Hauser C. Pharmacological prevention of serious
anaphylactic reactions due to iodinated contrast media: systematic review. BMJ. 2006 Sep 30;333(7570):675.
Prednisone, oral: Lasser EC, Berry CC, Talner LB, Santini LC, Lang EK, Gerber FH, Stolberg HO. Pretreatment
with corticosteroids to alleviate reactions to intravenous contrast material. N Engl J Med. 1987 Oct 1;317(14):845-
vMcDonald JS, McDonald RJ, Comin J, Williamson EE, Katzberg RW, Murad MH, Kallmes DF. Frequency of acute
kidney injury following intravenous contrast medium administration: a systematic review and meta-analysis.
Radiology. 2013 Apr;267(1):119-28.http://www.ncbi.nlm.nih.gov/pubmed/23319662
viDavenport MS, Khalatbari S, Cohan RH, Dillman JR, Myles JD, Ellis JH. Contrast material-induced nephrotoxicity
and intravenous low-osmolality iodinated contrast material: risk stratification by using estimated glomerular filtration
rate. Radiology. 2013 Sep;268(3):719-28.http://www.ncbi.nlm.nih.gov/pubmed/23579046
viiMcCullough PA, Adam A, Becker CR, Davidson C, Lameire N, Stacul F, Tumlin J; CIN Consensus Working
Panel. Risk prediction of contrast-induced nephropathy.Am JCardiol. 2006 Sep 18;98(6A):27K-36K.

viii Mehran R, Aymong ED, Nikolsky E, Lasic Z, Iakovou I, Fahy M, Mintz GS, Lansky AJ, Moses JW, Stone GW,
Leon MB, Dangas G. A simple risk score for prediction of contrast-induced nephropathy after percutaneous
coronary intervention: development and initial validation. J Am CollCardiol. 2004 Oct 6;44(7):1393-
2019 22.3
CHAPTER 23
SEDATION
23.1 SEDATION
DESCRIPTION
Sedation aims to reduce some combination of anxiety, agitation and pain while
the patient retains control of airway, breathing and blood pressure.
23.1.1 PROCEDURAL SEDATION AND ANALGESIA

Procedural sedation and analgesia is a technique that uses medications to
allow patients to tolerate unpleasant medical, interventional or diagnostic
procedures.
It is a brief intervention, unlike sedation in intensive or palliative care. It is
commonly used in emergency units, dentistry and for certain endoscopic and
gynaecological procedures.
The information described does not apply to:
» Patients receiving inhaled anaesthetics.
» Patients receiving analgesia for pain without sedation.
» Patients receiving sedation to manage behavioural emergencies.
» Patients who are intubated.
GENERAL MEASURES
Procedural sedation is a continuum: ranging from minimal sedation
(anxiolysis), moderate sedation/analgesia, deep sedation/analgesia, to
general anaesthesia.
Deep sedation/analgesia includes the dissociative state caused by medicines
like ketamine. It is often difficult to predict levels of sedation and therefore
clinicians undertaking procedural sedation should be adequately trained in this
technique. The clinician should have a detailed understanding of the risks and
benefits of all the medicines used. Further the clinician should be competent
in resuscitation, airway management and assisted ventilation.
Procedural sedation should only be performed in an area with adequate light,
space and fully functional and adequate observation, monitoring and
resuscitation equipment.
Besides the clinician performing the procedure, there must be one other
trained health care provider present responsible for observing the patient,
assisting with resuscitation if necessary and monitoring the patient. The
trained health care provider should observe the patient until the patient is
ready for discharge.
Patient monitoring and details of the types and amounts of all medicines used
must be recorded for each procedure. After the procedure the patient’s fitness
to leave the observation area should be formally assessed and recorded.
Sedation level:
2019 23.1
CHAPTER 23 SEDATION
Sedation
Depth Minimal Moderate Deep General
Other aims Anxiolysis Analgesia anaesthesia
Examples Nitrous oxide Opioid Opioid

OR AND AND
benzodiazepine benzodiazepine benzodiazepine
OR
propofol
OR
etomidate
Response to Purposefully to Purposefully only
stimuli Verbal verbal or tactile after Unrousable
repeated/painful
Airway Not required Not usually May be needed Requires
intervention needed assistance
Breathing Normal Usually normal May need Requires

(spontaneous assistance assistance
ventilation /positive
adequate) pressure
ventilation
BP/Pulse Normal May need
Usually normal/ maintained support
Monitoring As for any
Intermittent Continuous pulse oximetry and heart general
review of vital rate, intermittent BP and respiratory anaesthetic
signs rate. Continuous ECG if CVS disease
or sedation with more than one agent
Cognitive Loss of
Function or Impaired depressed consciousness
level of
conscious
LoE:IIIi
Ketamine
Ketamine administration leads to a dissociative state (patients may not be able
to speak coherently or respond purposefully to verbal commands) and
provides both sedation and analgesia. Used on its own, it rarely requires
airway intervention or affects breathing, but may cause hypertension and
tachycardia because of sympathetic stimulation.
LoE:IIIii
MEDICINE TREATMENT
Patient characteristics and required depth and/or duration of sedation lead to
differences in dosing requirements; the doses listed serve only as a guide,
and incremental further dosing may be required depending on clinical
response.
Minimal sedation and anxiolysis (no analgesic effect required)

Oral sedation may be appropriate for certain procedures.
Initial dose (further dose increments may be necessary – consult full
prescribing information for each agent to determine maximum safe dosages,
and reduce doses in the frail and elderly):
2019 23.2
CHAPTER 23 SEDATION
 Diazepam, IV, 0.1 mg/kg. (In a 60 kg patient, give boluses of 2 mg every

minute; may require up to 10 mg).
OR LoE:IIiii
Midazolam, IV, 0.05 mg/kg. (In a 60 kg patient, give
boluses of 1 mg every minute; may require up to 3 mg).
OR
Nitrous oxide, inhaled 20 to 50%, in oxygen (will also provide some
analgesia).
Benzodiazepines may cause respiratory depression; monitor accordingly.
Moderate sedation and analgesia

If analgesia is required, one of the above is usually combined with an opioid.
However, ketamine has analgesic activity and can be used on its own, or
combined with a benzodiazepine. The opioids may cause respiratory
depression; monitor accordingly.
Initial doses:
 Fentanyl, IV, 0.25 mcg/kg.
o Titrate to effect and repeat dose every five minutes until desired level
of analgesia has been achieved.
OR LoE:IIIiv
Morphine, IV, 0.1 mg/kg, in increments of 2 mg every 5 minutes.
OR
Ketamine, IV, 0.5 mg/kg (the addition of a benzodiazepine is often
recommended to reduce the incidence/severity of phenomena such as
hallucinations and dreaming, but the benefit of this is unclear).
o Repeat doses of 0.5 mg/kg as required, every 5 to 10 LoE:IIIv
minutes.
OR
Nitrous oxide, 20–50% inhaled, in oxygen.
LoE:IIIvi
Other agents for moderate sedation
Propofol on its own provides moderate sedation for short procedures (e.g.
endoscopy), but without analgesia:
 Propofol, IV, 0.5 mg/kg, repeated as 0.25 mg/kg boluses every 5
minutes as required. Specialist consultation. LoE:IIIvii
Etomidate is a short-acting agent like propofol, but is more likely to cause

myoclonus. It has minimal haemodynamic effects and a reliable onset of
action, but no analgesic effect and is more commonly used for emergency unit
procedures, rather than endoscopies.
 Etomidate, IV, 0.1 mg/kg. LoE:IIIviii

o Repeat doses of 0.05 mg/kg every 5 minutes, as
required.
2019 23.3
CHAPTER 23 SEDATION
Deep sedation and analgesia

This is usually achieved with either higher doses of medications used for
moderate sedation, or by combining an opioid, a benzodiazepine, and either
propofol or etomidate.
When agents are combined, lower doses may be adequate. Always have
another health care provider monitoring the patient and resuscitation
equipment present.
Supplemental analgesia
Simple analgesics can be given before or after the procedure as appropriate:
AND/OR
 NSAID, e.g.:
 Ibuprofen, oral, 400 mg 8 hourly with meals after the procedure.
Other routes (e.g. rectal or intramuscular) may be appropriate for certain

indications and medications.
Reversal Agents must be available as medicine doses for sedation/analgesia

are highly variable as are patient’s age, concurrent medication and medical
conditions. Supportive management is aimed at maintaining cardiorespiratory
function.
For opioid toxicity:
 Naloxone, IV, 0.08 mg immediately. LoE:IIIix
o Repeat doses as required at 2 minute intervals.
o Maximum total dose is 10 mg.

23.1.2 SEDATION IN INTENSIVE CARE
Indications for sedation in intensive care need to be defined for each patient,
and may include one or more of: anxiolysis, analgesia, agitation control, or to
help patients tolerate uncomfortable situations or procedures (e.g. intubation
and ventilation). Sedation requirements fluctuate rapidly and warrant regular
review. Individualised sedation objectives should be clearly defined, and level of
sedation regularly recorded. Sedation protocols that recognise the need for dose
minimisation, weaning and sedation interruptions probably improve outcomes.
LoE:IIx
Adequate pain control is often more efficacious than
sedatives for reducing agitation. Delirium should be considered, and managed
appropriately. The doses listed apply to ventilated patients in whom short term
respiratory depression is not a concern.
2019 23.4
CHAPTER 23 SEDATION
Short term sedation (less than 24 hours)

 Midazolam, IV infusion, 0.05–0.2 mg/kg/hour.
OR
Propofol, IV infusion, 0.5 mg/kg/hour.
Note: Propofol does have cardiovascular effects; benzodiazepines
are preferred. LoE:IIIxi
Longer term sedation (expected 72 hours or more)

 Lorazepam, IV, 0.1 mg/kg/hour.
OR
Midazolam, IV, 0.2 mg/kg/hour.
Note: Lorazepam (0.1 mg/kg/hour) is as effective (and as easy to wean) as
midazolam 0.2 mg/kg/hour) but is more difficult to titrate. Due to high fat
solubility, midazolam also becomes ‘long acting’ after infusions of more than
24 hours.
Supplemental analgesia:
Analgesia can be added to any of the above regimens:
 Morphine, IV infusion, 0.1–0.2 mg/kg/hour.
OR
 Fentanyl, IV infusion, 1 mcg/kg/hour (also becomes long acting after
prolonged infusion due to fat solubility.)
LoE:IIIxii
23.1.3 SEDATION IN PALLIATIVE CARE
See section 24.5: Sedation in palliative care.
2019 23.5
CHAPTER 23 SEDATION
References:
i Medication used for sedation: American Society of Anesthesiologists Task Force on Sedation and Analgesia by
Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology.
2002 Apr;96(4):1004-17. http://www.ncbi.nlm.nih.gov/pubmed/11964611
Medication used for sedation: The South African Society of Anaesthesiologists. South African Society of
Anaesthesiologists Sedation Guidelines, 2015. South Afr J AnaesthAnalg 2015;21(2)S1-
S36.http://www.sasaweb.com/content/images/SAJAA_V21N2_1665_Sedation_Guideline.pdf
ii Ketamine: American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-
Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. 2002
Apr;96(4):1004-17. http://www.ncbi.nlm.nih.gov/pubmed/11964611
iii Diazepam: Mitchell AR, Chalil S, Boodhoo L, Bordoli G, Patel N, Sulke N. Diazepam or midazolam for external
DC cardioversion (the DORM Study). Europace. 2003 Oct;5(4):391-5.
Midazolam: Mitchell AR, Chalil S, Boodhoo L, Bordoli G, Patel N, Sulke N. Diazepam or midazolam for external
DC cardioversion (the DORM Study). Europace. 2003 Oct;5(4):391-
iv Fentanyl IV: The South African Society of Anaesthesiologists. South African Society of Anaesthesiologists
Sedation Guidelines, 2015. South Afr J AnaesthAnalg 2015;21(2)S1-
Fentanyl IV: Poulos JE, Kalogerinis PT, Caudle JN. Propofol compared with combination propofol or
midazolam/fentanyl for endoscopy in a community setting. AANA J. 2013 Feb;81(1):31-6.
v Benzodiazepines (ketamine-induced agitation): Strayer RJ, Nelson LS. Adverse events associated with ketamine
for procedural sedation in adults. Am J Emerg Med. 2008 Nov;26(9):985-1028.
Benzodiazepines (ketamine-induced agitation): Akhlaghi N, Payandemehr P, Yaseri M, Akhlaghi AA,
Abdolrazaghnejad A. Premedication With Midazolam or Haloperidol to Prevent Recovery Agitation in Adults
Undergoing Procedural Sedation With Ketamine: A Randomized Double-Blind Clinical Trial. Ann Emerg Med. 2019
vi Morphine, IV: American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-
Morphine, IV: The South African Society of Anaesthesiologists. South African Society of Anaesthesiologists
Ketamine, IV: American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-
Ketamine, IV: The South African Society of Anaesthesiologists. South African Society of Anaesthesiologists
Nitrous oxide, inhaled, in 20-30% oxygen: American Society of Anesthesiologists Task Force on Sedation and
Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists.
Anesthesiology. 2002 Apr;96(4):1004-17. http://www.ncbi.nlm.nih.gov/pubmed/11964611
vii Propofol, IV: Poulos JE, Kalogerinis PT, Caudle JN. Propofol compared with combination propofol or
midazolam/fentanyl for endoscopy in a community setting. AANA J. 2013 Feb;81(1):31-6.
viii Etomidate, IV: American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-
ix Naloxone, IV (reversal agent for opioid toxicity): The South African Society of Anaesthesiologists. South African
Society of Anaesthesiologists Sedation Guidelines, 2015. South Afr J AnaesthAnalg 2015;21(2)S1-
x Sedation protocols in intensive care: Jackson DL, Proudfoot CW, Cann KF, Walsh T. A systematic review of the
impact of sedation practice in the ICU on resource use, costs and patient safety. Crit Care. 2010;14(2):R59.
xi Propofol, IV (short-term sedation: second line option): The South African Society of Anaesthesiologists. South
African Society of Anaesthesiologists Sedation Guidelines, 2015. South Afr J AnaesthAnalg 2015;21(2)S1-
Propofol, IV (short-term sedation: second line option): South African Medicines Formulary. 12th Edition. Division
xii Propofol, IV: Ostermann ME, Keenan SP, Seiferling RA, Sibbald WJ. Sedation in the intensive care unit: a
systematic review. JAMA. 2000 Mar 15;283(11):1451-9. http://www.ncbi.nlm.nih.gov/pubmed/10732935
2019 23.6
CHAPTER 24
MEDICINES USED IN PALLIATIVE CARE
PALLIATIVE CARE
Palliative care is an approach that improves the quality of life of patients and
their families facing problems associated with life-threatening illness,
regardless of whether or not they also receive life-prolonging treatment. It
requires a multidisciplinary approach and aims to address physical,
psychosocial, and spiritual problems.
Life threatening illnesses are where death is expected to be a direct

consequence of the specified illness.
Analysis of available evidence suggested 11 common symptoms occurring in
the advanced stages and end of life stages: anorexia, anxiety, constipation,
delirium, depression, diarrhoea, dyspnoea, fatigue, nausea and vomiting, pain
and respiratory tract secretions.
All symptoms should be managed by a multi-disciplinary team to ensure a
holistic approach.
Note: Please be advised that the recommendations in this chapter are
directed at treating common symptoms associated with end-of-life care
(acute and sub-acute) - a component of palliative care. The approach to end-
of-life care may differ from supportive palliative care. Refer to relevant
sections for supportive palliative care, e.g. section 15.3.1: Depressive
disorders.
Always refer to the latest National Guidelines on Palliative Care.
For management of pain in palliative care see chapter 26: Pain.
24.1 GASTROINTESTINAL CONDITIONS
24.1.1 ANOREXIA AND CACHEXIA

R63.0/R63.4/R64 + (Z51.1)
DESCRIPTION
Anorexia/cachexia syndrome is a complex metabolic process found in many
end-stage illnesses. It is characterised by loss of appetite, weight loss and
muscle wasting, and cannot be fully reversed by conventional nutritional
support. It may impact significantly on the quality of life of patients, leading to
increased anxiety and distress for both patients as well as family.
2019 24.1
CHAPTER 24 MEDICINES FOR PALLIATIVE CARE
GENERAL MEASURES
Reduced food and fluid intake is expected at the end of life, and treatment of
anorexia and weight loss may not be appropriate if these symptoms are not
having a direct impact on quality of life. This should be explained to caregivers
and family.
Management of anorexia and weight loss includes identification and, if
appropriate, treatment of possible underlying cause(s). It may include the use
of pharmacological and non-pharmacological treatment approaches.
Identify reversible problems that may contribute to or exacerbate anorexia/
cachexia including:
 Pain, nausea, heartburn, dyspnoea, gastritis, depression, constipation
anxiety dysphagia, medication and fatigue
 Oral problems e.g. dry mouth, ulcers, candidiasis, etc.
 Odours e.g. fungating lesions, cooking smells, incontinence etc.
 Delayed gastric emptying due to local disease, autonomic neuropathy
with early satiety and vomiting of undigested foods
If appropriate, moderate exercise must be encouraged, along with pacing of
activities and good sleep hygiene.
Nutritional advice includes eating small amounts of enjoyable food frequently.
MEDICINE TREATMENT
If the anorexia and/ cachexia contributes significantly to decreased quality of
life and the patient has a short life expectancy.
 Prednisone, oral, 0.5 mg/kg (e.g. 20–30 mg) daily.
o The effect may be rapid but usually decreases after 3–4 weeks.
o If there is no benefit after 1 week, stop the treatment.
LoE:IIIi
If symptoms of reflux or gastritis: see section 1.1.3: Gastro-oesophageal reflux
disease.
If gastroparesis is present, see section 8.7.1 Diabetic neuropathies.
24.1.2 CONSTIPATION
K59.0 + (Z51.1)
DESCRIPTION
Constipation is the passage of small, hard faeces infrequently and with
difficulty. Individuals vary in the weight they give to the different components
of this definition when assessing their own constipation and may introduce
other factors, such as pain and discomfort when defecating, flatulence,
bloating or a sensation of incomplete evacuation. Constipation may also be
secondary to other conditions e.g. dehydration, immobility poor diet, anorexia,
tumour compressing bowel wall or hypercalcaemia.
2019 24.2
GENERAL MEASURES
Ensure privacy and comfort to allow a patient to defecate normally.
Increase fluid intake within the patient’s limits.
Encourage activity and increased mobility within the patient’s limits.
Anticipate the constipating effects of pharmacological agents such as opioids,
anticholinergic agents (e.g. tricyclic antidepressants), antacids, iron, 5HT3
antagonists and provide laxatives prophylactically.
MEDICINE TREATMENT
The combination of a softener and stimulant laxative is generally
recommended, and the choice of laxatives should be made on an individual
basis.
 Sennosides A and B, oral, 13.5 mg, 1 tablet at night.
o In resistant cases increase to 2 tablets.
AND/OR LoE:IIIii
Lactulose, oral, 15–30 mL 12–24 hourly.
LoE:IIIiii
Severe constipation in patients who are unable to swallow:
 Bisacodyl, rectal, 10 mg suppository daily.
OR LoE:IIIiv
Glycerine (glycerol), rectal, 1.698 mL/2.4 g suppository when necessary.
LoE:III
If these therapies are not effective, other options could be considered.
Note: Manual removal should only be undertaken if the patient has received
adequate pain relief and sedation, if relevant.
If bowel obstruction is suspected refer/consult for appropriate radiological
investigations and, if appropriate, surgical interventions.
24.1.3 DIARRHOEA
A09.0/A09.9/K52.2/K52.9 + (Z51.5)
See Primary Health Care chapter: Medicines for palliative care: section 22.1.2:
Diarrhoea.
24.1.4 NAUSEA AND VOMITING

R11 + (Z51.5)
GENERAL MEASURES
Treat the underlying cause and rehydrate the patient.
Reversible causes include medication, hypercalcemia, constipation, uraemia,
gastritis, gastroenteritis, coughing and infections.
Manage odours e.g. cooking smells and fungating wounds.
2019 24.3
MEDICINE TREATMENT
Treat the underlying cause.
 Metoclopramide, oral/IM/IV, 10 mg 8 hourly, 30 minutes before a meal.
If metoclopramide is ineffective or contra-indicated (i.e. inoperable bowel
obstruction):
 Haloperidol, oral, 0.75–5 mg daily.
OR LoE:IIIv
Haloperidol, SC/IM/IV
o Initiate 0.5 mg 12 hourly.
o Titrate to a maximum dose of 5 mg 8 hourly. LoE:IIIvi
Drug-induced parkinsonism: LoE:IIIvii
ADD
 Orphenadrine, oral, 50–150 mg daily according to individual response
o Usual dose: 50 mg 8 hourly.
o Use with caution in the elderly as it may cause confusion and urinary
retention.
Note: Anticholinergic medicines (e.g. orphenadrine) should not be added
prophylactically to antipsychotics to prevent extrapyramidal side effects.
If haloperidol is ineffective/ inoperable bowel obstruction:

 Promethazine, IM/IV, 12.5–25 mg, 4–6 hourly. LoE:IIIviii
Corticosteroids can decrease cerebral oedema: See section: 14.12.1 Brain
oedema due to tumours and inflammation.
REFERRAL
Refer to the appropriate discipline if the underlying cause can be reversed e.g.
bowel obstruction - refer to a surgeon.
Consult a palliative care trained doctor if the vomiting persists.
24.2 NEUROPSYCHIATRIC CONDITIONS

24.2.1 ANXIETY
F40.0-2/F40.8-9F41.3/ F41.8-9/F42.0-2/F42.8-9 + (Z51.1)
DESCRIPTION
Anxiety is defined as the apprehensive anticipation of future danger or
misfortune accompanied by a feeling of dysphoria or somatic symptoms of
tension. Anxiety is characterised by excessive feelings of fear apprehension
and worry. Anxiety may be associated with symptoms of depression, poor
concentration, insomnia, irritability, panic attacks, sweating, tremor and
nausea. It is a common symptom in Palliative Care and the complex multi-
2019 24.4
causative nature of anxiety in patients with life threatening illnesses always

require a multimodal approach.
GENERAL MEASURES
Address any contributing factors such as pain and dyspnoea. Consider other
underlying conditions that may mimic anxiety e.g. electrolyte imbalance,
hyperthyroidism, hypoxia, arrhythmias and many medicine side effects.
Assess for depression or any other previous psychiatric illness.
Include the caregivers
Ensure the patient and caregivers have received the desired amount of
information around the nature of the disease, treatment, side-effects and
outcomes.
MEDICINE TREATMENT
A multi-disciplinary team approach is recommended (including a spiritual
carer).
Acute management of anxiety:

For an acute episode or intense prolonged anxiety:
 Benzodiazepine, e.g.:
 Diazepam, oral, 2.5–5 mg as a single dose.
o Repeat if required up to 12 hourly. LoE:IIIix
o Duration of therapy: up to 2 weeks, taper off to zero
within 6 weeks.
o Avoid if liver function impaired.
OR LoE:IIIx
 Lorazepam, oral, 0.5–1 mg, immediately.
o Repeat as necessary to control symptoms. LoE:IIIxi
o Tablets may be crushed and administered sublingually.
LoE:IIIxii
Patient unable to take oral medication/ terminal sedation required:
See section 24.5: Sedation in palliative care.
CAUTION
Patients with liver dysfunction require lower doses.
Monitor patients closely. LoE:IIIxiii
In the short-term, benzodiazepines can aggravate delirium.
» In frail and elderly patients or where respiratory depression is a
concern, reduce the dose by half. LoE:IIIxiv
» The safest route of administration is oral with the IV route
having the highest risk of respiratory depression and arrest. Use the safest
route wherever possible.
» Monitor vital signs closely during and after administration.
2019 24.5
» Use haloperidol instead of benzodiazepines in patients with respiratory

insufficiency.
» To avoid inappropriate repeat dosing allow at least 15–30 minutes for the
medication to take effect. Repeated IM doses of benzodiazepines may
result in toxicity owing to accumulation.
 SSRI e.g.:
 Citalopram, oral. LoE:Ixv
o Initiate at 10 mg daily for 2 weeks.
o Then increase to 20 mg daily.
OR LoE:Ixvi
Fluoxetine, oral.
o Initiate at 20 mg every alternate day for 2 weeks
o Increase to 20 mg daily after 2–4 weeks
o Delay dosage increase if increased agitation/panicked feelings occur.
LoE:IIIxvii
Note: Effect of SSRIs are only apparent after 2–3 weeks of
treatment, so they should be reserved for patients where end-of-life is not
imminent.
REFERRAL
Poor response to treatment.
24.2.2 DELIRIUM
F02.0-4/F02.8/F03/F05.0-1/F05.8-9 + (Z51.5)
DESCRIPTION
Delirium (confusion) is very common in the terminal stages of advanced
disease and is associated with a short prognosis. When treatment of the
underlying cause(s) of delirium is not possible or unsuccessful,
pharmacological management is necessary. Causal treatment may not be
indicated in patients with limited prognosis and pharmacological symptomatic
therapy has to be initiated without delay.
GENERAL MEASURES
Assess for underlying causes e.g. infection or electrolyte imbalance.
Remove factors that can agitate the patient (e.g. full bladder, thirst, pain,
constipation, medicines such as opioids, steroids, benzodiazepines,
withdrawal of medicines, dehydration, liver or renal impairment and cerebral
tumour).
Reduce polypharmacy.
Where appropriate, ensure adequate fluid and nutritional intake (not indicated
in the pre-terminal stage).
Mobilise early when appropriate.
Monitor for sensory deficits and manage accordingly e.g. using hearing aids.
2019 24.6
Keep the family involved and informed. Provide tools of care such as how to
orientate and reassure the patient.
MEDICINE TREATMENT
 Haloperidol, SC/IV, 0.5 mg 8 hourly.
OR
Haloperidol, oral, 0.75–5 mg 12 hourly.
o Titrate dosage up as required and use the minimum dose that controls
the symptoms.
LoE:IIIxviii
In the elderly or where there is no response or resistance to
haloperidol:
ADD
 Lorazepam, oral, 0.5–1 mg 2–4 hourly as required.
o Tablets may be crushed and administered LoE:IIIxix
sublingually.
OR LoE:IIIxx
Patients unable to swallow:
 Midazolam, SC/IV, 0.5–5 mg immediately.
o Titrate up slowly. LoE:IIIxxi
o Lower doses are indicated for patients with liver
dysfunction.
24.2.3 DEPRESSION
F32-3/F32.8-.9/F33.0-4/F33.8-9/F34.1 + (Z51.5)
DESCRIPTION
Depression is characterized by persistent feelings of extreme sadness and
low mood associated with loss of interest in activities and inability to
experience pleasure. There are often associated biological features of
significant changes in appetite and weight, disturbed sleep, fatigue and poor
concentration.
Diagnosis of major depression in a terminally ill patient often relies more on

the psychological or cognitive symptoms (worthlessness, hopelessness,
excessive guilt and suicidal ideation) than the physical/somatic signs (weight
loss and sleep disturbance) described in depression in patients who are not
terminally ill. The key indicators of depression in the terminally ill are persistent
feelings of hopelessness and worthlessness and/or suicidal ideation.
Demoralisation is a phenomenon where hope and meaning is lost and where

patients wish to hasten their death because they cannot foresee any future
pleasure.
GENERAL MEASURES
2019 24.7
Exclude physical reversible causes e.g. hypothyroidism, hyperthyroidism, or

hypercalcaemia.
MEDICINE TREATMENT
 SSRI, e.g.:
o Initiate at 10 mg daily for 2 weeks.
o Then increase to 20 mg daily.
OR LoE:IIIxxii
If sedation is required:
 Amitriptyline, oral, at bedtime.
o Start with: 25 mg, increase by 25 mg/day at 3–4 day intervals.
o Dose range: 75–150 mg daily.
Note: Effect of SSRIs are only apparent after 2-3 weeks of treatment, so they
should be reserved for patients where end-of-life is not imminent.
24.2.4 FATIGUE
R53 + (Z51.5)
DESCRIPTION
Fatigue is defined as a subjective feeling of tiredness, weakness or lack of
energy. The pathophysiology is not fully understood but will be multifactorial
in most palliative care patients, including disease- and treatment-related
causes. Fatigue may be severe, distressing and persistent, regardless of
adequate amounts of sleep and rest.
GENERAL MEASURES
Treat underlying causes such as anaemia, depression, and infections.
Encourage aerobic exercises, where appropriate.
Ensure that the multidisciplinary team assists with activity pacing, assisted
devices where indicated, and diet.
MEDICINE TREATMENT
Note: Because of limited evidence, consideration of steroids in palliative care
should be restricted to use in the terminally ill with fatigue and a specific short-
term treatment goal.
Fatigue can also protect patients at the end of life from physical and emotional
distress.
 Prednisone, oral 0.5 mg/kg (e.g.:15–30 mg) daily, for 1 week.
LoE:IIIxxiii
24.3 PAIN
2019 24.8
24.3.1 CHRONIC CANCER PAIN

See section 26.1.2: Analgesia for chronic cancer pain.
24.3.2 NEUROPATHIC PAIN
See section 26.1.4: Neuropathic pain.
24.4 RESPIRATORY CONDITIONS
24.4.1 DYSPNOEA
R06.0+ (Z51.5)
DESCRIPTION
Dyspnoea is the subjective unpleasant sensation of being unable to breathe
adequately (breathlessness). Dyspnoea is a complex multidimensional
symptom with physical, psychological, and emotional dimensions, especially
anxiety. The intensity of dyspnoea is generally not related to the oxygen
saturation.
Look for reversible causes, e.g. infection, pulmonary embolism, pleural effusion,
bronchospasm and anxiety
The aim should always be to address the cause. However, in end stage disease
symptomatic treatment is indicated.
GENERAL MEASURES
Ideally, include a physiotherapist and occupational therapist for pulmonary
rehabilitation and to teach patients pursed lip breathing, pacing of activities,
relaxation techniques, and positioning.
The use of a fan may reduce the sensation of dyspnoea.
Treat the underlying cause (e.g. antibiotics for underlying respiratory infection)
wherever possible.
MEDICINE TREATMENT
 Morphine syrup, oral.
o Starting dose: 2.5–5 mg, 4 hourly as required, titrating up slowly.
Dyspnoea associated with hypoxaemia

 Oxygen.
24.4.2 RESPIRATORY SECRETIONS

R06.0 + (Z51.5)
DESCRIPTION
Excessive respiratory tract secretions (also referred to as death rattle), is used
to describe a rattling noise produced by accumulated secretions in the airway
which oscillate in time with inspiration and expiration. Generally, respiratory
secretions occur in patients who are extremely weak and close to death.
2019 24.9
GENERAL MEASURES
Change position of the patient.
Explain to caregivers and relatives that the patient is not distressed by the
secretion. Patients are not conscious that they are unable to clear secretions.
Minimal oropharyngeal suctioning is required.
MEDICINE TREATMENT
 Hyoscine butylbromide, SC/IM, 20 mg.
o Increase dose to effect to maximum of 120 mg.
LoE:IIIxxiv
24.5 SEDATION IN PALLIATIVE CARE

Y47.9 + (Z51.5)
Sedation in palliative care has unique objectives, and tolerance for some
adverse effects may be greater than in other situations. There is also an
emphasis on avoiding parenteral medication. Palliative sedation should be
undertaken by clinicians experienced in the process and the advice of an
expert should be sought where necessary. Sedation should only be started
after discussion with, and with the consent of, the patient and/or family (when
the patient is unable to consent).
The aim of sedation in palliative care is to ameliorate refractory suffering and

not to hasten death.
Palliative care medication addresses symptoms such as pain, dyspnoea,
nausea and depression. Managing many of these symptoms involves the use
of medications which may have sedative properties. Palliative sedation
involves the additional use of medication where sedation is the primary
objective, and is appropriate only after standard care has proven
unsuccessful.
GENERAL MEASURES
Pain must always be the first symptom to be excluded.
Always look for reversible causes of symptoms prior to prescribing sedation
such as dehydration, hypoxia, concurrent synergistic sedative medicines,
hypercalcaemia, renal failure, or infection.
Caution should be exercised and palliative care prescription examined for
possible drug-drug interactions, prior to commencing sedation (or escalating
doses of sedative medicines).
Dose escalation may be considered only if there is evidence of inadequate
sedation.
MEDICINE TREATMENT
Dosing in frail, elderly patients should be titrated to effect.
2019 24.10
 Lorazepam, oral, 0.5 mg 4 hourly.

o Tablets may be crushed and administered sublingually.
OR LoE:IIIxxv
Haloperidol, oral, 0.75 mg 4 hourly.
Patient unable to take oral medication or terminal sedation required:

 Midazolam, SC/IV:
o Initial dose: 1–5 mg as needed
o Titrate to effect.
LoE:IIIxxvi
24.6 END OF LIFE CARE

Z51.1
DESCRIPTION
Patients can be defined as being terminal when there is irreversible decline in
functional status prior to death. It is essential during this time to ensure the
ethical management of the dying phase and to minimise distress for the
patient, family and fellow health care professionals by using a biopsychosocial
and spiritual approach.
Signs of dying:
» The patient may gradually spend more time sleeping during the day and
at times will be difficult to rouse.
» There may be decreased need for food and drink.
» The patient may become increasingly confused about time, place and
identity of friends and family.
» Arms and legs may become cool to the touch and the undersides of the
body may become darker in colour.
» Loss of control of bowel and bladder may occur.
» Urine output may decrease.
» Saliva and mucus may collect at the back of the throat as the swallowing
and cough reflexes diminish. This sometimes causes a noise known as
the “death rattle”.
» Vision and hearing may decrease.
» Breathing patterns may become irregular, with longer intervals between
breaths.
GENERAL MEASURES
Communication is at the centre of care. The following aspects should be
addressed:
» Honest, direct, compassionate and culturally sensitive information about
the prognosis.
» Evaluation of the patient and family resources and needs, especially
spiritual needs.
» Decision making on place of death as many patients want to go home.
2019 24.11
» Education about patient care.

