Standard Treatment Guidelines for Adults

Papua New Guinea

Introduction

These Standard Treatment Guidelines (STGs) have been developed to guide healthcare providers in the clinical management of common diseases affecting adults in Papua New Guinea. The guidelines aim to standardize treatment approaches, optimize resource utilization, and improve patient outcomes across the healthcare system.

These guidelines reflect current best practices, taking into consideration the local epidemiology, resource constraints, and healthcare infrastructure of Papua New Guinea. They should be used as a reference tool alongside clinical judgment and individual patient assessment.

General Principles of Care

• Provide patient-centered care that respects cultural beliefs and practices
• Ensure accurate history taking and physical examination before initiating treatment
• Consider drug interactions, contraindications, and allergies before prescribing
• Use the lowest effective dose for the shortest duration possible
• Educate patients about their condition, treatment, and expected outcomes
• Arrange appropriate follow-up care and monitoring

Common Infectious Diseases

Acute Respiratory Infections

Upper Respiratory Tract Infections (URTIs):

• Most URTIs are viral and self-limiting
• Supportive care: rest, adequate hydration, analgesics (paracetamol)
• Antibiotics NOT recommended unless complications or bacterial superinfection

Pharyngitis/Tonsillitis:

• Streptococcal pharyngitis: Penicillin V 500 mg every 6 hours for 10 days OR
• Amoxicillin 500 mg every 8 hours for 10 days
• Alternative for penicillin-allergic patients: Erythromycin 500 mg every 6 hours for 10 days

Pneumonia (Community-acquired):

• Mild cases: Amoxicillin 500 mg every 8 hours for 7 days
• Severe cases or high-risk patients: Ceftriaxone 1 g IV daily + Azithromycin 500 mg daily

Gastrointestinal Infections

Acute Diarrhea:

• Rehydration is the cornerstone: Oral rehydration solution (ORS) as needed
• Antibiotics only for bloody diarrhea (shigellosis) or suspected cholera
• Cholera: Doxycycline 300 mg single dose
• Shigellosis: Ciprofloxacin 500 mg twice daily for 3 days

Amebiasis:

• Asymptomatic carriers: No treatment required
• Symptomatic disease: Metronidazole 750 mg three times daily for 5-10 days followed by paromomycin 500 mg three times daily for 7 days

Giardiasis:

• Metronidazole 500 mg twice daily for 5-7 days OR
• Tinidazole 2 g single dose

Tuberculosis

• All patients should be treated according to the National TB Program guidelines
• New cases (drug-sensitive): Directly Observed Treatment, Short-course (DOTS) with Isoniazid, Rifampicin, Pyrazinamide, and Ethambutol for 2 months, followed by Isoniazid and Rifampicin for 4 months
• Drug-resistant TB: Refer to specialized treatment centers

Malaria

Uncomplicated P. falciparum:

• Artemether-lumefantrine (co-formulated): 4 tablets at 0, 8, 24, 36, 48, and 60 hours

Uncomplicated P. vivax:

• Chloroquine 600 mg (base) on day 1, 300 mg on day 2, and 300 mg on day 3
• Plus Primaquine 15 mg daily for 14 days (only after G6PD testing)

Severe Malaria:

• Parenteral Artemether: 3.2 mg/kg loading dose, then 1.6 mg/kg daily until oral therapy possible
• Alternatively: Intravenous Quinine 20 mg/kg loading dose, then 10 mg/kg every 8 hours

Non-Communicable Diseases

Hypertension

Lifestyle modifications:

• Sodium restriction, weight loss, regular exercise, smoking cessation

Pharmacological treatment:

• Stage 1 hypertension (140-159/90-99 mmHg): ACE inhibitors/ARBs or calcium channel blockers
• Stage 2 hypertension (160/100 mmHg): Two-drug combination (ACE inhibitor/ARB + calcium channel blocker or thiazide diuretic)
• Titrate medications to achieve target BP (<140/90 mmHg, <130/80 for diabetics)

Diabetes Mellitus

Type 2 Diabetes:

• Lifestyle modifications: Diet, weight management, regular physical activity
• First-line pharmacotherapy: Metformin 500 mg daily, gradually increased to 2000 mg/day if tolerated
• Target HbA1c: <7% for most patients
• Complication screening: Annual eye examinations, foot examinations, and urine protein screening

Type 1 Diabetes:

• Insulin is mandatory for all patients
• Multiple daily injection regimens preferred
• Regular blood glucose monitoring

Cardiovascular Diseases

Heart Failure:

• ACE inhibitors or ARBs for all patients
• Beta-blockers (carvedilol, metoprolol) for stable patients
• Diuretics for fluid management
• Mineralocorticoid receptor antagonists for select patients

Angina Pectoris:

• Immediate relief: Sublingual nitroglycerin 0.5 mg as needed
• Prophylaxis: Beta-blockers, calcium channel blockers, or long-acting nitrates
• Aspirin 81 mg daily for secondary prevention

Mental Health Conditions

Depression

• Mild to moderate: Psychotherapy and/or pharmacotherapy
• Moderate to severe: Pharmacotherapy with or without psychotherapy
• First-line medications: SSRIs (e.g., fluoxetine 20-60 mg daily)
• Treatment duration: At least 6-12 months after remission

Psychotic Disorders

• Acute psychosis: Antipsychotic medication (e.g., risperidone 2-6 mg daily, haloperidol 2-10 mg daily)
• Long-term management: Maintenance antipsychotics, psychotherapy, and social support
• Regular monitoring for metabolic side effects

Anxiety Disorders

• First-line: SSRIs or SNRIs (e.g., sertraline 25-200 mg daily, venlafaxine 37.5-225 mg daily)
• Short-term anxiolytics: Benzodiazepines (maximum 2-4 weeks)
• Psychotherapy (CBT) recommended for all patients

Pain Management

WHO analgesic ladder approach:

• Step 1 - Mild pain: Non-opioids (paracetamol, NSAIDs)
• Step 2 - Moderate pain: Weak opioids (codeine, tramadol) non-opioids
• Step 3 - Severe pain: Strong opioids (morphine) non-opioids

Emergency Care

Anaphylaxis

• Adrenaline (epinephrine) 0.5 mg intramuscular (0.5 mL of 1:1000)
• Repeat every 5 minutes if needed
• Second-line: Antihistamines, corticosteroids, bronchodilators

Status Epilepticus

• First-line: Lorazepam 0.1 mg/kg IV (max 4 mg) OR Diazepam 0.15-0.2 mg/kg IV
• Second-line: Phenytoin 15-20 mg/kg IV (max 1000 mg) OR Fosphenytoin

Special Considerations

Pregnant Patients

• Many medications are contraindicated during pregnancy
• Always consider potential fetal risks when prescribing
• Refer to specific pregnancy treatment guidelines when available
• Antenatal care should be integrated with treatment of any concurrent conditions

Elderly Patients

• Dose adjustments often necessary due to changes in metabolism and excretion
• Increased risk of adverse drug reactions
• Be mindful of polypharmacy and potential drug interactions
• Consider functional status when determining treatment goals