Doxycycline 2-4mg/kg/day IV/PO in 1-2 divided dose (max. 200mg/day) for 5-7 days

Severe disease

IV doxycycline and azithromycin combination

Azithromycin 10mg/kg/dose PO q24h (max. 500mg/dose) for 3 days

Doxycycline can be used in young children (even below 8 years old) since safety data approved its use for rickettsial diseases. 

Rifampicin 15-20mg/kg/day PO in 1-2 divided doses (max. 600-900mg/day) for 6 weeks

PLUS

For children <8 years old:

Trimethoprim/sulfamethoxazole (TMP dose) 10mg/kg/day (max. 480mg TMP/day) PO in 2 divided doses for 6 weeks

OR

For children >8 years old:

Doxycycline 4.4mg/kg/day PO in 2 divided doses (max. 200mg/day) for 6 weeks

Serious illness

Rifampicin 15-20mg/kg/day PO in 1-2 divided doses (max. 600-900mg/day) for 6 weeks

PLUS

For children <8 years old:

Trimethoprim/sulfamethoxazole (TMP dose) 10mg/kg/day (max. 480mg TMP/day) PO in 2 divided doses for 6 weeks

OR

For children >8 years old:

Doxycycline 4.4mg/kg/day PO in 2 divided doses (max. 200mg/day) for 6 weeks

PLUS

Gentamicin 5mg/kg/dose IV q24h for 7-14 days 

--

For non-localised disease: Can use two-drug combination.

Drug of choice for Brucellosis for children >8 years old: Doxycycline (plus rifampicin)

Amoxicillin 40-45 mg/kg/day PO in 3 divided doses (max. 500 mg/dose) 

For children >8 years old:

Doxycycline 2mg/kg/dose PO q12h (max. 200mg/day)

Duration: 7 days

Benzylpenicillin 200,000units/kg/day IV in 4 divided doses (max. 12-18 million units/day)

Ceftriaxone 100mg/kg/day IV q24h (max. 2g/day)

OR

Cefotaxime 150-200mg/kg/day IV in 3-4 divided doses (max. 12g/day) 

Duration: 7 days

Metronidazole 30mg/kg/day IV in 3-4 divided doses (max. 500 mg/dose) for 7-10 days

Neutralisation of toxin:

Human tetanus globulin (TIG) 500IU IM as a single dose. 

Benzylpenicillin 200,000units/kg/day IV in 4 divided doses (max. 12-18 million units/day) for 7-10 days

Neutralisation of toxin:

If TIG not available: IVIG 200-400mg/kg as a single dose

Primary tetanus infection:

Clinical diagnosis to be made as negative culture is often negative.

Steps in care:

1. Early airway protection & treatment of reflex spasm with benzodiazepine (midazolam).

2. Neutralisation of toxin: TIG single dose, administered IM 250-500IU.

3. Surgical debridement of infected tissues.

4. Refer Table for tetanus wound prophylaxis

Ceftazidime 200mg/kg/day IV in 3-4 divided doses (max. 6g/day)

Imipenem/cilastatin 75-100mg/kg/day IV in 4 divided doses (max. 1g/ dose)

OR

Meropenem 75mg/kg/day IV in 3 divided doses

(Neurological melioidosis: 120-150mg/kg/day IV in 3 divided dose) 

(max. 2g/dose)

Duration: 2-8 weeks

• Uncomplicated: 2 weeks

• Complicated pneumonia, deep-seated infection, neurological melioidosis, osteomyelitis & septic arthritis: 4-8 weeks

Trimethoprim/sulfamethoxazole 4-6 mg/kg/dose (of TMP component) PO q12h up to 240mg then to follow adult dose

PLUS (if high risk relapse)*

Doxycycline 4mg/kg/day PO in 2 divided doses (children above 8 years old) (max. 200mg/day) 

Children below 8 years old:

Amoxicillin/clavulanate 20mg/kg/dose (of amoxicillin component) PO q8h

(higher relapse rate)

Ratio dose depends on product available (7:1 or 14:1)

Duration:12- 20 weeks

Folic acid 5mg PO q24h to be given for patients on Trimethoprim/sulfamethoxazole.

*Consider combination therapy of two drugs in maintenance phase if high risk of relapse.