» Emergency contact details, especially if the patient wants to go home.
» Compassionate information about symptoms that might develop and how
to manage them.
» Nutrition and hydration.
Discontinue all non-essential, futile procedures and medicines e.g.

discontinue 4-hourly blood pressure measurements and vitamin tablets.
Ensure medicines are prescribed for symptom management and prescribe
medicine when needed to pre-empt common symptoms during the terminal
phase using the appropriate route of administration:
» Pain (see section above)
» Nausea and vomiting (see section above)
» Respiratory secretions (see section above)
» Agitation /restlessness/delirium (see section above)
Discuss feeding and hydration with the family. If the decision is to hydrate and/
feed, ensure gentle hydration and monitor oedema, especially in patients with
hypoalbuminaemia. Hydration does not improve quality of life, survival, or
symptom burden at the end of life, and should not be given as routine
management. Rather offer sips of water if the patient is able to swallow.
2019 24.12
References:
i Corticosteroids, oral/IV (anorexia/cachexia): National Department of Health: Affordable Medicines, EDP-Primary
Health Care. Medicine Review: Betamethasone/dexamethasone for management of anorexia in adult palliative
care patients, 29 July 2017. http://www.health.gov.za/
Corticosteroids, oral/IV (anorexia/cachexia): Miller S, McNutt L, McCann MA, McCorry N. Use of corticosteroids
for anorexia in palliative medicine: a systematic review. J Palliat Med. 2014 Apr;17(4):482-5.
Corticosteroids, oral/IV (anorexia/cachexia): Back I., Watson M., Lucas C., Hoy A. and Armstrong P. 2012.
Anorexia, cachexia and asthenia. Palliative Care Guidelines Plus [Internet]. [Accessed 23 November 2017].
Available: http://book.pallcare.info/index.php?p=pdf&op_target=print&id=339&media=pdf&pdffmt=1&dg=1
ii Sennosides A and B, oral: University of Cape Town,Division of Clinical Pharmacology. South African Medicines
Formulary. 12th Edition. 2016.

Sennosides A and B, oral: Librach SL, Bouvette M, De Angelis C, Farley J, Oneschuk D, Pereira JL, Syme A;
Canadian Consensus Development Group for Constipation in Patients with Advanced Progressive Illness. Consensus
recommendations for the management of constipation in patients with advanced, progressive illness. J Pain Symptom
Manage. 2010 Nov;40(5):761-73. https://www.ncbi.nlm.nih.gov/pubmed/21075273
iii Lactulose, oral: Librach SL, Bouvette M, De Angelis C, Farley J, Oneschuk D, Pereira JL, Syme A; Canadian
Consensus Development Group for Constipation in Patients with Advanced Progressive Illness. Consensus
recommendations for the management of constipation in patients with advanced, progressive illness. J Pain Symptom
Manage. 2010 Nov;40(5):761-73. https://www.ncbi.nlm.nih.gov/pubmed/21075273
ivBisacodyl suppository: Canadian Agency for Drugs and Technologies in Health (CADTH). Rapid response report -
Routine Bowel Care for Patients in Long-Term or Palliative Care: Guidelines; 2015 Dec 7. [Internet]. Canadian
[cited 2017 October 30]. Available from:
https://www.cadth.ca/sites/default/files/pdf/htis/dec-2015/RB0940%20Bowel%20Care%20in%20LTC%20Final.pdf
Bisacodyl suppository: Larkin PJ ,Sykes NP, Centeno C, Ellershaw JE, Elsner F, Eugene B, Gootjes JRG, Naba
M, Noguera IA, Ripamonti C, Zucco F, Zuurmond WWA .The management of constipation in palliative care: clinical
practice recommendations Palliative Medicine. Vol 22, Issue 7, pp.796 – 807.
http://dx.doi.org/10.1177%2F0269216308096908
Bisacodyl suppository: National Department of Health: Affordable Medicines, EDP-Primary Health Care.
Medicine Review: Bisacodyl suppository in palliative care, 29 August 2017. http://www.health.gov.za/
v Haloperidol, oral/parenteral: Digges M, Hussein A, Wilcock A, Crawford GB, Boland JW, Agar MR, Sinnarajah A,
Currow DC, Johnson MJ. Pharmacovigilance in Hospice/Palliative Care: Net Effect of Haloperidol for Nausea or
Vomiting. J Palliat Med. 2018 Jan;21(1):37-43. https://www.ncbi.nlm.nih.gov/pubmed/28772094
Haloperidol, oral/parenteral: Doyle D, Woodruff R. The IAHPC Manual of Palliative Care. 3rd ed. IAHPC Press, 2013.
Available from: https://hospicecare.com/what-we-do/publications/manual-of-palliative-care/ [Accessed August 2019]
vi Haloperidol, parenteral (subcutaneous administration): Franken LG, Mathot RAA, Masman AD, Baar FPM,
Tibboel D, van Gelder T, Koch BCP, de Winter BCM. Population pharmacokinetics of haloperidol in terminally ill
adult patients. Eur J Clin Pharmacol. 2017 Oct;73(10):1271-1277. https://www.ncbi.nlm.nih.gov/pubmed/28681176
Haloperidol, parenteral (subcutaneous administration): Doyle D, Woodruff R. The IAHPC Manual of Palliative
Care. 3rd ed. IAHPC Press, 2013. Available from: https://hospicecare.com/what-we-do/publications/manual-of-
palliative-care/ [Accessed August 2019]
viiOrphenadrine, oral (parkinsonism side-effects): South African Medicines Formulary. 12th Edition. Division of
Clinical Pharmacology. University of Cape Town. 2016.

viii Promethazine, IM/IV: Wiffen, P. Palliative Care Formula 5th edition, 2014. http://www.palliativedrugs.com/
ix Benzodiazepines: Salt S, Mulvaney CA, Preston NJ. Drug therapy for symptoms associated withanxiety in adult
palliative care patients. Cochrane Database Syst Rev. 2017 May 18;5:CD004596.
x Diazepam, oral (anxiety): South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.
xi Lorazepam, oral (anxiety): BCGuidelines.ca. Palliative Care for the Patient with Incurable Cancer or Advanced
Disease - Part 2: Pain and Symptom Management, 22 February 2017 [Internet] [Accessed 23 November 2017].
Available at: https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/palliative-
pain-management
xii Lorazepam, oral formulation administered sublingually (anxiety): Greenblatt DJ, Divoll M, Harmatz JS, Shader
RI. Pharmacokinetic comparison of sublingual lorazepam with intravenous, intramuscular, and oral lorazepam. J
Pharm Sci. 1982 Feb;71(2):248-52. https://www.ncbi.nlm.nih.gov/pubmed/6121043
xiii Diazepam, parenteral (liver impairment): South African Medicines Formulary. 12th Edition. Division of Clinical

xiv Benzodiazepines: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.

xv SSRIs, oral (anxiety): Salt S, Mulvaney CA, Preston NJ. Drug therapy for symptoms associated with anxiety in
adult palliative care patients. Cochrane Database Syst Rev. 2017 May 18;5:CD004596.
xvi Citalopram, oral (anxiety): South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.

xvii Fluoxetine, oral (anxiety): Baldwin D, Woods R, Lawson R, Taylor D. Efficacy of drug treatments for generalised

Fluoxetine, oral (anxiety): South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.
2019 24.13
xviiiHaloperidol, oral/IV/SC (delirium): Candy B, Jackson KC, Jones L, Leurent B, Tookman A, King M. Drug therapy
for delirium in terminally ill adult patients. Cochrane Database Syst Rev. 2012 Nov
14;11:CD004770.https://www.ncbi.nlm.nih.gov/pubmed/23152226
Haloperidol, oral/IV/SC (delirium): Grassi L, Caraceni A, Mitchell AJ, Nanni MG, Berardi MA, Caruso R, Riba M.
Management of delirium in palliative care: a review. Curr Psychiatry Rep. 2015 Mar;17(3):550.
Haloperidol, oral/IV/SC (delirium): BCGuidelines.ca. Palliative Care for the Patient with Incurable Cancer or
Advanced Disease - Part 2: Pain and Symptom Management, 22 February 2017 [Internet] [cited 23 November
2017]. Available at: https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-
guidelines/palliative-pain-management
Haloperidol, oral/IV/SC (delirium): Agar MR, Lawlor PG, Quinn S, Draper B, Caplan GA, Rowett D, Sanderson
C, Hardy J, Le B, Eckermann S, McCaffrey N, Devilee L, Fazekas B, Hill M, Currow DC. Efficacy of Oral
Risperidone, Haloperidol, or Placebo for Symptoms of Delirium Among Patients in Palliative Care: A Randomized
Clinical Trial. JAMA Intern Med. 2017 Jan 1;177(1):34-42. https://www.ncbi.nlm.nih.gov/pubmed/27918778
xixLorazepam (added to haloperidol): Hui D, Frisbee-Hume S, Wilson A, Dibaj SS, Nguyen T, De La Cruz M, Walker
P, Zhukovsky DS, Delgado-Guay M, Vidal M, Epner D, Reddy A, Tanco K, Williams J, Hall S, Liu D, Hess K, Amin
S, Breitbart W, Bruera E. Effect of Lorazepam With Haloperidol vs Haloperidol Alone on Agitated Delirium in
Patients With Advanced Cancer Receiving Palliative Care: A Randomized Clinical Trial. JAMA. 2017 Sep
Lorazepam dose: South African Medicines Formulary. 12th Edition. Division of Clinical Pharmacology.
xx Lorazepam, oral formulation administered sublingually (anxiety): Greenblatt DJ, Divoll M, Harmatz JS, Shader
xxi Midazolam, IV/SC (delirium): NHS Scotland. Scottish Palliative Care Guidelines – Delirium, 15 April 2014.
[Internet] [Accessed 23 November 2017] Available at:

http://www.palliativecareguidelines.scot.nhs.uk/guidelines/symptom-control/Delirium.aspx
Midazolam, IV/SC (delirium): Bush SH, Tierney S, Lawlor PG. Clinical Assessment and Management of Delirium
in the Palliative Care Setting. Drugs. 2017 Oct;77(15):1623-1643. https://www.ncbi.nlm.nih.gov/pubmed/28864877
xxii Citalopram, oral (depression): South African Medicines Formulary. 12th Edition. Division of Clinical

xxiiiCorticosteroids (fatigue): Mücke M; Mochamat, Cuhls H, Peuckmann-Post V, Minton O, Stone P, Radbruch L.
Pharmacological treatments for fatigue associated with palliative care. Cochrane Database Syst Rev. 2015 May
Corticosteroids (fatigue): National Department of Health: Affordable Medicines, EDP-Primary Health Care.
Medicine Review: Betamethasone/dexamethasone for management of fatigue in adult palliative care patients, 29
July 2017. http://www.health.gov.za/
Corticosteroids (fatigue): Radbruch L, Strasser F, Elsner F, Gonçalves JF, Løge J, Kaasa S, Nauck F, Stone P;
Research Steering Committee of the European Association for Palliative Care (EAPC). Fatigue in palliative care
patients -- an EAPC approach. Palliat Med. 2008 Jan;22(1):13-32. https://www.ncbi.nlm.nih.gov/pubmed/18216074
xxiv Hyoscine butylbromide, SC/IM, (respiratory secretions): National Department of Health: Affordable Medicines,
EDP-Adult Hospital Level. Medicine Review: Hyoscine butylbromide for management of respiratory secretions in
adult palliative care patients, December 2017. http://www.health.gov.za/
Hyoscine butylbromide, SC/IM, (respiratory secretions): NICE guideline: Care of dying adults in the last days of
life, 16 December 2015. Available at: https://www.nice.org.uk/guidance/ng31
Hyoscine butylbromide, SC/IM, (respiratory secretions): NHS Lanarkshire Palliative Care Guidelines, March
2012. [Internet] [Accessed January 2018] Available at:
http://www.nhslanarkshire.org.uk/Services/PalliativeCare/Documents/NHS%20Lanarkshire%20Palliative%20Care
%20Guidelines.pdf
Hyoscine butylbromide, SC/IM, (respiratory secretions): Waitemata District Health Board Palliative Care
Guidelines: Hyoscine N-Butylbromide, subcutaneous, April 2016. [Internet] [Accessed January 2018] Available at:
http://www.waitematadhb.govt.nz/health-professionals/medicines/palliative-care-guidelines/
xxv Lorazepam, oral formulation administered sublingually (anxiety): Greenblatt DJ, Divoll M, Harmatz JS, Shader
xxviMidazolam IV/SC: Schildmann EK, Schildmann J, Kiesewetter I. Medication and monitoring in palliative sedation
therapy: a systematic review and quality assessment of published guidelines. J Pain Symptom Manage. 2015
Apr;49(4):734-46. https://www.ncbi.nlm.nih.gov/pubmed/25242022
Midazolam, SC/IV: Cherny NI, Radbruch L; Board of the European Association for Palliative Care. European
Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat
Med. 2009 Oct;23(7):581-93. https://www.ncbi.nlm.nih.gov/pubmed/19858355
2019 24.14
CHAPTER 25
SEXUALLY TRANSMITTED INFECTIONS
SEXUALLY TRANSMITTED INFECTIONS MANAGED AT

SECONDARY LEVEL OF CARE
These guidelines apply to patients who are referred from primary healthcare
centres for further investigation and management of persistent STI symptoms
or syndromes that have not improved or resolved and are still present 7 days
after administration of standard first-line syndromic therapy.
25.1 MALE URETHRITIS SYNDROME (MUS)

A64 + N34.1
Male urethritis/ visible urethral discharge that persists despite appropriate

syndromic management should be investigated for suspected ceftriaxone-
resistant gonorrhea. Referral letter from PHC should include all relevant
information (including HIV status, treatment history and partner notification
and management).
INVESTIGATIONS
» It is essential to confirm ceftriaxone-resistant gonorrhea.
» All NHLS standard laboratory forms must include the following information:
 Name and contact details (cellphone number + email address) of
requesting healthcare worker.
» Genital specimen collection and test requests (to confirm presence of any
STI pathogens and if Neisseria gonorrhoeae present, and determine
ceftriaxone susceptibility):
 Materials: Two Dacron swabs (wire shaft, slender tip); Amies transport
medium (all obtained from local NHLS laboratory).
> Urethral swab 1: Gently insert 2cm into the urethral meatus, and
rotate for 5-10 seconds. Place this swab immediately into Amies
transport medium.
> Test request: Transport on ice to local NHLS laboratory as soon as
possible, preferably within 24 hours for Neisseria gonorrhoeae
culture and sensitivity testing. (Contact laboratory for directions on
transport of specimens).
> Presumptive diagnosis: Persistent urethritis due to possible
ceftriaxone-resistant gonorrhea.
> Urethral swab 2: Gently insert 2cm into urethral meatus, and rotate
for 5-10 seconds. Place in a sterile universal container or tube, cut
off the wire shaft and close the container.
2019 25.1
CHAPTER 25 SEXUALLY TRANSMITTED INFECTIONS
> Test request: transport on ice to NICD STI reference laboratory as

soon as possible for PCR genital discharge pathogens.
> Presumptive diagnosis: Persistent urethritis due to possible
MEDICINE TREATMENT
Persistent urethral discharge after 7 days confirmed on examination, pending
results:
 Ceftriaxone, IM, 1 000 mg immediately as a single dose.
o Dissolve ceftriaxone 1 g in 3.6 mL lidocaine 1% LoE: IIIi
without adrenaline (epinephrine).
AND LoE: IIIii
LoE: IIIiii
Severe penicillin allergy: Z88.0
 Gentamicin, IM, 6 mg/kg, IM as a single dose. (See Appendix II for
AND LoE: IIIiv
Ask patient to return in two weeks for follow-up of laboratory results and further
clinical evaluation. Treat accordingly.
25.2 VAGINAL DISCHARGE SYNDROME (VDS)

B37.3/N76.0/N89.8
Abnormal vaginal discharge that persists despite appropriate syndromic

management should be investigated. Referral letter from PHC should include all
relevant information (including HIV status, treatment history and partner
notification and management).
INVESTIGATIONS
» Genital specimen collection and test requests (to confirm presence of STI
pathogens and if Neisseria gonorrhoeae is present, and determine
ceftriaxone susceptibility):
 Materials: One cotton-tip swab (plastic shaft); two Dacron swabs
(plastic shaft, slender tip); Amies transport medium (all obtained from
local NHLS laboratory). Insert speculum to visualize cervix.
 Endocervical swab 1: Gently insert Dacron swab 2cm into the
endocervical canal, and rotate for 5-10 seconds. Place this swab
immediately into Amies transport medium.
2019 25.2
> Test request: Transport on ice to local NHLS laboratory as soon as

possible, preferably within 24 hours for Neisseria gonorrhoeae
culture & sensitivity testing.
> Presumptive diagnosis: Persistent cervicitis due to possible
 Endocervical swab 2: Gently insert Dacron swab 2cm into the
endocervical canal, and rotate for 5-10 seconds. Place in sterile
universal container or tube, break off plastic shaft and close the
container.
> Test request: Transport on ice to NICD STI Reference laboratory
as soon as possible for PCR genital discharge pathogens.
> Presumptive diagnosis: Persistent cervicitis/vaginal discharge due
to possible ceftriaxone-resistant gonorrhea.
 Vaginal swab1: Gently insert cotton-tip swab into the vagina and then
dip swab in the poster fornix fluid. Place swab in sterile universal
container or tube, break off plastic shaft and close the container.
> Test request: Transport to local NHLS laboratory as soon as
possible for M/C/S - for bacterial vaginosis; Candida culture and
sensitivity testing.
> Presumptive diagnosis: Persistent vaginal discharge due to
bacterial vaginosis or candidiasis.
MEDICINE TREATMENT
Persistent cervicitis confirmed on speculum examination, pending results:
 Ceftriaxone, IM, 1 g immediately as a single dose.
o Dissolve ceftriaxone 1 g in 3.6 mL lidocaine 1% LoE: IIIv
AND LoE: IIIvi
If metronidazole, oral was not given at PHC prior to referral administer:
 Metronidazole, oral, 2 g as a single dose. LoE: IIIvii
Severe penicillin allergy: Z88.0
 Gentamicin, IM, 6 mg/kg, IM as a single dose. (See Appendix II for
AND LoE: IIIviii
If metronidazole, oral was not given at PHC prior to referral administer:
 Metronidazole, oral, 2 g as a single dose. LoE: IIIix
clinical evaluation. Treat accordingly.
2019 25.3
25.3 GENITAL ULCER SYNDROME (GUS)

A60.9/A51.0
Genital ulcer disease that persists despite appropriate syndromic management

should be investigated. Referral letter from PHC should include all relevant
information (including HIV status, treatment history and partner notification and
management).
INVESTIGATIONS
» Genital specimen collection and test requests:
 Materials: Two cotton-tip swabs (plastic shaft); one Dacron swab (wire
shaft); glass slide, slide box (all obtained from local NHLS laboratory)
 Cotton swab 1: Prior to taking specimen, roll a cotton-tip swab across
the lesion gently to remove exudates from secondary infection and/ or
debris in a way that minimizes bleeding. Discard cotton swab.
 Cotton swab 2: Roll a second cotton-tip swab over the base of the
ulcer, including the ulcer edges. Make a thin smear by rolling evenly
over the centre of a labelled-glass slide to the size of a R2 coin. Air
dry slide and place in slide box. Discard cotton swab.
 Dacron swab: Collect material from base of ulcer lesion; place swab in
sterile universal container or tube and cut off wire shaft. Close
container.
> Test request: Transport glass slide and Dacron swab on ice to NICD
STI Reference laboratory as soon as possible for microscopy for
Donovanosis and PCR genital ulcer pathogens.
> Presumptive diagnosis: Persistent genital ulcer disease
» Venous blood specimen: 5 mL in serum separator tube for syphilis
serology – send to local NHLS laboratory.
MEDICINE TREATMENT
clinical evaluation. Treat accordingly, but note that syphilis does not require
re-treatment if benzathine penicillin was used to treat GUS.
If the syndromic treatment at PHC used doxycycline instead of benzathine
penicillin and syphilis is detected on PCR, treat with:
 Benzathine benzylpenicillin, IM, 2.4 MU immediately as a single dose.
o Dissolve benzathine benzylpenicillin, IM, 2.4 MU in 6 mL lidocaine 1%
LoE: IIIx
Recurrent herpes
For frequent recurrences of herpes simplex (i.e. ≥4 episodes of clinically
apparent reactivations per year), suppressive antiviral therapy may be
considered.
2019 25.4
 Antiviral (active against herpes simplex) e.g.: LoE: IIxi

 Aciclovir, oral, 400 mg 12 hourly.
o Review annually for ongoing suppressive therapy.
LoE: IIIxii
REFERRAL
If ulcer PCR results for STI pathogens are inconclusive and genital ulceration
persists, refer to specialist for genital ulcer biopsy and histopathological
examination to exclude a non-infectious cause, which includes cancer.
25.4 BUBO
A58
Buboes that persist despite appropriate syndromic management should be

investigated. Referral letter from PHC should include all relevant information (i.e.
HIV status, treatment history and partner notification and management).
INVESTIGATIONS
» Genital specimen collection and test requests:
Materials: One Dacron swab (wire shaft); 21-gauge sterile needle and
syringe; two sterile universal containers or tubes (all obtained from local
NHLS laboratory).
1. If genital ulcer is present:
 Dacron swab: Collect material from base of ulcer lesion; place swab in
sterile universal container or tube and cut off wire shaft. Close
container.
> Test request: Transport Dacron swab on ice to NICD STI reference
laboratory as soon as possible for PCR for chancroid and LGV.
2. If genital ulcer is absent:
 After topical disinfection, insert 21-gauge needle into bubo and
aspirate pus into syringe. Transport pus in two sterile tubes/ containers
to laboratory.
> Test request: send one tube on ice to NICD STI reference
laboratory as soon as possible for PCR for chancroid and
Lymphogranuloma Venereum (LGV).
> Test request: send one tube to local NHLS laboratory for bacterial
M/C/S.
 Presumptive diagnosis: Persistent bubo unresponsive to syndromic
management.
MEDICINE TREATMENT
 Doxycycline 100 mg, oral 12 hourly for 21 days.
LoE: IIIxiii
2019 25.5
Note: Follow-up until there is complete resolution of symptoms. Fluctuant buboes

may require frequent needle aspiration to prevent rupture – review every 72 hours,
as necessary.
For laboratory-confirmed diagnosis of LGV:
 Doxycycline 100 mg, oral 12 hourly for more than 21 days may be required
for complete resolution of disease.
LoE: IIIxiv
References:
i Ceftriaxone (1000mg - MUS): Fifer H, Natarajan U, Jones L, Alexander S, Hughes G, Golparian D, Unemo M.
Failure of Dual Antimicrobial Therapy in Treatment of Gonorrhea. NEJM 2016. 374;25: 2504-2506.
Ceftriaxone (1000mg - MUS): Bignell C, Unemo M; European STI Guidelines Editorial Board. 2012 European
guideline on the diagnosis and treatment of gonorrhoea in adults. Int J STD AIDS.2013 Feb;24(2):85-92.
iiLidocaine 1%:MCC registered package inserts of Kocef® 250 mg, 500 mg, 1 g; Rociject® 500 mg, 1 g; Oframax®
250 mg, 1 g.
iii Azithromycin (2000mg - MUS): Bignell C, Unemo M; European STI Guidelines Editorial Board. 2012 European
guideline on the diagnosis and treatment of gonorrhoea in adults. Int J STD AIDS.2013 Feb;24(2):85-92.
ivGentamicin, IM + azithromycin, oral: Workowski KA, Bolan GA; Centers for Disease Control and Prevention.
Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015 Jun 5;64(RR-03):1-137.
Erratum in: MMWR Recomm Rep. 2015 Aug 28;64(33):924.https://www.ncbi.nlm.nih.gov/pubmed/26042815
v Ceftriaxone, IM + azithromycin: World Health Organisation: WHO guidelines for the treatment of Neisseria
gonorrhoeae, 2016. http://apps.who.int/iris/bitstream/10665/246114/1/9789241549691-eng.pdf

viLidocaine 1%:MCC registered package inserts of Kocef® 250 mg, 500 mg, 1 g; Rociject® 500 mg, 1 g; Oframax®
250 mg, 1 g.
viiMetronidazole: Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted
Recomm Rep. 2015 Aug 28;64(33):924.https://www.ncbi.nlm.nih.gov/pubmed/26042815
viiiGentamicin, IM + azithromycin, oral: Workowski KA, Bolan GA; Centers for Disease Control and Prevention.
Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015 Jun 5;64(RR-03):1-137.
Erratum in: MMWR Recomm Rep. 2015 Aug 28;64(33):924.https://www.ncbi.nlm.nih.gov/pubmed/26042815
ixMetronidazole: Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted
Recomm Rep. 2015 Aug 28;64(33):924.https://www.ncbi.nlm.nih.gov/pubmed/26042815
x Benzathine benzylpencillin (GUS): World Health Organization. ixWHO guidelines for the treatment of Treponema
pallidum (syphilis), 2016. http://www.who.int/reproductivehealth/publications/rtis/syphilis-treatment-guidelines/en/

xi Antiviral therapy, oral (recurrent herpes simplex): Le Cleach L, Trinquart L, Do G, Maruani A, Lebrun-Vignes B,
Ravaud P, Chosidow O. Oral antiviral therapy for prevention of genital herpes outbreaks in immunocompetent and
nonpregnant patients. Cochrane Database Syst Rev. 2014 Aug 3;(8):CD009036.
xii Antiviral therapy, oral (recurrent herpes simplex): Workowski KA, Bolan GA; Centers for Disease Control and
Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015 Jun 5;64(RR-
03):1-137. Erratum in: MMWR Recomm Rep. 2015 Aug 28;64(33):924.
Aciclovir, oral: Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted
xiii Doxycyline (21 days: Bubo): de Vries HJ, Smelov V, Middelburg JG, Pleijster J, Speksnijder AG, Morré SA.
Delayed microbial cure of lymphogranuloma venereum proctitis with doxycycline

treatment. Clin Infect Dis. 2009 Mar 1;48(5):e53-6. https://www.ncbi.nlm.nih.gov/pubmed/19191633
xiv Doxycyline (> 21 days: Bubo): Oud EV, de Vrieze NH, de Meij A, de Vries HJ. Pitfalls in the diagnosis and
management of inguinal lymphogranuloma venereum: important lessons from a case

series. Sex Transm Infect. 2014 Jun;90(4):279-82. https://www.ncbi.nlm.nih.gov/pubmed/24787368
2019 25.6
CHAPTER 26
PAIN
26.1 PAIN, CHRONIC

Pain is an unpleasant sensory and emotional experience associated with
actual or potential tissue damage. The relationship between pain (a subjective
experience) and tissue damage (which may be assessed directly by others)
is moderated by socio-cultural context as well as the nervous system.
The goals of pain management include pain reduction and improved function,
sleep, and well-being. Family members play an important part in the patient’s
treatment and should be included where possible.
Measure care outcomes by evaluating pain severity, quality of life, and

functionality, e.g. Pain, Enjoyment and General Activity (PEG) scale,
http://www.med.umich.edu/1info/FHP/practiceguides/pain/PEG.Scale.12.201
6.pdf
26.1.1 ANALGESIA FOR CHRONIC NON-CANCER PAIN

ASSESSEMENT OF CHRONIC NON-CANCER PAIN
A biopsychosocial assessment is necessary to inform effective pain
management.
Ascertain the aetiology and perpetuating factors and manage accordingly.

Note that there may be overlap between different aetiologies, and condition-
specific pain management may be required.
» Nociceptive pain, e.g. osteoarthritis (see section 13.3); rheumatoid arthritis
(see section 13.1); gout (see section 13.4); spondylarthritis (see section
13.5); chronic post-surgical or injury pain; visceral pain, e.g. chronic
pancreatitis; chronic cancer pain (see section 26.1.2); endometriosis (see
section 5.4).
» Neuropathic pain (see section 26.1.4).
» Fibromyalgia and irritable bowel syndrome (see PHC STGs and EML,
section 2.12).
» Mental illness, e.g. mood disorders (depression and bipolar disorder),
anxiety, post-traumatic stress disorder (see chapter 15: Mental health
conditions), somatic symptoms, and related disorders.
» Substance use disorders, including over the counter analgesics, opioids,
benzodiazepines, and alcohol.
Ascertain the patient’s beliefs about their pain and hopes of care. Common
issues to address are:
» Idealised nature of reality, e.g. that life must be pain-free.
» That pain means exercise and physical activity must be avoided.
2019 26.1
CHAPTER 26 PAIN
» Catastrophic thinking regarding the pain.

» A need to be unwell to be cared for by others.
» Fear of work and responsibility, for various reasons.
» Stigma, with denial of mental illness or interpersonal conflict.
Social stressors, trauma, interpersonal conflict or violence may predispose to
and perpetuate chronic pain.
GENERAL AND SUPPORTIVE MEASURES

Patients with chronic pain should be treated with a biopsychosocial approach,
according to findings of a comprehensive assessment. Note that those with
greater subjective pain complaints may also be at higher risk of an opioid use
disorder.
» Validate the pain experienced and manage with empathy.
» Educate regarding the cause of pain, prognosis (including that pain may
not be fully relieved), and realistic expectations regarding pain reduction.
» Establish goals of care with the patient and select a measure of
effectiveness e.g. Pain, Enjoyment and General Activity (PEG) scale,
http://www.med.umich.edu/1info/FHP/practiceguides/pain/PEG.Scale.12.
2016.pdf
» Treat the underlying physical cause of pain. Refer for specialist care (e.g.
rheumatologist, orthopaedic surgeon) where necessary.
» Treat underlying or comorbid mental illness.
» Manage substance use, refer to SANCA/ rehabilitative services.
» Encourage physical activity; refer to Physiotherapy and Occupational
Therapy (OT).
» Address self-esteem, motivation, daily function, and social skills; refer to
OT.
» Address social stressors and interpersonal conflicts; refer to social worker,
counselling services, psychologist, social welfare organisations, NGOs
(e.g. FAMSA, http://famsa.org.za, or if there is domestic violence, POWA,
https://www.powa.co.za)
LoE:IIIi
MEDICINE TREATMENT
Paracetamol, ibuprofen and tramadol may be used alone or in combination
according to the severity of the pain.
Mild/moderate pain:
 NSAID, e.g.: LoE:Iii

o May be used in combination with paracetamol or opioids.
2019 26.2
CHAPTER 26 PAIN
CAUTION
Avoid long-term use of NSAIDs (e.g. ibuprofen) as they are
associated with an increased risk of arterial thrombosis, renal
impairment and gastrointestinal bleeding.
shortest duration. Explore and manage exacerbating factors for pain.
See section 26.1: Chronic pain.

ADD LoE:IIIiii
 PPI, e.g.:
Severe pain:
o Warn patient of adverse effects and addiction potential. Advise not to
operate machinery/drive initially and after dosage increases.
o Evaluate response to treatment using a rating scale at 2 weeks, and
every following 4 weeks: taper and stop tramadol if not reducing
pain.
o In patients with uncontrolled pain the dose can be increased to a
maximum of 100 mg (2 x 50 mg) 6 hourly.
o Improved effect when given with paracetamol. LoE:IIIiv
2019 26.3
CHAPTER 26 PAIN
CAUTION
» Tramadol causes respiratory depression and may be fatal in overdose.
» Avoid concurrent prescribing of opioid pain medication,
benzodiazepines or other respiratory depressants.
» After a period of no treatment, re-initiate at 25 mg. Treat overdose as
in section 19.5.3. Opioid poisoning.
» Avoid use in those at high risk of opioid addiction (a personal or family
history of any substance use disorder, comorbid mental illness, high
levels of subjective pain and younger people).
» Inhibits reuptake of noradrenaline and serotonin – increases risk of
seizures, of serotonin syndrome, and mania or hypomania. Avoid use
in at-risk groups (e.g. epilepsy, head injury, if taking antidepressants,
bipolar disorder). Educate the patient, optimise treatment of primary
condition, avoid polypharmacy and monitor closely.
» Other adverse effects include constipation, dry mouth, drowsiness,
confusion. LoE:IIIv
OR
 Morphine syrup (Mist morphine), oral.
o Starting dose: 10–15 mg (maximum 0.2 mg/kg) 4 hourly.
o Elderly or frail patients: 2.5–5 mg oral (maximum 0.1 mg/kg) 4 hourly.
o Increase dose by 50% every 24 hours if pain control is inadequate.
o Reduce the dosing interval if there is regular breakthrough pain.
o Increase the dosing interval in patients with renal or liver
impairment.
When stable on morphine syrup, the morphine syrup can be changed to an
equivalent dose of long- acting, slow release morphine:
 Morphine, long-acting, oral, 12 hourly.
o Available in tablets of 10 mg, 30 mg and 60 mg
o Duration of action 12 hours.
o Dose according to previous morphine syrup requirement: e.g. a patient
whose pain is controlled by 6 doses of morphine syrup 10 mg per 24
hours (i.e. 60 mg morphine per day) can be converted to slow release
morphine tablets, 30 mg 12 hourly, oral.
o Maximum dose for non-cancer pain is usually 60 mg 12 hourly.
Note:
» When morphine is used for chronic non-cancer pain, discuss potential side-
effects with the patient, the maximum dose of opioids that will be
prescribed and anticipated duration of treatment.
» Avoid in patients with history of alcohol or other drug addiction, where
possible.
2019 26.4
CHAPTER 26 PAIN
26.1.2 ANALGESIA FOR CHRONIC CANCER PAIN

The term “cancer pain” also includes pain due to terminal illness.
The same steps as given in section 26.1.1: Analgesia for chronic non-cancer
pain should be followed with the following exceptions:
 Morphine:
» There is no maximum dose of morphine that may be needed.
» Concerns regarding addiction should not compromise adequate pain
control with opioids when used to treat terminal illnesses.
» For terminally ill patients on slow release morphine, it is advisable to still
prescribe morphine syrup for breakthrough pain or for painful
procedures.
Note:
» Opioid–induced hyperalgesia is defined as increasing pain sensitivity in
patients chronically exposed to opioids without any new causes for pain.
Increasing doses of morphine paradoxically result in increased pain, often
with features of neuropathic pain such as hyperalgesia or allodynia.
» It can be managed by switching to methadone, in consultation with a
specialist familiar with the use of this agent. LoE:IIIvi
Bisphosphonates may be considered for metastatic bone pain – refer to the

Tertiary and Quaternary EML (specialist management/consultation).
26.1.3 TREATMENT OF ADVERSE EFFECTS OF CHRONIC

OPIOID USE
Y45.0
Constipation:
Patients on chronic opioids should routinely be prescribed a laxative.
 Sennosides A and B, oral, 13.5 mg, 1–2 tablets at night.
o Contraindicated in patients with potentially obstructive lesions.
LoE:IIIvii
In patients with potentially obstructive lesions:
 Lactulose, oral, 10–20 mL 12 hourly.
LoE:IIIviii
Nausea and vomiting:
 Metoclopramide, oral/IM/slow IV, 10 mg 8 hourly (See section 12.7.5.2
treatment of PONV).
OR
Promethazine, oral, 10 mg 8 hourly. LoE:III
OR
 Ondansetron, oral, 8 mg 12 hourly.
2019 26.5
CHAPTER 26 PAIN
26.1.4 NEUROPATHIC PAIN

G62.9/G50.0
DESCRIPTION
Defective functioning of nerves, which may involve both peripheral nerves
(peripheral neuropathy) and cranial nerves. Different patterns are noted, i.e.
polyneuropathy, mononeuritis multiplex, and mononeuropathy, each of which
may be caused by axonal degeneration or demyelination or a combination of
the above. Clinical features may be predominantly of a sensory, sensorimotor
or motor nature.
Important causes of a predominantly sensory neuropathy include:
» alcohol,
» diabetes,
» HIV infection,
» thiamine deficiency, vitamin B12 deficiency, (although the latter more
commonly presents as subacute combined degeneration of the cord),
» medicines (e.g. isoniazid, stavudine, metronidazole, amiodarone)
Important causes of a predominantly motor neuropathy include:

» Acute Inflammatory Demyelinating Polyradiculoneuropathy (AIDP – also
known as Guillain-Barrè syndrome),
» Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP),
» acute porphyrias
GENERAL MEASURES
If there is a history of rapid progression, particularly in patients with features
suggestive of AIDP, (e.g. rapid progression with stabilisation within 4 weeks)
admit the patient and monitor vital capacity carefully with spirometry, as
intubation and ventilatory support may be required.
Manage the cause where possible.
Specialised nursing care and dedicated physiotherapy may be indicated. If not
managed appropriately, chronic cases may develop contractures, weakness
affecting gait, and chronic bedsores, and they may become wheel chair-bound.
Encourage activity, with referral to OT and physiotherapy.
Address psychosocial stressors and enhance perceived social support, and
refer to social worker as required.
Treat comorbid mental illness (see chapter 15: Mental health conditions).
Assess outcome of treatment with objective measures of function, e.g. Pain,
Enjoyment and General Activity (PEG) scale.
http://www.med.umich.edu/1info/FHP/practiceguides/pain/PEG.Scale.12.201
6.pdf
MEDICINE TREATMENT
Most cases respond to management of the underlying disease process or
removal of the aetiological agent.
2019 26.6
CHAPTER 26 PAIN
In addition to the analgesics for chronic nociceptive pain (see section 12.13.1
Analgesia for chronic non-cancer pain), anti-neuropathic pain medicines to
stabilise affected sensory nerves can be used.
 Amitriptyline, oral, 10 mg, two hours before usual sleep time.

o Titrate up to 75 mg (to a maximum of 200 mg) at LoE:IIix
night if needed.
o In the elderly: 10–25 mg daily, increasing gradually up to 50–100 mg
daily, if required and tolerated. A single bedtime dose
is optimal for most patients. LoE:IIIx
o Use regularly, as takes 2–6 weeks for maximal effect.
LoE:IIIxi
Post-herpetic neuralgia
Initiate treatment with adjuvant amitriptyline therapy early. LoE:IIxii
If no response after 2-4 weeks or amitriptyline is contraindicated:
ADD/REPLACE WITH
 Carbamazepine, oral, 100–200 mg 12 hourly for 2 weeks.
o If response is inadequate, increase the dose every 2 weeks to a
maximum dose of 600 mg 12 hourly.
o Monitor for possible drug interactions in patients on ART.
LoE:IIxiii
Note: Aciclovir is not beneficial in treating post-herpes zoster neuropathy.
Isoniazid–induced polyneuropathy
 Pyridoxine, oral 75 mg daily for 3 weeks.
o Follow with 25–50 mg daily.
Trigeminal neuralgia (G50.0)

Sudden, usually unilateral, severe, brief, stabbing, recurrent episodes of pain
in the distribution of one or more branches of the trigeminal nerve.
 Carbamazepine, oral 100 mg 12 hourly, initial dose.
o Increase dose slowly. Doses of up to 1 200 mg daily may be required.
o After exacerbation, reduce to maintenance dose of 400–800 mg daily.
LoE:IIIxiv
REFERRAL
For neuropathic pain unresponsive to these medicines, refer patient to an
experienced pain clinician.
2019 26.7
CHAPTER 26 PAIN
26.2 ANALGESIA FOR ACUTE NON-SURGICAL PAIN

26.2.1 MEDICAL CONDITIONS ASSOCIATED WITH
SEVERE PAIN
R52.9
There are numerous medical conditions associated with severe acute pain
e.g. myocardial infarction, renal colic, sickle-cell crisis and intra-articular
haemorrhage due to haemophilia.
The analgesic treatment for these conditions is as for patients with acute post-
operative pain (see section 12.4.2: Postoperative pain in the recovery room).
Patients should be monitored for respiratory and cardiovascular depression
when IV opioids are administered.
Patients already on opioids for chronic pain, who experience an acutely
painful event, may be opioid tolerant and require higher IV opioid boluses in
order to control their pain.
26.2.2 ACUTE PAIN DUE TO GASTROINTESTINAL COLIC

R10.84
 Hyoscine butylbromide, IV/oral, 10 mg 8 hourly.
2019 26.8
CHAPTER 26 PAIN
References:
i Management of chronic non-cancer pain: Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing
Opioids for Chronic Pain--United States, 2016. JAMA. 2016 Apr 19;315(15):1624-45.
Management of chronic non-cancer pain: Ballantyne JC, Kalso E, Stannard C. WHO analgesic ladder: a good
concept gone astray. BMJ. 2016 Jan 6;352:i20. https://www.ncbi.nlm.nih.gov/pubmed/26739664
Management of chronic non-cancer pain: The Royal College of Anaesthetists. Opioid Aware Resource, 2019.
[Accessed August 2019]. https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-aware
Management of chronic non-cancer pain: Ortho-Mcneil Pharmaceutical, Inc. The U.S. Food and Drug
Administration approved drug label for tramadol tablets, 2008.
https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020281s032s033lbl.pdf
ii NSAIDs as a therapeutic class (diclofenac, naproxen, ibuprofen): Affordable Medicines, EDP-Adult Hospital
iii Lansoprazole, oral (high risk patients on chronic NSAID therapy): McQuaidKR ,Laine L . Systemic review and
meta-analysis of adverse events of low-dose aspirin and clopidogrel in randomized controlled trials. Am J Med
2006;119:624–38. http://www.ncbi.nlm.nih.gov/pubmed/16887404
Lansoprazole, oral (high risk patients on chronic NSAID therapy): Serrano P, Lanas A, Arroyo MT, Ferreira IJ.
Risk of upper gastrointestinal bleeding in patients taking low-dose aspirin for the prevention of cardiovascular
diseases. Aliment PharmacolTher. 2002 Nov;16(11):1945-53. http://www.ncbi.nlm.nih.gov/pubmed/12390104
Lansoprazole, oral (high risk patients on chronic NSAID therapy): Lanza FL, Chan FK, Quigley EM; Practice
Parameters Committee of the American College of Gastroenterology. Guidelines for prevention of NSAID-related
ulcer complications. Am J Gastroenterol. 2009 Mar;104(3):728-38. http://www.ncbi.nlm.nih.gov/pubmed/19240698
iv Tramadol, oral: Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain--
United States, 2016. JAMA. 2016 Apr 19;315(15):1624-45. https://www.ncbi.nlm.nih.gov/pubmed/26977696

Tramadol, oral: Ortho-Mcneil Pharmaceutical, Inc. The U.S. Food and Drug Administration approved drug label
for tramadol tablets, 2008. https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020281s032s033lbl.pdf
Tramadol, oral: The Royal College of Anaesthetists. Opioid Aware Resource, 2019. [Accessed August 2019].
https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-aware
v Tramadol - caution: Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain--
United States, 2016. JAMA. 2016 Apr 19;315(15):1624-45. https://www.ncbi.nlm.nih.gov/pubmed/26977696

Tramadol - caution: The Royal College of Anaesthetists. Opioid Aware Resource, 2019. [Accessed August
2019]. https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-aware
Tramadol - caution: Kaye AD, Jones MR, Kaye AM, Ripoll JG, Galan V, Beakley BD, Calixto F, Bolden JL,
Urman RD, Manchikanti L. Prescription Opioid Abuse in Chronic Pain: An Updated Review of Opioid Abuse
Predictors and Strategies to Curb Opioid Abuse: Part 1. Pain Physician. 2017 Feb;20(2S):S93-S109.
Tramadol– caution: Beakley BD, Kaye AM, Kaye AD. Tramadol, Pharmacology, Side Effects, and
Serotonin Syndrome: A Review. Pain Physician. 2015 Jul-Aug;18(4):395-400.
Tramadol – caution: Sharma V. Tramadol-Induced Hypomania and Serotonin Syndrome. Prim Care
Companion CNS Disord. 2016 Dec 15;18(6). https://www.ncbi.nlm.nih.gov/pubmed/28002658
Tramadol – caution: Hassamal S, Miotto K, Dale W, Danovitch I. Tramadol: Understanding the Risk of
Serotonin Syndrome and Seizures. Am J Med. 2018 Nov;131(11):1382.e1-1382.e6.
2019 26.9
CHAPTER 26 PAIN
vi Methadone, oral: Dietis N, Guerrini R, Calo G, Salvadori S, Rowbotham DJ, Lambert DG. Simultaneous targeting
of multiple opioid receptors: a strategy to improve side-effect profile. Br J Anaesth 2009; 103: 38–49.
Methadone, oral: Holtman JR, Jr, Wala EP. Characterization of the antinociceptive and pronociceptive effects of
methadone in rats. Anesthesiology 2007; 106: 563–71. http://www.ncbi.nlm.nih.gov/pubmed/17325516
vii Sennosides A and B, oral: University of Cape Town,Division of Clinical Pharmacology. South African Medicines

viii Lactulose, oral: University of Cape Town,Division of Clinical Pharmacology. South African Medicines

ix Amitriptyline, oral: Moore RA, Derry S, Aldington D, Cole P, Wiffen PJ. Amitriptyline for neuropathic pain in adults.
Cochrane Database Syst Rev. 2015 Jul 6;7:CD008242. http://www.ncbi.nlm.nih.gov/pubmed/26146793

Amitriptyline, oral: Chetty S, Baalbergen E, Bhigjee AI, Kamerman P, Ouma J, Raath R, Raff M, Salduker S;
South African Expert Panel. Clinical practice guidelines for management of neuropathic pain: expert panel
recommendations for South Africa. S Afr Med J. 2012 Mar 8;102(5):312-25.
x Amitriptyline, oral (dosing in the elderly): South African Medicines Formulary. 12th Edition. Division of Clinical

xi Amitriptyline, oral (time to maximal effect): Onghena P, Van Houdenhove B. Antidepressant-induced analgesia in
chronic non-malignant pain: a meta-analysis of 39 placebo-controlled studies. Pain. 1992 May;49(2):205-19.

xii Amitriptyline, oral: Bowsher D. The effects of pre-emptive treatment of postherpetic neuralgia with amitriptyline: a
randomized, double-blind, placebo-controlled trial. J Pain Symptom Manage. 1997 Jun;13(6):327-

xiii Carbamazepine, oral (neuropathy): Wiffen PJ, Derry S, Moore RA, Kalso EA. Carbamazepine for chronic
neuropathic pain and fibromyalgia in adults. Cochrane Database Syst Rev. 2014 Apr 10;(4):CD005451.
xiv Carbamazepine, oral (trigeminal neuralgia): The National Institute for Health and Care Excellence. Neuropathic
pain – pharmacological management, February 2017. NICE clinical guideline 173.

http://guidance.nice.org.uk/CG173
2019 26.10
APPENDIX I ANTIMICROBIAL MEDICINES
The list of antimicrobial medicines, below, excludes antiretroviral medicines.

It is important to refer to the text of the standard treatment guidelines for detailed
information of specific medicines for specific indications (i.e. duration of therapy, if
used in combination with other antibiotics, prescriber level, etc.).
ACICLOVIR
4.5: Atopic eczema/dermatitis, eczema herpeticum (if patient is unable to swallow
due to odynophagia):
 Aciclovir, IV, 5 mg/kg 8 hourly for 7 days.
9.12: Varicella (chickenpox), complicated, 9.13: Zoster (Shingles – with secondary
dissemination or neurological involvement), 14.6.2: Viral meningoencephalitis:
 Aciclovir, IV, 10 mg/kg 8 hourly.
18.5.1: Keratitis, herpes simplex:
 Aciclovir, ophthalmic ointment 3%, applied into lower conjunctival sac,
five times daily.
9.12: Varicella (chickenpox), complicated, 9.13: Zoster (Shingles), 18.4: Herpes
zoster ophthalmicus:
 Aciclovir, oral, 800 mg five times a day or 4 hourly while awake.
4.5: Atopic eczema/dermatitis, eczema herpeticum; 18.5: Keratitis; 25.3: Genital
ulcer syndrome (GUS):
 Aciclovir, oral, 400 mg 8 hourly for 7 days or five times a day for 10-14
days or 12 hourly.
AMIKACIN
9.1.3: Hospital-Acquired Pneumonia (HAP), 9.1.4: Urinary tract infections,
catheter associated, 10.1.1: Management of selected antiretroviral ADRs - drug-
induced liver injury:
AMOXICILLIN
6.12: Preterm Labour (PTL) AND Preterm Prelabour Rupture of Membranes
(PPROM), 16.4: Chronic obstructive pulmonary disease (COPD):
1.1.8: Peptic ulcer, H. pylori +ve:
 Amoxicillin, oral, 1 g 12 hourly for 14 days.
3.5: Endocarditis, infective, prophylaxis:
 Amoxicillin, oral, 2 g one hour before dental procedure.
16.6: Pneumonia, community acquired (uncomplicated), 17.4: Otitis media, acute
 Amoxicillin, oral, 1 g 8 hourly.
2019 AI.1

AMOXICILLIN/CLAVULANIC ACID
1.1.2: Diverticulosis, 1.2.5: Liver abscess, pyogenic, 1.2.7: Acute cholecystitis and
acute cholangitis, 1.3.8: Bacterial peritonitis, 4.7: Leg ulcers, complicated, 5.3:
Pelvic inflammatory disease (PID), 5.8.4: Septic miscarriage, 6.18: Postpartum
fever, 6.21.2: Urinary tract infection in pregnancy: acute pyelonephritis, 8.7.1:
Diabetic neuropathies, 16.3: Bronchiectasis, 16.4: Chronic obstructive pulmonary
disease (COPD), 16.5: Lung abscess, 16.6: Pneumonia, community acquired,
16.7: Pneumonia, aspiration, 16.8: Empyema, 17.1: Epiglottis, 17.4: Otitis media,
acute, 17.8: Abscess, Peritonsillar, 19.2: Snakebites: secondary infection:
 Amoxicillin/clavulanic acid 875/125 mg, oral, 12 hourly.
1.2.7: Acute cholecystitis and acute cholangitis, 1.1.2: Diverticulosis: cannot take
oral medicines, 1.1.6: Pancreatitis acute: abscess of the pancreas, 1.2.5: Liver
Abscess, pyogenic , 1.3.8: Bacterial peritonitis, 5.8.4: Septic miscarriage, 6.18:
Postpartum Fever, 8.7.3: Diabetic foot ulcers: severe infection, 16.5: Lung
abscess, 16.7: Pneumonia, aspiration, 16.8: Empyema, 17.8: Abscess,
peritonsillar:
AMPHOTERICIN B
9.1.1: Intravascular catheter infections, candidaemia:
 Amphotericin B, IV, 0.7 mg/kg daily.
2.2: Febrile neutropenia, 10.2.4.2: Symptomatic, non-meningeal Cryptococcosis
10.2.4.3: Cryptococcal meningitis: , 14.6.1.2.2: Cryptococcal meningitis, HIV-
uninfected:
 Amphotericin B, slow IV infusion, 1 mg/kg daily.
AMPICILLIN
16.6: Pneumonia, community acquired:
 Ampicillin, IV, 1 g 6 hourly.
3.5: Endocarditis, infective, prophylaxis, if patient cannot take oral medicines:
 Ampicillin, IV/IM, 2 g one hour before dental procedure.
14.6.1: Meningitis: Listeria monocytogenes meningitis:
 Ampicillin, IV, 3 g 6 hourly for 21 days.
AZITHROMYCIN
3.7: Rheumatic heart disease, prophylaxis of recurrent disease, severe penicillin
allergy:
 Azithromycin, oral, 250 mg daily.
11.4: Antibiotic prophylaxis:
 Azithromycin, 500 mg, IV, as a single dose.
16.6: Pneumonia, community acquired (severe pneumonia):
 Azithromycin, 500 mg, slow IV (over not less than 60 minutes) daily for 3
days.
2019 AI.2

1.1.8: Peptic ulcer, severe penicillin allergy, 3.7: Rheumatic heart disease, acute
rheumatic fever - severe penicillin allergy, 4.2: Cellulitis and erysipelas – severe
penicillin allergy, 4.3: Impetigo – severe penicillin allergy, 6.12: Preterm Labour
(PTL) AND Preterm Prelabour Rupture of Membranes (PPROM) - severe
penicillin allergy, 10.2.8: Mycobacteriosis - disseminated non tuberculous, 16.3:
Bronchiectasis - severe penicillin allergy, 16.4: Chronic obstructive pulmonary
disease (COPD) - severe penicillin allergy, 17.1: Epiglottitis - severe penicillin
allergy, 17.4: Otitis media, acute - severe penicillin allergy:
9.10: Tick bite fever, in pregnancy:
 Azithromycin, oral, 500 mg 12 hourly for 3 days.
5.3: Pelvic Inflammatory Disease (PID) - stage I, 5.3: Pelvic Inflammatory Disease
(PID), stage II-IV: chlamydia (also for severe penicillin allergy), 5.10: Sexual
Assault (STI prophylaxis), 7.3.4: Prostatitis (acute bacterial prostatitis), 13.2:
Arthritis, Septic and osteomyelitis, acute , 13.5.1: Arthritis, reactive: 10.4.2: Non
occupational post exposure prophylaxis, sexual assault and inadvertent exposure:
5.3: Pelvic Inflammatory Disease (PID)-stage I, severe penicillin allergy, 10.5.2:
Non occupational post exposure prophylaxis, sexual assault, 25.1: Male urethritis
syndrome (MUS), 25.2: Vaginal discharge syndrome (VDS):
BENZATHINE BENZYLPENICILLIN
3.7: Rheumatic heart disease, prophylaxis:
 Benzathine benzylpenicillin (depot formulation), IM, 1.2 mu every 3–4
weeks.
3.7: Rheumatic heart disease, acute rheumatic fever:
 Benzathine benzylpenicillin (depot formulation), IM, 1.2 mu as a single
dose.
6.8: Syphilis, asymptomatic well baby:
 Benzathine benzylpenicillin (depot formulation), IM, 50 000 units/kg as a
single dose into the antero-lateral thigh.
25.3: Genital ulcer syndrome (GUS):
 Benzathine benzylpenicillin (depot formulation), IM, 2.4 mu immediately
as a single dose.
6.8: Syphilis, mother:
 Benzathine benzylpenicillin (depot formulation), IM, 2.4 mu weekly for 3
doses.
2019 AI.3

BENZYL PENICILLIN
6.8: Syphilis, symptomatic baby:
 Benzylpenicillin (Penicillin G), IV, 50 000 units/kg, 12 hourly for 10 days.
17.8: Abscess, peritonsillar:
 Benzylpenicillin (penicillin G), IV, 2 million units 6 hourly.
9.9: Tetanus:
 Benzylpenicillin (penicillin G), IV, 5 MU 6 hourly for 10 days.
3.5: Endocarditis, infective – empiric therapy and directed therapy for native valve:
 Benzylpenicillin (penicillin G), IV, 5 MU 6 hourly for 4 weeks.
14.6.1: Meningitis (meningococcal meningitis – confirmed meningococcal disease
only), 14.6.1: Meningitis (pneumococcal meningitis):
for 10 days.
14.6.3: Meningovascular Syphillis:
 Benzylpenicillin (penicillin G), IV, 20 MU daily in 4–6 divided doses for
10 days.
CEFALEXIN
4.2: Cellulitis and erysipelas:
 Cefalexin, oral, 500 mg 6 hourly for 5 days.
CEFAZOLIN
11: Cardiac surgery, 11: Endoscopic gastrointestinal procedures, 11:
Gastrointestinal surgery, 11: General surgery, 11: Neurosurgery , 11: Obstetrics/
gynaecology surgery, 11: Orthopaedic surgery , 11: Otorhinolaryngology/ Head and
neck surgery: severe beta lactam allergy, 11: Plastic and reconstructive surgery, 11:
Thoracic surgery, 11: Urology, 11: Vascular surgery:
 Cefazolin, IV, 1-3 g as a single dose.
4.2: Cellulitis and erysipelas, 4.4: Furuncles and abscesses, 9.1.2: Surgical wound
infections:
3.5: Endocarditis, infective – empiric therapy and directed therapy for native valve,
13.2: Arthritis, Septic and osteomyelitis, acute:
CEFEPIME
2.2: Febrile neutropenia; 9.1.3: Hospital-acquired pneumonia (HAP):
 Cefepime, IV, 2 g 12 hourly.
2019 AI.4

CEFTAZIDIME
18.2: Endophthalmitis, bacterial (endogenous endophthalmitis and post-surgical
endophthalmitis):
CEFTRIAXONE
5.3: Pelvic Inflammatory Disease (PID), stage I, 5.10: Sexual assault, 7.3.4:
Prostatitis, associated urethritis, 10.5.2: Non occupational post exposure
prophylaxis, sexual assault and inadvertent exposure, 13.5.1: Arthritis, reactive:
1.3.2: Acute inflammatory diarrhoea (dysentery), 1.3.8: Bacterial peritonitis, 5.3:
Pelvic Inflammatory Disease (PID), stage II-IV, 6.2.1.2: Pyelonephritis, acute,
7.3.2: Urinary tract infection (UTI), acute pyelonephritis: impaired renal function,
13.2: Arthritis, septic and osteomyelitis, acute, 17.1: Epiglottitis, 17.1: Epiglottitis,
2.2: Febrile neutropenia, 25.1: Male urethritis syndrome (MUS) , 25.2: Vaginal
discharge syndrome (VDS):
 Ceftriaxone, IV, 1 g, daily.
9.11: Typhoid fever (enteric fever), 14.6.1: Meningitis, 14.6.4: Brain abscess,
14.6.5: Antimicrobial use in patients with head injuries, penetrating brain injuries,
17.3: Sinusitis, bacterial, complicated, 17.6: Mastoiditis:
16.3: Bronchiectasis, 18.2: Endophthalmitis, bacterial, 16.6: Pneumonia,
community acquired, patients >65 years, comorbid disease, 16.6: Pneumonia,
community acquired, severe pneumonia,20.11.2.2: Septic shock, 9.1.3: Hospital-
Acquired Pneumonia (HAP), no risk factors for MDR infection, 9.1.2: Surgical
wound infections: female uro-genital tract, open GIT surgery:
 Ceftriaxone 2 g, IV, daily.
CHLORAMPHENICOL
18.10.1: Chemical burn, 19.2.3: Snake venom in the eye:
 Chloramphenicol 1%, ophthalmic ointment, applied 6 hourly.
18.1.3: Conjunctivitis, bacterial:
 Chloramphenicol 1%, ophthalmic ointment, applied 8 hourly.
11: Ophthalmic surgery:
 Chloramphenicol 0.5% ophthalmic drops, instil 1 drop 2–4 hourly for 24
hours prior to surgery.
CIPROFLOXACIN
17.5: Otitis media, chronic, suppurative:
 Ciprofloxacin 0.3%, ophthalmic drops, 3–4 drops instilled into the ear
2019 AI.5

every 8 hours for 7 days after mopping.