Artemether/lumefantrine (Riamet®) (20mg artemether/ 120mg lumefantrine per tablet)

The patient should receive an initial STAT dose, followed by second dose 8 hours later, then 1 dose q12h for the following two days

5-14kg: 1 tablet per dose

15-24kg: 2 tablet per dose

25-35kg: 3 tablet per dose

≥35 kg: 4 tablet per dose

Artesunate/mefloquine FDC (ASMQ)

(ASMQ is available as FDC tablet 25/55mg & 100/220mg)

5-8kg: 25/55mg PO q24h

9-17kg: 50/110mg PO q24h

18-29kg: 100/220mg PO q24h

>30kg: 200/440mg PO q24h

Duration: 3 days

Artesunate/mefloquine may cause seizure in children with epilepsy.

 Riamet® should be served with high-fat diet e.g. milk to enhance absorption.

  Primaquine 0.25mg base/kg to be given on Day 1 as a single dose in addition to artemisinin-based combination therapy (ACT) (G6PD testing is not required prior to administration of this dose).

An alternative artemisinin-based combination therapy (ACT) regimen to be used.

(If Riamet® is used as the first line regimen, use ASMQ & vice versa)

Artesunate 4mg/kg/dose PO q24h

PLUS

Clindamycin 10mg/kg/dose PO q12h for 7 days

OR

Quinine 10mg salt/kg/dose PO q8h

PLUS

Clindamycin 10mg/kg/dose PO q12h for 7 days

Artesunate/mefloquine may cause seizure in children with epilepsy.

Riamet® should be served with high-fat diet e.g. milk to enhance absorption.

Primaquine 0.25mg base/kg to be given on Day 1 as a single dose in addition to artemisinin-based combination therapy (ACT) (G6PD testing is not required prior to administration of this dose). 

Children > 20 kg

Day 1: 

IV artesunate 2.4mg/kg on admission, then repeat again at 12 & 24 hours

Day 2-7: 

IV artesunate 2.4 mg/kg OD or switch to oral ACT

Children < 20 kg

Day 1: 

IV artesunate 3.0mg/kg on admission, then repeat again at 12 & 24 hours

Day 2-7: 

IV artesunate 3.0mg/kg OD or switch to oral ACT

Duration: 7 days

(Parenteral artesunate should be given for a minimum of 24 hours (3 doses) or until patient is able to tolerate orally and thereafter to complete treatment with a complete course of oral ACT (3 days of ASMQ or Riamet®).

Day 1: *Quinine loading dose 20mg/kg IV (dilute in 250 ml D5%) run over 4 hours; followed by maintenance dose 8 hours later;

Quinine 10mg/kg IV q8h till Day 7 (max. 600mg base)

PLUS

Doxycycline 2.2mg/kg/dose (max. 100mg/dose) PO q12h

OR

Clindamycin 10mg/kg/dose PO q12h

Duration: 7 days

Avoid using ASMQ (artesunate/ mefloquine) if patient presents initially with impaired consciousness as increased incidence of neuropsychiatric complications associated with mefloquine following cerebral malaria have been reported.

Do not use IV artesunate as monotherapy. If IV artesunate needs to be continued indefinitely, clindamycin must be added to the regimen to complete 7 days of treatment.

IM artesunate (same dose as IV) can be used in patients with difficult intravenous access.

Children with severe malaria should be started on broad-spectrum antibiotic treatment immediately at the same time as antimalarial treatment.

*Change to quinine PO if able to tolerate orally (max. quinine per dose = 600 mg). Reduce quinine IV dose by one third of total dose if unable to change to quinine PO after 48 hours (10 mg/kg q8h to 10 mg/kg q12h) or in renal failure or liver impairment.

ACT (Riamet® or ASMQ)

(dosing as per P. falciparum treatment)

PLUS

Primaquine 0.5mg/kg PO q24h for 14 days (max. 30mg base/dose)

Quinine 10mg salt/kg PO q8h for 7 days

PLUS

Primaquine 0.5mg/kg PO q24h for 14 days (max. 30mg base/dose)

Mefloquine 15 mg/kg single dose combined with primaquine have been found to be effective (except for P. knowlesi) 

Primaquine is ONLY needed for P. vivax for a total of 14 days.

Primaquine (0.5mg/kg) may cause haemolysis in individuals with G6PD deficiency, hence G6PD testing is required before administration of primaquine above 0.25mg/kg.

For those found to have mild to moderate G6PD deficiency, an intermittent primaquine regimen of 0.75 mg base/kg weekly for 8 weeks can be given under medical supervision.

In severe G6PD deficiency, primaquine is contraindicated and should not be used.

P. knowlesi (monkey malaria) can cause severe malaria and should be treated as severe malaria secondary to P. falciparum.