18.1.3: Conjunctivitis, bacterial, 18.5.2: Keratitis, suppurative:
 Ciprofloxacin 0.3%, ophthalmic drops.
14.6.1: Meningitis, nasopharyngeal carriage eradication, 14.6.1: Meningitis,
prophylaxis of contacts:
1.3.1: Cholera, 1.3.2: Acute inflammatory diarrhoea (dysentery) , 1.3.8: Bacterial
peritonitis, 5.3: Pelvic inflammatory disease (stage II-IV) – severe penicillin
allergy, 5.8.4: Septic miscarriage, severe penicillin allergy, de-escalation therapy,
7.3.2: Urinary tract infection (complicated community acquired UTI) , 7.3.2:
Urinary tract infection (UTI), acute pyelonephritis: de-escalation therapy, 7.3.4:
Prostatitis, 9.1.4: Urinary tract infections, catheter associated, 9.11: Typhoid fever
(enteric fever), chronic carriers, 9.11: Typhoid fever (enteric fever), following
ceftriaxone IV, based on culture sensitivity results,10.2.7: Cystoisosporiasis,
cotrimoxazole allergy
 Ciprofloxacin, oral, 500 mg 12 hourly.
16.3: Bronchiectasis, pseudomonas infection, 17.7.1: Otitis externa, necrostising,
18.2: Endophthalmitis, bacterial, prophylaxis/soft tissue injury:
9.10: Tick bite fever, cannot take oral medicines:
 Ciprofloxacin, IV, 400 mg 8 hourly.
CLINDAMYCIN
4.2: Cellulitis and erysipelas, severe penicillin allergy, 4.4: Furuncles and
abscesses, severe penicillin allergy, 5.3: Pelvic Inflammatory Disease (PID), stage
II-IV: severe penicillin allergy, 5.8.4: Septic miscarriage, severe penicillin allergy,
9.1.2: Surgical wound infections, severe penicillin allergy, 17.8: Abscess,
peritonsillar, severe penicillin allergy, 13.2: Arthritis, septic and osteomyelitis,
acute, severe penicillin allergy:
3.5: Endocarditis, infective, prophylaxis: severe penicillin allergy (if patient cannot
take oral), 11: Cardiac surgery, severe penicillin allergy, 11: Endoscopic
gastrointestinal procedures: severe penicillin allergy, 11: Gastrointestinal surgery:
severe penicillin allergy, 11: General surgery: severe penicillin allergy, 11:
Neurosurgery: severe penicillin allergy, 11: Obstetrics/ gynaecology surgery:
severe penicillin allergy, 11: Orthopaedic surgery: severe penicillin allergy, 11:
Otorhinolaryngology/Head and neck surgery: severe penicillin allergy, 11: Plastic
and reconstructive surgery: severe penicillin allergy, 11: Thoracic surgery: severe
penicillin allergy, 11: Urology: severe penicillin allergy, 11: Vascular surgery:
severe penicillin allergy:
 Clindamycin, IV, 600 mg as a single dose.
2019 AI.6

3.5: Endocarditis, infective, prophylaxis, severe penicillin allergy:

 Clindamycin, oral, 600 mg one hour before the procedure.
8.7.3: Diabetic foot ulcers, severe penicillin allergy:
 Clindamycin, oral, 150-450 mg 8 hourly.
4.2: Cellulitis and erysipelas: severe penicillin allergy, 4.4: Furuncles and
abscesses: severe penicillin allergy, 4.5: Atopic eczema/dermatitis: severe
penicillin allergy, 5.3: Pelvic Inflammatory Disease (PID), stage II-IV: severe
penicillin allergy, de-escalation therapy, 5.8.4: Septic miscarriage, severe
penicillin allergy, de-escalation therapy,, 9.1.1: Intravascular catheter infections,
erythema beyond catheter site, 9.1.2: Surgical wound infections, severe penicillin
allergy, de-escalation therapy, 13.2: Arthritis, septic and osteomyelitis, acute:
severe penicillin allergy, 17.8: Abscess, peritonsillar, 21.2.2: Extravasations:
3.5: Endocarditis, infective, prophylaxis, severe penicillin allergy:
 Clindamycin, oral, 600 mg one hour before the dental procedure.
10.2.9: Pneumocystis pneumonia, cotrimoxazole intolerance, unsuccessful
cotrimoxazole desensitisation:
CLOTRIMAZOLE
4.10: Fungal infections, yeast and dermatophytes:
 Clotrimazole 1%, topical, apply 8 hourly until clear of disease (i.e. for at
least 2 weeks after the lesions have cleared).
COTRIMOXAZOLE
7.3.3: Recurrent UTI, prophylaxis:
 Cotrimoxazole 80/400 mg, oral, 1 tablet at night.
10.2.2: Opportunistic infection prophylaxis, with cotrimoxazole, 10.2.7:
Cystoisosporiasis, secondary prophylaxis, 10.2.9: Pneumocystis pneumonia,
secondary prophylaxis, 10.2.10: Cerebral toxoplasmosis, secondary prophylaxis:
 Cotrimoxazole, oral, 160/800 daily.
10.2.9: Pneumocystis pneumonia: <60kg:
 Cotrimoxazole, oral, 240/1200 6 hourly for 21 days.
10.2.10: Cerebral toxoplasmosis:
 Cotrimoxazole 320/1600, oral, 12 hourly for 28 days, followed by 240/1200
tablets 12 hourly for 3 months.
10.2.7: Cystoisosporiasis:
 Cotrimoxazole 320/1600, oral, 12 hourly for 10 days.
10.2.9: Pneumocystis pneumonia, >60kg:
2019 AI.7

 Cotrimoxazole 320/1600 mg, oral, 6 hourly for 21 days.

10.2.9: Pneumocystis pneumonia, if vomiting:
 Cotrimoxazole, IV, 6 hourly.
o < 60 kg 240/1200 mg.
o > 60 kg 320/ 1600 mg.
DAPSONE
10.2.9: Pneumocystis pneumonia, if primaquine not available:
 Dapsone, oral, 100 mg daily for 21 days.
10.2.9: Pneumocystis pneumonia, secondary prophylaxis, cotrimoxazole
intolerant:
 Dapsone, oral, 100 mg daily for at least 6 months.
DOXYCYCLINE
4.1: Acne, inflammatory (moderate):
 Doxycycline, oral, 100 mg daily for 3 months.
9.10: Tick bite fever, 16.4: Chronic obstructive pulmonary disease (COPD) –
severe penicillin allergy:
 Doxycycline, oral, 100 mg 12 hourly for 5 or 7 days.
9.3: Brucellosis:
25.4: Bubo:
 Doxycycline, oral, 100 mg 12 hourly for 21 days (or more for laboratory-
confirmed diagnosis of LGV).
ECHINOCANDIN
9.1.1: Intravascular catheter infections (specialist motivation).
ERTAPENEM
9.1.2: Surgical wound infections (gram-negative organism):
 Ertapenem, IV, 1 g daily.
ETHAMBUTOL
16.11.1: INH monoresistant TB:
 Ethambutol, oral, 15 mg/kg daily for 6-9 months.
10.2.8: Mycobacteriosis - disseminated non tuberculous:
 Ethambutol, oral, 15–20 mg/kg daily.
10.1.1: Management of selected antiretroviral ADRs: drug-induced liver injury:
 Ethambutol, oral, 800 - 1200 mg daily.
2019 AI.8

FLUCLOXACILLIN
13.2: Arthritis, septic and osteomyelitis, acute:
 Flucloxacillin, oral, 1 g 6 hourly (after 2 weeks of IV cloxacillin therapy
in patients with good clinical response to complete the 4 weeks
treatment).
4.2: Cellulitis and erysipelas, 4.3: Impetigo , 4.4: Furuncles and abscesses, 4.5:
Atopic eczema/dermatitis (infected eczema), 9.1.2: Surgical wound infections ,
9.13: Zoster (Shingles)- if there is suspected associated bacterial cellulitis:
FLUCONAZOLE
4.10: Fungal infections, dermatophyte hair and nail infections;
immunocompomised with extensive skin infection, 4.10: Fungal infections,
onychomycosis:
 Fluconazole, oral, 200 mg weekly.
10.2.3: Candidiasis of oesophagus/trachea/bronchi, 10.2.4.1: Asymptomatic
cryptococcosis, CrAg positive, maintenance therapy, 10.2.4.2: Symptomatic, Non-
Meningeal Cryptococcosis, maintenance therapy, 10.2.4.3: Cryptococcal
meningitis, maintenance therapy, 14.6.1.2.2: Cryptococcal meningitis, HIV-
uninfected:
10.2.3: Candidiasis of oesophagus/trachea/bronchi, if vomiting or unable to
swallow:
 Fluconazole, IV, 200 mg daily.
14.6.1.2.2: Cryptococcal meningitis, HIV-uninfected:
9.1.1: Intravascular catheter infections, candidaemia,10.2.4.1: Asymptomatic
cryptococcosis, CrAg positive, consolidation phase , 10.2.4.2: Symptomatic, Non-
Meningeal Cryptococcosis, consolidation phase , 10.2.4.3: Cryptococcal
meningitis, consolidation phase , 14.6.1.2.2: Cryptococcal meningitis, HIV-
uninfected:
 Fluconazole, oral, 800 mg daily
10.2.4.1: Asymptomatic cryptococcosis, CrAg positive, induction therapy ,
10.2.4.2: Symptomatic, Non-Meningeal Cryptococcosis, induction therapy ,
10.2.4.3: Cryptococcal meningitis, induction therapy:
 Fluconazole, oral, 1200 mg daily
FOSFOMYCIN
6.21.1: Cystitis (in pregnancy), 7.3.2: Urinary tract infection (UTI):
 Fosfomycin 3 g, oral, as a single dose.
2019 AI.9

GANCICLOVIR
10.2.6: Cytomegalovirus (CMV), HIV:
 Ganciclovir, IV, 5 mg/kg 12 hourly.
18.6: Retinitis, HIV CMV:
 Ganciclovir, intravitreal, 2 mg once a week.
GENTAMICIN
3.5: Endocarditis, infective, empiric therapy (prosthetic and native valve);
staphylococcal directed therapy; streptococcal directed therapy (native valve):
 Gentamicin, IV, 1.5 mg/kg 12 hourly.
3.5: Endocarditis, infective, enterococcal directed therapy (native valve):
 Gentamicin, IV, 1 mg/kg 8 hourly.
7.3.2: Urinary tract infection (UTI):
 Gentamicin, IM, 5 mg/kg as a single dose
14.6.1: Meningitis: Listeria monocytogenes meningitis:
 Gentamicin, IV, 5 mg/kg daily for 7 days (may be prolonged if response
is poor).
2.2: Febrile neutropenia, 3.5: Endocarditis, infective, 5.3: Pelvic Inflammatory
Disease (PID), stage II-IV: severe penicillin allergy, 5.8.4: Septic miscarriage
(severe penicillin allergy), 6.21.2: Pyelonephritis, acute, in pregnancy, 7.3.2:
Urinary tract infection (UTI), acute pyelonephritis: normal renal function, 8.7.3:
Diabetic foot ulcers – severe penicillin allergy, 9.3: Brucellosis, 11:
Gastrointestinal surgery: severe penicillin allergy, 11: Obstetrics/ gynaecology
surgery: severe penicillin allergy, 11: Urology procedures: severe penicillin allergy,
25.1: Male urethritis syndrome (MUS), 25.2: Vaginal discharge syndrome (VDS):
 Gentamicin, IV, 6 mg/kg, daily.
IMIPENEM
2.2: Febrile neutropenia (if fever develops after 48 hours of admission – also
consider local susceptibility patterns):
 Imipenem/cilastin, IV, 500/500 mg 6 hourly.
9.1.3: Hospital-Acquired Pneumonia (HAP), with risk factors, Ventilator
Associated Pneumonia (VAP):
 Imipenem/cilastin, IV, 1000/1000 mg 8 hourly (except CNS infections or
known epileptics).
ISONIAZID
10.1.1: Management of selected antiretroviral ADRs, drug-induced liver injury,
10.2.1: Isoniazid preventive therapy (IPT):
 Isoniazid, oral 300 mg daily.
2019 AI.10

LEVOFLOXACIN
16.11.1: Isoniazid monoresistant TB:
 Levofloxacin 750–1000 mg daily.
MEROPENEM
2.2: Febrile neutropenia:
 Meropenem, IV, 1 g 8 hourly.
14.6.1: Meningitis, 9.1.3: Hospital-Acquired Pneumonia (HAP), with risk factors,
VAP, CNS infections/seizures:
 Meropenem, IV, 2 g 8 hourly.
METRONIDAZOLE
1.3.4: Diarrhoea, antibiotic associated, 6.12: Preterm labour (PTL) and preterm
prelabour rupture of membranes (PPROM) , 14.6.4: Brain abscess:
 Metronidazole, oral, 400 mg 8 hourly
1.1.8: Peptic ulcer, H. pylori +ve, 5.3: Pelvic Inflammatory Disease (PID), stage I:
 Metronidazole, oral, 400 mg 12 hourly for 7/14 days.
1.2.6: Liver abscess, amoebic, 1.3.5: Amoebic dysentery:
1.3.6: Giardiasis, 5.10: Sexual assault , 10.5.2: Non occupational post exposure
prophylaxis, sexual assault and inadvertent exposure, 25.2: Vaginal discharge
syndrome (VDS):
 Metronidazole, oral, 2 g.
11: Gastrointestinal surgery, 11: Obstetrics/ gynaecology surgery, 11:
Otorhinolaryngology/ Head and neck surgery, 11: Urology, 11: Thoracic surgery;
11: Vascular surgery:
 Metronidazole, IV, 500 mg, as a single dose.
1.3.4: Clostridum difficile diarrhoea, 5.3: Pelvic Inflammatory Disease (PID), stage
II-IV, 9.1.2: Surgical wound infections, female uro-genital tract, open GIT surgery,
9.9: Tetanus , 14.6.4: Brain abscess:
 Metronidazole, IV, 500 mg, 8 hourly.
MOXIFLOXACIN
9.1.3: Hospital-Acquired Pneumonia (HAP), severe penicillin allergy, 16.3
Bronchiectasis if pseudomonas infection is suspected, severe penicillin allergy,
16.5: Lung abscess, severe penicillin allergy 16.6: Pneumonia, community
acquired, severe penicillin allergy, 16.7: Pneumonia, aspiration, severe penicillin
allergy, 16.8: Empyema, severe penicillin allergy:
 Moxifloxacin, IV, 400 mg daily, until patient apyrexial for 24 hours.
2019 AI.11

9.1.3: Hospital-Acquired Pneumonia (HAP), severe penicillin allergy, 10.1.1:

Management of selected antiretroviral ADRs, 16.3 Bronchiectasis if pseudomonas
infection is suspected, severe penicillin allergy, 16.5: Lung abscess, severe
penicillin allergy 16.6: Pneumonia, community acquired, severe penicillin allergy,
16.7: Pneumonia, aspiration, severe penicillin allergy, 16.8: Empyema, severe
penicillin allergy:
 Moxifloxacin, oral, 400 mg daily.
NATAMYCIN
18.5.2: Keratitis, suppurative, fungal infection:
 Natamycin 5%, ophthalmic drops.
NITROFURANTOIN
6.21.1: Cystitis (pregnancy); 7.3.2: Urinary tract infection (UTI):
 Nitrofurantoin, oral, 100 mg 6 hourly for 5 days.
PHENOXYMETHYLPENICILLIN
3.7: Rheumatic heart disease, prophylaxis:
 Phenoxymethylpenicillin, oral, 250 mg 12 hourly.
3.7: Rheumatic heart disease, acute rheumatic fever:
 Phenoxymethylpenicillin, oral, 500 mg 12 hourly for 10 days.
6.8: Syphilis, penicillin desensitisation:
 Phenoxymethylpenicillin, IV, 250 mg/5 mL.
PIPERACILLIN/TAZOBACTAM
2.2: Febrile neutropenia, 9.1.2: Surgical wound infections, 9.1.3: Hospital-
Acquired Pneumonia (HAP), with risk factors, Ventilator Associated Pneumonia
(VAP), CNS infections/seizures:
PROCAINE PENICILLIN
6.8: Syphilis, symptomatic baby:
 Procaine penicillin, IM, 50 000 units/kg daily for 10 days (Not for I.V. use).
PYRAZINAMIDE
 Pyrazinamide, oral, 25 mg/kg daily.
2019 AI.12

RIFABUTIN
10.1: Antiretroviral therapy, TB treatment for patients on ATV/r or darunavir when
rifampicin is contraindicated:
 Rifabutin, oral, 150 mg daily.
RIFAMPICIN
3.5: Endocarditis, infective, 9.3: Brucellosis:
 Rifampicin, oral, 7.5 mg/kg 12 hourly for 6 weeks.
 Rifampicin, oral, 10 mg/kg daily.
10.1.1: Management of selected antiretroviral ADRs, drug-induced liver injury;
<60kg:
 Rifampicin, oral 450 mg daily.
10.1.1: Management of selected antiretroviral ADRs, drug-induced liver injury:
 Rifampicin, oral 600 mg daily.
RIFAMPICIN/ISONIAZID
16.9: Tuberculosis, pulmonary, continuation phase: 30-37kg, 16.10:
Tuberculosis, pleural, continuation phase: 30-37kg:
 Rifampicin/isoniazid, oral, 300/150 mg, daily for 4 months.
16.9: Tuberculosis, pulmonary, continuation phase: 38-54kg, 16.10: Tuberculosis,
Pleural, continuation phase: 38-54kg:
16.9: Tuberculosis, pulmonary, continuation phase: >55kg, 16.10: Tuberculosis,
Pleural, continuation phase: >55kg:
RIFAMPICIN/ISONIAZID/PYRAZINAMIDE/ETHAMBUTOL
16.9: Tuberculosis, pulmonary, initial phase: 30-37kg, 16.10: Tuberculosis,
Pleural, initial phase: 30-37kg, 16.11.1: Isoniazid monoresistant TB (single
medicines unavailable): 30-37kg:
 Rifampicin/isoniazid/pyrazinamide/ethambutol, oral, 300/150/800/500
mg, daily for 2–6 months.
16.9: Tuberculosis, pulmonary, initial phase: 38-54kg:16.10: Tuberculosis, Pleural,
initial phase: 38-54kg, 16.11.1: Isoniazid monoresistant TB (single medicines
unavailable): 38-54kg:
16.9: Tuberculosis, pulmonary, initial phase:55-70kg, 16.10: Tuberculosis, Pleural,
initial phase:55-70kg, 16.11.1: Isoniazid monoresistant TB (single medicines
2019 AI.13

unavailable):55-70kg:
16.9: Tuberculosis, pulmonary, initial phase:71kg and over, 16.10: Tuberculosis,
Pleural, initial phase:71kg and over, 16.11.1: Isoniazid monoresistant TB (single
medicines unavailable): >71kg:
TENOFOVIR
1.2.4.2: Hepatitis B, chronic (non-HIV co-infection):
 Tenofovir, oral, 300 mg daily.
VALGANCICLOVIR
10.2.6: Cytomegalovirus (CMV), 18.6: Retinitis, HIV CMV:
 Valganciclovir, oral, 900 mg 12 hourly for 3 weeks, then 900 mg daily
until until immune recovery (CD4 >100 cells/mm3).
VANCOMYCIN
1.3.4: Clostridum difficile diarrhoea:
 Vancomycin, oral, 125 mg 6 hourly. (Give the parenteral formulation
orally).
18.2: Endophthalmitis, bacterial:
3.5: Endocarditis, infective:
 Vancomycin, IV, 20 mg/kg 12 hourly.
2.2: Febrile neutropenia, IV, skin infection, 9.1.1: Intravascular catheter infections,
S. aureus infection, 9.1.2: Surgical wound infections, MRSA:
12 hourly.
2019 AI.14

APPENDIX II PRESCRIBING INFORMATION FOR SPECIFIC MEDICINES
AMIKACIN, IV
o If BMI is >40 kg/m2 use ideal body weight* + 40% of the difference
between ideal and actual body weight).
o In severe sepsis or septic shock, a loading dose of 25 mg/kg should be
given (irrespective of renal function).
o If eGFR is 40–60 mL/minute, adjust maintenance dose to 15 mg/kg
every 36 hours (check trough amikacin level and give the next dose
when level <5 mg/L).
o Maximum daily dose 1.5 g, usually for a maximum of 10 days.
o Amikacin is potentially nephrotoxic and ototoxic – monitor creatinine
three times per week and discontinue if vestibular or cochlear symptoms
develop. Regular audiometry is essential with longer term use in patients
with drug-resistant TB.
o Therapeutic drug monitoring: pre-dose amikacin trough levels after the
third dose. Aim for a trough level of <5 mg/L.
 Normal renal function: do not wait for the amikacin level before giving
the next dose. The level should be used to adjust the dose for the
next day if applicable.
 Impaired renal function: wait for the amikacin level and give the next
dose when level <5 mg/L.
 In obese patients or in patients with resistant Gram-negative bacteria
also measure peak concentrations (0.5–1 hours after infusion). Aim
for peak >30 mg/L (or ten times higher than the MIC for resistant
organisms).
* ideal body weight calculator: https://www.mdcalc.com/ideal-body-weight-
adjusted-body-weight
AMIODARONE, ORAL
 Amiodarone, oral, 800 mg daily for 7 days.
o Hypotension may occur, especially during the loading dose phase
o Titrate to maintenance dose of 200–400 mg daily.
o May cause hypothyroidism or thyrotoxicosis - monitor thyroid function
every 6 months.
o Monitor for pulmonary symptoms and perform baseline CXR before
starting long-term therapy and annually thereafter to monitor for
interstitial pulmonary fibrosis.
AMOXICILLIN/CLAVULANIC ACID, ORAL

 Amoxicillin/clavulanic acid, oral, 875/125 mg (containing 875 mg amoxicillin
trihydrate and 125 mg clavulanic acid) 12 hourly.
o When treating pneumonia in areas where there is a confirmed high
prevalence (≥ 5%) of Streptococcus pneumoniae with intermediate
2019 AII.1
resistance to penicillin : dose 8 hourly
ADD: Amoxicillin 1 g, oral, daily between the amoxicillin/clavulanic acid
doses (i.e. 8 hours after the morning dose of amoxicillin/clavulanic acid).
AMOXICILLIN/CLAVULANIC ACID, IV
Amoxicillin/clavulanic acid IV is not suitable for intramuscular or
subcutaneous administration.
 Amoxicillin/clavulanic acid, 1.2 g powder vials for intravenous injection
containing amoxicillin sodium equivalent to 1 g of amoxicillin and potassium
clavulanate equivalent to 200 mg clavulanic acid.
o Dosage Recommendation: Amoxicillin/clavulanic acid, 1.2 g, IV, 8
hourly.
o Directions for use:
- Powder vials for injection can be reconstituted by dissolving in 20 mL
water for injection.
- Reconstituted vials can be administered intravenously by injection
over 2 minutes or slow intravenous infusion over
- For intravenous infusion, the reconstituted vial should be further
diluted with the desired volume of a suitable infusion fluid (e.g.
Sodium chloride 0.9%, 100 mL).
- 30 minutes.
- The contents of the vials must be used within 20 minutes.
o Precautions:
- Allergy to penicillins.
- Drug-induced cholestatic hepatitis may occur, typically a few weeks
after starting therapy. Use with caution in patients with evidence of
hepatic dysfunction.
- Dosage adjustments required in renal impairment:
 CrCl >70 mL/minute: no dose adjustment required.
 CrCl 10–30 mL/minute: 1.2 g as a single dose followed by 600 mg
12 hourly.
 CrCl <10 mL/minute: 1.2 g as a single dose followed by 600 mg daily.
AMPHOTERICIN B, IV
 Amphotericin B, IV, 0.7–1 mg/kg daily, dose and duration of therapy depend
on indication for use and infecting organism.
o Reconstitue in 5% dextrose water only (as incompatibile with saline
solution).
o Administer over a period of 2–6 hours.
o Ensure adequate hydration to minimise the risk of nephrotoxicity.
Monitoring
- Serum potassium, magnesium and creatinine (baseline and twice
weekly). Monitoring of serum potassium and creatinine should occur
more frequently in neutropenic patients (3 times a week).
2019 AII.2
- Monitor haemoglobin (baseline and weekly).
- Careful attention to fluid monitoring of intake and output.
- For management of hypokalaemia, see section 7.2.2: Hypokalaemia.
Management of elevated creatinine

If creatinine increases by ≥2 fold from baseline value, either omit an
amphotericin B dose, or increase pre-hydration to 1 litre 8 hourly.
- Once improved, restart at 0.7 mg/kg daily and consider alternate day
amphotericin B.
- If creatinine remains elevated i.e. ≥2 fold from baseline value,
discontinue amphotericin B and continue with fluconazole, oral, 800 mg
daily (for fungal infections known to be responsive to fluconazole, e.g.
Cryptococcus).
(Adapted from: WHO. Rapid advice: diagnosis, prevention and management of cryptococcal
disease in HIV-infected adults, adolescents and children: Prevention, monitoring and
management of amphotericin B toxicity. 2011 [Online] [Accessed March 2016]
http://www.ncbi.nlm.nih.gov/books/NBK299520/pdf/Bookshelf_NBK299520.pdf
CEFEPIME, IV
 Cefepime IV/IM, 1–2 g 12 hourly.
o Renal adjusted dosing:
 eGFR >50 mL/minute: 100% of daily dose
 eGFR 10–50 mL/minute: 50–100% of daily dose
 eGFR <10 mL/minute: 25–50% of daily dose
(Source: Bennet, WM. Drug prescribing in renal failure. Fifth edition).
CLINDAMYCIN, IV
 Clindamycin IV, 600 mg, 8 hourly (maximum of 4.8 g/day)
o Dilute the contents of the vial in 100 mL of diluent prior to infusion.
o Infuse over 20 minutes.
o Note: Rapid infusion can cause flushing, pain, thrombophlebitis,
hypotension and cardiopulmonary arrest.
DIGOXIN, ORAL
 Digoxin, oral, 0.125 mg daily, adjust according to rate response, if in atrial
fibrillation, and trough plasma level.
maintained between 0.6–1 nmol/L. Monitor after 7 days and periodically
thereafter.
o Patients at high risk of digoxin toxicity are:
 the elderly,
 patients with renal dysfunction,
 hypokalaemia, and
 patients with low lean body mass.
2019 AII.3
GENTAMICIN, IV
 Gentamicin, IV, 5–6 mg/kg once daily.
o If BMI is >40 kg/m2 use ideal body weight* + 40% of the difference
between ideal and actual body weight.
o Administer slowly over 3 minutes or infused over 20–30 minutes up to 2
hours, diluted in 5% dextrose or 0.9% sodium chloride solution.
o For streptococcal endocarditis: 1.5 mg/kg 12 hourly (in combination with
penicillin).
o Renal impairment dosage adjustment (eGFR <60 mL/minute):
- Administer 3–4 mg/kg loading dose and adjust further dosing
according to plasma concentrations.
o Gentamicin is potentially nephrotoxic and ototoxic – monitor creatinine
three times per week and discontinue if vestibular or cochlear symptoms
develop.
o Therapeutic drug monitoring: Sample after the third dose;
- Draw trough concentrations immediately before dose; peak
concentrations 0.5–1.0 hours after dosing from the drip-free arm.
- Therapeutic ranges: Peak >8 mcg/ml, trough <1 mcg/ml
- Reduce the dose per kg or consider omitting a dose if concentration
is supratherapeutic. If the plasma concentration is subtherapeutic
but the patient has signs of toxicity, change to an alternative agent.
* ideal body weight calculator: https://www.mdcalc.com/ideal-body-weight-
LABETALOL, IV
 Labetalol, IV infusion, 2 mg/minute to a total of 1–2 mg/kg.
o Initial dose: 2 mg/minute
o Titrate to response up to 300 mg total cumulative dose (e.g. discontinue
after 2.5 hours of 2 mg/minute).
o Usual total dose required is 50–200 mg (1–2 mg/kg).
o Commence an oral antihypertensive regimen as soon as the infusion is
discontinued.
LITHIUM, ORAL
 Lithium, oral, 250 mg 12 hourly.
o Usual dose range: 200–500 mg/dose 12 hourly.
o May be given as a single total daily dose at night to improve adherence and
to protect renal function.
o Measure serum concentrations at steady state (i.e. after 5 days) at about
12 hours after the last dose.
o Lithium has a narrow therapeutic window. The therapeutic range is
0.4–0.8 mmol/L for maintenance therapy, and 0.8–1.0 mmol/L in
mania.
2019 AII.4
o If levels are sub-therapeutic and the patient is adherent increase the
daily dose by 250 mg and repeat trough plasma levels after 5 days.
o Maintain therapeutic blood levels of lithium for as long as the patient is
on lithium. Monitor lithium levels and renal function at least monthly for
the first 3 months of therapy.
o Monitor lithium levels 6 monthly once stable levels have been achieved,
together with serum creatinine, sodium and potassium.
o Check TSH (for lithium-induced hypothyroidism) and serum calcium (for
lithium-induced hyperparathyroidism) before starting treatment and
annually thereafter.
o Beware of combining lithium with ACE-inhibitors, NSAIDs and thiazide
diuretics, as they all potentiate the risk for lithium toxicity.
Pregnancy - Lithium has been associated with congenital abnormalities
in the newborn with first trimester exposure. Risk-benefit assessment
required for indication of maternal use during pregnancy.
METFORMIN, ORAL
 Metformin, oral, 500 mg twice daily with meals.
o Titrate dose slowly depending on HbA1c and/or fasting blood glucose
levels to a maximum dose of 850 mg 8 hourly.
o Monitor renal function.
o Dose-adjust in renal impairment as follows:
- eGFR > 60 mL/minute: Normal daily dose (see above).
- eGFR < 60 mL/minute: Half of the daily dose.
- eGFR < 30 mL/minute: Stop metformin.
o Contra-indicated in:
- renal impairment i.e. eGFR < 30 mL/minute,
- uncontrolled congestive cardiac failure,
- severe liver disease,
- patients with significant respiratory compromise, or
- peri-operative cases.
o Drug-drug interaction with dolutegravir (DTG): DTG may increase the
serum concentration of metformin. Limit maximum dose of metformin to
1000 mg daily if concomitant use with DTG.
MORPHINE, IV
 Morphine, IV, to a maximum dose of 10 mg.
o Morphine, IV, 3–5 mg as a single dose then further boluses at intervals
of 5–10 minutes and monitor all vitals closely.
o Dilute 10 mg up to 10 mL with sodium chloride 0.9%.
o Monitor response to pain and effects on respiration and blood pressure.
o Onset 5–10 minutes. Duration of action 4-5 hours.
2019 AII.5
PHENYTOIN, IV
 Phenytoin, IV, 20 mg/kg diluted in sodium chloride 0.9% (not dextrose)
administered not faster than 50 mg/minute, with cardiac monitoring.
o Mixing instructions: For preparation of the infusion, the contents of a vial
of phenytoin should be well mixed in 0.9% sodium chloride at a
concentration of less than 4 g/L and be completely administered within
1 hour of mixing to avoid precipitation.
o Cardiac monitoring should be done during the infusion.
o If dysrhythmias occur, interrupt the infusion temporarily and reintroduce
slowly, once rhythm becomes stable.
o Continue with, IV, 5 mg/kg/day (300 mg daily for most adults).
POTASSIUM CHLORIDE, IV
Must always be diluted before infusion.
 Potassium chloride, IV, diluted in 1 L sodium chloride 0.9%.
o Rapid infusion of potassium chloride can cause fatal dysrhythmias.
o Infusion rates > 20 mmol/hour are very irritable to peripheral veins.
o Potassium chloride 15% for intravenous use contains 20 mmol K+ per
10 mL ampoule.
o Potassium chloride infusion – see diabetes section for the administration
of potassium infusion in DKA (Section 8.6.2: Diabetic ketoacidosis
(DKA) and hyperosmolar hyperglycaemic state (HHS)).
o Non DKA; Dilute potassium chloride in a non-glucose containing solution
(e.g. 0.9% sodium chloride) to a concentration not exceeding 40 mmol/L.
Maximum rate of infusion should not exceed 20 mmol/ hour.
o As large volumes of solution may need to be given, monitor the patient
for fluid overload.
o For preparation of the infusion, the contents of an ampoule of potassium
chloride should be well mixed in 0.9% sodium chloride.
An example prescription might be: ‘dilute two 10 ml ampoules of 20 mmol
KCl in 1 litre of 0.9% sodium chloride, and mix thoroughly. Infuse at a rate of
125 ml/hour, and repeat 8 hourly (i.e. give three litres of the solution
containing 40 mmol KCl per litre as a constant infusion over a 24 hour
period)’.
PREDNISONE, ORAL
Prednisone tapering - generally required after prolonged use (i.e. >1 week)
- Example of a dose reduction regimen: for an initial dose of 60 mg daily,
reduce initial dose by 2/3, and continue as follows:
» 40 mg/day in week 2,
» 10 mg /day in week 6 and
2019 AII.6
» thereafter 5 mg daily for 1 week and then discontinue.
Note: Weaning should be adjusted according to clinical context. If control
deteriorates on weaning return to the previous effective dose.
VANCOMYCIN, IV
 Vancomycin, IV, 30 mg/kg as a loading dose. Follow with 20 mg/kg/dose 12
hourly. Duration depends on the organism & site of infection: for methicillin-
resistant Staphylococcus aureus duration is 2 weeks after first negative
blood culture, or 4 weeks for complicated infections (e.g. endocarditis).
o The rate of infusion should not exceed 1 g/hour (i.e. at least 2 hours for
a 2 g infusion).
o Note: Rapid infusion can cause flushing, pain, thrombophlebitis,
hypotension and cardiopulmonary arrest.
o Weigh patients and estimate eGFR (see chapter 7: Nephrological/
urological disorders).
o See table for dosing interval and measurement of trough concentrations.
o Aim for trough concentration of 10–20 mcg/mL except in osteitis or
endocarditis or if MIC > 1 when trough should be 15–20 mcg/mL.
o If trough is too low, increase dose (specialist consultation if unsure how
much to increase) and/or shorten dose interval to 8 hourly.
o If trough too high increase dosing interval (specialist consultation if
unsure how much to increase).
o Vancomycin is not significantly removed by conventional intermittent
haemodialysis. Dosing and monitoring as for those with eGFR <25
mL/minute.
Dosing intervals and when to measure trough concentrations of vancomycin:
eGFR Measurement of trough
Dosing interval (hours)
(mL/minute) concentrations
>80 12 Before 3rd dose
50-79 24 Before 3rd dose
35-49 36 Before 2nd dose
25-34 48 Before 2nd dose
<25
or
haemodialysis When trough level <15 3 days after loading dose
or
CAPD
(Adapted with permission from Groote Schuur hospital’s protocol).
2019 AII.7
WARFARIN, oral
 Warfarin, oral, 5 mg daily adjusted to maintain INR between 2 and 3.
o Warfarin interactions:
A large number of medicines interact with warfarin leading to under- or
over-anticoagulation, and careful evaluation of all new medicines, herbal
and over-the counter products is critical. This includes (but is not an
exhaustive list):
- Medicines altering platelet function e.g. NSAIDs, aspirin, clopidogrel,
etc.
- Food or medicines altering vitamin K synthesis e.g. antibiotics.
- Medicines interfering with warfarin metabolism e.g. efavirenz,
rifampicin, macrolide antibiotics, simvastatin, phenytoin,
carbamazepine, etc.
- Grapefruit juice.
Unless INR is markedly out of range the modest adjustments recorded

below should be followed:
Initiation
Warfarin initiation dosing protocol (week 1) with INR target: 2–3
Day therapy INR Value Total daily dose
Day 1 5 mg daily
(2.5 mg daily for high sensitivity)

2 to 3 days after initiation < 1.5 5–7.5 mg daily
1.5 – 1.9 2.5–5 mg daily
2.0 – 2.5 2.5 mg daily
> 2.5 Hold warfarin and recheck INR next day

2 to 3 days after last INR < 1.5 7.5–10 mg daily
check
1.5 – 1.9 5–10 mg daily
2.0 – 3.0 2.5–5 mg daily
> 3.0 Hold warfarin and recheck INR in1–2 days
2019 AII.8
Frequency of INR monitoring after initiation of warfarin
Check INR
Every 2–3 days Until INR within therapeutic range on 2 consecutive INR
checks
Then every week Until INR within therapeutic range on 2 consecutive INR
checks
Then every 2 weeks Until INR within therapeutic range on 2 consecutive INR
checks
Then every 4 weeks When dose is stable, check monthly
Maintenance
Warfarin maintenance dosing protocol to maintain an INR 2-3:
INR<1.5 INR: INR: INR: INR: INR: INR>9.0
1.5-1.9 2.0-3.0 3.1-4.0 4.1-5 5.1-9.0
Extra Increase No Decrease Withhold *Withold 2 Admit.
Dose. weekly change. weekly 1 dose. doses.
dose 5%. dose 5%.
Increase Decrease Decrease
weekly weekly weekly
dose 10%. dose dose
10%. 20%.
*History and examination to exclude bleeding. Admit persons with additional risks for bleeding.
Frequency of INR monitoring for maintenance of warfarin

Check INR
Every 3–5 days If start/stop interacting medication, change in diet,
change in activity level or other change that could
affect INR.
Every 1–2 weeks If dose needed adjustment by 5–10%.
Every 4 weeks If maintained on same stable dose < 6 months.
Every 6–8 weeks If maintained on same stable dose ≥ 6 months.
2019 AII.9
APPENDIX III MEDICINES IN PREGNANCY
MEDICINES AND BIRTH DEFECTS

Some medicines are known to cause abnormal fetal development resulting in
fetal death or babies born with birth defects. Some of these effects may happen
very early in pregnancy, within the first 6 weeks of gestation, before most
patients realise they are pregnant. It is therefore important that women who are
in their reproductive age and are prescribed any teratogenic medicine should
be made aware of the risk and placed on reliable contraception. Some
medicines can cause fetal damage in the second or third trimester.
Where possible, stop teratogenic medicines before a pregnancy is planned and
prescribe suitable alternatives.
Any medicine that is prescribed during pregnancy must be carefully evaluated,
and risk versus benefit should be assessed before use. Refer to prescriber
information for details regarding risks in pregnancy. .
Refer pregnancies exposed to teratogenic medicines during the first trimester
for a detailed fetal anomaly scan.
The table below lists some commonly used medicines that are associated with
birth defects.
MEDICINES ADVERSE FETAL EFFECTS LoE
Androgens Masculinisation of the developing female fetus can IIIi
occur.
ACE- inhibitors/ Fetal hypotension resulting in fetal kidney hypoperfusion IIIii
ARBs and anuria, with fetal growth restriction and demise.
Anticonvulsants:
Carbamazepine Increases the risk of facial dysmorphology, neural tube
defects, cardiovascular defects, and urinary tract
defects.
IIiii
Phenytoin Increases the risk of fetal hydantoin syndrome,
consisting of facial dysmorphology, cleft palate,
ventricular septal defect, and growth and intellectual
disability.
Valproic acid Increases the risk of spina bifida, facial dysmorphology,
autism, atrial septal defect, cleft palate, hypospadias,
polydactyly, craniosynostosis, limb abnormalities,
neurodevelopmental problems (approximately 40%) and
autismiv.

i Androgens:Wilkins L. Masculinization of female fetus due to use of orally given progestins. JAMA. 1960 Mar
5;172(10):1028–32. https://jamanetwork.com/journals/jama/article-abstract/327726
ii Hanssens M, Keirse MJ, Vankelecom F, Van Assche FA. Fetal and neonatal effects of treatment with angiotensin-
converting enzyme inhibitors in pregnancy. Obstet Gynecol. 1991 Jul;78(1):128–35.

iii Anticonvulsants: Weston J, Bromley R, Jackson CF, Adab N, Clayton-Smith J, Greenhalgh J, Hounsome J, McKay
AJ, Tudur Smith C, Marson AG. Monotherapy treatment of epilepsy in pregnancy: congenital malformation outcomes
in the child. Cochrane Database Syst Rev. 2016 Nov 7;11:CD010224.
iv Valproic acid – caution in pregnancy: European Medicines Agency - Pharmacovigilance Risk Assessment
Committee. Assessment report EMA/198940/2018 - valproate exposure in pregnancy, 8 February 2018.
2019 AIII.1
Antidepressants SSRIs should in general be continued during pregnancy IIIv
and breastfeeding. There is uncertainty in the evidence,
but potential complications may include an increased
risk of birth defects, postpartum haemorrhage,
premature birth and low birth weight.
Carbimazole Increased risk of birth defects in the first trimester and at IIIvi
high daily doses of ≥15 mg.
Dolutegravir There is an increased risk of neural tube birth defects IIIvii
involving the brain, spine, and spinal cord; if used within
the first 6 weeks of pregnancy.
Efavirenz No increased prevalence of birth defects detected and Iviii
in a large multi-cohort analysis or from a South African
exposure registry.
Lithium First trimester exposure is associated with an increased IIix
risk of birth defects.
Macrolide In a large population-based cohort study, when IIIx
compared to penicillin, first trimester macrolide exposure
was associated with increased risk of cardiovascular
malformations, and macrolide exposure in any trimester
was associated with increased risk of genital
malformations. The majority of macrolide exposures in
http://www.ema.europa.eu/docs/en_GB/document_library/Referrals_document/Valproate_2017_31/Position_provided
_by_CMDh/WC500250221.pdf
Valproic acid – caution in pregnancy: Meador K, Reynolds MW, Crean S, Fahrbach K, Probst C. Pregnancy
outcomes in women with epilepsy: a systematic review and meta-analysis of published pregnancy registries and
cohorts. Epilepsy Res. 2008 Sep;81(1):1-13. https://www.ncbi.nlm.nih.gov/pubmed/18565732
v Antidepressants: ACOG Committee on Practice Bulletins--Obstetrics. ACOG Practice Bulletin: Clinical management
guidelines for obstetrician-gynecologists number 92, April 2008 (replaces practice bulletin number 87, November
2007). Use of psychiatric medications during pregnancy and lactation. Obstet Gynecol. 2008 Apr;111(4):1001–20.
Antidepressants: National Institute of Clinical Excellence: National Clinical Guideline Number 192: Antenatal and
postnatal mental health – clinical management and service guidance, April 2018.
vi Carbimazole: Bowman P, Vaidya B. Suspected Spontaneous Reports of Birth Defects in the UK Associated with
the Use of Carbimazole and Propylthiouracil in Pregnancy. J Thyroid Res. 2011;2011:235130.

vii Dolutegravir: Raesima MM, Ogbuabo CM, Thomas V, Forhan SE, Gokatweng G, Dintwa E, et al. Dolutegravir Use
at Conception - Additional Surveillance Data from Botswana. N Engl J Med. 2019 29;381(9):885–7.
viii Efavirenz: Mehta UC, van Schalkwyk C, Naidoo P, Ramkissoon A, Mhlongo O, Maharaj NR, et al. Birth outcomes
following antiretroviral exposure during pregnancy: Initial results from a pregnancy exposure registry in South Africa.
South Afr J HIV Med. 2019;20(1):971. https://www.ncbi.nlm.nih.gov/pubmed/31616571
Efavirenz: Martinez de Tejada B, European Pregnancy and Paediatric HIV Cohort Collaboration Study Group.
Birth Defects After Exposure to Efavirenz-Based Antiretroviral Therapy at Conception/First Trimester of Pregnancy: A
Multicohort Analysis. J Acquir Immune Defic Syndr. 2019 01;80(3):316–24.
Efavirenz: Zash R, Holmes L, Diseko M, Jacobson DL, Brummel S, Mayondi G, Isaacson A, Davey S, Mabuta J,
Mmalane M, Gaolathe T, Essex M, Lockman S, Makhema J, Shapiro RL. Neural-Tube Defects and Antiretroviral
Treatment Regimens in Botswana. N Engl J Med. 2019 Aug 29;381(9):827-840.
ix Lithium: Munk-Olsen T, Liu X, Viktorin A, Brown HK, Di Florio A, D'Onofrio BM, et al. Maternal and infant outcomes
associated with lithium use in pregnancy: an international collaborative meta-analysis of six cohort studies. Lancet
Psychiatry. 2018 Aug;5(8):644-652. https://www.ncbi.nlm.nih.gov/pubmed/29929874
x Fan H, Gilbert R, O'Callaghan F, Li L. Associations between macrolide antibiotics prescribing during pregnancy and
adverse child outcomes in the UK: population based cohort study. BMJ. 2020 Feb 19;368:m331.
2019 AIII.2
this study (93%) were to erythromycin, but a class effect
cannot be ruled out. Macrolides should only be
prescribed in pregnancy when clearly indicated.
Methotrexate Pregnancy loss, growth restriction, microcephaly, IIIxi
intellectual disability.
Contraceptive There is no risk for congenital defects if contraceptive IIxii
agents and sex agents were used inadvertently during the first trimester.
steroids Very high doses of androgen hormone-derived progestin
(progestin) may produce masculinisation if used before 13 weeks of
pregnancy.
Prednisone Prednisone does not represent a major teratogenic risk IIxiii
in humans at therapeutic doses, but there is an
increased risk (about 3-fold) for cleft palate.
Retinoids Oral formulation is associated with increased risk of IIIxiv
CNS, cardioaortic, ear, and clefting defects.
Topical administration is very unlikely to have
teratogenic potential because teratogenic serum levels
cannot be attained by topical exposure to retinoids.
Tetracyclines (e.g. Produces bone and teeth staining; it does not increase IIIxv
docycycline) the risk of any malformations but should not be used
during pregnancy.
Warfarin Early exposure during pregnancy can result in nasal IIxvi
hypoplasia, intrauterine growth restriction and
miscarriage. CNS malformations can occur in late
pregnancy exposure because of bleeding.
In women with new generation prosthetic heart valves
taking warfarin daily at a dose of ≤5mg, the risk of
serious teratogenesis is small and warfarin may be
safely continued in the first trimester being discontinued
prior to delivery to avoid intracranial bleeding in the
newborn (substituted with heparin).
ACE-inhibitor: angiotensin-converting enzyme inhibitor; ARB: angiotensin receptor blocker; LoE: level of evidence; DS-
TB: drug-sensitive tuberculosis; RHZE: rifampicin/isoniazid/pyrazinamide/ethambutol; CNS: central nervous system

xi Methotrexate: Kozlowski RD, Steinbrunner JV, MacKenzie AH, Clough JD, Wilke WS, Segal AM. Outcome of first-
trimester exposure to low-dose methotrexate in eight patients with rheumatic disease. Am J Med. 1990
Jun;88(6):589–92. https://www.ncbi.nlm.nih.gov/pubmed/2189302
xii Contraceptive agents and sex steroids (progesterone): Raman-Wilms L, Tseng AL, Wighardt S, Einarson TR, Koren G.
Fetal genital effects of first-trimester sex hormone exposure: a meta-analysis. Obstet Gynecol. 1995 Jan;85(1):141–9.
xiii Prednisone: Park-Wyllie L, Mazzotta P, Pastuszak A, Moretti ME, Beique L, Hunnisett L, et al. Birth defects after
maternal exposure to corticosteroids: prospective cohort study and meta-analysis of epidemiological studies. Teratology.
2000 Dec;62(6):385–92. https://www.ncbi.nlm.nih.gov/pubmed/11091360
xiv Retinoids: Heckel S, Favre R, Weber P, Dellenbach P. [Teratogenicity of retinoids. A case and review of the literature].
J Gynecol Obstet Biol Reprod (Paris). 1993;22(1):43-7.https://www.ncbi.nlm.nih.gov/pubmed/8463566

Retinoids: Jick SS, Terris BZ, Jick H. First trimester topical tretinoin and congenital disorders. Lancet. 1993 May
xv Tetracycline (e.g. docycycline): Wormser GP, Wormser RP, Strle F, Myers R, Cunha BA. How safe is doxycycline for
young children or for pregnant or breastfeeding women? Diagn Microbiol Infect Dis. 2019 Mar;93(3):238–42.
xvi Warfarin: Steinberg ZL, Dominguez-Islas CP, Otto CM, Stout KK, Krieger EV. Maternal and Fetal Outcomes of
Anticoagulation in Pregnant Women With Mechanical Heart Valves. J Am Coll Cardiol. 2017 Jun 6;69(22):2681–91.
2019 AIII.3
APPENDIX IV EXTEMPORANEOUS PREPARATIONS
EXTEMPORANEOUS COMPOUNDING
Compounding is the process where a pharmacist or other registered person

prepares, mixes, combines, packages or labels a medicine for an individual
patient.
Medicines compounded, or prepared “extemporaneously”, are unlicensed

medicines and not subject to Medicines Regulatory Authority oversight. Thus,
assumptions cannot be made regarding quality and stability of these
compounded products relative to licensed medicines.
In terms of Section 22C(5) of the Medicines and Related Substances Act, 1965
(Act No. 101 of 1965), “No person shall compound or dispense a medicine
unless he or she is authorised thereto in terms of the Pharmacy Act, 1974, is a
veterinarian or is the holder of a licence as contemplated in subsection (1) (a).”
This license may be granted by the Director-General to a medical practitioner,
dentist, practitioner, veterinarian, nurse or other person registered under the
Health Professions Act, 1974 (Act No. 56 of 1974).
Pharmacists or other registered persons should only engage in

extemporaneous preparation when all routes of timely procurement have been
exhausted (medicine cannot be sourced locally or globally; suitable therapeutic
alternatives are not available or the medicine is not available from an authorised
specialised compounding facility), or if the appropriate formulation or strength
of the medicine is no readily available.
Extemporaneous preparations should be compounded by a pharmacist or other

registered person in accordance with the Medicines and Related Substances
Act, 1965 (Act No. 101 of 1965), as amended (adhering to minimum standards
relating to premises, facilities and equipment) and at a facility that is licenced
according to the Pharmacy Act.
Section 3 of the General Regulations to the Medicines and Related Substances

Act, 2017, provides the conditions for compounding a medicine. In terms of
Section 3(1) of the Regulations:
“A pharmacist or other person licensed in terms of section 22C(1)(a) of the Act
to compound a medicine for sale in terms of section 14(4) of the Act, shall only
compound a quantity that is intended to be used by a patient for no more than
30 consecutive days from the date of compounding: Provided that the date of
compounding and the statement “Use within 30 days” are clearly indicated on
the label.”
Standard operating procedures will assist to minimise risk regarding calculation

errors, inappropriate validation of the preparation, microbial contamination,
stability and storage of the compounded product, labelling errors, patient
2019 AIV.1
acceptability and the health and safety of personnel involved in compounding –
appropriately aligned with Good Pharmacy Practice regulations.
Labelling should contain batch number, date of preparation, expiry date, the
statement “Use within 30 days”, and all relevant labelling specific to the
preparation. Relevant record-keeping should be maintained.
Standardised formulas have been provided for the following essential

medicines that have supply constraints:
MORPHINE, ORAL SOLUTION

 Morphine, oral solution:
o 1 mg/mL (0.1%)
o 5 mg/mL (0.5%)
o 20 mg/mL (2%)
Declaration:
Active ingredient: Morphine hydrochloride/sulphate 1 mg/mL; 5 mg/mL; 20
mg/mL
Dosage form: Oral solution
Excipients: Benzoic acid, propylene glycol, sorbitol, purified water
Formula:
1 mg/mL 5 mg/mL 20 mg/mL
Morphine hydrochloride/sulphate 50 g 250 g 1000 g
Benzoic acid solution 5%* 100 mL 100 mL 100 mL
Sorbitol 70% 1500 mL 1500 mL 1500 mL
Sterile water, add to 5000 mL 5000 mL 5000 mL
(Smaller volumes can be formulated - calculate proportions).
Preparation:
Dissolve the morphine in approximately 2000 mL of the purified water. Dissolve
the benzoic acid solution 5% in this solution. Add the 70% sorbitol solution and
a sufficient quantity of purified water to a volume of 5000 ml and mix well.
Quality requirements
Identity: as stated under the section "Declaration", above.
Content of morphine hydrochloride: 90–110% of the declared amount,
calculated as the pure substance.
pH: ≤ 4
Appearance: The solution is clear and almost free of visible particles.
Storage: Glass amber bottle, below 25 °C with an expiry date of 1 month.
2019 AIV.2
*To make the benzoic acid 5% solution: Dissolve the benzoic acid in the
propylene glycol, adding the hot purified water to a volume of 1000 mL.
Benzoic acid 50 g
Propylene glycol 750 mL
o
Sterile water, heated to ±60 C, add to 1000 mL
Storage: Glass amber bottle, below 25 °C with an expiry date of 1 month.
Note: Commercial preparation of methyl parahydroxybenzoate, propyl

hydroxybenzoate, alcohol and purified wateri could be considered as the diluent
for morphine, oral solution, if available.
PODOPHYLLIN, TOPICAL SOLUTION

 Podophyllin 20% in compound benzoin tincture BP, 100 mL.
Active ingredient: Podophyllin 200 mg/mL

Dosage form: Topical solution
Excipients: Compound Benzoin Tincture BP
Formula
Podophyllin resin BP 20 g
Compound benzoin tincture BP, add to 100 mL
Preparation
1. Weigh out the podophyllin resin, and place in 100 mL amber glass bottle
(previously dried out with a few drops of 70% alcohol).
2. Add compound benzoin tincture to 100 mL and mix well.
3. Decant 10 mL in an amber glass bottle for a treatment course and label
appropriately.
Storage: Glass amber bottle, below 25 °C with an expiry date of 6 months.
Quality requirements
Identity: as stated under the section "Declaration", above.
Content of podophyllin: 90–110% of the declared amount, calculated as the
pure substance.
Appearance: The solution is clear and almost free of visible particles.
Label: Appropriately labelled for external use only.

i
Commercial preparation formulated in accordance with the World Health Organisation. Model formulary: Morphine
formulations on the Essential Medicines List for Children.
http://www.who.int/selection_medicines/committees/expert/19/applications/Morphine_2_2_C_NF.pdf
2019 AIV.3
APPENDIX V ASTHMA MONITORING
PEAK EXPIRATORY FLOW RATES
Peak expiratory flow in normal adult subjects
Adapted with permission from

Nunn AJ Gregg I, Br Med J 1989:298;1068-70
and Clement Clarke International.
2019 AV.1
CALCULATING % PREDICTED PEAK FLOW RATE
 Take the best of 3 of the patient’s observed peak flow rate:

e.g. 200, 180, 190 performed – so take 200.
 Find the patient’s sex, age and height predicted value from the nomogram.
e.g. 440 for a woman of age 25 years and height 167 cm
 Divide patient’s observed peak flow rate over their predicted peak flow rate:
e.g. 200/440 = 0.45
 Multiply by 100:
e.g. 0.45X100 = 45%
So, in this example, the patient’s observed peak flow rate is 45% of predicted.
CALCULATING PEAK FLOW VARIABILITY
There are a number of methods for calculating PEF variability.
One method is described below:

 Subtract the lowest from the highest reading.
 Divide by the highest reading.
 Multiply by 100.
So, in this example, where a patient has readings of 300 to 400, the variability is
25%. If these readings were taken before and after a test dose of salbutamol,
asthma is diagnosed. (See sections 16.1 Asthma, acute and 16.2 Asthma,
chronic persistent).
2019 AV.2
ASTHMA CONTROL TEST™

This is a validated measure of clinical asthma control that can be completed by
the patient (after initial instruction) at each visit to the clinic prior to consultation.
A value of ≥19 suggests adequate asthma control.
Online version of the test is accessible at: https://www.asthmacontroltest.com/
Reference: Nathan RA, Sorkness CA, Kosinski M, Schatz M, Li JT, Marcus P,

Murray JJ, Pendergraft TB. Development of the asthma control test: a survey
for assessing asthma control. J Allergy Clin Immunol. 2004 Jan;113(1):59-65.
2019 AV.3
GUIDELINES FOR THE MOTIVATION OF A NEW MEDICINE
ON THE NATIONAL ESSENTIAL MEDICINES LIST
Section 1: Medication details

» Generic name.
A fundamental principle of the Essential Drug Programme is that of generic
prescribing. Most clinical trails are conducted using the generic name.
» Proposed indication.
» There will usually be many registered indications for the medication. However,
this section should be limited to the main indication which is supported by the
evidence provided in section 2.
» Prevalence of the condition in South Africa
» This information is not always readily available. However, it is an important
consideration in the review of a proposed essential medicine.
» Prescriber level.
» Here the proposed prescriber level should be included. If more than one level
is proposed each relevant box should be ticked.
Section 2: Evidence and motivation

» Estimated benefit:
 Effect measure: this is the clinical outcome that was reported in the clinical
trial such as BP, FEV, CD4, VL etc.
 Risk benefit: this should reported in the clinical trial and, in most cases,
includes the 95% confidence level (95% CI). Absolute risk reduction, also
termed risk difference, is the difference between the absolute risk of an
event in the intervention group and the absolute risk in the control group.
 Number Need to Treat (NNT): gives the number of patients who need to be
treated for a certain period of time to prevent one event. It is the recipr ocal
of the absolute risk or can be calculated using the formula below.
Calculations
Bad outcome Good outcome Total patients
Intervention group a c a+c
Control group b d b+d
Measure Equation
Absolute risk: [b/(b+d)] – [a/(a+c)]
1
Number needed to treat
[b/(b+d)] – [a/(a+c)]
Relative risk [a/(a+c)] ÷ [b/(b+d)]
Odds ratio [a/(a+c)] ÷ [c/(a+c)]

= (a/c) ÷ (b/d)
[b/(b+d)] ÷ [d/(b+d)]
Reference - Aust Prescr 2008;31:12–16)
xli
» Motivating information (Level of evidence based on the SORT system):
 The National Essential Medicine List Committee has endorsed the
adoption of the SORT system for categorising levels of evidence. This
system1 contains only three levels:
Level I Good quality evidence Systematic review of RCTs with
consistent findings
High quality individual RCT
Level II Limited quality patient Systematic review of lower quality
orientated evidence studies or studies with inconsistent
findings
Low quality clinical trial
Cohort studies
Case-control studies
Level III Other Consensus guidelines, extrapolations
from bench research, usual practice,
opinion, disease-oriented
evidence (intermediate or physiologic
outcomes only), or case series
A: Newer product: for most newer products, level 1 evidence such as high
quality systematic reviews or peer-reviewed high quality randomised
controlled trials should be identified and referenced in the space provided.
B: Older products: many of these products were developed prior to the wide
use of randomised controlled trials. However, there may be level 1 evidence
where the product was used as the control arm for a newer product. If no level
1 evidence can be identified, then level II data from poorer quality controlled
trials or high quality observational studies should be referenced in the space
provided.
» Cost considerations:
 Where a published reference supporting the review of cost is available
comments should be made regarding its applicability to the South African
public sector environment.
 Possible unpublished information that can be included:
o Cost per daily dose or course of therapy – for long term or chronic
therapy such as hypertension the usual daily dose should be
calculated (Dose x number of times a day) and converted into the
number of dosing units e.g. tablets. This is then used to calculate the
cost per day. For medications used in a course of therapy such as
antibiotics this is then multiplied by the number of days in the course
of therapy.
1
Ebell MH, Siwek J, Weiss BD, et al. Strength of recommendation taxonomy (SORT): a
patient-centered approach to grading evidence in the medical literature. Am Fam Physician.
2004;69:550-6.
xlii
o Cost minimisation is used where there is evidence to support
equivalence and aims to identify the least costly treatment by
identifying all the relevant costs associated with the treatment.
o Cost-effectiveness analysis is used to compare treatment
alternatives that differ in the degree of success in terms of the
therapeutic or clinical outcome. By calculating a summary
measurement of efficiency (a cost-effectiveness ratio), alternatives
with different costs, efficacy rates, and safety rates can be fairly
compared along a level playing field.
Where any of these have been performed tick the relevant block and send as an
attachment with all the calculations. If possible, the spread sheet should be
supplied electronically.
Section 3: Motivator’s Details

The receipt of all submission will be acknowledged. In addition, all decisions with
supporting arguments will be communicated where appropriate. This section
therefore forms a vital link between the motivator and the decision making
process.
xliii
Motivation form for the inclusion of a new
medication
on the National Essential Medicines List
Section 1: Medication details

Generic name (or International Non-proprietary Name):
Proposed indication:
Prevalence of condition (based on epidemiological data, if any):
Prescriber level
Primary Health Care Medical Officer Specialist Designated Specialist
1 2 3 4
Section 2: Evidence and motivation

2.1 Estimated benefit
Effect measure
Risk difference (95% CI)
NNT
2.2: Motivating information (Level of evidence based on the SORT system)
A. Newer product: High quality systematic reviews or peer-reviewed high quality randomised
controlled trials (Level I)
Author Title Journal ref
B. Older product with weaker evidence base: Poorer quality controlled trials or high quality
observational studies (Level II)
2.3: Cost-considerations
Have you worked up the cost? YES NO
Daily cost Cost minimisation Cost-effectiveness analysis
Other relevant cost information if available:
2.4: Additional motivating comments.
Section 3: Motivator’s Details

Name: Date submitted:
Qualification: Registration number:
PTC motivation: Y/N PTC Details:
PTC Chair: PTC Chair signature:
GUIDELINES FOR ADVERSE DRUG REACTION REPORTING
National Pharmacovigilance Programme

The South African Health Products Regulatory Authority (SAHPRA) has a responsibility
to ensure the safety, efficacy and quality of all medicines used by the South African
public. The National Pharmacovigilance Programme is coordinated by the SAHPRA
and has a dedicated Unit, The National Adverse Drug Event Monitoring Centre
(NADEMC), in Cape Town, which monitors the safety of all registered medicines in
South Africa.
What is Pharmacovigilance?
Pharmacovigilance is defined as the science and activities concerned with the
detection, assessment, understanding and prevention of adverse reactions to
medicines (i.e. adverse drug reactions or ADRs). The ultimate goal of this activity is to
improve the safe and rational use of medicines, thereby improving patient care and
public health.
What is an Adverse Drug Reaction (ADR)?

SAHPRA defines an Adverse Drug Reaction (ADR) as a response to a medicine which
is noxious and unintended, including lack of efficacy, and which occurs at any dosage
and can also result from overdose, misuse or abuse of a medicine.
Who should report Adverse Drug Reactions?

All health care workers, including doctors, dentists, pharmacists, nurses and other
health professionals are encouraged to report all suspected adverse reactions to
medicines (including vaccines, X-ray contrast media, traditional and herbal remedies),
especially when the reaction is not in the package insert, potentially serious or clinically
significant.
xlv
What happens to a report?
All ADR reports are entered into a national ADR database. Each report is evaluated to
assess the causal relationship between the event and the medicine. A well-completed
adverse drug reaction/product quality form submitted could result in any of the
following:
» additional investigations into the use of the medicine in South Africa;
» educational initiatives to improve the safe use of the medicine;
» appropriate package insert changes to include the potential for the reaction, and
» changes in the scheduling or manufacture of the medicine to make it safer.
The purpose of ADR reporting is to reduce the risks associated with the use of
medicines and to ultimately improve patient care.
Will reporting have any negative consequences on the health worker or the
patient?
An adverse drug reaction report does not constitute an admission of liability or that the
health professional contributed to the event in any way. The outcome of a report,
together with any important or relevant information relating to the reaction, will be sent
back to the reporter as appropriate. The details of a report are stored in a confidential
database. The names of the reporter or any other health professionals named on a
report and that of the patient will be removed before any details about a specific
adverse drug reaction are used or communicated to others. The information is only
meant to improve the understanding of the medicines used in the country.
Is the event possibly an ADR?

The following factors should be considered when an adverse drug reaction is
suspected:
1. What exactly is the nature of the reaction? (Describe the reaction as clearly as
possible and where possible provide an accurate diagnosis.)
2. Did the reaction occur within a reasonable time relationship to starting treatment
with the suspected medicine? (Some reactions occur immediately after
administration of a medicine while others take time to develop.)
xlvi
3. Is the reaction known to occur with the particular medicine as stated in the
package insert or other reference? (If the reaction is not documented in the
package insert, it does not mean that the reaction cannot occur with that particular
medicine.)
4. Did the patient recover when the suspected medicine was stopped? (Some
reactions can cause permanent damage, but most reactions are reversible if the
medication is stopped.)
5. Did the patient take the medicine again after the reaction abated (i.e. rechallenge).
If so, did the same reaction occur again? (In most situations it is not possible or
ethical to rechallenge the patient with the same medicine. If such information is
available or if such a rechallenge is necessary, recurrence of the event is a strong
indicator that the medicine may be responsible.)
6. Can this reaction be explained by other causes (e.g. underlying disease/s; other
medicine/s; toxins or foods)? (It is essential that the patient is thoroughly
investigated to decide what the actual cause of any new medical problem is. A
medicine-related cause should be considered, when other causes do not explain
the patient’s condition.)
What types of reactions should be reported?

The following adverse drug reactions should be reported:
 All ADRs to newly marketed drugs or new medicines added to the EML
 All serious reactions and interactions
 ADRs that are not clearly stated in the package insert.
 All adverse reactions or poisonings to traditional or herbal remedies
Report even if you are not certain that the medicine caused the event.
xlvii
What Product Quality Problems should be reported?
The following product quality problems should be reported:
 suspected contamination;
 questionable stability;
 defective components;
 poor packaging or labeling;
 therapeutic failures.
How can ADRs be prevented from occurring?

Some ADRs are unavoidable and cannot be prevented. However, most ADRs can be
prevented by following the basic principles of rational use of medicines.
How are adverse drug reactions reported?

An Adverse Drug Reaction/Product Quality Report Form is enclosed in this book and
should be completed in as much detail as possible before returning it by fax or post to
any of the addresses provided below. Additional forms can be obtained by contacting
the MCC at these addresses. Report forms may also be accessed via the following
website: https://www.sahpra.org.za/
1. The Registrar of Medicines

South African Health Products Regulatory Authority (SAHPRA), Private Bag X828
Pretoria, 0001
Tel: (021) 842 7609/10; E-mail: [email protected]
2. The National Adverse Drug Event Monitoring Centre (NADEMC)

C/o Division of Pharmacology, University of Cape Town,
Observatory, 7925
(021) 447 1618; Fax: (021) 448 6181
xlviii
ADVERSE DRUG REACTION (ADR)/PRODUCT QUALITY PROBLEM REPORT FORM
(PUBLIC AND PRIVATE SECTOR) (Including Herbal Products)
Reporting Health Care Facility/Practice
Tel: 012 842 7609/10 (SAHPRA) Facility/Practice

021 447 1618 (NADEMC)
District Tel
Fax: 021 448 6181
E-mail: [email protected] Province Fax
Patient Details
Patient
File/Reference Number Date of Birth/Age
Initials
Sex □ M □ F □ Unk Race Weight (kg) Height (cm) Pregnant? □N□Y
Allergies Estimated Gestational Age at time of reaction
Suspect Medicine(s) [Medicines suspected to have caused the ADR]
Trade Name [Generic Name if Dose (mg) and Date Reason for Batch Expiry
Route Date Stopped
Trade Name is unknown] Interval Started/Given use Number Date
All other Medicines Patient was taking at time of reaction [Including over-the-counter and herbal products]
Trade Name [Generic Name if Dose (mg) and Date Reason for Batch Expiry
Route Date Stopped
Trade Name is unknown] Interval Started/Given use Number Date
Adverse Drug Reaction/Product Quality Problem

Date and time of onset of reaction Date reaction resolved/duration
Please describe Adverse Reaction/Product Quality Problem: (kindly add as much clinical information as possible)
Intervention(tick all that apply) Patient Outcomes (tick all that apply)
□ No intervention □ ADR recovered/resolved□ recovering/resolving
□ Intervention unknown □ not recovered/not resolved
□ Patient Counselled/non-medical treatment □ Patient Died: Date of death: __________________________
□ Discontinued Suspect Drug; Replaced with: _________________ □ Impairment/Disability □ Congenital Anomaly
□ Decreased Suspect Drug Dosage; New Dose: ________________ □ Patient Hospitalised or Hospitalisation prolonged
□ Treated ADR - with: ____________________________________ □ Life Threatening □ Other: ___________________________
□ Referred to Hospital: Hospital Name______________________ □ ADR reappeared after restarting suspect drug/similar drug
□ Other Intervention (e.g. dialysis): _________________________ (rechallenge)?: □ N □ Y □ Not done □ Unknown
Laboratory Results Additional Laboratory Results

Lab Test Test Result Test Date Lab Test Test Result Test Date
Co-morbidities/Other Medical Condition(s)
Reported by
Name E-mail
Designation □ Nurse □ Pharmacist □ Doctor □ Other: Telephone
Date reported: Signature
THIS ADR REPORT IS NOT A CONFIRMATION THAT THE REPORTER OR THE SUSPECT MEDICINE(S) CAUSED THE ADR V5.0 05/19
ARF 1
ADVICE ABOUT VOLUNTARY REPORTING
Report adverse experiences with:  therapeutic failures

 medications (drugs, vaccines and biologicals)
 medical devices (including in-vitro diagnostics) Report even if:
 complementary / alternative medicines (including  you're not certain the product caused the event
traditional, herbal remedies, etc.)  you don't have all the details
Please report especially: Important numbers:

 adverse drug reactions to newly marketed products
 serious reactions and interactions with all products Investigational Products and Product Quality Problems:
 adverse drug reactions which are not clearly reflected in  phone: (012) 842-7609/10 or 082 256 2626/083 387 3358
the package insert.  email: [email protected]
Report Product Quality Problems such as: Adverse Events Following Immunisation:
 suspected contamination  phone: (012) 395 9461/063 6996 114
 questionable stability  email: [email protected]
 defective components
 poor packaging or labelling
Confidentiality: Identities of the reporter and patient will remain strictly confidential.
Your support of the South African Health Products Regulatory Authority’s adverse drug reaction monitoring
programme is much appreciated. Information supplied by you will contribute to the improvement of medicine safety
and therapy in South Africa.
6.04_ARF1_v5.1_27Jan2020 January 2020

DISEASE NOTIFICATION PROCEDURES
The disease reporting system in South Africa is based on government law (the Health Act,
Act No. 61 of 2003), together with regulations on the reporting of specific diseases to the
Local, Provincial and/or National Health Department.
Who should notify

The first health care professional to come into contact with a patient presenting with one of
the prescribed Notifiable Medical Conditions (NMCs) is required by law to notify. This may
include clinic personnel, infection control nurses, other hospital staff or private medical
practitioners. In the event of deaths (or cases) in the community, a member of the
community is obliged to notify the event.
Which diseases to notify

Currently 33 broad medical conditions are currently notifiable in South Africa (see List of
Notifiable Medical Condition). Some conditions (e.g. tuberculosis and viral hepatitis) have
been divided into various components, resulting in more than 40 notifiable medical
conditions.
Notifiable medical conditions have been sub-divided into two categories according to type
of disease:
Category 1 NMC: Requires immediate reporting by the most rapid means available upon
clinical or laboratory diagnosis followed by a written or electronic notification to the
Department of Health, within 24 hours of diagnosis by health care providers, private health
laboratories or public health laboratories.
Any health care professional identifying even a single case of a disease (presumptive or
laboratory confirmed) contained in the Category 1 should make an immediate notification
directly to the designated local health officer through fax or telephonically as rapidly as
possible (within 24 hours). The local health officer must report to the Provincial health
officer and/or to the National Department of Health. Where it is applicable, laboratory
confirmation should be obtained at the earliest opportunity and also reported to the
designated health office. After reporting through a telephone/fax, it is still required of the
health care provider to send a complete GW17/5 form to the designated local health
authority within five days after telephonic reporting.
Category 2 NMC: Requires reporting through a written or electronic notification to the

Department of Health, within 7 days of diagnosis by health care providers, private health
laboratories or public health laboratories.
The notification system is based on clinical notifications and, therefore, all suspected cases
of a notifiable condition must be notified immediately.
li
Reporting a Notifiable Disease during an outbreak
During an outbreak of a notifiable disease, report all cases by phone, email or fax. Daily
reporting by health facilities should be maintained through an Outbreak Case Line Listing
Form as well through the notification form (GW17/5) to the local health authority that must
report to the provincial health officials and the National Department of Health.
Priority Reporting of MDR & XDR-TB

Tuberculosis (TB) is one of 33 medical conditions, which is notifiable in terms of the
National Health Act (Act 61 of 2003). The Directorate: Epidemiology and Surveillance have
instituted a priority reporting for MDR and XDR TB. This means that all health care
facilities, public and private, including clinics, hospitals, laboratories, general practitioners
and private specialist doctors, are required to report all cases of MDR and XDR TB to the
Department of Health within 24 hours.
How to notify
The initial notification of a medical condition is done on a case-based form (GW 17/5) with
the relevant details by the health personnel e.g., clinic personnel, infection control nurses,
other hospital staff, public or private medical practitioners. Initial notification makes tracing
as easy as possible, since a disease notification demands action (follow-up) at the
peripheral level.
The GW17/5 form makes provision for the notification of cases as well as deaths. Any
person contracting a notifiable disease and then dies from the disease should be notified
twice: first as a “CASE” and then later as a “DEATH”. This will ensure that when
estimating the “Case Fatality Rate” (CFR%), all deaths in the numerator are also included
in the denominator. Depending on the structural organization of the province, the
completed GW 17/5 forms is sent to the relevant local health authority, district health office
or the provincial office.
Electronic reporting can also be done via the NMC mobile or web based APP.
National Department of Health

Cluster: Health Information, Evaluation & Research (HIER)
Directorate: Epidemiology & Surveillance
Private Bag X828
PRETORIA
0001
Tel: 012 395 8150/1
National NMC contact details:

Helpline: 072 621 3805
Fax no: 086 639 1638
Sms/whatsup line (for copy/photograph submissions): 072 621 3805
Email address: [email protected]
lii
List of Notifiable Medical Conditions
Category 1: Immediate notification (within 24 hours) of diagnosis
Acute flaccid paralysis
Acute rheumatic fever
Anthrax
Botulism
Cholera
Diphtheria
Food borne disease outbreak*
Haemolytic uraemic syndrome (HUS)
Listeriosis
Malaria
Measles
Meningococcal disease
Pertussis
Plague
Poliomyelitis
Rabies (human)
Respiratory disease caused by a novel respiratory pathogen**
Rift valley fever (human)
Smallpox
Viral haemorrhagic fever diseases***
Yellow fever
Category 2: Notification within seven days of diagnosis

Agricultural or stock remedy poisoning
Bilharzia (schistosomiasis)
Brucellosis
Congenital rubella syndrome
Congenital syphilis
Haemophilus influenzae type B
Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis E
Lead poisoning
Legionellosis
Leprosy
Maternal death (pregnancy, childbirth and puerperium)
Mercury poisoning
Soil transmitted helminths
Tetanus
Tuberculosis: pulmonary
Tuberculosis: extra-pulmonary
Tuberculosis: multidrug-resistant (MDR-TB)
Tuberculosis: extensively drug-resistant (XDR-TB)
liii
INDEX OF CONDITIONS
Abscess, Peritonsillar 17.6
Acid aspiration prophylaxis 12.13
Acne 4.1
Acquired coagulation defects 2.17
Acromegaly 8.1
Acute coronary syndromes 3.5; 20.7
Angina pectoris, stable 3.12
Atherosclerotic peripheral arterial disease 3.13
Chronic management of STEMI / NSTEMI / UA 3.11
Non-ST elevation myocardial infarction (NSTEMI) and Unstable angina (UA) 3.9
ST elevation myocardial infarction (STEMI) 3.5
Acute kidney injury (AKI) 7.8; 20.20
Adrenal insufficiency (addison disease) 8.1
Adult vaccination 9.7
Aggressive disruptive behaviour in adults 15.1
Alcohol 15.29
Alcohol withdrawal delirium (delirium tremens) 15.29
Amenorrhoea 5.6
Amoebic dysentery 1.19
Anaemia 2.1
Anaemia in pregnancy 6.1
Anaemia, aplastic 2.7
Anaemia, chronic disorder 2.5
Anaemia, haemolytic 2.5
Anaemia, iron deficiency 2.1
Anaemia, megaloblastic 2.3
Anaemia, sickle cell 2.7
Anaesthesia, epidural 12.15
Anaesthesia, general 12.1
Inhalation agents 12.2
Induction 12.2
Maintenance 12.2
Intravenous induction (and/or maintenance) agents 12.1
Anaesthesia, spinal (intrathecal) 12.13
Anaesthesia, topical 12.16
Anaesthetic-related acute hypertension 12.11
Anaesthetic-related acute hypotension 12.11
Analgesia for acute non-surgical pain 26.8
Acute pain due to gastrointestinal colic 26.8
Medical conditions with severe pain 26.8
Anaphylaxis/anaphylactic shock 20.8
Androgen deficiency 8.3
Angioedema 20.7
Anorexia and cachexia 24.1
Antimicrobial stewardship 9.1
Antimicrobial use in patients with head injuries 14.23
Antiretroviral therapy 10.1
Management of selected antiretroviral adverse drug reactions 10.9
Anxiety and obsessive-compulsive disorders 15.6; 24.4
Arthritis, rheumatoid (RA) 13.1
Arthritis, septic and osteomyelitis, acute 13.4
Asthma, acute 16.1; 20.7
Asthma, chronic persistent 16.3
Atopic eczema/ dermatitis 4.5
Bacterial peritonitis 1.20
Benign prostatic hyperplasia 7.19
Benzodiazepine withdrawal 15.34
liv

INDEX OF CONDITIONS

Bipolar and related disorders 15.14
Bites and stings 20.20
Bleeding disorders 2.11
Bowel preparations 1.1
Brain abscess 14.23
Bronchiectasis 16.6
Brucellosis 9.7
Bubo 25.5
Burns 20.20
Candidiasis of oesophagus/trachea/bronchi 10.18
Cannabis withdrawal 15.34
Cardiac arrest - cardiopulmonary resuscitation algorithm 20.1
Cardiac arrest in adults 20.2
Cardiac dysrhythmias 3.14; 20.6
Narrow QRS complex (supraventricular) tachydysrhythmias 3.14
Atrial fibrillation 3.15
Atrial flutter 3.18
AV junctional re-entry tachycardias 3.18
Wide QRS (ventricular) tachyarrhythmias 3.20
Regular wide QRS tachycardias 3.20
Non-sustained (<30 seconds) irregular wide QRS tachycardias 3.21
Sustained (>30 seconds) irregular wide QRS tachycardias 3.21
Torsades de pointes ventricular tachycardia (VT) 3.22
Cellulitis and erysipelas 4.2
Cerebral toxoplasmosis 10.26
Cerebrovascular disease 14.1
Cholecystitis, acute and cholangitis, acute 1.16
Cholera 1.16
Chorea 14.26
Chronic Kidney Disease (CKD) 7.1
Chronic obstructive pulmonary disease (COPD) 16.7
Clostridum difficle diarrhoea 1.18
Congestive cardiac failure (CCF) 3.24
Conjunctivitis 18.1
Conjunctivitis, Adenoviral 18.1
Conjunctivitis, Allergic 18.2
Conjunctivitis, Bacterial 18.2
Constipation 21.5; 21.8; 24.2
Cryptococcosis 10.19
Asymptomatic cryptococcosis, CrAg positive 10.19
Cryptococcal meningitis 10.21; 14.20
Cryptococcal meningitis, HIV-infected 10.21; 14.20
Cryptococcal meningitis, HIV-uninfected 14.20
Symptomatic, non-meningeal cryptococcosis (HIV-infected) 10.21
Cryptosporidiosis diarrhoea 10.22
Cushing syndrome 8.4
Cystitis 6.27
Cystoisosporiasis 10.24
Cytomegalovirus (CMV) 10.23
Dehydration/Ketosis in labour 6.24
Delirium 14.7; 24.6
Delirium with perceptual disturbances 20.10
Dementia 14.6
Depressive disorders (depression) 15.11; 21.8; 24.7
Diabetes mellitus 8.5
Diabetes mellitus in pregnancy 6.2
Type 1 diabetes mellitus 8.10
Type 2 diabetes mellitus 8.7
Diabetic emergencies 8.12; 20.11
lv

INDEX OF CONDITIONS

Diabetic ketoacidosis (DKA) and hyperosmolar hyper-glycaemic state (HHS) 8.14
Hypoglycaemia 8.12
Complications of diabetes 8.17
Diabetic foot ulcers 8.18
Diabetic kidney disease 8.18
Diabetic neuropathies 8.17
Diagnostic contrast agents and related substances 22.1
Diarrhoea 1.16; 21.4; 24.3
Diarrhoea, acute non-inflammatory 1.17
Discontinuation symptoms of serotonin reuptake inhibitors 15.27
Disseminated intravascular coagulation (DIC) 2.17
Diverticulosis 1.1
Dry eye 18.9
Dysentery (Acute inflammatory diarrhoea) 1.17
Dyslipidaemia (in diabetes) 8.19
Dysmenorrhoea 5.1
Eclampsia 6.10
Emerging respiratory Pathogens, e.g. Covi-19: Coronavirus-19 disease, Middle East Respiratory 9.7
Syndrome CoronaVirus infection (Mers CoV)
Empyema 16.16
Endocarditis, infective 3.27
Endometriosis 5.5
Endophthalmitis, Bacterial 18.2
Envenomation 19.1
Epiglottitis 17.1
Epilepsy 14.7
Erectile dysfunction 7.20
Erythema multiforme, stevens johnson syndrome, toxic epidermal necrolysis 4.7
Essential tremor 14.26
Eye injuries 20.24
Medical management of eye injury 18.9
Chemical burn 18.9
Eye injury: blunt/penetrating/foreign body 18.9
Family planning referrals from primary care 5.19
Intra-uterine contraceptive device 5.19
Implants 5.20
Injectable contraception 5.20
Fatigue (palliative care) 24.8
Febrile neutropaenia 2.9; 21.2
Fungal infections 4.12
Furuncles and abscesses 4.4
Gastrointestinal conditions 1.1; 24.1
Gastro-oesophageal reflux disease (GORD) 1.2
Genital ulcer syndrome (GUS) 25.3
Giardiasis 1.20
Glaucoma 18.3
Glomerular Disease and Nephritic Syndrome 7.6
Gout 13.7
Graves’ hyperthyroidism 8.32
Headache and facial pain syndromes 14.14
Cluster headache 14.15
Idiopathic intracranial hypertension (pseudotumour cerebri) 14.16
Medication overuse headache 14.16
Migraine 14.14
Tension headache 14.15
Haematuria 7.15
Haemophilia A and B, von willebrand’s disease 2.11
Haemorrhagic fever syndrome 9.9
Healthcare-associated and hospital acquired infections 9.1
lvi

INDEX OF CONDITIONS

Hospital-acquired pneumonia (HAP) 9.4
Intravascular catheter infections 9.2
Surgical wound infections 9.3
Urinary tract infections, catheter associated 9.6
Heart block (second or third degree) 3.23
Heart disease in pregnancy 6.5
Hepatic disorders 1.7
Hepatitis B in pregnancy 6.16
Hepatitis B, acute 1.12
Hepatitis B, chronic (HIV coinfection) 1.15
Hepatitis B, chronic (non-HIV coinfection) 1.13
Hepatitis, non-viral 1.8
Hepatitis, viral 1.11
Herpes zoster (shingles) 4.14; 9.17
Herpes zoster, ophthalmicus 18.5
Hiatus hernia 1.4
Hirsutism and virilisation 5.6
HIV and kidney disease 10.27
HIV in pregnancy 6.12
Hydatid disease 9.10
Hypercalcaemia, including primary hyperparathyroidism 8.21
Hyperemesis gravidarum 6.18
Hyperkalaemia 7.10
Hypernatraemia 7.11
Hypertension 3.31
Chronic hypertension (obstetrics) 6.11
Hypertension, asymptomatic severe 3.37
Hypertensive crisis, hypertensive emergency 3.38
Hypertensive disorders in pregnancy 6.7
Hypertensive urgency 3.37
Hyperthyroidism 8.32
Hyperviscosity and leucostatic syndromes 21.2
Hypocalcaemia 8.22
Hypokalaemia 7.10
Hyponatraemia 7.12
Hypothyroidism 8.23
Immune reconstitution inflammatory syndrome (IRIS) 10.16
Immune thrombocytopenia (ITP) 2.15
Impetigo 4.3
Infectious and parasitic conditions (neurological) 14.17
Infertility 5.7
Inflammatory bowel disease 1.4
Insect bites and stings 19.1
Insomnia 15.26
Intensive care 12.16
Intravenous fluids 12.9
Crystalloids 12.9
Ischaemic heart disease and atherosclerosis, prevention 3.1
Jaundice in pregnancy 6.17
Kaposi Sarcoma (KS) 10.28
Keratitis 18.6
Keratitis, herpes simplex 18.6
Keratitis, suppurative 18.6
Labour induction 6.21
Labour pain, severe 6.23
Leg ulcers, complicated 4.9
Liver abscess, amoebic 1.15
Liver abscess, pyogenic 1.15
Liver failure, acute 1.9
lvii

INDEX OF CONDITIONS

Local anaesthetic toxicity 12.10
Lung abscess 16.12
Major electrolyte abnormalities 7.10
Malaria 9.10
Malaria, severe 9.11
Malaria, uncomplicated 9.10
Male urethritis syndrome (MUS) 25.1
Malignant hyperthermia 12.10
Mastoiditis 17.5
Medical emergencies 20.7
Medical management of ectopic pregnancy 5.18
Medicines to treat complications of anaesthesia 12.10
Meningitis 14.17
Meningovascular syphilis (neurosyphilis) 14.22
Menopause and perimenopausal syndrome 5.16
Mental health conditions 15.1
Methaqualone (mandrax/whitepipe) withdrawal 15.34
Miscarriage 5.7
Incomplete miscarriage in the first trimester 5.8
Midtrimester miscarriage (from 13–22 weeks gestation) 5.8
Septic miscarriage 5.9
Silent miscarriage or early fetal death 5.8
Trophoblastic neoplasia (hydatidiform mole) 5.10
Mood disorders 15.11
Movement disorders 14.24
Multiple sclerosis 14.27
Muscle relaxants 12.3
Depolarising muscle relaxants 12.3
Muscle relaxation for rapid sequence intubation 12.4
Medicines to reverse muscle relaxation 12.4
Non-depolarising muscle relaxants (NDMR) 12.3
Myasthenia gravis 14.27
Mycobacteriosis – disseminated non-tuberculous 10.24
Myelodysplastic syndromes 2.10
Myelopathy, acute 14.27
Nausea and vomiting 21.8; 24.3
Nephrology disorders 7.1
Nephrotic syndrome 7.7
Neurocysticercosis 14.23
Neuropsychiatric conditions 24.4
Nutritional support 12.16
Oedema, cerebral 14.27
Brain oedema due to traumatic injury 14.28
Brain oedema due to tumours and inflammation 14.28
Oncological emergencies 21.1
Metabolic emergencies 21.1
Hypercalcemia of malignancy 21.1
Syndrome of inappropriate antidiuretic hormone (SIADH) 21.1
Tumour lysis syndrome 21.1
Haematologic emergencies 21.2
Febrile neutropaenia 2.9; 21.2
Hyperviscosity and leucostatic syndromes 21.2
Structural emergencies 21.3
Epidural spinal cord compression 21.3
Malignant pericardial effusion 21.3
Superior vena cava syndrome 21.4
Opiate (e.g. heroin, unga, whoonga, nyaope) withdrawal 15.31
Oppurtunistic diseases (in HIV) 10.17
Opportunistic infection prophylaxis, with cotrimoxazole 10.18
lviii

INDEX OF CONDITIONS

Oral analgesics 12.5
Osteoarthritis 13.6
Osteomalacia/rickets 8.26
Osteoporosis 8.24
Otitis externa 17.5
Otitis media, acute 17.3
Otitis media, chronic, suppurative 17.4
Overactive bladder 7.20
Paget’s disease 8.26
Pain, chronic 12.16; 24.8; 26.1
Analgesia for chronic cancer pain 26.5
Analgesia for chronic non-cancer pain 26.1
Chronic cancer pain 24.8
Neuropathic pain (Neuropathy) 14.26; 24.9; 26.6
Treatment of adverse effects of chronic opioid use 26.5
Trigeminal neuralgia 14.15
Palliative care 24.1
End of life care 24.11
Pancreatitis, acute 1.4
Pancreatitis, chronic 1.5
Papular urticaria 4.12
Parkinsonism, primary 14.24
Idiopathic parkinson disease 14.24
Parkinsonism, secondary 14.25
Pelvic inflammatory disease (PID) 5.3
Peptic ulcer 1.6
Perioperative analgesia 12.5
Examples of ward prescriptions for postoperative analgesia according to anticipated pain severity 12.7
Intravenous analgesics 12.6
Perioperative analgesics 12.5
Peripheral nerve block or wound infiltration 12.15
Phaeochromocytoma 8.30
Pituitary disorders 8.26
Anterior hypopituitarism 8.27
Diabetes insipidus (posteriorhypopituitarism) 8.28
Prolactinoma 8.26
Pneumocystis pneumonia 10.25
Pneumonia, aspiration 16.15
Pneumonia, community acquired 16.13
Poisoning 19.10
Poisons information centres 19.1
Alcohols (poisonings) 19.29
Ethanol poisoning 19.29
Ethylene glycol poisoning 19.30
Methanol poisoning 19.31
Analgesic poisoning 19.14
Opioid poisoning 19.18
Paracetamol poisoning 19.14
Salicylate poisoning 19.17
Anticoagulant (warfarin and rodenticide superwarfarin) poisoning 19.35
Antidepressant poisoning 19.19
Tricyclic antidepressant poisoning 19.19
Antiretroviral agents poisoning 19.26
Calcium channel blocker and beta blocker poisoning 19.24
Carbon monoxide poisoning 19.37
Cotrimoxazole poisoning 19.25
Exposure to poisonous substances 20.24
Heavy metal poisoning 19.38
Hydrocarbon poisoning 19.28
lix

INDEX OF CONDITIONS

Illicit drugs 19.26
Amphetamine derivatives poisoning 19.27
Cocaine poisoning 19.26
Ingestion of caustic substances 19.29
Iron poisoning 19.20
Isoniazid poisoning 19.23
Pesticides and rodenticides 19.32
Amitraz poisoning 19.32
Organophosphate poisoning 19.33
Paraquat poisoning 19.35
Poisoning with substances that cause methaemoglobinaemia 19.39
Sedative hypnotic poisoning 19.22
Benzodiazepine poisoning 19.22
Lithium poisoning 19.22
Theophylline poisoning 19.21
Portal hypertension and cirrhosis 1.10
Post cardiac arrest care 20.4
Post-exposure prophylaxis 10.29; 20.24
Post-exposure prophylaxis, occupational 10.29
Non occupational post exposure prophylaxis, inadvertent non-occupational 10.33
Non occupational post exposure prophylaxis, sexual assault 10.32
Postoperative analgesia ward prescriptions 12.7
Postoperative nausea and vomiting (PONV) 12.11
Prevention of PONV 12.11
Treatment of PONV 12.12
Postoperative pain in the recovery room 12.6
Postpartum fever 6.24
Postpartum haemhorrhage 6.25
Premedication 12.1
Preterm labour (PTL) and preterm prelabour rupture of membranes (PPROM) 6.18
Prevention of preterm labour (singleton pregnancies only) 6.20
Primary aldosteronism 8.31
Prostatitis 7.19
Psoriasis 4.10
Psychotic disorders 15.21
Acute and transient psychotic disorders 15.22
Schizophrenia spectrum disorders 15.22
Pulmonary oedema, acute 20.11
Pyelonephritis, acute 6.28
Rabies vaccination 9.7
Recurrent UTI 7.18
Renal calculi 7.21
Renal replacement therapy 7.9
Respiratory conditions (palliative care) 24.9
Dyspnoea 24.9
Respiratory secretions 24.9
Retinitis, HIV CMV 18.7
Rheumatic heart disease 3.39
Rhinitis, Allergic, persistent 17.1
Schistomiasis 9.12
Scorpion envenomation 19.6
Sedation 12.16; 23.1
Procedural sedation and analgesia 23.1
Sedation in intensive care 23.4
Sedation in palliative care 23.5; 24.10
Seronegative spondylarthritis 13.10
Arthritis, reactive 13.11
Sexual assault 5.14
Shock 20.13
lx

INDEX OF CONDITIONS

Cardiogenic shock 20.18
Distributive shock 20.15
Hypovolaemic shock 20.13
Massive transfusion 20.14
Neurogenic shock 20.16
Non-trauma-related hypovolaemic shock 20.13
Obstructive shock 20.18
Septic shock 20.17
Trauma-related hypovolaemic shock 20.13
Side effects from oncology treatment agents 21.4
Extravasations 21.5
Side-effects from pain medication 21.8
Side-effects from radiation and chemotherapy 21.5
Radiation and chemotherapy related mucositis 21.5
Radiation or chemotherapy induced cystitis 21.8
Radiation or chemotherapy induced pneumonitis 21.7
Radiation proctitis 21.7
Wet desquamation of skin 21.6
Single toxic nodules 8.33
Sinus arrest 3.24
Sinus bradycardia 3.24
Sinusitis, bacterial, complicated 17.2
Snakebites 19.2
Boomslang snakebite 19.5
Cytotoxic and neurotoxic snakebite 19.3
Snake venom in the eye 19.6
Soft tissue injuries 20.24
Spider envenomation 19.8
Spinal cord injury, acute 14.5
Anticoagulants and spinal or epidural blocks 12.14
Sprains and strains 20.24
Status epilepticus 14.12; 20.19
Stimulant withdrawal, including cocaine and amphetamine type stimulants (e.g.methamphetamine/ 15.34
tik, methcathinone/cat)
Stress incontinence 5.15
Stroke 14.1
Subarachnoid haemorrhage 14.5
Substance misuse 15.28
Suppression of labour for fetal distress 6.21
Surgical and diagnostic products 18.8
Surgical antibiotic prophylaxis 11.3
Dosage reccomendations 11.2
General principles 11.1
Process measures 11.5
Special considerations 11.5
Syphilis 6.15
Systemic lupus erythematosus (SLE) 13.11
Termination of pregnancy (TOP) 5.10
TOP: From the thirteenth week (12 weeks and 1 day) up to the twentieth week (19 weeks and 6 days) 5.13
TOP: Management for pregnancies ≤14 weeks of gestation 5.11
Tetanus 9.13
The Rhesus negative woman 6.26
Thrombotic thrombocytopenic purpura-haemolytic uraemic syndrome (TTP-HUS) 2.16
Thyroid crisis 8.34
Thyroiditis 8.34
Tick bite fever 9.15
Toxic multinodular goiter 8.33
Transient ischaemic attack (TIA) 14.3
Trauma and injuries 20.20
lxi

INDEX OF CONDITIONS

Trauma and stress-related disorders 15.20
Tuberculosis
Drug-resistant TB 16.19
Isoniazid monoresistant TB 16.19
Multidrug-resistant TB 16.20
Tuberculosis preventive therapy (TPT) 10.17
Tuberculosis, pleural (TB pleurisy) 16.18
Tuberculosis, pulmonary 16.17
Tuberculous meningitis 14.19
Typhoid 1.20
Typhoid fever (enteric fever) 9.15
Urgency incontinence (overactive bladder) 5.16
Urinary incontinence 5.15
Urinary tract infection (UTI) 7.16
Urinary tract infection (UTI) in pregnancy 6.27
Urological disorders 7.15
Urticaria 4.11
Uterine bleeding, abnormal 5.1
Uveitis 18.7
Vaginal discharge syndrome (VDS) 25.2
Varicella (chickenpox), complicated 9.16
Venous thrombo-embolism 2.18
Vertigo, acute 17.7
Viral infections (dermatological) 4.13
Viral meningoencephalitis 14.21
Viral warts/anogenital warts 4.13

lxii

INDEX OF MEDICINES
Abacavir/lamivudine, oral 10.3, 10.4, 10.5, 10.10
ACE-inhibitor, oral 1.11, 3.8, 3.9, 3.11, 3.25, 3.26, 3.34, 3.35, 3.36,
3.37, 3.38,3.39, 6.11, 7.3, 7.7, 8.6, 8.10,15.16,
20.7, 20.8,
Acetazolamide, oral 14.17, 18.5
Acetic acid, topical 17.5
Acetylcholine chloride intra-ocular irrigation 18.8
Aciclovir, ophthalmic drops 18.6
Aciclovir, oral 4.6, 9.17, 9.18,18.5,18.6, 25.5
Aciclovir, parenteral 4.7, 9.17, 14.21
Activated charcoal, oral 19.13, 19.15, 19.17, 19.21, 19.25, 19.33, 19.34,
19.35
Adenosine, parenteral 3.19
Adrenaline (epinephrine), nebulisation 17.1
Adrenaline (epinephrine), parenteral 3.23, 12.10, 19.4, 20.1, 20.3, 20.4, 20.5, 20.6,
20.8, 20.9, 20.16, 20.17, 22.1
Albendazole, oral 9.10, 14.24
Albumin, parenteral 1.11
Alendronic acid, oral 8.25
Alfacalcidol, oral 8.23
Alfentanil, parenteral 12.11
Allopurinol, oral 13.9, 21.2
Alpha blocker, oral 7.20, 8.30
Alpha-agonist/sympathomimetic, ophthalmic 18.4
drops
Alteplase, parenteral 3.6, 14.1
Aluminium hydroxide BP, oral 7.5
Amikacin, parenteral 2.10, 9.5, 9.6, 10.14
Amiodarone, oral 3.17, 3.20, 3.21
Amiodarone, parenteral 3.20, 3.21, 20.1, 20.3
Amitriptyline, oral 9.18, 13.3, 13.7, 14.14, 14.16, 15.13, 18.6, 21.7,
24.7, 24.8, 26.7
Amlodipine, oral 3.13, 3.35, 3.38, 3.37, 6.8, 7.7, 8.31, 13.12, 14.3
Amoxicillin, oral 1.7, 3.30, 6.19, 16.10, 16.4, 17.3
Amoxicillin/clavulanic acid, oral 1.2, 1.15, 1.16, 1.20, 4.10, 5.4, 5.9, 5.10, 6.25,
6.28, 8.18, 16.6, 16.10, 16.12, 16.14, 16.15,
16.16, 17.1, 17.3, 17.7, 19.3
Amoxicillin/clavulanic acid, parenteral 1.2, 1.5, 1.15, 1.16, 1.20, 4.10, 5.10, 6.25, 8.18,
16.12, 16.15, 16.16, 17.6, 17.3,17.7,19.3
Amphotericin B, parenteral 2.10, 9.3, 10.21, 10.22, 14.20
Ampicillin, parenteral 3.31, 14.19, 16.14
Angiotensin receptor blocker (ARB), oral 3.9, 3.11, 3.26, 3.35, 3.39, 7.3, 8.10
Anti-allergic, ophthalmic drops 18.2
Anticholinergic agents, oral 14.25, 15.25, 24.4
Anticholinergic agents, parenteral 12.13, 14.25
Antithrombotic agent (including LMWH), 2.8, 2.19, 2.20, 6.6, 8.16
parenteral
Anti-D immunoglobulin, parenteral 5.9, 5.13, 6.26, 6.27
Antiviral, (active against herpes simplex), oral 25.4
Antiviral, (active against herpes zoster), oral 9.17
Antiviral, (active against varicella zoster), oral 9.17
Aqueous cream, topical 4.5
Artemether/lumefantrine, oral 9.11
Artesunate, parenteral 9.11
Aspirin, oral 3.5, 3.10, 3.12, 3.14, 6.9, 8.21, 13.13, 14.2, 14.4
Atazanavir, oral 3.5, 10.4, 10.6, 10.30
Atenolol, oral 3.8, 3.10, 3.12, 3.16, 3.17, 3.19, 3.34, 3.36,
3.38. 8.32, 8.34
lxiii

INDEX OF MEDICINES
Atorvastatin, oral 3.4, 3.5, 3.8, 3.11, 3.13, 3.14, 8.20, 10.10, 14.2,
14.4
Atropine, parenteral 3.23, 12.4, 19.25, 19.34
Atropine, ophthalmic drops 18.8
Azathioprine, oral 1.9, 13.12, 14.27
Azithromycin, oral 1.7, 3.40, 4.2, 4.3, 5.4, 5.5, 5.15, 6.19, 7.19,
9.15, 10.25, 10.33, 13.5, 13.11, 16.6,
16.10,17.1, 17.3, 25.2, 25.3
Azithromycin, parenteral 11.2, 11.4, 16.14
Balanced solution, parenteral 12.10, 20.17
Beclomethasone, inhaler 16.2, 16.4, 16.5, 16.11
Beclomethasone, nasal 17.2
Benzathine benzylpenicillin, parenteral 3.39, 3.40, 6.15, 6.16, 25.4
Benzylpenicillin (Penicillin G), parenteral 3.28, 3.29, 6.16, 9.14, 14.19, 14.23
Benzodiazepine, oral, 15.4, 15.8, 15.34, 24.5
Benzodiazepine, parenteral 14.12, 15.30, 20.10
Β-blocker, oral 3.36, 8.32, 8.34
Betamethasone, oral 8.4, 14.28
Betamethasone, parenteral 6.18, 14.28
Betamethasone, topical 4.6, 4.11, 4.12
Betaxolol, ophthalmic drops 18.4
Bezafibrate, oral 8.21, 10.10
Bimatoprost, ophthalmic drops 18.4
Biperiden, parenteral 12.13, 14.25
Bisacodyl, per rectum 24.3
Bisphosphonate, oral 8.25
Bisphosphonate, parenteral 8.22
Boomslang monovalent antivenom 19.2, 19.5
Brimonidine, ophthalmic drops 18.4
Bromocriptine, oral 8.27
Budesonide, inhaler 16.2, 16.4, 16.5
Bupivacaine, parenteral 12.15
Bupivacaine (spinal), parenteral 12.13, 12.15
Bupivacaine with dextrose (spinal), parenteral 12.13, 12.14
Calcitriol, oral 7.5
Calcium (carbonate), oral 6.9, 7.5
Calcium channel blocker, oral 3.12, 3.35, 3,36, 3.37, 3.38, 8.30, 14.3
Calcium gluconate, parenteral 1.5, 6.10, 7.9, 8.23, 19.8, 19.9, 19.25
Carbamazepine, oral 14.9, 26.7
Carbidopa/levodopa, oral 14.25
Carbimazole, oral 8.32, 8.34
Cardio-selective b-blocker, oral 3.8, 3.10, 3.12, 3.19
Carvedilol, oral 3.16, 3.17, 3.26, 3.36
Cefalexin, oral 4.2
Cefazolin, parenteral 3.28, 3.30, 4.2, 4.4, 9.4, 11.2, 11.3,13.5
Cefepime, parenteral 2.10, 9.5
Ceftazidime, parenteral 18.3
Ceftriaxone, parenteral 1.17, 1.20, 2.9, 5.4, 5.15, 6.28, 7.18, 7.19, 9.4,
9.5, 9.16, 10.33, 13.5, 13.11, 14.18, 14.19,
14.23, 16.6, 16.14, 17.1, 17.3, 17.5, 18.2, 20.17,
25.2, 25.3
Cetirizine, oral 4.12, 17.2, 17.4, 20.8, 20.10
Chloramphenicol, ophthalmic drops 11.5
Chloramphenicol, ophthalmic ointment 18.2, 19.6
Chlorhexidine, topical 20.23
Chlorhexidine (aqueous solution), topical 19.3
Chloroquine sulphate, oral 113.1, 3.2, 13.12
Chlorphenamine, oral 4.6, 4.12
Chlorpromazine, oral 15.24
lxiv

INDEX OF MEDICINES
Ciprofloxacin, ophthalmic drops 17.5, 18.2, 18.6

Ciprofloxacin, oral 1.16, 1.17, 1.20, 5.5, 5.10, 7.17, 7.18, 7.19, 9.6,
9.16, 10.24, 14.18, 16.7, 17.6, 18.3
Ciprofloxacin, parenteral 9.15
Cisatracurium, parenteral 12.3
Citalopram, oral 5,18, 15.7, 15.10, 15.13, 15.21, 24.6, 24.8
Clindamycin, oral 3.31, 4.3, 4.4, 4.6, 5.5, 5.10. 8.18, 9.2, 9.4,
10.26, 13.5, 17.7, 21.5
Clindamycin, parenteral 3.31, 4.3, 4.4, 5.4, 5.10, 9.4, 11.2, 11.5, 13.5,
17.7
Clomifene, oral 5.7
Clonazepam, oral 15.4, 15.5, 15.20, 20.10
Clonazepam, parenteral 6.11, 14.12, 15.4, 15.5, 15.30, 19.24, 20.10
Clopidogrel, oral 3.5, 3.10
Clotrimazole, topical 4.13
Clozapine, oral 15.18, 15.19, 15.24, 15.25
Coal tar, topical 4.10
Colchicine, oral 13.9
Combined oral contraceptive (monophasic) - 5.1, 5.2, 5.5, 6.4
low to moderate VTE risk
Combined oral contraceptive (monophasic) - 5.20
50mcg ethinyl estradiol
Combined oral contraceptive (triphasic) - low 5.1, 5.2, 5.5, 6.4
to moderate VTE risk
Conjugated estrogens 5.2, 5.17
Corticosteroid (Glucocorticoids), inhaler 16.2, 16.4
Corticosteroid - intermediate-acting, oral 1.8, 8.3, 8.22, 8.34, 9.13, 10.16, 10.26, 13.2,
13.8, 13.12, 14.15, 14.20, 14.24, 16.1, 16.2,
16.5, 16.9, 16.10, 16.11, 17.2, 21.7, 22.1, 24.2,
24.8
Corticosteroid, intra-articular (Glucocorticoid), 2.16, 13.4, 13.7
parenteral
Corticosteroid, nasal spray 17.2
Corticosteroid, ophthalmic drops 18.8
Cotrimoxazole, oral 7.18, 10.9, 10.18, 10.24, 10.25, 10.26, 10.27,
10.28
Cotrimoxazole, parenteral 10.25
Cryoprecipitate, parenteral 2.18
Cu T 380A, per vagina 5.14, 6.4
Cyclopentolate, ophthalmic drops 18.8
Cyclopentolate/phenylephrine, ophthalmic 18.8
drops
Cyclophosphamide, oral 13.12
Cyproterone acetate/ethinyl estradiol, oral 4.1
Dantrolene, parenteral 12.10
Deferoxamine, parenteral 19.21
Desmopressin, nasal 8.29
Desmopressin, oral 8.29
Desmopressin, parenteral 8.29
Dexamethasone, oral 8.4
Dexamethasone, parenteral 6.18, 6.19, 12.12, 14.20, 14.28, 21.3
Dexamethasone, ophthalmic drops 18.8
Dextrose, parenteral 2.10, 6.4, 7.9, 7.12, 8.2, 8.13, 8.15, 8.23, 9.11,
10.21, 10.22, 19.5, 19.7, 19.9, 19.16, 19.17,
19.25, 19.30, 20.5, 20.13, 20.18
Diazepam, oral 15.4, 15.8, 15.29, 15.20, 15.29, 15.30, 15.32,
15.34, 15.35, 20.10, 24.5
Diazepam, parenteral 6.11, 9.14, 12.10, 12.13, 14.13, 15.30, 19.24,
19.35, 20.10, 23.3
lxv

INDEX OF MEDICINES
Diclofenac, parenteral 7.22, 12.7, 12.9

Digoxin, oral 3.16, 3.17, 3.26
Dinoprostone, per vagina 6.21, 6.22
Dobutamine, parenteral 19.25, 20.13, 20.18
Dolutegravir, oral (not as part of FDC) 6.13, 10.3, 10.4, 10.6, 10.7, 10.8
Doxazosin, oral 8.30
Doxycycline, oral 9.7, 9.15, 16.10, 25.6
Echinocandin, parenteral 9.3
Efavirenz, oral 6.14, 10.3, 10.6, 10.7
Emulsifying ointment, topical 4.5, 4.6
Enalapril, oral 3.8, 3.11, 3.25, 3.35, 3.37, 3.39, 7.3
Enoxaparin, parenteral 2.8, 2.19, 2.20, 3.7, 3.10, 6.6, 6.7, 8.16
Ephedrine, parenteral 12.11
Ergometrine, parenteral 6.26
Ertapenem, parenteral 9.4
Erythropoietin, parenteral 7.5
Estradiol valerate, oral 5.17
Estradiol valerate /cyproterone acetate, oral 5.17
Estradiol/norethisterone acetate, oral 5.17
Ethambutol, oral 10.14, 10.25, 16.18, 16.20
Ethanol, oral 19.30, 19.31
Ethinylestradiol, oral 5.20
Etomidate, parenteral 12.2, 23.2, 23.3
Factor IX, parenteral 2.14
Factor VIII, parenteral 2.13, 2.14
Fenoterol ,nebulisation 16.9
Fentanyl, parenteral 12.6, 12.13, 12.14, 23.3, 23.5
Ferrous fumarate, oral 2.2, 6,1, 7.5
Ferrous sulfate compound BPC (dried), oral 2.1, 2.2, 6.1, 7.5
Fibrate, oral 8.21
Flucloxacillin, oral 4.2, 4.3, 4.4, 4.6, 9.4, 9.18, 13.5
Fluconazole, oral 4.13, 9.3, 10.18, 10.19, 10.21, 10.22, 14.21
Fluconazole, parenteral 10.18
Fludrocortisone, oral 8.3
Fluoroquinolone, ophthalmic drops 18.2, 18.6
Fluorescein, ophthalmic drops 18.8
Fluorescein, ophthalmic strips 18.8
Fluoxetine, oral 5.17, 15.7, 15,13, 15.21, 24.6
Flupenthixol decanoate, parenteral 15.24
Fluticasone, nasal 17.2
Folic acid, oral 2.4, 2.6, 2.8, 13.2, 14.11
Formoterol, inhaler 16.5, 16.10, 16.11
Fosfomycin, oral 6.27, 7.16, 7.17
Fresh frozen plasma (FFP), parenteral 1.8, 1,9, 2.14, 2.17, 2.18, 19.36, 20.8, 20.15
Furosemide, oral 1.10, 3.25, 3.26, 3.36, 3.38, 7.4, 7.7, 7.8, 7.13,
14.17
Furosemide, parenteral 3.39, 6.7, 7.7, 20.12
Ganciclovir, parenteral 10.23, 10.24, 18.7
Gentamicin, parenteral 2.9, 3.28, 3.29, 3.30, 5.5, 5.10, 6.28, 7.16, 7.17,
8.18, 9.7, 11.2, 11.5, 14.19, 25.2, 25.3
Glibenclamide, oral 8.8
Glimepiride, oral 8.8
Glycerine (glycerol), oral 18.5
Glycerine (glycerol), per rectum 24.3
Glyceryl trinitrate, parenteral 3.7, 3.10. 3.39, 20.12
Glycopyrrolate, parenteral 12.5
Haemophilus influenza type B, vaccine 11.5
Haloperidol, oral 14.6, 14.26, 15.24, 15.31, 23.5, 24.4, 24.7,
24.11
lxvi

INDEX OF MEDICINES
Haloperidol, parenteral 15.5, 15.31, 20.10, 24.4, 24.7

Halothane, gas 12.2
Hepatitis B immunoglobulin, parenteral 1.12, 10.31
Hepatitis B vaccine, parenteral 1.12, 9.6, 10.31
HMG CoA reductase inhibitor, oral 3.4, 3.8, 3.11, 3.13, 3.14, 8.20, 8.21, 14.2, 14.4
Homatropine, ophthalmic drops 18.8
Hydralazine, oral 6.7
Hydrochlorothiazide, oral 3.25, 3.34, 3.35, 3.36, 7.7, 14.3
Hydrocortisone, oral 8.2
Hydrocortisone, parenteral 8.2, 8.3, 8.34, 16.2, 16.10, 17.1, 20.8, 20.9
Hydrocortisone, topical 4.6, 4.11
Hydroxypropyl methylcellulose, ophthalmic 18.8, 18.9
drops
Hydroxyurea, oral 2.9
Hyoscine butylbromide, oral 15.32, 26.8
Hyoscine butylbromide, parenteral 24.10, 26.8
Ibuprofen, oral 3.40, 4.2, 5.1, 5.2, 5.3, 5.5, 5.12, 5.13, 5.20,
6.24, 7.22, 8.26, 8.34, 10.16, 12.5, 12.8, 12.9,
13.3, 13.5, 13.6, 13.8, 13.9, 13.10, 13.12, 14.14,
14.18, 14.22, 15.32, 17.7, 23.4, 26.2
Imidazole, topical 4.13
Imipenem/cilastin, parenteral 2.10, 9.5
Indomethacin, oral 6.18
Inhaled corticosteroids 16.2
Insulin, biphasic, parenteral 6,3, 6.4, 8.9, 8.11, 8.15
Insulin, short acting (soluble), parenteral 6.3, 6.4, 7.9, 8.11, 8.16, 19.25
Insulin, intermediate acting, parenteral 6.3, 8.9, 8.11
Intermediate-acting neuromuscular blocking 12.3
agents, parenteral
Iohexol, parenteral 22.1
Iopamidol, parenteral 22.1
Iopromide, parenteral 22.1
Ioversol, parenteral 22.1
Ipratropium bromide, nebulisation 16.1, 16.9, 20.9
Iron sucrose, parenteral 2.3, 6.2
Isoflurane, gas 12.2
Isoniazid, oral 10.14, 10.17, 16.18
Isosorbide dinitrate, sublingual 3.7, 3.10, 3.12, 20.12
Isosorbide dinitrate, oral 3.13, 6.7
Isosorbide mononitrate, oral 3.13
Ketamine, parenteral 12.2, 12.6, 23.2, 23.3
Labetalol, parenteral 3.39, 6.9, 12.11
Lactulose, oral 1.9, 1.11, 7.9, 24.3, 26.5
Lamotrigine, oral 10.8, 14.9, 14.10, 14.11, 15.18, 15.19
Lanolin, ophthalmic ointment 18.9
Lansoprazole, oral 1.3, 1.7, 13.3, 13.6, 13.8, 13.10, 13.11, 13.12,
26.3
Letrozole, oral 5.7
Levofloxacin, oral 10.14, 16.20
Levonorgestrel (emergency contraception), 5.14, 10.32
oral
Levothyroxine, oral 8.24
Lidocaine, parenteral 3.22, 5.12, 6.24, 12.15, 19.8
Lidocaine, topical jelly 12.16
Lidocaine, topical spray 12.16
Lidocaine with adrenaline, parenteral 12.15
Lidocaine without adrenaline (epinephrine), 3.39, 3.40, 5.4, 5.15, 6.15, 10.33, 13.11. 25.2,
parenteral 25.3, 25.4
Lidocaine/prilocaine, topical 12.16
lxvii

INDEX OF MEDICINES
Lipase, oral 1.6

Lipid emulsion, parenteral 12.10
Lithium, oral 15.16, 15.18, 15.19
Local anaesthetics, ophthalmic drops 18.8, 19.6
Long acting β2-agonist (LABA),inhaler 16.10
Long-acting β2-agonist/corticosteroid 16.4, 16.10
combination (LABA/ICS), inhaler
Loperamide, oral 1.18, 10.23, 15.32
Lopinavir/ritonavir, oral 6.14, 10.3, 10.4, 10.5, 10.6, 10.30
Lorazepam, oral 12.1, 15.4, 15.18, 20.10, 24.5, 24.7, 24.10
Lorazepam, parenteral 6.11, 14.12, 15.4, 15.30, 19.24, 20.10, 23.5
Losartan, oral 3.9, 3.11, 3.26, 3.35, 3.36, 3.39, 7.3
Low molecular weight iron dextran, parenteral 2.3
Lugols iodine, oral 8.34
Lyophilised plasma (FDP), parenteral 1.8, 2.14, 2.17, 2.18, 19.36, 20.8, 20.15
Macrolide, oral 3.40,17.1, 17.3
Magnesium sulfate, parenteral 1.5, 6.10, 12.11, 16.2
Mannitol, parenteral 14.28, 18.5
Medroxyprogesterone acetate, oral 5.2, 5.5, 5.6, 5.17
Medroxyprogesterone acetate (long-acting), 5.1
parenteral
Meningococcal polysaccharide vaccine 11.5
(ACW135Y)
Meropenem, parenteral 2.10, 9.5, 14.18, 14.19
Metformin, oral 6.3, 8.8, 10,8
Methadone, oral 15.33
Methotrexate, oral 13.2
Methotrexate, parenteral 5.19
Methyldopa, oral 6.8
Methylene blue, parenteral 19.39
Methylprednisolone acetate ,parenteral 2.16, 13.4, 13.7
Metoclopramide, oral 1.12, 5.14, 6.18, 8.17, 10.33, 14.14, 19.21, 21.7,
24.2, 24.4, 26.5
Metoclopramide, parenteral 1.12, 6.18, 7.22, 12.13, 14.14, 19.21, 21.7, 24.4,
26.5
Metronidazole, oral 1.7, 1.15, 1.18, 1.19, 1.20, 5.4, 5.15, 6.19, 10.3,
14.23, 25.3
Metronidazole, parenteral 1.19, 5.4, 9.4, 9.14, 11.2, 11.3, 11.4
Midazolam (parenteral formulation), buccal 14.12, 15.4, 19.24
Midazolam, oral 12.1, 15.4
Midazolam, parenteral 3.18, 3.20, 3.21, 14.12, 14.13, 15.4, 19.24, 23.3,
23.5, 24.7, 24.11
Mifepristone, oral 5.12, 5.13
Misoprostol (oral formulation), buccal 5.8, 5.9, 5.13
Misoprostol, oral 5.8, 6.22
Misoprostol (oral formulation), per rectum 6.26
Misoprostol (oral formulation), per vagina 5.8, 5.9, 5.11, 5.12, 5.13, 6.26
Misoprostol (oral formulation), sublingual 5.8, 5.9, 5.12, 5.13, 6.26
Morphine, parenteral 1.4, 3.8, 3.10, 3.23, 5.9, 5.11, 5.13, 6.23, 6.24,
7.22, 9.14, 12.6, 12.7, 12.9, 14.5, 14.21, 19.3,
20.13, 20.22, 23.3, 23.5
Morphine syrup ,oral 24.9, 26.4, 26.5
Morphine, long-acting, oral 26.4, 26.5
Moxifloxacin, oral 9.5, 10.14, 16.7, 16.12, 16.14, 16.15, 16.16
Moxifloxacin, parenteral 9.5, 16.7, 16.12, 16.15, 16.16
N-acetylcysteine, oral 19.17
N-acetylcysteine, parenteral 19.16
Naloxone, parenteral 19.18, 23.4
Natamycin, ophthalmic drops 18.7
lxviii

INDEX OF MEDICINES
Neostigmine, parenteral 12.4

Nevirapine, oral 6.14, 10.6
Nicotinamide, oral 14.7
Nifedipine, oral 6.8, 6.18
Nimodipine, oral 14.5
Nitrates, short acting, sublingual 3.7, 3.10, 3.12, 20.12
Nitrofurantoin, oral 6.27, 7.17
Nitrous oxide, gas 6.23, 23.2, 23.3
Non-sedating antihistamine, oral 17.2, 17.4
Non-selective β-blocker, ophthalmic drops 18.4
Norethisterone, oral 5.2
NSAID, oral 3.40, 4.2, 5.1, 5.2, 5.3, 5.5, 5.12, 5.13, 5.20,
6.24, 7.22, 8.26, 8.34, 10.16, 12.5, 12.8, 12.9,
13.3, 13.5, 13.6, 13.8, 13.9, 13.10, 13.11, 13.12,
14.14, 14.18, 14.21, 15.32, 17.7, 23.4, 26.2
Olanzapine, oral 15.18, 15.19, 15.24
Omeprazole, oral 1.3
Ondansetron, oral 26.5
Ondansetron, parenteral 6.18, 12.12
Oral rehydration solution (ORS) 1.16, 1.17, 1.18, 1.19, 4.8, 10.22, 10.24, 20.22
Organic nitrates, oral 3.13
Orphenadrine, oral 14.25, 15.25, 24.4
Oxazepam, oral 15.27
Oxybuprocaine hydrochloride 0.4%, ophthalmic 18.8
drops
Oxybutynin, oral 7.20
Oxygen, gas 2.8, 3.5, 3.10, 6.10, 6.23, 7.6, 10.25, 12.10,
14.8, 14.12, 14.15, 15.5, 16.1, 16.9, 16.13,
17.1, 19.38, 19.39, 20.1, 20.3, 20.9, 20.11,
20.14, 20.16, 20.17, 20.18, 21.4, 22.1, 23.3,
24.9
Oxymetazoline, nasal 17.2
Oxymetazoline, ophthalmic drops 18.1
Oxytocin, parenteral 5.9, 6.9, 6.22, 6.23, 6.25, 6.26
Oxytocin/ergometrine, parenteral 6.26
Paracetamol, oral 4.2,5.1, 5.12, 5.13, 6.24, 9.14, 9.18, 10.16, 12.5,
12.7, 12.8, 12.9, 13.3, 13.5, 13.6, 13.12, 14.5,
14.14, 14.18, 14.21, 15.32, 17.3, 17.4, 17.5,
19.2, 19.3, 19.7, 19.9, 20.6, 20.23, 23.4, 26.2,
26.3
Parenteral iron 2.3, 6.2, 7.5
Parenteral nutrition, combinations (standard bag) 12.16
Pethidine, parenteral 6.23, 6.24
Petroleum jelly 4.14, 21.6
Phenoxymethylpenicillin, oral 3.39, 3.40, 6.15
Phenylephrine, parenteral 12.11
Phenytoin, oral 14.9, 14.11, 14.12, 14.13
Phenytoin, parenteral 14.11, 14.13
Phosphate enema 7.9
Pilocarpine, ophthalmic drops 18.4
Piperacillin/tazobactam, parenteral 2.10, 9.4, 9.5
Platelets 2.16, 20.15
Podophyllotoxin, topical 4.14
Polyacrylic acid, ophthalmic gel 18.8
Polyethylene glycol (PEG)/sodium sulfate, oral 1.1, 19.13, 19.17
Polyvalent pneumococcal vaccine 11.5
Polyvalent snake antivenom 19.2, 19.3, 19.5
Potassium chloride, oral 7.10
Potassium chloride, parenteral 6.4, 7.10, 8.15, 19.22
lxix

INDEX OF MEDICINES
Potent topical corticosteroid 4.6, 4.11, 4.12

Povidone-iodine, topical 4.10
Praziquantel, oral 7.15, 9.13
Prednisone, oral 1.8, 2.6, 2.15, 4.6, 8.3, 8.22, 8.34, 9.13, 10.17,
10.26, 13.2, 13.8, 13.12, 14.15, 14.20, 14.24,
16.1, 16.2, 16.5, 16.9, 16.10, 16.11, 17.2, 21.2,
21.7, 22.1, 24.2, 24.8
Primaquine, oral 10.26
Procaine penicillin, parenteral 6.16
Progesterone, per vagina 6.20
Progestin only pills (monophasic) - low VTE risk 6.4
Promethazine, oral 17.8, 26.5
Promethazine, parenteral 12.12, 12.13, 14.26, 15.5, 20.8, 20.9, 24.4
Propofol, parenteral 12.2, 14.13, 23.2, 23.3, 23.4, 23.5
Propranolol, oral 1.11, 14.15, 14.26, 15.26
Prostaglandin analogue, ophthalmic drops 18.4
Prostaglandins, per vagina 6.21
Proton pump inhibitor (PPI) - high dose, oral 1.7, 24.8, 26.3, 26.5
Proton pump inhibitor (PPI) - low dose, oral 1.3
Proton pump inhibitor (PPI) - standard dose, 1.3, 1.7, 13.3, 13.6, 13.8, 13.10, 13.11, 13.12,
oral 26.3
Pyrazinamide, oral 10.14, 16.18, 16.20
Pyridostigmine, oral 14.27
Pyridoxine, oral 6.18, 10.17, 16.18, 19.24, 19.31, 26.7
Quetiapine, oral 15.17, 15.18, 15.19
Quinine, parenteral 9.11
Radioactive iodine, parenteral 8.33
Red blood cells 2.6, 20.15
Rifabutin, oral 10.8
Rifampicin, oral 3.28, 9.7, 10.7, 10.8, 10.14, 16.18, 16.19
Rifampicin/isoniazid ,oral 16.18
Rifampicin/isoniazid/pyrazinamide/ethambutol, 16.18, 16.20
oral
Ringer Lactate, parenteral 12.10, 20.17
Risperidone, oral 15.18, 15.24
Ritonavir, oral 3.5, 10.4, 10.6, 10.30
Rocuronium, parenteral 12.4
Salbutamol, inhaler 16.2, 16.4, 16.10, 16.11
Salbutamol, nebulisation 7.9, 16.1, 16.9, 20.9
Salbutamol, parenteral 6.21
Salbutamol/ipratropium bromide, nebulisation 16.1, 20.9
Salmeterol/fluticasone, inhaler 16.4, 16.10
Scorpion antivenom 19.7
Selenium sulfide, parenteral 4.13
Sennosides A and B, oral 24.3, 26.5
Serotonin (5HT3) antagonist, parenteral 12.12
Sevoflurane, gas 12.2
Short acting β2 agonist (SABA), inhaler 16.4, 16.10, 16.11
Short-acting benzodiazepines, oral 15.27
Simvastatin, oral 3.4, 3.8, 3.11, 3.13, 3.14, 8.20, 8.21, 14.2, 14.4
Sodium bicarbonate, parenteral 19.17, 19.19, 19.31
Sodium chloride, irrigation 4.10, 18.1, 19.6, 20.23
Sodium chloride, nebulisation 7.9, 16.18, 17.1
Sodium chloride, parenteral 1.5, 2.3, 3.6, 3.19, 5.9, 6.2, 6.9, 6.10, 6.18, 6.21,
6.22, 6.23, 6.24, 6.26, 6.28, 7.10, 7.13, 7.14, 8.2,
8.14, 8.15, 8.16, 8.22, 8.23, 12.6, 12.9, 14.11,
14.13, 16.2, 19.5, 19.7, 19.9, 19.25, 19.37, 20.3,
20.4, 20.6, 20.9, 20.13, 20.14, 20.16, 20.17, 20.18,
20.22, 21.2, 21.4
lxx

INDEX OF MEDICINES
Sodium citrate, oral 12.13

Sodium hyaluronate, parenteral 18.8
Sodium polystyrene sulfonate, oral 7.9
Sodium polystyrene sulfonate, per rectum 7.9
Spider antivenom 19.9
Spironolactone, oral 1.10, 3.26, 3,36, 3.38, 8.31
SSRI, oral 15.7, 15.10, 15.13, 15.21, 24.6, 24.8
Sterile intraocular irrigating solution 18.8
Sterile water, parenteral 4.10, 18.1, 19.11, 20.3, 20.4
Streptokinase, parenteral 3.6
Sulfasalazine, oral 13.1, 13.2
Sulfonylureas, oral 8.8
Suxamethonium, parenteral 12.3
Tamsulosin, oral 7.20
Tenofovir, oral 1.14, 10.5
Tenofovir/emtricitabine, oral 6.14, 10.3, 10.4, 10.5, 10.30
Tenofovir/emtricitabine/efavirenz, oral 6.13, 6.14, 10.2, 10.3, 10.5
Tenofovir/lamivudine, oral 10.3, 10.4
Tenofovir/lamivudine/dolutegravir, oral 6.13, 6.14, 10.2, 10.3, 10.4, 10.5, 10.30
Testosterone cypionate, parenteral 7.21, 8.4, 8.28
Tetanus immunoglobulin, parenteral 9.14, 19.3, 19.7, 19.9
Tetanus toxoid, vaccine 9.7, 9.14, 19.3, 19.7, 19.9, 20.3
Tetracaine, ophthalmic drops 19.6
Theophylline, oral 16.11
Thiamine, oral 1.8, 3.27, 14.7, 15.6, 15.29, 15.31, 19.31
Thiamine, parenteral 3.27, 14.7, 15.31, 19.30
Thiopental, parenteral 12.2, 14.13
Timolol ,ophthalmic drops 18.4, 18.5
Tramadol, oral 9.18, 12.5, 12.8, 12.9, 14.18, 15.33, 26.3
Tramadol, parenteral 7.22, 12.7
Tranexamic acid, oral 2.14, 5.2, 5.20
Tranexamic acid, parenteral 6.26, 20.15
Tropicamide, ophthalmic drops 18.8
Unfractionated heparin, parenteral 2.8, 2.20, 3.10, 6.6, 6.7, 8.17
Valganciclovir, oral 10.23, 10.24, 18.7
Valproate (valproic acid), oral 10.8, 14.9, 14.10, 15.18, 15.19
Vancomycin, parenteral 1.18, 1.19, 2.10, 3.28, 3.29, 3.30, 9.3, 9.4, 18.3
Varicella-zoster immunoglobulin ,parenteral 9.17
Vecuronium, parenteral 12.3
Verapamil, oral 3.16, 3.17, 3.19, 14.15
Vitamin B complex, parenteral 6.18
Vitamin B12, parenteral 2.4
Vitamin D (Calciferol), oral 7.5, 8.25, 13.12
Vitamin K, oral 19.36, 19.37
Vitamin K, parenteral 19.37
Von Willebrand factor VIII concentrate, parenteral 2.14
Warfarin, oral 2.21, 3.16, 6.6, 13.13, 14.4, 19.37
Water for injection, parenteral 3.39, 3.40, 12.10
Zidovudine/lamivudine, oral 10.3, 10.4, 10.5, 10.30
Zoledronic acid, parenteral 8.22
Zuclopenthixol acetate, parenteral 15.5
Zuclopenthixol decanoate, parenteral 15.24
Italics indicates a therapeutic class. Therapeutic classes are designated in the “Medicine
treatment” sections of the STGs which provide classes of medicines followed by an example of
each class. Additional medicines in the class that has been reviewed and approved by NEMLC is
listed in the Therapeutic Interchange database – available on the National Department of Health
website at: http://www.health.gov.za/index.php/standard-treatment-guidelines-and-essential-
medicines-list/category/286-hospital-level-adults
lxxi

ABBREVIATIONS
3TC lamivudine M molar
ab antibody m2 square metre
ABC abacavir MAC minimum alveolar concentration
ACE-inhibitor angiotensin converting enzyme MAP mean arterial pressure
inhibitor
ACR albumin creatinine ratio mcg microgram
ACTH adrenocorticotropic hormone MCH mean corpuscular haemoglobin
ADH antidiuretic hormone MCV mean corpuscular volume
ADR adverse drug reaction MDEA 3,4-methylenedioxy-N-ethylamphetamine
(“Ice”, “Eve”)
AED automated external defribillator MDI metered dose inhaler
AIDP acute inflammatory MDMA 3,4-methylenedioxymethamphetamine
demyelinating (“Ecstacy”)
polyradiculoneuropathy
AIDS Acquired Immune Deficiency MDR-TB multi-drug resistant tuberculosis
Syndrome
AKI acute kidney injury MERS Middle East Respiratory Syndrome
ALP alkaline phosphatase MERS-CoV Middle East Respiratory Syndrome
Coronavirus
ALT alanine aminotransferase mg milligram
AMH anti-mullerian hormone MHCA Mental Health Care Act No. 17 of 2002
aPTT activated partial thromboplastin MHCU mental health care user
time
ARB Angiotensin receptor blocker MI myocardial infarction
ART antiretroviral therapy MIC Minimum Inhibitory Concentration
AST aspartate aminotransferase mL millilitre
ATV/r atazanavir/ritonavir mm3 Cubic millimetre
AUB abnormal uterine bleeding mmHg Millimeters mercury
AV atrioventricular mmol millimole
AZT zidovudine mOsm milliosmole
β-hCG beta human chorionic MRI magnetic resonance imaging
gonadotropin
β-blocker beta-receptor blocker MRSA Methicillin reistant Staphyloccal aureus
β2-agonist beta2-receptor blocker MTB Mycobacterium tuberculosis
BD bipolar disorder MU million units
BMI body mass index MUS male urethritis syndrome
BP blood pressure MVA manual vacuum aspiration
BPRS Brief Psychiatric Rating Scale Na sodium
bpm beats per minute NAC N-acetylcysteine
BSA body surface area NaCl sodium chloride
Ca calcium NCD non-communicable disease
CAB (sequence) circulation airway breathing NDMR non-depolarising muscle relaxant
(sequence)
CCF congestive cardiac failure NEMLC National Essential Medicines List Committee
CD crohn's disease NERD non-erosive reflux disease
CD4 cluster of differentiation 4 (T- ng nanogram
cells)
CHC community health centre NGO non-government organisation
CHD coronary heart disease NGT nasogastric tube
CIDP chronic inflammatory NHLS National Helath Laboratory Services
demyelinating
polyradiculoneuropathy
CIN contrast induced nephrotoxicity NICD National Institute of Communicable Diseases
CKD chronic kidney disease NICE National Institute for Health and Care
Excellence
cm centimetre NMA normetanephrine
CMV cytomegalovirus nmol nanomole
CNS cental nervous system NRTI nucleoside reverse transcriptase inhibitor
lxxii

ABBREVIATIONS

COPD chronic obstructive pulmonary NNT number needed to treat
disease
CPAP continuous positive airway NPH insulin Neutral Protamine Hagedorn insulin
pressure
CPR Cardio-pulmonary resuscitation NRS numeric rating scale
CrAg cryptococcal antigen NSAID(s) non-steroidal anti-inflammatory drug(s)
CrCl creatinine clearance NSTEMI non-stress test
CRP c-reactive protein NSTEMI non-ST elevation myocardial infarction
CSF cerevrospinal fluid NTD neurotubular defect
CT computerized tomography NVP nevirapine
CTG cardiotocography NYHA New York Heart Association (functional
classification)
CVD cardiovascular disease OOWS objective opioid withdrawal scale
CXR chest x-ray ORS oral rehydration solution
DBP diastolic blood pressure OT occupational therapy
DC direct current PaCO2 partial pressure of carbon dioxide in arterial
blood
DILI drug-induced liver injury PaO2 partial pressure of oxygen in arterial blood
DIC disseminated intravascular PAIR percutaneous aspiration injection of
coagulation helminthicidal agent and re-aspiration
dL decilitre PANSS Positive and Negative Syndrome Scale
DKA diabetic ketoacidosis PCA patient controlled analgesia
DMARD disease-modifying anti- PCI percutaneous coronary intervention
rheumatic drug
DNA deoxyribonucleic acid PCR protein creatinine ratio/polymerase chain
reaction
DTG dolutegravir PCV13 polyvalent conjugated vaccine (13-valent)
DU duodenal ulcer PEA pulseless electrical activity;
DVT deep venous thrombosis PEF peak expiratory flow
EC emergency contraception PEG polyethylene glycol
ECG electrocardiogram PEG (scale) pain, enjoyment and general activity (scale)
ECT electroconvulsive therapy PEP post exposure prophylaxis
EEG electroencephalogram pH acidity (partial pressure of hydrogen)
EFV efavirenz PHC primary health care
EFW estimated fetal weight PI protease inhibitor
e.g. example PID pelvic inflammatory disease
eGFR estimated Glomerular Filtration PLHIV people living with HIV
Rate
ELISA enzyme-linked immunosorbent PMTCT prevention of mother to child transmission
assay
E or EMB ethambutoal PO4 phosphate
EML essential medicines list PONV postoperative nausea and vomiting
EPI expanded programme on PPG post prandial plasma glucose
immunisation
EPO erythropoietin PPH post-partum haemorrhage
ESR erythrocyte sedimenattion rate PPI proton pump inhibitor
ESRD end-stage renal disease PPROM preterm prelabour rupture of membranes
FAMSA Families South Africa PROM prelabour rupture of membranes at term
FBC full blood count PPS23 pneumococcal polysaccharide vaccine (23-
valent)
FDC fixed dose combination PT Prothrombin time
FEV1 forced expiratory volume in 1 PTH parathyroid hormone
second
FFP fresh frozen plasma PTL preterm labour
FH familial hyperlipidaemia PTT prolonged partial thromboplastin time
FiO2 fraction of inspired oxygen PV per vagina (vaginal route)
FPG fasting plasma glucose PZA or Z pyrazinamide
FSH follicle stimulating hormone RA rheumatoid arthritis
FTA-ABS fluorescent treponemal antibody RAAS Renin-angiotensin-aldosterone system
lxxiii

ABBREVIATIONS

absorption
FTC emtricitabine RAL raltegravir
FVC forced vital capacity R or RIF rifampicin
g gram RBC red blood cell
G6PD glucose-6-phosphate Rh Rhesus
dehydrogenase
GDM gestational diabetes mellitus RH rifampicin/isoniazid combination
GGT gamma-glutamyl transferase RHZE rifampicin/isoniazid/pyrazinamide/ethambutol
combination
GI(T) gastrointestinal (tract) RNA rheumatoid factor
GORD gastro-oesophageal reflux RPR rapid plasma reagin
disease
GU gastric ulcer RRT renal replacement therapy
GUS genital ulcer syndrome RSTI repeated supratherapeutic ingestion
H or INH isoniazid RUT rapid urease test
Ham-D Hamilton Depression Rating SABA short-acting beta2 agonist
Scale
HAP hospital-acquired pneumonia SANCA South African Nursing Council
Hb haemoglobin SAPS South African Police Services
HbA1c haemoglobin A1c SBGM self-blood glucose monitoring
HBeAg hepatitis B e antigen SBP systolic blood pressure
HBIG hepatits B immunoglobulin SC subcutaneous
HbS sickle haemoglobin SIADH syndrome of inappropriate antidiuretic
hormone (SIADH)
HBsAb hepatitis B surface antibody SJS Stevens-Johnson Syndrome
HBsAg hepatitis B surface antigen SL sublingual
HbSS sickle cell haemoglobin SLE systemic lupus erythematosus
HBV hepatitis B virus SPEP serum protein electrophoresis
HCl hydrochloric acid SSRI selective serotonin re-uptake inhibitor
HCO3 bicarbonate STEMI ST elevation myocardial infarction
HCV hepatitis C virus STD/ STI sexually transmitted disease/infection
HCW healthcare workers STG standard treatment guideline
HCTZ hydrochlorothiazide SVC superior vena cava
HDL high density lipoprtein T3 triiodothyonine
HE hepatic encephalopathy T4 thyroxine
HELLP syndrome haemolysis, elevated liver TB tuberculosis
enzymes, low platelet count
syndrome
Hep B hepatitis B TBM tuberculosis meningitis
HHS hyperglycaemic hyperosmolar TBSA total body surface area
syndrome
HIV human immunodeficiency virus TCA tricyclic antidepressants
HMGCoA 3-hydroxy-3-methyl-glutaryl- TDD total daily dose
coenzyme A (statin)
H2O water TDF tenofovir
HR heart rate TEN Toxic Epidermal Necrolysis
HSV herpes simplex virus TFT thyroid function test
HT hormone therapy TIA transient ischaemic attack
ICS inhaled corticosteroid TIP transjugular intrahepatic portosystemic
ICU intensive care unit TOD target organ damage
IgG immunoglobulin G TOP termination of pregnancy
IgM immunoglobulin M TP Treponema pallidum
IHD ischaemic heart disease TPHA Treponema pallidum haemagglutination
assay
IM intramuscular TPN total parenteral nutrition
INR international normalized ratio TPT tuberculosis preventive therapy
InSTI integrase inhibitor TSH thyroid stimulating hormone
IOP intraocular pressure TTP-HUS thrombotic thrombocytopenic purpura-
Haemolytic uraemic syndrome
lxxiv

ABBREVIATIONS

IRIS immune reconstitution UA unstable angina
inflammatory syndrome
ITP Immune thrombocytopenia UDV unit dose vial
iu international units ULN upper limit of normal
IUCD intrauterine contraceptive device UE ung emulsificans (emulsifying ointment)
IV intravenous UTI urinary tract infection
J Joule v volt
K potassium VAP ventilator-associated pnwumonia
kg kilogram VDRL test venereal disease research laboratory test
KS Kaposi Sarcoma VDS vaginal discharge syndrome
L litre VF ventricular fibrillation
LABA long-acting beta2 agonist VHF viral haemorrhagic fevers
LAM (urine test) lipoarabinomannan (urine test) VL viral load
LBBB left bundle branch block VSD ventricular septal defect
LDH lactate dehydrogenase VTE Venous thromboembolism
LDL (-C) low density lipoprotein (- VT ventricular tachycardia
cholesterol)
LGV Lymphogranuloma Venereum VWF von Willebrand factor
LH luteinising hormone VZIG varicella-zoster immunoglobulin
LMWH low molecular weight heparin WCC white cell count
LNG levonorgestrel WHO World Health Organisation
LP lumbar puncture WHO DAS WHO Disability Assessment Schedule
LPA line probe assay WOCP women of childbearing potential
LoE level of evidence WPW Wolf-Parkinson-White
LPV/r lopinavir/ritonavir XDR-TB extensively drug-resistant tuberculosis
LV left ventricular YMRS Young Mania Rating Scale
lxxv

DECLARATION OF INTERESTS
Selection of medicines for the essential medicines list requires measures to

ensure that the best possible assessment of scientific evidence is achieved in
an independent environment, free of either direct or indirect pressures. Thus,
to assure the credibility of the process, it is necessary to avoid situations in
which financial or other interests may unduly influence decision-making.
All members of the NEMLC, Adult Hospital Level Technical Expert Review
Committee and co-opted experts were required to make formal declarations of
interest on application and at the start of each meeting. Guidance for declaring,
assessing and handling conflicts of interests is outlined in the NEMLC conflict
of interest policy, accessible at: http://www.health.gov.za/index.php/national-
essential-medicine-listcommittee-nemlc. The following specific declarations
were noted and managed during the development of the Adult Hospital Level
STGs and EML:
Adult Hospital Level Committee (2017-2020)

Dr A Black Astra Zeneca: Attendance and accommodation to attend Pulmonology
(Chair: March 2017- Update in Cape Town; Pfizer: Sponsorship to attend Pneumococcal
March 2019) weekend summit in Cape Town; Bristol Meyers Squib Foundation: Pro
rata fee for training on Lung Cancer screening and diagnosis, as part
of a Lung Cancer screening and Diagnosis grant.
Dr H Dawood MSD: Attendance of SAASP meetings and ESCMID 2018 conference;
(Chair: April 2019- Aids Clinical Trial Group (Crytptococcal meningitis): Investigator for
2020) trial A 5225; Adcock Ingram: Speaker for HIV discussion for GPs,
2017; Pfizer South Africa: SA Pneumococcal disease summit: 2017,
2018; IDEAL Summit, 2018; Advisory Committee for Cef/taz; Novartis
South: Speaker fees, 2015; The Infectious Diseases Society of
Southern Africa (IDSSA): President elect, 2018; HPCSA Research
Ethics Committee member; The HIV Prevention Trials Network
(HPTN): HPTN077, AMP: investigator of records; The South African
HIV Clinicians Society: Cryptococcal meningitis management
guidelines; Biomerieux workshop.
Dr E Bera National Committee for Confidential Enquiry into Maternal Deaths
(Vice Chair) (NCCEMD): Guideline development: Hypertension in Pregnancy,
June 2018
Prof R Coetzee MSD: SAASP meetings and workshop.
Prof PJC Commerford McMaster University (PHRI)/ Bayer: Together with spouse, run
COMPASS in South Africa and remunerated by PHRI (COMPASS
tests rivaroxaban); GlaxoSmithKline: Served on steering committee of
the trials evaluating fondaparinux (OASIS) in CV disease and was a
co-author on some of the papers. My institution received payment for
conducting the studies; Novartis: Speakers fee and travel sponsorship
for chairing a meeting on heart failure; Pfizer: Sponsored meeting in
Cape Town and provided speaker fees for chairing.
Prof GS Gebhardt Royal College of Obstetricians and Gynaecologists (RCOG):
Sponsorship for congress attendance; HAIN Life Science: Partner
works for HAIN Lifescience involved in TB diagnostics; Abbvie:
Support to Province in Perinatal conference (support for conference
and not for self); SA-Medical Research Council: Sponsor
Accommodation sponsored for Cochrane workshop.; National
Committee for Confidential Enquiry into Maternal Deaths (NCCEMD):
Hypertension in Pregnancy Guidelines (2018); Maternity Care
Guidelines
lxxvi

Dr R Griesel UCT: Involved in drafting the initial motivation for fondaparinux,
(resigned) submitted to the Western Cape PTC.
Dr Y Hookamchand Janssen Pharmaceutica: Honoria for Pain Internship and Community
(resigned) service officer training 2017; Sponsorship registration and
accommodation: PAIN2016, WIP2015; MundiPharma: Sponsored Tea
and Lunch At Pain CSO & Intern Training 2016, 2017.
Dr L Robertson Sanofi Aventis: Lunch and attend price sensitivity meeting on public
sector cost of amisulpiride; Speaker honorarium donated to the Society
for Mental Health and Deafness via South African Society of
Psychiatrists (SASOP); Lundbeck: Lunch - January 2019; Astra
Zeneca: Lunch 25 July 2017; Dr Reddy’s Laboratories: Annual
sponsorship for congress attendance and accommodation, 2014 –
2019; Janssen Pharmaceutica: Meeting to discuss training and other
support of community psychiatry; Various pharmaceutical companies:
Sponsorship to the SASOP; Various pharmaceutical companies:
Sponsorships to the South African Orthopaedic Association (Spouse
is a member).
Dr A Sherriff National Department of Health: Breast cancer control policy, 2017;
South African Society of Radiation Oncologists Board: President of
College of Radiation Oncologists; Roche Products: Sponsorship to
attend breast cancer congress; Oncology trial involvement: Ecufs:
104/2011 – Trastusamab vs Pertuzumab adjuvant yherapy in patients
with HER-2 positive primary breast cancer, Ecufs: 100/2014 –
Veliparib in HER-2 neg metastatic or locally advanced unresesctable
BRCA breast cancer, Ecufs: 225/2015 – Pembrolizumab evaluating
biomarkers in advanced solid tumours, Ecufs 226/2015 –
Pembrolizumab in colorectal cancer, Ecufs: 17/2015 – BI695502 in
advanced nonsquamus non-small cell lung cancer, Ecufs 227/2015 –
ABT414 for gioblastoma.
Dr AS Rossiuw Boehringer Ingelheim: Conference sponsorship (ESOC 2017, Prague)
and honorarium (training and workshop: Integrated care pathway,
Thrombolysis in Eastern Cape). Honararium received in 2018 for
conference attendance, training and workshops as well as steering
committee; Sanofi Aventis: Honorarium received in 2015 and 2018 for
workshop attendance and training (including workshop on the
approach to management of epilepsy); Bayer: Attended product launch
of rivaroxaban; SA-Medical Research Council: Grant for pilot research.
Dr S Takuva Sanofi Pasteur/GlaxoSmithKline Biologicals/Novartis: Medical
Monitor/Safety Physician for a number of studies using Pfizer’s / GSK
Biologicals’/ Novartis’ experimental products (vaccines for HIV) in
Phase 1/2a/ 2b and 3 trials - position funded through a grant to the
HVTN from the NIH and Gates Foundation; Janssen Pharmaceutica
(Johnson and Johnson): Conduct periodically training for clinicians and
non-clinicians on HIV vaccinology and immunology. No speaker fees
received.
Ad hoc technical support to the Committee
Dr J Nel AbbVie: consultation on study relating to antiretrovirals; Mylan:
consultation on antiretroviral regimens; Helen Joseph Hospital:
Research on cryptococcal meningitis;
Dr L Weich Rickett Benkiser & Equity Pharmaceuticals: sponsorship of snacks for
patient open day 2011-2014; Adcock Critical Care & Equity
Pharmaceuticals: sponsorship of snacks for patient open day 2011-
2014; The South African HIV Clinicians Society: Cryptococcal
meningitis management guidelines.
Secretariat to the Adult Hospital Level Committee
Ms TD Leong ISPOR-SA: Sponsorship and honorarium for ISPOR-SA 2019
conference.
lxxvii

National Essential Medicines List Committee (2017- )
Dr G Reubenson Aspen, GlaxoSmithKline, Pfizer, Sanofi: Speaker fees and conference
(Vice Chair) support (local and international).
Dr A Black (resigned) See above
Prof S Boschmans Spouse employed by Aspen Pharmacare.
Dr H Dawood See above
Prof K Cohen Non-commercial entity: Co-author of journal article on the use of IPT
in HIV-infected pregnant women, submitted to NEMLC.
Dr R de Waal Non-commercial entity: Co-author of journal article on the use of IPT
Mr A Gray: Non-executive director of Jembi Health Systems
Dr G Grobler Sanofi, Dr Reddy’s Laboratories: Sponsored meetings in 2019
Dr T Kredo SA- Medical Research Council: Receipt of grants.
Prof G Maartens GlaxoSmithKline: Advisory Board for Dolutegravir clinical therapy;
Non-commercial entity: Co-author of journal article on the use of IPT
Ms N Makalima Haemophilia Medical and Scientific Advisory Council meeting (7-8
November 2019): conference and travel sponsorship
Prof M Mendelson MSD, Pfizer, GSK, Galderma, PharmaDynamics: Honoraria for non-
(resigned) product related education on antibiotic stewardship; Pfizer: Advisory
board: influenza vaccine; MSD: Travel grants to attend ESCMID 2013,
2014, 2015, 2016
Prof P Ruff Wits University Health Consortium: Clinical trial funding and honoraria
from various pharmaceutical companies involved in oncology trials and
funds are directed to Wits Health Consortium.
Mr R Wiseman Liberty Health: Employed by Liberty Health
Secretariat to the National Essential Medicines List Committee
Ms TD Leong See above
Funding
 Discovery Health: commissioned Levnorgestrel IUS economic evaluation.
 United States Agency for International Development (USAID) through The USAID
funded Global Health Supply Chain - Technical Assistance program: commissioned
Flucytosine economic evaluation.
lxxviii

USEFUL NUMBERS AND URL LINKS
POISONS INFORMATION CENTRES
Poison Information Helpine 0861555 777
Red Cross War Memorial Children’s Hospital Poisons 0216585308
Information Service Email: [email protected]
http://www.paediatrics.uct.ac.za/poisons-
information-centre
Tygerberg Poison Information Centre 0219388596
www.sun.ac.za/poisoncentre
University of the Free State Poison Control and 082491 0160
Medicine Information Centre
Information on poisons https://www.afritox.co.za/
COMMUNICABLE DISEASES
COVID-19 hotline Clinicians: 080011131
Public: 080002999
http://www.nicd.ac.za/
https://sacoronavirus.co.za/
Rabies hotline (NICD) 082883 9920
Viral Haemmorhagic Fever outbreak hotline (NICD) 082883 9920
South African Vaccine Producers 0113866063/2/00

National notifiable medical conditions surveillance Helpline: 0726213805
Fax: 0866391638
MEDICINE INFORMATION CENTRES

Medicine Information Centre (Cape Town) 0214066829
0861100531
Amayeza Info Centre 011678 2332
National HIV Healthcare Worker Hotline 0800 212 506

0214066782
DEPARTMENT OF HEALTH
National Department Health website www.health.gov.za
Essential Drugs Programme www.health.gov.za/edp.php

Email:[email protected]
Third line ART applications Email: [email protected]
Medicine stock availability reporting Email: [email protected]
Adverse drug reporting: The National Adverse Drug Event

Monitoring Centre (NADEMC):
021 4471618
Fax: 021448 6181
South African Health Products Regulatory
Authority (SAHPRA)
012 842 7609/10
[email protected]
Central Chronic Medicine Dispensing and Distribution 012 395 8988
(CCMDD) 012 395 8362
lxxix

OTHER NUMBERS
Women abuse helpline 0800150150
Child line 0800055555
South African Police Services Crime Stop 086010111
National Human Trafficking Helpline 0800222777
Suicide helpline 0800567567
MISCELLANEOUS
Antiretroviral pregnancy registry http://www.APRegistry.com/
Antiretroviral therapy: drug-drug interactions https://www.hiv-
druginteractionslite.org/checker
http://www.mic.uct.ac.za/
Asthma control test™ https://www.asthmacontroltest.com/
BMI-based CVD risk tool https://www.framinghamheartstudy.org/fhs-
riskfunctions/cardiovascular-disease-10-
year-risk/#
COPD: Modified Medical Research Council (mMRC) https://www.mdcalc.com/mmrc-modified-
dyspnea scale calculator medical-research-council-dyspnea-scale `
Dietary phosphate restriction https://www.kidney.org/
ECG analysis: Reference guide ECG APPtitude: http://q-r.to/baoxer
ECG ONLINE: http://ecgonline.uct.ac.za
eGFR calculator https://www.kidney.org/professionals/KDOQ
I/gfr_calculator
Haemophilia centres http://www.haemophilia.org.za/treatment-
centres/
Ideal weight calculator https://www.mdcalc.com/ideal-body-weight-
Hyponatraemia: Infusion rate calculator https://reference.medscape.com/calculator/
hyponatremia-correction-infusate-rate
Mental health conditions: support groups www.SADAG.org
www.SAFMH.org.za
NSTEMI: Risk stratification calculators TIMI: http://www.mdcalc.com/timi-risk-
score-for-uanstemi/
Grace Risk Score:
http://www.mdcalc.com/grace-acs-risk-and-
mortality-calculator/
Opioid withdrawal: Objective opioid withdrawal scale https://medicine.yale.edu/sbirt/OOWS_2517
(OOWS) 73_284_5_v1.pdf
Pain (chronic): Rating scale to measure pain severity, Pain, Enjoyment and General Activity (PEG)
quality of life, and functionality scale:
http://www.med.umich.edu/1info/FHP/practi
ceguides/pain/PEG.Scale.12.201
6.pdf
Potassium deficit calculator http://www.medicinehack.com/2011/07/hypo
kalemia-potassiumreplacement.html
QT prolongation: Medicines causing QT prolongation https://www.sads.org.uk/drugs-to-
avoid/?doing_wp_cron=1585301751.39966
79782867431640625
Renal impairment: Medicines requiring dose http://www.globalrph.com/index_renal.htm
adjustment in renal
impairment
Scorpion identification http://www.cmej.org.za/index.php/cmej/articl
e/view/2545/2580
Spider identification http://www.cmej.org.za/index.php/cmej/articl
e/view/2547/2582
Substance use disorder: rating scales ASSIST:
http://www.who.int/substance_abuse/activiti
es/assist/en/
DUDIT:
lxxx

https://paihdelinkki.fi/sites/default/files/dudit
manual.pdf
Valproate: acknowledgement of risk form https://www.sahpra.org.za/documents/f150b
f3f6.28_Valproate_Annual_Risk_Acknowled
gement_Form_Dec18_v1.pdf
Vertigo: benign paroxysmal positional vertigo Dix-Hallpike test:
diagnosis https://www.youtube.com/watch?v=8RYB2Q
lO1N4
Epley manoeuvre:
https://www.youtube.com/watch?v=jBzID5n
VQjk
VTE: Risk assessment tools Padua Prediction Score:
https://www.mdcalc.com/padua-prediction-
score-risk-vte
IMPROVE VTE risk score:
https://www.outcomes-
umassmed.org/IMPROVE/risk_score/vte/ind
ex.html
Geneva risk score:
https://www.mdcalc.com/geneva-risk-score-
venous-thromboembolism-vte-prophylaxis
Water deficit calculator http://www.nephromatic.com/water_deficit.p
hp
lxxxi

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Standard Treatment Guidelines

and Essential Medicines List

Hospital Level, Adults

Print copies may be obtained from:

First printed 1998

© Copyright 2019, The National Department of Health.

Published and funded by:

NATIONAL ESSENTIAL MEDICINES LIST COMMITTEE (2017 - present)

ADULT HOSPITAL LEVEL EXPERT REVIEW COMMITTEE (2017-2020)

TECHNICAL AD HOC SUPPORT TO THE ADULT HOSPITAL LEVEL

MEDICINE REVIEW AUTHORS/PEER REVIEWERS

COSTINGS/ ECONOMIC ANALYSES

COMMENTS AND CONTRIBUTIONS

South African Medical Association

DIRECTOR: AFFORDABLE MEDICINES

CHAPTER 1: ALIMENTARY TRACT 1.1

1.3.8 Bacterial peritonitis 1.20

CHAPTER 2: BLOOD AND BLOOD FORMING ORGANS 2.1

CHAPTER 3: CARDIOVASCULAR SYSTEM 3.1

3.3.2.4 Torsades de pointes ventricular tachycardia (VT) 3.22

CHAPTER 4: DERMATOLOGY 4.1

CHAPTER 5: GYNAECOLOGY 5.1

5.8.2 Incomplete miscarriage in the first trimester 5.8

CHAPTER 6: OBSTETRICS 6.1

6.19 Postpartum haemhorrhage 6.25

CHAPTER 7: NEPHROLOGY/UROLOGICAL DISORDERS 7.1

CHAPTER 8: ENDOCRINE CONDITIONS 8.1

8.6.2 Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemic state

CHAPTER 9: SYSTEMIC AND HEALTHCARE-ASSOCIATED INFECTIONS 9.1

9.6 Hydatid disease 9.10

CHAPTER 10: HIV AND AIDS 10.1

CHAPTER 11: SURGICAL ANTIBIOTIC PROPHYLAXIS 11.1

Dosage recommendations 11.2

CHAPTER 12: ANAESTHESIOLOGY AND INTENSIVE CARE 12.1

12.8 Epidural anaesthesia 12.15

CHAPTER 13: MUSCULOSKELETAL CONDITIONS 13.1

CHAPTER 14: NEUROLOGICAL DISORDERS 14.1

14.6.1.2.1 Cryptococcal meningitis, HIV-infected 14.20

CHAPTER 15: MENTAL HEALTH CONDITIONS AND SUBSTANCE MISUSE 15.1

Stimulant withdrawal, including cocaine and amphetamine type stimulants (e.g.

CHAPTER 16: RESPIRATORY DISORDERS 16.1

CHAPTER 17: EAR, NOSE AND THROAT DISORDERS 17.1

CHAPTER 18: EYE DISORDERS 18.1

18.4 Herpes zoster Ophthalmicus 18.5

CHAPTER 19: POISONINGS 19.1

19.14 Illicit drugs 19.26

CHAPTER 20: EMERGENCIES AND INJURIES 20.1

20.11.2.2 Septic shock 20.17

CHAPTER 21: ONCOLOGIC EMERGENCIES 21.1

21.4 Side-effects from pain medication 21.8

CHAPTER 22: MEDICINES USED FOR DIAGNOSIS 22.1

CHAPTER 24: MEDICINES FOR PALLIATIVE CARE 24.1

CHAPTER 25: SEXUALLY TRANSMITTED INFECTIONS 25.1

CHAPTER 26: PAIN 26.1

1 National Drugs Policy, 1996. https://www.gov.za/documents/national-drugs-policy

Navigating the guidelines

Revisions to previous recommendations are accompanied by the level of

THERAPEUTIC DRUG MONITORING (TDM)

Notes on specific medicines